Block 1 Flashcards
Which of the following drugs increases the rate of gastric emptying in the vagotomised stomach?
Ondansetron
Metoclopramide
Cyclizine
Erythromycin
Chloramphenicol
Erythromycin
Vagotomy seriously compromises gastric emptying which is why either a pyloroplasty or gastro-enterostomy is routinely performed at the same time.
Chloramphenicol has no effect on gastric emptying. Ondansetron slows gastric emptying slightly. Metoclopramide increases the rate of gastric emptying but its effects are mediated via the vagus nerve. Erythromycin enhances gastric emptying by acting via the motilin receptor in the gut.
What factors delay gastric emptying?
Hormonal:
Gastric inhibitory peptide
Cholecystokinin
Enteroglucagon
What factors increase gastric emptying?
Gastrin
Parasympathetic stimulation by the vagus nerve
What do patients undergoing truncal vagotomy require and why?
Routinely require either a pyloroplasty or gastro-enterostomy or they would otherwise have delayed gastric emptying
What may the consequences of diseases affecting gastric emptying be?
Bacterial overgrowth
Retained food-> bezoars that may occlude the pylorus
Fermentation of food may cause dyspepsia, reflux and foul smelling belches of gas
Iatrogenic factors impacting gastric emptying
Any procedure that disrupts the vaugs nerve-> depayed emptying. vagotomy not routinely performed but oesophagectomy may also disrupt vagal nervous supply of the stomach.
When a distal gastrectomy is performed, the type of anastomosis performed impacts on emptying. e.g. when a gastro-enterostomy is constructed, posterior retrocolic gastroenterostomy will empty better than an anterior one
How does the type of gastro-enterostomy performed affect gastric emptying?
When a distal gastrectomy is performed, the type of anastomosis performed will impact on emptying. When a gastro-enterostomy is constructed, a posterior, retrocolic gastroenterostomy will empty better than an anterior one.
Diabetic
Episodes of repeated and protracted vomiting
?Diabetic gastroparesis
Pathophysiology of diabetic gastroparesis
Predominantly due to neuropathy affecting the vagus nerve
Diagnosis of diabetic gastroparesis
Upper GI endoscopy
Contrast studies
Radio-nucleotide scan may be used rarely to demonstrate abnormality
Treatment of diabetic gastroparesis
Drugs such as metoclopramide don’t work as effectively as they exert their effect via the vagus nerve.
Erythromycin is one of the few prokinetic drugs that does as it works via the motilitin receptor
Malignancies causing delayed gastric emptying
Distal gastric cancer
Malignancies of the pancreas may cause extrinsic compression of duodenum
Treatment of gastric outflow obstruction by malignancy
Gastric decompression with wide bore NG tube (Ryles tube)
Insertion of stent
Or surgical bypass via gastroenterostomy
Where is the anatsomosis placed in gastroenterostomy due to malignancy
In the anterior wall despite less good emptying
What type of bypass may also be used in obstructing gastric malignancy
Roux en Y bypass
Typically a disease of infancy. Most babies will present around 6 weeks of age with projectile non bile stained vomiting. It has an incidence of 2.4 per 1000 live births and is more common in males.
Pyloric stenosis
Diagnostic test in in py sten
USS- hypertrophied pylorus
Metabolic abnormality in pyloric stenosis
Hypochloraemic hypokalaemic metabolic alkalosis
What is the earliest complication that can occur following construction of an ileostomy?
Prolapse
Retraction
Necrosis
Parastomal hernia
Dermatitis
Necrosis
Construction of a stoma may be complicated by several factors. Necrosis may occur because of technical errors in mesenteric division, excessive tension or failure to construct a fascial defect of adequate size to permit safe passage of the mesentery and the bowel.
Where are ileostomies generally fashioned?
RIF in the triangle between ASIS, symphysis pubis and umbilicus
Should lie one-third of the distance between the umbilicus and ASIS.
Process of ileostomy formation
They should lie one-third of the distance between the umbilicus and anterior superior iliac spine. A 2cm skin incision is made and dissection continued through the rectus muscle. A cruciate incision should be made, and generally dilated to admit two fingers. The ileum is brought through the incisions and should generally be spouted to a final length of 2.5cm. Ileostomies that are too short may cause problems with appliance fixation and those which are too long may cause problems with tension and subsequent ulceration or prolapse.
What is the most common complication post-ileostomy
Dermatitis
What is the usual ileostomy output?
5-10ml/kg/24h
When might ileostomy output require additional IVF
20ml/kg/24h
Medical management of high output ileostomy
Oral loperamide
Foods containing gelatine.
What proportion of ileostomy patients will respond to conservative management of high output stoma?
50%
Which of the following structures is not transmitted by the jugular foramen?
Hypoglossal nerve
Accessory nerve
Internal jugular vein
Inferior petrosal sinus
Vagus nerve
Contents of the jugular foramen:
Anterior: inferior petrosal sinus
Intermediate: glossopharyngeal, vagus, and accessory nerves
Posterior: sigmoid sinus (becoming the internal jugular vein) and some meningeal branches from the occipital and ascending pharyngeal arteries
What are the anterior contents of the jugular foramen?
Inferior petrosal sinus
What are the intermediate contents of the jugular foramen?
Glossopharyngeal, vagus, accessory nerves
What are the posterior contents of the jugular foramen
Sigmoid sinus (becoming the IJV) and some meningeal branches from the occipital and ascending pharyngeal arteries
Location of foramen ovale
Sphenoid bone
Contents of the foramen ovale
Otic ganglion
V3 (mandibular branch of V)
Accessory meningeal artery
Lesser petrosal nerve
Emissary veins
What is the location of the foramen spinosum
Sphenoid bone
Contents of the foramen spinosum
MMA
Meningeal branch of mandibular nerve
Location of the foramen rotundum
Sphenoid bone
Contents of the foramen rotundum
Maxillary nerve V2
Location of the foramen lacerum/carotid canal
Sphenoid bone
What foramina are found in the sphenoid bone?
Foramen ovale
Foramen spinosum
Foramen rotundum
Foramen lacerum/carotid canal
Superior orbital fissure
Optic canal
What are the contents of the foramen lacerum
Base of the medial pterygoid plate
Internal carotid artery*
Nerve and artery of the pterygoid canal
*= In life the foramen lacerum is occluded by a cartilagenous plug. The ICA initially passes into the carotid canal which ascends superomedially to enter the cranial cavity through the foramen lacerum.
What is the location of the jugular foramen
Temporal bone
Location of the foramen magnum
Occipital bone
Contents of the foramen magnum
Anterior and posterior spinal arteries
Vertebral arteries
Medulla oblongata
Location of the stylomastoid foramen
Temporal bone
Contents of the stylomastoid foramen
Stylomastoid artery
Facial nerve
Contents of the superior orbital fissure
III
Recurrent meningeal artery
IV
Larcimal, frontal and nasociliary branches of V1
VI
Superior ophthalmic vein
At what levels are lumbar punctures best performed?
L3/4 or L4/5
At what level does the SC terminate?
L1
What does the needle pass through on LP
Supraspinous ligament- connects the tips of the spinous processes and the interspinous ligaments between adjacent borders of the spinous processes
Ligamentum flavum which may cause a give as it is penetrated
A second give represents penetration of the needle through the dura mater into the subarachnoid space.
Clear CSF should be obtained at this point.
What do parietal cells secrete?
HCl, Ca, Na. Mg, IF
What do chief cells secrete?
Pepsinogen
What do gastric surface mucosal cells secrete?
Mucus and bicarbonate
Which of the following is not secreted by the parietal cells?
Hydrochloric acid
Mucus
Magnesium
Intrinsic factor
Calcium
Mucus
Outline the process of gastric acid secretion
Produced by parietal cells
pH of 2- maintained by H/K ATPase, bicarbonate ions secreted into the surrounding vessels.
Na and Cl are actively secreted from parietal cells into the cannaliculus, this sets up a negative potential across the membrane and as a result sodium and potassium ions diffuse across into the cannaliculus
Carbonic anhydrase forms carbonic acid which dissociates and the hydrogen ions formed by dissociation leave the cell via the H/K antiporter pump
At the same time, Na ions are actively absorbed. This leaves H + Cl ions in the canaliculus, these mix and are secreted into the lumen of the oxyntic gland
What are the 3 phases of gastric acid secretion
Cephalic phase (smell/taste of food)
Gastric phase (stomach distension)
Intestinal phase (food in duodenum)
Outline the cephalic phase of gastric acid secretion
30% acid produced
Vagal cholinergic stimulation causing secretion of HCl and gastrin release from G Cells
Outline the gastric phase of gastric acid secretion
60% acid produced
Stomach distension/low H+/peptides cause gastrin release
Outline the intestinal phase of gastric acid secretion
10% of acid produced
High acidity/distension/hypertonic solutions in the duodenum inihibt gastric acid secretion via enterogastrones (CCK, secretin) and neural reflexes
What are the factors increasing gastric acid secretion
Vagal nerve stimulation
Gastrin release
Histamine release (indirectly following gastrin release) from enterochromaffin like cells
What are the factors decreasing gastric acid production
Somatostatin (inhibits histamine relase)
Cholecystokinin
Secretin
Describe the factors affecting gastric acid release
Gastrin comes from
G cells in the antrum of the stomach
CCK comes from
I cells in the upper small intestine
Secretin comes from
S cells in upper small intestine
VIP comes from
Small intestine, pancreas
Somatostatin comes from
D cells in the pancreas and stomach
Action of gastrin
increase HCl
Pepsinogen and IF secretion
Increase gastric motility
Trophic effect on gastric mucosa
Action of CCK
Increases secretion of enzyme-rich fluid from pancreas
Contraction of galbladder, relaxation of sphincter of Oddi
Decreases gastric emptying
Trophic effect on pancreatic acinar cells
Induces satiety
Action of secretin
Increases secretion of bicarbonate-rich fluid from pancreas and hepatic duct cells
Decreases gastric acid section
Trophic effect on pancreatic acinar cells
Action of VIP
Stimulates secretion by pancreas and intestines
Inhibits acid and pepsinogen secretion
Action of somatostatin
Decreases acid and pepsin secretion
Decreases gastrin secretion
Decreases pancreatic enzyme secretion
Decreases insulin and glucagon secretion
Inhibits trophic effects of gastrin
Stimulates gastric mucous production
Stimulus for gastrin
Distension of stomach
Extrinsic nerves
Inhibited by low antral pH, somatostatin
Stimulus for CCK
Partially digested proteins and TGs
Stimulus for secretin
Acidic chyme, FAs
Stimulus for VIP
neural
Stimulus for somatostatin
Fat, bile salts and glucose in the intestinal lumen
A 45 year old motor cyclist sustains a tibial fracture and is noted to have anaesthesia of the web space between his first and second toes. Which of the nerves listed below is most likely to be compromised?
Superficial peroneal nerve
Deep peroneal nerve
Sural nerve
Long saphenous nerve
Tibial nerve
The deep peroneal nerve lies in the anterior muscular compartment of the lower leg and can be compromised by compartment syndrome affecting this area. It provides cutaneous sensation to the first web space. The superficial peroneal nerve provides more lateral cutaneous innervation.
Origin of the deep peroneal nerve
From the common peroneal nerve at the lateral aspect of the fibula, deep to peroneus longus
Nerve roots of the deep peroneal nerve
L4, L5, S1
Course of the deep peroneal nerve
Pierces the anterior intermuscular septum to enter the anterior compartment of the lower leg
Passes anteriorly down the ankle joint, midway between the two malleoli
Terminates in the dorsum of the foot
Muscles innervated by deep peroneal nerve
Tibialis anterior
EHL
EDL
Peroneus tertius
EDB
Cutaneous innervation of deep peroneal nerve
Web spaceof the first and second toes
Actions of the deep peroneal nerve
Dorsiflexion of the ankle joint
Extension of all toes (EHL and EDL)
Inversion of the foot
Which nerve produces these movements:
Dorsiflexion of the ankle joint
Extension of all toes (EHL and EDL)
Inversion of the foot
Deep peroneal nerve
What happens to the deep peroneal nerve after its bifurcation at the ankle joint?:
After its bifurcation past the ankle joint, the lateral branch of the deep peroneal nerve innervates the extensor digitorum brevis and the extensor hallucis brevis
The medial branch supplies the web space between the first and second digits.
A 40 year old women presented with a mass on her forehead. On examination, she had a fluctuant pulsatile mass on her head. Examination of her neck revealed a mass inferior to the hyoid with a positive Berry’s sign. What is the most likely underlying diagnosis?
Follicular thyroid cancer
Medullary thyroid cancer
Papillary thyroid cancer
Anaplastic thyroid cancer
Parathyroid gland cancer
Follicular thyroid cancer
Papillary thyroid cancers will tend to spread via lymphatics and present with disease that is nearly always confined to the neck. Follicular carcinomas may metastasise haematogenously and the skull may be the presenting site of disease in between 2 and 8% of patients.
Berry’s sign
Absence of carotid pulse due to malignant thyromegaly
Commonest sub-type of thyroid malignancy
Papillary carcinoma
Histologically, they may demonstrate psammoma bodies (areas of calcification) and so called ‘orphan Annie’ nuclei
Papillary carcinoma
How does follicular thyroid carcinoma tend to spread?
Haematogenously-> higher mortality rate
What is an issue with follicular thyroid lesions
Cannot be accurately diagnosed on FNA and thus all FNAs (THY 3f) will require at least a hemi-thyroidectomy
These are tumours of the parafollicular cells ( C Cells) and are of neural crest origin.
The serum calcitonin may be elevated which is of use when monitoring for recurrence.
Medullary carcinoma
Spread of medullary thyroid carcinoma
Spread may be either lymphatic or haematogenous and as these tumours are not derived primarily from thyroid cells they are not responsive to radioiodine.
Theme: Result of nerve injury
A.Teres major
B.Brachialis
C.Serratus anterior
D.Trapezius
E.Flexor digitorum profundus
F.Biceps
G.Supinator
H.Adductor pollicis
I.Abductor pollicis brevis
J.Abductor digiti minimi
For each of the nerves listed below, please identify the muscle which is most likely to be affected.
Damage to the accessory nerve during a lymph node excision biopsy.
Damage to the median nerve during a carpal tunnel release.
Injury to the radial nerve in a humeral shaft fracture.
The correct answer is Trapezius
The correct answer is Abductor pollicis brevis
Adductor pollicis and abductor digiti minimi are innervated by the ulnar nerve
The correct answer is Supinator
Posterior triangle LN biopsy associated with what nerve lesion
Accessory nerve
Llyod davies stirrups and what nerve
Common peroneal
Thyrodiectomy what nerve
Laryngeal nerve
Anterior resection of rectum- what nerve at risk of injury
Hypogastric autonomic nerves
Axillary node clearance, what nerves at risk of injury?
LTN
Thoracodorsal
Intercostobrachial
Inguinal surgery, what nerve
Ilioinguinal
Varicose vein surgery, what nerve at risk of injury
Sural and saphenous
Posterior approach to the hip, what nerve at risk
Sciatic nerve
Cartoid endarterectomy and what nerve
Hypoglossal
What is the most common cause of mesenteric infarction?
Mesenteric vein thrombosis
Acute embolism affecting the superior mesenteric artery
Acute on chronic thrombus of the superior mesenteric artery
Sub intimal dissection of the superior mesenteric artery
Proximal migration of abdominal aortic aneurysm
Acute embolic events account for up to 50% of cases of mesenteric infarcts. These may occur as a result of long standing atrial fibrillation, ventricular anuerysms and post myocardial infarction.
What proportion of surgical admissions is accounted for by mesenteric iscahemia?
1 in 1000 acute surgical admissions
What is the primary cause of mesenteric vessel disease and where is it more likely to occur?
Arterial embolism-> colonic infarction
Areas such as the splenic flexure that are located at the borders of arterial territories
Sudden onset abdominal pain followed by profuse diarrhoea.
May be associated with vomiting.
Rapid clinical deterioration.
Serological tests: WCC, lactate, amylase may all be abnormal particularly in established disease. These can be normal in the early phases.
Acute mesenteric emboluc (commonest mesenteric vessel disease- 50%)
Usually longer prodromal history.
Post prandial abdominal discomfort and weight loss are dominant features. Patients will usually present with an acute on chronic event, but otherwise will tend not to present until mesenteric flow is reduced by greater than 80%.
When acute thrombosis occurs presentation may be as above. In the chronic setting the symptoms will often be those of ischaemic colitis (mucosa is the most sensitive area to this insult).
Acute on chronic mesenteric ischaemia
Usually a history over weeks.
Overt abdominal signs and symptoms will not occur until venous thrombosis has reached a stage to compromise arterial inflow.
Thrombophilia accounts for 60% of cases.
Mesenteric vein thrombosis
This occurs in patients with multiple co morbidities in whom mesenteric perfusion is significantly compromised by overuse of inotropes or background cardiovascular compromise.
The end result is that the bowel is not adequately perfused and infarcts occur from the mucosa outwards.
Low flow mesenteric infarction
Diagnosis of mesenteric ischaemia
Serological tests: WCC, lactate, CRP, amylase (can be normal in early disease).
Cornerstone for diagnosis of arterial AND venous mesenteric disease is CT angiography scanning in the arterial phase with thin slices (<5mm). Venous phase contrast is not helpful.
SMA duplex USS is useful in the evaluation of proximal SMA disease in patients with chronic mesenteric ischaemia.
MRI is of limited use due to gut peristalsis and movement artefact.
What is the cornerstone for diagnosis of arterial and venous mesenteric disease?
CT angiography in the arterial phase with thin slices (<5mm). Venous phase contrast is not helpful
Management of mesenteric ischaemia
Peritonitic- laparotomy
At operation limited resection of frankly necrotic bowel with view to relook laparotomy at 24-48h. In the interim urgent bowel revascularisation via endovascular (preferred) or surgery.
Management of mesenteric vein thrombosis if not peritonitic
IV heparin
Px of mesenteric ischaemia
Overall poor. Best outlook is from an acute ischaemia from an embolic event where surgery occurs within 12h. Survival may be 50%. This falls to 30% with treatment delay. The other conditions carry worse survival figures.
A patient undergoes a femoral hernia repair and at operation the surgeon decides to enter the abdominal cavity to resect small bowel. She makes a transverse incision two thirds of the way between umbilicus and the symphysis pubis. Which of the structures listed below is least likely to be divided?
Rectus abdominis
External oblique aponeurosis
Peritoneum
Fascia transversalis
Posterior lamina of the rectus sheath
An incision at this level lies below the arcuate line and the posterior wall of the rectus sheath is deficient at this level.
Rectus sheath above the costal margin
Anterior sheath: External oblique aponeurosis
Costal cartilages posterior
Rectus sheath from the costal margin to arcuate line
External oblique and anterior part of internal oblique aponeurosis
Posterior part of the sheath: posterior internal oblique aponeurosis and transversus abdominis
Rectus sheath below the arcuate line
Aponeuroses of all the abdominal muscles lie in anterior aspect of the rectus
Posteriorly lies the transversalis fascia and peritoneum
What does the arcuate line represent?
The point at which the inferior epigastric vessels enter the rectus sheath
Lymphatic drainage of the ovaries
Para-aortic nodes via gonadal vessels
Lymphatic drainage of the uterine fundus
Runs with ovarian vessels-> para-aortic nodes
Some drainage may also pass along the round ligament to the inguinal nodes
Lymphatic drainage of the body of the uterus
Lymphatics contained within the broad ligament to the iliac LNs
Lymphatic drainage of the cervix
Laterally through the broad ligament to EI nodes
Uterosacral fold to the presacral nodes
Posterolaterally along lymphatics lying alongside uterine vessles to the IA nodes
heme: Axillary anatomy
A.Medial pectoral nerve
B.Thoracodorsal nerve
C.Lateral pectoral nerve
D.Intercostobrachial nerve
E.Medial cord of the brachial plexus
F.Long thoracic nerve
G.Axillary nerve
H.Accessory nerve
Please identify the structure that is most likely to be affected in the scenarios described below. Each structure may be used once, more than once or not at all.
A 44 year old lady has undergone a mastectomy and axillary node clearance. Post operatively, she notices a patch of anaesthesia of her axillary skin when she applies an underarm deodorant.
A 44 year old lady has undergone a mastectomy and axillary node clearance to treat breast cancer. Post operatively, it is noted that she has winging of the scapula.
A 44 year old lady who works as an interior decorator has undergone a mastectomy and axillary node clearance to treat breast cancer. Post operatively, she comments that her arm easily becomes fatigued when she is painting walls.
The correct answer is Intercostobrachial nerve
The intercostobrachial nerves traverse the axilla and innervate the overlying skin. These can be injured or divided during axillary surgery and the result is anaesthesia of the overlying skin.
Long thoracic nerve
Injury to the long thoracic nerve (which innervates the serratus anterior) can occur as it lies at the medial aspect of the axilla, winging of the scapula will then result.
The correct answer is Thoracodorsal nerve
The most likely explanation for this is that the thoracodorsal nerve has been injured. This will result in atrophy of latissimus dorsi and this will become evident with repetitive arm movements where the arm is elevated and moving up and down (such as in painting). Injury to the pectoral nerves may produce a similar picture but this pattern of injury is very rare and the pectoral nerves are seldom injured in breast surgery.
Medial boundary of the axilla
Chest wall and serratus anterior
Lateral boundary of the axilla
Humeral head
Floor of the axilla
Subscapularis
Anterior aspect of the axilla
Lateral border of pec major
Fascia of the axilla
Clavipectoral fascia
Contents of the axilla
LTN
Thoracodorsal nerve and thoracodorsal trunk
Axillary vein
inercostobrachial nerves
LNs
Derived from C5-C7 and passes behind the brachial plexus to enter the axilla. It lies on the medial chest wall and supplies serratus anterior. Its location puts it at risk during axillary surgery and damage will lead to winging of the scapula.
Long thoracic nerve (of Bell)
Innervate and vascularise latissimus dorsi.
Thoracodorsal nerve and thoracodorsal trunk
Lies at the apex of the axilla, it is the continuation of the basilic vein. Becomes the subclavian vein at the outer border of the first rib.
Axillary vein
Traverse the axillary lymph nodes and are often divided during axillary surgery. They provide cutaneous sensation to the axillary skin.
Intercostobrachial nerves
A 25 year old man is shot in the abdomen and is transferred to the operating theatre following arrival in the emergency department, as he is unstable and a FAST scan is positive. At operation there is an extensive laceration to the right lobe of the liver and involvement of the IVC. There is massive haemorrhage. What is the most appropriate approach to blood component therapy?
Use Factor VIII concentrates early
Avoid use of “o” negative blood
Transfuse packed cells, FFP and platelets in fixed ratios of 1:1:1
Transfuse packed cells and FFP in a fixed ratio of 4:1
Perform goal directed transfusion based on the Hb, PT and TEG studies
There is strong evidence to support the use of haemostatic transfusion in the setting of major haemorrhage due to trauma. This advocates the use of 1:1:1 ratios.
Def: massive transfusion
Replacement of patient’s total blood volume in <24h or the acute administration of >1/2 of the patient’s estimated blood volume per hour.
CRASH 2 study provides evidence of what?
Haemorrhaging patients following trauma- evidence to support initital adminsitration of tranexamic acid.
CRASH study
A large simple placebo controlled trial, among adults with head injury and impaired consciousness, of the effects of a 48 hour infusion of corticosteroids on death and neurological disability
.These results show there is no reduction in mortality with methylprednisolone in the 2 weeks after head injury. The cause of the rise in risk of death within 2 weeks is unclear.
CRASH-2
CRASH-2 Study of Tranexamic Acid to Treat Bleeding in Trauma Patients
Tranexamic acid vs placebo within 3 hours of head injury
Tranexamic acid was associated with a significant reduction in all cause mortality and deaths from bleeding.
A 35 year old farm labourer injures the posterior aspect of his hand with a mechanical scythe. He severs some of his extensor tendons in this injury. How many tunnels lie in the extensor retinaculum that transmit the tendons of the extensor muscles?
One
Three
Four
Five
Six
There are six tunnels, each lined by its own synovial sheath.
Attachments of the extensor retinaculum
The pisiform and triquetral medially
The end of the radius laterally
Structures superficial to the extensor retinaculum
Basilic vein
Dorsal cutaneous branch of the ulnar nerve
Cephalic vein
Superficial branch of the radial nerve
Structures passing deep to the extensor retinaculum
Extensor carpi ulnaris tendon
Extensor digiti minimi tendon
Extensor digitorum and extensor indicis tendon
Extensor pollicis longus tendon
Extensor carpi radialis longus tendon
Extensor carpi radialis brevis tendon
Abductor pollicis longus and extensor pollicis brevis tendons
Radial artery passage into the hand
Passes between the lateral collateral ligament of the wrist joint and the tendons of abductor pollicis longus and extensor pollicis brevis
A 23 year old man undergoes an orchidectomy. The right testicular vein is ligated; into which structure does it drain?
Right renal vein
Inferior vena cava
Common iliac vein
Internal iliac vein
External iliac vein
The testicular venous drainage begins in the septa and these veins together with those of the tunica vasculosa converge on the posterior border of the testis as the pampiniform plexus. The pampiniform plexus drains to the testicular vein. The left testicular vein drains into the left renal vein. The right testicular vein drains into the inferior vena cava.
Where do the sympathetic nerve fibres lie in the spermatic cord?
Lie on arteries
Where do the parasympathetic nerve fibres lie in the spermatic cord?
On vas
Genital branch of the genitofemoral nerve supplies what muscle?
Cremaster
Arterial supply of the scrotum
Anterior and posterior scrotal arteries
What is the organisation of the tunica vaginalis
Surround the testes.
Parietal layer of the tunica vaginalis is adjacent to internal spermatic fascia.
Testicular arteries arise from?
The aorta, immediately inferior to the renal arteries
Which of the muscles listed below is not innervated by the median nerve?
Flexor pollicis brevis
Lateral two lumbricals
Pronator teres
Opponens pollicis
Adductor pollicis
Adductor pollicis is innervated by the ulnar nerve.
Medial two lumbricals innervated by the ulnar nerve.
Formation of the median nerve?
The median nerve is formed by the union of a lateral and medial root respectively from the lateral (C5,6,7) and medial (C8 and T1) cords of the brachial plexus; the medial root passes anterior to the third part of the axillary artery. The nerve descends lateral to the brachial artery, crosses to its medial side (usually passing anterior to the artery). It passes deep to the bicipital aponeurosis and the median cubital vein at the elbow.
Passage of the median nerve in the lower arm?
Passes between the two heads of pronator teres and runs on the deep surface of flexor digitorum superficialis (within its fascial sheath)
Passage of the median nerve into the hand
Near the wrist it becomes superficial between the tendons of the flexor digitorum superficialis and flexor carpi radialis, deep to palmaris longus.
Passes deep to the flexor retinaculum to enter the palm but lies anterior to the long flexor tendons within the carpal tunnel
Branches of the median nerve in the upper arm?
No branches, although the nerve commonly communicates with the musculocutaneous nerve
Muscles innervated by median nerve in forearm
Pronator teres
Flexor carpi radialis
Palmaris longus
Flexor digitorum superficialis
Flexor pollicis longus
Flexor digitorum profundus (only the radial half)
Branches of the median nerve in the distal forearm, proximal to the carpal tunnel
Palmar cutaneous branch
Motor function of the median in the hand
LOAF
Lateral 2 lumbricals
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis
Sensory function of the median nerve in the hand
Thumb and lateral 2.5 fingers
On the plamar aspect this projects proximally, on the dorsal aspect only the distal regions are innervated. With the radial nerve providing the more proximal cutaneous innervation
paralysis and wasting of thenar eminence muscles and opponens pollicis (ape hand deformity)
sensory loss to palmar aspect of lateral (radial) 2 ½ fingers
Median nerve damage at the wrist
e.g. carpal tunnel
unable to pronate forearm
weak wrist flexion
ulnar deviation of wrist
Median nerve damage at the elbow
Anterior interosseus nerve
Branch of the median nerve, leaves just below elbow.
Results in loss of pronation of forearm and weakness of long flexors of the thumb and index finger.
A 45 year old man with recurrent episodes of confusion is found to have a 1.5cm insulinoma of the pancreatic head. What is the most appropriate management?
Whipples procedure
Total pancreatectomy and en bloc splenectomy
Pylorus preserving pancreatico duodenectomy
Enucleation of the lesion
External beam radiotherapy
Enucleation
Most insulinomas are benign and radical resection is therefore not justified.
Symptomatic hypoglycaemia during fasting
Concomitant blood glucose of less than 3mmol/L
Relief of hypoglycaemia by use of glucose
Insulinoma
Def: insulinoma
Proportion benign?
Insulin producing tumours of the pancreatic beta cells
90% benign
What proportion of insulinomas are MEN associated?
5-10% have MEN1
What proportion of MEN1 sufferers will develop pancreatic islet cell tumours?
75%
Testing in insulinoma
When neuroglycopenic symptoms occur blood is taken for serum insulin levels, serum glucose, C-peptide and pro insulin concentrations. The plasma insulin concentration is >10 micro U/ml in patients with the disorder.
What is the most effective method for benign insulinoma localisation
Endoscopic USS (75%)
Diagnostic accuracy of MRI for malignant insulinomas?
Near 100%
Methods of insulinoma localisation
USS (25% accuracy), endoscopic USS better (75% accuracy)
CT scanning (pancreatic protocol=40% accuracy)
Malignant insulinomas are larger and diagnostic accuracy with MRI is nearly 100% in such cases
Somatostatin receptor scintigraphy (50% accuracy)
Treatment of insulinomas
Since the majority of tumours are benign; the blind segmental resection of the pancreas (e.g. Whipples) cannot be justified, this may be considered acceptable for malignant lesions. The best approach at laparotomy is to corroborate pre operative imaging with intraoperative ultrasonography to identify the lesion. Tumours may be close of the pancreatic duct and this must be appreciated by the operating surgeon. The perioperative use of octreotide reduces the amount of pancreatic drainage, but not overall complications.
A 39 year old man notices a swelling in his left hemiscrotum. On examination he has a left sided varicocele. The ipsilateral testis is normal on palpation. What is the most appropriate course of action?
Scrotal exploration and ligation of the varicocele
Abdominal ultrasound
Scrotal ultrasound
Left orchidectomy
Discharge
A left sided varicocele is a recognised presenting sign of a renal tumour occluding the renal vein (into which the left testicular vein drains). An abdominal ultrasound should be undertaken to exclude this. Surgery for uncomplicated varicocele is usually unnecessary.
Histopathology of RCC
Adenocarcinoma of renal cortex, believed to arise from PCT
Usually solitary lesions, 20% may be multifocal, 20% may be calcified, 20% may have a cystic component or be wholly cystic.
Often circumscribed by a pseudocapsule of compressed normal renal tissue
Spread of RCC
Direct extension into the adrenal gland, renal vein or surrounding fascia.
Distal disease is haematogenous to lungs, bone or brain
Demographics of RCC
85% of all renal malignancies
Males>females
Sporadic tumours
6th decade
Symptoms of RCC
Haematuria (50%), loin pain (40%), mass (30%) and up to 25% may have symptoms of metastasis.Less than 10% have the classic triad of haematuria, pain and mass.
Classic triad in RCC?
Haematuria
Pain
Mass
Ix in RCC
Many cases will present as haematuria and be discovered during diagnostic work up. Benign renal tumours are rare, so renal masses should be investigated with multislice CT scanning. Some units will add an arterial and venous phase to the scan to demonstrate vascularity and evidence of caval ingrowth.
CT scanning of the chest and abdomen to detect distant disease should also be undertaken.
Routine bone scanning is not indicated in the absence of symptoms.
Biopsy should not be performed when a nephrectomy is planned but is mandatory before any ablative therapies are undertaken.
Assessment of the functioning of the contra lateral kidney.
Mx of T1 renal lesions
T1 lesions may be managed by partial nephrectomy and this gives equivalent oncological results to total radical nephrectomy. Partial nephrectomy may also be performed when there is inadequate reserve in the remaining kidney.
Mx of T2 renal lesions
For T2 lesions and above a radical nephrectomy is standard practice and this may be performed via a laparoscopic or open approach. Preoperative embolisation is not indicated nor is resection of uninvolved adrenal glands. During surgery early venous control is mandatory to avoid shedding of tumour cells into the circulation.
Chemotherapy in RCC
Patients with completely resected disease do not benefit from adjuvant therapy with either chemotherapy or biological agents. These should not be administered outside the setting of clinical trials.
Mx of TCC involving kidneys
Patients with transitional cell cancer will require a nephroureterectomy with disconnection of the ureter at the bladder.
A 65 year old man is admitted for a below knee amputation. He is taking digoxin. Clinically the patient has an irregularly irregular pulse. What would you expect to see when you examine the jugular venous pressure?
Absent y waves
Slow y descent
Cannon waves
Steep y descent
Absent a waves
Absent a waves = Atrial fibrillation Large a waves = Any cause of right ventricular hypertrophy, tricuspid stenosis Cannon waves (extra large a waves) = Complete heart block Prominent v waves = Tricuspid regurgitation Slow y descent = Tricuspid stenosis, right atrial myxoma Steep y descent = Right ventricular failure, constrictive pericarditis, tricuspid regurgitation
‘a’ wave =
atrial contraction
large if atrial pressure e.g. tricuspid stenosis, pulmonary stenosis, pulmonary hypertension
absent if in atrial fibrillation
Cannon ‘a’ waves
caused by atrial contractions against a closed tricuspid valve
are seen in complete heart block, ventricular tachycardia/ectopics, nodal rhythm, single chamber ventricular pacing
‘c’ wave
closure of tricuspid valve
not normally visible
‘v’ wave
due to passive filling of blood into the atrium against a closed tricuspid valve
giant v waves in tricuspid regurgitation
‘x’ descent =
= fall in atrial pressure during ventricular systole
‘y’ descent
= opening of tricuspid valve
Draw and label JVP
‘a’ wave = atrial contraction
large if atrial pressure e.g. tricuspid stenosis, pulmonary stenosis, pulmonary hypertension
absent if in atrial fibrillation
Cannon ‘a’ waves
caused by atrial contractions against a closed tricuspid valve
are seen in complete heart block, ventricular tachycardia/ectopics, nodal rhythm, single chamber ventricular pacing
‘c’ wave
closure of tricuspid valve
not normally visible
‘v’ wave
due to passive filling of blood into the atrium against a closed tricuspid valve
giant v waves in tricuspid regurgitation
‘x’ descent = fall in atrial pressure during ventricular systole
‘y’ descent = opening of tricuspid valve
A 44 year old lady is undergoing an abdominal hysterectomy and the ureter is identified during the ligation of the uterine artery. At which site does it insert into the bladder?
Posterior
Apex
Anterior
Base
Superior aspect of the lateral side
The ureters enter the bladder at the upper lateral aspect of the base of the bladder. They are about 5cm apart from each other in the empty bladder. Internally this aspect is contained within the bladder trigone.
Where does the uretur overlie the transverse processes
L2-L5
Relationship of ureturs to the iliac vessels
Anterior to bifurcation
Bloody supply of the ureturs
Segmental: renal artery, aortic branches, gonadal branches, common iliac, internal iliac
Relationship of ureturs to the uterine artery
Lies below
Where does the ureteric muscle coat become three layers?
As it crosses into the bony pelvis
What is the correct embryological origin of the stapes?
First pharyngeal arch
Second pharyngeal arch
Third pharyngeal arch
Fourth pharyngeal arch
Fifth pharyngeal arch
The dorsal ends of the cartilages of the first and second pharyngeal arches articulate superior to the tubotympanic recess. These cartilages form the malleus, incus and stapes. At least part of the malleus is formed from the first arch and the stapes from the second arch. The incus is most likely to arise from the first arch.
The ectoderm covering the outer aspect of the second arch originates from a strip of ectoderm lateral to the metencephalic neural fold. The cartilaginous element to this, eponymously known as Reicherts cartilage extends from the otic capsule to the midline on each side. Its dorsal end separates and becomes enclosed in the tympanic cavity as the stapes.
When do the pharyngeal arches develop and from what?
Fourth week of embryonic growth from a series of mesodermal outpouchings
Develop and fuse in the ventral midline.
Pharyngeal pouches form on the endodermal side between the arches
Muscular contributions of the first pharyngeal arch
Muscles of mastication
Anterior belly of digastric
Mylohyoid
Tensor tympani
Tensor veli palatini
Skeletal contributions of the first pharyngeal arch
Maxilla
Meckels cartilage
Incus
Malleus
Arterial contributions of the first pharyngeal arch
Maxillary
External carotid
Nerve contributions of the first pharyngeal arch
Mandibular
Fate of the 5th pharyngeal arch
Does not contribute any useful structures and often fuses with the sixth arch
Muscular contributions of the second pharyngeal arch
Buccinator
Platysma
Muscles of facial expression
Stylohyoid
Posterior belly of digastric
Stapedius
Skeletal contributions of the second pharyngeal arch
Stapes
Styloid process
Lesser horn and upper body of hyoid
Arterial contributions of the second pharyngeal arch
Inferior branch of superior thyroid artery
Stapedial artery
Nerve contributions of the second pharyngeal arch
Facial nerve
Muscular contributions of the third pharyngeal arch
Stylopharyngeus
Endocrine contributions of the third pharyngeal arch
Thymus
Inferior parathyroids
Skeletal contributions of the third pharyngeal arch
Greater horn and lower part of hyoid
Vascular contributions of third pharygneal arch
Common and internal carotid
Nervous contributions of the third pharyngeal arch
Glossopharyngeal
Muscular contributions of the fourth pharyngeal arch
Cricothyroid
All intrinsic muscles of the soft palate
Skeletal contributions of the fourth pharyngeal arch
Thyroid and epiglottic cartialges
Endocrine contributions of the fourth pharyngeal arch
Superior parathyroids
Vascular contributions of the fourth pharyngeal arch
Right subclavian artery
Left aortic arch
Nerve contributions of the fourth pharyngeal arch
Vagus
Muscular contributions of the sixth pharyngeal arch
All intrinsic muscles of the larynx except cricothyroid
Skeletal contributions of the sixth pharyngeal arch
Cricoid, arytenoid and corniculate cartilages
Vascular contributions of the sixth pharyngeal arch
Right pulmonary artery
Left pulonary artery
Ductus arteriosus
Nervous contributions of the sixth pharyngeal arch
Vagus and RLN
A 68 year old man with poorly controlled diabetes presents with severe otalgia and headaches. On examination, there is granulation tissue within the external auditory meatus. What is the most likely underlying infective agent?
Pseudomonas aeruginosa
Streptococcus pyogenes
Staphylococcus aureus
Actinomyces
Bacteroides fragilis
Malignant otitis externa is caused by Pseudomonas aeruginosa
Severe pain, headaches and granulation tissue within the external auditory meatus are key features of malignant otitis externa. Diabetes mellitus is one of the commonest risk factors.
Uncommon type of otitis externa that is found in immunocompromised individuals (90% cases found in diabetics)
Infective organism is usually Pseudomonas aeruginosa
Infection commences in the soft tissues of the external auditory meatus, then progresses to involve the soft tissues and into the bony ear canal
Progresses to temporal bone osteomyelitis
Malignant otitis externa
What are the key features in the history for malignant otitis externa?
DM or immunosuppression
Severe, unrelenting, deep-seated otalgia
Temporal headaches
Purulent otorrhea
Possibly dysphagia, hoarseness and or facial nerve dysfunction
Treatment of malignant otitis externa
Antipseudomonal antimicrobial agents
Topical agents
Hyperbaric oxygen may be used in refractory cases
Theme: Paediatric gastrointestinal disorders
A.Liver transplant
B.Rectal biopsy
C.Roux-en-Y portojejunostomy
D.Ramstedt pyloromyotomy
E.Abdominal CT scan
F.Upper GI contrast study
G.Laparotomy and formation of stoma
H.Laparotomy
I.Colonoscopy
J.Gastroscopy
What is the best management option for these children? Each option may be used once, more than once or not at all.
2.A male infant, born at term appears well following delivery. Six hours later, he is noted to have bilious vomiting by the paediatricians. On examination he seems well and his abdomen is soft and non tender.
A 2 month old baby presents with jaundice. He has an elevated conjugated bilirubin level. Diagnosis is confirmed by cholangiography during surgery.
A male infant, born at term by normal vaginal delivery is well. However, 72 hours following delivery, he has still not passed meconium. On examination, his abdomen is soft and not particularly distended. He has a normally sited anus.
Upper GI contrast study
Bilious vomiting in neonates is a surgical emergency and is intestinal malrotation and volvulus until otherwise proven. It is investigated with an upper GI contrast study. Contrast should be seen to exit the stomach and the location of the DJ flexure is noted (it lies to the left of the midline). If this is not the case, or the study is inconclusive, a laparotomy is performed.
Roux-en-Y portojejunostomy
This child has biliary atresia. The aim is to avoid liver transplantation (however, most will come to transplant in time).
Rectal biopsy
Delayed passage of meconium is suggestive of Hirschsprung’s disease and the investigation of choice is full thickness suction rectal biopsy. If Hirschprungs is confirmed, then the correct treatment is laparotomy and stoma formation. At between 9 and 12 months of age, definitive surgery (usually resection and primary anastomosis) is performed.
Acute appendicitis in <3y/o
Uncommon, may present atypically
Colicky pain, diarrhoea and vomiting, sausage shaped mass, red jelly stool.
Intussuception
Paediatric, central abdominal pain and URTI
Mesenteric adenitis
Pathology of intussuception
Telescoping bowel
Proximal to or at the level of ileocaecal valve
6-9 months old
Diagnosis of malrotation
Upper GI contrast study and USS
Treatment of malrotation
Laparotomy, if volvulus is present or patient at high risk of volvulus than a Ladds procedure is performed
Ladd’s procdure
The procedure involves surgical division of Ladd’s bands, widening of the small intestine’s mesentery, performing an appendectomy and correctional placement of the cecum and colon.
High caecum at the midline
Features in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia
Malrotation
def: Hirschsprung’s
Absence of ganglion cells from myenteric and submucosal plexuses
Delayed passage of meconium and abdominal distension
?Hirschsprung’s
Dx of Hirschsprung’s
Full thickness rectal biopsy
Treatment of Hirschsprung’s
Rectal washouts initially, then anorectal pull through procedure
Usually delayed passage of meconium and abdominal distension
Majority have cystic fibrosis
?meconium ileus
Ix in meconium ileus
XR may not show a fluid level as meconium is viscid.
PR contrast studies may dislodge meconium plugs
Mx of meconium ileus
PR contrast
NG n-acetyl cysteine
Surgery
Jaundice >13d
Increased conjugated bilirubin
Neonate
Biliary atresia
Treatment of Biliary atresia
Urgent Kasai procedure
Kasai proceudre
Hepatoportoenterostomy.
Prematurity is the main risk factor
Early features include abdominal distension and passage of bloody stools
X-Rays may show pneumatosis intestinalis and evidence of free air
Increased risk when empirical antibiotics are given to infants beyond 5 days
Treatment is with total gut rest and TPN, babies with perforations will require laparotomy
NEC
An injured axillary artery is ligated between the thyrocervical trunk of the subclavian and subscapular artery. Subsequent collateral circulation is likely to result in reversal of blood flow in which of the vessels listed below?
Circumflex scapular artery
Transverse cervical artery
Posterior intercostal arteries
Suprascapular artery
Profunda brachii artery
It’s an easy question really, we just made the wording difficult (on purpose). It is asking about the branches of the axillary artery and knowledge of the fact that there is an extensive collateral network around the shoulder joint. As a result, the occlusion of the proximal aspect of the circumflex humeral inflow (from the axillary artery) ceases and there is then retrograde flow through it from collaterals.
The circumflex scapular artery is a branch of the subscapular artery and normally supplies the muscle on the dorsal aspect of the scapula. In this instance, flow is reversed in the circumflex scapular and subscapular arteries forming a collateral circulation around the scapula.
Extent of the axillary artery
Outer border of first rib to the lower border of teres major
Where is the first part of the axillary artery
Above pec minor
Where is the second part of the axillary artery
posterior to pec minor
Where is the third part of the axillary artery?
Inferior to pec minor
Relations of the first part of the axillary artery
Enclosed within the cords of the brachial plexus.
Contained with axillary vein in the axillary sheath, a prolongation of the prevertebral fascia.
Posteriomedial to the sheath lies the first intercostal space, the superior aspect of serratus anterior and the LTN.
Within the sheath, the medial cord of the brachial pexus lies behind the aretery.
Anteriorly is the clavipectoral fascia.
Superolaterally lie the lateral and posterior cords of the brachial plexus.
Inferomedially= axillary vein
Relations of the second part of the axillary artery
Posterior to it is the posterior cord of the brachial plexus and subscapularis muscle.
Anteriorly lie pectoralis minor and major
Lateral cord of the brachial plexus lies laterally.
Medially lies the medial cord of the brachial plexus, here it separates the artery from the vein
Relations of the third part of the axillary aretery
Posterior: subscapularis, lat dorsi, teres major.
Interspersed between the vessel and subscapularis are the axillary and radial nerves.
Anterior to the vessel is the medial root of the median nerve.
Laterally lies the median and musculocutaneous nerves and coarcobrachialis.
Axillary vein is related medially.
What are the branches of the axillary artery
Highest thoracic artery
Thoraco-acromial artery
Lateral thoracic artery
Subscapular artery
Posterior circumflex humeral
Anterior circumflex humeral
A 20 year old lady presents with pain on the medial aspect of her thigh. Investigations show a large ovarian cyst. Compression of which of the nerves listed below is the most likely underlying cause?
Sciatic
Genitofemoral
Obturator
Ilioinguinal
Femoral cutaneous
The cutaneous branch of the obturator nerve is frequently absent. However, the obturator nerve is a recognised contributor to innervation of the medial thigh and large pelvic tumours may compress this nerve with resultant pain radiating distally.
Obturator nerve roots
Ventral parts of L2, L3, L4
L3 forms the main contribution and second lumbar branch is occasionally absent.
Course of the obturator
Branches unite in the substance of psoas major and descend vertically in its posterior part to emerge from its medial border at the lateral margin of the sacrum
It crosses the sacroiliac joint to enter lesser pelvis, descending on obturator internus to enter the obturator groove.
Relations of obturator in the lesser pelvis
Lateral to the II vessels and uretur.
Joined by obturator vessels lateral to the ovary or ductus deferens
Motor functions of obturator
Muscles supplied: external obturator, adductor longus, adductor brevis, adductor magnus (not the lower part- sciatic nerve), gracilis
Cutaneous function of obturator
Cutaneous branch often absent.
When present it passes between gracilis and adductor longus near the middle part of the thigh and supplies the skin and fascia of the distal 2/3rds of the medial aspect
Contents of the obturator canal
Obturator artery
Vein
Nerve which divides into anterior and posterior nerve
A 73 year old man presents with a tumour at the central aspect of the posterior third of the tongue. To which of the following lymph node groups is it most likely to metastasise?
Submental
Submandibular
Ipsilateral deep cervical nodes
Contralateral deep cervical nodes
Bilateral deep cervical nodes
Posterior third tumours of the tongue commonly metastasise to the bilateral deep cervical lymph nodes
Tumours of the posterior third of the tongue will typically metastasise early and bilateral nodal involvement is well recognised, this is most often true of centrally located tumours and those adjacent to the midline as the lymph vessels may cross the median plane at this location.
Outline the lymphatic drainage of the anterior 2/3rds of the tongue
Shows only minimal communication of lymphatics so metastasis to ipsilateral nodes is usual
Lymphatic drainage of the posterior third of the tongue
Has communicating networks, as a result bilateral nodal metastases are more common in this area
Lymphatic drainage of the tip of the tongue
Submental nodes and from there to deep cercival nodes
Lymphatic drainage from the mid portion of the tongue
Submandibular nodes and then to the deep cervical nodes.
Mid tongue tumors that are laterally located will usually drain to ipsilateral deep cervical nodes.
Those from more central regions may have bilateral deep cervical nodal involvement
A 6 month old child is brought to the surgical clinic because of non descended testes. What is the main structure that determines the descent path of the testicle?
Processus vaginalis
Cremaster
Mesorchium
Inguinal canal
Gubernaculum
The gubernaculum is a ridge of mesenchymal tissue that connects the testis to the inferior aspect of the scrotum. Early in embryonic development the gubernaculum is long and the testis are located on the posterior abdominal wall. During foetal growth the body grows relative to the gubernaculum, with resultant descent of the testis.
A 21 year old man undergoes surgical removal of an impacted 3rd molar. Post operatively, he is noted to have anaesthesia on the anterolateral aspect of the tongue. What is the most likely explanation?
Injury to the hypoglossal nerve
Injury to the inferior alveolar nerve
Injury to the lingual nerve
Injury to the mandibular branch of the facial nerve
Injury to the glossopharyngeal nerve
The lingual nerve is closely related to the third molar and up to 10% of patients undergoing surgical extraction of these teeth may subsequently develop a lingual neuropraxia. The result is anaesthesia of the ipsilateral anterior aspect of the tongue. The inferior alveolar nerve innervates the teeth themselves.
What is the function of the lingual nerve
Sensory nerve to the mucosa of the presulcal part of the tongue, floor of mouth and mandibular lingual gingivae
Whence does the lingual nerve arise?
Posterior trunk of the mandibular nerve (branch of trigeminal)
Theme: Transplantation
A.Xenograft
B.Allograft
C.Autograft
D.Isograft
Please select the type of transplantation that has occurred in the situation described. Each option may be used once, more than once or not at all.
A 38 year old lady donates her kidney to her identical twin sibling.
Isograft
Theme: Causes of dysphagia
A.Benign oesophageal stricture
B.Globus
C.Carcinoma of the oesophagus
D.Achalasia
E.Hiatus hernia
F.Pharyngeal pouch
G.Oesophageal web
H.Oesophageal atresia
Please select the the most likely cause of swallowing difficulties for the scenarios described. Each option may be used once, more than once or not at all.
13.A 55 year old man presents with a history of progressive dysphagia over the past 4 weeks. For the preceding 5 years he had regularly attended his general practitioner with symptoms of dyspepsia and reflux.
A 40 year old man presents with symptoms of dysphagia that have been present for many months. His investigations demonstrate lack of relaxation of the lower oesophageal sphincter during swallowing.
A 4 year old presents with sudden onset of dysphagia. He undergoes an upper GI endoscopy and a large bolus of food is identified in the mid oesophagus. He has no significant history, other than a tracheo-oesophageal fistula repair soon after birth.
Carcinoma of the oesophagus
Theme from January 2013 Exam
A short history of progressive dysphagia in a middle aged man who has a background history of reflux is strongly suggestive of malignancy. Long standing reflux symptoms may be suggestive of a increased risk of developing Barretts oesophagus. Note that not all patients with Barretts transformation alone are symptomatic.
Achalasia
Patients with dysphagia will usually undergo an upper GI endoscopy as a first line investigation. Where this investigation is normal, the next stage is to perform studies assessing oesophageal motility. These comprise fluroscopic barium swallows and oesophageal manometry and pH studies. Lack of sphincter relaxation suggests achalasia (pressures are usually high).
Benign oesophageal stricture
Children with tracheo-oesophageal fistulas will commonly develop oesophageal strictures following repair. These may require regular dilations throughout childhood.
How can the causes of dysphagia be classified?
Extrinsic
Oesophageal wall
Intrinsic
Neurological
Extrinsic causes of dysphagia
Mediastinal masses
Cervical spondylosis
Oesophageal wall causes of dysphagia
Achalasia
Diffuse oesophageal spasm
Hypertensive LOS
Intrinsic causes of dysphagia
Tumours
Strictures
Oesophageal web
Schatzki rings
Schatzki ring
A Schatzki ring or Schatzki–Gary ring is a narrowing of the lower esophagus that can cause difficulty swallowing (dysphagia). The narrowing is caused by a ring of mucosal tissue (which lines the esophagus) or muscular tissue.[1] A Schatzki ring is a specific type of “esophageal ring”, and Schatzki rings are further subdivided into those above the esophagus/stomach junction (A rings),[2] and those found at the squamocolumnar junction in the lower esophagus (B rings).[3]
Patients with Schatzki rings can develop intermittent difficulty swallowing or, more seriously, a completely blocked esophagus. The ring is named after the German-American physician Richard Schatzki.
Neurgolocial causes of dysphagia
CVA
PD
MS
Brainstem pathology
MG
Ix in dysphagia
Upper GI endoscopy
Motility disorders best appreciated with fluorscopic swallowing studies
FBC
Ambulatory oesophageal pH and manometry studies amy be used
A 48 year old lady presents with discomfort in the right breast. On examination she has a discrete soft fluctuant area in the upper outer quadrant of her right breast. A mammogram is performed and a “halo sign” is seen by the radiologist.
A.Mondors disease
B.Duct ectasia
C.Periductal mastitis
D.Lactational breast abscess
E.Fibroadenoma
F.Breast cyst
G.Intraductal papilloma
H.Atypical ductal hyperplasia
I.Radial scar
Breast cyst
Lesions such as breast cysts compress the underlying fat and produce a radiolucent area (halo sign). If symptomatic, these cysts should be aspirated.
How can fibroadenomas be classified?
Juvenile
Common
Giant
Mx of fibroadenomas
>4cm- biopsy
<3cm- consider watch and waiting.
Natural history of fibroadenomas
10% increase in size
30% regress
Remainder stay the same.
Changes during pregnancy
What proportion of breast lumps are accounted for by fibroadenomas?
13%
What propotion of breast lumps are accounted for by breast cysts
15%
In what age groups are breast cysts most frequent
Perimenopausal females
What is the most important structure involved in supporting the uterus?
Round ligament
Broad ligament
Uterosacral ligaments
Cardinal ligaments
Central perineal tendon
The central perineal tendon provides the main structural support to the uterus. Damage to this structure is commonly associated with the development of pelvic organ prolapse, even when other structures are intact.
Blood supply of the uterus
Uterine body is via the uterine artery (branch of IIA), uterine artery passes from the inferior aspect of the uterus (lateral to the cervix) and runs alongsisde the uterus
Frequently anastomoses with ovarian artery superiorly
Supporting ligaments of the uterus
Central perineal tendon
Lateral cervical
Round
Uterosacral ligaments
A 76 year old woman with a body weight of 50 kg is undergoing an excision of a lipoma from her forehead. It is the first time the senior house officer has performed the procedure. He administers 30ml of 2% lignocaine to the area. The procedure is complicated by bleeding and the patient experiences discomfort, a further 10ml of the same anaesthetic formulation is then administered. Over the following 5 minutes the patient complains of tinnitus and becomes drowsy. Which of the drugs listed below should be administered?
Temazepam
Lorazepam
Naloxone
Intralipid 20%
Sodium bicarbonate 20%
Local anaesthetic toxicity treatment = Intralipid
Intralipid is indicated for the treatment of local anaesthetic toxicity. In this case the safe dose of local anaesthetic has been exceeded and is thus this lady’s symptoms are likely to represent toxicity.
Pathophysiology of local anaesthetic toxicity
LA not only exert a membrane stabilising effect on peripheral nerves but also act on excitable membranes within CNS and heart
Sensory neurones in CNS are suppressed before the motor ones
Early symptoms are typically those of circumoral paresthesia and tinnitus-> falling GCS and coma
Management of local anaesthetic toxicity
Stop injecting agent
High flow O2
CV monitoring
Lipid emulsion (intralipid 20%) at 1.5ml/kg over 1 minute as a bolus
Consider infusion at 0.25ml/kg/minute
If toxicity due to prilocaine then administer methylene blue
Lignocaine dose
3mg/Kg
7mg/Kg with adrenaline
Dose of bupivicane
2mg/Kg
2mg/Kg with adrenaline
Dose of prilocaine
6mg/kg
9mg/kg with adrenaline
Treatment of prilocaine toxicity
Methylene blue
A 38 year old lady presents with a recent episode of renal colic. As part of her investigations the following results are obtained:
Corrected Calcium3.84 mmol/l
PTH88pg/ml (increased)
Her serum urea and electrolytes are normal.
What is the most likely diagnosis?
Carcinoma of the bronchus
Secondary hyperparathyroidism
Primary hyperparathyroidism
Tertiary hyperparathyroidism
Carcinoma of the breast
In this situation the most likely diagnosis is primary hyperparathyroidism. The question mentions that serum urea and electrolytes are normal, which makes tertiary hyperparathyroidism unlikely.
Most common causes of primary hyperparathyroidism
Solitary adenoma
Causes of primary hyperparathyroidsim
80%: solitary adenoma
15%: hyperplasia
4%: mulitple adenoma
1%: carcinoma
Polydipsia, polyuria
Peptic ulceration/constipation/pancreatitis
Bone pain/fracture
Renal stones
Depression
HTN
?hypercalcaemia
Associations of primary hyperparathyroidism
HTN
MEN1 and 2
Raised Ca
Low P
PTH may be raised or normal
?primary hyperparathyroidism
Biochemistry of primary hyperparathyroidism
Raised Ca, low P
PTH may be raised or normal
Scan in primary hyperparathyroidism
Technetium-MIBI subtraction scan
Which Hodgkin’s lymphoma does not have Reed-Sternberg cells?
Nodular lymphocyte predominant Hodgkin lymphoma
A 24 year old man is diagnosed as having Hodgkins lymphoma. Which subtype is associated with the most favorable prognosis?
Nodular sclerosing
Lymphocyte depleted
Nodular lymphocyte predominant
Classical lymphocyte predominant
Mixed cellularity
The classical lymphocyte predominant variant has the most favorable prognosis. Nodular lymphocyte predominant disease is a very different disease entity and does not have the same favorable prognosis.
Which Hodgkin’s lymphoma subtype has the worst prognosis?
Lymphocyte depleted
What are poor prognostic patient demographic factors in Hodgkin’s lymphoma?
Advancing age
Male sex
Advanced stage disease
Theme: Proctology
A.Fissure in ano
B.Fistula in ano
C.Rectal prolapse
D.Juvenile polyps
E.Rectal adenoma
F.Intersphincteric abscess
G.Haemorrhoids
Please select the most likely underlying cause for the presentations described. Each option may be used once, more than once or not at all.
A 21 year old female presents with a 24 hour history of increasingly severe ano-rectal pain. On examination she is febrile and the skin surrounding the anus looks normal. She did not tolerate an attempted digital rectal examination.
A 21 year old male presents with a 4 week history of frank, bright red, rectal bleeding. This typically occurs post defecation into the toilet pan. He has a long standing history of constipation and a previous fissure in ano. On examination the skin surrounding the anus is normal and digital rectal examination is normal.
A 21 year old lady presents with a 6 month history of an offensive discharge from the anus. She is otherwise well, but is increasingly annoyed at the need to wear pads. On examination she has a small epithelial defect in the 5 o’clock position, approximately 3cm from the anal verge.
The presence of fever and severe pain makes an abscess more likely than a fissure. Although fissures may be painful they do not, in themselves, cause fever. The usual management for this condition is examination of the ano-rectum under general anaesthesia and drainage of the abscess.
Haemorrhoids are a common cause of bright red rectal bleeding. The bleeding is typically painless. A history of constipation is usual and may have been previously associated with a fissure (though this is less common). Haemorrhoids are not always associated with external features and digital rectal examination is usually unremarkable.
Fistulas usually occur following previous ano-rectal sepsis. The discharge may be foul smelling and troublesome. Patients should be listed for examination under anaesthesia. Fistulas which are low and have little or no sphincter involvement are usually laid open.
Location of haemorrhoids?
3, 7, 11 o’clock
Internal or external
Location of fissure in ano?
Midline 6 (posterior midine 90%) and 12 o’clock position
Distal to dentate line
Triad in chronic fissure
Ulcer
Sentinal pile
Enlarged anal papillae
?6/52
Positions of anorectal abscess?
Perianal
Ischiorectal
Pelvirectal
Intersphincteric
Location of anal fistula
Usually due to previous ano-rectal abscess
Intersphincteric
Transsphincteric
Suprasphincteric
Extrasphincteric
What determines fistula location?
Goodsall’s rule
Goodsall’s rule
Fistulas with an external opening in relation to the anterior half of the anus is of the direct type i.e. straight line
Fistulas with external openings in relation to the posterior half of the rectus have a curved track, may be of horseshoe type, open in the midline posteriorly and may present with multiple external opening all connected to a single internal opening
What is an issue with external rectal prolapse
Can ulcerate and impair continence in the long term.
Associated with chronic straining and constipation
Histology shows mucosal thickening.
Lamina propria replaced with collagen and smooth muscle (fibromuscular obliteration)
Solitary rectal ulcer
What is the most common type of anal neoplasm?
Squamous cell carcinoma
What are the treatments for rectal prolapse
Reduce it acutely
Delormes procedure
Altmeirs procedure
Rectopexy
Delormes procedue
Excision of rectal mucosa and plication (high recurrence rates)
May be used for external prolapse
Altmeir proecdure
Resects colon via the perineal route but carries the risk of anastomotic leak
Used for rectal prolapse
Rectopexy
Abdominal procedure in which the rectum is elevated and usually supported at the level of the sacral promonotory
Post operative constipation may be reduced by limiting the dissection to the anterior plane
Typically painful PR bleeding (bright red).
Nearly always in the posterior midline.
Usually solitary.
Fissure in ano
Treatment of fissure in ano
Stool softeners
Topical diltiazem
If treatments fail then botulinum toxin
Females who do not respond to botulinum toxin should under go ano rectal manometry studies and endo anal USS prior to being offered surgery
A surgical resection specimen is analysed histologically. The pathologist comments that at the periphery of the resected specimen, oxyphil cells are identified. In which of the structures listed below are these cells typically found?
Thymus
Thyroid gland
Parathyroid gland
Lymph node
Adrenal gland
Oxyphil cells are typically found in parathyroid glands
Location of the parathyroid gland
4 glands
Posterior to the thyroid
Lie within the pretracheal fascia
Embryology of the parathyroids
Develop from extermitites of the third and fourth pharyngeal pouches
Those derived from the fourth pharyngeal pouch are superior and associated with thyroid gland.
Those derived from third pharyngeal pouch lie more inferiorly and may become associated with thymus
Blood supply of the parathyroids
Derived from the inferior and superior thyroid arteries
Rich anastomosis between the two vessels.
Venous drainage into the thyroid veins
Lateral relation of the parathyroid
Common carotid
Medial relations of the parathyroids
Recurrent laryngeal nerve, trachea
Anterior relations of the parathyroid
Thyroid
Posterior relations of the parathyroid
Pretracheal fascia
Represents the wave of depolarization that spreads from the SA node throughout the atria
Lasts 0.08 to 0.1 seconds (80-100 ms)
The isoelectric period immediately after represents the time in which the impulse is traveling within the AV node
P wave
Time from the onset of the P wave to the beginning of the QRS complex
Ranges from 0.12 to 0.20 seconds in duration
Represents the time between the onset of atrial depolarization and the onset of ventricular depolarization
PR interval
Represents ventricular depolarization
Duration of is normally 0.06 to 0.1 seconds
QRS
Normal P wave length
0.08 to 0.1 seconds
Normal PRI
0.12 to 0.2
QRS
0.06-0.1
Isoelectric period following the QRS
Represents period which the entire ventricle is depolarized and roughly corresponds to the plateau phase of the ventricular action potential
ST segment
Represents ventricular repolarization and is longer in duration than depolarization
A small positive U wave may follow the T wave which represents the last remnants of ventricular repolarization.
T wave
Represents the time for both ventricular depolarization and repolarization to occur, and therefore roughly estimates the duration of an average ventricular action potential.
QT interval
What is the QTc
At high heart rates, ventricular APs shorten in duration, which decreases the QT interval. The QT interval is divided by the square root of the R-R interval.
This allows an assessment of the QT interval that is independent of heart rate
Normal QTc
0.44
A 45 year old male has alcoholic cirrhosis and decompensated liver failure, which of the following clotting factors is least likely to be affected?
Factor V
Factor VII
Factor IX
Factor VIII
Factor XI
Factor VIII is synthesised in the endothelial cells of the liver rather than the liver itself and therefore is less prone to the effects of hepatic dysfunction.
Affects synthesis of factors 2,7,9,10
Warfarin
Affects Factors 1,2,5,8,11
DIC
Affects Factors 1,2,5,7,9,10,11
Liver disease
Prevents activation factors 2,9,10,11
Heparin
APTT increased
PT normal
Bleeding time normal
Haemophilia
APTT increased
PT normal
Bleeding time increased
vWD
APTT increased
PT increased
Bleeding time normal
Vit K deficiency
A 53 year old man undergoes a reversal of a loop colostomy. He recovers well and is discharged home. He is readmitted 10 days later with symptoms of vomiting and colicky abdominal pain. On examination he has a swelling of the loop colostomy site and it is tender. What is the most likely underlying diagnosis?
Haematoma
Intra abdominal adhesions
Anastomotic leak
Anastomotic stricture
Obstructed incisional hernia
In this scenario the most likely diagnosis would be obstructed incisional hernia. The tender swelling coupled with symptoms of obstruction point to this diagnosis. Prompt surgical exploration is warranted. Loop colostomy reversals are at high risk of this complication as the operative site is at increased risk of the development of post operative wound infections.
A 34 year old lady suffers from hyperparathyroidism. The right inferior parathyroid is identified as having an adenoma and is scheduled for resection. From which of the following embryological structures is it derived?
Second pharyngeal pouch
Third pharyngeal pouch
Fourth pharyngeal pouch
First pharyngeal pouch
None of the above
The inferior parathyroid is a derivative of the third pharyngeal pouch. The superior parathyroid originates from the fourth pharyngeal pouch.
A 43 year old lady has recently undergone a wide local excision and sentinel lymph node biopsy for carcinoma of the breast. Of the factors listed below, which will provide the most important prognostic information?
Mitotic number
Grade
Nodal status
Size
Oestrogen receptor status
Nodal status is important because it serves as a marker of tumour metastatic potential. This translates to survival advantages of up to 40% at five years. Both grade and size are of secondary importance as they both less concerning in the absence of nodal involvement.
What is the most common breast carcinoma
Invasive ductal carcinomas
When might a mastectomy be indicated?
Multifocal tumour
Central tumour (central lesions may be managed using breast conserving surgery although this is rarely the case in small breasts)
Large lesion in small breast
DCIS >4cm
Patient choice
When might a wide local excision be indicated
Solitary lesion
Peripheral tumour
Small lesion in large breast
DCIS <4cm
Patient choice
How to caclulate NPI
Tumour size x 0.2 + LN score + grade score
A 23 year old man falls and slips at a nightclub. A shard of glass penetrates the skin at the level of the medial epicondyle, which of the following sequelae is least likely to occur?
Atrophy of the first dorsal interosseous muscle
Difficulty in abduction of the the 2nd, 3rd, 4th and 5th fingers
Claw like appearance of the hand
Loss of sensation on the anterior aspect of the 5th finger
Partial denervation of flexor digitorum profundus
Injury to the ulnar nerve in the mid to distal forearm will typically produce a claw hand. This consists of flexion of the 4th and 5th interphalangeal joints and extension of the metacarpophalangeal joints. The effects are potentiated when flexor digitorum profundus is not affected, and the clawing is more pronounced.More proximally sited ulnar nerve lesions produce a milder clinical picture owing to the simultaneous paralysis of flexor digitorum profundus (ulnar half).
This is the ‘ulnar paradox’, due to the more proximal level of transection the hand will typically not have a claw like appearance that may be seen following a more distal injury. The first dorsal interosseous muscle will be affected as it is supplied by the ulnar nerve.
Origin of the ulnar nerve
C8 T1
Muscles supplied by the ulnar nerve
FCU
FDP
FD minimi
Abductor minimi
Opponens digiti minimi
Adductor pollicis
Interossei
Third and fourth lumbricals
Palmaris brevis
Path of the ulnar nerve
Posteromedial aspect of the upper arm to flexor compartment of the forearm
Then along the ulnar
Passes beneath the flexor carpi ulnaris muscle, then superficially through the flexor retinaculum into the hand
What muscles in the upper arm are supplied by the ulnar nerve?
None
What are the branches of the ulnar nerve
Muscular branch
Palmar cutaneous branch (arises near the middle of the forearm)
Dorsal cutaneous branch
Superficial branch
Deep branch
Muscular branch of the ulnar supplies?
FCU
Medial half of FDP
Palmar cutaneous branch of the ulnar supplies?
Skin on medial part of the palm
Dorsal cutaneous branch of the ulnar supplies
Dorsal surface of the medial part of the hand
Superifical branch of the ulnar supplies
Cutaneous fibres to the anterior surfaces of the medial 1.5 digits
Deep branch of the ulnar supplies
Hypothenar muscles
All of the interoessei
Third and fourth lumbricals
Adductor pollicis
Medial head of flexor pollicis brevis
Damage to ulnar, where?
Wasting and paralysis of intrinsic hand muscles (claw hand)
Wasting and paralysis of hypothenar muscles
Loss of sensation medial 1 and half fingers
At the wrist
Damage to the ulnar, where
Radial deviation of the wrist
Clawing less in 4th and 5th digits
Damage at the elbow
Explain the ulnar paradox
The ulnar nerve also innervates the ulnar (medial) half of the flexor digitorum profundus muscle (FDP). If the ulnar nerve lesion occurs more proximally (closer to the elbow), the flexor digitorum profundus muscle may also be denervated. As a result, flexion of the IP joints is weakened, which reduces the claw-like appearance of the hand.[3] (Instead, the fourth and fifth fingers are simply paralyzed in their fully extended position.) This is called the “ulnar paradox” because one would normally expect a more proximal and thus debilitating injury to result in a more deformed appearance.
Simply put, as reinnervation occurs along the ulnar nerve after a high lesion, the deformity will get worse (FDP reinnervated) as the patient recovers - hence the use of the term “paradox”. A simple way to remember this is: ‘the closer to the Paw, the worse the Claw’.
Theme: Abdominal stomas
A.End ileostomy
B.End colostomy
C.Loop ileostomy
D.Loop colostomy
E.End jejunostomy
F.Loop jejunostomy
G.Caecostomy
For each of the following scenarios, please select the most appropriate type of stoma to be constructed. Each option may be selected once, more than once or not at all.
A 56 year old man is undergoing a low anterior resection for carcinoma of the rectum. A primary anastomosis is planned.
A 23 year old man with uncontrolled ulcerative colitis is undergoing an emergency sub total colectomy.
A 63 year old women presents with large bowel obstruction. On examination she has a carcinoma 10cm from the anal verge.
The correct answer is Loop ileostomy
Theme from April 2014 Exam
Colonic resections with an anastomosis below the peritoneal reflection may have an anastomotic leak rate (both clinical and radiological) of up to 15%. Therefore most surgeons will defunction such an anastomosis to reduce the clinical severity of an anastomotic leak. A loop ileostomy will achieve this end point and is relatively easy to reverse.
The correct answer is
Following a sub total colectomy the immediate surgical options include an end ileostomy or ileorectal anastomosis. In the emergency setting an ileorectal anastomosis would be unsafe.
The correct answer is Loop colostomy
Large bowel obstruction resulting from carcinoma should be resected, stented or defunctioned. The first two options typically apply to tumours above the peritoneal reflection. Lower tumours should be defunctioned with a loop colostomy and then formal staging undertaken prior to definitive surgery. An emergency attempted rectal resection carries a high risk of involvement of the circumferential resection margin and is not recommended.
Use of gastrostomy
Gasrtic decompression or fixation
Feeding
Use of loop jejunostomy
Seldom used as very high output
May be used following emergency laparotomy with planned early closure
Use of percutaneous jejunostomy
Usually performed for feeding purposes and site in the proximal bowel
Use of loop ileostomy
Defunctioning of colon e.g. following rectal cancer surgery
Does not decompress colon if ileocaecal valve competenet
Use of end ileostomy
Usually following complete excision of colon or where ileo-colic anastomosis is not planned.
May be used to defunction colon but reversal is more difficult
Use of end colostomy
Where a colon is diverted or resected and anastomosis is not primarily achievable or desirable
Use of loop colostomy
To defunction a distal segment of colon.
Since both lumens are present, the distal lumen acts as a vent
Use of caecostomy
Stoma of last resort where loop colostomy is not possible
Use of mucous fistula
To decompress a distal segment of bowel following colonic diversion or resection
Where closure of distal resection margin is not safe or achievable
A 56 year old man is undergoing a superficial parotidectomy for a pleomorphic adenoma. During the dissection of the parotid, which of the following structures will be encountered lying most superficially?
Facial nerve
External carotid artery
Occipital artery
Maxillary artery
Retromandibular vein
Most superficial structure on the parotid gland = facial nerve
The facial nerve is the most superficial structure in the parotid gland. Slightly deeper to this lies the retromandibular vein, with the arterial layer lying most deeply.
Location of the parotid gland
Overlying the mandibular ramus, anterior and inferior to the ear
Salivary duct of the parotid gland
Crosses the masseter, pierces the buccinator and drains adjacent to the second upper molar tooth (Stensen’s duct)
What are the structures passing through the parotid?
Facial nerve
External carotid artery
Retromandibular vein
Auriculotemporal nerve
Branches of the facial nerve
Ten Zulus Buggered My Car
Temporal
Zygomatic
Buccal
Mandibular
Cervical
Anterior relations of the parotid
Masseter
Medial pterygoid
Superficial temporal and maxillary artery
Stylomandibular ligament
Posterior relations of the parotid
Posterior belly of digastric muscle
Sternocleidomastoid
Stylohyoid
ICA
Mastoid process
Styloid process
Arterial supply of the parotid
Branches of ECA
Venous drainage of the parotid
Retromandibular vein
Lymphatic drainage of the parotid
Deep cervical nodes
Parasympathetic innervation of the parotid
Stimulation produces
Secretomotor
Water rich, serous saliva
Sympathetic innervation of the parotid
Stimulation leads to
Superior cervical ganglion
Secretion of a low volume, enzyme-rich saliva
Sensory supply of the parotid
Greater auricular nerve
A 43 year old man is stabbed outside a nightclub. He suffers a transection of his median nerve just as it leaves the brachial plexus. Which of the following features is least likely to ensue?
Ulnar deviation of the wrist
Complete loss of wrist flexion
Loss of pronation
Loss of flexion at the thumb joint
Inability to oppose the thumb
Loss of the median nerve will result in loss of function of the flexor muscles. However, flexor carpi ulnaris will still function and produce ulnar deviation and some residual wrist flexion. High median nerve lesions result in complete loss of flexion at the thumb joint.
A 78 year old man is due to undergo an endarterectomy of the internal carotid artery. Which of the following nervous structures are most at risk during the dissection?
Recurrent laryngeal nerve
Sympathetic chain
Hypoglossal nerve
Phrenic nerve
Lingual nerve
During a carotid endarterectomy the sternocleidomastoid muscle is dissected, with ligation of the common facial vein and then the internal jugular is dissected exposing the common and the internal carotid arteries. The nerves at risk during the operation include:
Hypoglossal nerve
Greater auricular nerve
Superior laryngeal nerve
The sympathetic chain lies posteriorly and is less prone to injury in this procedure.
What nerves are at risk during a carotid endarterectomy
Hypoglossal
Greater auricular
Superior laryngeal nerve
Where does the internal carotid form
From the common carotid opposite the upper border of the thyroid cartilage
Extends superiorly to enter the skull via the carotid canal
Where does the internal carotid divide into the anterior and middle cerebral arteries
After it passes through the cavernous sinus, above which it divides into the anterior and middle cerebral arteries
What are the posterior relations of the carotid in the neck?
Longus capitis
Pre-vertebral fascia
Sympathetic chain
Superior laryngeal nerve
What are the medial relations of the ICA in the neck
External carotid
Wall of pharynx
Ascending pharyngeal artery
What are the lateral relations of the ICA in the neck
IJV (moves posteriorly at entrance to the skull)
Vagus nerve (most posterolaterally)
What are the anterior relations of the ICA in the neck
Sternocleidomastoid
Lingual and facial veins
Hypoglossal nerve
What are the relations of the ICA in the carotid canal
Internal carotid plexus
Cochlea and middle ear cavity
Trigeminal ganglion (superiorly)
Leaves canal above the foramen lacerum
Path of the ICA in the cranial cavity
Bends sharply forward in the cavernous sinus
Abducens lies close to its inferolateral aspect.
The oculomotor, trochlear, ophthalmic and usually the maxillary nerves lie in the lateral wall of the sinus.
Near the SOF it turns posteriorly and pass posteromedially to pierce the roof of the cavernous sinus inferior to the optic nerve
It then passes between the optic and oculomotor nerves to terminate below the anterior perforated substance by dividing into the anterior and middle cerebral arteries
What are the branches of the ICA
Anterior and MCA
Ophthalmic artery
PComm
Anterior choroid artery
Meningeal arteries
Hypophyseal arteries
Which of the structures listed below articulates with the head of the radius superiorly?
Capitulum
Trochlea
Lateral epicondyle
Ulna
Medial epicondyle
The head of the radius articulates with the capitulum of the humerus.
Upper end of the radius
Articular cartilage covers medial > lateral side
Articulates with radial notch of the ulna by the annular ligament
Muscle attachment: biceps brachii at the tuberosity
Muscles attached to the upper third of the body of the radius
Supinator
FDS
FPL
Muscles attached to the middle third of the body of the radius
Pronator teres
Muscles attached to the lower quarter of the body of the radius
Pronator quadratus
Tendon of supinator longus
Relations of the lower end of the radius?
Quadrilateral
Anterior surface: capsule of wrist joint
Medial surface: head of ulna
Lateral surface: ends in the styloid process.
Posterior surface has 3 grooves containing various tendons
What are the tendons in the grooves of the radius?
Tendon of ECR longus and brevis
Tendon of EPL
Tendon of extensor indicis
Theme: Management of urinary tract calculi
A.Nephrectomy
B.Open ureteric exploration
C.Extra corporeal shock wave lithotripsy
D.Percutaneous nephrostomy
E.Pyeloplasty
F.Conservative management
G.Percutaneous nephrolithotomy
Please select the most appropriate management for the scenario given. Each option may be used once, more than once or not at all.
A 23 year old male is admitted with left sided loin pain and fever. His investigations demonstrate a left sided ureteric calculi that measures 0.7cm in diameter and associated hydronephrosis.
A 23 year old man is admitted with left sided loin pain that radiates to his groin. His investigations demonstrate a 1cm left sided calculus within the renal pelvis.
A 30 year old male presents with left sided loin pain. His investigations demonstrate a large left sided staghorn calculus that measures 2.3cm in diameter.
An obstructed, infected system is an indication for urgent decompression. This may be achieved by ureteroscopy or nephrostomy. In addition to this the patient should also receive broad spectrum, intravenous antibiotics.
Stones with a total volume of less than 2cm can be considered for lithotripsy. If it is impacted in the upper ureter then some may consider a ureteroscopy.
Large, proximal stones are generally best managed with a percutaneous nephrolithotomy. The use of lithotripsy has low clearance rates. Where stones remain after the initial procedure a repeat percutaneous nephrolithotomy is generally preferred over follow up lithotripsy.
When is urgent treatment of ureteric stones indicated
Ureteric obstruction
Renal developmental abnormality
Previous renal transplant.
Process of shockwave lithotripsy
A shock wave is generated external to the patient, internally cavitation bubbles and mechanical stress lead to stone fragmentation. The passage of shock waves can result in the development of solid organ injury. Fragmentation of larger stones may result in the development of ureteric obstruction. The procedure is uncomfortable for patients and analgesia is required during the procedure and afterwards.
Ureteroscopy management of stones
A ureteroscope is passed retrograde through the ureter and into the renal pelvis. It is indicated in individuals (e.g. pregnant females) where lithotripsy is contraindicated and in complex stone disease. In most cases a stent is left in situ for 4 weeks after the procedure.
Process of PCNL
In this procedure access is gained to the renal collecting system. Once access is achieved, intra corporeal lithotripsy or stone fragmentation is performed and stone fragments removed.
Treatment options for stones:
Stone burden of less than 2cm in aggregate
Stone burden of less than 2cm in pregnant females
Complex renal calculi and staghorn calculi
Ureteric calculi less than 5mm
Lithotripsy
Ureteroscopy
Percutaneous nephrolithotomy
Theme: Head and neck lumps
A.Branchial cyst
B.Cystic hygroma
C.Carotid body tumour
D.Lymphadenopathy
E.Adenolymphoma of the parotid
F.Pleomorphic adenoma of the parotid
G.Submandibular tumour
H.Thyroglossal cyst
I.Thoracic outlet syndrome
J.Submandibular gland calculus
A 60 year old Tibetan immigrant is referred to the surgical clinic with a painless neck swelling. On examination, it is located on the left side immediately anterior to the sternocleidomastoid muscle. There are no other abnormalities to find.
A 40 year old woman presents as an emergency with a painful mass underneath her right mandible. The mass has appeared over the previous week with the pain worsening as the lump has increased in size. On examination, there is a 4cm mass underneath her mandible, there is no associated lymphadenopathy.
A 73 year old male smoker is referred to the clinic by his GP. On examination he has a 3cm soft mass immediately anterior to his ear. It has been present for the past five years and is otherwise associated with no symptoms.
Carotid body tumours typically present as painless masses. They may compress the vagus or hypoglossal nerves with symptoms attributable to these structures. Over 90% occur spontaneously and are more common in people living at high altitude. In familial cases up to 30% may be bilateral. Treatment is with excision.
The sub mandibular gland is the most common site for salivary calculi. Patients will usually complain of pain, which is worse on eating. When the lesion is located distally the duct may be laid open and the stone excised. Otherwise the gland will require removal.
Warthins tumours (a.k.a. adenolymphoma) are commoner in older men (especially smokers). They are the second commonest benign tumour of the parotid gland, they may be bilateral. They are soft and slow growing and relatively easy to excise. Pleomorphic adenomas typically present in females aged between 40 - 60 years.
By far the most common cause of neck swellings. There may be a history of local infection or a generalised viral illness
Reactive lymphadenopathy
Rubbery, painless lymphadenopathy
The phenomenon of pain whilst drinking alcohol is very uncommon
There may be associated night sweats and splenomegaly
Lymphoma
May be hypo-, eu- or hyperthyroid symptomatically
Moves upwards on swallowing
Thyroid swelling
More common in patients < 20 years old
Usually midline, between the isthmus of the thyroid and the hyoid bone
Moves upwards with protrusion of the tongue
May be painful if infected
Thyroglossal cyst
More common in older men
Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
Usually not seen, but if large then a midline lump in the neck that gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough
Pharyngeal pouch
A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side
Most are evident at birth, around 90% present before 2 years of age
Cystic hygroma
An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx
Develop due to failure of obliteration of the second branchial cleft in embryonic development
Usually present in early adulthood
Branchial cyst
More common in adult females
Around 10% develop thoracic outlet syndrome
Cervical rib
Pulsatile lateral neck mass which doesn’t move on swallowing
Carotid aneurysm
Which of the following fascial structures encases the apex of the lungs?
Waldeyers fascia
Sibsons fascia
Pretracheal fascia
Clavipectoral fascia
None of the above
Sibson’s fascia overlies the apices of both lungs
The suprapleural fascia (Sibson’s fascia) runs from C7 to the first rib and overlies the apex of both lungs.It lies between the parietal pleura and the thoracic cage.
General lung anatomy
Right lung composed of 3 lobes, divided by the oblique and transverse fissures.
Left lung has two lobes divided by the oblique fissure.
Apex is approximately 4cm superior to the sterno-costal joint of the first rib.
Immediately below this is a sulcus created by the subclavian artery.
What are the peripheral contact points of the lung
Base: diaphragm
Costal surface: corresponds to the cavity of the chest
Mediastinal surace: contacts the mediastinal pleura. Has the cardiac impression. Above and behind this concavity is a triangular depression where the structures that form the root of the lung enter and leave (i.e. hilum)
These are invested by viscus, which below the hilum and behind the pericardial impression forms the pulmonary ligament
Outline the relations of the right lung
Above hilum is the azygos. Superior to this is the groove for the SVC and right inominate vein.
Behind this and nearer the apex is the groove for the inominate artery.
Behind the attachment of the pulmonry ligament is a vertical groove for the oesophagus.
In front and to the right of the lower part of the oesophageal groove is a deep concavity for the extracardiac portion of the IVC.
The root of the right lung lies behind the SVC and the RA and below the azygos vein.
A 12 year old child is admitted with a 12 hour history of colicky right upper quadrant pain. On examination the child is afebrile and is jaundiced. The abdomen is soft and non tender at the time of examination. What is the most likely cause?
Infectious hepatitis
Acute cholecystitis
Cholangitis
Hereditary spherocytosis
Gilberts syndrome
Cholecystitis is unlikely in the absence of focal tenderness
Theme from September 2012 Exam
The child is most likely to have hereditary spherocytosis. In these individuals there may be disease flares precipitated by acute illness. They form small pigment stones. These may cause biliary colic and some may require cholecystectomy.
Gilbert’s syndrome is an inherited condition causing unconjugated hyperbilirubinaemia. Patients may have jaundice or be asymptomatic. The other LFTs are normal and Gilbert’s may be confirmed with a fasting test or Nicotinic acid test. There is no need for treatment as it is a benign condition.
Most common disorder of the red cell membrane, it has an incidence of 1 in 5000. The abnormally shaped erythrocytes are prone to splenic sequestration and destruction. This can result in hyperbilirubinaemia, jaundice and splenomegaly. In older patients an intercurrent illness may increase the rate of red cell destruction resulting in more acute symptoms.
Severe cases may benefit from splenectomy.
Hereditary Spherocytosis
Theme: Management of biliary disease
A.Acute laparoscopic cholecystectomy
B.Delayed laparoscopic cholecystectomy
C.Percutaneous cholecystostomy
D.Elective cholecystectomy and intra operative cholangiogram
E.Endoscopic retrograde cholangiopancreatography
F.Choledochoduodenostomy
G.Bile duct excision and hepatico-jejunostomy
H.Operative cholecystostomy
A 72 year old lady underwent an open cholecystectomy 12 years previously. She has been admitted since with 2 episodes of cholangitis and stones were retrieved at ERCP. She has just recovered from a further episode of sepsis and MRCP has shown further biliary stones.
A 26 year old women is admitted with acute cholecystitis of 24 hours duration. LFT’s are normal and Ultrasound shows a thick walled gallbladder containing stones.
A 32 year old lady is seen in the outpatients. She has had multiple episodes of biliary colic and ultrasound shows thin walled gallbladder with multiple calculi. Her ALT is slightly raised but other parameters are normal.
A patient with long standing common bile duct stones is at risk of developing duct fibrosis and ductal disproportion. This can result in impaired biliary drainage. Not only may further stones be formed in the bile that is present, but because of the ductal disproportion the tendency will be for the stones to accumulate (rather than pass spontaneously, as would usually be the case post ERCP and sphincterotomy). A biliary bypass procedure is the standard method dealing with this and a choledochoduodenstomy is one procedure that can be used.
This is an ideal case for an acute cholecystectomy, provided that surgery can be undertaken promptly. After 48 -72 hours the patient should receive parenteral antibiotics and delayed cholecystectomy performed.
The easiest option is to perform an intraoperative cholangiogram. It is unlikely to reveal any stones. If is does then either laparoscopic bile duct exploration or urgent ERCP can be performed. An MRCP pre op is an alternative strategy.
Typically history of biliary colic or episodes of chlolecystitis. Obstructive type history and test results.
Gallstones
Usually obstructive and will have Charcot’s triad of symptoms (pain, fever, jaundice)
Cholangitis
Typically painless jaundice with palpable gallbladder (Courvoisier’s Law)
Pancreatic cancer
Usually follows long term use of TPN and is usually painless with non obstructive features
TPN (total parenteral nutrition) associated jaundice
Depending upon the type of injury jaundice may be of sudden or gradual onset and is usually of obstructive type
Bile duct injury
Picture of jaundice in cholangiocarcinoma
Gradual onset of obstructive pattern
Aetiology of jaundice in a septic surgical patient
Gradual onset obstructive pattern.
Caused be a combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis
Pathophysiology of jaundice in metastatic disease
Combination of liver sythnetic failure (late) and extrinsic compression by nodal disease, anatomical compression of intrahepatic structures (earlier)
Mixed hepatic and post-hepatic picture
When may Roikitansky-Aschoff sinuses be seen microscopically
Chronic cholecystitis
Pathogenesis of gallstones
Usually small calibre gallstones which can pass through the cystic duct. No jaundice unless Mirizzi syndrome
Mirizzi syndrome
Compression of the bile bile duct by gallstones.
One of the rare times that cholecystitis may present with jaundice.
Pathophysiology of cholangitis
Ascending infection of the bile ducts usually by E. Coli and by definition occurring in a pool of stagnant bile
Bacteria associated with cholangitis?
E. Coli
Pathophysiology of pancreatic cancer causing jaundice
Direct occlusion of distal bile duct or pancreatic duct by tumour.
Sometimes nodal disease at the porta hepatis may be the culpirt
When may the bile duct be of normal calibre in pancreatic cancer + jaundice?
Nodal disease at the porta hepatis
Pathophysiology of jaundice in TPN
Often due to hepatic dysfunction and fatty liver which may occur with LT TPN usage
Pathophysiology of bile duct injury
Often due to difficult laparosocopic cholecystectomy when anatomy in Calot’s triangle is not appreciated.
Worst case: bile duct excised and jaundice develops rapidly post-op
More insidious is bile duct stenosis that may be caused by clips or diathermy injury
Calot’s triangle
Calot triangle is a small (potential) triangular space at the porta hepatis of surgical importance as it is dissected during cholecystectomy. Its contents, the cystic artery and cystic duct must be identified before ligation and division to avoid damaging them during the operation.
Boundaries of the triangle of Calot
Right: cystic duct.
Left common hepatic duct
Superior: inferior suface of the liver (in the original description by Calot, the cystic artery is defined as the superior margin)
Contents of the triangle of Calot
Right hepatic artery
Cystic artery
Cystic lymph node of Lund
Connective tissue
Lymphatics
Occasionally accessory hepatic ducts and arteries
Which of the structures listed below inserts into the site labelled in the image.
© Image provided by the University of Sheffield
Psoas minor
Psoas major
Sartorius
Obturator externus
Gemellus
Psoas major inserts onto the lesser trochanter.
Extent of the femur
From a rounded head which articulates with the acetabulum down to the knee where the two large condyles at its inferior aspect articulate with the tibia.
Superior aspect of the femur
Comprises a head and neck which pass inferolaterally to the body and the two trochanters which lie at the junction between the neck and the body.
The neck meets the body of the femur at an angle of 125 degrees.
Describe the intertrochanteric crest of the femur
Demarcates the neck of the femur from the body.
Continues inferomedially as a spiral line that runs below the lesser trochanter.
Medially, the intertrochanteric line gives attachments to the inferior end of the iliofemoral ligament.
Neck is covered by a synovial membrane up to the intertrochanteric line.
Posterior aspect of the neck is demarcated from the shaft by the intertrochanteric crest and only its medial aspect is covered by the synovium and the joint capsule
Greater trochanter attachments
Form the site of attachment of the gluteal muscles.
Laterally, the greater trochanter overhangs the body and this forms part of the origin of vastus lateralis
What is the origin of the vastus intermedius
Surface of the anterior aspect of the body of the femur
What attaches to the upper and middle aspects of the linea aspera?
Thigh adductors
Course of the linea aspera.
As it continues inferiorly, it spans out to form the bony floor of the popliteal fossa.
At the inferior aspect of the popliteal surface, it curves posteriorly to form the femoral condyles.
Structures attached to the inferior aspect of the linea aspera?
Split with it as it approaches the popliteal fossa:
vastus medialis and adductor magnus continue with the medial split.
Biceps femoris and vastus intermedius along the lateral split
As regards the internal jugular vein, which of the following statements is untrue?
It lies within the carotid sheath
It is the continuation of the sigmoid sinus
The terminal part of the thoracic duct crosses anterior to it to insert into the right subclavian vein
The hypoglossal nerve is closely related to it as it passes near the atlas
The vagus nerve is closely related to it within the carotid sheath
The terminal part of the thoracic duct crosses anterior to it to insert into the right subclavian vein
Course of the IJV
Begins in the jugular foramen as a continuation of the sigmoid sinus.
Terminate at the medial end of the clavicle where they unite with subclavian vein.
Lies within the carotid sheath throughout its course.
Below the skull, the internal carotid and the last 4 CNs are anteromedial to the vein. Thereafter it is in contact medially with the ICA then CCA. Vagus lies posteromedially.
At its superior aspect, the vein is overlapped by sternocleidomastoid and covered by its inferior aspect
Below the transverse process of the atlas, it is crossed on its lateral side by the accessory nerve.
At its midpoint it is crossed by inferior root of the ansa cervicalis.
Posterior to the vein are transverse processes of the cervical vertebrae. The phrenic nerve as it descends on scalenus anterior and the fist part of subclavian.
On the left side it is also related to the thoracic duct.
Theme: Management of ano-rectal disease
A.Excision and primary closure
B.Incision and drainage
C.Topical steroids
D.Topical diltiazem
E.Steroid injections
F.Haemorroidectomy
G.Manual anal dilation
H.Injection with 88% aqueous phenol
I.Sphincterotomy
A 19 year old female presents with severe anal pain and bleeding which typically occurs post defecation. On examination she has a large posteriorly sited fissure in ano.
A 43 year old male has been troubled with symptoms of post defecation bleeding for many years. On examination he has large prolapsed haemorroids, colonoscopy shows no other disease.
A 20 year old man presents with a 24 hour history of anal pain. On examination he has a peri anal abscess.
Initial therapy should be with pharmacological agents to relax the sphincter and facilitate healing. This is particularly true in females presenting for the first time.
Prolapsed haemorroids are best managed surgically if symptomatic. Note that phenol injections are usually only used for minor internal haemorroids. Where used low concentration phenol in oil is used, the phenolic solution above is used to ablate the nail bed in toe nail surgery!
Abscesses require incision and drainage as a first line treatment.
Treatment of acutely thrombosed haemorrhoids?
Treatment of this acute condition is usually conservative and consists of stool softeners, ice compressions and topical GTN or diltiazem to reduce sphincter spasm. Most cases managed with this approach will settle over the next 5-7 days. After this period there may be residual skin tags that merit surgical excision or indeed residual haemorroidal disease that may necessitate haemorroidectomy.
Treatment of small mild haemorrhoids
Conservatively
Core marked symptoms of bleeding and occasional prolapse, where the haemorroidal complex is largely internal may benefit from ?
Stapled haemorroidopexy
Stapled haemorroidopexy?
This procedure excises rectal tissue above the dentate line and disrupts the haemorroidal blood supply. At the same time the excisional component of the procedure means that the haemorroids are less prone to prolapse. Adverse effects of this procedure include urgency, which can affect up to 40% of patients (but settles over 6-12 months) and recurrence. The procedure does not address skin tags and therefore this procedure is unsuitable if this is the dominant symptom.
Treatment of large haemorrhoids with a substantial external component?
Milligan Morgan haemorroidectomy
Milligan morgan haemorroidecctomy
In this procedure three haemorroidal cushions are excised, together with their vascular pedicle. Excision of excessive volumes of tissue may result in anal stenosis. The procedure is quite painful and most surgeons prescribe metronidazole post operatively as it decreases post operative pain.
Treatment of fissure in ano?
Definitevely is lateral internal spincterotomy
Permanent and nearly all patients will recover.
Not as readily used in females due to risk of faecal incontinence
Usual first line therapy is topical GTN or diltiazem for 6/52
Failure of topical therapy will usually-> botulinum
Typical fissures usually present in the posterior midline, multiple or unusually located fissures should prompt a search for
Underlying cause e.g. IBD or internal prolapse.
Treatment for refractory cases of fissure in ano?
?Advancement flaps
Treatment of fistula in ano when fistula is below sphincter and uncomplicated?
Fistulotomy
What can be used to assess extent of sphincter involvement in fistula in ano?
MRI or endoanal USS
Treatment of fistula in in ano in patients with Crohn’s?
LT seton left in situ and medical management as attempts at complex surgical repair nearly always fail
Treatment of uncomplicated fistula in ano involving the sphincters?
Draining seton suture
Management of fistulas in patients without IBD in whom seton has failed?
Advancement flaps
Newer technique of ligation of intersphincteric tract is reported to have good results in selected centres
LIFT technique
LIFT technique is the novel modified approach through the intersphincteric plane for the treatment of fistula-in-ano, known as LIFT (ligation of intersphincteric fistula tract) procedure. LIFT procedure is based on secure closure of the internal opening and removal of infected cryptoglandular tissue through the intersphincteric approach. Essential steps of the procedure include, incision at the intersphincteric groove, identification of the intersphincteric tract, ligation of intersphincteric tract close to the internal opening and removal of intersphincteric tract, scraping out all granulation tissue in the rest of the fistulous tract, and suturing of the defect at the external sphincter muscle.
A 21 year old man is involved in a road traffic accident. After a transient period of concussion he is found to have a GCS of 15 by the paramedics. On arrival at hospital he is monitored in a side room of the emergency department. When he is next observed he is noted to have a GCS of 3 and a blown right pupil. Which of the processes below best accounts for this deterioration?
Hydrocephalus
Intraventricular bleed
Sub dural bleed
Trans tentorial herniation
Sub arachnoid haemorrhage
The presence of a blown right pupil is a sign of a third cranial nerve compression. The most likely cause is an extradural bleed. However, since this option is not listed the process of trans tentorial herniation would be the most applicable answer. Intraventricular bleeds are typically more common in premature neonates, deterioration due to hydrocephalus is more chronic.
A 28 year old man requires a urethral catheter to be inserted prior to undergoing a splenectomy. Where is the first site of resistance to be encountered on inserting the catheter?
Bulbar urethra
Membranous urethra
Internal sphincter
Prostatic urethra
Bladder neck
The membranous urethra is the least distensible portion of the urethra. This is due to the fact that it is surrounded by the external sphincter.
Describe the female urethra
Shorter and more acutely angulated than the male.
Extra-peritoneal and embedded in the endopelvic fascia.
Neck of the bladder is subject to transmitted IAP and therefore deficiency in this area may result in stress urinary incontinence.
Between the layers of the urogenital diaphragm the female urethra is surrounded by the external urethral sphincter.
It ultimately lies anterior to the vagina orifice
Innervation of the female external urethral sphincter?
Pudendal nerve
Innervation of pre-prostatic urethra and its signficance?
Sympathetic noradrenergic fibres.
Composed of striated muscle bundles that contract and prevent retrograde ejaculation
What is the narrowest part of the urethra?
Membranous urethra as it is surrounded by the external sphincter
What is the infrabulbar fossa?
Dilatation of the penile urethra at its origin.
Urothelium cellular type?
Transitional nearer to the bladder.
Becomes squamous more distally
What is the most common abdominal emergency in children under 1 year of age?
Appendicitis
Intussusception
Intestinal malrotation
Pyloric stenosis
Mid gut volvulus
Intussuception
The commonest emergency in this age group is inguinal hernia followed by intussusception. Appendicitis is commoner in those older than 1 year of age.
A 28 year old man has a carcinoid tumour identified in his appendix. Blood testing for which of the substances listed below is likely to be helpful during follow up?
CA19-9
Alkaline phosphatase
AFP
CEA
Chromogranin A
It is important to distinguish between blood and urine tests for carcinoid syndrome. Blood tests usually measure chromogranin A,neuron-specific enolase (NSE), substance P, and gastrin. Urine tests usually measure 5 HIAA, which is a metabolite of serotonin. Sometimes blood tests for 5 hydroxytryptamine (serotonin) are also performed.
Clinical features of carcinoid syndrome
Onset: insidious
Flushing face
Palpitations
Pulmonary valve stenosis and TR causing dyspnoea
Asthma
Severe diarrhoea (secretory and persists despite fasting)
Investigations in carcinoid syndrome?
5-HIAA in 24 hour urine
Somatostatin receptor scintigraphy
CT scan
Blood testing for chromogranin A
A 40 year old man presents with obstructive jaundice and dysphagia. Twenty years previously he underwent a right hemicolectomy for a mucinous right sided colonic carcinoma. He was subsequently diagnosed as having Lynch syndrome. A recent colonoscopy was normal. What is the most likely cause of his jaundice?
Hepatocellular carcinoma
Liver metastasis from colonic cancer
Pancreatic carcinoma
Duodenal carcinoma
Gastric carcinoma
Lynch syndrome usually results in colonic cancer which is right sided and mucinous. The next most common site to be affected is the uterus. The stomach is at particular risk and this risk is up to 10 times greater in HNPCC (Lynch) patients than the general population. Duodenal adenomas (and rarely carcinoma) are usually seen in association with FAP. Whilst pancreatic carcinoma is associated with HNPCC it is far less likely to occur than gastric cancer.
Genetics of CRC
Lifetime risk of 5%
Up to 5% of newly diagnosed bowel cancers will be in those individuals with genetic component.
Cancers arising in the low-moderate genetic risk group are ~30% of newly diagnosed bowel cancer
More than 100 adenomatous polyps affecting the colon and rectum. Duodenal and fundic glandular polyps
FAP
Gene in FAP
APC
As FAP but with desmoid tumours and mandibular osteomas
Gardner syndrome
Autosomal dominant condition, affects 1 in 12,000. Accounts for 0.5% of all CRCs. Lifetime incidence of colorectal cancer in untreated FAP =100%. Up to 25% cases are caused by de-novo germ line mutations and show no prior family history. The APC tumour suppressor gene is affected in most cases.
FAP
Inheritance of FAP?
AD
Polyposis and colonic tumours and CNS tumours
Turcots syndrome
Colorectal cancer without extensive polyposis. Endometrial cancer, renal and CNS
HNPCC
Hamartomatous polyps in GI tract and increased risk of GI malignancy
Peutz-Jeghers syndrome
Cowden disease
Multiple hamartomas
Autosomal recessive, multiple adenomatous polyps in GI tract, those in colon having somatic KRAS mutations
MYH associated polyposis
Genes implicated in Turcots?
APC +MLH1 and PMS2
Genes implicated in HNPCC?
MSH2, MLH1, PMS2 and GTBP
Genes implicated in Peutz-Jeghers?
LKB1 and STK11 (in up to 70%)
Genes implicated in Cowden disease?
PTEN (85%)
APC in non inherited colorectal cancer
Up to 80% of sporadic colorectal cancers will have somatic mutations that inactivate APC[1]. Both alleles are usually affected. Although the APC protein more than likely has multiple critical cellular functions, the best-established role for APC in the cancer process is as a major binding partner and regulator of the β- catenin protein in the so-called canonical or β- catenin dependent Wnt signaling pathway.
How do HNPCC cancers differ from conventional tumours?
In the colon, tumours are more likely to be right sided.
More likely to be mucinous and have dense lymhpocytic infiltrates
Genetic pathophysiology of HNPCC?
Stem primarily from microsatellite instaiblity affecting DNA MMR genes.
In HNPCC the mismatch repair genes most commonly implicated include; MSH2 and MLH1 and these occur in up to 70% of people with HNPCC
Microsatellite instability in sporadic CRCs?
Unusual
What can be used to diagnose HNPCC?
Amsterdam criteria:
HNPCC tumours in at least 3 individuals (one of whom must be first degree relative to the other two)
In two successive generations.
At least 1 cancer < 50y/o
FAP excluded
What proportion of inividuals fulfilling Amsterdam criteria will not be found to have MMR defects?
60%
Impact of Amsterdam criteria fulfillment on cancer risk?
The risk of developing colorectal cancer in those who have not demonstrated mutation of the mismatch repair genes is increased if they fulfill the Amsterdam criteria, but not to the extent that it is increased in those who fulfill the criteria AND have evidence of mismatch repair gene defects.
Also known as multiple hamartoma syndrome. Rare autosomal dominant condition with incidence of 1 in 200,000.. It is characterised by multiple mucocutaneous lesions, trichilemmomas, oral papillomas and acral keratosis. Most often diagnosed in third decade of life. Breast carcinoma may occur in up to 50% of patients and conditions such as fibrocystic disease of the breast may occur in 75% of women. Thyroid disease occurs in 75% and may include malignancy. Endoscopic screening will identify disease in up to 85% although the small bowel is rarely involved. There is a 15-20% risk of developing colorectal cancer and regular colonoscopic screening from age 45 is recommended.
Cowden syndrome
KRAS Mutations
The RAS family of small G proteins act as molecular switches downstream of growth factor receptors. KRAS and the other two members of the family; HRAS and NRAS, are the site of mutation in approximately 40% of colorectal cancers. When adenomas are examined the proportion of adenomas less than 1cm showing KRAS mutations was only 10% which contrasts with 50% in those lesions greater than 1cm.
p53 mutations
The p53 protein functions as a key transcriptional regulator of genes that encode proteins with functions in cell-cycle checkpoints at the G1/S and G2/M boundaries, in promoting apoptosis, and in restricting angiogenesis . As such, selection for p53 defects at the adenoma-carcinoma transition may reflect the fact that stresses on tumor cells activate cell-cycle arrest, apoptotic, and antiangiogenic pathways in cells with wild-type p53 function. Many colonic tumours will demonstrate changes in the p53 gene that may facilitate tumour progression through from adenoma to carcinoma.
Why do cardiac transplant patients have higher resting heartrates?
Spontaneous depolarisationof the SAN is 100bpm.
There is no vagal stimulation
What is a typical end diastolic volume?
130-160mL
Average stroke volume?
70mL
What is the incisura
In early diastole all valves are closed. Isovolumetric ventricular relxation occurs. Pressure wave associated with closure of aortic valve increases aortic pressure. The pressure dip before this rise can be seen on arterial waveforms= incisura.
What is significant about negative atrial pressures?
Clinical importance as they can allow air embolisation to occur if neck veins are exposed to air.
Patient positioning is important in head and neck surgery to avoid this occurrence if veins are inadvertently cut or during CVP insertion.
What is the Bainbridge reflex?
Atrial stretch receptors.
Very rapid infusion of blood will cause an increase in heart rate mediated by these receptors.
(normally increased blood volume causes increased PNS activity).
Consequences of atrial stretch?
Increased BV-> increased parasympathetic activity.
Decreases in receptor stimulation results in increased sympathetic activity-> reduced RBF, decreases GFR, decreases urinary sodium excretion. Renin secreted by JGA-> increased AngII
Increased atrial stretch will also stimulate the release of ANP
At the level of the wrist joint, which of the statements below best describes the relationship of the ulnar artery to the ulnar nerve?
It lies on its radial side
It lies deep to it
It lies superficial to it
It lies on its ulnar side
None of the above
It lies on its radial side
In the middle of the forearm, the artery is overlapped by the flexor carpi ulnaris and on the flexor retinaculum it is covered by a superficial layer from that structure. In its distal two-thirds, flexor digitorum superficialis lies on its radial side, and the ulnar nerve is situated on its ulnar side.
Where does the ulnar artery start?
Middle of the ACF
Passage of the ulnar artery in the forearm?
Passes obliquely downward, reaching the ulnar side of the forearm at a point midway between the elbow and wrist.
Follows the ulnar border to the wrist, crossing over the flexor retinatculum
It than divides into the superficial and deep volar arches
Branch of ulnar artery?
Anterior interosseous artery
What structures is the ulnar artery deep to?
Pronator teres
Flexor carpi radialis
Palmaris longus
Relationship between the ulnar artery and the flexor retinaculum
Superificial to the flexor retinaculum at the wrist
What does the ulnar artery lie on?
Brachialis and FDP
Relationship between the ulnar artery and the median nerve
Related to the median side of the artery for about 2.5cm. Crosses the vessel, separated from it by the ulnar head of pronator teres
Relationship between the ulnar nerve and artery
Ulnar nerve lies medially to the lower two-thirds of the artery
Which of the following anatomical structures lies within the spiral groove of the humerus?
Median nerve
Radial nerve
Tendon of triceps
Musculocutaneous nerve
Axillary nerve
The radial nerve lies in this groove and may be compromised by fractures involving the shaft.
A 24 year old man falls and sustains a fracture through his scaphoid bone. From which of the following areas does the scaphoid derive the majority of its blood supply?
From its proximal medial border
From its proximal lateral border
From its proximal posterior surface
From the proximal end
From the distal end
The blood supply to the scaphoid enters from a small non articular surface near its distal end. Transverse fractures through the scaphoid therefore carry a risk of non union.
A 21 year old man has an inguinal hernia and is undergoing a surgical repair. As the surgeons approach the inguinal canal they expose the superficial inguinal ring. Which of the following forms the lateral edge of this structure?
Inferior epigastric artery
Conjoint tendon
Rectus abdominis muscle
External oblique aponeurosis
Transversalis fascia
The external oblique aponeurosis forms the anterior wall of the inguinal canal and also the lateral edge of the superficial inguinal ring. The rectus abdominis lies posteromedially and the transversalis posterior to this.
A 27 year old man is involved in a road traffic accident. He is seen in the emergency department with chest pain. Clinical examination is essentially unremarkable and he is discharged. He subsequently is found dead at home. What is the most likely underlying injury?
Tracheobronchial tree injury
Traumatic aortic disruption
Cardiac laceration
Diaphragmatic rupture
Rupture of the oesophagus
Aortic injuries that do not die at the scene may have a contained haematoma. Clinical signs are subtle and the diagnosis may not be apparent on clinical examination. Without prompt treatment the haematoma usually bursts and the patient dies.
Mechanism of thoracic aorta rupture
Decelerating force i.e. RTA, fall from a great height
Most people die at the scene
Survivors have an incomplete laceration at the ligamentum arteriosum of the aorta
Clinical features of thoracic aorta rupture
Contained haematoma
Detected mainly by history and CXR changes
CXR changes in thoracic aorta rupture
Widened mediastinum
Trachea/oesophagus to the right
Depression of left main stem bronchus
Widened paratracheal stripe/paraspinal interfaces
Space between aorta and pulmonary artery obliterated
Rib#/ left haemothorax
Diagnosis of thoracic aorta rupture
Angiography, usually CT aortogram
Supine trauma chest radiograph showing widened mediastinum with deviation of the trachea to the right, depression of the left main bronchus, left apical pleural capping and increased density of the left hemithorax consistent with haemothorax. Combination of findings is highly suspicious for traumatic aortic rupture.
Treatment of thoracic aorta rupture
Repair or replacement, ideally endovascular repair
A 45 year old lady presented with a 2cm mobile breast mass. A mammogram is indeterminate (M3), USS is normal (U2), clinical examination is also indeterminate (P3). What is the next most appropriate course of action?
Re-assure and discharge
Fine needle aspiration cytology
Excision biopsy
Image guided core biopsy
Wide local excision
All discrete breast lumps, including those that seem benign, should have a confirmed histological diagnosis. In this case, a core biopsy has not yet been performed. This may yield a diagnosis that is concordant with imaging findings. In which case, this concludes the investigative process (if benign). If it remains unclear, excision biopsy will be needed.
Develop from a whole lobule
Mobile, firm breast lumps
12% of all breast masses
Over a 2 year period up to 30% will get smaller
No increase in risk of malignancy
Fibroadenoma
Usually presents as a smooth discrete lump (may be fluctuant)
Small increased risk of breast cancer (especially if younger)
Breast cyst
Usually presents as a breast lump or breast pain
Causes mammographic changes which may mimic carcinoma
Cause distortion of the distal lobular unit, without hyperplasia (complex lesions will show hyperplasia)
Considered a disorder of involution, no increase in malignancy risk
Sclerosing adenosis, (radial scars and complex sclerosing lesions)
Variable clinical presentation ranging from generalised lumpiness through to discrete lump
Disorder consists of increased cellularity of terminal lobular unit, atypical features may be present
Atypical features and family history of breast cancer confers greatly increased risk of malignancy
Epithelial hyperplasia
Up to 40% cases usually have a traumatic aetiology
Physical features usually mimic carcinoma
Mass may increase in size initially
Fat necrosis
Usually present with nipple discharge
Large papillomas may present with a mass
The discharge usually originates from a single duct
No increase risk of malignancy
Duct papilloma
Treatment of fibroadenoma
If >3cm surgical excision is usual, Phyllodes tumours should be widely excised (mastectomy if the lesion is large)
Treatment of breast cyst
Cysts should be aspirated, those which are blood stained or persistently refill should be biopsied or excised
Treatment of Sclerosing adenosis, (radial scars and complex sclerosing lesions)
Lesions should be biopsied, excision is not mandatory
Treatment of breast epithelial hyperplasia
If no atypical features then conservative, those with atypical features require either close monitoring or surgical resection
Treatment of Fat necrosis
Imaging and core biopsy
Treatment of duct papilloma
Michododcetomy
Which of the following cranial venous sinuses is unpaired?
Transverse sinus
Superior sagittal sinus
Cavernous sinus
Sigmoid sinus
Inferior petrosal sinus
The superior sagittal sinus is unpaired. It begins at the crista galli, where it may communicate with the veins of the frontal sinus and sometimes with those of the nasal cavity. It arches backwards in the falx cerebri to terminate at the internal occipital protuberance (usually into the right transverse sinus). The parietal emissary veins link the superior sagittal sinus with the veins on the exterior of the cranium.
Why do the cranial venous sinsuses have a strong potential for spreading sepsis?
They have no valves
Theme: Management of colonic polypoidal lesions
A.Reassure and discharge
B.Pan proctocolectomy
C.Hot biopsy
D.Snare polypectomy
E.Segmental colonic resection
F.Repeat endoscopy at 3 years
G.Repeat endoscopy at 1 year
H.Repeat endoscopy at 5 years
Please select the most appropriate management for the scenario given. Each option may be used once, more than once or not at all.
A 43 year old man is investigated for altered bowel habit. At colonoscopy he is found to have a 2cm polyp on a long stalk in the proximal sigmoid colon. The rest of the colonoscopy is normal. It bears no macroscopic features of malignancy.
A 60 year old lady is investigated for abdominal pain. A polyp is identified at the proximal descending colon, three small polyps are also noted in the sigmoid colon. The largest lesion is removed by snare polypectomy and the pathology report states that this polyp is a low grade dysplastic adenoma measuring 3cm in diameter. The remaining lesions are ablated using diathermy.
A 73 year old lady is investigated for anaemia. At colonoscopy she is found to have a flat broad based lesion in the caecum. This is biopsied and the histology report states that these have diagnostic features of an adenoma with high grade dysplasia.
Snare polypectomy
Polyps on long stalks are best managed by snare excision. It is important to retrieve the polyp for histology.
Repeat endoscopy at 1 year
She is at high risk of malignancy and should be closely followed up. Fulguration of polyps without histology is unhelpful.
Segmental colonic resection
Management of right sided colonic polyps such as this is controversial. There is a high liklihood that this lesion will harbor an focus on invasive malignancy (which should generally be managed with resection). This is further suggested by the background history of anaemia. It is for this reason that resection over right sided colonic endoscopic mucosal resection is chosen.
Polypectomy of flat broad lesions in the right colon is difficult and where concern arises a right hemicolectomy is probably the safest option.
What is the association in adenomas and risk of malignancy for colonic polyps
Increased since= increased risk. ~10% risk in a 1cm adenoma.
Features of low risk colonic polyps
1 or 2 adenomas less than 1cm
F/U of low risk colonic polyps
No F/U or repeat colonoscopy at 5 years
Features of moderate risk colonic polyps?
3 or 4 small adenomas or 1 adenoma greater than 1cm
F/U for moderate risk colonic polyps
Re-scope at 3 years
Features of high risk colonic poylps
More than 5 small adenomas or more than 3 with 1 of them >1cm
Action in high risk colonic polyps
Re scope at 1 year
When should segmental resection or complete colectomy be considered in the context of colonic polyps?
- Incomplete excision of malignant polyp
- Malignant sessile polyp
- Malignant pedunculated polyp with submucosal invasion
- Polyps with poorly differentiated carcinoma
- Familial polyposis coli
- Screening from teenager up to 40 years by 2 yearly sigmoidoscopy/colonoscopy
- Panproctocolectomy and Ileostomy or Restorative Panproctocolectomy.
Rectal polypoidal lesions may be amenable to trans anal endoscopic microsurgery.
Which of the following laryngeal tumours will not typically metastasise to the cervical lymph nodes?
Glottic
Supraglottic
Subglottic
Transglottic
Aryepiglottic fold
Glottic
The vocal cords have no lymphatic drainage and therefore this region serves as a lymphatic watershed. The supraglottic part drains to the upper deep cervical nodes through vessels piercing the thyrohyoid membrane. The sub glottic part drains to the pre laryngeal, pre tracheal and inferior deep cervical nodes. The aryepiglottic and vestibular folds have a rich lymphatic drainage and will metastasise early.
What are the paired laryngeal cartilaginous segments?
Arytenoid
Corniculate
Cuneiform
What are the unpaired cartilaginous segments of the larynx?
Thyroid
Cricoid
Epiglottic
Location of the larynx?
Anterior part of the neck at the levels of C3-C6
Extent of the laryngeal cavity?
Extends from the laryngeal inlet to the level of the inferior border of the cricoid cartilage
What are the divisions of the laryngeal cavity?
Laryngeal vestibule
Laryngeal ventricle
Infraglottic cavity
Extent of the laryngeal vestibule
Superior to the vestibular folds
Extent of the laryngeal ventricle
Between vestibular folds and superior to the vocal cords
Extent of the infraglottic cavity?
Extends from vocal cords to the inferior border of the cricoid cartilage
What is the function and composition of the vocal cords?
Control sound production.
The apex of each fold projects medially into the laryngeal cavity. Each vocal fold includes
vocal ligament
vocalis muscle (most medial part of the thyroarytenoid muscle)
Composition of the glottis?
Vocal folds, processes and rima glottidis.
What is the rima glottidis?
The narrowest potential site within the larynx, as the vocal cords may be completely opposed, forming a complete barrier
What are the muscles of the larynx?
Posterior cricoarytenoid
Lateral cricoarytenoid
Thyroarytenoid
Transverse and oblique arytenoids
Vocalis
Cricothyroid
Innervation of the muscles of the larynx
All recurrent laryngeal nerve except cricothyroid (external laryngeal)
What is the only muscle of the larynx not innervated by the recurrent laryngeal nerve?
Cricothyroid (external laryngeal)
Origin of the posterior cricoarytenoid
Posterior aspect of lamina of cricoid
Insertion of posterior cricoarytenoid
Muscular process of arytenoid
Action of posterior cricoarytenoid
Abducts vocal fold
Origin of lateral cricoarytenoid
Arch of cricoid
Insertion of lateral cricoarytenoid
Muscular process of arytenoid
Action of lateral cricoarytenoid
Adducts vocal fold
Origin of thyroarytenoid
Posterior aspect of thyroid cartilage
Insertion of thyroarytenoid
Muscular process of arytenoid
Action of thyroarytenoid
Relaxes vocal fold
Origin of the transverse and oblique arytenoids
Arytenoid cartilage
Insertion of the transverse and oblique arytenoids
Contralateral arytenoid
Action of the transverse and oblique arytenoids
Closure of the intercartilagenous part of the rima glottidis
Origin of vocalis
Depression between lamina of thyroid cartilage
Insertion of vocalis
Vocal ligament and vocal process of arytenoid cartilage
Action of vocalis
Relaxes posterior vocal ligament, tenses anterior part
Origin of cricothyroid
Anterolateral part of cricoid
Insertion of cricothyroid
Inferior margin and horn of thyroid cartilage
Action of cricothyroid
Tenses vocal fold
Arterial supply of the larynx
Laryngeal arteries, branches of the superior and inferior thyroid arteries
Relation of the superior laryngeal artery?
Internal laryngeal nerve
Relation of the inferior laryngeal artery?
Related to the inferior laryngeal nerve.
Venous drainage of the larynx?
Via superior and inferior laryngeal veins.
Superior laryngeal vein drains to?
Superior thyroid vein
Inferior thyroid vein drains into
Either middle thyroid vein or thyroid venous plexus
Lympathic drainage of the vocal cords?
No lymphatic drainage- this site acts as a watershed
Supraglottic lymphatic drainage?
Upper deep cervical nodes
Subglottic lymphatic drainage
Prelarygneal and pretracheal nodes and inferior deep cervical nodes
What is an issue with malignancies at the aryepiglottic fold and the vestibular folds?
Have a dense plexus of associated lymphatics-> greater propensity for nodal metastasis
