Blue Boxes Flashcards
Describe the potential space in which prostheses are placed to repair inguinal hernias
Space of Bogros = anterolateral portion of potential space between the transversalis fascia and the parietal peritoneum
When and why is a protuberant abdomen normal?
Infants and young children; abdomen is full of air, abdominal cavity is enlarging, and abdominal muscles are still gaining strength
6 F’s of abdominal protrusion
Food Fluid Fat Feces Flatus Fetus
Eversion of the umbilicus may be a sign of increased abdominal pressure d/t what 2 causes?
Ascites
Large mass
What type of hernia protrudes through the linea alba?
Epigastric hernia
Hernia along the semilunar lines, usually associated with obesity
Spigelian hernia
The common nerve supply of the skin and muscles of the abdominal wall explains why ________ occurs when palpating the abdomen with cold hands, or when palpating an acute abdomen (e.g., appendicitis)
Guarding
Superficial abdominal reflex
Contraction of the abdominal muscles elicited by quickly stroking horizontally lateral to medial toward umbilicus
What 3 nerves supply multi-segmental innervation of abdominal muscles?
Inferior thoracic spinal nn (T7-12)
Iliohypogastric n
Ilioinguinal n
Surgeons avoid transecting muscles in order to avoid irreversible necrosis of muscle fibers. What is the exception to this in the abdominal wall?
Rectus abdominis - can be transected bc its muscle fibers run short distances between tendinous intersections, and the segmental nn supplying it enter the lateral part of the rectus sheath where they can be located and preserved
What type of incision is preferred for exploratory operations because they offer good exposure of and access to the viscera and can be extended as necessary with minimal complicaation?
Longitudinal incisions
What type of incisions can be made rapidly without cutting muscle, major vessels, or nerves?
Median/midline incisions - can be made along any part of length of linea alba from xiphoid to pubic symphysis
Note that bc of relatively poor blood supply, linea alba may undergo necrosis and degeneration after incision if its edges are not aligned properly during closure
Can a transverse incicion be made through the tendinous intersections of the rectus abdominis?
No, bc cutaneous nn and branches of superior epigastric vessels pierce these regions
What type of incision is used to access the gallblader and biliary ducts on the right side and the spleen on the left?
Subcostal incisions
What 2 types of incisions are considered “high-risk”?
Pararectus - along lateral border of rectus sheath (may cut nerve supply to rectus abdominis)
Inguinal incisions - may injure ilioinguinal n
An incisional hernia is a protrusion of _____ or organ through surgical incision
Omentum
When flow in the SVC or IVC is obstructed, anastomoses form between tributaries of these systemic veins, such as the ____ v., providing collateral pathway for blood back to the heart
Thoracoepigastric vv
______ = undescended testis, or non-retractable testis
Cryptorchidism
Undescended testes are typically found somewhere along the normal path of prenatal descent, commonly in what location?
Inguinal canal
What type of hernia leaves the peritoneal cavity medial to that of a direct inguinal hernia, repair of which puts the iliohypogastric nerve at risk
External supravesical hernia
The umbilical vein (which later forms the round ligament of the liver) is patent for some time after birth. What procedure might it be used for?
Umbilical vein catheterization for exchange transfusion during early infancy, for ex. in infants with erythroblastosis fetalis
Metastatic uterine cancer cells (especially from tubmors adjacent to the proimal attachment of the round ligament) can spread from the uterus to what location?
Labium majus, and from there to superficial inguinal nodes
Which is more common, direct or indirect inguinal hernias?
Indirect
The peritoneal part of the hernial sac of an indirect inguinal hernia is formed by what embryonic remnant in males?
Processus vaginalis of testes
[if the entire stalk of the processus vaginalis persists, the hernia extends into the scrotum superior to the testis, forming complete indirect inguinal hernia]
Describe the cremasteric muscle reflex. What nerve is responsible?
Elicited by lightly stroking the skin on the medial aspect of the superior part of the thigh
Ilioinguinal n. stimulation causes rapid elevation of the testis on the same side
Indirect inguinal hernias are more common in men, but when the processus vaginalis persists in females, it forms a small peritoneal pouch called what? What is the significance?
Canal of Nuck
Canal may extend into labia majus, can enlarge and form cysts in inguinal canal which produce a bulge in the anterior part of labium majus and have the potential to develop into an indirect inguinal hernia
What surgical correction is made to prevent reccurence or occurence of torsion of spermatic cord on contralateral side?
Both testes are surgically fixed to the scrotal septum
How would you go about anesthetizing the scrotum?
Since the anterolateral surface is supplied by the lumbar plexus (primarily L1 via ilioinguinal n) and the postero-inferior surface is supplied by the sacral plexus (primarily S3 via pudendal n), a spinal anesthetic agent must be injected more superiorly to anesthitize the anterolateral surface than is necessary to anesthetize its posteroinferior surface
Retention cyst in the epididymis containing milky fluid
Spermatocele
What embryological remnants may be seen around the testes when the tunica vaginalis is opened (if pathological changes have occurred)
Appendix of testes (vesicular remnant of paramesonephric duct)
Appendices of epididymis (remnants of mesonerphric ducts)
Why do varicoceles predominantly occur on the left side?
Likely bc acute angle at which right vein enters IVC = more favorable to flow than nearly 90 degree angle at which left testicular v. enters left renal v.
Metastasis of testicular cancer
Initially to retroperitoneal lumbar LNs which lie just inferior to renal veins; subsequently to mediastinal and supraclavicular LNs
[may also occur hematologically to lungs, liver, brain, and bone]
Metastasis of cancer of the scrotum
Superficial inguinal LNs, which lie in subQ tissue just inferior to inguinal ligament and along terminal part of great saphenous v
What is the purpose of hysterosalpingography?
Tests the patency of uterine tubes - air or dye is injected into uterine cavity from which it normally flows through uterine tubes into peritoneal cavity
Infection and inflammation of the peritoneum due to contamination during surgery or ruptured organ
Peritonitis
Cause exudation of serum, fibrin, cells, and pus into peritoneal cavity + pain in overlying skin and increase in tone of anterolateral abdominal mm.
May cause severe abdominal pain, tenderness, nausea, vomiting, fever, and/or constipation
Perforation of an ulcer through the stomach or duodenum, spilling acid content into the peritoneal cavity may cause what 2 conditions?
General peritonitis
Ascites
Paradoxical abdominothoracic rhythm may indicate what 2 conditions?
[rhythmic movements of anterolateral abdominal wall - abdomen drawn in as chest expands]
May indicate peritonitis or pneumonitis
What causes adhesions to form in the abdomen?
Damage to the peritoneum causes inflammation and fibrin deposit on peritoneal surfaces making them sticky, a they heal fibrin is replaced by fibrous tissue causing adherence of surfaces
Treatment of general peritonitis
Removal of ascitic fluid via paracentesis and large doses of abx
Needle inserted through anterolateral abdominal wall into peritoneal cavity through the linea alba, superior to urinary bladder in a location that avoids the inferior epigastric a.
What tx involving the peritoneum may be used to treat renal failure in which waste products such as urea have accumulated in the blood and tissues?
Peritoneal dialysis - soluble substances and excess water are removed from the system by transfer across the peritoneum, using dilute sterile solution introduced to peritoneal cavity on one side then drained from the other
Functions of greater omentum
Prevents visceral peritoneum from adhering to parietal peritoneum
Forms adhesions adjacent to inflamed organ, sometimes walling it off and protecting other viscera from it
Cushions abdominal organs against injury
Insulation against loss of body heat
Perforation of duodenal ulcer, rupture of gallbladder, or perforation of appendix may lead to formation of _____ = circumscribed collection of purulent exudate in subphrenic recess
Abscess
____ ____ provide pathways for flow of ascitic fluid and spread of intraperitoneal infections in that purulent material can be transported along into the pelvis when pt is upright
Paracolic gutters
How should a patient with peritonitis be positioned?
Seated at 45 degree angle - to facilitate flow of exudate into pelvic cavity where absorption of toxins is slow
What causes fluid to accumulate in omental bursa?
Perforation of posterior stomach wall
Inflamed or injured pancreas —> pancreatic pseudocyst
How would you go about treating a strangulated loop of small intestine that has passed through the omental foramen into the omental bursa?
None of the boundaries of the foramen can be incised bc each contains blood vessles, so the swollen intestine must be decompressed with a needle prior to returning it to the greater sac of the peritoneal cavity through the foramen
What artery must be ligated and severed during a cholecystectomy? What if it is severed prior to ligation?
Cystic a.
Surgeon must control hemorrhage by compressing hepatic a. as it traverses the hepatoduodenal ligament; the index finger is placed in omental foramen and thumb on its anterior wall. Alternate compression and release of pressure allows surgeon to identify bleeding artery and clamp it
Most common type of esophageal discomfort or substernal pain
Pyrosis - d/t GERD (Heartburn)
Pyrosis may be associated with what type of hernia
Hiatal
Esophageal varices commonly develop in persons who have developed which of the following
A. Hiatal hernia B. Pylorospasm C. Pyloric stenosis D. Pancreatitis E. Liver cirrhosis
E. Liver cirrhosis
With sliding hiatal hernias, some regurgitation of stomach contents may occur because the clamping action of what muscle on the inferior end of the esophagus is weak?
The right crus of the diaphragm
____ = characterized by failure of smooth muscle fibers encircling the pyloric canal to relax normally, resulting in overfilled stomach which can lead to discomfort and vomiting
Pylorospasm
What nodes can and cannot be removed in gastric cancer?
Can be removed: nodes along splenic vessels, nodes along gastroomental vessels
Cannot be removed (or very difficult to remove): aortic and celiac nodes and those around head of pancreas
Partial gastrectomy of pyloric antrum = greater omentum is incised parallel and inferior to right gastroomental a., requiring ligation of all its branches. Why does the omentum not degenerate following this procedure?
Anastomoses of other arteries such as the omental branches of the L gastroomental a.
Removal of what pyloric lymph nodes is commonly done in cases of pyloric carcinoma?
Pyloric LNs
Right gastroomental LNs
As cancer advances, celiac LNs may also be removed - to which all gastric nodes drain
Difference b/w gastric ulcers and peptic ulcers
Gastric = open lesions of stomach mucosa
Peptic = lesions of mucosa of pyloric canal or duodenum
Removal of what nerve is performed in some people with chronic or recurring ulcers to reduce the production of acid?
Vagus n. (Selective gastric vagotomy or selective proximal vagotomy - preserves vagus innervation to pylorus, liver, biliary ducts, intestines, and celiac plexus)
A posterior gastric ulcer may erode through stomach wall into pancreas, resulting in referred pain to the _____; in such cases, the erosion of the ___ artery results in severe hemorrhage in peritoneal cavity
Back; splenic
Where is visceral referred pain from a gastric ulcer perceived?
Epigastric region bc stomach is supplied by pain afferents that reach T7 and 8 spinal sensory ganglia and spinal cord segments through greater splanchnic n. The brain interprets the pain as though the irritation occured in the skin of the epigastric region, which is also supplied by the same sensory ganglia and spinal cord segments
Rebound tenderness
Extreme localized pain felt when digital pressure is applied to the anterolateral abdominal wall over the site of inflammation then removed suddenly
Where do most duodenal ulcers occur?
Posterior wall of superior part of duodenum within 3 cm of pylorus
What structures are most likely to adhere to the duodenum in the event of peritonitis d/t ruptured duodenal ulcer?
Liver
Gallbladder
Pancreas
May also get erosion of gastroduodenal a
T/F: during the early fetal period, the entire duodenum has a mesentery
True - it later fuses with posterior abdominal wall d/t pressure from transverse colon
What vessels must you watch out for while repairing a paraduodenal hernia?
Inferior mesenteric a. and v.
Ascending branches of left colic a.
Embryonic midgut rotation occurs around the axis of what structure?
SMA
Occlusion of the ______ by emboli results in ischemia and possible necrosis of the involved segment, and possibly _____, which is an obstruction of the intestine accompanied by severe colicky pain and abdominal distension, vomiting, fever, and dehydration
Vasa recta; ileus
Most common method of diagnosing an ileus
Superior mesenteric arteriogram
Most common cause of appendicitis in young people
Hyperplasia of lymphatic follicles in the appendix, occluding the lumen
Most common cause of appendicitis in old people
Fecalith (coprolith) - concretion that forms around a center of fecal matter; when secretions from appendix cannot escape, the appendix swells, stretching the visceral peritoneum
Pain pattern of appendicitis
Early on it presents around periumbilical region bc afferent pain fibers enter spinal cord at T10
Later, severe pain in RLQ d/t irritation of parietal peritoneum lining posterior abdominal wall
What surgical correction is typically made when the inferior part of the ascending colon has a mesentery and is thus mobile in the abdominal cavity?
Cecopexy = fixation (necessary to avoid volvulus of colon)
In this procedure tenia coli of the cecum and proximal acending colon is sutured to abdominal wall
Removal of terminal ileum, colon, rectum, and anal canal
Colectomy
Chronic inflammation of the colon
colitis (crohn disease)
Procedure done after colectomy to establish a stoma, an artificial opening of ileum through skin of anterolateral abdominal wall
Ileostomy
Procedure done after partial colectomy to create artificial cutaneous opening for terminal part of colon
Colostomy
Where do most tumors of the large intestine occur?
Sigmoid colon
Rectum
Often near the rectosigmoid junction
Why aren’t colonic diverticula considered true diverticula
Bc they are formed from protrusions of mucous membrane only, evaginated through weak points in muscle fibers rather than involving whole wall of colon
Where do colonic diverticula most commonly occur
Mesenteric side of 2 nonmesenteric teniae coli, where nutrient arteries perforate the muscle coat to reach the submucosa
Complications of volvulus of sigmoid colon
Constipation
Ischemia
Fecal impaction
Necrosis
What is the frequently injured organ in the abdomen?
Spleen, although it is well protected by 9th and 10th ribs, but the close relationship of spleen to ribs can be detrimental with rib fractures following severe blows to L side
In addition, blunt trauma to abdomen that causes increased intraabdominal pressure can cause thin fibrous capsule and overlying peritoneum of the spleen to rupture, causing intraperitoneal hemorrhage and shock
What is the typical tx for ruptured spleen?
Splenectomy, since surgical repair is difficult
Subtotal splenectomy is followed by rapid regeneration of tissue. What are the results of total splenectomy? Why doesnt it produce serious effects?
Most of its functions are assumed by other reticuloendothelial organs like liver and bone marrow, but there is greater susceptibility to bacterial infection
Splenomegaly may accompany which of the following
A. Hypercholesterolemia
B. Hypertension
C. Diabetes
D. Hyperlipidemia
B. Hypertension
What may cause persistence of symptoms requiring splenectomy to persist after the operation is performed?
Presence of accessory spleen(s)
The relationship of the costodiaphragmatic recess of the pleural cavity to the spleen is clinically important. This potential space descends into the level of the ___ rib in the _____ line.
Its existence must be kept in mind when doing what types of procedures regarding the spleen? What condition results if care is not taken during these procedures?
10th; midaxillary
Splenic needle biopsy
Splenoportography
If caare is not taken, material may enter pleural cavity and cause pleuritis
What 2 structures join to make the hepatopancreatic ampulla
Main pancreatic duct
Bile duct
A gallstone passing along the extrahepatic end of the hepatopancreatic ampulla may lodge in the constricted distal end of the ampulla where it opens at the summit of what structure? What is the result?
Major duodenal papilla
Neither bile nor pancreatic juice can enter the duodenum. Bile may back up and enter pancreatic duct resulting in pancreatitis
Reflux of bile into the pancreas may be caused by spasms at what sphincter
Hepatopancreatic sphincter
What is standard procedure for diagnosis of both pancreatic and biliary disease?
Endoscopic retrograde cholangiopancreatography
Fiberoptic endoscope passed thru mouth, esophagus, and stomach. Then duodenum is entered and cannula is inserted into major duodenal papilla and advanced under fluoroscopic control into the duct of choice for injection of radiographic contrast
Where might you find accessory pancreatic tissue?
Stomach
Duodenum
Ileum
Ileal diverticulum
(Stomach or duodenum= most common)
Accessory pancreatic tissue may contain pancreatic islet cells that produce what?
Glucagon
Insulin
Treatment of chronic pancreatitis
Pancreatectomy - cannot remove entire head of pancreas d/t relationships and blood supply to bile duct and duodenum
Usually rim of pancreas along medial border is retained to maintain blood supply
What condition accounts for most cases of extrahepatic obstruction of biliary ducts?
Cancer of pancreatic head
Results in retention of bile pigments, enlargement of gallbladder, and obstructive jaundice
Most common type of pancreatic cancer and most common presenting symptom
Ductular adenocarcinoma, presents with severe pain in the back
Complications of cancer in the neck and body of the pancreas
Hepatic portal or IVC obstruction
Why is surgical resection of the cancerous pancrease nearly futile?
The pancreas’ extensive drainage to relatively inaccessible lymph nodes, and the fact that pancreatic cancer typically metastasizes to the liver early via the hepatic portal vein
Palpation of the liver
Patient supine: place left hand posteriorly behind lower rib cage, then put right hand on person’s RUQ, lateral to rectus abdominis and inferior to costal margin. Have pt take deep breath and press posterosuperiorly with right hand and pull anteriorly with left
Peritonitis may result in abscess formation in what common sites of the peritoneal cavity?
Right or left subphrenic recess - more common on right because of frequency of ruptured appendices and perforated duodenal ulcers
Pus from subphrenic abscess may drain into one of the hepatorenal recesses, especially when patients are bedridden
How are subphrenic abscesses drained
Usually by incision inferior to or through bed of 12th rib, making it unnecessary to open pleura or peritoneum
An anterior subphrenic abscess is often drained through a subcostal incision located inferior and parallel to right costal margin
Why is it possible to perform hepatic lobectomies without excessive bleeding?
The right and left part of the liver do not communicate in terms of hepatic arteries and ducts or portal veins
Most injuries to the liver involve which side?
Right
What procedure makes it possible to remove only those liver segments that have sustained severe injury or are affected by a tumor?
Hepatic segmentectomies
What serve as the guides to the planes between the hepatic divisions?
Right, intermediate, and left hepatic veins
[must determine pattern using US, dye injection, or balloon catheter prior to operating]
Why is the liver easily injured?
Large
Fixed in position
Friable
Often a fractured rib that perforates the diaphragm will tear the liver, causing hemorrhage and RUQ pain; tx by surgical dissection or segmentectomy
The more common variety of R or L hepatic artery that arises as a terminal branch of the hepatic artery proper may be replaced in part or entirely by an accessory artery arising from another source.
The most common source of an accessory right hepatic a. is the ______, the most common source of an accessory left hepatic a. is the ___
SMA; L gastric a.
In most people, right hepatic a. Crosses anterior to hepatic portal v. and posterior to common hepatic duct. What are some variations?
May cross posteriorly. May also run anterior to common hepatic duct or arise from SMA and so does not cross the common hepatic duct at all.
Any rise in central venous pressure is directly transmitted to what organ
Liver, bc the IVC and hepatic vv lack valves
Liver enlargement stretches the fibrous capsule, producing pain around the lower ribs, particularly in right ___________.
Hypochondrium
Conditions that cause hepatomegaly
CHF
Bacterial and viral hepatitis
Tumors
The liver is common site of metastatic carcinoma, particularly from which locations?
Large intestine (bc drained by portal system of veins)
Right breast - bc communications between thoracic LNs and lymphatic vessels draining the bare area of the liver
Most common cause of portal hypertension
Alcoholic cirrhosis
Tx of advanced hepatic cirrhosis
Surgical creation of portosystemic or portocaval shunt, anastomosing the portal and systemic venous systems
Procedure for liver biopsy
Patient instructed to hold breath in full expiration to reduce costodiaphragmatic recess and lessen possibility of lung damage
Needle directed through right 10th intercostal space in midaxillary line
In a small population of people, gallbladder is suspended by short mesentery, increasing its mobility. Mobile gallbladders are subject to what complications?
Vascular torsion
Infarction
Variations in cystic and hepatic ducts (important to know for cholecystectomy)
- Cystic duct runs alongside common hepatic duct and adheres to it
- Cystic duct may be very short or absent
- Low union of cystic and common hepatic ducts —> bile duct is short and lies posterior to superior part of duodenum or even inferior to it making surgical clamping difficult without injuring CBD
- High union of cystic and common hepatic ducts near porta hepatis
- Cystic duct spirals anteriorly over common hepatic duct
_____ = common structures in positions of danger during cholecystectomy bc they leak bile if inadverdently cut during surgery
Accessory/aberrant hepatic ducts
Cholelithiasis
Gallstones
Potential sites of impaction for gallstones
Distal end of hepatopancreatic ampulla
Hepatic duct
Cystic duct (causes biliary colic)
Abnormal sacculation (hartmann pouch) at neck of gallbladder
How might gallstones enter the duodenum?
Peptic duodenal ulcer ruptures —> false passage forms from hartmann pouch at neck of gallbladder to superior part of duodenum
May also occur due to cholecystoenteric fistula to duodenum or transverse colon
Pain pattern for impaction of gallbladder
Develops in epigastric region and shifts to right hypochondriac region at junction of 9th costal cartilage and lateral border of rectus sheath
Pain pattern of gallbladder inflammation
Posterior thoracic wall or right shoulder, owing to irritation of diaphragm
Gallstone ileus
Large gallstone that has entered the small intestine and trapped at ileocecal valve producing a bowel obstruction
What creates the diagnostic radiological sign of gallstones in the duodenum
Cholecystoenteric fistula permits gas from GI tract to enter gallbladder
The cystic a. typically arises from the _____ a. in the cystohepatic triangle (calot triangle)
Right hepatic
Borders of cystohepatic triangle
Inferior = cystic duct Medially = common hepatic duct Superior = inferior surface of the liver
Common method for reducing portal HTN is to divert blood by creating portocaval anastomosis. What another way to reduce portal pressure, performed after a splenectomy?
Join splenic v. To left renal v.
In lean adults, the inferior pole of the right kidney is palpable by bimanual examination as a firm, smooth, somewhat rounded mass that descends during inspiration. How is this kidney palpated?
Press flank between 11th and 12 ribs and iliac crest anteriorly with one hand while palpating deeply at the costal margin with the other
[left kidney is not usually palpable unless enlarged or displaced
What happens to abnormally mobile kidneys when the person stands upright? What does this mean for suprarenal glands?
The kidneys descend; the suprarenal glands remain in place bc they’re in separate fascial compartment firmly attached at the diaphragm
What is nephroptosis?
Dropped kidney; distinguished from ECTOPIC kidney by a ureter of normal length that has loose coiling or kinks bc the distance to the bladder has been reduced
Symptoms = intermittent pain in renal region, relieved by lying down (d/t traction on renal vessels)
Where are kidneys placed when they are transplanted? Why?
Iliac fossa; d/t lack of inferior support in lumbar region, availability of major blood vessels, convenient access to nearby bladder
How is a transplanted kidney hooked up to the recipient’s system?
Renal a. and v. Are joined to the external iliac a. and v.
Ureter is sutured into the urinary bladder
Renal transplant is preferred treatment for chronic renal failure. What happens to the suprarenal gland during renal transplant?
It is left undamaged in the donor.
What is an important cause of renal failure and is inherited as an autosomal dominant trait, resulting in kidney enlargement and distortion by masses as large as 5 cm?
Polycystic disease of the kidneys
Why might extension of the hip joints increase pain resulting from inflammtion in the pararenal areas?
The close relationship of the kidneys to the psoas major mm. (Responsible for hip flexion)
What causes the formation of accessory renal vessels?
During kidney ascent in embryonic development, blood supply and venous drainage form from successively more superior vessels. Usually inferior vessels degenerate as superior ones take over; the ones that do not degenerate become accessory renal arteries and veins, some of which enter/exit poles of the kidney
Complication of inferior polar (accessory) renal artery?
Inferior polar artery crosses the ureter and may obstruct it
In crossing the midline to reach the IVC, the longer left renal vein traverses an acute angle between the ____ anteriorly and the ______ posteriorly. Downward traction on the anterior vessel may compress the left renal vein, resulting in _______
SMA; abdominal aorta
Renal vein entrapment syndrome (nutcracker syndrome - based on appearance of vein in acute arterial angle in a sagittal view)
Signs/symptoms of renal vein entrapment syndrome (nutcracker)
Hematuria Proteinuria Flank pain Nausea Vomiting Left testicular pain in men Left sided varicocele
An uncommon congenital anomaly of the kidney is a ____ ureter, which leaves the kidney and passes posterior to the IVC
Retrocaval
Incomplete division of the ____ results in a bifid ureter; complete division results in a _______ kidney
Ureteric bud; supernumerary
At what vertebral level does a horseshoe kidney typically form? Why?
L3-L5 bc root of inferior mesenteric a. prevented normal relocation of the kidneys
Sometimes embryonic kidneys on one or both sides fail to enter the abdomen and lie anterior to the sacrum. Where do pelvic kidneys typically receive their blood supply from?
Aortic bifurcation or a common iliac a.
______ = composed of salts or inorganic or organic acids or of other materials that may form and become located in the calices of kidneys, ureters, or urinary bladder
Calculi
What size of renal calculi typically causes excessive distension of the ureter, causing severe ureteric colic and/or obstruction?
3 mm
Pain from a renal calculi is referred to cutaneous areas innervated by what nerves?
Spinal cord segments and sensory ganglia, which also receive visceral afferents from the ureter, mainly T11-L2
Pain may extend into proximal anterior aspect of thigh by projection through genitofemoral n. (L1, L2)
Methods for visualization and removal of renal calculi
Observation and removal via nephroscope
Lithotripsy = shockwave through body that breaks calculus into small fragments that pass with urine
Involuntary spasmodic contractions of the diaphragm, causing sudden inhalations that are rapidly interrupted by the spasmodic closure of the glottis
Hiccups
What causes hiccups
Irritation of afferent or efferent nerve endings, or of medullary centers in the brainstem that control the muscles of respiration, particularly the diaphragm
may have many causes such as indigestion, diaphragm irritation, alcoholism, cerebral lesions, and thoracic and abdominal lesions, all of which disturb the phrenic nn.
Section of a ___ nerve in the neck results in complete paralysis and eventual atrophy of the muscular part of the corresponding half of the diaphragm
Paralysis of the _____ can be recognized radiographically by its permanent elevation and paradoxical movement
Phrenic
Hemidiaphragm
Referred pain location from diaphragm
Irritation of diaphragmatic pleura or the diaphragmatic peritoneum —> shoulder region, area of skin supplied by C3-5 segments of the spinal cord which also contribute to anterior rami of phrenic nn
Irritation of peripheral regions of diaphragm, innervated by the inferior intercostal nn, is more localized —> skin over costal margins of anterolateral abdominal wall
Rupture of diaphragm and herniation of viscera can result from sudden large increase in intrathoracic or intraabdominal pressure, usually d/t MVC. Most diaphragmatic ruptures occur on which side? Why?
Left - bc substantial mass of liver on the right side is protective physical barrier
Non-muscular area of variable size that usually occurs between the costal and lumbar parts of the diaphragm, normally formed only by fusion of the superior and inferior fascias of the diaphragm
Lumbocostal triangle
What type of hernia occurs when stomach, small intestine and mesentery, transverse colon, and spleen pass through the lumbocostal triangle?
Traumatic diaphragmatic hernia
What structures may be injured in a surgical procedure of the esophageal hiatus?
Vagal trunks
L inferior phrenic vessels
Esophageal branches of L gastric vessels
In congenital diaphragmatic hernia, part of stomach and intestine herniate through what opening? Which side is more common?
Herniation through large posterolateral defect called foramen of Bochdalek in the region of the lumbocostal trigone of the diaphragm
Usually on left due to presence of liver on right
What is the only relatively common congenital anomaly of the diaphragm?
Posterolateral defect of the diaphragm
With limited space for abdominal viscera in prenatal pulmonary cavity, one lung (usually left) does not have room to develop normally or to inflate after birth; high mortality rate bc consequential pulmonary hypoplasia occurs
An abscess resulting from Tb in the lumbar region tends to spread from vertebrae to where? What is the consequence of this?
Psoas fascia, producing a psoas abscess
Causes fascia to thicken to form strong stocking like tube. Pus from the abscess passes inferiorly along psoas muscle within the fascia over the pelvic brim and deep to inguinal ligament. The pus usually surfaces in superior part of thigh
Pus can also reach the psoas fascia by passing from the posterior mediastinum when the thoracic vertebrae are diseased
The inferior part of the iliac fascia is often tense and raises a fold that passes to the internal aspect of the iliac crest. The superior part of this fascia is loose and may form a pocket, the __________, posterior to the above-mentioned fold. Part of the large intestine such as cecum or appendix on the right side and the sigmoid colon on the left side may become trapped in this fossa, causing considerable pain
Iliacosubfascial fossa
What is the iliopsoas test? When is it performed?
Performed when intra-abdominal inflammation is suspected (kidneys, ureters, cecum, appendix, sigmoid colon, pancreas, lumbar LNs, or nerves of posterior abdominal wall)
Patient lies on unaffected side and extends thigh on affected side against resistance of physician; postive test = pain
What might cause the protective reflex of a spasm of the iliopsoas?
Disease of intervertebral and sacroiliac joints
What type of cancer invades the muscles and nerves of the posterior abdominal wall in its advanced stages, producing excruciating pain?
Adenocarcinoma of the pancreas
Treatment of some patients wtih arterial disease in lower limbs by surgical removal of 2+ lumbar sympathetic ganglia by division of their rami communicantes
Partial lumbar sympathectomy
Surgical access to sympthetic trunks for partial lumbar sympathectomy
What covers the left vs. right sympathetic trunks?
Access through lateral extraperitoneal approach bc trunks are retroperitoneal in fatty tissue. Surgeon splits the muscles of anterior abdominal wall and moves the peritoneum medially and anteriorly to expose medial edge of psoas major, along which the sympathetic trunk lies.
The left trunk is overlapped slightly by aorta, right trunk is covered by IVC (puts these vessels at risk)
A tumor of which 2 organs could be mistaken for a AAA?
Stomach
Pancreas
[bc they overlie the abdominal aorta and tumor could transmit pulsations]
How are AAA detected?
Deep palpation of the midabdomen can detect aneurysm (typically result of congenital or acquired weakness of arterial wall)
Pulsations of large aneurysm can be detected to the left of midline; pulsatile mass can be moved easily from side to side. Medical imaging can confirm the diagnosis in doubtful cases
When the anterior abdominal wall is relaxed, particularly in children and thin adults, the inferior part of the abdominal aorta may be compressed against the body of the ____ vertebra by firm pressure on anterior abdominal wall over the umbilicus. This pressure may be applied to control bleeding in pelvis or lower limbs d/t ruptured AAA
L4
There are 3 collateral routes for abdominopelvic venous blood.
- Superior and inferior epigastric vv.
- Thoracoepigastric v.
What is the third?
Epidural venous plexus inside the vertebral column, which communicates with lumbar veins of inferior caval system and the tributaries of the azygous system of veins, which is part of the superior caval system
Why are IVC anomalies relatively common? Where do most of them occur?
Because it develops from parts of 3 sets of embryonic veins
Most of them, such as a persistent left IVC, occur inferior to the renal veins. These anomalies result from the persistence of embryonic veins on the left side, which normally disppear. If a left IVC is present, it may cross to the right side at the level of the kidneys
