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RLH MRCS > Cracking: Applied surgical anatomy > Flashcards

Cracking: Applied surgical anatomy Flashcards

1
Q

Abdominal aorta: Where does it begin and end?

A

Starts at T12 as it transverses the diaphragm Ends at L4 where it bifurcates into the common iliac arteries

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2
Q

Abdominal aorta: What are it’s relations?

A

Passes in the midline in the retroperitoneum Anterior: Left renal vein, pancreas, lesser sac Posterior: anterior longitudinal ligament, vertebral bodies Right: Cisterna chyli, thoracic duct, azygos vein Left: duodenojejunal flexure

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3
Q

Abdominal aorta: What are it’s branches and at what level do they branch?

A

Paired: T12 Inferior phrenic artery ->adrenal gland and diaphragm T12 Adrenal artery -> Adrenal gland L2 Renal artery -> Kidneys, adrenal glands, ureter L2-3 Gonadal artery -> Gonads, ureters L2-3 Lumbar arteries (4 pairs) -> lumbar musculature L4 Iliac arteries (terminal) -> legs and pelvic viscera Unpaired: T12 Coeliac trunk - foregut + liver, spleen, pancreat L1 SMA - midgut L3 IMA - hindgut L4 Median sacral artery - sacrum

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4
Q

Anal Canal: What is the embryology?

A

Starts off as an endodermal tube Ectoderm invaginates and meets the endoderm to form the anal canal So, distal half is ectoderm (proctoderm) derived, whilst the proximal half is endoderm derived

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5
Q

Anal Canal: What is the anatomy? - relations

A

Posterior: anococcygeal body and coccyx Laterally: ischiorectal fossa Anterior: perineal body (M&F), penis (M), Vagina (F)

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6
Q

Anal Canal: What is the anatomy? - structure above v below the dentate line

A
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7
Q

Anal Canal: What is the anatomy? - sphincters

A

External sphincter - voluntary control. 3 parts: subcutaneous, superficial, deep (parts)

+Puborectalis sling around anal canal/lower rectum -> acute angle to help maintain continence

Internal sphincter - autonomic control

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8
Q

Anal Canal: What is the sequence of events in defecation?

A

Faeces arrive at the rectum from emptying of the distal large bowel -> urge to defecate

Intra-abdominal pressure rises with increased in diaphragmatic and abdo muscle pressures

Anal sphincterns voluntarily relax

Faeces are evacuated

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9
Q

Biliary system: anatomy?

A

Divided into intra-hepatic and extra-hepatic systems

Biliary tree starts intra-hepatically as bile canaliculi which divide into bile ductules and small interlobular tributaries of the bile ducts. These join each other to form larger ducts.

R hepatic duct drain the right lobe and the left the left. These two ducts leave the liver at the porta hepatis to become extra-hepatic

The then join (amalgamates) to form the common hepatic duct

This then joins (accepts) the cystic duct to for the common bile duct

The CBD with the hepatic artery (left) and portal vein (behind) travels in the free edge of the lesser omentum at the porta hepatis

At the distal edge it joins (accepts) the pancreatic duct

The CBD terminates at the sphincter of Oddi/ampulla of Vater which opens into the medial aspect of the second part of the duodenum

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10
Q

Biliary system: Relations of the common bile duct?

A

It is 8cm in length

Diameter: 6mm = upper limit of normal (but get’s 1mm larger every 10 years after 60yo + is larger post cholecystectomy)

Travels in the free edge of the lesser omentum in the porta hepatis with the common hepatic artery (left) and the portal vein (behind)

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11
Q

Biliary system: CBD is divided into three parts…

A
  1. First part: anterior to the opening of the Lesser sac
  2. Second part: Posterior to the first part of the duodenum
  3. Third part: Posterior surface of the head of the pancreas
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12
Q

Biliary system: what is the histiological layout of the biliary system?

A

Liver is divided into functional units - lobules

At the periphery of each are the portal triads - bile ductule, terminal hepatic artery branch, terminal portal vein tributary

Each lobule had a central terminal hepatic venule

Blood flows from the portal triad (portal vein & hepatic artery), in the sinusoids, to the central venule. Peripherally to centrally.

These venules then transport blood to the hepatic vein

Bile flows through the canaliculi in the opposite direction to the portal triads peripherally

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13
Q

Biliary system: Gallbladder anatomy

A
  • Pear shaped viscus
  • Lines with columnar epithelium
  • Contains some smooth muscle in the wall
  • Can hold 50mL bile
  • Consists of fundus, body, neck
  • Lies in the gallbladder fossa attached to ventral surface of the right lobe of the liver
  • Neck is continuouse with the systic duct, a small diverticulum at this point, Hartmann’s pouch, is where stones can impact

Arterial supply - cystic artery

Venous drainage - snall veins into the substance of the liver

Lymphatic drainage - cystic node in Calot’s triangle

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14
Q

Biliary system: What is pringle’s manoeuvre?

A

Place a clamp over the free edge of the lesser omentum and occlude the vessels descrived above

Useful, temporary measure for controlling heavy bleeding from liver, e.g. trauma, by occluding the liver’s blood supply, because it can be done quickly

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15
Q

Biliary system: What is Calot’s triangle?

A

Triangle formed by the liver, Common hepatic duct, Cystic duct

The cystic artery runs within it.

It is important in identification of the cystic artery in laparoscopic cholecystectomies

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16
Q

Blood supply to the heart:

Anatomy of Right Coronary Artery

A

Arises from right (anterior) aortic sinus

Runs between pulmonary trunk and Rt auricle

Gives off marginal branch @junction of posterior interventricular groove and AV sulcus (which descends over the front of the ventricle),

and continues as the posterior interventricular artery continueing in the interventricular groove and anastomoses with anterior interventricular artery

It supplies the right ventricle, SAN (60%) and AVN, and part of the left ventricle

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17
Q

Blood supply to the heart:

Anatomy of Left Coronary Artery

A

Arises from the left (posterior) aortic sinus and divides into circumflex and anterior interventricular (left anterior descending)

Circumflex travels in AV sulcus to anastomose with the RCA

the anterior interventricular (LAD) travels in the interventricular groove to anastomose with the posterior interventricular artery

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18
Q

Blood supply to heart: Venous drainage

A

All V except for anterior cardiac V drain into coronary sinus which opens into post wall of R atrium

Anterior cardiac V runs across surface of R ventricl and drains directly into r atrium

Tributaries:

  • Great cardiac V: travels with anterior interventricular artery and drains into left prox aspect of CS
  • Middle cardiac V: travels with posterior interventricular artery and drains into CS
  • Small Cardialc V : drain proximally into CS (Right marginal vein travels along the interior surfaceof heart and drains into the SCV)
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19
Q

The Diaphragm:

Anatomy

A
  • Consists of peripheral muscular part and inserts via central tendon which fuses with the pericardium
  • Bi-domes, reaching the fifth rib at its highest extent
  • 2 crura - sites of origin of the diaphragm:
    • R crus - from first 3 lumbar vertebrae
    • L crus - from first 2 lumbar vertebra
  • Right crus - sling around oesophagus and prevents reflux
  • Medial and lateral arcuate ligaments are lateral to crura, contribute to origin of diaphragm
  • Supplied by phrenic nerve (C3,4,5 keeps the diaphragm alive)
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20
Q

The Diaphragm: Development

A

Develops from septum transversum, pleuroperitoneal membranes, paraxial mesoderm of abdo wall and oesophageal mesenchyme

Spetum transversum, which initially forms an embryonic partition between thorax & abdo (emb wk 5-7) -> Central tendon

Crura of the diaphragm are derived from foregut mesenchyme

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21
Q

The Diaphragm: Diaphragmatic Hernias

A

through persisting pleuroperitoneal communications (where above contributions fail to fuse)

Morgani hernia - through foramen of M - into anterior mediatinum

Bonchdalek hernia - through foramen of B - posteriorly

diagnosed by CT

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22
Q

The Diaphragm: Openings

A
  • T8 - IVC, and right phrenic nerve
  • T10 - Oesophagus, and vagus nerve
  • T12 - Abdominal aorta, and thoracic duct + azygos vein

Subcostal nerve - under lateral arcuate ligament

Sympathetic chain - behind medial arcuate ligament

Left phrenic nerve - pierces muscular portion of diaphragm

Great, lesser, least splanchnic N - pierces crura

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23
Q

The Diaphragm: Functions

A
  • Main muscle of respiration
  • Aids venous return to <3 (intermittent increased intra-abdo pressure on resp)
  • Straining - defecation and micturition
  • Support to vertebral columm
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24
Q

Femoral Triangle: Boundaries

A
  • Superiorly: inguinal ligament
  • Medially: medial border of adductor longus
  • Laterally: medial border of sartorius
  • Roof: Fascia lata
  • Floor (M->L): adductor longus, adductor brevis, pectineus, iliopsoas
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25
Q

Femoral Triangle: Contents

A

(Lateral to Medial)

Nerve, Artery, Vein, (Y fronts)

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26
Q

Femoral Sheath: Contents

A

Contains: Femoral canal (potential space containing fat and Coquet’s lymph note, in which vein can expand during increased venous return), Vein and Artery

i.e. does not contain femoral nerve

Femoral branch of genitogemoral nerve runs in the sheath and pierces is anteriorly to supply the skin overlying the triangle

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27
Q

Kidney: structure

A
  • Retroperitoneal
  • R lower than left (due to liver)
  • 12x6x3cm
  • Left hilum = Transpyloric plane (L1)
    • L1 = superior pole of right kidney
  • Enclosed in fibrous capsule and embedded in fat, bounded by gerotas’s fascia
    • GF is attached to the renal pelvis but n inferior opening allows pus to track out in renal disease
  • Divided into outer cortex (nephrons), inner medulla (collective ducts and loop of henle)
  • Cortical pyramids -> papillae -> calyces -> denal pelvis - > ureter
  • Pyramids = seperated by columns of Bertin
  • Hilum of kidney = vein, arteryx2, ureter, artery (Ant to post)
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28
Q

Kidney: relations

A
  • Posteriorly: diaphragm, quadratus lumborum muscle, psoas, subcostal, iliohypogastric, ilioinguinal nerves, 11th + 12th ribs
  • Anteriorly: liver, 2nd part of duodenum, hepatic flexure, spleen, stomach, pancreas, splenic flexure
  • Superiorly: suprarenal glands, pleural reflexion
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29
Q

Kidney: Blood supply and lymphatic drainage

A

Renal arteries bilaterally <- branches of aorta

Renal veins -> IVC

Lymphatics follow arteries -> para-aortic lyph nodes

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30
Q

Renal: What is the significance of left varicocele?

A

Left testicular vein -> Left renal vein -> IVC

(Right testicular vein -> IVC)

RCC on left, invades renal vein -> obstruction of left gonadal (testicular) vein

Left varicocele -> Renal USS

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31
Q

Renal: Nerve supply

A

Renal sympathetic plexus via renal vessels -> pain and vasomotor tone

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32
Q

Renal: Development and anomalies

A

Day 32:

Definitive kidney (metanephros) is induced by the primitive ureteric bud (from the mesonephric duct) to form sacral intermediate mesoderm

The ureteric bud is induced to branch by metanephros, these branches = calyces

Metanephros ascends from the sacral area to the lumbar region

  • Failure to ascent = pelvic kidney*
  • ‘If caught under IMA -> Fuse = Horseshoe kidney*
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33
Q

Liver: Development

A

Develops as ventral endoderm bud within off the gut tube, and forms within the ventral mesentry (attaching to the anterior abdo wall)

The attachment to the anterior abdo wall -becomes-> falciform ligament

The attachment to the gut tube/stomach -becomes-> lesser omentum

(The free edge of the lesser omentums is the point up to which the ventral mesentery involutes embryologically)

In addulthood the liver is almost completely covered in peritoneum with the exception of the bare area of the liver

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34
Q

Liver: Blood supply

A

Liver has a dual blood supply

  1. Portal system: 70%. Products of digestion for liver metabolism
  2. Hepatic Artery: 30%. Oxygenated blood

Drainage = hepatic vein -> IVC

Embryologically, umbilical vein (oxygenated) venous blood from the placenta bypasses the liver via the ductus venosus

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35
Q

Liver: Relations

A
  • Superior: diaphragm
  • Inferior: duodenum, stomach, gallbladder, hepatic flexure
  • Posterior: R kidney and adrenal, retroperitoneum, oesophagus, aorta, IVB
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36
Q

Liver: surface markings

A

Upper border = 6th rib mid-clavicular line

Span = c.12.5cm

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37
Q

Liver: mesenteric attachments and ligaments of liver

A
  • Falciform ligament: 2 layered fold of peritoneum from umbilicus to superior surface of liver, longitudinally
    • superiorly, falciform ligament splits onto 2
      • Right = coronary ligament
        • Right triangular = most extreme part of coronary lig
      • Left = left triangular
  • Lesser omentum: attached to lesser curve of stomach and porta hepatis = ventral mesentery
    • Free edge carries = portal vein, hepatic artery, bile duct
  • Ligamentum teres: obliterated umbilical vein
    • joins left branch of portal vein in porta hepatis
  • Ligamentum venosum: obliterated ductus venosus.
    • Joins left branch of portal vein to be attached to SVC
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38
Q

Liver: Lymphatics

A

Liver produced 1/3rs of body lumph

Lymphatics pass through porta hepatis nodes -> coeliac nodes

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39
Q

Liver: Nerve sypply

A

Coealiac plexus (sympathetic and parasympathetic)

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40
Q

Liver: anatomy

A
  • Largest gland in the body
  • Lies in RUQ of abdo
  • Anatomical lobes: at levels of falciform
    • Right
    • Left = caudate + quadrate
  • Functional lobes:
    • Right & left hepatic arter/portal vein territories, divided at a line drawns from the middle of gallbladder
  • 8 segments:
    • Caudate = 1&2
    • Left (anatomica) = 3&4
    • Right = 5, 6, 7, 8
  • Gallbladder = undersurface of Rt lobs of liver
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41
Q

Median nerve: What is the course of the median nerve?

A

C5, 6, 7, 8, T1 nerve roots

Medial and lateral cords of brachial plexus in axilla

Initially medial to brachial artery, crosses in front

Enters antecubital fossa, passes over corachobrachialis and brachialis, lies MEDIAL to brachial artery in cubital fossa, leaves by passing between 2 heads of pronator teres

Travels in forearm, between FDS and FDP

Gives off Anterior Interosseus N in forearm - runs on interosseus membrane

Gives off palmar cutaneous branch proximal to wrist -> superficial to flexor retinaculum

Enters carpal tunnel and divides into terminal branches -> supply hand

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42
Q

Median nerve: what does it supply?

A

Motor Supply:

  • Flexors of forearm: PT, FCR, PL, FDS
  • Anterior interosseus: FPL, 1/2 FDP
  • Lat lumbricals, opponens pollicis, Abductor pollicis brevis, Flexor pollicis brevis

Intrinsic muscles of hand = ulnar nerve exceps LOAF (from median)

Sensory supply:

  • Lat 3.5 fingers and lat 2/3rds of palm

note - palmar cutaneous br supplies lat palmar skin and is therefore spares by division of median N @ carpan tunnel, whereas if M Nerve is divided in upper arm whol median nerve teritory becomes insensate

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43
Q

Median Nerve: What are the differences between dividing the median nerve at the elbow and wrist?

A

Wrist:

  • most common
  • Loss of sesnation - lat 2/3rds of hand and lat 3.5 fingers
  • loss of motor function of LOAF - test ABductor pollicis brevis for pute median nerve function - point thumb to ceiling with palm upwards and test resisted abduction of thumb (push thimb down and lateral from its base) & Look for thenar wasting

Elbow:

  • 2nd to sharp trauma/supracondular # of humerus
  • Long flexors - medial 1/2 of FDP, FPL, Pronator teres
    • Hand held supinated (loss of pronation)
    • Loss of flexion of dital phalanc of thumb (loss of FPL)
    • index and middle fingers remain straight when asked to make a fist (loss of FDP)
    • Wasting of bulk of flexor compartment of forearm
44
Q

Median nerve: Specific signs for CTS

A
  • Tinel’s test: Tap CT -> electric shock in sensory distribution of nerve
  • Phalen’s test: forced flexion of wrist -> electric shock in sensory distribution of nerve
45
Q

Pancreas: structure

A
  • Exocrine and endocrie gland
  • Retroperitoneal organ, crosses transpyloric plane
  • Divided into head, body, tail
  • Head lies in concavity of duodenum and pancreatic duct drains into 2nd part
  • Tail lies in lienorenal ligament and contacts hilum of spleen. It can be damaged in splenectomy -> distula formation
46
Q

Pancreas: relations

A
  • Posteriorly (Right to Left): CBD, Portal vein, splenic vein, IVC, aorta, SMA, left psoas, left kidney & adrenal, hilum of spleen
  • Anteriorly: transverse colon, transverse mesocolon, lesser sac, stomach
47
Q

Pancreas: blood supply and lymphatic drainage

A
  • Splenic artery, superior and inferior pancreaticoduodenal arteries
  • Corresponding veins drain into portal system
  • Lymphatics follow arteries to coeliac and superior mesenteric nodes
48
Q

Pancreas: nerve supply

A

Sympathetic branches of vagus

49
Q

Pancreas: development and anomalies

A
  • Day 26 D&V pancreatic buds arise from gut tube @ level of duodenum
  • ventral pancreatic bud migrates posteriorly around the duodenum & fuses with dorsal bud -> uncinate prod
  • Anomaly - 2 ventral buds migrate in opposite directions -> annular pancreas
  • Duct systems fuse, ventral ducts -> main pancreatic duct, dorsal duct -> involutes or -> accessory duct of Santorini
50
Q

Phrenic nerve: Course

A

Phrenic nerve, front

51
Q

What would be the effect of a spinal cord transection at C6 on respiration?

A

Phrenic nerve (C3/4/5) would not be involved therefore diaphragm would not be paralysed

HOWEVER

intercostals below would not be spared -> some difficulties ventilating -> LRTI

52
Q

Vagus nerve

A
53
Q

What is the consequence of bilateral recurrent laryngeal nerve division?

A

Rare complication of thyroidectomy

Surgical EMERGENCY

Adduction of both true vocal cords -> acute airway obstruction

-> Surgical cricothyroidotomy & tracheostomy

54
Q

What is a portal circulation? Where in the body would you find one?

A
  • Two sets of capillaries in series
  • Seen in hepatic portal system and the pituitary
  • Pituitary portal system starts as capillaries in hypothalamus and ends in anterior pituitary gland
    • Releases hormones from hypothalamus to pituitary
55
Q

Heparic portal system

A

Portal capilaries in the organs drained (intestinal organs) and ends as capillaries within the liver

Portal vein:

  • formed behind pancreatic neck by union of the superior mesenteric and splenic veins @L2 (R. of midline)
  • 5cm long
  • Runs posterior to 1st part of duodenum
  • Runs in free edge of lesser omentum into porta hepatis, posterior to bile duct and hepatic artery
56
Q

Hepatic portal system: Portosystemic anastomoses

A

Where portal capillaries are in continuation with systemic capillaries

Usual direction of flow is towards the liver, not portal to systemic

Portal hypertension - blood flows portal to systemic & anastomoses dilate

Sites:

57
Q

Radial Nerve: course

A
  • C5-T1
  • Posterior cord of brachial plexus
  • Posterior cutaneous nerve of forearm is given off in axilla
  • Passes between long and medial heads of triceps
  • Passes along humerus in spiral groove posteriorly, accompanied by profunda vessels
  • Pierces (& supplies) anconeus
  • Continues into ACF between brachialis and brachioradialis (& supplies elbow J)
  • In ACF, divides into deep and superficial branches
    • Superficial = sensory = hand
    • Deep = motor = extensors of forearm
58
Q

Radial nerve: Motor supply

A
  • Radial nerve:
    • Triceps, brachialis, brachioradialis
  • Deep radial nerve:
    • Extensors fo forearm: Extensor digitorum, extensor digiti minimi, extensor carpi ulnaris, abductor pollicis longus, extensor pollicis longus, extensor pollicis brevis, extensor indicis
59
Q

Radial nerve: Sensory supply

A
  • Superficial branch of radial nerve:
    • Radial 1.5 fingers dorsally
  • Posterior cutaneous nerve of forearm:
    • Posterior aspect of forearm
60
Q

Radial nerve: What coexisting injuries would you be worries about if a patient suffers a spiral fracture of humerus?

A
  • i.e. division at the level of the spiral groove
  • Superficial and deep branches of radial nerve in forearm
    • loss of sensation and motor
      • paralysis of extensors of forearm (leaving unopposed flexors)
        • Wrist drop
      • loss of synergy of flexors & extensors
        • loss of grip strength
      • paraesthesia over 1st dorsal interosseus
61
Q

Salivary glands: Parotid Gland Anatomy

A
  • Paired
  • Largest
  • Serous
  • Wedge shaped
  • Surrounded by connective tissue capsule - investing layer of deep cervical fascia
  • Divided into superficial and deep lobes by 5 division of facial nerve
  • Overlies angle of the mandible
  • Superior margin extends behind TMJ
  • Anterior margin superficial to masseter
  • Deep part between medial pterygoid and ramus of mandible
  • Parotid duct - from facial process of glant (anterior aspect) over masseter. Pierces buccinator, runs submucosal course, until opens into papilla opposite upper 2nd molar tooth
62
Q

Salivary glands: Parotid Gland Content

A
  • Facial nerve - and branches:
    • Temporal/zygomatic/buccal/marginal mandibular branch/cervical branch
  • Retromandibular vein
  • External carotid artery
  • Parotid lymph nodes

Note - superficial parotidectomy spared the facial nerve

63
Q

Salivary glands: Parotid Gland

Blood supply

A

External carotid artery

64
Q

Salivary glands: Parotid Gland

Lymphatic drainage

A

Parotid and deep cervical nodes

65
Q

Salivary glands: Submandibular glands anatomy

A
  • Paired
  • Serous and mucinous acini
  • Connective tissue capsule, derived from investing layer of deep cervical fascia
  • Superficial and deep part - in continuity with each other around posterior border of mylohyoid
    • Superficial part lies within digastric(anterio) triangle of neck
66
Q

Salivary glands: Submandibular glands Relations

A
  • Lateral: medial aspect of mandible, facial nerve (cervical), facial vein
  • Medial: hyoglossus, styloglossus
  • Anterior: Anterior belly of digastric
  • Posterior: stylohyoid, posterior belly of digastric, lingual N, hypoglossal N
  • Superiorly: lingual N
  • Inferiorly: Hypoglossal N
67
Q

Salivary glands: Submandibular glands

Blood supply

A

Facial and lingual arteries

68
Q

Salivary glands: Submandibular glands

Lymphatic drainage

A

Submandibular, deep cervical nodes

69
Q

Salivary glands: Submandibular glands

What is at risk during excision?

A

If incision is made low - Medibular branch of facial N -> angle of mouth will droop

70
Q

Salivary glands: Sublingual glands anatomy

A
  • Smallest
  • Paired
  • Serous and mucinous
  • Submucosally near midline
71
Q

Salivary glands: Sublingual glands relations

A
  • Anterior: opposite gland
  • Posterior: Deep submandibular gland
  • Medial: Genioglossus, Lingual N
  • Lateral: Mandible
  • Inferior: Mylohyoid muscle

Serveral ducts open into the floor of the mouth adj to submandibular duct opening

72
Q

Stomach: Parts

A
  • Fundus
  • Carida
  • Body
  • Antrum
  • Pylorus

J shaped

73
Q

Stomach: Relations

A
  • Anterior: Abdo wall, left costal margin, diaphragm, left lobe of liver
  • Posteriorly: lesser sac (seperates stomach from pancreas), transverse mesocolon, left colic flexure, upper pole of left kidney, left suprarenal gland, spleen and splenic artery
  • Superiorly: left dome of diaphragm

Lesser omentum is attached along lesser curvature of stomach, greater omentum along greater curvature

Omenta contain vascular and lymphatic supply of stomach

74
Q

Stomach: Blood supply

A
  • Left gastric artery - coeliac axis
  • Right gastric artery - hepatic artery
  • Right gastroepiploic artery - gastroduodenal branch of hepatic artery
  • Left gastroepiploic artery - splenic artery
  • Short gastric arteries - splenic artery

Both sets anastomose with each other and gastric curvatures

during oesophagectomy - short gastrics, left gastroepiploic, left gastric arteries are divided to mobilise upper part of stomach in order to form neo-oesophagus

Stomach then derives its blood supply solely from R gastric and R gastroepiploic arteries

75
Q

Stomach: Venous drainage

A

Corresponding veins (as per arterial supply) which then drain into portal system

76
Q

Stomach: Lymphatic drainage

A

3 drainage zones:

  1. Area I: Superior 2/3rds drain along left and right gastric vessels to aortic nodes
  2. Areal II: R 2.3rds of inferior 1/3rd drains along R gastroepiploic to subpyloric nodes to aortic nodes
  3. Area IIIL left 1.3 of greater curvature along short gastric arteries and splenic vessels in gastrosplenic and lienorenal ligaments, via suprapancreatic nodes to aortic group

Clinical implications: extensive lymphatic drainage and technical difficulty of complete removal makes stomach cancer surgery v difficult with poor results.

Nodes around splenic vessels - removal of spleen and ligaments, body and tail of pancreas

Gastroepiploic LN - excise greater omentum

v. difficult to remove LN around aorta and head of pancreas!

77
Q

Stomach: Gastric innervation

A
  • Anterior and posterior vagi - motility and secretion
  • Both vagi enter via oseophageal hiatus
  • Anterior vagus:
    • Lies close to stomach wall
    • supplies cardia, lesser curve, runs with left gastric artery
    • aka anterior nerve of Latarget
    • branches to anterior stomach and large hepatic branch to pyloric antrum
  • Posterior vagus:
    • Back of lesser omentum behind anterior trunk
    • aka posterior nerve fo Latarget
    • Supplies ant and post aspect of body of stomach
    • Bulk of nerve = coeliac branch

Truncal vagotomy

  • Management of complicated peptic ulcer disease
  • both trunks at lower oesophagus -> reduced gastric secretion & paralysis of pyloric antrum
  • resultant gastric stasis requires drainage procedure
    • .e.g pyloriplasty/gastrojejunostomy
  • Highly selective vagotomy - targets nerves supplying acid production @body/antrum, spares pylorus
  • Posterior truncal vagotomy - spared anterior pyloric nerves
    • coupled with anterior seromyotomy
78
Q

Thyroid gland: anatomy

A
  • 2 lobes - L & R
  • Connected by isthmus
  • Occasionally 3rd, pyramidal, lobe - projecting up from isthmus
  • Surrounded by sheath derived from pretracheal layer of deep cervical fascia
  • Anterior triangle of neck
  • Follicular tissue -> Thyroxine (T4) and Triiodothyronine (T3)
  • Medullary C-Cells -> Calcitonin
79
Q

Thyroid: Relations

A
  • Posteriolateral: carotid sheath - common carotid artery, internal jugular vein, vagus nerve
  • Anterolateral: strap muscles
  • Medially: larynx, trachea, oesophagus, recurrent laryngeal N (breanch of vagus N in groove between trachea and oesophagus)
80
Q

Thyroid: blood supply

A
  • 2 arteries - superior, inferior
  • 3 veins - superior, middle, inferior
  • Superior thyroid artery - br of external carotid
  • Inferior thyroid artery - br of thyrocervical, from subclavian
  • Superior and middle thyroid V - internal jugular V
  • Inferior thyroid V - left brachicephalic V
81
Q

Thyroid: lymphatic drainage

A

Deep cervical nodes

82
Q

Thyroid: Development

A

derived from foramen cecum @ divide between ant 2/3rds and post 1/3 of tongue, guided by thyroglossal duct to final position (ant to trachea)

Thyroglossal duct hooks behind hyoid bone - must be excised with central part of hyoid bone in duct excision during Sistrunk’s operation

83
Q

Parathyroid gland: anatomy

A
  • 4
  • PTH and in turn mediat calcium homeostasis
  • Ochre in colour but stained by methylene blue -> blue
  • 2 superior glands = posterior border at level of mid-thyroid
  • 2 inferior glands = at inferior thyroid, can lie in thyrothymic ligament or superior meiastinum
  • Supplied by superior and inferior thyroid arteries
84
Q

Surface marking of gallbladder

A

9th costal margin mid clavicular line

85
Q

Subcostal plan

A

Across lower margins of thoracic cage formed by 10th costal cartilage on each side

Level of 3rd lumbar vertebra

Level of origin on IMA

86
Q

Where is the transpyloric plane?

A

AKA transpyloric plane of addison

Perpendicular line connecting jugular notch and pubic symphysis

Passes through L1

1/2 way between xiphisternum and umbilicu

Surfact anatomy c. hand’s bredth below xiphoid process

87
Q

What structures are found at the transpyloric plane?

A
  1. fundus of gallbladder
  2. lower border of L1 vertebra
  3. End of spinal cord
  4. Pylorus of stomach
  5. Neck of pancreas
  6. Attachment of transverse mesocolon
  7. SMA - branching off aorta
  8. Portal V - formed from superior mesenteric vein & splenic vein
  9. Hilum of spleen
  10. Hilum of kidneys and their vascular pedicles
  11. Duodenojejunal junction
88
Q

What level does the umbilicus bifurcate

A

L4 - level of umbilicus - dermatome T10

89
Q

Triangles of neck: names

A

Posteriorr triangle

Anterior traingle:

  • Carotid
  • Digastric
  • Submental
  • Muscular
90
Q

Posterior triangle: borders

A
  • Anterior: posterior border of SCM
  • Posterior: Anterior boder of trapezium
  • Inferior: clavicle
91
Q

Posterior triangle: Contents

A
  • Muscles (floor): splenius capitis, levator scapulae, scalenus medius (scalenus anterior, serratus anterior)
  • Nerves: Br of cervical plexus, spinal accessory nerve (from 1/3rd way down posterior border of SCM to trapezius); trunks of brachial plexus
  • Other: LN (occipital/supraclavicular), subclavian artery. Transverse cervical and suprascapular vessel

The Trunks are in The Triangle

92
Q

Anterior triangle: borders

A
  • Midline
  • Posterior border of SCM
  • Ramus of mandible
93
Q

Anterior triangle: borders of subtriangle

A
  • Carotid: SCM, post belly of digastric, sup belly of omohyoid
    • Key content: common and ext carotid artery
  • Digastric triangle: mandible, anterior and posterior bellies of digastric
    • Key content: submandibular gland
  • Submental triangle: ant bellies of digastric, body of hyoid
    • Key content: ant jugular veins
  • Muscular triangle: sternocleidomastoid, superior belly of omohyoid, midline
    • Key content: larynx, trachea, thyroid gland, parathyroid gland
94
Q

Anterior triangle: subtriangle key contents

A
  • Carotid: Key content: common and ext carotid artery
  • Digastric triangle: Key content: submandibular gland
  • Submental triangle:Key content: ant jugular veins
  • Muscular triangle: Key content: larynx, trachea, thyroid gland, parathyroid gland
95
Q

Anterior triangle of neck: contents

A
  • Suprahyoid muscles
    • digastric, styohyoid, mylohyoid, geniohyoid
  • Strap uscles:
    • thyrohyoid, sternothyroid, sternohyoid
  • Nerves:
    • Ansa cervicalis, hypoglossal, vagus
      • recurrent and external laryngeal nerves (from vagus)
  • Vessels:
    • common carotid artery + bifurcation, branches of external carotid artery, jugular vein
  • Other:
    • Thyroid gland, parathyroid gland, submandibular gland, trachea, oesophagus
96
Q

Ulnar nerve: Course

A
  • Origin: C7/8/T1 roots
  • Medial cord of brachial plexus, in axilla
  • Runs between axillary artery and vein, in upper arm
  • Lies on coracobrachialis, medial to brachial artery
  • Passes behind medial epicondyle of humerus
  • Passes between 2 heads of FCU (supplies it)
  • Lies between FDP and FCU
  • Passes superficial to carpal tunnel
  • Divides into terminal br at pisiform
97
Q

Ulnar nerve: Motor supply

A
  • Forearm: ulnar 1/2 of FDP, FCU
  • Intrinsic hand muscles, with exception of LOAF (median N)
98
Q

Ulnar nerve: what is ulnar paradox

A

Division of ulnar N : wrist -> severely clawed ulnar fingers due to loss of lumbrical and interossei innervation (FDP remains in tact giving flexion)

Division of ulnar N : elvor -> less severely clawed hand as intrinsic AND FDP are loss resulting in less flexion of ulnar 2 fingers

99
Q

Ulnar nerve: What do the lumbricals do and how many are there?

A

4 lumbrical muscles

lateral 2 = median nerve

medial 2 = ulnar nerve

Originate from FDP tendons, Insert into corresponding extensor expansion

Act to flex the metacarpophalangeal joints and extend the interphalangeal joints

In conjunction with interossei enable coordination of fine movements of fingers e.g. writing/playing musical instrument

100
Q

Ulnar nerve: What do the interossei do and how many are there?

A

4 palmar and 4 dorsal interossei

supplied by ulnar nerve

Origin: metacarpal base

Insertion: proximal phalanx

Palmar interossei adduct

Dorsal interossei: aBduct

PAD DAB

101
Q

Ulnar nerve: Sensory supply

A

medial 1.5 fingers and medial 1/3rd of palm

102
Q

Clinical test for ulnar nerve

A

Wasting of small muscle of hand - hypothenar eminence

Test grip of paper between middle and ring finger

Froment’s sign - grip paper between thumb and lateral aspect of forefinger -> patient will flex thumb as adductor is lost

Sensory distribution - loss of medial 1.5 fingers and medial 1/3rd of palm

103
Q

Ureter: Course and relations

A
104
Q

Ureter: Key facts

A
  • 25cm long
  • Lined by transitional epithelium - possible TCC
  • Blood supply
    • Superiorly: ureteric branch of renal artery
    • Inferiorly: superior vesiccal and gonadal
    • Middle: aorta, gonadal, iliac vessels
  • Lymph drainage - with arteries
    • superior: para-aortic LN
    • inferior: iliac LN
  • Autonomic nerve supply - pain fibres accompany sympathetics
105
Q

Ureter: course of the ureter on a KUB film

A

passes down level with tips of transverse processes of lumbar vertebrae, commending at medial aspect of kideny

Turns medially at level of ischial spine

Points of narrowing:

  1. Pelviureteric junction (PUJ)- over brim of pelvis
  2. Vesicoureteric junction (VUJ) - at point of entry to the bladder

^points of impaction of ureteric stone

106
Q

What organs are palpable in the normal abdomen?

A

Aorta

lower pole of left kidney

Pathological: hepatomagaly, splenomegaly

RLH MRCS (22 decks)

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