EMRCS Flashcards
Tissue Processing Steps
1) Place specimen in vessel for transport
2) Clear labelling with patient details + provision of clinical details
3) Treatment with saline/formalin
4) Tissue Fixing
5) Impregnation with wax
6) Microtome cutting / embedding
7) Staining - H&E + Immunohystochemistry
Method of assessment for intraoperative tissue assessment
1) Call pathology department to warn of frozen section
2) Tissue taken to pathology department
3) Tissue cut
4) Frozen in liquid nitrogen
5) Cut using cryostat
6) Staining
7) Examined by pathologist
Why might cytology not be adequate for assessment of disease?
Architectural elements of certain pathologies are important:
Capsule Breach
Basement membrane intact
Formation of psuedocysts
Formalin:
- Frozen Section or Embedded Section?
- How does it work?
Formalin Fixation is used in the Embedded Section process - this is not used intraoepratively/ in emergency
- Used in conjunction with wax and in general is better in terms of quality than Frozen sections
- time consuming process
Works by causing crosslinking of collagen fibres maintaing architectural integrity of samples.
Clostridium Difficile
- Basic Bacteriology
- Toxins
- What facilitates its transmission
- What is a spore
- Risk Factors
- Drugs used for treatment of C Diff
- Treatment of Toxic Megacolon
Gram Positive, Spore Forming Rod - Facultative Anaerobe
Toxins - Enterotoxin A and Cytotoxin B
Spread - is conferred through highly resistant spores
Spore - spores are one cell organisms capable of giving rise to new individual organisms without sexual fusion
Risk Factors - Antibiotics, Anti Acids, Transmission
Treatment - Metronidazole PO, Vancomycin PO, Fidoxamicin
Toxic Megacolon - Resuscitate patient. Usually no place for further antibiotics. Laparatomy - Subtotal Colectomy + End Ileostomy Formation
Factors Reducing the rate of SSIs:
6
Do wound protectors reduce the risk?
1) Not shaving
2) Good sterility practice
3) Perioperative/Postoperative antibiotics
4) Skin Prep
5) Not using incise drapes - Non idoine drape if necessary
6) Use a knife rather than diathermy for skin incision
Wound protectors have not demonstrated reduced risk
Key acute inflammation features
1) Vasodilation
2) Protein Rich Exudate
3) Neutrophils/Mast Cells –> Macrophages/Lymphocytes
Why do abscesses form?
1) High Microbial Load at site
2) Anatomical Factors Causing confinement of the exudate
3) Hypoxic core of abscess leads to imedence of the normal pathogen eradication mechanisms (Free Radicals, phagocytosis)
Definition:
Empyema
Histological Diagnostic Feature of acute inflammation
Metaplasia
Fournier’s Gangrene
Empyema - Formation of pus in a hollow viscus
Presence of neutrophils are a histological diagnostic feature of acute inflammation
Metaplasia - Transformation of specialised epithelium to another
Fourniere’s Gangrene - Synergistic infection - necrotising fascitis of the scrotal area
Sequelae of acute inflammation (4)
Resolution
Organisation - Fibrosis formation
Suppuration - Formation of abscess/empyema
Chronic Inflammation - Balance between inflammation and reparation
Amyloid Protein Types:
Most common sites (2)
Diagnosis
AL - Myeloma
AA - Chronic Inflammatory Conditions (rhemuatoid, ank spond)
Common Sites for amyloid Deposition:
Heart and Kidney
Diagnosis:
Congo Red Stain
Birefringence of polarised light
Barrett’s histology
Worry with finding of dysplasia in sample
Treatment options for severe dysplasia as a finding
Specifics regarding biopsies
Treatment of barratt’s
Barrett’s:
Change from squamous cell in oesophagus to columnar epithelium + goblet cells
Dysplasia Finding in biopsy:
May be the case that there is a missed foci of cancer that has not been picked up
Severe Dysplasia Treatments:
Photodynamic therapy, Endoscopic submucosal resection, lasar ablation + Segmental Resection
Biopsies should be :
Quadrantic and at 2-3 cm intervals/ Time interval 2 -5 years
Barratt’s Treatment:
PPI, Lifestyle modification.
Regular Endoscopy
Consider pH and manometry - ?Anti GORD procedure
Altered Tissue Perfusion, Sepsis and Cutaneous Anaesthesia
Cause
Types
RFs
Mx
Necrotising Fascitis - Altered Tissue Perfusion, Sepsis and Cutaneous Anaesthesia
Cause-Sometimes trauma. Mixed Antibiotics (Group A Strep + Anaerobes)
Types - I - Polymicrobial, II- Group A Strep, III - Clostridium Perfringens
RFs - Immunosuppresion, PAD, DM
Mx - Investigations Resusc, Broad Spec Antibiotics, Surgical Debridement (Wide Debridement, return to theatre every 24o
- Internal Oblique
- Anterior Rectus Sheath
- Rectus Abdominis
- Transversus Aponeurosis
- Conjoint tendon
- Inguinal Ligament
- Spermatic Cord
- External Spermatic Fascia
- Ilioinguinal Nerve
Define :
1) Borders of inguinal canal
2) What is the inguinal canal
3) What is the Superficial ring
4) What is the deep ring
5) Spigellian Hernia
6) Borders of hasselbach’s triangle
1) Inguinal Canal:
Anterior - External oblique aponeurosis
Roof - Transversalis Fascia, Internal Oblique + Transversus Abdominus
Floor- Inguinal Ligament (continuous with external oblique aponeurosis) + Lacunar Ligament (medially)
Posterior - Transversalis Fascia
2) Inguinal canal:
Oblique muscular canal connecting the preperitoneal space at the deep ring to the superficial ring beneath the skin at the pubis
3) Superficial Ring is a defect in the inguinal ligament (EO aponeurosis) medial to pubic tubercle
4) Deep ring is a defect in the transversalis fascia 1cm above amove midpoint of inguinal ligament
5) Spigellian hernia:
At the level of arcuate line. Hernia between:
Laterally - Semilunar line and
Medially - Lateral rectal muscle
Through- spigellian fascia
6) hasselbach’s triangle
Medial - Lateral border of rectus muscle
Lateral - Inferior epigastric vessels
Inferior - Inguinal ligament
Rectus Abdominus:
1) Origin
2) Insertion
3) Two bands divided by
4) innervation
Rectus Abdominus
1) Origin - Xiphoid process, 5th, 6th, 7th Costal cartilages
2) Insertion - Pubic Crest, symphysis, tubercle
3) Two bands divided by linea alba
4) innervated by - Lower 6th Thoracic Nerves
External Oblique
1) Origin
2) Insertion
3) innervation
External Oblique
1) Origin - 5th-12th Rib
2) Inserts - Linea ALba, pubic crest, pubic tubercle, anterior half of iliac crest
3) Innervated by lower 6th thoracic nerve
Internal Oblique
1) Origin
2) Insertion
3) Innervation (as well as transversus abdominus)
Internal Oblique
1) Origin - lumbar fascia, iliac crest, inguinal ligament
2) insertion - linea alba, and pubic crest
3) Innervated by lower 6th thoracic nerves, iliohypogastric nerve + ilioinguinal nerves
Contents of inguinal canal
Contents of spermatic cord
Inguinal Canal
Spermatic Cord (male)
Round ligament (female)
+
Ilioinguinal Nerve
Spermatic Cord (Four Threes)
Fascia - External spermatic (EO aponeurosis), cremasteric (IO Aponeurosis), internal spermatic (Transv. Fascia)
Artery- Testicular, Cremasteric, Artery of vas
Nerves- Genitofemoral (genital branch), Ilioinguinal, Sympathetic nerves
Others- Vas deferens, Pampiniform venous plexus, Lymph
Methods of inguinal hernia repair:
6
1) Laparoscipic (TAP or TEP)
2) Lichtenstein mesh repair - reinforce transversalis fascia
3) Mesh plug - occludes the deep ring
4) Bassini Repair - Opposes conjoint tendon of the medial posterior wall of inguinal canal (aponeurosis of IO and TA muscles) and the inguinal ligament
5) Darn repair - sutures between the conjoint tendon and inguinal ligament
6) Shouldice Repair - open inguinal canal and running sutures approximating the musclular/fascial components
- Rectus Abdominus
- Transversus Aponeurosis
- Peritoneum
- Inferior Epigastric Artery
- Testicular Artery
- Artery of vas
- Ductus deferens
- Pampiniform Plexus
- Internal Spermatic Fascia.
- External Spermatic Fascia
- Testes.
- Tail of epididymis
Definitions:
Femoral Canal
Femoral ring/canal boundaries
Femoral Triangle boundaries
Contents of femoral triangle
Hunter’s Canal Borders
Hunter’s Canal contents
1) Femoral Canal is the medial compartment of the femoral sheath that opens into abdomen via femoral ring - contains Cloquet’s LN and Lymph vessels
2) Fem Ring Boundaries:
Ant - Inguinal Ligament
Post - pectineal ligament
Medial - Lacunar Ligament
Laterally - Femoral Vein
3) Femoral Triangle:
Lateral - Sartorius
Medial - Adductor Longus
Superior - inguinal ligament
Floor - pectineus, adductor longus, illiopsoas
Roof - Fascia Lata
4) Contents of femoral triangle:
Femoral nerve, sheath, artery, vein (great saphenous + deep femoral), deep inguinal lymph nodes
5) Hunter’s Canal (tunnel from femoral triangle to opening in adductor magnus [hiatus])
Anteriorly - Sartoritus
Posteromedially - adductor longus and magnus
laterally - vastus medialis
6) Contents of hunter’s canal
Femoral artery, vein, saphenous nerve, nerve to vastus medialis
Inguinal vs Femoral hernias
Palpation
Strangulation
Structures at risk in fem hern surgery
Palpation :
Inguin. - above and medial to Pubic Tub.
Fem. - below and lateral to pubic tub.
Strangulation:
Fem - more likely to strangulate as canal is narrow + lacunar ligament is robust and sharp
Danger to Femoral vein + abhorrent obturator artery in fem hern. surgery
- ASIS
- Pubic Tubercle
- Inguinal ligament
- Fem Vein
- Fem ARtery
- Fem Nerve
- Femoral Branc. of Genitofemoral nerve
- Sup. Ext. Pudendal Artery
- Great Saphenous Vein.
- Lat. Circ. Artery (Ascending)
- Lat. Circ. Artery Proper
- Intermediate Cutaneous nerve of thigh
- Psoas Major
- Iliacus
- Sartorius
- Pectineus
- Adductor Longus
Femoral Artery
Branches
1- suprainguinal
5 - infrainguinal
Suprainguinal (before inguinal ligament)
Inferior epigastric artery
infrainguinal
Superficial External Pudendal
Deep external pudendal
Superficial Circumflex iliac
Superficial epigastric
Profunda femoris artery - after which CFA continues as SFA. Profunda femoris itself gives off medial and lateral circumflex arteries
Emryological Divisions of gut and their blood supplies
Foregut - to Major duodenal pappilla Coeliac Trunk
Midgut - From major duodenal papilla to 2/3 transverse colon SMA
Hindgut - to ectodermal anal canal - IMA
1-9
1 - Aorta 2- IMA 3- CIA 4 - EIA
5 - Superior Rectal Art. 6 - Gonadal Artery
7 - Inferior Vena Cava 8 - Left Common Iliac Vein 9 - Portal Vein
23- 28
23 -Lat. Cut. nerve of thigh. 24 - Femoral N.
25 - Obturator Nerve
26 - Genital branch of genitofemoral nerve
27 - Femoral branch of genitofemoral nerve
28 - Ilioinguinal nerve
10-22
10 - Gall bladder 11 - Liver
12 - Pancreas 13 - Spleen 14 - Kidney
15- Transversus Abdom. 16 - IO 17 - EO
18 - QL 19 - Iliacus 20 - Psoas Major
21 - Ureters 22- Inguinal Ligament
Aorta:
Structures to its right immediatel below diaphragm
to the left
Branches
Subdiaphragmatic: (passes through T12)
Right - IVC, azygos vein, right sympathetic trunk, thoracic duct
Left - Left sympathetic trunk
Branches:
Phrenic Arteries - Immediately subdiaphragmatic
Coeliac Axis - T12
SMA - L1
Renal arteries - L2
Gonadal Arteries - L2 (more centrally from aorta)
IMA - L3
Some lumbar and sacral arteries
Aorta bifurcates at L4 - Common iliac arteries (branch at SI joint)
What is supplied by the internal iliac artery?
Pelvic Organs, Perineum, Buttock and Anal Canal
Retroperitoneal Organs
SAD PUCKER
S - uprarenal glands
A - orta/IVC
D - uodenum (2nd + 3rd)
P - ancreas (except tail)
U - reters
C - olon (ascending and descending)
K - idneys
E - osophagus
R ectum (upper 2/3)
Pancreas
Arterial SUpply
Arterial Supply :
1) splenic artery - arteria pancreatica magna
2) Superior pancreaticoduodenal artery - (GDA) head and uncinate
3) Inferior Pancreticoduodenal artery - (SMA) head and uncinate
Spleen
Size
Relaions
Ligamentous Attachments
Vasculature
Size
1 inch by 3 inch by 5 inch and weighs 7 oz
Relations
9th-11th ribs (left)
Anterior- Stomach
Posterior - Diaphragm
Medial - L Kidney
Inferior - Splenic flexure of colon
Ligamentous attachments
Gastrosplenic Ligaments - spleen to greater curv stomach (conveys short gastr + L gastroepiploeic vessels)
Lienorenal ligament - spleen to post. abdo wall (conveys splenic vessels)
Vasculature (In lienorenal ligament)
Splenic Artery - from coeliac trunk
Splenic vein - Joins with SMV to form PV
Main sites of portosystemic anastamosis
5
Oesophageal Veins - L Gastric Vein(port) –> Azygos vein (systemic)
Rectal Veins - Superior rectal vein (port)–. inferior rectal vein (syst)
Retroperitoneal - mesenteric veins (port) –> retroperitoneal veins (syst)
Abdominal Wall - Portal veins –> Abdominal wall veins (via falciform ligament)
Diaphgram - Portal veins –> Diaphragmatic veins
Describe:
Greater Omentum
Lesser Omentum
Mesentery
Omentum - double fold of peritoneum
Greater:
Drape over the small intestine. Originate from greater curve of stomach + duodenum then fold over the intestine and enfold the transverse colon
Lesser:
Extend from the liver to the lesser curvature of stomach and duodeunum. 2 ligaments - hepatogastric + hepatoduodenal ligament
Mesentery:
Folds of peritoneum attached to the abdominal wall enclosing visceral components. Rich vascularity.
Notable mesentery - Small intestine, transverse mesocolon, sigmoid mesocolon,
Oesophagus:
Anatomical Extent
Divisions
Vascular Supply
Innervation
Anatomical Extent - from cricoid cartilage to the cardiac orifice of stomach
Divisions-
Cervical - Cricoid to Superior Mediastinum
Thoracic - Superior Mediastinum to Diaphragm (t10)
Abdominal - Diaphragm to stomach
Vasculature -
Arterial - Thoracic (Inferior thyroid artery/Thoracic Aorta) + Abdominal (Left Gastric Artery)
Venous - Thoracic (Inf. Thyr. Vein/ Azygous Vein) + Abdominal (L Gastric Vein- port. + Azygous Vein - system.)
Innervation-
Vagus nerve - peristalsis and glands
Cervical and thoracic sympathetic trunk
Oesophageal Narrowings
Oesophageal Sphincters
Narrowings
1) Level of cricoid cartilage
2) Aortic Arch (crosses)
3) Left Main Bronchus ( Crosses)
4) Through the diaphragmatic arpeture
Sphincters - closed unless swallowing.
Upper - Skeletal muscle (non-voluntary) surrounding the upper oesphagus - predominantly cricopharyngeus
Lower - Surrounding cardio-oesophageal junction
Swallowing.
Describe the process
Describe swallowing
Epiglottis moves posteriorly to cover larynx
Upper sphincter relaxes + peristalsis in the oesophagus begins
Lower sphincter relaxes in tandem with peristalsis
1- Oesophagus 2 - GOJ 3 - Cardia
4 - Fundus 5 - Body 6- Pyloric Antrum
7- Pyloric Canal 8 - Pyloric Sphincter
9 - 1st part duodenum 10- Lesser Curvature
11 - Greater Curvature
Stomach Anatomy:
Arterial Supply (5)
Arterial:
Lesser Curve:
Left Gastric Artery - Coeliac trunk
Right Gastric Artery - Hepatic Artery
Greater Curve:
Left Gastroepiploic artery - Splenic artery
Right Gastroepiploic artery - GDA (Hepatic artery)
Short Gastric Artery - Splenic Artery
Gastric Ulcers:
Lesser Curve
Greater Curve
Lesser Curve - can erode into L/R Gastric Arteries
Greater Curve - can erode into pancreas
1 - 13
1 - Portal Vein 2 - Splenic Vein 3 - Sup. Mes. V
4- Common Hepatic 5 - GDA 6 - Coeliac Trunk
7- Splenic artery 8 - L Gastr. ARt. 9 - R Gastr. ARt.
10 - Sup. Pancreaticoduodenal art.
11 - R Gastroepiploic art. 12- L gastroepiploic Art. 13 - Splenic art/ short gastr.
14-23
14 - CBD 15 - Cardia of stomach 16 - Fundus of stomach
17 - Body of stomach 18 - lesser curvature
19 - greater curvature 20 - Pyloric antrum
21 - pyloric Sphinceter 22 - 1st part duodenum
23 - Greater omentum
What are the features of gastric innervation
Parasympathetic - Vagus Nerve (Through T10 diaphgramatic arpeture).
Known as nerves of laterjet
R Vagus - Posterior Nerve of laterjet - coeliac branch and continues over post. surface. of stomach
L Vagus - Anterior Nerve of Laterjet - Hepatic + Pyloric branches - supplying sphincter
Both descend from the cardia passing along the lesser curvature
Sympathetic - Splanchnic nerve (derivative T5-T10) - synapse in coeliac axis
Types of Gastrectomy
Vagotomy - effect on stomach
Bilroth I - Distal Gastrectomy - direct anastamoses to duodenum
Bilroth II - Partial gastrectomy - Blind ended proximal duodenum.
Roux en Y gastrectomy - Ileum opened and stomach anastamosed to ileum. Duodenal distal end anastamosed distally to small bowel and proximal duodenum closed
Vagotomy - causes reduced acid production and dysmotility ( coupled with a pyloroplasty/ gastrojejunostomy)
Selective vagotomy - selects for acid producing fibres
Describe Gastric Dumping:
Caused by pyloric sphincter deficiency
Early - Fast passage of hyperosmolar load into small intestine leads to fluid shifts –> Hypovoloemia
Late - Fast passage of carbohydrate leads to insulin spike and subsequent hypoglycaemia 2-3 hours after meal
What is the Z line of the upper GI tract?
Z line - is at the GOJ. Where the epithelium changes from squamous (oesophageus) to columnar
Beyond the Z line the gastric cardia begins
Blood Supply
How long is the sigmoid colon
How long is the rectum
What is the watershed region of the large intestine
Blood Supply
- SMA - Ileocolic artery, Right Colic Artery, Middle Colic Artery
IMA - Left Colic Artery, Sigmoid Artery, Superior Rectal Artery
Marginal Artery of drummond - a long straight vessel formed as a result of anastamosis from contributing vessels to the colon. Runs in inner side of colon.
Sigmoid colon is 40 cm long
Rectum is 12 cm long beginning at 3rd sacral vert.
Watershed region also known as Griffith’s Point is where the anastamsosis between IMA and SMA are weaker 2/3 along the transverse colon
Appendix
What is it
Possible positional variants
Why the propensity to necrosis?
Why do caecums perforate
Appendix is a blind ending tubular structure originating from the caecum
It is usually
i) retrocaecal or ii) retrocolic
but can also be
iiI) pelvic iv) pre-ileal or v) retroileal
Appendices undergo rapid necrosis as appendicular arter is an end artery therefore if compromised the appendix becomes ischaemic rapidly
Caecum perforate - thin walled and an intact ileocaaecal valve prevent the dispersion of pressure
Large Bowel Vasculature
Broadly supplied by the SMA and IMA (connected via the marginal artery) :
SMA :
Ileocolic Artery
Right Colic
Middle colic
IMA:
Left Colic
SIgmoid Artery
Superior Rectal ARtery
Middle rectal artery from the IIA
Inferior rectal artery from the internal pudendal artery
How is the transverse colon suspended?
What are the two main anatomical variants of the descending colon?
It is held up by the:
i) Greater omentum which originates from the greater curvature of stomach + first part of duodenum drapes across the small intestine and envelops the transerve colon
ii) Transverse mesentery/mesocolon which is connected to the posterior abdominal wall
Descending Colon is usually i) retroperitoneal but when ii) intrapertioneal has a short mesentery
1-10
1- Falciform Ligament 2- L/R Triangular Ligaments
3 - Coronal Ligament 4 - IVC
5 - Portal Vein 6- Common Hepatic Duct
7 - Hepatic Artery 8 - Bare Area
9 - Diaphragmatic Surface 10 - Visceral Surface
11-15
11 - Gall Bladder 12 - Quadrate Lobe 13 - caudate lobe
14- right lobe 15 - left lobe
epiploic foramen
What’s Pringle’s Manouvere?
Is a window (foramen of winslow) connecting the greater peritoneal sac to the lesser peritoneal sac.
Boundaries:
Anteriorly - hepatoduodenal ligament (Bile Duct L, Hepatic artery R, PV behind)
Posteriorly - IVC
Inferiorly - 1st part of duodenum
Superiorly - caudate lobe of liver
Pringle’s Manouvere :
Compression over the hepatoduodenal ligament helps control bleeding from liver/ cystic artery
Anatomically Divide the liver
Functionally Divide the liver
Structures in the porta hepatis
Anatomically
R + L
Anteriorly - falciform ligament
Posteriorly - teres + venosum
Functionally
Divided by a plane through the gall bladder fossa + IVC fossa - this signifies a distinct blood supply/biliary drainage for each half
Porta hepatis (ant. to post.)
Common Hepatic Duct > hepatic artery > portal vein
+ nerves + lymph
1-9
1- Right Hep. Duct 2- Gall Bladder 3 - Cystic Duct.
4- Left hep. duct 5 - Common hep. duct
6 - CBD 7 - Pancreat. Duct 8 - Sphinct. of oddi
9 - 2nd part of duodenum
1) Where do the R and L Hep. Ducts Join
2) Blood supply of the Gall Bladder
3) Describe Calot’s Triangle Borders
4) Describe Calot’s Triangle Contents
5) What do GB stones cause
6) What do CBD stones cause
1) The two hepatic ducts join at the porta hepatis to become the common hepatic duct
2) Mainly cystic artery (R Hep. Artery) and partially small arteries from liver bed. Venous drainage directly into the liver bed
3) Calot’s Triangle - Med. CHD Lat. Cystic Duct. Superiorly - Liver
4) Contents - R Hep Art, Lund LN, ?Cyst. Artery
5) GB stones - colic, cholecystitis, gallst. ileus
6) CBD Stones - Jaundice, ascending cholangitis
What interventions can be performed through ERCP?
Main risks of ERCP?
Interventions
i) Sphincterotomy ii)Stone removal
iii) Stent Insertion iv) Balloon dilatation
Risks
Pancreatitis, Cholangitis, Biliary system damage, bowel damage, failure
1-17
1- R Kidney 2 - L Kidney
3- Upper pole 4 - Lower pole
5- R ureter 6- L Ureter (bifid)
7 - Renal Art. 8 - aorta 9 - IMA
10 - CIA 11 - SMA 12 - Coeliac Trunk
13- Common Hepatic Artery 14- Splenic Artery
15 - Segment. Arteries (renal) 16 - Ileal/ Jejunal arteries
17 - L Gonadal Vein
1) Which Kidney Sits Higher?
2) L Renal Vein vs R Renal Vein
3) L Renal Art vs R Renal Art
4) describe path of R ureter
1) Left. Right is lower due to liver
2) L renal vein passes anterior to aorta just inferior to SMA . It has two tributaries adrenal + gonadal vein.
3) R Renal art passes posterior to IVC to reach kidney. Its origin is slightly inferior to that of the L Renal ARt
4) Exits pelvis and descends on psoas major just lat. to IVC. Crossos Iliac bifurcation then crosses obt. nerve + ant. int. iliac art. branches.
1) Structures at renal hilum
2) Layers surrounding kidney
3) Relations of kidney
1) Renal hilum (on concave surface of kidney) - Renal Vein, Artery + Ureter
2) Out to in . Perirenal fat, Capsule, gerota’s fascia, pararenal fat
3)
L - Ant. - Adrenal, spleen, stomach, Splenic flexure, pancreas, jejunum
Post. - QL, Psoas, Transversus Abdominis Diaphagm, 11+12 rib,
R - Ant. - Adrenal, Liver, 2nd part duodenum, hepatic flexure
Post. - Diaphragm, 12th rib, Psoas, QL, Transversus Abdominis,
1) Classic description of how ureters enter the bladder
2) Blood supply of ureters
They travel posterioinferiorly on pelvic wall and then pass anteromedially to enter the posterior aspect of bladder
Ureter blood supply:
Segmental
Upper - Renal Art.
Middle - CIA, Gonodal, Aorta
Lower - IIA, Sup. Vesic. Art, Mid. Rect. Art, Men - Inf. Vesic. Women- Uterine + vaginal art.
Why is ureteric pain referred to the back and sides?
Supplying nerves travel to spinal segments T12- L2
T12 - L2 dermatomes are back, sides, scrotum/labia majora + upper thigh
1-11
1+2 - Lateral Thyroid Lobes 3 - Thyroid Isthmus
4- Trachea 5 - Cricothyr. lig+memb.
6 - ICA (Carot. Sinus) 7. Thyrohyoid Membr.
8. Thyr. Notch. 9. Thyr. Lam.
10. Scal. Anterior. 11. Scal. Med.
12- 25
12. Inominate art. 13. Subcl. Art. 14. CCA
15. CCA 16. Intern. Thoracic Art. 17. Vert. Art.
18. Inf. Thyroid Art. 19. Transv. Cerv. Art.
20 - Suprascap. Art. 21. - Sup. Thyr. Art.
22. - Sup. Laryng Art. (Branch of STA)
23 - Brachial plexus 24. - Phrenic Nerv.
25 - Upper brachial plexus
Autoclave Process
What is the Bowie Dick test
Delivery of high pressure and temperature steam
for a period of 134 degrees for 3 minutes into a closed unit
Bowie Dick Test - strips used to test the function of an autoclave strip
