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MRCS Part B > EMRCS > Flashcards

EMRCS Flashcards

1
Q

Tissue Processing Steps

A

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

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2
Q

Method of assessment for intraoperative tissue assessment

A

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

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3
Q

Why might cytology not be adequate for assessment of disease?

A

Architectural elements of certain pathologies are important:

Capsule Breach

Basement membrane intact

Formation of psuedocysts

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4
Q

Formalin:

  • Frozen Section or Embedded Section?
  • How does it work?
A

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.

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5
Q

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
A

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

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6
Q

Factors Reducing the rate of SSIs:

6

Do wound protectors reduce the risk?

A

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

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7
Q

Key acute inflammation features

A

1) Vasodilation
2) Protein Rich Exudate
3) Neutrophils/Mast Cells –> Macrophages/Lymphocytes

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8
Q

Why do abscesses form?

A

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)

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9
Q

Definition:

Empyema

Histological Diagnostic Feature of acute inflammation

Metaplasia

Fournier’s Gangrene

A

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

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10
Q

Sequelae of acute inflammation (4)

A

Resolution

Organisation - Fibrosis formation

Suppuration - Formation of abscess/empyema

Chronic Inflammation - Balance between inflammation and reparation

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11
Q

Amyloid Protein Types:

Most common sites (2)

Diagnosis

A

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

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12
Q

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

A

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

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13
Q

Altered Tissue Perfusion, Sepsis and Cutaneous Anaesthesia

Cause

Types

RFs

Mx

A

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

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14
Q
A
  1. Internal Oblique
  2. Anterior Rectus Sheath
  3. Rectus Abdominis
  4. Transversus Aponeurosis
  5. Conjoint tendon
  6. Inguinal Ligament
  7. Spermatic Cord
  8. External Spermatic Fascia
  9. Ilioinguinal Nerve
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15
Q

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

A

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

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16
Q

Rectus Abdominus:

1) Origin
2) Insertion
3) Two bands divided by
4) innervation

A

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

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17
Q

External Oblique

1) Origin
2) Insertion
3) innervation

A

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

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18
Q

Internal Oblique

1) Origin
2) Insertion
3) Innervation (as well as transversus abdominus)

A

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

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19
Q

Contents of inguinal canal

Contents of spermatic cord

A

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

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20
Q

Methods of inguinal hernia repair:

6

A

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

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21
Q
A
  1. Rectus Abdominus
  2. Transversus Aponeurosis
  3. Peritoneum
  4. Inferior Epigastric Artery
  5. Testicular Artery
  6. Artery of vas
  7. Ductus deferens
  8. Pampiniform Plexus
  9. Internal Spermatic Fascia.
  10. External Spermatic Fascia
  11. Testes.
  12. Tail of epididymis
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22
Q

Definitions:

Femoral Canal

Femoral ring/canal boundaries

Femoral Triangle boundaries

Contents of femoral triangle

Hunter’s Canal Borders

Hunter’s Canal contents

A

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

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23
Q

Inguinal vs Femoral hernias

Palpation

Strangulation

Structures at risk in fem hern surgery

A

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

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24
Q
A
  1. ASIS
  2. Pubic Tubercle
  3. Inguinal ligament
  4. Fem Vein
  5. Fem ARtery
  6. Fem Nerve
  7. Femoral Branc. of Genitofemoral nerve
  8. Sup. Ext. Pudendal Artery
  9. Great Saphenous Vein.
  10. Lat. Circ. Artery (Ascending)
  11. Lat. Circ. Artery Proper
  12. Intermediate Cutaneous nerve of thigh
  13. Psoas Major
  14. Iliacus
  15. Sartorius
  16. Pectineus
  17. Adductor Longus
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25
**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**
26
**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**
27
**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
28
**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
29
**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
30
**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)
31
**What is supplied by the internal iliac artery?**
Pelvic Organs, Perineum, Buttock and Anal Canal
32
**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)
33
**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
34
**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
35
**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
36
**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,
37
**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
38
**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
39
**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
40
**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
41
**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
42
**Gastric Ulcers:** Lesser Curve Greater Curve
Lesser Curve - can erode into L/R Gastric Arteries Greater Curve - can erode into pancreas
43
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.
44
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
45
**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
46
**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
47
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
48
**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
49
**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
50
**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
51
**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
52
**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
53
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
54
11-15
**11** - Gall Bladder **12 -** Quadrate Lobe **13 -** caudate lobe **14-** right lobe **15 -** left lobe
55
**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
56
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
57
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
58
**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
59
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
60
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
61
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.
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**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,
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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.
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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
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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.
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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
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**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
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MRCS Part B (11 decks)

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