eMRCS Abdomen and Perineum Flashcards
A 23 year old man complains of severe groin pain several weeks after a difficult inguinal hernia repair. Which nerve is most likely to have been involved?
Genitofemoral Ilioinguinal Femoral Iliohypogastric Pudendal
Ilioinguinal nerve
The ilioinguinal nerve may have been entrapped in the mesh causing a neuroma.
Arises from the 1st lumbar ventral ramus with the iliohypogastric nerve. Passes inferolaterally through psoas major and over the anterior surface of quadratus lumborum. Pierces internal oblique and passes deep to aponeurosis of external oblique. Enters inguinal canal and passes through superficial ring to reach the skin.
A 67 year old man is undergoing an angiogram for gastro intestinal bleeding. The radiologist advances the catheter into the coeliac axis. At what spinal level does this vessel typically arise from the aorta?
T10 L3 L4 T12 None of the above
T12
Coeliac axis lies at T12, takes an almost horizontal angle off the aorta. It has three major branches: left gastric, common hepatic, splenic arteries.
A 45 year old man is undergoing a low anterior resection for a carcinoma of the rectum. Which of the following fascial structures will need to be divided to mobilise the mesorectum from the sacrum and coccyx?
Denonvilliers fascia Colles fascia Sibsons fascia Waldeyers fascia None of the above
Waldeyers fascia
Separates the mesorectum from the sacrum and will need to be divided.
A 73 year old man is due to undergo a radical prostatectomy for carcinoma of the prostate gland. To which of these lymph nodes will the tumour drain primarily?
Para-aortic Internal iliac Superficial inguinal Mesorectal None of the above
Internal iliac nodes
The prostate lymphatic drainage is primarily to the internal iliac nodes and also the sacral nodes. Although internal iliac is the first site.
Following an oesophagogastrectomy the surgeons will anastomose the oesophageal remnant to the stomach, which of the following is not part of the layers that comprise the oesophageal wall?
Serosa Adventitia Muscularis propria Submucosa Mucosa
Serosa
The wall lacks a serosa which can make the wall hold sutures less securely.
A 35 year old man presents to the surgical clinic with a suspected direct inguinal hernia. These will pass through Hesselbach’s triangle. Which of the following forms the medial edge of this structure?
External oblique aponeurosis Inferior epigastric artery Rectus abdominis muscle Inferior epigastric vein Obturator nerve
Rectus abdominis
Direct inguinal hernias pass through Hesselbach’s triangle (although this is of minimal clinical significance). Its medial boundary is the rectus muscle.
A 72 year old man develops a hydrocele which is being surgically managed. As part of the procedure the surgeons divide the tunica vaginalis. From which of the following is this structure derived?
Peritoneum External oblique aponeurosis Internal oblique aponeurosis Transversalis fascia Rectus sheath
Peritoneum
The tunica vaginalis is derived from peritoneum, it secretes the fluid that fills the hydrocele cavity.
A 23 year old man is undergoing an inguinal hernia repair. The surgeons mobilise the spermatic cord and place it in a hernia ring. A small slender nerve is identified superior to the cord. Which nerve is it most likely to be?
Iliohypogastric nerve Pudendal nerves Femoral branch of genitofemoral nerve Ilioinguinal nerve Obturator nerve
Ilioinguinal nerve
The ilioinguinal nerve passes through the inguinal canal and is the nerve most commonly identified during hernia surgery.
The genitofemoral nerve splits into two branches, the genital branch passes through the inguinal canal within the cord structures. The femoral branch of the genitofemoral nerve enters the thigh posterior to the inguinal ligament, lateral to the femoral artery.
The iliohypogastric nerve pierces the external oblique aponeurosis above the superficial inguinal ring.
A 60 year old female is undergoing a Whipples procedure for adenocarcinoma of the pancreas. As the surgeons begin to mobilise the pancreatic head they identify a large vessel passing inferiorly over the anterior aspect of the uncinate process. What is it likely to be?
Coeliac axis SMA IMA Aorta Left gastric artery
SMA
Arises from the aorta and passes anterior to the lower part of the pancreas. Invasion of this structure is a relative contraindication to resectional surgery.
An 84 year old lady presents with a tender painful lump in the right groin and signs of small bowel obstruction. What is the most appropriate surgical incision to address this problem?
Lotheissen McEvedy Midline abdominal Paramedian Kochers
McEvedy
Traditionally used to approach incarcerated femoral hernias.
The disadvantage of the Lotheissen approach is that it weakens the inguinal canal and predisposes to inguinal hernia formation.
The other incisions would not usually address femoral hernias. Given the features of bowel obstruction, a low approach would be inappropriate.
At what level does the aorta bifurcate into the left and right common iliac arteries?
L1 L2 L3 L4 L5
L4
The aorta typically bifurcates at L4. This level is usually fairly constant and is often tested in the exam.
What structures are located on the transpyloric plane (L1)? (where lateral border of rectus muscle crosses the costal margin)
Pylorus of stomach Fundus of gallbladder Neck of pancreas DJ flexure 2nd part of duodenum Spleen Left and right colic flexure Root of transverse mesocolon SMA Portal vein Upper part of conus medullaris SMA
Anatomical planes and their levels?
Subcostal plane
Transpyloric plane
Intercristal plane
Intertubercular plane
Subcostal - Lowest margin of 10th costal cartilage
Transpyloric - L1
Intercristal - L4 (highest point of iliac crest)
Intertubercular - L5
Common level landmarks?
IMA
Bifurcation of aorta into common iliac arteries
Formation of IVC
Diaphragm apertures
IMA - L3
Bifurcation of aorta - L4
Formation of IVC - L5 (union of common iliac veins)
Diaphragm apertures - T8 IVC, T10 oesophagus, T12 aorta
A 63 year old man who smokes heavily presents with dyspepsia. He is tested and found to be positive for helicobacter pylori infection. One evening he has an episode of haematemesis and collapses. What is the most likely vessel to be responsible?
Portal vein Short gastric arteries SMA Gastroduodenal artery Splenic artery
Gastroduodenal artery
He is most likely to have a posteriorly sited duodenal ulcer. These can invade the gastroduodenal artery and present with major bleeding. Although gastric ulcers may invade vessels they do not tend to produce major bleeding of this nature.
Arises from common hepatic artery of coeliac trunk. Terminates by bifurcating into superior pancreaticoduodenal artery and right gastroepiploic artery. Supplies pylorus of stomach, proximal part of duodenum and indirectly into pancreatic head (via ant and post sup pancreaticoduodenal arteries)
The transversalis fascia contributes to which of the following?
Pectineal ligament Deep inguinal ring Cremaster muscle and fascia Inguinal ligament External spermatic fascia
Deep inguinal ring
The principal outpouching of the transversalis fascia is the internal spermatic fascia. The mouth of the outpouching is the deep inguinal ring.
The internal spermatic fascia invests:
Ductus deferens
Testicular vessels
During the course of a radical gastrectomy the surgeons detach the omentum and ligate the right gastro-epiploic artery. From which vessel does it originate?
Coeliac axis SMA IMA Common hepatic artery Gastroduodenal artery
Gastroduodenal artery
Arises at the superior part of the duodenum and descends behind it to terminate at its lower border. It terminates by dividing into the right gastro-epiploic artery and the superior pancreaticoduodenal artery.
The right gastro-epiploic artery passes to the left and between the layers of the greater omentum to anastomose with the left gastro-epiploic artery.
A 25 year old man has an inguinal hernia, which of the following structures must be divided (at open surgery) to gain access to the inguinal canal?
Transversalis fascia External oblique aponeurosis Conjoint tendon Rectus abdominis Inferior epigastric artery
External oblique aponeurosis
Question is asking what structure forms the anterior wall of the inguinal canal. The anterior wall is formed by the external oblique aponeurosis.
Once this is divided the canal is entered, the cord can be mobilised and a hernia repair performed.
The transversalis fascia and conjoint tendons form the posterior wall and would not routinely be divided to gain access to the inguinal canal itself.
Which of the vessels listed below is the most inferiorly sited single aortic branch?
Common iliac artery IMA SMA Gonadal artery Median sacral artery
Median sacral artery
Leaves the aorta a little above its bifurcation. It descends in the midline anterior to L4 and L5.
The inferior aspect of the vagina drains to which of the following lymph node groups?
Superficial inguinal nodes Internal iliac nodes Para-aortic nodes Obturator nodes Meso-rectal nodes
Superficial inguinal nodes
The lymph vessels from the superior aspect of the vagina join the internal and external iliac nodes, those from the inferior aspect of the vagina drain to the superficial inguinal nodes.
Which of the following is most important in providing support to the duodenojejunal flexure?
Mesentery of transverse colon Uncinate process of pancreas Gerotas fascia Ligament of Treves Ligament of Treitz
Ligament of Treitz
The suspensory muscle of the duodenum which is referred to as the ligament of Treitz is most important.
The ligament of Treves is located between the ileum and caecum.
A 25 year old man is being catheterised, prior to a surgical procedure. As the catheter enters the prostatic urethra which of the following changes will occur?
Resistance increase significantly Resistance increase slightly Resistance decrease It will lie horizontally It will deviate laterally
Resistance will decrease
The prostatic urethra is much wider than the membranous urethra and therefore resistance will decrease. The prostatic urethra is inclined superiorly.
A 73 year old lady with gallstones is about to undergo a laparoscopic cholecystectomy. The surgeon inserts a Verress needle and performs a successful drop test prior to establishing a pneumoperitoneum. A 5 minute delay ensues before a 10mm infraumbilical trocar is inserted. The surgeon performs a diagnostic laparoscopy which shows a thickened gallbladder but is otherwise normal. The anaesthetist complains that the patient has become hypotensive with a blood pressure of 80/40 mmHg. Of the options below, which is the most appropriate course of action?
Release of pneumoperitoneum Perform a laparotomy Administer IV adrenaline Administer IV amiodarone End the operation
Release of pneumoperitoneum
Excessive intra-abdominal pressure may cause decreased venous return and hypotension.
Since the preliminary laparoscopy did not show any major vascular catastrophe an emergency laparotomy would not be indicated. In most cases the release of pressure is often sufficient.
In cases of a vaso-vagal episode (which may be induced by peritoneal stretching) a dose of atropine may be required.
Which of the following structures lies posterior to the femoral nerve in the femoral triangle?
Adductor longus Pectineus Psoas major Iliacus None of the above
Iliacus
The iliacus lies posterior to the femoral nerve in the femoral triangle. The femoral sheath lies anterior to the iliacus and pectineus muscles.
Branches of the femoral nerve (L2-4)?
Medial cutaneous nerve of thigh
Intermediate cutaneous nerve of thigh
Saphenous nerve
What does the femoral nerve innervate?
Vastus lateralis/medius/intermedius
Quadriceps/rectus femoris
Sartorius
Pectineus
A 29 year old woman has had a Pfannenstiel incision. She has pain over the inguinal ligament which radiates to the lower abdomen. There is tenderness when the inguinal canal is compressed. Which of the following is most likely to have been affected?
Genitofemoral nerve Ilioinguinal nerve Lateral cutaneous nerve of thigh Iliohypogastric nerve Saphenous nerve
Ilioinguinal nerve
Surgeries and their associated nerve lesions:
Posterior triangle LN biopsy Lloyd Davies stirrups Thyroidectomy Anterior resection of rectum Axillary node clearance Inguinal hernia surgery Varicose vein surgery Posterior approach to hip Carotid endarterectomy
Posterior triangle LN biopsy - accessory nerve
Lloyd Davies stirrups - common peroneal nerve
Thyroidectomy - laryngeal nerve
Anterior resection of rectum - hypogastric autonomic nerves
Axillary node clearance - long thoracic, thoracodorsal, intercostobrachial nerve
Inguinal hernia surgery - ilioinguinal nerves
Varicose vein surgery - sural and saphenous nerves
Posterior approach to hip - sciatic nerve
Carotid endarterectomy - hypoglossal nerve
Which of the following overlies the outer muscular layer of the intrathoracic oesophagus?
Serosa Meissners plexus Auerbach's plexus Loose connective tissue None of the above
Loose connective tissue
The oesophagus has no serosal covering and hence holds sutures poorly. The Auerbach’s and Meissner’s nerve plexuses lie in between the longitudinal and circular muscle layers and submucosally. The sub mucosal location of the Meissner’s nerve plexus facilitates its sensory role.
The following are true of the femoral nerve, except:
Derived from L2-4 nerve roots Supplies sartorius Supplies quadriceps femoris Gives cutaneous innervations via saphenous nerve Supplies adductor longus
It supplies adductor longus
Adductor longus is supplied by the obturator nerve.
Which of the following structures is not directly related to the right adrenal gland?
Diaphragm posteriorly Kidney inferiorly Right renal vein Inferior vena cava Hepato-renal pouch
Right renal vein
The right renal vein is very short and lies more inferiorly.
An 18 year old boy is undergoing an appendicectomy for appendicitis. At which of the following locations is the appendix most likely to be found?
Pre-ileal Pelvic Retrocaecal Post-ileal None of the above
Retrocaecal
Most appendixes lie in the retrocaecal position. If a retrocaecal appendix is difficult to remove then mobilisation of the right colon significantly improves access.
A 43 year old man is diagnosed as having a malignancy of the right adrenal gland. The decision is made to resect this via an open anterior approach. Which of the following will be most useful during the surgery?
Division of coronary ligaments of liver Mobilisation of colonic hepatic flexure Division of right renal vein Division of ligament of Treitz Division of right colic artery
Mobilisation of colonic hepatic flexure
Mobilisation of the hepatic flexure and right colon are standard steps in open adrenal surgery from an anterior approach. Mobilisation of the liver is seldom required.
A 62 year old man is undergoing a left hemicolectomy for carcinoma of the descending colon. The registrar commences mobilisation of the left colon by pulling downwards and medially. Blood soon appears in the left paracolic gutter. The most likely source of bleeding is the:
Marginal artery Left testicular artery Left renal vein Spleen None of the above
Spleen
The spleen is commonly torn by traction injuries in colonic surgery. The other structures are associated with bleeding during colonic surgery but would not manifest themselves as blood in the paracolic gutter prior to incision of the paracolonic peritoneal edge.
A 56 year old lady is undergoing an adrenalectomy for Conns syndrome. During the operation the surgeon damages the middle adrenal artery and haemorrhage ensues. From which of the following structures does this vessel originate?
Aorta Renal artery Splenic artery Coeliac axis SMA
Aorta
The middle adrenal artery is usually a branch of the aorta, the lower adrenal artery typically arises from the renal vessels.
A 63 year old man undergoes a radical cystectomy for carcinoma of the bladder. During the procedure there is considerable venous bleeding. What is the primary site of venous drainage of the urinary bladder?
Vesicoprostatic venous plexus Internal iliac vein External iliac vein Gonadal vein Common iliac vein
Vesicoprostatic venous plexus
The urinary bladder has a rich venous plexus surrounding it, this drains subsequently into the internal iliac vein.
The vesicoprostatic plexus may be a site of considerable venous bleeding during cystectomy.
A 23 year old man is admitted with a suspected ureteric colic. A KUB style x-ray is obtained. In which of the following locations is the stone most likely to be visualised?
Tips of transverse processes between L2-5
Tips of transverse processes between T10-L1
At the crest of the ilium
Over the S3 foramina
Over the sacrococcygeal joint
Tips of transverse processes between L2-5
The ureter lies anterior to L2 to L5 and stones may be visualised at these points, they may also be identified over the sacro-iliac joints.
During a liver resection a surgeon performs a pringles manoeuvre to control bleeding. Which of the following structures will lie posterior to the epiploic foramen at this level?
Hepatic artery Cystic duct Greater omentum SMA IVC
IVC
Bleeding from liver trauma or a difficult cholecystectomy can be controlled with a vascular clamp applied at the epiploic foramen.
What are the boundaries of the epiploic foramen?
Anterior
Posterior
Superior
Inferior
Anterior (free edge of lesser omentum) - bile duct to right, portal vein behind, hepatic artery to the left
Posterior - IVC
Inferior - 1st part of duodenum
Superior - Caudate process of liver
A 73 year old lady presents with symptoms of faecal incontinence. On examination she has weak anal sphincter muscles. What are the main nerve root values of the nerves supplying the external anal sphincter?
S2-3 L5, S1 S4-5 S5 S2-4
S2-4
The external anal sphincter is innervated by the inferior rectal branch of the pudendal nerve, this has root values of S2, 3 and the perineal branch of S4.
A 53 year old man is undergoing a radical gastrectomy for carcinoma of the stomach. Which of these structures will need to be divided to gain access to the coeliac axis?
Lesser omentum Greater omentum Falciform ligament Median arcuate ligament Gastrosplenic ligament
Lesser omentum
The lesser omentum will need to be divided. During a radical gastrectomy this forms one of the nodal stations that will need to be taken.
A 56 year old lady is referred to the colorectal clinic with symptoms of pruritus ani. On examination a polypoidal mass is identified inferior to the dentate line. A biopsy confirms squamous cell carcinoma. To which of the following lymph node groups will the lesion potentially metastasise?
Internal iliac External iliac Mesorectal Inguinal None of the above
Inguinal
Lesions distal to the dentate line drain to the inguinal nodes. Occasionally this will result in the need for a block dissection of the groin.
What is the most important structure involved in supporting the uterus?
Round ligament Broad ligament Uterosacral ligaments Cardinal ligaments Central perineal tendon
Central perineal tendon
The central perineal tendon provides the main structural support to the uterus. Damage to this structure is commonly associated with the development of pelvic organ prolapse, even when other structures are intact.
A 23 year old man is stabbed in the chest approximately 10cm below the right nipple. In the emergency department a abdominal ultrasound scan shows a large amount of intraperitoneal blood. Which of the following statements relating to the likely site of injury is untrue?
Part of its posterior surface is devoid of peritoneum
The quadrate lobe is contained within the functional right lobe
Its nerve supply is from the coeliac plexus
The hepatic flexure of the colon lies postero-inferiorly
The right kidney is closely related posteriorly
Quadrate lobe is contained within the functional right lobe
The right lobe of the liver is the most likely site of injury. Therefore the answer is B as the quadrate lobe is functionally part of the left lobe of the liver. The liver is largely covered in peritoneum. Posteriorly there is an area devoid of peritoneum (the bare area of the liver). The right lobe of the liver has the largest bare area (and is larger than the left lobe).
Mobilisation of the left lobe of the liver will facilitate surgical access to which of the following?
Abdominal oesophagus Duodenum Right colic flexure Right kidney Pylorus of stomach
Abdominal oesophagus
The fundus of the stomach is a posterior relation. The pylorus lies more inferolaterally. During a total gastrectomy, division of the ligaments holding the left lobe of the liver will facilitate access to the proximal stomach and abdominal oesophagus. This manoeuvre is seldom beneficial during a distal gastrectomy.
An enthusiastic surgical registrar undertakes his first solo splenectomy. The operation is far more difficult than anticipated and the registrar leaves a tube drain to the splenic bed at the end of the procedure. Over the following 24 hours approximately 500ml of clear fluid has entered the drain. Biochemical testing of the fluid is most likely to reveal:
Elevated creatinine Elevated triglycerides Elevated glucagon Elevated amylase None of the above
Elevated amylase
During splenectomy the tail of the pancreas may be damaged. The pancreatic duct will then drain into the splenic bed, amylase is the most likely biochemical finding. Glucagon is not secreted into the pancreatic duct.
Which of the following statements relating to quadratus lumborum is false?
Causes flexion of thoracic spine Causes rib cage to be pulled down Innervated by anterior primary rami of T12 and L1-3 Attached to the iliac crest Inserts into the 12th rib
Causes flexion of thoracic spine
The rectus abdominis causes flexion of the thoracic spine and therefore the statement suggesting that quadratus lumborum does so is incorrect.
What is the lymphatic drainage of the membranous urethra?
Deep inguinal nodes Superficial inguinal nodes Internal iliac nodes External iliac nodes Para-aortic nodes
Internal iliac nodes
The prostatic and membranous urethra drain to the internal iliac nodes.
A 45 year old lady is undergoing a Whipples procedure for carcinoma of the pancreatic head. The bile duct is transected. Which of the following vessels is mainly responsible for the blood supply to the bile duct remnant?
Cystic artery Hepatic artery Portal vein Left gastric artery None of the above
Hepatic artery
The bile duct has an axial blood supply which is derived from the hepatic artery and from retroduodenal branches of the gastroduodenal artery. Unlike the liver there is no contribution by the portal vein to the blood supply of the bile duct. Damage to the hepatic artery during a difficult cholecystectomy is a recognised cause of bile duct strictures. In this scenario the distal vessels have been removed as the patient is undergoing a resection.
A 72 year old man is undergoing an open abdominal aortic aneurysm repair. The aneurysm is located in a juxtarenal location and surgical access to the neck of aneurysm is difficult. Which of the following structures may be divided to improve access?
Cisterna chyli Transverse colon Left renal vein SMA Coeliac axis
Left renal vein
The left renal vein will be stretched over the neck of the anuerysm in this location and is not infrequently divided. This adds to the nephrotoxic insult of juxtarenal aortic surgery as a supra renal clamp is also often applied. Deliberate division of the cisterna chyli will not improve access and will result in a chyle leak. Division of the transverse colon will not help at all and would result in a high risk of graft infection. Division of the SMA is pointless for a juxtarenal procedure.
From which structure is the central tendon of the diaphragm derived?
Septum transversum Pleuroperitoneal folds Diaphragmatic crura Dorsal mesocardium Oropharyngeal membrane
Septum transversum
The septum transversum is a thick ridge of mesodermal tissue in the developing embryo that separates the thoracic and abdominal cavities and forms the central tendon of the diaphragm.
The septum transversum is a thick ridge of mesodermal tissue in the developing embryo that separates the thoracic and abdominal cavities and forms the central tendon of the diaphragm.
T9 T10 L2 L3 L4
L2
The renal arteries usually branch off the aorta on a level with L2.
The right renal artery is longer than the left renal artery. The renal vein/artery/pelvis enter the kidney at the hilum
A 23 year old man is undergoing a hernia repair and the mesh is to be sutured to the inguinal ligament. From which of the following does the inguinal ligament arise?
Transversus abdominis fascia Internal oblique Rectus sheath Rectus abdominis muscle External oblique aponeurosis
External oblique aponeurosis
The inguinal ligament runs from the pubic tubercle to the anterior superior iliac spine.
A 56 year old man is undergoing a radical nephrectomy via a posterior approach. Which of the following structures is most likely to be encountered during the operative approach?
6th rib 8th rib 9th rib 10th rib 12th rib
12th rib
The 11th and 12th ribs lie posterior to the kidneys and may be encountered during a posterior approach. A pneumothorax is a recognised complication of this type of surgery.
Which of the following statements relating to the greater omentum is false?
It is less well-developed in children under 5
It has no relationship to the lesser sac
It contains the gastroepiploic arteries
Has an attachment to the transverse colon
It may be a site of metastatic disease in ovarian cancer
It has no relationship to the lesser sac
It is connected with the lesser sac and the transverse colon. This plane is entered when performing a colonic resection. It is a common site of metastasis in many visceral malignancies.
Which of the following structures is not at the level of the transpyloric plane?
Hilum of left kidney SMA Fundus of gallbladder Cardioesophageal junction Root of transverse mesocolon
Cardioesophageal junction
= T11
The oesophagus extends from C6 (the lower border of the cricoid cartilage) to T11 at the cardioesophageal junction. Note that in the neonate the oesophagus extends from C4 or C5 to T9.
A 48 year old man with newly diagnosed hypertension is found to have a phaeochromocytoma of the left adrenal gland and is due to undergo a laparoscopic left adrenalectomy. Which of the following structures is not directly related to the left adrenal gland?
Crus of diaphragm Lesser curvature of stomach Kidney Pancreas Splenic artery
Lesser curvature of stomach
The left adrenal gland is slightly larger than the right. It is crescent in shape and its concavity is adapted to the medial border of the upper part of the left kidney. The upper area is covered by peritoneum of the omental bursa which separates it from the cardia of the stomach. The lower area is in contact with the pancreas and splenic artery and is not covered by peritoneum. On the anterior surface is a hilum from which the suprarenal vein emerges. The lateral aspect rests on the kidney. The medial is small and is on the left crus of the diaphragm.
A 44 year old lady is undergoing an abdominal hysterectomy and the ureter is identified during the ligation of the uterine artery. At which site does it insert into the bladder?
Posterior Apex Anterior Base Superior aspect of lateral side
Base
The ureters enter the bladder at the upper lateral aspect of the base of the bladder. They are about 5cm apart from each other in the empty bladder. Internally this aspect is contained within the bladder trigone.
A patient is found to have an ischaemic left colon. Which artery arising from the aorta at around the level of L3 is most likely to account for this situation?
SMA IMA Superior rectal artery Ileocolic artery Middle colic artery
IMA
Only the IMA is likely to affect the left side of the colon and originate at L3.
A 55 year old man is due to undergo a radical prostatectomy for carcinoma of the prostate gland. Which of the following vessels directly supplies the prostate?
External iliac artery Common iliac artery Internal iliac artery Inferior vesical artery None of the above
Inferior vesical artery
The arterial supply to the prostate gland is from the inferior vesical artery, it is a branch of the prostatovesical artery. The prostatovesical artery usually arises from the internal pudendal and inferior gluteal arterial branches of the internal iliac artery.
Two teenagers are playing with an airgun when one accidentally shoots his friend in the abdomen. He is brought to the emergency department. On examination, there is a bullet entry point immediately to the right of the rectus sheath at the level of the 1st lumbar vertebra. Which of the following structures is most likely to be injured by the bullet?
Head of pancreas Right ureter Right adrenal gland Fundus of gallbladder Gastric antrum
Fundus of gallbladder
The fundus of the gallbladder lies at this level and is the most superficially located structure.
A 56 year old man is undergoing a high anterior resection. Which of the following structures is at greatest risk of injury in this procedure?
SMA Left ureter External iliac vein External iliac artery IVC
Left ureter
A careless surgeon may damage all of these structures. However, the structure at greatest risk and most frequently encountered is the left ureter.
Which of the following vessels does not drain directly into the inferior vena cava?
Superior mesenteric vein Right common iliac vein Right hepatic vein Left hepatic vein Right testicular vein
Superior mesenteric vein
The superior mesenteric vein drains into the portal vein. The right and left hepatic veins drain into it directly, this can account for major bleeding in more extensive liver shearing type injuries.
Which of the following structures is not located in the superficial perineal space in females?
Posterior labial arteries Pudendal nerve Superficial transverse perineal muscle Greater vestibular glands None of the above
Pudendal nerve
The pudendal nerve is located in the deep perineal space and then branches to innervate more superficial structures.
A 42 year old woman is due to undergo a left nephroureterectomy for a transitional cell carcinoma involving the ureter. Which of the following structures is not related to the left ureter?
Round ligament of uterus Internal iliac artery Ovarian artery Peritoneum Sigmoid mesocolon
Round ligament of uterus
The ureter is not related to the round ligament of the uterus, it is related to the broad ligament and is within 1.5cm of the supravaginal part of the cervix.
A 56 year old man is left impotent following an abdomino-perineal excision of the colon and rectum. What is the most likely explanation?
Psychosexual issues related to an end colostomy
Damage to sacral venous plexus during total mesorectal excision
Damage to the left ureter during sigmoid mobilisation
Damage to the hypogastric plexus during mobilisation of the IMA
Damage to the internal iliac artery during total mesorectal excision
Damage to the hypogastric plexus during mobilisation of the IMA
Autonomic nerve injury is the most common cause.
A 28 year old man is undergoing an appendicectomy. The external oblique aponeurosis is incised and the underlying muscle split in the line of its fibres. At the medial edge of the wound is a tough fibrous structure. Entry to this structure will most likely encounter which of the following?
Internal oblique Rectus abdominis Transversus abdominis Linea alba Peritoneum
Rectus abdominis
This structure will be the rectus sheath and when entered the rectus abdominis muscle will be encountered.
A surgeon is due to perform a laparotomy for perforated duodenal ulcer. An upper midline incision is to be performed. Which of the following structures is the incision most likely to divide?
Rectus abdominis External oblique muscle Internal oblique muscle Linea alba None of the above
Linea alba
Upper midline abdominal incisions will involve the division of the linea alba. Division of muscles will not usually improve access in this approach and they would not be routinely encountered during this incision.
Which of the following statements about the spleen is false?
The hilum contains splenic vessels The spleen is derived from endodermal tissue White pulp has immune function Colon lies inferiorly Weighs 150g
The spleen is derived from endodermal tissue
Most of the gut is derived endodermally except for the spleen which is from mesenchymal tissue.
The spleen is: 1 inch thick, 3 inches wide, 5 inches long, weighs 7oz (150-200g), lies between the 9th and 11th ribs
A 38 year old man undergoes an OGD to investigate dyspepsia. Following intubation of the duodenum, the ampulla of Vater is identified. At which of these sites, is it most likely to be located?
Inferior aspect of 1st part of duodenum Medial aspect of 3rd part of duodenum Lateral aspect of 2nd part of duodenum Lateral aspect of 3rd part of duodenum Medial aspect of 2nd part of duodenum
Medial aspect of 2nd part of duodenum
The Ampulla of Vater is usually located 8-10cm from the pylorus and 2-3cm inferior to the opening of the accessory pancreatic duct of the lesser duodenal papilla. Knowledge of the location of the Ampulla is important when cannulating it at ERCP.
A 10 year old girl has right iliac fossa pain and an appendicectomy is to be performed. What is the best incision for this procedure?
Paramedian Midline abdominal Kochers Lanz Gridiron
Lanz
Both Lanz and Gridiron incisions can be used to perform an open appendicectomy. However, a Lanz incision provides for a superior cosmetic scar and is more easily extended than a Gridiron incision.
A 66 year old man is undergoing a left nephro-ureterectomy. The surgeons remove the ureter, which of the following is responsible for the blood supply to the proximal ureter?
Branches of the renal artery External iliac Internal iliac Common iliac Direct branches from the aorta
Branches of the renal artery
The proximal ureter is supplied by branches from the renal artery. Other feeding vessels: aortic branches, gonadal branches, common iliac, internal iliac arteries
Which of the following pairings are incorrect?
Aortic bifurcation and L4
Transpyloric plane and L1
Termination of dural sac and L4
Oesophageal passage through diaphragm and T10
Transition between pharynx and oesophagus at C6
Termination of dural sac and L4
It terminates at S2, which is why it is safe to undertake an LP at L4/5 levels. The spinal cord itself terminates at L1.
At which level does the aorta traverse the diaphragm?
T12
A 63 year old lady is diagnosed as having an endometrial carcinoma arising from the uterine body. To which nodal region will the tumour initially metastasise?
Para-aortic nodes Iliac lymph nodes Inguinal nodes Presacral nodes Mesorectal lymph nodes
Iliac lymph nodes
Tumours of the uterine body will tend to spread to the iliac nodes initially. Tumour expansion crossing different nodal margins this is of considerable clinical significance, if nodal clearance is performed during a Wertheims type hysterectomy.
A 44 year old man has a malignant melanoma and is undergoing a block dissection of the groin. The femoral triangle is being explored for intra operative bleeding. Which of the following forms the medial border of the femoral triangle?
Femoral artery Biceps femoris Adductor longus Sartorius Adductor magnus
Adductor longus
Boundaries of femoral triangle:
Superior - inguinal ligament
Lateral - sartorius
Medial - adductor longus
Floor - iliopsoas, adductor longus and pectineus
Roof - fascia lata and superficial fascia, superficial inguinal LNs, long saphenous vein
A 22 year old man presents with appendicitis. At operation the appendix is retrocaecal and difficult to access. Division of which of the following anatomical structures should be undertaken?
Ileocolic artery Mesentery of the caecum Gonadal vessels Lateral peritoneal attachments of the caecum Right colic artery
Lateral peritoneal attachments of the caecum
The commonest appendiceal location is retrocaecal. Those struggling to find it at operation should trace the taenia to the caecal pole where the appendix is located. If it cannot be mobilised easily then division of the lateral caecal peritoneal attachments (as for a right hemicolectomy) will allow caecal mobilisation and facilitate the procedure.
A 20 year old lady presents with pain on the medial aspect of her thigh. Investigations show a large ovarian cyst. Compression of which of the nerves listed below is the most likely underlying cause?
Sciatic Genitofemoral Obturator Ilioinguinal Femoral cutaneous
Obturator nerve
The cutaneous branch of the obturator nerve is frequently absent. However, the obturator nerve is a recognised contributor to innervation of the medial thigh and large pelvic tumours may compress this nerve with resultant pain radiating distally.
Arises from ventral divisions of nerve roots L2-4. The branches unite in substance of psoas major, descending vertically in its posterior aspect to emerge from its medial border at lateral margin of sacrum. Then crosses sacroiliac joint to enter lesser pelvis, descends on obturator interbus to enter the obturator groove.
A 56 year old lady is due to undergo a left hemicolectomy for carcinoma of the splenic flexure. The surgeons decide to perform a high ligation of the inferior mesenteric vein. Into which of the following does this structure usually drain?
Portal vein IVC Left renal vein Left iliac vein Splenic vein
Splenic vein
The inferior mesenteric vein drains into the splenic vein, this point of union lies close to the duodenum and this surgical maneouvre is a recognised cause of ileus.
Note: beware ureteric injury in colonic surgery.
A 1 year old boy is referred because of an impalpable testis in the left scrotum. Which of the following positions describes an ectopic testis?
Intracanalicular At superficial ring At deep ring At base of penis Upper scrotum
At base of penis
A testis at the base of the penis is ectopic, not listed is the superficial inguinal pouch (one of the commonest ectopic sites).
A testis located at deep or superficial rings or intracanalicular is not ectopically located.
What is the longest part of the male urethra?
Membranous urethra Spongy urethra Prostatic urethra Urethra within the internal urethra orifice Urethra within the urethral crest
Spongy urethra
The spongy urethra is around 15cm long and is the longest part of the male urethra.
