EMRCS anatomy Flashcards
At what level the cardio-oesophageal junction?
T11
At what level is the transpyloric plane?
L1
What structures can be found at the transpyloric plane?
(1) L1 vertebra
(2) pylorus of the stomach
(3) hilum of the spleen(the spleen lies more superiorly,and the left adrenal and ureter are unlikely to be injured in isolation)
(4) hilum of kidneys
- hilum of the left kidney(L1-left one)
- hilum of the right kidney(1.5 cm lower than the left one)
- the left kidney lies in this location and is the most likely structure to be injured
(5) neck of the pancreas
(6) sphincter of oddi
(7) 2nd part of the duodenum
(8) duodenojejunal flexture
(9) left and right colic flexture
(10) root of the transverse mesocolon
(11) fundus of the gall bladder(the most superficially located)
(12) origin of the superior mesentric artery
(13) origin of the portal vein
(14) end of the spinal cord(upper part of the conus medullaris)
(15) 9th costal cartilages
What is the other name for transpyloric plane?
(1) Transpyloric plane of Addison
(2) Plane of Addison
(3) Addison’s plane
Define the transpyloric plane
Halfway or midpoint between the jugular notch and the symphysis pubis,approximately the level of the L1 vertebra
What is the other name for transtubercular plane?
Intertubercular plane
Define the transtubercular(intertubercular)plane?
Horizontal line that runs between the superior aspect of the right and left iliac crests,approximately at the level of L5 vertebral body
Define the term(vertical planes )of the anterior abdominal wall
Vertical planes-run from the middle of the clavicle to the midinguinal point(halfway between the anterior superior iliac spine and the symphysis pubis).These planes are the mid-clavicular lines
Define the subcostal plane
Passes by the lowest part of the costal margin (10th costal cartilage),approximately at the level of L3 vertebra.
What is the other name for intercristal plane?
Supracristal plane
Define the intercristal(supracristal)plane
Passes by the highest point of iliac crest,approximately at the level of L4 vertebral body
How we can identify the transpyloric plane?
By asking the supine patient to sit up without using their arms.The plane is located where the lateral border of the rectus muscle crosses the costal margin
What is the the vertebral level of subcostal plane?
L3
What is the vertebral level of the intercristal(supracristal)plane?
L4 vertebral body
What is the vertebral level of intertubercular plane?
L5 vertebral body
What is the costal level of the subcostal plane?
10th costal cartilage
What is the vertebral level of inferior mesentric artery?
1) Leaves the aorta at L3.
2) It supplies the left colon and sigmoid.
3) Its proximal continuation with the middle colic artery is via the marginal artery.
What is the vertebral level of the bifurcation of aorta into common iliac arteries?
L4
What is the vertebral level of the formation of the IVC?
L5(union of common iliac veins)
What are the vertebral levels of the diaphragmatic apertures?
Mnemonic:VOA
(1) Vena cava T8
(2) Oesophagus T10
(3) Aortic hiatus T12
Discuss the midline abdominal incision
. Commonest approach to the abdomen
. Structures or layers divided:
(1) linea alba(Upper midline incisions will involve the
division of the linea alba)
(2) transversalis fascia
(3) extra peritoneal fat
(4) peritoneum(avoid falciform ligament above the
umbilicus)
. Bladder can be accessed via an extra peritoneal
approach through the space of Retzius
. Division of muscles will not usually improve access
in upper midline incision and they would not be
routinely encountered in this incision
What are the structures or layers divided in midline abdominal incision?
(1) linea alba(Upper midline incisions will involve the
division of the linea alba)
(2) transversalis fascia
(3) extra peritoneal fat
(4) peritoneum(avoid falciform ligament above the
umbilicus)
Discuss paramedian abdominal incision
. Location: parallel to the midline(about 3-4cm)
. Structures or layers divided or retracted:
(1) Anterior rectus sheath
(2) Rectus(retracted)
(3) Posterior rectus sheath
(4) Transversalis fascia
(5) Extra peritoneal fat
(6) Peritoneum
. Technique: Incision is closed in layers
What is the location of the paramedian abdominal incision?
parallel to the midline(about 3-4cm)
What are the structures or layers divided in paramedian abdominal incision?
(1) Anterior rectus sheath
(2) Rectus(retracted)
(3) Posterior rectus sheath
(4) Transversalis fascia
(5) Extra peritoneal fat
(6) Peritoneum
What is the technique for the paramedian abdominal incision?
Incision is closed in layers
Discuss space of Retzius
Define the space of Retzius
What are the other names for the space of Retzius?
Mnemonic: RAP/PCR
1) Retropubic space
2) Anterovessical space
3) Paravesical space
4) Pararectal space
5) Cave of Retzius
6) Retzius cavity
Discuss Battle incision
. Similar location to paramedian but rectus displaced
medially(and thus denervated)
. Now seldom used
Discuss Kocher’s incision
Incision under right subcostal margin e.g.,cholecystectomy(open)
Discuss Gridiron incision
1) Oblique incision centred over McBurney’s point
2) usually appendicectomy
3) less cosmetically accepted than lanz
Discuss Lanz incision
Incision in right iliac fossa e.g., appendicectomy
Discuss Gable incision
Rooftop incision
Discuss Pfannenstiel’s incision
Transverse suprapubic,primarily used to access pelvic organs
Discuss McEvedy’s incision
Groin incision e.g., Emergency repair strangulated femoral hernia
Discuss Rutherford Morrison incision
1)Extra peritoneal approach to left or right lower
quadrants.
2) Give excellent access to iliac vessels
3) The approach of choice for first time renal
transplantation
Illustrate different types of abdominal incision
What is the origin of the ulnar nerve?
C8-T1
What are the muscles supplied by the ulnar nerve?
Mnemonic; 3FAO/A/ITP
What is course of the ulnar nerve?
What are the branches of the ulnar nerve and what they supply?
What are the structures supplied by the muscular branch of the ulnar nerve?
(1) Flexor carpi ulnaris
(2) Medial half of the flexor digitorum profundus
Where is the site of origin of the palmar cutaneous branch of the ulnar nerve?
Arises near the middle of the forearm
What is the structure supplied by the palmar cutaneous branch of the ulnar nerve?
skin on the medial part of the palm
What is the structure supplied by the dorsal cutaneous branch of the ulnar nerve?
Dorsal surface of the medial part of the hand
What is the structure supplied by the superficial branch of the ulnar nerve?
Cutaneous fibres to the anterior surfaces of the medial one and one-half digits
What is the structure supplied by the deep branch of the ulnar nerve?
Mnemonic; HITAF
(1) (H)ypothenar muscles
(2) All the (I)nterosseous muscles
(3) (T)hird and fourth lumbericals
(4) (A)dductor pollicis
(5) Medial head of the (F)lexor pollicis brevis
What is the effect of ulnar nerve injury?
What is the effect of ulnar nerve injury when the damage is at the wrist?
What is the effect of ulnar nerve injury when the damage is at the elbow?
Discuss development of the pancreas
What is the location of the pancreas?
(1) A retroperitoneal organ
(2) Lies posterior to the stomach
How can we access the pancreas surgically?
By dividing the peritoneal reflection that connects the greater omentum to the transverse colon
What is the location of the pancreatic head?
It sits in the curvature of the duodenum
What is the location of the pancreatic tail?
Close to the hilum of the spleen, a site of potential injury during splenectomy
Discuss relations of the pancreas
Discuss the posterior relations of the pancreatic head?
Mnemonic; ICRS
1) Inferior vena cava
2) Common bile duct
3) Rt and Lt renal veins
4) Superior mesentric vein and artery
Discuss the posterior relations of the pancreatic neck?
1) Superior mesentric vein
2) Portal vein
Discuss the posterior relations of the pancreatic body?
Mnemonic; LC/PAKA or LCP/AKA or RCP/AKA
1) (L)eft (R)enal vein
2) (C)rus of diaphragm
3) (P)soas muscle
4) (A)drenal gland
5) (K)ideney
6) (A)orta
Discuss the posterior relations of the pancreatic tail?
Left kidney
Discuss the anterior relations of the pancreas?
Discuss the posterior relations of the pancreas ?
Discuss the anterior relations of the pancreatic head?
1) 1st part of the duodenum
2) Pylorus
3) SMA and SMV(uncinate process)
Discuss the anterior relations of the pancreatic body?
1) Stomach
2) Duodenojejunal flexture
Discuss the anterior relations of the pancreatic tail?
Splenic hilum
What are the superior relation of the pancreas?
Coeliac trunk and its branches
1) common hepatic artery and
2) splenic artery
What is the cause of the grooves of the head of the pancreas?
2nd and 3rd part of the duodenum
What is the arterial supply of the pancreas?
What is the venous drainage of the pancreas?
Discuss ampulla of Vater
Define ampulla of Vater
Merge of pancreatic duct and common bile duct
Discuss formation of ampulla of Vater
Merge of pancreatic duct and common bile duct
What is the anatomical significance of ampulla of Vater?
Is an important landmark,halfway along the 2nd part of duodenum,that marks the anatomical transition:
1) from foregut to midgut
2) between regions supplied by the coeliac trunk and
SMA
Discuss the thoracic duct
- Definition
Continuation of the cisterna chyli in the abdomen - Location
(1) lies posterior to the oesophagus for most of its intrathoracic course
(2) passes to the left at the level of the
a) angle of Louis
b) T5
(3) enters the thorax at T12 alongside with the aorta - Course
(1) Lymphatics draining the left side of the head and neck join the thoracic duct prior to its insertion into the junction between left subclavian and internal jugular veins.
(2) Lymphatics draining the right side of the head and neck drain via the subclavian and jugular trunks into the right lymphatic duct and thence into the mediastinal trunk and eventually the right brachiocephalic vein. - Clinical significance
Its location in the thorax makes it prone to injury during oesophageal surgery. Some surgeons administer cream to patients prior to oesophagectomy so that it is easier to identify the cut ends of the duct.
Define the thoracic duct
Continuation of the cisterna chyli in the abdomen
What is the location of the thoracic duct?
(1) lies posterior to the oesophagus for most of its intrathoracic course
(2) passes to the left at the level of the
a) angle of Louis
b) T5
(3) enters the thorax at T12 alongside with the aorta
Discuss the course of the thoracic duct
(1) Lymphatics draining the left side of the head and neck join the thoracic duct prior to its insertion into the junction between left subclavian and internal jugular veins.
(2) Lymphatics draining the right side of the head and neck drain via the subclavian and jugular trunks into the right lymphatic duct and thence into the mediastinal trunk and eventually the right brachiocephalic vein.
What is the successive order of the thoracic duct draining the right side of the head and neck?
(1) lymphatics draining the right side of the head and neck
(2) the subclavian and jugular trunks
(3) the right lymphatic duct
(4) the mediastinal trunk
(5) the right brachiocephalic vein
What is the clinical significance of the location of the thoracic duct?
Its location in the thorax makes it prone to injury during oesophageal surgery. Some surgeons administer cream to patients prior to oesophagectomy so that it is easier to identify the cut ends of the duct.
Discuss the thoracic duct drainage of the left side of the head and neck
Lymphatics draining the left side of the head and neck join the thoracic duct prior to its insertion into the junction between left subclavian and internal jugular veins.
Discuss the thoracic duct drainage of the right side of the head and neck
Lymphatics draining the right side of the head and neck drain via the subclavian and jugular trunks into the right lymphatic duct and thence into the mediastinal trunk and eventually the right brachiocephalic vein.
What is the vertebral level at which the thoracic duct enters the thorax?
T12
What is the vertebral level at which the thoracic duct passes to the left ?
T5
Define the oesophagus
Discuss the features of the oesophagus
What is the length of the oesophagus?
10 in.(25 cm) long
Discuss the constrictions in the oesophagus
What are the other names for cervical oesophageal constriction?
1) cervical oesophageal constriction
2) cricopharyngeus
3) cricoid cartilage
4) the first
5) at the beginning
How many centimetres and inches to increase for the distance between the nostril and upper incisor teeth in oesophageal constrictions?with an example
Increase 1.2in(3 cm) for each nostril from the upper incisor teeth,for example for cervical oesophageal constriction ,the distance to upper incisor teeth is 6 in(15 cm) and by increasing that to 7.2 in(18 cm) we get the distance from the nostril.
Define the cervical(cricopharyngeus)oesophageal constriction
At the start of the oesophagus immediately behind the cricoid cartilage of the larynx where the pharynx joins the upper end of the oesophagus
What is distance of the cervical(cricopharyngeus)oesophageal constriction from upper incisor teeth and nostril?
Distance from the
1) upper incisor teeth = 6 in(15 cm)
2) nostril = 7.2(18 cm)
What is the other names for bronchaortic oesophageal constriction?
1) aortic arch constriction
2) the 2nd
Define the bronchoaortic constriction(aortic arch constriction)
Where the aortic arch and the left primary bronchus cross the front of the oesophagus
What is distance of the bronchoaortic(aortic arch )oesophageal constriction from upper incisor teeth and nostril?
Distance from the
1) upper incisor teeth = 10 in(25 cm)
2) nostril = 11.2 in(28 cm)
What is the other name for diaphragmatic oesophageal constriction?
1) opening in the diaphragm
2 the third
Define the diaphragmatic(opening in the diaphragm)constriction
Occurs at the oesophageal hiatus(opening) where the oesophagus passes through the diaphragm to enter into the stomach.
What is distance of the diaphragmatic(opening in the diaphragm)oesophageal constriction from upper incisor teeth and nostril?
Distance from the
1) upper incisor teeth = 16 in(41 cm)
2) nostril = 17.2(44 cm)
What is clinical importance of the oesophageal constrictions?
Draw schematic diagram for the oesophageal constrictions
What is the structure of the oesophagus?
At what level the oesophagus starts?
It originates at the
1) inferior border of the cricoid cartilage
2) C6
At what level the oesophagus extends?
Extends to the cardiac orifice of the stomach at the T11 vertebral
At what level the oesophagus pierces the diaphragm(the oesophageal opening)?
1) 1 inch to the left of the midline
2) opposite to
a) body of T10
c) 7th left costal cartilage
At what level the oesophagus ends?
T11
What is the distance of the duodenum from the upper incisor teeth and nostril?
Distance from the
1) upper incisor teeth =22-26in(65-66 cm
(2) nostril =23.2-27.2in(59-69 cm)
What is the location of the oesophagus?
Discuss the course of the oesophagus?
Discuss the course of the oesophagus in the neck(cervical oesophagus?
Discuss the course of the oesophagus in the thorax (thoracic oesophagus)?
Discuss the course of the oesophagus in the abdomen(abdominal oesophagus?
What is the location of the cervical oesophagus?
(1) starts at the level of cricoid cartilage (C6)
(2) in front of the prevertebral fascia
(3) slightly(1 inch) to the left of the midline
(4) behind trachea
Discuss the histology of the oesophagus
Discuss the relations of the oesophagus
What are the relations of the cervical oesophagus?
What are the relations of the thoracic oesophagus?
What are the relations of the abdominal oesophagus?
What are the relations of the oesophagus on its right side ?
Lesser sac of peritoneum
What are the relations of the oesophagus on its left side ?
Lesser sac of peritoneum
Discuss the specific relations of the oesophagus
Discuss the vasculature of the oesophagus
Discuss the blood supply to the oesophagus
Discuss the arterial supply to the oesophagus
Discuss the venous drainage of the oesophagus
What is the surgical importance of the the blood supply of oesophagus?
What is the clinical importance of the venous drainage of the oesophagus?
Discuss lymphatic drainage of the oesophagus
Discuss the nerve supply to the oesophagus
Draw a schematic table for the arteries,veins,nerves and lymphatic drainage and muscularis externa of the oesophagus
Discuss gastro-oesophageal sphincter
Enumerate the factors controlling competence of the cardia
Discuss surface anatomy of the oesophagus
Mention some points of surgical importance for the oesophagus
What is the relation of the oesophagus to the left atrium of the heart?
Write short notes on development of the oesophagus
What are the types of the gastro-oesophageal sphincter?
1) anatomic sphincter
2) physiologic sphincter
Define the anatomic gastro-oesophageal sphincter
Doesn’t exist at the lower end of the oesophagus
Define physiologic gastro-oesophageal sphincter
The circular layer of smooth muscle in this region serves as a physiologic sphincter
Discuss the mechanism of the physiologic gastro-oesophageal sphincter
Define peristalsis of the oesophagus
1) Wave-like contractions of the muscular coat called peristalsis
2) Propel the food onward
What are the functions of the oesophagus?
1) Food conduction
The oesophagus conducts food from pharynx into the stomach
2) Peristalsis
Wave-like contractions of the muscular coat called peristalsis,propel the food onward
What is the other name for achalasia of the cardia?
Oesophageal achalasia
Define achalasia of the cardia
Failure of normal relaxation of the gastro-oesophageal sphincter resulting in obstruction of flow into the stomach
Discuss the aetiology of the achalasia
Discuss the clinical picture of the achalasia of the cardia
What is the incidence of GORD?
Discuss the aetiology of GORD
Discuss the clinical picture of GORD
Define Barrett’s oesophagus
Metaplastic transformation of squamous oesophageal epithelium to columnar gastric type epithelium
Discuss types of Barrett’s oesophagus
1st/According to the site (1) Intestinal (high risk) (2) Cardiac (3) Fundic #the latter two are difficult to diagnose
2nd/According to the length
(1) Short< 3 cm
(2) Long > 3 cm
#the length of the affected segment correlates strongly with the chances of identifying metaplasia
What is the prevalence of Barrett’s oesophagus?
1) difficult to be determined
2) 1 in 20 in general
3) up to 12% of those undergoing endoscopy for reflux
How to diagnose Barrett’s oesophagus
The most concrete diagnosis is made by
Endoscopic features + deep biopsy
#the deep biopsy demonstrates
Goblet cell metaplasia + oesophageal glands
What should be demonstrated in the deep biopsy of Barrett’s oesophagus?
Goblet cell metaplasia + oesophageal glands
What is the means of surveillance of Barrett’s oesophagus?
Endoscopic surveillance(i.e.,regular endoscopic monitoring) as follows
1) Usual cases-every 2-5 years
2) Moderate dysplasia-more frequently
3) Severe dysplasia-be very wary of small foci of cancer
Why a regular surveillance should be done for Barrett’s oesophagus?
Because metaplasia will progress to dysplasia
What is the regular interval in which surveillance should be done for Barrett’s oesophagus?
Every 2-5 years
What are the characteristics of a good biopsy in Barrett’s oesophagus?
1) deep
2) adequate
3) quadrantic
4) taken at 2-3 cm intervals
#where mass lesions are present,endoscopic submucosal resection should be done
What is the indication of endoscopic submucosal resection in Barrett’s oesophagus?
Mass lesions
What is the complication of Barrett’s oesophagus
With endoscopic submucosal resection up to 40% of patients will be upstaged from high grade dysplasia to invasive malignancy
What is the treatment of Barrett’s oesophagus?
1) long term proton pump inhibitor
2) consider pH and manometry studies in young patients who prefer an anti reflux procedure
3) Endoscopic surveillance(i.e.,regular endoscopic monitoring) as follows
a) Usual cases-every 2-5 years
b) Moderate dysplasia-more frequently
c) Severe dysplasia-be very wary of small foci of cancer
What is the indication pH and manometry?
consider pH and manometry studies in young patients who prefer an anti reflux procedure
What are the clinical features of Mallory-Weiss tear?
(1) antecedent vomiting followed by vomiting of small amount of blood(i.e.,typically brisk to moderate volume of bright red blood following bout of repeated vomiting)
(2) melaena-rare
(3) there is usually little in the
- way of systemic disturbance
- prior symptoms
(4) usually ceases spontaneously
What are the clinical features of the hiatus hernia of gastric cardia?
(1)longstanding dyspepsia
(2)dysphagia or haematemesis
Uncomplicated hiatus hernias
should not be associated with
dysphagia or haematemesis
(2)overweight
Define oesophageal rupture
Complete disruption of the oesophageal wall in absence of pre-existing pathology
What is the commonest site for oesophageal rupture?
Left posterolateral wall(2-3cm from OG junction)
What are the clinical features of oesophageal rupture?
Suspect in patients with
1) severe chest pain without cardiac diagnosis
2) signs of pneumonia
- without convincing history
- history of vomiting
What is the simplest investigation could be performed for oesophageal rupture?
CXRs-shows infiltrate or effusion in 90% of cases
What does CXRs show in oesophageal rupture?
Infiltrate or effusion in 90% of cases
What are the clinical features of squamous cell carcinoma of the oesophagus?
(1) progressive dysphagia
(2) weight loss
(3) little or no H/O previous GORD symptoms
(4) increase risk with achalasia
What are the clinical features of adenocarcinoma of the oesophagus?
(1) progressive dysphagia
(2) previous symptoms of GORD or Barrett’s oesophagus
What are the clinical features of peptic stricture?
(1) longer history of dysphagia,often not progressive
(2) symptoms of GORD
(3) often lack systemic features seen with malignancy
What are the clinical features of dysmotility disorder ?
(1) dysphagia
- episodic
- non progressive
(2) retrosternal pain-May accompany the episodes
What is the differential diagnosis of oesophageal disease?
(1) Mallory Weiss tear
(2) Hiatus hernia of the gastric cardia
(3) Oesophageal rupture
(4) squamous cell carcinoma of the oesophagus
(5) adenocarcinoma of the oesophagus
(6) peptic stricture
(7) dysmotility disorder
What are the investigations for any oesophageal disease?
(1) upper GI endoscopy
for accurate diagnosis of most patients
(2) ph and manometry+radiological contrast swallows
if endoscopy fails to show mechanical stricture
What is the importance of surgery in oesophageal cancer?
Surgical resection is the mainstay of treatment
What is the indication for surgery in oesophageal cancer?
Staging investigations are negative for metastatic disease
What are the contraindications for surgical resection in oesophageal cancer?
(1) distant metastasis
2) N2 disease( in spite of nodal disease is not itself a contraindication to resection to resection
What are the surgical options available for oesophageal cancer?
(1) endoscopic mucosal resection
(2) oesophagectomy
a)transhiatal oesophagectomy
b)Ivor Lewis oesophagectomy
c)McKeon oesophagectomy
What are the indications of endoscopic mucosal resection?
(1) early localised adenocarcinoma of the distal oesophagus
(2) in situ disease-managed by endoscopic mucosal resection although its use is still debated
What is the advantage of endoscopic mucosal resection for management of oesophageal cancer?
Survival mirror that of surgical resection for Tis and T1 disease
What is the indication for transhiatal oesophagectomy?
(1) Junctional type II tumours
where limited thoracic oesophageal resection is required
(2) very distal tumours
transhiatal oesophagectomy is an attractive option as the penetration of two visceral cavities required for Ivor Lewis which increases the morbidity and mortality
What is the advantage of transhiatal oesophagectomy?
Less morbidity than two fields oesophagectomy
What is the indication for Ivor Lewis oesophagectomy?
Two stage approach for middle and distal(lower) 1/3rds oesophageal tumours
What is the incidence of Ivor Lewis oesophagectomy?
Very commonly performed
What are the complications of Ivor Lewis oesophagectomy?
(1) anastomotic leak
- aetiology:
as the result of devascularised stomach in which the only blood supply is from the gastroepiploic artery as all others will have been divided
- management:
if a leak does not occur then conservative management with prolonged NGT drainage and TPN.
- sequale:
a) mediastinitis
b) up to 50% of patients with anastomotic leak will not survive to discharge
(2) atelectasis
due to thoracotomy and lung collapse
(3) delayed gastric emptying
avoided by pylorplasty
Discuss anastomotic leak caused by Ivor Lewis oesophagectomy
- aetiology:
as the result of devascularised stomach in which the only blood supply is from the gastroepiploic artery as all others will have been divided - management:
if a leak does not occur then conservative management with prolonged NGT drainage and TPN. - sequale:
a) mediastinitis
b) up to 50% of patients with anastomotic leak will not survive to discharge
What is the aetiology of anastomotic leak caused by Ivor Lewis oesophagectomy?
as the result of devascularised stomach in which the only blood supply is from the gastroepiploic artery as all others will have been divided
what is the management of anastomotic leak caused by Ivor Lewis oesophagectomy?
if a leak does not occur then conservative management with
(1) prolonged NGT drainage and
(2) TPN.
What is the sequale of anastomotic leak caused by Ivor Lewis oesophagectomy?
a) mediastinitis
b) up to 50% of patients with anastomotic leak will not survive to discharge
What is the aetiology of atelectasis caused by Ivor Lewis oesophagectomy?
thoracotomy and lung collapse
How we can avoid delayed gastric emptying caused by Ivor Lewis oesophagectomy?
by pylorplasty
What is the advantage of Ivor Lewis oesophagectomy for the treatment of oesophageal cancer?
Lower incidence of recurrent laryngeal nerve injury
Define Ivor Lewis oesophagectomy
Combined laparotomy and right thoracotomy
What are the preparation steps for Ivor Lewis oesophagectomy?
1st/ staging with a combination of
(1) CT chest,abdomen and pelvis- if no metastatic disease
(2) staging laparoscopy- to detect peritoneal disease
2nd/ if both of the previous modalities are negative
(1) PET CT scan-to detect occult metastatic disease
(2) resection- if no evidence of advanced disease
3rd/ the following should be available
(1) GA
(2) double lumen endotracheal tube-to allow for lung deflation
(3) CVP
(4) arterial monitoring
What is the incision used for Ivor Lewis oesophagectomy and why?
- incision- rooftop incision
- why- to access the stomach and duodenum
What are the steps of performing an Ivor Lewis oesophagectomy?
(FOR READING ONLY)
What is the other name for Mckeown oesophagectomy?
Total oesophagectomy
What is the indication for Mckeown oesophagectomy?
Three fields approach for more proximal oesophageal tumours with anastomosis to cervical the cervical oesophagus
What is the advantage and disadvantage of Mckeown oesophagectomy for treatment of oesophageal cancer?
Advantage
Less serious anastomotic leak
Disadvantage
Higher incidence of recurrent laryngeal nerve injury
What is the advantage of Mckeown oesophagectomy for treatment of oesophageal cancer?
Less serious anastomotic leak
What is the disadvantage of Mckeown oesophagectomy for treatment of oesophageal cancer?
Higher incidence of recurrent laryngeal nerve injury
Define neoadjuvant and adjuvant therapy in general
Neoadjuvant therapy
Neoadjuvant or induction therapy is defined as therapy administered prior to definitive local treatment
Adjuvant therapy Additional cancer treatment given after the primary treatment to lower the recurrence rate of cancer. Adjuvant therapy may include (1) chemotherapy (2) radiotherapy (3) hormone therapy (4) targeted therapy (5) biological therapy
What is the indication of neoadjuvant radiotherapy?
Given prior to resection(i.e.,surgery)
What is the disadvantage of neoadjuvant radiotherapy for the treatment of oesophageal cancer?
if used alone,
(1) it confers little benefit
(2) not routinely performed
Discuss types of adjuvant therapy for treatment of oesophageal cancer
Discuss palliative strategies for treatment of oesophageal cancer?
What is the indication of combination chemotherapy as a palliative strategy for the treatment of oesophageal cancer?
Non operable disease
What is the advantage of combination chemotherapy as a palliative strategy for the treatment of oesophageal cancer?
Improves quality of life
What is the indication of Trastuzumab as a palliative strategy for the treatment of oesophageal cancer?
HER2 positive tumours
What is the advantage of Trastuzumab as a palliative strategy for the treatment of oesophageal cancer?
Improves survival
What is the indication of oesophageal intubation with self expanding metal stents as a palliative strategy for the treatment of oesophageal cancer?
Treatment of choice for occluding tumours > 2 cm from cricopharyngeus
What is the indication of covered metal stents as a palliative strategy for the treatment of oesophageal cancer?
Malignant fistulas
What is the indication of laser and argon plasma coagulation as a palliative strategy for the treatment of oesophageal cancer?
(1) Tumour overgrowth
(2) Bleeding
What is the disadvantage of photodynamic therapy and ethanol as a palliative strategy for the treatment of oesophageal cancer?
(1) confer little benefit
(2) should not routinely used
Draw a schematic diagram to illustrate the difference between different types of surgical procedures used for treatment of oesophageal cancer
What is the aetiology for oesophageal bleeding?
(1) oesophagitis
(2) cancer
(3) Mallory Weiss tear
(3) varices
What are the clinical features of oesophagitis
(1) blood-fresh+small volume
(2) streaking vomiting
(3) Melena-rare
(4) ceases spontaneously
(5) H/O antecedent GORD symptoms
What are the clinical features of oesophageal varices?
(1) small volume of fresh blood
(2) melena-swallowed blood causes melena
(3) haemodynamic compromise
(4) ceases spontaneously but rebleed are common until approximately managed
What are the clinical fractures of oesophageal cancer as a cause of upper GI bleeding?
(1) small volume except as per terminal event with erosion of major vessels
(2) symptoms of dysphagia
(3) constitutional symptoms such as weight loss
(4) recurrent until malignancy managed
What is the the most common cause of biliary disease in patients with HIV?
Sclerosing cholangitis due to infections such as
(1) CMV
(2) cryptosporidium
(3) microsporidia
What is the the most common cause of pancreatitis in patients with HIV?
(1) antiretroviral treatment(especially didanosine)
(2) opportunistic infections,e.g.,CMV
Define insulinoma
Insulin producing tumours of the pancreatic B cells
What type of cells is affected by insulinoma?
(1) Pancreatic B cells
(2) 75% of patients with MEN I develop pancreatic islet cell tumours
What is the incidence of insulinoma?
1/1000,000/year
What are the type of insulinoma tumours?
90% are benign
What is the size of insulinoma tumours?
< 2 cm
What are the syndromes associated with insulinoma?
MEN I
(1) 5-10% have MEN I
(2) 75% of patients with MEN I develop pancreatic islet cell tumours
What is the incidence of MEN I in insulinoma tumours?
5-10%
What is incidence of patients with MEN I developing islet cell tumours?
75%
What are the typical clinical features of insulinoma?
When is testing done for insulinoma?
When neuroglycopenic symptoms occur
What are the investigations done to test for insulinoma?
(1) serum insulin = plasma insulin concentration is >10 Micro U/ ml in insulinoma
(2) serum glucose = less than 3 mmol/l in insulinoma
(3) C- peptide
(4) pro insulin concentration
How are insulinoma tumours localised?
Discuss treatment of insulinoma
1st/segmental resection of the pancreas (e.g.,Whipples)
- unjustifiable as most insulinomas are benign
- acceptable for malignant tumours
2nd/the best approach at laparotomy is to localise the tumour by
- preoperative imaging + intraoperative US
#tumours are usually close to pancreatic duct and
this must be appreciated by the operating surgeon
3rd/peri operative use of octreotide
Reduces pancreatic drainage but not overall complications
What is the most common type of pancreatic cancer?
Adenocarcinoma
What are the risk factors pancreatic cancer?
(1) smoking
(2) diabetes
(3) adenoma
(4) familial adenomatous polyposis
What is the most common site of pancreatic cancer?
Head of pancreas(70%)
How does the pancreatic cancer metastasise?
(1) locally
(2) metastasises to the liver
What is the differential diagnosis of pancreatic cancer?
Other periampullary tumours with better prognosis
What are the clinical features of pancreatic cancer?
What are the investigations of pancreatic cancer?
What is the treatment of pancreatic cancer?
What is the pathogenesis of pancreatic cancer?
(1) ascending infection of the bile duct by E.coli occurring in a pool of stagnant bile
(2) nodal disease at the porta hepatis in which the bile duct is of normal calibre
Define hyperamylasaemia
Elevation of amylase 3 times the normal range
What are the causes of hyperamylasaemia?
Mnemonic;MAD/APP
(1) (M)esenric infarct
(2) (A)cute pancreatitis
(3) (D)iabetic ketoacidosis
(4) (A)cute cholecystitis
(5) (P)ancreatic pseudogout
(6) (P)erforated viscus
What is the the disadvantage of amylase testing?
Amylase may give both positive and negative results
What is the the substitute of amylase testing and why?
Serum lipase because
(1) is both more sensitive and specific than serum amylase
(2) has longer half life
What are the advantages and disadvantages of serum amylase testing?
Advantages
(1) is both more sensitive and specific than serum amylase
(2) has longer half life
Disadvantages
Does not correlate with disease severity
What are the advantages of serum amylase testing?
(1) is both more sensitive and specific than serum amylase
(2) has longer half life
What are the disadvantages of serum amylase testing?
Does not correlate with disease severity
What are the tools for assessing severity of pancreatitis?
Mnemonic;GRAB
(1) Glasgow
(2) Ranson scoring system
(3) APPACHE II
(4) Biochemical scoring e.g., CRP
Discuss features that may predict a severe attack of pancreatitis within 48 hours of admission to the hospital?
Discuss initial assessment of features that may predict a severe attack of pancreatitis within 48 hours of admission to the hospital?
Discuss features that may predict a severe attack of pancreatitis 24 hours after admission to the hospital?
Discuss features that may predict a severe attack of pancreatitis 48 hours after admission to the hospital?
What are the steps of managing pancreatitis?
(1) nutrition
(2) use of antibiotics
(3) surgery
Discuss each step of management of pancreatitis
1st/Nutrition
(1) entral nutrition doesn’t worsen the outcome in pancreatitis
(2) most trials did not show a conclusive benefit
(3) the rationale behind feeding that it prevents bacterial translocation from the gut thereby contributing to the development of infected pancreatic necrosis
2nd/Use of antibiotics
(1) there is very little evidence to support the use of antibiotics in acute pancreatitis
(2) there are potential benefits of administering Imipenem to patients with pancreatic necrosis to avert the progression of infection
(3) antibiotics administration in mild attacks of pancreatitis
- will not affect outcome
- contribute to antibiotic resistance
- increase the risk of antibiotic associated diarrhoea
3rd/Surgery
The choice of procedure depends upon local expertise
(1) acute pancreatitis due to gall stones-early cholecystectomy
(2) obstructed biliary system due to stones-early ERCP
(3) extensive necrosis where the infection is suspected-FNA for culture
(4) infected necrosis-radiological drainage or surgical necrosectomy
Discuss nutrition for management of pancreatitis
(1) entral nutrition doesn’t worsen the outcome in pancreatitis
(2) most trials did not show a conclusive benefit
(3) the rationale behind feeding that it prevents bacterial translocation from the gut thereby contributing to the development of infected pancreatic necrosis
What are the advantages of nutrition in management of pancreatitis?
(1) entral nutrition doesn’t worsen the outcome in pancreatitis
(2) the rationale behind feeding that it prevents bacterial translocation from the gut thereby contributing to the development of infected pancreatic necrosis
What are the disadvantages of nutrition in management of pancreatitis?
most trials did not show a conclusive benefit
Discuss antibiotic therapy in pancreatitis
(1) there is very little evidence to support the use of antibiotics in acute pancreatitis
(2) there are potential benefits of administering Imipenem to patients with pancreatic necrosis to avert the progression of infection
(3) antibiotics administration in mild attacks of pancreatitis
- will not affect outcome
- contribute to antibiotic resistance
- increase the risk of antibiotic associated diarrhoea
What is benefit of administering Imipenem in patients with pancreatic necrosis?
Avert the progression to infection
What are the side effects of giving antibiotics in mild attacks of pancreatitis?
antibiotics administration in mild attacks of pancreatitis
- will not affect outcome
- contribute to antibiotic resistance
- increase the risk of antibiotic associated diarrhoea
Discuss the surgical options for pancreatitis
The choice of procedure depends upon local expertise
(1) acute pancreatitis due to gall stones-early cholecystectomy
(2) obstructed biliary system due to stones-early ERCP
(3) extensive necrosis where the infection is suspected-FNA for culture
(4) infected necrosis-radiological drainage or surgical necrosectomy
What is the surgical options for acute pancreatitis due to gall stones?
Early cholecystectomy
What is the surgical option for pancreatitis caused by obstructed biliary system due to stones?
Early ERCP
What is the surgical option for extensive necrosis due to pancreatitis?
FNA for culture
What is the surgical option for infected necrosis due to pancreatitis?
(1) radiological drainage
OR
(2) surgical necrosectomy
What does the choice of surgical procedure to be done for pancreatitis depend on?
Local expertise
Define Trousseau’s sign
Migratory superficial thrombophlebitis
What are the indications of pancreatic stents?
Both benign and malignant biliary obstruction
What are the types of pancreatic stents?
(1) plastic stents(or tubes)
2) metallic stents(self expanding
Compare between metallic and plastic pancreatic stents
Enumerate the different methods of placing pancreatic stents
(1) percutaneously
(2) at ERCP
(3) open surgery(less common now)
What are the complications of pancreatic stents?
(1) blockage
(2) displacement
(3) those related to the method of insertion
What are the sequalae of pancreatitis?
(1) peripancreatic fluid collection
(2) pseudocyst
(3) pancreatic necrosis
(4) pancreatic abscess
(5) haemorrhage
What is the incidence of peripancreatic fluid collection as a sequelae of pancreatitis?
25%
What is the location of peripancreatic fluid collection as a sequelae of pancreatitis?
In or near the pancreas
What is the histological feature of peripancreatic fluid collection as a sequelae of pancreatitis?
Lack a wall of granulation tissue or fibrous tissue
What is the fate of peripancreatic fluid collection as a sequelae of pancreatitis?
(1) spontaneous resolution
OR
(2) development of pseudocyst or abscess
What is the management of peripancreatic fluid collections as a sequelae of pancreatitis?
Since most collections resolve spontaneously,aspiration and drainage is best avoided as it may precipitate infection
Define pancreatic pseudocyst
What are the characteristics of the pancreatic pseudocyst?
The collection is
(1) walled by fibrous or granulation tissue
(2) occurs 4 weeks or more after an attack of acute pancreatitis
When does the pancreatic pseudocyst occur?
4 weeks or more after an attack of acute pancreatitis
What is the location of the pancreatic pseudocyst?
Retrogastric
What are the investigations of the pancreatic pseudocyst?
(1) amylase(75% are associated with persistent mild elevated amylase)
(2) CT
(3) ERCP
(4) MRI or
(5) endoscopic USS
What is management of the pancreatic pseudocyst?
(1) symptomatic cases may be observed for 12 weeks as up to 50% resolve
(2) cholecystectomy
- endoscopic or
- surgical
OR
(3) aspiration
For how long the patient with pancreatic pseudocyst should be observed?
12 weeks
What is the percentage of patients who gets well post pancreatic pseudocyst?
50% resolve
Define pancreatic necrosis
Involves both
(1) pancreatic parenchyma
(2) surrounding fat
What is the cause of the pancreatic necrosis?
Linked to extent of
(1) parenchymal necrosis
(2) necrosis overall
What is the management of pancreatic necrosis?
(1) early necrosectomy
- has a high mortality rate
- should be avoided unless strongly indicated
(2) conservative for sterile necrosis(at least initially)
(3) FNA cytology
- for suspected infections
- false negatives may occur
(4) surgery-the extent of sepsis and organ dysfunction may be a better guide to surgery
Define pancreatic abscess
What is the cause of pancreatic abscess?
Infected pancreatic pseudocyst
What is treatment for pancreatic abscess?
Placement of percutaneous drains
Define pancreatic haemorrhage
Mention a sign that presents in pancreatic haemorrhage
Grey Turner’s sign-found in retroperitoneal haemorrhage
What are the boundaries of the axilla?
What are the contents of the axilla?
Mnemonic;LTAIL
What happens in axillary exploration?
What is the number of interossei?
4 palmar and 4 dorsal interossei
What is the location of the interossei in general?
Occupy the spaces between the metacarpal bones
What is the origin of the interossei?
(1) each palmar interossei originates from the metacarpal bone of the digit on which it acts
(2) each dorsal interossei comes from the surface of the adjacent metacarpal bone on which it acts
Which one is bigger the dorsal or palmar interossei?
The dorsal interossei are twice the size of the palmar interossei
What is the insertion of the interossei?
What is the ligament posterior to the insertion of the interossei?
Deep transverse metacarpal ligament
What is the action of the interossei?
Mnemonic;PAD and DAB
(P)almr interossei (AD)duct
(D)orsal interossei (AB)duct
What is the effect of interossei injury?
What is the nerve supply of the interossei?
They are all innervated by the ulnar nerve
Define the inguinal canal
Is an oblique intermuscular passage through the lower part of the anterior abdominal wall
What is the location of the inguinal canal?
It lies parallel to and immediately above the medial 1/2 of the inguinal ligament
Discuss the length of the inguinal canal
Discuss sex differences of inguinal canal
Discuss extension and direction of the inguinal canal
What is the anatomical significance of the inguinal canal?
Where does the inguinal canal begin and end?
What are the other names for the rings of the inguinal canal?
(1) Deep inguinal ring
- internal ring
- inlet
(2) Superficial inguinal ring
- external ring
- outlet
What is the other name for deep inguinal ring?
(1) internal ring
(2) inlet
What is the other name for superficial inguinal ring?
(1) external ring
(2) outlet
Define the superficial inguinal ring
Is a defect or opening in the external oblique aponeurosis
What is the location of the superficial inguinal ring?
What is the shape of the superficial inguinal ring?
(1) triangular slit or aperture
- small
- oblique
(2) V shaped
What is the size of the superficial inguinal ring?
1 inch long
Discuss the formation of the superficial inguinal ring
(1) formed by invagination of the external oblique
(2) forms the exit of the inguinal canal
Discuss the constituents of the superficial inguinal ring
What is the base of superficial inguinal ring formed of?
Formed by the lateral 1/2 of the pubic crest
What is the direction of the base of the superficial inguinal ring?
Directed upward and laterally
Discuss the sides of the superficial inguinal ring
Discuss the intercrural fibres of the superficial inguinal ligament
What is the function of the intercrural fibres of the superficial inguinal ligament?
Prevent the separation of the 2 crura
What is the significance of the intercrural fibres of the superficial inguinal ligament?
They represent fibres that cross the middle line from one external abdominal oblique to the other
Discuss the surface anatomy of the superficial inguinal ring
What is the relation of the superficial inguinal ring?
How is the external spermatic fascia formed?
As the cord traverses the superficial inguinal ring,it carries the external spermatic fascia from the ring’s margins
Define the deep inguinal ring
An outpouching of the transversalis fascia that forms the entrance to the inguinal canal
What is the origin of the deep inguinal ring?
In the transversalis fascia
What is the location of the deep inguinal ring?
Discuss the formation of the deep inguinal ring
At the midinguinal point which is :-
What is the shape of the deep inguinal ring?
What is the relations of the deep inguinal ring?
(1) inferior epigastric vessels
- the deep inguinal ring lies just lateral to the inferior epigastric vessels
- the inferior epigastric vessels,which pass upward from the external iliac vessels,lie medial to the deep inguinal ring(i.e., it demarcates it medially)
(2) fibres of transversus abdominis muscle
the deep inguinal ring lie below fibres of the transversus abdominis muscle
(3) internal spermatic fascia
Draw a schematic diagram for superficial and deep inguinal rings of inguinal canal
Write short notes on the epigastric artery
Discuss the surface anatomy of both superficial and deep inguinal rings
What are the boundaries(walls) of the inguinal canal?
What are the anterior boundaries of the inguinal canal?
What are the posterior boundaries of the inguinal canal?
What are the superior(roof) boundaries of the inguinal canal?
What are the inferior(floor) boundaries of the inguinal canal?
What are the lateral and medial boundaries of the inguinal canal?
What are the lateral boundaries of the inguinal canal?
What are the medial boundaries of the inguinal canal?
What are the contents of the inguinal canal?
What are the covering of the spermatic cord as it passes through the inguinal canal?
Write short notes on the ilioinguinal nerve
What are the boundaries of both superficial and deep inguinal canal?
What are the other names for Hasselbach’s triangle?
(1) inguinal triangle
(2) triangle of Halshted
Define Hasselbach’s triangle
What is the location Hasselbach’s triangle?
Discuss boundaries of Hasselbach’s triangle
Discuss subdivisions of Hasselbach’s triangle
What is the origin of the ilioinguinal nerve?
Arises from the ventral ramus of L1 with the iliohypogastric nerve
What is the course of the ilioinguinal nerve?
What is the relation of the ilioinguinal nerve to the psoas muscle?
It passes inferolaterally through the substance of psoas muscle
What is the relation of the ilioinguinal nerve to the quadratus lumborum muscle?
It passes inferolaterally over the anterior surface of quadratus lumborum muscle
What is the relation of the ilioinguinal nerve to the internal oblique muscle?
It pierces the internal oblique muscle
What is the relation of the ilioinguinal nerve to the posterior wall of the inguinal canal?
It pierces the posterior wall of the inguinal canal
What is the relation of the ilioinguinal nerve to the external oblique aponeurosis ?
It passes deep to the external oblique aponeurosis
What is the relation of the ilioinguinal nerve to the inguinal canal?
What are the structures supplied by the branches of the ilioinguinal nerve?
What is the surgical significance of the ilioinguinal nerve?
Write short notes on iliohypogastric nerve
Write short notes on genitofemoral nerve
What is the origin of the radial nerve?
A continuation of the posterior cord of brachial plexus (nerve root values C5 to T1)
What is the root values of the radial nerve?
C5 to T1
Discuss the course of the radial nerve
What is the course of the radial nerve in the axilla?
+Lies posterior to the axillary artery
+On— (1)Subscapularis
(2) Latissimus dorsi
(3) Teres major
What is the course of the radial nerve in the arm?
(1)Enters the arm between the brachial artery and
the long head of triceps (medial to humerus).
(2)Spirals around the posterior surface of the
humerus in the groove for the radial nerve.
(3)At the distal third of the lateral border of the
humerus it then pierces the intermuscular septum
and descends in front of the lateral epicondyle.
(4)At the lateral epicondyle it lies deeply between
brachialis and brachioradialis where it then divides
into a superficial and deep terminal branch.
What are the related structures to the radial artery on entering the arm?
(1)Brachial artery
(2)Long head of triceps
What is the location of the radial artery to the humerus on entering the arm?
Medial to the humerus
What is the relation between the humerus and the radial nerve along its course?
1st/Medial: Enters the arm between the brachial
artery and the long head of triceps
(medial to humerus).
2nd/Posterior: Spirals around the posterior surface
of the humerus in the groove for the
radial nerve.
3rd/Lateral: At the distal third of the lateral border
of the humerus it then pierces the
intermuscular septum and descends in
front of the lateral epicondyle.
4th/Deep: At the lateral epicondyle it lies deeply between
brachialis and brachioradialis where it then
divides into a superficial and deep terminal branch.
5th/Deep branch crosses the supinator to become the
posterior interosseous nerve.
Where does the radial nerve divide into its terminal branches?
At the lateral epicondyle:-
it lies deeply between the brachialis and the brachioradialis where it then divides into a superficial and deep terminal branches
What are the regions innervated by the radial nerve?
What are the regions innervated by the motor branch of the main radial nerve?
What are the regions innervated by the motor branch of the posterior interosseous nerve?
What are the regions innervated by the sensory branch of the main radial nerve?
Discuss Muscular innervation and effect of denervation of the radial nerve?
What is the specific muscle in the shoulder that is innervated by the radial nerve and what is the effect of its injury or paralysis in the shoulder?
Muscle affected—Long head of triceps
Effect of paralysis—Minor effects on shoulder
stability in abduction
What is the specific muscle in the arm that is innervated by the radial nerve and what is the effect of its injury or paralysis in the arm?
Muscle affected—triceps
Effect of paralysis—loss of elbow flexion
What is the specific muscle in the forearm that is innervated by the radial nerve and what is the effect of its injury or paralysis in the forearm?
Muscle affected— (1)Supinator
(2)Brachioradialis
(3)Extensor carpi radialis longus
and brevis
Effect of paralysis—Weakening of
(1)supination of prone hand and
(2)elbow flexion in mid prone
position
What is the effect of radial nerve injury in the shoulder?
Minor effects on shoulder stability in abduction
What is the effect of radial nerve injury in the arm?
Loss of elbow extension
What is the effect of radial nerve injury in the forearm?
Weakening of
(1)supination of prone hand and
(2)elbow flexion in mid prone position
What is the nerve injury associated with posterior triangle lymph node biopsy?
Accessory nerve lesion
What is the nerve injury associated with Lloyd Davies stirrups?
Common peroneal nerve injury
What is the nerve injury associated with thyroidectomy?
Laryngeal nerve injury
What is the nerve injury associated with anterior resection of rectum?
Hypogastric autonomic nerve injury
What is the nerve injury associated with axillary node clearance?
Mnemonic; LIT
(1) Long thoracic nerve
(2) Intercostobrachial nerve
(3) Thoracodorsal nerve
What is the nerve injury associated with inguinal hernia surgery?
Ilioinguinal nerve injury
What is the nerve injury associated with varicose vein surgery?
(1)Sural nerve
(2)Saphenous nerve
What is the nerve injury associated with the posterior approach to the hip?
Sciatic nerve injury
What is the nerve injury associated with carotid endarterectomy?
Hypoglossal nerve injury
What is the main cause of nerve injury in general?
They commonly occur when surgeons operate
(1)in an unfamiliar tissue plane or
(1)by blind placement of haemostats
(not recommended).
What is the vertebral levels that is consistent with the origin of the trachea?
The trachea commences at C6.
It terminates at the level of upper border of T5 (or T6 in tall subjects in deep inspiration).
What is the vertebral levels that is consistent with the termination of the trachea?
The trachea commences at C6.
It terminates at the level of upper border of T5 (or T6 in tall subjects in deep inspiration).
What is the vertebral levels that is consistent with the termination of the trachea in tall subjects?
T6
What is the vertebral levels that is consistent with the termination of the trachea in deep inspiration?
T6
What is the location of the trachea?
C6 vertebra to the upper border of T5 vertebra (bifurcation)
What is the vertebral level of bifurcation of the trachea?
Upper border of T5
What are the relations of the trachea?
What are the relations of the trachea in the neck?
What are the anterior relations of the trachea in the neck in order from superior to inferior ?
Mnemonic; In Inferior Arteries So Small Cathetre Accessed
What are the posterior relations of the trachea in the neck?
Oesophagus
What are the lateral relations of the trachea in the neck?
Mnemonic; Common Left & Right Inferior Recurrent
What are the relations of the trachea in the thorax?
What are the anterior relations of the trachea in the thorax?
Mnemonic; Memories Retrieved Anterograde Left Commonly Deep
OR
Men Ruminating A Left Common Cadaver
(1) Manubrium
(2) Remenants of thymus
(3) Aortic arch
(4) Left common carotid arteries
(5) Deep cardiac plexus
What are the lateral relations of the trachea in the thorax?
In superior mediastinum
1st/On the right side: (1) Pleura
(2) Right vagus
2nd/On the left side: Mnemonic;CARS
(1) Left Common carotid artery
(2) Aortic arch
(3) Left Recurrent nerve
(4) Subclavian arteries
What are the lateral relations of the trachea in the superior mediastinum of the thorax on the right side?
(1) Pleura
(2) Right vagus
What are the lateral relations of the trachea in the superior mediastinum of the thorax on the left side?
Mnemonic;CARS
(1) Left Common carotid artery
(2) Aortic arch
(3) Left Recurrent nerve
(4) Subclavian arteries
Discuss coeliac axis
What are the branches of the coeliac axis?
What are the branches of the common hepatic artery of the coeliac axis?
(1) Rt gastric artery
(2) Gastroduodenal artery which gives the Rt gastroepiploic artery
(3) Superior pancreaticoduodenal artery
(4) Cystic (occasionally)
What are the branches of the splenic artery of the coeliac axis?
(1) Pancreatic artery
(2) Short gastric artery
(3) Lt gastroepiploic artery
What are the relations of the coeliac axis?
What are the anterior relations of the coeliac axis?
Lesser omentum
What are the right side relations of the coeliac axis?
(1) Rt coeliac ganglion
(2) Caudate lobe of the liver
What are the left side relations of the coeliac axis?
(1) Left coeliac ganglion
(2) Gastric cardia
What are the inferior relations of the coeliac axis?
(1) Upper border of pancreas
(2) Renal vein
Discuss surface anatomy of the neck in details
What are the structures felt in the midline of the neck in order from above downward?
What is the vertebral level of the hyoid bone?
C3
What is the vertebral level of the notch of the thyroid cartilage?
C4
What is the vertebral level at which the cricoid cartilage terminates?
C6
What are the structures that lie at the lower border of the cricoid cartilage?
What are the relations of the subclavian vein?
*Anteriorly
(1) Subclavius
(2) Medial part of the clavicle
*Posterosuperiorly—on the following order
(1) rests on the 1st rib- below and in front of the 3rd part of the subclavian artery
(2) then on scalenus anterior, with the phrenic nerve on it,which separates it from the 2nd part of the subclavian artery
*Inferiorly— 1st rib and cervical pleura
What are the anterior relations of the subclavian vein?
(1) Subclavius
(2) Medial part of the clavicle
What muscle is anterior to the subclavian vein?
Subclavius
What bone is anterior to the subclavian vein?
Medial part of the clavicle
Which part of the clavicle is anterior to the subclavian vein?
Medial part of the clavicle
Which part of the clavicle is anterior to the subclavian vein?
Medial part of the clavicle
What are the posterosuperior relations of the subclavian vein?
On the following order
(1) rests on the 1st rib- below and in front of the 3rd part of the subclavian artery
(2) then on scalenus anterior, with the phrenic nerve on it ; which separates it from the 2nd part of the subclavian artery
Which bone is posterior to the subclavian vein?
rests on the 1st rib below and in front of the 3rd part of the subclavian artery
Which muscle is posterior to the subclavian vein?
Scalenus anterior , with the phrenic nerve on it,which separates the the subclavian vein from the 2nd part of subclavian artery
What is the origin of the subclavian vein?
As a continuation of the axillary vein
What is the site of origin of the subclavian vein?
At the outer border of the 1st rib
How does the subclavian vein terminate?
By joining the internal jugular vein to form the Innominate vein
What vein joins the subclavian vein and what is the end result?
Joins the internal jugular vein to form the Innominate artery
What are the tributaries of the subclavian vein?
It has only one tributary—External jugular vein
How many tributaries are there for the subclavian vein?
Only one tributary- the external jugular vein
How many tributaries are there for the subclavian vein?
Only one tributary- the external jugular vein
What is the origin of the external jugular vein?
(1) It is the only tributary of the subclavian vein
(2) Formed by the union of posterior auricular vein and retromandibular vein
What veins form the external jugular vein?
Formed by union of the
(1) posterior auricular vein
(2) retromandibular vein
What is the course of the external jugular vein?
It crosses perpendicular to the superficial surface of the sterncleidomastoid muscle beneath or deep to the platysma muscle
What are the relations of the external jugular vein?
It crosses perpendicular to the superficial surface of the sternocleidomastoid muscle and beneath or deep to the platysma muscle
What are the relations of the external jugular vein?
It crosses perpendicular to the superficial surface of the sternocleidomastoid muscle and beneath or deep to the platysma muscle
What is the origin of the internal jugular vein?
As a continuation of the sigmoid sinus
What is site of the origin of the internal jugular vein?
At the jugular foramen
Where does the internal jugular vein begin?
At the jugular foramen
How does the internal jugular vein terminate or end ?
By joining the subclavian vein to form the Innominate vein behind the sternal(medial) end of the clavicle
What are the relations of the internal jugular vein?
What is the relation between the internal jugular vein and the carotid sheath?
The internal jugular vein lies inside the carotid sheath lateral to the internal and common carotid arteries with the vagus nerve in between
What is the relation between the internal jugular vein and the internal carotid artery?
The internal jugular vein lies inside the carotid sheath lateral to the internal and common carotid arteries with the vagus nerve in between
What is the relation between the internal jugular vein and the common carotid artery?
The internal jugular vein lies inside the carotid sheath lateral to the internal and common carotid arteries with the vagus nerve in between
What is the relation between the internal jugular vein and the common carotid artery?
The internal jugular vein lies inside the carotid sheath lateral to the internal and common carotid arteries with the vagus nerve in between
What is the relation of the internal jugular vein and the vagus nerve?
The internal jugular vein lies inside the carotid sheath lateral to the internal and common carotid arteries with the vagus nerve in between
What is the relation between the internal jugular vein and the thoracic duct?
The internal jugular vein passes in front of the thoracic duct on the left side
What is the relation between the internal jugular vein and the deep cervical lymph nodes?
The internal jugular vein runs alongside the chain of deep cervical lymph nodes
What is the relation between the internal jugular vein and the phrenic nerve?
The internal jugular vein passes anterior to the phrenic nerve
What are the medial relations of the internal jugular vein?
(1) Internal carotid artery
(2) Common carotid artery
(3) Vagus nerve
What are the posterior relations of the internal jugular vein?
(1) Thoracic duct on the left side
(2) Phrenic nerve
What are the tributaries of the internal jugular vein?
Mnemonic; IF LIPS MJ
or
Mnemonic; IF Lingual Part Supero Medial J
(1) Inferior petrosal vein
(2) Common Facial vein
(3) Lingual vein
(4) Pharyngeal veins
(5) Superior thyroid vein
(6) Middle thyroid vein
(7) Jugular lymph trunk
What is the surface anatomy of the internal jugular vein?
From Sternoclavicular joint to the ear lobule
What is the relation between the subclavian vein and the subclavius?
The subclavian vein lies behind the
(1) subclavius
(2) medial ( sternal ) end of the clavicle
What is the relation between the subclavian vein and the clavicle?
The subclavian vein lies behind the
(1) subclavius
(2) medial ( sternal ) end of the clavicle
What is the relation between the subclavian vein and the 1st rib?
The subclavian vein rests on the 1st rib below and in front of the 3rd part of the subclavian artery and then on scalenus anterior which separates it from the 2nd part of the subclavian artery
What are the relations between the subclavian vein and the the scalenus anterior?
The subclavian vein rests on the 1st rib below and in front of the 3rd part of the subclavian artery and then on scalenus anterior which separates it from the 2nd part of the subclavian artery
What is the relation between the subclavian vein and the subclavian artery?
The subclavian vein is anterior to the subclavian artery separated from the artery by the scalenus anterior muscle
The subclavian vein rests on the 1st rib below and in front of the 3rd part of the subclavian artery and then on scalenus anterior which separates it from the 2nd part of the subclavian artery
