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MRCS Anatomy > Raftery Abdo and Perineum > Flashcards

Raftery Abdo and Perineum Flashcards

1
Q

How many folds of peritoneum are there below the umbilicus and what are they?

A

Three

Median umbilical fold - obliterated urachus
Medial umbilical fold - obliterated umbilical artery
Lateral umbilical fold - inferior epigastric artery

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2
Q

What are the relations of the omental bursa (lesser sac)?

A

Front - lesser omentum, stomach
Above - superior recess whose anterior border is the caudate lobe of liver
Below - projects downwards to transverse mesocolon
Left - spleen, gastrosplenic and lienorenal ligaments
Right - opens into greater sac via epiploic foramen

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3
Q

What are the relations of the epiploic foramen (Foramen of Winslow)?

A

Front - free edge of lesser omentum
Back - IVC
Above - caudate process of liver
Below - 1st part of duodenum

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4
Q

What are the contents of the epiploic foramen?

A

Right - bile duct
Left - hepatic artery
Behind - portal vein

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5
Q

What separates the right and left subphrenic spaces?

A

Falciform ligament

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6
Q

What are the boundaries of the right subhepatic space (renal well of Rutherford Morrison)?

A

Above - liver with attached gallbladder
Below - duodenum
Behind - posterior abdominal wall, kidney

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7
Q

What is the left subhepatic space?

A

Lesser sac

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8
Q

What are the bones in the posterior abdominal wall?

A

Bodies of lumbar vertebrae
Sacrum
Wings of ilium

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9
Q

What are the muscles in the posterior abdominal wall?

A

Posterior part of diaphragm
Psoas major
Quadratus lumborum
Iliacus

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10
Q

What are important structures on the posterior abdominal wall?

A 
Abdominal aorta
IVC
Kidneys
Adrenal glands
Lumbar sympathetic chain
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11
Q

What is the origin of psoas major?

A

Transverse processes of L1-5 and sides of bodies and intervening discs from T12-L5 vertebrae

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12
Q

Where does the psoas major insert?

A

Tip of lesser trochanter of femur

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13
Q

What is the nerve supply of psoas major?

A

L2-3

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14
Q

What are the actions of psoas major?

A

Flexion and medial rotation of extended thigh

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15
Q

What important structures lies on psoas major?

A

IVC
Ureters
Gonadal vessels

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16
Q

What lies in front of psoas major?

A

Retrocaecal or retrocolic appendix

Psoas/Cope’s sign = RLQ pain with flexion of right hip against resistance in appendicitis

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17
Q

What is the origin of quadratus lumborum?

A

Iliolumbar ligament and adjacent portion of iliac crest

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18
Q

Where does quadratus lumborum insert?

A

Medial half of lower border of 12th rib and by 4 small tendons into the transverse process of L1-4

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19
Q

What are some anterior relations of quadratus lumborum?

A

Colon
Kidney
Subcostal, ilioinguinal and iliohypogastric nerves

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20
Q

What is the origin of iliacus?

A

Greater part of iliac fossa extending into sacrum

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21
Q

What is the insertion of iliacus?

A

Lateral aspect of tendon of psoas major onto lesser trochanter of femur

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22
Q

What is the nerve supply of iliacus?

A

Branch of femoral nerve (L2-3)

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23
Q

What are the anterior relations of abdominal aorta (from up to down)?

A 
Lesser omentum
Stomach
Coeliac plexus
Pancreas
Splenic vein
Left renal vein
3rd part of duodenum
Root of mesentery
Coils of small intestine
Aortic plexus
Peritoneum
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24
Q

What are posterior relations of abdominal aorta?

A

Bodies of L1-4 vertebrae
Left lumbar veins
Cisterna chyli

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25
Q

What structures are found on the right side of the abdominal aorta?

A

IVC
Thoracic duct
Azygous vein
Right sympathetic trunk

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26
Q

What structures are found on the left side of the abdominal aorta?

A

Left sympathetic trunk

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27
Q

What are the branches of the abdominal aorta and their levels?

A

Anterior unpaired supplying abdominal viscera:

  1. Coeliac axis - T12
  2. SMA - L1
  3. IMA - L3

Lateral paired:

  1. Suprarenal - L1
  2. Renal - L1-2
  3. Gonadal (testicular/ovarian) - L2

Paired to parietes:

  1. Inferior phrenic - T12
  2. 4 lumbar arteries - L1-4

Terminal branches

  1. Common iliac - L4
  2. Median sacral - L4 (slightly above aortic bifurcation)
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28
Q

What are the branches of the coeliac axis?

A

Left gastric artery
Common hepatic artery
Splenic artery

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29
Q

What are the branches of the superior mesenteric artery?

A

Ileocolic
Middle colic
Right colic

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30
Q

What are the branches of the inferior mesenteric artery?

A

Left colic

Superior rectal

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31
Q

What are the anterior relations of common iliac artery?

A

Peritoneum
Small intestine
Ureters
Sympathetic nerves

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32
Q

Which artery runs along the brim of the pelvis on the medial side of psoas major?

A

External iliac artery

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33
Q

Inferior epigastric artery is a branch of?

A

External iliac artery

branch given off immediately before passing below inguinal ligament

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34
Q

Which structure passes backwards and downwards into the pelvis between the ureter (anteriorly) and internal iliac vein (posteriorly)?

A

Internal iliac artery

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35
Q

Where does the internal iliac artery divide into its anterior and posterior branches?

A

At the upper border of the greater sciatic notch

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36
Q

What do the branches of the internal iliac artery supply?

A

Pelvic organs
Perineum
Buttock
Anal canal

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37
Q

At which level does the common iliac veins join to form the inferior vena cava?

A

L5

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38
Q

At which level does the IVC pass through the diaphragm?

A

T8

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39
Q

What are the anterior relations of IVC?

A 
Mesentery
3rd part of duodenum
Pancreas
1st part of duodenum
Portal vein
Posterior surface of liver
Diaphragm
Arteries (from top to bottom): hepatic, right testicular, right colic, right common iliac
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40
Q

What are the posterior relations of IVC?

A 
Vertebral column
Right crus of diaphragm and psoas major
Right sympathetic trunk
Right renal artery
Right lumbar arteries
Right suprarenal arteries
Right inferior phrenic artery
Right suprarenal gland
To the left: aorta
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41
Q

What are the tributaries of IVC?

A 
Lumbar branches
Right gonadal vein
Right and left renal veins
Right suprarenal vein
Phrenic vein
Hepatic vein
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42
Q

Where does the lumbar sympathetic chain start?

A

Deep to the medial arcuate ligament of the diaphragm as a continuation of the thoracic sympathetic chain

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43
Q

What are the positions of the lumbar vessels relative to the lumbar sympathetic chain?

A

Lumbar arteries - lie deep to chain

Lumbar veins - may cross superficial to it

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44
Q

What are the branches of the lumbar sympathetic chain?

A 
Plexuses around abdominal aorta
Hypogastric plexus (presacral nerves) to supply the pelvic viscera distributed along internal iliac artery and its branches
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45
Q

What causes failure of ejaculation after resection of AAA or extensive pelvic dissection?

A

Removal of aortic and hypogastric plexuses

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46
Q

What may lumbar sympathectomy be carried out for?

A

Plantar hyperhidrosis or vasospastic conditions

Usually the 2nd-4th ganglia are excised with the intermediate chain

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47
Q

Muscles of the pelvic floor

A

Levator ani

Coccygeus

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48
Q

Muscles of the pelvic wall

A 
Piriformis (on front of sacrum)
Obturator internus (on lateral wall of true pelvis)

Both act on femur, described with LL muscles

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49
Q

Origins of levator ani

A

Back of body of pubis
Ischial spine
Between these from the fascia covering obturator internus along a thickening between the above 2 points

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50
Q

Insertion of levator ani

A

Perineal body - forms a sling around prostate (levator prostatae) or vagina (sphincter vaginae)

Puborectalis (deep part of anal sphincter at anorectal ring) - sling around rectum and anus

Sides of coccyx and a median fibrous raphe stretching between the apex of the coccyx and anorectal junction

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51
Q

Nerve supply of levator ani

A

Pelvic surface - perineal branch of S4

Perineal surface - branch of inferior rectal and perineal division of pudendal nerve (S2-3)

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52
Q

Actions of levator ani

A

Principal support of pelvic floor
Support pelvic viscera
Resist downward pressure of abdominal muscles
Sphincter action on rectum and vagina
Increase intra-abdominal pressure during defecation, micturition, parturition

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53
Q

What is the coccygeus?

A

A small triangular muscle behind and in the same plane as levator ani

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54
Q

Origin of coccygeus

A

Ischial spine

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55
Q

Insertion of coccygeus

A

Side of coccyx and lowest part of sacrum

Same attachments as sacrospinous ligament

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56
Q

Nerve supply of coccygeus

A

Perineal branch of S4

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57
Q

Action of coccygeus

A

Hold coccyx in natural forwards position
Pelvic fascia

Parietal pelvic fascia - strong membrane covering muscles of pelvic wall and attached to bones at margins of muscles, over fixed or non-distensible structures (e.g. prostate)
Visceral pelvic fascia - loose and cellular over moveable structures (e.g. levator ani, bladder, rectum)

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58
Q

Triangles of the perineum

A 
Urogenital triangle (anterior perineum)
Anal triangle (posterior perineum)
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59
Q

What is the urogenital triangle?

A

Triangle formed by the ischiopubic inferior rami and line joining the ischial tuberosities passing just in front of anus

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60
Q

What is the perineal membrane?

A

Inferior fascia of the urogenital diaphragm - a strong fascial sheath attached to the sides of the urogenital triangle

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61
Q

Contents of deep perineal pouch

A 
External urethral sphincter (striated muscle fibres surrounding membranous urethra)
Bulbourethral glands (of Cowper) - ducts pierce perineal membrane to open into bulbous ducts
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62
Q

Relations of the external urethral sphincter

A

Below - perineal membrane

Above - indefinite layer of fascia i.e. superior fascia of urogenital diaphragm

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63
Q

Contents of superficial perineal pouch

A

Male:

  1. Bulb of penis attached to undersurface of perineal membrane (bulbospongiosus covers corpus spongiosum)
  2. Crura of penis attached at angle between insertion of perineal membrane and ischiopubic rami (each crus surrounded by ischiocarnous muscle)
  3. Superficial transverse perineal muscle running transversely from perineal body to ischial ramus
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64
Q

What is the perineal body?

A

Fibromuscular nodule lying in the midline between anterior and posterior perineum

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65
Q

Attachments of perineal body

A

Anal sphincter
Levator ani
Bulbospongiosus
Transverse perineal muscle

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66
Q

What is the anal triangle?

A

Triangular area lying between ischial tuberosities on each side and coccyx

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67
Q

Contents of anal triangle

A

Anus and its sphincters
Levator ani
Ischiorectal fossa

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68
Q

What is the ischiorectal fossa?

A

Space between the anal canal and side wall of pelvis

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69
Q

Boundaries of ischiorectal fossa

A

Medial - fascia over levator ani, external anal sphincter
Lateral - fascia over obturator internus
Front - extends forwards as prolongation deep to urogenital diaphragm
Back - limited by sacrotuberous ligaments and origin of gluteus maximus from this ligament

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70
Q

What lies in the pudendal canal (of Alcock)?

A

Internal pudendal vessels and nerve

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71
Q

What is the pudendal canal (of Alcock)?

A

Tunnel of fascia continuous with fascia overlying the obturator internus

72
Q

Parts of penis

A

Root
Body
Glans

73
Q

Attachments of root of penis

A

Perineal membrane
Pubic rami by crura
Symphysis pubis by suspensory ligament

74
Q

What does the body of the penis comprise?

A

Corpus cavernosum

Corpus spongiosum

75
Q

How is corpus cavernosum attached to the pubic symphysis?

A

By a suspensory ligament

76
Q

Parts of male urethra (20cm long)

A

Prostatic
Membranous
Spongy

77
Q

Layers/coverings of the testis

A

Scrotal skin
Dartos fascia and muscle
External spermatic, cremaster muscle in cremasteric fascia, internal spermatic fascia
Parietal and visceral layers of tunica vaginalis
Tunica albuginea

78
Q

Blood supply of testicles

A

Testicular artery arising from aorta at level of renal vessels

79
Q

Origin of blood supply of vas deferens and epididymis

A

Artery to the vas from inferior vesical branch of internal iliac artery

80
Q

Venous drainage of testis

A

Pampiniform plexus of veins which become the testicular vein at deep inguinal ring

81
Q

Drainage of testicular veins

A

Right testicular vein into IVC, left into left renal vein

82
Q

Lymphatic drainage of testis

A

Accompany testicular veins into para-aortic nodes

83
Q

At which level does the testis arise from on the posterior abdominal wall?

A

L2/3

84
Q

How may a rapidly developing varicocoele be a presenting sign of tumour of left kidney?

A

Tumour of left kidney may invade the left renal vein, blocking the drainage of left testicular vein into the renal vein

85
Q

Where does the vas deferens join the seminal vesicle ducts to form the common ejaculatory duct?

A

At the most superior and posterior aspect of the prostate gland

86
Q

What does the common ejaculatory duct become?

A

Traverses the prostate to open into the prostatic urethra at the verumontanum on either side of the utricle

87
Q

Start and end points of oesophagus

A

From lower border of cricoid cartilage (C6) to cardiac orifice of stomach (T11)

88
Q

Parts of oesophagus

A

Cervical
Thoracic
Abdominal

89
Q

Relations of cervical oesophagus

A

Anterior - trachea, thyroid
Posterior - lower cervical vertebrae, prevertebral fascia
Left - left common carotid artery, inferior thyroid, subclavian artery, thoracic duct
Right - right common carotid artery, recurrent laryngeal nerves that lie on either side in the groove between trachea and oesophagus

90
Q

Where are the vagus nerves in relation to the thoracic oesophagus?

A

2 vagus nerves form a plexus on the surface of the oesophagus in the posterior mediastinum

Left vagus - anterior
Right vagus - posterior

91
Q

Relations of the thoracic oesophagus

A

Anterior - left common carotid artery, trachea, left main bronchus, pericardium (separating it from left atrium and diaphragm)
Posterior - thoracic vertebrae, thoracic duct, hemiazygous vein, descending aorta below
Left - left subclavian artery, aortic arch, left vagus nerve and recurrent laryngeal, thoracic duct, left pleura
Right - right pleura, azygous vein

92
Q

Where does the abdominal oesophagus lie?

A

In the groove on the posterior surface of the left lobe of liver with left crus of diaphragm behind

93
Q

Blood supply of oesophagus

A

Cervical - inferior thyroid arteries
Thoracic - branches of aorta
Abdominal - left gastric and inferior phrenic arteries

94
Q

Venous drainage of oesophagus

A

Cervical - inferior thyroid veins
Thoracic - azygous veins
Abdominal - azygous veins (systemic), partly to left gastric veins (portal)

95
Q

Nerve supply of oesophagus

A

Upper 1/3 - parasympathetics via recurrent laryngeal nerve, sympathetics from middle cervical ganglion via inferior thyroid artery

Lower 2/3 (below root of lung) - vagus and sympathetics nerves contribute to oesophageal plexus

96
Q

Layers of oesophagus

A

Mucous membrane lined by non-keratinised stratified squamous epithelium
Submucosa
Muscular layers - inner circular and outer longitudinal muscles
Muscularis externa upper 1/3 - striated muscle
Lower 2/3 - smooth muscle causing peristalsis
Adventitia
Outer layer of loose connective tissue

97
Q

Lymphatic drainage of oesophagus

A

Cervical - deep cervical nodes
Thoracic - mediastinal nodes
Abdominal - gastric nodes

98
Q

Surfaces of the stomach

A

Anterior

Posterior

99
Q

Curvatures of the stomach

A

Greater

Lesser

100
Q

Orifices of the stomach

A

Cardia

Pylorus

101
Q

What is the name of the notch that marks the junction of the body with pyloric antrum along the lesser curve?

A

Incisura angularis

102
Q

What is attached to the lesser and greater curves of the stomach?

A

Lesser and greater omentum respectively

103
Q

What marks the junction of the pylorus with the duodenum?

A

Constant prepyloric vein of Mayo, which crosses it vertically

104
Q

Relations of the stomach

A

Anterior (left to right) - diaphragm, abdominal wall, left lobe of liver
Posterior - separated from diaphragm, aorta, pancreas, spleen, left kidney and suprarenal gland, transverse mesocolon and colon by lesser sac of peritoneum

105
Q

Arterial supply of stomach

A

Left gastric artery (from coeliac axis) - runs along lesser curve and anastomoses with right gastric branch of common hepatic artery

Right gastroepiploic artery (from gastroduodenal branch of hepatic artery) - anastomoses along greater curve with left gastroepiploic artery (from splenic artery)

Short gastric arteries (from splenic artery)

106
Q

Venous drainage of stomach

A

Follows arteries, into the portal vein

107
Q

Lymphatic drainage of stomach

A

Cardiac area - drains along left gastric artery to coeliac nodes
Area supplied by splenic artery - drains via nodes accompanying that artery to LN at hilum of spleen then to those along upper border of pancreas, eventually to coeliac nodes

Rest of stomach:

  1. Via branches of hepatic artery through nodes along lesser curve to coeliac nodes
  2. Through nodes along right gastroepiploic vessels to subpyloric nodes, then to coeliac nodes
108
Q

Nerve supply of stomach

A

Anterior vagus nerve close to oesophageal wall - gives off hepatic branch and pyloric branch to pyloric sphincter

Posterior vagus nerve further from oesophageal wall - gives off coeliac branch passing to coeliac axis before sending a gastric branch to posterior surface of stomach

Gastric divisions of both vagi (nerves of Latarjet) reach the stomach at the cardia and descend along the lesse curve between the anterior and posterior peritoneal attachments of the lesser omentum

109
Q

What is the surface of gastric mucosa covered by?

A

Columnar epithelial cells which secrete mucus and alkaline fluid to protect the epithelium from mechanical injury and gastric acid

110
Q

What are the 3 areas of gastric mucosa?

A

Cardiac gland via area gastro-oesophageal junction - contains mucus-secreting cells

Acid-secreting region (oxyntic gland area) - contains parietal (oxyntic) cells and chief (zymogen) cells

Pyloric end area (distal 30% of stomach) - contains ‘G’ cells producing gastrin with mucus-secreting cells

111
Q

In a retrograde spread of gastric carcinoma, what can happen with regards to the lymphatic drainage?

A

Spread may occur into the hepatic LNs at porta hepatis - enlargement of these nodes may cause external compression of bile ducts resulting in obstructive jaundice

112
Q

Contents of femoral triangle

A 
(Medial to lateral)
Femoral vein
Femoral artery
Femoral nerve
Deep and superficial inguinal LNs
Lateral cutaneous nerve
Great saphenous vein
Femoral branch of genitofemoral nerve
113
Q

In the lesser pelvis, where does the obturator nerve lie?

A

Lateral to the internal iliac vessels and ureter

Joined by the obturator vessels lateral to the ovary and ductus deferens

114
Q

What does the obturator nerve supply?

A

Medial compartment of thigh

Muscles: external obturator, adductor longus/brevis/magnus (lower part by sciatic nerve), gracilis

115
Q

What does the cutaneous branch of the obturator nerve supply?

A

Note: cutaneous branch is often absent.

When present, it passes between gracilis and adductor longus near middle part of thigh.

Supplies skin and fascia of distal 2/3 of medial aspect.

116
Q

What is the obturator canal and its contents?

A

Connects the pelvis and thigh.

Contains: obturator artery and vein, nerve which divides into anterior and posterior branches.

117
Q

What is the spermatic cord formed by?

A

Vas deferens

118
Q

Layers of spermatic cord and their origins

A

External spermatic fascia - external oblique aponeurosis

Cremasteric fascia - internal oblique aponeurosis

Internal spermatic fascia - transversalis fascia

119
Q

Contents of the spermatic cord

A

3 arteries - testicular (from AA), cremasteric (from inferior epigastric), artery to vas deferens (from inferior vesical, anterior division of internal iliac artery)

3 nerves - genital branch of genitofemoral nerve (to cremaster), sympathetic nerves (lies on arteries), ilioinguinal nerve (lies on cord, not within)

3 others - pampiniform plexus veins (drain to R/L testicular vein), vas deferens, lymphatics (to lumbar and para-aortic nodes)

120
Q

Arterial supply of scrotum

A

Anterior and posterior scrotal arteries

121
Q

Lymphatic drainage of scrotum

A

Inguinal lymph nodes

122
Q

Innermost layer of scrotum

A

Parietal layer of tunica vaginalis

123
Q

Lymphatic drainage of testes

A

Para-aortic nodes

124
Q

Where does the iliacus muscle lie?

A

Posterior to the femoral nerve in femoral triangle

125
Q

Where does the femoral sheath lie?

A

Anterior to the iliacus and pectineus muscles

126
Q

Femoral nerve root values

A

L2-4

127
Q

What does the femoral nerve innervate?

A

Pectineus
Sartorius
Quadriceps and rectus femoris
Vastus lateralis/medialis/intermedius

128
Q

Branches of femoral nerve

A

Medial and intermediate cutaneous nerves of thigh

Saphenous nerve

129
Q

Which muscle does the femoral nerve penetrate?

A

Psoas major

130
Q

How does the femoral nerve exit the pelvis?

A

By passing under the inguinal ligament to enter the femoral triangle

131
Q

What is the location of femoral nerve relative to the femoral artery and vein?

A

Lateral to femoral artery and vein

132
Q

Posterior relations of ascending colon

A

Iliacus
Quadratus lumborum
Perirenal fascia over lateral aspect of kidney

133
Q

How is the transverse colon attached to the anterior border of pancreas?

A

By the transverse mesocolon

134
Q

Relations of transverse colon

A

Anterior - greater omentum
Posterior - kidneys, 2nd part of duodenum, pancreas, small intestine
Superior - liver, gallbladder, greater curvature of stomach, spleen
Inferior - small intestine

135
Q

What lies between the splenic flexure and diaphragm?

A

Phrenicocolic ligament, a fold of peritoneum

136
Q

Relations of descending colon

A

Anterior - small intestine

Posterior - Left kidney, quadratus lumborum, iliacus

137
Q

Which structures does the root of sigmoid colon cross over?

A

External iliac vessels

Left ureter

138
Q

What are taenia coli?

A

3 flattened bands of longitudinal muscle passing from caecum to rectosigmoid and converging at base of appendix

139
Q

What are appendices epiploicae?

A

Fat-filled tags scattered over the surface of the colon, most numerous in sigmoid colon (absent in appendix, caecum, rectum)

140
Q

Commonest positions of appendix

A

Retrocaecal - 75%
Pelvic - 20%
Preileal or postileal - 5%

141
Q

Arterial supply of appendix

A

Appendicular artery (from ileocolic artery)

142
Q

Start and end points of rectum

A

~12cm long, starts anterior to 3rd segment of sacrum and ends ~2.5cm in front of coccyx

143
Q

What is the transition between sigmoid and rectum marked by?

A

Disappearance of taenia coli

144
Q

Extraperitoneal parts of rectum

A

Upper 1/3 - posterior
Middle 1/3 - posterior and lateral
Lower third - whole thing, lie below pelvic peritoneum

145
Q

What is the extraperitoneal rectum surrounded by?

A

Mesorectal fat containing lymph nodes

Note: this layer is removed during rectal cancer surgery (total mesorectal excision)

146
Q

Fascial layers surrounding rectum

A

Denonviliers fascia - anterior (prostate)

Waldeyers fascia - posterior (sacrum)

147
Q

Lateral inflexions of rectum

A

Left, right then left

Each inflexion is capped by valve of Houston

148
Q

Relations of rectum

A

Anterior (M) - rectovesical pouch, bladder, prostate, seminal vesicles
Anterior (F) - rectouterine pouch (Douglas), cervix, vaginal wall
Posterior - sacrum, coccyx, middle sacral artery, lower sacral nerves
Lateral - levator ani, coccygeus

149
Q

Arterial supply of rectum

A

Superior rectal artery (from IMA) - whole rectum and upper half of anal canal

Middle rectal artery (from internal iliac) - small, only muscle coats of rectum

Inferior rectal artery (from internal pudendal) - lower half of anal canal

150
Q

Venous drainage of rectum above vs below dentate line

A

Above - superior rectal vein (portal venous system)

Below - inferior rectal vein (systemic)

Note: site of portosystemic anastomosis

151
Q

Lymphatic drainage of rectum above vs below dentate line

A

Above dentate line - mesorectal nodes along superior rectal vessels draining into internal iliac nodes

Below dentate line - superficial inguinal nodes

152
Q

Epithelium above vs below dentate line

A

Above - columnar (adenocarcinoma

Below - non-keratinised stratified squamous (SCC) (until Hilton’s white line where anal verge becomes continuous with perianal skin containing keratinised epithelium)

153
Q

Embryological origin above vs below dentate line

A

Above - endoderm

Below - ectoderm

154
Q

Arterial/venous supply above vs below dentate line

A

Above - superior rectal

Below - middle and inferior rectal (venous only inferior)

155
Q

Nerve supply above vs below dentate line

A

Above - inferior hypogastric plexus (autonomic), not sensitive to pinprick

Below - inferior rectal nerves (somatic), sensitive to pinprick (relevant when injecting haemorrhoids)

156
Q

At which vertebral level does the left colon become the sigmoid?

A

L3-4

157
Q

What is the name of the artery that forms as a result of anastomoses between branches of SMA and IMA along length of colon?

A

Marginal artery (of Drummond) - from right colon

Weakest near splenic flexure. Can cause ischaemic colitis.

Contribution from the marginal artery becomes significant when IMA is surgically divided (e.g. during AAA repair).

158
Q

Position of rectal veins

A

1 on left, 2 on right

This explains the 3, 7 and 11 o’clock positions of haemorrhoids when anal canal is viewed with patient in lithotomy position.

159
Q

Where do the efferent vessels from nodes near origins of SMA and IMA drain into?

A

Cisterna chyli

160
Q

What can be found at the midpoint of the anal canal?

A

Vertical columns in the mucosa (columns of Morgagni)

161
Q

What can be found at the distal end of the vertical columns in the anal canal?

A

Valve-like folds (anal valves of Ball)

162
Q

Muscles of anal sphincters

A

Internal anal sphincter - smooth muscle continuous above with circular muscle of rectum, surrounds upper 2/3 of rectum, supplied by sympathetic nerves

External - striated muscle that surrounds the internal anal sphincter but extends further distally

163
Q

Parts of external anal sphincter

A

3 parts:

  • subcutaneous
  • superficial, attached to coccyx behind and perineal body in front
  • deep, continuous with puborectalis of levator ani
164
Q

What is the anorectal ring?

A

The deep part of external anal sphincter where it blends with levator ani together with internal sphincter

Note: anorectal ring is palpable with finger in anal canal where it forms a ring, immediately above which the finger enters the ampulla of the rectum

165
Q

What is the subcutaneous part of the external anal sphincter traversed by?

A

Fan-shaped expansion of longitudinal muscle fibres of anal canal

166
Q

Nerve supply of external anal sphincter

A

Inferior rectal branch of pudendal nerve (S2-3)

Perineal branch of S4

167
Q

Relations of 1st part of duodenum

A

Anterior - liver, gallbladder

Posterior - portal vein, CBD, gastroduodenal artery (IVC behind all these)

168
Q

Relations of 2nd part of duodenum

A

Anterior - transverse colon

Posterior - right kidney and ureter

169
Q

Relations of 3rd part of duodenum (longest part, ~10cm)

A

Anterior - root of mesentery, superior mesenteric vessels

Posterior - IVC, aorta, L3 vertebra

170
Q

How may the DJ flexure be identified during surgery?

At DJ flexure, small intestine leaves posterior abdo wall and acquires a mesentery

A

By presence of suspensory ligament of Treitz - a peritoneal fold descending from the right crus of diaphragm to termination of duodenum

171
Q

Arterial supply of duodenum

A

Superior pancreaticoduodenal artery (from gastroduodenal)

Inferior pancreaticoduodenal (from SMA)

These 2 arteries lie in the curve between duodenum and head of pancreas, supplying both structures

172
Q

Average length of small intestine

A

6 metres

173
Q

Length of mesentery of small intestine

A

About 15cm, attached across posterior abdominal wall

174
Q

Start and end points of small intestine

A

Starts at DJ flexure to the left of L2 vertebra, passes obliquely downwards to right sacroiliac joint

175
Q

Relations of root of mesentery of small intestine

A 
(Left to right)
3rd part of duodenum
Aorta
IVC
Right psoas major
Right ureter
Right gonadal vessels
Right iliacus
176
Q

Contents of mesentery of small intestine

A

Superior mesenteric vessels (enter mesentery anterior to 3rd part of duodenum)
LNs draining small intestine
Autonomic nerve fibres

177
Q

How do you distinguish between jejunum and ileum at surgery?

A

Jejunum has a thicker wall due to valvulae conniventes or plicae circularis (i.e. circular folds of mucosa) - larger and more numerous than in ileum

Jejunum has greater diameter

Final straight arteries to ileum shorter and more numerous than in jejunum

Mesentery becomes thicker and more fat-laden from above downwards

Jejunum most likely to be found at/above level of umbilicus while ileum tends to lie below umbilicus in the hypogastrium and pelvis

MRCS Anatomy (9 decks)

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