Tieman GI CIS Questions

Question 1

(Carcinoma of head of pancreas) What is the lymphatic drainage of pancreas?

Answer 1

Lymphatic drainage of pancreas: porta hepatis to undersurface of liver and to cisterna chyli

Question 2

(Carcinoma of head of pancreas) What are the relationships of the pancreas to surrounding vital structures?

Answer 2

head of pancreas linked w/ arteries to duodenum. Common bile duct goes through the parenchyma of the head of the pancreas, too.

Care must be taken to not cut the middle colic vessels when surgically approaching the pancreas through the transverse mesocolon. (quote from Gut Book)

Question 3

(Carcinoma of head of pancreas) If the duodenum and the head of the pancreas are to be resected, which structures must be transected or ligated, and which of those structures must be reattached?
Blood supply, biliary and pancreatic drainage, surrounding vital structures

Answer 3

Can I ligate the Superior Mesenteric Artery? NO! Need it for the bowel. Portal vein as well, it cannot be removed.

??? what else

Question 4

(Carcinoma of head of pancreas)

What structures have been transected and how can they be put back together?

Answer 4

?

incidentally: Palpable gallbladder & jaundice: Courvoisier’s sign. Pancreatic cancer until proven otherwise.

Question 5

(Open Herniorrhaphy) Between which two layers of the abdominal wall is the hernia sac located?

Answer 5

?

Question 6

(Open Herniorrhaphy) Which abdominal wall layers must be transected to reach the hernia (starting at the skin)?

Answer 6

Skin, scarpa’s, external oblique aponeurosis–> inguinal canal w/ hernia looking at us

Question 7

(Open Herniorrhaphy) Which nerves and/or vessels are at risk for injury? Which structures, if this were a male?

Answer 7

Careful not to injure ilioinguinal nerve
Also genitofemoral
In a male, look out for spermatic cord

posterior to the deep ring- iliac vessels

Question 8

(Open Herniorrhaphy) The hernia is protruding through the deep inguinal ring. What type is it?

Answer 8

indirect

Question 9

(Open Herniorrhaphy)

What embryological structure makes up the hernia sac?

Answer 9

caused by failure of embryonic closure of the deep inguinal ring after the testicle has passed through it.

as for the sac itself…? the hernia sac of a direct inguinal hernia should have only a covering of peritoneum and transversalis fascia, while an INDIRECT hernia can be covered first with the constituents of the spermatic cord, i.e. ductus deferens, testicular a., pampiniform plexus, etc., then all of the fascial coverings located in the cord.

Question 10

(Open Herniorrhaphy) If it were a direct hernia, which anatomical area would it transgress?

Answer 10

Hesselbach’s triangle. Borders: Medial border: Lateral margin of the rectus sheath, Superolateral border: Inferior epigastric vessels, Inferior border: Inguinal ligament,

acquired- weakness in transversalis fascia

Question 11

(Open Herniorrhaphy) Which abdominal muscle layer gives rise to the cremasteric muscle?

Answer 11

Internal abdominal oblique

Question 12

(LAPAROSCOPIC HERNIORRHAPHY) Which structures are at risk for injury? (nerves, vessels, other structures)

Answer 12

? Femoral vessels? internal, external obliques and transversus abdominis?

Question 13

(LAPAROSCOPIC HERNIORRHAPHY) The hernia sac is seen protruding through the abdominal wall lateral to the inferior epigastric vessels, what type is it?

Answer 13

Indirect

Question 14

(LAPAROSCOPIC HERNIORRHAPHY) In repairing the hernia, we must place mesh extraperitoneally . In which anatomical space will the mesh be located? Which anatomical structures will be covered with mesh?

Answer 14

?

Question 15

(Bleeding esophageal varices) The primary problem is portal hypertension from alcoholic hepatic cirrhosis. Why are the esophageal veins dilated?

Answer 15

Fibrotic liver  backup. Collateral channels to get the blood back to the IVC. Anastomoses between portal system and systemic system  prone to dilatation of the veins. R & L gastric  esophageal  azygos OR umbilical veins (caput medusa), superficial veins, or through inferior mesenteric  rectal arteries ways the body is trying to get back to the IVC.

Question 16

(Bleeding esophageal varices) Name all the possible venous communications by which portal blood can find its way back to the heart.

Answer 16

R & L gastric  esophageal  azygos OR umbilical veins (caput medusa), superficial veins, or through inferior mesenteric  rectal arteries ways the body is trying to get back to the IVC.

Question 17

(Bleeding esophageal varices) Which veins carry venous blood from the portal venous system to the esophageal veins?

Answer 17

?

Question 18

(Bleeding esophageal varices) Sometimes surgeons create a “shunt” from the portal system to the IVC. Which veins of the portal system could be connected to the IVC to create such a shunt? What might be some problems associated with this type of shunt?

Answer 18

Shunt: porto-caval shunt between portal vein and inferior vena cava

Question 19

(GI Bleeding) If the EGD had revealed a bleeding posterior duodenal ulcer, which artery would most likely be involved?

Answer 19

Gastroduodenal artery goes immediately behind the duodenum, will bleed in duodenal ulcers

Question 20

(GI Bleeding) If the patient had presented with hematochezia (bright red blood per rectum) instead of hematemesis (vomiting blood), beyond which anatomical structure would the bleeding most likely be coming from? (Hint: which structure divides the duodenum from the jejunum?)

Answer 20

?

Question 21

(GI Bleeding) Arteriography is sometimes used to identify and treat bleeding in the small and large intestine. Identify which vessel would have to be cannulated to demonstrate bleeding in the small intestine. The cecum? The ascending colon? The transverse colon? The sigmoid colon?

Answer 21

?

Question 22

(Appendicitis) Define the course of the arterial supply of the appendix, starting at the aorta

Answer 22

Superior Mes Art Ileocecal Artery 5 arteries. Anterior, posterior to cecum, right colon, ileum, underneath the ileum to the appendix. (important!)

Question 23

(Appendicitis) Why is the early pain of appendicitis vague and periumbilical and the later pain specific to the right lower quadrant?

Answer 23

Obstruction of the appendiceal lumen  extension of the appendiceal lumen (visceral afferent nerve fibers)  umbilical pain (mid gut).

When the inflammation moved to peritoneum, somatic fibers more specific, localizes to RLQ

Question 24

(Appendicitis) Which structures lie adjacent to the appendix in the male? In the female?

Answer 24

?

Question 25

(Appendicitis) Which nearby structures, if inflamed, might mimic appendicitis

Answer 25

?

Question 26

(Appendicitis) What are the various locations of the appendix relative to the cecum?

Answer 26

Various locations: if not rotated, find it in LUQ. Can be partially rotated, all over right quadrants. Acute appendicitis in pregnancy– RUQ

Question 27

(Abdominal Aortic Aneurysm) In repairing an infrarenal AAA by putting a graft from just below the renal arteries to just above the aortic bifurcation, which major artery must be ligated or reimplanted into the graft?

Answer 27

• Inferior mesenteric (below renal arteries, where aneurysms occur) needs to be ligated in order to take care of aneurysm, pay attention to the branches of the IMA

Question 28

(Abdominal Aortic Aneurysm) If the surgeon ligates this artery (the IMA), how is blood supplied to the colon?

Answer 28

• Marginal artery connects SMA system and the IMA system. Usually allows for ligation of IMA, except if there’s already atherosclerotic trouble it might also be insufficient.

Question 29

(Abdominal Aortic Aneurysm) If the surgeon must mobilize the duodenal-jejunal junction, what anatomical structures might be injured?

Answer 29

Duodenal-jejunal junction (ligament of treitz) is right over the aorta, too. Immediately posterior to that is the inferior mesenteric vein  back pressure in venous system can cause left colon problem.

Spinal artery (of adenowitz) occasionally comes off of abdominal aorta, can also accidentally ligate that.

What else?

Question 30

(Abdominal Aortic Aneurysm) How could a patient become paraplegic from this operation?

Answer 30

lack of perfusion, metabolism, and oxygen delivery to the spinal cord during the vulnerable period of aortic occlusion, when spinal cord blood flow is significantly reduced (

Question 31

(Splenectomy) Trace the blood supply to and from the spleen, beginning at the aorta and ending in the liver

Answer 31

Splenic artery supplies the spleen (from celiac trunk). Short gastrics go to the stomach,too.

Question 32

(Splenectomy) What are the four ligaments of the spleen?

Answer 32

4 ligaments of the spleen:
3 to divide: splenocolic, splenorenal, splenophrenic. In order to remove the spleen. Short gastrics are off the splenic and will also be in the way.

Question 33

(Splenectomy) Which vessels travel through the gastrosplenic ligament and which vessels do they originate from/drain into?

Answer 33

Short gastric vessels and left gastro-epiploic vessels

Both come off of the splenic artery

Question 34

(Splenectomy) In ligating the splenic artery and vein, which adjacent organ must we identify and be careful not to injure?

Answer 34

Watch out for the tail of the pancreas, don’t want that injured and leaking everywhere.

Question 35

(Splenectomy) If the splenic vein were thrombosed (obstructed), which veins would become dilated (varicose)?

Answer 35

Veins that would become dilated: short gastrics ( gastric varices) as it tries to get back through the azygos.