A. 8th rib
B. 10th rib
C. 6th rib
D. 12th rib
E. 9th rib
The 11th and 12th ribs lie posterior to the kidneys and may be encountered during a
posterior approach. A pneumothorax is a recognised complication of this type of
surgery.
Renal anatomy
Each kidney is about 11cm long, 5cm wide and 3cm thick. They are located in a deep
gutter alongside the projecting verterbral bodies, on the anterior surface of psoas
major. In most cases the left kidney lies approximately 1.5cm higher than the right.
The upper pole of both kidneys approximates with the 11th rib (beware pneumothorax
during nephrectomy). On the left hand side the hilum is located at the L1 vertebral
level and the right kidney at level L1-2. The lower border of the kidneys is usually
alongside L3.
Relations
Relations Right Kidney Left Kidney
Posterior Quadratus lumborum, diaphragm, Quadratus lumborum, diaphragm,
psoas major, transversus abdominis psoas major, transversus abdominis
Anterior Hepatic flexure of colon Stomach, Pancreatic tail
Superior Liver, adrenal gland Spleen, adrenal gland
Fascial covering
Each kidney and suprarenal gland is enclosed within a common and layer of investing
fascia that is derived from the transversalis fascia into anterior and posterior layers
(Gerotas fascia).
Renal structure
Kidneys are surrounded by an outer cortex and an inner medulla which usually
contains between 6 and 10 pyramidal structures. The papilla marks the innermost
apex of these. They terminate at the renal pelvis, into the ureter.
Lying in a hollow within the kidney is the renal sinus. This contains:
1. Branches of the renal artery
2. Tributaries of the renal vein
3. Major and minor calyces's
4. Fat
A. Posterior
B. Apex
C. Anterior
D. Base
Ureter
25-35 cm long
Muscular tube lined by transitional epithelium
Surrounded by thick muscular coat. Becomes 3 muscular layers as it crosses
the bony pelvis
Retroperitoneal structure overlying transverse processes L2-L5
Lies anterior to bifurcation of iliac vessels
Blood supply is segmental; renal artery, aortic branches, gonadal branches,
common iliac and internal iliac
Lies beneath the uterine artery
A 6 month old child is brought to the surgical clinic because of non descended testes.
What is the main structure that determines the descent path of the testicle?
A. Processus vaginalis
B. Cremaster
C. Mesorchium
D. Inguinal canal
E. Gubernaculum
Testicular embryology
Until the end of foetal life the testicles are located within the abdominal cavity. They
are initially located on the posterior abdominal wall on a level with the upper lumbar
vertebrae (L2). Attached to the inferior aspect of the testis is the gubernaculum testis
which extends caudally to the inguinal region, through the canal and down to the
superficial skin. Both the testis and the gubernaculum are extra-peritoneal.
As the foetus grows the gubernaculum becomes progressively shorter. It carries the
peritoneum of the anterior abdominal wall (the processus vaginalis). As the processus
vaginalis descends the testis is guided by the gubernaculum down the posterior
abdominal wall and the back of the processus vaginalis into the scrotum.
By the third month of foetal life the testes are located in the iliac fossae, by the
seventh they lie at the level of the deep inguinal ring.
The processus vaginalis usually closes after birth, but may persist and be the site of
indirect hernias. Part closure may result in development of cysts on the cord.
A 28 year old man requires a urethral catheter to be inserted prior to undergoing a
splenectomy. Where is the first site of resistance to be encountered on inserting the
catheter?
A. Bulbar urethra
B. Membranous urethra
C. Internal sphincter
D. Prostatic urethra
E. Bladder neck
Urethral anatomy
Female urethra
The female urethra is shorter and more acutely angulated than the male urethra. It is
an extra-peritoneal structure and embedded in the endopelvic fascia. The neck of the
bladder is subjected to transmitted intra-abdominal pressure and therefore deficiency
in this area may result in stress urinary incontinence. Between the layers of the
urogenital diaphragm the female urethra is surrounded by the external urethral
sphincter, this is innervated by the pudendal nerve. It ultimately lies anterior to the
vaginal orifice.
Male urethra
In males the urethra is much longer and is divided into four parts.
Pre-prostatic Extremely short and lies between the bladder and prostate gland.It
urethra has a stellate lumen and is between 1 and 1.5cm long.Innervated by
sympathetic noradrenergic fibres, as this region is composed of
striated muscles bundles they may contract and prevent retrograde
ejaculation.
Prostatic This segment is wider than the membranous urethra and contains
urethra several openings for the transmission of semen (at the midpoint of the
urethral crest).
Membranous Narrowest part of the urethra and surrounded by external sphincter. It
urethra traverses the perineal membrane 2.5cm postero-inferior to the
symphysis pubis.
Penile urethra Travels through the corpus songiosum on the underside of the penis.
It is the longest urethral segment.It is dilated at its origin as the
infrabulbar fossa and again in the gland penis as the navicular fossa.
The bulbo-urethral glands open into the spongiose section of the
urethra 2.5cm below the perineal membrane.
The urothelium is transitional in nature near to the bladder and becomes squamous
more distally.
A 23 year old man undergoes an orchidectomy. The right testicular vein is ligated;
into which structure does it drain?
Spermatic cord
Formed by the vas deferens and is covered by the following structures:
Layer Origin
Internal spermatic fascia Transversalis fascia
Cremasteric fascia From the fascial coverings of internal oblique
External spermatic fascia External oblique aponeurosis
Scrotum
Testes
The testes are surrounded by the tunica vaginalis (closed peritoneal sac). The
parietal layer of the tunica vaginalis adjacent to the internal spermatic fascia.
The testicular arteries arise from the aorta immediately inferiorly to the renal
arteries.
The pampiniform plexus drains into the testicular veins, the left drains into the
left renal vein and the right into the inferior vena cava.
Lymphatic drainage is to the para-aortic nodes.
A 21 year old man has an inguinal hernia and is undergoing a surgical repair. As the
surgeons approach the inguinal canal they expose the superficial inguinal ring. Which
of the following forms the lateral edge of this structure?
B. Conjoint tendon
E. Transversalis fascia
The external oblique aponeurosis forms the anterior wall of the inguinal canal and
also the lateral edge of the superficial inguinal ring. The rectus abdominis lies
posteromedially and the transversalis posterior to this.
Inguinal canal
Location
Contents
Males Spermatic cord and As it passes through the canal the spermatic
ilioinguinal nerve cord has 3 coverings:
The image below demonstrates the close relationship of the vessels to the lower limb
with the inguinal canal. A fact to be borne in mind when repairing hernial defects in
this region.
Image sourced from Wikipedia
A. Femoral
B. Pudendal
C. Sciatic
D. Obturator
E. Gluteal
The obturator nerve is most closely related to the bladder (see below)
Page 209 brs ana
Image sourced from Wikipedia
Obturator nerve
The obturator nerve arises from L2, L3 and L4 by branches from the ventral divisions
of each of these nerve roots. L3 forms the main contribution and the second lumbar
branch is occasionally absent. These branches unite in the substance of psoas major,
descending vertically in its posterior part to emerge from its medial border at the
lateral margin of the sacrum. It then crosses the sacroiliac joint to enter the lesser
pelvis, it descends on obturator internus to enter the obturator groove. In the lesser
pelvis the nerve lies lateral to the internal iliac vessels and ureter, and is joined by the
obturator vessels lateral to the ovary or ductus deferens.
Supplies
Obturator canal
Connects the pelvis and thigh: contains the obturator artery, vein, nerve which
divides into anterior and posterior branches.
Cadaveric cross section demonstrating relationships of the obturator nerve
A. Cystic artery
B. Hepatic artery
C. Portal vein
The bile duct has an axial blood supply which is derived from the hepatic artery and
from retroduodenal branches of the gastroduodenal artery. Unlike the liver there is no
contribution by the portal vein to the blood supply of the bile duct. Damage to the
hepatic artery during a difficult cholecystectomy is a recognised cause of bile duct
strictures.
Gallbladder
Arterial supply
Cystic artery (branch of Right hepatic artery)
Venous drainage
Cystic vein
Nerve supply
Sympathetic- mid thoracic spinal cord, Parasympathetic- anterior vagal trunk
Calot's triangle
A. Vitello-intestinal duct
B. Uranchus
C. Foregut
D. Hindgut
E. Midgut
The appendix is derived
from the midgut
It is derived from the midgut which is why early appendicitis may present with
periumbilical pain.
Appendix
McBurney's point
1/3 of the way along a line drawn from the Anterior Superior Iliac Spine to the
Umbilicus
6 Positions:
Retrocaecal 74%
Pelvic 21%
Postileal
Subcaecal
Paracaecal
Preileal
A 34 year old man presents to the surgical clinic 8 months following a laparotomy for
a ruptured spleen. He complains of a nodule in the centre of his laparotomy wound.
This is explored surgically and a stitch granuloma is found and excised. From which
of the following cell types do granulomata arise?
A. Polymorpho nucleocytes
B. Plasma cells
E. Macrophages
Granulomas are organised
collections of macrophages
Chronic inflammation
Overview
Chronic inflammation may occur secondary to acute inflammation.In most cases
chronic inflammation occurs as a primary process. These may be broadly viewed as
being one of three main processes:
Granulomatous inflammation
A granuloma consists of a microscopic aggregation of macrophages (with epithelial
type arrangement =epitheliod). Large giant cells may be found at the periphery of
granulomas.
Mediators
Growth factors released by activated macrophages include agents such as interferon
and fibroblast growth factor (plus many more). Some of these such as interferons may
have systemic features resulting in systemic symptoms and signs, which may be
present in individuals with long standing chronic inflammation.
A 53 year old man is undergoing a radical gastrectomy for carcinoma of the stomach.
Which of the following structures will need to be divided to gain access to the coeliac
axis?
A. Lesser omentum
B. Greater omentum
C. Falciform ligament
E. Gastrosplenic ligament
The lesser omentum will need to be divided. During a radical gastrectomy this forms
one of the nodal stations that will need to be taken.
Coeliac axis
Left gastric
Hepatic: branches-Right Gastric, Gastroduodenal, Right Gastroepiploic,
Superior Pancreaticoduodenal, Cystic.
Splenic: branches- Pancreatic, Short Gastric, Left Gastroepiploic
Relations
Anteriorly Lesser omentum
Right Right coeliac ganglion and caudate process of liver
Left Left coeliac ganglion and gastric cardia
Inferiorly Upper border of pancreas and renal vein
A 17 year old lady presents with right iliac fossa pain and diagnosed as having acute
appendicitis. You take her to theatre to perform a laparoscopic appendicectomy.
During the procedure the scrub nurse distracts you and you inadvertently avulse the
appendicular artery. The ensuing haemorrhage is likely to be supplied directly from
which of the following vessels?
C. Ileo-colic artery
Appendix
McBurney's point
1/3 of the way along a line drawn from the Anterior Superior Iliac Spine to the
Umbilicus
6 Positions:
Retrocaecal 74%
Pelvic 21%
Postileal
Subcaecal
Paracaecal
Preileal
A 63 year old man who smokes heavily presents with dyspepsia. He is tested
and found to be positive for helicobacter pylori infection. One evening he has
an episode of haematemesis and collapses. What is the most likely vessel to be
responsible?
A. Portal vein
D. Gastroduodenal artery
He is most likely to have a posteriorly sited duodenal ulcer. These can invade
the gastroduodenal artery and present with major bleeding. Although gastric
ulcers may invade vessels they do not tend to produce major bleeding of this
nature.
Gastroduodenal artery
Supplies
Pylorus, proximal part of the duodenum, and indirectly to the pancreatic head
(via the anterior and posterior superior pancreaticoduodenal arteries)
Path
Most commonly arises from the common hepatic artery of the coeliac trunk
Terminates by bifurcating into the right gastroepiploic artery and the superior
pancreaticoduodenal artery
Image sourced
Which of the following nerves is responsible for the cremasteric reflex?
B. Femoral nerve
C. Obturator nerve
D. Genitofemoral nerve
The motor and sensory fibres of the genitofemoral nerve are tested in the cremasteric
reflex. A small contribution is also played by the ilioinguinal nerve and thus the reflex
may be lost following an inguinal hernia repair.
Genitofemoral nerve
Supplies
- Small area of the upper medial thigh pg 162 brs
Path
- Arises from the first and second lumbar nerves
- Passes obliquely through Psoas major, and emerges from its medial border opposite
the fibrocartilage between the third and fourth lumbar vertebrae.
- It then descends on the surface of Psoas major, under cover of the peritoneum
- Divides into genital and femoral branches.
- The genital branch passes through the inguinal canal, within the spermatic cord, to
supply the skin overlying the skin and fascia of the scrotum. The femoral branch
enters the thigh posterior to the inguinal ligament, lateral to the femoral artery. It
supplies an area of skin and fascia over the femoral triangle.
1
2
Rate question: 3
4
5
A 73 year old lady is admitted with brisk rectal bleeding. Despite attempts at
resuscitation the bleeding proceeds to cause haemodynamic compromise. An upper
GI endoscopy is normal. A mesenteric angiogram is performed and a contrast blush is
seen in the region of the sigmoid colon. The radiologist decides to embolise the vessel
supplying this area. At what spinal level does it leave the aorta?
A. L2
B. L1
C. L4
D. L3
E. T10
The inferior mesenteric artery leaves the aorta at L3. It supplies the left colon and
sigmoid. It's proximal continuation to communicate with the middle colic artery is via
the marginal artery.
Levels
Transpyloric plane
Level of the body of L1
Pylorus stomach
Left kidney hilum (L1- left one!)
Right hilum of the kidney (1.5cm lower than the left)
Fundus of the gallbladder
Neck of pancreas
Duodenojejunal flexure
Superior mesenteric artery
Portal vein
Left and right colic flexure
Root of the transverse mesocolon
2nd part of the duodenum
Upper part of conus medullaris
Spleen
Can be identified 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.
Anatomical planes
Subcostal plane Lowest margin of 10th costal cartilage
Intercrestal plane Level of body L4 (highest point of iliac crest)
Intertubercular plane Level of body L5
Renal arteries L2
COELIC AXIS L1
Left colon into sigmoid L2-L3
Inferior mesenteric artery L3
Superior mesenteric artery L1
43 year old man is undergoing a right hemicolectomy and the ileo-colic artery is
ligated. From which of the following vessels is is derived?
C. Coeliac axis
D. Aorta
The ileocolic artery is a branch of the SMA and supplies the right colon and terminal
ileum. The transverse colon is supplied by the middle colic artery. As veins
accompany arteries in the mesentery and are lined by lymphatics, high ligation is the
norm in cancer resections. The ileo-colic artery branches off the SMA near the
duodenum.
Colon anatomy
The colon is about 1.5m long although this can vary considerably.
Components:
Ascending colon
Transverse colon
Descending colon
Sigmoid colon
Arterial supply
Superior mesenteric artery and inferior mesenteric artery: linked by the marginal
artery.
Ascending colon: ileocolic and right colic arteries
Transverse colon: middle colic artery
Descending and sigmoid colon: left colic artery
Venous drainage
From regional veins (that accompany arteries) to superior and inferior mesenteric vein
Lymphatic drainage
Initially along nodal chains that accompany supplying arteries, then para-aortic nodes.
Embryology
Midgut- Second part of duodenum to 2/3 transverse colon
Hindgut- Distal 1/3 transverse colon to anus
Peritoneal location
The right and left colon are part intraperitoneal and part extraperitoneal. The sigmoid
and transverse colon are generally wholly intraperitoneal. This has implications for
the sequelae of perforations, which will tend to result in generalised peritonitis in the
wholly intra peritoneal segments.
A 53 year old man is undergoing a distal pancreatectomy for trauma. Which of the
following vessels is responsible for the arterial supply to the tail of the pancreas?
A. Splenic artery
B. Pancreaticoduodenal artery
C. Gastric artery
D. Hepatic artery
There is an arterial "watershed" in the supply between the head and tail of the
pancreas. The head is supplied by the pancreaticoduodenal artery and the tail is
supplied by branches of the splenic artery.
Pancreas
The pancreas is a retroperitoneal organ and lies posterior to the stomach. It may be
accessed surgically by dividing the peritoneal reflection that connects the greater
omentum to the transverse colon. The pancreatic head sits in the curvature of the
duodenum. It's tail lies close to the hilum of the spleen, a site of potential injury
during splenectomy.
Relations
Posterior to the pancreas
Pancreatic head Inferior vena cava
Common bile duct
Right and left renal veins
Superior mesenteric vein and artery
Pancreatic neck Superior mesenteric vein, portal vein
Pancreatic body- Left renal vein
Crus of diaphragm
Psoas muscle
Adrenal gland
Kidney
Aorta
Pancreatic tail Left kidney
Arterial supply
Venous drainage
Ampulla of Vater
Surgical occlusion of which of these structures, will result in the greatest reduction in
hepatic blood flow?
A. Portal vein
D. Coeliac axis
The portal vein transports 70% of the blood supply to the liver, while the hepatic
artery provides 30%. The portal vein contains the products of digestion. The arterial
and venous blood is dispersed by sinusoids to the central veins of the liver lobules;
these drain into the hepatic veins and then into the IVC. The caudate lobe drains
directly into the IVC rather than into other hepatic veins.
Liver
Between the liver lobules are portal canals which contain the portal triad:
Hepatic Artery, Portal Vein, tributary of Bile Duct.
Porta hepatis
Location Postero inferior surface, it joins nearly at right angles with the left sagittal
fossa, and separates the caudate lobe behind from the quadrate lobe in
front
Transmits Common hepatic duct
Hepatic artery
Portal vein
Sympathetic and parasympathetic nerve fibres
Lymphatic drainage of the liver (and nodes)
Ligaments
Falciform 2 layer fold peritoneum from the umbilicus to anterior
ligament liver surface
Contains ligamentum teres (remnant umbilical vein)
On superior liver surface it splits into the coronary and
left triangular ligaments
Ligamentum teres Joins the left branch of the portal vein in the porta hepatis
Ligamentum Remnant of ductus venosus
venosum
Arterial supply
Hepatic artery
Venous
Hepatic veins
Portal vein
Nervous supply
C. Transversalis fascia
D. Rectus sheath
E. Peritoneum
The external oblique will be encountered first in this location. The rectus sheath lies more
medially.
The external oblique muscle is the most superficial of the abdominal wall muscles. It
originates from the 5th to 12th ribs and passes inferomedially to insert into the linea alba,
pubic tubercle and anterior half of the iliac crest. It is innervated by the thoracoabdominal
nerves (T7-T11) and sub costal nerves.
Abdominal wall
The 2 main muscles of the abdominal wall are the rectus abdominis (anterior) and the
quadratus lumborum (posterior).
The remaining abdominal wall consists of 3 muscular layers. Each muscle passes from the
lateral aspect of the quadratus lumborum posteriorly to the lateral margin of the rectus
sheath anteriorly. Each layer is muscular posterolaterally and aponeurotic anteriorly.
Internal Arises from the thoracolumbar fascia, the anterior 2/3 of the iliac
oblique crest and the lateral 2/3 of the inguinal ligament
The muscle sweeps upwards to insert into the cartilages of the lower
3 ribs
The lower fibres form an aponeurosis that runs from the tenth costal
cartilage to the body of the pubis
At its lowermost aspect it joins the fibres of the aponeurosis of
transversus abdominis to form the conjoint tendon.
Surgical notes
During abdominal surgery it is usually necessary to divide either the muscles or their
aponeuroses. During a midline laparotomy it is desirable to divide the aponeurosis. This will
leave the rectus sheath intact above the arcuate line and the muscles intact below it.
Straying off the midline will often lead to damage to the rectus muscles, particularly below
the arcuate line where they may often be in close proximity to each other.
A 23 year old man is undergoing an inguinal hernia repair. The surgeons mobilise the
spermatic cord and place it in a hernia ring. A small slender nerve is identified
superior to the cord. Which of the following nerves is it most likely to be?
A. Iliohypogastric nerve
B. Pudendal nerve
D. Ilioinguinal nerve
E. Obturator nerve
The ilioinguinal nerve passes through the inguinal canal and is the nerve most
commonly identified during hernia surgery. The genitofemoral nerve splits into two
branches, the genital branch passes through the inguinal canal within the cord
structures. The femoral branch of the genitofemoral nerve enters the thigh posterior to
the inguinal ligament, lateral to the femoral artery. The iliohypogastric nerve pierces
the external oblique aponeurosis above the superficial inguinal ring.
Ilioinguinal nerve
Arises from the first lumbar ventral ramus with the iliohypogastric nerve. It passes
inferolaterally through the substance of psoas major and over the anterior surface of
quaratus lumborum. It pierces the internal oblique muscle and passes deep to the
aponeurosis of the external oblique muscle. It enters the inguinal canal and then
passes through the superficial inguinal ring to reach the skin.
Branches
A 45 year old man is undergoing a low anterior resection for a carcinoma of the
rectum. Which of the following fascial structures will need to be divided to mobilise
the mesorectum from the sacrum and coccyx?
A. Denonvilliers fascia
B. Colles fascia
C. Sibsons fascia
D. Waldeyers fascia
Waldeyers fascia separates the mesorectum from the sacrum and will need to be
divided.
Rectum
Relations
Anteriorly (Males) Rectovesical pouch
Bladder
Prostate
Seminal vesicles
Anteriorly (Females) Recto-uterine pouch (Douglas)
Cervix
Vaginal wall
Posteriorly Sacrum
Coccyx
Middle sacral artery
Laterally Levator ani
Coccygeus
Arterial supply
Superior rectal artery
Venous drainage
Superior rectal vein
Lymphatic drainage
B. L2
C. L3
D. L4
E. L5
The SMA leaves the aorta at L1. It passes under the neck of the pancreas prior to giving its
first branch the inferior pancreatico-duodenal artery.
72 year old man is undergoing an open abdominal aortic aneurysm repair. The aneurysm is
located in a juxtarenal location and surgical access to the neck of aneurysm is difficult.
Which of the following structures may be divided to improve access?
A. Cisterna chili
B. Transverse colon
E. Coeliac axis
The left renal vein will be stretched over the neck of the anuerysm in this location and is not
infrequently divided. This adds to the nephrotoxic insult of juxtarenal aortic surgery as a
supra renal clamp is also often applied. Deliberate division of the Cisterna Chyli will not
improve access and will result in a chyle leak. Division of the transverse colon will not help at
all and would result in a high risk of graft infection. Division of the SMA is pointless for a
juxtarenal procedure.
Abdominal aorta
Abdominal aortic topography
Origin T12
Termination L4
Your consultant decides to perform an open inguinal hernia repair under local
anaesthesia. Which of the following dermatomal levels will require blockade?
A. T10
B. T12
C. T11
D. S1
E. S2
Dermatomes
The common dermatomal levels and cutaneous nerves responsible for them is
illustrated below.
A 53 year old man presents with an inguinal hernia. Which of the following surface
landmarks may be used to identify the location of the deep inguinal ring?
The surface markings of the deep inguinal ring are a commonly examined topic and should
be memorised. The surface marking is the midpoint of the inguinal ligament. The mid
inguinal point is the surface marking for the femoral artery. The pubic tubercle marks the
site of the superficial inguinal ring.
Inguinal canal
Location
Contents
Males Spermatic cord and ilioinguinal As it passes through the canal the spermatic cord
nerve has 3 coverings:
The image below demonstrates the close relationship of the vessels to the lower limb with
the inguinal canal. A fact to be borne in mind when repairing hernial defects in this region.
Image sourced from Wikipedia
A. L1
B. L2
C. T12
D. T11
E. L3
Remember L1 ('left one') is the level
of the hilum of the left kidney
Renal anatomy
Each kidney is about 11cm long, 5cm wide and 3cm thick. They are located in a deep
gutter alongside the projecting verterbral bodies, on the anterior surface of psoas
major. In most cases the left kidney lies approximately 1.5cm higher than the right.
The upper pole of both kidneys approximates with the 11th rib (beware pneumothorax
during nephrectomy). On the left hand side the hilum is located at the L1 vertebral
level and the right kidney at level L1-2. The lower border of the kidneys is usually
alongside L3.
The table below shows the anatomical relations of the kidneys:
Relations
Relations Right Kidney Left Kidney
Posterior Quadratus lumborum, diaphragm, Quadratus lumborum, diaphragm,
psoas major, transversus abdominis psoas major, transversus abdominis
Anterior Hepatic flexure of colon Stomach, Pancreatic tail
Superior Liver, adrenal gland Spleen, adrenal gland
Fascial covering
Each kidney and suprarenal gland is enclosed within a common and layer of investing
fascia that is derived from the transversalis fascia into anterior and posterior layers
(Gerotas fascia).
Renal structure
Kidneys are surrounded by an outer cortex and an inner medulla which usually
contains between 6 and 10 pyramidal structures. The papilla marks the innermost
apex of these. They terminate at the renal pelvis, into the ureter.
Lying in a hollow within the kidney is the renal sinus. This contains:
1. Branches of the renal artery
2. Tributaries of the renal vein
3. Major and minor calyces's
4. Fat
A. Portal vein
B. Phrenic vein
It drains directly via a very short vessel. If the sutures are not carefully tied then it
may be avulsed off the IVC. An injury best managed using a Satinsky clamp and a 6/0
prolene suture.
An enthusiastic surgical registrar undertakes his first solo splenectomy. The operation
is far more difficult than anticipated and the registrar leaves a tube drain to the splenic
bed at the end of the procedure. Over the following 24 hours approximately 500ml of
clear fluid has entered the drain. Biochemical testing of the fluid is most likely to
reveal:
A. Elevated creatinine
B. Elevated triglycerides
C. Elevated glucagon
D. Elevated amylase
During splenectomy the tail of the pancreas may be damaged. The pancreatic duct
will then drain into the splenic bed, amylase is the most likely biochemical finding.
Glucagon is not secreted into the pancreatic duct.
Splenic anatomy
The spleen is the largest lymphoid organ in the body. It is an intraperitoneal organ, the
peritoneal attachments condense at the hilum where the vessels enter the spleen. Its
blood supply is from the splenic artery (derived from the coeliac axis) and the splenic
vein (which is joined by the IMV and unites with the SMV).
Superiorly- diaphragm
Anteriorly- gastric impression
Posteriorly- kidney
Inferiorly- colon
Hilum: tail of pancreas and splenic vessels
Forms apex of lesser sac (containing short gastric vessels)
A 56 year old lady is referred to the colorectal clinic with symptoms of pruritus ani.
On examination a polypoidal mass is identified inferior to the dentate line. A biopsy
confirms squamous cell carcinoma. To which of the following lymph node groups
will the lesion potentially metastasise?
A. Internal iliac
B. External iliac
C. Mesorectal
D. Inguinal
Rectum
Relations
Anteriorly (Males) Rectovesical pouch
Bladder
Prostate
Seminal vesicles
Anteriorly (Females) Recto-uterine pouch (Douglas)
Cervix
Vaginal wall
Posteriorly Sacrum
Coccyx
Middle sacral artery
Laterally Levator ani
Coccygeus
Arterial supply
Superior rectal artery
Venous drainage
Superior rectal vein
Lymphatic drainage
A 72 year old man develops a hydrocele which is being surgically managed. As part
of the procedure the surgeons divide the tunica vaginalis. From which of the
following is this structure derived?
A. Peritoneum
D. Transversalis fascia
E. Rectus sheath
The tunica vaginalis is derived from peritoneum, it secretes the fluid that fills the
hydrocele cavity.
Spermatic cord
Formed by the vas deferens and is covered by the following structures:
Layer Origin
Internal spermatic fascia Transversalis fascia
Cremasteric fascia From the fascial coverings of internal oblique
External spermatic fascia External oblique aponeurosis
Scrotum
Testes
The testes are surrounded by the tunica vaginalis (closed peritoneal sac). The
parietal layer of the tunica vaginalis adjacent to the internal spermatic fascia.
The testicular arteries arise from the aorta immediately inferiorly to the renal
arteries.
The pampiniform plexus drains into the testicular veins, the left drains into the
left renal vein and the right into the inferior vena cava.
Lymphatic drainage is to the para-aortic nodes.
A 43 year old lady is donating her left kidney to her sister and the surgeons are
harvesting the left kidney. Which of the following structures will lie most anteriorly at
the hilum of the left kidney?
C. Left ureter
D. Left ovarian vein
The renal veins lie most anteriorly, then artery and ureter lies posteriorly.
Renal arteries
The right renal artery is longer than the left renal artery
The renal vein/artery/pelvis enter the kidney at the hilum
Relations
Right:
Anterior- IVC, right renal vein, the head of the pancreas, and the descending part of
the duodenum.
Left:
Branches
The renal arteries are direct branches off the aorta (upper border of L2)
In 30% there may be accessory arteries (mainly left side). Instead of entering
the kidney at the hilum, they usually pierce the upper or lower part of the
organ.
Before reaching the hilum of the kidney, each artery divides into four or five
segmental branches (renal vein anterior and ureter posterior); which then
divide within the sinus into lobar arteries supplying each pyramid and cortex.
Each vessel gives off some small inferior suprarenal branches to the
suprarenal gland, the ureter, and the surrounding cellular tissue and muscles.
A 56 year old lady is due to undergo a left hemicolectomy for carcinoma of the
splenic flexure. The surgeons decide to perform a high ligation of the inferior
mesenteric vein. Into which of the following does this structure usually drain?
A. Portal vein
E. Splenic vein
Beware of ureteric injury in
colonic surgery.
Left colon
Position
As the left colon passes inferiorly its posterior aspect becomes extraperitoneal,
and the ureter and gonadal vessels are close posterior relations that may
become involved in disease processes
At a level of L3-4 (variable) the left colon becomes the sigmoid colon and
wholly intraperitoneal once again
The sigmoid colon is a highly mobile structure and may even lie of the right
side of the abdomen
It passes towards the midline, the taenia blend and this marks the transition
between sigmoid colon and upper rectum.
Blood supply
Abdominal wall
The 2 main muscles of the abdominal wall are the rectus abdominis (anterior) and the
quadratus lumborum (posterior).
The remaining abdominal wall consists of 3 muscular layers. Each muscle passes from the
lateral aspect of the quadratus lumborum posteriorly to the lateral margin of the rectus
sheath anteriorly. Each layer is muscular posterolaterally and aponeurotic anteriorly.
Internal Arises from the thoracolumbar fascia, the anterior 2/3 of the iliac
oblique crest and the lateral 2/3 of the inguinal ligament
The muscle sweeps upwards to insert into the cartilages of the lower
3 ribs
The lower fibres form an aponeurosis that runs from the tenth costal
cartilage to the body of the pubis
At its lowermost aspect it joins the fibres of the aponeurosis of
transversus abdominis to form the conjoint tendon.
Surgical notes
During abdominal surgery it is usually necessary to divide either the muscles or their
aponeuroses. During a midline laparotomy it is desirable to divide the aponeurosis. This will
leave the rectus sheath intact above the arcuate line and the muscles intact below it.
Straying off the midline will often lead to damage to the rectus muscles, particularly below
the arcuate line where they may often be in close proximity to each other.
A 67 year old man is undergoing an angiogram for gastro intestinal bleeding. The
radiologist advances the catheter into the coeliac axis. At what spinal level does this
vessel typically arise from the aorta?
A. T10
B. L3
C. L4
D. T12
The coeliac axis lies at T12, it takes an almost horizontal angle off the aorta. It has
three major branches.
A. Ileocolic artery
C. Gastroepiploic artery
The vessels supplying the omentum are the omental branches of the right and left
gastro-epiploic arteries. The colonic vessels are not responsible for the arterial supply
to the omentum. The left gastro-epiploic artery is a branch of the splenic artery and
the right gastro-epiploic artery is a terminal branch of the gastroduodenal artery.
Omentum
The omentum is divided into two parts which invest the stomach. Giving rise
to the greater and lesser omentum. The greater omentum is attached to the
inferolateral border of the stomach and houses the gastro-epiploic arteries.
It is of variable size but is less well developed in children. This is important as
the omentum confers protection against visceral perforation (e.g.
Appendicitis).
Inferiorly between the omentum and transverse colon is one potential entry
point into the lesser sac.
Several malignant processes may involve the omentum of which ovarian
cancer is the most notable.
A 45 year old man has a long fermoral line inserted to provide CVP measurements. The
catheter passes from the common iliac vein into the inferior vena cava. At which of the
following vertebral levels will this occur?
A. L5
B. L4
C. S1
D. L3
E. L2
Origin
L5
Path
Left and right common iliac veins merge to form the IVC.
Passes right of midline
Paired segmental lumbar veins drain into the IVC throughout its length
The right gonadal vein empties directly into the cava and the left gonadal vein
generally empties into the left renal vein.
The next major veins are the renal veins and the hepatic veins
Pierces the central tendon of diaphragm at T8
Right atrium
Relations
Anteriorly Small bowel, first and third part of duodenum, head of pancreas, liver and bile
duct, right common iliac artery, right gonadal artery
Posteriorly Right renal artery, right psoas, right sympathetic chain, coeliac ganglion
Levels
Level Vein
L2 Gonadal vein
A. S4
B. S1, S2, S3
C. S2, S3, S4
D. L3, L4, L5
E. L5, S1, S2
Urethral anatomy
Female urethra
The female urethra is shorter and more acutely angulated than the male urethra. It is
an extra-peritoneal structure and embedded in the endopelvic fascia. The neck of the
bladder is subjected to transmitted intra-abdominal pressure and therefore deficiency
in this area may result in stress urinary incontinence. Between the layers of the
urogenital diaphragm the female urethra is surrounded by the external urethral
sphincter, this is innervated by the pudendal nerve. It ultimately lies anterior to the
vaginal orifice.
Male urethra
In males the urethra is much longer and is divided into four parts.
Pre-prostatic Extremely short and lies between the bladder and prostate gland.It
urethra has a stellate lumen and is between 1 and 1.5cm long.Innervated by
sympathetic noradrenergic fibres, as this region is composed of
striated muscles bundles they may contract and prevent retrograde
ejaculation.
Prostatic This segment is wider than the membranous urethra and contains
urethra several openings for the transmission of semen (at the midpoint of the
urethral crest).
Membranous Narrowest part of the urethra and surrounded by external sphincter. It
urethra traverses the perineal membrane 2.5cm postero-inferior to the
symphysis pubis.
Penile urethra Travels through the corpus songiosum on the underside of the penis.
It is the longest urethral segment.It is dilated at its origin as the
infrabulbar fossa and again in the gland penis as the navicular fossa.
The bulbo-urethral glands open into the spongiose section of the
urethra 2.5cm below the perineal membrane.
The urothelium is transitional in nature near to the bladder and becomes squamous
more distally.
A 32 year old man is undergoing a splenectomy. Division of which of the following
will be necessary during the procedure?
C. Gerotas fascia
E. Marginal artery
During a splenectomy the short gastric vessels which lie within the gastrosplenic
ligament will need to be divided. The splenic flexure of the colon may need to be
mobilised. However, it will almost never need to be divided, as this is watershed area
that would necessitate a formal colonic resection in the event of division.
Splenic anatomy
The spleen is the largest lymphoid organ in the body. It is an intraperitoneal organ, the
peritoneal attachments condense at the hilum where the vessels enter the spleen. Its
blood supply is from the splenic artery (derived from the coeliac axis) and the splenic
vein (which is joined by the IMV and unites with the SMV).
Superiorly- diaphragm
Anteriorly- gastric impression
Posteriorly- kidney
Inferiorly- colon
Hilum: tail of pancreas and splenic vessels
Forms apex of lesser sac (containing short gastric vessels)
Two teenagers are playing with an airgun when one accidentally shoots his friend in
the abdomen. He is brought to the emergency department. On examination there is a
bullet entry point immediately to the right of the rectus sheath at the level of the 1st
lumbar vertebra. Which of the following structures is most likely to be injured by the
bullet?
A. Head of pancreas
B. Right ureter
E. Gastric antrum
The fundus of the gallbladder lies at this level and is the most superficially located
structure.
Levels
Transpyloric plane
Level of the body of L1
Pylorus stomach
Left kidney hilum (L1- left one!)
Right hilum of the kidney (1.5cm lower than the left)
Fundus of the gallbladder
Neck of pancreas
Duodenojejunal flexure
Superior mesenteric artery
Portal vein
Left and right colic flexure
Root of the transverse mesocolon
2nd part of the duodenum
Upper part of conus medullaris
Spleen
Can be identified 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.
Anatomical planes
Subcostal plane Lowest margin of 10th costal cartilage
Intercristal plane Level of body L4 (highest point of iliac crest)
Intertubercular plane Level of body L5
hich of the following anatomical planes separates the prostate from the rectum?
A. Sibsons fascia
B. Denonvilliers fascia
D. Waldeyers fascia
The Denonvilliers fascia separates the rectum from the prostate. Waldeyers fascia
separates the rectum from the sacrum
Prostate gland
The prostate gland is approximately the shape and size of a walnut and is located
inferior to the bladder. It is separated from the rectum by Denonvilliers fascia and its
blood supply is derived from the internal iliac vessels. The internal sphincter lies at
the apex of the gland and may be damaged during prostatic surgery, affected
individuals may complain of retrograde ejaculation.
INTERNAL PUDENDAL AR
INFERIOR VESICULAR AR
INTERNAL ILIAC
MIDDLE RECTAL ARTERY
Relations
Anterior Pubic symphysis
Prostatic venous plexus
Posterior Denonvilliers fascia
Rectum
Ejaculatory ducts
Lateral Venous plexus (lies on prostate)
Levator ani (immediately below the puboprostatic ligaments)
I
A 56 year old lady is undergoing an adrenalectomy for Conns syndrome. During the
operation the surgeon damages the middle adrenal artery and haemorrhage ensues.
From which of the following structures does this vessel originate?
A. Aorta
B. Renal artery
C. Splenic artery
D. Coeliac axis
The middle adrenal artery is usually a branch of the aorta, the lower adrenal artery
typically arises from the renal vessels.
Anatomy
24 year old man falls and lands astride a manhole cover. He suffers from a injury to
the anterior bulbar urethra. Where will the extravasated urine tend to collect?
A. Lesser pelvis
D. Ischiorectal fossa
This portion of the urethra is contained between the perineal membrane an the
membranous layer of the superficial fascia. As these are densely adherent to the
ischiopubic rami, extravasated urine cannot pass posteriorly because the 2 layers are
continuous around the superficial transverse perineal muscles.
Types of injury
i.Bulbar rupture
- most common
- straddle type injury e.g. bicycles
- triad signs: urinary retention, perineal haematoma, blood
at the meatus
ii. Membranous rupture
- can be extra or intraperitoneal
- commonly due to pelvic fracture
- Penile or perineal oedema/ hematoma
- PR: prostate displaced upwards (beware co-existing
retroperitoneal haematomas as they may make examination
difficult)
A. T10
B. L2
C. L3
D. T8
E. T12
Coeliac trunk
branches:
Left gastric
Hepatic
Splenic
Coeliac axis
Left gastric
Hepatic: branches-Right Gastric, Gastroduodenal, Right Gastroepiploic, Superior
Pancreaticoduodenal, Cystic.
Splenic: branches- Pancreatic, Short Gastric, Left Gastroepiploic
Relations
Anteriorly Lesser omentum
A. Hepatic artery
B. Cystic duct
C. Greater omentum
Liver
Between the liver lobules are portal canals which contain the portal triad:
Hepatic Artery, Portal Vein, tributary of Bile Duct.
Porta hepatis
Location Postero inferior surface, it joins nearly at right angles with the left sagittal
fossa, and separates the caudate lobe behind from the quadrate lobe in
front
Transmits Common hepatic duct
Hepatic artery
Portal vein
Sympathetic and parasympathetic nerve fibres
Lymphatic drainage of the liver (and nodes)
Ligaments
Falciform 2 layer fold peritoneum from the umbilicus to anterior
ligament liver surface
Contains ligamentum teres (remnant umbilical vein)
On superior liver surface it splits into the coronary and
left triangular ligaments
Ligamentum teres Joins the left branch of the portal vein in the porta hepatis
Ligamentum Remnant of ductus venosus
venosum
Arterial supply
Hepatic artery
Venous
Hepatic veins
Portal vein
Nervous supply
Which of the following is not considered a major branch of the descending thoracic
aorta?
A. Bronchial artery
B. Mediastinal artery
E. Oesophageal artery
The inferior thyroid artery is usually derived from the thyrocervical trunk, a branch of
the subclavian artery.
Thoracic aorta
Origin T4
Terminates T12
Relations Anteriorly (from top to bottom)-root of the left lung, the
pericardium, the oesophagus, and the diaphragm
Posteriorly-vertebral column, azygos vein
Right- hemiazygos veins, thoracic duct
Left- left pleura and lung
C. Aorta
E. Gonadal vessels
The gonadal vessels and ureter are important posterior relations that are at risk during
a right hemicolectomy.
Caecum
The caecum is the most distensible part of the colon and in complete large
bowel obstruction with a competent ileocaecal valve the most likely site of
eventual perforation.
The proximal ureter is supplied by branches from the renal artery. For the other
feeding vessels - see below.
Ureter
25-35 cm long
Muscular tube lined by transitional epithelium
Surrounded by thick muscular coat. Becomes 3 muscular layers as it crosses
the bony pelvis
Retroperitoneal structure overlying transverse processes L2-L5
Lies anterior to bifurcation of iliac vessels
Blood supply is segmental; renal artery, aortic branches, gonadal branches,
common iliac and internal iliac
Lies beneath the uterine artery
A. Portal vein
B. Hepatic artery
C. Cystic duct
D. Hepatic lymph nodes
The cystic duct lies outside the porta hepatis and is an important landmark in
laparoscopic cholecystectomy. The structures in the porta hepatis are:
Portal vein
Hepatic artery
Common hepatic duct
These structures divide immediately after or within the porta hepatis to supply the
functional left and right lobes of the liver.
The porta hepatis is also surrounded by lymph nodes, that may enlarge to produce
obstructive jaundice and parasympathetic nervous fibres that travel along vessels to
enter the liver.
Liver
Between the liver lobules are portal canals which contain the portal triad:
Hepatic Artery, Portal Vein, tributary of Bile Duct.
Relations of the liver
Anterior Postero inferiorly
Diaphragm Oesophagus
Xiphoid process Stomach
Duodenum
Hepatic flexure of colon
Right kidney
Gallbladder
Inferior vena cava
Porta hepatis
Location Postero inferior surface, it joins nearly at right angles with the left sagittal
fossa, and separates the caudate lobe behind from the quadrate lobe in
front
Transmits Common hepatic duct
Hepatic artery
Portal vein
Sympathetic and parasympathetic nerve fibres
Lymphatic drainage of the liver (and nodes)
Ligaments
Falciform 2 layer fold peritoneum from the umbilicus to anterior
ligament liver surface
Contains ligamentum teres (remnant umbilical vein)
On superior liver surface it splits into the coronary and
left triangular ligaments
Ligamentum teres Joins the left branch of the portal vein in the porta hepatis
Ligamentum Remnant of ductus venosus
venosum
Arterial supply
Hepatic artery
Venous
Hepatic veins
Portal vein
Nervous supply
Sympathetic and parasympathetic trunks of coeliac plexus
B. Gastric antrum
C. Spleen
Levels
Transpyloric plane
Level of the body of L1
Pylorus stomach
Left kidney hilum (L1- left one!)
Right hilum of the kidney (1.5cm lower than the left)
Fundus of the gallbladder
Neck of pancreas
Duodenojejunal flexure
Superior mesenteric artery
Portal vein
Left and right colic flexure
Root of the transverse mesocolon
2nd part of the duodenum
Upper part of conus medullaris
Spleen
Can be identified 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.
Anatomical planes
Subcostal plane Lowest margin of 10th costal cartilage
Intercristal plane Level of body L4 (highest point of iliac crest)
Intertubercular plane Level of body L5
Common level landmarks
Inferior mesenteric artery L3
Bifurcation of aorta into common iliac arteries L4
Formation of IVC L5 (union of common iliac veins)
Diaphragm apertures Vena cava T8
Oesophagus T10
Aortic hiatus T12
A surgeon is due to perform a laparotomy for perforated duodenal ulcer. An upper midline
incision is to be performed. Which of the following structures is the incision most likely to
divide?
C. Linea alba
Upper midline abdominal incisions will involve the division of the linea alba. Division of
muscles will not usually improve access in this approach and they would not be routinely
encountered during this incision.
Abdominal incisions
B. Portal vein
E. Ileocolic vein
The middle colonic vein drains into the SMV, if avulsed during mobilisation then
dramatic haemorrhage can occur and be difficult to control.
Transverse colon
The right colon undergoes a sharp turn at the level of the hepatic flexure to
become the transverse colon.
At this point it also becomes intraperitoneal.
It is connected to the inferior border of the pancreas by the transverse
mesocolon.
The greater omentum is attached to the superior aspect of the transverse colon
from which it can easily be separated. The mesentery contains the middle colic
artery and vein. The greater omentum remains attached to the transverse colon
up to the splenic flexure. At this point the colon undergoes another sharp turn.
Relations
Superior Liver and gall-bladder, the greater curvature of the stomach, and the lower
end of the spleen
Inferior Small intestine
Anterior Greater omentum
Posterior From right to left with the descending portion of the duodenum, the head of
the pancreas, convolutions of the jejunum and ileum, spleen
A 23 year old man is stabbed in the chest approximately 10cm below the right nipple.
In the emergency department a abdominal ultrasound scan shows a large amount of
intraperitoneal blood. Which of the following statements relating to the likely site of
injury is untrue?
The right lobe of the liver is the most likely site of injury. Therefore the answer is B
as the quadrate lobe is functionally part of the left lobe of the liver. The liver is largely
covered in peritoneum. Posteriorly there is an area devoid of peritoneum (the bare
area of the liver). The right lobe of the liver has the largest bare area (ans is larger
thant the left lobe).
Liver
Between the liver lobules are portal canals which contain the portal triad:
Hepatic Artery, Portal Vein, tributary of Bile Duct.
Porta hepatis
Location Postero inferior surface, it joins nearly at right angles with the left sagittal
fossa, and separates the caudate lobe behind from the quadrate lobe in
front
Transmits Common hepatic duct
Hepatic artery
Portal vein
Sympathetic and parasympathetic nerve fibres
Lymphatic drainage of the liver (and nodes)
Ligaments
Falciform 2 layer fold peritoneum from the umbilicus to anterior
ligament liver surface
Contains ligamentum teres (remnant umbilical vein)
On superior liver surface it splits into the coronary and
left triangular ligaments
Ligamentum teres Joins the left branch of the portal vein in the porta hepatis
Ligamentum Remnant of ductus venosus
venosum
Arterial supply
Hepatic artery
Venous
Hepatic veins
Portal vein
Nervous supply
Which of the following nerves passes through the greater sciatic foramen and
innervates the perineum?
A. Pudendal
B. Sciatic
C. Superior gluteal
D. Inferior gluteal
Rectal nerve
Perineal nerve
Dorsal nerve of penis/
clitoris
The pudendal nerve innervates the perineum. It passes between piriformis and
coccygeus medial to the sciatic nerve.
Gluteal region
Gluteal muscles
Gluteus maximus: inserts to gluteal tuberosity of the femur and iliotibial tract
Gluteus medius: attach to lateral greater trochanter
Gluteus minimis: attach to anterior greater trochanter
All extend and abduct the hip
Piriformis
Gemelli
Obturator internus
Quadratus femoris
Nerves
Superior gluteal nerve (L5, S1) Gluteus medius
Gluteus minimis
Tensor fascia lata
A. Vitellino-intestinal duct
B. Hind gut
C. Mid gut
D. Fore gut
E. Woolffian duct
The left colon is embryologically part of the hind gut. Which accounts for its separate
blood supply via the IMA.
Colon anatomy
The colon is about 1.5m long although this can vary considerably.
Components:
Ascending colon
Transverse colon
Descending colon
Sigmoid colon
Arterial supply
Superior mesenteric artery and inferior mesenteric artery: linked by the marginal
artery.
Ascending colon: ileocolic and right colic arteries
Transverse colon: middle colic artery
Descending and sigmoid colon: left colic artery
Venous drainage
From regional veins (that accompany arteries) to superior and inferior mesenteric vein
Lymphatic drainage
Initially along nodal chains that accompany supplying arteries, then para-aortic nodes.
Embryology
Midgut- Second part of duodenum to 2/3 transverse colon
Hindgut- Distal 1/3 transverse colon to anus
Peritoneal location
The right and left colon are part intraperitoneal and part extraperitoneal. The sigmoid
and transverse colon are generally wholly intraperitoneal. This has implications for
the sequelae of perforations, which will tend to result in generalised peritonitis in the
wholly intra peritoneal segments.
You excitedly embark on your first laparoscopic cholecystectomy and during the
operation the anatomy of Calots triangle is more hostile than anticipated. Whilst
trying to apply a haemostatic clip you avulse the cystic artery. This is followed by
brisk haemorrhage. From which source is this most likely to originate ?
B. Portal vein
C. Gastroduodenal artery
D. Liver bed
The cystic artery is a branch of the right hepatic artery. There are recognised
variations in the anatomy of the blood supply to the gallbladder. However, the
commonest situation is for the cystic artery to branch from the right hepatic artery.
Gallbladder
Arterial supply
Cystic artery (branch of Right hepatic artery)
Venous drainage
Cystic vein
Nerve supply
Sympathetic- mid thoracic spinal cord, Parasympathetic- anterior vagal trunk
Calot's triangle
A 43 year old man suffers a pelvic fracture which is complicated by an injury to the
junction of the membranous urethra to the bulbar urethra. In which of the following
directions is the extravasated urine most likely to pass?
Urogenital triangle
It transmits the urethra in males and both the urethra and vagina in females. The
membranous urethra lies deep this structure and is surrounded by the external urethral
sphincter.
Superficial to the urogenital diaphragm lies the superficial perineal pouch. In males
this contains:
Bulb of penis
Crura of the penis
Superficial transverse perineal muscle
Posterior scrotal arteries
Posterior scrotal nerves
In females the internal pudendal artery branches to become the posterior labial arteries
in the superficial perineal pouch.
Which of the following statements relating to the gastroduodenal artery is untrue?
The portal vein is located posteriorly and then separated from the artery by the
pancreas. The anatomy of this artery is important as it is a site of bleeding in
posteriorly sited duodenal ulcers. At laparotomy for bleeding from this vessel, the
relation of the bile duct should be remembered less it be caught inadvertently in a
stitch.
Gastroduodenal artery
Supplies
Pylorus, proximal part of the duodenum, and indirectly to the pancreatic head (via the
anterior and posterior superior pancreaticoduodenal arteries)
Path
Most commonly arises from the common hepatic artery of the coeliac trunk
Terminates by bifurcating into the right gastroepiploic artery and the superior
pancreaticoduodenal artery
Image showing stomach reflected superiorly to illustrate the relationship of the
gastroduodenal artery to the first part of the duodenum
Image sour
Through which of the following foramina does the genital branch of the genitofemoral
nerve exit the abdominal cavity?
B. Sciatic notch
C. Obturator foramen
D. Femoral canal
The genitofemoral nerve divides into two branches as it approaches the inguinal
ligament. The genital branch passes anterior to the external iliac artery through the
deep inguinal ring into the inguinal canal. It communicates with the ilioinguinal nerve
in the inguinal canal (though this is seldom of clinical significance).
Genitofemoral nerve
Supplies
- Small area of the upper medial thigh
Path
- Arises from the first and second lumbar nerves
- Passes obliquely th’/
rough Psoas major, and emerges from its medial border opposite the fibrocartilage
between the third and fourth lumbar vertebrae.
- It then descends on the surface of Psoas major, under cover of the peritoneum
- Divides into genital and femoral branches.
- The genital branch passes through the inguinal canal, within the spermatic cord, to
supply the skin overlying the skin and fascia of the scrotum. The femoral branch
enters the thigh posterior to the inguinal ligament, lateral to the femoral artery. It
supplies an area of skin and fascia over the femoral triangle.
A 63 year old lady is diagnosed as having an endometrial carcinoma arising from the
uterine body. To which nodal region will the tumour initially metastasise?
C. Inguinal nodes
Tumours of the uterine body will tend to spread to the iliac nodes initially. When the
tumour is expanding to cross different nodal margins this is of considerable clinical
significance if nodal clearance is performed during a Wertheims type hysterectomy.
The uterine fundus has a lymphatic drainage that runs with the ovarian vessels
and may thus drain to the para-aortic nodes. Some drainage may also pass
along the round ligament to the inguinal nodes.
The body of the uterus drains through lymphatics contained within the broad
ligament to the iliac lymph nodes.
The cervix drains into three potential nodal stations; laterally through the
broad ligament to the external iliac nodes, along the lymphatics of the
uterosacral fold to the presacral nodes and posterolaterally along lymphatics
lying alongside the uterine vessels to the internal iliac nodes.
Which of the following structures is not located in the superficial perineal space in
females?
B. Pudendal nerve
The pudendal nerve is located in the deep perineal space and then branches to
innervate more superficial structures.
Urogenital triangle
A fascial sheet is attached to the sides, forming the inferior fascia of the urogenital
diaphragm.
It transmits the urethra in males and both the urethra and vagina in females. The
membranous urethra lies deep this structure and is surrounded by the external urethral
sphincter.
Superficial to the urogenital diaphragm lies the superficial perineal pouch. In males
this contains:
Bulb of penis
Crura of the penis
Superficial transverse perineal muscle
Posterior scrotal arteries
Posterior scrotal nerves
In females the internal pudendal artery branches to become the posterior labial arteries
in the superficial perineal pouch.
Which of the following is not a branch of the hepatic artery?
A. Pancreatic artery
B. Cystic artery
Coeliac axis
Left gastric
Hepatic: branches-Right Gastric, Gastroduodenal, Right Gastroepiploic, Superior
Pancreaticoduodenal, Cystic.
Splenic: branches- Pancreatic, Short Gastric, Left Gastroepiploic
Relations
Anteriorly Lesser omentum
A 56 year old man is undergoing a nephrectomy. The surgeons divide the renal artery.
At what level do these usually branch off the abdominal aorta?
A. T9
B. L2
C. L3
D. T10
E. L4
The renal arteries usually branch off the aorta on a level with L2.
Renal arteries
The right renal artery is longer than the left renal artery
The renal vein/artery/pelvis enter the kidney at the hilum
Relations
Right:
Anterior- IVC, right renal vein, the head of the pancreas, and the descending part of
the duodenum.
Left:
Branches
The renal arteries are direct branches off the aorta (upper border of L2)
In 30% there may be accessory arteries (mainly left side). Instead of entering
the kidney at the hilum, they usually pierce the upper or lower part of the
organ.
Before reaching the hilum of the kidney, each artery divides into four or five
segmental branches (renal vein anterior and ureter posterior); which then
divide within the sinus into lobar arteries supplying each pyramid and cortex.
Each vessel gives off some small inferior suprarenal branches to the
suprarenal gland, the ureter, and the surrounding cellular tissue and muscles.
A 22 year old man presents with appendicitis. At operation the appendix is retrocaecal
and difficult to access. Division of which of the following anatomical structures
should be undertaken?
A. Ileocolic artery
C. Gonadal vessels
Appendix
McBurney's point
1/3 of the way along a line drawn from the Anterior Superior Iliac Spine to the
Umbilicus
6 Positions:
Retrocaecal 74%
Pelvic 21%
Postileal
Subcaecal
Paracaecal
Preileal
A variety of different procedures carry the risk of iatrogenic nerve injury. These are
important not only from the patients perspective but also from a medicolegal
standpoint.
The following operations and their associated nerve lesions are listed here:
There are many more, with sound anatomical understanding of the commonly
performed procedures the incidence of nerve lesions can be minimised. They
commonly occur when surgeons operate in an unfamiliar tissue plane or by blind
placement of haemostats (not recommended).
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2
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A 73 year old man is due to undergo a radical prostatectomy for carcinoma of the prostate
gland. To which of the following lymph nodes will the tumour drain primarily?
A. Para aortic
B. Internal iliac
C. Superficial inguinal
D. Meso rectal
The prostate lymphatic drainage is primarily to the internal iliac nodes and also the sacral
nodes. Although internal iliac is the first site.
Prostate gland
The prostate gland is approximately the shape and size of a walnut and is located inferior to
the bladder. It is separated from the rectum by Denonvilliers fascia and its blood supply is
derived from the internal iliac vessels. The internal sphincter lies at the apex of the gland
and may be damaged during prostatic surgery, affected individuals may complain of
retrograde ejaculation.
Relations
A 28 year old man has sustained a non salvageable testicular injury to his left testicle.
The surgeon decides to perform an orchidectomy and divides the left testicular artery.
From which of the following does this vessel originate?
A. Abdominal aorta
B. Internal iliac artery
Spermatic cord
Formed by the vas deferens and is covered by the following structures:
Layer Origin
Internal spermatic fascia Transversalis fascia
Cremasteric fascia From the fascial coverings of internal oblique
External spermatic fascia External oblique aponeurosis
Scrotum
Testes
The testes are surrounded by the tunica vaginalis (closed peritoneal sac). The
parietal layer of the tunica vaginalis adjacent to the internal spermatic fascia.
The testicular arteries arise from the aorta immediately inferiorly to the renal
arteries.
The pampiniform plexus drains into the testicular veins, the left drains into the
left renal vein and the right into the inferior vena cava.
Lymphatic drainage is to the para-aortic nodes.
A 44 year old man is stabbed in the back and the left kidney is injured. A
haematoma forms, which of the following fascial structures will contain the
haematoma?
A. Waldeyers fascia
B. Sibsons fascia
C. Bucks fascia
D. Gerotas fascia
E. Denonvilliers fascia
Renal anatomy
Each kidney is about 11cm long, 5cm wide and 3cm thick. They are located in
a deep gutter alongside the projecting verterbral bodies, on the anterior surface
of psoas major. In most cases the left kidney lies approximately 1.5cm higher
than the right. The upper pole of both kidneys approximates with the 11th rib
(beware pneumothorax during nephrectomy). On the left hand side the hilum
is located at the L1 vertebral level and the right kidney at level L1-2. The
lower border of the kidneys is usually alongside L3.
Relations
Relations Right Kidney Left Kidney
Posterior Quadratus lumborum, diaphragm, Quadratus lumborum, diaphragm,
psoas major, transversus abdominis psoas major, transversus abdominis
Anterior Hepatic flexure of colon Stomach, Pancreatic tail
Superior Liver, adrenal gland Spleen, adrenal gland
Fascial covering
Each kidney and suprarenal gland is enclosed within a common and layer of
investing fascia that is derived from the transversalis fascia into anterior and
posterior layers (Gerotas fascia).
Renal structure
Kidneys are surrounded by an outer cortex and an inner medulla which usually
contains between 6 and 10 pyramidal structures. The papilla marks the
innermost apex of these. They terminate at the renal pelvis, into the ureter.
Lying in a hollow within the kidney is the renal sinus. This contains:
1. Branches of the renal artery
2. Tributaries of the renal vein
3. Major and minor calyces's
4. Fat
A. Diaphragm posteriorly
E. Hepato-renal pouch
The right renal vein is very short and lies more inferiorly.
Adrenal gland anatomy
Anatomy
A. Abdominal oesophagus
B. Duodenum
D. Right kidney
E. Pylorus of stomach
The fundus of the stomach is a posterior relation. The pylorus lies more
inferolaterally. During a total gastrectomy division of the ligaments holding the left
lobe of the liver will facilitate access to the proximal stomach and abdominal
oesophagus. This manoeuvre is seldom beneficial during a distal gastrectomy.
Liver
Between the liver lobules are portal canals which contain the portal triad:
Hepatic Artery, Portal Vein, tributary of Bile Duct.
Porta hepatis
Location Postero inferior surface, it joins nearly at right angles with the left sagittal
fossa, and separates the caudate lobe behind from the quadrate lobe in
front
Transmits Common hepatic duct
Hepatic artery
Portal vein
Sympathetic and parasympathetic nerve fibres
Lymphatic drainage of the liver (and nodes)
Ligaments
Falciform 2 layer fold peritoneum from the umbilicus to anterior
ligament liver surface
Contains ligamentum teres (remnant umbilical vein)
On superior liver surface it splits into the coronary and
left triangular ligaments
Ligamentum teres Joins the left branch of the portal vein in the porta hepatis
Ligamentum Remnant of ductus venosus
venosum
Arterial supply
Hepatic artery
Venous
Hepatic veins
Portal vein
Nervous supply
A 32 year old man presents with an inguinal hernia and undergoes an open surgical repair.
The surgeons decide to place a mesh on the posterior wall of the inguinal canal to complete
the repair, which of the following structures will lie posterior to the mesh?
A. Transversalis fascia
B. External oblique
C. Rectus abdominis
D. Obturator nerve
This is actually quite a straightforward question. It is simply asking for the structure that
forms the posterior wall of the inguinal canal. This is composed of the transversalis fascia,
the conjoint tendon and more laterally the deep inguinal ring.
Inguinal canal
Location
Contents
Males Spermatic cord and ilioinguinal As it passes through the canal the spermatic cord
nerve has 3 coverings:
The image below demonstrates the close relationship of the vessels to the lower limb with
the inguinal canal. A fact to be borne in mind when repairing hernial defects in this region.
A 22 year old man is involved in a fight outside a nightclub. He is stabbed in the back,
on the left side, approximately 3cm below the 12th rib in the mid scapular line. The
structure most likely to be injured first as a result is the:
A. Spleen
B. Left kidney
D. Left ureter
The left kidney lies in this location and is the most likely structure to be injured. The
Spleen lies more superiorly, and the left adrenal and ureter are unlikely to be injured
in isolation.
Levels
Transpyloric plane
Level of the body of L1
Pylorus stomach
Left kidney hilum (L1- left one!)
Right hilum of the kidney (1.5cm lower than the left)
Fundus of the gallbladder
Neck of pancreas
Duodenojejunal flexure
Superior mesenteric artery
Portal vein
Left and right colic flexure
Root of the transverse mesocolon
2nd part of the duodenum
Upper part of conus medullaris
Spleen
Can be identified 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.
Anatomical planes
Subcostal plane Lowest margin of 10th costal cartilage
Intercristal plane Level of body L4 (highest point of iliac crest)
Intertubercular plane Level of body L5
A 23 year old man is undergoing an hernia repair and the mesh is to be sutured to the
inguinal ligament. From which of the following does the inguinal ligament arise?
B. Internal oblique
C. Rectus sheath
D. Rectus abdominis muscle
The inguinal ligament is formed by the external oblique aponeurosis. It runs from the pubic
tubercle to the anterior superior iliac spine.
Abdominal wall
The 2 main muscles of the abdominal wall are the rectus abdominis (anterior) and the
quadratus lumborum (posterior).
The remaining abdominal wall consists of 3 muscular layers. Each muscle passes from the
lateral aspect of the quadratus lumborum posteriorly to the lateral margin of the rectus
sheath anteriorly. Each layer is muscular posterolaterally and aponeurotic anteriorly.
Internal Arises from the thoracolumbar fascia, the anterior 2/3 of the iliac
oblique crest and the lateral 2/3 of the inguinal ligament
The muscle sweeps upwards to insert into the cartilages of the lower
3 ribs
The lower fibres form an aponeurosis that runs from the tenth costal
cartilage to the body of the pubis
At its lowermost aspect it joins the fibres of the aponeurosis of
transversus abdominis to form the conjoint tendon.
Transversus Innermost muscle
abdominis Arises from the inner aspect of the costal cartilages of the lower 6
ribs , from the anterior 2/3 of the iliac crest and lateral 1/3 of the
inguinal ligament
Its fibres run horizontally around the abdominal wall ending in an
aponeurosis. The upper part runs posterior to the rectus abdominis.
Lower down the fibres run anteriorly only.
The rectus abdominis lies medially running from the pubic crest and
symphysis to insert into the xiphoid process and 5th, 6th and 7th
costal cartilages. The muscles lies in a aponeurosis as described
above.
Nerve supply: anterior primary rami of T7-12
Surgical notes
During abdominal surgery it is usually necessary to divide either the muscles or their
aponeuroses. During a midline laparotomy it is desirable to divide the aponeurosis. This will
leave the rectus sheath intact above the arcuate line and the muscles intact below it.
Straying off the midline will often lead to damage to the rectus muscles, particularly below
the arcuate line where they may often be in close proximity to each other.
A 56 year old man is undergoing a high anterior resection. Which of the following
structures is at greatest risk of injury in this procedure?
B. Left ureter
A careless surgeon may damage all of these structures. However, the structure at
greatest risk and most frequently encountered is the left ureter.
Colon anatomy
The colon is about 1.5m long although this can vary considerably.
Components:
Ascending colon
Transverse colon
Descending colon
Sigmoid colon
Arterial supply
Superior mesenteric artery and inferior mesenteric artery: linked by the marginal
artery.
Ascending colon: ileocolic and right colic arteries
Transverse colon: middle colic artery
Descending and sigmoid colon: left colic artery
Venous drainage
From regional veins (that accompany arteries) to superior and inferior mesenteric vein
Lymphatic drainage
Initially along nodal chains that accompany supplying arteries, then para-aortic nodes.
Embryology
Midgut- Second part of duodenum to 2/3 transverse colon
Hindgut- Distal 1/3 transverse colon to anus
Peritoneal location
The right and left colon are part intraperitoneal and part extraperitoneal. The sigmoid
and transverse colon are generally wholly intraperitoneal. This has implications for
the sequelae of perforations, which will tend to result in generalised peritonitis in the
wholly intra peritoneal segments.
A 42 year old lady undergoes a difficult cholecystectomy and significant bleeding is
occurring. The surgeons place a vascular clamp transversely across the anterior border
of the epiploic foramen. Which of the following structures will be occluded in this
manoeuvre?
A. Cystic artery
B. Cystic duct
D. Portal vein
The portal vein, hepatic artery and common bile duct are occluded.
Epiploic Foramen
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5
A 56 year old lady undergoes a Hartmans style resection of the sigmoid colon, with
ligation of the vessels close to the colon. Which of the following vessels will be
responsible to supplying the rectal stump directly?
This question is addressing the blood supply to the rectum. Which is supplied by the
superior rectal artery. High ligation of the IMA may compromise this structure.
However, the question states that during the Hartmans procedure the vessels were
ligated close to the bowel. Implying that the superior rectal was preserved.
Rectum
Relations
Anteriorly (Males) Rectovesical pouch
Bladder
Prostate
Seminal vesicles
Anteriorly (Females) Recto-uterine pouch (Douglas)
Cervix
Vaginal wall
Posteriorly Sacrum
Coccyx
Middle sacral artery
Laterally Levator ani
Coccygeus
Arterial supply
Superior rectal artery
Venous drainage
Superior rectal vein
Lymphatic drainage
A. Gonadal vessels
B. Appendix base
C. Appendix tip
D. Ileocaecal valve
E. Ileocolic artery
Caecum
Location Proximal right colon below the ileocaecal valve
Intraperitoneal
The caecum is the most distensible part of the colon and in complete large
bowel obstruction with a competent ileocaecal valve the most likely site of
eventual perforation.
Which of the following structures lies most posteriorly at the porta hepatis?
A. Cystic artery
D. Portal vein
The portal vein is the most posterior structure at the porta hepatis.The common bile
duct is a continuation of the common hepatic duct and is formed by the union of the
common hepatic duct and the cystic duct.
Liver
Between the liver lobules are portal canals which contain the portal triad:
Hepatic Artery, Portal Vein, tributary of Bile Duct.
Porta hepatis
Location Postero inferior surface, it joins nearly at right angles with the left sagittal
fossa, and separates the caudate lobe behind from the quadrate lobe in
front
Transmits Common hepatic duct
Hepatic artery
Portal vein
Sympathetic and parasympathetic nerve fibres
Lymphatic drainage of the liver (and nodes)
Ligaments
Falciform 2 layer fold peritoneum from the umbilicus to anterior
ligament liver surface
Contains ligamentum teres (remnant umbilical vein)
On superior liver surface it splits into the coronary and
left triangular ligaments
Ligamentum teres Joins the left branch of the portal vein in the porta hepatis
Ligamentum Remnant of ductus venosus
venosum
Arterial supply
Hepatic artery
Venous
Hepatic veins
Portal vein
Nervous supply
A. L1
B. T10
C. L4
D. L5
E. L2
The aorta bifurcates at L4. An important landmark that is tested frequently.
Abdominal aorta
Abdominal aortic topography
Origin T12
Termination L4
The abdominal aorta
Image sourced from Wikipedia
It is connected with the lesser sac and the transverse colon. This plane is entered when
performing a colonic resection. It is a common site of metastasis in many visceral
malignancies.
Omentum
The omentum is divided into two parts which invest the stomach. Giving rise
to the greater and lesser omentum. The greater omentum is attached to the
inferolateral border of the stomach and houses the gastro-epiploic arteries.
It is of variable size but is less well developed in children. This is important as
the omentum confers protection against visceral perforation (e.g.
Appendicitis).
Inferiorly between the omentum and transverse colon is one potential entry
point into the lesser sac.
Several malignant processes may involve the omentum of which ovarian
cancer is the most notable.
A 48 year old man with newly diagnosed hypertension is found to have a
phaeochromocytoma of the left adrenal gland and is due to undergo a
laparoscopic left adrenalectomy. Which of the following structures is not
directly related to the left adrenal gland?
C. Splenic hilum
D. Pancreas
E. Splenic artery
The splenic hilum lies more laterally and is therefore not a direct relation of
the left adrenal gland.
Adrenal gland anatomy
Anatomy
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An 18 year old boy is undergoing an appendicectomy for appendicitis. At which of
the following locations is the appendix most likely to be found?
A. Pre ileal
B. Pelvic
C. Retrocaecal
D. Post ileal
Appendix
McBurney's point
1/3 of the way along a line drawn from the Anterior Superior Iliac Spine to the
Umbilicus
6 Positions:
Retrocaecal 74%
Pelvic 21%
Postileal
Subcaecal
Paracaecal
Preileal
A 56 year old man is undergoing a pancreatectomy for carcinoma. During resection of
the gland which of the following structures will the surgeon not encounter posterior to
the pancreas itself?
D. Portal vein
E. Gastroduodenal artery
Pancreas
The pancreas is a retroperitoneal organ and lies posterior to the stomach. It may be
accessed surgically by dividing the peritoneal reflection that connects the greater
omentum to the transverse colon. The pancreatic head sits in the curvature of the
duodenum. It's tail lies close to the hilum of the spleen, a site of potential injury
during splenectomy.
Relations
Posterior to the pancreas
Pancreatic head Inferior vena cava
Common bile duct
Right and left renal veins
Superior mesenteric vein and artery
Pancreatic neck Superior mesenteric vein, portal vein
Pancreatic body- Left renal vein
Crus of diaphragm
Psoas muscle
Adrenal gland
Kidney
Aorta
Pancreatic tail Left kidney
Arterial supply
Venous drainage
Ampulla of Vater
I
A 55 year old man is admitted with a brisk haematemesis. He is taken to the
endoscopy department and an upper GI endoscopy is performed by the
gastroenterologist. He identifies an ulcer on the posterior duodenal wall and spends an
eternity trying to control the bleeding with all the latest haemostatic techniques. He
eventually asks the surgeons for help. A laparotomy and anterior duodenotomy are
performed, as the surgeon opens the duodenum a vessel is spurting blood into the
duodenal lumen. From which of the following does this vessel arise?
E. Splenic artery
The vessel will be the gastroduodenal artery, this arises from the common hepatic
artery.
Gastroduodenal artery
Supplies
Pylorus, proximal part of the duodenum, and indirectly to the pancreatic head (via the
anterior and posterior superior pancreaticoduodenal arteries)
Path
Most commonly arises from the common hepatic artery of the coeliac trunk
Terminates by bifurcating into the right gastroepiploic artery and the superior
pancreaticoduodenal artery
A. Pyramidalis
E. Rectus abdominis
Abdominal wall
The 2 main muscles of the abdominal wall are the rectus abdominis (anterior) and the
quadratus lumborum (posterior).
The remaining abdominal wall consists of 3 muscular layers. Each muscle passes from the
lateral aspect of the quadratus lumborum posteriorly to the lateral margin of the rectus
sheath anteriorly. Each layer is muscular posterolaterally and aponeurotic anteriorly.
Internal Arises from the thoracolumbar fascia, the anterior 2/3 of the iliac
oblique crest and the lateral 2/3 of the inguinal ligament
The muscle sweeps upwards to insert into the cartilages of the lower
3 ribs
The lower fibres form an aponeurosis that runs from the tenth costal
cartilage to the body of the pubis
At its lowermost aspect it joins the fibres of the aponeurosis of
transversus abdominis to form the conjoint tendon.
Surgical notes
During abdominal surgery it is usually necessary to divide either the muscles or their
aponeuroses. During a midline laparotomy it is desirable to divide the aponeurosis. This will
leave the rectus sheath intact above the arcuate line and the muscles intact below it.
Straying off the midline will often lead to damage to the rectus muscles, particularly below
the arcuate line where they may often be in close proximity to each other.
Which of the following vessels does not drain directly into the inferior vena cava?
The superior mesenteric vein drains into the portal vein. The right and left hepatic veins
drain into it directly, this can account for major bleeding in more extensive liver shearing
type injuries.
Origin
L5
Path
Left and right common iliac veins merge to form the IVC.
Passes right of midline
Paired segmental lumbar veins drain into the IVC throughout its length
The right gonadal vein empties directly into the cava and the left gonadal vein
generally empties into the left renal vein.
The next major veins are the renal veins and the hepatic veins
Pierces the central tendon of diaphragm at T8
Right atrium
Image sourced from Wikipedia
Relations
Anteriorly Small bowel, first and third part of duodenum, head of pancreas, liver and bile
duct, right common iliac artery, right gonadal artery
Posteriorly Right renal artery, right psoas, right sympathetic chain, coeliac ganglion
Levels
Level Vein
L2 Gonadal vein
A 17 year old male has a suspected testicular torsion and the scrotum is to be explored
surgically. The surgeon incises the skin and then the dartos muscle. What is the next
tissue layer that will be encountered during the dissection?
A. Visceral layer of the tunica vaginalis
B. Cremasteric fascia
The layers of the spermatic cord and scrotum are a popular topic in the MRCS exam.
Spermatic cord
Formed by the vas deferens and is covered by the following structures:
Layer Origin
Internal spermatic fascia Transversalis fascia
Cremasteric fascia From the fascial coverings of internal oblique
External spermatic fascia External oblique aponeurosis
Scrotum
Composed of skin and closely attached dartos fascia.
Arterial supply from the anterior and posterior scrotal arteries
Lymphatic drainage to the inguinal lymph nodes
Parietal layer of the tunica vaginalis is the innermost layer
Testes
The testes are surrounded by the tunica vaginalis (closed peritoneal sac). The
parietal layer of the tunica vaginalis adjacent to the internal spermatic fascia.
The testicular arteries arise from the aorta immediately inferiorly to the renal
arteries.
The pampiniform plexus drains into the testicular veins, the left drains into the
left renal vein and the right into the inferior vena cava.
Lymphatic drainage is to the para-aortic nodes.
A 25 year old man is stabbed in the groin and the area, which lies within the femoral triangle
is explored. Which structure forms the lateral wall of the femoral triangle?
A. Adductor longus
B. Pectineus
C. Adductor magnus
D. Sartorius
E. Conjoint tendon
The sartorius forms the lateral wall of the femoral triangle (see below).
Boundaries
Laterally Sartorius
Contents
A 19 year old man undergoes an open inguinal hernia repair. The cord is mobilised and the
deep inguinal ring identified. Which of the following structures forms its lateral wall?
C. Conjoint tendon
The transversalis fascia forms the superolateral edge of the deep inguinal ring. The epigastric
vessels form its inferomedial wall.
Inguinal canal
Location
Contents
Males Spermatic cord and ilioinguinal As it passes through the canal the spermatic cord
nerve has 3 coverings:
External spermatic fascia from external
oblique aponeurosis
Cremasteric fascia
Internal spermatic fascia
The image below demonstrates the close relationship of the vessels to the lower limb with
the inguinal canal. A fact to be borne in mind when repairing hernial defects in this region.
Image sourced from Wikipedia
A 34 year old lady presents with symptoms of faecal incontinence. Ten years
previously she gave birth to a child by normal vaginal delivery. Injury to which of the
following nerves is most likely to account for this process?
A. Genitofemoral
B. Ilioinguinal
C. Pudendal
E. Obturator
Pudendal nerve
The pudendal nerve arises from nerve roots S2, S3 and S4 and exits the pelvis through
the greater sciatic foramen. It re-enters the pelvis through the lesser sciatic foramen. It
travels inferior to give innervation to the anal sphincters and external urethral
sphincter. It also provides cutaneous innervation to the region of perineum
surrounding the anus and posterior vulva.
Traction and compression of the pudendal nerve by the foetus in late pregnancy may
result in late onset pudendal neuropathy which may be part of the process involved in
the development of faecal incontinence.
A 56 year old man undergoes an abdomino-perineal excision of the rectum. He is
assessed in the outpatient clinic post operatively. His wounds are well healed.
However, he complains of impotence. Which of the following best explains this
problem?
Penile erection
Physiology of erection
Autonomic Sympathetic nerves originate from T11-L2 and parasympathetic
nerves from S2-4 join to form pelvic plexus.
Parasympathetic discharge causes erection, sympathetic
discharge causes ejaculation and detumescence.
Somatic Supplied by dorsal penile and pudendal nerves. Efferent signals are
nerves relayed from Onufs nucleus (S2-4) to innervate ischiocavernosus and
bulbocavernosus muscles.
Autonomic discharge to the penis will trigger the veno-occlusive mechanism which
triggers the flow of arterial blood into the penile sinusoidal spaces. As the inflow
increases the increased volume in this space will secondarily lead to compression of
the subtunical venous plexus with reduced venous return. During the detumesence
phase the arteriolar constriction will reduce arterial inflow and thereby allow venous
return to normalise.
Priapism
Prolonged unwanted erection, in the absence of sexual desire, lasting more than 4
hours.
Classification of priaprism
Low flow Due to veno-occlusion (high intracavernosal pressures).
priaprism
Most common type
Often painful
Often low cavernosal flow
If present for >4 hours requires emergency treatment
Causes
Tests
Management
E. Renal artery
Mnemonic for the Descending abdominal aorta branches from diaphragm to iliacs:
'Prostitutes Cause Sagging Swollen Red Testicles [in men] Living In Sin':
Phrenic [inferior]
Celiac
Superior mesenteric
Suprarenal [middle]
Renal
Testicular ['in men' only]
Lumbars
Inferior mesenteric
Sacral
The superior phrenic artery branches from the aorta in the thorax.
Abdominal aortic branches
Branches Level Paired Type
Inferior phrenic T12 (Upper border) Yes Parietal
Coeliac T12 No Visceral
Superior mesenteric L1 No Visceral
Middle suprarenal L1 Yes Visceral
Renal L1-L2 Yes Visceral
Gonadal L2 Yes Visceral
Lumbar L1-L4 Yes Parietal
Inferior mesenteric L3 No Visceral
Median sacral L4 No Parietal
Common iliac L4 Yes Terminal
A 23 year old man is admitted with a suspected ureteric colic. A KUB style x-ray is
obtained. In which of the following locations is the stone most likely to be visualised?
The ureter lies anterior to L2 to L5 and stones may be visualised at these points, they
may also be identified over the sacro-iliac joints.
Ureter
25-35 cm long
Muscular tube lined by transitional epithelium
Surrounded by thick muscular coat. Becomes 3 muscular layers as it crosses
the bony pelvis
Retroperitoneal structure overlying transverse processes L2-L5
Lies anterior to bifurcation of iliac vessels
Blood supply is segmental; renal artery, aortic branches, gonadal branches,
common iliac and internal iliac
Lies beneath the uterine artery
A 55 year old man is due to undergo a radical prostatectomy for carcinoma of the prostate
gland. Which of the following vessels directly supplies the prostate?
The arterial supply to the prostate gland is from the inferior vesical artery, it is a branch of
the prostatovesical artery. The prostatovesical artery usually arises from the internal
pudendal and inferior gluteal arterial branches of the internal iliac artery.
Prostate gland
The prostate gland is approximately the shape and size of a walnut and is located inferior to
the bladder. It is separated from the rectum by Denonvilliers fascia and its blood supply is
derived from the internal iliac vessels. The internal sphincter lies at the apex of the gland
and may be damaged during prostatic surgery, affected individuals may complain of
retrograde ejaculation.
Relations
A. Uranchus
B. Wolffian duct
C. Vitello-intestinal duct
D. Mesonephric duct
E. Cloaca
Ureter
25-35 cm long
Muscular tube lined by transitional epithelium
Surrounded by thick muscular coat. Becomes 3 muscular layers as it crosses
the bony pelvis
Retroperitoneal structure overlying transverse processes L2-L5
Lies anterior to bifurcation of iliac vessels
Blood supply is segmental; renal artery, aortic branches, gonadal branches,
common iliac and internal iliac
Lies beneath the uterine artery
A 56 year old man is having a long venous line inserted via the femoral vein into the right
atrium for CVP measurements. The catheter is advanced through the IVC. At which of the
following levels does this vessel enter the thorax?
A. L2
B. T10
C. L1
D. T8
E. T6
Origin
L5
Path
Left and right common iliac veins merge to form the IVC.
Passes right of midline
Paired segmental lumbar veins drain into the IVC throughout its length
The right gonadal vein empties directly into the cava and the left gonadal vein
generally empties into the left renal vein.
The next major veins are the renal veins and the hepatic veins
Pierces the central tendon of diaphragm at T8
Right atrium
Image sourced from Wikipedia
Relations
Anteriorly Small bowel, first and third part of duodenum, head of pancreas, liver and bile
duct, right common iliac artery, right gonadal artery
Posteriorly Right renal artery, right psoas, right sympathetic chain, coeliac ganglion
Levels
Level Vein
L2 Gonadal vein
C. Spleen
The spleen is commonly torn by traction injuries in colonic surgery. The other
structures are associated with bleeding during colonic surgery but would not manifest
themselves as blood in the paracolic gutter prior to incision of the paracolonic
peritoneal edge.
Left colon
Position
As the left colon passes inferiorly its posterior aspect becomes extraperitoneal,
and the ureter and gonadal vessels are close posterior relations that may
become involved in disease processes
At a level of L3-4 (variable) the left colon becomes the sigmoid colon and
wholly intraperitoneal once again
The sigmoid colon is a highly mobile structure and may even lie of the right
side of the abdomen
It passes towards the midline, the taenia blend and this marks the transition
between sigmoid colon and upper rectum.
Blood supply
52 year old female renal patient needs a femoral catheter to allow for haemodialysis. Which
of the structures listed below is least likely to be encountered during its insertion?
D. Femoral vein
Femoral access catheters are typically inserted in the region of the femoral triangle.
Therefore the physician may encounter the femoral, vein, nerve, branches of the femoral
artery and tributaries of the femoral vein. The deep circumflex iliac artery arises above the
inguinal ligament and is therefore less likely to be encountered than the superficial
circumflex iliac artery which arises below the inguinal ligament.
Boundaries
Laterally Sartorius
Contents
A 53 year old man with a chronically infected right kidney is due to undergo a
nephrectomy. Which of the following structures would be encountered first during a
posterior approach to the hilum of the right kidney?
B. Ureter
The ureter is the most posterior structure at the hilum of the right kidney and would
therefore be encountered first during a posterior approach.
Renal arteries
The right renal artery is longer than the left renal artery
The renal vein/artery/pelvis enter the kidney at the hilum
Relations
Right:
Anterior- IVC, right renal vein, the head of the pancreas, and the descending part of
the duodenum.
Left:
Branches
The renal arteries are direct branches off the aorta (upper border of L2)
In 30% there may be accessory arteries (mainly left side). Instead of entering
the kidney at the hilum, they usually pierce the upper or lower part of the
organ.
Before reaching the hilum of the kidney, each artery divides into four or five
segmental branches (renal vein anterior and ureter posterior); which then
divide within the sinus into lobar arteries supplying each pyramid and cortex.
Each vessel gives off some small inferior suprarenal branches to the
suprarenal gland, the ureter, and the surrounding cellular tissue and muscles.
Which of the following regions of the male urethra is entirely surrounded by Bucks
fascia?
A. Preprostatic part
B. Prostatic part
C. Membranous part
D. Spongiose part
Theme from 2010 Exam
Bucks fascia is a layer of deep fascia that covers the penis it is continuous with the
external spermatic fascia and the penile suspensory ligament. The membranous part
of the urethra may partially pass through Bucks fascia as it passes into the penis.
However, the spongiose part of the urethra is contained wholly within Bucks fascia.
Urethral anatomy
Female urethra
The female urethra is shorter and more acutely angulated than the male urethra. It
is an extra-peritoneal structure and embedded in the endopelvic fascia. The neck of
the bladder is subjected to transmitted intra-abdominal pressure and therefore
deficiency in this area may result in stress urinary incontinence. Between the layers
of the urogenital diaphragm the female urethra is surrounded by the external
urethral sphincter, this is innervated by the pudendal nerve. It ultimately lies
anterior to the vaginal orifice.
Male urethra
In males the urethra is much longer and is divided into four parts.
Pre-prostatic Extremely short and lies between the bladder and prostate gland.It has a
urethra stellate lumen and is between 1 and 1.5cm long.Innervated by sympathetic
noradrenergic fibres, as this region is composed of striated muscles bundles
they may contract and prevent retrograde ejaculation.
Prostatic This segment is wider than the membranous urethra and contains several
urethra openings for the transmission of semen (at the midpoint of the urethral
crest).
Penile urethra Travels through the corpus songiosum on the underside of the penis. It is
the longest urethral segment.It is dilated at its origin as the infrabulbar fossa
and again in the gland penis as the navicular fossa. The bulbo-urethral
glands open into the spongiose section of the urethra 2.5cm below the
perineal membrane.
The urothelium is transitional in nature near to the bladder and becomes squamous
more distally.
48 year old lady is undergoing a left sided adrenalectomy for an adrenal
adenoma. The superior adrenal artery is injured and starts to bleed, from which
of the following does this vessel arise?
C. Aorta
D. Splenic
A. Appendicitis
B. Threatened miscarriage
C. Ectopic pregnancy
D. Irritable bowel syndrome
E. Mittelschmerz
F. Pelvic inflammatory disease
G. Adnexial torsion
H. Endometriosis
I. Degenerating fibroid
Please select the most likely cause of abdominal pain for the clinical scenario given.
Each option may be used once, more than once or not at all.
The most likely diagnosis is pelvic inflammatory disease. Right upper quadrant
pain occurs as part of the Fitz Hugh Curtis syndrome in which peri hepatic
inflammation occurs.
Mid cycle pain is very common and is due to the small amount of fluid released
during ovulation. Inflammatory markers are usually normal and the pain
typically subsides over the next 24-48 hours.
A number of women will present with abdominal pain and subsequently be diagnosed
with a gynaecological disorder. In addition to routine diagnostic work up of
abdominal pain, all female patients should also undergo a bimanual vaginal
examination, urine pregnancy test and consideration given to abdominal and pelvic
ultrasound scanning.
When diagnostic doubt persists a laparoscopy provides a reliable method of assessing
suspected tubulo-ovarian pathology.
The vessel damaged is the epigastric artery. This originates from the external iliac artery (see
below).
Epigastric artery
The inferior epigastric artery arises from the external iliac artery immediately above the
inguinal ligament. It then passes along the medial margin of the deep inguinal ring. From
here it continues superiorly to lie behind the rectus abdominis muscle.
A 73 year old man has a large abdominal aortic aneurysm. During a laparotomy for planned
surgical repair the surgeons find the aneurysm is far more proximally located and lies near
the origin of the SMA. During the dissection a vessel lying transversely across the aorta is
injured. What is this vessel most likely to be?
D. Ileocolic artery
Origin T12
Termination L4
A 18 year old man presents with an indirect inguinal hernia and undergoes surgery. The
deep inguinal ring is exposed and held with a retractor at its medial aspect. Which structure
is most likely to lie under the retractor?
A. Ureter
D. Femoral artery
Superolaterally - transversalis
fascia
Inferomedially - inferior
epigastric artery
The deep inguinal ring is closely related to the inferior epigastric artery. The inferior
epigastric artery forms part of the structure referred to as Hesselbach's triangle.
Inguinal canal
Location
Contents
Males Spermatic cord and ilioinguinal As it passes through the canal the spermatic cord
nerve has 3 coverings:
The image below demonstrates the close relationship of the vessels to the lower limb with
the inguinal canal. A fact to be borne in mind when repairing hernial defects in this region.
Rate question: 3
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In a patient with a carcinoma of the distal sigmoid colon, what is the most likely
source of its blood supply?
A. Ileocolic artery
During a high anterior resection of such tumours, the inferior mesenteric artery is
ligated. Note that the branches (mainly middle rectal branch) of the internal iliac
artery are important in maintaining vascularity of the rectal stump and hence the
integrity of the anastomoses.
Rectum
Arterial supply
Superior rectal artery
Venous drainage
Superior rectal vein
Lymphatic drainage
D. Ileo-colic artery
The ileo - colic artery supplies the caecum and would require high ligation during a
right hemicolectomy. The middle colic artery should generally be preserved when
resecting a caecal lesion.
This question is essentially asking you to name the vessel supplying the caecum. The
SMA does not directly supply the caecum, it is the ileocolic artery which does this.
Caecum
Location Proximal right colon below the ileocaecal valve
Intraperitoneal
The caecum is the most distensible part of the colon and in complete large
bowel obstruction with a competent ileocaecal valve the most likely site of
eventual perforation.
A 72 year old man is undergoing a repair of an abdominal aortic aneurysm.
The aorta is cross clamped both proximally and distally. The proximal clamp
is applied immediately inferior to the renal arteries. Both common iliac
arteries are clamped distally. A longitudinal aortotomy is performed. After
evacuating the contents of the aneurysm sac a significant amount of ongoing
bleeding is encountered. This is most likely to originate from:
B. Testicular artery
C. Splenic artery
E. Lumbar arteries
The lumbar arteries are posteriorly sited and are a common cause of back
bleeding during aortic surgery. The other vessels cited all exit the aorta in the
regions that have been cross clamped.
Abdominal aortic branches
Branches Level Paired Type
Inferior phrenic T12 (Upper border) Yes Parietal
Coeliac T12 No Visceral
Superior mesenteric L1 No Visceral
Middle suprarenal L1 Yes Visceral
Renal L1-L2 Yes Visceral
Gonadal L2 Yes Visceral
Lumbar L1-L4 Yes Parietal
Inferior mesenteric L3 No Visceral
Median sacral L4 No Parietal
Common iliac L4 Yes Terminal
The superficial inguinal ring is traversed by which of the following nerves?
A. Subcostal
B. Iliohypogastric
C. Ilioinguinal
D. Obturator
E. Pudendal
Ilioinguinal nerve entrapment may be a cause of neuropathic pain following inguinal
hernia surgery.
The ilioinguinal nerve passes through the superfical inguinal ring and is routinely
encountered when exploring the inguinal canal during hernia surgery. The
iliohypogastric nerve pierces the aponeurosis of the external oblique muscle superior
to the superficial inguinal ring.
Ilioinguinal nerve
Arises from the first lumbar ventral ramus with the iliohypogastric nerve. It passes
inferolaterally through the substance of psoas major and over the anterior surface of
quaratus lumborum. It pierces the internal oblique muscle and passes deep to the
aponeurosis of the external oblique muscle. It enters the inguinal canal and then
passes through the superficial inguinal ring to reach the skin.
Branches
A 63 year old man undergoes a radical cystectomy for carcinoma of the bladder.
During the procedure there is considerable venous bleeding. What is the primary site
of venous drainage of the urinary bladder?
D. Gonadal vein
The urinary bladder has a rich venous plexus surrounding it, this drains subsequently
into the internal iliac vein. The vesicoprostatic plexus may be a site of considerable
venous bleeding during cystectomy.
Bladder
The empty bladder is contained within the pelvic cavity. It is usually a three sided
pyramid. The apex of the bladder points forwards towards the symphysis pubis and
the base lies immediately anterior to the rectum or vagina. Continuous with the apex
is the medial umbilical ligament, during development this was the site of the
uranchus.
The inferior aspect of the bladder is retroperitoneal and the superior aspect covered by
peritoneum. As the bladder distends it will tend to separate the peritoneum from the
fascia of tansversalis. For this reason a bladder that is distended due to acute urinary
retention may be approached with a suprapubic catheter that avoids entry into the
peritoneal cavity.
The trigone is the least mobile part of the bladder and forms the site of the ureteric
orifices and internal urethral orifice. In the empty bladder the ureteric orifices are
approximately 2-3cm apart, this distance may increase to 5cm in the distended
bladder.
Arterial supply
The superior and inferior vesical arteries provide the main blood supply to the
bladder. These are branches of the internal iliac artery.
Venous drainage
In males the bladder is drained by the vesicoprostatic venous plexus. In females the
bladder is drained by the vesicouterine venous plexus. In both sexes this venous
plexus will ultimately drain to the internal iliac veins.
Lymphatic drainage
Lymphatic drainage is predominantly to the external iliac nodes, internal iliac and
obturator nodes also form sites of bladder lymphatic drainage.
Innervation
Parasympathetic nerve fibres innervate the bladder from the pelvic splanchnic nerves.
Sympathetic nerve fibres are derived from L1 and L2 via the hypogastric nerve
plexuses. The parasympathetic nerve fibres will typically cause detrusor muscle
contraction and result in voiding. The muscle of the trigone is innervated by the
sympathetic nervous system. The external urethral sphincter is under concious
control. During bladder filling the rate of firing of nerve impulses to the detrusor
muscle is low and receptive relaxation occurs. At higher volumes and increased intra
vesical pressures the rate of neuronal firing will increase and eventually voiding will
occur.
A 60 year old female is undergoing a Whipples procedure for adenocarcinoma of the
pancreas. As the surgeons begin to mobilise the pancreatic head they identify a large vessel
passing inferiorly over the anterior aspect of the pancreatic head. What is it likely to be?
B. Coeliac axis
D. Aorta
Pancreas
The pancreas is a retroperitoneal organ and lies posterior to the stomach. It may be
accessed surgically by dividing the peritoneal reflection that connects the greater omentum
to the transverse colon. The pancreatic head sits in the curvature of the duodenum. It's tail
lies close to the hilum of the spleen, a site of potential injury during splenectomy.
Relations
Posterior to the pancreas
Arterial supply
Venous drainage
Ampulla of Vater
C. Transversalis fascia
D. Rectus sheath
E. Campers fascia
The outermost covering of the spermatic cord is derived from the external oblique
aponeurosis.This layer is added as the cord passes through the superficial inguinal
ring.
Spermatic cord
Formed by the vas deferens and is covered by the following structures:
Layer Origin
Internal spermatic fascia Transversalis fascia
Cremasteric fascia From the fascial coverings of internal oblique
External spermatic fascia External oblique aponeurosis
Scrotum
Testes
The testes are surrounded by the tunica vaginalis (closed peritoneal sac). The
parietal layer of the tunica vaginalis adjacent to the internal spermatic fascia.
The testicular arteries arise from the aorta immediately inferiorly to the renal
arteries.
The pampiniform plexus drains into the testicular veins, the left drains into the
left renal vein and the right into the inferior vena cava.
Lymphatic drainage is to the para-aortic nodes.
A 53 year old male presents with a carcinoma of the transverse colon. Which of the
following structures should be ligated close to their origin to maximise clearance of
the tumour?
D. Ileo-colic artery
Transverse colon
The right colon undergoes a sharp turn at the level of the hepatic flexure to
become the transverse colon.
At this point it also becomes intraperitoneal.
It is connected to the inferior border of the pancreas by the transverse
mesocolon.
The greater omentum is attached to the superior aspect of the transverse colon
from which it can easily be separated. The mesentery contains the middle colic
artery and vein. The greater omentum remains attached to the transverse colon
up to the splenic flexure. At this point the colon undergoes another sharp turn.
Relations
Superior Liver and gall-bladder, the greater curvature of the stomach, and the lower
end of the spleen
Inferior Small intestine
Anterior Greater omentum
Posterior From right to left with the descending portion of the duodenum, the head of
the pancreas, convolutions of the jejunum and ileum, spleen
Which of the following structures does not lie posterior to the right kidney?
A. Psoas major
B. Transversus abdominis
C. Quadratus lumborum
E. 10th rib
Renal anatomy
Each kidney is about 11cm long, 5cm wide and 3cm thick. They are located in a deep
gutter alongside the projecting verterbral bodies, on the anterior surface of psoas
major. In most cases the left kidney lies approximately 1.5cm higher than the right.
The upper pole of both kidneys approximates with the 11th rib (beware pneumothorax
during nephrectomy). On the left hand side the hilum is located at the L1 vertebral
level and the right kidney at level L1-2. The lower border of the kidneys is usually
alongside L3.
Relations
Relations Right Kidney Left Kidney
Posterior Quadratus lumborum, diaphragm, Quadratus lumborum, diaphragm,
psoas major, transversus abdominis psoas major, transversus abdominis
Anterior Hepatic flexure of colon Stomach, Pancreatic tail
Superior Liver, adrenal gland Spleen, adrenal gland
Fascial covering
Each kidney and suprarenal gland is enclosed within a common and layer of investing
fascia that is derived from the transversalis fascia into anterior and posterior layers
(Gerotas fascia).
Renal structure
Kidneys are surrounded by an outer cortex and an inner medulla which usually
contains between 6 and 10 pyramidal structures. The papilla marks the innermost
apex of these. They terminate at the renal pelvis, into the ureter.
Lying in a hollow within the kidney is the renal sinus. This contains:
1. Branches of the renal artery
2. Tributaries of the renal vein
3. Major and minor calyces's
4. Fat
A. Pubic tubercle
B. Femoral vein
C. Femoral artery
D. Conjoint tendon
E. Femoral nerve
The canal exists to allow for the physiological expansion of the femoral vein, which lies
lateral to it.
Femoral canal
The femoral canal lies at the medial aspect of the femoral sheath. The femoral sheath is a
fascial tunnel containing both the femoral artery laterally and femoral vein medially. The
canal lies medial to the vein.
Lymphatic vessels
Cloquet's lymph node
Physiological significance
Allows the femoral vein to expand to allow for increased venous return to the lower limbs.
Pathological significance
As a potential space, it is the site of femoral hernias. The relatively tight neck places these at
high risk of strangulation.
How many unpaired branches leave the abdominal aorta to supply the abdominal
viscera?
A. One
B. Two
C. Three
D. Four
E. Five
There are three unpaired branches to the abdominal viscera. These include the coeliac
axis, the SMA and IMA. Branches to the adrenals, renal arteries and gonadal vessels
are paired. The fourth unpaired branch of the abdominal aorta, the median sacral
artery, does not directly supply the abdominal viscera.
The prostatic urethra is much wider than the membranous urethra and therefore resistance
will decrease. The prostatic urethra is inclined vertically.
Prostate gland
The prostate gland is approximately the shape and size of a walnut and is located inferior to
the bladder. It is separated from the rectum by Denonvilliers fascia and its blood supply is
derived from the internal iliac vessels. The internal sphincter lies at the apex of the gland
and may be damaged during prostatic surgery, affected individuals may complain of
retrograde ejaculation.
Relations
A 78 year old man develops a carcinoma of the scrotum. To which of the following
lymph node groups may the tumour initially metastasise?
A. Para aortic
B. Obturator
C. Inguinal
D. Meso rectal
Spermatic cord
Formed by the vas deferens and is covered by the following structures:
Layer Origin
Internal spermatic fascia Transversalis fascia
Cremasteric fascia From the fascial coverings of internal oblique
External spermatic fascia External oblique aponeurosis
Scrotum
Testes
The testes are surrounded by the tunica vaginalis (closed peritoneal sac). The
parietal layer of the tunica vaginalis adjacent to the internal spermatic fascia.
The testicular arteries arise from the aorta immediately inferiorly to the renal
arteries.
The pampiniform plexus drains into the testicular veins, the left drains into the
left renal vein and the right into the inferior vena cava.
Lymphatic drainage is to the para-aortic nodes.
An 22 year old soldier is shot in the abdomen and amongst his various injuries
is a major disruption to the abdominal aorta. There is torrential haemorrhage
and the surgeons decide to control the aorta by placement of a vascular clamp
immediately inferior to the diaphragm. Which of the following vessels may be
injured in this maneouvre?
C. Splenic artery
D. Renal arteries
Image sou
Which of the following statements relating to the gallbladder is untrue?
Gallbladder
Arterial supply
Cystic artery (branch of Right hepatic artery)
Venous drainage
Cystic vein
Nerve supply
Sympathetic- mid thoracic spinal cord, Parasympathetic- anterior vagal trunk
Calot's triangle
C. Tibial nerve
D. Sural nerve
Anterior compartment
Tibialis anterior Deep peroneal nerve Dorsiflexes ankle joint, inverts foot
Extensor digitorum longus Deep peroneal nerve Extends lateral four toes, dorsiflexes
ankle joint
Extensor hallucis longus Deep peroneal nerve Dorsiflexes ankle joint, extends big toe
Peroneal compartment
Peroneus longus Superficial peroneal nerve Everts foot, assists in plantar flexion
Peroneus brevis Superficial peroneal nerve Plantar flexes the ankle joint
Nerve Action
Gastrocnemius Tibial nerve Plantar flexes the foot, may also flex the knee
A 25 year old man is being catheterised, prior to a surgical procedure. As the catheter enters
the prostatic urethra which of the following changes will occur?
The prostatic urethra is much wider than the membranous urethra and therefore resistance
will decrease. The prostatic urethra is inclined vertically.
Prostate gland
The prostate gland is approximately the shape and size of a walnut and is located inferior to
the bladder. It is separated from the rectum by Denonvilliers fascia and its blood supply is
derived from the internal iliac vessels. The internal sphincter lies at the apex of the gland
and may be damaged during prostatic surgery, affected individuals may complain of
retrograde ejaculation.
AP diameter (2cm)
Height (3cm)
Lobes
Lateral lobes x 2
Isthmus
Zones
Peripheral zone: subcapsular portion of posterior prostate. Most prostate cancers are here
Central zone
Transition zone
Stroma
Relations
Rectum
Ejaculatory ducts
[http://cdn.emrcs.com/images_eMRCS/swb129b.png]
Which of the following nerves is the primary source of innervation to the anterior
scrotal skin?
B. Pudendal nerve
C. Ilioinguinal nerve
E. Obturator nerve
Scrotal sensation
The scrotum is innervated by the ilioinguinal nerve and the pudendal nerve. The
ilioinguinal nerve arises from L1 and pierces the internal oblique muscle. It eventually
passes through the superficial inguinal ring to innervate the anterior skin of the
scrotum.
The pudendal nerve is the principal nerve of the perineum. It arises in the pelvis from
3 nerve roots. It passes through both greater and lesser sciatic foramina to enter the
perineal region. The perineal branches pass anteromedially and divide into posterior
scrotal branches. The posterior scrotal branches pass superficially to supply the skin
and fascia of the perineum. It cross communicates with the inferior rectal nerve.
A. Pectineal ligament
D. Inguinal ligament
The principal outpouching of the transversalis fascia is the internal spermatic fascia. The
mouth of the outpouching is the deep inguinal ring.
Abdominal wall
The 2 main muscles of the abdominal wall are the rectus abdominis (anterior) and the
quadratus lumborum (posterior).
The remaining abdominal wall consists of 3 muscular layers. Each muscle passes from the
lateral aspect of the quadratus lumborum posteriorly to the lateral margin of the rectus
sheath anteriorly. Each layer is muscular posterolaterally and aponeurotic anteriorly.
Internal Arises from the thoracolumbar fascia, the anterior 2/3 of the iliac
oblique crest and the lateral 2/3 of the inguinal ligament
The muscle sweeps upwards to insert into the cartilages of the lower
3 ribs
The lower fibres form an aponeurosis that runs from the tenth costal
cartilage to the body of the pubis
At its lowermost aspect it joins the fibres of the aponeurosis of
transversus abdominis to form the conjoint tendon.
Surgical notes
During abdominal surgery it is usually necessary to divide either the muscles or their
aponeuroses. During a midline laparotomy it is desirable to divide the aponeurosis. This will
leave the rectus sheath intact above the arcuate line and the muscles intact below it.
Straying off the midline will often lead to damage to the rectus muscles, particularly below
the arcuate line where they may often be in close proximity to each other.
A 73 year old lady is admitted with right iliac fossa pain. A plain abdominal x-ray is
taken and the caecal diameter measured. Which of the following caecal diameters are
pathological?
A. 4cm
B. 5cm
C. 6cm
D. 7cm
E. 10cm
Right colon
Ileocaecal valve
Appendix
At the base of the caecum the taenia coalesce to mark the base of the appendix
This is a reliable way of locating the appendix surgically and is a constant
landmark
The appendix has a small mesentery (the mesoappendix) and in this runs the
appendiceal artery, a branch of the ileocolic artery.
The posterior aspect of the right colon is extra peritoneal and the anterior aspect
intraperitoneal.
Relations
Posterior
Superior
Medial
Mesentery which contains the ileocolic artery that supplies the right colon and
terminal ileum. A further branch , the right colic artery, also contributes to supply the
hepatic flexure and proximal transverse colon. Medially these pass through the
mesentery to join the SMA. This occurs near to the head of the pancreas and care has
to be taken when ligating the ileocolic artery near to its origin in cancer cases for fear
of impinging on the SMA.
- Anterior
Coils of small intestine, the right edge of the greater omentum, and the anterior
abdominal wall.
Nerve supply
Arterial supply
Ileocolic artery and right colic artery, both branches of the SMA. While the
ileocolic artery is almost always present, the right colic can be absent in 5-
15% of individuals.
Ligamentum venosum is posterior to the liver. The portal triad contains the portal vein
rather than the hepatic vein. There is the 'bare area of the liver' created by a void due
to the coronary ligament layers being widely separated. There are sympathetic and
parasympathetic nerves in the porta hepatis.
Liver
Between the liver lobules are portal canals which contain the portal triad:
Hepatic Artery, Portal Vein, tributary of Bile Duct.
Porta hepatis
Location Postero inferior surface, it joins nearly at right angles with the left sagittal
fossa, and separates the caudate lobe behind from the quadrate lobe in
front
Transmits Common hepatic duct
Hepatic artery
Portal vein
Sympathetic and parasympathetic nerve fibres
Lymphatic drainage of the liver (and nodes)
Ligaments
Falciform 2 layer fold peritoneum from the umbilicus to anterior
ligament liver surface
Contains ligamentum teres (remnant umbilical vein)
On superior liver surface it splits into the coronary and
left triangular ligaments
Ligamentum teres Joins the left branch of the portal vein in the porta hepatis
Ligamentum Remnant of ductus venosus
venosum
Arterial supply
Hepatic artery
Venous
Hepatic veins
Portal vein
Nervous supply
he following statements regarding the rectus abdominis muscle are true except:
B. Its nerve supply is from the ventral rami of the lower 6 thoracic nerves
C. It has collateral supply from both superior and inferior epigastric vessels
The 2 main muscles of the abdominal wall are the rectus abdominis (anterior) and the
quadratus lumborum (posterior).
The remaining abdominal wall consists of 3 muscular layers. Each muscle passes from the
lateral aspect of the quadratus lumborum posteriorly to the lateral margin of the rectus
sheath anteriorly. Each layer is muscular posterolaterally and aponeurotic anteriorly.
Internal Arises from the thoracolumbar fascia, the anterior 2/3 of the iliac
oblique crest and the lateral 2/3 of the inguinal ligament
The muscle sweeps upwards to insert into the cartilages of the lower
3 ribs
The lower fibres form an aponeurosis that runs from the tenth costal
cartilage to the body of the pubis
At its lowermost aspect it joins the fibres of the aponeurosis of
transversus abdominis to form the conjoint tendon.
Surgical notes
During abdominal surgery it is usually necessary to divide either the muscles or their
aponeuroses. During a midline laparotomy it is desirable to divide the aponeurosis. This will
leave the rectus sheath intact above the arcuate line and the muscles intact below it.
Straying off the midline will often lead to damage to the rectus muscles, particularly below
the arcuate line where they may often be in close proximity to each other.
A 42 year old male sustains a back injury resulting in the compression of the conus
medullaris. Which of the dematomes below is most likely to be affected by this process?
A. S1
B. L1
C. S3
D. L3
E. L5
Dermatomes
The common dermatomal levels and cutaneous nerves responsible for them is illustrated
below.
Image sourced from Wikipedia
During liver mobilisation for a cadaveric liver transplant the hepatic ligaments will
require mobilisation. Which of the following statements relating to these structures is
untrue?
A. Lesser omentum arises from the porta hepatis and passes the lesser
curvature of the stomach
B. The falciform ligament divides into the left triangular ligament and
coronary ligament
Liver
Between the liver lobules are portal canals which contain the portal triad:
Hepatic Artery, Portal Vein, tributary of Bile Duct.
Porta hepatis
Location Postero inferior surface, it joins nearly at right angles with the left sagittal
fossa, and separates the caudate lobe behind from the quadrate lobe in
front
Transmits Common hepatic duct
Hepatic artery
Portal vein
Sympathetic and parasympathetic nerve fibres
Lymphatic drainage of the liver (and nodes)
Ligaments
Falciform 2 layer fold peritoneum from the umbilicus to anterior
ligament liver surface
Contains ligamentum teres (remnant umbilical vein)
On superior liver surface it splits into the coronary and
left triangular ligaments
Ligamentum teres Joins the left branch of the portal vein in the porta hepatis
Ligamentum Remnant of ductus venosus
venosum
Arterial supply
Hepatic artery
Venous
Hepatic veins
Portal vein
Nervous supply