Download Anatomy – Whole Block Review

Anatomy – Whole Block Review
Planes of the Abdomen
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To divide the abdomen into 4 quadrants, what two planes are used?
o Medial Line
o Umbilicus
 What are the four quadrants called?
o Right Upper Quadrant (RUQ)
o Left Upper Quadrant (LUQ)
o Right Lower Quadrant (RLQ)
o Left Lower Quadrant (LLQ)
 To divide the abdomen into 9 areas, what three planes are used?
o Transpyloric Plane
o Transtubercular Plane
o Medial Plane
 What are the 9 Areas called?
o Right Hypochondriac, Epigastric, Left Hypochondriac
o Right Lumbar, Umbilicus, Left Lumbar
o Right Inguinal, Hypogastric, Left Inguinal
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Anterior Abdominal Wall
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What are the three muscles of the Anterior Abdominal Wall?
o External Oblique
o Internal Oblique
o Transversus Abdominus
What way do the fibers run for the three muscles of the Anterior Abdominal
Wall?
o External Oblique – Hands in pockets – Inferior/Medial
o Internal Oblique – Hands on tits – Superior/Medial
o Transversus Abdominus – Transverse/Horizontal
What muscles’ aponeurosis forms the Inguinal Canal?
o External Oblique
How are the muscles of the Anterior Abdominal Wall functioning?
o They are muscles of forced expiration.
What is the Conjoint tendon formed from? What is the clinical significance?
o It is formed from the Internal Oblique and the Transversus
Abdominis.
o It can protect from Direct Inguinal Hernias.
What structures go through the Inguinal Canal?
o Ilioinguinal Nerve
o Spermatic Cord (Males)
o Round Ligament of Uterus (Females)
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What are the Rectus Abdominis muscles sectioned by?
o Tendinous Intersections
What are the layers of tissue starting with the skin and ending before the
muscles?
o Camper’s Fascia – fatty
o Scarpas Fascia – membranous
o Transversalis Fascia
o Peritoneum
What do the fascia layers become?
o T: Transversalis Fascia  I: Internal Spermatic Fascia
o I: Internal Oblique Fascia  C: Cremasteric Fascia
o E: External Oblique Fascia  E: External Spermatic Fascia
What does the Peritoneum become?
o Tunica Vaginalis
What does the Scarpa’s Fascia become?
o Colle’s Fascia
o Darto’s Fascia
What is the Linea Alba?
o The fibrous band that extends in the mid-line of the body, where the
aponeurosis of the muscles insert
What is the Linea Semilunaris?
o Two lines (one on each side) lateral to the Rectus Abdominis, where
the aponeuroses also fuse.
How are the fascia organized above and below the Arcuate Line?
o ABOVE:
 External Oblique
 ½ Internal Oblique
 Rectus Muscle
 ½ Internal Oblique
 Transversus Abdominis
 Transversalis Fascia
 Peritoneum
o BELOW:
 External Oblique
 Internal Oblique
 Transversus Abdominis
 Rectus Muscle
 Transversalis Fascia
 Peritoneum
Two arteries in the Anterior Abdominal Wall anastomose. What are these
arteries, and where do they come from?
o Superior Epigastric Artery (from Internal Thoracic  Subclavian 
Aorta)
o Inferior Epigastric Artery (External Iliac  Common Iliac  Aorta)
What are the nerves that are located in the Anterior Abdominal Wall?
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T7-T8-T9-T10-T11
T12 – Subcostal
L1 – Iliohypogastric & Ilioinguinal
Genitofemoral Nerve (L1-L2)
Muscle
External Oblique
Origin
Ribs 5-12
Internal Oblique
Iliac Crest, Inguinal
Ligament
Iliac Crest, Inguinal
Ligament
Pubic Crest
Transversus
Abdominis
Rectus Abdominis
Insertion
Linea Alba, Iliac
Crest, Pubic
Tubercle
Linea Alba, Pubic
Crest
Linea Alba, Pubic
Crest
Xiphoid Process
Nerve
T7-T12
T7-T12
L1
T7-T12
L1
T7-T12
Peritoneal Landmarks:
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What does the Median Umbilical Fold come from?
o Urachus
What does the Medial Umbilical Fold come from?
o Umbilical Artery
What does the Lateral Umbilical Fold come from?
o Inferior Epigastric Artery and Vein
What does the Ligamentum Teres (of the Falciform Ligament) come from?
o Umbilical Vein
Dermatomes:
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What are the names of the following dermatomes?
o T7 – Xiphoid Process
o T10 – Umbilicus
o T12 – Suprapubic Region
o L1 – Upper Medial Thigh and Genitalia
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Retroperitoneal Organs:
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What does retroperitoneal mean?
o The organ lies on the Posterior Abdominal Wall, and is only covered
with peritoneum on the anterior surface.
What does intraperitoneal mean?
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o The organ lies directly inside of the abdominal cavity, and is
suspended by mesentery.
Which organs are Retroperitoneal?
o S: Suprarenal Gland
o A: Aorta (IVC)
o D: Duodenum (2nd and 3rd)
o P: Pancreas (not the tail!)
o U: Ureters
o C: Colon (Ascending and Descending)
o K: Kidneys
o E: Esophagus
o R: Rectum
There are 5 major peritoneal folds. What are they?
o Greater Omentum
o Lesser Omentum
o Mesentery
o Falciform Ligament
o Mesocolon
The Greater Omentum divides into the Supracolic and the Infracolic. Where
are these divisions?
o Supracolic – above the transverse colon
o Infracolic – below the transverse colon
What two ligaments make up the Lesser Omentum?
o Hepatoduodenal Ligament
o Gastrohepatic Ligament
Kidneys
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Discuss the path of urine from the arteries to the ureter.
o Renal Artery  Segmental Artery  Interlobar Artery  Arcuate
Artery  Interlobular Artery  Radiate Artery  Capsular Artery 
Glomerulus  Proximal Convoluted Tubule  Loop of Henle  Distal
Convoluted Tubule  Collecting Duct  Papilla  Minor Calyxes 
Major Calyxes  Renal Pelvis  Ureter
What is another name for the Adrenal Gland?
o Suprarenal Gland
The Suprarenal Gland has three different blood supplies. What are they, and
what do they originate from?
o Superior Suprarenal Artery  Inferior Phrenic Artery
o Middle Suprarenal Artery  Aorta
o Inferior Suprarenal Artery  Rental Artery
What is the Renal Fascia a continuation of?
o Transversalis Fascia
Which kidney is lower and why?
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o The right kidney is lower because the liver is in the way on the right
side.
The ureters run from the kidneys to the bladder. How does it run in relation
to the Psoas Muscle? What vessel does it cross over?
o Media to Psoas Muscle
o Crosses over Common Iliac Vessels
The Pancreas:
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What are the alternate names for the Main Duct and the Accessory Duct of
the Pancreas?
o Main Duct – Wirsung Duct
o Accessory Duct – Duct of Santorini
Where do the Main Duct and the Accessory Duct drain into before going to
the Duodenum?
o Main Duct – Major Papilla
o Accessory Duct – Minor Papilla
What is the “hole” called in the duodenum where the contents from the Main
Pancreatic Duct pour through?
o Ampulla of Vater
What is the sphincter called at the site of pancreatic (and biliary) drainage
into the duodenum?
o Sphincter of Oddi
What is the landmark that separates the Foregut and the Midgut in the
Pancreas?
o The Sphincter of Oddi
Posterior Abdominal Wall:
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What are the four muscles that make up the Posterior Abdominal Wall?
o Psoas Major
o Psoas Minor
o Iliacus
o Quadratus Lumborum
 Two of these muscles that make up the Posterior Abdominal Wall come
together in the upper thigh to function as a major hip flexor. What are these
two muscles?
o Psoas Major
o Iliacus
o Become Iliopsoas
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Lymphatic Drainage:
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If the drainage is occurring above the umbilicus, what lymph nodes drain it?
o Axillary Lymph Nodes
If the drainage is occurring below the umbilicus, what lymph nodes drain it?
o Superficial Inguinal Lymph Nodes
The Inferior Mesenteric, Superior Mesenteric, and Co-Iliac Nodes are all
connected to drain into one location. What is this location? What main duct
does it drain into?
o Cysterna Chyli  Thoracic Duct
Where does the Thoracic Duct drain?
o Into the junction of the Left Subclavian and Left Internal Jugular Veins
The Gut
Description
Arterial Supply
Sympathetic
Nerves
(PAIN)
Referred Pain
Parasympathetic
Nerve
(REFLEX GUT)
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Foregut
Mouth  2nd Part
of Duodenum
Midgut
2nd Part of
Duodenum  2/3
of Transverse
Colon
Celiac Trunk
Right Colic/Middle
Colic (SMA)
Pre: Greater
Pre: Lesser
Splanchnic (T5-T9) Splancnic (T11Post: Celiac
T12)
Ganglion
Post: Superior
Mesenteric
Ganglion
Epigastrium
Umbilical
DRG: T5-T9
DRG: T10-T11
Vagus
Vagus
What are the 4 main layers of the wall of the GI Tract?
o Serosa
o Muscularis
o Submucosa
o Mucosa
At what level does the Esophagus pierce the diaphragm?
o T10
There are 4 main parts to the stomach – what are they?
o The Cardia
o The Fundus
o The Body
Hindgut
1/3 of Transverse
Colon  Rectum
Left Colic (IMA)
Pre: Lumbar
Splanchnic (L1-L2)
Post: Inferior
Mesenteric
Ganglion
Hypogastrium
DRG: L1-L2
Pelvic Splanchnic
S2-S4
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o The Pylorus
How many parts make up the duodenum?
o 4
Which part of the duodenum is where the Accessory Pancreatic Duct and the
Bile Duct enter?
o 2nd Part
Which part of the duodenum is constricted in SMA Syndrome?
o 3rd Part
The duodenum makes a C-shape. What (specific part) organ sits in this area?
o The Head and Uncinate Process of the Pancreas
How much of the small intestine is made up by the Jejunum and the Ileum?
o Jejunum: 2/5
o Ileum: 3/5
What is the difference in the vascularization of the Jejunum vs Ileum?
o Jejunum: Long Vasa Recta, Few Arcades
o Ileum: Short Vasa Recta, Many Arcades
Starting with the Ileocecal Junction and ending at the Rectum, what is the
order of the Large Intestine?
o Cecum (with Appendix)  Ascending Colon  Hepatic Flexure 
Transverse Colon  Splenic Flexure  Ascending Colon  Sigmoid
Colon  Rectum
There are three distinguishing features on the Large Intestine – what are
they?
o Epiploic Appendages – fatty tags
o Haustrae Coli – segmented walls
o Taenia Libera – ribbons of smooth muscle
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Gallbladder
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What does the Gallbladder do?
o Stores bile
When a Gall Stone is passed through the Common Bile Duct, what is its path?
o Cystic Duct  Bile Duct  Major Papilla  Ampulla of Vater  2nd
Part of the Duodenum  Small Intestines  Ileocecal Junction
(usually lodges)
When a Gall Stone breaks through the body of the Gall Bladder, what is its
path?
o 2nd Part of the Duodenum  Small Intestines  Ileocecal Junction
(usually lodges)
When a Gall Stone breaks through the Fundus of the Gall Bladder, what is its
path?
o Transverse Colon  Passed via Feces
What artery supplies the Gall Bladder?
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o Cystic Artery
What is Hartmann’s Pouch?
o A pouch by the neck of the Gallbladder where stones could possibly
lodge, causing no problems in the patient. (It would go undetected)
What duct combines with the Cystic Duct to form the Bile Duct?
o Hepatic Duct
Nerves
Lumbar Plexus
Root
Function
Innervation
Iliohypogastric
L1
Sensory
Ilioinguinal
L1
Sensory
Skin above
pubis
Skin of Penis
Genitofemoral
L1/L2
Both
Lateral Femoral
Cutaneous
L2/L3
Sensory
Scrotal Sac/
Upper Anterior
Thigh
Lateral Thigh
Femoral
L2/L3/L4
Both
Anterior Thigh
Obturator
L2/L3/L4
Both
Medial Thigh
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Clinical
Correlate
---Through
inguinal canal
(hernias)
Cremasteric
Reflex
Calvin Klein
Syndrome
(Meralgia
Paresthetica)
Does not go
through
Femoral
Sheath
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Where does the Femoral Nerve, and the Ilioinguinal Nerve run in relation to
the Inguinal Canal?
o Femoral: Runs deep to the Inguinal Canal (along with the artery and
vein)
o Ilioinguinal: Runs INSIDE of the Inguinal Canal
In the Anterior Abdominal Wall, everything is innervated by T6-T12, what
two muscles do most of these nerves lie in between?
o Internal Oblique and Transversus Abdominis.
Cremasteric Muscle & Reflex
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What is the Cremasteric Reflex?
o It pulls the testicles upwards and into the body.
What is the significance of the reflex?
o It protects the testicles
o It regulates external temperature changes
o It moves them out of the way during intercourse.
What nerve is involved in this reflex?
o Genitofemoral
What branches of the Lumbar Plexus are the roots of the Genitofemoral
Nerve?
o L1/L2
What are the two branches of the Gentiofemoral Nerve? Are they motor or
sensory?
o Genital – Motor
o Femoral – Sensory
Arteries
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At what level does the Aorta pierce the diaphragm?
o T12
What are the three branches of the Celiac Trunk? What does the Celiac
Trunk come off of?
o Branches:
 Left Gastric Artery
 Splenic Artery
 Common Hepatic Artery
o Comes off of the Aorta
What ligament does the Splenic Artery run through?
o Spleno-Renal Ligament
What ligament does the Right and Left Gastric Arteries run through?
o Gastrohepatic Ligament
What ligament does the Right and Left Gastroepiploic Arteries run through?
o Gastrosplenic Ligament
What is the branch off of the Left Gastric Artery?
o Esophageal Artery
What are the branches off of the Splenic Artery?
o Pancreatic Branches
o Short Gastric Artery
o Left Gastroepiploic Artery
What are the branches off of the Common Hepatic Artery?
o Proper Hepatic Artery  L&R Hepatic Arteries and Cystic Artery
o Right Gastric Artery
o Gastroduodenal Artery
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What are the Branches off of the Gastroduodenal Artery?
o Right Gastroepiploic Artery
o Superior Pancreaticoduodenal Artery (Anterior and Posterior)
What are the branches of the Superior Mesenteric Artery (SMA)? – Include
sub-branches
o Middle Colic Artery (Ascending and Descending)
o Right Colic Artery (Ascending and Descending)
o Ileocolic Artery (Iliocecal and Appendicular Branches)
o Inferior Pancreaticoduodenal Artery
o ** Also includes arteries going directly to the Jejunum and Ileum **
What are the braches of the Inferior Mesenteric Artery (IMA)?
o Left Colic Artery
o Sigmoidal Artery
o Superior Rectal Artery
What are the braches of the Internal Iliac Artery? (Posterior and Anterior)
o Anterior:
 Umbilical Artery
 Obturator
 Uterine/Ductus Deferens
 Vaginal/Inferior Vesicle
 Middle Rectal
 Inferior Gluteal
 Interal Pudendal
o Posterior:
 Iliolumbar
 Lateral Sacral
 Superior Gluteal
ARTERIES OF THE ILIAC VESSELS
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What two Iliac Vessels branch from the Abdominal Aorta?
o Left Common Iliac
o Right Common Iliac
The Right Common Iliac further branches into two. What are these two
branches?
o External Iliac
o Internal Iliac
The External Iliac gives off two branches before becoming the Femoral
Artery. What are these two branches?
o Deep Circumflex
o Inferior Epigastric
What landmark causes the External Iliac to turn into the Femoral?
o Inguinal Ligament
What does the Deep Circumflex Artery supply?
o Iliac Crest
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What is special about the Inferior Epigastric Artery?
o It anastomoses with the Superior Epigastric Artery
The Internal Iliac further divides into two more branches. What are these?
o Anterior Division
o Posterior Division
What are the three branches of the Posterior Division?
o Iliolumbar
o Lateral Sacral
o Superior Gluteal
The Iliolumbar further divides into two branches. What are these branches,
and what do they supply?
o Iliac Branch  Iliacus Muscle
o Lumbar Branch  Psoas Major and Quadratus Lumborum Muscles
What does the Lateral Sacral branch supply?
o Piriformis Muscle
o Sacral Canal
What does the Superior Gluteal Branch supply?
o Gluteus Maximus
The Anterior Division of the Internal Iliac gives off two branches before the
special branch that is different between males and females. What are these
two branches? Where do they supply?
o Umbilical  Becomes Medial Fold (not functioning)
 Superior Vesical  Bladder
o Obturator  Medial Thigh
The Anterior Division of the Internal Iliac has a special branch that is
different in males and females. What is the name of this branch in both
sexes?
o Males – Inferior Vesical
o Females – Utero/Vaginal Trunk
What three (or possibly 4) branches does the Superior Vesical give off?
Where does the Superior Vesical Artery go?
o Artery to the Seminal Vesicles
o Artery to the Ductus Deferens
o Artery to the Prostate
o Superior Vesical Artery  Bladder
In females, the Utero/Vaginal Artery splits into two. What are these
branches? What is unique about them?
o Uterine
o Vaginal
o THEY ANASTOMOSE
The Vaginal Artery splits into two (or three) branches. What are these?
What do they supply?
o Vaginal  Vagina
o Interior Vesical  Bladder
o Middle Rectal  Rectal Canal
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After the special M/F Artery is given off of the Anterior Division of the
Internal Iliac, the Anterior Division splits and turns into two new arteries.
What are these? Where do they go?
o Internal Pudendal  Inferior Rectal, Sex Organs
o Inferior Gluteal  Gluteus Minimus, Gluteus Medius
Spermatic Cord
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What is included in the Spermatic Cord?
o FANS+1
 F: Fascial Layers
 External Spermatic
 Cremasteric
 Internal Spermatic
 A: Arteries
 Cremasteric Artery
 Artery to Vas Deferens
 Testicular Artery
 N: Nerves
 Genital Branch of Geniofemoral Nerve
 Sympathetics
 Ilioinguinal Nerve
 S: Structures
 Pampiniform Plexus
 Vas Deferens
 Lymphatics
 +1
 Processus Vaginalis
Osteology
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What three bones form the Acetabulum?
o Ilium
o Pubis
o Ischium
Which is the largest bone of the hip?
o Ilium
What are the wings of the Ilium called?
o Ala
What muscle attaches to the iliac fossa of the ilium?
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o Iliacus
What is the name of the joint that connects the two pubic bones?
o Pubic Symphysis
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The Liver
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What is the portal hepatitis?
o The entry point of the portal triad into the liver
What is the portal triad?
o The Hepatic Proper Artery
o The Hepatic Portal Vein
o The Bile Duct
What are the FUNCTIONAL lobes of the liver divided by?
o The IVC (posteriorly)
o The Gall Bladder (inferiorly)
The functional lobes can actually be further broke down, so that one branch
of the Portal Triad goes to each. How many lobes are there?
o 8
There are two further lobes, which exist just to the left of the Right Lobe.
What are these lobes, and what main lobe do they belong to (functionally)?
o Caudate Lobe (posterior) and is functionally independent
o Quadrate Lobe (anterior) and is functionally part of the left lobe.
What are the STRUCTURAL lobes of the liver divided by?
o The Falciform Ligament
Where is the Bare Area?
o The area where the liver is continuous with the diaphragm. It has not
peritoneum.
Because the peritoneum does not unite at the bare area, two recesses are
formed. What are they?
o Subphrenic Recess
o Hepatorenal Recess (right kidney)
What part of the liver has the most Islets of Langerhans?
o The tail.
There is an important pouch located around the liver. What is this pouch and
what is the significance?
o The Hepatorenal Pouch (Morrison’s Pouch)
o Located between the liver and the kidneys.
o Abdominal infection can gather here when the person is lying down.
The Pelvic Diaphragm
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What are the three Levator Ani muscles?
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o Puborectalis
o Pubococcygeus
o Iliococcygeous
What is the additional muscle of the Pelvic Diaphragm that is NOT a Levator
Ani muscle?
o Coccygeus
The Bladder/Urethra
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There are 4 sections to the male urethra. What are they?
o Prostatic Urethra
o Membranous Urethra
o Bulbous Urethra
o Spongy Urethra
Who has the loner urethra? Males or females?
o Males
How many sphincters do both males and females have?
o Both have 2
What is a Trigone?
o A small, triangular region of the internal bladder formed by the
ureteral orifices. It senses the expansion of the bladder and sends the
signal to the brain so you know when you have to empty it.
What is the muscle of the bladder?
o Detrusor
Male Reproductive System
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What is the sperms path from the testes?
o Semiiniferious Tubules  Epididymis  Vas Deferens  Ejaculatory
Duct  Prostatic Urethra  Glans Penis  Exit
What is the order of nerves, arteries, and veins in the penis?
o Nerve Artery Vein Artery Nerve
How do Sympathetics and Parasympathetics work together in the penis?
o Point and Shoot
 Parasympathetics cause erection
 Sympathetics cause ejaculation
What muscle keeps the penis erect?
o Ischiocavernous Muscle
What muscle causes ejaculation?
o Bulbospongiosus Muscle
What are Hypospadia and Epispadia? What is the difference?
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o Hypospadia – condition where the Urethra opens on the ventral side
of the penis, instead of in the glans like normal.
o Epispadia – condition where the Urethra opens on the dorsal side of
the penis, instead of in the glans like normal.
What is the Perineal Body in the male?
o The location between the Bulb of the Penis and the Anus
If the Perineal Body is damaged, what can occur?
o Prolapse of the Rectum or the Bladder
What are the serous glands in the Male called? What Perineal Pouch are they
located in?
o Bulbourethal Glands (Cowper’s Glands)
o Deep Perineal Pouch
What is Cryptochidism?
o Failure of the testes to descend
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Female Reproductive System
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What is the Perineal Body in the female?
o The location between the Vagina and the Anus
If the Perineal Body is damaged, what can occur?
o Prolapse of the Rectum, Uterus, or Bladder
What are the serous glands in the Female called? What Perineal Pouch are
they located in?
o Bartholin’s Glands
o Superficial Perineal Pouch
What pouch is located between the Rectum and the Uterus?
o Rectouterine Pouch – Pouch of Douglass
What is the pouch located between the Uterus and the Bladder?
o Vesicouterine Pouch – Pouch of Dunn
How do you drain the Pouch of Douglass?
o Through the Posterior Fornix of the Vagina
What is the procedure called when you go through the Posterior Fornix of the
Vagina?
o Culdocentesis
What are the four parts of the Fallopian Tube?
o Infundibulum
o Ampulla
o Isthmus
o Uterine Part
What parts of the Fallopian Tube do most ectopic pregnancies occur?
o Ampulla
When doing a Hysterectomy, there are two arteries that you must be aware
of. What are they, and where do they come from?
o Uterine Artery from Internal Iliac Artery
o Ovarian Artery from the Aorta
o BOTH have to be clamped to prevent bleeding.
 What do we call the normal position of the Uterus?
o Anteverted and Anteflexed
 What are the three structures that come off of the Fundus of the Uterus?
o Fallopian Tube
o Round Ligament of Uterus
o Ovarian Ligament
 What is the “water under the bridge” in females?
o The Ureter runs under the Uterine Artery
 What is a Bicornuate Uterus? What ducts are involved?
o A V-Shaped Uterus (usually no pathology)
o Mullerian ducts fuse completely
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Clinical Correlates:
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Nutcracker Syndrome
o What is compressed? What is it compressed between?
 Compressed: Left Renal Vein (turns into Testicular Vein)
 Between the Aorta and Superior Mesenteric Artery (SMA)
o What are the symptoms?
 Varicocele in the scrotal sac
 Looks like “bag of worms”
Clinical Presentation
Esophageal Varices
Caput Medusa
Internal Hemorrhoids
(painless)
External Hemorrhoids
(painful)
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Portal
Esophageal Branch of
Left Gastric Vein
Paraumbilical Veins
Superior Rectal Vein
(IMV)
Right, Left, Middle Colic
Caval
Esophageal Branch of
Azygous Vein
Superficial Epigastric
Veins
Middle Rectal Vein
Inferior Rectal Vein
Renal, Suprarenal,
Gonadal Veins
Horseshoe Kidney
o What stops the kidneys from ascending and separating, causing
horseshoe kidney?
 Inferior Mesenteric Artery
Meckel’s Diverticulum
o What is another name for it?
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 Littre’s Hernia
o What is the “Rule” you use to identify this?
 Rule of 2’s
o How far from the ileocecal valve?
 2 feet
o How much of the population has it?
 2%
o What is the length of the protrusion?
 2 inches
o What is the common age of presentation?
 2 years old
o What is the ratio of males to females?
 2:1
Pringle Maneuver
o What is the Pringle Maneuver?
 During Liver Surgery, you compress structures to stop the
bleeding if the liver is hemorrhaging.
o What structures are compressed?
 Bile Duct
 Hepatic Proper Artery
 Hepatic Portal Vein
o What ligament do these structures lie in?
 Hepatoduodenal Ligament
o If you perform the Pringle Maneuver and there is still bleeding, what
does this mean?
 That there is an aberrant or an accessory artery that is still
bleeding, which you must find.
o What are the possibilities for aberrant or accessory arteries?
 Aberrant Left Hepatic Artery arising from Left Gastric Artery
 Aberrant Right Hepatic Artery arising from Superior
Mesenteric Artery
 Accessory – If these are in addition (and not replacing) the
normal ones
o What foramen does this lie in (there are three names for it)?
 Epiploic Foramen
 Foramen of Winslow
 Omental Foramen
o The Epiploic Foramen allows for communication between two areas.
What are these areas?
 Greater Omentum
 Lesser Omentum
Hesselbach’s Triangle
o What are the borders?
 Inferior Epigastric Vessels
 Linea Semilunaris
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 Inguinal Ligament
o What type of hernia goes through the triangle?
 Direct Hernia
o Are Direct Hernias congenital or acquired?
 Acquired
o Are Indirect Hernias congenital or acquired?
 Congenital
o Are Direct Hernia’s medial or lateral to Epigastric Vessels?
 Medial
o Are Indirect Hernias medial or lateral to Epigastric Vessels?
 Lateral
o Where does an Indirect Hernia protrude?
 Through the deep inguinal canal
Congenital Diaphragmatic Hernia
o What is another name for it?
 Bochdalek Hernia
o Where does it occur?
 The intestines herniate through the left side of the diaphragm
(because liver protects the right side)
o Why is this a medical emergency?
 The hernia impinges on the lungs, and the baby cannot
breathe.
McBurney’s Point
o What is McBurney’s Point used for?
 To locate the approximate location of the appendix so an
incision can be made.
o How do you find this point?
 Find Umbilicus
 Find Anterior Superior Iliac Spine
 Draw a line between them
 Point is 2/3 from umbilicus
Prostate Cancer
o How many lobes are there?
 Anterior
 Middle
 Posterior
o Which lobe has generally benign tumors? What does this cause?
 The Middle Lobe has benign tumors. However, the tumor can
press on the ureter or the seminal vesicle and block the flow.
o Which lobe has metastatic tumors? (Prostate cancer)
 Posterior Lobe
o What is ascities?
 The accumulation of fluid in the peritoneal cavity (between the
visceral and parietal layers), which causes abdominal
distention
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Peptic Ulcers
o Where do Peptic Ulcers occur most often?
 The first part of the Duodenum (closest to the stomach)
Compare and Contrast Hydrocele and Varicocele by answering the following
questions:
o What causes Hydrocele?
 The Processus Vaginalis does not close like it should, and
continues to produce fluid, which fills the scrotal sac.
o What causes Varicocele?
 The Left Renal Vein is compressed between the SMA and the
Aorta.
o When doing the Light Test, how do you determine if the patient has
Hydrocele or Varicocele?
 Hydrocele – the scrotal sac would illuminate red because it is
filled with serous fluid
 Varicocele – the scrotal sac would not illuminate because it is
filled with blood
o Can Hydrocele and Varicocele both occur on both sides of the body?
 Hydrocele – yes
 Varicocele – just on the left
o Which one is painful?
 Varicocele
o Which one makes the scrotal sac look like a “bag of worms”?
 Varicocele
Abscesses
o If abscesses in the pelvic region are found, where does the incision
need to be made and what are you trying to avoid?
 As medial as possible, to avoid the Pudendal (Alcock’s) Canal,
which contains the Pudendal Nerve, Vein, and Artery
o Where is the Pudendal Canal located?
 Between the Sacrotuberous Ligament and the Sacrospinous
Ligament
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ADDITIONAL QUESTIONS FROM REVIEW
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What is the Seat of the Devil?
o Virchow’s Node that is located on the left side of the neck.
What are other names for Virchow’s Nodes?
o Signal Nodes
o Sentinel Nodes
What “sign” is used to determine that Virchow’s Nodes are swollen?
o Troisier’s Sign
What does Troisier’s Sign indicate?
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o Gastric Carcinoma
o Metastatic spread of cancer (from liver)
Where does the Cysterna Chyli drain?
o Thoracic Duct
What is a Cholecystectomy?
o Removal of Gall Bladder
Why would you remove a Gall Bladder?
o Because gallstones can form causing pain.
What part of the Gall Bladder do stones accumulate?
o Hartmann’s Pouch
What is Calot’s Triangle?
o A triangle in the Gall Bladder Area
o Contains:
 Cystic Artery
 Cystic Duct
 Common Hepatic Artery
When a patient has Gallstones, what nerve causes the pain and where is the
pain felt?
o Inferior Phrenic Nerve
o Sensory to Diaphragm  Pain felt in right diaphragmatic area
What are the three ligaments surrounding the spleen?
o Splenophrenic
o Splenocolic
o Gastroplenic
When performing a splenectomy, what vessels do you ligate?
o Splenic Artery
o Splenic Vein
When doing a splenectomy, what vessels can be affected by ligation?
o Short Gastric Artery  Fundus of the Stomach
o Left Gastroepiploic Artery  Greater Curvature of the Stomach
When performing exploratory surgery in the abdomen, where do you make
the incision and why?
o Paramedian Incision
o You prefer to do an incision of the Linea Alba because you have a
lesser chance of hitting nerves, but that does not lead to the best
healing because there are also no blood vessels.
If you have to do Emergency Surgery in the abdomen, where do you make an
incision?
o Linea Alba
What is an incisional hernia?
o A hernia through a previous surgical incision
What is a Spigelian Hernia?
o A hernia between the rectus abdominis muscle and the semilunar line.
o Usually below the arcuate line
What is a Petit Hernia?
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o A hernia in the Lumbar Triangle
o Boundaries:
 Latissimus Dorsi
 External Oblique
 Iliac Crest
What pouch are Bartholin’s Glands located in? M/F?
o F
o In the Superficial Pouch
How do you drain blockages in the Bartholin’s Glands?
o Posterior Fornix of Uterus  Pouch of Douglas (aka Rectouterine)
What two structures can be affected when you have a Sliding Hernia? What
pathology does a Sliding Hernia cause?
o Vagal Nerve
o Esophageal Artery
o GERD
What is Water Under the Bridge in M/F?
o F: Uterine Artery above the Ureter
o M: Vas Deferens above the Ureter
What nerve roots compose the Pudendal Nerve?
o S 2-3-4
What two ligaments is the Pudendal Nerve between?
o Sacrospinous Ligament
o Sacrotuberous Ligament
The Pudendal does both Sensory and Motor. Which structures are Sensory
and which are Motor?
o Sensory: External Genitalia and Anal Region
o Motor: Pelvic Muscles, External Urethral Sphincter, External Anal
Sphincter
What is Hirchspring’s Disease?
o Aganglionic Mesocolon in children
What is Potter Sequence?
o Oligohydramnios
o Lack of amniotic fluid in utero
o Causes clubbed feet, compressed facial features, renal problems