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Anatomy Examen 1 > Abdomen > Flashcards

Abdomen Flashcards

1
Q

Liposuction

A

Remove subcutaneous fat with a percutaneously placed suction tube and high vacuum pressures
Tubes inserted subdermally through small skin incisions

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2
Q

Closing abdominal skin incisions inferior to the umbilicus

A

Include membranous layer of subcutaneous tissue when suture bc of strength

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3
Q

What is between the membranous layer of subcutaneous tissue and the deep fascia covering the rictus abdominis and external oblique muscles

A

Potential space where fluid may accumulate (urine from ruptured urethra)

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4
Q

Where can fluid spread from between the membranous layer of subcutaneous tissue and deep fascia covering rictus abdominis and external oblique

A

Can spread superiorly
Can’t spread inferiorly into thigh bc the deep membranous later of subcutaneous tissues fuse with the deep fascia of the thigh along a line approximately 5.5cm inferior and parallel to the inguinal ligament

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5
Q

Why is the endoabdominal fascia of importance in surgery

A

Provides a plane that can be opened , enabling the surgeon to approach structures on or in the anterior aspect of the posterior abdominal wall , such as kidneys or bodies of lumbar vertebrae without entering the membranous peritoneal space between the transversalis fascia and the parietal peritoneum is used for placement of prostheses when repairing inguinal hernias

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6
Q

Space of bogros and what is it used for

A

Between the transversalis fascia and the parietal peritoneum

Placing prostheses when repairing inguinal hernias

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7
Q

Why is. a prominent abdomen normal in infants and young children

A

Abdomen contains a lot of air and anterolateral abdominal cavities are enlarging an their abdominal muscles gaining strength

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8
Q

What are the six common causes of abdominal protrusion

A

6F
Food, Fluid, Fat, Feces, Flatus, Fetus

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9
Q

What is inversion of the umbilicus a sign of

A

Increased intra abdominal pressure usually ascites or large mass , organometallic

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10
Q

Most obesity fat is what

A

Subcutaneous
But can be extraperitoneal

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11
Q

What happens when anterior abdominal muscles are underdeveloped or atrophy from aging or insufficient exercise

A

Insufficient tonus to resist the increased weight of a protuberant abdomen on the anterior pelvis. The pelvis tilts anteriorly at the hip joints when standing producing excessive lordosis of the lumbar spine

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12
Q

Where do anterolateral abdominal wall hernias occur

A

Places where something (vessels, spermatic cord) pierce the abdominal wall creating a potential weakness

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13
Q

Where do most hernias occur

A

Inguinal, umbilical, epigastric

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14
Q

Umbilical hernia

A

Think neonates (esp low birth weight) bc the anterior abdominal wall is weak in the umbilical reign, which had failed to close normally, causing a protrusion of the umbilicus

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15
Q

Sooo what causes umbilical hernia in baby

A

Increased abdominal pressure in the presence of weakness and incomplete closure of the anterior abdominal wall after ligation of the umbilical cord at birth

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16
Q

Acquired umbilical hernia

A

Most commonly in women and obese people
Extraperitoneal fat and,or peritoneum protrude into the hernial sac
Lines along which the fibers of the abdominal aponeurosis interlace are also potential sites of herniation(can have gaps where these fiber exchanges occur)

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17
Q

What is a common site of gaps where fiber exchange occurs

A

Midline or in the transition from aponeurosis to rectus sheath

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18
Q

What causes these gaps that hernias can happen at

A

Congenital, obesity stress, aging, surgical or traumatic wounds

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19
Q

Epigastric hernia

A

Through linea alba at midline between diploid process and the umbilicus
Usually just lobules of fat

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20
Q

Are epigastric hernias painful

A

YES especially when a nerve is compressed

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21
Q

Spigelian hernias

A

Along semilunar lines

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22
Q

Who gets spigelian hernias

A

People over 40 that are obese

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23
Q

In spigelian hernia what is in the sac

A

The hernial sac is composed of peritoneum and covered with only skin and fatty subcutaneous tissue, but may occur deep to muscle

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24
Q

Why are warm hands important when palpating the abdominal wall

A

Cold hands cause guarding

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25
Q

Is guarding voluntary of involuntary

A

Involuntary

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26
Q

What is guarding a sign of

A

Acute abdomen
-inflamed organ

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27
Q

Why do these spasms occur

A

Common nerve supply of the skin and muscles of the wall explain it
Protect viscera

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28
Q

What position is patient when palpating abdominal wall ..why

A

Supine with legs flexed slightly
To relax anterolateral abdominal wall
Hands at side with pillow under head

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29
Q

If legs are fully extended why is the anterolateral abdominal wal not relaxed

A

Deep fascia if the thighs pulls on the membranous layer of abdominal subcutaneous tissue, tensing the abdominal wall

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30
Q

Some people place their hands being their head when lying supine-is this ok for abdominal wall examination

A

No tightens the muscles and makes the examination difficult

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31
Q

How do you elicit the superficial abdominal reflex

A

Quickly stroking horizontally, lateral to medial, toward the umbilicus
Get contraction of the abdominal muscles

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32
Q

Who may not have a felt superficial abdominal reflex

A

Obese people

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33
Q

What is the superficial abdominal reflex in people with abdominal skin injury

A

Rapid reflex contraction of the abdominal muscles

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34
Q

What nerves approach the abdominal musculature separately to provide the multisegmental innervates of the abdominal muscles

A

Inferior thoracic spinal nerves (t7-t12)
Iliohypogastric and ilioinguinal nerves(L1)

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35
Q

What is the course of the inferior thoracic spinal nerves and iliohypogastric and ilioinguinal nerves on the abdomen

A

Across the anterolateral abdominal wall where they run oblique but mostly horizontal courses

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36
Q

Where and when are the inferior thoracic spinal nerves and iliohypogastric and ilioinguinal nerves susceptible to injury

A

Surgery or trauma at any even of the abdominal wall

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37
Q

What happens if get injury of the anterolateral abdominal wall

A

Weakening of the muscles.

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38
Q

What is a risk of an oblique subcostal incision used for liver ,pancreas surgery

A

Enervation of part of the abdominal wall if the nerves are not carefully identified and spared

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39
Q

What does weakness in the inguinal region cause

A

Predisposition of inguinal hernia

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40
Q

When making abdominal incisions, what is the ideal direction and spot

A

Follow cleavage lines in the skin
Take into account location of nerves and aponeurosis

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41
Q

Would a surgeon rather transact or split a muscle

A

Split in direction of fibers

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42
Q

What muscle can be safely transected

A

Its muscle fibers run short distances between tendinitis intersections and the segmental nerves supplying it enter the lateral part of the rectus sheath where they can be located and preserved

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43
Q

Are muscles and viscera retracted towards or away from their neuromuscular supply

A

Toward

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44
Q

Why may one or two small branches be cut without a noticeable loss of motor supply

A

Overlapping areas of interaction between nerves

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45
Q

What are two longitudinal incisions and when are they performed

A

Median and paramedian
Exploratory operations bc they offer good exposure of and access to the viscera and can be extended as necessary with minimal complication

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46
Q

Median incisions, made on linea alba from diploid to pubic symphysis. What is benefit

A

Can be made rapidly without cutting muscle, major blood vessels or nerves

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47
Q

Bad about median incision

A

Some people may have abundant and well vascularized fat
Poor blood supply so may undergo necrosis and subsequent degeneration after incision if edges not aligned properly during closure

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48
Q

Paramedian incision

A

Sagittarius plane and may extend front he costal margin to the pubic hairline
After incision passses through the anterior layer of the rectus sheath, the muscle is retracted laterallly without sectioning to prevent tension and injury to the vessels and nerves ….the posterior layer of the rectus sheath and the peritoneum are then incised to enter the peritoneal cavity

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49
Q

Gridiron(muscle splitting) incisions are used for what

A

Appendectomy

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50
Q

Describe the gridiron mcburney incision

A

At mcburney point 2.5 cm superomedial to the ASIS not he spinoumbilical line
The external oblique aponeurosis is incised inferomedially in the direction of its fibers and retracted
The musculocutaneous-aponeurotic fibers of the internal oblique and trans versus abdominis are then split int he line of their fibers and retracted

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51
Q

During appendectomy the __ nerve is identified and preserved

A

Iliohypogastric

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52
Q

During appendectomy, there should be no cut of musculo-aponeurosis fibers. Why is this important

A

When incision is closed the muscle fibers move together and the abdominal wall is as strong after the operation as before

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53
Q

Suprapubic incision are made where

A

Pubic hair Line

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54
Q

Why do a suprapubic incision

A

Gyno
And obstetrical operations (c section)

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55
Q

How do a suprapubic incision

A

Linea alba and anterior layers of the rectus heaths are transected and respected superiorly and the rectus muscles are retracted laterally or divided through their tendinitis parts allowing reattachment without muscle fiber injury

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56
Q

What nerves need to be identified and preserved in suprapubic incision

A

Iliohypogastric and ilioinguinal

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57
Q

___ incisions through the anterior layer of the rectus sheath and rectus abdominis provide good access and cause the least possible damage to the nerve supply of the rectus abdominis

A

Transverse incision

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58
Q

Why may the recut abdominis be cut transversely without damage

A

New transverse band forms when the msucle segments are rejoined.

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59
Q

Transverse segments are not made through the tendinous intersections why

A

Cutaneous nerves and branches of their superior epigastric vessels pierce these fibrous regions of the msucle

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60
Q

What do we use subcostal incisions for

A

Gallbladder and biliary duct on the right and spleen on the left

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61
Q

Describe subcostal incision

A

Paralelll but 2.5 cm inferior to the costal margin to avoid the 7th and 8th thoracic spinal nerves

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62
Q

What are high risk incisions

A

Pararectus and inguinal incisions

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63
Q

What is a pararectal incision

A

Along the lateral border of the rectus sheath

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64
Q

Why is a pararectal incision risky

A

Maycut nerve supply to rectus abdominis

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65
Q

What are inguinal incisions for and why are they risky

A

Repairing hernias
May injure the ilioinguinal nerve

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66
Q

Incisional hernia

A

Protrusion of omentum( a fold of peritoneum) or an organ through a surgical incision

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67
Q

What causes incisional hernia

A

Muscular and aponeurotic layers of the abdomen do not heal properly

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68
Q

Laparascope

A

For minimally invasive surgery
Tiny perforations of the abdominal wall allow the entry of the instruments operated externally, replacing the larger conventional incisions

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69
Q

What does minimally invasive surgery minimize

A

Hernia, nerve injury, contamination, time to heal

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70
Q

If the superior or inferior vena cava is obstructed what happens

A

Anastomoses between the tributaries of these systemic veins such as the thoraco-epigastric vein, may provide collateral pathways by which the obstruction may be bypassed allowing blood to return to the heart

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71
Q

When inferior or superior vena cava obstructed, what two veins can you see cutaneously from increased flow

A

Superficial epigastric vein
Thoraco epigastric vein

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72
Q

Cryptorchid

A

Undescended testis

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73
Q

Cryptorchid is in _ % of full term infants and _% of preterm

A

3
30

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74
Q

95% of undescended testes are ___

A

Unilateral

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75
Q

Where is the undescended teste

A

Along the normal path of its prenatal descent, commonly in the inguinal canal

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76
Q

People with cryptorchid said are at increased risk of what

A

Malignancy in undescended testis bc it is not palpable and not detected until cancer has progressed
And
Infertility-needs cooler environment

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77
Q

How correct cryptorchid

A

Surgery corrected in childhood

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78
Q

What does the umbilical vein become after birth

A

Round ligament of the liver

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79
Q

The umbilical vein is patent for some time after birth. What is this used for

A

Umbilical vein catheteriation for exchange transfusion during early infancy

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80
Q

Why may we do exchange transfusion through umbilical vein in infant

A

Erythroblastosis fetealis or hemolytic anemia disease of the neonate

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81
Q

In metastese of the uterus, the veins and lymph vessels mostly drain via ____ routes

A

Deep

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82
Q

However some lymphatic vessels from uterus follow the course of what

A

Round ligament through the inguinal canal

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83
Q

So where do uterine cancers metastecize

A

Deep more often
Or TO THE LABIUM MAJUS and from there to the superficial inguinal nodes which receive lymph from the skin of the perineum (and labia)

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84
Q

Where are the majority of abdominal hernias

A

Inguinal hernias 75%

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85
Q

Are inguinal hernias more common in males or females

A

Males bc of the passage of the spermatic cord through the inguinal canal

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86
Q

What is an inguinal hernia

A

Protrusion of parietal peritoneum and viscera, such as the small intestine through a normal or abnormal opening from the cavity in which they belong

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87
Q

Two types of inguinal hernia

A

Direct and indirect

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88
Q

Are most hernias direct or indirect

A

Indirect

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89
Q

Indirect (congenital ) hernia predisposing factors

A

Patency of processus vaginalis (complete of at least superior part) in younger persons, the great majority which are males

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90
Q

Indirect (congenital) frequency

A

2/3 of inguinal hernias

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91
Q

Indirect (congenital) exit from abdominal cavity

A

Peritoneum of persistent processus vaginalis plus all three fascial coverings of cord/round ligament

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92
Q

Indirect (congenital) course

A

Traverse inguinal canal (entire canal if it is of sufficient size)

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93
Q

Indirect (congenital) exit from anterior abdominal wall

A

Via superficial ring inside cord, commonly passing into scrotum/labium majus

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94
Q

Direct (acquired) hernia predisposing factors

A

Weakness of anterior abdominal walll in inguinal triangle (eg owing to distended superficial ring, narrow inguinal falx, or attenuation of aponeurosis in males>40 )

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95
Q

Direct (acquired) hernia frequency

A

1/3

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96
Q

Direct (acquired) exit from abdominal cavity

A

Peritoneum plus transversalis fascia (lies outside inner one or two fascial coverings of cord)

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97
Q

Direct (acquired) hernia course

A

Passes through or around the inguinal canal, usually transversing only medial third of canal , external and parallel to vestige of processus vaginalis

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98
Q

Direct (acquired) exit from anterior abdominal wall

A

Via superficial ring, lateral cord ; rarely enter scrotum

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99
Q

Normally, most of the processus vaginalis obliterates before birth, except what part

A

Distal part that forms the tunica vaginalis of the testis

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100
Q

The peritoneal part of the hernial sac of an indirect hernia is formed by the persisting ___ ___

A

Processus vaginalis

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101
Q

What happens if entire stalk of the processus vaginalis persists

A

Hernia extends into the scrotum superior to the testis forming a complete indirect inguinal hernia

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102
Q

Where is the superficial inguinal ring palpable

A

Superolateral to the pubic tubercle by invaginating the skin of the upper scrotum with the index finger . The examiners finger follows the spermatic cord superolateral to the superficial inguinal ring.

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103
Q

Is the finger able to go into the superficial inguinal ring

A

If it is dilated

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104
Q

While palpating the superficial inguinal ring, how can you tell if a hernia is present

A

Ask patient to cough and a hernia is present if feel a sudden impulse felt against either the tip or pad of the examining finger when the patient is asked to cough

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105
Q

Does feeling an impulse at the superficial inguinal ring mean a direct or indirect hernia

A

Both types go through superficial inguinal ring…cant discriminate

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106
Q

How can you feel the deep inguinal ring

A

With palmar surface of the finger against the anterior abdominal wall, the deep inguinal ring may be felt as a skin depression superior to the inguinal ligament 2-4 cm superolateral to the pubic tubercle.

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107
Q

What indicates an indirect hernia

A

Detection of impulse at superficial ring and a mass at the site of the deep ring

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108
Q

Cremasteric reflex

A

Contraction of the cremaster muscle is elicited by lightly stroking the skin on the medial aspect of the superior part of the thigh with an applicator stick or tongue depressor

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109
Q

What nerve supplies the skin of the superior part of the thigh

A

Ilioinguinal nerve

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110
Q

The cremasteric reflex is extremely active in ___

A

Kids

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111
Q

Hyperactive cremasteric reflexes mat stimulate ___ ___

A

Undescended testes

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112
Q

How can you abolish hyperactive reflex in kid

A

Sit cross legged , squatting position

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113
Q

Why would you want to abolish a hyperactive cremasteric reflex in kid

A

If the testes are descended can then palpate them int he scrotum

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114
Q

Indirect inguinal hernias are 20x more common in __

A

Men

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115
Q

What happens if processus vaginalis is patent in females

A

May form a small peritoneal pouch (canal of nuck) in the inguinal canal that may extend to the labium majus

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116
Q

Clinical picture of patent processus vaginalis in females

A

Can enlarge and form cysts in the inguinal canal
Cyst may produce a bulge in the anterior part of the labium majus and have the potential to develop into an indirect inguinal hernia

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117
Q

Hydrocele

A

Presence of excess fluid in a persistent processus vaginalis

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118
Q

What is a hydrocele associated with

A

Indirect hernia

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119
Q

What is the fluid from in a hydrocele

A

Secretion of an abnormal amount of serous fluid from the visceral layer of the tunica vaginalis

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120
Q

The hydrocele of the testis is confined to the ___ and distended the tunica vaginalis

A

Scrotum

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121
Q

The hydrocele of the spermatic cord is confined to the ___ ___ and distended the persistent part of the stalk of the processus vaginalis

A

Spermatic cord

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122
Q

A congenital hydrocele of the cord and testis may communicate with the ___ ___

A

Peritoneal cavity

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123
Q

How do you detect hydrocele

A

Transillumination ….bright light applied to scrotum in darkened room

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124
Q

If have hydrocele what color does scrotum glow …indicating excess serous fluid

A

Red

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125
Q

Newborn male infants often have residual peritoneal fluid in their tunica vaginalis. However it is absorbed in the _ year

A

1st

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126
Q

What may cause hydrocele in adults

A

Certain pathological conditions, such as injury and/or inflammation of the epididymis

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127
Q

Hematocele of testis

A

Collection of blood in the tunica vaginalis

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128
Q

What causes hematocele of the testis

A

Trauma may produce a scrotal and/or testicular hematoma (accumulation of blood)

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129
Q

Transillumination of hematocele

A

Does not transilluminate

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130
Q

A hematocele of the testis may be associated with a scrotal hematocele resulting from effusion of blood into he scrotal tissues

A

Yup

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131
Q

Torsion of the spermatic cord

A

Surgical emergency bc of necrosis

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132
Q

Why get necrosis with torsion of spermatic cord

A

Blocks the venous drainage with resultant edema and hemorrhage and subsequent arterial obstruction

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133
Q

Where is the twisting in torsion spermatic cord

A

Just above the upper pole of the testis

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134
Q

Clinical prevention of torsion of spermatic cord

A

Testis seem to lie transversely
See with ultrasound to confirm

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135
Q

How prevent recurrence of spermatic cord torsion

A

Both testes are surgically fixed to the scrotal septum

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136
Q

The anterolateral surface of the scrotum is supplied by the __ __ and the posteroinferior aspect is supplied by the __ ___

A

Lumbar plexus (mainly L1 fibers via ilioinguinal nerve)
Sacral plexus (primarily s3 fibers via pudendal nerve)

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137
Q

A spinal anesthetic agent must be injected more ___ to anesthetize the anterolateral surface of the scrotum than is necessary to anesthetize its postero-inferior surface

A

Superiorly

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138
Q

Spermatocele

A

Retention cyst in the epididymis usually near its head

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139
Q

What is in a spermatocele

A

Milky fluid and generally asymptomatic

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140
Q

What is an epididymal cyst

A

Collection of fluid anywhere in the epididymis

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141
Q

When the tunica vaginalis is open what is seen

A

Rudimentary structures may be observed at the superior aspects of the testes and epididymis —-small remnants of genital ducts in the embryo-rarely observed unless pathological changes occur

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142
Q

Appendix of the testis

A

Vesicular remnant of the cranial end of the paramesonephric duct (mullerian) the embryonic genital duct that in the female forms half of the uterus . It is attached to the upper pole of the testis

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143
Q

Appendix of the epididymis

A

Remnants of the cranial end of the mesonephric duct (wolffian), the embryonic genital duct that in the male forms part of the ductus deferens. The appendices are attached to the head of the epididymis

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144
Q

Varicocele

A

Vine like pampiniform plexus of veins may become dilated (varicose) and tortuous, producing varicocele

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145
Q

When is varicocele visible when is it not visible

A

When man is standing or straining when lying down alllowing gravity to empty veins

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146
Q

What does palpating a varicocele feel like

A

Bag of worms

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147
Q

What amuses varicocele

A

Defective valves in the testicular vein, but kidney or renal vein problems can also result in distension of the pampiniform veins

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148
Q

Which side does varicocele happen on. Why

A

Left
Acute angle at which the right vein enters the IVC is more favorable to flow than the nearly 90 degree angle at which the left testicular vein enters the left renal vein, making it more susceptible to obstruction or reversal of flow

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149
Q

___ metastasis is common to all testicular tumors

A

Lymphogenous

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150
Q

Bc the testes relocate from the posterior abdominal wall to the scrotum during fetal development, their lymphatic drainage differed from that of the scrotum which is an outpouching of anterolateral abdominal skin.

A

Ya

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151
Q

How does cancer of the testes spread

A

Metastasizes initially to the retroperitoneal lumbar lymph nodes, which lie just inferior to the renal veins . Subsequent spread may be to mediastinal and supraclavicular nodes

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152
Q

How does cancer of the scrotum spread

A

Metasticize to the superficial inguinal lymph nodes, which lie in the subcutaneous tissue inferior to the inguinal ligament and along the terminal part of the great saphenups vein

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153
Q

How do surgeons approach testicular tumors

A

Through an inguinal incision so that vessels and lymphatics can be controlled early.

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154
Q

Why is a classic pitfall of approaching a testicular tumor going through a scrotal incision , why would u do this

A

Think its a hydrocele (use ultrasound to check )

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155
Q

Metastasis of testicular cancer hematogenous spread

A

To lungs liver brain and bone

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156
Q

How does the body limit spread of organisms from uterine tubes to peritoneal cavity

A

Mucus plug-blocks external os of uterus to most things, except sperm

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157
Q

How do we test latency of uterine tubes —hysterosalpingography

A

Air or radioopaque dye is injected into the uterine cavity from which it normally flows through the uterine tubes into the peritoneal cavity

Tests whether Fallopian tubes are blocked (important for fertility)

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158
Q

Why do patients undergoing abdominal surgery experience more pain with large invasive open incisions of the peritoneal mood than with small laparoscopic incisions

A

Peritoneum is well innervated

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159
Q

Reperitonealization

A

The visceral peritoneal (serosal)covering makes it easy to achieve a water tight anastomoses of intraperitoneal organs

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160
Q

Can surgeons easily achieve a water tight anastomoses or extraperitoneal organs

A

No harder if have adventitia, like the thoracic esophagus

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161
Q

Complications of opening the peritoneal cavity , how can we prevent

A

Peritonitis
Adhesions

Even in surgeries where open peritoneal cavity-try to remain outside..lets limit contamination of the cavity

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162
Q

How get peritonitis

A

Bacterial contamination during laparotomy or when gut traumatically Penetrated or ruptured as a result of infection or inflammation, allowing gas fecal matter and bacteria to enter peritoneal cavity

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163
Q

What does peritonitis cause

A

Exudation of serum, fibrin, cells and pus into the peritoneal cavity accompanied by pain in overlying skin and increase in tone of the anterolateral abdominal muscles

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164
Q

Why is generalized(widespread) peritonitis dangerous

A

Extent of peritoneal surface and rapid absorption

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165
Q

Signs of generalized peritonitis

A

Severe abdominal pain, vomiting, fever, constipation

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166
Q

How can an ulcer ofthe stomach or duodenum cause general peritonitis

A

Perforate the wall of stomach of duodenum , spilling acidic contents into peritoneal cavity

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167
Q

Ascetic fluid

A

Extra fluid in peritoneal cavity

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168
Q

What causes ascites

A

Mechanical injury , portal hypertension, widespread metastasis, starvation (plasma protein fall)

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169
Q

What is the normal rhythmic movement of the anterolateral abdominal wall normally accompanying respiration’s

A

Abdomen drawn in and chest deflates
Abdomen drawn out and chest expands

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170
Q

What rhythmic movement of the anterlateral abdominal wall is present if there is peritonitis or pneumonitis

A

Paradoxical
Abdomen drawn in and chest expands

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171
Q

How do patients lay when they have peritonitis and why

A

With knees plexus to relax their anterolateral abdominal muscles
Bc of pain

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172
Q

How do patients breathe when they have peritonitis

A

Slowly and more rapidly to minimize intrabadominal pressure and pain

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173
Q

The suction effect of the diaphragm during respiration draws fluid into what space. Why is this a problem with peritonitis

A

Subphrenic space
Subphrenic recess is a frequent complication of peritonitis

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174
Q

If the peritoneum is damaged, the peritoneal surface becomes inflamed, making them sticky with ___

A

Fibrin

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175
Q

When the peritoneum heals from a wound, the fibrin may be replaced by what. Why is this a problem

A

Fibrous tissue, forming abnormal attachments between the visceral peritoneum of adjacent viscera or between the visceral peritoneum of an organ and the parietal peritoneum of the adjacent abdominal wall

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176
Q

Adhesion

A

Scar tissue form after an abdominal operation and limit normal movement of the viscera

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177
Q

Clinical issue of adhesions

A

Limit movement of viscera
Chronic pain
Intestinal obstruction when the intestinal becomes twisted around an adhesion

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178
Q

Volvulus

A

Intestinal obstruction when the intestine becomes twisted around an adhesion

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179
Q

Adhesiolysis

A

Surgical separation of adhesions

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180
Q

Most cases of peritonitis are secondary, what does this mean

A

Have a surgical cause

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181
Q

Ascites can result from __ of the liver or in association with malignancy

A

Cirrhosis

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182
Q

How may one get primary peritonitis

A

People with chronic ascites, such as in cirrhosis, in which the ascites become infected without surgical cause

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183
Q

How treat generalized peritonitis

A

Removal of the ascitic fluid and diagnosis(culture)—-ANTIBIOTICS

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184
Q

Paraccentesis

A

Surgical puncture of the peritoneal cavity for the aspiration or drainage of the fluid

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185
Q

In paracentesis, where is the needle and cannula inserted

A

Anterolateral abdominal wall through linea alba superior to the empty urinary bladder in a location that avoids the inferior epigastric artery

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186
Q

Why is fluid that is injected into the peritoneal cavity absorbed rapidly

A

The peritoneum is a semipermeable membrane with an extensive surface area, much of which overlies blood and lymphatic capillary beds

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187
Q

In __ failure, waste products such as urea accumulate in the blood and tissues and may reach fatal levels

A

Renal

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188
Q

Peritoneal dialysis

A

Soluble substances and excess water are removed from the system by transfer across the peritoneum, using a dilute sterile solution that is introduced into the peritoneal cavity on one side then drained from the other side . Diffusable solutes and water are transferred between the blood and peritoneal cavity as a result of concentration gradients between the two fluid compartments.

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189
Q

Lon term peritoneal dialysis?

A

Prefer to go through blood using renal dialysis machine

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190
Q

What is the greater omentum. What does it do

A

Large and fat laden double layer of peritoneum that attaches stomach to another viscous. It hangs from the greater curvature of the stomach.
It prevents the visceral peritoneum from adhering to the parietal peritoneum.

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191
Q

Why is the greater omentumcalled the “policeman if the abdomen”

A

Goes to the site of trouble. Forms adhesions adjacent to inflamed organ such as appendix , sometimes walling it off and protecting other viscera from it

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192
Q

When doing surgery is it common to find the omentum displaced

A

Yup

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193
Q

What else does the greater omentum do

A

Cushions abdominal organs and forms insulation against loss of body heat

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194
Q

Lesser omentum

A

Attaches the lesser curvature of the stomach to the liver superiorly

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195
Q

Perforation of the duodenal ulcer, rupture of the gallbladder, or perforation of the appendix may lead to the formation of an ____ in the __ ___

A

Abscess in the subphrenic recess

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196
Q

An abscess in the subphrenic recess may be walled inferiorly by adhesions of the __ __

A

Greater omentum

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197
Q

What determines the extent and direction of spread of fluids that may enter the peritoneal cavity

A

Peritoneal recesses

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198
Q

What are paracolic gutters

A

Spaces between colon and abdominal wall

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199
Q

Why are paracolic gutters of clinical importance

A

Provide pathways for the flow of ascitic fluid and the spread of intraperitoneal infections

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200
Q

Purluent material in the abdomen can be transported along the paracolic gutters into the _____, especially when the person is ___

A

Pelvis
Upright

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201
Q

Why would someone with peritonitis be placed in the sitting position

A

To facilitate flow of exudate into the pelvic cavity where absorption of toxins is easy to drain

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202
Q

Infections of the pelvis may extend superiorly to the ___ ___ situated under the diaphragm especially when they are ___

A

Subphrenic recess
Supine

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203
Q

Paracolic gutters and spread of cancer?

A

YES
Pathway for spread of cancer cells that have sloughed from the ulcerated surface of a tumor and entered the peritoneal cavity

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204
Q

Perforation of the posterior wall of the stomach results in passage of its fluid into the __ __

A

Omental bursa

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205
Q

What is the omental bursa

A

The lesser sac
Cavity in abdomen formed by the lesser and greater omentum

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206
Q

What connects the lesser sac to the greater sac

A

Omental foremen (foramen of Winslow)

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207
Q

An inflamed or injured pancreas can also result in the passage of the pancreatic fluid into the bursa forming a ___ ___

A

Pancreatic pseudocyst

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208
Q

Can any boundaries of the omental foramen be incised

A

No all contain vessels

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209
Q

Sometimes a loop of small intestine may pass through the omental foramen….how fix this if cant cut any of the walls

A

Swollen intestine must be decompressed using a needle so it can be returned to the greater sac of the peritoneal cavity through the omental foramen

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210
Q

What is the greater sac

A

Inside the peritoneum but outside the lesser sac (the general cavity)

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211
Q

The __ artery must be lighted or clamped during cholecystectomy

A

Cystic

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212
Q

What is a cholecystectomy

A

Removal of gallbladder

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213
Q

What do if accidentally sever the cystic artery

A

Control bleeding by compressing hepatic artery as it transverse the hepatoduodenal ligament
Place index finger in omental foramen and thumb on anterior wall
Alternating compression and relaxation allows surgeon to identify bleeding artery and clamp it.

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214
Q

Pringle manuever

A

Alternate compression and release of pressure on the hepatic artery allows the surgeon to identify the bleeding artery and clamp it….. sometimes to provide temporary control during cases of severe trauma to the liver or associated structures

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215
Q

Because the submucosal veins of the inferior esophagus drain to both the __ and ___ venous systems, they constitute what

A

Portal
Systemis
Portosystemic anastomsis

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216
Q

Describe portal hypertension

A

Increased blood pressure in the portal venous system

Blood is unable to pass through the liver vie the hepatic portal vein, causing a reversal of flow in the esophageal tributary

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217
Q

What does the large volume of blood causes the submucosal veins to enlarge markedly. What is this

A

Esophageal varices

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218
Q

Concern with esophageal varices

A

Distended collateral channels may rupture and cause severe hemorrhage that is life threatening and difficult to control surgically

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219
Q

What population commonly gets esophageal varices

A

Alcoholic cirrhosis

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220
Q

Pyrosis

A

Heart burn

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221
Q

Pyrosis in abdominal part of esophagus is result of what

A

GERD

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222
Q

Pyrosis may also be associated with __ hernia

A

Hiatal

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223
Q

Pyrosisis is commonly perceived as what

A

Chest sensation

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224
Q

Why do bariatric surgery

A

Morbidly obese people to achieve weight loss

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225
Q

Restrictive bariatric surgery

A

Reducing stomach volume

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226
Q

Malabsorptive bariatric procedures

A

Reducing nutrient absorptive area
Rerouting of the connection of the stomach with the small intestine and,or variable portions of the small intestine

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227
Q

Mixed bariatric procedure

A

Combination
Gastric bypass

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228
Q

Banding

A

Fixed or adjustable bands externally to the stomach

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229
Q

Fundoplication

A

Resectioning of the stomach creating a small pouch or tubular sleeve or folding of the stomach on itself

230
Q

Bariatric surgery benefits

A

Weight loss
Reduce diabetes and sleep apnea

231
Q

Do you have to eat healthy after bariatric surgery

A

YES important factor for success

232
Q

Complications of bariatric surgery

A

Common

233
Q

Why may the stomach be displaced anteriorly

A

Pancreatic pseudocysts and abscesses in the omental bursa may push the stomach anteriorly

234
Q

Following pancreatitis, the posterior wall of the stomach may adhere to the part of the posterior wall of the __ ___ that covers the pancreas

A

Omental bursa

235
Q

Hiatal hernia

A

Protrusion of part of the stomach into the mediastinum through the esophageal hiatus of the diaphragm

236
Q

Who gets haital hernias and why

A

After middle age bc of weakening of muscular part of the diaphragm and widening of the esophageal hiatus

237
Q

Two main types of hiatal hernia

A

Paraesophageal and sliding

238
Q

Which hiatal hernia is more common

A

Sliding

239
Q

Paraesophageal hernia

A

Cardia remains in its normal position
However, a pouch of peritoneum, often containing part of the fungus of the stomach( phreno-esophageal ligament), extends through the esophageal hiatus anterior to the esophagus.

240
Q

Is there regurgitation of gastric contental in para esophageal hernia

A

No bc cardinal orifice is in its normal position

241
Q

Sliding hiatal hernia

A

Abdominal part of the esophagus, the cardia, and parts of the fungus of the stomach slide superiorly through the esophageal hiatus into the thorax, especially when the person lies down or bends over

242
Q

Is there regurgitation of stomach contents into the esophagus with a sliding hiatal hernia

A

Ya
Bc clamping action of the right crus of the diaphragm on the inferior end of the esophagus is weak

243
Q

Pylorospasm

A

Spasmodic contraction of the pyloric occurring in infants 2-12 weeks

244
Q

Characterization of pylorospasm

A

Failure of the smooth muscle fibers encircling the pyloric canal to relax normally so food can not pass easily from stomach into duodenum and stomach becomes overly full—-discomfort and vomiting

245
Q

Congenital hypertrophic pyloric stenosis

A

Thickening of the smooth muscle in the pylorus that affects 1/150 male infants and 1/750 female infants

246
Q

Normally the gastric peristalsis pushes chyme through the pyloric canal and orifice into the small intestine at irregular intervals. What about in neonates with pyloric stenosis

A

Elongated overgrown pyloric canal is narrow resisting gastric emptying . Proximally the stomach may become secondarily dilated

247
Q

Genetic congenital hypertrophic pyloric stenosis

A

Yea bc common in monozygotic twins

248
Q

Pyloromyotomy

A

Pyloric stenosis surgery in which cut through hypertrophied circular muscle layer of the pylorus allowing free passage

249
Q

Can you palpate a stomach tumor

A

Yea sometimes

250
Q

Gastroscope

A

Can look at mucosa and take biopsies

251
Q

Surgical issue with stomach cancer

A

Extensive lymphatic drainage of the stomach and the impossibility of removing all the lymph nodes

252
Q

How excise nodes along splenic vessels

A

Remove spleen , gastrosplenic, and splenorenal ligaments and body and tail of pancreas

253
Q

How remove gastro-omental nodes

A

Respecting the greater omentum however hard to remove aortic and celiac nodes and those around head of pancreas

254
Q

Most gastric cancers are detected too late for surgical control

A

:(

255
Q

Total gastrectomy

A

Total removal of stomach

256
Q

Partial gastrectomy

A

Remove region involved in carcinoma

257
Q

Why is it ok to legate one or more arteries during partial gastrectomy

A

Because the anastomoses of the arteries supplying the stomach provide good collateral circulation, without seriously affecting the blood supply

258
Q

Removing pyloric antrum

A

Cut greater omentum parallel and inferior to the right gastro-omental artery requiring ligation of the omental branches of the artery
But omentum doesn’t degenerates bc of anastomoses such as the omental branches of left gastro-omental arteries

259
Q

If dealing with cancer important to remove lymph nodes. What lymph nodes drain pyloric region need to be removed

A

Pyloric lymph nodes and gastro-omental nodes

260
Q

As stomach cancer becomes more advanced, the malignant cells spread to the ___ nodes, to which all gastric nodes drain

A

Celiac

261
Q

Most ulcers of the stomach and duodenum are associated with ______

A

H pylori

262
Q

People with extreme emotions chronic ___ are at risk for peptic ulcer

A

Anxiety

263
Q

Why are anxious people prone to peptic ulcers

A

High gastric acid secretion rates that are markedly higher than normal between meals
Overwhelms bicarbonate
And reduces effectiveness of mucous lining , leaving it vulnerable to h pylori

264
Q

What does h pylori do

A

Bacteria erode the protective mucous lining of the stomach , inflaming the mucosa and making it vulnerable to the effects of the gastric acid and digestive enzymes (pepsin) produced by the stomach

265
Q

What happens if the ulcer erodes into the gastric arteries

A

Can cause life threatening bleeding

266
Q

How can we reduce production of acid

A

Vagotomy

267
Q

Vagotomy

A

Surgical section of vagus nerves-bc the vagus nerves control secretion of acid by parietal cells of the stomach

268
Q

Treatment for h pylori

A

Vagotomy maybe with resection of an ulcerated area to reduce acid secretion

269
Q

Truncal vagotomy

A

Surgical section of vagaries trunk
Rarely done bc innervates other abdominal structures

270
Q

Selective proximal vagotomy

A

Denervate even more specifically the area in which the parietal cells are located, hoping to affect the acid producing cells while sparing other gastric function (motility) stimulated by the vagus nerve

271
Q

Posterior gastric ulcer may erode through the stomach wall into the ____, resulting in referred pain to the ___

A

Pancreas
Back

272
Q

What artery is of concern with posterior gastric ulcer erosion and why

A

Splenic artery may cause severe hemorrhage into peritoneal cavity

273
Q

Pain impulses from the stomach are carried by visceral afferent fibers that accompany ____ nerves . How know this

A

Sympathetic

Pain in recurrent peptic ulcer sometimes persisted after complete vagotomy, whereas patients who had bilateral sympathectomy could have perforated peptic ulcer with no pain

274
Q

Organic pain

A

From organ
Varies from dull to severe
Poorly localized
Radiates to the dermatologist level which receives visceral afferent fibers from the organ concerned

275
Q

Visceral referred pain from gastric ulcer

A

Referred to the epigastric region bc the stomach is supplied by pain afferent that reach the T7 and T8 spinal sensory ganglia and spinal cord segments through the greater splanchnic nerve

276
Q

Pain from the parietal peritoneum is ____ and usually severe and the site of origin can be ___

A

Somatic
Site of origin can be localized

277
Q

Why can parietal peritoneum pain be localized

A

Parietal peritoneum is supplied by somatic sensory fibers through thoracic nerves, whereas a viscous such as the appendix is supplied by visceral afferent fibers in theesser splanchnic nerve

278
Q

Rebound tenderness

A

Finger into the anterolateral abdominal wall over inflammation the parietal peritoneum is stretched when remove finger feel extreme localized pain

279
Q

Duodenal ulcer (peptic)

A

Inflammatory erosions of the duodenal mucosa

280
Q

Most duodenal ulcers occur where

A

Posterior wall of the superior part of the duodenum within 3 cm of the pylorus

281
Q

If duodenal ulcer (especially anterior) perforated the duodenal wall we get

A

Peritonitis

282
Q

Since the liver, gallbladder, and pancreas are close to the duodenum, what happens if the duodenum is inflamed

A

Structures may become adherent
Ulcerated as the lesion continues to erode the tissue that surrounds it

283
Q

Why may get severe hemorrhage from duodenal ulcer

A

Intraluminal bleeding
Or erosion of the gastroduodenal artery (posterior relation) by a perforating ulcer results in severe hemorrhage into the peritoneal cavity (hemoperitoneum)

284
Q

During the early fetal period, the entire duodenum has a ____: however, most of it fuses with the posterior abdominal walll because of pressure from the overlying transverse colon

A

Mesentery

285
Q

The attachment of the mesoduodenum is ___ why

A

Secondary
It occurred through formation of a fusion fascia

286
Q

Secondary attachment allows the duodenum and pancreas to be __ during surgery

A

Separated from the retroperitoneal viscera without endangering the blood supply to the kidney or the ureter

287
Q

Paraduodenal fold and fossa

A

Large and lie to the left of the ascending part of the duodenum. If a loop of intestine enters this fossa it may strangulate

288
Q

Paraduodenal hernia repair what vein and artery must be avoided

A

Care taken to not injure the branches of the inferior mesenteric artery and vein or the ascending branches of the left colic artery

289
Q

Primordial foregut comprises the __, ___ and ___

A

Foregut, midgut and hindgut

290
Q

Pain arising from foregut derivatives, esophagus, stomach, pancreas, duodenum, liver, and biliary ducts, cause pain where

A

Epigastric region

291
Q

Pain arising from midgut derivatives, small intestine distal to the bile duct, cecum, appendix, ascending colon, and most of transverse colon, localized where

A

Periumbilical region

292
Q

Pain arising from hind gut derivatives, distal part of transverse colon, descending colon, sigmoid colon, and rectum, localized where

A

Hypogastric region

293
Q

For 4 weeks, the rapidly growing midgut, supplied by the SMA, is physiologically herniated through the proximal part of the __ ___

A

Umbilical cord

294
Q

It is attached to the umbilical vehicle by the __ __ _

A

Omphalo-enteric duct (yolk stalk)

295
Q

As the relative size of liver and kidney decrease, the midgut returns to the abdominal cavity bc space is available

A

Woo

296
Q

As the parts of the intestine reach their definitive positions their mesenteric attachments undergo modification. Some shorten, others disappear. As what organs become secondarily retroperitoneal

A

Duodenum, pancreas, ascending and descending colons

297
Q

What are consequences of normal rotation of the midgut

A

-duodenum passes posterior to the SMA
-transverse colon and mesocolon are transversely oriented, pass anterior to the SMA and divide the peritoneal cavity into Supra and infracoloc compartments
-the ascending and descending colons lie on right and left sides and are RETROPERITONEAL
-most of the ileum occupies the left superolateral part of the infracolic compartment
-momost of the ileum, cecum, and appendix occupy the right inferolateral part of the infraacolic compartment

298
Q

Malrotation of the midgut(intestine)

A

Several congenital anomalies such as volvulus of intestine

299
Q

When doing surgery how feel which direction of intestine u are following (road or caudad)

A

Follow mesentary with finger to roots

300
Q

Occlusion of vasa recta by emboli or atherosclerotic occlusion results in ___

A

Ischemia

301
Q

If ischemia is severe

A

Necrosis of involved segment and ileus (bstruction of intestine) of the paralytic type

302
Q

Ileus symptoms

A

Severe colicky pain with abdominal dissension, vomiting, and often fever and dehydration.

303
Q

Emboli from the heart sent inferiorly via the descending aorta tend to lodge in the ___ or its branches . Why

A

SMA
Arises at a less acute angle than aorta

304
Q

Ideal diverticula (meckel diverticulum)

A

Congenital anomaly that occurs in 1-2% of the population

305
Q

What is the ideal diverticulum

A

Remnant of the proximal part of the embryonic omphalo-enteric duct (yolk stalk)

306
Q

How does ideal diverticulum appear

A

Finger like pouch ALWAYS at the site of attachment of the omphalo-enteric duct on the antimesenteric border of the ileum

307
Q

The diverticulum is usually 30-60cm from the ileocecal junction in ___ and 50 cm in ___

A

Infants adults

308
Q

Is the ideal diverticulum more commonly free or attached to the umbilicus

A

Free

309
Q

The mucosa of the ideal diverticulum is mostly ideal, but what else may be included

A

Acid producing gastric tissue, pancreatic tissue, or jejunal or colonic mucosa

310
Q

What happens if ideal diverticulum becomes inflamed

A

Pain that mimics appendicitis

311
Q

Retrocecal appendix

A

Extends superiorly toward the right colic flexor and is usually freely mobile

312
Q

What happens if appendix if beneath the peritoneal covering of the Cecum. What is the problem

A

Fuse
If inflamed more difficult to remove

313
Q

The appendix may also project inferiorly

A

Ok

314
Q

Why do we care about anatomical position of appendix

A

Surgery
Also determines symptoms and side of muscular spasm and tenderness when the appendix is inflamed

315
Q

Where is mcburney point

A

One third from ASIS to umbilicus ………careful if have a subhepatic cecum

316
Q

Appendicitis

A

Acute inflammation of the appendix …common cause of acute abdomen

317
Q

What usually causes appendicitis in young people

A

Hyperplasia of lymphatic follicles in the appendix that concludes the lumen obstruct the appendix

318
Q

What causes appendicitis in older people

A

Obstruction from fecalith (coprolith) a concretion that forms around a center of fecal matter ..

319
Q

What happens when the appendix is occluded

A

Secretions cant escape
The appendix swells
Stretching the visceral peritoneum

320
Q

Initial pain of appendicitis

A

Vague pain in the periumbilical region because affferent pain fibers enter the spinal cord at T10

321
Q

Later pain of appendicitis

A

Severe pain in the right lower quadrant from irritation of the parietal peritoneum liningthe posterior abdominal wall (usually formed by the peso as and iliacus muscles in the region of the appendix) so extending the thigh and hip may cause pain

322
Q

Acute infection of the appendix may result in thrombosis in the ____ artery, which often results in ischemia, gangrene, and perforation of an inflamed appendix

A

Appendicular

323
Q

Rupture of the appendix

A

Peritonitis
Abdominal pain
Nausea
Vomiting
Abdominal RIGIDITY

324
Q

With appendicitis, why does flexion in the right thigh ameliorate pain

A

Relaxes the right spots muscle, a flexor of the thigh

325
Q

How do an appendectomy

A

Gridiron incision perpendicular to the spino-umbilical line, but a transverse incision is also common

Laparoscopic (peritoneal cavity inflated with CO2)

326
Q

During an appendectomy, what is the surgeon cant find the base of the appendix or appendix itself

A

Look for convergence of the three tenaie on the surface of the cecum after finding ileocecal valve

327
Q

Why may the appendix not be in the lower right quadrant

A

Malrotation of the intestine
Failure of descent of the cecum

328
Q

Where is the appendix when you have a high (subhepatic) cecum

A

Upper right hypochondriac region and pain localized there not the LRQ

329
Q

What is appendicitis in late pregnancy

A

Will be displaced cephalad by the enlarging uterus

330
Q

What happens when the inferior part of the ascending colon has mesentery

A

The cecum and proximal part of the colon are abnormally mobile

331
Q

How many people have mobile ascending colon

A

11%

332
Q

Mobile ascending colon may cause cecal bascule or cecal volvulus what are these

A

Cecal bascule-folding of the mobile cecum
Cecal volvulus-roll twist of mobile cecum

333
Q

What is bad about cecal bascule or cecal volvulus

A

May obstruct the intestine

334
Q

Cecopexy

A

Fixation
To avoid volvulus and possible obstruction of the colon

Tenia coli of the cecum and proximal ascending colon is sutured to the abdominal wall

335
Q

Chrons and ulcerative cholitis

A

Chronic inflammation of the colon characterized by severe inflammation and ulceration of the colon and rectum

336
Q

Colonectomy to my for chronic inflammation of colon

A

Terminal ileum and colon, and rectum and anal canal removed.

337
Q

Ileostomy

A

Constructed to eestablish a stoma , an artificial opening of the ileum through the skin of the anterolateral abdominal wall
The terminating ileum is delivered through and sutured to the periphery of an opening int he anterolateral abdominal wall, allowing the egress of its contents

338
Q

Following partial colonectomy

A

Colostomy or sigmoidoscomy is performed to create an artificial cutaneous opening for the terminal part of the colon

339
Q

What does temporary or permanent ostomy prevent

A

Fecal contents from going through the anastomsis , thus if the anastomsis has a small imperfection causing a leak, the result is not catastrophic peritonitis

340
Q

Colonoscope

A

For colonoscopy

341
Q

Sigmoidoscope

A

Shorter endoscope can go into sigmoid and take samples or do surgery

342
Q

Most tumors of the large intestine occur in the _____

A

Sigmoid colon and rectum (near rectosigmoid junction_ or ascending colon

343
Q

Tumors of ascending colon

A

Most common among women and older patients

344
Q

Rectosigmoidal tumors

A

Men and younger patients

345
Q

Diverticulosis

A

Multiple false diverticula develop along the intestine

346
Q

Where is diverticulosis commonly found

A

Sigmoid colon , ending where the teniae expand and converge at the colorectal junction

347
Q

Who gets diverticulosis

A

Middle aged and elderly people

348
Q

Are colonic diverticula true diverticulum? Why

A

No, they are formed from protrusions of mucous membrane only, evaginated through weak points developed between muscle fibers rather than involving the whole wall of the colon

349
Q

Where are colonic diverticula

A

On mesenteric side of the two nonmenenteric teniae coli, where nutrient arteries perforate the msucle coat to reach submucosa

350
Q

Diverticulitis

A

Infection or rupture of diverticula which can distort and erode the nutrient arteries leading to hemorrhage

351
Q

What kind of diet is beneficial for reducing diverticulosis

A

High fiber

352
Q

Volvulus of sigmoid colon

A

Rotation and twisting of the mobile loop of sigmoid colon and mesocolon

353
Q

Problem with volvulus of the sigmoid colon

A

Obstruction of the lumen of the descending loon and any part of the sigmoid colon proximal to the twisted segment

354
Q

What happens if obstruction of the lumen

A

Obstipation (cant fart or poop)
Ischemia

355
Q

What to do if see volvulus

A

ACUTE EMERGENCY….. necrosis and tissue death if untreated

356
Q

What is the most frequently injured organ of the abdomen

A

Spleen

357
Q

What ribs is the spleen protected by

A

Ribs 9-12

358
Q

How injure spleen

A

Blunt trauma to the left side or to other regions of the abdomen cause sudden increase in intra abdominal pressure can cause the thin fibrous capsule and overlying peritoneum of the spleen to rupture

Or when break ribs ..can rupture or lacerate

359
Q

What happens if rupture spleen

A

Profuse bleeding (intraperitoneal hemorrhage) and shock

360
Q

Treat ruptured spleen

A

Splenectomy

361
Q

Subtotal splenectomy

A

Done when possible, get rapid regeneration after.

362
Q

Consequences of total splenectomy

A

Not bad functions assumed by other reticuloendothelial organs (liver, bone marrow)
Greater susceptibility to certain bacterial infections

363
Q

Diseased spleen from granulocytic leukemia

A

Splenomegaly (10x normal size) and hypertension

364
Q

Is the spleen palpable in the adult

A

No

365
Q

What is you can palpate the spleen

A

Enlarged about 3 times normal

366
Q

Hemolytic or granulocytic anemia

A

Splenomegaly
Do splenectomy

367
Q

One or more small accessory spleens may develop prenatal near the ___ __

A

Splenic hilum ….may be embedded partly or wholly in the tail of the pancreas between the layers of the gastrosplenic ligament in the infracolic compartment , in the mesentery, in in close proximity to an ovary or testis

368
Q

Accessory spleen may resemble a __ __

A

Lymph node

369
Q

Why should you be aware of the presence of a possible accessory spleen

A

If not removed during splenectomy, the symptoms (splenic anemia) that indicated removal may persist

370
Q

Splenosis

A

Generalized auto implantation of a topic splenic tissue into the peritoneum, omentum, or mesenteries….sometimes follows splenic rupture

371
Q

What is the relationship of the costodiaphragmatic recess do the pleural cavity to the spleen important

A

Potential space descends tot he level of the 10th rib in the mid axillary line. Its existence must be kept in mind when doing a splenic needle biopsy , or when injecting radioopaque material into the splanchnic for visualization of the hepatic portal vein

372
Q

Splenoportography

A

Injecting radio opaque material into the spleen for visualization of the hepatic portal vein

373
Q

If inject material into the costodiaphragmatic recess while doing splenoportography

A

May enter pleural cavity causing pleuritis

374
Q

The main pancreatic duct joint the bile duct to form the ___ ____ and pierces the duodenal wall

A

Hepatopancreatic ampulla

375
Q

A gallstone passing along the extrahepatic bile passing along the extrahepatic bile passages where it opens at the summit of the ___ ___ ___

A

Major duodenal papilla

376
Q

What is blocked if a gallstone is lodged at the distal end of ampulla

A

Biliary and pancreatic duct systems and neither bile of pancreatic juice can enter the duodenum

377
Q

Why does a blocked hepatopancreatic ampulla cause pancreatitis

A

Bile may back up and enter the pancreatic duct, causing ancreatitis

378
Q

Normally the __ of the pancreatic duct prevents reflux of bile into the pancreatic duct. However is obstructed it may be unable to prevent the pressure

A

Sphincter

379
Q

Accessory pancreatic duct and blockage of hepatopancreatic ampulla

A

May compensate for obstructed main pancreatic duct or spasm of the hepatopancreatic sphincter

380
Q

Magnetic resonance cholangiopancreatography (MRCP)

A

MRI for diagnosis of pancreatic and biliary disease.
Can look at hepatobiliary and pancreatic systems including the liver, gallbladder, bile ducts, pancreas, and pancreatic duct.

381
Q

Endoscopic retrograde cholangiopancreatography (ERCP)

A

Used when interventions are required.
Fiber optic endoscope through mouth to duodenum is entered and a cannula inserted into major duodenal papilla and advanced under fluoroscopic control into the duct of choice for injection of radiographic contract. Can also do intervention

382
Q

Where does ectopic accessory pancreatic tissue typically develop

A

Stomach, duodenum, ileum, ileal diverticulum

383
Q

What does ectopic accessory pancreatic tissue do

A

Contain pancreatic islet cells that produce glucagon and insulin

384
Q

Is the pancreas palpable

A

No…it is well protected

385
Q

Most exocrine pancreatic problems are secondary to ___ problems

A

Biliary

386
Q

How may pancreas be directly damaged

A

Forceful and sudden compression of the abdomen , such as the force of impalement on a steering wheel in an automobile accident . Bc the pancreas lies transversely, the vertebral column acts as an anvil, and the traumatic force may rupture the friable pancreas

387
Q

What happens if rupture pancreas

A

Tears the duct system allowing pancreatic juice to enter the parenchyma of the gland and to invade adjacent tissue. ….this is very painful due to digestion of tissues by pancreatic juice

388
Q

When is pancreatectomy performed

A

Tumors are detected

389
Q

Susbtotal or partial pancreatectomy

A

Remove ruptured portions of the pancreas and for the treatment of chronic pancreatitis after nonsurgical options fail

390
Q

What happens when pancreatic enzymes activated before they are released into the small intestine

A

Damage. Begin to digest and attack pancreas

391
Q

Subtotal pancretomy reduces pancreatic secretion how

A

Reducing size of the pancreas

392
Q

Its easy to remove the body and tail of the pancreas. Tell me about head removal

A

Blood supply, bile duct, and duodenum, make it impossible to remove the entire head of the pancreas without removing the duodenum and terminal bile duct

393
Q

What do we do to prevent removal of duodenum in pancreatectomy

A

Rim of pancreas is retained along the medial border of the duodenum to preserve the duodenal blood supply

394
Q

What causes most cases of extrahepatic obstruction of the biliary duct

A

Cancer of the pancreatic head

395
Q

What does cancer of the head of the pancreas obstruct

A

The bile duct and/or the hepatopancreatic ampulla

396
Q

What happens if bile duct obstructed

A

Bile pigment retention, enlargement of the gallbladder, and obstructive jaundice.

397
Q

Most common pancreatic cancer

A

Ductular adenocarcinoma

398
Q

Where do people with pancreatic cancer have pain

A

Back

399
Q

Why may cancer of the neck and body of the pancreas may cause hepatic portal vein or inferior vena canal obstruction why

A

Bc the pancreas ever lies these veins

400
Q

Why is pancreatic cancer difficult to resect and hard to detect early

A

Extensive drainage to relatively inaccessible lymph nodes and the fact that pancreatic cancer typically metasticize to the liver early via the hepatic portal vein

401
Q

Whipple procedure

A

For cancer of pancreas and biliary tract
(Pancreatoduodenectomy)
Remove head of pancrea, part of duodenum, and gallbladder

402
Q

Tumor on body and tail of pancreas

A

Removed by subtotal procedure called distal pancreatectomy

403
Q

Is the liver palpable. Why

A

In supine bc of the inferior movement of the diaphragm and liver that accompanies deep inspiration

404
Q

How do you palpate the liver

A

Left hand behind lower rib cage and put right hand on RUq lateral to the rectus abdominis and inferior to the costal margin
Take deep breath and press posterosuperiorly and pull anteriorly

405
Q

What is a common site for abscess in peritonitis and on what side

A

Subphernic recess on the right

406
Q

Why are subphrenic recesses more common on the right

A

Frequency of ruptured appendices and perforated duodenal ulcers

407
Q

Why may pus from the subphrenic recess spread to the hepatorenal recess

A

They are continuous

408
Q

How do you drain a subphrenic recess

A

Incision in bed of 12th rib so don’t have to make incision into pleura or peritoneum

409
Q

Drain anterior subphrenic recess

A

Through subcostal incision located inferior and parallel to the right costal margin.

410
Q

Hepatic lobectomies

A

Can do! Right and left hepatic Arteries and ducts and branches of right and left hepatic portal veins do not communicate

Don’t get excessive bleeding

411
Q

Hepatic segmentectomies

A

Remove only those segments that have tumor,

412
Q

What is the portal triad

A

Hepatic portal vein, hepatic artery, bile duct

413
Q

Hepatic veins

A

Left intermediate and right

414
Q

Umbilical fissure

A

Left hepatic vein

415
Q

Main portal fissure

A

Intermediate hepatic vein

416
Q

Right sagittal fissure

A

Right hepatic vein

417
Q

Why is the liver easily injured

A

Large, fixed in position, friable

418
Q

What happens with liver laceration (rib)

A

Hemorrhage in URQ and pain there
Excessive vasculature

419
Q

How manage injured liver

A

Remove foreign material and packing or embolization (deliberate blocking of blood vessels to control bleeding)

420
Q

Resection of the liver is a last resort. Why?

A

Lobectomy or segmentectomy

421
Q

Aberrant right hepatic artery source

A

SMA

422
Q

Aberrant left hepatic artery source

A

Left gastric artery

423
Q

In most people the right hepatic artery crosses __ to the hepatic portal vein

A

Anterior

424
Q

In some people, the right hepatic artery passes posterior to the hepatic portal vein

A

Ok

425
Q

In most people the right hepatic artery runs ___ to the common hepatic duct

A

Posterior

426
Q

In some individuals the right hepatic artery crosses anterior to the common hepatic duct or the right hepatic artery arises from the SMA and so does not cross the common hepatic duct at all

A

Ok

427
Q

Both the IVC and hepatic veins lack __

A

Valves

428
Q

Any rise in central venous pressure is directly transmitted to the __, which enlarges as a results

A

Liver

429
Q

What does hepatomegaly cause when temporary

A

Pain around lower ribs particularly right hypochondriac

430
Q

Runners stitch

A

Engorgement of liver in conjunction with increased or sustained diaphragmatic activity

431
Q

What is an important disease that produces hpatic engorgement

A

CHF, bacterial and viral disease, hepatitis,

432
Q

Can you feel an enlarged liver

A

Readily palpable and may even go down to pelvic brim

433
Q

Do tumors enlarge the liver

A

Yup

434
Q

The liver is a common site of ____ carcinoma

A

Metastatic ….secondary cancers spreading from organs drained by the portal system

435
Q

Why may cancer from the right breast spread to the liver

A

Communications between thoracic lymph nodes and the lymphatic vessels draining the bare area of the liver .

436
Q

Histology of metastatic liver tumors

A

Hard, rounded nodules within the hepatic parenchyma

437
Q

The ___ is the primary site for detoxification of substances absorbed by the GI tract. What does this imply

A

Liver
Vulnerable to damage and scarring accompanied by regenerative nodules

438
Q

There is progressive destruction of ___ in hepatic cirrhosis and replacement of these cells by __

A

Hepatocytes
Fat and fibrous tissue

439
Q

Causes of cirrhosis

A

Alcoholism
Carbon tetrachloride

440
Q

Alcoholic cirrhosis causes __ hypertension

A

Portal

441
Q

Characterization of alcoholic cirrhosis

A

Portal HTN
Hepatomegaly
Hobnail liver appearance
Fatty changes and fibrosis

442
Q

In cirrhosis why is metabolic evidence of liver failure late

A

Great functional reserve

443
Q

In cirrhosis, fibrous tissue surrounds the intra hepatic blood vessels and biliary ducts. What does this cause

A

Liver becomes firm and impedes the circulation of blood through it (HTN portal)

444
Q

Treatment liver cirrhosis

A

Transplant
Portosystemic or portocaval shunt which anastomsing the portal and systemic venous systems

445
Q

How get liver biopsy

A

Needle 10th intercostal space in mid axillary line HODL BREATH IN FULL EXPIRATION to reduce costodiaphragmatic recess and lessen the possibility of damaging the lung and contaminating the pleural cavity

446
Q

Is the gallbladder fixed

A

Usually closely attached to the fossa for gallbladder on liver surface

447
Q

In 4% of people the gallbladder is mobile…

A

Suspended from the liver by a short mesentery increasing its mobility

448
Q

Proble with mobile gallbladder

A

Vascular torsion and infarction (sudden insuffiency of arterial or venous blood supply)

449
Q

There are a ton of variations in cystic and hepatic ducts. Why is this important

A

Surgeons when they ligate the cystic duct during cholecystectomy

450
Q

Are accessory hepatic ducts common

A

Yes

451
Q

In what surgery are accessory hepatic ducts vulnerable

A

Cholecystectomy

452
Q

What is an accessory hepatic duct

A

Normal segmental. Duct that joins the biliary system outside the liver instead of within it

453
Q

What happens if accessory hepatic duct is cut during surgery

A

Leak bile

454
Q

What is a gallstone (cholelithiasis)

A

Connection in the gallbladder, cystic duct, or bile duct composed chiefly of cholesterol crystals

455
Q

Gallstones more common in males or females and old or young

A

Females older

456
Q

50% of people gallstones are __

A

Silent

457
Q

When does a gallstone cause symptoms

A

Size sufficient to produce mechanical injury to the gallbladder or obstruction of the biliary tree

458
Q

What is common site of gall bladder impaction

A

Distal end of the common bile duct is narrow part of the biliary passages

459
Q

What does a stone lodged in the cystic duct cause

A

Biliary colic….when gallbladder relaxes it may move back to the gallbladder
Cholecystitis

460
Q

Cholecystitis

A

Stone block cystic duct
Inflammation of the gallbladder
Bile accumulation causing enlargement

461
Q

Sacculation(Hartman pouch)

A

Common site of gallstone impaction
Junction of the neck of gallbladder and cystic duct

462
Q

What happens when Hartman pouch is large

A

Cystic duct arises from its upper left aspect, not from what appears to be the apex of the gallbladder….gallstones collect int he pouch

463
Q

If a peptic duodenal ulcer ruptures, a false passage may form between the pouch and the superior part of the duodenum….allowing what

A

Pouch and superior part of duodenum connection
Allowing gallstones to enter duodenum

464
Q

Where do you get pain from impaction of the gallbladder

A

Epigastric region and later shifts to the right hypochondriac region at the junction of the 9th costal cartilage and the lateral border of the rectus sheath.

465
Q

Inflammation of the gallbladder may cause pain in the posterior thoracic wall or right shoulder owing to irritation of the ___

A

Diaphragm

466
Q

If bile cant leave the gallbladder and enters the blood it may cause ____

A

Jaundice

467
Q

What technique is used to detect stones

A

Ultrasound and CT

468
Q

A dilated and enlarged gallbladder may adhere to adjacent viscera…may result. In cholecysto-enteric fistula. What areas are most likely to get this fistula

A

Duodenum and transverse colon

469
Q

What happens if get cholecysto-enteric fistula

A

Gallstone too large to pass through the cystic duct will enter the IGI

470
Q

If a gallstone enters the GI, where may it get trapped

A

Ileocecal valve producing a bowel obstruction (gallstone ileus)

471
Q

A cholecysto-enteric fistula also permits GI stuff to enter the gallbladder , providing what

A

Diagnostic radiographic sign

472
Q

Cholecystectomy

A

If have extreme biliary colic

473
Q

The cystic artery most commonly rises from the ___ artery int he cystohepatic triangle

A

Right hepatic

474
Q

Boundaries of the cystohepatic artery

A

Inferior-cystic duct
Medially-common hepatic duct
Superiorly-inferior surface of the liver

475
Q

Why must we carefully dissect the cystohepatic triangle when doing a cholecystectomy

A

Safeguard the structures should there be anatomical variation

476
Q

Why are there common errors in gallbladder surgery

A

Failure to appreciate variation in anatomy of biliary system , especially the blood supply

477
Q

Before removing the gallbladder what must a surgeon identify

A

Three biliary ducts, cystic and hepatic arteries

478
Q

The __ ___ artery is in danger during gallbladder surgery and must be located before lighting the ___ artery

A

Right hepatic
Cystic

479
Q

Portal hypertension

A

When scarring and fibrosis from cirrhosis obstruct the hepatic portal vein in th liver, pressure rises in the vein and its tributaries

480
Q

The large volume of blood flowing from the portal system to the systemic system at the sites of portal-systemic anastomoses may produce __ ___

A

Varicocele veins

481
Q

Problem with varicose veins

A

Walls may rupture-hemorrhage

482
Q

Esophageal varicose

A

Dilated veins at distal end of esophagus …severe, fatal if bleeding

483
Q

In severe portal obstruction, the veins of the anterior abdominal wall (normally caval tributaries) that anastomoses with the para umbilical veins(portal tributaries0 may become varicose and look somewhat like small snakes radiating under the skin around the umbilicus. What is this called

A

Caput medusae

484
Q

How reduce portal hypertension

A

Divert blood from the portal venous system to the systemic venous system

485
Q

How do we create communication between hepatic portal vein and systemic venous system

A

Communicate hepatic portal vein and a IVC
Connect usually where they lie close to each other posterior to the liver

486
Q

What is this called

A

Portocaval anastomoses or portosystemic shunts

487
Q

After splenectomy, how could we reduce portal htn

A

Connect splenic vein to the left renal vein (splenorenal anastomesis or shunt)

488
Q

Are these anastomses common now?

A

No replaced by liver transplant

489
Q

Transjugular intrahepatic portosystemic shunt (TIPS)

A

By interventional radiologist
Introducing a catheter tipped with an unexpanded stent into the right internal jugular vein and directing it under fluoroscopic guidance into one of the major hepatic veins via the right brachiocephalic vein, superior vena cava, right atrium, and inferior vena cava. Once in the hepatic vein, the unopened stent is pushed through the parenchyma of the liver into the portal vein. The stent is expanded setting it in place and providing the portosystemic shunt.

490
Q

How palpate the kidney

A

Can’t really
In thin -right kidney is palpable by bimanual examination as round mass that descends with inspiration

491
Q

Why can we palpate right kidney

A

It is 1-2 cm inferior from left

492
Q

Where can u feel the right kidney

A

Between 11 and 12 ribs and iliac crest from behind and feel anteriorly at costal margin

493
Q

Why would the left kidney be palpable

A

If enlarged or retroperitoneal mass has displaced it inferiorly

494
Q

What determines the path of extension of the perinephric abscess

A

Attachments of the perinephric fascia

495
Q

Fascia at the renal hilum attaches to the renal vessels and ureter, usually representing spread where

A

To the contralateral side

496
Q

How can pus get from perinephric abscess to the pelvis

A

Between the loosely attached anterior and posterior layers of the renal fascia

497
Q

Nephroptosis

A

Dropped kidney

498
Q

Why do kidneys drop

A

Layers of renal fascia do not fuse firmly inferiorly to offer resistance, abnormally mobile kidneys may descend more than the normal 3 cm when erect body

499
Q

When the kidneys descend, what happens to suprarenal glands

A

They stay up bc in separate fascial compartment and are firmly attached to the diaphragm

500
Q

How distinguish nephroptosis from ectopic kidney

A

Ureter of normal length that has loose coiling or kinks bc the distance to bladder has been reduced

501
Q

Symptom of dropped kidney

A

Intermittent pain in the renal region received by lying down bc of traction on renal vessels

502
Q

Why are transplanted kidneys placed in the iliac fossa

A

Lack of inferior support for the kidneys in th lumbar region
Availability of major blood vessels and convenient access to the nearby bladder

503
Q

Renal transplant

A

For chronic renal failure
Don’t damage suprarenal gland bc of weak septum of renal fascia that separates them
Transplant to iliac fossa of greater pelvis -site supports so no traction
Renal artery and vein are joined ot the external iliac artery and vein and ureter is sutured into bladder

504
Q

Adult polycystic disease of the kidneys

A

Can cause renal failure
Inherited AD
Kidneys enlarged by cysts

505
Q

If inflammation of pararenal areas, why extension of hip painful

A

Close relationship between kidney and psoas major
These muscles flex thigh at hip

506
Q

During their ascent to their final state, the embryonic kidneys receive their blood supply and venous drainage from successively more __ vessels

A

Superior

507
Q

Usually the vessels degenerate, what if they don’t

A

Accessory renal arteries and veins

Can have polar or inferior
Polar arteries- cross ureter and may obstruct
Superior-poles of kidney

508
Q

Renal vein entrapment syndrome mesoaortic compression of the left renal vein

A

Also known as nutcracker syndrome

509
Q

In crossing the midline to reach the IVC, the longer _ renal vein transverse an acute angle between the SMA anteriorly and the abdominal aorta posteriorly

A

Left

510
Q

What does downward traction on the SMA cause

A

Compress the left renal vein resulting in renal vein entrapment syndrome

511
Q

Why is renal vein entrapment syndrome also called nutcracker syndrome

A

Based on appearance of the vein in the acute arterial angle in a sagittal view

512
Q

Symptoms of renal vein entrapment syndrome

A

He matures
Proteinuria
Left flak abdominal pain
Nausea and vomiting
Left testicular pain in men
Maybe left sided varicocele

513
Q

Bifid renal pelvis and ureter

A

Common .. from division of the ureteric bud (metanephric diverticulum), the primordium of the renal pelvic and ureter

514
Q

Bifid renal pelvis may be unilateral or bilateral, but separate openings into the bladder are ___

A

Uncommon

515
Q

What causes bifid ureter

A

Incomplete division of the ureteric bud

516
Q

What causes supernumerary kidney

A

Complete division of ureteric bud

517
Q

Retrocaval ureter

A

Leaves the kidney and passes posterior to the ivc

518
Q

Horseshoe kidney

A

1/600 fetus the inferior poles of kidneys fuse for make U shape

519
Q

Where does a horseshoe kidney lie

A

L3-L5 bc the root of the inferior mesenteric artery prevented normal relocation of the kidneys

520
Q

Symptoms of horseshoe kidney

A

Not really….may obstruct ureter

521
Q

Ectopic pelvic kidney

A

Embryonic kidney on one or both sides fails to enter the abdomen and lies anterior to the sacrum

522
Q

Why need to know about ectopic kidneys

A

Don’t want to confuse for a pelvic tumor and remove it
Can also cause obstruction during childbirth

523
Q

Where do pelvic kidneys usually receive their blood supply from

A

The aortic bifurcation or a common iliac artery

524
Q

Calculi

A

Composed of salts of inorganic or organic acids or other materials
Form and becomes located in the calices of the kidneys, ureters, or urinary bladder

525
Q

Renal calculus(kidney stone)

A

May pass from kidney into renal pelvis and then into ureter

526
Q

What does a calculi in ureter cause

A

Excessive distension of this muscular tube , the ureteric calculus will cause severe intermittent pain (ureteric colic) as it if forced down the ureter by waves of contraction

527
Q

Does a calculus cause complete or intermittent obstruction of urinary flow

A

Can cause both

528
Q

How observe and remove ureteric calculi

A

Nephroscope an instrument inserted through a small incision
Lithotripsy-focuses on shockwave through the body that breaks the calculus into small fragments that pass with the urine

529
Q

The pan from ureteric calculi is referred to the cutaneous areas innervated by spinal cord segments and sensory ganglia which also receive visceral afferent from the ureter, mainly ______

A

T11-L2

530
Q

The pain passes inferno-anteriorly from “ ____ _ ___” as stone passes through ureter

A

Loin to groin

531
Q

The pain from ureteric calculi may extend into the proximal anterior aspect of the thigh by projection through the ____ nerve (-), the scrotum in males and the labia majora in females

A

Genitofemoral
L1, L2

532
Q

The extreme pain may be accompanied by what in ureteric colliculus

A

Digestive upset, generalized sympathetic response that may to various degrees mask the more specific symptoms

533
Q

Hiccups

A

Involuntary spasmodic contractions of the diaphragm, causing sudden inhalation’s that are rapidly interrupted by spasmodic closure of the glottis that checks the inflow of air and produces the sound

534
Q

What hiccups result from

A

Irritation of afferent or efferent nerve endings or of medullary centers in the brainstem that control the muscles of respiration, particularly the diaphragm

535
Q

What causes hiccups

A

Indigestion, diaphragm irritation, alcoholism, cerebral lesions, thoracic and abdominal lesions, which all disturb phrenic nerves

536
Q

Section of the phrenic nerve causes what

A

Complete paralysis and eventual atrophy of the muscular part of the corresponding Half of the diaphragm, except if have accessory phrenic nerve
“Paralysis of hemidiaphragm” seen radiographically

537
Q

Where is referred pain from the diaphragmatic pleura or diaphragmatic peritoneum

A

Shoulder region ..area of skin supplied by c3-c5

538
Q

Where is pain from irritation of the peripheral regions of the diaphragm

A

Innervated by the inferior intercostal nerves more localized..being referred to the skin over the costal margins of the anterolateral abdominal wall

539
Q

What may cause rupture of the diaphragm and herniation of viscera

A

Sudden large increase in either intrathoracic or intra-abdominal pressure
Severe trauma to the thorax or abdomen during a MVA

540
Q

Why are most diaphragmentic ruptures on the left side

A

Bc substantial mass of the liver, intimately associated with the diaphragm on the right side provides a physical barrier

541
Q

Where is the lumbocostal triangle

A

Between the costal and lumbar parts of the diaphragm
Nonmuscular
Normally formed only by fusion of the superior and inferior fascial of the diaphragm

542
Q

When a traumatic diaphragmatic hernia occurs, the stomach, small intestine, and mesentery, transverse colon, and spleen may herniate through what

A

The lumbocostal triangle into the thorax

543
Q

What is a hiatal hernia

A

Protrusion of part of stomach into the thorax through the esophageal hiatus

544
Q

What structures pass through the esophageal hiatus

A

Vagal trunks, left inferior phrenic vessels, esophageal branches of the left gastric vessels
Careful may be injured in surgical procedures not he esophageal hiatus

545
Q

Congenital diaphragmatic hernia

A

Part of the stomach and intestine herniate through a large posterolateral defect (foramen of bochdalek) in the region of the lumbocostal trigone of the diaphragm

546
Q

Why does congenital diaphragmatic hernia almost always occur on the left

A

Presence of the liver on the right

547
Q

Why get a congenital diaphragmatic hernia

A

Posterolateral defect of the diaphragm is the only relatively common congenital anomaly of the diaphragm 1/2000

With abdominal viscera int he limited space of the prenatal pulmonary cavity, one lung (usually left lung) does not have room to develop normally or to inflate after birth…bc of the pulmonary hypoplasia the mortality rate in these infants is high

548
Q

There is currently a resurgence of TB, especially where

A

Africa, asia….owing to aids and drug resistance

549
Q

TB of the vertebral colum is common. How may is spread

A

Through blood to the vertebrae particularly in young children

550
Q

An abscess of TB in the lumbar region tends to spread from the vertebrae into the ___ __ , producing what

A

Psoas fascia
Psoas abscess

551
Q

What happens with a psoas abscess

A

Fascia thickens
To form a strong stocking like tube

552
Q

Where may pus from a psoas abscess spread

A

Inferiorly along the psoas muscles within the fascia tube over the pelvic brim and deep into the inguinal ligament
The pus usually surfaces in the superior part of the thigh
Pus can also reach the psoas fascia by passing from the posterior mediastinum when the thoracic vertebrae are diseased

553
Q

The inferior part of the iliac fascia is often tense and raises a fold that passes to the internal aspect of the iliac crest. The superior part of this fascia is loose and may do what

A

Form a pocket m the iliacosubfascial fossa, posterior to the above mentioned fold.

554
Q

Clinical concern of the iliacosubfascial fossa

A

Part of the large intestine such as the cecum and or appendix on the right side of the sigmoid colon on the left side may become trapped in this fossa, causing considerable pain

555
Q

The iliopsoas muscle has extensive clinically important relations to what

A

Kidney, ureteric, cecum, appendix, sigmoid colon, pancreas, lumbar lymph nodes and nerves of the posterior abdominal wall.

556
Q

When any of the structures associated with the iliopsoas are diseased what happens

A

Movement of the iliopsoas causes pain

557
Q

When is the iliopsoas test performed

A

Intra abdominal inflammation is suspected

558
Q

Bc the psoas lies along the vertebral column and the iliacus crosses the sacro-iliac joint, disease of the intervertebral and sacro-iliac joints may cause what

A

Spasm of the iliopsoas, a protective reflex

559
Q

Adenocarcinoma of the pancreas in advanced stages invades the muscles and nerves of what

A

Posterior abdominal wall , producing excruciating pain because of the close relationship of the pancreas to the posterior abdominal wall

560
Q

Partial lumbar sympathectomy

A

Surgical removal of two or more lumbar sympathetic ganglia by division of their rami communicates ….to treat disease of the lower limbs

561
Q

How get access to the sympathetic trunk

A

Through lateral extraperitoneal approach because the sympathetic trunks lie retroperitoneally in the extraperitoneal fatty tissue

562
Q

The surgeon splits the muscles of the anterior abdominal wall and moves. The peritoneum medially and anteriorly to expose the medial edge of the psoas major along which the sympathetic trunk lies

A

The sympathetic trunk is covered by the IVC. The intimate relationship of the sympthetic trunk to the aorta and ivc also makes these large vessels vulnerable to injury during lumbar sympathectomy . Consequently the surgeon carefully retracts them to expose the sympathetic trunks that usually lie in the groove between the psoas major laterally and the lumbar vertebral bodies medially. Those trunks are often obscured by fat and lymphatic tissue. Knowing that identification of the sympthetic trunk is not easy, great care is taken not to remove inadvertently part of the genitofemoral nerve, lumbar lymphatics or ureter

563
Q

Because the aorta lies posterior to the pancreas and stomach , a tumor of these regions may cause what

A

Pulsation of the aorta that could be mistaken for an abdominal aortic aneurysm(a localized enlargement of the aorta)

564
Q

How tell if its an aneurysm

A

Can be palpate midabdomen to the left of midline (the pulsating mass can be moved easily from side to side), which usually results from a congenital weakness of the arterial wall

565
Q

Acute rupture of abdominal aortic aneurysm

A

Severs pain in abdomen or back
90% death rate due to blood loss

566
Q

How can surgeons repair an aneurysm

A

Opening it and inserting a prosthetic graft and sewing the wall of the aneurysm aorta over the graft to protect it

Now using catheterization procedures

567
Q

How may we control bleeding in the pelvis or lower limbs

A

Compress inferior part of abdominal aorta against the body of L4 by putting firm pressure on the anterior abdominal wall over the umbilicus

568
Q

What are the three routes, formed by valveless veins of the trunk that are available for venous blood to return to the heart when the IVC is obstructed or lighted

A

Superior and inferior epigastric veins
Thoracoepigastric vein
Epidural venous plexus

569
Q

Where is the epidural venous plexus

A

Inside the vertebral column

570
Q

What does the epidural venous plexus communicate with

A

Lumbar veins of the inferior canal system and the tributaries of the azygos system of veins which is part of the superior canal system

571
Q

Why are inferior vena cava anomalies common , most occurring inferior to the renal veins, like persistent left IVC)

A

The inferior part of the IVC has a complicated development bc it forms from parts of three sets of embryonic veins

572
Q

What do anomalies of the inferior vena cava result from

A

Persistence of embryonic veins on the left side which normally disappear ….if a left IVC is present, it may cross to the right side at the level of the kidney

Anatomy Examen 1 (7 decks)

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