Abdomen Flashcards
558 – From a functional perspective, the liver is divided into eight segments. Which of the following responses is MOST correct?
A. The falciform ligament represents the division into right and left sides of the liver.
B. The division between the right and left sides of the liver is through the gallbladder bed.
C. There are six segments on the right side and two on the left side.
D. The quadrate lobe is identical with segment 1.
E. The right side of the liver is fed by the portal vein and the left side by the hepatic artery.
B
The morphological lobes of the liver do not correspond to the right and left sides of the liver. The falciform ligament was previously used to separate right and left lobes, but it is the portal trinity which divides the liver into right and left sides. B Correct. The division between right and left sides of the liver, supplied respectively by the right and left halves of the portal trinity (hepatic artery, portal vein and bile duct) runs through the gall bladder bed inferiorly. The right side of the liver consists of four segments (segments 5 and 8 anteriorly, 6 and 7 posteriorly). The left side contains three segments (segments 3 and 4 anteriorly, and 2 posteriorly).
Segment 1 (caudate lobe) receives branches from both sides.
20697 – S. The anatomical right lobe of the liver is much larger than the
left BECAUSE R. the right hepatic artery supplies the caudate and quadrate lobes
S is true and R is false
Last (6) PAGE: 299
22189 – The quadrate lobe of the liver
1: forms the anterior wall of the upper recess of the lesser sac
2: is bounded by the fissure for the ligamentum venosum
3: is bounded by the fissure for the ligamentum teres
4: is in close contact with the right kidney
FFTF
Last (8) PAGE: 344
Quadrate lobe bounded by
- Anterior - anterior margin of liver
- Behind - porta hepatis
- Right - fossa for gallbladder
- Left - fossa for umbilical vein
Caudate lobe bounded by
- Below - porta hepatis
- Right - fossa for IVC
- Left - fossa for ductus venosis and ligamentum venosum
23644 – The falciform ligament of the liver
1: has the ligamentum teres in its free border
2: passes from the anterior abdominal wall to the liver
3: prevents ptosis of the liver
4: ascends from the umbilicus to the left of the median plane
TTFF
3 - the vasculature holds up the liver?
4 - goes from posterior surface of the right rectus abdominis muscle by the right margin of the umbilicus to left lobe of liver
721 – The liver
1: is partly supplied by the phrenic nerves.
2: has a fissure for the ligamentum teres which extends to the porta hepatis.
3: is separated from the subdiaphragmatic part of the inferior vena cava by the peritoneum.
4: develops from a foregut diverticulum in the septum transversum.
FTFT
The liver develops from a foregut diverticulum within the septum transversum (26.4 true). The ventral mesentery of the septum transversum persists as the lesser omentum running from stomach to liver, splitting to enclose the liver, and continuing as the falciform ligament to the anterior abdominal wall and diaphragm. Bilateral reduplications of the peritoneum are drawn out into the small left triangular ligament and the much larger coronary ligament and right triangular ligament. The two enclose a large area of the liver posteriorly bare of peritoneum, where the liver sits flush against the diaphragm with the inferior vena cava embedded in its posterior surface. This bare area of the liver is in direct contact with the inferior vena cava (25C true, 26.3 false), right suprarenal gland and posterior cupola of diaphragm. The lower free margin of the ventral mesentery contains the ligamentum teres. This runs back from umbilicus to a fissure in the lower surface of the liver which extends to the porta hepatis (26.2 true). The phrenic nerves are motor to the right and left halves of the diaphragm (26.1 false). The liver receives an autonomic supply of sympathetic and vagal fibres. The sympathetic supply enters via the
coeliac ganglion into the portal hepatis; one or more hepatic vagal branches run within the upper part of the lesser omentum from the left vagus.
13494 – The liver
1: is not separated by peritoneum from the oesophagus
2: is separated from the subdiaphragmatic part of the inferior vena cava by peritoneum
3: has a fissure for the ligamentum teres which extends to the right end of the porta hepatis
4: has a bare area separated by renal fascia from the right adrenal gland
FFFT
The peritoneal attachments of the liver form the subphrenic spaces. The liver is entirely separated by peritoneum from the oesophagus (A false). The ventral mesentery by which the liver is suspended from the diaphragm forms the left and right triangular ligaments with a bare area bordered by their attachment to the liver. The subdiaphragmatic part of the inferior vena cava occupies the bare area below the central tendon. The vena cava is thus an immediate posterior relation of the liver, contained in a groove on its posterior surface (B false). The ligamentum teres is a rounded fibrous cord in the free lower edge of the falciform ligament. It is the remnant of the obliterated left umbilical vein of the foetus and it runs in the free edge of the falciform ligament from the umbilicus to the anterior surface of the liver. It lies in a deep groove, the fissure for the ligamentum teres, on the under surface of the liver as far as the left end of the porta hepatis (C false). The lower reflection of the right triangular ligament runs horizontally across the diaphragm near the level of the upper pole of the right kidney; the right adrenal gland lies in the bare area along with the inferior vena cava. The renal fascia surrounds the kidney and sends an extension over the right adrenal (D true).
715, 19288 – The bare area of the liver is in direct contact with parts of
A. the head of the pancreas
B. the right sympathetic chain
C. the inferior vena cava
D. the left supra renal gland
E. the pelvis of the right ureter
C
Last (6) PAGE: 298. The bare area of the liver is in direct contact with the inferior vena cava which is embedded in its posterior surface.
732 – Concerning the blood supply of the liver
1: the hepatic artery inflow and hepatic venous drainage do not communicate across left and right halves of the liver.
2: the portal vein has a Y-shaped division into left and right portal vein branches in the porta hepatis.
3: the hepatic ducts in the porta hepatis lie in front of the branches of the hepatic artery & portal vein.
4: the quadrate and caudate lobes receive their major blood supply from the right hepatic artery and right portal vein.
FFTF
The right and left hepatic arteries do not communicate. Each of the individual right and left arterial branches is functionally an end artery, as are their segmental branches which run together with the accompanying portal vein branches and hepatic duct tributaries in the ensheathing ‘portal canals’ of histological sections. Arterial and portal venous blood mix in the sinusoids and drain to hepatic vein tributaries in the centre of each ‘lobule’, which unite to form the hepatic veins. The hepatic venous drainage, as distinct from the unmixed vascular inflow, allows mixing of the drainage coming from right and left liver halves (1
false)
The left and right hepatic veins have a very short extrahepatic course; and drain segments 2 & 3, and 5 & 8 respectively. A long middle hepatic vein marks the junction between left and right liver halves posteriorly; and receives part of the drainage of both right (segments 6 & 7) and left (segment 4) halves of the liver. The middle hepatic vein runs vertically and drains into the vena cava or may join the left hepatic vein. A number of accessory hepatic veins below the main veins drain separately into
the vena cava along its length, including one from the caudate lobe. Ligation of the main hepatic artery may be possible without liver infarction because of the double vascular inflow; and has been used to inhibit growth of hepatic metastases. The operation is now less
commonly performed; chemotherapy delivered via percutaneous hepatic arterial infusion is less
hazardous and less invasive. Portal venous diversion by portacaval or reversed (Warren) lienorenal shunting can reduce bleeding
risks from varices in portal hypertension. The division of the hepatic artery into right and left hepatic artery branches in the porta hepatis is Y-shaped, and differs from the portal vein bifurcation, which is at a higher level via a T-junction into right and left portal veins (2 false). The hepatic ducts in the porta hepatis accompany the corresponding arteries. They lie anteriorly to the arterial and venous
branches, rendering the ducts more easily accessible to surgical exploration (3 true).
KEY ISSUE
Although quadrate and caudate lobes are described by older nomenclature as part of the right liverlobe (ie the portion lying to the right of the falciform ligament), it is essential surgically to appreciate that functionally the caudate lobe (segment 1) and most of the quadrate lobe (segment 4) belong to the left half of the liver they receive blood supply from the left hepatic arterial and left portal vein branches and drain bile to the left hepatic duct (4 false).
20475 – S. Needle biopsy of the liver should be performed through the right eighth or ninth intercostal space in the mid axillary line BECAUSE R. this level is below the level of the lung
S is true, R is true and a valid explanation of S
Last 9th ed. Page: 347
22919 – The common hepatic artery usually
1: gives off the gastro-duodenal artery
2: is entirely retroperitoneal
3: gives off the cystic artery
4: divides into right and left branches in the porta hepatis
TTFF
Last (8) PAGE: 326
726 – The right hepatic artery may arise anomalously from the
A. superior mesenteric artery.
B. left gastric artery.
C. splenic artery.
D. superior pancreatic-duodenal artery.
E. short gastric arteries.
A
The arterial blood supply of the liver is via the hepatic artery. This arises from the coeliac axis, and runs in the lesser omentum to the porta hepatis where it normally divides into right and left branches. The right hepatic artery normally passes behind the common hepatic duct and then has intrahepatic divisions into anterior and posterior segmental branches the right hepatic artery suppling liver segments 5 & 8 anteriorly and 6 & 7 posteriorly.
Variations in the common hepatic artery and in its left and right hepatic branches are common and important; particularly in liver transplantation and in resectional liver and biliary surgery. The commonest and most important abnormality is that either the common hepatic artery or its right and
left hepatic branches may arise from the superior mesenteric artery rather than from the coeliac trunk (A true).
18886 – The right hepatic artery may arise from
A. the superior mesenteric artery
B. the left gastric artery
C. the splenic artery
D. the superior pancreatic-duodenal artery
E. the short gastric arteries
A
Last (8) PAGE: 346
13499 – The portal vein
1: runs upwards behind the epiploic foramen (aditus to the lesser sac)
2: is usually formed by the union of the splenic and superior mesenteric veins
3: has no tributaries other than the veins forming it
4: lies posterior to the (common) hepatic artery
FTFT
The portal vein is usually formed by the union of the superior mesenteric and splenic veins (B true), and runs upward in the free edge of the lesser omentum anterior to the epiploic foramen (A false). It has a number of important tributaries (C false). In the free margin of the lesser omentum it is posterior to the hepatic artery and the bile duct (D true).
801, 19893 – The portal vein
A. commences at the level of the third lumbar vertebra
B. is formed by the union of the splenic and inferior mesenteric veins
C. lies anterior to the bile duct
D. has a valve at its commencement
E. receives the left gastric vein
E
Last (6) PAGE: 302
A - 1st lumbar vertebra
E - It receives its major tributaries from pancreaticoduodenal veins, right and left gastric veins including oesophageal venous drainage, cystic veins, periumbilical veins and the remains of the embryonic umbilical veins (39E true and A, B, C, and D false).
807, 14163 – The portal vein
1: runs upwards between the layers of the lesser omentum
2: is usually formed by the union of the splenic and superior mesenteric veins
3: has gastric and oesophageal tributaries
4: lies posterior to the (common) hepatic artery
TTTT
Refer to Last, 10th Ed, page 260.
The portal vein is formed by the junction of splenic and superior mesenteric veins (40.2 true) at the level of the first lumbar vertebra behind the neck of the pancreas.
The portal vein and its tributaries are valveless, and measurements of the portal venous pressure can therefore be made readily from any of the tributaries of the vein or from the soft tissue pulp of the spleen. The portal vein in its first part runs vertically upwards behind pancreas and first part of duodenum and in front of the vena cava. It then loses contact with the vena cava and enters between the two layers of the lesser omentum where it lies behind the bile duct and hepatic artery to run to the porta hepatis (40.1 & 4 true). Here it divides in a T-shape into right and left branches which supply the respective liver halves. It receives its major tributaries from pancreaticoduodenal veins, right and left gastric veins including oesophageal venous drainage (40.3 true), cystic veins, periumbilical veins and the remains of the embryonic umbilical veins.
606 – S:Caput medusae is a feature of portal hypertension because R:the left umbilical vein joins the left branch of the portal vein.
S is true, R is true and a valid explanation of S
The umbilicus is an area of potential communication between the portal and systemic venous circulation.
In the fetus, fetal blood is oxygenated in the placenta, not in the lungs, and returns from the placenta via the left umbilical vein to the portal venous system by running into the left portal vein in the porta hepatis (R true). This oxygenated blood then short circuits the liver by running directly into the systemic circulation to the inferior vena cava via the ductus venosus. The two vessels (left umbilical vein and ductus venosus) run in a cleft in the liver from front to rear along its inferior surface. After birth the left umbilical vein and ductus venosus become fibrous cords - the ligamentum teres and ligamentum venosum - which lie imbedded in their respective fissures.
After birth the umbilicus becomes the watershed between cephalic and caudal direction of venous return from the subcutaneous tissues. Anastomosing networks of veins radiate upwards via the lateral thoracic vein to axillary vein; and downwards to the great saphenous vein and femoral vein. Within the peritoneal cavity, veins within the ligamentum teres continue to drain into the portal system. In portal hypertension shunting of blood occurs from the portal to the systemic venous circulation via the ligamentum teres and umbilicus to the subcutaneous veins. These dilate and run centrifugally from
the umbilicus - upwards and downwards to either the axillary or femoral veins, forming a Caput Medusae (S true). These anastomotic channels are an aid to diagnosis of portal hypertension. Both S and R are thus correct and R validly explains S.
Dilated subcutaneous abdominal wall collateral venous channels are also seen following thrombosis of the inferior vena cava. In this instance the venous flow is entirely upwards.
The other main site of collateral venous channels linking portal and systemic circulations in portal hypertension is across the mucosa of stomach and oesophagus as oesophageal submucosal varices.
20361 – S. The liver is supported by the hepatic veins BECAUSE R. the hepatic veins attach the liver firmly to the adjacent inferior vena cava
S is true, R is true and a valid explanation of S
Last (6) PAGE: 345
20997 – S. In the porta hepatis the hepatic ducts are inaccessible BECAUSE R. the hepatic ducts lie behind the hepatic artery and portal vein
Answer: both S and R and false
Last (8) PAGE: 344
743, 24289 – The common bile duct
1: is formed by the junction of the right and left hepatic ducts
2: lies in the free edge of the lesser omentum
3: lies behind the neck of the pancreas
4: opens at the ampulla, 10 cm. from the pylorus
FTFT
Last 10th Ed, Ch 5, page 259.
The bile duct is formed by the junction of cystic duct with common hepatic duct (1 false), which in turn is formed by the junction of right and left hepatic ducts. The bile duct is most surgically accessible in its upper third where it lies in the free edge of the lesser omentum supraduodenally to the right of the hepatic artery and in front of the portal vein (2 true). The bile duct in its second third passes behind the duodenum inclining to the right away from the portal vein, which runs more vertically. The lowest third then runs behind the pancreas in a groove between the head of the pancreas and the C of the duodenum, now some distance to the right of the portal vein which lies behind the neck of the pancreas (3 false). The bile duct opens into the duodenum at the ampulla approximately 10cm from the pylorus (4 true).
KEY ISSUE
The most surgically important variations of the biliary ducts are cystic duct anomalies - these range from an absence of cystic duct with the gall bladder opening directly into the common hepatic duct, to a long cystic duct entering the main duct system so low down in the third part of the main channel that there is effectively no (common) bile duct, just a long common hepatic duct and adjacent cystic duct - often united by a fascial ensheathment. The cystic duct may also drain into the right hepatic duct or into an aberrant or accessory right hepatic duct.
23859 – The common bile duct
1: crosses anterior to the right renal vein
2: has a middle part lying between the first part of the duodenum and the inferior vena cava
3: lies in the substance of the neck of the pancreas
4: is formed by the junction of right and left hepatic ducts in the porta hepatis
TTFF
Last (7) PAGE: 303
15218 – The (common) bile duct
A. lies over the inferior vena cava in the middle 1/3 of its course
B. is about 12 cm long in the adult
C. lies to the left of the hepatic artery
D. opens into the duodenum at the vertebral level of L3
E. receives the right and left hepatic ducts
Answer: A
Refer to Last, 10th Ed, Ch 5, page 259
13504 – The (common) bile duct
1: is lined by tall columnar epithelium which is mucus-secreting
2: is related posteriorly, in succession from above downwards, to the portal vein, inferior vena cava and right renal vein
3: lies in a deep groove on the posterior surface of the head of the pancreas
4: lies to the left of the hepatic artery
TTTF
The extrahepatic bile ducts are all lined by tall columnar epithelium which is mucus-secreting (A true). The accessible upper third of the bile duct lies in the free edge of the lesser omentum in front of the portal vein and to the right of the hepatic artery. The middle third lies behind the first part of the duodenum and on the inferior vena cava below the aditus to the lesser sac. The lower third runs to the right behind the head of the pancreas in a deep groove in front of the right renal vein (B and C true). The bile duct lies to the right of the hepatic artery (D false).
19294 – The bile duct
A. is lined by tall columnar, non-mucus secreting epithelium
B. is formed by the right and left hepatic ducts
C. passes anterior to the right renal vein
D. lies to the left of the hepatic artery
E. is about 14 cm in length
C
Last (8) PAGE: 350
E - Lasts 6-8cm not more than 8cm
24279 – With respect to the gall bladder
1: its bed forms one border of the caudate lobe
2: the mucosa in the body of the gall bladder contains mucus-secreting glands
3: it contains considerable smooth muscle in its wall
4: it is lined by simple columnar epithelium
FFFT
Last 8th ed. PAGE: 349.
18880 – The gall bladder
A. is lined by simple columnar epithelium
B. is in contact extraperitoneally with the duodenum
C. is directed downwards, backwards, and laterally from the fundus to duct
D. has considerable smooth muscle in its wall
E. has a submucosa with mucous glands
A
Last (8) PAGE: 350
13215 – The gall bladder
A. bed forms one border of the caudate lobe of the liver
B. bed lies entirely within the functional right lobe of the liver
C. contains mucus-secreting glands in the mucosa of its body
D. neck is an anterior relation of the right kidney
E. has a submucosa in its wall
E
The gall bladder bed forms one border of the quadrate, not the caudate, lobe (A false). The gallbladder bed lies on the division between the left and right lobes of the liver (B false). There are no mucous glands in the body of the gall bladder (C false), although few mucous glands are found in its neck. The neck of the gall bladder is superior and medial to the anterior surface of the right kidney (D false). There is a submucosa in the gall bladder (E true).
13379 – S:Truncal vagotomy causes hypotonia of the gallbladder because R:in truncal vagotomy fibres destined for the hepatic branch of the vagus are spared
S is true and R is false
Truncal vagotomy eliminates all the branches of the vagus below the diaphragm including the hepatic branch. Transection of the hepatic branch of the vagus results in a dilated and hypotonic gall bladder with increased risk of gall stone formation (S true). In truncal vagotomy the vagus is transected proximal to the hepatic branch whereas in selective or highly selective vagotomy the vagus is transected distal to the hepatic branch (R false).
737, 19629 – The cystic artery usually arises from
A. the superior mesenteric artery
B. the hepatic artery directly before its bifurcation
C. the right gastric artery
D. the right branch of the hepatic artery
E. the gastroduodenal artery
D
Last 8th ed. PAGE: 350.
The cystic artery normally arises from the right hepatic artery (D true) behind the biliary passages to run to the neck of the gall bladder in a triangle formed by the liver, common hepatic duct and cystic duct (Calot’s triangle). Variations in its origins are very common and
are important in gall bladder surgery. The right hepatic artery may run in front of the common hepatic duct, and the cystic artery may come from such an aberrant right hepatic artery or from the main hepatic artery itself. In any of these instances the cystic artery may pass in front of the biliary passages to reach the gall bladder, instead of passing behind these structures as is the normal pattern. An aberrant hepatic artery may be divided, if its course takes it unusually close to the gall bladder, in a mistaken belief that it is the cystic artery.
KEY ISSUE
The morphological lobes of the liver do not correspond to the right and left sides of the liver. The portal trinity divides the liver into right and left sides. The surgical importance of such a division is manifest; the right side of the liver consists of a right lateral (posterior) sector and a right medial (anterior) sector. The left side of the liver consists of left medial (anterior) and left lateral (posterior) sectors. The right medial (anterior) sector comprises segments 5 & 8, the right lateral (posterior) sector comprises segments 6 & 7; the left medial (anterior) sector comprises segments 3 & 4, and the left lateral (posterior) sector comprises segment 2. Segment 1 is the caudate lobe receiving branches from both sides and draining independently into vena cava.
21963 – The lesser sac
1: extends behind the first 2.5cm of duodenum
2: lies behind the transverse mesocolon
3: extends down in front of the stomach
4: has the common hepatic artery in its posterior wall
TFFT
Last (6) PAGE: 274.
1- 2-2.5cm
23094 – In pancreatic tissue
1: islets of Langerhans are scattered irregularly among the numerous glandular acini
2: the islets are paler staining than the acini in haematoxylin and eosin preparations
3: acinar cells have abundant rough endoplasmic reticulum
4: the alcohol-soluble B granules contain glucagon, and the A granules contain insulin
TTTF
Leeson & Leeson PAGE: 377, 380
4 - B granules contain insulin?
762 – The pancreas
1: has the splenic vein as a posterior relation.
2: has a neck which is anterior to the origin of the portal vein.
3: has the splenic artery running above its upper border.
4: is related to the lesser sac.
TTTT
1 is true. The splenic vein lies behind much of the body of the pancreas as a direct posterior relation.
2 is true. The neck of the pancreas is anterior to the origin of the portal vein from the superior mesenteric and splenic vein junctions.
3 is true. The splenic artery runs to the left just above the upper border of the pancreas.
4 is true. The pancreas is almost entirely retro-peritoneal and forms an important posterior relationship of the stomach in the stomach bed behind the lesser sac.
14158 – The pancreas
1: mostly lies in the supracolic compartment
2: is supplied by the splenic artery
3: lies at the level of the first lumbar vertebra
4: lies anterior to the common hepatic duct
TTTF
Last p352
767 – The tail of the pancreas
1: lies in the gastro-splenic ligament.
2: lies in the lieno-renal ligament.
3: is anterior to the left renal hilum.
4: touches the hilum of the spleen.
FTTT
1 is false. The tail of the pancreas does not lie within the gastro-splenic ligament. The gastro-splenic ligament contains the short gastric branches of the splenic artery.
2 is true. The tail of the pancreas lies within the two layers of the lieno-renal ligament.
3 is true. The tail of the pancreas lies anterior to the hilum of the left kidney.
4 is true. The tail of the pancreas abuts the hilum of the spleen accompanied by the splenic vessels and associated lymph nodes. In this site it is at potential risk during the operation of splenectomy.
778 – The pancreas usually receives arterial branches from the
1: splenic artery.
2: left gastric artery.
3: superior mesenteric artery.
4: right gastro epiploic artery.
TFTF
The blood supply of the pancreas straddles the junction of the coeliac and superior mesenteric arterial territories. The main supply is by the splenic artery from the coeliac axis which gives the artery pancreatica magna running the length of the organ. Much of the head is supplied by pancreaticoduodenal arteries arising both from coeliac and superior mesenteric arteries (35.1 & 3 true, 2 & 4 false). Venous return is by numerous small veins running to the splenic vein along the tail
and body and into superior mesenteric and portal veins from the head. The development of the pancreas as a dorsal and ventral bud into both dorsal and ventral mesogastria (the latter in common with the bile duct) leads to close adherence of the pancreas within the concavity of the duodenal C and to multiple vascular connections via pancreaticoduodenal vessels across this junction. Pancreatic resections thus usually require removal of the adjacent duodenal second part. In pancreaticoduodenectomy careful separation of the pancreas from its portal venous connections is the key feature of the operation. In pancreatic transplantation it is necessary to use both the superior mesenteric artery and the splenic artery inflow (either as separate anastomoses or using a Carrel patch from the aorta containing the origin of both vessels), to use the portal vein as the venous effluent, and to transplant the pancreas and second part of duodenum as a composite block, draining exocrine pancreatic secretions into gut or bladder. The pancreas can be transplanted either into the portal venous circulation or into the systemic venous circulation without apparent variation in results.
757, 22319 – The main pancreatic duct
1: drains all but the lower part of the head of the pancreas.
2: opens into the first part of the duodenum.
3: usually communicates with the accessory duct when this is present.
4: opens into the duodenum proximal to the accessory duct.
TFTF
Last (8) PAGE: 351.
1 is true. The main pancreatic duct drains all of the pancreas except for the uncinate process and lower part of the head.
2 is false. The main pancreatic duct opens into the second part of the duodenum about half way down its length.
3 is true. Communication between the two duct systems of the pancreas is common.
4 is false. The main pancreatic duct opens into the duodenum distal to the accessory duct; the latter opens more proximally into the second part of the duodenum.
The main pancreatic duct running from the tail to the head drains into the duodenal papilla about halfway down the second part of the duodenum. All the pancreas except for the uncinate process and lower part of the head are drained by the main pancreatic duct. The accessory pancreatic duct draining the remaining structures opens more proximally into the second part of the duodenum. Communication between the two duct systems is common (32.1 & 3 true, 2 & 4 false).
20451 – S. Splenectomy may be complicated by a pancreatic fistula BECAUSE R. the pancreatic tail touches the hilum of the spleen
S is true, R is true and a valid explanation of S
13233, 19581 – The spleen
A. has a convex surface related to the diaphragm and quadratus lumborum muscles
B. has a long axis which lies along the line of the seventh rib
C. projects into the lesser sac
D. is in the supra colic compartment
E. develops from the ventral mesogastrium
D
The convex surface of the spleen is related entirely to the diaphragm (A false). The long axis lies along the line of the tenth rib, not the seventh (B false). The spleen projects into the greater sac, not the lesser sac (C false), and lies in the supra-colic compartment (D true). It develops from the dorsal mesogastrium (E false).
19941 – The spleen
A. extends forward to the left costal margin
B. receives its main blood supply via the gastrolienal ligament
C. develops in the ventral mesogastrium
D. lies within the lesser sac
E. develops in the dorsal mesogastrium
E
Last (6) PAGE: 304
752 – The spleen
1: receives its main blood supply via the gastrolienal ligament.
2: develops in the dorsal mesogastrium.
3: projects into the greater sac.
4: is in contact with the tail of the pancreas at its hilum.
FTTT
The spleen develops in the dorsal mesogastrium (2 true), lying to the left of the lesser sac. It projects into the greater sac (3 true) covered by peritoneum of the original left leaf of the dorsal mesogastrium. The spleen is attached to the posterior abdominal wall by the lienorenal ligament, which contains the main splenic artery and vein (1 false) and the tail of the pancreas (which is in contact with the hilum of the spleen) (4 true). Damage to the tail of the pancreas is a potential complication of slenectomy. The dorsal mesogastrium continues from the spleen to stomach as the gastrolienal ligament containing the short gastric vessels. Splenectomy involves division of both peritoneal ligaments, taking care to avoid potential damage to pancreas and splenic flexure of colon posteriorly, and to stomach
anteriorly.
21398 – The spleen
1: contains lymphatic nodules which collectively form the white pulp
2: contains red pulp in which are found the splenic cords (of Billroth), venous sinuses and arterioles
3: has trabeculae of connective tissue which extend inward from the capsule
4: possesses lymphatic nodules with germinal centres containing Hassall’s corpuscles
TTTF
Leeson & Leeson PAGE: 297
13239 – The splenic vein
A. is valveless
B. empties into the inferior vena cava
C. joins the superior mesenteric vein behind the body of pancreas
D. receives the left testicular vein
E. has none of the above properties
A
The splenic vein is valveless (A true). The vein or splenic pulp can be used to measure the pressure in the portal vein, of which the splenic vein is a tributary (B false). The splenic vein joins the superior mesenteric vein behind the neck of the pancreas (C false). The left testicular vein drains into the left renal vein (D false).
19384 – The oesophagus
A. commences about 25 cm from the incisor teeth in the average adult
B. is constricted to some extent by the right main bronchus
C. is anterior to the thoracic aorta above the diaphragm
D. usually passes between the two crura of the diaphragm
E. has a thickening of circular muscle at its lower end just below the diaphragm
C
Last 10th ed. Page: 201 et seq
20283 – S. Air does not enter the oesophagus on inspiration BECAUSE R. tonic contraction of the crico-pharyngeus muscle is maintained through its innervation by external and/or recurrent laryngeal nerves
S is true, R is true and a valid explanation of S
Last 9th Edition PAGE: 488
564 – A surgeon is planning to mobilise the stomach into the chest to form a conduit after an oesophagectomy for cancer. Which blood vessel will she preserve to maintain its vascularity?
A. The left gastric artery.
B. The gastro-omental arcade.
C. The short gastric vessels.
D. The posterior gastric artery.
E. The splenic artery.
B
The gastro-omental arcade containing right gastro-epiploic and left gastroepiploic vessels needs to be preserved along the greater curvature of the stomach as this is mobilised. This arcade will maintain the vascularity of the stomach up to the fundus after division of the other vessels.
13489 – With respect to the stomach
1: anterior relations include diaphragm, anterior abdominal wall and left lobe of liver
2: the posterior wall is in direct contact with the spleen
3: the body of the pancreas separates the posterior wall of the stomach from the left renal vein
4: the posterior wall is related to the splenic vein on the posterior wall of the lesser sac
TFTF
The upper part of the stomach and lesser curvature are overlapped by the left lobe of the liver; elsewhere the anterior surface is in contact with the anterior abdominal wall and diaphragm (A true).
The posterior wall of the stomach is separated from the spleen by two layers of peritoneum (B false).
The hilum of the spleen lies in the angle between the stomach and the left kidney. The body of the pancreas separates the posterior wall of the stomach from the left renal vein (C true). At a slightly more cephalic level the splenic vein also is covered by the pancreas. The tortuous splenic artery lies above the upper border of the pancreas (D false).
23129 – With respect to the stomach
1: the body of the pancreas separates the posterior wall of the stomach from the left renal vein
2: anterior relations include diaphragm, anterior abdominal wall and left lobe of liver
3: the posterior wall is in direct contact with the spleen
4: the posterior wall is directly related to the splenic vein on the posterior wall of the lesser sac
TTFF
Last (8) PAGE: 334
The upper part of the stomach and lesser curvature are overlapped by the left lobe of the liver; elsewhere the anterior surface is in contact with the anterior abdominal wall and diaphragm.
The posterior wall of the stomach is separated from the spleen by two layers of peritoneum.
The hilum of the spleen lies in the angle between the stomach and the left kidney. The body of the pancreas separates the posterior wall of the stomach from the left renal vein. At a slightly more cephalic level the splenic vein also is covered by the pancreas. The tortuous splenic artery lies above the upper border of the pancreas.
659, 19066 – The stomach
A. has a posterior surface related, in part, to the inferior vena cava
B. has its junction with the duodenum indicated by the prepyloric vein
C. sends lymphatics from the lesser curvature to the pancreatico-lienal lymph nodes
D. has its cardiac orifice at the level of the 9th thoracic vertebra
E. is separated from the spleen by the lesser sac of peritoneum
B
Last (6) PAGE: 290.
A - Behind the lesser sac and stomach are the aorta and its upper branches (not the inferior vena cava), the diaphragm, pancreas, left suprarenal and left kidney
B - The gastroduodenal junction is often indicated by a prepyloric vein draining into the portal system.
C - The lymphatic drainage of the lesser curvature is predominantly to gastric nodes adjacent to the left and right gastric arteries. The lower part of the stomach’s anterior and posterior surfaces drain to splenic and pancreatic nodes.
D - The cardiac orifice under the diaphragm lies just to the left of the midline at the level of the 10th thoracic vertebra
E - The spleen also lies behind the
stomach, but stomach and spleen are separated by the greater peritoneal sac.
664 – The stomach
1: has an anterior surface innervated by the left vagal nerve.
2: is completely invested by peritoneum.
3: may lie with the greater curvature in the pelvis.
4: is supplied by coeliac axis vessels only.
TTTT
The stomach is a large mobile muscular bag relatively fixed at both ends; the ends are relatively close together on either side of the midline. The cardiac orifice under the diaphragm lies just to the left of the midline at the level of the 10th thoracic vertebra; and the pyloric opening is to the right of the midline at the level of the L1 vertebra. The stomach is completely invested by peritoneum (20:2
true) with the lesser omentum attached to its lesser curvature and the greater omentum to greater curvature. The fundus is in contact with the left diaphragmatic dome. The greater curvature may extend as far distally as the pelvis (20.3 true) in the upright position. The stomach’s anterior surface is related to the left lobe of the liver and abdominal wall. The posterior surface is related to the lesser
sac, behind which is the stomach bed covered by peritoneum of the posterior abdominal wall. Behind the lesser sac and stomach are the aorta and its upper branches (not the inferior vena cava), the diaphragm, pancreas, left suprarenal and left kidney. The spleen also lies behind the
stomach, but stomach and spleen are separated by the greater peritoneal sac. The gastroduodenal junction is often indicated by a prepyloric vein draining into the portal system. The blood supply of the stomach comes from the coeliac axis (20.4 true) via left and right
gastric and gastroepiploic, gastroduodenal and short gastric vessels. The anastomosis across the junction of coeliac axis and superior mesenteric artery blood supply is via pancreaticoduodenal vessels. The lymphatic drainage of the lesser curvature is predominantly to gastric nodes adjacent to the left and right gastric arteries. The lower part of the stomach’s anterior and posterior surfaces drain to splenic and pancreatic nodes. The left vagus supplies the anterior surface (20.1 true).
23489 – The trans-pyloric plane is
1: at the lower limit of the spinal cord
2: just above the level of the fundus of the gall-bladder
3: the level of origin of the coeliac artery
4: where the linea semilunaris meets the 8th costal cartilage
TTFF
Last (8) PAGE: 311.
22184 – The first part of the duodenum
1: has no villi
2: is touched by the gall bladder
3: is anterior to the bile duct
4: forms the lower boundary of the epiploic foramen
FTTT
Last (9) PAGE: 335-336.
13221 – The first part of the duodenum
A. runs backwards and downwards from the pylorus
B. lies opposite the eleventh thoracic vertebra in the recumbent position
C. is completely invested by peritoneum
D. lies anterior to the hilum of the right kidney
E. in part of its course is in contact with the anterior surface of the inferior vena cava
E
The first part of the duodenum runs to the right, backwards and somewhat upwards from the pylorus towards the posterior abdominal wall and inferior vena cava (A false), and extends from the level of L1 to T12 (B false). The first part is about 5 cm (2”) long. The first half is called the free or mobile part of the duodenum (the duodenal cap by radiologists) and lies between the peritoneal folds of the greater and lesser omenta. It is mobile because it is not attached to the posterior abdominal wall. The
next 3 cm of the first part passes backwards and upwards on the right crus of the diaphragm and right psoas muscle to reach the medial border of the right kidney. Its posterior surface is bare of peritoneum (C false). The first part of the duodenum is above the hilum of the right kidney; the second part lies anterior to the hilum as it curves downwards (D false). The first part of the duodenum forms the lowermost boundary of the epiploic foramen (opening into the less sac) and lies upon the bile duct, gastroduodenal artery and portal vein. Behind the epiploic foramen lies the inferior vena cava and the first part of the duodenum near its termination has the anterior surface of the inferior vena cava (E true).
694 – The first part of the duodenum
1: runs upwards and posteriorly from the pylorus.
2: is partly invested in peritoneum.
3: in part of its course, is closely applied to the anterior surface of the inferior vena cava.
4: forms the lowermost boundary of the opening into the lesser sac.
TTTT
1is correct.The first part of the duodenum runs upwards, posteriorly and to the right from the pylorus.
2 is correct.The first part of the duodenum is partly invested in peritoneum. Only the first 1 inch of the first part is mobile and is invested by the peritoneal folds of the greater and of the lesser omenta. The fixed second 1 inch is retro-peritoneal.
3 is correct. The fixed second half of the first part of the duodenum is retro-peritoneal and crosses the anterior surface of the vena cava.
4 is correct. The first part of the duodenum forms the lowermost boundary of the opening into the lesser sac.
The first part of duodenum runs upwards, posteriorly and to the right from the pylorus (21.1 true). Its initial 1” only is mobile and invested in the peritoneal folds of greater and of lesser omenta (21.2 true); this “duodenal cap” of radiologists is without macroscopic folds, unlike the reminder of the duodenum. This first 1” of the duodenum forms the lowermost boundary of the opening into the lesser sac (epiploic foramen, foramen of Winslow) (21.4 true). The fixed second 1” is retroperitoneal and crosses
the anterior surface of the inferior vena cava (21.3 true), where it lies immediately to the right of the aditus to the lesser sac.
699 – The first part of the duodenum
1: has no villi.
2: is touched by the gall bladder.
3: is anterior to the bile duct.
4: is approximately 5cm in length.
FTTT
1 is wrong. Like all the rest of the small bowel the duodenum’s absorbing mucosal surface is enhanced by microscopic villi.
2 is correct. An important anterior relation of the first part of the duodenum is the neck of the gallbladder and Hartman’s pouch. This is the site at which cholecystoduodenal fistulae can occur as a complication of cholelithiasis.
3 is correct. At the junction of its free and fixed halves, the first part of the duodenum crosses the bile duct anteriorly.
4 is correct. The first part of the duodenum is approximately 5 cm (2 inches) in length. The first half of this is free and mobile; the second half is fixed and retro-peritoneal.
At the junction of its free and fixed halves the first part of duodenum also crosses the bile duct anteriorly (22.3 true). An important anterior relation of the first part is the neck of the gall bladder and Hartmann’s pouch (22.2 true). Acute cholecystitis can be associated with impaction of a stone which erodes and fistulates between gall bladder and duodenum to cause gall stone ileus by subsequent impaction, usually in lower small bowel. Like all the rest of the small bowel, the duodenum’s absorbing mucosal surface is enhanced by microscopic villi (22.1 false); and
(except for the first 1” of the first part) also by macroscopic folds, the circular plicae or valvulae
conniventes. The first part totals 5cm in length (22.4 true).
23999 – The 3rd part of the duodenum
1: is anterior to the inferior mesenteric vein
2: is anterior to the right ureter
3: is crossed by the root of the mesentery
4: is posterior to the superior mesenteric vessels
FTTT
Last 8th ed./Leeson and Leeson PAGE: 292 / 338.
The inferior mesenteric vein is a posterior relation of the fourth part of the duodenum, not the third part
13227 – The third part of the duodenum
A. is anterior to the superior mesenteric vessels
B. is anterior to the bile duct
C. is anterior to the right ureter
D. is anterior to the inferior mesenteric vein
E. has no circular folds
C
The superior mesenteric vessels and the root of the mesentery run across the anterior aspect of the third part of the duodenum (A false). The bile duct terminates in the second part of the duodenum and never becomes a relation of third part of the duodenum. lt is anterior to the right ureter (C true), psoas muscle, right gonadal (testicular or ovarian) vessels, the inferior vena cava and the abdominal aorta.
The inferior mesenteric vein is a posterior relation of the fourth part of the duodenum, not the third part (D false). Circular folds are not found at the commencement of the duodenum but begin to appear 2.5-5 cm distal to the pylorus. Distal to the sphincter of Oddi they are large and close to each other (E false). In the upper half of the jejunum they are large and numerous, but beyond this point they diminish considerably in size, being almost absent in the distal part of the ileum.
23654 – The fourth part of the duodenum
1: lies on the left lumbar sympathetic trunk and the left psoas muscle
2: is associated with the duodenal recesses
3: is suspended from the right crus of the diaphragm by a suspensory ligament
4: has a mesentry
TTTF
Last (8) PAGE: 337-338
3 - The duodenojejunal flexure is also supported by a suspensory ligament with some muscular fibres (ligament of Treitz) running from the right crus in front of the aorta but behind the body of the pancreas.
