Abdomen

Question 1

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.

Answer 1

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.

Question 2

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

Answer 2

S is true and R is false
Last (6) PAGE: 299

Question 3

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

Answer 3

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

Question 4

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

Answer 4

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

Question 5

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.

Answer 5

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.

Question 6

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

Answer 6

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).

Question 7

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

Answer 7

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.

Question 8

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.

Answer 8

TFTF
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).

Question 9

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

Answer 9

S is true, R is true and a valid explanation of S
Last 9th ed. Page: 347

Question 10

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

Answer 10

TTFF
Last (8) PAGE: 326

Question 11

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.

Answer 11

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).

Question 12

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

Answer 12

A
Last (8) PAGE: 346

Question 13

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

Answer 13

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).

Question 14

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

Answer 14

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).

Question 15

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

Answer 15

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.

Question 16

606 – S:Caput medusae is a feature of portal hypertension because R:the left umbilical vein joins the left branch of the portal vein.

Answer 16

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.

Question 17

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

Answer 17

S is true, R is true and a valid explanation of S
Last (6) PAGE: 345

Question 18

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 18

Answer: both S and R and false
Last (8) PAGE: 344

Question 19

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

Answer 19

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.

Question 20

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

Answer 20

TTFF
Last (7) PAGE: 303

Question 21

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 21

Answer: A
Refer to Last, 10th Ed, Ch 5, page 259

Question 22

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

Answer 22

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).

Question 23

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

Answer 23

C
Last (8) PAGE: 350
E - Lasts 6-8cm not more than 8cm

Question 24

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

Answer 24

FFFT
Last 8th ed. PAGE: 349.

Question 25

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

Answer 25

A Last (8) PAGE: 350

Question 26

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

Answer 26

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).

Question 27

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

Answer 27

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).

Question 28

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

Answer 28

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.

Question 29

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

Answer 29

TFFT Last (6) PAGE: 274. 1- 2-2.5cm

Question 30

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

Answer 30

TTTF Leeson & Leeson PAGE: 377, 380 4 - B granules contain insulin?

Question 31

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.

Answer 31

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.

Question 32

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

Answer 32

TTTF Last p352

Question 33

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.

Answer 33

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.

Question 34

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.

Answer 34

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.

Question 35

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.

Answer 35

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).

Question 36

20451 – S. Splenectomy may be complicated by a pancreatic fistula BECAUSE R. the pancreatic tail touches the hilum of the spleen

Answer 36

S is true, R is true and a valid explanation of S

Question 37

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

Answer 37

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).

Question 38

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

Answer 38

E Last (6) PAGE: 304

Question 39

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.

Answer 39

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.

Question 40

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

Answer 40

TTTF Leeson & Leeson PAGE: 297

Question 41

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

Answer 41

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).

Question 42

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

Answer 42

C Last 10th ed. Page: 201 et seq

Question 43

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

Answer 43

S is true, R is true and a valid explanation of S Last 9th Edition PAGE: 488

Question 44

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.

Answer 44

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.

Question 45

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

Answer 45

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).

Question 46

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

Answer 46

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.

Question 47

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

Answer 47

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.

Question 48

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.

Answer 48

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).

Question 49

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

Answer 49

TTFF Last (8) PAGE: 311.

Question 50

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

Answer 50

FTTT Last (9) PAGE: 335-336.

Question 51

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

Answer 51

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).

Question 52

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.

Answer 52

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.

Question 53

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.

Answer 53

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).

Question 54

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

Answer 54

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

Question 55

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

Answer 55

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.

Question 56

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

Answer 56

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.

Question 57

704 – The fourth part of the duodenum A. is anterior to the left lumbar sympathetic trunk. B. is crossed anteriorly by the inferior mesenteric vein. C. is crossed anteriorly by the inferior mesenteric artery. D. lies anterior to the left ureter. E. is crossed by the attachment of the transverse colon.

Answer 57

A The duodenal ‘C’ defines 1st, 2nd, 3rd and 4th parts, which are respectively 2, 3, 4 and 1 inches long. The duodenum’s second, third and fourth parts complete a retroperitoneal C. The duodenum makes its loop around the head of the pancreas in its first 3 parts, crossing aorta and IVC twice. The short 4th part to the left of the aorta ascends to the duodenojejunal flexure at the level of L2, below the body of pancreas. It lies on the left psoas muscle and left lumbar sympathetic trunk (23A true). The 4th part is bound to the psoas fascia. 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. The transverse mesocolon attachment runs along the anterior border of the pancreas and lies above the fourth part and its duodenojejunal flexure (23E false). The mesentery of the small bowel runs downwards to the right from the duodenojejunal flexure, crossing the 3rd part of duodenum which is also crossed by the superior mesenteric artery and vein the vein lying to the right of the artery. The inferior mesenteric artery originates at the level of L4, below the 3rd and 4th parts of duodenum (23C false), and the inferior mesenteric vein ascends to the left of the 4th part to drain into the splenic vein (23B false). The 2nd part of duodenum lies over the pelviureteric junction of right kidney, but the fourth part is medial to the kidney and left ureter throughout (23D false).

Question 58

18874 – The fourth part of the duodenum A. is anterior to the left lumbar sympathetic trunk B. is attached to the left crus by a suspensory muscle C. is crossed anteriorly by the inferior mesenteric artery D. lies anterior to the left ureter E. is crossed by the attachment of the transverse colon

Answer 58

A Last (8) PAGE: 338 Fig. 5.29

Question 59

13349 – S:During mobilization of the right colon, the duodenum may be damaged at the junction of its second and third parts because R:the junction of the second and third parts of the duodenum is directly related to the colon

Answer 59

S is true, R is true and a valid explanation of S During mobilisation of the right colon, the colon and its mesentery are lifted away from the second and third parts of the duodenum (S true) which they overlie (R true and is a valid explanation).

Question 60

25716 – Concerning a loop ileostomy A. the opening is flush on the skin B. the effluent fluid is nonirritant to the skin C. is used as a routine to defunctional anterior resection anastomosis D. is often temporary E. is easy to manage

Answer 60

D

Question 61

20427 – S. Significant tears in the jejunal mesentery can lead to bowel necrosis BECAUSE R. the straight vessels from the arterial arcades in the jejunal mesentery are end arteries

Answer 61

S is true, R is true and a valid explanation of S Last 8th ed. PAGE: 327

Question 62

25981 – The jejunum differs from the ileum in that the former has 1: taller villi 2: a thicker wall 3: Peyer's patches on the antimesenteric border 4: a wider lumen

Answer 62

TTFT Last (6) Page:293, 289

Question 63

710 – Characteristics of the small intestine are 1: the jejunum is wider, thicker and redder than the ileum and has taller villi. 2: the wall of the jejunum is thicker and feels double layered, the wall of the ileum is thinner and feels single layered. 3: the lower part of the ileum has Peyer’s patches on the antimesenteric border. 4: Meckel’s diverticulum is present in approximately 2% of people, 60cm (2ft) from the caecum.

Answer 63

TTTT The small intestine from duodenojejunal flexure to ileocaecal valve comprises upper jejunum (l. empty) and lower ileum (l. twisted), the ileum contributing a little more than half the total. The length is variable and depends upon circumstances of measurement. The length is shorter during life than in cadavers, the endoscopic distance from pylorus to ileocaecal valve in living humans is about 300cm (120 inches). The more important aspect is the minimal length required after resection before short bowel syndrome becomes severely manifest (around 50-100cm, depending upon whether the colon and ileocaecal valve remain intact). Differences between jejunum and ileum are the wider lumen and thicker wall of the jejunum which feels of double thickness and is juicier and redder, in contrast to the thinner single-walled ileum; and the presence of lymphoid Peyer’s patches in the lower ileum on the antimesenteric border. The jejunum’s mucous membrane is also thicker with taller villi (1, 2, 3 true). Meckel’s diverticulum, a remnant of the vitellointestinal duct, has characteristics as stated (present in approximately 2% of people, 60cm (2ft) from the caecum, 4 true). The arcades of mesenteric vessels in the jejunum are long and narrow like Gothic cathedral windows; those of ileum are shorter and stubbier and less transparent because obscured by fat more like earlier Romanesque or Norman church windows. KEY ISSUE Notwithstanding the above, the only way to establish indubitably which part of small bowel is which is to find the duodenojejunal flexure and work down, or the ileocaecal junction and work up. Failure to observe this simple but vital rule has led to inadvertent gastroileal instead of gastro-jejunal anastomoses after partial gastrectomy, or to embarrassingly reversed Roux-Y loops. Make sure it doesn’t happen again with you or your patients. See also the Nutrition/Metabolism resource unit regarding rapid access to the duodenojejunal flexure.

Question 64

20265 – S. The jejunum has a greater absorptive area than the ileum BECAUSE R. the jejunum has more circular folds and longer villi than the ileum

Answer 64

S is true, R is true and a valid explanation of S Last Page: 339 Leeson & Leeson Page: 362

Question 65

7079 – The jejunum differs from the ileum in that the jejunum has A. shorter vasa recta B. a greater number of mucosal circular folds C. aggregated lymphatic nodules in the submucosa D. a lesser vascularity E. a thinner wall

Answer 65

B The jejunum has a greater number of mucosal circular folds than does the ileum. This accounts for the differences in appearance of dilated upper and lower small bowel loops. The jejunum has numerous transverse folds running across the lumen - the valvulae conniventes; the lower ileum looks more like a blown up featureless balloon without internal folds.

Question 66

21888 – Posterior relations of the root of the mesentery include the 1: inferior vena cava 2: right ureter 3: right gonadal vessels 4: third part of the duodenum

Answer 66

TTTT Last (8) PAGE: 314 The origin of the dorsal mesentery of fore, mid and hind gut from the posterior abdominal wall is modified from its simple vertical midline origin because of the rotational development of the gut and subsequent peritoneal fusions (zygosis). The mesentery of the small intestine extends from the level of the duodenojejunal flexure to the left of the midline, across the spinal column into the right iliac fossa to the caecum. The root of the mesentery crosses successively the 3rd part of duodenum, IVC, right gonadal vessels and ureter (42 1, 2, 3 & 4 true).

Question 67

20469 – S. Superior mesenteric arterial embolism usually results in midgut gangrene BECAUSE R. the superior mesenteric artery is functionally an end artery

Answer 67

Answer: S is true, R is true and a valid explanation of S

Question 68

783 – The termination of the superior mesenteric artery is at A. the ileocaecal junction. B. the appendix. C. the caecum. D. the terminal ileum. E. none of the above sites.

Answer 68

D The termination of the superior mesenteric artery is in the terminal ileum at the apex of the loop of the midgut which is the site of attachment of the vitello-intestinal duct. This is about 60 cm proximal to the caecum; the rotation of the midgut loop occurs around the superior mesenteric artery and its axis.

Question 69

24244 – The superior mesenteric artery supplies the 1: ileo-colic artery 2: inferior pancreatico-duodenal artery 3: superior pancreatico-duodenal artery 4: gastroduodenal artery

Answer 69

TTFF Last 10th Ed, Ch 5, page 238

Question 70

818 – Posterior relations of the root of the small bowel mesentery include 1: inferior vena cava. 2: right ureter. 3: right gonadal vessels. 4: third part of the duodenum

Answer 70

TTTT The origin of the dorsal mesentery of fore, mid and hind gut from the posterior abdominal wall is modified from its simple vertical midline origin because of the rotational development of the gut and subsequent peritoneal fusions (zygosis). The mesentery of the small intestine extends from the level of the duodenojejunal flexure to the left of the midline, across the spinal column into the right iliac fossa to the caecum. The root of the mesentery crosses successively the 3rd part of duodenum, IVC, right gonadal vessels and ureter (42 1, 2, 3 & 4 true).

Question 71

812 – The mesentery of the A. small intestine is attached obliquely along a line extending from the descending part of the duodenum to the left sacroiliac joint. B. small intestine contains branches of the inferior mesenteric artery. C. transverse colon is attached transversely to the anterior border of the pancreas. D. sigmoid colon lies over the promontory of the sacrum. E. sigmoid colon does not attach below the pelvic brim.

Answer 71

C The midgut mesentery contains duodenal and jejuno-ileal branches from the superior mesenteric midgut artery. The transverse mesocolon is attached transversely to the anterior border of the pancreas (41C true).

Question 72

19234 – The mesentery of the A. small intestine is attached obliquely along a line extending from the descending part of the duodenum to the left sacroiliac joint B. small intestine contains branches of the inferior mesenteric artery C. transverse colon is attached transversely to the anterior border of the pancreas D. sigmoid colon lies over the promontory of the sacrum E. sigmoid colon does not attach below the pelvic brim

Answer 72

C Last (6) PAGE: 271 et. seq. The midgut mesentery contains duodenal and jejuno-ileal branches from the superior mesenteric midgut artery. The transverse mesocolon is attached transversely to the anterior border of the pancreas (41C true).

Question 73

823, 23119 – The large bowel is characterised by 1: taeniae coli, converging on the appendix and the terminal sigmoid. 2: a mucosa with large crypts and villi. 3: a sigmoid colon mesentery with its apex over the bifurcation of the common iliac artery. 4: a transverse colon freely suspended by a mesocolon.

Answer 73

TFTT Last (8) PAGE: 339. The large bowel is characterised by taeniae coli, which are three separate bands of longitudinal smooth muscle converging on the appendix base at the caecum and again at the termination of sigmoid colon (1 true), where they become a continuous covering. Their relatively short length compared to the bowel gives the colon its characteristic sacculations. The ascending and descending colons are retroperitoneal, the transverse colon is freely suspended by its mesentery (4 true). The sigmoid colon has a mesentery attached in the shape of an upside down V. The upper limb runs along the pelvic brim, with the apex over the bifurcation of the common iliac artery (3 true) and close to where the left ureter crosses the external iliac artery at its origin. The lower limb descends into the pelvis to the 3rd piece of the sacrum. The mucosa of the large bowel contains numerous goblet cells and large crypts, but no villi (2 false).

Question 74

23639 – The left colic flexure 1: lies lower than the right colic flexure 2: receives parasympathetic vagal fibres 3: lies directly anterior to the left adrenal gland 4: is attached to the diaphragm by the phrenico-colic ligament

Answer 74

FFFT Last (6) PAGE: 272, 295

Question 75

19917 – The caecum A. is retroperitoneal B. bears more appendices epiploicae than the sigmoid colon C. is supplied by the right colic vessels D. has a continuous coat of longitudinal muscle E. has none of the above properties

Answer 75

E Last 10th, Ch 5 PAGE:249

Question 76

23834 – The vermiform appendix 1: arises from the posteromedial aspect of the caecum 2: has numerous lymphoid follicles 3: usually has a complete longitudinal muscle coat 4: is attached by a mesoappendix to the left leaf of the mesentery of the terminal ileum

Answer 76

TTTT Last (9) PAGE: 345

Question 77

795, 19593 – The appendicular artery arises from A. the anterior caecal artery B. a branch of the terminal ileal artery C. the marginal artery D. the posterior caecal artery E. none of the above

Answer 77

D Last 10th Ed, Ch 5 PAGE: 249, 250. The appendicular artery normally arises from the posterior caecal artery (D true) which in its turn arises from the descending terminal branch of the ileocolic artery. The appendicular artery is contained in the free margin of the meso-appendix, lying behind the terminal ileum and its mesentery. The artery finally runs directly on the wall of the appendix to terminate.

Question 78

19623 – The sigmoid colon A. receives parasympathetic innervation from the vagus B. sends venous drainage into the inferior vena cava C. is retroperitoneal D. is supplied by the pelvic splanchnic nerve (the nervi erigentes) E. has a mesocolon with a 5cm base over the common iliac vessels

Answer 78

D Last (8) PAGE: 342

Question 79

789 – The middle colic artery is a branch of the A. superior mesenteric artery B. inferior mesenteric artery. C. coeliac trunk. D. common hepatic artery. E. left gastric artery.

Answer 79

A The superior mesenteric artery is the artery of the mid gut, supplying the territory from the middle of the second part of the duodenum to the region of the transverse colon near the splenic flexure. Its main branches are the ileocolic, right colic and middle colic arteries (37A true), as well as jejunal, ileal, and pancreatico duodenal arteries. It terminates in the lower ileum at the site of the embryological apex of the midgut loop (36D true), and at the site at which Meckel's diverticulum develops. The rotation of the midgut loop is based around the axis of the artery.

Question 80

8398 – The peritoneum has 1: a firm attachment to the pancreas 2: an opening into the omental bursa, lying behind the pyloric antrum 3: a diaphragmatic part innervated completely by the phrenic nerve 4: its visceral part innervated by the intercostals

Answer 80

TFFF Last 10th ed, Ch 5

Question 81

19420 – The lesser omentum A. contains the splenic artery B. contains the right gastro-epiploic artery C. contains the left gastric artery D. is attached to the fissure for the ligamentum teres E. has none of the above properties

Answer 81

C Last 8th ed. Page: 317

Question 81

22494 – The lesser omentum is attached to 1: the greater curvature of the stomach 2: the margin of the caudate lobe of the liver 3: the quadrate lobe 4: porta hepatis

Answer 81

FTFT Last (9) PAGE: 315

Question 82

22043 – The lesser omentum 1: contains the hepatic branches of the anterior vagal trunk 2: has a L shaped attachment to the lower surface of the liver 3: has an anterior layer which is continuous with the posterior layer of the left triangular ligament 4: develops from the ventral mesogastrium

Answer 82

TTTT Last (8) PAGE: 317.

Question 83

21893 – The greater omentum is attached to 1: oesophagus 2: stomach 3: left kidney 4: colon

Answer 83

TTTT Last p314

Question 84

14086 – S: Surgical removal of the right suprarenal gland is especially hazardous because R: the right suprarenal gland is drained by a short vein directly into the inferior vena cava

Answer 84

Answer: S is true, R is true and a valid explanation of S Refer to Last, 10th ed, page 281

Question 85

21898 – The right suprarenal gland 1: lacks a peritoneal covering over the inferior half of its anterior surface 2: is drained by a short vein directly into the inferior vena cava 3: is crescentic in shape 4: lies between the right crus of the diaphragm and the inferior vena cava

Answer 85

FTFT Last 9th ed. Page: 373.

Question 86

22549 – The left suprarenal gland 1: is pyramidal in shape 2: is separated from the kidney by the renal fascia 3: is separated by peritoneum from the pancreas 4: produces mineralocorticoids mainly in the zona glomerulosa

Answer 86

FTFT Last (8) Page: 373 Wheater Page: 268

Question 87

24004 – The left suprarenal gland 1: surmounts the upper pole of the left kidney 2: is partially covered by peritoneum of the lesser sac 3: lies lateral to the left crus of the diaphragm 4: is crossed by the splenic artery

Answer 87

FTFT Last 10th Ed., Ch 5, p281.

Question 88

20433 – S. The adrenal medulla contains cells equivalent to post-ganglionic neurones BECAUSE R. the adrenal medulla is of neuroectodermal origin

Answer 88

Answer: S is true, R is true and a valid explanation of S Wheater et al Chapter: 17 Page: 271

Question 89

24239 – The right kidney 1: has a long axis sloping downwards and laterally 2: in the erect position, lies opposite the first three lumbar vertebrae 3: has the suprarenal gland in direct contact with its true capsule 4: is separated from the duodenum by peritoneum

Answer 89

TTFF Last (7) PAGE: 316,318.

Question 90

22038 – The muscles lying posterior to the kidney include the 1: quadratus lumborum 2: diaphragm 3: psoas major 4: transversus abdominis

Answer 90

TTTT Last 8th ed. PAGE: 367

Question 91

19599 – Which structure makes contact with the surface of the left kidney A. left suprarenal gland B. the 4th part of the duodenum C. the left lumbar sympathetic trunk D. the pancreas E. the duodenojejunal flexure

Answer 91

D Last (6) PAGE: 315 et seq

Question 92

20301 – S. Pneumothorax may occur during operations on the kidney BECAUSE R. the pleura is a posterior relation of the kidney

Answer 92

Answer: S is true, R is true and a valid explanation of S

Question 93

8540 – The left ureter in the female 1: crosses the genitofemoral nerve 2: is crossed superficially by the uterine artery 3: crosses the anterior to the inferior mesenteric vessels 4: is lateral to the obturator nerve in the pelvis

Answer 93

TTFF Last 10th ed, Ch 5

Question 94

22929 – The right ureter 1: crosses posterior to the right colic artery 2: crosses anterior to the right common iliac artery 3: crosses anterior to the right gonadal vessels 4: runs along the lateral margin of the right psoas major muscle

Answer 94

TTFF Last (8) PAGE: 372 et seq

Question 95

21533 – Structures marking the normal course of the ureter in an intravenous pyelogram include 1: tips of lumbar transverse processes 2: sacro-iliac joints 3: ischial spines 4: pubic tubercles

Answer 95

TTTT Last (6) PAGE: 320

Question 96

23854 – The ureter 1: crosses the genito femoral nerve 2: is 35 cm long 3: is lined by cubical epithelium 4: has a sole arterial supply from the renal artery

Answer 96

TFFF Last (6) PAGE: 320, 331

Question 97

21838 – The right renal artery 1: arises at the level of the 1st lumbar vertebra 2: crosses the right crus and psoas muscles 3: runs posterior to the inferior vena cava 4: is longer than the left renal artery

Answer 97

FTTT Last 8th ed. Page: 363 1: L1 on left, L2 on right

Question 98

14173 – The right renal vein 1: joins the inferior vena cava at the level of the second lumbar vertebra 2: receives the right suprarenal vein 3: lies anterior to the right renal artery 4: sometimes receives the right gonadal vein

Answer 98

TFTT Refer to Last, 10th Ed, page 271

Question 99

14982 – The renal artery 1: is posterior to the pancreas 2: lies posterior to the renal vein 3: has no branches except to the kidney 4: is the only paired branch of the aorta

Answer 99

TTFF Refer to Last, 10th Ed, page 268

Question 100

833 – The structure labelled 'D' in the abdominal CT scan (refer to illustration 3) - left renal vein 1: is three times as long as its right sided equivalent. 2: receives the left adrenal vein. 3: connects with the azygos and vertebral venous systems. 4: receives the left gonadal vein.

Answer 100

TTTT The left renal vein is about three times as long as its right sided counter part (1 true). The right renal vein incidentally can be seen entering the vena cava from the right kidney, and is a short stubby vein usually receiving no tributaries. The left renal vein, which crosses the aorta to reach the inferior vena cava, receives a number of tributaries. The left adrenal vein enters it from above, and it may also receive from above the left inferior phrenic vein. It receives the left gonadal vein inferiorly. This junction may or may not contain a valve, which is probably relevant to the development of varicocele in males. The left renal vein connects the azygos and vertebral venous systems (2, 3 & 4 true). The other major tributaries of the left renal vein of importance are one or more lumbar veins. These various tributaries and their control are of particular importance in the operation of left nephrectomy. In living donor nephrectomy, the increased length of the left renal vein makes the use of the left kidney more desirable than the right. The other structures illustrated in the CT scan are the superior mesenteric artery (C) and vein (B) passing in front of the uncinate process of the pancreas (A) with the head of the pancreas to the right of this. The lower part of the liver is also seen, together with some loops of large and small bowel containing contrast, and the beginnings of psoas and quadratus lumborum posteriorly.

Question 101

8525 – The arch of the aorta is crossed on the left side by 1: the left superior intercostal vein 2: branches from the cervical ganglia of the sympathetic trunk 3: the left vagus 4: the left phrenic nerve

Answer 101

TTTT Last 10th ed, Ch 4.

Question 102

829 – The structure outlined by "B" in the aortogram (refer to illustration 2) - SMA 1: lies anterior to the 3rd part of the duodenum. 2: lies posterior to the left renal vein. 3: lies anterior to a part of the pancreas. 4: gives branches to the duodenum.

Answer 102

TFTT The superior mesenteric artery comes off at L1 level behind the body of the pancreas and is labeled B. Its jejunal and other branches are not yet visible. It runs from its origin steeply downwards behind the splenic vein and the neck of the pancreas with the superior mesenteric vein on its right side. It then crosses in front of successively the left renal vein (2 false), the uncinate process of the pancreas, and the anterior surface of the third part of the duodenum, and then leaves the posterior abdominal wall to enter the upper end of the small gut mesentery. Its first branch is the inferior pancreaticoduodenal artery supplying the duodenum below the entrance of the bile duct, and running in the curve between the duodenum and the head of the pancreas (true 1, 3 and 4). The remaining arteries illustrated are the right renal artery C, the right inferior phrenic artery E giving branches to the suprarenal, and what appears to be an aberrant renal artery supplying the lower pole of the left kidney. When investigating live donors for renal transplantation, careful study of the first phases of aortography is important in identifying any anomalous renal arterial branches, which can be difficult to separate from lumbar arteries and jejunal arteries in later phases of the aortogram.

Question 103

23109 – At the level of the 12th thoracic vertebra the aorta 1: lies to the right of the median plane 2: lies to the right of the thoracic duct 3: passes through the left crus 4: gives off the coeliac trunk

Answer 103

FFFT Last p359

Question 104

23499 – The lumbar arteries on the right side 1: are separated by psoas major from the lumbar vertebrae 2: are five in number 3: pass behind the inferior vena cava 4: usually pass posterior to the lumbar sympathetic trunks

Answer 104

FFTT Last (6) PAGE: 307

Question 105

22504 – The inferior vena cava 1: receives blood from the five paired lumbar veins 2: is formed behind the right common iliac artery 3: receives both gonadal veins directly 4: is anterior to the right lumbar sympathetic trunk

Answer 105

FTFT Last 8th ed. Page: 367

Question 106

13509 – The inferior vena cava 1: commences at the level of the fourth lumbar vertebra 2: enters a deep groove on the bare area of the liver to the left of the caudate lobe 3: is posterior to the medial part of the right suprarenal gland 4: enters the right atrium to the right of the fossa ovalis

Answer 106

FFFT The inferior vena cava is formed by the junction of the right and left common iliac veins at a slightly lower level than the bifurcation of the aorta, behind the commencement of the right common iliac artery. The aorta bifurcates on the body of the fourth lumbar vertebra and the inferior vena cava forms on the body of the fifth lumbar vertebra (1 false). The inferior vena cava runs in a deep groove on the bare area of the liver to the right of the caudate lobe (2 false). The medial part of the right supra-renal gland insinuates itself behind the vena cava (3 false). The inferior vena cava ends by entering the right atrium. The fossa ovalis is in the inter-atrial septum above the site of entry of the vena cava and the atrium is thus to its right (D true).

Question 107

13968 – The sympathetic trunk enters the abdomen A. through the aortic opening B. behind the medial arcuate ligament C. together with the greater splanchnic nerve D. behind the lateral arcuate ligament E. through the crura

Answer 107

B Refer to Last, 10th Ed, page 180

Question 108

24049 – The sympathetic trunk 1: is usually crossed anteriorly by lumbar vessels 2: enters the abdomen by passing behind the medial arcuate ligament 3: passes anterior to the common iliac arteries 4: ends in front of the coccyx as the ganglion impar

Answer 108

FTFT Last (7) PAGE: 314, 344 The sympathetic trunk lies in front of the segmental vessels (1 false). It leaves the chest by passing behind the medial arcuate ligament (2 true). The common iliac vessels lie in front of the sympathetic trunks at the pelvic brim (3 false). The trunks converge at the front of the coccyx and unite at a small swelling, the ganglion impar (4 true).

Question 109

13479 – The abdominal sympathetic trunk 1: is crossed anteriorly by lumbar vessels 2: leaves the abdomen by passing through the aortic opening 3: passes anterior to the common iliac arteries 4: ends in front of the coccyx as the ganglion impar

Answer 109

FFFT The sympathetic trunk lies in front of the segmental vessels (1 false). It leaves the chest by passing behind the medial arcuate ligament (2 false). The common iliac vessels lie in front of the sympathetic trunks at the pelvic brim (3 false). The trunks converge at the front of the coccyx and unite at a small swelling, the ganglion impar (4 true).

Question 110

20313 – S. Injury to the superior hypogastric plexus may reduce male fertility BECAUSE R. loss of contraction of the internal urethral muscle may result in retrograde ejaculation

Answer 110

S is true, R is true and a valid explanation of S Last 10th Ed, Ch 5, page 291, 313

Question 111

21338 – The coeliac ganglion 1: gives postganglionic fibres to the foregut 2: supplies postganglionic fibres to the hindgut 3: contains the ganglion cells of visceral afferent neurons 4: is mainly concerned with the parasympathetic innervation of the gut

Answer 111

TTFF Last p365 two large irregularly shaped masses of nerve tissue in the upper abdomen. part of sympathetic subdivision of the autonomic nervous system. largest ganglia and innervate most of the digestive tract. appearance of lymph glands either side of midline in front of the crura of diaphragm close to suprarenal glands R side is behind inferior vena cava. contain neurons whose post ganglionic axons innervate the stomach, liver, gallbladder, spleen, kidney, small intestine and ascending and transverse colon. directly innervate ovarian theca and secondary interstitial cells, indirect on luteal cells

Question 112

15913 – The coeliac plexus 1: bradykinin 2: complement activation by-product (C5a) 3: prostacyclin ( PGI2) 4: fibronectin

Answer 112

TFTF Last (9) PAGE: 314; 365. behind the stomach and omental bursa. in front of the crura of the diaphragm at level of L1 formed in part by greater and lesser splanchnic nerves and anterior and posterior vagal trunks consisting of coeliac ganglia and aorticorenal ganglia catecholamines, neuropeptides, nitric oxide. main is acetylcholine

Question 113

19258 – The greater splanchnic nerve contains mainly A. somatic afferent fibres B. somatic efferent fibres C. preganglionic sympathetic fibres D. postganglionic sympathetic fibres E. para-sympathetic fibres from the vagus

Answer 113

C Last p363 thoracic splanchnic nerves arise from sympathetic trunk in the thorax and travel inferiorly to provide sympathetic supply to the abdomen. the nerves contain preganglionic sympathetic fibres and general visceral afferent fibres That craniosacral thing where sympathetic is in the middle then parasympathetic craniosacrally There are three main nerves: greater splanchnic. nerve roots T5-9 - modulates activity of enteric nervous system, blood flow, sympathetic innervation to adrenal medulla and catecholamine release. lesser T9-12 enteric nerveous system modulation of midgut least T12 - fibres synapse in the renal plexus

Question 114

3484 – With respect to the distribution of the vagal nerve trunks 1: the posterior vagus gives rise to hepatic branches which enter the liver via the lesser omentum and the porta hepatis 2: the main terminal branch of the anterior vagus nerve crosses the stomach distal to the incisura angularis about 5-6 cm from the pylorus 3: vagal branches to the stomach run parallel with the branches of the left and right arteries 4: some vagal fibres travelling to the parietal cell mass may sink into the muscular wall at the oesophagus some distance above the cardia

Answer 114

FTFT The anterior vagus gives rise to hepatic branches in the upper part of the lesser omentum (A false), and the main terminal branch of the anterior vagus (nerve of Latarget) runs down the lesser curvature and crosses onto the anterior wall of the stomach about 5-6 cm from the pylorus, and is preserved in highly selective vagotomy (B true). Vagal nerve fibres to the stomach do not accompany blood vessels but run obliquely downwards whereas the vessels tend to run transversely (C false). To denervate the upper stomach, it is necessary to clear the lowermost 5 cm or so of the oesophagus of all vessels and nerves, suggesting that some vagal fibres travelling to the parietal cell mass may sink into the muscle wall of the oesophagus well above the cardia (D true).

Question 115

618 – In the photograph of the abdominal wall (refer to illustration No.1) 1: ‘A’ lies over the linea alba. 2: ‘B’ lies over the fundus of the gall bladder. 3: ‘C’ lies at the level of the transpyloric plane. 4: ‘D’ lies at the level of the aortic bifurcation

Answer 115

TT

Question 116

3484 – With respect to the distribution of the vagal nerve trunks 1: the posterior vagus gives rise to hepatic branches which enter the liver via the lesser omentum and the porta hepatis 2: the main terminal branch of the anterior vagus nerve crosses the stomach distal to the incisura angularis about 5-6 cm from the pylorus 3: vagal branches to the stomach run parallel with the branches of the left and right arteries 4: some vagal fibres travelling to the parietal cell mass may sink into the muscular wall at the oesophagus some distance above the cardia

Answer 116

FTFT The anterior vagus gives rise to hepatic branches in the upper part of the lesser omentum (A false), and the main terminal branch of the anterior vagus (nerve of Latarget) runs down the lesser curvature and crosses onto the anterior wall of the stomach about 5-6 cm from the pylorus, and is preserved in highly selective vagotomy (B true). Vagal nerve fibres to the stomach do not accompany blood vessels but run obliquely downwards whereas the vessels tend to run transversely (C false). To denervate the upper stomach, it is necessary to clear the lowermost 5 cm or so of the oesophagus of all vessels and nerves, suggesting that some vagal fibres travelling to the parietal cell mass may sink into the muscle wall of the oesophagus well above the cardia (D true).

Question 117

618 – In the photograph of the abdominal wall (refer to illustration No.1) 1: ‘A’ lies over the linea alba. 2: ‘B’ lies over the fundus of the gall bladder. 3: ‘C’ lies at the level of the transpyloric plane. 4: ‘D’ lies at the level of the aortic bifurcation.

Answer 117

TTTF In the photograph of the abdominal wall A lies over the linea alba (1 true). The aponeuroses of all the abdominal flat muscles are fused between the recti to form the linea alba in the midline. This runs vertically from the xiphoid to the pubis. Below the umbilicus it is thinner and weaker than above the umbilicus where the distance between the recti is greater (as shown in the picture). The fused aponeuroses form a thick felted fibrous band, the fibres criss-cross like a radial ply tyre. B lies at the junction of the lateral rectus edge with the costal margin at the site of the tip of the ninth costal cartilage; which corresponds to the surface anatomy of the fundus of the gall bladder (2 true). The transpyloric plane at level C runs transversely at the mid point between the sternal notch above and pubic symphysis below. It crosses the costal margin at the tip of the ninth costal cartilage at the lateral rectus edge (3 true); it marks the approximate surface anatomy of the pylorus and the lower border of lumbar vertebra 1. Its anterior surface manifestation, as well as often corresponding with an abdominal skin crease, as shown in the photograph, can be used to mark the transition from the epigastrium above to the umbilical region below; although many find a more convenient junction at the sub-costal plane, which is at a lower level (approximately at the plane indicated by A) which also often has a transverse skin crease and marks a functional boundary between upper and lower abdominal integument. D, which overlies the umbilicus (4 false) lies approximately at the level of disc between third and fourth lumbar vertebrae (quartering the abdomen around the umbilicus is another common descriptive device). The transpyloric plane also lies approximately halfway between the lower end of the sternum and the umbilicus. The bifurcation of the aorta is below and to the left of the umbilicus, at approximately the level of the disc between the fourth and fifth lumbar vertebrae. The pulsation of the aorta can be felt in slim patients and for the most part is above the umbilicus. Similarly an aortic aneurysm gives a predominantly epigastric swelling.

Question 118

612, 13209 – The right-sided intercostal nerve that is invariably cut in a Kocher's subcostal incision is the A. seventh B. eighth C. ninth D. tenth E. eleventh

Answer 118

C Kocher's oblique subcostal incision divides the rectus abdominis muscle and extends laterally for a variable distance, depending on the patient's build. The seventh and eighth intercostal nerves run upwards and transversely close to the costal margin within the sheath and are often spared (A and B false). The ninth intercostal nerve runs obliquely across the incision at the lateral edge of the rectus sheath and is invariably cut (C true). The tenth, and rarely the eleventh, nerves may be divided only if the incision is extended laterally (D and E false).

Question 119

633, 13519, 23484 – At the site of a McBurney’s incision for appendicectomy 1: the ilio-inguinal nerve may be seen running superficial to the internal oblique muscle. 2: the external oblique muscle is entirely aponeurotic. 3: the transversus abdominis muscle is almost entirely fleshy. 4: the internal oblique muscle is almost entirely fleshy.

Answer 119

FFFT When performing appendicectomy through a McBurney or Lanz incision, the external oblique is aponeurotic in most of its extent but fleshy fibres are encountered laterally (2 false). The internal oblique muscle is split almost entirely in its fleshy portion, becoming aponeurotic just lateral to the rectus abdominis muscle (4 true). The ilio-inguinal nerve runs in the plane between the internal oblique and transversus abdominis muscles to enter the inguinal canal, and may occasionally be injured (1 false). The transversus abdominis has an aponeurosis extending more laterally than that of the internal oblique, and is split where it is usually half aponeurotic and half fleshy (3 false).

Question 120

20691 – S. Accidental damage to the ilio-inguinal nerve can occur during appendicectomy BECAUSE R. the ilio-inguinal nerve runs obliquely over the iliacus muscle in the right iliac fossa

Answer 120

S is true and R is false Last PAGE: 131.

Question 121

7343 – S Accidental damage to the ilio-inguinal nerve can occur during open appendicectomy Because R the ilio-inguinal nerve runs obliquely superior the iliacus on the posterior abdominal wall in the right iliac fossa

Answer 121

S is true, R is true but not a valid explanation of S The ilio-inguinal nerve can be damaged by the incision through the anterior abdominal wall during open appendectomy. The course of the nerve across the posterior abdominal wall on iliacus is correctly described, but this is not the site of iatrogenic damage to the nerve.

Question 121

922, 19222 – Blind incision of the lacunar ligament in operative treatment of strangulated femoral hernia via a low approach may be dangerous, because of the presence of an abnormal obturator artery arising from the A. femoral artery B. external iliac artery C. inferior epigastric artery D. cremasteric artery E. medial circumflex femoral artery

Answer 121

C Last (9) PAGE: 305. The obturator artery normally arises from the internal iliac artery, giving a pubic branch which anastomoses with the pubic branch of the inferior epigastric artery. An anomalous obturator artery occurs when the normal obturator artery is replaced by an aberrant origin from the inferior epigastric artery, which runs along the edge of the lacunar ligament to reach the obturator foramen. In this position it is at risk from blind incision of the lacunar ligament in operations for strangulated femoral hernia done by the low approach (C true).

Question 122

20103 – S. Division of the lacunar ligament during repair of a femoral hernia may result in haemorrhage BECAUSE R. an abnormal obturator artery may run medial to the femoral canal

Answer 122

S is true, R is true and a valid explanation of S Last 8th ed. PAGE: 397

Question 123

20511 – S. Lateral to the rectus sheath a transverse abdominal incision will minimise postoperative pain BECAUSE R. the direction of pull and maximal tension of the lateral abdominal muscles is generally transverse

Answer 123

S is true, R is true and a valid explanation of S C.S.S. 2nd ed. PAGE: 308 STEM Module: Gastrointestinal

Question 124

7718, 13343 – S: During lumbar sympathectomy, the peritoneum is less likely to be injured if the transversus abdominis muscle is split in the line of its fibres starting from the most medial aspect of the wound and extending laterally because R: the peritoneum is closely adherent to the lateral part of the transversus abdominis muscle

Answer 124

Answer: both S and R and false Last 10th ed, Ch 5 MCQs in Basic Surgical Science, Buzzard & Bandaranayake. During the operation of lumbar sympathectomy the transversus abdominis muscle is split in the line of its fibres starting preferably at the extreme lateral aspect of the wound where the fibres are muscular (S false), rather than medially where the fibres are aponeurotic and closely adherent to the underlying peritoneum (R false).

Question 125

594 – The medial umbilical fold contains the A. urachus. B. inferior epigastric artery. C. obliterated umbilical artery. D. umbilical vein. E. falciform ligament.

Answer 125

C - one median umbilical fold on the median umbilical ligament which in turn contains the urachus - two medial umbilical folds on the occluded/obliterated umbilical artery - two lateral umbilical folds on the inferior epigastric vessels In the lower abdomen peritoneal folds are raised on the posterior abdominal wall by the obliterated urachus running in the vertical midline from bladder apex to umbilicus as the median umbilical fold (A false), by the obliterated umbilical arteries on either side of the midline as the medial umbilical folds (C true), and by the inferior epigastric arteries before they pass in front of the posterior rectus sheath at the arcuate line as the lateral umbilical folds (B false). In the upper abdomen the falciform (sickle-shape) ligament connects the posterior rectus sheath and diaphragm with the anterior surface of the liver. The free lower edge of the falciform ligament contains a fibrous cord, the obliterated left umbilical vein, comprising the round ligament of the liver (D & E false).

Question 126

19474 – The medial umbilical fold contains A. the urachus B. the inferior epigastric artery C. the obliterated umbilical artery D. the umbilical vein E. the falciform ligament

Answer 126

C Last 8th ed. Page: 304

Question 127

21528 – The rectus abdominis muscle 1: is completely enclosed within the internal oblique aponeurosis 2: forms part of the anterior wall of the inguinal canal 3: is supplied by T7-T12 ventral rami 4: extends above the costal margin

Answer 127

FFTT Last (6) PAGE: 257. Arises: pubic crest and pubic symphysis Inserts: 5,6,7 costal cartilages, med inf costal margin, and posterior aspect of xiphoid. Nerve: ant primary rami 7-12

Question 128

24079 – The rectus abdominis muscle 1: is attached below to the ilio-pectineal line 2: is attached by tendinous intersections to the posterior wall of the rectus sheath 3: has a sheath formed entirely from the aponeuroses of external and internal oblique muscles 4: is attached above to the 4th costal cartilage

Answer 128

FFFF Last (8) PAGE: 298. Arises: pubic crest and pubic symphysis Inserts: 5,6,7 costal cartilages, med inf costal margin, and posterior aspect of xiphoid. Nerve: ant primary rami 7-12

Question 129

628, 13514 – The rectus abdominis muscle fibres 1: may atrophy in part following a paramedian muscle-splitting incision. 2: must be carefully sutured after division, to prevent incisional hernia 3: are divided in a Kocher’s sub-costal incision. 4: are attached superiorly to the seventh, eighth and ninth costal cartilages.

Answer 129

TFTF The medial portion of the rectus abdominis muscle may atrophy after a paramedian muscle-splitting incision (1 true). Division of the muscle as in a Kocher or transverse incision causes a new tendinous intersection to develop; the muscle need not be sutured (2 false, 3 true). The attachment of rectus abdominis superiorly is to the fifth, sixth and seventh costal cartilages (4 false).

Question 130

20823 – S. The rectus abdominis muscle is made more powerful by the presence of transverse intersections attached to both the anterior and posterior walls of its sheath BECAUSE R. the power of a muscle is dependent on the number of muscle fibres it contains, and not on their length

Answer 130

Answer: S is false and R is true Last (6) PAGE: 6, 257

Question 131

25983 – The semicircular fold of Douglas of the rectus sheath is 1: anterior to the rectus abdominis muscle 2: at the level of the umbilicus 3: the line below which the transversus aponeurosis, which include transversus, passes anterior to the rectus abdominis muscle 4: lateral to the rectus abdominis muscle

Answer 131

FFTT Last's 8th Ed., p299. arcuate line of rectus sheath./ arcuate line . it is where the inferior epigastric artery and vein perforate the rectus abdominis it occurs about half the distance from the umbilicus to the pubic crest.

Question 132

588, 13203, 18928 – The surface landmark which is a guide to the position of the gastro-oesophageal orifice is the A. seventh left costal cartilage B. left linea semilunaris C. tip of the ninth left costal cartilage D. eighth thoracic vertebra E. left nipple

Answer 132

A Last 10th ed. PAGE: 201. The oesophagus extends from the cricoid cartilage at the level of the sixth cervical vertebra, to the cardiac orifice of the stomach at the level of the lower part of the tenth thoracic vertebra over the left seventh costal cartilage, a thumb breadth from the side of the sternum (A true). The left linea semilunaris marks the lateral rectus edge which crosses the costal margin at the tip of the left ninth costal cartilage, or approximately the level of L1 (B and C false). The eighth thoracic vertebral level marks the inferior vena caval orifice at the dome of the diaphragm to the right of the midline (D false); and the left nipple is commonly in the fourth left intercostal space (E false).

Question 133

20907 – S. Lymph drainage from the anterior abdominal wall between the umbilicus and costal margin is to the inguinal region BECAUSE R. lymphatic channels may follow subcutaneous veins

Answer 133

Answer: S is false and R is true Last 10th ed, pgs 173 & 178. Goes to axillary nodes

Question 134

21968 – The inferior epigastric artery 1: runs between the transversus and internal oblique muscles 2: runs anterior to the rectus abdominis muscle 3: gives rise to the artery of the ductus deferens 4: lies medial to the deep inguinal ring

Answer 134

FFFT Last (9) PAGE: 300 1: superior to peritoneum but deep to the transversalis fascia. Superior epigastric a supplies the rectus muscle and anastomoses within it with the inferior epigastric artery. This vessel leaves the external iliac at the inguinal ligament, passes upwards behind the conjoint tendon, slips over the semicircular fold and so enters the sheath. Veins accompany these arteries, draining to internal thoracic and external iliac veins respectively.

Question 135

13474, 21508 – The umbilicus 1: lies nearer to the xiphoid than to the pubis 2: is supplied with cutaneous innervation by the 11th thoracic nerve 3: transmits, during development, the umbilical cord containing two arteries and two veins 4: usually lies at about the level of the disc between the third and fourth lumbar vertebrae

Answer 135

FFFT Last (6). The umbilicus lies approximately midway between xiphoid and pubis (A false), derives its cutaneous innervation from the tenth thoracic nerve (B false), transmits, during development, the umbilical cord, containing two arteries and one vein (C false) and lies at about the level of the disc between the third and fourth lumbar vertebrae (D true).

Question 136

14992 – In relation to the diaphragm 1: the inferior vena cava passes through in the midline 2: the thoracic duct passes through the aortic opening 3: the right crus has more extensive attachments than the left 4: the sympathetic trunk passes posterior to the median arcuate ligament

Answer 136

FTTF Refer to Last, 10th Ed, page 179-180 1 - slightly to the right 4 - posterior to the medial arcuate ligament (median has the aorta)

Question 137

18850 – The internal oblique muscle A. is attached to the lateral 2/3 of the inguinal ligament B. becomes aponeurotic in the lumbar region C. forms the posterior rectus sheath immediately above the inguinal ligament D. has a free upper muscular border E. is innervated by the 7 - 12 intercostal nerves exclusively

Answer 137

A Last 10th Ed, page 217

Question 138

21498 – The internal oblique muscle of the abdomen 1: has partial origin from the inguinal ligament 2: innervated from 7th to 12th intercostal nerves exclusively 3: has a free upper muscular border 4: corresponds to the internal intercostal muscle layer in the thorax

Answer 138

TFFT Last (6) PAGE: 256 Arises lumbar fascia, anterior two thirds of iliac crest and latearal two thirds of inguinal ligament inserts costal margin (ribs and costal cartilages), aponeurosis of rectus sheath (anterior and post), conjoint tendon to pubic crest and pectineal line Nerve anti primary rami T7-12 and conjoint tendon ilioinguinal N (L1) 1: lateral 2/3 of inguinal ligamnet 2: innervated by 7-12 and ilioinguinal

Question 139

19216 – The external oblique muscle of the abdomen A. arises from the costal cartilages of the lowest eight ribs B. attaches to the lumbar fascia posteriorly C. interdigitates with the serratus anterior muscle D. has an aponeurotic attachment to the iliac crest E. is innervated by the ilio-inguinal nerve

Answer 139

C Last 8th ed. PAGE: 295 Arises: anterior angles of lower eight ribs Inserts: outer half of iliac crest, inguinal ligament, pubic tubercle and crest and aponeurosis of anterior rectus sheath, linea alba, and xiphisternum Nerve: anterior primary rami T7-12 Interdigitates with four lips of serratus anterior and four of latissimus dorsi A: not costal cartilage B. not lumbar D; attaches directly to iliac crest E: innervated by primary ant rami T7-12 - internal oblique is also supplied by ilioinguinal nerve