MGA test 4

The expanded region of the lower rectum, where fecal matter is retained, is known as the: Anal columns Anal sinuses Ampulla Transverse folds

Ampula

The terminal ends of the ilioinguinal nerves in the female are referred to as: Anterior cutaneous branches Anterior labial Cremasterics Iliohypogastrics

B The ilioinguinal nerves supply motor and sensory fibers to the abdominal wall inferior to the umbilicus. What differentiates these nerves from the iliohypogastric nerves is that the ilioinguinal nerves also innervate the scrotum or labia by passing through the inguinal canal. These branches are called the anterior scrotal or labial nerves. Anterior cutaneous branches pretty much describes what these branches are, but there's an answer here that is a little more specific. The genital branch of the genitofemoral nerve innervates the cremaster muscle.

Which organs are in contact with the spleen?

Colon Diaphragm Pancreas Stomach

The nerve that innervates the cells of the suprarenal medulla consists of fibers of the: Greater thoracic splanchnic nerve Lesser thoracic splanchnic nerve Least thoracic splanchnic nerve Anterior vagal trunk Posterior vagal trunk

Greater thoracic splanchnic nerve ( is on upper abdominal region)

Which nerve passes through the superficial inguinal ring and may therefore be endangered during inguinal hernia repair?

Ilioinguinal

After giving birth, a patient complains of urinary stress incontinence characterized by dribbling of urine with an increase in intra-abdominal pressure. Her physician suspects injury to the pelvic floor during delivery which may have altered the position of the neck of bladder and the urethra. Which muscle was most likely damaged during the vaginal delivery? Bulbospongiosus Coccygeus Levator ani Obturator internus Piriformis

Levator ani

The nerves of the lumbar plexus are arranged around specific muscles of the posterior abdominal wall. Which of these nerves lies immediately medial to the psoas major muscle?

Obturator

During a vasectomy, the ductus deferens is ligated in the superior part of the scrotum. Two months following this sterilization procedure, the subsequent ejaculate contains:

Seminal fluid and prostatic fluid

The skin of the mons pubis is supplied by which nerve? Anterior scrotal Anterior labial Femoral branch of the genitofemoral Iliohypogastric nerve Subcostal nerve

The correct answer is: Anterior labial The anterior labial nerve (anterior scrotal in males) is the terminal branch of the ilioinguinal nerve. It innervates the skin of the mons pubis in females and the skin of the anterior scrotum in males. The femoral branch of the genitofemoral nerve provides sensory innervation to the upper medial thigh. The iliohypogastric nerve innervates muscles of the abdominal wall. The subcostal nerve is the ventral primary ramus of the twelfth thoracic nerve. It innervates muscles of the abdominal wall and skin of the lower abdominal wall.

The cisterna chyli accompanies which structure as it passes through the diaphragm?

The correct answer is: Aorta

Which is not a boundary of the epiploic (omental) foramen? Aorta Caudate lobe of the liver First part of the duodenum Hepatoduodenal ligament

The correct answer is: Aorta The epiploic (omental) foramen is a passageway between the greater peritoneal sac and the lesser peritoneal sac. It is located posterior to the hepatoduodenal ligament and the first part of the duodenum. The caudate lobe of the liver forms the posterior wall of the epiploic foramen. The aorta is retroperiteoneal, and it does not form a boundary of this foramen.

The prostate gland: Contains upper, middle and lower lobes Encircles the urethra Is well imaged radiologically using an intravenous urogram Is extraperitoneal B and D

The correct answer is: B and D There are two true statements here. First, the prostate gland encircles the urethra. It circles around the first part of the urethra, the prostatic urethra. This is why urinary retention is one symptom of prostatic hypertrophy--if the prostate is enlarged, it may close around the urethra, occluding this passage and preventing urine from exiting the bladder. The prostate gland is also extraperitoneal. Remember: the *rectovesicular pouch, a fold of peritoneum that hangs between the bladder and rectum, is the lowest extent of the peritoneal cavity in males* . But, the prostate is found on the posterior side of the bladder, below the point where the peritoneal membrane created this fold. So, it is an extraperitoneal organ. The* lobes of the prostate are: anterior, posterior, lateral, and middle. *Finally, the prostate would not be imaged using an intravenous urogram. In an intravenous urogram, a patient is given IV contrast, and radiographic images are taken as the contrast is excreted, passing through the kidneys, ureters, and bladder. Since the prostate is not part of this excretory pathway, it would not be viewed through this method.

During a hysterectomy and an oophorectomy, the uterine and ovarian vessels must be ligated. These vessels can be found in which ligaments? Broad and ovarian Broad and suspensory Round and ovarian Round and suspensory Suspensory and ovarian

The correct answer is: Broad and suspensory *The uterine vessels are found in the inferior portion of the broad ligament, while the ovarian vessels are found in the suspensory ligaments of the ovaries.* The suspensory ligaments of the ovaries are peritoneal folds covering ovarian arteries, veins, nerves, and lymphatics as the structures pass over the pelvic brim to reach the ovary. The ovarian ligament proper is a round cord which attaches the ovary to the uterus, just below the entrance of the uterine tube into the uterus. The round ligament of the uterus is a connective tissue band that attaches to the inner aspect of the labium majus and the uterus--it traverses the inguinal canal and it is found in the broad ligament.

During exploratory surgery of the abdomen, an incidental finding was a herniation of bowel between the lateral edge of the rectus abdominis muscle, the inguinal ligament and the inferior epigastric vessels. These boundaries defined the hernia as a(n):

The correct answer is: Direct inguinal hernia The boundaries listed in this question are the boundaries of the inguinal triangle, which is the site for direct inguinal hernias. Remember--direct inguinal hernias protrude through the weak fascia of the abdominal wall, medial to the inferior epigastric vessels. Indirect inguinal hernias (which can also be called congenital inguinal hernias) occur lateral to the inferior epigastric vessels--they protrude through the deep inguinal ring. Femoral hernias protrude through the femoral ring, into the femoral canal. They can be felt in the femoral triangle, inferior to the pubic tubercle. Finally, an umbilical hernia is an abnormal protrusion of abdominal contents into a defect in the umbilical area. These are common in the newborn, but they usually resolve by age two.

The vagus nerve passes into the abdomen by passing through the

The correct answer is: Esophageal hiatus

The superficial inguinal ring is an opening in which structure?

The correct answer is: External abdominal oblique aponeurosis

The pararenal fat in the kidney bed is an elaboration of: Peritoneum Extraperitoneal connective tissue Transversalis fascia Fusion fascia

The correct answer is: Extraperitoneal connective tissue

Which ligament is a derivative of the dorsal mesogastrium?

The correct answer is: Gastrocolic Structures involving the spleen and posterior part of the developing stomach (which becomes the greater curvature) are derived from the dorsal mesogastrium. This includes the gastrocolic ligament (including the omental apron), gastrophrenic ligament, gastrosplenic ligament, and the splenorenal ligament. The liver develops in the ventral mesogastrium. This means that any structures involving the liver and its attachment to the lesser curvature of the stomach or the body wall will be derivatives of the ventral mesogastrium. This includes the coronary ligament, the falciform ligament, the left and right triangular ligaments, the hepatogastric ligament, and the hepatoduodenal ligament.

In order to approach the area posterior to the stomach, a surgeon decided to go through the lesser omentum. Before incising the mesentery she was careful to find and preserve a nerve lying in the upper portion of the hepatogastric ligament, i.e., the

The correct answer is: Hepatic branch of the anterior vagal trunk

patient was diagnosed with pancreatitis due to a reflux of bile into the pancreatic duct caused by a gallstone. The stone is likely to be lodged at the:

The correct answer is: Hepatopancreatic ampulla

Following an emergency appendectomy your patient complained of having paresthesia (numbness) of the skin at the pubic region. The most likely nerve that has been injured during the operation is: Genitofemoral Iliohypogastric Subcostal Spinal nerve T10 Spinal nerve T9

The correct answer is: Iliohypogastric The iliohypogastric nerve is a branch of the lumbar plexus. It provides sensory innervation to the skin of the lower abdominal wall, upper hip and upper thigh. This is the region where the patient is experiencing paresthesia, so this nerve must be injured. The genitofemoral nerve is another nerve from the lumbar plexus. It provides sensory innervation to the skin of the anterior scrotum or labia majora and upper medial thigh. The subcostal nerve is the ventral primary ramus of T12--it is the equivalent of an intercostal nerve at a higher thoracic level. It provides sensory innervation to the anterolateral abdominal wall, but in an area superior to the pubic region. A spinal nerve would not have been injured in the operation. Remember--the spinal nerve is just that small segment of nerve that exists once the dorsal and ventral rootlets come together, before the dorsal and ventral primary rami branch off. In any case, the T9 and T10 dermatomes are superior to the area where the patient is experiencing paresthesia.

The spleen normally does not descend below the costal margin. However, it pushes downward and medially when pathologically enlarged. What structure limits the straight vertical downward movement? Left colic flexure Left suprarenal gland Ligament of Treitz Pancreas Stomach

The correct answer is: Left colic flexure The left colic flexure, also called the splenic flexure, is the point where the colon takes a sharp downward turn. This flexure is the point where the transverse colon ends and the descending colon begins. It is located immediately inferior to the spleen, so an enlarged spleen must move medially to avoid this colic flexure. The left suprarenal gland is a retroperitoneal structure which sits superior to the kidney. The suspensory muscle of the duodenum or ligament of Treitz is a thin sheet of muscle derived from the right crus of the diaphragm--it suspends the fourth part of the duodenum from the posterior abdominal wall. Both the pancreas and stomach lie medial to the speen. These organs would not prevent the spleen from descending inferiorly.

A patient presented with a swollen spleen, which protruded medially toward the umbilicus in the abdomen. A vertical and downward expansion of the spleen was resisted by the: Tail of the pancreas Left colic flexure Left kidney Left renal artery Stomach

The correct answer is: Left colic flexure The left colic flexure, also called the splenic flexure, is the point where the colon takes a sharp downward turn. This flexure is the point where the transverse colon ends and the descending colon begins. It is located immediately inferior to the spleen, so an enlarged spleen must move medially to avoid this colic flexure. The stomach lies medial to the speen, and the tail of the pancreas inserts into the hilum of the spleen. These organs would not prevent the spleen from descending inferiorly. The kidney and left renal artery are retroperitoneal organs; they would not obstruct movement of the spleen.

The normal pattern of venous and lymphatic drainage of the superficial tissues of the anterior abdominal wall is arranged around a horizontal plane. Above that plane, drainage is in a cranial direction; below the plane drainage is in a caudal direction. This reference plane corresponds to:

The correct answer is: Level of umbilicus The umbilicus is an important landmark for venous and lymphatic drainage of the abdominal wall. Above the umbilicus, lymphatics drain into the axillary lymph nodes and the venous blood drains into the superior epigastric vein, which drains to the internal thoracic vein. Below the umbilicus, lymphatics drain into the superficial inguinal lymph nodes, while venous blood drains into the inferior epigastric vein and the external iliac vein.

Upon endoscopic examination of a 65-year-old man who had a history of a chronic duodenal ulcer, it was found that the ulcer had been eroding the posterior wall of the first part of the duodenum. If erosion perforates the wall, the gastric expellant of high acidity would endanger the structures in its vicinity. Which is least likely to be endangered?

The correct answer is: Main pancreatic duct The pancreas is inferior to the superior portion of the duodenum, and the main pancreatic duct is found deep within the pancreas.

During a hysterectomy, the uterine vessels are ligated. However, the patient's uterus continues to bleed. The most likely source of blood still supplying the uterus is from which artery? Inferior vesical Internal pudendal Middle rectal Ovarian Superior vesical

The correct answer is: Ovarian The ovarian artery has branches which supply the uterus. In fact, this artery anastomoses with the uterine artery. So, if the uterus is still bleeding after ligating the uterine artery, the ovarian artery is probably supplying the uterus. *The inferior vesical artery supplies the inferior part of the bladder--it anastomoses with the middle rectal artery.* The internal pudendal artery supplies blood to the perineum. The middle rectal artery supplies blood to the rectum. The superior vesical artery supplies blood to the superior bladder.

A pediatrician has diagnosed a newborn baby of having right-sided cryptorchidism (undescended testis). The testis may have been trapped in any site EXCEPT: At the deep inguinal ring Just outside the superficial inguinal ring Pelvic brim Perineum Somewhere in the inguinal canal

The correct answer is: Perineum To understand this question, you need to understand the descent of the testes. The testes begin as retroperitoneal structures in the posterior abdominal wall. They are attached to the anterolateral abdominal wall by the gubernaculum. The gubernaculum "pulls" the testes through the deep inguinal ring, inguinal canal, superficial inguinal ring, and over the pelvic brim. The gubernaculum is preceded by the processus vaginalis, which is derived from the peritoneum anterior to the testes. The processus vaginalis "pushes" the muscle and fascia layers, which will eventually make up the canal and spermatic cord, into the scrotum. After the testes are in position in the scrotum, the gubernaculum persists as the scrotal ligament, while part of the processus vaginalis remains as a bursa-like sac called the tunica vaginalis testis. So, the testes could get caught in the deep inguinal ring, inguinal canal, at the superficial inguinal ring, or at the pelvic brim. The testes are never in the perineum, and they wouldn't get stuck there.

A female patient is found to have an ectopic (tubal) pregnancy (embryo develops in the uterine tube). In order to gain access to the peritoneal cavity endoscopically to remove the embryo, the instrument can be passed into the vagina and through the: anterior fornix cervix posterior fornix retropubic space vesicouterine pouch

The correct answer is: Posterior fornix In females, the rectouterine pouch is a peritoneal fold reflecting from the rectum to the posterior fornix of the vagina. This means that an incision made through the posterior fornix of the vagina will allow a surgeon to enter the rectouterine pouch of the peritoneal cavity and remove the embryo. Take a look at Netter Plate 337 for a picture of this relationship. Entering the anterior fornix of the vagina would not allow a surgeon to enter the peritoneal cavity. The cervix is the inferior portion of the uterus which connects the uterus to the vagina--passing through the cervix would allow the surgeon to enter the uterus, but not the peritoneal cavity. The vesicouterine pouch is a fold of peritoneum reflected from the uterus onto the posterior margin of the superior surface of the bladder--it helps to separate the uterus from the bladder.

In a CT scan of the pelvis, the uterus is located: posterior to the bladder and rectum posterior to the bladder and anterior to the rectum anterior to the bladder and rectum anterior to the bladder and posterior to the rectum

The correct answer is: Posterior to the bladder and anterior to the rectum In the female pelvis, the bladder is the most anterior organ; the uterus is posterior to the bladder, and the rectum is posterior to the bladder and uterus. See Netter Plate 337 for a picture.

he nerves that end on the secretory cells of the medulla of the suprarenal glands are principally: Preganglionic fibers from the greater thoracic splanchnic nerve Postganglionic fibers from the celiac plexus Postganglionic fibers from the aorticorenal ganglia Preganglionic fibers from the lesser thoracic splanchnic nerve Postganglionic fibers from the renal plexus

The correct answer is: Preganglionic fibers from the greater thoracic splanchnic nerve

In a female with an indirect inguinal hernia, the herniated mass lies along side of which structure as it traverses the inguinal canal? Iliohypogastric nerve Inferior epigastric artery Ovarian artery and vein Pectineal ligament Round ligament of the uterus

The correct answer is: Round ligament of the uterus In females, the round ligament of the uterus is the main structure traversing the inguinal canal. In males, the most important structure in the inguinal canal is the spermatic cord.

A caudal epidural block is a form of regional anesthetic used in childbirth. Within the sacral canal, the anesthetic agent bathes the sacral spinal nerve roots which would anesthetize all of the following nerves except:

The correct answer is: Sacral splanchnics

EMBRYO *Which pair of structures does NOT differentiate from comparable embryonic structures in the male and female?*

The correct answer is: Shaft of penis and labia majora The shaft of the penis is an analog of the shaft of the clitoris, while the labia majora is derived from the same embryonic structures as the scrotum. The other three answer choices list structures that come from comparable embryonic structures in the male and female. See Netter Plate 389 for a picture of the homologous structures in males and females!

During the surgical repair of a hiatal hernia, the celiac branch of the posterior vagal trunk was severed accidentally. The damage to this nerve would affect the muscular movements, as well as some secretory activities, of the gastrointestinal tract (GI). Which segment is least likely to be affected by the nerve damage? Ascending colon Cecum Jejunum Ileum Sigmoid colon

The correct answer is: Sigmoid colon The vagus nerve supplies parasympathetic fibers to all of the abdominal organs which receive blood from the celiac trunk or superior mesenteric artery. This means that the vagus supplies parasympathetics to the entire GI tract, up to the last part of the transverse colon. The end of transverse colon and all GI structures distal to that point receive parasympathetic innervation from the pelvic splanchnic nerves and blood from the inferior mesenteric artery. So, the ascending colon, cecum, jejunum, and ileum would all be affected by damage to the vagus nerve. The sigmoid colon, which receives parasympathetic innervation from the pelvic splanchnics, would not be affected.

In order to do a vagotomy (section of vagal nerve trunks) to reduce the secretion of acid by cells of the stomach mucosa in patients with peptic ulcers, one needs to cut the gastric branches and retain vagal innervation to other abdominal organs. Where would a surgeon look for these branches in relation to the stomach?

The correct answer is: along the lesser curvature

A 27-year-old woman is examined by her gynecologist. Upon rectal examination, a firm structure, directly in front of the rectum in the midline, is palpated through the anterior wall of the rectum. This structure is the: bladder body of uterus cervix of uterus pubic symphysis vagina

The correct answer is: cervix of the uterus The cervix of the uterus is anterior to the rectum. Since the cervix is the inferior part of the uterus that is protruding into the vagina, it should feel like a firm structure upon palpation. The bladder is the most anterior organ in the pelvis, in front of the uterus and rectum. So, the bladder would not be directly in front of the anterior wall of the rectum. The body of the uterus lies upon the bladder, so it is too far in front of the anterior rectal wall to be palpated. The pubic symphysis is the joint connecting the two pubic bones. It forms the anterior boundary of the pelvis, and would be too far forward to palpate through the rectum. Although the vagina is directly anterior to the rectum, it would not feel like a distinct and firm structure upon palpation.

The presence of which feature (also obvious on a radiograph with barium contrast) distinguishes small from large bowel? Circular folds of the mucosa Circular smooth muscle layer in the wall Mucosal glands Longitudinal smooth muscle layer in the wall Serosa

The correct answer is: circular folds of the mucosa The small intestine features circular folds of tissue that are covered with villi - these folds are very obvious on a radiograph with barium contrast. The colon does not have similar folds in the mucosa

As the bowel is exposed, the surgeon says in amazement, "This is a loop of large bowel!" Which characteristic(s) would identify it specifically as large bowel? A serosa Circular folds Epiploic appendages Tenia C and D

The correct answer is: C and D There are three features that distinguish the large intestine from the small intestines. The large intestine does not have a continuous longitudinal muscle layer--instead, it has three strips of longitudinal muscle known as teniae coli. The large intestine is covered with omental appendages, which are fat-filled pendants of peritoneum on the surface of the large intestine. Finally, the large intestine is folded into sacculations known as haustra, which form where the longitudinal muscle layer of the wall of the large intestine is deficient. Serosa is a general term for the outermost coat or serous layer of a visceral structure that lies in the body cavities of the abdomen or thorax. Circular folds are found in the small intestine, and semilunar (sometimes called semicircular) folds are found in the large intestine. These folds are actually much more prominent in the small intestine; in the large intestine, there are mostly semicircular folds which do not continue around the entire intestine.

Which statement regarding the suprarenal glands is correct? Its entire arterial supply is directly from the abdominal aorta. Veins from both glands drain directly into the inferior vena cava. The glands are localized in the pararenal space. Cells that secrete epinephrine and norepinephrine are innervated by preganglionic fibers from the greater thoracic splanchnic nerve.

The correct answer is: Cells that secrete epinephrine and norepinephrine are innervated by preganglionic fibers from the greater thoracic splanchnic nerve.

Regarding the diaphragm, which, is paired INCORRECTLY? Vertebrocostal trigone - lateral arcuate ligament Esophageal hiatus - right crus Medial arcuate ligament - psoas muscle Central tendon - aortic hiatus Vena caval foramen - right phrenic nerve

The correct answer is: Central tendon--aortic hiatus The aortic hiatus is not in the central tendon of the diaphragm--the caval opening, for the inferior vena cava, is found in the central tendon of the diaphragm. *The aortic hiatus is formed by the median arcuate ligament, which unites the two crura of the diaphragm.* The vertebrocostal trigone is an area of the diaphragm superior to the lateral arcuate ligament. Here, the diaphragmatic muscle is deficient and the *trigone is closed primarily by the inferior and superior fascia of the diaphragm. It is a significant area for hernias.* The esophageal hiatus is formed entirely by the fibers of the right crus. The psoas major muscle passes behind the medial arcuate ligament. Finally, the *right phrenic nerve passes through the central tendon of the diaphragm, near the vena caval foramen.* See Netter Plate 181 for a picture of all these structures and their relationships.

You are observing a laparoscopic cholecystectomy. The surgeon states that he is next going to expose the cystic artery in order to staple across it. He asks you where he should look for it. You reply, "In the triangle of Calot." What stuctures form this triangle and are the keys to finding the artery?

The correct answer is: Common hepatic duct, liver and cystic duct The triangle of Calot is formed by the cystic duct laterally, the liver superiorly, and the common hepatic duct medially.

Which of the following veins does not run a course parallel to the artery of the same name? superior epigastric superficial circumflex iliac inferior mesenteric superior rectal ileocolic

The correct answer is: inferior mesenteric The inferior mesenteric vein and inferior mesenteric artery do not run in tandem. The inferior mesenteric vein is part of the portal venous system--it drains into the splenic vein which drains into the hepatic portal vein. The inferior mesenteric artery is a branch off the descending aorta at the level of the L3 vertebral body. However, the inferior mesenteric artery and vein supply/drain the same region: the descending and sigmoid colon and the rectum. The superior epigastric vessels run together and are the continuation of the internal thoracic artery and vein. The superficial circumflex iliac vessels run together in the superficial fat of the abdominal wall. The superior rectal vessels are the terminal ends of the inferior mesenteric vessels, found on the superior surface of the rectum. The ileocolic artery and vein are branches off the superior mesenteric vessels. They are both running in the mesentery, supplying/draining the cecum, appendix, and terminal portion of the ileum.

Which structure is outlined with contrast on a CT using intraperitoneal contrast material? Ovary Prostate Rectum Seminal Vesicles Vagina

The correct answer is: ovary The ovary is entirely covered by a layer of peritoneum called the mesovarium. The mesovarium, along with the mesometrium and the mesosalpinx, creates the broad ligament. Because the ovary is completly encased in peritoneum, it would be outlined on a CT with intraperitoneal contrast material. The prostate, seminal vesicles and vagina are located below the rectovesicular pouch or rectouterine/vesicouterine pouches. So, they are not associated with the peritoneal cavity and would not be seen on the CT scan. Although peritoneum drapes over the rectum, forming the rectovesicular fold in males and the rectouterine fold in females, the rectum would not be clearly outlined by the intraperitoneal contrast since it is not covered by peritoneum on all sides.

If one were to make an incision parallel to and 2 inches above the inguinal ligament, one would find the inferior epigastric vessels between which layers of the abdominal wall?

The correct answer is: transversus abdominis and peritoneum The inferior epigastric vessels lay on the inner surface of the transversus abdominis and are covered by parietal peritoneum. Remember, the peritoneum lies over the inferior epigastric vessels to make the lateral umbilical fold. Camper's fascia and Scarpa's fascia are two layers of the superficial fascia - Camper's is the fatty layer and Scarpa's is the membranous layer.

Which structure does NOT form part of the boundary defining the trigone of the bladder? Interuteric crest Left Ureteric Orifice Right Ureteric Orifice Urachus Urethral Orifice

The correct answer is: urachus The trigone of the bladder is bounded by the openings of the left and right ureteric orifices superolaterally, the interureteric crest between the openings of the ureters and the internal urethral orifice inferiorly. The urachus is the structure that joins the apex of the fetal bladder to the umbilicus. After birth, it becomes the median umbilical ligament.

Preganglionic parasympathetic nerve fibers within the pelvic (inferior hypogastric) plexus arise from S2, 3, 4 and enter the plexus via: gray rami communicantes hypogastric nerves pelvic splanchnic nerves sacral splanchnic nerves white rami communicantes

The external iliac vein lies medial to the external iliac artery

The inferior mesenteric vein usually joins which vein?

The inferior mesenteric vein usually empties into the splenic vein. The splenic vein and the superior mesenteric vein then unite to form the portal vein. Look at Netter Plate 290 for a picture of this. Remember--the inferior vena cava and left renal vein are caval veins--they are not involved in draining the gut.

A Kocher manuever dissects in the avascular plane behind which organ that becomes retroperitoneal during rotation of the gut?

he correct answer is: Duodenum A Kocher maneuver involves reflecting the duodenum and pancreas medially by cutting through the fusion fascia along the right side of the descending part of the duodenum. This technique is used to gain access behind the pancreas. However, even if you didn't know the exact definition of a Kocher maneuver, you could still answer this question. The question is asking you to pick which organ is secondarily retroperitoneal, and the only secondarily retroperitoneal organ listed is the duodenum. The kidney and suprarenal gland were retroperitoneal during the entire developmental process, and the transverse colon and spleen are peritonealized. So, duodenum is the only answer that makes sense here.

The extension of the vaginal lumen around the intravaginal part of the uterine cervix is the: Cervical canal Uterine lumen Fornix Rectouterine Pouch Uterovesical Pouch

he correct answer is: fornix The cervix is the inferior end of the uterus that projects into the vagina. This means that the vagina comes up and wraps around the cervix, creating the vaginal fornix. There are multiple fornices at the top of the vagina: anterior, posterior, and lateral. The cervical canal is the passageway through the cervix to the vagina. The uterine lumen is the hollow center of the uterus. The rectouterine and uterovesicular pouches are two peritoneal folds found in the pelvic cavity. The rectouterine pouch is a peritoneal fold extending across the floor of the pelvic cavity from the sacrum (beside the rectum) to the uterus. The uterovesicular pouch is a peritoneal fold extending from the uterus to the bladder.

Sympathetic fibers in the greater splanchnic nerve arise from neuron cell bodies found in the: brainstem celiac ganglion chain ganglion spinal cord superior mesenteric ganglion

he correct answer is: spinal cord The sympathetic fibers in the greater thoracic splanchnic nerve are preganglionic sympathetic fibers that have left the sympathetic chain and are going to synapse in abdominal ganglia. These preganglionic sympathetic fibers originate in the lateral horn of the spinal cord grey matter. The celiac ganglia and the superior mesenteric ganglia are the two ganglia where the fibers from the greater thoracic splanchnic nerve can go to synapse. Finally, remember that these fibers did not originate in the chain ganglia--the fibers from there are the postganglionic sympathetic fibers.

Structures within the lower gastrointestinal tract specialized for physical support of fecal material are the: Transverse rectal folds Circular folds Anal valves Anal columns

he correct answer is: transverse rectal folds

*An elderly male patient presents with dysuria and urgency. You suspect benign prostatic hypertrophy which has caused an enlargement of the:*

he correct answer is: uvula The uvula of the bladder is an elevation on the posterior wall of the bladder. The uvula is caused by the middle lobe of the prostate gland. If the prostate becomes enlarged (either by benign hypertrophy or malignancy), the uvula can constrict the internal urethral orifice and cause difficulty in voiding the bladder. The interureteric crest is an elevation on the posterior wall of the bladder, between the two ureteric orifices. The seminal collicus is an elevation on the posterior wall of the prostatic urethra. At the summit of the seminal collicus, you can find the prostatic utricle, which is a small blind diverticulum in the posterior wall of the prostatic urethra. Finally, the sphincter urethrae is a muscle which encircles the urethra and compresses the urethra. None of these other structures would be enlarged in a case of benign prostatic hypertrophy.

A female patient is found to have an ectopic (tubal) pregnancy. In order to gain access to the peritoneal cavity endoscopically to remove the tubal embryo, the instrument can be passed through the posterior fornix of the vagina piercing into the: external os internal os rectouterine pouch rectovesical pouch vesicouterine pouch

rectouterine pouch

what is the urachus?

remnant of the umbilical cord

A 45-year-old man had developed a direct inguinal hernia several months after having an emergency appendectomy. The examining doctor linked the cause of hernia to accidental nerve injury that happened during appendectomy and weakened the falx inguinalis. Which nerve had been injured? Femoral branch of the genitofemoral Genital branch of the genitofemoral Ilioinguinal Subcostal Ventral primary ramus of T10

The correct answer is: Ilioinguinal A direct inguinal hernia is caused by a weakness in the abdominal muscles which prevents a patient from contracting these muscles strongly. If this patient can't contract his muscles, he can't pull the falx inguinalis down to cover the thin area of weak fascia on the posterior wall of the inguinal canal. The ilioinguinal nerve is important for innervating the muscles of the lower abdominal wall. So, if this nerve was damaged during the appendectomy, the man might not be able to contract his abdominal muscles and pull the falx inguinalis over the weak fascia. This could have led him to develop the direct inguinal hernia. The genitofemoral nerve innervates the cremaster muscle. An injury to this muscle would lead to an inability to elevate the testes, but it would not compromise the strength of the abdominal wall. The subcostal nerve and the ventral primary ramus of T10 innervate muscles, skin & fascia of the abdominal wall above the inguinal region. The anterior cutaneous branch of T10 reaches the umbilicus specifically.

An elderly patient with a large indirect inguinal hernia came to your clinic complaining of pain in the scrotum. You conclude that the hernial sac is compressing the following nerve: Femoral branch of the genitofemoral Femoral Iliohypogastric Ilioinguinal Subcostal

The correct answer is: Ilioinguinal nerve The ilioinguinal nerve runs in the inguinal canal, so this nerve could easily be compressed by an inguinal hernia. The ilioinguinal nerve also gives off the anterior scrotal nerve, which is the nerve responsible for sensory innervation to the anterior scrotum. The location of this hernia and the scrotal pain both fit with an injury to the ilioinguinal nerve. The femoral branch of the genitofemoral provides sensory innervation to the upper medial thigh. The femoral nerve innervates the anterior compartment of the thigh, and has some cutaneous sensory branches to the thigh. The iliohypogastric nerve innervates the skin of the lower abdominal wall, upper hip, and upper thigh. Finally, the subcostal nerve is the ventral primary ramus of T12, which innervates the skin of the anterolateral abdominal wall.

The internal thoracic artery is sometimes surgically cut near the caudal end of the sternum and used to supply blood to a region of the heart. In these cases, maintenance of adequate blood flow to the rectus abdominis may be dependent on increased flow through which artery? Superficial epigastric Inferior epigastric Umbilical Superficial circumflex iliac Deep circumflex iliac

The correct answer is: Inferior epigastric If the internal thoracic artery was ligated, blood would no longer flow to the superior epigastric artery, which is the branch of the internal thoracic that supplies blood to rectus abdominis. However, the superior epigastric artery communicates with the inferior epigastric artery, a branch of the external iliac artery. This means that blood could flow from the external iliac, to the inferior epigastric, to the superior epigastric and the rectus abdominis. The superficial epigastric and superficial circumflex iliac arteries are two superficial branches of the femoral artery. They do not supply deep structures in the abdomen. The distal portions of the umbilical arteries are obliterated in adults--they are the medial umbilical ligaments that form the medial umbilical folds. The deep circumflex iliac artery courses along the iliac crest on the inner surface of the abdominal wall. It is too lateral to supply blood to rectus abdominis.

A 45-year-old porter develops a direct inguinal hernia. If the hernia extended through the superficial inguinal ring, it would be surrounded by all of the abdominal wall layers EXCEPT the: External spermatic fascia Internal spermatic fascia Peritoneum and extraperitoneal connective tissue Weak fascia of the transversus abdominis muscle lateral to the falx

The correct answer is: Internal spermatic fascia The internal spermatic fascia is derived from the transversalis fascia. As the testes descend through the deep inguinal ring, the transversalis fascia is pulled along, forming the innermost covering of the spermatic cord. So, in an adult, the spermatic cord is lying in the inguinal canal, covered by the internal spermatic fascia. Now, think about what happens in the direct inguinal hernia--a piece of bowel begins to protrude through the weak fascia on the posterior wall of the inguinal canal. But at that location, the spermatic cord is already lying in the inguinal canal, covered by the internal spermatic fascia. This means that the direct inguinal hernia will lie next to the spermatic cord, but it cannot enter the spermatic cord. In contrast, an indirect inguinal hernia passes through the deep inguinal ring, and it will be covered by the internal spermatic fascia of the spermatic cord. *Both types of hernias are covered by the external spermatic fascia, the peritoneum, and extraperitoneal connective tissue.* The direct inguinal hernia passes through the weak fascia of transversus abdominus, so it would be covered by that layer which is absent from an indirect inguinal hernia.

Regarding the 2nd portion of the duodenum, all are correct EXCEPT:

The correct answer is: It is thin walled and circular folds are absent in its interior The first part of the duodenum features thin walls and no circular folds. It is called the ampulla of the duodenum. Once the duodenum turns and becomes the second part, the walls become thicker, and circular folds develop. The second part of the duodenum has the hepatopancreatic ampulla in its medial wall, which is the duct formed as the common bile duct and pancreatic duct join to empty their secretions into the duodenum. The transverse colon overlies the second part of the duodenum, and the second part of the duodenum is a secondarily retroperitoneal organ. Also, remember that the anterior and posterior superior pancreaticoduodenal arteries are branches of the gastroduodenal artery, which receives blood from the celiac trunk. The anterior and posterior inferior pancreaticoduodenal arteries receive blood from the superior mesenteric artery.

A surgical maneuver which takes advantage of the avascular plane of fusion fascia can be applied to mobilize all of the organs below, except the: Ascending colon Descending colon Duodenum Kidney Pancreas

The correct answer is: Kidney Fusion fascia forms when an organ becomes secondarily retroperitoneal. Secondarily retroperitoneal organs started out in a mesentery, but then got pushed against the posterior body wall during development. So, the peritoneal covering on the face of these organs which was pushed against the posterior body wall became fusion fascia--a relatively avascular plane of fascia that holds these organs to the posterior body wall. The ascending colon, descending colon, duodenum, and pancreas are all secondarily retroperitoneal organs which are attached by fusion fascia. The kidney is an entirely retroperitoneal organ that was never associated with a mesentery during development. So, it is not attached to the body wall by fusion fascia.

A twenty-year-old woman was broad-sided on the driver side by an SUV and was taken to the hospital emergency room. Examination showed low blood pressure and tenderness on the left mid-axillary line. Also, a large swelling was felt protruding downward and medially below the left costal margin. X-rays revealed that her 9th and 10th ribs were fractured near their angles on the left side. The abdominal organ most likely to be injured by the fracture is:

The correct answer is: Spleen *The spleen is usually well protected by the 9th through 12th ribs on the left side*. But, if one or more of these ribs gets fractured, the spleen is the first organ to be ruptured. The spleen can also be damaged if there is blunt trauma to the abdomen or a sudden increase in intraabdominal pressure. This patient has several symptoms of a ruptured spleen--she has tenderness on the left posterior axillary line and hypotension. (Because of its spongy parenchyma and thin capsule, a ruptured spleen will bleed profusely and a patient may become hypotensive.) The stomach, splenic flexure of the colon, tail of the pancreas, left kidney, and suprarenal gland are in the same quadrant of the abdomen, and they are also at risk for injury. But, you should remember that the spleen is at greatest risk because of its close relationship with the 9th through 12th ribs.

You are observing an operation to remove the left suprarenal gland. To expose the gland the surgeon mobilizes the descending colon by cutting along its lateral attachment to the body wall and dissecting medialward in the fusion fascia behind it. Suddenly the operative field is filled with blood. The surgeon realizes he has failed to cut a mesenteric attachment between the left colic flexure and another organ. As a result of the traction, the surface of the organ tore. Which organ was injured?

The correct answer is: Spleen The spleen is a peritonealized organ that is attached to the left colic flexure.

A medical student was asked to identify a small specimen taken for pathological examination from a surgically removed duodenum. The student noted that the specimen revealed a thin wall and no circular folds. The specimen is from which segment?

The correct answer is: Superior The superior part of the duodenum is the one segment of the duodenum that has no circular folds. *When food enters the duodenum from the pyloric sphincter, it enters the ampulla, which is a smooth area of the duodenum containing a high percentage of mucosal cells.* These cells secrete mucus to neutralize the acidic contents of the stomach. If the stomach contents is not sufficiently neutralized, the thin wall of the ampulla may develop an ulcer. If the ulcer burns through the entire wall, it might jeopardize the gastroduodenal artery, lying behind the first segment of the duodenum. The descending, horizontal, and ascending portions of the duodenum all have circular folds. For an illustration of the different linings of the duodenum, see Netter Plate 262.

Visceral pain is often referred to a site on the body wall (where the patient "feels" it) that is innervated by the same spinal cord segment that innervates the visceral organ involved. Pain of appendicitis is often first felt around the umbilicus, indicating that the appendix receives its sympathetic (and thus visceral afferents) from which spinal cord segment?

The correct answer is: T10 *Sensation from around the umbilicus is mediated by T10. This is an important landmark to remember!*

While performing a hysterectomy, the resident must ligate the uterine artery. To avoid iatrogenic injury to the ureters, she must be aware that the ureter passes ___________ the artery at the level of the ______________.

The correct answer is: Under; cervix Remember--the ureter passes under the uterine artery, in the inferior portion of the mesometrium, near the cervix!

An elderly patient is having difficulty in voiding (urinating). He complains that after voiding, he still feels as though he needs "to go" again. You suspect that this patient suffers from benign prostatic hypertrophy, which has caused enlargement of the __________ of the bladder. seminal colliculus interureteric crest ampulla trigone uvula

The correct answer is: Uvula The uvula of the bladder is an elevation on the posterior wall of the bladder. The uvula is produced by the middle lobe of the prostate gland. If the prostate becomes enlarged (either by benign hypertrophy or malignancy) the uvula can constrict the internal urethral orifice and cause difficulty in voiding the bladder. The seminal collicus is an elevation on the posterior wall of the prostatic urethra. The interureteric crest is an elevation on the posterior wall of the bladder, between the two ureteric orifices. The ampulla of the ductus deferens is the dilated part of the ductus deferens located posterior to the bladder. It joins with the duct of the seminal vesical to form the ejaculatory duct. The trigone is a triangular area on the posterior wall of the bladder. It is delineated by the two ureteric orifices and the internal urethral orifice, which form an equilateral triangle known as the trigone.

The rectouterine pouch is the lowest extent of the female peritoneal cavity. At its lowest, it provides a coat of peritoneum to a portion of the: urinary bladder urethra uterine cervix vagina

The correct answer is: Vagina In females, the rectouterine pouch is a peritoneal fold reflecting from the rectum to the posterior fornix of the vagina. At its lowest extent, the rectouterine fold is draped over the posterior fornix of the vagina. This means that surgeons can make an incision in the posterior fornix of the vagina and enter the rectouterine pouch to harvest eggs from the ovaries or remove an ectopic pregnancy. Take a look at Netter Plate 337 for a picture of this relationship.

Meckel's diverticulum: is an abnormal persistance of the urachus is a site of ectopic pancreatic tissue is caused by a failure of the midgut loop to return to the abdominal cavity is an abnormal connection of the midgut to the duodenum is associated with polyhydramnios

The correct answer is: a site of ectopic pancreatic tissue Meckel's diverticulum is an out-pouching of the small bowel that is present in 2% of the people and usually occurs about 2 feet before the junction with the cecum. It can be lined by the mucosa of the stomach and ulcerate. Or, it can be lined with ectopic pancreatic tissue. An abnormal persistence of the urachus is called a urachal fistula. Since the urachus is attached to the bladder, this can be detected if yellow fluid (urine) is seen coming from the umbilicus of a newborn. A failure of the midgut loop to return to the abdominal cavity is called an omphalocele. In this instance, the midgut remains in the body stalk, where it had left the gut to rotate. Polyhydramnios is an excess production of amniotic fluid , often caused by anencephaly or an esophageal fistula. The other conditions will be covered more in embryology - for now, focus on Meckel's diverticulum.

A 64-year-old woman was diagnosed as having carcinoma of the distal gastrointestinal tract. At surgery, lymph nodes from the sacral, internal iliac and inguinal lymph node groups were removed and sent to pathology for study. Only the superificial inguinal nodes contained cancerous cells. In which part of the GI tract was the tumor localized?

The correct answer is: cutaneous portion of the anal canal The pectinate line is more than the line where the mucosal lining of the anal canal changes to skin. It is also a key dividing point for the flow of lymph in the anal canal. Above the pectinate line, lymph flows to the inferior mesenteric and internal iliac lymph nodes. Below the pectinate line, lymph flows to the superficial inguinal lymph nodes. So, the pathology report tells you that the tumor must be somewhere below the pectinate line since the superficial inguinal lymph nodes are the only nodes involved. The only answer representing a tumor below the pectinate line is A, the cutaneous portion of the anal canal. The proximal and distal rectum represents a space far above the pectinate line, and the mucosal zone of the anal canal is, by definition, above the pectinate line. At the pectinate line itself, lymph should be flowing to all the sets of nodes, and it would be unlikely that a tumor at the pectinate line would involve only the superficial inguinal lymph nodes.

The spleen:

The correct answer is: develops in the dorsal mesogastrum The spleen and pancreas develop behind the stomach in the dorsal mesogastrium; the liver develops in the ventral mesogastrium. The spleen is not a retroperitoneal organ--it is covered by visceral peritoneum on all its surfaces.

Which of the following does not conduct spermatozoa? Ampulla of the ductus deferens Duct of the seminal vesicle Epididymis Prostatic Urethra

The correct answer is: duct of the seminal vesicle The duct of the seminal vesicle carries seminal fluid, a basic fluid containing fructose. The contents of the seminal fluid buffers the acid in the vagina and provides nutrients for sperm. The duct of the seminal vesicle joins with the ampulla of the ductus deferens (which is carying sperm) to form the ejaculatory duct. This is the first place where seminal fluid mixes with sperm. Sperm is first formed in the seminiferous tubules. They then travel from the head to the tail of the epididymis, through the ductus deferens, into the ejaculatory duct where they mix with seminal fluid, into the prostatic urethra, through the rest of the urethra, and then out the penis. So, all of the other answer choices are places that are important for the passage of sperm.

Which organ becomes retroperitoneal during rotation of the gut tube? Duodenum Kidney Spleen Stomach Transverse Colon

The correct answer is: duodenum This question is asking you to identify the organ that is secondarily retroperitoneal. This means that it started out peritonealized but became pressed against the posterior body wall and stuck there during development. Except for the first few centimeters of the superior segment and the duodenojejunal junction, the duodenum is a secondarily retroperitoneal organ - it used to have a mesentery, but that was lost during gut rotation. Although the kidney is a retroperitoneal organ, it is not secondarily retroperitoneal - it started developing in the retroperitoneum and stayed there. The spleen, stomach, and transverse colon are all peritonealized. What segments of the colon are peritonealized? The cecum, transverse colon, and the sigmoid colon are peritoneal, but the ascending and descending colon are retroperitoneal.

During the course of surgery for benign prostatic hypertrophy (benign enlargement of the prostate tissue which occludes the prostatic urethra) an electrical cutting device is inserted into the penile, then prostatic urethra, to remove the hypertrophic tissue. The posterior wall of the prostatic urethra is by necessity removed as well. Which part of the male seminal tract may also be partially removed? duct of seminal vesicle ductus deferens ejaculatory duct fossa navicularis seminiferous tubule

The correct answer is: ejaculatory duct The ejaculatory duct travels through the prostate and opens into the prostatic urethra. So, it is likely that this duct might get removed or damaged during the surgery. The duct of the seminal vesicle and the ductus deferens are the two ducts that join to make the ejaculatory duct. They both lie on the posterior surface of the bladder and would not be interrupted by the surgery. The fossa navicularis is a dilation in the penile urethra. It would not be harmed by surgery in the prostatic urethra. Finally, the seminferous tubules are the tubules in the testes where sperm are formed.

The division between the true right and left lobes (internal lobes) of the liver may be visualized on the outside of the liver as a plane passing through the: gallbladder fossa and round ligament of liver falciform ligament and ligamentum venosum gallbladder fossa and inferior vena cava falciform ligament and right hepatic vein gallbladder fossa and right triangular ligament

The correct answer is: gallbladder fossa and inferior vena cava This question is asking you to identify the structures that make the line that separates the true/functional lobes of the liver. The concept of functional lobes contrasts with traditional anatomical terminology, which separated the liver into the left, right, quadrate and caudate lobes. These traditional lobes were based on anatomical appearance, while the functional lobes are based on the distribution of the portal vein, hepatic arteries, and hepatic bile ducts. The functional lobes of the liver are separated into a right and left lobe by the gallbladder fossa and the inferior vena cava. So, the old "right lobe" corresponds to the functional right lobe, while the caudate, quadrate, and left lobes under anatomical terminology are lumped together as one big left lobe.

Which is a derivative of the dorsal mesogastrium?

The correct answer is: greater omentum During the development of the gut, there are two mesogastria attaching to the developing stomach: the dorsal mesogastrium and the ventral mesogastrium. Different organs begin to develop in each mesogastrium--the spleen and pancreas develop in the dorsal mesogastrium and the liver develops in the ventral mesogastrium. So, the structures involving the spleen and the posterior part of the developing stomach (which becomes the greater curvature) are derived from the dorsal mesogastrium. These include: the greater omentum (gastrophrenic ligament, gastrosplenic ligament, gastrocolic ligament) and splenorenal ligament. The structures involved with the liver and its attachment to the stomach wall form the ventral mesogastrium. These include the lesser omentum (hepatogastric ligament, hepatoduodenal ligament) and the ligaments of the liver (falciform ligament, coronary ligaments, right and left triangular ligaments). Of the answer choices, only the greater omentum is part of the dorsal mesogastrium.

After successfully performing two adrenalectomies (removal of the adrenal gland), the surgical resident was disappointed to learn that he would be merely assisting at the next one. The chief of surgery told him: "I'm doing this one, since the one on the right side may be a little too difficult for you." The difficulty he envisioned stems from the fact that the right suprarenal gland is partly overlain anteriorly by the:

The correct answer is: inferior vena cava Remember that the inferior vena cava is a little off center, on the right side of the abdomen. This means that structures on the right might be closely associated with this vessel, while structures on the left will need to have longer venous channels to connect with the IVC and drain into it. In the case of the suprarenal glands, you can see that the IVC is laying over the right suprarenal gland and is very far from the left gland. (This means that the right gland is draining directly into the inferior vena cava, while the left gland is draining into the renal vein.) As far as the other structures in the question go... The aorta lies fairly evenly between the suprarenal glands--it is not overlying either gland. The left hepatic vein, which drains blood from the liver to the inferior vena cava, is superior to the kidneys and not really involved with this area. The right crus of the diaphram is a set of fibers that splits to make the esophageal hiatus, and the right renal artery is a branch off the aorta to the kidney which enters the kidney below the level of the suprarenal gland.

Blood from an injured kidney will seep through the perirenal fat until it contacts the internal surface of the renal (Gerota's) fascia. Without perforating this fascia the blood could then continue to pass in what direction?

The correct answer is: inferiorly toward the pelvis The kidney is surrounded by a perirenal fatty capsule, the renal (Gerota's) fascia and pararenal fat. The fat offers no resistance to hemorrhage, but blood is contained in the renal fascia. This means that blood would not flow toward the body wall, other kidney, or toward the diaphragm. However, a kidney injury might involve part of the urinary collecting system, and blood from such damage would travel into the ureters and bladder.

A structure which is homologous to the male scrotum:

The correct answer is: labia majora The labia majora and scrotum are homologous structures. The labia minora is the female counterpart of the pentscrotal raphe. The glans of the clitoris and glans of the penis are homologous structures. Finally, the shaft of the corpus cavernosum in the female is the shaft of the clitoris, which is homologous to the shaft of the penis.

The celiac plexus of nerves may contain fibers derived from all of the following sources except: posterior vagal trunk greater thoracic splanchnic nerve lesser thoracic splanchnic nerve lumbar splanchnic nerves

The correct answer is: lesser thoracic splanchnic nerve The celiac plexus of nerves contains fibers from the greater thoracic splanchnic nerves, which are synapsing in the celiac ganglia. This plexus also contains vagal fibers. Even though the vagus does not synapse in the celiac ganglia, it passes through the ganglia and contributes to the celiac plexus. This allows the vagal fibers to travel on arteries to reach their eventual targets. *The lesser thoracic splanchnic nerves are not part of the celiac ganglia--these nerves synapse in the aorticorenal ganglia and contribute to the renal plexus. The first lumbar splanchnic nerve may occasionally contribute to the celiac plexus.*

A loop of bowel protrudes through the abdominal wall to form a direct inguinal hernia; viewed from the abdominal side, the hernial sac would be found in which region? Deep inguinal ring Lateral inguinal fossa Medial inguinal fossa Superficial inguinal ring Supravesical fossa

The correct answer is: medial inguinal fossa *A direct inguinal hernia passes through the weak fascia in the medial inguinal fossa.* This is the area between the medial and lateral umbilical folds (made of the obliterated umbilical artery and inferior epigastric vessels, respectively). A direct inguinal hernia does not pass through the deep inguinal ring or the lateral inguinal fossa--that's what an indirect hernia does. Although it's much more common for an indirect hernia to pass through the superficial inguinal ring, direct hernias could go through this ring too. However, the question is asking you to identify which region the hernia enters on the abdominal side, so superficial inguinal ring is not the correct answer. The supravesicular fossa is between the median and medial umbilical folds--it is formed where the peritoneum reflects from the anterior abdominal wall onto the bladder. Potentially, a very rare external supravesicular hernia could form here.

During a laparoscopic examination of the deep surface of the lower anterior abdominal wall (using a lighted scope on a thin tube inserted through the wall), the attending physician noted something of interest and asked the young resident to look at the medial inguinal fossa. To do so, the young doctor would have to look at the area between the: inferior epigastric artery and urachus medial umbilical ligament and urachus inferior epigastric artery and lateral umbilical fold medial umbilical ligament and inferior epigastric artery median umbilical ligament and medial umbilical ligament

The correct answer is: medial umbilical ligament and inferior epigastric artery Remember, the medial umbilical fold is made by the medial umbilical ligament (the obliterated portion of the umbilical artery), while the lateral umbilical fold is a fold of peritoneum over the inferior epigastric vessels. The median umibilical fold is a midline structure made by the median umbilical ligament (obliterated urachus). The medial inguinal fossa is the space on the inner abdominal wall between the medial umbilical fold and the lateral umbilical fold. This is the place in the abdominal wall where there is an area of weak fascia called the inguinal triangle--direct inguinal hernias can break through this space. The lateral inguinal fossa is a space lateral to the lateral umbilical fold--indirect inguinal hernias push through the deep inguinal ring in this space.

The part of the uterine wall which is not shed during menstruation is the:

The correct answer is: myometrium

During development of the gut: the sigmoid colon is retroperitoneal the inferior mesenteric artery is the axis for rotation of the midgut loop the stomach rotates around its longitudinal axis causing the ventral border to become the greater curvature the liver is non-functional none of the above

The correct answer is: none of the above None of the statements about development are correct. During development, structures that are peritonealized become retroperitoneal when they are pressed against the body wall and stay there. Structures do not start out retroperitoneal and become peritonealized later. Since the sigmoid colon is peritonealized in the adult, it has not and will not ever be retroperitoneal. The superior mesenteric artery is the axis for rotation of the midgut loop. This should make sense, since the SMA supplies the midgut. When the stomach rotates, the ventral border becomes the lesser curvature. Finally, the liver is functional in the fetus - it is an early site for the formation of erythrocytes.

Lymphatic drainage of the terminal portion of the gastrointestinal tract may flow initially into either the superficial inguinal nodes or the pararectal nodes, depending upon whether the lymph is formed above or below the:

The correct answer is: pectinate line The pectinate line is the place where the lining of the anal canal changes from skin to mucosa. It is also a landmark that divides the lymphatic drainage, vascular supply, and innervation of the anal canal. *Lymph coming from structures above the pectinate line drains to the inferior mesenteric lymph nodes or the internal iliac nodes.* Lymph from structures below the pectinate line travels to the superficial inguinal lymph nodes. As far as vasculature and nerves go... Superior to the pectinate line, arterial blood comes from the superior rectal artery and drains to the portal system through the superior rectal veins. This area is innervated by the inferior hypogastric plexus (autonomic innervation). Inferior to the pectinate line, blood comes from the inferior rectal arteries and is drained into the caval system. Innervation here comes from the inferior rectal nerves (somatic innervation). The anorectal junction is the point where the rectal ampulla narrows due to a U-shaped sling created by the puborectalis muscle. This area is superior to the pectinate line. The white line is a transitional area inferior to the pectinate line that represents some subtle changes as the mucosal lining becomes "regular" skin. Finally, the cutaneous zone is the area of skin at the very end of the rectum.

Which statement is true regarding pelvic veins? The external iliac vein lies medial to the external iliac artery The external iliac veins join to form the inferior vena cava The inferior vena cava cannot be imaged Pelvic veins are usually imaged using an arteriogram

The correct answer is: pelvic splanchnic nerves Pelvic splanchnic nerves carry parasympathetic fibers from the lateral horn of the spinal cord at the S2, 3, and 4 levels.

Benign hyperplasia (excessive growth of cells) of which part of the male reproductive system would be most likely to interfere with the passage of urine?

The correct answer is: periurethral zone of the prostate Remember that the prostatic urethra travels through the prostate gland. So, if the periurethral zone of the prostate hypertrophied, the nearby prostatic urethra would be occluded. The central and peripheral zones of the prostate are not as close to the urethra. If they enlarged, they would not restrict the flow of urine quite as much. The ejaculatory duct is the duct formed once the ductus deferens joins with the duct of the seminal vesicle. It passes through the prostate gland, but its enlargement would have no effect on the prostate or the urethra. Finally, the seminal vesicle is a sac on the posterior surface of the bladder which is superior to the prostate gland. It produces seminal fluid, and changes in the seminal vesicle should not alter the flow of urine.

A structure which takes the form of a hood anterosuperior to the clitoris:

The correct answer is: prepuce The prepuce is a fold of smooth skin that extends over the glans clitoris. It is formed by the joining of the anterior divisions of the labia minora. The frenulum of the clitoris is a small fold found posterior to the clitoris. It is formed by the joining of deeper, posterior, divisions of the labia minora. The labia majora are fat-filled elevations of skin lying on each side of the vestibule of the vagina. The labia minora are smaller folds of skin lying medial to the labia majora. They extend posteriorly and inferiorly from the clitoris.

Which of the following would be most likely to be damaged by a stab wound into the ischiorectal (ischioanal) fossa 2 cm lateral to the anal canal?

The correct answer is: pudendal nerve The pudendal nerve is found about 2 cm lateral to the anal canal. Therefore, it is the structure most likely to be damaged by the stab wound. The crus of the penis is the lateral part of the corpus cavernosum found at the base of the penis. It is anterior, not lateral, to the anal canal. The perineal body is a structure found in the female only--it is a fibromuscular mass found in the plane between the anal canal and the perineal membrane that serves at the convergence of several muscles. It is anterior to the anal canal. The inferior rectal artery is a branch of the internal pudendal artery that delivers blood to the inferior part of the rectum. It would not be injured by the stabbing because it is located on the surface of the rectum, not 2 cm lateral to the anal canal. Finally, the vesicular bulb is a structure of erectile tissue located on either side of the vestibule of the vagina, attached to the perineal membrane. So, it would be anterior to the site of the stabbing.

The most inferior extent of the peritoneal cavity in the female is the:

The correct answer is: rectouterine pouch Remember: The rectouterine and vesicouterine pouches are the two pouches created by draping the peritoneum over the pelvic organs.

*Which structure is found only in males? * Anterior recess of ischoianal fossa Genital Hiatus Ischiocavernosus muscle Rectovesical pouch Sphincter urethrae muscle

The correct answer is: rectovesicular pouch The rectovesicular pouch is a reflection of the peritoneum between the rectum and the bladder. It can only be found in males because females have the uterus sitting between the rectum and the bladder. This means that females have two pouches created by reflections of peritoneum draped over the pelvic viscera: the rectouterine and vesicouterine pouches. The ischioanal fossa is the fat filled space located lateral to the anal canal and inferior to the pelvic diaphragm. It has an anterior recess that extends superior to the perineal membrane and sphincter urethrae muscle, and it is found in both males and females. The genital hiatus is also found in both sexes--it is the place where the urethra/vagina and anus exit the pelvic diaphragm. The ischiocavernosis muscle compresses the corpus cavernosum of the penis or clitoris. Finally, the sphincter urethrae encircles and compresses the urethra in both sexes.

*A malignant tumor in the cutaneous zone of the anal canal would most likely metastasize (spread) to which group of lymph nodes? * Inferior mesenteric Pararectal Sacral Superficial inguinal

The correct answer is: superficial inguinal lymph nodes Remember, the pectinate line (the line in the anus where mucosa changes to skin) is the dividing line for lymphatic drainage. Structures above the pectinate line drain into the inferior mesenteric and internal iliac nodes. Structures below the pectinate line drain into the superficial inguinal nodes. Since the tumor is in the cutaneous (skin) region of the anal canal, it is going to be drained by the superficial inguinal nodes. This means that these nodes would be the first site of metastases.

A 57-year-old male complains of intense chest pain, but tests rule out any cardiac pathology. It was determined that the patient suffers from an esophageal (hiatal) hernia in which the stomach herniates through an enlarged esophageal hiatus. Muscle fibers from which of the following parts of the diaphragm would border directly on this hernia? left crus right crus central tendon costal fibers sternal fibers

The correct answer is: right crus The right crus is the part of the diaphragm that takes origin from L1-L3. It splits to enclose the esophagus. So, in the case of an esophageal hernia, the herniating stomach would be entirely surrounded by the fibers of the right crus. The left crus is the part of diaphragm that takes origin from L1 and L2. It is smaller and shorter than the right crus, and it intermingles with the right crus around the aortic hiatus. It does not contribute to the esophageal hiatus. The central tendon is the tendon in the middle of the diaphragm where all the fibers of the diaphragm attach. It provides an opening for the inferior vena cava. Finally, sternal and costal fibers refer to muscle fibers in the diaphragm that take origin from the xyphoid process or the ribcage. This could not refer to the right crus, since it originates on the lumbar vertebrae.

While performing emergency surgery to control hemorrhage brought on by arterial erosion caused by a duodenal ulcer, surgeons ligated the badly damaged gastroduodenal artery near its origin, which affected all of its branches as well. Assuming "average anatomy", in which of the following arteries would blood now flow in retrograde fashion (backwards) from collateral sources? Left hepatic Right gastroepiploic Short gastric Left gastric Omental branches

The correct answer is: right gastroepiploic If the gastroduodenal artery and its branches were ligated, blood would flow in a retrograde direction from the left gastroepiploic artery, which is a branch of the splenic artery, to the right gastroepiploic artery, a ligated branch of the gastroduodenal artery. This flow from the left to right gastroepiploic artery would allow blood to reach the entire greater curvature of the stomach. Remember--there are many anastomoses around the stomach that will allow this organ to receive blood even if one branch is ligated. The left hepatic artery is a branch of the proper hepatic artery; it supplies blood to the left and quadrate lobes of the liver, as well as part of the caudate lobe. The short gastric arteries are branches of the splenic artery which supply the fundus of the stomach. The left gastric artery is a branch of the celiac trunk which supplies the left portion of the lesser curvature. Omental branches are branches of the left and right gastroomental arteries which supply the greater omentum.

Which structure passes through the deep inguinal ring? Iliohypogastric nerve Ilioinguinal nerve Inferior epigastric artery Medial umbilical ligament Round ligament of the uterus

The correct answer is: round ligament of the uterus The round ligament of the uterus passes through the deep inguinal ring and runs through the inguinal canal. It is a derivative of the gubernaculum, a structure which pulled the gonads into place during embryonic development. In males, the scrotal ligament is what remains from the gubernaculum. Also keep in mind that, in males, the spermatic cord passes through the deep inguinal ring. Of the other answer choices, the *ilioinguinal nerve* is the only other one that courses through the inguinal canal. Remember--it leaves through the superficial ring and gives off the anterior labial or scrotal branch as a cutaneous continuation. However, the ilioinguinal nerve does not pass through the deep ring - it enters the inguinal canal on the side. The iliohypogastric nerves run between the internal oblique and transversus abdominis in the abdominal wall, piercing the internal oblique at the anterior superior iliac spine to travel deep to just the external oblique. The inferior epigastric artery runs between the transversus abdominis and the peritoneum, forming the lateral umbilical fold. The medial umbilical ligament is the obliterated umbilical artery--it lies within the medial umbilical fold of peritoneum.

Which of the following structures does not lie at least partially in the retroperitoneum? adrenal gland duodenum kidney pancreas spleen

The correct answer is: spleen The spleen is the only organ listed which is covered entirely by visceral peritoneum. About the other organs... *The kidney and suprarenal glands are retroperitoneal organs*. This is different than the secondarily retroperitoneal organs that started out in a mesentery and then got pushed against the posterior wall. The kidneys and the suprarenal glands began developing in the retroperitoneum and stayed there. The duodenum and pancreas are partially peritonealized and partially retroperitoneal. The first two centimeters of the superior duodenum is peritonealized, but the rest of the duodenum, until the duodenojejunal junction, is retroperitoneal. For the most part, the pancreas is secondarily retroperitoneal, although the tail of the pancreas is peritonealized, lying within the splenorenal ligament.

While performing a splenectomy (removal of the spleen) following an automobile accident, the surgeons were especially attentive to locate and preserve the tail of the pancreas which is closely associated with the spleen. This they found in the:

The correct answer is: splenorenal ligament The splenorenal ligament is the peritoneal structure that connects the spleen to the posterior abdominal wall over the left kidney. It also contains the tail of the pancreas. The gastrocolic ligament connects the greater curvature of the stomach with the transverse colon. The gastrosplenic ligament connects the greater curvature of the stomach with the hilum of the spleen. The phrenicolic ligament connects the splenic flexure of the colon to the diaphragm. Finally, the transverse mesocolon connects the transverse colon to the posterior abdominal wall.

Which skeletal feature would you consider to be most characteristic of the female pelvis? Subpubic angle of 90 degrees or greater Marked anterior curvature of the sacrum Tendency to vertical orientation of the iliac bones Prominent medial projection of the ischial spines

The correct answer is: subpubic angle of 90 degrees or greater There are four major differences between the male and female pelvis. First, the subpubic angle and pubic arch are greater in the female pelvis than in the male pelvis. This is why A is correct-- females often have a subpubic angle of 90 degrees or greater. A second difference between the female and male pelvis is that the pelvis inlet for females is rounded, while for males it is heart shaped. Third, the pelvic outlet for females is larger than in males. Finally, the female pelvis has iliac wings that are more flared than in males.