MGA Exam 2: (Grays, BRS, Lab Quests,ect)

An obstetrician performs an episiotomy posteriorly from the vagina through the perineal body (median episiotomy). Which of the following structures would be spared by an incision through the perineal body? A.Cardinal ligament B.External anal sphincter C.Perineal membrane D.Pubovaginalis portion of pubococcygeus E. Superficial and deep transverse perineal muscles

A (Cardinal ligament) is correct. Cardinal, or transverse cervical, ligaments pass laterally to the walls of the pelvis from the cervix of the uterus superior to the pelvic diaphragm. They have no connection with the perineal body.

Knowledge of the structures located anterior to the kidney is crucial during nephrectomy. Which of the following structures is in direct contact with the anteromedial surface of the right kidney in the region of the hilum? A.Duodenum B.Head of pancreas C.Liver D.Right colic flexure E.Suprarenal gland

A (Duodenum) is correct. The descending part of the duodenum lies on the medial margin of the right kidney near the hilum. Therefore a duodenal fistula may develop during dissection of the renal pelvis in a loin approach to the right kidney.

An abdominal arteriogram shows an aneurysm of an artery that descends from the umbilical region to the left lateral and left inguinal regions. Which of the following arteries is most likely affected? A.Inferior mesenteric B.Renal C.Splenic D.Superior epigastric E.Superior mesenteric

A (Inferior mesenteric) is correct. The anterior abdominal wall is divided by two transverse and two vertical planes into nine regions that are used to locate the signs and symptoms of abdominal disease. The inferior mesenteric artery arises from the abdominal aorta in the umbilical region and descends to the left to supply the descending colon in the left lateral region and the sigmoid colon in the left inguinal region.

A 54-year-old woman has a low-grade fever and mild chills accompanied by pain in the right upper quadrant that radiates to the back over the lower scapular region. She is nauseated and cannot eat. Acute cholecystitis is diagnosed, and she undergoes a cholecystectomy. Which of the following best describes the gallbladder? A.It has a surface projection at the junction of the lateral and middle thirds of a line connecting the umbilicus and the right anterior superior iliac spine B.It is completely covered by peritoneum C.It lies between the quadrate lobe and the right lobe of the liver D.Its inferior surface is in contact with the fourth part of the duodenum

A (It lies between the quadrate lobe and the right lobe of the liver) is correct. The gallbladder lies in the shallow gallbladder fossa on the visceral surface of the liver between the right lobe and the quadrate lobe. The quadrate lobe is functionally part of the left lobe of the liver.

Hemorrhage from esophageal varices is a potentially fatal complication of portal hypertension. Esophageal varices occur in portal hypertension because esophageal tributaries of the azygos system anastomose with esophageal tributaries of which of the following veins? A.Left gastric B.Left hepatic C.Left inferior phrenic D.Right gastric E.Splenic

A (Left gastric) is correct. Veins of the lower esophagus drain superiorly into the azygos system of veins (systemic circulation) and inferiorly into the left gastric vein (portal circulation). In portal hypertension, blood flow is increased superiorly through the anastomoses between the two circulations, resulting in dilated submucosal esophageal varices. These varices may rupture, resulting in severe hemorrhage.

The posterior layer of the rectus sheath ends inferiorly at the A. Arcuate line B. Intercrestal line C. Linea alba D. Pectineal line E. Semilunar line

A. Arcuate line The arcuate line is an anatomical feature on the inner surface of the abdominal wall. It is the point at which the posterior lamina of the rectus sheath ends and transversalis fascia lines the inner surface of rectus abdominis.

35 year old man comes to the physician because of intermittent groin pain. He is a construction work and states that his pain is worse with lifting heavy loads after a long day of working. Physical examination shows a bulge above the inguinal ligament. The bulge increases in size when he bears down. Ultrasound reveals that the mass originates medial to the inferior epigastric vessels. The patient's condition is most likely caused by which of the following? A. Breakdown of the transversalis fascia B. failure of the internal inguinal ring to close C. Patent processus vaginalis D. Weakness of the rectus abdominis muscle E. Widening of the femoral ring

A. Breakdown of the transversalis fascia

A 60-year-old woman arrived at the emergency room complaining of acute abdominal pain. She was diagnosed with ischemic bowel resulting from an obstruction of one or more branches of the inferior mesenteric artery. Which of the following is most likely NOT to be seriously affected by the ischemia? A. Cecum B. Descending colon C. Rectum D. Sigmoid colon E. Splenic flexure

A. Cecum The inferior mesenteric artery supplies blood to the end of the transverse colon and all distal structures in the GI tract. This means that the splenic flexure, descending colon, sigmoid colon, and rectum would all be deprived of blood if the inferior mesenteric artery was occluded. The cecum receives blood from the superior mesenteric artery, so it would not be affected by the obstruction.

A newborn undergoes surgical repair of esophageal atresia. Pathological examination of resected tissue shows that the esophagus is fibrotic and has no lumen. Which of the following embryonic germ layers is the most likely origin of the cells that fill the lumen? A. Endoderm B. Intermediate mesoderm C. Neural crest D. Paraxial mesoderm E. Surface ectoderm

A. Endoderm The endoderm tube forms the epithelial lining of the entire GI tract and the epithelial components of its associated structures (Esophageal lining is endoderm)

You were asked to assist in a surgical operation on a young patient to treat an ulcer in the first part of the duodenum. You would expect that the surgeon will approach the ulcer by doing an anterior abdominal wall incision in the following region: A. Epigastric B. Left inguinal C. Left lumbar D. Right hypochondrial E. Hypogastric

A. Epigastric The epigastric region is one of the nine regions of the abdomen. It contains the duodenum, part of the stomach, part of the liver, and the pancreas. This is the region that the surgeon would need to enter to reach the ulcer in the first part of the duodenum. The left inguinal region contains the sigmoid colon. The left lumbar region contains the descending colon and kidney. The right hypochondrial region contains part of the liver and the gall bladder. Finally, the hypogastric region contains the bladder and rectum.

A 70-year-old man with cancer of the ascending colon was admitted to the hospital for tumor removal. The surgeon may perform any of these surgical procedures EXCEPT: A. an incision in the left lower quadrant to access the tumor. B. examination of the superior mesenteric lymph nodes for possible metastasis. C. ligation of the relevant branches of the superior mesenteric artery. D. mobilization of the concerned intestinal segment by freeing its fusion fascia. E. protect the peritoneum from possible fecal contamination.

A. an incision in the left lower quadrant to access the tumor The ascending colon is on the right side of the abdomen--the surgeon would not need to explore the left lower quadrant! Because the ascending colon is supplied by the superior mesenteric artery, the surgeon might need to ligate branches of this artery, and the surgeon would also want to check the superior mesenteric nodes for metastasis. Since the ascending colon is secondarily retroperitoneal, it can be mobilized by freeing its fusion fascia. Finally, it's always a good idea to protect the peritoneum from fecal contamination!

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? A. cutaneous portion of anal canal B. distal rectum C. mucosal zone of anal canal D. pectinate line of anal canal E. proximal rectum

A. 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.

Which structure is NOT found within the true pelvis? A. Femoral nerve B. Hypogastric nerve C. Internal pudendal artery D. Obturator artery E. Pelvic splanchnic nerves

A. femoral nerve To answer this question, you need to understand what the true pelvis is. The true pelvis is the area beneath the pelvic brim (pelvic inlet), where the pelvic viscera are located. The false pelvis is the area above the pelvic brim, bounded by the iliac blades. Now, you just need to think about the structures listed and determine which ones are in which location. The femoral nerve is the structure that is not in the true pelvis. After coming off the lumbar plexus with contributions from L2, 3, and 4, the femoral nerve runs along the border between the psoas major muscle and the iliacus to travel into the lower limb. It never descends below the pelvic brim, so it is not in the true pelvis. Hypogastric nerves connect the superior and inferior hypogastric plexuses. Since the inferior hypogastric plexus is lying between the pelvic viscera and the pelvis wall, in the true pelvis, the hypogastric nerves should also be in the true pelvis. The internal pudendal artery is a branch of the anterior division of the internal iliac artery. It lies in the true pelvis and supplies blood to the perineum. The obturator artery is a branch of the anterior internal iliac artery or, if it is the aberrant obturator, the inferior epigastric artery. It is in the true pelvis, and exits the pelvis through the obturator foramen. The pelvic splanchnic nerves represent the sacral portion of the craniosacral outflow (parasympathetic) of the autonomic nervous system. They come from the ventral rami of the second, third, and fourth sacral nerves. So, that puts them in the true pelvis, too.

Which of the following is present in the rectal portion of the large intestine but not in the sigmoid colon? A.Complete layer of circular smooth muscle B.Complete layer of longitudinal smooth muscle C.Epiploic appendages D.Haustra coli E.Mesentery

B (Complete layer of longitudinal smooth muscle) is correct. The teniae coli are three narrow, equidistant bands of longitudinal smooth muscle located outside of the circular muscle layer in the wall of the large intestine. The bands usually extend from the base of the vermiform appendix to the end of the sigmoid colon. The teniae coli merge to form a complete layer of longitudinal smooth muscle in the wall of the rectum.

A 53-year-old man has recurring gastric ulcers. A selective vagotomy is performed to decrease the parasympathetic stimulation of acid secretion by gastric parietal cells. The cell bodies of preganglionic parasympathetic fibers to the stomach are located in which of the following sites? A.Celiac ganglion B.Dorsal motor nucleus C.Intermediolateral cell column D.Paravertebral ganglia E.Ventral horn of the spinal cord

B (Dorsal motor nucleus) is correct. The stomach receives parasympathetic innervation via the vagus nerve (CN X). The cell bodies of the preganglionic parasympathetic fibers are located in the dorsal motor nucleus of the vagus. A selective vagotomy sections those fibers that stimulate gastric acid secretion while preserving those fibers that cause relaxation of the pylorus.

A 53-year-old-man is undergoing surgical repair of an infrarenal abdominal aortic aneurysm. Which of the following arteries arises from the aorta in the area of this aneurysm and is most likely to carry insufficient blood after the repair? A.Celiac trunk B.Inferior mesenteric artery C.Renal artery D.Superior mesenteric artery

B (Inferior mesenteric artery) is correct. Abdominal aortic aneurysms are most commonly infrarenal. The inferior mesenteric artery originates from the aorta in front of vertebra L3, placing it in the middle of an infrarenal abdominal aortic aneurysm.

On gross examination of a sectioned kidney obtained during partial nephrectomy, the lighter cortex is observed to be interspersed with darker triangular structures known as renal pyramids. The ducts of each renal pyramid open into which of the following structures? A.Major calyx B.Minor calyx C.Renal papilla D.Renal pelvis E.Renal sinus

B (Minor calyx) is correct. The ducts (collecting tubules) of each renal pyramid drain through a renal papilla and into a minor calyx. A renal pyramid is part of the medulla of the kidney.

While examining radiographs and angiograms of a 52 year old patient, a physician is trying to distinguish the jejunum from the ileum. He observed tha tthe jejunum has: A. Fewer plicae circulares B. Fewer mesenteric arterial arcades C. Less digestion and absorption of nutrients D. Shorter Vasa recta E. More fat in its mesentery

B. Fewer mesenteric arterial arcades

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: A. Genitofemoral B. Iliohypogastric C. Subcostal D. Spinal nerve T10 E. Spinal nerve T9

B. 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 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? A. Superficial epigastric B. Inferior epigastric C. Umbilical D. Superficial circumflex iliac E. Deep circumflex iliac

B. 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.

In order to reduce a hernia (return it to the abdominal cavity), a surgeon finds it necessary to ligate an artery in the extraperitoneal connective tissue (preperitoneal fat) running vertically just medial to the bowel as the bowel passes through the abdominal wall. This artery is the: A. Deep circumflex iliac B. Inferior epigastric C. Superficial circumflex iliac D. Superficial epigastric E. Superficial external pudendal

B. Inferior epigastric The inferior epigastric vessels are found in the preperitoneal fat of the abdomen. They lie just superficial to the peritoneum and form the lateral umbilical fold. Hernias may pass lateral or medial to these vessels. If the hernia is lateral to the vessels (which is what happened in this case), it is an indirect inguinal hernia. If the hernia is medial to these vessels, it is a direct inguinal hernia. The deep circumflex artery courses along the iliac crest on the inner surface of the abdominal wall. This artery is very lateral on the abdominal wall, and hernias would pass medial to this vessel. The superficial circumflex iliac, superficial epigastric, and superficial external pudendal arteries are all superficial arteries that arise from the femoral artery. They are all found in the superficial fascia--not in the preperitoneal fat.

A 21-year-old man comes to the emergency department because of excruciating anal pain for the past 4 hours. Examination shows a 15-mm, blue-tinged, rounded mass at the anal margin. This mass most likely represents a thrombosis in a tributary of which of the following blood vessels? A. Inferior rectal artery B. Inferior rectal vein C. Middle rectal artery D. Middle rectal vein E. Superior rectal artery F. Superior rectal vein

B. Inferior rectal vein Remember with external hemorrhoids. They are painful, and involve dilated tributaries of the inferior rectal vein

A 22-yr-old woman, gravida 1, para 1, is brought to the ER because of a 2-day history of fever and severe vaginal bleeding. Four days ago, she delivered a healthy male newborn spontaneously at term. Her temperature is 38.1 C (100.6 F). Pelvic examination shows an open cervix and heavy vaginal bleeding. Ultrasonography of the uterus shows no retained placental tissue or large thrombi. If an operation is required to control the bleeding, ligation of a branch of which of the following arteries is most appropriate? A. External iliac B. Internal iliac C. Internal pudendal D. Median sacral E. Obturator

B. Internal Iliac (specifically the Ovarian artery)

Which pair of structures does NOT differentiate from comparable embryonic structures in the male and female? A. Bulb of corpus spongeosum and vestibular bulb B. Shaft of penis and labia majora C. Glans of penis and glans of clitoris D. Crus of corpus cavernosum penis and crus of corpus cavernosum clitoris

B. 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

What bony landmark on the lateral pelvic wall may be used as a reference for localizing female pelvic anatomy or pain phenomena? A. Coccyx B. Ischial spine C. Ischial tuberosity D. Obturator canal E. Pectineal line

B. The correct answer is: Ischial spine The ischial spine is the only answer choice on the lateral pelvic wall. It arises just superior to the lesser sciatic notch and serves as the site of attachment of the sacrospinous ligament. The coccyx is the most inferior part of the vertebral column, resulting from the fusion of the four coccygeal vertebrae. It articulates with the sacrum, which means that it is associated with the posterior wall of the pelvis. The ischial tuberosity protrudes posteroinferiorly, not laterally, from the body of the ischium. This is where weight rests when the body is in the sitting postion. The ischial tuberosity also serves as the site of attachment for the sacrotuberous ligament. The obturator canal is the space in the obturator foramen that is not covered with obturator membrane. It transmits the obturator nerve and vessels, and it is on the anterior, not lateral, side of the pelvis. Finally, the pectineal line is the ridge on the pubis that creates the anterior border of the pelvic inlet and is an important landmark of the inguinal region.

Which of the following structures develops from the dorsal mesentery of the embryo? A.Central tendon of diaphragm B.Falciform ligament C.Greater omentum D.Hepatogastric ligament E.Lesser omentum

C (Greater omentum) is correct. The greater omentum develops from the dorsal mesentery of the embryo.

A 35-year-old woman has an aortic aneurysm that occludes both ovarian arteries. Her ovarian hormone levels are within normal range, indicating that the ovaries are functioning. The survival of ovarian function in this patient can be attributed to a blood supply from branches of which of the following arteries? A.External iliac B.Inferior mesenteric C.Internal iliac D.Internal pudendal E.Superior mesenteric

C (Internal iliac) is correct. The ovary is supplied by both the ovarian artery from the abdominal aorta and the ovarian branch of the uterine artery. These vessels anastomose between layers of the broad ligament. The uterine artery is a branch of the internal iliac artery, the artery of the pelvis.

A 30-year-old man who consumes a large amount of alcohol develops hematemesis after vomiting. Endoscopy confirms a tear of the distal esophageal mucosa near the gastroesophageal junction. The bleeding most likely involves the blood supply to the lower third of the esophagus from esophageal branches of which vessel? A.Descending thoracic aorta B.Internal thoracic artery C.Left gastric artery D.Right gastric artery E.Splenic artery

C (Left gastric artery) is correct. The upper third of the esophagus is supplied primarily by the inferior thyroid artery, the middle third by branches of the descending thoracic aorta, and the lower third by the left gastric artery. Mallory-Weiss tears involve bleeding from the area of the left gastric artery with hematemesis.

Which of the following structures is the part of the intermediate mesoderm that gives rise to the urinary system? A.Genital ridge B.Metanephric mass C.Nephrogenic cord D.Neural crest

C (Nephrogenic cord) is correct. The nephrogenic cord is part of the urogenital ridge, which develops from intermediate mesoderm. The nephrogenic cord gives rise to the urinary system through the sequential development of three sets of kidneys: pronephros, mesonephros, and metanephros. The metanephros becomes the permanent kidney.

On physical examination, the pediatrician notices urine leaking from the umbilicus of a neonate. Which of the following is the most likely diagnosis? A.Gastroschisis B.Omphalocele C.Persistent lumen of the allantois D.Persistent vitelline duct E.Umbilical hernia

C (Persistent lumen of the allantois) is correct. Urine may leak from the umbilicus if the lumen of the allantois remains patent (urachal fistula) and allows the urinary bladder to communicate with the umbilicus.

A misdirected instrument may perforate the posterior fornix of the vagina. What structure is immediately adjacent to the vagina at this point? A.Anal canal B.Base of bladder C.Rectouterine pouch D.Urethra E.Vesicouterine pouch

C (Rectouterine pouch) is correct. The rectouterine pouch of the peritoneal cavity may be mistakenly entered through the posterior fornix of the vagina, endangering loops of the ileum and the sigmoid colon.

The cell bodies of preganglionic sympathetic neurons are most likely to be found in which of the following anatomic locations? A.All spinal cord segments B.All sympathetic chain ganglia C.Spinal cord segments T1-L2 only D.Spinal cord segments S2-S4 only E.Sympathetic chain ganglia T1-L2 only

C (Spinal cord segments T1-L2 only) is correct. The cell bodies of preganglionic sympathetic neurons are located in the intermediolateral cell column (lateral horn gray matter) of spinal cord segments T1-L2. The cell bodies of postganglionic sympathetic neurons are located in paravertebral ganglia (sympathetic chain ganglia) or in preverterbral ganglia near the abdominal aorta.

A 47-year-old man has an acquired umbilical hernia that has split the linea alba and also damaged the posterior lamina of the rectus sheath. A surgeon repairing this defect must remember that at the level of the umbilicus the posterior layer of the rectus sheath consists of which of the following layers? A.External oblique aponeurosis and internal oblique aponeurosis B.Transversalis fascia only C.Transverse abdominal aponeurosis and internal oblique aponeurosis D.Transverse abdominal aponeurosis, internal oblique aponeurosis, and external oblique aponeurosis

C (Transverse abdominal aponeurosis and internal oblique aponeurosis) is correct. The arcuate line, which is located between the umbilicus and the pubis, is the inferior limit of the posterior layer of the rectus sheath. Superior to the arcuate line, the internal oblique aponeurosis splits to enclose the rectus abdominis; therefore the posterior layer of the rectus sheath is formed by the internal oblique and transverse abdominal (transversus abdominis) aponeuroses, and the anterior layer is formed by the internal oblique and external oblique aponeuroses. Remember from lecture: Transitional "Line" located 1/3 the distance from the Umbilicus to the Pubic Crest

A 33-year-old mother of four is examined by her gynecologist, who finds that the patient has a partial prolapse of the uterus. The patient does not wish to have a hysterectomy and elects instead to undergo surgical repair of the pelvic floor. Thickenings of endopelvic fascia referred to as pelvic ligaments help support the uterus. What is the primary ligament supporting the cervix of the uterus? A.Broad ligament of uterus B.Round ligament of uterus C.Transverse cervical ligament D.Uterosacral ligament

C (Transverse cervical ligament) is correct. The paired transverse cervical (cardinal, Mackenrodt's) ligaments extend from the cervix to the lateral walls of the pelvis. They are the major ligamentous supports of the uterus, which is also supported passively by the perineal body and by the bladder (due to the uterus' anteverted and anteflexed posture). The uterus is supported dynamically by the pelvic diaphragm.

An emergent hernia repair is scheduled. As the attending physician is driving to the hospital , the medical student assisting on the surgery is trying to commit to memory that the internal oblique abdominis muscle contributes to the formation of which of the following structures? A. Inguinal Ligament B. Deep inguinal ring C. Falx inguinalis (conjoint tendon) D. Internal spermatic fascia E. Reflected inguinal ligament

C. Falx Inguinalis (conjoint tendon) is formed by the aponeuroses of the internal oblique and transversus muscles of the abdomen.

An 80-yr-old man with type 2 DM is brought to the physician because of a 2-month history of severe constipation. Use of over-the-counter laxatives has not relieved his symptoms. Abdominal examination shows distention. Colonoscopy shows no abnormalities. This patient most likely has dysfunction of which of the following nerves? A. Hypogastric B. Inferior rectal C. Pelvic splanchnic D. Perineal E. Sacral sympathetic

C. Pelvic Splanchnic Why? Defecation is controlled by parasympathetic stimulation. (also controls stimulation of peristalsis and secretion of digestive juices, contracting the rectum to inhibit the internal anal sphincter to cause defecation)

The usual location for an appendectomy incision is the: A. left lower quadrant B. left upper quadrant C. right lower quadrant D. right upper quadrant

C. Right lower quadrant Since the appendix is located in the right lower quadrant, you would probably want to make your incision there to remove it! The appendix is the terminal portion of the cecum which has a small, dead-end lumen. It is located just behind the cecum in the right internal iliac fossa. Where are incisions made for other procedures? For a cholecystectomy (gall bladder removal), there is an incision in the right upper quadrant. (Or, this surgery can be performed laproscopically.) For a caesarian, a transverse suprapubic incision (also called a Pfannenstiel incision) is used. A midline incision, through the linea alba, may be used to repair an aortic aneurysm.

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: A. bladder B. body of uterus C. cervix of uterus D. pubic symphysis E. vagina

C. 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.

A medical student was asked by her preceptor to palpate the margin of the superficial inguinal ring of a healthy male patient. After passing her finger down the edge of the medial crus of the superficial inguinal ring, she felt a bony protuberance deep to the lateral edge of the spermatic cord, which she correctly identified as the : A. pecten pubis B. pubic symphysis C. pubic tubercle D. iliopubic eminence E. iliopectineal line

C. pubic tubercle The pubic tubercle is a bony process that would be felt lateral to the edge of the spermatic cord at the superficial inguinal ring. (This is really the only answer choice that could feel like a bony prominence when palpated.)The pubic tubercle serves as the point of attachment for the inguinal ligament, which makes up the floor of the inguinal canal. The pubic pecten is the ridge on the superior surface of the superior pubic ramus. This is the place where you find the pectineal ligament, a thickening of fascia on the pecten of the pubis. The pectineal ligament is a good place to put sutures when doing surgery. The pubic symphysis is the joint between the two pubic bones. The iliopubic eminence is a bony process on the pubis found near its articulation with the ilium. The iliopectineal line is a line formed by the arcuate line of the ilium and the pectineal line of the pubis. This line forms a plane that marks the transition between the abdominal and pelvic cavity.

A 27-year-old woman has an infection localized in the superficial perineal pouch. What structure is most likely to be infected? A.Deep transverse perineal muscle B.Dorsal artery of clitoris C.Dorsal nerve of clitoris D.Greater vestibular gland E.Sphincter urethrae muscle

D (Greater vestibular gland) is correct. Unlike the bulbourethral glands of the male, the greater vestibular (Bartholin's) glands of the female are located in the superficial perineal pouch.

Dissection of the porta hepatis and identification of the structures contained within is necessary during hepatic resection. Which of the following structures connects to the liver at a site other than the porta hepatis? A.Common hepatic duct B.Hepatic arteries C.Hepatic nerve plexus D.Hepatic veins E.Portal vein

D (Hepatic veins) is correct. The hepatic veins emerge from the posterior surface of the liver and empty directly into the inferior vena cava.

A 54-year-old-man is diagnosed with a left-sided varicocele. The area around the left renal vein is examined by ultrasound imaging to rule out obstruction of the vein by a retroperitoneal tumor. What is the best description of the left renal vein? A.It lies posterior to the renal pelvis B.It is part of the hepatic portal system C.It is shorter than the right renal vein D.It receives the left testicular vein E.It terminates in the cisterna chyli

D (It receives the left testicular vein) is correct. The left testicular vein typically ends in the left renal vein, whereas the right testicular vein ends directly in the inferior vena cava. For this reason, most varicoceles occur on the left side.

Soon after undergoing surgery, a 63-year-old man develops a high temperature with nausea and vomiting. Computed tomography (CT) scans indicate the presence of subphrenic and pelvic abscesses. The infection most likely has spread into the pelvic cavity via the right paracolic gutter along the ascending colon. The right paracolic gutter is present because the ascending colon is: A.Intraperitoneal B.Part of subphrenic recess C.Retroperitoneal D.Secondarily retroperitoneal

D (Secondarily retroperitoneal) is correct. Secondarily retroperitoneal organs are parts of the gut that lose their mesentery during development. The ascending colon is intraperitoneal early in development, but later it fuses with the posterior body wall so that it is covered only anteriorly by visceral peritoneum. The subphrenic recesses are continuous with the hepatorenal recess, and the right (lateral) paracolic gutter provides a pathway for the spread of infection from the hepatorenal recess (Morison's pouch) into the pelvis.

The deep inguinal ring is a common site of inguinal hernias in young males. The deep inguinal ring is an evagination of what layer? A.Camper's fascia B.Parietal peritoneum C.Scarpa's fascia D.Transversalis fascia E.Visceral peritoneum

D (Transversalis fascia) is correct. The deep inguinal ring is an oval evagination of the transversalis fascia that continues as the internal spermatic fascia around the spermatic cord. The deep inguinal ring forms during development as a result of descent of the testis.

When fluid is drained from a hydrocele, the coverings of the spermatic cord must be traversed by the trocar and cannula. The covering that lies immediately outside the parietal layer of the tunica vaginalis testis is continuous with which layer of the anterior abdominal wall? A.External abdominal oblique aponeurosis B.Internal abdominal oblique aponeurosis C.Scarpa's fascia D.Transversalis fascia E.Transversus abdominis aponeurosis

D (Transversalis fascia) is correct. The internal spermatic fascia is formed from transversalis fascia as the testis descends through the deep inguinal ring during development. The internal spermatic fascia lies just external to the parietal layer of the tunica vaginalis testis. The wall of the scrotum consists, from superficial to deep, of skin, dartos fascia, external spermatic fascia, cremaster muscle and fascia, internal spermatic fascia, and tunica vaginalis testis.

While performing an exploratory laparotomy, the physician observes a fold of peritoneum extending from the apex of the urinary bladder onto the anterior abdominal wall. The remnant of what structure is responsible for raising this fold of peritoneum? A.Ductus venosus B.Umbilical artery C.Umbilical vein D.Urachus E.Vitelline duct

D (Urachus) is correct. The urachus is formed by constriction of the fetal allantois into a fibrous cord. It attaches the apex of the bladder to the umbilicus and persists as the median umbilical ligament of the adult. The urachus occasionally remains patent in the neonate and leaks urine (urachal fistula).

The inferior border of the rectus sheath posteriorly is called the: A. Falx inguinalis B. Inguinal ligament C. Internal inguinal ring D. Arcuate line E. Linea alba

D. Arcuate Line The rectus sheath is a tough, tendinous sheath over the rectus abdominis muscle. It covers the entire anterior surface of the rectus abdominis. However, on the posterior side of the muscle, the sheath is incomplete-- it ends inferiorly at the arcuate line. Below the arcuate line, the rectus abdominis is covered by transversalis fascia, not the rectus sheath! The linea alba is also related to the rectus abdominis--it is a ligament that runs down the middle of the abdomen, bisecting the rectus abdominis. It is made by the intermingling of the aponeuroses of the external oblique, internal oblique, and transversus abdominis. It's a good place to make a vertical incision. All of the other answer choices are related to the inguinal canal. The falx inguinalis (sometimes called the inguinal falx or conjoint tendon), is the inferomedial attachment of transversus abdominis with some fibers of internal abdominal oblique--it contributes to the posterior wall of the inguinal canal. The inguinal ligament is the ligament that connects the anterior superior iliac spine with the pubic tubercle--it makes the floor of the inguinal canal. The internal (deep) inguinal ring is the entrance to the inguinal canal, where the transversalis fascia pouches out and creates an opening through which structures can leave the abdominal cavity.

21 year old man receives a penetrating knife wound in the abdomen and is injured in both the superior mesenteric artery and the vagus nerve. Which portion of the colon would most likely be impaired by this injury? A. Ascending and descending colon B. Transverse and sigmoid colon C. Descending and sigmoid colon D. Ascending and Transverse colons E. Transverse and descending colons

D. Ascending and Transverse colons Both receive blood from the superior mesenteric artery and parasympathetic nerve fibers from the vagus nerve. Descending and sigmoid colons receive blood from the inferior mesenteric artery and parasympathetic from the pelvic splanchnic nerve arising from the sacral plexus S2-S4

36 year old woman with yellow pigmentation of the skin and sclera presents at the outpatient clinic. Which of the following conditions most likely is the cause of her obstructive jaundice? A. Aneurysm of the splenic artery B. Perforated ulcer of the stomach C. Obstructive of the main pancreatic duct D. Cancer of the head of the pancreas E. Cancer of the body of the pancreas

D. Cancer of the head of the pancreas because the bile duct transverse the head of the pancreas, cancer in the head of the pancreas obstructs the bile duct resulting in jaundice.

35 year old woman comes to local hospital with abdominal tenderness and acute pain. On examination her physician observes that an abdominal infection has spread retroperitoneally. Which of the following structures is most likely affected? A. Stomach B. Transverse Colon C. Jejunum D. Descending colon E. Spleen

D. Descending colon

Which statement about the pelvic floor is NOT correct? A. Along with the pelvic brim, it defines the true pelvic cavity B. It is a funnel-shaped skeletal muscle C. It is referred to as the pelvic diaphragm D. It is tensed during defecation E. It projects into the anal triangle

D. It is tensed during defecation. The pelvic floor is not tensed during defecation--it is relaxed so that feces can be released from the rectum. When rectal stretch receptors are stimulated, afferent impulses are sent to the spinal cord (which mediates local reflexes) and to the brain (which alerts the body of the urge to defecate). The pelvic splanchnic nerves mediate local parasympathetic reflexes that cause the rectal musculature to contract and the internal sphincter to relax. These reflexes are promoting the expulsion of feces. However, the external sphincter and levator ani muscles can be voluntarily contracted--they receive somatic innervation from the pudendal and levator ani nerves. This contraction allows feces to be retained until a suitable time. So, tensing the pelvis floor does not expel feces--it retains feces. The area between the pelvic floor and the pelvic brim is the true pelvic cavity. This is the area that contains the pelvic viscera. Pelvic diaphragm is another name for the pelvic floor, and it is mostly made by levator ani, a funnel-shaped muscle. The pelvic floor also projects into the anal triangle, a space bounded by the posterior margin of the perineal membrane and the two sacrotuberous ligaments.

29 year old woman admitted after severely tearing her pelvic diaphragm during childbirth. This led to paralysis of which of the following muscles? A. Piriformis B. Sphincter urethrae C. Obturator internus D. Levator ani E. Sphincter ani externus

D. Levator ani The pelvic diaphragm is formed by the levator ani and coccygeus muscle.

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

D. 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.

42 year old with portal hypertension secondary to cirrhosis of the liver and ascites needs to have his portal blood shunted around the liver. Patient is refusing transjugular intrahepatic portosystemic shunt (TIPS) procedure. What would be the most practical method to do this? A. Superior Mesenteric vein to the inferior mesenteric vein B. Portal vein to superior vena cava C. Portal vein to left renal vein D. Splenic vein to left renal vein E. Superior rectal vein to the left colic vein

D. Splenic vein to left renal vein Portal hypertension can be reduced by diverting blood from the portal to caval system. This is done by connecting the splenic vein to the left renal vein or by creating a communication between the portal vein and the IVC. Could also make a connection between a hepatic vein and a portal vein via TIPS procedure, but as stated in the question stem, patient declined this.

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

D. Superficial inguinal Lymph nodes

59 year old woman comes to the local hospital for uterine cancer surgery. As the uterine artery passes from the internal iliac artery to the uterus it crosses superior to which of the following structures that is sometimes mistakenly ligated during surgery? A. Ovarian Artery B. Ovarian Ligament C. Uterine Tube D. Ureter E. Round ligament of the uterus

D. Ureter Remember FEMALE water under the bridge relationship

A 62-year-old man undergoes cystoscopy for investigation and removal of a suspected renal calculus. During the procedure, a cystoscope is inserted through the penis and into the bladder. Slit-like openings are then visualized near the lateral ends of the top of the trigone region of the bladder. Which of the following best describes these structures? A. Ducts of the bulbourethral glands B. Ejaculatory ducts C. Internal urethral orifices D. Utereric orifices E. Uvulae of the bladder

D. Ureteric Orfices

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: A. gastrocolic ligament B. gastrosplenic ligament C. phrenicocolic ligament D. splenorenal ligament E. transverse mesocolon

D. 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.

Imaging studies of a patient with pancreatic carcinoma show an annular pancreas. This developmental anomaly results from which of the following conditions? A.Failure of dorsal pancreatic bud to migrate B.Failure of septum transversum to migrate C.Failure of ventral and dorsal pancreatic buds to fuse D.Migration of two components of dorsal pancreatic bud in opposite directions E.Migration of two components of ventral pancreatic bud in opposite directions

E (Migration of two components of ventral pancreatic bud in opposite directions) is correct. An annular pancreas results when the two components of a bifid ventral pancreatic bud migrate in opposite directions, surrounding the second part of the duodenum. The lumen of the duodenum may be obstructed by the constricting annular tissues shortly after birth, or obstruction may occur much later, after inflammation or carcinoma of the pancreas develops. Annular pancreas in utero may prevent the fetus from swallowing amniotic fluid, resulting in polyhydramnios.

A 38-year-old woman with a history of bleeding gastric ulcers is brought to the emergency room, where she is pronounced dead. An autopsy shows that she suffered a fatal hemorrhage, which was caused by erosion of a gastric ulcer through the posterior wall of the body of the stomach into an underlying vessel. Which of the following arteries was most likely involved? A.Celiac trunk B.Gastroduodenal artery C.Left gastric artery D.Right gastric artery E.Splenic artery

E (Splenic artery) is correct. The bed of the stomach includes the spleen, left kidney and suprarenal gland, pancreas, and splenic artery. Erosion of a gastric ulcer through the posterior stomach wall into the splenic artery may cause fatal hemorrhage.

A 16-year-old female patient sustains abdominal trauma in a motor vehicle accident that necessitates removal of her spleen. When performing a splenectomy, it is important to remember that the lienorenal ligament contains what structure? A.Left gastro-omental artery B.Left renal artery C.Left ureter D.Short gastric arteries E.Tail of the pancreas

E (Tail of the pancreas) is correct. The tail of the pancreas and the terminal portion of the splenic artery reach the hilum of the spleen through the lienorenal (splenorenal) ligament and may be injured there with an incision. Most patients do well after splenectomy, but fatal overwhelming postsplenectomy sepsis develops in a small percentage of cases (more frequently in children).

6 year old boy comes to his pediatrician with a lump in the groin near the thigh and pain in the groin. On examination the physician makes a diagnosis of a direct inguinal hernia because of the herniated tissue: A. Enters the deep inguinal ring B. Lies lateral to the inferior epigastric artery C. Covered by the spermatic fascia D. Descends into the scrotum E. Develops after birth

E. Develops after birth a direct hernia is acquired after birth. indirect inguinal hernia is congenital. direct hernia does not enter the deep inguinal ring but occurs through the posterior wall of the inguinal canal

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: A. Transpyloric plane B. Level of anterior superior iliac spines C. Transtubercular line D. Level of arcuate line E. Level of umbilicus

E. 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.

46 year old woman presents with infection of perineal region. Exam shows a tear of the superficial boundary of the superficial perineal space. Which of the following structures is most likely damaged? A. Pelvic Diaphragm B. Colle's fascia C. Superficial perineal fascia D. Deep perineal fascia E. Perineal membrane

E. Perineal membrane The superior (or deep) boundary of the superficial perineal space is the perineal membrane (aka the inferior fascia of the UG Diaphragm)

A newborn has male genital ducts but female external genitalia. Cytogenetic analysis shows a 46,XY karyotype, and genetic testing shows a mutation of the gene encoding 5-alpha-reductase. In the absence of this mutation, the apparent labia majora of this newborn would have developed into which of the following structures? A. Glans penis B. Penile shaft C. Penile urethra D. Prostatic utricle E. Scrotum

E. Scrotum (structure that is the female homolog of the scrotum is the labia majora)

The artery of the midgut is the: A. Celiac trunk B. Inferior mesenteric C. Proper hepatic D. Splenic E. Superior mesenteric

E. Superior mesenteric The superior mesenteric artery is the artery of the midgut. The celiac trunk is the artery of the foregut, and the inferior mesenteric artery is the artery of the hindgut. The splenic artery is a branch of the celiac artery, and the proper hepatic artery is a branch of the common hepatic artery, which is a branch of the celiac artery.

32 year old female presents to the office with severe nausea and recurrent bilious vomiting. Her symptoms initially began as postprandial epigastric pain and early satiety, but have progressed over the last 2 weeks. She works as an actress and tells you that her symptoms only started when "she landed the role in a soap opera" which inspired her to lose 20lbs on a crash diet. Her abdomen in tender and slightly distended with high pitched bowel sounds. Concerned about small bowel obstruction, you admit her to the hospital. A laparotomy is performed and you observe that the angle between the SMA and aorta is slightly decreased. Which of the following structures is most likely obstructed by the artery ? A. Ascending portion of the duodenum B. Descending portion of the duodenum C. Duodenal bulb D. Duodenojejunal flexure E. Gastric antrum F.Transverse portion of the duodenum

F. Transverse portion of duodenum This portion of the duodenum lies between the aorta and SMA at L3

The thoracic duct passes into the thorax by passing through the: a. Aortic hiatus b. Esophageal hiatus  c. Caval foramen d. Lateral arcuate ligament e. Medial arcuate ligament

a. Aortic hiatus (BB Hermey Question)

A 60-year-old woman arrived at the emergency room complaining of acute abdominal pain. She was diagnosed with ischemic bowel resulting from an obstruction of one or more branches of the inferior mesenteric artery. Which of the following is most likely NOT to be seriously affected by the ischemia? a. Cecum b. Descending colon c. Rectum d. Sigmoid colon e. Splenic flexure

a. cecum (BB Hermey Question)

A patient was diagnosed with bleeding ulcer of the lesser curvature of the stomach. Which artery is most likely involved?  a. Gastroduodenal b. Left gastric c. Left gastro-omental (epiploic) d. Right gastro-omental (epiploic) e. Short gastric

b. Left gastric (BB Hermey Question)

Orally ingested contrast medium opacifies all of the following structures except the:  a. colon b. duodenum c. esophagus d. Gallbladder e. stomach

d. gallbladder (BB Hermey Question)

A man is moving into a new house and during the process lifts a large chest of drawers. As he lifts he feels a severe pain in the lower right quadrant of his abdomen. He finds that he can no longer lift without pain and the next day goes to see his physician. Surgery is indicated and during the surgery the surgeon opens the inguinal region and finds a hernial sac with a small knuckle of intestine projecting through the abdominal wall just above the inguinal ligament and lateral to the inferior epigastric vessels. The hernia was diagnosed as a:  a. congenital inguinal hernia b. direct inguinal hernia c. femoral hernia d. incisional hernia e. indirect inguinal hernia

e. Indirect hernia (BB Hermey Question)

Surgical approaches to the abdomen sometimes necessitate a midline incision between the two rectus sheaths, i.e., through the: a. Linea aspera b. Arcuate line c. Semilunar line d. Iliopectineal line e. Linea alba

e. Linea alba (BB Hermey Question)