HAD Unit III Review

1. HAD Unit III Review Tom Eck ecktw@umdnj.edu

2. Unit III Exam • A ton of material, but questions tend to be a bit more targeted—be sure to use the TBL as a guide • Lab: review the prosections, especially the pelvis ones

3. Abdominal Wall • Perineum • Gastrointestinal Tract • Genitourinary • Lower Limb • Lymphatics • Embryology • Shelf

4. Abdominal Wall • Fascia Layers • Innervation – intercostals, iliohypogastric, ilioinguinal • Musculature – rectus abd., obliques, quad. lumborum • Vessels – inferior and superior epigastric • Hernias – inguinal, femoral, congenital • Abdominal folds • Median = urachus • Medial = umbilical arteries (deoxygenated) • Lateral = inferior epigastric vessels

5. 1. When surgeons cut through the anterior abdominal wall below the arcuate line, which of the following do they NOT encounter? • Camper’s fascia • Scarpa’s fascia • Anterior layer of rectus sheath • Posterior layer of rectus sheath • Transversalis fascia

6. Layers of Anterior Abdominal Wall • Skin • Camper (fatty) • Scarpa (fibrous) • Muscles -External Oblique -Internal Oblique -TransversusAbdominus • Transversalis Fascia (fibrous) • Extraperitoneal Fat • Parietal Peritoneum • Above the arcuate line, the aponeuroses of the abdominal muscles ensheath the rectus abdominus • Below the arcuate line, they pass in front of it

7. 2. What would likely result from a vertical incision through the right semilunar line superior to the umbilicus? • Paralysis of the right rectus abdominis • Ischemia of the right rectus abdominis • Paralysis of the right external oblique • Ischemia of the right external oblique

8. Innervation and Blood Supply to Rectus Abdominus Blood Supply via Superior Epigastric Semilunar Line Innervation via Intercostals Blood Supply via Inferior Epigastric

9. 3. You palpate a mass lateral to the inferior epigastric artery and superior to the inguinal ligament. What is true of this hernia? • It always passes through the superficial inguinal ring • It is encased in spermatic fascia • It does not pass through the deep inguinal ring • It passes medial to femoral vein

10. Hernias of the Myopectineal Orifice • Superior to Inguinal Ligament = Inguinal • Direct: between medial and lateral umbilical folds (in Hesselbach’s Triangle) • medial fold = obliterated umbilical artery • lateral fold = inferior epigastric vessels • Indirect: lateral to lateral umbilical fold; may be congenital, due to failure of processus vaginalis to close • Inferior to the Inguinal Ligament = Femoral • Passes through the femoral canal medial to the femoral veins

11. 4. Which nerve supplies the efferent limb of the cremasteric reflex? • Iliohypogastric nerve • anterior scrotal nerve • Ilioinguinal nerve • genital branch of genitofemoral nerve • femoral branch of genitofemoral nerve

12. Cremasteric Reflex • Afferent Limb: femoral branch of genitofemoral nerve and ilioinguinal nerve • Efferent Limb: genital branch of genitofemoral nerve • Iliohypogastric Nerve (L1): skin above inguinal ligament • Ilioinguinal Nerve (L1): skin of anterior scrotum and adjacent thigh • Genitofemoral (L1, L2): skin below inguinal ligament, motor to cremaster • Note: both the ilioinguinal nerve and the genital branch of the genitofemoral nerve pass through the inguinal canal

13. Perineum • Fascia Layers • Muscles – external urethral sphincter, external anal sphincter, bulbospongiosus, ischiocavernosus • Innervation – Pudendal Nerve, primarily • Autonomics (i.e. point and shoot)

14. 5. When fluid deep to Scarpa’s fascia in the abdominal wall reaches the perineum, where does it accumulate? • just under the skin • the superficial perineal pouch • the deep perineal pouch • the ischioanalfossa

15. Perineal Spaces (of Urogenital Triangle) Skin Subcutaneous Fat  Camper Fascia on Abdomen Colles Fascia*  Scarpa’s Fascia of Abdomen  Dartos Fascia of Scrotum Deep Superficial Superficial Perineal Compartment (Ischiocavernosus, Bulbospongiosus, etc.) Perineal Membrane Deep Perineal Compartment (External Sphincter, etc.) LevatorAni (Encased in Fascia) *Note: also continuous with the fascia lata of the thigh, though fluid will not pass laterally

16. 6. When anesthetic is injected near the ischial spine, which of the following areas retains sensation? • anal region • anterior labium majora • posterior labium majora • anterior labium minora • posterior labium minora

17. Pudendal Nerve • S2, S3, S4 • the pudendal nerve supplies ALL of the perineal muscles and ALL of the overlying skin… • EXCEPT for the anterior scrotum/labium majora, which are supplied by the ilioinguinal nerve • Path: exits greater sciatic foramen and wraps around the ischial spine to enter the lesser sciatic foramen, extending anteriorly to the perineum

18. Pudendal Nerve Block Block here • anesthetized it as it wraps around the ischial spine • Pudendal Nerve Branches • Inferior Anal Nerves: external anal sphincter, perianal skin • Perineal Nerve: perineal muscles, perineal skin • Dorsal Nerve of the Penis/Clitoris: external urethral sphincter

19. GI Tract • Arterial Supply • Foregut = Celiac Truck • Midgut = Superior Mesenteric Artery • Hindgut = Inferior Mesenteric Artery • Portal Circulation • Biliary Flow • Innervation (Sympathetic and Parasympathetic) • major relationships (i.e. superior mesenteric artery passes over the third part of the duodenum)

20. 7. Which artery is in direct danger from an ulcer eroding the posterior wall of the stomach’s body? • common hepatic • left gastric • right gastric • gastroduodenal • splenic

21. The Celiac Trunk Splenic Artery • artery of the foregut • Three branches: • Splenic • Common hepatic • Left gastric • Artery endangered by ulcer in posterior wall of first part of the duodenum? • Gastroduodenal artery Celiac Trunk

22. 8. Which vessel(s) have reversed flow to permit a collateral circulation in this patient with chronic hepatitis? • periumbilical veins • left umbilical vein • gastric veins • middle rectal veins • Inferior rectal veins

23. Porto-Caval Anastamoses • Paraumbilical veins  superficial veins of abdominal wall Caput medusae • Superior rectal veins  Middle and Inferior Rectal Veins (Inferior Iliac Vein) Internal hemorrhoids • Gastric veins  Veins of Lower Esophagus ( Azygous System) Esophageal varices 1,2,3

25. 9. If the left renal vein becomes occluded near its termination, which of the following will result? • caput medusae • esophageal varices • internal hemorrhoids • left varicocele • right varicocele

26. Memorize major branches/tributaries of the abdominal aorta and IVC as well as how they relate to each other. Be able to draw this out.

27. 10. When the pain of acute appendicitis moves into the right lower quadrant from the periumbilical region, which nerves carry this sensation? • visceral afferents from the foregut • visceral afferents from the midgut • visceral afferents from the hindgut • intercostal nerves

28. Referred Pain in Appendicitis • Initial pain = periumbilical; visceral afferents from inflamed appendix refer to the T10 dermatome • Later pain = LRQ; as the parietal peritoneum is irritated, somatic afferents from intercostal nerves (subcostal, iliohypogastric, etc.) transmit well-localized pain

29. Genitourinary • Arterial Supply • Follow the Urinary Tract • Female Reproductive Tract • Male Reproductive Tract • SEVEN UP (Seminiferous Tubules, Epididymus, Vas Deferens, Ejaculatory Duct, (Nothing), Urethra and Penis) • Innervation (Sympathetic and Parasympathetic)

30. 11. If a surgeon were to accidentally lacerate one of the following, which would involve the least risk of hemorrhage? • suspensory ligament • mesovarium • mesosalpinx • mesometrium • round ligament • cardinal ligament

31. Ligaments of the Female Reproductive Tract • Broad ligament • Mesovarium • Mesosalpinx • Mesometrium • Suspensory Ligament: carries ovarian neurovascular bundle • Cardinal Ligament: carries the uterine artery, situated below the broad ligament • Round Ligament (and Ovarian ligament): remnant of gubernaculum

32. 12. What does this hysterosalpingogram demonstrate? • uterine fistula • endometriosus • fallopian tube obstruction • congenital ovarian agenesis • normal anatomy

33. the female reproductive tract communicates with the peritoneal cavity via the fallopian tubes • a major route for spread of infection • basis for abdominal pregnancy

34. 13. Which of the following is at greatest risk in a hysterectomy? • uterine artery • ureter • urinary bladder • urethra • rectum

35. The Ureter • Know the path of the ureter • At risk for damage when the uterine artery is ligated • Passes along the posterior abdominal cavity • Crosses the external iliac artery lateral to the internal iliac artery below the pelvic brim • “water under the bridge” - passes under the uterine artery, lateral to the lateral fornix of the vagina before entering the urinary bladder

36. 14. Along which nerve(s) do fibers carrying pain from the prostate travel? • hypogastric nerve • sacral splanchnic nerves • pelvic splanchnic nerves • thoracoabdominalsplanchnic nerves

37. Visceral Pain • pain line = lower limit of peritoneum • above the pelvic pain line, visceral afferents follow sympathetic fibers • below the pain line, visceral afferents follow parasympathetic fibers • Pelvic splanchnic nerves carry Parasympathetic fibers • Sacral splanchnic nerves carry Sympathetic fibers (as do all other splanchnic nerves) • Don’t get hung up on pathways for autonomics (i.e. greater splanchnic celiac ganglion, etc.; straight from Dr. Vasan); symptoms are more important

38. 15. Which branch of the internal iliac artery supplies the superior portion of the bladder? • obturator • umbilical • uterine • vaginal • superior vesicle

39. The Internal Iliac Artery • posterior division: superior gluteal, iliolumbar, lateral sacral • anterior division: supplies the viscera of the pelvis from anterosuperior to posteroinferior

40. The Anterior Division Obturator Foramen Obturator Umbilical ( S. vesicle) Uterine Greater Sciatic Foramen Vaginal Inferior Vesicle (in males) Middle Rectal Internal Pudendal Inferior Gluteal

41. Lower Limb • Muscles, Actions, and Innervations • Same kinds of things as upper limb, except… • ligaments are stressed a bit more • the foot matters <<< the hand • In general, somewhat less detail required—knowing muscle compartment often enough to define action and innervation • know all major nerve deficits, how to recognize them, and what structures are involved

42. 16. What action at the hip might be lost if the nerve that passes through the obturator foramen were damaged? • flexion • extension • adduction • abduction • medial rotation • lateral rotation

43. Medial Compartment of Thigh • Innervation: obturator nerve • Receives blood supply, in part, from the obturator artery • Muscles: adductors longus, brevis, and magnus; gracilis, obturatorexternis* • For most muscles, simply knowing the compartment will tell you its primary action *The pectineus is the only muscle that contributes to adduction, but is not innervated by the obturator nerve.

44. 17. If a tumor were to compress the structures that exit the greater sciatic foramen superior to the piriformis, which of the following might be lost? • thigh extension • hip abduction • foot eversion • posterior thigh sensation • urinary continence

45. Greater Sciatic Foramen • formed from greater sciatic notch, closed off inferiorly by the sacrospinous ligament and posteromedially by the sacrotuberous ligament • the superior gluteal nerve innervates the gluteus medius, gluteus minimus, and tensor of the fascia lata all three provide hip abduction (and medial rotation); loss = “hip drop” • thigh extension = tibial, inferior gluteal; • foot eversion = peroneal (superficial); • posterior thigh sensation = post. femoral cutaneous • urinary continence = pudendal (external urethral sphincter)

46. 18. What action at the hip would be most weakened by avulsion of the lesser trochanter of the femur? • extension • flexion • abduction • adduction • elevation

47. Iliopsoas Psoas Major Iliacus • The most powerful flexor of the hip • Three muscles: psoas major, psoas minor, iliacus • Psoas major and iliacus are the only muscles that insert at the lesser trochanter • Psoas major significant for signaling apendicitis, route for spread of infection to/from thigh • Greater trochanter: most of the gluteal muscles; gluteus medius, minimus, gemelli, obturatorinternis, piriformis Greater Trochanter Lesser Trochanter

48. Important Attachment Sites • Greater trochanter • Lesser trochanter • Tibialtuberosity = quadriceps femoris • Ischialtuberosity = hamstrings (except short head of biceps femoris) • Base of 5th metatarsal = fibularisbrevis • Base of 1st metatarsal = fibularislongus • For most of the rest, simply knowing the bone (or general region) should suffice

49. 19. Following injury, if you note ease in abducting the tibia, causing visual deformity (genu valgum), which ligament may have been damaged? • anterior cruciate • posterior cruciate • fibular collateral • tibial collateral • patellar

50. Ligaments of the Knee • The knee is the largest and least stable joint of the body; know the deficits • ACL = laxity in anterior displacement of tibia; connects lateral femoral condyle to anterior tibia • PCL = laxity in posterior displacement of tibia; connects medial femoral condyle to posterior tibia • FCL (lateral) = genuvarum • TCL (medial) = genuvalgum • vaLgum = Lateral displacement of distal component • varum = medial displacement of distal component • Coxa = hip; genu = knee; hallux = big toe