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  1. contents of inguinal canal
    • spermatic cord or round ligament
    • ilioinguinal nerve
  2. inguinal canal borders
    • inferiorly: inguinal ligament
    • anteriorly: external oblique aponeurosis
    • posteriorly: transversalis fascia
    • superiorly: arching fibres of internal oblique and tranversus abdominis
  3. deep inguinal ring
    • tubular evagination of transversalis fascia
    • where spermatic cord or round ligament emerge from abdomen
    • midway between ASIS and pubic tubercle, lateral to inferior epigastric vessels
  4. superficial inguinal ring
    • triangular opening in aponeurosis of external oblique muscle above and lateral to pubic tubercle
    • folds of external oblique aponeurosis form external spermatic fascia which covers spermatic cord
  5. femoral canal borders
    • superiorly: inguinal ligament
    • medially: lacunar ligament
    • laterally: femoral vessels (NAVY) so femoral vein
    • inferiorly: pubic ramus
  6. what forms the conjoint tendon and what is it continuous with?
    • formed by fusion of aponeuroses of internal oblique and transversus abdominis
    • continuous with cremasteric fascia
  7. continuation of transversalis fascia in the scrotum?
    internal spermatic fascia
  8. continuation of extraperitoneal fat in scrotum?
    areolar connective tissue
  9. layers covering testicles and their abdominal equivalents)
    • tunica albuginea
    • tunica vaginalis (parietal peritoneum)
    • areolar connective tissue (extraperitoneal fat)
    • internal spermatic fascia (transversalis fascia)
    • cremasteric muscle (internal oblique and transversus abdominis aponeuroses/conjoint tendon)
    • external spermatic fascia (external oblique aponeurosis)
    • dartos muscle (membraneous Scarpa's fascia)
    • skin (skin)
  10. direct inguinal hernia
    • herniation of bowel through weak point in lower abdominal wall fascia: inguinal triangle
    • medial to inferior epigastric artery
    • most common in elderly men
  11. indirect inguinal hernia
    • herniation of bowel through inguinal canal vai deep inguinal ring and out through superficial inguinal ring
    • lateral to inferior epigastric artery
    • most common in males because the inguinal canal is more prominent than in women
  12. femoral hernia
    • herniation of bowel through femoral canal
    • more common in women than men because women have wider hips
    • prone to strangulation due to narrow opening
  13. congenital hernia
    persistence of processus vaginalis between peritoneum and tunica vaginalis
  14. pantaloon hernia
    simultaneous direct and indirect hernias forming a pantaloon like shape due to inferior epigastric artery separating them
  15. omentocoel
    hernia of the omentum
  16. clinical test to differentiate direct and indirect hernias
    • gently press on deep inguinal ring (midway between ASIS and pubic symphysis) and ask patient to stand and cough to increase intraabdominal pressure
    • if indirect: will not bulge out
    • if direct: will still bulge medial to deep inguinal ring
  17. indirect hernia treatment
    • usually laparascopic or inguinal incision access to peritoneal cavity
    • return bowel to peritoneal cavity and close off the deep inguinal ring
  18. contents of spermatic cord
    • ductus deferens
    • testicular artery
    • pampiniform plexus of veins
    • genital branch of genitofemoral nerve
    • sympathetic nerves
    • cremaster muscle
    • lymphatics
  19. drainage of gonadal (testicular and ovarian) veins
    • R to IVC
    • L to L renal vein
  20. gonadal sensory afferents
    • postganglionic sympathetic nerves travel with gonadal arteries from preaortic plexus
    • cell bodies of sensory afferents travelling with these fibres are in the DRG at T10 level
    • umbilical area referred pain e.g. mittelschmertz
  21. vasectomy incision and procedure
    • bilateral longitudinal incisions at neck of scrotum to gain entry into spermatic cord
    • tie ductus deferens
  22. ligaments of anterior abdominal wall
    • median umbilical ligament: contains urachus, the fibrous remnant of allantois (fold of endoderm/yolk sac)
    • medial umbilical ligament: contains fibrous remnant of umbilical arteries
    • lateral umbilical ligament: contains inferior epigastric vessels
  23. anatomical factors preventing gastroesophageal reflux
    • LAMP
    • LES: formed by thickening of esophageal circular muscle and R crus of diaphragm contracts with inspiration and increased intraabdominal pressure closing the lower esophagus off from the stomach
    • angle: at which the esophagus enters the stomach
    • mucosa: mucosal folds at the cardia
    • pressure: intraabdominal component of esophagus is under increased
    • pressure when there is increase in intraabdominal pressure, tending to close it
  24. surface anatomy of liver
    • between ribs 7-11 MAL
    • inferior margin palpable 1-2cm below costal margin on inspiration
    • upper border reaches 5th rib MCL on expiration
  25. retroperitoneal organs of the abdominal cavity
    distal 3/4 of duodenum, pancreas, ascending colon (excluding cecum, appendix), descending colon, rectum, kidneys, suprarenal glands
  26. crc commonest sites and associated symptoms
    • 1. ascending colon (30%): occult bleeding, anemia
    • 2. sigmoid (25%): obstruction, overt bleeding
    • 3. rectum (20%): tenesmus, pain, bleeding
  27. borders of epiploic foramen
    • anteriorly: hepatoduodenal ligament (portal triad)
    • posteriorly: IVC
    • superiorly: liver (caudate)
    • inferiorly: duodenum
  28. components of lesser omentum
    • hepatoduodenal ligament (contains portal triad)
    • hepatogastric ligament
    • gastrosplenic ligament
    • splenorenal ligament
  29. pathway of bile storage and release
    • hepatocytes
    • bile canaliculi
    • biliary ducts
    • R/L hepatic ducts
    • common hepatic duct (within portal triad)
    • cystic duct
    • gallbladder (storage)
    • cystic duct
    • common bile duct
    • hepatopancreatic ampulla (w sphincter of oddi around major duodenal papilla)
    • duodenum
  30. celiac trunk level and branches
    • T12
    • left gastric
    • common hepatic
    • splenic
  31. left gastric artery
    • branch of celiac trunk
    • forms anastomoses with right gastric artery (branch of common hepatic artery)
    • gives off lower esophageal branches to intraabdominal esophagus
  32. common hepatic artery
    • branch of celiac trunk with four main branches
    • right gastroduodenal artery: branches further into right gastroepiploic artery which anastomoses with left gastroepiploic artery, branch of splenic artery; and suprerior pancreaticoduodenal artery
    • right gastric artery: anastomoses with left gastric artery
    • hepatic artery proper: enters liver as part of portal triad and forms terminal branches of common hepatic artery, the R/L hepatic arteries
    • cystic artery: branch of right hepatic artery
  33. splenic artery
    • branch of celiac trunk which has two main branches
    • left gastoepiploic artery: anastomoses with right gastroepiploic artery, branch of common hepatic artery
    • short gastric arteries: to the fundus
  34. hepatobiliary triangle borders
    • cystic duct
    • common hepatic duct
    • inferior surface of liver
  35. hepatic artery variation
    usually arises from common hepatic artery of celiac trunk but in 15% of population arises from SMA
  36. gastric arteries
    anatomoses of left and right gastric arteries on the lesser curvature of stomach
  37. gastroepiploic arteries
    anastomoses of left and right gastroepiploic arteries on the greater curvature of stomach
  38. celiac trunk supplies
    foregut: intraabdominal esophagus to major duodenal papilla
  39. SMA supplies
    midgut: major duodenal papilla to proximal 2/3 transverse colon
  40. IMA supplies
    hindgut: distal 1/3 transverse colon to anal canal
  41. duodenal ulceration site and cause
    • site: superior (first) part of duodenum most common
    • cause: H pylori infection or NSAID use
  42. complications of duodenal ulceration
    • perforation
    • anteriorly: acute peritonitis
    • posteriorly: erosion of gastroduodenal artery leading to hematemesis or melena
  43. venous drainage of GIT
    SMV drains into splenic vein which drains into IMV to form the portal vein
  44. portosystemic anastomoses sites
    • risk of haemorrhage in portal hypertension
    • esophagus: esophageal varices and haematemesis
    • rectum: haemorrhoids
    • paraumbilical: caput medusae
  45. esophageal portosystemic anastomosis
    upper esophagus is drained by azygos vein which has anastomoses with left gastric vein which drains the lower esophagus
  46. DDx enlarged spleen
    • portal HTN
    • haematological disorder
    • infection
    • malignancy
  47. vertebral level SMA
  48. vertebral level renal and gonadal arteries
  49. vertebral level IMA
  50. vertebral level aortic bifurcation
  51. commonest appendix positions
    • retrocecal
    • pelvic
    • others include preileal, postileal and subcecal
  52. differences between jejunum and ileum
    • wall thickness: thinner distally
    • blood supply: distally, shorter vasa recta (smaller boxes) and more arcades (anastomoses) to increase redundancy in high strangulation risk area
    • plicae circularis: more proximally, in jejunum
    • mesenteric fat: more distally, in ileum
    • lymphoid tissue: more distally, in ileum (Peyers patches)
  53. features of colon
    • taenia coli: longitudinal muscular band
    • haustra: sacculations
    • appendices epiploicae: fatty tags
  54. lymphatic drainage of GIT
    • follows arterial supply central pre aortic nodes around the arterial branch
    • foregut: celiac central nodes
    • midgut: superior mesenteric central nodes
    • hindgut: inferior mesenteric central nodes
    • all drain into intestinal trunk which collects into cisterna chyli (T12/L1), thoracic duct, L subclavian vein
  55. visceral nerve plexuses of abdomen
    • celiac: supply foregut (T6-9, referred pain to epigastrium)
    • SM: supply midgut (T8-T10, referred pain to umbilicus)
    • aorticorenal: around the paired parietal branches renal and gonadal, supplying suprarenal glands, kidneys, gonads (T10-L2)
    • IM: supply hindgut (T11-S4, referred pain to suprapubic area)
  56. visceral nerve plexus components
    • sympathetic and parasympathetic visceral motor fibres
    • sympathetic ganglia
    • visceral afferent sensory fibres
  57. visceral nerve inputs
    • vagus nerve parasympathetic innervation (major)
    • thoracolumbar paravertebral ganglia of sympathetic trunk
    • thoracic sympathetic greater, lesser, least splanchnic nerves
    • some pelvic parasympathetic splanchnic nerves
  58. visceral sensory fibres
    • conscious: run with sympathetic fibres via dorsal root, DRG, dorsal horn, afferent pathway (spinothalamic tract)
    • unconscious: run with parasympathetic fibres
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