Abdomen and Pelvis

Small And Large Intestines Question And Answers

Question 1. Describe in detail about the different parts of the duodenum and its relations.
Answer:

Duodenum

Duodenum Parts:

1. Superior
2. Descending
3. Horizontal
4. Ascending

• The first part of small intestine
• It is the shortest and widest part of small intestine
• Length: 25 cm
• Extend: Pylorus to duodenojejunal flxure
• It is generally retroperitoneal except for its beginning
• It is C-shaped
• It encloses the head of pancreas in the concavity of ‘C’
• Vertebral level—L1, L2, L3

Duodenum is divided into 4 parts:

1. Duodenum First Part/Superior Part

• Foregut derivative
• Partly retroperitoneal
• Length: 5 cm
• Extend: Pyloric orifice to neck of the gallbladder

Duodenum First Part Or Superior Part Course:

Read And Learn More: Anatomy Question And Answers 

Duodenum First Part Or Superior Part Relations:

• Peritoneal Relations
  • Proximal 2.5 cm
    • The intraperitoneal part, it is movable
    • Attached to:
      • Lesser omentum:
      • Above
      • Greater omentum:
      • Below
  • Distal 2.5 cm
    • Retroperitoneal part, it is fied
• Visceral Relations
  • Anteriorly
    • Quadrate lobe of liver
    • Gallbladder
  • Posteriorly
    • Gastroduodenal artery
    • Common bile duct
    • Portal vein
  • Superiorly: Epiploic foramen
  • Inferiorly: Head and neck of the pancreas

Duodenum First Part Or Superior Part Applied Anatomy

• The first part of the duodenum is overlapped by the liver and gallbladder; either of these structures can adhere to the duodenum, and may be eroded by the duodenal ulcer, if present
• It is in the first part of the duodenum where the majority of ulcers are present.

2. Duodenum Second Part/Descending Part

• Upper half of 2nd part up to ampulla of Vater: Foregut derivative
• Lower half of 2nd part from ampulla of Vater: Midgut derivative
• Length: 7.5 cm
• Duodenum Second Part/Descending Part Extend: Neck of gallbladder to lower border of L3 vertebrae

Duodenum Second Part/Descending Part Course:

Duodenum Second Part/Descending Part Relations

• Peritoneal 
  • Retroperitoneal
  • Fixed
  • The anterior surface is covered by the peritoneum mostly
  • Except at a region near the middle of the second part (here it is in direct contact with the colon)
• Visceral
  • Anteriorly
    • Right lobe of liver
    • Gallbladder
    • Transverse colon
    • Transverse mesocolon
    • Coils of intestine
  • Posteriorly
    • Anterior surface of right kidney
    • Right renal vessels
    • Right edge of inferior vena cava
    • Right psoas major
  • Medially
    • Head of the pancreas
    • Bile duct
  • Laterally
    • Right lobe of liver
    • Right colic flexure
    • Ascending colon

3. Duodenum Third Part/Inferior Part

• Derived from midgut
• Longest part
• Length – 10 cm

Duodenum Third Part/Inferior Part Course:

Duodenum Third Part/Inferior Part Relations

• Peritoneal
  • Retroperitoneal, fied
  • The anterior surface is covered by the peritoneum all over except at the regions in the median plane, where it is crossed by superior mesenteric vessels and root of the mesentery
• Visceral
  • Anteriorly
    • Root of mesentery
    • Superior mesenteric vessels
    • Coils of jejunum
  • Posteriorly
    • Right ureter
    • Right psoas major
    • Inferior vena cava
    • Abdominal aorta
    • Right testicular/ovarian vessels
  • Superiorly: Head of pancreas and it’s uncinate process
  • Inferiorly: Coils of jejunum

Duodenum Fourth Part/Ascending Part

• Derived from midgut
• Retroperitoneal
• Length – 2.5 cm

Duodenum Fourth Part/Ascending Part Course:

Duodenum Fourth Part/Ascending Part Relations

• Peritoneal
  • Anteriorly covered by peritoneum
  • Terminal part is mobile and suspended by the mesentery
• Visceral
  • Anteriorly
    • Transverse colon
    • Transverse mesocolon
    • Lesser sac
  • Posteriorly
    • Left psoas major muscle
    • Left sympathetic chain
    • Left renal artery
    • Left gonadal artery
    • Inferior mesenteric vein
  • Superiorly: Body of pancreas
  • To the right: Upper part of the root of mesentery
  • To the left:
    • Left kidney
    • Left ureter

Question 2. Describe briefly about the interior of duodenum.
Answer:

The interior of duodenum:

Mucosa shows plica circularis: The permanent spiral folds, villi—permanent figer-like projections of lamina propria that extend into the intestinal lumen, microvilli—the cytoplasmic extensions that cover the apices of intestinal absorptive cells—all these aids the absorption better

The Interior of 2nd part of duodenum has the following special features:

• Major duodenal papilla:
  • It is an elevation present on the posteromedial wall of duodenum
  • Situated 8–10 cm distal to pylorus
  • The common hepatopancreatic duct opens at the summit of the papilla.
• Minor duodenal papilla:
  • It is a small conical elevation situated 6–8 cm distal to the pylorus
  • The accessory pancreatic duct opens at the summit of the papilla.
• Arch of plica semicircularis:
  • They are permanent folds of mucous membrane and form complete or incomplete circles
  • They begin in the second part of duodenum
  • It forms an arch above the major duodenal papilla like a hood.
• Plica longitudinalis:
  • Vertical tortuous fold of mucous membrane
  • Extends downwards from major duodenal papilla.

Question 3. Write a note on the blood supply, lymphatic drainage, and nerve supply of different parts of the duodenum.
Answer:

Different parts of the duodenum

Blood Supply of Duodenum

• Duodenum is developed from the foregut up to the level of opening of the bile duct into the 2nd part
• Below this level, it is derived from midgut
• So part of the duodenum:
  • Derived from foregut: Supplied by superior pancreaticoduodenal artery, a branch of the celiac trunk (artery of foregut)
  • Derived from midgut: Supplied by the inferior pancreaticoduodenal artery, a branch of the superior mesenteric artery (artery of midgut)
• Both these arteries gives of anterior and posterior branches
• These branches anastomose and forms anterior and posterior pancreaticoduodenal arterial arcades and supply duodenum
• Additional supply for first part of duodenum
  • Right gastric artery
  • Supraduodenal artery of Wilkie
  • Retroduodenal artery
  • Infraduodenal artery.

Duodenum Venous Drainage: Veins drain into

• Splenic vein
• Superior mesenteric vein
• Portal vein.

Duodenum Lymphatic Drainage

Lymph flows into pancreaticoduodenal nodes—it lies at the junction of the pancreas and duodenum (inner curve of the duodenum)

Duodenum Nerve Supply

• Sympathetic supply: From T9–T10 spinal segments
• Parasympathetic supply: From vagus, through celiac plexus and superior mesenteric plexus.

Question 4. What is the duodenal cap?
Answer:

Duodenal cap

In a barium meal procedure, after intake of contrast, the first part of the duodenum becomes visible in the radiograph as a triangular shadow called the duodenal cap and is emptied to the jejunum every one minute.

Question 5. Write a note on the ligament of Treitz.
Answer:

Ligament of Treitz

• Suspensory muscle of duodenum
• It consists of a fibromuscular band, suspending the duodenojejunal flexure from the right crus of the diaphragm

Ligament Of Treitz Attachments:

• Upper end: Right crus of diaphragm
• Lower end: Posterior aspect of duodenojejunal flexure
• This band comprises of 3 types of fibers (from above to below)
  1. Striated muscle fibers
  2. Elastic fibers
  3. Non-striated muscle fibers

Ligament Of Treitz Functions

• Fixes the duodenojejunal flexure and prevents the pulling down by loop of intestine
• In the radiological investigation of duodenum, the position of the ligament of Treitz is of utmost importance, normally it should be demonstrated to the left of and at the same level or above of the first part of the duodenum.
• Change in position indicates malrotation of the duodenum
• Embryologically, it is derived from mesoderm.

Question 6. Differentiate between jejunum and ileum.
Answer:

Difference between jejunum and ileum

• The mobile part of the intestine
• Extend: Duodenojejunal flexure to the ileocecal junction
• They are suspended from the posterior abdominal wall by mesentery, which gives them considerable mobility
• Jejunum is located in the left upper quadrant and the ileum in the right lower quadrant of the abdomen.

Jejunum

• Length: Upper 2/5th of the mobile part of small intestine
• Wall: Thicker and more vascular
• Lumen: Wider (diameter–4 cm) and often empty
• Villi: Larger, thicker, and leaf-like and numerous
• Plica circulars: Longer and more closely set
• Mesentery: Contains less fat
  • 1 or 2 arterial arcades
  • Vasa recta are longer and fewer
  • Windows present
• Peyer’s patches: Absent

Ileum

• Length: Lower 3/5th of the mobile part of small intestine
• Wall: Thinner and less vascular
• Lumen: Narrower (diameter-3.5 cm) and often full
• Villi: Shorter thinner and figer like
• Plica circulars: Smaller and sparsely set
• Mesentery: Contains more fat
  • 3–6 arterial arcades
  • Vasa recta shorter and numerous
  • Windows absent
• Peyer’s patches: Present

Question 7. Write a note on the blood supply, lymphatic drainage, and nerve supply of the jejunum and ileum.
Answer:

Jejunum and Ileum Arterial Supply

• Jejunum: Jejunal arteries from the superior mesenteric artery
• Ileum: Two arteries
  • Ileal arteries: Branch of superior mesenteric artery
  • Ileal branch from the ileocolic artery
• These arteries enter the mesentery and get divided into smaller branches
• Smaller branches anastomoses and form arterial arcades
• Arterial arcades are more complex in the ileum
• From the concavities of arterial arcades, small parallel, and straight vessels arise, known as vasa recta, supplies the opposite surface of the small intestine.

Jejunum and Ileum Venous Drainage

Drained by corresponding veins of the arteries, into superior mesenteric vein.

Jejunum and Ileum Lymphatic Drainage

Lymph vessels of small intestine mesenteric lymph nodes superior mesenteric nodes.

Jejunum and Ileum Nerve Supply

• Sympathetic supply: From T10–T11 segments, through splanchnic nerves and superior mesenteric plexus
• Parasympathetic supply: From the vagus nerve, through celiac and superior mesenteric plexuses
• Due to T10 supply: Pain is referred to as umbilicus (T10 segment).

Question 8. Mention about the features of the large intestine.
Answer:

Large intestine

• Wider than the small intestine
• Length: 1.5 m
• Extend: Ileocecal junction to anus

Large Intestine Divided into:

• Cecum
• Ascending colon
• Transverse colon
• Descending colon
• Sigmoid colon
• Rectum
• Anal canal

Large Intestine Appendix: It is a narrow diverticulum present at the angle between the cecum and the terminal part of the ileum

Gross distinguishing features of the large intestine are: Taenia coli

• They are three ribbon-like bands of the longitudinal muscle coat
• Proximally these bands converge at the base of the appendix and spread out to become continuous with a longitudinal muscle coat of the rectum
• Based on the position of taenia coli on the cecum, ascending colon, descending colon, and transverse colon they are named accordingly:

1. Taenia libera mesocolic

• Position in the cecum, ascending colon, and descending colon: Anterior
• Position in the transverse colon: Inferior

2. Taenia mesolica

• Position in the cecum, ascending colon, and descending colon: Posteromedial
• Position in the transverse colon: Posterior

3. Taenia omentalis

• Position in cecum, ascending colon, and descending colon: Posterolateral
• Position in the transverse colon: Superior

Large Intestine Appendices Epiploic:

• Fat filed bags of visceral peritoneum attached to taenia coli
• Thy are seen on all parts of the large intestine except in the appendix, rectum, and anal canal

Large Intestine Sacculations Or Haustrations:

Dilated parts in between the taenia coli, gives the characteristic puckered appearance to the large intestine.

Question 9. Explain in detail about the cecum and briefly mention its development.
Answer:

Cecum

• Dilated sac
• Forms the first part of large intestine

 

Cecum Relations

• Anteriorly
  • Coils of small intestine
  • Anterior abdominal wall
  • Greater omentum
• Posteriorly
  • Muscles: Right psoas major, iliacus
  • Vessels: Right gonadal vessels, right iliac artery (sometimes)
  • Nerves: Femoral nerve, genitofemoral nerve, lateral cutaneous nerve of thigh
  • Retrocecal recess containing the appendix.

Cecum Orifies And Valves: Cecum has 2 orifices, guarded by their respective valves:

1. Ileocecal Orifice:

• Location: Posteromedial aspect of cecocolic junction
• Measures 2.5 cm transversely
• It is guarded by ileocecal valve.

The ileocecal valve has two lips:

• Upper smaller horizontal lip: Lies at ileocolic junction
• Lower longer concave lip: Lies at the ileocecal junction
  • The two lips fuse at the ends of the opening and form two frenula—right and left cecal frenulum
  • The valves are closed by:
    • Sympathetic innervation
    • Mechanically by distension of cecum

Ileocecal Orifie Applied Anatomy: The ileocecal valve prevents the reflux of contents from the cecum to ileum.

2. Appendicular orifice

• Small circular orifice
• Location: 2 cm below and posterior to ileocecal orifice
• This orifice is also guarded by a semicircular mucous membrane fold known as the valve of Gerlach

Appendicular Orifie Blood Supply

• Arterial supply: Anterior and posterior cecal branches of the ileocolic artery (branch of a superior mesenteric artery)
• Venous drainage: Veins accompany the arteries and drain into a superior mesenteric vein, then into portal vein
• Lymphatic drainage: Lymphatics drain into → Ileocolic nodes → Superior mesenteric group of preaortic lymph nodes.

Development Of Cecum

Cecum develops from the proximal part of cecal bud arising from the caudal limb of the primitive intestinal loop.

Question 10. What is a vermiform appendix, what are its features and what is its surgical importance?
Answer:

Positions Of Appendix

Vermiform Directions Or Positions Of Appendix

• Paracolic/11 ‘O’ clock position (2%)
  • Appendix is directed upwards and to the right
• Retrocecal/12 ‘O’ clock position (65%)—most common
  • Directed upwards
  • Lies behind the cecum and ascending colon
• Splenic/2‘O’ clock position
  • Directed upwards and to the left
  • Pointed towards the spleen
• The appendix may be:
  • Anterior to ileum—preileal
  • Posterior to ileum—post-ileal
• Promonteric/3‘O’ clock position (<1%)
  • Directed horizontally and to the left pointing to the sacral promontory
• Pelvic/4‘O’ clock position (30%)
  • The appendix descend into the pelvis
• Midinguinal/6‘O’ clock position
  • Directed vertically downwards
  • Pointed towards the inguinal ligament
  • Lies behind cecum

Development Of Vermiform Appendix

Vermiform appendix develops from the distal part of the cecal bud arising from the caudal limb of the primitive intestinal loop.

Vermiform Applied Anatomy

• In preileal position—infection of the appendix can spread into general peritoneal cavity, so this position is considered as the most dangerous
• Peritoneal relations
  • Intraperitoneal
  • It is suspended by mesoappendix/appendicular mesentery (small triangular fold of peritoneum)
  • The appendicular artery runs through the mesoappendix

Vermiform Blood Supply

• Arterial supply
  • By appendicular artery (end artery): Branch of the inferior division of ileocolic artery

Vermiform Course:

Vermiform Venous drainage: Veins accompany the arteries, drains into superior mesenteric vein, and from it to portal vein

Vermiform Lymphatic drainage

• Most lymphatics drain directly into ileocolic lymph nodes
• Few lymphatics drain indirectly through appendicular nodes (present in the mesoappendix) in to ileocolic lymph nodes.

Vermiform Nerve supply

• Sympathetic supply: From T10 spinal segments through lesser splanchnic nerve and superior mesenteric plexus
• Parasympathetic supply: From both vagus.

Vermiform Applied Anatomy

• Acute appendicitis: Acute inflammation of the appendix, commonly due to obstruction of its lumen, the pain is referred initially to the umbilical region (Because both are supplied by same spinal segment-T10)
• Mcburney’s point: It is the point of maximum tenderness during appendicitis.
  • It is a point at the junction of the lateral 1/3rd and medial 2/3rd of the line joining anterosuperior iliac spine and umbilicus.

Question 11. Explain in detail about the divisions of the colon. Also, mention about the colic flexures.
Answer:

It is divided into four parts namely: Ascending colon, transverse colon, descending colon, and sigmoid colon.

Ascending Colon

• Upward continuation of cecum
• Lies in right paracolic gutter
• Length: 2.5 cm
• Extent: Cecum to the inferior surface of right lobe of liver
• It is enclosed by peritoneum on 3 sides
• The posterior surface lies on 3 muscles:
  • Transversus abdominis
  • Quadratus lumborum
  • Iliacus

Ascending Colon Relations

• Anteriorly
  • Anterior abdominal
  • Right edge of the greater omentum
  • Coils of the small intestine
• Posteriorly
  • Muscles: Transversus abdominis, quadratus lumborum, iliacus
  • Kidney
  • Nerves: Ilioinguinal, iliohypogastric, lateral cutaneous nerve.

Right Colic Flexure/Hepatic Flexure

• It lies at the junction of ascending colon and transverse colon in the right lumbar region
• Vertebral level: L2
• Here the distal end of ascending colon bends forwards, downwards and to the left forming the flexure.

Transverse Colon

• Largest and most mobile part of the large intestine
• Length: 50 cm
• Extent: From right colic flexure (in the right lumbar region) to left colic flexure (in the left hypochondrium)
• The transverse colon is not actually transverse, it hangs low as a loop in front of loops of small intestine suspended by transverse mesocolon
• This attains an ‘U’ shape (with limbs of unequal length)
• Lower most point of loop usually extends up to the umbilicus (sometimes it can extend in to the pelvis)

Transverse Colon Relations:

• Anteriorly: Greater omentum and anterior abdominal wall
• Posteriorly: Second part of the duodenum, head of the pancreas, coils of the small intestine.

Left Colic Flexure/Splenic Flexure

• Lies at the junction of transverse colon and descending colon in the left hypochondrium
• Level: T12 vertebrae
• Here the distal end of the transverse colon bends downwards and backwards forming the flexure
• It is attached to the diaphragm by the phrenicocolic ligament.

Descending Colon

• Length – 25 cm
• Extent: From left colic flexure to sigmoid colon
• From the left colic flexure, the descending colon descends through the left lateral region, and the left inguinal region to reach the left side of the brim of the true pelvis
• Here it meets up with sigmoid colon

Descending Colon Relations:

• Anteriorly: Coils of small intestine
• Posteriorly
  • Muscles: Transversus abdominis, quadratus lumborum, iliacus, and psoas
  • Nerves: Ilioinguinal and iliohypogastric nerves, lateral cutaneous nerve, femoral nerve.

Sigmoid Colon

• Length: 37.5 cm
• S-shaped
• Extent: From lower end of descending colon to 3rd piece of sacrum
• The sigmoid colon forms a convoluted loop
• It is enclosed on all sides by the peritoneum
• It is attached to posterior abdominal wall by sigmoid colon.

Blood Supply Of Colon

• Arterial Supply
  • Right, middle, and left colic arteries
  • Ileocolic artery
  • Sigmoid artery
  • Superior rectal artery.
• Venous Drainage
  • Portal circulation

• Lymphatic Drainage
  • Paracolic nodes
  • Intermediate colic nodes
  • Epiploic nodes.

Question 12. Write a note on Meckel’s diverticulum and what is the rule of 2.
Answer:

Meckel’s diverticulum

• Midgut communicates with the yolk sac at the embryological stage through the vitellointestinal duct
• Normally vitellointestinal duct involutes and disappears; occasionally the duct closes at the umbilical end but remain patent at the intestinal end
• Patent vitellointestinal duct gives rise to Meckel’s diverticulum
• This patent part appears as out pocketing of ileum
• Rule of 2: Occurs in 2% of subjects, 2 inches long and situated 2 ft. proximal to ileocecal valve, occurs most commonly in children under 2, and is symptomatic in 2% of patients.

Small And Large Intestines Multiple Choice Questions

Question 1. Most of the small intestine receives its blood supply from branches of the _____ artery:

1. Middle colic
2. Celiac
3. Gastroduodenal
4. Inferior mesenteric
5. Superior mesenteric

Answer: 5. Superior mesenteric

Question 2. All the following are features of the large intestine except:

1. Has leaf-like villi
2. Absorbs salt and water
3. Appendices epiploic
4. The epithelium contains goblet cells in large numbers
5. Presence of Brunner’s glands

Answer: 1. Has leaf-like villi And 5. Presence of Brunner’s glands

Question 3. Payer’s patches are seen in the:

1. Ileum
2. Duodenum
3. Jejunum
4. All of the above

Answer: 1. Ileum

Question 4. All of these supply the first 2 cm of duodenum, except:

1. Left gastric artery
2. Right gastric artery
3. Supraduodenal artery
4. Gastroduodenal artery

Answer: 1. Left gastric artery

Question 5. Which portion of the primordial gut differentiates into the portion of the duodenum proximal to the opening of the bile duct?

1. Foregut
2. Midgut
3. Hindgut
4. Biliary system

Answer: 1. Foregut

Question 6. Which is intraperitoneal?

1. Pancreas
2. 2nd and 3rd part of the duodenum
3. Ascending colon
4. Transverse colon
5. Descending colon

Answer: 4. Transverse colon

 

Stomach Question And Answers

Question 1. Describe in detail about the location and external features of stomach.
Answer:

Stomach

• It is a muscular bag between the abdominal part of the esophagus and the first part of the duodenum
• It is the widest and most distensible part of GIT.

Stomach Location

• It lies obliquely
• In the upper left part of abdomen
• It occupies:
  • Left hypochondrium
  • Epigastrium
  • Umbilical region
• Most of it lies under cover of the left costal margin and the ribs
• Stomach Extent: From left hypochondrium to epigastric and umbilical region

Stomach Shape:

• J­shaped: Empty stomach
• Pyriform shape: Partially distended stomach
• Horizontal stomach: Obese.

Stomach Size:

• Length: 25 cm
• Capacity: 1.5–2 L in adults

Stomach External Features: Stomach has

• Two ends/orifices: Cardiac and pyloric
• Two curvatures: Greater curvature and lesser curvature
• Two surfaces: Anterior/anterosuperior and posterior /posteroinferior.

Stomach Two Ends

• Cardiac End
  • It is the upper end receiving the lower end of esophagus
  • It has an opening—cardiac orifice
  • Vertebral level—T1
  • Lies posterior to left 7th costal cartilage
• Pyloric End
  • It is the lower end, which is continuous with the first part of the duodenum
  • It has an opening called pyloric orifice
  • Vertebral level—L1
  • Lies 1.2 cm to the right of median plane.

Read And Learn More: Anatomy Question And Answers 

Stomach Two Curvatures

• Lesser curvature
  • The shorter right border of stomach
  • Concave in shape
  • Angular notch/incisura angularis
    • Most dependent part of the lesser curvature
    • It marks the junction of the body and pyloric part of stomach
  • Lesser curvature also provides attachment to the lesser omentum
• Greater curvature
  • Convex in shape
  • Upper end has a notch, called the cardiac notch
  • Ths cardiac notch separates the greater curvature from the left aspect of esophagus
  • Greater curvature provides attachment to:
    • Greater omentum
    • Gastrosplenic ligament
    • Gastrophrenic ligament.

Stomach Two Surfaces

• Anterior surface/anterosuperior surface
  • Faces forwards and upwards
• Posterior surface/posteroinferior surface
  • Faces backward and downwards.

Stomach Parts: Stomach has 4 parts

1. Cardiac part
2. Fundus part
3. Body part
4. Pyloric part

1. Cardiac Part: It surrounds the opening of esophagus into upper part of stomach.

2. Fundus Pary: It is the area located above the level of the cardiac opening.

Fundus Pary Traube’s Space: This area overlies the fundus of stomach and is tympanitic (hollow, high, drum-like sound)

Fundus Pary Boundaries

• Right side: Left lobe of liver
• Left side: Spleen
• Above: Lower margin of left lung resonance
• Below: Left costal margin

Fundus Pary Traube’s space is obliterated in:

• Left-sided pleural effsion
• Massive splenomegaly
• Full Stomach
• Fundal growth
• Massive pericardial effsion
• Enlarged left lobe of the liver

3. Body Part: Largest region of the stomach, between the fundus and pylorus.

4. Pyloric Part:

• It is a funnel-shaped outflow part of the stomach
• It is divided into pyloric antrum and pyloric canal
  • Pyloric antrum—proximal wide part
  • Pyloric canal—distal narrow tubular part
• The pyloric antrum and canal are separated by an inconstant sulcus in the greater curvature called as sulcus intermedius.

Question 2. Write a note on the relationship of the stomach and stomach bed.
Answer:

Relations Of Stomach And Stomach Bed

Stomach And Stomach Bed Peritoneal Relations

• Stomach is covered by the peritoneum on both surfaces except along the curvature (where blood vessels run) and a small part on the posterior surface of stomach near the cardiac orifice called the bare area of the stomach
• Peritoneal layers covering the anterior and posterior surfaces meet at the lesser curvature and extend as lesser omentum
• Peritoneal layers also meet at the upper 2/3rd of greater curvature and extend as greater omentum
• Two layers of peritoneum meet near the fundus and forms the gastrosplenic ligament
• From the uppermost part of fundus, the peritoneal layer covering the posterior surface of stomach extends as gastrophrenic ligament

Stomach And Stomach Bed Visceral Relations

• Anterior surface
  • Liver
  • Diaphragm
  • Rib cage
  • Anterior abdominal wall
• Posterior surface (The structures related posteriorly forms the stomach bed)
  • Diaphragm
  • Left suprarenal gland
  • Left kidney
  • Pancreas
  • Transverse mesocolon
  • Splenic flexure of the colon
  • Splenic artery
  • Spleen—sometimes

The stomach bed is separated from the stomach by a lesser sac, except for the spleen which is separated by the greater sac

Mnemonic: STOMACH BED: Dr. Santa Singh killed The Patients Cruelly And Mercilessly (Diaphragm, Suprarenal gland, Spleen, Kidney, Transverse colon, Pancreas, Splenic flexure of Colon, splenic Artery, Transverse Mesocolon).

Question 3. Write a note on the interior of stomach.
Answer:

The interior of stomach

Interior part of stomach presents with 3 important features, namely:

1. Gastric rugae
2. Gastric pits
3. Gastric canal

1. Interior Part  Of Gastric Rugae

• Gastric mucosa is thrown into numerous folds called as gastric rugae or gastric folds
• Rugae are longitudinal along the lesser curvature
• They are irregular in all other parts
• When the stomach is distended—rugae gets flattened.

2. Interior Part  Of Gastric Pits: They are small depressions present on the mucosal surface.

3. Interior Part  Of Gastric Canal

• Also known as magenstrasse
• It is the portion of the lumen of the stomach that lies along the lesser curvature, having longitudinal rugae
• It is formed temporarily during swallowing and allows rapid passage of swallowed liquids along the lesser curvature.

Question 4. Briefly explain the blood supply, lymphatic drainage, and nerve supply of the stomach.
Answer:

Stomach Arterial Supply

• Along lesser curvature
  • Left gastric artery: Direct branch of celiac trunk
  • Right gastric artery: Branch of hepatic artery proper
• Along greater curvature
  • Left gastroepiploic artery: Branch of splenic artery
  • Right gastroepiploic artery: Branch of the gastroduodenal artery
  • Short gastric artery (5–7 in number): Branch of the splenic artery.

Venous Drainage Of Stomach

• Veins accompany corresponding arteries
• Drains into portal vein, superior mesenteric vein, and splenic vein

Veins Of Stomach

• Right gastric vein
• Left gastric vein
• Right gastroepiploic vein
• Left gastroepiploic vein
• Short gastric veins

Drains Into Of Stomach

• Portal vein
• Superior mesenteric vein
• Splenic vein

Lymphatic Drainage Of Stomach

• Stomach can be divided into four lymphatic territories
• The first stomach is divided into right 2/3rd and left 1/3rd
• The right part is subdivided into upper 2/3rd and lower 1/3rd
• The left part is subdivided into upper 1/3rd and lower 2/3rd.

Stomach Nerve Supply

• Sympathetic supply
  • Derived from T6–T10 spinal segments
  • Sympathetic Supply Through
    • Greater splanchnic nerves
    • Celiac plexus
    • Hepatic plexus
  • Sympathetic Supply Actions
    • Vasomotor
    • Motor to pyloric sphincter
    • Pain sensation
• Parasympathetic supply
  • Derived from vagus nerve
  • Parasympathetic Supply Through
    • Esophageal plexus
    • Anterior and posterior gastric nerves

Stomach Applied Anatomy

• Since the upper part of the abdominal wall (epigastrium) is supplied by T6–T10, which is the same for the stomach
• So gastric pain is referred to the epigastric region.

Question 5. Write a note on the development of stomach.
Answer:

The development of stomach

• Distal part of foregut shows a fusiform dilatation
• Ths dilatation represents the primitive stomach
• The primitive stomach has anterior and posterior borders, right and left surfaces
• The posterior border grows faster than the anterior border
• It undergoes 90 degrees clockwise rotation along the vertical axis
• As a result, left and right surfaces become anterior and posterior surfaces, and posterior and anterior borders give rise to greater (left border) and lesser (right border) curvatures respectively.

Stomach Multiple Choice Question And Answers

Question 1. The lesser curvature of the stomach is associated with which of the following ligaments?

1. Gastrocolic
2. Hepatogastric
3. Hepatoduodenal
4. Gastrocolic and hepatogastric
5. All of the above

Answer: 2. Hepatogastric

Question 2. Referred stomach pain will be felt in what regions?

1. Right hypochondriac and epigastric region
2. Right hypochondriac and right lumbar region
3. Left hypochondriac and epigastric region
4. Left hypochondriac and left lumbar region

Answer: 3. Left hypochondriac and epigastric region

Question 3. Which of the following is absent in the stomach bed?

1. Transverse colon
2. 4th part of duodenum
3. Transverse mesocolon
4. Splenic artery

Answer: 2. 4th part of the duodenum

Question 4. Which is not true of the stomach?

1. Completely invested by peritoneum T
2. Cardia situated at T12 F–T11 according to Moore
3. Pyloric opening at L1 T
4. Aorta to the left of lesser curve F ­ to the R

Supplied by branches of the celiac trunk

Answer: 2. Cardia situated at T12 F–T11 according to Moore And 4. Supplied by branches of the celiac trunk

Question 5. What is the function of parasympathetic nerves innervating stomach?

1. Increase the mobility of stomach
2. Increase secretion of pepsin
3. Increase secretion of HCl
4. Inhibitory to pyloric sphincter

Answer: 1. Increase the mobility of stomach

 

 

Abdominal Cavity And Peritoneum Question And Answers

Question 1. Give a brief description about the contents, attachments, and functions of greater Omentum and why is it called as policeman of abdomen.
Answer:

The contents, attachments, and functions of greater Omentum

• Large thick fold of peritoneum
• It hangs down from:
  • Greater curvature of the stomach
  • The first part of the duodenum
  • It hangs down in the shape of an apron and covers the loops of intestine to a variable extent
  • Formed by 4 layers of peritoneum (anterior two layers and posterior two layers)
  • These 4 layers get fused to form a thin fenestrated membrane

Read And Learn More: Anatomy Question And Answers 

Greater Omentum Contents:

• Adipose tissue or fat
• Right and left gastroepiploic vessels anastomoses between the first two layers
• Macrophage aggregates, seen as dense milky spots

Greater Omentum Attachments:

• Anterior two layers
  • Hangs from greater curvature of the stomach to a variable extent
  • They fold upon themselves to form the posterior two layers
  • Mode of folding is such that:
    • The first layer becomes the fourth layer
    • Second layer becomes the third layer
• Posterior two layers
  • They ascend up to the transverse mesocolon
  • And the fourth layer loosely blends with the peritoneum on the anterior surfaces of the transverse colon and mesocolon.

Greater Omentum Functions

• When there is an infection in the peritoneal cavity, the greater omentum moves to the site of infection and seals it of from its surrounding thus limiting the spread of infection
• When there is any perforation of the gut, greater omentum plugs the gap to prevent the leakage of contents

For these reasons, it is termed as policeman of abdomen

• Storehouse of fat
• Macrophages present in the omentum protects the peritoneal cavity from infection.

Question 2. Describe Lesser Omentum.
Answer:

Lesser Omentum

• The double-layered fold of peritoneum
• Extent: From lesser curvature of the stomach and first part of the duodenum to the inferior surface of the liver

Lesser Omentum Attachments

• Superiorly
  • Attached to the liver (margins of fissure for ligamentum venosum and porta hepatis)
  • In an inverted L-shaped manner
• Inferiorly
  • Lesser curvature of stomach
  • Upper border of first 2 cm of duodenum.

Lesser Omentum Parts

• It is divided into two parts, they are:
  • Hepatogastric ligament: Part of lesser omentum between the stomach and liver
  • Hepatoduodenal ligament: Part of lesser omentum between duodenum and liver
• Right margin of lesser omentum is free and it forms the anterior boundary of the epiploic foramen
• The anterior and posterior layers of the peritoneum become continuous at the right margin.

Lesser Omentum Contents

• Contents of right free margin
  • Portal vein
  • Hepatic artery
  • Bile duct
  • Hepatic plexus of nerves
  • Lymphatics and lymph nodes

Contents along the lesser curvature of stomach

• Right and left gastric vessels
• Branches of left gastric nerve
• Gastric group of lymph nodes and lymphatics

Lesser Omentum DevelopmDent: derived from ventral mesogastrium.

Question 3. Write a note on the Mesentery of the small intestine. Describe root of the Mesentery and the free border of the mesentery.
Answer:

Mesentery of the small intestine

• Broad fan-shaped fold of peritoneum
• It suspends the coils of the small intestine (jejunum and ileum) from the posterior abdominal wall
• It is wider at the central and narrow at the proximal and distal ends
• Average width of the mesentery is 6 inches and at the center it is 8 inches
• Mesentery presents with two borders:
  • Root of the mesentery or attached border
  • Intestinal border or free border.

Root Of Mesentery

• It is 15 cm long
• Attached to an oblique line across the posterior abdominal wall

Mesentery Extent: Duodenojejunal flexure (lies on the left side of L2) to an ileocecal junction (lies at the upper part of the right sacroiliac joint)

• Directed obliquely downwards and to the right
• It crosses the following structures:
  • Third part of duodenum
  • Abdominal aorta
  • Inferior vena cava
  • Right gonadal vessels
  • Right ureter
  • Right psoas major
• The root of mesentery divides the infrasonic compartment into two parts namely right and left
  • Right part: Small, this part terminates in the right iliac fossa
  • Left part: Large, this part passes into true pelvis.

Lesser Omentum Intestinal Border/Free Border

• It is 6 m long
• Thown into pleats
• It covers the jejunum and ileum
• It is attached to gut and forms a serous coat.

Contents Of Mesentery

• Jejunal and ileal branches of superior mesenteric nartery and vein
• Autonomic nerve plexus
• Lacteals (lymphatics)
• Lymph nodes (100–200)
• Connective tissue and fat
• Jejunum and ileum.

Question 4. Write a note on Transverse Mesocolon.
Answer:

Transverse Mesocolon

• It is a broad transverse fold of the peritoneum
• It suspends the transverse colon from the posterior abdominal wall.

Transverse Mesocolon Attachments

• Root of transverse mesocolon is attached horizontally on the posterior abdominal wall, with an upward inclination towards the left
• Root of transverse mesocolon is also attached to:
  • Pancreas: Anterior surface of the head of the pancreas and anterior border of body of pancreas
  • Second part of the duodenum.

Transverse Mesocolon Contents

• Middle colic vessels
• Lymphatic and lymph nodes of the transverse mesocolon
• Nerves.

Question 5. Write a note on Sigmoid Mesocolon.
Answer:

Sigmoid Mesocolon

• It is a triangular fold of peritoneum
• It suspends the sigmoid colon from the pelvic wall
• The root of the sigmoid mesocolon is attached to the pelvic wall in the shape of an inverted ‘V’
• The apex of inverted ‘V’ lies over the left ureter at the point of termination of left common iliac artery
• Left limb of inverted ’V’ have an attachment along the upper half of left external iliac artery
• Right limb is directed downwards and medially from the apex towards the median plane up to the level of S3 and is attached to the posterior pelvic wall.

Sigmoid Mesocolon Contents

• Right limb: Superior rectal vessels
• Left limb: Sigmoid vessels
• Lymphatics and lymph nodes of sigmoid mesocolon
• Nerves.

Question 6. Describe in brief about the Peritoneal Cavity and write a note on its divisions.
Answer:

The Peritoneal Cavity

• Largest serous sac in the body, formed between the parietal and visceral layers of the peritoneum
• Secretes 30 ml of fluid/day
• Derived from coelomic cavity
• It is closed in males but open in female
• In females it communicates with the exterior through uterine tubes, uterus, and vagina
• Peritoneal cavity can be divided into two parts:
• Greater sac
• Lesser sac.

Peritoneal Cavity Greater Sac

• Main or larger compartment of the peritoneal cavity
• Extents across the entire area of the abdomen (from diaphragm to pelvic floor)
• It has 5 recesses:
  • Hepatorenal recess: It is the peritoneal pocket between liver and kidney
  • Subhepatic recess: It is the peritoneal pocket between the liver and transverse colon
  • Subphrenic recess: It is the peritoneal pocket between the diaphragm and the anterior part of the liver
  • Paracolic recess: Lies lateral to ascending and descending colon
  • Morrison’s pouch.

Peritoneal Cavity Subphrenic Spaces

• They are six recesses/spaces in the peritoneal cavity
• Situated between diaphragm and the anterior part of liver
• Three spaces are on the right and three on the left
• On each side:
  • One space: Extraperitoneal
  • Two spaces: Intraperitoneal
• They are namely:
  • Right anterior intraperitoneal compartment
  • Right posterior intraperitoneal compartment
  • Right extraperitoneal compartment
  • Left anterior intraperitoneal compartment
  • Left posterior intraperitoneal compartment
  • Left extraperitoneal compartment.

Peritoneal Cavity Lesser Sac

• Also known as omental bursa
• It is the left posterior intraperitoneal compartment
• This large recess of the peritoneal cavity is located behind:
  • Stomach
  • Lesser omentum
  • Caudate lobe of liver
• It is closed all around, except in the upper part of its right border
• Here, there is a slit-like opening called the epiploic foramen through which it communicates with the greater sac.

Peritoneal Cavity Boundaries

• Anterior wall
  • Anterior two layers of greater omentum
  • Stomach
  • Lesser omentum
  • Caudate lobe of liver
• Posterior wall
  • Diaphragm
  • Left suprarenal gland
  • Upper part of left kidney
  • Pancreas
  • Transverse mesocolon
  • Transverse colon (How to remember: Structures forming stomach bed—spleen)
  • Posterior two layers of greater omentum
• Upper border
  • Peritoneal reflction (from esophagus to diaphragm)
  • Fissure for ligamentum venosum (its upper end)
  • Caudate lobe of liver (its upper border)
• Lower border
  • Continuation of 2nd layer with the 3rd layer of greater omentum

Lesser sac has 3 recesses

• Superior recess: Lies posterior to lesser omentum and liver
• Inferior recess: Lies between anterior two layers and posterior two layers of greater omentum
• Splenic recess: Lies between lienorenal ligaments and gastrosplenic ligaments.

Question 7. Write a note on epiploic foramen.
Answer:

Epiploic foramen

• Also known as foramen of Winslow
• It is a vertical slit like opening of the lesser sac through which it communicates with the greater sac
• It is located at the level of T12 vertebrae
• Situated behind the right free margin of lesser omentum.

Epiploic Foramen Boundaries

• Anteriorly
  • Right free margin of lesser omentum and its contents
• Posteriorly
  • Inferior vena cava
  • Right suprarenal gland
  • T12 vertebrae
• Superiorly
  • Caudate process of liver
• Inferiorly
  • First part of the duodenum
  • Horizontal part of hepatic artery

Question 8. Describe about Morrison’s pouch or hepatorenal pouch.
Answer:

Morrison’s pouch

• Right posterior intraperitoneal compartment
• Most dependent part of peritoneal cavity
• It is situated between:
  • Anterior aspect of right kidney
  • The posteroinferior surface of liver.

Morrison’S Pouch Or Hepatorenal Pouch Boundaries

• Anteriorly
  • Visceral surface of the liver
  • Gallbladder
• Posteriorly
  • The second part of the duodenum
  • Hepatic flexure of colon
  • Transverse mesocolon
  • Right suprarenal gland
  • Upper part of right kidney
  • Head of pancreas
• Superiorly
  • Inferior layer of coronary ligament
• Inferiorly
  • Opens into the general peritoneal cavity

Morrison’S Pouch Or Hepatorenal Pouch Applied Anatomy

• It is the common site for subphrenic abscess
• Since it is open inferiorly to the general peritoneal cavity, infections from this pouch can easily enter the peritoneal cavity
• Usually, this recess is not filled with fluid but during conditions like hemoperitoneum, flids can get collected in this space or recess.

Question 9. Describe Rectouterine Pouch (pouch of Douglas).
Answer:

Rectouterine Pouch (pouch of Douglas)

• Peritoneal pouch present in females
• Situated behind the rectum and uterus

Rectouterine Pouch Features:

• In the upright position: Most dependent part of the peritoneal cavity
• In the supine position: Most dependent part of the pelvic cavity

Rectouterine Pouch Boundaries

• Anteriorly: Uterus and upper 1/3rd of vagina
• Posteriorly: Rectum
• Floor: Rectovaginal fold of peritoneum.

Abdominal Cavity And Peritoneum Multiple Choice Questions

Question 1. Which ligament is NOT part of the greater omentum?

1. Gastrocolic ligament
2. Hepatogastric ligament
3. Gastrosplenic ligament
4. Splenorenal ligament

Answer: 2. Hepatogastric ligament

Question 2. Which structure is the remnant of the umbilical vein?

• Ligament of Treitz
• Falciform ligament
• Round ligament (Teres)
• Coronary ligament

Answer: 3. Round ligament (Teres)

Question 3. Which of the following structures is most likely to get affected by a posteriorly perforating peptic ulcer?

1. Hepatorenal pouch
2. Greater sac
3. Lesser sac
4. Pouch of Douglas

Answer: 3. Lesser sac

Question 4. What is the posterior boundary of the epiploic foramen?

1. Caudate lobe of the liver
2. First part of the duodenum
3. Common bile duct
4. Inferior vena cava

Answer: 4. Inferior vena cava

Question 5. Foramen of Winslow is bounded:

1. Superiorly by the left lobe of liver
2. Anteriorly by lesser omentum
3. Posteriorly by the inferior vena cava
4. Inferiorly by the pylorus of stomach

Answer: 4. Inferiorly by the pylorus of stomach

 

Male Genital Organs Question And Answers

Question 1. Classify male genital organs.
Answer:

Male Internal Genital Organs

• Penis
• Scrotum

Male External Genital Organs

• Testis
• Epididymis
• Vas deferens
• Prostate
• Seminal vesicles
• Bulbourethral glands

Question 2. Enumerate the layers of the scrotum from outside to inside.
Answer:

The layers of the scrotum from outside to inside

1. Skin
2. Dartos muscle (which replaces the superficial fascia)
3. External spermatic fascia
4. Cremasteric muscle and fascia
5. Internal spermatic fascia.

Mnemonics: ‘Some Damn Englishman Called It scrotum’

Question 3. Mention the external features of the testis and explain in detail the coverings of the testis.
Answer:

The external features of the testis and explain in detail the coverings of the testis

Read And Learn More: Anatomy Question And Answers 

• Male gonad
• Homologous with ovary in female
• It is suspended in the scrotal sac by spermatic cord
• Lies obliquely in both half of the scrotum, such that the upper pole is tilted forwards and medially
• Function: Secretion of testosterone, production of spermatozoa
• Oval in shape, weight: 10–15 g
• Measurements
  • Length: 4–5 cm
  • Breadth: 2.5 cm
  • Anteroposterior diameter: 3 cm

Testis External Features: It has

• Two poles: Upper and lower
• Two borders: Anterior and posterior
• Two surfaces: Medial and lateral
  • Two poles are convex and smooth
  • The upper pole provides attachment to the spermatic cord

Testis Borders

1. Anterior border
   • Convex and smooth
   • Completely covered by tunica vaginalis
2. Posterior border
   • Straight
   • Partially covered by tunica vaginalis

Testis Relations:

• Epididymis lies on its lateral aspect
• Both are separated by an extension of the cavity of tunica vaginalis known as the sinus of the epididymis
  • Two surfaces (medial and lateral): Convex and smooth.

Appendix of the testis:

• Small oval body attached to upper pole of testis
• It is the remnant of the paramesonephric duct.

Coverings of Testis

• Testis is covered by 3 coats
• From superficial to deep, they are:

1. Tunica vaginalis (serous layer)
2. Tunica albuginea (fibrous layer)
3. Tunica vasculosa (vascular layer).

1. Tunica vaginalis

• It is a serous sac
• Represents the lower persistent portion of processus vaginalis
• It is invaginated by the testis from behind
• As a result, it has two layers (parietal and visceral) with a cavity between them
• Tunica vaginalis completely covers the testis, except for its posterior border.

2. Tunica albuginea

• The thick, dense, white fibrous layer
• It completely covers the testis
• It is enclosed by the visceral layer of tunica vaginalis except posteriorly where testicular nerves and vessels enter into testis
• Mediastinum testis: Vertical septum formed by the thickened posterior border of the tunica albuginea
• Numerous incomplete fibrous septa extend from the mediastinum into the inner aspect of Tunica albuginea
• These septa divide testis in to 200–300 lobules.

3. Tunica vasculosa

• Innermost vascular layer
• It lines the lobules.

Testis Blood Supply

1. Arterial Supply
   • Testicular artery
     • Branch of abdominal aorta given of at level of L2 vertebrae
     • Descends through posterior abdominal wall
     • Reach deep inguinal ring
     • Enters spermatic cord
     • Reaches posterior border of testis
     • Divides into:
       • Two large branches—medial and lateral
       • Small branches
     • Medial and lateral branches Pierces the tunica albuginea
     • Ramify in tunica vasculosa.
   • Artery to vas (sometimes)
2. Venous Drainage
   • By pampiniform plexus of veins
   • Thy condenses into two veins at the deep inguinal ring and accompanies testicular artery
   • Finally, two veins fuse together forming one vein which drains into the inferior vena cava.

Testis Lymphatic Drainage: Preaortic and para-aortic lymph nodes.

Testis Nerve Supply: By sympathetic fibers from the T10 segment.

Question 4. Write a note on the development of testis.
Answer:

The development of testis

The development of the testis and ovaries begins in a similar manner but parts way at a particular point.

Development Of Testis

• Sex cords increase in length and extend into the medulla of the developing gonad. Sex cords are now called as medullary cords
• The sex cords anastomose with each other and canalize resulting in the formation of seminiferous tubules
• The ends of seminiferous tubules anastomoses with one another giving rise to rete testis
• Two types of cells lines the seminiferous tubules:
  • Spermatogenic cells: Formed from primordial germ cells
  • Sertoli cells: Formed from coelomic epithelium
• A dense fibrous layer is formed by mesoderm which separates the sex cords from coelomic epithelium, known as the tunica albuginea.
• Mesoderm also gives rise to:
  • Leydig cells
  • The connective tissue around seminiferous tubules
  • Mediastinum testis
• The canal of the epididymis and vas deferens develop from the mesonephric duct. The development of the testis and ovaries begins in a similar manner but parts way at a particular point
• Gonads develop from three sources:
  • Intermediate mesoderm—which is present medial to the middle part of the mesonephros
  • Coelomic epithelium—which covers the intermediate mesoderm
  • Primordial germ cells from the wall of the yolk sac near the allantois
• Coelomic epithelium begins to proliferate and it gets thickened
• Mesoderm below the coelomic epithelium condenses due to the thickening of coelomic epithelium
• Both these processes lead to the formation of the genital ridge
• Coelomic epithelial cells continue to proliferate and they invade the condensed mesoderm in the form of solid cords, known as the ‘sex cords’
• Primordial germ cells from the wall of the yolk sac migrate along the dorsal mesentery of the hindgut toward the developing gonad
• Sex cords and primordial germ cells get intermixed
• Till this point, the development of the testis and ovaries are the same.

Question 5. What do you meant by descent of testis?
Answer:

Descent of testis

• Testis which develops in relation to lumbar region of the posterior abdominal wall starts to descend
• It gradually descends to the scrotum through the iliac fossa (3rd month) and the inguinal canal (7th month), finally reaching the scrotum by the end of 8th month.
• It is a mandatory developmental process to ensure that the mature testis promotes normal spermatogenesis
• Some factors responsible for descent of testis are:
  • Increased intra-abdominal pressure
  • Gubernaculum: A guiding force for the descent
  • Differential growth of body wall.

Question 6. Describe the features and course of vas deferens.
Answer:

The features and course of vas deferens

• Also known as ductus deferens
• Thick-walled muscular tubes
• Two in number
• Length: 45 cm
• Lumen: Narrow, but the terminal part (ampulla) is sacculated.

Vas Deferens Course: It has

• External course
• Internal course.

Vas Deferens  External Course

Vas Deferens Internal Course

Vas Deferens Blood Supply

1. Arterial Supply

• From artery to vas deferens
• This artery can arise from either
  • Superior vesical artery (common)
  • Inferior vesical artery or
  • Middle vesical artery.

2. Vas Deferens Venous Drainage

3. Vas Deferens Nerve Supply

Pelvic splanchnic nerves—parasympathetic.

Male Genital Organs Multiple Choice Questions

Question 1. The coverings of the testis are:

1. Tunica vasculosa
2. Tunica albuginea
3. Tunica vaginalis
4. All of the above

Answer: 4. All of the above

Question 2. Which of the following arteries gives blood supply to vas deferens?

1. Middle rectal artery
2. Inferior epigastric artery
3. Cremasteric artery
4. Superior vesical artery

Answer: 4. Superior vesical artery

Question 3. Which of the following statements are true about testis?

1. It has no parasympathetic supply T cannot find it in books but Blitz reckons it has a vagal supply
2. Appendix is inferior
3. Vas deferens in somewhere
4. Epididymis is somewhere else
5. Drains to para-aortic and inguinal nodes

Answer: 1. It has no parasympathetic supply T cannot find it in books but Blitz reckons it has a vagal supply

Question 4. Lymph from the vas deferens drains into nodes:

1. Superficial inguinal
2. External iliac
3. Internal iliac
4. Lumbar

Answer: 2. External iliac

Question 5. All of the following statements regarding ductus deferens are true, except:

1. It is separated from the base of the bladder by the peritoneum
2. It passes lateral to inferior epigastric artery at deep inguinal ring
3. It crosses the ureter in the region of the ischial spine
4. The terminal part is dilated to form an ampulla

Answer: 1. It is separated from the base of the bladder by the peritoneum

 

Anterior Abdominal Wall Question And Answers

Question 1. Describe about abdominal cavity and briefly mention its contents.
Answer:

• Abdominal Cavity  is the lower part of the trunk, below the diaphragm
• Walls surrounding the abdomen forms the abdominal cavity
• Boundaries of the abdominal cavity
  • Superiorly: Diaphragm
  • Inferiorly: Pelvic diaphragm
  • Anteriorly: Anterior abdominal wall (muscles)
  • Posteriorly: Posterior abdominal wall (muscles and lumbar vertebrae)
  • Both sides: Lateral ends of muscles of anterior abdominal wall, lower ribs.

Abdominal Cavity Contents

• Liver and gallbladder
• Pancreas
• Stomach
• Small intestine and major portion of large intestine
• Kidneys and upper part of ureters
• Suprarenal glands
• Spleen
• Arteries, veins, lymphatics, nerves, etc.

Question 2. Describe about the various abdominal planes and mention the abdominal quadrants.
Answer:

The various abdominal planes and mention the abdominal quadrants

Read And Learn More: Anatomy Question And Answers 

Transumbilical Plane

• A transverse plane passing through the umbilicus
• Lies between L3 and L4 vertebrae.

Median Vertical Plane

Median Vertical Plane is a plane passing through the suprasternal notch and pubic symphysis.

Lateral Vertical Plane is a plane passing through, the midway between mid inguinal point and middle of clavicle.

Transpyloric Plane of Addison

• A plane passing through the tip of 9th costal cartilage and midway between median vertical plane
• Anteriorly it passes through tip of 9th costal cartilage and posteriorly it passes through lower part of body of L1 vertebra
• The Pylorus, inferior margin of liver, neck of the gallbladder, anterior end of spleen, hilum of kidney, portal vein, etc. lie at this level.

Subcostal Plane

• A transverse plane passing just below 10th rib
• Lies at the upper border of L3 vertebra.

Transtubercular Plane

• Transverse passing through the level of tubercle on the iliac crest
• Lies at the upper border of L5 vertebra

Abdominal cavity is divided into nine regions by:

• Two transverse planes
• Two vertical planes
  • Upper transverse plane: Transpyloric plane
  • Lower transverse plane: Transtubercular plane
  • Vertical planes: Right and left lateral vertical planes.
• Nine regions from above to downwards and from right to left are:
  • Right hypochondrium
  • Right lumbar
  • Right iliac fossa
  • Epigastrium
  • Umbilical
  • Hypogastrium
  • Left hypochondrium
  • Left lumbar
  • Left iliac fossa

Question 3. Explain about the extent, formation, and contents of anterior abdominal wall.
Answer:

Firm and elastic wall

Anterior Abdominal Wall Extent:

• Superiorly from the costal margin and xiphoid process
• Inferiorly up to the iliac crest and pubic symphysis

The anterior abdominal wall is made up of 8 layers. They are:

• Superficial To Deep

• Deep fascia is absent in the anterior abdominal wall, which allows the abdomen to distend during pregnancy or after meals.

1. Umbilicus

• Umbilicus is a normal scar in the anterior abdominal wall, representing the site of attachment of root of the umbilical cord
• The position of the umbilicus is variable
• In most cases:
  • Adults: Lies a little below the midpoint of the linea alba
  • New-born: Slightly lower
  • Old age: Lower due to decreased tone of abdominal muscles.

Importance of Umbilicus

• It act as an important anatomical and embryological landmark
• Anatomically:
  • Watershed line: Venous and lymphatic flow is directed away from the umbilicus (directed upwards above the umbilicus and directed downwards below the umbilicus)
  • It is a site of portocaval anastomosis
  • Skin around the umbilicus comes under the T10 dermatome.
• Embryologically:
  • It is the meeting point of four folds of the embryonic plate:
    • Head
    • Two lateral plates
    • Tail
  • It is the meeting point of three systems in fetal life, they are:
    • Umbilical vessel (vascular system)
    • Vitello intestinal duct (digestive system)
    • Urachus (excretory system).

2. Superficial Fascia

• Made of layers of fat, more at the lower half
• Above the level of the umbilicus, the superficial fascia is made up of a single layer of fat
• Below this level, it is made up of two layers, namely:
  • Camper’s fascia: Superficial fatty layer
  • Scarpas fascia: Deep membranous layer.

Camper’s Fascia

• Superficial fatty layer
• It is continuous with superficial fascia with adjoining parts of the body
• Over the penis: It is devoid of fat
• Over scrotum: It is replaced by dartos muscle.

Scarpas Fascia

• Deep membranous layer
• Made up of elastic type of fibrous tissue
• It is continuous below with another membranous layer of the superficial fascia of the perineum, called the Colle’s fascia

Scarpas Fascia Attachments

• Midline: Linea alba
• Each side: It is separated from external oblique muscles by a layer of loose areolar tissue
• Inferiorly: Attached to fascia lata of thigh (this line of attachment is surface marked by Holden’s line)
• It encloses the penis up to the base of glans
• In the scrotum, it is replaced by dartos muscle.

Muscles of Anterior Abdominal Wall

Flat Muscles Of Anterior Abdominal Wall

• Muscle
  • External oblique muscle
  • Internal oblique muscles
  • Transversus abdominis muscle
• Nerve supply
  • Lower six thoracic nerves (T7–T12) and fist lumbar (L1) nerve
  • Internal oblique muscles
  • Transversus abdominis muscle
• Blood Supply
  • Blood supply of all felt muscles of anterior abdominal wall is from same source, they are:
  • Lower posterior intercostal arteries
  • Subcostal arteries
  • Superior and inferior epigastric arteries
  • Superfiial and deep circumflx arteries
  • Posterior lumbar artery.

Three important structures are formed by the above-mentioned felt muscles of the anterior abdominal wall, namely:

1. Inguinal ligament
2. Conjoint tendon
3. Cremaster muscle.

Out of which, inguinal ligament and conjoint tendon are explained in detail:

1. Anterior Abdominal Wall Inguinal ligament

• Thick fibrous band, lying beneath the fold of the groin
• Derived from the lower free border of the external oblique aponeurosis
• Extend: Anterior superior iliac spine to pubic tubercle
• The lower border of the inguinal ligament is attached to the fascia lata (deep fascia of thigh)
• Traction by this fascia pulls the inguinal ligament convex downwards.

Extensions of Inguinal ligament

• Lacunar ligament:
  • Triangular in shape
  • Apex attached to pubic tubercle
  • Base directed laterally
  • Lacunar Ligament Attachments
    • Anteriorly: Medial end of inguinal ligament
    • Posteriorly: Pecten pubis.
• Pectineal ligament:
  • It is the extension of posterior part of the lacunar ligament
  • Considered as a thickening in the upper part of the pectineal fascia.
• Reflcted part of inguinal ligament:
  • Formed by superficial fibers from the medial end of the inguinal ligament passing upwards and medially
  • These fiers intermix with those of opposite side at the line alba
  • It lies behind the superficial inguinal ring.
• Ilioinguinal ligament: Fibrous band between the inferior surface of the inguinal ligament to iliopectineal eminence.

2. Conjoint tendon

• Also known as falx inguinalis
• Formation: By the fusion of lower aponeurotic fibers of internal oblique and transversus abdominis muscle
• It has attachments to the pubic crest and medial part of the pecten pubis
• It forms the medial half of the posterior wall of the inguinal canal
• Medially it is continuous with the anterior wall of the rectus sheath
• Laterally it is usually free, but sometimes may be continuous with the interfoveolar ligament.

Conjoint Tendon Applied Anatomy

The portion of the abdominal wall which is weakened due to the presence of superficial inguinal ring is strengthened by the conjoint tendon.

Vertical Muscles of Anterior Abdominal Wall

1. Rectus Abdominis Muscle

• One of the two vertical muscles of anterior abdominal wall, the other being pyramidalis
• Extend: From the costal margin to the pubic symphysis along the linea alba
• It narrows as it descends downwards (wider above and narrow below)

Rectus Abdominis Muscle Origin: From two tendinous heads—lateral and medial

• Lateral head: From the lateral part of pubic crest and pubic tubercle
• Medial head: From the anterior pubic ligament

Rectus Abdominis Muscle Insertion:

• Inserted through 4 flashy slips
• These fleshy slips gets inserted along a horizontal line passing from lateral to medial on the 7th, 6th, 5th costal cartilages and xiphoid process

Rectus Abdominis Muscle Actions: Flexes the trunk, supports the abdominal viscera

Rectus Abdominis Muscle Nerve supply: T7–T12 thoracic nerves

Rectus Abdominis Muscle Blood supply: Superior and Inferior epigastric arteries.

2. Pyramidalis Muscle

• Triangular muscle
• Base of the triangle forms the origin and the apex forms the insertional part of the muscle
• Lies in front of the lower part of rectus abdominis
• It is covered by rectus sheath

Pyramidalis Muscle Origin: From the front of the pubis and pubic symphysis

Pyramidalis Muscle Insertion:

• Attached medially to the linea alba
• Point of attachment lies midway between the umbilicus and pubic symphysis

Pyramidalis Muscle Actions: Tenses the lower linea alba

Pyramidalis Muscle Nerve supply: Subcostal nerve

Pyramidalis Muscle Blood supply: Inferior epigastric artery, deep circumflex iliac artery.

Question 4. Describe about the features, formation, and contents of the rectus sheath.
Answer:

Rectus sheath

• It is an aponeurotic sheath formed from the aponeurosis of felt muscles of the anterior abdominal wall
• It encloses:
  • Rectus abdominis muscle
  • Pyramidalis muscle
• It has two walls: Anterior and posterior
  • Anterior wall:
    • It is complete, and covers the entire extend of muscle from the upper end to the lower end
    • It fimly adheres to tendinous intersections of the rectus abdominis muscle
  • Posterior wall
    • It is incomplete, it is deficient above and below
    • It is free from the Rectus abdominis muscle.

Rectus Sheath Formation:

• Above the costal margin
  • Anterior wall: By external oblique aponeurosis
  • Posterior wall: It is deficient (here rectus abdominis lies directly on 5th 6th and 7th costal cartilages)
• Between the costal margin and arcuate line (lies at the level of the anterior superior iliac spine).
  • Anterior wall:
    • By external oblique aponeurosis
    • Anterior lamina of aponeurosis of internal oblique
  • Posterior wall:
    • Transversus abdominis aponeurosis
    • Posterior lamina of aponeurosis of internal oblique
• Below the arcuate line
  • Anterior wall:
    • By the aponeurosis of all three flt muscles of anterior abdominal wall (internal oblique, external oblique, transversus abdominis)
    • External oblique aponeurosis contributes separately whereas aponeurosis of internal oblique and transversus abdominis fuses with each other
  • Posterior wall: It is deficient.

Rectus Sheath Contents

• Muscles: Rectus abdominis and pyramidalis
• Blood vessels: Superior and inferior epigastric arteries and veins
• Nerves: Terminal parts of:
  • Lower fie intercostal nerves
  • Subcostal nerves.

Rectus Sheath Applied Anatomy

• Rectus sheath maintains the strength of the anterior abdominal wall
• It also checks the boing of rectus abdominis muscle, thus increasing the efficiency of the rectus muscle.

Question 5. What is fascia transversalis, Briefly describe its extent and modifications.
Answer:

Fascia transversalis

• Fascia lining the inner surface of the transversus abdominis muscle
• It is separated from peritoneum by the extraperitoneal connective tissue

Fascia Transversalis Extent:

• Superiorly: Continuous with the diaphragmatic fascia
• Inferiorly: Continuous with fascia iliaca
• Anteriorly: Adherent to linea alba at a level above the umbilicus
• Posteriorly: Continuous with an anterior layer of the thoracolumbar fascia

Modifiations of fascia transversalis

• In the fascia transversalis there is an oval opening of about 1.2 cm above the midinguinal point, known as deep inguinal ring.
  • Mid inguinal point: Midpoint between the anterior superior iliac spine and the symphysis pubis.
  • Midpoint of inguinal ligament: Midpoint of the anterior superior iliac spine and pubic tubercle.
• Two prolongations:
  • Internal spermatic fascia: Tubular prolongation of fascia transversalis, which surrounds the spermatic cord
  • The anterior wall of femoral sheath: Prolongation of fascia transversalis into the thigh over the femoral vessels
• Iliopubic tract: Thckened inferior margin of fascia transversalis.

Question 6. Describe about the inguinal canal including its boundaries, contents, and inguinal rings, and also give a brief description about the spermatic cord and its contents.
Answer:

Inguinal canal

• It is an oblique intermuscular passage in the lower part of anterior abdominal wall (site of potential weakness in the lower part of anterior abdominal wall)
• Lies just above the medial half of the inguinal ligament
• It is larger in males than in females
• It allows the passage of structures, from the testis to the abdomen in male and round ligament in females
• Length: 4 cm
• Extent: From deep inguinal ring to superficial inguinal ring
• Direction: Downwards, forwards, and medially.

Deep inguinal ring: Oval opening in the fascia transversalis, 1.25 cm above the mid inguinal point.

Superfiial inguinal ring:

• The triangular gap in the external oblique aponeurosis
• Lies above and lateral to the pubic crest
• Base of the triangle is formed by the pubic crest
• Lateral or medial margins or crura forms the sides of triangle
• Length – 2.5 cm, breadth – 1.25 cm.

Inguinal Canal Boundaries

1. Anterior wall
   • In the whole extent 
     • Skin
     • Superficial fascia
     • External oblique aponeurosis
   • Lateral  2/3 rd
     • Internal oblique muscle
2. Posterior wall
   • In the whole extent 
     • Fascia transversal
     • Extraperitoneal tissue
     • Parietal peritoneum
   • Medial 2/3 rd
     • Conjoint tendon
     • Reflcted part of inguinal ligament
   • Lateral 1/3 rd
     • Interfoveolar ligament
3. Roof: Arched fiers of internal oblique and transversus abdominis muscle.
4. Floor: Inguinal ligament and lacunar ligament.

Inguinal Canal Contents

• Male: Spermatic cord, ilioinguinal nerve
• Female: Round ligament of uterus, ilioinguinal nerve.

Coverings of the spermatic cord

• Internal spermatic fascia: Derived from fascia transversalis, covers the cord completely
• Cremasteric fascia: Derived from internal oblique and transversus abdominis muscles, covers the cord above the level of the above-mentioned muscles
• External spermatic fascia: Derived from external oblique aponeurosis, covers the cord below the superficial inguinal ring.

Contents of the spermatic cord

• Ductus deferens
• Arteries: Testicular artery, cremasteric artery, artery to ductus deferens
• Pampiniform plexus of veins
• Nerves:
  • Genital branch of genitofemoral nerve
  • Sympathetic nerve plexus around the artery to ductus deferens
  • Lymphatics from the testis
  • Remnants of processus vaginalis.

Mnemonics: Inguinal canal walls: ‘MALT: 2M, 2A, 2L, 2T’:

• Starting from superior, moving around in order to posterior
• Superior wall (roof): 2 Muscles:
  • Internal oblique Muscle
  • Transverse abdominis Muscle
• Anterior wall: 2 Aponeuroses:
  • Aponeurosis of external oblique
  • Aponeurosis of internal oblique
• Lower wall (flor): 2 Ligaments:
  • Inguinal Ligament
  • Lacunar Ligament
• Posterior wall: 2Ts:
  • Transversalis fascia
  • Conjoint Tendon

Question 7. Describe about the mechanism of the inguinal canal preventing inguinal herniation and write a note on the inguinal hernia and Hesselbach’s triangle.
Answer:

The mechanism of the inguinal canal preventing inguinal herniation:

• The presence of inguinal canal causes a weakness in the lower part of the anterior abdominal wall as a result there is a chance of herniation of abdominal viscera into the inguinal canal
• But this is prevented by the following mechanisms:

1. Flap valve mechanism:
   • The inguinal canal is oblique (in children it is straight)
   • Deep and superficial inguinal rings do not lie opposite to each other
   • So when the intra-abdominal pressure increases, the anterior and posterior walls of the canal get approximated, like a flip obliterating the passage
2. Guarding of inguinal rings:
   • Deep inguinal ring: Guarded by internal oblique muscle
   • Superfiial inguinal ring: Guarded by conjoint tendon and reflcted part of inguinal ligament
3. Shutter mechanism:
   • Internal oblique muscle forms the anterior wall, roof, and posterior wall of the canal
   • When it is contracted the roof is pulled and gets approximated on the floor, like a shutter— obliterating the passage
4. Ball valve mechanism:
   • Contraction of cremasteric muscle pulls the testis up and this helps the spermatic cord to plug the superficial inguinal ring
5. Slit valve mechanism:
   • Contraction of the external oblique approximates the two crura of the superficial inguinal ring (like a slit valve).

Hesselbach’s Triangle Or Inguinal Triangle: Situated on the posterior wall of inguinal canal

Hesselbach’s Triangle Or Inguinal Triangle Boundaries

• Medially: Lateral border of rectus abdominis muscle (lower 5 cm)
• Laterally: Inferior epigastric artery
• Inferiorly: Medial half of the inguinal ligament
• Floor:
  • Fascia transversalis
  • Peritoneum
  • Extraperitoneal tissue.

Hesselbach’s Triangle Or Inguinal Triangle Applied Anatomy

Direct hernias occur commonly through Hesselbach’s triangle.

Inguinal Hernia

• It is the abnormal protrusion of a viscus or a part of it through the inguinal canal
• There are two types of inguinal hernias:
  • Direct
  • Indirect

Indirect Inguinal Hernia

• Most common type of hernia
• In an indirect inguinal hernia, the hernia sac enters the inguinal canal through the deep inguinal ring into the inguinal canal
• Common in children and young adults, male > female
• Commonly occurs due to persistent processus vaginalis sac
• It can be:
  • Congenital: Persistent processus vaginalis sac
  • Acquired: Increased intra-abdominal pressure, for example, weight lifting.

Types Of Indirect Hernia:

• Complete hernia: Hernial sac extent from deep inguinal ring to superficial inguinal ring to bottom of scrotum
• Funicular: Hernial sac extent from deep inguinal ring to root of scrotum
• Bubonocele: Hernial sac is present in the inguinal canal only.

Direct Inguinal Hernia

• Occurs through Hesselbach’s triangle (due to weakness in the posterior wall of the inguinal canal)
• Always congenital
• The precipitating factor is the weakness of fiers of transversus abdominis
• Occurs in elderly due to chronic cough, in smokers (decreased strength of abdominal muscles due to decreased elastin).

Coverings of Hernial Sac (outside to inside)

1. Indirect hernia
   • Skin
   • Superfiial fascia (campers and scarpas)
   • External spermatic fascia
   • Cremaster muscle and fascia
   • Internal spermatic fascia
   • Extraperitoneal fat
   • Peritoneum
2. Direct hernia
   • Skin
   • Superfiial fascia (campers and scarpas)
   • External oblique aponeurosis
   • Conjoint tendon
   • Fascia transversalis
   • Peritoneum

Anterior Abdominal Wall Multiple Choice Questions And Answers

Question 1. All the following structures passes through the inguinal canal except:

1. Inferior epigastric artery
2. Ilioinguinal nerve
3. Spermatic cord
4. Genital branch of genitofemoral nerve

Answer: 1. Inferior epigastric artery

Question 2. The posterior wall of the inguinal canal is mainly formed by:

1. Fascia transversalis and conjoint tendon
2. Internal oblique
3. External oblique
4. All of the above

Answer: 1. Fascia transversal and conjoint tendon

Question 3. Which of the following is a common structure in Hesselbach’s triangle and femoral (scarps) triangle?

1. Conjoint tendon
2. Rectus femoris
3. Inguinal ligament
4. Inferior epigastric artery

Answer: 3. Inguinal ligament

Question 4. The superior ¾ of the posterior rectus sheath is comprised of what layers?

1. Aponeurosis of external abdominal oblique and internal abdominal oblique
2. The aponeurosis of internal abdominal oblique and transverse abdominal muscle
3. The aponeurosis of external and internal abdominal oblique and transverse abdominal muscle
4. Transversalis fascia

Answer: 2. Aponeurosis of internal abdominal oblique and transverse abdominal muscle

Question 5. The median umbilical fold contains which of the following embryonic remnant(s)?

1. Urachus
2. Umbilical arteries
3. Superior epigastric arteries
4. Inferior epigastric arteries

Answer: 1. Urachus