Block3: Garq Simulator

Front 1

1. What is the common branching pattern of the celiac trunk? Make a diagram of the celiac trunk, and include, in addition to its three main branches, the following vessels: esophageal, short gastrics, left gastro-omental (gastro-epiploic), proper hepatic, cystic, right gastric, gastroduodenal, right gastro-omental (gastro-epiploic), and superior pancreaticoduodenal.

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Front 2

• 2. llustrate the common branching pattern of the superior mesenteric artery. Be sure to include these vessels – inferior pancreaticoduodenal, right colic, middle colic, intestinal branches, ileocolic. Also illustrate the vasa recta and the arterial arcades of the jejunum and of the ileum. What is the marginal artery (of Drummond)?

Back 2

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Front 3

• 3. A “filter” can be placed in the inferior vena cava (IVC) of patients in whom a DVT develops and who have contraindications to anticoagulation therapy. The filter is usually introduced through the femoral vein. Why? Describe the path taken by a thrombus in the left popliteal vein to reach the left pulmonary artery.


Diagram the inferior vena cava in its entirety. Superimpose your drawing on the illustration provided, an anterior view of the caudal portion of the vertebral column. Illustrate and label each tributary.

Back 3

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Front 4

4. Diagram the hepatic portal venous system. Be sure to include these tributaries -- left gastric vein, splenic vein, inferior and superior mesenteric veins, paraumbilical vein, and retroperitoneal veins associated with the ascending and descending colons. Also illustrate the normal branching pattern of the hepatic portal vein once it reaches the liver. Indicate the four possible sites where anastomosis between the portal and systemic venous systems can occur, and, in each case, identify the specific vessels involved.

Back 4

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Front 5

5. Describe the origin of the diaphragm from the sternum, from the ribs, from the fascial thickenings over the quadratus lumborum and psoas major muscles, and from the superior three lumbar vertebrae. What is the central tendon? What are the three apertures in the diaphragm, what does each transmit, and at what vertebral level does each occur? There is normally a small gap between the sternal and costal attachments of the diaphragm – what passes through this opening? How do the sympathetic trunks and the thoracic splanchnic nerves pass from thoracic to abdominal cavities? What is the lumbocostal triangle? What is the blood supply of the diaphragm? What are the roles of the phrenic nerves, and of the lower intercostal nerves and the subcostal nerve, in the innervation of the diaphragm?

Back 5

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Front 6

6. Diagram the abdominal aorta. Superimpose your drawing on the illustration provided, an anterior view of the caudal portion of the vertebral column. Illustrate and label each branch.

Back 6

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Front 7

7. Distinguish among and briefly describe foregut, midgut, and hindgut. In your discussion of each of these “subdivisions” of the gastrointestinal tract, be sure to enumerate the relevant organs and their blood and nerve supply.

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Front 8

• 8. Distinguish among these adjectives: peritoneal (peritonealized), primarily retroperitoneal, and secondarily retroperitoneal. List the organs that are secondarily retroperitoneal; list the structures that are primarily retroperitoneal. What is a mesentery? What is THE mesentery? Which abdominal organs possess a mesentery? Which abdominal organs DO NOT possess a mesentery? What is the lesser omentum? What is the greater omentum?

Back 8

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Front 9

• 9. Describe the course of the vagus nerves in the abdominal cavity. Begin with a consideration of the anterior and posterior vagal trunks. What is their distribution? Describe the route taken by the axons of preganglionic parasympathetic neurons in the vagal trunks to reach the pylorus of the stomach. Describe the route taken by similar fibers in the vagal trunks to reach the cecum. What are the functions/purposes of vagal innervation of the gastrointestinal tract? How do the pelvic splanchnic nerves contribute to the parasympathetic innervation of the gastrointestinal tract?

Back 9

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Front 10

• 10. Why did you want an abdominal CT? Describe the characteristics of midgut development that are pertinent here. What other special anatomical characteristics would you suspect that Johnny might show?

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Front 11

11. Describe the extrahepatic bile passages and the pancreatic ducts. Define cholecystitis, jaundice and pancreatitis. What are the four parts of the duodenum, and what are the distinguishing features of each? How are the pancreas and duodenum (anatomically) related?

Back 11

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Front 12

12. Describe the development of the liver, gall bladder, pancreas, and associated ducts. What lethal and non-lethal anomalies associated with these structures could occur?

Back 12

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Front 13

13. Explain the differences in the causes and characteristics of omphalocele and gastroschisis. Be complete by describing the organs and tissues involved, the timing of the defect, and specific reasons for each. Why is gastroschisis a more serious situation?

Back 13

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Front 14

• 14. Label the following on supplied diagrams of the liver: right lobe, left lobe, quadrate lobe, caudate lobe, portal vein, hepatic artery, hepatic veins, inferior vena cava, porta hepatis, falciform ligament and obliterated left umbilical vein (aka “round ligament of the liver”), ligamentum venosum (former ductus venosus), coronary ligament of the liver (right and left triangular ligaments), gall bladder (fundus, body, neck) and cystic duct. What is the portal triad? The circulatory system of the liver is unique. A majority--about 75%-- of the liver’s blood supply is venous blood, via the portal vein. The remaining 25% of the blood supply to the liver comes from the hepatic artery. Describe the pattern of blood flow through the liver, including consideration of the following: terminal branches of portal vein, terminal branches of hepatic artery, liver sinusoids, central veins, hepatic veins, inferior vena cava.

Back 14

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Front 15

15. What is the enteric division of the ANS (also called the “enteric nervous system”, or ENS)? Where is it located? What does it regulate? Are there both “motor” and “sensory” functions in the ENS?
• Sympathetic innervation is provided to smooth muscle and glands in the abdominal and pelvic cavities via splanchnic nerves. Briefly describe the thoracic, lumbar, and sacral splanchnic nerves. What are the immediate destinations of the thoracic splanchnic nerves, of the lumbar splanchnic nerves, and of the sacral splanchnic nerves? What are the ultimate destinations of the thoracic splanchnic nerves, of the lumbar splanchnic nerves, and of the sacral splanchnic nerves?
• Briefly describe the following “pre-aortic” nerve plexuses: celiac plexus, superior mesenteric plexus, inferior mesenteric plexus, aorticorenal and renal plexuses, superior hypogastric plexus, inferior hypogastric plexus, and the hypogastric nerves.
• Explain how transection of the greater thoracic splanchnic nerves can relieve pain associated with pancreatic cancer. Distinguish between the functions of visceral sensory neurons in parasympathetic nerves (the vagus and the pelvic splanchnics) and visceral sensory neurons in sympathetic nerves (e.g., thoracic and lumbar splanchnic nerves).
• How is the parietal peritoneum innervated? How is the visceral peritoneum innervated?

Back 15

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Front 16

• 16. Describe or draw the stomach. Include the following: esophageal and pyloric ostia and sphincters, cardia, fundus, body, pylorus (from the Greek pyle = “gateway”), greater and lesser curvatures. Describe the duodenum: what is its approximate length? What are the four “parts” of the duodenum and what is the approximate location of each (peritoneal? retroperitoneal? vertebral level?). Describe the relationship between the duodenum and pancreas. What is the location of the pancreas (peritoneal? retroperitoneal? vertebral levels?). Briefly describe the jejunum and ileum. While there is no specific demarcation of the boundary between the jejunum and ileum, each has distinctive structural features. Identify six such features that help differentiate between the jejunum and ileum. Describe the large intestine, considering its relationship to the peritoneum and the beginning and ending points of its portions—cecum and appendix, ascending colon, transverse colon, descending colon, sigmoid colon. Name and describe three features that distinguish the large intestine from the small intestine. Make a diagram of the inferior mesenteric artery. What is the territory (roughly) that each of its branches supplies?

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Front 17

• 17. Describe the lumbar and sacral plexuses, including the spinal cord levels involved in the formation of each. Describe the location (and “continuity”) of these plexuses. Name four branches of each plexus. Identify the spinal cord levels associated with each branch and identify a target structure supplied by each branch. Describe the proximal and distal attachments of the posterior abdominal wall muscles: iliacus, psoas major, quadratus lumborum . What is the innervation and the action(s) of each?

Back 17

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Front 18

• 18. Describe the location of the kidneys relative to the vertebral column and indicate the differences in position of the right and left kidneys. Describe the unique arrangement of fat and fasciae associated with the kidney (and adrenal gland). Describe the relationship of each kidney to the structures immediately anterior to it. Describe the relationship of the kidneys to the structures immediately posterior to them. Describe the gross structure of a kidney (cortex, medulla, major and minor calyces, renal pelvis), including the blood supply and venous drainage. What is the renal sinus? Briefly describe the adrenal (suprarenal) glands – location, blood supply, and innervation? What generally happens to the suprarenal gland during renal transplantation?

Back 18

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Front 19

19. Describe the course of the ureter. How does its course differ in the male and in the female? What is the blood supply of the ureter? How does the topography of the ureteric blood supply differ between abdomen and pelvis, and what is the surgical significance of this positioning? What is the pattern of lymphatic drainage of the ureter? Name three locations where a ureter is normally constricted. To what location would pain caused by the acute onset of a ureteric calculus (stone) typically be referred ? Trace a droplet of urine from a renal papilla to the exterior of the body. Name two mechanisms that help prevent reflux of the droplet.

Back 19

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Front 20

20. While the Latin word rectum means “straight,” the human rectum is characterized by flexures in both the sagittal and coronal planes. Describe the rectum. Include its flexures, peritoneal covering, and innervation. What structures are related to the anterior surface of the rectum in males? What structures are related to the anterior surface of the rectum in females? Describe the arterial supply and venous drainage of the rectum and anal canal.

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