Quiz On Abdominal Wall, Rectus Sheath & Abdominal Viscera

1. You are attempting to check for radio-femoral delay in your patient. To find the femoral artery your visualize a line from the ASIS to the pubic tubercle. You palpate for the femoral artery about a centimeter
below the midpoint of this line. Which ligament are you trying to approximate by visualizing this line? And from what structure is it formed?

Median umbilical ligament; urachus

Medial umbilical ligament; umbilical arteries

Inguinal ligament; external oblique muscle aponeuroses

Inguinal ligament; internal oblique muscle aponeuroses

Round ligament of the uterus; gubernaculum

: The ligament referred to here is the inguinal ligament. It is formed from the folding over of the aponeuroses of the EXTERNAL oblique muscle. The other ligaments are not landmarks for palpating
the femoral nerve.

Explanation

: The ligament referred to here is the inguinal ligament. It is formed from the folding over of the aponeuroses of the EXTERNAL oblique muscle. The other ligaments are not landmarks for palpating
the femoral nerve.

2. What structures make up the conjoint tendon?

Rectus abdominis and transversus abdominis

External oblique and internal oblique‬‬‬‬‬

Internal oblique and transversus abdominis

Rectus abdominis and internal oblique

Internal oblique and transversus abdominis aponeurotic fibers make up the conjoint tendon which inserts on the pubic tubercle and strengthens the posterior wall of the medial half of the inguinal canal.‬‬‬‬

Explanation

Internal oblique and transversus abdominis aponeurotic fibers make up the conjoint tendon which inserts on the pubic tubercle and strengthens the posterior wall of the medial half of the inguinal canal.‬‬‬‬

3. A 17 year-old, male with a past medical history of hypertension presents to your emergency clinic with severe abdominal pain. Past medical history reveals blunt trauma to the abdomen after engaging in a school fight that afternoon. Physical examination reveals a progressive contusion that you begin to worry about. You quickly call a surgical consult and obtain radiological imaging of the patient's abdomen, which confirms your suspicion. The MOST likely cause of this patient's bleed is damage to the:

Short gastric artery

Splenic artery

Left Gastric artery

Inferior Epigastric artery

Gastroduodenal artery

The key phrase in this question is "blunt trauma" to the anterior abdominal wall. This is commonly seen in athletes involved in different kinds of sports (i.e., karate) as well as foul play. The inferior epigastric artery and vein are MOST prone to damage in this type of trauma since they lie just on the deep surface of the rectus abdominis muscles. It should be clear to you that veins are more easily damaged than arteries simply due to the differences in the structures that make up their vascular wall. Since the inferior epigastric vein was not an answer choice here, the artery was the next best choice. The other answer choices are vessels related to gastric perfusion, which you will learn in lectures to come.

Explanation

The key phrase in this question is "blunt trauma" to the anterior abdominal wall. This is commonly seen in athletes involved in different kinds of sports (i.e., karate) as well as foul play. The inferior epigastric artery and vein are MOST prone to damage in this type of trauma since they lie just on the deep surface of the rectus abdominis muscles. It should be clear to you that veins are more easily damaged than arteries simply due to the differences in the structures that make up their vascular wall. Since the inferior epigastric vein was not an answer choice here, the artery was the next best choice. The other answer choices are vessels related to gastric perfusion, which you will learn in lectures to come.

4. During an abdominal surgery, the surgeon describes an area in the transpyloric plane. Which two structures are associated with this anatomical area?

Origin of the IMA and Pylorus of the stomach

Fundus of the Gall Bladder and fundus of the stomach

Pylorus of the stomach and neck of the pancreas

Origin of the SMA and fundus of the stomach

The transpyloric plane, which is typically at the level of L1, has many structures associated with it. Important structures to be aware of are the fundus of the gall bladder, pylorus of the stomach, origin of the SMA, neck of the pancreas, duodenojejunal junction, and the hilum of the kidney.

Explanation

The transpyloric plane, which is typically at the level of L1, has many structures associated with it. Important structures to be aware of are the fundus of the gall bladder, pylorus of the stomach, origin of the SMA, neck of the pancreas, duodenojejunal junction, and the hilum of the kidney.

5. The superior and inferior epigastric arteries lie directly beneath which structure?

External oblique

Transversus Abdominis

Rectus Abdominis

Internal oblique

These two arteries run directly underneath the Rectus Abdominis muscle. In the case of blunt force trauma to the lower abdomen it is common to present with a hematoma from injury to the Inferior Epigastric Artery.

Explanation

These two arteries run directly underneath the Rectus Abdominis muscle. In the case of blunt force trauma to the lower abdomen it is common to present with a hematoma from injury to the Inferior Epigastric Artery.

6. Which of the following is a true statement about the Scarpa's fascia?

It is discontinuous with the Dartos fascia.

It is continuous with the Colles fascia.

It is continuous with a deep penile fascia.

It is the most superficial layer of the abdominal wall.

It is the thickest layer of the abdominal wall.

This fascia is continuous with the Dartos fascia, Colles fascia and superficial penile fascia. It is deeper and thinner than the Camper's fascia.

Explanation

This fascia is continuous with the Dartos fascia, Colles fascia and superficial penile fascia. It is deeper and thinner than the Camper's fascia.

7. A 15-year-old male was taken to the Emergency Department complaining of tenderness and pain in the lower right quadrant of his abdomen. Upon palpation of the patient's abdomen, the patient vocalizes pain and elicits a "guarding reflex." The physician then correctly identifies that the patient is complaining from an inflamed appendix. Which of the following locations did the Physician palpate to elicit the pain in this patient?

Approximately 2/3 from the umbilicus to the Anterior Superior Iliac Spine (ASIS)

Approximately 2/3 from the umbilicus to the Iliac Spine

Approximately 1/3 from the umbilicus to the Anterior Superior Iliac Spine (ASIS)

Approximately 1/3 from the umbilicus to the Iliac Spine

This location describes McBurney's point, which is the approximate superficial anatomical appendix landmark

Explanation

This location describes McBurney's point, which is the approximate superficial anatomical appendix landmark

8. A patient with an inguinal hernia is undergoing surgery. The surgeon must cut through the rectus abdominis in the hypogastric region. The fascia that is posteriorly in contact with the abdominis rectus is made up of which aponeurosis?

Transversalis fascia

Transversalis fascia and oblique fascia

Internal oblique fascia and transversalis fascia

Internal oblique fascia

Past the arcuate line the posterior rectus sheath is absent and the rectus abdominis is in direct contact with transversalis fascia

Explanation

Past the arcuate line the posterior rectus sheath is absent and the rectus abdominis is in direct contact with transversalis fascia

9. You are performing surgery on a 56-year-old man with an ulcer in the first part of the duodenum. In which region of the anterior abdominal wall would you make your initial incision to treat the ulcer?

Left Lumbar

Right Lumbar

Right Hypochondriac

Epigastric

Left Hypochondriac

The duodenum, pancreas, and part of the stomach and liver are all located in the epigastric region of the abdomen

Explanation

The duodenum, pancreas, and part of the stomach and liver are all located in the epigastric region of the abdomen

10. A patient arrives at your clinical with a protruding mass from his superficial inguinal ring. He is diagnosed with an indirect inguinal hernia. What is the posterior border of the canal that this hernia passes through?

Fascia transversalis

Inguinal ligament

Aponeurosis of the transversus abdominis muscle

Fibers of the internal oblique muscle

External oblique aponeurosis

The posterior border throughout the inguinal canal is formed by the transversalis fascia, which is reinforced medially by the conjoint tendon (transversalis abdominis + internal oblique).

Explanation

The posterior border throughout the inguinal canal is formed by the transversalis fascia, which is reinforced medially by the conjoint tendon (transversalis abdominis + internal oblique).

11. A 55-year-old man with a history of alcohol abuse presents to the emergency department complaining of a cough, swelling in his abdomen and swelling in his ankles. On examination, the physician notes the man has a protruding abdomen and yellowing of the sclera of his eyes. The physician identifies that the patient is suffering from ascites and wants to drain the liquid accumulated in his abdomen that is causing the protruding abdomen. Which of the following techniques should the physician use?

Peritoneal lavage

Paracentesis

Pericardiocentesis

Culdocentesis

The man has symptoms suggesting portal hypertension, secondary to liver disease. The paracentesis technique should be sued to remove the fluid accumulated in the peritoneal cavity.

Explanation

The man has symptoms suggesting portal hypertension, secondary to liver disease. The paracentesis technique should be sued to remove the fluid accumulated in the peritoneal cavity.

12. A 43-year-old male is seen in the emergency room for chronic epigastric pain that is relieved by eating. He states he has had this complication for many years. Upper endoscopy reveals a large ulcer on the lesser curvature of the stomach. Which is the most likely complication, should the patients condition worsen?

Chronic pancreatitis

Acute hemorrhage from bleeding gastric arteries

Acute cholecystitis

Duodenal obstruction

Ulceration of the lesser curvature of the stomach can worsen and result in complete ulceration of the stomach wall and rupture of vessels in close proximity. The left and right gastric arteries are closely associated with the lesser curvature of the stomach and can rupture due to perforation of the stomach lining due to chronic ulceration. (A) Chronic pancreatitis results from enzymatic digestion of pancreatic tissue most commonly from chronic alcohol intake. (C) Acute cholecystitis is not a complication of gastric ulcer and is most likely due to obstruction of either cystic duct, common bile duct or traumatic event. (D) Duodenal obstruction is not a likely complication of gastric ulcer.

Explanation

Ulceration of the lesser curvature of the stomach can worsen and result in complete ulceration of the stomach wall and rupture of vessels in close proximity. The left and right gastric arteries are closely associated with the lesser curvature of the stomach and can rupture due to perforation of the stomach lining due to chronic ulceration. (A) Chronic pancreatitis results from enzymatic digestion of pancreatic tissue most commonly from chronic alcohol intake. (C) Acute cholecystitis is not a complication of gastric ulcer and is most likely due to obstruction of either cystic duct, common bile duct or traumatic event. (D) Duodenal obstruction is not a likely complication of gastric ulcer.

13. A surgeon performs a surgery on the lateral aspect of a patient's abdominal wall. He comes upon a muscle in which the fibers are running "down and in." What is the muscle or fascia that is most likely immediately deep to this muscle?

Scarpa's fascia

External Oblique

Internal Oblique

Transversalis fascia

Transverse Abdominis

The muscle that is being described, as fibers running "down and in" is the external oblique muscle. The layer that is immediately deep to this is the internal oblique muscle. It is important to know the layers in order from superficial to deep: Skin → Camper's Fascia → Scarpa's Fascia → External Oblique → Internal Oblique → Transverse Abdominis → Transversalis fascia → Extraperitoneal fascia → Parietal Peritoneum

Explanation

The muscle that is being described, as fibers running "down and in" is the external oblique muscle. The layer that is immediately deep to this is the internal oblique muscle. It is important to know the layers in order from superficial to deep: Skin → Camper's Fascia → Scarpa's Fascia → External Oblique → Internal Oblique → Transverse Abdominis → Transversalis fascia → Extraperitoneal fascia → Parietal Peritoneum

14. Which of the following is most consistent with the double-layered fold of peritoneum which connects the lesser curvature of the stomach and 1^st part of duodenum to the liver?

Is known as the greater omentum and contains the gastrocolic ligament

Is known as the greater omentum and contains the hepatoduodenal ligament

Is known as the lesser omentum and contains the gastrocolic ligament

Is known as the lesser omentum and contains the hepatoduodenal ligament

Is known as the greater omentum and contains the hepatogastric ligament

Is known as the lesser omentum and contains the gastrophrenic ligament

The lesser omentum is a fold of peritoneum, which connects the lesser curvature of the stomach and duodenum with the liver and contains the hepatoduodenal and hepatogastric ligaments. The hepatoduodenal ligament is especially important because it contains the structures of the portal triad (portal vein, common bile duct, and the hepatic artery proper).

Explanation

The lesser omentum is a fold of peritoneum, which connects the lesser curvature of the stomach and duodenum with the liver and contains the hepatoduodenal and hepatogastric ligaments. The hepatoduodenal ligament is especially important because it contains the structures of the portal triad (portal vein, common bile duct, and the hepatic artery proper).

15. A 45-year-old man develops an abdominal abscess following a complicated appendectomy. Which of the following structures functions to localize the resulting inflammatory process?

Lesser omentum‬

Greater omentum

Visceral peritoneum

Parietal peritoneum

The lesser omentum runs from the lesser curvature of the stomach superiorly; also, since the appendectomy was performed on the inferior aspect of the abdomen, the abscess was more likely to develop in the region of the greater omentum, which runs from the greater curvature of the stomach inferiorly. It is referred to as the "abdominal policeman" because of the function asked in this question. None of the remaining answer choices have a function in localizing infection.‬

Explanation

The lesser omentum runs from the lesser curvature of the stomach superiorly; also, since the appendectomy was performed on the inferior aspect of the abdomen, the abscess was more likely to develop in the region of the greater omentum, which runs from the greater curvature of the stomach inferiorly. It is referred to as the "abdominal policeman" because of the function asked in this question. None of the remaining answer choices have a function in localizing infection.‬

16. The round ligament of the liver is also known as the ligamentum teres hepatis. This structure found in adults is the remnant of what embryological structure?

Ligamentum venosum‬‬‬‬‬

Umbilical vein‬‬‬‬‬

Umbilical artery

Umbilical cord‬‬‬‬‬

Viteline duct‬‬‬‬‬

The round ligament of the liver (not to be confused with the round ligament of the uterus) is the remnant of the umbilical vein. Note that the umbilical vein carries oxygenated blood from the mother to the fetus.‬‬‬‬

Explanation

The round ligament of the liver (not to be confused with the round ligament of the uterus) is the remnant of the umbilical vein. Note that the umbilical vein carries oxygenated blood from the mother to the fetus.‬‬‬‬

17. Which of the following structures forms the medial border of the inguinal canal?

Inguinal ligament

Conjoint tendon

Lateral umbilical fold

Transversalis fascia

The conjoint tendon, formed by the fusion of the aponeuroses of the internal oblique and transversus abdominis muscles, forms the medial border of the inguinal canal. This canal is a passageway in the anterior abdominal wall that allows for the passage of structures such as the spermatic cord (in males) or the round ligament (in females).

Explanation

The conjoint tendon, formed by the fusion of the aponeuroses of the internal oblique and transversus abdominis muscles, forms the medial border of the inguinal canal. This canal is a passageway in the anterior abdominal wall that allows for the passage of structures such as the spermatic cord (in males) or the round ligament (in females).

18. Assisting in a surgery, you notice the surgeon's incision draws a large volume of blood immediately from the patient's para-umbilical region. You are startled and ask the surgeon why he isn't more concerned about the bleeding as he calmly clamps the artery and makes his deep incision through the rectus sheath. He explains that:

The artery is a branch off the internal iliac and the bleeding will stop on it's own

The artery is a superficial branch of the Superior epigastic and is not important.

The artery is an anastomosis off the femoral and is not likely to cause muscle ischemia

The artery is a branch off the Internal Thoracic, which is dual supplied by the portal system

the artery is the superficial epigastric and is above the rectus abdominis muscles. (A) is false, these branches don't supply the skin. (B) is false because the Superior epigastric is underneath the rectus abdominis muscle, which the surgeon dissected after clamping the superficial epigastric. (D) is wrong for so many reasons, mostly because the portal system is venous, and doesn't perfuse tissue, it drains them.

Explanation

the artery is the superficial epigastric and is above the rectus abdominis muscles. (A) is false, these branches don't supply the skin. (B) is false because the Superior epigastric is underneath the rectus abdominis muscle, which the surgeon dissected after clamping the superficial epigastric. (D) is wrong for so many reasons, mostly because the portal system is venous, and doesn't perfuse tissue, it drains them.

19. Which is true of the blood supply of the anterior abdominal wall?

Direct branches of the Aorta supply the lateral anterior abdominal wall

Multiple branches of the Subclavian Artery supply the anterior abdominal wall

Branches of the Internal Iliac Artery supply the anterior abdominal wall inferior to the arcuate line

Inferior Epigastric Arteries are found superficial to the rectus abdominus muscle

Posterior intercostal arteries, supplying the lateral borders of the anterior abdominal wall, originate directly off of the thoracic aorta. (B) The Internal Thoracic Artery is the only branch of the Subclavian Artery supplying the anterior abdominal wall giving off two branches including the Superior Epigastric Arteries. (C) No branches of the Internal Iliac Artery are involved in supplying the anterior abdominal wall. (D) Inferior Epigastric Arteries are found beneath (deep) to the rectus abdominus and superficial to the transversalis fascia both above and below the arcuate line.

Explanation

Posterior intercostal arteries, supplying the lateral borders of the anterior abdominal wall, originate directly off of the thoracic aorta. (B) The Internal Thoracic Artery is the only branch of the Subclavian Artery supplying the anterior abdominal wall giving off two branches including the Superior Epigastric Arteries. (C) No branches of the Internal Iliac Artery are involved in supplying the anterior abdominal wall. (D) Inferior Epigastric Arteries are found beneath (deep) to the rectus abdominus and superficial to the transversalis fascia both above and below the arcuate line.

20. After a motor vehicle accident, a patient is brought to the emergency department. X-ray reveals fractured left ninth and tenth ribs. She has a rapid heart rate and low blood pressure. Peritoneal lavage reveals free blood in the peritoneal cavity. A surgeon is able to stop the bleeding by placing a clamp across which of the following structures?

Falciform ligament

Hepatoduodenal ligament

Hepatogastric ligament

Splenorenal ligament

Gastrosplenic ligament

The spleen spans from about rib nine to rib ten. Therefore the fractured ribs should clue you in to a splenic rupture. The low blood volume, high heart rate, and peritoneal lavage are all indicators of intraperitoneal hemorrhage. The key to stopping the hemorrhage would be to clamp the arteries supplying blood to the spleen. The splenic vessels can be found in the splenorenal ligament, which also houses the tail of the pancreas.

Explanation

The spleen spans from about rib nine to rib ten. Therefore the fractured ribs should clue you in to a splenic rupture. The low blood volume, high heart rate, and peritoneal lavage are all indicators of intraperitoneal hemorrhage. The key to stopping the hemorrhage would be to clamp the arteries supplying blood to the spleen. The splenic vessels can be found in the splenorenal ligament, which also houses the tail of the pancreas.

21. The hepatoduodenal ligament is being pinched between my thumb and forefinger. Which branch of the Celiac trunk is found within this ligament?

Gastroduodenal Artery

Common Hepatic Artery

Hepatic Artery

Proper Hepatic Artery

The portal triad lies within the hepatoduodenal ligament and contains, the common bile duct, proper hepatic artery, and hepatic portal vein.

Explanation

The portal triad lies within the hepatoduodenal ligament and contains, the common bile duct, proper hepatic artery, and hepatic portal vein.

22. A man is in a car accident and breaks the tip of his sternum. At presentation to the ER he is found to be markedly hypotensive and his abdomen is distended. What is the most likely source of blood?

Gastroduodenal artery

Right Gastric artery

Common Hepatic artery

Splenic artery

The Gastroduodenal artery is the only artery, which lies centrally in the transpyloric plane.

Explanation

The Gastroduodenal artery is the only artery, which lies centrally in the transpyloric plane.