Subtopic: Cremasteric Artery
Keyword Definitions:
Cremasteric artery: A branch of the inferior epigastric artery that supplies the cremaster muscle and coverings of the spermatic cord.
Inferior epigastric artery: A branch of the external iliac artery supplying the lower anterior abdominal wall.
Cremaster muscle: A skeletal muscle that raises and lowers the testis to regulate temperature.
Spermatic cord: A bundle containing vas deferens, arteries, veins, and nerves that pass through the inguinal canal.
External iliac artery: Main artery of lower limb that gives rise to inferior epigastric and deep circumflex iliac arteries.
Pampiniform plexus: Venous network in spermatic cord aiding testicular thermoregulation.
Lead Question – 2014
Cremasteric artery is a branch of?
a) Internal pudendal artery
b) External pudendal artery
c) Inferior epigastric artery
d) Superior epigastric artery
Explanation: The cremasteric artery arises from the inferior epigastric artery, a branch of the external iliac artery. It supplies the cremaster muscle and coverings of the spermatic cord, anastomosing with the testicular and artery of the vas deferens. (Answer: c)
1) The inferior epigastric artery arises from:
a) Internal iliac artery
b) External iliac artery
c) Common iliac artery
d) Femoral artery
Explanation: The inferior epigastric artery arises from the external iliac artery just above the inguinal ligament and ascends to supply the rectus abdominis muscle and overlying skin. (Answer: b)
2) The cremaster muscle is derived from:
a) External oblique
b) Internal oblique
c) Transversus abdominis
d) Rectus abdominis
Explanation: The cremaster muscle is derived from the internal oblique muscle and its fascia. It covers the spermatic cord and helps elevate the testes during the cremasteric reflex. (Answer: b)
3) (Clinical) Injury to the inferior epigastric artery can lead to hematoma in:
a) Perineum
b) Rectus sheath
c) Inguinal canal
d) Scrotum
Explanation: Injury to the inferior epigastric artery causes bleeding into the rectus sheath, leading to a rectus sheath hematoma, often seen after trauma or laparoscopic surgery. (Answer: b)
4) The cremasteric artery anastomoses with:
a) Testicular artery and artery to vas deferens
b) Deep epigastric artery
c) Obturator artery
d) External pudendal artery
Explanation: The cremasteric artery forms anastomoses with the testicular artery and the artery to vas deferens, ensuring collateral circulation to the spermatic cord and testis. (Answer: a)
5) Cremasteric reflex involves contraction of:
a) Dartos muscle
b) Cremaster muscle
c) External oblique
d) Rectus abdominis
Explanation: The cremasteric reflex is the upward pull of the testis upon stroking the inner thigh, mediated by the cremaster muscle supplied by the genital branch of the genitofemoral nerve. (Answer: b)
6) (Clinical) In testicular torsion, cremasteric reflex is:
a) Exaggerated
b) Normal
c) Absent
d) Hyperactive
Explanation: In testicular torsion, the cremasteric reflex is absent due to ischemia and irritation of the genitofemoral nerve, which normally mediates this reflex. (Answer: c)
7) (Clinical) A surgeon ligating the inferior epigastric artery must be cautious of which nearby structure?
a) Vas deferens
b) Deep inguinal ring
c) Femoral vein
d) External pudendal vein
Explanation: The inferior epigastric artery runs just medial to the deep inguinal ring, an important landmark during hernia repairs. Injury here can cause bleeding and hematoma formation. (Answer: b)
8) External pudendal artery supplies:
a) Perineum and scrotal skin
b) Cremaster muscle
c) Testis
d) Internal oblique muscle
Explanation: The external pudendal artery, a branch of the femoral artery, supplies the perineum, penis, and scrotal or labial skin, not the cremaster muscle. (Answer: a)
9) (Clinical) A patient has a deep inguinal hernia. The artery lying medial to the deep inguinal ring is:
a) Inferior epigastric artery
b) Superficial epigastric artery
c) External pudendal artery
d) Deep circumflex iliac artery
Explanation: The inferior epigastric artery lies medial to the deep inguinal ring. This relationship helps differentiate direct from indirect inguinal hernias clinically. (Answer: a)
10) (Clinical) During orchiopexy, which artery must be preserved for testicular viability?
a) Cremasteric artery
b) Testicular artery
c) Artery to vas deferens
d) All of the above
Explanation: During orchiopexy for undescended testis, the testicular artery is the major blood supply, but preservation of all three arteries—testicular, cremasteric, and artery to vas deferens—ensures adequate perfusion and prevents ischemia. (Answer: d)
Topic: Arteries of the Anterior Abdominal Wall
Subtopic: Superficial Epigastric Artery
Keyword Definitions:
Superficial epigastric artery: A small branch of the femoral artery that supplies the lower part of the anterior abdominal wall and skin over the inguinal region.
Femoral artery: Main artery of the thigh, a continuation of the external iliac artery below the inguinal ligament.
Inferior epigastric artery: A deep branch of the external iliac artery that supplies the rectus abdominis muscle and anastomoses with the superior epigastric artery.
External pudendal artery: A branch of the femoral artery that supplies the perineum and external genitalia.
Superficial fascia: The fatty and membranous layer beneath the skin, especially well developed in the lower abdomen.
Inguinal ligament: Fibrous band extending from the anterior superior iliac spine to the pubic tubercle forming the base of the inguinal canal.
Lead Question – 2014
Superficial epigastric artery is a branch of?
a) Internal pudendal artery
b) External pudendal artery
c) Internal iliac artery
d) Femoral artery
Explanation: The superficial epigastric artery arises from the femoral artery just below the inguinal ligament. It runs upward and medially in the superficial fascia to supply the lower abdominal wall and skin over the inguinal region. (Answer: d)
1) The femoral artery begins at the level of:
a) Inguinal ligament
b) Pubic symphysis
c) Mid-inguinal point
d) Iliac crest
Explanation: The femoral artery begins at the mid-inguinal point, midway between the anterior superior iliac spine and the pubic symphysis, as a continuation of the external iliac artery. (Answer: c)
2) The superficial epigastric artery pierces which fascia?
a) Scarpa’s fascia
b) Camper’s fascia
c) Deep fascia
d) Fascia lata
Explanation: The superficial epigastric artery pierces the cribriform fascia (part of the fascia lata) just below the inguinal ligament before ascending in the superficial fascia of the lower abdominal wall. (Answer: d)
3) (Clinical) During hernia surgery, superficial epigastric vein injury leads to bleeding in which layer?
a) Deep fascia
b) Superficial fascia
c) Transversalis fascia
d) Peritoneum
Explanation: Bleeding from the superficial epigastric vein occurs in the superficial fascia, which lies beneath the skin. This vein accompanies the artery and drains into the femoral vein. (Answer: b)
4) The superficial epigastric artery anastomoses with:
a) Superior epigastric artery
b) Inferior epigastric artery
c) Deep circumflex iliac artery
d) Obturator artery
Explanation: The superficial epigastric artery anastomoses with branches of the inferior epigastric artery in the anterior abdominal wall, contributing to collateral blood supply between femoral and external iliac systems. (Answer: b)
5) (Clinical) A patient with obstruction of the femoral artery may retain some blood flow through:
a) Superficial epigastric and inferior epigastric anastomosis
b) External pudendal artery
c) Deep femoral artery
d) Obturator artery
Explanation: Collateral circulation via the superficial epigastric and inferior epigastric arteries can maintain blood flow to the lower abdominal wall when femoral artery flow is compromised. (Answer: a)
6) The superficial epigastric artery supplies:
a) Deep abdominal muscles
b) Lower part of anterior abdominal wall
c) Rectus abdominis muscle
d) Peritoneum
Explanation: The superficial epigastric artery supplies the skin and superficial fascia of the lower anterior abdominal wall and the inguinal region. (Answer: b)
7) (Clinical) Dilated superficial epigastric veins are seen in:
a) Deep vein thrombosis
b) Portal hypertension
c) Varicocele
d) Aneurysm of aorta
Explanation: Dilated superficial epigastric veins may be seen in portal hypertension due to portosystemic anastomosis between the paraumbilical and superficial epigastric veins. (Answer: b)
8) The superficial epigastric artery arises:
a) Above inguinal ligament
b) Below inguinal ligament
c) At mid-inguinal point
d) At pubic tubercle
Explanation: The superficial epigastric artery arises from the femoral artery below the inguinal ligament, near the saphenous opening. (Answer: b)
9) (Clinical) A surgeon performing varicose vein surgery near the saphenous opening must identify:
a) Superficial epigastric vein
b) Inferior epigastric vein
c) Obturator vein
d) Deep circumflex iliac vein
Explanation: The superficial epigastric vein joins the great saphenous vein near the saphenous opening, an important landmark in varicose vein surgery to prevent hemorrhage. (Answer: a)
10) (Clinical) A penetrating wound just below the inguinal ligament may damage which artery?
a) Inferior epigastric artery
b) Superficial epigastric artery
c) Deep circumflex iliac artery
d) Obturator artery
Explanation: A wound just below the inguinal ligament may injure the superficial epigastric artery as it arises from the femoral artery and pierces the fascia lata in this region. (Answer: b)
Topic: Venous Drainage of the Anterior Abdominal Wall
Subtopic: Inferior Epigastric Vein
Keyword Definitions:
Inferior epigastric vein: A vein that accompanies the inferior epigastric artery, draining blood from the lower part of the anterior abdominal wall.
External iliac vein: Major pelvic vein that continues as the femoral vein below the inguinal ligament and receives tributaries including the inferior epigastric vein.
Rectus sheath: Fibrous sheath enclosing the rectus abdominis muscle, formed by aponeuroses of the abdominal wall muscles.
Superficial epigastric vein: Vein accompanying the superficial epigastric artery, draining into the great saphenous vein.
Portosystemic anastomosis: Connection between portal and systemic venous systems, important in portal hypertension.
Linea alba: Fibrous midline structure where abdominal aponeuroses fuse, serving as a landmark for venous drainage zones.
Lead Question – 2014
Inferior epigastric vein drains into?
a) Femoral vein
b) External iliac vein
c) Internal iliac vein
d) Internal pudendal vein
Explanation: The inferior epigastric vein accompanies its artery and drains into the external iliac vein just above the inguinal ligament. It plays a role in collateral circulation between the femoral and internal thoracic veins. (Answer: b)
1) The inferior epigastric artery arises from:
a) External iliac artery
b) Internal iliac artery
c) Femoral artery
d) Inferior mesenteric artery
Explanation: The inferior epigastric artery arises from the external iliac artery just above the inguinal ligament and runs upward in the rectus sheath behind the rectus abdominis. (Answer: a)
2) (Clinical) Injury to inferior epigastric vessels during surgery occurs in:
a) Umbilical region
b) Lateral to deep inguinal ring
c) Medial to deep inguinal ring
d) Hypogastric region
Explanation: The inferior epigastric vessels lie just medial to the deep inguinal ring and may be injured during hernia repair or laparoscopic trocar insertion. (Answer: c)
3) The inferior epigastric vein forms an anastomosis with:
a) Superior epigastric vein
b) Superficial epigastric vein
c) Paraumbilical vein
d) Great saphenous vein
Explanation: The inferior epigastric vein anastomoses with the superior epigastric vein within the rectus sheath, forming a communication between femoral and internal thoracic venous systems. (Answer: a)
4) (Clinical) During portal hypertension, which vein may become dilated near the umbilicus?
a) Inferior epigastric vein
b) Paraumbilical vein
c) Great saphenous vein
d) Internal iliac vein
Explanation: In portal hypertension, the paraumbilical veins connect with the inferior and superior epigastric veins, leading to caput medusae appearance. (Answer: b)
5) The inferior epigastric vein lies:
a) Superficial to rectus abdominis
b) Within rectus abdominis
c) Behind rectus abdominis
d) Deep to transversalis fascia only
Explanation: The inferior epigastric vein lies behind the rectus abdominis muscle within the rectus sheath and accompanies its corresponding artery. (Answer: c)
6) (Clinical) A laceration below the arcuate line may cause bleeding from:
a) Superior epigastric artery
b) Inferior epigastric vessels
c) Deep circumflex iliac vessels
d) Internal thoracic artery
Explanation: Below the arcuate line, only the transversalis fascia covers the inferior epigastric vessels, making them prone to injury and significant bleeding in trauma or surgery. (Answer: b)
7) Inferior epigastric vein joins the external iliac vein:
a) Above the inguinal ligament
b) Below the inguinal ligament
c) At the level of pubic tubercle
d) Near the umbilicus
Explanation: The inferior epigastric vein joins the external iliac vein above the inguinal ligament, accompanying its artery through the transversalis fascia. (Answer: a)
8) (Clinical) In an indirect inguinal hernia, inferior epigastric vessels are located:
a) Medial to hernial sac
b) Lateral to hernial sac
c) Posterior to hernial sac
d) Superior to hernial sac
Explanation: In indirect inguinal hernia, the inferior epigastric vessels lie medial to the neck of the hernial sac, serving as an important landmark in differentiating hernia types. (Answer: b)
9) The inferior epigastric vein is formed by:
a) Two venae comitantes
b) A single trunk
c) A plexus of small veins
d) Fusion with superficial veins
Explanation: The inferior epigastric vein is formed by two venae comitantes accompanying the artery, which unite before draining into the external iliac vein. (Answer: a)
10) (Clinical) During laparoscopic trocar placement near the midline, which vessel must be avoided?
a) Inferior epigastric vessels
b) Superficial circumflex iliac vessels
c) Obturator vessels
d) Deep circumflex iliac artery
Explanation: Surgeons must avoid the inferior epigastric vessels located just lateral to the umbilicus and rectus abdominis to prevent bleeding during trocar insertion. (Answer: a)
Topic: Blood Supply of Rectum and Anal Canal
Subtopic: Venous Drainage of Rectum
Keyword Definitions:
Superior rectal vein: Drains blood from the upper rectum and continues as the inferior mesenteric vein.
Inferior mesenteric vein: Drains into the splenic vein and joins the portal venous system.
Internal iliac vein: Drains blood from pelvic organs and walls.
Internal pudendal vein: Drains perineum and external genitalia.
Lead Question (2014): Superior rectal vein drains into?
a) Inferior mesenteric vein
b) External iliac vein
c) Internal iliac vein
d) Internal pudendal vein
Explanation: Superior rectal vein drains into the inferior mesenteric vein, which is a part of the portal venous system. Middle and inferior rectal veins drain into systemic veins. Hence, the superior rectal vein forms an important portosystemic anastomosis site. Answer: a) Inferior mesenteric vein
1. Middle rectal vein drains into?
a) Internal pudendal vein
b) Internal iliac vein
c) Inferior mesenteric vein
d) External iliac vein
Explanation: The middle rectal vein drains into the internal iliac vein. It connects the rectal venous plexus with the systemic venous system. This contributes to portosystemic anastomosis. Answer: b) Internal iliac vein
2. Inferior rectal vein drains into?
a) Internal pudendal vein
b) External iliac vein
c) Superior rectal vein
d) Internal iliac vein
Explanation: The inferior rectal vein drains into the internal pudendal vein. This vein communicates between the lower rectum and perineal venous plexus. Answer: a) Internal pudendal vein
3. Which of the following veins forms part of the portosystemic anastomosis?
a) Superior rectal vein
b) Internal pudendal vein
c) Femoral vein
d) Obturator vein
Explanation: Superior rectal vein forms part of the portosystemic anastomosis by connecting the portal and systemic circulations through the middle and inferior rectal veins. Answer: a) Superior rectal vein
4. During portal hypertension, which condition may occur due to venous congestion in the rectal plexus?
a) Hemorrhoids
b) Fistula
c) Abscess
d) Anal fissure
Explanation: Portal hypertension causes venous congestion in the superior rectal vein, leading to dilatation of rectal veins and development of hemorrhoids (piles). Answer: a) Hemorrhoids
5. The superior rectal vein belongs to which venous system?
a) Systemic venous system
b) Portal venous system
c) Caval venous system
d) Vertebral venous system
Explanation: The superior rectal vein belongs to the portal venous system because it drains into the inferior mesenteric vein, which joins the splenic vein to form the portal vein. Answer: b) Portal venous system
6. A patient with portal hypertension develops rectal varices. Which veins are dilated?
a) Superior rectal veins
b) Internal iliac veins
c) Middle rectal veins
d) Inferior rectal veins
Explanation: Rectal varices result from dilation of superior rectal veins due to portal hypertension, leading to communication with systemic veins via the middle and inferior rectal veins. Answer: a) Superior rectal veins
7. Which vein drains the upper anal canal?
a) Superior rectal vein
b) Middle rectal vein
c) Inferior rectal vein
d) Internal pudendal vein
Explanation: The upper anal canal, derived from endoderm, is drained by the superior rectal vein, which connects to the portal venous system via the inferior mesenteric vein. Answer: a) Superior rectal vein
8. In portal hypertension, which type of hemorrhoids are formed due to superior rectal vein involvement?
a) Internal hemorrhoids
b) External hemorrhoids
c) Mixed hemorrhoids
d) None
Explanation: Internal hemorrhoids develop due to dilation of veins in the upper anal canal, involving the superior rectal veins, which belong to the portal venous system. Answer: a) Internal hemorrhoids
9. The inferior mesenteric vein drains into which of the following?
a) Splenic vein
b) Portal vein directly
c) Superior mesenteric vein
d) Hepatic vein
Explanation: The inferior mesenteric vein drains into the splenic vein, which later joins the superior mesenteric vein to form the portal vein. Answer: a) Splenic vein
10. In a surgery involving sigmoid colon, the superior rectal vein is injured. Which complication can occur?
a) Rectal bleeding
b) Constipation
c) Intestinal perforation
d) Hematuria
Explanation: Injury to the superior rectal vein can lead to rectal bleeding due to disruption of venous drainage from the upper rectum. Prompt hemostasis is necessary to prevent hemorrhage. Answer: a) Rectal bleeding
Topic: Spleen
Subtopic: Accessory Spleen
Keyword Definitions:
Accessory spleen: A small nodule of splenic tissue separate from the main spleen, often congenital.
Hilum of spleen: Site where splenic vessels enter and leave the spleen.
Splenic artery: Main arterial supply of the spleen, a branch of the celiac trunk.
Splenectomy: Surgical removal of the spleen, sometimes revealing accessory spleens.
Lead Question (2014): Most common location of accessory spleen?
a) Hilum of spleen
b) Greater omentum
c) Lesser omentum
d) None
Explanation: The most common location of an accessory spleen is at the hilum of the spleen or within the gastrosplenic ligament. These arise from failure of fusion of splenic tissue during embryonic development and are usually asymptomatic. Answer: a) Hilum of spleen
1. Which artery supplies an accessory spleen?
a) Left gastric artery
b) Splenic artery
c) Short gastric artery
d) Left gastroepiploic artery
Explanation: Accessory spleens are supplied by branches of the splenic artery, similar to the main spleen. This ensures their functional similarity and ability to take over partial splenic functions if required. Answer: b) Splenic artery
2. During splenectomy, failure to remove an accessory spleen can lead to?
a) Hypertension
b) Recurrence of hematologic disease
c) Portal thrombosis
d) Renal failure
Explanation: Failure to remove accessory spleens during splenectomy may lead to recurrence of hematologic disorders like ITP because the residual splenic tissue continues its immunologic functions. Answer: b) Recurrence of hematologic disease
3. Accessory spleen is most commonly found in which ligament?
a) Gastrosplenic ligament
b) Hepatogastric ligament
c) Falciform ligament
d) Phrenicocolic ligament
Explanation: Accessory spleens are frequently found in the gastrosplenic ligament, which connects the spleen to the greater curvature of the stomach. Answer: a) Gastrosplenic ligament
4. A 40-year-old male underwent splenectomy for ITP, but platelet count remains low. The cause could be?
a) Missed accessory spleen
b) Liver dysfunction
c) Bone marrow failure
d) Infection
Explanation: Persistence of low platelet count after splenectomy often indicates a missed accessory spleen, which continues to sequester platelets. Answer: a) Missed accessory spleen
5. Which imaging modality best detects accessory spleen?
a) CT scan
b) MRI
c) Ultrasonography
d) PET scan
Explanation: CT scan with contrast is the best imaging technique for detecting accessory spleens because it differentiates splenic tissue based on enhancement patterns. Answer: a) CT scan
6. Accessory spleen is derived from which embryological structure?
a) Dorsal mesogastrium
b) Ventral mesogastrium
c) Midgut loop
d) Septum transversum
Explanation: The spleen and accessory spleens develop from mesenchymal condensations in the dorsal mesogastrium during the 5th week of embryogenesis. Answer: a) Dorsal mesogastrium
7. The size of accessory spleen is usually less than?
a) 1 cm
b) 2 cm
c) 3 cm
d) 5 cm
Explanation: Accessory spleens are usually small, less than 2 cm in diameter, and composed of normal splenic tissue. Answer: b) 2 cm
8. In thalassemia patients after splenectomy, an accessory spleen may cause?
a) Persistent anemia
b) Jaundice
c) Hypertension
d) Renal failure
Explanation: In thalassemia, an accessory spleen may cause persistent anemia after splenectomy due to continued sequestration and destruction of red blood cells. Answer: a) Persistent anemia
9. Which of the following statements about accessory spleen is TRUE?
a) It is functionally inactive
b) It can undergo torsion
c) It never enlarges in hematologic disease
d) It always lies in retroperitoneum
Explanation: Accessory spleens are functionally active and may enlarge in hematologic disorders. Rarely, they can undergo torsion causing acute abdominal pain. Answer: b) It can undergo torsion
10. A surgeon accidentally finds a small splenic nodule near the pancreas tail. It represents?
a) Pancreatic pseudocyst
b) Accessory spleen
c) Lymph node
d) Neuroendocrine tumor
Explanation: A small, well-circumscribed nodule near the tail of the pancreas is typically an accessory spleen, arising due to splenic tissue inclusion during development. Answer: b) Accessory spleen
Subtopic: Vaginal Anatomy and Relations
Keyword Definitions:
Vagina: A fibromuscular canal extending from the cervix to the vulva, forming part of the female genital tract.
Posterior vaginal wall: The back wall of the vagina, longer than the anterior wall, related to the rectouterine pouch.
Hymen: A mucous membrane fold that partially covers the vaginal opening in virgins.
Vaginal fornices: Recesses around the cervix formed by the vaginal wall.
Lead Question (2014): Length of posterior vaginal wall is
a) Variable
b) Same as anterior vaginal wall
c) Less than anterior vaginal wall
d) More than anterior vaginal wall
Explanation: The posterior vaginal wall is about 9 cm long, which is longer than the anterior vaginal wall (approximately 7.5 cm). This difference exists because the vagina slopes upward and backward to the cervix. Answer: d) More than anterior vaginal wall
1. The average length of the vagina in adult females is?
a) 5–6 cm
b) 7–8 cm
c) 8–10 cm
d) 10–12 cm
Explanation: The average vaginal length in adult females is about 8–10 cm, with the posterior wall being slightly longer than the anterior. Answer: c) 8–10 cm
2. The posterior vaginal wall is related to which structure superiorly?
a) Rectouterine pouch
b) Urinary bladder
c) Urethra
d) Ureter
Explanation: Superiorly, the posterior vaginal wall is related to the rectouterine pouch (of Douglas), an important peritoneal space clinically significant for fluid collection. Answer: a) Rectouterine pouch
3. The vaginal blood supply mainly comes from?
a) Ovarian artery
b) Vaginal artery
c) Inferior epigastric artery
d) Uterine artery only
Explanation: The vagina receives its main blood supply from the vaginal artery, a branch of the internal iliac artery, with contributions from the uterine and internal pudendal arteries. Answer: b) Vaginal artery
4. A 32-year-old woman presents with fluid in the rectouterine pouch. This can be accessed through?
a) Posterior fornix of vagina
b) Anterior fornix of vagina
c) Cervical canal
d) Urethra
Explanation: The rectouterine pouch can be accessed surgically or diagnostically through the posterior fornix of the vagina for drainage or sampling. Answer: a) Posterior fornix of vagina
5. The epithelium lining the vagina is?
a) Stratified squamous non-keratinized
b) Simple cuboidal
c) Transitional
d) Ciliated columnar
Explanation: The vaginal epithelium is stratified squamous non-keratinized, providing resistance to friction during intercourse and childbirth. Answer: a) Stratified squamous non-keratinized
6. The nerve supply to the lower one-third of the vagina is?
a) Pudendal nerve
b) Pelvic splanchnic nerve
c) Hypogastric plexus
d) Sacral splanchnic nerve
Explanation: The lower one-third of the vagina is supplied by the pudendal nerve, which carries somatic sensory fibers, making it sensitive to pain. Answer: a) Pudendal nerve
7. During childbirth, the posterior vaginal wall may tear due to?
a) Prolonged second stage
b) Posterior position of head
c) Large fetal head
d) All of the above
Explanation: Posterior vaginal wall tears occur due to overdistension or trauma from a large fetal head or prolonged second stage of labor. Answer: d) All of the above
8. The anterior vaginal wall is related to which organ?
a) Rectum
b) Urinary bladder
c) Sigmoid colon
d) Uterus
Explanation: The anterior vaginal wall is related to the urinary bladder and urethra, which are closely apposed to it. Answer: b) Urinary bladder
9. A posterior colpotomy is performed through which part of vagina?
a) Posterior fornix
b) Anterior fornix
c) Vaginal vault
d) Cervix
Explanation: A posterior colpotomy is done through the posterior fornix of the vagina to access the peritoneal cavity for drainage or sterilization procedures. Answer: a) Posterior fornix
10. The vaginal wall lacks which of the following?
a) Serosa
b) Mucosa
c) Muscular layer
d) Adventitia
Explanation: The vaginal wall has mucosa, muscular, and adventitial layers but lacks a serosa, as it is not covered by peritoneum except at the posterior fornix. Answer: a) Serosa
Topic: Liver
Subtopic: Bare Area and Peritoneal Reflections
Keyword Definitions:
Bare area of liver: A region on the posterior surface of the right lobe of the liver not covered by peritoneum, in direct contact with the diaphragm.
Coronary ligament: A peritoneal fold enclosing the bare area, formed by reflections of visceral and parietal peritoneum.
Falciform ligament: A double fold of peritoneum connecting the anterior surface of the liver to the anterior abdominal wall.
Hepatorenal pouch: A space between the liver and right kidney, clinically important for fluid collection.
Lead Question (2014): Bare area of liver is related to -
a) Aorta
b) Hepatic vein
c) Portal vein
d) Gall bladder
Explanation: The bare area of the liver is in direct contact with the diaphragm and is bounded by the coronary ligament. It does not relate to the portal vein or gallbladder. Answer: a) Aorta
1. Which structure forms the boundary of the bare area of liver?
a) Round ligament
b) Coronary ligament
c) Ligamentum venosum
d) Falciform ligament
Explanation: The bare area is enclosed by reflections of the peritoneum forming the coronary ligament, which separates it from the rest of the peritoneal surface. Answer: b) Coronary ligament
2. The peritoneal reflections forming the coronary ligament meet to form which ligament?
a) Falciform ligament
b) Triangular ligament
c) Hepatoduodenal ligament
d) Ligamentum teres
Explanation: The anterior and posterior layers of the coronary ligament meet at the lateral ends to form the right and left triangular ligaments. Answer: b) Triangular ligament
3. The bare area of the liver is devoid of which covering?
a) Peritoneum
b) Connective tissue
c) Capsule
d) Blood vessels
Explanation: The bare area lacks peritoneal covering, exposing it to direct contact with the diaphragm but still covered by connective tissue and Glisson’s capsule. Answer: a) Peritoneum
4. Which clinical condition may allow infection to spread from the liver to the thoracic cavity through the bare area?
a) Subphrenic abscess
b) Cholecystitis
c) Hepatic cyst
d) Portal hypertension
Explanation: In subphrenic abscess, infection can spread between the liver and diaphragm through the bare area due to lack of peritoneal separation. Answer: a) Subphrenic abscess
5. The diaphragm is directly related to which part of the liver?
a) Bare area
b) Quadrate lobe
c) Caudate lobe
d) Gallbladder fossa
Explanation: The diaphragm is in direct contact with the bare area on the posterior surface of the right lobe of the liver without peritoneal covering. Answer: a) Bare area
6. A patient with hepatic abscess extending into the thoracic cavity likely has involvement of which region?
a) Bare area of liver
b) Ligamentum venosum
c) Falciform ligament
d) Hepatogastric ligament
Explanation: Infection can spread through the bare area directly to the diaphragm and thoracic cavity, especially forming a hepatodiaphragmatic abscess. Answer: a) Bare area of liver
7. The inferior boundary of the bare area corresponds to which structure?
a) Right kidney
b) Right suprarenal gland
c) Right colic flexure
d) Caudate lobe
Explanation: The right suprarenal gland lies inferior and medial to the bare area of the liver, separated only by connective tissue. Answer: b) Right suprarenal gland
8. Which vein runs near the bare area of the liver?
a) Right hepatic vein
b) Left hepatic vein
c) Middle hepatic vein
d) Inferior vena cava
Explanation: The inferior vena cava runs in a groove close to the bare area on the posterior surface of the liver, carrying venous drainage from hepatic veins. Answer: d) Inferior vena cava
9. The bare area is located on which lobe of the liver?
a) Left lobe
b) Quadrate lobe
c) Right lobe
d) Caudate lobe
Explanation: The bare area is located on the posterior surface of the right lobe of the liver, where it contacts the diaphragm directly. Answer: c) Right lobe
10. In a liver biopsy through the right intercostal space, which area is avoided due to the absence of peritoneal covering?
a) Bare area
b) Left lobe
c) Falciform ligament region
d) Inferior margin
Explanation: The bare area is avoided in biopsy or aspiration because it lacks peritoneal covering, increasing the risk of bleeding and infection spread. Answer: a) Bare area
Topic: Ureter
Subtopic: Developmental Anomalies of Ureter
Keyword Definitions:
Circumcaval ureter: A rare congenital anomaly where the ureter passes posterior to the inferior vena cava (IVC) and then loops anteriorly to reach the bladder.
Inferior vena cava (IVC): The large vein that returns deoxygenated blood from the lower body to the right atrium of the heart.
Type 1 and Type 2 circumcaval ureter: Type 1 has a “fish-hook” shape; Type 2 has a higher loop with less obstruction.
Embryological cause: Abnormal persistence of the right posterior cardinal vein leads to a circumcaval ureter.
Lead Question (2014): True about circumcaval ureter?
a) Developmental anomaly of ureter
b) Ureter passes in front of IVC from lateral to medial
c) Mostly involves right ureter
d) Type 2 is more common
Explanation: Circumcaval ureter is a developmental anomaly of the right ureter where it passes behind the IVC before turning anteriorly. It results from abnormal persistence of the right posterior cardinal vein during development. Answer: a) Developmental anomaly of ureter
1. Which embryological structure is responsible for circumcaval ureter formation?
a) Right posterior cardinal vein
b) Left subcardinal vein
c) Right vitelline vein
d) Common iliac vein
Explanation: Circumcaval ureter occurs due to abnormal persistence of the right posterior cardinal vein, which forms part of the IVC and traps the ureter behind it. Answer: a) Right posterior cardinal vein
2. Circumcaval ureter is most commonly found on which side?
a) Left side
b) Right side
c) Bilateral
d) Midline
Explanation: The circumcaval ureter almost always involves the right ureter because of its close embryological association with the formation of the inferior vena cava on the right side. Answer: b) Right side
3. Which radiological appearance is characteristic of circumcaval ureter on intravenous pyelography?
a) Fish-hook or S-shaped loop
b) Cobra-head deformity
c) Bird-beak sign
d) String sign
Explanation: The circumcaval ureter gives a classic “fish-hook” or “S-shaped” deformity on IVP due to looping of the ureter behind and around the IVC. Answer: a) Fish-hook or S-shaped loop
4. A 35-year-old male presents with right flank pain and hydronephrosis. Imaging shows the ureter looping behind the IVC. What is the diagnosis?
a) Circumcaval ureter
b) Retroperitoneal fibrosis
c) Horseshoe kidney
d) Duplex ureter
Explanation: Right-sided hydronephrosis due to looping of the ureter behind the IVC confirms the diagnosis of circumcaval ureter. Answer: a) Circumcaval ureter
5. Which type of circumcaval ureter is more common?
a) Type 1
b) Type 2
c) Type 3
d) Both equally
Explanation: Type 1 circumcaval ureter, showing a low loop and significant obstruction, is more common than Type 2, which is high and less obstructive. Answer: a) Type 1
6. In circumcaval ureter, the ureter crosses the IVC from -
a) Posterior to anterior
b) Anterior to posterior
c) Medial to lateral
d) Superior to inferior
Explanation: The ureter passes from posterior to anterior around the IVC, creating a characteristic loop and possible obstruction. Answer: a) Posterior to anterior
7. A CT scan shows right-sided hydronephrosis with the ureter passing posterior to the IVC. Which treatment is appropriate?
a) Ureteroureterostomy anterior to IVC
b) Nephrectomy
c) Stenting only
d) Observation
Explanation: Surgical correction involves ureteroureterostomy, repositioning the ureter anterior to the IVC to relieve obstruction and restore normal flow. Answer: a) Ureteroureterostomy anterior to IVC
8. Which symptom is commonly seen in circumcaval ureter?
a) Right flank pain
b) Hematuria
c) Incontinence
d) Polyuria
Explanation: Right flank pain due to hydronephrosis and ureteral obstruction is the most common presenting symptom of circumcaval ureter. Answer: a) Right flank pain
9. Which diagnostic imaging is most accurate for confirming circumcaval ureter?
a) Contrast-enhanced CT scan
b) Ultrasound
c) Plain X-ray
d) MRI abdomen
Explanation: Contrast-enhanced CT scan clearly shows the course of the ureter passing posterior to the IVC, confirming circumcaval ureter with high accuracy. Answer: a) Contrast-enhanced CT scan
10. A patient with recurrent urinary tract infections and right flank pain is diagnosed with circumcaval ureter. What complication may arise if untreated?
a) Hydronephrosis and renal damage
b) Pyelolithiasis only
c) Bilateral renal failure
d) Bladder carcinoma
Explanation: Persistent obstruction from circumcaval ureter can cause hydronephrosis, infection, and eventual renal parenchymal damage if left untreated. Answer: a) Hydronephrosis and renal damage
Topic: Retroperitoneal Structures
Subtopic: Anatomy of Retroperitoneal Organs
Keyword Definitions:
Retroperitoneal structures: Organs located behind the peritoneum but in front of the posterior abdominal wall, such as kidneys, ureters, pancreas (except tail), duodenum (except first part), and adrenal glands.
Peritoneum: A serous membrane lining the abdominal cavity and covering abdominal organs.
Primary retroperitoneal organs: Organs that develop and remain behind the peritoneum, like kidneys and ureters.
Secondary retroperitoneal organs: Organs initially intraperitoneal but later become retroperitoneal, like duodenum and pancreas.
Lead Question (2014): Which of the following is a retroperitoneal structure?
a) Ileum
b) Jejunum
c) Ureter
d) Appendix
Explanation: The ureter is a primary retroperitoneal structure, meaning it develops and remains behind the peritoneum throughout life. Ileum, jejunum, and appendix are intraperitoneal structures surrounded by peritoneum and suspended by mesentery. Answer: c) Ureter
1. Which of the following organs is secondarily retroperitoneal?
a) Pancreas
b) Kidney
c) Ureter
d) Adrenal gland
Explanation: The pancreas is a secondarily retroperitoneal organ because it initially develops intraperitoneally but becomes fixed to the posterior abdominal wall as the peritoneum fuses during development. Answer: a) Pancreas
2. Which of the following organs is intraperitoneal?
a) Spleen
b) Kidney
c) Ureter
d) Duodenum (2nd part)
Explanation: The spleen is completely covered by peritoneum and attached by ligaments, making it an intraperitoneal organ. The others are retroperitoneal. Answer: a) Spleen
3. Which part of the duodenum is intraperitoneal?
a) First part
b) Second part
c) Third part
d) Fourth part
Explanation: The first part of the duodenum (ampulla) is intraperitoneal and mobile, while the rest (2nd, 3rd, and 4th parts) are retroperitoneal and fixed. Answer: a) First part
4. A patient undergoing surgery for a right renal mass has the peritoneum intact anteriorly. Which space is entered during surgery?
a) Retroperitoneal space
b) Intraperitoneal cavity
c) Subphrenic space
d) Omental bursa
Explanation: The kidney lies in the retroperitoneal space, so accessing it surgically without breaching the peritoneum keeps the dissection within the retroperitoneal space. Answer: a) Retroperitoneal space
5. The pancreas is considered retroperitoneal because -
a) It becomes fixed to posterior wall during development
b) It develops in the posterior wall
c) It is mobile within peritoneal cavity
d) It is surrounded by peritoneum completely
Explanation: The pancreas starts intraperitoneally but becomes secondarily retroperitoneal when the dorsal mesentery fuses with the posterior abdominal wall. Answer: a) It becomes fixed to posterior wall during development
6. A stab injury to the right lumbar region injures a retroperitoneal organ. Which structure is likely affected?
a) Kidney
b) Spleen
c) Stomach
d) Gall bladder
Explanation: The kidney lies in the retroperitoneal space of the lumbar region, making it prone to injury from posterior or lateral penetrating wounds. Answer: a) Kidney
7. Which retroperitoneal organ crosses the psoas major muscle?
a) Ureter
b) Spleen
c) Duodenum (1st part)
d) Jejunum
Explanation: The ureter descends vertically along the anterior surface of the psoas major muscle in the retroperitoneal space, from the renal pelvis to the urinary bladder. Answer: a) Ureter
8. Which statement about retroperitoneal organs is true?
a) They are partially covered by peritoneum
b) They are fully surrounded by peritoneum
c) They hang freely by mesentery
d) They lie inside the peritoneal cavity
Explanation: Retroperitoneal organs are only partially covered by peritoneum on their anterior surface, lying behind the peritoneal cavity. Answer: a) They are partially covered by peritoneum
9. A 50-year-old man with blunt trauma to the abdomen shows retroperitoneal hemorrhage on CT. Which organ is most likely injured?
a) Kidney
b) Spleen
c) Stomach
d) Small intestine
Explanation: Retroperitoneal hemorrhage typically arises from injury to retroperitoneal organs such as kidneys, pancreas, or duodenum. Answer: a) Kidney
10. Which retroperitoneal structure lies anterior to the right psoas major and crosses the pelvic brim?
a) Ureter
b) Appendix
c) Cecum
d) Sigmoid colon
Explanation: The right ureter passes anterior to the psoas major muscle, crosses the pelvic brim near the bifurcation of the common iliac vessels, and continues to the urinary bladder. Answer: a) Ureter
Topic: Liver and Peritoneal Ligaments
Subtopic: Falciform Ligament and Its Contents
Keyword Definitions:
Falciform ligament: A sickle-shaped peritoneal fold connecting the anterior surface of the liver to the anterior abdominal wall and diaphragm.
Ligamentum teres: Fibrous remnant of the fetal umbilical vein found in the free margin of the falciform ligament.
Ligamentum venosum: Fibrous remnant of the fetal ductus venosus connecting the left branch of the portal vein to the inferior vena cava.
Peritoneal ligaments: Double layers of peritoneum connecting organs to each other or to the abdominal wall.
Lead Question (2014): Falciparum ligament contains?
a) Ligamentum venosus
b) Ligamentum teres
c) Linorenal ligament
d) None of the above
Explanation: The falciform ligament contains the ligamentum teres hepatis (round ligament of the liver), which is the fibrosed remnant of the left umbilical vein. It connects the liver to the anterior abdominal wall and diaphragm. Answer: b) Ligamentum teres
1. Ligamentum teres is the remnant of which fetal structure?
a) Umbilical vein
b) Umbilical artery
c) Ductus venosus
d) Portal vein
Explanation: The ligamentum teres is derived from the obliterated left umbilical vein, which carried oxygenated blood from the placenta to the fetus during intrauterine life. Answer: a) Umbilical vein
2. Ligamentum venosum connects -
a) Left branch of portal vein and IVC
b) Right branch of portal vein and hepatic vein
c) Common bile duct and cystic duct
d) Portal vein and hepatic artery
Explanation: The ligamentum venosum is a fibrous cord connecting the left branch of the portal vein to the inferior vena cava, representing the obliterated ductus venosus. Answer: a) Left branch of portal vein and IVC
3. Which of the following structures separates the right and left lobes of the liver on the anterior surface?
a) Falciform ligament
b) Coronary ligament
c) Lesser omentum
d) Round ligament
Explanation: The falciform ligament divides the right and left lobes of the liver anteriorly and anchors the liver to the anterior abdominal wall and diaphragm. Answer: a) Falciform ligament
4. The round ligament of the liver is located in which part of the falciform ligament?
a) Free inferior margin
b) Attached superior margin
c) Middle portion
d) Posterior attachment
Explanation: The ligamentum teres (round ligament) lies in the free inferior margin of the falciform ligament, extending from the umbilicus to the inferior surface of the liver. Answer: a) Free inferior margin
5. Which ligament connects the liver to the anterior abdominal wall?
a) Falciform ligament
b) Coronary ligament
c) Hepatogastric ligament
d) Hepatorenal ligament
Explanation: The falciform ligament attaches the anterior surface of the liver to the anterior abdominal wall and diaphragm, acting as a support structure. Answer: a) Falciform ligament
6. A 45-year-old patient undergoing laparoscopic surgery is found to have a fibrous cord extending from the liver to the umbilicus. It represents:
a) Ligamentum teres
b) Ligamentum venosum
c) Median umbilical ligament
d) Medial umbilical ligament
Explanation: The fibrous cord extending from the liver to the umbilicus is the ligamentum teres, the remnant of the left umbilical vein. Answer: a) Ligamentum teres
7. The ligamentum venosum is situated in relation to which lobe of the liver?
a) Caudate lobe
b) Quadrate lobe
c) Right lobe
d) Left lobe
Explanation: The ligamentum venosum lies in a fissure separating the caudate and left lobes of the liver on the visceral surface. Answer: a) Caudate lobe
8. Which peritoneal ligament connects the spleen to the left kidney?
a) Lienorenal ligament
b) Gastrosplenic ligament
c) Falciform ligament
d) Hepatorenal ligament
Explanation: The lienorenal ligament extends between the spleen and left kidney, containing splenic vessels and the tail of the pancreas. Answer: a) Lienorenal ligament
9. During liver surgery, a surgeon finds a fold between the liver and the anterior abdominal wall. Which structure does it contain?
a) Ligamentum teres
b) Ligamentum venosum
c) Round ligament of uterus
d) Left gastric artery
Explanation: The fold between the liver and anterior abdominal wall is the falciform ligament, and it contains the ligamentum teres in its free margin. Answer: a) Ligamentum teres
10. A newborn with umbilical vein persistence may develop abnormal communication between -
a) Umbilicus and liver
b) Portal vein and IVC
c) Gall bladder and duodenum
d) Spleen and pancreas
Explanation: Persistent umbilical vein may cause abnormal communication between the umbilicus and liver through the falciform ligament, potentially leading to portal hypertension. Answer: a) Umbilicus and liver