Essay - Handwritten Prose. 10 Points.

True/False. 0.5 Point Each.

1. The arcuate line is where all aponeuroses become deep to the rectus abdominis.
2. Inferior to the umbilicus on the anterior abdominal wall, the tela subcutanea is composed of a fatty layer named Scarpa's fascia and a membranous layer named Camper's fascia.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: A 30 year-old male presents with a swelling in the groin region. Through examination and palpation of the scrotum you determine the patient has an indirect inguinal hernia. Indirect inguinal hernias pass into a patent processus vaginalis. Abdominal viscera may move through the processus vaginalis into the scrotum. Describe the pathway of an indirect inguinal hernia and its relation to testis development. Review the anatomy of the spermatic cord, including layers and contents (nerves, blood vessels, lymphatic vessels, embryonic remnants, and reproductive structures).
• Essay Question #2: A 64-year-old male reports of a painful swelling in the scrotum. Upon examination you notice a “bag of worms” appearance of the scrotum, characteristic of a varicocele. A varicocele occurs due to distention of the pampiniform venous plexus. Describe the layers and contents of the scrotum, including nerves, blood vessels, lymphatic vessels, and reproductive structures.

True/False. 0.5 Point Each.

1. The ilioinguinal nerve is a content of the inguinal anal, but not of the spermatic cord.
2. The conjoint tendon is formed by the aponeuroses of the internal abdominal oblique and external abdominal oblique and gets displaced medially if a direct inguinal hernia occurs.
3. Lymph from the testis and scrotum both drain to superficial inguinal lymph nodes.
4. External spermatic fascia provides a layer to the spermatic cord at the superficial inguinal ring and is derived from external abdominal oblique.
5. The right testicular vein drains into the right renal vein, while the left testicular vein drains into the left renal vein.
6. The round ligament of the uterus and the ovarian ligament are remnants of the gubernaculum in the female.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: A 64-year-old male with peptic ulcer disease reports to the ED, after an ulcer eroded the posterior wall of his stomach. Acidic gastric contents spilled into the lesser sac. Define the boundaries of the lesser sac. Account for dull pain followed by sharp pain when the posterior stomach wall perforates. Discuss the pathway of spilled stomach contents that pass from the lesser sac into the greater sac into the greater sac, and the location of these contents with respect to body position.

True/False. 0.5 Point Each.

1. Similar to the pleural and pericardial cavities, the peritoneal cavity is lined by mesothelium.
2. The visceral peritoneum is associated with sharp, localized pain, whereas the parietal peritoneum is associated with dull, poorly localized pain.
3. Mesentery marks a transition between parietal and visceral peritoneum that suspends the gut tube and provides a route for neurovasculature to retroperitoneal organs.
4. The epiploic (a.k.a. omental) foramen of Winslow is the communication between the greater sac and lesser sac.
5. The inferior vena cava is the posterior boundary of the epiploic foramen.
6. The quadrate lobe is the superior boundary of the epiploic foramen.
7. The hepatoduodenal ligament is the anterior boundary of the epiploic foramen.
8. The duodenal cap (first part of the duodenum) is the inferior boundary of the epiploic foramen.
9. The contents of the portal triad are contained within the hepatogastric ligament.
10. The greater omentum has attachments at the greater curvature of the stomach and the transverse colon.
11. The greater omentum has three named portions: the gastrocolic ligament, the gastrolienal ligament, and the gastrophrenic ligament.
12. The ostia of the uterine tubes represent two potential communications with the peritoneal cavity.
13. The falciform ligament is an embryological remnant of ventral mesentery that connects the liver to the anterior abdominal wall.
14. The round ligament of the liver (ligamentum teres hepatis) is a fibrous remnant of the left umbilical vein and is located in the inferior free edge the falciform ligament.
15. The rectovesical pouch is the inferior extent of the peritoneal cavity in females.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: During the surgical repair of a perforated duodenal ulcer in a 50-year old male patient, the gastroduodenal artery is ligated prior to it giving off its first branch. Discuss the arteries that branch from the gastroduodenal artery, which organ(s) they supply (be specific), and explain any pertinent anastomotic relationships in your answer.

• Essay Question #2: A 75-year old female with a previous history of lymphoma and a gastric mass presents with multiple liver masses. Examination and other tests provide evidence of liver cancer which is causing portal hypertension. Discuss the anatomical position of the liver, including all liver supportive ligaments and their attachment sites, and explain if any ligaments have an embryonic remnant. Please also include the ligaments that form the lesser omentum.

True/False. 0.5 Point Each.

1. The superior mesenteric artery syndrome is known to constrict the third (transverse) portion of the duodenum, which can cause bilious vomiting and dehydration.
2. The stomach and the tail of the pancreas are intraperitoneal, but the superior portion of the duodenum is secondarily retroperitoneal.
3. The falciform ligament separates the subphrenic spaces into right and left recesses and extends between the liver and the anterior abdominal wall.
4. The Magenstrasse (or stomach road) is an important route for gastric emptying and contains gastric rugae.
5. Short gastric arteries travel through the gastrolienal ligament to supply the fundus of the stomach.
6. Meckel’s Diverticulum is a true diverticulum because it contains all three layers of the bowel.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: Acute appendicitis is caused by an obstruction of the lumen and can lead to suppuration, infarction, and necrosis. Discuss the structure, support, relationships, innervation, vasculature, and lymphatics to the appendix. Account for the referred pain to the paraumbilical region.
• Essay Question #2: Hirschsprung’s is characterized by the lack of parasympathetic innervation resulting in the inability to move stool through the intestine. Discuss the anatomy of the left colic flexure. Include structure, support, relationships, innervation, vasculature, and lymphatics.

True/False. 0.5 Point Each.

1. The Celiac trunk provides blood supply to the proximal 2/3’s of the transverse colon.
2. The Marginal Artery (of Drummond) provides an anastomosis between the midgut and hindgut.

Essay - Handwritten Prose. 10 Points.

• Essay Question: A 36-year-old female comes to your office complaining of frequent bouts of dysphagia (difficulty swallowing) and heartburn. On physical exam, you auscultate active bowel sounds in the thorax. A barium swallow is performed. In addition to evidence of gastroesophageal reflux, the cardia and fundus of the stomach are noted to be in the left hemithorax. Discuss the anatomy of the diaphragm. Be sure to mention the named part of the diaphragm that the cardia and fundus of the stomach may have herniated through to enter the left hemithorax.
• Essay Question: A 50-year-old male complains of left testicular pain as well as frequent nausea and vomiting. You collect a urine sample, and the subsequent urine test reveals proteinuria. The patient is diagnosed with renal vein entrapment syndrome, or “nutcracker syndrome.” Discuss the anatomy of the left kidney, including the arterial supply to and venous drainage of the organ.

True/False. 0.5 Point Each.

1. The sympathetic trunk enters the abdomen by passing posterior to the lateral arcuate ligament.
2. The anterior and posterior vagal trunks enter the abdomen with the esophagus by traveling through the esophageal hiatus, which is located within the right crus of the diaphragm.
3. The lumbosacral trunk is formed by a contribution from the L5 anterior ramus and the entirety of the S1 anterior ramus.
4. The iliohypogastric and ilioinguinal nerves may emerge from the lateral border of the psoas major muscle as a common trunk.
5. The lumbar plexus lies within the quadratus lumborum muscle.
6. The lumbar splanchnic nerves contain postganglionic sympathetic fibers that are traveling to the hindgut.
7. The posterior surface of each kidney is in contact with the psoas major, quadratus lumborum, and internal oblique muscles (from medial to lateral).
8. The kidneys, suprarenal glands, and pararenal fat are located between the anterior and posterior layers of renal fascia.
9. The ureters travel anterior to the testicular vessels but posterior to the ovarian vessels.
10. The ureters are naturally constricted at three locations: the uretopelvic junction, the pelvic brim, and the bladder wall.
11. The right and left suprarenal veins drain into the right and left renal artery, respectively.
12. Postganglionic sympathetic neurons synapse on medullary chromaffin cells of the suprarenal gland.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: At a 6-week postnatal checkup, a 29-year-old female speaks to her family care physician about highly localized pressure and pain within the anal canal. She mentions that since giving birth she has also experienced rectal bleeding during defecation and excessive straining to pass stool. Upon visual examination and a digital rectal exam, the physician finds large internal and external hemorrhoids. Describe the anatomy, histology, innervation, vascular supply, and lymphatics of the anal canal. How do these contribute to defecation, continence, and hemorrhoids?
• Essay Question #2: A 60-year-old male presents to the emergency department complaining of incontinence. He explains difficulty urinating, which is painful and burning in sensation when successful. He also explains difficulty defecating, with stool appearing thin and ribbon-like. Upon digital exam of the rectum, you note the prostate is donut-shaped and enlarged. Describe the anatomy of the prostate including vascular supply, innervation, relationships, and lymphatics. How do these contribute to the metastasis of prostatic carcinoma?

True/False. 0.5 Point Each.

1. The prostates lymphatic vasculature drains to the superficial inguinal nodes and internal iliac nodes.
2. Rupture of the bulbar urethra would cause extravasation of urine that perforates Bucks fascia.
3. Sympathetic innervation to the neck of the bladder causes contraction in males and females.
4. The distal ureters lie immediately posterior to the ovaries when passing anterior to the internal iliac vessels.
5. The middle transverse fold of the rectum is on the right side and is just inferior to the peritoneal reflection.The

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: Rectal cancers may invade the presacral space. Discuss the anatomy (structure, vasculature, lymphatic drainages, nerve supply, relationships, and clinical significant) of the presacral space.
• Essay Question #2: Culdocentesis is a procedure for withdrawing fluids from the rectouterine pouch. Discuss the anatomy (structure, vasculature, lymphatic drainages, nerve supply, relationships, and clinical significant) of the rectouterine pouch.

True/False. 0.5 Point Each.

1. The retropubic space provides surgical access to the pubovesical ligaments without the need to enter the peritoneal cavity.
2. The vesicouterine pouch is the most inferior extent of the peritoneal cavity.
3. The piriformis muscle is located, in part, within the presacral space.
4. The anterior sacral foramina provide communication between the spinal canal and the presacral space.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: A 57 year-old female patient comes to your clinic with a perianal abscess that requires surgical drainage. Explain the boundaries of the ischioanal fossa to describe the location where the infection would spread. Describe the neurovascular structures which could be compromised.
• Essay Question #2: A 24 year-old male complains of groin pain and paresthesia after a period of extensive bicycle riding. Discuss the anatomy of the superficial and deep perineal pouches. Include in your answer musculature, neurovasculature, and structures of external genitalia which could be affected.

True/False. 0.5 Point Each.

1. The boundaries of the urogenital triangle are defined by the attachments of the perineal membrane.
2. An infection within the ischioanal fossa would not enter the deep perineal pouch.
3. The posterior free edge of the UG diaphragm serves as an attachment point for Buck’s fascia.
4. The perineal body is a site of attachment for both the superficial transverse perineal muscle and the bulbospongiosus muscle.
5. The greater vestibular glands are located inferior to the bulb of the vestibule in the male superficial perineal pouch.
6. The external urethral sphincter in both males and females is found in the superficial perineal pouch.

Essay - Handwritten Prose. 10 Points.

• Essay Question 1: When placing a catheter, the angle at the membranous urethra can result in a tear of the inferior fascia of the urogenital and the extravasation of urine from the deep pouch to the superficial perineal pouch. Discuss the boundaries of Scarpa's fascia and with respect to containment of urine in the male.
• Essay Question 2: The mnemonic Point and Shoot is a simplified version of the autonomic control of sexual function. Describe innervation (autonomic and somatic) to relevant pelvic viscera and musculature.

True/False. 0.5 Point Each.

1. The seminal vesicle is lateral the to ampulla of the vas deferens.
2. The bulb of the vestibule contributes to the clitoris.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: During childbirth, a 29-year-old female tears her puborectalis muscle. Describe the anatomy of the puborectalis muscle including relationships, innervation, and function. Describe the role of puborectalis in defecation and fecal continence.
• Essay Question #2: A 40-year-old woman who has given birth to 4 kids comes to the clinic reporting of urine dribbling during coughing, sneezing, and lifting. You diagnose her with urinary stress incontinence and perform surgery to elevate the pubovesical ligament. What space would allow access to the pubovesical ligament for this procedure? Describe the anatomy of the pubovesical ligament and the other ligaments of the female pelvic floor.

True/False. 0.5 Point Each.

1. The pelvic cavity is contained within the true pelvis.
2. The subpubic angle in females is wider than in males.
3. Contraction of the puborectalis muscle straightens the rectum and anal canal, allowing for defecation.
4. The levator ani muscle is composed of 3 muscles: puborectails, pubococcygeus, and ischiococcygeus.
5. The urogenital hiatus allows the urethra and vagina to exit the pelvic floor in females.
6. The tendinous arch of levator ani is a thickening of obturator fascia.
7. The transverse cervical (cardinal or Mackenrodt's) ligament transmits the uterine artery and vein.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: A 32-year-old woman with endometriosis and chronic pelvic pain has an elective presacral neurectomy. Three weeks later, she reports to your clinic with complications of constipation and urinary retention. Describe the autonomic innervation of the pelvic viscera, including three routes of sympathetic fibers and one route of parasympathetic fibers. Describe the rationale of a presacral neurectomy and how this procedure may perturb function of the pelvic viscera.
• Essay Question #2: A 71-year-old male reports to PSCOM’s Heart and Vascular Institute with an aneurysm of his internal iliac artery with high risk of rupture. Describe the typical branching pattern of the internal iliac artery, including its anterior and posterior divisions. Describe anatomical landmarks within the pelvic cavity that will help you to identify branches. Account for potential variation of the internal iliac artery.

True/False. 0.5 Point Each.

1. Typically, the iliolumbar artery, the lateral sacral arteries, and the inferior gluteal artery are branches of the posterior division of the internal iliac artery.
2. Lateral sacral arteries can be traced into the anterior sacral foramina where they supply sacral ventral rami and spinal meninges.
3. The umbilical artery has a patent portion that supplies superior vesical arteries before obliterating to become the medial umbilical ligament.
4. In the absence of an obturator artery from the internal iliac artery, a branch from the external iliac artery (or inferior epigastric artery) that travels through the obturator canal should be referred to as an “aberrant obturator artery.”
5. Typically, both the inferior gluteal artery and internal pudendal arteries are terminal branches of the posterior division of the internal iliac artery.
6. The median sacral artery typically arises from the anterior aspect the aorta and is applied to the midline of the sacrum bone in the presacral space.
7. Alcock’s canal is bounded laterally by the obturator internus muscle and medially by obturator fascia.
8. The lumbosacral trunk receives contributions from ventral rami L3 and L4, as it passes anterior to the ala of the sacrum.
9. The superior hypogastric plexus contains sympathetic fibers as well as visceral afferent fibers.
10. The right and left hypogastric nerves represent a communication between the superior and inferior hypogastric plexuses.
11. Pelvic splanchnic nerves arise from ventral rami S1-S3 and convey preganglionic parasympathetic fibers to the inferior hypogastric plexus.
12. Sacral splanchnic nerves convey preganglionic sympathetic fibers from the sacral sympathetic ganglia to the inferior hypogastric plexus.
13. Regarding autonomic information, the superior hypogastric plexus contains only sympathetic fibers, whereas the inferior hypogastric plexus contains a mix of sympathetic and parasympathetic information.
14. In the pelvic cavity, gray rami communicantes convey postganglionic sympathetic fibers from the sacral sympathetic trunk ganglia to the sacral ventral rami.
15. The “pelvic pain line” corresponds to the inferior extent of the parietal peritoneum.
16. As a general rule, visceral afferent fibers superior to the pelvic pain line travel toward the CNS via the superior hypogastric plexus, while visceral afferent fibers inferior to the pelvic pain line travel either via pelvic splanchnic or pudendal nerve pathways.

Essay - Handwritten Prose. 10 Points.

• Essay Question #1: Deseases of the uterus and adnexa are commonly observed in the dissection laboratory. Discuss the anatomy (structure, vasculature, lymphatic drainages, nerve supply, relationships, and clinical significant) of the uterus, uterine tube, and ovary.

True/False. 0.5 Point Each.

1. Lymphatic drainage from the fundus of the uterus is expected to be primarily toward upper lumber nodes.
2. Lymphatic drainage from the inferior pole of the ovary is expected to be primarily toward superficial inguinal nodes.
3. Lymphatic drainage from the cervix is expected to be primarily toward internal inguinal nodes.

Essay - Handwritten Prose. 10 Points.

• Essay Question #2: Pelvic fractures may damage the S2-4 spinal nerves. Discuss the nerve supply to the urinary bladder. Include accounts for the cord, autonomous, and atonic bladder conditions.

True/False. 0.5 Point Each.

1. The atonic bladder has intact motor efferent (parasympathetic) nerve supply and damaged visceral afferent (sensory) nerve supply.
2. The cord bladder has intact spinal cord reflexes that are mediated at cord levels S2-4.
3. The autonomous bladder does not have extrinsic nervous supply.
4. The atonic bladder may distend to the point of bursting.

• Laboratory Examination: Monday, September 21, 2020: 1:00 - 2:15 (1 hr 15 min = 75 Min, 90 Sec per Identification)
• The laboratory examination will be worth 100 points.
  • 50 Identifications
  • 90 Seconds per Identification
  • Clipboards and answer sheet will be provided (bring pencil)
  • Touching is acceptable pending instructions on the answer answer card.
  • Dissection is not allowed. We want the question to be the same for everyone.
• Written Examination: Monday, September 21, 2020: 2:30 - 5:30 (3 hrs = 180 Min, 18 min per question for 10 questions)
• The written examination will be worth 100 points.
  • 10 pts of radiography identification (Dr. French). Radiographs are on website.
  • 10 pts True/False (Dr. Evey and Teaching Assistants). True/False examples are on website.
  • 80 pts of written essay. (Dr. Evey and Teaching Assistants). Essay question pool is on website.
  • Essay answers shall be handwritten in prose.
• Grading
  • The written examination will not be graded according to keywords. A demonstration of understanding is requested.
  • Your essay answers should be written, not as recall of rote memorization, but as a stand-alone communication to a colleague or patient.