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lab manual

By Donald Robertson,2014-11-17 21:53
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lab manual

    Lab Manual of Regional Anatomy

    (for Chinese Students)

    Department of Regional Anatomy & Operative Surgery

    stThe 1 Affiliated Hospital of China Medical University

    NOTICE

    ; Try to find the answers to the questions before practice class. ; Preview the cases before practice class. Don’t pay much attention on

    disease. Try to find corresponding anatomical points in the cases and study

    on them. In the practice class, the cases will be discussed in English. Every

    student will get a score according to their appearance in discussion.

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Assignments:

    Complete the learning module entitled abdominal wall, inguinal region and peritoneal cavity.

Objectives:

    1. Recognize and define the abdominal cavity, peritoneal cavity. Describe the divisions of the anterolateral abdominal wall and abdominal cavity. 2. Describe the general layers of the anterolateral abdominal wall and the relationships of the layers, partitions and compartments one encounters when dissecting from superficial to deep in any particular region. 3. Describe the blood supply and innervations of the anterolateral abdominal wall.

    4. Recognize the anatomical structures related to incisions on anterolateral abdominal wall.

    5. Recognize and define the inguinal region. Describe the general layers of the inguinal region and ligaments in this region.

    6. Recognize and define the inguinal canal and the 4 walls and 2 openings of it.

    7. Recognize and define the inguinal triangle.

Questions:

    1. Try to describe the differences of the abdomen, abdominal cavity and peritoneal cavity.

    2. How to locate the pyloric level? What important structures at this level? 3. Which layers will you meet when you choose a McBurney’s incision?

    How about transrectal incision?

    4. Try to describe the distribution of superficial blood vessels, lymphatic vessels and cutaneous nerves of anterolateral abdominal wall. 5. Try to describe the blood vessels and nerves in the deep layers of anterolateral abdominal wall.

    6. Why do hernias occur in inguinal region?

    7. Try to locate the inguinal canal and describe the four walls and two openings of it.

    8. Where to perform an abdominal puncture? Why?

    9. Which nerves go alongside the spermatic cord? Describe the passage of them. What will happen if they were damaged?

    10. How to distinguish the direct or indirect hernia?

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    11. You should pay attention on which blood vessels and nerves in

    herniorrhaphy. Try to tell their relationships.

    12. Try to describe the divisions of abdominal cavity.

    Case 1

    A twenty-five year-old female presented to the emergency room with a complaint of “colicky” periumbilical pain which had intensified over the last

    -8 hours and started to migrate to the right lower quadrant. The patient 6

    reported some initial nausea, and as the pain had increased, she had an increasing emesis and anorexia. Physical exam demonstrated that the patient had no distension, auscultation revealed hyperactive bowel sounds, and palpation on the McBurney’s Point demonstrated abdominal guarding, rebound

    tenderness, and the muscles of the anterior wall in the right lower quadrant were rigid. In addition, the patient had a low-grade fever, and laboratory tested reveal a rising white blood cell count. The attending determined that the patient had acute appendicitis and then the patient had been taken to the O.R. for an appendectomy.

    The surgeons chose the McBurney’s incision in the right lower quadrant and

    then opened and explored the abdominal cavity. After finding the vermiform appendix, surgeons ligated the mesoappendix, and then cut the appendix successfully. Finally, the abdomen was closed layer by layer.

    2 days after the operation, the patient got a high fever suddenly, with the tenderness at the right upper quadrant. The patient had been diagnosed as liver abscess” according to the report of the ultrasound examination.

    Case 2

    Jone, a 25-year-old man, was carrying furniture out to a moving van in preparation for his family’s move. When Jone strained to pick up a particularly heavy coffee table, he suddenly felt a sharp pain in his right inguinal region. Later, he noticed that a painful bulge had developed in his inguinal region which disappeared when he laid on his back. He did not like going to the doctor, so he ignored the condition. After several months, the pain and the bulge in his groin increased and he finally consented to see a physician. On examination, the physician observed a swelling which began about midway between the anterior superior iliac spine and the midline, progressed medially for about 4 cm, and then turned toward the scrotum. The doctor asked Jone to lie down and saw the swelling disappeared gradually. Then he marked a point

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    which was about 1.5 cm above the midpoint of the inguinal ligament on the skin, and pressed it hardly. At the same time, he told Jone to stand up and hold breath. The swelling couldn’t be seen. Taking the history and physical findings

    into account, the physician made a diagnosis of indirect inguinal hernia. Then the doctor ligated the hernial sac at high lever, and then repaired the hernia. 7 days later, the patient left the hospital with the syndrome never happened again.

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Assignments:

    1. Complete the learning module entitled stomach.

    2. Complete the learning module entitled duodenum.

    3. Complete the learning module entitled jejunum and ileum. 4. Complete the learning module entitled cecum and appendix. 5. Complete the learning module entitled colon.

    Objectives:

    1. Describe the position and relationship of the stomach, duodenum, jejunum, ileum, cecum, appendix and colon.

    2. Master the features of the stomach, duodenum, jejunum, ileum, cecum, appendix and colon.

    3. Master the blood supply, lymphatic drainage and innervations of these organs.

    Questions:

    1. Which structures are adjacent with the posterior wall of stomach? 2. Which arteries supply the stomach? Which ligament are they in? 3. Why the patients with perforation of gastroduodenal ulcer suffer pain in the right lower quadrant, which is confused with acute appendicitis? 4. How to recognize the boundary between the stomach and the duodenum in an operation?

    5. Please describe the blood supply, venous and lymphatic drainage of the stomach.

    6. In theory, why the high selective vagotomy is the ideal method to treat the duodenal ulcer?

    7. Why patient with cancer of pancreas head has the symptoms of jaundice, ascites, edema of lower limbs and intestinal obstruction? 8. Try to describe the position and relationship of pancreas. 9. How to approach the pancreas after opening the peritoneal cavity according to the position and relationship of pancreas? 10. Why the head of pancreas, duodenum and parts of common bile duct have to be removed when the patient with cancer of head or ampulla of pancreas considering the anatomy here.

    11. How to distinguish the large intestine and small intestine in an operation?

    12. How to recognize the duodenojejunal flexure in an operation?

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13. How to distinguish the jejunum and ileum in an operation?

    14. Try to locate the vermiform appendix. How to recognize the appendix

    in an operation? Why suppurative appendicitis can cause the liver

    abscess?

    15. Try to describe the blood supply of the large intestine.

    A 42-year-old business executive was admitted to the hospital after visiting the emergency room complaining of severe epigastric pain and pain over her right shoulder. She had a history of gastric ulcer which had been treated previously with medication, but on questioning, she admitted that she had been so busy recently that she had forgotten to refill her prescription and had not taken her medication in some time. As a result of the history and physical findings, the physician suspected that she was suffering from a perforated gastric ulcer. Gastroscopy was performed which confirmed the diagnosis. When the surgeon examined the patient's stomach during the surgery, she found a small perforation on the posterior aspect of the body of the stomach near the lesser curvature. The surgeon found it necessary to cut the left gastric artery, but at the same time, he also found that the common hepatic artery was from the left gastric artery. After treat it carefully, he had the stomach cut and anastomose the left stomach with the jejunum. Then the surgeon also determined to do vagotomy to reduce the acid secretion. 12 days after the operation, the patient left the hospital and back to work.

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Assignments:

    1. Complete the learning module entitled liver.

    2. Complete the learning module entitled extrahepatic bile ducts. 3. Complete the learning module entitled pancreas.

    4. Complete the learning module entitled spleen.

    5. Complete the learning module entitled portal venous system. Objectives:

    1. Describe the position of the liver.

    2. Master the three porta hepatic.

    3. Recognize the interhepatic ducts: Glisson’s system. Hepatic venous.

    4. Master the eight liver segments and how to divide it?

    5. Recognize the structure of the extrahepatic bile ducts. 6. Recognize the relationship of the gallbladder

    7. Master the Calot’s triangle.

    8. Recognize common bile duct, bile drainage.

    9. Describe the position, relationship and division of pancreas, pancreatic duct, blood supply of pancreas.

    10. Describe the position of spleen and blood supply of spleen. 11. Master the relationship (diaphragmatic surface, visceral surface) of spleen.

    12. Recognize the portal venous system.

    13. Recognize communications between the portal venous system and caval venous system.

    Questions:

    1. How to divide the liver? Why?

    2. What are important structures in the hepatoduodenal ligament? How they are arranged? How to recognize the common bile duct in an operation? 3. What is cystic triangle? What does it mean in clinic?

    4. Why should the middle hepatic vein be reserved in the half hepatectomy, whatever left or right?

    5. What are the extrahepatic bile ducts? Try to describe the divisions and relationships of the common bile duct.

    6. Which ligaments should be cut off in splenectomy? Which blood vessels should be ligated in spenectomy?

    7. What collateral circulations are between portal and caval venous system in portal hypotension? What symptoms will exist?

    8. Try to explain why the abscess is common in the right liver according to

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    the anatomy of portal vein.

    9. try to describe the constitues, relationship, main tributaries and features of

    portal vein.

    A 48-year-old male with a history of alcoholism is brought into the ER with severe epigastric pain and hematemesis. Upon physical examination you find him to be jaundiced and tachycardic with low blood pressure. Other physical findings include spider nevi (hemangiomas) on the cheeks, neck, upper extremities, and torso; ascites; splenomegaly; and tortuous dilated veins radiating from the umbilicus (caput medusae). The patient also tells you that he often has bloody stools, which prompts you to perform a rectal examination during which you find internal hemorrhoids. After completing your work-up, you correctly make a diagnosis of alcoholic cirrhosis of the liver. Then according to the patients situation, you determine to create a shunt between left renal and splenic vein to reduce the portal hypertension.

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Assignments:

    1. Complete the learning module entitled posterior abdominal region. 2. Complete the learning module entitled kidneys and suprarenal glands. 3. Complete the learning module entitled abdominal aorta.

    4. Complete the learning module entitled inferior vena cava. Objectives:

    1. Describe the boundaries of posterior abdominal region.

    2. Describe the position, neighbors, blood supply and the captures of the kidneys. Define the “renal angle”, “renal hilum”, “renal pedicle”, “renal vascular segments”.

    3. Describe the position, neighbors, blood supply of the suprarenal glands. 4. Describe the course, neighbors, blood supply of the ureters. 5. Describe the course, main branches of the abdominal aorta. 6. Describe the course, main branches of the inferior vena cava. Questions:

    1. Try to describe the points in nephrectomhy according to the position and relationship of kidney.

    2. How are the structures in renal pedicle arranged? What are the characters of renal blood vessels? What are their common variations and clinical meanings?

    3. Try to describe the differences between the left and right renal veins. 4. How to divide the kidney into segments? Why? What are the clinical meanings of it?

    5. What are the characters and clinical meanings of renal capsules? 6. Why does the pain radiate to the inguinal region in pararenal abscess according the relationship of kidney? Why does the hip flex and adduct? 7. Why is the left varicocele common according to the regional anatomic view?

    8. Try to describe the similarities and differences between the abdominal arterial supply and venous drainage.

    During a football game between two arch rivals, the wide receiver of one team was involved in a pass pattern across the middle of the field. The quarterback was being rushed and threw the pass high. The wide receiver leapt to catch the pass and just as he did so he was "sandwiched" between the cornerback and free safety. The two defensive players hit the receiver just below the ribs on the right side, one in front and one from

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