Nerve supply of Appendix:

- T10 supplies the peritoneal coverings of the appendix, so reffered appendicular pain is felt at the umbilicus.

#Surgery

Descent of the Testes:

- At the 6th month of the intrauterine life, they lie at the internal inguinal rings(common site for undescended testis).

- At 7th month they go through the inguinal canal.

-At 8th month they lie at the external inguinal rings or at the neck of scrotum.

-They descend to scrotum just before birth.

#Surgery

Remember:


-Malignant transformation in undescended testis is 20 times more common than normally descended testis.
-It is higher in abdominal than in inguinally located testis.
-Seminoma is the most common malignancy in undescended testis.
-The testis which has normally descended on other side testis (in case of unilateral undescended testis), is also more prone for malignant transformation than normal individual.

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What is the commonest plane of lipoma?

-Subcutaneous (between the deep fascia and skin).

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What is slip sign?

-If the edge of the lump is pressed, the swelling slips from beneath the finger.
-This can be easily demonstrated in the case of a subcutaneous lipoma and it is said to be pathognomonic.

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Associated Anomalies with undescended testis:

-Epididymal anomalies and patent processus vaginalis upto 90%.

-Renal Anomalies in10% cases (Renal hypoplasia, agenesis,horseshoe kidney, PUJ obstruction)

-Hypospadias.

#Surgery

-In most pediatric centers, orchiopexy for unilateral UDT is done when patient have reached about 6 months of age.

-This early intervention may permit post-natal germ cell development to proceed normally.

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Differences between torsion testis and acute epididymo-orchitis.

#Surgery

To differentiate between testicular torsion and acute epididymo-orchitis:

-If pain is relieved by scrotal elevation, it is acute epididymo-orchitis.

-If pain is increased by scrotal elevation, then it's torsion. "Prehn's sign".


(Prehn’s sign):
Acute epididymo-orchitis—elevation of the scrotum for one hour, relieves the pain of acute epididymo-orchitis but aggravates in case of torsion testis.

#Surgery

-Portal vein consists of SMV and splenic vein.

-It begins behind the head of pancreas and in front of IVC, ends at porta
-hepatis.
-About 3inch length.
-About 0.8-1.2 cm diameter.


Direct tributaries:
Portal vein drains the whole. intra-abdominal alimentary tract and anterior abdominal wall:

- Left and right gastric veins.
-Small pancreatic & duodenal veins.
-Para-umbilical veins into left branch of portal vein.
- Splenic vein.
-SMV.
-Cystic vein.

Pressure: 10 - 20 cmH2O (7 - 11 mmHg).

#Surgery

Murphy's sign.
This is the classical method.

#Surgery

Methods to elicit MURPHY’S SIGN:

1)Patient in upright/sitting  position, the right hand of the examiner curls  up under the  right  costal  margin (or extended fingers  with moderate pressure) of the patient at the tip of the ninth rib and patient is requested to  take  a deep breath. If the gallbladder is inflamed, the  patient will experience  pain (winces with  pain and catch  the breath) as the gallbladder descends and contacts the palpating  hand.

2)The extended and abducted  left thumb is placed  in right subcostal region without pressing deep; the patient is requested to take a deep  breath.This is  elicited  in lying down supine position. Called Moynihan’s modification of eliciting Murphy’s sign.

3)Identify the right Midclavicular line then descend to the right costal margin and put your one or two fingers there, as that site is the anatomical position of GB fundus.

4)From linea semilunaris and ascend to right costal margin. This isn't good in obese patients.

5)A line from left ASIS to the umblicus and other from the umblicus to the right costal margin tip of 9th costal cartilage. It's called Grey Turner line.

6)From the RIF and ascend upward, this facilitates the detection if there is also hydropes of GB. د. رمزي

7)Sonographic Murphy’s sign  is eliciting same sign using sonographic transducer. It is more sensitive and more accurate.

The sign is described by John murphy, a professor of surgery chicago USA.

•Murphy's Triad:
-It is associated with acute appendicitis, a medical emergency which presents with:
1-Lower right abdominal pain
2-Nausea and vomiting
3-Fever.

•Murphy's sign:
-It is useful for differentiating pain in the right upper quadrant.
-Typically, it is positive in acute cholecystitis, but negative in choledocholithiasis, pyelonephritis, and ascending cholangitis.

•Murphy's test
-It is a costovertebral angle (CVA) tenderness that results from touching the region inside of the costovertebral angle.

•Murphy's drip:
-It is a rectal infusion apparatus to administer the medical procedure of proctoclysis, also known as rectoclysis.

#Surgery

The right supraclavicular node is called Scalene node.

#Surgery

Remember:

Development of the Thyroid Gland:
-The thyroid gland begins to develop during the third week as an entodermal thickening in the midline of the floor of the pharynx between the tuberculum impar and the copula.

-By the seventh week, it reaches its final position in relation to the larynx and trachea.

-The thyroid gland develops from a median down growth of a column of cells from the pharyngeal floor between the first and second pharyngeal pouches (subsequently marked by the foramen caecum of the tongue).

#Surgery

What is the bone that has not articulation with any bone?

-The hyoid bone is a mobile single bone found in the midline of the neck below the mandible and abides the larynx.
-It does not articulate with any other bones.

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