SFA 271 - Advanced Surgical Anatomy

Credits: 6

     A.          Describe the layers of muscles of the thoracic wall.

     B.          Identify the anatomical considerations during an intercostal thoracotomy incision and closure (i.e., location of nervous and vascular structure.)

     C.          Compare the sternocostal projections of the pleurae and lungs, and explain the clinical significance of the pleural recesses/sinuses not filled by lung.

     D.          Describe the anatomical structure of the mediastinum.

     E.          Explain where one would expect to find most aspirated foreign bodies and why.

     F.          Compare the size and structure of the right and left lungs, and compare the relationships of vascular, bronchial, and nervous elements at their hila.

     G.         Describe the changes that occur in the lining epithelium from the trachea to the lung alveoli.

     H.         Explain why the arterial element is clamped first during anatomic lung resections.

     I.           Following a lung resection, explain why the pleural cavity is usually flooded with saline before closing the chest and whether the temperature of the saline matters.

     J.          List the different types of bronchogenic carcinomas.

     K.         Discuss metastasis to the lung.

     L.         Describe the anatomical, histological, vascular, and neurological structures of the heart.

     M.        Describe the conduction system of the heart.

     N.         List the risk factors for coronary artery disease (CAD) and define "unstable" angina.

     O.         Describe the changes that occur in the histologic and gross appearance of the heart after MI, and relate these to common complications of MI.

     P.          Differentiate the signs and symptoms of right and left congestive heart failure.

     Q.         Explain the adult cardiac procedures and the pathologies leading up to them.

     R.         Explain the difference between valvular stenosis and valvular insufficiency/regurgitation.

     S.          Discuss the embryologic origin, location, and potential complications of congenital cardiac anomalies.

     T.          Explain the clinical significance of the esophageal veins during liver disease, such as cirrhosis.

     U.         Describe the Azygos vein system.

     V.          Describe the location and significance of the thoracic duct.

     W.         Describe the location of the openings in the diaphragm and describe the structures and function of those structure passes.

     X.          Describe the procedures associated with pediatric cardiac procedures.

 2.    Relate the anatomical structures of the abdomen to common surgical procedures.

     A.          Describe the gross anatomy, vasculature, embryology, histology, and neurology of the GI system.

     B.          Relate the two layers of the subcutaneous connective tissue below the umbilicus to the placement of sutures.

     C.          Name an incision that may encounter the Pyramidalis muscle.

     D.          Explain how the "peritoneal cavity" differs from the "abdominal cavity."

     E.          Name the structures that form the median, medial, and lateral umbilical folds and identify the surgical procedure during which they are most apt to be seen.

     F.           Discuss the various types of peptic ulcers, including the risk of undergoing malignant changes.

     G.          Differentiate Billroth I and Billroth II procedures and explain "dumping syndrome."

     H.          Describe the major manifestations and usual treatment of pyloric stenosis.

     I.            Explain the surgical interest in the duodenal "bulb"/"cap."

     J.           Discuss the possible results of traumatic injury to the pancreas.

     K.           Define a Whipple procedure.

     L.           Discuss common mechanisms of splenic injury and the possible complications of splenic trauma and surgery.

     M.          Explain why the liver is easily lacerated or ruptured with blunt trauma and what instrumentation should be available during liver trauma surgery.

     N.          Discuss the histologic and gross characteristics and the common clinical manifestations of cirrhosis.

     O.         Discuss the most common cause of malignancy in the liver.

     P.          Diagram the "triangle of Calot" and explain its importance during cholecystectomy.

     Q.         Discuss the various types of gallbladder disease, including their etiology, symptomatology, and major diagnostic tests.

     R.          Explain how the pattern of blood supply to the jejunoileum affects vascular occlusions and surgical resections of the small bowel.

     S.          Discuss intussusception, Crohn's disease, ulcerative colitis, Irritable Bowel Syndrome, polyps, and diverticulosis.

     T.          Describe how a surgeon usually locates the appendix and explain the clinical significance of the pattern of blood supply to the appendix.

     U.         Differentiate between “external hemorrhoids” and “internal hemorrhoids” and identify which are painful and why.

3.    Demonstrate understanding of the anatomical features of the post abdominal wall and kidneys in relation to common surgical procedures.

     A.          Describe the gross anatomy of the posterior abdominal wall, including the vasculature

     B.          Differentiate a “true” aneurysm, a “false” aneurysm, and a “dissecting” aneurysm or “dissection.”

     C.          Discuss the pre- and post-operative aspects of an abdominal aortic aneurysm.

     D.          Explain why how long the Aorta can be cross-clamped depends on the level at which it is clamped and why the aneurysm is not dissected free from the Inferior Vena Cava.

     E.          List the signs and symptoms of an expanding or ruptured AAA and differentiate the operative mortality.

     F.          Describe the changing relationships between the Inferior Vena Cava and the Aorta in their courses through the abdomen, and how the tributary pattern of the Inferior Vena Cava differs from the arterial pattern of the Aorta.

     G.         Discuss the indications for inserting an intracaval filtering device.

     H.         Describe the gross anatomy, physiology, histology, neurology, embryology, and vasculature of the kidney and ureter.

     I.           Discuss the etiologies of glomerulonephritis and pyelonephritis, and differentiate acute and chronic renal failure.

     J.          Define “shock kidney.”

     K.          Describe the anatomical structures that must be protected during the usual surgical approach for nephrectomy.

     L.          Identify the most common cause of kidney trauma and the most common cause of ureteral injury.

     M.         Compare the various methods of “angio-access.”

     N.          Define Continuous Ambulatory Peritoneal Dialysis (CAPD) and list its advantages over hemodialysis.

     O.          Explain the usual placement of a transplanted kidney.

 4.    Demonstrate understand of the anatomical features of the male and female pelvis in relation to surgical procedures.

     A.          Describe the relationship between the pelvic inlet and the pelvic outlet.

     B.          List the structures that define the diamond-shaped boundaries and the floor of the perineum.

     C.          Define the internal and external female pelvis: gross anatomy, histology, neurology, vasculature, all organs, and their functions.

     D.          Define the internal and eternal male pelvis: gross anatomy, histology, neurology, vasculature, all organs, and their functions.

     E.          Describe the process of micturition and the autonomic influences.

     F.          Differentiate hypospadias and epispadias and define Chorde

     G.         State the danger inherent in an ascending URI.

     H.         Differentiate the characteristics of testicular and prostatic cancers, and discuss how each is treated.

     I.           Define BPH and discuss theories about its etiology.

     J.          List the indications for the four surgical methods of prostatectomy and discuss possible treatment alternatives.

     K.          Define and describe the dangers of cryptorchidism and testicular torsion.

     L.          Discuss the common causes and treatments of impotency.

     M.         Compare the female perineum with that of the male.

     N.          Discuss the purposes and locations of the performance of an episiotomy.

     O.          Explain the location of referred pain from the ovary and during pregnancy.

     P.           Identify the most common venereal infections and define PID.

     Q.          Explain what a Pap smear is looking for, and define CIN grading.

     R.          Compare cervical and uterine cancers.

     S.          Define endometriosis, compare the theories of its etiology, and describe the sequelae.

     T.           Explain how the character of a fibroid changes with varying estrogen levels.

     U.          Identify what types of ovarian tumors are most common in young women and discuss the usually prognosis for ovarian cystadenocarcinoma.

     V.          List the indications for Cesarean section delivery.

     W.         Compare and contrast the location, character, and predisposing factors of direct and indirect inguinal hernias.

     X.          Compare a laparoscopic hernia repair with an open surgical repair.

     Y.           Discuss where femoral hernias occur and the possible consequences.

     Z.           Define “Richter’s hernia”, “Spigelian hernia”, and “diastasis recti.”

     AA.        Discuss indications for surgical interventions of pathology relating to the abdomen.

5.    Describe the normal anatomy and function of the structure of the lower extremity, common injuries to the lower extremity, and common surgical interventions.

     A.          Describe the normal gross osteology, arthrology, neurology, and vasculature of the anterior, medial, lateral, and posterior thigh.

     B.          Describe the “cruciate anastomosis” of blood vessels on the lateral side of the greater trochanter.

     C.          Describe the common surgical approach for insertion of a hip screw/pin/nail.

     D.          Identify the most common indications for a total hip replacement, and describe the surgical approach when a patient is in lateral position.

     E.          Identify the structures that compensate for the inherent instability of the knee joint.

     F.          Explain why a meniscal tear usually does not heal.

     G.         Describe the mechanism for “locking” the knee in extension and “unlocking” it for flexion.

     H.         Define Baker’s cyst.

     I.           List the indications for a total knee arthroplasty and compare the function of a knee prosthesis with that of a total hip prosthesis.

     J.          Explain why tibial fractures can be problematic.

     K.         Define “intermittent claudication” and explain why it occurs.

     L.          Compare the techniques of AK and BK amputations.

     M.         List the muscles of the anterior/posterior compartment of the leg, their actions, innervation, and blood supply.

     N.         Compare the Greater and Lesser Saphenous veins, including origin, drainage, and companion structures.

     O.         Discuss the causes, possible complications, and indications for surgical treatment of varicosed veins of the leg.

     P.          Explain why the Common Peroneal nerve is easily injured and discuss the possible results of injury.

     Q.         List the structures contained in the four compartments beneath the flexor retinaculum at the medial malleolus.

     R.          Identify the bones and ligaments of the ankle and the foot and their functions; discuss where most ankle sprains occur and why, and explain why surgery may be indicated and what the procedure does.

     S.          Compare the long tendons and intrinsic muscles of the foot to those of the hand.

     T.           Compare the arterial supply and nerve distribution of the foot to that of the hand.

     U.          Define Pott’s fracture, “clubfoot”, Morton’s neuroma, and “flat feet.”

     V.           Differentiate an ankle arthrodesis from a triple arthrodesis.

     W.          Define a bunion and compare the most common types of surgical treatment.

 6.    Discuss the significance of structural components of the skull and brain in intracranial pathologies.

     A.          Name the cranial and facial bones and the main suture lines of the calvarium.

     B.          List and explain different types of congenital cranial deformities.

     C.          Relate a craniotomy approach and closure to the layers of the scalp and the special character of skull bone.

     D.         Describe the brain’s meningeal coverings, dural duplications and cranial venous sinuses.

     E.          Explain the relationship of the ventricular system to diagnostic imaging, hydrocephalus and shunting surgery.

     F.          Locate the major areas and features of the brain and describe the function(s) associated with each.

     G.         List the general principles concerning the organization of cranial nerve nuclei in the brainstem.

     H.         Be able to sketch the major vascular structures that comprise the Circle of Willis and explain why the anastomosing system among the four major contributing arteries is important.

     I.           Discuss the location, most common presenting signs and symptoms, mortality rate, and  principles of surgical management of cerebral aneurysms and AVM’s.

     J.          Explain how the knowledge of brain functions is used to diagnose and locate brain tumors.

     K.         List methods of resection for benign and malignant brain tumors.

     L.          Define types of skull fractures.

     M.         Differentiate the character of the bleeding of an epidural vs. a subdural hematoma, and describe how different types of hemorrhages or hematomas are treated.

     N.         Select the area of injury or pathology that produces various characteristic signs.

     O.         Relate foramina of the skull to the structure(s) passing through them.

     P.          List the functions of cerebrospinal fluid.

     Q.         Describe the pathway of CSF from its production to its drainage

     R.         Differentiate the causes of “communicating’ vs. ‘non-communicating’ hydrocephalus, and discuss types of shunting procedures and their potential long term complications.

     S.          List diagnostic methods for intracranial pathologies

     T.           Describe different approaches and methods for cranial entry.

     U.          Define the Glascow Coma Scale and discuss methods for assessing levels of consciousness.

     V.          Discuss different neurosurgical procedures and their complications.

 7.    Discuss anatomical considerations relevant to surgery of the face, eye, ear, nose, neck and throat.

     A.          Name the components of the bony orbit and identify its anatomical relationships.

     B.          List the innervation and function(s) of each of the extra ocular eye muscles, and explain how eye movements are used to test the integrity of cranial nerves.

     C.          List the functions of each of the cranial nerves around the eye and explain the significance of the ciliary ganglion to eye surgery performed under Local anesthesia.

     D.          Describe the circulation pathway of aqueous humor and relate it to the treatment options for glaucoma.

     E.          Define a cataract, explain how it can occur, and compare surgical treatment options.

     F.           Describe the features of the retina, define retinal detachment, and explain why a retinal detachment that is approaching the macula requires immediate surgery.

     G.          Define diabetic retinopathy and describe how it is treated.

     H.          Explain how the optic disk can reflect increased intracranial pressure.

     I.           Describe what happens to the distribution of optic nerve fibers at the optic chiasma and explain how various lesions along the optic pathway affect vision.

     J.          Describe the temporomandibular joint (TMJ) and its actions.

     K.          Describe the course, functions, and anatomical relationships of the branches of the Trigeminal (facial) Nerve.

     L.          Trace the course of the Facial Artery and explain the significance of the system of anastomoses near the medial canthus/angle of the eye.

     M.         Describe the veins/arteries of the neck.

     N.         Discuss the clinical significance of the carotid sinus during Carotid Endarterectomy.

     O.         List the suprahyoid and infrahyoid muscles, name their innervations, and explain how their functions relate to each other.

     P.          List the nerves responsible for general sensation, taste, and motor function in the tongue.

     Q.         Describe the arterial supply, venous drainage and other anatomic relationships of the thyroid gland.

     R.          Describe the surgical approach for open tracheostomy.

     S.          Identify the major sources of blood supply to the palatine tonsils.

     T.          Describe the muscular coats of the pharynx and the functions of the pharyngeal plexus.

     U.         List the major cartilages of the larynx and the innervations of the muscles of the larynx.

     V.          Explain the clinical significance of the fascial compartments of the neck.

     W.        Describe surgical options for eye pathology.

8.    Relate structures of the chest wall and superficial back to pathology and surgery of the chest wall, breast and axilla.

     A.          Demonstrate the movements of the humerus and the scapula

     B.          List the superficial back muscles and anterior chest wall muscles, and describe their functions

     C.          Describe the gross and histologic architecture of the normal breast, identify where most breast cancers occur, and explain what alterations occur with benign and malignant changes

     D.         List the major structures contained in the axilla

     E.          Define “radical mastectomy”, “modified radical mastectomy”, and “lumpectomy”

     F.           Name the major nerves and vessels that must be identified and protected during breast and axillary surgery

     G.          Draw and label the components of the Brachial Plexus

     H.          Describe the different surgical options for the pathology of the breast.

9.    Relate anatomical considerations to orthopedic pathology and surgery of the upper limb.

     A.          Describe the usual incisional approach to the shoulder joint.

     B.          Name the components of the “rotator cuff” and describe their insertions and functions.

     C.          Differentiate between a “shoulder separation” and a shoulder dislocation.

     D.          List intracapsular structures that might be seen during a shoulder arthroscopy.

     E.          List the muscles, nerves, and arteries of the arm and forearm, along with their functions.

     F.           Describe common injuries to nervous and vascular structures in the arm and forearm and their resulting limitations (i.e. clinical manifestations).

     G.          Describe the fascial features of the wrist and how the forearm tendons are organized.

     H.          Describe  osteology, arthology, musculature, vasculature, and neurology of the wrist and hand.

     I.            Discuss the relevance of the extensor “hood”, vincula, and fascial features of a digit to hand injuries.

     J.           Define carpal tunnel syndrome, Dupuytren’s contracture, and DeQuervain’s contracture.

     K.           Describe what happens to the hand with rheumatoid arthritis.

     L.           Explain the order of treatment priorities on an injured hand.

     M.           Discuss the different surgical options for pathology of the upper limb.

10.  Discuss pathologies of and surgical approaches to the vertebral column and spinal cord.

     A.          Define the characteristics that differentiate cervical, thoracic, and lumbar vertebrae.

     B.          Relate the vertebral ligaments to a laminectomy approach.

     C.          Describe the contents of the vertebral canal, including the blood vessels.

     D.         State where a spinal anesthetic is injected and explain why.

     E.          List and describe the various meningeal specializations around the spinal cord.

     F.          Describe the arterial supply to the spinal cord.

     G.         Describe a ruptured lumbar disc.

     H.         Explain the reasons for the usual surgical approach to a herniated cervical disc and describe what complications may be associated with this approach.

     I.           Identify aspects of the spinal cord in cross-section and discuss their functions.

     J.          Describe surgical approaches to correct congenital or acquired pathologies of the spine.