Unit 16 Question Bank
Sourcing: items tagged TMU 2021–22 come from the real final paper. Items tagged
Slide come from the TMU lecture. Items tagged Gray's are built from the textbook to cover
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0 / 20 answered
1Which organ does NOT belong to the intraperitoneal organs?
Answer: A
The second, third and fourth parts of the duodenum are retroperitoneal; only the first part is intraperitoneal. The jejunum, ileum, ovary and transverse colon are all intraperitoneal.TMU 2021–22 final, Section II Q9 · Gray's 4e Ch.4
2The lesser omentum extends from the liver to the ( ).
Answer: B
From the lesser curvature of the stomach and the first part of the duodenum to the inferior surface of the liver. Its two parts are the hepatogastric and hepatoduodenal ligaments.TMU 2021–22 Section III Q4 · TMU Lecture 19 Slide 7
3The free edge of the lesser omentum contains the ( ).
Answer: C
The portal triad: proper hepatic artery on the left, common bile duct on the right, hepatic portal vein behind both — the hepatoduodenal ligament.TMU 2021–22 Section III Q4
4The anterior boundary of the epiploic (omental) foramen is the ( ).
Answer: D
The free edge of the lesser omentum containing the portal triad. Posteriorly is the IVC, above is the caudate lobe, below is the first part of the duodenum.Gray's 4e Ch.4 · TMU Lecture 19 Slide 7
5The greater omentum hangs from the ( ).
Answer: A
A four-layered apron hanging from the greater curvature over the transverse colon and small intestine, then folding back to the transverse colon.Gray's 4e p.294
6Which part of the colon is retroperitoneal?
Answer: B
The ascending and descending colon are retroperitoneal; the transverse and sigmoid colon are intraperitoneal, slung on their mesocolons.Gray's 4e Ch.4
7The lowest part of the peritoneal cavity in a supine patient is the ( ).
Answer: C
The hepatorenal recess, between the liver and right kidney — the first place fluid collects and the first place a FAST scan looks in trauma.TMU Lecture 19 Slide 8 · Snell's 10e Ch.6
8The transverse colon and its mesocolon divide the peritoneal cavity into the ( ).
Answer: D
Into the supracolic compartment (liver, stomach, spleen, superior duodenum) and the infracolic compartment (small intestine, remaining colon).TMU Lecture 19 Slide 4
9The parietal peritoneum is supplied by ( ).
Answer: A
Somatic nerves (lower intercostal and subcostal), so it localises pain precisely and produces guarding. The visceral peritoneum has autonomic supply only and gives vague midline pain.Gray's 4e Ch.4
10Appendicitis pain migrates from the umbilicus to the right iliac fossa because ( ).
Answer: B
Early visceral peritoneal pain is referred to the T10 dermatome around the umbilicus; once the inflamed appendix irritates the parietal peritoneum, pain localises sharply to the right iliac fossa.Gray's 4e Ch.4 (clinical application)
11The greater omentum is nicknamed the 'policeman of the abdomen' because it ( ).
Answer: C
Being mobile and rich in immune cells, it wraps around an inflamed appendix or perforated ulcer, limiting generalised peritonitis. It is shorter in children, one reason perforation spreads more readily in the young.Snell's 10e Ch.6 (clinical)
12The Pringle manoeuvre works by compressing the ( ).
Answer: D
A finger through the epiploic foramen pinches the hepatoduodenal ligament, occluding the hepatic artery and portal vein together and stopping almost all inflow to the liver.Snell's 10e Ch.7 (clinical)
13Which is the hepatogastric ligament?
Answer: A
The larger, medial part of the lesser omentum, running from the lesser curvature to the liver. The hepatoduodenal ligament is the thickened free right edge containing the portal triad.TMU Lecture 19 Slide 7
14The pancreas is ( ).
Answer: B
Retroperitoneal except the tail, which lies in the splenorenal ligament and is therefore intraperitoneal.Gray's 4e Ch.4
15Pus from a perforated appendix typically tracks to the subphrenic region via the ( ).
Answer: C
Up the right paracolic gutter to the hepatorenal recess and the subphrenic space. The paracolic gutters are the channels connecting the two compartments.Snell's 10e Ch.6 (clinical)
16The omental bursa is also known as the ( ).
Answer: D
The lesser sac — the flattened space behind the stomach and lesser omentum, communicating with the greater sac through the epiploic foramen.TMU Lecture 19 Slide 5
17The posterior boundary of the epiploic foramen is the ( ).
Answer: A
The inferior vena cava. This is why the Pringle manoeuvre compresses only the arterial and portal inflow in front — the cava behind is untouched.Gray's 4e Ch.4
18Which ligament is part of the peritoneal attachment of the liver?
Answer: B
The falciform ligament, with the coronary and triangular ligaments, attaches the liver to the anterior abdominal wall and diaphragm. Its free lower edge carries the round ligament (ligamentum teres).TMU Lecture 19 Slide 6
19Which organ is intraperitoneal?
Answer: C
The spleen is intraperitoneal, suspended by the gastrosplenic and splenorenal ligaments. The kidneys, suprarenals and aorta are all retroperitoneal.Gray's 4e Ch.4
20A mesentery serves principally to ( ).
Answer: D
Every peritoneal fold is a conduit — the vessels, nerves and lymphatics reach the organ between its two layers. That is the organising principle of peritoneal anatomy.Gray's 4e Ch.4
1 Lesser omentum — TMU 2021–22 · 7′+
A two-layered fold of peritoneum extending from the lesser curvature of the stomach and the first part of the duodenum to the inferior surface of the liver (porta hepatis and fissure for the ligamentum venosum).
Two ligaments:
• Hepatogastric ligament — the medial part
• Hepatoduodenal ligament — the thickened free right edge
Contents of the free edge (portal triad): proper hepatic artery (left) · common bile duct (right) · hepatic portal vein (behind), with lymphatics, nodes and the hepatic nerve plexus.TMU 2021–22 Section III Q4
Two ligaments:
• Hepatogastric ligament — the medial part
• Hepatoduodenal ligament — the thickened free right edge
Contents of the free edge (portal triad): proper hepatic artery (left) · common bile duct (right) · hepatic portal vein (behind), with lymphatics, nodes and the hepatic nerve plexus.TMU 2021–22 Section III Q4
2 Epiploic (omental) foramen — 3′+
The opening connecting the greater and lesser sacs of the peritoneal cavity.
Anteriorly: free edge of the lesser omentum (hepatoduodenal ligament) with the portal triad.
Posteriorly: inferior vena cava.
Superiorly: caudate lobe of the liver.
Inferiorly: first part of the duodenum.
Clinical: the route for the Pringle manoeuvre.Gray's 4e Ch.4 · TMU Lecture 19 Slide 7
Anteriorly: free edge of the lesser omentum (hepatoduodenal ligament) with the portal triad.
Posteriorly: inferior vena cava.
Superiorly: caudate lobe of the liver.
Inferiorly: first part of the duodenum.
Clinical: the route for the Pringle manoeuvre.Gray's 4e Ch.4 · TMU Lecture 19 Slide 7
3 Greater omentum — 2′+
A large apron-like fold of four layers of peritoneum hanging from the greater curvature of the stomach, draping over the transverse colon and small intestine before folding back to attach to the transverse colon and mesocolon.
Function: mobile and rich in immune cells, it migrates to and walls off inflamed or perforated viscera — the 'policeman of the abdomen'.Gray's 4e p.294
Function: mobile and rich in immune cells, it migrates to and walls off inflamed or perforated viscera — the 'policeman of the abdomen'.Gray's 4e p.294
4 Hepatorenal recess (Morison's pouch) — 2′+
The peritoneal recess between the inferior surface of the liver and the right kidney.
It is the lowest part of the peritoneal cavity in the supine position, so blood or pus collects there first. It is the first area examined on a FAST scan in trauma, and a common site for a subphrenic abscess after appendicitis, pus reaching it via the right paracolic gutter.TMU Lecture 19 Slide 8
It is the lowest part of the peritoneal cavity in the supine position, so blood or pus collects there first. It is the first area examined on a FAST scan in trauma, and a common site for a subphrenic abscess after appendicitis, pus reaching it via the right paracolic gutter.TMU Lecture 19 Slide 8
5 Omental bursa (lesser sac) — 3′+
A flattened space of the peritoneal cavity lying behind the stomach and the lesser omentum, formed by rotation of the stomach during development.
It communicates with the greater sac only through the epiploic foramen. Collections of fluid here (for example a pancreatic pseudocyst) are difficult to drain for exactly that reason.TMU Lecture 19 Slide 5
It communicates with the greater sac only through the epiploic foramen. Collections of fluid here (for example a pancreatic pseudocyst) are difficult to drain for exactly that reason.TMU Lecture 19 Slide 5
6 Intraperitoneal and retroperitoneal — 3′+
Intraperitoneal: an organ almost completely invested in visceral peritoneum and suspended by a mesentery — stomach, spleen, liver, gallbladder, jejunum, ileum, transverse and sigmoid colon, appendix, first part of the duodenum, ovary.
Retroperitoneal: an organ lying behind the peritoneum with only its anterior surface covered — kidneys, ureters, suprarenal glands, pancreas (except the tail), 2nd–4th parts of the duodenum, ascending and descending colon, abdominal aorta and inferior vena cava.Gray's 4e Ch.4
Retroperitoneal: an organ lying behind the peritoneum with only its anterior surface covered — kidneys, ureters, suprarenal glands, pancreas (except the tail), 2nd–4th parts of the duodenum, ascending and descending colon, abdominal aorta and inferior vena cava.Gray's 4e Ch.4
1
Describe the position and ligament composition of the lesser omentum. What structures are included in the ligaments?
7′
Real question — TMU 2021–22 final, Section III Q4.
Position
A two-layered fold of peritoneum passing from the lesser curvature of the stomach and the first part of the duodenum upward to the inferior surface of the liver, attaching at the porta hepatis and the fissure for the ligamentum venosum. It forms the anterior wall of the omental bursa (lesser sac).
Ligament composition
- Hepatogastric ligament — the larger medial part, between the lesser curvature and the liver
- Hepatoduodenal ligament — the thickened free right edge, between the first part of the duodenum and the liver
Structures included
In the hepatoduodenal ligament (the free edge) — the portal triad:
- Proper hepatic artery — on the left
- Common bile duct — on the right
- Hepatic portal vein — posterior to both
- Together with lymphatic vessels, lymph nodes and the hepatic nerve plexus
In the hepatogastric ligament — the right and left gastric vessels running along the lesser curvature.
Relation worth adding
The epiploic (omental) foramen lies immediately behind the free edge, bounded posteriorly by the inferior vena cava. This is the basis of the Pringle manoeuvre, in which the free edge is compressed to occlude hepatic inflow.
Marking guide: position and attachments 2 · two ligaments named 2 · portal triad with positions 2 · gastric vessels or epiploic foramen 1.
2
Classify the abdominal organs as intraperitoneal or retroperitoneal.
6′
Definitions
- Intraperitoneal: almost completely covered by visceral peritoneum and suspended by a mesentery — therefore mobile
- Retroperitoneal: lying behind the peritoneum with only the anterior surface covered — therefore fixed
| Intraperitoneal | Retroperitoneal |
|---|---|
| Stomach · spleen · liver · gallbladder | Kidneys · ureters · suprarenal glands |
| Jejunum · ileum · appendix · caecum | Pancreas except the tail |
| Transverse and sigmoid colon | Ascending and descending colon |
| First part of the duodenum | 2nd, 3rd and 4th parts of the duodenum |
| Ovary and uterine tube | Abdominal aorta · inferior vena cava · rectum (lower part) |
Clinical significance
- A posterior duodenal ulcer (retroperitoneal wall) erodes the gastroduodenal artery and bleeds; an anterior one perforates into the peritoneal cavity
- Retroperitoneal organs can be approached surgically without entering the peritoneal cavity — the basis of the loin approach to the kidney
- Retroperitoneal haemorrhage can be massive yet produce few peritoneal signs
Marking guide: definitions 1 · intraperitoneal list 2 · retroperitoneal list 2 · one clinical consequence 1.
3
Describe the peritoneal cavity, its compartments and recesses, and their clinical importance.
7′
Arrangement
A closed serous sac (in the male) lined by parietal peritoneum and reflected over the organs as visceral peritoneum, with a thin film of fluid between.
Compartments
The transverse colon and its mesocolon divide the cavity into:
- Supracolic compartment — liver, stomach, spleen, superior duodenum
- Infracolic compartment — small intestine and the remaining colon
They communicate through the paracolic gutters lateral to the ascending and descending colon.
The lesser sac
The omental bursa lies behind the stomach and lesser omentum, communicating with the greater sac only through the epiploic foramen.
Key recesses
- Hepatorenal recess (Morison's pouch) — between liver and right kidney; the lowest part of the cavity when supine
- Subphrenic spaces — beneath the diaphragm on each side
- Rectovesical / rectouterine pouch — the lowest part when erect
Clinical importance
- Blood after trauma collects in Morison's pouch — the first place a FAST scan looks
- Pus from a perforated appendix tracks up the right paracolic gutter to form a subphrenic abscess
- Fluid in a supine patient collects posteriorly; in an erect patient, in the pelvis
Marking guide: parietal/visceral/cavity 1.5 · two compartments and divider 1.5 · lesser sac and foramen 1 · two recesses 1.5 · clinical 1.5.
4
Give the boundaries of the epiploic foramen and explain its surgical importance.
6′
Definition
The epiploic (omental) foramen is the only communication between the greater sac and the lesser sac (omental bursa) of the peritoneal cavity.
Boundaries
- Anteriorly: the free edge of the lesser omentum — the hepatoduodenal ligament, containing the proper hepatic artery, common bile duct and hepatic portal vein
- Posteriorly: the inferior vena cava
- Superiorly: the caudate lobe of the liver
- Inferiorly: the first part of the duodenum
Surgical importance — the Pringle manoeuvre
In torrential bleeding from a liver injury, the surgeon passes a finger through the foramen and compresses the free edge of the lesser omentum between finger and thumb. This occludes the hepatic artery and portal vein simultaneously, stopping almost all inflow to the liver and allowing the bleeding point to be identified.
The manoeuvre works precisely because of the boundaries: the vessels to be compressed lie in front of the foramen, while the inferior vena cava lies behind it and is untouched.
Other relevance
Collections within the lesser sac — for example a pancreatic pseudocyst — communicate with the rest of the cavity only through this small opening, which is why they become loculated.
Marking guide: four boundaries 4 (1 each) · Pringle manoeuvre described 1.5 · reason it works 0.5.
5
Explain the nerve supply of the peritoneum and how it explains the clinical presentation of appendicitis.
6′
Nerve supply
- Parietal peritoneum — supplied by somatic nerves: the lower intercostal and subcostal nerves over the abdominal wall, the phrenic nerve centrally on the diaphragm, and the obturator nerve in the pelvis. Pain is sharp and precisely localised, and irritation produces guarding and rebound tenderness.
- Visceral peritoneum — supplied by autonomic nerves only. Pain is dull, poorly localised and referred to the midline at the dermatome level of the organ's embryological origin.
Applied to appendicitis
- Early: the inflamed appendix stretches its visceral peritoneum. Because the appendix is a midgut structure, pain is referred to the T10 dermatome — around the umbilicus — and is vague and colicky.
- Later: as inflammation reaches the surface, the adjacent parietal peritoneum of the right iliac fossa is irritated. Pain becomes sharp, constant and localised at McBurney's point, with guarding and rebound tenderness.
The classic migration of pain from umbilicus to right iliac fossa is therefore not a curiosity but a direct read-out of which peritoneal layer is involved.
The same principle elsewhere
Irritation of the central diaphragmatic peritoneum — by blood or by gallbladder disease — is referred to the shoulder tip, because the phrenic nerve is C3–C5.
Marking guide: parietal supply and character of pain 1.5 · visceral supply and character 1.5 · early appendicitis 1.5 · migration explained 1 · one other referred pain example 0.5.