Case Based Surgery Guide

Dr Bhatia Medical Institute

Case Based Questions for Surgery

Powered by –

1. A 65-year-old man who is hospitalized with pancreatic carcinoma develops abdominal distention and obstipation. The following abdominal radiograph is obtained. Appropriate management would best be achieved by (See Figure)

A. Urgent colostomy or cecostomy B. Discontinuation of anticholinergic medications and narcotics and correction of metabolic disorders C. Digital disimpaction of a fecal mass in the rectum D. Diagnostic and therapeutic colonoscopy 1. Ans. (D) Diagnostic and therapeutic colonoscopy

As classically described, Olgilvie syndrome was associated with the rare occurrence of malignant infiltration of

the colonic sympathetic nerve supply in the region of the celiac plexus. The eponym is now applied to the

condition in which massive cecal and colonic dilation is seen in the absence of mechanical obstruction. Other

terms used to describe this condition are acute colonic pseudo-obstruction, colonic ileus, and functional

colonic obstruction. It tends to occur in elderly patients in the setting of cardiopulmonary insufficiency, in

other systemic disorders that require prolonged bed rest, and in the postoperative state. The diagnosis of

Olgilvie syndrome cannot be confirmed until mechanical obstruction of the distal colon is excluded by

colonoscopy or contrast enema. Anticholinergic agents and narcotics need to be discontinued, but any delay in

decompressing the dilated cecum is inappropriate since colonic ischemia and perforation become a distinct

hazard as the cecum reaches this degree of dilation. Cautious endoscopic colonic decompression has been

demonstrated recently to be a safe and effective form of treatment. Endoscopy should be combined with

rectal tube placement, correction of metabolic abnormalities, and the discontinuation of medications that

diminish gastrointestinal motility. The high complication rate in this population notwithstanding, a direct

surgical approach to decompression becomes necessary when colonoscopic decompression fails; a perforated

cecum is a catastrophic event in such patients.

2. After a weekend drinking party , a 45-year-old alcoholic man presents to the hospital with abdominal pain, nausea, and vomiting. On physical examination the patient is afebrile and is noted to have a palpable tender mass in the epigastrium. Laboratory tests reveal an amylase of 250 U/dL . A CT scan done on the second hospital day is pictured below. Which of the following statements concerning this patient’s condition is true? (See Figure)

A. The mass may cause gastric outlet or extrahepatic biliary obstruction B. Spontaneous resolution almost never occurs C. The mass is seen only with acute pancreatitis D. The mass has an epithelial lining

2. Ans. (A) The mass may cause gastric outlet or extrahepatic (Schwartz, 9/e, pp 1485–1487.)

Pancreatic pseudocysts can develop in the setting of acute and chronic pancreatitis. They are cystic collections

that do not have an epithelial lining and therefore have no malignant potential. Most pseudocysts

spontaneously resolve. Therapy should not be considered for 6 wk to allow for the possibility of spontaneous

resolution as well as to allow for maturation of the cyst wall if the cyst persists. Complications of pseudocysts

include gastric outlet and extrahepatic biliary obstructions as well as spontaneous rupture and hemorrhage.

Pseudocysts can be excised, externally drained, or internally drained into the gastrointestinal tract (most

commonly the stomach or a Roux-en-Y limb of jejunum).

3. An 89-year-old man has lost 12 Kg over the past 2 years. He reports that food frequently sticks when he swallows. He also complains of a chronic cough. Pulmonary function tests show a vital capacity of 60% of expected, and forced expiratory volume is 50% of predicted. Barium swallow is shown below. Which of the following statements is true? (See Figure)

A. The carotid bifurcation lies adjacent to the lesion B. Esophagoscopy and biopsy should be performed to confirm the x-ray findings C. This patient is atypical in that the lesion usually appears in the second or third decade of life D. The patient should be treated with antituberculous medications before any surgical intervention is considered 3. Ans. (A) The carotid bifurcation lies adjacent to the lesion (Schwartz, 9/e, p 1125.) Pharyngoesophageal (Zenker’s) diverticulum is an outpouching of mucosa between the lower pharyngeal

constrictor and the cricopharyngeus muscles. It is thought to result from an incoordination of cricopharyngeal

relaxation with swallowing.

These diverticula occur in elderly patients and more commonly on the left. The typical patient presents with

complaints of dysphagia, weight loss, and choking. Other patients present with the effects of repeated

aspiration, pneumonia, or chronic cough. A mass is sometimes palpable and a gurgle may be heard. Treatment

is excision and division of the cricopharyngeus muscle, which can be done under local anesthesia in a

cooperative patient. Esophagoscopy is dangerous because the blind pouch is easily perforated. Even though

the pouch may extend down into the mediastinum, the origin of the diverticulum is at the cricopharyngeus

muscle near the level of the bifurcation of the carotid artery.

4. An 80-year-old man is found to have an asymptomatic abdominal mass. An arteriogram is obtained, which is pictured below. This patient should be advised that (See Figure)

A. Surgery should be performed, but a mortality of 20% is to be anticipated B. Surgery should be performed only if symptoms develop C. Surgery will improve his 5-year survival D. Surgery this extensive should not be performed in a patient of his age

4. Ans. (C) Surgery will improve his 5-year survival (Schwartz, 9/e, pp 941–944.)

Most abdominal aortic aneurysms are asymptomatic and are discovered on palpation by a physician. A

radiograph of the abdomen is useful in demonstrating the aneurysm if there is calcification in the walls.

Ultrasound is generally the first diagnostic procedure in confirming the presence of an aneurysm, with

arteriography being performed if the aneurysm is considered large enough to require resection (greater than 5

cm in diameter). Recently CT scan has been found to be useful as a preoperative study in patients suspected of

having aneurysms. Surgery should be performed despite the absence of symptoms and can be carried out with

a mortality of less than 5%. With leaking or ruptured aneurysms, the operative mortality associated with this

emergency situation is upward of 75%. The patient’s age is not a contraindication to surgery, because several

studies have demonstrated a low mortality (less than 5%) and satisfactory long-term survival and quality of life

in elderly, even octogenarian, patients.

5. The provided figure demonstrates classification of primary melanoma into different levels. To the left is demonstrated one system of doing so”A” and to the right is another system “B”. What do A and B respectively stand for? (See Figure)

A. Clark, Breslow B. Breslow, Clark C. Clark, T classification of AJCC D. Breslow, T classification of AJCC 5. Ans: (A) Clark, Breslow

The original staging system classified melanoma into local (stage I), regional lymph node (stage II), and

metastatic (stage III) disease. This staging system was not advantageous given that most patients were

categorized into stage I disease, therefore limiting its usefulness in prognostic studies. The most current

staging system, from the American Joint Committee on Cancer (AJCC), contains the best method of

interpreting clinical information in regard to prognosis of this disease. 156 Historically, the vertical thickness of

the primary tumor (Breslow thickness) and the anatomic depth of invasion (Clark level) have represented the

dominant factors in the T classification the melanoma staging system.

The T classification of lesions comes from the original observation by Clark that prognosis is directly related to

the level of invasion of the skin by the melanoma. Whereas Clark used the histologic level (I, superficial to

basement membrane [in situ]; II, papillary dermis; III, papillary/reticular dermal junction; IV, reticular dermis;

and V, subcutaneous fat), Breslow modified the approach to obtain a more reproducible measure of invasion

by the use of an ocular micrometer. The lesions were measured from the granular layer of the epidermis or

the base of the ulcer to the greatest depth of the tumor (I, 0.75 mm or less; II, 0.76 to 1.5 mm; III, 1.51 to 4.0

mm; IV, 4.0 mm or more). 157 These levels of invasion have been subsequently modified and incorporated in

the AJCC staging system. The new staging system has largely replaced the Clark level with another histologic

feature, ulceration, based on analysis of large databases available to the AJCC Melanoma Committee.

6. The following diagram demonstrates various levels of cervical lymph nodes. Of these the level V stands for ? (See Figure)

A. Upper jugular nodes B. Mid jugular nodes C. Pretracheal nodes D. Posterior triangle nodes. 6. Ans: (D) Wide resection of the mass

Patterns of Lymph Node Metastasis

The regional lymphatic drainage of the neck is divided into seven levels. These levels allow for a standardized

format for radiologists, surgeons, pathologists, and radiation oncologists to communicate concerning specific

sites within the neck and does not represent regions isolated by fascial planes. The levels are defined as the

following:

Level I—the submental and submandibular nodes

Level Ia—the submental nodes; medial to the anterior belly of the digastric muscle bilaterally, symphysis of

mandible superiorly, and hyoid inferiorly

Level Ib—the submandibular nodes and gland; posterior to the anterior belly of digastric, anterior to the

posterior belly of digastric and inferior to the body of the mandible

Level II—upper jugular chain nodes

Level IIa—jugulodigastric nodes; deep to sternocleidomastoid (SCM) muscle, anterior to the posterior

border of the muscle, posterior to the posterior aspect of the posterior belly of digastric, superior to the

level of the hyoid, inferior to spinal accessory nerve (CN XI)

Level IIb—submuscular recess; superior to spinal accessory nerve to the level of the skull base

Level III—middle jugular chain nodes; inferior to the hyoid, superior to the level of the hyoid, deep to SCM

from posterior border of the muscle to the strap muscles medially

Level IV—lower jugular chain nodes; inferior to the level of the cricoid, superior to the clavicle, deep to

SCM from posterior border of the muscle to the strap muscles medially

Level V—posterior triangle nodes

Level Va—lateral to the posterior aspect of the SCM, inferior and medial to splenius capitis and trapezius,

superior to the spinal accessory nerve

Level Vb—lateral to the posterior aspect of SCM, medial to trapezius, inferior to the spinal accessory

nerve, superior to the clavicle

Level VI—anterior compartment nodes; inferior to the hyoid, superior to suprasternal notch, medial to the

lateral extent of the strap muscles bilaterally

Level VII—paratracheal nodes; inferior to the suprasternal notch in the upper mediastinum

Patterns of spread from primary tumor sites in the head and neck to cervical lymphatics are well described. 93

The location and incidence of metastasis vary according to the primary site. Primary tumors within the oral

cavity and lip metastasize to the nodes in levels I, II, and III. The occurrence of skip metastases with oral

tongue lesions makes possible the involvement of nodes in level III or IV without involvement of higher-

echelon nodes. Tumors arising in the oropharynx, hypopharynx, and larynx most commonly spread to the

lymph nodes in levels II, III, and IV. Isolated level V nodes are uncommon with oral cavity, pharyngeal, and

laryngeal primaries; however, level V adenopathy may be seen with concomitant involvement of higher

echelon nodes. Malignancies of the nasopharynx and thyroid commonly spread to posterior lymph nodes in

addition to the jugular chain nodes. Retropharyngeal nodes are sites for metastasis from tumors of the

nasopharynx, soft palate, and lateral and posterior walls of the oropharynx and hypopharynx. Tumors of the

hypopharynx, cervical esophagus, and thyroid frequently involve the paratracheal nodal compartment, and

may extend to the lymphatics in the upper mediastinum (level VII). The Delphian node, a pretracheal lymph

node, may become involved by advanced tumors of the glottis with subglottic spread.

7. A young male comes to emergency room following an accident and is unconscious. A CT is done, shown below. The neurosurgeon orders immediate surgical decompression. As a surgery internee the probable diagnosis based on clinical scenario and the CT is ? (See Figure)

A. Epidural bleed B. Subdural bleed C. Subarachnoid bleed D. Isolated brain contusion 7. Ans: (A) Epidural bleed

Cerebral pathologic lesions from blunt trauma include hematomas, contusions, hemorrhage into ventricular

and subarachnoid spaces, and diffuse axonal injury (DAI). Hematomas are further classified according to

location. Epidural hematomas occur when blood accumulates between the skull and dura, and are caused by

disruption of the middle meningeal artery or other small arteries in that potential space from a skull fracture.

They typically appear biconvex. Subdural hematomas occur between the dura and cortex, and are caused by

venous disruption or laceration of the parenchyma of the brain. They appear typically as concavo-convex

hyperdense lesion overlying cerebral convexities. Because of the underlying brain injury, prognosis is much

worse with subdural hematomas. Intraparenchymal hematomas and contusions can occur anywhere within

the brain. Hemorrhage may occur into the ventricles, and while usually not massive, this blood may cause

postinjury hydrocephalus. Diffuse hemorrhage into the subarachnoid space may cause vasospasm and reduce

cerebral blood flow. It appears as hyperdense lesion in sulcal spaces and basal cisterns. DAI results from high-

speed deceleration injury and represents direct axonal damage. On CT, a blurring of the gray-white matter

interface may be seen, along with multiple small punctate hemorrhages. While prognosis is difficult to predict

and extremely variable, early evidence of DAI on CT scan is associated with a poor outcome. Magnetic

resonance imaging (MRI) can often identify DAI with greater precision than CT.

8. The ?? in the following diagram is an important bony landmark used to differentiate between inguinal

and femoral hernias. It is? (See Figure)

A. Pubic symphysis

B. Ilio-pectinate line

C. Pubic tubercle

D. Iliopubic eminence.

8. Ans: (C) Pubic tubercle

Physical Examination

Physical examination is the best way to determine the presence or absence of an inguinal hernia. The

diagnosis may be obvious by simple inspection when a visible bulge is present. The differential diagnosis must

be considered in questionable cases (Table 36-4). Nonvisible hernias require digital examination of the inguinal

canal. This is best done in both the lying and standing position. The examiner should place the tip of the index

finger at the most dependent part of the scrotum and direct it into the external inguinal ring. The patient is

then asked to strain. The ritual of having the patient cough is discouraged as it results in the overdiagnosis of a

hernia because of the difficulty of differentiating a normal expansile bulge of muscle from a true hernia,

especially in asthenic individuals.

Numerous authors have shown that the accuracy with which direct and indirect inguinal hernias can be

distinguished clinically before surgery is low. 28, 29, 30 However, classic teaching is that an indirect hernia will

push against the fingertip, whereas a direct hernia will push against the pulp of the finger. In addition,

applying pressure over the mid-inguinal point (midway between the anterior superior iliac spine and the pubic

tubercle, and just above the inguinal ligament) with the fingertip will control an indirect hernia and prevent it

from protruding when the patient strains. A direct hernia will not be affected with this maneuver.

A femoral hernia presents as a swelling below the inguinal ligament and just lateral to the pubic tubercle.

Femoral hernias are overdiagnosed because of the presence of a prominent femoral fat pad, a so-called

femoral pseudohernia. Thin patients commonly have prominent bilateral bulges below the inguinal ligament

medial to the femoral vessels. They are asymptomatic and disappear spontaneously when the patient assumes

a supine position. Surgery is not indicated.

9. A 76-year-old woman is admitted with back pain and hypotension. A CT scan is obtained, and the patient is taken to the operating room. Three days after resection of a ruptured abdominal aortic aneurysm, she C/O severe, dull left flank pain and passes bloody mucus per rectum. The diagnosis that must be immediately considered is (See figure)

(A). Staphylococcal enterocolitis (B). Diverticulitis (C). Bleeding AV malformation (D). Ischemia of the left colon 9. Ans. (D). Ischemia of the left colon The CT scan reveals a fractured ring of calcification in the abdominal aorta with significant density in the paraaortic area. The inferior mesenteric artery (IMA) is always at risk in patients with the changes in the vessel wall characteristic of abdominal aneurysms, but particularly so in the presence of rupture and retroperitoneal dissection of blood under systemic arterial pressures. The incidence of ischemic colitis following abdominal aortic resection is about 2%. Blood flow to the left colon normally derives from the IMA with collateral flow from the middle and inferior hemorrhoidal vessels. The superior mesenteric artery (SMA) may also contribute via the marginal artery of Drummond. If the SMA is stenotic or occluded, flow to the left colon will be primarily dependent on an intact IMA. The IMA is usually ligated at the time of aneurysmorrhaphy. Those patients at highest risk for diminished flow through collateral vessels are those with a history of visceral angina, those found to have a patent IMA at the time of operation, patients who have suffered an episode of hypotension following rupture of an aneurysm, those in whom preoperative angiograms reveal occlusion of the SMA, and those in whom Doppler flow signals along the mesenteric border cease following occlusion of the IMA. Recognition of bowel ischemia at the time of operation should be treated by reimplantation of the IMA into the graft to restore flow.

10. An arteriogram on the above patient is shown below. The patient has mild hypertension and mild COPD. The current recommendation for this man would be (See figure)

(A). Medical therapy with aspirin 325 mg/day and medical risk factor management (B). Medical therapy with warfarin (C). Angioplasty of the carotid lesion followed by carotid endarterectomy if the angioplasty is unsuccessful (D). Carotid endarterectomy 10. Ans. (D). Carotid endarterectomy (Executive Committee, JAMA 273:1421–1428,1995.) In a recent prospective, randomized, multicenter trial involving 1662 patients in a study known as the Asymptomatic Carotid Atherosclerosis Study, patients with asymptomatic carotid artery stenosis of 60% or greater reduction in diameter and whose general health made them good candidates for elective surgery were found to have a significant reduction in the 5-year risk for ipsilateral stroke with surgery compared with medically treated cohorts (5.1 vs. 11.0%). Medically treated patients were treated with aspirin on a daily basis. Warfarin has not been shown to be effective in the management of patients with carotid disease. Angioplasty of carotid stenoses is being performed in some institutions on a purely investigational basis and to date has not replaced surgery as the treatment for high-grade carotid stenoses.

11. Indications for placement of the device pictured in the abdominal x-ray include (See figure)

(A). Recurrent pulmonary embolus despite adequate anticoagulation therapy (B). Axillary vein thrombosis (C). Pulmonary embolus in a patient with a perforated duodenal ulcer (D). Pulmonary embolus due to deep vein thrombosis of the lower extremity that occurs 2 wk postoperatively 11. Ans. (A). Recurrent pulmonary embolus despite adequate anticoagulation therapy (Schwartz, 7/e, p 1014.) The Greenfield filter pictured on the x-ray is used to interrupt migration of emboli to the lungs from the veins below the level of the filter. It is indicated in patients who sustain a recurrent pulmonary embolus despite adequate anticoagulant therapy or in patients with pulmonary emboli who cannot receive anticoagulants because of a contraindication (e.g., bleeding ulcer, intracranial hemorrhage). The filter is not used in patients who sustain a single pulmonary embolus. It is placed in the inferior vena cava just below the renal veins and therefore would not be effective for emboli that arise cephalad to its position. Despite the hypercoagulable state seen in some patients with metastatic pancreatic cancer, anticoagulation can still be used as a first-line defense.

12. A child presented with a 3 cm sized swelling in his ingiuno-scrotal region. After assessment and ultrasound the radiologist provided the following schematic representation of the abnormality. Without referring to the report what do you think the diagnosis is ? (See figure)

(A). Tunica vaginalis hydrocele (B). Communicating vaginal hydrocele (C). Hydrocele of cord (D). Spermatocele 12. Ans. (C). Hydrocele of cord A hydrocele consists of a collection of fluid within the tunica or processus vaginalis. Although it may occur within the spermatic cord, it is most often seen surrounding the testis. Surgical correction is only required if the patient has symptoms secondary to the size of or discomfort associated with the hydrocele. Communicating hydrocele of infancy and childhood is secondary to a patent processus vaginalis, which is continuous with the peritoneal cavity. It is also a form of indirect inguinal hernia. Most communicating hydroceles spontaneously close by 1 year of age. However, persistent communicating hydroceles and presence of bowel content within the hydrocele sac may require surgical correction. Spermatocele A spermatocele is a painless fluid-filled sac with sperm that is often located above and posterior to the testicle. Although most spermatoceles are smaller than 1 cm, some may become large and hard, mimicking a solid neoplasm. Spermatocele is differentiated from hydrocele of the tunica vaginalis in that the latter covers the entire anterior surface of the testicle. Spermatoceles do not require intervention unless the patient experiences discomfort associated with it.

13. A newly born premature infant was found to have herniation of loops of small bowel, through a defect in the abdominal wall lateral to the insertion of umbilical cord, at birth, as shown in the (See Figure). Which of the following statements is true about this congenital anomaly?

(A) This congenital anomaly is known as omphalocele (B) It is believed to arise at site of involution of left umbilical vein (C) Emergency operation is not necessary (D) It is not associated with chromosome abnormalities 13. Ans. (D). It is not associated with ………. This congenital anomaly is known as gastroschisis. Gastroschisis is a defect in the abdominal wall that usually is to the right of the normal insertion of the umbilical cord. It is believed to arise at the site of normal involution of the right umbilical vein, though there is some evidence that it results from rupture of an omphalocele sac in utero. It is twice as common as omphalocele. The small and large bowel herniated through the abdominal wall defect, and, as is not the case with omphaloceles, the liver is never present in the hernia, and the viscera are not covered by peritoneum or amnion. When the anomaly is discovered in utero by ultrasound, planned delivery at a tertiary care hospital where immediate operation can be performed is possible. Unlike omphalocele, urgent repair is necessary. Unlike omphalocele, gastroschisis is not associated with chromosome abnormalities or other severe defects, and therefore, the survival rate is excellent. Omphalocele is a midline abdominal wall defect. The abdominal viscera are contained within a sac composed of peritoneum and amnion from which the umbilical cord arises at the apex and center. When the defect is less than 4 cm, it is termed a hernia of the umbilical cord; when greater than 10 cm it is termed a giant omphalocele.

14. Consider the following schematic diagram depicting a specific pathology. False about this condition is? (See figure)

(A). It is common than rolling type. (B). The competence of cardia is disturbed (C). Stricture formation occurs in late stages. (D). No regurgitation occurs 14. Ans. (D). No regurgitation occurs The diagram represents a sliding type of hiatus hernia. A number of defects may occur, giving rise to a variety of congenital herniae through the diaphragm. These may be: 1. Through the foramen of Morgagni; anteriorly between the xiphoid and costal origins; 2. Through the foramen of Bochdalek—the pleuroperitoneal canal—lying posteriorly; 3. Through a deficiency of the whole central tendon (occasionally such a hernia may be traumatic in origin); 4. Through a congenitally large oesophageal hiatus. Far more common are the acquired hiatus herniae (subdivided into sliding and rolling herniae). These are found in patients usually of middle age where weakening and widening of the oesophageal hiatus has occurred. In the sliding hernia the upper stomach and lower oesophagus slide upwards into the chest through the lax hiatus when the patient lies down or bends over; the competence of the cardia is often disturbed and peptic juice can therefore regurgitate into the gullet in lying down or bending over. This may be followed by oesophagitis with consequent heartburn, bleeding and, eventually, stricture formation. In the rolling hernia (which is far less common) the cardia remains in its normal position and the cardio-oesophageal junction is intact, but the fundus of the stomach rolls up through the hiatus in front of the oesophagus, hence the alternative term of para-oesophageal hernia. In such a case there may be epigastric discomfort, flatulence and even dysphagia, but no regurgitation because the cardiac mechanism is undisturbed.

15. The following diagram represents a very important landmark for biliary surgeries. Identify it. (See figure)

(A). Calot’s triangle (B). Triangle of doom (C). Apex triangle (D). Triangle of death 15. Ans. (A). Calots triangle 1. Errors in gall-bladder surgery are frequently the result of failure to appreciate the variations in the anatomy of the biliary system; it is important, therefore, before dividing any structures and removing the gallbladder, to have all the three biliary ducts clearly identified, together with the cystic and hepatic arteries. The cystic artery is constantly found in Calot’s triangle , formed by the cystic duct, the common hepatic duct and the inferior aspect of the liver. 2. Haemorrhage during cholecystectomy may be controlled by compressing the hepatic artery (which gives off the cystic branch) between the finger and thumb where it lies in the anterior wall of the foramen of Winslow (Pringle’s manoeuvre) . 3. Gangrene of the gall-bladder is rare because even if the cystic artery becomes thrombosed in acute cholecystitis there is a rich secondary blood supply coming in from the liver bed. Gangrene may occur in the unusual event of a gall-bladder on an abnormally long mesentery undergoing torsion, which will destroy both its sources of blood supply. 4. Stones in the common duct can usually be removed endoscopically using a Dormia basket introduced after dividing the sphincter of Oddi. At other times, the common bile duct is explored via an incision in its supraduodenal portion. Sometimes a stone impacted at the ampulla of Vater must be approached via an incision in the second part of the duodenum. This last approach is also used when it is necessary to divide the sphincter of Oddi or to remove a tumour arising at the termination of the common bile duct.

16. Consider the relationship of uterus, cervix and vagina as shown in the figure (See figure). What will you describe this position as?

(A). Anteverted anteflexed (B). Anteverted retroflexed (C). Retroverted anteflexed (D). Retroverted retroflexed. 16. Ans. (B). Anteverted Retroflexed. In fetal life the cervix is considerably larger than the body; in childhood (the infantile uterus) the cervix is still twice the size of the body but, during puberty, the uterus enlarges to its adult size and proportions by relative overgrowth of the body. The adult uterus is bent forward on itself at about the level of the internal os to form an angle of 170°; this is termed anteflexion of the uterus. Moreover, the axis of the cervix forms an angle of 90° with the axis of the vagina—anteversion of the uterus. The uterus thus lies in an almost horizontal plane. In retroversion of the uterus, the axis of the cervix is directed upwards and backwards. Normally on vaginal examination the lowermost part of the cervix to be felt is its anterior lip; in retroversion either the os or the posterior lip becomes the presenting part. In retroflexion the axis of the body of the uterus passes upwards and backwards in relation to the axis of the cervix. Frequently these two conditions co-exist. They may be mobile and symptomless—as a result of distension of the bladder or purely as a development anomaly. Indeed, mobile retroversion is found in a quarter of the female population and may be regarded as a normal variant. Less commonly, they are fixed, the result of adhesions, previous pelvic infection, endometriosis or the pressure of a tumour in front of the uterus

Study on the go; get high quality complete preparation courses now on your

mobile!