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CKO (central clinical orientation) 3: Day 1, PR 1

Table 1: Complete trunk + skeleton C150


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Study the wall of the trunk and mark the boundaries between thorax and
abdomen. Use the skeleton for this if necessary.
Where is the liver and the spleen in relation to the ribs (upper and lower
border)?
Remember the practicum bodypaint from the first year.
At which places could you safely bring in a thorax drain?
At which places could you safely do a punction of the pericard? In what
cases would that be necessary?
At which place do you project the bifurcation aortae? So where could you
palpate an AAA?
Where is the ligament of Poupart? Which tendon (aponeurose) is it part of?
Where is the point of McBurney? Localize on the body the place where the
incisions are made for a correction of an inguinal hernia, appendectomy, a
small incision cholecystectomy, median laparotomy, Pfannenstiel,
nefrectomy and a clamshell incision. What sort inciscions should,
cosmetically seen, be preferred?
In this dissection you can also see the course of the arteria epigastrica
inferior. To which arteries is it connected?

Table 2: Abdominal wall C187


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Name and localize the four muscle of the abdominal wall. Describe the
course of the fibres. How are these muscles vascularized and innervated?
Study the course of the musculus rectus abdominis. What is a intersection
tendinae? How is the rectus sheath formed?
What is the linea arcuata and where can you localize it. What is the course
of the plates of fascia cranial and caudal of this line?
Between which layers of the abdominal wall (but also the thoracic wall), go
the vessels and the nerves that vascularise and innervate the abdominal
wall (and skin)?
Look at the nuscuki pectoralis major and minor. Name the origin and
insertion and discuss the function.
You can also see the funiculus permaticus (spermatic cord) in this
dissection. Which structures go through here?
o Palpate the ductus deferens

Table 3: Mamma + arm pit


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Study the position of the mamma on the fascia of the musculus pectoralis
major. Localize the origo and insertion of this muscle. What is the function?
Do the same for the m. pectoralis minor.
Name and localize the boundaries of the fosa axillaris as it is used in a
lymph node dissection of the axilla. What is the posterior and anterior
axillary fold?
Try to localize the lymph node stations of the mamma in the fossa axillaris.
Where could the sentinel node be? In what ways do we find the sentinel
node if it has to be removed?
Name the three groups (levels) lymph nodes in this area. Which are
removed in a dissection of a mammaca? Which is possible in a melanoma
on the arm.
Which three important nerves (and the blood vessels that run with it) can
you name in the fossa? Which structures do they innervate? Which can
sometimes not be spared during a lymph node dissection in this area and
which complaints can this give postoperatively?
Discuss (with your teacher if necessary), using the dissection, how a
sentinel node is removed and how a modificated radical mastectomy is
executed?

Table 4: Groin C245


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Study from which structure the ligamentum inguinale (Poupart) is formed.


What is the course of this ligament?
Name and localize (as far as it is visible) the structures that go through the
inguinal canal. What is the length of the inguinal canal?
Now name the structures that go through the inguinal canal. Together they
form the . (give Latin, English and Tanzanian name)? Name the
differences between male and female I this area.
Can you now localize the place of development of a lateral and medial
inguinal hernia? What is the name based on? What is the developing
mechanism of both?
Can you differ between both during a physical examination? Different
inguinal hernias? How do you examine a patient whom you suspect of a
inguinal hernia?
Now discuss, using the dissection, what happens if a hernia inguinalis gets
oppressed?
In the dissection an obvious hernia inguinalis on the right is visible. Is it a
medial or lateral hernia?
You can also see that there has been a surgery (postmortem) on this
dissection. The open procedure, a surgery according to Lichtenstein. Go
through the steps of the operation (with your teacher if necessary):
o Incision in the skin ca. 2 cm cranial from Poupart starting at the os
pubis, several centimetres to lateral.
o Splitting the aponeurose of the m. obliquus internus.
o
The inguinal canal is now opened, make it more open to cranial and
caudal.
o Identify the n. ilioinguinalis. Which other nervus goes deeper in the
funiculus and is not visible?
o Mobilize the funiculus.
o Make the inguinal sac that is stuck in the funiculus free.
o Resection of the inguinal sac if necessary.
o Place and fixate the mesh on the backwall, so that the whole
inguinal hernia is well covered.
o Close the wound in layers.

Table 5: Groin from the inside HEUN 223 and HEUN 224
In these two dissections you can study the inguinal canal and its surroundings
from the inside.
Dissection A.
Put this dissection upright (on its legs) so you can look into it.
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Identify the peritoneum (pincet)


o Which three structures that go through the inguinal canal can you
localize and how do they run compared to the peritoneum?
o Now name the vessel supply of the testes, their origins and where
they end.
Localize these vessels (if you had not done so before).
Localize the annulus inguinalis internus and externus.
Study (palpate) the course of the ductus deferens.
Now discuss, using the dissection, how a medial and lateral inguinal hernia
develop. Carefully palpate with your finger in the inguinal canal.

Dissection B.
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Identify:
o The ligamentum inguinale
o The internal and external annulus inguinalis
o The testicular vessels
o The ductus deferens
Localize the marks of the border between a medial and lateral inguinal
hernia.
How can an urologist or a general practitioner do a vasectomy in an easy
way?
Where do you localize a hernia femoralis?

Table 6: Fossa iliaca and Trigonum femorale.


This is a plastinated dissection of a male. You can study it without gloves.
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Study a couple of structures of the abdominal wall


o The rectus sheath
o The aponeuroses of the m. obliquus externus
Then identify in the lesser pelvis:
o The mm. psoas major, iliacus and psoas minor,
o The ureter
o The ductus deferens
o Which nerve goes over the m. psoas major?
Study the structures in and round the inguinal canal
o The ligamentum inguinale (Poupart)
o The annulus inguinalis internus and externus
o The funiculus spermaticus
o Which two nerves go through the inguinal canal (not visible)?
Localize the lacuna vasorum. Which structures go through here?
Localize the lacuna musculorum. Which structures go through here?
Determine the localization of the inguinal canal in relation to the two
lacunae and the lig. Inguinale.
What are the boundaries of the trigonum femorale?
o Which structures go through here?
o What is the DD of a swelling in this area?
o Explain how a retroperitoneal abscess, after for instance a
duodenum perforation, can manifest itself in this trigonum?
o In which place will you be able to palpate a hernia femoralis?

CKO 3, PR day 2
Table 1: Upper abdomen, superficial
Projection organs on the abdominal skin.
Superficial dissection of the abdomen. This is a so called hooded dissection. In
other words: the complete anterior abdominal (and thoracic) wall is removed to
give you an optimal view. Do realize that the surgical access is often via a median
laparotomy, there the overview is obviously less optimal.
-

The upper border of the abdominal wall is the diaphragm of course.


Determine that a part of the abdominal contents is behind the thoracic
wall. What is the name of an abscess under the diaphragm?
Study the omentum majus and its position. From which embryologic
structure did it develop? So with which organs does it have a connection?
Which function does the omentum majus have during a inflammation of
the abdomen, for instance during a cholecystitis or an appendicitis? How
do picture this?
Study the position of the stomach. Localize and name the different parts
from the distal oesophagus, including both curvatures, till the transition to
the duodenum. Look up how the duodenum will go to retroperitoneal.
Localize the omentum minus (from which embryologic structure?). Which
space lies behind the omentum minus and the stomach?
Localize the liver, the ligamentum falciforme hepatis. In which embryologic
structure did it develop and which (also embryologic) structure goes
through this ligament? Look up the gall bladder. Palpate with your index
finger the foramen of Winslow (=epiploicum, = omentale). The tip of your
finger is now in ? Also, ventral from your finger, there is an important
structure. Which one? Are there concrements in the gall bladder? Look up
in an atlas the position of the 8 liver segments.
Where would you localize of the pancreas? Why is it not directly visible and
how would you get a good access for an operation to the pancreas?
Localize the spleen. In which embryologic structure does the milt develop?
What is the position in relation to the diaphragm? Does a connection
between them exist? What is the relation to the stomach>
Now localize the parts of the colon and look if the mesentery is present.
The mesocolon can be considered the lower border of the bursa omentalis.
What is the relation with the omentum? Can the appendix still be found?

Table 2: bursa omentalis, gall ducts, pancreas, duodenum (725)


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Determine where the bursa omentalis is and name the boundaries of the
bursa.
o At the ventral side
o At the dorsal side
o The caudal boundary
o Left from the bursa lies.
o Right is
Localize the foramen of Winslow and the ligamentum hepatoduodenale.
o Which three structures go through the ligament and localize them in
the dissection.
o What is the Pringle maneuver?
By which structures is the triangle of Calot formed?
o Localize and name the gall ducts in the dissection, as far as they are
visible.
o What do we understand under the syndrome of Mirizzi? Show it in
the dissection.
How would you remove the gall bladder and which important complication
would you have to prevent? Think also of the anatomic variations.
Localize the truncus coeliacus.
o Name the branches of the truncus and localize them as far as they
are visible.

Table 3: Rest of the abdomen, small intestine, colon 316


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Localize the duodenum


o Follow the course from intraperitoneal to extraperitoneal and the
transition to the jejunum.
o Which structures cross the curve of the duodeunum at the dorsal
side?
o What is the ligament of Treitz? (Is it still very visible here)
o What is the manoeuvre according to Kocher (it has been done here)?
For instance during inspection of the dorsal side of the duodenum
when suspecting an aortaduodenal fistula.
Follow the course of the whole small intestine. Notice that the mesentery
stem goes from left at the top to right at the bottom.
Name the parts of the colon and determine which parts do and do not have
a mesentery (in other words: which parts lie secondary retroperitoneal?).
o What do we mean with the paracolic gutters?
o A part of the colon is mobilized. Which parts and which structures
can identify dorsal from here?
Is there still an appendix? If not, where would it have been?
Where is the art. Mesenterica superior and inferior? How is the blood
supply of the small and large intestine?
o During a closure of the art. Mesenterica superior, which part of the
intestine will most probably not survive this and which part does still
have a chance?

Table 4: lesser pelvis, rectum and external genitalia, 239


In this body you will inspect the contents of the (lesser) pelvis. But also look first
at how well you can see the course of the duodenum.
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Study the course of the colon descendens, sigmoid and rectum.


During a sigmoidresection the surgeon starts splitting the peritoneum at
the lateral side. The sigmoid with its mesentery can be flipped over to
medial, just as in this dissection.
o Which artery resides in the mesentery?
o Which structures can you now localize dorsal from the mesentery?
So how are they positioned in relation to the peritoneum?
o We hope that you now realize what structure could unintentionally
perish in a difficult procedure (like with a divericulitis).
Follow the colon to distal.
o Where reside the so called folds of the peritoneum?
o If you would make an incision around the peritoneal fold around the
rectum, you would make the start for a Total Mesorectal Excision
(TME).
o How is the rectum supplied with blood?
Study the internal genitalia.
o Localize the uterus, tubae, fimbriae and ovaria.
o How are these organs supplied with blood? How does this differ from
the blood supply of the testes?
o Where goes the ligamentum latum?
Palpate the cavum Douglasi and realize that you can palpate this space
during a rectal examination and thus can determine if there is a Douglas
abscess.

Table 5: Retroperitoneum and vascularisation 626


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In the SSA you have already studied the side branches of the abdominal
aorta. Name and localize again all the side braches and their
vascularisation area till the ligament of Poupart, using the dissection. Think
again of the unpaired ventral and the paired lateral branches.
o Three ventral unpaired branches. What is their vascularisation area?
o The lateral paired branches. Do they lie retroperitoneal?
o Look at the relations/distances between the branches of the kidney
arteries, the gonadal arteries, the truncus coeliacus and the arteria
mesenterica superior.
Which two manifestations (in general, not necessarily for this dissection) of
atherosclerosis in this area of the abdominal aorta are there? What could
theoretically be the treatment of each of the two abnormalities?
Study the position of the aorta in the area of the kidney arteries. An
aneurysm of the aorta can be treated with an endovascular stent in some
cases. In a case like that, what and why would you want to know about the
position and length of the aneurysm? In other words, when is such a stent
treatment possible and when not?
Localize both ureters again.

Table 6: resections and stomas


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This body has a stoma left in the lower abdomen. Remove the hood.
This body (this former patient) might have had a Hartmann procedure.
What is meant by this?
o At which part has this (terminal) stoma been made? Can you still
find the stump of the rectum?
o If not, which operation would this patient have had then?
In this dissection a resection has been done (by us, post mortem).
o Which resection has been done?
o What kind of anastomosis has been made?
o What other anastomoses are there?
There are other resections possible. Of the following procedures, the
questions are again and again:
o Which part will be removed
o Where are the cutting edges?
A hemicolectomy on the right
A hemicolectomy on the left
An anterior resection
A low anterior resection
What is a terminal stoma, a double barrel stoma, what is
meant by term such as an afferent loop and efferent loop.

Now put back the hood in its place for the next group!

CKO 3 PR dag 3
Table 1. Shoulder, arm.
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Name the bone parts of the upper extremity, use the skeleton for this.
Where is the (only) joint connection with the trunk situated?
Repeat the knowledge on the five most important nerves that come out of
the plexus brachialis using both dissections.
o Which five nerves are meant and try to localize them in the
dissection.
o What is the global course of each nerve? Use the skeleton again.
o Which muscle groups are innervated by these nervi?
o Localize the aforementioned muscle groups.
What is the further course of the arteria subclavia in the arm to the hand
called? Localize this in the dissection.
o Where goes the arcus Palmaris?
o For which operation do you need to have knowledge on this arcus as
a preparation?
How do you explain the loss of sensibility in the area of the lateral
shoulder/upper arm due to a luxation of the shoulder?

Table 2. Superficial muscle groups


NB. You can touch the plastinated dissections with your bare hands,
but you CANNOT touch them with gloves drenched in formaline!
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Name and localize in the plastinated dissections the muscles of the


rotator cuff.
o Explain the impingement syndrome, using the dissections and the
skeleton.
Name and localize the muscles in the embalmed dissections (flexors and
extensors)
o Of the upper arm
o Superficial groups of the fore-arm
Now repeat the innervations of these groups.
Discuss the following case
Case
Patient A, male, 23-years, passionate amateur racing cyclist, fell down in
the final sprint in an important but local competition and broke his fall with
his right arm. He has various scrapes on his right arm and hip, pain in his
right shoulder. He also tells that he has felt an substantial swelling on top
of his shoulder.
o

What is the DD of this injury and what is the treatment?

Patient B, a nine-year old girl, falls out of the climbing rack on the square
in front of the house on a Sunday afternoon. She has a lot of pain in her left
arm and she has to cry a lot. Due to a calm anamnesis of the medical
student at the first aid she is able to tell that most of the pain is near her
elbow. There is an obvious swelling and function laesa.
o

What is the most probable diagnosis of this injury and what is the
treatment.

Patient C, a 3-year old girl was lifted up by her hands by her parents
and was swung forward and backwards as a game. It was a sweet and
kind gesture, but immediately the girl had pain in her left elbow (side of
the father) and she did not want to use her left arm anymore. During
physical examination the arm stands at 90 degrees. There is no
swelling, but there is function laesa.
o

What is the most probable diagnosis and what is the treatment.

Table 3: Deep muscle groups of the arm.


-

Study the deeper muscle groups of the fore-arm in the model and the
dissections.
Which muscles are involved in supination and pronation. Study these
muscles with their origo and insertion. Try to localize them in the
dissection.
Study, by using the dissections, by which structures the tabatiere
anatomique is formend. Also use your own wrist for this.
At the volair side of the wrist run a couple of tendons (..) and muscles.
Study them using the dissections and try if you can find them in your own
wrist.
Where is the carpal tunnel? How is this formed? What is the CTS? What is
the diagnosis and treatment.

Study the following case


Case
Patient D, 34-years old, bouncer at a well know disco, has injured his right hand
during a work accident a week ago. In the beginning he had some pain at the
ulnair side of his hand, but he thought (I can handle a lot of pain, doctor.) that it
was a sprain. Now the pain has gotten worse in the last few days, his hand is
swollen and he visits the first aid at 5.00 oclock in the morning, immediately
after his work.
Study the bony structures in the hand. Think about a differential diagnosis and
possible treatment.

Table 4: Hip and upper leg


NB. You can touch the plastinated dissections with your bare hands, but
you CANNOT touch them with gloves drenched in formaline!
-

Study and name the part of the skeleton at the pelvis and upper leg.
Localize the muscle groups around the hip and those of the upper leg in
the model and the dissections.
By which nervi are these groups innervated?
o What is the course of these nerves?
o What is a meralgia paresthetica?

Study the following case


Case
Patient E, a 22-year old girl has came in with the ambulance after she fell of her
horse, where the horse fell partially on her pelvis. She complains about a lot of
pain around her pelvis with every movement that she makes.
o
o
o

Which kind of pelvic fractures are there?


What can be a severe direct complication of a severe pelvic
fracture? Name two.
Think about the treatment.

Table 5: Knee and lower leg


NB. You can touch the plastinated dissections with your bare hands, but
you CANNOT touch them with gloves drenched in formaline!

Study in the plastinated dissections of the knee:


o The collateral bands,
o The menisci and their differences
o The cruciate ligaments
Name and localize the 4 loges of muscles in the lower leg
Several fractures occur very often. In the embalmed and plastinated
dissections you can see quite well the relations in the articulation
tarsocrualis.
Study:
o The ligaments of the ankle
o The course of the Achilles tendon.
o What are the Ottawa ankle rules?
o What is the compartment syndrome, how can it develop and what is
the treatment?
Study the following case

Case

Patient F, a 53-year old woman, felt a sudden pain in her right calf during her
monthly tennis game, like someone struck her from behind with a racket. She
also thought she heard some kind of snap. She complains about pain, but not
severely so, in her right calf and she also walks a little crippled, according to her
story.
o

What is the most probable diagnosis and what is the treatment?

Patient G, a 34-year old woman, wanted to walk up the stairs quickly and took
of with her right leg. She felt a sudden severe pain in her right calf. Walking hurts
and she thinks that she has notices a swelling in her calf.
o

What is the most probable diagnosis and what is the treatment?

Table 6: Peripheral vessels of the leg. This is a plastinated dissection.


Gloves are not necessary.
The surgical interventions of the vascular surgeon occur for the main part (aside
from the area of the arteria carotis) in the area of the abdominal aorta and iliacal
vessels. But also the course of the peripheral vessels in the leg is an important
area.
-

Name and localize in the dissection the vessels of the arterial system
starting from the bifurcation aortae to the foot. The structures are all
labelled with thread.
Name also the same arteries in the accompanying angiogram.
At which places can you palpate the arteries during you physical
examination?
Which treatment options are there in theory (3) for a patient with a severe
claudication intermittens and a complete obstruction at the beginning of
the arteria femoralis superficialis, (so just after the bifurcation with the
arteria femoralis profunda)?
What is meant with a fem-fem crossover bypass?
What is an axillobifemoral bypass? In which case could this be necessary?