Membership of the Royal College of Surgeons (MRCS) Applied Surgical Anatomy Syllabus

Applied Surgical Anatomy syllabus — full chapter and topic list

Expand any chapter to see its topics and sub-topics. This is the whole examinable outline for Applied Surgical Anatomy in Membership of the Royal College of Surgeons (MRCS), not a summary of it.

1. 1

   Thorax

   4 topics

   • Thoracic wall and breast
     • Intercostal spaces, ribs and neurovascular bundle
     • Breast structure, blood supply and lymphatic drainage to axilla
     • Diaphragm: openings, attachments and innervation
   • Mediastinum and great vessels
     • Divisions of the mediastinum and contents
     • Aortic arch branches and azygos system
     • Thoracic duct course and relations
   • Heart and pericardium
     • Chambers, valves and surface markings
     • Coronary artery anatomy and dominance
     • Conducting system
   • Lungs, pleura and airways
     • Bronchopulmonary segments
     • Pleural reflections and recesses
     • Hila and root of the lung
2. 2

   Abdomen, Pelvis and Perineum

   5 topics

   • Anterior abdominal wall and inguinal region
     • Rectus sheath and arcuate line
     • Inguinal canal boundaries and contents
     • Hesselbach's triangle and femoral canal
   • Peritoneum and gastrointestinal tract
     • Foregut, midgut and hindgut blood supply
     • Peritoneal ligaments, omenta and lesser sac
     • Portal venous system and portosystemic anastomoses
   • Hepatobiliary and pancreatic anatomy
     • Liver segments (Couinaud) and porta hepatis
     • Biliary tree and Calot's triangle
     • Pancreatic relations and ductal anatomy
   • Retroperitoneum and urinary tract
     • Kidneys, ureters and adrenal glands
     • Abdominal aorta and IVC branches
   • Pelvis and perineum
     • Pelvic floor and ischioanal fossa
     • Rectum and anal canal blood supply and continence
     • Male and female reproductive organs
3. 3

   Head, Neck and Spine

   5 topics

   • Triangles of the neck and fascial planes
     • Anterior and posterior triangle contents
     • Deep cervical fascia and tissue spaces
   • Thyroid, parathyroid and related nerves
     • Recurrent and external laryngeal nerves
     • Thyroid blood supply and embryology
   • Cranial nerves and skull base
     • Course and foramina of cranial nerves
     • Cavernous sinus contents
   • Larynx, pharynx and salivary glands
     • Parotid gland and facial nerve relations
     • Laryngeal cartilages and muscles
   • Vertebral column and spinal cord
     • Vertebral anatomy and intervertebral discs
     • Spinal cord tracts and meninges
4. 4

   Upper and Lower Limb

   5 topics

   • Brachial plexus and shoulder
     • Roots, trunks, divisions, cords and branches
     • Rotator cuff and glenohumeral joint
   • Upper limb nerves and compartments
     • Median, ulnar and radial nerve lesions
     • Cubital fossa and carpal tunnel
   • Hip, thigh and femoral triangle
     • Femoral triangle and adductor canal
     • Hip joint blood supply and capsule
   • Lower limb nerves and popliteal fossa
     • Sciatic, tibial and common peroneal nerves
     • Compartments of the leg and foot
   • Joints and surgical approaches
     • Knee menisci and ligaments
     • Common fracture sites and neurovascular risk
5. 5

   Neuroanatomy and Embryology

   4 topics

   • Central nervous system organisation
     • Cerebral lobes, ventricles and CSF circulation
     • Circle of Willis and cerebral blood supply
   • Autonomic nervous system
     • Sympathetic and parasympathetic outflow
     • Referred pain pathways
   • Surgically relevant embryology
     • Gut rotation and congenital anomalies
     • Branchial arch and thyroglossal development
     • Urogenital and diaphragmatic development
   • Surface anatomy and imaging
     • Cross-sectional CT and MRI interpretation
     • Surface landmarks for procedures

Applied Surgical Anatomy flashcards for Membership of the Royal College of Surgeons (MRCS)

25 of 67 cards from the Applied Surgical Anatomy deck — real questions with worked answers.

1. Which intercostal structures lie within the costal groove on the inferior border of each rib, and in what order from superior to inferior?

   From superior to inferior: intercostal Vein, Artery, Nerve (mnemonic VAN). They run in the costal groove, so a chest drain/needle should be passed just above the rib below (over the upper border) to avoid the neurovascular bundle.

2. What is the arterial blood supply and venous/lymphatic drainage of the breast relevant to surgery?

   Arteries: internal thoracic (medial mammary/perforating branches), lateral thoracic and thoracoacromial (from axillary), and lateral cutaneous branches of posterior intercostals. Lymph drains ~75% to axillary nodes and the rest to internal thoracic (parasternal) nodes; this guides axillary clearance in breast cancer.

3. At which vertebral level is the sternal angle of Louis, and what key structures lie at this plane?

   At the T4/T5 intervertebral disc. It marks: the 2nd costal cartilage, bifurcation of the trachea (carina), start and end of the aortic arch, and the level where the azygos vein arches over the right main bronchus.

4. Define the boundaries and contents of the superior mediastinum.

   Bounded superiorly by the thoracic inlet, inferiorly by the plane of the sternal angle (T4/5), anteriorly by the manubrium, posteriorly by T1-T4 vertebrae. Contents include the aortic arch and its branches, brachiocephalic veins and upper SVC, trachea, oesophagus, thoracic duct, thymic remnant, vagus and phrenic nerves.

5. What are the three branches of the aortic arch in order, and which is most variable?

   In order: brachiocephalic (innominate) trunk, left common carotid artery, left subclavian artery. The most common variant is a common origin of the brachiocephalic trunk and left common carotid ('bovine arch').

6. How do the courses of the right and left recurrent laryngeal nerves differ, and why does this matter surgically?

   The right recurrent laryngeal nerve hooks under the right subclavian artery; the left hooks under the aortic arch (lateral to ligamentum arteriosum). The left therefore has a longer intrathoracic course and is more vulnerable in thoracic/mediastinal pathology (e.g. left vocal cord palsy from a lung apex tumour or enlarged left atrium).

7. Describe the coronary artery supply to the conducting system of the heart.

   The SA node is supplied by the SA nodal artery (from the right coronary artery in ~60% of people). The AV node is supplied by the AV nodal artery, which arises from whichever artery is 'dominant' (the right coronary in ~85-90% of people, defining right dominance).

8. What constitutes the 'dangerous' clinical anatomy of the pericardium, and how is cardiac tamponade relieved?

   The fibrous pericardium is inextensible, so rapid fluid accumulation in the pericardial cavity raises intrapericardial pressure and impairs ventricular filling (tamponade), seen as Beck's triad: hypotension, raised JVP, muffled heart sounds. Relieved by pericardiocentesis, classically via the subxiphoid (Larrey's point) approach directed toward the left shoulder.

9. Name the bronchopulmonary segments and explain the surgical importance of the bronchopulmonary segment.

   There are 10 segments in the right lung and 8-10 in the left. Each segment is a self-contained functional unit with its own segmental bronchus and pulmonary artery branch (segmental veins lie intersegmentally). This independence allows surgical segmentectomy without disrupting neighbouring segments.

10. Why are inhaled foreign bodies more likely to lodge in the right main bronchus?

    The right main bronchus is wider, shorter and more vertical (more in line with the trachea) than the left, so aspirated material preferentially enters it, typically the posterobasal segment of the right lower lobe in an upright patient.

11. Distinguish visceral from parietal pleura in terms of innervation and clinical pain.

    Visceral pleura has autonomic (visceral afferent) innervation and is insensitive to pain. Parietal pleura is innervated by the intercostal nerves (costal/mediastinal parts) and phrenic nerve (central diaphragmatic part); irritation causes sharp, well-localised pleuritic pain, and diaphragmatic irritation can refer to the shoulder tip (C3-5).

12. Describe the layers traversed when making a gridiron incision in the anterior abdominal wall at McBurney's point.

    From superficial to deep: skin, Camper's then Scarper's fascia, external oblique aponeurosis, internal oblique, transversus abdominis, transversalis fascia, extraperitoneal fat, and parietal peritoneum. McBurney's point lies one-third of the way along a line from the ASIS to the umbilicus.

13. What are the boundaries of the inguinal canal and its deep and superficial rings?

    Floor: inguinal ligament (and lacunar ligament medially). Roof: arching fibres of internal oblique and transversus abdominis. Anterior wall: external oblique aponeurosis (reinforced laterally by internal oblique). Posterior wall: transversalis fascia (reinforced medially by conjoint tendon). Deep ring lies in transversalis fascia lateral to the inferior epigastric vessels; superficial ring is a defect in external oblique aponeurosis above the pubic tubercle.

14. How are indirect and direct inguinal hernias distinguished anatomically relative to the inferior epigastric vessels?

    An indirect hernia passes lateral to the inferior epigastric vessels, through the deep ring, traversing the canal (often into the scrotum). A direct hernia pushes through a weakness in the posterior wall (Hesselbach's triangle) medial to the inferior epigastric vessels.

15. What are the boundaries of Hesselbach's (inguinal) triangle?

    Medially: lateral border of rectus abdominis (linea semilunaris). Laterally: inferior epigastric vessels. Inferiorly: inguinal ligament. Direct inguinal hernias protrude through this triangle.

16. List the structures forming the boundaries of the epiploic foramen of Winslow.

    Anterior: free edge of the lesser omentum containing the portal triad (bile duct, hepatic artery, portal vein). Posterior: inferior vena cava. Superior: caudate lobe of the liver. Inferior: first part of the duodenum. It connects the greater and lesser sacs; compressing the free edge controls bleeding (Pringle manoeuvre).

17. Differentiate the foregut, midgut and hindgut by their arterial supply and the level of referred pain.

    Foregut: coeliac trunk (T7-T9), pain referred to epigastrium. Midgut: superior mesenteric artery (T8-T12/L1), pain referred to umbilicus. Hindgut: inferior mesenteric artery (L1-L3), pain referred to suprapubic/hypogastrium. The foregut-midgut junction is at the 2nd part of the duodenum (ampulla); the midgut-hindgut junction is at the distal/splenic-flexure region of the transverse colon (proximal two-thirds vs distal one-third).

18. What are the anatomical features that distinguish the large bowel from small bowel at laparotomy?

    Large bowel has: taeniae coli (three longitudinal muscle bands), haustra (sacculations), appendices epiploicae (fatty tags), and a wider but less mobile lumen. Small bowel has none of these and shows valvulae conniventes (plicae circulares) on imaging.

19. Where do the three taeniae coli converge, and how is this used surgically?

    They converge at the base of the appendix. Following the anterior taenia (taenia libera) distally on the caecum leads the surgeon directly to the appendiceal base, useful when locating a retrocaecal appendix.

20. Describe the anatomical segments of the liver (Couinaud classification) and its functional basis.

    The liver is divided into 8 functionally independent segments (I-VIII), each with its own portal pedicle (branch of portal vein, hepatic artery, bile duct) and drained by a hepatic vein. Segment I is the caudate lobe. This anatomy permits segmental/sectional resections along avascular planes.

21. What structures make up the portal triad, and what is its surgical relevance in the Pringle manoeuvre?

    The portal triad (in the free edge of the lesser omentum/hepatoduodenal ligament) contains the portal vein (posterior), hepatic artery proper (left anterior), and common bile duct (right anterior). The Pringle manoeuvre clamps the triad at the epiploic foramen to control hepatic arterial and portal inflow during liver bleeding.

22. Describe Calot's triangle (hepatobiliary/cystohepatic triangle) and its surgical importance.

    Boundaries: cystic duct (inferolaterally), common hepatic duct (medially), inferior surface of the liver (superiorly). It contains the cystic artery (usually a branch of the right hepatic artery) and a cystic lymph node (of Lund). Careful dissection here ('critical view of safety') prevents bile duct/vessel injury in cholecystectomy.

23. Where does the common bile duct join the pancreatic duct, and what regulates outflow?

    They unite at the hepatopancreatic ampulla of Vater, which opens at the major duodenal papilla in the second part of the duodenum. Outflow is controlled by the sphincter of Oddi. The accessory pancreatic duct (Santorini) usually opens at the minor papilla more proximally.

24. What are the anatomical relations of the pancreas relevant to its surgical approach?

    The head sits in the C-loop of the duodenum with the uncinate process behind the superior mesenteric vessels. The neck overlies the formation of the portal vein (SMV + splenic vein). The body lies over the aorta, left kidney/adrenal and splenic vessels; the tail reaches the splenic hilum within the splenorenal ligament. It is retroperitoneal except the tail.

25. List the retroperitoneal structures using the mnemonic SAD PUCKER.

    Suprarenal (adrenal) glands, Aorta/IVC, Duodenum (2nd-4th parts), Pancreas (except tail), Ureters, Colon (ascending and descending), Kidneys, oEsophagus (lower part), Rectum. These are the secondarily and primarily retroperitoneal viscera.

See more Applied Surgical Anatomy flashcards →

Planning Applied Surgical Anatomy for Membership of the Royal College of Surgeons (MRCS)

Applied Surgical Anatomy (Membership of the Royal College of Surgeons (MRCS)) FAQ