Lymphocele has been defined as a lymph-filled collection in the retroperitoneum without an epithelial lining. In kidney transplanted patients, lymphocele is a pseudocystic entity with lymph content covered with a hard fibrous capsule frequently localized around the graft. Lymphocele is one of the most common complications after kidney transplantation. It is usually asymptomatic, but can cause pressure on the kidney transplant, ureter, bladder, and adjacent vessels with deterioration of graft function, ipsilateral leg oedema, and external iliac vein thrombosis. Peritoneal fenestration is a well-established method for treatment.

Familial adenomatous polyposis (FAP) is an autosomal dominant, hereditary colon cancer syndrome that is characterized by the presence of innumerable adenomatous polyps in the colon and rectum. Gardner’s syndrome is a variant of FAP, which in addition to the colonic polyps, also presents extracolonic manifestations, including desmoid tumours, osteomas, epidermoid cysts, various soft tissue tumours, and a predisposition to the thyroid and periampullary cancers.
Of patients with FAP, 75%-80% have a family history of polyps and/or colorectal cancer at age 40 years or younger.
Mutations of the APC gene are thought to be responsible for the development of FAP, and the location of the mutation on the gene is thought to influence the nature of the extracolonic manifestations that a given patient might develop.
Though patients are often asymptomatic, bleeding, diarrhoea, abdominal pain and mucous discharge frequently occur. Diagnostic tools include genetic testing, endoscopy, and monitoring for extra-intestinal manifestations.
If left untreated, all patients with this syndrome will develop colon cancer by age 35-40 years. Besides, an increased risk exists for the development of other malignancies.
Currently, surgery is the only effective means of preventing progression to colorectal carcinoma. Restorative proctocolectomy with ileal pouch-anal anastomosis (RPC/IPAA) with mucosectomy is the preferred surgical procedure since it attempts to eliminate all colorectal mucosa without the need for an ostomy. Periampullary carcinoma and intra-abdominal desmoid tumours are a significant cause of morbidity and mortality in these patients after colectomy. Frequent endoscopy is needed to prevent the former, while there is no definitive treatment available yet for the latter.

A midline incision is the most commonly used route of access to the abdominal cavity.
Peritoneal closure
A number of randomized, controlled trials have shown no benefit to peritoneal closure; thus, refraining from closing the peritoneum is a commonly accepted practice. Some surgeons believe that closure of the peritoneum reduces adhesions between the abdominal contents and the suture line; however, at this time, there is only limited scientific evidence for this belief.
Fascial closure
The technique of fascial closure is highly variable among surgeons; however, the various approaches may be grouped into two primary methods as follows:
Layered closure
Mass closure
Layered closure is the sequential closure of each fascial layer individually. The primary advantage of this method is that multiple suture strands exist so that if a suture breaks, the incision is held intact by the remaining sutures.
Mass closure is continuous fascial closure with a single suture. This method allows even distribution of tension across the entire length of the suture, resulting in minimization of tissue strangulation. The goal is an approximation of tissue edges to allow scar formation. Excessive tension leads to tissue necrosis and eventual failure of the closure.
The theoretical disadvantage of mass closure is that a single suture is responsible for maintaining the integrity of the closure. The benefits of mass closure include decreased cost and decreased operating time. There is no evidence that mass closure is associated with an increased incidence of hernia formation or wound dehiscence.
When rectus muscle is incorporated, using absorbable suture and a loose closure in order to decrease postoperative pain and tissue necrosis is important. The assistant following the continuous closure should apply sufficient tension to approximate the tissue without strangulating it. The suture is run in 1-cm intervals (maximally), with at least a 1-cm bite of fascia in each throw.
The two primary methods of skin closure are with suture or staples. Suture closure is generally performed with 3-0 or 4-0 absorbable suture in a running subcuticular fashion or with nylon running or interrupted transdermal suture. Staple closure is a viable alternative to suturing the skin. In a study comparing scar cosmesis at 6 months, no difference in appearance existed in patients with suture versus staple skin closure
What is Jenkins Rule?
It is a rule for closure of the abdominal wound. It states that for a continuous suture, the length of suture used should be at least four times the length of the wound with sutures 1cm apart and with 1cm bites of the wound edge

Neuroblastoma is associated with a deletion on chromosome 1 and inactivation of a suppressor gene. Neurofibromas and osteogenic sarcoma are associated with an abnormality on chromosome 17. Retinoblastoma (Rb) is associated with an abnormality on chromosome 13. Wilms’ tumours of the kidney are associated with an abnormality on chromosome 11.

Thromboangiitis obliterans, also known as Buerger’s disease, is a rare type of occlusive peripheral arterial disease, usually seen in smokers, most commonly in men aged 20 to 40. Symptoms most often include intermittent claudication, skin changes, painful ulcers on extremities, pain in the extremities during rest and gangrene. Diagnosis is based on clinical findings, arteriography, echocardiography, and computed tomography angiography. A difference in blood pressure between arms, or between the arms and legs is a common finding. Electrocardiographic findings include nonspecific abnormality or normal results.

Reversal of the central effects of midazolam by intravenous flumazenil after general anaesthesia. Since many benzodiazepines have longer half lives than flumazenil patients still require close monitoring after receiving the drug. Other drugs provided in the options would not characteristically be used for the reversal of midazolam.

In 1–10% of all patients with acute middle cerebral artery occlusion, the subsequent ischemic stroke can be classified as “malignant,” defined by ischemic brain tissue large enough to cause a considerable increase of ICP and potential cerebral herniation.
Clinically, the patients present with severe hemispheric symptoms including hemiparesis or hemiplegia, loss of visual field, gaze deviation and, depending on the affected hemisphere, neglect or aphasia. Patients may also show an impaired level of consciousness, nausea, vomiting, papillary changes and papilledema as signs of increased ICP.
Decompressive craniectomy is the only therapeutic approach that is based on data of large randomized controlled trials in this condition. Decompressive craniectomy reduces the mortality rate in these patients, however leaving the majority of patients with at least some disability. Other treatment options like osmotherapy may be used in an individual risk-benefit-assessment, but evidence for these treatments and procedures is scarce.

Brucellosis is a highly contagious zoonosis caused by ingestion of unpasteurized milk or undercooked meat from infected animals, or close contact with their secretions.

EBV is known to be carcinogenic for B-cell lymphoma, nasopharyngel carcinoma and Hodgkin’s lymphoma.

A sperm granuloma is a lump of extravasated sperm that appears along the vasa deferentia or epididymides in vasectomized men.
Sperm granulomas are rounded or irregular in shape, one millimetre to one centimetre or more, with a central mass of degenerating sperm surrounded by tissue containing blood vessels and immune system cells. Sperm granulomas can be either asymptomatic or symptomatic (i.e., either not painful or painful, respectively). If it is painful, it can be treated using over-the-counter anti-inflammatory /pain medication. If it causes unbearable discomfort, it may need to be surgically removed. However, they generally heal by themselves. Statistics suggest that between 15-40% of men may develop a granuloma post-vasectomy.

High-voltage electrical burns are associated with rhabdomyolysis. Acute tubular necrosis may also occur.

Electrical burns occur following exposure to electrical current. Full-thickness burns are third-degree burns. With these types of burns, the epidermal and dermal layers of skin are destroyed, and the damage may even penetrate the layer of fat beneath the skin.

Following the burn, there is a local response with progressive tissue loss and release of inflammatory cytokines. Systemically, there are cardiovascular effects resulting from fluid loss and sequestration of fluid into the third space. There is a marked catabolic response as well. Immunosuppression is common with large burns, and bacterial translocation from the gut lumen is a recognised event. Sepsis is a common cause of death following major burns.

After the initial management and depth assessment of the burn, the patient is transferred to burn centre if:
1. Needs burn shock resuscitation
2. Face/hands/genitals affected
3. Deep partial-thickness or full-thickness burns
4. Significant electrical/chemical burns

Management options include:
1. The initial aim is to stop the burning process and resuscitate the patient. Adults with burns greater than 15% of total body surface area require burn fluid resuscitation. Fluids administration is calculated using the Parkland formula. Half of the fluid is administered in the first eight hours. A urinary catheter should be inserted and analgesics should be started.

2. Conservative management is appropriate for superficial burns and mixed superficial burns that will heal in two weeks. More complex burns may require excision and skin grafting. Excision and primary closure is not generally practised as there is a high risk of infection.

3. Circumferential full-thickness burns affecting a limb or severe torso burns impeding respiration may require escharotomy to divide the burnt tissue.

4. There is no evidence to support the use of antimicrobial prophylaxis or topical antibiotics in burn patients.

The muscles of the back of the leg are subdivided into two groups: superficial and deep. Superficial muscles include gastrocnemius, soleus and plantaris. Deep muscles include tibialis posterior, flexor hallucis longus, flexor digitorum longus and popliteus. The superficial ( calf muscles) which are responsible for plantarflexion of the foot are supplied by the tibial nerve as follows: the gastrocnemius and soleus muscles are supplied by the first and second sacral nerves and the plantaris by the fourth and fifth lumbar and first sacral nerve (the tibial nerve).

In adults, the most common primary site of tumour is in the lungs, compared to children wherein the most common primary site is the blood.

Excess of circulating free thyroid hormones (thyroxine and/or triiodothyronine) leads to hyperthyroidism. Common causes include Graves’ disease, toxic thyroid adenoma and toxic multinodular goitre. Grave’s disease is the most common cause and is responsible for 70-80% cases of hyperthyroidism. Other causes include excess intake of thyroid hormone, amiodarone-related. It is important that hyperthyroidism is not confused with hyperthyroxinaemia (high levels of thyroid hormone in blood), which includes causes like thyroiditis. Both the conditions lead to thyrotoxicosis (symptoms due to hyperthyroxinemia). Symptoms include weight loss associated with increased appetite, anxiety, weakness, heat intolerance, depression, increased sweating, dyspnoea, loss of libido, diarrhoea, palpitations and occasionally arrhythmias. If there is an acute increase in metabolic rate, the condition is known as ‘thyroid storm’. Elderly sometimes present only with fatigue and weight loss and this is called apathetic hyperthyroidism. Neurological symptoms are also seen in hyperthyroidism and these are tremor, chorea, myopathy and periodic paralysis. One of the most serious complications of hyperthyroidism is stroke of cardioembolic origin due to coexisting atrial fibrillation.

Answer: Undertake an open inguinal herniotomy

Inguinal hernia is a type of ventral hernia that occurs when an intra-abdominal structure, such as bowel or omentum, protrudes through a defect in the abdominal wall. Inguinal hernias do not spontaneously heal and must be surgically repaired because of the ever-present risk of incarceration. Generally, a surgical consultation should be made at the time of diagnosis, and repair (on an elective basis) should be performed very soon after the diagnosis is confirmed.

The infant or child with an inguinal hernia generally presents with an obvious bulge at the internal or external ring or within the scrotum. The parents typically provide the history of a visible swelling or bulge, commonly intermittent, in the inguinoscrotal region in boys and inguinolabial region in girls. The swelling may or may not be associated with any pain or discomfort.

Open herniotomy is its standard treatment against which all alternative modalities of treatment are evaluated. It is credited with being easy to perform, having a high success rate, and low rate of complications.
The use of prosthetic mesh in these patients is rare, however not uncalled for. Laparoscopic inguinal herniotomy is significantly associated with longer operative time for unilateral cases and a reduction in metachronous hernia development when compared to open inguinal herniotomy. There was a trend towards higher recurrence rate for laparoscopic repairs and shorter operative time for bilateral cases. A well conducted randomized controlled trial is warranted to compare both approaches.

Answer: 6

Eye Opening Response
Spontaneous–open with blinking at baseline – 4 points
Opens to verbal command, speech, or shout – 3 points
Opens to pain, not applied to face – 2 point
None – 1 point

Verbal Response
Oriented – 5 points
Confused conversation, but able to answer questions – 4 points
Inappropriate responses, words discernible – 3 points
Incomprehensible speech – 2 points
None – 1 point

Motor Response
Obeys commands for movement – 6 points
Purposeful movement to painful stimulus – 5 points
Withdraws from pain – 4 points
Abnormal (spastic) flexion, decorticate posture – 3 points
Extensor (rigid) response, decerebrate posture – 2 points
None – 1 point

He opens his eyes to pain and groans or grunts. He extends his hands at the elbow on application of painful stimulus. This gives him a Glasgow score of 6: eye opening response of 2, verbal response 2 and motor response 2.

In a direct inguinal hernia, visceral contents exit the abdomen through a weak point in the fascia in the medial inguinal fossa i.e. the area between the medial and lateral umbilical folds. Such a hernia doesn’t pass through the deep inguinal ring or the lateral inguinal fossa. Note that direct hernias can go through the superficial inguinal ring, although rarely. The supravesical fossa, between the median and medial umbilical folds, is formed by a peritoneal reflection from the anterior abdominal wall onto the bladder and the retrovesical fossa is the region behind the urinary bladder.

The different types of diarrhoea are:
1. Secretory diarrhoea – Due to increased secretion or decreased absorption. There is minimal to no structural damage in this type. The most common cause is cholera toxin which stimulates secretion of anions (especially chloride), with sodium and water.
2. Osmotic diarrhoea – Due to increased osmotic load, there is water loss. This occurs in cases of maldigestion syndromes, such as coeliac or pancreatic disease.
3. Motility-related diarrhoea – Occurs in cases of abnormal gastrointestinal motility. Due to increased motility, there is poor absorption and this leads to diarrhoea. This is seen post-vagotomy or in diabetic neuropathy.
4. Inflammatory diarrhoea – Due to damage to the mucosa or brush border, there is a loss of protein-rich fluids and poor absorption. Features of all the above three types can be seen in this type. Aetiology includes bacterial, viral, parasitic infections or autoimmune problems including inflammatory bowel disease.

The scaphoid bone is the most commonly fractured carpal bone. Fractures are most often localized in the middle third of the scaphoid bone.
Generally, scaphoid bone fractures result from indirect trauma when an individual falls onto the outstretched hand with a hyperextended and radially deviated wrist. Pain when applying pressure to the anatomical snuffbox is highly suggestive of a scaphoid bone fracture.
X-ray is the initial test of choice for diagnosis. Computer tomography and magnetic resonance imaging may be indicated, if x-ray findings are negative but clinical suspicion is high.
Treatment can be conservative (e.g., wrist immobilization) or in certain cases surgical (e.g., proximal pole fracture). Complications include non-union and avascular necrosis.

In performing noncardiac surgery on patients on anticoagulation, the major concern is when it is safe to perform surgery without increasing the risk of haemorrhage or increasing the risk of thromboembolism (e.g., venous, arterial) after discontinuing treatment.
Any patient who is on long-term anticoagulation and is to undergo a major surgery needs proactive management.
Heparin is discontinued 6-12 hours before surgery and restarted at 200-400 U/h at 4-6 hours after surgery. Coumadin is restarted as soon as tolerated by the patient. Stop oral anticoagulants at least 5 days preoperatively, and do not perform the procedure until the PT is in the reference range.

Normally, the transfer of oxygen from air spaces to blood takes place across the alveolar-capillary membrane by simple diffusion and depends entirely on the amount of blood flow (perfusion-limited process). Diseases that affect this diffusion will transform the normal process to a diffusion limited process. Thus, the diseases which cause a thickened barrier (such as pulmonary oedema due to increased extravascular lung water or asbestosis) will limit the diffusion of oxygen. Chronic obstructive lung diseases will have little effect on diffusion. Inhaling hyperbaric gas mixtures might overcome the diffusion limitation in patients with mild asbestosis or interstitial oedema, by increasing the driving force. Strenuous (not mild) exercise might also favour diffusion limitation and decrease passage time. Increasing the rate of ventilation will not have this affect but will only maintain a high oxygen gradient from air to blood.

Cryptosporidium parvum is one of several species that causes cryptosporidiosis, a parasitic disease of the mammalian intestinal tract. Primary symptoms of C. parvum infection are acute, watery, and non-bloody diarrhoea. C. parvum infection is of particular concern in immunocompromised patients, where diarrhoea can reach 10–15 l per day.

Answer: Measurement of faecal calprotectin

Based on Rome criteria, this patient has Irritable Bowel Syndrome (IBS). Irritable bowel syndrome (IBS) is a group of symptoms—including abdominal pain and changes in the pattern of bowel movements without any evidence of underlying damage. These symptoms occur over a long time, often years. It has been classified into four main types depending on whether diarrhoea is common or constipation is common, or both are common, or neither occurs very often (IBS-D, IBS-C, IBS-M, or IBS-U respectively). IBS negatively affects quality of life and may result in missed school or work. Disorders such as anxiety, major depression, and chronic fatigue syndrome are common among people with IBS.

The recommendations for physicians are to minimize the use of medical investigations. Rome criteria are usually used. They allow the diagnosis to be based only on symptoms, but no criteria based solely on symptoms is sufficiently accurate to diagnose IBS. Worrisome features include onset at greater than 50 years of age, weight loss, blood in the stool, iron-deficiency anaemia, or a family history of colon cancer, celiac disease, or inflammatory bowel disease. The criteria for selecting tests and investigations also depends on the level of available medical resources.

Rome criteria
The Rome IV criteria includes recurrent abdominal pain, on average, at least 1 day/week in the last 3 months, associated with two or more of the following criteria:

Related to defecation
Associated with a change in frequency of stool
Associated with a change in form (appearance) of stool.
Physicians may choose to use one of these guidelines or may simply choose to rely on their own anecdotal experience with past patients. The algorithm may include additional tests to guard against misdiagnosis of other diseases as IBS. Such red flag symptoms may include weight loss, gastrointestinal bleeding, anaemia, or nocturnal symptoms. However, red flag conditions may not always contribute to accuracy in diagnosis; for instance, as many as 31% of people with IBS have blood in their stool, many possibly from hemorrhoidal bleeding.

The diagnostic algorithm identifies a name that can be applied to the person’s condition based on the combination of symptoms of diarrhoea, abdominal pain, and constipation. For example, the statement 50% of returning travellers had developed functional diarrhoea while 25% had developed IBS would mean half the travellers had diarrhoea while a quarter had diarrhoea with abdominal pain. While some researchers believe this categorization system will help physicians understand IBS, others have questioned the value of the system and suggested all people with IBS have the same underlying disease but with different symptoms

The main diseases that cause an increased excretion of faecal calprotectin are inflammatory bowel diseases, coeliac disease, infectious colitis, necrotizing enterocolitis, intestinal cystic fibrosis and colorectal cancer.

Although a relatively new test, faecal calprotectin is regularly used as indicator for inflammatory bowel diseases (IBD) during treatment and as diagnostic marker. IBD are a group of conditions that cause a pathological inflammation of the bowel wall. Crohn’s disease and ulcerative colitis are the principal types of inflammatory bowel disease. Inflammatory processes result in an influx of neutrophils into the bowel lumen. Since calprotectin comprises as much as 60% of the soluble protein content of the cytosol of neutrophils, it can serve as a marker for the level of intestinal inflammation. Measurement of faecal calprotectin has been shown to be strongly correlated with 111-indium-labelled leucocytes – considered the gold standard measurement of intestinal inflammation. Levels of faecal calprotectin are usually normal in patients with irritable bowel syndrome (IBS). In untreated coeliac disease, concentration levels of faecal calprotectin correlate with the degree of intestinal mucosal lesion and normalize with a gluten-free diet.

Faecal calprotectin is measured using immunochemical techniques such as ELISA or immunochromatographic assays. The antibodies used in these assays target specific epitopes of the calprotectin molecule.

Gallbladder ultrasonography should be considered if the patient has recurrent dyspepsia or characteristic postprandial pain.

Abdominal computed tomography (CT) scanning is appropriate to screen for tumours, obstruction, and pancreatic disease if these are diagnostic possibilities.

CT and magnetic resonance (MR) enterography or wireless capsule endoscopy are employed if red flags exist to suggest enteritis (small bowel inflammation) or a tumour.

Colonoscopy is appropriate if alarm symptoms are present and in patients who otherwise qualify for screening colonoscopy.

The most likely diagnosis is aortic dissection.

Aortic dissection occurs following a tear in the aortic intima with subsequent separation of the tissue within the weakened media by the propagation of blood. There are four different classifications of aortic dissection and the commonest one used is the Stanford classification dividing them into type A and type B. A type A dissection involves the ascending aorta and/or the arch whilst type B dissection involves only the descending aorta and occurs distal to the origin of the left subclavian artery.

Aortic dissection in pregnancy occurs most commonly in the third trimester due to the hyperdynamic state and hormonal effect on vasculature. Other common predisposing factors for aortic dissection include Marfans syndrome, Ehlers-Danlos syndrome, and bicuspid aortic valve. Aortic dissection often presents with sudden severe, tearing chest pain, vomiting, and syncope, most often from acute pericardial tamponade. The patient may be hypertensive, clinically. The right coronary artery may become involved in the dissection, causing myocardial infarct in up to 2% of the cases (hence ST-segment elevation in the inferior leads). An aortic regurgitant murmur may be auscultated.

The management options during pregnancy include:
1. <28 weeks of gestation: aortic repair with the foetus kept in utero
2. 28–32 weeks of gestation: dependent on foetal condition
3. >32 weeks of gestation: caesarean section followed by aortic repair in the same operation

Anterior cruciate ligament (ACL) injuries are most often a result of low-velocity, noncontact, deceleration injuries and contact injuries with a rotational component. Contact sports also may produce injury to the ACL secondary to twisting, valgus stress, or hyperextension all directly related to contact or collision.

Symptoms of an acute ACL injury may include the following:
– Feeling or hearing a “pop” sound in the knee
– Pain and inability to continue the activity
– Swelling and instability of the knee
– Development of a large hemarthrosis

Differential Diagnoses
A- Medial Collateral Knee Ligament Injury
Contact, noncontact, and overuse mechanisms are involved in causing MCL injuries.
Contact injuries involve a direct valgus load to the knee. This is the usual mechanism in a complete tear.
Noncontact, or indirect, injuries are observed with deceleration, cutting, and pivoting motions. These mechanisms tend to cause partial tears.
Overuse injuries of the MCL have been described in swimmers. The whip-kick technique of the breaststroke has been implicated. This technique involves repetitive valgus loads across the knee.

B- Posterior Cruciate Ligament Injury
Knowledge of the mechanism of injury is helpful. The following 4 mechanisms of PCL injury are recognized:
– A posteriorly directed force on a flexed knee, e.g., the anterior aspect of the flexed knee striking a dashboard, may cause PCL injury.
– A fall onto a flexed knee with the foot in plantar flexion and the tibial tubercle striking the ground first, directing a posterior force to the proximal tibia, may result in injury to the PCL.
– Hyperextension alone may lead to an avulsion injury of the PCL from the origin. This kind of injury may be amenable to repair.
– An anterior force to the anterior tibia in a hyperextended knee with the foot planted results in combined injury to the knee ligaments along with knee dislocation.

In chronic PCL tears, discomfort may be experienced with the following positions or activities:
– A semi flexed position, as with ascending or descending stairs or an incline
– Starting a run
– Lifting a load
– Walking longer distances
– Retro patellar pain symptoms may be reported as a result of posterior tibial sagging.
– Swelling and stiffness may be reported in cases of chondral damage.
– Individuals may describe a sensation of instability when walking on uneven ground
– Medial joint line pain may be reported.

EAU Guidelines on Urolithiasis recommend that
Proximal Ureteral Stone:
< 10 mm: shock wave lithotripsy (SWL) or ureterorenoscopy (URS)
> 10 mm: 1. URS (ante- or retrograde) 2. SWL

Contraindications of extracorporeal shock wave lithotripsy:
– Pregnancy, due to the potential effects on the foetus.
– Bleeding diatheses, which should be compensated for at least 24 hours before and 48 hours after
treatment.
– Uncontrolled UTIs
– Severe skeletal malformations and severe obesity, which prevent targeting of the stone.
– Arterial aneurysm in the vicinity of the stone.
– Anatomical obstruction distal to the stone.

Lowering shock wave frequency from 120 to 60-90 shock waves/min improves SFRs.
The number of shock waves that can be delivered at each session depends on the type of lithotripter and shock wave power. There is no consensus on the maximum number of shock waves.
Starting SWL on a lower energy setting with stepwise power (and SWL sequence) ramping can achieve vasoconstriction during treatment, which prevents renal injury.

Haemoglobin S is an abnormal type of haemoglobin seen in sickle cell anaemia. This allows for the haemoglobin to crystalize within the RBC upon exposure to low partial pressures of oxygen. This results in rupture of the RBCs as they pass through microcirculation, especially in the spleen. This can cause blockage of the vessel down stream and ischaemic death of tissues, accompanied by severe pain.

A ‘claw hand’ is associated with injury to the ulnar nerve at the wrist affecting the interossei, lumbricals and hypothenar muscles of the hand. It is characterized by hypothenar eminence wasting, hyperextended metacarpophalangeal joints and flexed interphalangeal joints.

The epiploic foramen is an important anatomical opening that allows for the communication between the greater peritoneal sac and the lesser peritoneal sac. Its boundaries are formed; superiorly by the caudate lobe of the liver, anteriorly by the hepatoduodenal ligament (containing the components of the portal triad), inferiorly by the first part of the duodenum and posteriorly by the peritoneum covering the inferior vena cava. The superior aspect of the first part of the duodenum, which forms the inferior boundary of the foramen of Winslow, forms the course of the hepatic artery before it ascends to the porta hepatis where it divides into its right and left branches.

Three main types of variations in the relations of the occipital artery and the hypoglossal nerve are found according to the level at which the nerve crosses the external carotid artery and the point of origin of the occipital artery. In Type I, the hypoglossal nerve crosses the external carotid artery inferior to the origin of the occipital artery; in Type II, the nerve crosses the external carotid artery at the level of origin of the occipital artery; and in Type III, it crosses superior to that level. In Type III the occipital artery makes a loop around the hypoglossal nerve and is in a position to pull and exert pressure on the nerve. This possibility should be taken into consideration in the diagnosis of peripheral paresis or paralysis of the tongue and during surgery in this area.