Dr Bhatia Medical Institute

Case Based Questions for Surgery

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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 patients
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 14851487.)
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 (Zenkers) 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 941944.)
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 patients 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 soA 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 Ithe submental and submandibular nodes
Level Iathe submental nodes; medial to the anterior belly of the digastric muscle bilaterally, symphysis of
mandible superiorly, and hyoid inferiorly
Level Ibthe 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 IIupper jugular chain nodes
Level IIajugulodigastric 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 IIbsubmuscular recess; superior to spinal accessory nerve to the level of the skull base
Level IIImiddle 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 IVlower 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 Vposterior triangle nodes
Level Valateral to the posterior aspect of the SCM, inferior and medial to splenius capitis and trapezius,
superior to the spinal accessory nerve
Level Vblateral to the posterior aspect of SCM, medial to trapezius, inferior to the spinal accessory
nerve, superior to the clavicle
Level VIanterior compartment nodes; inferior to the hyoid, superior to suprasternal notch, medial to the
lateral extent of the strap muscles bilaterally
Level VIIparatracheal 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 273:14211428,1995.)
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 Bochdalekthe pleuroperitoneal canallying 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). Calots 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 Calots 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
(Pringles 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 vaginaanteversion 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 symptomlessas 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











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