Core Surgical Skills and Postoperative Care Extra Questions

1. Regarding the use of adhesion prevention agents, which of the following is true?

2. Select the single most appropriate statement with reference to abdominal incisions and preoperative preparations in a gynaecological surgery:

3. A 45-year-old woman undergoes an abdominal hysterectomy for a large fibroid uterus. She is found to have a fibroid in broad ligament, and there is a concern that her ureter may have been damaged during the difficult surgery. Which of the following is the least possible site of ureteric injury in this surgery?

4. Regarding nonabsorbable suture materials, which of the following statements is correct?

5. A patient who underwent an abdominal hysterectomy a few days ago complains of numbness over the skin over the anterior aspect of the upper thigh. This could be attributed to neuropathy of the:

6. Staples are used for wound closure. Which of the following statements about the use of staples in a gynaecological surgery is incorrect?

7. Following massive blood transfusion, what is the recommended dose of fresh frozen plasma to be administered to prevent coagulation problems?

8. Axonotmesis is best described as an iatrogenic nerve injury which involves:

9. Which of the following statements regarding laparoscopic entry in cases of previous abdominal surgery is false?

10. Which of the following is an example of a self-retaining retractor?

11. Ms. XY is a Para 1 who has had an emergency caesarean section for failure to progress. Her epidural catheter was removed at 8:00 AM today, 6 h after her CS. She is written up to have prophylactic LMWH daily, commencing today for 10 days. Her postnatal check is satisfactory. Which of the following times is most appropriate for her to have the LMWH?

12. Ms. XY, 48 years old, para 3, is due to undergo a NovaSure endometrial ablation in theatre for heavy menstrual bleeding. A WHO surgical safety checklist is in progress. Which of the following is not a component to the sign out?

13. A surgical position which involves the patient in supine position of the body with hips flexed at 15° as the basic angle and with a 30° head-down tilt is known as:

14. Ms. XY is 35 years old. She is a para 3 with 2 previous caesarean sections and desires permanent contraception. She has opted to have a laparoscopic tubal occlusion/ sterilisation procedure. Her BMI is 33. She has had a successful Veress needle insufflation (first pass). What level of pressure must be obtained before passing the trocar?

15. Intraoperative cell salvage is a strategy to reduce the use of banked blood. If IOCS is done for nonsensitised rhesus negative women at the term of a term caesarean section, which of the following statements is true regarding the minimum dose of anti-D to be administered?

16. All of the following are true about surgical needles except:

17. Which of the following is correct regarding synthetic tissue adhesives?

18. A downward and inward muscle-splitting incision from the McBurney point that allows extraperitoneal drainage of abscesses is called:

19. The ilioinguinal and iliohypogastric nerves can be injured during a gynaecological surgery. Which of the following describes these nerves the best?

20. Which of the following is not a known risk factor for nerve injury during a gynaecological surgery?

21. The inferior epigastric artery originates from:

22. A 34-year-old woman had a caesarean section after 24 h of labour due to secondary arrest of cervical dilatation and maternal exhaustion. Two hours post-LSCS, she complained of acute-onset left-sided chest pain radiating to the left shoulder and arm along with breathlessness. She had no previous known medical conditions or family history of cardiac disease. Which of the following statements is true regard- ing investigations planned to rule out acute myocardial infarction?

23. While operating on a patient in lithotomy position, the padding between the lateral fibular heads and the stirrup prevents injury to:

24. Ms. XY is in theatre for repair of a 3C tear. She has been given spinal anaesthetic and antibiotics. Which suturing technique is most suited for the torn IAS (internal anal sphincter)?

25. Ms. XY is in theatre for repair of a 3C tear. She has been given spinal anaesthetic and antibiotics. What structures are torn in a 3C tear?

26. A medical student asks you how to measure blood pressure.
What maximum pressure should you inflate the cuff to measure systolic blood pressure in pregnancy?

27. A healthy 39-year-old woman with no significant past medical history attends a preoperative assessment clinic.
She is due to undergo a total abdominal hysterectomy for heavy menstrual bleeding following a local anaesthetic endometrial ablation that was unsuccessful.
She is fit and well.
What preoperative investigation is required?

28. On deciding where to place your secondary lateral ports at laparoscopy, care should be taken to avoid the inferior epigastric vessels.
Where can these be found?

29. Your hospital has recently had an increase in postoperative infections. As a result, you are formulating a new guideline that includes information on skin preparation and hair removal prior to surgery. What is the most appropriate method of hair removal prior to surgery?

30. Following delivery, a woman is found to have a third degree tear and a trainee wishes to do the repair under supervision.

31. A 45-year-old woman is undergoing an abdominal hysterectomy for a history of heavy menstrual bleeding that has not responded to medical treatment. The patient has a past history of pelvic pain and the operation notes from a previous laparoscopy comments that the patient had ‘pelvic adhesions’

What is the most appropriate action in terms of protecting the ureter?

32. What is the preferred distension medium for outpatient diagnostic hysteroscopy?

GTG 59 Best Practice in Outpatient Hysteroscopy

Uterine distension with normal saline allows improved image quality and allows outpatient diagnostic hysteroscopy to be completed more quickly as compared with uterine distension with carbon dioxide.

33. At what pressure should the pneumoperitoneum be maintained during the insertion of secondary ports for a laparoscopic procedure?

34. What is the background rate of venous thromboembolism in healthy non-pregnant non-contraceptive using women?

35. What proportion of patients having a surgical procedure will develop a surgical site infection?

36. What is the most common source of microorganisms causing surgical site infection?

37. A 54-year-old patient has had an insertion of a mid-urethral retropubic tape and following the procedure there was a significant fall in the haemoglobin levels from 12.3 g/dl to 7.8 g/dl. Imaging investigations show the presence of retropubic hematoma. A decision is made to evacuate the hematoma. The most appropriate incision would be:

39. Apostoperativepatientwhohadahysterectomyreceivedmorphine in recovery and then again in the gynaecology ward. Her respiratory rate is suppressed; she is drowsy and has pinpoint pupils.

What medication would you give to reverse this potential morphine overdose?

39. A patient who is frail, old and overweight has undergone a midline laparotomy and pelvic clearance for an endometrial cancer.

On postoperative day 4, the nursing staff notice that she has a pressure ulcer with full thickness skin loss, but the bone, tendon and muscle are not exposed.

What type of pressure ulcer grade is this?

40. A woman had an emergency caesarean section for a pathological CTG and pyrexia in labour. She was discharged on postoperative day 4 but re-admitted on day 6 with pyrexia, tachypnoea, tachycardia and hypotension. Haemoglobin is 105 g/l.

Septic shock is the main differential diagnosis.

Following the Sepsis 6 bundle, along with antibiotics and blood cultures, which other important blood test needs to be taken?

41. A patient undergoes a challenging hysterectomy. A drain is left in the pelvis. You are called to review the patient eight hours later as the nurses have noted a high serous drain output and poor urinary output.

What finding would identify if the drain fluid is urine (suggestive of a bladder/ureteric injury) or normal peritoneal fluid?

42. A patient has ventouse delivery Two days later she reports general malaise, fever and feeling unwell.
With sepsis, which is the first clinical sign to deteriorate, which can be detected through the use of early warning scores?

43. Oral fluids and food are often delayed following major gynaecological surgery.
Which gastrointestinal complication is improved by early postoperative feeding?

44. Following a difficult hysterectomy, a 65-year old woman has returned to the gynaecology ward. She had large amounts of morphine in the recovery area for pain relief and is also connected to a patient-controlled analgesia device.

The nurses note that she is drowsy and her respiratory rate is low. The anaesthetist decides to perform arterial blood gas sampling. What disturbance of acid–base balance is this most likely to show?

45. A 31-year-old para 1 undergoes radical vaginal trachelectomy and laparoscopic bilateral lymph node dissection for early cervical cancer. She presents with paraesthesia over the mons pubis, labia majora and the femoral triangle.

Her symptoms are most likely caused by injury to which of the following?

46. A 57-year-old para 4 undergoes vaginal hysterectomy and sacrospinous ligament xation. She complains of postoperative gluteal pain that worsens in the seated position.
Her symptoms are most likely caused by injury to which of the following?

47. The enhanced recovery approach to preoperative, perioperative and postoperative care has major benefits for many patients in relation to quicker recovery following major surgery. It facilitates shorter hospital stay with no increase in readmission rates. This has clear benefits for patients and their families and for healthcare services.

Which of the following is not a component of the enhanced recovery pathways?

48. A 65-year-old diabetic patient with a BMI of 35 kg/m2 had a AH+BSO for complex endometrial hyperplasia with atypia.
What is the best pharmacologic thromboprophylaxis regimen for this patient?

49. Myomectomy for large uterine fibroids can be associated with massive blood loss, blood transfusion and conversion from myomectomy to hysterectomy.
Which of the following is not a recognized intervention to reduce blood loss at the time of open myomectomy?

50. You are asked to prepare a talk for your colleagues on laparoscopic electrosurgical complications.
Which of the following is not one of the safety measures to prevent such laparoscopic complications?

51. T e Smead–Jones closure is a mass closure technique of the anterior abdominal wall using a far–far, near–near approach. The closure is performed using a delayed absorbable suture to include all the abdominal wall structures on the far–far portion and only the anterior fascia on the near–near portion. This allows good healing without intervening fat or muscle.

Which of the following best describes the rate of fascial dehiscence with running mass closure of the abdomen?

52. You are assisting your consultant in a Burch colposuspension procedure for urodynamic stress incontinence after an unsuccessful V procedure.
Which of the following transverse skin incisions allows the easiest access to the space of Retzius?

53. A 39-year-old para 2 presents with an 8-month history of pelvic pain. She has a previous vertical abdominal incision for a ruptured appendix and undergoes a diagnostic laparoscopy using closed-entry technique at Palmer’s point.

Which of the following describes the correct anatomic position of Palmer’s point?

54. You are asked to see a 49-year-old patient in the emergency department who is day 9 following a AH for multiple uterine fibroids. She presents feeling unwell and has lower abdominal pain. Her bowels have been opening regularly and she has had no bloating, nausea or vomiting. On examination her pulse rate is 92 bpm, BP 110/70 mm Hg, temperature 38°C and respiratory rate of 20 per minute. Urinalysis is clear. T e wound is erythematous, indurated and tender to touch. Her haemoglobin is 100 g/L, WBC is 15 × 109/L and CRP of 50 mg/L.

What is the most likely diagnosis?

55. You see a 28-year-old woman in your clinic. She is referred by her GP with a 6-month history of chronic pelvic pain and deep dyspareunia. A pelvic ultrasound scan shows a retroverted uterus, 4 cm endometrioma on the right ovary, normal le ovary and no free fluid in the pelvis. She is using the progesterone-only pill for contraception, and this has helped slightly with the pain. You consent her for laparoscopy and ovarian cystectomy and discuss risks and potential complications associated with these.

Which of the following best describes the risk of bowel injury?

56. You see a 42-year-old woman in your gynaecology clinic. She presents with a history of heavy periods and is up to date with her smears. T ere is no postcoital bleeding. Pelvic ultrasound on the second day of her menstrual cycle shows a bulky uterus with a small, well-de ned hyperechoic mass in the endometrial cavity. A feeding vessel extending to the mass is noted on colour Doppler imaging and both ovaries are unremarkable. The appearances are suggestive of an endometrial polyp. You consent her for diagnostic hysteroscopy, endometrial polypectomy and insertion of LNG-IUS.

What is the risk of damage to the uterus?

57. You see a 45-year-old African-Caribbean woman in your clinic who presents with a large, painless abdominal swelling for 12 months and reports urinary frequency but no dysuria. There is no change in her bowel pattern. Her cycle is 5/28 with passage of blood clots and ooding. She has completed her family and is up to date with her smears. On examination, her abdomen is distended and palpates an irregular and firm mobile nontender pelviabdominal mass equivalent to a 28-week- sized pregnancy. On bimanual examination it is not possible to palpate the uterus separate from this mass. Abdominal and pelvic ultrasound scan suggests multiple uterine fibroids, the largest of which is intramural and measures 14 × 12 × 10 cm. Both ovaries are unremarkable. You discuss abdominal hysterectomy with her and she tells you she wants to keep her cervix.

What is the rate for residual stump cancer of the cervix?

58. You are asked to see a 21-year-old para 1 in the early pregnancy assessment unit. She is 9 weeks into her second pregnancy and presents with cramping abdominal pain and vaginal bleeding. Pelvic ultrasound scan shows a picture of incomplete miscarriage. She opts for surgical management of the miscarriage, and you consent her for surgical evacuation.

What is the risk of uterine perforation at the time of surgical evacuation?

59. You have been asked by your consultant to write a patient information leaflet on caesarean section. You decide to include information on serious and frequently occurring risks.
What is the incidence of ureteric injury at the time of caesarean section?

60. You are performing a diagnostic laparoscopy for a 31-year-old para 1 with a 10-month history of pelvic pain. You attempt insertion of the Veress needle twice. The intra-abdominal pressure is 15 mm Hg. What is your most appropriate next step?

62. You perform laparoscopy for a 27-year-old para 2 with a 6 × 5 × 7 cm le ovarian dermoid cyst. She has had two previous caesarean sections. You use closed-entry technique and insu ate the abdomen to 25 mm Hg before inserting the primary trocar in the umbilicus. After introducing the laparoscope you suspect that a loop of bowel is adherent to the anterior abdominal wall at the primary port site.

62. You are assisting in a total laparoscopic hysterectomy and BSO for extensive endometriosis. The le ureter is accidentally transected at the time of coagulation and division of the uterine artery.

What is the most appropriate intervention?

63. You are performing a hysteroscopy and endometrial biopsy on a 65-year-old para 3 who presents with postmenopausal bleeding and a 9-mm-thick endometrium. You manage to dilate the cervix but there is sudden loss of resistance. You suspect uterine perforation, introduce a 5-mm hysteroscope and recognize a hole on the anterior uterine wall.

What is the most appropriate immediate intervention?

64. You see a 75-year-old patient who had an abdominal hysterectomy 2 days previously. She complains of muscle weakness, palpitations and paraesthesia, and she is oliguric. An ECG shows loss of P-waves, wide QRS complexes and peaked -waves. T e K+ level is 6.3 mmol/L.

What is the most appropriate immediate intervention?