Tables

Question 1

What is the recommended thromboprophylaxis for a patient with a high risk of symptomatic VTE (~6.0%) and an average risk of bleeding (~1%)?
A. IPC
B. LDUH or LMWH
C. LDUH or LMWH plus IPC
D. Fondaparinux or low-dose aspirin

Answer 1

C. LDUH or LMWH plus IPC. For patients with a high risk of symptomatic VTE and an average risk of bleeding, the table recommends a combination of pharmacological (LDUH or LMWH) and mechanical (IPC) prophylaxis.

Question 2

What is the suggested thromboprophylaxis for a patient undergoing high-risk cancer surgery with a high risk of bleeding?
A. IPC until risk for bleeding diminishes and pharmacologic prophylaxis can be added
B. LDUH or LMWH plus IPC
C. Fondaparinux or low-dose aspirin
D. No specific prophylaxis

Answer 2

A. IPC until risk for bleeding diminishes and pharmacologic prophylaxis can be added. This recommendation minimizes the risk of bleeding while still addressing the need for thromboprophylaxis.

Question 3

How would you manage a patient who has a moderate risk of symptomatic VTE (~3.0%) and a high risk of bleeding (~2%)? Why?

Answer 3

For a patient with a moderate risk of symptomatic VTE and a high risk of bleeding, IPC would be recommended. This mechanical method of prophylaxis helps prevent the formation of blood clots without introducing the bleeding risks associated with pharmacological methods like LDUH or LMWH.

Question 4

How would you manage a high-risk patient for whom LDUH and LMWH are contraindicated or not available, and who has an average risk of bleeding?

Answer 4

For such a patient, fondaparinux or low-dose aspirin (160 mg), IPC, or both are recommended. These options provide alternatives for pharmacologic prophylaxis when LDUH and LMWH are contraindicated or unavailable.

Question 5

What is the recommended thromboprophylaxis for a patient with very low risk for symptomatic VTE (<0.5%)?

Answer 5

No specific prophylaxis.

Question 6

What does IPC stand for in the context of thromboprophylaxis?

Answer 6

Intermittent Pneumatic Compression.

Question 7

What are LDUH and LMWH in the context of thromboprophylaxis?

Answer 7

Low-Dose Unfractionated Heparin (LDUH) and Low Molecular Weight Heparin (LMWH).

Question 8

What is recommended for patients undergoing high-risk cancer surgery with an average risk of bleeding?

Answer 8

LDUH or LMWH plus IPC and extended-duration prophylaxis with LMWH post-discharge.

Question 9

What is recommended for a high-risk patient for whom LDUH and LMWH are contraindicated or not available, and who has an average risk of bleeding?

Answer 9

Fondaparinux or low-dose aspirin (160 mg), IPC, or both.

Question 10

What is fondaparinux?

Answer 10

Fondaparinux is an anticoagulant medication that helps prevent blood clots. It is a synthetic pentasaccharide (a sugar molecule composed of five sugar units) that binds to and inhibits the action of a natural anticoagulant inhibitor in the body called antithrombin III. This binding leads to the inhibition of Factor Xa, a key player in the coagulation cascade, and thereby prevents the formation of blood clots.

Fondaparinux is commonly used for the prophylaxis of deep vein thrombosis (DVT) in patients undergoing hip fracture surgery, hip replacement surgery, knee replacement surgery, or abdominal surgery. It is also used to treat acute DVT and pulmonary embolism in conjunction with warfarin, another anticoagulant medication.

As with other anticoagulants, the primary side effect of fondaparinux is an increased risk of bleeding. Therefore, it is used with caution in patients who have a high risk of bleeding. Its use may also be contraindicated in individuals with kidney disease due to decreased drug clearance. It does not require monitoring like warfarin but has a longer half-life which can be problematic in situations where reversal of anticoagulation is needed.

Question 11

What is the recommended management for a Grade 1–2 distal ureteral injury?
A. Ureteroneocystotomy ± psoas hitch or Boari flap
B. Ureteral stent or nephrostomy tube × 2–6 weeks
C. Uretero-ureterostomy over ureteral stent
D. Percutaneous nephrostomy tube

Answer 11

B. Ureteral stent or nephrostomy tube for 2–6 weeks (stent preferred)

Question 12

What is the preferred method for delayed repair of a Grade 5 proximal ureteral injury?
A. There is no preferred method, and options include Ureterocalicostomy, Transureteroureterostomy, Ileal ureter interposition, Autotransplantation, or Appendiceal on lay or buccal mucosal graft.
B. Ureterocalicostomy
C. Transureteroureterostomy
D. Ileal ureter interposition

Answer 12

A. There is no preferred method, and options include Ureterocalicostomy, Transureteroureterostomy, Ileal ureter interposition, Autotransplantation, or Appendiceal on lay or buccal mucosal graft.

Question 13

How would you manage a Grade 3–5 injury in the mid or proximal ureter?

Answer 13

For a Grade 3–5 mid or proximal ureteral injury, a uretero-ureterostomy over a ureteral stent would be the management of choice.

Question 14

What are the options for delayed repair of a Grade 5 proximal ureteral injury?

Answer 14

For a Grade 5 proximal ureteral injury, options for delayed repair include Ureterocalicostomy, Transureteroureterostomy, Ileal ureter interposition, Autotransplantation, or Appendiceal on lay or buccal mucosal graft.

Question 15

What is the treatment for a Grade 1-2 distal ureteral injury?

Answer 15

Ureteral stent or nephrostomy tube for 2–6 weeks (stent preferred).

Question 16

What is the management approach for a Grade 3–5 distal ureteral injury?

Answer 16

Ureteroneocystotomy with or without psoas hitch or Boari flap.

Question 17

How do you manage a Grade 3–5 mid or proximal ureteral injury?

Answer 17

Uretero-ureterostomy over a ureteral stent.

Question 18

What are the options for delayed repair of a Grade 5 proximal ureteral injury?

Answer 18

Options include Ureterocalicostomy, Transureteroureterostomy, Ileal ureter interposition, Autotransplantation, or Appendiceal on lay or buccal mucosal graft.

Question 19

What characterizes a Grade 1 ureteral injury?
A. Contusion or hematoma without devascularization
B. Less than 50% transection
C. More than 50% transection
D. Complete transection with devascularization greater than 2 cm

Answer 19

A. Contusion or hematoma without devascularization

Question 20

What grade of ureteral injury represents complete transection with ≤2 cm devascularization?
A. Grade 3
B. Grade 4
C. Grade 5
D. Grade 6

Answer 20

B. Grade 4

Question 21

What is the difference between a Grade 2 and Grade 3 ureteral injury?

Answer 21

A Grade 2 ureteral injury involves a laceration resulting in less than 50% transection of the ureter, whereas a Grade 3 ureteral injury involves a laceration resulting in more than 50% transection.

Question 22

What does a Grade 6 ureteral injury indicate?

Answer 22

A Grade 6 ureteral injury indicates that the ureter is not salvageable, which means that surgical or medical intervention is unlikely to restore its function.

Question 23

What is a Grade 1 ureteral injury?

Answer 23

A Grade 1 ureteral injury is characterized by a contusion or hematoma without devascularization.

Question 24

What is a Grade 4 ureteral injury?

Answer 24

A Grade 4 ureteral injury is a complete transection with devascularization less than or equal to 2 cm.

Question 25

What does a Grade 6 ureteral injury indicate?

Answer 25

A Grade 6 ureteral injury indicates that the ureter is not salvageable.

Question 26

What is the classification for an extraperitoneal bladder wall laceration less than 2 cm?
A. Grade 1
B. Grade 2
C. Grade 3
D. Grade 4

Answer 26

B. Grade 2

Question 27

Which grade of bladder injury represents a laceration extending into the trigone (bladder neck or ureteral orifice)?
A. Grade 3
B. Grade 4
C. Grade 5
D. Grade 6

Answer 27

C. Grade 5

Question 28

What is the difference between a Grade 3 and Grade 4 bladder injury?

Answer 28

A Grade 3 bladder injury involves an extraperitoneal bladder wall laceration greater than 2 cm, or an intraperitoneal bladder wall laceration less than 2 cm. A Grade 4 bladder injury, on the other hand, involves an intraperitoneal bladder wall laceration greater than 2 cm.

Question 29

What does a Grade 6 bladder injury indicate?

Answer 29

A Grade 6 bladder injury indicates that the bladder is not salvageable, which means that surgical or medical intervention is unlikely to restore its function.

Question 30

What characterizes a Grade 1 hematoma bladder injury?

Answer 30

A Grade 1 hematoma bladder injury is characterized by a contusion or intramural hematoma.

Question 31

What is a Grade 4 bladder injury?

Answer 31

A Grade 4 bladder injury is an intraperitoneal bladder wall laceration greater than 2 cm.

Question 32

What does a Grade 6 bladder injury indicate?

Answer 32

A Grade 6 bladder injury indicates that the bladder is not salvageable.

Question 33

What nerve is at risk during a psoas hitch procedure?
A. Ilioinguinal nerve
B. Obturator nerve
C. Genitofemoral nerve
D. Femoral nerve

Answer 33

C. Genitofemoral nerve

Question 34

What strategy can help avoid injury to the obturator nerve during pelvic lymph node dissection?
A. Longitudinal placement of anchoring sutures parallel to the psoas tendon
B. Careful placement of retractors, avoiding compression on the psoas muscle
C. Careful identification, isolation, and preservation of the nerve within the inguinal canal
D. Complete visualization of the nerve prior to clip placement

Answer 34

D. Complete visualization of the nerve prior to clip placement

Question 35

What are the potential deficits associated with an injury to the genitofemoral nerve during a psoas hitch procedure?

Answer 35

An injury to the genitofemoral nerve during a psoas hitch procedure can result in paresthesias or pain distributed along the base of the scrotum and penis, and upper/medial thigh.

Question 36

How can one avoid injuring the ilioinguinal nerve during an inguinal orchiectomy or hernia repair?

Answer 36

To avoid injuring the ilioinguinal nerve during an inguinal orchiectomy or hernia repair, it is recommended to carefully identify, isolate, and preserve the nerve within the inguinal canal.

Question 37

What nerve is at risk during a psoas hitch procedure and what are the potential deficits?

Answer 37

The genitofemoral nerve is at risk during a psoas hitch procedure, which can result in paresthesias or pain along the base of the scrotum and penis, and upper/medial thigh.

Question 38

What strategy can prevent injury to the obturator nerve during pelvic lymph node dissection?

Answer 38

Complete visualization of the nerve prior to clip placement can help prevent injury to the obturator nerve during pelvic lymph node dissection.

Question 39

What nerve can be affected in the supine position due to inadequate cushioning or padding?

Answer 39

A: The sciatic nerve.

Question 40

What is the deficit in radial nerve injury in the supine position?

Answer 40

Wrist drop.

Question 41

How can median nerve injury be prevented in the supine position?

Answer 41

By avoiding arm dislodgement off the armrest in pronation and ensuring adequate securement.

Question 42

What nerve can be affected by compression against stirrups in lithotomy position?

Answer 42

The posterior tibial nerve.

Question 43

What are the prevention measures for peroneal nerve injury in lithotomy position?

Answer 43

Adequate padding of the dependent leg and avoiding compression of stirrups laterally around the fibular neck.

Question 44

What deficit can occur from obturator nerve injury in lithotomy position?

Answer 44

Motor weakness with thigh adduction.

Question 45

What is the mechanism of anterior tibial nerve injury in prone position?

Answer 45

Extended period of plantarflexion.

Question 46

What is the prevention measure for brachial plexus injury in prone position?

Answer 46

Avoid shoulder and elbow abduction >90 degrees.

Question 47

Which nerve injury in the supine position can lead to a weakened grip and diminished palmar sensation?

A. Sciatic nerve
B. Radial nerve
C. Median nerve
D. Ulnar nerve

Answer 47

C. Median nerve. Explanation: Median nerve injury in the supine position can lead to a weakened grip and diminished palmar sensation. This can be prevented by ensuring the arm is not dislodged off the armrest in pronation.

Question 48

Which nerve injury in the lithotomy position can lead to incontinence (although rare)?

A. Posterior tibial nerve
B. Peroneal nerve
C. Pudendal nerve
D. Obturator nerve

Answer 48

C. Pudendal nerve. Explanation: Pudendal nerve injury, due to excess traction and compression against stirrups, can lead to variable perineal sensory loss and in rare cases, incontinence.

Question 49

What is a deficit resulting from the injury to the anterior tibial nerve in the prone position?

A. Foot drop
B. Shoulder pain
C. Numbness of anterolateral thigh
D. Weakened foot eversion

Answer 49

A. Foot drop. Explanation: Injury to the anterior tibial nerve in the prone position, due to extended periods of plantarflexion, can lead to foot drop. This can be prevented with careful padding and positioning of ankles, foot, leg.

Question 50

Describe the mechanism, deficit, and prevention strategies for a brachial plexus injury in the supine position.

Answer 50

A brachial plexus injury in the supine position can occur due to excessive arm abduction greater than 90 degrees, external arm rotation, and posterior shoulder displacement. This can lead to shoulder pain and variable arm and hand weakness. To prevent such an injury, avoid ipsilateral arm abduction greater than 90 degrees, ensure careful ulnar padding of the contralateral hand, and place the axillary roll just caudal to the axilla.

Question 51

Discuss how peroneal nerve injury can occur in the lithotomy and prone positions, the resulting deficits, and prevention strategies.

Answer 51

In the lithotomy position, peroneal nerve injury can occur due to compression of stirrups laterally around the fibular neck. This can lead to foot drop, weak dorsiflexion, and weakened foot eversion. In the prone position, peroneal nerve injury can occur due to inadequate padding of the dependent leg. The same deficits are observed. Prevention strategies include adequate padding of the dependent leg in the prone position and avoiding lateral compression around the fibular neck in the lithotomy position.

Question 52

What does Grade 1 on the Clavien-Dindo Scale indicate?

Answer 52

Any deviation from the normal postoperative course without the need for pharmacologic treatment or surgical, endoscopic, or radiologic intervention.

Question 53

What does Grade 3 on the Clavien-Dindo Scale indicate?

Answer 53

Complications that require surgical, endoscopic, or radiologic intervention.

Question 54

What does Grade 4 on the Clavien-Dindo Scale indicate?

Answer 54

Life-threatening complications that require intensive care or ICU management.

Question 55

What does Grade 5 on the Clavien-Dindo Scale indicate?

Answer 55

The death of a patient.

Question 56

What does the suffix “d” on the Clavien-Dindo Scale indicate?

Answer 56

The patient has a complication at the time of discharge, indicating the need for a follow-up to fully evaluate the complication.

Question 57

What is the difference between Grade 3A and 3B on the Clavien-Dindo Scale?

A. 3A involves pharmacologic treatment; 3B involves surgical intervention
B. 3A involves intervention not under general anesthesia; 3B involves intervention under general anesthesia
C. 3A involves single-organ dysfunction; 3B involves multi-organ dysfunction
D. 3A involves normal postoperative course; 3B involves deviation from normal postoperative course

Answer 57

B. 3A involves intervention not under general anesthesia; 3B involves intervention under general anesthesia. Explanation: Grade 3 on the Clavien-Dindo Scale involves complications that require surgical, endoscopic, or radiologic intervention, with the distinction between 3A and 3B being whether general anesthesia is used.

Question 58

Which grade on the Clavien-Dindo Scale includes complications that require blood transfusions and total parenteral nutrition?

A. Grade 1
B. Grade 2
C. Grade 3
D. Grade 4

Answer 58

B. Grade 2. Explanation: Grade 2 on the Clavien-Dindo Scale involves complications requiring pharmacologic treatment with drugs other than those allowed for Grade 1, and also includes blood transfusions and total parenteral nutrition.

Question 59

Explain what is meant by a Grade 4 complication on the Clavien-Dindo Scale, and the difference between 4A and 4B.

Answer 59

Grade 4 on the Clavien-Dindo Scale indicates life-threatening complications that necessitate intensive care or ICU management. Grade 4 is further divided into two categories: 4A refers to single-organ dysfunction, which can include conditions requiring dialysis; whereas 4B refers to multi-organ dysfunction, a more critical situation where more than one organ system is affected.

Question 60

What does the “d” suffix in the Clavien-Dindo Scale mean, and when is it used?

Answer 60

The “d” suffix in the Clavien-Dindo Scale stands for “disability.” It is used when a patient has a complication at the time of discharge. This label indicates that a follow-up is required to fully evaluate the nature and impact of the complication.