Surgery

Question 1

Which statement concerning X-ray gowns is correct?

A. Theose worn in the operation theatre must contain lead.
B. Lead gowns are always effective at preventing transmission of X-rays.
C. They may contain antimony (Sb51)
D. They may contain iodine

Answer 1

C. They may contain antimony (Sb51)

Question 2

The Clavien-Dindo system grades complications in relation to:

A. Severity
B. Time from surgery
C. Individual surgeon’s experience
D. Overall survival

Answer 2

A. Severity

Question 3

In abdominal wall closure using a monofilament continuous suture, the ration of suture-length to wound-length should be at least:

A. 2:1
B. 4:1
C. 6:1
D. 8:1

Answer 3

B. 4:1

Question 4

When closing a midline incision, which stragey is best in minimising the risk of surgical site infection or incisional hernia?

A. Large stitches placed more than 1 cm from the wound edge.
B. Small stitches placed 5-8 mm from the wound edge and less than 5 mm apart
C. Alternating small (about 5-8 mm from the wound edge) with large stitches (> 1 cm from the wound edge).
D. The size of the stitches does not matter, as long as the suture length: wound ratio is more than 4:1

Answer 4

B. Small stitches placed 5-8 mm from the wound edge and less than 5 mm apart

Question 5

When gaining open access to the kidney, subcostal and transcostal approaches are options. Weakness, relaxation or partial paralysis of the flank muscles is a known complication with this approach, caused by damage to which nerve?

A. Subcostal nerve
B. Ilioinguinal nerve
C. Genitofemoral nerve
D. Iliohypogastric nerve

Answer 5

A. Subcostal nerve

Question 6

When performing a robot-assisted laparoscopic prostatectomy due to prostate cancer, a 10x7 mm defect in the anterior part of the rectum is noticed. What is the next step?

A. Primary repair with meticulous stitching
B. Conversion to open surgery is mandatory
C. Make a colostomy and leave the defect for a secondary closure
D, Prolonged catheter drainage and antibiotics for at least one month is mandatory

Answer 6

A. Primary repair with meticulous stitching

Question 7

Which vessels will be clamped during a right radical nephrectomy for a level II inferior vena cava (IVC) tumour thrombus (TT) prior to performing the cavatomy?

A. Left renal vein, right renal artery, IVC above and below the TT
B. Lefter renal vein, left renal artery, right renal artery, IVC above and below the TT
C. Suprahepatic veins, left renal vein, right renal artery, IVC above and below the TT
D. Hepatic artery and vein, left renal vein, right renal artery, IVC above and below the TT

Answer 7

A. Left renal vein, right renal artery, IVC above and below the TT

Question 8

Select the correct surgical step performed during the Pringle’s manoueuvre:

A. The liver is mobilised medially
B. The small bowel is rotated
C. The duodenum is mobilised medially
D The hepatic artery and portal vein are clamped/compressed

Answer 8

D The hepatic artery and portal vein are clamped/compressed

Question 9

According to the surgical description of the technique of bladder psoas hitch, te bladder will be anchored to:

A. The psoas muscle using 2 stitches at least 5 mm in depth
B. The psoas muscle laterally to distal part of the external iliac artery, using reabsorbable stitches
C. The psoas minor tendon at least 3 cm above the common iliac artery, using reabsorbable stitches
D. The tendon of the psoas muscle laterally to the bifurcation of iliac vessels using non-reabsorbable stitches

Answer 9

C. The psoas minor tendon at least 3 cm above the common iliac artery, using reabsorbable stitches

Question 10

As far as the technique of urinary diversion according to Bricker is concerned, what is the length of small bowel that is used to create the diversion and how long is the distance between distal portion of bowel loop and ileo-caecal valve?

A. The measurement is tailored to the diameter of the ileum
B. The distance and the length are correlated with body mass index of the patient
C. The loop of ileum is 12-15cm long and it is taken about 15 cm proximally to the ileo-caecal
D. The loop of ileum is 20-25 cm long and it is taken about 5 cm proximally to the ileo-caecal valve

Answer 10

C. The loop of ileum is 12-15cm long and it is taken about 15 cm proximally to the ileo-caecal

Question 11

The hydrodistension of the bladder during cystoscopy in bladder pain syndrome should be performed with a pressure in the bladder of:

A. 2-10 cm H₂O
B. 0-30 cm H₂O
C. 80-100 cm H₂O
D. 130-140 cm H₂O

Answer 11

C. 80-100 cm H₂O

Question 12

In Clavien-Dindo classification a pulmonary embolism post-operatively, is complication class:

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

Answer 12

B. 2

Question 13

Absolute contraindications for laparoscopic surgery include all of the following except:

A. Haemodynamic instability
B. Uncorrectable coagulopathy
C. Prior abdominal or pelvic surgery
D. Significant abdominal wall infection

Answer 13

C. Prior abdominal or pelvic surgery

Question 14

What is the recommended length of pharmacological thromboembolic prophylazis after surgery?

A. Time spent in hospital
B. One week
C. 15 days
D One month

Answer 14

D One month

Question 15

In patients with severe chronic obstructive pulmonary disease (COPD), further studies (i.e., arterial blood gases and pulmonary function tests) are required because of the physiologic effects of the ____

Answer 15

In patients with severe chronic obstructive pulmonary disease (COPD), further studies (i.e., arterial blood gases and pulmonary function tests) are required because of the physiologic effects of the CO 2pneumoperitoneum.

Question 16

Contraindications to laparoscopic surgery include

Answer 16

uncorrectable coagulopathy, intestinal obstruction unless there is an intention to treat, significant abdominal wall infection, massive hemoperitoneum or hemoretroperitoneum, generalized peritonitis, and suspected malignant ascites.

Question 17

When is the preferred time to perform an indicated laparoscopic surgery on a pregnant patient?

Answer 17

The second trimester is a preferred time for necessary surgery, given the completion of fetal organogenesis and reduced chance of inducing labor.

Question 18

Where is the preferred site for insertion of a veress needle when extensive intraabdominal adhesions are expected ie the palmer point

Answer 18

When extensive intra-abdominal or pelvic adhesions are suspected, careful consideration must be given to the possible site of Veress needle insertion as well as to obtaining open access with a Hassonstyle cannula. The Palmer point (subcostal in the midclavicular line on the left side) is the preferred site for Veress needle insertion when extensive intra-abdominal adhesions are suspected (Palmer, 1974). Alternatively, in patients with suspected adhesions, a retroperitoneal approach may be preferable to a transperitoneal approach, or the procedure can be initiated retroperitoneally and the peritoneum entered via the retroperitoneal access

Question 19

Which of the ff results in a greater chance of rhabdomyolysis from flank pressure

Answer 19

A BMI greater than or equal to 25, use of a kidney rest, and full-table flexion as opposed to half-table flexion were associated with increases in interface pressure; of these, use of the kidney rest was believed to be the most detrimental, and its use beyond 20 to 30 minutes was discouraged. Therefore male patients with a BMI of 25 or higher undergoing laparoscopic surgery in the lateral position with the kidney rest elevated and the table completely flexed are at highest risk of developing rhabdomyolysis from flank pressure. In this study the unaugmented operating table mattress was superior to egg crate or gel padding as an augmenting surface material; egg crate padding was equal or superior to the more expensive gel padding.

Question 20

Which is routinely done as preoperative preparation of a patient for laparoscopic or robotic Urologic surgery

Answer 20

Contraindications to laparoscopic or robotic surgery include uncorrectable coagulopathy, intestinal obstruction unless treatment is intended, significant abdominal wall infection, massive hemoperitoneum or hemoretroperitoneum, generalized peritonitis, and suspected malignant ascites.

Question 21

Principles to remember in using monopolar electrosurgical devices during laparoscopy include:

Answer 21

The insulation of the instrument should be routinely checked for damage before use

Question 22

Disadvantages of ultrasonic sealing or cutting instruments compared to monopolar devices include:

Answer 22

Longer time to cool after use

Question 23

Which electrosurgical device is recommended for use in patients with pacemakers?

Answer 23

ultrasonic device

Question 24

Which is the proper sequential order to confirm the proper entry of a Veress needle intraperitoneally?

Answer 24

After placement of the Veress needle, insufflation should never be initiated unless all of the signs for proper peritoneal entry (negative aspiration, easy irrigation of saline, negative aspiration of saline, positive drop test result, and normal advancement test) have been confirmed.

Question 25

The characteristic of carbon dioxide gas that makes it ideal for use as an insufflant is:

Answer 25

CO 2 is the most commonly used insufflant for laparoscopic and robotic surgery and is favored by most minimally invasive surgeons thanks to its properties (colorless, noncombustible, very soluble in blood, and inexpensive). Prolonged postoperative distention of the abdomen does not occur because CO 2 is quickly absorbed (Wolf and Stoller, 1994). It is highly soluble in water and easily diffuses in body tissues. It readily moves out of the peritoneal cavity as a result of a high diffusion gradient caused by the difference in concentration of CO 2 between the intraperitoneal space and the surrounding components (e.g., blood). However, the characteristic of rapid absorption, which lessens the chance of a CO 2 gas embolus, may also lead to potential problems (e.g., hypercapnia, hypercarbia, associated cardiac arrhythmias). In particular, patients with COPD may not be able to compensate for the absorbed CO 2 by increased ventilation; this may result in dangerously elevated levels of CO 2 in these patients, thereby necessitating the direct testing of arterial blood gases during laparoscopy or robotics in the pulmonary compromised patient. Carbon dioxide also stimulates the sympathetic nervous system, which results in an increase in heart rate, cardiac contractility, and vascular resistance. Last, CO 2 is also stored in various body compartments (e.g., viscera, bones, muscles). After prolonged laparoscopic or robotic procedures it may take hours before the patient has eliminated the extra CO 2 that has accumulated in these storage areas; again, this is more often the case and a problem in patients with pulmonary compromise (Lewis et al., 1972; Puri and Singh, 1992; Tolksdorf et al., 1992; Wolf and Stoller, 1994). Therefore, as previously noted, all patients, and in particular those with pulmonary disease, must be closely monitored after a lengthy laparoscopic or robotic procedure for possible signs or symptoms of hypercarbia; indeed, their greatest chance of compromise as a result of hypercarbia may occur after extubation in the postanesthesia recovery room.

Question 26

The traditional pelvic Gibson incision is an ___ or ____ incision from a few centimeters medial to the anterior ____ extending down toward the inguinal fold and terminating just lateral to the____ or continued to above the____

Answer 26

The traditional pelvic Gibson incision is an oblique or curvilinear incision from a few centimeters medial to the anterior superior iliac spine (ASIS) extending down toward the inguinal fold and terminating just lateral to the rectus muscle or continued to above the symphysis pubis

Question 27

For midline incisions, One should identify by palpation the ____, the aponeuroses of the abdominal wall muscles in the midline, and incise along it to avoid cutting through the rectus abdominus muscle.

Answer 27

One should identify by palpation the linea alba, the aponeuroses of the abdominal wall muscles in the midline, and incise along it to avoid cutting through the rectus abdominus muscle.

Question 28

what vessels to avoid during abdominal incisions

Answer 28

1. Lateral cutaneous nerves
2. Anterior cutaneuos perforating nerves

3 Superficial epigastric artery and vein

4, inferior epigastric artery and vein

5. Lumbar artery and nerve
6. subcostal artery
7. Thoracic artery and nerve

4

Question 29

types of flank approach incision

Answer 29

1. 12th rib supracostal
2. 11th rib transcostal
3. thoracoabdominal
4. foley muscle splitting
5. flank subcostal

Question 30

Positioning for dorsal lumbotomy position. The position of the patient on the operating table is important and is characterized by three main features. The laterolateral axis makes a____ with the operating table. It is not necessary for the table to be bent too much because the muscles do not need to be stretched; on the contrary, it is better if they are relaxed to allow easier retraction. The thorax is turned ___ and the pelvis ___ to allow a better opening of the ___ space. The legs and the upper arm are positioned as usual for a flank incision.

Answer 30

Positioning for dorsal lumbotomy position. The position of the patient on the operating table is important and is characterized by three main features. The laterolateral axis makes a 45-degree angle with the operating table. It is not necessary for the table to be bent too much because the muscles do not need to be stretched; on the contrary, it is better if they are relaxed to allow easier retraction. The thorax is turned ventrally and the pelvis dorsally to allow a better opening of the dorsolumbar space. The legs and the upper arm are positioned as usual for a flank incision.

Question 31

The only contraindication to a scrotal incision is ___ or ____, which should be approached through an____

Answer 31

The only contraindication to a scrotal incision is presumed testicular or intrascrotal malignancy, which should be approached through an inguinal incision

Question 32

Perineal incisions are most commonly used as an approach to the __ and ___

Answer 32

Perineal incisions are most commonly used as an approach to the proximal urethra and base of the penis.

Question 33

The radical perineal prostatectomy is done through a large ____. The apex of the incision is about ___cm from the ___, and the ____ are used as landmarks.

Answer 33

The radical perineal prostatectomy is done through a large inverted horseshoe incision. The apex of the incision is about 2 cm from the anal verge, and the ischial tuberosities are used as landmarks.

Question 34

Which of the following is not considered an indication for an open abdominal approach (as opposed to minimally invasive)?

a. Multiple prior abdominal surgeries b. Complex renal mass with caval thrombus c. Previous abdominal hernia repair with mesh d. Patient with multiple comorbidities e. Surgeon’s preference and experience

Answer 34

d. Patient with multiple comorbidities. With an aging and more complex population, having multiple comorbidities on its own is not an indication for open surgery compared to minimally invasive surgery. Answers a, b, c, and e are all considered relative indications for open surgery. Patients with multiple previous abdominal procedures are more likely to have adhesions and difficulties establishing a pneumoperitoneum. Complicated renal tumors with caval thrombi, although possible to do laparoscopically, should be considered for open surgery. A large abdominal wall mesh could significantly complicate a minimally invasive approach, and surgeon skill and preference is another important consideration for an open approach

Question 35

Following a motor vehicle crash (MVC), a 35-year-old male is found to have a significant right-sided renal hilar injury on imaging. He becomes hemodynamically unstable, despite intravenous fluid resuscitation and massive transfusion protocol. The decision is made to take him to the OR. What incision should you use?

a. Flank incision b. Complete midline incision c. Chevron incision d. Subcostal incision e. Thoracoabdominal incision

Answer 35

b. Complete midline incision. Trauma nephrectomies should always be approached with a laparotomy or complete midline incision. The other approaches would not be appropriate in this clinical setting.

Question 36

Which approach of abdominal wall fascial closure has been shown to have a higher rate of abdominal wall hernias?

a. Rapidly absorbable suture, running continuous closure b. Rapidly absorbable suture, interrupted closure c. Slowly absorbable suture, running continuous closure d. Slowly absorbable suture, interrupted closure

Answer 36

. a. Rapidly absorbable suture, running continuous closure. In a 2002 meta-analysis of closure techniques for midline abdominal incisions, Riet et al. found that continuous rapidly absorbable sutures had significantly more incisional hernias than slowly absorbable or non-absorbable sutures. No difference in hernia rates between slowly absorbable and non-absorbable sutures

Question 37

A 25-year-old patient has been cleared to donate her left kidney to her cousin who recently was started on dialysis for end-stage renal disease. She is seeing you for pre-surgical consultation. You inform her you will be performing the nephrectomy laparoscopically and will be extracting the kidney through ___________ because this has been shown to have _________. a. extension of the inferior port site; lower morbidity and incisional hernia rates b. extension of the midline port site; decreased pain scores and complications c. pfannenstiel incision; lower morbidity and incisional hernia rates d. pfannenstiel incision; decreased pain scores and complications e. extension of the superior most port site; decreased pain scores and complications

Answer 37

c. Pfannenstiel incision; lower morbidity and incisional hernia rates. A prospective study comparing Pfannenstiel incision versus port site expansion for nephrectomies showed that morbidity and length of stay were shorter in the pfannensteil group, while a metaanalysis for extractions in laparoscopic bowel surgery showed lower hernia rates with pfannensteil

Question 38

A 45-year-old female had deceased donor renal transplant placed 5 years ago. She has been noncompliant with immunosuppressive medications and the allograft has failed. She has developed periallograft abscess, and the allograft must be removed. Which incision is best for renal allograft nephrectomy? a. Lower midline b. Inguinal incision c. Subcostal incision d. Gibson incision e. Flank incision

Answer 38

d. Gibson incision. Renal transplants and renal allograft nephrectomies are performed through a traditional Gibson incision, which gives extraperitoneal access to the iliac vessels and bladder.

Question 39

Which of the following is NOT an advantage of the thoracoabdominal incision as an approach to large renal tumors? a. Exposure of adjacent thorax b. Exposure of retroperitoneum c. Early vascular control d. Large incision e. Access to inferior vena cava (IVC) for advanced disease/caval thrombus

Answer 39

d. Large incision. The thoracoabdominal incision, although considered to be a large invasive incision, provides the added benefit of significantly improved exposure, ability to achieve early vascular control, and access to major vessels (including the IVC) and organs for advanced renal tumors.

Question 40

Which is the second muscle layer incised in a typical flank incision? a. External oblique b. Internal oblique c. Serratus anterior d. Latissimus dorsi e. Transversalis

Answer 40

b. Internal oblique. The muscle and fascial layers encountered in a traditional flank incision, from skin to abdomen, are the external oblique, internal oblique, and transversalis muscles

Question 41

Which of the following is not considered a true flank incision approach? a. 12th rib supracostal b. 11th rib transcostal c. Subcostal d. 9th rib supracostal

Answer 41

d. 9th rib supracostal. True flank incisions include the 12th rib supracostal, 11th rib transcostal, and subcostal approaches. Going above this level is often in the context of a thoraco-abdominal incision rather than a true flank incision.

Question 42

Which nerve must be carefully handled to avoid injury during surgery in the inguinal canal? a. Femoral nerve b. Sciatic nerve c. Genitofemoral nerve d. Ilioinguinal nerve e. Lateral femoral cutaneous nerve

Answer 42

d. Ilioinguinal nerve. The ilioinguinal nerve runs in the inguinal canal alongside the spermatic cord and should be identified upon opening and closure of an inguinal incision above the inguinal ligament. The genital branch of the genitofemoral nerve is present with the cord structures but is not exposed in the inguinal canal. The other nerves listed do not run through the inguinal canal.

Question 43

Which incision was used for the first-ever planned nephrectomy? a. Thoracoabdominal incision b. Flank incision c. Posterior lumbodorsal incision d. Subcostal incision e. Gibson incision

Answer 43

c. Posterior lumbodorsal incision. The first-ever planned nephrectomy was performed in 1870 through a posterior lumbodorsal incision by Simon. This incision had multiple benefits over other open approaches. These include lack of muscle or rib distortion, faster convalescence, and decreased intra-peritoneal complications.

Question 44

Which are NOT considered benefits of the dorsal lumbotomy approach compared to flank incisions? a. Rib and muscle sparing b. Less postoperative pain c. Decreased hospitalization d. Better surgical exposure for vascular control e. Decreased intra-peritoneal complications

Answer 44

d. Better surgical exposure for vascular control. The dorsal lumbotomy approach, although not as common now, did boast multiple advantages over subcostal or anterior abdominal approaches. These include faster convalescence, less pain, less musculoskeletal complications (flank bulge), decreased hospitalization, and less intra-peritoneal complications. The major disadvantage was limited surgical exposure to the renal hilum and vessels for vascular control.

Question 45

Which of the following is NOT a border of the lumbodorsal region? a. 12th rib–superiorly b. Quadratus lumborum–inferiorly c. Spinal processes–medially d. Iliac crest–inferiorly e. Line between anterior superior iliac spine (ASIS) and costal margin–laterally

Answer 45

b. Quadratus lumborum–inferiorly. The borders of the lumbodorsal region are the 12th rib superiorly, iliac crest inferiorly, spinous processes of vertebral columns medially, and a line between the ASIS (anterior superior iliac spine) and costal margin laterally. The incision is generally made directly over the quadratus lumborum, but it is not a border of this region.

Question 46

4. Which superficial muscles are NOT encountered during a dorsal lumbotomy approach?
   a. Internal oblique b. External oblique c. Latissimus dorsi d. Sacrospinalis e. Quadratus lumborom

Answer 46

a. Internal oblique. The superficial muscles encountered are the sacrospinalis (medially), latissimus dorsi (posteriorly), and external oblique (anteriorly). The incision is deepened through the lumbodorsal fascia where the sacrospinalis muscle is encountered and a “Y” should be made around it

Question 47

What investigations should you consider in a pre-operative assessment of a patient?

Answer 47

1. CBC
2. Basic metabolic panel (electrolytes, Cr)
3. PT/PTT (mandatory if on blood thinners)
4. Pregnancy test (MANDATORY in any woman of childbearing age)
5. CXR
6. ECG (MANDATORY in patients over the age of 40 or pre-existing cardiac history)

Question 48

What are the ASA classifications?

Answer 48

I - Normal healthy patient
II - Patient with mild systemic disease
III - Patient with severe systemic disease that limits activity but is not incapacitating
IV - Patient who has incapacitating disease that is a constant threat to life
V - Moribund patient that is not expected to survive 24 hours with or without an operation
VI - Brain dead patient undergoing organ harvest
*add E for any patient undergoing emergent surgery

Question 49

What is the goal of a pre-operative cardiac evaluation?

Answer 49

Utilize history, physical and ECG to identify serious cardiac diseases such as CAD, HF, arrhythmias, presence of pacemaker, defibrillator or orthostatic hypotension.

Question 50

How long should you wait after an MI before performing an elective surgery

Answer 50

4-6 weeks

Question 51

How do you assess functional capacity and what is the goal of this?

Answer 51

Functional capacity is the ability to meet aerobic demands for an activity. and is measured in METs.
if greater than 4MET’s no further investigation. If able to climb up two flights of stairs without issues equivalent to 4 METs.

Question 52

What are specific patient risk factors for pulmonary complications following surgery?

Answer 52

1. COPD
2. Smoking
3. Pre-operative dyspnea
4. Pre-operative sputum production
5. Pneumonia
6. OSA

Question 53

What objective metric is used to assess pulmonary risk?

Answer 53

FEV1. FEV1 <0.8L/sec or <30% of predicted are at high risk for complications

Question 54

What are the two assessment tools that can be used to assess peri-operative risk in cirrhotic patients?

Answer 54

1. Childs Pugh Classification

2. MELD score

Question 55

For how long must patients quit smoking pre-operatively to significantly lower their complication risk?

Answer 55

8 weeks. If less than 8 weeks actually higher risk of complications. If 6 months or greater risk comparable to non-smokers.

Question 56

How should you manage non-insulin dependent diabetes peri-operatively?

Answer 56

Non-insulin dependent diabetics should have their medications held prior to surgery and managed with a sliding scale with regular glucose monitoring and then have them restarted in the post operative period once the patient is eating.

Question 57

How should you manage insulin dependent diabetics peri-operatively?

Answer 57

If they have insulin pumps they should continue with basal insulin and the pump will adjust as needed. Otherwise should be monitored with a sliding scale and close monitoring of blood glucose levels

Question 58

How do you manage patients with hypo or hyperthyroidism?

Answer 58

If they are not euthyroid at the time of assessment they should be assessed by an endocrinologist.

The greatest risk in the hypothyroid patient is thyroid storm (fever, tachycardia, CVS collapse etc.)

Question 59

How do you manage patients taking steroid medications and what are you concerned about?

Answer 59

Suppression of the HPA axis (adrenal crises).

In patients taking more than 20mg of prednisone each day or its equivalent for more than 3 weeks require stress dosing of steroids

need to factor in inhaled steroids and topical steroids

If patient taking 5mg of prednisone or equivalent each day - can continue with dosing and no stress dose required

Question 60

How do you stress dose steroids?

Answer 60

Give 50-100mg of IV hydrocortisone before induction of anesthesia, and 25-50mg of IV hydrocortisone q8h x 24-48h until normal steroids can be resumed.

Question 61

What is the safest time to perform surgery on a pregnant patient?

Answer 61

Second trimester. First trimester high risk of teratogenic effects from anaesthesia/radiation. Third trimester high risk of causing pre-mature labour.

Question 62

How can you assess nutritional status on history?

Answer 62

Ask about weight loss. If greater than 20lbs in 3 months prior to surgery should investigate further (albumin)

Question 63

When should you consider post-operative parenteral nutrition.

Answer 63

Patients that will be unable to meet their required caloric demand for 7-10 days after surgery (cystectomy patients)

Question 64

Who should you consider pre-operative nutritional support and what methods are available to you and preferred?

Answer 64

1. Total parenteral nutrition
   7-10 days beneficial in severely malnourished. Harmful in moderately malnourished (increased risk of sepsis)
2. Enteral feeding preferred over TPN - methods NG tubes, gastrostomy feeding or jejunostomy feeding

Question 65

What things should you consider when making patient centred decisions on antibiotic prophylaxis?

Answer 65

1. Patient susceptibility to infection.
2. Inherent infection risk of procedure
3. Potential morbidity of infection

• in older immunocompromised patients prophylaxis is reasonable for benign procedures*

Question 66

List 10 patient factors that increase the risk of infection?

Answer 66

1. Advanced age
2. Anatomic anomalies
3. Poor nutritional status
4. Smoking
5. Chronic steroid use
6. Immunodeficiency
7. Chronic indwelling hardware
8. Infected endogenous or exogenous material
9. Distant coexistent infection
10. Prolonged hospitalization

Question 67

What is the surgical classification of wounds?

Answer 67

1. Clean
   - Uninfected wound without inflammation or entry into the genital, urinary or alimentary tract. Primary wound closure, closed drainage.
2. Clean contaminated Uninfected wound with controlled entry into the genital, urinary, or alimentary tract. Primary wound closure, closed drainage.
3. Contaminated
   Uninfected wound with major break in sterile technique (gross spillage). Open fresh accidental wounds
4. Dirty Infected
   Wound with pre-existing clinical infection or perforated viscera. Old traumatic wounds with devitalized tissue.

Question 68

When should antibiotic prophylaxis be given?

Answer 68

Within 30 minutes of incision.

Question 69

List lower tract urologic procedures that warrant post-procedural antibiotic prophylaxis?

Answer 69

1. Cystoscopy with manipulation

2. TRUS Bx

Question 70

List upper tract urologic procedures that warrant post-procedural antibiotic prophylaxis?

Answer 70

1. ESWL
2. Percutaneous renal surgery
3. Ureteroscopy

Question 71

What are your choices for mechanical and pharmacologic prophylaxis against VTE?

Answer 71

1. SCD’s
2. LMWH - nephrotoxic
3. UFH - can be used in renal insufficiency

Question 72

What are patient related risk factors for VTE?

Answer 72

1. Malignancy
2. Surgery
3. Immobility
4. Smoking
5. Pregnancy
6. Trauma
7. OCP
8. Older age
9. EPO
10. Myeloproliferative disorders
11. Obesity
    12 Central venous catheterisation
12. Inherited or acquired thrombophilia
13. Nephrotic syndrome
14. Previous VTE

Question 73

How do you risk stratify urologic patients for VTE?

Answer 73

Low risk: minor surgery age < 40, no additional risk factors

Moderate risk: minor surgery in patients with additional risk factors, surgery in patients aged 40-60

High risk: surgery in patients older than 60, patients aged 40-60 with additional risk factors

Question 74

What prophylaxis measures should you take in low risk patients, moderate risk patients and high risk patients?

Answer 74

low risk - no prophylaxis (early ambulation)

moderate risk - SCD’s or heparin

high risk - SCD’s and heparin

Question 75

What is the pharmacologic half-life of warfarin and when should it be stopped prior to surgery?

Answer 75

36 hours - should stop warfarin therapy 5 days before surgery (*3 half lives) to ensure INR < 1.5

Question 76

In what patients that are anti coagulated pre-operatively should you consider bridging anticoagulation?

Answer 76

Any moderate and high risk patients

Moderate risk = A-fib (CHADs 3-4), VTE in past 3-12 months, non-severe thrombophilia, aortic valve prosthesis + 1 of (a-fib, stroke, TIA, HTN, DM, CHF)

High Risk = A-fib Chads 5+, recent stroke within 6 months, mitral valve prosthesis, severe thrombophilia, recent VTE < 3 months

Question 77

When should aspirin and clopidogrel be stopped prior to surgery

Answer 77

7-10 days

Question 78

In what setting should stopping antiplatelet therapy not be considered?

Answer 78

Cardiac stent placement. high risk of stent thrombosis if dual antiplatelets stopped within 6 weeks of a bare metal stent or within 12 months of a drug eluting stent

Should consider single anti platelet agent and communicate with cardiologist.

Question 79

What are the indications for FFP transfusion?

Answer 79

1. Immediate reversal of warfarin induced coagulopathy
2. Replacement in patients with specific clotting factor deficiencies
3. Evidence of bleeding and INR > 1.5
4. In massive transfusion

Question 80

What are the two major causes of hypothermia in the OR?

Answer 80

1. Anesthetic agents induce a peripheral vasodilation re-distributing heat
2. Conductive heat loss during the procedure

Question 81

How do you define normothermia?

Answer 81

Core temperature of 36-38 degrees

Question 82

What are some of the consequences of hypothermia?

Answer 82

1. Coagulopathy - worsening clotting cascade function, decreased platelet function
2. Increased risk of wound infection 3 fold

Question 83

What are explanatory mechanisms of patient position induced peripheral neuropathy

Answer 83

1. Excessive stretch
2. Prolonged compression
3. Ischemia

Question 84

What precautions should you take in upper extremity positioning to prevent peripheral neuropathy?

Answer 84

1. Limit arm abduction to 90 degrees or less in supine.
2. Pad ulnar groove
3. If arms are tucked at side have them in a neutral forearm position

Question 85

What precautions should you take in lower extremity positioning to prevent peripheral neuropathy?

Answer 85

1. Lithotomy positions should avoid overstitching hamstrings
2. Pad peroneal nerve (at fibular head)
3. Keep flexion of the hips to 80-100 degrees with 30-45 degrees of abduction

Question 86

List the names and locations of different kinds of incisions?

Answer 86

1. Midline abdominal incision (peritoneal and retroperitoneal access)
2. Pfannensteil (transverse lower abdominal)
3. Gibson (oblique incision in lower quadrant) - for access to distal ureters
4. Flank incision (over 11th or 12th rib for retroperitoneal access)
5. Anterior subcostal incision (for access to kidneys via peritoneum)

Question 87

What are the three phases of wound healing?

Answer 87

1. Reactive phase (24h)
2. Proliferative phase (1 week)
3. Maturational phase (1-6 weeks)

Question 88

What occurs during the reactive phase?

Answer 88

Hemostasis and inflammation.

Question 89

Decreased sensation of lateral leg
Inability to evert foot
Foot drop

Answer 89

Peroneal nerve injury (stir-up pressure on side of leg)

Question 90

thigh weakness after hyperflexion of thigh at hip

Answer 90

obturator nerve

Question 91

weak plantar flexion, lateral foot sensation loss, posterior calf parasthesia

Answer 91

posterior tibial nerve (compression of posterior knee against stirrup)

Question 92

Numbness in anterior & lateral thigh after pressure on lateral thigh

Answer 92

lateral femoral cutaneous nerve

Question 93

Shoulder pain & arm weakness after hyper-abduction or arm under rib cage

Answer 93

brachial plexus

Question 94

During psoas hitch, you can get a ___ nerve injury leading to loss of sensation to scrotum & medial thigh

Answer 94

genitofemoral nerve

Question 95

During a pelvic lymph node dissection, a ____ nerve injury can impair leg adduction

Answer 95

obturator

Question 96

During orchiectomy or hernia repair, a ___ nerve injury can lead to loss of inguinal and lateral scrotal sensation

Answer 96

Ilioinguinal

Question 97

Free air in abdomen can be expected up to ___ Days post-op from insufflation

Answer 97

7

Question 98

Rectal injury most commonly occurs during ___ dissection near the prostatic ____

Answer 98

posterior dissection…. prostatic apex

Question 99

Cardiac response to insufflation

\_\_\_\_ venous return
\_\_\_\_ cardiac output
\_\_\_ stroke volume
\_\_\_ SVR
\_\_\_\_ HR

Answer 99

Decrease venous return
Decrease CO & SV
Increased SVR
= or Increased HR

Question 100

Respiratory response to insufflation

____ inspiratory pressure
___ compliance
____ dead space
____ tidal volume

Answer 100

Increased inspiratory pressure & dead space

Decreased compliance & tidal volume

Question 101

Intra-op urine output is NOT predictive of post-op ___

Answer 101

AKI

Question 102

Trendelenburg effects

____ HR & SVR
____ CO & MAP
____ pulm compliance
___ intra-cranial pressure

Answer 102

Decreased HR & SVR

Increase CO & MAP

Decreased pulm compliance

Increase ICP

Question 103

Normal patient increases _____ to blow off absorbed CO2 during insufflation

Answer 103

minute ventilation

Question 104

Young, thin patient who become bradycardic during insufflation - management?

Answer 104

Desufflate abdomen

Atropine

Question 105

Management of air embolism

Answer 105

Desufflate
100% FiO2
Right side up Trendelenberg
CVC to aspirate gas bubble

Question 106

Grade I

Answer 106

Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic and radiological interventions
Allowed therapeutic regimens are: drugs as antiemetics, antipyretics, analgetics, diuretics and electrolytes and physiotherapy. This grade also includes wound infections opened at the bedside.

Question 107

Grade II

Answer 107

Requiring pharmacological treatment with drugs other than such allowed for grade I complications.
Blood transfusionsand total parenteral nutritionare also included.

Question 108

Grade III

Answer 108

Requiring surgical, endoscopic or radiological intervention

Question 109

Grade IIIa

Answer 109

Requiring surgical, endoscopic or radiological intervention

-Intervention not under general anesthesia

Question 110

Grade IIIb

Answer 110

Requiring surgical, endoscopic or radiological intervention

-Intervention under general anesthesia

Question 111

Grade IV

Answer 111

Life-threatening complication (including CNS complications)* requiring IC/ICU-management

Question 112

Grade IVa

Answer 112

Life-threatening complication (including CNS complications)* requiring IC/ICU-management
-single organ dysfunction (including dialysis)

Question 113

Grade IVb

Answer 113

Life-threatening complication (including CNS complications)* requiring IC/ICU-management
-multiorgandysfunction

Question 114

Grade V

Answer 114

Death of a patient

Question 115

Question 1:
A patient experiences prolonged postoperative ileus after cystectomy and is managed with observation and normal IV fluids. According to the Clavien-Dindo Classification of Complications, which grade does this example fall under?

A) II
B) IIIa
C) IVb
D) I

Answer 115

Correct Answer: D

Explanation:
The vignette describes a deviation from the normal postoperative course without the need for pharmacologic treatment or surgical intervention, aligning with Grade I of the Clavien-Dindo Classification. This grade allows therapeutic regimens such as antiemetics, antipyretics, analgesics, diuretics, etc.

Memory Tool:
Think of Grade I as “1” for one step, like treating symptoms without more intense intervention.

Citation:
Modified from Dindo D, Demartines N, Clavien PA. Ann Surg 240(2):205–213, 2004. Table 6.3.

Rationale:
Understanding Grade I complications is essential for postoperative management without needing additional treatments.

Question 116

Question 2:
A patient has perioperative bleeding after nephrectomy requiring blood transfusion but no ICU admission. Which Clavien-Dindo Classification Grade is this?

A) I
B) II
C) IIIa
D) IVa

Answer 116

Correct Answer: B

Explanation:
Grade II involves any deviation requiring pharmacologic treatment other than those allowed for grade I complications, like a blood transfusion in this case.

Memory Tool:
Grade II is “2” for “To Need Medication” outside the regular postop course.

Citation:
Modified from Dindo D, Demartines N, Clavien PA. Ann Surg 240(2):205–213, 2004. Table 6.3.

Rationale:
Recognizing Grade II complications is important for clinicians to decide on further pharmacologic interventions that don’t require ICU admission.

Question 117

Question 3:
In the Clavien-Dindo Classification, what is the key differentiator between Grades IIIa and IIIb?

A) Single vs. multi-organ dysfunction
B) Requiring ICU admission or not
C) Need for general anesthesia
D) Severity of CNS complications

Answer 117

Correct Answer: C

Explanation:
Grade IIIa requires surgical, endoscopic, or radiologic intervention without the need for general anesthesia, whereas IIIb requires general anesthesia for the intervention.

Memory Tool:
IIIa is “A” for “Anesthesia Not Needed,” and IIIb is “B” for “Bring on the Anesthesia.”

Citation:
Modified from Dindo D, Demartines N, Clavien PA. Ann Surg 240(2):205–213, 2004. Table 6.3.

Rationale:
Knowing the difference between IIIa and IIIb guides the medical team’s choices in anesthesia and sedation, thus influencing the course of treatment.

Question 118

Question 4:
A patient experiences myocardial infarction and hypotension after partial nephrectomy, resulting in renal failure and acute respiratory distress syndrome. They are transferred to ICU for intubation, pressors, and dialysis. What Clavien-Dindo Classification Grade would this complication be categorized under?

A) IIIb
B) IVa
C) IVb
D) V

Answer 118

Correct Answer: C

Explanation:
The case involves a life-threatening complication requiring ICU management and exhibits multi-organ dysfunction, which falls under Grade IVb.

Memory Tool:
Remember IVb as “IV-Be Careful,” indicating complications affecting multiple organs and requiring ICU management.

Citation:
Modified from Dindo D, Demartines N, Clavien PA. Ann Surg 240(2):205–213, 2004. Table 6.3.

Rationale:
Identifying Grade IVb complications is crucial because it dictates high-level intensive care unit management and can have life-threatening implications.

Question 119

Question 5:
Which grade in the Clavien-Dindo Classification refers to the death of a patient due to postoperative complications?

A) II
B) IVa
C) V
D) IIIb

Answer 119

Correct Answer: C

Explanation:
Grade V in the Clavien-Dindo Classification explicitly refers to the death of a patient due to postoperative complications.

Memory Tool:
Think of “V” as the Roman numeral for 5, and remember “5” rhymes with “no longer alive.”

Citation:
Modified from Dindo D, Demartines N, Clavien PA. Ann Surg 240(2):205–213, 2004. Table 6.3.

Rationale:
Grade V is a critical classification to understand as it marks the most severe outcome and necessitates a thorough evaluation of what went wrong in the treatment course.

Question 120

Question 6:
Which of the following CNS complications is NOT excluded from the Clavien-Dindo Classification?

A) Brain hemorrhage
B) Ischemic stroke
C) Subarachnoid bleeding
D) Transient Ischemic Attacks (TIAs)

Answer 120

Correct Answer: D

Explanation:
Transient Ischemic Attacks (TIAs) are specifically excluded from the Clavien-Dindo Classification for CNS complications.

Memory Tool:
Think “TIAs” = “Take It Away,” meaning these are excluded from the classification.

Citation:
Modified from Dindo D, Demartines N, Clavien PA. Ann Surg 240(2):205–213, 2004. Table 6.3.

Rationale:
Knowing which complications are excluded helps clinicians understand the full scope of this classification system and avoid any pitfalls in categorizing postoperative complications.