Cholecystectomy

Question 1

True or False?

at the time of laparotomy or laparoscopy for an unrelated pathology, cholecystectomy can be considered for those with documented gallstones even if currently asymptomatic because the incremental risk of the added procedure is small.

Answer 1

Ans TRUE

Blumgart 6e Pg 569

Question 2

Indications for cholecystectomy in asymptomatic cholelithiasis are all except -

A. Sickle cell Disease
B. Total Parenteral Nutrition
C. Abdominal surgery for other indications
D. Remote Location
E. Bariatric surgery

Answer 2

E. Bariatric surgery

Question 3

which of the following is not an advantage of laparoscopic cholecystectomy over open cholecystectomy

A. Decreased incidence of incisional hernia 
B. Better cosmesis
C. Shorter length of stay
D. Earlier return to function
E. Decreased overall cost
F. Decreased risk of CBD injury

Answer 3

F. Decreased risk of CBD injury

Question 4

True of False.

Laparoscopic cholecystectomy as a outpatient procedure is universally accepted and considered safe even in elderly population

Answer 4

Ans True.

Blumgart 6e Pg 569

Question 5

All of the following are watched for during creation of pneumoperitoneum except -

A. Hypercarbia
B. Hypotension
C. Arrythmias
D. Hypothermia

Answer 5

D - Hypothermia

if any of these occur then immediate desufflation is done.

Blumgart 6e Pg 571

Question 6

what is the patient position for laparoscopic cholecystectomy?
Multiple options correct

A. Reverse Trendelenburg 15 degree
B. Reverse Trendelenburg 30 degree
C. Left Low 15 degree
D. Left Low 30 degree

Answer 6

Ans - B and C -

Reverse trendelenburg 30 degree with left low 15 degree.

Blumgart 6e Pg 571

Question 7

in case of a significantly distended gall bladder during cholecystectomy a puncture can be made at the _______ to decompress the GB.

A. Fundus
B. Body
C. Neck
D. Infundibulum

Answer 7

Ans A - Fundus.

Blumgart 6e Pg 572

Question 8

Triangle of cholecystectomy is limited by all of the following except -

A. CHD
B. Cystic Duct
C. Cystic Artery
D. Inferior edge of liver

Answer 8

Answer - cystic artery

Blumgart 6e Pg 573

Question 9

The boundaries are Calot’s triangle are all of the following except

A. CHD
B. Cystic Duct
C. Cystic Artery
D. inferior surface of liver

Answer 9

Answer - Inferior surface of liver

Blumgart 6e Pg 573

Question 10

the plane during dissection of the gall bladder from the liver bed is ideally between

A. Cystic plate and GB wall
B. GB wall and Liver
C. Cystic plate and Liver
D. Any of the above

Answer 10

Ans - A - cystic plate and GB wall.

Blumgart 6e Pg 574

Question 11

Best port for the removal of the gall bladder ?

A. Right Subcostal
B. Subxiphoid
C. Subcostal mid clavicular
D. Umbilical

Answer 11

Ans D - umbilical port is the best for extraction of the Gall Bladder because enlarging this port causes less pain and has a better cosmetic effect that enlarging other ports.

Blumgart 6e Pg 574.

Question 12

True or False -

All fascial defects more than 10 mm in size during laparoscopy should be closed.

Answer 12

True

Blumgart 6e Pg 574.

Question 13

True or False

SILS associated with a lower rate of incisional hernia and wound complications compared to 4 port lap cholecystectomy

Answer 13

False -

SILS compared to 4 port laparoscopic cholecystectomy has been found have higher rates of wound complications and incisional hernia.
hernia - 1.2% for lap and 8.4% for SILS
Blumgart 6e Pg 574

Question 14

Absolute contraindications to cholecystectomy - open and laparoscopic are all except -

A. Refractory Coagulopathy
B. Inability to tolerate General Anesthesia
C. Severe Sepsis causing hemodynamic instability
D. Diffuse peritonitis with hemodynamic instability and unclear diagnosis

Answer 14

Ans D -

diffuse peritonitis with hemodynamic instability and unclear diagnosis can be explored with open approach.

Question 15

Which of the following is not an absolute contraindication to cholecystectomy - open/Lap

A. Refractory coagulopathy
B. Inability to tolerate General Anesthesia
C. severe sepsis causing hemodynamic instability or end organ failure
D. Cirrhosis with portal hypertension
E. Pregnancy

Answer 15

Ans D and E -

Cirrhosis with portal hypertension and pregnancy are relative contraindications but not absolute contraindications.

Although a pregnancy, morbid obesity, previous abdominal operations with extensive adhesions and suspicion of gall bladder cancer may be considered as absolute contraindication by some authors for laparoscopic cholecystectomy.

Blumgart 6e Pg 576

Question 16

Preferred technique of cholecystectomy in patients with cirrhosis -

A. Cholecystectomy is absolutely contraindicated
B. Open cholecystectomy
C. Laparoscopic cholecystectomy
D. Mini-laparotomy

Answer 16

Ans C - laparoscopic cholecystectomy is the procedure of choice in this population since it is well tolerated and has decreased rate of

• • infection
• • Bleeding
• • transfusion
• • Liver failure

laparoscopic cholecystectomy should be preferred over open in Child Pugh’s A and B classes in these patients.

Blumgart 6e Pg 576.

Question 17

what is the average conversion rate to open cholecystectomy

A. 10-20%
B. 5-10%
C. 2-5%
D. <2%

Answer 17

ans B - 5-10%

A national study in USA has shown the average conversion rate to be 5-10%, although it is higher in less experienced surgeons.

Blumgart 6e Pg 576

Question 18

True of False

The antegrade or fundus down technique is used in cases of severe inflammation obstructing the visualisation of cystic duct

Answer 18

Ans - FALSE

this technique should not be used in this situation as there is a significant risk of biliary injury.

the cystic artery should not be dissected for more than 1cm in this technique to avoid injury to the CHD or CBD.

Blumgart 6e Pg 578.

Question 19

During a partial cholecystectomy the gall bladder is opened at the -

A. Fundus
B. Infundibulum
C. Body
D. A or B

Answer 19

Ans - D -

the GB can be opened at the fundus (Commonly) or infundibulum. The posterior wall of the GB is left behind and the mucosa is cauterized.

If bile is found oozing from the CD stump then it is closed with surgical clips or sutures.

Blumgart 6e Pg 580

Question 20

absence of the cystic duct is

A. Physiological
B. Pathological
C. Either A or B
D. Never seen

Answer 20

Ans B -

Absence of the cystic duct is a pathological process due to repeated bouts of inflammation, and this is usually not identified until at the time of the operation.

Blumgart 6e p580

Question 21

most extra-hepatic bile duct anomaly -

A. cystic duct emptying into the RHD
B. cystic duct emptying into a right sectoral duct
C. anomalous right sectoral duct that drains into the CHD or Cystic duct
D. absence of cystic duct

Answer 21

Ans C -

anomalous right sectoral duct that drains into the CHD or Cystic duct is the most common anomaly in extrahepatic bile ducts.

Anomalies in the extrahepatic bile ducts can be present in as many as 12% of the patients.

Blumgart 6e p580.

Question 22

what percentage of patients may have a double Cystic Artery

A. 1-2%
B. 2-12%
C. 12-25%
D. 20-30%

Answer 22

ans C - 12-25% patients.

also when cystic duct arises from an aberrant source it more often than not travels outside the triangle of Calot.

Blumgart 6e pg 581

Question 23

most common artery injured in vasculobiliary injuries -

A. Common Hepatic artery
B. Right hepatic artery
C. Hepatic Artery proper
D. Left Hepatic Artery

Answer 23

Ans B - right hepatic artery is injured in 92% of cases of vasculobiliary injury.

Blumgart 6e Pg 581

Question 24

Most common intraoperative complication during cholecystectomy ?

A. Gall Bladder Perforation
B. Hemmorrhage
C. Bile duct injury
D. Spilled stones

Answer 24

Ans A - gall bladder perforation is the most common intraoperative complication, especially during the learning curve.
but it rarely requires conversion to open.
Rates can be upto 30-40% cases.

GB spillage may cause more postoperative pain, ileus and infection.

Blumgart 6e Pg 581.

Question 25

All of the following are true except - A. most of bile duct injuries are caused by attending surgeons B. Most of the bile duct injuries go unrecognized intraoperatively C. most common cause is misperception of the normal anatomy D. Routine use of cholagiography is the current standard technique to reduce the rate of bile duct injuries.

Answer 25

Ans D - Routine use of Intra-op cholangiography was initially proposed to reduce injury. However it is no longer recommended routinely since - there is a risk of injury while performing Cholangiography itself. - proper interpretation of the anatomy on cholangiography remains challenging. Critical view of safety is the current standard technique to reduce the rate of bile duct injuries. Blumgart 6e Pg 581.

Question 26

Classic injury of laparoscopic cholecystectomy occurs when - A. Cystic duct is mistaken for CBD B. Anomalous right sectoral duct is ligated. C. Cystic duct is mistaken for CHD D. CBD is mistaken for Cystic duct

Answer 26

Ans D - the classical injury during laparoscopic cholecytectomy is when the CBD is mistaken for being the Cystic duct and clipped. Blumgart 6e Pg 582

Question 27

which of the following is not true regarding the classic injury in laparoscopic cholecystectomy ? A. Cystic duct is mistaken for CBD and clipped. B. Cystic duct is pulled too vigorously laterally causing the Cystic duct and CBD to stretch into alignment and appear as one. C. The left side of CHD is mistaken to be the underside of the GB. D. CHD is misidentified as a second cystic duct or an accessory duct E. Right hepatic artery is the most commonly associated arterial injury in this scenario

Answer 27

Ans A - CBD is mistaken as the cystic duct and divided, and not the other way around. 1. CBD is mistaken as cystic duct due to excessive lateral traction causing the cystic duct and CBD to become aligned and appear as one. 2. the dissection then continues postero-superiorly along the left side of the CHD believing it to be the underside the GB 3. the CHD is then divided as the surgeon tries to dissect while he or she believes to be dissection the 'GB from the liver bed' - at this point even if the CHD is identified as a bile duct it is often considered to be a second cystic duct or accessory duct, and therefore if this is also ligated then a even more proximal injury occurs. Blumgart 6e Pg 582

Question 28

What should be the best course of action if a bile duct injury is identified at the time of surgery ? A. assess the extent of injury, and one's own ability to repair it. B. assess patient's current condition, resources of the hospital and availability of specialized hepatobiliary expertise. C. often the most prudent action is to terminate the surgery, leave a drain, and close the patient with immediate referral to a specialized hepatobiliary centre. D. all of the above.

Answer 28

Ans D - all of the above. Early referral to a specialist centre results in a better long term outcome. Blumgart 6e Pg 582