Core Surgical Skills

Question 1

What is the overall rate of serious complications at gynaecological laparoscopy?

Answer 1

1 in 1,000 cases

Question 2

Which complications must be explained for every woman having a gynaecolgical laparoscopy?

Answer 2

Damage to bladder, bowel and urinary tract, and incisional hernia

Question 3

What is the evidence for open (Hasson’s) versus closed (Veress/Visiport) laparoscopic entry?

Answer 3

No significant safety advantage to either method on meta-analysis

Question 4

What two points of technique are evidenced to improve successful Veress needle entry?

Answer 4

1. Not elevating the abdominal wall
2. Observe that the initial insufflation pressure is <8mmHg

Question 5

What intra-abdominal pressures should be used during and after laparoscopic entry?

Answer 5

1. Entry pressure of 20-25mmHg
2. Operating pressure of 12-15mmHg

Question 6

Where is Palmer’s point?

Answer 6

3cm below the left costal margin in the mid-clavicular line

Question 7

What are the rules for the deep rectus sheath should be closed at a port site?

Answer 7

1. Any non-midline port over 7mm should be closed
2. Any midline port over 10mm should be closed

Question 8

Why may saline be a better distension medium than CO2 at outpatient hysteroscopy?

Answer 8

1. It is associated with fewer cases of vasovagal syncope
2. Image quality is often better than with CO2
3. Saline is required if using bipolar electrosurgery

Question 9

What analgesia should be provided if grasping the cervix with a tenaculum is necessary at outpatient hysteroscopy?

Answer 9

Topical local anaesthetic

Question 10

What is the evidence for cervical preparation with prostaglandins prior to outpatient hysteroscopy?

Answer 10

1. No reduction in rate of cervical lacerations across a meta-analysis
2. No reduction in failure rates across a meta-analysis
3. Less pain during cervical dilatation for post-menopausal women who received Misoprostol prior to OPH

Question 11

Which incision gives access to the space of Retzius, necessary for some urogynaecological surgery?

Answer 11

Cherney’s incision

Question 12

Which pelvic side-wall artery can be more easily accessed with a Cherney incision?

Answer 12

The internal iliac

Question 13

What is the major risk of the Maylard incision?

Answer 13

Lower extremity ischaemia due to inferior epigastric artery ligation

Question 14

What can be a useful landmark to identify the midline during midline laparotomy?

Answer 14

The pyramidalis muscle

Question 15

What structures can be damaged if a transverse incision is extended beyond the lateral edges of the rectus muscles?

Answer 15

The ilioinguinal and iliohypogastric nerves

Question 16

What closure technique is favoured by the literature?

Answer 16

Mass closure technique using looped, delayed-absorbable suture (i.e. loop PDS), with a wound: suture length ratio of 1:4

Question 17

Which closure technique can be described as far-far, near-near?

Answer 17

Smead-Jones

Question 18

What is the relative risk of wound infection for morbidly obese patients?

Answer 18

7:1

Question 19

Above what size laparoscopic port incision should deep sheath closure be done?

Answer 19

> 7mm for non-midline
10mm for midline

Question 20

Approximately how many days does PDS take to be absorbed?

Answer 20

180-210 days

Question 21

Approximately how many days does Vicryl take to be absorbed?

Answer 21

60-90

Question 22

What is the incidence of neuropathy following gynaecological surgery?

Answer 22

1.1-1.9%

Question 23

Why is regeneration of nerve function possible with axonotmesis?

Answer 23

Because the Schwann cell layer is not disrupted

Question 24

Why might lateral thigh pain happen following Caesarean section?

Answer 24

Due to damage of the lateral cutaneous branches of the iliohypogastric and ilioinguinal nerves

Question 25

What are the nerve roots of the femoral nerve?

Answer 25

L2-L4

Question 26

What is the course of the femoral nerve?

Answer 26

Passes infero-laterally through the psoas muscle Exits the pelvis beneath the inguinal ligament, lateral to the femoral vessels

Question 27

What is the incidence of femoral nerve injury with abdominal hysterectomy?

Answer 27

11%

Question 28

Weakness of hip flexion and adduction, and knee extension is suggestive of damage to which nerve?

Answer 28

The femoral nerve

Question 29

Which nerve roots give rise to the ilioinguinal and iliohypogastric nerves?

Answer 29

T12-L1

Question 30

What is the course of the ilioinguinal and iliohypogastric nerves?

Answer 30

Pass laterally through the head of the psoas muscle Run diagonally along quadratus lumborum

Question 31

What is the incidence of ilioinguinal or iliohypogastric nerve injury at Pfannenstiel incison?

Answer 31

3.7%

Question 32

What is the diagnostic triad for ilioinguinal/iliohypogastric nerve entrapment syndrome?

Answer 32

1. Sharp burning pain radiating from the incision site to the mons pubis, labia and thigh 2. Paresthesia over the nerve distribution areas 3. Pain relief following administration of local anaesthetic

Question 33

What are the nerve roots of the genitofemoral nerve?

Answer 33

L1-L2

Question 34

What is the course of the genitofemoral nerve?

Answer 34

Traverses the anterior surface of psoas Lies lateral to the external iliac vessels Genital branch enters the deep inguinal ring Femoral branch passes deep to the inguinal ligament

Question 35

What nerve is most likely to be injured during removal of external iliac lymph nodes

Answer 35

The genitofemoral nerve

Question 36

What are the nerve roots of the lateral cutaneous nerve?

Answer 36

L2-L3

Question 37

What is the course of the lateral cutaneous nerve?

Answer 37

Emerges from lateral border of psoas Crosses iliac fossa anterior to iliacus Enter the thigh posterior to the lateral end of the inguinal ligament

Question 38

What are the nerve roots of the sciatic nerve?

Answer 38

L4-S3

Question 39

What is the course of the sciatic nerve?

Answer 39

Emerges below the piriformis muscle Lies midway between the posterior superior iliac spine and the ischial tuberosity

Question 40

Which nerve winds forward around the neck of the fibula?

Answer 40

The common peroneal nerve

Question 41

What motor impairment is caused by sciatic nerve injury?

Answer 41

Weakness of hip extension and knee flexion

Question 42

What are the roots of the sciatic nerve?

Answer 42

Anterior branches of L2-L4

Question 43

What is the course of the obturator nerve?

Answer 43

Roots converge behind Psoas muscle Passes over pelvic brim in front of the sacroiliac joint Passes behind common iliac vessels and through obturator foramen

Question 44

During which surgeries is the obturator nerve most commonly injured?

Answer 44

Excision of endometriosis Retroperitoneal surgery

Question 45

How does obturator neuropathy present?

Answer 45

Sensory loss in upper medial thigh Motor weakness in hip adductors

Question 46

What are the nerve roots of the pudendal nerve?

Answer 46

S2-S4

Question 47

What is the course of the pudendal nerve?

Answer 47

Exits the pelvis through the greater sciatic foramen Runs behind the lateral third of the sacrospinous ligament and ischial spine Re-enters the pelvis through the lesser sciatic foramen

Question 48

During which surgery is the pudendal nerve most commonly injured?

Answer 48

Sacrospinous fixation

Question 49

Whilst most postoperative neuropathies resolve spontaneously, how long does this typically take for sensory and motor neuropathies?

Answer 49

Sensory neuropathies typically within 5 days Motor neuropathies up to 10 weeks

Question 50

What is the gold standard way of placing self-retaining retractors to avoid nerve injury?

Answer 50

Cradle the rectus muscle without compressing the psoas muscle underneath

Question 51

What is the procedure most commonly associated with uterine perforation?

Answer 51

TOP

Question 52

What is the average incidence of uterine perforation at outpatient hysteroscopy?

Answer 52

0.002-1.7%

Question 53

What is the incidence of uterine perforation with operative hysteroscopy?

Answer 53

1.6%

Question 54

What is the rate of hysterectomy due to perforation at TOP?

Answer 54

7 per 100,000

Question 55

What is the most common site of uterine perforation?

Answer 55

Anterior body of the uterus

Question 56

What is the name of the tapered dilator used in some SMM sets and why is it used in preference to Hegar dilators?

Answer 56

Hawkins-Ambler dilators Some papers suggest less force is needed for cervical dilatation than with Hegar dilator

Question 57

What percentage of doctors leave O&G before completion of training?

Answer 57

30%

Question 58

What is the name of the law which gives the inverted U shaped anxiety-performance curve?

Answer 58

Yerkes-Dodson law

Question 59

What is the rate of bowel injury at laparoscopy?

Answer 59

0.4 in 1,000