Test prep Flashcards by Emily Schmidt-Beuchat

Intracorporeal suture length

6in (15cm)

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Extracorporeal suture length

30inches (76.2cm)

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Curved SH needle port site needed for removal

10mm

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Port site size needed for linear stapler

12mm

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You are working in the mid-pelvis. The initial step for establishing pneumoperitoneum is:
a. Increase abdominal pressure to 18mm
b. Place in steep trendelenburg
c. place extra secondary ports

b. Place in steep trendelenburg

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You’re doing a Chole and need cholangiogram, best patient positioning

a. Have foot board
b. Have reverse trend
c. Have patient with head at foot of the bed

c. Have patient with head at foot of the bed

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An obese man has laparoscopy and 12h post op he is tachycardic and febrile with pain and fullness at trocar insertion site and CT shows incarcerated bowel, best next step after IVF resuscitation

a. CT abd/pelv PO + IV contrast
b. Call anesthesia for better pain control
c. Tell him to apply heating pad
d. Proceed with ex-lap

d. Proceed with ex-lap

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22yo girl preg @20 w with Appy

a. consult OB and do LSC Appy
b. laparoscopy is contraindicated

a. consult OB and do LSC Appy

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Best time for laparoscopy in preg

a. 2-4 w
b. 5-8w
c. 12-18w
d. 28-32w

c. 12-18w

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You’re doing pelvic surgery and encounter bleeding from a small artery, best initial step:

a. Electrocautery
b. Pressure
c. Sutures
d. Staples

b. Pressure

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You’re doing a staging procedure for pancreatic cancer and w/ the ultrasound you notice a deep 2.5cm lesion within left lobe of liver

a. Wedge biopsy
b. Leave it alone
c. Use US for core needle biopsy
d. Image it post op

c. Use US for core needle biopsy

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You see a 1cm lesion on the edge of the left lobe of the liver. What do you do?

a. Tru-cut biopsy
b. Wedge biopsy
c. FNA

b. Wedge biopsy

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You’re operating with a monopolar device and see a “significant” spark, what caused it

a. Patient is not grounded
b. Arching
c. O2 in the field

b. Arching

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What instrument is inappropriate for vessels >4mm

a. monopolar
b. bipolar
c. ultrasound shear
d. ligating bipolar instrument

a. monopolar

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At the beginning of your case, you are trying to obtain hemostasis with monopolar and you are not getting the desired effect with coagulation. What is the least likely cause?

a. Contact with unintended tissue proximal to the target tissue
b. contact with fatty tissue
c. the cord is disconnected from the power source
d. the cord is disconnected from the instrument

b. contact with fatty tissue

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You’re operating on a 108kg man and made a 15mm incision, how do you close it BEST

a. Extend incision and close fascia with a running absorbable suture
b. Use a keith needle
c. Use a port closure device
d. Grab the fascia with 2 alice clams and close with a running non-absorbable suture

c. Use a port closure device

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Patient comes in 4 days post op after uneventful laparoscopic surgery with abdominal pain and has infra diaphragmatic air on plane film, why

a. Didn’t desufflate properly
b. injury to bowel with subsequent perforation
c. spontaneous perforation due to secondary unrelated
d. intra-abdominal with gas-producing bacteria

b. injury to bowel with subsequent perforation

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What is a contraindication to LSC

a. chronic peritonitis
b. inability to tolerate GA
c. small bowel obstruction
d. renal insufficiency

b. inability to tolerate GA

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You are doing an appy, you deploy stapler and cut but there were no staples, what do you do next

a. Staple again and incorporate cecum
b. Convert to open
c. suture the appendiceal stump
d. clips on appendiceal stump

a. Staple again and incorporate cecum

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The scope went dark, what is most likely reason why?

a. Bulb burnt out
b. Light cord is disconnected from laparoscope
c. Light cord is disconnected from monitor

b. Light cord is disconnected from laparoscope

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The scope went dark in the middle of your surgery, what is “the most efficient” thing to do

a. Have a replacement bulb in the OR
b. Have a replacement light cord in the OR
c. Convert to Open
d. routinely replace the bulb prior to the end of its lifespan

d. routinely replace the bulb prior to the end of its lifespan

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Similarity between LSC and Ex-lap
a. Post op pain
b. Hospital days
c. Complication rate

c. Complication rate

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You’re using ultrasonic shears to ligate a vessel and notice bleeding below where you used them, why?

a. The active blade burned adjacent vessel
b. The active blade injured adjacent vessel
c. The power setting is too low

b. The active blade injured adjacent vessel

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The surgical field should be
a. Between the surgeon and monitor
b. between the surgeon and assistant

a. Between the surgeon and monitor

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Worst candidate for LSC a. BMI 15 b. BMI 22 c. BMI 30 d. BMI 45

d. BMI 45

Absolute contraindication to LSC

a. Inability to tolerate laparotomy

Contraindication to LSC a. INR of 1.3 b. FEVI of 1L c. SBP 60

c. SBP 60

Contraindication to open Hasson umbilical port placement a. Umbilical hernia with mesh b. Midline vertical skin scar c. ESRD with intraperitoneal dialysis

Mesh in place

Decrease postop N/V by: a. minimize opioids and use NSAIDs b. obtain pain control with morphine c. use bupivicaine and propofol to induce anesthesia

a. minimize opioids and use NSAIDs

In right decubitus position, what is the most important consideration

place a roll in the axilla of the dependent side

Why is CO2 preferred insufflation gas:

Easily eliminated

If intra-abdominal pressure is 3mmHg and P flow is 0.1L/min and CO2 use is 24L then: a. Replace CO2 tank b. The needle tip is not intraperitoneal c. The patient is not relaxed

a. Replace CO2 tank

You place the veress and do saline drop test, then you connect the gas and the pressure is high and the flow is 0. What is most likely happening: a. Youre not intraperitoneal b. The stopcock is closed c. The insufflation tubing is kinked

c. The insufflation tubing is kinked

You're operating and anesthesia says the BP is 60/40 and P is 60 and the abdominal pressure is 28, next best step a. Look for a source of bleeding b. Fluid Bolus c. Give more paralytic d. Desufflate

d. Desufflate

If someone had a hysterectomy and surgery for lymphoma and now has chronic RLQ – going to OR for DSC LSC, LOA and possible Appy- what is bed position in a. Lithotomy with arms tucked b. Both arms out c. Left arm out d. Supine 30degree right tilt

d. Supine 30degree right tilt

Patient had a history of myomectomy with 2 subsequent vaginal deliveries who now has chronic RLQ pain, possible adhesions, and is taken to OR for dx lsc, LOA, possible appy: position is a. lithotomy with uterine manipulator b. supine with right tilt

a. lithotomy with uterine manipulator

Monopolar Circuit

Tissue Heating = Current Density ^2 Current Density = Current (amps)/Area (cm^2) (small area of contact = high current density = fast heating)

Cutting mode

Goal = heat tissue quickly to cause tissue to explode | Low voltage is "pure cut"

Coag mode

High voltage, intermittent wave form | Rapid surface heating with shallow depth of necrosis = fulguration

Current diversion

Following the path of least resistance, current passes through unintentional tissue or pathways

Capacitive coupling

Transfer of current between two conductors (can transfer 40% of power to passive electrode which can store the energy and transfer it to tissue once in contact)

Which has lower lateral tissue damage and necrosis? Bipolar or monopolar

BIPOLAR

During monopolar electrosurgery, the method of heating tissue quickly, converting cell water to steam, and causing the cell to explode is descriptive of which of the following? A) Cutting mode? B) Coag mode? C) Blend option

A: Cutting mode

Absolute contraindications to LSC

Inability to tolerate laparotomy Hypovolemic shock Lack of proper surgeon training and/or experience Lack of appropriate institutional support

Relative Contraindication to LSC

``` Inability to tolerate GA Long-standing peritonitis Large abdominal or pelvic mass Massive or incarcerated ventral and inguinal hernias Severe cardiopulmonary disease ```

Elimination of CO2

Through the lungs via increased minute ventilation Pneumoperitoneum however creates reduced FRC, increased peak airway pressure, and reduced pulmonary compliance (which resolve almost immediately once gas is evacuated)

N2O (nitrous oxide) for insufflation

Does NOT suppress combustion in presence of methane - DONT USE FOR BOWEL PERFORATION CASES Less acid base disturbances and better tolerated with patients who have severe CPD

Inert gases (Argon, Helium)

Less soluble, increased risk of gas emboli

Gas embolus

``` Very rare (0.015%) and presents as sudden cardiovascular collapse - - severe hypotension, JVD, tachycardia, mill wheel murmur, bleeding ``` Tx: place in t-burg, left side down, rapid fluids, central line to evacuate embolus in RH chamber

Patient has a history of DVT and you’re performing laparoscopy for gastric leiomyoma: a. lithotomy with candy canes b. lithotomy with molded stirrups c. frog leg and low on bed d. supine

b. lithotomy with molded stirrups

During Hasson entry, when will you most likely cause enterotomy: a. Incision fascia b. Incision on skin c. Placing deep fascial stay suture d. Finger sweep

a. Incision fascia

In Hasson technique you incise the skin, incise the fascia, incise the peritoneum, what is it the next step a. Finger sweep- trocar placement- camera insertion b. Trocar placement- camera insertion- low flow gas c. Finger sweep- Camera insertion- low flow gas d. Trocar placement, Trocar sweep- low flow gas

Finger sweep- trocar placement- camera insertion

How to best avoid inferior epigastrics

avoid placing trocars in the midline of the rectus muscles

UOP decreases with pneumo because a. Decreased venous return b. Decreased Renin c. Kinks the ureter

a. Decreased venous return

Effect of pneumo on LE a. Decreased venous flow only b. Significant decrease in venous flow, mild in arterial flow c. Significant decrease in venous and arterial flow d. Decrease in Arterial flow more than venous

b. Significant decrease in venous flow, mild in arterial flow

Laparoscopy in people with cancer a. contraindicated in cancer b. can be an alternative to open in some types of cancer c. can be used for staging alone

b. can be an alternative to open in some types of cancer

A pregnant lady needs a LSC

place SCDs

CO2 pneumo causes: a. Metabolic alkalosis b. Respiratory Alkalosis c. Metabolic Acidosis d. Respiratory Acidosis

d. Respiratory acidosis (increase in CO2)

Physiology of CO2 pneumo which is NOT true a. Decrease preload b. Increase venous return c. Decrease FRC d. Decrease Pulm Compliant

b. Increase venous return

NO is a fire hazard when ...

theres a bowel injury and the GI tract has not been prepped with a mechanical lavage

CO2 gas is least likely to...

Cause a gas embolism (its the most soluble)

CO2 insufflation can cause a. Low PO2 b. High PO2 c. Low PCO2 d. High PCO2

d. High PCO2

Position for upper abdomen laparoscopy ...

arms out and reverse trendelenberg

Bleeding when you take out the trocar, immediate first step a. Reinsert the trocar b. Foley tamponade c. Ex-lap

Why do we tuck the arms in pelvic laparoscopy: a. Ergonomics b. Keep the patient warm c. Access the pelvic vessels

a. ergonomics

What grasper to use for an appy a. No teeth b. With teeth c. With cautery potential d. With cutting blade

a. NO TEETH

What is most accurate about running the bowel a. Use a 2 hand technique b. Use a touching assistance technique c. Don’t do it for an SBO

a. use a 2 hand technique

Peri-aortic LN biopsy

Excisional

Core needle biopsy of liver, get hemostasis with first?

Pressure!!!

You notice a small bleed for a seromuscular injury on bowel that does not stop with pressure, what is next step

serosal stitch

Best suture to use for serosal stitch on bowel

Braided, dyed, fixed to needle

You’re teaching someone intracorporeal knot tying who is a novice, with less skill than you. You tell them:

make a C-loop

You staple across the mesentery and notice that its bleeding, which is most likely reason a. Defective stapler b. You used a 3.5mm staple c. The mesentery has vessels too big for staples d. patient is hypertensive

B. You used a 3.5mm staple

You run into bleeding and the field of view is getting smaller, best next step a. Increase Pressure b. Increase Flow c. Stop aspirating

c. stop aspirating

Diaphragmatic irritation is seen when?

1-3d post op

Veress inserted and saline drop test confirms placement. However, you aspirate large amount of blood. Next step a. convert to ELAP b. reinsert Veress and insufflate c. use open hasson technique and ??

a. convert to ELAP

You insert the veress needle and the saline drop test confirms placement. However, your pressure is high and the flow is 0 a. advance veress b. withdraw veress c. use open hasson technique instead d. kinked tubing or block or muscle not relax

d. kinked tubing or block or muscle not relax

65. In diagnostic lsc, what is not able to be fully examined? a. Duodenum b. Ileum c. Jejunum d. Stomach

a. duodenum

Initial lsc entry is usually through periumbilical region, when would you consider another site? a. Umbilical hernia b. Prior midline scar

a. Umbilical hernia | but really, both are true

Which one of these is an effect of CO2 pneumo? a. Minute ventilation perfusion mismatch b. Increased venous return c. Increased functional residual capacity

a. Minute ventilation/perfusion mismatch

During a laparoscopic procedure, the insufflation pressure reading drops. What most likely caused this? a. Disconnected insufflation tubing b. Kinked insufflation tubing c. inadequate patient relaxation d. turning the insufflation valve on the trocar to off

a. Disconnected insufflation tubing

After firing the endoscopic stapler during a laparoscopic appendectomy, you notice that the appendix has been transected but the staples were not deployed. All of the following are appropriate management strategies EXCEPT a. restapling the cecum incorporating the appendiceal stump b. converting to a small laparotomy to oversew the base c. closing the appendiceal orifice with laparoscopic sutures d. using clips to close the appendiceal orifice

d. using clips to close the appendiceal orifice

A patient has undergone a laparoscopic procedure. In the recovery room, the patient is hemodynamically stable but complains of shoulder pain. Which of the following is the most likely etiology of the patient complaint? a. Patient positioning during procedure b. Incomplete CO2 evacuation c. MI d. Acute gastric distension

b. Incomplete CO2 evacuation

What is the best indication for using a Hasson cannula? a. The patient had previous open abdominal surgery b. The standard trocars you have available are reusable c. The cost of a Hasson is less d. The patient is hemodynamically unstable

a. The patient had previous open abdominal surgery

You are planning an elective laparoscopic procedure in a morbidly obese patient. What adjustment might you have to make in comparison to a thin patient? a. use bipolar instead of monopolar b. use mini-lap instruments (2 mm) c. Use open hasson technique for initial port d. use a higher insufflation pressure

c. Use open hasson technique for initial port

Twelve hours after a laparoscopic procedure, the patient complains of severe, diffuse pain, is tachycardic, is febrile, and has a tender, distended abdomen. A blood gas reveals a metabolic acidosis and a base excess of -10. After fluid resuscitation, what is the most appropriate next step? a. Perform a CT scan of the abdomen with oral and IV contrast b. Transfer two units of PRBCs and transfer to monitored setting c. Consult anesthesia or pain team to readjust medications or consider an epidural d. Proceed directly to the operating room for an abdominal exploration

d. Proceed directly to the operating room for an abdominal exploration

The potential of current to arc onto adjacent tissue is most likely to occur with which of the following energy sources? a. ultrasonic shears b. monopolar c. bipolar d. Holmium laser

b. monopolar

Which statement is true regarding the effects of pneumoperitoneum on the renal system? a. pneumoperitoneum may cause ureteric obstruction b. pneumoperitoneum may result in transient oliguria c. pneumoperitoneum does not affect renal pathology d. pneumoperitoneum may result in excessive diuresis

b. pneumoperitoneum may result in transient oliguria

During a laparoscopic cholecystectomy, the use of a long-lasting local anesthetic is most appropriate in which of the following circumstances? a. infiltration of the trocar sites prior to port insertion b. Irrigation of the gallbladder fossa at the end of the case c. Irrigation of the right diaphragm at the end of the case d. flushing of the common bile duct during the cholangiogram

a. infiltration of the trocar sites prior to port insertion

Peritoneal lesions, biopsy technique

Small = excision with biopsy forceps (can incise larger lesions) and remove through 5-10mm port

LN biopsy

Excisional biopsy - smaller nodes can be removed through 10-12mm port - larger nodes - use specimen retrieval sac

Test prep Flashcards

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