Surgery – Postop(SBA-EMQ)-Surgery and postop_Module_part2

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Surgery - Postop(SBA-EMQ)-Surgery and postop_Module_part2

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Ms. XY, 48 years old, a Para 3, is due to undergo a NovaSure endometrial ablation
in theatre for heavy menstrual bleeding. A WHO surgical safety checklist is in prog ress. Which of the
following components of the checklist need to be completed
before the surgical procedure begins?

A) Sign in and sign out

B) Sign in and time in

C) . Sign in and time out

D) Time in and time out

E) Time in and sign out

A 45-year-old woman undergoes an abdominal hysterectomy for a large fi broid
uterus. She is found to have a fi broid in broad ligament, and there is a concern that
her ureter may have been damaged during the diffi cult surgery. Which of the follow ing is the least
possible site of ureteric injury in this surgery?

A) . At the level of the uterosacral ligament

B) . Lateral to the uterine vessels

C) . Renal pelviureteric junction

D) The area of the ureterovesical junction close to the cardinal ligaments

E) The base of the infundibulopelvic ligament as the ureters cross the pelvic brim at the ovarian fossa

A surgical position which involves the patient in supine position of the body with
hips fl exed at 15° as the basic angle and with a 30° head-down tilt is known as:

A) Lithotomy position

B) . Lloyd–Davies position

C) . Sim’s position

D) . Trendelenburg position

E) Ward Mayo position

.38-year-old woman has had an emergency laparotomy and salpingo-oopherectomy for a
symptomatic tuboovarian abscess unresolved after medical management. Her BMI is 45. She smokes 20
cigarettes a day and is a poorly controlled diabetic on metformin.
What is the most appropriate step to reduce the incidence of scar dehiscence?

A) Antibiotics for 2 weeks

B) Deep retention (or tension) sutures with non-absorbable suture material

C) Smoking cessation advice

D) Suture removal at 10 days

E) Switch from metformin to insulin for diabetic control

5) A 38-year-old woman, para 1, presents to the labour ward at 41 weeks of

gestation with regular contractions every 3 minutes. Abdominal examination

reveals ballotable head and vaginal examination reveals early labour. An hour

later, she has a spontaneous rupture of membranes and cord prolapse. She

is pushed to theatre for crash caesarean section. What is her risk of bladder

injury?

A) 4–6/10,000

B) 1/1000

C) 3/1000

D) 5/1000

E) 1–2/100

What is the most appropriate suture material to repair the anorectal mucosa in a
fourth-degree perineal tear?

A) . Polydiaxonone (PDS)

B) Polyglactic 910 (Vicryl rapide)

C) Polyglactin (Vicryl)

D) Polyglecaprone (Monocryl)

E) Polyglycolic acid (Dexon)

Safety measures to prevent laparoscopic electrosurgical complications include
all of the following except:
.

A) . Inspect insulation carefully before use.

B) . Use the highest possible effective power setting.

C) Use available technology; newer tissue response generators and active electrode monitoring technology eliminate concerns about insulation failure and capaci tive coupling

D) Use a low-voltage waveform for monopolar diathermy (cut).

E) Use bipolar electrosurgery when appropriate.

8) Which of the following is least likely to be a complication of lower segment caesar ean section?

A) Anal sphincter injury

B) . Bladder dome injury

C) . Colonic perforation

D) . Intra-abdominal haemorrhage

E) . Transient tachypnea of the newborn

Regarding nonabsorbable suture materials, which of the following statements is
correct?

A) . All nonabsorbable sutures are monofi lamentous and have lower incidence of wound infection.

B) Polypropylene has higher tissue reactivity than polytetrafl uoroethylene.

C) Surgical silk has higher tensile strength than nylon.

D) The incidence of wound dehiscence and hernia is lower for nonabsorbable than slowly absorbable sutures.

E) The incidence of prolonged wound pain and suture sinus is signifi cantly higher with a nonabsorbable suture

10)

You see a 75-year-old patient who had an abdominal hysterectomy 2
days previously. She complains of muscle weakness, palpitations and
paraesthesia, and she is oliguric. An ECG shows loss of P-waves, wide
QRS complexes and peaked -waves. T e K+
level is 6.3 mmol/L.
What is the most appropriate immediate intervention?

A) . IV 10 ml 10% calcium gluconate over 2 to 5 minutes.

B) 10 IU fast-acting insulin (Actrapid) added to 50 ml of 50% dextrose infused IV over 20 minutes.

C) 5 mg salbutamol nebulizer.

D) . Stat 500 ml bolus of Hartmann’s solution IVI

E) Stop any drugs that contain potassium

12)

Your hospital has introduced Enhanced Recovery (ER) in gynaecology, which aims to facilitate a
rapid recovery and return to normal activity following elective gynaecological surgery.
When should preoperative risk assessment of the patient's health and fitness for a surgical procedure
start?

A) Community level prior to referral

B) Gynaecology review appointment

C) Outpatient gynaecology clinic appointment

D) Pre-admission clinic (nurse led)

E) Pre-assessment anaesthetist review

13)

You are performing a diagnostic laparoscopy for a 31-year-old para 1
with a 10-month history of pelvic pain. You attempt insertion of the
Veress needle twice. T e intra-abdominal pressure is 15 mm Hg.
What is your most appropriate next step?

A) Proceed with pneumoperitoneum.

B) . Proceed with laparotomy.

C) Proceed with direct trocar insertion.

D) Proceed with third attempt.

E) . Proceed with Palmer’s point entry

14)

You are assisting in a total laparoscopic hysterectomy and BSO for
extensive endometriosis. T e le ureter is accidentally transected at the
time of coagulation and division of the uterine artery.
What is the most appropriate intervention?

A) Ureteroureterostomy.

B) . ransureteroureterostomy.

C) . Ureteroneocystostomy.

D) . Percutaneous nephrostomy.

E) . Ureteric stent.

16)

All of the following are safe surgical principles during placement of a primary tro car in laparoscopic
surgery except:

A) Emptying the bladder

B) . Maintaining an intra-abdominal pressure of 25 mmHg

C) . Open laparascopy in high-risk patients

D) Saline test after Veress placement

E) Trendelenburg position

17)

A 45-year-old nulliparous woman who is otherwise fit and well attends for an
outpatient hysteroscopy to investigate a potential polyp, which was suggested on
an ultrasound scan.
What pharmacotherapy would be recommended to reduce pain in the
immediate postoperative period?

A) . Administration of a paracervical anaesthetic block

B) . Instillation of local anaesthetic gel into the cervical canal

C) . Oral non-steroidal anti-inflammatory drug (NSAID) an hour before the procedure

D) . Oral opiate analgesia 1 hour before the procedure

E) Use of conscious sedation

58-year-old woman underwent a total abdominal hysterectomy and bilateral salpingoophorectomy
under general anaesthetic for a complex endometrial hyperplasia. She developed pyrexia of 38°C, 12
hours after surgery. There were no other symptoms.

18) Which of the following is the most likely cause of her pyrexia?

A) Deep venous thrombosis

B) Pelvic collection

C) Pulmonary atelectasis

D) Urinary tract infection

E) Wound infection

19)

Which nerve is particularly susceptible to damage when self-retaining retractors
are used in gynaecological surgery?

A) . Femoral nerve

B) . Genitofemoral nerve

C) . Iliohypogastric nerve

D) . Obturator nerve

E) . Pudendal nerve

21) The best route to perform a hysterectomy (if technically feasible) is:

A) Abdominal

B) Laparascopically assisted vaginal hysterectomy

C) . Robot-assisted hysterectomy

D) . Total laparoscopic hysterectomy

E) Vaginal

22)

A 25-year-old woman is admitted to the gynaecology ward following an
evacuation of retained products of conception for a presumed molar pregnancy.
On examination, her vital signs are within the normal range and stable. She is
continuing to vomit and is unable to tolerate oral feed or fluids.
What volume of fluid should be used for maintenance intravenous therapy?

A) 5–9 ml/kg/day of fluid

B) 10–14 ml/kg/day of fluid

C) . 15–19 ml/kg/day of fluid

D) 20–24 ml/kg/day of fluid

E) . 25–29 ml/kg/day of fluid

23)

During primary entry with a force of 3 kg for gynaecological laparoscopy, what is
the depth below the indented umbilicus with a peritoneal insufflation pressure of
25 mmHg?

A) <4 cm

B) 4–8 cm

C) . 9–13 cm

D) . 14–18 cm

E) >18 cm

24)

.A 38-year-old woman attends for hysterectomy for a fibroid uterus. Due to the size of the uterus
there are concerns regarding the course of the ureter. Following surgery there are concerns regarding
urine output despite adequate fluid intake.
Which is the most appropriate investigation?

A) CT pelvis

B) Cystoscopy

C) Intravenous urogram

D) MRI pelvis

E) Pelvic ultrasound

25)

What is the risk of major vessel injury with the Hasson (open) technique of
laparoscopic entry?

A) . <0.1 in 1000

B) . 0.2 in 1000

C) 0.5 in 1000

D) 1 in 1000

E) 2 in 1000

29)

A patient who underwent an abdominal hysterectomy a few days ago complains of
numbness over the skin over the anterior aspect of the upper thigh. This could be
attributed to neuropathy of the:

A) . Femoral nerve

B) Obturator nerve

C) Peroneal nerve

D) Pudendal nerve

E) . Sciatic nerve

30)

During a primary caesarean section, at what point during the operation is a
bladder injury most likely to occur?

A) . Closure of the uterine incision

B) Delivery of the baby

C) . Dissection of bladder from the lower segment

D) . During catheterisation

E) . Entry into the peritoneal cavity

31)

Select the single most appropriate statement with reference to abdominal incisions
and preoperative preparations in a gynaecological surgery:

A) Horizontal incisions cause minimum nerve damage.

B) Preoperative showering with antiseptics reduces the infection rate to almost half.

C) . A scalpel should be changed after superfi cial incision for a deep incision

D) . Vertical skin incisions have better cosmetic results and greater strength.

E) Wound infection rates are less if no hair is removed as compared to depilatory preparation.

32) .Which absorbable suture has the greatest tensile strength?

A) . Polydiaxonone (PDS)

B) . Polyglactic 910 (Vicryl rapide)

C) Polyglactin (Vicryl)

D) Polyglecaprone (Monocryl)

E) . Polyglycolic acid (Dexon)

33)

The ilioinguinal and iliohypogastric nerves can be injured during a gynaecological
surgery. Which of the following describes these nerves the best?

A) Both nerves pass laterally through the head of the psoas muscle before running diagonally along quadratus lumborum.

B) . The iliohypogastric nerve is both sensory and motor, while the ilioinguinal nerve has a sensory function only.

C) . The ilioinguinal nerve arises from the L5–S1 nerve root, while the iliohypogas tric nerve arises from the T12-L1 nerve root.

D) . The ilioinguinal nerve pierces the external oblique aponeurosis above the superfi cial inguinal ring, while the iliohypogastric nerve emerges through it.

E) The reported incidence of ilioinguinal or iliohypogastric neuropathy following a Pfannenstiel incision is less than 1 %.

34) An 18-year-old woman comes with abdominal pain to the gynaecology

emergency unit. A clinical examination reveals tender abdomen. An

ultrasound scan of pelvis is normal. Clinically there are no signs of infection.

She was taken to theatre for diagnostic laparoscopy. A Veress needle was

inserted for gas insufation.

What is the recommended pressure for port insertion?

A) 10 mm of Hg

B) . 15 mm of Hg

C) . 20 mm of Hg

D) 25 mm of Hg

E) 30 mm of Hg

35)

. A 56-year-old woman has a staging laparotomy for stage 3 ovarian cancer.
Te following measures improve the best possible outcome with regards to
abdominal incisions except for one. Which statement is the exception?

A) Making a transverse suprapubic skin incision has cosmetic advantages compared with longitudinal incisions but may not allow adequate access

B) . A subcuticular suture also improves the cosmetic appearance and enhances postoperative comfort

C) . Longitudinal incisions (particularly midline) are more likely to be complicated by the development of wound dehiscence and incisional hernia

D) . Mass closure of longitudinal incisions reduces the risk of complete abdominal wound dehiscence and incisional hernia

E) . Closure of peritoneal surfaces decreases the risk of intestinal obstruction resulting from adhesions

36) Which of the following is an example of a self-retaining retractor?

A) . Balfour

B) Deaver

C) . Doyen’s

D) . Langenbeck

E) Morris

37)

A downward and inward muscle-splitting incision from the McBurney point that
allows extraperitoneal drainage of abscesses is called:

A) . Elliot incision

B) Gridiron incision

C) . Kustner incision

D) . Mouchel incision

E) . Rockey–Davis incision

38)

An 18-year-old woman comes with abdominal pain to the gynaecology
emergency unit. A clinical examination reveals tender abdomen. An
ultrasound scan of pelvis is normal. Clinically there are no signs of infection. She was taken to theatre for
diagnostic laparoscopy. She had one suprapubic
7 mm port, one 10 mm umbilical port and one lateral 7 mm port on the lef
side and one lateral 5 mm port on the right side.
Which of the following port sites rectus sheath should be closed with Vicryl 1?

A) All port sites

B) . 7 mm lateral port, 7 mm suprapubic port and 10 mm umbilical port

C) . 7 mm suprapubic port and 10 mm umbilical port

D) 7 mm lateral port and 5 mm lateral port

E) Only 10 mm umbilical port

39) Regarding the use of adhesion prevention agents, which of the following is true?

A) Steroids must be used in fertility-conserving surgery for prevention of adhesions.

B) . Dextran when used as an anti-adhesive agent can cause anaphylaxis.

C) The use of Adept in gynaecological surgeries has not shown signifi cant reduc tion in de novo adhesions

D) Seprafi lm is oxidised regenerated cellulose.

E) Evidence shows defi nite benefi t of using adhesion prevention agents in caesar ean section

40)

Ms. XY is 35 years old. She is a para 3 with 2 previous caesarean sections and desires
permanent contraception. She has opted to have a laparoscopic tubal occlusion/

sterilisation procedure. Her BMI is 33. She has had a successful Veress needle insuffl ation
(fi rst pass). What level of pressure must be obtained before passing the trocar?

A) 0–5 mm of Hg

B) 10–15 mm of Hg

C) 15–20 mm of Hg

D) . 20–25mm of Hg

E) 30–35 mm of Hg

41)

.44-year-old woman with no past medical history is undergoing laparoscopic hysterectomy for heavy
menstrual bleeding.
When considering venous thromboembolism prophylaxis in the immediate postoperative period, which
of the following statements is the most accurate?

A) Both LMWH and UFH reduces the incidence of wound haematomas

B) Intermittent pneumatic compression is not as effective as heparins in the prevention of asymptomatic DVT

C) There is no difference between UFH and LMWH in prevention of DVT

D) There is no difference between UFH and LMWH in reducing bleeding complications

E) There is no difference between UFH and LMWH in reducing fatal PE

43)

What proportion of ureteric injuries are recognised intraoperatively during
laparoscopic surgery?

A) . 10%

B) 25%

C) 33%

D) . 50%

E) 67%

44) The most effective method of preventing enterocele formation after vaginal hyster ectomy is:

A) . MacDonald culdoplasty

B) Mackenrodt culdoplasty

C) . Mackenzie culdoplasty

D) McCall culdoplasty

E) . McRobert culdoplasty

46) The following statements regarding energy sources in endoscopy are true except:

A) . The bipolar device avoids risk of burn injury to the patient.

B) . Bipolar circuits form a circuit within the instrument.

C) . Both require non-electrolytic solutions when used in operative hysteroscopy.

D) . Monopolar energy needs the patient to be part of the circuit.

E) . A return electrode is attached to the patient in monopolar circuit.

47) All of the following are true about surgical needles except:

A) . Blunt-point needle is used for patients with hepatitis B.

B) Needles with ‘eye’ are rarely used nowadays.

C) .Surgical needles have three basic components—the attachment point, the body and the point.

D) . The deeper the pane of surgery, the more curved the needle should be.

E) . The diameter of the needle is generally bigger than that of the suture material.

49)

22-year-old woman is brought in by ambulance to A&E with acute pelvic pain. On admission, her
urine pregnancy test is positive and a bedside ultrasound scan in A&E demonstrates free intraabdominal fluid. You, as the gynaecology registrar, are fast bleeped to review her as she has become
unconscious with a BP of 70/40 mmHg and pulse of 140 bpm. A ruptured ectopic pregnancy is suspected.
What is the most appropriate option of obtaining consent for proceeding to theatre?

A) Contact Trust director on-call

B) Contact Trust legal advisor

C) Perform the surgery and provide full explanation after recovery

D) Resuscitate with fluids and obtain consent

E) Obtain consent from the next of kin

Your score is