Core Surgical Skills and Postoperative Care Extra Questions Batch B – MCQ

1. T e Smead–Jones closure is a mass closure technique of the anterior abdominal wall using a far–far, near–near approach. The closure is performed using a delayed absorbable suture to include all the abdominal wall structures on the far–far portion and only the anterior fascia on the near–near portion. This allows good healing without intervening fat or muscle.

Which of the following best describes the rate of fascial dehiscence with running mass closure of the abdomen?

2. You are assisting your consultant in a Burch colposuspension procedure for urodynamic stress incontinence after an unsuccessful V procedure. Which of the following transverse skin incisions allows the easiest access to the space of Retzius?

3. A 39-year-old para 2 presents with an 8-month history of pelvic pain. She has a previous vertical abdominal incision for a ruptured appendix and undergoes a diagnostic laparoscopy using closed-entry technique at Palmer’s point.

Which of the following describes the correct anatomic position of Palmer’s point?

4. You are asked to see a 49-year-old patient in the emergency department who is day 9 following a AH for multiple uterine fibroids. She presents feeling unwell and has lower abdominal pain. Her bowels have been opening regularly and she has had no bloating, nausea or vomiting. On examination her pulse rate is 92 bpm, BP 110/70 mm Hg, temperature 38°C and respiratory rate of 20 per minute. Urinalysis is clear. T e wound is erythematous, indurated and tender to touch. Her haemoglobin is 100 g/L, WBC is 15 × 109/L and CRP of 50 mg/L.

What is the most likely diagnosis?

5. You see a 28-year-old woman in your clinic. She is referred by her GP with a 6-month history of chronic pelvic pain and deep dyspareunia. A pelvic ultrasound scan shows a retroverted uterus, 4 cm endometrioma on the right ovary, normal le ovary and no free fluid in the pelvis. She is using the progesterone-only pill for contraception, and this has helped slightly with the pain. You consent her for laparoscopy and ovarian cystectomy and discuss risks and potential complications associated
with these.
Which of the following best describes the risk of bowel injury?

6. You see a 42-year-old woman in your gynaecology clinic. She presents with a history of heavy periods and is up to date with her smears. T ere is no postcoital bleeding. Pelvic ultrasound on the second day of her menstrual cycle shows a bulky uterus with a small, well-de ned hyperechoic mass in the endometrial cavity. A feeding vessel extending to the mass is noted on colour Doppler imaging and both ovaries are unremarkable. The appearances are suggestive of an endometrial polyp. You consent her for diagnostic hysteroscopy, endometrial polypectomy and insertion of LNG-IUS.

What is the risk of damage to the uterus?

7.You see a 45-year-old African-Caribbean woman in your clinic who presents with a large, painless abdominal swelling for 12 months and reports urinary frequency but no dysuria. There is no change in her bowel pattern. Her cycle is 5/28 with passage of blood clots and ooding. She has completed her family and is up to date with her smears. On examination, her abdomen is distended and palpates an irregular and firm mobile nontender pelviabdominal mass equivalent to a 28-week- sized pregnancy. On bimanual examination it is not possible to palpate the uterus separate from this mass. Abdominal and pelvic ultrasound scan suggests multiple uterine fibroids, the largest of which is intramural and measures 14 × 12 × 10 cm. Both ovaries are unremarkable. You discuss abdominal hysterectomy with her and she tells you she wants to keep her cervix.
What is the rate for residual stump cancer of the cervix?

Options

8. You are asked to see a 21-year-old para 1 in the early pregnancy assessment unit. She is 9 weeks into her second pregnancy and presents with cramping abdominal pain and vaginal bleeding. Pelvic ultrasound scan shows a picture of incomplete miscarriage. She opts for surgical management of the miscarriage, and you consent her for surgical evacuation.

What is the risk of uterine perforation at the time of surgical evacuation?

Options

9. You have been asked by your consultant to write a patient information leaflet on caesarean section. You decide to include information on serious and frequently occurring risks. What is the incidence of ureteric injury at the time of caesarean section?
Options

10. 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. The intra-abdominal pressure is 15 mm Hg. What is your most appropriate next step?

11. You perform laparoscopy for a 27-year-old para 2 with a 6 × 5 × 7 cm le ovarian dermoid cyst. She has had two previous caesarean sections. You use closed-entry technique and insu ate the abdomen to 25 mm Hg before inserting the primary trocar in the umbilicus. After introducing the laparoscope you suspect that a loop of bowel is adherent to the anterior abdominal wall at the primary port site.

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

13. You are performing a hysteroscopy and endometrial biopsy on a 65-year-old para 3 who presents with postmenopausal bleeding and a 9-mm-thick endometrium. You manage to dilate the cervix but there is sudden loss of resistance. You suspect uterine perforation, introduce a 5-mm hysteroscope and recognize a hole on the anterior uterine wall.

What is the most appropriate immediate intervention?

14. 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?