16- Surgical Techniques & Technology MSQs Only

Question 1

1 of 67

In which electrosurgical modality is the active electrode placed in direct contact with the tissue and is characterised by low current and high voltage over a broad area?

Answer 1

Desiccation

In desiccation the device is placed in direct contact with the tissues (unlike fulguration). Because it is applied over a broad area it tends not to cause protein damage (unlike coagulation).

Question 2

2 of 67

Which of the following is a permanent suture material best suited for interrupted mattress dermal closure?

Answer 2

3/0 Polypropylene

Of the sutures listed only prolene is a permanent suture material. It is a good agent for skin closure as it does not incite an inflammatory response and thus provides good cosmesis.

Question 2

3 of 67

A 5 year old suffers 20% burns to the torso. On examination, there is fixed pigmentation and the affected area has a white and dry appearance. Which of the following options represents the best management plan?

Answer 2

Debridement and split thickness skin graft

This is a full thickness burn and will require split thickness skin grafting. Meshing the graft may increase the donor site yield. However, this is at the expense of cosmesis. The burn itself must be debrided first to ensure an adequate wound bed.

Question 3

4 of 67

If a 2 x 2 cm autologus skin graft is placed on an area of healthy granulation tissue. After about a week, a thin bluish - white margin appears around the graft and spreads at a rate of 1mm per day. What is it?

Answer 3

Epidermis alone

This is the process of re-epithelialisation.

Question 3

5 of 67

A 67 year old lady undergoes a mastectomy and axillary node clearance for breast cancer. The surgeon decides to insert a drain to prevent the development of a seroma. What is the most appropriate device to use?

Answer 3

A closed suction drainage system made of polypropylene

Following breast surgery, it is standard practice to use a Redivac type system that is made of polypropylene.

Question 4

6 of 67

A 56 year old man is 8 days following a left hemicolectomy. He has developed a swinging pyrexia over the past 48 hours and has an ileus clinically. What is the most appropriate investigation?

Answer 4

Abdominal CT scan with IV contrast

This would most likely be the result of an anastomotic leak with abscess formation. Detailed imaging is required to allow accurate diagnosis and planning of management.

Question 5

7 of 67

Which of the following local anaesthetics is not an amino amide type?

Answer 5

Lignocaine
Xylocaine
Procaine(Right)
Bupivacaine
Prilocaine
………………………………….
All local anaesthetics have a chemical bond linking an amine to either an amide or an ester. Most local anaesthetics are of the amino- amide types, these have a more favorable side effect profile and are more stable in solution. Procaine and benzocaine have amino - ester groups, these are metabolised by pseudocholinesterases.

Question 6

8 of 67

A 53 year old lady undergoes a low anterior resection for rectal cancer. The procedure is performed as open surgery, what is the most appropriate method for closure of the abdominal wall?

Answer 6

Mass closure of the abdomen obeying Jenkins rule using 1 PDS

The standard closure technique for most laparotomy incisions is to use a mass closure method obeying Jenkins rule using 1 or 2 PDS or nylon. Few surgeons would use a narrower gauge suture such as 1/0 or 2/0 for abdominal wall closure.

Question 7

9 of 67

A 34 year old man has a tissue defect measuring 3 cm by 1 cm following an excision of a lipoma from the scapula. What is the best option for managing the wound?

Answer 7

Direct primary closure

This wound should be amenable to primary closure. There is minimal associated tissue loss and the surgery is minor and uncontaminated.

Question 8

10 of 67

Which of the following surgical energy devices would be most appropriate for the dissection of the posteriomedial aspect of the thyroid gland during thyroidectomy?

Answer 8

Bipolar diathermy

This will minimise thermal trauma to the recurrent laryngeal nerve

Question 9

11 of 67

A 72 year old man undergoes a ray amputation for an infection complicating long standing diabetes. What is the best method for healing the resultant wound?

Answer 9

Vacuum assisted closure system

Ray amputations for diabetic foot infections do not heal well and should never be primarily closed. The use of vacuum assisted closure devices has been shown to improve healing rates.

Question 9

12 of 67

A 23 year old man is undergoing an open appendicectomy. The surgeons extend the incision medially and suddenly encounter troublesome bleeding. What is the best course of action?

Answer 9

Ligate the bleeding vessel

Medial extension of an appendicectomy incision carries the risk of injury to the inferior epigastric artery. This can bleed briskly and is best managed by ligation.

Question 10

13 of 67

Which of the following visceral anastomoses has the lowest risk of anastomotic leak? You may assume that all are constructed in ideal circumstances.

Answer 10

Hand sewn anastomosis of the proximal ileum

Rectal and oesophageal surgery have some of the highest rates of anastomotic leakage. Following anterior resection leaks are quoted to occur in up to 10% of cases. Small bowel anastomoses are the most technically forgiving. Factors increasing the risk of anastamotic leakage include previous irradiation, sepsis, malnutrition, poor blood supply and poor technique.
The defunctioning of rectal anastomoses may reduce the clinical impact of anastomotic leak and make it amenable to percutaneous drainage, but does not necessarily reduce the incidence of leaks themselves.

Question 11

14 of 67

A 73 year old man undergoes a laparotomy for mesenteric infarction. An extensive small bowel resection is undertaken. A planned re-look laparotomy is scheduled to occur in 24 hours time. What is the most appropriate closure strategy in this situation?

Answer 11

Application of a Bogota bag

Where there are definite plans for early re-look surgery and it is desirable to visualize the viscera (as it would be in this case), application of a Bogota bag will provide the best closure option.

Question 12

15 of 67

Which of the following substances is commonly used to sterilize endoscopic equipment?

Answer 12

Glutaraldehyde

Most endoscopic processors use glutaraldehyde which is an effective antimicrobial agent. It is widely recognized as being a cause of hypersensitivity reactions and is thus used in closed systems.

Question 13

16 of 67

In which of the following operations would the use of a cell salvage device be permitted?

Answer 13

Revision arthroplasty of the hip for recurrent dislocation

Infection and malignancy are contra indications to use of cell saver devices.

Question 14

17 of 67

A 72 year old woman fractured her distal radius. A Biers Block is planned to facilitate reduction of the fracture. Which of the following agents should be used?

Answer 14

1% prilocaine

This is the best local anaesthetic for this. Bupivacaine may cause cardiotoxicity and should be avoided.

Question 15

18 of 67

A 5 year old boy develops a persistent fever following an open appendicectomy for gangrenous appendicitis. On examination, he has erythema of the wound and some abdominal distension. What is the most appropriate course of action?

Answer 15

Arrange an abdominal ultrasound scan

This patient has risk factors for a wound infection which is not in itself an indication for scanning. However, he also had abdominal distension and this, together with the history of distension would generally attract a recommendation for imaging. A USS will show an abdominal wall collection and more importantly any phrenic or pelvic collections. Unlike adult practice, CT scanning is rarely performed in children.

Question 16

19 of 67

A 28 year old man undergoes an incision and drainage of an axillary abscess. How should the wound be managed?

Answer 16

Packing with alginate dressing

Use of gauze is inappropriate and will be painful to redress. Abscess wounds should not be closed.

Question 17

20 of 67

One of the senior surgeons in the hospital advises as to the best management of Merkel cell tumours of the skin in which she has a special interest. What level of evidence is this?

Answer 17

V

Personal expert opinion qualifies for level V evidence.

Question 18

21 of 67

A 53 year old cleaner is admitted with a fall. She is haemodynamically stable and a CT has shown a massive retroperitoneal haematoma. She is on warfarin. What is the most appropriate course of action?

Answer 18

Infusion of human prothrombin complex and vitamin K

Each hospital has different protocols and would recommend discussion with a haematologist. However Human Prothrombin Complex with vitamin K is indicated in this situation, as the condition is life threatening.

Question 19

22 of 67

Which of the following sutures would be most appropriate for closure of the scrotal skin following an orchidopexy in a 3 year old boy who is otherwise well?

Answer 19

5/0 vicryl rapide

In children, its always best to use absorbable sutures where possible (removal is a very challenging undertaking). Most surgeons prefer vicryl rapide for this purpose and 5/0 provides adequate strength.

Question 20

23 of 67

In which electrosurgical modality does a sinusoidal, non modulated waveform result in vaporization of the tissues?

Answer 20

Cutting current

The high energy levels result in tissue vaporisation and cleavage of tissues.

Question 20

25 of 67

A 53 year old man undergoes an elective right hemicolectomy. A stapled ileo-colic anastomosis is constructed. Eight hours later he becomes tachycardic and passes approximately 600ml of dark red blood per rectum. Which of the following processes is the most likely explanation for this occurrence?

Answer 20

Anastomotic staple line bleeding
…………………………………………………………
Safe visceral anastamosis requires:
Mucosal to mucosal apposition
Adequate vascularity
Minimal tension

Stapled anastomoses are associated with staple line bleeding and this may typically occur in the early post operative phase. They should be managed conservatively as most will settle.
Stapled anastomoses are quicker to perform. Ironically, although they may appear easy they can carry considerably more potential pitfalls than their hand sewn equivalent and should be used with caution by the inexperienced, this is especially true if the bowel is very thick walled.

Question 21

24 of 67

Which of the following sutures is most suitable for the mass closure of an abdominal wall following a laparotomy?

Answer 21

1 polydiaxone

Only 1 polydiaxone would have sufficient tensile strength.

Question 22

26 of 67

A group of surgeons are trying to decide which type of mesh to use for incisional hernia repair. Their assimilated evidence includes two case series and one randomised controlled trial. What level of evidence is this?

Answer 22

II

Data which includes at least one RCT will usually qualify for level II evidence.

Question 23

27 of 67

A 34 year old lady is due to undergo a laparoscopic cholecystectomy. Which of the following intrabdominal pressures should typically be set on the gas insufflation system?

Answer 23

10mm Hg

Pressures lower than 7mm Hg are not usually compatible with satisfactory views.
Pressures >15mm Hg are usually associated with decreased venous return and hypotension.

Question 24

28 of 67

A 67 year old women is undergoing a femoral hernia repair and the surgeon is using a bipolar diathermy unit for haemostasis. Which of the following is a recognised risk with the use of bipolar diathermy?

Answer 24

Fires when used near alcoholic skin preparations that have pooled
…………………………………………………….
Capacitive coupling occurs when alternating current is transferred from an insulated instrument to an uninsulated instrument through a capacitor.

In bipolar units the flow of electricity is from one electrode to the other over a small area. As a result a contact plate is not used and coupling and capacitance injuries are uncommon. They have a low risk of thermal injury to adjacent structures and are preferred for this reason. However, they may cause sparks and ignite inflammable solutions.

Question 25

29 of 67

Which of the following is least likely to reduce the risk of post operative wound infection?

Answer 25

Routine use of mechanical bowel preparation
…………………………………………
The routine use of mechanical bowel preparation is not recommended. There is some recent evidence to support the use of selective gut decontamination.
However, this is not in mainstream practice at present.

Question 26

30 of 67

A 73 year old lady with gallstones is about to undergo a laparoscopic cholecystectomy. The surgeon inserts a Verress needle and performs a successful drop test prior to establishing a pneumoperitoneum. A 5 minute delay ensues before a 10mm infraumbilical trocar is inserted. The surgeon performs a diagnostic laparoscopy which shows a thickened gallbladder but is otherwise normal. The anaesthetist complains that the patient has become hypotensive with a blood pressure of 80/40 mmHg. Of the options below, which is the most appropriate course of action?

Answer 26

Release of pneumoperitoneum

Excessive intra-abdominal pressure may cause decreased venous return and hypotension. Since the preliminary laparoscopy did not show any major vascular catastrophe an emergency laparotomy would not be indicated. In most cases the release of pressure is often sufficient. In cases of a vaso-vagal episode (which may be induced by peritoneal stretching) a dose of atropine may be required.

Question 27

31 of 67

What is the mechanism of action of ciprofloxacin?

Answer 27

Inhibition of DNA gyrase

Question 28

32 of 67

A 19 year old male presents with axillary lymphadenopathy and symptoms suggestive of Hodgkins lymphoma. What is the most appropriate investigation?

Answer 28

Excision biopsy of a lymph node
………………………………………………….
When a diagnosis of lymphoma is suspected, the correct investigation is excision biopsy of a complete lymph node to confirm the diagnosis.

Excision of a single node is appropriate. Lymphoma is usually treated with chemotherapy and axillary node clearance is therefore inappropriate. FNA and core biopsy will not allow accurate diagnosis and are therefore not appropriate.

Question 29

33 of 67

A 72 year old man has discharge from a healed abdomino-perineal resection wound. On examination, it has almost completely healed but there is prominent granulation tissue at the apex of the wound. There is no evidence of an underlying collection and he is otherwise well. What is the best course of action?

Answer 29

Application of topical silver nitrate

Silver nitrate will cauterise the exuberant granulation tissue and promote healing.

Question 30

34 of 67

A surgeon wishes to determine whether different methods of perioperative shaving have an effect on post operative wound infection rates. Which of the following is the best method for assessing whether one method is better than the other?

Answer 30

Randomised controlled study

A randomised controlled study is the best method for assessing this relationship. It is important to analyse data from RCT’s on an intention to treat basis.

Question 31

35 of 67

You are the specialist trainee asked to review a 39 year old man post gastrectomy for bleeding duodenal ulcers. He is hypotensive and tachycardic. His drain has increased output, contains pus and has bubbles. There is excoriated skin around the drain site. What is the explanation for this presentation?

Answer 31

Proximal enterocutaneous fistula

Suspect an enterocutaneous fistula if there is excessive drainage and bubbles. Pus may confuse surgeons, leading them to make a diagnosis of wound infection. If there is any uncertainty, methylene blue can be given. If methylene blue is found in the drain, this confirms a fistula.

Question 32

36 of 67

A 75 year old man undergoes a Hartman’s procedure for sigmoid diverticular disease with pericolic abscess and colovesical fistula. What type of drain should be inserted following this procedure?

Answer 32

Wallace Robinson drain (non suction)

A non suction drain is the preferred option here.

Question 33

37 of 67

Which of the following sutures would be most appropriate for securing a chest drain following a thoracotomy?

Answer 33

2/0 silk

Silk is popular for securing drains as it knots reliably and is easy to handle.

Question 34

38 of 67

Which of the following infection control modalities would be standard practice for a 53 year old male undergoing a Mayo repair of a paraumbilical hernia?

Answer 34

Aqueous iodine applied to the skin

The patient will require skin preparation. However, use of glutaraldehyde or sodium hypochlorite would be an inappropriate choice. As the Mayo repair does not involve implantation of prosthetic mesh the use of antibiotics is not appropriate.

Question 35

39 of 67

A 43 year old lady is due to undergo a diagnostic laparoscopy. Which of the agents listed below should be used for inducing pneumoperitoneum?

Answer 35

Carbon dioxide

Carbon dioxide is the agent of choice. It is rapidly re-absorbed, does not support combustion and is cheap. It is rapidly cleared from the lungs and so effects on pH are unusual.

Question 36

40 of 67

A 43 year old lady underwent an acute cholecystectomy for cholecystitis. A drain is left during the procedure. Over the next 5 days the drain has been accumulating between 100-200ml of bile per 24 hour period. What is the most appropriate course of action?

Answer 36

Arrange an ERCP

The most likely cause of a bile leak in this scenario would be a dislodged clip from the cystic duct. Whilst it may be tempting to try and plan to manage this surgically the anatomy is often unfavorable and the duct very difficult to identify. An ERCP has the advantage of demonstrating the cause of the leak and allowing placement of a stent. This will usually allow the resolution of most leaks without the need for surgery.

Question 37

41 of 67

A 24 year old man is due to undergo an excision of a sebaceous cyst of his scalp which of the agents below should be used for local anaesthesia?

Answer 37

1% lignocaine with 1 in 200,000 adrenaline

Scalp wounds often bleed and the addition of adrenaline is therefore desirable.
Lignocaine is fast acting and the preferred agent.

Question 38

43 of 67

A 43 year old man has symptoms of carcinoid syndrome. Which of the following is the most effective therapeutic agent in controlling the symptoms?

Answer 38

Octreotide

Octreotide is the usual treatment for carcinoid syndrome. Somatostatin inhibits the release of a number of gut hormones. Octreotide is the synthetic alternative to somatostatin and thus the most appropriate therapeutic agent.

Question 38

42 of 67

Which surgical energy device is most appropriate for performing a sphincterotomy during an ERCP?

Answer 38

Monopolar diathermy device in cutting mode

The cutting monopolar mode is needed, that’s why this can be complicated by bleeding.

Question 39

44 of 67

A 68 year old lady has a 3cm basal cell carcinoma excised from her right cheek. There is a rhomboid defect measuring 4cm by 4cm. What is the best option for managing the wound?

Answer 39

Local rotational flap

A local rotational flap or full thickness graft would both be acceptable options here.

Question 39

45 of 67

A 73 year old lady sustains a distal radius fracture and this is manipulated using a Biers block with prilocaine as the local anaesthetic agent. During the procedure the occlusion cuff deflates and the patient becomes progressively cyanosed. What is the treatment of choice?

Answer 39

Intravenous methylene blue

Prilocaine is a recognised cause of methaemoglobinaemia, this is characterised by the development of cyanosis and dyspnoea. This disorder occurs because of the change haemoglobin to a ferric subtype rather than ferrous (Fe ). This type of change shifts the oxygen dissociation curve to the left and tissue hypoxia occurs. Methylene blue will revert the haemoglobin to the ferrous type and reverse this effect.

Question 40

46 of 67

Which of the following is not an absorbable suture material?

Answer 40

Chromic catgut
Nylon(Right)
Vicryl
Dexon
Poly diaxone (PDS).

Question 41

47 of 67

A 74 year old male with colon cancer sustains an iatrogenic splenic injury during surgery. He is bleeding profusely. What is the most appropriate course of action?

Answer 41

Infusion of packed red cells

The cell saver is inappropriate because the cells will be contaminated with malignant cells and faecal matter from the open bowel.

Question 42

48 of 67

You have just completed a laparotomy for peritonitis due to a perforated peptic ulcer. What is the best surgical strategy for avoidance of a complete abdominal wound dehisence?

Answer 42

Mass closure of the midline wound using a 1 polydiaxone suture

The incidence of post operative wound dehisence is minimise by following Jenkins rule which advocates mass closure of the midline wound. However, the suture strength is an important consideration and 3/0 sutures do not have sufficient tensile strength. Both polydiaxone (PDS) and polypropylene (Prolene) or nylon (Ethilon) are all equally suitable. Although separate closure of the peritoneum was practised it has no bearing on the incidence of abdominal wound dehisence.

Question 43

49 of 67

A group of surgeons review a meta-analysis of a series of randomised controlled trials on the Cochrane database and decide that one type of hip replacement is superior to another. What level of evidence is this?

Answer 43

I

A meta- analysis of more than one well designed trials will typically represent level I evidence. It does, of course, depend on how well the trials were conducted and
reported.

Question 44

50 of 67

Which of the energy devices below would be most suited for resection of a parietal lobe tumour?

Answer 44

CUSA device

CUSA systems minimize thermal injury and current flow to the surrounding areas.

Question 45

51 of 67

During an open Watsons Fundoplication, the inferior pole of the spleen is injured causing troublesome bleeding. What is the best course of action?

Answer 45

Use of argon plasma coagulation system

The argon plasma coagulation system is very good for managing splenic bleeding. Alternatives include topical haemostatic agents. Its not necessary to ligate the hilar vessels, if this is required, a splenectomy is the usual outcome.

Question 46

52 of 67

A 28 year old man is undergoing an appendicectomy for perforated appendicitis. What is the single most important modality for reducing the risks of post operative wound infection?

Answer 46

Peri- operative administration of antibiotics

Antibiotics are the single most important factor. Clips make infections easier to manage but do not reduce the risks. Drains have no effect on the skin wounds in these cases.

Question 47

54 of 67

Which of the following methods is most effective at destroying spores of the tubercle bacilli?

Answer 47

Autoclaving

The tubercle bacilli has a waxy outer membrane that renders it more resistant to sterilisation and cleaning methods. Whilst 0.1% sodium hypochlorite will destroy many microbes it is less reliable in destroying tubercle bacilli. Hot air ovens provide less reliable pathogen destruction than autoclaving, but may be indicated in situations where the equipment is sensitive to the autoclaving process. From the list of options above, autoclaving will most reliably destroy tubercle bacilli.

Question 47

53 of 67

In which electrosurgical mode is the electrode held away from the tissue, where the current utilises a low amplitude and high voltage?

Answer 47

Fulguration

Fulguration typically avoids contact between the electrode and the tissue with the current configured to favor arc formation.

Question 47

57 of 67

Which of the following sutures has the largest diameter?

Answer 47

1 Polypropylene

The sizes of suture material are not related to the composition of the suture material.

Question 48

56 of 67

A 7 year old boy is due to undergo a circumcision for phimosis. Which of the following devices would be the most appropriate agent to use for achieving haemostasis?

Answer 48

Bipolar unit

The danger with the use of any source other than bipolar diathermy in this setting is the risk of causing trauma to end vessels. All the monopolar units, regardless of the setting will carry this risk.

Question 49

58 of 67

A 63 year old man with end stage osteoarthritis of the hip is due to undergo a total hip replacement. The skin has been prepared and antibiotics given. What is the single most important modality to reduce the risks of infection?

Answer 49

Laminar flow theatre

A laminar flow is the single most important intervention, many units will also use exhaust suits but these are less essential. Shaving skin on the ward increases infection rates. Extended chemoprophylaxis increases risks of antibiotic associated diarrhea.

Question 50

59 of 67

Which of the sutures listed below would be most suitable for the sub cuticular closure of an inguinal hernia repair wound?

Answer 50

3/0 polydiaxone

A 6/0 suture would lack sufficient tensile strength, the other sutures are too thick or otherwise unsuitable.

Question 51

60 of 67

During a pelvic lymphadenectomy, the common iliac vein is injured and there is profuse bleeding. What is the best course of action?

Answer 51

Occlude the bleeding point with digital pressure and consider direct sutured repair with 5/0 polypropylene

The use of digital pressure and careful sutured repair is the preferred option.

Question 52

61 of 67

Which of the following is not utilised as a descriptive statistic?

Answer 52

Mean
Median
Mode
Z score (Right)
Standard deviation
……………………………………………
The z score is determined using the normal distribution and is not a descriptive statistic.

Question 53

62 of 67

A 68 year old man undergoes a wide local excision of a squamous cell carcinoma from the lateral aspect of his nose. At the completion of the operation the alar cartilage is visible. What is the best method of closing the wound?

Answer 53

Local rotational flap

This type of wound should be managed with a local rotational flap.

Question 54

63 of 67

A 73 year old lady presents with an ulcer overlying her medial malleolus. It is painless and has been present for 4 months. She has oedema of the lower limbs and her ABPI measures 0.9. What is the best management option?

Answer 54

Compression bandages

This is likely to be a venous leg ulcer. These are typically managed using compression bandages. Contra indications to this technique include peripheral vascular disease (not present here).

Question 55

64 of 67

An orthopaedic surgeon makes a modification to an operative approach for total knee arthroplasty. After he has completed 25 cases, he stops and reviews his patient outcomes. He publishes the data. What level of evidence is supplied by this type of data?

Answer 55

IV

Case series that are non randomised and lack concurrent controls at best supply level IV evidence only. To qualify for level I and II evidence a prospective randomised controlled trial with appropriate blinding, control matching and power calculations is needed.

Question 56

65 of 67

Which of the sutures listed below would be most suitable for suturing the femoral artery following an embolectomy?

Answer 56

5/0 polypropylene

Vascular sutures should be monofilament and non absorbable. Of the material listed, only polypropylene fulfills this criteria.

Question 57

67 of 67

A 59 year old lady undergoes an exploration of the common bile duct and insertion of a T Tube. Which of the devices listed below would be the most appropriate for this purpose?

Answer 57

Latex T tube on passive drainage

When the decision is made to insert a T Tube following CBD exploration, it is standard practice to use an agent that elicits a fibrotic response to a track will form. Of the agents listed, latex has this property. However, it would not be usual to apply suction to it. A penrose drain would fall out and is not indicated here.

Question 57

66 of 67

Which of the following local anaesthetic preparations would be most suitable for an 18 year old male undergoing a unilateral Zadeks procedure?

Answer 57

Ring block with 1% lignocaine alone
………………………………………………………………..
Local anaesthetics: avoid use of adrenaline in extremities

This is excision of the toe nail and a fast acting local anaesthetic is indicated. Adrenaline should be avoided in this setting as it can cause digital ischaemia.

Question 58

55 of 67

A 68 year old man has a seborrhoiec wart on his left cheek this is removed by use of curretage leaving a superficial defect approximately 1cm in diameter. What is the best course of action?

Answer 58

Application of simple dressing

This type of superficial wound will re-epithelialise satisfactorily without grafting.