Surgical Techniques and Technology Flashcards
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?
5/0 vicryl 5/0 vicryl rapide 5/0 polypropylene 3/0 vicryl 3/0 silk
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.
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?
Infusion of factor VIII concentrate Infusion of vitamin K alone Infusion of human prothrombin complex and vitamin K Infusion of human prothrombin complex alone Infusion of packed red cells
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.
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?
I II III IV V
V
Personal expert opinion qualifies for level V evidence.
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?
Latex T tube on passive drainage Polypropylene T Tube on passive drainage Polypropylene T tube on suction drainage Latex T tube on suction drainage Penrose drain
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.
Which of the following local anaesthetic preparations would be most suitable for an 18 year old male undergoing a unilateral Zadeks procedure?
Ring block with 0.5% bupivacaine with 1 in 200,000 adrenaline Application of topical amethocaine Ring block with 1% lignocaine alone Ring block with 1% lignocaine and 1 in 200, 000 adrenaline Ring block with 0.25% bupivacaine with 1 in 80,000 adrenaline
Ring block with 1% lignocaine alone
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.
A 28 year old man undergoes an incision and drainage of an axillary abscess. How should the wound be managed?
Primary closure Delayed primary closure Packing with alginate dressing Packing with gauze Skin grafts
Packing with alginate dressing
Use of gauze is inappropriate and will be painful to redress. Abscess wounds should not be closed.
Which of the sutures listed below would be most suitable for suturing the femoral artery following an embolectomy?
5/0 polyglactin 5/0 polypropylene 5/0 silk 5/0 polyglyconate 5/0 polyester
5/0 polypropylene
Vascular sutures should be monofilament and non absorbable. Of the material listed, only polypropylene fulfills this criteria.
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?
Diagnostic laparoscopy Open the wound Arrange an abdominal ultrasound scan Arrange an abdominal CT scan Arrange an abdominal X-ray
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.
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?
1% lignocaine 1% lignocaine with 0.5% bupivacaine mixed in 50:50 mixture 1% prilocaine 1% lignocaine with 1 in 200,000 adrenaline 1% prilocaine with 1 in 200,000 adrenaline
1% prilocaine
This is the best local anaesthetic for this. Bupivacaine may cause cardiotoxicity and should be avoided.
In which of the following operations would the use of a cell salvage device be permitted?
Ivor - Lewis oesophagectomy Revision arthroplasty of the hip for recurrent dislocation Revision abdominal aortic aneurysm surgery for graft infection Mastectomy and latissimus dorsi flap for invasive ductal carcinoma Excision of osteogenic sarcoma from the femur
Revision arthroplasty of the hip for recurrent dislocation
Infection and malignancy are contra indications to use of cell saver devices.
Which of the following substances is commonly used to sterilize endoscopic equipment?
Aqueous phenol 80% phenol Absolute alcohol Glutaraldehyde Gamma irradiation
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.
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?
II IV III V I
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.
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?
Compression bandages Non compression bandaging Split thickness skin grafting Full thickness skin grafting Angioplasty and non compression bandages
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).
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?
Interrupted 3/0 silk Local rotational flap Split thickness skin graft Vacuum assisted closure system Full thickness skin graft
Local rotational flap
This type of wound should be managed with a local rotational flap.
Which of the following is not utilised as a descriptive statistic?
Mean Median Mode Z score Standard deviation
Z score
The z score is determined using the normal distribution and is not a descriptive statistic.
During a pelvic lymphadenectomy, the common iliac vein is injured and there is profuse bleeding. What is the best course of action?
Clamp the vessel to gain a better view and then ligate it Occlude the bleeding point with digital pressure and consider direct sutured repair with 5/0 polypropylene Use diathermy at high coagulation current to stem the bleeding Apply surgicell to the site and wait for bleeding to cease Apply digital pressure to the vessel and suture the vessel with 2/0 polypropylene
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.
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?
Mass closure of the abdomen obeying Jenkins rule using 2 PDS Application of a Bogota bag Mass closure of the abdomen obeying Jenkins rule using 2/0 PDS Mass closure of the abdomen obeying Jenkins rule using 2 nylon Mass closure of the abdomen obeying Jenkins rule using 2/0 nylon
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.
Which of the sutures listed below would be most suitable for the sub cuticular closure of an inguinal hernia repair wound?
2/0 polyglactin 2/0 silk 6/0 polydiaxone 3/0 polydiaxone 1 polydiaxone
3/0 polydiaxone
A 6/0 suture would lack sufficient tensile strength, the other sutures are too thick or otherwise unsuitable
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?
Laminar flow theatre Exhaust suits Skin shaving on the ward Total body scrubbing of the surgical team Extended antibiotic chemoprophylaxis as routine
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.
Which of the following visceral anastomoses has the lowest risk of anastomotic leak? You may assume that all are constructed in ideal circumstances.
Stapled ileocolic anastomosis Hand sewn anastomosis of the proximal ileum Stapled colorectal anastomosis defunctioned with loop ileostomy Stapled colorectal anastomosis defunctioned with loop colostomy Hand sewn oesophagojejunal anastomosis
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.
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?
Apply topical haemostatic agents to the vessel Ligate the bleeding vessel Apply bipolar diathermy to the vessel Use monopolar diathermy on blend setting to seal the vessel Inject the area with dilute adrenaline
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.
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?
Compression bandaging Vacuum assisted closure system Split thickness graft Primary closure with 2/0 polypropylene Full thickness skin graft
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
Which of the following surgical energy devices would be most appropriate for the dissection of the posteriomedial aspect of the thyroid gland during thyroidectomy?
Harmonic ACE Monopolar diathermy in coagulation mode Bipolar diathermy CUSA device Argon plasma coagulation device
Bipolar diathermy
This will minimise thermal trauma to the recurrent laryngeal nerve
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?
Direct primary closure Delayed primary closure Pedicled skin graft Free flap Rotational flap
Direct primary closure
This wound should be amenable to primary closure. There is minimal associated tissue loss and the surgery is minor and uncontaminated
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?
Mass closure of the abdomen obeying Jenkins rule using 1 PDS Mass closure of the abdomen obeying Jenkins rule using 2/0 PDS Mass closure of the abdomen obeying Jenkins rule using 1/0 nylon Mass closure of the abdomen obeying Jenkins rule using 0 polygalactan Use of deep tension sutures closure method using 5 polyester sutures
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.
Which of the following local anaesthetics is not an amino amide type?
Lignocaine Xylocaine Procaine Bupivacaine Prilocaine
Procaine
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
