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
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?
Abdominal CT scan with IV contrast Abdominal MRI scan Abdominal ultrasound scan PET CT scan Erect chest x-ray
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.
Which of the following sutures has the largest diameter?
6/0 Polypropylene 5/0 Silk 3/0 Nylon 1 Polypropylene 0 Polydiaxone
1 Polypropylene
The sizes of suture material are not related to the composition of the suture material.
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?
A closed suction drainage system made of polypropylene A closed suction drainage system made of latex A passive drainage system made of polypropylene Insertion of a penrose drain Use of a VAC wound closure system
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.
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?
Blended current Cutting current Coagulation current Desiccation Fulguration
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).
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?
Monopolar unit in cutting mode Bipolar unit Monopolar unit in coagulation mode Monopolar unit in blend mode Monopolar unit configured to spray mode
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.
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?
Epidermis alone Epidermis and dermis Dermis alone Inflammatory exudate Fibrin
Epidermis alone
This is the process of re-epithelialisation.
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?
Rotational myocutaneous flap Full thickness skin graft Excision and delayed primary closure Debridement and split thickness skin graft Excision and direct primary closure
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.
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?
Application of simple dressing Split thickness skin graft Full thickness skin graft Suturing of the wound with 2/0 nylon Rotational local flap
Application of simple dressing
This type of superficial wound will re-epithelialise satisfactorily without grafting.
Which of the following methods is most effective at destroying spores of the tubercle bacilli?
Immersion in 0.5% chlorhexidine in alcohol Immersion in aqueous iodine Heating in a hot air oven Immersion in 0.1% sodium hypochlorite Autoclaving
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.
Which of the following is a permanent suture material best suited for interrupted mattress dermal closure?
2/0 Polydiaxone 3/0 Polydiaxone 4/0 Polyglycolic acid 1/0 Dexon 3/0 Polypropylene
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.
In which electrosurgical mode is the electrode held away from the tissue, where the current utilises a low amplitude and high voltage?
Desiccation Fulguration Blended current Cutting current Coagulation current
Fulguration
Fulguration typically avoids contact between the electrode and the tissue with the current configured to favor arc formation.
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?
Peri- operative administration of antibiotics Use of suction drains in the abdominal wall Use of passive drains in the abdomen Use of skin clips for closure Use of incise drapes
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.
During an open Watsons Fundoplication, the inferior pole of the spleen is injured causing troublesome bleeding. What is the best course of action?
Removal of the entire spleen Partial splenectomy Use of argon plasma coagulation system Sutured splenorrhaphy Sutured ligation of the splenic hilar vessels
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.
Which of the energy devices below would be most suited for resection of a parietal lobe tumour?
Monopolar diathermy in coagulation mode Harmonic ACE CUSA device Monopolar diathermy in cutting mode Ligasure system
CUSA device
CUSA systems minimize thermal injury and current flow to the surrounding areas.
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?
II III I V IV
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.
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?
Use of skin clips to close the skin rather than sub cuticular sutures Careful approximation of the peritonum with non absorbable sutures Mass closure of the midline wound using a 1 polydiaxone suture Direct apposition of the rectus muscle rather than linea alba aponeurosis Mass closure of the midline wound using a 3/0 polypropylene suture
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.
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?
Infusion of human prothrombin complex Infusion of packed red cells Infusion of blood from the cell saver salvaged during surgery Infusion of factor VIII concentrate Infusion of gelofusine
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.
Which of the following is not an absorbable suture material?
Chromic catgut Nylon Vicryl Dexon Poly diaxone (PDS).
Nylon
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?
Intravenous calcium gluconate Exchange transfusion Intravenous methylene blue Intravenous sodium thiosulphate Intravenous gelofusine
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 (Fe2+). 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
A 72 year old lady has a 4cm 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?
Delayed primary closure Direct primary closure Full thickness skin graft Split thickness skin graft Myocutaneous flap
Full thickness skin graft
Facial wounds that are large and irregularly shaped are best managed with full thickness skin grafts.
A 43 year old man has symptoms of carcinoid syndrome. Which of the following is the most effective therapeutic agent in controlling the symptoms?
Atenolol Octreotide Glucagon Somatostatin Spironolactone
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.
Which surgical energy device is most appropriate for performing a sphincterotomy during an ERCP?
Monopolar diathermy device in cutting mode Bipolar diathermy Monopolar diathermy in coagulation mode Harmonic ACE CUSA
Monopolar diathermy device in cutting mode
The cutting monopolar mode is needed, that’s why this can be complicated by bleeding.
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?
1% lignocaine with 1 in 200,000 adrenaline 1% lignocaine alone 1% prilocaine 0.5% bupivicaine 0.25% bupivacaine with 1 in 200,000 adrenaline
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.
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?
Undertake a laparotomy Arrange an abdominal CT scan Arrange an ERCP Arrange an abdominal USS Order an erect CXR
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.
A 43 year old lady is due to undergo a diagnostic laparoscopy. Which of the agents listed below should be used for inducing pneumoperitoneum?
Argon Helium Air Carbon dioxide Nitrogen
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.
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?
Sodium hypochlorite solution applied to the skin Administration of clindamycin Aqueous iodine applied to the skin Administration of gentamicin Pre operative shaving
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.
Which of the following sutures would be most appropriate for securing a chest drain following a thoracotomy?
2/0 silk 4/0 silk 1 polypropylene 1/0 polypropylene 3/0 vicryl rapide
2/0 silk
Silk is popular for securing drains as it knots reliably and is easy to handle.
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?
T Tube drain Wallace Robinson drain (non suction) Redivac drain Corrugated drain No drain
Wallace Robinson drain (non suction)
A non suction drain is the preferred option here.
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?
Distal enterocutaneous fistula Superficial wound infection Proximal enterocutaneous fistula Entero-enteric fistula Colocutaneous fistula
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.
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?
Cohort study Retrospective study Case controlled study Cross over study Randomised controlled study
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.
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?
Excision of the area Cryotherapy Application of topical silver nitrate Compression dressings Application of alginate dressings
Application of topical silver nitrate
Silver nitrate will cauterise the exuberant granulation tissue and promote healing.
A 19 year old male presents with axillary lymphadenopathy and symptoms suggestive of Hodgkins lymphoma. What is the most appropriate investigation?
Fine needle aspiration of the lymph nodes Freehand needle core biopsy of the lymph nodes Image guided core biopsy of the lymph nodes Excision biopsy of a lymph node Axillary node clearance
Excision biopsy of a lymph node
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.
What is the mechanism of action of ciprofloxacin?
Inhibition of DNA gyrase Direct injury to the bacterial cell wall Osmotic damage to the cell Inhibition of reverse transcriptase Destruction of bacterial aquaporin proteins
Inhibition of DNA gyrase
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?
Release of pneumoperitoneum Perform a laparotomy Administration of intravenous adrenaline Administration of intravenous amiodarone End the operation
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.
Which of the following is least likely to reduce the risk of post operative wound infection?
Electrical clippers to remove body hair Use of proviodone impregnated drapes Antibiotic prophylaxis for prosthesis placement Routine use of mechanical bowel preparation Chlorhexidine to prepare the skin
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.
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?
Patient burns at the site of the contact plate Fires when used near alcoholic skin preparations that have pooled Coupling injuries Risk of thermal injury to regional vessels as a result of tissue heating Capacitance injuries
Fires when used near alcoholic skin preparations that have pooled
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.
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?
4mm Hg 10mm Hg 20mm Hg 40mm Hg 60mm Hg
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.
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?
III I IV II V
II
Data which includes at least one RCT will usually qualify for level II evidence.
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?
Anastomotic leak Discharging mesenteric haematoma Bleeding peptic ulcer Anastomotic staple line bleeding Mesenteric infarct
Anastomotic staple line bleeding
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.
Which of the following sutures is most suitable for the mass closure of an abdominal wall following a laparotomy?
1 polydiaxone 1/0 polydiaxone 2/0 polydiaxone 1/0 silk 1/0 polglactin
1 polydiaxone
Only 1 polydiaxone would have sufficient tensile strength.
In which electrosurgical modality does a sinusoidal, non modulated waveform result in vaporization of the tissues?
Coagulation current Cutting current Blended current Fulguration Desiccation
Cutting current
The high energy levels result in tissue vaporisation and cleavage of tissues.
