Ovarian masses. Laparoscopy can be used to differentiate benign from malignant ovarian lesions. Additionally, staging of ovarian malignancy with intra -abdominal washings and biopsies can be accomplished with laparotomy.
Abdominal trauma to diagnose injuries
A suspected abdominal catastrophe or abscess in a critically ill ICU patient
I Laparoscopic hysterectomy
Indications
Menorrhagia, chronic cervicitis, dysmenorrhea, and leiomyoma may all be indications for a hysterectomy. In these routine cases, there is minimal advantage in a laparoscopic approach (except in cases of a large uterus or significant myomata).
The presence of an adnexal mass associated with an indication for hysterectomy would indicate a laparoscopic evaluation and treatment.
Patients postcesarean section or patients with chronic pelvic inflammatory disease are poor candidates for vaginal hysterectomy but have been successfully treated with laparoscopic hysterectomy.
Contraindications. A potentially curable malignancy is best treated with en bloc resection through a laparotomy.
J
Laparoscopic staging of malignancy is being used with increasing frequency in a variety of different roles. The exact role of many of these procedures is uncertain and depends on treatment algorithms for different diseases at different institutions.
“Formal” staging procedures. These usually include exploratory laparoscopy, formal lymph node sampling or dissection, liver biopsy, and other interventions as needed for the particular disease process. Examples include gastrointestinal cancers (esophagus, lung, stomach), genitourinary cancers (testicular, bladder, prostate), lymphoma, and gynecological cancers (uterus, cervix). Results may be used to select neoadjuvant treatment prior to definitive surgery.
Directed staging procedures to assess resectability for cure, such as for pancreatic cancer. The abdomen is inspected for evidence of occult distant metastases, the presence or absence of local invasion into surrounding organs is determined, and specific lymph nodes may be sampled.
Biopsy of specific abnormalities detected on imaging studies or screening exams. Examples include evaluation of suspicious masses or areas on CT or positron emission tomography (PET) scans during followup for colon cancer, directed liver biopsy for any reason, and excisional biopsy of suspicious retroperitoneal lymph nodes in patients with lymphoma.
K Other laparoscopic procedures
Many additional procedures are routinely performed depending on surgeon expertise and clinical volume at different institutions. Though they may be the
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“procedure of choice” among some surgeons, it is difficult to make broad statements about long-term efficacy and morbidity, as many of the procedures are performed infrequently by the average general surgeon. A few notable examples follow, but the list is by no means all inclusive.
Laparoscopic adrenalectomy is regarded as the procedure of choice for most patients with benign adrenal
tumors. It is contraindicated in patients with adrenocortical carcinoma and malignant pheochromocytoma.
Laparoscopic splenectomy is ideal in patients without severe splenomegaly or uncorrectable coagulopathy, such as those with well-controlled idiopathic thrombocytopenic purpura (ITP). It is more difficult in patients with splenic abscess and is relatively contraindicated in patients with malignancy, excluding staging procedures. In appropriate patients, laparoscopic splenectomy confers clear recovery advantages over open splenectomy.
Laparoscopic liver resection. All types of resection, from wedge resection to true anatomic resection, have been reported. The procedure is more popular in France and Japan than in the United States. Though technical feasibility has been established, the procedure is not widely performed at present.
Laparoscopic adhesiolysis for chronic partial bowel obstruction or chronic abdominal pain can be effective in carefully selected patients. A few relatively small series have reported 50%–75% improvement in quality of life. Long-term follow-up is not available.
Laparoscopic donor nephrectomy is considered the procedure of choice for harvest of renal allografts in appropriate patients. Allograft function from laparoscopic donors is equivalent to that of kidneys from open donors, with significant improvements in recovery time and morbidity to the kidney donor.
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Study Questions for Part VII
Directions: Each of the numbered items in this section is followed by several possible answers. Select the ONE lettered answer that is BEST in each case.
1.In which of the following situations would the best results be obtained for an emergency department thoracotomy?
A Cardiac arrest in a construction worker after falling from a scaffold eight stories high
B Cardiac arrest following a motor vehicle accident with expulsion of the individual from the car C Cardiac arrest following a gunshot wound to the abdomen
D External cardiac massage that has failed after more than 10 minutes in a trauma patient E Cardiac arrest following a stab wound to the chest
View Answer
2.A trauma patient undergoes exploratory laparotomy for severe blunt injury with a positive diagnostic peritoneal lavage. After splenorrhaphy is performed for a splenic laceration, a retroperitoneal hematoma overlying the pancreas is explored. The pancreas is found to be transected overlying the vertebral bodies. What is the optimal management of this injury?
A Sump drainage
B Resection of the distal pancreas
C End -to -end repair of the pancreatic duct D Whipple resection
E Anastomosis of the jejunum to the severed pancreatic duct View Answer
3.A 21 -year-old male is brought to the emergency room after an assualt with a baseball bat. He has suffered obvious head trauma. He opens his eyes spontaneously, does not speak but makes incomprehensible sounds, and localizes to pain. What is his Glasgow Coma Scale (GCS) score ?
A 8 B 9 C 10 D 11 E 12
View Answer
Questions 4–5
A 50 -year -old man is brought to the emergency department immediately after suffering full -thickness burns over
the entire surface of both upper extremities and the anterior chest and abdomen. His weight is approximately 155 pounds. Initial fluid resuscitation has been started with lactated Ringer's solution.
4. The initial resuscitation rate should be approximately which of the following?
A 300 mL/hour
B 600 mL/hour
C 900 mL/hour
D 1,200 mL/hour
E 1,500 mL/hour View Answer
The patient responds to treatment.
5. After 8 hours, the fluid rate should be changed to which of the following?
A 300 mL/hour
B 600 mL/hour
C 900 mL/hour
D 1,200 mL/hour
E 1,500 mL/hour View Answer
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6.A 22 -year-old previously healthy male presents with a 2-month history of fevers, night sweats, and a 20 - pound weight loss. On physical examination, he is found to have palpable cervical and inguinal lymphadenopathy. A computed tomography (CT) scan of the chest and abdomen reveals mediastinal and abdominal para -aortic enlarged lymph nodes. Excisional biopsies are performed on a cervical and inguinal lymph node. Both of these biopsies reveal lymphocyte-depleted Hodgkin's disease. What should be the next step in the management of this patient?
A Radiation therapy
B Surgical debulking of the enlarged lymph nodes followed by chemotherapy
C Staging laparotomy to include splenectomy, liver biopsy, and biopsies of intra -abdominal lymph nodes D Systemic chemotherapy
E Mediastinoscopy View Answer
7.A 55 -year-old patient with alcoholism who is still actively drinking presents to the emergency department with hematemesis. The bleeding stops, and he undergoes upper endoscopy. This reveals large varices in the gastric fundus. Physical examination is notable for splenomegaly and the absence of ascites. His prothrombin time is 14 seconds, but his bilirubin and albumin are normal. An ultrasound and Doppler examination of the abdomen reveal a small nodular liver, a large spleen, calcifications throughout the pancreas, a thrombosed splenic vein, and patent superior mesenteric and portal veins with hepatopetal flow. What is the recommended treatment for this patient?
A Orthotopic liver transplant B Peritoneovenous shunt
C Mesocaval shunt
D Distal splenorenal shunt E Splenectomy
View Answer
Questions 8–9
A 65 -year -old woman with no other significant past medical history presents with a large mass in the right breast. The mass measures approximately 6 cm in diameter and appears to be fixed to the chest wall. In addition, bulky adenopathy is present in the right axillary region. The patient states that the mass has been enlarging for the last several years.
8. Following mammography, what should be the next step in this patient's evaluation?
AFine -needle aspiration
BIncisional or core biopsy
CExcisional biopsy
D Modified radical mastectomy
E Radical mastectomy
View Answer
The diagnosis for this patient is invasive ductal carcinoma. A mammogram reveals no other lesions in the right breast and no abnormalities in the left breast. A chest radiograph, bone scan, and liver function tests are normal.
9.What should the next step in the management of this patient involve?
A Neoadjuvant chemotherapy
B Radiation therapy to the breast and axilla C Radical mastectomy
D Modified radical mastectomy E Simple mastectomy
View Answer
10.A 47 -year-old patient with a history of left-sided nephrectomy for trauma 20 years ago presents with right flank pain and hematuria. Laboratory studies reveal a creatinine of 2.5 mg/dL. Which of the following is the appropriate management plan?
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A Hydration overnight, followed by repeat evaluation of serum creatinine
B Intravenous pyelography (IVP)
C CT scan of abdomen and pelvis with oral and intravenous contrast
D Ultrasonography followed by urgent cystoscopy
E Percutaneous nephrostomy tube placement
View Answer
11.Which of the following are potential sequelae of benign prostatic hyperplasia?
A Bladder stone formation
B Recurrent urinary tract infections secondary to prostatitis C Prostate cancer
D Bladder cancer
E Organic impotence View Answer
12.A 68 -year-old man undergoes a CT scan of the abdomen as part of the evaluation for some mild abdominal tenderness after a motor vehicle collision. The scan reveals no evidence of trauma, but a 4-cm solid left renal mass is noted. There is evidence of thrombus in the inferior vena cava. Which of the following treatments is not indicated?
A Preoperative chemotherapy and radiation to downstage tumor B Resection of the left adrenal gland
C Resection of the para -aortic lymph nodes D Resection of the left kidney
E Incision of vena cave and removal of thrombus View Answer
13.A 23 -year-old man has a solid mass in his left testis. When it is removed, the pathology reveals an embryonal carcinoma with a teratoma. A CT scan of the chest and abdomen reveals 8 cm of lymphadenopathy in the periaortic nodes. What is the recommended treatment?
A Modified nerve -sparing retroperitoneal lymph node dissection B Full bilateral retroperitoneal lymph node dissection
C Chemotherapy with paclitaxel (Taxol), gemcitabine, and cisplatin D Chemotherapy with cisplatin, etoposide, and bleomycin
E Chemotherapy plus retroperitoneal radiation View Answer
14.Which testicular cancer cell type is extremely radiosensitive?
A Embryonal carcinoma B Yolk sac tumor
CSeminoma
DChoriocarcinoma
ETeratocarcinoma View Answer
15.A 21 -year-old male patient is brought to the emergency department for evaluation after a motor vehicle accident. As part of this secondary survey, the patient is found to have blood at the urethral meatus. What is the next maneuver?
AFoley catheter insertion followed by cystogram
BUrethrogram
CIVP
DCT scan
EDiagnostic peritoneal lavage
View Answer
16. A 24 -year-old woman was admitted to the hospital complaining of dysuria and urinary frequency. She had a temperature of 101°F, pyuria, and bacteriuria. Her chest was clear and her abdomen normal on physical examination. Tenderness was noted at the costovertebral angle. With which of the following should this patient be treated ?
A Antibiotics for 1 day B Antibiotics for 1 week
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CAntispasmodics
DFluids and observation
EBethanechol View Answer
17.A 47 -year-old woman is undergoing a left mastectomy for a large breast cancer. Postoperative chemotherapy is planned. Which of the following is not true?
AA tissue expander can be placed at the time of the initial operation to provide reconstruction.
BA latissimus dorsi flap can provide adequate tissue for reconstruction.
CReconstruction must be delayed until after treatment for the primary tumor is complete.
DA contralateral reduction mammoplasty can provide symmetry.
ENipple reconstruction is typically performed as a separate procedure.
View Answer
18.A 68 -year-old woman has a Mohs' excision on the tip of her nose. A full-thickness skin graft with a tie - over dressing is used. On the fifth postoperative day, the dressing is removed, and the graft is pink. What is the most likely reason for this?
A Imbibition B Inosculation C Infection
D Fibrination E Collagenesis View Answer
19.A 5-year-old boy sustains a laceration to the cheek. It is bleeding profusely. What is the best way to initially control the bleeding?
A Direct pressure B Clamps
C Cautery
D Suture ligature E Dissolving clips View Answer
20.Which of the following is the best treatment for melanoma?
