Williams Gynecology, Second Edition (Schorge,Williams Gynecology), 2nd Edition

CHAPTER 40
Intraoperative Considerations

40–1. To achieve adequate blockade of Frankenhaüser plexus during paracervical blockade, injections should ideally be placed at what sites around the cervical base?

a. 1 and 6 o’clock

b. 2 and 10 o’clock

c. 3 and 9 o’clock

d. 4 and 8 o’clock

40–2. Classic signs of lidocaine toxicity include all EXCEPT which of the following?

a. Seizure

b. Tinnitus

c. Petechial rash

d. Perioral tingling

40–3. During the presurgical “time out,” the entire surgical team should routinely reach consensus agreement on all EXCEPT which of the following?

a. Patient identity

b. Procedure planned

c. Patient blood type

d. Side of patient to be treated

40–4. Correct patient positioning can avert many intraoperative neurologic injuries. All EXCEPT which of the following patient or surgical characteristics is associated with an increased risk of such injury?

a. Diabetes mellitus

b. Body mass index (BMI) of 25

c. 20 pack-year history of smoking

d. Use of a self-retaining retractor

40–5. Malpositioning of a self-retaining retractor can injure the femoral nerve as it runs near the psoas major muscle, as shown here. Which of the following may be seen classically with a femoral neuropathy?

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Reproduced, with permission, from Hamid CA, Hoffman BL: Intraoperative considerations. In Hoffman BL, Schorge JO, Schaffer JI, et al (eds): Williams Gynecology, 2nd ed. New York, McGraw-Hill, 2012, Figure 40-5.

a. Absent patellar reflex

b. Inability to flex the knee

c. Inability to extend the hip

d. Paresthesia over the posterior thigh

40–6. All EXCEPT which of the following procedures places the obturator nerve at risk of injury?

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Reproduced, with permission, from Corton MM: Anatomy. In Hoffman BL, Schorge JO, Schaffer JI, et al (eds): Williams Gynecology, 2nd ed. New York, McGraw-Hill, 2012, Figure 38-7.

a. Burch colposuspension

b. Abdominal sacrocolpopexy

c. Pelvic lymph node dissection

d. Resection of endometriosis adhered to the pelvic sidewall

40–7. In general, which of the following incisions for abdominal entry provides the LEAST operative space?

a. Cherney

b. Maylard

c. Pfannenstiel

d. Midline vertical

40–8. Which of the following is commonly used to lower postoperative wound infection and dehiscence rates?

a. Subcutaneous drain placement prior to skin closure

b. Closer of subcutaneous layer if greater than 2 cm deep

c. Wound irrigation with concentrated povidone-iodine solution prior to skin closure

d. All of the above

40–9. For most Pfannenstiel incisions, which of the following offers superior skin closure?

a. Staples

b. Subcuticular suturing

c. Octyl-2-cyanoacrylate (Dermabond)

d. All provide equivalent results

40–10. Which of the following blades would be preferred for incision and drainage of the cyst shown here?

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a. No. 11 blade

b. No. 10 blade

c. No. 20 blade

d. Beaver blade

40–11. Shown here, which of the following is traditionally used as a vaginal retractor?

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a. Deaver retractor

b. Richardson retractor

c. Harrington retractor

d. Breitsky-Navratil retractor

40–12. Placement of the grounding pad as shown here on the upper thigh prior to hysterectomy serves all EXCEPT which of the following goals?

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a. Provides a flat surface to maximize the exit site for current

b. Provides a small surface area on which to concentrate current

c. Provides an exit site for current that is close to the operative site

d. Aids prevention of electrical burns when using monopolar electrosurgery

40–13. Which of the following is true of cavitational ultrasonic surgical aspiration?

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Reproduced, with permission, from Word L, Hoffman BL: Surgeries for benign gynecologic conditions. In Hoffman BL, Schorge JO, Schaffer JI, et al (eds): Williams Gynecology, 2nd ed. New York, McGraw-Hill, 2012, Figure 41-28.3.

a. Requires a grounding pad for patient safety

b. Is less disruptive to tissues with a high water content

c. Disrupts tissue architecture using a process termed reabsorption

d. May be selected to minimize nerve and blood vessel damage within affected tissues

40–14. To control bleeding from an isolated small vessel, sealing the vessel using electrosurgical energy offers all EXCEPT which of the following advantages compared with suture ligature?

a. Is faster

b. Avoids suture ligature slippage

c. Creates less damage to surrounding tissues

d. More easily reaches vessels in narrow spaces

40–15. Which of the following topical hemostats does NOT include coagulation cascade proteins?

a. Fibrin sealants

b. Active hemostats

c. Flowable hemostats

d. Mechanical hemostats

40–16. Mechanical hemostats aid control of bleeding by which of the following mechanisms?

a. Create a pressure scaffold that entraps platelets

b. Bind directly to von Willebrand factor to promote platelet aggregation

c. Directly stimulate thromboxane-A synthase production of thromboxane

d. Bind to prothrombinase complex to promote direct conversion of prothrombin to thrombin

40–17. Bleeding in the space of Retzius may complicate all EXCEPT which of the following procedures?

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Reproduced, with permission, from Corton MM: Anatomy. In Hoffman BL, Schorge JO, Schaffer JI, et al (eds): Williams Gynecology, 2nd ed. New York, McGraw-Hill, 2012, Figure 38-24.

a. Burch colposuspension

b. Transobturator tape procedure

c. Tension-free vaginal tape procedure

d. Abdominal paravaginal defect repair

40–18. What is the blood volume of a 50-kg female?

a. 2500 mL

b. 3500 mL

c. 4500 mL

d. 5500 mL

40–19. What volume of blood typically can be lost by a 50-kg woman before tachycardia and blood pressure changes develop?

a. 500 mL

b. 1000 mL

c. 1250 mL

d. 1500 mL

40–20. Targets of fluid replacement include which of the following?

a. Urine output of 30 mL/hr or more

b. Heart rate less than 100 beats per minute

c. Systolic blood pressure above 90 mm Hg

d. All of the above

40–21. In those without significant heart disease, what is the threshold above which red blood cell transfusion is seldom required?

a. 8g/dL

b. 9g/dL

c. 10 g/dL

d. 11 g/dL

40–22. Side effects seen with an acute hemolytic transfusion reaction include all EXCEPT which of the following?

a. Fever

b. Dyspnea

c. Acute tubular necrosis

d. Fulminant liver failure

40–23. If acute hemolytic transfusion reaction is suspected, which of the following immediate steps is indicated?

a. Halt transfusion.

b. Initiate prompt diuresis with intravenous crystalloids and furosemide diuretic.

c. Obtain a patient blood sample for the hematology laboratory to compare with the transfused bag.

d. All of the above

40–24. Which of the following is true of packed red blood cell (RBC) transfusion?

a. Each unit of packed RBCs provides 500 mL of volume.

b. Each unit of packed RBCs has a hematocrit of approximately 70 percent.

c. Each unit of packed RBCs typically increases the hemoglobin level by approximately 3 g/dL.

d. Each unit of packed RBCs contains enough fibrinogen to raise the fibrinogen level by 10 g/dL.

40–25. Injury to the bladder during total abdominal hysterectomy may more commonly occur at which of the following surgical steps?

a. Closing the vaginal cuff

b. Opening the vesicovaginal space

c. Dissecting the bladder off the cervix

d. All of the above

40–26. Injury to the bladder may be identified using which of the following procedures?

a. Cystoscopy

b. Direct visualization of the Foley bulb

c. Retrograde instillation of sterile milk

d. All of the above

40–27. Injury to the ureter during total abdominal hysterectomy may more commonly occur at which of the following surgical steps?

a. Closing the vaginal cuff

b. Ligating the uterine artery

c. Ligating of the infundibulopelvic ligament

d. Opening the anterior leaf of the broad ligament

Chapter 40 ANSWER KEY

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