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

CHAPTER 41
Surgeries for Benign Gynecologic Conditions

41–1. Compared with a midline vertical incision, attributes of the Pfannenstiel incision include which of the following?

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Photograph contributed by Dr. Marlene Corton.

a. Inferior cosmetic results

b. Greater access to the upper abdomen

c. Fewer neurovascular structures encountered

d. Lower rates of subsequent incisional hernia

41–2. With wide transverse incisions, improper self-retaining retractor placement may lead to injury of which of the following nerves?

a. Femoral

b. Pudendal

c. Obturator

d. Lateral femoral cutaneous

41–3. The Pfannenstiel, Cherney, and Maylard incisions are abdominal incisions used for gynecologic procedures. The Maylard incision differs mainly from the Pfannenstiel and Cherney incisions in which of the following ways?

a. It is a transverse abdominal incision.

b. The tendons of the pyramidalis muscle are transected.

c. The tendons of the rectus abdominis muscle are transected.

d. The bellies of the rectus abdominis muscle are transected.

41–4. During oophorectomy, the infundibulopelvic ligament is isolated prior to clamping, transection, and ligation. This ideally averts injury to the structure shown in the second image beneath the arrow.

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Photographs contributed by Dr. David Miller.

a. Ureter

b. Uterine artery

c. Obturator nerve

d. Genitofemoral nerve

41–5. The images below illustrate which interval partial salpingectomy method?

Image

Reproduced, with permission, from Hnat MD: Tubal ligation at the time of cesarean section (update). In Cunningham FG, Leveno KL, Bloom SL, et al (eds), Williams Obstetrics, 22nd ed. Online, New York, McGraw-Hill, 2006, http://www.accessmedicine.com, Figures 5 and 6.

a. Uchida

b. Irving

c. Pomeroy

d. Parkland

41–6. The image below illustrates incision of the mesosalpinx, which is an early step performed in which of the following operative procedures?

Image

Reproduced, with permission, from Hoffman BL: Surgeries for benign gynecologic conditions. In Schorge JO, Schaffer JI, Halvorson LM, et al (eds): Williams Gynecology, 1st ed. New York, McGraw-Hill, 2008, Figure 41-25.1.

a. Cystectomy

b. Salpingostomy

c. Salpingectomy

d. Salpingoplasty

41–7. Gonadotropin-releasing hormone agonist (GnRH) use may benefit menorrhagia and anemia prior to myomectomy. Which of the following is an additional benefit of GnRH use preoperatively?

a. Decreases uterine volume

b. Increases uterine blood flow

c. Increases leiomyoma vascularity

d. None of the above

41–8. 8-Arginine vasopressin is effective in limiting uterine blood loss during myomectomy. Patients with which of the following health conditions may be poor candidates for 8-arginine vasopressin?

a. Migraine

b. Uncontrolled hypertension

c. Chronic obstructive pulmonary disease

d. All of the above

41–9. Which of the following has been shown to reduce the incidence of adhesion formation following myomectomy?

a. Postoperative antibiotics

b. Absorbable adhesion barriers

c. Normal saline pelvic irrigation

d. Postoperative transfusion for anemic patients

41–10. Of the hysterectomy types, which has the highest risk of bladder and ureteral injury?

a. Vaginal hysterectomy

b. Abdominal hysterectomy

c. Supracervical hysterectomy

d. Laparoscopic hysterectomy (LH)

41–11. Hysterectomy is one of the most frequently performed gynecologic procedures, with approximately 600,000 women undergoing this procedure annually in the United States. During this abdominal procedure, the figure below illustrates which of the following?

Image

Reproduced, with permission, from Hoffman BL: Surgeries for benign gynecologic conditions. In Schorge JO, Schaffer JI, Halvorson LM, et al (eds): Williams Gynecology, 1st ed. New York, McGraw-Hill, 2008, Figure 41-19.9.

a. Uterine artery transection

b. Round ligament transection

c. Cardinal ligament transection

d. Uterosacral ligament transection

41–12. With anterior peritoneal cavity entry during vaginal hysterectomy, the final layer incised to gain entry is which of the following?

Image

Reproduced and modified, 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 38-17.

a. Vesicouterine fold

b. Pubocervical fascia

c. Cul-de-sac of Douglas

d. Bladder fibrous bands

41–13. At the conclusion of the vaginal hysterectomy, to improve final suspension and support for the vaginal vault, which ligament is sutured to each lateral side of the vaginal cuff?

a. Round

b. Broad

c. Uterosacral

d. Infundibulopelvic

41–14. Nerve damage may occur from patient positioning for extended periods in the dorsal lithotomy position. Which of the following nerves are at greatest risk?

a. Genitofemoral

b. Common peroneal and femoral

c. Ilioinguinal and iliohypogastric

d. Abdominal extensions of the intercostals

41–15. With the resurgence of supracervical hysterectomy now performed via laparoscopy, rates of trachelectomy for benign causes are expected to rise in the future. Unlike vaginal hysterectomy, which of the following characterizes trachelectomy?

a. Clear tissue planes are usually encountered.

b. Entry into the peritoneal cavity is not required.

c. During separation of the vaginal wall from the cervix, blunt, not sharp, dissection is preferred.

d. None of the above

41–16. To decrease the risk of uterine perforation during sharp dilatation and curettage (D&C), which of the following is the first surgical step?

a. Uterine sounding

b. Uterine dilation

c. Bimanual examination

d. Transvaginal sonography

41–17. During suction dilatation and curettage (D&C), the rate of uterine perforation is greater with which of the following?

a. A soft uterus

b. A retroflexed uterus

c. A dilated cervical os

d. A cervical os that exhibits a healed obstetric tear

41–18. The main surgical goal following the incision and drainage of a Bartholin gland duct abscess includes steps to create which of the following?

a. A new duct ostium

b. Labia cosmetic reapproximation

c. A blocked epithelialized tract

d. All of the above

41–19. Compared with Word catheter placement, this treatment of a Bartholin gland duct cyst is associated with which of the following?

Image

Photograph contributed by Dr. William N. Denson.

a. Less operative pain

b. Higher recurrence rates

c. Smaller intraoperative incision

d. None of the above

41–20. A 48-year-old patient returns with repetitive recurrence of a painless vulvar cyst shown in the image below. Appropriate management includes which of the following?

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a. Sitz baths only

b. Incision and drainage of the cyst

c. An extended course of oral antibiotics

d. Incision and drainage of the cyst with biopsy of the cyst wall

41–21. Most cases of vulvodynia are managed conservatively, but for refractory cases, which of the following has been employed?

a. Perineoplasty

b. Vestibulectomy

c. Vestibuloplasty

d. All of the above

41–22. The most important factor for surgical success in treating vulvar pain is identifying the proper candidate. Which of the following coexists in approximately half of patients with vulvodynia and is associated with lower rates of postoperative pain relief?

a. Vaginismus

b. Vaginal atrophy

c. Chronic depression

d. A lichenoid epithelial process

41–23. Prior to correction of this condition, the consenting discussion should include which of the following points?

Image

Photograph contributed by Dr. Ellen Wilson.

a. Postoperative dyspareunia is a common complication.

b. Patient expectations should be realistic as to the final size, shape, and color of the labia.

c. Wound complications including hematoma, cellulitis and incisional dehiscence are common complications.

d. All of the above

41–24. Creation of a functional vagina is the treatment goal for many women with congenital agenesis of the vagina. Which of the following surgical procedures is commonly employed in the United States?

a. Septum revision

b. McIndoe procedure

c. Vaginal dilatation

d. Septum reapproximation

41–25. Cryotherapy has been used for decades to safely and effectively eliminate cervical intraepithelial lesions (CIN). The image below illustrates the creation of an iceball. To ensure a necessary 5-mm lethal zone for epithelium cell death, to what distance should the iceball extend beyond the outer margin of the cryoprobe?

Image

Photograph contributed by Dr. Claudia Werner. Reproduced, with permission, from Hoffman BL: Surgeries for benign gynecologic conditions. In Schorge JO, Schaffer JI, Halvorson LM, et al (eds): Williams Gynecology, 1st ed. New York, McGraw-Hill, 2008, Figure 41-13.3B.

a. 1mm

b. 2mm

c. 4mm

d. 7mm

41–26. Loop electrosurgical excision procedure (LEEP) uses electric current to generate energy waveforms through a metal electrode that either cuts or desiccates cervical tissue. During the patient consenting process, major complications may include bowel or bladder injury and hemorrhage. Of the following, what is the rate of major complications (percent)?

a. 0.5

b. 1.0

c. 5.0

d. 10

41–27. Compared to the loop electrosurgical excision procedure (LEEP), cervical cold-knife conization has a definitive greater risk of which of the following?

a. Cervical infection

b. Poor obstetric outcome

c. Cervical stenosis and bleeding

d. All of the above

41–28. A 55-year-old otherwise healthy patient presents with biopsy proven vulvar intraepithelial neoplasia (VIN) 2 as shown in the image below. Which of the following is the most appropriate management?

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a. Wide local excision

b. Skinning vulvectomy

c. Continued surveillance

d. Combined wide local excision and laser ablation

41–29. Of the following, what is the recommended postprocedural colposcopic vulvar surveillance schedule for high-grade vulvar intraepithelial neoplasia (VIN)?

a. Annually

b. Every 3 months

c. Every 6 months for 3 years

d. Every 6 months for 1 year, then annually thereafter

Chapter 41 ANSWER KEY

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