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

CHAPTER 42
Minimally Invasive Surgery

42–1. All EXCEPT which of the following are contraindications to the use of pneumoperitoneum during laparoscopy?

a. Acute glaucoma

b. Peritoneal shunt

c. Second-trimester pregnancy

d. Increased intracranial pressure

42–2. All EXCEPT which of the following may be used to effectively compensate for difficulties encountered during laparoscopy in an obese patient?

a. Steeper Trendelenburg position to improve patient ventilation

b. Veress needle insertion at an angle that is nearly perpendicular to the skin

c. Placement of additional ancillary ports to assist in lifting a fattier omentum from the operating field

d. Use of a gel pad beneath the patient and tucking of patient arms to limit patient slippage while in Trendelenburg position

42–3. The medial umbilical ligament and round ligament are ideally identified prior to ancillary trocar placement through the lower anterior abdominal wall. This assists in minimizing injury to which of the following vessels?

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Photograph contributed by Dr. Mayra Thompson.

a. Inferior epigastric artery

b. Superior epigastric artery

c. Superficial epigastric artery

d. Superficial circumflex iliac artery

42–4. When used for entry at the umbilicus, which of the following abdominal entry methods is associated with the lowest rate of puncture injury?

a. Open umbilical entry

b. Optical access trocar entry

c. Closed entry with Veress needle

d. All have similar rates

42–5. With abdominal entry using the Veress needle, what threshold for initial abdominal pressure is used to reassure the surgeon regarding correct intraperitoneal needle placement?

a<3mmHg

b<8mmHg

c<15 mm Hg

d<20 mm Hg

42–6. Transillumination of the anterior abdominal wall (shown here) may assist in locating which of the following vessels prior to ancillary trocar placement?

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a. Inferior epigastric artery

b. Superior epigastric artery

c. Superficial epigastric artery

d. Superficial circumflex iliac artery

42–7. Preoperative methods to prevent conception prior to laparoscopic sterilization include which of the following?

a. Perform surgery in the luteal phase of the menstrual cycle

b. Provide effective contraception well in advance of surgery

c. Provide mifepristone 600 mg in a single dose prior to the surgical procedure

d. All of the above

42–8. During sterilization counseling for tubal sterilization, all EXCEPT which of the following discussion points is correct?

a. Tubal sterilization is surgically challenging and costly to reverse.

b. Vasectomy is comparable in efficacy but is associated with fewer surgical complications.

c. If pregnancy occurs following tubal sterilization, the risk of ectopic pregnancy is less than 5 percent.

d. Risk of regret following sterilization is lower in those who are older at the time of surgery.

42–9. To ensure Filshie clip efficacy, which of the following is true?

a. Two clips are placed on each fallopian tube.

b. The clip must remain permanently around the tubal midsegment.

c. Following clip placement, chromotubation should be performed to document tubal occlusion.

d. Prior to clip application across the fallopian tube diameter, the tip of the lower jaw should be seen through the mesosalpinx.

42–10. At the time of hysterectomy, a Falope ring is seen loosely adhered to the fallopian tube. Which of the following is true regarding this method of sterilization?

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a. Sterilization is achieved by necrosis and fibrosis of the tubal ends.

b. A ring must remain around a midsegment loop of fallopian tube to sustain efficacy.

c. These silicone-based rings are no longer used due to their link with autoimmune disease.

d. In most cases, a Falope ring found in the cul-de-sac should be considered a dangerous foreign body.

42–11. Important care points for patients following salpingostomy for ectopic pregnancy include which of the following?

a. Administration of RhO (D) immunoglobulin to all patients to prevent Rh sensitization

b. Postoperative hysterosalpingogram on postoperative day 10 to document tubal patency on the affected side

c. Administration of single-dose methotrexate 50 mg/m2 on postoperative day 1 to prevent persistent trophoblastic tissue

d. Measurement of a serum human chorionic gonadotropin level on postoperative day 1 to exclude persistent trophoblastic tissue

42–12. With laparoscopic oophorectomy, all EXCEPT which of the following are appropriate steps completed to anticipate the possibility of ovarian malignancy?

a. Tumor markers are obtained preoperatively.

b. Pneumatic compression hose are placed preoperatively.

c. Pelvic washings are obtained following specimen removal to determine if any cyst contents have spilled.

d. Preoperatively, patients are counseled regarding the steps of surgical cancer staging that would be performed if malignancy is found intraoperatively.

42–13. Ovarian drilling may be indicated for which of the following patients with polycystic ovarian syndrome (PCOS)?

a. Those who choose to lower their risk of twins

b. Those who fail to ovulate with clomiphene citrate

c. Those with risk factors for ovarian hyperstimulation syndrome

d. All of the above

42–14. In addition to an intraligamentous location, which of the following characteristics increases the risk of complications during laparoscopic myomectomy?

a. Nulliparity

b. Pedunculated leiomyoma

c. More than three tumors requiring excision

d. All of the above

42–15. All EXCEPT which of the following are suitable techniques to employ during laparoscopic myomectomy?

a. Use of barbed suture to close the hysterotomy incision

b. Delivery of the enucleated leiomyoma through a colpotomy incision

c. Injection of dilute oxytocin into the myometrium to control bleeding during tumor enucleation

d. Copious irrigation to float and allow removal of myometrium pieces dropped during morcellation

42–16. Women with which of the following characteristics are considered poor candidates for vaginal hysterectomy?

a. Contracted pelvis

b. Large adnexal pathology

c. Suspected dense pelvic adhesions

d. All of the above

42–17. For vessel occlusion during laparoscopic hysterectomy, which of the following is a suitable choice?

a. Harmonic scalpel

b. Bipolar electrosurgery instruments

c. Monopolar electrosurgery instruments

d. All of the above

42–18. Women with which of the following characteristics are considered poor candidates for supracervical hysterectomy?

a. Those with high-grade endocervical dysplasia

b. Those with endometrial hyperplasia with atypia

c. Those unable to maintain routine Pap smear screening

d. All of the above

42–19. Which of the following is true of morcellation of the uterine fundus following supracervical hysterectomy?

a. Morcellated uterine fragments may be left intra-abdominally with no harmful patient effects.

b. A coring technique into the middle of the mass, rather than a peeling technique, is preferred.

c. Tissue is held stable in the anterior cul-de-sac, and the morcellator is moved to the mass.

d. None of the above

42–20. Uterine manipulators designed specifically for total laparoscopic hysterectomy may help with which of the following?

a. Displacing the ureters laterally

b. Maintaining pneumoperitoneum during colpotomy

c. Delineating the cervicovaginal junction for colpotomy

d. All of the above

42–21. Laminaria are shown before and after expansion. Alternatively, what other options may effectively ease cervical dilatation prior to hysteroscope insertion?

Image

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 41-16.1A.

a. Preoperative misoprostol orally

b. Preoperative misoprostol vaginally

c. Dilute vasopressin injected into the cervix intraoperatively

d. All of the above

42–22. During which of the following hysteroscopic procedures does carbon dioxide serve best as a distension medium?

a. Leiomyoma resection

b. Uterine septum excision

c. Diagnostic hysteroscopy

d. Endometrial polyp resection

42–23. If excess fluid volume is absorbed during hysteroscopy, patients are at greatest risk of developing hyponatremia with which of the following?

a. 5-percent mannitol

b. 1.5-percent glycine

c. Normal saline

d. All have equivalent risk of producing hyponatremia

42–24. If gas embolism is suspected, all EXCEPT which of the following should be performed?

a. Remove the hysteroscope

b. Clamp the cervical os closed

c. Place the patient in reverse Trendelenburg position

d. Move the patient to a left lateral decubitus position

42–25. Sonographic and hysteroscopic images display the same endometrial polyp. Hysteroscopic removal can be accomplished by which of the following methods?

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Photograph B contributed by Dr. Kimberly Kho.

a. Resectoscope loop

b. Hysteroscopic scissors

c. Hysteroscopic morcellator

d. All of the above

42–26. During saline-infusion sonography or hysteroscopy to evaluate leiomyoma characteristics prior to hysteroscopic myomectomy, leiomyomas may be grouped according to criteria from the European Society of Hysteroscopy. As shown here, which of the following classes is associated with the highest clinical success rate, lowest surgical risk, and an infrequent need for more than one surgical session to complete resection?

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Photograph contributed by Dr. Karen Bradshaw.

a. Class 0

b. Class I

c. Class II

d. Class III

42–27. In addition to the degree of tumor penetration and tumor size, which of the following other leiomyoma characteristics increases the difficulty of hysteroscopic resection?

a. Wide tumor base

b. Tumors along the lateral wall

c. Tumors in the upper portion of the cavity

d. All of the above

42–28. Patients undergoing endometrial ablation for a bleeding abnormality should not be guaranteed amenorrhea as a treatment goal. In general, which of the following rates of amenorrhea (percent) is expected?

a. 5–10

b. 15–35

c. 50-65

d. 75-80

42–29. What obstetric problems are associated with pregnancy following endometrial ablation?

a. Prematurity

b. Malpresentation

c. Abnormal adherent placenta

d. All of the above

42–30. Endometrial ablation using this device is achieved by which of the following mechanisms?

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a. Cryonecrosis

b. Microwave energy

c. Monopolar electrosurgical coagulation

d. None of the above

42–31. This device achieves sterilization by which of the following methods?

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a. Lies within the cervical canal to secrete spermicide

b. Wraps around the fallopian tube to occlude the lumen

c. Is placed within the tubal ostia to promote occlusive tissue ingrowth

d. Is placed within the endometrial canal to agglutinate the endometrium

42–32. Which of the following statement is true of women following Essure microinsert placement?

a. Sterilization is immediate.

b. Hysterosalpingogram is recommended at 6 months following placement.

c. The device in Question 42–30 can be used safely in Essure patients at a later date if needed.

d. None of the above

42–33. Intrauterine adhesions called synechiae may develop following uterine curettage and less commonly from pelvic irradiation or tuberculous endometritis. The presence of these adhesions, also termed Asherman syndrome, may lead to increased rates of which of the following?

a. Menorrhagia

b. Infertility

c. Pelvic inflammatory disease

d. All of the above

Chapter 42 ANSWER KEY

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