Minimally Invasive Surgery

Minimally Invasive Surgery Indian Medical PG Question 1: Match the following 1. Hirschsprung's disease 2. Posterior urethral valve 3. Choledochal cyst 4. Intussusception A. Jaundice B. Currant jelly stools C. Distended abdomen D. Oligohydramnios

• A. 1-C, 2-D, 3-B, 4-A
• B. 1-A, 2-D, 3-B, 4-C
• C. 1-C, 2-D, 3-A, 4-B (Correct Answer)
• D. 1-D, 2-C, 3-A, 4-B

Minimally Invasive Surgery Explanation: ***Correct Answer: 1-C, 2-D, 3-A, 4-B*** **Correct Associations:** - **Hirschsprung's disease (1) → Distended abdomen (C)**: Congenital absence of ganglion cells in the distal bowel leads to functional obstruction and subsequent abdominal distension. This is a hallmark presentation in neonates and infants. - **Posterior urethral valve (2) → Oligohydramnios (D)**: Urethral obstruction in utero prevents normal fetal urine output, resulting in decreased amniotic fluid (oligohydramnios). This can be detected on prenatal ultrasound. - **Choledochal cyst (3) → Jaundice (A)**: Congenital dilatation of the bile ducts causes biliary obstruction, presenting with jaundice as part of the classic triad (jaundice, abdominal mass, and pain). - **Intussusception (4) → Currant jelly stools (B)**: Telescoping of bowel causes mucosal ischemia and venous congestion, leading to bloody mucoid stools with characteristic "currant jelly" appearance. This is a pathognomonic feature. *Incorrect: 1-C, 2-D, 3-B, 4-A* - Incorrectly associates choledochal cyst with currant jelly stools (which is specific to intussusception) and intussusception with jaundice (which indicates biliary pathology). *Incorrect: 1-A, 2-D, 3-B, 4-C* - Wrongly links Hirschsprung's disease with jaundice instead of its characteristic abdominal distension, and misidentifies intussusception's primary feature. *Incorrect: 1-D, 2-C, 3-A, 4-B* - Swaps the associations between Hirschsprung's disease and PUV. Oligohydramnios is specific to urinary tract obstruction (PUV), not intestinal pathology (Hirschsprung's).

Minimally Invasive Surgery Indian Medical PG Question 2: Trendelenburg position produces decrease in all of the following except –

• A. Compliance
• B. Functional residual capacity
• C. Respiratory rate (Correct Answer)
• D. Vital capacity

Minimally Invasive Surgery Explanation: ***Respiratory rate*** - Trendelenburg position (head down, feet elevated) increases **venous return** to the heart and **intrathoracic blood volume**. - This position does not directly or consistently decrease the respiratory rate; instead, it might even slightly increase it due to **increased intrathoracic pressure** and reduced lung compliance. *Compliance* - The Trendelenburg position causes **abdominal contents** to shift towards the diaphragm, increasing **intra-abdominal pressure**. - This upward pressure on the diaphragm restricts its movement and reduces the **compliance** of the respiratory system, making it harder to inflate the lungs. *Functional residual capacity* - The cephalad displacement of the diaphragm by abdominal contents in the Trendelenburg position significantly reduces the **volume of air remaining in the lungs** after a normal exhalation. - This leads to a decrease in **functional residual capacity (FRC)**. *Vital capacity* - The decreased lung compliance and reduced FRC due to the elevated diaphragm in the Trendelenburg position make it more difficult for the lungs to fully expand. - This restriction can lead to a decrease in the **maximum amount of air** a person can exhale after a maximal inhalation, thus reducing **vital capacity**.

Minimally Invasive Surgery Indian Medical PG Question 3: Structure not forming boundaries of the "Triangle of doom" seen during laparoscopic inguinal hernia surgery dissection is:

• A. Spermatic cord vessels
• B. Vas deferens
• C. Peritoneum
• D. Inferior epigastric artery (Correct Answer)

Minimally Invasive Surgery Explanation: ***Inferior epigastric artery*** - The **inferior epigastric artery** does NOT form a boundary of the **"Triangle of Doom"** during laparoscopic inguinal hernia repair. - Instead, it forms the **lateral boundary of Hesselbach's triangle** and the **medial boundary of the "Triangle of Pain"** (another important anatomical landmark containing the lateral femoral cutaneous nerve and genitofemoral nerve). - The Triangle of Doom is bounded by the **vas deferens medially**, the **spermatic vessels (gonadal vessels) laterally**, and the **peritoneal reflection inferiorly**. *Spermatic cord vessels* - The **spermatic vessels (testicular artery and pampiniform plexus)** form the **lateral boundary** of the **"Triangle of Doom."** - This triangle contains the **external iliac artery and vein**, which pose significant risk of major hemorrhage if injured. - Careful identification of these vessels is crucial to avoid devastating vascular complications. *Vas deferens* - The **vas deferens** forms the **medial boundary** of the **"Triangle of Doom."** - This structure runs within the spermatic cord and must be carefully preserved to prevent male infertility. - Injury to the vas deferens during dissection can result in permanent reproductive consequences. *Peritoneum* - The **peritoneum (peritoneal reflection)** forms the **base/inferior boundary** of the **"Triangle of Doom."** - This serous membrane provides the anatomical floor of the triangle during laparoscopic visualization. - Understanding the peritoneal boundaries helps surgeons safely navigate this high-risk anatomical area.

Minimally Invasive Surgery Indian Medical PG Question 4: Among the following conditions, laparoscopy carries the highest risk in patients with:

• A. COPD (Correct Answer)
• B. Diabetes
• C. Hypertension
• D. Obesity

Minimally Invasive Surgery Explanation: ***COPD*** - **COPD** patients have severely compromised respiratory function, and the **pneumoperitoneum** from CO2 insufflation causes **diaphragmatic splinting** and reduced lung compliance, leading to dangerous **CO2 retention** and respiratory failure. - The increased **intra-abdominal pressure** significantly impairs ventilation in patients who already have limited respiratory reserve, making laparoscopy extremely high-risk. *Diabetes* - While diabetes increases risks of **poor wound healing** and **infection**, these complications are not specifically worse with laparoscopy compared to open surgery. - **Perioperative glucose management** can effectively control diabetes-related risks, and laparoscopy may actually offer benefits like smaller incisions. *Hypertension* - **Hypertension** requires careful **blood pressure monitoring** during surgery but doesn't pose risks unique to laparoscopic procedures. - Well-controlled hypertension with appropriate **antihypertensive medications** allows for safe laparoscopic surgery. *Obesity* - **Obesity** makes laparoscopy technically challenging due to **thick abdominal walls** and need for higher insufflation pressures. - However, laparoscopy is often **preferred over open surgery** in obese patients due to reduced wound complications and faster recovery.

Minimally Invasive Surgery Indian Medical PG Question 5: Regarding laparoscopic cholecystectomy, which of the following statements is correct?

• A. It is primarily done for cholecystitis in the third trimester of pregnancy
• B. It is associated with higher rate of bile duct injuries than open cholecystectomy (Correct Answer)
• C. It is safer than open cholecystectomy in patients with cardiorespiratory disease
• D. It is contraindicated in acute cholecystitis

Minimally Invasive Surgery Explanation: ***It is associated with higher rate of bile duct injuries than open cholecystectomy*** - **Historically**, laparoscopic cholecystectomy has been associated with a **higher rate of bile duct injuries** (0.4-0.6%) compared to open cholecystectomy (0.1-0.2%), particularly during the **learning curve period** in the 1990s. - Contributing factors include **limited visualization**, **altered anatomy** in acute inflammation, **reliance on 2D imaging**, and **misidentification of anatomic structures**. - Bile duct injuries, such as **common bile duct (CBD) laceration** or **transection**, can lead to significant morbidity. - **Note**: With increased surgeon experience and adoption of the **critical view of safety** technique, these rates have decreased, though the risk remains slightly higher than open surgery in some studies. *It is primarily done for cholecystitis in the third trimester of pregnancy* - **Laparoscopic cholecystectomy** during pregnancy is generally considered safe for symptomatic **gallstone disease**, with the **second trimester** being the optimal time for surgery. - In the **third trimester**, surgical considerations like **increased uterine size**, technical difficulty, and **fetal well-being** make laparoscopic surgery more challenging, and it is usually **deferred until after delivery** unless an emergency. - The primary indication for **cholecystectomy** is symptomatic gallstones or complications like **acute cholecystitis**, not specifically third trimester pregnancy. *It is safer than open cholecystectomy in patients with cardiorespiratory disease* - While **laparoscopic cholecystectomy** is generally associated with **less postoperative pain**, **reduced pulmonary complications**, and **faster recovery**, it involves **pneumoperitoneum** (CO2 insufflation), which increases intra-abdominal pressure. - **Pneumoperitoneum** can cause **decreased venous return**, **increased systemic vascular resistance**, **hypercarbia**, and **decreased lung compliance**, which may stress patients with severe **cardiorespiratory disease**. - The safety profile depends on individual patient factors, severity of cardiorespiratory disease, and anesthetic management. In many cases, the benefits of minimally invasive surgery outweigh the risks, but careful patient selection is essential. *It is contraindicated in acute cholecystitis* - This is **incorrect**. **Laparoscopic cholecystectomy** is the **gold standard treatment** for acute cholecystitis. - **Early laparoscopic cholecystectomy** (within **72 hours** of symptom onset) is preferred as it reduces complications, shortens hospital stay, and has better outcomes compared to delayed surgery. - Acute cholecystitis is an **indication**, not a **contraindication** for laparoscopic approach.

Minimally Invasive Surgery Indian Medical PG Question 6: In surgical stress all hormones are increased except:

• A. Insulin (Correct Answer)
• B. Epinephrine
• C. ACTH
• D. Cortisol

Minimally Invasive Surgery Explanation: ***Insulin*** - While other **stress hormones** increase, **insulin** levels typically **decrease** or remain stable due to increased **insulin resistance** during surgical stress. - This physiological response aims to maintain **blood glucose** levels for energy during heightened metabolic demands. *Epinephrine* - **Epinephrine** (adrenaline) is a key **catecholamine** released during surgical stress, leading to a "fight or flight" response. - It increases **heart rate**, **blood pressure**, and promotes **gluconeogenesis** to supply quick energy. *ACTH* - **Adrenocorticotropic hormone (ACTH)** is released from the **pituitary gland** in response to surgical stress. - **ACTH** stimulates the adrenal cortex to produce **cortisol**, a critical stress hormone. *Cortisol* - **Cortisol** levels significantly rise during surgical stress, mediated by **ACTH** release. - It plays a crucial role in **modulating inflammation**, **glucose metabolism**, and maintaining **hemodynamic stability**.

Minimally Invasive Surgery Indian Medical PG Question 7: Which of the following information needs to be disclosed in order to establish valid consent for surgical treatment? I. Condition and reasons why it warrants surgery II. Type of surgery proposed III. Unexpected hazards of proposed surgery IV. The surgical experience and expertise of the operating surgeon Select the correct answer using the code given below :

• A. II, III and IV
• B. I, II and IV
• C. I, II and III (Correct Answer)
• D. I, III and IV

Minimally Invasive Surgery Explanation: ***I, II and III*** - **Valid consent** requires the full disclosure of the **patient's condition and indication for surgery**, the **proposed surgical treatment**, and its **material risks and potential complications** (including unexpected hazards). - This ensures the patient has sufficient information to make an **informed decision** about their care. - These three elements form the **core requirements** for informed consent under traditional medical-legal principles. *II, III and IV* - While the type of surgery, risks, and surgeon's experience are relevant, omitting information about the **patient's underlying condition** and the reasons for surgery renders the consent incomplete. - A patient cannot make an informed choice without understanding **why the surgery is being performed** in relation to their health. *I, II and IV* - This option omits **"unexpected hazards/material risks of proposed surgery,"** which are crucial for true informed consent. - Patients must be aware of potential complications to weigh the **benefits and risks** adequately. - Disclosure of risks is a **fundamental requirement** for valid consent. *I, III and IV* - This option fails to include information about the **"type of surgery proposed,"** which is fundamental to understanding the planned procedure. - Without knowing the specific surgical intervention, the patient cannot provide **meaningful consent**. - Note: While disclosure of surgeon's experience is increasingly recognized in modern practice, it is **not traditionally considered a mandatory element** for valid consent in most jurisdictions.

Minimally Invasive Surgery Indian Medical PG Question 8: Preoperative investigations done prior to surgery depend upon which of the following? 1. Type of surgery 2. Patient origin 3. Patient comorbidities 4. Experience of surgeon

• A. 4. Experience of surgeon
• B. 1. Type of surgery (Correct Answer)
• C. 2. Patient origin
• D. 3. Patient comorbidities

Minimally Invasive Surgery Explanation: ***1. Type of surgery*** - The **type of surgery** is a primary determinant of preoperative investigations, as it defines the baseline assessment needed based on the procedure's complexity, invasiveness, and physiological stress. - Minor surgeries (e.g., superficial excisions) typically require minimal investigations, while major surgeries (e.g., cardiac, neurosurgery) mandate comprehensive cardiovascular, pulmonary, and hematological workups. - **Clinical Note:** In practice, preoperative investigations depend on BOTH the surgery type AND patient comorbidities working together, but this question likely seeks the most fundamental starting point. *3. Patient comorbidities* - **Patient comorbidities** are undeniably crucial in determining the extent and nature of preoperative investigations. - A patient with diabetes, hypertension, or cardiac disease requires additional specific investigations regardless of the surgery type. - However, the surgery type establishes the baseline framework, which is then modified based on comorbidities. *2. Patient origin* - **Patient origin** (geographical location, ethnicity) is generally not a direct determinant of preoperative investigation protocols. - While certain populations may have higher prevalence of specific conditions, investigations are based on individual patient assessment, not origin. *4. Experience of surgeon* - The **experience of the surgeon** does not alter the medical necessity or standard protocols for preoperative investigations. - Patient safety standards and investigation requirements remain consistent regardless of surgical expertise level.

Minimally Invasive Surgery Indian Medical PG Question 9: On the 4th postoperative day of laparotomy a patient presents with bleeding & oozing from the wound. Management is :

• A. Send for USG abdomen
• B. Start treatments for peritonitis
• C. IV fluids
• D. Dressing of wound & observe for dehiscence (Correct Answer)

Minimally Invasive Surgery Explanation: ***Dressing of wound & observe for dehiscence*** - **Bleeding and oozing from the wound** on the 4th postoperative day could indicate early wound dehiscence or a seroma/hematoma. - **Dressing the wound** provides local control, while diligent observation is crucial to detect progressive dehiscence requiring surgical intervention. *Send for USG abdomen* - An **ultrasound (USG) abdomen** would be useful for assessing intra-abdominal collections such as abscesses or hematomas, or to detect an incisional hernia, but not the immediate bleeding and oozing from the wound site itself. - While it might provide additional information, it's not the **first-line management** for local wound issues like bleeding and oozing. *Start treatments for peritonitis* - **Peritonitis** presents with signs of severe abdominal infection, such as fever, generalized abdominal pain, rigidity, and rebound tenderness, which are not described in the patient's presentation of only local wound bleeding and oozing. - Initiating peritonitis treatment without signs of widespread infection would be **inappropriate** and delay appropriate wound care. *IV fluids* - **Intravenous (IV) fluids** are used to manage dehydration, electrolyte imbalances, or hypovolemia, but the patient's primary complaint is localized wound bleeding and oozing, not systemic signs of instability requiring fluid resuscitation at this stage. - While **fluid balance** is always important postoperatively, it is not the specific management for the described wound issue.

Minimally Invasive Surgery Indian Medical PG Question 10: A patient presents with engorged neck veins, a blood pressure of 80/50 mmHg, and a pulse rate of 100 beats per minute following blunt trauma to the chest. The diagnosis is:

• A. Pneumothorax
• B. Right ventricular failure
• C. Cardiac tamponade (Correct Answer)
• D. Hemothorax

Minimally Invasive Surgery Explanation: ***Cardiac tamponade*** - The clinical presentation shows **two components of Beck's triad**: **engorged neck veins (elevated JVP)** and **hypotension** (80/50 mmHg). While muffled heart sounds (the third component) are not mentioned, this is not required for diagnosis. - The combination of **blunt chest trauma** and these symptoms strongly suggests fluid accumulation in the pericardial sac, compressing the heart and impairing its filling. - **Tachycardia** (100 bpm) represents a compensatory response to reduced cardiac output. *Pneumothorax* - While pneumothorax can cause respiratory distress and hypotension, it typically presents with **absent breath sounds** on the affected side and **hyperresonance to percussion**, which are not described. - Engorged neck veins are not characteristic of simple pneumothorax. **Tension pneumothorax** can cause distended neck veins and severe hypotension, but would also present with severe respiratory distress and tracheal deviation away from the affected side. *Right ventricular failure* - Right ventricular failure can cause **engorged neck veins** but usually presents with signs of systemic congestion like **peripheral edema** and hepatomegaly, developing over time. - This is not typically an acute, immediate consequence of blunt chest trauma. The **acute hypotension** and **tachycardia** are more indicative of obstructive shock (cardiac tamponade) rather than pump failure. *Hemothorax* - Hemothorax involves blood accumulation in the pleural space, leading to **absent breath sounds** and **dullness to percussion** on the affected side. - While it can cause hypotension and tachycardia due to **hypovolemic shock** from blood loss, **engorged neck veins** are not a feature. In fact, significant blood loss typically causes **flat or collapsed neck veins** due to reduced venous return.

Minimally Invasive Surgery Flashcard 1 of 9

Question: Hasson's trocar is used in the _____ method of creating a pneumoperitoneum and avoids the morbidity related to a blind puncture

Answer: open

Minimally Invasive Surgery Flashcard 2 of 9

Question: The procedure shown below is called _____ (POEM)

Answer: peroral endoscopic myotomy

Minimally Invasive Surgery Flashcard 3 of 9

Question: Verres needle is used in the _____ method of creating a pneumoperitoneum and involves blind puncture of the peritoneum.

Answer: closed

Minimally Invasive Surgery Flashcard 4 of 9

Question: Hasson's trocar is used in the _____ method of creating a pneumoperitoneum and avoids the morbidity related to a blind puncture

Answer: open

Minimally Invasive Surgery Flashcard 5 of 9

Question: Versapoint is _____ electrosurgical system that works in normal saline

Answer: bipolar

Minimally Invasive Surgery Flashcard 6 of 9

Question: Ligasure seals tissue by administration of _____ current and low voltage that of 180 V (low/high)

Answer: high

Minimally Invasive Surgery Flashcard 7 of 9

Question: Patients with medically intractable symptoms (ex. bradykinesia, rigidity) of Parkinsons disease may benefit from deep brain stimulation (DBS) of the _____ or the subthalamic nucleus

Answer: Globus pallidus internus

Minimally Invasive Surgery Flashcard 8 of 9

Question: The harmonic scalpel vibrates at _____ Hz range

Answer: 20,000 50,000

Minimally Invasive Surgery Flashcard 9 of 9

Question: Verres needle is used in the _____ method of creating a pneumoperitoneum and involves blind puncture of the peritoneum.

Answer: closed