Laparoscopic gynecologic procedures US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Laparoscopic gynecologic procedures. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Laparoscopic gynecologic procedures US Medical PG Question 1: A 33-year-old woman comes to the emergency department because of a 1-hour history of severe pelvic pain and nausea. She was diagnosed with a follicular cyst in the left ovary 3 months ago. The cyst was found incidentally during a fertility evaluation. A pelvic ultrasound with Doppler flow shows an enlarged, edematous left ovary with no blood flow. Laparoscopic evaluation shows necrosis of the left ovary, and a left oophorectomy is performed. During the procedure, blunt dissection of the left infundibulopelvic ligament is performed. Which of the following structures is most at risk of injury during this step of the surgery?
- A. Bladder trigone
- B. Uterine artery
- C. Kidney
- D. Ureter (Correct Answer)
Laparoscopic gynecologic procedures Explanation: ***Ureter***
- The **infundibulopelvic ligament** (also known as the suspensory ligament of the ovary) contains the **ovarian artery and vein** and is in close proximity to the ureter as it crosses the pelvic brim.
- During dissection or clamping of this ligament, especially in an emergency setting or when anatomy is distorted (e.g., by an enlarged ovary or edema), the **ureter** is highly susceptible to injury.
*Bladder trigone*
- The **bladder trigone** is the smooth triangular region at the base of the bladder, formed by the openings of the ureters and the internal urethral orifice.
- It is not directly adjacent to the infundibulopelvic ligament and is therefore at a comparably lower risk of injury during dissection of this ligament.
*Uterine artery*
- The **uterine artery** travels within the cardinal ligament and supplies the uterus; it is located more medially and inferiorly within the broad ligament.
- While important in pelvic surgery, it is not in the immediate vicinity of the infundibulopelvic ligament dissection itself.
*Kidney*
- The **kidneys** are retroperitoneal organs located much higher in the abdominal cavity, far superior to the pelvis.
- They are not at risk of direct injury during pelvic surgery involving the infundibulopelvic ligament.
Laparoscopic gynecologic procedures US Medical PG Question 2: A 36-year-old woman comes to the physician for a 2-month history of urinary incontinence and a vaginal mass. She has a history of five full-term normal vaginal deliveries. She gave birth to a healthy newborn 2-months ago. Since then she has felt a sensation of vaginal fullness and a firm mass in the lower vagina. She has loss of urine when she coughs, sneezes, or exercises. Pelvic examination shows an irreducible pink globular mass protruding out of the vagina. A loss of integrity of which of the following ligaments is most likely involved in this patient's condition?
- A. Infundibulopelvic ligament
- B. Broad ligament of the uterus
- C. Cardinal ligament of the uterus (Correct Answer)
- D. Round ligament of uterus
- E. Uterosacral ligament
Laparoscopic gynecologic procedures Explanation: ***Cardinal ligament of the uterus***
- The patient's symptoms, including **vaginal mass**, **urinary incontinence** with coughing/sneezing, and history of **multiple vaginal deliveries**, strongly suggest **uterine prolapse**.
- The cardinal ligaments are crucial in providing **lateral cervical support** and are often damaged during childbirth, leading to uterine descent.
*Infundibulopelvic ligament*
- This ligament primarily supports the **ovaries** and contains the **ovarian artery** and vein.
- Damage to this ligament is associated with ovarian prolapse or complications during oophorectomy, not uterine prolapse.
*Broad ligament of the uterus*
- The broad ligament is a **peritoneal fold** that drapes over the uterus, fallopian tubes, and ovaries.
- While it helps to hold these structures in place, its primary role is not in preventing uterine prolapse; it mainly provides a medium for neurovascular structures.
*Round ligament of uterus*
- The round ligament extends from the uterus to the **labia majora** and primarily helps maintain **anteversion** of the uterus.
- It plays a minor role in uterine support and its laxity is not a primary cause of uterine prolapse.
*Uterosacral ligament*
- The uterosacral ligaments provide **posterior support** to the uterus, particularly by anchoring the cervix to the sacrum.
- While damage to these ligaments contributes to **apical prolapse**, the cardinal ligaments are more critical for lateral support and more commonly implicated in overall uterine prolapse following childbirth.
Laparoscopic gynecologic procedures US Medical PG Question 3: A 25-year-old woman comes to the emergency department one hour after the sudden onset of diffuse abdominal pain and nausea. She has no history of serious illness. Menses occur at regular 27-day intervals and last 4 to 6 days with moderate flow. Her last menstrual period was 6 weeks ago. She is sexually active with two sexual partners and uses oral contraceptive pills inconsistently. She appears pale and diaphoretic. Her temperature is 37.7°C (99.9°F), pulse is 120/min, respirations are 20/min, and blood pressure is 85/70 mm Hg. Abdominal examination shows diffuse abdominal tenderness. Pelvic examination shows a normal appearing vagina, cervix, and uterus, with right adnexal tenderness. Her hemoglobin concentration is 13 g/dL, leukocyte count is 10,000/mm3, and platelet count is 350,000/mm3. Results of a pregnancy test are pending. Which of the following is the most appropriate next step in management?
- A. Perform exploratory laparoscopy
- B. Perform pelvic ultrasound
- C. Perform CT scan of the abdomen and pelvis with contrast
- D. Administer intravenous normal saline fluids (Correct Answer)
- E. Transfuse O negative packed red blood cells
Laparoscopic gynecologic procedures Explanation: ***Administer intravenous normal saline fluids***
- The patient presents with classic signs of **hypovolemic shock**: sudden onset of severe abdominal pain, nausea, pallor, diaphoresis, tachycardia (120/min), and hypotension (85/70 mm Hg).
- Immediate administration of **intravenous fluids** is crucial to restore blood volume and stabilize her hemodynamics before further diagnostic or surgical interventions.
*Perform exploratory laparoscopy*
- While exploratory laparoscopy may ultimately be necessary if an **ectopic pregnancy rupture** is suspected, it is not the *immediate* next step before attempting hemodynamic stabilization.
- Performing surgery on a patient in **unresuscitatable shock** significantly increases morbidity and mortality.
*Perform pelvic ultrasound*
- A pelvic ultrasound is a valuable diagnostic tool, especially if an **ectopic pregnancy** is suspected given her missed period, sexual activity, and inconsistent contraception.
- However, in a patient with signs of **hemodynamic instability**, performing an ultrasound before fluid resuscitation wastes critical time and could worsen her condition.
*Perform CT scan of the abdomen and pelvis with contrast*
- A CT scan can provide detailed imaging of the abdomen and pelvis but is **less appropriate** than a pelvic ultrasound for initial evaluation of suspected gynecological causes of acute abdominal pain in a young woman.
- Furthermore, administering contrast to a patient in **shock** could exacerbate her condition and delay immediate life-saving interventions.
*Transfuse O negative packed red blood cells*
- Although the patient's symptoms strongly suggest **internal hemorrhage** (e.g., ruptured ectopic pregnancy), her initial hemoglobin (13 g/dL) is within the normal range.
- While blood products may eventually be needed, initial management of hypovolemic shock prioritizes **crystalloid fluid resuscitation** until blood products can be prepared and cross-matched, unless massive transfusion protocol is activated for severe, ongoing hemorrhage.
Laparoscopic gynecologic procedures US Medical PG Question 4: A 17-year-old woman presents to the emergency department with abdominal and pelvic pain. She states it started 3 days ago and it has been getting gradually worse. She states it is diffuse and is located over her abdomen, pelvis, and inside her vagina. She also endorses vaginal pruritus and a discharge from her vagina. The patient works in an ice cream parlor and is sexually active with multiple different partners. Her temperature is 98.0°F (36.7°C), blood pressure is 122/80 mmHg, pulse is 82/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is notable for a foul smelling vagina with a thin, white discharge. Her abdomen is diffusely tender. The patient is noted to be itching her vagina during the exam. Which of the following is the most appropriate initial step in management?
- A. Wet mount (Correct Answer)
- B. KOH prep
- C. Urine hCG
- D. CT abdomen/pelvis
- E. Cervical swab and culture
Laparoscopic gynecologic procedures Explanation: **Wet mount**
- A **wet mount** is crucial in this case as the patient presents with symptoms suggestive of a vaginal infection, including **vaginal pruritus**, foul-smelling discharge, and diffuse abdominal/pelvic pain.
- This test can rapidly identify common causes of vaginitis such as **Trichomonas vaginalis** (motile trichomonads), **bacterial vaginosis** (clue cells), and **candidiasis** (yeast buds/hyphae), helping guide initial treatment.
*KOH prep*
- A **KOH prep** is specifically used to diagnose **candidiasis** by dissolving epithelial cells and highlighting fungal elements (hyphae and spores).
- While useful for yeast infections, it would not identify other potential causes of the patient's symptoms such as bacterial vaginosis or trichomoniasis, making a wet mount a more comprehensive initial diagnostic step.
*Urine hCG*
- A **urine hCG** test is used to detect pregnancy and is a standard part of evaluating women of reproductive age with acute abdominal/pelvic pain.
- While important to rule out ectopic pregnancy or other pregnancy-related complications, it does not directly address the likely infectious cause suggested by the vaginal discharge and pruritus.
*CT abdomen/pelvis*
- A **CT scan of the abdomen/pelvis** is an advanced imaging study typically reserved for cases where serious intra-abdominal or pelvic pathology (e.g., appendicitis, ovarian torsion, abscess) is suspected and cannot be ruled out by less invasive means.
- Given the strong indicators of a vaginal infection, less invasive and more targeted diagnostics are appropriate first.
*Cervical swab and culture*
- A **cervical swab and culture** is primarily used to detect sexually transmitted infections (STIs) such as **Chlamydia trachomatis** and **Neisseria gonorrhoeae**, which can cause cervicitis and pelvic inflammatory disease (PID).
- While STIs are a concern in a sexually active patient with pelvic pain, a wet mount provides a more immediate diagnosis for common vaginitis causes and helps prioritize treatment.
Laparoscopic gynecologic procedures US Medical PG Question 5: A 45-year-old man undergoes elective vasectomy for permanent contraception. The procedure is performed under local anesthesia. There are no intra-operative complications and he is discharged home with ibuprofen for post-operative pain. This patient is at increased risk for which of the following complications?
- A. Prostatitis
- B. Seminoma
- C. Testicular torsion
- D. Sperm granuloma (Correct Answer)
- E. Inguinal hernia
Laparoscopic gynecologic procedures Explanation: **Sperm granuloma**
- A **sperm granuloma** can occur after vasectomy due to the extravasation of sperm from the severed vas deferens, leading to a foreign body granulomatous reaction.
- This complication presents as a **palpable, tender nodule** at the vasectomy site and is a relatively common long-term issue.
*Prostatitis*
- **Prostatitis** is an inflammation of the prostate gland, and there is no direct mechanistic link or increased risk following a vasectomy.
- It is typically caused by bacterial infection or non-infectious inflammatory processes, unrelated to the **vas deferens** ligation.
*Seminoma*
- **Seminoma** is a type of testicular germ cell tumor, and extensive research has shown no increased risk of developing testicular cancer after vasectomy.
- The procedure does not alter the cellular processes or environment within the testicles that predispose to germ cell tumor formation.
*Testicular torsion*
- **Testicular torsion** is a urological emergency involving the twisting of the spermatic cord, which cuts off blood supply to the testis.
- This condition is not associated with vasectomy; it typically occurs due to an anatomical abnormality (e.g., **bell-clapper deformity**) or trauma.
*Inguinal hernia*
- An **inguinal hernia** is a protrusion of abdominal contents through a weakness in the abdominal wall, specifically in the inguinal canal.
- Vasectomy is a superficial procedure that does not involve manipulating or weakening the abdominal wall in a way that would increase the risk of an inguinal hernia.
Laparoscopic gynecologic procedures US Medical PG Question 6: A 32-year-old man is brought to the emergency department after a skiing accident. The patient had been skiing down the mountain when he collided with another skier who had stopped suddenly in front of him. He is alert but complaining of pain in his chest and abdomen. He has a past medical history of intravenous drug use and peptic ulcer disease. He is a current smoker. His temperature is 97.4°F (36.3°C), blood pressure is 77/53 mmHg, pulse is 127/min, and respirations are 13/min. He has a GCS of 15 and bilateral shallow breath sounds. His abdomen is soft and distended with bruising over the epigastrium. He is moving all four extremities and has scattered lacerations on his face. His skin is cool and delayed capillary refill is present. Two large-bore IVs are placed in his antecubital fossa, and he is given 2L of normal saline. His FAST exam reveals fluid in Morison's pouch. Following the 2L normal saline, his temperature is 97.5°F (36.4°C), blood pressure is 97/62 mmHg, pulse is 115/min, and respirations are 12/min.
Which of the following is the best next step in management?
- A. Diagnostic peritoneal lavage
- B. Emergency laparotomy (Correct Answer)
- C. Upper gastrointestinal endoscopy
- D. Close observation
- E. Diagnostic laparoscopy
Laparoscopic gynecologic procedures Explanation: ***Emergency laparotomy***
- The patient remains **hemodynamically unstable** (BP 97/62 mmHg, HR 115/min after 2L IV fluids) with evidence of **intra-abdominal fluid on FAST exam** (fluid in Morison's pouch).
- This clinical picture indicates active intra-abdominal hemorrhage requiring **immediate surgical intervention** to identify and control the source of bleeding.
*Diagnostic peritoneal lavage*
- **Diagnostic peritoneal lavage (DPL)** has largely been replaced by the focused abdominal sonography for trauma (FAST) exam and CT scans.
- While it can detect intra-abdominal bleeding, it is **invasive** and would delay definitive treatment in a hemodynamically unstable patient with positive FAST.
*Upper gastrointestinal endoscopy*
- This procedure is primarily for diagnosing and treating **upper gastrointestinal bleeding** or mucosal abnormalities.
- It is **not indicated** for evaluating traumatic intra-abdominal hemorrhage or hemodynamic instability following blunt abdominal trauma.
*Close observation*
- Close observation is appropriate for **hemodynamically stable patients** with blunt abdominal trauma and minor injuries or equivocal findings.
- This patient's persistent hypotension, tachycardia, and positive FAST findings rule out observation as a safe or appropriate next step.
*Diagnostic laparoscopy*
- **Diagnostic laparoscopy** is a minimally invasive surgical procedure used to evaluate the abdominal cavity.
- While it can be diagnostic, it is generally **contraindicated in hemodynamically unstable patients** as it can prolong the time to definitive hemorrhage control if a major injury is found.
Laparoscopic gynecologic procedures US Medical PG Question 7: A 42-year-old woman comes to the physician because of right flank pain that started 3 days following a procedure. Her vital signs are within normal limits. Physical examination shows right costovertebral angle tenderness. An intravenous pyelogram shows a dilated renal pelvis and ureter on the right with a lack of contrast proximal to the ureterovesical junction. This patient most likely recently underwent which of the following procedures?
- A. Hysterectomy (Correct Answer)
- B. Foley catheter insertion
- C. Cesarean delivery
- D. Appendectomy
- E. Inguinal hernia repair
Laparoscopic gynecologic procedures Explanation: ***Hysterectomy***
- **Ureteral injury** is a known complication of hysterectomy due to the ureter's close proximity to the uterine arteries and adnexa, especially near the **ureterovesical junction**.
- The presented symptoms of flank pain, CVA tenderness, and hydronephrosis (dilated renal pelvis and ureter with lack of contrast flow) occurring post-procedure strongly indicate **ureteral obstruction** or injury during the surgery.
*Foley catheter insertion*
- While catheterization can cause trauma, it would typically lead to **urethral or bladder injury**, not a ureteral obstruction at the ureterovesical junction causing hydronephrosis.
- The symptoms are more consistent with an injury higher up in the urinary tract that is not usually associated with a Foley catheter.
*Cesarean delivery*
- A C-section involves opening the abdomen to deliver a baby, but it generally does not involve dissection near the ureters to the extent that a hysterectomy does, making ureteral injury less common.
- The primary surgical field during a C-section is the uterus, while ureteral injury is more characteristic of procedures involving extensive pelvic dissection, such as hysterectomy.
*Appendectomy*
- An appendectomy is a procedure to remove the appendix and typically involves the right lower quadrant of the abdomen, away from the course of the ureter and ureterovesical junction.
- Injury to the ureter is a very rare complication of appendectomy and would not typically manifest as this type of obstruction.
*Inguinal hernia repair*
- Inguinal hernia repair involves structures in the groin region, anterior to the peritoneal cavity, and is far removed from the ureters and bladder.
- Ureteral injury is not a recognized complication of inguinal hernia repair.
Laparoscopic gynecologic procedures US Medical PG Question 8: Thirty minutes after normal vaginal delivery of twins, a 35-year-old woman, gravida 5, para 4, has heavy vaginal bleeding with clots. Physical examination shows a soft, enlarged, and boggy uterus. Despite bimanual uterine massage, administration of uterotonic drugs, and placement of an intrauterine balloon for tamponade, the bleeding continues. A hysterectomy is performed. Vessels running through which of the following structures must be ligated during the surgery to achieve hemostasis?
- A. Suspensory ligament
- B. Round ligament
- C. Ovarian ligament
- D. Uterosacral ligament
- E. Cardinal ligament (Correct Answer)
Laparoscopic gynecologic procedures Explanation: ***Cardinal ligament***
- The **uterine artery** and **uterine vein**, which supply the uterus, run through the **cardinal ligament** (also known as the transverse cervical ligament).
- Ligation of these vessels is crucial during a hysterectomy to control bleeding from the uterus.
*Suspensory ligament*
- The **suspensory ligament of the ovary** contains the **ovarian artery** and vein, which primarily supply the ovaries and fallopian tubes.
- While these may be ligated during a hysterectomy if the ovaries are removed, they are not the primary vessels causing uterine bleeding in postpartum hemorrhage.
*Round ligament*
- The **round ligament of the uterus** extends from the uterus to the labia majora and contains relatively small vessels, primarily contributing to uterine support.
- Ligation of this ligament alone would not effectively control heavy uterine bleeding.
*Ovarian ligament*
- The **ovarian ligament** connects the ovary to the uterus and contains small vessels that mainly supply the ovary.
- It does not house the major blood supply to the uterus itself.
*Uterosacral ligament*
- The **uterosacral ligaments** primarily provide support to the uterus by connecting it to the sacrum and contain small nerves and vessels.
- Ligation of these ligaments would not control the main arterial supply to the uterus.
Laparoscopic gynecologic procedures US Medical PG Question 9: A 30-year-old male gang member is brought to the emergency room with a gunshot wound to the abdomen. The patient was intubated and taken for an exploratory laparotomy, which found peritoneal hemorrhage and injury to the small bowel. He required 5 units of blood during this procedure. Following the operation, the patient was sedated and remained on a ventilator in the surgical intensive care unit (SICU). The next day, a central line is placed and the patient is started on total parenteral nutrition. Which of the following complications is most likely in this patient?
- A. Mesenteric ischemia
- B. Hypocalcemia
- C. Refeeding syndrome
- D. Sepsis (Correct Answer)
- E. Cholelithiasis
Laparoscopic gynecologic procedures Explanation: ***Sepsis***
- This patient has undergone **major abdominal surgery** after a **gunshot wound**, which carries a high risk of **peritoneal contamination** and subsequent infection.
- He also has several risk factors for sepsis, including **intubation**, central line placement, and possibly prolonged ventilation, all of which increase the risk of nosocomial infections and subsequent sepsis.
*Mesenteric ischemia*
- While possible in critically ill patients, there is no direct evidence such as advanced age, atherosclerosis, or specific signs of **bowel ischemia** (e.g., severe abdominal pain disproportionate to exam, bloody diarrhea) presenting in this case.
- The initial injury was to the small bowel, but the current context points more to systemic complications rather than a focal vascular event.
*Hypocalcemia*
- Hypocalcemia can occur in critically ill patients due to various reasons, but it is not the *most likely* complication given the patient's presentation primarily focused on surgical trauma and subsequent interventions.
- Dilutional effects from massive transfusions or **citrate toxicity** could contribute to temporary hypocalcemia, but sepsis poses a more immediate and widespread threat.
*Refeeding syndrome*
- Refeeding syndrome occurs when severely malnourished patients are rapidly refed, leading to shifts in **electrolytes** (especially **phosphate**, potassium, magnesium).
- Although the patient is starting **total parenteral nutrition (TPN)**, there's no indication of prior severe malnutrition, making sepsis a more prominent immediate concern due to the gunshot wound and surgery.
*Cholelithiasis*
- **Cholelithiasis** (gallstones) can be a long-term complication of total parenteral nutrition (TPN) due to gallbladder stasis.
- However, it is unlikely to develop so acutely within a day of starting TPN and is thus not the most immediate or likely complication for this patient's acute critical state.
Laparoscopic gynecologic procedures US Medical PG Question 10: A 20-year-old man presents to the family medicine clinic with left knee pain. He is the star running back for his college football team with a promising future in the sport. He states he injured his knee 2 days ago during the final game of the season while making a cutting move, where his foot was planted and rotated outward and his knee buckled inward. He admits to feeling a ‘pop’ and having immediate pain. He denies any locking, clicking, or giving way since the event. Physical examination reveals an antalgic gait with avoidance of active knee extension. His left knee demonstrates moderate, diffuse swelling and is very tender to palpation along the joint line. Which of the following structures is most likely damaged in this patient?
- A. Medial meniscus
- B. Anterior cruciate ligament (Correct Answer)
- C. Lateral meniscus
- D. Posterior cruciate ligament
- E. Medial collateral ligament
Laparoscopic gynecologic procedures Explanation: ***Anterior cruciate ligament***
- The mechanism of injury, described as a **cutting move** with the foot planted and knee buckled inward, is a classic non-contact mechanism for **ACL tears**.
- A palpable or audible **'pop'** at the time of injury, followed by immediate pain and swelling, is highly characteristic of an **ACL rupture**.
*Medial meniscus*
- While meniscal tears can cause pain and swelling along the joint line, the history of a **'pop' and immediate swelling** is more indicative of ligamentous injury.
- Absence of **locking or clicking** on the examination makes a primary meniscal tear less likely in this acute presentation.
*Lateral meniscus*
- The injury mechanism, an **external rotation force** on a planted foot, is less commonly associated with isolated lateral meniscal tears than with ACL or medial meniscal injuries.
- Similar to the medial meniscus, the lack of **locking or clicking** makes an isolated lateral meniscal tear less probable.
*Posterior cruciate ligament*
- PCL injuries typically result from a **direct blow to the anterior tibia** with the knee flexed or from a hyperextension injury, which is inconsistent with the described mechanism.
- A PCL injury would most likely present with **posterior laxity** on examination, rather than the general instability often associated with an ACL tear.
*Medial collateral ligament*
- MCL injuries result from a **valgus stress** to the knee, often without an audible 'pop' and usually causing localized pain on the medial side.
- While a valgus force can occur, the prominent **'pop' and immediate, diffuse swelling** are more consistent with an ACL injury than an isolated MCL sprain.
More Laparoscopic gynecologic procedures US Medical PG questions available in the OnCourse app. Practice MCQs, flashcards, and get detailed explanations.
