Complications of Minimally Invasive Surgery — MCQs

10 questions

Which of the following surgical incisions is associated with the highest risk of postoperative pulmonary complications ?

Which of the following is NOT a CONTRAINDICATION for laparoscopic surgery:

Most important early postoperative complication of ileostomy:

A 60 year old male patient was undergoing laparoscopic cholecystectomy. During the surgery, a sudden drop in EtCO2 to 8 mmHg was noted. His SpO2 became 90%, his blood pressure dropped to 80/50 mmHg, and peak airway pressure was 18 cm of H2O. What is the diagnosis?

Shoulder pain post laparoscopy is due to:

Shirodkar cerclage may be associated with all complications except:

Which of the following is a primary aim of damage control laparotomy?

To minimize ureteric damage, the following preoperative and operative precautions may be taken except:

The technique of laparoscopic cholecystectomy was first performed by whom?

Q10

Which of the following about Minimal Access Surgery are correct? I. Decreased intraoperative heat loss II. Improved visualization III. Increased chances of herniation IV. Improved mobility Select the answer using the code given below :

Complications of Minimally Invasive Surgery Indian Medical PG Practice Questions and MCQs

Question 1: Which of the following surgical incisions is associated with the highest risk of postoperative pulmonary complications ?

A. Median sternotomy
B. Horizontal laparotomy
C. Vertical laparotomy
D. Lateral thoracotomy (Correct Answer)

Explanation: ***Lateral thoracotomy*** - **Lateral thoracotomy** is associated with the **highest risk of postoperative pulmonary complications** among common surgical incisions, with complication rates ranging from **15-70%** depending on the procedure. - This incision **directly violates the chest wall** with rib resection or spreading, causing severe postoperative pain that significantly impairs respiratory mechanics. - The procedure disrupts **intercostal muscles**, damages **intercostal nerves**, and violates the **pleura**, leading to immediate risks like **pneumothorax**, **hemothorax**, and **pleural effusion**. - Severe pain leads to **splinting**, **shallow breathing**, **impaired cough**, and **reduced lung expansion**, markedly increasing the risk of **atelectasis**, **pneumonia**, and **respiratory failure**. - The **ipsilateral lung** is particularly affected with reduced functional residual capacity and impaired secretion clearance. *Vertical laparotomy* - **Upper abdominal vertical incisions** are indeed associated with high pulmonary complication rates (**30-50%**), second only to thoracotomy. - Pain leads to **diaphragmatic splinting** and impaired respiratory mechanics, increasing risk of **atelectasis** and **pneumonia**. - However, the chest wall itself remains intact, making complications generally less severe than with thoracotomy. *Median sternotomy* - While a major thoracic procedure, **median sternotomy** has relatively **lower pulmonary complication rates** compared to lateral thoracotomy. - The sternal split preserves **intercostal muscles** and **nerve integrity**, resulting in less severe pain and better preserved respiratory mechanics. - Postoperative pain management is generally more effective than with lateral thoracotomy. *Horizontal laparotomy* - **Transverse abdominal incisions** (e.g., Pfannenstiel, transverse supraumbilical) cause significantly less pain than vertical incisions. - These incisions follow **natural tissue planes**, cause less muscle disruption, and allow better respiratory mechanics. - Lower pain levels facilitate **effective coughing**, **deep breathing**, and **early mobilization**, reducing pulmonary complication risk.

Question 2: Which of the following is NOT a CONTRAINDICATION for laparoscopic surgery:

A. Severe COPD
B. Bowel herniation
C. Endometriosis (Correct Answer)
D. Severe cardiac compromise

Explanation: ***Endometriosis*** - **Endometriosis** is a *common indication* for laparoscopic surgery, as laparoscopy allows for both diagnosis and treatment (e.g., excision or ablation of endometrial implants). - It is *not* a contraindication; in fact, laparoscopy is the **gold standard** for diagnosing and managing endometriosis due to its minimally invasive nature and excellent visualization. *Severe COPD* - **Severe COPD** is a significant *contraindication* because pneumoperitoneum increases intra-thoracic pressure and elevates the diaphragm, reducing functional residual capacity. - This can cause *hypercarbia*, *hypoxemia*, and respiratory compromise in patients with already limited pulmonary reserve, making general anesthesia and laparoscopy high-risk. *Bowel herniation* - **Incarcerated or strangulated bowel herniation** is generally a *relative contraindication* due to the risk of intestinal injury during trocar insertion or manipulation. - The presence of *adhesions* and compromised bowel can make laparoscopic access challenging, though experienced surgeons may still attempt laparoscopic repair in selected cases. *Severe cardiac compromise* - **Severe cardiac compromise** is a significant *contraindication* because pneumoperitoneum causes increased intra-thoracic pressure, reduced venous return, and increased systemic vascular resistance. - This can lead to decreased *cardiac output*, arrhythmias, and hemodynamic instability, posing substantial risk to patients with severe cardiovascular disease.

Question 3: Most important early postoperative complication of ileostomy:

A. Necrosis (Correct Answer)
B. Prolapse
C. Obstruction
D. Diarrhea

Explanation: ***Necrosis*** - Stomal **necrosis** can occur early postoperatively due to issues with **blood supply** to the ileum, often caused by excessive tension on the mesentery or improper creation of the stoma. - This complication can lead to severe issues like perforation and sepsis if not promptly identified and managed. *Obstruction* - While **obstruction** can occur after ileostomy, it is typically a **delayed complication** often caused by adhesions, internal herniation, or food bolus impaction. - Early postoperative obstruction is less common unless there's an immediate surgical issue like a twisted loop or stricture. *Prolapse* - **Stoma prolapse**, where the bowel telescopes out through the stoma, is usually a **late complication** that develops over time due to weakened abdominal wall muscles or increased intra-abdominal pressure. - It is rarely seen in the immediate postoperative period without predisposing factors. *Diarrhea* - **High-output stoma** (sometimes referred to as diarrhea in general terms) is a common early postoperative issue, but it is considered a **physiological response** rather than a complication. - This is due to the lack of colonic absorption, leading to unformed stools and potential electrolyte imbalances, but it's not a direct surgical complication in the same way necrosis is.

Question 4: A 60 year old male patient was undergoing laparoscopic cholecystectomy. During the surgery, a sudden drop in EtCO2 to 8 mmHg was noted. His SpO2 became 90%, his blood pressure dropped to 80/50 mmHg, and peak airway pressure was 18 cm of H2O. What is the diagnosis?

A. Anaphylaxis
B. Malignant hyperthermia
C. Gas embolism (Correct Answer)
D. Pneumothorax

Explanation: ***Gas embolism*** - A sudden drop in **EtCO2** to 8 mmHg, **hypotension**, and **hypoxemia** during laparoscopic surgery are classic signs of a gas embolism, often from insufflated CO2 entering the bloodstream. - The drop in EtCO2 is due to a sudden decrease in pulmonary blood flow, preventing CO2 from reaching the lungs for exhalation. *Anaphylaxis* - While anaphylaxis can cause hypotension and hypoxemia, it typically presents with **bronchospasm** (increased peak airway pressure), **tachycardia**, and skin manifestations like **urticaria** or angioedema, which are not explicitly mentioned. - Anaphylaxis does not typically cause a drastic, sudden drop in EtCO2 to such low levels as seen with a gas embolism. *Malignant hyperthermia* - This condition is characterized by a rapid and sustained increase in **EtCO2**, **tachycardia**, muscle rigidity, and hyperthermia, which is the opposite of the EtCO2 findings here. - Malignant hyperthermia would lead to a significant elevation in metabolic CO2 production, not a sudden drop in EtCO2. *Pneumothorax* - A pneumothorax would typically present with **increased peak airway pressures**, **hypoxia**, and **hypotension**, but the EtCO2 would likely initially rise or remain stable before dropping due to decreased ventilation, not an acute drop to 8 mmHg. - The primary physiological issue in pneumothorax is lung collapse, leading to ventilation-perfusion mismatch, but not directly causing a sudden near-absence of exhaled CO2 in this manner.

Question 5: Shoulder pain post laparoscopy is due to:

A. Subphrenic abscess
B. CO2 retention (Correct Answer)
C. Compression of the lung
D. Positioning of the patient

Explanation: ***CO2 retention*** - Shoulder pain after laparoscopy is typically referred pain caused by **diaphragmatic irritation** due to residual **carbon dioxide (CO2)** gas used for insufflation. - The **phrenic nerve**, which innervates the diaphragm, shares sensory pathways with the shoulder, leading to referred pain. *Subphrenic abscess* - While a subphrenic abscess can cause diaphragmatic irritation and shoulder pain, it is a **delayed complication** and not an immediate cause of postoperative pain. - It would also be accompanied by signs of **infection** such as fever and leukocytosis, which are not implied here. *Compression of the lung* - **Lung compression** during laparoscopy can occur due to pneumoperitoneum but primarily causes respiratory symptoms and atelectasis, not typically shoulder pain. - Lung compression itself does not directly irritate the **diaphragm** in the same manner as CO2. *Positioning of the patient* - Poor patient positioning can cause musculoskeletal pain in the neck, back, or shoulders due to **nerve compression** or **muscle strain**. - However, the classic referred shoulder pain after laparoscopy is specifically attributed to **diaphragmatic irritation** from CO2, distinguishing it from general positioning discomfort.

Question 6: Shirodkar cerclage may be associated with all complications except:

A. Enterocele
B. Ureteral injury
C. Subacute intestinal obstructions
D. Paresthesia over inner aspect (Correct Answer)

Explanation: ***Paresthesia over inner aspect*** - Paresthesia over the inner thigh is typically associated with injury to the **femoral nerve** or its branches, or the **obturator nerve**. - While surgery in the pelvic region always carries some nerve injury risk, a Shirodkar sling operation, which is a cervical cerclage, is **unlikely to directly cause paresthesia** in this specific distribution. *Enterocele* - An **enterocele** is a type of pelvic organ prolapse where the small bowel descends into the lower pelvic cavity, creating a bulge in the vagina. - The Shirodkar sling procedure involves placing a suture around the cervix, which can alter pelvic anatomy and potentially contribute to the development or worsening of an enterocele, by **changing pressure dynamics** or creating adhesion. *Ureteral injury* - The **ureters** pass close to the cervix as they course into the bladder, especially where the uterosacral ligaments attach. - During the placement of the Shirodkar cervical cerclage, there is a risk of **ligating or damaging the ureters** due to their proximity to the surgical field. *Subacute intestinal obstructions* - Any pelvic surgery, including a Shirodkar sling operation, carries a risk of **adhesion formation**. - These **post-surgical adhesions** can involve segments of the bowel, potentially leading to kinking or narrowing of the intestinal lumen, which can cause symptoms of subacute intestinal obstruction.

Question 7: Which of the following is a primary aim of damage control laparotomy?

A. Arrest hemorrhage and control contamination. (Correct Answer)
B. Control contamination
C. Prevent coagulopathy
D. Arrest hemorrhage

Explanation: ***Arrest hemorrhage and control contamination.*** * The overarching goal of a **damage control laparotomy** is to rapidly address immediate life threats, primarily **hemorrhage** and **bowel contamination**, in severely injured, unstable patients. * This approach prioritizes patient survival by performing essential steps quickly, deferring definitive repairs until the patient is physiologically stable. *Control contamination* * While **controlling contamination** is a critical component of damage control laparotomy, it is not the sole primary aim. * Uncontrolled bleeding, even without contamination, can rapidly lead to death in a trauma patient. *Prevent coagulopathy* * Preventing **coagulopathy** is an important consideration during damage control, but it is a consequence of uncontrolled hemorrhage and hypothermia, rather than a primary surgical aim in the initial damage control phase. * The surgical steps in damage control directly address the sources of bleeding and contamination. *Arrest hemorrhage* * **Arresting hemorrhage** is indeed a primary aim, but it is often accompanied by the need to control contamination from injured hollow organs. * Many abdominal trauma cases involve both significant bleeding and potential contamination.

Question 8: To minimize ureteric damage, the following preoperative and operative precautions may be taken except:

A. Ureter should not be dissected off the peritoneum for a long distance
B. Cystoscopy (Correct Answer)
C. Bladder should be pushed downwards and outwards while the clamps are placed near the angles of vagina
D. Direct visualization during surgery

Explanation: ***Cystoscopy*** - **Cystoscopy** with or without ureteric catheterization can be used as an adjunct in some complex pelvic surgeries, but it is **not considered a primary or routine preventive measure** during most surgeries where ureteric injury risk exists. - While **intraoperative cystoscopy** may help identify ureters or detect injury post-operatively, it is more of a **diagnostic/confirmatory tool** rather than a direct anatomical protective measure during the surgical dissection itself. - Compared to the other listed options, cystoscopy is the **least direct method** of preventing mechanical ureteric injury during the actual surgical dissection and clamping phases. - The other three options represent **direct anatomical protective techniques** employed during surgery. *Ureter should not be dissected off the peritoneum for a long distance* - This is a crucial **surgical principle** to prevent ureteric injury. - Extensive dissection of the ureter from the peritoneum compromises its **blood supply** from adventitial vessels. - Maintaining peritoneal attachments preserves **vascularity** and reduces risk of **ischemic injury** and subsequent necrosis. *Bladder should be pushed downwards and outwards while the clamps are placed near the angles of vagina* - This is an important **anatomical displacement technique** in pelvic surgery. - The ureters course near the **lateral vaginal fornices** (approximately 2 cm lateral to the cervix). - Repositioning the bladder helps displace the ureters away from surgical **clamps, sutures, and electrocautery** applied to vaginal angles. - This maneuver provides a **safety margin** during cardinal ligament and uterosacral ligament procedures. *Direct visualization during surgery* - **Direct visualization** is the gold standard for ureteric protection during surgery. - Allows the surgeon to **identify anatomical location** and confirm ureter position before clamping or ligating. - Essential in complex pelvic procedures with **distorted anatomy** (endometriosis, adhesions, malignancy). - May involve identification of the ureter at the **pelvic brim** and tracing it through the surgical field.

Question 9: The technique of laparoscopic cholecystectomy was first performed by whom?

A. Erich Muhe (Correct Answer)
B. Eddie Joe Reddick
C. Philippe Mouret
D. Kurt Semm

Explanation: ***Erich Muhe*** - **Erich Muhe**, a German surgeon, performed the first laparoscopic cholecystectomy on September 12, 1985. - He is widely credited with pioneering this minimally invasive surgical technique for gallbladder removal. - This groundbreaking procedure marked the beginning of the laparoscopic revolution in surgery. *Philippe Mouret* - **Philippe Mouret** performed laparoscopic cholecystectomy in France in 1987, independently developing the technique. - While significant in advancing the procedure in Europe, his work followed Muhe's initial breakthrough. *Eddie Joe Reddick* - **Eddie Joe Reddick** was an American surgeon who, along with Douglas Olsen, was instrumental in popularizing and standardizing laparoscopic cholecystectomy in the United States in the late 1980s. - While not the first to perform the procedure, he played a crucial role in its widespread adoption and refinement. - His contributions were significant but came after Muhe's pioneering work. *Kurt Semm* - **Kurt Semm** was a German gynecologist who significantly advanced laparoscopic surgery in the 1980s, particularly in gynecology. - He developed many laparoscopic instruments and techniques, including the automatic insufflator. - Although a pioneer in laparoscopy, he did not perform the first laparoscopic cholecystectomy.

Question 10: Which of the following about Minimal Access Surgery are correct? I. Decreased intraoperative heat loss II. Improved visualization III. Increased chances of herniation IV. Improved mobility Select the answer using the code given below :

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

Explanation: ***I, II and IV (Correct Answer)*** **Statement I - Decreased intraoperative heat loss:** Correct. MAS involves smaller incisions with reduced exposure of internal organs to the operating room environment, resulting in significantly less heat loss compared to open surgery. **Statement II - Improved visualization:** Correct. Endoscopic cameras provide magnified, high-definition, and well-illuminated views of the surgical field, offering superior visualization compared to the naked eye in open procedures. **Statement IV - Improved mobility:** Correct. Patients experience faster post-operative recovery with less pain and earlier return to normal activities due to minimal tissue trauma from smaller incisions. **Statement III - Increased chances of herniation:** This statement is **INCORRECT** and is the key reason why options containing it are wrong. MAS typically results in *decreased* risk of incisional hernias due to smaller access points. While trocar-site hernias can occur, they are less common than the large incisional hernias seen in open surgery when proper fascial closure techniques are employed. *I, III and IV* - Incorrect because Statement III (increased herniation) is false. MAS reduces, not increases, herniation risk. *I, II and III* - Incorrect because Statement III (increased herniation) is false. Properly performed MAS has lower incisional hernia rates than open surgery. *II, III and IV* - Incorrect because Statement III (increased herniation) is false. Smaller incisions in MAS lead to reduced hernia formation compared to traditional open approaches.

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