Minimally Invasive Surgery — MCQs

Minimally Invasive Surgery Indian Medical PG Practice Questions and MCQs

Question 31: Which instrument is primarily used to establish pneumoperitoneum in closed laparoscopy technique?

A. Jamshidi needle
B. 3 mm Trocar
C. Hasson's cannula
D. Veress needle (Correct Answer)

Explanation: ***Veress needle***- It is primarily used to establish **pneumoperitoneum** (gas insufflation) in the **closed laparoscopy** technique, before placing trocars.- A key feature is its **blunt inner retractable stylet**. Once the needle passes the abdominal wall and enters the peritoneal cavity, the stylet advances forward automatically, reducing the risk of internal visceral injury.*Hasson's cannula*- This instrument is specifically designed for the **open laparoscopic technique** (Hasson technique), utilized when the closed technique is contraindicated due to scar tissue or risk of injury.- It involves a direct cut-down approach and fixation by sutures, making it a **blunt entry system** unlike the sharp, blind insertion of the Veress needle.*Jamshidi needle*- This is a specialized needle used for **bone marrow aspiration** or **biopsy**, typically used in hematology or oncology.- It is characterized by a **tapered distal end** with a sharpened tip and a stylet designed to penetrate dense bone tissue, which is unrelated to abdominal gas insufflation.*3 mm Trocar*- A trocar system consists of a **cannula and an obturator** and is used to create a working port for the introduction of the camera or surgical instruments, usually *after* pneumoperitoneum has been achieved.- While 3 mm is a small diameter, its function is creating an instrument channel, not the initial **insufflation** itself.

Question 32: 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.

Question 33: ‘Swiss cheese defects’ of anterior abdominal wall after exploratory laparotomy is best seen while doing:

A. Open inguinal hernia repair
B. Laparoscopic ventral hernia repair (Correct Answer)
C. Open ventral hernia repair
D. Laparoscopic inguinal hernia repair

Explanation: ***Laparoscopic ventral hernia repair*** - During **laparoscopic ventral hernia repair**, the surgeon has an **intra-abdominal view** of the anterior abdominal wall. - This allows for direct visualization of multiple, small fascial defects ("Swiss cheese defects") from an old laparotomy incision from the inside. - The **panoramic view** from within the peritoneal cavity enables comprehensive assessment of the entire abdominal wall, making it the best approach to identify scattered defects. *Open inguinal hernia repair* - This approach focuses on the **inguinal canal** and does not provide an adequate view of the entire anterior abdominal wall. - It is performed through an **external incision**, making it difficult to detect multiple small defects throughout the rectus sheath. *Open ventral hernia repair* - While an **open ventral hernia repair** addresses a defect in the anterior abdominal wall, the exposure is typically confined to the immediate area of the hernia. - It may not offer the comprehensive intra-abdominal view necessary to identify scattered "Swiss cheese defects" across a wider area of the fascia. *Laparoscopic inguinal hernia repair* - This procedure primarily involves repairing an **inguinal hernia**, with visualization focused on the inguinal region and the posterior aspect of the groin. - It does not provide the broad intra-abdominal perspective needed to assess for general anterior abdominal wall defects or "Swiss cheese defects" away from the repair site.

Question 34: The Chief of laparoscopic surgery asked his assistant to give him a laparoscopic port which has absolutely no chance of "capacitance coupling" during laparoscopic surgery. Which port should the assistant give to the Chief?

A. Metal port with plastic cuff
B. Complete plastic port (Correct Answer)
C. Metal laparoscopic port
D. Partial plastic port

Explanation: **Complete plastic port** - A **complete plastic port** is an **electrical insulator** and thus completely prevents the phenomenon of **capacitance coupling** during laparoscopic surgery. - This is the safest option when electrosurgery is used, as it eliminates the risk of inadvertent energy transfer to surrounding tissues through the trocar. *Metal port with plastic cuff* - While a plastic cuff might offer some insulation, the presence of a **metal outer cannula** still allows for the possibility of charge accumulation and subsequent **capacitance coupling**. - The plastic cuff alone is insufficient to prevent the capacitance effect from the metal shaft, as the internal metal may still induce a charge on nearby conductive objects. *Metal laparoscopic port* - A **metal laparoscopic port** is a **conductor** and is highly susceptible to **capacitance coupling**, transferring stray electrical currents to unintended tissues. - The direct contact of conductive metal with the abdominal wall can create a pathway for current leakage, increasing the risk of **thermal injury**. *Partial plastic port* - Similar to a metal port with a plastic cuff, a **partial plastic port** would still have exposed metal components that can accumulate charge and lead to **capacitance coupling**. - Any exposed metal section can act as an electrode, enabling the unintentional delivery of electrical energy to non-target tissues.

Question 35: “Triangle of Doom” dissected and seen during Laparoscopic inguinal hernia repair is bounded by all EXCEPT:

A. Vas deferens
B. Gonadal vessels
C. Cord structures
D. Peritoneal fold (Correct Answer)

Explanation: ***Peritoneal fold*** - The "Triangle of Doom" is an important anatomical landmark in **laparoscopic inguinal hernia repair** that contains critical vascular structures vulnerable to injury. - The **peritoneal fold** does not form a boundary of the Triangle of Doom, making this the correct answer to the EXCEPT question. - The triangle lies in the preperitoneal space and is not bounded by peritoneal reflections. *Vas deferens* - The **vas deferens** forms the **medial boundary** of the Triangle of Doom. - It courses from the internal ring into the pelvis and is a crucial landmark during dissection. - Injury can result in **infertility**, particularly if bilateral damage occurs. *Gonadal vessels* - The **gonadal vessels (testicular/ovarian vessels)** form the **lateral boundary** of the Triangle of Doom. - These vessels run parallel to the vas deferens and are at risk during lateral dissection. - The triangle's base is formed by the **iliac vessels** (external iliac artery and vein). *Cord structures* - The **cord structures** (including vas deferens and gonadal vessels) pass through or form the boundaries of the Triangle of Doom. - Within this triangle lie the **external iliac artery and vein** and the **femoral branch of the genitofemoral nerve**. - **Clinical significance**: Inadvertent stapling or dissection in this area can cause life-threatening **vascular injury** or nerve damage. **Note**: This should not be confused with the "Triangle of Pain" which is bounded laterally by the **inferior epigastric artery** and contains the lateral femoral cutaneous nerve and femoral branch of genitofemoral nerve.

Question 36: Which one of the following is the safest gas for creating pneumoperitoneum in operative laparoscopy?

A. Oxygen
B. Carbon monoxide
C. Nitrous oxide
D. Carbon dioxide (Correct Answer)

Explanation: ***Carbon dioxide*** - **Carbon dioxide (CO2)** is the gold standard for creating **pneumoperitoneum** because it is rapidly absorbed from the **peritoneal cavity** and excreted by the lungs, minimizing the risk of gas embolism. - Its **high solubility in blood** (20x more soluble than nitrogen) reduces the risk of serious complications if inadvertently injected intravascularly. - **Non-combustible** and does not support combustion, making it safe to use with electrocautery and other heat sources during surgery. *Oxygen* - **Oxygen** is highly **combustible** and would create a significant fire hazard in the presence of electrocautery or other heat sources during surgery. - It could also cause **gas emboli** if it enters the bloodstream, as it is less soluble than CO2. - Risk of **oxidative tissue damage** with prolonged exposure. *Carbon monoxide* - **Carbon monoxide** is extremely **toxic** and binds irreversibly to hemoglobin with 200-250 times greater affinity than oxygen, forming **carboxyhemoglobin**, which impairs oxygen transport. - Even minimal exposure can be life-threatening due to systemic hypoxia. - Absolutely contraindicated for clinical use. *Nitrous oxide* - **Nitrous oxide** can diffuse into gas-filled spaces (bowel loops) 30x faster than nitrogen, potentially causing **bowel distension** and increased intra-abdominal pressure during prolonged procedures. - Although less of a fire risk than oxygen, it can **support combustion** at high concentrations. - Less rapidly absorbed than CO2, posing higher embolism risk if intravascular injection occurs.

Question 37: Consider the following statements: 1. Carbon dioxide is the safest gas for creating pneumoperitoneum in operative laparoscopy. 2. Laparoscopic sterilization is not recommended during the period of immediate postpartum. Which of the statements given above is/are correct?

A. 1 only
B. Neither 1 nor 2
C. 2 only
D. Both 1 and 2 (Correct Answer)

Explanation: ***Both 1 and 2*** - **Carbon dioxide (CO2)** is the safest gas for creating pneumoperitoneum due to its **rapid absorption** and **excretion** by the body, minimizing the risk of gas embolism and tissue toxicity. - Laparoscopic sterilization is generally **not recommended during the immediate postpartum period** (first 6-8 weeks) due to the **enlarged uterus**, increased vascularity, and altered anatomy, which elevate the risk of complications such as hemorrhage and organ perforation. *1 only* - While carbon dioxide is indeed the safest gas for pneumoperitoneum, this option is incorrect because the second statement regarding postpartum sterilization is also accurate. - Selecting this option would imply that statement 2 is false, which is not the case. *Neither 1 nor 2* - This option is incorrect because both statements are clinically accurate and accepted practices in operative laparoscopy and postpartum care. - Both statements reflect standard surgical and obstetric guidelines. *2 only* - This option is incorrect because, in addition to the second statement being true, the first statement (regarding the safety of CO2 for pneumoperitoneum) is also correct. - Choosing this option would suggest that CO2 is not the safest gas, which contradicts established medical practice.

Question 38: 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)

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.

Question 39: Not an absolute contraindication of laparoscopy is

A. Patient on anticoagulant therapy
B. Diaphragmatic hernia
C. Generalized peritonitis
D. Previous incomplete laparoscopy (Correct Answer)

Explanation: ***Previous incomplete laparoscopy*** - This is a **relative contraindication**, not an absolute one, making it the correct answer. - Prior incomplete laparoscopy may result in **adhesion formation**, but this doesn't absolutely prevent future laparoscopic procedures. - Each case must be evaluated individually based on the **extent of adhesions**, surgical expertise, and risk-benefit analysis. - With proper technique and experience, repeat laparoscopy is often feasible and safe. *Patient on anticoagulant therapy* - While anticoagulation increases **bleeding risk** during laparoscopy, this is primarily a **relative contraindication** in modern practice. - Anticoagulants can typically be **held, reversed, or bridged** perioperatively based on thromboembolic risk. - Only **severe uncorrected coagulopathy** (not simply being on anticoagulants) would be considered absolute. - This represents a more significant concern than previous incomplete laparoscopy but is still manageable. *Diaphragmatic hernia* - This is generally a **relative contraindication**, though large hernias pose significant risks. - **Pneumoperitoneum** can potentially worsen herniation and cause **respiratory or cardiac compromise**. - Small diaphragmatic hernias may not preclude laparoscopy, while large ones require careful assessment. - The decision depends on hernia size, cardiopulmonary reserve, and surgical urgency. *Generalized peritonitis* - While traditionally controversial, severe generalized peritonitis is often considered a **strong relative** or practical contraindication. - **Bowel distension** and inflammation make trocar insertion technically challenging and increase **perforation risk**. - However, with experience and proper patient selection, laparoscopy may be performed in selected cases. - The presence of **septic shock** or hemodynamic instability would shift this toward absolute contraindication.

Question 40: Discectomy can be performed using:

A. Open surgery
B. Microdiscectomy
C. Endoscopic approach
D. All of the options (Correct Answer)

Explanation: ***All of the options*** - **Discectomy** can be performed through various surgical approaches, including open surgery, minimally invasive techniques using a microscope, and endoscopic procedures. - The choice of method depends on factors such as the **location and size of the disc herniation**, patient anatomy, and surgeon’s preference and expertise. *Open surgery* - This involves a larger incision to directly visualize and access the spinal structures and remove the **herniated disc material**. - While effective, it typically involves more muscle dissection, leading to increased **postoperative pain** and a longer recovery time compared to minimally invasive approaches. *Microscope* - **Microdiscectomy** uses a surgical microscope to provide magnified visualization of the surgical field through a smaller incision. - This minimally invasive approach reduces tissue dissection, leading to less pain, smaller scars, and **faster recovery** than traditional open surgery. *Endoscope* - **Endoscopic discectomy** utilizes a small camera (endoscope) inserted through a tiny incision, allowing the surgeon to view the surgical area on a monitor. - This is a highly minimally invasive technique that typically results in even **less tissue damage** and a quicker return to normal activities compared to microdiscectomy.

Practice by Chapter

Laparoscopic Equipment and Instrumentation

Practice Questions

Physiological Changes in Laparoscopy

Practice Questions

Laparoscopic Access Techniques

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Laparoscopic Cholecystectomy

Practice Questions

Laparoscopic Appendectomy

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Laparoscopic Hernia Repair

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Laparoscopic Colorectal Surgery

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Laparoscopic Upper GI Surgery

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Robotic Surgery

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Single Incision Laparoscopic Surgery

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NOTES (Natural Orifice Transluminal Endoscopic Surgery)

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Complications of Minimally Invasive Surgery

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