Laparoscopic gynecologic procedures — MCQs

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 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 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 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 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 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 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?

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 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 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?