Single-incision laparoscopic surgery — MCQs

10 questions

A 34-year-old patient presents with severe pain in the right upper quadrant that radiates to the right shoulder. During laparoscopic cholecystectomy, which of the following anatomical spaces must be carefully identified to prevent bile duct injury?

During a surgical procedure to repair an abdominal aortic aneurysm, the surgeon must be careful to avoid injury to which of the following arterial structures that originates near the level of the renal vessels?

A 27-year-old man presents to the emergency department after being stabbed. The patient was robbed at a local pizza parlor and was stabbed over 10 times with a large kitchen knife with an estimated 7 inch blade in the ventral abdomen. His temperature is 97.6°F (36.4°C), blood pressure is 74/54 mmHg, pulse is 180/min, respirations are 19/min, and oxygen saturation is 98% on room air. The patient is intubated and given blood products and vasopressors. Physical exam is notable for multiple stab wounds over the patient's abdomen inferior to the nipple line. Which of the following is the best next step in management?

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 14-year-old girl presents to the emergency room complaining of abdominal pain. She was watching a movie 3 hours prior to presentation when she developed severe non-radiating right lower quadrant pain. The pain has worsened since it started. She also had non-bloody non-bilious emesis 1 hour ago and continues to feel nauseated. Her temperature is 101°F (38.3°C), blood pressure is 130/90 mmHg, pulse is 110/min, and respirations are 22/min. On exam, she has rebound tenderness at McBurney point and a positive Rovsing sign. She is stabilized with intravenous fluids and pain medication and is taken to the operating room to undergo a laparoscopic appendectomy. While in the operating room, the circulating nurse leads the surgical team in a time out to ensure that introductions are made, the patient’s name and date of birth are correct, antibiotics have been given, and the surgical site is marked appropriately. This process is an example of which of the following human factor engineering elements?

A father brings his 1-year-old son into the pediatrician's office for a routine appointment. He states that his son is well but mentions that he has noticed an intermittent bulge on the right side of his son's groin whenever he cries or strains for bowel movement. Physical exam is unremarkable. The physician suspects a condition that may be caused by incomplete obliteration of the processus vaginalis. Which condition is caused by the same defective process?

A 32-year-old woman undergoes laparoscopic excision of ovarian endometrioma. During surgery with the patient in Trendelenburg position and pneumoperitoneum at 15 mmHg, the anesthesiologist notes peak airway pressures rising from 25 to 40 cmH2O, oxygen saturation dropping to 88%, and blood pressure decreasing. Apply the appropriate immediate intervention.

A 65-year-old man with locally advanced rectal cancer 6 cm from the anal verge completes neoadjuvant chemoradiation with good response. MRI shows tumor downsizing to 3 cm with no nodal involvement. The patient strongly prefers sphincter preservation. The surgeon can perform either open low anterior resection or robotic-assisted total mesorectal excision. Evaluate the optimal approach considering oncologic and functional outcomes.

A 50-year-old man with morbid obesity (BMI 48) undergoes laparoscopic sleeve gastrectomy. On postoperative day 5, he develops tachycardia, oliguria, and confusion. CT shows a small fluid collection along the staple line. Drain output is minimal. He is started on antibiotics. Twenty-four hours later, he remains tachycardic with rising lactate despite fluids. Evaluate the management priority.

Q10

A 28-year-old woman undergoes diagnostic laparoscopy for chronic pelvic pain. During trocar insertion using the Veress needle technique, the surgeon advances the needle through the umbilicus. Aspiration returns free-flowing blood. The patient remains hemodynamically stable. Evaluate the most appropriate next step in management.

Single-incision laparoscopic surgery US Medical PG Practice Questions and MCQs

Question 1: A 34-year-old patient presents with severe pain in the right upper quadrant that radiates to the right shoulder. During laparoscopic cholecystectomy, which of the following anatomical spaces must be carefully identified to prevent bile duct injury?

A. Foramen of Winslow
B. Lesser sac
C. Calot's triangle (Correct Answer)
D. Morrison's pouch

Explanation: ***Calot's triangle*** - **Calot's triangle** is the critical anatomical landmark containing the **cystic artery** and **cystic duct**, whose proper identification is essential to prevent injury to the hepatic artery or bile ducts during cholecystectomy. - Its boundaries are the **cystic duct** (lateral), the **common hepatic duct** (medial), and the **inferior border of the liver** (superior, sometimes described as the cystic artery). *Foramen of Winslow* - The **Foramen of Winslow** (epiploic foramen) is an opening connecting the **greater and lesser sacs** of the peritoneal cavity. - It is not directly relevant to identifying structures during cholecystectomy, but rather to accessing the lesser sac or for surgical procedures involving structures like the portal triad. *Lesser sac* - The **lesser sac** (omental bursa) is a peritoneal cavity posterior to the stomach and lesser omentum. - It is explored in procedures involving the pancreas, posterior gastric wall, or for assessing fluid collections, but not for direct identification of cystic structures during standard cholecystectomy. *Morrison's pouch* - **Morrison's pouch** is the **hepatorenal recess**, a potential space between the posterior aspect of the liver and the right kidney and adrenal gland. - It is a common site for **fluid accumulation** (e.g., ascites, blood) but is not directly incised or dissected for preventing bile duct injury during cholecystectomy.

Question 2: During a surgical procedure to repair an abdominal aortic aneurysm, the surgeon must be careful to avoid injury to which of the following arterial structures that originates near the level of the renal vessels?

A. Left renal artery (Correct Answer)
B. Celiac trunk
C. Right renal artery
D. Superior mesenteric artery

Explanation: ***Left renal artery*** - The **left renal artery** arises from the aorta usually just below the superior mesenteric artery, making it susceptible to injury during an **abdominal aortic aneurysm (AAA) repair** if the aneurysm extends proximally. - Its proximity to the typical location of AAA, often near or involving the **infrarenal aorta**, necessitates careful identification and protection during clamping or graft placement. *Celiac trunk* - The **celiac trunk** originates higher up from the aorta, typically at the level of **T12-L1 vertebrae**, well above the common infrarenal AAA repair site. - While important, it is generally less directly threatened during a typical infrarenal AAA repair compared to arteries immediately adjacent to or within the aneurysm sac. *Right renal artery* - The **right renal artery** also originates from the aorta near the level of the renal veins, but it is typically located more posteriorly and usually passes behind the inferior vena cava. - Although it can be at risk, the left renal artery's course is often more anterior and directly in the field of dissection for the **aortic neck** during AAA repair. *Superior mesenteric artery* - The **superior mesenteric artery (SMA)** originates from the aorta proximal to the renal arteries, typically around the L1 vertebral level. - While crucial, its origin is usually cephalad to the infrarenal aneurysm neck, making it generally less prone to direct injury during infrarenal AAA repair, though flow must be monitored.

Question 3: A 27-year-old man presents to the emergency department after being stabbed. The patient was robbed at a local pizza parlor and was stabbed over 10 times with a large kitchen knife with an estimated 7 inch blade in the ventral abdomen. His temperature is 97.6°F (36.4°C), blood pressure is 74/54 mmHg, pulse is 180/min, respirations are 19/min, and oxygen saturation is 98% on room air. The patient is intubated and given blood products and vasopressors. Physical exam is notable for multiple stab wounds over the patient's abdomen inferior to the nipple line. Which of the following is the best next step in management?

A. Exploratory laparotomy (Correct Answer)
B. Diagnostic peritoneal lavage
C. CT scan of the abdomen and pelvis
D. Exploratory laparoscopy
E. FAST exam

Explanation: ***Exploratory laparotomy*** - The patient presents with **multiple stab wounds** to the abdomen and signs of **hemorrhagic shock** (BP 74/54 mmHg, HR 180/min), which are clear indications for immediate surgical intervention. - An exploratory laparotomy allows for direct visualization and repair of internal injuries, which is critical in this life-threatening situation. *Diagnostic peritoneal lavage* - While DPL can detect intra-abdominal bleeding, it is an **invasive procedure** and may delay definitive treatment in a hemodynamically unstable patient with obvious penetrating trauma. - It is **less specific** than a laparotomy for identifying the exact location and nature of injuries, and it has largely been replaced by imaging studies or direct surgical exploration in unstable patients. *CT scan of the abdomen and pelvis* - A CT scan requires a **hemodynamically stable** patient and time for scanning and interpretation, which this patient does not have. - Delaying definitive treatment for imaging in a patient with severe shock could lead to worse outcomes. *Exploratory laparoscopy* - Although less invasive, laparoscopy can be time-consuming and may not be feasible or safe in a patient with **profound hemorrhagic shock** and extensive injuries, especially if major vascular or visceral damage is suspected. - Conversion to a **laparotomy** is often necessary in cases of significant injury, making immediate open exploration more efficient. *FAST exam* - A FAST exam can rapidly detect free fluid in the abdomen, suggesting internal bleeding, but it does **not provide specific information** about the source or extent of the injuries. - While useful in the initial assessment, a positive FAST exam in a hemodynamically unstable patient with penetrating trauma directly points to the need for immediate surgical intervention, not further diagnostic delay.

Question 4: 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

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.

Question 5: A 14-year-old girl presents to the emergency room complaining of abdominal pain. She was watching a movie 3 hours prior to presentation when she developed severe non-radiating right lower quadrant pain. The pain has worsened since it started. She also had non-bloody non-bilious emesis 1 hour ago and continues to feel nauseated. Her temperature is 101°F (38.3°C), blood pressure is 130/90 mmHg, pulse is 110/min, and respirations are 22/min. On exam, she has rebound tenderness at McBurney point and a positive Rovsing sign. She is stabilized with intravenous fluids and pain medication and is taken to the operating room to undergo a laparoscopic appendectomy. While in the operating room, the circulating nurse leads the surgical team in a time out to ensure that introductions are made, the patient’s name and date of birth are correct, antibiotics have been given, and the surgical site is marked appropriately. This process is an example of which of the following human factor engineering elements?

A. Forcing function
B. Safety culture
C. Simplification
D. Standardization (Correct Answer)
E. Resilience engineering

Explanation: ***Standardization*** - The surgical **time-out** is a prime example of **standardization** in healthcare, as it involves a prescribed, uniform procedure followed in every surgery to enhance safety. - It ensures critical safety checks—like patient identification, site marking, and antibiotic administration—are consistently performed, thus reducing variability and the potential for errors. *Forcing function* - A **forcing function** is a design element that makes it impossible to commit an error, such as a specific connector shape that prevents incorrect device attachment. - The time-out, while a critical safeguard, still relies on human compliance and does not physically prevent an error from occurring if the steps are not followed. *Safety culture* - **Safety culture** refers to the shared beliefs, values, and attitudes that employees have about safety within an organization. - While a time-out contributes to a strong safety culture, it is a specific process or tool, not the overarching culture itself. *Simplification* - **Simplification** aims to reduce complexity in a process to minimize cognitive load and potential for error. - The time-out adds a structured step rather than simplifying an existing process; its purpose is to ensure all necessary checks are systematically completed. *Resilience engineering* - **Resilience engineering** focuses on an organization's ability to anticipate, cope with, and recover from failures, maintaining stability in the face of disruptions. - While the time-out promotes safety, it primarily addresses error prevention rather than the broader organizational capacity to adapt and recover from system failures.

Question 6: A father brings his 1-year-old son into the pediatrician's office for a routine appointment. He states that his son is well but mentions that he has noticed an intermittent bulge on the right side of his son's groin whenever he cries or strains for bowel movement. Physical exam is unremarkable. The physician suspects a condition that may be caused by incomplete obliteration of the processus vaginalis. Which condition is caused by the same defective process?

A. Diaphragmatic hernia
B. Femoral hernia
C. Testicular torsion
D. Hydrocele (Correct Answer)
E. Varicocele

Explanation: ***Hydrocele*** - The patient's symptoms (intermittent groin bulge with crying/straining) are classic for an **indirect inguinal hernia**, which, like a hydrocele, results from an **incompletely obliterated processus vaginalis**. - A **hydrocele** involves the accumulation of **serous fluid** within the persistent processus vaginalis, as opposed to abdominal contents in a hernia. *Diaphragmatic hernia* - This condition involves the protrusion of abdominal contents into the chest cavity through a defect in the **diaphragm**. - It is unrelated to the obliteration of the processus vaginalis but rather to **diaphragmatic development**. *Femoral hernia* - A femoral hernia involves protrusion through the **femoral canal**, inferior to the inguinal ligament. - It does not involve the processus vaginalis and is more common in **multiparous women**. *Testicular torsion* - This condition is a surgical emergency caused by the **twisting of the spermatic cord**, compromising blood supply to the testis. - It is not related to the processus vaginalis but often involves an inadequately fixed testis (bell-clapper deformity). *Varicocele* - A varicocele is an abnormal dilation of the **pampiniform venous plexus** within the spermatic cord. - It is caused by incompetent valves in the testicular veins and not by a patent processus vaginalis.

Question 7: A 32-year-old woman undergoes laparoscopic excision of ovarian endometrioma. During surgery with the patient in Trendelenburg position and pneumoperitoneum at 15 mmHg, the anesthesiologist notes peak airway pressures rising from 25 to 40 cmH2O, oxygen saturation dropping to 88%, and blood pressure decreasing. Apply the appropriate immediate intervention.

A. Increase tidal volume and respiratory rate
B. Increase FiO2 and administer fluid bolus only
C. Release pneumoperitoneum and decrease Trendelenburg (Correct Answer)
D. Administer bronchodilators for bronchospasm
E. Check for endobronchial intubation and reposition tube

Explanation: ***Release pneumoperitoneum and decrease Trendelenburg*** - High **peak airway pressures** (40 cmH2O), **hypoxemia**, and **hypotension** indicate severe physiological compromise from **pneumoperitoneum** and positioning. - Releasing the gas and leveling the patient immediately facilitates **diaphragmatic descent**, increases **lung compliance**, and restores **venous return** to improve cardiac output. *Increase tidal volume and respiratory rate* - Increasing **tidal volume** in the presence of already high airway pressures significantly increases the risk of **barotrauma** and further cardiovascular collapse. - This intervention does not address the mechanical cause of **diaphragmatic splinting** caused by the CO2 insufflation. *Increase FiO2 and administer fluid bolus only* - While oxygenation may temporarily improve, this fails to correct the **reduced functional residual capacity** caused by the **positive pressure** in the abdomen. - Fluids may not compensate for the **inferior vena cava compression** if the source of high **intra-abdominal pressure** remains unchanged. *Administer bronchodilators for bronchospasm* - High airway pressures in laparoscopy are usually due to **decreased thoracic compliance**, not necessarily **bronchospasm**. - The sudden drop in blood pressure suggests a hemodynamic/mechanical cause rather than an isolated **obstructive lung** pathology. *Check for endobronchial intubation and reposition tube* - While cephalad movement of the diaphragm can cause **endobronchial intubation**, it does not typically explain the systemic **hypotension** seen here. - This step should follow the **immediate release** of abdominal pressure, which is the most life-threatening contributor to the current vitals.

Question 8: A 65-year-old man with locally advanced rectal cancer 6 cm from the anal verge completes neoadjuvant chemoradiation with good response. MRI shows tumor downsizing to 3 cm with no nodal involvement. The patient strongly prefers sphincter preservation. The surgeon can perform either open low anterior resection or robotic-assisted total mesorectal excision. Evaluate the optimal approach considering oncologic and functional outcomes.

A. Open low anterior resection for better tactile feedback
B. Abdominoperineal resection for oncologic safety
C. Transanal endoscopic microsurgery for organ preservation
D. Robotic-assisted TME for improved visualization in pelvis (Correct Answer)
E. Watch and wait approach given excellent response

Explanation: ***Robotic-assisted TME for improved visualization in pelvis*** - **Robotic surgery** provides a **3D high-definition view** and **wristed instrumentation**, which is particularly advantageous for precise dissection in the narrow male pelvis. - This approach facilitates **sphincter preservation** while maintaining equivalent **oncologic outcomes**, such as circumferential resection margin (CRM) clearance, compared to open surgery. *Open low anterior resection for better tactile feedback* - While offering **tactile feedback**, the open approach is more technically challenging in the deep pelvis and is associated with **increased blood loss** and longer recovery times. - It lacks the **magnified visualization** and ergonomic benefits offered by robotic platforms, which are crucial for preserving **pelvic autonomic nerves**. *Abdominoperineal resection for oncologic safety* - This procedure entails the permanent removal of the **anal sphincter** and creation of a colostomy, which contradicts the patient's strong preference for **sphincter preservation**. - Since the tumor is 6 cm from the **anal verge** and responded well to therapy, a low anterior resection is oncologically safe and clinically appropriate. *Transanal endoscopic microsurgery for organ preservation* - **Transanal endoscopic microsurgery (TEM)** is generally reserved for **early-stage (T1)** tumors without high-risk features and is not the standard for locally advanced cancer. - It does not allow for a complete **total mesorectal excision (TME)** or assessment of regional lymph nodes, leading to a high risk of **local recurrence** in this case. *Watch and wait approach given excellent response* - This strategy requires a **clinical complete response (cCR)**, which means no visible tumor on endoscopy or MRI; this patient still has a **3 cm residual mass**. - Implementing "watch and wait" for a patient with persistent tumor significantly increases the risk of **disease progression** and missing the window for curative surgery.

Question 9: A 50-year-old man with morbid obesity (BMI 48) undergoes laparoscopic sleeve gastrectomy. On postoperative day 5, he develops tachycardia, oliguria, and confusion. CT shows a small fluid collection along the staple line. Drain output is minimal. He is started on antibiotics. Twenty-four hours later, he remains tachycardic with rising lactate despite fluids. Evaluate the management priority.

A. Urgent laparoscopic exploration with drainage
B. Increase antibiotic coverage and vasopressor support
C. Continue antibiotics and obtain interventional radiology drainage
D. Endoscopic stent placement across the leak
E. Immediate open exploration, washout, and feeding jejunostomy (Correct Answer)

Explanation: ***Immediate open exploration, washout, and feeding jejunostomy*** - The patient exhibits signs of **septic shock** (tachycardia, rising lactate, confusion) due to a **staple line leak**, which requires immediate surgical source control. - An **open approach** is preferred over laparoscopy in a deteriorating, morbidly obese patient to ensure thorough **peritoneal washout**, secure drainage, and the placement of a **feeding jejunostomy** for long-term nutritional support. *Urgent laparoscopic exploration with drainage* - While laparoscopy is minimally invasive, it is technically difficult in the setting of severe **morbid obesity** and acute inflammation, potentially leading to incomplete **source control**. - This patient is failing to respond to initial management; therefore, a more definitive and reliable **open exploration** is prioritized to address the clinical deterioration. *Increase antibiotic coverage and vasopressor support* - Antibiotics and vasopressors are supportive measures but do not address the primary **surgical pathology**, which is the active leak from the gastric sleeve. - Relying solely on medical management for **anastomotic leaks** in the presence of rising **lactate** and organ dysfunction (oliguria) allows sepsis to progress to irreversible multi-organ failure. *Continue antibiotics and obtain interventional radiology drainage* - **IR drainage** is generally indicated for well-localized fluid collections in **hemodynamically stable** patients. - Because this patient's collection is small but his **systemic symptoms** are worsening, drainage alone will not achieve the necessary **source control** or mitigate the leak. *Endoscopic stent placement across the leak* - **Endoscopic stenting** is a management option for stable patients with chronic or subacute leaks to bypass the defect. - It is inappropriate for an unstable patient with **postoperative peritonitis** and sepsis, where the immediate priority is **surgical washout** and drainage of the abdominal cavity.

Question 10: A 28-year-old woman undergoes diagnostic laparoscopy for chronic pelvic pain. During trocar insertion using the Veress needle technique, the surgeon advances the needle through the umbilicus. Aspiration returns free-flowing blood. The patient remains hemodynamically stable. Evaluate the most appropriate next step in management.

A. Insert trocar through the needle tract and inspect for injury
B. Abort procedure and obtain CT angiography
C. Remove needle and proceed with Veress insertion at different site
D. Remove needle, convert to open Hassan technique at umbilicus
E. Remove needle, place Foley catheter, convert to open laparotomy (Correct Answer)

Explanation: ***Remove needle, place Foley catheter, convert to open laparotomy*** - Aspiration of **free-flowing blood** during Veress needle insertion is highly suggestive of a **major vascular injury**, such as the aorta or iliac vessels. - Even in **hemodynamically stable** patients, immediate **laparotomy** is required to assess for and repair potential life-threatening hemorrhage that laparoscopy cannot safely manage. *Insert trocar through the needle tract and inspect for injury* - Inserting a larger **trocar** into a suspected vascular injury can worsen the **laceration** and lead to catastrophic bleeding. - **Pneumoperitoneum** may temporarily tamponade a major bleed, masking the severity of the injury until it is too late. *Abort procedure and obtain CT angiography* - Delaying definitive surgical management for **imaging** is inappropriate when a major vascular or **solid organ injury** is suspected intraoperatively. - Clinical suspicion and the return of blood through the needle are sufficient indications for **immediate exploration**. *Remove needle and proceed with Veress insertion at different site* - Simply moving to a **different site** ignores the high probability of an existing internal injury that requires **immediate repair**. - Re-attempting insufflation elsewhere can lead to a **tension pneumoperitoneum** or delay the recognition of a retroperitoneal hematoma. *Remove needle, convert to open Hassan technique at umbilicus* - The **Hassan technique** is used for establishing laparoscopic access but does not provide sufficient **exposure** to control major vascular bleeding. - Once major blood vessel injury is suspected, a large **midline laparotomy** is the standard of care to ensure adequate visualization and surgical control.

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