Laparotomy

Laparotomy

Q. 1

Laparotomy performed in a case of ovarian tumor revealed unilateral ovarian tumor with ascites positive for malignant cells and positive pelvic lymph nodes. All other structures were free of disease. What is stage of the disease :

 A

Stage 11 c

 B

Stage III a

 C

Stage Ill b

 D

Stage III c

Q. 1

Laparotomy performed in a case of ovarian tumor revealed unilateral ovarian tumor with ascites positive for malignant cells and positive pelvic lymph nodes. All other structures were free of disease. What is stage of the disease :

 A

Stage 11 c

 B

Stage III a

 C

Stage Ill b

 D

Stage III c

Ans. D

Explanation:

Ans. is d i.e. Stage III C


Q. 2

Smt. Pushpa is a suspected case of ovarian tumors. On laparotomy bilaterally enlarged

 A

Granulosa cell tumour

 B

Krukenberg tumor

 C

Dysgerminoma

 D

Primary adenocarcinoma

Q. 2

Smt. Pushpa is a suspected case of ovarian tumors. On laparotomy bilaterally enlarged

 A

Granulosa cell tumour

 B

Krukenberg tumor

 C

Dysgerminoma

 D

Primary adenocarcinoma

Ans. B

Explanation:

Ans. is b i.e. Krukenberg tumour

This is the classic presentation of Krukenberg tumour. For details, on Krukenberg tumour, see answer 45


Q. 3

Which of the following is the safest method of sterilization in immediate post partum period :

 A

Minilaparotomy

 B

Laparoscopy

 C

Hysteroscopic method

 D

None

Q. 3

Which of the following is the safest method of sterilization in immediate post partum period :

 A

Minilaparotomy

 B

Laparoscopy

 C

Hysteroscopic method

 D

None

Ans. A

Explanation:

Minilaparotomy


Q. 4

Mini laparotomy is done in all except :

 A

Ectopic pregnancy

 B

Internal sterilisation

 C

Uterus elevations

 D

Tubectomy

Q. 4

Mini laparotomy is done in all except :

 A

Ectopic pregnancy

 B

Internal sterilisation

 C

Uterus elevations

 D

Tubectomy

Ans. A

Explanation:

Ectopic pregnancy


Q. 5 A 19-year-old female comes to the physician because of left lower quadrant pain for 2 months.
She states that she first noticed the pain 2 months ago but now it seems to be growing worse. She has had no changes in bowel or bladder function. She has no fevers or chills and no nausea, vomiting, or diarrhea. The pain is intermittent and sometimes feels like a dull pressure. Pelvic examination is significant for a left adnexal mass that is mildly tender. Urine hCG is negative. Pelvic ultrasound shows a 6 cm complex left adnexal mass with features consistent with a benign cystic teratoma. Which of the following is the most appropriate next step in management?
 A Repeat pelvic examination in 1 year
 B Repeat pelvic ultrasound in 6 weeks
 C Prescribe the oral contraceptive pill
 D Perform Laparotomy
Q. 5 A 19-year-old female comes to the physician because of left lower quadrant pain for 2 months.
She states that she first noticed the pain 2 months ago but now it seems to be growing worse. She has had no changes in bowel or bladder function. She has no fevers or chills and no nausea, vomiting, or diarrhea. The pain is intermittent and sometimes feels like a dull pressure. Pelvic examination is significant for a left adnexal mass that is mildly tender. Urine hCG is negative. Pelvic ultrasound shows a 6 cm complex left adnexal mass with features consistent with a benign cystic teratoma. Which of the following is the most appropriate next step in management?
 A Repeat pelvic examination in 1 year
 B Repeat pelvic ultrasound in 6 weeks
 C Prescribe the oral contraceptive pill
 D Perform Laparotomy
Ans. D

Explanation:

This patient has a presentation and findings that are most consistent with a benign cystic teratoma. Dermoids are a type of ovarian germ cell tumor. Germ cell tumors are the most common type of ovarian neoplasm in females under the age of 20 and dermoids are the most common benign ovarian neoplasm.Dermoids can range in size from small masses that are noted ncidentally on ultrasound and cause no symptoms, to large cysts that cause pain and pressure, as this patient has. Laparotomy is the most appropriate next step in the management of this patient because, as adnexal masses enlarge–especially when they become greater than 5 cm–the risk of ovarian torsion increases. Thus, laparotomy withremoval of the dermoid is indicated to prevent torsion. Also, this patient’s mass is causing her symptoms of pain and pressure and, on that basis, should be removeD. Finally, while the mass most likely is a dermoid, this is not certain without pathologic diagnosis and, therefore, the cyst should be removed and evaluated by a pathologist. At the time of surgery, close examination should be made of the other ovary because dermoids may be found bilaterally in more than 10% of cases. To repeat pelvic examination in 1 year (Choice A)would not be correct management. This patient is symptomatic with a 6 cm ovarian mass that is at risk for torsion. She should, therefore, be managed surgically. To repeat pelvic ultrasound in 6 weekschoice B. is appropriate for some adnexal masses. For example, in a young woman with a small complex cyst that appears consistent with a corpus luteum, it may be most prudent to recheck an ultrasound in 6 weeks to see if the cyst has resolveD. This patient, however, is symptomatic with a 6 cm cyst that appears to be adermoid, which will not resolve spontaneously. She, therefore, requires surgery. To prescribe the oral contraceptive pill (Choice C) may help to prevent future ovarian cysts but it will not resolve this cyst, which requires surgical management.


Q. 6 In comparing laparoscopic salpingostomy vs. laparotomy with sal-pingectomy for the treatment of ectopic pregnancy, laparoscopic therapy results in
 A Decreased hospital stays
 B Lower fertility rate
 C Lower repeat ectopic pregnancy rate
 D Comparable persistent ectopic tissue rate
Q. 6 In comparing laparoscopic salpingostomy vs. laparotomy with sal-pingectomy for the treatment of ectopic pregnancy, laparoscopic therapy results in
 A Decreased hospital stays
 B Lower fertility rate
 C Lower repeat ectopic pregnancy rate
 D Comparable persistent ectopic tissue rate
Ans. A

Explanation:

Conservative laparoscopic treatment of ectopic pregnancy is now commonplace, although not  yet  universal.  With  increasing sophistication of  techniques and  fiberoptics,  many  microsurgical procedures can be done through the laparoscope Recent studies uggest that the fertility rates for laparoscopy and laparo- tomy are comparable, as are the implications of repeat ectopic pregnancies. Certainly laparoscopy, because of its small incision, results in fewer break- downs and shorter hospital stays, but the incidence of complications due to retained ectopic tissue is higher.


Q. 7 A patient with necrotizing pancreatitis undergoes CT guided aspiration, which results in growth of E-coli on culture. The most appropriate treatment is:
 A Culture appropriate antibiotic therapy
 B ERCP with sphincterotomy
 C CT   guided   placement   of drain(s)
 D Exploratory laparotomy
 
Q. 7 A patient with necrotizing pancreatitis undergoes CT guided aspiration, which results in growth of E-coli on culture. The most appropriate treatment is:
 A Culture appropriate antibiotic therapy
 B ERCP with sphincterotomy
 C CT   guided   placement   of drain(s)
 D Exploratory laparotomy
 
Ans. D

Explanation:

Exploratory laparotomy The presence of secondary pancreatic infection suspected in patients whose systemic inflammatory response (fever, WBC count or organ dysfunction) fails to resolve, CT-guided aspiration of fluid from pancreatic bed for performance of Gram’s stain & culture analysis is of critical importance. A positive is Gram’s stain or culture or identification of gas within pancreas on CT-scan, mandate operative intervention.


Q. 8 A patient with mild skin pigmentation comes to you because of sudden abdominal pain, fever and a rigid abdomen. Her lab report show blood sugar of 55, Na 119, and K 6.2. Her BP  88/58. She undergoes exploratory laparotomy. Which statement is true?
 A Treatment with exogenous steroids is usually ineffective
 B This condition is commonly seen as a consequence of metastasis  of  distant  cancers, such  as  lung  or breast to the adrenal glands
 C Death from untreated chronic adrenal insufficiency may occur within hours of surgery
 D The  most  common  underlying  cause  today  is infection with MDR tuberculosis
Q. 8 A patient with mild skin pigmentation comes to you because of sudden abdominal pain, fever and a rigid abdomen. Her lab report show blood sugar of 55, Na 119, and K 6.2. Her BP  88/58. She undergoes exploratory laparotomy. Which statement is true?
 A Treatment with exogenous steroids is usually ineffective
 B This condition is commonly seen as a consequence of metastasis  of  distant  cancers, such  as  lung  or breast to the adrenal glands
 C Death from untreated chronic adrenal insufficiency may occur within hours of surgery
 D The  most  common  underlying  cause  today  is infection with MDR tuberculosis
Ans. C

Explanation:

Failure to recbgnize adrenal cortical insufficiency, particularly in the ppstoperative patient, may be a fatal error that is especially regrettable because therapy (exogenous steroids)  is   effective   and   easy  to   administer. Adrenal insufficiency may occur in a host of settings including tuberculosis (formerly the most common cause), autoimmune state, severe infections (classically, meningococcal septicemia), pituitary insufficiency, after burns, during anticoagulant therapy, and—most commonly today—aft€r interruption of chronically administered exogenous steroids. Although the adrenal gland is an occasion3l site for distant metastases, such as from lung or breast, it is rare for there to be enough destruction of the glands to produce clinical adrenal insufficiency Chronic adrenal insufficiency (classic Addison’s diease) should be recognizable preoperatively by the constellation of skin hyponatremia, and hyperkalemia. Death  may occur  within hours of surgery if a patient with Addison’s disease is operated on without cognizance of adreria! insufficiency and pretreatment with exogenous steroids. Patients who have adrenal insufficiency as a result of interruption of chronically administered exogenous steroids may not develop the classic electrolyte abnormalities until the preterminal period. Adrenal insufficiency may also develop insidiously in the postoperative period, progressing over a course of several days. This insidious course is seen when adrenal injury occurs in the perioperative period, as  would  be  the  case  with adrenal damage from hemorrhage into the  gland in a   patient  receiving  postoperative  anticoagulant PTT. therapy Measurement of blood corticosteroid levels, urinary corticosteroid secretion, urinary sodium levels, and response to exogenous steroids is helpful in establishing the diagnosis of adrenal insufficiency pigmentation, weakness, weight loss, hypotension, nausea, vomiting, abdominal pain, hypoglycemia,


Q. 9

In blunt trauma abdomen what should be the approach for doing laparotomy

 A

Depends on organ injured

 B

Always midline incision

 C

Always transverse

 D

Depends upon type of injury

Q. 9

In blunt trauma abdomen what should be the approach for doing laparotomy

 A

Depends on organ injured

 B

Always midline incision

 C

Always transverse

 D

Depends upon type of injury

Ans. B

Explanation:

Always rnidline incision [Ref: Schwartz 9/e p160 (8/e, p160)] Repeat from All India 07

All emergency abdominal explorations in adults are performed using a long midline incision because of its versatility. For children under the age of 6, a transverse incision may be advantageous.


Q. 10

A twenty years old woman has been brought to casualty with BP 70/40 mm Hg, pulse rate 120/ min. and a positive urine pregnancy test. She should be managed by :

 A

Immediate laparotomy

 B

Laparoscopy

 C

Culdocentesis

 D

Resuscitation and Medical management

Q. 10

A twenty years old woman has been brought to casualty with BP 70/40 mm Hg, pulse rate 120/ min. and a positive urine pregnancy test. She should be managed by :

 A

Immediate laparotomy

 B

Laparoscopy

 C

Culdocentesis

 D

Resuscitation and Medical management

Ans. A

Explanation:

Ans. is a i.e. Immediate laparotomy

Also Know :

Even in those cases where there is doubt of ruptured ectopic pregnancy – Laparotomy should be done to “open and see”

“Immediate laparotomy and clamping of the bleeding vessels may be the only means of saving the life of a moribund patient”.


Q. 11

A 70 kg, 34-yr old athlete is undergoing emergency laparotomy. Due to non-availability of vecuronium bromide, the surgery was conducted under intermittent doses of succinylcholine (total dose: 640 mg) After surgery, there were no respiratory movements and the patient was unable to move his limbs. What was the cause?

 A

Pseudocholinesterase deficiency causing prolonged action of succinylcholine

 B

Type II depolarizing block caused by succinylcholine

 C

Undiagnosed muscle dystrophy complicated by succinylcholine

 D

Fasciculations produced by succinylcholine

Q. 11

A 70 kg, 34-yr old athlete is undergoing emergency laparotomy. Due to non-availability of vecuronium bromide, the surgery was conducted under intermittent doses of succinylcholine (total dose: 640 mg) After surgery, there were no respiratory movements and the patient was unable to move his limbs. What was the cause?

 A

Pseudocholinesterase deficiency causing prolonged action of succinylcholine

 B

Type II depolarizing block caused by succinylcholine

 C

Undiagnosed muscle dystrophy complicated by succinylcholine

 D

Fasciculations produced by succinylcholine

Ans. B

Explanation:

The only depolarizing type of neuromuscular blocker in clinical use is succinylcholine (SCh).

Succinylcholine mimics acetylcholine in action and it causes muscle relaxation by causing persistent depolarization of motor end plate.
This is also known as phase I blockade.
Repeated doses or continuous infusion may cause phase II block.
Clinically relevant phase II block can occur with total succinylcholine doses as low as 4 mg/kg in some patients, with either repeat dosing or continuous infusions. Such block may be evident with tetanic stimulation in highly sensitive muscle groups, later respiratory muscles are involved.
Patients having abnormal pseudocholinesterase experiences prolonged paralysis after administration of succinylcholine.
 
Ref: Anaesthesia By M. Roy & E.Saha, 2008, Page 28; Surgery: Basic Science and Clinical Evidence By Jeffrey A. Norton, 2008, Page 369.

Q. 12

A patient with chronic kidney disease on dialysis is posted for emergency laparotomy. Which of the following anaesthetic agent is contraindicated in this patient?

 A

d-Tubocurarine

 B

Scoline

 C

Halothane

 D

Gallamine

Q. 12

A patient with chronic kidney disease on dialysis is posted for emergency laparotomy. Which of the following anaesthetic agent is contraindicated in this patient?

 A

d-Tubocurarine

 B

Scoline

 C

Halothane

 D

Gallamine

Ans. D

Explanation:

Gallamine is one of a series of synthetic substitutes for curare.

Gallamine has the most potent vagolytic properties of any relaxant, and it is entirely dependent on renal function for elimination.

In renal insufficiency the neuromuscular blockade that it causes is considerably prolonged and gallamine is contraindicated.

 
Ref: Butterworth IV J.F., Butterworth IV J.F., Mackey D.C., Wasnick J.D., Mackey D.C., Wasnick J.D. (2013). Chapter 11. Neuromuscular Blocking Agents. In J.F. Butterworth IV, J.F. Butterworth IV, D.C. Mackey, J.D. Wasnick, D.C. Mackey, J.D. Wasnick (Eds), Morgan & Mikhail’s Clinical Anesthesiology, 5e.

Q. 13

A case of blunt trauma is brought to the emergency, in a state of shock; he is not responding to IV crystalloids; next step in his management would be:

 A

Immediate laparotomy

 B

Blood transfusion

 C

Albumin transfusion

 D

Abdominal compression

Q. 13

A case of blunt trauma is brought to the emergency, in a state of shock; he is not responding to IV crystalloids; next step in his management would be:

 A

Immediate laparotomy

 B

Blood transfusion

 C

Albumin transfusion

 D

Abdominal compression

Ans. A

Explanation:

A patient not responding to fluids is likely to have a continuous source of bleeding.

An exploratory laparotomy to identify the source & appropriate management of the same, would be the best next step.
 
Ref: CSDT, 11th Edition, Pages 252, 249.

Q. 14

A patient with abdominal injury presents to the emergency department with signs of peritonitis and shock. His airway and breathing were secured and IV fluids were started with 2 large bore cannulas. The next line of management should be:

 A

FAST

 B

Exploratory Laparotomy under general anesthesia

 C

Insertion of abdominal drain followed by laparotomy

 D

Laproscopy

Q. 14

A patient with abdominal injury presents to the emergency department with signs of peritonitis and shock. His airway and breathing were secured and IV fluids were started with 2 large bore cannulas. The next line of management should be:

 A

FAST

 B

Exploratory Laparotomy under general anesthesia

 C

Insertion of abdominal drain followed by laparotomy

 D

Laproscopy

Ans. B

Explanation:

Patient with abdominal stab injury showing signs of shock and peritonitis require urgent exploratory laparotomy.
 
Ref: Textbook of orthopedics and trauma By GS Kulkarni, Page1331.

 


Q. 15

You are performing explorative laparotomy after a penetrating abdominal injury. The surgery is prolonged and you suspect heavy blood loss. Which of the following will give you the best understnding of the actual blood loss?

 A

Checking for pallor

 B

Volume in suction bottles & increase in weight of swabs

 C

Cardiac output by thermodilution method

 D

Transesophageal Doppler

Q. 15

You are performing explorative laparotomy after a penetrating abdominal injury. The surgery is prolonged and you suspect heavy blood loss. Which of the following will give you the best understnding of the actual blood loss?

 A

Checking for pallor

 B

Volume in suction bottles & increase in weight of swabs

 C

Cardiac output by thermodilution method

 D

Transesophageal Doppler

Ans. B

Explanation:

Here the Gravimetric method gives the best estimation of blood loss.

The weights of the swabs after use are subtracted from the dry weight of the swabs and this is added to the volume of blood collected in the suction bottles and/or drains.

Ref: Bailey and Love, 24th Edition, Page 61.


Q. 16

What should be the approach for doing laparotomy for intra-abdominal injuries?

 A

Depends on organ injured

 B

Always midline incision

 C

Always transverse

 D

Depends upon type of injury

Q. 16

What should be the approach for doing laparotomy for intra-abdominal injuries?

 A

Depends on organ injured

 B

Always midline incision

 C

Always transverse

 D

Depends upon type of injury

Ans. B

Explanation:

Laparotomy by midline incision is the “gold standard” therapy for intra-abdominal injuries.

It is definitive, rarely misses an injury, and allows for complete evaluation of the abdomen and retroperitoneum.

All patients with hypotension, abdominal wall disruption, or peritonitis need surgical exploration.

In addition, the presence of extraluminal, intra-abdominal, or retroperitoneal air on plain radiograph or CT should prompt surgical exploration.

Ref: Scalea T.M., Boswell S.A., Baron B.J., Ma O.J. (2011). Chapter 260. Abdominal Trauma. In J.E. Tintinalli, J.S. Stapczynski, D.M. Cline, O.J. Ma, R.K. Cydulka, G.D. Meckler (Eds), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e.


Q. 17

Prolonged postoperative ileus is best treated by?

 A

Long tube insertion

 B

Calcium pantothenate

 C

Laparotomy and exploration

 D

Peristaltic stimulants

Q. 17

Prolonged postoperative ileus is best treated by?

 A

Long tube insertion

 B

Calcium pantothenate

 C

Laparotomy and exploration

 D

Peristaltic stimulants

Ans. C

Explanation:

Most patients developed transient ileus after a major abdominal operation.

Most of these resolve within 3 to 5 days.

Condition like extensive operative manipulation, major small bowel injury, heavy narcotic use, intra abdominal infection and pancreatitis- can prolong the ileum to 5 to 7 days.

Ileus prolonged beyond this period is viewed with suspicion.
Management of postoperative ileus
  • The essence of treatment is prevention, with the use of nasogastric suction and restriction of oral intake until bowel sounds and passage of flatus return.
  • Electrolyte abnormality, if any is corrected.
  • A battery of laboratory tests are conducted to look for primary causes. which, if found is treated.
  • “If paralytic ileus is prolonged and threatens life, a laparotomy should be considered to exclude a hidden cause and facilitate bowel decompression”
Ref: Bailey & Love 25/e, Page 1201.

Q. 18

On her third day of hospitalization, a 70 yrs old woman who is being treated with antibiotics for acute cholecystitis develops increased pain and tenderness in the right upper quadrant with a palpable mass. Her temperature rises to 40°C (104°F) her blood pressure falls to 80/60 mmHg. Hematemesis, and melena ensue and petechiae are noted. Laboratory studies reveal thrombocytopenia, prolonged prothrombin time, and a decreased fibrinogen level. Which of the following is the most important step in the correction of this patient’s coagulopathy?

 A

Exploratory laparotomy

 B

Administration of heparin

 C

Administration of e-Aminocaproci acid

 D

Administration of fresh frozen plasma

Q. 18

On her third day of hospitalization, a 70 yrs old woman who is being treated with antibiotics for acute cholecystitis develops increased pain and tenderness in the right upper quadrant with a palpable mass. Her temperature rises to 40°C (104°F) her blood pressure falls to 80/60 mmHg. Hematemesis, and melena ensue and petechiae are noted. Laboratory studies reveal thrombocytopenia, prolonged prothrombin time, and a decreased fibrinogen level. Which of the following is the most important step in the correction of this patient’s coagulopathy?

 A

Exploratory laparotomy

 B

Administration of heparin

 C

Administration of e-Aminocaproci acid

 D

Administration of fresh frozen plasma

Ans. A

Explanation:

Patient in the question is showing features of disseminated intravascular coagulation secondary to sepsis caused by acute cholecystitis. Next best step in the management of patients coagulopathy, is to remove the foci of infection by doing an exploratory laparotomy.

The morbidity and mortality associated with DIC are primarily related to the underlying disease rather than the complications of the DIC. The control or elimination of the underlying cause should be the primary concern. Management of DIC involves, administration of fresh frozen plasma to replace the coagulation factors, cryoprecipitate to replace the low fibrinogen levels.

Ref: Harrison’s Internal Medicine, 18th Edition, Chapter 116


Q. 19

An ovarian cyst is detected in a pregnant woman, management is:

 A

Immediate removal by laprotomy

 B

Wait and watch

 C

Removal by laparotomy in second trimester

 D

Remove at time of cesarean section

Q. 19

An ovarian cyst is detected in a pregnant woman, management is:

 A

Immediate removal by laprotomy

 B

Wait and watch

 C

Removal by laparotomy in second trimester

 D

Remove at time of cesarean section

Ans. C

Explanation:

The principle is to remove the tumor once the diagnosis is made. The best time of elective operation is between 14th to 18th week, as the chance of abortion is less & access to pedicle is easy.
 
Ref: Art of Laparoscopic Surgery Textbook and Atlas (2 Vol) By Palanivelu, Page 144 ; Textbook of Obstetrics By D.C.Dutta, 5th Edition, Page 329

Q. 20

Laparotomy performed in a case of ovarian tumor revealed unilateral ovarian tumor with ascites positive for malignant cells and positive pelvic lymph nodes. All other structures were free of disease. What is stage of her disease?

 A

Stage II c.

 B

Stage III a.

 C

Stage III b.

 D

Stage III c.

Q. 20

Laparotomy performed in a case of ovarian tumor revealed unilateral ovarian tumor with ascites positive for malignant cells and positive pelvic lymph nodes. All other structures were free of disease. What is stage of her disease?

 A

Stage II c.

 B

Stage III a.

 C

Stage III b.

 D

Stage III c.

Ans. A

Explanation:

Since the patient has ovarian tumor with ascities positive for malignant cells and positive pelvic lymph nodes, she falls under FIGO staging, stage IIc.
 
Ref: Textbook of Gynecology By D C Dutta, 4th Edition, Page 346

Q. 21

A twenty years old woman is brought to casualty with BP 70/40 mmHg, pulse rate 120/min and a positive urine pregnancy test. She should be BEST managed by :

 A

Immediate laparotomy

 B

Laparoscopy

 C

Culdocentesis

 D

Resuscitation and Medical management

Q. 21

A twenty years old woman is brought to casualty with BP 70/40 mmHg, pulse rate 120/min and a positive urine pregnancy test. She should be BEST managed by :

 A

Immediate laparotomy

 B

Laparoscopy

 C

Culdocentesis

 D

Resuscitation and Medical management

Ans. A

Explanation:

This patient with a positive pregnancy test and hemodynamically unstable status would most likely have had a ruptured ectopic pregnancy.

In such situations emergency laparotomy should be done.

If the fallopian tube is healthy a salpingostomy should be done, while if it is damaged extensively complete or partial salpingectomy is recommended.

 If the patient is hemodynamically stable, the laparoscopic approach is usually preferred. 
 
Medical management with methotrexate is indicated in hemodynamically stable patients with who is compliant and has no medical contraindication to methotrexate.

Relative contraindications include a gestational sac larger than 3.5 cm, presence of fetal cardiac motion, or a β-hCG value higher than 15,000 mIU/mL.
 
Ref: CURRENT Diagnosis & Treatment: Surgery, 13e chapter 39.

Q. 22

Most common site for infra abdominal abscess following laparotomy is –

 A

Sub hepatic

 B

Subphrenic

 C

Pelvic

 D

Paracolic

Q. 22

Most common site for infra abdominal abscess following laparotomy is –

 A

Sub hepatic

 B

Subphrenic

 C

Pelvic

 D

Paracolic

Ans. A

Explanation:

Ans. is ‘a’ i.e., Sub hepatic 


Q. 23

A wide mouth meckels diverticulum is found. accidently on laparotomy. what will be t/t of choice‑

 A

Resection of diverticulum 

 B

Leave as such

 C

Ligate at base

 D

Resection withpart of ileum

Q. 23

A wide mouth meckels diverticulum is found. accidently on laparotomy. what will be t/t of choice‑

 A

Resection of diverticulum 

 B

Leave as such

 C

Ligate at base

 D

Resection withpart of ileum

Ans. B

Explanation:

Ans is ‘b’ ie leave it as such 

“A wide-mouthed, thin walled unattached diverticulum in an adult patient can probably quite safely be left alone.”

Maingot’s

  • Treatment
  • Any symptomatic Meckel’s diverticula is resected (Diverticulectomy)
  • There are two techniques for excision of the diverticulum

–  simple excision resection with the segment of ileum containing the diverticulum and then reanastomosis.

  • Resection of ileum with reanastomosis is reserved for patients with peptic ulceration in the ileal mucosa a gangrenous diverticulitis affecting the base of the diverticulum if the base of the diverticulum is inflamed or perforated in rare cases of malignant disease situated in Meckel’s diverticulum.
  • Management of asymptomatic Meckel’s diverticula found incidentally on laprotomy
  • Management is controversial and different books write differently.
  • According to Maingot’s

– a wide-mouthed, thin walled Meckel’s diverticulum without any attached band can be left.

– prophylactic diverticulectomy is done – if the diverticula has a narrow base if there is any palpable thickening or adhesions suggestive of ectopic tissue.

– if there is any attachment either by bands to the umbilicus or by a mesodiverticular vascular strand.


Q. 24

After Hemicolectomy, on the 6th post operative day pt. developed serous discharge from the wound. Following are to be done –

 A

Dressing of the wound only

 B

Start IVF

 C

Do urgent Laparotomy

 D

b and c

Q. 24

After Hemicolectomy, on the 6th post operative day pt. developed serous discharge from the wound. Following are to be done –

 A

Dressing of the wound only

 B

Start IVF

 C

Do urgent Laparotomy

 D

b and c

Ans. D

Explanation:

Ans: ‘b’ i.e. Start IVF; ‘c’ i.e. Do Urgent laprotomy 

  • This is a case of wound dehiscence (Burst abdomen)
  • Serous or serosanguinous discharge from the wound is the.first sign of dehiscence.Local Risk factors
  • Although wound dehiscence may occur at any time following wound closure, it is most commonly observed between the fifth and eigth postoperative day.
  • Wound dehiscence is partial or total disruption of any or all layers of the operative wound. Extrusion of abdominal viscera after rupture of all layers is known as evisceration
  • Factors predisposing wound dehiscence

1)       Inadequate closure-most imp.

2)       Increased intraabdominal pressure

3)       Deficient wound healing – d/t infections, seromas, hematomas or presence of drain.

  • Systemic Risk factors

–        Old age, obesity, systemic diseases (diabetes, uremia, jaundice, sepsis, cancer), immunosuppression increase the risk.

  • Management
  • For wound dehiscence without evisceration

prompt elective reclosure of wound.

  • For dehiscence with evisceration

wound is covered with moist towels with the pt. under general anaesthesia, any exposed bowel or omentum is rinsed with lactated Ringer’s solution containing antibiotics and then returned to the abdomen. the previous sutures are removed and the wound reclosed.


Q. 25

Most common indication for laparotomy in intestine T.B is –

 A

Peritonitis

 B

Intestinal obstruction

 C

Doubtful diagnosis

 D

Lower GI bleeding

Q. 25

Most common indication for laparotomy in intestine T.B is –

 A

Peritonitis

 B

Intestinal obstruction

 C

Doubtful diagnosis

 D

Lower GI bleeding

Ans. B

Explanation:

Ans. is ‘b’ i.e., Intestinal obstruction 


Q. 26

A case of blunt trauma is brought to the emergency, in a state of shock; he is not responding to IV crystalloids; next step in his management would be ‑

 A

Immediate laparotomy

 B

Blood transfusion

 C

Albumin transfusion

 D

Abdominal compression

Q. 26

A case of blunt trauma is brought to the emergency, in a state of shock; he is not responding to IV crystalloids; next step in his management would be ‑

 A

Immediate laparotomy

 B

Blood transfusion

 C

Albumin transfusion

 D

Abdominal compression

Ans. A

Explanation:

Ans. is ‘a’ i.e., Immediate laparotomy 

This patient is not responding to IV crystalloids is likely to have a continuous source of bleeding. His abdomen is evaluated by an ultrasound (if available in the emergency department) or by diagnostic peritoneal lavage (DPL), to rule out intrabdominal injuries as the source of blood loss & hypotension.

If ultrasound or DPL are positive, then immediate laparotomy is done.


Q. 27

Aims of abbreviated laparotomy

 A

Decreased chance of infection

 B

Early ambulation

 C

Early wound healing

 D

Hemostasis

Q. 27

Aims of abbreviated laparotomy

 A

Decreased chance of infection

 B

Early ambulation

 C

Early wound healing

 D

Hemostasis

Ans. D

Explanation:

Ans is ‘d’ (Hemostasis)

Damage control surgery

  • Is one of the major advances in surgical practice in the last 20 yrs in the management of trauma.
  • It defers the traditional surgical teaching that, the first chance of any surgical intervention is the best chance for any definitive repair or reconstruction with good result.
  • The conventional method of management of trauma patients was to bring the patients to the operating room after initial resuscitation, and to operate for complete repair of the injuries. Even patients with multiple complex injuries were operated aggressively over a prolonged period of time for definitive primary repair. Subsequently these patients were sent to the ICU where a good number of them died due to metabolic derangements.
  • Recognising that the cause of death in the major trauma victims was not due to failure of the initial surgery, but due to metabolic derangements or the physiological alterations in the body following severe exsanguinating polytrauma, a new method of management evolved k/a Damage Control Surgery or Staged Laprotomy.

In Damage control surgery, there are 3 phase:

1st Phase – only abbreviated laprotomy is done for life saving measure, then in

find phase – pt. is sent to ICU for the correction of metabolic disorders

III phase – following satisfactory correction of metabolic disorders, the patient is brought again to the operating room – this time for planned definitive surgery.

Abbreviated laparotomy

  • In abbreviated laparotomy life saving procedures are performed very rapidly.
  • Temporary quick-fix procedures are used limited to conspicuous lesions.
  • Control of hemorrhage is the top priority

by quickly clamping and ligating the major vessels.

– gauze packing for major liver or retroperitoneal injuries.

  • Contamination from damaged GI tract is managed quickly by ligating / stapling or simple running suture of the bowel.
  • No attempt is made for complex repair at this stage.
  • Tension free temporary closure of the abdomen is done with the help of towel clips (Silo or Bogota bags or vaccum pack) to avoid abdominal compartment syndrome

Q. 28

Abbreviated laparotomy done for:

 A

Coagulopathy

 B

Hypotension

 C

Early wound healing

 D

Early ambulation

Q. 28

Abbreviated laparotomy done for:

 A

Coagulopathy

 B

Hypotension

 C

Early wound healing

 D

Early ambulation

Ans. A

Explanation:

Ans is a i.e. Coagulopathy 

In critically injured patients, triad of hypothermia, acidosis, and coagulopathy is a vicious cycle that if uninterrupted, is rapidly fatal. Abbreviated laparotomy is utilized to quickly achieve hemostasis.

Patients are then transported to the surgical ICU for vigorous correction of metabolic derangements and coagulopathies.


Q. 29

Aim of damage control laparotomy are:

 A

Arrest hemorrhage

 B

Prevent Coagulopathy

 C

Control contamination

 D

All

Q. 29

Aim of damage control laparotomy are:

 A

Arrest hemorrhage

 B

Prevent Coagulopathy

 C

Control contamination

 D

All

Ans. D

Explanation:

Ans is A(Arrest hemorrhage), B(Prevent Coagulopathy) & C(Control contamination) 


Q. 30

An adult presented with hemetemesis and upper abdominal pain. Endoscopy revealed a growth at the pyloric antrum of the stomach. CT scan showed growth involving the pyloric antrum without infiltration or invasion into surrounding structures and no evidence of distant metastasis. At Laparotomy neoplastic growth was observed to involve the posterior wall of stomach and the pancreas extending 6cm up to tail of pancreas. What will be the most appropriate surgical management:

 A

Closure of the abdomen

 B

Antrectomy and vagotomy

 C

Partial Gastrectomy + Distal pancreatectomy

 D

Partial Gastrectomy + Distal pancreatectomy + splenectomy

Q. 30

An adult presented with hemetemesis and upper abdominal pain. Endoscopy revealed a growth at the pyloric antrum of the stomach. CT scan showed growth involving the pyloric antrum without infiltration or invasion into surrounding structures and no evidence of distant metastasis. At Laparotomy neoplastic growth was observed to involve the posterior wall of stomach and the pancreas extending 6cm up to tail of pancreas. What will be the most appropriate surgical management:

 A

Closure of the abdomen

 B

Antrectomy and vagotomy

 C

Partial Gastrectomy + Distal pancreatectomy

 D

Partial Gastrectomy + Distal pancreatectomy + splenectomy

Ans. C

Explanation:

Answer is C (Partial Gastrectomy + Distal pancreatectomy)

Partial gastrectomy with distal pancreatectomy should be adequate to manage this distal gastric tumor with direct invasion into the distal pancreas.

Tumors of the distal third / antrum of stomach require a subtotal gastrectomy (Partial gastrectomy). The distal pancreas should be removed as there is direct invasion of the distal pancreas. Splenectomy is not indicated as the tumor does not directly invade the spleen, and involvement of splenic hilar lymph nodes is unlikely as the tumor is located in the distal third of the stomach (and not in the proximal stomach). This patient is best managed by subtotal gastrectomy + lymphadenectomy + distal pancreatectomy.

Guidelines for management of Gastric carcinoma

  • Surgical resection remains the mainstay of treatment of gastric cancer either for cure or for palliation
  • The extent of gastric resection depends on the site of tumor in the stomach.

Tumors in the distal third or antrum of stomach require a subtotal gastrectomy (partial gastrectomy) while tumors of the middle or proximal third of the stomach require a total gastrectomy

Distal Third /Antrurn Gastric cancer                                        Middle Third /Proximal Gastric cancer

Subtotal Gastrectomv                                                        Total Gastrectomy

  • The extent of resection of adjacent structures (pancreas, spleen etc) depends on the location of primary tumor and local invasion

Pancreatic Resection

The distal pancreas should not be removed a part of a resection for a cancer of the distal two third of the stomach (unless there is direct invasion)

The distal pancreas should be removed only when there is direct invasion and still a chance of a curative procedure in patients with carcinoma of the proximal stomach

Splenic resection

Splenectomy is not indicated unless the tumor directly invades the spleen or involves the splenic hilar lymph nodes. Resection of spleen and splenic hilar lymph nodes may be considered in patients with tumors of the proximal stomach located in the greater curvature / posterior wall of the stomach close to the splenic hilum where the incidence of splenic hilar nodal involvement is likely to be high.


Q. 31

While doing suction & evacuation, there is perforation of an organ marked in the picture below. Next step is ? 

 A

Laparoscopy.

 B

Hysterotomy.

 C

Laparotomy.

 D

Hysterectomy.

Q. 31

While doing suction & evacuation, there is perforation of an organ marked in the picture below. Next step is ? 

 A

Laparoscopy.

 B

Hysterotomy.

 C

Laparotomy.

 D

Hysterectomy.

Ans. C

Explanation:

Organ marked in the picture above represents uterus.

Complication of suction & evacuation (S&E) and management

  • Diagnostic laparoscopy is often helpful to assess the size and site of perforation & the amount of haemorhhage.
  • If perforation has occurred prior to complete evacuation & if laparotomy is decided, then complete the evacuation either through the rent or anterior hysterotomy, if preservation of uterus is necessary.
  • Laparotomy is often needed to tackle the perforation. It also gives an opportunity to inspect intestine or omentum for evidence of injury
  • If perforation has occurred prior to complete evacuation & family is completed, then hysterectomy can be done.

Q. 32

A wide mouth structure as shown in the picture below is found accidently on laparotomy. What will be the t/t of choice ? 

 A

Resection of diverticulum.

 B

Leave as such.

 C

Ligate at base.

 D

Resection withpart of ileum.

Q. 32

A wide mouth structure as shown in the picture below is found accidently on laparotomy. What will be the t/t of choice ? 

 A

Resection of diverticulum.

 B

Leave as such.

 C

Ligate at base.

 D

Resection withpart of ileum.

Ans. B

Explanation:

The structure marked by an arrow in the picture above represents Meckel’s diverticulum.

“A wide-mouthed, thin walled unattached diverticulum in an adult patient can probably quite safely be left alone.”

– Maingot’s

  • Treatment
  • Any symptomatic Meckel’s diverticula is resected (Diverticulectomy)
  • There are two techniques for excision of the diverticulum

–  simple excision resection with the segment of ileum containing the diverticulum and then reanastomosis.

  • Resection of ileum with reanastomosis is reserved for patients with peptic ulceration in the ileal mucosa a gangrenous diverticulitis affecting the base of the diverticulum if the base of the diverticulum is inflamed or perforated in rare cases of malignant disease situated in Meckel’s diverticulum.
  • Management of asymptomatic Meckel’s diverticula found incidentally on laprotomy
  • Management is controversial and different books write differently.
  • According to Maingot’s

– a wide-mouthed, thin walled Meckel’s diverticulum without any attached band can be left.

– prophylactic diverticulectomy is done – if the diverticula has a narrow base if there is any palpable thickening or adhesions suggestive of ectopic tissue.

– if there is any attachment either by bands to the umbilicus or by a mesodiverticular vascular strand.


Q. 33

A 32-year old male with no past medical history is brought to the emergency department after being injured in a bomb blast. On examination he is suspected to have a splenic injury and is supposed to undergo an emergency laparotomy. Which of the following is the ideal anaesthetic agent of choice?

 A

Remifentan

 B

Morphine

 C

Etomidate

 D

Halothane

Q. 33

A 32-year old male with no past medical history is brought to the emergency department after being injured in a bomb blast. On examination he is suspected to have a splenic injury and is supposed to undergo an emergency laparotomy. Which of the following is the ideal anaesthetic agent of choice?

 A

Remifentan

 B

Morphine

 C

Etomidate

 D

Halothane

Ans. C

Explanation:

Ans. c. Etomidate



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