CFA Surgical Procedures & Techniques 3 — Questions and Answers
Question 1: During a laparoscopic cholecystectomy, the critical view of safety (CVS) requires that the hepatocystic triangle be:
- Cleared of fat and fibrous tissue, with only two structures entering the gallbladder (Correct answer)
- Identified by intraoperative cholangiogram
- Confirmed by palpation of the cystic duct
- Visualized only after clip application
Correct answer: Cleared of fat and fibrous tissue, with only two structures entering the gallbladder
The CVS requires the hepatocystic triangle cleared of fat/fibrous tissue and only the cystic duct and cystic artery entering the gallbladder base.
Question 2: The Trendelenburg position during pelvic laparoscopic surgery places the patient:
- Head up, feet down at 15-30 degrees
- Head down, feet up at 15-30 degrees (Correct answer)
- Lateral decubitus with hip flexion
- Supine with table broken at the hip
Correct answer: Head down, feet up at 15-30 degrees
Trendelenburg (head-down tilt) causes bowel to fall toward the diaphragm by gravity, improving visualization of pelvic structures.
Question 3: When assisting with an open inguinal hernia repair (Lichtenstein), the mesh is secured to the:
- External oblique aponeurosis and inguinal ligament (Correct answer)
- Internal oblique muscle and transversalis fascia
- Cooper's ligament and pubic tubercle only
- Scarpa's fascia and external ring
Correct answer: External oblique aponeurosis and inguinal ligament
In the Lichtenstein tension-free repair, the mesh is sutured to the inguinal ligament inferiorly and the external oblique aponeurosis/conjoined tendon superiorly.
Question 4: During a thyroidectomy, the first assistant must help protect which nerve by avoiding excessive traction on the thyroid lobe?
- Hypoglossal nerve
- Recurrent laryngeal nerve (Correct answer)
- External branch of superior laryngeal nerve
- Phrenic nerve
Correct answer: Recurrent laryngeal nerve
The recurrent laryngeal nerve runs in the tracheoesophageal groove and is vulnerable to injury from excessive traction on the thyroid lobe, causing hoarseness or vocal cord paralysis.
Question 5: In a right hemicolectomy, the ileocolic vessels are divided near their origin from the:
- Inferior mesenteric artery
- Superior mesenteric artery (Correct answer)
- Celiac trunk
- Internal iliac artery
Correct answer: Superior mesenteric artery
The ileocolic vessels branch from the superior mesenteric artery (SMA) and are divided at or near their SMA origin during oncologic right hemicolectomy.
Question 6: When using the electrosurgical unit (ESU) to achieve hemostasis of a vessel, the first assistant should:
- Apply energy while the vessel is submerged in pooled blood
- Grasp the vessel with forceps and apply brief current away from adjacent tissue (Correct answer)
- Use cutting mode for vessels larger than 3mm
- Hold energy on continuously until charring is visible
Correct answer: Grasp the vessel with forceps and apply brief current away from adjacent tissue
Grasping the vessel with forceps to elevate it from surrounding tissue and applying brief coagulation current minimizes thermal spread and collateral damage.
Question 7: During a mastectomy, the level I axillary lymph nodes are located:
- Posterior to the pectoralis minor muscle
- Lateral and inferior to the pectoralis minor muscle (Correct answer)
- Medial to the pectoralis minor muscle
- Along the thoracodorsal bundle only
Correct answer: Lateral and inferior to the pectoralis minor muscle
Level I axillary nodes lie lateral and inferior to the lateral border of the pectoralis minor muscle and are the first tier dissected in axillary lymph node dissection.
CFA Surgical Procedures & Techniques 3
During a laparoscopic cholecystectomy, the critical view of safety (CVS) requires that the hepatocystic triangle be: