FLS Clip Application 2 — Questions and Answers
Question 1: A standard medium-large titanium clip is typically appropriate for structures with a diameter up to:
- 3 mm
- 5 mm
- 9 mm (Correct answer)
- 12 mm
Correct answer: 9 mm
Medium-large clips are designed for structures up to approximately 9 mm in diameter; structures larger than this require larger clips or an alternative occlusion method.
Question 2: When using a 10 mm clip applier, the surgeon notices the jaws cannot fully close around the cystic duct. What is the most appropriate next step?
- Apply additional clips side by side to complete occlusion
- Use electrocautery to coagulate the duct instead
- Dissect more tissue to thin the duct before re-applying (Correct answer)
- Convert to open surgery immediately
Correct answer: Dissect more tissue to thin the duct before re-applying
Additional dissection to remove pericholecystic fat from the cystic duct allows the clip to fully encircle and occlude it; applying clips on a thick structure risks incomplete closure.
Question 3: Which of the following best describes the 'lock-out' feature found on many laparoscopic clip appliers?
- Prevents firing when the battery is low
- Prevents the device from firing if the jaws are not fully closed around a structure
- Prevents accidental clip deployment when not in the operative field (Correct answer)
- Locks the clip in place after deployment to prevent migration
Correct answer: Prevents accidental clip deployment when not in the operative field
The lock-out mechanism prevents accidental firing of clips when the jaws are open and not positioned around a structure, improving safety during instrument manipulation.
Question 4: During laparoscopic cholecystectomy, a clip is inadvertently placed across what appears to be the common hepatic duct. What is the immediate recommended action?
- Remove the clip with the clip applier jaws and continue the case
- Leave the clip in place and proceed with cholecystectomy
- Immediately convert to open surgery for biliary reconstruction (Correct answer)
- Apply a second clip to reinforce and complete the transection
Correct answer: Immediately convert to open surgery for biliary reconstruction
Injury to the common hepatic duct requires immediate conversion to open surgery for proper biliary reconstruction; attempting laparoscopic correction risks further injury.
Question 5: What is the advantage of using polymer locking clips (e.g., Hem-o-lok) over standard titanium clips for laparoscopic procedures?
- They are MRI-compatible with zero artifact
- They provide a self-locking mechanism reducing risk of dislodgement (Correct answer)
- They are absorbed within 30 days eliminating long-term foreign body
- They require less dissection clearance around the vessel
Correct answer: They provide a self-locking mechanism reducing risk of dislodgement
Polymer locking clips feature a ratcheting mechanism that locks them in place once applied, significantly reducing the risk of accidental dislodgement compared to non-locking titanium clips.
Question 6: In the FLS box trainer, clip application tasks are designed to assess which fundamental laparoscopic skill?
- Depth perception and bimanual tissue manipulation in a 2D video environment (Correct answer)
- Speed of pneumoperitoneum establishment
- Ability to switch between energy devices during a procedure
- Trocar placement accuracy under direct vision
Correct answer: Depth perception and bimanual tissue manipulation in a 2D video environment
Clip application in the FLS trainer evaluates the surgeon's depth perception and bimanual coordination when working with 2D laparoscopic video, which are key skills tested by the FLS program.
Question 7: When applying clips to the cystic artery, which anatomical variant most increases the risk of an inadequate clip placement?
- A replaced right hepatic artery arising from the superior mesenteric artery
- A short cystic artery arising directly from the right hepatic artery (Correct answer)
- An accessory cystic artery supplying the gallbladder fundus
- A cystic artery arising from the gastroduodenal artery
Correct answer: A short cystic artery arising directly from the right hepatic artery
A short cystic artery leaves minimal length for clip placement between its origin and the gallbladder wall, increasing the risk of the clip slipping off or injuring the right hepatic artery.
FLS Clip Application 2
A standard medium-large titanium clip is typically appropriate for structures with a diameter up to: