MRCS Picture Questions

Bk. 3

Tjun Tang, Bandipalyam Vamana Rao Praveen

• Publisher: CRC Press
• Year: 2018
• ISBN:
  9781315343129
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This superb, full-colour, visual revision aid has been designed specifically to candidates of the Member of the Royal College of Surgeons (MRCS) examination. It is also an invaluable diagnostic aid for all medical students and trainees, especially those on surgical rotations. Questions are based on a single clinical picture with comprehensive answers overleaf. Topics covered by this volume include laparoscopic surgery, upper and lower GI endoscopy, colorectal surgery and urology.

Section 1

Laparoscopic surgery

Case 1

The following pictures demonstrate the initial approach to a laparoscopic operation.

Figure 1.1a

Figure 1.1b

Figure 1.1c

Questions

Q1 Which technique for access to create a pneumoperitoneum is shown in Figures 1.1a–c?

Q2 Which anatomical structures need to be identified when applying it?

Q3 What alternative technique was widely used before this access?

Answers

A1 The Hasson, or ‘modified’ Hasson technique.

A2 The umbilicus and its insertion into the linea alba. The incision is made at this point, and the peritoneum punctured under direct vision to gain intraperitoneal access. A blunt trocar is then inserted and the abdomen insufflated with CO₂ under direct vision.

A3 The Veress needle puncture. This is still used in some centres but concern has been raised over its technique of ‘blind’ puncture, which can result in increased risk of bowel or vascular trauma.

Case 2

Figure 1.2 shows part of a stack used in laparoscopic surgery, the ‘endoflator’. It is important to know how this equipment works.

Figure 1.2

Questions

Q1 Describe the function of each of the columns labelled A, B, C.

Q2 What does the display to the left of ‘A’ indicate?

Q3 What might cause the left-hand LED in ‘A’ to rise sharply during surgery?

Answers

A1 This unit controls CO₂ insufflation. ‘A’ indicates the pressure level within the abdomen and allows the constant pressure to be set at a particular limit. Here it is set at 12 mmHg (right-hand LED). The actual abdominal pressure is indicated by the left-hand LED, zero at present as the unit is disconnected. ‘B’ indicates gas flow rate, usually set at 6–10 Litres/minute. Once the abdomen has reached its preset pressure the flow rate falls to zero. When gas escapes, reducing the pressure, this is detected by the unit and the flow restarts. ‘C’ indicates the total amount of gas used.

A2 This shows how much gas remains in the cylinder, and turns red when it is running low.

A3 A sudden rise would be accompanied by an alarm signal, and indicates a sudden rise in the intra-abdominal pressure. A common cause of this is the patient beginning to wake up with the return of voluntary abdominal wall contraction (this is often an earlier ‘warning signal’ for the anaesthetist than the anaesthetic machine responses!). It may also happen with a mechanical block to the gas pipe (e.g. the tap is turned off).

Case 3

A diagnostic laparoscopy was undertaken for acute-onset right upper abdominal pain in a 17-year-old female patient. The ultrasound scan was normal.

Figure 1.3

Questions

Q1 Figure 1.3 shows the view towards the right lobe of the liver. What pathology is shown on the picture?

Q2 What underlying disease is likely to have caused it?

Q3 What risks are associated with this condition?

Q4 What is the appropriate management for this...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Foreword
• Preface
• List of contributors
• Acknowledgements
• Dedications
• Section 1: Laparoscopic surgery
• Section 2: Gl endoscopy
• Section 3: Colorectal surgery
• Section 4: Urology
• Section 5: Radiology for the surgical trainee
• Reference
• Index