CSFA Intraoperative Procedures and Techniques 5 — Questions and Answers
Question 1: During a cesarean section, the surgical first assistant is asked to apply fundal pressure to assist delivery of the fetal head. At what point in the procedure is this maneuver performed?
- After closure of the uterine incision
- After the uterine incision is made and the fetal head is being delivered (Correct answer)
- During the skin incision phase
- After delivery of the placenta
Correct answer: After the uterine incision is made and the fetal head is being delivered
Fundal pressure is applied after the uterine incision (hysterotomy) to assist the surgeon in delivering the fetal head through the uterine opening.
Question 2: The surgical first assistant notices the patient's urine output has dropped to less than 0.5 mL/kg/hr during a prolonged abdominal case. What is the most appropriate immediate action?
- Administer furosemide 40 mg IV immediately
- Alert the anesthesia team to assess volume status and perfusion (Correct answer)
- Clamp the Foley catheter to allow the bladder to fill
- Increase the patient's intraabdominal pressure to improve renal perfusion
Correct answer: Alert the anesthesia team to assess volume status and perfusion
Oliguria during surgery signals possible hypovolemia or inadequate renal perfusion and should be immediately communicated to anesthesia for assessment and volume optimization.
Question 3: During an anterior cervical discectomy and fusion (ACDF), which vessel is at greatest risk if retraction on the medial side is excessive?
- Internal jugular vein
- Esophageal artery
- Carotid artery (Correct answer)
- Vertebral artery
Correct answer: Carotid artery
The carotid artery lies just lateral to the surgical dissection plane in ACDF; excessive medial retraction or incorrect plane development can injure it.
Question 4: When closing a midline laparotomy incision using a running suture, what suture-to-wound length ratio is recommended to minimize dehiscence?
- 2:1
- 4:1 (Correct answer)
- 1:1
- 6:1
Correct answer: 4:1
A suture-to-wound length ratio of at least 4:1 is evidence-based and associated with the lowest rates of incisional hernia and wound dehiscence.
Question 5: During a laparoscopic Nissen fundoplication, the posterior vagus nerve must be identified and protected. Where is this nerve typically located?
- Along the anterior surface of the esophagus at the gastroesophageal junction
- Posterior to the esophagus within the esophageal mesentery (Correct answer)
- Embedded within the gastric wall near the cardia
- Running lateral to the left crus of the diaphragm
Correct answer: Posterior to the esophagus within the esophageal mesentery
The posterior vagus nerve runs along the posterior esophagus and must be preserved during fundoplication to prevent gastroparesis and GI dysfunction.
Question 6: When assisting during a modified radical mastectomy, the surgical first assistant helps define the axillary dissection boundaries. What is the superior border of the axillary dissection?
- Pectoralis minor muscle
- Axillary vein (Correct answer)
- Serratus anterior muscle
- Clavipectoral fascia
Correct answer: Axillary vein
The axillary vein defines the superior boundary of the axillary dissection; dissection above it risks injury to neurovascular structures of the arm.
Question 7: During a laparoscopic cholecystectomy, intraoperative cholangiography (IOC) is performed. What is the primary purpose of IOC during this procedure?
- To measure bile duct pressure before transection
- To identify common bile duct anatomy and detect unsuspected stones or ductal injuries (Correct answer)
- To confirm adequate hepatic blood flow postresection
- To document cystic duct patency for the pathology report
Correct answer: To identify common bile duct anatomy and detect unsuspected stones or ductal injuries
IOC delineates ductal anatomy in real time, helping prevent bile duct injuries and simultaneously identifying retained common duct stones.
CSFA Intraoperative Procedures and Techniques 5
During a cesarean section, the surgical first assistant is asked to apply fundal pressure to assist delivery of the fetal head.
At what point in the procedure is this maneuver performed?