CSFA Intraoperative Surgical Procedures 3 — Questions and Answers
Question 1: During a thoracotomy, the surgical first assistant is asked to place a rib retractor. After inserting the retractor, how should spreading be performed?
- Spread rapidly to maximum width to reduce operative time
- Spread slowly and incrementally to minimize rib fracture (Correct answer)
- Spread only after packing the lung with dry sponges
- Place the retractor without spreading until the surgeon requests
Correct answer: Spread slowly and incrementally to minimize rib fracture
Gradual incremental spreading reduces the risk of rib fracture and neurovascular injury between intercostal spaces.
Question 2: Which knot is most appropriate when tying a deep pelvic suture with limited visibility and restricted hand movement?
- Square knot thrown by hand
- Surgeon's knot
- Instrument tie (Correct answer)
- Granny knot
Correct answer: Instrument tie
An instrument tie allows precise knot placement in deep, restricted spaces where hand tying is impractical.
Question 3: In a Whipple procedure (pancreaticoduodenectomy), which anastomosis is typically performed first?
- Hepaticojejunostomy
- Gastrojejunostomy
- Pancreaticojejunostomy (Correct answer)
- Choledochojejunostomy
Correct answer: Pancreaticojejunostomy
The pancreaticojejunostomy is technically the most challenging and is typically constructed first when the field is least fatigued.
Question 4: A surgeon requests 'figure-of-eight' sutures for fascial closure. The surgical first assistant should pass:
- Two separate simple interrupted sutures
- A single suture passed in a crossing pattern through tissue on each side creating an X configuration (Correct answer)
- A running locking suture
- A horizontal mattress suture
Correct answer: A single suture passed in a crossing pattern through tissue on each side creating an X configuration
A figure-of-eight suture passes through tissue twice in a crossing pattern, distributing tension and providing secure fascial closure.
Question 5: During a thyroidectomy, inadvertent injury to which structure would most likely result in immediate hoarseness?
- External branch of the superior laryngeal nerve
- Recurrent laryngeal nerve (Correct answer)
- Ansa cervicalis
- Phrenic nerve
Correct answer: Recurrent laryngeal nerve
The recurrent laryngeal nerve innervates the intrinsic laryngeal muscles responsible for vocal cord movement; injury causes immediate hoarseness.
Question 6: When assisting with a laparotomy in a patient with a history of multiple prior abdominal surgeries, the surgical first assistant should anticipate:
- Absence of adhesions
- Dense adhesions requiring careful lysis before proceeding (Correct answer)
- Larger operating space due to prior stretching
- Faster entry due to tissue thinning
Correct answer: Dense adhesions requiring careful lysis before proceeding
Prior abdominal surgeries reliably result in adhesion formation, which must be carefully lysed to prevent enterotomy.
Question 7: The surgical first assistant is asked to irrigate the peritoneal cavity at the end of a bowel resection. Which irrigant is most appropriate?
- Hydrogen peroxide solution
- Warm normal saline or Ringer's lactate (Correct answer)
- Povidone-iodine full strength
- Tap water
Correct answer: Warm normal saline or Ringer's lactate
Warm isotonic saline or Ringer's lactate effectively dilutes contaminants without damaging peritoneal tissue.
CSFA Intraoperative Surgical Procedures 3
During a thoracotomy, the surgical first assistant is asked to place a rib retractor.
After inserting the retractor, how should spreading be performed?