Question 1

A 48-year-old woman presents to the office complaining of intermittent right upper quadrant abdominal pain. She has had these symptoms for the past 6 weeks. She describes the pain as cramping, and she reports that the pain often occurs after eating. Ultrasonography reveals multiple stones located in the gallbladder and a dilated common bile duct.

Please choose the single most appropriate answer to the question

1. Low risk
   
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2. Moderate risk
   
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3. High risk
   
   This is correct.
   
   

   Objective: To know the predictors of choledocholithiasis

   
   

   Common bile duct stones may be discovered preoperatively, intraoperatively, or postoperatively. The surgeon's goal is to clear the ducts but to use the smallest number of procedures with the lowest risk of morbidity. Thus, before elective laparoscopic cholecystectomy, it is desirable to classify patients into one of three risk groups. High-risk patients are those who have clinical jaundice or cholangitis, visible choledocholithiasis, or a dilated common bile duct on ultrasonography.
   
   

   
   
   
4. Risk is unknown at this time
   
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Question 2

A 42-year-old man is scheduled to undergo laparoscopic cholecystectomy for cholelithiasis and recurrent cholecystitis. He has a long midline scar extending from just below the umbilicus to his xiphoid process. The scar is the result of an open splenectomy that he underwent for traumatic splenic rupture at 12 years of age. It impossible to avoid the scar, and there is concern about initial trocar placement.

Please choose the single most appropriate answer to the question

1. Extend the vertical incision with careful peritoneal dissection
   
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2. Insert the initial trocar high in the epigastrum
   
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3. Insert the initial trocar in the right anterior axillary line
   
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4. All of the above
   
   This is correct.
   
   

   Objective: To understand the placement of trocars for laparoscopic cholecystectomy

   
   

   Patients who have previously undergone abdominal surgery may have adhesions, both to the undersurface of the abdominal wall and intra-abdominally. Scars from previous operations may affect insertion of the initial trocar, depending on its orientation and location. If there is a long midline scar that is impossible to avoid, careful dissection of the peritoneum through a longer vertical incision usually affords safe access to the peritoneum. Other alternatives are to insert the initial trocar high in the epigastrum or in the right anterior axillary line, where bowel adhesions are less common.
   
   

   
   
   

Question 3

Yesterday, a 38-year-old woman underwent a laparoscopic cholecystectomy for cholelithiasis and was discharged home 8 hours after surgery. She returns this morning complaining of worsening abdominal pain. The oral narcotics that the patient was prescribed are ineffective in controlling the pain. The patient's temperature is 101#x00B0 F (38.3#x00B0 C). Laboratory studies reveal an elevated white blood cell count. Abdominal ultrasonography shows a large subhepatic fluid collection. The fluid is percutaneously aspirated and reveals enteric contents.

Please choose the single most appropriate answer to the question

1. Immediate laparotomy
   
   This is correct.
   
   

   Objective: To understand the postoperative complications of laparoscopic cholecystectomy

   
   

   If a patient complains of a great deal of abdominal pain that necessitates systemic narcotics, an intra-abdominal complication may have occurred. Blood should be drawn to determine the white blood cell count, the hemoglobin concentration, and the serum amylase level and to assess liver function. Abdominal ultrasonography may be helpful in diagnosing dilated intrahepatic ducts and subhepatic fluid collections. When a significant fluid collection is seen, it should be aspirated percutaneously under ultrasonographic guidance. If the fluid is enteric contents, immediate laparotomy is indicated.
   
   

   
   
   
2. Observation in the hospital until pain improves
   
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3. I.V. antibiotics and close observation
   
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4. None of the above
   
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Question 4

A 48-year-old woman presents for evaluation of abdominal pain. On the basis of routine ultrasound, a diagnosis of cholelithiasis is made. A routine laparoscopic cholecystectomy is scheduled for next week.

Please choose the single most appropriate answer to the question

1. Female sex
   
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2. Age less than 65 years
   
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3. History of acute cholecystitis
   
   This is correct.
   
   

   Objective: To know the factors that increase the probability of conversion to laparotomy

   
   

   Factors found to be predictive of an increased probability of conversion to laparotomy include acute cholecystitis, either at the time of surgery or at any point in the past; age greater than 65 years; male sex; and thickening of the gallbladder wall to more than 3 mm as measured by ultrasonography. Other factors more variably associated with an increased likelihood of conversion are obesity, previous upper abdominal operations, multiple gallbladder attacks over a long period, and severe pancreatitis.
   
   

   
   
   
4. All of the above
   
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