Examiner:

• "Mr. Thompson is a 58-year-old male with a significant surgical history, including a colectomy for diverticulitis 10 years ago and an open cholecystectomy 15 years ago. He presents with symptoms of intermittent abdominal pain, bloating, and nausea. A recent CT scan shows a single transition point in the right lower quadrant, raising concern for a possible partial small bowel obstruction due to adhesions. He feels better with initial nasogastric tube decompression, but a small bowel follow-through does not show contrast passing the transition point. He has worsening abdominal pain. What would you do prior to surgery?"

Examinee:

• Given Mr. Thompson's significant surgical history and the findings on imaging, I would ensure that the patient is adequately resuscitated prior to surgery, with attention to fluid and electrolyte balance. I would correct any electrolyte abnormalities and ensure that he is NPO with continued nasogastric decompression. I would also review the CT images in detail to assess the extent of adhesions and the location of the transition point and identify a safe abdominal access point. Preoperatively, I would discuss the risks of surgery with the patient, particularly the potential for bowel injury and the possibility of converting to an open procedure if necessary."

Examiner:

• "How would you access the abdomen in this patient, considering his previous surgeries?"

Examinee:

• "Given his history of multiple previous abdominal surgeries, I would opt for an open Hassan technique to establish pneumoperitoneum, as this reduces the risk of bowel injury compared to a Veress needle technique. I would choose a location away from previous scars if possible, often in the left upper quadrant, to minimize the risk of entering into dense adhesions. Once the open access is achieved and pneumoperitoneum is established, I would carefully introduce the laparoscope and perform an initial survey of the abdominal cavity to assess for adhesions and other potential complications."

Examiner:

• "During insufflation, Mr. Thompson's blood pressure drops from 120/80 mmHg to 85/55 mmHg, and his heart rate increases to 120 bpm."

Examinee:

• "The hypotension and tachycardia could be due to the physiological effects of pneumoperitoneum, including decreased venous return and increased intra-abdominal pressure. My first step would be to decrease the insufflation pressure to see if this improves the patient's hemodynamics. I would also communicate with the anesthesiologist to assess the patient's overall status, including checking for other causes such as hypovolemia or vagal response. If the patient's blood pressure does not improve with these adjustments, I would consider aborting the laparoscopic procedure and converting to an open approach."

Examiner:

• "Lowering the insufflation pressure to 10 mmHg improves the patient’s blood pressure to 105/70 mmHg. Anesthesia boluses the patient and you are able to proceed with the surgery. What precautions would you take moving forward?" 

Examinee:

• "With the patient stabilized, I would proceed with the surgery cautiously. I would maintain a lower insufflation pressure throughout the procedure and monitor the patient's hemodynamics closely. I would also avoid positioning that could further compromise venous return. I would place two additional working ports under direct vision and run the bowel from the terminal ileum proximally to identify and lyse any adhesions causing the obstruction. My goal would be to identify and address the cause of the obstruction while minimizing further trauma to the abdominal contents." 

Examiner:

• "During the exploration, you find dense adhesions in the right lower quadrant tethering a loop of bowel to the abdominal wall and causing interloop adhesions. During lysis, you make a full thickness enterotomy to the bowel with the laparoscopic scissors."

Examinee:

• "Upon identifying the enterotomy, I would immediately assess the extent of the injury. I would assess the surrounding area for any other injuries try to contain any contamination or spillage. If the injury is small and the bowel is otherwise healthy, I would proceed with a primary repair since it was made with scissors. I would do this laparoscopically in two layers, an inner full thickness layer with 3-0 Vicryl sutures in a transverse fashion to avoid narrowing the lumen followed by an outer 3-0 Vicryl imbricating layer. If this would require converting to an open for better exposure and to ensure a water-tight repairs, I would not hesitate to do so.

Examiner:

• "You successfully repair the enterotomy with a laparoscopic approach. Would you have done something different if the injury was made with a thermal device?"

Examinee: 

• "If the injury had been made with a thermal device, my approach would be more cautious due to the risk of thermal spread, which can cause tissue necrosis beyond the immediate area of the injury. Thermal injuries are more prone to delayed perforation and poor healing, so I would be more inclined to convert to an open procedure to fully assess the extent of the injury and ensure that all compromised tissue is adequately excised. I would debride any tissue that appears nonviable or damaged by the thermal injury before performing the repair. If this would narrow the lumen, I would opt for a segmental small bowel resection with stapled repair instead. Postoperatively, I would maintain a high index of suspicion for potential complications such as delayed perforation, infection, or abscess formation."

Examiner:

• "Ms. Davis is a 45-year-old obese female who presents to the trauma bay after sustaining a stab wound to the left chest near the costal margin during an altercation. The wound is located just below the left nipple, near the eighth intercostal space. She is talking well and oriented but complains of some shortness of breath. Her breath sounds are difficult to hear due to her habitus, but they sound present bilaterally. Her vitals are HR 100, BP 140/80, RR 23, SpO2 95% on 2L. She is neurologically intact and has no other signs of injury on exam."

Examinee: 

• "Given Ms. Davis’s symptoms of shortness of breath and the location of the stab wound, I am concerned about the possibility of a pneumothorax, hemothorax, or other thoracic injury. Her obesity makes the physical exam more challenging, so I would prioritize obtaining a chest X-ray to evaluate the thoracic cavity and perform an EFAST. In the meantime, I would keep her on oxygen and closely monitor her vital signs. If the chest X-ray is delayed or if she shows any signs of tamponade physiology, I would performing an immediate left sided thoracostomy."

Examiner: 

• "The chest X-ray shows a moderate left pneumothorax and left chest wall subcutaneous emphysema. The EFAST shows no pericardial fluid, no intrabdominal fluid, but a barcode sign in the left hemithorax. What is your next step?"

Examinee: 

• "The chest X-ray showing a moderate left pneumothorax, along with subcutaneous emphysema and the barcode sign on EFAST, confirms a left-sided pneumothorax. My next step would be to perform a left-sided thoracostomy tube placement to evacuate the pneumothorax, re-expand the lung, and address the subcutaneous emphysema. After obtaining consent, prepping and draping the patient, and administering Ancef and local anesthesia, I would make an incision over the left 4th-5th intercostal space between the mid and anterior axillary lines, bluntly dissect down to the chest wall, enter the left thorax bluntly over the rib, and place the chest tube toward the posterior apex. After placing the chest tube, I would confirm proper placement and lung re-expansion with a repeat chest X-ray and continue to monitor her respiratory status closely."

Examiner: 

• "The thoracostomy tube is placed, and Ms. Davis’s symptoms improve. A repeat chest X-ray shows re-expansion of the lung. However, a follow-up CT scan shows a suspicious area in the left hemidiaphragm that may represent a diaphragmatic injury. How would you proceed?"

Examinee:

• "Given the suspicious finding on the CT scan of a potential diaphragmatic injury, I would recommend proceeding with a diagnostic laparoscopy to evaluate the diaphragm directly. Diaphragmatic injuries can be difficult to diagnose and may lead to significant complications if missed, such as herniation of abdominal contents into the thoracic cavity. Laparoscopy allows for a definitive diagnosis and, if an injury is found, it can be repaired at the same time. Before proceeding, I would ensure that Ms. Davis is hemodynamically stable and that her pneumothorax is well-managed with the thoracostomy tube in place." 

Examiner:

• "In the operating room, you perform a diagnostic laparoscopy and identify a 2cm tear in the left diaphragm with some omentum herniating through the defect."

Examinee:

• "Upon identifying the small diaphragmatic tear, I would carefully reduce the herniated omentum back into the abdominal cavity. I would then repair the diaphragmatic defect using non-absorbable sutures in an interrupted, ensuring the repair is tension-free and secure. If the tear is larger or if there is concern about the strength of the repair, I would reinforce it with a synthetic mesh. After completing the repair, I would re-inspect the area to confirm hemostasis and the integrity of the repair before concluding the procedure. As the patient already has a chest tube, I would not perform transdiaphragmatic suction of the capnothorax. I would perform a thorough examination of the rest of the abdomen to rule out additional injuries, with careful attention to the stomach, pancreatic tail, spleen, and colon." 

Examiner:

• "During your thorough examination of the abdomen after repairing the diaphragmatic tear, you find a small, hemostatic grade 1 laceration to the spleen and a parenchymal injury to the pancreatic tail that does not violate the duct."

Examinee:

• "For the small grade 1 laceration to the spleen, which is hemostatic, I would manage it conservatively as no additional surgical intervention is needed for a grade 1 laceration if it is hemostatic. I would place a piece of Surgicel Snow over it. Regarding the parenchymal injury to the pancreatic tail that does not involve the duct, I would first ensure that there is no active bleeding from the injury site. Since the duct is not involved, this injury can often be managed conservatively as well. I would place a drain near the pancreatic tail through a left sided stab incision or using one of my working ports to monitor for any potential postoperative pancreatic fluid leakage."

Examiner:

• "Postoperatively, how would you manage this patient and what would be your specific concerns related to the injuries you found?"

Examinee:

• "Postoperatively, I would wean the chest tube toward removal in a sequential fashion, removing it when the output is < 200 cc/day, there is no residual hemothorax, and there is no air leak. Regarding the splenic injury, I would perform serial hemoglobins to ensure stability. I would ensure DVT prophylaxis within 24 hours after a stable hemoglobin. Regarding the pancreatic tail injury, my main concern is a pancreatic tail leak. I would carefully monitor the patient's exam and white count and I would study the drain output on post op day 3 to compare the amylase to the serum level looking for a fistula. If one was identified, I would consult GI for an ERCP and sphincterotomy to diver the flow. If not, I would discontinue the drain."