Deck 3: Surgery of the Liver, Biliary Tract, Pancreas and Spleen

Question 1

The donor liver OR is prepared for an open laparotomy procedure with basic laparotomy and vascular instruments and accessories. A second sterile instrument table is set up to receive and prepare the procured liver. Select the additional instruments and accessories needed on the donor organ preparation table.

A)vascular instruments, silk sutures and ties, sterile ice, flushing solution, and slush machine.
B)flushing solution, ice chest, sterile ice, powered sternal saw, and long Kocher clamps.
C)culture tubes, Wisconsin University forceps, Deaver retractors, and slush machine.
D)toothed forceps, vessel loops, two sterile plastic draw-string bags, and flushing solution.

Answer 1

A
The donor OR is prepared for a major laparotomy procedure. Basic instrumentation and equipment includes a basic laparotomy set, cardiovascular instruments, power sternal saw, and nephrectomy instruments. A sterile, draped, medium-size instrument table is needed for preparation of the liver away from the main sterile field and instrument tables. The procurement team provides special Collins solution for flushing the organs, sterile plastic containers and ice chests for organs, and in situ flush tubing. The liver is generally placed in two plastic Lahey bags immediately after procurement.

Question 2

Matthew Ryan, a 9-year-old boy, is admitted to the emergency department for a sledding accident, when he lost control of his sled and crashed into a tree. He is pale and in pain; his abdomen is tender and firm to palpation. The CT scan suggests rupture of the spleen with internal bleeding. Matthew's scheduled surgery will most probably be a(n):

A)laparoscopic splenic resection with sutured mesh overlay.
B)open splenic lobectomy with vascular ligation.
C)open total splenectomy.
D)open splenic repair with sutured anastomosis and argon plasma coagulation vessel sealing.

Answer 2

C
Splenectomy is removal of the spleen. It is performed for multiple reasons, including trauma to the spleen. Contraindications to laparoscopic splenectomy include severe portal hypertension, uncorrectable coagulopathy, severe ascites, extreme splenomegaly, extensive adhesions, and most traumatic injuries to the spleen. For these patients, an open approach is indicated.

Question 3

An example of a potential risk associated with pneumoperitoneum would be:

A)tachycardia caused by peritoneal irritation from the CO2.
B)CO2 absorption into the peritoneal capillaries, causing decreased oxygen saturation.
C)bradycardia from CO2 pressure lower than 15 mm Hg.
D)gas embolus into an exposed blood vessel during the procedure.

Answer 3

D
CO₂ is the gas of choice for pneumoperitoneum. The perioperative nurse should set the insufflation unit to a maximum pressure of 15 mm Hg. Pressure higher than 15 mm Hg may result in bradycardia or a change in blood pressure, or may force a gas embolus into an exposed blood vessel during the operative procedure.

Question 4

Open common bile duct (CBD) exploration may be indicated in some cases where:

A)the patient has undergone prior biliary surgery.
B)a positive cholangiogram shows a CBD obstruction during an open cholecystectomy.
C)laparoscopy technology is not available.
D)All of the options are correct.

Question 5

The head of the pancreas is fixed to the:

A)spleen.
B)duodenum.
C)stomach.
D)biliary tree

Question 6

Jan Stuyvesant, a surgical technologist, was the scrub person during a robotic-assisted laparoscopic cholecystectomy. She locked the robotic endoscissor into the adaptor on the robotic arm and positioned the tip end into the trocar port in order for the surgeon to dissect the cystic duct and artery, while the surgical assistant placed the clips on the cystic duct and artery. As she reached across the sterile field to insert the cholangiocatheter through the port, the anesthesia provider accidentally made contact with the distal end of the catheter as he stood up to reach the monitor controls. The contaminated end of the catheter touched the endoscopic clip applier, the endoscissor connector that the surgeon was using, the glove of the assistant, and Jan's gown sleeve. The surgeon ordered everyone to change their gown and gloves and covered the port area with a sterile towel. What was the rationale for the surgeon to continue to dissect and not change his attire?

A)The tip of the dissector that was in the patient's abdomen was not contaminated.
B)The surgeon planned to remove the dissector after he finished dissecting and then dispose it.
C)The surgeon's gown was not touched, just the dissector connection to the robotic arm.
D)The surgeon was not in contact with the sterile field because he worked from the robotic console.

Question 7

Joanne Grizwald, a 24-year-old woman with type 1 diabetes who is in end-stage kidney failure, is scheduled for a combined kidney-pancreas transplant. She is relatively healthy and at normal weight for her height in spite of her disease process. Her bleeding time and coagulation parameters are within normal limits. The circulating nurse has set up the autotransfusion system, verified Joanne's blood type, and crossmatched blood availability. The scrub person, while organizing the sterile back table, identified several instruments that she will not need. She organizes those instruments on the most distant part of the back table. What instruments is the scrub person unlikely to need during this procedure?

A)Based on Joanne's coagulation status, excess bleeding is not expected to be an issue.
B)Hemostasis will be achieved by the use of microfibrillar collagen agents that do not leave electrosurgical eschar (burned tissue) on the bleeding surfaces, thereby reducing the chance of infection.
C)Any excess bleeding will be removed and returned to the patient through the autotransfusion system.
D)The transplant procedure is an open approach and laparoscopic instruments (the insulated electrosurgical-adapted scissors, graspers, and the endoscopic suction tips) are not needed.

Question 8

The functional units of the liver are the lobules. The functional cells of the liver are the ______________ and they manufacture _______________.

A)Kupffer cells; phagocytes
B)sinusoid cells; lymphocytes
C)hepatocytes; bile
D)portal triad cells; ductal epithelium

Question 9

The liver is essential in the metabolism of carbohydrates, proteins, and fats, generating nutrient stores of which substance that supplies energy sources to the brain and body?

A)Carbohydrate glucose substrate
B)Glycogen
C)Serum glucosamine
D)Bile salts

Question 10

While the pancreas' function is carbohydrate metabolism with the production of insulin and digestive enzymes, the spleen's function is primarily ___________ with the production of _______________.

A)immunologic; leukocytes
B)metabolic; granulocytes
C)anabolic; plasma cells
D)as a blood reservoir; phagocytes

Question 11

The liver, pancreas, and spleen share many similarities. Select the statement about these organs that is true.

A)All three are solid organs and very vascular.
B)All three are metabolic organs.
C)All three organs have terminal attachments to the duodenum.
D)All of the options are false.

Question 12

The recipient liver OR is arranged for a major laparotomy and vascular procedure with customized instruments, supplies, and sutures according to the transplant surgeon's preference. In addition to the general patient care accessories, equipment, and supplies needed for any large surgery, also included are intraoperative laboratory testing and an autotransfusion system. Describe the boundaries of the surgical skin prep for the patient about to receive a liver transplant.

A)From neck to midthigh; midaxillary line to midaxillary line
B)From nipple line to pubis; bedline to bedline
C)From the neck to midthigh; bedline to bedline
D)From nipple line to midthigh; midaxillary line on the patient's left side, and bedline on the right

Question 13

An example of an indication for liver transplantation would be:

A)end-stage liver disease resulting from advanced hepatic cancer with metastasis.
B)acute fulminant biliary disease of unknown origin.
C)infection caused by untreated cystic anomalies.
D)primary hepatic cancer.

Question 14

The Whipple procedure is the removal of the head of the pancreas, the entire duodenum, a portion of the jejunum, the distal third of the stomach, and the ____________ as a surgical treatment for____________.

A)left lobe of the liver; metastatic hepatocytoma
B)distal segment of the spleen; pancreatic metastasis
C)inferior margin of the ligament of Treitz; pancreatic cancer
D)lower half of the common bile duct; pancreatic cancer

Question 15

What technologic characteristic of robotic surgery provides a superior indication for robotic-assisted laparoscopic cholecystectomy?

A)The surgeon controls two instruments plus a camera while an assistant suctions and retracts.
B)Bladeless robotic trocars minimize entry injury and inadvertent hemorrhage.
C)The magnified three-dimensional picture may reduce bile duct injuries during dissection.
D)Robotic stapler and suture devices promote intracorporeal anastomotic techniques.

Question 16

The biliary system (also called the biliary tree) drains bile from the gallbladder to the ampulla of Vater. The primary function of the gallbladder is to:

A)manufacture bile.
B)convert bile salts into bile enzymes.
C)store and concentrate bile.
D)contract to secrete bile into the hepatic duct.