.

• 1.
  

  a) T b) F c) F d) F e) F

Option (a) is the only true answer. This data was published by Professor Charles Chapron in a series of more than 29,000 surgeries.

• 2.
  

  a) F b) F c) T d) F e) F

On average, Palmer’s point is located 10 cm distance from the aorta, making it a good option to initiate pneumoperitoneum, especially in patients with previous midline incisions. This technique also allows the introduction of a 5mm camera in the LUQ (left upper quadrant) for intra-abdominal inspection and for safe entry of the remaining trocars, such as the umbilical trocar.

• 3.
  

  a) T b) F c) T d) F e) F

In a prospective observational study, Teoh et al (2005) evaluated all described tests (the double click, aspiration, hanging drop, and initial gas pressures measures), in 345 patients that underwent laparoscopic blind entry. Only initial gas pressures less than 10mmHg have a diagnostic value of adequate placement of the Veress needle.

• 4.
  

  a) T b) T c) F d) T e) T

Clearly laparoscopy can be used anatomically for all procedures except inguinal lymphadenectomy which has to be approached openly.

• 5.
  

  a) T b) T c) T d) T e) F

Laparoscopy has similar complication rates when compared to open surgery for all parameters except blood loss where it has been shown to reduce intra-operative blood loss.

• 6.
  

  a) T b) T c) F d) T e) T

All options except (c) improve the view and increase safety. Slow motion replay by definition is a post hoc review that can only be used for training subsequently, but cannot help at the time.

• 7.
  

  a) T b) T c) T d) F e) T

Rectal atony has not been reported following radical laparoscopic hysterectomy whereas all of the others have.

• 8.
  

  a) F b) F c) F d) T e) T

Veress needles should be avoided In situations where periumbilical adhesions are suspected, such as patients with previous surgeries with midline abdominal incisions. In these situations we may use the open technique (Hasson) or change to an alternate location (Palmer’s point). Bowel sutures should be done longitudinally in a manner so as not to reduce the bowel lumen. There is no evidence that mechanical bowel preparation should be done systematically. Some patients when exposed to antibiotics may develop C. difficile-associated disease (CDAD) ranging from mild watery diarrhea to life-threatening, transmural pan-colitis. There is evidence that prophylactic antibiotics in colorectal surgery may reduce surgical site infections.

• 9.
  

  a) F b) T c) T d) F e) F

Pregnancy rates are good after the shaving technique (above 50%). Segmental resection is associated with pregnancy rates of 40%. The double circular stapler (DCS) technique allows excision of larger nodules (up to 5cm) when compared with the traditional use of a single circular stapler. There are less early and late complications compared with segmental resection. Mobilization of the splenic flexure may be needed to reduce tension in the anastomosis and reduce dehiscence. Anastomotic stenosis may occur in up to 30% of cases and the use of a larger diameter circular stapler (33mm or 34mm) on colorectal anastomosis minimizes the risk of stenosis. Segmental resection is associated with earlier (dehiscence) and late complications (nerve damage) compared with conservative surgery.

• 10.
  

  a) F b) F c) T d) F e) T

The use of drains after colorectal surgery is controversial. Many randomized studies have demonstrated no advantages with their use. Anastomotic integrity could be checked during surgery by injecting air or liquid (usually methylene blue) into the rectum under pressure in a fluid-filled abdomen while the bowel is occluded proximal to the anastomosis. Air or contrast leak indicates inadequate anastomosis. Anastomoses lower than 5cm from the anal verge are at a high risk of dehiscence and ileostomy is an option to minimize this serious complication. Ileostomy is associated with less overall complications than colostomy in meta-analysis studies. Long procedures with the need for blood transfusion are associated with more bowel complications.

• 11.
  

  a) F b) T c) F d) T e) T

Although there are some benefits in supplemental oxygen in animals it is still a controversial issue in humans. Perioperative fluid restriction is associated with less anastomotic complications. Unfortunately the accuracy of imaging tests are not very good for detecting early anastomotic dehiscence. C-reactive protein rise, especially in the 4th postoperative day has a good predictive value for bowel complications. There is some evidences that fast track protocols after surgery are associated with a shorter hospital stay and less morbidity.

• 12.
  

  a) T b) F c) T d) F e) F

The expenditures for health care in Switzerland were rising from 8.8 % of the gross domestic product (GPD) in 1995 up to 10.9 % of the GDP in 2013. In the USA mean in-hospital costs of all patients without complications was US$ 27,946. The occurrence of Clavien-Dindo grade I complications creates significant additional costs of US$ 2793 per person. Costs for health care in Switzerland in 2013 were about US$69 billion and 28 percent of the total health care costs were generated by surgical departments.

• 13.
  

  a) T b) T c) F d) T e) T

The average intraoperative complication rate for hysteroscopy is 3.7 % and for laparoscopy is 2.8 %. The highest incidence of postoperative complication is infection. Diabetes Mellitus is shown to be a risk factor for postoperative detected organ damage. Intraoperative complications significantly increase the incidence of postoperative complications.

• 14.
  

  a) F b) T c) T d) F e) F

The most common intraoperative complication is intra-abdominal haemorrhage, not bowel injury. The second most common complication is bladder injury (0.17%). The most common intraoperative hysteroscopic complication is perforation of the uterus (1.79%). The most common postoperative hysteroscopic complication is infection (2.42%).

• 15.
  

  a) T b) T c) T d) F e) F

Operative Registers are a vital instrument to survey both complications and patient health care. Experiences from the NGER can indeed be transferred to other regional registers. The NGER has shown only an increase in postoperative wound infections and not in serious complications, in obese patients and is therefore not considered a contraindication to laparoscopy. Only 5 of 285 complications was due to equipment.

• 16.
  

  a) F b) F c) F d) T e) T

Fibroids are classified by their relationship with both the endometrium and the uterine serosa as this relates best to their likely clinical effects and how they are best treated.

• 17.
  

  a) F b) T c) T d) F e) F

VizAblate System® is a new device for the treatment of symptomatic myomas which allows transcervical fibroid thermal ablation under real-time sonography.

• 18.
  

  a) T b) T c) T d) T e) F

The barb allows maintenance of tension, makes laparoscopic suturing less tricky and does not need knot tying as the barb holds things in place. It is non-absorbable.

• 19.
  

  a) T b) T c) T d) T e) F

Morcellated surgical specimens can be removed vaginally, via a culdotomy in the posterior cul-de-sac, via mini-laparotomy as in a myomectomy or supracervical hysterectomy, or via the cervix using cervical coring techniques. Cervical removal of large specimens does require intraperitoneal morcellation by a power morcellator. As such, use of cervical morcellation may be limited in centres that do not perform power morcellation.

• 20.
  

  a) T b) T c) F d) T e) T

According to recommendations by the FDA described in the “FDA Safety Communication” from November 24, 2014, laparoscopic morcellation should be contraindicated in peri-menopausal women, post-menopausal women, women with tissue that is known or suspected to contain malignancy or women with specimens that are candidates for en-bloc removal. Selection (c), young women with fibroid greater than 6 cm, is false because the literature does not support a specific size fibroid and an increased risk of malignancy. Fibroid size was not mentioned in the FDA recommendations.

• 21.
  

  a) T b) F c) F d) F e) F

The bowel is the most common location of morcellation injuries with 31 cases documented in the MAUDE and MDR databases. Table 2 from the journal article “Laparoscopic morcellator-related complications” published in the Journal of Minimally Invasive Gynecology in 2014 displays the location and number of morcellator-related injury collected from 1992 to 2012 in the FDA operated Medical Device Reporting (MDR) and Manufacturer and User Facility Device Experience (MAUDE) databases. There were 31 bowel injuries, the majority of which were located in the large bowel. Of note, reporting is voluntary and as a result the MDR and MAUDE databases do not reflect all complications during that time period.

• 22.
  

  a) F b) F c) T d) F e) F

There is evidence presently that a minority of residents are comfortable with complex surgeries at the completion of their training. Residents will now look to specialized programs after training to reach proficiency as surgeons. Residents perform fewer surgeries compared to their predecessors as a result of decreased resident working hours. Residents are faced with decreased work hours and less case volumes. There is a paucity of standardized curricula to assist programs with simulation as an option for training.

• 23.
  

  a) T b) F c) F d) F e) F

Simulation leads to shorter learning curves for novices. Evidence shows that learners perform better in the operating room having been exposed to a simulation curriculum. There are low-cost simulation systems that do not require prohibitive costs and the simulated team-interactions should be an integral part of training. Simulation complements but does not replace the operating room experience. Operating room experience is required to collate and apply the learning from the simulation laboratory. There are both low fidelity (box trainer) and high fidelity (virtual reality) simulators available. There are different models for simulating minimally invasive gynaecology that involve both low and high fidelity simulators.

• 24.
  

  a) T b) T c) T d) T e) T

All have been shown to be true – they all well recognised facets of effective learning.

• 25.
  

  a) F b) F c) T d) F e) F

The generic error tool (GERT) is an objective assessment of surgical movement and steps during an operation. It is not used in an interactive way as it relies on video assessment. It does not provide an overall assessment but rather records error frequency. Using the tool while observing a video of the surgery will result in a feedback document that includes types of “errors” and gives objective data as to the frequency of these “errors” in a particular case. It is helpful in producing an objective marker of progress and it identifies the types of errors or patterns that should be included in the constructive feedback of a surgeon who is striving to improve. It identifies all errors, not only the ones that will lead to complications. The premise is that by decreasing a surgeon’s total error score, the risk of an error leading to a complication will be minimized. The global rating tools, such as OSATS, do not offer the detailed analysis of GERT but have the advantage of a quick gestalt opportunity for rating.

• 26.
  

  a) T b) F c) F d) F e) T

Face validity examines how closely the simulator resembles the real task. This can be assessed by various features, for example movement realism or how closely the console resembles the actual console. Construct validity has the ability to differentiate groups with different levels of competence. For example, a simulator with construct validity would be able to differentiate between a medical student and an expert. Content validity, examines whether the intended content domain is actually being measured by the device/exercise. Predictive validity examines the extent to which an assessment will predict future performance.

• 27.
  

  a) T b) F c) T d) T e) F

The dVSS simulator is the only simulator that has utilized the actual console. The Mimic dV-Trainer does not require an existing console. The RoSS simulator does use virtual reality to simulate an actual surgical experience from beginner to advanced, however it did not demonstrate construct validity. This means that it was not so useful in distinguishing between experts and novices. The RoSS simulator, however has demonstrated face and content validity in several studies.

• 28.
  

  a) F b) T c) T d) F e) T

While the purpose of proctoring is for the assessment and evaluation of a trainee’s skills, the purpose of a mentor is for educating the trainee and assisting in the trainee in the acquisition of new skills. Proctoring can serve medico-legal purposes by providing formal evaluation of a trainee’s skills for credentialing purposes. The mentoring console has two modes to facilitate collaboration. The ‘swap’ mode’ allows the mentor and trainee to operate simultaneously and affords the ability to swap control of each arm, so that at any instance, the mentor can transfer control of one or more of the robotic arms to the trainee and vice versa. In contrast, the ‘nudge mode’ allows both the mentor and trainee to control the same two robotic arm at the same time. This the trainee can feel the movements the mentor surgeon makes and can be “nudged” by the mentor surgeon.

• 29.
  

  a) T b) F c) T d) T e) T

The FSRS is designed for exclusive use on the RoSS virtual reality simulator, whereas the FRS and BSTC are not simulator-specific and can even be used on the robot itself. A unique feature of the European Association of Urology curriculum is that it includes an OR modular training program as both bedside assistant and console surgeon. Several studies have shown that both residents and program directors feel that there is a paucity of robotic surgical education in Obstetrical and Gynecological training programs.

• 30.
  

  a) T b) F c) F d) F e) F

Adelman et al reported an overall urinary tract injury rate of 0.23 % and a bladder and ureteric injury rate of 0.05 % and 0.12 % respectively for laparoscopic subtotal hysterectomy in a systematic review of 43357 cases. The risk of bladder lesions can be increased in patients with prior Caesarean sections and/or adhesions. The differences in the postoperative bleeding rate depend on surgical techniques, like the amputation level of the uterine body and the coagulation of the endocervix. It has been shown that the postoperative bleeding rate depends on the experience of the physician. The risk of trocar site hernia depends on the diameter of the used trocars. Trocar size larger than 10 mm is associated with an increased rate of hernia development. Therefore fascial closure is recommended in trocar size > 10 mm. Even when the morcellated uterine tissue is not malignant at the moment of morcellation, disseminated cells or fragments can be transformed as a long-term complication to pre-malignant or malignant lesions. Kill et al reported the possible progression of peritoneal implants to complex atypical endometrial hyperplasia after uterine morcellation. Ureteric injuries are correlated with higher postsurgical morbidity. Only 11.8 % of ureteric lesions are recognized during surgery. When recognition of the lesion is delayed, secondary surgery is required and fistulas can result.