FLS EXAM STUDY GUIDE
QUESTIONS WITH COMPLETE
SOLUTIONS
Upper Abdominal Laparoscopy - Position and equipment - Answer-Arms can be out on
arm boards
Reverse Trendelenberg position (need foot board and leg strap)
May need:
> to retract liver (retractor and holder)
> biopsy and hemostasis tools
> Ultrasound or C-arm
> Suturing capability
Diagnsotic laparoscopy for suspected pelvic pathology - Answer-Arms tucked
Trendelenberg position
Plan for retraction of uterus: uterine manipulator, laparoscopic retractor, suture
retraction to abdominal wall
Plan for biopsy (equipment, instruments, hemostasis, pathologist consultation)
Small intestine runs from the LUQ at the _____ to the RLQ at the _____ - Answer-
Ligament of treitz; ileocecal valve
Examination of the small intestine - Answer-Position 2 monitors - one near head, one
near feet (best monitor position are by the Lt shoulder and Rt hip)
Place ports along Lt abdomen if feasible
Keep instrument tips in field of view as much as possible
Use graspers designed for atraumatic handling
Avoid torquing bowel wall with graspers
Handle mesenteric fat rather than bowel wall when possible
Handle dilated bowel with extreme caution
Start at cecum and work proximally
Diagnostic laparoscopy for small bowel obstruction - Answer-Initial entry under direct
visualization
Begin examination of small bowel distantly (decompressed)
> start at the ileocecal valve with a relative collapsed bowel
Manipulate dilated small bowel with extreme caution
Perform instrument exchanges carefully due to decreased working space
,Diagnostic Laparoscopy for Retroperitoneal Structures ABOVE aortic bifurcation -
Position - Answer-Lateral position
Diagnostic Laparoscopy for Retroperitoneal Structures BELOW aortic bifurcation -
Position - Answer-Trendelenburg with or without lithotomy
What is the area for best placement of ports to view the kidneys and adrenal glands? -
Answer-Along the costal margin
Mention the biopsy methods used in laparoscopy - Answer-Peritoneal washing and
scrapings
FNA
Core needle biopsy (a form of incisional biopsy)
Incisional (wedge) biopsy
Excisional biopsy
FNA - Answer-20-22 gauge needle
Need sufficient needle length (eg. spinal needle)
Plunger with finger loops os helpful
Diagnostic Laparoscopy for Retroperitoneal Structures BELOW aortic bifurcation -
Position - Answer-Trendelenberg with or w/o lithotomy
Core needle biopsy - Answer-14-18 gauge needle
Most commonly used for biopsy of the liver
More at risk for bleeding
Biopsy forceps - Answer-Jaws have a cutting rim and are hollowed out in the center to
capture and prevent crushing the tissue sample
Incisional - larger lesions
Excisional - small lesions
Wedge biopsy - Answer-tissue sampling utilizing a scalpel, scissors or stapling device
Peritoneal washing - Answer-Should be obtain early in staging laparoscopy
infuse at least 100cc of 0.9NSS (unless abundant ascites present)
+/- mixed sample with a heparin solution for proper cytologic examination
Biopsy of peritoneal lesions - Answer-Small
Excisional biopsy of a single small lesion
> Biopsy forceps
> Grasper and scissors
Incisional biops of larger lesions
> Biopsy forceps
> Grasper and scissors
, Able to remove through 5 or 10 mm port
Lymph node biopsy - Answer-Excisional biopsy
Hemostasis
> Energy source - careful use during biopsy
> Topical hemostatic agent - useful after excision
Removal
> Smaller nodes - 10-12 mm port
> Larger nodes - specimen retrieval sac
Liver Biopsy - Parenchymal disease (cirrhosis) - Answer-Core needle biopsy
Wedge biopsy of edge of liver
Liver biopsy - Small surface lesions - Answer-Incisional or excisional biopsy
Core needle or wedge biopsy
Liver biopsy - Large surface lesions - Answer-Incisional biopsy, core needle or wedge
biopsy
Liver biopsy - Lession below the surface - Answer-FNA, or core needle biopsy
May need US to locate
Biopsy of the ovary - Answer-Oophorectomy - high suspicion for malignancy
Biopsy forceps - perform on the antemesenteric portion
Small wedge resection
In general, if an ovary is larger than 5 cm or has complex internal US characteristics,
biopsy should be by: - Answer-Oophorectomy
Which needle is safer for use in laparoscopic surgery taper or cutting needle? - Answer-
Taper needle (Smooth)
Needle shape - Answer-Straight, Partially straight, curved
Optimal port position for intracorporeal knot tying - Answer-At least 10 cm apart
(Surgeons elbows flexed at 90 degrees and adjacent to the surgeon's body)
Needle positioning - Answer-Pick up in the correct orientation
Pass needle back and forth rotating each pass
Fine adjustments by nudging needle and manipulating suture
What are the laparoscope diameters? - Answer-2-10mm
Which degree scope is best for a field in line with port? - Answer-0 degree
QUESTIONS WITH COMPLETE
SOLUTIONS
Upper Abdominal Laparoscopy - Position and equipment - Answer-Arms can be out on
arm boards
Reverse Trendelenberg position (need foot board and leg strap)
May need:
> to retract liver (retractor and holder)
> biopsy and hemostasis tools
> Ultrasound or C-arm
> Suturing capability
Diagnsotic laparoscopy for suspected pelvic pathology - Answer-Arms tucked
Trendelenberg position
Plan for retraction of uterus: uterine manipulator, laparoscopic retractor, suture
retraction to abdominal wall
Plan for biopsy (equipment, instruments, hemostasis, pathologist consultation)
Small intestine runs from the LUQ at the _____ to the RLQ at the _____ - Answer-
Ligament of treitz; ileocecal valve
Examination of the small intestine - Answer-Position 2 monitors - one near head, one
near feet (best monitor position are by the Lt shoulder and Rt hip)
Place ports along Lt abdomen if feasible
Keep instrument tips in field of view as much as possible
Use graspers designed for atraumatic handling
Avoid torquing bowel wall with graspers
Handle mesenteric fat rather than bowel wall when possible
Handle dilated bowel with extreme caution
Start at cecum and work proximally
Diagnostic laparoscopy for small bowel obstruction - Answer-Initial entry under direct
visualization
Begin examination of small bowel distantly (decompressed)
> start at the ileocecal valve with a relative collapsed bowel
Manipulate dilated small bowel with extreme caution
Perform instrument exchanges carefully due to decreased working space
,Diagnostic Laparoscopy for Retroperitoneal Structures ABOVE aortic bifurcation -
Position - Answer-Lateral position
Diagnostic Laparoscopy for Retroperitoneal Structures BELOW aortic bifurcation -
Position - Answer-Trendelenburg with or without lithotomy
What is the area for best placement of ports to view the kidneys and adrenal glands? -
Answer-Along the costal margin
Mention the biopsy methods used in laparoscopy - Answer-Peritoneal washing and
scrapings
FNA
Core needle biopsy (a form of incisional biopsy)
Incisional (wedge) biopsy
Excisional biopsy
FNA - Answer-20-22 gauge needle
Need sufficient needle length (eg. spinal needle)
Plunger with finger loops os helpful
Diagnostic Laparoscopy for Retroperitoneal Structures BELOW aortic bifurcation -
Position - Answer-Trendelenberg with or w/o lithotomy
Core needle biopsy - Answer-14-18 gauge needle
Most commonly used for biopsy of the liver
More at risk for bleeding
Biopsy forceps - Answer-Jaws have a cutting rim and are hollowed out in the center to
capture and prevent crushing the tissue sample
Incisional - larger lesions
Excisional - small lesions
Wedge biopsy - Answer-tissue sampling utilizing a scalpel, scissors or stapling device
Peritoneal washing - Answer-Should be obtain early in staging laparoscopy
infuse at least 100cc of 0.9NSS (unless abundant ascites present)
+/- mixed sample with a heparin solution for proper cytologic examination
Biopsy of peritoneal lesions - Answer-Small
Excisional biopsy of a single small lesion
> Biopsy forceps
> Grasper and scissors
Incisional biops of larger lesions
> Biopsy forceps
> Grasper and scissors
, Able to remove through 5 or 10 mm port
Lymph node biopsy - Answer-Excisional biopsy
Hemostasis
> Energy source - careful use during biopsy
> Topical hemostatic agent - useful after excision
Removal
> Smaller nodes - 10-12 mm port
> Larger nodes - specimen retrieval sac
Liver Biopsy - Parenchymal disease (cirrhosis) - Answer-Core needle biopsy
Wedge biopsy of edge of liver
Liver biopsy - Small surface lesions - Answer-Incisional or excisional biopsy
Core needle or wedge biopsy
Liver biopsy - Large surface lesions - Answer-Incisional biopsy, core needle or wedge
biopsy
Liver biopsy - Lession below the surface - Answer-FNA, or core needle biopsy
May need US to locate
Biopsy of the ovary - Answer-Oophorectomy - high suspicion for malignancy
Biopsy forceps - perform on the antemesenteric portion
Small wedge resection
In general, if an ovary is larger than 5 cm or has complex internal US characteristics,
biopsy should be by: - Answer-Oophorectomy
Which needle is safer for use in laparoscopic surgery taper or cutting needle? - Answer-
Taper needle (Smooth)
Needle shape - Answer-Straight, Partially straight, curved
Optimal port position for intracorporeal knot tying - Answer-At least 10 cm apart
(Surgeons elbows flexed at 90 degrees and adjacent to the surgeon's body)
Needle positioning - Answer-Pick up in the correct orientation
Pass needle back and forth rotating each pass
Fine adjustments by nudging needle and manipulating suture
What are the laparoscope diameters? - Answer-2-10mm
Which degree scope is best for a field in line with port? - Answer-0 degree
