AGES Exam MCQ PDF - Anatomy

**Add Headings (Format \> Paragraph styles) and they will appear in your table of contents.** **AGES Exam MCQ by topic** **Anatomy** 1. **With regard to ovarian blood supply, which is true?** a. b. c. d. Answer: A *Becker 2017 ESHRE Recommendations for the surgical treatment of endometri...

**Add Headings (Format \> Paragraph styles) and they will appear in your table of contents.** **AGES Exam MCQ by topic** **Anatomy** 1. **With regard to ovarian blood supply, which is true?** a. b. c. d. Answer: A *Becker 2017 ESHRE Recommendations for the surgical treatment of endometriosis -- part 1: ovarian endometrioma* - - - - 2. **Long stem regarding performing a BSO on a patient with BRCA mutation. Ovary is densely adhered to pelvic side wall. What is the best way to excise the adnexa in this case?** a. b. c. d. Answer: A 3. **Regarding the ureters, which is incorrect?** a. The line of projection of the ureter on a radiograph is medial to the tips of the transverse processes of the lumbar vertebrae and crosses the pelvic brim at the sacroiliac joint b. They exhibit peristaltic activity when stimulated c. They are lined by transitional epithelium with a thick muscularis mucosae d. They are supplied with sympathetic fibres from T11-L2 e. They are crossed superficially by the gonadal vessels Answer: B - - - - - - - - 4. **Anatomic knowledge and ability to identify or dissect the ureter once it enters the pelvic cavity is important to reduce the risk of ureteric injury in gynaecological procedures. To best avoid ureteric injury, which of following statement is *incorrect*?** a. Routine placement of ureteric stent is the safest way to protect the ureter at the start of any difficult gynaecological procedure b. Routinely identify the path of the ureter through the pelvis, in particular, all the regions where it is susceptible to injury c. Ensure the ureter is seen, or if required, dissected free \> 1 cm away from the uterine vessel before ligation of this vessel d. The bladder should be dissected free of cervix and the ureter identified before ligation of uterine vessels e. Take appropriate steps such as injection of indigo-carmine dye, cystoscopy and placement of ureteric stent to check ureteric integrity after controlling troublesome vaginal angle bleeding that requires suture or electro-diathermy after completion of hysterectomy Answer: A 5. **A midline abdominal incision below the umbilicus passes through all of the following *except for*:** a. b. c. d. e. Answer: A Midline laparotomy below umbilicus passes through: skin, subcutaneous fat (Camper's fascia), membranous fascia (Scarpa's fascia), linea alba, transversalis fascia, pre-peritoneal fat, peritoneum, abdominal cavity 6. **Regarding the anterior abdominal wall, which of the following is true:** a. b. c. d. e. Answer: A - - - - - - - - - 7. **Knowledge of abdominal and pelvic vasculature is important in avoiding vascular injury related to trocar placement in the abdomen. Which of the following statement is *correct* in avoiding or treating vascular injury during laparoscopy?** a. b. c. d. e. Answer: E - - - - 8. **Which of the following statements is *incorrect*?** a. b. c. d. e. Answer: D - - - - - - - - - - - - - - - - - - 9. **The abdominal aorta:** a. Passes into the abdomen behind the diaphragm at the level of the 10^th^ thoracic vertebra b. Bifurcates at the level of the body of the 2^nd^ lumbar vertebra c. Has a surface marking for its bifurcation as 2cm below and to the right of the umbilicus d. Gives rise to the coeliac artery at the level of the body of the 10^th^ thoracic vertebra e. Has the renal arteries arising at the level of the body of the 1^st^ lumbar vertebrae Answer: E Abdominal aorta: - - - - - - - - - 10. **Which is true regarding the inferior mesenteric artery?** a. Accompanies inferior mesenteric vein b. Gives rise to sigmoid artery before crossing the pelvic brim c. Becomes the inferior rectal artery d. Arises at L2 Answer: A IMA - - - - - - - - - - - 11. **Anterior relations to the common iliac arteries include all except:** a. Ureter b. Sympathetic trunk c. Peritoneum d. Superior rectal artery e. Superior hypogastric plexus Answer: B **Sympathetic trunk:** - - - - - **Superior rectal artery:** - - **Superior hypogastric plexus:** - - - - - 12. **The anterior division of the internal iliac artery has the following branches except:** a. Obturator b. Internal pudendal c. Inferior gluteal d. Inferior epigastric e. Middle rectal Answer: D **Internal iliac artery:** - - - - - - - - - - - - - - - **Branches of external iliac artery:** - - - 13. **The posterior division of the internal iliac artery has the following branches:** a. Iliolumbar b. Inferior epigastric c. Internal pudendal d. Inferior gluteal e. Lateral sacral Answer: A and E 14. **Branches of the sacral plexus include all except:** a. Nerves to piriformis b. Pelvic splanchnic nerve c. Obturator nerve d. Pudendal nerve e. Posterior femoral cutaneous nerve Answer: C **Sacral plexus:** - - - - - - - - - - 15. **The pelvic splanchnic nerve contains:** a. b. c. d. Answer: B **Pelvic splanchnic nerves:** are the pre-ganglionic parasympathetic nerve fibres that arise from the S2-4 nerve roots of the sacral plexus and they form the parasympathetic portion of the autonomic nervous system in the pelvis. 16. **In order to minimize the risk of neurologic injury in gynaecological surgery, knowledge of anatomy of abdominal and pelvic wall innervation is important. Which of the following statements is *incorrect*?** a. b. c. d. e. Answer: B **Ilio-hypogastric nerve**: - - - **Ilio-inguinal nerve:** - - - **Obturator nerve:** - - - - **Lumbar plexus:** - - - - - - - 17. **Which of the following statements regarding pelvic surgical anatomy is true?\ ** a. b. c. d. e. Answer: C A -- the obturator nerve forms the lateral border of the paravesical space  **Paravesical space:** - - - - - - **Sacral promontory:** - - - - C -- **Pararectal space** - - - **Hysteroscopy** 18. **Outpatient hysteroscopy has:** a. No need for routine antibiotics if diagnostic, but antibiotics should be used if operative b. A requirement for routine vaginal disinfection in operative procedures c. A requirement for routine vaginal disinfection both in diagnostic and operative procedures d. Routine antibiotics for all procedures Answer: B - 19. **Outpatient hysteroscopy is best performed:** a. In the secretory phase b. Using CO2 c. Using a vaginoscopic technique d. Using a para-cervical block routinely Answer: C - - - - 20. **Outpatient hysteroscopy should be:** a. Performed in a room which is part of the operative theatre facilities b. Performed using a flexible hysteroscope routinely c. Performed using saline d. Performed without opioid analgesia Answer: D - - - 21. **Outpatient hysteroscopy:** a. Is best performed with oral misoprostol 4 hours pre-operatively b. Is best performed with vaginal misoprostol 4 hours pre-operatively c. Is best performed with no misoprostol d. Is best performed with mifepristone pre-operatively Answer: C - - 22. **The risk of intra-uterine adhesions is highest following:** a. Curettage after miscarriage b. Diagnostic hysteroscopy c. Hysteroscopic resection of submucosal fibroids d. Hysteroscopic resection of endometrial polyps Answer: A 23. **Risk factors for failed Novasure include all of the following except:** a. Age \< 45yo b. Previous LUSCS c. Large uterine cavity d. Adenomyosis Answer: B **Single port surgery** 24. **Successful single port gynaecological surgery requires which of the following:** a. Non-articulating energy devices b. A standard 10mm 0° laparoscope c. A bariatric length 5mm 45° laparoscope d. A bariatric length 5mm 0° laparoscope Answer: C 25. **Proven benefits of single port gynaecological surgery include:** a. Decreased post-operative pain b. Better patient satisfaction with regard to cosmetic outcome c. Lower risk of visceral organ injury d. Shorter hospital stay Answer: B 26. **Which of the following is a contraindication to single port surgery?** a. Obesity b. Gynaecological malignancy c. Uterine fibroids d. Deeply infiltrative rectal endometriosis 27. **28yo G2P1 at 15 weeks' gestation, with severe acute right-iliac fossa pain and suspected torted right ovary, containing a large cyst. Which is true regarding laparoscopic during pregnancy?** a. Maximal CO2 pressures should not exceed 15mmHg b. Laparoscopy may only be safely performed in the second trimester c. Only open / Hasson entry may be safely used d. Tocolytics should be administered pre-emptively to all women undergoing laparoscopy in pregnancy Answer: A 28. **With respect to the RANZCOG/AGES Levels of Scope of Clinical Practice:** a. Describes 5 levels b. Credentialing in endoscopic surgery must always proceed on an individual basis c. Excludes robotic procedures d. Level 4 competency should be achieved by those awarded FRANZCOG who have completed the Generalist Pathway e. Excludes single site procedures Answer: B - - - - - - - - - - **Anaesthesia** 29. **With regards to end-tidal CO2: (recollected question)** a. It peaks at 5 minutes into an operation, then decreases b. It peaks at 15-20 minutes, then is stable c. It continually increases d. It is not affected by a gas embolism Answer: B **Laparoscopic entry** 30. The AGES / RANZCOG guidelines recommend that if placement of the Veress needle is considered to be incorrect following 2 attempts consider the following *except*: a. Seek assistance from a senior colleague b. Choose an alternate site for placement such as the left upper quadrant c. Choose an alternate entry type such as open entry d. Attempt a further Veress placement e. Immediate conversion to a midline laparotomy with assistance of a surgeon Answer: E RANZCOG/AGES guideline -- if placement is considered incorrect after *3 attempts* consider - - - - **Energy devices** 31. Which of the following statements is true with respect to electrosurgery: a. A setting of 40W of cut produces a modulated current b. A setting of 60W of fulguration produces a low voltage, unmodulated current c. A 'blend' setting mixes the cut and coagulation setting d. Disposable instruments preclude insulation failure Answer : C - - - 32. **Which of the following statements is true with respect to energy sources?** a. Bipolar energy sources have no lateral thermal spread b. Harmonic scalpel sources have no lateral thermal spread c. The lateral thermal spread can be user-controlled with unipolar laparoscopic scissors d. Return electrodes do not increase skin temperature at the point of contact Answer: C 33. **Electrosurgery is commonly used in laparoscopic surgery, hence knowledge of electrosurgery is important in achieving appropriate tissue effect and avoiding unintended tissue damage. Which of the following statements is *incorrect*?** a. The electrosurgical tissue effects depend on the mode (CUT/COAG), power settings, the size and geometry of the electrode, the time of activation and the surgeon's manipulation of the electrode b. Excision of peritoneal endometriosis or reflection of the bladder off the cervix during hysterectomy with a COAG current in contact mode would generate greater lateral thermal spread than a non-contact CUT current at the same power setting applied for the same time duration c. Dividing an adhered bowel loop away from the ovary or uterus using a high voltage current in COAG mode causes less risk of lateral thermal spread than cold cut scissors, and if necessary, suture repair d. With the same generator power setting (watts), the CUT mode delivers a continuously '100% on' current with lower voltage while the COAG mode delivers a '6% on' current at higher voltage e. The higher the voltage of a current, the greater the potential flow of electron, the greater the potential for increased lateral thermal spread Answer: C 34. **The wide variety of energy sources currently available for the surgeon to choose when performing laparoscopic procedures such as hysterectomy, myomectomy or excision of endometriosis requires the surgeon to have good understanding of the power and tissue effect of the selected energy. Which of the following factors is *important* when choosing a particular energy source?** a. Lateral thermal spread can occur with all energy sources b. Use an energy source with reliable high seal burst pressures to seal vessels \> 5 mm c. Avoid using the energy device as bowel retractor or grasping forceps immediately after its activation d. Ensure the ureter is \> 1 cm away before sealing and dividing the uterine vessels with bipolar diathermy or advanced bipolar device e. All of the above Answer: E 35. **Long stem: What is false with regard to energy devices?** a. Advanced bipolar devices seal vessels up to 5mm b. Harmonic blade turns ultrasound energy to mechanical at the blade c. The harmonic device vibrates at a rate of 55000 hz d. Advanced bipolar causes dissemination of collagen Answer: D Harmonic scalpel - - - - - Thunderbeat - 36. **Regarding mono polar electrosurgery:** a. Range of tissue effects less than other laparoscopic energy sources b. Risk of stray current injury cannot be eliminated by skill or experience of the surgeons c. Tissue effect with cut waveform is no contact mode with desiccation d. Tissue effect with coag waveform is no contact mode with desiccation Answer: B **Morcellation** 37. **With regard to the use of power morcellators in myomectomy / tumour dissemination:\ ** a. Vaginal Morcellation has a lower likelihood of dissemination when compared to abdominal morcellation b. Are not necessary in morcellation of benign lesions c. All methods are equal with regards to risk of dissemination d. ? Answer: C -- RCOG **Adhesions** 38. **Which primary port entry site is least likely to be associated with adhesions in the context of a previous midline laparotomy?** a. Umbilicus b. Supra-umbilicus c. Palmer's point d. Right upper quadrant Answer: C 39. **Adhesion barriers have been shown to:** a. Reduce pelvic pain b. Increase live birth rates c. Reduce ectopic pregnancy rates d. None of the above Answer: D **Hysterectomy** 40. **The overall hysterectomy rates over the past two decades have:** a. Increased b. Decreased c. Not changed d. Fluctuated Answer: B 41. **What has been shown to be the superior route for hysterectomy for benign disease, with respect to complications, hospital stay, recovery and cost?** a. Vaginal b. Abdominal c. Robotic d. Laparoscopic Answer: A 42. **Which of the following statistically significant result was found in the eVALuate study?** a. Increased bladder injuries with laparoscopic hysterectomy when compared to abdominal hysterectomy (2% vs. 1%) b. Increased bladder injury with vaginal hysterectomy when compared to abdominal hysterectomy c. Increased bladder injury with abdominal hysterectomy when compared to vaginal hysterectomy d. Increased bladder injury with vaginal hysterectomy when compared to laparoscopic hysterectomy Answer: A **eVALuate trial 2004** - - - - - - - - 43. **With respect to the eVALuate trial, which of the following statements is correct:** a. VH was associated with a higher mean cost per patient when compared to TLH b. TAH was associated with a higher mean cost per patient when compared to TLH c. VH was associated with a lower mean cost per patient when compared to TLH d. b\. and c. Answer: C 44. **In the VALUE study, the highest risk of complications at hysterectomy was associated with:** a. Abdominal b. Vaginal c. Laparoscopic d. No difference Answer: C **VALUE study:** - - - - 45. **The LACE trial showed which of the following?** a. Greater quality of life following total laparoscopic hysterectomy b. Increased operation time with total abdominal hysterectomy c. Increased serious adverse events with total laparoscopic hysterectomy d. None of the above Answer: A **LACE trial:** - - - - 46. **With regard to the route of hysterectomy (vaginal, abdominal, laparoscopic, robotic) for benign disease which of the following is *false*?** a. Vaginal hysterectomy is the safest and most cost-effective route of hysterectomy b. Desire to perform a salpingectomy/salpingo-oophorectomy is a contraindication to vaginal hysterectomy c. Laparoscopic hysterectomy is associated with more urinary tract injuries and longer operating time when compared to abdominal hysterectomy d. Abdominal hysterectomy is associated with increased febrile morbidity and longer hospital stay than laparoscopic hysterectomy or vaginal hysterectomy e. Robotic hysterectomy has not been demonstrated to be superior to laparoscopic hysterectomy Answer: B ACOG (2017): - - - - Cochrane (2015): - - - - - - 47. **Benefits of laparoscopic hysterectomy compared to abdominal hysterectomy include all of the following *except*:** a. Less intraoperative blood loss b. Reduced overall cost c. Faster return to normal activities d. Less wound infections e. Less risk of urinary tract injuries Answer: B -- TLH higher risk of urinary tract injuries and slightly more expensive (eValuate study) 48. **With laparoscopic hysterectomy and urinary tract injuries which of the following is *not true*:** a. The risk of urinary tract injuries (bladder and ureter) may be as high as 3% b. Increased surgeon experience is associated with a significant reduction in urinary tract injuries c. \>50% of ureteric injuries are not recognised intraoperatively during the hysterectomy d. A normal cystoscopy excludes ureteric injury e. Intraabdominal observation of ureteric peristalsis does not exclude ureteric injury Answer: D AAGL Practice Report: Practice guidelines for intraoperative cystoscopy in laparoscopic hysterectomy: - - - - - 49. **Laparoscopic suturing of the vaginal vault after laparoscopic hysterectomy has been found to reduce the risk of the following complications when compared to transvaginal suturing:** a. Vault dehiscence b. Vault haematoma c. Post-operative vault infection d. A,B&C e. B&C Answer: D Vault dehiscence (UpToDate): - - - - - - - 50. **When informing women of evidence-based information to help them decide whether to have total (TH) or supracervical hysterectomy (STH), which of the following information is correct?\ (ACOG Committee Opinion on Supracervical Hysterectomy, 2012 Cochrane)** a. There is level I evidence that STH offers improved post-operative sexual function compared to TH b. There is level I evidence that STH offers improved bladder function compared to TH c. Length of operation and amount of blood loss are significantly reduced during STH compared to TH d. Postoperative fever is more likely after STH than TH e. Overall, there is overwhelming evidence-based information to recommend STH to TH on the basis of improved outcomes for sexual, urinary and bowel function Answer: C Cochrane (2012): - - - 51. **You are asked to assist a colleague with post-partum haemorrhage for placenta praevia needing peripartum hysterectomy. Which of the following statement is false?** a. Ureteric injury is the most common injury in peripartum hysterectomy b. Subtotal peripartum hysterectomy reduces risk of bladder and Ureteric injury c. Subtotal peripartum hysterectomy has higher risk of taking back to theatres d. Internal artery ligation at the same time has not been proven to reduce blood loss Answer: A 52. **Prophylactic intravenous tranexamic acid in benign hysterectomy has been associated with the following, except for:** a. Reduced incidence of blood loss greater than 500mL b. Reduced incidence of reoperation due to post-operative haemorrhage c. Increased risk of venous thromboembolic events d. Reduced incidence of total blood loss Answer: C Prophylactic TXA: - **Fibroids** 53. **With regard to fibroids:** a. There is no evidence to suggest that sub-serosal (FIGO L5 to L7) fibroids decrease any measure of fertility b. There is a significant increase in levels of certain cytokines (mainly IL10 and glycodelin) in the mid- luteal uterine washings of women with sub-mucosal fibroids c. A synthesis of available evidence shows a 35% reduction in live birth rates following IVF, in women with non-cavity distorting intramural fibroids, when compared with non-fibroid controls d. a\. and b. Answer: A 54. **Which statement with respect to fibroids is correct?** a. Fibroids over 4cm are always associated with infertility b. Fibroids should be removed in all cases of infertility c. FIGO type 0 fibroids are associated with infertility d. Fibroids should be removed in all cases of recurrent pregnancy loss Answer: C FIGO classification fibroids: - - - - - - - - - 55. **Sub-mucosal fibroids are found:** a. In 23.4% of pre-menopausal women with HMB b. In 4.5% of post-menopausal women with HMB c. In all women experiencing AUB 7.5% of the time d. All of the above Answer: D 56. **Which statement with respect to fibroids is correct?** a. LDH accurately predicts malignant change b. An MRI should always be performed preoperatively c. Morcellation should only occur in women under the age of 50 d. Any myomectomy is associated with a risk of recurrence and persistence Answer: D 57. **With regard to fibroids:** a. The improvement in reproductive outcome following removal of fibroids is greater if done hysteroscopically rather than laparoscopically b. Regarding UAE: the uterine and ovarian artery have been shown to anastomose on angiography, in at least one side, in approximately 36% of women c. Conservative treatment measures (medical, UAE and MRgFUS) should not be routinely offered to women who wish to maintain or improve their fertility, due to lack of data on their safety and effectiveness d. It has been reported that there is a 35.2% rate of miscarriage in UAE conceptions as compared to 30% in fibroid-containing pregnancies Answer: C 58. **Sub-mucosal fibroids can be resected hysteroscopically if they are:** a. Type 0 fibroids b. Type 1 fibroids c. Type 2 fibroids d. a\. and b. Answer: D 59. **Daghni is a 46yo woman, who is referred to your clinic with heavy and irregular menstrual bleeding. She is requesting a laparoscopic myomectomy (LM). Conservative management has not been effective; Daghni is nulliparous, and is planning to undergo IVF next year. Transvaginal ultrasound reports a solitary intra-mural fibroid which shows high vascularity (but not necrosis), and is 9cm in diameter.** a. Age \>40yo b. Solitary fibroid c. Largest fibroid ≥ 8cm d. All of the above Answer: D 60. **Based on Daghni's age alone (46yo), what is her approximate risk of unsuspected leiomyosarcoma, at the time of surgery for presumed benign leiomyoma?** a. 1 in 300 b. 1 in 750 c. 1 in 1200 d. 1 in 1450 Answer: A 61. **Which of the following is *not* a proposed benefit of contained ('in-bag') power morcellation, over uncontained power morcellation?** a. Lower risk of internal organ injuries b. Lower risk of parasitic leiomyomata and disseminated peritoneal leiomyomatosis c. Shorter operative time d. Less spread of sarcomatous cells Answer: C 62. **Had *uncontained* power morcellation been used during Daghni's LM, what is her approximate risk of developing parasitic leiomyomata thereafter?** a. \< 0.1% b. 0.1-1% c. 2-5% d. 6-10% Answer: B 63. **To reduce blood loss in a laparoscopic myomectomy:** a. Uterine artery embolisation 3 weeks prior to the operation has been shown to reduce blood loss and increase haemoglobin b. Vasopressin can be used, in a dose of 40 units in 100mLs of saline injected into the myometrium at the beginning of the myomectomy c. GnRH agonist injection 3 to 6 months pre-operatively result in decreased uterine bleeding, improved haemoglobin pre-operatively, and decrease in uterine volume of up to 50% d. All of the above Answer: C 64. **Salwa is a 39yo woman, who presents to your rooms complaining of heavy menstrual bleeding, requesting a laparoscopic myomectomy (LM). Conservative management has not been effective. Transvaginal ultrasound reports three intra-mural fibroids (no suspicious features), the largest of which is 7cm in diameter.** **Which of the following information would you *not* require at this stage?** a. Further details from the ultrasound report (eg. position of Salwa's fibroids in relation to the myometrium b. Endometrial biopsy and cervical screening results c. Serum lactate dehydrogenase results d. Full blood count results Answer: C 65. **When counselling Salwa about the potential risks of a laparoscopic myomectomy, which of the following statements is *incorrect*:** a. Risk of hysterectomy at the time of the procedure is 0.0 - 0.3% b. 20% of women who have a laparoscopic myomectomy will have a hysterectomy within the following 10 years c. The approximate rate of overall complications during / after LM is approximately 11% d. The approximate rate of major complications during / after LM is approximately 2% Answer: B 66. **When considering methods to minimise blood loss at Salwa's LM, there is good evidence for the use of all of the following *except* for:** a. Pre-operative misoprostol b. Pre-operative GnRH-agonists (eg. goserelin) c. Intra-operative vasopressin d. Intra-operative IV tranexamic acid Answer: D **Hemostatic Techniques for Myomectomy: A EBM Review** **(JMIG, 2015) ** - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 67. **When performing Salwa's LM, which suture is an *inappropriate* choice?** a. Endometrium: 3-0 Vicryl b. Myometrium: 1-0 polydioxanone (PDS) c. Myometrium: 3-0 barbed suture (eg. 'V-Loc') d. Serosa: 3-0 polydioxanone (PDS) Answer: C 68. **Regarding Salwa's likely reproductive outcomes following her laparoscopic myomectomy, which of the following statements is true?** a. LM has been shown to improve fertility rates b. LM has been shown to decrease miscarriage rates c. LM has been shown to carry a lower risk of uterine rupture (during subsequent labours) than open myomectomy d. None of the above Answer: D 69. **You see a 34yo with a 10cm intramural fibroid and heavy menstrual bleeding. Which of the following regarding laparoscopic myomectomy are correct?** a. Increased operation time is associated with increased blood loss b. Blood loss is increased if a woman is menstruating at the time of surgery c. Blood transfusion occurs in \ a. Incidence is as low as 1 / 2000 b. Imaging modality for diagnosis is not very reliable c. Rapidly growing mass in a pre-menopausal woman is a reliable indicator of malignancy d. ? Answer: C **Ovarian surgery** 71. **You are seeing a 42yo woman in the rooms with an adnexal mass that has been incidentally detected. The ultrasound describes a 5cm cyst with no atypical features. She asks you about the risk of malignancy in this lesion, and you advise her that (according to the literature) the overall risk in a pre- menopausal woman with an adnexal mass without suspicious features is approximately:** a. 0.1% b. 1% c. 3% d. 5% e. 8% Answer: A RCOG -- the overall incidence of a symptomatic ovarian cyst in a premenopausal woman being malignant is 1:1000 to 3:1000 at the age of 50 (0.1-0.3%) 72. **You discuss tumour marker testing and advise:** a. CA125 is raised in almost all early stage epithelial ovarian carcinoma b. CA125 has high sensitivity & specificity for ovarian malignancy c. Serial CA125 levels can be effectively incorporated into screening programs for early ovarian cancer d. CA125 levels are not routinely required for simple ovarian cysts in premenopausal women e. CA125 is essentially a marker for germ cell tumours Answer: D Ca-125 - - 73. **When reviewing the pelvic ultrasound, the following are reassuring features consistent with a benign cyst:** a. Low echogenicity b. Unilocularity c. Thin cyst wall d. Absence of excrescences e. All of the above Answer: B B rules: - - - - - M rules: - - - - - 74. **You are seeing a 42yo woman in the rooms with an adnexal mass that has been incidentally detected. The ultrasound describes a 5cm cyst with no atypical features.\ All of the following are correct with regards to surgical management of this patient *except*:** a. Surgical removal of this lesion should be arranged routinely b. If spill of an unsuspected unilateral ovary-contained malignant cyst occurs, then the stage of disease is upstaged from IA to IC c. If required should include consideration of unilateral adnexectomy depending on thorough pre & intraoperative assessment d. Should include routine pre-operative discussion on proceedings if suspicious features detected intraoperatively e. Surgical removal may be warranted if the cyst increases in size Answer: A 75. **With regards to surgery for an adnexal mass all of the below are true *except*:** a. 10% of women will undergo a laparoscopy over their lifetime for an adnexal lesion b. Laparoscopy is the optimal approach for lesions without suspicious features c. A thorough intraoperative assessment should always occur both of the ovarian lesion and for extra-ovarian disease d. Aspiration is effective as it is associated with low risk of recurrence e. Spillage of cyst content should be avoided where possible as preoperative and intraoperative assessment cannot absolutely preclude malignancy Answer: D **Endometriosis** 76. **There are a multitude of different MRI sequences used in the assessment of endometriosis. Which is CORRECT?** a. On T1-weighted sequences, water (eg. bladder) appears white b. T2 shading is a specific sign of an endometrioma c. The most specific sign for the diagnosis of endometriomata are multiple, bilateral T1 bright cystic lesions d. A T1, fat-saturated sequence is not a useful sequence for the assessment of endometriosis Answer: C 77. **The revised ASRM classification of endometriosis:** a. Correlates well with pain b. Has 5 levels c. Is correlated well with infertility d. An aggregate score of 12 correlates with stage III disease e. Divides Pouch of Douglas disease into partial and complete Answer: E - - - - - - 78. **The revised Endometriosis Fertility Index classification of endometriosis includes all *except*:** a. Years of infertility b. Age c. Index correlated with infertility d. Least Function Score prior to surgery e. Divides Pouch of Douglas disease into partial and complete Answer: D - - - - - - 79. **In women with endometriosis, infertility is caused by:** a. Pain with intercourse b. Tubal obstruction c. Abnormal endometrial function d. Medical suppression of endometriosis e. All of the above Answer: E 80. **For nerve sparing surgery for endometriosis surgery, which statement is true?** a. All patients with DIE benefit from the nerve sparing approach b. Unilateral damage to the hypogastric nerve can affect bowel, bladder and sexual function c. Prospective RCTS exist to support nerve sparing surgery in endometriosis d. It is associated with significant improvement in bowel function Answer: B 81. **Regarding the pathogenesis and pathophysiology of endometriomas, what is true:** a. They are most often bilateral b. Due to their pathogenesis the plane of cleavage between endometrioma and cortex may not always exist like other cysts c. Coloemic metaplasia is the most commonly accepted theory of the pathogenesis d. Their prevalence is \< 10% of all women with endometriosis Answer: B - - 82. **During laparoscopy for woman with bilateral 10cm endometrioma it is deemed not possible to complete ideal surgery. All of following acceptable except:** a. Drain endometrioma alone b. Drain plus GnRH for 3-6 months c. Referral to tertiary/ specialist centre d. Laparotomy to complete procedure Answer: A 83. **Regarding peritoneal pocket visualisation at laparoscopy, which is true?** a. Endometriosis is present in 60-80% of peritoneal pockets b. 5-10% of women with endometriosis have peritoneal pockets c. Majority are lateral to ureter d. Pockets with no visible endometriosis have endometriosis confirmed on histopathology in 80- 90% Answer: A Koninckx 2021 - - Peritoneal pockets (Yeung 2016 Deep retraction pockets, endometriosis and QOL. Front. Public Health and Ilnitsky 2019 Pelvic peritoneal pockets: distribution, histopathology and clinical significance 2019) - - - - - - - - 84. **Thoracic endometriosis syndrome features all except:** a. Catemenial symptoms b. Left lung affected \ than the right c. Association with pelvic endometriosis d. Infertility Answer: B **Thoracic endometriosis** (Nezhat 2019 Thoracic endometriosis syndrome: A review of diagnosis and management. JSLS) - - - - - - - - 85. **A young girl presents with cyclical pelvic pain associated with nausea and vomiting. She also has non- cyclical pain that is increased with activity. Which of the following is incorrect?** a. Somatic pain is worse with activity and is not associated with nausea and vomiting b. Visceral afferent fibres make up 50% of ascending pain fibres c. Visceral pain is poorly localised d. Visceral pain occurs through the autonomic nervous system Answer: B Visceral afferent fibres make up 2-10% of ascending pain fibres (viscera poorly innervated) 86. **There is a patient with chronic pelvic pain. She's had 4 laps. She's on amitriptyline with minimal improvement.** a. Because the amitriptyline is not working it is unlikely to be neuropathic pain b. Laparoscopy for excision of endometriosis can exacerbate the pain c. Opioids are an ideal medication as the supress glial cell activation d. Because she has had pain from menarche endometriosis is the most likely cause Answer: B? (I think this was in the exam) - - - **Pelvic organ prolapse** 87. **Which muscle inserts at anococcygeus?** a. Ilio-coccygeus b. Coccygeus c. Pyramidalis d. Obturator Internus Answer: A The iliococcygeus muscle arises from the ischial spine and posterior part of the obturator fascia and inserts into the last two segments of the sacrum and the anococcygeal raphe. **Surgical complications** 88. **Upon dividing the uterine artery with a vessel sealing device at time of laparoscopic hysterectomy, it retracts into the parametrium towards the pelvic sidewall and begins to bleed profusely. *The most appropriate way* to get control of this situation, the surgeon *should*:** a. Immediately grasp the squirting vessel with bipolar forceps and activate diathermy until the bleeding stops b. Stop the bleeding by pressure with grasping forceps, suction to clear the view, assess the situation, and achieve haemostasis with bipolar diathermy, suture or clip after ensuring vision and safety of the ureters c. Perform cystoscopy, insert a ureteric stent before resuming to take control of the bleeding either by laparoscopy or laparotomy d. Dissect out the ureter from the pelvic brim, identify the posterior branch of the internal iliac vessel and ligate this vessel using vessel clips e. Identify the obliterated umbilical ligament to dissect the ureter before clipping or diathermy the superior vesical vessel as it is a major tributary to the uterine artery Answer: B 89. **Regarding laparoscopic-related bowel injury, which of the following statement is *correct*?** a. By being meticulous, a competent surgeon is expected to be able to recognise all bowel injuries intraoperatively at all times b. A patient with increasing postoperative abdominal pain on day 5 with mildly elevated CRP but normal CT scan can be discharged as she is past the danger time of bowel injury c. Bowel injury should be suspected when patient is found to have mild hypoxia with few peritoneal signs once respiratory infection and pulmonary embolism are excluded d. Thermal or traumatic bowel injury cannot occur if the surgeon can see all instruments being used at all times during surgery e. The surgeon should never resort to second-look laparoscopy or laparotomy if bowel injury is clinically suspected, but imaging tests are equivocal. Answer: C 90. **Ureteric injury is an inherent risk of all gynaecological procedures. When it comes to ureteric injury, which of the following statement is *incorrect*?** a. Flank or loin pain, incontinence, haematuria, fever, elevated urine creatinine in fluid collections should raise concern regarding delayed ureteric injury b. Seeing normal urine jets through ureteric orifices at cystoscopy should completely eliminate any concern of ureteric injury c. An IVP or CT scan should be performed if delayed ureteric injury is suspected d. Post-operative delayed ureteric injury typically presents 7 to 10 days after surgery e. Intravenous injection of indigo carmine can help confirm and locate intra-operative partial or complete transection ureteric injury Answer: B 91. **Intraoperative cystoscopy at TLH for detection ureteral injury has sensitivity of?** a. 90 - 100% b. 80 - 90% c. 70 - 80% d. 60 - 70% Answer: B Cystoscopy at TLH 85% sensitivity of ureteral injury 92. **Open disclosure does *not* include:** a. Open and timely communication b. Acknowledgment of any pain or suffering c. Apology or expression of regret d. Admission of liability e. Supporting, and meeting the needs and expectations of the patient Answer: D **Heavy menstrual bleeding** 93. Which of the following is not a suitable treatment for the symptoms of adenomyosis? a. Hysterectomy b. Uterine artery embolisation c. Levonorgestrel intra-uterine device d. Endometrial ablation Answer: D **Ethics** 94. **The principles of ethical medical decision-making involve:** a. Justice b. Autonomy c. Beneficence and non-maleficence d. All of the above Answer: D 95. **A nulliparous 29yo woman is referred with heavy menstrual bleeding, normal transvaginal ultrasound scan and baseline investigations. She requests a hysterectomy. The correct action is** a. Discuss and schedule surgery as per patient wishes b. Decline surgery in view of patient's age and nulliparity c. Discuss fertility sparing therapies only d. Counsel about risks, benefits, and alternative therapies, then refer patient for second opinion prior to scheduling surgery Answer: D 96. **Choose the best definition of informed consent** a. Informing the patient of the risks and benefits of a procedure b. Informed consent ensures that the woman's human right of self-determination is met by the process of communication that precedes any informed consent c. A consent obtained freely, after appropriate disclosure to the patient of adequate and understandable information in a form and language understood by the patient on diagnosis, proposed treatment, alternative treatment and risks and side-effects of treatment d. A legal process that will stand up in court showing that the patient has been given all the risks and benefits of a particular procedure Answer: C Informed consent -- is a person's decision, given voluntarily, to agree to a healthcare treatment, procedure or other intervention that is made following the provision of accurate and relevant information about the healthcare intervention and alternative options available. **Clinical audit and quality assurance** 97. **Good clinical governance of a gynaecological endoscopic unit includes the following *except*:** a. An identified leader who is accountable for unit outcomes b. Regular clinical audits to identify shortcomings and to provide a strategy to improve patient care c. Ensuring that staff members possess the appropriate skills and knowledge to fulfil their roles and responsibilities d. Revenue generating treatments and activities should be prioritised to enhance the status of the unit Answer: D 98. **Total quality management (TQM) is based on which of the following 3 principles?** a. Continuous quality improvement, customer focus and teamwork b. Continuous quality improvement, evidence-based best practice and teamwork c. Evidence-based best practice, customer focus and teamwork d. Continuous quality improvement, customer focus and open disclosure Answer: A 99. **You are the clinical director of a gynaecological endoscopy unit. A new consultant with many exciting ideas has joined your unit, including a proposal for a new experimental procedure that has not been previously performed. Your next step should be:** a. Allow the consultant to proceed and eagerly await the outcome. As a consultant the clinical responsibility lies solely with him/her b. Forbid the consultant from performing the procedure as the potential benefits are as of yet unproven c. Commend for innovative thinking but insist that as an experimental treatment it is reviewed first by the hospital ethics committee and the patient is made fully aware of the experimental nature of the procedure d. Insist that only senior consultant with more experience should perform this procedure Answer: C 100. **If there is a doctor who has a breach of professional standards that did not lead to an adverse outcome in a hospital situation, the doctor concerned should be:** a. Dealt with by the person who observed the breach of professionalism b. Met by a person in authority in a non-confrontational informal meeting c. Sent an official letter to meet a person of authority and have the breach documented, with consequences outlined d. Stood down until the matter is dealt with Answer: C **Research** 101. **What is the meaning of 'reliability' in research methodology?** a. The research is generalizable to other scientific settings b. The methodology allows for replication of the study c. The measures designed are stable for concepts at different sampling times d. ? Answer: B 102. **The following variables are examples of categorical variables except:** a. Number of episodes of pain in a patient over a year b. Serum AMH levels c. Endometriosis classification into minimal / mild / moderate / severe d. Reduction in blood pressure following anti-hypertensive treatment e. Fibroid dimensions Answer: E 103. **What is the meaning of research design?** a. A format for setting out methods, results, discussion b. The decision of whether qualitative vs quantitative methods are used c. A framework for every stage of data collection and data analysis d. The style of analysis of the variables that you want to measure Answer: C - 104. **Which is the lowest level of evidence in research?** a. Cohort study b. Case-control study c. RCT d. Systematic review Answer: B 105. **Select all of the statements which you believe are true regarding study design:** a. In a cluster randomised trial each individual in a cluster is randomised to a different treatment b. A case series must be prospective c. A multi-centre study may be experimental or observational d. Different study protocols are used in two or more of the centres in a multi-centre study e. The unit of observation in a medical study is always the individual person (This was in the exam) Answer: C - 106. **The arithmetic mean of a set of values:** a. Is used in non-parametric distributions b. Is a useful summary measure of location if the data are skewed to the right c. Coincides with the median if the distribution of the data is symmetrical d. Is always greater than the median e. Cannot be calculated if the data set contains both positive and negative values Answer: C 107. **The P-value is:** a. The probability that the null hypothesis is true b. The probability that the alternative hypothesis is true c. The probability of obtaining the observed or more extreme results if the alternative hypothesis is true d. The probability of obtaining the observed or more extreme results if the null hypothesis is true e. Always less than 0.05 Answer: D - - - - 108. **You are calculating the sample size for a study comparing rates of vault dehiscence with monofilament and poly-filament sutures. The power of the study is 80% to detect a relative risk reduction of 50% when monofilament is used at a significance of 95%. Which is true ?** a. 20% chance of type 1 error b. 1/50 chance of type 1 error c. 1/20 chance of type 1 error d. 10% chance of type 1 error Answer: C - - 109. **If there is a research project that a doctor is running:** a. The doctor has no obligations in recruiting from his/her patient population b. The doctor can provide medications free of charge to the patients in the trial c. The doctor has an obligation to provide the patient with independent advice from a third party d. b\. and c. Answer: D 110. **What clinical situation will repair of an isthmocele fix?** a. Post-menstrual spotting b. Dyspareunia c. Infertility d. Large asymptomatic defect e. All of the above Answer: E 111. **The physiological effects of Trendelenburg are:** - - - 112. **SUI** - - - 113. **With endometriomas:** - -