SAGES Web Quiz #4 -- August 1998

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Figure 1	Figure 2

Question 1: A 48 year old female presents with abdominal pain 18 months after an uneventful laparoscopic cholecystectomy. A HIDA scan and CT scan obtained are shown above (Figures 1 and 2). The next appropriate step is:

[] (a) exploratory laparotomy and common bile duct exploration
[] (b) percutaneous transhepatic cholangiography (PTHC)
[] (c) endoscopic retrograde cholangiopancreatography (ERCP)
[] (d) B or C
[] (e) Don't Know

Figure 3

Question 2: The patient underwent ERCP (Figure 3). The most likely etiology of the patients right hepatic duct stricture is:

[] (a) inadverted clipping of the right hepatic duct during laparoscopic cholecystectomy
[] (b) cholangiocarcinoma
[] (c) application of monopolar cautery near metallic clips in the triangle of Calot
[] (d) sclerosing cholangitis
[] (e) Don't Know

Question 3: In order to have prevented the bile duct injury in this patient, the surgeon should have:

[] (a) ordered a preoperative ERCP
[] (b) used laser dissection instead of monopolar cautery dissection in the triangle of Calot
[] (c) performed intraoperative cholangiography
[] (d) used blunt and sharp dissection instead of monopolar cautery dissection in the triangle of Calot
[] (e) all of the above
[] (f) Don't Know

Question 4: Iatrogenic proximal biliary duct strictures have the highest long term patency rates after:

[] (a) roux-en-y hepaticojejunostomy
[] (b) percutaneous transhepatic balloon dilation and percutaneous catheter drainage
[] (c) endoscopic retrograde hepatic duct balloon dilation and placement of metallic stent
[] (d) end to end duct anastamosis and placement of t-tube
[] (e) Don't Know

Question 5: Bile duct injuries, including right hepatic duct injuries, are seen more often after laparoscopic cholecystectomy than were previously seen during the era of open cholecystectomy. Conditions associated with an increased frequency of bile duct injuries include:

[] (a) scleroatrophic gallbladder
[] (b) Mirrizzi's syndrome
[] (c) fat in the porta hepatis
[] (d) inadequate hemostasis
[] (e) all the above
[] (f) Don't Know

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