Operative laparoscopy — structured SAQ (15 marks)

(a) Entry choice and performance (5 marks)

One mark per point, maximum five. The reasoning carries the marks here. ^[1][2]

• Do not default to the umbilicus. This is a thin patient (aorta close to the abdominal wall) with a previous midline laparotomy (likely periumbilical adhesions) — two independent reasons to avoid a blind umbilical Veress entry.^[2][3]
• Choose an open (Hasson) entry or Palmer's point (left upper quadrant) entry. Both keep the entry away from the scarred umbilicus; Palmer's point succeeded in 98.5 percent and carried no entry-related complications in series data, and it is underused.^[2]
• If a closed entry is used, verify placement before insufflating — intraperitoneal pressure at or under 10 mmHg as a placement proxy, a positive saline drop test, and free side-to-side needle movement.^[1]
• Raise a transient high intraperitoneal pressure (20 to 30 mmHg) to tent the abdominal wall before primary port insertion, then enter under control.^[1]
• Insert the primary port and immediately sweep 360 degrees under vision before placing any ancillary port, looking specifically for entry injury and adhesions.^[1]

(b) Immediate management of suspected major vessel injury (4 marks)

One mark per step, in the right order. Acting in series loses marks. ^[3]

• Desufflate and apply direct pressure to the bleeding site; leave the instrument in for tamponade if withdrawing worsens the bleed — do not remove it blindly.^[3]
• Call the vascular surgeon now and notify anaesthetics; activate the massive haemorrhage protocol with two large-bore cannulae, crossmatch, coagulation and FBC.^[3]
• Convert to laparotomy, gain proximal and distal control, and resuscitate in parallel with blood products.^[3]
• State the damage-control principle for a centre without vascular expertise: pack, close, resuscitate and transfer to a centre with a vascular surgeon.^[3]

(c) Energy source for adhesiolysis near bowel (3 marks)

One mark for the choice, one for the comparison, one for the safety principles. ^[4]

• Prefer a non-monopolar option (scissors, or an advanced bipolar or ultrasonic device) near bowel, reserving monopolar for tissue kept in clear view, because monopolar radiofrequency carries the unique risks of capacitive coupling, direct coupling and insulation failure that burn tissue outside the field of view.^[4]
• Compare the options: monopolar offers dissection and coagulation but the greatest out-of-view thermal risk; conventional and advanced bipolar confine current between electrodes; ultrasonic devices cut and coagulate without current flow. The choice depends on the task, training, cost and availability.^[4]
• State the safety principles: inspect instruments for insulation failure before use, activate only when the whole active electrode is in view, keep active-electrode monitoring where available, and avoid monopolar where instruments cross out of sight (notably single-port surgery).^[4]

(d) Port-closure practice and the evidence (3 marks)

One mark per point. ^[5]

• Close the 12 mm lateral port site fascia; the 5 mm site generally does not require routine closure. A systematic review of port-site hernias (11,699 patients) found an incidence of about 0.74 percent, with a high strangulation risk through the small defect.^[5]
• The evidence-based rule is to close all fascial defects 10 mm or larger, while smaller defects may require closure in some circumstances.^[5]
• State that port-site herniation is a completely preventable cause of morbidity that requires a second operation to repair, and that the larger port carries the higher risk.^[5]