Laparoscopic entry and complications — structured oral station (12 minutes)

Opening prompt — "Construct your entry plan for this patient."

Model response — say it in this order:

• "This patient has two specific risk factors: BMI 38 and previous midline laparotomy for ovarian cancer. Both increase the risk of adhesions to the anterior abdominal wall under the umbilicus, and obesity increases the depth of the abdominal wall."
• "I would plan open Hasson entry at the umbilicus with adhesiolysis under direct vision — this is the RANZCOG C-Gyn 7 default for the patient with previous midline surgery. Palmer's point (left upper quadrant, 3 cm below the costal margin in the mid-clavicular line) is the alternative if the umbilicus is hostile."
• "Insufflation pressure target: 12 mmHg in this obese patient — adequate working space with reduced cardiopulmonary compromise."
• "I would check the pre-entry checklist: anaesthetic depth, full muscle relaxation confirmed, NG tube decompressing stomach, urinary catheter decompressing bladder, patient in Trendelenburg as required."

Examiner is listening for: technique chosen with patient-specific justification, named alternative entry site (Palmer's point), pressure target with reasoning, pre-entry checklist.

Probe 1 — "You proceed with Veress at the umbilicus. The pressure rises rapidly to 14 mmHg after 0.5 L. What do you do?"

• "This is the classic signature of preperitoneal insufflation — the Veress tip is in the preperitoneal fat, not the peritoneal cavity."
• "I would stop insufflation, disconnect the CO2 line, withdraw the Veress, and not force."
• "In this patient with previous midline surgery, I would now use Palmer's point Veress insertion or convert to open Hasson under direct vision. I would confirm intraperitoneal placement by low initial pressure rise with 1.5–2 L delivered and the sliding sign on the camera before inserting the primary trocar."

Probe 2 — "After successful entry, the patient becomes acutely hypotensive with a falling end-tidal CO2 and a mill-wheel murmur on auscultation. What is happening and what do you do?"

• "Gas embolism. The anaesthetist will call it first — sudden hypotension, falling end-tidal CO2, mill-wheel murmur, in temporal relationship to insufflation."
• "Four-move resuscitation: (1) stop insufflation, (2) deflate the pneumoperitoneum, (3) place the patient in the Durant position (left lateral and Trendelenburg to trap gas in the right ventricle), (4) give 100% oxygen and aspirate a central venous catheter if present."
• "Large-bore IV access, fluid resuscitation, advanced life support with CPR if arrest. Declare the critical incident and document; anaesthesia-led debrief afterwards."

Probe 3 — "The case proceeds. At the end, on inspection of the small bowel, you identify a 4 mm full-thickness small bowel serosal injury on a loop adherent to the anterior abdominal wall. What do you do?"

• "This is the Lund / McKernan small bowel injury ladder: a small (under 5 mm) full-thickness injury with no significant contamination is amenable to laparoscopic repair in a single or two-layer technique with absorbable suture."
• "I would inspect the entire small bowel and the rest of the abdomen for additional injuries, take an image of the repair, give prophylactic broad-spectrum antibiotics (e.g. cefazolin + metronidazole), and request an intraoperative general surgical consult."
• "Enhanced postoperative observation with a low threshold for return to theatre if the patient deteriorates (tachycardia, fever, abdominal pain, ileus)."

Probe 4 — "The patient wakes up well and you go to see her on the ward the next morning. She asks what happened and whether she is safe to go home tomorrow."

This is a scored domain, not a courtesy. Demonstrate it out loud:^[1]".

• Move to her eye level, use her name, brief plainly: "The operation went well. We did find a very small graze on the bowel where it was stuck to the front of the abdomen — we repaired it during the same operation, and I have asked the bowel surgeons to review you today as well. We will keep a close eye on you for the next day or two to make sure there is no leak. You will be on antibiotics for a few days. You should be safe to go home when you are eating and drinking, mobilising, and your pain is controlled with tablets."^[1]".
• Acknowledge any concerns, invite questions, offer written information, and tell her how to contact the team.
• Document the conversation and the plan.

Probe 5 — "What are your top three learning points from this case?"

• "Entry technique must be patient-specific — open Hasson or Palmer's point when there is a previous midline scar, especially with obesity. The Cochrane review shows no universally safest technique; the choice is operator- and patient-specific."^[1]".
• "Recognise the lethal four early — preperitoneal placement, gas embolism, vascular injury, bowel injury. Each has a defined response that does not depend on improvisation."
• "Always inspect under the primary port site and the entire small bowel at the end of the case — the missed Veress injury lives there."^[1]".