Operative laparoscopy — structured oral station (12 minutes)

Opening prompt — "Talk me through your entry."

Model response — say it in this order: ^[1][2]

• "Before I scrubbed I assessed her abdomen and habitus: she is thin, so the aorta and iliac vessels sit close to the abdominal wall, and there are no scars or masses."
• "I insert the Veress at the umbilicus and verify placement before I insufflate: intraperitoneal pressure at or under 10 mmHg, a positive saline drop test, and free side-to-side movement of the needle."
• "I insufflate, raise a transient high pressure to tent the wall, enter, then sweep the abdomen 360 degrees under vision before I place any ancillary port."
• "If she had a previous laparotomy or a large mass, I would choose an open Hasson entry or Palmer's point instead of the umbilicus."^[2]

Examiner is listening for: placement verification before insufflation, the 360-degree sweep, and a patient-shaped entry decision. ^[1]

Probe 1 — "The anaesthetist calls out: blood pressure dropping, end-tidal CO2 falling. What is happening and what do you do?"

• "A fall in end-tidal CO2 with cardiovascular collapse during insufflation is a gas embolism until proven otherwise. I stop insufflation, disconnect the gas, flood the field, and go to Durant's position — left lateral head-down — with 100 percent oxygen, and call for help."^[3]
• "If instead there is dark blood in the field, that is a major vessel injury. I desufflate, apply direct pressure, leave the instrument in for tamponade, call the vascular surgeon, activate the massive haemorrhage protocol, and convert to laparotomy, resuscitating in parallel."^[3]
• "I would not be reassured by a young woman's near-normal pressure — she can decompensate abruptly."^[3]

Probe 2 — "No technique is proven safest. So how do you actually choose an entry method?"

• "By the patient, not by habit. The Cochrane review found no technique is proven safest overall; the one durable result is that direct trocar entry reduces failed entry versus Veress (OR 0.24)."^[1]
• "For the low-risk abdomen I use closed or direct entry with verification; for the previously-operated or high-adhesion abdomen I use an open Hasson entry or Palmer's point; for the large mass or umbilical hernia I avoid the umbilicus."^[2]
• "A network meta-analysis is reassuring on the headline: major complications are extremely rare and all three methods — Veress, direct trocar and open — can be performed without mortality."^[1]

Probe 3 — "You now need to divide an adhesion close to the bowel. What energy do you use?"

• "I avoid monopolar near bowel. Monopolar radiofrequency carries the risks of capacitive coupling, direct coupling and insulation failure, which burn tissue out of view — and surveys show around 18 percent of surgeons have had visceral burns."^[4]
• "I use sharp scissors or an advanced bipolar or ultrasonic device, keep the whole active electrode in view, and inspect the instrument for insulation failure before I use it."^[4]
• "The unrecognised thermal bowel injury declares itself days later with fever and peritonitis — that is why I am conservative with energy near bowel."^[5]

Probe 4 — "The anaesthetist and the scrub nurse are looking to you. The patient is awake at the end and frightened. Talk to them."

This is a scored domain, not a courtesy. Demonstrate it out loud: ^[3]

• To the team, in brief closed-loop orders: "Anaesthetics, this is a possible gas embolism — gas off, Durant's position, 100 percent oxygen. Scrub, call the consultant and theatre coordinator now. Scribe, note the time."
• To the patient at her eye level, by name: "You had a problem with the gas at the start of the operation. We stopped it straight away and you are stable. The consultant is here. I will keep telling you what is happening."
• Commit to a structured debrief afterwards, for the patient and the team.^[3]

Probe 5 — "What will you do for the rest of this list and afterwards?"

• Stand down the list until the event is reviewed; the consultant takes over.
• Document the entry technique, the event and the timing in the operative record, complete an incident report, and offer a team debrief — entry injuries dominate litigation, so the record and the review are part of the management.^[5]
• Counsel the patient on what happened, the plan for any future laparoscopy, and that an open or alternative entry will be used next time.