Deck 12: Surgery of the Biliary Tract, pancreas, liver, and Spleen

Question 1

The liver,pancreas,and spleen share many similarities.Select the statement about these organs that is true.

A) All three are solid organs and very vascular.
B) All three are metabolic organs.
C) All three organs have terminal attachments to the duodenum.
D) All three can be donor or recipient transplant organs.

Answer 1

A
A pathologic condition in the liver,biliary tract,pancreas,or spleen often requires surgical intervention.These organs are highly vascular and control many of the body's metabolic and immune functions.Solid organ transplantation,such as for the liver and pancreas,is a common means to treat primary hepatic tumors,end-stage liver disease,and insulin-deficient diabetes.

Question 2

Open common bile duct (CBD)exploration may be indicated in some cases where:

A) the patient has undergone prior biliary surgery.
B) a positive cholangiogram shows an obstruction in the pancreatic duct.
C) endoscopic, percutaneous, or laparoscopic techniques are possible.
D) computerized tomography (CT) reveals a hepatic duct less than 4 mm in size.

Answer 2

A
With the advent of endoscopic,percutaneous,and laparoscopic techniques,open exploration of the CBD is rare.The few contraindications to the laparoscopic approach to cholecystectomy include patients with suspected or diagnosed cancer of the gallbladder,third trimester of pregnancy,cirrhosis with portal hypertension,generalized peritonitis,septic shock,previous surgery that prevents access,and poor pulmonary or cardiac reserve.Such patients may not be able to tolerate the pneumoperitoneum required in laparoscopy.Further,if the surgeon is unable to identify all anatomic structures during a laparoscopic approach,conversion to an open procedure becomes necessary.

Question 3

The Whipple procedure is the removal of the head of the pancreas,the entire duodenum,a portion of the jejunum,the distal third of the stomach,and the ____________ as a surgical treatment for____________.

A) left lobe of the liver; metastatic hepatocytoma
B) distal segment of the spleen; pancreatic metastasis
C) inferior margin of the ligament of Treitz; pancreatic cancer
D) lower half of the common bile duct; pancreatic cancer

Answer 3

D
Pancreaticoduodenectomy (Whipple procedure)is the most common procedure for those with pancreatic cancer.In the Whipple procedure,the head of the pancreas,the entire duodenum,a portion of the jejunum,the distal third of the stomach,and the lower half of the common bile duct are removed,with reestablishment of continuity of the biliary,pancreatic,and GI tract systems.

Question 4

A 29-year-old man with paraplegia caused by a spinal cord injury from a diving accident 4 years ago is scheduled for an open cholecystectomy.The perioperative nurse conducts a preoperative assessment to prepare for his procedure.The patient tells the nurse that he is latex-sensitive because he was told that as a spinal cord injured person he should always be considered latex-allergic.An appropriate risk reduction strategy for the patient's latex sensitivity/allergy would be to:

A) provide the anesthesia provider with an H₂ blocker, diphenhydramine, and prednisolone for premedication.
B) alert the OR and postoperative recovery areas of his latex allergy, check the setup for latex-containing items, and replace those items with nonlatex alternatives.
C) turn FiO₂ to 100% oxygen.
D) position code and latex carts outside of the OR and watch for signs of latex reaction; tape an epinephrine-filled syringe to the head of his transport vehicle.

Question 5

A 42-year-old woman from India is visiting her daughter and new grandson.She is a devout follower of Hindu religious practices and has been diagnosed with splenomegaly,possibly from idiopathic thrombocytopenia.The patient is scheduled for a total splenectomy.During the preoperative assessment,the perioperative nurse,an observant practitioner of Hinduism,is concerned about the possibility of significant bleeding because of the patient's coagulopathy and the need for hemostatic agents that are typically used to stop bleeding.Many of these products are manufactured from bovine source products,and it would be in conflict with the patient's religion to use products from a cow.An appropriate risk-reduction strategy for selection of hemostatic agents that would not be in conflict with the patient's belief system would be:

A) substitute absorbable gelatin and oxidized collagen products; soak in thrombin.
B) substitute absorbable collagen products; apply with dry gloves.
C) substitute absorbable gelatin and oxidized collagen products.
D) substitute microfibrillar collagen soaked in thrombin; add epinephrine 1:1000.

Question 6

A 9-year-old boy is admitted to the emergency department (ED)after a sledding accident in which he lost control of his sled and crashed into a tree.He is pale and in pain; his abdomen is tender and firm to palpation.The computed tomography (CT)scan suggests rupture of the spleen with internal bleeding.The scheduled surgery will most probably be a(n):

A) laparoscopic splenic resection with sutured mesh overlay.
B) open splenic lobectomy with vascular ligation.
C) open total splenectomy.
D) open splenic repair with sutured anastomosis and argon plasma coagulation vessel sealing.

Question 7

The functional units of the liver are the lobules.The functional cells of the liver are the ______________,and they manufacture _______________.

A) Kupffer cells; phagocytes
B) sinusoid cells; lymphocytes
C) hepatocytes; bile
D) portal triad cells; ductal epithelium

Question 8

The head of the pancreas is fixed to the:

A) spleen.
B) duodenum.
C) stomach.
D) biliary tree.

Question 9

A 39-year-old,248-lb mother of four children is assisted with transfer from a transport vehicle to the OR bed for laparoscopic cholecystectomy,operative cholangiogram,and possible CBD exploration.The perioperative nurse identifies that the patient is at risk for positional injury related to her size and the positional requirements and OR bed manipulations required for this procedure.An appropriate nursing implementation for positioning this patient would be to:

A) place two safety belts over the thighs and lower legs to prevent the patient from sliding out of position when the surgeon tilts the table for better exposure and access.
B) place a positioning lift under the lower left side of the chest to elevate the lower rib cage for exposure and access to the viscera in the left upper quadrant of the abdomen.
C) abduct the patient's right arm on an arm board at less than 90 degrees to allow an assistant to stand near the patient's right upper quadrant and retract the liver with a wide Deaver retractor.
D) place the patient on a radiolucent OR bed and place a positioning lift under the lower right side of the chest to elevate the lower rib cage for exposure and access to the viscera in the right upper quadrant.

Question 10

The biliary system (also called the biliary tree)drains bile from the gallbladder to the ampulla of Vater.The primary function of the gallbladder is to:

A) manufacture bile.
B) convert bile salts into bile enzymes.
C) store and concentrate bile.
D) contract to secrete bile into the hepatic duct.

Question 11

What technologic characteristic of robotic surgery provides a superior indication for robotic-assisted laparoscopic cholecystectomy?

A) The surgeon controls two instruments plus a camera while the assistant suctions and retracts.
B) Bladeless robotic trocars minimize entry injury and inadvertent hemorrhage.
C) It provides a 360-degree range of motion, extending surgeon skill.
D) Robotic stapler and suture devices promote intracorporeal anastomotic techniques.

Question 12

The donor liver OR is prepared for an open laparotomy procedure with basic laparotomy and vascular instruments and accessories.A second sterile,draped medium-sized instrument table is set up to receive and prepare the procured liver away from the main sterile field.Select the additional instruments and accessories needed on the donor organ preparation table.

A) Flushing solution, sterile plastic containers, and in situ flush tubing
B) Flushing solution, ice chest, sterile ice, powered sternal saw, and long Kocher clamps
C) Culture tubes, Wisconsin University forceps, Deaver retractors, and slush machine
D) Toothed forceps, vessel loops, two sterile plastic draw-string bags, and flushing solution

Question 13

The liver is essential in the metabolism of carbohydrates,proteins,and fats,generating nutrient stores of which substance that supplies energy sources to the brain and body?

A) Carbohydrate glucose substrate
B) Glycogen
C) Serum glucosamine
D) Bile salts

Question 14

An example of an indication for liver transplantation would be:

A) end-stage liver disease resulting from advanced hepatic cancer with metastasis.
B) acute fulminant biliary disease of unknown origin.
C) infection caused by untreated cystic anomalies.
D) primary hepatic cancer.

Question 15

The circulating nurse approaches the preoperative holding lounge to see her next patient,a 57-year-old nurse,newly diagnosed with pancreatic cancer.He had an endoscopic retrograde cholangiopancreatography (ERCP)1 week ago and,based on the findings,was scheduled for surgery at the comprehensive cancer center,where he works in the interventional endoscopy unit.He is aware of the poor prognosis for this disease,and the nurse has recorded his nursing diagnosis as anxiety related to impending surgical procedure,perioperative events,and surgical outcome.An appropriate nursing action for the patient would be to:

A) encourage verbalization of his fears and reinforce the standardized age-appropriate coping mechanisms.
B) describe for him the steps of the operative procedure.
C) offer emotional reassurance by using touch, assisting him to a position of comfort on the OR bed, and offering warm blankets (thermal comfort).
D) share with him his nursing diagnosis and reinforce the desired nursing outcome related to anxiety.

Question 16

While the pancreas' function is carbohydrate metabolism with the production of insulin and digestive enzymes,the spleen's function is primarily ___________ with the production of _______________.

A) immunologic; leukocytes
B) metabolic; granulocytes
C) anabolic; plasma cells
D) as a blood reservoir; phagocytes

Question 17

A perioperative nurse was the scrub person during a robotic-assisted laparoscopic cholecystectomy.She locked the robotic endoscissor into the adaptor on the robotic arm and positioned the tip end into the trocar port in order for the surgeon to dissect the cystic duct and artery,while the surgical assistant placed the clips on the cystic duct and artery.As she reached across the sterile field to insert the cholangiocatheter through the port,the anesthesia provider accidentally made contact with the distal end of the catheter as he stood up to reach the monitor controls.The contaminated end of the catheter touched the endoscopic clip applier,the endoscissor connector that the surgeon was using,the glove of the assistant,and the perioperative nurse's gown sleeve.The surgeon ordered everyone to change their gown and gloves and covered the port area with a sterile towel.What was the rationale for the surgeon to continue to dissect and not change his attire?

A) The tip of the dissector that was in the patient's abdomen was not contaminated.
B) The surgeon planned to remove the dissector after he finished dissecting and then dispose of it.
C) The surgeon's gown was not touched, just the dissector connection to the robotic arm.
D) The surgeon was not in contact with the sterile field because he worked from the robotic console.

Question 18

A 51-year-old male with hepatobiliary disease is scheduled for surgery.The perioperative nurse,during the preoperative assessment,questions and examines the patient for signs and symptoms of jaundice,petechiae,and lethargy and:

A) reviews his chart for bleeding and coagulation times and the platelet count.
B) assesses for ascites and ensures a peritoneal drainage kit is available.
C) palpates his abdomen for left upper quadrant tenderness and liver margins.
D) reviews the findings of his endoscopic retrograde cholangiopancreatoscopy (ERCP).

Question 19

A 52-year-old man,9 days post liver transplant,presents to the ER with tachycardia,fever,right upper quadrant pain and jaundice.These symptoms are reflective of what postoperative complication?

A) Infection
B) Hepatic thrombosis
C) Acute graft rejection
D) Common duct obstruction

Question 20

An example of a potential risk associated with pneumoperitoneum would be:

A) tachycardia caused by peritoneal irritation from the CO₂.
B) CO₂ absorption into the peritoneal capillaries, causing decreased oxygen saturation.
C) bradycardia from CO₂ pressure lower than 15 mm Hg.
D) gas embolus into an exposed blood vessel during the procedure.

Question 21

Both Maryanne and Charles Rigler had surgery 6 days ago.Charles had a living-related donor liver transplant and Maryanne,the matched donor,provided a segment of her healthy liver for her husband.They have both recovered as expected and are preparing for discharge.They are concerned about who will be the primary caregiver,because they are both recovering at the same time and rate.They also realize that they will need clear and realistic instructions and support because of their unique situation.They are most concerned about incision care,symptoms that could mean complications,nutrition,and activity restrictions and escalation.An appropriate risk reduction strategy for Maryanne and Charles would give first priority to:

A) secure an order for social services consult.
B) secure an order for a physical rehabilitation plan.
C) provide Maryanne and Charles with the standard discharge education with emphasis on their concerns.
D) elicit their abilities to provide for themselves and their resources of support.

Question 22

The recipient liver OR is arranged for a major laparotomy and vascular procedure with customized instruments,supplies,and sutures according to the transplant surgeon's preference.In addition to the general patient care accessories,equipment,and supplies needed for any large surgery,also included are intraoperative laboratory testing and an autotransfusion system.Describe the boundaries of the surgical skin prep for the patient about to receive a liver transplant.

A) From neck to midthigh; midaxillary line to midaxillary line
B) From nipple line to pubis; bedline to bedline
C) From the neck to midthigh; bedline to bedline
D) From nipple line to midthigh; midaxillary line on the patient's left side, and bedline on the right

Question 23

Review the list below and select the first step the perioperative nurse must accomplish as a best practice for donor organ identification.

A) Sign receipt for organ.
B) Ensure crossmatch and ABO reports from human leukocyte lab and blood bank have been received.
C) Verify the recipient's preliminary crossmatch and ABO report.
D) Identify the recipient.