A woman on apixaban 5 mg twice daily for atrial fibrillation (CHA2DS2-VASc score 3), with creatinine clearance 80 mL/min, is booked for an open liver resection, a high bleeding-risk operation. How should apixaban be handled before surgery?

Stop 2 days before; no bridging

Stop 5 days before; bridge with LMWH

In the labour room, a primigravida at 26 weeks has right-sided abdominal pain, fever and tenderness higher than McBurney's point; ultrasound shows a non-compressible appendix of 9 mm. According to SAGES guidance, which approach is best?

Laparoscopic appendicectomy, adapted entry and left tilt

Antibiotics alone until delivery

Open appendicectomy only, as laparoscopy is unsafe after 20 weeks

Caesarean section followed by appendicectomy

Six weeks after a sleeve gastrectomy, a shop owner is brought by her husband: she has vomited after almost every meal for 3 weeks because of a narrowing at the incisura. Now she is confused, unsteady when walking and has nystagmus on lateral gaze. Capillary glucose is 62 mg/dL. The casualty officer has drawn up IV 25% dextrose. Which should be given first?

IV thiamine, before or with the dextrose

After a Veress needle is placed at the umbilicus, the insufflator shows an opening pressure of 14 mmHg at a flow of 1 L/min, and the abdomen distends unevenly, bulging only around the umbilicus. The patient is obese and had a previous lower midline scar. What should the surgeon do?

Withdraw and re-site, or use open entry

Increase the flow rate to 6 L/min

Continue until the pressure reaches 15 mmHg

Insert the first trocar blindly at once

Bariatric, minimal access surgery and perioperative care

52 NEET-PG practice questions on Bariatric, minimal access surgery and perioperative care, part of General Surgery. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Medium
A woman on apixaban 5 mg twice daily for atrial fibrillation (CHA2DS2-VASc score 3), with creatinine clearance 80 mL/min, is booked for an open liver resection, a high bleeding-risk operation. How should apixaban be handled before surgery?
1. AStop on the morning of surgery
2. BContinue it through surgery
3. CStop 5 days before; bridge with LMWH
4. DStop 2 days before; no bridging
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Answer: D · Stop 2 days before; no bridging
Direct oral anticoagulants have short half-lives, so they are stopped for a fixed interval without heparin bridging. With normal renal function, apixaban is held for 1 day before low bleeding-risk surgery and 2 days before high bleeding-risk surgery, as in the PAUSE study. Bridging only adds bleeding. Key point: Hold apixaban 2 days before high bleeding-risk surgery (1 day for low risk); DOACs do not need bridging.
- A: Stopping on the day leaves an anticoagulant effect during surgery.
- B: Continuing a DOAC through major liver surgery risks serious bleeding.
- C: Five days and bridging is the warfarin approach, not for a DOAC.
Question 2 · Medium
Physiological effects of a CO2 pneumoperitoneum at 15 mmHg: 1. Systemic vascular resistance rises. 2. Functional residual capacity falls. 3. Urine output falls. 4. Intracranial pressure falls. Which are correct?
1. A1 and 3 only
2. B1, 2, 3 and 4
3. C1, 2 and 3 only
4. D2, 3 and 4 only
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Answer: C · 1, 2 and 3 only
Raised intra-abdominal pressure and absorbed CO2 increase systemic vascular resistance and mean arterial pressure, push the diaphragm up so FRC and compliance fall, and compress the kidneys and their veins so urine output falls. Intracranial pressure rises, from hypercapnia and impaired venous drainage, so statement 4 is false. Key point: Pneumoperitoneum raises SVR and intracranial pressure and lowers FRC and urine output.
- A: Statement 2 is also true: FRC falls.
- B: Statement 4 is false, so all four cannot be correct.
- D: Statement 4 is false: intracranial pressure rises.
Question 3 · Medium
In the labour room, a primigravida at 26 weeks has right-sided abdominal pain, fever and tenderness higher than McBurney's point; ultrasound shows a non-compressible appendix of 9 mm. According to SAGES guidance, which approach is best?
1. AAntibiotics alone until delivery
2. BOpen appendicectomy only, as laparoscopy is unsafe after 20 weeks
3. CCaesarean section followed by appendicectomy
4. DLaparoscopic appendicectomy, adapted entry and left tilt
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Answer: D · Laparoscopic appendicectomy, adapted entry and left tilt
SAGES states laparoscopy can be done safely in any trimester when indicated. Adaptations include open (Hasson) or upper-abdominal entry above the uterine fundus, insufflation at 10-15 mmHg, left lateral tilt to relieve aortocaval compression, and fetal monitoring before and after. Delaying surgery for appendicitis raises perforation and fetal loss. Key point: Laparoscopy is safe in any trimester; adapt entry to fundal height and tilt the patient left.
- A: Delay risks perforation, which greatly increases fetal loss.
- B: Laparoscopy is not limited to before 20 weeks.
- C: Caesarean section is not indicated for appendicitis.
Question 4 · Hard
Six weeks after a sleeve gastrectomy, a shop owner is brought by her husband: she has vomited after almost every meal for 3 weeks because of a narrowing at the incisura. Now she is confused, unsteady when walking and has nystagmus on lateral gaze. Capillary glucose is 62 mg/dL. The casualty officer has drawn up IV 25% dextrose. Which should be given first?
1. AIV vitamin B12
2. BIV thiamine, before or with the dextrose
3. CIV 25% dextrose alone
4. DOral multivitamin tablets
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Answer: B · IV thiamine, before or with the dextrose
Persistent vomiting after bariatric surgery quickly depletes thiamine, and confusion, ataxia and nystagmus are Wernicke encephalopathy. Glucose given without thiamine can precipitate or worsen it, so high-dose IV thiamine is given first or with glucose, then the stricture is treated by endoscopic dilatation. Key point: Vomiting after bariatric surgery with confusion, ataxia and nystagmus: IV thiamine before glucose.
- A: B12 deficiency develops over months to years and does not give acute Wernicke features.
- C: Dextrose alone may worsen Wernicke encephalopathy.
- D: Oral tablets will not be absorbed or tolerated with vomiting.
Question 5 · Medium
After a Veress needle is placed at the umbilicus, the insufflator shows an opening pressure of 14 mmHg at a flow of 1 L/min, and the abdomen distends unevenly, bulging only around the umbilicus. The patient is obese and had a previous lower midline scar. What should the surgeon do?
1. AIncrease the flow rate to 6 L/min
2. BContinue until the pressure reaches 15 mmHg
3. CWithdraw and re-site, or use open entry
4. DInsert the first trocar blindly at once
Show answerHide answer
Answer: C · Withdraw and re-site, or use open entry
With a correctly placed needle the initial pressure is low, usually under 8-10 mmHg, and rises gradually with even distension. A high opening pressure or uneven swelling means the tip is in the preperitoneal space, omentum or bowel. The needle must be withdrawn and re-sited, or open Hasson entry used. Key point: A high opening pressure on Veress insufflation means misplacement: stop and re-site or use open entry.
- A: Higher flow will widen a preperitoneal or bowel insufflation.
- B: Reaching the target pressure in the wrong space is dangerous.
- D: Blind trocar entry with a misplaced needle risks bowel and vessel injury.
Question 6 · Medium
After an emergency laparotomy and splenectomy for a ruptured spleen, a motorcyclist is found on CT to have a small frontal contusion that the neurosurgeons are observing. On day 1 his haemoglobin is stable. Which VTE prophylaxis should be started now?
1. AProphylactic enoxaparin
2. BIntermittent pneumatic compression
3. CInferior vena cava filter
4. DTherapeutic enoxaparin
Answer and explanation in LearnFree account
Question 7 · Easy
Which bariatric operation is now performed most often worldwide?
1. AAdjustable gastric band
2. BRoux-en-Y gastric bypass
3. CSleeve gastrectomy
4. DBiliopancreatic diversion
Answer and explanation in LearnFree account
Question 8 · Hard
In the casualty, a motorcyclist hit by a truck has GCS 9 (E2V2M5), a CT head showing a contusion with mild midline shift, and right upper quadrant tenderness. He is haemodynamically stable after 1 L of crystalloid, with pulse 96/min and BP 124/80 mmHg. CT abdomen shows a grade III liver laceration with no contrast blush and a small amount of fluid, and no free gas. He is in the ICU with neurosurgical review awaited. The junior resident suggests a diagnostic laparoscopy to inspect the liver and wash out the blood. What is the best plan?
1. ANon-operative management with close monitoring, avoiding laparoscopy
2. BDiagnostic laparoscopy to assess and treat the liver injury
3. CImmediate laparotomy and packing
4. DAngioembolisation of the liver
Answer and explanation in LearnFree account
Question 9 · Medium
On day 3 after a laparoscopic cholecystectomy in an elderly obese woman, she has vomiting and colicky pain but still passes flatus. There is a small tender lump at the 12 mm umbilical port site. X-ray shows a few dilated small bowel loops. The fascia at the umbilical port was not closed because the incision was small. What is the most likely diagnosis?
1. ARichter-type port-site hernia
2. BPort-site infection
3. CPort-site haematoma
4. DRetained gallstone in the port tract
Answer and explanation in LearnFree account
Question 10 · Medium
On the fifth day after an open appendicectomy for a gangrenous appendix, the wound is red, tender and fluctuant, and a little pus leaks between two skin sutures. Temperature is 37.8 °C and pulse 92/min. There is no spreading cellulitis and the abdomen is soft. What is the best management?
1. AOral amoxicillin and observe
2. BUltrasound to look for a pelvic collection
3. CRe-explore the abdomen in theatre
4. DRemove sutures, drain and pack the wound
Answer and explanation in LearnFree account
Question 11 · Easy
Remission of type 2 diabetes within days of a Roux-en-Y gastric bypass, before much weight is lost, is mainly due to a rise in which hormone?
1. AGhrelin
2. BGlucagon
3. CGLP-1
4. DCortisol
Answer and explanation in LearnFree account
Question 12 · Medium
A man with a permanent pacemaker is listed for a laparoscopic colectomy. Which energy device best avoids electrical interference with the pacemaker?
1. AArgon beam coagulator
2. BUltrasonic (harmonic) shears
3. CMonopolar hook diathermy
4. DMonopolar spatula with a return plate on the thigh
Answer and explanation in LearnFree account
Question 13 · Medium
In the operating theatre, an open pancreatoduodenectomy has been running for 4 hours and 30 minutes. Cefazolin 2 g IV was given 15 minutes before incision, blood loss so far is 800 mL and renal function is normal. What should be done about antibiotic prophylaxis now?
1. ANothing more; one dose covers the operation
2. BGive a repeat dose of cefazolin now
3. CSwitch to meropenem for the rest of surgery
4. DContinue cefazolin 8-hourly for 5 days
Answer and explanation in LearnFree account
Question 14 · Medium
Ninety minutes after a sweet tea and biscuits, a patient who had a Roux-en-Y gastric bypass a year ago gets sweating, tremor and confusion; capillary glucose is 48 mg/dL. Diet advice (small meals, fewer simple sugars, protein with each meal) has not helped over 3 months, and she has had two such episodes while driving. Fasting glucose and HbA1c are normal. Which drug is the next choice?
1. AAcarbose
2. BGlibenclamide
3. CLoperamide
4. DMetformin
Answer and explanation in LearnFree account
Question 15 · Hard
Warfarin is being taken by a retired teacher for non-valvular atrial fibrillation (CHA2DS2-VASc score 2, no previous stroke or TIA); his INR is 2.6. He is listed for an elective laparoscopic right hemicolectomy for a caecal adenocarcinoma in 10 days. Creatinine clearance is 70 mL/min. His cousin, who has a mechanical mitral valve, was given enoxaparin injections before his own operation, and the patient asks for the same. The anaesthetist plans to check the INR on the day before surgery, and the patient is worried about having a stroke while off his tablets. Which plan is most appropriate?
1. AStop the day before and give IV vitamin K
2. BStop warfarin 5 days before; no bridging
3. CStop warfarin 5 days before; bridge with LMWH
4. DContinue warfarin; operate whatever the INR
Answer and explanation in LearnFree account
Question 16 · Medium
An insurance agent with BMI 44 kg/m2 and type 2 diabetes has severe heartburn on two PPIs a day; endoscopy shows grade C oesophagitis and a 3 cm hiatus hernia. He asks for a sleeve gastrectomy because a friend had one and it seemed simpler. HbA1c is 8.6% on two drugs. Which procedure is best?
1. ARoux-en-Y gastric bypass
2. BSleeve gastrectomy with hiatal repair
3. CEndoscopic intragastric balloon
4. DAdjustable gastric band
Answer and explanation in LearnFree account
Question 17 · Easy
For an elective laparoscopic cholecystectomy in an adult, the surgeon sets the CO2 insufflator before placing the working ports. At what intra-abdominal pressure is the pneumoperitoneum usually maintained?
1. A5-8 mmHg
2. B30-35 mmHg
3. C20-25 mmHg
4. D12-15 mmHg
Answer and explanation in LearnFree account
Question 18 · Hard
The anaesthetist plans a spinal anaesthetic for an open inguinal hernia repair at 9 a.m. in a man receiving enoxaparin 40 mg once daily as prophylaxis; his last dose was given at 8 p.m. yesterday. Coagulation tests and platelets are normal. What is the correct decision?
1. AWait until 24 hours after the last dose
2. BProceed; more than 12 hours have passed
3. CGive protamine, then do the spinal
4. DSpinal is contraindicated; give general
Answer and explanation in LearnFree account
Question 19 · Medium
On deficiencies after Roux-en-Y gastric bypass: 1. Iron deficiency is common because the duodenum is bypassed. 2. Vitamin B12 deficiency develops due to loss of intrinsic factor and acid. 3. Calcium and vitamin D absorption falls. 4. Lifelong supplements are not required once weight is stable. Which are correct?
1. A2, 3 and 4 only
2. B1, 2 and 3 only
3. C1 and 2 only
4. D1, 3 and 4 only
Answer and explanation in LearnFree account
Question 20 · Medium
Which bariatric procedure carries the highest risk of protein-calorie malnutrition and fat-soluble vitamin deficiency?
1. ARoux-en-Y gastric bypass
2. BDuodenal switch (BPD-DS)
3. CLaparoscopic sleeve gastrectomy
4. DAdjustable gastric band
Answer and explanation in LearnFree account
Question 21 · Medium
ALL of the following are core elements of an ERAS pathway for elective colorectal surgery EXCEPT:
1. AOpioid-sparing multimodal analgesia
2. BAvoiding fluid overload during surgery
3. CMobilisation on the day after surgery
4. DNil by mouth from midnight
Answer and explanation in LearnFree account
Question 22 · Hard
Ultrasound in a woman who had a Roux-en-Y gastric bypass 4 years ago shows a dilated CBD of 11 mm with a 9 mm distal stone; she has jaundice and a bilirubin of 5.2 mg/dL, and has already had a cholecystectomy. She is stable and has no cholangitis. The gastroenterologist says a standard ERCP cannot be done, and the patient asks why and what the alternative is. A long Roux limb was made during her bypass, and the surgical team has laparoscopic and endoscopic expertise on site. Which approach is most appropriate?
1. AExtracorporeal shock wave lithotripsy alone
2. BStandard ERCP with a side-viewing duodenoscope through the mouth
3. CLaparoscopy-assisted transgastric ERCP through the remnant stomach
4. DLong-term ursodeoxycholic acid to dissolve the stone
Answer and explanation in LearnFree account
Question 23 · Medium
Coronary stenting with a drug-eluting stent was done 6 weeks ago for an acute coronary syndrome in a man now on aspirin and ticagrelor. He has an uncomplicated, reducible inguinal hernia and asks to have it repaired. What is the best advice?
1. ARepair now after stopping both drugs for 7 days first
2. BDefer repair until dual antiplatelet therapy ends
3. CRepair now after stopping aspirin only
4. DRepair now with heparin bridging
Answer and explanation in LearnFree account
Question 24 · Medium
Two hours into a laparoscopic anterior resection at an insufflation pressure of 15 mmHg in a steep head-down position, urine output falls to 0.3 mL/kg/h. BP is 128/76 mmHg, pulse 78/min and end-tidal CO2 38 mmHg, and the catheter flushes freely. Neither ureter has been near the dissection. After the gas is released at the end, urine flow recovers within hours. What best explains the oliguria?
1. AUreteric obstruction from the head-down tilt
2. BRaised intra-abdominal pressure reducing renal perfusion
3. CHypercapnia blocking ADH release
4. DAcute tubular necrosis from hidden hypotension
Answer and explanation in LearnFree account
Question 25 · Easy
On the morning of a laparoscopic cholecystectomy, the ward nurse asks how the hair over the abdomen should be prepared before the patient goes to theatre. What is the recommended practice?
1. ADepilatory cream a week before
2. BClip only if needed, on the day
3. CRazor shave the night before
4. DRazor shave in the theatre
Answer and explanation in LearnFree account

27 more Bariatric, minimal access surgery and perioperative care questions

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Bariatric, minimal access surgery and perioperative care

A woman on apixaban 5 mg twice daily for atrial fibrillation (CHA2DS2-VASc score 3), with creatinine clearance 80 mL/min, is booked for an open liver resection, a high bleeding-risk operation. How should apixaban be handled before surgery?

Physiological effects of a CO2 pneumoperitoneum at 15 mmHg: 1. Systemic vascular resistance rises. 2. Functional residual capacity falls. 3. Urine output falls. 4. Intracranial pressure falls. Which are correct?

In the labour room, a primigravida at 26 weeks has right-sided abdominal pain, fever and tenderness higher than McBurney's point; ultrasound shows a non-compressible appendix of 9 mm. According to SAGES guidance, which approach is best?

After a Veress needle is placed at the umbilicus, the insufflator shows an opening pressure of 14 mmHg at a flow of 1 L/min, and the abdomen distends unevenly, bulging only around the umbilicus. The patient is obese and had a previous lower midline scar. What should the surgeon do?

After an emergency laparotomy and splenectomy for a ruptured spleen, a motorcyclist is found on CT to have a small frontal contusion that the neurosurgeons are observing. On day 1 his haemoglobin is stable. Which VTE prophylaxis should be started now?

Which bariatric operation is now performed most often worldwide?

On the fifth day after an open appendicectomy for a gangrenous appendix, the wound is red, tender and fluctuant, and a little pus leaks between two skin sutures. Temperature is 37.8 °C and pulse 92/min. There is no spreading cellulitis and the abdomen is soft. What is the best management?

Remission of type 2 diabetes within days of a Roux-en-Y gastric bypass, before much weight is lost, is mainly due to a rise in which hormone?

A man with a permanent pacemaker is listed for a laparoscopic colectomy. Which energy device best avoids electrical interference with the pacemaker?

In the operating theatre, an open pancreatoduodenectomy has been running for 4 hours and 30 minutes. Cefazolin 2 g IV was given 15 minutes before incision, blood loss so far is 800 mL and renal function is normal. What should be done about antibiotic prophylaxis now?

An insurance agent with BMI 44 kg/m2 and type 2 diabetes has severe heartburn on two PPIs a day; endoscopy shows grade C oesophagitis and a 3 cm hiatus hernia. He asks for a sleeve gastrectomy because a friend had one and it seemed simpler. HbA1c is 8.6% on two drugs. Which procedure is best?

For an elective laparoscopic cholecystectomy in an adult, the surgeon sets the CO2 insufflator before placing the working ports. At what intra-abdominal pressure is the pneumoperitoneum usually maintained?

The anaesthetist plans a spinal anaesthetic for an open inguinal hernia repair at 9 a.m. in a man receiving enoxaparin 40 mg once daily as prophylaxis; his last dose was given at 8 p.m. yesterday. Coagulation tests and platelets are normal. What is the correct decision?

Which bariatric procedure carries the highest risk of protein-calorie malnutrition and fat-soluble vitamin deficiency?

ALL of the following are core elements of an ERAS pathway for elective colorectal surgery EXCEPT:

Coronary stenting with a drug-eluting stent was done 6 weeks ago for an acute coronary syndrome in a man now on aspirin and ticagrelor. He has an uncomplicated, reducible inguinal hernia and asks to have it repaired. What is the best advice?

On the morning of a laparoscopic cholecystectomy, the ward nurse asks how the hair over the abdomen should be prepared before the patient goes to theatre. What is the recommended practice?