ABSITE Biliary Critical and Objective Assessment Exam Questions and verified and correct Marking Scheme, Newest Guaranteed 2024/2025
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ABSITE Biliary Critical and Objective Assessment Exam Questions and verified and correct Marking Scheme, Newest Guaranteed 2024/2025
A 19-year-old female is admitted with a diagnosis of choledocholithiasis. Preoperative MRCP reveals 4 filling defects in the extrahepatic biliary tree, three of wh...
ABSITE Biliary Critical and Objective
Assessment Exam Questions and verified
and correct Marking Scheme, Newest
Guaranteed 2024/2025
A 19-year-old female is admitted with a diagnosis of
choledocholithiasis. Preoperative MRCP reveals 4 filling defects
in the extrahepatic biliary tree, three of which are caudal and
one of which is cranial to the insertion of the cystic duct. The size
of the largest stone is 8 mm. Which of the following represents a
contraindication to laparoscopic transcystic common bile duct
exploration (LTCBDE) in this patient?
A. The presence of more than 3 stones
B. The size of the largest stone being 8 mm
C. The presence of a common hepatic duct stone
D. Age less than 21 - correct answer C. The presence of a
common hepatic duct stone
Correct.
The contraindications to LTCBDE are: greater than 8 CBD stones
(Choice A), stones greater than 1 cm in size (Choice B), common
hepatic duct stones (Choice C) and a small friable cystic duct.
Age is not a contraindication. The indications for LTCBDE
include less than 6 CBD stones, stones less than 9 mm in size,
and stones below the cystic duct insertion onto the bile duct.
Choledochoscopy can increase rates of CBD clearance to up to
95%. Completion cholangiogram to document CBD clearance is
recommended.
A 62-year-old female presents with choledocholithiasis. After an
attempt at laparoscopic cholecystectomy is aborted and
converted to open exploration secondary for failure to progress,
the cholecystectomy proceeds without difficulty. Preoperative
imaging revealed a 1.5-cm stone in the distal CBD. The decision
,is made to proceed with open CBD exploration. Which of the
following should be included as part of the procedure?
A. Make a small incision on the CBD so that a T-tube is not
necessary
B. Using a rigid choledochoscope in the case of an impacted
stone that cannot be extracted via flexible choledochoscopy
C. Mobilization of the duodenum
D. Placing the choledochotomy in a horizontal direction on the
CBD at the level of the cystic duct insertion - correct answer C.
Mobilization of the duodenum
Correct.
During both open and laparoscopic CBD exploration, the
choledochotomy should be made in a longitudinal, not horizontal
(Choice D) direction on the anterior surface of the supraduodenal
CBD at the level of the cystic duct insertion. During both
procedures, the choledochotomy should be closed over a T-tube
with 4-0 absorbable suture (Choice A). Rigid scopes should not
be used in the CBD because they may injure the biliary
epithelium (Choice B). Mobilization (Kocher maneuver) of the
duodenum is an important operative step in open CBDE
exploration as it allows for the milking of impacted CBD stones
from distal to proximal (Choice C).
A 42-year-old female presents to the Emergency Department
with jaundice four months following laparoscopic
cholecystectomy. She has normal vital signs, a WBC of 11.2 and
her serum bilirubin is 2.9. Magnetic resonance
cholangiopancreatography identifies a 2-cm biliary stricture near
the hepatic duct bifurcation without a subhepatic fluid collection.
What is the best next step to manage this patient?
A. Radionucleotide biliary scan
B. Endoscopic retrograde cholangiography
C. Percutaneous balloon dilation
,D. Choledochoduodenostomy
E. Roux-en-Y hepaticojejunostomy - correct answer Roux-en-Y
hepaticojejunostomy
Correct.
In most cases of postoperative biliary strictures,
hepaticojejunostomy constructed to a Roux-en-Y limb of jejunum
is the preferred procedure, especially given the stricture length
and location near the hepatic bifurcation. Anastomosis of the
proximal bile duct to the duodenum as a
choledochoduodenostomy is not suitable for most
postcholecystectomy strictures because an adequate length of
bile duct for creating a tension-free anastomosis usually cannot
be obtained. There is no evidence of bile leak on preoperative
imaging; therefore, a radionucleotide biliary scan is not
indicated. ERCP would not be beneficial in this case as MRCP
provides excellent delineation of the biliary anatomy and
preoperative biliary decompression in patients without
cholangitis has not been demonstrated to improve outcome.
Surgical repair for benign postoperative strictures appears to be
associated with fewer problems and a greater success rate than
balloon dilation.
A 58-year-old female is admitted with choledocholithiasis
(demonstrated on ultrasound), jaundice, and leukocytosis. MRCP
confirms a large stone in the distal CBD. She undergoes
attempted ERCP, but the stone Is unable to be extracted or
fragmented. You take her to the operating room for an open CBD
exploration. Despite kocherization of the duodenum, you are
unable to extract the stone, and decide to perform a
transduodenal sphincteroplasty. Where should the incision be
made on the sphincter?
A. 3 o'clock
B. 5 o'clock
C. 6 o'clock
D. 9 o'clock
, E. 11 o'clock - correct answer 11 o'clock
Correct.
A small longitudinal duodenotomy is made over the ampulla and
two stay sutures placed on each side of the ampulla to elevate it.
A small incision is made at the 11-o'clock position in the
sphincter taking care to avoid the pancreatic duct, which is
usually found at the 5-o'clock position. The sphincterotomy is
extended through the sphincter (approximately 1.5 cm) and the
impacted stone removed. The bile duct and duodenal mucosa are
then reapproximated with interrupted 4-0 absorbable sutures.
A 34-year-old female undergoing laparoscopic cholecystectomy
has evidence of bile leakage in the operative field. Intraoperative
cholangiogram confirms atypical anatomy with transection of a 5-
mm right hepatic posterior lobe segmental duct that drains
multiple hepatic segments into the cystic duct. The injured bile
duct segment is 2 mm in length. What is the most appropriate
intervention to reduce the incidence of postoperative
complications?
A. Simple ligation of the injured duct
B. Immediate end-to-end bile duct anastomosis
C. Immediate choledochoduodenostomy
D. Immediate Roux-en-Y choledochojejunostomy
E. Delayed Roux-en-Y hepaticojejunostomy - correct answer
Immediate end-to-end bile duct anastomosis
Correct.
Repair should be carried out at the time of injury if recognized to
avoid development of biliary stricture if a qualified surgeon is
available with experience in complex hepatobiliary work.
Primary, tension-free repair may be attempted. A segmental bile
duct 4 mm or larger is likely to drain multiple hepatic segments
or the entire right or left lobe and requires operative repair.
Simple ligation of an injured duct is adequate for a segmental or
accessory duct less than 3 mm that cholangiography
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