Unexpected findings in emergency surgery.

[davosPlatz]

---

Members don't see this ad.

This is an area of discrepancy between behavioral science review books, USMLEWorld and Kaplan QBank.

A 45 y/o woman with an acute abdomen presents to the ED and is taken to the OR for an appy. Upon resection her appendix is normal and not inflamed; a mass is discovered on her right ovary.

Here is how this scenario is approached:

Fadem Behavioral Science: vague. This is an emergency surgery. If it were non-emergent, do nothing and wait for patient consent.

UWorld: Biopsy the mass.

Kaplan Qbank: Close her and wait for consent.

The difficulty comes when the surgery is emergent and therefore the mass could be the cause of the acute abdomen. Thoughts?

 

[perilou]

This is an area of discrepancy between behavioral science review books, USMLEWorld and Kaplan QBank.

A 45 y/o woman with an acute abdomen presents to the ED and is taken to the OR for an appy. Upon resection her appendix is normal and not inflamed; a mass is discovered on her right ovary.

Here is how this scenario is approached:

Fadem Behavioral Science: vague. This is an emergency surgery. If it were non-emergent, do nothing and wait for patient consent.

UWorld: Biopsy the mass.

Kaplan Qbank: Close her and wait for consent.

The difficulty comes when the surgery is emergent and therefore the mass could be the cause of the acute abdomen. Thoughts?

Hmmm, if it is emergent, then I would think some action would need to be taken (biopsy/removal). Even though the patient is unconscious, I believe that, in the absence of a DNR, there is implied consent.

Now if it is non-emergent, you definitely need consent.

These are my guesses.

 

[pseudoknot]

The scenario you gave doesn't make it sound like the mass is causing peritonitis. Obviously if it were you'd have to treat it, but that would be too easy a question. It sounds like the usual situation where you go in for one thing and find something else. Technically, if you don't have consent for each procedure, you can't do it.

At my hospital, and probably most in the real world, the consent you actually sign is so broad as to negate this for the most part, but on the test I'd say close and talk to pt.

 

[Mortal_Lessons]

I did the Qbank question and it has a different answer choice than you are presenting. I think what you have done is conflate two answers and concepts with a similar presentation. If a patient presents with an acute abdomen and you take them to the ER for emergency surgery for what you think is acute appendicitis, if you open them up and find an ectopic pregnancy (which is what one of the Kaplan question says), then you can remove it regardless of whether she's Catholic and would object to the termination of a pregnancy. This is because the ectopic pregnancy can be acutely lethal if not removed, and this is an emergency situation.

There is another similar question but upon opening the abdomen, a large R ovarian mass is discovered. Because the mass is likely not going to acutely kill her, the correct answer is to biopsy the mass and close the abdomen. I'm not sure where you got "close her and wait for consent." It was "biopsy the mass and wait for further consent."

 

[PepperMD]

I did the Qbank question and it has a different answer choice than you are presenting. I think what you have done is conflate two answers and concepts with a similar presentation. If a patient presents with an acute abdomen and you take them to the ER for emergency surgery for what you think is acute appendicitis, if you open them up and find an ectopic pregnancy (which is what one the Kaplan question says), then you can remove it regardless of whether she's Catholic and would object to the termination of a pregnancy. This is because the ectopic pregnancy can be acutely lethal if not removed, and this is an emergency situation.

There is another similar question but upon opening the abdomen, a large R ovarian mass is discovered. Because the mass is likely not going to acutely kill her, the correct answer is to biopsy the mass and close the abdomen. I'm not sure where you got "close her and wait for consent." It was "biopsy the mass and wait for further consent."

I second this. I got that exact question (ectopic) just yesterday in a block and the answer was definitely resect first, ask questions later.

 

[SouthernSurgeon]

I did the Qbank question and it has a different answer choice than you are presenting.

There is another similar question but upon opening the abdomen, a large R ovarian mass is discovered. Because the mass is likely not going to acutely kill her, the correct answer is to biopsy the mass and close the abdomen. I'm not sure where you got "close her and wait for consent." It was "biopsy the mass and wait for further consent."

It has been a while since I did these questions for step I review - but this sounds like what I recall as well.

The difficulty comes when the surgery is emergent and therefore the mass could be the cause of the acute abdomen. Thoughts?

If it is an emergency surgery and the mass is potentially the cause of the acute abdomen, you can (actually must) take it out - the life-threatening nature of the process overrides the normal informed consent requirement. Additionally, the initial consent obtained covers the need for emergent life-saving surgery - by consenting to that surgery, the patient was saying "get in there and fix me" not "take out my appendix but don't touch anything else"

I agree with others that you are lumping two different scenarios together - an "ovarian mass" is an unlikely cause of the acute abdomen and thus doesn't fall under the emergency exemption I discussed above. In this case, I think biopsy then get consent prior to resecting is the correct answer (b/c it would be against the patient's best interests to close w/o biopsying, but your emergency consent doesn't cover what would normally be an elective surgery).

 

[SeminoleFan3]

I did the Qbank question and it has a different answer choice than you are presenting. I think what you have done is conflate two answers and concepts with a similar presentation. If a patient presents with an acute abdomen and you take them to the ER for emergency surgery for what you think is acute appendicitis, if you open them up and find an ectopic pregnancy (which is what one the Kaplan question says), then you can remove it regardless of whether she's Catholic and would object to the termination of a pregnancy. This is because the ectopic pregnancy can be acutely lethal if not removed, and this is an emergency situation.

There is another similar question but upon opening the abdomen, a large R ovarian mass is discovered. Because the mass is likely not going to acutely kill her, the correct answer is to biopsy the mass and close the abdomen. I'm not sure where you got "close her and wait for consent." It was "biopsy the mass and wait for further consent."

I don't think it matters if she's Catholic or not because ecoptic pregnancy is one of the situations where removing the mass is not considered a sin...just something I learned the other day while studying.

 

[davosPlatz]

I did the Qbank question and it has a different answer choice than you are presenting. I think what you have done is conflate two answers and concepts with a similar presentation. If a patient presents with an acute abdomen and you take them to the ER for emergency surgery for what you think is acute appendicitis, if you open them up and find an ectopic pregnancy (which is what one the Kaplan question says), then you can remove it regardless of whether she's Catholic and would object to the termination of a pregnancy. This is because the ectopic pregnancy can be acutely lethal if not removed, and this is an emergency situation.

There is another similar question but upon opening the abdomen, a large R ovarian mass is discovered. Because the mass is likely not going to acutely kill her, the correct answer is to biopsy the mass and close the abdomen. I'm not sure where you got "close her and wait for consent." It was "biopsy the mass and wait for further consent."

Yes, that's correct for UW. There is another question on Kaplan that suggests closure. There are multiple scenarios. The one you present exists. But the bottom line is, what gives you the right to biopsy the mass without consent? If it were truly an emergency, you would resect it. If it weren't, you would close and obtain consent. Don't be so smug with your choice.

 

[pseudoknot]

Aside from the consent issue, we were taught in class that you shouldn't biopsy ovarian masses because it can lead to intraperitoneal spread of the cancer.

 

[SouthernSurgeon]

Yes, that's correct for UW. There is another question on Kaplan that suggests closure. There are multiple scenarios. The one you present exists. But the bottom line is, what gives you the right to biopsy the mass without consent? If it were truly an emergency, you would resect it. If it weren't, you would close and obtain consent. Don't be so smug with your choice.

I think the principle would be that since the patient is already open, you would be exposing them to too much risk by closing them and them having to go back later for a second surgery

 

[NCF145]

BRS Behavioral Science, p.220

-If an unexpected finding during surgery necessitates a non-emergency procedure for which the patient has not given consent (e.g., biopsy of an ususpected ovarian malignancy found during tubal ligation), the patient must be given the opportunity to provide informed consent before the additional procedure can be performed. In an emergency in which it is impossible to obtain consent (e.g., a "hot" appendix is found serendipitously during a tubal ligation), the procedure can be done without obtaining consent.