Board Review Questions in Surgery

Anastasios K. Konstantakos, MD, Clinical Fellow Division of Cardiothoracic Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass

1. A 47-year-old man presents with a 4-cm anterior mediastinal mass. The preoperative diagnosis is thymoma. Which is the appropriate operative approach for resection?

1. median sternotomy
2. video-assisted thoracoscopic resection
3. clamshell incision
4. cervical incision
5. all of the above

2. A 37-year-old man is involved in a motor vehicle accident. His chest x-ray shows a widened mediastinum. An aortogram demonstrates a descending thoracic aortic injury. He is also noted to have a grade II splenic injury. Which of these approaches should not be used to repair the aortic injury?

1. total cardiopulmonary bypass
2. partial cardiopulmonary bypass using a Gott shunt
3. left atrial to left femoral bypass using a nonheparinized pump
4. clamp and sew without cardiopulmonary bypass
5. none of the above

3. A 17-year-old man is stabbed in the axilla. He is noted to have loss of function of the ulnar nerve. If nonoperative therapy is used for treatment of this nerve injury, at what rate is the nerve expected to regenerate?

1. 1 mm/wk
2. 1 mm/mo
3. 1 mm/d
4. 10 mm/mo
5. 1 cm/wk

4. A college football player injures his knee while being tackle. He has a positive anterior drawer test. The foot is slightly cooler than the uninjured foot; his dorsalis pedis pulses are palpable but weaker. The next step in management should include:

1. elevation of the leg in a long-length splint
2. manual reduction of the knee joint in a 90? position
3. arteriogram to rule out popliteal artery injury
4. duplex ultrasonography of the superficial femoral artery
5. computed tomography (CT) scan of the leg

5. A 47-year-old paraplegic patient is brought to the emergency department with abdominal distention. He has not had a bowel movement in several days. The abdomen is distended and minimally tender without evidence of peritoneal signs. An abdominal x-ray shows massive distention of the colon. The next step in management should include:

1. intravenous vancomycin
2. intravenous hydration and preparation for immediate operation
3. colonoscopic decompression
4. CT scan of the abdomen
5. diagnostic laparoscopy

6. The diagnosis of compartment syndrome in the lower extremity includes all the following conditions, except:

1. compartmental pressure >35 mm Hg
2. pain on passive dorsiflexion of the foot
3. diminished peripheral perfusion
4. paresthesias of the lower extremity
5. increased hyperemia below the knee

7. A 7-year-old child undergoes general anesthesia for repair of an inguinal hernia. Ten minutes into the operation, the patient is noted to have a temperature of 104?F, tachycardia, and diffuse skeletal muscle rigidity. The most appropriate treatment for this situation is:

1. hyperventilation to achieve a Pco₂ <25 mm Hg
2. dantrolene sodium
3. subcutaneous heparin sodium
4. intramuscular epinephrine
5. none of the above

8. A 67-year-old smoker undergoes a chest CT scan to evaluate a 1-cm lung nodule found on chest x-ray. The CT scan demonstrates mediastinal adenopathy. The next step in the workup should be:

1. magnetic resonance imaging (MRI) scan of the chest and abdomen
2. liver-spleen scan to evaluate for metastases
3. chemotherapy consultation
4. radiotherapy consultation
5. bronchoscopy and mediastinoscopy

9. A 47-year-old woman who noticed a lump at the base of her neck was found to have a 2-cm nodule in the right lower lobe of the thyroid gland. Fine-needle aspiration showed follicular cells. The next step in management should be:

1. CT scan of the neck and chest
2. MRI of the head and neck
3. excisional nodulectomy
4. hemithyroidectomy
5. total thyroidectomy followed by chemotherapy and radiation

10. A 65-year-old man presents with moderate epigastric pain of 2 weeks' duration radiating to his back. Evaluation reveals a 3-cm tumor in the head of the pancreas. All the following conditions would preclude tumor resectability, except:

1. the presence of extrapancreatic disease
2. evidence of tumor extension to the superior mesenteric artery
3. evidence of tumor extension to the celiac axis
4. a patent superior mesenteric vein?portal vein confluence
5. involvement of a single lymph node in the hepatic hilum

11. All the following statements are true regarding treatment for skin pressure ulcers, except:

1. sharp debridement is the most rapid and efficient method of removing devitalized tissue
2. mechanical debridement may remove granulation tissue as well as nonviable tissue
3. chemical debridement with enzymatic agents affects necrotic tissues such as protein, fibrin, and collagen
4. autolytic debridement uses the body's enzymes to digest devitalized tissue
5. autolytic debridement is typically quite painful

12. An established indication for coronary artery bypass grafting remains:

1. critical left main disease
2. triple-vessel disease with normal ventricular function
3. 2-vessel disease of the right coronary and left circumflex arteries
4. distal left anterior descending artery disease
5. right coronary artery disease with congestive heart failure

13. Indications for percutaneous transluminal angioplasty (PTA) and stenting of iliac arteries include all of the following, except:

1. ulcerated stenotic plaques
2. iliac arterial occlusions
3. arterial dissections after PTA
4. failure of PTA (residual stenosis >15%)
5. recurrent stenosis after PTA

ANSWERS

1?E. The traditional approach to thymectomy has been complete resection using a median sternotomy, but other approaches such as hemisternotomy, cervical incision, clamshell incision, and videoassisted thoracic surgery have all been used. Each has its advantages and disadvantages. Proponents of the various incisions claim similar curative rates.¹

Reference

Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice

1. Lau CL, Davis RD. Mediastinum. In: Townsend CM, ed. . 16th ed. Philadelphia, Pa: WB Saunders; 2001:1185-1204.

2?A. While several operative approaches have been described for repairing descending aortic injury in the setting of blunt trauma, the use of complete cardiopulmonary bypass with full-dose systemic heparinization is to be avoided in the patient with solid organ injury because of increased risk for life-threatening bleeding. There are advantages and disadvantages to each approach. Centers with extensive experience tend to use bypass techniques less often and have acceptable postoperative paraplegia and mortality rates.

3?C. When a nerve axon is disrupted, such as occurs with axonotmesis or neurotmesis, the distal nerve degenerates to the motor endplate and the proximal nerve degenerates back to the nodes of Ranvier. If scar tissue does not prohibit renewal, nerves will regenerate at an average of 1 mm/d.

4?C. Dislocation of the knee, with or without long bone fracture, is the most common injury associated with popliteal vascular trauma. Without prompt recognition and surgical treatment, the amputation rate may exceed 50%.¹

Reference

Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice

1. Hoyt DB, Coimbra R, Winchell RJ. Management of acute trauma. In: Townsend CM, ed. . 16th ed. Philadelphia, Pa: WB Saunders; 2001:311-344.

5?C. Colonic pseudoobstruction, otherwise known as Ogilvie's syndrome, usually affects patients who are bedridden, critically ill, or chronically debilitated. Initial treatment involves correcting any underlying medical etiology. If this does not rectify the pseudoobstruction, then urgent colonoscopic decompression is the treatment of choice.

6?E. Compartment syndrome of the lower extremity is an acute process characterized by increased pressure within one of the compartments of the lower leg. This is often the result of extensive bony or soft tissue injury, usually with an ischemic etiology. Pain is the most common symptom, especially when associated with passive dorsiflexion of the foot. Diagnosis is confirmed by elevated compartmental pressure, typically greater than 35 mm Hg, as measured by a manometric catheter.

7?B. Malignant hyperthermia is an unusual complication after administration of muscle relaxants and inhaled general anesthetics. Elevated fever, tachycardia, rigidity, skin mottling, and cyanosis occur within 30 minutes after induction of the offending agent. Treatment includes cessation of the operation as well as intravenous dantrolene sodium, which blocks calcium release from the sarcoplasmic reticulum.¹

Reference

Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice

1. Sherwood ER, Prough DS. Anesthesiology principles. In: Townsend CM, ed. . 16th ed. Philadelphia, Pa: WB Saunders; 2001:257-282.

8?E. Evaluation of a lung tumor found on radiologic imaging should include thorough assessment of the primary tumor site as well as a search for local and distant metastatic disease. Assuming a negative metastatic workup, the finding of mediastinal adenopathy in association with a lung tumor requires biopsy for diagnosis. This is often best approached via a bronchoscopy and mediastinoscopy, with biopsy of the mediastinal lymph nodes to evaluate the stage of the disease before further treatment.

9?D. The presence of follicular cells on a fine-needle aspiration biopsy of a thyroid mass is a vexing problem. Because these cells may indicate either benign follicular adenoma or follicular carcinoma, it may not be possible to arrive at the diagnosis preoperatively. The initial surgical approach?hemithyroidectomy versus total thyroidectomy? for a tumor with follicular cytology is a subject of debate.¹

Reference

Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice

1. Hanks JB. Thyroid. In: Townsend CM, ed. . 16th ed. Philadelphia, Pa: WB Saunders; 2001:603-628.

10?D. Criteria for periampullary tumor resectability on CT scan include absence of extrapancreatic disease, no evidence of tumor extension to the superior mesenteric artery or celiac axis, and a patent superior mesenteric vein?portal vein confluence.¹

Reference

J Am Coll Surg

1. Sohn TA, Lillemoe KD, Cameron JL, et al. Surgical palliation of unresectable periampullary adenocarcinoma in the 1990s. . 1999;188:658-666.

11?E. Mechanical debridement may remove granulation tissue as well as nonviable tissue. Sharp debridement is the most rapid and efficient method for removing nonviable tissue. Chemical debridement with enzymatic agents affects necrotic tissues such as protein, fibrin, and collagen. The type of enzyme chosen depends on the type of tissue to be removed. Autolytic debridement uses the body's enzymes to digest devitalized tissue. This technique is not painful but does require considerable time.¹

Reference

Clin Chest Med

1. Peerless JR, Davies A, Klein D, et al. Skin complications in the intensive care unit. . 1999;20:453-467.

12?A. Indications for surgical treatment of significant coronary artery disease include critical left main disease as well as triple-vessel disease with decreased ejection fraction.¹

Reference

J Am Coll Surg

1. Merrill WH. What's new in cardiac surgery. . 2002;194:617-635.

13?D. Patency rates after PTA for certain iliac lesions may be improved by placing a stent through the dilated segment. Indications for stenting include ulcerated stenotic plaques, iliac arterial occlusions, arterial dissections after PTA, failure of PTA (residual stenosis >30%), and recurrent stenosis after PTA. For long lesions, multiple stents can be placed, with stents overlapping each other by 2 to 3 mm.¹

Reference

Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice

1. Belkin M, Whittemore AD, Donaldson MC, et al. Peripheral arterial occlusive disease. In: Townsend CM, ed. . 16th ed. Philadelphia, Pa: WB Saunders; 2001:1373-1402.