These questions are similar to those asked on the American Board of Surgery Recertification Examination. Use them to prepare for the examination, fulfill learning requirements for various maintenance of competence programs, or simply improve your surgical knowledge. Answers can be viewed by following the "Read the Answers" link at the end.

1. The most common cause of wound dehiscence is
   1. Chronic obstructive pulmonary disease
   2. Steroid use
   3. Technical error
   4. Ascites
   5. Suture breakage


2. All of the following signs are absolute indications for neck exploration after penetrating neck trauma, except
   1. Open airway
   2. Branham's sign
   3. Large hematoma
   4. Subcutaneous emphysema
   5. Pulsatile bleeding


3. Rhabdomyolysis
   1. Is characterized by low creatine phosphokinase (CPK) levels
   2. Occurs after 6 hours of muscle ischemia
   3. Is improved after reperfusion
   4. Requires alkalinization of the urine to solubilize myoglobin
   5. Is best treated with diuresis induced by furosemide


4. The nerve that runs along the spermatic cord and supplies sensation to the upper medial thigh is the
   1. Iliohypogastric
   2. Ilioinguinal
   3. Obturator
   4. Genitofemoral
   5. Lumboinguinal


5. Carotid artery stenting for atherosclerotic occlusion
   1. Is indicated in patients who have undergone cervical radiation previously
   2. Has the same stroke rate as endarterectomy
   3. Has no effect on the contralateral carotid artery
   4. Should not be performed in conjunction with coronary artery bypass graft surgery
   5. Lowers the risk of distal embolization


6. Preparation of a patient with sickle cell disease for elective laparoscopic cholecystectomy should include all of the following, except
   1. Hydration
   2. Normothermia
   3. Oxygenation
   4. Prophylactic antibiotics
   5. Exchange transfusion


7. The MELD score
   1. Includes ascites in the determination
   2. Measures the expected success rate of liver transplantation
   3. Determines the expected 3-month mortality rates without transplantation
   4. Is less objective than the Child classification
   5. Is highly dependent on the level of serum albumin


8. Acute cholangitis
   1. Can be distinguished from acute cholecystitis by the presence of jaundice
   2. Requires immediate cholecystectomy
   3. Carries a mortality rate of 12%
   4. Is best treated using operative common duct exploration
   5. Is a component of acalculous cholecystitis


9. Neuroblastomas
   1. Occur most frequently in the mediastinum
   2. Frequently cause diarrhea due to hypersecretion of vasoactive intestinal polypeptide (VIP)
   3. Have a better prognosis if discovered before age 1 year
   4. Are stage III if unresectable and associated with positive ipsilateral lymph nodes
   5. Have the worst prognosis if the primary is in the mediastinum


10. Pseudoaneurysms
    1. Are most commonly caused by trauma
    2. Are generally asymptomatic
    3. Occur most commonly in the iliac artery
    4. Can be treated using ultrasonography-guided thrombin injection
    5. Are best diagnosed using computed tomography


11. Epigastric hernias
    1. Occur overwhelmingly in females
    2. Are common in children
    3. Are multiple in 20% of patients
    4. Require mesh for repair
    5. Are generally asymptomatic


12. All of the following are indications for operative therapy for bleeding duodenal ulcers, except
    1. Hemorrhage severe enough to induce shock
    2. Bleeding with no prior symptoms
    3. Persistent bleeding despite endoscopic therapy
    4. Bleeding in a patient who has ischemic heart disease
    5. Need for transfusion of 2 units of blood

Read the Answers

Answers

1. c—Although chronic obstructive pulmonary disease, steroid use, ascites, and suture breakage predispose patients to wound dehiscence, overwhelmingly, the most frequent cause is a technical error, generally taking inadequate bites of fascia.



2. c—A large hematoma arouses concern, but operative exploration is absolutely indicated only if the hematoma is expanding. Venous injuries, which can create large hematomas, often stop bleeding spontaneously and do not necessarily require exploration. An open airway and subcutaneous emphysema suggest tracheal injury, which needs to be repaired. Pulsatile bleeding implies arterial injury, and exploration and vascular repair are necessary. Branham's sign is a manifestation of an arteriovenous fistula that needs to be repaired.



3. d— Solubilization of myoglobin to facilitate its excretion is critical to protect the kidneys. Rhabdomyolysis is characterized by markedly elevated CPK levels and occurs after as few as 2 hours of ischemia. It is often worsened by reperfusion injury. Furosemide lowers urinary pH and is contraindicated. Saline infusion to induce diuresis is the most effective modality, with bicarbonate added to alkalinize the urine.



4. b—The iliohypogastric nerve is far cephalad and penetrates the quadratus lumborum. The ilioinguinal nerve runs along the spermatic cord and supplies sensation to the upper medial thigh. The obturator nerve passes beneath the iliac vessels. The genitofemoral nerve divides into the lumboinguinal nerve and the genital nerve, which supply the femoral triangle and the scrotal skin, respectively.



5. a—Radiation causes small vessel occlusion and wound problems; thus, stenting is preferable to endarterectomy. In low-risk patients, stenting is associated with a two-fold increase in stroke rate. Stenting puts the contralateral carotid artery at risk from the manipulation and instrumentation, and it does not prevent (rather, it facilitates) distal embolization on the ipsilateral side. Finally, it is the procedure of choice in patients with both coronary and carotid occlusion.



6. e—For patients with SS sickle cell disease undergoing extensive operations, exchange transfusion is indicated to lower hemoglobin S levels of <30% of total hemoglobin. It is not routinely indicated for those undergoing laparoscopic cholecystectomy. Alternatively, in very anemic patients, transfusion to a hemoglobin level of 10 g/dL may be used because administration of blood with 100% hemoglobin A dilutes the concentration of hemoglobin S. Hydration, normothermia, and oxygenation are all critical. Patients with sickle cell disease are somewhat immunosuppressed because of splenic infarcts; thus, prophylactic antibiotics are definitely indicated. In fact, many clinicians suggest maintenance of antimicrobial therapy for a minimum of 5 days postoperatively.



7. c—The MELD score is used to prioritize patients for liver transplantation by determining which ones are at greatest risk for early (3-month) mortality without transplantation. The MELD score is based on the international normalized ratio (INR) and serum creatinine and total bilirubin levels. The presence or absence of ascites and the serum albumin level are not factored into the calculation. Because the MELD score is quantitative, it is more objective than the Child classification. However, it does not predict survival after transplantation.



8. a—Cholangitis is caused by obstruction of the common hepatic duct or common bile duct and causes jaundice. In contrast, acute cholecystitis is caused by obstruction of the cystic duct, and although bilirubin levels may become minimally elevated, jaundice is not characteristic. The immediate need is for decompression of the bile duct (not cholecystectomy), which is best achieved by endoscopic retrograde cholepancreatography (ERCP). The mortality rate averages 2% to 5%. Acalculous cholecystitis is inconsistent with cholangitis, because no stones are present to obstruct the bile duct.



9. b—VIP-mediated watery diarrhea syndrome is a common paraneoplastic syndrome caused by neuroblastomas. Only 20% to 25% of neuroblastomas occur in the mediastinum, and these lesions have the best (not worst) prognosis. As described, these lesions are stage II. For a neuroblastoma to be classified as stage III, it needs to extend across the midline or be associated with positive contralateral lymph nodes. The prognosis is excellent if the lesion is discovered before (not after) the patient is 1 year old.



10. d—The recently developed thrombin injection has been an excellent minimally invasive modality for treating pseudoaneurysms. Most pseudoaneurysms are iatrogenic and are complications of arterial injections; the next most frequent cause is infection, followed by external trauma. Pseudoaneurysms are generally symptomatic and any pain is due to compression of adjacent structures. The most common site of occurrence is the femoral artery, specifically at the junction of the common and deep femoral arteries. These lesions are best evaluated using duplex ultrasonography, which defines their morphology, location, and size.



11. c—Epigastric hernias are frequently multiple, which must be considered when deciding how to treat affected patients. Epigastric hernias occur almost exclusively in males and adults. Because the defects are tiny, pain is caused by incarceration of preperitoneal fat. These hernias can be primarily repaired without using mesh.



12. e—Operation is indicated after 4 to 6 units of blood have been transfused, as long as the patient remains stable. Hemodynamic instability is an indication for operation, as is the failure of endoscopic therapy to stop bleeding. Patients who bleed but have no prior symptoms have a 30% chance of hemorrhage recurring, which is again likely to begin suddenly, with no previous symptoms or early warning signs; this scenario carries a 20% mortality rate. Patients with ischemic heart disease cannot tolerate any decrease in blood pressure; consequently, early operation is indicated in this group of patients.