Surgical Rounds®, December 2007, Volume 0, Issue 0

These questions are similar to those asked on the American Board of Surgery Recertification Examination. You can 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 incisional herniorrhaphy technique with the lowest recurrence rate is Component separation Mesh overlay Primary suture Mesh underlay
  2. A walled-off pelvic abscess secondary to sigmoid diverticulitis is Hinchey stage I II III IV
  3. A traumatic intimal flap in the superficial femoral artery Requires immediate operation Is best diagnosed in the operating room Commonly leads to pseudoaneurysm formation Usually heals without complication
  4. Following resolution of acute appendicitis, an interval appendectomy Always reveals luminal occlusion of the appendix Should be performed because of the high incidence of recurrent appendicitis Is not indicated in patients older than 40 years Needs to be performed open because of the fibrosis induced by appendicitis
  5. Splenic artery aneurysms Are more frequent in men Are the most common visceral artery aneurysms Rarely present as emergencies Require vascular reconstruction if proximal
  6. An 85-year-old has a life expectancy (50% likelihood of survival) of 7 years 2 years 12 years 1 year
  7. Prolactinomas Are the most common causes of galactorrhea Do not occur in men Occur in 40% of patients with MEN I (multiple endocrine neoplasia, type I) Are treated primarily by transsphenoidal resection
  8. Congenital arteriovenous malformations
    1. Require resection, regardless of size, if they are a component of Osler-Weber-Rendu syndrome
    2. Present in infancy
    3. Usually present with hemoptysis
    4. Cause left-to-right shunts
  9. Adenocarcinomas of the small intestine
    1. Usually occur in the ileum
    2. Have a 70% mean survival rate
    3. Most commonly present with intussusception
    4. Occur at an earlier age in patients with Crohn's disease

Web-Only Questions

  1. In octogenarians, endarterectomy for carotid artery occlusive disease
    1. Has a higher mortality rate than in younger patients
    2. Has a lower mortality rate than carotid artery stenting
    3. Carries a higher risk of neurologic symptoms than medical therapy
    4. Is contraindicated in patients with hemispheric symptoms
  2. The most successful operative therapy for rectal prolapse is
    1. Ripstein repair (prosthetic mesh placed around the mobilized rectum)
    2. Low anterior resection of the rectosigmoid colon
    3. Thiersch wire rectal encirclement
    4. Ivalon (polyvinyl alcohol) sponge placement in the pelvis posterior to the rectum

Read the Answers

Answers

  1. d—Placing the mesh beneath the fascia results in a recurrence rate of approximately 5%, the lowest of the methods listed. Primary suture repair has the highest recurrence rate (50%), and most surgeons have abandoned this technique, except in special circumstances. Component separation (separation of the external oblique and internal oblique/ transversalis muscles to close wide defects) and mesh overlay carry recurrence rates of 30% and 40%, respectively. 
  2. b—Stage I is a pericolic abscess, stage III is purulent peritonitis, and stage IV is feculent peritonitis. 
  3. d—Most intimal flaps (87%) heal without complication, so operation is rarely needed, immediately or later. The incidence of extremity ischemia is small. Rarely does this lesion progress to pseudoaneurysm formation, because the media is intact. Intimal flaps are diagnosed by angiography, and they are difficult to identify in the operating room, especially without opening the vessel. The difficulty in identifying intimal flaps provides strong impetus for completion angiography. 
  4. a—In 90% of interval appendectomies, the resected appendix has a patent lumen and no pathologic abnormality. The incidence of recurrent or persistent appendicitis is only 35%, which argues against routine interval appendectomy. Despite the adhesions, which are generally mild, 90% of interval appendectomies can be, and are, performed laparoscopically. 
  5. b—Splenic artery aneurysms constitute 60% of visceral artery aneurysms; hepatic artery aneurysms account for 20%; superior mesenteric, 6%; and the remainder, 14%. Splenic artery aneurysms occur four times more often in women than men; this lesion frequently occurs during pregnancy. These aneurysms present with free rupture in 35% of patients. This is particularly problematic, because these lesions are rarely symptomatic prior to rupture. The correct treatment for proximal lesions is ligation proximal and distal to the aneurysm. Distal lesions are best treated by splenectomy. Preoperative embolization may be useful, but it is not adequate as definitive therapy. 
  6. a—The longevity of octogenarians is a major reason why elderly patients should not be denied operative care. 
  7. c—Medications are the most cause of galactorrhea, particularly verapamil, tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs), and histamine-2 blockers. Prolactinomas do occur in men, who may present with impotence and visual symptoms resulting from pressure on the optic nerves at the sella turcica. Seventy percent of prolactinomas respond to dopamine agonists, and operation is required for only a small percentage of patients. 
  8. a—When congenital arteriovenous malformations are associated with the Osler-Weber-Rendu syndrome, as they often are, the likelihood of rupture and other symptoms is so great that operation is always indicated. These lesions present in adolescence and adulthood. The usual initial symptoms are dyspnea on exertion and easy fatigue; however, in large lesions, hemoptysis and cyanosis also occur. These lesions cause right-to-left shunts. 
  9. d—Crohn's disease is associated with an increased risk of adenocarcinoma (and lymphoma). These lesions usually occur in the fourth and fifth decades of life in Crohn's patients, much earlier than in non-Crohn's patients. Adenocarcinomas usually occur in the duodenum and jejunum and carry a 20% to 30% mean survival rate. They can cause intussusception, but they more commonly present with vague symptoms, such as weight loss, abdominal pain, anemia, and distention. 
  10. b—Despite its noninvasive nature, stenting carries a higher mortality rate than endarterectomy (5% vs 3%) in octogenarians. The perioperative mortality rates are identical in octogenarians and younger patients. Surgical therapy carries a lower risk of neurologic symptoms than medical therapy (13% vs 33%). Endarterectomy is as effective for hemispheric symptoms as for ophthalmic and motor disturbances.  
  11. b—Low anterior resection carries a low recurrence rate and is successful in curing prolapse-associated incontinence. The Ripstein repair has a higher recurrence rate and is complicated by erosion of the mesh into the bowel. The Thiersch wire operation has a 30% recurrence rate, permits erosion of the wire into the bowel, and does not improve incontinence. Placement of an Ivalon sponge into the pelvis causes scarring to maintain the correct position of the rectosigmoid colon; it is an easy operation with a low recurrence rate, but it is associated with a high incidence of pelvic abscess, which requires removal of the foreign body.