SMLE Surgery 6

Question 1

A 70-year-old patient undergoes emergency laparotomy for a perforated duodenal ulcer. Intraoperatively, a large perforation is found. What is the most appropriate surgical procedure?

Accepted Answer

Graham patch (omental patch repair)

Answer

In an emergency setting with a perforated duodenal ulcer, Graham patch (omental patch) repair is the safest and most commonly performed procedure. Definitive ulcer surgery is deferred, and H. pylori eradication and PPI therapy are initiated postoperatively.

Question 2

A 30-year-old male presents with a painless testicular mass. Ultrasound confirms a solid intratesticular lesion. What is the next step?

Accepted Answer

Radical inguinal orchidectomy

Answer

A solid intratesticular mass in a young male is testicular cancer until proven otherwise. Radical inguinal orchidectomy (not trans-scrotal to avoid scrotal contamination) is both diagnostic and therapeutic. Tumour markers (AFP, beta-hCG, LDH) should be drawn preoperatively.

Question 3

A patient develops high-output small bowel fistula postoperatively. What electrolyte abnormality is most likely?

Accepted Answer

Metabolic acidosis with dehydration

Answer

High-output small bowel fistulas cause significant losses of sodium, potassium, bicarbonate, and water. This leads to dehydration, metabolic acidosis (from bicarbonate loss), and electrolyte depletion requiring aggressive fluid and electrolyte replacement.

Question 4

A 55-year-old female presents with a 4 cm mass in the right lobe of the liver. AFP is markedly elevated. She has a history of hepatitis B cirrhosis. What is the most likely diagnosis?

Accepted Answer

Hepatocellular carcinoma

Answer

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy and frequently develops in the setting of hepatitis B cirrhosis. Markedly elevated AFP (>400 ng/mL) in a cirrhotic patient with a liver mass is highly suggestive of HCC.

Question 5

A 40-year-old male presents with epigastric pain radiating to the back, elevated serum lipase (>3× upper limit of normal), and a history of heavy alcohol use. What is the most important initial management?

Accepted Answer

NPO, IV fluids, and analgesia

Answer

Acute pancreatitis management is primarily supportive: nil per os (NPO), aggressive IV fluid resuscitation (preferably Ringer's lactate), and adequate analgesia. ERCP is only indicated if there is evidence of choledocholithiasis with cholangitis.

SMLE Practice Test

SMLE Practice Test

SMLE Surgery 6