Surgery Flashcards

A 58-year-old man undergoes an elective sigmoid colectomy for recurrent diverticulitis. On postoperative day 4, he develops fever to 38.9°C, tachycardia, and ileus. CT scan reveals a 4 cm pelvic fluid collection with air-fluid level and rim enhancement. Which management strategy is most appropriate?

Answer: CT-guided percutaneous drainage with broad-spectrum antibiotics

A well-defined, accessible pelvic abscess with air-fluid level on postoperative day 4 is best managed with CT-guided percutaneous drainage plus broad-spectrum antibiotics. This approach is minimally invasive, avoids the morbidity of re-operation, and is highly effective for contained pelvic collections. Immediate re-operation is reserved for peritonitis, anastomotic dehiscence with fecal contamination, or failure of percutaneous drainage. Transrectal drainage is an option for low pelvic abscesses abutting the rectal wall, which is not described here. Pure conservative management is insufficient for a 4 cm organized collection.

During a laparoscopic cholecystectomy, intraoperative cholangiography demonstrates a Type E4 (Strasberg) bile duct injury with complete transection of the common hepatic duct at the hepatic confluence. The patient is hemodynamically stable. What is the most appropriate immediate next step?

Answer: Place closed-suction drains, close, and arrange urgent transfer to a hepatobiliary center

A Strasberg E4 injury (injury at or above the hepatic confluence) is a complex, high-level biliary injury that carries significant morbidity. When recognized intraoperatively by a non-hepatobiliary surgeon, the safest strategy is damage control: place closed-suction drains to control bile leakage, close, and urgently transfer to a hepatobiliary center with expertise in complex biliary reconstruction. Attempting primary repair or Roux-en-Y reconstruction without hepatobiliary expertise leads to higher rates of stricture, cholangitis, and secondary biliary cirrhosis. ERCP/stenting cannot bridge a complete transection at the confluence. Outcomes are significantly better when complex reconstruction is performed electively by experienced hepatobiliary surgeons.

A 72-year-old woman with a known 5.8 cm infrarenal abdominal aortic aneurysm (AAA) undergoes elective EVAR. On postoperative day 2, she develops worsening left flank pain and CT angiography reveals a type II endoleak from the inferior mesenteric artery (IMA) with a 6.2 cm aneurysm sac at baseline measurement. What is the most appropriate management at this time?

Answer: Observation with repeat CT angiography in 6 months

Type II endoleaks (retrograde flow from branch vessels such as IMA or lumbar arteries) are the most common type after EVAR and are frequently self-limiting. The current guidelines recommend observation with follow-up imaging at 6 months for type II endoleaks without sac enlargement — the sac here measures 6.2 cm, which is essentially unchanged from the pre-EVAR 5.8 cm baseline (a slight increase at 2 days postoperatively is within measurement variability and expected). Intervention is indicated only if the sac enlarges more than 5 mm on sequential imaging at 6-month intervals. Emergent intervention, conversion to open repair, or aorto-uni-iliac conversion are not warranted without confirmed sac growth.

A 45-year-old woman undergoes a modified radical mastectomy for invasive ductal carcinoma. Three days postoperatively, her Jackson-Pratt drain output is 300 mL/day of milky white fluid. Fluid analysis reveals triglycerides of 380 mg/dL. Which of the following is the most likely injured structure?

Answer: Accessory lymphatic channels draining the axillary basin

Chylous leaks after axillary dissection most commonly arise from injury to accessory lymphatic channels in the axillary basin, not from the main thoracic duct. The thoracic duct drains into the left subclavian-jugular junction and is at risk during left-sided neck dissections or thoracic procedures, not right axillary surgery. The milky, triglyceride-rich fluid confirms chyle, but the anatomic source is the disrupted lateral axillary lymphatics. The right lymphatic duct drains the right head/neck/arm but is located at the right subclavian junction — not typically injured in mastectomy. Management includes low-fat diet with medium-chain triglycerides or TPN; operative ligation is reserved for persistent high-output leaks.

A 34-year-old male sustains blunt abdominal trauma in a motor vehicle collision. FAST exam is positive. CT reveals a grade IV splenic laceration with active extravasation and a grade II liver laceration without active bleeding. He is hemodynamically stable with BP 108/72 after 2L crystalloid. His INR is 1.1 and hemoglobin is 9.2 g/dL. What is the most appropriate management?

Answer: Angioembolization of the splenic artery

In a hemodynamically stable patient with a grade IV splenic laceration and CT evidence of active arterial extravasation (vascular blush), angioembolization is the preferred management. The combination of grade IV injury plus active contrast extravasation significantly increases the failure rate of pure nonoperative management (NOM), and angioembolization has been shown to reduce this failure rate from ~50% to ~10-15% in this setting. The patient's hemodynamic response to fluid resuscitation supports a non-operative approach over emergent laparotomy. Laparoscopy is not indicated for acute splenic trauma with extravasation. Pure NOM without embolization would be inappropriate given the active blush on CT.

A 61-year-old man undergoes a Whipple procedure (pancreaticoduodenectomy) for a pancreatic head adenocarcinoma. On postoperative day 5, serum amylase from the closed-suction drain measures 4,200 U/L (>3× upper limit of normal). He is tolerating a soft diet and has no fever or peritoneal signs. Drain output is 180 mL/day of serosanguineous fluid. According to the International Study Group of Pancreatic Fistula (ISGPF) classification, what grade is this leak and what is the most appropriate next step?

Answer: Grade A fistula (biochemical leak) — maintain drain in place, continue diet, repeat amylase in 3-4 days

The ISGPF 2016 revised classification defines a Grade A postoperative pancreatic fistula (POPF) — now termed 'biochemical leak' — as drain amylase >3× upper normal limit on postoperative day 3 or beyond without any clinical impact, change in management, or deviation from the expected postoperative course. This patient is asymptomatic, tolerating diet, afebrile, and without peritoneal signs — meeting Grade A criteria. Management is observation: maintain the drain in place to monitor output, continue oral intake, and recheck drain amylase in 3-4 days. Grade B requires a clinically relevant change in management (prolonged drain, restart TPN, antibiotics, or IR/endoscopic intervention). Grade C involves life-threatening deterioration requiring re-operation. Initiating octreotide or TPN in a Grade A patient is not indicated.