Surgery Flashcards

A 58-year-old man undergoes elective sigmoid colectomy. On postoperative day 5, he develops fever (38.9°C), tachycardia, and left lower quadrant tenderness. CT scan shows a 4 cm pericolic fluid collection with a small amount of free air. Which management strategy is most appropriate?

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

A contained anastomotic leak with a small pericolic abscess (<5 cm) and no diffuse peritonitis is best managed with CT-guided percutaneous drainage combined with broad-spectrum antibiotics. This allows source control without the morbidity of re-operation in a recently operated patient. Immediate laparotomy is reserved for diffuse fecal peritonitis, hemodynamic instability, or failure of non-operative management. Antibiotics alone are insufficient for a walled-off collection requiring drainage.

During a Whipple procedure (pancreaticoduodenectomy), the surgeon notices the superior mesenteric artery (SMA) has an aberrant replaced right hepatic artery arising from it. What is the most important implication of this anatomic variant?

Answer: Preservation of this vessel is critical to avoid right lobe hepatic ischemia

A replaced right hepatic artery (arising from the SMA rather than the proper hepatic artery) occurs in approximately 15–20% of patients. If ligated inadvertently during pancreaticoduodenectomy, it results in ischemia of the right hepatic lobe, which can cause hepatic necrosis or failure. The surgeon must identify and preserve this vessel during dissection. It runs posterolateral to the pancreatic head and CBD. Unless it traverses directly through the tumor, it is dissected free and preserved.

A 42-year-old woman with morbid obesity (BMI 47) undergoes laparoscopic Roux-en-Y gastric bypass. Two years postoperatively, she presents with episodic diaphoresis, palpitations, and confusion occurring 1–2 hours after meals, relieved by eating. Serum glucose during an episode is 38 mg/dL. Which of the following best explains this condition?

Answer: Nesidioblastosis causing non-insulinoma pancreatogenous hypoglycemia

Late postprandial hypoglycemia (1–3 hours after eating) after gastric bypass is most likely caused by nesidioblastosis (non-insulinoma pancreatogenous hypoglycemia syndrome, NIPHS). This involves beta-cell hypertrophy and hyperfunction, likely driven by elevated postprandial GLP-1 levels after bypass-induced changes in gut hormone secretion. Unlike insulinoma, symptoms occur postprandially. Early dumping syndrome occurs within 30 minutes and is not associated with true hypoglycemia. Management includes dietary modification, acarbose, calcium channel blockers, or partial pancreatectomy in refractory cases.

A 67-year-old man with a 6.2 cm infrarenal abdominal aortic aneurysm (AAA) is being evaluated for endovascular aneurysm repair (EVAR). CT angiography reveals a 14 mm infrarenal neck length, a 32° infrarenal neck angulation, and significant bilateral iliac tortuosity. Which anatomic finding is the most important contraindication to standard EVAR in this patient?

Answer: Infrarenal neck length less than 15 mm

An infrarenal neck length of 60° is also a relative contraindication for standard EVAR, the 32° angulation in this patient is acceptable. Iliac tortuosity is a technical challenge but can often be overcome. The aneurysm diameter is above the repair threshold (≥5.5 cm in men), not a contraindication to EVAR itself.

A trauma surgeon performs damage control laparotomy on a 29-year-old man with multiple gunshot wounds. The abdomen is packed and temporarily closed. On re-look at 48 hours, the surgeon notes the patient is in the 'lethal triad.' Which combination of parameters best defines this triad as it applies to surgical decision-making?

Answer: Hypothermia, acidosis, and coagulopathy

The 'lethal triad' of trauma surgery consists of hypothermia, metabolic acidosis, and coagulopathy. These three conditions are mutually reinforcing: hypothermia impairs enzyme function in the clotting cascade, acidosis (from poor perfusion/lactate accumulation) worsens coagulopathy, and coagulopathy leads to continued hemorrhage and further hemodynamic compromise. Damage control surgery is specifically designed to interrupt this cycle by achieving hemorrhage control quickly, deferring definitive repair, and allowing resuscitation in the ICU. Recognizing and correcting all three components is essential before the abdomen can be safely closed.

A 55-year-old woman is found to have a 2.2 cm follicular neoplasm (Bethesda IV) on thyroid FNA. She undergoes diagnostic hemithyroidectomy; final pathology shows follicular carcinoma with capsular invasion only (no vascular invasion), confined to a 2.2 cm nodule. According to current ATA guidelines, what is the most appropriate next step?

Answer: Observation without completion thyroidectomy

According to the 2015 American Thyroid Association (ATA) guidelines, minimally invasive follicular thyroid carcinoma (capsular invasion only, no vascular invasion) ≤4 cm has an excellent prognosis with a very low risk of recurrence or metastasis. For these low-risk lesions, hemithyroidectomy alone is considered sufficient definitive treatment, and completion thyroidectomy is not routinely recommended. RAI is not indicated because it requires total thyroidectomy and is reserved for higher-risk disease. This represents a significant paradigm shift from older guidelines that mandated total thyroidectomy for all follicular carcinomas.