SPEX Surgery 3 — Questions and Answers
Question 1: Which scoring system is used to predict the severity of acute pancreatitis and assess the risk of mortality within 48 hours of admission?
- Child-Pugh score
- APACHE II score and Ranson's criteria (Correct answer)
- MELD score
- Glasgow Blatchford score
Correct answer: APACHE II score and Ranson's criteria
APACHE II score and Ranson's criteria are both used to stratify severity of acute pancreatitis; Ranson's uses 11 criteria assessed at admission and 48 hours.
Question 2: A 55-year-old man undergoes right hemicolectomy. On postoperative day 3, he develops fever, tachycardia, and oliguria. CT shows a fluid collection near the anastomosis. What is the most likely diagnosis?
- Pulmonary embolism
- Anastomotic leak (Correct answer)
- C. difficile colitis
- Hepatic abscess
Correct answer: Anastomotic leak
Anastomotic leak after colorectal surgery typically presents on days 3-7 with fever, tachycardia, ileus, and peritoneal signs, often confirmed with CT showing extraluminal air or fluid.
Question 3: Which hernias are more common in women and have the highest risk of incarceration and strangulation?
- Indirect inguinal hernias
- Direct inguinal hernias
- Femoral hernias (Correct answer)
- Umbilical hernias
Correct answer: Femoral hernias
Femoral hernias are more prevalent in women, pass below the inguinal ligament through the femoral canal, and have the highest rate of strangulation among common hernias due to the narrow neck.
Question 4: During laparoscopic appendectomy, the appendix appears normal. What is the most important next intraoperative step?
- Remove the appendix regardless and close
- Inspect the terminal ileum for Meckel's diverticulum or Crohn's disease (Correct answer)
- Perform a diagnostic laparotomy
- Obtain peritoneal fluid cultures and close
Correct answer: Inspect the terminal ileum for Meckel's diverticulum or Crohn's disease
When the appendix is normal, careful inspection of at least 60-80 cm of terminal ileum for alternative pathology (Meckel's diverticulum, Crohn's disease, mesenteric adenitis) is essential.
Question 5: Which intraoperative finding in a patient undergoing cholecystectomy mandates conversion from laparoscopic to open technique?
- Mild adhesions around the gallbladder
- Inability to clearly delineate the critical view of safety (Correct answer)
- Presence of gallstones larger than 2 cm
- Bile duct diameter of 6 mm
Correct answer: Inability to clearly delineate the critical view of safety
The critical view of safety requires clear identification of the cystic duct and cystic artery; inability to achieve this mandates conversion to open surgery to prevent bile duct injury.
Question 6: A trauma patient arrives with a stab wound to zone II of the neck with an expanding hematoma. Which is the most appropriate management?
- CT angiography of the neck and selective operative management
- Mandatory operative exploration (Correct answer)
- Observation with serial physical exams
- Immediate intubation and ICU admission
Correct answer: Mandatory operative exploration
An expanding hematoma in zone II neck trauma is a hard sign of vascular injury requiring immediate mandatory operative exploration without delay for imaging.
Question 7: What is the preferred conduit for coronary artery bypass grafting (CABG) to the left anterior descending artery, due to its superior long-term patency?
- Saphenous vein graft
- Left internal mammary artery (Correct answer)
- Radial artery
- Cephalic vein graft
Correct answer: Left internal mammary artery
The left internal mammary artery (LIMA) to LAD bypass demonstrates 90-95% patency at 10 years, far superior to saphenous vein grafts, making it the gold standard conduit.
SPEX Surgery 3
Which scoring system is used to predict the severity of acute pancreatitis and assess the risk of mortality within 48 hours of admission?