SPEX Surgery 5 — Questions and Answers
Question 1: A 50-year-old man sustains blunt abdominal trauma with a grade III splenic laceration and is hemodynamically stable. What is the first-line management?
- Emergency splenectomy
- Diagnostic peritoneal lavage
- Non-operative management with monitoring in ICU (Correct answer)
- Exploratory laparotomy
Correct answer: Non-operative management with monitoring in ICU
Hemodynamically stable patients with blunt splenic injuries, including grade III lacerations, are managed non-operatively with serial abdominal exams and hemodynamic monitoring in an ICU setting.
Question 2: Which test is used intraoperatively to verify bile duct patency and identify retained stones during cholecystectomy?
- Intraoperative endoscopic retrograde cholangiopancreatography (ERCP)
- Intraoperative cholangiogram (IOC) (Correct answer)
- Hepatobiliary iminodiacetic acid (HIDA) scan
- Intraoperative MRI
Correct answer: Intraoperative cholangiogram (IOC)
Intraoperative cholangiogram (IOC) is performed by injecting contrast into the cystic duct under fluoroscopy to visualize bile duct anatomy and detect retained stones or ductal injury.
Question 3: A patient develops a triad of hypotension, distended neck veins, and muffled heart sounds after a stab wound to the chest. Which procedure is immediately indicated?
- Chest tube thoracostomy
- Pericardiocentesis or surgical pericardial window (Correct answer)
- Endotracheal intubation and positive pressure ventilation
- Emergent coronary angiography
Correct answer: Pericardiocentesis or surgical pericardial window
Beck's triad (hypotension, JVD, muffled heart sounds) indicates cardiac tamponade; immediate pericardiocentesis or surgical pericardial window is required to relieve the pressure.
Question 4: Which of the following is a contraindication to laparoscopic surgery in the acute abdomen?
- Suspected appendicitis
- Hemodynamic instability requiring damage control (Correct answer)
- Perforated peptic ulcer in a stable patient
- Acute cholecystitis
Correct answer: Hemodynamic instability requiring damage control
Hemodynamically unstable patients requiring damage control surgery are a contraindication to laparoscopy; pneumoperitoneum can further compromise venous return and cardiac output.
Question 5: What is the most common cause of early postoperative small bowel obstruction within the first 30 days after abdominal surgery?
- Malignant adhesions
- Internal hernia
- Postoperative ileus evolving into mechanical obstruction from adhesions (Correct answer)
- Intussusception
Correct answer: Postoperative ileus evolving into mechanical obstruction from adhesions
Early postoperative small bowel obstruction is most commonly caused by adhesions from the recent surgery and must be distinguished from prolonged ileus, as most will resolve with nasogastric decompression.
Question 6: In damage control surgery for abdominal trauma, which is the correct sequence of operations?
- Definitive repair → ICU resuscitation → planned reoperation
- Abbreviated surgery for hemorrhage/contamination control → ICU resuscitation → definitive repair (Correct answer)
- Full resection and anastomosis immediately → ICU → wound closure
- ICU resuscitation → laparotomy → damage control
Correct answer: Abbreviated surgery for hemorrhage/contamination control → ICU resuscitation → definitive repair
Damage control surgery follows a three-phase approach: abbreviated laparotomy to control hemorrhage and contamination, ICU resuscitation correcting the 'lethal triad,' then definitive repair at planned reoperation.
Question 7: A 60-year-old man with known liver cirrhosis develops an acute upper GI bleed. Endoscopy confirms active esophageal variceal hemorrhage. After band ligation, which medication is most appropriate to prevent rebleeding?
- Omeprazole
- Non-selective beta-blocker (propranolol or nadolol) (Correct answer)
- Vasopressin alone
- Octreotide long-term
Correct answer: Non-selective beta-blocker (propranolol or nadolol)
Non-selective beta-blockers (propranolol, nadolol) reduce portal pressure and are the standard pharmacologic prophylaxis for secondary prevention of variceal rebleeding after endoscopic therapy.
SPEX Surgery 5
A 50-year-old man sustains blunt abdominal trauma with a grade III splenic laceration and is hemodynamically stable.
What is the first-line management?