General Surgery Sample Questions
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QUESTION

247. A 78-year-old bed-bound, female nursing home resident with occasional fecal incontinence is admitted to the hospital for treatment of pneumonia. Her past medical history is significant for hypertension, chronic obstructive pulmonary disease and insulin-dependent diabetes mellitus.

On initial physical examination she is noted to have a protrusion from the anus consisting of everted bowel with concentric folds. No difference is noted during valsalva. She has no palpable bulging along the anterior or poster wall of her vagina (enterocele), and no hemorrhoids, polyps, or neoplasia.

Which of the following would be the MOST ideal treatment for this patient’s anal protrustion?

A) Perineal repair with mucosal stripping (Delorme Procedure)
B) Perineal rectosigmoidectomy (Altemeier Procedure)
C) Laparoscopic resection rectopexy
D) Laparoscopic anterior (Ripstein) rectopexy
E) Laparoscopic posterior (Wells) rectopexy

ANSWER

247.     A     Perineal repair with mucosal stripping (Delorme Procedure)

The benefit of a perineal repair for rectal prolapse is that it can be performed using local anesthesia and minimal sedation, and the morbidity is generally lower for these repairs. Perineal repairs are generally reserved for patients who are otherwise medically unfit for a conventional abdominal procedure. Perineal repairs such as the anal encircling procedure or Thiersch wire are associated with up to 60% recurrence rates and high morbidity and are generally reserved only for those with significant comorbidities. The Altemeier procedure combines perineal rectosdimoidectomy with levatorplasty. Recurrence is seen in up to 50% of patients. Delorme's procedure is less invasive than the Altemeier procedure and involves stripping of the affected mucosa, plication of the underlying rectal muscular wall, and reanastamosis of the distal and proximal mucosal margins. Recurrence is seen in 5 to 20% of these patients. In most cases, the Delorme approach is favored over the Altemeier, especially in patients with varying degrees of incontinence. Abdominal repairs generally involve mobilization and fixation of the rectum, usually to the fascia overlying the sacral promontory with mesh or suture. The anterior (Ripstein) repair wraps mesh around the anterior aspect of the rectum and affixes it to both sides of the sacral promontory. The posterior (Wells) repair fixes the mesh behind the rectum, tacking the lateral mesorectum to the presacral fascia. The laparoscopic Wells procedure is associated with reduced constipation and low recurrences on relatively short-term follow up, as well as reduced hospital length of stay. Anterior wraps are associated with stenosis and obstruction. Posterior repairs avoid stenosis and may also reduce constipation. Resection rectopexy also incorporates resection of the sigmoid and upper rectum and is favored in generally healthy patients with constipation. However, there is the added potential morbidity of a colorectal anastomosis. Recurrence rates are not generally significantly lower with resection. In this patient, with high comorbidities and incontinence, the Delorme procedure is favored of the perineal approaches.

1. Delaney CP, Senagore AJ. Rectal Prolapse. In Vazio VW, ed. Current Therapy in Colon and Rectal Surgery. Philadelphia. Elsevier Mosby, 2005:131-134.

QUESTION

30. A 29-year-old female is being evaluated by the anesthesiologist prior to an elective hernia repair. On direct questioning she reports that her aunt had an adverse reaction to anesthesia during an elective hysterectomy. She thinks it had something to do with elevated temperature and rigid muscles.

Which of the following statements regarding malignant hyperthermia is TRUE?

A) It is inherited as an autosomal recessive trait
B) It is more common in the elderly than in children
C) Patients with a family history of malignant hyperthermia cannot safely undergo elective surgery if general anesthetics are to be used
D) Termination of the procedure and intravenous use of danazol are the recommended treatment for patients experiencing an acute intraoperative episode of malignant hyperthermia
E) The pathogenesis is related to intramuscular calcium transport

ANSWER

30.     E     The pathogenesis is related to intramuscular calcium transport

Malignant hyperthermia is a rare condition presenting intraoperatively with increased metabolism, increased sympathetic nervous system activity, and rhabdomyolysis. It is triggered by exposure to halogenated inhalational agents and succinylcholine, and the pathophysiology is characterized by the excessive release of calcium from the sarcoplasmic reticulum of skeletal muscle in response to such agents. Malignant hyperthermia is inherited in an autosomal dominant pattern, but has incomplete penetrance, so there is not always a clearly documented family history of such a problem. It is more common in children and young adults. When recognized it is treated by discontinuing the offending agent, which may require ending the operation prematurely, and the immediate administration of dantrolene, 2.5 mg/kg. (Danazol is a synthetic steroid that depresses the pituitary-ovarian axis.) The use of oxygen, fluids and cooling blankets may be required, along with the correction of electrolyte and acid-base abnormalities, should they occur. With proper precautions and avoiding the use of known triggering agents, patients with a family history of this condition can safely undergo surgical procedures.

1. Weintraub, SL., Principles of Preoperative and Operative Surgery. In Townsend, CM., ed. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. Elsevier. 2004:233.

2. Dayton, MT., Surgical Complications. In Townsend, CM., ed. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. Elsevier. 2004:304-305.

QUESTION

150. A 3-year-old boy presents with three days of cyclical abdominal pain and vomiting. The mother reports no fever or diarrhea.

On examination, the patient is lethargic and his abdomen is soft, tender, and mildly distended. No masses are felt. His abdominal X-rays are nonspecific, but an ultrasound exam reveals intussusception.

Concerning this finding, which one of the following statements is TRUE:

A) The classic triad of abdominal pain, vomiting, and “currant jelly” stool is seen in about half of patients
B) The most common lead point in children with intussusception is the appendix
C) Hydrostatic reduction by contrast agent or air enema is successful in about 80% of cases
D) Recurrence after hydrostatic reduction is about 30%
E) Indications for surgical intervention include recurrence after hydrostatic reduction

ANSWER

150.     C     Hydrostatic reduction by contrast agent or air enema is successful in about 80% of cases

The classic triad of abdominal pain, vomiting, and “currant jelly” stool occurs in less than one-third of patients. Three quarters of patients with intussusception have two findings and 13% have only one or none. A pathologic lead point is found in up to 12% of patients and the incidence increases with age. The most common lead point for intussusception is a Meckel’s diverticulum; however, other causes must be considered, including polyps, the appendix, tumors, submucosal hemorrhage, foreign bodies, and intestinal duplication. Suggestive radiographic abnormalities include the presence of a mass, sparse gas within the colon, or complete distal small bowel obstruction. An abdominal ultrasound may also be helpful; characteristic findings include the “target sign” or intussuscepted layers of bowel on transverse view, or the “pseudokidney” sign when seen longitudinally. When the clinical index of suspicion is high, hydrostatic reduction by contrast agent or air enema is the diagnostic and therapeutic treatment of choice. Contraindications to this study include the presence of peritonitis or hemodynamic instability. Relative contraindications include prolonged symptoms (>24 hours), and evidence of obstruction or ischemia. Further, an intussusception located entirely within the small intestine is unlikely to be reached by enema and more likely to have an associated lead point. In uncomplicated cases, successful reduction is accomplished around 80% of the time, and is confirmed by resolution of the mass, along with reflux of air or contrast into the proximal ileum. To avoid radiation altogether, reduction by saline enema under ultrasound visualization may be employed. There is about an 11% recurrence rate after hydrostatic reduction, usually within the first 24 hours. This may be treated by another attempt at hydrostatic reduction, but a third recurrence is usually an indication for operative management. The indications for operation in patients with intussusception include peritonitis or a clinical examination consistent with necrotic bowel. The presence of complete small bowel obstruction, failure of hydrostatic complete reduction, or a history of several recurrences should also direct surgical intervention.

1. Warner B. Pediatric Surgery. In Townsend CM, ed., Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. Elsevier Saunders. 2004:2112-2113.

2. McCollough M. Abdominal surgical emergencies in infants and young children. Emergency Medicine Clinics of North America. 2003;21(4):909-35.

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