GENERAL​ ​SURGERY​ ​CERTIFYING​ ​EXAMINATION​ ​PREPARATION

A.​ ​ABDOMEN
1. (JFB)​ ​C​ ​diff​ ​colitis​ ​toxic​ ​megacolon​ ​after​ ​hospitalization​ ​for​ ​hip​ ​replacement​ ​and​ ​abx​ ​for​ ​UTI.​ ​Failed​ ​PO​ ​vancomycin​ ​and
vancomycin​ ​enemas.​ ​Total​ ​abdominal​ ​colectomy.​ ​Asked​ ​what​ ​are​ ​my​ ​proximal​ ​and​ ​distal​ ​margins​ ​for​ ​resection.​ ​End
ileostomy​ ​and​ ​rectum​ ​at​ ​sacral​ ​promontory​ ​with​ ​stump​ ​oversewn.​ ​Treat​ ​stump​ ​with​ ​Vanc​ ​enemas.​ ​Case​ ​3.

2. (JFB)​ ​Steroids​ ​COPD​ ​woman,​ ​had​ ​LAR,​ ​wound​ ​drainage,​ ​evisceration.​ ​Took​ ​to​ ​OR​ ​for​ ​washout,​ ​wound​ ​exploration​ ​and
closure.​ ​Found​ ​murky​ ​fluid​ ​and​ ​leak​ ​intraop.​ ​I​ ​oversewed,​ ​diverted​ ​with​ ​ileostomy,​ ​and​ ​drained​ ​pelvis.​ ​Closed​ ​abdomen
with​ ​retention​ ​sutures.​ ​Postop​ ​chemo​ ​timing?​ ​Case​ ​7.

3. (JFB)​ ​Older​ ​man​ ​s/p​ ​LAR​ ​who​ ​is​ ​currently​ ​anticoagulated​ ​with​ ​heparin​ ​gtt​ ​and​ ​coumadin​ ​for​ ​DVT.​ ​INR​ ​was​ ​2.1.​ ​Got
abdominal​ ​pain​ ​RLQ.​ ​Labs​ ​and​ ​CT​ ​revealed​ ​appendicitis.​ ​I​ ​preop​ ​typed​ ​and​ ​crossmatched​ ​blood.​ ​Reversed​ ​INR​ ​with​ ​FFP
and​ ​held​ ​heparin​ ​gtt​ ​6​ ​hours​ ​before​ ​my​ ​urgent​ ​surgery.​ ​Described​ ​lap​ ​appy.​ ​Retrocecal​ ​appendix.​ ​Cannot​ ​mobilize​ ​cecum
to​ ​expose​ ​appendix.​ ​Bleeds​ ​from​ ​staple​ ​line​ ​on​ ​mesentery​ ​then​ ​bleeds​ ​from​ ​appendiceal​ ​stump.​ ​Oversewed
laparoscopically​ ​and​ ​if​ ​not​ ​controlled​ ​like​ ​that​ ​then​ ​opened.​ ​Case​ ​11.

4. 72​ ​y/o​ ​with​ ​nausea,​ ​emesis,​ ​abdominal​ ​pain.​ ​On​ ​exam​ ​had​ ​incarcerated​ ​inguinal​ ​hernia.​ ​Describe​ ​hernia​ ​repair.
Scenarios:​ ​1)​ ​No​ ​necrotic​ ​bowel​ ​->​ ​Lichtenstein​ ​with​ ​mesh,​ ​2)​ ​necrotic​ ​bowel​ ​->​ ​tissue​ ​repair​ ​(McVay,​ ​Bassini,​ ​etc).​ ​Be
able​ ​to​ ​describe​ ​both​ ​operations:​ ​mesh​ ​versus​ ​no​ ​mesh.​ ​Management​ ​of​ ​complications:​ ​nerve​ ​entrapment​ ​and
neuropathy,​ ​or​ ​ischemic​ ​orchitis.

5. (AE)​ ​Routine​ ​inguinal​ ​hernia​ ​in​ ​clinic.​ ​In​ ​OR,​ ​describe​ ​laparoscopic​ ​and​ ​open​ ​inguinal​ ​hernia​ ​repairs,​ ​how​ ​to​ ​deal​ ​with​ ​post
op​ ​ilioinguinal​ ​nerve​ ​pain

6. 60​ ​y/o​ ​with​ ​proximate​ ​hx​ ​of​ ​mitral​ ​valve​ ​repair​ ​5​ ​days​ ​ago,​ ​in​ ​ICU,​ ​has​ ​bloody​ ​bowel​ ​movement.​ ​Work-up​ ​reveals​ ​LLQ
abdominal​ ​pain.​ ​WBC​ ​15.​ ​CT​ ​a/p​ ​shows​ ​sigmoid​ ​diverticulitis.​ ​Management?​ ​Abx,​ ​serial​ ​exams.​ ​Pain​ ​resolves.

7. 45​ ​y/o​ ​man,​ ​LLQ​ ​pain,​ ​nonoperative​ ​treatment​ ​of​ ​diverticulitis​ ​gets​ ​better.​ ​Needs​ ​colonoscopy​ ​6​ ​weeks​ ​later.​ ​In​ ​clinic
Pneumaturia​ ​develops​ ​with​ ​E.coli​ ​UTI.​ ​Colovescicular​ ​fistula.​ ​Work-up​ ​and​ ​management.​ ​Needs​ ​cystogram,​ ​lower​ ​GI.
Pre-op​ ​ureteral​ ​stenting​ ​then​ ​sigmoidectomy​ ​with​ ​repair​ ​of​ ​fistula/bladder.

8. 70​ ​y/o​ ​woman,​ ​abdominoperineal​ ​resection​ ​for​ ​colon​ ​cancer,​ ​get​ ​uncontrolled​ ​bleeding​ ​in​ ​pelvis.​ ​Management​ ​->​ ​pack​ ​the
pelvis,​ ​see​ ​bleeding​ ​from​ ​the​ ​foramina.​ ​Can​ ​control​ ​that​ ​bleeding​ ​with​ ​tacks​ ​or​ ​bone​ ​wax.​ ​Post-op​ ​patient​ ​is​ ​anuric.​ ​Was
making​ ​urine​ ​in​ ​OR.​ ​Work-up.​ ​OR​ ​exploration​ ​because​ ​you​ ​ligated/transected​ ​the​ ​ureters.
a. Elements​ ​of​ ​ureteral​ ​repair​ ​small​ ​segment​ ​(<​ ​2cm):​ ​upper​ ​third​ ​of​ ​ureter​ ​(primary​ ​repair​ ​with​ ​stent​ ​and​ ​drain),
mid​ ​third​ ​of​ ​ureter​ ​(primary​ ​repair​ ​with​ ​stent​ ​and​ ​drain),​ ​lower​ ​third​ ​of​ ​ureter​ ​(re-implantation​ ​into​ ​bladder​ ​with
Psoas​ ​hitch​ ​or​ ​Boari​ ​flap)
i. Spatulate​ ​the​ ​ends
ii. Absorbable​ ​sutures
iii. Double​ ​J​ ​stent
iv. Drains
b. Large​ ​segment​ ​ureteral​ ​repair​ ​(>​ ​2cm):​ ​upper​ ​third​ ​and​ ​middle​ ​third​ ​of​ ​ureter​ ​(ligation​ ​and​ ​percutaneous
nephrostomy​ ​with​ ​eventual​ ​staged​ ​ileal​ ​interposition​ ​or​ ​trans-ureteroureterostomy),​ ​lower​ ​third​ ​of​ ​ureter
(re-implantation​ ​into​ ​bladder​ ​with​ ​Psoas​ ​hitch​ ​or​ ​Boari​ ​flap)

9. 45​ ​y/o​ ​woman,​ ​hx​ ​of​ ​TAH-BSO​ ​in​ ​past,​ ​with​ ​abdominal​ ​distention.​ ​Has​ ​adhesive​ ​SBO​ ​on​ ​CT,​ ​fails​ ​medical​ ​non-op​ ​therapy.
Post-op​ ​develops​ ​fevers​ ​and​ ​abdominal​ ​pain.​ ​Either​ ​can​ ​have​ ​CT​ ​a/p​ ​shows​ ​abscess​ ​or​ ​develops​ ​fistula​ ​to​ ​midline​ ​wound.
Dealer’s​ ​choice.

10. 60​ ​y/o​ ​POD#5​ ​enterolysis​ ​for​ ​small​ ​bowel​ ​obstruction.​ ​On​ ​exam​ ​you​ ​see​ ​bilious​ ​drainage​ ​from​ ​midline​ ​incision.​ ​Next​ ​step?
Vitals,​ ​physical,​ ​and​ ​labs.
a. What​ ​is​ ​patient​ ​was​ ​hemodynamically​ ​stable,​ ​no​ ​peritonitis,​ ​labs​ ​with​ ​normal​ ​WBC.​ ​Management?​ ​Medical
management​ ​of​ ​fistula.​ ​Describe​ ​this…​ ​NPO,​ ​TPN,​ ​nutritional​ ​optimization,​ ​drainage​ ​control.
b. What​ ​about​ ​if​ ​patient​ ​was​ ​tachycardic,​ ​fevers,​ ​diffuse​ ​abdominal​ ​pain?​ ​OR​ ​and​ ​laparotomy​ ​with​ ​resection​ ​of
leak/oversewing.

11. 48​ ​y/o​ ​man​ ​with​ ​UGI​ ​bleed,​ ​upper​ ​abdominal​ ​pain.​ ​Acute​ ​management,​ ​including​ ​T&C,​ ​labs,​ ​resuscitate.​ ​EGD​ ​showed
ulcer​ ​posterior​ ​wall​ ​of​ ​duodenum​ ​first​ ​portion​ ​that​ ​they​ ​coagulated​ ​and​ ​clipped​ ​visible​ ​vessel.​ ​Anything​ ​else​ ​during

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endoscopy?​ ​Need​ ​to​ ​check​ ​stomach​ ​for​ ​H.​ ​pylori.​ ​Post-procedure​ ​management?​ ​NPO,​ ​IVF,​ ​PPI​ ​ggt​ ​for​ ​72​ ​hours.
Resuscitate​ ​and​ ​trend​ ​labs.​ ​Patient​ ​re-bleeds.​ ​Repeat​ ​endoscopy​ ​all​ ​they​ ​see​ ​is​ ​blood.​ ​What​ ​next​ ​doctor?​ ​Describe​ ​OR
procedure.​ ​Exlap,​ ​longitudinal​ ​duodenotomy,​ ​3​ ​point​ ​ligation​ ​of​ ​vessel​ ​at​ ​base​ ​of​ ​ulcer​ ​(superior,​ ​inferior,​ ​medially).​ ​Close
duodenotomy​ ​transversely.

12. 40​ ​y/o​ ​man,​ ​morbidly​ ​obese.​ ​Symptomatic​ ​ventral​ ​hernia.​ ​No​ ​PMHx​ ​or​ ​PSHx.​ ​No​ ​meds.​ ​Refer​ ​to​ ​lose​ ​weight.​ ​Comes​ ​back
6​ ​months​ ​no​ ​weight​ ​loss​ ​but​ ​intolerable​ ​pain​ ​but​ ​still​ ​reducible.​ ​Management?​ ​Pre-op​ ​eval​ ​with​ ​labs,​ ​EKG,​ ​CXR,​ ​stress
prn.​ ​Describe​ ​laparoscopic​ ​ventral​ ​hernia​ ​repair​ ​(overlap​ ​of​ ​borders?​ ​3-5cm).
a. Intra-op​ ​make​ ​and​ ​inadvertent​ ​enterotomy​ ​while​ ​reducing​ ​hernia​ ​sac
b. Management?​ ​Close​ ​hole​ ​primarily​ ​on​ ​bowel.​ ​Complete​ ​reduction​ ​of​ ​hernia​ ​and​ ​lysis​ ​of​ ​adhesions​ ​but​ ​no​ ​hernia
repair.​ ​Admit​ ​for​ ​24​ ​hours​ ​of​ ​observation​ ​+/-​ ​abx​ ​and​ ​come​ ​back​ ​in​ ​2​ ​weeks​ ​for​ ​laparoscopic​ ​ventral​ ​hernia
repair​ ​with​ ​permanent​ ​mesh.

13. 50​ ​y/o​ ​man,​ ​Child’s​ ​C​ ​cirrhotic​ ​with​ ​painful​ ​umbilical​ ​hernia.​ ​INR​ ​3.​ ​On​ ​exam​ ​it​ ​is​ ​incarcerated​ ​with​ ​skin​ ​changes.
Management?​ ​OR​ ​for​ ​exploration​ ​and​ ​find​ ​dead​ ​bowel​ ​incarcerated.​ ​Management:​ ​bowel​ ​resection,​ ​primary​ ​repair​ ​of
hernia,​ ​no​ ​mesh,​ ​+/-​ ​drain.​ ​(Just​ ​have​ ​some​ ​sort​ ​of​ ​plan​ ​for​ ​the​ ​ascites).​ ​Post-op​ ​the​ ​hernia​ ​repair​ ​is​ ​leaking​ ​ascites.​ ​What
to​ ​do​ ​now?​ ​Medical​ ​control​ ​of​ ​ascites​ ​(please​ ​describe:​ ​diuretics​ ​spironolactone​ ​and​ ​lasix,​ ​repeated​ ​paracentesis,​ ​low
sodium​ ​and​ ​fluid​ ​diet).

14. 45​ ​y/o​ ​woman​ ​with​ ​hx​ ​of​ ​RYGB​ ​for​ ​weight​ ​loss​ ​5​ ​years​ ​ago,​ ​presents​ ​for​ ​acute​ ​abdominal​ ​pain.​ ​HR​ ​110,​ ​BP​ ​100/70.​ ​Sharp
pain,​ ​no​ ​emesis,​ ​abdomen​ ​is​ ​distended.​ ​Labs​ ​and​ ​resuscitate.​ ​Management?​ ​CT​ ​shows​ ​some​ ​dilated​ ​loops.​ ​Now​ ​what?
OR​ ​for​ ​diagnostic​ ​laparoscopy.​ ​Find​ ​internal​ ​hernia.​ ​What​ ​locations?​ ​(Most​ ​commonly​ ​at​ ​the​ ​J-J​ ​anastomosis,​ ​otherwise
can​ ​be​ ​found​ ​at​ ​antecolic/retrocolic​ ​defects​ ​for​ ​the​ ​G-J).

15. 14​ ​y/o​ ​female,​ ​RLQ​ ​pain.​ ​WBC​ ​elevated.​ ​Urine​ ​preg​ ​test​ ​neg.​ ​U/S​ ​non-diagnostic.​ ​Pelvic​ ​negative​ ​for​ ​cervical​ ​motion
tenderness​ ​or​ ​cervical​ ​discharge.​ ​CT​ ​RLQ​ ​stranding.
a. Appendicitis
b. Tubo-ovarian​ ​abscess
c. Ovarian​ ​torsion

16. 14​ ​y/o​ ​male,​ ​RLQ​ ​pain.​ ​On​ ​exam​ ​RLQ​ ​tenderness.​ ​CT​ ​with​ ​stranding​ ​RLQ​ ​with​ ​thickened​ ​tubular​ ​structure.​ ​Diagnostic
laparoscopy:
a. Acute​ ​appendicitis​ ​->​ ​appendectomy
b. Crohns​ ​-​ ​>​ ​no​ ​appendiceal​ ​base​ ​involvement,​ ​incidental​ ​appendectomy
c. No​ ​abnormality​ ​of​ ​TI​ ​or​ ​appendix​ ​->​ ​run​ ​small​ ​bowel​ ​back​ ​for​ ​Meckel’s​ ​diverticulitis

17. Toxic​ ​megacolon,​ ​ulcerative​ ​colitis

18. Cecal​ ​volvulus

19. Sigmoid​ ​volvulus​ ​with​ ​or​ ​without​ ​ischemia​ ​and​ ​peritonitis

20. Ischemic​ ​colitis​ ​after​ ​AAA​ ​repair

21. 52​ ​y/o​ ​man,​ ​abdominal​ ​pain​ ​5​ ​days​ ​hx.​ ​In​ ​ED​ ​WBC​ ​18.​ ​Diffusely​ ​tender​ ​upper​ ​abdomen.​ ​CT​ ​a/p​ ​with​ ​pneumoperitoneum.
Management?​ ​Resuscitate.​ ​2​ ​large​ ​bore​ ​IV’s,​ ​IVF​ ​and​ ​abx,​ ​NGT,​ ​foley​ ​and​ ​OR​ ​for​ ​exlap.​ ​On​ ​exploration​ ​you​ ​see​ ​bile​ ​in
the​ ​lesser​ ​sac.​ ​Kocher​ ​maneuver​ ​shows​ ​posterior​ ​“penetrating​ ​ulcer”​ ​perforation​ ​of​ ​D1​ ​segment​ ​of​ ​duodenum​ ​into
retroperitoneum.​ ​Management?​ ​Antrectomy​ ​with​ ​B2​ ​reconstruction.​ ​Close​ ​the​ ​duodenal​ ​stump​ ​with​ ​g-tube,​ ​feeding​ ​j-tube,
and​ ​retrograde​ ​tube​ ​duodenostomy.
a. Post-op​ ​the​ ​patient​ ​get​ ​better​ ​but​ ​comes​ ​back​ ​to​ ​ED​ ​now​ ​with​ ​abdominal​ ​distention​ ​relieved​ ​by​ ​bilious​ ​emesis.
Diagnosis:​ ​afferent​ ​loop​ ​syndrome.​ ​Confirmation​ ​with​ ​EGD​ ​and​ ​HIDA.​ ​Tx:​ ​convert​ ​to​ ​RY​ ​reconstruction​ ​or​ ​uncut
Roux

22. 52​ ​y/o​ ​man,​ ​abdominal​ ​pain​ ​5​ ​days,​ ​WBC​ ​18​ ​CT​ ​with​ ​free​ ​air​ ​as​ ​above.​ ​Exlap​ ​shows​ ​bile​ ​staining​ ​of​ ​the​ ​gastrohepatic
ligament.​ ​Management?​ ​Exploration​ ​shows​ ​perforated​ ​gastric​ ​ulcer​ ​at​ ​lesser​ ​curvature.​ ​Management?​ ​Excise​ ​ulcer​ ​and
close​ ​in​ ​two​ ​layers

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23. 70​ ​y/o​ ​man,​ ​gastric​ ​outlet​ ​obstruction​ ​in​ ​MICU,​ ​hx​ ​of​ ​ulcer​ ​disease​ ​of​ ​stomach.​ ​KUB​ ​shows​ ​distended​ ​stomach.​ ​EGD
biopsies​ ​are​ ​benign.​ ​Exlap:
a. Subtotal​ ​gastrectomy​ ​with​ ​B2​ ​or​ ​RY​ ​reconstruction
b. Needs​ ​truncal​ ​vagotomy

24. Mallory-Weiss​ ​Tears,​ ​UGI​ ​bleed​ ​refractory​ ​to​ ​endoscopy,​ ​surgical​ ​approach

25. Management​ ​of​ ​UGI​ ​bleed,​ ​cirrhotic,​ ​fails​ ​attempts​ ​at​ ​banding​ ​endoscopically,​ ​needs​ ​TIPS

26. Toxic​ ​megacolon,​ ​fulminant​ ​colitis,​ ​fails​ ​medical​ ​therapy​ ​and​ ​gets​ ​total​ ​abdominal​ ​colectomy.​ ​Biopsies​ ​come​ ​back​ ​with
intranuclear​ ​inclusion​ ​bodies​ ​->​ ​must​ ​think​ ​CMV​ ​colitis​ ​and​ ​check​ ​HIV​ ​and​ ​CD4​ ​counts.

27. Recent​ ​chemotherapy,​ ​RLQ​ ​pain,​ ​neutropenic​ ​enterocolitis​ ​(typhlitis)​ ​management

28. 55​ ​y/o​ ​man​ ​with​ ​worsening​ ​dyspepsia​ ​on​ ​H2​ ​blockers.​ ​Boring​ ​pain​ ​in​ ​epigastrium.​ ​EGD​ ​with​ ​1.5​ ​cm​ ​ulcer​ ​on​ ​lesser
curvature,​ ​biopsies​ ​and​ ​H.​ ​pylori​ ​negative​ ​and​ ​benign.​ ​Repeat​ ​endoscopy​ ​after​ ​medical​ ​therapy​ ​PPI​ ​showed​ ​persistent
ulcer.​ ​Management?​ ​Wedge​ ​resection​ ​biopsy​ ​->​ ​T2​ ​gastric​ ​cancer​ ​on​ ​lesser​ ​curvature,​ ​within​ ​5cm​ ​of​ ​GE​ ​junction.
Management?​ ​Total​ ​gastrectomy​ ​with​ ​D1​ ​lymphadenectomy.

29. 35​ ​y/o​ ​with​ ​anal​ ​pain​ ​with​ ​defecation.​ ​Several​ ​months,​ ​tearing​ ​pain,​ ​hx​ ​of​ ​constipation​ ​and​ ​blood​ ​in​ ​stool.​ ​Management?
First​ ​EUA​ ​and​ ​colonoscopy​ ​(need​ ​to​ ​look​ ​for​ ​other​ ​colon​ ​pathology​ ​or​ ​diagnoses​ ​of​ ​IBD).​ ​Confirm​ ​diagnosis​ ​of​ ​fissure​ ​then
medical​ ​tx​ ​of​ ​fiber,​ ​sitz​ ​baths,​ ​nitropaste,​ ​and​ ​PO​ ​diltiazem​ ​did​ ​not​ ​work.​ ​Management?​ ​After​ ​6​ ​weeks​ ​of​ ​medical​ ​therapy
that​ ​failed,​ ​then​ ​lateral​ ​internal​ ​sphincterotomy.​ ​Describe​ ​this​ ​procedure​ ​and​ ​how​ ​much​ ​internal​ ​sphincter​ ​to​ ​transect.
a. How​ ​would​ ​management​ ​change​ ​if​ ​patient​ ​presents​ ​with​ ​lateral​ ​anal​ ​fissures​ ​(atypical​ ​location)​ ​with​ ​hx​ ​of​ ​bloody
stools​ ​and​ ​family​ ​hx​ ​of​ ​IBD​ ​->​ ​need​ ​to​ ​r/o​ ​IBD

30. 35​ ​y/o​ ​man​ ​with​ ​abdominal​ ​pain​ ​worsening​ ​in​ ​epigastrium.​ ​Fevers​ ​and​ ​chills.​ ​WBC​ ​15.​ ​Abdominal​ ​films​ ​show​ ​free​ ​air.
Exlap​ ​and​ ​find​ ​perforated​ ​duodenal​ ​ulcer.​ ​Management?​ ​Graham​ ​patch.
a. Variations:
i. No​ ​hx​ ​of​ ​PPI​ ​use:​ ​Graham​ ​patch​ ​and​ ​PPI​ ​post-op
ii. Extensive​ ​hx​ ​of​ ​PPI​ ​use​ ​pre-op:​ ​Graham​ ​patch​ ​and​ ​highly​ ​selective​ ​vagotomy
iii. Blown​ ​out​ ​duodenum​ ​and​ ​the​ ​first​ ​and​ ​second​ ​portions​ ​are​ ​gone​ ​->​ ​pyloric​ ​exclusion,​ ​Billroth​ ​2
reconstruction,​ ​g-tube,​ ​j-tube​ ​and​ ​retrograde​ ​duodenostomy

31. (AE)​ ​30​ ​yo​ ​female​ ​with​ ​RLQ​ ​pain,​ ​elevated​ ​white​ ​count,​ ​U/S​ ​shows​ ​fluid​ ​RLQ​ ​and​ ​pelvis,​ ​transvag​ ​shows​ ​same​ ​thing,​ ​OR
for​ ​lap​ ​appy,​ ​can’t​ ​identify​ ​appendix,​ ​open​ ​and​ ​mobilize​ ​colon,​ ​appendix​ ​blown​ ​out​ ​with​ ​inflamed​ ​cecum​ ​-​ ​he​ ​said​ ​have​ ​you
ever​ ​done​ ​something​ ​like​ ​that​ ​before?
a. Then​ ​changed​ ​situation​ ​to​ ​4cm​ ​TOA​ ​->​ ​Management?​ ​Drainage.

32. (PP)​ ​56​ ​y/o​ ​woman,​ ​POD#3​ ​s/p​ ​laparoscopic​ ​RYGB,​ ​discharged​ ​yesterday.​ ​Presented​ ​to​ ​ED​ ​with​ ​low​ ​grade​ ​fever,​ ​mild
abdominal​ ​pain,​ ​tachycardia​ ​120’s.​ ​Management?​ ​IV,​ ​resuscitate,​ ​CT​ ​a/p​ ​with​ ​PO​ ​contrast​ ​->​ ​leukocytosis​ ​and​ ​CT
showed​ ​leak​ ​with​ ​contrast​ ​extravasation.​ ​Management?​ ​Take​ ​back​ ​to​ ​OR,​ ​laparoscopic​ ​exploration,​ ​washout,​ ​omental
patch​ ​and​ ​suture​ ​repair,​ ​drains​ ​and​ ​g-tube.
a. POD#2​ ​patient​ ​becomes​ ​tachycardic,​ ​tachypneic,​ ​and​ ​hypoxic.​ ​Management?​ ​Start​ ​O2​ ​facemask.​ ​CXR.​ ​Pulse
ox.​ ​ABG.​ ​Start​ ​empiric​ ​heparin​ ​gtt.​ ​Dosing?​ ​(80u/kg​ ​bolus,​ ​18u/kg/hr​ ​infusion).​ ​CT​ ​PE​ ​protocol​ ​chest​ ​->​ ​negative
for​ ​PE’s.​ ​Management?​ ​Send​ ​troponins,​ ​EKG​ ​->​ ​positive.​ ​Management?​ ​Continue​ ​heparin​ ​gtt,​ ​ASA​ ​dose,
cardiology​ ​consultation.

33. 78​ ​y/o​ ​man​ ​s/p​ ​laparoscopic​ ​appendectomy​ ​30​ ​years​ ​ago​ ​presents​ ​with​ ​RLQ​ ​pain​ ​exactly​ ​same​ ​as​ ​appendicitis​ ​pain.
Management?​ ​Labs​ ​and​ ​CT​ ​a/p​ ​with​ ​PO​ ​and​ ​IV​ ​contrast.​ ​CT​ ​showed​ ​RLQ​ ​inflammation​ ​at​ ​cecum​ ​and​ ​surrounding​ ​small
bowel​ ​with​ ​dilated​ ​air​ ​fluid​ ​levels​ ​and​ ​no​ ​collections.​ ​Management?​ ​NPO,​ ​IVF,​ ​IV​ ​abx,​ ​observation.​ ​Next​ ​day​ ​patient​ ​has
worsened​ ​WBC​ ​and​ ​pain.​ ​Management?​ ​Diagnostic​ ​laparoscopy​ ​reveals​ ​stump​ ​appendicitis​ ​with​ ​inflammation​ ​of​ ​cecal
base.​ ​Management?​ ​Ileocecectomy​ ​and​ ​primary​ ​ileocolic​ ​anastomosis.
a. Patient​ ​in​ ​hospital​ ​with​ ​ileus​ ​develops​ ​fevers​ ​on​ ​POD#7​ ​and​ ​pain.​ ​Management?​ ​CT​ ​a/p​ ​revealed​ ​fluid
collection.​ ​Management?​ ​IR​ ​percutaneous​ ​drainage​ ​of​ ​purulent​ ​collection​ ​then​ ​advancement​ ​of​ ​diet.​ ​Drain
became​ ​progressively​ ​feculent.​ ​Management?​ ​No​ ​peritonitis​ ​or​ ​undrained​ ​sepsis,​ ​therefore​ ​it​ ​was​ ​controlled
fistula.​ ​Fistula​ ​output​ ​minimal.​ ​Management?​ ​Continue​ ​diet,​ ​fistulogram​ ​every​ ​2​ ​weeks​ ​to​ ​evaluate​ ​tract.​ ​Tract

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remained​ ​open.​ ​Management?​ ​At​ ​6​ ​weeks​ ​if​ ​nutrition​ ​optimized​ ​then​ ​take​ ​to​ ​OR​ ​after​ ​bowel​ ​prep​ ​for
laparotomy,​ ​fistula​ ​takedown​ ​and​ ​resection​ ​with​ ​primary​ ​anastomosis.

B.​ ​FOREGUT
34. (JFB)​ ​Dysphasia​ ​patient​ ​in​ ​clinic.​ ​Achalasia​ ​on​ ​gastrograffin​ ​esophagram.​ ​Described​ ​manometry​ ​findings​ ​(failure​ ​to​ ​relax
lower​ ​esophageal​ ​sphincter,​ ​aperistalsis​ ​of​ ​body​ ​of​ ​esophagus,​ ​hypertensive​ ​LES).​ ​OR​ ​description​ ​with​ ​myotomy​ ​6​ ​cm
onto​ ​esophagus​ ​and​ ​2-3​ ​cm​ ​down​ ​onto​ ​stomach.​ ​Leak​ ​intraop.​ ​How​ ​to​ ​manage​ ​(close​ ​defect​ ​in​ ​2​ ​layers,​ ​perform
myotomy​ ​180​ ​degrees​ ​to​ ​defect,​ ​still​ ​need​ ​fundoplication​ ​so​ ​do​ ​Dor​ ​fundoplication​ ​and​ ​tack​ ​fundus​ ​over​ ​the​ ​area​ ​of​ ​repair
for​ ​tissue​ ​bolstering).​ ​Case​ ​4.

35. 58​ ​y/o​ ​man,​ ​2​ ​month​ ​hx​ ​of​ ​dysphagia.​ ​Questions​ ​about​ ​solid​ ​or​ ​liquids​ ​dysphagia,​ ​weight​ ​loss,​ ​reflux​ ​hx,​ ​smoking​ ​and​ ​etoh
hx.​ ​Exam​ ​no​ ​lymphadenopathy.​ ​Narrowing​ ​of​ ​esophagus​ ​on​ ​esophagram.​ ​EGD​ ​finds​ ​stricture​ ​distal​ ​esophagus,​ ​cannot
get​ ​through,​ ​biopsies​ ​show​ ​atypical​ ​cells,​ ​indeterminate,​ ​no​ ​cancer​ ​seen.​ ​CT​ ​c/a/p​ ​narrowed​ ​esophagus,​ ​no​ ​lymph​ ​nodes
in​ ​mediastinum.
a. Peptic​ ​stricture​ ​-​ ​>​ ​can​ ​balloon​ ​dilate​ ​with​ ​fluoro,​ ​follow​ ​with​ ​EGD​ ​and​ ​biopsies​ ​to​ ​make​ ​sure​ ​not​ ​cancer,​ ​with
manometry​ ​and​ ​pH​ ​studies​ ​followed​ ​by​ ​reflux​ ​surgery​ ​as​ ​needed
b. Malignant​ ​or​ ​Indeterminate​ ​stricture​ ​->​ ​Ivor​ ​Lewis​ ​esophagectomy,​ ​need​ ​pre-op​ ​PFT’s

36. 50​ ​y/o​ ​man,​ ​HR​ ​120’s​ ​in​ ​ED,​ ​2​ ​days​ ​ago​ ​was​ ​on​ ​bender​ ​and​ ​puking.​ ​EKG​ ​sinus​ ​tachycardia.​ ​CBC​ ​18.​ ​CXR​ ​left​ ​pleural
effusion.​ ​Management?​ ​Resuscitation​ ​with​ ​2​ ​large​ ​bore​ ​IV’s,​ ​IVF,​ ​abx,​ ​foley.​ ​Gastrograffin​ ​followed​ ​by​ ​thin​ ​barium
esophagram​ ​as​ ​needed​ ​diagnosed​ ​esophageal​ ​perforation,​ ​a.k.a.​ ​Boerhaave’s.​ ​Treatment:​ ​left​ ​posterolateral
thoracotomy,​ ​repair​ ​in​ ​two​ ​layers,​ ​intercostal​ ​muscle​ ​flap,​ ​pass​ ​NG​ ​beyond​ ​repair,​ ​wide​ ​drainage​ ​with​ ​chest​ ​tubes,​ ​with
feeding​ ​jejunostomy​ ​tube​ ​either​ ​during​ ​first​ ​surgery​ ​if​ ​stabilizes​ ​or​ ​on​ ​second​ ​surgery​ ​once​ ​stable.​ ​Post-op​ ​day​ ​5​ ​the
patient​ ​gets​ ​septic,​ ​CT​ ​chest​ ​reveals​ ​free​ ​fluid​ ​in​ ​chest,​ ​not​ ​drained​ ​by​ ​your​ ​chest​ ​tubes,​ ​on​ ​pressors.​ ​Management?
Lateral​ ​loop​ ​esophagostomy​ ​and​ ​thoracotomy​ ​and​ ​drain​ ​the​ ​chest,​ ​vent​ ​the​ ​stomach​ ​with​ ​g-tube.

37. 65​ ​y/o​ ​woman,​ ​discomfort​ ​with​ ​eating,​ ​epigastric​ ​tenderness.​ ​EGD,​ ​manometry,​ ​esophagram​ ​shows​ ​hiatal​ ​hernia,
paraesophageal.​ ​Pre-op​ ​cardiac​ ​w/u,​ ​stress​ ​test​ ​and​ ​EKG.​ ​Describe​ ​hiatal​ ​hernia​ ​repair​ ​key​ ​steps​ ​with​ ​fundoplication.

38. 65​ ​y/o​ ​man​ ​with​ ​reflux​ ​for​ ​5​ ​years.​ ​EGD​ ​shows​ ​Barrett’s​ ​esophagus.​ ​Management:
a. No​ ​dysplasia​ ​->​ ​repeat​ ​endoscopy​ ​in​ ​1​ ​year
b. Low-grade​ ​dysplasia​ ​->​ ​repeat​ ​endoscopy​ ​6​ ​months
c. High-grade​ ​dysplasia​ ​->​ ​radiofrequency​ ​ablation​ ​or​ ​endoscopic​ ​mucosal​ ​resection​ ​with​ ​repeat​ ​endoscopies​ ​q3
months​ ​versus​ ​esophagectomy.
Biopsy​ ​shows​ ​malignancy,​ ​esophageal​ ​cancer.​ ​W/U​ ​includes:​ ​CBC,​ ​CMP,​ ​LFT’s,​ ​CT
c/a/p​ ​with​ ​PET,​ ​endoscopic​ ​ultrasound​ ​for​ ​staging.​ ​T3​ ​and​ ​above​ ​gets​ ​pre-op​ ​chemo-RT
then​ ​restage​ ​then​ ​Ivor-Lewis​ ​esophagectomy.​ ​Post-op​ ​management​ ​of​ ​anastomotic​ ​leak.

39. 70​ ​y/o​ ​with​ ​achalasia,​ ​had​ ​balloon​ ​dilation.​ ​Post-procedure​ ​developed​ ​left​ ​chest​ ​pain.​ ​Gastrograffin​ ​no​ ​leak.​ ​Thin​ ​barium
shows:​ ​(1)​ ​distal​ ​esophageal​ ​perforation​ ​into​ ​left​ ​chest.​ ​Describe​ ​management:​ ​Abx,​ ​fluid​ ​resuscitation,​ ​left​ ​posterolateral
thoracotomy,​ ​repair​ ​in​ ​two​ ​layers,​ ​intercostal​ ​muscle​ ​flap,​ ​180​ ​degree​ ​esophageal​ ​myotomy​ ​and​ ​wide​ ​drainage​ ​VERSUS
esophagram​ ​showing​ ​(2)​ ​perforation​ ​into​ ​abdomen​ ​->​ ​management​ ​with​ ​exlap,​ ​repair​ ​in​ ​two​ ​layers,​ ​coverage​ ​with
omentum,​ ​myotomy,​ ​and​ ​drainage.

40. 55​ ​y/o​ ​with​ ​GERD.​ ​Need​ ​hx,​ ​attempted​ ​therapy,​ ​dysphagia,​ ​medications.​ ​Work-up?​ ​(EGD,​ ​esophagram,​ ​manometry,​ ​24
hour​ ​pH​ ​testing​ ​->​ ​DeMeester​ ​score​ ​greater​ ​than​ ​14.72%).​ ​EGD​ ​shows​ ​distal​ ​Barrett’s​ ​esophagus,​ ​low​ ​grade​ ​dysplasia​ ​on
biopsies.​ ​Manometry​ ​shows​ ​normal​ ​motility.​ ​DeMeester​ ​19,​ ​esophagram​ ​negative​ ​for​ ​short​ ​esophagus​ ​or​ ​paraesophageal
hernia.​ ​Treatment​ ​is…​ ​laparoscopic​ ​Nissen​ ​fundoplication.​ ​Describe​ ​the​ ​surgery​ ​and​ ​port​ ​placement.​ ​(Ports​ ​upper
abdomen,​ ​camera​ ​port​ ​slightly​ ​to​ ​left​ ​of​ ​umbilicus,​ ​need​ ​5th​ ​port​ ​to​ ​retract​ ​liver​ ​with​ ​Nathanson​ ​liver​ ​retractor).

41. Esophageal​ ​stricture​ ​dilation,​ ​presents​ ​to​ ​ED​ ​POD#0​ ​with​ ​chest​ ​pain,​ ​tachycardia.​ ​Esophagram​ ​diagnoses​ ​perforation.​ ​On
operative​ ​exploration​ ​see​ ​mass​ ​at​ ​site​ ​of​ ​perforation,​ ​biopsy​ ​shows​ ​adenocarcinoma.​ ​Management?

C.​ ​HEPATO-PANCREATICO-BILIARY​ ​and​ ​ONCOLOGY

42. (JFB)​ ​Post​ ​lap​ ​chole​ ​1​ ​year.​ ​Stricture​ ​cbd.​ ​Elevated​ ​Tbili.​ ​PTC​ ​for​ ​drainage​ ​and​ ​elective​ ​exploration​ ​because​ ​could​ ​not
refer​ ​to​ ​tertiary​ ​center.​ ​Explore​ ​and​ ​cannot​ ​dissect​ ​out.​ ​Shot​ ​intraop​ ​cholangiogram​ ​via​ ​PTC​ ​but​ ​didn't​ ​help.​ ​I​ ​aborted​ ​the
surgery​ ​given​ ​concern​ ​that​ ​I​ ​would​ ​create​ ​hepatic​ ​vascular​ ​injury​ ​or​ ​other​ ​badness.​ ​Case​ ​8.

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 GENERAL​ ​SURGERY​ ​CERTIFYING​ ​EXAMINATION​ ​PREPARATION

43. (JFB)​ ​Solid​ ​pancreatic​ ​mass​ ​tail.​ ​Labs​ ​and​ ​EUS​ ​with​ ​biopsy​ ​showed​ ​adenocarcinoma.​ ​Preop​ ​splenectomy​ ​vaccinations
two​ ​weeks​ ​before.​ ​Staging​ ​CT​ ​c/a/p​ ​negative.​ ​Took​ ​to​ ​OR.​ ​Exploration​ ​showed​ ​no​ ​metastatic​ ​disease.​ ​Distal​ ​splenectomy
attempting​ ​to​ ​preserve​ ​spleen.​ ​Splenic​ ​vein​ ​bleeding.​ ​Stopped​ ​with​ ​pressure​ ​then​ ​stitch.​ ​Spleen​ ​became​ ​engorged.
Splenectomy.​ ​Case​ ​12.

44. 70​ ​y/o​ ​man​ ​POD#5​ ​after​ ​CABG​ ​with​ ​RUQ​ ​pain​ ​in​ ​ICU.​ ​Febrile.​ ​Abdominal​ ​pain​ ​RUQ.​ ​Elevated​ ​WBC​ ​and​ ​LFT’s.​ ​RUQ
ultrasound​ ​with​ ​acalculous​ ​cholecystitis.​ ​Management.

45. (AE)​ ​45​ ​yo​ ​female​ ​with​ ​choledocholithiasis​ ​-​ ​led​ ​down​ ​route​ ​of​ ​open​ ​bile​ ​duct​ ​exploration​ ​and​ ​t-tube

46. (PP)​ ​28​ ​y/o​ ​woman​ ​in​ ​second​ ​trimester​ ​pregnancy.​ ​Hx​ ​of​ ​gallstones.​ ​Presented​ ​to​ ​ED​ ​with​ ​bilirubin​ ​2.5.​ ​US​ ​nonvisualized
CBD​ ​but​ ​seens​ ​stones​ ​in​ ​GB.​ ​Management?
a. ERCP​ ​with​ ​shielding​ ​of​ ​fetus.​ ​Unable​ ​to​ ​cannulate​ ​sphincter​ ​of​ ​Vater.​ ​Management?
b. OR​ ​for​ ​laparoscopic​ ​cholecystectomy​ ​and​ ​CBD​ ​exploration.​ ​Describe​ ​port​ ​placement​ ​and​ ​procedure.
i. Describe​ ​critical​ ​view​ ​of​ ​safety
ii. Describe​ ​CBD​ ​exploration
1. Flush​ ​CBD,​ ​glucagon
2. Choledoschoscope,​ ​push​ ​stones​ ​into​ ​duodenum​ ​or​ ​basket​ ​and​ ​removal
3. Cholangiogram​ ​intra-op​ ​and​ ​shield​ ​baby
iii. Cannot​ ​remove​ ​stones.​ ​Open​ ​CBD​ ​exploration.​ ​Describe​ ​and​ ​how​ ​to​ ​close​ ​choledochotomy?​ ​Over
T-tube.

47. 35​ ​y/o​ ​man,​ ​healthy,​ ​no​ ​smoking​ ​or​ ​drinking,​ ​presents​ ​with​ ​12​ ​hours​ ​of​ ​epigastric​ ​abdominal​ ​pain​ ​radiating​ ​to​ ​back.
Tachycardic​ ​and​ ​BP​ ​80’s/50’s.​ ​Resuscitation?​ ​2​ ​large​ ​bore​ ​IV’s,​ ​IVF​ ​boluses​ ​and​ ​labs​ ​(CBC,​ ​CMP,​ ​amylase,​ ​lipase,​ ​T&C,
lactic​ ​acid).​ ​WBC​ ​28,​ ​LFT’s​ ​elevated​ ​450​ ​and​ ​400,​ ​Tbili​ ​5.​ ​Hematocrit​ ​18,​ ​lactic​ ​acid​ ​2,​ ​amylase​ ​and​ ​lipase​ ​3000.
Management?​ ​Continue​ ​IVF​ ​resuscitation,​ ​RUQ​ ​ultrasound​ ​->​ ​cholelithiasis,​ ​no​ ​cholecystitis,​ ​stone​ ​in​ ​CBD​ ​with​ ​dilation​ ​of
biliary​ ​tree.​ ​Management?​ ​ERCP​ ​for​ ​CBD​ ​clearance​ ​and​ ​admission​ ​to​ ​ICU​ ​for​ ​fluid​ ​resuscitation​ ​and​ ​monitoring.​ ​Keep
NPO.
a. Variations:​ ​when​ ​to​ ​take​ ​out​ ​gallbladder?
b. Complications:​ ​symptomatic​ ​pseudocyst,​ ​pancreatic​ ​necrosis,​ ​pancreatic​ ​abscess

48. In​ ​the​ ​OR,​ ​find​ ​leakage​ ​of​ ​bile​ ​from​ ​porta-hepatis​ ​during​ ​lap​ ​chole​ ​->​ ​transected​ ​cystic​ ​duct​ ​and​ ​artery​ ​already​ ​->​ ​IOC​ ​via
cystic​ ​duct​ ​stump​ ​shows​ ​direct​ ​filling​ ​into​ ​duodenum​ ​and​ ​spillage​ ​therefore​ ​must​ ​be​ ​CBD​ ​transection.​ ​Management?
Convert​ ​to​ ​open​ ​and​ ​find​ ​1.5cm​ ​gap​ ​in​ ​CBD​ ​and​ ​transected​ ​and​ ​ligated​ ​right​ ​hepatic​ ​artery.​ ​Management?​ ​RY
hepaticojejunostomy​ ​in​ ​end​ ​to​ ​side​ ​manner​ ​with​ ​drains.
a. Post-op​ ​1​ ​year​ ​patient​ ​was​ ​doing​ ​well​ ​but​ ​came​ ​to​ ​ED​ ​in​ ​septic​ ​shock.​ ​U/S​ ​showed​ ​dilated​ ​biliary​ ​tree​ ​and
cholangitis.​ ​Management?​ ​Resuscitate,​ ​IVF,​ ​IV​ ​abx,​ ​ICU​ ​and​ ​IR​ ​for​ ​PTC​ ​for​ ​drainage.​ ​They​ ​drain​ ​the​ ​biliary
tree.​ ​Anything​ ​else​ ​needed?​ ​Cholangiogram​ ​shows​ ​stenotic​ ​anastomosis.​ ​Management?​ ​IR​ ​dilation​ ​unable​ ​to
be​ ​done.​ ​Management?​ ​OR​ ​for​ ​revision​ ​of​ ​anastomosis.

49. 50​ ​y/o​ ​with​ ​right​ ​flank​ ​pain.​ ​CT​ ​shows​ ​10​ ​cm​ ​liver​ ​mass​ ​right​ ​lobe.​ ​H&P​ ​negative.​ ​No​ ​travel,​ ​no​ ​etoh,​ ​no​ ​hep​ ​C,​ ​no​ ​family
hx.​ ​Labs​ ​and​ ​imaging.​ ​CBC,​ ​CMP,​ ​CEA,​ ​CA19-9,​ ​AFP​ ​all​ ​negative.​ ​CT​ ​triple​ ​phase​ ​liver​ ​protocol​ ​->​ ​delayed
enhancement,​ ​peripheral​ ​pooling,​ ​delayed​ ​washout.​ ​Management?​ ​(Liver​ ​hemangioma​ ​->​ ​watch).​ ​No​ ​surgery.
a. Know​ ​your​ ​CT​ ​descriptors​ ​of​ ​liver​ ​lesions
i. Hepatocellular​ ​carcinoma​ ​-​ ​hypervascular,​ ​early​ ​enhancement,​ ​rapid​ ​washout
ii. Hepatic​ ​adenoma​ ​-​ ​similar​ ​to​ ​HCC​ ​but​ ​no​ ​liver​ ​disease​ ​history
iii. Focal​ ​nodular​ ​hyperplasia​ ​-​ ​central​ ​stellate​ ​scar,​ ​hypervascular
iv. Hemangioma​ ​-​ ​peripheral​ ​pooling,​ ​delayed​ ​enhancement,​ ​delayed​ ​washout
v. Metastatic​ ​disease​ ​-​ ​hypodense​ ​lesion,​ ​cancer​ ​hx

50. 28​ ​y/o​ ​woman​ ​came​ ​to​ ​ED​ ​with​ ​vague​ ​RUQ​ ​abdominal​ ​pain.​ ​LFT’s​ ​normal.​ ​RUQ​ ​ultrasound​ ​is​ ​obtained​ ​shows​ ​4cm​ ​mass
in​ ​liver.​ ​On​ ​OCP’s.​ ​Management?​ ​Labs​ ​and​ ​imaging​ ​including:​ ​CBC/CMP/AFP​ ​and​ ​CT​ ​a/p​ ​liver​ ​protocol​ ​->​ ​CT​ ​shows
early​ ​enhancing​ ​with​ ​late​ ​washout​ ​4cm​ ​mass.​ ​Diagnosis?​ ​Hepatic​ ​adenoma.​ ​Management?​ ​Discontinue​ ​OCP’s.​ ​No
change​ ​in​ ​size​ ​in​ ​6​ ​months.​ ​Management?​ ​Resection.

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51. 45​ ​y/o​ ​woman​ ​with​ ​wrenching​ ​pain​ ​several​ ​days​ ​ago,​ ​RUQ​ ​pain.​ ​Jaundiced.​ ​Focally​ ​tender​ ​RUQ.​ ​HR​ ​115.​ ​BP​ ​normal.
WBC​ ​15.​ ​AlkPhos​ ​elevated,​ ​Tbili​ ​3.​ ​Now​ ​what?​ ​Ultrasound​ ​revealed​ ​CBD​ ​8mm,​ ​with​ ​pericholecystic​ ​fluid​ ​and​ ​wall
thickening.​ ​Management?​ ​Laparoscopic​ ​cholecystectomy​ ​with​ ​intra-op​ ​cholangiogram.​ ​Describe​ ​procedure.

52. 30​ ​y/o​ ​female,​ ​lap​ ​chole​ ​5​ ​days​ ​ago​ ​has​ ​RUQ​ ​pain.​ ​Slight​ ​elevated​ ​WBC​ ​and​ ​LFT’s.​ ​What​ ​test?​ ​RUQ​ ​ultrasound​ ​shows
biloma​ ​in​ ​gallbladder​ ​fossa.​ ​What​ ​now?​ ​IR​ ​percutaneous​ ​drainage​ ​shows​ ​bile.​ ​Get​ ​ERCP:
a. ERCP​ ​shows​ ​leaking​ ​cystic​ ​duct​ ​stump​ ​->​ ​stent​ ​and​ ​sphincterotomy
b. ERCP​ ​shows​ ​abrupt​ ​cutoff​ ​of​ ​CBD​ ​->​ ​after​ ​5-7​ ​days​ ​need​ ​to​ ​wait​ ​at​ ​least​ ​6​ ​weeks​ ​for​ ​inflammation​ ​to​ ​calm​ ​down
prior​ ​to​ ​definitive​ ​repair,​ ​immediate​ ​identification​ ​then​ ​repair​ ​with​ ​hepatico-jejunostomy.

53. 65​ ​y/o​ ​man​ ​hx​ ​of​ ​colon​ ​cancer,​ ​had​ ​a​ ​T3N2​ ​colon​ ​cancer​ ​s/p​ ​right​ ​hemicolectomy​ ​two​ ​years​ ​ago.​ ​Recently​ ​CEA​ ​became
elevated.​ ​Management?​ ​Repeat​ ​colonoscopy​ ​negative​ ​and​ ​CT​ ​a/p​ ​->​ ​right​ ​liver​ ​lobe​ ​lesion.​ ​Management?​ ​IR​ ​biopsy
shows​ ​metastatic​ ​colon​ ​cancer.​ ​Management?​ ​Metastasis​ ​resection,​ ​leave​ ​post-op​ ​drains​ ​in​ ​surgical​ ​bed.
a. Post-op​ ​management​ ​of​ ​biliary​ ​leak​ ​from​ ​surgical​ ​bed.
b. Post-op​ ​therapy?​ ​Needs​ ​chemotherapy.

54. 70​ ​y/o​ ​woman​ ​with​ ​vague​ ​abdominal​ ​pain​ ​complaints,​ ​found​ ​to​ ​have​ ​3.5cm​ ​cystic​ ​lesion​ ​of​ ​pancreas​ ​in​ ​the​ ​head.​ ​H&P
unremarkable,​ ​no​ ​weight​ ​loss,​ ​no​ ​jaundice,​ ​no​ ​family​ ​hx,​ ​no​ ​hx​ ​of​ ​pancreatitis.​ ​Labs​ ​including​ ​CBC,​ ​CMP,​ ​amylase,​ ​lipase.
What​ ​imaging?​ ​CT​ ​pancreas​ ​protocol​ ​->​ ​shows​ ​dilated​ ​distal​ ​pancreatic​ ​duct​ ​with​ ​mass​ ​as​ ​above.​ ​Management?​ ​EUS
with​ ​biopsy​ ​of​ ​mass​ ​and​ ​cyst​ ​->​ ​cytology​ ​with​ ​elevated​ ​CEA​ ​and​ ​amylase.​ ​Management​ ​and​ ​post-op​ ​surveillance.
a. Be​ ​able​ ​to​ ​differentiate​ ​different​ ​cystic​ ​pancreatic​ ​masses
i. Intraductal​ ​papillary​ ​mucinous​ ​neoplasm​ ​-​ ​elevated​ ​CEA,​ ​elevated​ ​amylase
ii. Mucinous​ ​cystic​ ​neoplasm​ ​-​ ​elevated​ ​CEA,​ ​low​ ​amylase
iii. Serous​ ​cystic​ ​neoplasm​ ​-​ ​low​ ​CEA,​ ​low​ ​amylase
iv. Pancreatic​ ​pseudocyst​ ​-​ ​low​ ​CEA,​ ​elevated​ ​amylase

55. Perianal​ ​mass,​ ​large,​ ​shows​ ​dermatofibrosarcoma​ ​protuberans.​ ​Treatment​ ​wide​ ​local​ ​excision.​ ​What​ ​if​ ​cannot​ ​get​ ​full​ ​5cm
margin​ ​due​ ​to​ ​nearby​ ​structure​ ​(anal​ ​sphincters)​ ​->​ ​XRT​ ​since​ ​radiosensitive​ ​tumor.

56. 17​ ​y/o​ ​man,​ ​with​ ​middle​ ​of​ ​back​ ​mass.​ ​Asymmetric,​ ​irregular​ ​borders,​ ​color​ ​changes,​ ​diameter​ ​over​ ​6mm,​ ​evolved.​ ​Punch
biopsy​ ​shows​ ​3mm​ ​thick​ ​melanoma.​ ​Treatment:​ ​first​ ​needs​ ​metastatic​ ​w/u​ ​(CT​ ​chest,​ ​LDH,​ ​LFT’s,​ ​PET​ ​scan).​ ​Pre-op
node​ ​mapping.​ ​Excision​ ​with​ ​margins​ ​(2cm​ ​margins)​ ​and​ ​sentinel​ ​node​ ​+/-​ ​lymph​ ​node​ ​dissection.​ ​Adjuvant​ ​IFN​ ​therapy
with​ ​positive​ ​nodes.​ ​Radiation​ ​for​ ​>4​ ​nodes​ ​or​ ​extracapsular​ ​invasion.

57. GIST​ ​stomach,​ ​margins,​ ​>5​ ​mitoses​ ​per​ ​HPF,​ ​Gleevec​ ​adjuvant

58. 50​ ​y/o​ ​man​ ​14​ ​days​ ​s/p​ ​laparoscopic​ ​splenectomy​ ​for​ ​ITP​ ​presents​ ​to​ ​ED​ ​with​ ​LUQ​ ​abdominal​ ​pain,​ ​fevers,​ ​chills.
Management?​ ​Vitals,​ ​physical,​ ​labs,​ ​imaging​ ​including​ ​CT​ ​a/p​ ​shows​ ​LUQ​ ​fluid​ ​collection​ ​with​ ​rim​ ​enhancement​ ​and
stranding.​ ​Management?​ ​IV​ ​abx​ ​and​ ​ ​IR​ ​drain​ ​->​ ​purulent.
a. What​ ​if​ ​fluid​ ​drainage​ ​turns​ ​clear​ ​and​ ​persistent​ ​drainage?​ ​Management?​ ​Labs​ ​for​ ​fluid​ ​amylase​ ​->​ ​fluid
amylase​ ​30,000.​ ​Management?​ ​NPO,​ ​TPN,​ ​ERCP​ ​for​ ​pancreatic​ ​ductogram.​ ​Management?​ ​Pancreatic​ ​stenting
versus​ ​distal​ ​pancreatectomy​ ​for​ ​failure.

59. 65​ ​y/o​ ​woman​ ​presents​ ​with​ ​referral​ ​for​ ​pancreatic​ ​mass​ ​incidentally​ ​found.​ ​Tbili​ ​11​ ​H&P​ ​including​ ​weight​ ​loss,​ ​jaundice,
surgical​ ​hx,​ ​etc.​ ​What​ ​labs​ ​and​ ​imaging?​ ​CEA,​ ​CA19-9,​ ​amylase/lipase​ ​and​ ​CT​ ​pancreas​ ​(triple​ ​phase)​ ​shows​ ​mass​ ​in
uncinate​ ​process​ ​with​ ​50%​ ​involvement​ ​of​ ​SMV,​ ​no​ ​hepatic​ ​artery​ ​or​ ​SMA​ ​involvement.​ ​Management?​ ​Get​ ​ERCP​ ​with
stenting​ ​and​ ​brushings​ ​->​ ​adenocarcinoma.​ ​Pre-op​ ​then​ ​Whipple.​ ​Describe​ ​the​ ​surgery.
a. POD#4​ ​the​ ​pancreatico-j​ ​drain​ ​was​ ​cloudy​ ​->​ ​Amylase​ ​levels​ ​5000.
b. POD#5​ ​develops​ ​fevers​ ​and​ ​RUQ​ ​pain,​ ​WBC​ ​17,​ ​LFT’s​ ​normal,​ ​management?​ ​Get​ ​CT​ ​a/p​ ​->​ ​undrained​ ​fluid
collection​ ​via​ ​IR
c. POD#12,​ ​patient​ ​develops​ ​bloody​ ​drainage​ ​in​ ​abdominal​ ​drains.​ ​Management?​ ​CBC,​ ​T&C,​ ​coags​ ​and​ ​consult
IR​ ​for​ ​GDA​ ​blowout.

60. (AE)​ ​Know​ ​resectability​ ​criteria​ ​for​ ​pancreatic​ ​masses​ ​that​ ​need​ ​Whipple
a. No​ ​metastatic​ ​disease
b. Less​ ​than​ ​180​ ​degree​ ​involvement​ ​of​ ​SMV
c. No​ ​hepatic​ ​arterial​ ​or​ ​SMA​ ​involvement

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61. (PP)​ ​89​ ​y/o​ ​man​ ​demented​ ​with​ ​cachexia​ ​and​ ​jaundice.​ ​Labs​ ​revealed​ ​bilirubin​ ​9,​ ​US​ ​revealed​ ​dilated​ ​CBD.
Management?​ ​ERCP​ ​unable​ ​to​ ​cannulate​ ​ampulla​ ​of​ ​Vater.​ ​Management?​ ​IR​ ​for​ ​PTC​ ​and​ ​internal​ ​to​ ​external​ ​stent​ ​with
cholangiogram,​ ​brushings,​ ​and​ ​stenting.​ ​Brushings​ ​revealed​ ​adenocarcinoma.​ ​Management?​ ​CT​ ​c/a/p​ ​revealed
pancreatic​ ​head​ ​mass​ ​but​ ​no​ ​gross​ ​metastasis.​ ​Management​ ​options:
a. Palliation​ ​->​ ​patient​ ​is​ ​cachectic​ ​with​ ​dementia,​ ​needs​ ​metal​ ​biliary​ ​stent​ ​and​ ​if​ ​not​ ​successful​ ​then
hepatico-jejunostomy.
b. Too​ ​sick​ ​thus​ ​not​ ​candidate​ ​for​ ​Whipple​ ​procedure.
c. Patient’s​ ​daughter​ ​wants​ ​everything​ ​done​ ​for​ ​the​ ​cancer.​ ​Management?​ ​Must​ ​determine​ ​who​ ​is​ ​decision​ ​maker.
She​ ​doesn’t​ ​have​ ​paperwork​ ​for​ ​POA.​ ​Management?​ ​Ethics​ ​consultation,​ ​medical​ ​oncology,​ ​palliative​ ​care
consult.

62. (AE)​ ​R​ ​leg​ ​sarcoma​ ​with​ ​isolated​ ​lung​ ​met.​ ​Resected​ ​sarcoma​ ​and​ ​lung​ ​met​ ​and​ ​gave​ ​post​ ​op​ ​radiation

63. (PP)​ ​28​ ​y/o​ ​female​ ​with​ ​mid-thigh​ ​mass.​ ​Physical​ ​exam​ ​reveals​ ​8cm​ ​palpable​ ​mass.​ ​Management?​ ​MRI,​ ​CXR,​ ​core
needle​ ​biopsy.​ ​MRI​ ​and​ ​biopsy​ ​showed​ ​sarcoma​ ​away​ ​from​ ​vessels.​ ​Management?​ ​OR​ ​for​ ​excision.​ ​What​ ​margins?​ ​How
do​ ​you​ ​management​ ​specimen?​ ​Mark​ ​specimens​ ​to​ ​label​ ​direction.​ ​What​ ​else?​ ​Clips​ ​in​ ​wound​ ​bed​ ​for​ ​possible​ ​RT
post-op.​ ​Pathology​ ​showed​ ​low​ ​grade​ ​sarcoma.​ ​Management?​ ​Surveillance,​ ​CXR,​ ​physicals,​ ​and​ ​no​ ​RT.
a. Change​ ​scenario:​ ​ ​8cm​ ​mass​ ​near​ ​superficial​ ​femoral​ ​artery.​ ​Management?​ ​Preop​ ​RT​ ​then​ ​resection.​ ​Unable​ ​to
separate​ ​from​ ​vessel.​ ​Management?​ ​Obtain​ ​proximal​ ​and​ ​distal​ ​control​ ​of​ ​vessel,​ ​resect​ ​mass​ ​enbloc,
reconstruct​ ​with​ ​PTFE.
b. Change​ ​scenario:​ ​original​ ​mass,​ ​9​ ​months​ ​post-op​ ​patient​ ​develops​ ​LUL​ ​lung​ ​lesion​ ​on​ ​CXR.​ ​Management?​ ​CT
chest​ ​shows​ ​mass​ ​without​ ​lymphadenopathy.​ ​Management?​ ​VATS​ ​and​ ​wedge​ ​resection​ ​of​ ​metastasis.

64. (PP)​ ​58​ ​y/o​ ​man,​ ​with​ ​2​ ​cm​ ​mobile​ ​mass​ ​6​ ​cm​ ​from​ ​anal​ ​verge​ ​on​ ​colonoscopy,​ ​biopsy​ ​revealed​ ​adenocarcinoma.
Management?​ ​CT​ ​c/a/p​ ​with​ ​labs​ ​including​ ​CEA,​ ​LFT’s,​ ​and​ ​endorectal​ ​ultrasound.​ ​Pre-op​ ​staging​ ​is​ ​T1N0.
Management?​ ​Low​ ​anterior​ ​colon​ ​resection​ ​versus​ ​transanal​ ​excision.
a. What​ ​are​ ​requirements​ ​for​ ​transanal​ ​excision?​ ​Low​ ​rectal​ ​T1,​ ​<4cm,​ ​negative​ ​margins​ ​1cm,​ ​well​ ​differentiated,
no​ ​neurologic​ ​or​ ​vascular​ ​invasion
b. How​ ​do​ ​you​ ​follow-up​ ​these​ ​patients​ ​after​ ​transanal​ ​excision?​ ​CEA’s,​ ​exams,​ ​colonoscopy,​ ​scans
Patient​ ​returns​ ​with​ ​recurrence​ ​at​ ​anastomosis​ ​at​ ​18​ ​months.​ ​Management?​ ​Restage​ ​with​ ​APR​ ​versus​ ​LAR.​ ​How​ ​do​ ​you
determine​ ​LAR​ ​versus​ ​APR?​ ​Location​ ​and​ ​sphincter​ ​involvement.​ ​What​ ​are​ ​the​ ​concerns​ ​post-op​ ​for​ ​LAR​ ​or​ ​APR?
Incontinence,​ ​sexual​ ​dysfunction,​ ​anastomotic​ ​leak.
1. Change​ ​scenario:​ ​2cm​ ​mass,​ ​T1N0​ ​4cm​ ​from​ ​anus​ ​->​ ​transanal​ ​excision​ ​versus​ ​APR
2. Change​ ​scenario:​ ​2cm​ ​mass,​ ​T2N1​ ​6cm​ ​from​ ​anus​ ​->​ ​neoadjuvant​ ​chemoRT,​ ​restage,​ ​LAR
3. Change​ ​scenario:​ ​2cm​ ​mass,​ ​T2N1​ ​4cm​ ​from​ ​anus​ ​->​ ​neoadjuvant​ ​chemoRT,​ ​restage,​ ​LAR​ ​versus​ ​APR

65. 70​ ​y/o​ ​man​ ​with​ ​uncontrolled​ ​comorbidities​ ​(pulmonary​ ​and​ ​cardiac​ ​cripple)​ ​with​ ​abdominal​ ​distention,​ ​nausea,​ ​feculent
emesis.​ ​CT​ ​shows​ ​descending​ ​colon​ ​obstructing​ ​colon​ ​mass.​ ​Management?

66. 50​ ​y/o​ ​man​ ​with​ ​LUQ​ ​abdominal​ ​pain,​ ​found​ ​to​ ​have​ ​mass​ ​in​ ​left​ ​lobe​ ​of​ ​liver​ ​and​ ​pancreatic​ ​mass.​ ​What​ ​work-up?​ ​CBC,
CMP,​ ​CA19-9.​ ​Get​ ​CT​ ​a/p​ ​->​ ​midbody​ ​pancreatic​ ​mass​ ​3cm​ ​hypervascular​ ​mass,​ ​3cm​ ​liver​ ​lesion​ ​left​ ​lobe​ ​hypervascular
in​ ​segment​ ​III.​ ​Management?​ ​EUS​ ​with​ ​biopsy​ ​->​ ​pathology​ ​is​ ​neuroendocrine​ ​tumor.​ ​What​ ​lab?​ ​Chromogranin​ ​A​ ​->
elevated.​ ​Management?​ ​Exploratory​ ​laparotomy,​ ​distal​ ​pancreatectomy,​ ​liver​ ​metastectomy,​ ​with​ ​cholecystectomy.

67. 40​ ​y/o​ ​with​ ​hx​ ​of​ ​RYGB​ ​presents​ ​with​ ​RUQ​ ​abdominal​ ​pain,​ ​fevers,​ ​altered​ ​mental​ ​status.​ ​RUQ​ ​ultrasound​ ​shows​ ​CBD
dilation.​ ​Tachycardic​ ​and​ ​hypotensive.​ ​Management?​ ​2​ ​large​ ​bore​ ​IV’s,​ ​IVF,​ ​IV​ ​abx​ ​and​ ​consult​ ​IR​ ​for​ ​PTC​ ​->​ ​unable​ ​to
get​ ​access​ ​to​ ​biliary​ ​tree.​ ​Management?​ ​OR​ ​with​ ​GI,​ ​bring​ ​up​ ​gastric​ ​remnant,​ ​minilaparotomy,​ ​open​ ​gastric​ ​remnant,
ERCP​ ​through​ ​gastric​ ​remnant.

68. 76​ ​y/o​ ​woman​ ​25​ ​cm​ ​proximal​ ​to​ ​anal​ ​verge​ ​tumor​ ​on​ ​flex​ ​sig​ ​with​ ​colon​ ​adenocarcinoma.​ ​Needs​ ​labs,​ ​coags,​ ​CEA​ ​and
CXR​ ​with​ ​CT​ ​a/p.​ ​Needs​ ​full​ ​evaluation​ ​of​ ​colon:
a. Full​ ​colonoscopy
b. CT​ ​colonography
c. Lower​ ​GI
d. On​ ​table​ ​lavage​ ​and​ ​colonoscopy
What​ ​if​ ​jejunum​ ​and​ ​ureter​ ​are​ ​adherent​ ​to​ ​mass?​ ​Needs​ ​en-bloc​ ​resection​ ​with​ ​microscopically​ ​negative​ ​margins.​ ​What​ ​if

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metastatic​ ​lesion​ ​found​ ​on​ ​ovary?​ ​Resect​ ​ovary.

D.​ ​ENDOCRINE​ ​SURGERY

69. (JFB)​ ​Hyperparathyroid​ ​Ca​ ​13.1​ ​and​ ​PTH​ ​105.​ ​Sestamibi​ ​non​ ​localized.​ ​Perform​ ​exploration​ ​and​ ​found​ ​one​ ​adenoma​ ​but
PTH​ ​didn't​ ​drop.​ ​Can't​ ​find​ ​inferior.​ ​Describe​ ​locations​ ​where​ ​to​ ​look​ ​(look​ ​again​ ​for​ ​normal​ ​location,​ ​tracheoesophageal
groove,​ ​carotid​ ​sheath,​ ​intrathyroidal,​ ​cervical​ ​thymus).​ ​Case​ ​5.

70. 19​ ​y/o​ ​female,​ ​sore​ ​throat​ ​with​ ​fevers,​ ​malaise,​ ​dysphagia,​ ​rapid​ ​strep​ ​negative.​ ​Lump​ ​in​ ​neck​ ​4x5cm,​ ​midline​ ​neck​ ​mass,
submandibular​ ​positioning,​ ​tender,​ ​erythematous,​ ​no​ ​lymphadenopathy,​ ​moves​ ​with​ ​tongue​ ​protrusion!!!​ ​WBC​ ​15.​ ​U/S
neck​ ​reveals​ ​thyroglossal​ ​duct​ ​cyst.​ ​Needs​ ​pre-op​ ​TSH​ ​testing.​ ​Clear​ ​infection​ ​with​ ​abx​ ​and​ ​re-eval​ ​in​ ​2​ ​weeks.​ ​Take​ ​to
OR​ ​then.​ ​Describe​ ​sistrunk​ ​procedure.

71. 9​ ​m/o​ ​male​ ​patient,​ ​dehydrated,​ ​fevers,​ ​tachycardic,​ ​erythematous​ ​midline​ ​neck​ ​mass,​ ​moves​ ​with​ ​tongue​ ​protrusion.
Admitted​ ​to​ ​hospital​ ​and​ ​started​ ​on​ ​abx.​ ​Has​ ​persistent​ ​fevers​ ​in​ ​hospital​ ​despite​ ​IV​ ​abx.​ ​Perform​ ​I&D​ ​of​ ​thyroglossal​ ​duct
abscess​ ​in​ ​OR.​ ​Will​ ​eventually​ ​need​ ​TFT’s​ ​and​ ​ultrasound​ ​of​ ​neck​ ​(evaluate​ ​for​ ​other​ ​thyroid​ ​tissue​ ​prior​ ​to​ ​sistrunk
because​ ​if​ ​none​ ​will​ ​need​ ​life​ ​long​ ​thyroxine​ ​replacement).

72. 43​ ​y/o​ ​male,​ ​6​ ​weeks​ ​of​ ​asymptomatic​ ​neck​ ​mass.​ ​Took​ ​abx​ ​from​ ​PCP​ ​did​ ​not​ ​resolve.​ ​No​ ​associated​ ​lymphadenopathy,
2​ ​cm​ ​thyroid​ ​mass​ ​on​ ​exam.​ ​TFT’s​ ​ok.​ ​Check​ ​thyroglobulin​ ​levels.​ ​U/S​ ​shows​ ​right​ ​thyroid​ ​mass​ ​2cm.​ ​FNA​ ​at​ ​same​ ​time
shows​ ​follicular​ ​cells.​ ​Needs​ ​diagnostic​ ​thyroid​ ​lobectomy​ ​->​ ​final​ ​pathology​ ​showed​ ​follicular​ ​adenocarcinoma.​ ​When​ ​to
take​ ​back​ ​to​ ​OR???​ ​In​ ​one​ ​week​ ​approximately.​ ​What​ ​procedure?​ ​Needs​ ​laryngoscopy​ ​to​ ​evaluate​ ​bilateral​ ​vocal​ ​cords​ ​to
diagnose​ ​vocal​ ​cord​ ​injury​ ​from​ ​the​ ​past​ ​surgery,​ ​and​ ​completion​ ​thyroidectomy.​ ​Post-op​ ​treatment?​ ​Possible​ ​I-131.

73. Patient​ ​with​ ​thyroid​ ​mass,​ ​undergoes​ ​work-up​ ​with​ ​eventual​ ​diagnosis​ ​of​ ​follicular​ ​carcinoma​ ​of​ ​thyroid.​ ​No​ ​palpable
lymphadenopathy.​ ​Patient​ ​develops​ ​post-op​ ​stridor​ ​after​ ​total​ ​thyroidectomy.​ ​Management?

74. 2​ ​y/o​ ​male,​ ​s/p​ ​sistrunk​ ​procedure,​ ​in​ ​PACU,​ ​develops​ ​neck​ ​hematoma.​ ​Management?

75. Adrenal​ ​mass,​ ​function​ ​testing,​ ​differential​ ​diagnosis.​ ​+Serum​ ​and​ ​urine​ ​metanephrines​ ​and​ ​urine​ ​VMA.​ ​Pre-op
preparation​ ​first​ ​with​ ​alpha-blockade​ ​via​ ​phenoxybenzamine​ ​until​ ​orthostatic,​ ​secondarily​ ​with​ ​beta-blockade​ ​for​ ​HR
control.​ ​Pre-op​ ​admit​ ​for​ ​IVF​ ​hydration.​ ​Make​ ​sure​ ​anesthesia​ ​has​ ​IV​ ​pressors​ ​and​ ​nicardipine​ ​or​ ​nitroprusside.​ ​Approach
for​ ​adrenalectomy.

76. 39​ ​y/o​ ​man​ ​with​ ​abdominal​ ​pain,​ ​hx​ ​of​ ​etoh​ ​and​ ​cigarettes.​ ​8-10​ ​pounds​ ​weight​ ​loss.​ ​Taking​ ​a​ ​PPI​ ​super​ ​high​ ​doses.​ ​H&P.
Physical​ ​shows​ ​marfanoid​ ​habitus​ ​(distractor,​ ​has​ ​nothing​ ​to​ ​do​ ​with​ ​case),​ ​bilateral​ ​rales,​ ​deep​ ​epigastric​ ​tenderness,​ ​no
ascites,​ ​rectal​ ​exam​ ​is​ ​hemoccult​ ​positive.​ ​Labs​ ​negative.​ ​Management:​ ​EGD​ ​->​ ​2​ ​ulcers​ ​in​ ​3rd​ ​portion​ ​of​ ​duodenum,​ ​H.
pylori​ ​negative,​ ​ulcer​ ​biopsy​ ​negative.​ ​Management?​ ​Hold​ ​PPI​ ​and​ ​chest​ ​gastrin​ ​level​ ​after​ ​->​ ​1001​ ​(very​ ​high).
Management:​ ​fine​ ​cut​ ​CT​ ​a/p​ ​->​ ​no​ ​masses.​ ​Next​ ​step​ ​->​ ​EUS​ ​shows​ ​6x8mm​ ​submucosal​ ​mass​ ​in​ ​second​ ​portion​ ​of
duodenum.​ ​Management?​ ​Octreotide​ ​scan​ ​->​ ​non-localizing.​ ​Venous​ ​sampling​ ​non-localizing.​ ​Management?
a. Exlap,​ ​longitudinal​ ​duodenotomy,​ ​transilluminate​ ​duodenum​ ​or​ ​intra-op​ ​ultrasound,​ ​enucleate​ ​mass.
b. Post-op​ ​needs​ ​repeat​ ​EGD​ ​to​ ​assure​ ​resolution​ ​of​ ​ulcers.
c. Know​ ​the​ ​gastrinoma​ ​triangle​ ​->​ ​CBD,​ ​D2/3​ ​junction,​ ​neck​ ​of​ ​pancreas

77. Know​ ​MEN​ ​1​ ​and​ ​MEN​ ​2a​ ​and​ ​MEN​ ​2B.
a. MEN​ ​1​ ​-​ ​pancreas​ ​(m.c.​ ​gastrinoma),​ ​parathyroid,​ ​pituitary​ ​(m.c.​ ​prolactinoma)​ ​-​ ​MENIN​ ​gene
b. MEN​ ​2A​ ​-​ ​MTC,​ ​pheochromocytoma,​ ​parathyroid​ ​-​ ​RET​ ​proto-oncogene
c. MEN​ ​2B​ ​-​ ​MTC,​ ​pheochromocytoma,​ ​marfanoid​ ​habitus​ ​-​ ​RET​ ​proto-oncogene

78. 43​ ​y/o​ ​man​ ​with​ ​lump​ ​on​ ​neck,​ ​no​ ​improvement​ ​after​ ​abx.​ ​No​ ​family​ ​hx​ ​of​ ​malignancy​ ​or​ ​RT.​ ​Physical​ ​exam​ ​shows​ ​2.5​ ​cm
right​ ​lateral​ ​neck​ ​mass,​ ​mobile,​ ​firm,​ ​rubbery,​ ​no​ ​other​ ​lymphadenopathy,​ ​no​ ​oral​ ​cavity​ ​lesions.​ ​Management​ ​->​ ​FNA​ ​of
mass​ ​shows​ ​thyroid​ ​tissue.​ ​Thoughts?​ ​Must​ ​be​ ​papillary​ ​thyroid​ ​cancer,​ ​lymphatic​ ​spread.​ ​Management?​ ​Ultrasound
thyroid​ ​->​ ​no​ ​masses.​ ​Management?​ ​CT​ ​chest,​ ​LFT’s,​ ​pre-op​ ​labs,​ ​TSH,​ ​thyroglobulin.​ ​Management?​ ​Total
thyroidectomy,​ ​modified​ ​radical​ ​neck​ ​dissection​ ​and​ ​central​ ​compartment​ ​dissection.​ ​4/20​ ​lymph​ ​nodes​ ​positive.​ ​Staging?
a. Since​ ​under​ ​45​ ​y/o,​ ​patient​ ​is​ ​Stage​ ​1​ ​no​ ​matter​ ​what​ ​presentation
b. Management​ ​post-op:​ ​radioactive​ ​iodine

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79. 39​ ​y/o​ ​man​ ​with​ ​dizzy​ ​spells,​ ​HTN​ ​resistant​ ​to​ ​medications.​ ​H&P​ ​negative​ ​except​ ​palpitations.​ ​Labs:​ ​CBC,​ ​CMP,​ ​urinary
24​ ​hour​ ​VMA/catecholamines,​ ​serum​ ​catecholamines,​ ​urinary​ ​metanephrines.​ ​Serum​ ​K​ ​normal.​ ​Urine​ ​and​ ​plasma​ ​VMA
and​ ​metanephrines​ ​elevated.​ ​Management?​ ​CTc/a/p​ ​shows​ ​adrenal​ ​mass.​ ​Pre-op​ ​preparation​ ​of​ ​pheochromocytoma.
a. Phenoxybenzamine
b. Beta-blockade​ ​after​ ​alpha
c. Pre-op​ ​hydration
d. Anesthesia​ ​to​ ​have​ ​ready​ ​gtts​ ​of​ ​levophed,​ ​and​ ​nicardipine

80. (AE)​ ​35​ ​yo​ ​female​ ​with​ ​left​ ​adrenal​ ​pheochromocytoma​ ​and​ ​PTH.​ ​got​ ​into​ ​bleeding,​ ​opened​ ​and​ ​fixed​ ​vein​ ​but​ ​vein
occluded​ ​the​ ​entire​ ​way​ ​so​ ​I​ ​said​ ​do​ ​nephrectomy

E.​ ​BREAST​ ​SURGERY

81. (JFB)​ ​50​ ​y/o​ ​woman,​ ​breast​ ​lesion​ ​no​ ​palpable​ ​on​ ​mammogram.​ ​Discordant​ ​diagnostic​ ​mammogram​ ​and​ ​biopsy​ ​(BiRADS
5​ ​but​ ​biopsy​ ​was​ ​normal​ ​breast​ ​tissue).​ ​Underwent​ ​needle​ ​localization​ ​with​ ​specimen​ ​mammogram​ ​and​ ​marked
specimen.​ ​Was​ ​Infiltrating​ ​ductal​ ​carcinoma​ ​with​ ​positive​ ​bottom​ ​margin.​ ​Re-excised​ ​base​ ​and​ ​SLNBx.​ ​Cannot​ ​find​ ​SLN.
Performed​ ​ALND​ ​and​ ​had​ ​long​ ​thoracic​ ​nerve​ ​injury.​ ​Case1.

82. (AE)​ ​Breast​ ​abscess/cancer​ ​-​ ​37​ ​breast​ ​feeding​ ​pt​ ​came​ ​in​ ​with​ ​red​ ​tender​ ​4cm​ ​RUOQ​ ​mass,​ ​aspirated​ ​and​ ​was​ ​pus,​ ​sent
home​ ​with​ ​abx,​ ​came​ ​back​ ​with​ ​same​ ​thing,​ ​did​ ​I&D​ ​in​ ​office​ ​and​ ​sent​ ​for​ ​path​ ​(he​ ​said​ ​do​ ​you​ ​normally​ ​do​ ​this​ ​in​ ​the
office?),​ ​changed​ ​to​ ​57​ ​yo​ ​female,​ ​I​ ​said​ ​I​ ​would​ ​do​ ​same​ ​thing​ ​but​ ​make​ ​sure​ ​she​ ​had​ ​mammography,​ ​path​ ​came​ ​back
as​ ​cancer,​ ​I​ ​did​ ​partial​ ​mastectomy​ ​with​ ​SNLBx

83. (PP)​ ​52​ ​y/o​ ​female,​ ​mammogram​ ​with​ ​UOQ​ ​calcifications​ ​2.5cm,​ ​no​ ​palpable​ ​mass.​ ​Core​ ​needle​ ​biopsy​ ​showed​ ​DCIS
with​ ​comedonecrosis,​ ​ER/PR+,​ ​HER2-.​ ​Management?​ ​Needle​ ​localization​ ​with​ ​lumpectomy​ ​with​ ​SLBx,​ ​post-op​ ​tamoxifen
and​ ​RT​ ​versus​ ​mastectomy​ ​with​ ​SLBx​ ​with​ ​tamoxifen.​ ​Why​ ​perform​ ​SLBx​ ​in​ ​this​ ​case​ ​of​ ​DCIS?​ ​Large​ ​lesion​ ​with
comedonecrosis.​ ​Describe​ ​how​ ​to​ ​perform​ ​sentinel​ ​lymph​ ​node​ ​biopsy.
a. Change​ ​scenario:​ ​39​ ​y/o​ ​woman,​ ​Ashkenzi​ ​Jew,​ ​with​ ​family​ ​hx​ ​of​ ​same​ ​findings​ ​on​ ​mammogram​ ​and​ ​biopsy.
Management?​ ​Test​ ​for​ ​BRCA​ ​gene​ ​->​ ​BRCA​ ​positive.​ ​Management?​ ​Options​ ​are​ ​breast​ ​conservation​ ​with
lumpectomy​ ​with​ ​post-op​ ​tamoxifen​ ​and​ ​RT​ ​versus​ ​mastectomy​ ​with​ ​SLNBx​ ​with​ ​post-op​ ​tamoxifen​ ​and
reconstruction​ ​versus​ ​bilateral​ ​mastectomies​ ​with​ ​ipsilateral​ ​SLBx​ ​with​ ​post-op​ ​tamoxifen​ ​and​ ​reconstruction.

84. 59​ ​y/o​ ​woman,​ ​nipple​ ​discharge.​ ​Key​ ​questions:​ ​spontaneous?​ ​Single​ ​or​ ​both​ ​breasts?​ ​1​ ​or​ ​multiple​ ​ducts?​ ​Bloody​ ​or​ ​not?
Differential​ ​diagnosis:​ ​intraductal​ ​papilloma,​ ​DCIS,​ ​cancer,​ ​fibrocystic​ ​disease,​ ​prolactinoma.

85. 44​ ​y/o​ ​man​ ​nipple​ ​mass,​ ​core​ ​needle​ ​biopsy​ ​is​ ​breast​ ​tissue.​ ​Hx​ ​important​ ​for​ ​marijuana​ ​usage,​ ​drinking​ ​hx,​ ​and​ ​liver
disease.​ ​R/O​ ​male​ ​breast​ ​cancer.

86. 44​ ​y/o​ ​woman,​ ​firm​ ​rubbery​ ​breast​ ​mass​ ​for​ ​1​ ​year,​ ​expands​ ​over​ ​6​ ​months,​ ​on​ ​exam​ ​8cm​ ​mass.​ ​Phyllodes​ ​tumor​ ​->​ ​wide
local​ ​excision.​ ​What​ ​margins​ ​and​ ​what​ ​nodal​ ​evaluation​ ​intra-op?​ ​1cm​ ​margins,​ ​no​ ​nodes​ ​needed.

87. Same​ ​patient​ ​as​ ​above,​ ​change​ ​situation,​ ​44​ ​y/o​ ​woman​ ​with​ ​breast​ ​mass​ ​UOQ,​ ​aunt​ ​and​ ​sister​ ​with​ ​breast​ ​cancer.​ ​BRCA
testing​ ​positive.​ ​Needs​ ​transvaginal​ ​ultrasound​ ​or​ ​if​ ​over​ ​40​ ​or​ ​done​ ​with​ ​child​ ​bearing​ ​then​ ​BSO.

88. 55​ ​y/o​ ​woman,​ ​with​ ​LCIS​ ​on​ ​core​ ​needle​ ​biopsy.​ ​What​ ​management?​ ​Needs​ ​excisional​ ​biopsy.​ ​Why?​ ​Lifetime​ ​risk​ ​of
20-25%​ ​breast​ ​cancer​ ​in​ ​abnormality.​ ​What​ ​is​ ​margins​ ​are​ ​positive​ ​but​ ​mammographic​ ​abnormality​ ​removed?​ ​No
re-excision​ ​needed.​ ​What​ ​follow-up​ ​management​ ​options​ ​are​ ​available?​ ​Simple​ ​follow-up,​ ​versus​ ​tamoxifen,​ ​versus
bilateral​ ​prophylactic​ ​mastectomy.

89. 62​ ​y/o​ ​woman​ ​with​ ​red,​ ​inflamed​ ​edematous​ ​breast​ ​mass.​ ​Skin​ ​biopsy​ ​showed​ ​dermal​ ​lymphatic​ ​invasion​ ​of​ ​tumor​ ​->
a.k.a.​ ​Inflammatory​ ​breast​ ​cancer.​ ​Treatment:​ ​PRE-OP​ ​needs​ ​full​ ​metastatic​ ​work-up:​ ​CT​ ​c/a/p,​ ​bone​ ​scan​ ​or​ ​PET,​ ​LFT’s.
Neoadjuvant​ ​chemotherapy​ ​followed​ ​by​ ​Modified​ ​radical​ ​mastectomy,​ ​NO​ ​BREAST​ ​CONSERVATION.

90. 60​ ​y/o​ ​woman​ ​found​ ​on​ ​screening​ ​mammogram​ ​to​ ​have​ ​microcalcifications​ ​right​ ​breast.​ ​H&P​ ​normal.​ ​Diagnostic
mammogram​ ​with​ ​stereotactic​ ​biopsy​ ​->​ ​4x3cm​ ​DCIS,​ ​ER/PR+.​ ​Management?​ ​Needle​ ​localization​ ​versus​ ​mastectomy
with​ ​SLNBx.​ ​She​ ​gets​ ​breast​ ​conservation.​ ​What​ ​margins​ ​needed​ ​and​ ​what​ ​post-op​ ​treatment?​ ​2mm​ ​margins​ ​and​ ​post-op
RT​ ​with​ ​tamoxifen.
a. Patient​ ​comes​ ​back​ ​after​ ​all​ ​therapy​ ​with​ ​recurrent​ ​DCIS​ ​and​ ​palpable​ ​mass​ ​->​ ​biopsy​ ​shows​ ​comedonecrosis.

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b. Management?​ ​Needs​ ​mastectomy​ ​with​ ​SLNBx​ ​and​ ​tamoxifen​ ​(had​ ​RT​ ​already​ ​therefore​ ​no​ ​more​ ​breast
conservation).

91. 54​ ​y/o​ ​woman​ ​with​ ​7​ ​cm​ ​mass​ ​left​ ​breast,​ ​axilla​ ​is​ ​clinically​ ​negative.​ ​Get​ ​diagnostic​ ​mammogram​ ​and​ ​biopsy​ ​->​ ​infiltrating
ductal​ ​carcinoma,​ ​ER+,​ ​PR-,​ ​HER2+.​ ​Stage?​ ​cT3N0.​ ​Options?
a. Neoadjuvant​ ​chemo​ ​with​ ​herceptin,​ ​surgery,​ ​then​ ​post-op​ ​tamoxifen​ ​and​ ​RT​ ​(T3​ ​and​ ​above​ ​needs​ ​RT)
b. Mastectomy​ ​first​ ​with​ ​SLBx​ ​followed​ ​by​ ​chemo​ ​RT​ ​adjuvantly

92. 7​ ​cm​ ​mass,​ ​palpable​ ​axillary​ ​nodes.​ ​Management?​ ​Diagnostic​ ​mammogram​ ​with​ ​biopsy​ ​of​ ​mass​ ​and​ ​nodes.​ ​Needs
staging​ ​CT​ ​c/a/p​ ​with​ ​LFT’s​ ​and​ ​bone​ ​scan.
a. Options​ ​include:​ ​MRM​ ​with​ ​post-op​ ​chemoRT
b. Lumpectomy​ ​with​ ​axillary​ ​node​ ​dissection​ ​with​ ​post-op​ ​chemoRT

93. 58​ ​y/o​ ​woman​ ​with​ ​lump​ ​in​ ​axilla.​ ​Increased​ ​in​ ​size​ ​over​ ​4​ ​months.​ ​No​ ​palpable​ ​breast​ ​mass.​ ​US​ ​with​ ​biopsy​ ​shows
ER/PR+​ ​and​ ​Her2​ ​negative​ ​breast​ ​tissue.​ ​Diagnostic​ ​mammogram​ ​was​ ​negative.​ ​Management?​ ​MRI​ ​breast​ ​with​ ​biopsy​ ​if
indicated​ ​->​ ​shows​ ​7x6​ ​cm​ ​mass​ ​with​ ​DCIS.​ ​Now​ ​what?​ ​DCIS​ ​must​ ​be​ ​sampling​ ​error​ ​because​ ​no​ ​lymphatic​ ​spread​ ​of
breast​ ​tissue​ ​to​ ​axilla​ ​with​ ​DCIS,​ ​must​ ​be​ ​IDC.​ ​Management?​ ​Staging​ ​CT​ ​c/a/p​ ​with​ ​bone​ ​scan,​ ​LFT’s.​ ​Management?
a. MRM​ ​with​ ​adjuvant​ ​chemoRT
b. Neoadjuvant​ ​chemotherapy,​ ​breast​ ​conservation,​ ​with​ ​axillary​ ​node​ ​dissection,​ ​post-op​ ​RT

94. What​ ​is​ ​axilla​ ​is​ ​positive​ ​for​ ​infiltrating​ ​ductal​ ​cancer,​ ​breast​ ​is​ ​negative​ ​on​ ​exam​ ​or​ ​mammogram​ ​or​ ​MRI​ ​for​ ​any​ ​lesion?
a. MRM​ ​with​ ​adjuvant​ ​chemoRT
b. Axillary​ ​node​ ​dissection​ ​with​ ​adjuvant​ ​chemoRT

95. 60​ ​y/o​ ​post-menopausal​ ​woman​ ​with​ ​hx​ ​of​ ​MRM​ ​for​ ​breast​ ​cancer​ ​10​ ​years​ ​ago​ ​presents​ ​with​ ​nodule​ ​in​ ​chest​ ​wall​ ​near
incision.​ ​H&P​ ​negative​ ​except​ ​for​ ​hx​ ​of​ ​breast​ ​cancer​ ​s/p​ ​chemotherapy​ ​and​ ​tamoxifen.​ ​Management?​ ​Chest​ ​wall​ ​lesion
biopsy​ ​->​ ​carcinoma.​ ​Management?​ ​Metastatic​ ​work-up​ ​with​ ​CT​ ​c/a/p​ ​with​ ​bone​ ​scan,​ ​CT​ ​head​ ​if​ ​symptoms​ ​dictate,​ ​liver
function​ ​testing.​ ​No​ ​metastatic​ ​disease​ ​found.​ ​Management?​ ​ChemoRT,​ ​then​ ​surgical​ ​excision​ ​with​ ​aromatase​ ​inhibitor..

96. Management​ ​of​ ​breast​ ​cancer​ ​and​ ​chemotherapy​ ​in​ ​each​ ​trimester​ ​of​ ​pregnancy.

97. 32​ ​y/o​ ​woman,​ ​late​ ​second​ ​trimester​ ​pregnancy,​ ​found​ ​to​ ​have​ ​breast​ ​mass​ ​2cm​ ​size​ ​in​ ​UOQ.​ ​Diagnostic​ ​bilateral
mammogram​ ​with​ ​ultrasound​ ​and​ ​biopsy​ ​performed​ ​(shielding​ ​the​ ​fetus)​ ​->​ ​infiltrating​ ​ductal​ ​carcinoma.​ ​What​ ​are
management​ ​options?
a. BCT​ ​with​ ​lumpectomy​ ​and​ ​SLBx​ ​and​ ​post-pregnancy​ ​RT​ ​with​ ​tamoxifen
b. Mastectomy​ ​with​ ​SLBx
c. Modified​ ​radical​ ​mastectomy
She​ ​gets​ ​breast​ ​conservation​ ​and​ ​undergoes​ ​post-pregnancy​ ​RT​ ​with​ ​tamoxifen.​ ​Two​ ​years​ ​later​ ​presents​ ​with​ ​ipsilateral
axillary​ ​mass.​ ​Management?​ ​Ultrasound​ ​of​ ​axilla​ ​with​ ​biopsy​ ​->​ ​infiltrating​ ​ductal​ ​carcinoma.​ ​Management?
1. Staging​ ​CT​ ​c/a/p,​ ​bone​ ​scan,​ ​labs​ ​including​ ​LFT’s
2. Management?​ ​Modified​ ​radical​ ​mastectomy​ ​with​ ​adjuvant​ ​chemotherapy​ ​with​ ​axillary​ ​radiation.

F.​ ​TRAUMA​ ​SURGERY

98. (JFB)​ ​Blunt​ ​trauma​ ​hypotensive​ ​and​ ​tachycardic.​ ​ABCDE​ ​intact.​ ​Bolused​ ​crystalloid.​ ​FAST​ ​positive.​ ​CXR​ ​normal.​ ​PXR
with​ ​pelvic​ ​fracture.​ ​Wrapped​ ​pelvis​ ​and​ ​transfused​ ​blood.​ ​Called​ ​IR​ ​to​ ​be​ ​ready​ ​postop.​ ​Exlap.​ ​Spleen​ ​laceration​ ​to​ ​hilum.
Splenectomy.​ ​IR​ ​still​ ​not​ ​ready​ ​and​ ​patient​ ​still​ ​unstable.​ ​Pelvis​ ​packed​ ​extra​ ​peritoneal​ ​and​ ​intraperitoneal.​ ​Coagulopathic
so​ ​vac​ ​packed​ ​abdomen.​ ​Resuscitation​ ​in​ ​SICU.​ ​Parameters​ ​followed​ ​included​ ​coagulation​ ​parameters,​ ​UOP,​ ​TEG,​ ​and
vac​ ​output​ ​as​ ​well​ ​as​ ​hemodynamics.​ ​Case​ ​6.

99. 35​ ​y/o​ ​man,​ ​presents​ ​to​ ​ED​ ​s/p​ ​stab​ ​to​ ​left​ ​chest.​ ​Was​ ​slightly​ ​tachycardic​ ​in​ ​ambulance​ ​otherwise​ ​ok.​ ​5​ ​minute
ambulance​ ​ride.​ ​On​ ​presentation​ ​to​ ​ED​ ​patient​ ​is​ ​pulseless.​ ​Management?​ ​ER​ ​resuscitative​ ​thoracotomy.​ ​Describe​ ​the
elements​ ​of​ ​the​ ​resuscitative​ ​thoracotomy​ ​(open​ ​chest,​ ​open​ ​pericardium​ ​anterior​ ​to​ ​phrenic,​ ​release​ ​inferior​ ​pulmonary
ligament​ ​and​ ​clamp​ ​pulmonary​ ​hilum​ ​versus​ ​twist​ ​the​ ​lung,​ ​cross​ ​clamp​ ​aorta,​ ​clamp​ ​bleeding​ ​intra-thoracic​ ​subclavian).
a. Pericardial​ ​tamponade​ ​with​ ​ventricular​ ​injury​ ​near​ ​coronary​ ​artery
b. Pulmonary​ ​hilar​ ​injury
c. Left​ ​subclavian​ ​injury

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100. 20​ ​y/o​ ​man​ ​with​ ​GSW​ ​to​ ​left​ ​chest​ ​and​ ​left​ ​axilla​ ​presents​ ​to​ ​ED​ ​and​ ​codes​ ​in​ ​trauma​ ​bay.​ ​Management?​ ​ED​ ​thoracotomy.
No​ ​pericardial​ ​tamponade.​ ​No​ ​pulmonary​ ​hilar​ ​injury.​ ​After​ ​cross​ ​clamping​ ​aorta​ ​and​ ​massive​ ​blood​ ​resuscitation​ ​you​ ​get
back​ ​ROSC​ ​and​ ​blood​ ​pressure.​ ​Pulsatile​ ​bleeding​ ​from​ ​the​ ​left​ ​axillary​ ​injury.​ ​Quick​ ​secondary​ ​exam​ ​shows​ ​no​ ​other
GSW’s.​ ​Management?​ ​Digital​ ​pressure​ ​to​ ​left​ ​axilla​ ​and​ ​OR.​ ​Patient​ ​has​ ​palpable​ ​fracture​ ​deformity​ ​of​ ​left​ ​humerus.
a. Describe​ ​vascular​ ​exposure​ ​of​ ​distal​ ​axillary​ ​artery​ ​->​ ​infraclavicular​ ​incision​ ​extending​ ​down​ ​arm,​ ​proximal​ ​and
distal​ ​control​ ​on​ ​axillary​ ​and​ ​brachial​ ​arteries.​ ​Shunt​ ​with​ ​feeding​ ​tube​ ​and​ ​Rummel​ ​tourniquets.
b. During​ ​procedure​ ​anesthesia​ ​tells​ ​you​ ​the​ ​patient​ ​is​ ​becoming​ ​hypotensive.​ ​On​ ​exam​ ​the​ ​abdomen​ ​is​ ​distended
and​ ​difficult​ ​to​ ​bag​ ​ventilate.​ ​Management?​ ​Decompressive​ ​laparotomy.​ ​Now​ ​you​ ​find​ ​that​ ​the​ ​patient​ ​is​ ​oozing
from​ ​all​ ​wounds.​ ​Management?

101. Stab​ ​left​ ​upper​ ​chest,​ ​within​ ​anterior​ ​box.​ ​Got​ ​left​ ​chest​ ​tube​ ​and​ ​put​ ​out​ ​800mL​ ​blood.​ ​Work-up​ ​of​ ​box​ ​injury​ ​showed:
a. Stable​ ​with​ ​FAST​ ​with​ ​blood​ ​in​ ​pericardium
b. Vitals​ ​stable​ ​and​ ​got​ ​a​ ​CTA
c. Hypotensive​ ​and​ ​tachycardic​ ​with​ ​FAST​ ​positive
d. Cardiac​ ​arrest​ ​in​ ​ED

102. 27​ ​y/o​ ​motorcycle​ ​versus​ ​tree,​ ​unstable​ ​in​ ​ED,​ ​CXR​ ​neg,​ ​PXR​ ​neg.​ ​FAST​ ​positive.​ ​Management?​ ​OR​ ​exlap.​ ​Find​ ​large
liver​ ​laceration.​ ​Management​ ​of​ ​liver​ ​laceration.

103. MVC​ ​unstable​ ​vitals​ ​in​ ​field,​ ​BP​ ​9050,​ ​HR​ ​125,​ ​no​ ​gross​ ​injuries​ ​but​ ​pelvis​ ​unstable.​ ​FAST​ ​positive.​ ​Place​ ​pelvic​ ​binder.
Call​ ​IR​ ​but​ ​going​ ​to​ ​OR​ ​first,​ ​exlap​ ​shows​ ​spleen​ ​injury​ ​and​ ​pelvic​ ​zone​ ​3​ ​hematoma.​ ​IR​ ​not​ ​ready​ ​yet​ ​and​ ​patient​ ​still
unstable.​ ​Preperitoneal​ ​and​ ​intraperitoneal​ ​pelvic​ ​packing.​ ​Describe​ ​how​ ​to​ ​do​ ​it.

104. 25​ ​y/o​ ​left​ ​arm​ ​injury​ ​and​ ​pain​ ​after​ ​electrocution.​ ​Burns​ ​on​ ​palm​ ​and​ ​right​ ​forearm​ ​firm​ ​to​ ​palpation.​ ​Pain​ ​with​ ​passive​ ​and
active​ ​ROM.​ ​Management​ ​of​ ​forearm​ ​compartment​ ​syndrome​ ​and​ ​resulting​ ​rhabdomyolsis.

105. GSW​ ​right​ ​upper​ ​quadrant​ ​abdomen,​ ​hemodynamically​ ​stable.​ ​Gets​ ​CT​ ​abd/pelvis​ ​that​ ​shows​ ​bullet​ ​traverses​ ​peritoneal
cavity​ ​below​ ​liver.​ ​Exlap​ ​shows​ ​full​ ​thickness​ ​colon​ ​injury​ ​<25%​ ​circumference​ ​and​ ​lateral​ ​duodenal​ ​injury​ ​<25%
circumference.​ ​Approach​ ​and​ ​repair.

106. 27​ ​y/o​ ​stabbed​ ​in​ ​left​ ​neck.​ ​Perform​ ​primary​ ​survey,​ ​all​ ​intact.​ ​Slight​ ​hematoma​ ​of​ ​left​ ​neck.​ ​Adjuncts​ ​including​ ​CXR.​ ​Left
neck​ ​hematoma​ ​expanding.​ ​Management?​ ​Intubate​ ​immediately​ ​and​ ​explore​ ​in​ ​OR.​ ​Describe​ ​trauma​ ​neck​ ​exploration.
What​ ​structures​ ​to​ ​identify​ ​(carotids,​ ​IJ’s,​ ​trachea,​ ​esophagus)?​ ​Has​ ​hematoma​ ​around​ ​carotid.​ ​How​ ​to​ ​manage?​ ​Proximal
and​ ​distal​ ​control​ ​prior​ ​to​ ​entering​ ​hematoma…​ ​Find​ ​additionally​ ​after​ ​repairing​ ​carotid​ ​a​ ​tracheal​ ​backwall​ ​and
esophageal​ ​anterior​ ​wall​ ​injury.​ ​Describe​ ​repairs.​ ​Need​ ​to​ ​mention​ ​absorbable​ ​suture​ ​in​ ​trachea,​ ​repair​ ​of​ ​two​ ​layers​ ​of
esophagus,​ ​and​ ​placement​ ​of​ ​muscle​ ​flap​ ​between​ ​both​ ​structures.​ ​Post-op​ ​when​ ​to​ ​study?​ ​How​ ​to​ ​study?​ ​Needs​ ​thin
barium​ ​esophagram,​ ​no​ ​gastrograffin​ ​due​ ​to​ ​risk​ ​of​ ​gastrograffin​ ​pneumonitis​ ​with​ ​risk​ ​of​ ​traumatic​ ​TE​ ​fistula.
Management​ ​of​ ​thoracic​ ​duct​ ​leak​ ​as​ ​well.

107. 5​ ​y/o​ ​peds​ ​versus​ ​auto​ ​crossing​ ​street.​ ​HR​ ​140.​ ​BP​ ​70/40.​ ​Needs​ ​breslow​ ​tape.​ ​Approx​ ​ETT​ ​size​ ​=​ ​age/4+4.​ ​Describe
rapid​ ​sequence​ ​intubation.​ ​Confirmatory​ ​testing​ ​after​ ​intubation​ ​=​ ​color​ ​capnography​ ​(purple​ ​to​ ​gold),​ ​ETCO2,​ ​CXR.

108. 20​ ​y/o​ ​s/p​ ​high​ ​speed​ ​MVC.​ ​Presents​ ​to​ ​ED​ ​with​ ​intact​ ​ABC’s.CXR​ ​and​ ​pelvis​ ​are​ ​negative​ ​for​ ​injury.​ ​FAST​ ​is​ ​positive​ ​and
hemodynamically​ ​unstable,​ ​HR​ ​140’s,​ ​BP​ ​80/palp.​ ​Management?​ ​OR​ ​for​ ​exlap,​ ​pack,​ ​find​ ​large​ ​Grade​ ​4​ ​liver​ ​laceration.
Describe​ ​techniques​ ​for​ ​hemostasis​ ​of​ ​liver​ ​laceration.
a. Hemostasis:​ ​Packing,​ ​extended​ ​packing,​ ​electrocautery,​ ​suture​ ​ligation​ ​of​ ​vessels,​ ​liver​ ​resection,​ ​large
chromics​ ​on​ ​blunt​ ​liver​ ​needles,​ ​pack​ ​wound​ ​with​ ​omentum​ ​or​ ​surgicel,​ ​trauma​ ​liver​ ​resection,​ ​finger​ ​fracture
laceration​ ​to​ ​get​ ​at​ ​deep​ ​bleeding,​ ​total​ ​hepatic​ ​vascular​ ​isolation
b. Patient​ ​becomes​ ​coagulopathic​ ​in​ ​the​ ​OR.​ ​Management?
c. Post-op​ ​day​ ​5​ ​patient​ ​develops​ ​massive​ ​GI​ ​bleed.​ ​Management?​ ​EGD​ ​shows​ ​blood​ ​pooling​ ​in​ ​duodenum.
Nothing​ ​seen​ ​in​ ​stomach.​ ​Management?​ ​IR​ ​for​ ​liver​ ​angiogram​ ​for​ ​concern​ ​of​ ​hemobilia.

109. 25​ ​y/o​ ​woman,​ ​6​ ​months​ ​pregnant,​ ​presents​ ​after​ ​GSW​ ​to​ ​RUQ.​ ​ABC’s​ ​intact.​ ​Patient​ ​is​ ​stable​ ​but​ ​projectile​ ​trajectory
traverses​ ​the​ ​peritoneal​ ​cavity.​ ​Hemodynamically​ ​transiently​ ​responds​ ​to​ ​fluid​ ​resuscitation.​ ​Management?​ ​Exlap.​ ​Find
large​ ​liver​ ​laceration,​ ​hepatic​ ​flexure​ ​of​ ​colon​ ​<25%​ ​circumference​ ​injury,​ ​and​ ​laceration​ ​in​ ​dome​ ​of​ ​uterus.​ ​Management?

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110. 24​ ​y/o​ ​man,​ ​GSW​ ​left​ ​intercostal​ ​2nd​ ​space.​ ​Primary​ ​survey​ ​and​ ​left​ ​chest​ ​tube​ ​->​ ​large​ ​blowing​ ​air​ ​leak​ ​and​ ​desaturations
to​ ​80’s.​ ​Management?​ ​Intubate​ ​the​ ​patient.​ ​Still​ ​with​ ​blowing​ ​air​ ​leak​ ​now.​ ​Management?​ ​CXR​ ​shows​ ​lung​ ​not​ ​fully​ ​up​ ​and
lots​ ​of​ ​subq​ ​emphysema.​ ​Management?​ ​OR,​ ​bronchoscopy​ ​for​ ​identification​ ​of​ ​bronchial​ ​injury.​ ​Injury​ ​at​ l​ eft​​ ​mainstem
bronchus.​ ​Management?​ ​Right​​ ​anterolateral​ ​thoracotomy​ ​and​ ​repair​ ​of​ ​left​ ​mainstem​ ​bronchus

111. 30​ ​y/o​ ​man,​ ​high​ ​speed​ ​MVC,​ ​restrained​ ​driver​ ​to​ ​ED​ ​trauma.​ ​Stable​ ​vitals​ ​en-route.​ ​Primary​ ​exam​ ​intact​ ​but​ ​some
decreased​ ​breath​ ​sounds.​ ​Vitals​ ​also​ ​stable.​ ​Chest​ ​tube​ ​versus​ ​stable​ ​so​ ​get​ ​CXR.​ ​Chest​ ​tube​ ​you​ ​start​ ​to​ ​place​ ​but
palpate​ ​firm​ ​mass​ ​in​ ​left​ ​chest​ ​or​ ​subsequent​ ​CXR​ ​shows​ ​gastric​ ​bubble​ ​in​ ​left​ ​chest​ ​with​ ​concern​ ​for​ ​diaphragmatic
rupture.​ ​Management?​ ​Exlap,​ ​reduction​ ​of​ ​rupture​ ​contents,​ ​repair​ ​of​ ​diaphragm​ ​(permanent​ ​sutures),​ ​evaluate​ ​organs
(liver,​ ​spleen,​ ​bowel)​ ​per​ ​usual​ ​trauma​ ​laparotomy.​ ​Spleen​ ​laceration​ ​->​ ​splenectomy.​ ​POD#7​ ​patient​ ​still​ ​not​ ​tolerating
diet.​ ​Fevers​ ​and​ ​LUQ​ ​abd​ ​pain​ ​with​ ​elevated​ ​WBC.​ ​CT​ ​c/a/p​ ​shows​ ​LUQ​ ​abdominal​ ​collection/abscess.​ ​Management?​ ​IR
drainage​ ​and​ ​IV​ ​abx.​ ​Gets​ ​better.​ ​Patient​ ​ready​ ​to​ ​go​ ​home.​ ​Anything​ ​else?​ ​Post-splenectomy​ ​vaccines.​ ​(Pneumococcus,
Meningococcus,​ ​Haemophilus​ ​influenza).

112. 9​ ​y/o​ ​riding​ ​bike,​ ​peds​ ​versus​ ​auto.​ ​Primary​ ​ok.​ ​HR​ ​110.​ ​BP​ ​110/80.​ ​GCS​ ​12.​ ​Pupils​ ​equal.​ ​Secondary​ ​shows​ ​contused
left​ ​scalp,​ ​left​ ​chest​ ​contusion.​ ​Left​ ​tib-fib​ ​deformity.​ ​Adjuncts?​ ​CXR​ ​neg,​ ​Pelvis​ ​x-ray​ ​neg,​ ​LE​ ​x-rays​ ​tib-fib​ ​fx,​ ​FAST
positive​ ​for​ ​LUQ​ ​fluid.​ ​Patient​ ​stable.​ ​CT’s​ ​head/c-spine/chest/abd/pelvis.​ ​Head​ ​with​ ​subdural​ ​4mm​ ​no​ ​shift.​ ​C-spine​ ​neg.
Chest/a/p​ ​shows​ ​pulmonary​ ​contusions,​ ​grade​ ​2​ ​splenic​ ​laceration​ ​and​ ​pelvic​ ​free​ ​fluid.​ ​Management​ ​with​ ​stable​ ​patient?
ICU​ ​for​ ​resuscitation​ ​and​ ​non-operative​ ​therapy​ ​with​ ​serial​ ​exams​ ​and​ ​HgB’s.​ ​In​ ​ICU​ ​the​ ​HgB​ ​drops​ ​and​ ​patient​ ​drops
pressures.​ ​Management?​ ​Transfuse​ ​blood​ ​10mL/kg.​ ​Does​ ​not​ ​respond.​ ​Management?​ ​Exploration​ ​because​ ​must​ ​avoid
hypotension​ ​in​ ​head​ ​injury.​ ​Alternatively​ ​you​ ​could​ ​have​ ​gone​ ​right​ ​when​ ​patient​ ​got​ ​hypotensive​ ​initially,​ ​start​ ​blood​ ​and
OR​ ​same​ ​time.​ ​Just​ ​have​ ​good​ ​reasoning.​ ​In​ ​OR​ ​find​ ​spleen​ ​laceration​ ​bleeding​ ​and​ ​blood​ ​in​ ​belly​ ​with​ ​duodenal
hematoma.​ ​Management?​ ​Splenectomy​ ​and​ ​explore​ ​duodenal​ ​hematoma.​ ​Post-op​ ​management?​ ​Splenectomy​ ​vaccines
and​ ​PO​ ​PCN​ ​abx​ ​until​ ​14​ ​y/o.

113. Subclavian​ ​injury​ ​stab.​ ​Unstable.​ ​OR​ ​->​ ​approach​ ​is​ ​resection​ ​of​ ​clavicle​ ​with​ ​incision​ ​superior​ ​to​ ​clavicle.

114. Management​ ​of​ ​pelvic​ ​fracture,​ ​wrap​ ​pelvis​ ​covering​ ​the​ ​greater​ ​trochanters​ ​and​ ​call​ ​IR​ ​for​ ​pelvic​ ​angiography​ ​and
embolization,​ ​OR​ ​for​ ​extraperitoneal​ ​packing​ ​if​ ​unstable​ ​and​ ​no​ ​time​ ​to​ ​wait​ ​for​ ​IR.

115. Retroperitoneal​ ​injuries,​ ​blunt​ ​versus​ ​penetrating,​ ​know​ ​the​ ​zones​ ​and​ ​management​ ​differences​ ​(whether​ ​to​ ​explore​ ​or
not).

116. Penetrating​ ​injury,​ ​pancreatic​ ​transection:​ ​distal​ ​->​ ​distal​ ​pancreatectomy.

117. Penetrating​ ​injury​ ​to​ ​head​ ​of​ ​pancreas​ ​->​ ​drain​ ​and​ ​ERCP​ ​for​ ​stent.

118. Pediatric​ ​handlebar​ ​injury​ ​->​ ​duodenal​ ​hematoma,​ ​found​ ​incidentally​ ​versus​ ​found​ ​during​ ​surgery,​ ​management.

119. Pediatric​ ​handlebar​ ​injury,​ ​Chance​ ​fracture​ ​of​ ​L-spine,​ ​peritonitis​ ​->​ ​small​ ​bowel​ ​perforation.

120. Management​ ​of​ ​bladder​ ​perforation:​ ​extraperitoneal​ ​versus​ ​intraperitoneal.

121. Blunt​ ​head​ ​trauma,​ ​unequal​ ​pupils​ ​->​ ​management​ ​elevated​ ​ICP.

122. Abdominal​ ​compartment​ ​syndrome

a. Detection​ ​and​ ​management

123. (AE)​ ​35​ ​yo​ ​female​ ​with​ ​blunt​ ​trauma​ ​MVC,​ ​GCS5,​ ​grade​ ​4​ ​spleen​ ​and​ ​femur​ ​fx​ ​-​ ​i​ ​embolized​ ​but​ ​this​ ​eventually​ ​failed​ ​so
removed​ ​spleen.​ ​asked​ ​about​ ​neuro​ ​monitoring​ ​-​ ​i​ ​forgot​ ​to​ ​mention​ ​ICP​ ​monitor.​ ​Asked​ ​if​ ​i​ ​should​ ​fix​ ​femur​ ​fracture​ ​-​ ​i
thought​ ​so​ ​but​ ​then​ ​other​ ​examiner​ ​asked​ ​if​ ​I​ ​would​ ​fix​ ​it​ ​if​ ​she​ ​didn’t​ ​have​ ​gag​ ​and​ ​cough​ ​-​ ​the​ ​whole​ ​time​ ​the​ ​examiner
said​ ​neuroendocrine​ ​was​ ​stable.​ ​asked​ ​how​ ​to​ ​do​ ​brain​ ​death​ ​exam

124. (PP)​ ​28​ ​y/o​ ​man​ ​with​ ​GSW​ ​to​ ​LUQ​ ​and​ ​RLQ.​ ​Primary​ ​and​ ​secondary​ ​shows​ ​ABCDE​ ​intact.​ ​Management?​ ​Adjuncts
including​ ​CXR​ ​and​ ​AXR.​ ​2​ ​retained​ ​projectiles​ ​in​ ​abdomen.​ ​Patient​ ​becomes​ ​tachycardic​ ​and​ ​hypotensive​ ​transiently.
Management?​ ​OR​ ​for​ ​laparotomy.​ ​Describe​ ​the​ ​procedure.

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a. Exlap,​ ​pack​ ​abdomen,​ ​resuscitate.​ ​Patient​ ​stabilizes​ ​and​ ​is​ ​warm,​ ​UOP​ ​good,​ ​pH​ ​normal.​ ​Describe​ ​the​ ​following
repairs:
i. Anterior​ ​gastric​ ​injury​ ​->​ ​primary​ ​repair​ ​two​ ​layers
ii. 3​ ​small​ ​bowel​ ​enterotomies​ ​within​ ​10cm​ ​segment​ ​of​ ​jejunum​ ​->​ ​resection​ ​and​ ​primary​ ​anastomosis
iii. Small​ ​bowel​ ​enterotomy​ ​in​ ​terminal​ ​ileum,​ ​<25%​ ​circumference​ ​->​ ​primary​ ​repair​ ​two​ ​layers
iv. 2​ ​colon​ ​injuries​ ​in​ ​close​ ​proximity​ ​to​ ​each​ ​other,​ ​>50%​ ​circumference,​ ​minimal​ ​spillage​ ​->​ ​resection
and​ ​primary​ ​repair
v. Where​ ​else​ ​to​ ​examine?​ ​Posterior​ ​stomach​ ​in​ ​lesser​ ​sac,​ ​duodenum,​ ​retroperitoneum,​ ​pancreas
vi. How​ ​to​ ​close​ ​skin​ ​and​ ​abdomen?​ ​Close​ ​fascia​ ​with​ ​PDS​ ​running,​ ​leave​ ​skin​ ​open​ ​or​ ​close?
b. POD#2​ ​the​ ​patient​ ​develops​ ​low​ ​grade​ ​fevers​ ​and​ ​dishwater​ ​drainage​ ​from​ ​wound.​ ​Management?​ ​Open​ ​wound.
c. On​ ​next​ ​day,​ ​the​ ​patient​ ​has​ ​eviscerated.​ ​Management?​ ​Take​ ​back​ ​to​ ​OR​ ​for​ ​washout​ ​and​ ​exploration.
Washout​ ​and​ ​close​ ​with​ ​retention​ ​sutures.​ ​Describe​ ​how​ ​to​ ​do​ ​that?

G.​ ​CRITICAL​ ​CARE

125. (JFB)​ ​Postop​ ​LAR​ ​in​ ​ICU​ ​due​ ​to​ ​leak​ ​and​ ​fistula.​ ​Developed​ ​oliguria.​ ​Labs​ ​with​ ​Cr​ ​elevated.​ ​Hgb​ ​stable.​ ​ABG​ ​with​ ​base
deficit.​ ​FeNa​ ​less​ ​than​ ​1%.​ ​BUN/Cr​ ​ratio​ ​elevated.​ ​Foley​ ​flushed.​ ​Fluid​ ​resuscitated.​ ​Arterial​ ​line​ ​and​ ​central​ ​line​ ​placed.
IVC​ ​ultrasound​ ​showed​ ​under​ ​resuscitated.​ ​No​ ​other​ ​symptoms.​ ​TTE​ ​negative​ ​for​ ​MI​ ​or​ ​wall​ ​motion​ ​abnormality​ ​and
ejection​ ​fraction.​ ​Then​ ​anuric.​ ​Patient​ ​had​ ​hematuria​ ​in​ ​foley​ ​bag​ ​now.​ ​Had​ ​right​ ​hydronephrosis​ ​on​ ​ultrasound​ ​and​ ​duplex
of​ ​kidneys.​ ​Found​ ​out​ ​in​ ​end​ ​that​ ​patient​ ​had​ ​stents​ ​in​ ​original​ ​surgery​ ​that​ ​were​ ​removed.​ ​I​ ​consulted​ ​urology​ ​to​ ​get
stents​ ​replaced.​ ​Case​ ​10.

126. ARDS​ ​management

a. Low​ ​tidal​ ​volume​ ​ventilation​ ​(start​ ​6​ ​mL/kg​ ​and​ ​down​ ​titrate​ ​to​ ​4​ ​mL/kg​ ​based​ ​on​ ​plateaus)
i. Know​ ​and​ ​advanced​ ​ventilatory​ ​strategy​ ​like​ ​Bilevel​ ​or​ ​APRV,​ ​pressure​ ​control,​ ​etc.
b. Uptitrate​ ​respiratory​ ​rate​ ​to​ ​max​ ​35,​ ​permissive​ ​hypercapnea​ ​unless​ ​pH​ ​below​ ​7.15,​ ​then​ ​needs​ ​increased​ ​Vt
and​ ​bicarb​ ​gtt​ ​possibly
c. High​ ​PEEP​ ​and​ ​FiO2
d. Deep​ ​sedation
e. Paralysis
f. Prone​ ​positioning
g. Referral​ ​for​ ​ECMO

127. (PP)​ ​28​ ​y/o​ ​man​ ​POD#2​ ​after​ ​exlap​ ​for​ ​splenectomy,​ ​bilateral​ ​femur​ ​fractures.​ ​Patient​ ​was​ ​massively​ ​transfused​ ​in​ ​OR.
Patient​ ​is​ ​POD#2​ ​and​ ​tachypneic.​ ​Management?​ ​O2​ ​facemask,​ ​ABG,​ ​CXR,​ ​heparin​ ​gtt,​ ​sudan​ ​red​ ​stain​ ​of​ ​blood,​ ​CT​ ​PE
protocol.​ ​CT​ ​negative​ ​for​ ​PE.​ ​Stop​ ​heparin​ ​gtt.​ ​CT​ ​and​ ​CXR​ ​showed​ ​bilateral​ ​fluffy​ ​infiltrates.​ ​PaO2​ ​50​ ​on​ ​100%​ ​FiO2.
Management?
a. Intubation​ ​->​ ​describe​ ​rapid​ ​sequence​ ​intubation
b. What​ ​is​ ​diagnosis?​ ​ARDS.​ ​Describe​ ​ventilatory​ ​strategy​ ​for​ ​ARDS

128. 66​ ​y/o​ ​white​ ​man,​ ​elective​ ​open​ ​AAA​ ​repair​ ​for​ ​6cm​ ​AAA.​ ​Intra-op​ ​patient​ ​becomes​ ​pulseless.​ ​Management?
a. H’s​ ​-​ ​hypovolemia,​ ​hypoxia,​ ​acidosis,​ ​hypoglycemia,​ ​hypo/hyperkalemia
b. T’s​ ​-​ ​tension​ ​PTX,​ ​pericardial​ ​tamponade,​ ​thrombosis​ ​(PE,​ ​MI),​ ​toxins
He​ ​is​ ​found​ ​after​ ​ROSC​ ​to​ ​have​ ​ST​ ​segment​ ​elevations​ ​and​ ​trops​ ​uptrending.​ ​Management?​ ​PCI​ ​with​ ​no​ ​stent​ ​or​ ​bare
metal​ ​stent.​ ​Wait​ ​6​ ​months​ ​for​ ​repair​ ​of​ ​AAA.

129. Management​ ​of​ ​post-op​ ​oliguria

a. Pre-renal:​ ​under​ ​resuscitated,​ ​FeNa​ ​<​ ​1%,​ ​elevated​ ​BUN/Cr​ ​ratio
b. Renal:​ ​ATN,​ ​ask​ ​about​ ​intra-op​ ​hypotensive​ ​episodes,​ ​recent​ ​nephrotoxins,​ ​IV​ ​contrast,​ ​UA​ ​with​ ​casts
c. Post-renal:​ ​obstruction,​ ​bloody​ ​urine​ ​with​ ​clots,​ ​bladder​ ​scan,​ ​large​ ​prostate,​ ​get​ ​renal​ ​ultrasound​ ​for
hydronephrosis,​ ​etc.

130. Management​ ​of​ ​post-op​ ​tachyarrhythmia

a. Atrial​ ​fibrillation​ ​(stable​ ​versus​ ​unstable)
b. Sinus​ ​tachycardia​ ​(look​ ​for​ ​sepsis​ ​or​ ​leak)
c. Ventricular​ ​tachycardia​ ​(without​ ​or​ ​with​ ​pulses)
d. Ventricular​ ​fibrillation​ ​(needs​ ​emergent​ ​unsynchronized​ ​cardioversion)

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131. Treatment​ ​of​ ​sepsis​ ​->​ ​Surviving​ ​Sepsis​ ​Guidelines

132. Brain​ ​Death​ ​Determination

133. Management​ ​of​ ​acute​ ​myocardial​ ​infarction

134. Management​ ​of​ ​acute​ ​pulmonary​ ​embolism

a. Indications​ ​for​ ​systemic​ ​tPA

135. (AE)​ ​55​ ​childs​ ​B​ ​s/p​ ​left​ ​hemicolectomy​ ​in​ ​ICU​ ​now​ ​with​ ​decompensated​ ​liver​ ​failure.​ ​Management?​ ​Then​ ​NGT​ ​bloody,
scope​ ​showed​ ​varices,​ ​TIPS​ ​and​ ​blakemore​ ​tube​ ​-​ ​he​ ​asked​ ​how​ ​to​ ​place​ ​tube

H.​ ​VASCULAR​ ​SURGERY

136. (JFB)​ ​DVT​ ​pregnant​ ​woman​ ​diagnosed​ ​with​ ​LE​ ​venous​ ​duplex.​ ​Heparin​ ​gtt​ ​and​ ​lovenox,​ ​NO​ ​warfarin.​ ​Got​ ​a​ ​PE​ ​while
anticoagulated,​ ​VQ​ ​scan​ ​diagnosed​ ​PE.​ ​IVC​ ​filter​ ​and​ ​f/u​ ​recs​ ​for​ ​filter.​ ​Case​ ​9.

137. SMA​ ​embolism​ ​in​ ​atrial​ ​fibrillation,​ ​anticoagulate​ ​with​ ​heparin​ ​gtt,​ ​and​ ​explore​ ​with​ ​SMA​ ​embolectomy,​ ​bowel​ ​dusky.
Leave​ ​fascia​ ​open,​ ​close​ ​skin​ ​and​ ​re-explore​ ​in​ ​24-48​ ​hours.

138. Lower​ ​extremity​ ​acute​ ​limb​ ​ischemia,​ ​over​ ​6​ ​hours,​ ​fasciotomies,​ ​AKI​ ​post-op​ ​from​ ​rhabdomyolysis.

139. 50​ ​y/o​ ​female​ ​mail​ ​carrier​ ​with​ ​buttock​ ​and​ ​thigh​ ​claudication.​ ​PMHx​ ​smoker​ ​and​ ​HTN.​ ​On​ ​exam​ ​bilateral​ ​non-palpable
femoral​ ​pulses.​ ​CTA​ ​shows​ ​distal​ ​aortic​ ​occlusion​ ​from​ ​atherosclerosis.​ ​Management?​ ​Aortobifemoral​ ​bypass.​ ​Tunnel
graft​ ​under​ ​the​ ​ureters.

140. (AE)​ ​68​ ​y/o​ ​woman,​ ​abdominal​ ​pain​ ​and​ ​weight​ ​loss​ ​with​ ​food​ ​fright.​ ​2​ ​hours​ ​acute​ ​onset​ ​of​ ​abdominal​ ​pain,​ ​unrelenting.
WBC​ ​20.​ ​Lactate​ ​1.​ ​Creatinine​ ​1.2.​ ​CTA​ ​shows​ ​SMA​ ​occlusion.​ ​Management?​ ​Immediate​ ​heparinzation​ ​and​ ​OR.​ ​Exlap,
with​ ​SMA​ ​bypass​ ​of​ ​aorta​ ​to​ ​distal​ ​SMA​ ​or​ ​external​ ​iliac​ ​to​ ​SMA​ ​with​ ​RSVG.​ ​Describe​ ​exposure​ ​of​ ​SMA.

141. 72​ ​y/o​ ​man​ ​right​ ​carotid​ ​bruit,​ ​needs​ ​H&P,​ ​vascular​ ​exam,​ ​neurologic​ ​exam,​ ​visual​ ​exam,​ ​hx​ ​of​ ​strokes​ ​or​ ​TIA’s,
amaurosis​ ​fugax,​ ​facial​ ​droop,​ ​aphasia,​ ​numbness,​ ​weakness,​ ​etc.​ ​Labs​ ​unremarkable,​ ​elevated​ ​lipids.​ ​Carotid​ ​duplex
with​ ​PSV​ ​242,​ ​PDV​ ​120,​ ​Ratio​ ​5.2​ ​on​ ​right.​ ​Describe​ ​carotid​ ​endarterectomy​ ​(to​ ​shunt​ ​or​ ​not​ ​to​ ​shunt);(clamp​ ​order:
internal,​ ​common,​ ​external);(unclamp​ ​order:​ ​external,​ ​common,​ ​internal).
a. What​ ​if​ ​patient​ ​post-op​ ​cannot​ ​move​ ​left​ ​arm​ ​and​ ​leg​ ​->​ ​go​ ​back​ ​to​ ​sleep​ ​and​ ​open​ ​neck​ ​and​ ​shoot​ ​angiogram
and​ ​look​ ​for​ ​intimal​ ​flap
b. What​ ​if​ ​patient​ ​just​ ​had​ ​stroke?​ ​CEA​ ​in​ ​a​ ​couple​ ​days​ ​or​ ​within​ ​first​ ​week​ ​if​ ​recovered​ ​from​ ​symptoms.

142. 18​ ​y/o​ ​with​ ​posterior​ ​dislocation​ ​of​ ​knee​ ​6​ ​hours​ ​ago,​ ​took​ ​long​ ​time​ ​to​ ​get​ ​transferred.​ ​Vascular​ ​exam​ ​reveals​ ​pulseless
foot​ ​after​ ​reduction​ ​of​ ​dislocation​ ​in​ ​OSH​ ​ED.​ ​Transferred​ ​to​ ​you.​ ​Management?​ ​OR.​ ​Explore​ ​artery,​ ​shunt​ ​artery,​ ​then​ ​let
ortho​ ​fix​ ​the​ ​knee,​ ​then​ ​do​ ​definitive​ ​repair​ ​with​ ​bypass​ ​and​ ​LE​ ​fasciotomies.

143. 50​ ​y/o​ ​man​ ​stabbed​ ​in​ ​left​ ​thigh​ ​in​ ​bar​ ​fight.​ ​Presented​ ​via​ ​ambulance​ ​immediately​ ​after​ ​trauma,​ ​reportedly​ ​saw​ ​pulsatile
bleeding​ ​from​ ​left​ ​thigh.​ ​On​ ​exam​ ​in​ ​ED​ ​patient​ ​has​ ​pulseless​ ​left​ ​leg​ ​and​ ​is​ ​actively​ ​bleeding​ ​from​ ​the​ ​wound.
Management?​ ​Hold​ ​pressure.​ ​How​ ​to​ ​prep​ ​this​ ​patient​ ​out?​ ​From​ ​chin​ ​to​ ​feet​ ​bilaterally,​ ​prep​ ​in​ ​the​ ​person​ ​holding
pressure​ ​(they​ ​continue​ ​holding​ ​pressure​ ​until​ ​proximal​ ​and​ ​distal​ ​control​ ​is​ ​obtained​ ​or​ ​sterile​ ​tourniquet​ ​is​ ​placed).
a. Describe​ ​repair​ ​of​ ​SFA​ ​injury​ ​(proximal​ ​distal​ ​control,​ ​heparinization,​ ​flush​ ​proximally​ ​and​ ​distally​ ​with​ ​hep​ ​saline
to​ ​remove​ ​clots,​ ​fogarty​ ​for​ ​thrombectomy​ ​distally​ ​and​ ​proximally,​ ​interposition​ ​graft​ ​of​ ​PTFE​ ​or​ ​saphenous​ ​from
contralateral​ ​leg,​ ​prior​ ​to​ ​full​ ​completion​ ​of​ ​anastomoses​ ​need​ ​to​ ​fully​ ​flush/de-clot/​ ​and​ ​de-air​ ​the​ ​vessel,
completion​ ​angiogram​ ​or​ ​assessment​ ​of​ ​pulses​ ​distally​ ​or​ ​both)

144. AAA​ ​management,​ ​asymptomatic​ ​versus​ ​symptomatic,​ ​size​ ​criteria

145. In​ ​OR​ ​for​ ​AAA​ ​repair​ ​7​ ​cm​ ​infrarenal,​ ​no​ ​extension​ ​down​ ​iliacs,​ ​pre-op​ ​had​ ​palpable​ ​pulses​ ​in​ ​both​ ​feet.​ ​Describe
exposure​ ​of​ ​aorta​ ​and​ ​steps​ ​of​ ​repair.
a. Post-op​ ​patient​ ​has​ ​no​ ​palpable​ ​pulses​ ​in​ ​the​ ​left​ ​foot.​ ​Management?​ ​Angiogram​ ​and​ ​thrombectomy

146. Hx​ ​of​ ​AAA​ ​repair,​ ​herald​ ​GI​ ​bleed,​ ​presents​ ​to​ ​ED​ ​with​ ​aortoenteric​ ​fistula,​ ​diagnosis​ ​and​ ​management

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147. Infected​ ​aorto-bifem​ ​bypass​ ​graft​ ​management.​ ​IV​ ​abx​ ​then​ ​staged​ ​repair​ ​with​ ​extra-anatomic​ ​bypass​ ​(ax-fem​ ​with
fem-fem)​ ​then​ ​explant​ ​of​ ​graft​ ​and​ ​oversewing​ ​stump​ ​of​ ​aorta.

148. 65​ ​y/o​ ​man​ ​with​ ​type​ ​2​ ​diabetes.​ ​Poorly​ ​controlled.​ ​Presents​ ​to​ ​ED​ ​with​ ​foul​ ​smelling​ ​purulent​ ​drainage​ ​from​ ​great​ ​toe​ ​and
discoloration​ ​after​ ​podiatric​ ​debridement​ ​of​ ​toenail.​ ​Hemodynamically​ ​stable.​ ​Management?​ ​Never​ ​has​ ​occurred​ ​before.
Physical​ ​reveals​ ​expressible​ ​discharge​ ​from​ ​great​ ​toe.​ ​Vascular​ ​exam​ ​without​ ​palpable​ ​pulses.​ ​Dopplers​ ​show
monophasic​ ​signals​ ​DP/PT.​ ​Management?​ ​Plain​ ​films​ ​show​ ​edema​ ​of​ ​tissues,​ ​no​ ​subq​ ​air.​ ​Management?​ ​Admission,​ ​IV
abx,​ ​and​ ​OR​ ​debridement​ ​of​ ​wounds​ ​with​ ​interval​ ​angiogram​ ​and​ ​revascularization.
a. How​ ​would​ ​management​ ​change​ ​if​ ​patient​ ​was​ ​septic,​ ​palpable​ ​crepitus,​ ​and​ ​x-rays​ ​showing​ ​gas​ ​in​ ​tissue
planes?​ ​Management?​ ​Emergent​ ​debridement​ ​versus​ ​guillotine​ ​amputation​ ​for​ ​local​ ​sepsis​ ​control.​ ​IV​ ​abx,
admission​ ​to​ ​ICU.​ ​Resuscitation.​ ​Eventual​ ​assessment​ ​of​ ​vascular​ ​perfusion​ ​with​ ​angiogram​ ​and​ ​possible
revascularization.
b. How​ ​would​ ​management​ ​change​ ​if​ ​patient​ ​was​ ​80​ ​y/o​ ​demented​ ​with​ ​hx​ ​of​ ​stroke​ ​and​ ​non-ambulatory​ ​status
and​ ​dry​ ​gangrene​ ​of​ ​forefoot?​ ​Management?​ ​AKA.​ ​No​ ​offer​ ​for​ ​revascularization​ ​or​ ​more​ ​distal​ ​amputation.​ ​One
procedure​ ​with​ ​highest​ ​likelihood​ ​of​ ​healing​ ​and​ ​least​ ​anesthesia​ ​and​ ​operative​ ​stress...the​ ​above​ ​knee
amputation​ ​(AKA).

149. (PP)​ ​78​ ​y/o​ ​female​ ​with​ ​sudden​ ​onset​ ​back​ ​pain.​ ​Hx​ ​of​ ​vasculopath​ ​and​ ​hx​ ​of​ ​colectomy.​ ​Differential​ ​diagnosis?
Pancreatitis.​ ​AAA​ ​rupture.​ ​Aortic​ ​dissection.​ ​Management?​ ​Labs,​ ​imaging​ ​including​ ​ultrasound​ ​revealing​ ​AAA.​ ​Patient
became​ ​hypotensive.​ ​Management?​ ​Take​ ​to​ ​OR,​ ​prep​ ​and​ ​drape​ ​prior​ ​to​ ​induction​ ​of​ ​anesthesia.​ ​Induction​ ​then
laparotomy.​ ​Describe​ ​access​ ​to​ ​aorta.​ ​Colon​ ​up​ ​and​ ​to​ ​left,​ ​small​ ​bowel​ ​to​ ​right,​ ​expose​ ​retroperitoneum,​ ​and​ ​mobilize
duodenum.​ ​Open​ ​retroperitoneum​ ​over​ ​aorta​ ​proximal​ ​and​ ​distal​ ​to​ ​aorta.​ ​Proximal​ ​crossclamp​ ​and​ ​distal​ ​clamps​ ​on
iliacs.​ ​Open​ ​aneurysm,​ ​oversew​ ​lumbars.​ ​Assess​ ​back​ ​bleeding​ ​of​ ​IMA.​ ​Reimplant​ ​versus​ ​ligate.​ ​Sew​ ​in​ ​dacron​ ​graft.
a. Post-op​ ​patient​ ​develops​ ​rectal​ ​bleeding.​ ​Management?​ ​Flexible​ ​sigmoidoscopy​ ​and​ ​resuscitation​ ​with​ ​IV​ ​abx.

I.​ ​PEDIATRIC​ ​SURGERY

150. Hypertrophic​ ​pyloric​ ​stenosis
a. Diagnosis,​ ​ultrasound​ ​with​ ​16mm​ ​x​ ​4mm​ ​minimum​ ​measurements
b. Medical​ ​correction​ ​of​ ​alkalosis​ ​first​ ​with​ ​IVF​ ​resuscitation
c. Then​ ​surgical​ ​treatment​ ​with​ ​pyloromyotomy

151. (AE/NM)​ ​Baby​ ​with​ ​midgut​ ​volvulus​ ​and​ ​malrotation,​ ​describe​ ​surgery​ ​(Ladd’s​ ​procedure)
a. with​ ​gangrenous​ ​bowel
i. All​ ​bowel
ii. Small​ ​segment​ ​of​ ​bowel
b. without​ ​gangrenous​ ​bowel

152. Gastroschisis​ ​acute​ ​management

a. Immediate​ ​reduction​ ​versus​ ​silo​ ​and​ ​delayed​ ​reduction

153. Management​ ​pediatric​ ​umbilical​ ​hernia

a. Non-incarcerated​ ​infant​ ​versus​ ​4-5​ ​year​ ​old

154. Management​ ​of​ ​pediatric​ ​cryptorchidism

a. Wait​ ​till​ ​1​ ​year​ ​old.
b. What​ ​if​ ​cannot​ ​get​ ​testis​ ​to​ ​reach​ ​scrotum​ ​for​ ​orchidopexy?​ ​Fowler-Stevens​ ​procedure.
c. What​ ​if​ ​cannot​ ​find​ ​testis​ ​at​ ​inguinal​ ​ring?​ ​Look​ ​in​ ​abdomen.

155. 3​ ​y/o​ ​presents​ ​to​ ​the​ ​ED​ ​with​ ​dysphagia​ ​and​ ​drooling.​ ​Was​ ​sucking​ ​on​ ​car​ ​keychain​ ​and​ ​accidentally​ ​swallowed​ ​a​ ​button
battery.​ ​CXR​ ​shows​ ​battery​ ​in​ ​midesophagus,​ ​no​ ​mediastinal​ ​air.​ ​Labs​ ​normal.​ ​Vitals​ ​stable.​ ​Management​ ​->​ ​OR​ ​for​ ​rigid
bronchoscopy,​ ​removal​ ​of​ ​foreign​ ​body​ ​and​ ​examination​ ​of​ ​mucosa.
a. Perforation​ ​of​ ​esophagus​ ​seen​ ​->​ ​can​ ​see​ ​pericardium​ ​through​ ​the​ ​anterior​ ​perforation
b. Management?​ ​OR​ ​exploratory​ ​thoracotomy,​ ​repair​ ​of​ ​perforation,​ ​muscle​ ​flap,​ ​wide​ ​drainage,​ ​and​ ​IV​ ​antibiotics.
Pass​ ​NG​ ​beyond​ ​area​ ​of​ ​repair.​ ​Feeding​ ​j-tube.​ ​Study​ ​in​ ​a​ ​week​ ​or​ ​two​ ​with​ ​gastrograffin.

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156. (PP)​ ​6​ ​y/o​ ​female​ ​patient​ ​with​ ​right​ ​groin​ ​mass.​ ​Patient​ ​in​ ​too​ ​much​ ​pain​ ​and​ ​won’t​ ​let​ ​you​ ​fully​ ​examine​ ​but​ ​no​ ​overlying
erythema​ ​or​ ​skin.​ ​Management?​ ​Ultrasound​ ​showed​ ​fluid​ ​filled​ ​mass.​ ​Management?​ ​Attempted​ ​conscious​ ​sedation​ ​but
unsuccessful.​ ​Management?​ ​OR​ ​for​ ​groin​ ​exploration.​ ​Hernia​ ​reduced​ ​on​ ​anesthesia​ ​sedation.​ ​Management?
a. Laparoscope​ ​through​ ​hernia​ ​sac​ ​or​ ​umbilicus​ ​to​ ​examine​ ​bowel.​ ​You​ ​see​ ​dusky​ ​bowel.​ ​Management?
i. Excision​ ​and​ ​primary​ ​anastomosis​ ​through​ ​infraumbilical​ ​mini-laparotomy
b. How​ ​to​ ​repair​ ​pediatric​ ​hernia?​ ​High​ ​ligation​ ​of​ ​hernia​ ​sac.

J.​ ​ENDOSCOPY
157. (JFB)​ ​Hemorrhoids​ ​and​ ​BRBPR,​ ​colonoscopy​ ​with​ ​sessile​ ​polyp​ ​mid​ ​transverse​ ​colon​ ​and​ ​polyps​ ​sigmoid​ ​colon.​ ​Biopsied
and​ ​tattooed​ ​lesion​ ​mid​ ​transverse​ ​colon​ ​but​ ​only​ ​showed​ ​villous​ ​adenoma.​ ​How​ ​to​ ​do​ ​cscope​ ​and​ ​how​ ​to​ ​handle​ ​looping.
Transverse​ ​sessile​ ​polyp​ ​was​ ​villous​ ​adenoma​ ​and​ ​sigmoids​ ​were​ ​hyperplastic.​ ​Recommended​ ​extended​ ​right
hemicolectomy.​ ​Diet​ ​changes​ ​and​ ​eventual​ ​EUA​ ​anoscopy​ ​for​ ​hemorrhoids.​ ​Case​ ​2.

158. (AE)​ ​50​ ​yo​ ​male​ ​undergoing​ ​colonoscopy.​ ​Describe​ ​how​ ​to​ ​do​ ​colonoscopy​ ​(Preparation,​ ​monitoring,​ ​procedure).​ ​Patient
comes​ ​back​ ​with​ ​free​ ​air.​ ​Management?​ ​Exlap​ ​and​ ​oversewing​ ​of​ ​perforation​ ​after​ ​freshening​ ​edges.

159. (PP)​ ​56​ ​y/o​ ​man​ ​with​ ​dyspepsia​ ​and​ ​no​ ​other​ ​hx.​ ​Epigastric​ ​tenderness​ ​on​ ​exam.​ ​Labs​ ​with​ ​Hgb​ ​mildly​ ​anemic.
Management?​ ​EGD.​ ​Describe​ ​how​ ​to​ ​perform​ ​EGD​ ​(pre-procedure​ ​preparation,​ ​positioning,​ ​sedation,​ ​performance​ ​of
procedure).​ ​On​ ​EGD​ ​you​ ​find​ ​6cm​ ​ulcer​ ​at​ ​greater​ ​curvature.​ ​Management?​ ​Biopsy​ ​ulcer​ ​to​ ​r/o​ ​cancer​ ​and​ ​biopsy​ ​antrum
for​ ​H.​ ​pylori.​ ​Bleeding​ ​starts.​ ​How​ ​do​ ​you​ ​manage​ ​bleeding​ ​endoscospically?​ ​Clips​ ​versus​ ​epinephrine​ ​injection​ ​versus
coagulation.​ ​You​ ​continue​ ​EGD​ ​and​ ​find​ ​another​ ​ulcer​ ​in​ ​duodenum​ ​second​ ​portion.​ ​Management?​ ​Biopsy?​ ​Not​ ​usually.
a. Post-procedure​ ​patient​ ​has​ ​massive​ ​hemodynamically​ ​unstable​ ​UGI​ ​bleed.​ ​Management?​ ​2​ ​large​ ​bore​ ​IV’s,
IVF,​ ​type​ ​and​ ​cross​ ​and​ ​transfusion,​ ​and​ ​EGD.​ ​Duodenal​ ​ulcer​ ​was​ ​bleeding​ ​profusely,​ ​recalcitrant​ ​to
coagulation,​ ​clipping​ ​or​ ​injection.​ ​Management?​ ​Exlap,​ ​duodenotomy​ ​longitudinally,​ ​oversew​ ​three​ ​points​ ​the
ulcer​ ​(superior,​ ​inferiorly,​ ​medial​ ​base).​ ​What​ ​kind​ ​of​ ​suture?​ ​Silks.​ ​Bleeding​ ​improved​ ​but​ ​patient​ ​still​ ​oozing​ ​at
ulcer​ ​bed.​ ​Management?​ ​Surgicel​ ​and​ ​Tisseel.

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