Surgery Flashcards

A 58-year-old patient undergoes an elective sigmoid colectomy. On postoperative day 3, they develop fever (38.8°C), tachycardia, and a rising WBC. CT scan shows a small pelvic fluid collection without free air. The most appropriate INITIAL management is:

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

A contained pelvic abscess after colorectal surgery without peritonitis or free air is best managed initially with percutaneous CT-guided drainage combined with broad-spectrum antibiotics. This approach is both diagnostic and therapeutic, avoids the morbidity of reoperation, and is effective in 80–90% of cases. Immediate return to the OR is reserved for peritonitis, anastomotic dehiscence with free perforation, or failure of percutaneous drainage. Antibiotics alone are insufficient for a well-defined abscess cavity, and NG decompression does not address the infectious source.

During a laparoscopic cholecystectomy, the surgeon inadvertently clips and divides what is believed to be the cystic duct, but intraoperative cholangiography reveals the common bile duct has been transected. The proximal and distal ends are visible with approximately 2 cm of duct missing. What is the most appropriate next step?

Answer: Convert to open, close the abdomen, and transfer to a hepatobiliary specialist

Major bile duct injuries with segmental loss are best repaired by experienced hepatobiliary surgeons. Attempting primary repair or immediate Roux-en-Y reconstruction by a surgeon not specializing in hepatobiliary surgery carries high risk of stricture, bile leak, and long-term morbidity. The correct step is to control any hemorrhage, place drains, close the abdomen, and urgently transfer to a hepatobiliary center. Studies show significantly better outcomes when biliary reconstruction is performed by high-volume specialists. Attempting end-to-end anastomosis under tension with tissue loss has a high stricture rate.

A 72-year-old woman with a history of aortic stenosis undergoes open right hemicolectomy. On postoperative day 2 she develops an ST-elevation MI confirmed by ECG and troponin. She is hemodynamically stable (BP 110/70, HR 88). Cardiology recommends urgent percutaneous coronary intervention (PCI). The MOST important surgical consideration at this point is:

Answer: Proceed with PCI immediately; the anastomosis is not a contraindication

In a hemodynamically stable post-surgical patient with STEMI, PCI remains the preferred reperfusion strategy. Modern bare-metal and drug-eluting stents require dual antiplatelet therapy (DAPT), but the immediate risk of untreated STEMI (mortality, cardiogenic shock) outweighs the bleeding risk at the anastomosis in a stable patient. Dual antiplatelet therapy increases bleeding risk but does not typically cause anastomotic dehiscence. Delaying intervention to avoid antiplatelet agents is inappropriate for STEMI. CABG requires full anticoagulation and is higher risk in the immediate postoperative period. PCI with careful bleeding surveillance is the standard of care.

A 45-year-old man presents with recurrent variceal bleeding despite two prior endoscopic band ligation sessions. He has Child-Pugh Class B cirrhosis (score 8) and MELD score of 14. TIPS (transjugular intrahepatic portosystemic shunt) is being considered. Which finding would be the STRONGEST contraindication to TIPS placement?

Answer: Pulmonary arterial pressure of 45 mmHg on echocardiography

Moderate-to-severe portopulmonary hypertension (mean pulmonary arterial pressure >35 mmHg) is a strong contraindication to TIPS because the procedure acutely increases cardiac preload by diverting portal flow into the systemic circulation, which can precipitate right heart failure and death in patients with compromised pulmonary vasculature. Portal vein thrombosis is a relative contraindication but can sometimes be managed with recanalization before TIPS. Hepatic encephalopathy is a relative contraindication but is not absolute if controlled. Ascites is actually an indication for TIPS in refractory cases.

A trauma surgeon performs a damage control laparotomy on a 34-year-old male with a gunshot wound causing grade IV liver laceration and superior mesenteric vein injury. The abdomen is packed and temporarily closed. Resuscitation in the ICU normalizes lactate and coagulation. When planning the definitive re-look laparotomy (typically 24–48 hours later), which finding at initial laparotomy would most strongly favor early abdominal closure at re-look rather than continued open abdomen management?

Answer: Packing in only one quadrant with excellent hemostasis and no enteric injury

The goal of damage control is to achieve physiology correction ('lethal triad' reversal) as quickly as possible and close the abdomen definitively at the earliest safe opportunity. A patient with packing confined to one quadrant, excellent hemostasis at packing, no enteric spillage or injury requiring further decision-making, and normalized physiology is the ideal candidate for primary fascial closure at re-look. Bowel edema requiring a Bogota bag suggests abdominal compartment syndrome risk and favors continued open management. Ongoing coagulopathy requiring massive transfusion is a sign of incomplete resuscitation. Multiple serosal repairs may need reassessment for viability but don't preclude closure if the bowel looks healthy.

A 61-year-old woman with T2N1M0 rectal adenocarcinoma 6 cm from the anal verge completes neoadjuvant chemoradiation. Restaging MRI shows complete clinical response (yCR). She strongly desires organ preservation. Which management strategy is MOST consistent with current evidence-based guidelines for this scenario?

Answer: Offer a 'Watch and Wait' (non-operative management) protocol with strict surveillance

In patients achieving a complete clinical response (cCR) after neoadjuvant chemoradiation for rectal cancer, 'Watch and Wait' (non-operative management/NOM) is a validated organ-preservation strategy supported by multiple prospective studies and guidelines (NCCAP, ESMO). Approximately 25–30% of patients will have a local regrowth, most of which are salvageable with surgery. Long-term outcomes for sustained cCR patients are comparable to surgical resection for distant disease-free survival. APR is not required simply due to tumor location if sphincters can be spared or organ preservation is desired after cCR. Routine TME for all cCR patients is increasingly being questioned. Local excision alone is generally insufficient for T2+ tumors.