These questions are similar to those asked on the American Board of Surgery Recertification Examination. Use them to prepare for the examination, fulfill learning requirements for various maintenance of competence programs, or simply improve your surgical knowledge. Answers can be viewed by following the "Read the Answers" link at the end.

1. The greatest improvement in breast cancer survival rates is due to
   1. Improvements in operative therapy
   2. Routine use of screening mammography
   3. Reliance on sentinel lymph node biopsy
   4. Increased use of adjuvant chemotherapy
   5. Genetic screening of high-risk patients


2. During pregnancy
   1. The red cell mass increases by 50%
   2. Fibrinogen concentrations fall by 30%
   3. Serum creatinine concentrations increase by 40%
   4. Gastric emptying is accelerated
   5. Tidal volumes decrease by 30%


3. The most common soft-tissue sarcoma found in the lower extremity is
   1. Liposarcoma
   2. Synovial sarcoma
   3. Malignant fibrous histiocytoma
   4. Leiomyosarcoma
   5. Fibrosarcoma


4. The spinal accessory nerve
   1. Innervates the sternocleidomastoid muscle
   2. Is commonly injured during carotid endarterectomy procedures
   3. Lies deep to the internal jugular vein
   4. Is within the operative field during routine carotid surgery
   5. Provides sensory fibers to the pharyngeal mucosa


5. Malignant hyperthermia is associated with
   1. Metabolic alkalosis
   2. Uncontrolled accumulation of potassium in muscle cells
   3. Opiate administration
   4. High levels of creatinine kinase
   5. Hypokalemia


6. In laparoscopic surgery, the vessel most likely to be punctured during trochar placement is the
   1. Aorta
   2. Right common iliac artery
   3. Vena cava
   4. Left common iliac artery
   5. Right common iliac vein


7. Primary peritonitis (spontaneous bacterial peritonitis)
   1. Is a complication of peritoneal dialysis
   2. Is generally caused by gram-negative bacteria
   3. Is more likely to occur in patients with cirrhosis
   4. Requires immediate operation
   5. Is more common in adults


8. Pectus excavatum
   1. Has a well-characterized genetic predisposition
   2. Is associated with congenital cardiac lesions in 25% of patients
   3. Should be repaired only in patients with decreased cardiac or respiratory reserve
   4. Is best repaired during adolescence
   5. Is primarily a disease of male patients


9. A patient with a head injury who opens his or her eyes in response to pain, exhibits withdrawal in response to stimulation, and utters inappropriate words has a score on the Glasgow Coma Scale of
   1. 11
   2. 10
   3. 9
   4. 8
   5. 7


10. Vitamin D3
    1. Synthesis requires cutaneous ultraviolet activation
    2. Is the most common commercial form of vitamin D
    3. Is derived from ergosterol
    4. Inhibits calcium transport
    5. Is synthesized in the liver


11. In grade II traumatic liver lacerations
    1. The laceration should be sutured closed
    2. The abdomen should be packed and closed with the lap pads in place
    3. The incidence of hemobilia is 10% to 15%
    4. Drainage is not necessary
    5. There is no risk of hepatic ischemic injury if a Pringle maneuver is performed


12. Bronchiectasis
    1. Can be distinguished from bronchitis on bronchoscopy
    2. Primarily affects the apical segments of the upper lobes
    3. Is increasing in frequency
    4. Can occur distal to a bronchial obstruction
    5. Frequently requires operative therapy

Web-First Questions

13. Accelerated acute rejection
    1. Is mediated by antibodies
    2. Occurs within 1 hour
    3. Complicates 20% of transplants
    4. Has a good prognosis
    5. Occurs despite negative crossmatches


14. All of the following statements about morbid obesity are correct, except:
    1. Life expectancy is decreased by an average of 6 years.
    2. Operation is associated with a 4-fold increase in the rate of wound breakdown.
    3. Each increment of 1.0 kg/m2 above 40 increases the likelihood of congestive heart failure by 6%.
    4. Loss of 30% of body weight is necessary to improve associated comorbidities.
    5. Pulmonary functional residual capacity is decreased by 66%.

Read the Answers

Answers

1. b—Using screening mammography, most carcinomas of the breast can now be identified while they are stage I lesions. Tumors smaller than 1 cm that have no axillary node involvement are associated with a greater than 95% survival rate. There have been relatively few improvements in ablative surgery, other than a focus on minimalism, and enormous improvements in reconstructive techniques. Sentinel lymph node biopsy has facilitated axillary staging, but it has not improved survival rates, per se. Adjuvant chemotherapy has improved the survival chances of patients who have more advanced lesions, but screening mammography has decreased the incidence of these tumors. Fewer than 20% of breast cancers have a genetic basis, so the benefit of genetic screening, while important, is limited. Currently, genetic screening and counseling are not widespread, even among individuals with a strong family history of breast cancer.
    
2. a—The red cell mass increases significantly in pregnancy, despite the fact that the hematocrit generally falls. The increase (not decrease) in fibrinogen and the associated fall in protein S concentrations cause relative hypercoagulability. Serum creatinine levels fall by 20% as a result of dilution due to increased extracellular fluid volume. Gastric emptying is delayed (not accelerated), thereby increasing the risk of aspiration. Tidal volumes increase (not decrease), causing a compensatory respiratory alkalosis.
    
3. c—Malignant fibrous histiocytoma is the most common soft-tissue sarcoma found in the lower extremity, with liposarcoma, synovial sarcoma, and fibrosarcoma ranking second, third, and fourth, respectively, although the lower extremity is the most common site for all these lesions. Leiomysarcomas rarely occur in the lower extremity (but they do occur), and most originate from the viscera.
    
4. a—The spinal accessory nerve innervates both the sternocleidomastoid and trapezius muscles. It contains no sensory fibers; the glossopharyngeal nerve provides the sensory supply to the pharyngeal muscle. The spinal accessory nerve crosses superficial to the internal jugular vein; because it is so far cephalad, it lies outside the field of routine carotid surgery and thus is rarely injured. It can be injured, however, if the carotid artery must be dissected far cephalad to obtain proximal control.
    
5. d—Creatinine kinase levels peak 12 to 18 hours after the onset of malignant hyperthermia. The disease is associated with severe acidosis (not alkalosis), and calcium (not potassium) accumulates in muscle cells. Malignant hyperthermia is initiated by administration of succinyl choline, caffeine, halothane, and other halogenated anesthetic agents. This entity causes severe hyperkalemia (not hypokalemia).
    
6. b—The right common iliac artery lies directly beneath the umbilicus. The aorta and vena cava bifurcate just above this point. The left common iliac artery lies to the left of the umbilicus, and the right common iliac vein lies directly beneath the corresponding artery and is protected.
    
7. c—Patients susceptible to primary peritonitis include those with cirrhosis, nephrotic syndrome, and immunosuppression (either endogenous, which occurs with aquired immunodeficiency syndrome or malignancy; or exogenous, which results from the use of immunosuppressive medications). In primary peritonitis, the bloodstream acts as the portal of entry for bacteria; in peritoneal dialysis, the problem is that the peritoneal cavity is contaminated by dialysis fluid (this is considered iatrogenic peritonitis). The most common organisms are all gram-positive (Staphylococcus, pneumococcus, and Streptococcus). Once the diagnosis of primary peritonitis has been made, treatment is administration of antibiotics. Primary peritonitis is far more common in children than adults.
    
8. e—More than 75% of those afflicted with pectus excavatum are males, in whom the condition is generally less psychologically disturbing. Although 30% of patients have a familial history of sternal abnormalities, no genetic predisposition has been identified. Surprisingly, only 1.5% of afflicted patients have concomitant congenital cardiac abnormalities. This lesion causes significant psychosocial problems and interferes with normal self-image, so repair is indicated even when there is no significant cardiac or respiratory compromise. Repair is recommended when patients are between 2 to 5 years old.
    
9. b—Opening the eyes in response to pain counts for 3, withdrawal for 4, and uttering inappropriate words for 3, for a total Glasgow score of 10.
    
10. a—Conversion of 7-dehydrocholesterol (not ergosterol, the predecessor of vitamin D2) to D3 requires ultraviolet light, generally sunlight. Vitamin D2 is the most common commercial form of the vitamin. Vitamin D3 stimulates calcium transport and is synthesized in the kidneys.
     
11. d—There are good data which document that there is no advantage to draining superficial hepatic lacerations. Closing the laceration creates an area of dead space, which permits the accumulation of blood and facilitates subsequent infection. The bleeding in grade II lacerations should be readily controllable, without the need for packing. Hemobilia occurs in fewer than 1% of grade II lacerations. The Pringle maneuver, while fairly safe for short periods of time, does cause ischemic injury, and this becomes particularly severe in the presence of hypothermia.
     
12. d—Bronchiectasis is a destructive process that involves the small bronchi and adjacent pulmonary parenchyma. It is initiated by localized bacterial infection and commonly occurs distal to a bronchial or bronchiolar obstruction caused by tumor, infected node, or foreign body. Diagnosis is made using imaging studies, not bronchoscopy; however, bronchoscopy is indicated to clear the bronchial tree of tenacious purulent secretions and rule out malignancy or foreign-body obstruction. The frequency of this disease has markedly decreased since the advent of antibiotics. Bronchiectasis affects the basal segments of the lower lobes, and 90% of cases can be successfully treated with antibiotics (and without surgery).
     
13. e—Accelerated acute rejection occurs regularly in patients with negative crossmatches. In fact, it often occurs in patients with low antibody titers and low PRA (panel reactive antibody) scores. This form of rejection is mediated by T lymphocytes, and is a form of cellular (not humoral) rejection. It occurs within 12 to 24 hours. Rejection that occurs immediately or within 1 hour of transplantation is hyperacute rejection; this is antibody mediated and caused by the recipient reacting to donor antigens to which they have been presensitized. Accelerated acute rejection occurs after 1% to 4% of transplants and carries a terrible prognosis (&gte;40% organ loss).
     
14. d—Loss of as little as 5% to 10% of body weight causes significant improvement in comorbidities, such as diabetes, hypertension, and sleep apnea. The remaining statements are true.