Study Guide

ABS Certifying Exam: Operative Procedures Reference

Last updated: March 2026

A comprehensive reference of every operative procedure you may be tested on during the ABS Certifying Exam (general surgery oral boards). Each procedure includes key examiner focus points and links to a detailed page with a concise procedural description and common curveballs with how to address them. Click any procedure name to view its full page.

Showing 92 of 92 procedures

Alimentary Tract31

Esophagus

Nissen Fundoplication
Key examiner focus points
  • Preop workup: EGD, esophageal manometry, 24-hr pH study
  • Must rule out achalasia or severe dysmotility before 360° wrap
  • Divide short gastric vessels; close crura posteriorly
  • Wrap should be short (2–3 cm), floppy, and over a 56–60 Fr bougie
  • Recognize postop dysphagia vs wrap herniation vs slipped wrap
Heller Myotomy
Key examiner focus points
  • Indication: achalasia confirmed by manometry (aperistalsis + failed LES relaxation)
  • Myotomy extends 6 cm on esophagus and 2–3 cm onto gastric cardia
  • Always add a partial fundoplication (Dor anterior preferred) to prevent reflux
  • Intraop mucosal perforation must be recognized and repaired immediately
  • Know type I vs II vs III achalasia and how it affects treatment choice
Esophagectomy
Key examiner focus points
  • Approaches: Ivor Lewis (right thoracotomy + laparotomy), McKeown (three-field), transhiatal
  • Neoadjuvant chemoradiation (CROSS protocol) for locally advanced disease (T2+ or N+)
  • Gastric conduit is the preferred reconstruction; placed in the posterior mediastinum
  • Anastomotic leak is the most feared complication — know the management algorithm
  • Ensure adequate lymph node harvest (≥15 nodes recommended)
Zenker's Diverticulum Repair
Key examiner focus points
  • Pulsion diverticulum at Killian's triangle (between cricopharyngeus and inferior constrictor)
  • Cricopharyngeal myotomy is the essential component of the repair
  • Diverticulectomy or diverticulopexy is secondary to the myotomy
  • Endoscopic stapled diverticulotomy is a minimally invasive alternative
  • Recurrent laryngeal nerve at risk during open transcervical approach
Esophageal Perforation Repair
Key examiner focus points
  • Most common cause is iatrogenic (endoscopy); Boerhaave's is spontaneous (left distal esophagus)
  • Time to diagnosis is critical — < 24 hrs favors primary repair
  • Gastrografin swallow followed by thin barium if negative
  • Primary repair in two layers reinforced with tissue flap (intercostal muscle, pleura, omentum)
  • Delayed or septic presentation: drainage, exclusion/diversion, or T-tube drainage
Paraesophageal Hernia Repair
Key examiner focus points
  • Type II (true paraesophageal), III (mixed), IV (with additional organ herniation)
  • Surgical repair indicated for all symptomatic paraesophageal hernias
  • Complete hernia sac excision, tension-free crural closure, and fundoplication
  • Collis gastroplasty if short esophagus prevents tension-free intra-abdominal esophageal length
  • Emergent repair for incarceration, obstruction, or gastric volvulus

Stomach

Gastrectomy (Partial & Total)
Key examiner focus points
  • Distal: adequate 4–6 cm proximal margin; Billroth I (gastroduodenostomy) vs Billroth II (gastrojejunostomy) vs Roux-en-Y reconstruction
  • Total: en bloc resection with D2 lymphadenectomy for cancer; Roux-en-Y esophagojejunostomy reconstruction
  • Minimum 15 lymph nodes for adequate staging
  • Understand postgastrectomy syndromes: dumping, afferent loop, alkaline reflux gastritis, marginal ulcer
  • Neoadjuvant chemo (FLOT regimen) for locally advanced gastric cancer
Vagotomy (Truncal & Highly Selective)
Key examiner focus points
  • Truncal vagotomy requires a drainage procedure (pyloroplasty or gastrojejunostomy)
  • Highly selective (parietal cell) vagotomy preserves antral innervation — no drainage needed
  • Truncal vagotomy divides both anterior and posterior vagal trunks at the GEJ
  • Postvagotomy diarrhea occurs in ~10% of truncal vagotomy patients
  • Rarely performed today given effective PPI therapy; know for boards
Pyloroplasty
Key examiner focus points
  • Heineke-Mikulicz: longitudinal incision across pylorus, closed transversely
  • Finney: side-to-side gastroduodenostomy
  • Required as drainage procedure after truncal vagotomy
  • Also used for gastric outlet obstruction from chronic scarring
  • Know the landmarks — pyloric vein of Mayo marks the pylorus
Roux-en-Y Gastric Bypass
Key examiner focus points
  • Indications: BMI ≥ 40 or BMI ≥ 35 with obesity-related comorbidities
  • Small gastric pouch (15–30 mL), 75–150 cm Roux limb, 50 cm biliopancreatic limb
  • Internal hernia sites: Petersen's space and jejunojejunostomy mesenteric defect
  • Marginal ulcer at the gastrojejunostomy is most common late complication
  • Must supplement B12, iron, calcium, fat-soluble vitamins lifelong
Sleeve Gastrectomy
Key examiner focus points
  • Restrictive procedure: 75–80% of stomach resected along greater curvature
  • Staple line begins 4–6 cm from pylorus, calibrated with 36–40 Fr bougie
  • Staple line leak at the GEJ angle of His is most common leak location
  • Worsens or causes de novo GERD in some patients
  • Now the most commonly performed bariatric procedure in the US
PEG Tube Placement
Key examiner focus points
  • Indications: enteral access for patients unable to take oral nutrition > 4 weeks
  • Pull technique most common; transillumination and finger indentation confirm position
  • Contraindications: ascites, coagulopathy, interposed colon (Chilaiditi), peritoneal dialysis
  • Buried bumper syndrome: internal bumper migrates into gastric wall
  • If PEG cannot be placed, consider surgical or laparoscopic gastrostomy
Graham Patch Repair (Perforated Ulcer)
Key examiner focus points
  • Omental (Graham) patch over a perforated duodenal ulcer
  • Perform thorough peritoneal lavage (all four quadrants)
  • Biopsy the ulcer edges for gastric perforations to rule out malignancy
  • Postop: PPI therapy, H. pylori testing and eradication
  • Definitive acid-reducing surgery rarely needed in the PPI era

Small Bowel

Small Bowel Resection & Anastomosis
Key examiner focus points
  • Indications: ischemia, tumor, Crohn's stricture, trauma, incarcerated hernia with necrosis
  • Assess viability: color, peristalsis, mesenteric pulsation, Doppler, ICG fluorescence
  • Stapled vs hand-sewn anastomosis — both acceptable on boards
  • Preserve as much bowel length as possible (short bowel syndrome if < 200 cm)
  • Side-to-side (functional end-to-end) stapled anastomosis is most common
Strictureplasty
Key examiner focus points
  • Bowel-preserving technique for fibrotic Crohn's strictures
  • Heineke-Mikulicz for short strictures (< 10 cm), Finney for intermediate (10–20 cm)
  • Contraindicated if stricture harbors malignancy, perforation, or phlegmon
  • Can perform multiple strictureplasties in the same operation
  • Do NOT perform on colonic strictures in Crohn's (higher malignancy risk)
Meckel's Diverticulectomy
Key examiner focus points
  • Rule of 2s: 2% of population, 2 feet from ileocecal valve, 2 inches long, 2 types of ectopic tissue (gastric/pancreatic)
  • Technetium-99m pertechnetate scan detects ectopic gastric mucosa
  • Diverticulectomy vs segmental ileal resection depends on base width
  • If narrow base: stapled diverticulectomy perpendicular to bowel axis
  • If wide base or palpable ectopic tissue at base: segmental ileal resection
Lysis of Adhesions for SBO
Key examiner focus points
  • Most common cause of SBO in developed countries is adhesions from prior surgery
  • Initial management: NPO, NG decompression, IV fluids, serial abdominal exams
  • Operative indications: peritonitis, strangulation, closed-loop obstruction, failure of conservative management (48–72 hrs)
  • Water-soluble contrast (Gastrografin) challenge: if contrast reaches colon by 24 hrs, obstruction likely to resolve
  • Run the bowel from ligament of Treitz to ileocecal valve to identify all transition points

Colon & Rectum

Right Hemicolectomy
Key examiner focus points
  • Indications: cecal/ascending/hepatic flexure cancer, complicated appendicitis, cecal volvulus
  • Ligate ileocolic, right colic, and right branch of middle colic vessels
  • Ileocolic anastomosis: stapled side-to-side (functional end-to-end) preferred
  • Medial-to-lateral approach for laparoscopic technique
  • Minimum 12 lymph nodes for adequate cancer staging
Left Hemicolectomy
Key examiner focus points
  • Indications: splenic flexure or descending colon cancer
  • Ligate the inferior mesenteric artery (IMA) at its origin for cancer
  • Mobilize splenic flexure for a tension-free colorectal anastomosis
  • Left ureter and gonadal vessels at risk during retroperitoneal mobilization
  • Colorectal or colocolic anastomosis depending on level of resection
Sigmoid Colectomy
Key examiner focus points
  • Most common indications: diverticular disease (complicated), sigmoid cancer, volvulus
  • For cancer: high ligation of IMA for lymph node harvest
  • For diverticulitis: ligate IMA distal to left colic takeoff (preserves left colic artery)
  • Distal margin must be on the upper rectum (below the rectosigmoid junction)
  • Anastomosis to the upper rectum should be tension-free with adequate blood supply
Total Abdominal Colectomy
Key examiner focus points
  • Indications: synchronous cancers, FAP, fulminant C. difficile colitis, toxic megacolon in UC, massive lower GI bleed with no identified source
  • Resect cecum to rectosigmoid junction; ileorectal anastomosis if rectum is spared
  • End ileostomy if anastomosis is unsafe (sepsis, unprepared bowel, hemodynamic instability)
  • For FAP: total proctocolectomy with IPAA is preferred if rectum also has polyps
  • 3–5 liquid bowel movements per day expected after ileorectal anastomosis
Low Anterior Resection (LAR)
Key examiner focus points
  • Indicated for upper and mid rectal cancers (above the levator ani)
  • Total mesorectal excision (TME) is mandatory for oncologic quality
  • Neoadjuvant chemoradiation for T3/T4 or node-positive rectal cancer
  • Diverting loop ileostomy for low anastomoses (typically < 7 cm from anal verge)
  • Low anterior resection syndrome (LARS): urgency, frequency, incontinence
Abdominoperineal Resection (APR)
Key examiner focus points
  • Indicated for low rectal cancers involving the sphincter complex
  • Permanent end colostomy — the rectum and anus are completely removed
  • Perineal wound complications are common (dehiscence, abscess)
  • Risk to autonomic nerves (hypogastric plexus) causing urinary/sexual dysfunction
  • Cylindrical (extralevator) APR reduces positive CRM rates for low tumors
Hartmann's Procedure
Key examiner focus points
  • Sigmoid resection with end colostomy and rectal stump closure (Hartmann's pouch)
  • Indicated for complicated diverticulitis (Hinchey III/IV), obstructing sigmoid cancer in unstable patient
  • Avoids anastomosis in contaminated or unstable setting
  • Hartmann's reversal is a major operation with significant morbidity — many are never reversed
  • Alternative: resection with primary anastomosis and diverting loop ileostomy
Colostomy & Ileostomy Creation/Reversal
Key examiner focus points
  • End stoma: bowel brought out as a single lumen (matured, everted 2–3 cm for ileostomy, flush for colostomy)
  • Loop stoma: both limbs brought through one opening — used for temporary diversion
  • Preoperative stoma marking by enterostomal therapy nurse is essential
  • High-output ileostomy (> 1.5 L/day): dehydration, electrolyte abnormalities (hyponatremia, hypokalemia, metabolic acidosis)
  • Parastomal hernia is the most common long-term complication
Hemorrhoidectomy
Key examiner focus points
  • Excisional hemorrhoidectomy for grade III/IV internal or symptomatic external hemorrhoids
  • Must preserve adequate mucosal bridges between excision sites to prevent stenosis
  • Stapled hemorrhoidopexy (PPH) is an alternative for circumferential prolapse
  • Postoperative pain management is critical — multimodal approach
  • Urinary retention is the most common immediate complication
Fistulotomy & Fistula-in-Ano Management
Key examiner focus points
  • Goodsall's rule: anterior fistulas track radially; posterior fistulas curve to posterior midline
  • Simple intersphincteric or low transsphincteric: fistulotomy (lay open)
  • Complex/high transsphincteric: seton, LIFT, or advancement flap to preserve sphincter
  • Rule out Crohn's disease, malignancy, tuberculosis, and HIV in atypical or recurrent fistulas
  • MRI pelvis is the gold standard for mapping complex fistula anatomy
Lateral Internal Sphincterotomy
Key examiner focus points
  • Indicated for chronic anal fissure refractory to medical management
  • Divide the internal sphincter to the level of the dentate line in the lateral position
  • Medical therapy first: fiber, sitz baths, topical nitroglycerin or diltiazem, botulinum toxin
  • Risk of incontinence (particularly in women and elderly) — discuss preoperatively
  • Most fissures are posterior midline; lateral or multiple fissures suggest Crohn's, HIV, or malignancy
Rectal Prolapse Repair
Key examiner focus points
  • Perineal approach (Altemeier, Delorme) for elderly/high-risk patients
  • Abdominal approach (rectopexy +/- sigmoid resection) for fit patients
  • Altemeier: perineal proctosigmoidectomy — full-thickness resection from below
  • Distinguish full-thickness prolapse from mucosal prolapse (concentric vs radial folds)
  • Evaluate for concurrent fecal incontinence and constipation
Transanal Excision
Key examiner focus points
  • Indicated for benign polyps and selected T1 rectal cancers with favorable features
  • Favorable T1 features: well-differentiated, no lymphovascular invasion, < 3 cm, < 30% circumference, sm1 invasion
  • Full-thickness excision with 1 cm margins
  • TAMIS (transanal minimally invasive surgery) or TEO platforms for mid-rectal lesions
  • If pathology shows unfavorable T1 or T2: recommend radical resection (TME)

Appendix

Appendectomy
Key examiner focus points
  • Laparoscopic approach is standard; open via McBurney's (RLQ oblique) incision also acceptable
  • Mesoappendix divided with its blood supply (appendiceal artery); base stapled or ligated
  • Perforated with abscess: consider interval appendectomy after percutaneous drainage + antibiotics
  • If appendix is normal at surgery, explore for other pathology (Meckel's, Crohn's, ovarian)
  • Send all specimens for pathology — incidental carcinoid or adenocarcinoma may be found

Hepatobiliary & Pancreas13

Liver

Hepatic Lobectomy / Segmentectomy
Key examiner focus points
  • Couinaud segmental anatomy: 8 segments based on portal and hepatic vein anatomy
  • Future liver remnant (FLR) must be adequate: ≥ 20% (normal liver), ≥ 30% (chemo-treated), ≥ 40% (cirrhotic)
  • Portal vein embolization (PVE) to hypertrophy the FLR if inadequate
  • Pringle maneuver (hepatoduodenal ligament clamping) controls inflow hemorrhage
  • Most common indication: colorectal liver metastases, HCC, cholangiocarcinoma
Liver Abscess Drainage
Key examiner focus points
  • Pyogenic abscess: polymicrobial; often from biliary source or portal pyemia
  • Amebic abscess: Entamoeba histolytica; right lobe predominant; serologic testing
  • Percutaneous drainage is first-line for pyogenic abscess > 5 cm
  • Amebic abscess: metronidazole is usually curative; drain only if large, refractory, or ruptured
  • Always search for the underlying source (biliary obstruction, appendicitis, diverticulitis)
Hepatic Artery Embolization / Chemoembolization
Key examiner focus points
  • TACE (transarterial chemoembolization) for intermediate-stage HCC (BCLC stage B)
  • Exploits dual blood supply: tumors fed primarily by hepatic artery; normal liver fed by portal vein
  • Contraindicated in portal vein thrombosis (liver relies entirely on hepatic artery)
  • Post-embolization syndrome: fever, pain, nausea — expected and self-limited
  • Also used for bleeding hepatic tumors or traumatic hemorrhage (TAE)

Gallbladder & Bile Ducts

Cholecystectomy (Laparoscopic & Open)
Key examiner focus points
  • Critical view of safety (CVS): hepatocystic triangle cleared, two structures (cystic duct + cystic artery) visible, lower third of gallbladder separated from liver
  • Bail-out options if CVS cannot be achieved: subtotal cholecystectomy, fundus-first, open conversion
  • Strasberg classification for bile duct injuries
  • Intraoperative cholangiography or ultrasound to delineate unclear anatomy
  • Acute cholecystitis: early cholecystectomy (within 72 hrs) is safe and cost-effective
Common Bile Duct Exploration (CBDE)
Key examiner focus points
  • Indicated when CBD stones are found on intraop cholangiogram during cholecystectomy
  • Transcystic approach (through cystic duct) for small, few, distal stones
  • Choledochotomy (direct CBD incision) for large or multiple stones
  • Close choledochotomy over a T-tube or primarily if CBD is > 8 mm
  • Alternative: postoperative ERCP for stone extraction
Choledochojejunostomy (Roux-en-Y)
Key examiner focus points
  • Definitive repair for major bile duct injuries (Strasberg D and E types)
  • Also used for distal CBD obstruction (chronic pancreatitis, unresectable periampullary cancer)
  • Roux limb should be 60–70 cm to prevent bile reflux
  • Mucosa-to-mucosa anastomosis is critical for long-term patency
  • Timing of repair after injury: immediate if recognized, otherwise delay 6–12 weeks for inflammation to resolve
ERCP Management Concepts
Key examiner focus points
  • Therapeutic: sphincterotomy, stone extraction, stent placement for strictures
  • Indicated for choledocholithiasis, cholangitis, biliary stricture evaluation
  • Post-ERCP pancreatitis is the most common complication (5–10%)
  • Cholangitis management: antibiotics + urgent biliary decompression (ERCP preferred)
  • Rectal indomethacin and pancreatic duct stent reduce post-ERCP pancreatitis risk
Subtotal Cholecystectomy
Key examiner focus points
  • Bail-out procedure when CVS cannot be achieved safely
  • Two types: reconstituting (leaves posterior wall on liver, closes remnant) and fenestrating (leaves remnant open with drain)
  • Prevents bile duct injury in severely inflamed/fibrotic gallbladders
  • Accept a higher rate of recurrent biliary symptoms vs risk of major bile duct injury
  • Remove as many stones as possible and cauterize residual mucosa

Pancreas

Pancreaticoduodenectomy (Whipple)
Key examiner focus points
  • Indicated for periampullary tumors: pancreatic head, ampullary, distal CBD, duodenal cancer
  • Resects: pancreatic head, duodenum, distal CBD, gallbladder, distal stomach (classic) or pylorus-preserving
  • Three anastomoses: pancreaticojejunostomy (or pancreaticogastrostomy), hepaticojejunostomy, gastrojejunostomy (or duodenojejunostomy)
  • Pancreatic fistula is the most common serious complication (ISGPF classification)
  • Vascular involvement: SMV/portal vein resection and reconstruction is acceptable; SMA encasement is unresectable
Distal Pancreatectomy
Key examiner focus points
  • Resects body and/or tail of pancreas; usually includes splenectomy for cancer
  • Spleen-preserving approach for benign/borderline lesions (Warshaw or Kimura technique)
  • Pancreatic fistula rate is high (20–30%) — staple line management is key
  • Indications: pancreatic body/tail cancer, symptomatic cystic neoplasms (MCN, IPMN), chronic pancreatitis, trauma
  • Celiac axis involvement for body tumors may require modified Appleby procedure
Pancreatic Necrosectomy
Key examiner focus points
  • Indicated for infected pancreatic necrosis (walled-off necrosis with gas on CT or positive FNA)
  • Delay intervention as long as possible — optimally > 4 weeks to allow demarcation
  • Step-up approach: percutaneous drainage → endoscopic transgastric drainage/necrosectomy → surgical necrosectomy
  • Minimally invasive techniques (VARD — video-assisted retroperitoneal debridement) preferred over open
  • Open necrosectomy reserved for failure of minimally invasive approaches
Pseudocyst Drainage (Cystogastrostomy)
Key examiner focus points
  • Internal drainage indicated for symptomatic pseudocysts > 6 cm persisting > 6 weeks
  • Cystogastrostomy: drainage into posterior stomach wall (most common)
  • Cystojejunostomy (Roux-en-Y): for pseudocysts not adherent to the stomach
  • Must distinguish pseudocyst from cystic neoplasm (MCN, IPMN) — send fluid for CEA and amylase
  • Endoscopic (EUS-guided) cystogastrostomy is now first-line approach
Lateral Pancreaticojejunostomy (Puestow)
Key examiner focus points
  • Indicated for chronic pancreatitis with dilated main pancreatic duct (> 7 mm)
  • Longitudinal opening of the pancreatic duct with side-to-side Roux-en-Y jejunal anastomosis
  • Provides pain relief in 70–80% of patients with dilated duct disease
  • Does not address pancreatic head mass — consider Frey or Beger procedure if head is dominant
  • Preserves pancreatic parenchyma and endocrine/exocrine function

Breast6

Lumpectomy / Partial Mastectomy
Key examiner focus points
  • Breast-conserving surgery: excision of tumor with negative margins (no tumor on ink)
  • Must be followed by whole-breast radiation therapy
  • Equivalent survival to mastectomy for stage I–II breast cancer (NSABP B-06)
  • Contraindications: multicentric disease, prior chest wall radiation, positive margins after re-excision
  • Specimen orientation and margin assessment are critical
Total / Simple Mastectomy
Key examiner focus points
  • Removes all breast tissue, nipple-areolar complex, and skin envelope
  • No axillary lymph node dissection (ALND) unless nodes are clinically positive
  • Sentinel lymph node biopsy (SLNB) performed concurrently for staging
  • Nipple-sparing mastectomy appropriate for prophylactic or early cancer with adequate nipple margin
  • Skin-sparing mastectomy preserves skin envelope for immediate reconstruction
Modified Radical Mastectomy
Key examiner focus points
  • Total mastectomy PLUS axillary lymph node dissection (levels I and II)
  • Preserves the pectoralis major muscle (unlike Halsted radical mastectomy)
  • Indicated for clinically node-positive breast cancer confirmed by FNA/core biopsy
  • Long thoracic nerve (serratus anterior) and thoracodorsal nerve (latissimus dorsi) must be preserved
  • Intercostobrachial nerve sacrifice causes medial arm numbness — warn patient preop
Sentinel Lymph Node Biopsy (Breast)
Key examiner focus points
  • Dual tracer technique: technetium-99m sulfur colloid + isosulfan blue (or ICG)
  • Identifies the first draining lymph node(s) from the tumor
  • If SLN is negative: no further axillary surgery needed
  • If SLN has macrometastasis (> 2 mm): ACOSOG Z0011 allows omission of ALND in selected patients
  • Z0011 criteria: T1-T2, 1–2 positive SLNs, planned BCS + whole breast radiation, no extranodal extension
Axillary Lymph Node Dissection (ALND)
Key examiner focus points
  • Levels I and II nodes removed (lateral and posterior to pectoralis minor)
  • Level III (infraclavicular) dissection only if grossly involved
  • Minimum 10 lymph nodes for adequate staging
  • Preserve long thoracic, thoracodorsal, and medial pectoral nerves
  • Lymphedema risk 15–25%; higher with concurrent radiation
Excisional Biopsy / Needle-Localized Excision
Key examiner focus points
  • Wire-localized or seed-localized excision for nonpalpable lesions
  • Obtain specimen radiograph to confirm lesion is within the specimen
  • Orientation with sutures/clips for margin assessment
  • If core biopsy shows ADH or papilloma at clip site, excision is diagnostic, not therapeutic
  • Increasingly replaced by percutaneous core needle biopsy for diagnosis

Endocrine3

Thyroidectomy (Total & Lobectomy)
Key examiner focus points
  • RLN identification is mandatory — runs in the tracheoesophageal groove
  • Parathyroid glands must be identified and preserved (autotransplant if devascularized)
  • Total thyroidectomy for: Graves' disease, bilateral disease, cancer > 4 cm, or with extrathyroidal extension
  • Lobectomy acceptable for: thyroid nodule < 4 cm, low-risk well-differentiated cancer 1–4 cm
  • Postop hypocalcemia is the most common complication of total thyroidectomy
Parathyroidectomy
Key examiner focus points
  • Focused (minimally invasive) vs bilateral neck exploration
  • Preoperative localization: sestamibi scan + neck ultrasound (concordant = focused approach)
  • Intraoperative PTH monitoring (Miami criteria: > 50% drop from highest pre-excision level at 10 min)
  • Four-gland hyperplasia (MEN1, secondary/tertiary HPT): subtotal parathyroidectomy (3.5 glands) or total with autotransplant
  • Superior parathyroids derive from 4th branchial pouch; inferior from 3rd (more variable location)
Adrenalectomy
Key examiner focus points
  • Laparoscopic approach is standard for most adrenal pathology
  • Pheochromocytoma: alpha-blockade (phenoxybenzamine) for 10–14 days BEFORE surgery
  • Cortisol-producing adenoma (Cushing's): postop steroid replacement — contralateral gland is suppressed
  • Aldosteronoma (Conn's): confirm lateralization with adrenal vein sampling before unilateral adrenalectomy
  • Open approach for large tumors (> 6 cm) or suspected adrenocortical carcinoma (avoid morcellation)

Trauma & Critical Care11

Exploratory Laparotomy
Key examiner focus points
  • Midline incision from xiphoid to pubis for maximum exposure
  • Systematic exploration: four-quadrant packing, then eviscerate and inspect all viscera
  • Indications: penetrating abdominal trauma with peritonitis, hemodynamic instability, GSW traversing peritoneal cavity, blunt trauma with free fluid and instability
  • Control hemorrhage first, then contamination
  • If unstable: damage control — pack, stop bleeding, close temporarily
Damage Control Surgery
Key examiner focus points
  • Three-phase approach: abbreviated surgery → ICU resuscitation → planned re-exploration
  • Triggered by the lethal triad: hypothermia (< 35°C), acidosis (pH < 7.2), coagulopathy
  • Surgical goals: stop hemorrhage (packing, ligation, shunting) and control contamination (staple, drain)
  • Temporary abdominal closure (negative pressure wound therapy)
  • Definitive repair at planned re-exploration in 24–48 hours
Splenectomy
Key examiner focus points
  • Most common indication in trauma: high-grade splenic injury with hemodynamic instability
  • Elective indications: ITP refractory to medical therapy, hereditary spherocytosis, splenic abscess
  • Vaccinate against encapsulated organisms: pneumococcus, meningococcus, H. influenzae (ideally 2 weeks pre-op or within 2 weeks post-op)
  • Overwhelming post-splenectomy infection (OPSI) is rare but often fatal
  • Nonoperative management with observation + angioembolization is standard for stable splenic injuries
Thoracotomy (ED & OR)
Key examiner focus points
  • ED thoracotomy: left anterolateral in the 5th intercostal space
  • Indications for ED thoracotomy: penetrating trauma with witnessed loss of vitals or PEA
  • Goals: release tamponade, cross-clamp descending aorta, control cardiac/pulmonary hemorrhage
  • Blunt trauma: ED thoracotomy has very poor survival — reserved for witnessed arrest only
  • OR thoracotomy: posterolateral for lung, mediastinal, or esophageal injuries
Chest Tube / Tube Thoracostomy
Key examiner focus points
  • Insertion site: 5th intercostal space, anterior to mid-axillary line (safe triangle)
  • Indications: pneumothorax, hemothorax, empyema, pleural effusion
  • Massive hemothorax (> 1500 mL initial output or > 200 mL/hr for 2–4 hrs): OR thoracotomy
  • Use blunt dissection and finger sweep before inserting — avoid lung injury
  • 28–36 Fr tube for hemothorax; 20–28 Fr for pneumothorax
Pericardial Window
Key examiner focus points
  • Diagnostic and therapeutic for pericardial tamponade or effusion
  • Subxiphoid approach: incision below xiphoid, access pericardium extraperitoneally
  • Transdiaphragmatic approach during laparotomy: incise pericardium through central tendon
  • If blood is found and the patient is stable, proceed to median sternotomy for cardiac exploration
  • FAST (focused assessment with sonography for trauma) has largely replaced diagnostic pericardial window
Tracheostomy
Key examiner focus points
  • Typically performed between tracheal rings 2–3 or 3–4
  • Indicated for prolonged mechanical ventilation, upper airway obstruction, failed intubation
  • Open surgical vs percutaneous dilational technique (Ciaglia)
  • Avoid dividing the thyroid isthmus if possible; retract it superiorly
  • Early complications: hemorrhage, pneumothorax, false passage, tube dislodgement
Cricothyroidotomy
Key examiner focus points
  • Emergency surgical airway when intubation fails (can't intubate, can't oxygenate)
  • Incise through the cricothyroid membrane between thyroid and cricoid cartilage
  • Vertical skin incision (or horizontal) → horizontal stab through cricothyroid membrane
  • Use a 6.0 cuffed tracheostomy tube or endotracheal tube
  • Convert to formal tracheostomy within 24–72 hours to avoid subglottic stenosis
Four-Compartment Fasciotomy
Key examiner focus points
  • Indicated for compartment syndrome: pressure > 30 mmHg or within 30 mmHg of diastolic (delta pressure)
  • Lower leg has 4 compartments: anterior, lateral, superficial posterior, deep posterior
  • Two-incision technique: anterolateral (releases anterior + lateral) and posteromedial (releases both posterior)
  • Clinical signs: pain out of proportion, pain with passive stretch, tense compartments
  • Delayed fasciotomy > 6 hours leads to irreversible muscle necrosis and potential amputation
Liver Repair & Packing (Trauma)
Key examiner focus points
  • Most liver injuries (grade I–III) are managed nonoperatively if hemodynamically stable
  • Operative: Pringle maneuver to differentiate hepatic arterial/portal from hepatic vein bleeding
  • Perihepatic packing is the most effective hemorrhage control technique for severe injury
  • Deep suturing (hepatorrhaphy) for parenchymal lacerations
  • Grade V with juxtahepatic venous injury: packing, consider atriocaval shunt (high mortality)
Diaphragm Repair (Trauma)
Key examiner focus points
  • Left-sided diaphragm injuries are 3x more common (right side protected by liver)
  • Blunt mechanism causes large radial tears; penetrating causes small holes
  • Acute repair: primary closure with non-absorbable interrupted sutures (figure-of-eight or horizontal mattress)
  • Missed injury leads to chronic diaphragmatic hernia — may present years later with obstruction/strangulation
  • Laparoscopy during penetrating left thoracoabdominal trauma has high sensitivity for diagnosing occult injuries

Vascular6

Carotid Endarterectomy (CEA)
Key examiner focus points
  • Indicated for symptomatic stenosis ≥ 50% (NASCET) or asymptomatic stenosis ≥ 60–80% in selected patients
  • Symptom within 2 weeks: urgent CEA provides maximum benefit (CREST-2 criteria)
  • Patch angioplasty closure reduces restenosis vs primary closure
  • Shunt use varies by surgeon — mandatory if stump pressure < 40 mmHg or EEG changes
  • Postop stroke, cranial nerve injury (vagus, hypoglossal, marginal mandibular), and neck hematoma are key complications
Open AAA Repair
Key examiner focus points
  • Indicated for AAA ≥ 5.5 cm, rapid growth (> 0.5 cm/6 months), or symptomatic
  • Ruptured AAA: emergent repair — permissive hypotension until aortic control
  • Tube graft (infrarenal) for aortic disease; bifurcated graft if iliac disease present
  • Reimplant IMA if back-bleeding is poor or sigmoid appears ischemic
  • Postop complications: MI (most common cause of death), renal failure, colonic ischemia, spinal cord ischemia
Femoral-Popliteal Bypass
Key examiner focus points
  • Indicated for lifestyle-limiting claudication or critical limb ischemia (rest pain, tissue loss)
  • Great saphenous vein (reversed or in situ) is the preferred conduit — superior patency vs prosthetic
  • Above-knee popliteal: PTFE is acceptable if no vein; below-knee: autologous vein is strongly preferred
  • Preop assessment: ABI, duplex ultrasound, CTA or angiography for anatomic planning
  • Vein mapping preoperatively to assess caliber and suitability
Embolectomy (Fogarty Catheter)
Key examiner focus points
  • Indicated for acute limb ischemia from arterial embolus (atrial fibrillation is #1 cause)
  • Fogarty balloon catheter: insert beyond the clot, inflate, withdraw to extract thrombus
  • Perform through arteriotomy (typically at common femoral artery — groin access)
  • Completion angiography to confirm complete clot removal
  • 4-compartment fasciotomy if ischemia time > 4–6 hours (reperfusion injury risk)
Arteriovenous Fistula Creation
Key examiner focus points
  • Preferred vascular access for hemodialysis (fistula > graft > catheter)
  • Radiocephalic (wrist) → brachiocephalic (elbow) → brachiobasilic (transposition) hierarchy
  • Fistula needs 6–8 weeks to mature before use (Rule of 6s: > 6 mm diameter, < 6 mm depth, > 600 mL/min flow)
  • Steal syndrome: hand ischemia from arterial flow diversion — can require ligation or DRIL procedure
  • Preserve arm veins early in CKD patients — avoid venipuncture and PICC lines in the non-dominant arm
Mesenteric Bypass / Embolectomy
Key examiner focus points
  • Acute mesenteric ischemia: embolism (SMA most common — lodges 3–8 cm from origin), thrombosis, or NOMI
  • CTA is the diagnostic study of choice — filling defect in the SMA
  • Surgical embolectomy via SMA exposure at the root of the mesentery
  • Assess bowel viability after revascularization — second-look laparotomy in 24–48 hrs
  • Chronic mesenteric ischemia: antegrade or retrograde bypass from aorta or iliac artery

Thoracic4

Pulmonary Lobectomy
Key examiner focus points
  • Standard oncologic resection for early-stage non-small cell lung cancer (NSCLC)
  • Requires adequate pulmonary reserve: predicted postop FEV1 > 40% and DLCO > 40%
  • VATS (video-assisted) or robotic approach preferred over open thoracotomy when feasible
  • Systematic mediastinal lymph node dissection or sampling for staging
  • Bronchial stump tested underwater for air leak
Wedge Resection (Lung)
Key examiner focus points
  • Non-anatomic parenchymal resection — removes the lesion with a margin of normal lung
  • Indicated for peripheral nodules, metastasectomy, or patients who cannot tolerate lobectomy
  • For early NSCLC (< 2 cm): sublobar resection (segmentectomy preferred over wedge) is acceptable per JCOG0802/CALGB 140503
  • Adequate margin: ≥ 2 cm or ≥ size of the lesion
  • VATS approach is standard
Decortication / Empyema Drainage
Key examiner focus points
  • Indicated for organizing empyema (stage III) with trapped lung
  • Removes the fibrous peel (cortex) from the visceral pleura to allow lung re-expansion
  • Stage I (exudative): tube thoracostomy and antibiotics
  • Stage II (fibrinopurulent): VATS with lysis of adhesions and debridement
  • Stage III (organized): formal decortication via VATS or thoracotomy
Chest Wall Resection
Key examiner focus points
  • Indications: primary chest wall tumors (chondrosarcoma most common), locally invasive lung/breast cancer
  • Must achieve wide margins (≥ 2 cm) for sarcomas
  • Reconstruction required for defects > 5 cm or > 2 ribs: prosthetic mesh (Marlex/Gore-Tex) + soft tissue coverage
  • Posterior defects covered by the scapula may not need rigid reconstruction
  • Soft tissue coverage: latissimus dorsi, pectoralis major, serratus anterior, or omental flap

Skin & Soft Tissue5

Wide Local Excision (Melanoma)
Key examiner focus points
  • Margins based on Breslow thickness: in situ (0.5–1 cm), ≤ 1 mm (1 cm), 1.01–2 mm (1–2 cm), > 2 mm (2 cm)
  • Excision down to but not including the deep fascia
  • Concurrent sentinel lymph node biopsy for tumors ≥ 0.8 mm Breslow depth
  • Subungual melanoma may require digit amputation
  • Margins are measured clinically from the visible edge of the melanoma or biopsy scar
Sarcoma Wide Excision
Key examiner focus points
  • Wide excision with ≥ 1 cm margin or an intact fascial plane
  • Biopsy must be performed correctly: longitudinal incision in line with definitive resection
  • Neoadjuvant radiation for large (> 5 cm), deep, high-grade extremity sarcomas
  • MRI is the imaging modality of choice for local staging
  • Retroperitoneal sarcomas: en bloc resection with involved adjacent organs
Skin Grafting (STSG & FTSG)
Key examiner focus points
  • STSG (split-thickness): epidermis + partial dermis; harvested with dermatome; donor site heals by re-epithelialization
  • FTSG (full-thickness): epidermis + entire dermis; donor site closed primarily; better cosmetic result
  • Graft survival requires: adequate recipient bed vascularity, immobilization, absence of infection/hematoma
  • STSGs contract more than FTSGs; FTSGs are preferred for face, hands, and over joints
  • Graft take phases: plasmatic imbibition (24–48 hrs) → inosculation → neovascularization
Necrotizing Fasciitis Debridement
Key examiner focus points
  • Surgical emergency — early and aggressive debridement is the single most important intervention
  • Debride all necrotic fascia and tissue until healthy, bleeding tissue is reached
  • Hallmarks: pain out of proportion, crepitus, dishwater-gray drainage, rapidly spreading erythema
  • Type I (polymicrobial): diabetics, immunocompromised; Type II (group A Strep or Clostridium): healthy patients
  • Planned re-exploration every 24–48 hours until no further necrosis is found
Inguinal Lymph Node Dissection
Key examiner focus points
  • Indications: melanoma with positive inguinal SLN (if CLND indicated), squamous cell carcinoma metastases, vulvar/penile cancer
  • Boundaries: inguinal ligament (superior), adductor longus (medial), sartorius (lateral)
  • Femoral vessels are the deep boundary — preserve the femoral nerve
  • Saphenous vein preservation may reduce lymphedema
  • High wound complication rate: seroma, lymphocele, wound dehiscence, lymphedema (30–50%)

Hernia4

Inguinal Hernia Repair (Lichtenstein / Laparoscopic)
Key examiner focus points
  • Lichtenstein (open tension-free mesh): most common open technique; mesh placed over the floor of the inguinal canal
  • TEP (totally extraperitoneal): laparoscopic preperitoneal approach; no peritoneal entry
  • TAPP (transabdominal preperitoneal): laparoscopic transperitoneal approach; peritoneum closed over mesh
  • Indirect: hernia sac through internal ring lateral to epigastric vessels
  • Direct: hernia through Hesselbach's triangle (floor of inguinal canal) medial to epigastric vessels
Femoral Hernia Repair
Key examiner focus points
  • Hernia through the femoral canal (below the inguinal ligament, medial to the femoral vein)
  • Higher incarceration/strangulation rate than inguinal hernias — always repair when diagnosed
  • More common in women (but inguinal hernias are still more common overall in women)
  • Preperitoneal approach (laparoscopic or open) is ideal for mesh placement
  • Cooper's ligament (McVay) repair: open technique suturing to Cooper's ligament
Ventral / Incisional Hernia Repair
Key examiner focus points
  • Mesh reinforcement reduces recurrence from ~50% (suture) to ~10–15%
  • Sublay (retrorectus/Rives-Stoppa) position has the lowest recurrence rate
  • Laparoscopic IPOM (intraperitoneal onlay mesh) requires barrier-coated mesh to prevent adhesions
  • Component separation (anterior or posterior) for large defects to achieve fascial closure
  • Risk factors for recurrence: obesity, smoking, wound infection, tension on repair
Component Separation
Key examiner focus points
  • Anterior (external oblique release): release external oblique aponeurosis 1–2 cm lateral to the rectus sheath
  • Posterior (TAR — transversus abdominis release): release transversus abdominis muscle in the retrorectus space
  • Anterior CS gains 5–10 cm medial advancement per side; TAR gains 8–10 cm
  • TAR is preferred as it preserves the anterior abdominal wall blood supply
  • Used for complex ventral hernia with significant loss of domain

Pediatric Surgery5

Pyloromyotomy (Ramstedt)
Key examiner focus points
  • Indicated for infantile hypertrophic pyloric stenosis
  • Classic presentation: non-bilious projectile vomiting in a 2–8 week old; palpable olive-shaped mass
  • Correct hypochloremic, hypokalemic metabolic alkalosis BEFORE surgery
  • Myotomy divides the hypertrophied pyloric muscle down to submucosa without entering mucosa
  • Duodenal perforation is the most important intraoperative complication to recognize
Tracheoesophageal Fistula Repair
Key examiner focus points
  • Type C (proximal atresia + distal TEF) accounts for 85% of cases
  • Diagnosed by inability to pass an NG tube; X-ray shows coiled tube in proximal esophageal pouch
  • VACTERL association: Vertebral, Anorectal, Cardiac, TEF, Esophageal atresia, Renal, Limb anomalies
  • Right posterolateral thoracotomy: divide the fistula, primary esophageal anastomosis
  • Echocardiography BEFORE surgery to identify cardiac anomalies and confirm aortic arch side
Gastroschisis / Omphalocele Repair
Key examiner focus points
  • Gastroschisis: right paraumbilical defect, NO membrane, bowel exposed to amniotic fluid (matted, inflamed)
  • Omphalocele: midline defect with peritoneal sac (membrane), associated with Beckwith-Wiedemann, trisomies
  • Gastroschisis: primary closure if the bowel fits; silo (staged reduction) if not
  • Giant omphalocele (> 5 cm): may require nonoperative management (paint and wait with escharotic agents)
  • Monitor for abdominal compartment syndrome after reduction (bladder pressure, ventilatory pressures)
Ladd's Procedure (Malrotation)
Key examiner focus points
  • Midgut volvulus is a life-threatening emergency — bilious vomiting in a neonate = volvulus until proven otherwise
  • Upper GI series: corkscrew appearance of duodenum, DJ junction not crossing midline
  • Ladd's procedure: detorse the volvulus (counterclockwise), lyse Ladd's bands, widen the mesenteric root, appendectomy
  • The bowel is NOT fixed in normal position — the cecum is placed in the LLQ, duodenum stays on the right
  • Appendectomy is performed because the cecum is left in an abnormal position
Hirschsprung's Pull-Through
Key examiner focus points
  • Absence of ganglion cells in Meissner's and Auerbach's plexuses — distal bowel fails to relax
  • Diagnosis: rectal suction biopsy showing absent ganglion cells and hypertrophied nerve trunks
  • Transition zone: aganglionic (narrowed) to ganglionic (dilated) bowel
  • Pull-through: resect aganglionic segment, pull ganglionated bowel to the anus (Soave, Duhamel, or Swenson)
  • Enterocolitis is the most dangerous complication (both pre- and post-repair)

Head & Neck4

Neck Exploration (Penetrating Trauma)
Key examiner focus points
  • Zone I (clavicle to cricoid): most dangerous — great vessels, thoracic inlet structures
  • Zone II (cricoid to angle of mandible): most common; traditionally explored if platysma is violated
  • Zone III (angle of mandible to skull base): difficult surgical access; angiography preferred
  • Modern approach: CT angiography for all zones — selective exploration based on findings
  • Hard signs (active hemorrhage, expanding hematoma, air bubbling, massive hemoptysis): immediate OR
Sistrunk Procedure (Thyroglossal Duct Cyst)
Key examiner focus points
  • Excision of the thyroglossal duct cyst, the central portion of the hyoid bone, and the tract to the foramen cecum
  • Thyroglossal duct cyst is the most common midline neck mass in children
  • Moves with swallowing AND tongue protrusion (unlike thyroid nodule which only moves with swallowing)
  • Must confirm normal thyroid tissue exists before excision (the cyst may be the only thyroid tissue)
  • Simple excision without hyoid bone resection has a 50% recurrence rate
Parotidectomy
Key examiner focus points
  • Superficial parotidectomy for benign tumors (pleomorphic adenoma — most common parotid tumor)
  • Total parotidectomy for malignant tumors — preserve facial nerve if not directly invaded
  • Facial nerve (CN VII): identified at its main trunk emerging from the stylomastoid foramen
  • Frey's syndrome (gustatory sweating): most common long-term complication
  • FNA before surgery to differentiate benign vs malignant
Neck Dissection
Key examiner focus points
  • Radical: removes SCM, IJV, spinal accessory nerve (CN XI), and all five nodal levels
  • Modified radical: preserves one or more non-lymphatic structures (SCM, IJV, CN XI)
  • Selective: removes only specific nodal levels based on primary tumor location
  • Spinal accessory nerve injury causes shoulder drop and inability to abduct arm above 90°
  • Most common indication: cervical lymph node metastases from head and neck squamous cell carcinoma

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