GEN SURG Module 4

QUIZ 1 SAMPLEXES (Abdominal wall hernia, Breast)

2011-2018 🦄 MJLAbraham

Please check your bookmarks for quick access to each semester ☺

Credits to the UST Med Batches 2013-2019 💜
 2018 (CD2019)
NI HAO 王+ANGIEGENESIS

General Surgery Module 4 Quiz 1

Breast and Hernias
2018
BREAST
MATCHING TYPE:
A. Also called invasive ductal CA
B. Lowest axillary lymph node involvement
C. Features of multicentrality and bilaterailty
D. Can be mistaken for fibroadenoma

____1. Lobular carcinoma C

____2. Secretory carcinoma D
____3. Papillary carcinoma B
____4. Infiltrating ductal ca with productive A
fibrosis
____5. Profound desmoplastic response A

A. Luminal A
B. Luminal B
C. Triple negative
D. HER-2 neu

____6. Basal like C

____7. ER+ and/or PR+ HER2+ B
____8. ER+ and/or PR+ HER2- A
____9. Biologic Therapy D
____10. High ki-07 B

1|Page
 NI HAO 王+ANGIEGENESIS

CHOOSE THE BEST ANSWER:

____11. True of chronic mastitis EXCEPT:

A. Multiple Skin sinus

B. Simulate breast CA
C. Most common offending organism is TB bacilli
D. Treatment is simple mastectomy

D, Since the most common offending organism is TB bacilli, your treatment should be Anti-Koch’s regimen.
Also, don’t forget to do a BIOPSY in order to rule our malignancy.

____12. For patients with metastatic breast ca, selection of initial treatment depends on:
A. Tumors size
B. Grade of the tumor
C. Status of the axillary lymph nodes
D. Tumor is hormonally sensitive or not

D, Remember, we are talking about METASTATIC breast cancer. A, B, and C are of little significance at this
point. Our main treatment now will be either hormonal therapy or chemotherapy depending on the
sensitivity (is it ER + or -?)

40 year old woman sought consult because of a 6cm mass on her Right breast of 2 months duration. An
ultrasound showed the lesion to be solid with well defined margins. The axillary lymph nodes appeared
normal. A core needle biopsy revealed mesenchymal and epithelial components consistent with
phylloides tumor.

____13. The chance that the lesion is probably benign:

A. 50%
B. 60%
C. 70%
D. 90%

D, 90% are benign

____14. The treatment is:

A. Simple mastectomy
B. Lumpectomy
C. Wide excision with 1cm margin
D. MRM

2|Page
 NI HAO 王+ANGIEGENESIS

D, Do wide excision with 1cm margin. It has well defined margins. You don’t have to take our the breast.
Just take out the tumor with margins because you know there is still a chance for it to be malignant or
borderline.

____15. The final histopath report turned out to be malignant phylloides tumor with all resection margins
negative of tumor. What will you recommend?

A. Observation
B. Chemotherapy
C. Hormonal therapy
D. Radiotherapy

D, Now you see it was actually malignant. What do you do next? Adjuvant Radiotherapy. Remember, for
benign, observe. Borderline: +/- radiotherapy. Malignant: Radiotherapy. How bout chemo or hormonal
therapy? No, both have a LIMITED roles in the treatment of phylloides tumor.

____16. In managing breast mass., which of the ff is true?

A. Approach is the same regardless of age
B. Postmenopausal women with breast mass are just observed
C. Be aggressive to consider cancer especially when pain is a major component
D. Biopsy is in order for older age group

D, Remember, in the older age group (specifically postmenopausal), the likelihood that it is cancer
increases. A is wrong because of the epidemiology of fibroadenoma, fibrocystic change, and malignancy
for different age groups; therefore, approach will be different (eg. You don’t do mammography right away
in a 21-year-old.) C is also false because remember, pain or tenderness is RARELY a symptom of cancer. It
is the most common reason for consultation and is common for premenopausal women

____17. Fibrocystic change is:

A. Common in teens
B. Premalignant
C. Believed to be caused by repeated periodic menstrual exposure
D. Usually unilateral

C, That’s why it usually occurs during the menstrual cycle! It’s more common in premenopausal women,
NOT a risk factor for breast CA, and is usually BILATERAL (cause hormonal effects are systemic/diffused)

____18. Vertebral venous tributaries providing secondary route for metastasis to the vertebrae, skull,
pelvic bones and CNS in the absence of pulmonary metastasis
A. Veins of Retzus
B. Veins of Batson
C. Veins of Copernicus
D. Lumbar veins

B, This was lifted verbatim from the book. Damn.

3|Page
 NI HAO 王+ANGIEGENESIS

____19. Breast cancer patient with 3cm mass, hard nodules on the skin surface around the nipples, no
clinically palpable axillary lymph nodes. Clinical stage would be:

A. Stage IIB
B. Stage IIIA
C. Stage IIIB
D. Stage IV

C, You might think 3cm belongs to T2, BUT TAKE NOTE: there are hard nodules on the skin surface around
the nipples. This qualifies it as T4. Therefore the stage is T4N0M0 or IIIB. See below:

____20. The sine qua non in the diagnosis of breast ca on mammography:

A. Fine calcification
B. Spiculated density with ill-defined margins
C. Clustered microcalcifications
D. Ductal asymmetry

4|Page
 NI HAO 王+ANGIEGENESIS

____21. Added advantage of core needle biopsy for prognostication

A. Large sample size

B. Determination of ER/PR/Her2Neu
C. Able to determine metastasis
D. Higher sensitivity and specificity

B, Your FNAB only collects cells; they cannot be tested for ER/PR. But your Core Needle CAN because it
collects tissue samples.

ONE OR MORE COMPLETION:

A. 1, 2, 3 are correct
B. 1 & 3 are correct
C. 2 & 4 are correct
D. Only 4 is correct

____22. True of Male breast ca:

1. Peak evidence 60-69 years of age

2. Stage for stage have the same survival rate as women
3. Overall prognosis is poor because of the advanced stage of the disease at diagnosis
4. Tumor commonly ER (-)

A – 1,2,3 are all TRUE. Should be ER (+).

____23. True of breast cancer and pregnancy:

1. Breast conservative therapy is contraindicated during pregnancy

2. Mod. Radical mastectomy can be undertaken at any point in pregnancy
3. Termination of pregnancy has been shown to be of no benefit to maternal survival
4. Chemotherapy can be given with no risk from the first to third trimester

A – Yes, MRM can be done at ANY point in pregnancy. 4 is false because chemotherapy can be given from
2nd to 3rd trimester.

____24. Which of the following is/are correct in relation to gynecomastia?

1. Presence of a female type mammary gland in male

2. Excess of testosterone in relation to circulatory estrogen
3. Does not predispose the male breast cancer
4. Tamoxifen effective in 80% (or 50%? Blurred eh)

B – 2 should be estrogen excess. 4 should be 30%

5|Page
 NI HAO 王+ANGIEGENESIS

____25. Prospective randomized studies of routine mammographic screening confirms:

1. 10% increase in diagnosis of DCIS

2. 40% reduction for Stage II disease
3. 20% reduction in bilateral mastectomy
4. 30% increase in survival in patients found to have cancer

C – 2 and 4 are TRUE.

HERNIAS

Matching Type
A. Indirect Inguinal Hernia
B. Direct Inguinal Hernia
C. Femoral Hernia
D. All of the above

26. Nyhus type IIIC C – FEMORAL

27. Nyhus type IV D – ALL
28. Nyhus type IIIB A – INDIRECT
29. Nyhus type IIIA B – DIRECT
30. Nyhus type II A – INDIRECT
31. Weakness in the abdominal wall B – DIRECT
REMEMBER:
• Indirect – (+) hernial sac with patent
processus vaginalis (PPV)
• Direct – weakness in the abdominal wall
musculature

32. Taxis is an option in the management D – ALL

33. Highest incidence of strangulation C – FEMORAL
34. Mesh can be used to repair detect D – ALL
35. Tissue repair is an option D – ALL
36. Classified as inguinal hernia D – ALL
37. Sliding hernia A – INDIRECT or B
According to SurgWiki (brought to you by ANZ
Journal of Surgery) It can be both. But I would
personally choose indirect hernia.

6|Page
 NI HAO 王+ANGIEGENESIS

38. Protrudes medial to Hesselbach's triangle B – DIRECT

Medial: Direct
Lateral: Indirect

39. Borders of the opening involved are the C – FEMORAL

iliopubic tract, inguinal ligament, Cooper's This is the femoral triangle
ligament, and lacunar ligament

40. May present as a complete hernia A – INDIRECT

Indirect hernia is considered complete when the
hernial sac has reached the scrotum
CHOOSE THE BEST ANSWER

41. Which of the following statements is false regarding the incidence of abdominal wall hernia?

A. Two thirds of all inguinal hernias are classified as indirect

B. Femoral hernias are more common in females
C. Premature infants have a 10% incidence of inguinal hernias
D. Hernias generally occur with equal frequency in males and females
D, 27% for male, only 3% for female

42. Clinical feature that makes a bulge in the anterior abdominal wall most likely to be a hernia

A. (+) Fothergill sign

B. It is incarcerated
C. It disappears with recumbency
D. It has been present since birth

C, it is most likely an hernia if it disappears with recumbency. (+) Fothergill sign is for rectus sheath
hematoma. You do this to determine if an abdominal tumor arises within the abdominal wall. Ask the
patient to tense up his abdomen.
• (-) If it disappears - deep ung mass (retroperitoneum)
• (+) If it remains/becomes more prominent - nasa abdominal wall (superficial) ung mass

43. The most common anterior abdominal wall hernia comprising 75%

A. Inguinal hernia
B. Umbilical hernia
C. Incisional hernia
D. Femoral hernia
A

7|Page
 NI HAO 王+ANGIEGENESIS

44. True of femoral hernias:

A. The most common hernia in females

B. Presents below the inguinal ligament
C. Does not usually incarcerate
D. Unless strangulated, there is no indication for surgery

B, this is where the femoral triangle is. Remember, femoral hernia is more common in females BUT the
most common hernia in female is STILL indirect inguinal hernias. The have a high chance to incarcerate
and strangulate that is why when diagnosed, prompt surgical repair is advised.

45. Which of the following is false regarding direct inguinal hernias?

A. The most likely cause is destruction of connective tissue from physical stress
B. Should be repaired promptly to avoid risk of incarceration
C. A direct hernia may be a sliding hernia involving the bladder wall
D. A indirect hernia may co-exist with the direct hernia

A, Phyisical stress don’t usually cause attenuation or degeneration of tissues. ALL hernias are promptly
repaired since they tend to enlarge over time and eventually incarcerate, although watchful waiting is
acceptable and safe (except maybe for femoral because its risk is higher, while direct hernias have low
risk). C can be direct or indirect. D is called a Pantaloon Hernia.

46. The natural history of the majority of anterior abdominal hernias is that

A. The defect will continue to enlarge over time

B. The defect will remain the same but will not disappear
C. The defect will eventually close if it is congenital
D. They eventually become incarcerated

47. True statement regarding the floor of the inguinal canal, EXCEPT

A. The structure referred to is the transversalis fascia

B. The opening here where the cord structure exits is the external ring
C. This is the structure that attenuates in inguinal hernias
D. This is where Hesselbach's triangle is located

B, It should be the deep/internal ring.

8|Page
 NI HAO 王+ANGIEGENESIS

48. The borders of Hesselbach’s triangle include the following, EXCEPT

A. Lateral border of rectus muscle

B. Inferior epigastric vessels
C. Transversus abdominis muscle
D. Inguinal ligament
C

49. All are considered “tissue repair” types of herniorrhaphies, EXCEPT

A. Lichtenstein repair
B. Shouldice repair
C. McVay repair
D. Bassini repair

A, Lichtenstein repair is a MESH repair

50. All are clinical presentations of an inguinal hernia, EXCEPT

A. Scrotal mass
B. Inguinal mass
C. Inguino-scrotal mass
D. Incarcerated inguinal mass
A, a scrotal mass will most likely be a hydrocele or testicular tumor and NOT an hernia.

SOURCES:

Schwartz

Lecture PPT slides + Lecture Trans (Most of the answers are found here)

Allie Samplex + I<3NY + 2010, 2011, 2013, 2014, 2016 samplex

SurgWiki (Brought to you by ANZ Journal of Surgery)

9|Page

2017 (AB2019)
General Surgery Question Pool with(mostly) Schwartz Based Rationale

Module 4- Abdominal Wall and Breast

Part 1. Abdominal wall

True about inguinal hernias Conservative management of

asymptomatic inguinal hernias is not
acceptable

Elective repair of inguinal hernias can be

done using laparoscopic approach

Use of prosthetic mesh improves

recurrence whether repair is open or
laparoscopic

Recurrence of pain and quality of life are

not important outcome factors in repair

Source: Key Points Box, Chapter 37,

Schwartz 10 e
Boundaries of the inguinal canal except: External oblique aponeurosis anteriorly

Transversing fascia posteriorly

Spermatic cord superiorly

Inguinal ligament inferiorly

The boundaries of the inguinal canal are

comprised of the external oblique
aponeurosis anteriorly, the internal
oblique muscle laterally, the transversalis
fascia and transversus abdominis muscle
posteriorly, the internal oblique muscle
superiorly, and the inguinal (Poupart’s)
ligament inferiorly. The spermatic cord
traverses the inguinal canal, and it
contains three arteries, three veins, two
nerves, the pampiniform venous plexus,
and the vas deferens
Classification of inguinal hernias include Direct
the following except: Indirect
Ventral
Femoral

KLCB A 2019 ♪

 Inguinal hernias are generally classified as
indirect, direct, and femoral based on the
site of herniation relative to surrounding
structures.
46 y/o male left inguinal hernia that Indirect
protrudes medial to the inferior epigastric Direct
vessels with Hesselbach triangle Femoral
None

Indirect hernias protrude lateral to the

inferior epigastric vessels, through the
deep inguinal ring. Direct hernias
protrude medial to the inferior epigastric
vessels, within Hesselbach’s triangle.
Border of the Hesselbach’s Triangle Lateral edge of rectus sheath
except:
Inguinal ligament

Pubic tubercle

Inferior epigastric vessels

The borders of the triangle are the

inguinal ligament inferiorly, the lateral
edge of rectus sheath medially, and the
inferior epigastric vessels superolaterally.
56 y/o male with left inguinal hernia that Direct
protrudes through the internal inguinal Indirect
ring and lateral to the inferior epigastric Femoral
vessels Ventral
50 y/o female with hernia inferior to the Direct
inguinal ligament and upper middle Indirect
thigh. Other PE normal Femoral
None

Femoral hernias protrude through the

small and inflexible femoral ring. The
borders of the femoral ring include the
iliopubic tract and inguinal ligament
anteriorly, Cooper’s ligament posteriorly,
the lacunar ligament medially, and the
femoral vein laterally
Reccurrent hernia on Nyhus Classification Type I
Type II
Type III
Type IV

KLCB A 2019 ♪
 Nyhus Classification
I Indirect hernia, internal
abdominal ring normal,
typically in infants, children,
small adults
II Indirect hernia; internal ring
enlarged w/o impingement on
the floor of the inguinal canal;
does not extend to scrotum
IIIA Direct hernia, size not taken
into account
IIIB Indirect hernia that has
enlarged enough to encroach
upon the posterior inguinal
wall; indirect sliding or scrotal
hernias are usually placed in
this category because they are
commonly associated with
extension to the direct space;
also includes pantaloon
hernias
IIIC Femoral hernia
IV Recurrent hernia; modifiers A-D
correspond to indirect, direct,
femoral and mixed
respectively
68 y/o male right inguino- scrtotal mass. Direct hernia reducible
Claims for past 6 years mass protrudes Femoral hernia incarcerated
and reach scrotal area especially when Indirect hernia complete reducible
upright and disappears on supine Indirect hernia incomplete reducible

Questions should also be directed to

characterize whether the hernia is
reducible. Patients will often reduce the
hernia by pushing the contents back into
the abdomen, thereby providing
temporary relief. As the defect size
increases and more intra-abdominal
contents fill the hernia sac, the hernia
may become harder to reduce.
If patient above presents with the same Strangulated inguinal hernia
mass fixed to the right scrotal area and Incarcerated inguinal hernia
does not disappear or reduce on supine Incarcerated femoral hernia
position None

KLCB A 2019 ♪
 A hernia that cannot be reduced is
described as incarcerated and generally
requires surgical correction. Incarceration
of an intestinal segment may be
accompanied by nausea, vomiting, and
significant pain, and is a true surgical
emergency. If the blood supply to the
incarcerated bowel is compromised, the
hernia is described as strangulated, and
the localized ischemia may lead to
infarction and perforation
70 y/o presents to the ER with vomiting, Strangulated inguinal hernia
fever and pain at the right scrotal area. Incarcerated inguinal hernia
PE shows right scrotal mass, fixed and Incarcerated femoral hernia
tender on palpation, erythematous
overlying skin. WBC 20 000
Management of the above patient Further observe
Attempt taxis/reduce hernia
Emergent surgical repair
All of the above

The indication for emergent inguinal

hernia repair is impending compromise of
intestinal contents. As such, strangulation
of hernia contents is a surgical
emergency. Clinical signs that indicate
strangulation include fever, leukocytosis,
and hemodynamic instability. The hernia
bulge is usually warm and tender, and
the overlying skin may be erythematous
or discolored. Symptoms of bowel
obstruction in patients with sliding or
incarcerated inguinal hernias may also
indicate strangulation. Taxis should not be
performed when strangulation is
suspected, as reduction of potentially
gangrenous tissue into the abdomen
may result in an intra-abdominal
catastrophe. Preoperatively, the patient
should receive fluid resuscitation,
nasogastric decompression, and
prophylactic intravenous antibiotics
Hernia prone to complication so surgery is Indirect
suggested Direct
Femoral

KLCB A 2019 ♪
 Femoral and symptomatic inguinal
hernias carry higher complication risks,
and so surgical repair is performed earlier
for these patients.
For this reason, it is recommended that
femoral hernias and symptomatic
inguinal hernias be electively repaired,
when possible.
Repairs both the inguinal defect and the McVay Repair
femoral defect
The McVay repair addresses both inguinal
and femoral ring defects. This technique
is indicated for femoral hernias and in
cases where the use of prosthetic
material is contraindicated
Tissue based repair with 1% recurrence Shouldice

Demonstrated significantly lower rates of

hernia recurrence (OR 0.62, CI 0.45–0.85)
in patients undergoing Shouldice
operations when compared with other
open tissue-based methods.80 In
experienced hands, the overall
recurrence rate for the Shouldice repair is
about 1%
Repair with lowest recurrence Lichtenstein

In a multiinstitutional series, 3019 inguinal

hernias were repaired using the
Lichtenstein technique, with an overall
recurrence rate of 0.2%.86 Among other
tension-free repairs, the Lichtenstein
technique remains the most commonly
performed procedure worldwide.
Posterior approach repair Laparoscopic

After an initial anterior approach, the

posterior laparoscopic approach will
usually be easier and more effective than
another anterior dissection
Anterior rectus sheath above the line of The arcuate line (semicircular line of
douglas is composed of Douglas) lies roughly at the level of the
anterior superior iliac spines (Fig. 35-3).
Above the arcuate line, the anterior
rectus sheath is formed by the external
oblique aponeurosis and the external
lamina of the internal oblique

KLCB A 2019 ♪
 aponeurosis, whereas the posterior rectus
sheath is formed by the internal lamina of
the internal oblique aponeurosis and the
transversus abdominis aponeurosis. Below
the arcuate line, the anterior rectus
sheath is formed by the external oblique
aponeurosis, the laminae of the internal
oblique aponeurosis, and the transversus
abdominis aponeurosis
Multigravida with midline bulge. History of Rectus abdominis Diastesis results from
laparoscopy with CS. Diagnosis? separation of the two rectus abdominis
muscle pillars. This results in the
characteristic bulging of the abdominal
wall in the epigastrium that is sometimes
mistaken for a ventral hernia. It is an
acquired condition with advancing age,
obesity, or following pregnancy. In the
postpartum setting, rectus diastasis tends
to occur in women of advanced
maternal age, after multiple or twin
pregnancies, or in women who deliver
high-birth-weight infants. Diastasis is
usually easily identified on physical
examination
Patient unstable with expanding rectus Specific treatment depends on the
sheath hematoma. Treatment: severity of the hemorrhage. Small,
unilateral, and stable hematomas may
be observed without hospitalization.
Bilateral or large hematomas will likely
require hospitalization, as well as
potential resuscitation. Transfusion or
coagulation factor replacement may be
indicated in some situations.
Angiographic embolization is required
infrequently, but may be necessary if
hematoma enlargement, free bleeding,
or clinical deterioration occurs. Surgical
therapy is used in the rare situations of
failed angiographic treatment or
hemodynamic instability that precludes
any other options. The operative goals
are evacuation of the hematoma and
ligation of any bleeding vessel identified.
Mortality in this condition is rare, but has
been reported in patients requiring
surgical treatment and in the elderly.

KLCB A 2019 ♪
 Familial adenomatous polyposis (FAP), Radical resection with frozen section
enlarging mass with ill-defined borders. margins and immediate mesh
Treatment: reconstruction of any consequent
abdominal wall defect is the most
commonly recommended treatment.
Best treatment for above patient Chemotherapy
Chemotherapy and radio
Enucleation
Wide resection

Medical treatment with an antineoplastic

agent such as doxorubicin, dacarbazine,
or carboplatin can produce remission for
variable periods in up to 50% of patients,
although the prognosis of advanced
desmoids, particularly in FAP, is poor, with
a 5-year mortality rate as high as 50%
reported. Combined medical treatments
and the addition of imatinib have been
used with some success in small numbers
of patients; radiation therapy has been
used in both adjuvant and palliative roles
with high response rates
75 y/o female with 2 year history of on Sigmoid volvulus
and off mild vague abdominal pain Acute cholecystitis
suddenly presents with severe abdominal Acute omental torsion
pain. PE shows abdomen with Acute mesenteric ischemia
hypoactive bowel sound. She is
tachycardic and tachypneic in atrial Vascular occlusive disease of the
fibrillation mesenteric vessels is a relatively
uncommon but potentially devastating
condition that generally presents in
patients over 60 years of age, is three
times more frequent in women, and has
been recognized as an entity since 1936.
The incidence of such a disease is low
and represents 2% of the
revascularization operations for
atheromatous lesions. The most common
cause of mesenteric ischemia is
atherosclerotic vascular disease. In acute
embolic mesenteric ischemia, the emboli
typically originate from a cardiac source
and frequently occur in patients with
atrial fibrillation or following myocardial
infarction.

KLCB A 2019 ♪
 The best diagnosis (diagnostic CT-Scan
procedure) for this patient MRI
Selective mesenteric angiography
PET CT

Arteriography is the gold standard for the

diagnosis of mesenteric occlusive
disease; however, it can be a time-
consuming diagnostic modality. In this
group of patients, immediate exploration
for assessment of intestinal viability and
vascular reconstruction is the best
choice.

Lecture- Selective mesenteric

angiography is the Dx of choice
28 year old presents with hypertension, Retroperitoneal abscess
vague abdominal pain in flanks and Urinary Bladder CA
back with edema of the lower extremity Retroperitoneal fibrosis
and shows dilated ureters on ultrasound Retroperitoneal sarcoma

Retroperitoneal abscess causes

hydronephrosis (lecture)

The site of pain may be variable and can

include the back, pelvis, or thighs.
Erythema may be observed around the
umbilicus or flank. The diagnosis is best
established by CT, which may
demonstrate a unilocular or multilocular
collection along with retroperitoneal soft
tissue stranding.
True of malignant retroperitoneal Preop history dx is mandatory
sarcoma Most are responsive to chemo and radio
Mainstay of treatment is surgery

Wide resection – standard of treatment

(Complete surgical resection is the most
effective treatment for primary or
recurrent retroperitoneal sarcoma- book)
Most studies have failed to show a
survival benefit from adjuvant
chemotherapy for retroperitoneal
sarcoma. Radiation treatment is
complicated because of tumor size

KLCB A 2019 ♪
 Preop history dx might be hard- patient
may present with only an abdominal
mass with no other symptoms (Lecture)
Successful treatment of retroperitoneal Size
sarcoma Completeness of resection
Location
Grading

In prognosis, histologic grade is the most

important factor

Complete resection of all gross disease

improves local control and disease-
specific survival (Lecture)

The complicated anatomy might not

allow complete resection and might
leave microscopically positive margins
which will increase recurrence rates.
(Uptodate)
Multigravid patient Diastasis recti
Palpable mass unchanged with Fothergill’s sign in rectus sheath
contraction hematoma
3 months mass, weight loss, mass is fixed Exploratory laparoscopy
and non-ballotable CT Scan
Chemotherapy
Radiotherapy

CT scan is the most definitive study to

establish correct diagnosis (Lecture)
Mass that is adherent to the descending Resection with preservation of colon and
colon and small bowel bowel
Resecton and en bloc of colon and
bowel
Biopsy and chemotherapy
None

Not sure. Resect affected organs daw,

but practically di naman ata pwede na
lahat ng colon and bowel tanggalin?
HAHA.
Most common (ito lang talaga, tapos Most common retroperitoneal tumor-
type of sarcoma yung choices so ilagay sarcomas
ko na lang lahat ng %) Histologic subtypes:
Liposarcoma (41%)
Leiomyosarcoma (28%)
Malignant fibrous histiocytoma (7%)

KLCB A 2019 ♪
 Fibrosarcoma (6%)
Malignant peripheral nerve sheath tumor
(3%)
True of retroperitoneal tumors except Malignant
1/3 are soft tissue sarcoma
70% are greater than 10cm
1/3 are high grade

50% (1/2) are high grade (lecture)

55 y/o male presents with a progressively UTZ
enlarging palpable abdominal mass. No MRI
other associated symptoms. PE: VS stable. CT Scan
Abdomen shows an ill defined abdominal PET Scan
mass around 6 cm in diameter, non-
tender, with smooth consistency. No CT is also the preferred imaging
other findings of note. The best imaging technique for evaluating retroperitoneal
procedure to determine the nature of the sarcomas (Fig. 36-2).30 Current CT
mass is? techniques can provide a detailed
image of the abdomen and pelvis and
can delineate adjacent organs and
vascular structures.
Above test shows the mass to be solid, 10 Exploratory laparotomy, enbloc resection
cm in size, retroperitoneal in location, with Radiotherapy
involvement of right kidney. The next best Chemotherapy
thing to do is CT guided biopsy

CT-guided core needle biopsy is

appropriate to provide a tissue diagnosis;
however, negative biopsy findings should
not delay operative intervention.
Among hernia repair techniques that do Bassini repair
not use a prosthetic mesh, the following McVay
has the lowest recurrence rate Shouldice
Marcy

Bassini- triple layer repair

McVay- indicated for femoral hernias
and in cases where use of prosthetic is
C/I
Type of hernia which contains a Meckel’s Litre’s hernia
diverticulum
Type of hernia wherein part of the bowel Sliding hernia
wall forms part of the hernial sac
A change in bowel habits or urinary
symptoms may indicate a sliding hernia
consisting of intestinal contents or

KLCB A 2019 ♪
 involvement of the bladder within the
hernia sac.
Contributory factors in development of Weakness of the iliopubic tract
direct inguinal hernia except Limited insertion of the iliopubic tract
aponeurosis into the Cooper’s ligament
Weakness of the anterior inguinal wall
Limited insertion of the transversus
abdominis muscle into the pubis
Complications of an elective Paralytic ileus
herniorrhapy and the most common is: Nausea and vomiting
Urinary retention
Aspiration pneumonia

Most common complication of

herniorrhapy- recurrence (book/lecture)
The following is/are factors in the Change in color
assessment of bowel viability in cases of Presence/absence of peristalsis
incarcerated inguinal hernia Presence/absence of arterial pulsation
Which of the following is true regarding May be performed for indirect, direct and
mesh hernia repair? recurrent hernias
Requires spinal anesthesia
Px advised bed rest post-op for 2-3d
Manual labor is restricted
Most important concept that has led to a Tension-free repair
decrease in recurrence rates following
hernia repair The popularization of tension-free
prosthetic mesh repairs signified a
paradigm shift in the surgical concept of
inguinal hernia pathophysiology. Mesh-
based hernioplasty is the most commonly
performed general surgical procedure,
owing to the technique’s efficacy and
improved outcomes. The techniques of
the most commonly performed prosthetic
repairs are presented in this section.
35 y/o develops sudden onset of severe Rectus sheath hematoma
abdominal pain after a workout in the
fitness center. He is tachycardic with
normal BP. On PE, there is bluish
discloloration in the abdominal wall with
tenderness. Ill-defined mass is also
palpable. Most likely Dx?
A Fothergill test shows that the mass Abdominal mass vs intraabdominal mass
persists on flexing the abdomen. This is Persistence with flexion shows that it is
used to differentiate: intraabdominal. Fothergill’s sign is
classically associated with rectus sheath
hematoma

KLCB A 2019 ♪
 If the mass is expanding, and px is stable, Surgery (see previous question)
best management is
35 y/o woman presents with an enlarging Excision biopsy
mass in the anterior abdominal wall. She Needle aspiration biopsy
is a known case of familial adenomatous Incisional biopsy
polyposs. CT scan of the abdomen Core needle biopsy
reveals a 4 cm tumor with ill-defined
borders involving the rectus sheath and Radical resection with frozen section
muscles. Next best thing to do? margins and immediate mesh
reconstruction of any consequent
abdominal wall defect is the most
commonly recommended treatment
True about torsion of the omentum Commonly diagnosed preoperatively
Mimics most common causes of acute
abdomen
Commonly caused by a tumor in the
omentum
AOTA

Rarely diagnosed preoperatively,

commonly caused by rotation around a
proximal fixed point (lecture)
80 y/o male known diabetic and Ruptured sigmoid diverticulitis
hypertensive complains of severe Ruptured appendicitis
abdominal pain of few days duration. Acute mesenteric ischemia
The patient is restless and disoriented. BP
100/80. PR is 110/min; temp 38.5 C on PE,
bowel sounds are hypoactive with
abdominal tenderness and guarding. The
following should be considered in the
patient:
If the scout film of the abdomen is done, Thumbprinting of the bowel wall
the following findings suggest bowel Pneumatosis intestinalis
ischemia Pneumoperitoneum

These are non-specific and late-stage

manifestations (lecture)
If this is acute mesenteric ischemia the Acute thrombosis of the SMA
most likely cause is: Embolism of the SMA
Non-occlusive- mesenteric ischemia
(NOMI)- seen in patients with vasopressor
agents
Mesenteric venous thrombosis- seen in px
with heritable or acquired coagulation
dse

KLCB A 2019 ♪
 Even if the most common cause is
embolus, the patient’s co-morbidities is
associated with acute thrombosis (in the
background of vascular injury)
Most common location: SMA
The patient is best managed by Emergency laparotomy
If on chest auscultation the heart sounds Embolism of SMA
are irregular and the ECG shows atrial
fibrillation, then the most likely cause is:
Best treatment for the above Surgical embolectomy

Part 2. Breast

Mammogram of a 60 y/o female Invasive ductal CA

revealed a 3 cm spiculated lesion of the Medullary CA
R breast. Doing a core needle would Lobular CA
possibly reveal? Tubular CA

Invasive ductal carcinoma is the most

common (75-80%) that affects 40-60 y/o
age group (Lecture)
She underwent MRM, histopath showed See table 17-10 and table 17-11 of
infiltrating ductal CA with fibrosis. Tumor Schwartz 10 e for staging
size 3cm, one of 15 axillary LN (+)
metastasis. No distant metastasis. Stage? Stage 2B
Expected 5 year survival rate is? 90%
80%- answer ng samplex
70%
60%

The overall 5-year relative survival for

breast cancer patients from the time
period of 2003–2009 from 18 SEER
geographic areas was 89.2%. The 5-year
relative survival by race was reported to
be 90.4% for white women and 78.7% for
black women.
The 5-year survival rate for patients with
localized disease (61% of patients) is
98.6%; for patients with regional disease
(32% of patients), 84.4%; and for patients
with distant metastatic disease (5% of
patients), 24.3%.
Consistent with a benign mass Hard
Irregular
Fixed
mobile

KLCB A 2019 ♪
 20 y/o F with 2x2x2 mobile, well- Fibroadenoma
circumscribed and non-tender mass.
What is your diagnosis? Fibroadenomas are seen and present
symptomatically predominantly in
younger women aged 15 to 25 years (Fig.
17-10).31 Fibroadenomas usually grow to
1 or 2 cm in diameter and then are stable
but may grow to a larger size.
58 y/o with a rubbery, movable 2x2 Watchful waiting
breast mass. What shoud NOT be done? Mammography + Biopsy
Biopsy without mammography
Surgery
True of fibrocystic change Common in 25-45 y/o
Pre-malignant
Presents as breast mass
Usually large

(Lecture)
20 y/o saleslady complained of breast CA
tenderness becoming more severe Normal premenstrual tension
before menses, cycle is regular. PE of Fibroadenoma
breast is unremarkable. Likely cause? Fibrocystic changes
What do you do? Reassurance
Group of lymphnodes intersposed Rotter’s Node
between pectoralis major and minor?
The interpectoral group (Rotter’s lymph
nodes), which consists of one to four
lymph nodes that are interposed
between the pectoralis major and
pectoralis minor muscles and receive
lymph drainage directly from the breast.
Findings on mammography that is the Spiculated density with ill-defined
MOST RELIABLE SIGN OF BREAST CA margins
NOT TRUE regarding use of ultrasound in Ultrasound can differentiate solid from
diagnosis of breast problems cystic lesions

It is an effective screening tool for breast

CA as it can detect microcalcifications

can be used to diagnose solid lesions as

fibroadenoma particularly in young
patients

it is an alternative to mammography for

patients needing further evaluation of
breast mass but with very low threshold
for pain

KLCB A 2019 ♪
 45 y/o female complains of bilateral Normal premenstrual tension
breast tenderness becoming more severe
before menses. On PE, they were nodular
without a definite mass, your diagnosis is:
Symptoms of above may be alleviated Danazol and Analgesics
by the following
*also bromocriptine or tamoxifen
Pathologic nipple discharge Pathologic:
Spontaneous
Bloody
With a mass
Unilateral
Single duct

Physiologic:
Comes with compression
Clear, white, yellow or dark green
Bilateral
Multiple duct
48 y/o complained of progressively Phyllodes tumor
enlarging left breast mass of 1 yr duration.
PE: 20x14x10 cm firm multinodular mass Phyllodes tumor is classified as benign,
with solid and cystic components. Left borderline or malignant. Benign phyllodes
axilla is negative for palpable nodes. tumor resembles fibroadenoma.
Most probable diagnosis?
Core needle biopsy of the above Modified radical mastectomy- answer in
showed mesenchymal and epithelial samplex, but this includes axillary lymph
component w/ no malignant cells. Tx is? node dissection so maybe it should be
simple mastectomy

Large phyllodes tumors require

mastectomy and axillary dissection is not
recommended because axillary lymph
node metastasis rarely occur.
Breast feeding mother to a 6 mos old Acute mastitis
baby has tender reddish mass in the UOQ
of the R breast. Most likely diagnosis?
27 y/o female lives in squatters area TB mastitis
complains of non healing R breast ulcer
with draining sinus for the last 4 yrs. On PE,
she has decreased breath sounds on the
right chest and axilla has no palpable
lymphnodes. She is probably suffering
from?
Most common breast problem why Breast tenderness
females consult a physician?

KLCB A 2019 ♪
 TRUE regarding fibroadenoma It is pre malignant- does not become
cancer

Estrogen dependent
Not prone to recurrence

Usually 5-6 cm in size- usually 2-3 cm

Breast CA with triple negative (ER, PR, HER Poorly differentiated
2)
Humanized monoclonal antibody with Trastuzumab
specificity for extracellular domain of the
human epidermal growth factor (HER2) Bevacizumab—specificity for VEGF
receptor
Trastuzumab when added to chemo as 50%
an adjuvant for breast CA with (+) axillary
lymph nodes results in reduction of risk of 30% reduction in risk for death
recurrence by how many percent?
Treatment of choice for CA of the male Modified radical mastectomy
breast
Most important prognostic correlate for Axillary lymph node status
disease free and overall survival in breast
CA? One of the most important predictors of
10- and 20-year survival rates in breast
cancer is the number of axillary lymph
nodes involved with metastatic disease
First lymph node to which cancer is likely Sentinel Lymph node
to spread
Delphian node- thyroid gland
2x3x2 cm ovoid mass on upper quadrant Fibroadenoma
of R breast with well delineated borders,
mobile is most likely Fibrocystic change- pain with multiple
cystic lesions

Intraductal papilloma

Carcinoma
A biopsy was taken on a 55 y/o Fibroadenoma-
premenopausal lady with a 3x2x5 cm
mobile, firm, nontender with well Intraductal CA with fibrosis
delineated borders. Most likely histopath
is Fibrocystic change

Medullary carcinoma- Grossly, the

cancer is soft and hemorrhagic. A rapid
increase in size may occur secondary to
necrosis and hemorrhage (this is the
answer in the samplex)

KLCB A 2019 ♪
 Breast cancer is most likely to occur Lady with menarche at 10, menopause at
56 with regular menses and no
pregnancy

Breast CA Risk/Etiology
1. Family history
2. High fat intake and obesity
3. Prolonger HRT
4. Late menopause >45y/o
5. Infertility and nulliparity
6. History of primary breast CA
7. Previous exposure to therapeutic
chest wall irradiation
8. Germ line mutation
a. BRCA 2 17q21
b. BRCA 2 13q12-13
True of breast CA 3rd leading cause of cancer death

Facts and figures (2005; in lecture)

• 2nd leading site for both sexes, 1st
among women
• 3rd leading cause of CA deaths
• Median survival among females is
60 mos
• Survival at the 5th yr is 50.10%
• Survival at the 10th yr is 32.38%
• Incidence starts rising steeply at 30
• Incidence is one in 8
True of breast CA facts and figures in the Median survival among females is 60 mos
PH
The major route of drainage for breast Level III
CA is via the axillary lymph nodes. If the
affected nodes are MEDIAL to the Level I (Low)- inferior and lateral to the
pectoralis minor, this is called: pectoralis minor muscle
Level II (Central)- posterior to the
pectoralis minor and below the axillary
vein
Level III (Apical)- medial to the pectoralis
minor and against the chest wall
Proven breast imaging methods EXCEPT PET Scan
True of mammography Sine qua non: spiculated density with ill-
defined borders
Mammography:
• Sensitive but NOT specific
• 25% of nonpalpable lesions
detected are found to be
malignant at biopsy

KLCB A 2019 ♪
 • Sine qua non: spiculated density
with ill defined borders
• Features that are SUGGESTIVE but
not diagnostic of CA
o Clustered
microcalcifications
o Assymetric density
o Ductal asymmetry
o Distortion of skin, nipple and
normal breast architecture
Most important issue for both patient and Establish whether the patient does or
physician faced with any breast problem does not have cancer
is:
Known risk factors for breast CA EXCEPT Bilateral oophorectomy at age 25

*see other question for answers on risk

factors and etiology
Characterized by chronic eczematoid Paget’s disease
eruption of the nipple
True Luminal A tumors 80% response rate with tamoxifen
Which of the following symptoms/signs Breast pain
more commonly represents a benign
breast disorder rather than carcinoma
Therapy specifically directed at disrupting Targeted therapy
molecular genetic alteration promoting
cancer growth
Features of Ductal CA in Situ Majority are in post menopausal patients
(>50%)
Microcalcification on mammography
Axillary metastasis rare
MRM is the gold standard of treatment
Treatment options in Lobular CA in Situ Quadrantectomy
Bilateral mastectomy with immediate
reconstruction
MRM
Observation with tamoxifen
Components of a modified radical Total mastectomy
mastectomy (MRM) Internal mammary lymph node sampling
Axillary lymph node dissection
Breast augmentation
Study at your own risk!

KLCB A 2019 ♪
GENERAL SURGERY 2
MODULE 4:
2017 (CD2018) 5. True of Breast CA in the Philippines:

Abdominal Wall, Breast, Trauma and Soft Tissue A. The 2nd leading cause of cancer in
women
LONG QUIZ 1: April 16, 2017 B. The leading cause of cancer in both
1. Abdominal Wall Hernias sexes
2. Breast C. The 3rd leading cause of cancer
deaths in both sexes
Trans by ALLIE  D. 1 in 10 women will develop Breast CA

BREAST 6. True of Breast CA facts and figures in the

Philippines:
1. A 2x3x2 cm ovoid mass on the upper right
quadrant of a right breast, with well- A. Median survival among females is
delineated borders, mobile, is most likely: 60 months
B. Survival at the 5th year is 70%
A. Fibrocystic Change C. 10 year survival rate is 50%
B. Fibroadenoma D. Incidence starts rising steeply at age
C. Intraductal Papilloma 50
D. Carcinoma
7. The major route of drainage for Breast CA
2. A biopsy was taken on a 55 year old is via the axillary lymph nodes. If the
premenopausal lady with a 3x2x5 cm, affected nodes are found medial to the
mobile, firm, non-tender, with well- pectoralis minor, this is called:
delineated borders. Most likely histopath
is: A. Level 1
B. Level 2
A. Fibroadenoma C. Level 3
B. Medullary Carcinoma D. Level 4
C. Intraductal Carcinoma with Fibrosis
D. Fibrocystic Change 8. Proven breast imaging methods,
EXCEPT:
3. Breast cancer is most likely to occur in:
A. Mammography
A. A 50 year old with 10 pregnancies B. PET Scan
B. A lady with menarche at 10, C. Ultrasound
menopause at 56, with regular D. Ductography
menses and no pregnancy
C. Multigravid, menopause at 42, 9. True of mammography:
weighing 98 lbs on a 5 feet 6 inches
body A. Highly specific
D. Breastfeeding multigravida B. 50% of non-palpable lesions detected
are found to be malignant on biopsy
4. A 40-year old female complained of C. Sine qua non for Breast CA:
bilateral breast pain more pronounced just speculated density with ill-defined
before menses and relieved after margins
menstruation with multiple nodulations on D. Features that are diagnostic of cancer
both breasts. Most likely diagnosis: include coarse calcifications

A. Fibroadenoma 10. The most important issue for both patient

B. Fibrocystic Change and physician faced with any breast
C. Traumatic Fat Necrosis problem is:
D. Intraductal Papilloma
A. Definition of precise histology
B. Provision of symptomatic relief
 C. Whether the patient wants the breast 17. Which of the following symptoms/signs
preserved or not more commonly represents a benign
D. Establish whether the patient does breast disorder rather than carcinoma?
or does not have cancer
A. Hard mass
11. Known risk factors for Breast CA, B. Bloody nipple discharge
EXCEPT: C. Breast pain
D. Orange peel
A. Family history
B. High dietary fat intake, Obesity 18. Therapy specifically directed at disrupting
C. Bilateral oophorectomy at age 25 molecular genetic alteration promoting
D. Prolonged hormone replacement cancer growth:
therapy
A. Hormonal Therapy
12. The most important prognostic correlate B. Immunotherapy
for recurrent disease and survival: C. Chemotherapy
D. Targeted Therapy
A. Age
B. Axillary Nodal Status One or More Completion:
C. Histologic Grade
D. ER and PR Status A. 1, 2 and 3 are correct
B. 1 and 3 are correct
13. The first lymph node to which cancer is C. 2 and 4 are correct
most likely to spread from the primary D. ALL or ONLY 4 is correct
tumor:
19. Features of Ductal Carcinoma in Situ:
A. Rotter’s LN 1. Majority are in post-menopausal
B. Sentinel LN patients
C. Fernandez LN 2. Micro-calcification on mammography
D. Delphian LN 3. Axillary node metastases are rare
4. Modified radical mastectomy is the
14. The incidence of locally advanced Breast gold standard of treatment
CA as reported in the best medical school
in the country in 2002 is: Answer: A

A. 20% 20. Treatment options for Lobular Carcinoma

B. 30% in Situ:
C. 40% 1. Quadrantectomy
D. 50% 2. Bilateral Mastectomy with Immediate
Reconstruction
15. Characterized by chronic eczematoid 3. Modified Radical Mastectomy
eruption of the nipple: 4. Observation with Tamoxifen

A. Paget’s Disease Answer: D

B. Tubular Carcinoma
C. Medullary Carcinoma 21. Components of Modified Radical
D. Mucinous Carcinoma Mastectomy:
1. Total Mastectomy
16. True of Luminal A tumors: 2. Internal Mammary LN Sampling
3. Axillary LN Dissection
A. Incidence is 25% 4. Breast Augmentation
B. Usually a high grade tumor
C. Disease-free survival rate of 30% Answer: B
D. A response rate of 80% with
Tamoxifen
 22. True statements regarding conservative ABDOMINAL WALL & HERNIA
breast surgery:
1. Surgery may include lumpectomy or 26. True statements regarding Rectus
quadrantectomy Diastasis, EXCEPT:
2. Results of treatment are comparable
to Modified Radical Mastectomy for A. Abdominal wall bulging due to
Stage 1 and 2 disease separation of rectus muscles in the
3. Includes Radiotherapy as part of the midline
treatment B. May be mistaken for a Ventral Hernia
4. Popularized by Dr. William Halsted C. Majority of cases are congenital
D. CT scan is useful in doubtful cases
Answer: A
27. True statement regarding diagnosis and
23. True of Stage 3 Breast CA: treatment of Rectus Diastasis:
1. Also called locally advanced Breast
CA A. Cannot be differentiated clinically from
2. Presence of isolated bone metastasis a Ventral Hernia
3. Matted axillary nodal metastasis B. CT scan will show the aponeurotic
4. Bloody nipple discharge defect
C. Surgery consists of plication of the
Answer: B broad midline aponeurosis
D. All patients will eventually require
24. True statements regarding Breast CA surgery
during pregnancy:
1. Stage for stage carcinoma of the 28. The POSTERIOR rectus sheath is
breast in pregnancy is associated with deficient below this structure:
a prognosis similar to that of the non-
pregnant female A. Semi-circular Line of Douglas
2. There are more patients with Stages 2 B. Linea Semilunaris
and 3 Breast CAs diagnosed in C. Conjoined Tendon
pregnancy that in the general D. Transumbilical Line
population
3. Termination of pregnancy has no role 29. History and profile of most patients who
in the management of Stage 1 or 2 most frequently develop Rectus Sheath
disease Hematoma:
4. Modified Radical Mastectomy can be
undertaken only during the 2nd A. Athletes who are into contact sports
trimester of pregnancy B. Multiparous women following difficult
labor
Answer: A C. Elderly patients and those on anti-
coagulants
25. True of locally recurrent Breast CA after D. Patients with chronic lung disease
breast conservation surgery:
1. Curable in most cases 30. True statements regarding Rectus Sheath
2. Treatment is salvage MRM Hematoma, EXCEPT:
3. Seldom associated with distant
metastasis A. Fothergill sign positive
4. 40% 5-year survival rate B. Majority of patients are managed non-
surgically
Answer: A C. May be mistaken for an acute surgical
condition
D. All patients should be managed in
(Answers for questions on BREAST were dictated the hospital setting
by the facilitators and are ANSWER-KEY based.
The following are Dra. Lim’s answers only, no key
provided for Abdominal Wall and Hernia.)
31. True statements regarding Desmoid 37. Which of the following is FALSE regarding
Tumors, EXCEPT: Direct Inguinal Hernias?

A. They are benign tumors A. The most likely cause is destruction of

histologically but may metastasize connective tissue from physical stress
B. CT scan is the procedure of choice to B. Should be repaired promptly to
determine extent and resectability avoid risk of incarceration
C. Wide excision is the treatment of C. A direct hernia may be a sliding hernia
choice involving the bladder wall
D. Repair of the abdominal wall defect is D. An indirect hernia may co-exist with
accomplished with a mesh the direct hernia

32. The most common cause of Acute 38. The natural history of the majority of
Mesenteric Ischemia is: abdominal hernias is that:

A. Embolic occlusion of the SMA A. The defect will continue to enlarge

B. Acute mesenteric occlusion over time
C. Mesenteric vein thrombosis B. The defect will remain the same but
D. Low flow states will not disappear
C. The defect will eventually close if it’s
33. Which of the following statements is congenital
FALSE regarding the incidence of D. The eventually become incarcerated
abdominal wall hernias?
39. True statements regarding the floor of the
A. Two-thirds of all inguinal hernias are inguinal canal, EXCEPT:
classified as indirect
B. Femoral hernias are more common in A. The structure referred to is the
females transversalis fascia
C. Premature infants have a 10% B. The opening where the cord
incidence of inguinal hernias structure exits is the external ring
D. Hernias generally occur with equal C. This is the structure that attenuates in
frequency in males and females inguinal hernias
D. This is where Hesselbach’s Triangle is
34. Clinical feature that makes a bulge in the located
abdominal wall most likely to be hernia:
40. The borders of Hesselbach’s Triangle
A. (+) Fothergill sign include the following, EXCEPT:
B. It is incarcerated
C. It disappears with recumbency A. Lateral border of rectus muscle
D. It has been present since birth B. Inferior epigastric vessels
C. Transversus abdominis muscle
35. The most common anterior abdominal D. Inguinal ligament
hernia comprising 75%:
41. All are considered “tissue repair” types of
A. Inguinal Hernia herniorraphies, EXCEPT:
B. Umbilical Hernia
C. Incisional Hernia A. Lichtenstein Repair
D. Femoral Hernia B. Shouldice Repair
C. McVay Repair
36. True of Femoral Hernias: D. Bassini Repair
A. The most common hernia in females
B. Presents below the inguinal
ligament
C. Does not usually incarcerate
D. Unless strangulated, there is no
indication for surgery
42. Following a tissue based hernia repair, the C. Observe for now as the hernia may
most common cause of a hernia still close ‘til the infant is 5 years
recurrence is: old
D. Seek immediate consultation if the
A. Surgical site infection hernia does not spontaneously reduce
B. Unfamiliarity with the surgical anatomy
C. Unfamiliarity with the surgical 47. The recommended treatment advised for
technique the majority of Ventral Hernias is:
D. Tension across the sutured
structures A. Observe
B. Advise to wear abdominal binders or
43. All are clinical presentations of an Inguinal inguinal “supporters”
Hernia, EXCEPT: C. Elective surgery once diagnosed
D. Emergency surgery once complicated
A. Scrotal Mass
(Note: Should be “INGUINO-Scrotal”) 48. The procedure of choice for a 10 year old
B. Inguinal Mass boy with Indirect Inguinal Hernia:
C. Inguino-Scrotal Mass
D. Incarcerated Inguinal Mass A. High ligation of the hernial sac
B. Simple suture closure of the internal
44. True statements regarding Indirect ring
Inguinal Hernias, EXCEPT: C. Any of the tissue repairs (e.g. Bassini)
D. Mesh repair
A. Results from a patent processus
vaginalis (Dra. Lim: In GenSurg, the standard is MESH, but
B. Occurs medial to the inferior for PediaSurg, high ligation is recommended.) 
epigastric vessels
C. Are the most common hernias 49. The hernia that is LEAST likely to
D. The hernial sac may reach down to the incarcerate:
scrotum A. Indirect Inguinal Hernia
B. Direct Inguinal Hernia
45. Findings consistent with Indirect Inguinal C. Femoral Hernia
Hernia on PE with the examining finger D. Umbilical Hernia
inserted through the external ring and
patient is asked to cough: 50. A hernia is thought to be strangulated
when:
A. The examiner feels an impulse at
the tip of his finger A. It has been irreducible for more than 6
B. The examiner feels the impulse at the hours
pulp of his finger B. The patient develops fever and
C. Both A and B simultaneously leukocytosis
D. No impulse should be felt by the C. The hernia is extremely tender on
examiner palpation
D. There are inflammatory changes in
46. A 4 month old infant presents with a 2 cm the overlying skin
umbilical hernia that bulges when the
infant cries and disappears when he is
asleep. All are appropriate advice for the
mother, EXCEPT:

A. Immediate repair to prevent

complications
B. Emergency surgery if and when the
hernia incarcerates
 2016 (CD2017)
D

C
Premenopausal
B

D
B

godlike
 C

C
A?

D
B
B

A
B

B
A/B

godlike
C
 D

C?

B
A
B
B
A

C
D
C

godlike
 B/D

B Above- EO and IO
Below- EO,IO, TA

C Anterolateral hernia
Congenital hernia - abdominal to thoracic cavity

D
C

B
Multiple
B

godlike
 C

Acquired
B
Femoral

A EO

A
A
A
A
C
D Pantaloon or femoral hernia
D
C Femoral
B?

B
A
B
A
C
B
C
B/C
A
A

godlike
 Dankey
TOPIC  1:  MIXED  BREAST  TOPICS  
1. Not  a  cause  of  Gynecomastia:  EXCESS  CIRCULATING  TESTOSTERONE  IN  RELATION  TO  ESTROGEN  
2. Common  reason  for  surgery  in  gynecomastia:  SOCIAL  STIGMA  BECAUSE  OF  THE  ENLARGED  BREAST  
3. Common  to  all  patients  with  Gynecomastia  is:  AN  EXCESS  OF  ESTROGENS  IN  RELATION  TO  CIRCULATING  
TESTOSTERONE  
4. Route  of  breast  cancer  metastases  to  the  vertebrae,  skull,  pelvic  bones,  and  central  nervous  system:  BATSON’S  
PLEXUS  
5. The  group  of  Lymph  nodes  intersposed  between  the  pectoralis  major  and  minor  muscles:  ROTTER’S  NODES  
6. Fibrous  band  within  the  breast  that  tends  support  and  form:  SUSPENSORY  LIGAMENT  OF  COOPER  
7. Chronic  eczematoid  eruption  of  the  nipple:  PAGET’S  DISEASE  
8. Nipple  discharge  may  be  the  initial  presentation:  PAGET’S  DISEASE  
9. Soft,  hemorrhagic  bulky  mass:  MEDULLARY  CARCINOMA  
10. 25-­‐70%  risk  for  invasive  CA  in  5  years:  DUCTAL  CARCINOMA  IN  SITU  (DCIS)  
11. Risk  of  developing  cancer  is  21%  over  15  years:  LOBULAR  CARCINOMA  IN  SITU  (LCIS)  
12. Most  common  form  of  breast  CA:  INFILTRATING  DUCTAL  CARCINOMA  W/PRODUCTIVE  FIBROSIS  
13. Soft,  hemorrhagic  bulky  tumors  can  grow  to  a  large  size  within  the  breast  (5-­‐10  cm):  MEDULLARY  CARINOMA  
14. 75-­‐80%  of  all  cases  of  breast  cancer:  INVASIVE  DUCTAL  CARCINOMA  
15. High  propensity  for  bilaterality,  multicentricity  &  multifocality  among  the  variant  of  invasive  breast  carcinoma:  
INVASIVE  LOBULAR  CARCINOMA  
16. Not  usually  considered  as  breast  cancer:  INFLAMMATORY  CARCINOMA  
17. Peau  d’  orange  and  skin  ridging  w/  or  w/o  a  palpable  mass:  INFLAMMATORY  CARCINOMA  
18. Inflammatory  CA  of  the  breast  is  characterized  by:  LETHAL  AND  AGGRESSIVE  FORM  OF  BREAST  CA.  
19. Most  differentiated  variant  of  invasive  breast  CA:  TUBULAR  CARCINOMA  
20. Cut  surface:  glistening,  glaring  &  gelatinous:  MUCINOUS  CARCINOMA  
21. Secretory  carcinoma:  JUVENILE  CARCINOMA  
22. Most  common  form  of  breast  cancer  in  children  and  adolescents:  SECRETORY  CARCINOMA  
23. Lowest  frequency  of  axillary  nodal  involvement  among  the  variants  of  invasive  breast  CA:  PAPILLARY  CARCINOMA  
24. True  about  fibrocystic  change:  USUALLY  PRESENTS  AS  A  BREAST  MASS  
25. A  reddish,  tender,  warm  breast  in  a  nursing  mother  is  most  likely  suffering  from:  ACUTE  MASTITIS  
26. True  about  fibrocystic  change:  ANTI-­‐FOLLICLE  STIMULATING  HORMONE  IS  ONE  OF  THE  ACCEPTED  TREATMENTS  
27. Characteristic  of  a  pathologic  nipple  discharge:  SPONTANEOUS  ESPECIALLY  IF  BLOODY  
28. For  someone  who  presents  with  bloody  nipple  discharge,  the  most  likely  diagnosis  is:  INTRADUCTAL  PAPILLOMA  
29.  20  y/o  complaining  of  bilateral  breast  tenderness  just  before  menses  with  no  associated  breast  findings  on  PE  is  most  
likely  suffering  from:  NORMAL  PREMENSTRUAL  TENSION  
30. Sine  qua  non  of  breast  cancer  in  Mammography  is:  SPICULATED  DENSITY  WITH  ILL  DEFINED  MARGIN  
31. A  chronic  ulcer  of  the  breast  with  draining  sinus  in  the  slum  areas  of  the  third  world  is  most  likely:  TB  MASTITIS  
32. The  most  common  breast  problem  why  females  consult  a  physician  is:  BREAST  TENDERNESS  
33. Breast  cancers  that  are  triple  negative  (ER,  PR,  HER  2  neu  negative)  are  characteristically:  POORLY  DIFFERENTIATED  
34. A  humanized,  monoclonal  antibody  with  specificity  for  the  extracellular  domain  of  the  human  epidermal  growth  factor  
receptor  2  (HER  2/neu):  TRASTUZUMAB  
35. The  first  lymph  node  to  which  cancer  is  likely  to  spread  from  the  primary  tumor:  SENTINEL  LYMPH  NODE  
36. Most  important  prognostic  correlate  for  recurrent  disease  &  survival  in  breast  cancer:  AXILLARY  NODE  STATUS  
37. True  regarding  Phylloides  tumor:  LOCALLY  INVASIVE  
38. Radiotherapy  after  breast  conservative  treatment  will  lead  to:  REDUCTION  OF  LOCAL  RECURRENCE  
39. Herceptin  when  added  to  chemotherapy  as  an  adjuvant  treatment  for  breast  cancer  with  positive  axillary  lymph  nodes  
results  in  reduction  of  recurrence  by  how  many  percent:  50%  
40. Standard  treatment  option  for  locally  advanced  breast  carcinoma:  INDUCTION  CHEMOTHERAPY,  SURGERY  AND/OR  
RADIOTHERAPY  
41.  Components  of  breast  conservative  treatment:  
a. LUMPECTOMY/QUADRANTECTOMY  
b. AXILLARY  LYMPH  NODE  DISSECTION  
c. RADIOTHERAPY  
 

 
 42. Locally  advanced  breast  cancer:    
a. TUMORS  WITH  SKIN  OR  CHEST  WALL  INVOLVEMENT  (T4)  
b. INTERNAL  MAMMARY  LN  METASTASIS  (N3)  
43. Advantages  of  Induction  chemotherapy:  
A. REDUCTION  OF  THE  INITIAL  TUMOR  BURDEN  BEFORE  SURGERY  
B. ABILITY  TO  TREAT  THE  POTENTIAL  SYSTEMIC  DISEASE  W/O  DELAY  
C. ABILITY  TO  ASSESS  THE  RESPONSE  OF  THE  TUMOR  TO  THE  TREATMENT  BEING  RENDERED  
44. The  treatment  of  choice  for  carcinoma  of  the  male  breast  is:  MODIFIED  RADICAL  MASTECTOMY  
45. Most  common  operation  performed  for  breast  cancer  in  the  Philippines:  MODIFIED  RADICAL  MASTECTOMY  
46. The  factor  LEAST  associated  with  an  increased  risk  for  the  development  of  breast  cancer  is:  MULTIPLE  
FIBROADENOMAS  
47. A  positive  estrogen  receptor  assay  would  point  to  the  following:    
A. GOOD  PROGNOSIS  
B. GOOD  RESPONSE  TO  HORMONAL  THERAPY  
C. WELL  DIFFERENTIATED  TUMOR  
48. Modified  radical  mastectomy  has  gained  much  popularity  in  the  treatment  of  Breast  Carcinoma  because:  
A. BREAST  RECONSTRUCTION  IS  EASIER  TO  DO  
B. CAUSES  LESS  FUNCTIONAL  AND  COSMETIC  IMPAIRMENT  
C. RESULTS  OF  TREATMENT  IS  COMPARABLE  TO  MORE  RADICAL  PROCEDURES  
49. True  statement/s  regarding  statistics  for  Breast  Cancer:  
A. BREAST  CA  IS  THE  SECOND  MOST  COMMON  CANCER  IN  BOTH  SEXES  
B. CANCER  OF  THE  BREAST  IS  THE  MOST  COMMON  CAUSE  OF  CANCER  IN  FEMALE  
50. Etiology  of  Breast  Cancer  includes  the  following:    
A. FAMILY  HISTORY  
B. IRRADIATION  TO  THE  CHEST  
51. Contraindication/s  to  breast  conservative  surgery:  
A. LOCALLY  ADVANCED  BREAST  CANCER  
B. MULTIPLE  TUMORS  W/IN  THE  BREAST  CONFIRMED  TO  BE  MALIGNANT  
C. LARGE  TUMOR  IN  A  SMALL  BREAST  
52. Locally  advanced  breast  cancer:  
A. MATTED  AXILLARY  NODAL  METASTASIS  
B. SUPRACLAVICULAR  LN  METASTASIS  
53. True  of  sentinel  node  
A. FIRST  AXILLARY  LYMPH  NODE  THAT  GETS  HIT  BY  METASTASIS  
B. PROSPECTIVE  RANDOMIZED  TRAILS  HAVE  SHOWN  THE  SAFETY  OF  OMITTING  AXILLARY  LYMPH  NODE  
DISSECTION  (ALND)  FOR  WOMEN  WHOSE  SENTINEL  NODE  (SN)  IS  FREE  OF  METASTATIC  DISEASE  
C. DETECTED  USUALLY  BY  USE  OF  ISOSULFAN  DYE,  METHYLENE  BLUE  AND  PATENT  BLUE  DYE  WITH  OR  
WITHOUT  RADIOCOLLOID  
 
TOPIC  2:  ANATOMY  OF  THE  ANTERIOR  ABDOMINAL  WALL  
1. The  aponeuroses  of  external  and  internal  oblique  muscles  form  the  anterior  rectus  sheat:  ABOVE  THE  ACRUATE  LINE  
2. The  aponeuroses  of  external  and  internal  oblique  muscles  and  the  transversus  abdominis  muscle  form  the  anterior  
rectus  sheath:  BELOW  THE  SEMICURCULAR  LINE  OF  DOUGLAS  
3. The  blood  supply  ot  the  muscles  of  the  anterior  abdominal  wall:  SUPERIOR  &  INFERIOR  EPIGASTRIC  ARTERIES  
4. A  Fothergill  test  shows  that  the  mass  persists  on  flexing  the  abdomen.  The  test  is  used  to  differentiate:  ABDOMINAL  
WALL  MASS  FROM  INTRAABDOMINAL  MASS  
 
TOPIC  3:  RECTUS  SHEATH  HEMATOMA  (RSH)  
A  25-­‐year  old  male,  complaiened  of  sudden  sever  abdominal  pain  while  doing  abdominal  crunches.  On  PE,  he  is  tachycardic  but  
normal  BP.  Abdominal  exam  shows  a  tender  palpable  mass  at  the  anterior  abdomen  above  the  umbilicus.    
1. This  is  most  likely:  RECTUS  SHEATH  HEMATOMA  
2. The  mass  is  most  likely  located  in  the  anterior  abdominal  wall  if  upon  flexing  the  abdominal  wall,  there  is:  
PERSISTENCE  OF  ABDOMINAL  MASS  

 
 3. Clinical  features  of  RSH:  
a. SUDDEN  ABDOMINAL  PAIN  WITH  CONTRACTION  OF  RECTUS  MUSCLES  
b. PALPABLE  TENDER  MASS  ON  ANTERIOR  ABDOMINAL  WALL  
4. Diagnostic  for  RSH:  HISTORY  &  PE  
5. Diagnostic  procedure  of  choice  in  RSH:  CT  SCAN  
6. If  the  mass  is  non-­‐expanding  and  the  patient  is  stable,  this  is  managed  by:    
a. ANALGESICS  
b. COLD  COMPRESS  
7. If  the  mass  is  nonexpanding  but  the  patient  is  unstable,  this  patient  is  best  managed  by:  REVERSAL  OF  
ANTICOAGULATION  THERAPY  
8. If  the  mass  is  expanding  and  the  patient  is  unstable,  the  best  management  is:  
a. ANGIOGRAPHY  WITH  EMBOLIZATION  
b. SURGICAL  EXPLORATION  
9. In  patients  who  will  require  surgical  exploration  for  rectus  sheath  hematomas,  this  is  true:  ANGIOGRAPHIC  
EMBOLIZATION  NOT  NECESSARY  
10. Angiography  is  required  in  almost  all  patients  with  rectus  sheath  hematoma:  FALSE  
11. A  50-­‐year  old  multigravid  female  presents  with  bulging  of  the  midline  abdomen  especially  on  straining.  On  PE,  there  
seems  to  be  a  defect  at  the  midline.  These  statements  best  describe  this  woman’s  condition:    
a. DUE  TO  A  SEPARATION  OF  THE  RECTUS  ABDOMINIS  MUSCLE  PILLARS  
b. BULGING  OF  THE  ABDOMINAL  WALL  MISTAKEN  FOR  A  VENTRAL  HERNIA  
c. MAY  BE  CONGENITAL  
 
TOPIC  4:  OMENTAL  INFARCTION  
1. Differential  diagnosis:  TWISTED  OVARIAN  CYST  
2. Patients  with  omental  infarction  typically  present  with  signs  of  an:  ACUTE  ABDOMEN  
3. Many  cases  of  omental  infarction  are:  CLINICALY  INDISTINGUISHABLE  
4. Omental  infarction  is  frequently  diagnosed:  INTRAOPERATIVELY  
5. Omental  infarction  is  a  common  cause  of  an  acute  abdomen:  FALSE  
6. Plain  abdominal  x-­‐rays  of  patients  with  omental  infarction  will  show  pneumoperitoneum:  FALSE  
7. Omental  torsion  is  a  relatively  common  condition:  FALSE  
8. Omental  torsion  is  commonly  caused  by  a  tumor  in  the  omentum:  FALSE  
9. A  diagnostic  and  therapeutic  procedure  to  manage  omental  torsion:  LAPAROSCOPY  
 
TOPIC  5:  MESENTERIC  CYST  
1. Acute  abdominal  pain  of  mesenteric  cyst  is  generally  caused  by:    
a. RUPTURE  
b. TORSION  
c. ACUTE  HEMORRHAGE  
2. Highly  recommended  management  to  mesenteric  cysts  because  they  have  a  high  propensity  to  recur:  CYST  EXCISION  
3. Chronic  intermittent  abdominal  pain  in  mesenteric  cysts  is  secondary  to  vascular  thrombosis:  FALSE  
4. In  mesenteric  cyst,  PE  may  reveal  an  abdominal  mass  that  is  fixed  (Tillaux’s  sign):  FALSE  
 
TOPIC  6:  RETROPERITONEAL  ABSCESS  
1. Inferior  boundary  of  the  retroperitoneum:  PELVIS  
2. Patients  seek  treatment  early  in  retroperitoneal  abscess:  TRUE  
3. Retroperitoneal  abscess  usually  presents  with:  NON-­‐SPECIFIC  SYMPTOMS  
4. Management  of  retroperitoneal  infections:  
a. IDENTIFICATION  AND  TREATMENT  OF  THE  UNDERLYING  CONDITION  
b. IV  ADMINISTRATION  OF  ANTIBIOTICS  
5. Unilocular  abscesses  are  best  treated  by:  CT-­‐GUIDED  ASPIRATION  
 
TOPIC  7:  RETROPERITONEAL  FIBROSIS  
1. Retroperitoneal  fibrosis  affects  individuals  in  this  group:  MIDDLE  AGE  

 
 2. Retroperitoneal  fibrosis  is  a  common  disorder  affecting  2  in  100,000  patients  annually:  FALSE  
3. Circulating  antibodies  against  albumin  are  found  in  more  than  90%  of  patients  in  retroperitoneal  fibrosis:  FALSE  
 
TOPIC  8:  RETROPERITONEAL  SARCOMA  
A  58  year-­‐old  male  presents  with  a  palpable  mass  of  one  month  duration  accompanied  by  weight  loss.  On  PE,  the  mass  is  
smooth  with  ill-­‐defined  borders  and  not  movable.  CT  scan  reveals  an  8  cm  tumor  in  the  retroperitoneum  
1. The  most  likely  diagnosis:  LIPOSARCOMA  
2. The  patient  is  best  managed  by:  SURGICAL  EXCISION  
3. The  posterior  boundary  of  the  abdominal  wall  is  the:  VERTEBRAL  COLUMN  
4. In  patients  with  retroperitoneal  tumors  who  are  candidates  for  surgery,  these  are  not  preferred  prior  to  surgery:    
a. ULTRASOUND  GUIDED  FNAB  
b. CT  GUIDED  FNAB  
c. OPEN  BIOPSY  
5. The  most  important  prognostic  factor  for  patients  with  sarcoma:  HISTOLOGIC  GRADE  
6. The  features  that  define  histologic  grade  of  sarcomas:  NUMBER  OF  MITOTIC  FIGURES  
7. Role  of  CT  Scan  in  RPS:  
a. DIAGNOSTIC  PROCEDURE  OF  CHOICE  
b. ASSESS  LIVER  OR  PERITONEAL  METASTASES  
c. ASSESS  RESECTABILITY  
8. True  about  RPS:  EQUAL  M:F  sex  ratio  
9. 18  months  after  undergoing  a  curative  resection  for  a  retroperitoneal  liposarcoma,  this  patient  presented  with  a  
solitary  pulmonary  nodule  on  the  right  upper  lung  on  follow-­‐up  chest  x-­‐ray.  The  next  best  thing  to  do  is:  CHEST  CT-­‐
SCAN  
10. If  this  patient  has  pulmonary  metastasis,  these  are  factors  that  will  affect  treatment:  
a. PRESENCE  OF  LIVER  METASTASES  
b. PRESENCE  OF  LOCAL  RECURRENCE  
c. KARMOFKSY  PERFORMANCE  STATUS  
11. If  the  above  patient  has  a  Karnofsky  performance  status  of  50%,  and  the  tumor  is  resectable,  the  best  initial  
management  is:  LAPAROTOMY  
12. Management  of  patients  with  pulmonary  metastasis  with  no  evidence  of  disease  in  other  areas  is  best  treated  with:  
PULMONARY  METASTECTOMY  W/  RESECTION  
13. Favorable  prognostic  factors  in  patients  undergoing  pulmonary  metastectomy  due  to  sarcomas:  COMPLETE  REMOVAL  
OF  METASTASES  
14. Surveillance  following  complete  resection  of  low  grade  retroperitoneal  sarcoma:  CT  SCAN  EVERY  3-­‐6  MONTHS  FOR  2  
YEARS  THEN  YEARLY  
15. In  patients  with  retroperitoneal  malignant  lymphoma,  this  patient  is  best  managed  by:  CHEMOTHERAPY  ALONE  
 
TOPIC  9:  ACUTE  MESENTERIC  ISCHEMIA  
An  85-­‐year  old  female  patient  with  atrial  fibrillation  develops  suddent  onset  of  severe  abdominal  pain.  On  PE,  there  is  minimal  
tenderness  and  guarding.  Vital  signs  show  tachychardia  with  normal  BP  and  temperature.  Bowel  sounds  are  hypoactive.  
1. The  most  likely  diagnosis  is:  ACUTE  MESENTERIC  ISCHEMIA  
2. If  the  scout  film  of  the  abdomen  is  done,  findings  that  will  suggest  bowel  ischemia  include:  THUMB  PRINTING  OF  THE  
BOWEL  WALL  
3. On  chest  auscultation,  the  heart  sounds  are  irregular.  ECG  shows  atrial  fibrillation.  The  most  likely  cause  of  AMI  is:  
MESENTERIC  VENOUSE  THROMBOSIS  
4. Clinical  parameter  which  will  help  early  diagnosis  of  acute  mesenteric  ischemia:  HIGH  INDEX  OF  SUSPICION  
5. PE  finding  which  is  highly  sensitive  for  the  diagnosis  of  acute  mesenteric  ischemia:  NONE  
6. The  above  patient  is  best  managed  by:  SURGICAL  EMBOLECTOMY  
 
A  patient  with  severe  abdominal  pain  with  minimal  abdominal  findings  with  thumb  printing  and  pneumatosis  intestinalis  on  
abdominal  x-­‐rays  
1. The  single  most  important  diagnostic  test  for  the  above  patient:  SELECTIVE  MESENTERIC  ANGIOGRAPHY  
2. This  patient  most  likely  has:  ACUTE  MESENTERIC  OCCULUSION  WITH  GANGERNOUS  BOWEL  

 
 3. The  above  patient  is  best  managed  by:  LAPAROTOMY  
 
TOPIC  10:  ANATOMY  OF  THE  INGUINAL  AREA  
1. Inguinal  ligament:  ASIS  TO  PUBIC  TUBERCLE  
2. Inguinal  ligament  may  be  used  for:  HERNIA  REPAIR  
3. Inguinal  ligament  is  also  known  as  Poupart’s  ligament:  FALSE  
4. Nerve  which  travels  with  the  spermatic  cord  from  the  internal  to  the  external  ring:  ILIO-­‐INGUINAL  NERVE  
5. Medial  boundary  of  Hesselbach’s  triangle:  LATERAL  BORDER  OF  THE  RECTUS  
6. Lateral  boundary  of  the  Hesselbach’s  triangle:  INFERIOR  EPIGASTRIC  VESSEL  
7. Inferior  boundary  of  the  Hesselbach’s  triangle:  INGUINAL  LIGAMENT  
8. Features  of  Hesselbach’s  triangle:    
a. DEVOID  OF  MUSCLES  
b. MESH  IS  PLACED  
c. COMPOSED  OF  APONEUROSIS  
9. The  superficial  boundary  of  the  inguinal  canal:  EXTERNAL  OBLIQUE  APONEUROSIS  
10. The  conjoined  tendon  is  formed  by  the:    
a. MEDIAL  ASPECT  OF  THE  INTERNAL  OBLIQUE  APONEUROSIS  
b. TRANSVERSE  ABDOMINIS  APONEUROSIS  
11. The  conjoined  tendon  is  present  only  in:  5-­‐10%  OF  PATIENTS  
12. Boundaries  of  the  femoral  ring:    
a. FEMORAL  VEIN  
b. SUPERIOR  PUBIC  RAMUS  
c. IDIOPUBIC  TRACT  
13. The  transversus  abdominis  aponeurotic  arch  is  formed  by:  
a. TRANSVERSUS  ABDOMOINIS  ARCHES  
b. EXTERNAL  OBLIQUE  MUSCLE  
c. INTERNAL  OBLIQUE  MUSCLE  
 
TOPIC  11:  INGUINAL  HERNIA  
1. Testicular  torsion,  epididymo-­‐orchitis,  testicular  torsion  may  present  as:  PAINFUL  SCROTAL  MASS  
2. Majority  of  inguinal  hernias:  INDIRECT  
3. A  decrease  in  this  tissue  protein  has  been  observed:  HYDROXYPROLINE  
4. These  are  risk  factors  in  the  pathogenesis  of  inguinal  hernia:  
a. ADVANCED  AGE  
b. HEAVY  EXERCISE  
c. OBSTRUCTING  COLON  CANCER  
d. CHRONIC  INCREASE  IN  INTRAABDOMINAL  PRESSURE  
e. INTRINSIC  ABNORMALITIES  OF  COLLAGEN  FORMATION  
f. PREMATURE  INFANTS  
5. Hernias  in  general  are  more  common  in:  FEMALES  
6. Surgery  is  advised  before  patient  reaches  school  age  in  infants  and  children  with  inguinal  hernia:  FALSE  
7. Majority  of  the  hernias  in  infants  and  children:  UNILATERAL  
8. Inguinal  hernias  are  associated  with  a  high  incidence  of  strangulation:  FALSE  
9. Inguinal  ring  contains  a  Meckel’s  diverticulum:  FALSE  
10. Inguinal  hernias  are  best  treated  laparoscopically:  FALSE  
 
TOPIC  12:  DIRECT  INGUINAL  HERNIA  
1. Majority  of  direct  inguinal  hernias:  CONGENITAL  
2. Surgery  is  advised  for  direct  inguinal  hernias  once  diagnosed:  FALSE  
3. The  following  are  contributory  factors  in  the  development  of  direct  inguinal  hernia:    
a. WEAKNESS  OF  THE  ILIOPUBIC  TRACT  
b. LIMITED  INSERTION  OF  THE  ILIOPUBIC  TRACT  APONEUROSIS  INTO  THE  COOPER’S  LIGAMENT  
c. LIMITED  INSERTION  OF  THE  TRANSVERSE  ABDOMINIS  MUSCLE  INTO  THE  PUBIS  

 
 d. ACQUIRED  WEAKNESS  IN  THE  ABDOMINAL  WALL  
4. Features  of  direct  inguinal  hernia:  
a. COMMON  IN  HESSELBACH’S  TRIANGLE  
b. MORE  RECURRENT  TYPE  AFTER  REPAIR  
c. MEDIAL  TO  INFERIOR  EPIGASTRIC  ARTERY  
 
TOPIC  13:  INDIRECT  INGUINAL  HERNIA  
40-­‐year  old  man  was  brought  to  the  emergency  room  of  UST  hospital  because  of  right  inguinal  mass  of  8  months  duration,  
which  appears  after  lifting  heavy  object.  Prior  to  this  event,  the  mass  appears  on  standing,  disappears  on  lying  down,  and  the  
mass  extends  up  to  the  scrotum.  
1. The  most  likely  diagnosis  is:  INDIRECT  INGUINAL  HERNIA,  COMPLETE  REDUCIBLE  
2. The  usual  initial  presentation  of  an  indirect  inguinal  hernia  in  a  young  adult:  REDUCIBLE  INGUINAL  MASS  
3. When  physical  examination  is  doubtful  regarding  the  presence  of  an  inguinal  hernia,  the  following  test  offers  the  
highest  sensitivity:  MRI  
4. The  initial  treatment  to  be  done  in  the  ER  are:    
a. GIVE  IV  FLUIDS  
b. GIVE  MUSCLE  RELAXANT  
c. APPLY  ICEBAG  ON  THE  RIGHT  SCROTUM  
d. TRENDELENBURG  POSITION  
5. The  treatment  of  choice:  ADMIT  AND  OPERATE  ON  ADMISSION  
6. After  10  minutes  of  manual  manipulation,  the  hernia  was  reduced.  The  treatment  of  choice:  INGUINAL  
HERNIORRHAPHY  TO  BE  DONE  ONE  DAY  AFTER  ADMISSION  
th
7. On  the  5  postoperative  day,  the  testicle  and  spermatic  cord  became  swollen,  hard,  tender  and  retracted.  The  patient  
is  suffering  from:  ISCHEMIC  ORCHITIS  
8. Spontaneous  reduction  of  the  hernia  in  the  pre-­‐op  period  is  proof  that  the  contents  were  not  strangulated:  FALSE  
9. Percentage  of  adult  patients  presenting  with  a  unilateral  indirect  inguinal  hernia  that  will  have  an  unrecognized  
contralateral  hernia  verified  by  laparoscopy:  20%  
10. Features  of  indirect  hernia  
a. HERNIA  SAC  REACHES  THE  SCROTUM  
b. PASSES  THROUGH  THE  INTERNAL  INGUINAL  RING  
c. LATERAL  TO  INFERIOR  EPIGASTRIC  ARTERY  
d. PRONE  TO  LACERATION  
e. PERSISTENTLY  PATENT  PROCESSUS  VAGINALIS  
f. REQUIRES  HIGH  LIGATION  OF  THE  SAC  &  REPAIR  OF  THE  FLOOR  
g. HIGH  RISK  OF  STRANGULATION  
 
A  29-­‐year  old  male  waiter  was  admitted  because  of  a  right  inguino-­‐scrotal  mass  of  6  hours  duration.  In  his  teenage  years,  the  
mass  would  appear  when  lifting  heavy  objects,  coughing  and  sneezing  and  disappear  spontaneously  upon  lying  in  supine  
position  or  by  manual  reduction  
1. The  most  likely  diagnosis:  INDIRECT  INGUINAL  HERNIA  
2. 6  hours  prior  to  admission,  upon  carrying  a  pail  of  water,  the  mass  appeared  on  the  right  scrotum  and  at  this  time,  it  
cannot  be  reduced  anymore  even  with  manual  reduction.  This  was  accompanied  by  nausea  and  vomiting  and  
generalized  abdominal  pain.  The  severity  of  the  pain  prompted  the  patient  to  seek  consult  and  subsequently  admitted.  
PE  abdomen  hyperactive  bowel  sounds,  tenderness  on  admission.  Presence  of  a  6x6  cm  right  scrotal  mass,  tender  and  
irreducible.  The  most  likely  diagnosis:  INCARCERATED  HERNIA  
3. These  are  appropriate  steps  in  the  management:  
a. PATIENT  IS  ADVISED  ADMISSION  FOR  EMERGENCY  HERNIA  REPAIR  
b. PRE-­‐OPERATIVE  ANTIBIOTICS  ARE  GIVEN  
c. REDUCTION  OF  THE  HERNIA  IS  ATTEMPTED  PRE-­‐OPERATIVELY  
 
TOPIC  14:  FEMORAL  HERNIA  
1. Femoral  hernias:  
a. MORE  COMMON  IN  FEMALES  

 
 b. MORE  PRONE  TO  INCARCERATION  
2. Femoral  hernia  pass:  
a. UNDER  THE  INGUINAL  LIGAMENT  ANTEROMEDIAL  
b. MEDIAL  TO  FEMORAL  ARTERY  &  VEIN  
 
TOPIC  15:  RECURRENT  INGUINAL  HERNIA  
A  50-­‐year  old  man  who  is  an  athlete  is  diagnosed  to  have  recurrent  inguinal  hernia.  
1. In  patients  with  recurrent  inguinal  hernia,  the:  PREVIOUS  REPAIR  IS  SIGNIFICANT  
2. If  his  previous  repair  was  open,  the  choice  now  is:  LAPAROSCOPIC  MESH  REPAIR  
3. A  patient  with  recurrent  inguinal  hernia  has  to  refrain  from  sports  for  4-­‐6  weeks  after  surgery:  FALSE  
 
TOPIC  16:  MANAGEMENT  OF  INGUINAL  HERNIA  
1. This  has  the  lowest  recurrence  rates  following  open  hernia  repair:  SHOULDICE  REPAIR  
2. Most  commonly  affected  nerve  during  open  hernia  repair:  
a. ILIOINGUINAL  NERVE  
b. ILIOHYPOGASTRIC  NERVE  
c. GENITAL  BRANCH  OF  THE  GENITOFEMORAL  NERVE  
3. Procedure  of  choice  in  infants  and  children  with  inguinal  hernias:  HIGH  LIGATION  OF  THE  HERNIAL  SAC  
4. For  large,  complete  indirect  hernias,  a  mesh  repair  is  indicated:  FALSE  
5. Treatment  for  inguinal  hernias  in  reducing  recurrence  rates:  MESH    
6. Mesh-­‐plug  hernia  repair:  
a. PERFORMED  FOR  INDIRECT,  DIRECT  &  RECURRENT  
b. DOES  NOT  REQUIRE  SPINAL  ANESTHESIA  
7. Patients  are  advised  bed  rest  post-­‐op  for  2-­‐3  days  in  mesh-­‐plug  hernia  repair:  FALSE  
8. Manual  labor  is  restricted  for  4-­‐6  weeks  in  mesh-­‐plug  hernia  repair:  FALSE  
9. These  conditions  will  lead  to  a  decrease  in  the  incidence  of  recurrence  rates  following  hernia  surgery:  
a. ROUTINE  USE  OF  PROSTHETIC  MATERIALS  
b. ACCEPTANCE  OF  THE  ‘TENSION-­‐FREE’  REPAIR  
c. USE  OF  LAPAROSCOPY  IN  HERNIA  REPAIR  
10. The  most  important  concept  that  has  led  to  a  decrease  in  recurrence  rates  following  hernia  repair:  TENSION-­‐FREE  
REPAIR  
11. Modification  in  the  Bassini  repair  will  lead  to  a  decrease  in  the  incidence  of  recurrence  rates  following  hernia  surgery:  
FALSE  
12. Inguinal  hernias  are  best  treated  laparoscopically:  FALSE  
13. Indications  for  abdominal  exploration  in  case  of  inguinal  hernia:  
a. TO  ASSESS  BOWEL  INABILITY  AND  THE  NEED  FOR  RESECTION  IF  THE  PRESENCE  OF  NECROTIZED  BOWEL  IS  
SUSPECTED  
b. PRESENCE  OF  DARK  OR  BLOODY  FLUID  WITHIN  THE  PERIOTNEAL  SAC  
c. SIGNS  &  SYMPTOMS  OF  PERITONITIS  
14. The  most  likely  complication  that  may  happen  during  inguinal  herniorrhaphy:  WOUND  INFECTION  
15. The  most  common  complication  of  elective  herniorrhaphy:  URINARY  RETENTION  
 
TOPIC  17:  UMBILICAL  HERNIA  
1. Umbilical  hernia  in  adults  are  due  to:  GRADUAL  WEAKENING  OF  THE  PERIUMBILICAL  FASCIAL  TISSUE  
2. Repair  in  adults  with  umbilical  hernia  is  generally  indicated:  TRUE  
3. Umbilical  hernia  represents  the  embryonic  equivalent  of  a  small  omphalocoele:  FALSE  
4. In  umbilical  hernias,  repair  in  infants  is  usually  deferred  until  approximately  1  year  old:  FALSE  
5. The  usual  presenting  symptom  in  infants  with  umbilical  hernia  is  incarceration:  FALSE  
 
TOPIC  18:  INCISIONAL  HERNIA  
A  46-­‐year  old  female  is  diagnosed  to  have  an  incisional  hernia  form  a  previous  midline  CS  scar.  
1. Factors  that  will  lead  to  incisional  hernia:    
a. POOR  SURGICAL  TECHNIQUE  

 
 b. POSTOPERATIVE  WOUND  INFECTION    
c. SMOKER’S  COUGH  
2. The  most  common  cause  of  incisional  hernia:  INADEQUATE  FASCIAL  CLOSURE  
3. Repair  of  these  hernias  have  up  to:  30%  RECURRENCE  RATE  
4. Decreased  the  recurrence  in  the  repair  of  incisional  hernia:  USE  OF  PROSTHETIC  MATERIALS  
5. The  overall  incidence  of  incisional  hernias  is  from:  2-­‐10%  AFTER  SURGERY  
6. Comorbid  conditions  like  obesity  and  diabetes  are  not  significant  factors  in  patients  with  incisional  hernias:  FALSE  
 
TOPIC  19:  SLIDING  HERNIA  
1. A  type  of  hernia  when  an  internal  organ  comprises  a  portion  of  the  wall  of  the  hernia  sac:  SLIDING  HERNIA  
2. The  most  common  viscus  involved  in  sliding  hernia:  COLON  OR  URINARY  BLADDER  
3. The  primary  danger  associated  with  sliding  hernia:  FAILURE  TO  RECOGNIZE  THE  VISCERAL  COMPONENT  OF  THE  
HERNIA  SAC  BEFORE  INJURY  TO  THE  BOWEL  OR  BLADDER  
 
TOPIC  20:  OTHER  HERNIAS  
1. Weakening  of  the  obturator  membrane  may  result  in  enlargement  of  the  obturator  canal  and  lead  to  formation  of  this  
type  of  hernia:  OBTURATOR  HERNIA  
2. Weakness  of  the  lumbodorsal  fascia  through  either  the  superior  lumbar  triangle  or  inferior  lumbar  triangle  lead  to  the  
formoation  of  this  type  of  hernia:  LUMBAR  HERNIA  
3. The  risks  of  surgical  site  infection  (SSI)  can  be  decreased  by:    
a. USING  PROPER  OPERATIVE  TECHNIQUE  
b. PREOPERATIVE  ANTISEPTIC  SKIN  PREPARATION  
c. APPROPRIATE  HAIR  REMOVAL  (SHAVING)  
4. A  40-­‐year  old  woman  complains  of  abdominal  pain  which  presents  with  signs  and  symptoms  of  small  bowel  
obstruction.  Past  history-­‐  no  previous  abdominal  surgery.  PE  –  no  palpable  abdominal  mass  in  the  groin,  hernia  region.  
Presence  of  localized  point  of  tenderness  over  a  small  region  inferior  to  the  umbilicus  and  lateral  to  the  rectus  
abdominal  muscle.  This  is  your  diagnosis:  SPEGILEAN  HERNIA  
5. Littre’s  hernia  contains:  INTESTINAL  DIVERTICULUM  
6. Richter’s  hernia  involves:  ANTIMESENTERIC  PORTION  OF  INTESTINE  
7. Type  of  hernia  which  can  result  in  strangulation  and  necrosis  in  the  absence  of  intestinal  obstruction:  RICHTER  HERNIA  
8. A  type  of  hernia  which  results  when  the  contents  of  an  incarcerated  hernia  becomes  ischemic  secondary  to  tissue  
swelling  and  compromised  blood  supply:  STRANGULATED  HERNIA  
9. Pantaloon  hernia:  DIRECT  &  INDIRECT  COMPONENT  SURROUNDS  INFERIOR  EPIGASTRIC  VESSELS  
 
 

 
 2014 (CD2015)
 
C2015    
Surgery2:  Module  4  
Quiz  #2:  Hernia  and  breast  
   
 
I  didn’t  get  number  1  and  2.  Sorry!  L  
 
3. There  are  only  two  organs  that  are  considered  which  when  involved  are  unresectable:  
IVC  and  Aorta  [if  they  are  involved,  you  do  a  biopsy,  when  other  organs  are  involved  
you  can  do  en  bloc  resection]    So  in  the  case  it  involved  the  IVC  therefore  the  answer  
is:  biopsy    
 
4. Treatment  for  lymphoma:  chemoradiation  [malignant  lymphomas  are  almost  
always  responsive  primarily  to  chemotherapy  and  radiation  therapy  secondarily]  
 
5. Hernia  techniques  that  does  not  use  a  prosthetic  mesh:  Shouldice    
 
6. Type  of  hernia  wherein  the  wall  of  the  hernia  sac  is  an  organ  like  the  bladder  or  the  
colon:  sliding  hernia  [If  it  contains  meckel’s:  littre’s  hernia  ;  If  both  a  direct  and  an  
indirect  hernia  develop  on  the  same  side  of  the  groin:  pantaloon  hernia  ]  
 
7. The  follow  are  contributing  factors  in  the  development  of  direct  inguinal  hernia,  
except:  Anterior  wall  [Pathophysiology  of  direct  is  posterior  wall]  
 
8. The  following  are  complications  of  an  elective  herniorrhaphy.  Most  common  is:  
urinary  retention    
 
9. The  following  is/are  factors  in  the  assessment  of  bowel  injury:  ALL  
 
10. Which  of  the  following  is  true  regarding  hernia  repair:  It  may  be  used  for  direct,  
indirect,  and  recurrent.  [Mesh  can  be  done  for  any  type  of  hernia]  
 
11. The  most  important  concept  that  has  led  to  a  decrease  in  recurrence  rate:  tension-­‐  
free  repair    [It  is  likewise  the  most  common  cause  of  recurrence  K  ]  
 
12.  35  year  old  with  sudden  onset  of  severe  abdominal  pain:  rectus  sheath  hematoma    
 
13.  Straining  tests  show  that  the  mass  persists.  This  is  to  differentiate:  intraabdominal  
from  abdominal  
 
14. 34  year  old  male  suddenly  develops  intraabdominal  pain,  he  is  taking  warfarin:  
Rectus  sheath  hematoma  
 
15. Mass  is  expanding  but  the  patient  is  stable.  The  best  management  is:  Embolization  
[keyword:  stable  if  the  patient  is  unstable:  surgery]  
 
16. 35  year  old  woman  with  an  enlarging  mass  at  the  anterior  abdominal  wall.  She  has  
adenomatous  polyposis  based  on  the  history,  ct  scan  4cm  tumor  with  ill  defined  

 
 border.  The  next  best  thing  to  do  is:  Core  needle  biopsy  [because  she  has  history  
and  you  want  to  be  sure]  
17. True  about  torsion  of  the  omentum:  Mimics…    
 
18. 80  year  old  male  known  diabetic  and  hypertensive  presents  with  severe  abdominal  
pain.  Bowel  sounds  are  hypoactive  (+)  guarding  and  abdominal  tenderness.  The  
following  should  be  considered:  All    
 
19. If  a  scout  film  of  the  abdomen  is  done,  findings  that  suggest  ischemia:  All  [thumb  
printing,  hemoperitonium,  hematosis…  ]  
 
20. If  this  ACUTE  mesenteric  ischemia,  the  most  likely  cause  is:  Acute  thrombosis    
 
21. The  above  patient,  acute  mesenteric  ischemia,  is  best  managed  by:  [If  we  say  acute,  
bowels  are  compromised,  they  can  be  gangrenous  so  the  next  step  is  surgery  
Emergency  laparotomy]    
 
22. If  on  chest  auscultation  the  heart  sounds  are  irregular,  you  think  of:  Embolism  
[because  you  have  arrhythmia  which  is  the  most  common  cause  of  embolism]  
 
23. The  best  treatment  is:  Embolectomy    
 
24. 58  year  old  presents  with  a  palpable  mass  of  one  month  duration.  Mass  is  smooth  
ill-­‐define  border  :  Sacroma  [retroperitoneal  mass  is  well  defined]  
 
25. This  patient  is  best  managed  by:  Surgical  aspiration  and  vascular  resection?  
 
26. Bulging  in  the  midline:  Due  to  separation  of  the  external  and  internal  oblique  
aponeurosis  
 
27. 58  year  old  male  presents  with  pulmonary  nodules  on  the  left  lung,  he  had  previous  
surgery  for  sarcoma  and  was  resected.  This  is  a  recurrent  case.  This  patient  is  
advised  to  undergo:  All  [ct  of  the  chest,  abdomen  or  pet.  You  do  this  because  you  want  
to  know  if  there  are  any  other  forms  of  metastasis]  
 
28. If  it  is  localized  you  do:  Resection    [the  above  test  shows  two  nodules  in  the  upper  
lobe  so  resect]  
 
29. 58  year  old  presents  with  multiple  enlarging  abdominal  mass.  He  has  multiple  
enlarged  inguinal  and  cervical  lymph  nodes.  Ct  scan  5cm  with  encasement  of  the  
aorta  and  IVC.  [remember  you  cannot  resect!]  :  CT  guided  biopsy  
 
30. Characteristics  of  desmoid  tumors:  A    J    

 
2013 (CD2014)
2012 (AB2014)
2011 (AB2013)