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9. Desarda repair of an inguinal hernia utilizes:
A. Internal oblique, transversus abdominis and trans-
versalis fascia.
B. Cooper ligament.
C. A strip of the external oblique aponeurosis.
D. Prosthetic mesh.
CHAPTER 37
Inguinal Hernias
Answer: C
The Desarda hernia repair was recently described in 2001,
and it consists of a mesh-free repair utilizing a strip of external oblique aponeurosis. An oblique skin incision is made,
and dissection is carried down to the external oblique fascia.
The integrity of the fascia is preserved as much as possible.
The cremasteric muscle is then incised, and the spermatic
cord along with the cremasteric muscle is separated from the
inguinal floor. Excision of the sac is done in all cases except
in small direct hernias, where it is inverted. The medial leaf
of the external oblique aponeurosis is sutured to the inguinal ligament from the pubic tubercle to the abdominal ring
using 1–0 ethilon or prolene interrupted sutures. The first
two sutures are taken at the junction of the anterior rectus
sheath and esophageal obturator airway (EOA). The last
suture is taken so as to sufficiently narrow the abdominal
ring without constricting the spermatic cord (Fig. 37-3). Each
suture is passed first through the inguinal ligament, then the
transversalis fascia, and then the EOA. The index finger of the
left hand is used to protect the femoral vessels and retract
the cord structures laterally while taking lateral sutures. A
splitting incision is then taken in the EOA, partially separating a strip. This splitting incision is extended medially up to
the pubic symphysis and laterally 1 to 2 cm beyond the reconstructed abdominal ring. (See Schwartz 11th ed., p. 1611.)
1
4
5
6
FIG. 37-3. The Desarda repair. A. The medial leaf of the external oblique aponeurosis is sutured to the inguinal ligament. 1 Medial leaf,
2 interrupted sutures taken to suture the medial leaf to the inguinal ligament, 3 pubic tubercle, 4 abdominal ring, 5 spermatic cord,
6 lateral leaf. B. Undetached strip of the external oblique aponeurosis forming the posterior wall. 1 Reflected medial leaf after a strip has
been separated, 2 internal oblique muscle seen through the splitting incision made in the medial leaf, 3 interrupted sutures between
the upper border of the strip and conjoined muscle and internal oblique muscle, 4 interrupted sutures between the lower border
of the strip and the inguinal ligament, 5 pubic tubercle, 6 abdominal ring, 7 spermatic cord, 8 lateral leaf.
6
2
7
8
3
1
2
3
4
5
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10. Robotic-assisted inguinal hernia repair:
A. Does not decrease in cost as the volume increases at
each center.
B. Cost of robotic and laparoscopic repairs converge as
volume grows at each center.
C. Complications are likely to be less in obese patients
compared to open repair.
D. Is less suited than laparoscopic repair for recurrent
hernias.
11. The medical issue NOT associated with hernia recurrence is:
A. Malnutrition.
B. Steroid use.
C. Smoking.
D. Alcohol use.
Answer: C
Retrospective data have had mixed results when comparing robot-assisted surgery vs laparoscopy. One recent study
has shown longer operative time, another analysis has shown
increased cost. It should be noted, however, that there is a
decrease in cost with robotic surgery as the volume of procedures increases at each center, though it is still unlikely that
the costs will ever converge to that of laparoscopic surgery.
A retrospective, single-institution study has shown greatly
reduced complication rates with robotic-assisted surgery in
obese patients; however, this was compared against open
inguinal hernia repair (10.8% vs 3.2%, P = 0.047), the two
groups were covariate matched for preoperative risk. Studies
have also shown excellent long-term (36-month) quality of
life indicators in robot-assisted transabdominal preperitoneal
(TAPP), though this was a single surgeon survey. Further randomized trials will shed more light into cost issues as surgeons
gain more experience with robotic application that would lead
to shorter operative time and minimize additional instrument
use. (See Schwartz 11th ed., p. 1616.)
Answer: D
Hernia recurrence: When a patient develops pain, bulging,
or a mass at the site of an inguinal hernia repair, clinical
entities such as seroma, persistent cord lipoma, and hernia
recurrence should be considered. Common medical issues
associated with recurrence include malnutrition, immunosuppression, diabetes, steroid use, and smoking. Technical
causes of recurrence include improper mesh size, tissue ischemia, infection, and tension in the reconstruction. A focused
physical examination should be performed. As with primary
hernias, ultrasound (US), computed tomography (CT), or
magnetic resonance imaging (MRI) can elucidate ambiguous
physical findings. When a recurrent hernia is discovered and
warrants re-operation, an approach through a virgin plane
facilitates its dissection and exposure. Extensive dissection of
the scarred field and mesh may result in injury to cord structures, viscera, large blood vessels, and nerves. After an initial
anterior approach, the posterior laparoscopic approach will
usually be easier and more effective than another anterior
dissection. Conversely, failed preperitoneal repairs should
be approached using an open anterior repair. (See Schwartz
11th ed., p. 1618.)
CHAPTER 37
Inguinal Hernias
12. Fibrin glue fixation of a synthetic prosthesis is:
A. Vastly inferior to the suture fixation.
B. Causes less pain than tacker fixation.
C. More likely to cause a hernia recurrence compared to
tacker fixation.
D. Best for larger hernias.
Answer: B
Fibrin glue fixation is a successful alternative to tack fixation
in hernia repair with a synthetic prosthesis. Recent studies
comparing fibrin glue fixation and suture fixation in open
hernia repair show superior rates of chronic pain with both
Lichtenstein and Plug and Patch techniques. Meta-analyses
of endoscopic hernia repair determined the incidence of
chronic postoperative pain after tacker fixation was significantly higher than after fibrin glue fixation, with one showing
a relative risk of 4.64 (CI 1.9–11.7). Rates of other postoperative complications and recurrence were similar between
both fixation methods. Glue fixation is a promising technical
refinement, and several studies have shown long-term benefit; however, its questionable efficacy in larger hernias and
cost remain considerations. (See Schwartz 11th ed., p. 1618.)
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13. Nonciceptive pain is:
A. The result of ligamentous or muscular trauma and
inflammation.
B. The result of direct nerve damage or entrapment.
C. The result of pain conveyed through afferent auto-
nomic pain fibers.
D. Characterized as diffuse.
CHAPTER 37
Inguinal Hernias
14. Injury to the lateral femoral cutaneous nerve results in:
A. Inguinodynia.
B. Osteitis pubis.
C. Meralgia paresthetica.
D. Nerve entrapment.
Answer: A
Pain after inguinal hernia repair is classified into acute or
chronic manifestations of three mechanisms: nociceptive
(somatic), neuropathic, and visceral pain. Nociceptive pain is
the most common of the three. Because it is usually a result of
ligamentous or muscular trauma and inflammation, nociceptive pain is reproduced with abdominal muscle contraction.
Treatment consists of rest, nonsteroidal anti-inflammatory
drugs (NSAIDs), and reassurance, as it resolves spontaneously in most cases. Neuropathic pain occurs as a result of
direct nerve damage or entrapment. It may present early or
late, and it manifests as a localized, sharp, burning or tearing sensation. It may respond to pharmacologic therapy and
to local steroid or anesthetic injections when indicated. Visceral pain refers to pain conveyed through afferent autonomic
pain fibers. It is usually poorly localized and may occur during ejaculation as a result of sympathetic plexus injury. (See
Schwartz 11th ed., p. 1619.)
Answer: C
Other chronic pain syndromes include local nerve entrapment, meralgia paresthetica, and osteitis pubis. At greatest
risk of entrapment are the ilioinguinal and iliohypogastric
nerves in anterior repairs and the genitofemoral and lateral
femoral cutaneous nerves in laparoscopic repairs. Clinical
manifestations of nerve entrapment mimic acute neuropathic
pain, and they occur with a dermatomal distribution. Injury
to the lateral femoral cutaneous nerve results in meralgia paresthetica, a condition characterized by persistent paresthesias
of the lateral thigh. Initial treatment of nerve entrapment
consists of rest, ice, nonsteroidal anti-inflammatory drugs
(NSAIDs), physical therapy, and possible local corticosteroid
and anesthetic injection. Osteitis pubis is characterized by
inflammation of the pubic symphysis and usually presents as
medial groin or symphyseal pain that is reproduced by thigh
adduction. Avoiding the pubic periosteum when placing
sutures and tacks reduces the risk of developing osteitis pubis.
Computed tomography (CT) scan or magnetic resonance
imaging (MRI) excludes hernia recurrence, and bone scan is
confirmatory for the diagnosis. Initial treatment is identical
to that of nerve entrapment; however, if pain remains intractable, orthopedic surgery consultation should be sought for
possible bone resection and curettage. Irrespective of treatment, the condition often takes 6 months to resolve. (See
Schwartz 11th ed., p. 1619.)
15. Ischemic orchitis at the time of an inguinal hernia is:
A. Most commonly caused by an injury to the pampini-
form plexus.
B. Most commonly caused by an injury to testicular
ar ter y.
C. Manifests immediately after the injury.
D. Occurs in >1% of primary hernia repair.
Answer: A
Injury to spermatic cord structures may result in ischemic
orchitis or testicular atrophy. Ischemic orchitis is most commonly caused by injury to the pampiniform plexus and not
to the testicular artery. It usually manifests within 1 week of
inguinal hernia repair as an enlarged, indurated, and painful testis, and it is almost certainly self-limited. It occurs in
<1% of primary hernia repairs; however, this figure is larger
for recurrent inguinal hernia repairs. Ultrasound (US) will
demonstrate testicular blood flow to differentiate between
ischemia and necrosis. Emergent orchiectomy is only necessary in the case of necrosis. Injury to the testicular artery
itself may lead to testicular atrophy, which is manifest over
a protracted period but does not always lead to testicular
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necrosis. This is because despite compromise of the artery,
there is collateral flow from the inferior epigastric, vesical, prostatic, and scrotal arteries that supply the testes, and
in the case of insufficiency, there is atrophy. Treatment for
ischemic orchitis most frequently consists of reassurance,
nonsteroidal anti-inflammatory drugs (NSAIDs), and comfort
measures. Intraoperatively, proximal ligation of large hernia
sacs to avoid cord manipulation minimizes the risk of injury.
(See Schwartz 11th ed., p. 1620.)
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CHAPTER 37
16. Regarding recurrences after a hernia repair, which one is
TRUE?
A. Among tissue repair, Shouldice repair is associated
with the least incidence of recurrence.
B. Shouldice repair is primarily of historical significance
and is rarely performed.
C. Compared with mesh repairs, Shouldice operation
has a lower incidence of recurrence.
D. Shouldice technique may be reliably replicated by a
novice surgeon.
17. The outcome found more commonly with transabdominal preperitoneal (TAPP) repair compared to totally
extraperitoneal (TEP) repair is:
A. Length of stay.
B. Time to recovery.
C. Risk of intra-abdominal injuries.
D. Higher short-term recurrence rates.
Answer: A
A 2012 meta-analysis from the Cochrane database 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. In
experienced hands, the overall recurrence rate for the Shouldice repair is about 1%. Although it is an elegant procedure,
its meticulous nature requires significant technical expertise
to achieve favorable outcomes, and it is associated with longer
operative duration and longer hospital stay. One study found
the recurrence rate for Shouldice repairs decreased from
9.4% to 2.5% after surgeons performed the repair six times.
Compared with mesh repairs, the Shouldice technique
resulted in significantly higher rates of recurrence (OR 3.65,
CI 1.79–7.47); however, it is the most effective tissue-based
repair when mesh is unavailable or contraindicated. (See
Schwartz 11th ed., p. 1621.)
Answer: C
Although controversy persists regarding the utility of TEP vs
TAPP, reviews to date find no significant differences in operative duration, length of stay, time to recovery, or short-term
recurrence rate between the two approaches. In TAPP repair,
the risk of intra-abdominal injury is higher than in TEP repair.
This finding prompted the International Endohernia Society
(IEHS) to recommend that TAPP should only be attempted
by surgeons with sufficient experience. A Cochrane systematic review found that rates of port-site hernias and visceral
injuries were higher for the TAPP technique, whereas TEP
may be associated with a higher rate of conversion to an alternative approach; however, neither finding was sufficiently
compelling to recommend one technique over the other. (See
Schwartz 11th ed., p. 1622.)
Inguinal Hernias
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CHAPTER 38
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Thyroid, Parathyroid, and Adrenal
1. What condition occurs as a complication of total thyroidectomy in patients, particularly in children, who do
not receive thyroid replacement therapy?
A. Sarcoidosis
B. Myxedema
C. Dysphonia
D. Pseudohyperparathyroidism
2. What congenital anomaly arises from the formation of
the thyroid gland?
A. The thyroid isthmus
B. The cricothyroid arch
C. A thyroglossal duct cyst
D. An endobranchial cyst
3. The arterial supply of the thyroid arises from which of
the following vessels?
A. The aorta
B. The external carotid arteries
C. The thyrocervical trunk
D. All of the above
Answer: B
Myxedema, with the development of cretinous features, was
an early complication of total thyroidectomy in children.
It is prevented by thyroid hormone replacement therapy.
(See Schwartz 11th ed., p. 1625.)
Answer: C
The medial thyroid anlage descends from the base of the
tongue through a channel called the thyroglossal duct at
week 3–4 of gestation. The duct normally closes after its
descent, but may remain patent and is susceptible to secondary infection and dilatation, referred to as a thyroglossal duct
cyst. Removal is accomplished with the Sistrunk operation,
which also removes the central portion of the hyoid bone.
(See Schwartz 11th ed., pp. 1625–1626.)
Answer: D
The superior thyroid arteries arise from the external carotid
arteries, and the inferior thyroid arteries arise from the
thyrocervical trunk shortly after their origin from the subclavian arteries. A thyroid ima artery arises directly from the
aorta or innominate artery in 1% to 4% of cases. (See Schwartz
11th ed., p. 1628.)
4. In what location, relative to the inferior thyroid artery
(ITA), is the recurrent laryngeal nerve (RLN) found?
A. Medial or posterior to the ITA
B. Lateral or anterior to the ITA
C. Passing between the branches of the ITA
D. All of the above
5. Although injury to the recurrent laryngeal nerve results in
hoarseness (unilateral injury) or airway obstruction (bilateral injury), injury to the superior laryngeal nerve (SLN)
results in a more subtle injury, affecting the ability to:
A. Sing high notes.
B. Whisper.
C. Protrude the tongue.
D. Grimace.
Answer: D
The RLN courses within the tracheoesophageal groove after
emerging from the vagus nerve at the level of the aortic arch.
As it ascends in the neck, the RLN may branch, and may pass
anterior, posterior, or interdigitate with branches of the ITA.
The location of the RLN must be confirmed before the ITA is
divided. (See Schwartz 11th ed., pp. 1628–1629.)
Answer: A
The external branch of the SLN lies on the inferior pharyngeal
constrictor muscle and descends alongside the superior thyroid
vessels before innervating the cricothyroid muscle. Therefore
the superior pole vessels should not be ligated en masse, but
should be individually divided low on the thyroid gland. Injury
to the SLN leads to inability to tense the ipsilateral vocal cord,
and impairs the ability to “hit high notes” while singing, or projecting the voice loudly. (See Schwartz 11th ed., pp. 1628–1629.)
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6. Thyroid hormones (T3 and T4) have regulatory roles in
all of the following EXCEPT:
A. The hypoxia and hypercapnia drives of the respira-
tory center in the brain.
B. Cholesterol synthesis and degradation.
C. The speed of muscle contraction and relaxation.
D. Auditory acuity.
CHAPTER 38
7. Which hormone directly mediates the release of thyroid
hormones from the gland?
A. Thyroglobulin
B. Thyrotropin-releasing hormone (TRH)
C. Thyroid Stimulating Hormone (TSH)
Thyroid, Parathyroid, and Adrenal
D. Adrenalin
8. Near-total or total thyroidectomy is preferred for the
treatment of Graves disease:
A. When radioactive iodine therapy is contraindicated.
B. When the goiter is large (>80 g) or airway obstruc-
tion appears immanent.
C. In patients with demonstrated poor compliance with
or tolerance of anti-thyroid medications.
D. All of the above.
Answer: D
Thyroid hormones are responsible for maintaining the normal hypoxic and hypercapnic drive in the respiratory center of
the brain, and regulate cholesterol synthesis and degradation.
They also regulate bone and protein turnover and the speed
of muscle contraction and regulation, gastrointestinal motility, hepatic gluconeogenesis, and intestinal glucose absorption but are not regulators of auditory acuity. (See Schwartz
11th ed., pp. 1632–1633.)
Answer: C
Thyroglobulin is contained within the follicles of the thyroid
gland and its tyrosine residues are iodinated to produce tetraiodothyronine or thyroxin (T4) or triiodothyronine (T3).
TRH is secreted by the hypothalamus and stimulates the pituitary gland to secrete TSH which directly mediates the release
of T4 and T3 from the gland. Adrenalin does not directly
regulate T4 or T3 release. (See Schwartz 11th ed., p. 1630.)
Answer: D
Near-total or total thyroidectomy is now preferred over subtotal thyroidectomy due to a lower recurrence rate. Surgery
is preferred over medical therapy (radioactive iodine) in
childbearing women who desire to have children in the near
future, in non-compliant patients, or when airway obstruction appears likely. (See Schwartz 11th ed., p. 1637.)
9. What is the recommended course of action when fine
needle aspiration biopsy (FNAB) of a thyroid nodule is
interpreted as “suspicious for malignancy”?
A. Repeat FNAB
B. Lobectomy
C. Lobectomy and isthmusectomy
D. Total thyroidectomy
10. Which diseases are associated with germline mutations
in the RET tyrosine kinase receptor gene?
A. Multiple endocrine neoplasia type 2A (MEN2A)
B. Multiple endocrine neoplasia type 2B (MEN2B)
C. Hirschsprung Disease
D. All of the above
11. Children exposed to the Chernoble disaster in 1986 subsequently demonstrated an increased incidence of which
thyroid cancer?
A. Papillary thyroid cancer (PTC)
B. Follicular thyroid cancer (FTC)
C. Medullary thyroid cancer (MTC)
D. Anaplastic thyroid cancer (ATC)
Answer: B
Most papillary and other cancers can be diagnosed by FNAB
but the features can be subtle and lobectomy or near-total
thyroidectomy is recommended because 60% to 75% turn
out to be malignant. Follicular neoplasms of the thyroid are
less aggressive than papillary neoplasms, and an FNAB may
be unable to differentiate between a follicular adenoma and
a follicular carcinoma. For this reason unilateral lobectomy
is recommended for this FNAB diagnosis. (See Schwartz
11th ed., p. 1644.)
Answer: D
Mutations in the extracellular domain of the RET tyrosine
kinase receptor are associated with MEN2A, familial medullary thyroid cancer (FMTC), and Hirschsprung disease.
Mutations in the intracellular domain are associated with
MEN2B, FMTC, and Hirschsprung disease. (See Schwartz
11th ed., pp. 1645–1646.)
Answer: A
Papillary thyroid cancer accounts for 80% of all thyroid malignancies and is the predominant thyroid cancer in children
and individuals exposed to external radiation. (See Schwartz
11th ed., p. 1647.)
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12. The recommended treatment for an otherwise healthy
50-year-old man with a 2 cm follicular thyroid cancer in
the left lobe diagnosed by fine needle aspiration biopsy
(FNAB) is:
A. Left lobectomy.
B. Left lobectomy and isthmusectomy.
C. Total left lobectomy and subtotal right lobectomy.
D. Total thyroidectomy.
13. An adolescent patient with a thyroid mass undergoes
fine needle aspiration biopsy which returns as medullary
carcinoma of the thyroid (MCT). What other diseases
should be screened for before treatment is undertaken?
A. Hyperparathryroidism
B. Pheochromocytoma
C. Mucocutaneous ganglioneuromas
D. All of the above
14. An asymptomatic child with a normal physical examination is found to harbor a mutation in codon 918 of the
RET tyrosine kinase receptor, compatible with MEN2B.
Ultrasound of the neck is unremarkable and serum calcitonin levels are normal. What course is indicated?
A. Repeat examination and ultrasound yearly
B. Planned thyroidectomy in 3 to 5 years
C. Total thyroidectomy
D. Total thyroidectomy with bilateral neck dissection
Answer: D
Total thyroidectomy is the recommended treatment particularly in younger patients. Prophylactic neck dissection is not
required unless nodal involvement is suspected. Recurrent
disease can be treated with radioiodine therapy. (See Schwartz
11th ed., p. 1651.)
Answer: D
MCT can be spontaneous (in 75%) or familial (in 25%) in
multiple endocrine neoplasia syndrome type 2 (MEN2).
MEN2A is associated with pheochromocytoma and hyperparathyroidism, whereas MEN2B is associated with pheochromocytoma, Marfanoid habitus, and mucocutaneous
ganglioneuromas. (See Schwartz 11th ed., p. 1655.)
Answer: C
Children with mutations at codon 634 of the RET tyrosine
kinase receptor gene (MEN2A) are advised to undergo thyroidectomy before age 5, whereas children with mutations at
codon 918 (MEN2B) should undergo thyroidectomy before
age 1. If ultrasound of the neck is normal and calcitonin
levels are normal, a formal neck dissection can be avoided.
(See Schwartz 11th ed., pp. 1656–1657.)
CHAPTER 38
Thyroid, Parathyroid, and Adrenal
15. Postoperative complications of thyroid surgery which
may require immediate reoperation include:
A. Hypocalcemia.
B. Dyspnea.
C. Dystonia.
D. Wound hematoma.
16. A patient with primary hyperparathyroidism undergoes
neck exploration where four small, normal appearing
glands are found. What are the possible locations of an
additional, supernumerary gland?
A. In the thyroid gland
B. In the thymus
C. In the tracheoesophageal groove
D. All of the above
Answer: D
Inadvertent injury (ischemia) or removal of the parathyroid glands can cause acute neuromuscular excitability due
to hypocalcemia. This can be ameliorated with intravenous
calcium. Dyspnea may be a consequence of pain or anxiety
but rarely indicates airway compromise. Bilateral vocal cord
dysfunction with airway compromise requires reintubation.
An expanding hematoma in the neck may not cause bleeding from the wound but can compress the membranous portion of the trachea and cause dyspnea. The wound should be
opened at the bedside and the patient returned to the operating room for wound exploration and reclosure. (See Schwartz
11th ed., p. 1663.)
Answer: D
Supernumerary parathyroid glands occur in 7% to 13% of
people, and may be located in the thymus (most commonly),
within the parenchyma of the thyroid gland, or in the tracheoesophageal groove, the mediastinum, or elsewhere in the
neck. (See Schwartz 11th ed., pp. 1663–1664.)
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17. A 70-year-old woman with early dementia but otherwise good physical health has an elevated parathyroid
hormone (PTH) level and a sestamibi scan which localizes a single focus of increased activity to the left lower
neck. An ultrasound conforms an enlarged gland in the
same area. What treatment is likely to provide the best
outcome?
A. Bilateral neck exploration under general anesthesia
CHAPTER 38
Thyroid, Parathyroid, and Adrenal
B. Unilateral, “mini-incision” parathyroidectomy under
local anesthesia
C. Minimally invasive videoscopic parathyroidectomy
from a left axillary approach under general anesthesia
D. Percutaneous alcohol ablation with ultrasound guid-
ance under local anesthesia
18. A 65-year-old woman with mild dementia and elevated
calcium and parathyroid hormone levels undergoes
bilateral neck dissection. Two upper pole parathyroid
glands and one lower pole parathyroid gland are found
but despite a diligent search, the fourth gland is not
apparent. What steps are appropriate to locate the fourth
gland?
A. The thyrothymic ligament should be mobilized and
the upper end of the thymus gently retracted into the
field for dissection and removal if any mass is found.
B. The carotid sheath should be opened from the bifur-
cation to the base of the neck and explored.
C. Intraoperative ultrasonography can be employed to
examine the thyroid lobe on the side of the missing
parathyroid to detect an intrathyroidal location.
D. All of the above.
Answer: B
Localization studies such as sestamibi scans have been shown
to allow more limited operations, including those utilizing
“min-incisions” under local anesthesia, for patients who are
not good risks for general anesthesia. Improved cosmesis,
shorter lengths of stay, and reduced complications are benefits from this approach. (See Schwartz 11th ed., p. 1674.)
Answer: D
The position of the parathyroid glands can be quite variable. In addition to the tracheoesophageal groove adjacent
to the posterior capsule of the thyroid, the gland may be
intra- thyroidal, intra-thymic, within the carotid sheath, retroesophageal, or in the posterior mediastinum. (See Schwartz
11th ed., p. 1675.)
19. Gastrointestinal complications of primary hyperparathyroidism include all of the following EXCEPT:
A. Peptic ulcer disease.
B. Acute pancreatitis.
C. Cholelithiasis.
D. Hepatitis.
20. A 50-year-old man with chronic renal failure develops
hypercalcemia (>11 mg/dL) and an elevated parathormone level (>800 pg/mL). Ultrasound and radionuclide
studies of the neck reveal no localized mass. On bilateral
neck exploration, four variably sized but enlarged parathyroid glands are found. Which of the following surgical options is NOT indicated?
A. Total parathyroidectomy
B. Subtotal parathyroidectomy with retention of one-
half of the smallest gland
C. Total thyroidectomy with reimplantation of 1 mm
cubes of one gland into the brachioradialis muscle of
the nondominant forearm
D. Subtotal parathyroidectomy with retention of one-
half of the smallest gland combined with upper
thymectomy
Answer: D
Primary hyperparathyroidism has been associated with
peptic ulcer disease, both with and without an accompanying gastrinoma. It is sometimes a cause of acute pancreatitis
although usually only when serum calcium levels are very
high (>12.5 mg/dL). An increased incidence of cholelithiasis
is also seen, presumably due to an increase in biliary calcium
excretion, but hepatitis is not associated with the disease.
(See Schwartz 11th ed., p. 1668.)
Answer: A
Total parathyroidectomy is contraindicated in patients who
are candidates for renal transplantation. Subtotal parathyroidectomy with retention of one-half of the smallest gland,
with or without upper thymectomy, is considered appropriate, as is total parathyroidectomy with auto-transplantation of
a portion of the smallest gland, depending on surgeon experience and preference. Recurrent disease after this procedure
can be managed with removal of the auto-transplanted gland
avoiding repeat neck exploration. (See Schwartz 11th ed.,
pp. 1679–1680.)
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21. A 50-year-old, healthy-appearing man undergoes evaluation of persistent hypertension. Serum chemistries reveal
hypokalemia (<3.2 mmol/L) and imaging studies reveal
a unilateral adrenal mass. What is the likely diagnosis?
A. Secondary hypercortisolism (Cushing’s disease)
B. Primary hypercortisolism (Cushing’s syndrome)
C. Hyperaldosteronism (Conn’s syndrome)
D. Pheochromocytoma
22. A 35-year-old woman undergoes an evaluation for
infertility. She has gained almost 100 pounds in the past
year, is hypertensive, and is borderline diabetic. She also
complains of easy bruising. Her serum chemistries are
normal with the exception of an elevated glucose. Imaging studies reveal a unilateral adrenal mass. What is the
likely diagnosis?
A. Secondary hypercortisolism (Cushing’s disease)
B. Primary hypercortisolism (Cushing’s syndrome)
C. Hyperaldosteronism (Conn’s syndrome)
D. Pheochromocytoma
23. All of the following imaging techniques are useful to
localize a pheochromocytoma EXCEPT:
A. Computed tomography (CT) scan.
B. Magnetic resonance imaging (MRI) scan.
C. Metaiodobenzylguanidine (MIBG) scan.
D. Octreotide scan.
Answer: C
Primary aldosteronism, or Conn’s syndrome, is seen in about
1% of hypertensive patients. It is more common in middle
aged individual and is usually associated with a single adenoma of the adrenal cortex. The hypertension is usually
refractory to medical treatment, and is classically associated
with hypokalemia, but may be seen in normokalemic individuals. (See Schwartz 11th ed., pp. 1685–1688.)
Answer: B
Cushing’s syndrome refers to any cause of hypercortisolism
caused by either an adrenal source or exogenous administration of steroids. Cushing’s disease refers only to an adrenocorticotropin hormone (ACTH)-secreting adenoma of the
pituitary gland. Cushing’s syndrome due to an isolated adrenal adenoma is far less common than hypercortisolism due
to a pituitary adenoma, but adrenalectomy is curative for primary adrenal tumors or for adrenal hyperplasia that persists
despite efforts to resect a pituitary tumor. (See Schwartz 11th
ed., pp. 1688–1689.)
Answer: D
Pheochromocytomas are solid tumors which appear on
CT scan as soft tissue masses. They are detected with 85%
to 95% accuracy, but it is important to avoid intravenous
contrast enhancement when a pheochromocytoma is suspected; intravenous contrast can provoke a hypertensive crisis due to release of catecholamines. MRI is useful to identify
pheochromocytomas, both because they identify soft tissue
masses, but also because this tumor tends to enhance on
T2-weighted images. Radio-labeled MIBG is taken up avidly
by the pheochromocytoma because its structure is similar to
norepinephrine.
Therefore, the MIBG scan can localize an occult tumor.
Octreotide scans are not used for pheochromocytoma as
the tumor does not overexpress somatostatin receptors. (See
Schwartz 11th ed., p. 1694.)
CHAPTER 38
Thyroid, Parathyroid, and Adrenal
24. Pheochromocytomas are associated with all of the following diseases EXCEPT:
A. Multiple endocrine neoplasia (MEN) type 2A.
B. Multiple endocrine neoplasia (MEN) type 2B.
C. Von Hippel Lindau (VHL) disease.
D. Familial adenomatous polyposis (FAP) disease.
25. The preoperative preparation of a patient with pheochromocytoma should include all of the following EXCEPT:
A. An alpha-adrenergic blocker such as phentolamine.
B. A beta-adrenergic blocker such as propranolol.
C. Intravenous hydration to avoid volume depletion.
D. Systemic steroids to avoid adrenal insufficiency.
Answer: D
Pheochromocytomas are caused by germline mutations in
the RET proto-oncogene (the origin of both MEN 2A and
MEN 2B) as well as the VHL gene mutation. Adrenal and
extra-adrenal pheochromocytomas may occur spontaneously
or as part of a neoplastic syndrome, but they are not associated with the FAP syndrome. (See Schwartz 11th ed., p. 1693.)
Answer: D
The preoperative preparation of a patient with a catecholamine-secreting tumor includes alpha-adrenergic blockade
to control hypertension, a beta-adrenergic blocker to prevent
tachycardia, and volume replacement to avoid hypotension
due to alpha- and beta-blockade. Steroids are not needed
to prevent adrenal insufficiency. (See Schwartz 11th ed.,
pp. 1694–1695.)
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