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MarcNeff· AlecBeekley·
KahyunYoon-Flannery·
AsanthiRatnasekeraEditors
Passing theGeneral
Surgery Oral Board
Exam
ThirdEdition
123
Passing the General Surgery Oral Board Exam
Marc Ne • Alec Beekley
Kahyun Yoon-Flannery • Asanthi Ratnasekera
Editors
Passing the General Surgery
Oral Board Exam
Third Edition
Editors
Marc Neff
Center for Surgical Weight Loss
Jefferson Health of New Jersey
Cherry Hill, NJ, USA
Alec Beekley
Bariatric and Metabolic Surgery
Thomas Jefferson University Hospital
Philadelphia, PA, USA
Kahyun Yoon-Flannery
Janet Knowles Breast Cancer Center
Cooper Medical School of Rowan Universit
Camden, NJ, USA
Asanthi Ratnasekera
Division of Trauma, Surgical Critical Care and
Acute Care Surgery
Christiana Care Health System
Newark, DE, USA
ISBN 978-3-031-78243-5 ISBN 978-3-031-78244-2 (eBook)
https://doi.org/10.1007/978-3-031-78244-2
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2006,
2014, 2025
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or
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developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specic statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed
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expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been
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This Springer imprint is published by the registered company Springer Nature Switzerland AG
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Ashanthi...
“I would like to dedicate this work to my husband, Jim Cavello. Without his
unwavering support and cheerleading, the milestones I have met thus far in
my career would not have been possible. His whole-hearted dedication to
being a father and a husband has been the cornerstone of success in our
lives.”
Kay...
“For Ella, Leo, Max, and Nathan—who are the reasons I strive to be better
everyday. Experiencing life through your eyes everyday has been nothing
short of amazing. I am grateful to be your mom everyday.”
Marc...
“For Erica, Lily, Emmy, and Sparkles. You have reminded me of a lesson from
long ago; that we fall down, so that we learn how to get back up.”
Alec...
“For my wife Melodie, who knows me better than I know myself; and for my
children Alexandra and Wyatt for having a veteran and surgeon as their
father.”
Acknowledgments
Every patient is a trap for the unwary physician.—Marc Neff
It is hard to believe that I have been a board-certied surgeon for over 20 years. I can vividly
remember freezing on my rst attempt on my board exam in front of Drs. Lillemoe and Ponsky.
Sadly, I wish I could forget reading that letter in November of 2002 that said I failed the exam.
After several days of licking my wounds, I sat down and took an audit of my career up till then.
I set out a plan and created a timeline. Over the next year, I spent countless hours studying for
my second attempt at the Oral Boards. Nights, holidays, and weekends, I put a little bit of time
in every day. It was out of that studying that I put together my rst edition of this book. Once
I passed, I approached an unsuspecting vendor at an ACS meeting and slyly asked at the
Springer booth if they had an Oral Board review book. When they said they didn’t, I asked if
they would be interested in one. When they said they would, I told them I’d return the next day
with the book they’d want to publish on a jump drive, and to have an editor meet me here.
Never could I have imagined that out of that horrible oral examination experience would birth
a review book downloaded thousands of times and now in the third edition.
I was once asked to devise my own personal mission statement. After much consideration,
I came up with, “To have the greatest positive impact on the greatest number of people.” From
the ashes of that failed rst attempt, the universe has helped me do just that. If not for that
failure, I wouldn’t be talking to you now. I share that as an opening to this third edition as a
reminder to trust in the ebb and ow of your career, and to trust in your determination and
discipline to get to this point. News ash for you, you will eventually pass this exam. And, if it
isn’t on the rst try, then on the second. And if it comes after the second attempt, maybe you’ll
write a book to help thousands of others make it happen over the next 20 years.
My rst thanks, as in the rst and second edition, goes to my family. They are the ones who
must bear the brunt of the moody surgeon coming home after a bad day in the ofce or the
operating room (or worse, the courtroom). They are the ones who help with the real-life chores
of laundry, shopping, walking the dog, and cleaning the house when I am just too exhausted to
move. They are the ones who remind me to take the much-needed vacations and help me nd
my way back home when my brain can’t fathom how to navigate an airport. They are the ones
who remind me that there is life outside of the operating room.
My second thanks belongs to my fellow surgeons and surgeons-to-be. First, to my fellow
editors. They had immeasurable patience with this project. Countless emails over the past year
and a half plagued their in-boxes. They taught me how to use Google drive (and had patience
for my poor comprehension), taught me how to combine topics, solicit authors from all over the
country (and how to keep track of them), and without them, this project would have never
crossed the nish line. I can’t imagine a more dynamic group of master surgeons to create these
books for Springer with. This project also, as you will see, included many attending surgeons,
residents, and fellows, from a variety of institutions. For all those who participated and had
patience with this project coming to completion (after many stalls and delays from holidays and
ABSITE exams), I sincerely offer my thanks. As you read this tome of knowledge, you’ll see
many “Words of Wisdom” sections which include their hard-fought experience battling surgical
diseases. I consider myself quite blessed to have been part of this remarkable endeavor.
vii
Introduction
At a mortality and morbidity conference a few months ago, I got into a heated argument with
one of the other surgeons in attendance. Without going into any specic details about the case,
the general topic will be familiar—did the resident demonstrate competence during the procedure. Now, I’m not one who ever believes the resident is at fault during an M&M.Either I put
them in an inappropriate position by asking them to do something they weren’t prepared to do,
or at the wrong time of day, or with the wrong instrument, or with the wrong support staff, but
we are the mentors training the next generation and we have to put them in a position to be
successful. It’s a very difcult task to put them in a position that helps them learn without hurting patients or put our own licenses in jeopardy. All that being said (and you may disagree with
my philosophy), but the larger theme of competence is what the American Board of Surgery
(ABS) is testing.
The ABS recognizes that a surgeon with 5–7 years of training has not obtained mastery over
a topic. How could they? It takes another 10 years of operating experience and patient care
after residency to truly have developed mastery of the surgical arena. Up until then, you just
haven’t seen every permutation of the surgical disease process in question. Maybe you have
seen and managed 100 different patients with perforated diverticulitis, but have you done it in
a patient with liver failure on a transplant list with ascites? Maybe you have seen and managed
the acute cholecystitis 200 times, but how often have you seen it with a true Type IV Mirizzi
Syndrome? The ABS is testing whether or not you will be a safe surgeon, or if you will be a
cowboy/cowgirl. Do you know what the standard of care is? Will you gamble or guess when it
comes to the care of your patient when you don’t know what to do?
I like to think that the exam tests “conscious competence.” If you search the internet on this
topic, you’ll see a very interesting description of the four stages of competence. I was taught
this by an assistant in the operating room in 2016 and have used it ever since. The four stages
of competence are: unconscious incompetence, conscious incompetence, conscious competence, and nally unconscious competence. Or, in other simpler words: wrong intuition, wrong
analysis, right analysis, right intuition.
Let’s take the example of a postoperative patient on the oor. They had a very difcult laparoscopic cholecystectomy with some hemostatic agent placed in the liver bed at the end of the
case. Unconscious incompetence is the surgical intern who does the post op check 6h post op.
They are concerned about getting the note done because they have ve other notes to do and
consults to see on the oor and in the ED.They note that the patient is distended and is borderline hypotensive, but they don’t appreciate that might be bleeding because the vital signs are
“stable.” They failed to note that the patient is on a beta blocker and that is why they aren’t
tachycardic. Conscious incompetence is the junior resident who sees the same patient and
understands the trap of the beta blocker the surgical intern made but still doesn’t think that the
patient is bleeding. They think that giving the beta blocker post op was wrong initially post op.
It was too soon or an overdose and that’s causing the hypotension. They order an abdominal
X-ray to evaluate the presumed ileus and give some Ativan because the patient is acting anxious. Conscious competence is the senior resident who sees the distended belly, does a quick
targeted history and physical exam, notes the vital signs, again reviews the meds, and calls the
ix
x
attending concerned that the patient might be bleeding. They order uids, labs, type and screen,
and a CT scan to assess the degree of bleeding. They also alert the OR, recheck the patient after
the bolus, and discuss their differential with their team, the patient, and their family.
Unconscious competence is the attending who comes in, remembering that the case was oozy,
already in the back of their mind knows the vital signs are unreliable because of the patient’s
history and medication use, and takes the patient back to the operating room to stop the bleeding because they’ve seen this situation 50 times over the past 10 years. They do all the same
things as the senior resident, but don’t waste the time on the imaging study.
Conscious competence means that you are competent in performing as a surgeon, but that
you still need to pay close attention to each step in order to do it successfully. You are not
expected to know what the master knows. That’s not what the ABS is testing. That comes much
later in your career. Don’t try to be the master. Each step on this journey for you to become a
board certied surgeon is a well-worn step walked by thousands of surgeons before you, and
will be, by thousands who come after.
This edition differs from the previous two in several specic ways. First, we have expanded
our contributing authors to include those from multiple institutions all across the country.
Second, we have expanded our topics covered to include multiple new areas including bariatric
surgery, ventilatory management, and futile care. While these may not specically be tested on
the exam, we sought to expand this study guide to include topics that may be important for
further “Oral Board” style interrogations at M&M conferences, daily rounds, conferences, and
departmental meetings. Lastly, many sections now include a “words of wisdom” section—a
few extra morsels of information and some pearls to carry with you on your journey in your
surgical career. As we all learn, “wisdom comes from experience, the best wisdom, from the
worst experience.”
Introduction
Contents
Part I Breast
1 Nipple Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Jenna Mancinelli and Adrian Lopez
2 Abnormal Mammogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Jenna Mancinelli and Adrian Lopez
3 Breast Mass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Ryland J. Gore
4 Ductal Carcinoma In Situ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Ryland J. Gore
5 High Risk Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Carly Wareham and Salvatore Nardello
6 Inflammatory Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Tahereh Soleimani and Carla Fisher
7 Breast Cancer in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Lucy M. de La Cruz, Nathan Wong, and Carmen de Carvajal
8 Invasive Lobular Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Michele Fantazzio
9 Hereditary Breast Cancer (BRCA1/2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Carly Wareham and Salvatore Nardello
10 Locally Advanced Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Adrian Lopez and Jenna Mancinelli
11 Metastatic Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Kahyun Yoon-Flannery and Candice N. Ford
12 Paget’s Disease of the Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Michele Fantazzio
Part II Colon and Small Bowel
13 Mesenteric Ischemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Keshav Kooragayala and Maureen Moore
14 Hemorrhoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Kristen Knapp and Danica N. Giugliano
15 Colonic Volvulus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Kristen Knapp and Danica N. Giugliano
xi
xii
16 Rectal Prolapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Hannah Soeld and Danica N. Giugliano
17 Appendiceal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Leah Steinmetz and Danica N. Giugliano
18 Small Bowel Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Johanna Lou and Kahyun Yoon-Flannery
19 Mesenteric Volvulus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Keshav Kooragayala and Maureen Moore
20 Meckel’s Diverticulum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
M. Virginia Butchy, John Williamson, and Danica N. Giugliano
21 Colon Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Leah Steinmetz and Danica N. Giugliano
22 Enterocutaneous Fistulas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Patrick Murphy
23 Diverticulitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Johanna Lou and Kahyun Yoon-Flannery
24 Adult Appendicitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Johanna Lou and Kahyun Yoon-Flannery
Contents
25 Large Bowel Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Victoria Sharp and Maseray S. Kamara
26 Intussusception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Victoria Sharp
27 Lower Gastrointestinal Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Danica N. Giugliano
28 Peri-Rectal Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Hannah Soeld and Danica N. Giugliano
29 Rectal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Matthew C. Moccia and Danica N. Giugliano
30 Right Lower Quadrant Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Anna Shu and Victoria Sharp
31 Crohn’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Arielle Brackett, Joseph A. Sciacca, and David Palange
32 Ulcerative Colitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Joseph A. Sciacca, Arielle Brackett, and David Palange
33 Zenker’s Diverticulum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Michael Pryor and Victoria Sharp
Part III Esophagus
34 Achalasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Sneha Alaparthi
35 Barrett’s Esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
James Fraser
36 Esophageal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Isheeta Madeka