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80
V. Sharp
>80% of cases have successful reduction (Conrmed
by resolution of the mass and reux of air into the
proximal ileum).
Recurrence rates are 11% and usually recur within
the rst 24h.
• First recurrence is managed with repeat
enema.
• Further recurrence is an indication for surgery.
• Operative Management:
– Indications to consider surgery: peritonitis, hemody-
namic instability, complete small bowel obstruction,
small bowel location, failure of hydrostatic complete
reduction, history of several recurrences.
– Laparoscopy or primary exploratory laparotomy
(transverse incision in pediatrics).
– Reduce by squeezing the mass retrograde from distal
to proximal until reduced. Do NOT pull out the
intussusceptum.
– Bowel resection is indicated when the intussusception
cannot be reduced, bowel is not viable/viability is
uncertain, or a led point is identied. Ileocolectomy w/
primary anastomosis is usually performed.
Common Curveballs
• Patient becomes peritoneal during air/barium enema
attempts.
• Multiple recurrences occur after successful reduction.
• Patient is an adult (concern that malignancy is the
problem).
• Patient is a post-bariatric surgery patient and the intus-
susception is at the jejunojejunostomy.
• Other causes are found to be the cause: polyps, the appen-
dix, intestinal neoplasm, submucosal hemorrhage associated with Henoch-Schönlein purpura, a foreign body is
found, ectopic pancreatic or gastric tissue is found in the
pathology specimen.
• This is a Meckel’s diverticulum (remember the rules of
2’s: 2% of the population, within 2feet of the IC valve,
2 inches in length, two types of mucosa (gastric/
pancreatic).
Clean Kills
• Taking a patient with peritonitis for enema reduction.
• Patient starts having signicant bloody stools.
• Not proceeding to surgery for hemodynamic instability/
peritonitis.
• Not resecting a clear lead point.
Summary
Children with intussusception can often be reduced without surgical intervention and are commonly due to
benign causes like swollen lymphoid tissue from recent
viral infection. Children are less likely to have a lead
point but can be found in up to 12% in pediatric patients
and this risk increases with age. In adults intussusception
is more likely to require surgical resection as it is more
commonly due to a pathologic lead point of some kind.
Always proceed to surgery in any patient, regardless of
age, who demonstrates peritonitis or hemodynamic
instability.
Bibliography
Townsend JCM, Beauchamp RD, Evers BM, Mattox KL.Sabiston text-
book of surgery. 21st ed. Elsevier—Health Sciences Division; 2022.
Lower Gastrointestinal Hemorrhage
DanicaN.Giugliano
27
Lower Gastrointestinal Hemorrhage
• Bleeding source originates distal to the ligament of Treitz
• Common cause of hospital admissions
• Often stops spontaneously before denitive diagnosis can
be made
• Etiologies:
– Hemorrhoidal bleeding and ssure (5–20%) usually
cause minor bleeding over time and unlikely to cause
massive lower GI hemorrhage
– Diverticulosis coli bleeding (30–65%) can occur in
15% of patients with diverticulosis
Risk factors include NSAID use, hypertension, and
anticoagulant use
Up to 80% of these types of bleeds spontaneously
stop
– Angioectasia (3–15%) is a submucosal dilated, tortu-
ous vascular abnormality
– Ischemic colitis (10%) is usually less severe bleeding
than diverticular bleeding or angioectasia bleeding
Splenic exure (Grifths’ point) and rectosigmoid
colon (Sudeck’s point) are “watershed” regions and
can cause ischemic colitis
Cramping abdominal pain with abdominal tenderness on the left side of the abdomen can accompany
bleeding
Symptoms usually resolve in 2–3days unless acute
mesenteric vascular occlusion or non-occlusive
mesenteric ischemia (NOMI) has occurred
– Neoplasm (<10%) can cause ulceration and bleeding
A 70-year-old man presents to the emergency department
with 2hours of bright red blood per rectum that is continu-
D. N. Giugliano (*)
Division of Colon and Rectal Surgery, Department of Surgery,
Cooper University Hospital, Camden, NJ, USA
Cooper Medical School of Rowan University, Camden, NJ, USA
e-mail: giugliano-danica@cooperhealth.edu
ous. He feels weak and dizzy and reports this has not happened previously. He takes Eliquis for a history of atrial
brillation.
What do you do next?
• Assessment of patient stability and placement of two
large-bore intravenous lines
• Rapid volume resuscitation with crystalloid uid
• Get laboratory studies and order blood products
– Keep hemoglobin >9–10 if cardiac history, otherwise
>7
– May need concurrent administration of platelets and
fresh frozen plasma
• Continuous monitoring of vital signs and foley placement
to monitor urine output
• History questions include duration of bleeding, frequency,
color of blood, as well as surgical history and radiation
history
• Physical examination include abdominal exam and digital
rectal exam with anoscopic exam if possible
• Place an NG tube and assess for blood or bile. If blood
clot or coffee grounds, obtain upper endoscopy
– Clear uid is indeterminate
If the patient stabilizes and bleeding stops over the next
24h, what do you do next?
• Colonoscopy
Evaluation
• Colonoscopy
– If bleeding is self-limiting, administer mechanical
bowel preparation prior to colonoscopy
– Advantageous since diagnosis and therapeutic inter-
ventions can be performed
Therapeutic interventions include clipping, band
ligation, injection of epinephrine or saline, monop-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_27
81
82
D. N. Giugliano
olar or bipolar electrocautery, laser coagulation or
argon plasma coagulation (APC)
• Radionuclide Scintigraphy
– Tc99-RBC scan cans how active hemorrhage with
high sensitivity and slow washout of tracer
– Detection of bleeding as slow as 0.04–0.05cc/min
– Screening test prior to proceeding with mesenteric
angiogram
• Computed Tomography Angiography (CTA)
– Usually used prior to Tc99-RBC scan
– Detection of bleeding as slow as 0.03cc/min
– Sensitivity is 91–92% when bleeding is active or
45–47% when bleeding is intermittent
– Advantage of also being able to identify coexisting
pathology but disadvantage of small risk of
nephropathy
– A positive scan should prompt angiographic emboliza-
tion or surgical resection for massive hemorrhage
• Diagnostic Angiography
– Requires bleeding rate of 0.5–1.5cc/min
– Provocative angiography can be used for recurrent
intermittent lower GI bleeding
– Risks include bleeding, access complications, throm-
boembolic events, contrast-induced nephropathy
What if the patient has recurrent bleeding and cta is positive for active bleeding and the splenic exure? what do you
do now?
• Therapeutic Angiography
– Microcoils, polyvinyl alcohol particles, and Gelfoam
can be used
– Cessation of active bleeding seen in up to 90% of
patients
– Complications include transmural ischemia and
colonic stricture formation
Surgery
• Emergency surgery without localization occurs in less
than 5% of patients
• Indicated if patient is hemodynamically unstable with
refractory, ongoing bleeding, if therapeutic efforts are
unsuccessful or not feasible despite localization, or if
massive transfusion requirements (6 units of PRBC in
24h period)
• Exploratory laparotomy
– Examine small bowel for Meckel’s diverticulum and
for masses
– Transilluminate small bowel for angioectasia
– Intraoperative colonoscopy and/or push enteroscopy
can be performed if patient is stable
– If no obvious source from stomach, small bowel, or
anorectum, perform a total abdominal colectomy with
end ileostomy
• Rebleeding after TAC is <5%
• If bleeding site is localized, a targeted segmental resection with or without an anastomosis can be performed
– Rebleeding rate is 4–10%
Clean Kills
• Not stabilizing patient with two large bore IVs and IV
uids
• Not ruling out upper GI bleeding with NG tube lavage
• Performing segmental resection without localization of
bleed
Bonus Points
• Other etiologies of lower intestinal hemorrhage:
– Post-polypectomy hemorrhage
– Inammatory bowel disease
– NSAIDs
– Infectious colitides due to bacterial infection
(Campylobacter, Salmonella, Shigella, Escherichia
coli, Yersinia)
– Radiation injury
– Rectal ulceration
– Dieulafoy’s lesions
Words ofWisdom
• The management of lower gastrointestinal hemorrhage is
important to understand, as it is a common condition with
many etiologies. Be sure to hemodynamically stabilize
the patient and use diagnostic testing to try to localize the
source of bleeding. Surgery is reserved for patients who
either have localized bleeding and therapeutic angiography is not successful or able to be performed, or for
patients who are unstable despite resuscitation.
Bibliography
Score. https://www.surgicalcore.org.
Steele SR, etal., editors. The ASCRS manual of colon and rectal sur-
gery. NewYork, NY: Springer; 2019.
Peri-Rectal Abscess
HannahSoeld andDanicaN.Giugliano
28
Perianal Abscess
• Most common, around 60% of anorectal abscesses. They
are supercial and do not involve the external anal
sphincter.
Ischioanal Abscess
• Occur in the ischiorectal fossa (Borders: inferiorperineum, superior- levator ani, lateral- ischium and obturator internus, medial- external sphincter)
Intersphincteric Abscess
• Occur between the internal and external sphincters
Supralevator Abscess
• Occur superior to the levator ani
Horseshoe Abscess
• Abscess in any space that crosses the midline
A 25-year-old male presents with perianal pain for the
past 3days. He denies fevers or chills. On exam, you see a
H. Soeld
Department of Surgery, Cooper University Hospital,
Camden, NJ, USA
e-mail: soeld-hannah@cooperhealth.edu
D. N. Giugliano (
Division of Colon and Rectal Surgery, Department of Surgery,
Cooper University Hospital, Camden, NJ, USA
Cooper Medical School of Rowan University, Camden, NJ, USA
e-mail: giugliano-danica@cooperhealth.edu
*)
2.5cm erythematous, uctuant, and tender area in the right
posterolateral anal area. How do you proceed?
• Obtain further medical history, need to ask about fecal
continence, history or risk factors for Crohn’s disease,
and prior abscesses.
The patient has no fecal incontinence, denies prior
abscesses, and no symptoms of Crohn’s disease. What treatment would you offer this patient?
• Incision and drainage of the abscess under local anesthesia, if the patient can tolerate it. Otherwise, the patient will
need operative debridement. Incision (elliptical or cruciate) should be made as close as possible to the anal verge,
and this limits length of stula tract if it were to form.
How should you counsel the patient prior to surgery?
• Risk of fecal incontinence (8–50%), risk of recurrence
(~50%), risk of stula formation (~50%)
Does the patient need antibiotics? What if the patient was
experiencing systemic symptoms?
• The patient does not need antibiotics given the absence of
systemic symptoms; drainage of the abscess is sufcient
treatment. Antibiotics are warranted when systemic symptoms are present or the patient is immunocompromised.
Three months later, he returns with a recurrence of the
abscess. How do you manage this patient?
• This patient likely has a stula. The patient needs an exam
under anesthesia to assess the presence or absence of a
stula tract and, if found, surgical treatment of the stula.
• MRI pelvis can be used preoperatively to dene anatomic
relationships of the stula if stula is recurrent or if multiple external openings.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_28
83
84
H. Soeld and D. N. Giugliano
How would management change if there was extension of
the abscess into the contralateral side?
• This is a horseshoe abscess and requires a counter incision during the drainage procedure. A seton can also be
used. The patient should be counseled that horseshoe
abscesses carry a high risk of recurrence.
Intersphincteric Fistula (Parks Type 1)
• Involve a portion of the internal sphincter, course through
the intersphincteric plane, external opening in perianal skin
Transsphincteric Fistula (Parks Type 2)
• Traverse both internal and external sphincters
Suprasphincteric Fistula (Parks Type 3)
• Track through anal crypt, encircles the entire external
sphincter
Extrasphincteric Fistula (Parks Type 4)
• Least common type, not cryptoglandular in origin, encircle both internal and external sphincters
• This is a simple stula as it involves no external sphincter.
Treatment would be primary stulotomy. This is accomplished by unroong the entire length of the stula while
a probe is in place.
How would you proceed if the stula was transsphincteric?
• Transsphincteric stulas involve both the internal and
external sphincters and thus cannot be treated with stulotomy due to high risk of incontinence. There are two
options, a seton can be placed to attempt to brose the
tract, or a LIFT (ligation of the intersphincteric stula
tract) procedure can be performed. During a LIFT procedure, the stula tract between the internal and external
sphincters is identied and ligated.
• An Endorectal advancement ap can be used for high
transsphincteric or suprasphincteric stulas. This includes
debridement of the stula tract with mobilization of a
mucosal ap and coverage of the internal opening with
suture.
The patient returns 4months later with a new stula on
the left side. How do you proceed?
Further Classication
• Simple: managed through stulotomy without risk of fecal
incontinence, involving minimal to no external sphincter.
• Complex: involve more than 30% of the external sphincter, have multiple tracts, or are caused by Crohn’s disease,
malignancy, or radiation; these cannot be managed by
stulotomy.
Alternate Scenario A 25-year-old male with history of two
prior anorectal abscesses presents with intermittent drainage near his anus. How do you proceed?
• Obtain focused history of risk factors for anorectal
abscesses and stulas including Crohn’s disease, hidradenitis suppurativa, pelvic sepsis, trauma, or malignancy.
• Perform an anorectal examination including a digital rectal exam.
The patient’s history is negative for risk factors. On exam-
ination you notice a small external opening 2cm lateral to
the anal verge on the left side, when pressed a scant amount
of serous uid is expressed. What is your next step?
• Proceed to an examination under anesthesia to assess the
type and extent of stula.
In the operating room, the stula can be probed to its
internal opening, and there is partial internal sphincter
involvement. How do you proceed?
• A new stula on the opposite side raises suspicion for
Crohn’s disease. Patients should be referred to a gastroenterologist for Crohn’s disease evaluation including a colonoscopy. Crohn’s disease stulas, even if simple, should
not be treated with primary stulotomies. The safest
approach to management while pursuing diagnostic
workup is placing a seton in the stula tract. More denitive stula management can be discussed with the patient
once a stable Crohn’s disease treatment regimen is
established.
What if a simple stula was observed in a 65-year-old
female with poor fecal continence at baseline?
• Primary fistulotomy is NOT recommended for
patients if a patient has a history of fecal incontinence. Surgical options are seton placement or a
LIFT procedure.
Clean Kills
• Not asking about history or symptoms of Crohn’s
disease
• Offering a primary stulotomy to a Crohn’s patient
• Performing a primary stulotomy for an intersphincteric
stula
• Not initiating antibiotics in a patient with systemic
symptoms
• Not performing a counter incision for a horseshoe abscess
28 Peri-Rectal Abscess
85
Bonus Points
• Adipose-derived stem cells is a new technique to treat
complex anal stulas, mostly in patients with Crohn’s disease. Research with multicenter randomized controlled
trials using this technique is currently underway.
Words ofWisdom
• The management of peri-rectal abscesses requires thorough knowledge of the pelvic oor anatomy and spaces
occupying the anus. Draining these abscesses can be done
in the ofce or in the operating room. Necrotizing infections should go immediately to the operating room and
require aggressive surgical debridement. Fistulas occur in
50% of patients with perianal abscesses, and are managed
based on their location in relation to the anal sphincter
complex.
Bibliography
Score. https://portal.surgicalcore.org/modulecontent.aspx?id=130173.
Score. https://www.surgicalcore.org/modulecontent.aspx?id=130568.
Scott R.Steele et al. The ASCRS manual of colon and rectal surgery.
NewYork, NY: Springer, 2019.
Rectal Cancer
MatthewC.Moccia andDanicaN.Giugliano
29
A 61-year-old man presents with occasional bright red blood
per rectum. He had a Ct performed in the ER that is concerning
for the presence of a rectal mass. He is hemodynamically stable
and otherwise asymptomatic. How should you proceed?
• As with the workup of nearly every other disease process,
the rst step includes a complete history and physical
examination.
• Ask about changes in bowel habits (especially any
obstructive symptoms), fecal continence history, environmental factors, history of colonoscopy, and family history
of gastrointestinal, biliopancreatic, and gynecologic
malignancies.
• Physical exam should almost always include a rectal exam.
• Standard laboratory tests should be ordered, with the
addition of a CEA.
• A colonoscopy should be used to assess tumor location
and characteristics and obtain biopsy for pathology
review.
• Once the presence of a tumor is conrmed, obtain staging
studies including a CT chest/abdomen/pelvis and rectal
cancer protocol MRI (standard of care).
• If MRI is not available obtain endorectal ultrasound.
• Up to 98% of rectal cancers are adenocarcinoma, but just
be aware that other histological types can occur (carcinoids, sarcomas, lymphomas, etc.).
• If an obstructing or near obstructing tumor is seen, this
should prompt discussion for fecal diversion and decompression with a loop colostomy (must be distal to the ileocecal valve).
M. C. Moccia
Department of Surgery, Cooper University Healthcare,
Camden, NJ, USA
e-mail: moccia-matthew@cooperhealth.edu
D. N. Giugliano (
Division of Colorectal Surgery, Department of Surgery, MD
Anderson Cancer Center at Cooper, Camden, NJ, USA
Cooper Medical School of Rowan University, Camden, NJ, USA
e-mail: giugliano-danica@cooperhealth.edu
*)
A 61-year-old man was recently in the ER and was diag-
nosed with a non-obstructing rectal adenocarcinoma. He
is anxious to know his treatment options. What do you tell
him?
• The management of rectal cancer has evolved signicantly since the turn of the millennium. Any patient with
unresectable disease on presentation should be discussed
at a multidisciplinary management meeting including surgical, medical, and radiation oncologists.
• For resectable disease, certain T1 tumors can be removed
transanally via a variety of methods (transanal excision,
transanal minimally invasive surgery, transanal endoscopic microsurgery, endoscopic submucosal dissection),
as long as there is no nodal involvement seen on staging
examinations.
• For higher stage tumors or those not amenable to transanal removal, surgical technique is based mainly on tumor
location within the rectum and the presence or absence of
sphincter involvement.
– Surgical options include low anterior resection (LAR),
resection with coloanal anastomosis, or abdominoperineal resection (APR).
– The goal is to achieve a total mesorectal excision
(TME).
– High ligation of the inferior mesenteric artery should
be achieved and a minimum of 12 lymph nodes should
also be removed.
– The involved segment should be completely removed,
ideally with 5-cm margins. However, a distal negative
margin of 1cm or less is acceptable in patients undergoing sphincter-preserving surgery.
– Any local structures or organs invaded by the primary
tumor should be removed en bloc.
• Patients with isolated hepatic metastases should be offered
surgical resection of the metastases when feasible.
– If the hepatic metastases are unresectable, other treat-
ment options include radiofrequency ablation, chemoembolization, and brachytherapy.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_29
87
88
M. C. Moccia and D. N. Giugliano
Total Neoadjuvant Therapy (TNT)
• TNT is administering all systemic chemotherapy and
radiation therapy before surgery.
• TNT was developed and applied to a number of new multimodal treatment strategies for locally advanced rectal
cancer that administer both radiation and systemic therapy before surgical resection. These strategies can vary
substantially in their radiation dosages and fractionations,
chemotherapy options and sequencing of modalities, but
what they have in common is the administration of both
radiation and full systemic chemotherapy (as opposed to
lower radio-sensitizing chemotherapy doses) in the neoadjuvant setting, before surgery.
• The sequence of TNT regimens can be classied as induction chemotherapy (chemotherapy rst) or consolidation
chemotherapy (radiation rst).
• Landmark randomized controlled trials (RAPIDO,
PRODIGE-23), TNT has moved to the forefront of locally
advanced rectal cancer treatment and is considered a standard option in selected patients.
• TNT should be considered (although not necessarily
always given) for all locally advanced rectal cancers.
• Indications for TNT include clinical T4 disease or close
or involved circumferential resection margin, N2, lateral
pelvic node involvement or extramural vascular invasion.
• TNT is associated with higher rates of pathologic complete response, better downstaging and downsizing, and
improved chemotherapy completion rates over non-TNT
approaches.
A 61-year-old man has recently nished treatment for his
stage II rectal adenocarcinoma. He sees you in the ofce and
asks how frequently he should be seeing you in the future.
What do you tell him?
between colonoscopies is 5years. Of note, proctoscopy
should be performed every 6months for 3–5years if the
patient underwent local instead of radical excision.
A 25-year-old patient presents to your ofce after being
referred for the presence of rectal cancer. What special consideration is warranted in this patient?
• The diagnosis of rectal cancer in any patient younger than
45 should prompt consideration for genetic testing. There
are a few genetic syndromes with which you should be
aware.
– Familial adenomatous polyposis (FAP) is an autoso-
mal dominant disorder caused by a mutation in the
adenomatous polyposis coli (APC) gene
– Lynch syndrome/hereditary nonpolyposis colorectal
cancer (HNPCC) is an autosomal dominant disorder
affecting DNA mismatch repair (MMR) genes
– Peutz-Jeghers syndrome (PJS) is an autosomal domi-
nant disorder affecting the serine-threonine-kinase
tumor suppressor (STK11) gene
– MUTYH-associated polyposis (MAP) is an autosomal
recessive disorder resulting from biallelic mutations in
the MUTYH gene
Bonus Points
• Amsterdam criteria 3-2-1 rule: three relatives with
colorectal (one is a rst degree relative) cancer, two con-
secutive generations affected, one relative diagnosed
before age 50, FAP excluded
• Pathology specimens should undergo IHC for MMR pro-
tein expression and PCR for MSI analysis
• Surveillance is recommended for stage 1 disease with
high-risk features, stage 2 and 3 disease, and stage 4 disease when isolated metastases are resected for cure.
• An ofce visit with CEA is recommended every
3–6months for 2years, then every 6months until 5years.
• CT chest/abdomen/pelvis should be obtained every year
for 5years.
• A colonoscopy needs to be completed 1year after surgery, unless the entire colon was not visualized preoperatively, in which case colonoscopy should be performed
3–6months after surgery. Subsequent colonoscopies will
be performed after either 1, or 3years, depending on the
ndings from the colonoscopy. The longest time period
patients with a history of rectal cancer should have
Words ofWisdom
• Rectal cancer can present without any symptoms, or with
subtle symptoms such as change in bowel habits and/or
rectal bleeding. Proper diagnosis and preoperative staging
are essential for proper treatment. TNT has become
increasingly common for more advanced tumors. The
types of TNT have been evolving and being up-to-date
with randomized controlled studies is important for future
management of these patients. In combination with preoperative treatment, proper surgical excision is also
essential for the best outcomes. Performing a TME with
negative margins is important for reducing the rate of
tumor recurrence.
29 Rectal Cancer
89
Bibliography
Herzig D, Hardiman K, Weiser M, You N, Paquette I, Feingold DL,
Steele SR. The American Society of Colon and Rectal Surgeons
Clinical Practice Guidelines for the Management of Inherited
Polyposis Syndromes. Dis Colon Rectum. 2017;60(9):881–94.
https://www.cancer.gov/types/colorectal/hp
https://www.mdanderson.org/for- physicians/clinical- tools- resources/
clinical- practice- algorithms/cancer- treatment- algorithms.html
https://www.surgicalcore.org
Johnson GGRJ, Park J, Helewa RM, Goldenberg BA, Nashed M, Hyun
E.Total neoadjuvant therapy for rectal cancer: a guide for surgeons.
Can J Surg. 2023;66(2):E196–201.
Right Lower Quadrant Pain
AnnaShu andVictoriaSharp
30
Acute Appendicitis
Way Question May BeAsked?
“A 26-year-old woman presents to the emergency department with abdominal pain that began last night associated
with nausea and vomiting. Her pain was initially periumbilical but is now localized to the right lower quadrant. Her
vitals are normal, physical examination reveals tenderness in
the right lower quadrant at McBurney’s point.”
How toAnswer?
History
• Anorexia, nausea, abdominal pain migrating to the right
lower quadrant
• Gynecological history in females, last menstrual period
• DDx: Gastrointestinal (gastroenteritis, colitis, inammatory bowel disease, Meckel’s diverticulum), urological
(urinary tract infection, pyelonephritis), or gynecologic
(ovarian torsion, ectopic pregnancy)
Physical Examination
• Vitals signs
• Abdominal exam
– Tenderness to palpation over McBurney’s point
– Rovsing’s sign—RLQ pain with palpation of the LLQ
– Obturator sign—Pain with passive internal rotation in
right hip exion
– Psoas sign—Pain with straight leg raise
– Peritoneal signs
• Pelvic exam in females
– Adnexal mass
– Cervical motion tenderness
Diagnostic Tests
• Complete blood count
• Basic metabolic panel
• Pregnancy test
• Urinalysis
• Type and screen
• CT scan or ultrasound
• MRI in pregnancy
Treatment
• Uncomplicated appendicitis: Antibiotics and appendec-
tomy
• Perforated appendicitis with abscess: Antibiotics and
image-guided percutaneous drainage followed by interval
appendectomy
• Perforated appendicitis with peritonitis: Antibiotics and
surgical exploration
Key Technical Steps
A. Shu
Trauma, Acute, and Critical Care Surgery Central Michigan
University College of Medicine, Saginaw, MI, USA
Trauma, Acute, and Critical Care Surgery, Trinity Health Ann
Arbor, Ypsilanti, MI, USA
e-mail: shu1a@cmich.edu
V. Sharp (
Trauma, Acute, and Critical Care Surgery, Trinity Health Ann
Arbor, Ypsilanti, MI, USA
e-mail: victoria_sharp@ihacares.com
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_30
*)
Laparoscopic Appendectomy
• General anesthesia, supine position with the left arm
tucked, decompressed bladder
• Three-port-site approach at umbilicus and per surgeon
preference
• Systematic exploration of the abdomen
• Mobilize appendix and create a mesenteric defect at the
base of the appendix
91