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73 Hyperparathyroidism
235
Words ofWisdom
Parathyroid surgery for hyperparathyroidism could be a very
difcult question with a vague presentation. A very careful
history and workup will keep you on the right track.
Preoperative labs and localization should be exhaustive to
show you are operating for the right diagnosis. Intraoperative
localization techniques, anatomy, and conrmation methods
will always be asked. What to do after surgery, if you could
not nd the gland, hypocalcemia, nerve injury. You cannot
go wrong if you transfer patients to a high-volume center for
reoperative surgery.
Thyroid Nodule
CandaceL.Ward andRadiZaki
Way Question May BeAsked?
A 31-year-old female presented to her primary care physician for a sore throat and was found to have a left thyroid
mass. What do you want to do?
Could be presented with the mass found by a family MD
and sent to you, could be given symptoms of hyperthyroidism. After your initial H+P, all patients get U/S and FNA.
How toAnswer?
• Complete history and physical examination
– Questions related to hyper- or hypothyroidism
Weight loss or gain
Fatigue
Depression
Heat or cold intolerance
Diarrhea (medullary thyroid cancer)
Palpitations or tachycardia
History of neck radiation (i.e. breast cancer or
Hodgkin’s lymphoma)
Recent changes to voice (hoarseness, breathiness)
Any personal or family history of MEN syndrome
(pheochromocytoma and hypercalcemia)
Family history: goiter, MEN II, thyroid cancer
• Physical exam
– Vitals: look for tachycardia, hypertension
– Description of mass: visible, asymmetric, palpable,
xed vs. mobile, any movement with swallowing
– Cervical lymph node exam
– Vocal cord evaluation (nasopharyngeal laryngoscopy)
if any voice changes
• Diagnostic tests
– Perform ultrasound rst to characterize the nodule.
74
Look for size, nodule characteristics such as cystic
vs. solid, lymphadenopathy.
Risk factors for malignancy include heterogeneous
nodules with cystic and solid components, microcalcications, irregular margins, taller than wide,
etc.
TIRADS score is provided and should guide
management.
– Prior to biopsy, obtain blood tests: T4, TSH, thyroid
peroxidase antibodies (if TSH is elevated), calcitonin
(only if suspected medullary thyroid cancer), and calcium level.
Initial measurement of thyroglobulin is not recommended for thyroid nodule workup. Calcitonin levels are controversial in initial workup.
Elevated calcium levels may alter management so
prepare for changes in scenario.
If pheochromocytoma suspected, obtain calcitonin,
serum calcium, serum phosphate, and urine
studies.
– Fine needle aspiration (FNA) should be performed in
nodules 1cm and above with suspicious characteristics and in all nodules 1.5cm and above.
Exception: purely cystic nodules.
– Consider radionuclide scan if TSH is low or when
ectopic thyroid tissue or a retrosternal goiter is
suspected.
Evaluating for a “hot” nodule, which is more likely
to be benign.
Will want to assess whether it is multinodular
(MNG) or a single nodule.
– Molecular testing: controversial, likely to evolve in the
next few years.
Results ofFNA
C. L. Ward (*) · R. Zaki
Department of Surgery, Einstein Healthcare Network,
Philadelphia, PA, USA
e-mail: Radi.zaki@jefferson.edu
© 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_74
• Nondiagnostic. Repeat FNA. If repeatedly inadequate,
consider ultrasound-guided core-needle biopsy or surgical excision.
237
238
C. L. Ward and R. Zaki
• Benign. Repeat ultrasound in 12 months and physical
exams.
– If symptomatic or compressive, consider surgical
excision.
– If growing in size >50% over the observation period,
repeat FNA is indicated.
• Indeterminate—atypia of undetermined signicance
(AUS), follicular lesion of undetermined signicance
(FLUS), or follicular neoplasm/suggestive of follicular
neoplasm (FN/SFN).
– Low-risk indeterminate nodules (AUS/FLUS): 5–15%
malignant.
Consider repeat FNA.
If negative personal and family history, small lesion
size, can consider conservative management.
If suspicious US ndings, lobectomy and
isthmusectomy.
– High-risk indeterminate nodules (FN/SFN or Hürthle
cell neoplasm): 15–30% malignant.
Repeat FNA not recommended.
Diagnostic lobectomy and isthmusectomy; consider total thyroidectomy. Frozen sections are not
helpful.
• Suspicious—60–75% malignant; treat as malignant.
– Lobectomy and isthmusectomy.
– Can consider intraoperative frozen sections to guide
clinical decision making.
• Malignant—surgical management.
If anaplastic, metastatic, or thyroid lymphoma, further
diagnostic workup is indicated prior to surgical
intervention.
Surgical Treatment
• Lobectomy: low risk papillary (<2 cm) and follicular
carcinoma.
• Total thyroidectomy
– Multinodular goiter
– All other thyroid cancers (> 1 cm, medullary thyroid
cancer, etc.)
• Completion total thyroidectomy: if diagnostic lobectomy
performed.
– Indications: tumor >4 cm, gross positive resection
margins, gross extrathyroidal extension, conrmed
nodal metastasis, conrmed contralateral disease, vascular invasion, lymphatic invasion, macroscopic multifocal disease, poorly differentiated cancer.
• Central neck dissection (CND): remove levels VI and VII
nodes. Only for medullary thyroid cancer or positive central neck nodes (intraoperative nding or imaging).
– CND not indicated for small (T1–2), noninvasive, clin-
ically node-negative papillary cancers, and most follicular cancers.
– Prophylactic dissection indicated in patients with T3–4
papillary carcinoma, clinically involved lateral neck
nodes.
– Therapeutic dissection for clinically involved central
nodes.
• Modied radical neck dissection (MRND): biopsy-proven
metastatic lateral cervical lymphadenopathy.
• Total thyroidectomy, en bloc resection, MR lymph node
dissection, +/− tracheostomy, +/− chemoradiation therapy: anaplastic cancer.
– Most anaplastic cancers present with unresectable or
metastatic disease however the diagnosis itself is not a
barrier to resection.
Postoperative Cancer Treatment
• Radioactive iodine ablation
– Indications: gross extrathyroidal extension (T4), dis-
tant metastatic disease, follicular thyroid cancer with
extensive vascular invasion, incomplete tumor resection, bulky or >5 positive lymph nodes, elevated thyroglobulin level
– Recommend low-iodine diet 1–2weeks prior to treat-
ment or 4–6weeks off TSH suppression medication.
– Other option: Cytomel (short-life T4) to avoid side
effects of hypothyroidism; can hold for just a week.
• TSH suppression
– Utilize levothyroxine or Cytomel (T4) to suppress
TSH levels in papillary, follicular, or oncocytic
carcinoma.
– Ensure adequate supplementation of calcium and vita-
min D while taking levothyroxine.
• External-beam radiation therapy: consider for patients
with aero-digestive tract invasion or with gross residual
disease (R2 dissection).
Surveillance
• Thyroglobulin levels, anti-thyroglobulin antibody levels.
Calcitonin for medullary cancer.
– Remember to test thyroglobulin levels without TSH
suppression.
• Neck ultrasound at 6–12 months postoperatively, then
yearly for 3–5years.
• Radioiodine scan—if high risk for persistent or recurrent disease, distant metastases, disease-specic mortality, patients with previous RAI-avid mets, patients
with abnormal thyroglobulin levels, stable or increasing
74 Thyroid Nodule
239
thyroglobulin antibodies, or abnormal ultrasound
results.
Common Curveballs
• Be prepared for airway compromise post-op.
• Be prepared for vocal cord paralysis post-op.
• Asked about possible nerve injuries (recurrent laryngeal
and sup. laryngeal) and their consequences.
• Be prepared for hypocalcemia post-op.
• Part of a MEN syndrome.
• Follicular cells on FNA.
• Justifying your reasoning for total thyroidectomy.
• Will be nodules in both lobes.
• Will be goiter plus a nodule.
• Thyroglobulin levels will increase several months
post-op.
• Thyroid scan will show “hot nodule”.
Clean Kills
• Failing to rule out MEN syndrome.
• Not knowing how to deal with post-op complications.
• Not performing FNA.
• Not knowing when to follow calcitonin levels (medullary
carcinoma) and when to follow thyroglobulin levels.
• Not performing central node dissection in medullary
carcinoma.
• No placing patient on levothyroxine post-op.
Summary
get an ultrasound and biopsy if large or suspicious. Based
on the biopsy, your option will generally be surveillance,
lobectomy, or thyroidectomy. Do not forget preoperative
evaluation of vocal cords if indicated as well as investigation into any possible MEN syndrome (thyroidectomy
before adrenalectomy if a patient has a pheochromocytoma is a fail!). Be prepared to defend your decision to
perform a lobectomy instead of a total thyroidectomy.
CND is indicated in all cases with clinically positive central nodes as well as medullary thyroid cancer; modied
radical neck dissection is usually guided by clinically
positive or biopsy-proven locoregional disease. Anticipate
postoperative complications as part of your scenario.
Adjuvant management should include close surveillance,
TSH suppression, and consideration of RAI.
Bibliography
Dean DS, Gharib H.Epidemiology of thyroid nodules. Best Pract Res
Clin Endocrinol Metab. 2008;22:901–11.
Gharib H, Papini E, Garber JR, etal. American Association of Clinical
Endocrinologists, American College of Endocrinology, and
Associazione Medici Endocrinologi Medical Guidelines for clinical practice for the diagnosis and management of thyroid nodules2016 update appendix. Endocr Pract. 2016;22:1–60.
Haddad RL, Bischoff L, Ball D, et al. Thyroid carcinoma, version
2.2022, NCCN clinical practice guidelines in oncology. J Natl
Compr Cancer Netw. 2022;20(8):925–51. https://doi.org/10.6004/
jnccn.2022.0040.
Haugen BR, Alexander EK, Bible KC, etal. 2015 American Thyroid
Association management guidelines for adult patients with
thyroid nodules and differentiated thyroid cancer. Thyroid.
2016;26(1):1–133.
Nabhan F, Ringel MD. Thyroid nodules and cancer management
guidelines: comparisons and controversies. Endocr Relat Cancer.
2017;24(2):R13–26. https://doi.org/10.1530/ERC- 16- 0432.
Thyroid nodules are very common and very algorithmic,
although management can get more complicated with the
varying subtypes of cancers. Every thyroid nodule should
Part X
Genitourinary
Renal Artery Stenosis
MadisonCrutcher
75
Way Question May BeAsked?
A 57-year-old male with a history of type II diabetes mellitus
and tobacco abuse presents with medically refractory hypertension (on four medications with poor control). He also has
stage 2 chronic renal insufciency. His primary care doctor
thought he heard an abdominal bruit.
How toAnswer?
• Start with history and physical exam, with focus on other
signs of systemic vascular disease.
• Obtain abdominal/renal ultrasound.
– Normal renal artery peak systolic velocity (PSV) is
60–100cm/s.
– Renal artery PSV >180 cm/s is indicative of RAS
>60%.
• For medical therapy for hypertension, the rst line recommendation is ACE inhibitor (ACEI) or angiotensin-2
receptor blocker (ARB).
– Calcium channel blockers, beta blockers, chlorothia-
zide, or hydralazine may be added.
– Statins should be used to treat hyperlipidemia.
– Antiplatelet agents are to be used in patients after
endovascular RAS revascularization.
– Smoking cessation.
– Glycemic control.
• If intervening surgically, endovascular approach is
preferred.
– Obtain CTA of abdomen and pelvis or formal
arteriogram.
– Obtain perioperative cardiac risk stratication for all
vascular surgery patients.
M. Crutcher (*)
Department of Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
Surgical Treatment
• Endovascular repair
– First choice access site is femoral access.
– Obtain aortogram.
– Weight-based heparization when sheath size selected.
– Wire placed into the affected renal artery.
– Balloon angioplasty and stent placement performed
with stent extending in the aorta.
– Completion angiogram to ensure patency.
– Reversal of heparin.
– Closure of access site.
• Complications
– Renal artery rupture: covered stent placement over site
of perforation.
• Open repair
– Considered in patients already undergoing open aortic
surgery for other reasons or those with lesions not
amenable to endovascular approach.
– Aortorenal artery bypass
Midline incision allows for any other indicated
procedures.
Small bowel retracted to the right side of the abdomen or can perform full mobilization of the left
colon/splenic exure.
Retroperitoneum opened to expose the aorta.
Left renal vein retracted cephalad to expose underlying aorta and left renal artery.
Proximal right renal artery can be accessed through
above exposure, exposure of distal right renal artery
might require mobilization of the right colon.
Mannitol can be given to prevent the development
of acute renal failure.
Systemic heparinization prior to clamping of renal
arteries.
Saphenous vein or synthetic grafts used to create
bypass.
End-to-side anastomosis on aorta.
Distal end of graft and distal end of renal artery
spatulated, end-to-end anastomosis.
© 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_75
243
244
M. Crutcher
– Extra-anatomic renal artery bypass options
Left renal artery can be revascularized using the
transected splenic artery.
Right renal artery can be revascularized using the
common hepatic artery.
– Aortorenal endarterectomy
Bilateral renal arteries and circumferential aorta
dissected free.
Vascular loops around bilateral renal arteries, atraumatic clamps on supra- and infrarenal aorta.
Transverse arteriotomy extending onto the renal
arteries.
Plaque removed with vascular freer.
Closed with patch aortoplasty.
Common Curveballs
• The patient has advanced atherosclerotic disease of the
descending aorta.
– Consider extra-anatomic bypass if splenic/hepatic
arteries are patent, or aortorenal endarterectomy.
• The patient suffers a pulseless foot in the immediate postoperative period.
– Return to operating room arteriogram and thromboem-
bolectomy. Check of intimal ap or thrombogenic
problem at renal artery intervention site.
Clean Kills
• Failure to obtain proper history and physical exam
– Failure to obtain perioperative cardiac risk stratica-
tion prior to surgical intervention.
• Treating RAS patients surgically without appropriate
indications.
Words ofWisdom
This may be an uncommon question to be asked on the general surgery oral boards exam, but surgeons should still be
prepared for it. Oftentimes, the questioner may focus on preoperative evaluation or preparation of the patient, or postoperative complications.
Bibliography
Giglia JS. Atherosclerotic renal artery stenosis. In: Cameron
JL, Cameron AM, editors. Current surgical therapy. 13th ed.
Philadelphia, PA: Elsevier; 2019. p.1029–34.
Singh N, Hemingway J. Abdominal and aortoiliac aneurysm. 2023.
Available from: https://www.surgicalcore.org/modulecontent.
aspx?id=1000548
Kidney Stones
FariFall
76
Concept
Nephrolithiasis should be suspected in patients presenting
with frank pain or renal colic, especially in the presence of
hematuria. The location of pain is usually dependent on the
site of obstruction. Upper ureteral or kidney pelvic obstruction leads to ank pain or tenderness, whereas lower ureteral
obstruction causes pain that may radiate to the ipsilateral testicle or labium.
Workup, in addition to a thorough history and physical
exam, should include basic laboratory testing and imaging of
the kidneys, ureters, and bladder to assess for the presence of
stones and also signs of obstruction such as hydronephrosis.
Gross or microscopic hematuria occurs in most patients with
symptomatic nephrolithiasis. However, the absence of hematuria in the setting of acute ank pain does not exclude kidney stones.
Many patients can be managed conservatively with pain
medication and IV hydration until the stone passes. The likelihood of stone passage depends on the size and location,
with smaller (up to 5mm) and more distal stones more likely
to pass without intervention. Surgical intervention is indicated in the presence of infection, solitary kidney, acute kidney injury, anuria and/or intractable pain, nausea, and
vomiting. In patients with obstructing stones and suspected
infection, the collecting system must be urgently drained
with a stent or nephrostomy tube with delayed stone treatment. An alternative to stent placement is stone removal
either by extracorporeal shock wave lithotripsy (EWL) or
ureteroscopy. EWL is contraindicated in pregnant patients as
well as patients with untreated UTI, uncorrected coagulopathy, or those who must continue receiving anticoagulant or
antiplatelet therapy. Once the acute episode has passed, any
retrieved stone should be sent for analysis, and the patient
should be evaluated for possible underlying risk factors for
F. Fall (*)
Department of Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
e-mail: Fari.Fall@jefferson.edu
nephrolithiasis. If left untreated, nephrolithiasis can lead to
persistent kidney obstruction, which may result in permanent
kidney damage.
Way Questions May BeAsked?
A 47-year-old man presents to the emergency department
with right ank pain, nausea, and vomiting that began a few
hours prior to the presentation. He is afebrile with stable
vital signs. What do you think is going on, and how would
you manage it?
Alternate Scenario
A 26-year-old female with a history of nephrolithiasis presents to the emergency department at 30weeks gestational
age with acute onset right ank pain, nausea, and emesis.
Her temperature is 101.2, but the rest of her vital signs are
within normal limits. What do you think is going on, and how
would you manage it?
How toAnswer?
• Start with a thorough history and physical exam
– The differential diagnosis for ank pain is very broad
and includes nephrolithiasis, pyelonephritis, diverticulitis, appendicitis, ectopic pregnancy, ovarian torsion,
retroperitoneal bleed or mass, renal trauma, renal vein
thrombosis, ureteral obstruction, etc. As such, it is
important to obtain a thorough history and physical
exam that can narrow the differential and facilitate
prompt diagnosis.
• History: A thorough history should include characteris-
tics of the pain (location, duration, quality, severity, radiation, aggravating and alleviating factors) and associated
symptoms such as fever, chills, nausea, vomiting, anuria,
dysuria, and hematuria.
© 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_76
245
246
F. Fall
– Be sure to also ask about past medical history, includ-
ing personal or family history of nephrolithiasis,
dietary habits, medications that predispose to stone
formation, diabetes, trauma, bariatric surgery, inammatory bowel disease, chronic diarrhea/malabsorption, and pelvic inammatory disease, sexually
transmitted infections.
– In women of reproductive age, include gynecological
history.
• Physical Exam: The physical exam should be used to
exclude other problems in the differential.
– Pay attention to the overall appearance of the patient
and vital signs.
– Complete abdominal exam, being sure to check for
surgical scars, hernias, abdominal tenderness, and
CVA tenderness.
• Diagnostic tests
– CBC to look for evidence of infection.
– BMP to evaluate kidney function and detect renal
impairment.
– Clean catch urinalysis with reex culture-check for
hematuria and signs of concurrent urinary tract infection (UTI) (nitrites, leukocyte esterase).
– Noncontrast CT of the abdomen and pelvis is the
imaging modality of choice.
Very sensitive (99%) and specic (96%) in detecting renal calculi with an accurate description of the
size and location, assessing secondary signs of
obstruction such as hydronephrosis, renal enlargement, perinephric stranding) and can be used to
determine other nonrenal causes of ank pain.
– In pregnant women, ultrasound of the kidneys and
bladder is the preferred initial imaging modality.
Reliably detects hydronephrosis, but it is less sensitive in detecting stones, is operator-dependent, and
is limited in obese patients.
MRI is second line imaging choice in such patients.
• Treatment
– Most uncomplicated ureteral stones <10 mm can be
managed conservatively with pain control and hydration, with or without medical expulsive therapy (MET)
with alpha-blockers (e.g., tamsulosin) until the stone
passes or symptoms resolve.
– The likelihood of spontaneous stone passage correlates
with stone size and location with smaller and more distal ureteric stones most likely to pass spontaneously.
– The American Urological Society recommends deni-
tive stone management after 4–6weeks of unsuccessful conservative management of uncomplicated
stones.
• An infected, obstructed renal system is a urological
emergency that requires decompression with either
stenting or percutaneous nephrostomy. Antibiotics
should also be started and tailored to sensitivities once
available. Denitive treatment of the stone should be
delayed until the sepsis resolves.
• Surgical Management
– Urgent decompression of the collecting system is
required in the following:
Obstructing stone in the presence of concurrent
UTI.
Unilateral obstruction and AKI in patients with solitary kidney.
Bilateral obstruction with AKI.
– Elective surgery is recommended in the following:
Ureteral stones >10mm.
Uncomplicated ureteral stones ≤10mm that do not
pass after 4–6weeks of observation with or without
MET.
Recurrent UTI secondary to stones.
Persistent kidney obstruction due to stone.
Pregnant patients who fail observation.
• The three most common treatment modalities include
EWL, percutaneous nephrolithotomy (PCNL), and ureteroscopy with laser lithotripsy.
Common Curveballs
• The patient is pregnant, requiring alternative imaging,
and treatment strategies.
• The presentation sounds like acute appendicitis but is
actually a symptomatic kidney stone.
Clean Kills
Failure to emergently decompress the ureters in a patient
with concurrent infection.
Words ofWisdom
Although typically treated by urologists, general surgeons
should have a thorough knowledge of the workup and treatment of kidney stones. Examinees may be presented with
cases which initially sound like another common surgical
problem (e.g., appendicitis or cholecystitis), but turn out to
be kidney stones.
Bibliography
Assimos D, Krambeck A, Miller NL, etal. Surgical management of
stones: American Urological Association/Endourological Society
guideline. American Urological Association Education and
Research, Inc; 2016.
76 Kidney Stones
247
Curhan GC, Aronson MD, Preminger GM.Kidney stones in adults:
diagnosis and acute management of suspected nephrolithiasis
[Internet]. UpToDate; 2023.
Humphreys MR, Lieske JC.Evaluation and medical management of
kidney stones. In: Potts JM, editor. Essential urology: a guide to
clinical practice. Humana Press; 2012.
Khan SR, Pearle MS, Robertson WG, etal. Kidney stones. Nat Rev Dis
Primers. 2017;3:17001.
Preminger GM.Kidney stones in adults: surgical management of kid-
ney and ureteral stones [Internet]. UpToDate; 2023.
Sorensen M, Walsh TJ, Haider MA.Urinary stone disease. In: Current
medical diagnosis & treatment 2022. McGraw Hill; 2022.