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REVIEW of
SURGERY for
ABSITE andi / BOARDS
JSSBmå

Christian de Virgilio
Areg Grigorian
Associate Editors
Amanda C. Purdy
Eric O. Yeates
Naveen Balan
Illustrator
Stephanie Cohen

THIRD EDITION
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2022v1.0
 Review of Surgery for
ABSITE AND
BOARDS
 Review of Surgery for
ABSITE AND BOARDS
THIRD EDITION

EDITORS
Christian de Virgilio, MD, FACS Areg Grigorian, MD
Chair Assistant Clinical Professor of Surgery
Department of Surgery Department of Surgery
Harbor-UCLA Meical Center Division of Trauma, Burns an Critical Care
Torrance, California; University of California, Irvine
Co-Chair Orange, California
College of Applie Anatomy;
Professor of Surgery
UCLA School of Meicine
Los Angeles, California

ASSOCIATE EDITORS

Amanda C. Purdy, MD Eric O. Yeates, MD Naveen Balan, MD

Surgical Resient Physician Resient Physician Surgical Resient
Department of Surgery Department of Surgery Department of Surgery
Harbor-UCLA Meical Center University of California, Irvine Harbor-UCLA Meical Center
Torrance, California Orange, California Torrance, California

ILLUSTRATOR
Stephanie Cohen, MD
Surgical Resient
Beth Israel Deaconess Meical Center
Boston, Massachusetts
1600 John F. Kenney Blv.
Ste 1800
Philaelphia, PA 19103-899

REVIEW OF SURGERY FOR ABSITE AND BOARDS, THIRD EDITION ISBN: 978-0-33-87054-

Copyright © 2023 by Elsevier Inc. All rights reserved.

No part of this publication may be reprouce or transmitte in any form or by any means, electronic or mechan-
ical, incluing photocopying, recoring, or any information storage an retrieval system, without permission in
writing from the publisher. Details on how to seek permission, further information about the Publisher’s permis-
sions policies, an our arrangements with organizations such as the Copyright Clearance Center an the Copyright
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This book an the iniviual contributions containe in it are protecte uner copyright by the Publisher (other
than as may be note herein).

Notice

Practitioners an researchers must always rely on their own experience an knowlege in evaluating an using
any information, methos, compouns, or experiments escribe herein.Because of rapi avances in the
meical sciences, in particular, inepenent verication of iagnoses an rug osages shoul be mae. To the
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use or operation of any methos, proucts, instructions, or ieas containe in the material herein.

Previous eitions copyrighte 018 an 010.

Content Strategist: Jessica McCool

Content Development Specialist: Shweta Pant
Publishing Services Manager: Shereen Jameel
Project Manager: Beula Christopher
Design Direction: Ryan Cook

Printe in the Unite States of America.

Last igit is the print number: 9 8 7 6 5 4 3  1
 To my family, who always support me, and to all students of surgery, who motivate and inspire me to
always keep learning the art and science of medicine.

—Christian de Virgilio

I would not be where I am today if it wasn't for my mentors. Dr. de Virgilio—you are the reason I love surgical
education.Dr. Demetriades, you taught me trauma surgery but more importantly, you taught me how to be an
effective and inspiring teacher. Dr. Inaba, you have taught me how to be an effective leader both inside and outside
the operating room. Dr.Nahmias, you have taught me how to be an academician and researcher. And to my loving
wife, Rebecca Grigorian—a superhero mom and physician! Thank you all!

—Areg Grigorian
 Contributors

Mark Archie, MD Christian de Virgilio, MD, FACS

Assistant Clinical Professor of Surgery Chair
Department of Surgery Department of Surgery
Harbor-UCLA Medical Center Harbor-UCLA Medical Center
David Geffen School of Medicine at UCLA Torrance, California;
Los Angeles, California Co-Chair
College of Applied Anatomy;
Naveen Balan, MD
Professor of Surgery
Surgical Resident
UCLA School of Medicine
Department of Surgery
Los Angeles, California
Harbor-UCLA Medical Center
Torrance, California Benjamin DiPardo, MD
Jeremy M. Blumberg, MD Resident
Chief of Urology Department of Surgery
Harbor-UCLA Medical Center; UCLA
Associate Professor of Urology Los Angeles, California
David Geffen School of Medicine at UCLA
Richard Everson, MD
Los Angeles, California
Assistant Clinical Professor of Surgery
Nina M. Bowens, MD Department of Surgery
Assistant Professor Harbor-UCLA Medical Center
Department of Surgery David Geffen School of Medicine at UCLA
David Geffen School of Medicine at UCLA; Los Angeles, California
Associate Program Director, Vascular Surgery Program
Division of Vascular and Endovascular Surgery Mytien Goldberg, MD
Harbor-UCLA Medical Center Assistant Clinical Professor of Surgery
Torrance, California Department of Surgery
Harbor-UCLA Medical Center
Caitlyn Braschi, MD David Geffen School of Medicine at UCLA
Resident Physician Los Angeles, California
Department of Surgery
Harbor-UCLA Medical Center Areg Grigorian, MD
Torrance, California Assistant Clinical Professor of Surgery
Department of Surgery
Formosa Chen, MD, MPH
Division of Trauma, Burns and Critical Care
Health Sciences Assistant Clinical Professor
University of California, Irvine
Department of Surgery
Orange, California
David Geffen School of Medicine at UCLA
Los Angeles, California Joseph Hadaya, MD, PhD
Kathryn T. Chen, MD Resident Physician
Assistant Professor Department of Surgery
Department of Surgery David Geffen School of Medicine at UCLA
Harbor-UCLA Medical Center Los Angeles, California
Torrance, California
Danielle M. Hari, MD, FACS
Christine Dauphine, MD, FACS Division Chief, Surgical Oncology
Vice Chair, Education Department of Surgery
Department of Surgery Harbor-UCLA Medical Center;
Harbor-UCLA Medical Center Associate Professor
Torrance, California; Department of Surgery
Professor of Surgery David Geffen School of Medicine at UCLA
David Geffen School of Medicine at UCLA Los Angeles, California
Los Angeles, California vii
viii Contributors

Dennis Kim, MD Beverley A. Petrie, MD, FACS, FASCRS

Trauma Medical Director Professor of Surgery
Island Health Trauma Services Department of Surgery
Victoria, British Columbia, Canada David Geffen School of Medicine at UCLA
Los Angeles, California;
Catherine M. Kuza, MD, FASA Assistant Chief
Assistant Professor Division of Colon and Rectal Surgery, Department of Surgery
Department of Anesthesiology, Division of Critical Care Harbor-UCLA Medical Center
Keck School of Medicine of the University of Southern Torrance, California
California
Los Angeles, California Amanda C. Purdy, MD
Surgical Resident Physician
Steven L. Lee, MD, MBA Department of Surgery
Professor and Chief Harbor-UCLA Medical Center
Pediatric Surgery Torrance, California
UCLA Mattel Children’s Hospital
Los Angeles, California Shonda L. Revels, MD, MS
Assistant Professor
John McCallum, MD, MPH Department of Surgery
Assistant Professor UCLA
Department of Surgery Los Angeles, California
Harbor-UCLA Medical Center
Torrance, California Jordan M. Rook, MD
Resident Physician
Michael A. Mederos, MD Department of Surgery
Resident Physician David Geffen School of Medicine at UCLA
Department of Surgery Los Angeles, California
UCLA
Los Angeles, California Saad Shebrain, MBBCh, MMM, FACS
Program Director, Associate Professor of Surgery
Alexandra Moore, MD Department of Surgery
Surgery Resident Western Michigan University Homer Stryker M.D. School
Department of Surgery ofMedicine
UCLA Kalamazoo, Michigan
Los Angeles, California
Eric R. Simms, MD
Jeffry Nahmias, MD, MHPE Chief
Associate Professor Division of General, Bariatric and Minimally Invasive Surgery,
Department of Surgery Assistant Program Director of Surgery Residency
University of California, Irvine Department of Surgery
Orange, California Harbor-UCLA Medical Center
Torrance, California
Kristofer E. Nava, MD
Department of General Surgery Veronica Sullins, MD
Western Michigan University Homer D. Stryker School Assistant Clinical Professor of Surgery
of Medicine Department of Pediatric Surgery
Kalamazoo, Michigan David Geffen School of Medicine at UCLA
Los Angeles, California
Junko Ozao-Choy, MD, FACS
Vice Chair, Research Maria G. Valadez, MD
Department of Surgery General Surgery Resident
Harbor-UCLA Medical Center Department of Surgery
Torrance, California; Harbor-UCLA Medical Center
Associate Professor of Surgery Torrance, California
David Geffen School of Medicine at UCLA
Los Angeles, California Luis Felipe Cabrera Vargas, MD, MACC, FACS,
MACCVA, MFELAC
Joon Y. Park, MD President of the Future Surgeons Chapter of the Colombian
Surgery Resident Surgery Association,
Department of Surgery Professor of the Universidad Javeriana and Universidad El Bosque,
David Geffen School of Medicine at UCLA Fellow of Vascular Surgery of the Universidad Militar Nueva
Los Angeles, California Granada
Bogotá, Colombia
 Contributors ix

Zachary N. Weitzner, MD Eric O. Yeates, MD

Resident Physician Resident Physician
Department of Surgery Department of Surgery
UCLA University of California, Irvine
Los Angeles, California Orange, California

James Wu, MD Amy Kim Yetasook, MD

Assistant Clinical Professor of Surgery MIS and Bariatric Surgeon
Department of Surgery Department of Surgery
UCLA Medical Center Harbor-UCLA Medical Center
David Geffen School of Medicine at UCLA Torrance, California;
Los Angeles, California Assistant Professor
Department of Surgery
Tajnoos Yazdany, MD David Geffen School of Medicine at UCLA
Vice Chair of Education Los Angeles, California
Program Director, Obstetrics and Gynecology Residency,
Chief and Program Director, Female Pelvic Medicine and
Reconstructive Surgery,
Associate Professor
David Geffen School of Medicine at UCLA
Harbor-UCLA Medical Center
Torrance, California

It is an honor to write the forewor to the thir eition
of Review of Surgery for ABSITE and Boards by one of
the foremost surgical eucators of our time, Dr. Chris-
tian e Virgilio. This book grew out of his initial infor-
mal attempts to improve ABSITE scores among his
own resients at Harbor-UCLA. Over the years, this
effort has grown an expane, incluing collabora-
tors from multiple institutions, to prouce a book that
has become an essential tool in the surgical resient’s
armamentarium.
The most valuable aspect of this book, in my hum-
ble opinion, is that in aition to questions testing
pure “iactic” knowlege—factois the resient is
expecte to learn by rote an memorize—there are
many clinical questions that require an avance level
of cognitive effort. Here, the learner is expecte to syn-
thesize anatomic an physiologic knowlege within a
clinical context an exercise surgical jugment base
on probabilities of ifferent outcomes. Too often, books
specically targete at passing multiple-choice exam-
inations ten to skip the latter, in favor of questions
that have easy answers—hence the common surgical
aphorism that there are more exam questions on the
clinical presentation of MEN- synrome than patients
with this isease! Writing questions that test esoteric
minutiae is easy; writing questions that promote fur-
ther reaing an stuy of complex surgical scenarios
is much harer. I applau Dr. e Virgilio an his col-
leagues for reaching this higher goal, while still inclu-
ing the “knowlege-regurgitation” questions that are
an inevitable part of the stanarize exam process.
Each question is followe by a thoughtful expla-
nation of the right answer, with accompanying
Foreword
references, to provie a brief summary of essential rel-
evant knowlege. The newest eition also inclues a
summary of “high-yiel” principles at the beginning
of each chapter, which will further enhance the goal
of rapi issemination of essential information on a
given topic.
In aition to serving as a valuable training tool for
the in-service examination, it is our hope that this book
will also inspire the resient to augment their learn-
ing by elving into relevant sections of textbooks an
online resources, incluing vieos an pocasts—all
part an parcel of the total eucational package freely
available to moern surgical trainees. The breath
an epth of multimeia eucation available toay is
enormous, compare to what I ha as a resient; con-
versely, the volume of knowlege an technical skills
new surgeons are expecte to learn an master has
also increase signicantly.
The oubling of scientic knowlege, in meicine
an surgery, is now occurring at an exponential pace,
an we nee all the help we can get to keep up! I am
grateful to Dr. e Virgilio an his colleagues for con-
tinuing to invest the effort necessary to upate this
wonerful book, so it can continue to serve as a vital
resource for present an future surgeons.
Sharmila Dissanaike, MD, FACS, FCCM
Peter C. Canizaro Chair,
University Distinguishe Professor of Surgery,
Texas Tech University Health Sciences Center
Lubbock, Texas
xi

We are thrille about this thir eition of Review of
Surgery for ABSITE and Boards, create to help stuents
of surgery prepare for the American Boar of Surgery
In-Training (ABSITE) an the American Boar of Sur-
gery (ABS) Qualifying (written) Examination. The
original inspiration for the book stemme from a sur-
gery review program we evelope at Harbor-UCLA
Meical Center, esigne to stimulate the resients to
rea, improve performance on the ABSITE, an en-
hance their likelihoo of passing the ABS examinations
on the rst try. We were inspire to hear that the rst
two eitions prove to be a valuable resource.
With that in min, we have strive to make the
3r eition even better with some exciting upates an
changes. Areg Grigorian an I have ae three new
Assistant Eitors to our team, Drs. Amana Pury, Eric
Yeates, an Naveen Balan. All are surgical resients;
Drs. Pury an Balan at Harbor-UCLA an Dr. Yeates
at UC Irvine. We hanpicke them because of their
outstaning recor of accomplishment in test taking
an question writing an their emonstrate strong
interest in surgical eucation. We have also ae nu-
merous resients an surgical eucators from aroun
the country (an even one from Colombia) as contrib-
uting authors. Another important new feature is that
we ae a summary of high-yiel information at the
beginning of each chapter. We feel this will serve as a
rapi-re way to brush up on key points. We have also
ae new, high-yiel questions to remain up-to-ate
with the ever-changing an ynamic el of surgery.
Preface
Finally, we have ae illustrations from an increi-
bly talente surgical illustrator, Dr. Stephanie Cohen,
who is a surgical resient at Beth Israel Deaconess. We
love her work so much that we aske her to make a
rawing for the cover!
The cover illustration, which combines elements of
art, music, an anatomy, remins us that Surgery is
both an art an a science. To master the arts requires
tremenous eication. Excellent surgical knowlege
is one characteristic that is paramount to becoming an
outstaning surgeon. This requires a lifelong commit-
ment to reaing an then testing your knowlege. We
believe that the ieal way to acquire knowlege is to
create a year-roun reaing program. Strive to rea
aily, even if just for 15 minutes.
As with the original version, we believe that the
greatest value of our book lies in the esign of the
questions an the robust responses. The questions are
intene to make you think (try not to get frustrate if
you miss many of them!). We provie in-epth expla-
nations for why we feel the correct answer is right an
why the incorrect answers are wrong. Please be aware
that no textbook or review book has all the answers.
Some questions an answers may be controversial. If
you isagree with a question or think you foun an
error, we woul love to hear back from you (our emails
are cevirgilio@lunquist.org an agrigori@uci.eu).
We sincerely hope you n our review book useful.
Christian de Virgilio and Areg Grigorian
xiii

We would like to acknowledge the efforts of Elsevier for
the timely preparation and publication of this review
book, in particular Jessica McCool, Content Strategist,
who helped with the development of this book and sup-
ported it throughout production, and the contributions
made by Shweta Pant, Senior Content Development
Acknowledgments
Specialist, Beula Christopher, Senior Project Manager,
and Ryan Cook, Book Designer. In addition, we would
like to thank the surgery faculty and residents at Harbor-
UCLA and UC Irvine Medical Centers who assisted in
the production and inspiration of this project.
xv
 Contents

PArt i: PATIENT CARE

1. Abdomen—General, 1
Naveen Balan, Areg Grigorian, and Christian de Virgilio
2. Abdomen—Hernia, 9
Amanda C. Purdy and Amy Kim Yetasook
3. Abdomen—Biliary, 19
Amanda C. Purdy and Danielle M. Hari
4. Abdomen—Liver, 33
Naveen Balan, Kathryn T. Chen, and Danielle M. Hari
5. Abdomen—Pancreas, 47
Joon Y. Park and Danielle M. Hari
6. Abdomen—Spleen, 65
Maria G. Valadez, Benjamin DiPardo, and Eric R. Simms
7. Alimentary Tract—Esophagus, 75
Amanda C. Purdy and Eric R. Simms
8. Alimentary Tract—Stomach, 87
Naveen Balan, Amy Kim Yetasook, and Kathryn T. Chen
9. Alimentary Tract—Small Bowel, 105
Zachary N. Weitzner, Formosa Chen, and Beverley A. Petrie
10. Alimentary Tract—Large Intestine, 123
Joseph Hadaya, Formosa Chen, and Beverley A. Petrie
11. Alimentary Tract—Anorectal, 143
Michael A. Mederos, Formosa Chen, and Beverley A. Petrie
12. Breast, 155
Naveen Balan, Junko Ozao-Choy, and Christine Dauphine
13. Endocrine Surgery, 175
Michael A. Mederos and James Wu
14. Skin and Soft Tissue, 197
Eric O. Yeates, Areg Grigorian, and Christian de Virgilio
15. Surgical Critical Care, 205
Eric O. Yeates and Dennis Kim
16. Trauma, 219
Naveen Balan, Caitlyn Braschi, and Dennis Kim

xvii
xviii ContEnts

17. Vascular—Arterial, 245

Amanda C. Purdy and Nina M. Bowens
18. Vascular—Venous, 265
Amanda C. Purdy and John McCallum
19. Vascular—Access, 275
Luis Felipe Cabrera Vargas, Mark Archie, and Christian de Virgilio
20. Transplant, 283
Joseph Hadaya, Areg Grigorian, and Christian de Virgilio
21. Thoracic Surgery, 291
Jordan M. Rook and Shonda L. Revels
22. Pediatric Surgery, 305
Alexandra Moore, Veronica Sullins, and Steven L. Lee
23. Plastic Surgery, 321
Amanda C. Purdy and Mytien Goldberg
24. Genitourinary, 327
Amanda C. Purdy and Jeremy M. Blumberg
25. Gynecology, 339
Amanda C. Purdy and Tajnoos Yazdany
26. Head and Neck, 347
Zachary N. Weitzner and James Wu
27. Nervous System, 357
Eric O. Yeates and Richard Everson

PArt ii: MEDICAL KNOWLEDGE

28. Anesthesia, 365
Eric O. Yeates and Catherine M. Kuza
29. Fluids, Electrolytes, and Acid-Base Balance, 379
Jordan M. Rook, Areg Grigorian, and Christian de Virgilio
30. Immunology, 391
Kristofer E. Nava and Saad Shebrain
31. Infection and Antimicrobial Therapy, 397
Eric O. Yeates and Jeffry Nahmias
32. Nutrition and Metabolism, 409
Eric O. Yeates, Areg Grigorian, and Christian de Virgilio
33. Oncology and Tumor Biology, 417
Alexandra Moore, Areg Grigorian, and Christian de Virgilio
34. Pharmacology, 427
Eric O. Yeates, Areg Grigorian, and Christian de Virgilio
35. Preoperative Evaluation and Perioperative Care, 437
Naveen Balan, Areg Grigorian, and Christian de Virgilio
36. Transfusion and Disorders of Coagulation, 451
Caitlyn Braschi, Joon Y. Park, and Eric R. Simms
37. Wound Healing, 465
Eric O. Yeates, Areg Grigorian, and Christian de Virgilio
PART I PATIENT CARE

Abdomen—General
NAVEEN BALAN, AREG GRIGORIAN,
AND CHRISTIAN DE VIRGILIO
1
ABSITE 99th Percentile High-Yields
I. Enhance recovery after surgery (ERAS) – associate with a lower overall complication rate, although there
is no ifference in surgical complications or mortality
A. Preoperative optimization
1. Inclues preamission patient eucation on analgesia management after OR, control of meical
comorbiities, smoking cessation, prehabilitation, nutritional care, an correction of anemia
. Ieal patient is ASA 1 or , ambulatory, goo nutritional status; absolute contrainication is urgent
surgery, ASA 4–6, severely malnourishe, or immobile
B. Intraoperative management
1. Stanar anesthesia protocol, minimizing intraoperative uis, preventing intraoperative hypothermia,
maintain normal serum glucose, minimally invasive approach (when feasible), avoi routine use of rains
C. Postoperative care
1. Avoi routine use of nasogastric (NG) tubes, multimoal analgesia to minimize opioi use, use
of epiurals in laparotomy cases, use of TAP (transversus abominis plane) blocks, early urinary
catheter iscontinuation, an early mobilization

QUESTIONS
1. A 56-year-ol male unergoes laparoscopic
peritoneal ialysis (PD) catheter placement.
Several months later the patient comes to the
emergency epartment reporting problems
with his PD catheter. He reports that he can
instill ialysate without ifculty but is unable
to withraw ui through the catheter. His
abomen is istene an he has mil abominal
pain. He is afebrile an not tachycaric. What is
the next best step?
A. Prompt removal of PD catheter
B. Abominal x-ray
C. Instill tPA through the catheter
D. Intraperitoneal antibiotics
E. Intravenous antibiotics
2. A 4-year-ol male unergoes laparotomy for an
anterior abominal stab woun with peritoneal
violation. A small perforation of the transverse
colon is repaire primarily. While examining the
small bowel, an antimesenteric iverticulum is
foun 10 cm proximal from the ileocecal junction.
It is 3 cm in iameter, 3 cm in height, an there is
a brous ban extening from the iverticulum
to the abominal wall. There is no palpable
abnormality ajacent to the iverticulum an no
evience or history of GI bleeing. What is the
appropriate management of the iverticulum?
A. Obtain aitional imaging postoperatively
B. Diverticulectomy
C. Biopsy
D. Observation
E. Segmental resection
1
2 PArt i Patient Care
3. Which of the following is true about
intraabominal hypertension (IAH) an
abominal compartment synrome (ACS)?
A. Diagnosis of ACS is establishe when
intraabominal pressure is greater than 0
mmHg
B. Intraabominal hypertension is ene as
intraabominal pressure >1 mmHg
C. Neuromuscular blockae reuces mortality in
patients with ACS
D. Paracentesis is contrainicate in patients with
IAH
E. Cerebral perfusion is increase in ACS
4. Which of the following is true regaring omental
torsion?
A. Seconary torsion is more common than
primary
B. If surgery is necessary, management consists of
etorsion an omentopexy
C. Treatment is usually observation with pain
control
D. The pain is usually in the left lower quarant
of the abomen
E. It typically prouces purulent-appearing
peritoneal ui
5. The most common organism isolate from the
infecte peritoneal ui of a patient with a PD
catheter is:
A. Beta-hemolytic streptococcus
B. Enterococcus
C. Escherichia coli
D. Coagulase-negative staphylococcus
E. Coagulase-positive staphylococcus
6. A 70-year-ol woman presents with progressive
abominal pain an abominal istention with
nonshifting ullness. A CT scan emonstrates
loculate collections of ui an scalloping of the
intraabominal organs. At surgery, several liters
of yellowish-gray mucoi material are present on
the omentum an peritoneal surfaces. Which of
the following is true about this conition?
A. There is no role for surgical resection
B. It is most commonly of ovarian origin
C. There is a strong genetic inuence
D. It is more common in males
E. Cytoreuctive surgery may be of benet
7. The most common cause of a retroperitoneal
abscess is:
A. Diverticulitis
B. Appenicitis
C. Renal infection
D. Tuberculosis of the spine
E. Hematogenous sprea from a remote location
8. A 50-year-ol male with cirrhotic ascites
seconary to hepatitis C presents with fever,
elevate white bloo cell count, an abominal
pain. He has a history of esophageal varices. He
has been on the liver transplant list for 6 months.
Paracentesis was performe an cultures were
sent. A single organism grows from the culture.
Which of the following is true regaring this
conition?
A. It is most likely ue to appenicitis
B. Prophylactic use of uoroquinolone can be
use to prevent this conition
C. In aults, nephrotic synrome is the most
common risk factor
D. In chilren, E. coli is the most common isolate
E. He will likely nee an exploratory laparotomy
9. A 74-year-ol male presents to clinic hoping to
have his reucible umbilical hernia repaire
seconary to increasing but intermittent pain
an iscomfort. Two ays before his clinic visit,
he ha been ischarge from the hospital for
unstable angina, for which he unerwent balloon
angioplasty with placement of a bare metal
coronary artery stent (BMS). When shoul his
surgery be scheule?
A.  weeks
B. 1 month
C.  months
D. 6 months
E. 1 year
10. Which of the following is true regaring
abominal incisions an the prevention of
incisional hernias?
A. A 4:1 suture:woun length is the current
recommene closure length
B. There is no ifference in hernia occurrence
between a running closure an an interrupte
closure
C. A permanent monolament suture is
preferre in the closure of the fascia in a
running fashion
D. Prophylactic use of mesh after open aortic
aneurysm surgery is not efcacious
E. A 1-cm bite between each stitch is the
recommene istance uring abominal
closure

11. A 55-year-ol obese male presents to the hospital
for his bariatric sleeve gastrectomy proceure. His
comorbiities inclue iabetes an hypertension,
an he states he was iagnose with “walking
pneumonia”  weeks ago an place on
antibiotics, which he has nishe. Which of the
following woul not be benecial if the SCIP
measures for preoperative an postoperative care
are followe?
A. Placing the patient on an insulin sliing
scale to keep glucose levels between 80 an
10mg/L
B. Clipping the patient’s abominal hair with an
electric shaver before operating
C. Aministering anticoagulation on
postoperative ay 1
D. Aministering antibiotics within 1 hour of
surgery
E. Discontinuing antibiotics by postoperative
ay 1
12. A 3-year-ol female who is 4 weeks pregnant
presents to the emergency epartment with acute
onset of abominal pain, fever, an vomiting. She
states that the pain woke her up in the mile of
the night with suen onset of epigastric pain
that is now iffuse. She has no vaginal bleeing
an fetal monitoring emonstrates normal vitals
for the fetus. Upon physical exam, the patient has
iffuse tenerness with guaring throughout the
abomen, worse in the epigastric region. Pelvic
examination is normal. She has a leukocytosis
of 15,000 cells/L. Abominal x-ray series shows
some ilate bowel loops but no other nings.
What is your next step in management of this
patient?
A. Abominal ultrasoun
B. CT scan of the abomen/pelvis with contrast
C. Amit an observe with serial abominal
exams
D. Exploratory laparotomy
E. Diagnostic laparoscopy
13. Which of the following is true regaring a rectus
sheath hematoma?
A. If locate above the umbilicus, it is more likely
to resemble an acute intraabominal process
B. If locate below the umbilicus, it is more likely
to cause severe bleeing
C. The majority are associate with a history of
trauma
D. Operative rainage is the treatment of choice
in most cases
E. Angiographic embolization is not useful
CHAPtEr 1 Abdomen—General 3
14. A woman presents with a rm, enlarging mass on
her abominal wall. After appropriate workup,
she is iagnose with a esmoi tumor. Which of
the following is true about this conition?
A. There is a high rate of metastasis without
proper treatment
B. The chance of local recurrence is low after
appropriate intervention
C. These tumors ten to enlarge uring
menopause
D. They occur most commonly in women after
chilbirth
E. These tumors arise from proliferative
chonroblastic cells
15. Which of the following is true regaring
retroperitoneal sarcomas?
A. They are best manage by enucleation
B. Prognosis is best etermine by histologic grae
C. Fibrosarcomas are the most common type
D. Lymph noe metastasis is common
E. Raiation therapy is often curative for small
sarcomas
16. A 75-year-ol female with recently iagnose
atrial brillation, for which she was given an
anticoagulant, presents with suen onset
abominal pain unrelate to oral intake. Surgical
history is remarkable for a total hip arthroplasty
3 years ago. Her physical exam is signicant for
a tener, palpable abominal wall mass above
the umbilicus that persists uring exion of
abominal wall muscles. The mass is most likely
relate to which of the following?
A. A malignancy
B. Bleeing from the superior epigastric artery
C. Occult trauma
D. An intraabominal infection
E. Bleeing from the inferior epigastric artery
4 PArt i Patient Care
ANSWERS
1. B. PD catheters can become malpositione postopera-
tively espite intraoperative conrmation of proper place-
ment. Instilling ialysate in the peritoneal cavity without the
ability to remove it may lea to abominal istention an
mil pain. The rst step for a suspecte malpositione PD
catheter that may have been ippe or kinke is to obtain a
KUB. If the catheter appears malpositione, then a reason-
able next step woul be to return to the OR for iagnostic
laparoscopy to reposition the catheter. For catheters that are
clogge (resistance to instilling ialysate through the cath-
eter or inability to instill ui), tPA can be use (C). Omen-
topexy or omentectomy can also be helpful in cases of a
malfunctioning catheter ue to obstruction. Peritonitis is a
common complication of PD an accounts for 50% of techni-
cal failures. This complication presents with abominal pain,
fever, an clouy ialysate. The initial management involves
intraperitoneal antibiotics, most commonly vancomycin,
which cures 75% of cases without iscontinuation of PD (D).
Patients who continue to become increasingly septic may
require intravenous (IV) antibiotics as well (E). Any fungal
infection of PD requires prompt removal of the catheter (A).
Reference: Miller M, McCormick B, Lavoie S, Biyani M, Zim-
merman D. Fluoroscopic manipulation of peritoneal ialysis cathe-
ters: outcomes an factors associate with successful manipulation.
Clin J Am Soc Nephrol. 01;7(5):795–800.
2. B. This patient has a Meckel iverticulum. This is a
true intestinal iverticulum that results from the failure
of the vitelline uct to obliterate uring the fth week
of fetal evelopment. It is the most common congenital
anomaly of the GI tract. Pancreatic heterotopia is foun in
a minority of cases. The most common heterotopic tissue
foun in resecte specimens is gastric mucosa, which can
lea to ulcer formation an GI bleeing. Meckel with gas-
tric mucosa is locate at the antimesenteric borer; how-
ever, ulceration occurs in the opposite mesenteric borer of
the ileum. Symptomatic cases require surgical intervention.
The management of an incientally iscovere asymptom-
atic Meckel iverticulum uring abominal exploration
is a controversial topic. Recently, it has been suggeste to
selectively intervene on patients with risk factors, namely
age <50, male sex, large iverticulum > cm in iameter,
presence of heterotopic tissue, palpation of abnormal no-
ules, or presence of brous bans. This patient has three
inications for removal incluing age <50, male sex, an
brous ban (D). The ectopic tissue in a Meckel iverticu-
lum secretes aci leaing to ulcer formation in the ajacent
ileum. Thus a segmental bowel resection shoul be per-
forme in cases of GI bleeing to inclue the iverticulum
(E). Otherwise, a simple iverticulectomy is appropriate.
Routine use of 99mTc-pertechnetate scans in asymptomatic
patients is not inicate (A). Biopsy of a Meckel iverticu-
lum is not typically require; however, the most common
cancer in Meckel is carcinoi (C, D).
Reference: Blouhos K, Boulas KA, Tsalis K, et al. Meckel’s iver-
ticulum in aults: surgical concerns.Front Surg. 018;5:55.
3. B. IAH is ene as an intraabominal pressure
>1 mmHg. This is assesse by measuring the blaer pres-
sure while the patient is paralyze. ACS is ene by IAH
>0 mmHg AND evience of en-organ malperfusion (i.e.,
oliguria) (A). Patients who are mechanically ventilate often
have high peak pressures. Primary ACS occurs most com-
monly after surgical proceures associate with massive
resuscitation an tense fascial closure. Seconary ACS is ue
to meical conitions such as ascites or conitions requiring
resuscitation without an abominal proceure (i.e., signicant
burn injury). Nasogastric ecompression an neuromuscular
blockae are conservative measures to treat IAH but neither
has been proven to signicantly reuce mortality (C). Reuc-
ing IAH with paracentesis shoul be performe rst in sec-
onary ACS ue to ascites (D). In refractory cases an all other
cases of ACS, ecompressive laparotomy shoul be performe
expeitiously to lower mortality. The pathophysiology of ACS
involves compression of the IVC, which can lea to elevate
SVC pressures, an in turn increase intracranial pressures
resulting in ecrease cerebral perfusion pressures (E).
Reference: Muresan M, Muresan S, Brinzaniuc K, et al. How
much oes ecompressive laparotomy reuce the mortality
rate in primary abominal compartment synrome?: a single-
center prospective stuy on 66 patients. Medicine (Baltimore).
017;96(5):e6006.
4. A. It is important to be aware of omental torsion because
it reaily mimics an intraabominal perforation. Because
it is typically very ifcult to iagnose preoperatively, the
iagnosis is most often mae at surgery. Torsion of the omen-
tum escribes a twisting of the omentum aroun its vascular
peicle along the long axis. Primary torsion, in which case
there is no unerlying pathology, is extremely rare. Secon-
ary torsion is much more common, an the torsion is usually
precipitate by a xe point such as a tumor, an ahesion,
a hernia sac, or an area of intraabominal inammation.
Omental torsion is much more common in aults in their
fourth or fth ecae of life. Chilren with torsion are typi-
cally obese, likely contributing to a fatty omentum that pre-
isposes to twisting. Other factors that preispose a patient
to torsion inclue a bi omentum an a narrowe omental
peicle. In primary omental torsion, the twiste omentum
tens to be localize to the right sie; thus, it is most com-
monly confuse with acute appenicitis, acute cholecysti-
tis, an pelvic inammatory isease (D). Complicating the
iagnosis is the fact that the omentum itself tens to migrate
an envelop areas of inammation. Laparoscopy is ieal for
establishing the iagnosis an excluing other etiologies.
Treatment is to resect the twiste omentum, which can often
be infarcte at the time of surgery, an to correct any other
relate conition that may be ientie (B, C). The ning of
purulent ui woul suggest another iagnosis because it is
not consistent with omental torsion. The ui usually seen is
serosanguinous (E).
References: Chew DK, Holgersen LO, Frieman D. Primary
omental torsion in chilren. J Pediatr Surg. 1995;30(6):816–817.

Sánchez J, Rosao R, Ramírez D, Meina P, Mezquita S, Gallaro
S. Torsion of the greater omentum: treatment by laparoscopy. Surg
Laparosc Endosc Percutan Tech. 00;1(6):443–445.
Young TH, Lee HS, Tang HS. Primary torsion of the greater
omentum. Int Surg. 004;89():7–75.
5. D. Coagulase-negative staphylococci (Staphylococcus epi-
dermidis) is by far the most common cause of peritoneal cath-
eter–relate infections (A–C). Staphylococcus aureus is coagu-
lase positive (E). Another ening feature of S. aureus is that
it is catalase positive. The iagnosis is mae by a combina-
tion of abominal pain, evelopment of clouy peritoneal
ui, an an elevate peritoneal ui white bloo cell count
greater than 100/mm3. Initial treatment consists of intraper-
itoneal antibiotics, which seem to be more effective than IV
antibiotics for a total of  weeks. If the infection fails to clear
base on abominal examination, clinical picture, or per-
sistent peritoneal ui leukocytosis, then the catheter nees
to be remove an a temporary hemoialysis catheter will
nee to be inserte. S. aureus an gram-negative organism
infections are less likely to respon to antibiotic manage-
ment alone.
6. E. Pseuomyxoma peritonei is a rare process in which
the peritoneum becomes covere with semisoli mucus an
large loculate cystic masses. There is no familial preispo-
sition (C). A useful classication erive from a large series
uses two categories: isseminate peritoneal aenomucinosis
(DPAM) an peritoneal mucinous carcinomatosis (PMCA).
DPAM is histologically a benign process an is most often
ue to a rupture appenix. In one large series, appeniceal
mucinous aenoma was associate with approximately 60%
of patients with DPAM. In patients classie as PMCA, the
origin was either a well-ifferentiate appeniceal or intesti-
nal mucinous aenocarcinoma (B). Pseuomyxoma peritonei
is most common in women age 50 to 70 years (D). It is often
asymptomatic until late in its course. Symptoms are often
nonspecic, but the most common symptom is increase
abominal girth. Physical examination may emonstrate a
istene abomen with nonshifting ullness. Management
is surgical, with cytoreuction of the primary an secon-
ary implants, incluing peritonectomy an omentectomy
(A). If there is a clear origin at the appenix, a right colec-
tomy shoul also be performe. If the origin appears to be
the ovary, total abominal hysterectomy with bilateral salp-
ingo-oophorectomy is recommene. The recurrence rate is
very high (76% in one series).
References: Gough D, Donohue J, Schutt AJ, et al. Pseuo-
myxoma peritonei: long-term patient survival with an aggressive
regional approach. Ann Surg. 1994;19():11–119.
Hinson FL, Ambrose NS. Pseuomyxoma peritonei. Br J Surg.
1998;85(10):133–1339.
Ronnett BM, Zahn CM, Kurman RJ, Kass ME, Sugarbaker PH,
Schmookler BM. Disseminate peritoneal aenomucinosis an peri-
toneal mucinous carcinomatosis: a clinicopathologic analysis of 109
cases with emphasis on istinguishing pathologic features, site of
origin, prognosis, an relationship to “pseuomyxoma peritonei.”
Am J Surg Pathol. 1995;19(1):1390–1408.
7. C. Primary retroperitoneal abscesses are seconary to
hematogenous sprea while seconary retroperitoneal
abscesses are relate to an infection in an ajacent organ.
The most common source of retroperitoneal abscesses is sec-
onary, with renal infections accounting for nearly 50% of all
CHAPtEr 1 Abdomen—General 5
cases. Hematogenous sprea is not a signicant contribut-
ing factor for seconary retroperitoneal abscesses (E). Other
common causes inclue retrocecal appenicitis (B), perfo-
rate uoenal ulcers, pancreatitis, an iverticulitis (A). In
rare cases, patients may have Pott isease, which is a is-
seminate form relate to tuberculosis (D). Patients typically
present with back, pelvic, ank, or thigh pain with associate
fever an leukocytosis. Flank erythema may be present. Ki-
ney infections often have gram-negative ros such as Proteus
an E. coli. Treatment consists of broa-spectrum antibiotics
an rainage, an ientication of the source. If the abscess
is simple an unilocular, then CT-guie rainage is the
treatment of choice. Operative rainage may be require for
complex abscesses.
8. B. Spontaneous (primary) bacterial peritonitis (SBP) is
ene as bacterial infection of ascitic ui in the absence
of any surgically treatable intraabominal infection. Patients
usually present with fever, iarrhea, an abominal pain,
but if severe enough, they will also have altere mental
status, hypotension, hypothermia, an a paralytic ileus.
However, 13% of patients will be completely asymptomatic.
Treatment is with antibiotics alone. Prophylactic antibiotics
(with uoroquinolones) to prevent SBP shoul be consi-
ere in high-risk patients with cirrhosis, ascites, an history
of gastrointestinal bleeing (as in the present case). Patients
with cirrhosis who have low ascitic ui protein (<1.0 g/
L) an those with a serum bilirubin greater than .5 mg/L
shoul also be starte on prophylactic antibiotics. Opsonic
or bactericial activity of ascitic ui is relate to protein
concentration. One of the key features of primary peritoni-
tis is that the isolate is usually a single organism an that
organism usually is not an anaerobe. Seconary peritonitis
refers to peritonitis in the setting of a bowel perforation.
Thus, polymicrobial or anaerobic cultures shoul raise sus-
picion for bowel perforation (A) an seconary peritonitis
(E). In aults, the most common pathogens in SBP are the
aerobic enteric ora E. coli an Klebsiella (C). In chilren with
nephrogenic or hepatogenic ascites, group A Streptococcus,
S. aureus, an Streptococcus pneumoniae are common isolates
(D). The iagnosis is mae by paracentesis emonstrating
more than 50 neutrophils/mm3 of ascitic ui in the pres-
ence of a correlating clinical presentation. This shoul be
evaluate before initiating antibiotics because cultures will
return falsely negative. An active infection is consiere a
contrainication for liver transplantation.
References: Bell RB, Seymour NE. Abominal wall, omentum,
mesentery, an retroperitoneum. In: Brunicari FC, Anersen DK,
Billiar T, et al., es. Schwartz’s principles of surgery. 8th e. New York:
McGraw-Hill; 1990:1317–138.
Runyon BA. Monomicrobial nonneutrocytic bacterascites: a vari-
ant of spontaneous bacterial peritonitis. Hepatology. 1990;1(4 Pt 1):
710–715.
Turnage RH, Li B, McDonal, JC. Abominal wall, umbili-
cus, peritoneum, mesenteries, omentum an retroperitoneum. In:
Townsen CM Jr, Beauchamp RD, Evers BM, Mattox KL, es. Sabis-
ton textbook of surgery: The biological basis of modern surgical practice.
17th e. Philaelphia: W.B. Sauners; 004:1171–1198.
9. B. Goo communication between the cariologist an
surgeon is essential before performing coronary interven-
tions in a patient who requires surgery. Coronary revascu-
larization before elective surgery is not recommene if the
6 PArt i Patient Care
patient has asymptomatic coronary artery isease (CAD).
However, in the setting of an acute coronary synrome
(acute myocarial infarction [MI], unstable angina), a percu-
taneous coronary intervention (PCI) is recommene before
surgery. The options are to perform balloon angioplasty
alone or a a bare metal stent (BMS) or a rug-eluting stent
(DES). The DES is the best long-term option, but it requires
a longer elay of surgery. Thus, the ecision of which to use
epens on the urgency of the subsequent operation (urgent,
time sensitive, or elective) an the feasibility of operating
with antiplatelet agents on boar. If the operation is urgent
(within  weeks), a PCI with balloon angioplasty may be
best because the waiting perio for surgery is  weeks (A). If
the operation is time sensitive (–6 weeks), a BMS is a better
option because it is less likely to suenly occlue as com-
pare with angioplasty alone. However, one shoul wait 1
month before performing surgery (C). Because this patient
has a relatively symptomatic hernia, the operation is time
sensitive. Finally, if a DES is place, the recommenation is
to wait 6 months before performing surgery (D, E).
References: Fleisher LA, Fleischmann KE, Auerbach AD, etal.
014 ACC/AHA guieline on perioperative cariovascular evalua-
tion an management of patients unergoing noncariac surgery:
a report of the American College of Cariology/American Heart
Association Task Force on Practice Guielines. J Am Coll Cardiol.
014;64():e77–e137.
Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann
HJ, American College of Chest Physicians Antithrombotic Therapy
an Prevention of Thrombosis Panel. Executive summary: anti-
thrombotic therapy an prevention of thrombosis, 9th e: American
College of Chest Physicians Evience-Base Clinical Practice Guie-
lines [publishe corrections appear in Chest. 141(4):119].
Dosage error in article text. Chest. 01;14(6):1698.
Dosage error in article text]. Chest. 01;141( suppl):7S–47S.
Livhits M, Ko CY, Leonari MJ, Zingmon DS, Gibbons MM, e
Virgilio C. Risk of surgery following recent myocarial infarction.
Ann Surg. 011;53(5):857–864.
10. A. The material an the surgical technique use to close
an open abomen are important eterminants of the risk of
eveloping an incisional hernia. The European Hernia Soci-
ety has recently come out with guielines recommening
that a small bite closure be performe using at least a 4:1
suture:woun length uring closure. It has also been shown
that running closure is superior to an interrupte closure (B).
Prophylactic use of mesh uring closure has been shown to be
efcacious after open aortic aneurysm surgery because of the
high rate of incisional hernia (D). A ranomize control trial
looking at small bites compare to large bites has recently
been performe, looking at 560 patients who receive either
small, 5-mm bites 5 mm apart or large, 1-cm bites 1 cm apart.
They foun a statistically signicant reuce rate of hernia
occurrence in the small bite group, which is now the recom-
mene bite size an length (E). A slowly absorbable monol-
ament suture (polyioxanone suture [PDS]) has been shown
to also be the recommene suture in abominal closure (C).
References: Deerenberg EB, Harlaar JJ, Steyerberg EW, et al.
Small bites versus large bites for closure of abominal miline inci-
sions (STITCH): a ouble-blin, multicentre, ranomise controlle
trial. Lancet. 015;386(10000):154–160.
Muysoms FE, Antoniou SA, Bury K, etal. European Hernia Soci-
ety guielines on the closure of abominal wall incisions. Hernia.
015;19(1):1–4.
11. A. The Surgical Care Improvement Project (SCIP) is
a national quality partnership of organizations intereste
in improving surgical outcomes that began in 006. Care is
taken by all institutions to follow the recommenations by
the Joint Commission because all these outcomes are ocu-
mente an measure quarterly. The core measures inclue
giving antibiotics within 1 hour of surgery (D) an iscon-
tinuing within 4 hours (E), Foley catheter removal by post-
operative ay , an hair removal by clipping on the ay of
surgery. Shaving the hair off has been shown to increase the
risk of infection (B). Other benecial measures inclue being
on appropriate venous thromboembolism (VTE) prophylaxis
within 4 hours of surgery an glucose control. The impor-
tance of glucose control an surgical outcomes has been
well establishe; however, in 009, the NICE-SUGAR trial
emonstrate that strict glucose control was actually associ-
ate with worse outcomes. It is now wiely accepte that the
goal shoul be to keep glucose levels below 180 mg/L (C).
Reference: NICE-SUGAR Stuy Investigators, Finfer S, Chit-
tock DR, etal. Intensive versus conventional glucose control in criti-
cally ill patients. N Engl J Med. 009;360(13):183–197.
12. B. Fear of raiation exposure uring pregnancy shoul
not take preceence over quickly establishing the correct
iagnosis an initiating treatment. Base on the patient’s
acute onset of symptoms an location, the presentation is
concerning for peritonitis, potentially ue to a perforate
viscus, such as a peptic ulcer, or a close-loop bowel obstruc-
tion. In this situation, the best next step woul be to per-
form a compute tomography (CT) scan of the abomen (A,
C–E). As a general rule, the care of the patient, not the fetus,
shoul take rst priority. Base on the National Guieline
Clearinghouse, expeitious an accurate iagnosing shoul
take preceence over risk of ionizing raiation. The effects
of raiation exposure on the fetus epen on the gestational
age an the amount of raiation. In general, the earlier the
gestational age, the greater the risk. High ose (>10 ras)
exposure early in pregnancy (within the rst 4 weeks) can
lea to fetal emise. However, such a high exposure excees
the ose of typical imaging (abominal x-ray is 00 mra
while abominal an pelvic CT is about 3–4 ras). Between
8 an 15 weeks’ gestation, high-ose (>10 ras) raiation can
lea to intrauterine growth retaration an central nervous
efects. Beyon 15 weeks (as in the present case), there o
not appear to be any eterministic effects (ose-epenent
events such as fetal loss, congenital efects) on the fetus.
Stochastic effects (those that are not ose epenent), such
as the subsequent risk of cancer or leukemia, are increase
with exposure of 1 ra or more. The risk is about 1 cancer for
every 500 exposures. Conversely, if the pregnant patient with
an acute abomen progresses to peritonitis an bowel per-
foration, the risk of fetal emise is very high. Thus, the risk
of fetal miscarriage is higher with visceral perforation than
with raiation exposure, an therefore all measures shoul
be taken for an accurate iagnosis. Magnetic resonance imag-
ing (MRI) is consiere a goo imaging option in pregnancy;
however, its use in the emergent setting may be limite by
its availability. Ultrasoun is also useful but woul be more
useful if the patient presente with right upper quarant
pain (suspecte biliary isease) or right lower quarant pain
(suspecte appenicitis).

Reference: Khanelwal A, Fasih N, Kielar A. Imaging of acute
abomen in pregnancy. Radiol Clin North Am. 013;51(6):1005–10.
13. B. Rectus sheath hematomas are clinically signicant
because of the fact that they can easily be mistaken for an
intraabominal inammatory process. The etiology is an
injury to an epigastric artery within the rectus sheath. In
most cases, there is no clear history of trauma (C). Particu-
larly in the elerly who are taking oral anticoagulants, these
typically occur spontaneously. Patients frequently escribe a
suen onset of unilateral abominal pain, sometimes pre-
cee by a coughing t. In one series, 11 of 1 patients were
women, an in another series, all 8 were women, with an
average age in the sixth ecae. Below the arcuate line, there
is no aponeurotic posterior covering to the rectus muscle.
Therefore, hematomas below this line can cross the miline,
causing a larger hematoma to form, an then cause bilateral
lower quarant pain resembling a perforate viscus. On
physical examination, a mass is often palpable. The Fothergill
sign is the ning of a palpable abominal mass that remains
unchange with contraction of the rectus muscles. This helps
istinguish it from an intraabominal abscess, which woul
not be palpable with rectus contraction. The iagnosis is best
establishe with a CT scan, which will emonstrate a ui
collection in the rectus muscle. The hematocrit shoul be
closely monitore. Once the iagnosis is establishe, man-
agement is primarily nonoperative an consists of resuscita-
tion, monitoring of serial hemoglobin/hematocrit levels, an
reversal of anticoagulation (D). However, one shoul be cau-
tious with reversal of anticoagulation, as stable patients may
benet from continue anticoagulation (e.g., recent mechan-
ical valve). On rare occasions, angiographic embolization
may be necessary (E). Surgical management, while rarely
necessary, woul involve ligation of the bleeing vessel an
evacuation of the hematoma.
References: Berná JD, Zuazu I, Marigal M, García-Meina
V, Fernánez C, Guirao F. Conservative treatment of large rectus
sheath hematoma in patients unergoing anticoagulant therapy.
Abdom Imaging. 000;5(3):30–34.
Zainea GG, Joran F. Rectus sheath hematomas: their pathogene-
sis, iagnosis, an management. Am Surg. 1988;54(10):630–633.
14. D. Desmoi tumors are unusual soft-tissue neoplasms
that arise from fascial or bro-aponeurotic tissue. They are
proliferations of benign-appearing broblastic cells with
abunant collagen an few mitoses (E). Desmoi tumors
o not metastasize (A); however, they are locally aggressive
an have a very high local recurrence rate reaching almost
50% (B). They have been associate with Garner synrome
(intestinal polyposis, osteomas, bromas, an epiermal or
sebaceous cysts) an familial aenomatous polyposis (FAP),
which is why patients shoul be scheule for a colonos-
copy soon after iagnosis. In sporaic cases, surgical trauma
appears to be an important cause. Desmoi tumors may
evelop within or ajacent to surgical scars. Patients with
FAP have a 1000-fol increase risk of the evelopment of
esmoi tumors. Desmois are more common in women of
chilbearing age, ten to occur after chilbirth, an may be
linke to estrogen. Oral contraceptive pills (OCP) have also
been foun to be associate with the occurrence of these
tumors, whereas antiestrogen meications may lea to shrink-
age. They’ve been reporte to shrink after menopause (C).
CHAPtEr 1 Abdomen—General 7
Patients are typically in their thir or fourth ecae of life
an present with pain, a mass, or both. They are classie
as either extra abominal (extremities, shouler), abominal
wall, or intraabominal (mesenteric an pelvic). There are no
typical raiographic nings, but MRI may elineate mus-
cle or soft-tissue inltration an is require in larger tumors
to elineate anatomic relations before surgical intervention.
Core neele biopsy often reveals collagen with iffuse spin-
le cells an abunant brous stroma, which may suggest a
low-grae brosarcoma; however, the cells lack mitotic activ-
ity. An open incisional biopsy of lesions larger than 3 to 4 cm
is often necessary. Wie local excision with negative margins
is inicate for symptomatic esmoi tumors. Nonresect-
able or incientally foun, asymptomatic, intraabominal
esmoi tumors (even if resectable) shoul be treate with
nonsteroial antiinammatory agents (e.g., sulinac) an
antiestrogens, which have met with objective response rates
of 50%. In regar to ajuvant therapy, recent retrospective
reviews have seen signicant reuctions in recurrence with
raiation combine with surgery an even with raiation
alone. More research is necessary for the use of chemotherapy
agents, but it has been seen that when cytotoxic chemother-
apy agents are use in inoperable esmoi tumors, there is a
0% to 40% positive response. The aggressive nature of these
tumors an high rate of occurrence make esmoi tumors the
secon most common cause of eath in patients with FAP,
after colorectal carcinoma.
References: Ballo MT, Zagars GK, Pollack A, Pisters PW, Pollack
RA. Desmoi tumor: prognostic factors an outcome after surgery,
raiation therapy, or combine surgery an raiation therapy. J Clin
Oncol. 1999;17(1):158–167.
Hansmann A, Aolph C, Vogel T. High ose tamoxifen an
sulinac as rst-line treatment for esmoi tumors. Cancer.
004;100(3):61–60.
Janinis J, Patriki M, Vini L, Aravantinos G, Whelan JS. The phar-
macological treatment of aggressive bromatosis: a systematic
review. Ann Oncol. 003;14():181–190.
Nuyttens JJ, Rust PF, Thomas CR Jr, Turrisi AT 3r. Surgery
versus raiation therapy for patients with aggressive bromato-
sis or esmoi tumors: a comparative review of  articles. Cancer.
000;88(7):1517–153.
15. B. Most retroperitoneal tumors are malignant an com-
prise approximately half of all soft-tissue sarcomas. The
most common sarcomas occurring in the retroperitoneum
are liposarcomas, malignant brous histiocytomas, an
leiomyosarcomas (C). Approximately 50% of patients will
have a local recurrence an 0% to 30% will en up having
istant metastases. Lymph noe metastases are rare (D).
Retroperitoneal sarcomas present as large masses because
they o not typically prouce symptoms until their mass
effect creates compression or invasion of ajacent struc-
tures. Symptoms may inclue gastrointestinal hemorrhage,
early satiety, nausea, vomiting, an lower extremity swell-
ing. Retroperitoneal sarcomas have a worse prognosis than
nonretroperitoneal sarcomas. The best chance for long-term
survival is achieve with an en bloc, margin-negative resec-
tion. Tumor stage at presentation, high histologic grae,
unresectability, an grossly positive resection margins are
strongly associate with increase mortality rates. Tumor
grae is the most signicant preictor of outcome. Complete
surgical resection is the most effective treatment for primary
or recurrent retroperitoneal sarcomas (A, E). Surgical cure
8 PArt i Patient Care
can be limite because the margins are often compromise
by anatomic constraints. There is no ifference in survival
between those who ha a resection with a grossly positive
margin an those with inoperable tumors. Unlike extremity
sarcomas, external beam raiation therapy is limite for ret-
roperitoneal malignancies because there is a low tolerance
for raiation to surrouning structures. Postoperative an
intraoperative raiation therapy have been shown to reuce
local recurrence, but further stuies are neee to etermine
if this leas to improve survival.
Reference: Lewis JJ, Leung D, Wooruff JM, Brennan MF. Ret-
roperitoneal soft-tissue sarcoma: analysis of 500 patients treate an
followe at a single institution. Ann Surg. 1998;8(3):355–365.
16. B. This patient was recently iagnose with atrial
brillation an starte on oral anticoagulants. One shoul
suspect a rectus sheath hematoma in oler patients taking
anticoagulants who present with the clinical tria of acute
abominal pain, an abominal wall mass, an anemia. The
mass is palpable even uring exion of abominal wall mus-
cles, helping to ifferentiate this from an intraperitoneal pro-
cess (Fothergill sign) (D). In a review of 16 patients by Mayo
Clinic, anticoagulation was associate with 70%. Above the
arcuate line, the etiology is often relate to a lesion to the
superior epigastric artery within the rectus sheath (E). In
most cases, there is no clear history of trauma (C). In partic-
ular, in the elerly who are taking oral anticoagulants, they
typically occur spontaneously. The most common treatment
for patients with rectus sheath hematomas is rest, analgesics,
an bloo transfusions as necessary. In general, coagulop-
athies are correcte; however, continuing anticoagulation
may be pruent in select patients (e.g., biomechanical valve,
recent sale embolus). In extreme cases, angioembolization
may be require.
References: Alla VM, Karnam SM, Kaushik M, Porter J. Sponta-
neous rectus sheath hematoma. West J Emerg Med. 010;11(1):76–79.
Cherry WB, Mueller PS. Rectus sheath hematoma: review of 16
cases at a single institution. Medicine (Baltimore). 006;85():105–110.
 Abdomen—Hernia
AMANDA C. PURDY AND AMY KIM YETASOOK 2
ABSITE 99th Percentile High-Yields
I. Abominal Wall Hernia
a. From skin to peritoneum: skin → fascia of Camper → fascia of Scarpa → external oblique → internal
oblique → transversus abominis → transversalis fascia → preperitoneal fat → peritoneum
b. Superior to arcuate line:
1. Anterior sheath comprise of aponeurosis of external oblique an the anterior half of the aponeurosis
of internal oblique
. Posterior sheath comprise of aponeurosis of transversus abominis an aponeurosis of the posterior
half of internal oblique; posterior sheath not present inferior to arcuate line
c. Ten to 15% of all incisions will evelop into ventral (incisional) hernia; woun infection after surgery
oubles risk of a hernia evelopment
. Miline epigastrium is a physiologic area of weakness in the abomen where patients can evelop
iastasis recti an/or epigastric hernia; risk factors inclue pregnancy an weight gain
e. Diastasis recti: attenuation of linea alba causing rectus muscle separation; when the rectus contract, a
bulge appears in the upper miline abomen; no fascial efect, not a hernia

II. Umbilical Hernias

a. Peiatric umbilical hernias
1. Congenital efect, repair by age 5 or sooner if symptomatic
b. Umbilical hernias in aults
1. Acquire efect, increase intraabominal pressure causes weakening of transversalis fascia an of
the umbilical ring
. Women are 3 times more likely to evelop umbilical hernias than men (ue to pregnancy), an up to
90% of women evelop an umbilical hernia uring pregnancy; incarceration occurs more in men
3. Cirrhotic patients with uncomplicate umbilical hernias shoul be meically optimize before
unergoing elective surgical repair; this inclues free water restriction, iuretics, an large volume
paracentesis (with infusion of albumin); mesh can be use

III. Inguinal Hernias

a. Cremaster muscle bers arise from internal oblique muscle, inguinal ligament from external oblique
muscle; the internal oblique an transversalis fascia form the internal ring of the inguinal canal; the
conjoint tenon is the lower common aponeurosis of the internal oblique an the transversus abominis
b. Though wiely believe as true, there is little evience to support physical activity with inguinal hernia
evelopment; inguinal hernias have increase type 3 collagen an ecrease type 1 collagen
c. During issection, an inirect hernia sac is foun on the anteromeial aspect of spermatic cor
. The genital branch of the genitofemoral nerve supplies sensation to the mons an labia majora in women,
an in men it supplies motor to the cremaster an sensation to the scrotum; it runs within the spermatic
cor an exits via the eep inguinal ring

9
10 PArt i Patient Care

e. The iliohypogastric nerve arises from the rst lumbar branch an travels between the transversus
abominis an the internal oblique muscles
f. The ilioinguinal nerve runs anterior to the spermatic cor in men or roun ligament in women an
passes through the supercial inguinal ring; supplies sensation to the upper meial thigh
g. Peiatric inguinal hernias (ue to a congenital failure of the processus vaginalis to close):
1. Repair only requires high ligation of the hernia sac (ligation at the internal ring)

IV. Hernia Repair

a. Open repair
i. Open repair with mesh (<10% recurrence rate)
1. Lichtenstein repair (tension free): mesh is suture meially to the transversus abominis arch, an
the lateral ege of mesh is suture to the inguinal ligament; mesh shoul overlap  cm over pubic
tubercle an  to 4 cm lateral to the internal ring
ii. Open repair without mesh (30%–50% recurrence rate)
1. Bassini repair: the conjoint tenon is suture to the inguinal ligament with interrupte,
nonabsorbable sutures
. McVay repair: the conjoint tenon is suture to Cooper ligament (also calle the pectineal
ligament); nee to expose Cooper ligament by incising transversalis fascia an entering
preperitoneal space; relaxing incision has to be mae in the anterior rectus sheath; repairs both
inguinal an femoral hernias
3. Shoulice repair: the transversalis fascia is incise an reapproximate, 4-layer closure with
running suture
b. Laparoscopic repair
i. Best option for recurrent hernias (previously treate with an open approach), bilateral hernias, an
obese patients; contrainicate in patients with large scrotal hernias or who have unergone prior
extensive lower abominal or pelvic surgery
ii. Mesh xation inferior to the iliopubic tract an lateral to the epigastric vessels (triangle of pain) is
avoie because of the risk of injury to the lateral femoral cutaneous nerve; similarly, avoi xation
below the internal ring, which is borere laterally by spermatic vessels an meially by vas eferens
(triangle of oom), as this risks injury to the external iliac artery an vein
iii. The two laparoscopic proceures: transabominal preperitoneal (TAPP) an totally extraperitoneal
(TEP) repair
1. TAPP: the peritoneal space is entere at umbilicus, peritoneum overlying inguinal oor is
issecte away as a ap, hernia is reuce, mesh is xe over internal ring opening in the
preperitoneal space, an peritoneum is reapproximate; can also examine contralateral sie
. TEP: the preperitoneal space is evelope w issecting balloon inserte between posterior rectus
sheath an rectus abominis an irecte towar pelvis inferior to arcuate ligaments; other ports
inserte into preperitoneal space without ever entering peritoneal cavity; avantage here is that
you never open peritoneum so no mesh exposure to abominal organs, so less ahesions
c. If chronic groin pain after hernia surgery, perform a pelvic MRI; risk of chronic groin pain after hernia
repair is 15% to 0%
. Most common location for breakown of laparoscopic hernia repair is the meial portion of the mesh;
often because the mesh is too small or that it was not appropriately attache meially

V. Femoral Hernia
a. Femoral triangle: femoral vein laterally, auctor longus meially an inguinal ligament superiorly
b. Bounaries of femoral canal: superior (inguinal), meial (lacunar ligament), lateral (femoral vein), an
posterior or oor (iliacus an psoas tenon; fascia of pectineus)
c. All femoral hernias shoul be repaire as they have a 15% to 0% risk of strangulation
 CHAPtEr 2 Abdomen—Hernia 11

VI. Miscellaneous Hernias

a. Obturator hernia: Howship-Romberg sign is internal thigh pain with external rotation; repair for
obturator hernia shoul be an abominal approach as this allows access to the efect an reuction of
contents, may require incision of the obturator membrane
b. Petit hernia is boun by latissimus orsi, iliac crest, an external oblique muscle; Grynfeltt hernia is
boun by sacrospinous muscle, internal oblique, an the 1th rib
c. Spigelian hernia is efect through Spigelian fascia, which is area between semilunar line an lateral
borer of rectus abominis; majority occur just below arcuate line where no posterior rectus sheath exists
. A sports hernia is not a true hernia; it is a weakness of the inguinal oor eveloping in those with
signicant physical activity (athletes); pressure is place on the genital branch of the genital femoral
nerve an can lea to chronic groin pain; on exam, there may be tenerness with palpation of the
inguinal oor through the external ring, but no hernia is ientie with Valsalva

Fig. 2.1
12 PArt i Patient Care
Fig. 2.2
QUESTIONS
1. A 45-year-ol woman with iabetes mellitus
an a BMI of 35 kg/m presents to clinic for an
intermittent, painful bulge in her mi-abomen
over an ol miline laparotomy scar. On exam,
there is a reucible miline bulge with a 7 by
3 cm fascial efect. She woul like to procee
with surgery. What is the most appropriate
management?
A. Physical therapy referral for abominal wall
strengthening
B. Open hernia repair with onlay mesh
C. Open hernia repair with sublay mesh
D. Laparoscopic hernia repair with mesh
E. Component separation an primary repair
2. A 55-year-ol man with a history of
abominoperineal resection for rectal cancer two
years ago has intermittent pain an fullness next
to his colostomy that is sometimes associate with
nausea an vomiting. On exam, his colostomy
appears healthy, an no bulge is palpate. CT
emonstrates a loop of bowel supercial to the
fascia that is ajacent to the stoma. What is the
best management?
A. Primary repair of parastomal hernia
B. Relocate the colostomy
C. Repair with prosthetic mesh
D. Repair with biologic mesh
E. Reassurance an return precautions
3. A 30-year-ol patient unerwent exploratory
laparotomy for trauma. Which of the following
closure techniques is associate with the lowest
risk of eveloping an incisional hernia?
A. Placing stitches 1 cm apart an 1 cm from the
fascial ege
B. Placing sutures 5 mm apart an 5 mm from
the fascial ege
C. Placing stitches 1 cm apart an 5 mm from the
fascial ege
D. Using running suture with a suture to woun
length ratio of :1
E. Using running suture with a suture to woun
length ratio of 3:1
4. A 60-year-ol woman with chronic kiney isease
is unergoing elective peritoneal ialysis catheter
placement. At her preoperative appointment, she
is note to have a small, nontener, reucible
inguinal hernia. She says it has been there for
years an that it oes not bother her. What is the
most appropriate management?
A. Peritoneal ialysis catheter placement alone
B. Inguinal hernia repair with mesh with
peritoneal ialysis catheter placement 6 weeks
later
C. Inguinal hernia repair without mesh with
peritoneal ialysis catheter placement 6 weeks
later

D. Concurrent inguinal hernia repair with mesh
an peritoneal ialysis catheter placement
E. Concurrent inguinal hernia repair without
mesh an peritoneal ialysis catheter placement
5. The genital branch of the genitofemoral nerve:
A. is typically foun anteriorly on top of the
spermatic cor
B. provies sensation to the base of the penis an
inner thigh
C. typically lies on the anterior surface of the
internal oblique muscle
D. if cut will result in ipsilateral loss of
cremasteric reex
E. often intermingles with the iliohypogastric nerve
6. Which of the following is true regaring hernia
anatomy?
A. Poupart ligament is forme from the
anteroinferior portion of the external oblique
aponeurosis
B. The cremaster muscle arises from the
transversus abominis muscle
C. The genital branch of the genitofemoral nerve
passes through the supercial ring
D. The femoral branch of the genitofemoral nerve
innervates the cremasteric muscle
E. Inirect hernias most often arise within the
borers of the rectus muscle, inferior inguinal
ligament, an inferior epigastric artery
7. Which of the following is true regaring the
arcuate line?
A. It is usually locate a few centimeters above
the umbilicus
B. Below this line, the internal oblique
aponeurosis splits
C. Below this line, the rectus muscle lies on the
transversalis fascia
D. Below this line, the posterior rectus sheath is
thinner
E. Below this line, the external oblique muscle
oes not contribute to the anterior rectus
sheath
8. A 55-year-ol male presents with a painful bulge
in the left groin that rst appeare several months
ago. His surgical history inclues a right-sie
open inguinal hernia repair. Upon examination
you also note a bulge in the right groin over his
previous incision. Both masses are reucible.
Which of the following is true regaring this
patient’s conition?
A. Open repair is preferre
B. In laparoscopic repair, failure to tack the mesh
lateral to the inferior epigastric vessels can
lea to recurrence through the internal ring
CHAPtEr 2 Abdomen—Hernia 13
C. Violation of the peritoneum uring a
totally extraperitoneal (TEP) repair requires
conversion to an open or transabominal
preperitoneal (TAPP) approach
D. Persistent numbness or pain of the lateral
thigh is more common with open versus
laparoscopic repair
E. Laparoscopic repair will prevent him from
eveloping a femoral hernia in the future
9. A 8-year-ol male patient is asking for avice
on whether to pursue open mesh repair or TEP
repair of a newly iagnose, reucible right-sie
inguinal hernia. What can you tell the patient
about these two methos of repair?
A. Chronic pain is reuce with an open mesh
repair
B. Operative time is not signicantly ifferent
between the two
C. TEP repair is associate with a quicker return
to work an normal activities
D. Open mesh repair is associate with a higher
rate of intraoperative complications
E. Recurrence is relatively common (>5%) no
matter which metho is chosen
10. One hour after laparoscopic repair of a left
inguinal hernia, the patient complains of severe
burning groin pain. Which of the following is the
most appropriate recommenation?
A. Immeiate return to the OR for laparoscopy
B. Nonsteroial antiinammatory rugs
C. Neurontin
D. Opioi analgesia
E. Inject groin region with local anesthetic
11. Ischemic orchitis after inguinal hernia repair is
most often ue to:
A. Too tight a reconstruction of the inguinal ring
B. Preexisting testicular pathology
C. Inavertent ligation of the testicular artery
D. Completely excising a large scrotal hernia sac
E. Anomalous bloo supply to the testicle
12. A 45-year-ol man presents with an
asymptomatic right inguinal hernia. It is easily
reuce with gentle pressure. Which of the
following is true about this conition?
A. The likelihoo of strangulation eveloping is
high without surgery
B. Without surgery, intractable pain will most
likely evelop
C. Waiting until symptoms evelop is a
reasonable alternative to surgery
D. Laparoscopic repair is the best option
E. If the hernia is small, there is a lower chance of
incarceration
14 PArt i Patient Care
13. A 5-month-ol previously full-term male infant
presents with a tener left groin mass that has
been present for the past several hours. There is
slight erythema over the skin. He is afebrile an
his labs are normal. Which of the following is the
best next step?
A. Attempt manual reuction, an if successful,
scheule surgical repair when infant reaches 1
year of age
B. Attempt manual reuction, an if successful,
immeiately take to the operating room for
surgical repair
C. Attempt manual reuction, an if successful,
scheule repair in  ays
D. Attempt manual reuction, an if successful,
scheule left-sie surgical repair with
contralateral groin exploration in  ays
E. Take immeiately to the operating room for
operative repair
14. Which of the following best escribes umbilical
hernias in chilren?
A. They have a signicant risk of incarceration.
B. Repair is inicate once an umbilical hernia is
iagnose
C. Repair shoul be performe if the hernia
persists beyon 6 months of age
D. Most close spontaneously
E. Repair shoul be performe only if the chil is
symptomatic
15. Which of the following is true regaring umbilical
hernias in aults?
A. Most are congenital
B. Repair is contrainicate in patients with
cirrhosis
C. Strangulation is less common than in chilren
ANSWERS
1. D. This patient has a symptomatic ventral incisional her-
nia. The best option for repair in this patient with multiple
risk factors for perioperative infection (iabetes an obe-
sity) is laparoscopic hernia repair with mesh. Compare to
open incisional hernia repair, laparoscopic repair has a lower
incience of surgical site infection an is the best option for
patients at risk for postoperative infection (C–D). Open an
laparoscopic ventral hernia repairs with mesh have similar
recurrence rate. Component separation is a technique where
the anterior rectus sheath is incise  cm lateral to the semi-
lunar line in orer to primarily close large efects while
D. Small, asymptomatic hernias can be clinically
observe
E. Primary closure has recurrence rates similar to
those of mesh repair
16. Which of the following is true regaring femoral
hernias?
A. They are the most common hernia in females
B. The Cooper ligament is consiere the anterior
borer of the femoral canal
C. They are lateral to the femoral vein
D. Repair involves approximating the iliopubic
tract to the Cooper ligament
E. A Bassini operation is consiere an
appropriate surgical option
17. A 55-year-ol woman presents with a painless
abominal wall bulge. She reports a successful
iet an exercise program an has lost almost
40 kg over the past  years. However, she is
worrie because yesteray when she was
sitting up in be, she notice an upper miline
abominal bulge that looks like a large rige
between her rib cage an belly button. On
physical exam the bulge becomes visible when
she lifts her hea off the be. Which of the
following is true regaring her conition?
A. Surgical repair shoul be one immeiately
before signs of incarceration evelop
B. There are both congenital an acquire
etiologies
C. A strict regimen of abominal wall exercises
usually results in complete resolution
D. The efect is limite to the transversalis fascia
E. Typically these efects contain only
preperitoneal fat
minimizing tension. This is unnecessary in this case, as the
efect is only 3 cm wie, an a minimally invasive technique
is more appropriate (E). Abominal wall strengthening exer-
cises are the primary repair for rectus iastasis, which is an
attenuation of the linea alba in the superior abominal wall
without a true hernia. This patient has a hernia, as evience
by fascial efect on physical exam (A).
Reference: Guielines for laparoscopic ventral hernia repair.
SAGES. Publishe June 7, 016. https://www.sages.org/publications/
guielines/guielines-for-laparoscopic-ventral-hernia-repair

2. C. This patient has a parastomal hernia. Although the inci-
ence of parastomal hernias is higher with en ostomies than
with loop ostomies, this may simply be ue to loop ostomies
getting reverse more often, an sooner than en ostomies
that are more often permanent. The majority of parastomal
hernias are asymptomatic an o not require intervention.
However, this patient is experiencing symptoms with inter-
mittent bowel obstruction an shoul unergo repair (E). The
best option for management of a symptomatic parastomal her-
nia is to take the ostomy own if appropriate. Unfortunately,
this is not an option for this patient with a prior abomino-
perineal resection (APR). The next best option is repair of the
hernia with synthetic mesh using the Sugarbaker technique,
where intraperitoneal mesh covers the entire efect, an the
bowel leaing to the ostomy enters laterally between the
mesh an abominal wall. Biologic mesh is associate with
higher recurrence rates compare to prosthetic mesh (D). It
may be consiere for patients with signicant contamina-
tion. Primary repair of parastomal hernias has been largely
abanone ue to unacceptable recurrence rates of up to
70% (A). Ostomy relocation solves the problem at han (the
current symptomatic parastomal hernia); however, it is infe-
rior to repair with mesh as there is a high risk of eveloping
another parastomal hernia at the new ostomy site (B).
Reference: Hansson BM, Slater NJ, van er Velen AS, et al. Sur-
gical techniques for parastomal hernia repair: a systematic review of
the literature. Ann Surg. 01;55(4):685–695.
3. B. After vertical miline abominal incision, approx-
imately 10% to 0% of patients evelop incisional hernias.
Ranomize controlle trials have shown that small (5 mm)
fascial bites 5 mm apart have a signicantly lower rate of
eveloping incisional hernia than large (1 cm) bites 1 cm
apart (A, C). Also, a suture to woun length ratio of at least
4:1 is associate with less tension an a ecrease incience
of incisional hernia evelopment (D, E).
References: Deerenberg EB, Harlaar JJ, Steyerberg EW, et al.
Small bites versus large bites for closure of abominal miline inci-
sions (STITCH): a ouble-blin, multicentre, ranomise controlle
trial. Lancet (London, England). 015;386(10000):154–160.
Millbourn D, Cengiz Y, Israelsson LA. Effect of stitch length on
woun complications after closure of miline incisions: a ranom-
ize controlle trial. Arch Surg. 009;144(11):1056–1059.
4. D. Conitions that increase intraabominal pressure
(cystic brosis, chronic lung isease, ventriculoperitoneal
shunts, constipation, an peritoneal ialysis) are associate
with higher risk for eveloping an inguinal hernia. Patients
with small asymptomatic hernias are at risk for eveloping
symptoms as their hernias enlarge uring peritoneal ial-
ysis. Therefore, everyone unergoing peritoneal ialysis
shoul be examine for presence of abominal hernias pre-
operatively. If a hernia is foun, the patient shoul unergo
concurrent herniorrhaphy at the time of peritoneal ialysis
catheter placement (A–C). Hernia repair shoul be one with
mesh, as mesh is associate with ecrease recurrence rates
an are safe in patients unergoing peritoneal ialysis (E).
Reference: Chi Q, Shi Z, Zhang Z, Lin C, Liu G, Weng S. Ingui-
nal hernias in patients on continuous ambulatory peritoneal ialysis:
is tension-free mesh repair feasible? BMC Surg. 00;0(1):310.
5. D. The genitofemoral nerve arises from the L1-L level.
The genital branch innervates the cremaster muscle an
CHAPtEr 2 Abdomen—Hernia 15
sensation to the sie of the scrotum an the labia. It is respon-
sible for the cremasteric reex. In women, it accompanies
the roun ligament of the uterus. The genital branch of the
genitofemoral nerve is part of the cor structures. It lies on
the iliopubic tract an accompanies the cremaster vessels (B).
The ilioinguinal nerve lies on top of the spermatic cor (A). It
innervates the internal oblique muscle an is sensory to the
upper meial thigh ajacent to the genitalia. The nerve can
sometimes splay out over the cor, making issection if-
cult. The iliohypogastric an ilioinguinal nerves arise from
the T1-L1 level an intermingle. They provie sensation to
the skin of the groin, the base of the penis, an the upper
meial thigh. The iliohypogastric nerve lies on the internal
oblique muscle (C), provies sensory innervation from the
skin overlying the pubis, an oes not intermingle with the
genitofemoral nerve because they cross ifferent paths (E).
Reference: Wantz GE. Testicular atrophy an chronic resiual
neuralgia as risks of inguinal hernioplasty. Surg Clin North Am.
1993;73(3):571–581.
6. A. Poupart ligament is another name for the inguinal lig-
ament. The inguinal ligament is forme from the anteroinfe-
rior portion of the external oblique aponeurosis foling back
on itself. It extens from the anterosuperior iliac spine to the
pubic tubercle, turning posteriorly to form a shelving ege.
The cremaster muscle bers arise from the internal oblique
muscle an surroun the spermatic cor (B). The genital
branch of the genitofemoral nerve passes through the eep
ring (C), whereas the ilioinguinal nerve passes through the
supercial ring. The genital branch innervates the cremas-
ter muscle, whereas the femoral branch controls sensation to
the upper lateral thigh (D). Inirect hernias arise lateral to
the inferior epigastric vessels, whereas irect hernias arise
meial to the inferior epigastric vessels. The lateral borer
of the rectus muscle, inferior inguinal ligament, an inferior
epigastric artery ene the borers of Hesselbach triangle
an ene the location of a irect hernia (E).
7. C. The arcuate line is locate below the umbilicus, typ-
ically one-thir the istance to the pubic crest (A). Between
the costal margin an the arcuate line, the anterior rectus
sheath is mae up of a combination of the aponeurosis of the
external an internal oblique muscles. The posterior sheath is
mae up of a combination of the aponeuroses of the internal
oblique an transverse abominal muscles. Below the arcu-
ate line, the anterior sheath is mae up of the aponeuroses
of all three abominal muscles (E). The internal oblique apo-
neurosis splits above the arcuate line to envelop the rectus
abominis muscle (B). There is no posterior sheath below the
arcuate line (D), an the transversalis fascia therefore makes
up the posterior aspect of the rectus abominis muscle.
8. E. This patient has bilateral inguinal hernias, one of
which is recurrent an shoul be offere a laparoscopic
repair. The avantages of this inclue the ability to visualize
both sies through a single incision an a potentially eas-
ier surgery in the setting of recurrence. It also protects the
patient from eveloping a femoral hernia since the femoral
canal is covere by the mesh. Of note, femoral hernias are
known to evelop after open inguinal hernia repair. They
evelop on average sooner than a typical recurrence, sug-
gesting that the original hernia was in fact a femoral one an
16 PArt i Patient Care
was misse at the original surgery. The two laparoscopic
approaches inclue TEP an TAPP. TEP involves issecting
a plane in the preperitoneal space, which may actually be
avantageous when compare to TAPP because intraab-
ominal ahesions are avoie (A). This oes not hol true
for prior pelvic surgery as the preperitoneal space may be
obliterate in these patients, necessitating a TAPP. If the peri-
toneum is violate uring TEP, it is important to repair the
efect to prevent ahesion formation postoperatively, but
it is not manatory to convert to a ifferent technique (C).
Though there are few absolute contrainications to laparo-
scopic hernia surgery, bowel ischemia with perforation or
sepsis preclues the use of mesh, which is require in both
TEP an TAPP. Tacking of the mesh in either laparoscopic
approach can reuce mesh migration but shoul be avoie
lateral to the epigastric vessels an inferior to the iliopubic
tract to avoi placement in the “triangle of oom” or the “tri-
angle of pain,” which contains the external iliac vessels an
several nerves (lateral femoral cutaneous an femoral branch
of genitofemoral, respectively) (B). Injury to these nerves is
relatively specic to laparoscopic repairs (D).
Reference: Fischer JE. Fischer’s mastery of surgery. Wolters Klu-
wer Health/Lippincott Williams & Wilkins; Chicago, IL, 01.
9. C. The preferre initial approach for an uncomplicate
inguinal hernia is still actively ebate within the surgi-
cal community. The LEVEL-trial specically compare TEP
repair versus open mesh repair an emonstrate reuce
pain in the immeiate postoperative perio an earlier return
to work. However, this came at the expense of longer operat-
ing room times an higher intraoperative complication rates
(B, D). This seems to be consistent with the results of a New
England Journal of Medicine (NEJM) stuy from 004 comparing
open mesh repair to all methos of laparoscopic mesh repair.
However, they iverge on reporte recurrence rates, with the
NEJM stuy favoring open repair (recurrence of 4% versus
10.1%) while the LEVEL-Trial showe equivalent recurrence
rates (3.0% for open an 3.8% for TEP) (E). The LEVEL-Trial
also inicate an equivalent prevalence of chronic pain, which
was not one of the outcomes in the NEJM article (A).
References: Langevel HR, van’t Riet M, Weiema WF, et al.
Total extraperitoneal inguinal hernia repair compare with Lichten-
stein (the LEVEL-Trial): a ranomize controlle trial. Ann Surg.
010;51(5):819–84.
Neumayer L, Giobbie-Hurer A, Jonasson O, et al. Open mesh
versus laparoscopic mesh repair of inguinal hernia. N Engl J Med.
004;350(18):1819–187.
10. A. Severe groin pain eveloping in the recovery room
following laparoscopic hernia repair is most likely ue to a
stapling/tacking injury to a nerve. If this complication is sus-
pecte, the patient shoul return to the operating room to
remove the offening tack. Acute groin pain is most likely
from injury to the ilioinguinal nerve. However, the most
commonly injure nerve uring laparoscopic hernia repair
is the lateral femoral cutaneous nerve (provies sensation
to the lateral thigh). Injecting the groin with local anesthetic
may not relieve the pain an if it works, it will only be a
temporary measure (E). Meical therapy is not appropriate
if the suspecte etiology is irritation of the nerve seconary
to stapling/tacking (B–D). Chronic groin pain may occur in
10% to 5% of patients 1 year after surgery. The etiology is
thought to be entrapment of the nerve uring surgery or
postoperative scarring. Chronic groin pain is best worke up
with MRI. If conservative management oes not resolve the
pain, operative exploration an ivision of the nerve(s) have
met with success. The ieal approach in the setting of her-
nia reoperation after open repair is to enter a space in which
the tissue planes have not been violate. The preferre man-
agement is a laparoscopic retroperitoneal triple neurectomy,
which allows a single stage approach to access the ilioingui-
nal, iliohypogastric, an genitofemoral nerves.
11. D. Ischemic orchitis is thought to evelop as a result of
thrombosis of veins of the pampiniform plexus, leaing to
testicular venous congestion. It has thus been terme con-
gestive orchitis. The precise etiology of ischemic orchitis is
unclear. The most commonly ientie risk factor is exten-
sive issection of the spermatic cor. This occurs particularly
when a patient has a large hernia sac, an the entire istal
sac is issecte an excise. As such, it is recommene that
the sac instea is ivie an the istal sac left in situ. In
aition, the cor shoul never be issecte past the pubic
tubercle. The presentation is that of a swollen, tener testicle,
usually  to 5 ays after surgery. The testicle is often high
riing. This may eventually progress to testicular atrophy.
Scrotal uplex ultrasonography has been shown to be useful
in evaluating the perfusion of the testicle after hernia repair.
However, it oes not change the management of ischemic
orchitis. Management is expectant. In the past, attempts to
reexplore the groin were unertaken to try to loosen the
inguinal ring, but this was not successful (A). The bloo sup-
ply to the testicle is via the testicular artery, but there are rich
collaterals incluing the external spermatic artery an the
artery to the vas. Thus, inavertent ligation of the testicular
artery oes not typically lea to this complication (C). Preex-
isting testicular pathology (B) or anomalous bloo supply (E)
to the testicle is not thought to contribute to ischemic orchitis
following inguinal hernia repair. However, ischemic orchi-
tis can occur more frequently in recurrent inguinal hernia
surgery using the anterior approach; thus, the laparoscopic
approach shoul be consiere for recurrent hernias.
References: Holloway B, Belcher HE, Letourneau JG, Kun-
berger LE. Scrotal sonography: a valuable tool in the evaluation of
complications following inguinal hernia repair. J Clin Ultrasound.
1998;6(7):341–344.
Wantz GE. Testicular atrophy an chronic resiual neuralgia as
risks of inguinal hernioplasty. Surg Clin North Am. 1993;73(3):571–581.
12. C. A large prospective ranomize stuy in men
emonstrate that watchful waiting for patients with
asymptomatic or minimally symptomatic inguinal hernias
is an acceptable option for surgery (D). The patients were
followe for as long as 9 years. Acute hernia incarceration
without strangulation evelope in only one (0.3%) patient,
an acute incarceration with bowel obstruction evelope
in only one (A). Approximately one-fourth of the watchful
waiting group eventually crosse over to receive surgical
repair ue to increase hernia-relate pain (B). Smaller her-
nias ten to have a smaller neck, placing them at higher risk
for eveloping incarceration (E).
Reference: Fitzgibbons RJ Jr, Giobbie-Hurer A, Gibbs JO, etal.
Watchful waiting vs repair of inguinal hernia in minimally symptom-
atic men: a ranomize clinical trial. JAMA. 006;95(3):85–9.

13. C. The vast majority of inguinal hernias in chilren are
the inirect type ue to a persistent patent processus vagi-
nalis. Approximately 1% to 5% of chilren can evelop an
inguinal hernia. However, the incience increases in preterm
infants an those with a low birth weight. Right-sie her-
nias are more common, an 10% of hernias iagnose at
birth are bilateral. Incarceration is a more serious problem
in peiatric patients than in aults. Emergent operation on
an infant with an incarcerate hernia can be very challeng-
ing. Thus, it is preferable to try to reuce the hernia, which
is successful in 75% to 80% of cases, allow the inammation
to subsie over several ays, an then perform the repair
semielectively. The routine use of contralateral groin explo-
ration is not wiely supporte (D). For elective cases, one
option is to perform laparoscopy via the hernia sac to look
for a contralateral hernia an, if foun, procee to repair. If
there are any signs of strangulation (e.g., leukocytosis, fever,
elevate lactate), then manual reuction shoul be avoie,
an the patient shoul be taken immeiately to the operating
room for surgical intervention (E). In the patient escribe,
though the skin is erythematous, there are no signs of sys-
temic toxicity. Methos to achieve reuction inclue the use
of intravenous (IV) seation, Trenelenburg positioning, ice
packs, an gentle irect pressure. Reuction without sub-
sequent surgery is not appropriate. That being sai, infants
with anemia an history of prematurity are at signicantly
increase risk of postoperative apnea an woul require
overnight monitoring.
Reference: Özemir T, Arıkan, A. Postoperative apnea after
inguinal hernia repair in formerly premature infants: impacts of ges-
tational age, postconceptional age an comorbiities. Pediatr Surg
Int. 013;9(8):801–804.
14. D. In chilren, umbilical hernias are congenital. They
are forme by a failure of the umbilical ring to close, causing
a central efect in the linea alba. Most umbilical hernias in
chilren are small an will close by  years of age, particu-
larly if the efect is less than 1 cm in size. As such, repair is
not always inicate at the time of iagnosis (B). Aition-
ally, the ecision to perform an elective repair is not solely
etermine by the presence of symptoms (E). If closure oes
not occur by age 4 or 5 years, elective repair is then consi-
ere a reasonable option (C), even if the patient is asymp-
tomatic. If the hernia efect is large (> cm) or the family is
bothere by the cosmetic appearance, repair shoul be con-
siere. Although umbilical hernias in chilren can incarcer-
ate, this is very rare (A). If the chil presents with abominal
pain, bilious emesis, an a tener, har mass protruing
from the umbilicus, immeiate exploration an hernia repair
are inicate.
15. D. Unlike in chilren, umbilical hernias in aults are
usually acquire (A). Risk factors are any conitions that
increase intraabominal pressure, such as pregnancy, obe-
sity, an ascites. Overall strangulation of umbilical hernias
in aults is uncommon, but it occurs more often than in chil-
ren (C). Small, barely palpable an asymptomatic hernias
can be followe clinically. Larger or symptomatic hernias
shoul be repaire. In patients with cirrhosis an ascites, the
markely increase pressure causes the skin overlying the
hernia to become thin an eventually ischemic. One of the
most catastrophic complications in this setting is rupture of
CHAPtEr 2 Abdomen—Hernia 17
the hernia through the ischemic skin, leaing to peritonitis
an eath. Thus, patients with cirrhosis an ascites shoul
unergo repair if there is evience that the skin overlying
the hernia is thinning or becoming ischemic (B). However,
repair shoul be elaye until after meical management of
the ascites. If meical management fails an the skin over the
hernia is thinne an tense, then a transjugular portosystemic
shunt shoul be consiere before repair. Alternatively, if the
patient is a caniate for liver transplant, the hernia can be
repaire uring the transplantation. Umbilical hernias have
historically all been repaire by primary closure. Borrow-
ing from the low recurrence rates using mesh for inguinal
hernias, umbilical hernias are now more frequently being
repaire using mesh, particularly those with large efects.
A recent prospective, ranomize stuy compare primary
closure with mesh repair. The early complication rates such
as seroma, hematoma, an woun infection were similar in
the two groups. However, the hernia recurrence rate was sig-
nicantly higher after primary suture repair (11%) than after
mesh repair (1%) (E). Some authors are now avocating for
the routine use of mesh for all ault umbilical hernias in the
absence of bowel strangulation.
References: Arroyo A, García P, Pérez F, Anreu J, Canela F,
Calpena R. Ranomize clinical trial comparing suture an mesh
repair of umbilical hernia in aults. Br J Surg. 001;88(10):131–133.
Belghiti J, Duran F. Abominal wall hernias in the setting of cir-
rhosis. Semin Liver Dis. 1997;17(3):19–6.
16. D. Femoral hernias occur more commonly in females
an have a high risk of incarceration. However, the most
common overall hernia in females is an inirect inguinal
hernia (A). Bowel entering a femoral hernia passes own
a narrow femoral canal. This is because the femoral ring,
which serves as the entrance for the femoral canal, is very
rigi an unyieling. Thus, the xe neck of a femoral her-
nia is prone to pinching off the bowel, putting the patient
at risk for incarceration. The borers of the femoral canal
are as follows: inguinal ligament (anterior) (B), Cooper
ligament (posterior), femoral vein (lateral), an Poupart
ligament (meial). Femoral hernias occur most commonly
lateral to the lymphatics an meial to the femoral vein,
within the empty space (C). It is important to recognize
that femoral hernias pass eep (posterior) to the inguinal
ligament. As such, repairs to the inguinal ligament (such
as a Bassini operation an stanar mesh repair) will not
obliterate the efect (E). The femoral hernia can be xe
either through a stanar inguinal approach or irectly
over the bulge using an infrainguinal incision. The essen-
tial elements of femoral hernia repair inclue issection
an removal of the hernia sac an obliteration of the efect
in the femoral canal. This can be accomplishe by either
approximation of the iliopubic tract to the Cooper ligament
or by placement of prosthetic mesh.
Reference: e Virgilio C, Frank PN, Grigorian A, es. Surgery: a
case based clinical review. Springer; 015.
17. B. It is important to unerstan the ifference between
epigastric hernias an iastasis recti because the former is
a true hernia, which shoul be repaire, an the latter is
a benign conition. Diastasis recti is cause by increase
separation of the rectus abominis muscles an a relative
thinning of the linea alba, which can mimic a hernia. The
18 PArt i Patient Care
conition can be acquire, such as in multiparous women
where the repeate stretching of the abominal wall causes
the rectus muscles to separate, or congenital, seconary to
more lateral attachment of the rectus muscles at birth. Clas-
sically, patients present after recent weight loss because this
allows for the lesion to be visible. There is no risk for stran-
gulation in iastasis recti because all of the facial layers are
intact (A, D). Though several methos of surgical repair have
been escribe, these are mainly cosmetic. In general, all that
is require is reassurance an abominal wall exercises to
help strengthen the musculature—though complete resolu-
tion in aults is unlikely (C). In contrast, epigastric hernias
are true hernias an represent a true efect in the linea alba.
They are generally small an contain either preperitoneal fat
or part of the falciform ligament (E). They arise from efects
in the fascia in locations where neurovascular bunles
perforate through. Though small, they can cause signicant
pain because of compression of the nerves traveling through
the efect. There is some evience to suggest that iastasis
rectus may increase the risk for evelopment of an epigastric
hernia an will make primary repair of epigastric hernias
more challenging. Of note, patients with iastasis recti are at
increase risk of abominal aortic aneurysms.
References: Brunicari FC, Anersen DK, Schwartz SI.
Schwartz’s principles of surgery. 10th e. McGraw-Hill Eucation.
Köhler G, Luketina RR, Emmanuel K. Suture repair of pri-
mary small umbilical an epigastric hernias: concomitant rectus
iastasis is a signicant risk factor for recurrence. World J Surg.
015;39(1):11–16.
Townsen CM, Jr, Beauchamp RD, Evers BM, Mattox KL, es.
Sabiston textbook of surgery: the biological basis of modern surgical prac-
tice. 17th e. Philaelphia, PA: W.B. Sauners; 004.
 Abdomen—Biliary
AMANDA C. PURDY AND DANIELLE M. HARI 3
ABSITE 99th Percentile High-Yields
I. Physiology
A. Bile consists of water, bile salts, phospholipis, an cholesterol
B. Primary bile acis (cholic & chenoeoxycholic acis) become seconary bile acis when ehyroxylate
by gut bacteria (lithocholate an eoxycholate acis)
C. Mechanism of bile concentration in the gallblaer: active transport of NaCl into gallblaer mucosal
cells, passive absorption of water

II. Cholecystitis, Choleocholithiasis, an Cholangitis

A. Acute calculous cholecystitis: gallblaer inammation ue to gallstone impacte in the neck;
management is NPO, IV antibiotics, resuscitation, laparoscopic cholecystectomy
B. Acute acalculous cholecystitis: usually seen in critically ill patients in the ICU; US emonstrates
gallblaer wall thickening, pericholecystic ui, with no stones; HIDA if US is equivocal, tx is IV
antibiotics, resuscitation, an percutaneous cholecystostomy tube if critically ill versus laparoscopic
cholecystectomy if stable for surgery
C. Choleocholithiasis: may have obstructive jaunice; elevate irect bilirubin, may have transaminitis; US
emonstrates gallstones, ilate CBD, +/− stone in the CBD (sensitivity only 50%); tx is ERCP followe
up by laparoscopic cholecystectomy
1. If intraoperative cholangiogram is positive for choleocholithiasis: rst attempt to ush the stone
with saline; if it oesn’t work try ushing after giving 1 mg IV glucagon (relaxes sphincter of Oi); if
stones on’t clear, options inclue:
a) Postoperative ERCP
b) Transcystic CBD exploration—best for small stones, large cystic uct, or small CBD; generally
preferre over transuctal CBD exploration because it avois a CBD incision
c) Transuctal CBD exploration—best for large stones (>8–10 mm), large CBD, proximal stones
(above cystic uct), choleochotomy mae anterior to avoi vasculature laterally
D. Acute ascening cholangitis: Charcot tria (RUQ pain, fever, jaunice) presents in about 0%; Reynols
penta as hypotension an confusion; RUQ US: +/− gallstones, ilate CBD, elevate irect BR; tx is IV
antibiotics, ui resuscitation, pressors if in septic shock, followe by ERCP or percutaneous transhepatic
cholangiography (PTC) tube placement after resuscitation; laparoscopic cholecystectomy uring same
amission if ue to gallstones
E. Mirizzi synrome: large stone in the gallblaer neck compresses the common hepatic uct (CHD), can
cause CHD stricture or stula between the gallblaer an CHD; usually presents similar to cholecystitis
an iagnose uring cholecystectomy; manage with cholecystectomy

III. Choleochal cysts

A. Due to an anomalous pancreaticobiliary junction, with a fuse, long common pancreaticobiliary channel
allowing pancreatic enzymes to reux into the biliary tree leaing to inammation an cystic egeneration

19
20 PArt i Patient Care

B. More common in females an those of Asian escent, 60% iagnose before age 10
C. First step in workup is US but MRCP is best for iagnosis an preop planning
D. Associate with cholangiocarcinoma an gallblaer cancer; type III has very low risk of malignancy;
management for all types besies type III is surgical to ecrease subsequent malignancy risk
1. Management is base on location (escribe by Toani Classication):
. Type I (fusiform ilation, most common): cyst excision, Roux-en-Y hepaticojejunostomy,
cholecystectomy
3. Type II: cyst excision, primary closure, cholecystectomy
4. Type III: enoscopic sphincterotomy an cyst unroong
5. Type IVa: cyst excision, partial hepatectomy, Roux-en-Y hepaticojejunostomy, cholecystectomy
6. Type IVb: cyst excision, Roux-en-Y hepaticojejunostomy, cholecystectomy
7. Type V (Caroli isease): if only in one lobe of the liver—hepatic resection an cholecystectomy; if
bilobar or unresectable—liver transplant

IV. Gallblaer Polyps

A. Polypoi lesions of the gallblaer: cholesterolosis (most common, cholesterol-laen macrophages in the
lamina propria), aenomatous polyp (risk for gallblaer cancer)
B. Inications for cholecystectomy for gallblaer polyps: symptomatic, polyp >10 mm, primary sclerosing
cholangitis, an polyp of any size
C. If cholecystectomy is not inicate, shoul follow patient with serial US in 6 to 1 months

V. Gallblaer Aenocarcinoma (most common biliary malignancy)

A. Risk factors: gallstones, gallblaer polyp >10 mm, porcelain gallblaer with selective mucosal
calcication (as oppose to transmural calcication)
B. May present similarly to cholecystitis, often iagnose on pathology after cholecystectomy
C. Management:
1. T1a (into lamina propria) → cholecystectomy
. >T1b (into muscularis) OR >N1 → cholecystectomy, segment IVb & V hepatectomy, portal
lymphaenectomy (port site resection not inicate); followe by ajuvant chemotherapy
(gemcitabine an cisplatin)
3. If positive cystic uct margin, nee extrahepatic bile uct resection an hepaticojejunostomy

VI. Cholangiocarcinoma
A. Risk factors: primary sclerosing cholangitis, ulcerative colitis, choleochal cyst, liver uke infection
B. Can present with painless jaunice; suspect in patient with focal bile uct stenosis without history of
biliary surgery or pancreatitis; best imaging is MRCP
C. Unresectable if istant metastasis, which inclues multifocal hepatic isease an lymph noe mets
beyon the porta hepatis
D. For potentially resectable cholangiocarcinoma, start with iagnostic laparoscopy; goal of surgery is
negative margins; all surgery inclues portal lymphaenectomy; management epens on location:

Location/Classięcation Management
Lower 1/3 of extrahepatic bile duct Whipple
Middle 1/3 of extrahepatic bile duct Resection, hepaticojejunostomy
Upper 1/3 of bile duct Type I CHD (not to the conĚuence) If localized to one side—hemi-
AKA Klatskin tumor hepatectomy, extrahepatic
Type II CHD to the conĚuence
Further classięed with the bile duct excision, Roux-en-Y
Bismuth classięcation: Type IIIa CHD + RHD hepaticojejunostomy
Type IIIb CHD + LHD If unresectable hilar tumor ≤3cm
without nodal disease or distant
Type IV CHD + RHD + LHD mets—evaluate for transplant
 CHAPtEr 3 Abdomen—Biliary 21

VII. Bile uct injuries (incience 0.3%–0.8%, most commonly ue to cystic uct stump leak)
A. Risk of bile uct injury higher with laparoscopic cases an elective (not emergent/urgent cases)
B. Principles of management: control sepsis, rain bile collections, an establish secure biliary rainage
C. Marke laboratory abnormalities are not typical; bilirubin may be elevate ue to systemic resorption;
US is initial imaging stuy, +/− HIDA
D. In immeiate postop perio, treat with IV antibiotics, ui resuscitation, percutaneous rainage an
ERCP with stent placement an/or sphincterotomy as this is sufcient for majority of cases; if not,
percutaneous transhepatic catheter require; if leak has not heale in 6 to 8 weeks, biliary reconstruction
is consiere with Roux-en-Y hepaticojejunostomy
E. If iscovere intraoperatively, repair only inicate if aequate hepatobiliary surgical experience is
available; otherwise, wie rainage an referral to higher level of care

Fig. 3.1 Biliary Cysts.

22 PArt i Patient Care
Questions
1. A 10-year-ol boy with sickle cell isease
presents with right upper quarant pain, nausea,
vomiting, fever, an yellowing of the eyes for the
past ay. He enies ark urine or light stool. On
exam, he is febrile, hemoynamically stable, an
has a positive Murphy sign. He has leukocytosis,
elevate alkaline phosphatase, an elevate
unconjugate bilirubin. On ultrasoun, there are
gallstones, pericholecystic ui, an gallblaer
wall thickening, an CBD iameter is 4 mm. After
starting IV ui resuscitation an IV antibiotics,
what is the next step?
A. MRCP
B. ERCP
C. Percutaneous transhepatic cholangiography
D. Laparoscopic cholecystectomy
E. Cholecystostomy tube
2. A 5-year-ol woman is unergoing elective
laparoscopic cholecystectomy for symptomatic
cholelithiasis. When removing the gallblaer
from the fossa, a -mm tubular structure is
completely transecte an is leaking bile. The
structure appears to come from the liver fossa an
enter irectly into the gallblaer. What is the
most appropriate management?
A. Laparoscopic clip placement
B. Repair over a T-tube
C. Roux-en-Y hepaticojejunostomy
D. Immeiate transfer to a hospital with a
hepatobiliary surgeon
E. Complete cholecystectomy an plan for
postoperative ERCP
3. A 45-year-ol male presents with hematemesis
two weeks after a motor vehicle accient in which
he suffere a liver injury that was manage
nonoperatively. Laboratory values are signicant
for an elevate total bilirubin an alkaline
phosphatase, as well as signicant anemia.
This patient is most likely to have which of the
following?
A. Arterioportal vein stula
B. Arteriohepatic vein stula
C. Arterial pseuoaneurysm
D. Portal venous pseuoaneurysm
E. Cavernous hemangioma
4. Which of the following patients shoul be offere
a cholecystectomy?
A. A 40-year-ol woman with an incientally
iscovere 6-mm gallblaer polyp
B. A 30-year-ol man with asymptomatic
gallstones unergoing gastric bypass
C. A 65-year-ol woman with asymptomatic
gallstones an an incientally iscovere
porcelain gallblaer with selective mucosal
calcication
D. A 50-year-ol man with a history of iabetes
an asymptomatic gallstones
E. A 1-year-ol boy with sickle cell isease an
asymptomatic gallstones
5. Which of the following is true regaring bile an
gallstones?
A. The primary bile acis are eoxycholic an
lithocholic aci
B. The primary phospholipi in bile is lecithin
C. Cholecystectomy ecreases bile salt secretion
D. Brown pigmente gallstones are more likely to
be foun in the gallblaer versus the CBD
E. Bile consists of an equal part of bile salts,
phospholipis, an cholesterol
6. Which of the following is true regaring the
gallblaer?
A. It passively absorbs soium an chlorie
B. In the setting of cholelithiasis, cholecystokinin
(CCK) can cause gallblaer pain that waxes
an wanes
C. It harbors an alkaline environment
D. Glucagon can help empty the gallblaer
E. Its contraction is inhibite by vagal
stimulation

7. A 75-year-ol woman presents to the emergency
epartment with a -ay history of nausea,
feculent vomiting, an obstipation. Her bloo
pressure on amission is 80/60 mm-Hg, an
her heart rate is 10 beats per minute, both of
which normalize after uis. Plain lms reveal
istene loops of small bowel with air–ui
levels an air in the biliary tree. Which of the
following is the best management option?
A. Small bowel enterotomy with removal of the
gallstone plus
B. Small bowel enterotomy with removal of the
gallstone
C. Small bowel enterotomy with removal of
the gallstone followe 8 weeks later by
cholecystectomy an takeown of stula
D. Small bowel resection to inclue area of
impacte gallstone
E. Small bowel resection to inclue area of
impacte gallstone plus cholecystectomy an
takeown of the stula
8. Jaunice with absent urine urobilinogen is most
consistent with:
A. Hepatitis
B. Cirrhosis
C. Hemolysis
D. Biliary obstruction
E. Sepsis
9. Which of the following is true regaring bile an
gallblaer isease?
A. Primary bile acis are forme by econjugation
B. Bile acis are passively absorbe in the
terminal ileum
C. Bile acis are responsible for the yellow color
of bile
D. Bile uct stones occurring 1 year after
cholecystectomy are consiere primary
common uct stones
E. In between meals, gallblaer emptying is
stimulate by motilin
10. Which of the following is true regaring biliary
anatomy?
A. The right hepatic uct tens to be longer than
the left an more prone to ilation
B. Venous return from the gallblaer is most
often via a cystic vein to the portal vein
C. Heister valves have an important role in the
gallblaer’s function as a bile reservoir
D. The CBD an pancreatic uct typically unite
outsie the uoenal wall
E. The arterial supply to the CBD erives
primarily from the left hepatic an right
gastric arteries
CHAPtEr 3 Abdomen—Biliary 23
11. Ultrasonography of the gallblaer reveals a
polypoi lesion. This most likely represents:
A. a cholesterol polyp
B. aenomyomatosis
C. a benign aenoma
D. aenocarcinoma
E. an inammatory polyp
12. Which of the following is the correct pairing of
anatomic structure an irection for retraction
uring a laparoscopic cholecystectomy?
A. Gallblaer funus laterally
B. Gallblaer infunibulum laterally
C. Gallblaer boy laterally
D. Gallblaer infunibulum cephala
E. Gallblaer funus meially
13. Hyrops of the gallblaer:
A. Poses a signicantly increase risk of
malignancy
B. Is ue to a stone impacte in the cystic uct
C. Typically starts with an enteric bacterial
infection
D. Is associate with marke right upper
quarant tenerness
E. Results in the gallblaer getting lle with
bile-staine ui
14. During a laparoscopic cholecystectomy for
symptomatic cholelithiasis, the surgeon
inavertently transects the CBD. An experience
hepatobiliary surgeon is available. The best choice
for operative repair is:
A. En-to-en CBD anastomosis
B. Choleochouoenostomy
C. Choleochojejunostomy
D. Hepaticouoenostomy
E. Hepaticojejunostomy
15. The most common cause of benign bile uct
stricture is:
A. Ischemia from operative injury
B. Chronic pancreatitis
C. Common uct stones
D. Acute cholangitis
E. Sclerosing cholangitis
24 PArt i Patient Care
16. A 45-year-ol man has a 50% total boy
surface area thir-egree burn. Fever, marke
leukocytosis, an right upper quarant pain
evelop on hospital ay 7. His bloo pressure
is 130/80 mm-Hg, an his heart rate is 110 beats
per minute. Ultrasonography shows a istene
gallblaer with gallblaer wall thickening an
sluge. However, it is negative for gallstones.
Antibiotics are initiate. The next step in
management woul consist of:
A. Laparoscopic cholecystectomy
B. Compute tomography
C. Hepatobiliary iminoiacetic aci (HIDA) scan
D. Percutaneous cholecystostomy
E. Upper enoscopy
17. During laparoscopic cholecystectomy, bile
appears to be emanating near the junction of
the CBD an cystic uct. Upon conversion to
open cholecystectomy, the injury is note to be
a 3-mm longituinal tear in the anterolateral
istal common hepatic uct. The uct itself
measures 7 mm in iameter. Management
consists of:
A. Primary repair of the injury without a T tube
B. Primary repair of the injury over a T tube
C. Primary repair of the injury with a T tube
place through a separate choleochotomy
D. Hepaticojejunostomy
E. Choleochouoenostomy
18. Which of the following statements is
true regaring the use of intraoperative
cholangiography (IOC) uring laparoscopic
cholecystectomy?
A. It helps prevent inavertent incision of the
common bile uct (CBD)
B. It is the best way to ientify clinically
signicant common uct stones
C. Routine use is justie because of its ability
to ientify anatomic anomalies of the hepatic
ucts
D. Routine use is helpful to ensure complete
removal of the gallblaer an cystic uct
E. Routine use is unnecessary
19. An 80-year-ol patient presents with nausea,
fever, an right upper quarant pain an
tenerness. Ultrasonography reveals gallstones
as well as air in the wall of the gallblaer. His
temperature is 103.5°F an bloo pressure is
70/40 mm-Hg. Meical therapy is initiate, an
pressors are neee to maintain bloo pressure.
Which of the following is true regaring this
conition?
A. Metroniazole is an important antibiotic
choice
B. Emergent cholecystectomy is inicate
C. Urgent percutaneous rainage is preferre
over cholecystectomy
D. The most common organism is an anaerobic
gram-negative ro
E. Perforation of the gallblaer is rare
20. Which of the following best escribes the role of
preoperative biliary rainage before a Whipple
proceure in a patient with obstructive jaunice?
A. It has been shown to ecrease the rate of
cholangitis
B. It has been shown to increase the rate of
woun infections
C. It shoul be performe routinely if the
bilirubin level is greater than 8 mg/L
D. It has been shown to shorten the hospital stay
E. It has been shown to ecrease the mortality
rate
21. A 35-year-ol Chinese man presents with a
fever of 103.5°F, right upper quarant pain,
an jaunice. Laboratory values are signicant
for a white bloo cell count of 15,000 cells/L,
an alkaline phosphatase level of 400 U/L,
an a serum bilirubin level of 3.8 mg/L.
Magnetic resonance cholangiopancreatography
(MRCP) emonstrates a markely ilate CBD,
markely ilate intrahepatic ucts with several
intrahepatic uctal strictures, an multiple stones
throughout the uctal system. Which of the
following is true regaring this conition?
A. It is associate with close contact with ogs
an sheep
B. It is more commonly associate with black
pigment stones versus brown pigment stones
C. It more commonly affects males
D. Metroniazole is able to resolve the majority of
cases
E. Initial treatment is with enoscopic retrograe
cholangiopancreatography an transhepatic
cholangiography

22. A 65-year-ol woman presents with symptoms
an signs of acute cholecystitis an unergoes
an uneventful laparoscopic cholecystectomy.
On postoperative ay 7, the pathology report
inicates a supercial gallblaer carcinoma that
invaes the perimuscular connective tissue. There
is no evience of istant metastasis on subsequent
imaging. Which of the following woul be the
best management?
A. Raiation an chemotherapy
B. Observation
C. Reoperation with resection of liver segments
IVB an V
D. Reoperation with resection of liver segments
IVB an V an regional lymph noe issection
E. Reoperation with resection of liver segments
IVB an V, regional lymph noe issection,
an resection of all port sites
23. A 4-year-ol male presents with acholic stools
an cola-colore urine. Alkaline phosphatase
is 000 IU/L, AST is 78 IU/L, ALT is 88 IU/L,
an total bilirubin is .1 mg/L. Liver biopsy
emonstrates periuctal concentric brosis
aroun macroscopic bile ucts. He is positive for
perinuclear antineutrophil cytoplasmic antiboy
(p-ANCA). Which of the following is true about
this conition?
A. It is more commonly associate with Crohn
isease than it is with ulcerative colitis
B. Cancer antigen (CA) 19-9 levels shoul be
etermine
C. Enoscopic retrograe
cholangiopancreatography (ERCP) will
preominantly emonstrate irregular
narrowing of the intrahepatic biliary tree
D. Symptoms are often well controlle with
meical management
E. It is more common in females
24. Which of the following is a feature of gallblaer
cancer?
A. Speckle cholesterol eposits are foun on the
gallblaer wall
B. There are thickene noules of mucosa an
muscle
C. Gallblaer cancer is more common in males
D. It is more likely to be accompanie by large
gallstones compare with smaller ones
E. Cancer invaing muscularis layer is manage
with cholecystectomy alone
CHAPtEr 3 Abdomen—Biliary 25
25. Choleochal cyst isease is thought to be cause
by an abnormality of the:
A. Bile uct smooth muscle
B. Bile composition
C. Bile uct aventitia
D. Pancreaticobiliary uct junction
E. Bile uct mucosa
26. On CT scan, a type I choleochal cyst appears
to be aherent to the posterior wall of the portal
vein. Management consists of:
A. Partial excision of the cyst, leaving posterior
wall behin, an cholecystectomy with Roux-
en-Y hepaticojejunostomy
B. Complete excision of the cyst, cholecystectomy,
an hepaticojejunostomy
C. Partial excision of the cyst, fulguration of
posterior cyst mucosa, an cholecystectomy
with Roux-en-Y hepaticojejunostomy
D. Observation
E. Roux-en-Y cyst jejunostomy
27. Which of the following is the best management of
a localize Klatskin tumor?
A. Pancreaticouoenectomy (Whipple
proceure)
B. Resection of the entire extrahepatic biliary tree
with hepatic resection if necessary
C. Resection of the mile thir of the biliary tree
with hepaticojejunostomy
D. Chemotherapy
E. Raiation followe by chemotherapy
28. Which of the following is true regaring
cholangiocarcinoma?
A. The majority are intrahepatic
B. Bismuth-Corlette type I cholangiocarcinoma
occurs above the conuence of the right an
left hepatic ucts
C. Most patients benet from ajuvant
chemoraiation after surgical intervention
D. It arises from malignant transformation in
hepatocytes
E. Resection with biliary-enteric bypass is
consiere appropriate management in
patients with early isease
26 PArt i Patient Care
Answers
1. D. This patient with sickle cell isease has acute calculous
cholecystitis an shoul unergo laparoscopic cholecystec-
tomy after ui resuscitation an initiation of antibiotics.
Signs that point to acute cholecystitis in this case inclue:
fever, positive Murphy sign, leukocytosis, an ultrasoun
nings of gallstones, gallblaer wall thickening, an peri-
cholecystic ui. MRCP is reasonable if there is concern for
possible choleocholithiasis. However, it is important to is-
tinguish obstructive jaunice from jaunice from hemolytic
anemia (as seen in this patient) (A). Although this patient has
jaunice, his labs show an increase unconjugated bilirubin.
He also oes not have ark urine or acholic stools, an CBD
iameter is normal. This is more consistent with hemolytic
anemia than with obstructive jaunice (in which you woul
expect conjugate bilirubinemia, ark urine, acholic stools,
an CBD ilation). This young patient with sickle cell is-
ease has chronic hemolysis, which likely le to evelopment
of pigmente gallstones, an now cholecystitis. Sepsis can
trigger increase hemolysis in patients with sickle cell isease
an is responsible for his perceive increase jaunice since
symptom onset. ERCP woul be an appropriate choice if there
is a very high suspicion for choleocholithiasis or ascening
cholangitis; however, there is no evience of biliary obstruc-
tion in this case (B). Percutaneous transhepatic cholangiogra-
phy can also be use to ecompress the biliary tree, which is
not inicate in this case (C). Cholecystostomy tube can be
consiere in patients with cholecystitis that are too unstable
to unergo cholecystectomy, which is not true in this case (E).
2. A. Ducts of Luschka are small ucts that originate in the
gallblaer fossa an rain irectly into the gallblaer, as
escribe in this question. When transecte, they can cause
bile leaks. When iscovere intraoperatively, the uct shoul
be clippe or oversewn. More commonly these are iag-
nose postoperatively as a ui collection at the gallblaer
fossa (biloma) an shoul be raine percutaneously an
an ERCP with sphincterotomy an stent placement shoul
be performe to encourage bile ow into the uoenum (E).
Primary repair over a T-tube an Roux-en-Y hepaticojeju-
nostomy are the appropriate treatment for common bile uct
injuries (with <50% luminal injury an >50% luminal injury,
respectively), which is not what is escribe in this case (B,
C). If a common uct injury occurs at a hospital without a
surgeon who is experience in biliary reconstruction, the sur-
geon shoul place wie rains an then arrange transfer to a
referral center. However, that is not necessary in this case (D).
References: Mercao MA, Domínguez I. Classication an man-
agement of bile uct injuries. World J Gastrointest Surg. 011;3(4):43–48.
Spanos CP, Syrakos T. Bile leaks from the uct of Luschka (sub-
vesical uct): a review. Langenbecks Arch Surg. 006;391(5):441–447.
3. C. Hemobilia is a rare conition an presents with a
classic (Quinke) tria of upper gastrointestinal bleeing
(hematemesis), combine with jaunice an right-sie
upper abominal pain. It is most often a result of iatrogenic
injury of the right hepatic artery (more common if there is
an aberrant right hepatic artery off the superior mesenteric
artery) uring laparoscopic cholecystectomy but may also
occur following blunt an penetrating traumatic injuries.
The unerlying lesion is typically an arterial pseuoaneu-
rysm that has a connection with the biliary tree (hence the
jaunice). It can also occur in association with gallstones,
tumors, inammatory isorers, an vascular isorers.
Treatment in most instances involves angiographic emboli-
zation of the artery (thus angiography is most likely to be
the therapeutic stuy of choice). Enoscopy may show bloo
coming from the ampulla of Vater but will not typically be
therapeutic (because the bleeing is coming from a hepatic
artery pseuoaneurysm). The remaining answer choices are
not thought to play a role in hemobilia (A, B, D, E).
References: Ahrent SA, Pitt HA. Biliary tract. In: Townsen
CM, Jr, Beauchamp RD, Evers BM, Mattox KL, es. Sabiston textbook
of surgery: the biological basis of modern surgical practice. 17th e. Phila-
elphia: W.B. Sauners; 004:1597–164.
Bloechle C, Izbicki JR, Rashe MY, et al. (1994). Hemobilia:
presentation, iagnosis, an management. Am J Gastroenterol.
1994;89(9):1537–1540.
Croce MA, Fabian TC, Spiers JP, Kusk KA. Traumatic
hepatic artery pseuoaneurysm with hemobilia. Am J Surg.
1994;168(3):35–38.
Nicholson T, Travis S, Ettles D, etal. Hepatic artery angiography
an embolization for hemobilia following laparoscopic cholecystec-
tomy. Cardiovasc Radiol. 1999;(1):0–4.
4. C. Asymptomatic patients who are incientally is-
covere to have gallstones usually o not require surgery
because the lifetime risk of eveloping symptoms is <5%.
There are, however, certain inications for cholecystectomy
in asymptomatic patients. These inclue gallblaer polyps
≥10 mm an a porcelain gallblaer with selective mucosal
calcication of the gallblaer because both have an asso-
ciate malignancy risk (A). Historically, all patients with
porcelain gallblaer unerwent cholecystectomy because
of the malignancy risk. It is now unerstoo that the risk is
not as high as originally thought, an only selective muco-
sal calcication is associate with malignancy risk, while
transmural calcication is not. More extensive intramural
eposits cause mucosal sloughing, which reuces the rate
of aenocarcinoma, while the selective calcication yiels
to a continue inammatory stimulus. Thus, a stronger
recommenation for prophylactic cholecystectomy is mae
for the selective mucosal calcication pattern in an asymp-
tomatic patient. Patients with cholelithiasis unergoing gas-
tric bypass are at increase risk for eveloping gallstones
because of rapi weight loss. However, most o not evelop
symptoms requiring cholecystectomy, an prophylactic cho-
lecystectomy in these patients is not inicate (B). Diabetes is
also not an inication for cholecystectomy in the absence of
symptoms (D). Patients with conitions that cause hemolytic
anemia, such as sickle cell isease an hereitary sphero-
cytosis, are at increase risk of eveloping pigmente gall-
stones. However, surgery for asymptomatic cholelithiasis in
these patients is only recommene if they are unergoing
another abominal operation (such as splenectomy for chil-
ren with hereitary spherocytosis [E]).

References: Warschkow R, Tarantino I, Ukegjini K, et al. Con-
comitant cholecystectomy uring laparoscopic Roux-en-Y gastric
bypass in obese patients is not justie: a meta-analysis. Obes Surg.
013;3(3):397–407.
Overby DW, Apelgren KN, Richarson W, Fanelli R, Society of
American Gastrointestinal an Enoscopic Surgeons. SAGES guie-
lines for the clinical application of laparoscopic biliary tract surgery.
Surg Endosc. 010;4(10):368–386.
5. B. Bile consists of bile salts, phospholipis, an choles-
terol in the following concentrations: 80%, 15%, an 5%,
respectively (E). Normally, more than 95% of bile salts are
reabsorbe by the enterohepatic circulation an negative
feeback accounts for replacement of the 0.5 g loss of bile salts
in the stool. The primary bile acis are cholic aci an che-
noeoxycholic aci. The seconary bile acis are lithocholate
an eoxycholate acis (A). Cholecystectomy has minimal
effect on bile aci secretion but oes increase enterohepatic
circulation of bile salts (C). Pigment stones get their charac-
teristic color from calcium bilirubinate. Brown pigment gall-
stones occur more commonly in the setting of biliary stasis
such as cholangitis an ten to form in the CBD. Black pig-
ment stones are associate with hemolytic isorers an are
more likely to be foun within the gallblaer (D).
Reference: Osottir M, Hunter JG. Gallblaer. In: Bruni-
cari FC, Anersen DK, Billiar TR, etal., es. Schwartz’s principles of
surgery. 8th e. New York: McGraw-Hill; 005:1187–100.
6. D. The gallblaer concentrates an stores bile. It oes
so by rapily absorbing soium an chlorie against a con-
centration graient by active transport an passive water
absorption (A). The epithelial cells of the gallblaer secrete
mucous glycoproteins an hyrogen ions into the gallbla-
er lumen. The secretion of hyrogen ions aciies the bile,
increasing calcium solubility, an thus preventing its pre-
cipitation as calcium salts (C). Inammation of the gallbla-
er mucosa seems to affect the ability to secrete hyrogen
ions, making the bile more lithogenic. Vagal innervation
stimulates contraction of the gallblaer (E). CCK causes
steay an tonic contraction. The term biliary colic is a mis-
nomer because postpranial gallblaer pain seconary to
cholelithiasis oes not wax an wane but rather stays con-
stant for up to several hours (B). The more appropriate term
is symptomatic cholelithiasis. The gallblaer normally lls by
contraction at the sphincter of Oi at the ampulla of Vater.
In contrast, glucagon relaxes the sphincter of Oi an cre-
ates the path of least resistance allowing the gallblaer to
empty into the uoenum.
References: Ahrent SA, Pitt HA. Biliary tract. In: Townsen
CM, Jr, Beauchamp RD, Evers BM, Mattox KL, es. Sabiston textbook
of surgery: the biological basis of modern surgical practice. 17th e. Phila-
elphia, PA: W.B. Sauners; 004:1597–164.
Osottir, M, Hunter, JG. Gallblaer. In: Brunicari FC,
Anersen DK, Billiar TR, etal., es. Schwartz’s principles of surgery.
8th e. New York: McGraw-Hill; 005:1187–100.
7. B. The presentation is consistent with gallstone ileus.
Gallstone ileus is a misnomer because it is actually a type of
mechanical small bowel obstruction. It occurs more com-
monly in elerly females (>70 years). The most specic
stuy to help conrm iagnosis is a CT scan showing air
in the biliary tree. It usually results from a large gallstone
(>.5 cm) that has eroe through the gallblaer into the
CHAPtEr 3 Abdomen—Biliary 27
ajacent uoenum an causing air in the biliary tree, cre-
ating a cholecystouoenal stula (the most common type
of biliary stula). Less commonly, the stula can be between
the gallblaer an the colon (hepatic exure) or the stom-
ach. The stone typically loges in the narrowest portion of
the gastrointestinal tract—the istal ileum, near the ileoce-
cal valve. The iagnosis of gallstone ileus is mae preopera-
tively in only approximately half of cases because a history of
biliary isease may be absent, pneumobilia may not be seen,
the gallstone may not be visualize, or the abominal raio-
graphic nings may be nonspecic. Because many of these
patients are elerly, have other major comorbiities, an are
often markely ehyrate, initial surgical management
shoul focus on relieving the obstruction. This is best accom-
plishe by a transverse enterotomy proximal to the palpable
stone an stone removal (C–E). It is also important to run
the small bowel because a signicant portion of patients
will have more than one gallstone. Leaving the stula oes
not seem to lea to signicant morbiity on long-term fol-
low-up. Most surgeons woul not recommen taking the
patient back at a later time for stula takeown. A resection
of the small bowel is usually not necessary.
References: Ahrent SA, Pitt HA. Biliary tract. In: Townsen
CM, Jr, Beauchamp RD, Evers BM, Mattox KL, es. Sabiston textbook
of surgery: the biological basis of modern surgical practice. 17th e. Phila-
elphia: W.B. Sauners; 004:1597–164.
Roríguez-Sanjuán JC, Casao F, Fernánez MJ, Morales DJ,
Naranjo A. Cholecystectomy an stula closure versus enterolithot-
omy alone in gallstone ileus. Br J Surg. 1997;84(5):634-637.
Tan YM, Wong WK, Ooi LLPJ. A comparison of two surgical
strategies for the emergency treatment of gallstone ileus. Singapore
Med J. 004;45():69–7.
Halabi WJ, Kang CY, Ketana N, Lafaro KJ, Nguyen VQ, Sta-
mos MJ, Imagawa DK, Demirjian AN. Surgery for gallstone ileus:
a nationwie comparison of trens an outcomes. Ann Surg.
014;59():39–35.
8. D. Bilirubin is the result of the breakown of ol re
bloo cells into heme. Heme is broken own into biliver-
in an then bilirubin. Bilirubin is boun to albumin in the
circulation, but as it reaches the liver, it is conjugate an
eventually enters the gastrointestinal tract. In the gastroin-
testinal tract, it is econjugate into urobilinogen by bacteria.
Some urobilinogen gets reabsorbe in the gut, returns to the
liver, an is excrete in the urine, where it is eventually con-
verte to urobilin, giving urine its yellow appearance. The
remaining urobilin is oxiize to stercobilin in the intestines,
giving stool its brown appearance. In the presence of biliary
obstruction, less bilirubin enters the gut, less urobilinogen is
mae, an therefore less appears in the urine. Less sterco-
bilin is mae an therefore the stools turn pale. Hemolysis
woul generate an increase in bilirubin an a corresponing
increase in urobilinogen in the gut an in the urine (C). The
remaining answer choices o not play a signicant role in
bilirubin metabolism (A, B, E).
Reference: Ahrent SA, Pitt HA. Biliary tract. In: Townsen
CM, Jr, Beauchamp RD, Evers BM, Mattox KL, es. Sabiston textbook
of surgery: the biological basis of modern surgical practice. 17th e. Phila-
elphia: W.B. Sauners; 004:1597–164.
9. E. Cholesterol that has been conjugate with taurine or
glycine is consiere a primary bile (cholic an chenoe-
oxycholic aci). Seconary bile acis are a result of bacterial
28 PArt i Patient Care
econjugation in the gastrointestinal tract (A). Although bile
acis are passively absorbe along the entirety of the small
intestine, they are actively absorbe only in the terminal
ileum (B). Bile acis are colorless, an the yellow hue of bile
is a result of the pigmente biliverin (breakown prouct
of bilirubin) that is also foun in bile (C). Bile uct stones
occurring after  years are consiere primary common uct
stones an are often pigmente (D). During the fasting state,
gallblaer emptying is stimulate by motilin.
Reference: Luiking YC, Peeters TL, Stolk MF, et al. Motilin
inuces gall blaer emptying an antral contractions in the faste
state in humans. Gut. 1998;4(6):830–835.
10. D. The left hepatic uct is longer than the right an is
more likely to be ilate in the presence of istal obstruction
(A). The spiral Heister valves within the cystic uct o not
have any true valvular function (C). In approximately three-
fourths of iniviuals, the CBD an the main pancreatic uct
unite outsie the uoenal wall an traverse the uoenal
wall as a single uct. The bloo supply to the CBD runs along
the lateral an meial walls at the 3 an 9 o’clock positions
an comes from the right hepatic artery an retrouoenal
artery (off gastrouoenal artery) (E). Thus, a transverse
hemitransection of the uct will likely interrupt the bloo
supply an rener a repair prone to ischemia an stricture.
Venous return of the gallblaer is typically raine irectly
to the parenchyma of the liver (B).
Reference: Osottir, M, Hunter, JG. Gallblaer. In: Bruni-
cari FC, Anersen DK, Billiar TR, etal., es. Schwartz’s principles of
surgery. 8th e. New York: McGraw-Hill; 005:1187–100.
11. A. Most polypoi lesions of the gallblaer are benign,
an of these, cholesterol polyps are the most common. They
are usually small (<10 mm), peunculate, an multiple.
They are usually seen in association with cholesterolosis.
Ultrasoun imaging often emonstrates hyperechoic foci
with a comet tail artifact; unlike gallstones, these foci on’t
prouce shaowing. Aenomyomatosis polyps are the sec-
on most common (B). They appear as sessile polyps that
cause focal thickening of the wall. Inammatory polyps
are the thir most common (E). All three are benign an
are pseuopolyps. Aenomas an aenocarcinomas of the
gallblaer are generally larger than 10 mm. However, is-
tinguishing between a benign an a malignant polyp on
ultrasonography is generally not reliable (C, D). Thus, when
a polyp is foun on ultrasoun, the general inications for
cholecystectomy are (1) a symptomatic polyp, () a polyp in
association with gallstones, (3) a polyp larger than 6 mm, an
(4) patient age over 50. For asymptomatic gallstone polyps
that o not meet the above criteria, the recommene man-
agement is follow-up ultrasoun in 6 months.
References: Ahrent SA, Pitt HA. Biliary tract. In: Townsen
CM, Jr, Beauchamp RD, Evers BM, Mattox KL, es. Sabiston textbook
of surgery: the biological basis of modern surgical practice. 17th e. Phila-
elphia: W.B. Sauners; 004:1597–164.
Myers R, Shaffer E, Beck P. Gallblaer polyps: epiemiology, nat-
ural history an management. Can J Gastroenterol. 00:16(3):187-194.
Shinkai H, Kimura W, Muto T. Surgical inications for small pol-
ypoi lesions of the gallblaer. Am J Surg. 1998;175():114–117.
12. B. A total of four trocar sites is typically place uring
laparoscopic cholecystectomy: (1) a 5-mm umbilical port for
the laparoscope, () a 1-mm epigastric port for issection
an retrieval of the specimen, (3) a 5-mm right-sie sub-
costal port, an (4) an aitional 5-mm port inferior an lat-
eral to the subcostal port. The 5-mm ports allow graspers to
retract the gallblaer funus superiorly (A, E) an infun-
ibulum, or the neck, laterally. This is the ieal positioning to
achieve the “critical view” an prevent CBD injury because
it allows the cystic uct to remain perpenicular to the CBD.
Excess cephala retraction of the gallblaer infunibulum
shifts the cystic uct in line with the CBD an is consiere
the most common cause of CBD injury (D). The gallblaer
boy shoul not be use as a retraction site (C).
13. B. When a gallstone becomes impacte in the cystic
uct, the typical course is that acute cholecystitis will evelop
in the patient. Less frequently, an acute infection oes not
evelop in the patient even though the cystic uct remains
obstructe. In this situation, bile within the gallblaer
becomes absorbe, but the gallblaer epithelium continues
to secrete glycoprotein (mucus). The gallblaer becomes
istene with mucinous material (E). This is known as
hyrops. The gallblaer may be palpable but oes not cre-
ate the Murphy sign (D). Hyrops of the gallblaer may
result in eema of the gallblaer wall an perforation.
Although hyrops may persist with few consequences, cho-
lecystectomy is generally inicate to avoi complications.
Hyrops of the gallblaer oes not signicantly increase
the risk for malignancy (A). Although this can subsequently
become infecte, enteric bacterial infection is not typically
responsible for the evelopment of hyrops (C).
Reference: Osottir, M, Hunter, JG. Gallblaer. In: Bruni-
cari FC, Anersen DK, Billiar TR, etal., es. Schwartz’s principles of
surgery. 8th e. New York: McGraw-Hill; 005:1187–100.
14. E. The majority of common bile uct injuries occur iat-
rogenically uring laparoscopic cholecystectomy in patients
with relatively benign gallblaer isease (e.g., symptomatic
cholelithiasis, acute cholecystitis). The management of an
intraoperative bile uct injury epens on the type of injury
an the clinical setting. If a small lateral injury (<50%) is
create in the CBD, this can be repaire by closing the uc-
totomy over a T tube an leaving a rain. Conversely, if the
common bile uct is transecte, this results in an interruption
in the bloo supply to the uct an attempts at primary repair
will inevitably lea to stricture formation an recurrent epi-
soes of cholangitis (A). Thus, if a transection is recognize
intraoperatively, an an experience hepatobiliary surgeon is
available, it is best to repair it immeiately an to o so with
a biliary enteric bypass. Because most of these injuries will
be in the common bile uct, the best option is to perform a
hepaticoenterostomy (B, C). A critical element of the repair
is to perform a tension-free, mucosa-to-mucosa uct enteric
anastomosis. Hepaticouoenostomy has largely been aban-
one for benign liver isease ue to ongoing enteric reux
(D). It is also more technically challenging to perform because
it is ifcult to reach the uoenum to the hepatic uct; thus
most surgeons prefer a Roux-en-Y hepaticojejunostomy. If an
experience hepatobiliary surgeon is not available, the best
option is to rain the area, place transhepatic catheters, an
refer the patient to higher level of care. If the injury is iscov-
ere postoperatively an there has been a long elay, the best
option is to perform transhepatic rainage an elay primary
repair for 6 to 8 weeks to allow the inammation to subsie.

References: Ahrent SA, Pitt HA. Biliary tract. In: Townsen
CM, Jr, Beauchamp RD, Evers BM, Mattox KL, es. Sabiston textbook
of surgery: The biological basis of modern surgical practice. 17th e. Phil-
aelphia: W.B. Sauners; 004:1597–164.
MacFayen BV Jr, Vecchio R, Ricaro AE, Mathis CR. Bile uct
injury after laparoscopic cholecystectomy: the Unite States experi-
ence. Surg Endosc. 1998;1(4):315–31.
Narayanan SK, Chen Y, Narasimhan KL, Cohen RC. Hepati-
couoenostomy versus hepaticojejunostomy after resection of cho-
leochal cyst: a systemic review an meta-analysis. J Pediatr Surg.
013;48(11):336–34.
15. A. Most benign bile uct strictures are iatrogenic an
are ue to a technical error uring cholecystectomy, such as
excessive use of cautery, incorrect placement of a surgical
clip, an overly aggressive issection near the CBD, all of
which may be the result of unclear anatomy (B–E). Regar-
less of the cause, the eventual response is brosis an stric-
ture formation. As many as three-fourths of injuries that
lea to strictures are not recognize at surgery, an as many
as one-thir occur 5 years or more after the operation. The
majority of iatrogenic strictures are short an occur in the
common bile uct an can present with an episoe of chol-
angitis. The workup consists of ultrasonography, which will
etect ilate ucts proximal to the stricture, a compute
tomography scan to look for masses, an enoscopic retro-
grae cholangiography (ERCP) with enoscopic ultrasoun
(EUS), which can be both iagnostic an therapeutic. EUS can
be helpful in etecting a tumor within the bile uct. During
ERCP, a brushing of the bile uct shoul be taken for cytol-
ogy to rule out a malignancy. Management of focal benign
strictures by a biliary enteric bypass or stenting remains
ebatable because of the lack of ranomize trials an the
lack of goo long-term follow-up with stenting. The pri-
mary concern with stenting is that the strictures may become
obstructe an lea to recurrent cholangitis. Given the much
less invasive nature of stenting, strong consieration shoul
be given to this approach. If recurrent obstructive symptoms
subsequently evelop, a biliary enteric bypass shoul be
performe.
References: Ahrent SA, Pitt HA. Biliary tract. In: Townsen
CM, Jr, Beauchamp RD, Evers BM, Mattox KL, es. Sabiston textbook
of surgery: the biological basis of modern surgical practice. 17th e. Phila-
elphia: W.B. Sauners; 004:1597–164.
Chun K. Recent classications of the common bile uct injury.
Korean J Hepatobiliary Pancreat Surg. 014;18(3):69–7.
Costamagna G, Shah SK, Tringali A. Current management of
postoperative complications an benign biliary strictures. Gastroin-
test Endosc Clin N Am. 003;13(4):635–648.
Lopez RR, Jr, Cosenza CA, Lois J, etal. Long-term results of metal-
lic stents for benign biliary strictures. Arch Surg. 001;136(6):664–669.
Osottir M, Hunter, J. G. Gallblaer. In: Brunicari FC, Aner-
sen DK, Billiar TR, etal., es. Schwartz’s principles of surgery. 8th e.
New York: McGraw-Hill; 005:1187–100.
Siriwarana HPP, Siriwarena AK. Systematic appraisal of the
role of metallic enobiliary stents in the treatment of benign bile uct
stricture. Ann Surg. 005;4(1):10–19.
16. A. The presentation is consistent with acalculous cho-
lecystitis. The initial stuy of choice is ultrasonography,
which can be performe at the besie. Finings to conrm
the iagnosis woul inclue thickening of the gallblaer
wall, sluge (as in this patient), an pericholecystic ui. If
the ultrasoun nings are negative an the patient is not
CHAPtEr 3 Abdomen—Biliary 29
critically ill, the next stuy woul be a HIDA scan with sin-
calie or morphine. A positive stuy ning woul emon-
strate nonlling of the gallblaer with visualization of the
tracer in the liver an small bowel. Morphine ecreases the
rate of false-positive HIDA scan results because it leas to
sphincter of Oi contraction an thus increases the like-
lihoo of lling of the gallblaer in the absence of chole-
cystitis. A HIDA scan is not recommene in critically ill
patients in whom a elay in therapy can be potentially fatal
(C). Acalculous cholecystitis requires urgent intervention,
preferably cholecystectomy. The proceure can be attempte
laparoscopically; however, there is a higher chance of ning
gangrenous cholecystitis an neeing to convert to open. If
the patient is too ill for surgery, percutaneous ultrasonogra-
phy or CT-guie cholecystostomy is the treatment option of
choice (B, D). Upper enoscopy is not inicate (E).
Reference: Ahrent SA, Pitt HA. Biliary tract. In: Townsen
CM, Jr, Beauchamp RD, Evers BM, Mattox KL, es. Sabiston textbook
of surgery: the biological basis of modern surgical practice. 17th e. Phila-
elphia: W.B. Sauners; 004:1597–164.
17. B. All of the provie options are potential repairs for
a bile uct injury. Sharp, clean, an small injuries in a large
CBD or common hepatic uct are more amenable to primary
repair. Repair is generally performe over a T tube (A). It is
important to bear in min that the CBD is supplie via two
main arteries running at the right an left borer of the uct,
entering at “3 o’clock” an “9 o’clock.” As such, injuries that
are less than 50% in circumference are less likely to have
interrupte the bloo supply on both sies an are therefore
less likely to evelop ischemic stricture with primary repair.
If the uct is transecte, nearly transecte (>50% circumfer-
ence), or very small, a Roux-en-Y hepaticojejunostomy is rec-
ommene (D). Injuries to the proximal CBD can be treate
with a hepaticojejunostomy (D), while injuries to the istal
CBD can be treate with a choleochouoenostomy (E). If
the bile uct injury is the result of thermal injury, a primary
repair with a T tube place through a separate choleochot-
omy is the preferre approach (C).
References: Osottir, M, Hunter, JG. Gallblaer. In: Bruni-
cari FC, Anersen DK, Billiar TR, etal., es. Schwartz’s principles of
surgery. 8th e. New York: McGraw-Hill; 005:1187–100.
Garen JO, e. Hepatobiliary and pancreatic surgery. 4th e. New
York: Elsevier; 009:08.
18. E. The routine use of IOC to prevent bile uct injury is
controversial, but most surgeons woul say that routine use
is unnecessary. Because the overall risk of bile uct injury
is so small, to ate there are no sufciently large-scale ran-
omize stuies to answer this question. Most likely, the use
of IOC will not prevent an injury to the CBD (A). However,
IOC seems to allow earlier recognition of a CBD injury an
prevent complete transection of the CBD. Although routine
IOC will ientify unsuspecte CBD stones, in most instances,
CBD stones are suspecte preoperatively by abnormal liver
function tests, a ilate CBD, or a history of gallstone pancre-
atitis. In a nationwie retrospective analysis, CBD injury was
foun in 0.39% of patients unergoing cholecystectomy with
IOC an in 0.58% of patients without IOC (unajuste rela-
tive risk, 1.49). After controlling for patient-level factors an
surgeon-level factors, the risk of injury was increase when
IOC was not use (ajuste relative risk, 1.71). Some sur-
geons prefer selective use of IOC an obtain what is known
30 PArt i Patient Care
as the “critical view,” whereby the cystic uct an artery are
carefully ientie an not clippe or cut until conclusive
ientication has been mae. This is one by completely is-
secting the Calot triangle free of all fat an brous tissue an
issecting the lower part of the gallblaer off the liver be,
such that only two skeletonize structures (the cystic uct
an artery) are seen to be entering the gallblaer.
Reference: Sauners WB, Detry O, De Roover A, Detroz B. The
role of intraoperative cholangiography in etecting an preventing
bile uct injury uring laparoscopic cholecystectomy. Acta Chirur-
gica Belgica. 003;103():161–16.
19. C. Emphysematous cholecystitis occurs in less than 1%
of acute cholecystitis cases. It is a isease that occurs pre-
ominantly in elerly iabetic men. The hallmark feature is
characterize by gas within the gallblaer wall or lumen.
This can be seen on plain raiograph, ultrasoun, or com-
pute tomography (CT) scan. Gangrene of the gallblaer
is present in three-fourths of all cases, an perforation of
the gallblaer occurs in more than 0% of cases (E). In one
large series, the mortality rate was 5% an the morbiity
rate was 50% espite aggressive treatment with broa-spec-
trum antibiotics an emergent surgery. In patients that are
unstable, an not eeme suitable for general anesthesia
(such as a patient on pressors or multiple meical problems),
percutaneous rainage with cholecystostomy shoul be per-
forme rst. If the patient is more stable, cholecystectomy
is preferre (B). Although prior stuies suggeste open cho-
lecystectomy was preferre, laparoscopic cholecystectomy
is an acceptable approach, provie a low threshol for
conversion an stanar principles are use. Antimicrobial
coverage shoul inclue Clostridia perfringens, which is an
anaerobic gram-positive ro an consiere the most com-
mon cause of emphysematous cholecystitis (D). High-ose
penicillin shoul be starte immeiately (A). Other common
biliary pathogens associate with emphysematous cholecys-
titis inclue Clostridia welchii, Escherichia coli, Enterococcus,
an Klebsiella.
References: Ahrent SA, Pitt HA. Biliary tract. In: Townsen
CM, Jr, Beauchamp RD, Evers BM, Mattox KL, es. Sabiston textbook
of surgery: the biological basis of modern surgical practice. 17th e. Phila-
elphia: W.B. Sauners; 004:1597–164.
Tellez GS, Roriguez-Montes L, Fernanez e Lis J. Acute
emphysematous cholecystitis: report of twenty cases. Hepatogastro-
enterology. 1999;46(8):144–148.
20. B. Several stuies have analyze the role of preoper-
ative biliary rainage via ERCP an stenting in patients
with malignant obstructive jaunice who are to unergo a
Whipple proceure. Theoretically, relief of jaunice might
improve the operative risk of the subsequent Whipple proce-
ure. However, a large meta-analysis an single-center stu-
ies faile to show improve morbiity an mortality rates
with preoperative biliary rainage. In fact, the routine use
of preoperative biliary rainage seems to increase the risk
of infectious complications incluing woun infection (10%
with rainage versus 4% without) an increases the risk of
pancreatic stula (10% with rainage versus 4% without).
Thus, it shoul only be use selectively (e.g., presence of
cholangitis or severe, intractable pruritus). It has not been
emonstrate to ecrease the risk of cholangitis (A), shorten
hospital stay (D), or ecrease the mortality rate (E). Aition-
ally, obstructive jaunice provies the surgeon with a ilate
pancreatic uct at the time of surgery, making the pancre-
aticojejunostomy in a Whipple proceure easier to perform.
References: Ahrent SA, Pitt HA. Biliary tract. In: Townsen
CM, Jr, Beauchamp RD, Evers BM, Mattox KL, es. Sabiston textbook
of surgery: the biological basis of modern surgical practice. 17th e. Phila-
elphia: W.B. Sauners; 004:1597–164.
Sewnath ME, Karsten TM, Prins MH, Rauws EJA, Obertop H,
Gouma DJ. A meta-analysis on the efcacy of preoperative bili-
ary rainage for tumors causing obstructive jaunice. Ann Surg.
00;36(1):17–7.
Sohn TA, Yeo CJ, Cameron JL, Pitt HA, Lillemoe KD. Do preoper-
ative biliary stents increase postpancreaticouoenectomy compli-
cations? J Gastrointest Surg. 000;4(3):58–67.
21. E. This patient presents with a history an nings
consistent with cholangiohepatitis, also known as recurrent
pyogenic cholangitis. It is enemic in Asia, although the inci-
ence has been ecreasing. Cholangiohepatitis affects both
sexes equally (C). The etiology of cholangiohepatitis seems to
be a combination of bacterial an parasitic (Clonorchis sinen-
sis, Opisthorchis viverrini, an Ascaris lumbricoides) infections
in the biliary tree. The bacteria econjugate bilirubin, which
has a greater propensity to precipitate as bile sluge. Brown
pigment stones form as a consequence of the sluge an
ea bacterial cells (B). In aition, the nucleus of the stone
may harbor a parasite egg. The stones lea to recurrent epi-
soes of cholangitis, liver abscesses, stricture formation, liver
failure, an an increase risk of cholangiocarcinoma. Recur-
rence is high. Initial treatment is with ERCP an transhepatic
cholangiography. Patients often require multiple interven-
tions to clear the biliary tree. The patient may eventually
require a biliary enteric bypass, but this woul not be the
initial proceure of choice. Metroniazole is the treatment of
choice for amebic liver abscess (D). Hyati liver isease is a
liver cyst cause by Echinococcus an is associate with close
contact with ogs an sheep (A).
22. D. Cancer of the gallblaer is preominantly aenocar-
cinoma. The majority of cases are iscovere in an avance
state with istant metastases. Thus, the overall prognosis is
very poor, with a 5-year survival rate of only 5%. The best
chance of cure is if it is iscovere incientally at the time of
cholecystectomy. It is 17 times more likely to be iscovere in
patients following open cholecystectomy as compare with
laparoscopic cholecystectomy. Gallblaer cancer metas-
tasizes rst to the celiac axis lymph noes. Recent stuies
inicate that those that are iscovere incientally an are
supercial, such as carcinoma in situ an T1 lesions (o not
exten into perimuscular connective tissue), an have neg-
ative margins, can be manage by cholecystectomy alone
(B), with a 100% 5-year survival. Those that are more locally
avance, such as T through T4 lesions (those that invae
the perimuscular connective tissue or irectly invae the
liver), are treate with a raical cholecystectomy, which
inclues subsegmental resection of segments IVb an V, plus
hepatouoenal ligament lymphaenectomy, which results
in prolonge survival (C). The caveat is that there must be no
evience of istant metastases. In one series of 48 patients,
the overall 5-year survival rate was 13%, but it was 60% for
patients who unerwent raical cholecystectomy. The rai-
cal cholecystectomy group ha signicantly longer survival
than the simple cholecystectomy group for all stages except

stage I (T1N0). Although port sites are associate with peri-
toneal isease an ecrease survival, removing them oes
not improve survival an shoul not be one routinely in all
patients with incientally iscovere gallblaer cancer (E).
Raiation therapy with uorouracil raiosensitization is the
most commonly use postoperative treatment.
References: Osottir, M, Hunter, J G. Gallblaer. In: Bruni-
cari FC, Anersen DK, Billiar TR, etal., es. Schwartz’s principles of
surgery. 8th e. New York: McGraw-Hill; 005:1187–100.
Rei KM, Ramos-De la Meina A, Donohue JH. Diagnosis an
surgical management of gallblaer cancer: a review. J Gastrointest
Surg. 007;11(5):671–681.
Taner CB, Nagorney DM, Donohue JH. Surgical treatment of
gallblaer cancer. J Gastrointest Surg. 004;8(1):83–89.
Pitt SC, Jin LX, Hall BL, Strasberg SM, Pitt HA. Inciental gall-
blaer cancer at cholecystectomy: when shoul the surgeon be sus-
picious? Ann Surg. 014;60(1):18–133.
23. B. Sclerosing cholangitis is characterize by the pres-
ence of multiple inammatory brous thickenings resulting
in irregular narrowing of the entire biliary tree (C). It is pro-
gressive an as such leas eventually to biliary obstruction,
recurrent biliary infection, cirrhosis, an liver failure, as well
as a signicantly increase risk of cholangiocarcinoma (in
10%–0% of patients). All patients shoul be checke for an
elevate level of CA 19-9. It is twice as common in men, an
also tens to occur in younger patients (E). Risk factors for
sclerosing cholangitis inclue inammatory bowel isease,
pancreatitis, an iabetes. The strongest association is with
ulcerative colitis (A). Approximately two-thirs of patients
have ulcerative colitis. In fact, it is usually iscovere in these
patients when an abnormal liver function test result is note.
Alkaline phosphatase is characteristically elevate out of pro-
portion to an elevate bilirubin level. Patients may test posi-
tive for p-ANCA antiboies (in contrast to antimitochonrial
antiboies for primary biliary cirrhosis). It is less commonly
associate with Crohn isease. Other iseases associate
with sclerosing cholangitis inclue Rieel thyroiitis an
retroperitoneal brosis. Removing the colon in patients with
ulcerative colitis oes not affect the course of the sclerosing
cholangitis. In aition, the severity of inammation oes not
preict the onset of malignancy. All newly iagnose patients
with sclerosing cholangitis with or without an inammatory
bowel isease iagnosis shoul be scheule for a screen-
ing colonoscopy. Patients can be manage initially with ste-
rois, methotrexate, an cyclosporine, but the majority will
ultimately require more invasive treatment incluing biliary
stenting (D). Currently, the best option is liver transplanta-
tion in patients who progress to liver failure.
Reference: Osottir, M, Hunter, JG. Gallblaer. In: Bruni-
cari FC, Anersen DK, Billiar TR, etal., es. Schwartz’s principles of
surgery. 8th e. New York: McGraw-Hill; 005:1187–100.
24. D. Gallblaer cancer is two to three times more com-
mon in females (C). It is also more common in Native Amer-
icans in both North an South America. Approximately 90%
of patients with carcinoma also have gallstones. Large single
stones have a much higher risk of cancer than multiple small
stones, likely the result of creating more mucosal inam-
mation; large stones also are more likely to lea to chole-
cystoenteric stulas. Other risk factors inclue choleochal
cysts (which may be ue to an abnormal pancreaticobiliary
junction), sclerosing cholangitis, gallblaer polyps, an
CHAPtEr 3 Abdomen—Biliary 31
exposure to carcinogens (nitrosamines, azotoluene). Obe-
sity has recently been shown to be a risk factor for a wie
range of cancers, incluing the gallblaer (E). Speckle
cholesterol eposits on the gallblaer wall are a feature of
cholesterolosis an are not associate with an increase risk
of cancer (A). Selective mucosal calcium eposits (porce-
lain gallblaer) may have an increase risk of malignancy.
Thickene noules of mucosa an muscle in the gallblaer
are a feature of aenomyomatosis (B). Tumor invaing the
lamina propria, but not yet invae all the way through an
to the unerlying muscularis, is consiere T1a isease an
treate with simple cholecystectomy. Invasion to the uner-
lying muscularis is T1b isease an requires resection of liver
segments IVb an V an regional lymph noe issection.
References: Osottir M, Hunter J. G. Gallblaer. In: Bruni-
cari FC, Anersen DK, Billiar TR, etal., es. Schwartz’s principles of
surgery. 8th e. New York: McGraw-Hill; 005:1187–100.
Stephen AE, Berger DL. Carcinoma in the porcelain gallblaer:
a relationship revisite. Surgery. 001;19(6):699–703.
Chen, G. L., Akmal, Y., DiFronzo, A. L., etal. (015).
25. D. The exact etiology of choleochal cysts is unclear.
The most likely explanation is that there is an anomalous
pancreaticobiliary uct junction. Specically, the pancreatic
uct joins the common bile uct more than 1 cm proximal
to the ampulla, resulting in a long common channel. The
long channel leas to free reux of pancreatic secretions
into the biliary tract, resulting in increase biliary pressures
an inammatory changes in the biliary epithelium, which
eventually lea to ilation an cyst formation. Although an
abnormal pancreaticobiliary junction is present in the major-
ity of patients with choleochal cysts, it is not uniformly
seen. Choleochal cysts are more common in females an
Asians. It classically presents in chilhoo with jaunice
an an abominal mass accompanie by abominal pain.
In infants, it may be confuse with biliary atresia. However,
less than 50% of patients present with all three features, an
thus the iagnosis is often elaye. The most common pre-
sentation is nonspecic abominal pain. The iagnosis is
mae by ultrasonography, which can sometimes etect the
cyst antenatally. There are ve types. Type I is the most com-
mon (90%) an consists of fusiform ilation of the bile uct.
Type V, also known as Caroli isease, is characterize by
multiple intrahepatic ilations. Because of the risk of malig-
nant egeneration, treatment involves excising the cyst with
a biliary enteric bypass (typically hepaticojejunostomy). The
risk of malignancy increases with the more avance age at
which the cyst is etecte. Type V (Caroli) will nee a par-
tial liver resection or liver transplant. Biliary smooth muscle
(A), mucosa (E), uctal aventitia (C), an bile (B) are not
thought to play a role in choleochal cyst isease.
References: Osottir, M, Hunter, J. G. Gallblaer. In: Bruni-
cari FC, Anersen DK, Billiar TR, etal., es. Schwartz’s principles of
surgery. 8th e. New York: McGraw-Hill; 005:1187–100.
Toani T, Watanabe Y, Fujii T, Uemura S. Anomalous arrange-
ment of the pancreatobiliary uctal system in patients with a chole-
ochal cyst. Am J Surg. 1984;147(5):67–676.
26. C. Type I choleochal cysts are the most common type
an are ilations of either the entire common hepatic uct an
CBD or a segment of it. Management consists of excision of
the entire cyst an a biliary enteric bypass. An exception is if
the posterior wall of the cyst is stuck to the portal vein, which
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Title: Fra i due mondi

Author: Guglielmo Ferrero

Release date: March 1, 2024 [eBook #73083]

Language: Italian

Original publication: Milano: Treves, 1913

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*** START OF THE PROJECT GUTENBERG EBOOK FRA I DUE

MONDI ***
FRA I DUE MONDI
 Guglielmo Ferrero

FRA I DUE MONDI

MILANO
FRATELLI TREVES, EDITORI
1913
Secondo migliaio.
 PROPRIETÀ LETTERARIA.
I diritti di riproduzione e di traduzione sono riservati per
tutti i paesi, compresi la Svezia, la Norvegia e l’Olanda.
Copyright by Fratelli Treves, 1913.
Si riterrà contraffatto qualunque esemplare di
quest’opera che non porti il timbro della Società
Italiana degli Autori.
Milano — Tip. Fratelli Treves.
 PREFAZIONE.

Emilio Mitre, il Barone di Rio Branco, Teodoro Roosevelt: questi tre

nomi ho il dovere di scrivere sulla prima pagina del volume. E su tre
ricordi indelebili il memore pensiero indugia con una dolcezza non
scevra di melanconia, nel momento in cui anche questo libro sta per
affrontare il destino. Il primo, Parigi e la vigilia del giorno in cui
dovevo terminare al Collège de France il Corso della Fondazione
Michonnis — la sera del 29 novembre 1906: quando Emilio Mitre
d’improvviso venne a trovarmi, e con amabile semplicità m’invitò a
fare il lungo viaggio dell’Argentina, a nome suo e della «Nación», il
grande giornale di Buenos-Aires. Poi la sera del 24 giugno 1907:
quando il Barone di Rio Branco, ministro degli Esteri della
Confederazione del Brasile, spedì incontro alla mia signora ed a me,
nella meravigliosa baia di Rio de Janeiro, ove il «Cordova» faceva
scalo, una eletta rappresentanza della Accademia brasiliana, guidata
da Giuseppe Graça Aranha, a farci gli onori della città e ad invitarci a
visitare il Brasile al ritorno. Infine il giorno del febbraio 1908 in cui —
terza sorpresa del nuovo mondo, non meno gradita delle prime due
— mi giunse, trasmesso con nobili parole dal barone Mayor des
Planches, l’invito di Teodoro Roosevelt.
Molto dovrei a queste tre persone — a Emilio Mitre sopra tutti,
perchè fu il primo — anche se essi mi avessero procurata soltanto la
facilità di due lunghi viaggi, confortati da tutte le cortesie di una
magnifica ospitalità. Ma essi mi hanno reso un ben maggiore
servigio. Mi hanno strappato con gentile violenza a quell’antico
mondo, in cui mi ero chiuso da dieci anni; e mi hanno buttato
all’improvviso in mezzo all’immane tumulto delle due Americhe. Se
la vita è la scuola che non chiude mai le sue porte e non sospende
mai i suoi corsi, per chi sente l’ambizione di imparare senza tregua e
di sempre far meglio, questa gran lezione capitò per me al buon
momento, e fu forse la più proficua di tutte. Non mi raccapezzai da
prima. Poi, a poco a poco, volgendomi indietro, dal fondo della
Pampa argentina, dal montuoso altipiano di San Paolo, dalle immani
città industriali dell’America del Nord, a riguardare la Roma di
Cesare e di Augusto, misurai l’immenso cammino percorso
dall’uomo in mezzo a questa gran valle di venti secoli. Quanto è
vasta oggi la terra a paragone di quel piccolo bacino mediterraneo,
intorno alle cui sponde per tanto tempo la civiltà si raccolse! Come
deboli e pavidi appariscono gli uomini, anche nelle più gloriose età
del passato, a petto della formidabile potenza di cui noi disponiamo!
Eppure.... Eppure.... Per quale ragione, al sommo della potenza,
l’uomo non è contento; non trova pace; spesso quasi fa mostra di
voler sprezzare le prodigiose ricchezze, di cui è pur così avido e
fiero; ed ogni tanto è preso dalla smania di ammirare e invidiare
quelle antiche civiltà, che pur quasi più nemmeno capisce? Perchè
ogni oggetto, sul quale si sia posata la polvere di un secolo o due, è
venerato ormai come una reliquia? Perchè mentre gli Europei,
affamati di oro, voltano le spalle al vecchio mondo maledicendolo, gli
Americani, sazi d’oro, volgono verso quello la prua, come a cercare
qualche cosa, che manca in mezzo alle loro immense ricchezze?
Che è questo strano e incessante via vai dell’Oceano; questo
inquieto cercarsi dei due continenti, nessun dei quali sembra più
poter vivere da solo nè trasfondersi interamente nell’altro?
Quante volte, viaggiando le due Americhe, il mio pensiero ritornò a
quell’antica civiltà, che era stata tanti anni l’oggetto delle mie
ricerche e dei miei studi! Sinchè alla fine, viaggiando con la mente
tra un mondo e l’altro, mi parve di capire: di capire quale grandioso
perturbamento l’America ha arrecato nella vecchia storia del mondo,
comparendo ad un tratto nell’Oceano innanzi agli occhi dell’inquieto
genovese, che l’andava cercando. Turbamento piccolo da principio e
che crebbe poi, a poco a poco, nei secoli, con le scoperte delle
scienze, con le invenzioni, con il trionfo della libertà e con le
accumulate ricchezze: fervida lotta tra la quantità e la qualità, tra la
forza che spinge gli uomini a rovesciare tutti i limiti per dilagare sul
mondo e conquistarne i tesori, e il natural bisogno dell’uomo di
appoggiarsi a dei limiti per riconoscere sicuramente il Bene, la Verità
e la Bellezza: vertiginoso accumular di tesori, nel tempo stesso in cui
si confondono e annebbiano nella mente le credenze, i gusti, i
sentimenti, che gli antichi avevano cercato, con diuturna opera, di
chiarire, affinare e precisare: rapido grandeggiare di un mondo
senza limiti e quindi senza appoggi, nel quale l’uomo procede come
un gigante che vacilla ad ogni passo!
E così finalmente venni nell’idea di raffigurare questo conflitto dei
due mondi — non dell’America e dell’Europa soltanto, ma delle
antiche civiltà limitate ancora vive in tante tradizioni con le
aspirazioni le ambizioni e passioni di questa civiltà nuova, che tutti i
limiti vuol rovesciare — rinnovando una antica forma letteraria. Che
cosa è questo libro? Un romanzo? Un racconto di viaggio? Un
dramma? Un trattato di filosofia o di sociologia? No: è un dialogo.
Cara agli antichi, strumento prediletto di Platone e di Galileo, questa
forma letteraria, ha detto Ernesto Renan, è fatta apposta per trattare
le questioni che la mente umana, ripiglia sempre a discutere, perchè
non può scioglierle mai definitivamente. Ma anche il dialogo, insieme
con tante altre cose belle, è oggi come una pianta assiderata dal
crudo inverno. Fu temerario il pensare che potesse ridar qualche
fiore?
Mi conforterà in tal caso il pensiero di aver potuto almeno dipingere
in questo quadro antico la figura di uno degli uomini che ho più
amato e ammirato. Tra i personaggi fantastici di questo dialogo,
Emilio Rosetti è vero. Veri ne sono il nome e il cognome: vera la
storia che di lui è raccontata: veri storicamente una parte dei
discorsi, idealmente tutti. Uomo raro per ingegno, per dottrina, per
disinteressata brama di sapere e nobiltà di sensi, egli avrebbe potuto
oscurare molti i cui nomi risplendono di maggior lustro, se non
avesse incessantemente praticata quella gran regola del senno
antico, che ogni uomo deve desiderare e tentare meno di quanto
può fare ed avere. Onde nessun altri avrebbe potuto intendere ed
esporre meglio di lui quella filosofia dei limiti, a cui la lunga disputa
mette capo.
E così si chiude nella mia vita e nei miei studi la lunga parentesi
aperta da Emilio Mitre, con il suo invito, la sera del 29 novembre
1906. Pur troppo la gioia di aver terminata una lunga ed aspra fatica
mi è ora amareggiata dal pensiero che nè ad Emilio Mitre nè al
Barone di Rio Branco io potrò mandare — piccolo omaggio della
mia, gratitudine — questo volume. Grazie al cielo però Teodoro
Roosevelt è vivo e vegeto non solo, ma ammirabile esempio di
quella alacrità infaticabile, di quella fiducia in sè e nelle cose che
sono tra le più belle virtù dell’America. A lui almeno giunga questo
libro e gli dica la imperitura riconoscenza che sento per lui; per le
Due Americhe generose e ospitali; per le molte cose che vi ho
imparate; per gli aiuti e le cortesie senza numero che ne ho ricevuti.
Marzo 1913.
Guglielmo Ferrero.
 PARTE PRIMA.

I.

Ad uno ad uno, i vaporetti che da due ore ronzavano intorno al

«Cordova» si allontanarono; e il «Cordova» restò per qualche tempo
solo, fermo sulle àncore, in mezzo alla baia di Rio de Janeiro.
Rivolto il viso verso la poppa, sul ponte di comando, dove il capitano
della nave, il cavaliere Federico Mombello, aveva invitati la Gina e
me a dar l’estremo addio alla città, io guardavo ancora una volta,
aspettando che la nave salpasse, la azzurra e luminosa catena dei
monti Tinguà, della Stella, degli Organi, che chiude a settentrione la
baia; la erta corona di punte, di cuspidi, di obelischi, di denti, di
creste che la sormontano; il fulgido e turgido festone di grandi nuvole
bianche che in quel meraviglioso pomeriggio di primavera era
appeso ai suoi fianchi: guardavo e pensavo che tra pochi minuti si
chiuderebbe per sempre, nel volume della mia vita, uno di quegli
episodi che non si ripetono.... Addio, addio per sempre, America,
due volte visitata nei due emisferi: immenso mondo in cui ero entrato
con così ardente curiosità; che avevo corso con tanta foga; dove
avevo viste e intraviste tante cose ignote, sfiorita la primizia di un
trionfo non ancora goduto da altri, asceso un gradino sulla scala
della fortuna! Nell’ora della partenza quelle cento montagne, quelle
mille vette parevano spogliarsi della materia e del peso, evaporare in
fulgide nuvole azzurre al contatto delle rilucenti nuvole bianche; e le
nuvole bianche inghirlandavano le azzurre; e le azzurre reggevano
disteso al sole il luminoso festone delle bianche; e le bianche e le
azzurre si confondevano in un immenso splendore che empiva il
cielo; come se dopo tante magnificenze della natura e degli uomini,
l’America volesse rifulgere ancora una volta ai miei occhi — ultima
magnificenza — in quella celeste muraglia di vapore e di luce. Onde
me pungeva, in quel momento, non so se una tristezza soave o una
melanconica gioia, soffusa di un vago sgomento. Sentivo che stava
per trapassare sul mio capo un istante irrevocabile; che avrei potuto
rifar quante volte volessi il viaggio d’America, ma non rifare mai più
quel primo viaggio che allora finiva.
Una campana, dei segnali squillarono. Lenta lenta, a sinistra, sul
fianco destro della nave, la costa su cui sorge Rio si mosse. Erano le
cinque in punto. Addio, addio per sempre, ancora una volta addio, o
prima o unica America, che non potrei rivedere mai più! E mi voltai
verso prua. Una immensa conca verde, quasi tutta ancora
soleggiata, si apriva dinanzi. Attraversavamo l’ultima parte della
baia, il suo vestibolo verso l’Oceano, un lago azzurro, chiuso a
levante e a ponente entro due montagne cupamente verdi e
ricoperte di un fitto vello di folte foreste. Sospinti dall’irrevocabile
precipitare dell’ultimo istante, spaziammo con la vista nella gran
conca, vaghi di ricapitolarne ancora una volta le bellezze molteplici:
a levante, a piè della verde parete dei monti, le estreme case di
Niteroy nascosta in un seno e la divina spiaggia di Icarahy, sulla
quale avevamo passato un così delizioso pomeriggio con Graça
Aranha sotto il nembo dei profumi che il vento scuoteva su noi dalle
vicine foreste; gli isolini e gli isolotti boscosi che si vedevano far
capolino e rimpiattarsi da ogni parte, uno dietro l’altro, quasi immensi
cespugli natanti o cime di una gigantesca foresta sommersa; la
verde parete montuosa di ponente e il Corcovado nel mezzo, che
appuntava al sole la cuspide aguzza, ripido e scosceso come un
precipizio: Rio infine, ai suoi piedi! Rio, la città, inghirlandata di
palme e di avanzi della foresta millenaria; la città che tuffa i piedi nel
mare e posa il capo sulla montagna, tra le selve; l’ultima delle grandi
metropoli americane da me visitate, sulle sponde dell’Atlantico, nei
due emisferi. Dovunque, in basso come in alto, dalla spiaggia a
sommo della collina, a destra e a sinistra, singole case e branchi di
case spuntavano, scomparivano, rifacevano capolino, si
appiattavano di nuovo, tra cupi boschetti di grandi alberi o sotto
altissime palme, i cui ciuffi sormontavano da ogni parte. Ripensai in
quel momento a New-York; alla folle furia della città diabolica che,
esasperata dalla ferrea cintura dell’indilatabile spazio, accatasta
frenetica le moli per scalare le nubi. Ripensai alla opulenta Buenos-
Aires, comoda e come discinta nell’immensa pianura, e che in quella
si dilata, radente al suolo, con le contigue innumeri case romane di
un piano solo, con le strade diritte e interminabili, simile ad una
Pompei viva e infinita. Quanto diversa dall’una e dall’altra la
metropoli che vedevo dal «Cordova» sbandarsi in riva al mare o
sulla collina! La città che si adagia nella foresta della baia, antica
come un’avola e bella come una giovane amante; e dei suoi pezzi
più magnifici fa ventaglio contro il sole troppo ardente; e le
fondamenta dei propri edifici intreccia con le sue radici secolari; e
con lei respira i venti della montagna e dell’Oceano che quella
fecondano; e la foresta si lascia vivere e crescere sul giovane corpo,
facendosi da lei avviluppare quasi come da un’edera gigantesca:
unica forse tra le città della terra che non fugga, inorridita come da
una tentazione d’incesto, le carezze della madre natura!
Il «Cordova» intanto accelerava l’elica verso la porta della baia, che
sta di fronte alle eccelse montagne del fondo; queste, il fulgore del
giorno incominciando a velarsi, ripigliavano a poco a poco corpo e
peso, incupendo; apparve a un tratto a sinistra, bianco in riva al
mare azzurro e a piè della verde collina, il bel palazzo di Monroe,
sotto la cui cupola avevo discorso di Roma antica; si avvicinò; lo
vedemmo di fronte; si allontanò a destra: rivedemmo per l’ultima
volta la bella passeggiata del Botafogo e il grande squarcio pietroso,
grigio nella verde montagna, che la sovrasta. Poi montagne di
orrenda stranezza si accostarono: il Pan di Zucchero, il monolito
posto a guardia della baia, che ha verde il corpo e nero e calvo il
capo: al di là del Pan di Zucchero il dorso di un gigantesco
dromedario, le cime gibbose del Gran Gabbiano. Già per metà sotto
l’ombra, Rio scompariva come in uno scorcio.... Addio, addio per
sempre, unica città della terra nelle cui vie si sente e si gode la
foresta: le sue smanie d’amore effuse nei soavissimi olezzi che
invadono al mattino le case; le ombre meditabonde che essa offre
invano ad ogni ora del giorno al frettoloso passante; la torbida arsura
e la collera minacciosa degli imminenti cicloni; la sua saziata
freschezza e la giovinezza rinata, dopo i torrenziali diluvi: le lunghe
estasi immote dei silenzi silvani, sospesi nel meriggio sulle vie
deserte: i sommessi e arcani sussurri, che le cime degli alberi
mormorano tra di loro al tramonto all’altezza dei tetti: il tumulto dei
venti, che investono e scuotono e fanno fremere con lo stesso soffio
tronchi e rami, vetri e finestre! E di nuovo, in quel momento, e per
l’ultima volta, mi parve di sentire o presentire, che lì in quel
frammento della meravigliosa America apparsa ai primi esploratori,
in quell’avanzo quasi intatto della più antica natura non ancora rifatta
dall’uomo, qualcuno — non so chi — doveva non saprei, se godere
o imaginare o musicare o descrivere in verso e in prosa, un
inebriante idillio della natura e dell’uomo, dei sensi e
dell’immaginazione, dell’amore e del pensiero; idea, o aspirazione, o
fantasia germinante a fatica, che da parecchie settimane irritava il
mio spirito e non riusciva a sbocciare!
Ma il «Cordova» era ormai in mezzo alla porta della baia, a piè
dell’orrida e smisurata muraglia del Pan di Zucchero, piccolo come
un insetto. Mi volsi a prua: già si vedeva l’Oceano, pronto a caricarci
sulle spalle possenti per portarci al nostro destino: ma tra l’Oceano e
noi si interponevano in orrenda mischianza nuovi mostri: le isole, gli
isolotti, gli scogli, accovacciati come bestie, a guardia della porta.
Passammo tra gli uni e gli altri; mi voltai verso poppa, per veder
l’America sino all’ultimo istante: ed ecco a poco a poco — a mano a
mano che la nave si allontanava — emergere dalle acque delle
groppe, delle criniere, dei musi, dei corni, dei corpi dì animali,
abbozzi informi di una confusa creazione, appena abborracciata
nella rude materia dei monti, delle isole e delle scogliere. Il Pan di
Zucchero si era voltato, ci guardava ora con la faccia deforme del
«Gran Gigante di Pietra» intravisto dai primi navigatori; alla sua
destra e alla sua sinistra si distendeva una parete di roccie, nera nel
nimbo d’oro entro cui il sole l’avvolgea, scoscesa, precipitosa, irta di
punte aguzze, scabra di orride sporgenze, spaccata ogni tanto da
capo a fondo da enormi anfratti in cui si vedeva spumeggiare
l’Oceano: una muraglia di granito formicolante di animali
antidiluviani, di bestie fantastiche, di mostri, ora accoppiati insieme a
due, a tre, a quattro, ora separati dal mare. Ma la nave affrettava
sempre più il passo e il sole declinava all’occaso; a poco a poco le
roccie, le isole, i mostri si confondevano e appiattivano in una
muraglia nera, nella quale non si discerneva più che a fatica la porta
della baia.... L’istante irrevocabile tra tutti stava per trapassare! Mi
volsi ancora una volta, per guardare a prua. L’orizzonte era soffuso
di un rosso chiaror vespertino; e verso quel chiarore traeva la nave,
con tutta la forza delle eliche, ma senza fretta, con passo eguale e
cadenzato, alzando ogni tanto la prua, come un cavallo che scuota il
capo al fastidio del morso. La nave ancora una volta aveva ritrovata
la via nel vasto piano delle acque e risolutamente drizzata la prua
verso il lontano destino; l’istante irrevocabile tra tutti — l’ultimissimo
— era passato; di tante cose vedute, godute, vissute, dell’America
insomma, non ci restava più che — pallido fantasma — il ricordo!

II.

— È la più bella città del mondo. Il modello delle città future. L’urbs
del ventesimo secolo....
Così diceva un’ora dopo, a pranzo, a mezzo di una animata
conversazione, l’avvocato Arnaldo Alverighi: e non parlando, come il
lettore potrebbe forse supporre, di Parigi o di Roma, ma di New-
York. La sala da pranzo del «Cordova» aveva tre ordini di mense:
una tavola lunga nel mezzo, a capo della quale sedeva il capitano;
cinque tavole piccole a destra e cinque a sinistra, ciascuna capace
di cinque persone. Alla tavola di mezzo, dove il comandante mi
aveva assegnato il secondo posto alla sua sinistra — il primo era
riserbato alla Gina, che era rimasta sul ponte — io mi ero, quella
sera, ritrovato con parecchi amici del Brasile e dell’Argentina: a
destra del capitano, al primo posto, l’ammiraglio José Maria
Guimaraês, un vecchio asciutto e arzillo, sui sessantacinque anni,
che il governo brasiliano mandava in Europa a comprar navi e
cannoni; al terzo posto — il secondo era vuoto — un diplomatico e
letterato pur esso brasiliano, il quale però portava un bel nome
fiorentino di conio antico, molto diffuso nel Brasile, Cavalcanti:
accanto a lui l’ingegnere Emilio Rosetti, e infine, dalla mia stessa
parte, al quarto posto (il terzo era riservato al nostro figlio che allora
già era a letto) l’avvocato Arnaldo Alverighi. Il Rosetti, che tornava
da Buenos-Aires, era un mio vecchio e carissimo amico di Milano:
l’Alverighi, l’avevo conosciuto a Rosario: il Guimaraês e il Cavalcanti
a Rio. Avevo quindi presentato, dopo i primi convenevoli, il Rosetti e
l’Alverighi, che venivano da Buenos-Aires, ai due brasiliani che si
erano imbarcati con me, poche ore prima, a Rio: ovvia cortesia, ma il
cui effetto fu che ben presto tutti e quattro — anzi tutti e cinque, il
capitano compreso — mi furono addosso per farmi ricominciare a
ritroso con i discorsi il lungo viaggio allora allora finito. Me lo
aspettavo, del resto! Avevamo dunque ragionato un po’ del Brasile,
dell’Uruguay, dell’Argentina; poi eravamo trapassati nell’altro
emisfero; e tutti allora a interrogarmi ancora più curiosi. Avevo io
vedute quelle favolose ricchezze del Settentrione? Quelle città
smisurate? Quella indescrivibile vertigine di opere? Quei Titani, quei
Semidei, quei Demoni del commercio, della banca, dell’industria?
Sinchè eravamo venuti con il discorso alla metropoli americana che
l’Alverighi, il Cavalcanti, l’ammiraglio e il Rosetti avevano tutti
visitata. Ma qui presto una fierissima disputa si era accesa tra
l’Alverighi che l’ammirava o gli altri tre che ne ridevano; avevamo
discusso per un po’ in tumulto se New-York era una città bella o
brutta; quando l’Alverighi, alla fine, aveva a un tratto,
perentoriamente, quasi a sfida, proclamata New-York bellissima tra
le città moderne!
— Ci siamo! — pensai. — Chi sa quale indiavolata baruffa mi
scatena ora, quel benedetto avvocato!
Io solo quindi, che lo conoscevo, non mossi ciglio e non dubitai che
dicesse sul serio: degli altri invece, il Rosetti si volse a me
sorridendo: l’ammiraglio squadrò lo strano interlocutore come per
leggergli sulla faccia se intendeva scherzare: il capitano, piegandosi
verso di me, mormorò a mezza voce: «Non le pare un po’ troppo?»:
ma incerti tutti se l’avvocato dicesse o no sul serio, nessuno rispose.
L’Alverighi però non li lasciò a lungo nel dubbio.
— Un europeo — egli disse, — non può capire New-York. New-York
è l’intestino dell’America che digerisce le immondizie di tutta la terra,
i rifiuti dell’universo: e di quelli fa un sangue purissimo, che nutre un
continente....
Ed entrato in questo intestino per la bocca della metafora, chi sa per
qual via ne sarebbe uscito, se le braccia nude, le spalle ravvolte in
un velo celeste, i cui lembi le svolazzavano ai fianchi, sfolgorante in
una sfarzosa veste azzurra di gala, come venisse a un pranzo di
cerimonia, non fosse comparsa a questo punto sulla porta una
signora. Il capo dei camerieri accorse a lei e le fu guida fino al posto
che tra l’ammiraglio e il Cavalcanti era vuoto: l’ammiraglio e il
Cavalcanti si levarono in piedi, per ossequiarla, e la fecero sedere:
ma la sala, una modesta sala dove poche signore pranzavano
indossando le vesti della giornata, e che non si aspettava nè quel
lusso nè quelle braccia nude, sbalordita smise tutta di pranzare e di
discorrere, per rimirarla. Era giovane ancora — trentacinque anni le
avrei dati, così a occhio — e in un piccolo viso ovale aveva degli
occhi dorati e ridenti, una bella fronte candida, delle sopraciglia nere
e sottili, un piccolo naso profilato e una piccola bocca rossa e fresca.
Intanto essa, in cospetto della sala ammutolita e senza sentire il
silenzio in cui l’aveva piombata, buttava a tergo il velo mostrando
dopo le braccia le spalle nude e un magnifico vezzo di perle: poi il
busto e la testa erette, appoggiata ai bracciuoli della poltrona,
aspettando di esser servita, fece un cenno del capo e un sorrisetto a
ognuno di noi a mano a mano che l’ammiraglio la presentava,
mormorando un nome che non intesi: infine, questa cerimonia
compiuta, prese a sorbire il brodo servitole dal cameriere, con la
fretta di chi giunge affamato a mezzo del pranzo.
Il pranzo era stato sospeso per un istante. Ma ecco i camerieri
accorsero con la terza portata: coltelli e forchette a poco a poco
tinnirono di nuovo sui piatti; occhi e discorsi, per un istante sviati,
ripigliarono la via dei loro oggetti consueti. Al nostro tavolo non
l’Alverighi, messo un po’ in soggezione dalla bella sconosciuta, ma
l’ammiraglio, che certamente la conosceva, ricominciò la
conversazione. Parlando per la prima volta in francese (avevamo fin
allora adoperato l’italiano, che i due brasiliani parlavano benissimo)
con un certo fare malizioso e un accorto sorriso:
— Sa di che cosa stavamo ragionando, signora? — le disse. —
Indovini! Di New-York. E il signore, — accennò l’Alverighi, ciò
dicendo, — ci dimostrava che New-York è la più bella città del
mondo! Sicuro: del mondo!
— New-York? — esclamò, riavuta dal primo stupore, la signora, —
New-York?
E scoppiò in una risata squillante.
Sbirciai l’Alverighi con la coda dell’occhio: si rannuvolava! Ma
l’ammiraglio continuò a far l’ingenuo.
— Dunque, lei, che ci vive da tanti anni, non è di questo parere?
— Ma ammiraglio, — protestò allora la signora tirandosi il velo sul
collo, — lei sa che io ho orrore di tutte le cose che mancano
d’armonia e di proporzione.
Ma l’Alverighi afferrò al volo queste parole e:
— Sicuro, — ripose. — A New-York voi trovate la Babele
dell’architettura. L’Asia e l’Europa, il paganesimo e il cristianesimo,
trenta secoli scomposti nei loro elementi e ricomposti a capriccio da
un genio bislacco, ironico, folle, sublime. E proprio per questa
ragione io adoro New-York. L’armonia e la proporzione sono
l’estetica delle civiltà decrepite. La vita è scabra, ruvida, ineguale,
violenta, come New-York. L’europeo non ci si raccapezza, in quella
nebulosa incandescente; è naturale, perchè arriva da un pianeta
spento; e si domanda, sgomento: ma dove sono? In Grecia? a
Parigi? a Norimberga, a Bagdad, al principio del ventesimo secolo,
al tempo dei Normanni, sotto lo scettro dei Faraoni? In una città vera
o in una città astrale, edificata nel pianeta Marte o in un altro
pianeta, da esseri conformati diversamente, più intelligenti e
possenti?
Forse troppo occupata in quel momento a sorvegliare la scollatura
dell’abito, la signora non rispose. Sottentrò il Cavalcanti. Che
l’avvocato dicesse sul serio nessuno poteva più dubitare: ma non
era questa ragione bastevole perchè nessuno dei suoi ascoltatori
non sentisse la voglia di volgere la sua tesi in ischerzo. Mi parve
infatti che il Cavalcanti volesse stuzzicare un po’ l’estro paradossale
del suo interlocutore con insidiose domande.
— Dunque — egli disse — l’armonia e la proporzione sono l’estetica
dei popoli decrepiti. Che cosa pensa lei, allora, della tragedia greca?
— Buona per il teatro dei burattini — rispose pronto, senza esitare
un attimo, l’Alverighi.
— Ah! — esclamò il Cavalcanti come chi è percosso in pieno petto:
nè disse altro. Poi, dopo un istante, soggiunse: — E la scultura
greca?
— E la scultura greca? — gridò l’Alverighi riscaldandosi
all’improvviso. — Quello sì che è un bel caso, per Dio! Basta visitare
un museo e non essere un professore di archeologia, per capire che
la scultura greca è un’arte sensuale, fiorita in un tempo in cui una
bella donna o un bell’uomo erano rari come le mosche bianche.
— Ma io credevo — obbiettò la signora — che i Greci non avessero
sotto occhio che corpi bellissimi... Che così educarono il gusto!
— Se ci fosse stata abbondanza di belle donne in carne ed ossa, —
replicò l’avvocato — i Greci non ne avrebbero fabbricate tante di
marmo. No: quella è un’arte sensuale.
E non so se per riguardo alla signora o per poter esprimere il suo
pensiero con minore fatica, continuò in italiano:
— Ma nossignori: a un certo momento, dei professori, degli
archeologi, dei filosofi tedeschi si sentono presi anch’essi da una
matta voglia di ammirar quelle appetitose nudità: ma come si fa,