These secrets are 100 of the top board alerts. They summarize the concepts, principles, and most salient details of surgical practice.

1. Clinical determinants of brain death are the loss of the
   papillary, corneal, oculovestibular, oculocephalic, oropharyngeal, and
   respiratory reflexes for > 6 hours. The patient should also undergo
   an apnea test, in which the pCO₂ is allowed to rise to at
   least 60 mmHg without coexistent hypoxia. The patient should be
   observed for the absence of spontaneous breathing.
2. The estimated risks of HBV, HCV, and HIV transmission by
   blood transfusion in the United States are 1 in 205,000 for HBV, 1 in
   1,935,000 for HCV, and 1 in 2,135,000 for HIV.
3. The most common location of an undescended testicle is the
   inguinal canal.
4. The most common solid renal mass in infancy is a congenital
   mesoblastic nephroma and in childhood a Wilms’ tumor.
5. Ogilvie’s syndrome is acute massive dilatation of the cecum
   and the ascending and transverse colon without organic obstruction.
6. The best screening method for prostate cancer is digital
   rectal exam combined with serum prostate-specific antigen.
7. The most common histologic type of bladder cancer is
   transitional cell carcinoma.
8. Carcinoma in situ of the bladder is treated with
   immunotherapy with intravesical bacillus Calmette-Guérin.
9. Localized renal cell carcinoma is treated with surgery
   (radical nephrectomy).
10. The most common cause of male infertility is varicocele.
11. The most common nonbacterial cause of pneumonia in
    transplant patients is cytomegalovirus.
12. Chimerism is leukocyte sharing between the graft and the
    recipient so that the graft becomes a genetic composite of both the
    donor and the recipient.
13. OKT3 is a mouse monoclonal antibody that binds to and
    blocks the T-cell CD3 receptor.
14. The most common disease requiring liver transplant is
    hepatitis C.
15. Cystic hygroma is a congenital malformation with a
    predilection for the neck. It is a benign lesion that usually presents
    as a soft mass in the lateral neck.
16. In neuroblastomas, age at presentation is the major
    prognostic factor. Children younger than 1 year have an overall
    survival rate > 70%, whereas the survival rate for children older
    than 1 year is < 35%.
17. The most feared complication of diaphragmatic hernia is
    persistent fetal circulation.
18. The three most common variants of tracheoesophageal fistula
    are (1) proximal esophageal atresia with distal tracheoesophageal
    fistula, (2) isolated esophageal atresia, and (3) tracheo-esophageal
    fistula with esophageal atresia.
19. Atresia can occur anywhere in the GI tract: duodenal (50%),
    jejunoileal (45%), or colonic (5%). Duodenal atresia arises from
    failure of recanalization during the 8th-10th week of gestation;
    jejunoileal and colonic atresia are caused by an in utero mesenteric
    vascular accident.
20. The types of aortic dissection are ascending (type A)
    dissection, which involves only the ascending or both the ascending and
    descending aorta, and descending dissection (type B), which involves
    only the descending aorta.
21. A solitary pulmonary nodule is < 3 cm and is discrete on
    chest radiograph. It is usually surrounded by lung parenchyma.
22. Mediastinal staging is indicated in patients with apparent
    or documented lung cancer who have (1) known lung cancer with
    mediastinal nodes > 1 cm accessible by cervical mediastinal
    exploration, as assessed by CT scan; (2) adenocarcinoma of the lung and
    multiple mediastinal lymph nodes < 1 cm; (3) central or large (>

    5 cm) lung cancers with mediastinal lymph nodes < 1 cm; and (4) lung
    cancer with risk of thoracotomy and lung resection.

23. The most common causes of aortic stenosis are now
    congenital anomalies and calcific (degenerative) disease.
24. In mitral regurgitation, the left ventricle ejects blood
    via two routes: (1) antegrade, through the aortic valve, or (2)
    retrograde, through the mitral valve. The amount of each stroke volume
    ejected retrograde into the left atrium is the regurgitant fraction. To
    compensate for the regurgitant fraction, the left ventricle must
    increase its total stroke volume. This ultimately produces volume
    overload of the left ventricle and leads to ventricular dysfunction.
25. The indications for CABG are (1) left main coronary artery
    stenosis; (2) three-vessel coronary artery disease (70% stenosis) with
    depressed left ventricular (LV) function or two-vessel coronary artery
    disease (CAD) with proximal left anterior descending (LAD) involvement;
    and (3) angina despite aggressive medical therapy.
26. Hibernating myocardium is improved by CABG. Myocardial
    hibernation refers to the reversible myocardial contractile function
    associated with a decrease in coronary flow in the setting of preserved
    myocardial viability. Some patients with global systolic dysfunction
    exhibit dramatic improvement in myocardial contractility after CABG.
27. The surgical treatment of ulcerative colitis is total
    colectomy with ileoanal pouch anastomosis.
28. Dieulafoy’s ulcer is a gastric vascular malformation with
    an exposed submucosal artery, usually within 2-5 cm of the
    gastroesophageal junction. It presents with painless hematemesis, often
    massive.
29. The role of blind subtotal colectomy in the management of
    massive lower gastrointestinal bleeding is limited to a small group of
    patients in whom a specific bleeding source cannot be identified. The
    procedure is associated with a 16% mortality rate.
30. Colorectal polyps < 2 cm have a 2% risk of containing
    cancer, 2 cm polyps have a 10% risk, and polyps > 2 cm have a cancer
    risk of 40%. Sixty percent of villous polyps are > 2 cm, and 77% of
    tubular polyps are < 1 cm at the time of discovery.
31. Patients with colorectal cancer with lymph node involvement
    (Dukes’ C) should receive chemotherapy postoperatively to treat
    micrometastases.
32. Goodsall’s rule states the location of the internal opening
    of an anorectal fistula is based on the position of the external
    opening. An external opening posterior to a line drawn transversely
    across the perineum originates from an internal opening in the
    posterior midline. An external opening, anterior to this line,
    originates from the nearest anal crypt in a radial direction.
33. Incarcerated inguinal hernia: structures in the hernia sac
    still have a good blood supply but are stuck in the sac because of
    adhesions or a narrow neck of the hernia sac. Strangulated inguinal
    hernia: hernia structures have a compromised blood supply because of
    anatomic constriction at the neck of the hernia.
34. Chvostek’s sign is spasm of the facial muscles caused by
    tapping the facial nerve trunk. Trousseau’s sign is carpal spasm
    elicited by occlusion of the brachial artery for 3 minutes with a blood
    pressure cuff.
35. The two surgical options for Graves’ disease are subtotal
    thyroidectomy or near-total thyroidectomy.
36. The only biochemical test that is routinely needed to
    identify patients with unsuspected hyperthyroidism is serum
    thyroid-stimulating hormone concentration.
37. The surgically correctable causes of hypertension are
    renovascular hypertension, pheochromocytoma, Cushing’s syndrome,
    primary hyperaldosteronism, coarctation of the aorta, and unilateral
    renal parenchymal disease.
38. The “triple negative test” or “diagnostic triad” for
    diagnosing a palpable breast mass includes physical examination, breast
    imaging, and biopsy.
39. Chest wall radiation is indicated after mastectomy in
    patients with greater than 5 cm primary cancers, positive mastectomy
    margins, or more than four positive lymph nodes, all of which are
    associated with heightened locoregional recurrence rates.
40. Sentinel lymph nodes are the first stop for tumor cells
    metastasizing through lymphatics from the primary tumor.
41. The most common site of origin of subungual melanomas is
    the great toe. Amputation at or proximal to the metatarsal phalangeal
    joint and regional sentinel lymph node biopsy are advised by most
    authors.
42. Ramus marginalis mandibularis, the lowest branch of the
    nerve that innervates the depressor muscles of the lower lip, is the
    most commonly injured facial nerve branch during parotidectomy.
43. Waldeyer’s ring is the mucosa of the posterior oropharynx
    covering a bed of lymphatic tissue that aggregates to form the
    palatine, lingual, pharyngeal, and tubal tonsils. These structures form
    a ring around the pharyngeal wall. This may be the site of primary or
    metastatic tumor.
44. A patient in whom the head and neck examination is
    completely normal but FNA of a cervical node reveals squamous cancer
    should have examination of the mouth, pharynx, larynx, esophagus, and
    tracheobronchial tree under anesthesia (triple endoscopy). If nothing
    is seen, blind biopsy of the nasopharynx, tonsils, base of tongue, and
    pyriform sinuses should be done at the same sitting.
45. The microorganisms implicated in atherosclerosis include Chlamydia
    pneumoniae, Helicobacter pylori, streptococci, and Bacillus
    typhosus.
46. The cumulative 10-year amputation rate for claudication is
    10%.
47. The absolute reduction in risk of stroke is 6% over a
    5-year period in asymptomatic patients with > 60% stenosis who
    undergo carotid endarterectomy plus aspirin versus patients treated
    with aspirin alone (5.1% versus 11%).
48. Abdominal aortic aneurysm’s average expansion rate is 0.4
    cm/year.
49. Heparin binds to antithrombin III, rendering it more
    active.
50. The patient with suspected intermittent claudication should
    initially be evaluated by obtaining ankle brachial index or segmental
    limb pressures at rest.
51. Shock is suboptimal consumption of O₂ and
    excretion of CO₂ at the cellular level.
52. Nitric oxide is synthesized in vascular endothelial cells
    by constitutive nitric oxide synthase and inducible NOS, using arginine
    as the substrate.
53. Saliva has the hightest potassium concentration (20 mEq),
    followed by gastric secretions (10 mEq), then pancreatic and duodenal
    secretions (5 mEq).
54. Basal caloric expenditure = 25 kcal/kg/day with a
    requirement of approximately 1 g protein/kg/day.
55. 6.25 g of protein contains 1 g of nitrogen.
56. Dextrose has 3.4 kcal/g, protein 4 kcal/g, fat 9 kcal/g
    (20% lipid solution delivers 2 kcal/mL).
57. Maximal glucose infusion rates in parenteral formulas
    should not exceed 5 mg/kg/min.
58. Refeeding syndrome occurs in moderately to severely
    malnourished patients (e.g., chronic alcoholism or anorexia nervosa)
    who, upon presentation with a large nutrient load, develop clinically
    significant decreases in serum phosphorus, potassium, calcium, and
    magnesium levels. Hyperglycemia is common secondary to blunted insulin
    secretion. ATP production is mitigated, and the classic presentation is
    respiratory failure.
59. Glutamine is the most common amino acid found in muscle and
    plasma. Levels decrease after surgery and physiologic stress. Glutamine
    serves as a substrate for rapidly replicating cells (interestingly, it
    is also the number one metabolic substrate for neoplastic cells),
    maintains the integrity and function of the intestinal barrier, and
    protects against free radical damage by maintaing GSH levels. Glutamine
    is unstable in IV form unless linked as a dipeptide.
60. Fever is caused by activated macrophages that release
    interleukin-1, tumor necrosis factor, and interferon in response to
    bacteria and endotoxin. The result is a resetting of the hypothalamic
    thermoregulatory center.
61. Cardiac output = heart rate x stroke volume; normal CO is
    5-6 L/min.
62. SVR = [(MAP - CVP)/CO] x 80; normal SVR is 800-1200
    dyne.sec/cm^-5.
63. Hypovolemic shock: low CVP and PCWP, low CO and SVO₂,
    high SVR.
64. Cardiogenic shock: high CVP and PCWP, low CO and SVO₂,
    variable SVR.
65. Septic shock: low or normal CVP and PCWP, high CO
    initially, high SVO₂, low SVR.
66. Kehr’s sign is concurrent LUQ and left shoulder pain,
    indicating diaphragmatic irritation from a ruptured spleen or
    subdiaphragmatic abscess. Anatomically, the diaphragm and the back of
    the left shoulder enjoy parallel innervation.
67. Rebound tenderness implies peritoneal inflammation and
    irritation not simply abdominal tenderness.
68. The 5 Ws of post-operative fever are wound
    (infection), water (UTI), wind (atelectasis,
    pneumonia), walking (thrombophlebitis), and wonder
    drugs (drug fevers).
69. Cricothyroidotomy should not be performed in
    patients < 12 years old or any patient with suspected direct
    laryngeal trauma or tracheal disruption.
70. The radial (wrist) pulse estimates SBP > 80 mmHg;
    femoral (groin) pulse estimates SBP > 70 mmHg; and carotid (neck)
    pulse estimates SBP > 60 mmHg.
71. A general rule for crystalloid infusion to replace blood
    loss is a 3:1 ratio of isotonic crystalloid to blood.
72. Raccoon eyes (periorbital ecchymosis) and Battle’s sign
    (mastoid ecchymosis) are clinical indicators of basilar skull fracture.
73. CPP = MAP – ICP. Some debate exists on the minimum
    allowable CPP, but consensus indicates that a cerebral perfusion
    pressure of 50-70 mmHg is necessary.
74. Violation of the platysma defines a penetrating neck wound.
75. Tension pneumothorax is air accumulation in the pleural
    space eliciting increased intrathoracic pressure and resulting in a
    kinking of the SVC and IVC that compromises venous return to heart.
76. The most common site of thoracic aortic injury in blunt
    trauma is just distal to the take-off of the left subclavian artery.
77. The most common manifestation of blunt myocardial injury is
    arrhythmia.
78. Indications for thoracotomy in a stable patient with
    hemothorax include an immediate tube thoracostomy output of > 1500
    mL and ongoing bleeding of 250 mL/h for 4 consective hours.
79. Beck’s triad is hypotension, distended neck veins, and
    muffled heart sounds.
80. The hepatic artery supplies approximately 30% of blood flow
    to the liver while the portal vein supplies the remaining 70%. The
    oxygen delivery, however, is similar for both at 50%.
81. The Pringle maneuver is a manual occlusion of the
    hepatoduodenal ligament to interrupt blood flow to the liver.
82. Splenectomy significantly decreases IgM levels.
83. 90% of trauma fatalities due to pelvic fractures are due to
    venous bleeding and bone oozing; only 10% of fatal pelvic bleeding from
    blunt trauma is arterial (most common site is superior gluteal artery).
84. Intraperitoneal bladder rupture from blunt trauma:
    operative management; extraperitoneal rupture: observant management.
85. Pseudoaneurysm is a disruption of the arterial wall leading
    to a pulsatile hematoma contained by fibrous connective tissue (but not
    all three arterial wall layers, which defines a true aneurysm).
86. The earliest sign of lower extremity compartment syndrome
    is neurologic in the distribution of the peroneal nerve with numbness
    in the first dorsal webspace and weak dorsiflexion.
87. Posterior knee dislocations are associated with popliteal
    artery injuries and are an indication for angiography.
88. Management of suspected navicular fracture despite negative
    radiography is short-arm cast and repeat x-ray in 2 weeks; at high risk
    for avascular necrosis.
89. Parkland formula: lactated Ringer’s at 4 mL/kg x %TBSA
    (second- and third-degree only) of burn. Infuse 50% of volume in first
    8 hours and the remaining 50% over the subsequent 16 hours.
90. The metabolic rate peaks at 2.5 times the basal metabolic
    rate in severe burns > 50% TBSA.
91. Gallstones and alcohol abuse are the two main causes of
    acute pancreatitis.
92. Alcohol abuse accounts for 75% of cases of chronic
    pancreatitis.
93. Isolated gastric varices and hypersplenism indicate splenic
    vein thrombosis and are an indication for splenectomy.
94. The treatment for gallstone pancreatitis is cholecystectomy
    and intraoperative cholangiogram during the same hospital stay once the
    pancreatitis has subsided.
95. Proton pump inhibitors irreversibly inhibit the parietal
    cell hydrogen ion pump.
96. Definitive treatment of alkaline reflux gastritis after a
    Billroth II includes a Roux-en-Y gastro-jejunostomy from a 40-cm
    efferent jejunal limb.
97. Cushing’s ulcer is a stress ulcer found in critically ill
    patients with central nervous system injury. It is typically single and
    deep, with a tendency to perforate.
98. Curling’s ulcer is a stress ulcer found in critically ill
    patients with burn injuries.
99. Marginal ulcer is an ulcer found near the margin of
    gastroenteric anastomosis, usually on the small bowel side.
100. The most common cause of small bowel obstructions is
     adhesive disease; the second most common cause is hernias.