Saudi Board General Surgery Final Written Exam (SCFHS)

A 45-year-old male is initiated on total parenteral nutrition (TPN) after a prolonged period of starvation due to severe small bowel obstruction. On day 3 of TPN, he develops muscle weakness, cardiac arrhythmias, and confusion. Laboratory studies reveal a serum phosphorus of 1.2 mg/dL. Which of the following is the most appropriate next step in management?

• AIncrease the TPN infusion rate to deliver more calories
• BAdminister aggressive intravenous phosphate replacement and reduce caloric intake
• CAdminister intravenous insulin to correct hyperglycemia
• DDiscontinue TPN immediately and start clear liquid diet

A patient undergoing an elective laparoscopic cholecystectomy is scheduled for incision at 09:00. At what time should the prophylactic dose of cefazolin be administered to ensure maximum tissue concentrations?

• AAt 07:00 (2 hours before incision)
• BBetween 08:00 and 09:00 (within 60 minutes before incision)
• CImmediately after the skin incision is made
• DUpon arrival in the post-anesthesia care unit (PACU)

Six hours after receiving a transfusion of packed red blood cells, a 62-year-old female develops acute dyspnea, hypoxemia (SpO2 85%), and fever. Chest radiograph shows bilateral pulmonary infiltrates. Her pulmonary capillary wedge pressure (PCWP) is normal, and there are no signs of jugular venous distention or peripheral edema. Which of the following is the most likely diagnosis?

• ATransfusion-Associated Circulatory Overload (TACO)
• BTransfusion-Related Acute Lung Injury (TRALI)
• CHemolytic Transfusion Reaction
• DAnaphylactic Transfusion Reaction

A 55-year-old postoperative patient who has been receiving prophylactic unfractionated heparin develops a sudden drop in platelet count from 250,000 to 90,000/microL on postoperative day 7, accompanied by a new cold, painful left leg. What is the most appropriate next step in management?

• ADiscontinue heparin and start a low-molecular-weight heparin (LMWH) infusion
• BDiscontinue heparin and initiate a direct thrombin inhibitor (e.g., argatroban)
• CTransfuse platelets immediately and repeat the platelet count in 2 hours
• DDiscontinue heparin and start oral warfarin immediately

Which of the following physiological changes is most commonly observed as a direct result of establishing carbon dioxide pneumoperitoneum during laparoscopic surgery?

• AIncreased cardiac output and decreased systemic vascular resistance (SVR)
• BDecreased cardiac output, increased systemic vascular resistance (SVR), and decreased ren…
• CDecreased peak airway pressure and increased venous return
• DRespiratory alkalosis due to passive hyperventilation

During a local block for an inguinal hernia repair under local anesthesia and sedation, the patient suddenly develops perioral numbness, metallic taste, visual disturbances, and muscle twitching. What is the most appropriate first-line rescue therapy for this condition if it progresses to cardiovascular collapse?

• AIntravenous lidocaine bolus
• BIntravenous dantrolene sodium
• CIntravenous 20% lipid emulsion therapy
• DIntravenous amiodarone

A postoperative patient with a history of chronic mesenteric ischemia develops severe abdominal pain out of proportion to physical examination. Arterial blood gas shows a pH of 7.22, pCO2 of 28 mmHg, and HCO3 of 12 mEq/L. The serum lactate is 6.5 mmol/L. What is the primary acid-base disturbance?

• ANormal anion gap metabolic acidosis
• BHigh anion gap metabolic acidosis
• CRespiratory acidosis with metabolic compensation
• DMixed metabolic acidosis and respiratory acidosis

A patient develops a surgical site infection (SSI) on postoperative day 10. The infection involves the subcutaneous tissue but does not extend into the fascial layer or muscle. How is this SSI classified?

• ASuperficial incisional SSI
• BDeep incisional SSI
• COrgan/Space SSI
• DMucocutaneous SSI

A 72-year-old male is scheduled for an elective ventral hernia repair. He has a history of stable angina and managed hypertension. According to the Revised Cardiac Risk Index (RCRI), which of the following variables is considered a predictor of major perioperative cardiac complications?

• AAge greater than 65 years
• BHistory of ischemic heart disease
• CHistory of essential hypertension
• DObesity (BMI > 30 kg/m2)

A patient in the intensive care unit is diagnosed with septic shock. Despite receiving a 30 mL/kg crystalloid fluid bolus, the patient remains hypotensive with a mean arterial pressure (MAP) of 52 mmHg. What is the recommended first-line vasopressor of choice according to the Surviving Sepsis Campaign guidelines?

• ADopamine
• BEpinephrine
• CNorepinephrine
• DVasopressin

During which phase of wound healing does collagen deposition reach its peak, and which collagen type is primarily deposited initially before being replaced?

• AInflammatory phase; Collagen type I replaced by type III
• BProliferative phase; Collagen type III replaced by type I
• CRemodeling phase; Collagen type II replaced by type I
• DProliferative phase; Collagen type I replaced by type II

Shortly after induction of anesthesia with succinylcholine and sevoflurane for an emergency laparotomy, a 28-year-old male develops masseter muscle rigidity, generalized hyperthermia (temp 40.2 C), tachycardia, and severe mixed respiratory-metabolic acidosis. What is the pathophysiological mechanism of this condition?

• AUncontrolled release of calcium from the sarcoplasmic reticulum due to ryanodine receptor…
• BAutoimmune destruction of acetylcholine receptors at the neuromuscular junction
• CInadequate dopamine levels in the basal ganglia
• DExcessive serotonin activity in the central nervous system

A trauma patient is undergoing massive transfusion. The surgeon requests a Thromboelastography (TEG) to guide resuscitation. The TEG result shows a prolonged R-time (reaction time). Which of the following is the most appropriate blood product to transfuse based on this specific TEG abnormality?

• APlatelets
• BFresh Frozen Plasma (FFP)
• CCryoprecipitate
• DPacked Red Blood Cells (PRBCs)

A critically ill postoperative patient has a functioning gastrointestinal tract but is unable to take oral nutrition. Why is enteral nutrition (EN) consistently preferred over parenteral nutrition (PN) in this patient?

• APN is associated with a higher risk of acute renal failure
• BEN maintains the mucosal barrier integrity of the gut, preventing bacterial translocation
• CPN does not allow adequate delivery of lipid emulsions
• DEN is associated with a lower rate of aspiration pneumonia

A neurosurgical patient develops hyponatremia (serum sodium 124 mEq/L) on postoperative day 3. Further workup reveals high urine sodium (65 mEq/L), high urine osmolality (450 mOsm/kg), and a clinical assessment of hypovolemia. Which of the following is the most likely diagnosis?

• ASyndrome of Inappropriate Antidiuretic Hormone (SIADH)
• BCerebral Salt Wasting (CSW)
• CDiabetes Insipidus (DI)
• DPsychogenic Polydipsia

A 65-year-old female on long-term prednisone therapy for rheumatoid arthritis undergoes a low anterior resection. On postoperative day 1, she becomes hypotensive (BP 80/40 mmHg) and tachycardic, refractory to aggressive fluid boluses. Lab values show sodium 130 mEq/L and potassium 5.2 mEq/L. What is the most appropriate next step in management?

• AAdminister a continuous infusion of norepinephrine
• BAdminister a bolus of 4 mEq of potassium chloride
• CAdminister intravenous hydrocortisone (100 mg)
• DPerform an emergency bedside laparotomy for suspected bleeding

During a laparoscopic ventral hernia repair, the anesthesiologist reports a sudden, precipitous drop in end-tidal CO2 (ETCO2) from 38 to 15 mmHg, accompanied by severe hypotension, hypoxia, and a new 'mill-wheel' murmur on auscultation. What is the immediate management for this condition?

• AIncrease the insufflation pressure to 20 mmHg to tamponade any venous bleeding
• BPlace the patient in the left lateral decubitus and Trendelenburg position (Durant's mane…
• CAdminister a rapid fluid bolus and place the patient in the reverse Trendelenburg position
• DPerform emergency needle thoracostomy in the second intercostal space

A patient with acute kidney injury is found to have a serum potassium level of 6.8 mEq/L, and ECG shows peaked T waves and widened QRS complexes. Which of the following interventions should be administered first to stabilize the cardiac membrane?

• AIntravenous insulin and 50% dextrose
• BIntravenous calcium gluconate
• CSodium polystyrene sulfonate (Kayexalate) orally
• DNebulized albuterol

A 22-year-old male is brought to the emergency department unconscious with a gunshot wound to the abdomen. He is hypotensive (BP 70/40 mmHg) and requires emergency laparotomy. No family members are present, and the patient is unable to provide consent. What is the most appropriate course of action regarding surgical consent?

• ADelay the surgery until a legal surrogate can be located by social services
• BProceed with the surgery under the emergency exception rule without formal consent
• CObtain consent from the hospital administrator before proceeding to the OR
• DObtain verbal consent from two other patients in the emergency room as witnesses

According to the World Health Organization (WHO) Surgical Safety Checklist, which of the following tasks is performed during the 'Time Out' phase (immediately before skin incision)?

• AConfirm that the patient has verified their identity, surgical site, and procedure
• BConfirm that all team members have introduced themselves by name and role
• CReview the key concerns for recovery and management of the patient
• DConfirm the completion of the instrument, sponge, and needle counts

A 38-year-old female presents with progressive dysphagia to both solids and liquids, regurgitation of undigested food, and mild weight loss. A barium swallow reveals a dilated esophagus with a smooth tapering at the lower esophageal sphincter ('bird-beak' sign). What is the gold standard diagnostic test to confirm this condition?

• AEsophagogastroduodenoscopy (EGD)
• BHigh-resolution esophageal manometry
• C24-hour pH monitoring
• DCT scan of the chest and abdomen

A 52-year-old male with a history of long-standing GERD undergoes surveillance endoscopy. Biopsies of the distal esophagus reveal Barrett's esophagus with high-grade dysplasia. What is the most appropriate next step in management according to current guidelines?

• AAnnual endoscopic surveillance only
• BEndoscopic mucosal resection (EMR) followed by radiofrequency ablation (RFA)
• CIvor-Lewis esophagectomy
• DDouble-dose proton pump inhibitor (PPI) therapy and repeat endoscopy in 6 months

A 60-year-old male is diagnosed with biopsy-proven adenocarcinoma of the stomach. CT scan shows thickening of the gastric wall and perigastric lymphadenopathy without distant metastasis. What is the standard surgical oncological recommendation regarding lymphadenectomy for this patient?

• AD1 lymphadenectomy (removal of perigastric lymph nodes only)
• BD2 lymphadenectomy (removal of perigastric and regional lymph nodes along main arterial t…
• CNo lymphadenectomy is required if margins are negative
• DPancreatectomy and splenectomy as part of standard lymph node clearance

A 48-year-old female undergoes resection of a 6-cm subepithelial gastric mass. Pathology reveals a Gastrointestinal Stromal Tumor (GIST) arising from the muscularis propria. Immunohistochemistry is positive for CD117 (c-KIT) and DOG1. Mitotic rate is 8 per 50 high-power fields. Which of the following statements regarding GIST is correct?

• AGISTs arise from epithelial cells and are highly sensitive to conventional chemotherapy
• BGISTs arise from the interstitial cells of Cajal, and adjuvant treatment with imatinib is…
• CWide lymph node dissection (D2) is mandatory due to high rates of lymphatic spread
• DRadiotherapy is the primary treatment for GISTs

A 35-year-old male presents with sudden onset of severe, generalized abdominal pain. Physical exam reveals a rigid, board-like abdomen with guarding. Upright chest radiograph shows free air under the diaphragm. During emergency laparotomy, a 1-cm perforation is identified on the anterior wall of the duodenal bulb. What is the most appropriate surgical management?

• ADistal gastrectomy and Billroth II reconstruction
• BPrimary closure of the perforation with an omental patch (Graham patch repair)
• CTrunk vagotomy and antrectomy
• DPrimary closure of the perforation with a loop duodenojejunostomy

A 55-year-old female presents with nausea, vomiting, abdominal distention, and obstipation. She has a history of prior open cholecystectomy. Abdominal radiograph shows dilated loops of small bowel with air-fluid levels and no colonic gas. Which of the following clinical signs or findings is the strongest indication for immediate surgical exploration?

• AFecalization of small bowel contents on CT scan
• BPresence of a transition point on CT scan
• CPersistent tachycardia, localized peritonitis, leukocytosis, and elevated serum lactate
• DHypokalemic hypochloremic metabolic alkalosis

A 28-year-old male with long-standing Crohn's disease presents with recurrent episodes of small bowel obstruction. CT enterography reveals three short-segment fibrotic strictures in the mid-jejunum, each measuring less than 4 cm in length. The rest of the small bowel is normal. What is the most appropriate surgical technique to address these strictures while preserving bowel length?

• AResection of the entire jejunum containing the strictures and primary anastomosis
• BStrictureplasty using the Heineke-Mikulicz technique
• CStrictureplasty using the Finney technique
• DBy-pass enterenterostomy around the strictured segment

A 32-year-old female with medically refractory ulcerative colitis is scheduled for surgery. She desires to avoid a permanent stoma and maintain fecal continence. What is the surgical procedure of choice for this patient?

• ATotal abdominal colectomy with end ileostomy
• BTotal proctocolectomy with permanent Brooke ileostomy
• CRestorative proctocolectomy with ileal pouch-anal anastomosis (IPAA)
• DSegmental colectomy and primary coloproctostomy

A 26-year-old pregnant female at 20 weeks gestation presents with a 24-hour history of right-sided abdominal pain, nausea, and low-grade fever. Physical exam reveals tenderness in the right upper quadrant. What is the most appropriate first-line diagnostic imaging modality to evaluate for suspected appendicitis in this patient?

• AContrast-enhanced CT scan of the abdomen and pelvis
• BAbdominal ultrasound
• CMagnetic Resonance Imaging (MRI) of the abdomen and pelvis
• DDiagnostic laparoscopy

A 62-year-old male is admitted with left lower quadrant pain, fever, and leukocytosis. A CT scan of the abdomen and pelvis reveals sigmoid diverticulitis with a 5-cm walled-off pelvic abscess, without free air or contrast extravasation. How is this classified according to the Hinchey staging system, and what is the most appropriate initial treatment?

• AHinchey Stage I; Outpatient oral antibiotics
• BHinchey Stage II; Intravenous antibiotics and percutaneous CT-guided drainage
• CHinchey Stage III; Emergent laparoscopic lavage
• DHinchey Stage IV; Emergent Hartmann's procedure

A 65-year-old male is diagnosed with moderately differentiated adenocarcinoma of the sigmoid colon. Workup shows no distant metastases. What is the standard recommended screening age to start colonoscopy for average-risk individuals according to updated 2026 guidelines, and what is the primary surveillance marker used after resection?

• AStart screening at age 50; surveillance marker is CA 19-9
• BStart screening at age 45; surveillance marker is Carcinoembryonic Antigen (CEA)
• CStart screening at age 40; surveillance marker is Alpha-Fetoprotein (AFP)
• DStart screening at age 55; surveillance marker is CEA

A 58-year-old male is diagnosed with biopsy-proven adenocarcinoma of the mid-rectum, located 7 cm from the anal verge. Staging MRI reveals a T3N1Mx tumor. What is the standard recommended treatment sequence according to NCCN guidelines?

• AUpfront Total Mesorectal Excision (TME) followed by adjuvant chemotherapy
• BNeoadjuvant chemoradiation (or total neoadjuvant therapy - TNT) followed by TME
• CDefinitive chemoradiation alone with watch-and-wait approach for all patients
• DTME followed by postoperative radiation therapy only

A 19-year-old male undergoes a screening colonoscopy due to a family history of colon cancer. The endoscopist finds more than 500 adenomatous polyps scattered throughout the colon and rectum. Genetic testing confirms a mutation in the APC gene. What is the most appropriate long-term management for this patient?

• ARepeat colonoscopy and polypectomy every 6 months
• BProphylactic total proctocolectomy
• CStart daily NSAIDs and monitor with annual colonoscopy
• DSegmental colectomy of the most densely affected area

During a Lichtenstein inguinal hernia repair under local anesthesia, the surgeon identifies a hernia sac protruding medial to the inferior epigastric vessels, within Hesselbach's triangle. What type of hernia is this, and what are the boundaries of Hesselbach's triangle?

• AIndirect inguinal hernia; bounded by inguinal ligament, rectus sheath, and inferior epiga…
• BDirect inguinal hernia; bounded by inguinal ligament (inferiorly), lateral border of rect…
• CFemoral hernia; bounded by Cooper's ligament, femoral vein, and lacunar ligament
• DDirect inguinal hernia; bounded by sartorius muscle, inguinal ligament, and adductor long…

A 55-year-old male with a large, recurrent incisional ventral hernia is scheduled for repair. The surgeon plans a posterior component separation. Which of the following describes the correct anatomic plane of dissection for a transversus abdominis release (TAR)?

• ADissection between the external and internal oblique muscles
• BIncising the posterior rectus sheath medially, dissecting laterally in the retrorectus pl…
• CDissection subcutaneous to the anterior rectus sheath
• DSplitting the rectus abdominis muscle vertically in the midline

A 70-year-old female presents with severe right upper quadrant pain, high fever (39.0 C), confusion, and hypotension (BP 85/50 mmHg). Labs reveal elevated bilirubin and leukocytosis. Right upper quadrant ultrasound shows a distended gallbladder with stones, gallbladder wall thickening (5 mm), and a sonographic Murphy's sign. According to the Tokyo Guidelines 2018 (TG18), what is the severity grade of her acute cholecystitis, and what is the most appropriate initial management?

• AGrade I (Mild); Early laparoscopic cholecystectomy
• BGrade II (Moderate); Delayed laparoscopic cholecystectomy after 6 weeks
• CGrade III (Severe); Urgent percutaneous cholecystostomy tube drainage and stabilization
• DGrade III (Severe); Immediate emergency open cholecystectomy

A 45-year-old female presents with epigastric pain radiating to the back. Labs show lipase > 3,000 U/L, total bilirubin 3.2 mg/dL, and alkaline phosphatase 280 U/L. Right upper quadrant ultrasound reveals cholelithiasis and a dilated common bile duct (8 mm). Over the next 24 hours, her abdominal pain resolves, and repeat total bilirubin drops to 1.1 mg/dL. What is the most appropriate management strategy?

• AUrgent Endoscopic Retrograde Cholangiopancreatography (ERCP) followed by outpatient chole…
• BLaparoscopic cholecystectomy with intraoperative cholangiogram during the same hospital a…
• CDischarge the patient with oral antibiotics and schedule cholecystectomy in 6 weeks
• DLong-term ursodeoxycholic acid therapy and lifestyle modification

A 42-year-old male with severe acute pancreatitis on day 14 of admission develops high fever, leukocytosis, and hemodynamic instability. A CT scan of the abdomen shows necrotizing pancreatitis with gas bubbles in the retroperitoneum. What is the standard recommended step-up approach for this patient?

• AImmediate emergency open necrosectomy
• BBroad-spectrum antibiotics followed by percutaneous or endoscopic drainage, reserving min…
• CRepeated CT scans every 48 hours and observation
• DEmergency distal pancreatectomy and splenectomy

A 62-year-old female presents with painless jaundice and weight loss. CT scan shows a 3-cm mass in the head of the pancreas causing dilation of the common bile duct and pancreatic duct ('double-duct' sign). There is no involvement of the celiac axis, hepatic artery, or superior mesenteric artery. Which of the following is the standard surgical procedure for this patient?

• ATotal pancreatectomy
• BDistal pancreatectomy and splenectomy
• CPancreaticoduodenectomy (Whipple procedure)
• DLaparoscopic cholecystojejunostomy and gastrojejunostomy

A 25-year-old male is scheduled to undergo an elective splenectomy for refractory Immune Thrombocytopenic Purpura (ITP). To minimize the risk of Overwhelming Post-Splenectomy Sepsis (OPSS), at what time should the patient receive vaccinations against encapsulated organisms?

• AOn the day of surgery, immediately prior to incision
• BAt least 14 days before the scheduled splenectomy
• COn postoperative day 1, before discharge
• DVaccinations are not required for patients under the age of 30

A 34-year-old male is brought to the emergency department after a motor vehicle crash. He is awake but tachypneic and complaining of severe chest pain. According to the Advanced Trauma Life Support (ATLS) guidelines, what is the correct first step in the primary survey?

• AObtain a portable chest radiograph
• BAssess the airway and protect the cervical spine
• CEstablish two large-bore intravenous lines
• DPerform a Focused Assessment with Sonography for Trauma (FAST) exam

A 28-year-old male presents with severe midface fractures, massive oral bleeding, and an inability to maintain his airway. Endotracheal intubation is attempted twice by an experienced anesthesiologist but fails due to blood obscuring the cords. The patient's oxygen saturation drops to 78%. What is the most appropriate next step in management?

• AAttempt a third intubation using a videolaryngoscope
• BInsert a laryngeal mask airway (LMA)
• CPerform an emergent surgical cricothyroidotomy
• DAdminister intravenous epinephrine and bag-valve-mask ventilate

A 45-year-old male is brought to the trauma bay after a gunshot wound to the thigh. He is confused, cold, and pale. Vital signs are: HR 135 bpm, BP 82/46 mmHg, and RR 32 breaths/min. Based on the ATLS classification of hemorrhagic shock, which class of shock is this patient experiencing?

• AClass I Shock
• BClass II Shock
• CClass III Shock
• DClass IV Shock

A trauma patient in hemorrhagic shock requires activation of the Massive Transfusion Protocol (MTP). What is the standard recommended ratio of blood products to transfuse, and what is the role of Tranexamic Acid (TXA) according to the CRASH-2 trial?

• ARatio of 4:1:1 (RBC:FFP:Platelets); TXA should be given within 6 hours of injury
• BRatio of 1:1:1 (RBC:FFP:Platelets); TXA should be administered within 3 hours of injury
• CRatio of 2:1:1 (RBC:FFP:Platelets); TXA is only indicated for head trauma
• DTransfuse only RBCs until the hematocrit is >30%, then add FFP; TXA is not recommended

A 22-year-old male is brought to the emergency department after a stabbing to the right chest. He is hypoxic, tachycardic, and hypotensive (BP 75/40 mmHg). On exam, he has absent breath sounds on the right side and tracheal deviation to the left. What is the immediate treatment for this condition?

• AObtain an emergent chest CT scan to locate the laceration
• BPerform immediate needle decompression in the fifth intercostal space (anterior axillary…
• CInsert a 36-French chest tube in the right hemithorax
• DPerform an emergency department thoracotomy

A 30-year-old male presents after a stab wound to the left parasternal area. He is pale and sweating. Vital signs are: HR 125 bpm, BP 85/55 mmHg. On exam, his neck veins are distended, and heart sounds are muffled. FAST exam shows a dark strip of fluid around the heart. What is this clinical triad called, and what is the immediate treatment?

• ACushing's triad; emergency burr hole
• BBeck's triad; emergent pericardiocentesis or surgical pericardial window
• CCharcot's triad; emergent ERCP
• DVirchow's triad; intravenous heparin

A 25-year-old male arrives at the emergency department by ambulance after sustaining a stab wound to the left chest. CPR is in progress. The paramedic reports that the patient lost pulses 5 minutes before arrival. What is the most appropriate indication for performing an Emergency Department Thoracotomy (EDT)?

• ALoss of vitals signs for more than 30 minutes after blunt trauma
• BPenetrating thoracic trauma with witnessed loss of vital signs in the ED or with short tr…
• CAny trauma patient arriving in cardiac arrest, regardless of mechanism or duration
• DTo perform coronary artery bypass grafting in the acute trauma setting