The recertifying exam is a written exam , you don't meet or talk to anybody.

It's a computer based exam held in specialized exam centers throughout the USA.

You will be assigned a cubical and a piece of paper and a pen, computer screen and a mouse, you cannot have anything else.

They have very strict rules on your movement in and out from and into the exam room.

There will be other people taking other exams, not necessarily medical exam (the one next to me was a police officer taking her own certifying exam and she seemed very unhappy...!).

The exam format is extremely simple, most questions start with a presentation/scenario and you have 4 possible answers from which you have to choose one ( the most appropriate, the next step, the most urgent, the most likely...etc), the exam starts directly with the first question and you have to click the answer and go to the next one.

You can flag any question and come back to it at the end.

You will have three sessions, each one is about 2 hours with ten minutes break in between, the time remaining and the number of questions remaining will be displayed on the screen at all times.

Any extra break you take (to go to the restroom...), out of your regular ten minutes break, will be taken out of your exam time.

There are no more pictures or X-rays in the recertifying exam.

Most of the questions are clinical scenarios asking you at the end about the best next step in management or the most common probable cause of the presentation...

Apparently, several groups of specialists have written the questions , then, they were put together, because there was some unusual repetition of some questions especially in areas crossing between specialties like abdominal right lower quadrant pain and trauma.

For an average surgeon, I think , he/she should start to prepare for the recertifying exam about two months in advance, 2 -3 hrs a day and on weekends, a book like this one should be read at least twice during this period...other references can be used depending on each surgeon particular strengths and weaknesses.

Samples of some of the information added to " Safe Answers" for the specific purpose of the recertifying exam preparation (In the book there are hundreds of such notes and presentations):

Breast lesions that can be diagnosed with mammogram with near certainty:

Calcified fibroadenoma.


Intra mammary lymph nodes.

Fat necrosis?

Indications for bariatric gastric restrictive surgery are:

Age 18-65, obesity more than 5 years.

More than 100 kg above IBW.

BMI (body mass index) which is the weight in kilograms divided by the height in meters, is more than 40 (or 35 with co morbidity).

There are two phases of dumping syndrome:

Early phase: hyperglycemia caused by the rapid transmission of carbohydrate into the intestinal track.

Late phase: hypoglycaemia caused by the hyperinsulinemia introduced by early phase causing vasomotor symptoms such as flushing... etc.

Initially rapid passage of high carbohydrate into the intestine increases osmotic pressure inside the intestine drawing fluids into it, causing hypotension but the absorption of this sudden high amount of carbohydrate will cause reactive sudden and sharp increase in the insulin secretion causing subsequently reactive hypoglycaemia. For its treatment, most dumping syndromes are treated medically by diet modification and Lomotil, when surgery is needed, reversing the pyloroplasty may be helpful (interpositioning of a reversed intestinal segment is very rarely needed).

MALTOMAS of the stomach: Most are symptomatic because of the intense H. Pylori inflammation associated with them and it is manifest by weight loss and epigastric pain upon eating and they should be considered lymphoma in situ of the gastric mucosa and treated by triple H. Pylori therapy with re-scoping the patient in 4-6 weeks and re-biopsying the lesion. (they may actually require limited local resection for diagnosis since a small biopsy many not be enough to differentiate them from invasive gastric lymphoma).

Mucocele of the appendix is really a dilated thin walled appendix filled with mucin with fibrotic obliteration of its orifice and is treated by appendectomy only (if mucocele ruptures, it will not lead to pseudomyxoma). Cystadenoma of the appendix is associated at times with ovarian cyst and is a benign neoplasm distinguish pathologically from mucocele but its importance arise from the fact that it is a precursor of cyst adenocarcinoma and if it ruptures it could in fact cause pseudomyxoma peritonei.

Factors associated with increased incidence of recurrence of Crohn's patients after surgery include:

Younger age at first surgery.

Perforation as the cause for the surgery.

Multiple sites involved.

Ileal disease (and not colon involvement as you may think).

All the above factors increase the virulence of Crohn's disease.

Recurrent pyogenic cholangitis or oriental cholangiohepatitis is a recurrent form of jaundice caused by ascending cholangitis by E. coli. in oriental patients and is usually associated with intra hepatic bile duct dilation and stricture with a propensity toward the left lobe. Cholecystectomy with Sphincterotomy is of help in these patients for unclear reason and is better than choledochojejunostomy or choledochoduodenostomy because all these choledocho-enterostomies can increase the chance of E. coli contamination in the biliary ducts. There is a slight increase in cholangiocarcinoma in these patients and some advanced cases may require actually hepatic resection or roux en y choledochojejunostomy.

The most common sarcoma in adults is MFH (malignant fibrous histiocytoma) and it is seen mostly in the extremities. Note that the presence of unilateral or bilateral mets in the lung from a sarcoma will not effect the prognosis as much as you would think, other factors such as the number of different metastases and disease free period are more important from the prognosis point of view.

Marjolin's ulcer is seen in burns, chronic inflammatory conditions such as osteomyelitis, fistula sites, etc, or radiation dermatitis. It could be develop squamous cell carcinoma which is very aggressive (50% of these patients have positive lymph nodes upon diagnosis of SCC). Treatment is wide local excision with regional lymph node dissection. Prognosis is poor, only 10% 5 years survival.

BRCA - 1 mutation: increases the risk for breast and ovarian cancer, advice this patient of early childbearing so bilateral oophorectomy can be performed early in life to avoid ovarian cancer and consider also bilateral mastectomy or at least discuss with the patient or consider placing the patient on Tamoxifen (under study), these patients should undergo annual mammogram and have their serum CA-125 tested every 6 months.

Whenever you are presented with an incidental finding of an adrenal mass on a CT scan of the abdomen: order functionality tests and decide your next step based on size of the mass and symptoms and functionality of the tumor.
Adrenal mass in an asymptomatic patient less than 4 cm observe and follow by serial CT scan every 6 months.
Adrenal mass even if asymptomatic larger than 4 cm, the patient will require adrenalectomy. Rapid growth of an otherwise smaller mass i.e., more than 0.5 cm in 6 months would also indicate surgery. Getting the MRI adrenal mass/liver ratio would help a little bit in making decision. Fine needle aspiration is not diagnostic for adrenal mass and not indicated with the exception of confirming suspected metastasis to the adrenal.

Splenectomy is indicated in the following conditions:
AIDS patients with unexplained repeated infection/fever, ITP (70% response), splenic vein thrombosis, staging laparotomy, hemolytic spherocytosis (more than 90% response), hairy cell leukemia (not other type of leukemia). Remember that the primary treatment of TTP is plasmapheresis, if it fails then splenectomy is indicated.

Order of cells arrival in wound healing (PPMFL):
Platelets ==> PMNs ==> Macrophages ==> Fibroblast ==> Lymphocytes

Predominant cells type by days in wound healing:

Days 0-2 PMNs

Days 3-4 Macrophages

Days 5 onwards Fibroblast

Cystosarcoma phyllodes: (You can consider it a large fibroadenoma) usually presents as a solitary large mass (bigger than 5 cm) in a 40-50 year old ladies. A wide local excision with 1-2cm margin should suffice unless it is clinically malignant and seems to be invading surrounding tissue (in 10-20% of the cases a total mastectomy should be done without lymph nodes dissection). Chemotherapy with doxorubicin and ifosfamide is added to patients with greater than 5 cm tumors and evidence of stromal overgrowth. These tumors when malignant metastasize to the lung and recur locally. Remember that cystosarcoma phyllodes is one of the tumors that malignancy is decided mostly on a clinical basis during surgery by the finding of adjacent tissue infiltration (the other two tumors that have the same characteristics and their malignancy is also decided on a clinical basis are pheochromocytoma and malignant thymic tumors).

Adjuvant Chemotherapy and Hormonal Therapy in Breast Cancer

There are three factors that determine the need and the type of treatment post-operatively in breast cancer patients:

Pre or post menopausal status.

ER/PR receptors status (more than 5-10 F.M./mg protein is considered positive).

Axillary lymph node status is the most important prognostic factor (the number of lymph nodes involved has direct relation to long term prognosis).


The simplest and safest answer to the question of adjuvant therapy in breast cancer according to most recent studies is the following:

All pre-menopausal women with invasive breast cancer more than 0.5 cm in size should receive chemotherapy and tamoxifen regardless of their node status or ER/PR receptor status. The addition of Tamoxifen in ER positive patients is indicated , its benefits in ER negative patients have been also demonstrated in a large study and should be offered to the patient.

All post-menopausal women with invasive breast cancer should receive Tamoxifen. Chemotherapy is added to post-menopausal women with positive axillary lymph nodes or large primary tumor (i.e., bigger than 2cm).

Carcinoid in stomach


Hx: Family history of MEN I syndrome, heart problems, carcinoid syndrome symptoms.
Test: Octreotide scan for search of the lesions in the GI track and elsewhere. CT scan of the abdomen, 24-hours urine 5 HIAA, serum Gastrin and calcium (for possible MEN I).


Tumor less than 1 cm with elevated Gastrin and no atypical cells can be locally excised endoscopically or surgically.

Tumor bigger than 1 cm or associated with normal Gastrin level or have atypical cells will require gastrectomy and D1 dissection (a cancer operation).
(Gastric carcinoid patients with normal Gastrin level behave more aggressively and should be treated as such.)

Haggitt's classification of cancerous polyps include:

Stage I and II (cancer is limited to the polyp and can be treated locally).

stage III (cancer reaching the stalk - the junction - still can be treated locally only if it is well differentiated with no ulceration, no lymph-angio invasion, and no involved/enlarged lymph nodes).

stage IV need cancer operation.


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