3 Free General Surgery Board Review Practice Questions
With the vast amount of knowledge that is potentially testable on the ABS Qualifying Exam (QE), it can be hard to see the forest through the trees. It’s important to take your time when studying. Don’t rush yourself. And get all the help you can by exploring the resources available to you. Below are 3 free general surgery practice questions from TrueLearn’s ABS Qualifying SmartBank to show you want you would get with a subscription.
First Free Board Review Practice Question
A 45-year-old man presents for evaluation of painless hematochezia for 4 weeks. There is blood on the toilet paper when he wipes, and sometimes he notices drops of blood in the toilet after a bowel movement. He also states that at times when he is straining to have a bowel movement, he feels something protrude from his anus, but it goes back in spontaneously. He believes he has hemorrhoids, and he has tried taking fiber supplements and using sitz baths at the recommendation of his primary care provider. On digital rectal examination, there are palpable internal hemorrhoids. He has no evidence of external hemorrhoidal disease. What is the most appropriate initial treatment to offer him?
- A. cryotherapy
- B. closed hemorrhoidectomy
- C. stapled hemorrhoidopexy
- D. rubber band ligation
- E. open hemorrhoidectomy
The Answer and Explanation
Did you get it right? The correct answer is: D
Rubber band ligation is an in-office procedure that is an excellent therapy for patients with internal hemorrhoids that remain symptomatic despite conservative measures.
Internal hemorrhoids are graded 1-4, based on the degree of prolapse. Grade 1 internal hemorrhoids do not prolapse. Grade 2 internal hemorrhoids prolapse through the anus but reduce spontaneously. Grade 3 hemorrhoids prolapse and must be manually reduced. Grade 4 hemorrhoids are unable to be reduced.
Grade 1 and 2 internal hemorrhoids often respond to conservative measures, such as increases in dietary fiber and modifications in toileting habits. Grade 1 and 2 hemorrhoids that remain symptomatic can be treated with in-office procedures such as rubber band ligation. Rubber band ligation is the most common in-office procedure for internal hemorrhoids in the United States. Operative procedures are generally reserved for patients who fail in-office treatment, have significant external hemorrhoids, or have advanced (grade 3 or 4) internal hemorrhoids. Cryotherapy is associated with significant complications and is not commonly employed.
Incorrect Answer Explanations
Answer A: Cryotherapy for hemorrhoids has been described but can be associated with anal stenosis and sphincter damage, so it is not commonly used.
Answer B: Closed (Ferguson) hemorrhoidectomy is a reasonable option for patients who have significant external hemorrhoidal disease in addition to internal hemorrhoids, or who have failed more conservative office-based technique.
Answer C: Stapled hemorrhoidopexy is a reasonable option for patients who have failed more conservative procedures, or have grade 3 or 4 internal hemorrhoids.
Answer E: Open (Milligan-Morgan) hemorrhoidectomy is a reasonable option for patients with significant external hemorrhoidal disease, grade 3 or 4 internal hemorrhoids, or those who have failed more conservative techniques.
Bottom Line
Rubber band ligation is an in-office procedure that is an excellent therapy for patients with internal hemorrhoids that remain symptomatic despite conservative measures.
For more information, see:
Singer MA. Hemorrhoids. In: Beck DE, ed. The ASCRS Manual of Colon and Rectal Surgery. 2nd ed. Springer; 2014:211-234.
Home and office treatment of symptomatic hemorrhoids: UpToDate
Second Free General Surgery Practice Question
A 58-year-old man with no known medical history presents to the emergency department with complaints of sudden onset, severe epigastric abdominal pain. He is hemodynamically stable but is noted on exam to have peritonitis. He is taken to the OR, where a 3-cm perforated duodenal ulcer is identified. There is extensive inflammation that limits the mobilization of the duodenum and the tissue is friable. Which of the following describes the most appropriate surgical technique for this patient?
- A. antrectomy with Billroth I reconstruction
- B. primary closure with omental patch buttress only
- C. placement of tube duodenostomy
- D. jejunal serosal patch, pyloric exclusion, and feeding jejunostomy without gastric decompression
- E. primary repair buttressed with omental patch followed by the triple tube technique with decompressive gastrostomy, decompressive retrograde jejunostomy, and antegrade feeding jejunostomy
The Answer and Explanation
Did you get it right? The correct answer is: E
Surgical options for perforated duodenal ulcers depend on the ulcer size, tissue quality, and patient condition at the time of operation. Giant perforations (> 2-3 cm) are particularly difficult to manage given the risk of a persistent leak. There are a number of described techniques for the management of giant perforated duodenal ulcers; however, the overall goals are control of the leak, re-establishment of GI continuity, and access to nutrition.
For ulcers adjacent to and proximal to the pylorus, an antrectomy +/- duodenal bulb resection may be considered. Although Billroth I reconstruction is generally preferred as it avoids the creation of a duodenal stump, it is often not feasible when significant inflammation prohibits adequate mobilization of the duodenum. In this setting, either Billroth II or Roux-en-Y reconstruction should be performed. However, the risk with these reconstructive options is a vulnerable duodenal stump, particularly in the setting of severe inflammation, which could cause the staple line to give out.
For giant ulcer perforations involving the distal first portion of the duodenum or the second portion of the duodenum, options include primary closure of the defect after debridement buttressed by an omental or falciform patch or if primary closure is not possible, an omental or falciform patch can be placed into the hole and secured with a double-arm suture placed into the plug and then inside-out in the duodenum in the vicinity of the perforation. Another option for large ulcers is the creation of a Thal (jejunal serosal) patch.
Regardless of which of the above repair techniques is used for a giant ulcer, the repair is typically tenuous at best and needs some sort of protection via bypass, exclusion, and/or drainage/decompression. These procedures are typically performed in conjunction with the above repair procedures. Pyloric exclusion involves closing the pylorus by nonabsorbable suture through a gastrotomy or via a linear stapler and creation of a loop gastrojejunostomy for GI continuity. The triple tube technique is another option to help protect a high-risk duodenal repair and involves placing a decompressive gastrostomy tube, a retrograde jejunostomy tube which is passed into the duodenum for decompression, and an antegrade feeding jejunostomy. Another option for a difficult large duodenal perforation is a Roux-en-Y duodenojejunostomy, which involves mobilizing a Roux limb and anastomosing it to the duodenal ulcer after debriding the ulcer edges. In this patient with a 3 cm perforated duodenal ulcer, primary repair with omental buttress should be used along with the triple tube technique to protect the repair.
In hemodynamically unstable patients, “damage control” options may involve the creation of a tube duodenostomy by placing a Malecot catheter through the perforation. Regardless of the surgical approach, definitive enteral access in the form of a jejunostomy tube +/- gastrostomy tube for decompression should be considered given the risk of an ongoing leak.
An omental (or Graham) patch closure. A tongue of healthy omentum is secured over the perforation with interrupted sutures.
A jejunal serosal (or Thal) patch closure. An initial gastrostomy incision (1) is made followed by pylorus closure (2) with non-absorbable sutures. (3) A loop of jejunum is secured over the duodenal perforation with interrupted seromuscular sutures and a gastrojejunostomy is created to drain the stomach.
Incorrect Answer Explanations
Answer A: Antrectomy may be considered if the ulcer is close to the pylorus; however, not all duodenal ulcers will be amenable to this approach. Billroth I reconstruction would not be feasible in this patient given the severe inflammation in the duodenum and inability to mobilize the duodenum. Attempting a Billroth I reconstruction in this patient would lead to a prohibitively high risk of leak. Therefore, a Billroth II or Roux-en-Y gastrojejunostomy would be required.
Answer B: Primary closure with an omental patch buttress alone would lead to a high risk of leak in a giant perforated duodenal ulcer without any type of protection or diversion for the repair.
Answer C: A tube duodenostomy could be used as a last resort but a persistent duodenal fistula would develop. This option is typically used in hemodynamically unstable patients who would not tolerate a prolonged operation. This patient is hemodynamically stable so other options should be attempted first.
Answer D: Jejunal serosal patch and pyloric exclusion would be an option for repair of a giant duodenal ulcer. However, pyloric exclusion leaves the GI tract in discontinuity, albeit temporarily, so a decompressive gastrojejunostomy, or at the least gastric decompression, would be necessary to prevent gastric distention and post-op vomiting.
Bottom Line
Omental patch alone may be inadequate in the setting of giant perforated duodenal ulcers. There are multiple surgical techniques available; however, the goal is control of leakage, re-establishment of gastrointestinal continuity, and nutritional access.
For more information, see:
Chapter 13: Management of Duodenal Ulcers. In: Cameron JL, Cameron AM, eds. Current Surgical Therapy. 15th ed. Elsevier; 2026:76-81.
Arshad SA, Murphy P, Gould JC. Management of perforated peptic ulcer: a review. JAMA Surg. 2025 Apr 1;160(4):450-454. doi: 10.1001/jamasurg.2024.6724
Rasslan S, Coimbra R, Rasslan R, Utiyama EM. Management of perforated peptic ulcer: What you need to know. J Trauma Acute Care Surg. 2025;99(1):1-9. doi: 10.1097/TA.0000000000004561
Clinch D, Damaskos D, Di Marzo F, Di Saverio S. Duodenal ulcer perforation: A systematic literature review and narrative description of surgical techniques used to treat large duodenal defects. J Trauma Acute Care Surg. 2021;91(4):748-758. doi: 10.1097/TA.0000000000003357
Third Free Practice Question
A 32-year-old man arrives after a high-speed motor vehicle collision. He is obtunded with a Glasgow Coma Scale of 6, making agonal respirations, and his airway is intermittently obstructed by blood that clears with suctioning. Breath sounds are equal, and pulses are weak. Vital signs: pulse rate 122/min, blood pressure 98/62 mm Hg, respiratory rate 8/min, SpO₂ 86% on a non-rebreather. His cervical spine is immobilized. While preparing for rapid sequence intubation, the team notes he has an active gag reflex, clenched jaw, and increasing secretions. They ask what the most appropriate immediate next step is before administering paralytics. Which of the following is the most appropriate next step?
- A. attempt nasotracheal intubation to avoid neck manipulation
- B. perform a jaw thrust and apply anterior mandibular displacement for improved airway position
- C. proceed directly with paralytics to facilitate rapid oral endotracheal intubation
- D. perform blind finger sweeps before rapid sequence intubation to clear secretions
- E. insert an oropharyngeal airway to improve patency
The Answer and Explanation
Did you get it right? The correct answer is: B
A jaw thrust with anterior mandibular displacement provides airway patency while maintaining cervical spine precautions. It helps relieve soft tissue obstruction, improves oxygenation, and prepares the airway for safe RSI (rapid sequence intubation). It is the standard initial action in ATLS for a trauma patient who cannot maintain their airway.
In trauma patients with neurologic impairment, ATLS emphasizes that airway obstruction must be corrected immediately while protecting the cervical spine. Prior to administering induction medications or paralytics for rapid sequence intubation, basic airway maneuvers should be used to optimize oxygenation and maintain patency. The jaw thrust with anterior mandibular displacement opens the airway without extending the neck and is the safest, most appropriate next step for this patient, who remains hypoxic, obstructed, and difficult to ventilate. Contraindicated or unsafe alternatives—such as blind sweeps, nasotracheal intubation, or inserting an oropharyngeal airway in a patient with a gag rFeflex—should not be used.
| Key Airway Maneuvers in Trauma | ||
| Action | Appropriate Use | Major Concerns |
| Jaw thrust | Opens airway while maintaining c-spine neutrality | Preferred maneuver in trauma |
| Mandibular displacement | Improves patency prior to rapid sequence intubation | Requires proper technique |
| Nasotracheal intubation | Limited use; must be spontaneously breathing | Contraindicated in trauma, facial injury, or low GCS |
| Oropharyngeal airway | Only for unconscious pts without gag reflex | Gag reflex → vomiting, aspiration, laryngospasm |
| Blind finger sweeps | Never appropriate | May worsen obstruction or cause injury |
The GCS is the most common scoring system used to describe the level of consciousness and neurologic dysfunction in a person following a traumatic brain injury. The test is simple, reliable, and correlates well with outcomes following severe brain injury. The GCS is an objective way of recording the initial and subsequent level of consciousness in a person after a brain injury.
The best motor score from either side is used. For example, if the score from the right side is 5 (localizes to stimuli, as in this patient), but 1 on the other side (no response to stimuli), the motor score is still M5. Patients with a GCS score of ≤ 8 requires intubation as they do not have enough level of consciousness to protect their airway. Airway being the first priority in Advance Trauma Life Support’s (ATLS) primary survey Airway, Breathing, Circulation (ABC), intubation should be the next step in this patient prior to anything else.
| Glasgow Coma Scale | |
| Response | Score and Scale |
| Eye Opening (E) | 4 = spontaneous3 = to voice2 = to pain1 = no eye-opening |
| Verbal Response (V) | 5 = normal conversation4 = disoriented conversation3 = words, but not coherent2 = no words, only sounds1 = none |
| Motor Response (M) | 6 = normal5 = localized to pain4 = withdraws to pain3 = decorticate posture (an abnormal posture that can include rigidity, clenched fists, legs held straight out, and arms bent inward toward the body with the wrists and fingers bent and held on the chest)2 = decerebrate (an abnormal posture that can include rigidity, arms and legs held straight out, toes pointed downward, head and neck arched backwards)1 = none |
Incorrect Answer Explanations
Answer A: Nasotracheal intubation requires a spontaneously breathing, cooperative patient, and it is contraindicated in trauma—particularly with altered mental status, blood in the airway, and potential facial injury. This patient needs a controlled, definitive airway via rapid sequence intubation, not a blind/indirect nasal route.
Answer C: Administering paralytics before correcting the airway obstruction or optimizing positioning risks creating a “can’t intubate, can’t ventilate” scenario. The patient already has poor oxygen saturation, secretions, and a clenched jaw; paralysis without preparation is unsafe.
Answer D: Blind sweeps are never recommended. They risk pushing debris deeper into the airway, causing soft tissue injury, or inducing vomiting. Suction and proper airway maneuvers are the correct initial approach.
Answer E: An oropharyngeal airway is only safe when the patient has no gag reflex. This patient does have an active gag reflex, making oropharyngeal airway insertion dangerous and likely to cause vomiting, aspiration, or laryngospasm. It is contraindicated.
Bottom Line
Before rapid sequence intubation in a trauma patient with airway obstruction and c-spine precautions, the jaw thrust with mandibular displacement is the safest and most appropriate immediate maneuver.
TrueLearn Insight
In practice, many of the components of ABCDE are done simultaneously in a systematic manner by the trauma team. However, you must know the order/priority, so that the practice of later components does not interfere with the earlier ones.
For more information, see:
Chapter 7: Trauma. In: Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Kao LS, Hunter JG, Matthews JB, Pollock RE, eds. Schwartz’s Principles of Surgery. 11th ed. McGraw-Hill; 2019:183-250.
Initial management of trauma in adults: UpToDate
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