A 65-year-old male presents with hepatocellular carcinoma in segment VIII of the liver. The surgical team is planning a right hemihepatectomy. Which of the following anatomical structures defines the plane of resection for a functional right hemihepatectomy?

• A line connecting the gallbladder fossa to the inferior vena cava

• The falciform ligament

• The main portal vein bifurcation

• The right hepatic vein

Answer explanation

Cantlie's line, which connects the gallbladder fossa to the inferior vena cava, defines the functional division between the right and left lobes, crucial for right hemihepatectomy.

A 48-year-old female undergoes a segmentectomy for a focal nodular hyperplasia in segment IV. Which major vascular structure forms the superior boundary of Couinaud's segment IV?

• Middle hepatic vein

• Left portal vein branch

• Right hepatic vein

• Inferior vena cava

Answer explanation

The middle hepatic vein runs within the main portal fissure and serves as the superior boundary for segments IV, V, and VIII, including segment IV.

A rural farmer presents with abdominal pain. Ultrasound shows a large liver cyst with daughter vesicles. What is the most likely infective agent?

• Echinococcus granulosus

• Schistosoma mansoni

• Entamoeba histolytica

• Fasciola hepatica

Answer explanation

The presence of a liver cyst with daughter vesicles (water lily sign, honeycombing) is characteristic of hydatid disease caused by Echinococcus granulosus.

A 35-year-old male is diagnosed with an amoebic liver abscess, measuring 6.5 cm, located in the subcapsular region of the left hepatic lobe. Despite 48 hours of high-dose intravenous metronidazole, his pain is worsening, and he develops localized peritonitis signs. What is the immediate surgical intervention indicated?

• Laparoscopic drainage of the abscess

• Open surgical débridement

• Exploratory laparotomy and liver biopsy

• Placement of a percutaneous biliary stent

Answer explanation

The subcapsular location, increasing size (relative to the initial threshold for drainage), worsening pain, and peritonitis signs suggest impending or actual rupture, necessitating urgent surgical drainage. Laparoscopic approach is often preferred.

A 70-year-old male with a history of recurrent cholangitis presents with severe sepsis. Imaging reveals a large common bile duct stone causing complete obstruction. He is deemed high-risk for ERCP due to comorbidities. Considering the immediate need for biliary decompression in this critically ill patient, what would be the most appropriate alternative surgical intervention?

• Open choledocholithotomy

• Laparoscopic common bile duct exploration

• Percutaneous transhepatic biliary drainage (PTBD)

• Urgent cholecystectomy

Answer explanation

For a critically ill patient with severe sepsis from obstructive cholangitis who is high-risk for ERCP, PTBD offers a less invasive method of immediate biliary decompression, which is crucial for stabilizing the patient before definitive stone removal.

During a laparoscopic cholecystectomy for symptomatic cholelithiasis, the surgeon encounters significant inflammation and scarring in Calot's triangle. To ensure patient safety and prevent iatrogenic injury, which of the following structures is most critical to definitively identify before clip application and division?

• Cystic artery

• Right hepatic artery

• Portal vein

• Gastroduodenal artery

Answer explanation

The cystic artery is located within Calot's triangle and supplies the gallbladder. Its definitive identification and secure ligation are crucial to prevent hemorrhage during and after cholecystectomy.

Following a difficult cholecystectomy, a patient develops persistent right upper quadrant pain, fever, and a rising bilirubin 7 days post-surgery. MRCP shows a partial transection of the common hepatic duct with an associated biloma. Which Strassberg classification best describes this injury?

• Type A

• Type B

• Type D

• Type E2

Answer explanation

A partial transection of the common hepatic duct with an associated biloma falls under the Strassberg Type E classification. Specifically, if the injury is within 2 cm of the hepatic hilum, it is Type E2.

What is a key distinguishing principle of the BCLC staging system for HCC compared to TNM staging?

• BCLC integrates tumor, liver function, and performance status to guide treatment.

• BCLC is for metastatic HCC only; TNM is for localized disease.

• BCLC relies heavily on AFP; TNM primarily uses imaging.

• BCLC is used for all liver cancers; TNM is HCC-specific.

Answer explanation

BCLC offers a comprehensive approach by integrating tumor burden (TNM), liver function (Child-Pugh), and patient performance status to link directly to treatment algorithms.

A 62-year-old male presents with a 3-week history of painless jaundice, pruritus, and significant weight loss. Physical examination reveals a palpable, non-tender gallbladder. Which of the following is the most likely diagnosis?

• Pancreatic adenocarcinoma

• Cholangiocarcinoma

• Ampullary carcinoma

• Cholecystitis

Answer explanation

Pancreatic adenocarcinoma, especially in the head of the pancreas, often presents with painless jaundice, weight loss, and a palpable gallbladder (Courvoisier’s sign) due to obstruction of the common bile duct.

A 52-year-old woman presents with a 4-month history of a painful, pruritic rash. The rash began in the groin and has now spread to her lower legs. Examination reveals erythematous plaques with central blistering, crusting, and superficial erosions. She was also recently diagnosed with type 2 diabetes mellitus and reports feeling unusually low in mood. Her HbA1c is 8.5%, and a complete blood count is normal. What is the most likely underlying diagnosis?

• Glucagonoma

• Acrodermatitis enteropathica

• Pemphigus foliaceus

• Pellagra

Answer explanation

The constellation of necrolytic migratory erythema (NME), new-onset diabetes, and depression forms the classic triad for a glucagon-secreting pancreatic neuroendocrine tumor.