General Surgery 1

Question 1

Inguinal Hernia

75% of abdominal wall hernias

1. How many patients will be male?
2. What clinical features are seen?
3. How do you differentiate between direct and indirect? (although does NOT effect management)
4. How is it managed?

Answer 1

1. 95%
2. • out pouching superior and lateral to pubic tubercle
   • discomfort and ache: worse on activity
3. after reduction, cover the deep inguinal ring and the patient coughing will result in the direct hernia returning
4. routine referral for surgical correction
   mesh inserted
   open repair if unilateral, laparotomy if bilateral or recurrence

Question 2

Femoral hernia

1. What is it?
2. What clinical features are seen?
3. Who are they more commonly seen in?
4. How is it managed?

Answer 2

1. herniation of bowel through femoral ring into the femoral canal

2.

• outpuching inferior + lateral to pubic tubercle
• possibly accompanied by pain
• often non-reducible

3. • women
   • multiparous
4. surgical repair
   higher urgency than inguinal hernia repair due to higher risk of complications of bowel ischaemia + obstruction (these would be surgical emergency)

Question 3

1. What clinical features will be seen in umbilical hernia?

2. How does this differ for paraumbilical hernia

Answer 3

1.

• often infants + children (more common in premature and afro-caribbean babies)
• symmetrical out pouching below the umbilicus

2. bulge will be asymmetrical

Question 4

Epigastric hernia

1. Where is the outpouching seen?
2. What are the risk factors for it?

Answer 4

1. on the midline between the xiphisternum and umbilicus
2. • chronic cough
   • extensive physical training
   • obesity

Question 5

Obturator hernia

1. What happens?
2. How does it typically present?
3. Who is it more common in?

Answer 5

1. bowel herniates through obturator foramen
2. with bowel obstruction
3. females

Question 6

Which rare hernia can often present with symptoms of strangulation but no symptoms of obstruction?

Answer 6

Richter hernia

where anti mesenteric border of bowel herniates through fascial defect

Question 7

Congenital Inguinal hernia

1. What is the likely presentation?
2. How is it managed?

Answer 7

1. indirect hernia in premature boy on right hand side

pathophysiology just to help remember: this is because of defect of closure of processus vaginalis. This is out pouching of peritoneum in embryology in which testes descend through canal into scrotum. Right descends after left and premature gives less time for this to close over

2. surgical repair (no mesh) soon after diagnosis due to risk of incarceration

Question 8

How should you manage the complete opening of an abdominal wound?

Answer 8

• cover with saline gauze
• IV broad spectrum antibiotics
• analgesia
• IV fluids
• arrange return to theatre

Question 9

Benign liver lesions

What clinical features are seen in the following?

1. haemangioma
2. liver cell adenoma
3. Liver abscess
4. Amoebic abscess
5. Hyatid cysts

Answer 9

1. • reddish/ purplish hypervascular lesions
   • contained within fibrous capsule
   • hyper echoic on US (more dense so more white)
2. • 90% women 20-50
   • COCP link
   • no fibrous capsule but sharply demarcated
   • heterogeneous texture
3. often preceded by biliary sepsis therefore has symptoms of RUQ pain, fever + jaundice
4. [needs added]
5. [needs added]

Question 10

Cryptorchidism

1. What is the definition of this?
2. How is this managed?

Answer 10

1. undescended testes after 3 months of age

2. orchidopexy 6-18 months of age
surgery to move the testes down to bottom of scrotum

Question 11

Spina bifida

1. What is it?
2. What are the types and their clinical features?

Answer 11

1. failure of the neural tube to close and non fusion of vertebral arches possibly allowing the spinal cord to push out the back
2. • myelomeningocele (worst): spinal cord and protective membranes push out through the back and form sac

• meningocele: protective membranes push out through the back
• occulta: 1 or more vertebrae do not form properly but gap very small
  (very common and most people do not know they have it: can be marked by birth mark or hair patch)

Question 12

Spondylolysis

1. What is it?
2. What can it cause?

Answer 12

1. deficiency of pars interarticularis of neural arch of a vertebral body (usually L4/5)
2. spondylolisthesis

Question 13

Spondylolisthesis

1. What is this?
2. What can cause it?
3. What will traumatic cases show?

Answer 13

1. when a vertebrae is displaced in comparison to its immediately inferior vertebral body
2. • stress fracture
   • spondylosis
3. “scotty dog” appearance on XR

Question 14

PEG tube

1. When can it be used?
2. When can it be removed?

Answer 14

1. 4 hrs after insertion

2. must be in for at least 2 weeks

Question 15

When is a patient identified as being malnourished?

Answer 15

BMI <18.5
>10% weight loss in 3-6 months
>5% weight loss in 3-6 months AND BMI <20

(I.e. low weight, high weight loss or a bit of both)

Question 16

What are the possible complications of enteral feeding?

Answer 16

diarrhoea (1 in 6)
aspiration
metabolic: hyperglycaemia, refeeding syndrome

refeeding syndrome:

• quick reintroduction of food leading to dangerously rapid electrolyte shift
• classically see hypophosphataemia

mnemonic: DAM we’ve had a complication

Question 17

Fistulas

1. They will often heal. When would this not be the case?
2. Enterocolic / enteroenteric fistulae can lead to bacterial overgrowth. What can this cause?
3. How should abdominal fistulae be managed?

Answer 17

1. • IBD
   • Distal obstruction
2. malabsorption syndromes
   (particularly serious in IBD)

3.

• protect overlying skin with fell fitted stoma
• if high volume being secreted (>500ml), consider ocreotide which reduces pancreatic secretions

Question 18

Fluid resuscitation in burns

1. When should fluid resuscitation be administered?
2. How is it managed?
3. When should fluid resuscitation be stopped?

Answer 18

1. burns to 15% of total body area (10% in children)
2. Parkland formula
   first 24 hrs (starting at time of injury): crystalloid fluid administered
   4 x burn surface area (%) x body weight (kg)
   ^ (deduct any fluids which have already been given from this)
   50% given in first 8 hrs
   50% given in following 16 hrs

After 24hrs:
colloid infusion - 0.5 x burn surface area (%) x body weight (kg)

crystalloid infusion - 1.5 x burn surface area (%) x body weight (kg)

3. urine output 0.5-1 ml/kg/hr

Question 19

What type of imaging is used:

1) to detect vesico-uretetric reflux
2) for renal patients with reduced GFR

Answer 19

1) micturating cystourethrogram

2) MAG 3 renogram

Question 20

Hiatus hernia

1. What is meant by
   a) sliding
   b) rolling (AKA paraoesophageal)
2. What are the risk factors for it?
3. What clinical features are seen?
4. What investigation is most sensitive?
5. How is it managed?

Answer 20

1a) gastroesophageal junction moves above diaphragm (95%)
b) gastroesophageal junction remains below diaphragm but separate part of stomach herniates through oesophageal hiatus

2. • obesity
   • increased intrabdominal pressure (e.g. multiparty)
3. • reflux
   • regurgitation
   • chest pain
   • dysphagia

(think about this in the order it would happen)

4. 
barium swallow (but often happens tom be diagnosed on endoscopy) 

5. conservatively e.g. weight loss
   PPIs
   surgical if rolling

Question 21

Hydatid Cysts

1. What causes them?
2. Where in the world are they very common?
3. What clinical features can be seen?

Answer 21

1. tapeworm parasite echinococcus granulosus
2. mediterranean and middle eastern countries
3. • cysts can occur in any organ but most commonly liver or lungs
   • cyst bursting causes type 1 allergic reaction
     e. g. biliary cyst rupture would cause biliary colic, jaundice + urticaria