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Surgery > General Surgery > Flashcards

General Surgery Flashcards

1
Q

What are the 3 clinical findings in an Abdominal Artery Aneurysm?

A

Hypotension
Retroperitoneal pain
Pulsatile abdominal mass

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2
Q

What is a Kocher incision used in?

A

Open cholecystectomy

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3
Q

What is a Chevron incision used in?

A

Upper GI surgery

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4
Q

What is a Mercedes Benz incision used in?

A

Liver transplant

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5
Q

Where is a battle incision made?

A

Paramedian incision for open appendicectomy

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6
Q

Where is a McBurney incision made?

A

Oblique incision for open appendicectomy

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7
Q

What is a Lanz incision and where is it made?

A

Transverse incision for open appendicectomy

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8
Q

What is a Rutherford Morrison incision for?

A

Open appendicectomy and colectomy

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9
Q

What is the difference between a Pfannenstiel Incision and a Joel-Cohen incision?

A

Pfannensiel incision is a curved incision 2 fingers width above pubic symphysis cf Joel-Cohen incision is a straight incision slightly higher (recommended)

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10
Q

What is the difference between monopolar and bipolar diathermy?

A

Monopolar diathermy uses an electrode at the probe and a grounding plate which allows a direct route for the current to pass out via the body to the grounding pad.

Bipolar diathermy involves an instrument with two electrodes thus current is kept locally, and not passed to the rest of the body

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11
Q

Which of the following is an absorbable suture material?

A. Polypropylene

B. Nylon

C. Silk

D. Monocryl

A

D

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12
Q

What does the WHO Surgical Safety Checklist comprise of?

A

Before induction of anaesthesia

Before skin incision

Before leaving theatre

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13
Q

A patient with an ASA I grade is…?

A

Normal, healthy

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14
Q

A patient with ASA III grade is?

A

Severe, systemic disease

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15
Q

A severe, systemic disease threatening life is which ASA grade?

A. IV

B. V

C. II

D. III

A

A

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16
Q

A patient who is in a permanent vegetative state and donating their organs is which ASA grade?

A. V

B. IV

C. VI

D. III

A

C

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17
Q

What investigations may be required prior to operation?

A

FBC
U+Es
HbA1C

PFTs

ABG
ECG
Echo
Clotting testing

G+S
Cross-matching

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18
Q

What is the difference between G+S and Crossmatching a sample?

A

Group and save is used when there is a low % of transfusion required. Blood taken, sample matched for blood transfusion. Blood is valid for a certain period of days.

Crossmatching involves taking blood, matching it and assigning it to a patient. This is done when there is a higher % of requiring the blood product.

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19
Q

How long should you fast before surgery?

A

6 hours for solids

2 hours for fluid

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20
Q

When are DOACs stopped prior to surgery?

A

24-72 hours

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21
Q

When should Oestrogen-containing contraception be stopped prior to surgery?

A. 2 weeks

B. 3 days

C. 4 weeks

D. 6 weeks

A

C

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22
Q

What do you do to a patients 10mg Prednisolone dose post-operatively?

A. Half it

B. Double it

C. Stop it

D. Give usual dose

A

B

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23
Q

What is the criteria for a patient to give capacity?

A

Understand the decision
Retain the information long enough to make the decision
Weigh up the pros and cons
Communicate their decision

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24
Q

What are the principles of enhanced recovery?

A

Aim to get patient back to pre-op condition ASAP

Preparation for surgery 
Minimally-invasive surgery
Adequate analgesia 
Good nutrition
Return to oral diet
Early mobilisation
Avoid drains and NG tubes
Early discharge
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25
Q

In which conditions may post-op NSAIDs be inappropriate?

A

Asthma
Renal impairment
Stomach ulcers
Heart disease

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26
Q

When is Post-Operative Nausea and Vomiting most common?

A

first 24 hours

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27
Q

Which of the following is not a risk factor for PONV?

A. Female

B. Smoker

C. Younger age

D. Use of opiates

A

B

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28
Q

Pressure at which bodily region may reduce nausea?

A

P6 acupuncture point on inner wrist

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29
Q

What is a common side effect of Total Parenteral Nutrition if given peripherally?

A

Thrombophlebitis

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30
Q

At which Hb should a transfusion be started?

A. <90g/L

B. <100g/L

C. <80g/L

D. <70g/L

A

What is the Hb criteria for commencement of iron?

D. <70g/L

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31
Q

What is the gold-standard investigation for appendicitis?

A

Diagnostic laparoscopy

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32
Q

What is the management of appendicitis?

A

A-E approach
+
Lap appendicectomy

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33
Q

What are the big 3 causes of bowel obstruction?

A

Adhesions

Hernias

Malignancy

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34
Q

what are the causes for a closed-loop obstruction?

A

Obstructing lesion(s) ± Competent IC valve

Adhesions
Hernia
Volvulus
Single point obstruction AND competent IC valve

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35
Q

What is the upper limit of normal bowel diameter in the colon?

A. 3cm

B. 6cm

C. 9cm

D. 7cm

A

B

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36
Q

What is the upper limit of normal bowel diameter in the small bowel?

A. 3cm

B. 6cm

C. 9cm

D. 7cm

A

A

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37
Q

What is the upper limit of normal bowel diameter in the caecum?

A. 3cm

B. 6cm

C. 9cm

D. 7cm

A

C

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38
Q

What is the first line management of a small bowel obstruction?

A. Stent

B. NG tube insertion

C. Exploratory surgery

D. Adhesiolysis

A

B

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39
Q

A patient has been in small bowel obstruction which has been refractory to conservative management. CT-Abdomen shows adhesions. How would this be managed

A. Stent

B. NG tube insertion

C. Exploratory surgery

D. Adhesiolysis

A

D

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40
Q

What are the two main types of volvulus?

A

Sigmoid

Caecal

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41
Q

What is the difference between a direct and indirect inguinal hernia?

A

Direct = Via Hesselbach’s Triangle, weak point

Indirect = via deep inguinal ring at patent processus vaginalis

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42
Q

In clinical examination, how may you tell the difference between a direct inguinal hernia and an indirect inguinal hernia?

A

When an indirect hernia is reduced and pressure is applied (with two fingertips) to the deep inguinal ring (at the mid-way point from the ASIS to the pubic tubercle), the hernia will remain reduced.

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43
Q

What are the borders of Hesselbach’s triangle?

A

Mnemonic: RIP

Rectus abdominus (medial)

Inferior epigastric vessels (superior)

Poupart’s ligament (inferior)

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44
Q

What are the borders of the femoral canal?

A

Mnemonic: FLIP

Femoral vein (lateral)

Lacunar ligament (medial)

Inguinal ligament (anterior)

Pectineal ligament (posterior)

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45
Q

What are the contents of the femoral triangle?

A

NAVY-C

Femoral nerve
Femoral artery
Femoral Vein 
Y fronts 
Femoral Canal
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46
Q

What are the borders of the femoral canal?

A

Mnemonic: FLIP

Femoral vein (lateral)

Lacunar ligament (medial)

Inguinal ligament (anterior)

Pectineal ligament (posterior)

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47
Q

What are the borders of the femoral triangle?

A

Mnemonic: SAIL

Sartorius (lateral border)

Adductor longus (medial border)

Inguinal Ligament (superior border)

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48
Q

What are the management options of a hernia?

A

Conservative

Tension-free (mesh)

Tension repair

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49
Q

What is a Richter’s hernia?

A

Only portion of the bowel wall and lumen herniate through the defect with the remainder remaining in the peritoneal cavity

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50
Q

What is a Maydl’s hernia?

A

Maydl’s hernia refers to a specific situation where two different loops of bowel are contained within the hernia.

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51
Q

Positive internal rotation of the thigh at the hip precipitates marked pain in a patient with an Obturator hernia?

A. Romberg Sign

B. Howship-Romberg Sign

C. Thomas Sign

D. Mossoah Sign

A

B

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52
Q

A hernia presenting lateral to the rectus abdominus muscle but within the linea semilunaris is called?

A

Spigelian Hernia

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53
Q

what is the definitive management of a Hiatus hernia?

A

Laparoscopic fundoplication (tying stomach around lower oesophagus to narrow cardiac sphincter)

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54
Q

Why should you check with the anaesthetist prior to insufflation?

A

insufflation may trigger systole due to Vagal feedback

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55
Q

A non-inflamed, white appendix may be described as?

A

Lily white appendix

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56
Q

What are the borders of Calot’s Triangle?

A

Inferior border of liver (superior)

Common hepatic duct (medial)

Cystic duct (lateral)

57
Q

Outline the importance of the critical view of safety in a laparoscopic cholecystectomy.

A

Allows identification of the cystic duct and artery

1) Hepatocystic (Calot) Triangle cleared of fat and fibrous tissue
2) Lower 1/3 of gallbladder separated from the liver
3) Only two structures seen entering the gallbladder

58
Q

What is the most common anatomical position of the appendix?

A

Retrocaecal (64%)

59
Q

Which of the following is not a risk factor for haemorrhoids?

A. Chronic coughing

B. Pregnancy

C. Obesity

D. Constipation

A

D

60
Q

How may you describe the position of a haemorrhoid?

A

Using clock face - if patient is in lithotomy position

61
Q

A haemorrhoid which has no prolapse is classified as?

A. 2nd degree

B. 1st degree

C. 3rd degree

D. 4th degree

A

B

62
Q

A haemorrhoid which prolapses on straining only is classified as?

A. 2nd degree

B. 1st degree

C. 3rd degree

D. 4th degree

A

A

63
Q

A haemorrhoid which prolapses on straining and does not return on relaxing but can be pushed back in is classified as?

A. 2nd degree

B. 1st degree

C. 3rd degree

D. 4th degree

A

C

64
Q

A haemorrhoid which is permanently prolapsed is classified as?

A. 2nd degree

B. 1st degree

C. 3rd degree

D. 4th degree

A

D

65
Q

What are the management options for a haemorrhoid?

A

Conservative: RF modification (increased fibre; fluids; laxatives); Anusol; Germoloids cream

Non-surgical: Rubber band ligation; Injection sclerotherapy; IR coagulation

Surgical: Haemorrhoidal artery ligation; Haemorrhoidectomy; Stapled haemorrhoidectomy

66
Q

What of the following is not a risk factor for diverticulosis?

A. Advanced ageing

B. Obesity

C. NSAIDs

D. Eastern Diet

A

D, it is a Western diet

67
Q

What are the complications of acute diverticulitis?

A

Perforation
Large haemorrhage requiring blood transfusions
Peritonitis
Peridiverticular abscess
Fistula (e.g., between the colon and the bladder or vagina)
Ileus / obstruction

68
Q

What are the branches of the abdominal aorta, perfusing the abdominal organs?

A

Coeliac Trunk (T12)

SMA (L1)

IMA (L3)

69
Q

what are the branches of the coeliac trunk?

A

L Gastric Art.

Splenic Art.

Common Hepatic Artery

70
Q

What are the branches of the SMA?

A

Right Colic Art.

Middle Colic Art.

Ileocolic Art.

Caecal Art.

Jejunal Art.

71
Q

What are the branches of the IMA?

A

Left Colic Art.

Sigmoid Art.

Middle Rectal Art.

72
Q

What are the clinical features of chronic mesenteric ischaemia?

A

This is angina of the gut…

Central abdominal pain: colicky; post-prandial 30mins-90mins

Weight loss: Anorexia

Abdominal bruit

73
Q

What is the gold-standard investigation for Mesenteric Ischaemia?

A

CT Angiography

74
Q

What is the gold-standard investigation for acute mesenteric ischaemia?

A

Contrast CT

75
Q

What biochemical markers may be deranged in acute mesenteric ischaemia?

A

Metabolic acidosis

Raised lactate

76
Q

Which of the following is not a risk factor for Bowel Cancer?

A. ∆MYC gene

B. Smoking

C. Eastern diet

D. Family history of bowel cancer

A

C

77
Q

What is the gold-standard investigation for a bowel cancer diagnosis?

A

Colonoscopy

78
Q

What classification system may be used in Bowel Cancer?

A

Duke’s (A-D)

TNM

79
Q

A removal of the distal transverse and descending colon is known as?

A. Left hemicolectomy

B. Right hemicolectomy

C. High anterior resection

D. Hartmann’s Procedure

A

A

80
Q

A removal of the caecum, ascending colon and proximal transverse colon is known as?

A. Left hemicolectomy

B. Right hemicolectomy

C. High anterior resection

D. Hartmann’s Procedure

A

B

81
Q

A removal of the sigmoid colon is known as?

A. Left hemicolectomy

B. Right hemicolectomy

C. High anterior resection

D. Hartmann’s Procedure

A

C

82
Q

A removal of the sigmoid colon and upper rectum is known as?

A. Left hemicolectomy

B. Low anterior resection

C. High anterior resection

D. Hartmann’s Procedure

A

B

83
Q

A removal of the rectosigmoid colon and creation of a rectal stump with creation of a colostomy is known as?

A. Left hemicolectomy

B. Right hemicolectomy

C. High anterior resection

D. Hartmann’s Procedure

A

D

84
Q

What are the complications of bowel cancer surgery?

A 
Anaesthetic risks 
Bleeding 
Infection 
Pain
Iatrogenic damage: nerves, bladder, ureter or bowel 
Failure of anastomosis 
Incisional hernia 
Adhesions 
VTE
Post-operative ileus
85
Q

Following surgery to remove a tumour which was Duke’s Stage B, found in the rectum, a patient develops severe flatulence and tenesmus. The AXR is unremarkable.

What is the likely diagnosis?

A. Free gas in the abdomen

B. IBS

C. Post-op analgesia side effects

D. Low anterior resection syndrome

A

D

86
Q

What initial investigations may be done in primary care upon suspicion of a bowel cancer?

A

CEA

FIT testing

87
Q

What is a stoma?

A

Stomas are artificial openings of a hollow organ (for example the bowel).

88
Q

Upon inspection, you see a stoma. The stoma is producing solid stool.

What type of stoma is this?

A. Colostomy

B. Ileostomy

C. Gastromy

D. Urostomy

A

A

89
Q

Upon inspection, you see a stoma. The stoma is producing liquid stool.

What type of stoma is this?

A. Colostomy

B. Ileostomy

C. Gastromy

D. Urostomy

A

B

90
Q

Upon inspection, you see a stoma. The stoma is present i the RIF and has a large spout.

What type of stoma is this?

A. Colostomy

B. Ileostomy

C. Gastromy

D. Urostomy

A

B

91
Q

Why do ileostomies have a tight spout?

A

So they drain directly into a tightly fitting bag without contents contacting surrounding skin which are skin irritants

92
Q

What alternative is there to an end-colostomy following a panproctocolectomy?

A

Ileo-anal anastomosis (J-pouch) whereby ileum folded back on itself and fashioned into a larger pouch to function as the rectum

93
Q

What are the complications of a stoma?

A 
Psychosocial impact 
Local skin irritation 
Constipation 
Obstruction
Prolapse 
Retraction 
Bleeding 
Granulomas causing raised red lumps around the stoma 
Parastomal hernia
94
Q

What is the name of the muscle controlling bile efflux at the ampulla of Vater?

A

Sphincter of Oddi

95
Q

What are the risk factors for Cholecystitis?

A 
Fat
Fair
Forty
Female
Fertile
96
Q

Why are patients with gallstones advised to avoid fatty food?

A

Fat entering the duodenum triggers CCK release which contracts the gallbladder - augmenting biliary colic pain.

97
Q

How can you compare LFTs to interpret whether this is hepatic or obstructive?

A

ALT + AST (hepatic) vs ALP (obstructive)

98
Q

What is the first line investigation for a patient with suspected cholelithiasis?

A

US-Abdomen

Showing hyperchoic regions; acoustic shadow; bile duct dilation (>6mm); fluid around the gallbladder; thickened gallbladder wall

99
Q

What is the gold-standard diagnostic test for choledocholithiasis?

A

MRCP

100
Q

What is the management for a patient with cholelithiasis?

A

Supportive: A-E; admission; Prep for surgery
+
Surgery: Cholecystectomy

101
Q

What are the complications following a cholecystectomy?

A 
Anaesthetic risks 
Bleeding 
Iatrogenic damage to abdominal structures
Stones left in the abdomen
VTE 
Post-cholecystectomy syndrome
102
Q

What is the most common cause of acute cholecystitis?

A

Gallstones - trapped in neck of gallbladder or in the cystic duct

Calculous cholecystitis cf less common acalculous cholecystitis

103
Q

What sign is elicited by placing hand in RUQ to palpate and asking patient to breath which elicits pain?

A

Murphy’s sign

104
Q

What are the complications of acute cholecystitis?

A 
Perforation
Sepsis 
Peritonitis 
Gallbladder empyema
Gangrenous gallbladder
105
Q

Outline Charcot’s Triad.

A

Right upper quadrant pain
Fever
Jaundice (raised bilirubin)

106
Q

Outline Reynold’s Pentad.

A

RUQ Pain
Fever
Jaundice

Hypotension
Confusion

107
Q

What are the most common pathogens causing acute cholangitis?

A

Escherichia coli
Klebsiella species
Enterococcus species

108
Q

What is the gold-standard management for Ascending Cholangitis?

Outline the process.

A

A-E approach then ERCP

Involves: passing an endoscope down oesophagus, stomach and into duodenum to the Sphincter of Oddi. Injection of contrast into duct to visualise biliary system.

Sphincterotomy allows stone removal with biliary stenting or balloon dilation.

Biopsy may be taken

109
Q

The palpation of a gallbladder in a patient with a markedly raised sBr is termed?

A

Courvoisier’s Law - suggestive of cancer. Either cholangiocarcinoma or pancreatic cancer.

110
Q

What tumour marker is elevated in cholangiocarcinoma?

A

Ca19-9

111
Q

What is the most common type of pancreatic cancer?

A

PDAC

112
Q

A patient presents to the GP with 3/12 weight loss and abdominal pain with nausea. No obvious cause is delineated.

What is your next step?

A. Watch and wait

B. Prescribe anti-emetics and analgesia

C. Refer to Gastroenterology

D. Direct access CT abdomen referral

A

D, suspected pancreatic cancer is the only scenario where GPs can refer directly for a CT scan. Whenever guidelines and clinical practice have notable exceptions like this it is worth taking note of, as these make good facts for examiners to test your knowledge on.

113
Q

What is the term for migratory thrombophlebitis seen in cancer?

A

Trousseau’s Sign

114
Q

What tumour marker is elevated in PDAC?

A

Ca19-9

115
Q

What are the causes of Pancreatitis?

A 
Idiopathic 
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune 
Scorpion stings
Hyperlipideaemia
ERCP
Drugs (diuretics; azathioprine)
116
Q

What biochemical marker is suggestive of pancreatitis?

A

Amylase 3x normal

117
Q

Which scoring system may be used to assess severity of Pancreatitis?

Outline it.

A

Glasgow Score

0 or 1 = mild pancreatitis

2 = moderate pancreatitis

3< = severe pancreatitis

Mnemonic: PANCREAS

PaO2 <8kPa
Age >55
Neutrophils >15
Calcium <2 
uRea >16
Enzymes (LDH >600 or AST/ALT > 200)
Albumin <32
Sugar (glucose >10)
118
Q

How do you manage acute pancreatitis?

A

Supportive: A-E; IV fluids; NBM; analgesia; admission; pre-op

119
Q

What are the types of liver transplants?

A

Orthotopic transplant
Split donation
Living donor transplant

120
Q

What are the indications for a liver transplant?

A

Acute liver failure: Paracetamol overdose; acute viral hepatitis
Chronic liver failure: HCC; NAFLD; AFLD; Liver conditions whereby eGFR <15

121
Q

What incision is used in an open Liver transplant?

A

Mercedes Benz incision

Rooftop incision

122
Q

What are the complications of acute pancreatitis?

A 
Necrosis of the pancreas
Infection in a necrotic area
Abscess formation
Acute peripancreatic fluid collections
Pseudocysts (collections of pancreatic juice) can develop 4 weeks after acute pancreatitis
Chronic pancreatitis
123
Q

What are the fluid compartments in the body?

A

Intracellular space 2/3 fluids

Extracellular space 1/3 fluids

  • Intravascular
  • Interstitial (fluid around the cells)
  • Third space
124
Q

Which of the following is not a third space?

A. Peritoneal cavity

B. Pleural cavity

C. Joints

D. Blood vessels

A

D

125
Q

Which of the following is not an insensible fluid loss?

A. Burns

B. Urine output

C. Respiration

D. Stools

A

B

126
Q

What general indications are there for IV fluids?

A

Resuscitation

Replacement

Maintenance

127
Q

What are the main types of IV Fluid?

Give the components of each.

A

IV fluid can be broken down into crystalloid vs colloids

Crystalloid: Saline; Dextrose; Hartmann’s Solution; Plasma-Lyte 148

Saline (0.9%)
1L water
154mmol Na
154mmol Cl

5% Dextrose
1L water
No electrolytes
50g glucose

0.18% NaCl in 4% dextrose 
1L water
31mmol Na
31mmol Cl
40g glucose
Hartmann's Solution 
1L water
131mmol Na
111mol Cl
5mmol K+
2mmol Ca
29mmol lactate

Human albumin solution - for use in patients with decompensated liver disease; increases intravascular plasma volume via increasing oncotic pressure of plasma which draws in and retains fluid

128
Q

What fluid would you use in a resuscitation and why?

A

I would use an isotonic fluid such as 0.9% Saline which has the same tonicity (osmotic pressure gradient) as the blood thus you will not lose fluid into the interstitial space; the intravascular volume will be increased which will increase blood pressure (volume in a given space)

129
Q

What is the amount of fluid you give in a child?

A

20ml/kg in a child

130
Q

How do you determine how much replacement IV fluid to give?

A

IV fluids can be used to replace fluids in a patient with a negative fluid balance, where the fluid losses are greater than the fluid intake. This involves calculating or estimating the losses and prescribing additional fluids to account for these losses.

131
Q

What is maintenance IV fluids?

A

Maintenance IV fluids are used for the shortest time possible where the patient is unable to take fluid orally, for example, while nil by mouth waiting for surgery or in bowel obstruction. As soon as they are able to meet their nutritional needs orally, the IV fluids should be stopped.

132
Q

What are the NICE guidelines approximate values for maintenance IV fluids?

A

25-30mL/kg/day

1mmol/kg/day of Na, K, Cl-

50-100g/day of glucose

Values calculated off ideal body weight, not BMI (to avoid hypervolaemia in obese patients)

133
Q

Who should you be cautious with regarding fluid prescribing?

A 
Elderly 
Renal impairment 
Cardiac impairment
Liver impairment
Electrolyte abnormalities
Significant oedema
134
Q

When prescribing fluids, how do you quantify the rate?

A

STAT

Over X hours

XmL/hour (make it clear) for the nurses

Note: Prescribe the amount to see them through for a period of time; think about nights/changeovers and the next doctor on call

135
Q

What are the main differences between omphalocoele and gastroschisis?

A

Omphalocoele = umbilical; sac covering

Gastroschisis = paraumbilical; no sac

136
Q

What decision-making tool can be used to determine the severity of Ulcerative Colitis?

A

Truelove and Witts Severity Index –> Mild/Moderate/Severe

137
Q

An AXR shows a double bubble sign in a child with biliary vomiting.

What is your most likely DDx?

A. Duodenal atresia

B. Malrotation with volvulus

C. Jejunal atresia

D. Meconium ileus

A

A

138
Q

An upper GI contrast study shows DJ medially placed in a child with haemodnamic instability and peritoneal signs.

What is your most likely DDx?

A. Duodenal atresia

B. Malrotation with volvulus

C. Jejunal atresia

D. Meconium ileus

A

B

139
Q

An AXR shows a air-fluid levels in a 12 hour old baby.

What is your most likely DDx?

A. Duodenal atresia

B. Malrotation with volvulus

C. Jejunal atresia

D. Meconium ileus

A

C

Surgery (10 decks)

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