General Surgery Flashcards
What are the 3 clinical findings in an Abdominal Artery Aneurysm?
Hypotension
Retroperitoneal pain
Pulsatile abdominal mass
What is a Kocher incision used in?
Open cholecystectomy
What is a Chevron incision used in?
Upper GI surgery
What is a Mercedes Benz incision used in?
Liver transplant
Where is a battle incision made?
Paramedian incision for open appendicectomy
Where is a McBurney incision made?
Oblique incision for open appendicectomy
What is a Lanz incision and where is it made?
Transverse incision for open appendicectomy
What is a Rutherford Morrison incision for?
Open appendicectomy and colectomy
What is the difference between a Pfannenstiel Incision and a Joel-Cohen incision?
Pfannensiel incision is a curved incision 2 fingers width above pubic symphysis cf Joel-Cohen incision is a straight incision slightly higher (recommended)
What is the difference between monopolar and bipolar diathermy?
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
Which of the following is an absorbable suture material?
A. Polypropylene
B. Nylon
C. Silk
D. Monocryl
D
What does the WHO Surgical Safety Checklist comprise of?
Before induction of anaesthesia
Before skin incision
Before leaving theatre
A patient with an ASA I grade is…?
Normal, healthy
A patient with ASA III grade is?
Severe, systemic disease
A severe, systemic disease threatening life is which ASA grade?
A. IV
B. V
C. II
D. III
A
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
C
What investigations may be required prior to operation?
FBC
U+Es
HbA1C
PFTs
ABG
ECG
Echo
Clotting testing
G+S
Cross-matching
What is the difference between G+S and Crossmatching a sample?
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.
How long should you fast before surgery?
6 hours for solids
2 hours for fluid
When are DOACs stopped prior to surgery?
24-72 hours
When should Oestrogen-containing contraception be stopped prior to surgery?
A. 2 weeks
B. 3 days
C. 4 weeks
D. 6 weeks
C
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
B
What is the criteria for a patient to give capacity?
Understand the decision
Retain the information long enough to make the decision
Weigh up the pros and cons
Communicate their decision
What are the principles of enhanced recovery?
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
In which conditions may post-op NSAIDs be inappropriate?
Asthma
Renal impairment
Stomach ulcers
Heart disease
When is Post-Operative Nausea and Vomiting most common?
first 24 hours
Which of the following is not a risk factor for PONV?
A. Female
B. Smoker
C. Younger age
D. Use of opiates
B
Pressure at which bodily region may reduce nausea?
P6 acupuncture point on inner wrist
What is a common side effect of Total Parenteral Nutrition if given peripherally?
Thrombophlebitis
At which Hb should a transfusion be started?
A. <90g/L
B. <100g/L
C. <80g/L
D. <70g/L
What is the Hb criteria for commencement of iron?
D. <70g/L
What is the gold-standard investigation for appendicitis?
Diagnostic laparoscopy
What is the management of appendicitis?
A-E approach
+
Lap appendicectomy
What are the big 3 causes of bowel obstruction?
Adhesions
Hernias
Malignancy
what are the causes for a closed-loop obstruction?
Obstructing lesion(s) ± Competent IC valve
Adhesions
Hernia
Volvulus
Single point obstruction AND competent IC valve
What is the upper limit of normal bowel diameter in the colon?
A. 3cm
B. 6cm
C. 9cm
D. 7cm
B
What is the upper limit of normal bowel diameter in the small bowel?
A. 3cm
B. 6cm
C. 9cm
D. 7cm
A
What is the upper limit of normal bowel diameter in the caecum?
A. 3cm
B. 6cm
C. 9cm
D. 7cm
C
What is the first line management of a small bowel obstruction?
A. Stent
B. NG tube insertion
C. Exploratory surgery
D. Adhesiolysis
B
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
D
What are the two main types of volvulus?
Sigmoid
Caecal
What is the difference between a direct and indirect inguinal hernia?
Direct = Via Hesselbach’s Triangle, weak point
Indirect = via deep inguinal ring at patent processus vaginalis
In clinical examination, how may you tell the difference between a direct inguinal hernia and an indirect inguinal hernia?
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.
What are the borders of Hesselbach’s triangle?
Mnemonic: RIP
Rectus abdominus (medial)
Inferior epigastric vessels (superior)
Poupart’s ligament (inferior)
What are the borders of the femoral canal?
Mnemonic: FLIP
Femoral vein (lateral)
Lacunar ligament (medial)
Inguinal ligament (anterior)
Pectineal ligament (posterior)
What are the contents of the femoral triangle?
NAVY-C
Femoral nerve Femoral artery Femoral Vein Y fronts Femoral Canal
What are the borders of the femoral canal?
Mnemonic: FLIP
Femoral vein (lateral)
Lacunar ligament (medial)
Inguinal ligament (anterior)
Pectineal ligament (posterior)
What are the borders of the femoral triangle?
Mnemonic: SAIL
Sartorius (lateral border)
Adductor longus (medial border)
Inguinal Ligament (superior border)
What are the management options of a hernia?
Conservative
Tension-free (mesh)
Tension repair
What is a Richter’s hernia?
Only portion of the bowel wall and lumen herniate through the defect with the remainder remaining in the peritoneal cavity
What is a Maydl’s hernia?
Maydl’s hernia refers to a specific situation where two different loops of bowel are contained within the hernia.
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
B
A hernia presenting lateral to the rectus abdominus muscle but within the linea semilunaris is called?
Spigelian Hernia
what is the definitive management of a Hiatus hernia?
Laparoscopic fundoplication (tying stomach around lower oesophagus to narrow cardiac sphincter)
Why should you check with the anaesthetist prior to insufflation?
insufflation may trigger systole due to Vagal feedback
A non-inflamed, white appendix may be described as?
Lily white appendix
What are the borders of Calot’s Triangle?
Inferior border of liver (superior)
Common hepatic duct (medial)
Cystic duct (lateral)
Outline the importance of the critical view of safety in a laparoscopic cholecystectomy.
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
What is the most common anatomical position of the appendix?
Retrocaecal (64%)
Which of the following is not a risk factor for haemorrhoids?
A. Chronic coughing
B. Pregnancy
C. Obesity
D. Constipation
D
How may you describe the position of a haemorrhoid?
Using clock face - if patient is in lithotomy position
A haemorrhoid which has no prolapse is classified as?
A. 2nd degree
B. 1st degree
C. 3rd degree
D. 4th degree
B
A haemorrhoid which prolapses on straining only is classified as?
A. 2nd degree
B. 1st degree
C. 3rd degree
D. 4th degree
A
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
C
A haemorrhoid which is permanently prolapsed is classified as?
A. 2nd degree
B. 1st degree
C. 3rd degree
D. 4th degree
D
What are the management options for a haemorrhoid?
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
What of the following is not a risk factor for diverticulosis?
A. Advanced ageing
B. Obesity
C. NSAIDs
D. Eastern Diet
D, it is a Western diet
What are the complications of acute diverticulitis?
Perforation
Large haemorrhage requiring blood transfusions
Peritonitis
Peridiverticular abscess
Fistula (e.g., between the colon and the bladder or vagina)
Ileus / obstruction
What are the branches of the abdominal aorta, perfusing the abdominal organs?
Coeliac Trunk (T12)
SMA (L1)
IMA (L3)
what are the branches of the coeliac trunk?
L Gastric Art.
Splenic Art.
Common Hepatic Artery
What are the branches of the SMA?
Right Colic Art.
Middle Colic Art.
Ileocolic Art.
Caecal Art.
Jejunal Art.
What are the branches of the IMA?
Left Colic Art.
Sigmoid Art.
Middle Rectal Art.
What are the clinical features of chronic mesenteric ischaemia?
This is angina of the gut…
Central abdominal pain: colicky; post-prandial 30mins-90mins
Weight loss: Anorexia
Abdominal bruit
What is the gold-standard investigation for Mesenteric Ischaemia?
CT Angiography
What is the gold-standard investigation for acute mesenteric ischaemia?
Contrast CT
What biochemical markers may be deranged in acute mesenteric ischaemia?
Metabolic acidosis
Raised lactate
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
C
What is the gold-standard investigation for a bowel cancer diagnosis?
Colonoscopy
What classification system may be used in Bowel Cancer?
Duke’s (A-D)
TNM
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 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
B
A removal of the sigmoid colon is known as?
A. Left hemicolectomy
B. Right hemicolectomy
C. High anterior resection
D. Hartmann’s Procedure
C
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
B
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
D
What are the complications of bowel cancer surgery?
Anaesthetic risks Bleeding Infection Pain Iatrogenic damage: nerves, bladder, ureter or bowel Failure of anastomosis Incisional hernia Adhesions VTE Post-operative ileus
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
D
What initial investigations may be done in primary care upon suspicion of a bowel cancer?
CEA
FIT testing
What is a stoma?
Stomas are artificial openings of a hollow organ (for example the bowel).
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
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
B
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
B
Why do ileostomies have a tight spout?
So they drain directly into a tightly fitting bag without contents contacting surrounding skin which are skin irritants
What alternative is there to an end-colostomy following a panproctocolectomy?
Ileo-anal anastomosis (J-pouch) whereby ileum folded back on itself and fashioned into a larger pouch to function as the rectum
What are the complications of a stoma?
Psychosocial impact Local skin irritation Constipation Obstruction Prolapse Retraction Bleeding Granulomas causing raised red lumps around the stoma Parastomal hernia
What is the name of the muscle controlling bile efflux at the ampulla of Vater?
Sphincter of Oddi
What are the risk factors for Cholecystitis?
Fat Fair Forty Female Fertile
Why are patients with gallstones advised to avoid fatty food?
Fat entering the duodenum triggers CCK release which contracts the gallbladder - augmenting biliary colic pain.
How can you compare LFTs to interpret whether this is hepatic or obstructive?
ALT + AST (hepatic) vs ALP (obstructive)
What is the first line investigation for a patient with suspected cholelithiasis?
US-Abdomen
Showing hyperchoic regions; acoustic shadow; bile duct dilation (>6mm); fluid around the gallbladder; thickened gallbladder wall
What is the gold-standard diagnostic test for choledocholithiasis?
MRCP
What is the management for a patient with cholelithiasis?
Supportive: A-E; admission; Prep for surgery
+
Surgery: Cholecystectomy
What are the complications following a cholecystectomy?
Anaesthetic risks Bleeding Iatrogenic damage to abdominal structures Stones left in the abdomen VTE Post-cholecystectomy syndrome
What is the most common cause of acute cholecystitis?
Gallstones - trapped in neck of gallbladder or in the cystic duct
Calculous cholecystitis cf less common acalculous cholecystitis
What sign is elicited by placing hand in RUQ to palpate and asking patient to breath which elicits pain?
Murphy’s sign
What are the complications of acute cholecystitis?
Perforation Sepsis Peritonitis Gallbladder empyema Gangrenous gallbladder
Outline Charcot’s Triad.
Right upper quadrant pain
Fever
Jaundice (raised bilirubin)
Outline Reynold’s Pentad.
RUQ Pain
Fever
Jaundice
Hypotension
Confusion
What are the most common pathogens causing acute cholangitis?
Escherichia coli
Klebsiella species
Enterococcus species
What is the gold-standard management for Ascending Cholangitis?
Outline the process.
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
The palpation of a gallbladder in a patient with a markedly raised sBr is termed?
Courvoisier’s Law - suggestive of cancer. Either cholangiocarcinoma or pancreatic cancer.
What tumour marker is elevated in cholangiocarcinoma?
Ca19-9
What is the most common type of pancreatic cancer?
PDAC
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
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.
What is the term for migratory thrombophlebitis seen in cancer?
Trousseau’s Sign
What tumour marker is elevated in PDAC?
Ca19-9
What are the causes of Pancreatitis?
Idiopathic Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion stings Hyperlipideaemia ERCP Drugs (diuretics; azathioprine)
What biochemical marker is suggestive of pancreatitis?
Amylase 3x normal
Which scoring system may be used to assess severity of Pancreatitis?
Outline it.
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)
How do you manage acute pancreatitis?
Supportive: A-E; IV fluids; NBM; analgesia; admission; pre-op
What are the types of liver transplants?
Orthotopic transplant
Split donation
Living donor transplant
What are the indications for a liver transplant?
Acute liver failure: Paracetamol overdose; acute viral hepatitis
Chronic liver failure: HCC; NAFLD; AFLD; Liver conditions whereby eGFR <15
What incision is used in an open Liver transplant?
Mercedes Benz incision
Rooftop incision
What are the complications of acute pancreatitis?
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
What are the fluid compartments in the body?
Intracellular space 2/3 fluids
Extracellular space 1/3 fluids
- Intravascular
- Interstitial (fluid around the cells)
- Third space
Which of the following is not a third space?
A. Peritoneal cavity
B. Pleural cavity
C. Joints
D. Blood vessels
D
Which of the following is not an insensible fluid loss?
A. Burns
B. Urine output
C. Respiration
D. Stools
B
What general indications are there for IV fluids?
Resuscitation
Replacement
Maintenance
What are the main types of IV Fluid?
Give the components of each.
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
What fluid would you use in a resuscitation and why?
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)
What is the amount of fluid you give in a child?
20ml/kg in a child
How do you determine how much replacement IV fluid to give?
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.
What is maintenance IV fluids?
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.
What are the NICE guidelines approximate values for maintenance IV fluids?
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)
Who should you be cautious with regarding fluid prescribing?
Elderly Renal impairment Cardiac impairment Liver impairment Electrolyte abnormalities Significant oedema
When prescribing fluids, how do you quantify the rate?
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
What are the main differences between omphalocoele and gastroschisis?
Omphalocoele = umbilical; sac covering
Gastroschisis = paraumbilical; no sac
What decision-making tool can be used to determine the severity of Ulcerative Colitis?
Truelove and Witts Severity Index –> Mild/Moderate/Severe
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
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
B
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
C
