General Surgery

Question 1

Where is the appendix found

Answer 1

The appendix is found at the proximal large bowel, at the ileo-ceacal valve. It is found at the convergence of the tenia coli. Can be located caecally, retrocaecally, or in the pelvis. Commonly found in the RIF. Can be located elsewhere with conditions such as malrotation and situs inverticus.

Question 2

When should you commence antibiotics in a patient who has symptoms and signs of appendicitis?

Answer 2

Antibiotics should be commenced once the decision to operate has been made. Should be commenced on cephalosporin and metronidazole. Given prophylactically and attempted to reach peak concentration by the time of first incision.

Question 3

What are the important differential diagnoses to consider when managing a 17 year-old woman who has the symptoms and signs of appendicitis?

Answer 3

Gynaecological -> endometriosis, ectopic, PID, PCOS, period pain, salpingitis
Bowel -> Crohn’s, UC, IBS, bowel obstruction, intussusception, volvulus
KUB -> renal stone, ureter stone, UTI
MSK -> Psoas abscess, rectus abdominus haematoma

Question 4

How would you proceed to manage a 22 year-old female patient who presents to you with a 24 hour history of right iliac fossa pain?

Answer 4

History -> duration, frequency, diarrhoea/nausea, pregnancy risk, menstruation, urinary symptoms
Examination -> vitals, guarding, rebound tenderness, Rovsing’s (McBurney’s point)/obturator/psoas signs, bowel sounds
Investigation -> bHCG, FBC, UEC, dipstick, abdo Xray,
Manage -> provide fluid and analgesia as appropriate. Refer to the surgical/gynaecological reg as appropriate.

Question 5

What is the indication for imaging in suspected appendicitis?

Answer 5

Appendicitis is largely a clinical diagnosis that does not require imaging. Imaging may be considered useful if the diagnosis is uncertain, or the patient is female and there is risk of a gynaecological cause. Sometimes in obese/older patients CT imaging is required

Question 6

Why does the pain and discomfort of appendicitis classically ‘migrate’ from generalised abdominal pain to become localised in the RIF?

Answer 6

Change comes from movement from visceral (generalised) pain to somatic (localised) pain.
Appendix is embryologically a midgut organ and so visceral pain refers to the umbilicus (innervated by lesser splachnic nerve (T10-11).
Progression introduces involvement from local somatic nerves (spinocerebral tracts) -> sharp touch

Question 7

What are the indications for a laparoscopic approach to appendicectomy?

Answer 7

Most appendicectomies are laporascopic due to decreased recovery, SSI risk, complications.
Open approach is used in obese patient, pregnant women, diagnostic uncertainty (exploratory) or surgeon’s preference

Question 8

What are the classical symptoms and signs of acute appendicitis?

Answer 8

Pain lasting <72 hours, pain in RIF, fever, vomiting, guarding and rebound tenderness.
Other symptoms include tachycardia, tachypnoea, Rovsing’s sign, obturator sign, psoas sign,
Alvarado score determines likelihood of appendicitis (MANTRELS)

Question 9

What is a sentinel node biopsy in the management of breast cancer?

Answer 9

Sentinel node is the first lymph node that the lymphatic system drains to from the site of the suspected primary. Biopsy of this node can determine the presence of node involvement, as it is the first node that will be involved. Useful in staging and determining management of cancer.
Automatic removal is not indicated as only ~25% of breast cancer patients have nodal involvement.
Nodes should be examined as a part of the triple assessment.

Question 10

What is a hernia?

Answer 10

A hernia is an abnormal protrusion of a viscous organ through a cavity in which it is normally contained. The most common types of hernia are umbilical, inguinal, femoral, incisional, hiatus.
Common contents include omentum, bowel contents, peritoneum, stomach, bladder

Question 11

What is the anatomical difference between an inguinal hernia and a femoral hernia?

Answer 11

Inguinal hernias are defined as direct or indirect.
Indirect hernias protrude through the deep inguinal ring (lateral to Hesselbach’s triangle)
Direct hernias protrude out from the superficial ring (Hesselbach’s triangle)
Femoral hernias project through the femoral canal, located inferiorly to the inguinal ligament

Question 12

On examination, what is the difference between an inguinal hernia and a femoral hernia?

Answer 12

On examination get the patient to stand and cough. Palpate the hernia and determine the origin. See if it is reducible.
Inguinal hernias -> lump usually disappears when supine, can be reducible, can have a +ve cough impulse, lower risk of incarceration.
Femoral hernias -> usually small and just inferior to inguinal ligament. Cough impulse is rarely detected and is normal irreducible

Question 13

What is the importance of deciding whether a hernia is inguinal or femoral?

Answer 13

Femoral hernias have a higher rate of complications (strangulation), meaning they are of greater risk to the patient and require management. Inguinal hernias can just be monitored. Reasons for surgery include:
symptomatic, incarcerated/strangulated hernia, femoral hernia

Question 14

What is the difference between an incarcerated or irreducible hernia, and a strangulated hernia?

Answer 14

Incarcerated hernias are irreducible. Causes for irreducibility include:
incarcerated -> hernia is stuck due to adhesions holding it in place, or the sac is wider than the abdominal opening
obstructed -> neck of bowel obstructs contents of bowel
strangulated -> blood supply is compromised

Question 15

A 75 year-old woman presents to the emergency department with a 24 hour history of vomiting and cramping abdominal pain. She has not passed flatus or stool for 24 hours. She has no relevant previous medical history. On examination, she has a distended abdomen, and a tender, red coloured lump in the right groin. What is the most likely diagnosis and what should be done to help this patient?

Answer 15

Incarcerated hernia that has become strangulated and caused a SBO.
Management should be with IV fluid, analgesic and antiemetics
Requires surgical reduction. Potential resection of affected bowel.
Do not try and reduce the hernia. Hernias strangulated for >4 hours may perforate

Question 16

What are the common causes of a lower GI bleed?

Answer 16

Lower GI bleeds occur distally to the Ligament of Treitz (suspensory ligament of the duodenum). The patient will often complain of haematochezia.
Anatomical causes -> diverticulosis, Meckel’s diverticulum, haemorrhoids, anal fissure, abscess
Vascular -> angiodysplasia, ischaemia, radiation induced
Inflammatory -> IBD, infectious colitis
Neoplastic -> CRC

Question 17

What are the signs and symptoms of a lower GI bleed?

Answer 17

Signs and symptoms will depend on the source of the bleed. Can present with:
Haematochezia, haemodynamic instability, pain, cramping, weight loss, anaemia, SOB, fevers, night sweats,

Question 18

What is the management of a large, acute, Lower GI bleed?

Answer 18

Initial management should include a primary survey. Correct any haemodynamic instability the patient may have. If still not responding, consider emergency laparotomy. Once stable:
History, examination, investigation to determine the cause of the lower GI bleed. Management should be targeted to the cause.
History -> duration, severity, pain, systemic features, PMH, smoking
Examination ->
Investigations -> FBC, UEC, LFT, CT abdo, X-ray, stool MCS, colonoscopy

Question 19

What is a Meckel’s diverticulum

Answer 19

Meckel’s diverticulum is the most common congenital defect of the bowel wall. It is a true diverticulum, meaning it affects all layers of the bowel wall. It is due to incomplete obliteration of the vitelline duct. This duct joins the yolk sac to the midgut lumen through the umbilical cord in a developing foetus. It is located in the small bowel. It can be described by the ‘rule of 2s’
2% of people have it, of which 2% are symptomatic, 2 types of tissue (gastric or pancreatic), 2 inches long, 2 feet from ileocaecal valve, 2:1 male:female

Question 20

What symptoms can be caused by a Meckels diverticulum and why?

Answer 20

Most patients will remain asymptomatic, with ~2% becoming symptomatic. Can present with:
GI bleeding -> gastric mucosa secretes acid and causes inflammation and irritation
bowel obstruction -> adhesions, volvulus, stricture, intussusception
Meckel’s diverticulitis -> narrow neck and inflammation
peritonism -> perforation of the diverticula
abdominal pain

Question 21

What are the causes of an obstruction of a luminal structure (e.g the bowel, the ureter, biliary tree, or blood vessel)?

Answer 21

Functional or mechanical
Functional -> ileus, drug induced, electrolyte abnormality
mechanical
intraluminal -> tumour, stone, thrombus, atherosclerosis, faeces
luminal -> tumour, stricture, IBD
extraluminal -> tumour, volvulus, intussusception, adhesions, BPH

Question 22

What are the signs and symptoms of a large, acute upper GI bleed?

Answer 22

Depends on origin of the bleed. Upper GI is above the ligament of Treitz.
Include:
haematomesis, abdo pain, SOB, malaena, CV instability, x, nausea/vomiting, weight loss, night sweats, malaise, jaundice

Question 23

What is the treatment of an acute upper GI bleed?

Answer 23

Depends on the cause of the bleed.
ABCDE to regain stability. Determine cause through history/examination
Endoscopy with banding, ligation, cautery, adrenaline injection
Laparotomy may have to be performed -> open the duodenum and stitch the gastroduodenal artery

Question 24

What do you do as the intern if you think someone is having an acute UGI bleed?

Answer 24

ABCDE
Determine cause with history, examination, investigation
Refer as appropriate to surgery

Question 25

What are the risk factors contributing to the aetiology of a peptic ulcer?

Answer 25

peptic ulcer penetrates through muscularis mucosa into deeper layers. Most common aetiology is H pylori infection and NSAID use.
Other factors are smoking, obesity, alcohol, FHx

Question 26

What are the initial investigations in the ED for a perforated ulcer?

Answer 26

Initial stabilisation of patient (ABCDE). 
Bloods (FBC, UEC, LFT, VBG)
ECG
Abdo X-Ray (pneumoperitoneum)
CT

Question 27

What are the physical signs suggestive of a perforated ulcer

Answer 27

Perforation into the peritoneum causes peritonitis. Perforation typically occurs in the anterior duodenum just posterior to the pylorus.
Presentation:
sudden acute gastric pain aggravated by movement, vomiting, guarding, tenderness, patient not shocked or toxic, decreased bowel sounds

Question 28

What is the treatment for a perforated duodenal ulcer?

Answer 28

Emergency surgery is indicated for nearly all cases of upper GI perforation.
Surgical magement:
resuscitate patient, provide NG decompression, laparotomy/laparoscopy, inspect abdomen and perform peritoneal toilet, duodenal perforation corrected by suturing vascularised omentum over the defect, NSAID/H. Pylori treatment

Conservative management includes fluid and resuscitation, NG decompression, PPI + antibiotics (amxoycillin, clarithromycin)

Question 29

What are the common skin cancers?

Answer 29

BCC -> ~70%, locally invasive keratinocyte cancer, resulting from UV exposure, mostly on face/upper back, flesh coloured, pearly bump, excision biopsy
SCC -> ~30%, invasive cancer of keratinocytes, spreads locally and through lymph, appears as red firm bump/scaly patch, excision biopsy
Melanoma -> malignancy of melanin, grow radially/superficially spreading (~80%) or vertically (nodular), flat dark lesions, spread locally and through blood, Breslow thickness

Question 30

What features of a mole on the skin would make you concerned that it had become malignant?

Answer 30

Asymmetry, irregular Borders, Colour variation, Diameter (>6mm), Evolution (growing)

Question 31

What are the principles of initial treatment of a mole on the skin that you are concerned may have undergone malignant change?

Answer 31

History and examination. Confirmed on histology with biopsy.
Melanomas <1mm thick -> 1cm margin
1-4mm -> 2cm margin
>4mm -> 3 cm margin
Elective lymph node dissection improves survival for palpable or USS detected nodes

Question 32

What is a volvulus of the colon?

Answer 32

Volvulus is when colon twists on its own mesentery resulting in acute, sub acute or chronic obstruction. Most common place is at the sigmoid colon or caecum.
Patients are often elderly and present with chronic constipation. Cramping abdo pain, distention, obstipation and constipation are common. Constant pain typically precedes gangrene and perforation

Question 33

How is a sigmoid volvulus treated (after initial history, examination and investigation)?

Answer 33

Initial management of ABCDE and analgesia.
Volvulus with no peritonism should have sigmoidoscope inserted with flatus tube passed through site of obstruction.
Treatment for peritonism is laparotomy (potential perforation/gangrene) and may require resection.
May be visible changes on colon including ischaemia, inflammation, erythema

Question 34

This 18 year-old man has this lump in his groin. What is the most likely diagnosis?
What are the differential diagnoses?

Answer 34

The most likely diagnosis is an inguinal hernia.

DDx include femoral hernia, inguinal lymphadenopathy, femoral artery aneurysm, psoas abscess

Question 35

This 18 year-old man has this lump in his groin. It is a hernia. What is most likely to be in the hernia?

Answer 35

Omentum, peritoneal fat, small bowel, large bowel
Most direct hernias do not have a peritoneal sac and contain only omentum
Most indirect hernias do contain peritoneal sac and contain omentum and SB

Question 36

What are the common methods of repairing an inguinal hernia in a fit 18 year-old?

Answer 36

Hernia repair is not always indicated. Strangulated, incarcerated, femoral or aesthetics are indications.
Repair can be either open or closed.
OPEN -> mesh or tension repair. This is the preferred option for most inguinal hernias.
CLOSED -> Total extraperitoneal surgery (TEPS) or trans-abdominal pre-peritoneal surgery (TAPS)

Question 37

What are the common complications of an inguinal hernia repair, and what are the serious complications of this operation?

Answer 37

Intra-operatively -> haemorrhage, perforation, inguinal ligament damage, bladder damage, anaesthetic reaction
Post-operatively -> failure, SSI, mesh displacement, mesh infection, pain, seroma, haematoma, urine retention

Question 38

What specific history and examination will you perform for a 70 year-old man who presents with a lump in the neck that is clearly not in the thyroid or other midline structures?

Answer 38

History -> duration, initiating factor, progression, pain, dysphagia, anorexia, weight loss, night sweats, fevers, myalgias, PMH, Lx, haemoptysis, vocal changes,
Examination -> size, shape, consistency, warmth, fluctuance, mobility, clubbing, tar staining

Question 39

What are the differences in pathology between UC and Crohns?

Answer 39

UC and Crohn’s disease are both IBD.
Crohn’s -> transmural inflammation of the bowel present in skip lesions. The bowel wall thickens due to oedema, especially in the submucosa. The epithelium remains largely intact but is accompanied with cross-crossing deep fissured ulcers.
UC -> inflammatory infiltrate in lamina propria, crypt abscesses. Definitive features are rectal involvement, only in colon, no transmural lymphoid or granule aggregates.
neutrophilia on histology

Question 40

What are the main types of bariatric operations that are performed for obesity?
How do they work?

Answer 40

Bariatric operations for obesity can be categorised into restrictive and malabsorptive.
Restrictive -> gastric banding (adjustable), sleeve gastrectomy (removal), vertical banded gastroplasty (combination of
Malabsorptive -> biliopancreatic bypass (gastric sleeve performed and attached to jejunum, with bile still going through duodenum), Roux-en-Y (gastric band like procedure performed with attachment to the jejunum)

Question 41

This man has complained about a swelling at his umbilicus. Q1. What can you see and what is the diagnosis?
Q2. What is the likely contents?
Q3. What is the risk of serious complications with this hernia as it stands.
Q4. What would be the correct approach if this were to become acutely painful and incarcerated?

Answer 41

Diagnosis is an umbilical hernia
Likely contents is peritoneal fat, omentum, small bowel
Complications include incarceration and strangulation. This is a surgical emergency
Correct approach is to perform laparotomy/laparoscopy to remove affected bowel and anastamose back

Question 42

This patient has become aware of a skin abnormality for years that has developed hair growth during adolescence. Q1. What is the abnormality?
Q2. What is it’s significance?
Q3. What treatment is needed?

Answer 42

The abnormality is a supernumerary nipple.
This is significant as there is an increased risk of breast related pathology (cancer, lactation, polycystic changes, fibromas)
Treatment is either nothing or surgical excision and removal .

Question 43

This is the abdominal photograph of an 80 year-old woman who presents with a painful lump in the right groin. She has had it for 24 hours. Q1. What could it be?

She has had generalised colicky abdominal pain from about 12 hours and some vomiting.

Q2. What is the most likely diagnosis here?
Q3. What is the most appropriate treatment strategy?

Answer 43

Could be hernia, lymphadenopathy, psoas abscess, saphena varix, aneurysm
Most likely diagnosis is a femoral hernia. May also be a inguinal hernia.
Borders of femoral hernia are inguinal ligament, lacunar ligament, femoral vein, pectineal ligament
Most appropriate treatment is to resect the affected section of bowel and replace with a mesh repair.

Question 44

This lady had a swelling on the back of her lower neck. It has been present for years. It had slowly enlarged over that time and is producing no other symptoms. Q1. What is the most likely diagnosis?
Q2. What tests other than physical examination are likely to be helpful.
Q3. What are the common complications of operative removal of this?

Answer 44

Most likely diagnosis is a lipoma or epidermoid cyst.

USS, FBC, LFT, FNA/core biopsy, CT

Operative removal can cause haemorrhage, SSI, seroma formation, pain, scar formation

Question 45

A 65 year-old woman presents to the ED with vomiting, abdominal distension and colicky pain. She has never had an operation. She has a CT scan.
Q1. What does this show? (volvulus)
Q2. What does the surgical registrar do the minute he sees this scan?
Q3. What does he find?
Q4. What is the treatment?

Answer 45

CT shows volvulus

Urgent referral to theatre for sigmoidoscopy
Patient requires analgesic, fluid resuscitation and NG decompression
On sigmoidoscopy there is a close bowel, potential erythematous
Flatus tube inserted through obstruction with use of sigmoidoscopy

Question 46

Q1. What is the massive transfusion protocol?

Q2. In what circumstances should it be used?

Answer 46

Massive transfusion protocol relates to massive transfusion of blood product to a patient. It should be used in profusely bleeding patients that require a large blood transfusion. It is defined as:
>1 blood volume in 24 hours
>50% blood volume in 4 hours
>40mL/kg in children
This should be used in profusely bleeding patients rather than normal saline to reduce DIC and restore coagulative properties

Question 47

A 75 year-old lady was admitted with abdominal pain and vomiting, this Xray was taken.
Q1. What are the possible causes of her small bowel obstruction?
Q2. What are the priorities in managing her in the ED?

Answer 47

Two most common causes of SBO are adhesions and hernias. Other causes include IBD, volvulus, ileus, stricture, trauma, electrolyte imbalances

Management priorities include ABCDE, fluid resuscitation, analgesia, NG decompression, NBM. Cause of SBO identified through Hx, Ex, Ix with CT abdo.
If partial obstruction, supportive care is sufficient. If complete obstruction, laparotomy required.