Surgery Flashcards
Which anatomical structure is implicated in most cases of anterior epistaxis?
Kiesselbach Plexus
Outline the Paradise criteria for tonsillectomy.
- ≥7 episodes of tonsillitis in the past 12 months
- ≥5 episodes of tonsillitis per year for 2 years
- ≥3 episodes of tonsillitis per year for 3 years
- ≥2 peritonsillar abscesses at any point in the patient’s life (≥1 in children)
How should an asymptomatic thyroglossal cyst be managed?
Excision (as there is a risk of infection if left untreated)
What is the best investigation for confirming a diagnosis of bacterial tonsillitis?
Throat Swab for Microscopy and Culture
What is the most appropriate management option for viral pharyngitis?
Symptomatic Management
Analgesia (paracetamol, ibuprofen)
Difflam® Spray
How should a secondary post-tonsillectomy bleed be managed?
Admit for ENT review
May require antibiotics or exploration in theatre
Which features are considered by the Centor criteria?
Age
Fever
Tonsillar Exudate
Cervical Lymphadenopathy
Absence of Cough
What is the best investigation for confirming a diagnosis of bacterial tonsillitis?
Throat Swab for Microscopy and Culture
What is the most appropriate management option for viral pharyngitis?
Symptomatic Management
Analgesia (paracetamol, ibuprofen)
Difflam® Spray
What are the indications for adenoidectomy?
Recurrent otitis media with effusion (glue ear)
Nasal obstruction
Chronic rhinosinusitis
Chronic sinusitis
Obstructive sleep apnoea
Aside from modifying risk factors, what other management option is commonly used for intermittent claudication?
Structured Exercise Programme
For further information:
NICE guidelines on peripheral arterial disease: https://www.nice.org.uk/guidance/cg147
Outline the Fontaine classification for chronic limb ischaemia.
Fontaine A: Asymptomatic
Fontaine B1: Symptoms when walking more than 200 metres
Fontaine B2: Symptoms when walking less than 200 metres
Fontaine C: Rest pain
Fontaine D: Evidence of tissue loss (ulcers and gangrene)
What is the first step in assessing a patient with suspected peripheral artery disease?
Ankle Brachial Pressure Index
For further information:
NICE guideline on peripheral arterial disease: diagnosis and management https://www.nice.org.uk/guidance/cg147/chapter/Recommendations#diagnosis
Outline the Fontaine classification for chronic limb ischaemia.
Fontaine A: Asymptomatic
Fontaine B1: Symptoms when walking more than 200 metres
Fontaine B2: Symptoms when walking less than 200 metres
Fontaine C: Rest pain
Fontaine D: Evidence of tissue loss (ulcers and gangrene)
Aside from modifying risk factors, what other management option is commonly used for intermittent claudication?
Structured Exercise Programme
For further information:
● NICE guidelines on peripheral arterial disease: https://www.nice.org.uk/guidance/cg147
Which surgical approach is most appropriate for a patient with critical limb ischaemia and unilateral iliac disease (i.e. complete occlusion of one common iliac artery)?
Femoral-Femoral Crossover
What is a feature of non-viability of a limb in a patient with acute limb ischaemia?
Complete paralysis or paraesthesia
Fixed mottling
How should an abdominal aortic aneurysm measuring 4.9 cm in diameter upon screening be managed?
Invite for repeat ultrasound in 3 months
What is the first investigation that would be performed in a patient with a suspected ruptured abdominal aortic aneurysm?
Abdominal Ultrasound Scan
Which diagnosis should you always consider in a patient who is haemodynamically unstable and has presented with acute abdominal pain?
Ruptured Abdominal Aortic Aneurysm
How does intermittent claudication present?
Leg pain on exertion that is relieved by rest
Describe the typical presenting features of varicose veins.
Unsightly, distended veins usually around the calves
May be associated with some itching and discomfort
Worsened by prolonged standing
What is an appropriate intervention for a patient with severe varicose veins who is not suitable for a general anaesthetic?
Injection Sclerotherapy
What initial imaging modality is used in the assessment of varicose veins?
Duplex Ultrasound Scan
What surgical intervention is most commonly performed to treat a Dupuytren’s contracture that is affecting a patient’s quality of life?
Fasciectomy
What are the indications for weight loss surgery?
● BMI > 40 kg/m2, OR BMI > 35 kg/m2 AND have at least one other significant disease (e.g. type 2 diabetes mellitus) which could be improved with weight loss
● The patient has failed to achieve sustained weight loss with all other non-surgical management
● The patient is fit enough for anaesthesia and surgery
● The patient will receive intensive management in a specialist centre
● The patient must commit to long-term follow-up
What is the initial imaging modality that is used in the assessment of patients with critical limb ischaemia?
Duplex Ultrasound Scan
What is the most important initial investigation to request in a patient with progressive dysphagia?
OGD
What is likely to be the most appropriate treatment option for a T2N1M0 oesophageal cancer?
Oesophagectomy and chemotherapy
What are the features of aortoiliac occlusive disease (Leriche syndrome)?
Buttock claudication
Absent leg pulses
Erectile dysfunction
What is Fournier’s gangrene and how does it present?
Necrotising fasciitis of the perineum
Presents with out of proportion pain in the perineum and features of sepsis
How is a large full-thickness tear of the subscapularis muscle likely to be managed?
Arthroscopic Tendon Repair
What are the main presenting features of compartment syndrome?
Out of proportion pain within limb
Sensory deficit
Usually occurs in the context of trauma
Which diagnostic tests may be used in the diagnosis of compartment syndrome?
It is primarily a clinical diagnosis, however, compartmental needle manometry and MRI may aid diagnosis.
How should lower limb compartment syndrome be managed?
Two-incision four-compartment fasciotomy
How does compartment syndrome of the anterior compartment of the leg manifest?
Foot drop
Numbness of interweb spaces of the first and second toes
NOTE: the deep peroneal nerve runs through the anterior compartment
What are the clinical features of aortic dissection?
Sudden-onset severe chest pain that radiates to the interscapular region
Unequal arm pulses
Aortic regurgitation
Consequences of involvement of the branches of the aorta (e.g. stroke)
What is the gold-standard imaging modality for aortic dissection?
CT Aortogram
What blood pressure target should be set in patients with aortic dissection?
Systolic blood pressure 100-110 mm Hg.
Which scoring systems are used for aortic dissection?
Stanford A: Originates in the ascending aorta
Stanford B: Originates distal to the left subclavian artery.
DeBakey Type 1: originates in ascending aorta and continues to at least the aortic arch, often more distally.
DeBakey Type 2: The dissection is confined to the ascending aorta.
DeBakey Type 3: The dissection originates distal to the left subclavian artery and rarely extends proximally, but often extends distally.
What is the initial investigation used to investigate possible carotid artery stenosis?
Carotid Doppler Ultrasound Scan
When is a carotid endarterectomy indicated?
Symptoms (i.e. stroke or TIA in the hemisphere supplied by the affected carotid artery)
50-99% stenosis
Describe the characteristics of an arterial ulcer.
Punched-out appearance
Painful
Usually at the peripheries of the feet (e.g. in between the toes)
What initial investigation is important to conduct in any patient with a leg ulcer?
ABPI - allows assessment of arterial insufficiency
What is the first step in the management of compartment syndrome?
Urgent Fasciotomy
What is lipodermatosclerosis?
Subcutaneous fibrosis and hardening of the skin of the lower legs – this leads to a “upside-down champagne bottle” like appearance with narrowing of the distal limb.
What is the most appropriate initial step in the management of acute limb ischaemia?
IV Heparin
Outline the possible outcomes of abdominal aortic aneurysm screening.
< 3 cm: Discharged from screening programme
3.0-4.4 cm: Yearly USS
4.5-5.4 cm: 3-monthly USS
> 5.5 cm: Consideration for surgical repair
Patients should also be considered for surgical repair if the aneurysm is growing by more than 1 cm per year or if the aneurysm is symptomatic
What are the two main surgical approaches for managing an abdominal aortic aneurysm?
Open Repair (preferred option in otherwise fit patients as it is associated with a lower rate of reintervention)
Endovascular Aneurysm Repair
How does acute limb ischaemia present?
Acute-onset leg pain
Palor
Cold
Pulseless
Paralysis or paraesthesia
Which interventions can be used to revascularise an acutely ischaemic leg that is still viable?
Embolectomy
Local intra-arterial thrombolysis
Bypass
Angioplasty
What are some of the manifestations of a Stanford type A dissection?
Sudden-onset tearing chest pain
New aortic regurgitation (early diastolic murmur)
Myocardial ischaemia (due to coronary artery involvement)
What is the first step in assessing a patient with suspected peripheral artery disease?
Ankle Brachial Pressure Index
For further information:
● NICE guideline on peripheral arterial disease: diagnosis and management https://www.nice.org.uk/guidance/cg147/chapter/Recommendations#diagnosis
Which cancer is associated with left-sided varicoceles?
Renal Cell Carcinoma
How are hydroceles in newborns managed?
Most resolve spontaneously within 1 year of life
If it fails to resolve by 1 year, referral to paediatric surgery should be considered
Which investigation should be requested in patients with a persistent varicocele?
CT Abdomen and Pelvis (to rule out an intra-abdominal mass)
What is phimosis?
Pathological non-retractile foreskin (the vast majority of boys should be able to retract their foreskin by the age of 16 years)
Outline the indications for urgent referral to urology in patients with a varicocele.
Fails to reduce when lying down
Sudden-onset, new varicocele in a man over the age of 40 years
Right-sided varicocele
Outline the examination findings you would expect in a patient with an epididymal cyst.
Fluctuant swelling superior and separate to the testis
Transilluminates (if large enough)
Which intervention should be used for large renal stones (> 20 mm)?
Percutaneous Nephrolithotomy
Which surgical approach is used for non-obstructive distal ureteric calculi?
Ureteroscopic Lithotripsy
Which cancer is associated with left-sided varicoceles?
Renal Cell Carcinoma
How are hydroceles in newborns managed?
Most resolve spontaneously within 1 year of life
If it fails to resolve by 1 year, referral to paediatric surgery should be considered
Which investigation should be requested in patients with a persistent varicocele?
CT Abdomen and Pelvis (to rule out an intra-abdominal mass)
What is phimosis?
Pathological non-retractile foreskin (the vast majority of boys should be able to retract their foreskin by the age of 16 years)
Outline the indications for urgent referral to urology in patients with a varicocele.
Fails to reduce when lying down
Sudden-onset, new varicocele in a man over the age of 40 years right-sided variocele
Outline the examination findings you would expect in a patient with an epididymal cyst.
Fluctuant swelling superior and separate to the testis
Transilluminates (if large enough)
Which clinical features would raise suspicion of a diagnosis of a testicular torsion as opposed to a different cause of acute testicular pain?
Absent cremasteric reflex
Testicle is high in the scrotum and with a horizontal lie
Prehn’s sign negative
What is the most appropriate treatment option for symptomatic but uncomplicated phimosis with no evidence of balanitis?
Application of 0.05% betamethasone ointment
What is the most important first step in the management of acute urinary retention?
Catheterise
How does bladder cancer tend to present?
Painless macroscopic haematuria
What is the most important investigation to arrange in a patient with suspected bladder cancer?
Cystoscopy
How are primary hydroceles in infants usually managed?
Watchful Waiting
Which reflex is often tested when assessing a patient with suspected testicular torsion?
Cremasteric reflex (presence can help rule out a diagnosis of testicular torsion)
How should superficial, high-risk bladder tumours be managed?
Repeat TURBT with intravesical BCG treatment
What is the most important intervention to perform in the case of an infected and obstructive urinary system?
Percutaneous Nephrostomy
How should any case of suspected testicular torsion be managed?
Urgent referral to urology for consideration of exploratory surgery with bilateral fixation of the testicles
How should a 22 mm non-obstructing stone in the renal pelvis be managed?
Percutaneous Nephrolithotomy
What is the most appropriate treatment option for a patient with BPH who has failed to respond to medical therapy?
Transurethral Resection of the Prostate (TURP)
NOTE: transurethral incision of the prostate may be considered in mild-to-moderate BPH (prostate mass < 30 g)
How should a patient with a salvageable testicular torsion be surgically managed?
Unilateral orchidopexy (of affected testicle) and contralateral fixation
How is a muscle-invasive bladder tumour normally managed surgically?
Radical Cystectomy
Which investigation should be urgently arranged in patients with an acquired hydrocele?
Testicular Ultrasound Scan (to rule out underlying malignancy)
What is the gold-standard investigation for a suspected urinary tract calculus?
Non-Contrast CT KUB
What is the most appropriate management option for a stone at the pelviureteric junction that is 15 mm in size?
Ureteroscopy
NOTE: extracorporeal shockwave lithotripsy is more appropriate for stones that are under 10 mm
Which investigation is important in a patient with acute urinary retention who has evidence of an AKI on their blood tests?
Renal Ultrasound Scan
What are some intermediate measures that can be taken to prevent urinary retention in a patient who is awaiting a TURP?
Long-Term Catheter
Intermittent Self-Catheterisation
Which examination should be performed first in a patient with suspected benign prostatic hyperplasia?
Digital Rectal Examination
When is an anterior resection used for colorectal cancer?
When the tumour lies more than 5 cm above the anal verge
Which surgical approach is used for tumours of the ascending colon?
Right Hemicolectomy
What is the mainstay of managing acute cholecystitis?
Laparoscopic cholecystectomy within 1 week of presentation
https://pathways.nice.org.uk/pathways/gallstone-disease#content=view-node%3Anodes-management
Describe the clinical features of oesophageal perforation.
History of forceful vomiting preceding the onset of symptoms
Chest/neck/upper abdominal pain
Haemodynamic instability
Respiratory distress
Fever
Subcutaneous emphysema
How does acute cholecystitis manifest?
Right upper quadrant pain
Nausea and vomiting
Fever
What is the most appropriate first-line investigation for acute cholecystitis?
Ultrasound Abdomen
How can you clinically assess an inguinal hernia to see whether it is direct or indirect?
The hernia should be reduced, a finger should be placed over the deep inguinal ring (just above the midpoint of the inguinal ligament) and the patient should be asked to cough (increase intra-abdominal pressure). If the hernia reappears, it suggests the hernia is direct (passing through a weak point in the posterior wall of the inguinal canal). If it does not reappear, it is suggestive of an indirect inguinal hernia.
How should a strangulated inguinal hernia be managed?
Emergency Surgery (to reduce the hernia, repair the defect and resect any non-viable bowel)
What are the boundaries of the inguinal canal?
Anterior Wall: aponeurosis of the external oblique, reinforced laterally by the internal oblique muscle
Posterior Wall: transversalis fascia
Superior Wall (roof): transversalis fascia, internal oblique and transversus abdominis
Inferior Wall (floor): inguinal ligament thickened medially by the lacunar ligament
What are the boundaries of Hesselbach’s triangle?
Medial: lateral border of the rectus abdominis
Lateral: inferior epigastric vessels
Inferior: inguinal ligament
What subsequent investigation should a patient undergo after having a positive FIT result?
Colonoscopy
How does acute cholecystitis manifest?
Right upper quadrant pain
Nausea and vomiting
Fever
What is the most appropriate first-line investigation for acute cholecystitis?
Ultrasound Abdomen
How can you clinically assess an inguinal hernia to see whether it is direct or indirect?
The hernia should be reduced, a finger should be placed over the deep inguinal ring (just above the midpoint of the inguinal ligament) and the patient should be asked to cough (increase intra-abdominal pressure). If the hernia reappears, it suggests the hernia is direct (passing through a weak point in the posterior wall of the inguinal canal). If it does not reappear, it is suggestive of an indirect inguinal hernia.
How should a strangulated inguinal hernia be managed?
Emergency Surgery (to reduce the hernia, repair the defect and resect any non-viable bowel)
What are the boundaries of the inguinal canal?
Anterior Wall: aponeurosis of the external oblique, reinforced laterally by the internal oblique muscle
Posterior Wall: transversalis fascia
Superior Wall (roof): transversalis fascia, internal oblique and transversus abdominis
Inferior Wall (floor): inguinal ligament thickened medially by the lacunar ligament
What are the boundaries of Hesselbach’s triangle?
Medial: lateral border of the rectus abdominis
Lateral: inferior epigastric vessels
Inferior: inguinal ligament
What subsequent investigation should a patient undergo after having a positive FIT result?
Colonoscopy
Which surgical approach is likely to be used for a tumour of the hepatic flexure?
Right hemicolectomy with ileocolic anastomosis
Which cancers are patients with HNPCC at increased risk of developing?
Colorectal Cancer (nearly 100%)
Endometrial Cancer (~60%)
Gastric Cancer (~10%)
Ovarian Cancer (~10%)
How do femoral hernias and inguinal hernias differ?
Femoral hernias are inferior and lateral to the pubic tubercle
Inguinal hernias are superior and medial to the pubic tubercle
Femoral hernias are more common in women and have an increased risk of incarceration and strangulation
What diagnosis should you consider in a patient who continues to have fevers despite antibiotic therapy after having an appendicectomy?
Appendicular Abscess
Intra-Abdominal Collection
What is the first-line management option for excessive output stomas?
Loperamide
PPI (e.g. omeprazole)
What are the components of the Glasgow-Imrie criteria?
PaO2
Age
WCC
Calcium
Urea
LDH
Albumin
Glucose
Which treatment options are typically used for Grade 2 haemorrhoids?
Rubber band ligation
Injection sclerotherapy
Topical hydrocortisone (for perianal itching)
How can TPN lead to cholestasis?
No food will be entering the intestines so various hormones that promote biliary motility (e.g. cholecystokinin) will not be produced, resulting in cholestasis.
Outline the measures that can be taken to reduce the risk of postoperative atelectasis?
Incentive Spirometry
Early Mobilisation and Physiotherapy
What is a pilonidal sinus?
Chronic inflammatory condition caused by an ‘ingrown hair’ usually in the natal cleft of the buttocks.
The insertion of hair into the skin initiates an inflammatory response which leads to the formation of a sinus tract deep into the tissue. This will usually present as a painful swelling with purulent, foul-smelling discharge.
What are the ways in which the biliary system can be decompressed in a patient with ascending cholangitis secondary to an obstructing CBD stone?
Percutaneous Cholecystostomy
Percutaneous Transhepatic Cholangiography with Stent Insertion
ERCP
Endoscopic Ultrasound-Guided Biliary Drainage
Describe how direct and indirect inguinal hernias can be distinguished clinically.
Once a hernia has been reduced, applying pressure over the midpoint of the inguinal ligament will occlude the deep inguinal ring, so, in cases of indirect inguinal hernias, the lump will not reappear. If the lump reappears upon coughing, that is suggestive of a direct inguinal hernia.
What are the components of the Glasgow-Imrie criteria for acute pancreatitis?
PaO2 < 8 kPa
Age > 55 years
Neutrophils (WCC) > 15x109/L
Calcium < 2 mmol/L
Renal function: urea > 16 mmol/L
Enzymes: LDH > 600 IU/L
Albumin < 32 g/L
Sugar (serum glucose) > 10 mmol/L
