General Surgery

Question 1

Ix for lymphoma

Answer 1

Bloods- FBC, UE, LFTs, Ca, Infectious mononucleosis, Hep B &C, HIV

US guided core biopsy/LN excision biopsy

If confirmed lymphoma - Ct C/A/P and PET CT

Haem MDT

Question 2

Hodgkins Lymphoma

Answer 2

Defined by presence of Reed-Sternberg cells on biopsy

majority are classics (95%) (5% Noular lymphocytic - poor prognosis)

Subdivide into 4 subtypes
1- Nodular sclerosing
2- Lymphocyte rich
3-Lymphocyst deplete
4- Mixed cellularity

Question 3

Staging of Hodgkins Lymphoma

Answer 3

Ann Arbor staging

Early Favourable 0 Stage 1 and 2A

Early unfavourable - Stage 2b with high ESR or >3 lymph node areas

Advanced - Stage 2B with extra nodal / large mediastinal mass stage 3/4

Stop smoking
Tx - combination of chemotherapy and radiotherapy - 90% with early disease and 80% with advanced disease achieve long-term remission

Question 4

How to select patients for day surgery

Answer 4

Guildlines from British association of Day Surgery

1) Social Factors
2)Medical factors
3)Surgical factors
4) Post-operative factors

Question 5

Indications for elective splenectomy

Answer 5

1) ITP - plus coated in autoantibodies - splenectomy if refractory or recurrent - 50-85% response rate (accessory spleen cause failure) - Good repose in young and immediate post-splenectomy thrombocytosis

2) Hereditary Spherocytosis - Required in moderate to severe causes - usually after 6yrs old

3 TTP - thrombosis in small vessels causing low plus - splenectomy if refectory to steroids and plasmaphereis

Less common - thalassaemia, sickle, PKD, Hodgkins, Feltys syndrome, splenic asbcess/cysts and sarcoidosis

Question 6

Post splenectomy blood film

Answer 6

Howell jolly bodies - nuclear remnants
Pappenheimer bodies - iron inclusions
Target cells - immature RBC
Heinz bodies - denatured haemoglobin inclusions
Spur cells - deformed membranes
Leucocytosis - left shift
Thrombocytosis

Question 7

Anatomical attachment software the spleen

Answer 7

Gastrosplenic ligaments - hilum of spleen to greater curve (short gastric)
Spleno-renal ligaments - hilum of spleen to anterior surface of left kidney (Containes splenic vessels and tail of pans
Splenocolic ligament
Splenophrenic ligament

Question 8

Complications of splenectomy

Answer 8

Immediate - Bleeding

Early - pneumonia, gastric stasis, dilatation and necrosis, thromocystosis, pancreatic leak/fistula/pseudocyst, SMV thrombosis and abscess formation

Late - Overwhelming post- splenectomy infection (OPSI), splenosis, AV fistula, thromocystosis

Question 9

OPSI

Answer 9

Uncommon (5% lifetime risk)
Typically occurs in first 2 yrs
80% mortality
Usually cause by Streptococcus Pneumonia / encapsulated bacteria

Question 10

Splenectomy vaccinations

Answer 10

Usually 2 weeks before or prior to discharge:
Haemophilus influenza type 8, Men C + Men B + pneumococcal vacine

1 month post - Men ACWY + 2nd Men B

Yearly Flu vacine

Pneumococcal booster every 5 yrs

Long term Abe debated (lifelong or 2yrs) - Phenoxy-methyl-penicillin or erythromycin if pen allergic

Question 11

Anatomy of the inguinal canal

Answer 11

4cm inferomedially running tunnel from deep to superficial ring
Anterior - External oblique + internal oblique (lateral 1/3)
Inferior - inguinal ligament
Posterior - conjoint tendon and transversals fascia
Roof - conjoint tendon

Question 12

Sliding hernia

Answer 12

When a retroperitoneal organ protrudes with the peritoneal surface forming the hernia sac (5-8%)

Question 13

Lap vs open inguinal hernia

Answer 13

NICE recommends for recurrent and bilateral primary and as an alternative for primary unilateral

Majority of meta-analysis show lower rate of chronic pain and fewer wound complications and reduced surgical site infections and earlier return to work.

European Hernia Society guidelines 2018 - personalised strategy

Question 14

Risks of open hernia repair

Answer 14

1% recurrence (2.5% after Lap)
Chronic pain 10-40% (2% lap)
Wound complications - infection, bleeding, haematoma, serum

Injury to cord, ischaemic orchitis/testicular atrophy, injury to Vas, hydrocele

Risks of surge Generally

Mortality low approx 0.15%

Question 15

Treatment of Chronic Pain post groin hernia

Answer 15

Simple analgesia - watch and wait
Referral to specialist in chronic pain
Systemic agents such as gabapentin, tricyclics SSRI
Nerve blocks
Chemical neurectomy -22% successful
Surgical neurectomy 71% successful - anterior or posterior approach.

Question 16

Pilonidal sinus surgery

Answer 16

Lay open and secondary healing - lowest recurrence rate
Simple excision and closure - wound breakdown in approx 50%
Bascom 1 and 2
Karadakis
Both involve removal of pits/tracts with off midline incision and closure with flattening of natal cleft

Recurrence rate at least 10%

Question 17

Loss of domain

Answer 17

No standard definition but usually over 20% of peritoneal contents are within hernial sac.
Great the volume the more difficult it is to close

Question 18

Classification of incisional hernia

Answer 18

European Hernia Society 2009

Midline Zones (M1-5) and lateral Zones L1-4 Right to left)

Width (prognostic) W1 <4cm, W2 4-10cm W3 >10cm

Question 19

Planning AWR

Answer 19

Can use Carbonyl Ratio - Sum of rectus width to defect ration
>2 can do Rives-Stoppa (retrorectus meshed midline closure - gold standard)

<2 or >10cm then consider other adjusts - Anterior component separation, Transversus Abdomens release, Pre-op botulinum/penumoperioteum

Question 20

Prophylactic mesh for midline closure

Answer 20

PRISMA trial - high risk patients. - 2 year recurrence rates slower with no significant increase in complications

Question 21

Mental Capacity Act

Answer 21

2005
Provides conditions under which people can be deemed to lack capacity to make decisions regarding their healthcare

Lack capacity when unable to understand, weight and use info provided to make an informed decision

Question 22

Gillick Competence

Answer 22

Under 16 and able to consent for their own medical treatment without parental permission or knowledge

Gillick vs West Norfolk and Wisbech Area Health Authority 1986

Question 23

CT Abdo/Pelvis vs colonosopy

Answer 23

6.9% cancer detection rate for unprepared CT Abdo/Pelvis vs 11% for colon

Question 24

Spegalian Hernia

Answer 24

Defect lateral to linea semilunares at or below the arcuate line

Often intra-parietal passing through the transverses and the internal oblique aponeuroses but staying below the intact aponeurosis of the external oblique

Question 25

Testicualr tumour markers

Answer 25

Important for diagnosis and staging - prognostic Seminomas (1/3 Raised HCG) and non-seminomatous (60% AFP and HCG raised) LDh is less specific and increased levels proportional to tumour volume

Question 26

Types of monopolar diathermy

Answer 26

Cutting - continuous waveform Blend - mix of cutting and coat waveform Spray (fulgurate) - pulsed waveform resulting in heating and necrosis + greater thermal spread) Desiccate - coagulation with deep necrosis and greater thermal spread

Question 27

Warfarin around surgery

Answer 27

British Committee for standards in Haematology Guidlines Stop 5 days prior Doesn't need bridging unless very high risk or recurrent VTE (previous DVT/PE on therapeutic anticoagulant (INR 3-5) <3months prior) Check on day of surgery - proceed if INR <1.5 Restart day of surgery (4hrs post) or next day if afternoon case Recheck INR day 2 post-op before 3rd dose. Continue prophylactic LMWH until INR >2 for 2 days or for 5 days

Question 28

Rivaroxaban perioperative

Answer 28

Stop 48hrs prior to surgery unless Creat clearance <30ml/min then 72hrs Restart 48hrs post if high bleeding risk Bridge with prophylactic dose LWMH post until restarted if high risk of VTE Can be reversed by Andexanet in emergency

Question 29

Clostridium Difficile

Answer 29

Gram +ve, anaerobic, spore forming bacillus Present in 2-3% of healthy adultsProduces 2 toxins A - enterotoxin and B cytotoxin Detected in lab by PCR, GDH EIA and toxin EIA Severe causes - WCC >15, Acute raise in Creat >50, Temp >38.5, evidence of severe colitis, Latate >5 Tx - Mild (<3 stools) - Nil Mild to moderate - oral metro Severe oral vanc. Recurrenct 20% - once replaced risk of subsequent is 50-60% - evidence for fidaxomicin

Question 30

Polycystic Kidney Disease

Answer 30

Autosomal dominant progressive systemic disease Cyst formation in kidney, liver, aping and spleen Half require renal replacement by age of 60 Bloods - FBC, UE, LFTs, Calcium, phosphate and PTH US Liver cysts can result in portal HTN, ascites, varies and malnutriation Cerebral aneurysms occur in 10% Renal stones in 20-30% Genetic screening exists. - useful for -ve US patients wanting to be donors

Question 31

Need for nutritional support

Answer 31

Should be considered according to NICe in anyone malnutrished BM<18.5 Unintentional weightless >10% in last 36months or BMI20 >5% Risk of becoming malnourished - eaten little or nothing in last 5 days or next 5 days Poor absorptive capacity or high nutrient losses/increased needs (catabolism)

Question 32

Radiation Enteritis

Answer 32

Small bowel disease secondary to radiation injury - Acute or Chronic Chronic - typically 18mnths to 6yrs post Radiation initially causes mucosal inflammation which can lead to progressive ischaemica causing fibrosis and impairing function

Question 33

GIST

Answer 33

Gastrointestinal stromal TUmours Uncommon sarcoma derived from mesenchymal origin Majority driven by KIT gene mutation and stain positive for CD117/CD34 Commonest site stomach 60-70%, SB 20-30% but rarely in oesophagus, mesentery, omens and colorectal. EUS - hypoechoeic mass contiguous with muscular proprietary/mucosa Most are PET Avid - used to stage, look for mets or response to imatinib

Question 34

Management of GIST

Answer 34

<2cm watch and wait Larger tumours of symptomatic - resect Cause use imatinib (Glivec) to downstage Adjuvent Imatinib used for 3yrs in high risk of replies patients - Miettinen 2006 criteria (Size, location and mitotic rate) If mets or unresectable - Imatinib 400mg OD incraed to 800mg OD - second Line is sunitinib

Question 35

Follow up for GIST

Answer 35

AUGIS 2009 Guidlines Very low risk - Nil Low risk CT at 3 months then clinical Intermediate risk - CT at 3 months then 6monthly for 2 years then annually for 5yrs High risk - 3months post surgery, then 3monthly for 2 yrs then 6monthly for 2yrs then annually In patients with adjacent - 3months post surgery, then 6months for 2yrs then annually for 5yrs

Question 36

Drainage of liver abscess

Answer 36

Systemic review in 2014 favoured US guided drain over aspiration alone Facilitates higher success rate and reduced time required to achieve clinic relief

Question 37

Amoebic liver abscess

Answer 37

Collection of pus in the liver in response to intestinal parasite Entamoeba histolytica Usually in endemic areas of the world On imagining usually have poorly defined boundaries Majority in right lobe - led lobe indicates advanced disease Usually have antibodies detectable using ELISA Tx - can aspirate if risk of rupture or uncertain - anchovy paste) Metronidazole for abscess Paromomycin for eradication of amoebiasis

Question 38

Appendix NET

Answer 38

Critical info from Histology Size, location, depth of invasion, mesoappediceal, L/V invasion, Ki67 score, perforation and R status See in clinic, ask about carcinoid symptoms. Arranged CT C/A/P and Chromogranin A blood test, can consider urinary 5- HIAA (>25mg per day in carcinoid syndrome Discuss at MDT Can consider Idium 11 SPECT or PET with Gallium 68 labelled somatostatin analogues if suspicion of incomplete resection, residual disease or mets Follow up Post surgery - if no LN - No follow up If LN then long term FU - 3,6,12month then yearly. Chromogranin A and possible MRI - no consensus

Question 39

Carcinoid crisis

Answer 39

Pre-op octreotide 100micrograms YDS for 2 weeks Peri-op IV octreotide at 50-100 mic/hr Post - slowly ceased over first week

Question 40

Surgical site infections Classification

Answer 40

US Centrers for Disease Control and Prevention CDC Superficial, Deep or organ space Degrees of contamination 1) Clean 2) Clean -contaminated 3)Contaminated - major breach of sterile technique/spillage. Open traumatic wounds older then 12-24hrs) 4) Dirty/infected

Question 41

Antibiotics to prevent SSI

Answer 41

Clean surgery with prosthesis or implant Clean contaminated surgery Contaminated surgery

Question 42

Trials in SSI

Answer 42

SUNRISE - Multicentre RCT using -ve pressure dressing - no difference at 30days Falcon study - 2%alcoholic chlorhex vs iodine and triclosan coated sutures vs non-coated - Nil difference Cheetah study - changing gloves and instruments prior to closure reduced SSI 18.9% vs 16%

Question 43

Splenic Cysts

Answer 43

Most cysts (80%) are secondary cysts - usually post trauma or infection. 20% are primary - epithelial or epidermoid cysts Need to take aHx and evaluate symtpoms MRI or CT can help evaluate further Mangement - conservative, radiology or surgical F/U every 6-12months depending on symptoms

Question 44

Retroperitoneal sarcomas

Answer 44

40-50% - liposarcoma 25-30% leiomyosarcoma Less common - malignant peripheral nerve sheath tumours, fibrosarcomas, undifferentiated pleomorphic sarcomas Ix - Contrast enhanced CT. MRI may be useful - Core needle biopsy to confirm histology Mx - Surgery with -ve margins Can consider neoadj radio to attempt down staging and adj to high grade tumours or positive margins. Limited role for chemo F/U3-6monthly Clinical and CT for 2-3yrs then yearly. Looking for reoccurane Mets - Liver and longs - depending on subtype Leiomyosarcoma - lungs liposarcomas -liver and intra-abdominal sites

Question 45

Parastomal hernia classification

Answer 45

European hernia society according to site - Ileostomy or colostomy - Size -1-3 (largest_ Content - Type 1 - fat, 2,, small bowel, 3 colon