Surgery

Question 1

What are the contraindications to laparoscopic surgery?

Answer 1

Absolute contraindications
- haemodynamic instability/shock
- raised intracranial pressure
- acute intestinal obstruction with dilated bowel loops (e.g. > 4 cm)
- uncorrected coagulopathy

Question 2

What are the complications of laparoscopy?

Answer 2

• general risks of anaesthetic
• vasovagal reaction (e.g. bradycardia) in response to abdominal distension
• extra-peritoneal gas insufflation: surgical emphysema
• injury to gastro-intestinal tract
• injury to blood vessels e.g. common iliacs, deep inferior epigastric artery

Question 3

What is the protocol of AAA?

Answer 3

< 3 cm = No further action
3 - 4.4 cm = Rescan every 12 months
4.5 - 5.4 cm = Rescan every 3 months
≥ 5.5cm = Refer within 2 weeks to vascular surgery for probable intervention

Any rapidly growing AAA
- >1cm a year
- Urgent endovascular aneurysm repair
- even if asymptomatic

Question 4

Mx: inguinal hernias

Answer 4

• Treat even if asymptomatic
• Unilateral = open repair with mesh
• Bilateral and recurrent = laparoscopically

Question 5

What does the ‘coffee bean’ represent?

Answer 5

sigmoid volvulus
- large bowel obstruction caused by sigmoid twisting on itself

px:
- constipation
- abdo blosting
- abdo pain
- vomiting

Question 6

Mx: volvulus

Answer 6

sigmoid volvulus:
rigid sigmoidoscopy with rectal tube insertion

caecal volvulus:
1. emergency laparotomy or laparoscopy:
- if bowel is viable: right hemicolectomy (removes the redundant mobile caecum and prevents recurrence) followed by primary ileocolic anastomosis
- if bowel is non-viable (ischaemia/perforation): right hemicolectomy + stoma (e.g. end ileostomy with mucous fistula).

Question 7

Causes of hydronephrosis

Answer 7

Unilateral causes – PACT

1. Pelvic-ureteric junction (PUJ) obstruction (congenital or acquired)
2. Aberrant renal vessels causing extrinsic compression
3. Calculi (ureteric stones)
4. Tumours of the renal pelvis or ureter

Bilateral causes – SUPER

1. Stenosis of the urethra
2. Urethral valves (posterior urethral valves in males)
3. Prostatic enlargement (benign or malignant)
4. Extensive bladder tumour causing outflow obstruction
5. Retroperitoneal fibrosis

Question 8

Ix: hydronephrosis

Answer 8

Ultrasound – first-line: confirms hydronephrosis and assesses kidney size and cortical thickness

IVU (Intravenous urogram) – defines site and degree of obstruction

Antegrade or retrograde pyelography – diagnostic and therapeutic

If renal colic suspected: CT KUB (non-contrast) – detects most calculi

Question 9

Mx: hydronephoris and renal stone

Answer 9

RELIEVE OBSTRUCTION + DRAIN URINE

unilateral acute
- nephorstomy tube insertion (urgent decompression)

bilateral
- bilateral nephrostomies

chronic obstruction
- ureteric stent or pyeloplasty

Question 10

Describe different testicular lumps

Answer 10

Epididymal cyst
- smooth, regular
- separate from body and testicle

Testicular cancer
- irregular
- extension of testicle

varicocele
- bag of worms

hydrocele
- difficult to feel testile
- transilluminates

lipoma
- firm smooth lump
- rare in testicle

Question 11

Ix: suspected prostate cancer

Answer 11

PSA

1. MRI
2. likert scale 1-2 = TRUS biopsy

Question 12

Racoon eyes and battle signs are signs of what?

Answer 12

basilar skull fracture

Question 13

How to classify severity of pancreatitis?

Answer 13

P - PaO2 (< 7.9 kPa).

A - age (>55).

N - neutrophils (white cell count > 15x 109/L).

C - calcium (calcium < 2 mmol/L).

R - renal function (urea > 16 mmol/L).

E - enzymes (lactate dehydrogenase > 600 IU/L).

A - albumin (albumin < 32 g/L).

S - sugar (blood glucose > 10 mmol/L).

3 points and above suggests a high risk for severe pancreatitis.

Question 14

Mx: anal fissure

Answer 14

acute anal fissure (< 1 week)
1. soften stool
- dietary advice: high-fibre diet with high fluid intake
- bulk-forming laxatives are first-line - if not tolerated then lactulose should be tried
2. lubricants e.g. petroleum jelly
3. topical anaesthetics
4. analgesia

Chronic anal fissure
- topical (GTN)
- if not effective after 8 weeks then secondary care referral = surgery (sphincterotomy)
lateral internal sphincterotomy

botulinum toxin injection