Surgery

Question 1

What is the most commonly performed operation for this upper rectal tumours ?

Answer 1

Anterior resection

Question 2

What is the most commonly performed operation for this lower rectal tumours ?

Answer 2

excised using an abdomino-perineal excision of the rectum.

Question 3

How long does Finasteride treatment of BPH before results are seen?

Answer 3

up to 6 months
(finasteride works by inhibiting the conversion of testosterone into dihydrotestosterone (DHT), which contributes to prostate enlargement. The reduction in prostate size and associated symptom relief, therefore, takes some time.)

Question 4

subdural haematoma

Answer 4

Fluctuating confusion/consciousness?
risk factors for a subdural haematoma including old age, alcoholism and anticoagulation

Question 5

subarachnoid haemorrhage is suspected next step in management?

Answer 5

CT head done > 6 hours after symptom onset is normal, a lumbar puncture should be done to confirm or exclude the diagnosis (indicated to check for xanthochromia or blood in the cerebrospinal fluid. If the lumbar puncture is negative, alternative diagnoses should be considered, for example, reversible cerebral vasoconstriction syndrome and venous sinus thrombosis.)

Question 6

Congenital inguinal hernias What is the most appropriate action?

Answer 6

Refer to paediatric surgery

Question 7

Penile cancer diagnosis?

Answer 7

squamous cell carcinoma

Question 8

single best medication that might reduce his stone formation?

Answer 8

Thiazide diuretic (In a patient with hypercalciuria and renal stones, calcium excretion and stone formation can be decreased by the use of thiazide diuretics)

Question 9

What monitoring equipment is most important to assess this patient’s intubation?

Answer 9

Capnography can be used to detect accidental oesophageal intubation

Question 10

31-year-old man presents as he and his partner have been having problems conceiving. On examination there is a diffuse lumpy swelling on the left side of his scrotum. This is not painful and the testicle, which can be felt separately, is normal.

Answer 10

Varicocele

Question 11

A 44-year-old man notices a pea-sized lump on his right testicle. On examination a discrete soft mass can be felt posterior to the right testicle.

Answer 11

Epididymal cyst

Question 12

A 75-year-old man presents with a swelling in his right scrotum. On examination a large, non-tender swelling is found in the scrotum. You cannot palpate above the swelling during the examination.

Answer 12

Inguinal hernia

Question 13

50-year-old man has re-presented to ED with abdominal pain. He reports an episodic intense dull discomfort made worse by eating which usually lasts around six hours for each episode. His past medical history includes Crohn’s disease which is currently in remission and has never required operative management. His abdomen is soft with mild discomfort in the right upper quadrant. He is apyrexial with a heart rate of 90/min. what is the definitive management for the patient’s condition?

Answer 13

An elective laparoscopic cholecystectomy is the treatment of choice for biliary colic

There is no evidence of infection or cholestasis. He should have an outpatient ultrasound and, if confirmatory for gallstone disease, an elective laparoscopic cholecystectomy.

Note the increased prevalence of gallstones in patients with Crohn’s disease.

Question 14

The stoma bag is located on the upper left quadrant of her abdomen. The bag is completely empty, and you can notice that the proximal portion of the resected bowel is flush to the skin. Her abdomen is distended and you can hear tinkling bowel sounds.

What type of stoma does this patient have?

Answer 14

End colostomy

A colostomy is flush to the skin, as the enzymes in the colon are less alkaline than those in the small intestine and so are less damaging to the skin

To differentiate between a colostomy and a small intestine stoma you can use multiple hints. Usually, an ileostomy is on the right iliac fossa whilst a colostomy is on the left iliac fossa. But they can be located on any part of the abdomen, hence to differentiate between them you should look at the output. If it is spouted, it means that you are looking at an ileostomy because the small bowel’s contents are irritant to the skin, hence the spouting protects it. If it is flush to the skin, you are looking at a colostomy, because the large bowel contents are not irritant. Additionally, the faecal material will be liquid in an ileostomy, whilst a colostomy would contain more solid contents.

Question 15

end ileostomy

Answer 15

usually done following complete excision of the colon or where the ileocolic anastomosis is not planned. It may be used to defunction the colon, but a reversal is difficult. It would look spouted, whilst in this case, it looks flush to the skin.

Question 16

loop ileostomy

Answer 16

involves taking a loop of the ileum, performing a horizontal incision and bringing it up to the skin. It is indicated to defunction the colon, for example, after rectal cancer surgery. Eventually, it can be reversed. It would look spouted, whilst in this case, it looks flush to the skin.

Question 17

loop jejunostomy

Answer 17

used as a very high output stoma. It may be used following emergency laparotomy with planned early closure. It would look spouted, whilst in this case, it looks flush to the skin.

Question 18

percutaneous jejunostomy

Answer 18

involves the insertion of a feeding tube directly into the jejunum. You would notice a tube on the abdomen of the patient rather than a stoma bag.

Question 19

Chronic anal fissure what is the appropriate next step after lifestyle modifications?

Answer 19

topical glyceryl trinitrate (Rectal GTN increases blood flow to the area to aid healing of the fissure. It also reduces pressure in the area by relaxing the anal tone.
)

Question 20

A 23-year-old man was driving a car at high speed whilst intoxicated, he was wearing a seat belt. The car collides with a brick wall at around 140km/h. When he arrives in the emergency department he is comatose. His CT scan appears to be normal. He remains in a persistent vegetative state. What is the most likely underlying cause?

Answer 20

Diffuse axonal injury occurs when the head is rapidly accelerated or decelerated. There are 2 components:

1. Multiple haemorrhages
2. Diffuse axonal damage in the white matter

Up to 2/3 occur at the junction of grey/white matter due to the different densities of the tissue. The changes are mainly histological and axonal damage is secondary to biochemical cascades. Often there are no signs of a fracture or contusion.

Question 21

Combined oral contraceptive pill

Answer 21

Any oestrogen-containing medication such as HRT or the COCP should be stopped 4 weeks before surgery to reduce the risk of blood clots.

Question 22

Apixaban

Answer 22

stopped 1-3 days before an operation

Question 23

Lithium

Answer 23

stopped around 1-3 days before major surgery but can be continued for minor surgery. The exact timing depends on the type of surgery and the patient’s mental health history. Lithium can interfere with electrolyte management, the effects of anaesthetic drugs and there is a greater risk of lithium toxicity in the peri-operative period.

Question 24

Ramipril

Answer 24

usually stopped 1 day before surgery to reduce the risk of severe hypotension intra-operatively. It may sometimes be continued up until the day of surgery depending on individual factors.

Question 25

hiatus hernias most appropriate management plan for this patient?

Answer 25

Lifestyle advice and omeprazole The vast majority of patients with hiatus hernias do not require surgical repair

Question 26

Ken, 76, has been diagnosed with a mid-rectal tumour. Following a CT scan and other investigations it is concluded that the tumour is graded as T2N0M0 and is deemed acceptable to be operated on. Which of the following surgeries is the preferable option for Ken?

Answer 26

Low anterior resection A low anterior resection would be the most preferable surgery for the patient in this scenario. The important information to consider when answering this question is the position of the tumour, the grading and whether it is operable. The fact that this patients tumour is rectal means that there are only two surgical procedures in the list of possible answers that could be right; abdominoperineal resection and low anterior resection. Left hemicolectomy and total colectomy are used to surgically treat colonic diseases, including malignancies. Furthermore, Hartmann's procedure is no longer used as frequently as in the past, and is now largely reserved for emergency colorectal surgery and terminally ill patients. Due to this, these options are inappropriate responses to this question. Both abdominoperineal resections and low anterior resections are used to treat rectal malignancy. However, abdominoperineal resections, which involve the removal of the anus, rectum and section of sigmoid colon, are used for tumours located in the distal one third of the rectum. Given that the patient in this question has a mid-rectal tumour, this surgical procedure would be inappropriate. Low anterior resection is the operation of choice for this patient and patients whose malignancy lies in the upper two thirds of their rectum. This surgery involves resection of the area of malignancy, followed by anastomosis. To attempt to reduce complication rates, a defunctioning ileostomy can be created, which results in the majority of bowel matter bypassing the newly formed anastomosis.

Question 27

inguinal hernia most appropriate management?

Answer 27

Routine referral for surgical repair

Question 28

initial management of acute limb ischaemia?

Answer 28

analgesia, IV heparin (Morphine) and vascular review

Question 29

Previous surgery patient developed severe post-op nausea and vomiting. Which of the following anaesthetic agents would be most appropriate to use?

Answer 29

Propofol is an antiemetic and is therefore particularly useful for patients with a high risk of post-operative nausea and vomiting (PONV)

Question 30

A 27-year-old man reports that his right testicle has recently swollen. He denies any pain or urinary symptoms. He is otherwise well and is a fit, healthy football player. On examination, you note that the right testicle is double the size of the left testicle. There is no pain elicited on examination. He denies any recent trauma to the testicles. Which one of the following is the most appropriate course of action?

Answer 30

2 week wait referral for suspected testicular cancer

Question 31

Constipated. The team suspects a large bowel obstruction due to cancer and orders a CT scan, that shows a mass in the hepatic flexure. Which one of the following surgical management plans is the most appropriate for the patient?

Answer 31

Right hemicolectomy - Caecal, ascending or proximal transverse colon cancer → right hemicolectomy The patient presents with the symptoms of large bowel obstruction due to hepatic flexure cancer. Cancers of the cecum, ascending or a proximal third of the transverse colon are resected using a right hemicolectomy. The procedure involves removing the cecum, the ascending colon and the proximal third of the transverse colon. However, an extended right hemicolectomy may be executed for lesions on the hepatic flexure, including the whole middle colic territory.

Question 32

Hartmann's procedure

Answer 32

is executed in emergencies, such as bowel obstruction or perforation. This involves complete resection of the rectum and sigmoid colon with the formation of an end colostomy and the closure of the rectal stump. This can be revised later, with anastomosis of the two stumps.

Question 33

high anterior resection is used to excise upper rectal tumours

Answer 33

It involves the resection of the proximal rectum and sigmoid colon, with the advantage of leaving the anal sphincter intact. This allows the creation of anastomoses between the descending colon and the lower rectum. Often a loop ileostomy is performed to defunction the colon to allow healing of the anastomoses. This will be reversed later when the anastomoses have healed.

Question 34

left hemicolectomy

Answer 34

is used to excise tumours of the distal two-thirds of the transverse colon and descending colon. It involves removing the distal transverse colon, the descending colon and the sigmoid colon. The rectum is left intact and anastomosed with the proximal transverse colon, so the patient will not have a permanent stoma.