Surgery

Question 1

Which women should be offered radiotherapy after a mastectomy?

Answer 1

1. Women with T3 or T4 graded cancers
2. Those with 4+ nodes affected

NB: All women receiving a wide-local excision should receive it

Question 2

What do you need to tell women taking the contraceptive pill before having major surgery?

Answer 2

If it contains oestrogen stop 4 weeks before
If they forget, give thromboprophylaxis

If progesterone-only it can be continued

Question 3

1st and 2nd line treatmenr for neuropathic pain

Answer 3

1st: amitriptyline (SNRI) or pregabalin (acts on GABA system)
2nd: amitriptyline and pregabalin

Question 4

How large would a ductal carcinoma in situ (in the breast) have to be for a woman to receive a mastectomy rather than a wide local excision?

Answer 4

4cm

Question 5

Borders of the femoral canal?

Answer 5

Posterior- pectineus muscle
Anterior- inguinal ligament
Lateral- femoral vein
Medial- lacunar ligament

Question 6

Borders of the inguinal canal

Answer 6

The deep inguinal ring is found at the mid point between the ASIS and pubic tubercle

Anterior- external oblique aponeurosis + internal oblique
Posterior- transversalis fascia
Roof- transversalis fascia, internal oblique
Floor- inguinal ligament and thickened medially by lacunar ligament

Question 7

Things to ask about in a breast lump history?

Answer 7

PC- obesity
PMH- previous breast cancer
Obs- nulliparity, 1st pregnancy over 30 years, no breastfeeding
Gynae- early menarche, late menopause
DHx- HRT, the Pill
FHX- relatives (unilateral, bilateral, degree of closeness, any men, BRCA+)

Question 8

What might microcalcification on mammography indicate?

Answer 8

Ductal carcinoma in situ- unifocal or widespread

Question 9

Types of breast cancer

Answer 9

Invasive ductal 70%
Invasive lobular 15%
Medullary cancers 5% (aggressive looking, BRCA1, good prognosis)
Colloid 2%

Question 10

Which features of a breast tumour’s expressed receptors are associated with good or bad prognosis?

Answer 10

Oestrogen +ve good prognosis

HER2 +ve poor prognosis (aggressive disease)

Question 11

Risks of axillary radiotherapy for treatment of +ve lymph nodes in breast cancer

Answer 11

Brachial plexoplexy- weakness, sensation change, pain
Lymphoedema

Pneumonitis
Rib fractures
Pericarditis

Question 12

Outline the management of stage 1-2 breast cancer?

Answer 12

Surgery- wide local excision or mastectomy
Radiotherapy- for any WLE
Chemotherapy- post surgery (Adjuvant) improves survival
Hormonal- tamoxifen (pre-menopausal) or anastrozole (aromatase inhibitor) or GnRH analogues

Question 13

Outline the management of stage 3-4 breast cancer.

(Stage 3- tumour fixed to muscle, not chest wall, skin involvement
Stage 4- distant mets, chest wall fixation)

Answer 13

IHx: CXR, CT or PET CT or MRI, bone scan, liver USS, LFTs, Ca+

Hormonal: tamoxifen
Chemotherapy:
Monoclonal: trastuzumab HER2 targeting

Question 14

Describe the inclusion criteria of the breast cancer screening programme

Answer 14

2 view mammography every 3 years

If aged 47-73

Question 15

Why are aromatase inhibitors only indicated for menopausal women with breast cancer?

Answer 15

They prevent conversion of testosterone and it’s precursor into oestrogen, which is the only way menopausal women gain oestrogen, however in the premenopausal woman the ovaries have alternative pathways to produce oestrogen.

Question 16

What does the triple assessment of a breast lump entail?

Answer 16

Clinical exam
Radiology- USS if under 35 years, + mammography if over 35 years
Histology- fine needle aspiration or core biopsy

Question 17

What is a fibroadenoma and how is it managed?

Answer 17

Solid tumours of collagenous mesenchyme which are firm, smooth and mobile.
May increase in size during pregnancy + regress after menopause.

IHx: reassure, if in doubt USS ± fine needle aspiration

Question 18

How is a simple breast cyst diagnosed?

Answer 18

Suspicion confirmed with aspiration- if clear fluid is withdrawn with no residual mass, it may be considered a simple cyst.
Enlargement of the cyst may cause pain

The cyst is derived from the terminal duct lobular unit, which fills with fluid is the efferent ductule becomes blocked

Question 19

What kind of imaging is needed for triple assessment of the breast of a woman who has had implants

Answer 19

MRI

Question 20

In patients with acute urinary retention, what medication can be given alongside catheterisation?

Answer 20

alpha 1a-blockers like Tamulosin

Relaxation of these receptors in the bladder neck and in the smooth muscle of the urethra enable passage of urine

Question 21

How may chronic and acute urine retention be distinguished?

Answer 21

Chronic- may drain >1.5L
In acute can go up to 1L but unlikely to be more than that

Need an urgent renal US incase backup of fluid and pressure has caused hydronephrosis

Question 22

In the histology of prostate hyperplasia which zone enlarges compared to in prostate malignancy?

Answer 22

Hyperplasia- the inner transitional zone

Carcinoma- peripheral zone

Question 23

Lower urinary tract symptoms to ask about

Answer 23

Irritative: nocturia, frequency, urgency
Obstructive: poor flow, hesitancy, post-micturition dribbling

Incontinence- can be a sign of acute-on-chronic with overflow

Question 24

3 investigations to rule out prostate cancer in someone with lower urinary tract symptoms?

Answer 24

PSA (before PR)
Transrectal USS
± biopsy

Also PR obviously

Question 25

Conservative management of benign prostatic hyperplasia

Answer 25

Lifestyle: avoid caffeine + alcohol, void twice in a row, bladder training (hold on for longer) Rx: a1A blockers- tamulosin, alfuzosin, doxazosin, terazosin 5a-reductase inhibitors- finasteride to reduce testosterone's conversion to dihydrotestosterone

Question 26

SEs of benign prostatic hyperplasia drugs?

Answer 26

a1A-blockers Low BP, dizziness, ejaculatory failure (SHOOT), dry mouth 5a-reductase Lower libido, impotence from less dihydrotestosterone

Question 27

Surgical options for benign prostatic hyperplasia?

Answer 27

> Transurethral resection of prostate- 14% risk of impotence > Transurethral incision of the prostate- for smaller prostates, some cuts reduce urethral pressure as the tissue can spring apart > Transurethral laser-induced prostatectomy > Retropubic prostatectomy- open op for very large prostate

Question 28

Why do U+Es need to be checked after a transurethral rection of prostate?

Answer 28

The water used can be absorbed leading to hyponatraemia, fits and low temperature

Question 29

What complications may arise following insertion of a catheter for chronic urinary retention?

Answer 29

Hyperkalaemia Metabolic acidosis (from Na+ and HCO3- loss, see below) Post-obstructive diuresis (provide resus fluids, matching output) Sodium and bicarbonate losing nephropathy- replace Infection- MC and S

Question 30

Why would a patient get faeculent vomiting?

Answer 30

Where there is colonic fistula with the proximal gut or potentially ileal obstruction Can recognise it by the smell on the breath

Question 31

How can ileus be differentiated from mechanical bowel obstruction?

Answer 31

There may be vomiting, nausea and anorexia in both but there is no pain in ileus, and bowel sounds are not present

Question 32

What are the three types of mechanical bowel obstruction?

Answer 32

1. Simple- one obstructing point, no vascular compromise 2. Closed loop- obstruction at two points forming a grossly distended bowel at risk of perforation (sigmoid volvulus, competent ileocaecal valve) 3. Strangulated- sharper, more constant and localised pain

Question 33

Management of bowel obstruction

Answer 33

Drip and suck Bloods- inc amylase AXR, erect CXR Catheter Surgery for closed loops (like sigmoid volvulus) or strangulation

Question 34

Management of sigmoid volvulus causing bowel obstruction

Answer 34

Sigmoidoscopy with insertion of a flatus tube | Occasionally may need sigmoid colectomy

Question 35

How distended does the large bowel need to get for you to worry about urgent decompression?

Answer 35

12cm should be getting urgent surgery

Question 36

What is Ogilvie's syndrome (acute colonic pseudo-obstruction) and how is it managed?

Answer 36

Mechanical GI obstruction, so bowel is active (not ileus) where no obstruction can be found (on CT or otherwise). Occurs after cardiac events and surgery, thought to be related to too much parasympathetic Rx: Neostigmine (anti-cholinesterase, which may increase parasympathetic output)

Question 37

What is the definition of a fistula?

Answer 37

Abnormal connection between epithelial surfaces

Question 38

What prevents fistulae spontaneously closing?

Answer 38

``` Presence of: Malignant tissue Distal obstruction Foreign body Chronic inflammation Muco-cutaneous junction (stoma) ```

Question 39

What is thought to be the cause of a fistulo-in-ano (fistula between skin and anal canal)

Answer 39

Blockage of deep intramuscular gland ducts leads to build up of secretions and then an abscess forms, which discharges by forming a fistula tract

Question 40

How does Goodsall's rule describe the path of a fistula track around the anus?

Answer 40

Goodsall's rule: Anterior opening- the track is in a straight line to the anus Posterior opening- the internal opening is always at 6 o clock, so when excising, cut a track that goes posterior immediately, then curves round

Question 41

Patient has bloody pus draining from a hole near their anus and pain on deification. What IHx what help determine if there is a fistula in ano there?

Answer 41

MRI | Endoanal US scan

Question 42

Treatment of a fistula-in-ano?

Answer 42

Fistulotomy + excision | Or lay open the fistula if low (heals by second intention)

Question 43

Causes of anal fistulas?

Answer 43

Inflammatory: Crohn's disease, immunocompromise Infectious: TB, perianal abscess (DM more common) Structural: Diverticular disease, rectal carcinoma

Question 44

What are haemorrhoids and what positions around the anus are they found in?

Answer 44

Dilated anal cushions (masses of spongy vascular tissue) From lithotomy position- 3, 7 and 11 o clock

Question 45

What's the innervation of the anus?

Answer 45

Above the dentate line (squamomucosal junction) = visceral supply from inferior hypogastric plexus Below dentate line- supplied by inferior rectal nerve (pudendal nerve branch) has somatic supply.

Question 46

Differential of rectal bleeding- bright red blood coating stools, found on PR

Answer 46

Perianal haematoma Anal fissure- incredibly painful (below dentate line) Abscess Tumour

Question 47

In suspected haemorrhoids, what 3 questions would make you thing about more sinister causes?

Answer 47

Weight loss Change in bowel habit Tenesmus

Question 48

How should you investigate internal + external suspected haemorrhoids?

Answer 48

Abdo exam + PR (internal ones won't be palpable) Proctoscopy- for internal Sigmoidoscopy- identifies any pathology up to the rectosigmoidal junction

Question 49

Management of haemorrhoids:

Answer 49

Conservative: fluid + fibre ± stool softener (docusate) Non-operative: rubber band ligation, sclerosants (more occurrence), infra-red coagulation Surgical: excisional haemorrhoidectomy, stapled haemorrhoidectomy (more reoccurrence)

Question 50

Classification of haemorrhoids:

Answer 50

1st: remain in the rectum 2nd: prolapse through anus on defecation, spontaneously reduce 3rd: need digital reduction 4th: persistently prolapsed Medical treatment only for 1st degree haemorrhoids, otherwise non-operative or surgical treatment

Question 51

Definition of hernia

Answer 51

Protrusion of tissue or an organ through the wall of the cavity in which it is normally contained

Question 52

How are inguinal and femoral hernias different?

Answer 52

Inguinal = commoner in males, Femoral in females Inguinal is superior + medial to the pubic tubercle Femoral is inferior + lateral to the pubic tubercle Femoral= more likely to be strangulated due to rigidity of canal borders

Question 53

Differential of a femoral hernia:

Answer 53

1. Inguinal hernia (wrong place mate) 2. Saphena varix (vein) 3. Enlarged Cloquet's node (lymph) 4. Lipoma (fat) 5. Femoral aneurysm (artery) 6. Psoas abscess (infection)

Question 54

What are the three different approaches to wound closure?

Answer 54

First intention- clean wound, all tissues are sewn up including skin Second intention- dirty wound with large epithelial loss, wound is left open and granulation tissue forms to close the wound slowly Third intention- wound is left open and then if found to be clean enough is sewed closed

Question 55

Which form of IBD is associated with the formation of fistulas?

Answer 55

Crohns disease (not UC)

Question 56

Risk factors for paraumbilical hernias?

Answer 56

Obesity | Ascites

Question 57

What is a Spigelian hernia?

Answer 57

One that occurs through the linea semilunaris (lateral edge of the rectus sheath, runs parallel to the linea alba)

Question 58

What is a Richter's hernia?

Answer 58

A hernia of the bowel wall which does not involved the whole lumen of the bowel

Question 59

What is a Maydl's hernia?

Answer 59

When a double loop of bowel is herniating- one loop through and another Becomes strangulated

Question 60

What is a littre's hernia?

Answer 60

Hernia of Meckel's diverticulum (Remnant of the yolk stalk, in 2% of people, 2 feet before the ileocaecal valve, 2 inches lng, 2 years for age of presentation)

Question 61

Main difference between gastroschisis and exomphalos

Answer 61

In exomphalos the gut herniates through the umbilicus and surgical repair is less urgent as the bowel is covered by a 3-layer membrane of peritoneum, Wharton's jelly and amnion. In gastroschisis, the herniation is right of the umbilicus and only a thin peel covers the protruding bowel. URGENT surgery needed

Question 62

What kind of inguinal hernias do male infants get?

Answer 62

Indirect hernias (from the patent procesus vaginalis)

Question 63

What is the management of umbilical and inguinal hernia's in infants?

Answer 63

Inguinal hernias need surgical repair, within days to weeks Umbilical hernias should close themselves (due to defect in the transversalis fascia)- not an omphalocele

Question 64

Difference between indirect and direct inguinal hernias:

Answer 64

1. Direct go through abdominal wall, indirect go through deep inguinal ring 2. Direct is medial to inferior epigastric vessel, indirect is lateral 3. Clinically on reduction of the hernia and occlusion at the deep inguinal ring, a cough will lead to re-protrusion in a direct hernia (theoretically)

Question 65

Contents of the inguinal canal:

Answer 65

3 fascial layers: External spermatic fascia (from ext oblique) Cremasteric (from internal oblique + transverses abdominus) Internal spermatic fascia (from transversalis fascia) 3 nerves: Sympathetics, genitofemoral nerve branch, ilioinguinal nerve 1 Artery, pampiniform plexus + vas deferenes + lymphatics

Question 66

What is the difference between a sliding and rolling hiatus hernia?

Answer 66

Sliding: gastro-oesophageal junction slides up into the chest. Often reflux. Rolling: gastro-oestrophageal junction remains in abdomen, with a bulge of stomach herniating into the chest. Reflux less common as sphincter remains intact

Question 67

Best diagnostic test for a hiatus hernia?

Answer 67

Barium swallow In cases of reflux, upper GI endoscopy can determine if there is oesophagitis of the mucosa but not reliably exclude hiatus hernia.

Question 68

Indications for surgery in someone with a hiatus hernia?

Answer 68

30% of those over 50 have a hiatus hernia, so medical therapy for reflux is recommended foremost: antacids, alginates, PPI Indication: intractable symptoms with medical management Complications of oesophagitis- Barrett's oesophagus, ulcers, benign strictures, iron-deficiency anaemia

Question 69

When examining a lump what things should be mentioned?

Answer 69

3S, 3C, 4T: Site, size, shape Colour, contour, consistency Tethered, temperature, tender, transilluminable

Question 70

What are dermoid cysts?

Answer 70

Slow-growing benign subcutaneous nodules forming where squamous epithelial cells get caught in deeper tissue In congenital cases, they will form along the midline, often in the neck. In ovarian cysts, these are better known as teratomal cysts Rx: surgical excision

Question 71

What is the cause of vulval warts?

Answer 71

Human papillomavirus (HPV) mostly 6+11

Question 72

Treatment of vulval warts?

Answer 72

If in a post-menopausal woman, always biopsy | Otherwise: diathermy, cryocautery or laser

Question 73

Treatment of common warts?

Answer 73

Salicylic acid | Cryotherapy

Question 74

How are plantar warts treated?

Answer 74

Plantar warts = large confluent Rx-resistant warts Occlusive plaster and combination therapy Ie Salicyclic acid + podophyllotoxin (topoisomerase inhibitor)

Question 75

What are the malignant and pre-malignant forms of skin moles?

Answer 75

Actinic keratoses > SCC in situ (Bowen's disease) > SCC Lentigo maligna > malignant melanoma Basal cell carcinoma (rodent ulcer)

Question 76

At what age should testicles ideally be fixed if they have failed to descend in an infant?

Answer 76

1 year Reduces infertility and risk of neoplasm and torsion (Malignancy risk still higher than normal, but easier to identify if testis are descended)

Question 77

What is the management for suspected testicular torsion?

Answer 77

Surgery within 6 hours Gain consent for orchidectomy (incase necrotic) and bilateral fixation. Can do Doppler USS if uncertain of diagnosis to demonstrate lack of blood flow to testes

Question 78

Patient has severe pain in the testis, and it appears tender, hot and swollen. What is the differential?

Answer 78

Testicular torsion- testis may lie high and transversely Epididymo-orchitis (+ dysuria, gradual onset of pain) Torsion of testicular appendage (less pain, blue nodule) Doppler USS can differentiate

Question 79

Causes of epididymo-orchitis:

Answer 79

Dysuria, fever, tender swelling NET MuCh ``` Neisseria gonorrhoea E Coli TB Mumps Chlamydia ```

Question 80

Rx of chlamydia

Answer 80

Doxycycline 100mg BD

Question 81

Rx of gonorrhoea (neisseria)

Answer 81

Ceftriaxone 500mg IM STAT | Often Azithromycin also for chlamydia as it's an atypical

Question 82

First line investigations for suspected renal stones?

Answer 82

Spiral non-contrast CT (Superior to IV urography) Need to exclude a ruptured AAA

Question 83

Conservative management of ureteral stones? (Urolithiasis)

Answer 83

Assess likelihood of spontaneous stone passage: If under 5mm, single stone, no evidence of complications (hydronephrosis) and low down, likely to spontaneously pass NSAIDs + IV fluids if vomiting (Opioids if NSAIDs CI) > 5mm or pain unresolving- nifedipine or tamulosin (a-blocker) > 1 cm requires urological input

Question 84

Interventional management of renal stones?

Answer 84

Under 1cm- extracorporeal shockwave lithotripsy or ureteroscopy Large or multiple stones- percutaneous nephrolithotomy (keyhole)

Question 85

What indications are there for urgent stone removal in nephrolithiasis?

Answer 85

Systemic demise: If infected AND obstructed Urosepsis Intractable pain or vomiting Kidney demise: Impending acute kidney injury Single kidney working Bilateral obstructing stones = percutaneous nephrostomy or stent

Question 86

What prevention can be given for patients who have suffered calcium-based kidney stones?

Answer 86

Diet: Maintain normal calcium intake (low Ca cause increased oxalate excretion) Rx: thiazide for calcium stones Pyridoxine for oxalate stones

Question 87

Preventative treatment for urate and cystine stones?

Answer 87

Allopurinol for urate stones Sodium bicarbonate (urine alkinalinization) for urate or cystine stones D-penicillamine for cystine stones

Question 88

Who gets cystine stones?

Answer 88

Those with cystinuria- an autosomal recessive defect in reabsorbing the amino acid cystine from the PCT Rx: High fluid intake Urinary alkalinization- sodium bicarbonate D-Penacillamine (forms a more soluble precipitate) Given with pyridoxine to prevent vit B6 deficiency

Question 89

3 features of Dent's disease?

Answer 89

Proteinuria Hypercalciuria Nephrocalcinosis = form alot of stones

Question 90

Medical causes of abdominal pain?

Answer 90

MI KEY to PNEU where POOR THEOry may LEAD ``` MI Ketoacidosis Pneumonia Porphyria Lead poisoning ```

Question 91

What are the borders of Hesselbach's triangle and why is it significant?

Answer 91

Base- inguinal ligament Lateral- inferior epigastric artery Medial- rectus sheath Where direct inguinal hernias occur

Question 92

Indications for end colostomies:

Answer 92

Can't tell from examination whether it's temporary or permanent : 1. Abdominoperitoneal resection (no anus)- permenant 2. Hartmann's- for resting the bowel in diverticulus or diverting if obstruction, temporary (may be mucous fistula)

Question 93

Indications for loop colostomy:

Answer 93

2 lumens, flush with skin: To protect distal anastomoses- for example after an anterior resection (proximal colon is anastomosed to the top of the anal canal)

Question 94

Indications for loop ileostomies:

Answer 94

2 lumens, spouted, often RIF: To protect distal anastomoses

Question 95

Indications for end ileostomy?

Answer 95

Panproctolectomy- for ulcerative colitis or familial adenomatous polyposis

Question 96

Indications for urostomy?

Answer 96

1 lumen, RIF, may have a catheter: New bladder conduit formed with a fragment of ileum, ureters are attached

Question 97

Complications of stomas:

Answer 97

Early: Haemorrhage, high output (loss of K_) Stoma ischaemia or obstruction (from adhesions) Stoma retraction Late: Obstruction, stenosis, stoma intussusception, stoma prolapse Dermatitis, parasternal hernia, fistulae Psychological and adjustment difficulties

Question 98

Indications for surgical amputation of a leg?

Answer 98

``` Irreversible ischaemia (necrosis) Refractory ulceration Loss of function such that it is not neeeded Extensive rhabdomyolysis ```

Question 99

When is an ultrasound not going to be able to pick up a suspected DVT? What should be used instead?

Answer 99

In veins above the common femoral vein, better to use CT venography for IVC and iliac vein thromboses.

Question 100

A patient with cancer develops a DVT, how should it be managed differently to a person who gets a DVT for a different reason?

Answer 100

LMWH instead of Warfarin for the duration of the anti-coagulation Anticoagulate for 6 months rather than 3 month norm for a provoked DVT

Question 101

Imaging for a patient with a PE + renal impairment?

Answer 101

V/Q lung scan | Rather than CTPA scan, lower radiation also so may be preferred in a young patient

Question 102

What are the different markers associated with different types of testicular tumours?

Answer 102

AFP- yolk sac (germ-cell, non-seminomatous) BHCG- choriocarcinoma*, syncytiotrophoblast (germ cell, non-seminomatous) Choriocarcinoma also known as malignant trophoblastic teratoma

Question 103

Which histological types of breast cancer have a good or bad prognosis?

Answer 103

Bad: no specific type (ductal) Good: tubular, mucinous + lobular