Summative Revision Notes
These notes consolidate the seven Surgery Morning Rounds. They are written for rapid pre-exam revision — not first-time learning. Each section heading links to its quiz. Summative pill-badges at the end of each section capture the single-line facts most likely to appear as isolated IBQs.
Pathology: loss of inhibitory (NO/VIP) neurons in Auerbach's (myenteric) plexus → tonically contracted LES + aperistalsis. Barium: bird-beak / rat-tail sign. Diagnosis: high-resolution manometry (gold standard). Pseudoachalasia trap: carcinoma of GEJ mimics achalasia — always endoscope to biopsy, especially if age >55, symptom duration <1 year, or rapid weight loss.
| Treatment | Notes |
|---|---|
| Pneumatic dilation | First-line non-surgical; 80–90% initial success; ~30% recurrence |
| Heller's cardiomyotomy + partial fundoplication | Surgical gold standard (Dor or Toupet wrap to prevent GORD) |
| POEM | Per-oral endoscopic myotomy; equivalent efficacy; no anti-reflux component |
| Type | Site | Acid | Key point |
|---|---|---|---|
| I | Incisura angularis, lesser curvature (MC, ~60%) | Normal/low | H. pylori; lowest malignancy risk; Billroth I preferred |
| II | Body + concurrent duodenal ulcer | High | Treat as duodenal ulcer (acid-driven) |
| III | Prepyloric (<3 cm from pylorus) | High | Behaves like duodenal ulcer |
| IV | Near GEJ (high lesser curvature) | Normal/low | Highest malignancy risk; biopsy mandatory |
| V | Anywhere | Normal/low | NSAID-induced; no H. pylori link |
All gastric ulcers: 6–8 biopsies from ulcer edge + repeat endoscopy at 8 weeks to confirm healing.
| Early | Late | |
|---|---|---|
| Timing | 15–30 min post-meal | 1.5–3 hrs post-meal |
| Mechanism | Hyperosmolar load → fluid shift → VIP/serotonin | Rapid glucose absorption → insulin overshoot → hypoglycaemia |
| Symptoms | Flushing, palpitations, diarrhoea (vasomotor) | Sweating, tremor, confusion (neuroglycopenic) |
| Blood glucose | Normal or slightly elevated | Low (<3.5 mmol/L) |
Management: small, frequent, low-carbohydrate meals; no fluids with meals; lie down post-meals. Octreotide if refractory. Roux-en-Y revision for severe medically refractory cases.
Endoscopic band ligation (EBL) = endoscopic treatment of choice. Pharmacological agent: start vasoactive drug immediately on suspicion — terlipressin (V1-selective; reduces mortality) or octreotide/somatostatin. Never use PPI as primary treatment for variceal bleed. Prophylactic antibiotics (ceftriaxone) mandatory in all cirrhotics — reduces SBP, rebleeding, mortality. Sengstaken-Blakemore tube = bridge only when EBL fails.
Achalasia: NO/VIP neuron loss Type I GU: incisura, low acid Type IV GU: highest Ca risk Early dumping: vasomotor, normal glucose Varices: terlipressin + EBL + prophylactic antibiotics
▶ Open Quiz 01MC cause of intestinal obstruction in infants 3 months–3 years (peak 5–10 months). Triad: colicky pain + redcurrant jelly stool + sausage-shaped mass. Dance's sign = empty RIF. USS: target/doughnut sign. First-line: pneumatic (air) enema — 80–90% success. Surgery for failed enema, peritonitis, perforation, or gangrene. Lead points (older children): Meckel's diverticulum, lymphoma, HSP.
| Feature | Crohn's | UC |
|---|---|---|
| Distribution | Any site, skip lesions, rectal sparing | Rectum → proximal, continuous, always involves rectum |
| Wall | Transmural | Mucosal + submucosal only |
| Histology | Non-caseating granulomas | Crypt abscesses; no granulomas |
| Surgery | NOT curative; conserve bowel; disease recurs | Curative; proctocolectomy + IPAA |
| Unique complications | Fistulae, abscesses, strictures, perianal disease | Toxic megacolon, PSC (primary sclerosing cholangitis) |
Gene: STK11/LKB1 (chr 19p). Features: mucocutaneous melanin pigmentation (lips, buccal mucosa, fingertips) + hamartomatous polyps (jejunum > ileum; arborising smooth muscle core on histology). MC complication: intussusception (polyps = lead points). Cancer risk: colorectal (39%), gastric (29%), pancreatic (36%), breast (54%), gonadal. Surveillance: 2-yearly capsule endoscopy + colonoscopy from age 8.
MC colonic volvulus (80%). Coffee-bean / omega sign pointing to RUQ. First-line (viable bowel): endoscopic decompression (flexible sigmoidoscopy + flatus tube). Hartmann's procedure for gangrenous bowel / failed decompression. Definitive: elective sigmoid resection (recurrence ~50% without surgery). Caecal volvulus: coffee-bean in RLQ points to LUQ — endoscopy rarely works → surgery (right hemicolectomy).
MANTRELS mnemonic (max 10): Migration (1) + Anorexia (1) + Nausea/vomiting (1) + Tenderness RIF (2) + Rebound (1) + Elevated temp (1) + Leukocytosis (2) + Shift to left (1). Score ≥7 in males → proceed to theatre without imaging. Score 5–6 → USS or CT. Ochsner-Sherren regimen: appendicular mass (day 3–5, no peritonitis) → conservative + interval appendicectomy at 6–8 weeks.
Intussusception: pneumatic enema first Crohn's: not curative PJS: STK11, arborising polyp Sigmoid volvulus: endoscopy first Alvarado ≥7 in males: direct to OT
▶ Open Quiz 02Charcot's triad: RUQ pain + fever + jaundice. Reynold's pentad: triad + altered sensorium + hypotension (septic cholangitis, Grade III — mortality >50%). MC cause: choledocholithiasis (~85%). Management: IV antibiotics + resuscitation → ERCP + sphincterotomy + stone extraction within 24–48 hrs (Grade II) or within 12 hrs (Grade III). Surgery (CBD exploration) reserved for failed ERCP.
| Ranson's — Admission (5) | Ranson's — 48 hours (6) |
|---|---|
| Age >55 · WBC >16,000 · Glucose >11 mmol/L · LDH >350 · AST >250 | HCT fall >10% · BUN rise >5 · Ca²⁺ <2 mmol/L · PaO₂ <60 · Base deficit >4 · Fluid >6 L |
Score <3 = mild; 3–4 = moderate-severe; ≥5 = severe (>50% mortality). Cannot be calculated until 48 hours. Best single marker: CRP >150 mg/L at 48 hrs. Amylase/lipase levels do NOT correlate with severity. Key management rules: aggressive IV Ringer's lactate; early enteral nutrition via NJ tube; no prophylactic antibiotics; surgery (necrosectomy) only for confirmed infected necrosis, never in first 2 weeks.
MC cause of conjugated neonatal jaundice. Acholic stools + dark urine + conjugated hyperbilirubinaemia + elevated GGT. USS: absent/small GB, non-dilated ducts. HIDA scan: no tracer excretion into gut. Diagnosis: intraoperative cholangiogram. Treatment: Kasai hepatoportoenterostomy — must be performed before 60 days of age for best outcome. ~70–80% eventually require liver transplantation.
Echinococcus granulosus (dog = definitive host; sheep = intermediate; humans = accidental). Gharbi classification: Type I = unilocular; Type II = multivesicular/daughter cysts; Type III = solid matrix; Type IV = calcified wall (inactive); Type V = fully calcified. First-line (Gharbi I/II): PAIR (Puncture, Aspiration, Injection of scolicidal agent, Re-aspiration) under ultrasound + albendazole cover. Surgery for large (>10 cm), infected, biliary communication, or superficial cysts. Never drain without scolicidal agent — secondary hydatidosis.
Courvoisier's law: painless, palpable, non-tender GB + jaundice = malignant obstruction (chronic stone disease fibroses GB wall). Double-duct sign: simultaneous CBD + pancreatic duct dilatation on MRCP = periampullary/pancreatic head Ca. Resectability: no distant mets + SMA/coeliac axis clear + SMV/portal vein patent (only ~15–20% at presentation). Whipple's: pancreatic head + duodenum + CBD + GB + distal stomach resected. MC post-op complication: delayed gastric emptying. Dreaded: pancreatic fistula.
Reynold's pentad: Grade III cholangitis Ranson's: not before 48 hrs Kasai: before 60 days PAIR + albendazole for hydatid Courvoisier's: malignant obstruction
▶ Open Quiz 03Intraductal papilloma: MC cause of blood-stained single-duct spontaneous discharge in reproductive-age women. Treatment: microdochectomy (single duct excision; cannulate pre-operatively with lacrimal probe). Duct ectasia: green/cheesy, bilateral, multiple ducts, older women, nipple retraction → Hadfield's operation (total duct excision). Paget's disease: eczematous nipple-areola change + underlying DCIS/invasive Ca; Paget cells (clear halo) on biopsy.
| Type | Cell | Spread | Marker | Histology hallmark |
|---|---|---|---|---|
| Papillary (MC, 80%) | Follicular | Lymphatic | Thyroglobulin | Orphan Annie nuclei + Psammoma bodies |
| Follicular (~10%) | Follicular | Haematogenous | Thyroglobulin | Capsular/vascular invasion (needs excision — cannot diagnose on FNAC) |
| Medullary (~5%) | C-cells (parafollicular) | Lymphatic + haematogenous | Calcitonin | Amyloid stroma (Congo red +ve) |
| Anaplastic (~2%) | Follicular | Direct invasion | None | Pleomorphic giant cells; median survival 3–6 months |
Follicular Ca trap: FNAC cannot diagnose it — capsular/vascular invasion is only seen on excision histology. FNAC reports follicular neoplasm (Bethesda IV) → hemithyroidectomy for diagnosis.
Parathyroid devascularisation → ↓ PTH → ↓ Ca²⁺. Signs: Chvostek (facial twitch, CN VII) + Trousseau (carpal spasm, BP cuff). Symptomatic / Ca²⁺ <1.9 mmol/L: IV calcium gluconate (not chloride IV). Mild: oral calcium carbonate + alfacalcidol. RLN injury: unilateral = hoarse voice; bilateral = airway compromise → emergency tracheostomy.
10% bilateral · 10% extra-adrenal (paraganglioma; MC = organ of Zuckerkandl) · 10% malignant · 10% familial (MEN 2A/2B, VHL, NF1) · 10% in children. Diagnosis: 24-hr urinary metanephrines (most sensitive). Pre-op preparation (mandatory): alpha-blockade FIRST (phenoxybenzamine 10–14 days) → then add beta-blockade. Never beta-first: unopposed alpha → hypertensive crisis. High-salt diet + liberal fluids to expand contracted plasma volume.
| Type | Gene | Components | Surgery sequence |
|---|---|---|---|
| MEN 1 (Wermer) | Menin, chr 11q13 | 3 Ps: Parathyroid (MC) + Pituitary + Pancreas (gastrinoma) | Parathyroidectomy (3½ glands) |
| MEN 2A (Sipple) | RET, chr 10q11 | Medullary thyroid Ca + Phaeochromocytoma + Hyperparathyroidism | Phaeochromocytoma first, then thyroidectomy |
| MEN 2B | RET codon 918 | MTC + Phaeochromocytoma + Mucosal neuromas + Marfanoid | Prophylactic thyroidectomy <6 months of age |
RET = proto-oncogene (gain of function). Menin = tumour suppressor (loss of function). In MEN 2A/2B: always screen for phaeochromocytoma before any elective surgery.
Papilloma: microdochectomy Follicular Ca: FNAC cannot diagnose Medullary Ca: calcitonin marker Phaeochromocytoma: alpha before beta MEN 2: phaeochromocytoma first
▶ Open Quiz 04MC urological malignancy; 90% transitional cell carcinoma. Risk factors: smoking (MC), aniline dyes (2-naphthylamine), schistosomiasis (SCC, not TCC), cyclophosphamide. Painless haematuria = bladder Ca until proven otherwise. NMIBC (Ta/T1/Tis): TURBT + intravesical BCG (high-grade) or single-dose mitomycin C (low-grade). MIBC (T2+): radical cystectomy + urinary diversion (ileal conduit or neobladder) ± neoadjuvant cisplatin.
Surgical emergency. Bell-clapper deformity (bilateral in ~50%). Triad: sudden onset severe scrotal pain + high-riding horizontal testis + absent cremasteric reflex. 6-hour rule: 100% salvage <6 hrs; 50% at 12 hrs; 10% at 24 hrs. Do not wait for Doppler USS if clinical diagnosis is confident. Operation: scrotal exploration → if viable: detorsion + bilateral orchidopexy (three-point fixation). If non-viable: orchidectomy + contralateral orchidopexy.
| Feature | Indirect | Direct |
|---|---|---|
| Relation to inferior epigastric artery | Lateral (through deep ring) | Medial (through Hesselbach's triangle) |
| Coverings | 3 layers (inc. internal spermatic fascia) | 2 layers |
| Scrotal descent | Common | Rarely descends |
| Strangulation risk | Higher | Lower |
Hesselbach's triangle (RIP): Rectus abdominis (medial) + Inferior epigastric artery (lateral) + Poupart's ligament (inferior). Triangle of Doom: vas deferens (medial) + testicular vessels (lateral) — contains external iliac vessels; no staples/tacks here in TEP/TAPP. Corona Mortis: aberrant obturator artery (~30% of patients) — fatal bleeding if divided.
Orchidopexy timing: 6–18 months, ideally before 12 months (germ cell loss begins from 6 months). Malignancy risk 3–5× higher (MC tumour: seminoma). Orchidopexy does not eliminate cancer risk but brings testis into an examinable position. Hormonal therapy (hCG/GnRH): <20% success for inguinal UDT — not recommended. Impalpable testis: diagnostic laparoscopy first.
Absorption of hypotonic glycine 1.5% irrigation fluid through open venous sinuses during TURP → dilutional hyponatraemia (Na⁺ <125 mEq/L) + hypervolaemia + glycine neurotoxicity (visual disturbance). Treatment: fluid restriction + IV furosemide + hypertonic saline (1.8–3%) if Na⁺ <120 or severe symptoms (correct ≤10 mEq/L/24 hrs). Prevention: bipolar TURP or HoLEP (use saline irrigation).
T2 bladder Ca: radical cystectomy Torsion: 6-hour window Direct hernia: medial to inf. epigastric Triangle of Doom: external iliac vessels Orchidopexy: 6–18 months
▶ Open Quiz 05MC injured organ: spleen > liver > small bowel/mesentery. Haemodynamically unstable + positive FAST → emergency laparotomy (no CT). Stable + positive FAST → CT abdomen for grading and management planning. Damage control surgery: abbreviated laparotomy — pack + clamp + temporary closure; avoid lethal triad (hypothermia + acidosis + coagulopathy). FAST: free fluid in Morrison's pouch, splenorenal pouch, pelvis, pericardium.
Proximal DVT: LMWH bridge → DOAC (rivaroxaban or apixaban) for minimum 3 months (provoked). Unprovoked: 3–6 months + reassess. Cancer-associated: LMWH or DOAC indefinitely. IVC filter: only if anticoagulation absolutely contraindicated. Thrombolysis: only for massive PE with haemodynamic instability or phlegmasia cerulea dolens. Stop OCP; thrombophilia screen after anticoagulation completed.
| Body region (adult) | TBSA % |
|---|---|
| Head & neck | 9% |
| Each upper limb | 9% |
| Anterior trunk | 18% |
| Posterior trunk | 18% |
| Each lower limb | 18% |
| Perineum | 1% |
Parkland formula: 4 mL × weight (kg) × %TBSA = total Ringer's lactate in 24 hrs. ½ in first 8 hrs from time of burn (not admission); ½ in next 16 hrs. Titrate to UO 0.5–1 mL/kg/hr. IV fluids for ≥15% TBSA (adult), ≥10% (child). No colloid in first 24 hrs. Eponyms: Curling's ulcer = stress ulcer in burns (duodenum); Marjolin's ulcer = SCC in chronic burn scar.
Stage I: asymptomatic · IIa: claudication >200 m · IIb: claudication <200 m · III: rest pain · IV: tissue loss. CLTI = Stages III + IV. ABPI: normal 0.9–1.3; mild 0.7–0.9; moderate 0.4–0.7; severe <0.4; >1.3 = non-compressible (diabetics). First-line for claudication (Stage II): supervised exercise therapy + smoking cessation + statin + antiplatelet. Revascularisation for disabling claudication or CLTI.
Elective repair: ≥5.5 cm in men; ≥5.0 cm in women; or any symptomatic/rapidly expanding (>1 cm/year) regardless of size. EVAR vs open: EVAR = lower 30-day mortality but requires lifelong surveillance for endoleaks + higher reintervention rates; long-term survival equivalent. Open = more durable, no mandatory follow-up imaging. Laplace's law: wall tension ∝ pressure × radius. Ruptured AAA triad: tearing back pain + hypotension + pulsatile mass → direct to theatre.
Unstable FAST+: laparotomy not CT DVT: DOAC 3 months minimum Parkland: time of burn not admission Fontaine IIb: supervised exercise first AAA ≥5.5 cm: elective repair
▶ Open Quiz 06| Feature | Extradural (EDH) | Subdural (SDH) |
|---|---|---|
| Source | Middle meningeal artery (arterial) | Bridging cortical veins (venous) |
| CT shape | Biconvex (lens-shaped); does not cross sutures | Crescent-shaped; crosses sutures freely |
| Classic history | Lucid interval (KO → recovery → rapid decline) | Acute: severe injury; Chronic: elderly, minor trauma/anticoagulants |
| Location | Temporal/temporoparietal (pterion fracture) | Frontoparietal; bilateral in chronic |
| Treatment | Emergency craniotomy + clot evacuation | Acute: craniotomy; Chronic: burr hole drainage |
Kernohan's notch: uncal herniation compresses contralateral cerebral peduncle → ipsilateral hemiplegia — a false localising sign. Pterion: thinnest skull bone, overlies MMA groove.
Features suggesting malignancy: >5 cm + deep to deep fascia + hard + heterogeneous on MRI + rapid growth. Biopsy: core needle (or incisional along long axis — so tract is excised en bloc). Never excisional biopsy — shelling through pseudocapsule seeds tumour. Treatment: wide local excision (R0) + post-operative radiotherapy — limb salvage in ~90%. Amputation reserved for tumours involving major neurovascular structures. Metastasis: haematogenous → lungs (not lymph nodes, except synovial sarcoma).
95% SCC; lower lip 90% (sun exposure, pipe smoking). T staging: T1 ≤2 cm; T2 2–4 cm; T3 >4 cm. N1 = single ipsilateral node ≤3 cm. Management: wide excision (V-plasty for <⅓ width; Abbe/Karapandzic flap for larger) + ipsilateral supraomohyoid neck dissection (levels I–III) for N+ disease. Occult nodal rate ~30% in cN0 T2 → elective neck treatment recommended.
Fulminant bacteraemia with encapsulated organisms (SHiN: Streptococcus pneumoniae [MC], Haemophilus influenzae type b, Neisseria meningitidis). Mortality 50–70% once established. Prevention: three vaccines (pneumococcal + meningococcal ACWY + Hib) ≥2 weeks pre-op (elective) or 2 weeks post-op (emergency) + lifelong penicillin V + emergency antibiotic card. Post-splenectomy findings: Howell-Jolly bodies, target cells, thrombocytosis.
| Class | Definition | SSI risk | Antibiotic prophylaxis |
|---|---|---|---|
| I — Clean | GI/GU/resp not entered; no inflammation | <2% | Only if implant used |
| II — Clean-contaminated | Controlled GI/GU/resp entry; minor break | 5–10% | Yes |
| III — Contaminated | Fresh trauma; major break; acute inflammation | ~20% | Yes (therapeutic) |
| IV — Dirty/Infected | Old wound; established infection; perforated viscus | >30–40% | Yes (therapeutic) |
Prophylaxis: given 30–60 minutes before skin incision (cefazolin first choice). Superficial incisional SSI: open wound + send swab + saline-moistened dressings + healing by secondary intention. Antibiotics not routinely required if adequately drained.
EDH: lucid interval + biconvex CT STS: never shell through pseudocapsule Lip SCC: supraomohyoid dissection OPSI: SHiN organisms Prophylaxis: 30–60 min before incision
▶ Open Quiz 07| Classification | What it grades | Key anchor |
|---|---|---|
| Modified Johnson's (I–V) | Gastric ulcer site + acid | Type I = incisura, low acid (MC); Type IV = GEJ, highest Ca risk |
| Ranson's (11 criteria) | Pancreatitis severity | Cannot calculate before 48 hrs; ≥5 = severe |
| Gharbi (I–V) | Hydatid cyst | I/II = active (PAIR); IV/V = inactive (no treatment) |
| Alvarado / MANTRELS (10) | Acute appendicitis | ≥7 in males = direct to OT; RIF tenderness + leukocytosis = 2 pts each |
| Fontaine (I–IV) | PAD severity | III/IV = CLTI; ABPI <0.4 = critical |
| Wound class (I–IV) | SSI risk | I <2%; II 5–10%; III ~20%; IV >30% |
Charcot's triad: pain + fever + jaundice (cholangitis) Reynold's pentad: + confusion + hypotension Courvoisier's sign: palpable non-tender GB = malignant obstruction Dance's sign: empty RIF in intussusception Cullen's / Grey Turner's: retroperitoneal haemorrhage (pancreatitis) Chvostek / Trousseau: hypocalcaemia Kernohan's notch: false localising sign (EDH) Curling's ulcer: stress ulcer in burns Marjolin's ulcer: SCC in burn scar Bell-clapper deformity: testicular torsion Goodsall's rule: fistula-in-ano tract direction
Parkland: 4 × kg × %TBSA; ½ in first 8 hrs from burn AAA repair: ≥5.5 cm (men), ≥5.0 cm (women) Torsion: 6-hr window for 100% salvage Orchidopexy: 6–18 months (ideal: 12 months) Kasai: before 60 days MEN 2B thyroidectomy: <6 months of age TUR syndrome: Na⁺ <125; correct ≤10 mEq/L/24 hrs Prophylaxis timing: 30–60 min before incision OPSI vaccines: ≥2 weeks pre-op or 2 weeks post-op
MEN 2A: phaeochromocytoma first, thyroid second Phaeochromocytoma: alpha-block before beta-block Corrosive ingestion: never vomit, never neutralise Pancreatitis necrosectomy: never in first 2 weeks Burns: Ringer's lactate, no colloid in first 24 hrs TURBT before cystectomy: stage the bladder first