ABS General Surgery cheat sheet

Upper GI bleed: resuscitate first, then endoscopy within 24 h; IV PPI infusion reduces rebleeding in high-risk peptic ulcers (Forrest Ia-IIb).

Acute appendicitis: Alvarado score components = migration of pain, anorexia, nausea/vomiting, tenderness RIF, rebound, fever, leukocytosis, left shift.

Small bowel obstruction: 80% resolve with NG decompression and IV fluids; operate for strangulation signs (fever, tachycardia, constant pain, peritoneal signs, closed loop).

Colorectal cancer obstruction: right-sided usually managed with resection/anastomosis; left-sided obstructing lesions may need stoma or stent as bridge to surgery.

Crohn disease surgery is for complications (stricture, fistula, abscess), not cure; preserve bowel length with strictureplasty where feasible.

Mesenteric ischemia: pain out of proportion to exam, acidosis, elevated lactate; treat with heparin, revascularization, and resection of frankly necrotic bowel with second-look laparotomy.

Gastric cancer: D2 lymphadenectomy improves staging; R0 resection is the only curative option; adjuvant chemo for stage IB-III.

Perforated peptic ulcer: omental (Graham) patch repair plus peritoneal lavage; test and treat H. pylori postoperatively.

Lower GI bleed: colonoscopy after rapid prep; if brisk and unstable, angiography (CTA or embolization) or surgery.

Inguinal hernia: indirect passes lateral to inferior epigastric vessels through deep ring; direct passes medial through Hesselbach triangle.

Femoral hernia lies below and lateral to pubic tubercle, medial to femoral vein; high strangulation risk - repair promptly.

Acute cholecystitis: early laparoscopic cholecystectomy (within 72 h) is preferred over delayed surgery in fit patients.

Choledocholithiasis: MRCP or EUS for diagnosis; ERCP for clearance; choledochotomy with T-tube if ERCP fails.

Acute pancreatitis: fluid resuscitation, analgesia, early enteral feeding; ERCP only for concurrent cholangitis or persistent obstruction.

Splenectomy indications: trauma (hemodynamic instability), ITP refractory, hereditary spherocytosis; vaccinate against encapsulated organisms preoperatively when possible.

Abdominal compartment syndrome: bladder pressure >20 mmHg with new organ dysfunction; decompressive laparotomy is definitive.

Hepatic abscess: pyogenic usually polymicrobial from biliary source; amebic from Entamoeba histolytica - metronidazole, drainage if large.

Triple assessment = clinical exam + imaging (mammogram/US) + tissue sampling (core biopsy) for any suspicious breast mass.

BI-RADS categories: 0 incomplete, 1-2 benign, 3 probably benign (<2% malignancy), 4 suspicious (biopsy), 5 highly suggestive (>95%).

Sentinel lymph node biopsy is standard for clinically node-negative invasive breast cancer; axillary dissection for node-positive disease or failed SLNB.

Breast conservation requires negative margins (no tumor on ink) plus whole-breast radiation; contraindicated in multicentric disease or prior chest radiation.

Inflammatory breast cancer: diffuse erythema, peau d'orange, dermal lymphatic invasion - treat with neoadjuvant chemotherapy then mastectomy, not primary surgery.

ER/PR-positive, HER2-negative early breast cancer: endocrine therapy (tamoxifen or aromatase inhibitor) reduces recurrence; Oncotype DX guides chemo.

Male breast cancer: usually ER-positive ductal; treat with mastectomy and endocrine therapy; BRCA2 association.

Nipple discharge: bloody or unilateral spontaneous warrants duct excision or ductoscopy; galactorrhea is usually bilateral and medical (prolactin).

Abscess: incision and drainage is primary therapy; antibiotics are adjunct for systemic signs, immunosuppression, or extensive cellulitis.

Necrotizing soft tissue infection: LRINEC score, pain out of proportion, crepitus, skin necrosis; treat with urgent wide debridement and broad-spectrum antibiotics.

Cellulitis: Streptococcus and Staphylococcus coverage; mark borders and reassess at 24-48 h; consider MRSA coverage for purulent or penetrating trauma.

Melanoma: Breslow thickness drives prognosis and margins (in situ 0.5-1 cm, ≤1 mm 1 cm, 1-2 mm 1-2 cm, >2 mm 2 cm).

Sentinel lymph node biopsy for melanoma offered for tumors >1 mm thick or 0.8-1 mm with ulceration/mitoses.

Squamous cell carcinoma: high-risk features (depth >2 mm, perineural invasion, immunosuppression, ear/lip) warrant nodal evaluation and wider margins.

Basal cell carcinoma: rarely metastasizes; Mohs surgery for high-risk facial lesions; standard excision with 4-6 mm margins for low-risk.

Burn resuscitation: Parkland formula 4 mL/kg/%TBSA lactated Ringer over 24 h, half in first 8 h from burn time.

Thyroid nodule: TSH first; FNA for nodules >1 cm with suspicious ultrasound features; Bethesda category guides surgery extent.

Papillary thyroid cancer: total thyroidectomy for tumors >4 cm or bilateral; central neck dissection for clinically positive nodes; radioiodine for high-risk.

Medullary thyroid cancer: calcitonin and CEA markers; RET mutation testing; total thyroidectomy with central neck dissection; no radioiodine.

Primary hyperparathyroidism: elevated calcium with inappropriately normal/high PTH; sestamibi or 4D-CT for localization; focused parathyroidectomy with intraoperative PTH drop >50%.

Pheochromocytoma: alpha-blockade (phenoxybenzamine) before beta-blockade to avoid hypertensive crisis; measure plasma metanephrines.

Adrenal incidentaloma: assess hormonal function (cortisol, aldosterone, metanephrines) and imaging; resect if >4 cm or functional.

Cushing syndrome: 24-h urine free cortisol, late-night salivary cortisol, dexamethasone suppression; pituitary MRI and inferior petrosal sinus sampling for source.

Insulinoma: Whipple triad, elevated insulin and C-peptide during hypoglycemia; enucleation or distal pancreatectomy.

Sepsis-3: suspected infection plus SOFA increase ≥2; qSOFA (RR ≥22, SBP ≤100, altered mentation) is a bedside screen.

Septic shock: vasopressors to MAP ≥65 mmHg and lactate >2 mmol/L despite adequate fluids; norepinephrine first-line.

ARDS Berlin criteria: acute onset, bilateral opacities, PaO2/FiO2 ≤300 on PEEP ≥5, not cardiogenic; low tidal volume 6 mL/kg predicted body weight.

Ventilator-associated pneumonia: occurs >48 h after intubation; diagnose with quantitative cultures or clinical criteria; treat 7 days typically.

Acute kidney injury: KDIGO staging by creatinine rise and urine output; continuous renal replacement for hemodynamic instability.

Transfusion: restrictive threshold (Hgb 7 g/dL, 8 g/dL in cardiac surgery or CAD) noninferior to liberal in most critically ill patients.

Nutrition: enteral feeding within 24-48 h in critically ill; parenteral if enteral contraindicated; trophic feeding acceptable in ARDS.

DVT prophylaxis: LMWH or UFH for most ICU patients; mechanical prophylaxis when bleeding risk high.

TNM staging defines prognosis and treatment; multidisciplinary tumor board guides neoadjuvant vs adjuvant sequencing.

R0 resection (microscopically negative margins) is the goal in curative oncologic surgery; R1/R2 indicate residual disease.

Sentinel lymph node mapping uses dye and/or radiotracer to identify first draining node; applies to breast cancer and melanoma.

Neoadjuvant therapy downsizes locally advanced tumors (rectal, esophageal, breast, pancreatic borderline resectable) to improve resectability.

Colorectal liver metastases: resectable disease has 5-year survival ~40-50%; use RAS/BRAF testing and perioperative chemotherapy.

GIST: driven by KIT/PDGFRA mutations; treat with imatinib; resect if resectable without rupture; avoid tumor rupture.

Soft tissue sarcoma: wide local excision with negative margins; radiation for high-grade or large deep tumors; limb-sparing preferred.

Palliative care improves quality of life and may improve survival when integrated early with oncology care.

ATLS primary survey: Airway with cervical spine protection, Breathing, Circulation with hemorrhage control, Disability, Exposure/Environment.

Hemorrhagic shock classes: I (<15% loss), II (15-30%), III (30-40%), IV (>40%); class III/IV need blood products.

Massive transfusion protocol: balanced 1:1:1 ratio of PRBC:FFP:platelets; give tranexamic acid within 3 h of injury.

FAST exam detects free fluid in pericardial, perihepatic, perisplenic, and pelvic windows; repeat if initially negative and unstable.

Tension pneumothorax: clinical diagnosis - immediate needle decompression then tube thoracostomy; do not wait for imaging.

Splenic injury: nonoperative management for hemodynamically stable patients; angioembolization for grade III-V with blush; splenectomy if unstable.

Pelvic fracture with hemorrhage: binder, angioembolization or preperitoneal packing; exclude urethral injury before Foley.

Traumatic brain injury: avoid hypotension and hypoxia; ICP >20 mmHg warrants treatment; hypertonic saline or mannitol for herniation.

Damage control laparotomy: control hemorrhage and contamination, temporary closure, ICU resuscitation, planned reexploration.