Surgery: Assessment, Timing, and Safe Operative Decisions
Priority concepts
Expect questions on the acute abdomen, perioperative risk stratification, wound classification, trauma resuscitation, and the complications that announce themselves late. Master the differential for abdominal pain by quadrant and by onset, the features that separate obstruction from ileus, and the indications for urgent versus emergent operation. Know that the most common cause of small bowel obstruction is adhesions, but in a patient with no prior abdominal surgery, consider hernia, malignancy, or inflammatory stricture first.
Perioperative assessment is risk-focused: functional capacity, cardiopulmonary reserve, anaemia, glycaemic control, VTE risk, and medication management (anticoagulants, antiplatelets, steroids). Wound classification (clean, clean-contaminated, contaminated, dirty) predicts infection and drives antibiotic prophylaxis timing - within 60 minutes of incision for most agents.
Traps
Distractors describe the correct diagnosis but the wrong urgency. A stable patient with uncomplicated diverticulitis does not need theatre; a patient with pneumoperitoneum does. Fever and leucocytosis are non-specific and should not be allowed to override peritoneal signs. Conversely, absence of fever does not exclude a surgical abdomen in the elderly or immunosuppressed.
Worked example
A 68-year-old with right upper quadrant pain, fever, and jaundice (Charcot triad) has ascending cholangitis. The answer is resuscitation plus antibiotics and urgent biliary drainage, usually endoscopic retrograde cholangiopancreatography - not cholecystectomy as the initial step.
Rule of thumb
In trauma, follow the primary survey in order and treat each threat before moving on; the commonest reversible causes of deterioration are airway loss, tension pneumothorax, haemorrhage, and tamponade. In any acute abdomen, ask: does this patient need the operating theatre now, soon, or never?