Arab Board Surgery Final Written cheat sheet

Phases of wound healing: haemostasis (minutes), inflammation (days 1–4), proliferation (days 4–21) and remodelling (day 21 to 1 year); type III collagen is progressively replaced by type I.

Wound tensile strength is about 5% of normal at 1 week, 20% at 3 weeks and 70–80% by 3 months; it never returns fully to that of uninjured skin.

Systemic factors delaying healing include diabetes, uraemia, jaundice, malnutrition (albumin below 30 g/L), corticosteroids, chemotherapy, radiotherapy and smoking.

Maintenance crystalloid by the 4-2-1 rule: 4 mL/kg/h for the first 10 kg, 2 mL/kg/h for the next 10 kg and 1 mL/kg/h for each remaining kilogram.

ASA physical status: I healthy; II mild systemic disease; III severe disease not incapacitating; IV incapacitating constant threat to life; V moribund unlikely to survive 24 hours without operation; VI brain-dead organ donor.

Haemorrhagic shock classes by blood loss: I under 15%, II 15–30% (tachycardia, narrowed pulse pressure), III 30–40% (hypotension, confusion), IV over 40% (obtunded, negligible urine output).

Surgical antibiotic prophylaxis is given within 60 minutes of skin incision (120 minutes for vancomycin and fluoroquinolones) and re-dosed every two half-lives or after 1500 mL blood loss.

Postoperative fever by timing: days 1–2 wind (atelectasis, pneumonia), days 3–5 water (urinary or line infection), days 5–7 wound (infection, abscess), after day 7 walk (deep vein thrombosis).

Perioperative nutrition targets 25–30 kcal/kg/day with 1.2–1.5 g/kg/day protein; enteral feeding is preferred and started within 24–48 hours of major surgery, including after anastomosis.

Appendicitis classically shows migration of pain to the right iliac fossa, anorexia, low-grade fever and leucocytosis; the Alvarado score (maximum 10) stratifies the need for imaging versus appendicectomy.

Small bowel obstruction is due to adhesions in about 75–80% of cases; manage with nil by mouth, nasogastric decompression and balanced crystalloid, and operate for fever, tachycardia, constant pain or raised lactate suggesting strangulation.

Perforated peptic ulcer shows free subdiaphragmatic gas on an erect chest radiograph; treatment is an omental (Graham) patch repair with peritoneal lavage and Helicobacter pylori eradication.

Forrest classification of bleeding ulcers: Ia spurting, Ib oozing, IIa visible vessel, IIb adherent clot, IIc flat pigment spot, III clean base; endoscopic haemostasis is indicated for stages Ia to IIb.

Inguinal hernia: indirect passes lateral to the inferior epigastric vessels through the deep ring, direct passes medial through Hesselbach's triangle, and femoral hernia lies below and lateral to the pubic tubercle.

Right-sided colorectal cancer presents with iron-deficiency anaemia and a mass, left-sided with obstruction and altered bowel habit, and rectal cancer with tenesmus and bleeding.

Anal fissure is typically in the posterior midline; chronic fissure with a sentinel tag is treated with lateral internal sphincterotomy or topical glyceryl trinitrate or diltiazem.

Haemorrhoids are graded I (bleeding only) to IV (irreducibly prolapsed); grades I–II respond to rubber band ligation while grade III–IV may require haemorrhoidectomy.

Sigmoid volvulus produces a coffee-bean sign on plain radiograph; flexible sigmoidoscopic detorsion with flatus tube placement is first line when there is no peritonitis or gangrene.

Couinaud's liver has eight segments, each with its own portal pedicle and hepatic vein tributary; segment I is the caudate lobe and drains directly into the inferior vena cava.

Child–Pugh score uses bilirubin, albumin, prothrombin time or INR, ascites and encephalopathy; class A (5–6), B (7–9) and C (10–15) predict operative risk and survival.

MELD uses bilirubin, INR and creatinine (with sodium in MELD-Na) and is used to prioritise allocation for liver transplantation.

Atlanta classification of acute pancreatitis: mild is interstitial without organ failure; moderately severe has transient organ failure under 48 hours or a local complication; severe has persistent organ failure beyond 48 hours.

Enteral feeding within 48 hours is preferred in acute pancreatitis, reduces infective complications compared with parenteral nutrition, and does not require waiting for enzyme normalisation.

Courvoisier's law: a palpable, non-tender gallbladder with painless jaundice is unlikely to be caused by stones and suggests periampullary or pancreatic head malignancy.

Choledocholithiasis with cholangitis or persistent obstruction is treated by ERCP within 24–48 hours; MRCP is the non-invasive confirmatory investigation.

After splenectomy give pneumococcal, meningococcal and Haemophilus influenzae type b vaccines at least 2 weeks preoperatively, lifelong penicillin V prophylaxis and a patient alert card.

Portal hypertension: hepatic venous pressure gradient above 10 mmHg predicts varices and above 12 mmHg predicts bleeding; non-selective beta-blockers and endoscopic band ligation are first-line prophylaxis.

Triple assessment of a breast lump combines clinical examination, imaging (ultrasound under 40 years, mammography from 40 years) and tissue diagnosis by core needle biopsy.

Breast cancer receptor status directs treatment: ER-positive receives endocrine therapy, HER2-positive receives trastuzumab, and triple-negative disease has the worst prognosis and relies on chemotherapy.

Sentinel lymph node biopsy with dye and radio-isotope is standard for clinically node-negative invasive breast cancer; axillary dissection is reserved for node-positive disease or failed mapping.

Papillary thyroid cancer spreads via lymphatics and takes up iodine-131; follicular spreads haematogenously to bone and lung; medullary secretes calcitonin; anaplastic is rapidly fatal.

Post-thyroidectomy hypocalcaemia causes perioral tingling with positive Chvostek and Trousseau signs; check corrected calcium and give intravenous calcium gluconate if symptomatic.

Recurrent laryngeal nerve injury causes hoarseness and a weak cough; external branch of the superior laryngeal nerve injury causes loss of high pitch; bilateral palsy causes stridor.

Primary hyperparathyroidism shows raised calcium, low phosphate and raised PTH; sestamibi scan and ultrasound localise a single adenoma, and focused or four-gland exploration with intraoperative PTH is definitive.

Phaeochromocytoma is diagnosed with plasma free metanephrines or 24-hour urinary metanephrines; give alpha-blockade with phenoxybenzamine for 10–14 days before adding beta-blockade to avoid hypertensive crisis.

An adrenal incidentaloma larger than 4 cm, or one with malignant imaging features or hormone excess, is excised; smaller non-functioning lesions are followed with imaging.

Ankle–brachial pressure index: normal 1.0–1.4, below 0.9 indicates peripheral arterial disease, below 0.5 indicates critical limb ischaemia, and above 1.3 suggests calcified non-compressible vessels.

Fontaine stages: I asymptomatic, IIa claudication beyond 200 m, IIb claudication under 200 m, III rest pain and IV ulceration or gangrene; Rutherford grades 0–6 add treadmill and pressure data.

Abdominal aortic aneurysm repair is offered at a diameter above 5.5 cm in men or 5.0 cm in women, if growth exceeds 1 cm per year, or if the aneurysm becomes symptomatic.

Ruptured AAA presents with back or abdominal pain, hypotension and a pulsatile mass; management is permissive hypotension, immediate transfer and EVAR or open repair.

Acute limb ischaemia shows the six Ps of pain, pallor, pulselessness, paraesthesia, paralysis and perishing cold; give intravenous heparin at once and revascularise within about 6 hours.

Symptomatic carotid stenosis of 70–99% (NASCET) warrants endarterectomy ideally within 14 days of the index event; 50–69% is decided case by case and below 50% is medical therapy.

Autogenous arteriovenous fistula is the preferred dialysis access; the rule of sixes at 6 weeks is flow above 600 mL/min, diameter above 6 mm, depth under 6 mm and usability within 6 weeks.

Diabetic foot assessment covers neuropathy (10 g monofilament), ischaemia (ABPI, pulses) and infection; Wagner grades 0–5 guide care, with offloading, debridement and revascularisation when ischaemic.

Deep vein thrombosis: use the Wells score, D-dimer for low or intermediate probability and compression ultrasound; anticoagulate for 3 months if provoked and longer if unprovoked or recurrent.

The primary survey follows ABCDE, with control of catastrophic external haemorrhage before airway; reassess after every intervention and treat each problem before moving on.

Trauma resuscitation uses balanced blood products; a massive transfusion ratio of 1:1:1 packed cells to fresh frozen plasma to platelets reduces mortality compared with crystalloid-heavy strategies.

The lethal triad is hypothermia, metabolic acidosis and coagulopathy; hypoperfusion and dilution worsen it, so damage control surgery corrects physiology before definitive repair.

Tension pneumothorax is a clinical diagnosis of respiratory distress, unilateral absent breath sounds, distended neck veins and hypotension; treat immediately with needle decompression followed by tube thoracostomy.

Cardiac tamponade shows Beck's triad of hypotension, distended neck veins and muffled heart sounds; FAST demonstrates pericardial fluid and treatment is pericardiocentesis or thoracotomy.

Major pelvic fracture: apply a pelvic binder at the level of the greater trochanters, give tranexamic acid within 3 hours, and consider preperitoneal packing or angioembolisation for continuing haemorrhage.

Burns: the Parkland formula gives 4 mL/kg per percent total body surface area of crystalloid in the first 24 hours, half in the first 8 hours, targeting urine output 0.5–1.0 mL/kg/h in adults.

Rule of nines in adults: head 9%, each arm 9%, each leg 18%, anterior trunk 18%, posterior trunk 18% and perineum 1%; the patient's palm represents about 1%.

Damage control laparotomy sequence: control bleeding by packing, ligation or shunting, control contamination, apply temporary abdominal closure, then rewarm and correct coagulopathy in intensive care.

TNM staging describes tumour size and local invasion (T), regional nodes (N) and distant metastases (M); stage is a stronger predictor of survival than grade.

Tumour grade describes differentiation and mitotic activity; high grade predicts local recurrence and metastasis but never overrides stage in prognostication.

Rectal cancer staged as T3 or T4, or with involved nodes, receives neoadjuvant long-course chemoradiotherapy or short-course radiotherapy before total mesorectal excision.

Tumour markers: CEA for colorectal, CA19-9 for pancreatic and biliary, alpha-fetoprotein for hepatocellular, CA-125 for ovarian and calcitonin for medullary thyroid carcinoma; none is diagnostic alone.

Sentinel node concept: the first draining node is identified with dye and isotope; if histologically negative the rest of the nodal basin is spared unnecessary dissection.

Soft tissue sarcoma requires wide local excision with a cuff of normal tissue; enucleation increases local recurrence, and radiotherapy is added for high-grade or large deep tumours.

The multidisciplinary team reviews imaging, pathology and staging to agree neoadjuvant therapy, surgical strategy and adjuvant treatment before definitive management of any solid tumour.

Palliative cancer pain follows the WHO ladder of non-opioid, weak opioid then strong opioid with adjuvants, given as regular background dosing plus breakthrough doses rather than as-required alone.

Sepsis-3 defines sepsis as life-threatening organ dysfunction from infection with a SOFA score rise of 2 or more; septic shock adds vasopressor requirement for MAP 65 mmHg and lactate above 2 mmol/L despite fluids.

qSOFA uses respiratory rate 22/min or more, systolic blood pressure 100 mmHg or less and Glasgow Coma Scale below 15; two or more criteria flag high-risk patients at the bedside.

Surviving Sepsis Campaign: measure lactate, take cultures before antibiotics, give broad-spectrum antibiotics within 1 hour in shock, and give 30 mL/kg crystalloid for hypotension or lactate of 4 or more.

Noradrenaline is the first-line vasopressor with a MAP target of 65 mmHg; vasopressin or adrenaline is added in refractory shock and hydrocortisone considered in vasopressor-dependent sepsis.

ARDS (Berlin criteria): onset within 1 week, bilateral opacities not explained by cardiac failure, and PaO2/FiO2 below 300 with PEEP of at least 5; ventilate at 6 mL/kg predicted body weight.

Abdominal compartment syndrome is sustained intra-abdominal pressure above 20 mmHg with new organ dysfunction; intra-abdominal hypertension is above 12 mmHg; treatment is decompressive laparotomy.

Antibiotic stewardship: culture before starting, review at 48–72 hours, de-escalate to the narrowest effective agent, and limit duration to 5–7 days for most intra-abdominal infections after source control.

Ventilator-associated pneumonia prevention: head of bed at 30–45 degrees, daily sedation interruption and spontaneous breathing trials, oral care, and subglottic suction in high-risk patients.

Nutrition in the critically ill: start enteral feeding within 24–48 hours at 25–30 kcal/kg/day with protein 1.2–2.0 g/kg/day, adding parenteral nutrition only when enteral intake remains inadequate.

Hypertrophic pyloric stenosis presents at 3–6 weeks with projectile non-bilious vomiting, a palpable olive and visible gastric waves; biochemistry shows hypochloraemic hypokalaemic metabolic alkalosis with paradoxical aciduria.

Intussusception affects children aged 6–36 months with colicky pain, redcurrant-jelly stool and a target or doughnut sign on ultrasound; pneumatic or hydrostatic reduction is first line if there is no peritonitis.

Biliary atresia presents with conjugated hyperbilirubinaemia and pale stools; Kasai portoenterostomy before 60 days of age improves native liver survival, otherwise transplantation is required.

Necrotising enterocolitis affects preterm infants; Bell staging runs from suspected to definite with pneumatosis intestinalis to advanced with perforation; treat with nil by mouth, antibiotics and surgery for perforation.

Meckel's diverticulum obeys the rule of twos: 2% of the population, 2 feet from the ileocaecal valve, 2 inches long, 2 ectopic tissue types, and symptoms before age 2 in half of cases.

Hirschsprung disease is aganglionosis of the distal colon; rectal biopsy shows absent ganglion cells with acetylcholinesterase-positive hypertrophic nerves, and treatment is a pull-through procedure.

Congenital diaphragmatic hernia (Bochdalek, usually left) shows respiratory distress, a scaphoid abdomen and bowel sounds in the chest; avoid bag-mask ventilation, pass a nasogastric tube and ventilate gently before repair.

Undescended testis is corrected by orchidopexy between 6 and 18 months of age to reduce the risk of malignancy and torsion and to preserve fertility.

Oesophageal atresia with tracheo-oesophageal fistula presents with frothy secretions, choking on feeds and a coiled nasogastric tube; it is part of the VACTERL association and needs staged repair.

Acute compartment syndrome presents with pain out of proportion, pain on passive stretch, paraesthesia and a tense compartment; pulselessness is a late sign and treatment is urgent fasciotomy.

Open fractures need tetanus prophylaxis, intravenous antibiotics within 1 hour, splinting and debridement with skeletal stabilisation; the Gustilo–Anderson grade guides fixation and soft tissue coverage.

Hyperacute rejection occurs within minutes to hours from preformed antibodies and is prevented by cross-matching; acute cellular rejection occurs in days to weeks and chronic rejection over months to years.

Glasgow Coma Scale: eye opening 1–4, verbal response 1–5, motor response 1–6, total 3–15; a score of 8 or less indicates the need for airway protection.

Extradural haematoma classically causes a lucid interval, an ipsilateral fixed dilated pupil and contralateral hemiparesis; CT shows a biconvex collection and urgent craniotomy is required.

Raised intracranial pressure causes headache, vomiting and papilloedema; Cushing's triad of hypertension with bradycardia and irregular respiration is a late and preterminal sign.

Ureteric colic: stones under 5 mm pass spontaneously in most patients; obstruction with fever or a solitary kidney requires urgent decompression by nephrostomy or ureteric stent.

Prostate cancer is investigated with PSA and digital rectal examination; a raised PSA leads to risk calculation and multiparametric MRI before biopsy, with Gleason score and stage guiding treatment.

Skin grafts need a vascular bed and cannot cover exposed bone, tendon or joint; flaps carry their own blood supply and are classified as random, axial, pedicled or free.