Surgery: Assessment, Complications and Safe Disposition
What you must understand
Surgical items reward a systematic approach. Learn: (1) the acute abdomen - appendicitis, cholecystitis, pancreatitis, small and large bowel obstruction, perforated viscus, diverticulitis, testicular torsion; (2) trauma principles - primary survey, tension pneumothorax and cardiac tamponade, pelvic fracture with haemorrhage, head injury and Glasgow Coma Scale; (3) perioperative care - fasting, VTE prophylaxis, antibiotic prophylaxis, wound classification, consent; (4) postoperative complications by timeline - immediate (haemorrhage, anastomotic leak, anaesthetic issues), early (infection, ileus, atelectasis, urinary retention), late (adhesional obstruction, incisional hernia); (5) common referrals - hernia, breast lump, thyroid swelling, skin lesions, and the red flags that mandate urgent referral.
Traps that appear
- Analgesia does not mask a surgical abdomen - withholding it is a classic wrong answer.
- "Normal" inflammatory markers early in appendicitis or obstruction.
- Confusing small bowel (central, multiple levels, early vomiting) with large bowel obstruction (peripheral, distension, later vomiting).
- Missing the red flag in an otherwise benign-sounding presentation (weight loss, rectal bleeding, night pain, family history).
- Choosing imaging over resuscitation in an unstable patient.
Rule of thumb
Unstable patient → resuscitate and call for senior/surgical help; stable patient → targeted investigation. For any lump, ask: is it tender, mobile, fluctuant, pulsatile, and does it transilluminate?
Worked example
A 24-year-old woman has 12 hours of periumbilical pain migrating to the right iliac fossa with localised guarding and low-grade fever. Which is the most appropriate next step? The answer is surgical review with analgesia and appropriate imaging/blood tests - not discharge with reassurance, and not delaying analgesia.