General Surgery: Core Principles for the GSSE
Prioritising the acute abdomen
The single most examinable skill is triage: separating the patient who needs resuscitation and theatre from the one who needs investigation. Work through airway, breathing, circulation first, then assess the abdomen. Resuscitate before you investigate - a hypotensive patient with peritonitis goes to theatre after damage-control resuscitation, not to CT. Remember that analgesia does not mask signs and should not be withheld.
The classic patterns
Learn the pathognomonic histories: migration of pain from periumbilical to right iliac fossa (appendicitis), colicky pain radiating to the groin (ureteric stone), sudden severe epigastric pain radiating to the back (pancreatitis or perforated ulcer), and pain out of proportion to findings (mesenteric ischaemia). Rigidity and rebound signify peritonitis. Absent bowel sounds suggest ileus or peritonitis; hyperactive sounds suggest obstruction.
Investigations and their traps
Erect chest X-ray detects free air in roughly two-thirds of perforations - a normal film does not exclude it, and CT is more sensitive. Amylase is neither sensitive nor specific for pancreatitis; lipase is preferred. White cell count and CRP are supportive, not diagnostic. Always consider pregnancy in women of childbearing age (urine or serum beta-hCG) and consider AAA in older patients with back pain and hypotension.
Worked rule of thumb
For any acute abdominal presentation, ask: is this perforation, obstruction, ischaemia, or bleeding? Each has a surgical answer. A 65-year-old smoker with sudden back pain, hypotension, and a pulsatile mass has a ruptured AAA until proven otherwise - do not send for a CT if unstable; call vascular surgery immediately.
Postoperative principles
Understand the timeline of complications: haemorrhage and anastomotic leak early, wound infection around day five, and adhesive obstruction later. Fever plus tachycardia after bowel surgery is leak until excluded.