Iraqi Board General Surgery cheat sheet

Cellular response to injury: reversible swelling → mitochondrial vacuolization → irreversible membrane rupture with lysosomal enzyme release; necrosis triggers inflammation, apoptosis does not.

Wound tensile strength: ~5% at 1 week, ~20% at 3 weeks, ~70–80% of final at 6 weeks; final plateau ~80% of unwounded skin.

Collagen types: type I mature scar and bone; type III early granulation tissue and fetal skin; type IV basement membrane; type V corneal stroma and fetal tissue.

Nerve conduction: A-alpha (motor/proprioception) fastest and most sensitive to pressure; A-delta and C fibers carry pain and are blocked first by local anesthetics (C fibers most sensitive to blockade).

Frank–Starling: stroke volume rises with preload up to the optimal sarcomere length; beyond it, volume loading does not increase output and worsens pulmonary edema.

Surgical microbiology: Staphylococcus aureus and coagulase-negative staph dominate skin flora; Bacteroides fragilis and E. coli dominate colonic flora; Clostridioides difficile follows broad-spectrum antibiotics.

Pharmacology: aminoglycosides are nephrotoxic and ototoxic and need renal dosing; vancomycin needs trough/AUC monitoring; metronidazole covers anaerobes; cephalosporins cover gram-positive and many gram-negative organisms.

Tumor markers: CEA (colorectal, not for screening), CA 19-9 (pancreas), AFP (hepatocellular, germ cell), CA 125 (ovarian), calcitonin (medullary thyroid), thyroglobulin (differentiated thyroid follow-up).

Acid–base: anion gap = Na − (Cl + HCO3), normal 8–12; delta ratio >2 suggests concurrent metabolic alkalosis, <1 concurrent normal-gap acidosis.

Surgical site infection (SSI) prevention: prophylactic antibiotic within 60 minutes before incision (120 minutes for vancomycin/fluoroquinolones), redosing at 2 half-lives or large blood loss, stop within 24 hours.

Wound classification: clean (no viscus entered), clean-contaminated (controlled viscus entry), contaminated (gross spillage, acute inflammation), dirty (pus, perforation) - infection rates rise accordingly.

Healing phases: hemostasis (minutes), inflammation (days 1–4), proliferation (days 4–21), remodeling (weeks to months); vitamin C and zinc deficiency, steroids, diabetes, and ischemia impair healing.

Shock types: hypovolemic (low CVP, low CO, high SVR), cardiogenic (high CVP, low CO, high SVR), distributive/septic (low CVP, high CO, low SVR), obstructive (high CVP, low CO).

ATLS adult crystalloid: 1 L warm isotonic crystalloid as initial bolus, then blood products in 1:1:1 ratio (plasma:platelets:red cells) for hemorrhagic shock; permissive hypotension until hemorrhage control.

Maintenance fluids: 4-2-1 rule (4 mL/kg/h first 10 kg, 2 mL/kg/h next 10 kg, 1 mL/kg/h thereafter); replace deficits with isotonic crystalloid and monitor urine output 0.5 mL/kg/h.

Nutrition: enteral feeding preferred when the gut works; start within 24–48 hours after major surgery; refeeding syndrome risk needs thiamine and phosphate replacement.

Perioperative risk: ASA class, revised cardiac risk index (RCRI) ≥2, and functional capacity <4 METs predict cardiac complications; continue beta-blockers, stop smoking ≥4 weeks preoperatively.

Esophageal cancer: adenocarcinoma distal esophagus (Barrett, reflux) vs squamous cell (upper/mid, smoking, alcohol); staging with EUS and PET-CT; neoadjuvant chemoradiation for locally advanced disease.

Gastric cancer: intestinal type follows H. pylori gastritis; diffuse type (signet ring) is hereditary (CDH1 mutation); D2 lymphadenectomy for resectable disease; margins ≥5 cm for diffuse type.

Peptic ulcer bleeding: Forrest classification (Ia spurting, Ib oozing, IIa visible vessel, IIb adherent clot, IIc flat spot, III clean base); endoscopic therapy for Ia–IIb; high-dose PPI infusion after endoscopic hemostasis.

Small bowel obstruction: air-fluid levels on plain film, transition point on CT; initial nasogastric decompression and fluids; operate for strangulation signs (fever, tachycardia, peritoneal signs, closed loop).

Colorectal cancer: right-sided tumors cause anemia and mass; left-sided cause obstruction; staging by TNM; adjuvant chemotherapy for stage III and high-risk stage II; CEA for surveillance.

Acute appendicitis: Alvarado score (migration, anorexia, nausea, tenderness, rebound, fever, leukocytosis, shift); CT or ultrasound in equivocal cases; laparoscopic appendectomy is standard.

Liver: Child–Pugh and MELD predict operative risk; portal triad (hepatic artery, portal vein, common bile duct); Couinaud segments based on hepatic veins; Pringle maneuver controls inflow.

Biliary: choledocholithiasis with cholangitis (Charcot triad: fever, jaundice, right upper quadrant pain; Reynolds pentad adds shock and confusion) needs ERCP and antibiotics.

Pancreas: acute pancreatitis - elevated lipase/amylase, Atlanta classification (interstitial edematous vs necrotizing); gallstone pancreatitis cholecystectomy on index admission; splenectomy indicated for trauma, ITP, hereditary spherocytosis.

Thyroid: papillary (lymphatic spread, excellent prognosis, radioactive iodine), follicular (hematogenous spread, needs histology for diagnosis), medullary (calcitonin, RET mutation, MEN2), anaplastic (rapid, poor prognosis).

Recurrent laryngeal nerve injury causes hoarseness; bilateral injury causes stridor and airway obstruction; external branch of superior laryngeal nerve injury causes voice fatigue and loss of high pitch.

Hypocalcemia after total thyroidectomy: perioral numbness, Chvostek and Trousseau signs; check calcium and treat with IV calcium gluconate if symptomatic; risk rises with central neck dissection.

Thyroid storm: fever, tachycardia, agitation, heart failure; treat with beta-blocker, thionamide (PTU), iodine after thionamide, steroids, and supportive care.

Primary hyperparathyroidism: elevated calcium with inappropriately normal/high PTH; most commonly a single adenoma; sestamibi and ultrasound for localization; indications for surgery include calcium >1 mg/dL above normal, renal stones, osteoporosis, age <50.

Adrenal: pheochromocytoma causes episodic hypertension, headache, sweating, palpitations; check plasma metanephrines; alpha-blockade before beta-blockade to avoid hypertensive crisis.

Conn syndrome (primary aldosteronism): hypertension with hypokalemia, elevated aldosterone-to-renin ratio; adrenal vein sampling to lateralize; adrenalectomy for unilateral adenoma.

Breast cancer: triple assessment (clinical, imaging, core biopsy); sentinel node biopsy for clinically node-negative disease; receptor status (ER, PR, HER2) determines adjuvant therapy; axillary dissection for node-positive disease.

Breast: fibroadenoma (young women, mobile, rubbery), fibrocystic change (cyclical), duct ectasia (periareolar discharge), Paget disease (eczematous nipple, underlying carcinoma).

Peripheral arterial disease: ankle-brachial index (ABI) <0.9 is abnormal; 0.5–0.9 claudication, <0.4 rest pain, <0.2 tissue loss; falsely elevated in diabetes and renal failure due to calcified vessels.

Acute limb ischemia: 6 Ps (pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia); Rutherford classification; heparin immediately, embolectomy or thrombolysis within 6 hours.

Aortic aneurysm: elective repair for infrarenal AAA ≥5.5 cm or rapid growth >1 cm/year; symptomatic or ruptured AAA needs immediate surgery; endovascular repair preferred when anatomy allows.

Carotid disease: symptomatic stenosis ≥70% benefits from endarterectomy; asymptomatic ≥60–70% may benefit; operate within 2 weeks of transient ischemic attack.

Varicose veins: great saphenous vein incompetence; treat with compression, endovenous ablation, or surgery; venous ulcers occur at the medial malleolus with hyperpigmentation.

Deep vein thrombosis: Virchow triad (stasis, endothelial injury, hypercoagulability); duplex ultrasound for diagnosis; anticoagulation for 3 months for provoked, longer for unprovoked or cancer-associated.

Amputation: below-knee amputation preserves knee function and needs a viable posterior flap; above-knee for non-salvageable below-knee disease; rehabilitation with early prosthesis fitting.

Vascular access: radiocephalic (Brescia–Cimino) arteriovenous fistula is first choice; maturation takes 6–8 weeks; avoid ipsilateral subclavian lines in dialysis patients to preserve veins.

Primary survey: airway with cervical spine control, breathing, circulation, disability, exposure; reassess after each intervention; adjuncts include monitoring, urinary catheter, and gastric tube.

Tension pneumothorax: tracheal deviation, distended neck veins, absent breath sounds; immediate needle decompression then chest tube - never wait for imaging.

Massive hemothorax: >1500 mL immediately or >200 mL/h for 2–4 hours; chest tube plus blood products; thoracotomy for persistent bleeding.

FAST exam: pericardial, perihepatic, perisplenic, and pelvic windows; unstable patient with positive FAST needs laparotomy; stable patient with positive FAST needs CT.

Damage control surgery: control hemorrhage and contamination, temporary closure, correct hypothermia, acidosis, and coagulopathy, then definitive repair.

Burns: Wallace rule of nines (head 9%, each arm 9%, each leg 18%, anterior trunk 18%, posterior trunk 18%, perineum 1%); Parkland formula 4 mL/kg/% TBSA for 24 hours, half in first 8 hours.

Burn depth: superficial (erythema, no blister), superficial partial (blisters, painful, moist), deep partial (mottled, less painful), full thickness (leathery, insensate, charred).

Abdominal trauma: blunt - spleen most commonly injured; penetrating - liver and bowel; seat-belt sign suggests hollow viscus injury; free air on CT indicates perforation.

Critical care: sepsis-3 defines sepsis as infection plus SOFA ≥2; septic shock needs vasopressors to maintain MAP ≥65 mmHg with lactate >2 mmol/L despite fluids.

TNM staging: T = primary tumor size/invasion, N = regional nodes, M = distant metastasis; stage grouping determines prognosis and treatment; AJCC staging is updated periodically.

R0 resection means microscopically negative margins; R1 microscopic positive; R2 macroscopic residual disease; R0 is the goal of curative resection.

Sentinel lymph node biopsy: inject blue dye and/or radiolabeled colloid; first draining node predicts regional status; used in breast cancer and melanoma.

Adjuvant therapy: chemotherapy for stage III colorectal cancer; trastuzumab for HER2-positive breast cancer; imatinib for c-KIT-positive gastrointestinal stromal tumor.

Neoadjuvant therapy: downstages locally advanced rectal, esophageal, and breast cancer; improves sphincter preservation in rectal cancer and resectability in esophageal cancer.

Colorectal liver metastases: resectable disease has 5-year survival up to 40–50%; use FOLFOX/FOLFIRI plus anti-EGFR or anti-VEGF to convert borderline resectable disease.

Tumor lysis syndrome: hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia; prevent with hydration and allopurinol or rasburicase in high-risk lymphoma.

Paraneoplastic syndromes: hypercalcemia (squamous cell lung, breast, myeloma), Cushing syndrome (small cell lung), hypoglycemia (hepatocellular carcinoma), polycythemia (renal cell carcinoma).

Hypertrophic pyloric stenosis: 3–6 weeks old, nonbilious projectile vomiting, olive-shaped mass, hypochloremic hypokalemic metabolic alkalosis; correct electrolytes then pyloromyotomy.

Intussusception: 6–18 months, colicky pain, red currant jelly stool, sausage-shaped mass; ultrasound target sign; air or contrast enema reduction if stable.

Hirschsprung disease: absent ganglion cells in distal bowel, delayed meconium, abdominal distension; diagnosis by rectal biopsy; treatment is pull-through resection.

Biliary atresia: jaundice beyond 2 weeks with direct hyperbilirubinemia, acholic stools; Kasai portoenterostomy before 60 days improves outcome; liver transplant for failure.

Neonatal bowel obstruction: duodenal atresia (double bubble), jejunoileal atresia, meconium ileus (cystic fibrosis), malrotation with volvulus (bilious vomiting - surgical emergency).

Inguinal hernia in infants: indirect, high risk of incarceration; repair promptly after diagnosis; umbilical hernia usually closes spontaneously by age 2–5 years.

Undescended testis: orchidopexy by 6–12 months to reduce malignancy and infertility risk; retractile testis needs observation only.

Cryptorchidism, hypospadias, and vesicoureteral reflux: hypospadias repair is deferred and circumcision avoided until repair; VUR graded I–V, low grades managed with antibiotic prophylaxis.

Skin graft: split-thickness graft (epidermis plus part of dermis) survives by imbibition, inosculation, and revascularization; full-thickness graft provides better color match and less contraction.

Flap classification: random vs axial blood supply; local, regional, or free; perforator flaps; free flaps need microvascular anastomosis and monitoring for congestion or ischemia.

Burn reconstruction: contracture release with Z-plasty or skin grafting; pressure garments for hypertrophic scars; splinting to maintain joint position.

Hand examination: assess tendons (FDP, FDS), nerves (median, ulnar, radial), and vascularity; Kanavel signs of flexor tenosynovitis (fusiform swelling, tenderness along sheath, finger held in flexion, pain on passive extension).

Nerve injury: Sunderland I–V (neuropraxia, axonotmesis, neurotmesis); repair with primary suture or graft; recovery rate ~1 mm/day.

Tendon repair: flexor zone II injuries need careful repair and early controlled mobilization; extensor injuries splinted in extension.

Compartment syndrome: pain out of proportion, pain on passive stretch, paresthesia, pallor, paralysis, pulselessness (late); fasciotomy is urgent; pressure >30 mmHg or delta <30 mmHg supports diagnosis.

Burns: escharotomy for circumferential full-thickness burns with compromised perfusion; early excision and grafting improve survival.

Head injury: Glasgow Coma Scale (eye 1–4, verbal 1–5, motor 1–6); GCS ≤8 needs intubation; CT for any loss of consciousness, vomiting, seizure, focal deficit, or anticoagulation.

Intracranial pressure: normal 5–15 mmHg; CPP = MAP − ICP; maintain CPP 60–70 mmHg; head elevation 30 degrees, avoid hypoxia and hypotension.

Epidural hematoma: middle meningeal artery, lens-shaped on CT, lucid interval; subdural hematoma: bridging veins, crescent-shaped, common in elderly and alcoholics.

Cushing reflex: hypertension, bradycardia, irregular respiration indicates raised ICP and impending herniation.

Lung cancer: non-small cell (adenocarcinoma most common, squamous central, large cell) vs small cell (central, paraneoplastic, chemotherapy not surgery); staging with CT and PET-CT, mediastinoscopy for nodes.

Pneumothorax: primary spontaneous in tall thin young men; secondary in COPD; tension pneumothorax is a clinical diagnosis requiring immediate decompression.

Empyema: pleural pus, loculations; treat with antibiotics and chest tube drainage; decortication or VATS for organized empyema.

Esophageal perforation: Boerhaave syndrome (effort rupture, left distal esophagus), pain, subcutaneous emphysema, mediastinitis; urgent surgery or stenting.

Thoracic trauma: rib fractures, flail chest (paradoxical movement), pulmonary contusion; analgesia and physiotherapy prevent pneumonia.

Fracture healing: primary (direct, rigid fixation) vs secondary (callus formation); stages - hematoma, inflammation, soft callus, hard callus, remodeling.

Fracture principles: reduce, hold, and rehabilitate; open fractures need antibiotics within 1 hour, tetanus prophylaxis, and debridement; Gustilo–Anderson classification guides treatment.

Compartment syndrome after fracture: most commonly tibial shaft and forearm; pain on passive stretch is the earliest reliable sign; fasciotomy within 6 hours prevents necrosis.

Hip fracture: intracapsular (femoral neck - risk of avascular necrosis, hemiarthroplasty or total hip replacement in elderly) vs extracapsular (intertrochanteric - dynamic hip screw).

Anesthesia: general (inhalational agents, IV agents, muscle relaxants) vs regional (spinal, epidural, nerve blocks); preoxygenation and rapid sequence induction for full stomach.

Malignant hyperthermia: autosomal dominant ryanodine receptor mutation triggered by volatile anesthetics and succinylcholine; treat with dantrolene, cooling, and supportive care.

Local anesthetics: maximum doses - lidocaine 3 mg/kg without epinephrine (7 mg/kg with), bupivacaine 2–2.5 mg/kg; toxicity causes perioral numbness, seizures, then cardiac arrest; treat with lipid emulsion.

Pain management: multimodal analgesia (paracetamol, NSAIDs, opioids, regional blocks); WHO analgesic ladder; patient-controlled analgesia for postoperative pain.

Informed consent: must include diagnosis, nature and purpose of procedure, risks and benefits, alternatives, and consequences of refusal; capacity requires understanding, appreciation, reasoning, and communication of choice.

Four ethical principles: autonomy, beneficence, non-maleficence, justice; confidentiality may be breached when required by law or when there is serious risk to others.

Patient safety: WHO surgical safety checklist (sign in, time out, sign out); hand hygiene; medication reconciliation; root cause analysis for adverse events.

Error types: latent (system) vs active (human); Swiss cheese model; just culture encourages reporting without blame for system errors.

Evidence hierarchy: systematic reviews and meta-analyses of randomized trials > randomized controlled trials > cohort > case-control > case series > expert opinion.

Study measures: sensitivity = TP/(TP+FN); specificity = TN/(TN+FP); positive predictive value depends on prevalence; number needed to treat = 1/absolute risk reduction.

Randomized trial: randomization reduces selection bias; blinding reduces measurement bias; intention-to-treat analysis preserves randomization; confidence intervals describe precision.

Research ethics: institutional review board approval, informed consent, Declaration of Helsinki, data protection, and declaration of conflicts of interest.