Surgery (General and Subspecialties)
Surgery (外科) spans general, gastroenterological, cardiovascular, thoracic, paediatric surgery, orthopaedics, neurosurgery, and urology, plus perioperative care. Questions favour decisions: operate or observe, which operation, and in what order, rather than operative technique.
Core rules
- Acute abdomen: always examine the hernial orifices and perform a rectal or genital examination. Free air on plain film means perforation; CT is first-line in the haemodynamically stable patient.
- Acute cholangitis (Tokyo Guidelines): Charcot triad → Reynolds pentad; treatment is biliary drainage (ERCP) plus antibiotics, and severity determines timing.
- Trauma: ABCDE with simultaneous resuscitation; tension pneumothorax is a clinical diagnosis treated by immediate decompression; FAST for the unstable patient; damage-control laparotomy for the lethal triad of acidosis, hypothermia, and coagulopathy.
- Perioperative: fasting 2 h for clear fluids, 4 h breast milk, 6 h light meal, 8 h fatty meal; antibiotic prophylaxis within 60 minutes of incision; VTE prophylaxis with intermittent pneumatic compression ± low-molecular-weight heparin.
- Colorectal cancer: TNM staging; right-sided tumours present with anaemia, left-sided with obstruction. Breast cancer subtype (ER/PR/HER2) determines neoadjuvant therapy.
Worked example
A 74-year-old man has fever 39°C, right upper quadrant pain, jaundice, BP 88/50, and biliary dilatation on ultrasound. Reasoning: Reynolds pentad indicates acute cholangitis with sepsis. Resuscitate, obtain blood cultures, start broad-spectrum antibiotics, and arrange urgent ERCP drainage. Laparoscopic cholecystectomy is not the first step; delaying drainage in a septic patient increases mortality.
Traps
- Dismissing abdominal pain in an older adult as gastroenteritis - peritoneal signs may be absent.
- Forgetting tetanus prophylaxis in a contaminated wound.
- Sending an unstable patient to CT before resuscitation.