Surgery and Surgical Specialties
The surgical section tests recognition of the acute abdomen, the decision and timing of operation, and safe postoperative management. High-yield conditions are acute appendicitis, acute cholecystitis, acute pancreatitis, strangulated hernia, perforated peptic ulcer, bowel obstruction and blunt abdominal trauma.
Core rules
- Resuscitate and operate in parallel: ABCDE, two wide-bore cannulae, cross-match, nasogastric tube where indicated. Peritonitis and strangulation are not improved by waiting.
- Localise by anatomy. Migration of pain to the right iliac fossa, Murphy's sign, board-like rigidity with free air under the diaphragm, and colicky pain with distension and air–fluid levels each point to a different diagnosis.
- Use the Alvarado score for suspected appendicitis: migratory pain, anorexia, nausea, right iliac fossa tenderness, rebound, fever, leucocytosis, left shift. A score of 7 or more supports appendicectomy.
- Antibiotic prophylaxis 30–60 minutes before incision; therapeutic antibiotics for established peritonitis.
- Postoperative fever timing: within 48 hours atelectasis; days 3–5 urinary infection; days 5–7 wound infection or abscess; later deep abscess or venous thrombosis.
Worked example
A 24-year-old man has 18 hours of periumbilical pain that has moved to the right iliac fossa, temperature 38.1 °C, white cells 14.5 × 10⁹/L and rebound tenderness. Reasoning: the migration, fever and leucocytosis give an Alvarado score of 8; the correct plan is appendicectomy with perioperative antibiotics, not a trial of antibiotics with observation, because a high score carries a substantial risk of perforation.
Traps
- Calling right lower abdominal pain in a woman appendicitis without excluding gynaecological causes.
- Missing a femoral or inguinal hernia in an elderly patient with obstruction - always examine the groins.
- Withholding analgesia for fear of masking signs; analgesia does not obscure diagnosis.
- Forgetting tetanus prophylaxis and documentation in trauma.