1

PRINCIPLES OF
SURGERY-IN-GENERAL
Principles of surgery-in-general questions 3
1 THEME: PREOPERATIVE FITNESS FOR SURGERY 1
A Electrocardiogram (ECG) alone
B ECG and urea and electrolytes (U&E)
C ECG, U&E, and full blood count (FBC)
D FBC, ECG, U&E and chest X-ray
E FBC, ECG, U&E, chest X-ray and lung function tests
F FBC and U&Es
G No investigation required
H Urea and electrolytes alone
From the list above pick the single most appropriate answer listing the
obligatory tests required for the following clinical scenarios. The items may be
used once, more than once or not at all.
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1 A 4-year-old boy undergoing an elective repair of a ventriculoseptal defect,
American Society of Anaesthesiologists (ASA) grade 1.
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2 A 69-year-old woman booked for an elective total hip replacement with a
past medical history of left ventricular failure, limiting her exercise tolerance
to 180 metres (200 yards).
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3 A 9-year-old boy with moderate asthma undergoing an elective tonsillec-
tomy.
Q
PERIOPERATIVE CARE
4 Principles of surgery-in-general answers
A
1 PREOPERATIVE FITNESS FOR SURGERY 1
1** D FBC, ECG, U&E and chest X-ray
2 C ECG, U&E and FBC
3 G No investigations required
See ERN MRCS Book 1, Chapter 6, section 1 and the National Institute
for Health and Clinical Excellence (NICE) guidelines CG3 Preoperative
tests (www.nice.org.uk/page.aspx?o=73376).
All patients undergoing cardiovascular surgery require FBC, U&E, ECG
and chest X-ray, regardless of other risk factors.
Although commonly performed, chest X-ray is not a requirement for
patients with limiting cardiovascular disease (ASA grade 3).
Children do not require any routine investigations unless they are likely
to have sickle cell disease, are undergoing neurological or cardiovascular
surgery, or are known to have a life-threatening disease.
Principles of surgery-in-general questions 5
2 THEME: PREOPERATIVE FITNESS FOR SURGERY 2
A ECG alone
B ECG and U&E
C ECG, U&E and full blood count
D FBC alone
E FBC and U&E
F FBC, U&E, ECG and chest X-ray
G FBC, U&E, ECG, chest X-ray and lung function tests
H No investigation required
I U&Es only
From the list above pick the single most appropriate answer containing the
obligatory tests required for the following clinical scenarios. The items may be
used once, more than once or not at all.
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1 A 75-year-old man with chronic renal impairment (ASA grade 3) undergoing
an elective hernia repair.
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2 A 43-year-old woman undergoing elective right hemicolectomy for
colorectal cancer. She is otherwise t and well.
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3 A 56-year-old man with a past history of angina undergoing elective right
inguinal hernia repair (day case). He has no limitation to his exercise
tolerance.
Q
2 PREOPERATIVE FITNESS FOR SURGERY 2
1** B ECG and U&E
Hernia repair is intermediate surgery. FBC is not considered mandatory.
2 D FBC alone
3 A ECG alone
ECG alone is the answer as this man is ASA grade 2 (cardiovascular) and
undergoing intermediate surgery.
See ERN MRCS Book 1, Chapter 6, section 1 and the NICE guidelines
CG3 Preoperative tests (www.nice.org.uk/page.aspx?o=73376).
FBC is infrequently recommended for minor and intermediate surgery,
although it is often listed as a test to be considered.
Group and save has not been explicitly dealt with in the NICE
guidelines.
6 Principles of surgery-in-general answers
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Principles of surgery-in-general questions 7
3 THEME: PERIOPERATIVE MANAGEMENT OF ASSOCIATED
CARDIORESPIRATORY DISEASE
A Administration of of
2
-agonist at induction
B Administration of -blockers
C Administration of intravenous digoxin
D Aggressive uid resuscitation
E Avoidance of opioid analgesia
F Consideration of spinal anaesthesia
G Delay surgery for 3 months
H Diuretic therapy
I Endocarditis prophylaxis
J Humidied oxygen therapy
K Post-operative chest physiotherapy
L Titration of intravenous uids to central venous pressure (CVP)
measurements
The following scenarios all refer to issues concerning the perioperative
management of cardiorespiratory disease. Select the single most appropriate
action from the list above. The items may be used once, more than once or not
at all.
J
1 A 62-year-old man attends the preoperative assessment clinic 1 week prior
to his scheduled laparoscopic cholecystectomy. The patient informs you that
he was only recently discharged from the hospital following an admission
for myocardial infarction.
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2 A 53-year-old woman is due to undergo an emergency laparotomy for a
suspected perforated duodenal ulcer. She has a body mass index (BMI) of
35, and her past medical history includes obstructive sleep apnoea.
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3 A 74-year-old woman with a prosthetic aortic valve is admitted to the
hospital ward 3 days prior to an elective anterior resection for rectal
carcinoma, as she needs to be on intravenous heparin while her warfarin is
stopped.
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4 You are on call and the ward sister asks you to review a 69-year-old man
with poor urine output. He has recently undergone an emergency
Hartmanns procedure for a perforated sigmoid colon secondary to
diverticular disease, and his past medical history includes ischaemic heart
disease. Examination reveals a pulse rate of 114 beats per minute (bpm),
systolic blood pressure (BP) of 100 mmHg, gross peripheral oedema and 30
ml urine output over the past 3 hours. Serum albumin is 18 g/l.
Q
3 PERIOPERATIVE MANAGEMENT OF ASSOCIATED
CARDIORESPIRATORY DISEASE
1 G Delay surgery for 3 months
This is because there is a 46% risk of perioperative reinfarction.
2** E Avoidance of opioid analgesia
3 I Endocarditis prophylaxis
Indicated in patients with prosthetic heart valves, previous endocarditis,
mitral valve regurgitation and hypertrophic obstructive cardiomyopathy.
4** L Titration of intravenous uids to CVP measurements
Perioperative management of cardiovascular disease:
See ERN MRCS Book 1, Chapter 6, section 2.2.
Generally, cardiac medications should not be stopped before surgery.
Post-operative management of such patients includes adequate
analgesia, supplemental oxygen therapy, maintenance of euvolaemia
with or without intravenous CVP monitoring.
Perioperative management of respiratory disease:
See ERN MRCS Book 1, Chapter 6, section 2.3.
Cessation of smoking, delaying surgery in the event of preoperative
chest infection and adequate post-operative analgesia and chest
physiotherapy may reduce the risk of respiratory complications post-
operatively.
8 Principles of surgery-in-general answers
A
Principles of surgery-in-general questions 9
4 THEME: CESSATION OF MEDICATION
A Convert from intravenous to oral route
B Do not cease medication
C Gradual withdrawal of medication
D Immediate cessation of medication
E Stop for 1 week preoperatively
F Stop for 4 days preoperatively
G Stop for 4 days preoperatively, and replace with rapidly reversible equivalent
H Stop for 48 hours preoperatively
The following scenarios all refer to issues concerning the cessation of
medication prior to surgery. Select the single most appropriate answer from the
list above. The items may be used once, more than once or not at all.
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1 A 62-year-old man is on warfarin, as part of the management of atrial
brillation. He is on the waiting list for a laparoscopic cholecystectomy.
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2 A 74-year-old woman is on clopidogrel, as part of the management of
ischaemic heart disease. She is on the waiting list for a reversal of Hartmanns
procedure.
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3 A 21-year-old man attends Accident and Emergency (A&E) with abdominal
pain and the passage of bloody motions up to seven times per day. As part
of his management, he is started on intravenous hydrocortisone. Following
2 days of conservative management, the patients symptoms have only
marginally improved, and stool cultures are positive for Escherichia coli
O157:H7.
Q
4 CESSATION OF MEDICATION
1 F Stop for 4 days preoperatively
Invasive surgery is generally safe (from major haemorrhagic
complications) when the international normalised ratio (INR) < 1.5.
2 E Stop for 1 week preoperatively
Applies to other antiplatelet drugs as well.
3** D Immediate cessation of medication
This patient has infective not ulcerative colitis.
See ERN MRCS Book 1, Chapter 6, section 2.1.
Systemic corticosteroids can be stopped abruptly in those who are
unlikely to relapse and who have received treatment for < 3 weeks,
otherwise gradual withdrawal should be performed.
Metformin should be stopped 48 hours preoperatively as it can cause
lactic acidosis.
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Principles of surgery-in-general questions 11
5 THEME: CONSENT FOR SURGERY
A Advance refusal
B Battery
C Best interests (treatment in) under common law
D Consent for medical research
E Implied consent (assent)
F Informed consent
G Negligence
H Parental consent
I Treatment under the Mental Health Act
J Ward of court
The following scenarios all refer to issues concerning informed consent. Select
the single most appropriate answer from the list above. The items may be used
once, more than once or not at all.
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1 A 20-year-old woman with severe right iliac fossa pain, but no signs of sepsis,
underwent a diagnostic laparoscopy plus proceed to further surgery as
required. At the time of the operation, no macroscopic organic pathology
could be identied, but the surgeon proceeded to remove the appendix via
the open approach in case of mucosal inammation. The pathology report
later revealed the appendix to be normal. Legal action was taken by the
patient against the surgeon.
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2 A 46-year-old man underwent proctoscopic injection sclerotherapy of grade
II haemorrhoids in the surgical clinic. He developed acute pelvic discomfort
at the time of injection, followed by urgency, dysuria, fever, and aching in
the left testis. His symptoms settled with antibiotics and anti-inammatory
analgesics, but he takes legal action, claiming he was not informed of the
risks of the procedure.
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3 An 18-year-old man is brought into A&E following an assault. He is uncon-
scious and severely haemodynamically unstable with a stab wound to the
right hypochondrium. Following intubation and ventilation, the patient is
immediately taken to the operating room for an emergency laparotomy.
Q
5 CONSENT FOR SURGERY
1 B Battery
This is violation of civil law that forbids intentionally touching another
person without their consent. In this situation, harm can be construed as
the moral violation of the patients right to exercise autonomous control
over procedures performed on their body.
2** G Negligence
This is failure of the professional duty of the surgeon to adequately
inform patients about a chosen procedures complications and any
appropriate alternatives. In this scenario, the patient could argue that he
would not of consented to the procedure had he known the risks.
3 C Best interests (treatment in) under common law
See ERN MRCS Book 1, Chapter 6, section 2.1; Department of Health,
policy and guidance, Health and social care topics
(www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics);
General Medical Council, Seeking patients consent: the ethical
considerations (www.gmc-uk.org/guidance/archivelibrary/consent.asp)
Informed consent is the process whereby a mentally competent patient
agrees to undergo a procedure after discussion of the indications,
alternatives, potential side effects and complications.
12 Principles of surgery-in-general answers
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