Answering Techniques for Surgery Papers

How to answer definitions ?

Definitions are often asked in the exams – both in theory exams and viva-voce. As the content is vast, mugging them up is not a good idea. If you have a good understanding over the topic, you can write down a good definition by including following things wherever possible:

  1. Basic pathophysiology or process: Nature of infection, Premalignant condition, Benign/malignant neoplasm, Localized collection, etc.
  2. Involved structures: Layers of skin, Structures invaded by malignancy, etc.
  3. Peculiar identifying feature: certain size, duration, etc.
  4. Can include: Diagnostic clinical feature(s), Indication, The difference from a common differential diagnosis

Example:

Delayed Primary Closure (DPC): Surgical closure of a wound (1) 3-5 days after the thorough cleansing or debridement of the wound bed (3) when there is contamination or high risk of contamination (4).

Aneurysm: Pathological, localized, permanent dilation of an artery (1) to >1.5 times (3) the original diameter involving all 3 layers (2 and 4 – mentions the involved layers and also differentiates from pseudoaneurysm which doesn’t involve all the 3 layers of arterial wall) of its parent wall.

Locally Advanced Breast Carcinoma (LABC): Malignant neoplasm of the breast (1) that has not spread to distant sites i.e. Mo (3) but may be one of the following (2):

  • Primary tumor >5 cm (T3)
  • Chest wall and/or skin involvement including inflammatory carcinoma (T4)
  • Ipsilateral fixed axillary lymph nodes and/or internal mammary nodes or infraclavicular or supraclavicular nodes (N2 or N3)

How to answer causes and etiologies ?

List down the causes in a systematic manner after classifying them. The general rules for doing them are –

a. Causes involving conditions in a hollow viscus:

  1. Mechanical:
    • In the lumen: usually stones, foreign body or worms
    • In the wall: usually inflammatory or neoplastic conditions and strictures
    • Outside the wall: usually enlargement of adjacent structures, lymph nodes or abnormal protrusions
  2. Non-mechanical: usually neuromuscular and metabolic causes

Example:

dysphagia-causes

 

Causes of dysphagia:

  1. Mechanical:
    • In the lumen: Foreign body (dentures, coin)
    • In the wall:
      • Inflammation: Infectious esophagitis, tuberculosis
      • Neoplasm: Carcinoma esophagus
      • Inflammatory or post-irradiation strictures
    • Outside the wall: Aortic aneurysm, retropharyngeal abscess, thyroid enlargement, cardiomegaly, mediastinal nodes
  2. Non-mechanical: Myasthenia gravis, Polymyositis, Achalasia, Scleroderma, Cranial nerve IX and/or X lesions

 

Causes of intestinal obstruction:

  1. Mechanical:
    • In the lumen: gallstones, impacted feces, meconium, worms, foreign body
    • In the wall: Inflammatory or malignant strictures, Diverticulitis
    • Outside the wall: Adhesions and bands, cancers, hernia, volvulus
  2. Non-mechanical:
    • Paralytic ileus: postoperative abdominal surgery, mesenteric ischemia, hypokalemia, hypothyroidism, etc.
    • Pseudo-obstruction

b. For answering all other etiologies:

Use a surgical seive and remember them using a mnemonic like “MEDIC HAT PIN

  • Metabolic
  • Endocrine
  • Degenerative
  • Infective
  • Congenital
  • Hematological
  • Autoimmune
  • Trauma
  • Psychological
  • Inflammatory
  • Neoplastic

Example:

Causes of splenomegaly –

  1. Idiopathic: Idiopathic thrombocytopenic purpura
  2. Vascular: portal vein obstruction, Budd-Chiari syndrome, haemoglobinopathies (Sickle-cell disease, thalassemia)
  3. Infective: AIDS, mononucleosis, septicaemia, tuberculosis, brucellosis, malaria, infective endocarditis
  4. Traumatic: haematoma, rupture
  5. Autoimmune: rheumatoid arthritis, SLE
  6. Metabolic: Gaucher’s disease, mucopolysaccharidoses, amyloidosis, Tangier disease
  7. Inflammatory: sarcoidosis
  8. Neoplastic: CML, metastases, myeloproliferative disorders

Note: Always highlight the commonest and more common causes when using these systems for answering.

How to answer the clinical features of the given disease conditions ?

Classify into symptoms (subjective complaints and remember to elaborate using a mnemonic – SOCRATES; elaborate the main complaint and keep others as associated features) and signs (objective findings) expected in the disease condition; Use eponymous signs and elaborate in one line whenever possible –

Example:

In Acute Appendicitis –

A) Symptoms:

  • Site of pain: Right iliac fossa
  • Onset of pain: Acute over 24-48 hours
  • Character of pain: Initially dull visceral pain, later becoming sharp and localized due to parietal peritoneum involvement
  • Radiation or migration: Migrating to RIF from umbilicus
  • Associated symptoms: Anorexia, Nausea/vomiting, Fever, etc. (Murphy’s triad – pain, vomiting and fever)
  • Timing: No association
  • Exacerbating and relieving factor: As in all cases of peritonism – increased by movement and coughing and relieved partially by rest

B) Signs:

  • Pointing sign, Blumberg’s sign, Obturator sign, Psoas sign, Rovsig’s sign, Sherren’s triangle hyperesthesia, Rectal wall tenderness on PR, etc.

How to answer the investigations for given disease conditions ?

Always mention the expected findings of the tests and answer in the following order –

  1. Investigations to prove diagnosis
  2. Investigations to rule out differential diagnoses
  3. Routine investigations, pre-operative investigations and Investigations to rule out or identify complications
  4. Investigations for monitoring the disease

Example:

In Acute Pancreatitis –

1. Investigations to prove diagnosis:

  • Serum amylase and lipase: Increased by atleast 3 times
  • Abdominal USG: Can detect gallstone, biliary obstruction and pseudocyst formation
  • CECT abdomen: Confirms the diagnosis and aids in providing prognosis to the disease
  • Plain AXR: Sentinel loop sign, Colon cut-off sign, Renal halo sign, Pancreatic calcifications
  • LFT: can suggest if the cause is gallstone or alcohol

2. Investigations to rule out differential diagnosis:

  • ECG: To rule out MI
  • Plain abdominal X-ray erect and supine: To rule out perforation
  • Stool for occult blood: To rule out mesenteric ischemia
  • USG abdomen: To rule out cholecystitis

3. Routine, Pre-op investigations and Investigations to identify complications:

  • CBC and HCt: resembling SIRS or septic shock
  • RFT: to rule out renal failure due to hypovolemia
  • RBS: Hyperglycemia
  • Serum albumin: Decreased
  • Serum calcium: Decreased
  • ABG: Metabolic acidosis
  • Plain Chest X-ray: Pleural effusion, ARDS
  • Pre-op investigations: Serology, Blood grouping and cross-matching

4. Investigations for monitoring disease progression:  CBC and HCt, ABG, Serum calcium, RFT, etc.

How to answer treatment for a give disease conditions ?

Whenever possible, follow the following order –

  • Firstly: Stabilization of vitals (Go with ABC approach as in BLS) and emergency management
  • Secondly: Conservative management (if possible)
  • Thirdly: Medical and Surgical management

Example:

For treatment of nephrolithiasis –

Firstly: Manage acute pain, UTI and deranged renal function if present

  1. Analgesics: NSAIDs (1st choice), Opioids (2nd choice)
  2. Anti-emetics: If vomiting
  3. Alpha-blockers: reduces recurrent colic
  4. IV hydration
  5. Antibiotics for UTI
  6. Percutaneous nephrostomy for decompression may be required

Secondly: Conservative management if possible

  • Adequate water intake (atleast 2 litres per day)
  • Exercise
  • Urine alkalizer +/- allopurinol for suspected urate stones
  • Periodic evaluation

Thirdly: Medical or Surgical management with indications

 

renal stone treatment

Replicate contents from textbooks into concise flowcharts whenever possible.

This has 2 advantages:

  1. Saves time
  2. Easy to the examiner’s eyes.

How to answer the asked procedures ?

Be concise and answer in following order – Indications, Requirements, Description of procedre site, Procedure (Position, Anesthesia, Incision, Dissection, Performing targeted procedure, Closure), Confirm correct placement and if the intervention is functional and Complications

Example:

Explaining Chest tube insertion –

  1. Indications:
    • Traumatic hemothorax
    • Traumatic pneumothorax
    • Drainage of empyema
    • Following thoracotomy
  2. Requirements: Sialistic chest tube drain, Underwater seal drainage bag, Inj. 1% lignocaine, Straight and curved clamp, Suture and dressing set
  3. Working site: Safety triangle – bounded by anterior border of latissimus dorsi, posterior border of pectoralis major, superior border of 5th rib
  4. Procedure:
    • Anesthesia: Backrest lifted to 45 degrees
    • Anesthesia: LA 1% inj. lignocaine (skin to parietal pleura)
    • Incision: Over safety triangle
    • Dissection: Intercostal muscles separated using curved clamp, Blunt dissection with finger down upto pleura
    • Chest tube inserted towards apex for pneumothorax and towards base for effusion
    • Chest tube clamped and closed end cut-off to connect to a water seal draiange bag (2-3 cm inside water)
    • Drain fixed – stictch in a circular fashion
    • Sterile dressing pad applied
  5. Confirmation:
    • Correct placement: Chest X-ray
    • Functional: Tidalling, Bubbles in the underwater seal drain (pneumothorax)
  6. Complications:
    • Hemorrhage
    • Intercostal neurovascular injury
    • Lung and mediastinal injury
    • Infection

How to answer the complications of a procedure or surgery ?

Classify and present as following:

1. Per-operative:

  • Surgery-related: Anatomical injury (Vessels and Organs)
  • Anesthesia related

2. Post-operative:

  • Immediate (<24 hrs):
    • Local: Reactionary hemorrhage
    • General: Asphyxia (Airway obstruction with tongue fall or aspiration of vomitus)
  • Early (upto 3 weeks):
    • Local:
      • Paralytic ileus (abdominal surgeries)
      • Infection (wound, peritonitis, pelvic, subphrenic)
      • Secondary hemorrhage
      • Dehiscence (wound, anastomosis)
      • Obstruction (fibrinous adhesions)
    • General:
      • Pulmonary: Collapse, Bronchopneumonia, Emboli
      • Urinary: Retention, ATN
      • DVT
      • Enterocolitis
      • Bedsores
      • Parotitis
  • Late (>3 weeks):
    • Local:
      • Obstruction (fibrous adhesions)
      • Incisional hernia
      • Persistent wound sinus
      • Recurrence of original lesion
      • Scar probles (hypertrophic scars, keloid)
    • General: After extensive resections or gastrectomy
      • Anemia
      • Vitamin deficiency
      • Steatorrhea and/or diarrhea
      • Dumping syndrome
      • Osteoporosis

Example:

After thyroidectomy –

1. Per-operative:

  • Surgery related:
    • Vascular injury: Primary hemorrhage from superior or inferior thyroid artery, thyroid ima. artery, carotid artery, jugular vein
    • Nerve injury: External laryngeal nerve
    • Solid organ injury: Injury to parathyroid gland, apex of lung
    • Hollow viscus injury: Trachea, esophagus, larynx
  • Anesthesia related

2. Post-operative:

  • Immediate:
    • Local: Reactionary hemorrhage, Asphyxia due to hematoma, Hoarseness due to recurrent laryngeal nerve injury
    • General: Asphyxia, Thyrotoxic crisis
  • Early:
    • Local: Wound infection, Laryngeal edema
    • General: Chest infection
  • Late:
    • Local: Scar, Stitch granuloma
    • General: Thyroid and parathyroid insufficiency

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