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Answering Techniques for Surgery Papers

Dr. Sulabh Kumar Shrestha, MS Orthopedics
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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):

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:

 

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”

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:

B) Signs:

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:

2. Investigations to rule out differential diagnosis:

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

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 –

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

Thirdly: Medical or Surgical management with indications

 

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:

2. Post-operative:

Example:

After thyroidectomy –

1. Per-operative:

2. Post-operative:

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