FRCS Part 2 January 2019
Format:
Group 1:
Day 1 (all day): vivas
Day 2 (morning only): clinicals
Group 2:
Day 2 (afternoon only): clinicals
Day 3 (all day): vivas
You’ll be randomly put into either group 1 or group 2 which will decide which order you have your exams in and on which days. The exam dates are published as 3 days but you can see from the above that you’ll only need to attend on 2 of those days.
The viva day starts very early (ID check at 7.45am!).
Stations:
Vivas:
There are four stations, each lasting 30 minutes, with minimum an hour between stations. There are two examiners per station – one will examine you for 15 minutes on three topics/scenarios, then the other will do the same (except for the academic station where the first examiner spends all 15 minutes on the academic paper you’ve read), so there are a total of 6 topics covered per station.
1. Academic foundation and basic principles (special interest):
You have 30 minutes before this station to read an academic paper (which is in your specialty). The first 15 minutes are spent going through the paper – you are asked to present/summarise it and then will be asked specific points on it and more general academic points. The second 15 minutes are spent on basic science in your special interest. I had:
- Academic paper: impact factor, sensitivity/specificity, positive and negative predictive values, graphs used and how to interpret them; are you aware of any existing papers/evidence that have agreed/disagreed with this paper?
- Screening programs (with reference to mammographic screening), advantages and disadvantages
- Blood supply to the breast; anatomy; level 1 and 2 oncoplastic procedures
- Histological subtypes of breast cancer and their different prognoses; adjuvant endocrine treatment options
2. Special interest surgery – clinical practice:
Clinical scenarios on your special interest. They seem to choose more complicated or controversial topics rather than your completely straightforward day-to-day stuff. This is where there is the opportunity to discuss evidence (if you know it), but that is only needed if you want to score an 8. I had:
- Paget’s disease: pathophysiology, diagnosis, treatment, how do you explain it to a patient, surgical techniques for central excision
- Breast cancer in pregnancy (with lots of apologies from the examiner!!): diagnosis, treatment, safety of various interventions in different trimesters
- Inflammatory breast cancer: diagnosis, treatment, prognosis
- Lactational abscess: likely organisms, antibiotic choice, when to offer surgery over aspiration
- Oncoplastic options for 10cm of DCIS in a ptotic DD breast: breast conserving vs mastectomy and recon
3. Emergency general surgery/trauma/critical care:
Basic science (usually using a clinical situation as a springboard) and clinical scenarios. I had:
- High output stoma: investigation, biochemical changes, intestinal failure, management, early reversal
- Incidental carcinoid in an appendicectomy
- Liver laceration: trauma scenario, grading, trauma laparotomy
- Trauma scenario: GSW to R flank, retroperitoneal haematoma and DJ flexure perforation
- Post operative fever and anastomotic leak: investigation and management
- Groin abscess: SHO takes it to theatre and it’s an infected pseudoaneurysm. Other candidates got the same scenario but the examiners used it to go down the nec fasc route
4. General surgery principles and clinical practice:
Outpatient general surgery (not in your specialist interest). I had:
- Elective splenectomy for ITP: surgical approaches, vaccinations (and why), complications/consent, need for prophylactic Abx
- Retained swab 3/12 post-TAH: never events, how to manage it surgically, who is responsible, how to report it, root cause analysis
- Referral for elective lap chole: normal bloods but CBD 10mm – options (MRCP/OTC/lap CBD exploration), ERCP as definitive treatment for old, frail patient; post-sphincterotomy bleeding
- Incisional and parastomal hernia in patient with BMI 40: don’t touch them with a barge pole! Strategies if they present emergently, Sugarbaker/technical considerations
- Complications of carboperitoneum: resp, CVS, bleeding, CO2 embolus
Clinicals:
You have two stations, each lasting 40 minutes. One station is general and emergency surgery and the other in your subspecialty. Each station has one ‘long case’ (20 mins) and two ‘short cases’ (10 mins) and they tell you which one it is so you know how long you have to spend on each. One examiner examines you for the long case and the other for the two short cases. Lots of the patients have multiple pathologies so they might be used as a hernia for one candidate and as a thyroid lump for the next candidate. Everyone talks about their cases in the waiting room which can be distracting but there were a couple of weird and wonderful things that came up in mine that I’d overheard someone else mention so I did a quick Google between stations in case I got that patient.
1. General surgery:
Long case (20 mins):
‘Please take a brief history and examine him’.
60-year old man with a symptomatic (keen walker/builder) right inguinal hernia. Previous LIH repair (open with mesh) 10 years ago. MI 3 months ago and on dual antiplatelets. On examination, smallish hernia on the right, fully reducible. Cough impulse ?recurrence on the left (asymptomatic).
Wanted to discuss: stopping antiplatelets – benefits/risks and timing. Approaches to repair (one at a time vs both together, open vs lap, is management of the recurrent side any different to the other side), risks/benefits of not repairing.
Short case 1 (10 mins):
‘Please take a brief history and examine her’.
40-year old woman who originally presented with upper abdominal pain (not typically biliary colic), had a lap chole 3/12 ago, pain still the same. On examination, scars from lap chole, supraumbilical hernia (incision below the umbilicus) – I asked the pt if it was there pre-op and it was.
Wanted to discuss: biliary colic vs other pathologies – how to distinguish clinically/on investigation; post-cholecystectomy syndrome; would you repair a paraumbilical hernia at the same time as doing a lap chole?
Short case 2 (10 mins):
‘Please take a brief history and examine him’.
78-year old man who had ‘major surgery, I don’t know what’ 30 years ago, he thinks it was for a ‘burst ulcer’. Then had ‘difficulties swallowing’ so had more ‘major surgery’. Then had an episode of ‘being yellow’ with severe RUQ pain and rigors. On examination, midline laparotomy and a second laparotomy scar just next to it.
Wanted to discuss: what surgery would he have had 30 years ago for a perforated DU (oversew and vagotomy). What might his second operation have been (stricture at oversew site -> some form of bypass). What was his third presentation (cholangitis – likely gallstones given his pain); would you ERCP him; what alternatives to ERCP are there; why did he get gallstones.
2. Special interest (breast) surgery:
Long case (20 mins):
‘Please take a brief history’.
60-year old woman who presented 20 years ago with L arm symptoms from axillary nodal disease. Found out to have breast ca, had WLE + ANC + DXT. Follow up mammography for 5 years all NAD. Screening mammo at 52 showed contralateral microcalc, DCIS on biopsy. Had WLE + DXT. Now presents with a new lump on the DCIS side.
Wanted to discuss: causes for recall from screening (what sort of mammo abnormalities might you see; what proportion are cancer); lymphoedema risk post ANC/axillary DXT; what might the new lump on the DCIS side be (fat necrosis, recurrence, angiosarcoma – which it was!!); angiosarcoma diagnosis and management.
Then asked to examine her and talk through what surgery she had had – mastectomy with some of pec major taken on the angiosarcoma side with no recon.
Short case 1 (10 mins):
‘Please take a brief history and examine her’.
40-year old woman presented with a symptomatic lump. FHx: known BRCA-1, had discussed and declined risk reducing surgery and enhanced screening. On examination, bilateral skin-sparing, nipple-sacrificing mastectomies with dermal sling and implant recon.
Wanted to discuss: why patients might decline screening/risk reduction (difficult to have that discussion in front of the patient); alternatives (chemoprevention); reconstruction options.
Short case 2 (10 mins):
‘Please take a brief history and examine her’.
24-year old woman treated two years ago for breast cancer. Identical twin sister had thyroid cancer, mother had endometrial cancer. Known genetic mutation. On examination, thyroidectomy scar, bilateral mastectomies – on right, evidence of DXT, recon with implant and LD; on left skin-sparing mastectomy with implant recon.
Wanted to discuss: Cowden’s disease (P-TEN mutation); alternative recon options post-DXT.