Academic viva

Discussion about retrospective studies, disadvantages

Impact factor calculation

Impact factor of BJS
Randomization process, stratification
Levels of evidence
Power and sample size calculation

Type 1/2 error

What does p < 0.05 actually mean?
Inclusion/exclusion criteria

Does this paper change surgical practice?
How long do you think this paper took to get published?
Was this the first journal it was sent to?
Is this paper important?

 

Emergency surgery/critical care viva

 
Stab to posterior triangle of neck – possible structures injured;  ATLS from door of resus;  Complex airway managment;  Management of transected ext jugular, internal jugular, caroti

Acute cholecystitis;  Diagnosis, investigations, CBD stone;  Discussion of ERCP, OTC, when to explore CBD;  Cholangitis;  Causes of rigor;  Management of elderly with CBD stones

Large bowel obstruction;  History, investigation – CT v gastrograffin enema;  Role of stenting, advantages/ disadvantages

Oliguria following anterior resection in patient with rheumatoid on long term NSAIDs; Full history + exam – features of dehydration; Role of CVP measurement; Post-renal causes, mild bilateral hydronephrosis, rx with nephrostomies

 

Nutrition in critical care. Values of protein, nitrogen, calories, volume, rate of feeding etc.;  Rivers paper recommendation for tight glucose control – now not thought to be so important

Strangulated femoral hernia, INR 10
What is INR? + how calculated

Methods of reversal

Gunshot to abdo

ATLS and trauma laparotomy

Oliguria leading on to management of iatrogenic damage to ureters

Respiratory complications post bariatric surgery dd and rx of sob on ward, when to ventilate

 

Levels of Care
Monitoring in critical care- pulse oximeter-what does it measure, what wavelength and why(?),

Massive blood transfusion – unwanted effects

Which clotting factors would you be concerned about?

DIC

How do you assess patients for general anaesthetic and the level of care required post-op? Why should we avoid unnecessary level three [ICU] care admissions?

How can HAIs be reduced? [Hand hygiene/bed spacing/sufficient staffing level]

How many staff do you need for a 1:1 ratio for a 6-bedded ICU?

Older woman with vomiting/abdominal pain/distension – explain what to look for in the history, examination and observations

What would the patient have to have to prompt an immediate operation? [peritonitis/fever/strangulated hernia]

 

Old lady with cold, pale, paralysed leg

Salient points in the history (AF,IC) and examination (AF, normal pulses in other leg)

Interventional radiology

On-table angiography

 

Warzone gunshot wound – mandatory laparotomy

Scenario modified to UK urban trauma – stable/unstable – FAST/CT

Bloke 6/52 after MI with acute abdo pain ? perf – initial management, Ixs
Conservative management strategy, outcomes
Operative Rx – risk depends on timing from MI (50% risk of MI within 6/52 of last one)
What sorts of MI is worst (causes hypotension- subendocardial?)
What’s the mechanism of a subendocardial MI
What op – Open patch repair and lavage
Laparoscopic?

75 year old lady with massive rectal bleeding
Management – OGD, angio
If fails – op with intra-op colonscopy/enteroscopy
What operation – segmental if source identified otherwise subtotal and end ileostomy
What to do before going to angio – procto-sigmoidoscopy to exclude haemorrhoidal bleeding

Distended abdo on ITU – ACS
What is it – definition, causes detection, measurement of IAH (values)

Treatment – decompress, temporary abdominal closure with Bogata bag/VAC
Delayed closure

Second look laparotomy – dead gut

Brain death criteria in depth

 

Thoraco-abdominal crush injury – management
ATLS ABC ? liver splenic injury
48 hours later on ITU K+ of 7 – ARF from rhabdomyolysis and myoglobinuria
RRT

 

Nutrition in the cachectic ITU patient

Post-oesophagectomy nutrition

Enteral v parenteral
Routes of enteral – NG/NJ
Problems – bolus v continuous, overnight feeding, metabolic problems (dumping hypersosmolar stuff)
Parenteral – problems, metabolic, phosphate re-feeding
What energy requirement and nitrogen need, lipid load
Cholestatic jaundice
Jejunostomy or gastrostomy
Complications – leaks (feed or bowel content), erosion, migration, falling out

Emergency presentation of advanced breast cancer – bleeding, pain from bony mets, pleural effusion;   Hypercalcaemia – Rx

Splenic injury – scoring systems, conservative/surgical (spleen conserving);  Splenectomy – indications, complications, vaccinations, antibiotic prophylaxis;  Post-splenectomy fever

SIRS/Sepsis/Shock (definitions)/mediators, etc;  Blood gases;  Insertion of chest drain;  Contraindications for transplant

Pseudo-obstruction;  Diagnosis + management;  Ogilvie – who he was and where he worked!!??

Post op diarrhoea;  C Diff  + other infective causes;  Management of C diff – isolation/ward closing, antibiotics, hand washing;  Colectomy (subtotal/segmental resections) in C diff colitis

Stab injury right flank – possible organs involved
Evaluation and management
25 F appendicitis, which turned into a tubal ectopic;  Post op fever, pelvic collection

Severe acute pancreatitis- management, necrosectomy, ?antibiotic prophylaxis

Pulmonary embolus

Hyperkalaemia – causes, management

Risk stratification – ASA/Schumacher’s/POSSUM/Goldmann

Burns – management, fluid resus

Rule of 9s – ways of assessing how much burn

Degree of burns – 1^st/2^nd/3^rd

Escharotomy

Contractures

Trauma scoring systems 

Head Injury/GCS

Principles of management

Burr holes

Diverticulitis – Hinchey classification

Measurement of cardiac output

Mechanical limb injury – structures injured, neurological exam + basic operative management

ARDS

Oxygen-dissociation curve – factors affecting

Neurovascular injuries in patients undergoing long operations

Trauma – indications for thoracotomy, diaphragmatic injury

Starlings law – contractility, effects of pre-load, factors affecting curve

 

 

General surgery viva

30 year old female patient with RIF mass – investigation + diagnosis
CT shows complex phlegmon RIF

Management of acute Crohn’s

Fulminant colitis in young man – when to operate, choice of surgery, what to do with rectal stump?

Intra-op bile duct injury – discussion of OTC
Management of slit in CBD, transection of CBD, when to call HPB surgeon
Laparoscopic CBD exploration

Strasbourg + Bismuth classifications of duct injury

Breast abscess – different scenarios – in post menopausal, lactating, heavy smoker
Investigation, likely organisms, flora changes in different groups
Management – different antibiotics, breast feeding, penicillin allergy

Pre-op management of anti-coagulated patient, prophylaxis – dependant on reason for anti-coagulation

Acute pancreatitis-causes and complications

Scoring systems

Prognostic indicators

Treatment – complications, pseudocysts, etc

 

Wound healing – which factors are important?

What are the important minerals and vitamins? (Selenium, zinc and vitamin C)

How does vitamin C work? (collagen cross-linking)

Which amino acid does Vitamin C attach to? (Proline)

Dehiscence – management (Bogota/DTS/VAC)
Incisional hernias – risks factors

Scenario with an infected mesh, then MRSA, then long-term MRSA-potent antibiotics (linezolid)

 

Ix of Fe-deficiency anaemia
History and exam, then top and tail and haematinics
Other types of anaemia
Top and tail is normal what do you do now
CT Abdo with oral + IV contrast (portal venous phase)
Colonoscopy shows a small caecal lesion + biopsy confirms adenocarcinoma
Staging colorectal Ca

Hard lump in anterior triangle neck, just above clavicle
History and examination – risks factors for aerodigestive malignancy, head and neck infections, pan endoscopy
FNAC +/- USS guidance
CT head neck chest and abdo

Enhanced recovery programmes
What are they, how they work?
Pain control, differences in anaesthesia
Early oral nutrition – with what, types, pre-op CHO loading
With what – what type of drink
Bowel prep – use/not use, fluid shifts
Causes of and problems with post-op gut oedema

Acute/critical limb ischaemia
Embolectomy
Fasciotomy

In-growing toe nail in diabetic – exam, Rx, surgical steps

Management of pancreatic fistulae – stents/MRCP/ERCP

Gastric Ulcer – management; Non-healing gastric ulcer, what next?

Principles of day case surgery – How to set up

General clinical

RIF/Appendix mass – management 

Arterial examination on chap with bilateral iliac stents.
Hernia old man – should you operate, chap with a previous bile duct injury and subsequent reconstruction – management of bile duct injury and long term complications, thyroid, ascites, renal transplant and dialysis access, splenomegaly, umbilical hernia

Incisional hernia and causes
Scleroderma and assoc problems- CREST syndrome so ask about symptoms rel to renauds, oesophagus etc, also gut symptoms as they get diarrhoea
Pancreatic pseudocyst- history and CT scans
Thyroid exam and management of small lump
Abdo exam- pt had bilat congenital polycystic kidneys
Vascular exam- small aneurysm & patient had only part of one kidney and bilat nephrectomy scars. Discussion about small aneurysm trial and pt management
Pt w short gut syndrome and Hickman line for home feeds

Polycystic kidneys – genetics, dominant/recessive

Thyroid exam – enlarged lobe – Ixs, is pt euthyroid (how could you make them); Eye signs (causes); Role of FNAC; Management of Medullary thyroid Ca

Short gut syndrome – home TPN, medical optimisation

Bilateral IH – which op?

Colorectal Ca surveillance

Parastomal hernia, incisional hernia, inguinal hernia (with co-morbids+++)

Diverification recti

Facial BCCs/SqCCs

Infected parastomal hernia repair; Difference between cellulitis and abscess;  Approaches to parastomal hernia repair
Hyperlipidaemic smoker with recurrent acute pancreatitis and a RIF stoma;  What had happened (pancreatic necrosis into Tx colon – defunctioned); When to close stoma?

Paraumbilical hernia – methods of repair
Also had divarication – would you fix it
Man in for investigation of episodic sweating and flushing with diarrhoea. Take a history;  No physical findings – Ixs, what would you do?

Cachectic man with midline scar and LIF stoma. Poor historian;  Had Hartmanns for obstructed colon 2/52 prior;  Why still in hospital (nutrition, stoma care [had Parkinsons], home circumstance)

Lymphoedema

Axillary vein thrombosis

Multinodular goitre

CT scan – retained swab

Fem-pop bypass

Male with multiple scars – median sternotomy, thoracotomy, rooftop incision, lap chole scars, vertical paramedian scar
Discussed screening for AAA

Soft tissue lump

Male with roof top incision for pancreatic necrosectomy
Indications, technique

Hepatomegaly with chronic liver disease  – abdo exam, illicit signs, examine for ascites/free fluid

Incisional hernia, examine

Indications for surgery
CBD stones – ERCP + on-going mx

Appendicectomy scar incisional hernia

Massive pseudocyst in lady with no previous episodes of pancreatitis

Cystic Hygroma

GORD, HH and atypical asthma – surgical options
Big epidiymal cyst

Reflux- paraoesophageal hernia- Ba swallow, surgical options

Incisional hernia and hepatomegaly in patient post ILOG – how do you repair hernias?  (onlay mesh/pre-peritoneal)

Abdominoplasty, and divarication of recti – repair or not, discussion of Bariatric surgery and difference between restrictive and malabsorptive operations

Parotid swelling- investigation, surgery

Renal Tx and multiple SCC’s on back

Upper GI/HPB viva

GIST- options, recurrent disease? adjuvant therapy – Glivec (TKI)

Junctional tumours – definition, staging (EUS/CT/laparoscopy/peritoneal lavage), management (inc. neoadj chemo – pros + cons of)

Chemotherapy/chemoradiotherapy for oesophageal Ca

Achalasia – Causes (degeneration of myenteric plexuses);  Long-term outcomes of treatments

ARP – what, when to do open?;  Indications for + complications of ARP

pH/Manometry – what it means, classical appearances;  Normal/Abnormal values

Laparoscopic hernia repairs – TAPP/TEP; Acute/chronic pain, percentages; Neuralgia paraesthetica – lap cutaneous nerve of thigh

Oesophagectomy – complications of, percentages, predictors of mortality (fitness for surgery);  Classification of leaks – lerut/siewert – look up.

Management of bleeding ulcer.

Operative steps – oesophagectomy, gastrectomy, PPPD, bile duct exploration

Types of staple cartridge.

Ursodeoxycholic acid for GS – evidence

Upper GI/HPB clinical

Nodule in Barrett’s – HGD- what you going to do, doesn’t want surgery;  Now asymptomatic but frank carcinoma- options (patient still fit 73year old)

Long history of GORD – respiratory symptoms (typical and atypical reflux symps) on high dose PPI; Options – ph and manometry, type of fundoplication

Dysphagia

Ooesophageal carcinoma – staging and surgery; Lymph node stations removed at ILOG;  Chemo/radiotherapy – OE02, OE05

GIST- endoscopy pictures, CT, surgical options