FRCS Norwich May 2019
Clinicals
General surgery
- Long case:
Take a history from a lady with RUQ/upper abdo pain
Examine her abdo – lap ports and kochers incision
How to investigate RUQ pain
Pros/cons of emergency vs delayed lap chole
Consent her for lap chole
Unwell post op – what are you thinking
Bile duct injury – how to manage (washout/drains/HPB)
Options for reconstruction (hepjej/roux loop)
Developed recurrent symptoms ? CBD stones – MRCP showed portal vein thrombosis – how do you manage/anticoagulate
2. Short case
Take a history from patient with RUQ/upper abdo pain/SOB
Already had gallbladder out – normal bloods/USS/OGD, CXR showed raised R hemidiaphragm
Asked for CT – showed diaphragmatic hernia anteriorly (Morgagni)
How to manage operatively (examiner highlighted that despite he was soon retiring, he had never come across this) – common sense/pragmatic way of treating and reasoning behind it
3. Short case
Showed me lady with bilateral mastectomy – right side horribly scarred and skin graft taken from R thigh
Had WLE then recurrence on right side and contralateral metachronous tumour
On anastrozole, not had herceptin – what does this mean? Good or bad?
Mother had breast cancer – went through possibility of BRCA, are there any other inherited conditions (Li Fraumeni, Lynch)
Options available for reconstruction and justification of which were appropriate or not for this lady
Colorectal
- Long case
Inpatient with drain in. Patient gave clear history about previous UC, colonoscopy showed pre cancerous changes then had colectomy and pouch. Then had pouchitis and excision. Developed a pelvic collection which was radiological drained, superficial wound dehis. Examined and summarised findings
Discussed what is meant by dysplasia/why is it important
When do UC get cancer?
Management of pouchitis/classification systems
2. Short case
Anal cancer. Treated by primary excision in Spain! Then had chemo/radiotx. Then had recurrence and pelvic excenteration/groin dissection. Nephrostomy as now blocked ureters.
What do you think about her treatment?
Risk factors for anal cancer
Treatment protocol/Nigro protocol
3. Short case
Hysterectomy followed by sigmoid cancer and then recurrent rectal cancer.
Discussed about Lynch – screening strategies and how/when to test (MSI,Bethesda and Amsterdam)
Features of Lynch tumours
Genetic basis
Associations
Family implications
Screening in general – how does the test work? New FIT test, why is it better? Any other screening programmes you are aware of?
Vivas
Trauma/critical care
1. Liver injury. Showed a CT with a blush on it – are you aware of an injury grading system? What grade is this? Management – ATLS principles followed by approach to conservative management. Options for interventional radiology – what artery would you embolise? Patient deteriorates – how to do laparotomy and pack a liver. Complications of embolisation and liver trauma (immediate and late)
2. Bile duct leak. Patient unwell post lap chole – what are you thinking? How do you manage? Likeliest cause of a bile leak. Take patient for washout/drains. What do you do? Who to refer to?
3. Burns. Chest and face burns. ATLS principles. What are your concerns? Who do you need involved? How to assess for threatened airway and signs of CO poisoning. Parkland and Wallace rules. Consequences of burn injuries – what are the causes of mortality/morbidity/long term consequences.
4. Post op complication. Lady readmitted with a collapse after gynae adhesionlysis. What is your differential and how to manage. Resus/stabilises and then she goes off again. I took her straight to theatre for laparotomy but discussed options of putting a scope in first. Lots of liquid in abdomen – what are you thinking? Likely bladder injury – how to manage (i.e. sew it up, leave catheter and do a cystogram later). If the bladder is fine, where else would you look – ureter and how you would locate it. What would you do if ureter was damaged? Phone urology! What would they do? Repair over stent
5. Neck stabbing. Management/ATLS principles. What injuries are you worried about? How to manage? Zones and triangles of the neck. Level of carotid bifurcations. Patient has subcutaneous emphysema – what do you think now? Also then develops Horners syndrome… (Didn’t like this one!)
6. Low urine output. Asked to review a patient post op day one. What are you thinking? Discussed options ranging from the normal physiological response/blocked catheter/inadequately filled/renal failure/drug and contrast related/sepsis and how I would go about assessing which it was. What investigations were required and how you would treat. Classification of renal failure (mentioned RIFLE and pre/renal/post). How to differentiated between pre and renal failure based on urine osm/Na. Indications for dialysis/escalation. Different options for dialysis and why filtration used in critical setting.
Academic and basic sciences
1. Paper. Meta analysis on lap washout vs Hartmanns for diverticular disease. Talked about levels of evidence and advantages of a meta analysis. Conversation about paper critique and major flaws (more of a discussion really). Would this change your practice? What would you do if you did the paper again? The asked about T1/T2 error/when to use chi squared/multivariate and univariate analysis. What is a forest plot – draw it and explain.
2. Basic science one. Patient presents with colon cancer. Explain the TMN and Dukes staging systems (We had a random conversation about who Dukes was here!). Why do we now use TMN (more accurate N staging especially. What is meant by R0/R1/R2 resections? What is meant by c/p/y prefixes to TMN system.
3. Basic science two. High output stoma. Patient returns to renal unit after anterior and defunctioning ileostomy. How to manage/what to rule out – why does this happen (discussion of drinking too much hypotonic fluid). What are the electrolyte imbalances involved. What do you expect to happen and management options (stepwise introduction of ORT/St Marks, loperamide, codeine, octreotide and pros/cons of each/how do they work). Other option is stoma reversal.
4. Basic science three. Pelvic vein injury whilst performing an anterior resection. What do you do? (pressure, ask for help, liaise with anaesthetist etc). Describe the anatomy of the pelvic blood vessels and what they supply. Any other vessels that can bleed during anterior? I.e. pre sacral and how to manage (don’t touch them in the first place/appreciate the planes! Pack if not getting on top of and come back later). Considerations when approaching vessel injuries.
Speciality viva
1. Hereditary bowel cancer. Tell me about hereditary bowel cancers. What percentage of all colorectal cancers are these? Patient presents with metachronous cancers – what are you thinking? What are the characteristics of Lynch tumours/associated tumours? Already had a R hemi and now has sigmoid cancer – what op would you offer? Amsterdam and Bethesda criteria. Surveillance and follow up guidelines.
2. Anterior fistula in ano. Patient with obstetric history. Principles of assessment and management. Main concerns (especially in females). Methods of treatment ranging from loose seton to alternative strategies. Parks classification. Cryptoglandular theory and likely organisms in a perianal abscess (skin vs bowel).
3. Rectal cancer. Assessment and management. Investigations needed and what do you tell from each of them. Options for surgery and when you would consider each one.
4. Anastomotic leak. Patient unwell 5 days after anterior resection. What are you thinking? How to assess/manage and differentiate between them. How to manage a leak post op – operate at 5 days vs radiological drain. When you would choose each.
5. Prolapse. Patient presents with something coming out of her back passage. What are you thinking and how to differentiate between the potential diagnoses. Options for managing an old lady with prolapse. Pros and cons of delormes/altmeiers. Different options of abdominal approach. How would you approach a young man with rectal prolapse. Evidence?
6. Patient wanting colonoscopy. How do you approach? Says has a family history – what are the guidelines? Patient demands having a colonoscopy now and not recommended – how do you approach? Enquire about change in bowel habit/clear family history. When would you scope dependent on family history.
General surgery viva
1. Incisional hernia. How to approach – optimise/reduce BMI/stop smoking pre op. CT scan to clarify anatomy if large/complex. Options of repair – best method. Discussed about component separation. Patients returns with chronic non healing sinus – how to manage/what are you thinking.
2. WHO checklist and evidence. Lots of waffling was done here. How to manage a consultant colleague who won’t engage with the WHO checklist. What benefits has it shown.
3. Psoas abscess. Showed a CT image first and asked what the abnormality was. What is it? How to manage? Possible sources (Bowel, groin abscess, spine etc). Treatment options – antibiotics, radiological drain. If you can’t drain radiologically and not improving, how do you operate: open/transabdominal – what structures are at risk especially in retroperitoneum? Other option – retroperitoneal which avoids abdominal contamination.
4. Obstructive jaundice. Patient presents with jaundice – key questions you would want to know from the history (painful, rigours, foreign travel alcohol, gallstones, weightless etc) and what do each suggest. First line of investigations – bloods inc coag (why do they become coagulopathic?), USS/CT/MRI and which is best for each potential diagnosis. Told me it was painless jaundice + weight loss therefore I said likely Ca pancreas. Anything else? Cholangio. What would you do in terms of treatment options – palliative vs curative, when to use a stent etc. Why do patients with pancreas tumour loose weight? Not my finest answer to this last one…
5. Neck lump. What questions you would take in the history and what would you examine. Looking to see whether this is a thyroid lump, node or gland. What are you thinking if this is a lymph node – infective (bacterial or viral, don’t forget TB), primary or secondary malignancy. What tests – USS +/- FNA or excision biopsy. If it showed squamous cell or adenocarcinoma, where would you look. Staging for lymphoma (Ann Arbor classification). Said I would liaise with haematology MDT + excision biopsy if necessary.
6. Breast haematoma post op. Had mastectomy and implant reconstruction yesterday – ℅ chest pain. Differentials: post op pain, cardiorespiratory causes, haematoma. How would you assess? You see a tense haematoma, nil in the drains. Said I would take back to theatre and wash out/haemostasis/replace drains/sew up would as before. I said I would leave the implant in situ, inform breast team and start antibiotics.