Surgery

Starting a surgical job can feel like learning a completely new language. It may be the first time seeing patients in acute severe pain with a variety of lumps and bumps and a past history of previously unheard of complex operations. It can be easy to get hung up on whether the distended large bowel loop on the X- ray is a caecal or sigmoid volvulus or whether the strangulated hernia is femoral or inguinal. Ultimately, however, the most important point is that, as a junior doctor, it is being able to recognize that the patient is acutely unwell and may require an operation that will save lives. Ironically, a surgical rotation involves little time in the operating theatre— mostly, it will be spent dealing with problems during the peri-­operative period. This may start a week or two before the patient is even admitted, in the shape of a pre- assessment clinic, though these are increasingly nurse- led clinics with minimal input from junior doctors. Such clinics are, however, a good opportunity to see stable patients with interesting pathology and good clinical signs and to establish how well they look before the majority of their large bowel or their stomach is removed. The preoperative preparation of the patient goes beyond bloods and a cursory chat, and will require one to be on the lookout for previously undiagnosed cardiorespiratory or rheumatological conditions, among others, that might affect the patient getting to sleep or staying safely asleep under anaesthesia. Liaising with the anaesthetist about possible sources of difficulty well in advance of the planned procedure will ensure that operations do not get cancelled. The acute abdomen will take centre stage during general surgical takes. A thorough history and sound anatomical knowledge will help create a list of differential diagnoses. Accurate and careful palpation of the abdomen will reveal peritonism and the presence of any masses, and simple bedside observations and tests can greatly aid the diagnosis. Surgical specialties have a heavy reliance on imaging— erect chest X- ray, ultrasound, computed tomography (CT)/ magnetic resonance imaging (MRI) scan— each providing different information for the symp­toms displayed.