Vascular surgery

As the patient in clinic describes the cramp-like pain that he gets in his calf when he walks, a pain that disappears on resting but which is exac­erbated by walking up hills and necessitates him stopping to look in shop windows when out and about, you will be thinking about questioning him for risk factors for vascular disease. Atherosclerosis is a systemic disease. Identification and early treatment of diabetes, hypercholesterolaemia, hypertension, and provision of antiplatelet agents and smoking cessation therapy will confer important cardio- and cerebroprotective benefits. Acute vascular emergencies requiring an urgent response include the patient with sudden onset, limb-threatening ischaemia; the collapsed patient with a ruptured aortic aneurysm; and the patient in whom haemorrhage or ischaemia comprises part of the picture of complex trauma. Rapid, but thorough examination, appropriate resuscitation, and judicious use of diagnostic imaging will help to underpin urgent manage­ment and interventions necessary to obtain the best outcomes for these patients. Despite increasing reliance on minimally invasive diagnostic modali­ties including duplex Doppler ultrasound, magnetic resonance angiog­raphy, and computed tomography angiography, principles of history taking and good clinical examination remain of paramount importance. Observation to detect nuances of ischaemic trophic changes and skin colour, as well as more overt signs of necrosis, gangrene, and ulceration, complements palpation of pulses, detection of subtle changes in skin temperature, delayed capillary refill, and presence of sensory neuropa­thy. A positive Buerger’s test, with pallor of the foot and venous gutter­ing on leg elevation, and rubor (redness), due to reactive hyperaemia on dependency, may help clinch the diagnosis of critical limb ischaemia when other diagnostic features are equivocal. Careful distinction between features of arterial insufficiency, venous hypertension, and diabetic neuropathy may help to determine aetiol­ogy of a recalcitrant lower limb ulcer and the consequent course of management. In the UK, vascular surgery has recently become an independent surgi­cal specialty. This chapter will test your understanding of signs and symp­toms of vascular disease and will hopefully stimulate your understanding of priorities for investigation and management of the range of conditions comprising this exciting sphere of surgery.

Orthopaedic surgery

Sound knowledge of anatomy and understanding of musculoskeletal function underpins good orthopaedic practice. Bones and joints may be affected by genetic and degenerative conditions, by infection, primary and secondary neoplasia, by endocrine and metabolic anomalies, and by trauma. As in other areas of surgery, a comprehensive history and thorough examination are essential in leading the clinician to a correct diagno­sis. Appropriate imaging complements clinical acuity. The plain X-ray remains the primary modality of investigation for visualizing bony injuries and pathology, but MRI is a valuable adjunct for investigating soft tissues and joints. Principles of fracture healing, reduction and fixation, and knowledge of consequences of complications which delay healing, or cause non-union, are integral to the practice of orthopaedic surgery. This chapter will help you to revise basic tenets of orthopaedic prac­tice and the common injuries and conditions encountered by the ortho­paedic surgeon.

Trauma surgery

Appreciation of the ‘golden hour’ for resuscitation, and adoption of prin­ciples of the advanced trauma life support (ATLS) system are key factors in improving outcome for the patient with major injuries. Adherence to the strict protocols of the ABCDEs of the primary survey enables the trauma team to identify and deal with life-threatening conditions, prior to definitive treatment of problems with lesser immediacy. The clinician who understands the mechanism of injury will main­tain heightened levels of suspicion for clinical signs which point to well-recognized conditions resulting in early mortality and morbidity, for instance, tension pneumothorax, cardiac tamponade, and rising intrac­ranial pressure. This chapter will probe your grasp of the principles of trauma manage­ment. You will also be tested on common patterns of thoracic, abdomi­nal, vascular, and cranial injuries. Whilst clinical presentations of civilian trauma have remained consist­ent in recent years, the impact of military trauma in worldwide theatres of conflict has stimulated numerous advances in the management of trauma. The current impetus for reorganization of trauma services in the UK is tacit acknowledgement of the improvement in outcomes that can be achieved by adherence to recognized protocols in this challenging and demanding field of surgery.

Paediatric surgery

Understanding that children are not small adults, and that they come in different sizes and stages of development, is fundamental to paediatric surgery. Knowledge of a child’s weight is crucial when considering fluid and medication administration. Moreover, babies have immature physiology and less functional reserve compared to older children. Understanding basic embryology will unravel some of the mysteries of developmental pathology encoun­tered by the paediatric surgeon, such as oesophageal atresia, malrotation of the gut, annular pancreas, and maldescent of the testis. The paediatric surgeon deals with some of the same surgical condi­tions that affect adults, but even management of a common condition such as inguinal hernia, has different therapeutic implications in children and adults. Paediatric surgery demands gentle tissue handling and deli­cate technique. Good communication skills are a prerequisite for dealing with the distraught or ill child and anxious parents, and the surgeon often retains a clinical interest in his or her patient, well into young adulthood. This chapter will test your knowledge of principles of surgical manage­ment of sick children and your understanding of presentations of some of the more commonplace conditions encountered by surgeons in this demanding, yet rewarding, discipline.

Colorectal surgery

Among the abdominal surgical specialities, colorectal surgery is, argu­ably, the most wide ranging. It spans a number of areas of practice each requiring many distinct knowledge bases. A large part of the speciality revolves around colorectal neoplasia which involves understanding of epidemiology, cell biology, and clinical genetics as well as appreciation of the major surgical presentations including some of the commoner abdominal emergencies, principles of surgical oncology, and pathology. Inflammatory bowel disease features a crossover area with medicine but all students of surgery need to understand the role of surgery in the context of advanced medical therapies including newer biological immu­nomodulatory treatments. On the other hand, functional pelvic floor dis­orders and diseases of the anal canal and rectum require understanding of anatomy and the wide range of local therapies available. This chapter will test all these areas from pathology to anatomy, prin­ciples of major surgery, and outpatient treatments.

Hepatobiliary surgery

The reaction of most students to questions about hepatobiliary dis­ease is a sinking feeling of despair! ‘Lots of biochemistry and anatomy together with a bunch of funny eponymous syndromes to remember!’ Well, hepatobiliary disease is remarkably logical; knowledge of the basic principles of biliary metabolism and the key anatomical facts is usually more than enough if it is coupled with a sound appreciation of the com­mon clinical presentations. These presentations are extremely common; most days on call will see the surgical team looking after at least one patient with one of the range of hepatopancreaticobiliary problems that can present as an emergency. This chapter will review the basic principles of liver and pancreatic disease and the anatomy that goes with it. Both elective and emergency surgical presentations will also be covered, allowing you to revise knowl­edge of key clinical presentations in practice.

Breast and endocrine surgery

One of the main ‘complaints’ about breast disease is that ‘it is all so similar’ and that there are lots of treatment options which can seem confusing at first. The key to understanding breast disease and preparing for questions about it is to keep the basic facts about breast anatomy and pathology to the forefront, learn to recognize key patterns of clinical signs and symptoms, and then match them to the clinical scenario. The EMQs are particularly useful at practising fitting questions into clinical patterns and rehearsing the patterns. Endocrine disease poses its own challenges. Even for a surgeon it is important to understand and recognize the underlying biochemistry and how this affects the clinical presentations. Endocrine surgical disease is much less about anatomy or surgical procedures themselves as it is about understanding how treatment is matched to the pathophysiology of the conditions.

Head and neck surgery

In almost no other surgical specialty does use of a diagnostic screen have such prominence than when considering the diagnosis of a lump in the head or neck. Is the lump neoplastic and if so, is it likely to be of benign, malignant, or of mixed malignant potential? Does the mass have features of a developmental condition or could it represent sequelae of acute or chronic infection? Are there associated signs suggesting endocrine or metabolic dysfunction in association with the mass? Is there a traumatic origin or are there features of degenerative disease? Enlarged lymph nodes may be reactive due to inflammation, acute or chronic infection, or may represent primary or secondary neoplastic dis­ease. Anatomical knowledge of lymph drainage patterns provides clues as to the region of primary pathology. Developmental abnormalities such as thyroglossal cyst, dermoid inclu­sion cyst, and brachial fistula exhibit specific clinical signs and are found in characteristic anatomical locations. Systemic clinical signs may occur in endocrine abnormalities asso­ciated with hyper- or hypothyroidism and, for instance, in primary hyperparathyroidism. Bimanual examination will assist localization of sialolithiasis and the alert examiner will search for clinical involvement of the facial nerve which may help to suggest the nature of the neoplastic pathology involv­ing a pre-auricular mass. CT scan and fibre-endoscopy are powerful diagnostic tools in inves­tigation of the oro- and nasopharynx and of the pathologies that may lie therein. Head and neck pathologies may be treated by ENT, head & neck, or general surgical specialists. Irrespective of which specialty eventually manages the patient, it behoves the medical student and surgical trainee to ensure that he or she is conversant with the common clinical mani­festations and anatomical features of conditions that occur in this region. This chapter will help you to revise distinct features of some of the most common clinical pathologies affecting the head and neck, and should remind you of rationales for specific diagnostic and therapeutic avenues.

Surgical pathology

Understanding of the fundamental processes of pathology is essential both to the understanding of how many surgical conditions arise and develop and to the vital role of appreciating the principles of how best to treat conditions. For example, the nature and behaviour of infecting organisms determines whether radical debridement of tissue or simple surgical drainage is required; the stage and grade of tumours influence not only the choice of surgical procedure but the use of adjuvant thera­pies. These ‘surgical’ pathologies are often seen as rather ‘old-fashioned’ compared to the emphasis on cell and molecular biology so often found in books describing medical specialities but they form the bulk of the processes of disease suffered worldwide and remain fundamental to the skilled practice of surgery today.

Urological surgery

When the student contemplates potential causes of urinary tract obstruction, considering the anatomy of the drainage system from renal pelvis to urethral meatus and appreciation of potential causes of block­age will provide a useful diagnostic screen and will help one to review the breadth of conditions which may affect the renal tract. These include extrinsic compression, (for instance, due to retroperitoneal fibrosis or prostatic hypertrophy), mural involvement (infection, inflammation and transitional cell carcinoma), or luminal obstruction, (blood clot, stone, or valve). A firm grasp of appropriate investigations for urinary tract disease will aid diagnostic accuracy. Urological surgery encompasses various aspects of neoplasia and developmental conditions. This chapter will test your knowledge of the presentation, diagnosis, management, and pathology of common urological malignancies including renal adenocarcinoma, transitional cell tumours, testicular tumours, and carcinoma of the prostate. Urological conditions often occur in patients who may have other co-morbidities. Understanding the causes, investigation, and management of renal failure, appreciating the significance of haematuria, and knowing how to deal with an urological emergency of acute urinary obstruction will add to the medical student’s or trainee surgeon’s breadth of compe­tence in general surgical practice.