Master Surgery
for FMGE

What the FMGE Tests in Surgery

The FMGE Surgery section tests your ability to manage common surgical presentations in the Indian emergency and ward setting. You must demonstrate knowledge of indications for surgery, pre-operative optimisation, post-operative complications, and trauma triage. Expect clinical vignettes requiring diagnosis of acute abdomen, hernia complications, thyroid swellings, breast lumps, and colorectal emergencies. You will be asked to choose the most appropriate first-line investigation (e.g., USG abdomen for suspected appendicitis), the correct drug regimen (e.g., tetanus prophylaxis in wounds), or the next step in management (e.g., emergency laparotomy for perforated peptic ulcer). Critical cut-off values (e.g., Ranson's criteria ≥3 for severe pancreatitis) and scoring systems (e.g., Alvarado score for appendicitis) are frequently tested. Knowledge of standard surgical antibiotic prophylaxis (e.g., cefazolin 2 g IV pre-incision) and fluid resuscitation protocols (e.g., Parkland formula for burns) is essential.

High-Yield Concepts

• Acute Appendicitis – Alvarado Score & Management: Score ≥7 indicates high probability; urgent appendicectomy. Score 5-6: observe with serial exams and CT/USG. First-line antibiotic: co-amoxiclav or metronidazole + cefuroxime. McBurney's point tenderness is classic. Do not delay surgery >24 hours from symptom onset to reduce perforation risk.
• Perforated Peptic Ulcer – Emergency Laparotomy Criteria: Presence of free air under diaphragm on erect chest X-ray in a patient with epigastric pain and peritonism mandates emergency laparotomy with Graham patch repair (omentopexy). Pre-op: IV fluids, nasogastric tube, broad-spectrum antibiotics (e.g., piperacillin-tazobactam), and PPI (pantoprazole 80 mg IV bolus then 8 mg/h infusion).
• Burns – Parkland Formula & Tetanus Prophylaxis: Total fluid in first 24 hours = 4 mL × weight (kg) × %TBSA (second/third degree). Give half in first 8 hours from injury, remainder over 16 hours. Use Ringer's lactate. Tetanus-prone wounds: give tetanus immunoglobulin 250 IU IM + tetanus toxoid if last booster >5 years ago. Non-tetanus-prone: toxoid only if >10 years.
• Inguinal Hernia – Indirect vs Direct & Emergency Management: Indirect: passes through deep ring, lateral to inferior epigastric vessels, common in young. Direct: through Hesselbach's triangle, medial to vessels, common in elderly. Strangulated hernia: tender, irreducible, with signs of obstruction – emergency herniotomy with bowel resection if non-viable. Use mesh only in clean, elective cases.
• Thyroid Swellings – Solitary Nodule & Malignancy Risk: Fine needle aspiration cytology (FNAC) is first-line. Bethesda classification: category V/VI → total thyroidectomy. Cold nodule on scan (99mTc) has higher malignancy risk. Medullary carcinoma: raised calcitonin; associated with MEN 2A/2B. Pre-op: check TFT, calcium, vocal cord mobility. Post-thyroidectomy hypocalcaemia: check corrected calcium <2.1 mmol/L, treat with IV calcium gluconate.
• Acute Pancreatitis – Ranson's Criteria & Management: Ranson's criteria: at admission (5: age >55, WBC >16,000, LDH >350, AST >250, glucose >11 mmol/L) and at 48 hours (6: Hct drop >10%, BUN rise >1.8 mmol/L, Ca <2 mmol/L, PaO2 <60, base deficit >4, fluid sequestration >6 L). ≥3 indicates severe pancreatitis. Management: aggressive IV fluids (Ringer's lactate), analgesia (IV morphine/paracetamol), no prophylactic antibiotics unless infected necrosis. ERCP only for cholangitis/obstruction.
• Breast Lump – Triple Assessment & Common Diagnoses: Triple assessment: clinical examination, imaging (mammogram if >35 years, USG if <35), and biopsy (core needle biopsy preferred). Fibroadenoma: mobile, well-defined, 'breast mouse'. Carcinoma: irregular, fixed, peau d'orange. For invasive ductal carcinoma: wide local excision + sentinel node biopsy + radiotherapy for early stage; modified radical mastectomy for advanced.
• Colorectal Emergencies – Obstruction & Perforation: Large bowel obstruction: most common cause is carcinoma (left-sided). Erect X-ray shows peripheral haustra; CT confirms. Treatment: urgent laparotomy, Hartmann's procedure if perforation/obstruction with faecal peritonitis. Diverticulitis: Hinchey classification; Hinchey I/II: IV antibiotics (piperacillin-tazobactam) and bowel rest; Hinchey III/IV: emergency laparotomy + lavage ± resection.

Common Traps in Surgery Questions

• Confusing direct and indirect inguinal hernias based on deep ring location relative to inferior epigastric vessels – remember indirect is lateral.
• Using the Parkland formula incorrectly by including first-degree burn surface area – only count second and third degree.
• Ordering a CT abdomen for suspected acute appendicitis before USG in young adults – USG is first-line to reduce radiation exposure.
• Administering prophylactic antibiotics for acute pancreatitis without evidence of infected necrosis – this is not indicated and promotes resistance.
• Treating a cold thyroid nodule as benign without FNAC – cold nodules have higher malignancy risk and require cytology.
• Delaying surgery for a strangulated inguinal hernia to perform bowel preparation – this is an emergency, not elective.

How to Revise Surgery for the FMGE

Focus on emergency surgical decision-making and trauma management. Questions often present as a clinical scenario with a critical time pressure (e.g., 'what is the next step?'). Prioritise memorising scoring systems (Alvarado, Ranson's, Glasgow-Blatchford for upper GI bleed) and their cut-offs. Know standard antibiotic prophylaxis for clean-contaminated surgeries (e.g., colorectal: oral neomycin + erythromycin pre-op, IV cefoxitin). Practise fluid and electrolyte management in burns and pancreatitis. Review common post-operative complications by day: haemorrhage (first 24h), wound infection (day 5-7), anastomotic leak (day 7-10). Use the 'ABCDE' approach for trauma vignettes. Spend extra time on hernia anatomy and breast lump differentiation – these are heavily tested. Revise from standard Indian textbooks (e.g., Das, SRB) and focus on bullet-point summaries of management algorithms.

Practise it: MedLumen has 50 Surgery questions for the FMGE, each with a full explanation and references.