Master Surgery
for FMGE

Core Concepts

Surgery encompasses the principles of invasive medical treatment. Key pillars include sterile technique (asepsis), hemostasis (blood control), tissue handling, and appropriate wound closure. Pre-operative assessment involves risk stratification (e.g., ASA score), optimizing comorbidities, informed consent, and essential investigations. Post-operative care focuses on pain management, fluid and electrolyte balance, early mobilization, DVT prophylaxis, nutrition, and vigilant monitoring for complications.

• ATLS (Advanced Trauma Life Support): Primary survey (ABCDE - Airway, Breathing, Circulation, Disability, Exposure), resuscitation, secondary survey (head-to-toe exam), definitive care.
• Shock: A state of inadequate tissue perfusion. Types: Hypovolemic, Cardiogenic, Obstructive, Distributive (Septic, Anaphylactic, Neurogenic). Initial management: ABCs, IV fluids, vasopressors as needed, identify and treat underlying cause.
• Surgical Infections: Common causes include skin flora, enteric organisms. Examples: Cellulitis, abscess, necrotizing fasciitis. Management involves antibiotics, source control (drainage, debridement).
• Wound Healing:
  • Primary Intention: Clean, approximated wound edges (e.g., surgical incision).
  • Secondary Intention: Open wound with tissue loss, fills with granulation tissue, contracts (e.g., pressure ulcer).
  • Tertiary Intention (Delayed Primary Closure): Wound initially left open to resolve infection/edema, then closed later.
• Acute Abdomen: Sudden onset severe abdominal pain, often requiring surgical intervention. High index of suspicion for perforation, obstruction, ischemia, inflammation.

Clinical Presentation

• Acute Abdomen: Sudden severe pain, nausea, vomiting, fever, changes in bowel habits. Localized vs. generalized pain suggests underlying pathology (e.g., Right Iliac Fossa pain in appendicitis, Right Upper Quadrant pain in cholecystitis).
• Lumps and Swellings: Palpable masses varying in size, consistency, mobility, tenderness. Common sites: Neck (thyroid, lymph nodes), Breast, Abdominal wall (hernias, lipomas), Extremities.
• Trauma: Injuries from external forces; blunt or penetrating. Presents with pain, deformity, bleeding, altered consciousness.
• Gastrointestinal Bleeding:
  • Upper GI (UGIB): Hematemesis, melena.
  • Lower GI (LGIB): Hematochezia.
• Vascular Issues:
  • Deep Vein Thrombosis (DVT): Unilateral leg swelling, pain, tenderness, warmth.
  • Acute Limb Ischemia: Sudden onset of 6 P's (Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia).
  • Peripheral Arterial Disease (PAD): Intermittent claudication, rest pain, non-healing ulcers.
• Hernias: Protrusion of an organ or tissue through an abnormal opening. Presents as a visible or palpable bulge, often reducible, may be painful, especially on straining. Can be inguinal, femoral, umbilical, incisional.

Diagnosis (Gold Standard)

Diagnosis in surgery often begins with a thorough history and physical examination, followed by targeted investigations.

• Acute Abdomen: Clinical assessment is paramount.
  • Appendicitis: CT abdomen (though clinical diagnosis often suffices for appendectomy).
  • Cholecystitis: Ultrasound abdomen.
  • Bowel Obstruction: Abdominal X-ray (erect and supine), CT abdomen.
  • Perforation: Erect chest X-ray (free air under diaphragm), CT abdomen.
• Lumps:
  • Breast Lumps: Triple assessment (clinical exam, imaging (USG/mammography), biopsy (FNAC/core biopsy)).
  • Thyroid Nodules: Ultrasound, Fine Needle Aspiration Cytology (FNAC).
• DVT: Duplex Ultrasound of the affected limb.
• GI Bleeding: Endoscopy (upper for UGIB, colonoscopy for LGIB).
• Trauma: ATLS primary/secondary survey, X-rays of injured areas, FAST (Focused Assessment with Sonography for Trauma), CT scan (head, chest, abdomen/pelvis).

Management (First Line)

Initial management priorities include resuscitation, stabilization, and control of life-threatening conditions, followed by definitive surgical or non-surgical intervention.

• Acute Abdomen (General): NPO, IV fluids, broad-spectrum antibiotics, pain control, urgent surgical consultation.
  • Appendicitis: Laparoscopic or open appendectomy.
  • Acute Cholecystitis: Cholecystectomy (often laparoscopic, early vs. delayed depending on severity).
  • Bowel Obstruction: NPO, NGT decompression, IV fluids. Laparotomy for strangulation or failure of conservative management.
  • Peritonitis/Perforation: Emergency laparotomy for source control (repair, resection) and peritoneal lavage.
• Trauma: Adhere to ATLS principles (ABCDE). Hemorrhage control, fluid resuscitation, fracture immobilization, definitive repair of injuries.
• Surgical Infections:
  • Abscess: Incision and Drainage (I&D) with culture-directed antibiotics.
  • Necrotizing Fasciitis: Aggressive surgical debridement of necrotic tissue and broad-spectrum antibiotics.
• Hernias: Surgical repair (herniorrhaphy/hernioplasty) to prevent incarceration and strangulation. Emergency repair for incarcerated/strangulated hernias.
• DVT: Anticoagulation (e.g., LMWH followed by oral anticoagulant).
• Acute Limb Ischemia: Emergency revascularization (embolectomy, bypass surgery, thrombolysis).