Master General Surgery & Perioperative Care
for PLAB 1

What the PLAB 1 Tests in General Surgery & Perioperative Care

PLAB 1 tests your ability to recognise and manage common surgical presentations (e.g., acute abdomen, hernia, colorectal cancer, biliary disease) and perioperative care (pre-op assessment, fluid and electrolyte management, DVT prophylaxis, wound care, and recognition of complications like anastomotic leak or surgical site infection). You must know NICE and SIGN guidelines for emergency laparotomy, sepsis, and VTE prevention. Questions often present a clinical scenario requiring selection of the most appropriate next investigation (e.g., CT abdomen with contrast for suspected diverticulitis) or management step (e.g., IV fluids and antibiotics for acute cholecystitis). You need to recall specific criteria (e.g., Alvarado score for appendicitis, Wells' criteria for PE) and drug doses (e.g., enoxaparin 40 mg SC OD for VTE prophylaxis). The exam emphasises safe, evidence-based decision-making in a UK hospital setting.

High-Yield Concepts

• Acute Appendicitis – Alvarado Score: Score ≥7 suggests high probability; first-line is CT abdomen with IV contrast if equivocal. Key components: migration of pain (1), anorexia (1), nausea/vomiting (1), tenderness in RLQ (2), rebound pain (1), fever >37.3°C (1), leukocytosis >10,000 (2). Surgery (laparoscopic appendicectomy) within 12-24 hours.
• Bowel Obstruction – Management: Suspect small bowel obstruction (SBO) with colicky pain, vomiting, distension, and high-pitched tinkling sounds. First-line: NBM, IV fluids (e.g., Hartmann's), nasogastric tube, CT abdomen with oral/IV contrast. For large bowel obstruction (LBO), consider sigmoidoscopy with stent or emergency surgery. Strangulation requires urgent laparotomy.
• Perioperative VTE Prophylaxis – NICE Guidelines: For all surgical patients with >90 min anaesthesia or pelvic/abdominal surgery: enoxaparin 40 mg SC OD (or dalteparin 5000 IU OD) plus mechanical prophylaxis (graduated compression stockings or intermittent pneumatic compression). Continue for 28 days after major cancer surgery. Contraindications: active bleeding, heparin-induced thrombocytopenia.
• Fluid Resuscitation in Surgery – Hartmann's vs Saline: Use Hartmann's solution (lactated Ringer's) for most surgical patients as it is more physiological; avoid 0.9% saline in large volumes due to hyperchloremic acidosis. For haemorrhagic shock, give blood products (1:1:1 ratio) and tranexamic acid 1 g IV within 3 hours. Monitor urine output >0.5 mL/kg/hr.
• Acute Cholecystitis – Diagnosis and Management: Murphy's sign positive, elevated LFTs and WCC, ultrasound shows thickened gallbladder wall (>4 mm) and pericholecystic fluid. First-line: IV antibiotics (co-amoxiclav 1.2 g TDS or piperacillin-tazobactam 4.5 g QDS), NBM, IV fluids, and laparoscopic cholecystectomy within 72 hours (or next available list).
• Hernia – Strangulation vs Incarceration: Incarcerated hernia: irreducible but no ischaemia; strangulated: irreducible with pain, tenderness, and signs of obstruction/ischaemia. Strangulated inguinal hernia requires emergency surgery (open or laparoscopic) with bowel resection if non-viable. Richter's hernia involves only part of bowel wall; high risk of strangulation without obstruction.
• Colorectal Cancer – Screening and Referral: NICE guidelines: urgent 2-week wait referral for patients >50 with rectal bleeding and change in bowel habit, or >60 with iron-deficiency anaemia (Hb <110 g/L). Screening: faecal immunochemical test (FIT) every 2 years for 60-74 year olds. Staging: CT chest/abdomen/pelvis; MRI for rectal cancer.
• Surgical Site Infection – Prevention and Management: Give prophylactic antibiotics (e.g., cefuroxime 1.5 g IV + metronidazole 500 mg IV) within 60 minutes of incision. For infection: open wound, take swab for culture, start empirical antibiotics (flucloxacillin 500 mg QDS or co-amoxiclav). Use NICE SSI risk assessment: diabetes, smoking, obesity, prolonged surgery.

Common Traps in General Surgery & Perioperative Care Questions

• Confusing Alvarado score for appendicitis with Glasgow score for pancreatitis (the latter uses age, LDH, glucose, etc.)
• Assuming all abdominal pain with fever is appendicitis – always consider cholecystitis, diverticulitis, and perforated peptic ulcer
• Giving 0.9% saline for all surgical patients without considering hyperchloremic acidosis risk
• Forgetting to check for heparin-induced thrombocytopenia before starting enoxaparin prophylaxis
• Treating an incarcerated hernia as strangulated and rushing to surgery without assessing for signs of ischaemia
• Missing the need for urgent 2-week wait referral in a 55-year-old with rectal bleeding and change in bowel habit

How to Revise General Surgery & Perioperative Care for the PLAB 1

For PLAB 1, focus on the 'next step' in management: e.g., after diagnosing acute cholecystitis, the next step is IV antibiotics and urgent cholecystectomy, not just observation. Questions often present a list of investigations – know when to choose CT abdomen over ultrasound (e.g., suspected diverticulitis). Practise applying scoring systems (Alvarado, Wells, Glasgow) rapidly. Memorise key antibiotic regimens (co-amoxiclav for biliary, piperacillin-tazobactam for severe intra-abdominal sepsis). Also, perioperative care questions frequently test fluid balance and VTE prophylaxis – be comfortable calculating maintenance fluids (30 mL/kg/day) and recognising signs of hypovolaemia. Review NICE guidelines for emergency laparotomy (e.g., lactate >2, SIRS criteria) and surgical site infection prevention.

Practise it: MedLumen has 50 General Surgery & Perioperative Care questions for the PLAB 1, each with a full explanation and references.