Master General Surgery & Perioperative Care
for PLAB 1

Core Concepts

General Surgery encompasses a broad range of surgical conditions, primarily focusing on the alimentary tract from the oesophagus to the anus, abdominal organs (e.g., liver, pancreas, gallbladder, spleen), breast, endocrine glands (e.g., thyroid, parathyroid, adrenal), and hernias. Perioperative care covers the entire patient journey: pre-operative assessment and optimisation, intra-operative management, and post-operative monitoring and complication management. Key principles include accurate diagnosis, timely intervention, patient safety, pain management, fluid and electrolyte balance, infection control, and early mobilisation. Understanding ASA (American Society of Anesthesiologists) physical status classification is vital for risk assessment, and ERAS (Enhanced Recovery After Surgery) protocols are increasingly standard for optimising recovery.

Clinical Presentation

• **Acute Abdomen:** Sudden onset, severe abdominal pain (location, character, radiation), nausea, vomiting, change in bowel habits, fever, guarding, rigidity, rebound tenderness.
• **Appendicitis:** Periumbilical pain migrating to RIF, anorexia, nausea, vomiting, low-grade fever, tenderness at McBurney's point.
• **Cholecystitis/Biliary Colic:** RUQ pain radiating to right shoulder/back, often post-fatty meal, nausea, vomiting, fever, positive Murphy's sign.
• **Bowel Obstruction:** Colicky abdominal pain, distension, absolute constipation (later stages), vomiting (bilious to faeculent), tinkling bowel sounds (early) or absent (late).
• **Hernias:** Palpable lump (groin, umbilical, incisional) often reducible, may cause discomfort or pain, worse on straining. Incarceration presents as irreducible, painful lump; strangulation adds signs of ischaemia/obstruction.
• **Gastrointestinal Bleeding:** Haematemesis (upper GI), melaena (upper/small bowel), fresh PR bleeding (lower GI), signs of shock (tachycardia, hypotension, pallor).
• **Peritonitis:** Severe, generalised abdominal pain, board-like rigidity, rebound tenderness, fever, systemic signs of sepsis.
• **Breast Lumps:** Palpable mass, skin changes (dimpling, nipple retraction), nipple discharge, lymphadenopathy.

Diagnosis (Gold Standard)

Diagnosis begins with thorough clinical history and physical examination. **Blood tests** are crucial: FBC (WBC, Hb), U&Es, LFTs, Amylase/Lipase, CRP, coagulation screen, Group & Save/X-match, lactate, ABG. **Imaging:** **CT scan (abdomen/pelvis)** is the gold standard for most acute abdominal pathologies (appendicitis, diverticulitis, pancreatitis, bowel obstruction, abscesses). **Ultrasound** is first-line for suspected gallstones, cholecystitis, appendicitis (in children/pregnant), and AAA. Plain **X-rays (AXR/CXR)** can show bowel obstruction (dilated loops, air-fluid levels) and perforation (free air under diaphragm). **Endoscopy (OGD/Colonoscopy)** is vital for GI bleeding and tumour diagnosis. Diagnostic laparoscopy may be used when other methods are inconclusive.

Management (First Line)

Initial management for acute surgical emergencies focuses on **ABCDE resuscitation**: IV fluids, oxygen, pain relief, antiemetics, NGT (if obstruction/vomiting), urinary catheter. Empirical broad-spectrum **antibiotics** are started for suspected infection/sepsis (e.g., intra-abdominal). Specific surgical interventions include: **Appendectomy** for appendicitis; **Laparoscopic cholecystectomy** for symptomatic gallstones/cholecystitis; **Hernia repair (hernioplasty/herniorrhaphy)** for symptomatic or incarcerated hernias; **Laparotomy/Laparoscopy** for peritonitis, bowel obstruction, perforation, or trauma. Haemostasis via endoscopy or surgery for GI bleeding. Post-operatively, focus on adequate analgesia, fluid management, DVT prophylaxis, early mobilisation, wound care, and close monitoring for complications. Adherence to **ERAS protocols** is encouraged for faster recovery.

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