Master General Surgery
for SMLE

What the SMLE Tests in General Surgery

General Surgery in the SMLE tests the ability to recognise and manage acute surgical presentations (e.g., acute abdomen, trauma, gastrointestinal bleeding), prioritise life-threatening conditions (e.g., ruptured AAA, mesenteric ischaemia, perforated viscus), and apply evidence-based perioperative care (e.g., VTE prophylaxis, antibiotic timing). Candidates must know diagnostic criteria (e.g., Alvarado score for appendicitis, Ranson criteria for pancreatitis), first-line imaging (CT with IV contrast for suspected diverticulitis; erect CXR for perforation), and surgical decision-making (e.g., when to operate vs. conservative management in cholecystitis or adhesional SBO). Knowledge of common surgical pathologies (hernias, haemorrhoids, thyroid nodules, breast lumps) and their management (e.g., tension-free mesh repair, Milligan-Morgan haemorrhoidectomy, FNAC for thyroid nodules) is essential. The exam emphasises clinical reasoning, complication recognition (e.g., bile leak post-cholecystectomy, anastomotic leak), and guideline-based resuscitation (e.g., ATLS principles, sepsis six for cholangitis).

High-Yield Concepts

• Acute Appendicitis – Alvarado Score: Use the Alvarado (MANTRELS) score: Migration of pain (1), Anorexia (1), Nausea/vomiting (1), Tenderness in RLQ (2), Rebound pain (1), Elevated temperature >37.3°C (1), Leukocytosis >10,000/μL (2), Left shift >75% neutrophils (1). Score 1-4: low risk; 5-6: equivocal (CT or US); 7-10: high risk (proceed to appendicectomy). First-line imaging in children/adults is US; CT with IV contrast if equivocal.
• Acute Cholecystitis – Tokyo Guidelines 2018: Diagnose with: (A) local signs (Murphy’s sign, RUQ mass/pain), (B) systemic inflammation (fever >38°C, CRP >30 mg/L, WBC >10,000/μL), (C) imaging (US: wall thickening >4 mm, distended gallbladder, pericholecystic fluid). Grade I (mild): no organ dysfunction; Grade II (moderate): WBC >18,000/μL, palpable tender mass, duration >72h; Grade III (severe): organ dysfunction (CVS, resp, renal). First-line: IV antibiotics (piperacillin-tazobactam or ceftriaxone + metronidazole), early laparoscopic cholecystectomy within 72h for Grade I/II.
• Pancreatitis – Ranson Criteria & Management: Ranson criteria: at admission (age >55, WBC >16,000/μL, glucose >11 mmol/L, LDH >350 IU/L, AST >250 IU/L) and at 48h (Hct drop >10%, BUN rise >1.8 mmol/L, Ca <2 mmol/L, PaO2 <60 mmHg, base deficit >4 mEq/L, fluid sequestration >6 L). Mortality: 0-2 = 1%, 3-4 = 15%, 5-6 = 40%, >6 = 100%. Initial management: aggressive IV crystalloids (Hartmann’s, 250-500 mL/h first 12h), analgesia (morphine), NG tube if vomiting, CT with IV contrast if severe or uncertain diagnosis. Indications for ERCP: cholangitis or persistent biliary obstruction.
• Hernias – Inguinal & Femoral: Indirect inguinal hernia: through deep ring, lateral to inferior epigastric vessels, common in young males. Direct: through Hesselbach’s triangle, medial to vessels, common in elderly. Femoral hernia: below inguinal ligament, medial to femoral vein, high risk of strangulation (40%). Management: elective tension-free mesh repair (Lichtenstein) for most; emergency surgery if obstructed/strangulated. Antibiotic prophylaxis only for high-risk patients (recurrent, immunocompromised).
• Colorectal Cancer – Screening & Staging: NHS Bowel Cancer Screening: faecal immunochemical test (FIT) every 2 years ages 60-74. Colonoscopy if positive. Staging: CT chest/abdomen/pelvis, MRI for rectal cancer (assess CRM involvement). TNM: T1 invades submucosa, T2 muscularis propria, T3 pericolorectal fat, T4 visceral peritoneum or other organs. Management: stage I-III – surgical resection (colectomy with lymphadenectomy) + adjuvant chemotherapy for stage III (FOLFOX). Rectal cancer: neoadjuvant chemoradiotherapy (long-course) if T3/T4 or node-positive.
• Breast Lumps – Triple Assessment: Triple assessment: clinical examination, imaging (mammography for >35y, US for <35y or dense breasts), and core needle biopsy (CNB) or FNAC. BI-RADS 4/5 lesions require biopsy. Management of invasive breast cancer: wide local excision or mastectomy + sentinel lymph node biopsy (SLNB) if clinically node-negative; axillary clearance if positive. Adjuvant: radiotherapy (post-BCS), endocrine therapy (tamoxifen or aromatase inhibitors if ER+), chemotherapy (if triple-negative, HER2+, high-risk).
• Acute Limb Ischaemia – Rutherford Classification: Rutherford categories: I (viable) – no sensory loss, audible Doppler; IIa (marginally threatened) – sensory loss only, inaudible arterial Doppler; IIb (immediately threatened) – motor loss (weakness), inaudible arterial Doppler; III (irreversible) – paralysis, rigor, no Doppler signals. Management: immediate heparin (IV 5000 IU bolus then infusion), CT angiography or duplex, then embolectomy (Fogarty catheter) or thrombolysis (catheter-directed alteplase) for IIa/IIb <14 days. Amputation for III.
• Perioperative VTE Prophylaxis – NICE Guidelines: Assess risk: Caprini score (surgery type, age, BMI, cancer, previous VTE). Low risk: early mobilisation. Moderate/high risk: LMWH (enoxaparin 40 mg SC daily) or fondaparinux, starting 6-12h post-op, continued for 7-14 days. For major cancer surgery: extend to 28 days. Mechanical prophylaxis (intermittent pneumatic compression) if high bleeding risk. Contraindications to anticoagulation: active bleeding, coagulopathy, recent haemorrhagic stroke.

Common Traps in General Surgery Questions

• Confusing direct and indirect inguinal hernias by anatomical relation to inferior epigastric vessels – remember indirect is lateral, direct is medial.
• Assuming all right lower quadrant pain is appendicitis – consider mesenteric adenitis in children, Crohn’s terminal ileitis, or ovarian torsion in women.
• Ordering CT with oral contrast for suspected perforation – erect CXR is first-line; CT with IV only if CXR negative and high suspicion.
• Using morphine for pancreatitis without considering need for early ERCP in gallstone pancreatitis with cholangitis – check LFTs and bilirubin first.
• Failing to start antibiotics immediately in cholangitis (e.g., piperacillin-tazobactam) before ERCP – delay increases mortality.
• Forgetting to check for AAA in elderly patients with abdominal or back pain – bedside US is quick and life-saving.

How to Revise General Surgery for the SMLE

Focus on acute surgical decision-making: SMLE questions frequently present a clinical scenario (e.g., 65-year-old with sudden epigastric pain radiating to back) and ask for the next best step (e.g., CT with IV contrast, Ranson scoring). Prioritise learning validated scoring systems (Alvarado, Ranson, Tokyo, Glasgow-Blatchford for UGIB) and their cut-offs. Practise interpreting imaging reports (e.g., 'thickened gallbladder wall with pericholecystic fluid' = cholecystitis). Be fluent in ATLS primary survey sequence for trauma (ABCDE) and indications for emergency laparotomy (peritonitis, haemodynamic instability from ruptured viscus). Revise common post-op complications (wound infection, anastomotic leak, ileus) and their management (e.g., CT with oral contrast for leak). Use NICE guidelines for VTE prophylaxis, antibiotic prophylaxis, and colorectal cancer screening. Questions often test recognition of 'can't miss' diagnoses: ruptured AAA, mesenteric ischaemia, necrotising fasciitis.

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