Master General Surgery
for SMLE

Core Concepts

• **Scope:** Diagnosis & management of diseases involving the GI tract (esophagus to rectum), endocrine glands (thyroid, parathyroid, adrenal, pancreas), breast, soft tissues, vascular system, and acute surgical conditions (trauma, critical care).
• **Key Principles:**
  • **Acute vs. Elective:** Differentiate urgent surgical emergencies from planned procedures.
  • **Sterile Technique:** Fundamental for preventing surgical site infections.
  • **Pre-operative Assessment:** Optimize patient health to minimize risks (cardiac, pulmonary, renal, nutrition, NPO, DVT/antibiotic prophylaxis).
  • **Post-operative Care:** Pain management, fluid balance, early mobilization, monitoring for complications (bleeding, infection, DVT/PE, ileus, anastomotic leak).
  • **Shock & Resuscitation:** Recognize and manage hypovolemic, septic, cardiogenic, obstructive shock (ATLS principles for trauma).

Clinical Presentation

• **Acute Abdomen:** Sudden severe abdominal pain.
  • **Appendicitis:** Periumbilical pain migrating to RIF, anorexia, N/V, fever, McBurney's tenderness.
  • **Acute Cholecystitis:** RUQ pain radiating to R shoulder/back, fever, N/V, positive Murphy's sign.
  • **Diverticulitis:** LLQ pain, fever, altered bowel habits (often elderly).
  • **Small Bowel Obstruction (SBO):** Colicky pain, vomiting, distension, absolute constipation, tinkling bowel sounds.
  • **Perforated Viscus (e.g., Peptic Ulcer):** Sudden, severe, generalized abdominal pain, guarding, "board-like" rigidity.
  • **Acute Pancreatitis:** Severe epigastric pain radiating to back, N/V.
  • **Ruptured AAA:** Sudden severe back/abdominal pain, hypotension, pulsatile abdominal mass.
• **Gastrointestinal Bleeding:** Hematemesis/melena (UGI), hematochezia (LGI).
• **Hernias:** Palpable bulge; pain, irreducibility, or strangulation signs (erythema, systemic toxicity) are critical.
• **Breast Lumps:** Palpable mass, skin changes (peau d'orange), nipple discharge/retraction.
• **Thyroid Pathology:** Neck lump/swelling (goiter), dysphagia, dyspnea, hoarseness, +/- hypo/hyperthyroid symptoms.
• **Trauma:** Injuries following blunt/penetrating force; focus on ABCDE assessment.
• **Surgical Infections:** Localized pain, swelling, redness, warmth, fever (e.g., abscesses, cellulitis, necrotizing fasciitis).
• **Vascular:**
  • **Peripheral Arterial Disease (PAD):** Intermittent claudication, rest pain, trophic changes, non-healing ulcers.
  • **Deep Vein Thrombosis (DVT):** Leg pain, swelling, tenderness, warmth, erythema.

Diagnosis (Gold Standard)

• **History & Physical Examination:** Always the first and most crucial step.
• **Laboratory Tests:** CBC (leukocytosis, anemia), U&E, LFT, Amylase/Lipase, Coagulation profile, G&S, ABG.
• **Imaging:**
  • **Plain Radiographs (CXR/AXR):** CXR: free air under diaphragm (perforation). AXR: dilated bowel loops, air-fluid levels (SBO).
  • **Ultrasound (US):** Highly useful for gallstones/cholecystitis, appendicitis (peds/pregnant), AAA, DVT, breast lumps, thyroid nodules.
  • **Computed Tomography (CT) Scan:** **Often gold standard for acute abdomen** (appendicitis, diverticulitis, perforation, AAA, trauma assessment, staging malignancy). CT angiography for vascular disease.
  • **Endoscopy (EGD/Colonoscopy):** Gold standard for diagnosing and often treating GI bleeding, strictures, masses.
  • **Biopsy (Histopathology):** **Definitive for malignancy** (breast, thyroid, GI masses).
  • **Angiography:** Gold standard for vascular lesions (PAD, acute ischemia).

Management (First Line)

• **Resuscitation & Stabilization:**
  • **ABCDE Assessment:** Prioritize airway, breathing, circulation.
  • **IV Fluids:** Crystalloids (e.g., Normal Saline, Ringer's Lactate) for hypovolemia/shock.
  • **Oxygen:** Supplemental O2 for hypoxia.
  • **Analgesia:** Early pain control (e.g., opioids).
  • **NPO & Nasogastric Tube (NGT):** For bowel obstruction, pancreatitis, pre-op.
• **Antibiotics:** Empiric broad-spectrum for suspected infection (e.g., intra-abdominal sepsis, diverticulitis, cholecystitis) or prophylaxis.
• **Specific Surgical Interventions:**
  • **Acute Appendicitis/Cholecystitis:** Laparoscopic appendectomy/cholecystectomy.
  • **Perforated Viscus:** Emergency exploratory laparotomy with primary repair or resection.
  • **Small Bowel Obstruction (SBO):** Initial conservative management (NPO, NGT, IV fluids); surgical lysis of adhesions or resection for strangulation/failure of conservative Rx.
  • **Hernia:** Elective repair (herniorrhaphy/hernioplasty); emergency repair for incarcerated/strangulated hernias.
  • **GI Bleeding:** Endoscopic intervention (clipping, coagulation) often first line; surgical exploration for refractory bleeding.
  • **Breast/Thyroid Cancer:** Surgical resection (mastectomy/thyroidectomy) + adjuvant therapy.
  • **Trauma:** Damage control surgery for severe trauma, specific repairs based on injury.
  • **Abscess:** Incision and drainage (I&D).
  • **PAD:** Revascularization (angioplasty/stenting, bypass surgery) for critical limb ischemia.
  • **DVT:** Anticoagulation (heparin followed by warfarin/DOACs).