Appendicitis
What are the anatomic positions the appendix can occupy, and how does each change the presentation?
Where is McBurney’s point? What are Rovsing’s, psoas and obturator signs, and what does each one localize?
Describe the pathophysiology of appendiceal perforation. Why does the appendix not simply burst from pressure alone?
What is the significance of an appendicolith on CT?
What imaging would you choose in a child, in a pregnant patient, and in a thin young adult? Defend each choice.
What is the Alvarado score and what are its limitations?
What did the CODA trial show about antibiotics versus appendectomy, and what happened to those patients over longer follow-up?
Define complicated versus uncomplicated appendicitis.
What is an interval appendectomy, when is it considered, and what is the argument against it?
When does appendicitis require an ileocecectomy rather than an appendectomy?
What is stump appendicitis?
What proportion of appendectomy specimens contain a neoplasm? Which findings on pathology mandate a right hemicolectomy?
Gallbladder
Define biliary anatomy.
What is the physiologic function of the gallbladder?
How does the gallbladder fill?
What are the indications for cholecystectomy?
What is the difference between biliary colic and cholecystitis?
What are the surgical and non-surgical options for treating gallbladder disease?
What are the tests used to diagnose gallbladder disease?
When, and how, do we use HIDA scans?
What is the most feared complication during cholecystectomy?
What is the critical view of safety and how does it help avoid this?
What is a subtotal cholecystectomy and when is it the right operation?
Define Charcot’s triad and Reynolds’ pentad. What do they indicate and what is the treatment?
What is gallstone ileus and where does the obstruction typically occur?
What is Mirizzi syndrome?
Bowel obstruction
How does the most common cause of bowel obstruction differ between high and low income countries?
What are the hard indications for operating on a bowel obstruction?
What is a closed loop bowel obstruction?
What is the role of water soluble contrast (Gastrografin) in the management of bowel obstruction?
Distinguish mechanical obstruction from ileus, clinically and radiographically.
Roughly how much fluid does the GI tract secrete daily, and how does that explain the volume status of an obstructed patient?
Which electrolyte and acid-base abnormality is classic in a patient with prolonged vomiting from a proximal obstruction, and why?
How do proximal and distal obstructions differ in presentation?
What findings on examination, laboratory testing and CT raise concern for strangulation? Which of them are reliable?
What is a transition point, and what does the absence of one suggest?
How long is a trial of non-operative management reasonable, and what is the evidence for that number?
What is Ogilvie syndrome and how is it managed? At what cecal diameter does the risk of perforation become the driving concern?
What is a large bowel obstruction with a competent ileocecal valve, and why is it more dangerous?
What is the recurrence rate after adhesiolysis, and what does that imply about the threshold to operate?
Hernia
Define the anterior abdominal wall anatomy.
Name 20 different kinds of hernia.
What is the arcuate line and how does it relate to hernia?
What is a hernia?
Define Hesselbach’s triangle.
What are some of the different ways an inguinal hernia can be repaired?
What are the contraindications to mesh repair and what are the options in that setting?
Define incarceration and strangulation, and explain why the distinction changes management.
Describe a Richter’s hernia and explain why it is dangerous out of proportion to its size.
What is a Littre’s hernia? An Amyand’s hernia? A sliding hernia?
Why do femoral hernias have a disproportionately high rate of strangulation?
Describe the myopectineal orifice of Fruchaud and explain why it is the conceptual basis for preperitoneal repair.
Name the layers you divide, in order, in an open anterior inguinal hernia repair.
In laparoscopic inguinal anatomy, define the triangle of doom and the triangle of pain. What is in each?
Define onlay, inlay, sublay, retromuscular, preperitoneal and IPOM mesh positions.
What is the Fitzgibbons trial and what did it actually show about watchful waiting?
Why is tension the enemy of any hernia repair? Answer in terms of wound healing biology.
What is a component separation? How does a transversus abdominis release differ from an anterior component separation?
Name the three nerves at risk in an open inguinal repair and the sensory distribution of each.
Diverticulitis
What is the Hinchey classification for perforated diverticulitis?
How is each stage managed differently?
What is the difference between a true and a false diverticulum, and which is a colonic diverticulum?
Why do diverticula form where the vasa recta penetrate the muscular wall?
Why is the sigmoid the most common site? Answer using Laplace’s law.
How does right-sided diverticulitis differ from left-sided, and in which populations?
What is the evidence for treating uncomplicated diverticulitis without antibiotics? Name the trials.
At what abscess size does percutaneous drainage become preferable to antibiotics alone?
What are the current indications for elective sigmoid resection, and why was the “after two episodes” rule abandoned?
Hartmann’s procedure versus primary anastomosis with proximal diversion in the emergency setting. What does the evidence show and what pushes you toward one?
What is a colovesical fistula, how does it present, and what is the best test to demonstrate it?
Why does every patient need a colonoscopy after an episode, and when?
What is the evidence behind the nuts, seeds and popcorn advice, and why is it no longer given?
Ostomies
What is the anatomy of the small bowel and colon?
What are the parts of the small bowel?
What is a closed loop obstruction?
What is the difference between an end and a loop ostomy?
When is the colon versus the small bowel used for a stoma, and why?
What is normal ileostomy output, and at what volume does it become a high-output stoma?
What are the mechanisms of dehydration and acute kidney injury after ileostomy creation, and why is oral rehydration solution better than water?
Why is a loop ileostomy generally preferred over a loop colostomy for protecting a low anastomosis?
Why is an ileostomy everted as a Brooke ileostomy while a colostomy is not?
What is a mucous fistula and when is one created rather than leaving the distal end inside?
How is a stoma sited preoperatively, and what happens when it is sited badly?
What must be confirmed about the distal limb before a stoma is reversed, and how?
What are the mechanical complications of a stoma? Rank them by frequency.
What proportion of temporary stomas are never reversed, and why?
Paraesophageal hernia and gastric volvulus
Describe the anatomy of the esophageal hiatus. Which crus forms most of it?
What is the phrenoesophageal ligament and what happens to it in hiatal hernia?
Define hiatal hernia types I through IV. Which is most common overall, and which is the most common of the true paraesophageal hernias?
Why does a type II hernia often produce little reflux?
What are Cameron lesions and how do they present?
Describe organoaxial and mesenteroaxial gastric volvulus. Which is associated with paraesophageal hernia?
What is Borchardt’s triad?
What is the annual risk of an acute event in an asymptomatic large paraesophageal hernia, and how does that compare with operative mortality in an elderly patient?
Name the essential steps of a paraesophageal hernia repair. Which step is most often blamed for recurrence?
How much intra-abdominal esophageal length is required, and what do you do when you cannot get it?
What is a Collis gastroplasty and when is it indicated?
What is the argument for and against mesh at the hiatus?
Why are patients told to avoid retching and carbonated beverages postoperatively?
What is the radiographic recurrence rate after repair, and why is it so different from the reoperation rate?
Mesenteric ischemia
Mesenteric ischemia — what are the four types?
Name the three visceral arteries and the segment of bowel each supplies.
Describe the collateral pathways between them. What are the marginal artery of Drummond and the arc of Riolan? What are Griffith’s and Sudeck’s points, and why do they matter?
Why is pain out of proportion to the examination the hallmark of acute mesenteric ischemia? Answer in terms of visceral versus somatic innervation.
Where does an SMA embolus classically lodge, and why does that spare the proximal jejunum?
How does the extent of infarction differ between embolic and thrombotic SMA occlusion, and why?
What are the risk factors for non-occlusive mesenteric ischemia, and why does it carry the worst prognosis?
Which patient population gets mesenteric venous thrombosis, and how does management differ?
What is the sensitivity and timing of lactate elevation? Why can a normal lactate not exclude the diagnosis?
What imaging study is required, and what specifically must be requested?
What are the options for revascularization, and how does the choice depend on etiology?
What is a second-look laparotomy and why is it planned rather than reactive?
Describe the triad of chronic mesenteric ischemia. How many of the three vessels are typically diseased before symptoms appear?
What is short bowel syndrome? Approximately how much small bowel is required to avoid parenteral nutrition dependence, and how does the presence of an ileocecal valve change that number?
Abscess
What is an abscess, structurally? What is it made of?
Explain, pharmacologically, why antibiotics alone rarely cure an established abscess.
Why does local anesthetic work poorly in infected tissue? Answer in terms of pKa and tissue pH.
Distinguish cellulitis, phlegmon and abscess.
What is the evidence for and against packing a simple cutaneous abscess?
After incision and drainage of an uncomplicated skin abscess, what are the indications for antibiotics?
What size threshold and what anatomic considerations determine whether an intra-abdominal collection is drained percutaneously versus operatively?
Distinguish drainage from source control. Give two examples where drainage alone is insufficient.
Describe the cryptoglandular theory of perianal abscess.
Name the perianal spaces. Which abscess type is easiest to miss on external examination?
What proportion of perianal abscesses go on to form a fistula in ano?
What is Goodsall’s rule? What is the Parks classification?
What features distinguish a necrotizing soft tissue infection from an abscess? What is the LRINEC score and what is its main limitation?
Differentiate pyogenic from amebic liver abscess by history, imaging and treatment.
What does a recurrent abscess in the same location suggest? List the underlying causes worth excluding.
Wounds
Name the phases of wound healing and the approximate timeline of each. Where do they overlap?
What percentage of original tensile strength does a healed wound recover, and over what period? What does this imply about lifting restrictions?
Define healing by primary, secondary and tertiary intention. Give a clinical example of each.
Define the four surgical wound classes and state the expected infection rate for each.
Why is a grossly contaminated wound left open?
Distinguish superficial from fascial dehiscence. What is the significance of serosanguinous drainage from a laparotomy incision on postoperative day five?
By what mechanisms does negative pressure wound therapy accelerate healing?
Why is smoking the largest modifiable risk factor for wound complications? State the mechanism and the duration of preoperative cessation required.
What is the role of oxygen tension in collagen synthesis, and which vitamin is required?
How do corticosteroids impair healing, and what vitamin partially counteracts this?
Differentiate a hypertrophic scar from a keloid by definition, distribution and treatment response.
What is granulation tissue made of, and what does its absence in a chronic wound tell you?
Which suture would you select for fascia, for bowel, and for skin? Defend each choice.
Why general surgery?
I chose general surgery because to me, it afforded the broadest surgical skillset per time spent in training, especially for remote and rural applications. Another major perk is that the bread and butter of general surgical problems has arguably the highest ratio of life threatening problems that are actually fixable with surgery. A strangulated bowel containing hernia or a perforated viscus have mortality rates that approach 100% without surgery and outstanding outcomes with often short surgeries. I found that incredibly appealing.
As I’ve matured in medicine of course I have come to appreciate aspects of many other specialties, whose merits were perhaps too nuanced for my twenty-something brain. It’s easy to be wowed by the visual drama of a lot of what happens in surgery. This can be blinding in a carriage-horse way, to the coolness of more subtle specialties. So if I have any advice it’s to be open to that fact. What an interventional radiologist does for example may not look as cool to the gore-inspired student as a bloodied surgeon gaining vascular control. But on the other side of training, the merits of the former method are absolutely appreciated.