BDS General Surgery Syllabus

Thoracic trauma: name the immediately life-threatening injuries identified in the primary survey (the 'lethal six' are secondary).

Airway obstruction, tension pneumothorax, open pneumothorax, massive hemothorax, flail chest with pulmonary contusion, and cardiac tamponade.

Thoracic trauma: describe the clinical signs and immediate treatment of tension pneumothorax.

Signs: respiratory distress, absent breath sounds and hyperresonance on the affected side, tracheal deviation away, distended neck veins, hypotension. Treatment: immediate needle decompression (2nd intercostal space midclavicular line or 4th-5th ICS anterior axillary line) followed by chest tube.

Thoracic trauma: what defines a massive hemothorax requiring operative intervention?

Initial chest tube drainage of $>1500$ mL of blood, or ongoing loss of $>200$ mL/hr for $2$-$4$ hours.

Thoracic trauma: what is Beck's triad for cardiac tamponade?

Hypotension, muffled/distant heart sounds, and distended jugular veins (elevated JVP).

Abdominal trauma: what is the FAST exam and its four standard windows?

Focused Assessment with Sonography for Trauma; detects free fluid at: right upper quadrant (hepatorenal/Morison's pouch), left upper quadrant (splenorenal), pelvis (pouch of Douglas/rectovesical), and pericardium (subxiphoid).

Abdominal trauma: which solid organ is most commonly injured in blunt trauma, and what finding suggests it?

The spleen; suggested by left upper quadrant tenderness, left lower rib fractures, and referred left shoulder pain (Kehr's sign).

Abdominal trauma: what are indications for immediate laparotomy after blunt abdominal trauma?

Hemodynamic instability with positive FAST/peritoneal signs, evisceration, peritonitis, free air on imaging, or diaphragmatic rupture.

Orthopedic trauma: name the components of a complete open (compound) fracture management and the classification used.

Gustilo-Anderson classification (Types I-III); management: IV antibiotics early, tetanus prophylaxis, irrigation and debridement, fracture stabilization, and soft-tissue coverage.

Orthopedic trauma: what are the '5 Ps' (and 6th) of acute compartment syndrome?

Pain (out of proportion, worse on passive stretch), Paresthesia, Pallor, Pulselessness (late), Paralysis, and Poikilothermia; the earliest and most reliable sign is pain on passive stretch. Diagnosis confirmed by compartment pressure; treatment is emergent fasciotomy.

Orthopedic trauma: at what compartment pressure or delta pressure is fasciotomy generally indicated?

Absolute compartment pressure $>30$ mmHg, or a delta pressure ($\Delta P = $ diastolic BP $-$ compartment pressure) $<30$ mmHg.

Esophageal surgery: what is Boerhaave syndrome and its classic presentation?

Spontaneous transmural rupture of the esophagus (usually left posterolateral distal esophagus) from forceful vomiting; classic Mackler triad = vomiting, chest pain, and subcutaneous emphysema.

Esophageal surgery: what is the surgical treatment of achalasia and the underlying pathology?

Pathology: loss of inhibitory myenteric (Auerbach) plexus neurons causing failure of LES relaxation. Surgical treatment: laparoscopic Heller myotomy (often with partial fundoplication) or per-oral endoscopic myotomy (POEM).

Gastric surgery: what are the two main types of gastric cancer histology and the associated diffuse-type appearance?

Intestinal type (glandular, associated with H. pylori, better differentiated) and diffuse type (signet-ring cells, poorly cohesive; linitis plastica = diffuse infiltration causing a rigid 'leather bottle' stomach).

Gastric surgery: what is dumping syndrome and how do early and late forms differ?

A complication of gastric surgery from rapid gastric emptying. Early (15-30 min): osmotic fluid shift causing crampy pain, diarrhea, tachycardia. Late (1-3 hr): reactive hypoglycemia from an insulin surge after rapid glucose absorption.

Hepatobiliary surgery: what is Charcot's triad and Reynolds' pentad for cholangitis?

Charcot's triad: fever, right upper quadrant pain, jaundice. Reynolds' pentad adds hypotension (shock) and altered mental status, indicating suppurative cholangitis.

Hepatobiliary surgery: what is the critical view of safety in laparoscopic cholecystectomy?

A dissection technique to prevent bile duct injury: clearing the hepatocystic triangle of fat/fibrous tissue, exposing the lower third of the gallbladder off the liver bed, so that only two structures (cystic duct and cystic artery) are seen entering the gallbladder before clipping.

Hepatobiliary surgery: what are the boundaries of the hepatocystic (Calot's) triangle?

The cystic duct (inferiorly), the common hepatic duct (medially), and the inferior edge of the liver (superiorly); the cystic artery runs within it.

Pancreatic surgery: what operation is a Whipple procedure and what is resected?

Pancreaticoduodenectomy for tumors of the pancreatic head/periampullary region; resects the pancreatic head, duodenum, gallbladder, common bile duct, and often the gastric antrum, with reconstruction (pancreaticojejunostomy, hepaticojejunostomy, gastrojejunostomy).

Pancreatic surgery: which scoring systems assess severity of acute pancreatitis?

Ranson's criteria (assessed at admission and $48$ hours), APACHE II score, BISAP score, and the modified Glasgow (Imrie) criteria; contrast-enhanced CT (Balthazar/CT severity index) assesses necrosis.

Colorectal surgery: contrast the Hartmann's procedure with a low anterior resection.

Hartmann's: resection of the rectosigmoid with an end colostomy and closure of the rectal stump (no immediate anastomosis, used in emergencies/perforation). Low anterior resection: resection of rectal cancer with primary colorectal anastomosis preserving the anal sphincter.

Colorectal surgery: what is the difference between an ileostomy and a colostomy in output and location?

Ileostomy: usually right lower quadrant, spouted, produces liquid/high-volume effluent rich in enzymes (skin-corrosive). Colostomy: usually left lower quadrant, flush to skin, produces more formed/solid stool.

Colorectal surgery: what is the difference between Crohn's disease and ulcerative colitis relevant to surgery?

Crohn's: transmural, skip lesions anywhere mouth-to-anus, fistulae/strictures; surgery is not curative. Ulcerative colitis: mucosal, continuous, rectum-to-proximal colon; total proctocolectomy is curative and also removes cancer risk.

Cardiac surgery: describe the principle of cardiopulmonary bypass and the role of cardioplegia.

Cardiopulmonary bypass diverts blood from the heart/lungs to a machine that oxygenates and pumps it, allowing a bloodless, still operative field. Cardioplegia (typically high-potassium solution) arrests the heart in diastole and protects the myocardium during the procedure.

Cardiac surgery: what conduits are commonly used for coronary artery bypass grafting (CABG) and which has the best long-term patency?

Left internal mammary (thoracic) artery — best patency (>90% at 10 years, usually grafted to the LAD); also great saphenous vein grafts and radial artery grafts.

Cardiac surgery: contrast a mechanical versus a bioprosthetic heart valve.

Mechanical: durable (lifelong), but requires lifelong anticoagulation (warfarin) — preferred in younger patients. Bioprosthetic (tissue): no long-term anticoagulation needed but limited durability (~10-15 yr) — preferred in older patients or when anticoagulation is contraindicated.

Thoracic surgery: what are the standard anatomical lung resections for lung cancer?

Lobectomy (removal of a lobe — standard for early NSCLC), pneumonectomy (whole lung), segmentectomy and wedge resection (sublobar, for limited reserve or small peripheral tumors).

Thoracic surgery: what preoperative pulmonary function value generally predicts acceptable risk for lobectomy/pneumonectomy?

A predicted postoperative $FEV_{1}$ and $DLCO$ each $>40\%$ predicted (or preoperative $FEV_{1} > 2$ L for pneumonectomy, $>1.5$ L for lobectomy) generally indicates adequate reserve.

Vascular surgery: at what diameter is elective repair of an abdominal aortic aneurysm (AAA) generally indicated?

Diameter $\geq 5.5$ cm (in men), rapid expansion $>0.5$ cm in $6$ months, or symptomatic/tender aneurysm; women are often repaired at $\geq 5.0$ cm.

Vascular surgery: what are the '6 Ps' of acute limb ischemia?

Pain, Pallor, Pulselessness, Paresthesia, Paralysis, and Poikilothermia (Perishing cold); it is a surgical emergency requiring revascularization within ~6 hours to preserve limb viability.

Vascular surgery: how does claudication differ from critical limb ischemia (Fontaine/Rutherford)?

Claudication = reproducible muscle pain on exertion relieved by rest (Fontaine II). Critical limb ischemia = rest pain (Fontaine III) or tissue loss/ulceration/gangrene (Fontaine IV), typically with ankle-brachial index (ABI) $<0.4$.

Vascular surgery: what ABI (ankle-brachial index) values indicate normal, claudication, and critical ischemia?

Normal ABI $= 0.9$-$1.3$; peripheral arterial disease/claudication $= 0.4$-$0.9$; critical limb ischemia $< 0.4$; values $>1.3$ suggest non-compressible, calcified vessels (e.g., diabetes).

Cranial surgery: what is the Monro-Kellie doctrine?

The cranial vault is a fixed volume containing brain, blood, and CSF; an increase in one component (or a mass) must be compensated by a decrease in another, or intracranial pressure rises. It explains the limited compensatory reserve before ICP escalates.