Fellowship of the Royal College of Surgeons (FRCS) Specialty Surgery: Plastics, ENT, Paediatric, Cardiothoracic and Neurosurgery Syllabus

Specialty Surgery: Plastics, ENT, Paediatric, Cardiothoracic and Neurosurgery syllabus — full chapter and topic list

Expand any chapter to see its topics and sub-topics. This is the whole examinable outline for Specialty Surgery: Plastics, ENT, Paediatric, Cardiothoracic and Neurosurgery in Fellowship of the Royal College of Surgeons (FRCS), not a summary of it.

1. 1

   Plastic and Reconstructive Surgery

   4 topics

   • Principles of skin grafts and flaps
     • Reconstructive ladder
     • Free tissue transfer
   • Burns management
     • Assessment of burn depth and area
     • Fluid resuscitation and Parkland formula
     • Burn wound care and reconstruction
   • Skin cancer
     • Melanoma management
     • Non-melanoma skin cancer
   • Hand and peripheral nerve reconstruction
2. 2

   Otolaryngology (ENT)

   4 topics

   • Head and neck cancer
     • Neck lump assessment
     • Salivary gland disease
   • Thyroid and parathyroid surgery
     • Thyroid nodules and cancer
     • Hyperparathyroidism
   • Otology and rhinology disorders
   • Airway emergencies and epistaxis
3. 3

   Paediatric Surgery

   3 topics

   • Neonatal surgical emergencies
     • Oesophageal atresia and tracheo-oesophageal fistula
     • Congenital diaphragmatic hernia
     • Abdominal wall defects (gastroschisis, exomphalos)
   • Common paediatric general surgery
     • Pyloric stenosis and intussusception
     • Hernias and undescended testis
   • Paediatric fluid and physiological considerations
4. 4

   Cardiothoracic Surgery

   4 topics

   • Ischaemic heart disease and coronary bypass
   • Valvular heart disease and surgical management
   • Thoracic surgery
     • Lung cancer resection
     • Pneumothorax and pleural disease
   • Cardiopulmonary bypass principles
5. 5

   Neurosurgery

   4 topics

   • Traumatic brain injury
     • Intracranial pressure and herniation
     • Extradural and subdural haematoma
   • Subarachnoid haemorrhage and aneurysms
   • Brain and spinal tumours
   • Hydrocephalus and CSF diversion

Specialty Surgery: Plastics, ENT, Paediatric, Cardiothoracic and Neurosurgery flashcards for Fellowship of the Royal College of Surgeons (FRCS)

23 of 52 cards from the Specialty Surgery: Plastics, ENT, Paediatric, Cardiothoracic and Neurosurgery deck — real questions with worked answers.

1. What is the definition of a skin graft, and how does it differ fundamentally from a flap?

   A skin graft is a segment of epidermis (and variable dermis) completely detached from its blood supply and transferred to a recipient bed, on which it must revascularise to survive. A flap carries its own blood supply (pedicle) and therefore does not depend on the recipient bed for vascularity.

2. Compare split-thickness and full-thickness skin grafts in terms of composition, take, and contraction.

   Split-thickness (epidermis + partial dermis): takes more reliably, covers larger areas, but undergoes greater secondary contraction and poorer cosmesis. Full-thickness (epidermis + entire dermis): better cosmesis and minimal secondary contraction, but less reliable take and limited by donor site availability (must be closed directly).

3. Describe the three phases of skin graft 'take'.

   1) Imbibition (0–48 h): graft survives by plasmatic absorption of nutrients from the bed. 2) Inosculation (48–72 h): graft and recipient vessels align and connect. 3) Revascularisation/neovascularisation (after ~72 h): new capillary ingrowth establishes circulation.

4. What are the four classifications of flaps based on blood supply?

   Random pattern (supplied by dermal/subdermal plexus, no named vessel), axial (based on a named direct cutaneous artery), fasciocutaneous (perforators via the fascial plexus), and musculocutaneous (perforators through underlying muscle).

5. State the 'reconstructive ladder' from simplest to most complex.

   Healing by secondary intention → primary closure → delayed primary closure → skin graft → local/tissue flap (random/axial) → regional flap → distant/pedicled flap → free tissue transfer (microvascular free flap).

6. Using the Wallace 'rule of nines', give the percentage total body surface area (TBSA) for each region in an adult.

   Head and neck 9%, each arm 9%, anterior trunk 18%, posterior trunk 18%, each leg 18%, perineum 1%. The palm (including fingers) approximates 1% TBSA.

7. State the Parkland formula for burn fluid resuscitation and how it is administered.

   $\text{Volume} = 4\,\text{mL} \times \text{weight (kg)} \times \%\text{TBSA burned}$, using Hartmann's/lactated Ringer's. Half is given in the first 8 hours from the time of injury, and the remaining half over the next 16 hours. TBSA counts partial- and full-thickness burns only.

8. What urine output targets guide adequacy of adult and paediatric burn resuscitation?

   Adults: $0.5\text{–}1\,\text{mL/kg/h}$ (~30–50 mL/h). Children: $1\text{–}1.5\,\text{mL/kg/h}$. In electrical/myoglobinuric injury aim higher (~1–2 mL/kg/h).

9. How are burn depths classified clinically and how does each appear?

   Superficial (epidermal): red, dry, painful, blanches, no blister. Superficial partial-thickness: blisters, moist, pink, very painful, blanches with brisk capillary refill. Deep partial-thickness: blotchy red/white, less painful, sluggish refill. Full-thickness: white/leathery/charred, dry, painless, no blanching.

10. What are the criteria for and purpose of an escharotomy in burns?

    Escharotomy is incision through full-thickness circumferential eschar to relieve constriction. Indicated for circumferential limb burns causing distal ischaemia (loss of pulses/perfusion) or circumferential chest/torso burns impairing ventilation.

11. What is the ABCDE rule for clinical assessment of a suspicious pigmented skin lesion (melanoma)?

    Asymmetry, Border irregularity, Colour variation, Diameter $> 6\,\text{mm}$, and Evolution (change over time).

12. State the Breslow thickness staging breakpoints and their prognostic significance in melanoma.

    Breslow thickness measures depth from granular layer to deepest tumour cell. Key breakpoints: $\leq 1.0\,\text{mm}$, $1.01\text{–}2.0\,\text{mm}$, $2.01\text{–}4.0\,\text{mm}$, $> 4.0\,\text{mm}$. Greater thickness correlates with worse prognosis and wider excision margins; it is the single most important prognostic factor.

13. Recommended wide local excision margins for melanoma by Breslow thickness (UK/NICE guidance).

    In situ: 0.5 cm. $\leq 1\,\text{mm}$: 1 cm. $1.01\text{–}2\,\text{mm}$: 1–2 cm. $2.01\text{–}4\,\text{mm}$: 2 cm. $> 4\,\text{mm}$: 2 cm (2–3 cm). Margins are clinical, taken at definitive wide local excision.

14. Contrast basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) regarding behaviour and metastasis.

    BCC: most common skin cancer, locally invasive, very rarely metastasises; classic 'rolled pearly edge with telangiectasia' and central ulceration (rodent ulcer). SCC: arises from keratinocytes, can metastasise (especially lip/ear, immunosuppressed, >2 mm depth), often keratotic/ulcerated; may arise in chronic wounds (Marjolin's ulcer).

15. Describe the Seddon classification of peripheral nerve injury.

    Neuropraxia: conduction block with intact axon, full recovery (myelin only). Axonotmesis: axon disrupted but endoneurial tubes intact, Wallerian degeneration then regeneration possible. Neurotmesis: complete transection of axon and connective tissue sheaths, no spontaneous recovery, requires surgical repair.

16. In hand reconstruction, what is the order of repair priority for complex injuries?

    Skeletal stabilisation (bone) first, then flexor/extensor tendons, then nerve repair, then vascular repair (revascularisation/replantation), and finally soft tissue/skin cover. Bone provides the framework on which other structures are repaired.

17. What rate is generally used to estimate peripheral nerve axonal regeneration?

    Approximately $1\,\text{mm/day}$ (about 1 inch per month) following the onset of regeneration after injury or repair.

18. Which neck nodal levels are described in the cervical lymph node classification (I–VI)?

    Level I: submental/submandibular. Level II: upper jugular. Level III: middle jugular. Level IV: lower jugular. Level V: posterior triangle. Level VI: anterior/central compartment (pre-/paratracheal). This guides neck dissection in head and neck cancer.

19. What are the major risk factors for head and neck squamous cell carcinoma?

    Tobacco (smoking and chewing), alcohol (synergistic with tobacco), betel/areca nut, and human papillomavirus (HPV-16) — particularly for oropharyngeal cancer, which carries a better prognosis. Also EBV for nasopharyngeal carcinoma.

20. What blood supply do the parathyroid glands rely on, and why is this surgically important?

    Both superior and inferior parathyroid glands are predominantly supplied by the inferior thyroid artery. During thyroidectomy, ligating branches close to the thyroid capsule (rather than the main trunk) preserves parathyroid perfusion and reduces hypoparathyroidism risk.

21. Which nerve is at risk during thyroidectomy, what does injury cause, and its relation to the inferior thyroid artery?

    The recurrent laryngeal nerve (branch of vagus). It runs in the tracheo-oesophageal groove near/around the inferior thyroid artery. Unilateral injury causes hoarseness (ipsilateral cord paralysis); bilateral injury can cause airway obstruction requiring tracheostomy. The external branch of the superior laryngeal nerve (near superior pole vessels) supplies cricothyroid — injury weakens high-pitched phonation.

22. Outline the biochemical pattern of primary hyperparathyroidism.

    Elevated parathyroid hormone (PTH), high serum calcium, low serum phosphate, and raised urinary calcium excretion. Most commonly caused by a solitary parathyroid adenoma. Classic symptoms: 'stones, bones, abdominal groans, and psychiatric moans'.

23. Compare conductive and sensorineural hearing loss including a Rinne/Weber bedside pattern.

    Conductive (outer/middle ear pathology): Rinne negative (bone > air) on affected side; Weber lateralises to the affected ear. Sensorineural (cochlea/CN VIII): Rinne positive (air > bone) bilaterally; Weber lateralises to the better (unaffected) ear.

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