INI CET Surgery Syllabus

Which inherited polyposis syndrome is caused by an APC gene mutation, and what is its lifetime cancer risk if untreated?

Familial adenomatous polyposis (FAP); nearly 100% lifetime risk of colorectal cancer, so prophylactic colectomy is recommended.

What is the classic clinical and imaging picture of sigmoid volvulus?

Elderly/constipated patient with massive abdominal distension; plain film shows a distended 'coffee-bean'/'omega' loop pointing to the right upper quadrant. Initial treatment is endoscopic detorsion; recurrence/ischemia needs sigmoid resection.

State the components of Charcot's triad and Reynolds' pentad in cholangitis.

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

What is Courvoisier's law?

In the presence of painless jaundice, a palpable non-tender gallbladder is unlikely to be due to gallstones and suggests malignant obstruction of the bile duct (e.g., pancreatic head cancer), because a chronically stone-diseased gallbladder is fibrotic and cannot distend.

What is the gold-standard investigation for acute cholecystitis, and what is its hallmark ultrasound finding?

Ultrasound is first-line; HIDA scan is most sensitive/specific (non-visualization of gallbladder). USG signs: gallstones, gallbladder wall thickening (>3 mm), pericholecystic fluid, and a sonographic Murphy's sign.

What is the most common type of gallstone worldwide and its main risk factors?

Cholesterol/mixed stones; risk factors are the '5 Fs': Fat, Female, Forty, Fertile, Family history (plus rapid weight loss, OCPs).

What is the most common benign and most common malignant primary liver tumor?

Most common benign: hemangioma. Most common primary malignant: hepatocellular carcinoma (HCC).

What tumor marker is used for hepatocellular carcinoma, and what are the major risk factors?

Alpha-fetoprotein (AFP). Risk factors: cirrhosis (any cause), chronic hepatitis B and C, aflatoxin exposure, and alcohol.

What organism causes amoebic liver abscess, where is it usually located, and what is the classic aspirate appearance?

Entamoeba histolytica; usually a solitary abscess in the right lobe; aspirate is sterile 'anchovy-sauce' (reddish-brown) pus. Treatment is metronidazole, drainage only if large/non-responding.

What are the two most common causes of acute pancreatitis, and which scoring system is commonly used for severity?

Gallstones and alcohol. Severity is assessed with Ranson's criteria, APACHE II, or modified Glasgow score (and revised Atlanta classification).

In acute pancreatitis, name two early (admission) and two 48-hour Ranson criteria.

At admission: age >55, WBC >16,000, glucose >200 mg/dL, AST >250, LDH >350. At 48 h: Ca <8 mg/dL, hematocrit fall >10%, BUN rise >5 mg/dL, PaO2 <60 mmHg, base deficit >4, fluid sequestration >6 L.

What is the classic clinical triad of a pancreatic pseudocyst, and when is intervention indicated?

Persistent abdominal pain, palpable epigastric mass, and persistently elevated serum amylase after acute pancreatitis. Intervention (endoscopic/surgical cyst-gastrostomy) is considered for symptomatic, enlarging, or complicated cysts, usually after 4-6 weeks of maturation.

What is Whipple's procedure (pancreaticoduodenectomy), and for what condition is it performed?

Resection of the pancreatic head, duodenum, gallbladder, distal CBD, and (in classic Whipple) gastric antrum, with reconstruction. Performed for resectable periampullary/pancreatic head tumors.

What is the most common cause of hyperthyroidism, and its characteristic features?

Graves' disease (autoimmune, TSH-receptor antibodies); features include diffuse goiter, exophthalmos, pretibial myxedema, and a hyperthyroid state.

What nerve is most at risk during thyroid surgery, and what does its injury cause?

The recurrent laryngeal nerve. Unilateral injury causes hoarseness (vocal cord paralysis); bilateral injury can cause airway obstruction/stridor requiring tracheostomy. The external branch of the superior laryngeal nerve, if injured, weakens the cricothyroid (voice fatigue/loss of high pitch).

Which thyroid cancer is most common, which spreads via lymphatics, and which is associated with MEN 2?

Papillary carcinoma is most common and spreads via lymphatics (best prognosis). Follicular carcinoma spreads hematogenously. Medullary carcinoma (parafollicular C cells, secretes calcitonin) is associated with MEN 2A/2B.

What is the most common cause of primary hyperparathyroidism and its classic clinical mnemonic?

A solitary parathyroid adenoma. Symptoms: 'stones, bones, abdominal groans, and psychic moans' (renal stones, bone pain/osteitis fibrosa cystica, abdominal pain/constipation/peptic ulcers, depression/confusion) from hypercalcemia.

What biochemical pattern distinguishes primary from secondary hyperparathyroidism?

Primary: high PTH with HIGH calcium (often low phosphate). Secondary: high PTH with LOW or normal calcium (compensatory, e.g., chronic kidney disease/vitamin D deficiency).

What is a pheochromocytoma, its classic symptom triad, and the rule of 10s?

A catecholamine-secreting tumor of adrenal medulla chromaffin cells. Triad: episodic headache, palpitations, and sweating with hypertension. Rule of 10s: ~10% bilateral, 10% extra-adrenal, 10% malignant, 10% familial, 10% in children.

Before resecting a pheochromocytoma, which blockade must be established first, and why?

Alpha-blockade first (e.g., phenoxybenzamine), followed by beta-blockade. Giving beta-blockers before alpha-blockade risks unopposed alpha vasoconstriction and a hypertensive crisis.

What distinguishes Cushing's disease from Cushing's syndrome?

Cushing's syndrome is the clinical state of cortisol excess from any cause; Cushing's DISEASE specifically refers to an ACTH-secreting pituitary adenoma causing that excess.

What is the most common benign breast lump in young women, and its typical features?

Fibroadenoma; a smooth, firm, mobile, painless, well-defined 'breast mouse' typically in women under 30.

What benign breast condition presents with bloody nipple discharge from a single duct?

Intraductal papilloma (the most common cause of bloody single-duct nipple discharge).

What are the most common histological type of breast cancer and the receptor status that guides targeted therapy?

Invasive ductal carcinoma (NST) is most common. Receptor testing for ER/PR (hormone therapy, e.g., tamoxifen) and HER2 (trastuzumab) guides targeted treatment; triple-negative lacks all three.

What is the difference between a sentinel lymph node biopsy and an axillary lymph node dissection in breast cancer?

Sentinel node biopsy samples the first draining node(s) (using dye/radiotracer) to stage a clinically node-negative axilla with low morbidity; axillary dissection removes axillary nodal levels and is reserved for node-positive disease, carrying higher risk of lymphedema.

What is the ankle-brachial index (ABI), and what value indicates significant peripheral arterial disease vs critical limb ischemia?

ABI = highest ankle systolic pressure / highest brachial systolic pressure. Normal 0.9-1.3; <0.9 indicates PAD; <0.4 suggests critical limb ischemia. >1.3 suggests non-compressible calcified vessels (e.g., diabetes).

List the '6 Ps' of acute limb ischemia.

Pain, Pallor, Pulselessness, Paresthesia, Paralysis, and Poikilothermia (perishingly cold).

What are the components of the modified Wells criteria's key point for DVT, and what is the gold-standard imaging test?

Wells score risk-stratifies DVT probability (e.g., active cancer, immobilization, calf swelling >3 cm, localized tenderness). Compression duplex ultrasonography is the first-line/gold-standard test; D-dimer is useful to exclude DVT in low-probability patients.

What is the preferred long-term vascular access for chronic hemodialysis, and how long before use should it be created?

An autogenous arteriovenous fistula (e.g., radiocephalic/Brescia-Cimino), as it has the lowest infection and thrombosis rates; it should be created and allowed to mature for about 6-8 weeks (4-6 weeks minimum) before cannulation.

What does the primary survey (ABCDE) of trauma assessment stand for?

Airway (with C-spine protection), Breathing, Circulation (with hemorrhage control), Disability (neurologic/GCS), and Exposure/Environment (undress, prevent hypothermia).

What are the components and score range of the Glasgow Coma Scale?

Eye opening (1-4), Verbal response (1-5), Motor response (1-6); total ranges from 3 (deep coma) to 15 (fully alert). GCS <=8 generally indicates the need for definitive airway protection.

What is the classic CT appearance and source of an epidural (extradural) hematoma vs a subdural hematoma?

Epidural: biconvex/lens-shaped, doesn't cross suture lines, usually arterial (middle meningeal artery), classic lucid interval. Subdural: crescent-shaped, crosses suture lines, usually venous (bridging veins), common in elderly/alcoholics.

In trauma, which organs are most commonly injured in blunt vs penetrating abdominal trauma?

Blunt: spleen (most common), then liver. Penetrating (e.g., stab): liver and small bowel are most commonly injured.

What is FAST in trauma, and what four areas does it assess?

Focused Assessment with Sonography for Trauma; it checks for free fluid (blood) in the perihepatic/Morrison's pouch, perisplenic, pelvic (pouch of Douglas), and pericardial spaces.

What is the Salter-Harris classification used for, and what does Type II (the most common) involve?

It grades pediatric physeal (growth-plate) fractures. Type II (most common) is a fracture through the physis extending into the metaphysis (sparing the epiphysis). Mnemonic SALTR: I-Slip, II-Above, III-Lower, IV-Through, V-Ruined/crush.

What is the most commonly dislocated large joint, and in which direction does it most often dislocate?

The shoulder (glenohumeral joint); over 95% of dislocations are anterior, risking axillary nerve injury (test sensation over the deltoid 'regimental badge' area).

What is the most feared early and the most feared late complication of a femoral neck (intracapsular) fracture, and how does this guide treatment?

Avascular necrosis of the femoral head and nonunion (due to disrupted retinacular blood supply). Displaced intracapsular fractures in the elderly are usually treated with arthroplasty (hemi- or total hip replacement) rather than fixation.

What are the two most common indications for total hip/knee replacement, and a major long-term complication of the implant?

Osteoarthritis (most common) and rheumatoid arthritis (and AVN for hip). A major long-term complication is aseptic loosening from polyethylene wear/osteolysis; prosthetic joint infection is the most feared early/perioperative complication.

What is cauda equina syndrome, and why is it a surgical emergency?

Compression of the lumbosacral nerve roots (often by a large central disc herniation) causing saddle anesthesia, bowel/bladder dysfunction (urinary retention/incontinence), and bilateral leg weakness. It is an emergency because delayed decompression leads to permanent sphincter dysfunction.

What is the most common composition of urinary stones, and which stone type is radiolucent on plain X-ray?

Calcium oxalate stones are most common. Uric acid stones (and pure matrix/indinavir stones) are radiolucent on plain X-ray (seen on CT). Struvite stones form staghorn calculi with urease-producing organisms.

What is the first-line imaging for suspected renal/ureteric colic, and the typical treatment threshold for stone size?

Non-contrast CT KUB (most sensitive). Stones <5 mm usually pass spontaneously; larger stones may need ESWL, ureteroscopy, or PCNL (for large/staghorn stones >2 cm).

What is the classic clinical triad of renal cell carcinoma, and its most common histologic subtype?

Flank pain, hematuria, and a palpable abdominal mass (the classic but late triad, now uncommon). Clear cell carcinoma is the most common subtype; RCC may present with paraneoplastic syndromes and left-sided varicocele.

What is ureteropelvic junction (UPJ) obstruction, its most common cause in children, and the standard surgical correction?

Obstruction of urine flow from renal pelvis to ureter causing hydronephrosis. Most common congenital cause is an intrinsic adynamic/stenotic segment (or a crossing lower-pole vessel). Standard repair is a dismembered (Anderson-Hynes) pyeloplasty.

What is the most common cause of acquired ureteral strictures, and how are they generally classified?

Iatrogenic injury (e.g., during pelvic/ureteroscopic surgery) and impacted stones/instrumentation; others include radiation, malignancy, and TB. Classified as intrinsic vs extrinsic and benign vs malignant; management ranges from stenting/balloon dilation to reconstructive ureteroplasty/reimplantation.

What is the classic presentation of hypertrophic pyloric stenosis, and the typical electrolyte disturbance?

Non-bilious projectile vomiting at ~3-6 weeks of age, a palpable 'olive' mass in the epigastrium, and visible peristalsis; classic hypokalemic hypochloremic metabolic alkalosis. Treated with Ramstedt pyloromyotomy after fluid/electrolyte correction.

What congenital diaphragmatic hernia is most common, on which side, and what is the main physiologic threat?

Bochdalek hernia (posterolateral), most often left-sided. The main threat is pulmonary hypoplasia and persistent pulmonary hypertension, not the hernia itself; stabilize/optimize the neonate before surgical repair.

How do you distinguish gastroschisis from omphalocele in a newborn?

Gastroschisis: bowel herniates through a defect to the RIGHT of the umbilical cord, NO covering sac, usually isolated. Omphalocele: herniation THROUGH the umbilical ring covered by a peritoneal/amniotic sac, with frequent associated anomalies (cardiac, chromosomal).

What is the most common cause of intestinal obstruction in infants 3 months-3 years, its classic signs, and first-line treatment?

Intussusception (commonly ileocolic). Classic features: intermittent colicky pain with drawing up of legs, 'red-currant jelly' stools, and a sausage-shaped abdominal mass; ultrasound shows a 'target/doughnut' sign. First-line treatment is air or contrast enema reduction; surgery if reduction fails or perforation/peritonitis present.

What is Hirschsprung's disease, the gold-standard diagnostic test, and the most common affected segment?

Congenital aganglionosis (absent ganglion cells) of the distal bowel causing functional obstruction and delayed meconium passage. Rectal suction biopsy showing absent ganglion cells (with increased acetylcholinesterase) is the gold standard; the rectosigmoid is most commonly involved.