Membership of the Royal College of Surgeons (MRCS) Principles of Surgery-in-General Syllabus

Principles of Surgery-in-General syllabus — full chapter and topic list

Expand any chapter to see its topics and sub-topics. This is the whole examinable outline for Principles of Surgery-in-General in Membership of the Royal College of Surgeons (MRCS), not a summary of it.

1. 1

   Trauma and Emergency Surgery

   4 topics

   • Initial assessment and resuscitation
     • ATLS primary and secondary survey
     • Damage control surgery
   • Regional trauma
     • Head, chest and abdominal trauma
     • Pelvic and limb trauma
   • Burns and soft tissue injury
     • Burn assessment and fluid resuscitation
     • Compartment syndrome
   • The acute abdomen
     • Peritonitis and bowel obstruction
     • Acute appendicitis and perforation
2. 2

   Wound Management and Tissue Healing

   3 topics

   • Wound classification and healing
     • Primary and secondary intention
     • Factors impairing healing
   • Acute and chronic wounds
     • Pressure ulcers and leg ulcers
     • Negative pressure wound therapy
   • Scars and reconstruction
     • Hypertrophic and keloid scars
     • Skin grafts and flaps
3. 3

   Surgical Care of the Special Patient

   3 topics

   • Paediatric surgical principles
     • Fluid and physiological differences
     • Common paediatric conditions
   • The elderly surgical patient
     • Frailty and polypharmacy
     • Delirium and rehabilitation
   • The pregnant and obese patient
     • Physiological adaptations in pregnancy
     • Bariatric considerations
4. 4

   Principles of Operative Surgery

   3 topics

   • Surgical access and incisions
     • Common abdominal incisions
     • Minimal access and laparoscopic principles
   • Energy devices and haemostasis
     • Diathermy and laser safety
     • Intraoperative bleeding control
   • Surgical complications and theatre safety
     • Never events and retained instruments
     • Positioning and pressure injuries
5. 5

   Imaging and Investigation

   3 topics

   • Diagnostic imaging modalities
     • Plain radiography and ultrasound
     • CT, MRI and contrast studies
   • Interventional radiology
     • Drainage and embolisation
     • Stenting and angioplasty
   • Radiation safety and request principles
     • ALARP and IRMER principles
     • Appropriate test selection

Principles of Surgery-in-General flashcards for Membership of the Royal College of Surgeons (MRCS)

23 of 51 cards from the Principles of Surgery-in-General deck — real questions with worked answers.

1. In the ATLS primary survey, what does the 'ABCDE' sequence stand for?

   A – Airway (with C-spine control); B – Breathing and ventilation; C – Circulation with haemorrhage control; D – Disability (neurological status); E – Exposure/Environment (undress, prevent hypothermia).

2. What modification to the ATLS primary survey is now recommended for trauma with major external haemorrhage?

   'C-ABCDE' — Catastrophic haemorrhage control (e.g. tourniquet or direct pressure) is addressed first, before airway, because exsanguination kills faster than airway loss in these cases.

3. In the AVPU scale for rapid neurological assessment, what do the four levels mean?

   A – Alert; V – responds to Voice; P – responds to Pain; U – Unresponsive. A patient at 'P' or below roughly corresponds to a GCS $\leq 8$ and may need airway protection.

4. What are the three components of the Glasgow Coma Scale and the maximum/minimum total score?

   Eye opening (max 4), Verbal response (max 5), Motor response (max 6). Total ranges from $3$ (minimum) to $15$ (maximum); $\leq 8$ indicates coma and need for definitive airway.

5. According to ATLS, what classification system grades haemorrhagic shock and what is the approximate blood loss in Class III?

   The four-class ATLS system based on blood loss. Class III = $30\text{–}40\%$ loss (~$1500\text{–}2000$ mL in a $70$ kg adult), with marked tachycardia, hypotension, and altered mental state — usually requires blood transfusion.

6. What is the first-line fluid bolus recommended in ATLS for an adult in haemorrhagic shock, and the paediatric weight-based dose?

   Adult: $1$ L of warmed balanced crystalloid (newer guidance favours early blood/blood products). Paediatric: $10\text{–}20$ mL/kg crystalloid bolus, then reassess.

7. Name the components of the 'lethal triad' (trauma triad of death) in major trauma.

   Hypothermia, acidosis (metabolic), and coagulopathy. These reinforce each other and underpin the principle of damage-control resuscitation and permissive hypotension.

8. What is 'permissive hypotension' and a typical target in penetrating trauma before surgical control?

   Deliberately limiting fluid/blood resuscitation to maintain a lower-than-normal blood pressure (e.g. systolic ~$80\text{–}90$ mmHg or a palpable radial pulse) to avoid 'popping the clot', until definitive haemorrhage control is achieved.

9. Where are the three classic anatomical zones of the neck used to guide management of penetrating neck trauma?

   Zone I: clavicle/sternal notch to cricoid cartilage; Zone II: cricoid to angle of mandible; Zone III: angle of mandible to skull base. Zone II is the most accessible surgically.

10. What is the Wallace 'Rule of Nines' for estimating adult total body surface area (TBSA) burned?

    Head/neck $9\%$, each arm $9\%$, each leg $18\%$, anterior trunk $18\%$, posterior trunk $18\%$, perineum $1\%$. The patient's palm (including fingers) $\approx 1\%$ TBSA for scattered burns.

11. State the Parkland formula for fluid resuscitation in major burns.

    $$V = 4 \times \text{weight (kg)} \times \%\text{TBSA burned}$$ giving total Hartmann's (mL) for the first $24$ h; half is given in the first $8$ h from the time of burn, the remainder over the next $16$ h. Titrate to urine output ($0.5\text{–}1$ mL/kg/h adults).

12. How do superficial, superficial-partial, deep-partial and full-thickness burns differ clinically?

    Superficial (epidermal): red, painful, no blisters (e.g. sunburn). Superficial partial-thickness: blisters, moist, painful, blanches. Deep partial: mottled/cherry-red, less blanching, reduced sensation. Full-thickness: white/leathery/charred, painless, no blanching — needs grafting.

13. What is the formula for estimating maximum permissible blood loss before transfusion using allowable blood loss?

    $$ABL = EBV \times \frac{(Hct_i - Hct_f)}{Hct_i}$$ where $EBV$ is estimated blood volume (~$70$ mL/kg adult male), $Hct_i$ initial and $Hct_f$ lowest acceptable haematocrit.

14. In burns, when is escharotomy indicated and why?

    In circumferential full-thickness burns of limbs (causing distal ischaemia/compartment syndrome) or chest (restricting ventilation). Incisions through the eschar release the constriction; distinct from fasciotomy, which divides deep fascia.

15. What three features suggest inhalational airway injury in a burns patient mandating early intubation?

    Facial/perioral burns, singed nasal hairs, carbonaceous sputum/soot in oropharynx, hoarseness/stridor, and burns sustained in an enclosed space. Early intubation is done before airway oedema makes it impossible.

16. What is the carboxyhaemoglobin half-life on room air versus $100\%$ oxygen, and why does it matter in burns?

    $\approx 4$ hours on room air, reduced to $\approx 40\text{–}60$ minutes on $100\%$ oxygen. CO has ~$240\times$ greater affinity for haemoglobin than oxygen, so high-flow oxygen is first-line for CO poisoning.

17. List the six classic surgical causes of generalised peritonitis in the acute abdomen by perforation.

    Perforated peptic ulcer, perforated appendix, perforated diverticulum, perforated colorectal carcinoma, ruptured viscus from trauma, and ischaemic/perforated bowel. All cause a 'rigid', board-like abdomen.

18. What is the difference between visceral and parietal (somatic) abdominal pain?

    Visceral pain is dull, poorly localised to the midline (by embryological gut origin: foregut epigastric, midgut umbilical, hindgut suprapubic), from stretch/ischaemia. Parietal pain is sharp, well-localised, worse on movement, from peritoneal irritation.

19. Name three classic clinical signs of appendicitis and what each represents.

    Rovsing's sign (RIF pain on LIF palpation), Psoas sign (pain on right hip extension — retrocaecal appendix), and Obturator sign (pain on internal rotation of flexed right hip — pelvic appendix). McBurney's point tenderness localises the appendix base.

20. What scoring system stratifies appendicitis risk, and what is a key threshold?

    The Alvarado score (max $10$): migratory pain, anorexia, nausea, RIF tenderness, rebound, fever, leucocytosis, left shift. A score $\leq 4$ makes appendicitis unlikely; $\geq 7$ suggests it is likely.

21. Which four phases describe normal wound healing and their approximate timelines?

    Haemostasis (immediate, minutes), Inflammation (day 0–~5), Proliferation (days ~3–21: granulation, angiogenesis, epithelialisation), and Remodelling/Maturation (weeks to ~1–2 years). Phases overlap.

22. What is the difference between healing by primary, secondary, and tertiary (delayed primary) intention?

    Primary: clean wound edges apposed directly (e.g. sutured incision), minimal scar. Secondary: wound left open to granulate and contract (e.g. abscess cavity), larger scar. Tertiary: wound left open initially (e.g. for contamination) then closed surgically a few days later.

23. What is the maximum tensile strength a healed wound regains, and when does it reach ~80%?

    A healed wound regains only about $80\%$ of original (unwounded) tensile strength at best. At ~$1$ week it has ~$10\%$, at $3$ weeks ~$20\%$, reaching peak strength over many months during remodelling.

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