MRCS Part A 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 MRCS Part A, not a summary of it.

1. 1

   Preoperative Care

   4 topics

   • Patient Evaluation
     • Medical History
     • Physical Examination
     • Laboratory Tests
     • Imaging Studies
   • Risk Assessment
     • Cardiac Risk
     • Pulmonary Risk
     • Nutritional Status
     • Anesthesia Risk
   • Informed Consent
     • Legal Aspects
     • Ethical Considerations
     • Patient Communication
   • Preoperative Optimization
     • Medical Management
     • Nutritional Support
     • Preoperative Medications
     • Prehabilitation
2. 2

   Intraoperative Care

   4 topics

   • Surgical Techniques
     • Incisions and Closures
     • Hemostasis
     • Tissue Handling
     • Suturing Techniques
     • Minimally Invasive Surgery
   • Anesthesia
     • Types of Anesthesia
     • Anesthetic Agents
     • Monitoring During Surgery
     • Complications and Management
   • Intraoperative Monitoring
     • Vital Signs
     • Fluid Balance
     • Blood Loss
     • Electrolytes
   • Infection Control
     • Sterile Techniques
     • Antibiotic Prophylaxis
     • Surgical Site Infections
3. 3

   Postoperative Care

   4 topics

   • Immediate Postoperative Care
     • Recovery Room Management
     • Pain Management
     • Monitoring and Observation
   • Postoperative Complications
     • Infections
     • Thromboembolism
     • Wound Complications
     • Organ Dysfunction
   • Rehabilitation
     • Physical Therapy
     • Occupational Therapy
     • Nutritional Support
     • Psychological Support
   • Follow-up Care
     • Outpatient Visits
     • Long-term Monitoring
     • Chronic Pain Management
4. 4

   Surgical Ethics

   4 topics

   • Informed Consent
     • Patient Autonomy
     • Disclosure of Risks
     • Capacity and Competence
   • Resource Allocation
     • Equity in Healthcare
     • Prioritizing Care
     • Cost-effectiveness
   • Professionalism
     • Confidentiality
     • Conflict of Interest
     • Continuing Education
   • End-of-Life Care
     • Palliative Care
     • Advance Directives
     • Ethical Dilemmas
5. 5

   Surgical Techniques and Technology

   4 topics

   • Minimally Invasive Surgery
     • Laparoscopic Surgery
     • Robotic Surgery
     • Endoscopic Procedures
   • Advanced Surgical Techniques
     • Microsurgery
     • Laser Surgery
     • Image-Guided Surgery
   • Surgical Instruments and Devices
     • Surgical Tools
     • Energy Devices
     • Implants and Prosthetics
   • Surgical Simulation and Training
     • Virtual Reality
     • Simulation Models
     • Skills Assessment

Principles of Surgery-in-General flashcards for MRCS Part A

23 of 52 cards from the Principles of Surgery-in-General deck — real questions with worked answers.

1. What are the four essential components required for valid informed consent in surgery?

   (1) The patient has capacity, (2) the decision is voluntary (free from coercion), (3) the patient is adequately informed of risks, benefits and alternatives, and (4) consent is specific to the proposed procedure.

2. Following Montgomery v Lanarkshire (2015), what standard governs disclosure of surgical risk?

   Doctors must disclose any 'material risk' — a risk a reasonable person in the patient's position, or that particular patient, would attach significance to. It replaced the doctor-centred Bolam test for consent.

3. State the four core elements of mental capacity assessment under the Mental Capacity Act 2005.

   To have capacity a patient must be able to: understand the information, retain it, weigh/use it in the decision, and communicate the decision. Failure of any one means they lack capacity for that decision.

4. List the ASA Physical Status Classification (ASA I–VI).

   I: normal healthy patient; II: mild systemic disease; III: severe systemic disease; IV: severe disease that is a constant threat to life; V: moribund, not expected to survive without operation; VI: brain-dead organ donor. 'E' suffix denotes emergency.

5. What are the four Metabolic Equivalents (METs) of functional capacity considered the threshold for acceptable cardiac reserve before major surgery?

   $4$ METs — the ability to climb two flights of stairs or walk up a hill. Inability to reach $4$ METs indicates poor functional reserve and higher perioperative cardiac risk.

6. What does the Revised Cardiac Risk Index (Lee Index) predict, and name its six variables?

   It predicts major perioperative cardiac events. Variables: high-risk surgery, ischaemic heart disease, congestive heart failure, cerebrovascular disease, insulin-dependent diabetes, and preoperative creatinine $>177\ \mu mol/L$ ($>2\ mg/dL$).

7. Define the Surgical Safety Checklist's three phases (WHO).

   Sign In (before induction of anaesthesia), Time Out (before skin incision), and Sign Out (before the patient leaves theatre).

8. What is the formula for Body Mass Index (BMI) and the obesity threshold?

   $$BMI = \frac{\text{mass (kg)}}{[\text{height (m)}]^{2}}$$ Obesity is defined as $BMI \geq 30\ kg/m^{2}$.

9. According to the classic Cruse & Foord classification, what are the four wound classes and their approximate infection rates?

   Clean ($\approx 1\text{–}2\%$), Clean-contaminated ($\approx 5\text{–}10\%$), Contaminated ($\approx 15\text{–}20\%$), and Dirty/infected ($\approx 30\text{–}40\%$).

10. When should prophylactic antibiotics be administered relative to skin incision, and why?

    Within $60$ minutes before incision (within $120$ min for vancomycin/fluoroquinolones) so that adequate tissue concentrations are present at the time of contamination.

11. Define surgical asepsis versus antisepsis.

    Asepsis is the absence of pathogenic microorganisms (achieved by sterilisation/technique to prevent contamination); antisepsis is the destruction/inhibition of microorganisms on living tissue using antiseptic agents (e.g. chlorhexidine, povidone-iodine).

12. What temperature and time define standard steam sterilisation (autoclaving)?

    $134\,^{\circ}\mathrm{C}$ at $\approx 2.2\ bar$ for $3$ minutes, or $121\,^{\circ}\mathrm{C}$ for $15$ minutes. Prions may require extended cycles.

13. State the components of the WHO/enhanced recovery 'ERAS' pathway aim and give three key elements.

    ERAS (Enhanced Recovery After Surgery) reduces the physiological stress of surgery to speed recovery. Elements include: preoperative carbohydrate loading, avoidance of prolonged fasting, minimally invasive technique, early mobilisation, and early oral nutrition.

14. What are the standard preoperative fasting guidelines ('2-4-6 rule')?

    $2$ hours for clear fluids, $4$ hours for breast milk, and $6$ hours for solid food / formula / a light meal before anaesthesia.

15. Define the four phases of general anaesthesia (Guedel's stages).

    Stage I: analgesia (induction to loss of consciousness); Stage II: excitement/delirium; Stage III: surgical anaesthesia; Stage IV: respiratory paralysis/overdose (medullary depression).

16. What is the triad of general anaesthesia?

    Hypnosis (unconsciousness), analgesia (pain control), and muscle relaxation (akinesia).

17. Give the formula for calculating maximum safe dose of lidocaine and the standard limits.

    $$\text{Max dose (mg)} = \text{dose (mg/kg)} \times \text{weight (kg)}$$ Plain lidocaine: $3\ mg/kg$; with adrenaline: $7\ mg/kg$. (A $1\%$ solution contains $10\ mg/mL$.)

18. List the early signs and management of local anaesthetic systemic toxicity (LAST).

    Early: perioral tingling, tinnitus, metallic taste, agitation; then seizures, cardiac arrhythmia/arrest. Management: stop injection, ABC, and give $20\%$ lipid emulsion (Intralipid) $1.5\ mL/kg$ bolus then infusion.

19. What are the cardinal features and treatment of malignant hyperthermia?

    Triggered by volatile agents/suxamethonium: rising $\mathrm{EtCO_2}$, tachycardia, masseter/muscle rigidity, hyperthermia, acidosis, hyperkalaemia. Treat by stopping triggers, $100\%$ $\mathrm{O_2}$, active cooling, and dantrolene $2.5\ mg/kg$ IV.

20. Which standard monitors are mandated during anaesthesia (AAGBI minimum monitoring)?

    Pulse oximetry ($\mathrm{SpO_2}$), capnography ($\mathrm{EtCO_2}$), ECG, non-invasive blood pressure, inspired oxygen/agent concentration, and temperature. Airway pressure and a nerve stimulator when relaxants are used.

21. What does end-tidal $\mathrm{CO_2}$ (capnography) confirm intraoperatively, and its normal value?

    It confirms correct tracheal tube placement, ongoing ventilation and pulmonary perfusion. Normal $\mathrm{EtCO_2} \approx 4.6\text{–}6.0\ kPa$ ($35\text{–}45\ mmHg$).

22. Define diathermy and the difference between monopolar and bipolar.

    Diathermy uses high-frequency alternating current ($\sim 400\ kHz\text{–}10\ MHz$) to cut/coagulate tissue. Monopolar: current passes from active electrode through the patient to a return plate. Bipolar: current passes only between the two limbs of forceps — safer near end-arteries and with pacemakers.

23. What are the main risks of monopolar diathermy and how are they mitigated?

    Burns (from poor plate contact, channelling in narrow pedicles, or alternative earthing), fire with alcohol preps, and pacemaker interference. Mitigate with correct plate placement, avoiding end-arteries, bipolar near appendages, and dry skin prep.

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