SMLE Surgery Syllabus

Surgery syllabus — full chapter and topic list

Expand any chapter to see its topics and sub-topics. This is the whole examinable outline for Surgery in SMLE, not a summary of it.

1. 1

   General Surgery

   3 topics

   • Preoperative Care
   • Postoperative Care
   • Wound Healing
2. 2

   Trauma

   3 topics

   • Head Injury
   • Chest Trauma
   • Abdominal Trauma

Surgery flashcards for SMLE

18 of 50 cards from the Surgery deck — real questions with worked answers.

1. What is the target fasting time before elective surgery under ASA guidelines for clear liquids and for solid food/heavy meals?

   Clear liquids: stop $\geq 2$ hours before. Light meal/non-human milk: $\geq 6$ hours. Fatty/fried foods and heavy meals: $\geq 8$ hours. Breast milk: $\geq 4$ hours.

2. List the ASA Physical Status Classification (I-VI) used for preoperative risk assessment.

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

3. Which cardiac risk index is commonly used preoperatively, and name its 6 predictors?

   Revised Cardiac Risk Index (RCRI/Lee index). Predictors: (1) high-risk surgery, (2) ischemic heart disease, (3) history of congestive heart failure, (4) cerebrovascular disease, (5) insulin-dependent diabetes, (6) preoperative creatinine $> 2\,\text{mg/dL}$ ($177\,\mu\text{mol/L}$).

4. When should long-acting antiplatelet/anticoagulant agents typically be stopped before major elective surgery?

   Clopidogrel: stop ~5-7 days before. Aspirin: often continued for cardiac patients, otherwise stop ~7 days. Warfarin: stop ~5 days before (bridge with heparin if high thrombotic risk); target INR $< 1.5$. DOACs: stop 1-2 days (up to 3-4 with renal impairment).

5. How should metformin and insulin be managed on the day of surgery?

   Metformin: hold on the day of surgery (risk of lactic acidosis, especially with contrast/renal impairment). Long-acting insulin: give a reduced dose (~50-80%). Short-acting insulin: hold while fasting; monitor glucose and use sliding scale/dextrose infusion as needed.

6. What perioperative steroid coverage is needed for a patient on chronic glucocorticoids?

   Patients on chronic steroids (>3 weeks of prednisone $\geq 5\,\text{mg/day}$) risk adrenal crisis; give stress-dose hydrocortisone (e.g., $100\,\text{mg}$ IV at induction, then $50\,\text{mg}$ every 8 hours) tapered postoperatively based on surgical magnitude.

7. What are the three phases of wound healing and their approximate time frames?

   1) Inflammatory (hemostasis + inflammation): day 0 to ~3-5. 2) Proliferative (fibroplasia, angiogenesis, epithelialization, granulation): day ~4 to 3 weeks. 3) Remodeling/maturation (collagen cross-linking, type III $\to$ type I): 3 weeks up to 1 year or more.

8. What is the difference between primary, secondary, and tertiary (delayed primary) wound closure?

   Primary intention: clean wound edges approximated immediately (sutures/staples), minimal scarring. Secondary intention: wound left open to heal by granulation, contraction, and epithelialization (contaminated/tissue loss). Tertiary/delayed primary: wound left open initially, then closed after several days once infection risk falls.

9. What is the tensile strength of a healing wound at 1 week, 3 weeks, and at maximum (remodeling)?

   At ~1 week: roughly $3\%$ of original strength. At ~3 weeks: about $20\%$. Peak at ~3 months and beyond: about $70\text{-}80\%$ of unwounded skin strength (never regains $100\%$).

10. Which collagen type predominates early versus late in wound healing?

    Type III collagen predominates early (granulation tissue/proliferative phase). During remodeling it is replaced by stronger type I collagen, shifting the type I : type III ratio back toward the normal ~4:1.

11. List key local and systemic factors that impair wound healing.

    Local: infection, ischemia/poor perfusion, foreign body, tension, radiation, hematoma. Systemic: diabetes, malnutrition (protein, vitamin C, zinc deficiency), smoking, corticosteroids/immunosuppression, advanced age, uremia, jaundice, chemotherapy.

12. Differentiate a hypertrophic scar from a keloid.

    Hypertrophic scar: raised scar confined within the original wound borders, often regresses over time, follows tension lines. Keloid: overgrowth extending beyond the original wound margins, does not regress, common in darker skin and earlobes/sternum, high recurrence after excision.

13. What vitamin deficiency specifically impairs collagen cross-linking, and by what mechanism?

    Vitamin C (ascorbic acid) deficiency. Vitamin C is a cofactor for prolyl and lysyl hydroxylase; without it, collagen cannot be properly hydroxylated/cross-linked, causing weak wounds and scurvy.

14. How is a surgical wound classified by contamination (CDC classes I-IV)?

    Class I Clean (no inflammation, respiratory/GI/GU tracts not entered) ~$1\text{-}2\%$ infection. Class II Clean-contaminated (controlled entry of a tract). Class III Contaminated (open fresh trauma, major spillage, non-purulent inflammation). Class IV Dirty/infected (established infection or perforated viscus).

15. What defines the Glasgow Coma Scale, its component point ranges, and total range?

    GCS = Eye + Verbal + Motor. Eye opening: 1-4. Verbal response: 1-5. Motor response: 1-6. Total range: $3$ (worst) to $15$ (normal). Minimum in each category is 1, never 0.

16. How is head injury severity classified by GCS score?

    Mild: GCS $13\text{-}15$. Moderate: GCS $9\text{-}12$. Severe: GCS $\leq 8$ (indication for definitive airway/intubation).

17. Contrast the CT appearance and typical cause of epidural versus subdural hematoma.

    Epidural (extradural): biconvex/lentiform, does not cross suture lines; classically arterial from middle meningeal artery after temporal bone fracture; lucid interval then deterioration. Subdural: crescent-shaped, crosses suture lines; venous from bridging veins; common in elderly/alcoholics on anticoagulants.

18. What is the Monro-Kellie doctrine and how does it relate to intracranial pressure?

    The cranium is a fixed volume containing brain, blood, and CSF: $V_{brain} + V_{blood} + V_{CSF} = \text{constant}$. An increase in any component (or a mass) must be offset by a decrease in another; once compensation is exhausted, ICP rises sharply.

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