UK Medical Licensing Assessment (UKMLA) Surgery and Perioperative Care Syllabus

Surgery and Perioperative Care syllabus — full chapter and topic list

Expand any chapter to see its topics and sub-topics. This is the whole examinable outline for Surgery and Perioperative Care in UK Medical Licensing Assessment (UKMLA), not a summary of it.

1. 1

   Principles of Surgical and Perioperative Care

   4 topics

   • Preoperative assessment
     • Risk stratification and fitness for surgery
     • Medication management around surgery
     • Consent and the WHO surgical safety checklist
   • Postoperative care and complications
     • Postoperative fever and the surgical sieve
     • Wound complications and surgical site infection
     • Venous thromboembolism prophylaxis
   • Surgical fluids, nutrition and stoma care
   • Principles of wound healing and anastomoses
2. 2

   General and Gastrointestinal Surgery

   5 topics

   • Acute abdomen and peritonitis
   • Hepatobiliary surgery
     • Cholecystitis and biliary colic
     • Pancreatitis
     • Obstructive jaundice
   • Colorectal surgery
     • Appendicitis
     • Colorectal cancer
     • Diverticulitis and bowel obstruction
     • Anorectal conditions
   • Hernias and the groin
   • Oesophagogastric disease and upper GI cancer
3. 3

   Vascular and Urological Surgery

   6 topics

   • Peripheral arterial disease and critical limb ischaemia
   • Aneurysmal disease and aortic emergencies
   • Venous disease and the diabetic foot
   • Urological emergencies
     • Acute urinary retention
     • Testicular torsion
     • Renal colic and obstructed infected kidney
   • Lower urinary tract symptoms and benign prostatic hyperplasia
   • Urological malignancy
     • Prostate cancer
     • Bladder and renal cancer
     • Testicular cancer
4. 4

   Trauma and Orthopaedics

   4 topics

   • Fracture principles and management
     • Fracture description and healing
     • Open fractures and compartment syndrome
   • Common fractures by region
     • Hip and proximal femur fractures
     • Wrist and upper limb fractures
     • Fragility fractures
   • Joint and limb disorders
     • Dislocations
     • Septic arthritis and osteomyelitis
   • Paediatric orthopaedics
     • Developmental dysplasia of the hip
     • Slipped upper femoral epiphysis and Perthes
     • Limping child
5. 5

   Specialty Surgery: ENT, Ophthalmology and Maxillofacial

   3 topics

   • Ear, nose and throat
     • Otitis media and externa
     • Epistaxis and the acutely blocked airway
     • Tonsillitis and quinsy
     • Hearing loss and vertigo
     • Head and neck lumps and cancer
   • Ophthalmology
     • Acute red eye
     • Sudden loss of vision
     • Acute angle-closure glaucoma
     • Diabetic eye disease and chronic visual loss
   • Oral and maxillofacial emergencies
     • Facial trauma
     • Dental and oral infection

Surgery and Perioperative Care flashcards for UK Medical Licensing Assessment (UKMLA)

18 of 51 cards from the Surgery and Perioperative Care deck — real questions with worked answers.

1. In preoperative assessment, what does the ASA Physical Status Classification grade ASA III represent?

   A patient with severe systemic disease that is a substantive functional limitation but not a constant threat to life (e.g. poorly controlled diabetes/hypertension, COPD, BMI $\geq 40$). ASA I = healthy; II = mild 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.

2. Which preoperative medications should typically be stopped, and when, before major surgery: warfarin, the COCP, and metformin?

   Warfarin: stop ~5 days before (bridge with LMWH if high thrombotic risk; aim INR $<1.5$). Combined oral contraceptive pill: stop 4 weeks before major/lower-limb surgery (VTE risk). Metformin: usually continue but omit on the day if contrast or renal risk (lactic acidosis); long-acting/other agents per protocol.

3. What grade of Mallampati score and other airway findings predict a difficult intubation?

   Mallampati III (only soft palate/base of uvula visible) and IV (only hard palate visible) predict difficulty. Other predictors: thyromental distance $<6.5$ cm, mouth opening $<3$ cm, reduced neck extension, and a short/thick neck.

4. What are the standard preoperative fasting times for clear fluids, breast milk, and solids/formula?

   Clear fluids: up to 2 hours before. Breast milk: 4 hours. Solids, formula and non-clear fluids: 6 hours. (The '2-4-6' rule.)

5. Using the '5 Ws', list the classic timeline of causes of postoperative pyrexia.

   Wind (atelectasis/pneumonia, days 1-2); Water (UTI, days 3-5); Wound (surgical site infection, days 5-7); Walking (DVT/PE, days 5+); Wonder drugs / What did we do (drug reaction, transfusion, line sepsis/abscess, anytime). Day 0-1 fever is often inflammatory/atelectasis.

6. What is the definition and typical timing of an anastomotic leak after bowel surgery, and what are its red-flag signs?

   Leakage of luminal contents from a surgical join, classically presenting around days 5-7 postoperatively. Red flags: new/worsening abdominal pain, tachycardia, fever, ileus, raised CRP/WCC, faeculent or purulent drain output, and signs of sepsis or peritonitis.

7. What is the Clavien-Dindo classification used for, and what does Grade III represent?

   It grades the severity of postoperative complications by the treatment required. Grade I = any deviation needing no treatment beyond simple measures; II = needs pharmacological treatment/transfusion/TPN; III = requires surgical, endoscopic or radiological intervention (IIIa without, IIIb with general anaesthetic); IV = life-threatening, ICU/organ support; V = death.

8. State the Parkland formula for fluid resuscitation in major burns and how it is administered.

   $$V = 4 \times \text{weight (kg)} \times \%\text{TBSA burned}$$ giving mL of Hartmann's over the first 24 h from the time of burn. Half is given in the first 8 hours and the remaining half over the next 16 hours; titrate to a urine output of $0.5\text{-}1\,\text{mL/kg/h}$.

9. What are the daily adult maintenance requirements for water, sodium/potassium, and glucose in IV fluid prescribing (NICE)?

   Water $25\text{-}30\,\text{mL/kg/day}$; sodium, potassium and chloride approximately $1\,\text{mmol/kg/day}$ each; glucose $50\text{-}100\,\text{g/day}$ (to limit ketosis, not for nutrition).

10. What is refeeding syndrome, the key biochemical hallmark, and which patients are at high risk?

    A potentially fatal shift in fluids/electrolytes when feeding is reintroduced after starvation, driven by insulin surge. Hallmark is hypophosphataemia (also hypokalaemia, hypomagnesaemia, thiamine deficiency). High risk: BMI $<16$, $>15\%$ weight loss, little intake $>10$ days, or low baseline K/PO$_4$/Mg. Treat by slow feeding and replacing electrolytes/thiamine.

11. Compare an end colostomy and an end ileostomy in terms of site, spout and output.

    Colostomy: usually left iliac fossa, flush to skin (no spout), with formed/solid faecal output. Ileostomy: usually right iliac fossa, spouted to protect skin from enzymes, with liquid/watery output. The spout and liquid effluent distinguish an ileostomy.

12. List the classic phases of wound healing and the key cell or process of each.

    1) Haemostasis (vasoconstriction, platelet plug, clot); 2) Inflammation (neutrophils then macrophages, days 1-5); 3) Proliferation (fibroblasts, collagen III, angiogenesis, granulation tissue, days 4-21); 4) Remodelling/maturation (collagen III replaced by stronger collagen I, weeks to months).

13. What are the recognised factors that impair wound and anastomotic healing?

    Local: poor blood supply/tension, infection, foreign body, radiation, ischaemia. Systemic: diabetes, smoking, malnutrition, vitamin C/zinc deficiency, steroids/immunosuppression, advanced age, jaundice, malignancy. For anastomoses specifically: tension, poor perfusion, sepsis and distal obstruction are key.

14. Distinguish the typical pain of visceral versus parietal (somatic) peritoneal irritation in the acute abdomen.

    Visceral pain is dull, poorly localised to the midline by embryological origin (foregut = epigastric, midgut = periumbilical, hindgut = suprapubic). Parietal/somatic pain is sharp, well-localised and worsened by movement, signalling peritoneal inflammation (e.g. migration of appendicitis pain to the right iliac fossa).

15. Define peritonitis and contrast its localised versus generalised signs.

    Inflammation of the peritoneum, usually from infection/perforation. Localised: focal tenderness, guarding and rebound over the affected area (e.g. RIF in appendicitis). Generalised: a rigid 'board-like' abdomen, lying still, percussion tenderness, absent bowel sounds, and signs of sepsis/shock - a surgical emergency.

16. What clinical scoring tool grades acute appendicitis likelihood, and what are its components?

    The Alvarado score (mnemonic MANTRELS): Migration of pain, Anorexia, Nausea/vomiting, Tenderness in RIF (2 pts), Rebound, Elevated temperature, Leucocytosis (2 pts), Shift of WCC to the left. Max 10; $\geq 7$ suggests high probability of appendicitis.

17. Describe Charcot's triad and Reynolds' pentad and the conditions they indicate.

    Charcot's triad = right upper quadrant pain + fever + jaundice, indicating ascending cholangitis. Reynolds' pentad adds hypotension + confusion (altered mental status), indicating suppurative cholangitis with sepsis - a surgical/endoscopic emergency requiring biliary drainage (ERCP).

18. Differentiate biliary colic, acute cholecystitis and ascending cholangitis by cause and features.

    Biliary colic: transient cystic duct obstruction by a stone; RUQ pain after fatty food, no fever, normal inflammatory markers. Acute cholecystitis: sustained obstruction with gallbladder inflammation; constant RUQ pain, fever, positive Murphy's sign, raised WCC/CRP. Ascending cholangitis: CBD obstruction with infected bile; Charcot's triad of pain, fever and jaundice.

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