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

Compare the typical presentation of right-sided versus left-sided colorectal cancer.

Right-sided (caecum/ascending): occult bleeding causing iron-deficiency anaemia, weight loss and a mass; obstruction late (wide lumen, liquid stool). Left-sided (descending/sigmoid): change in bowel habit, PR bleeding, and early obstruction/tenesmus (narrow lumen, solid stool).

What gene/condition underlies FAP and HNPCC (Lynch), and what cancer risk do they carry?

Familial adenomatous polyposis (FAP): autosomal dominant APC gene mutation; hundreds of colonic polyps with near-100% lifetime colorectal cancer risk, requiring prophylactic colectomy. HNPCC/Lynch syndrome: mismatch-repair gene mutations (e.g. MSH2, MLH1); high colorectal (and endometrial) cancer risk via microsatellite instability, typically right-sided.

Describe the boundaries of Hesselbach's triangle and its relevance to hernias.

Bounded medially by the lateral border of rectus abdominis, laterally/superolaterally by the inferior epigastric vessels, and inferiorly by the inguinal ligament. Direct inguinal hernias protrude through this triangle (medial to the inferior epigastric vessels); indirect hernias arise lateral to the vessels through the deep ring.

How do you clinically distinguish a direct from an indirect inguinal hernia, and which is more likely to strangulate?

Reduce the hernia and occlude the deep inguinal ring (mid-point of the inguinal ligament, ~1.5 cm above the femoral pulse): an indirect hernia is controlled/does not reappear, a direct hernia still bulges medially. Indirect hernias (passing through the canal) are more prone to strangulation, but femoral hernias carry the highest strangulation risk overall.

Define the boundaries of the femoral canal/ring and explain why femoral hernias are dangerous.

The femoral ring is bounded anteriorly by the inguinal ligament, posteriorly by the pectineal (Cooper's) ligament, medially by the lacunar ligament, and laterally by the femoral vein. Because the ring is narrow and rigid, femoral hernias (more common in women) have the highest risk of incarceration and strangulation.

Differentiate the four terms describing hernia complications: reducible, incarcerated, obstructed and strangulated.

Reducible: contents can be pushed back. Incarcerated/irreducible: contents cannot be reduced but remain viable. Obstructed: bowel lumen is blocked causing intestinal obstruction. Strangulated: blood supply is compromised causing ischaemia/necrosis - a surgical emergency with a painful, tender, irreducible, non-pulsatile lump.

What is the classic alarm-symptom presentation and main histological types of oesophageal cancer?

Progressive dysphagia (solids then liquids) with weight loss, odynophagia and anaemia. Squamous cell carcinoma: upper/middle third, linked to smoking and alcohol. Adenocarcinoma: lower third, linked to GORD and Barrett's oesophagus (now the commonest type in the UK).

What is Barrett's oesophagus and why is it significant?

Metaplasia of the lower oesophageal squamous epithelium to columnar (intestinal-type) epithelium due to chronic acid reflux. It is premalignant, increasing the risk of oesophageal adenocarcinoma, and warrants endoscopic surveillance; high-grade dysplasia may need endoscopic resection/ablation.

Which features of dyspepsia are 'ALARM' red flags mandating urgent upper GI endoscopy?

Anaemia (iron deficiency), Loss of weight, Anorexia, Recent onset/progressive symptoms, Melaena/haematemesis, Swallowing difficulty (dysphagia). Also an upper abdominal mass and age $>55$ with new persistent dyspepsia.

What is the Fontaine classification of chronic lower limb peripheral arterial disease?

Stage I: asymptomatic. Stage II: intermittent claudication (IIa $>200$ m, IIb $<200$ m). Stage III: ischaemic rest pain. Stage IV: ulceration or gangrene (tissue loss). Stages III-IV constitute critical limb ischaemia.

How is the ankle-brachial pressure index (ABPI) calculated and interpreted?

$$\text{ABPI} = \frac{\text{highest ankle systolic pressure}}{\text{highest brachial systolic pressure}}$$ Normal $0.9\text{-}1.2$; $0.5\text{-}0.9$ = claudication/PAD; $<0.5$ = critical limb ischaemia; $>1.2$ suggests calcified, incompressible vessels (e.g. diabetes).

List the '6 Ps' of acute limb ischaemia and the time window for limb salvage.

Pain, Pallor, Pulselessness, Perishingly cold (Poikilothermia), Paraesthesia, and Paralysis. Paraesthesia and paralysis are late signs of impending irreversible damage. Irreversible ischaemia generally occurs after ~6 hours, so revascularisation is urgent.

Define an abdominal aortic aneurysm and state the UK thresholds for surveillance versus elective repair.

Permanent focal dilatation of the aorta to $\geq 1.5\times$ normal, i.e. infrarenal diameter $\geq 3$ cm. Surveillance: $3.0\text{-}4.4$ cm yearly, $4.5\text{-}5.4$ cm every 3 months. Elective repair offered when diameter $\geq 5.5$ cm, growth $>1$ cm/year, or symptomatic.

What is the classic triad of a ruptured abdominal aortic aneurysm and the immediate management principle?

Triad: sudden severe abdominal/back/flank pain, hypotension/collapse, and a pulsatile expansile abdominal mass. Management: high-flow oxygen, large-bore access, permissive hypotension (avoid over-resuscitation, target systolic ~$90$ mmHg), urgent vascular surgery for emergency EVAR or open repair - do not delay for imaging if unstable.

Using the Stanford classification, distinguish type A and type B aortic dissection and their management.

Stanford A: involves the ascending aorta (any dissection proximal to the left subclavian) - surgical emergency due to risk of tamponade, aortic regurgitation and coronary involvement. Stanford B: confined to the descending aorta (distal to the left subclavian) - usually managed medically with strict blood-pressure/heart-rate control unless complicated.

Contrast the ulcers and clinical features of chronic venous insufficiency versus arterial disease in the leg.

Venous: ulcer over the medial malleolus (gaiter area), shallow with irregular borders, oedema, haemosiderin/lipodermatosclerosis, warm leg with pulses present, aching relieved by elevation. Arterial: ulcer on toes/heel/pressure points, deep 'punched-out', painful (worse on elevation), cold, hairless leg with absent pulses and prolonged capillary refill.

What are the three contributors to diabetic foot ulceration and the key management principles?

Neuropathy (loss of protective sensation - painless plantar ulcers), peripheral arterial disease (ischaemia), and immunopathy/infection. Management: glycaemic control, debridement, offloading pressure, treat infection (osteomyelitis risk), revascularisation if ischaemic, and multidisciplinary foot care to prevent amputation.

Describe the presentation and emergency management of testicular torsion, including the relevant time window.

Sudden severe unilateral testicular pain (often with nausea), a high-riding/horizontal testis, absent cremasteric reflex, and negative Prehn's sign (no relief on elevation). It is a urological emergency: immediate surgical exploration with detorsion and bilateral orchidopexy; the testis is usually salvageable only within ~6 hours of onset.

What is the typical presentation of ureteric colic and the first-line imaging and analgesia?

Sudden severe colicky loin-to-groin pain, restlessness, nausea and haematuria. First-line imaging is non-contrast CT KUB. First-line analgesia is a NSAID (e.g. PR/IM diclofenac). Stones $<5$ mm usually pass spontaneously; consider medical expulsive therapy (alpha-blocker) and urgent intervention if there is infection, AKI or an obstructed solitary kidney.

How do storage versus voiding lower urinary tract symptoms differ in benign prostatic hyperplasia?

Voiding (obstructive): hesitancy, poor/intermittent stream, straining, terminal dribbling, incomplete emptying. Storage (irritative): frequency, urgency, nocturia, urge incontinence. BPH typically begins with voiding symptoms from bladder outflow obstruction.

What are the first-line medical therapies for BPH and their mechanisms?

Alpha-1 blockers (e.g. tamsulosin) relax prostatic/bladder-neck smooth muscle for rapid symptom relief (side effect: postural hypotension). 5-alpha-reductase inhibitors (e.g. finasteride) block conversion of testosterone to dihydrotestosterone, shrinking the prostate over months and reducing the long-term need for surgery; combined therapy for larger glands.

Compare the typical features of bladder cancer, renal cell carcinoma and prostate cancer presentation.

Bladder: painless visible haematuria (transitional cell carcinoma, smoking-related). Renal cell carcinoma: classic triad (often late) of haematuria, loin pain and a flank mass, plus paraneoplastic features. Prostate: often asymptomatic with raised PSA, LUTS, or bone pain from metastases; hard/irregular gland on DRE.

Describe how an open fracture is graded and the key first-line management.

Gustilo-Anderson classification: I = wound $<1$ cm, clean; II = $1\text{-}10$ cm, moderate soft-tissue damage; III = $>10$ cm or high-energy/severe soft-tissue injury (IIIa adequate coverage, IIIb needs flap, IIIc arterial injury). Management: photograph then cover wound with saline-soaked gauze, IV antibiotics, tetanus prophylaxis, realign/splint, neurovascular check, and urgent debridement/fixation.

What is the Salter-Harris classification of paediatric physeal (growth plate) fractures?

Mnemonic SALTR: I = Straight across the physis (Slipped); II = Above (through metaphysis, commonest); III = Lower (through epiphysis to joint); IV = Through both metaphysis and epiphysis; V = cRush/compression of the physis (worst prognosis for growth arrest).

What are the key components of fracture management described as the '4 Rs'?

Resuscitate (ATLS, manage life-threatening injuries), Reduce (restore anatomical alignment, open or closed), Restrict/Hold (immobilise with cast, splint, traction or internal/external fixation), and Rehabilitate (physiotherapy, mobilise, restore function). Neurovascular status must be assessed before and after reduction.

Name three fractures notorious for avascular necrosis due to their retrograde blood supply.

Scaphoid (proximal pole - blood supply enters distally), femoral neck (intracapsular - retrograde supply via retinacular vessels), and the talus. Displaced fractures in these sites risk non-union and avascular necrosis.

What is compartment syndrome, its cardinal early sign, and the definitive treatment?

A surgical emergency where raised pressure within a fascial compartment (often after fracture/crush/reperfusion) compromises perfusion. Cardinal early sign: pain out of proportion to injury, worsened by passive stretch of the muscles. Pulses are often present until late. Treatment: remove constricting casts and urgent fasciotomy; diagnose clinically (compartment pressure $>30$ mmHg or within $30$ mmHg of diastolic supports it).

Differentiate the typical joint involvement and X-ray findings of osteoarthritis versus rheumatoid arthritis.

Osteoarthritis: weight-bearing/large joints and DIPs (Heberden's nodes); X-ray (LOSS) = Loss of joint space, Osteophytes, Subchondral cysts, Subchondral Sclerosis. Rheumatoid: symmetrical small joints (MCPs/PIPs, sparing DIPs), morning stiffness; X-ray = soft-tissue swelling, periarticular osteopenia, joint-space loss, bony erosions and deformity.

Compare developmental dysplasia of the hip (DDH), Perthes disease and SUFE by typical age of presentation.

DDH: neonates/infants (screened with Barlow and Ortolani tests, US in first months). Perthes disease: avascular necrosis of the femoral head, typically ages 4-8 (more in boys). SUFE (slipped upper femoral epiphysis): adolescents ~10-16, often overweight boys, presenting with hip/knee pain and an externally rotated leg.

What are the features and emergency management of orbital (post-septal) cellulitis versus ENT 'red flag' presentations?

Orbital cellulitis: painful eye movements, proptosis, reduced acuity, diplopia and chemosis - a sight- and life-threatening emergency needing urgent CT, IV antibiotics and ENT/ophthalmology input (risk of cavernous sinus thrombosis). Distinguish from preseptal cellulitis (lid swelling only, normal eye movements/acuity). ENT red flags include stridor, drooling and tripod posture in epiglottitis.

List the sight-threatening 'red eye' emergencies and one distinguishing feature of each.

Acute angle-closure glaucoma: painful red eye, fixed mid-dilated oval pupil, haloes, hard eye, nausea. Anterior uveitis: painful photophobia with a small/irregular pupil and ciliary flush. Scleritis: severe boring pain, scleral injection. Keratitis/corneal ulcer: pain, photophobia, fluorescein-staining defect. Sudden painless visual loss (CRAO, retinal detachment, vitreous haemorrhage) is also an emergency.