I am general surgical resident in the UK.
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I am a general surgery resident doctor in the UK. I am new to Orris. Explain to me how I can best use you for my day to day work and learning. Are you able to help me prepare for MRCS Part B? If yes, how are you able to help me?
Welcome! Here's a practical rundown of how Orris can support your surgical training and MRCS Part B prep.
What Orris Can Do For You
1. Medical Knowledge - Backed by Textbooks
I have access to a medical library of authoritative textbooks covering surgery, anatomy, physiology, pathology, pharmacology, and more. When you ask a clinical question, I search these textbooks first and give you referenced, citable answers - not just general knowledge.
2. Current Evidence
I can search PubMed for the latest systematic reviews, RCTs, and clinical guidelines. Useful when you want to know the evidence base behind a surgical decision, or when guidelines may have changed.
3. Real-Time Web Search
I can search the web for current NHS guidelines, NICE guidance, RCS publications, and surgical society statements.
4. Medical Images
I can search a medical image library for clinical photos, histology slides, anatomical diagrams, ECGs, radiographs, and operative images - useful for visual learning.
5. Document & File Creation
I can generate Word documents, PDFs, PowerPoint slides, and Excel spreadsheets - useful for creating revision notes, teaching materials, audit summaries, or presentations.
MRCS Part B - Yes, I Can Help
MRCS Part B is an OSCE covering applied surgical science and critical care, anatomy and surgical pathology, and clinical and procedural skills. Here's specifically how I can help:
Anatomy
This is the highest-yield topic in Part B. I can:
- Walk you through surface anatomy, cross-sectional anatomy, and applied anatomy for surgical procedures
- Explain anatomical relations tested at common OSCE stations (inguinal canal, axilla, neck triangles, femoral triangle, etc.)
- Find anatomical diagrams and dissection images
- Quiz you on structures and their relations
Applied Surgical Science
- Physiology questions (shock, fluids, respiratory, renal, metabolic)
- Pathology of common surgical conditions
- Wound healing, haemostasis, and inflammatory response
- Surgical nutrition, sepsis, and critical care principles
Clinical Skills Stations
- Help you structure answers for history taking scenarios
- Talk through examination findings and their significance
- Explain operative steps for commonly tested procedures
Communication Stations
- I can roleplay as a patient or examiner for communication stations
- Help you structure how to break bad news, obtain consent, or explain a diagnosis
Viva-Style Q&A
Ask me any question the way an examiner would phrase it, and I'll give you a structured, concise answer. For example:
"Describe the anatomy of the inguinal canal and its surgical relevance." "What are the complications of a Hartmann's procedure?" "How would you manage a patient in septic shock?"
Practical Day-to-Day Uses
| Scenario | How to use Orris |
|---|---|
| Ward round prep | "Explain the pathophysiology of obstructive jaundice" |
| Pre-theatre | "What are the key steps in a laparoscopic appendicectomy?" |
| Post-take learning | "A patient has RIF pain and raised WCC - how do I work this up?" |
| Audit / QI | "Help me design a data collection proforma for colorectal surgery outcomes" |
| Teaching | "Create a 10-slide PowerPoint on management of acute pancreatitis" |
| M&M prep | "What does the literature say about anastomotic leak rates after anterior resection?" |
| MRCS revision | "Quiz me on the anatomy of the femoral triangle" |
Tips for Getting the Best Out of Orris
- Be specific - "Explain the relations of the common bile duct" works better than "tell me about the biliary system"
- Ask follow-up questions - I keep context across the conversation, so you can drill down
- Request images - Add "show me an image" or "find a diagram" and I'll search the medical image library
- Ask for evidence - Add "what does the evidence say" and I'll search PubMed
- Use me like a senior colleague - Frame questions the way you'd ask a consultant: clinical scenarios, differentials, management plans
What would you like to start with? Anatomy revision, a clinical scenario, or something from the wards today?
Are you also able to help me with my portfolio work? Such as drafting work place assessment forms for ISCP?
Yes, absolutely - portfolio work is one of the most practical ways I can save you time as a busy surgical resident.
ISCP Workplace-Based Assessments - How I Can Help
Here's what I can do across the main WBA types used in surgical training:
DOPS (Direct Observation of Procedural Skills)
You tell me:
- The procedure performed (e.g. insertion of chest drain, wound closure, laparoscopic port insertion)
- Your level of involvement (assisted, performed under supervision, performed independently)
- Any specific learning points or difficulties
I draft:
- A structured trainee self-reflection section
- Suggested assessor comments that are specific, evidence-based, and competency-linked
- Realistic areas for development that don't look generic
CBD (Case-Based Discussion)
You give me:
- A brief clinical summary (e.g. "62M, sigmoid volvulus, taken to theatre for Hartmann's")
- The aspects of care you want to highlight
I draft:
- A case summary narrative
- Discussion of your clinical reasoning and decision-making
- Reflection on what you learned and what you'd do differently
- Links to relevant guidelines or evidence if needed
Mini-CEX (Mini Clinical Evaluation Exercise)
You describe:
- The clinical encounter (e.g. clerking an acute abdomen, consent for appendicectomy)
- What went well and what was challenging
I draft:
- Structured reflection covering history, examination, clinical reasoning, communication
- Assessor-style commentary
A-CEX / Acute Care Assessment
Similar to Mini-CEX but for acute scenarios - I can help structure these around the ABCDE framework and your clinical decision-making.
Supervised Learning Events (SLEs) - General Reflections
For any clinical encounter, I can help you write:
- A reflective account using a recognised model (Gibbs, Driscoll, or ERA cycle)
- Learning objectives for future development
- Mapping to the surgical curricula domains (e.g. clinical judgement, technical skills, professionalism)
Audit & QI Entries
- Help structure your audit cycle write-up for your portfolio
- Draft a quality improvement project narrative
- Suggest how to frame the impact of your work
Teaching & Education Entries
- Help write up a teaching session you delivered
- Structure feedback and reflection
How to Use Me for This
Just paste or describe the case/procedure in plain language - you don't need to fill in a template first. For example:
"I did a CBD on a patient with acute pancreatitis. 45-year-old woman, gallstone pancreatitis, managed conservatively, CT showed no necrosis. I want to highlight my management of fluids and the decision about ERCP timing. Can you help me write the reflection?"
Or:
"Help me write a DOPS reflection for a laparoscopic appendicectomy where I did most of the dissection but my consultant took over for the mesoappendix due to adhesions."
I'll produce a draft you can edit, personalise, and paste into ISCP.
Important Caveat
The assessor sections on ISCP must be completed by your supervising consultant or senior colleague - I can help you draft suggested content or talking points to share with them, but the assessor's sign-off must be genuine. Reflections and trainee sections are yours to write - I just help you write them well and efficiently.
Want to try one now? Give me a case or procedure and I'll draft something for you.
fEVAR and bEVAR - difference
fEVAR (fenestrated EVAR) and bEVAR (branched EVAR) are both endovascular techniques for complex aortic aneurysms involving the visceral segment - where a standard EVAR cannot be used because the aneurysm extends to or above the renal arteries. The key difference is in how they incorporate the visceral vessels (renals, SMA, coeliac).
Searching sources...
Reading File
Searching the Web
fEVAR vs bEVAR fenestrated branched EVAR difference technique indications
Finding Sources
Searching Images
fenestrated EVAR branched EVAR aortic aneurysm endovascular repair diagram
Reading File
Reading File
Here is a clear breakdown of the differences between fEVAR and bEVAR:
fEVAR vs bEVAR
Both are advanced endovascular techniques for complex aortic aneurysms that extend to or above the visceral/renal arteries - situations where a standard infrarenal EVAR cannot provide an adequate proximal landing zone. The core difference lies in how the graft incorporates the visceral vessels (renal arteries, SMA, coeliac trunk).
fEVAR - Fenestrated EVAR
| Feature | Detail |
|---|---|
| Mechanism | The main aortic graft has holes (fenestrations) or scallops cut into the fabric that align with the origins of the target vessels |
| Vessel incorporation | Blood flows through the fenestrations directly into the vessel ostia - no bridging stent required if scalloped |
| Geometry | Works best when the target vessels arise close to the aortic wall - minimal gap between graft and vessel origin |
| Typical indication | Juxtarenal and pararenal AAA - aneurysm extends to but not significantly above the renal arteries |
| Precision required | Very high - requires both longitudinal AND rotational alignment of fenestrations with vessel ostia. Misalignment = "shuttering" (partial/complete vessel occlusion) |
| Customisation | Custom-made per patient using CT angiography with 3D reconstruction (manufacturing takes ~6-8 weeks) |
| Device length | Relatively shorter - confined mainly to the abdominal aorta |
| Spinal cord risk | Lower (less thoracic aortic coverage) |
bEVAR - Branched EVAR
| Feature | Detail |
|---|---|
| Mechanism | The main aortic graft has axially oriented internal cuffs (branches) - bridging stents are then deployed from these cuffs out to the target vessel ostia |
| Vessel incorporation | A bridging covered stent spans the gap between the graft branch and the vessel origin |
| Geometry | Needed when there is a larger gap between the aortic wall and the vessel origins - i.e., the target vessels arise from the aneurysm sac itself |
| Typical indication | Thoracoabdominal aortic aneurysms (TAAAs) - Crawford types I-IV - where all four visceral vessels (coeliac, SMA, bilateral renals) arise from the aneurysmal segment |
| Precision required | Less rotational precision than fEVAR - the internal branches give a small margin for longitudinal repositioning |
| Customisation | Also custom-made; off-the-shelf branched devices exist for urgent cases |
| Device length | Longer - extends well into the descending thoracic aorta to achieve a proximal seal |
| Spinal cord risk | Higher - significant coverage of thoracic aorta = risk of anterior spinal artery compromise and spinal cord ischaemia; requires spinal cord protection (CSF drainage, permissive hypertension, staged procedures) |
The Core Conceptual Difference - One Sentence
fEVAR uses holes in the graft aligned directly with vessel origins; bEVAR uses internal branches that bridge a gap to vessels arising from an aneurysmal/dilated segment.
Why the Distinction Matters Clinically
| fEVAR | bEVAR | |
|---|---|---|
| Aneurysm extent | Juxtarenal / pararenal AAA | TAAA (Crawford I-IV) |
| Visceral vessel anatomy | Arise near/at aortic wall | Arise from aneurysm sac |
| Gap to bridge | Minimal or none | Significant |
| Spinal cord risk | Low | Significant - needs active protection |
| Procedure complexity | High | Higher |
| UK availability | Specialised vascular centres | Highly specialised centres only |
Combined f/bEVAR
In practice, many complex TAAAs require a combination - fenestrations for some vessels and branches for others, depending on their anatomy. This is referred to as f/bEVAR.
UK Context
Both procedures are restricted to highly specialised vascular centres in the UK. They are not performed at district general hospitals. For your MRCS/FRCS preparation, understanding the anatomical basis (landing zones, visceral vessel anatomy) and the complications (endoleak types, spinal cord ischaemia, renal impairment, bridging stent occlusion) is the key focus.
- Miller's Anesthesia 10e, p. 8009 | Mulholland & Greenfield's Surgery 7e, p. 5126 | NCBI - fEVAR/bEVAR systematic review
Acute Limb Ischaemia Management Plan and Operative Intervention
Finding Sources
Finding Sources
Searching PubMed
"acute limb ischemia" AND revascularization
Searching the Web
acute limb ischaemia management guidelines Vascular Society UK Rutherford classification 2024
Searching Images
Rutherford classification acute limb ischaemia clinical categories
Reading File
Reading File
Acute Limb Ischaemia (ALI) - Management Plan and Operative Intervention
Structured for MRCS/day-to-day UK surgical practice
1. Definition & Time-Critical Principle
ALI = sudden decrease in limb perfusion threatening limb viability, typically <2 weeks duration. It is a vascular emergency - irreversible tissue damage occurs beyond ~6 hours of onset. Any patient with sudden-onset limb pain needs a high index of suspicion; misdiagnosis is catastrophic.
Two main causes:
- Embolic - sudden onset, no prior claudication history, often a clear embolic source (AF, recent MI, aneurysm, prosthetic valve). Classically causes profound ischaemia because no collaterals have developed.
- Thrombotic (in situ) - acute-on-chronic, on a background of PAD. Usually less severe due to pre-existing collaterals, but often a more difficult surgical/technical problem to treat definitively.
2. The 6 Ps
Pain, Pallor, Pulselessness, Paraesthesia, Paralysis, Perishingly cold. Paraesthesia and paralysis indicate an immediately/irreversibly threatened limb - these are late, ominous signs, not early warning signs.
3. Rutherford Classification - the Core Framework
This determines urgency and modality of treatment.
| Grade | Category | Sensory loss | Motor deficit | Arterial Doppler | Venous Doppler | Prognosis / Action |
|---|---|---|---|---|---|---|
| I | Viable | None | None | Audible | Audible | No immediate threat - can investigate/image first |
| IIa | Marginally threatened | None/minimal (toes only) | None | Inaudible | Audible | Salvageable if promptly treated |
| IIb | Immediately threatened | More than toes | Mild/moderate | Inaudible | Audible | Salvageable only with immediate revascularisation |
| III | Irreversible | Profound/insensate | Paralysed | Inaudible | Inaudible | Major tissue loss inevitable - primary amputation likely |
(Bailey & Love's Short Practice of Surgery, 28th ed., p. 1033)
Key resident take-home: Rutherford IIb with new sensory/motor deficit affecting more than the toes = needs direct, urgent transfer to a vascular hub and theatre - this is exactly the trigger point highlighted in the UK NCEPOD 2025 report "Risking Life and Limb."
4. Immediate Management (Do This on the Ward/ED Before Anything Else)
- A-E assessment, high-flow oxygen, IV access
- IV unfractionated heparin 5000 units bolus, then infusion - prevents proximal/distal thrombus propagation. Give this even if the patient is going straight to theatre or angiography.
- Analgesia - IV opioids, ischaemic pain is severe
- Urgent bloods: FBC, U&E (baseline renal function - reperfusion/rhabdo risk), clotting, group & save/crossmatch, creatine kinase (rhabdomyolysis), lactate, glucose
- ECG - look for AF or evidence of recent MI (embolic source)
- Keep the patient nil by mouth - likely going to theatre
- Urgent vascular surgery referral - do not delay for imaging if the limb is IIb/III with hard signs; time is muscle and nerve.
5. Investigations - Balance Speed vs Information
- Handheld Doppler of pedal vessels - triphasic/biphasic/monophasic/absent - document this, it's part of your clinical exam
- Duplex ultrasound - good non-invasive first-line if time allows
- CT angiography (CTA) - defines the level and extent of occlusion, run-off vessels, and helps decide open vs endovascular approach - but do not let imaging delay treatment in Rutherford IIb
- Catheter angiography can be diagnostic and therapeutic (on-table, in the endovascular suite)
6. Definitive Management - Decision by Rutherford Grade
| Grade | Typical approach |
|---|---|
| I | Can afford time for imaging (CTA/duplex) to plan definitive elective-urgent intervention; anticoagulate meanwhile |
| IIa | Urgent (within hours) - imaging to guide endovascular vs open; anticoagulate |
| IIb | Emergency - immediate revascularisation, usually surgical embolectomy or emergency endovascular intervention; no time for extensive workup |
| III | Often primary amputation - revascularising a dead/irreversibly damaged limb risks life-threatening reperfusion injury (hyperkalaemia, myoglobinuria, acidosis, compartment syndrome) without functional benefit |
7. Operative Intervention Options
A. Surgical (Open) Embolectomy - the classic emergency procedure
- Performed under local, regional, or general anaesthesia depending on patient factors
- Common femoral artery exposed (groin cutdown) - most common site given embolic lodging at bifurcations
- Longitudinal or transverse arteriotomy
- Fogarty balloon catheter passed proximally and distally to extract thrombus/embolus
- Completion angiography to confirm distal run-off and exclude residual thrombus
- Arteriotomy closed primarily or with a patch
B. Catheter-Directed Thrombolysis (CDT)
- Best suited to Rutherford I/IIa (viable/marginally threatened), where there is time (usually needs hours to work, not suitable if immediately threatened)
- Local infusion of tPA directly into the thrombus via a catheter positioned within it
- Requires ICU/HDU monitoring for bleeding complications; contraindicated in recent surgery, stroke, active bleeding, etc.
- Often combined with mechanical thrombectomy for speed
C. Percutaneous Mechanical/Aspiration Thrombectomy
- Increasingly used, particularly for IIa/IIb where lysis alone would be too slow
- Devices aspirate or macerate thrombus under fluoroscopic guidance
D. Hybrid Approaches
- Combination of open embolectomy plus on-table angioplasty/stenting for underlying stenotic lesion (especially in thrombotic-on-chronic disease)
E. Bypass Surgery
- Considered when embolectomy fails, or there's an underlying occlusive lesion not amenable to endovascular repair (e.g. long-segment SFA occlusion)
F. Fasciotomy
- Mandatory consideration after revascularisation of any limb ischaemic for a prolonged period
- 4-compartment fasciotomy of the leg (anterior, lateral, superficial posterior, deep posterior) if compartment syndrome develops or is anticipated
- Reperfusion injury causes capillary leak, oedema, and rising compartment pressures - measure if in doubt (>20-30 mmHg or clinical signs)
G. Primary Amputation
- Indicated in Rutherford III (insensate, paralysed limb) where revascularisation would risk fatal reperfusion syndrome (hyperkalaemic cardiac arrest, myoglobinuria-induced AKI) without limb salvage benefit
8. Post-Revascularisation Care
- Monitor for reperfusion injury: hyperkalaemia, myoglobinuria/AKI, metabolic acidosis - check bloods and urine output closely
- Watch for compartment syndrome - clinical exam +/- compartment pressure monitoring
- Continue anticoagulation, investigate embolic source (echocardiogram, AF workup, aneurysm screening) if embolic
- MDT input - cardiology if AF/MI, vascular surveillance long-term
9. Current Evidence Snapshot (worth knowing for viva)
- ESVS 2024/2020 guidelines remain the reference standard in Europe/UK for ALI management pathways
- NCEPOD 2025 "Risking Life and Limb" report (UK-specific) emphasises time-critical transfer to vascular hubs, standardised use of Rutherford classification, and auditing time-to-treatment - highly relevant to UK training and likely to feature in governance/audit discussions
- Recent systematic reviews (2025) comparing endovascular vs open surgical revascularisation for ALI show broadly comparable limb salvage outcomes, with a trend toward less invasive endovascular-first approaches where anatomy and time permit, though open embolectomy remains first-line for embolic occlusion with hard ischaemic signs (PMID: 40057270, PMID: 40428785 - both 2025 systematic reviews/meta-analyses, worth a quick read if you want granular numbers)
For Your MRCS Prep Specifically
This topic commonly appears as:
- A clinical scenario station (sudden onset painful pulseless leg - work through 6 Ps, Rutherford grading, and immediate management)
- An anatomy/operative station (embolectomy technique, arteriotomy closure, fasciotomy compartments and landmarks)
- A communication/consent station (consenting for embolectomy including risk of amputation, or discussing primary amputation with a patient/family)
Want me to run you through a mock OSCE scenario on this, or drill into the fasciotomy anatomy/technique in more detail?
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