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• Introduction
• Definitions
• Classifications with tables
• Detailed content under sub-headings
• Complications
• Management
• Bailey & Love chapter references

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Q1. Write a Note on Surgical Safety Checklist [2024]

(Bailey & Love, Chapter 15)

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Introduction

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Evidence Base

• Use of the checklist in eight hospitals worldwide showed:
  • Perioperative mortality reduced from 1.5% to 0.7%
  • Major inpatient complications reduced from 11.0% to 7.0%
• A 2015 Norwegian study demonstrated:
  • Complications fell from 19.9% to 11.5%
  • Mean length of stay fell by 2 days
  • Hospital mortality fell from 1.9% to 0.2%

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The Three Phases of the WHO Checklist

PHASE 1 - SIGN IN (Before Induction of Anaesthesia)

• Patient confirms identity, site, procedure and consent
• Site marked (where applicable)
• Anaesthesia machine and medication check complete
• Pulse oximeter on patient and functioning
• Known allergy? - confirmed
• Difficult airway/aspiration risk identified - equipment and assistance available if yes
• Risk of >500 mL blood loss (>7 mL/kg in children) - if yes, two IVs/central access and fluids planned

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PHASE 2 - TIME OUT (Before Skin Incision)

• All team members introduce themselves by name and role
• Patient name, procedure and incision site verbally confirmed
• Antibiotic prophylaxis given within last 60 minutes
• Anticipated Critical Events:
  • To Surgeon: Critical/non-routine steps; estimated case duration; anticipated blood loss
  • To Anaesthetist: Any patient-specific concerns
  • To Nursing Team: Sterility confirmed; equipment issues or concerns
• Essential imaging displayed

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PHASE 3 - SIGN OUT (Before Patient Leaves Operating Room)

• Nurse verbally confirms the name of the procedure performed
• Completion of instrument, sponge and needle counts confirmed
• Specimen labelling read aloud (including patient name)
• Any equipment problems to be addressed identified
• Key concerns for recovery and management communicated to entire team

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Surgical Never Events Prevented by the Checklist

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Successful Implementation Requires (Bailey & Love)

• Early engagement of staff
• Active leadership and local champions
• Extensive education, discussion and training
• Multidisciplinary involvement
• Ongoing feedback and local adaptation
• The checklist is not intended to be comprehensive - local modifications are encouraged

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Limitations

• 53-70% of surgical errors occur outside the operating theatre - checklists must extend to the entire surgical pathway, not just the intraoperative period
• Checklists solve specific problems but do not replace clinical judgement
• Without genuine attitude change and removal of barriers, a checklist has limited impact
• Over-reliance creates false confidence and may divert attention from other safety efforts

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Conclusion

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Q2. Discuss the Anatomical Basis, Advantages and Disadvantages of Various Surgical Incisions of the Abdomen [2024]

(Bailey & Love, Chapter 6)

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Introduction

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Anatomy of the Anterior Abdominal Wall

1. Skin and subcutaneous fat (Camper's and Scarpa's fascia)
2. External oblique - fibres run inferomedially; aponeurosis forms anterior rectus sheath
3. Internal oblique - fibres run superomedially
4. Transversus abdominis - horizontal fibres; deepest muscle layer
5. Rectus abdominis - paired vertical muscles within the rectus sheath; tendinous intersections anteriorly (do not extend posteriorly)
6. Linea alba - avascular fibrous raphe formed by fusion of all three aponeuroses at the midline
7. Transversalis fascia, preperitoneal fat, peritoneum

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Types of Abdominal Incisions

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1. Midline (Median) Incision

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2. Paramedian Incision

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3. Kocher's (Subcostal) Incision

• Right subcostal: Liver, gallbladder, biliary surgery
• Left subcostal: Splenectomy

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4. Gridiron (McBurney's) Incision

• Use: Open appendicectomy

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5. Lanz Incision

• Use: Appendicectomy; preferred for cosmesis

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6. Pfannenstiel Incision

• Uses: Gynaecological surgery, Caesarean section, pelvic surgery, open prostatectomy

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7. Rooftop (Bilateral Subcostal) Incision

• Bilateral subcostal incisions joined across the midline.
• Uses: Hepatic resection, pancreatic surgery, oesophagogastric surgery.
• Advantages: Excellent upper abdominal exposure.
• Disadvantages: Prolonged healing; denervation of rectus below the incision; not easily extended.

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8. Thoracoabdominal Incision

• Combined abdominal and thoracic approach crossing the costal margin.
• Uses: Oesophagectomy, large hepatic tumours, retroperitoneal tumours.
• Disadvantages: Chest drain required; significant morbidity.

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Principles of Wound Closure

• Midline laparotomy: Mass closure using continuous, slowly absorbable monofilament suture (PDS No. 1); suture length to wound length ratio ≥4:1; bites 5 mm from edge, 5 mm apart (Jenkins Rule).
• Subcuticular skin closure for elective cases (best cosmesis, lower SSI risk).
• Interrupted monofilament nylon for contaminated wounds.

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Conclusion

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Q3. Discuss the Surgical Technique for Closure of a Midline Incision [2022]

(Bailey & Love, Chapter 7)

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Introduction

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Anatomy Relevant to Closure

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Principles of Midline Closure (Jenkins Rule)

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Suture Material Selection

• Avoid braided/multifilament sutures in contaminated wounds - bacteria harbour in interstices.
• Non-absorbable sutures may cause chronic sinus formation or pain if tied too tightly.

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Step-by-Step Technique

• Patient supine; table flat to reduce wound tension.
• Peritoneal cavity irrigated with warm saline.
• Drains correctly sited and exteriorised away from the main wound.

• In modern practice, the peritoneum is frequently not closed separately - RCT evidence shows equivalent outcomes; closure adds operative time without benefit.
• If closed: continuous 2/0 or 0 Vicryl (polyglactin).

• Continuous mass closure with loop PDS No. 1 or PDS No. 1.
• Begin with a secure anchoring knot at each end of the wound.
• Two-suture technique: Start from each end and meet in the middle (reduces risk of suture running out).
• Each bite: 5 mm from the wound edge; 5 mm apart.
• Include linea alba only - not subcutaneous fat (which would strangulate fat and fail).
• Do not pull suture so tight that it cuts through tissue or blanches the wound edge.
• The suture length : wound length ratio must remain ≥4:1 throughout.

• Irrigate with saline.
• No separate suture needed unless there is >2 cm depth of dead space (obliterate dead space with interrupted absorbable sutures to reduce seroma/haematoma risk).

• Subcuticular absorbable suture (Monocryl or Vicryl 3/0): Best cosmesis; appropriate for clean wounds.
• Interrupted monofilament nylon (3/0 Ethilon/Prolene): Contaminated or high-risk wounds; removed at Day 7-10.
• Staples: Used for speed in emergency laparotomies.
• Delayed primary closure: In grossly contaminated wounds - wound left open, closed on Day 3-5 once clean.

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Special Situations

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Complications of Poor Closure

• Incidence: 0.5-3%; mortality: 10-35%
• Occurs: Day 5-10 post-op
• Presentation: Serosanguinous "pink fluid" discharge from wound; wound separates; omentum/bowel may extrude
• Risk factors: Malnutrition, obesity, diabetes, jaundice, steroids, emergency surgery, raised intra-abdominal pressure (coughing, ileus), SSI
• Management: Return to theatre; re-close with mass closure using non-absorbable retention sutures; treat underlying cause

• Occurs months to years later; incidence up to 20% after midline laparotomy
• Risk factors: Obesity, smoking, SSI, chronic cough, poor technique, multiple laparotomies
• Prevention: Correct technique, appropriate suture choice, avoiding tension, prophylactic mesh in high-risk patients

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Conclusion

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Q4. Describe Anastomosis in Surgery [2011]

(Bailey & Love, Chapter 7)

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Definition

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Prerequisites for a Safe Anastomosis

1. Adequate blood supply to both ends (most important)
2. Tension-free apposition of the ends
3. No distal obstruction (mechanical or functional)
4. Healthy, well-perfused bowel - no oedema, inflammation or ischaemia at the cut ends
5. Good surgical technique - accurate mucosal apposition, no strangulation of tissue
6. Haemostasis at anastomotic site
7. No significant faecal contamination at the time of anastomosis
8. Adequate nutritional status - albumin >30 g/L (below this, healing is impaired)

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Classification of Anastomosis

By Configuration

By Method of Construction

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1. Hand-Sewn Anastomosis

• Full-thickness interrupted or continuous sutures through all layers
• Provides accurate mucosal apposition with slight inversion
• Suture material: slowly absorbable monofilament (PDS 3/0 or 2/0, Vicryl)
• Interrupted sutures preferred in: oesophageal, rectal and oedematous bowel anastomoses (allows individual adjustment)
• Continuous sutures acceptable in small bowel and colon where speed is important

• Outer seromuscular (Lembert) interrupted non-absorbable + inner full-thickness (Connell) continuous absorbable
• Less commonly used now; associated with greater luminal narrowing

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2. Stapled Anastomosis

• Faster construction
• Consistent geometry and staple deployment
• Accessible for low pelvic/deep anastomoses inaccessible to hand-sewing
• The "doughnuts" (tissue rings cut by circular stapler) provide a quality check

• Expensive equipment
• Risk of misfiring - check before use
• Fixed ring diameter - cannot be used if bowel too narrow
• Cannot be used in ischaemic, inflamed or very oedematous bowel
• Staple line failure in the case of tension or poor tissue quality

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Testing the Anastomosis Intraoperatively

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Anastomotic Leak

• Poor blood supply / tension on anastomosis
• Faecal contamination at time of surgery
• Malnutrition / hypoalbuminaemia (<30 g/L)
• Immunosuppression (steroids, chemotherapy)
• Distal obstruction
• Emergency surgery in unprepared bowel
• Low rectal anastomosis (<5 cm from anal verge)
• Male gender, obesity, smoking

• Localised/controlled leak: IV antibiotics + CT-guided percutaneous drainage
• Generalised peritonitis: Emergency laparotomy, washout, anastomosis taken down, Hartmann's procedure (end stoma + rectal stump closure)
• Defunctioning loop ileostomy may be reversed once leak healed (confirm with gastrografin enema)

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Common Anastomoses in Surgery

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Conclusion

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Q5. Discuss the Role of Stoma Creation Versus Anastomosis After Gut Infection [2010/2011/2018]

(Bailey & Love, Chapter 7)

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Introduction

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Factors Favouring Primary Anastomosis

1. Elective operation with adequate mechanical bowel preparation
2. Well-nourished patient (albumin >30 g/L)
3. No or minimal peritoneal contamination
4. Adequate blood supply to both ends - no tension
5. No distal obstruction
6. Right-sided colonic resection (better blood supply; liquid faeces; lower leak rate)
7. Experienced surgeon; optimal operating conditions
8. Haemodynamically stable patient

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Factors Favouring Stoma Creation

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Types of Stoma

1. End (Hartmann's) Stoma

• Resection of diseased segment.
• Proximal end brought out as permanent or temporary end stoma.
• Distal end closed and left in pelvis (Hartmann's pouch) or exteriorised as mucous fistula.
• Classic scenario: Perforated sigmoid diverticulitis, obstructed/perforated left colonic cancer with peritonitis.
• Reversal (Hartmann's reversal): Major operation; performed 3-6 months later after full recovery and nutritional rehabilitation.

2. Loop Stoma (Defunctioning)

• Loop of bowel exteriorised over a rod or bridge through a separate incision.
• Both proximal (efferent) and distal (afferent) limbs are opened - proximal diverts faeces.
• Loop ileostomy: Most commonly used to protect a low anterior resection anastomosis.
• Loop colostomy: Used when ileum not accessible; less preferred (odour, management difficulty).
• Reversed at 6-12 weeks after confirming anastomotic integrity by gastrografin enema or flexible sigmoidoscopy.

3. End Ileostomy

• After total proctocolectomy for ulcerative colitis or familial adenomatous polyposis (FAP).
• Usually permanent.
• Brooke ileostomy: 2-3 cm spout created to protect skin from corrosive small bowel effluent.

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Principles of Stoma Construction (Bailey & Love)

• Site planned preoperatively by a specialist stoma therapist:
  • Away from bony prominences, skin folds, belt line and previous scars
  • Patient able to see and manage the stoma
• Brought through the rectus abdominis muscle (reduces parastomal hernia risk)
• Ileostomy: Must be spouted (Brooke technique - 2-3 cm everted spout) to prevent alkaline effluent burning peristomal skin
• Colostomy: Flush with skin (formed faeces; less skin corrosion)
• Mucocutaneous anastomosis with interrupted absorbable sutures

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Complications of Stoma

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Stoma Reversal

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Conclusion

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Q6. Drains in Gastrointestinal Surgery [2010/2011]

(Bailey & Love, Chapter 7)

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Introduction

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Classification of Drains

By Mechanism

By Material

• Rubber: Stimulates tissue reaction; rarely used now
• PVC / Silicone: Inert; minimal tissue reaction; preferred in modern practice

By Duration

• Short-term: Post-operative drains; removed within 5-7 days
• Long-term: External biliary drainage (T-tube), pancreatic fistula management (months)

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Indications for Drainage in GI Surgery

Definite/Established Indications (Bailey & Love)

Not Routinely Indicated (Evidence-Based)

• After uncomplicated colorectal anastomosis: RCT evidence does not support routine drainage - may increase infection and patient discomfort
• After elective open or laparoscopic cholecystectomy: No routine drain required
• After uncomplicated appendicectomy: No drain unless abscess present

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The T-Tube Drain

• Limbs: Short limbs lie within the CBD; long limb exits the anterior abdominal wall
• Function: Decompresses CBD; provides access for post-operative cholangiography
• T-tube cholangiogram: Performed on Day 7-10 to confirm complete CBD stone clearance and ductal patency
• Removal: After 10-14 days once a mature fibrous tract has formed around the drain
• Clamping test: Clamp tube for 24 hours before removal to confirm patient tolerates biliary flow
• Complication of premature removal: Bile leak causing biliary peritonitis (the fibrous tract has not yet matured)

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Reading the Drain Output

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Drain Amylase (Pancreatic Surgery)

• Measured on Day 3 after pancreaticoduodenectomy or distal pancreatectomy
• Drain amylase >3 times upper limit of normal on Day 3 = biochemical pancreatic fistula (ISGPF definition)
• Guides duration of drain retention and clinical management

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Drain Management Principles

• Record output daily (volume and character)
• Ensure drain is patent and not kinked
• Avoid dependent loops (raise collection bag to prevent back-flow)
• Remove when output is <30-50 mL/day of serous fluid and no evidence of complication
• Drains should not be left in place indefinitely - increase infection risk and patient discomfort with prolonged use

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Complications of Drains

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Conclusion

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Q7. Write a Note on Surgical Never Events [2020]

(Bailey & Love, Chapter 15)

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Definition

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Background

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NHS Surgical Never Events List

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Most Relevant Surgical Never Events

1. Wrong Site Surgery

• Failure to mark the operative site preoperatively
• Inadequate pre-operative verification
• Poor team communication; time pressure; fatigue
• Handover failures; unclear consent documentation

• Mandatory site marking by the operating surgeon before the patient enters the operating theatre
• Sign In phase of WHO checklist: patient verbally confirms identity, site and procedure
• Time Out phase: entire team verbally confirms site, procedure and patient before incision
• Patient actively involved in site verification (if conscious)
• Written consent with site clearly documented

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2. Retained Foreign Body (RFB)

• Emergency surgery and unplanned extension of procedure
• Obesity (deep wound, difficult counting)
• Multiple surgical teams; staff changes during operation
• Distraction, fatigue, time pressure
• Unrecognised dropped items

• Mandatory instrument, swab and needle counts:
  • Count at the START of the operation (baseline)
  • Count before closure of each body cavity
  • Final count confirmed before skin closure
  • Confirmed in WHO Sign Out phase
• Radiopaque markers on all surgical swabs (detectable on intraoperative X-ray)
• Intraoperative X-ray if count is incorrect before wound closure
• RFID (Radio Frequency Identification) tagged sponge systems - electronic scanning before closure
• Verbal confirmation by scrub nurse of all items used and accounted for

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3. Wrong Implant / Prosthesis

• Implant selection checked by surgeon AND scrub nurse before sterile packaging is opened
• Implant details confirmed during Time Out phase of WHO checklist
• Separate, clear storage of implant sizes with explicit labelling
• Manufacturer's checklist for high-risk implants (cardiac valves, spinal implants)

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Root Causes of Never Events

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The Swiss Cheese Model (James Reason)

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Reporting and Duty of Candour

• Every never event must be reported immediately to the hospital's risk management team and the national reporting system (Serious Incident framework in England).
• Mandatory Root Cause Analysis (RCA) must be completed.
• Duty of candour: The responsible clinician must:
  • Apologise to the patient within 10 working days
  • Explain clearly what happened
  • Offer a written account
  • Support the patient throughout the process
• Learning must be shared to prevent recurrence.

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Conclusion

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Q19. How Will You Assess the Nutritional Status of a Surgical Patient? Define and Classify Artificial Nutritional Treatment. Give an Account of Enteral Nutrition and its Advantages and Drawbacks [2015]

(Bailey & Love, Chapter 25)

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Introduction

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PART A: Assessment of Nutritional Status

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1. History

• Weight loss: >10% in 3-6 months = clinically significant malnutrition
• Reduced oral intake: duration, cause (dysphagia, anorexia, nausea, obstruction)
• Symptoms: dysphagia, vomiting, diarrhoea, constipation
• Alcohol use, medications (steroids, chemotherapy, diuretics, methotrexate, insulin)
• Underlying disease: cancer, IBD, liver disease, diabetes

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2. Anthropometric Measurements

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3. Biochemical Markers

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4. Functional Assessment

• Hand-grip dynamometry (handgrip strength): Simple, reproducible bedside test correlating well with overall muscle function and postoperative complications
• Respiratory muscle strength (peak expiratory flow): Reduced in malnutrition

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5. The MUST Score (Malnutrition Universal Screening Tool)

• Score 0 = Low risk: routine care
• Score 1 = Medium risk: observe and repeat weekly
• Score ≥2 = High risk: treat/refer to dietitian and nutrition support team

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PART B: Classification of Artificial Nutritional Support

• Normal resting: 25-35 kcal/kg/day
• Post-surgical/sepsis: up to 40 kcal/kg/day

ARTIFICIAL NUTRITIONAL SUPPORT
│
├── ENTERAL NUTRITION (EN) — always preferred when gut is functional
│    ├── Oral nutritional supplements (ONS)
│    ├── Nasogastric (NG) tube
│    ├── Nasojejunal (NJ) tube  
│    ├── Percutaneous Endoscopic Gastrostomy (PEG)
│    └── Surgical feeding jejunostomy
│
└── PARENTERAL NUTRITION (PN) — when gut non-functional
     ├── Peripheral PN (PPN) — short-term; peripheral vein; dilute solution
     └── Total Parenteral Nutrition (TPN) — central venous catheter; complete nutrition

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PART C: Enteral Nutrition (EN)

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Definition

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Routes of Enteral Nutrition

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Composition of Enteral Feeds (Bailey & Love)

• Most formulas: 1-2 kcal/mL and up to 0.6 g/mL protein
• Energy ratio: 150-250 kcal per gram of protein nitrogen
• Formulations: standard; disease-specific (renal, hepatic, diabetic); immune-modulating (arginine, glutamine, omega-3 fatty acids)

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Advantages of Enteral Nutrition (over Parenteral)

1. Preserves gut mucosal barrier - prevents bacterial translocation across gut wall
2. Maintains gut immunity - preserves gut-associated lymphoid tissue (GALT) and secretory IgA
3. Prevents gut atrophy - luminal nutrients maintain mucosal villi
4. Reduced infection rates - avoids catheter-related sepsis (major risk of TPN)
5. Better wound healing - direct delivery of nutrients to anabolic processes
6. Shorter hospital stay compared to parenteral nutrition
7. Physiological - maintains normal hormonal responses (CCK, GLP-1, secretin)
8. Cheaper - no central venous catheter; simpler preparation and monitoring
9. Fewer metabolic complications - less hyperglycaemia, electrolyte disturbance than TPN
10. Prevents stress ulceration - luminal nutrition provides gastric mucosal protection
11. Early enteral feeding (within 24-48 hours) reduces infectious complications and organ failure severity in critically ill/post-surgical patients

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Disadvantages / Complications (Summary box 25.3, Bailey & Love)

Tube-Related

• Malposition or displacement (NG tube in bronchus - fatal aspiration if feed given before X-ray confirmation)
• Blockage, kinking, breakage or leakage
• Local erosion of skin or nasal mucosa
• PEG: peristomal infection, buried bumper syndrome, tube fracture

Gastrointestinal

• Diarrhoea - occurs in >30% of patients; may be due to osmolarity, infection, antibiotics
• Bloating, nausea and vomiting
• Abdominal cramps
• Aspiration pneumonia - most serious complication; risk reduced by semi-recumbent position (30-45° head elevation) and post-pyloric feeding
• Constipation

Metabolic / Biochemical

• Electrolyte disorders (hypo/hyperkalaemia, hyponatraemia)
• Refeeding syndrome - most dangerous metabolic complication:
  • Occurs in severely malnourished patients when feeding is reintroduced too rapidly
  • Surge in carbohydrate intake drives insulin release → massive intracellular shift of phosphate, potassium and magnesium
  • Severe hypophosphataemia (<0.5 mmol/L) causes: arrhythmias, cardiac failure, respiratory failure, oedema, seizures, coma - can be fatal
  • Bailey & Love at-risk criteria: unintentional weight loss >10% in 3-6 months; little/no nutritional intake >5 days; alcohol abuse; insulin, chemotherapy or diuretic use
  • Management: Start at maximum 10 kcal/kg/day; increase slowly over 4-7 days; supplement thiamine, Vitamin B complex, multivitamins, trace elements; monitor and replace phosphate, potassium and magnesium
• Drug interactions with enteral feed

Contraindications to Enteral Nutrition

• Mechanical intestinal obstruction
• Paralytic ileus
• Severe haemodynamic instability
• Short bowel syndrome with <100 cm functional small bowel

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Conclusion

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Q20. Write in Short on Pre-Operative Assessment and Optimisation of Nutrition in Surgical Patients [2025]

(Bailey & Love, Chapter 25)

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Introduction

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Identifying At-Risk Patients

High-Risk Groups (Bailey & Love)

• Major upper GI oncological surgery: oesophagectomy, gastrectomy, Whipple's pancreaticoduodenectomy
• Head and neck cancer surgery
• Colorectal cancer with significant weight loss
• Inflammatory bowel disease with active flare
• Patients with prolonged pre-operative nil-by-mouth or markedly reduced oral intake
• BMI <18.5 or unintentional weight loss >10% in 3-6 months
• Serum albumin <30 g/L

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Pre-Operative Nutritional Screening

1. MUST Score (Malnutrition Universal Screening Tool)

• Incorporates BMI, percentage weight loss, and acute disease effect.
• Score ≥2 = high risk; requires referral to dietitian and nutritional support team.

2. NRS-2002 (Nutritional Risk Screening 2002)

• Validated specifically for hospitalised surgical patients.
• Score ≥3 indicates nutritional risk requiring intervention.
• Incorporates: nutritional status impairment + disease severity score.

3. SGA (Subjective Global Assessment)

• Clinician-rated assessment combining history and physical examination.
• Grades: A = well-nourished; B = moderately malnourished; C = severely malnourished.

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Pre-Operative Biochemical Assessment

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Pre-Operative Nutritional Optimisation Strategies

1. Oral Nutritional Supplements (ONS)

• First-line intervention for mild-to-moderate malnutrition.
• Commercially available: ~200 kcal and 2 g nitrogen per 200 mL carton.
• Given 2-3 times daily in addition to normal meals.
• Minimum 7-10 days before surgery; ideally 2-4 weeks for major operations.
• Simple to administer; no invasive access required.

2. Immunonutrition (Immune-Modulating Nutrition)

• Oral supplements enriched with arginine, omega-3 fatty acids, glutamine and nucleotides.
• Evidence supports use in malnourished patients undergoing major abdominal or oncological surgery.
• Given for 5-7 days preoperatively and continued 5-7 days postoperatively.
• Benefits: reduced infectious complications, shorter length of stay, improved wound healing.
• Brands: Oral Impact, Reconvan.

3. Pre-Operative Enteral Tube Feeding

• Indicated when oral supplements are inadequate to meet requirements.
• NG or NJ tube feeding for 10-14 days preoperatively in severely malnourished patients (albumin <20 g/L, weight loss >15%).
• Energy target: gradually increase to 25-35 kcal/kg/day; avoid rapid introduction (refeeding syndrome risk).
• Parenteral nutrition reserved for when the gut is non-functional.

4. When to Delay Elective Surgery for Nutritional Optimisation

• ESPEN Guidelines: If severe nutritional risk (NRS-2002 ≥5 or albumin <30 g/L), delay elective surgery by 7-14 days and provide intensive nutritional support.
• The benefit of nutritional prehabilitation outweighs the risk of delay in malnourished patients with non-urgent pathology.
• Reassess albumin and weight after the nutritional support period before proceeding.

5. Carbohydrate Loading (ERAS Protocol)

• Clear carbohydrate drinks (e.g., Nutricia PreOp - 50 g carbohydrate/200 mL):
  • 800 mL the evening before surgery
  • 400 mL up to 2 hours before surgery
• Mechanism: reduces pre-operative insulin resistance; attenuates the catabolic post-surgical stress response
• Benefits: reduced postoperative nausea/vomiting, reduced anxiety and thirst, improved insulin sensitivity
• Now standard in ERAS pathways for elective colorectal, hepatobiliary, oesophagogastric and vascular surgery.

6. Updated Perioperative Fasting Guidelines (ERAS / ESPEN)

• Prolonged preoperative starvation is actively harmful - causes insulin resistance, increases catabolism, depletes glycogen, worsens post-operative recovery.
• Traditional "nil by mouth from midnight" is now obsolete in elective surgery.

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Intraoperative Planning for Post-Operative Nutrition

• Place a surgical feeding jejunostomy (after oesophagectomy, gastrectomy, Whipple's)
• Insert a nasojejunal tube (placed under vision or radiologically)
• These allow early enteral feeding within 24 hours of surgery

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The Multidisciplinary Nutrition Support Team (Bailey & Love)

• Surgeon - identifies risk; plans access route at operation
• Dietitian - calculates requirements; prescribes enteral/parenteral regimens
• Specialist nutrition support nurse - manages tube feeding; trains ward staff; supports community discharge
• Pharmacist - formulates and checks parenteral nutrition bags
• Speech and language therapist - assesses dysphagia; advises on safe swallowing

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Key Principles (Bailey & Love)

1. "The nutritional status of the patient and the impact of any surgical intervention are taken into account when considering nutritional requirements and the mode of nutrient delivery."
2. Enteral route is always preferred over parenteral when the gut is functional.
3. Nutritional assessment should be part of every pre-operative clerking.
4. Appreciate and avoid complications of both enteral and parenteral nutrition, particularly refeeding syndrome in the chronically malnourished.

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Conclusion

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Reference: All answers are based on Bailey and Love's Short Practice of Surgery, 28th Edition (ISBN: 9780367548117) - Chapters 6, 7, 15, and 25.

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Q8. Discuss Various Surgical Risk Scores Used for Identifying High-Risk Surgical Patients (ASA, APACHE II, POSSUM, SORT) [2022]

(Bailey & Love, Chapter 21)

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Introduction

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Patient Risk Factors (Table 21.6, Bailey & Love)

• Previous severe cardiorespiratory illness (acute MI, COPD, stroke)
• Late-stage vascular disease involving the aorta
• Age >70 years with limited physiological reserve in one or more vital organs
• Extensive surgery for carcinoma
• Acute abdominal catastrophe with haemodynamic instability
• Acute massive blood loss >8 units
• Septicaemia / positive blood cultures
• Respiratory failure (PaO2 <8 kPa or FiO2 >0.4 or ventilation >48 hours)
• Acute renal failure (urea >20 mmol/L or creatinine >260 mmol/L)

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Surgery-Specific Risk (Table 21.7, Bailey & Love)

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1. ASA Score (American Society of Anesthesiologists)

• Does not account for patient age or nature of surgery
• Term "systemic disease" introduces subjectivity
• Examples of each grade added in 2015 to reduce inter-observer variability

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2. POSSUM Score

• Predicts all-cause mortality in postoperative critical care patients and non-cardiac morbidity
• Uses 12 physiological variables (preoperative) and 6 operative variables (intraoperative)
• Generates both a morbidity and a mortality risk percentage

• P-POSSUM (Portsmouth-POSSUM): Reduces over-prediction of mortality in low-risk groups; more accurate for individual risk
• CR-POSSUM: Colorectal-specific version; more accurate for colorectal surgery mortality

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3. APACHE-II Score

• Uses objective clinical indices - does not require intraoperative information
• Designed for ICU patients; predicts both mortality and morbidity
• Score range: 0-71; higher score = greater disease severity and mortality

• 12 acute physiology variables: Temperature, MAP, heart rate, respiratory rate, oxygenation, arterial pH, sodium, potassium, creatinine, haematocrit, WBC, GCS
• Age points: Added based on patient's age bracket
• Chronic health points: Severe organ insufficiency or immunocompromise (liver, cardiovascular, respiratory, renal, immune)

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4. SORT (Surgical Outcome Risk Tool)

• UK-developed preoperative risk score
• Does not require intraoperative information
• Predicts 30-day postoperative mortality
• Incorporates six variables:
  1. Urgency of surgery (elective/expedited/urgent/immediate)
  2. Severity of surgery (minor/intermediate/major/major+/complex)
  3. Surgical specialty
  4. ASA grade
  5. Presence of malignancy
  6. Age

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5. ACS NSQIP Surgical Risk Score

• American College of Surgeons National Surgical Quality Improvement Program
• Web-based tool completed preoperatively
• Estimates risk of complication or death for over 1000 different surgical procedures
• Compares patient's individual risk against the average risk for that procedure
• Based on 19 patient-specific preoperative risk factors
• Provides risk estimates for: death, serious complication, pneumonia, cardiac event, SSI, DVT, renal failure, readmission

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6. Lee's Revised Cardiac Risk Index (RCRI)

---

Clinical Application of Risk Scores (Bailey & Love)

• Predicted mortality >5%: Active consultant input required at all stages of management
• Predicted mortality >10%: Direct supervision by consultant surgeon/anaesthetist; postoperative critical care (HDU/ICU) admission mandatory
• Risk scores guide shared decision-making with patients regarding whether to proceed, modify, or decline surgery
• Allow comparison of outcomes between institutions and surgeons (audit)

---

Conclusion

---

---

Q9. Prophylactic Antibiotics [2008]

(Bailey & Love, Chapter 5)

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Introduction

---

The Decisive Period (Bailey & Love)

• Cover this period to be effective
• Achieve tissue levels above the MIC₉₀ (minimum inhibitory concentration for 90% of expected pathogens) at the time of contamination
• Be given at induction of anaesthesia - typically within 60 minutes before incision

---

Wound Classification (Altemeier's Classification)

---

Principles of Prophylactic Antibiotic Use

---

Commonly Used Regimens

---

When Prophylaxis is NOT Indicated

• Clean non-prosthetic surgery: infection rate too low to justify antibiotic use
• Indiscriminate use in low-risk clean surgery encourages resistant bacterial strains - a major consequence of prophylaxis abuse
• Bailey & Love: "The use of prophylaxis in non-prosthetic surgery is of less value as infection rates are low and the indiscriminate use of antibiotics simply encourages the emergence of resistant strains of bacteria."

---

Special Situations

• Screen preoperatively (nasal swabs)
• Decolonisation protocol: nasal mupirocin ointment + chlorhexidine body washes for 5 days before elective surgery
• Add glycopeptide (vancomycin or teicoplanin) to prophylaxis regimen if MRSA positive

• Mild (rash only): use cephalosporin (10% cross-reactivity risk)
• Severe (anaphylaxis): use clindamycin (orthopaedic) or metronidazole + gentamicin (abdominal)
• Document allergy clearly; inform anaesthetist

• Extended cover may be appropriate
• Discuss with microbiologist

---

Monitoring Efficacy

• Monitor SSI rates at the local, departmental and national level
• Report SSI rates for colorectal surgery to national surveillance programmes
• Regular audit of prophylaxis timing, agent choice and duration

---

Conclusion

---

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Q10. Rational Use of Antibiotics in Surgical Practice; Comment on Prevention of Antibiotic Abuse [2006]

(Bailey & Love, Chapter 5)

---

Introduction

---

Categories of Antibiotic Use in Surgery

1. Prophylactic (Perioperative)

• Administered at induction of anaesthesia (within 60 minutes before incision)
• Single dose; not continued beyond 24 hours
• Targeted at the most likely contaminants for that operative site
• Covers the decisive period (4-hour window before bacterial growth establishes)
• Tissue levels must exceed MIC₉₀ for expected pathogens

2. Empirical (Presumptive Therapeutic)

• Broad-spectrum coverage initiated before culture results are available
• Based on: clinical syndrome, likely pathogens, local resistance patterns
• Must be reviewed at 48-72 hours and de-escalated once sensitivities are known
• "Start broad, go narrow" - the essence of antibiotic stewardship

3. Definitive (Microbiologically Directed)

• Narrow-spectrum agent directed by culture and sensitivity results
• Duration guided by: clinical response, inflammatory markers (WBC, CRP, procalcitonin), imaging
• Most effective strategy - uses smallest necessary antibiotic burden

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Principles of Rational Antibiotic Use (Bailey & Love)

1. Source control is paramount - antibiotics cannot treat undrained pus, necrotic tissue or foreign body. Surgery and drainage take priority.
2. Prescribe for defined indications (not "just in case")
3. Choose agent based on likely organism and site of infection
4. Consider patient factors: allergy, renal/hepatic function, immunosuppression, pregnancy
5. Use microbiological data to guide - not replace - clinical judgement
6. Monitor response with serial clinical assessment and inflammatory markers
7. Stop antibiotics promptly when clinical improvement is established

---

Prevention of Antibiotic Abuse

1. Antibiotic Stewardship Programmes

• Hospital-based multidisciplinary teams (microbiologist, pharmacist, infectious disease specialist, surgeon)
• Monitor prescribing patterns, audit indications, implement restricted prescribing policies
• Identify outliers and provide feedback to clinical teams
• Publish local resistance data annually

2. Restrictive Prescribing Policies

• Reserve broad-spectrum agents (carbapenems, linezolid, colistin, daptomycin) for specialist indication only - require microbiologist approval
• Stop orders: Automatic review of antibiotic prescriptions at 48-72 hours
• Pre-authorisation for certain agents

3. No Prophylaxis Beyond 24 Hours

• Single-dose prophylaxis is standard
• Continuing "just in case" drives resistance without benefit
• Extension only permitted when there is a specific therapeutic indication

4. De-escalation Policy

• Move from broad-spectrum empirical to narrow-spectrum definitive therapy promptly after cultures
• Reduces antibiotic pressure on the microbiome and resistance selection

5. Culture Before Antibiotics

• Blood cultures × 2, wound swabs, drain/peritoneal fluid cultures whenever possible before starting antibiotics
• Blind prescribing without samples perpetuates empirical treatment indefinitely

6. Education

• Regular training for surgical teams on antibiotic pharmacology, resistance mechanisms and updated guidelines
• Education of nurses on correct administration, timing and monitoring

7. Institutional Measures

• Antibiotic formulary limiting the range of agents available at each hospital
• Pharmacy-level checking of dose, duration and indication

---

Consequences of Antibiotic Abuse

---

Conclusion

---

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Q11. Antibiotic Resistance in Surgery [2010] (Classification)

(Bailey & Love, Chapter 5)

---

Introduction

---

Mechanisms of Antibiotic Resistance

---

Classification of Clinically Important Resistant Organisms in Surgery

1. MRSA (Methicillin-Resistant Staphylococcus aureus)

• Resistance mechanism: altered PBP2a (encoded by mecA gene) - resistant to all beta-lactams
• Bailey & Love: Found in the nasopharynx of asymptomatic carriers among both patients and hospital workers
• Causes: wound infections, prosthetic infections, bacteraemia, pneumonia, osteomyelitis
• Screening: "Search and destroy" - nasal swabs before elective surgery; decolonise carriers with mupirocin nasal ointment + chlorhexidine body washes
• Treatment: Vancomycin or Teicoplanin IV; Linezolid for soft tissue infections

2. VRE (Vancomycin-Resistant Enterococcus)

• Resistance mechanism: altered cell wall precursor (D-Ala-D-Lac substitution) - vancomycin cannot bind
• Causes: urinary, biliary, wound and bloodstream infections
• Treatment: Linezolid or Daptomycin (for bloodstream infection)
• Transmission: faeco-oral; strict contact precautions

3. ESBL-Producing Organisms (Extended-Spectrum Beta-Lactamase)

• Organisms: E. coli, Klebsiella pneumoniae (most common)
• Resistance: resistant to most penicillins, cephalosporins and monobactams
• Causes: intra-abdominal, urinary, wound infections; bacteraemia
• Treatment: Carbapenems (meropenem, imipenem); consider Piperacillin/Tazobactam if MIC low
• Risk factors: prior antibiotic use, hospitalisation, urinary catheters, elderly patients

4. Carbapenem-Resistant Enterobacteriaceae (CRE)

• Mechanism: Carbapenemase enzymes (KPC, NDM, OXA-48) destroy carbapenems
• The "last resort" antibiotics become ineffective
• Treatment: Colistin (polymyxin), Fosfomycin, Tigecycline - often combination therapy needed
• Extremely difficult to treat; very high mortality (40-60% bacteraemia)

5. Pseudomonas aeruginosa (Multi-Drug Resistant)

• Intrinsic and acquired resistance to multiple antibiotic classes
• Causes: hospital-acquired pneumonia, wound infections, burns, peritonitis
• Treatment: Piperacillin/Tazobactam, Meropenem, Ceftazidime, Ciprofloxacin (combination)

6. Clostridium difficile

• Not traditionally "resistant" but emerges due to antibiotic-mediated disruption of normal flora
• Toxin A (enterotoxin) and Toxin B (cytotoxin) cause colitis
• High risk antibiotics: clindamycin, fluoroquinolones, broad-spectrum cephalosporins
• Presentation: watery diarrhoea, abdominal pain, fever after antibiotic exposure
• Treatment: mild/moderate = oral Metronidazole or Fidaxomicin; severe = oral Vancomycin; fulminant (toxic megacolon) = emergency colectomy

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Prevention of Resistance in Surgical Practice

---

Antibiotic Classification Relevant to Surgery

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Conclusion

---

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Q12. Surgical Site Infections - Risk Factors, Types, Signs and Symptoms, Causes, Prevention and Treatment [2007/2008]

(Bailey & Love, Chapter 5)

---

Definition

---

Types of SSI (CDC Classification)

1. Superficial Incisional SSI

• Involves only skin and subcutaneous tissue
• Presents within 30 days
• Signs: localised pain, swelling, erythema, warmth, purulent discharge from incision

2. Deep Incisional SSI

• Involves deep soft tissues (fascia and muscle layers)
• Presents within 30 days (or 1 year with implant)
• Signs: fever, wound dehiscence, deep pain, purulent drainage from depth

3. Organ/Space SSI

• Involves any anatomical structure opened or manipulated during surgery (e.g., peritoneal cavity, pleural space, joint space)
• Examples: intra-abdominal abscess, anastomotic leak with pelvic collection, empyema

---

Risk Factors (Summary Box 5.5, Bailey & Love)

Patient (Host) Factors

• Malnutrition - obesity (poor blood supply to subcutaneous fat) and weight loss (impaired immunity and healing)
• Metabolic disease: diabetes mellitus (impaired neutrophil function, poor microcirculation), uraemia, jaundice
• Immunosuppression: AIDS, malignancy, corticosteroids, chemotherapy, radiotherapy
• Poor perfusion: systemic shock or local ischaemia
• Advanced age
• Smoking (impairs tissue oxygenation)

Surgical/Local Factors

• Wound classification (contaminated > clean-contaminated > clean)
• Bacterial inoculum - size and virulence of contamination
• Poor surgical technique: devitalised tissue, excessive dead space, haematoma formation
• Foreign body material: sutures, mesh, prostheses, drains
• Prolonged operative time (>2 hours)
• Emergency surgery
• Colonisation and bacterial translocation in the GI tract

Microbial Factors

• Virulence of the organism
• Production of enzymes (streptokinase, collagenase, hyaluronidase)
• Ability to form biofilm (Staphylococci on prosthetics)

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Common Causative Organisms

---

Signs and Symptoms

• Pain and tenderness at wound
• Swelling, erythema, warmth (classical signs of inflammation)
• Wound discharge: purulent (bacterial), serous (may be early lymph leak), serosanguinous
• Wound dehiscence in deep SSI
• Crepitus in gas-forming organisms (Clostridium)

• Fever (typically Day 3-5 for wound SSI; earlier for streptococcal infection - Day 1-2)
• Tachycardia
• Raised WBC (neutrophilia)
• Raised CRP (peaks Day 2-4; failure to fall or secondary rise suggests SSI)
• Raised procalcitonin (specific for bacterial infection)

---

Prevention (Bailey & Love)

Preoperative

1. Optimise patient factors: control diabetes (target HbA1c <69 mmol/mol), correct malnutrition, stop immunosuppressants if possible
2. MRSA screening and decolonisation for elective surgery
3. Hair removal: electric clippers immediately before surgery (razors create micro-lacerations; increase SSI risk)
4. Bowel preparation in colorectal surgery (combined mechanical + antibiotic - current ERAS evidence)
5. Smoking cessation ≥4 weeks before elective surgery

Perioperative

1. Antibiotic prophylaxis: IV at induction; within 60 minutes of incision; single dose; covers expected organisms
2. Antiseptic skin preparation: 2% chlorhexidine in 70% isopropyl alcohol (superior to povidone-iodine)
3. Normothermia: Active warming (Bair Hugger); cold reduces tissue oxygenation and impairs immune function
4. Adequate tissue oxygenation: FiO2 0.8 intraoperatively and 2 hours post-op (reduces SSI in colorectal surgery)
5. Good surgical technique: meticulous haemostasis, avoid dead space, gentle tissue handling, appropriate suture choice, minimal use of foreign material

Postoperative

1. Aseptic wound care: sterile dressing changes
2. Negative pressure wound therapy (NPWT): for high-risk incisions (obese patients, contaminated wounds)
3. Nutritional support: early enteral nutrition; oral supplements in malnourished patients
4. Glycaemic control: maintain blood glucose <10 mmol/L in all postoperative patients

---

Treatment

---

Conclusion

---

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Q13. Intra-Abdominal Sepsis - Definition, Evaluation and Management [2010]

(Bailey & Love, Chapter 5)

---

Definition

---

Causes

Primary Peritonitis

• Haematogenous spread; no abdominal viscus perforation
• Spontaneous Bacterial Peritonitis (SBP) in cirrhotic patients with ascites (organisms: E. coli, Klebsiella, Streptococci)

Secondary Peritonitis

• Perforated peptic ulcer (duodenal > gastric)
• Perforated appendix
• Perforated diverticular disease (sigmoid colon most common)
• Anastomotic dehiscence post-operatively
• Acute cholecystitis (empyema, perforation)
• Intestinal ischaemia/infarction
• Strangulated hernia

Tertiary Peritonitis

• Persistent/recurrent infection after treatment of secondary peritonitis
• Often mixed flora with highly resistant organisms
• Associated with high mortality; seen in ICU patients

Intra-Abdominal Abscesses

• Subphrenic (right > left)
• Pelvic
• Paracolic
• Interloop (between bowel loops)

---

Evaluation

History and Examination

• Abdominal pain (onset, nature, site, radiation, progression)
• Fever, rigors, vomiting, altered bowel function
• Previous surgery, medications (steroids impair signs), comorbidities
• Examination: Temperature, HR, BP, RR, GCS; abdominal tenderness, guarding, rigidity, rebound tenderness; absent bowel sounds; peritonism

Investigations

• FBC: Neutrophilia (raised WBC); in overwhelming sepsis, WBC may paradoxically fall
• CRP: Rises within 12-24 hours; >150 mg/L suggests established infection
• Procalcitonin: More specific for bacterial infection; guides duration of antibiotic therapy
• Serum lactate: >2 mmol/L suggests tissue hypoperfusion; >4 mmol/L = severe shock
• U&E: Renal function (AKI common in sepsis)
• LFTs + Amylase: Identify biliary or pancreatic source
• ABG: Metabolic acidosis (base excess < -4) in established shock
• Coagulation: DIC screen if severe sepsis

• Blood cultures × 2 (different sites): Before antibiotics; positive in 20-30%
• Urine culture
• Peritoneal fluid culture (aspirated at laparotomy or by paracentesis): Most important for guiding therapy

---

Management

Step 1 - Immediate Resuscitation (Sepsis Six / Surviving Sepsis Campaign)

1. IV fluid challenge (500 mL crystalloid bolus; reassess; target MAP ≥65 mmHg, urine output ≥0.5 mL/kg/hr)
2. IV antibiotics within 1 hour (broad-spectrum empirical; blood cultures taken first)
3. Oxygen (titrate to SpO2 ≥94%); monitor urine output (IDC)

Step 2 - Source Control (Definitive Management)

Step 3 - Antibiotic Therapy

Step 4 - Organ Support (ICU)

• Vasopressors: Noradrenaline first-line for refractory hypotension (target MAP ≥65 mmHg)
• Renal replacement therapy (RRT): If AKI with oliguria unresponsive to fluid
• Mechanical ventilation: If respiratory failure (ARDS)
• Insulin infusion: Glycaemic control (target 6-10 mmol/L)
• Nutritional support: Early enteral nutrition via NG/NJ tube if gut functional

---

Conclusion

---

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Q14. Intra-Abdominal Infection - Definition, Investigation [2008]

(Bailey & Love, Chapter 5)

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Definition

Classification

• Infection is localised to a single organ without anatomical disruption or violation of the peritoneum
• Examples: acute appendicitis (pre-perforation), acute cholecystitis (before gangrene/perforation)
• Management: Source control (appendicectomy, cholecystectomy) ± short course antibiotics

• Infection extends beyond the organ of origin, causing peritonitis or abscess formation
• Requires either radiological drainage or surgical intervention
• Examples: perforated appendicitis with pelvic abscess, anastomotic leak with generalised peritonitis, perforated diverticular disease

• Develops outside hospital; organisms are typical community flora (E. coli, Bacteroides fragilis)
• Generally more predictable resistance patterns; respond to standard regimens

• Develops ≥48 hours after hospital admission, or in patients with recent hospitalisation
• Associated with resistant organisms (ESBL, Pseudomonas, Enterococcus); broader antibiotic cover needed

---

Investigation

Clinical Assessment

• History: Abdominal pain (site, onset, radiation, character); fever, vomiting, change in bowel habit; previous surgery; medications; comorbidities
• Examination: Temperature, HR, BP; abdominal tenderness, guarding, rigidity, rebound; Rovsing's sign; Murphy's sign; rectal examination; hernial orifices; peritonism

---

Laboratory Investigations

---

Microbiological Investigations

• Aerobic: E. coli (most common), Klebsiella, Enterococcus faecalis, Pseudomonas (hospital-acquired)
• Anaerobic: Bacteroides fragilis (dominant anaerobe in colonic perforation), Peptostreptococcus
• Mixed flora (aerobic + anaerobic): Typical in perforated colon

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Imaging Investigations

---

Scoring Systems for IAI Severity

---

Conclusion

---

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Q15. Post-Operative Fever - Causes and Management [2008]

(Bailey & Love, Chapters 5 & 21)

---

Definition

---

The "5 W's" Mnemonic - Causes by Postoperative Day

---

Causes by System

1. Pulmonary (Most Common Early Cause)

• Collapse of alveoli due to mucus plugging, shallow breathing, and diaphragm splinting from pain
• Most common cause of fever in first 48 hours
• Often confused with infection; usually self-limiting
• Management: Chest physiotherapy, incentive spirometry, adequate analgesia (allows deep breathing), early mobilisation, humidified oxygen

• Organisms: S. pneumoniae, Klebsiella, Pseudomonas (ventilated patients)
• Features: productive cough, crackles on auscultation, consolidation on CXR
• Management: Antibiotics (co-amoxiclav or piperacillin/tazobactam); physiotherapy; sputum cultures

• Sudden onset dyspnoea, pleuritic chest pain, haemoptysis, hypoxia
• Investigation: CT Pulmonary Angiography (gold standard)
• Management: Therapeutic anticoagulation (LMWH initially)

---

2. Urinary Tract Infection (Days 1-3)

• Most common cause: catheter-associated UTI
• Organisms: E. coli, Klebsiella, Enterococcus
• Features: dysuria, frequency, suprapubic discomfort, cloudy/offensive urine
• Investigation: Urine dipstick → M/C/S
• Management: Remove catheter if possible; antibiotics guided by culture (trimethoprim, nitrofurantoin, co-amoxiclav)

---

3. Wound Infection / SSI (Days 3-5)

• Streptococcal SSI: may present as early as Day 1-2 (rapidly spreading cellulitis)
• Staphylococcal SSI: typically Day 3-5
• Features: wound erythema, swelling, tenderness, purulent discharge
• Management: Open wound; drain pus; wound swab; antibiotics for spreading cellulitis

---

4. Deep Vein Thrombosis (Days 5-7)

• Low-grade fever; unilateral leg swelling, erythema, pain
• Investigation: Compression Doppler ultrasound (investigation of choice)
• Management: Therapeutic LMWH anticoagulation

---

5. Intra-Abdominal Collection / Deep SSI (Days 5-14)

• Classic presentation: "swinging fever" (fever with daily spikes) typically 10-14 days post-op
• Associated with: right upper quadrant pain, shoulder tip pain (diaphragmatic irritation), hiccough
• Investigation: CT abdomen; ultrasound
• Management: CT/US-guided percutaneous drainage; IV antibiotics

• Features: Day 5-7; fever, rising CRP, peritonism, tachycardia, change in drain output
• Investigation: CT abdomen/pelvis with rectal contrast
• Management: Surgical re-exploration; stoma formation

• After pelvic surgery; rectal examination reveals boggy tender mass
• Management: Transrectal/transanal drainage; antibiotics

---

6. Drug Fever (Any Day)

• Common culprits: beta-lactam antibiotics, heparin, phenytoin, allopurinol
• Diagnosis of exclusion; typically presents with rash, eosinophilia
• Management: Stop offending drug

---

7. Transfusion Reaction (During/After Transfusion)

• Febrile non-haemolytic reactions: most common (cytokine-mediated)
• ABO-incompatible haemolytic reaction: never event - potentially fatal
• Management: Stop transfusion immediately; check patient identity vs blood bag; send sample for cross-match and Coombs test

---

8. C. difficile Colitis (After Antibiotic Use)

• Features: watery diarrhoea (>3 loose stools/day), abdominal cramps, fever after antibiotic exposure
• Investigation: Stool C. difficile toxin PCR
• Management: Stop offending antibiotic; isolate patient; oral Vancomycin (severe) or Metronidazole (mild); fidaxomicin (recurrent)

---

Investigation of Post-Operative Fever

• Temperature chart; FBC; CRP; blood cultures × 2
• Urine dipstick + M/C/S
• Wound inspection and swab if appropriate
• Chest X-ray

• CT abdomen/pelvis if surgical cause suspected (Day 5+)
• Compression Doppler ultrasound if DVT suspected
• CTPA if PE suspected
• Stool C. difficile toxin if diarrhoea + antibiotic exposure
• Blood film and malaria antigen test if recent travel history

---

Management Summary

---

Conclusion

---

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Q16. Antibacterials

(Bailey & Love, Chapter 5)

---

Introduction

---

Classification of Antibacterials

---

1. Beta-Lactams

---

2. Aminoglycosides

---

3. Metronidazole (Nitroimidazole)

• Anaerobic cover in colorectal/appendicular/biliary prophylaxis
• Intra-abdominal sepsis (combined with aerobic cover)
• C. difficile colitis (mild-moderate disease; oral route)
• Liver abscess (amoebic)

---

4. Glycopeptides

---

5. Fluoroquinolones

---

6. Lincosamides

---

7. Macrolides

---

8. Tetracyclines

---

9. Oxazolidinones

---

10. Polymyxins

---

Summary Table

---

Conclusion

---

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Q17. Antibiotics in Abdominal Surgery - Current Guidelines and Practice [2022]

(Bailey & Love, Chapter 5)

---

Introduction

---

Part 1: Prophylaxis in Abdominal Surgery

Principles (NICE/SIGN/WHO Guidelines)

• Administered at induction of anaesthesia (within 60 minutes before incision)
• Single dose is usually sufficient
• Do not extend beyond 24 hours - no additional benefit; promotes resistance
• Repeat intraoperative dose if surgery >3 hours or blood loss >1500 mL
• Cover aerobic Gram-negative bacilli (E. coli, Klebsiella) and anaerobes (Bacteroides fragilis) for colorectal/gastric surgery

Recommended Regimens by Procedure

---

Part 2: Therapeutic Antibiotics in Abdominal Sepsis

Community-Acquired IAI (Mild-Moderate Severity)

• Co-amoxiclav 1.2 g IV TDS + Metronidazole 500 mg IV TDS OR
• Ceftriaxone 2 g IV OD + Metronidazole 500 mg IV TDS
• Duration: 4-5 days after adequate source control (IDSA 2010; WSES 2017)

Hospital-Acquired / Healthcare-Associated / Severe IAI

• Piperacillin/Tazobactam 4.5 g IV TDS (covers Pseudomonas + anaerobes) OR
• Meropenem 1 g IV TDS (for ESBL-producing organisms, severely unwell patients)
• Consider adding Vancomycin or Teicoplanin if MRSA suspected
• Consider adding Fluconazole if Candida isolated in peritoneal cultures

Specific Conditions

---

Part 3: Current Guidelines - Duration of Antibiotic Therapy

---

Part 4: Antibiotic Stewardship in Abdominal Surgery

---

Part 5: Antifungal Therapy in Abdominal Surgery

• Candida species isolated in peritoneal fluid are clinically significant and should be treated
• Indications for antifungal therapy:
  • Candida isolated from ≥2 sites
  • Immunocompromised patients
  • Post-operative recurrent IAI
  • Patients on prolonged broad-spectrum antibiotics
• First-line: Fluconazole 400 mg IV/oral OD (if sensitive)
• Echinocandins (Caspofungin, Micafungin): Used for resistant Candida or critically ill patients

---

Conclusion

---

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Q18. Describe the Clavien-Dindo Classification of Post-Operative Complications; Prevention and Diagnosis of Post-Operative DVT of Lower Limbs [2025]

(Bailey & Love, Chapters 5 & 21)

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PART A: Clavien-Dindo Classification of Post-Operative Complications

---

Introduction

---

The Classification

---

The "d" Suffix

---

Clinical Importance

• Used in: National Emergency Laparotomy Audit (NELA), ACS-NSQIP, colorectal cancer outcome reporting, hepatobiliary audit
• Enables objective comparison of complication severity between surgeons and centres
• Facilitates informed consent - patients can be told their individual risk of each grade of complication
• Identifies areas for quality improvement - a high proportion of Grade IIIb/IV complications triggers case review
• Recommended by Royal College of Surgeons of England for routine reporting of surgical outcomes

---

PART B: DVT of Lower Limbs - Prevention and Diagnosis

---

Pathophysiology - Virchow's Triad

---

Risk Stratification (Caprini/RCOG/NICE Model)

---

Prevention of DVT

A. Mechanical Methods

• Applied from admission to full mobilisation
• Reduce venous stasis by graduated compression (highest at ankle, reducing proximally)
• Contraindicated in: peripheral arterial disease (ABPI <0.6), severe leg oedema, peripheral neuropathy

• Pneumatic sleeves applied to calves/thighs; inflate and deflate cyclically
• Used intraoperatively and in the early post-operative period
• Particularly important when pharmacological prophylaxis is contraindicated (high bleeding risk)
• Reduce DVT risk by ~60% alone

• Single most effective non-pharmacological measure
• Target: patient out of bed Day 1 post-operatively for elective surgery
• Adequate analgesia enables early mobilisation

B. Pharmacological Methods

• Start: 12 hours post-operatively (after confirming haemostasis)
• Duration: Until fully mobile (minimum 7-10 days for most surgery)
• Extended prophylaxis (28 days): Recommended after major colorectal cancer surgery (NICE CG92)
• Monitoring: No routine anti-Xa monitoring except in renal impairment or obesity

• 5000 units SC BD or TDS
• Use in severe renal impairment (eGFR <30 mL/min) - LMWH accumulates; UFH safer
• Monitor APTT for therapeutic dosing

• Rivaroxaban: Licensed for orthopaedic thromboprophylaxis (hip/knee replacement)
• Apixaban: Extended prophylaxis post-hip replacement
• Not routinely used for general surgical prophylaxis currently

• Adequate IV/oral hydration (dehydration increases blood viscosity)
• Stop oestrogen-containing OCP and HRT 4 weeks before major elective surgery; restart 2 weeks after full mobilisation
• Thrombophilia screen in patients with recurrent DVT/PE or strong family history (Factor V Leiden, Protein C/S/Antithrombin III deficiency)

---

Diagnosis of Post-Operative DVT

Clinical Features

• Unilateral leg swelling, erythema, warmth, pain along the course of the deep veins
• Homan's sign (pain on forced dorsiflexion) - low sensitivity and specificity; not reliable in isolation
• Pitting oedema; dilated superficial veins (collateral circulation)
• Low-grade pyrexia (typically Day 5-7 post-op)
• Up to 50% of DVTs are clinically silent

Investigations

---

Treatment of Established Post-Operative DVT

---

Conclusion

---

Reference: All answers are based on Bailey and Love's Short Practice of Surgery, 28th Edition (ISBN: 9780367548117) - Chapters 5, 7, 15, and 21.

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MS GENERAL SURGERY - QUICK REVISION ANSWERS

Bailey & Love | 10 Marks | 15-Minute Format

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Q1. Surgical Safety Checklist [2024]

Three Phases:

• Patient confirms identity, site, procedure, consent
• Site marked; anaesthesia machine checked; pulse oximeter on
• Allergy status; difficult airway; risk of >500 mL blood loss

• Team introductions by name and role
• Confirm patient, procedure, site verbally
• Antibiotic prophylaxis given within 60 minutes
• Surgeon states: critical steps, duration, blood loss
• Anaesthetist: patient concerns; Nurse: sterility, equipment
• Imaging displayed

• Procedure name confirmed
• Instrument/swab/needle count complete
• Specimen labels read aloud
• Recovery concerns communicated

Never Events Prevented:

Implementation Requires:

Limitations:

---

Q2. Abdominal Incisions - Anatomical Basis, Advantages, Disadvantages [2024]

Types:

Closure:

---

Q3. Closure of Midline Incision [2022]

Jenkins Rule (Non-Negotiable):

• Suture length : wound length ≥ 4:1
• Bites: 5 mm from edge; 5 mm apart
• No excessive tension

Suture Choice:

• Elective: Loop PDS No.1 (slowly absorbable monofilament; retains strength >6 weeks)
• Contaminated: Nylon/Prolene (non-absorbable; resists infection)
• Avoid braided sutures in infected wounds

Technique:

1. Irrigate peritoneal cavity
2. Peritoneum - often not closed separately (no benefit shown)
3. Linea alba - continuous mass closure with loop PDS; two-suture technique (start from each end, meet in middle)
4. Subcutaneous - irrigate; close dead space only if >2 cm
5. Skin - subcuticular Monocryl (elective); interrupted nylon (contaminated); staples (emergency)

Special Situations:

• Damage control: Bogota bag / NPWT for temporary closure
• Contaminated/re-do: Non-absorbable + retention sutures; delayed skin closure

Complications:

• Burst abdomen: Day 5-10; pink serosanguinous discharge; return to theatre; re-close with retention sutures
• Incisional hernia: Months-years later; obesity/SSI/smoking major risk factors

---

Q4. Anastomosis in Surgery [2011]

Prerequisites (All Must Be Present):

1. Adequate blood supply to both ends
2. Tension-free apposition
3. No distal obstruction
4. Healthy, well-perfused bowel
5. Good technique - no tissue strangulation
6. Haemostasis
7. No significant faecal contamination
8. Adequate nutrition (albumin >30 g/L)

Classification by Configuration:

• End-to-end: Most physiological; used after bowel resection
• End-to-side: Size disparity; e.g., hepaticojejunostomy
• Side-to-side: Bypass procedures; gastroenterostomy

Methods:

• EEA (circular): Colorectal, rectal, oesophageal - creates everted double-staple line
• GIA (linear cutter): Side-to-side; bowel division
• TA (linear non-cutting): Bowel closure (rectal stump)

Intraoperative Testing:

• Colorectal: Air leak test (pelvis filled with saline; air per rectum; bubbles = leak)
• Check both EEA doughnuts for completeness

Anastomotic Leak:

• Incidence: Colorectal 3-8%; low rectal up to 15-20%
• Presents Day 3-7: fever, rising CRP, peritonism, tachycardia
• Investigate: CT with rectal contrast
• Manage: Localised - antibiotics + percutaneous drainage; Generalised - laparotomy + Hartmann's procedure

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Q5. Stoma vs Anastomosis After Gut Infection [2010/2011/2018]

Favour Primary Anastomosis:

• Elective surgery; well-nourished (albumin >30 g/L); no/minimal contamination; adequate blood supply; no distal obstruction; right-sided colonic resection; stable patient

Favour Stoma:

Types of Stoma:

Stoma Construction:

• Through rectus abdominis (reduces parastomal hernia)
• Sited by stoma therapist away from bony prominences, belt line, skin folds
• Ileostomy spouted; colostomy flush

Complications:

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Q6. Drains in Gastrointestinal Surgery [2010/2011]

Types:

Definite Indications:

• After bile duct exploration → T-tube
• After hepaticojejunostomy/bile duct repair
• After pancreatic surgery (Whipple's, distal pancreatectomy) - detect fistula
• After oesophageal anastomosis
• After peritoneal washout for peritonitis
• Drainage of established abscess

NOT Routinely Indicated (Evidence-Based):

• Uncomplicated colorectal anastomosis
• Elective cholecystectomy
• Uncomplicated appendicectomy

T-Tube Management:

• Cholangiogram Day 7-10 to confirm CBD clearance
• Clamp 24 hours before removal; remove Day 10-14
• Premature removal → bile peritonitis

Reading Drain Output:

• Bilious → bile leak | Faeculent → anastomotic leak | Milky white → chyle leak
• Drain amylase Day 3 after pancreatic surgery: >3× upper limit = pancreatic fistula (ISGPF)

Complications:

Removal:

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Q7. Surgical Never Events [2020]

NHS Never Events List (Surgical):

Root Causes:

• Human factors: fatigue, distraction, hierarchy
• System failures: absent protocols, poor handover
• Cultural: reluctance to speak up

Swiss Cheese Model (Reason):

After a Never Event:

1. Immediate patient safety action
2. Report to Risk Management + national body (Serious Incident)
3. Mandatory Root Cause Analysis (RCA)
4. Duty of Candour: Apologise to patient within 10 working days; written explanation; ongoing support
5. Share learning to prevent recurrence

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Q8. Surgical Risk Scores (ASA, APACHE II, POSSUM, SORT) [2022]

1. ASA Score

2. POSSUM

• Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity
• 12 physiological + 6 operative variables
• Predicts mortality AND morbidity
• Modifications: P-POSSUM (more accurate for individuals); CR-POSSUM (colorectal)
• Limitation: Requires intraoperative data

3. APACHE-II

• Acute Physiology and Chronic Health Evaluation II
• 12 acute physiology variables + age points + chronic health points
• Score 0-71; used in ICU; does NOT need intraoperative data
• Identifies patients needing postoperative critical care

4. SORT (Surgical Outcome Risk Tool)

• UK-developed; entirely preoperative; predicts 30-day mortality
• 6 variables: urgency, surgical severity, specialty, ASA grade, malignancy, age
• Simple; web-based; validated in UK population

5. ACS NSQIP Score

• Web-based; preoperative; covers >1000 procedures
• Based on 19 patient-specific factors
• Compares patient risk vs average for that procedure

Clinical Thresholds (Bailey & Love):

• >5% predicted mortality: Active consultant input required at all stages
• >10% mortality: Direct consultant supervision + mandatory HDU/ICU postoperative admission

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Q9. Prophylactic Antibiotics [2008]

The Decisive Period:

Wound Classification (Altemeier):

Rules:

• Give at induction (within 60 min of incision)
• Single dose - do not continue beyond 24 hours
• Repeat if surgery >3 hours or blood loss >1500 mL
• IV route ensures reliable tissue levels

Regimens:

When NOT Indicated:

Special Cases:

• MRSA: Mupirocin nasal + chlorhexidine washes ×5 days preop; add glycopeptide
• Penicillin anaphylaxis: Gentamicin + Metronidazole (abdominal); Clindamycin (orthopaedic)

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Q10. Rational Use of Antibiotics / Prevention of Abuse [2006]

Three Categories:

Core Principles:

1. Source control first - antibiotics cannot treat undrained pus
2. Prescribe for defined indications only
3. Choose based on likely organism and site
4. Culture before starting whenever possible
5. Review at 48-72 hours and de-escalate
6. Stop promptly when clinically improved

Prevention of Abuse:

• Antibiotic stewardship programmes - multidisciplinary team; audit; restrict broad-spectrum agents
• De-escalation: Broad → narrow once cultures available
• Stop orders: Automatic antibiotic review at 48-72 hours
• No prophylaxis beyond 24 hours
• Education of surgical and nursing staff
• Pre-authorisation for carbapenems, linezolid, colistin

Consequences of Abuse:

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Q11. Antibiotic Resistance in Surgery [2010]

Mechanisms:

Key Resistant Organisms:

MRSA Management (Bailey & Love):

• Preoperative "search and destroy" screening
• Decolonisation: nasal mupirocin + chlorhexidine washes ×5 days
• Treatment: Vancomycin/Teicoplanin IV
• Ward: isolation, deep cleaning, contact precautions

Prevention:

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Q12. Surgical Site Infection - Risk Factors, Types, Signs, Causes, Prevention, Treatment [2007/2008]

Types (CDC):

1. Superficial incisional - skin/subcutaneous only
2. Deep incisional - fascia/muscle
3. Organ/space - cavity opened during surgery (e.g., intra-abdominal abscess)

Risk Factors (Summary Box 5.5, Bailey & Love):

Organisms:

Signs & Symptoms:

Prevention Bundle:

1. Control diabetes; correct malnutrition; MRSA screen
2. Clippers (not razors) for hair removal
3. 2% chlorhexidine in alcohol skin prep
4. IV prophylactic antibiotics at induction
5. Maintain normothermia intraoperatively
6. Good technique: haemostasis, avoid dead space
7. NPWT for high-risk wounds

Treatment:

• Superficial: Open wound, drain pus; antibiotics only for cellulitis
• Deep/organ-space: CT-guided drainage or re-laparotomy; IV antibiotics by culture
• Principle: Source control first, antibiotics second

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Q13. Intra-Abdominal Sepsis - Definition, Evaluation, Management [2010]

Causes:

Evaluation:

• Bloods: FBC, CRP, procalcitonin, lactate (>2 = hypoperfusion; >4 = severe shock), U&E, LFTs, ABG
• Blood cultures ×2 before antibiotics
• Imaging: Erect CXR (free gas); CT abdomen/pelvis with IV contrast (gold standard)

Management - SEPSIS SIX (Bailey & Love):

1. IV fluid challenge (500 mL crystalloid; target MAP ≥65, urine ≥0.5 mL/kg/hr)
2. IV broad-spectrum antibiotics within 1 hour
3. Oxygen; monitor urine output (IDC)

Source Control (Definitive):

• Localised abscess → CT/US-guided percutaneous drainage
• Perforated viscus/generalised peritonitis → Emergency laparotomy: washout + resection ± stoma
• Anastomotic leak → Hartmann's procedure

Antibiotics:

• Community-acquired: Co-amoxiclav + Metronidazole OR Ceftriaxone + Metronidazole
• Severe/hospital-acquired: Piperacillin/Tazobactam OR Meropenem
• Duration: 4-7 days after adequate source control

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Q14. Intra-Abdominal Infection - Definition, Investigation [2008]

Classification:

• Uncomplicated: Localised to single organ, no peritoneal breach (acute appendicitis pre-perforation, acute cholecystitis)
• Complicated: Extends beyond organ; peritonitis or abscess (requires drainage or surgery)
• Community-acquired: Typical flora; predictable sensitivities
• Hospital-acquired: Resistant organisms; broader cover needed

Investigation:

• Blood cultures ×2 before antibiotics (positive 20-30%)
• Urine M/C/S
• Peritoneal fluid culture - most important; aerobic AND anaerobic
• Ascitic fluid: neutrophils >250/mm³ = SBP

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Q15. Post-Operative Fever - Causes and Management [2008]

The 5 W's:

Cause-Specific Management:

Investigations for Any Post-op Fever:

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Q16. Antibacterials

Classification by Mechanism:

• Penicillins: Co-amoxiclav (GI prophylaxis); Piperacillin/Tazobactam (Pseudomonas/severe IAI)
• Cephalosporins: Cefuroxime (prophylaxis); Ceftriaxone (biliary/meningitis)
• Carbapenems: Meropenem (ESBL; severe sepsis - broadest spectrum)

• Gentamicin: Gram-negative sepsis; urology prophylaxis
• Toxicity: Nephrotoxicity + ototoxicity (irreversible) - monitor levels

• Colorectal prophylaxis; anaerobic cover; C. difficile (mild; oral)

• Vancomycin: MRSA (IV); C. difficile (oral); "red man syndrome" with rapid infusion
• Teicoplanin: Once daily; fewer side effects

• Ciprofloxacin: Gram-negatives; urinary/biliary; Pseudomonas
• Risk: C. difficile; tendon rupture; QT prolongation

• Erythromycin: Gram-positive; atypicals; penicillin allergy; prokinetic

• MRSA soft tissue; VRE; expensive

• Last resort for CRE/MDR Pseudomonas; nephrotoxic

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Q17. Antibiotics in Abdominal Surgery - Current Guidelines [2022]

Prophylaxis Principles:

• Give at induction (within 60 min of incision); single dose; do not continue >24 hours
• Repeat if surgery >3 hours or blood loss >1500 mL

Prophylaxis Regimens:

Therapeutic Antibiotics:

• Biliary sepsis: Co-amoxiclav or Pip/Taz; drain urgently
• SBP: Cefotaxime 2 g TDS (no anaerobic cover needed)
• Infected pancreatic necrosis: Meropenem (penetrates pancreas)
• Candida in peritoneum: Fluconazole 400 mg OD

Duration (IDSA/WSES Guidelines):

• Uncomplicated appendicitis: 24 hours post-op only
• Most IAI after source control: 4-7 days
• Prolonging beyond this does NOT improve outcomes

Stewardship:

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Q18. Clavien-Dindo Classification + Post-Operative DVT [2025]

Part A: Clavien-Dindo Classification

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Part B: DVT of Lower Limbs - Prevention and Diagnosis

Virchow's Triad:

1. Venous stasis - immobility, anaesthesia, prolonged lithotomy position
2. Endothelial damage - surgical trauma, retractors, tourniquet
3. Hypercoagulability - post-surgical state, malignancy, OCP, thrombophilia

Prevention:

• TED stockings - from admission to full mobilisation
• IPC (pneumatic compression) - intraoperatively + early post-op; especially when pharmacological prophylaxis contraindicated
• Early mobilisation - most effective single measure; Day 1 post-op

• LMWH (Enoxaparin 40 mg SC OD) - start 12 hours post-op; continue until mobile (minimum 7-10 days)
• Extended prophylaxis 28 days after major colorectal cancer surgery (NICE)
• UFH (5000 units SC BD/TDS) - in severe renal impairment (eGFR <30)
• Stop oestrogen-containing OCP 4 weeks before major elective surgery

Diagnosis:

Treatment:

• Therapeutic LMWH initially → DOAC (rivaroxaban) or warfarin (INR 2-3)
• Duration: 3 months (post-surgical/provoked); 6 months (unprovoked); 6-12 months (cancer)
• Compression stockings ×2 years (prevents post-thrombotic syndrome)

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Q19. Nutritional Assessment + Enteral Nutrition [2015]

Part A: Nutritional Assessment

• BMI score + weight loss score + acute disease effect score
• Score 0 = low risk; 1 = medium; ≥2 = high risk → refer dietitian

Part B: Artificial Nutritional Support

• Enteral: Oral supplements | NG tube | NJ tube | PEG | Jejunostomy (always preferred if gut functional)
• Parenteral: Peripheral PN (short-term) | TPN via central venous catheter (gut non-functional)

Part C: Enteral Nutrition

1. Preserves gut mucosal barrier; prevents bacterial translocation
2. Maintains gut immunity (GALT, secretory IgA)
3. Prevents gut atrophy
4. Lower infection rate (no catheter-related sepsis)
5. Better wound healing; shorter hospital stay
6. Physiological; cheaper; fewer metabolic complications
7. Prevents stress ulceration
8. Early EN (within 24-48h) reduces organ failure and infectious complications

• Tube: Malposition (NG in bronchus - fatal); blockage; PEG site infection
• GI: Diarrhoea (>30%); aspiration pneumonia (most serious - prevent with 30-45° head elevation); bloating; vomiting
• Metabolic: Refeeding syndrome (most dangerous) - rapid feeding in malnourished → insulin surge → massive cellular uptake of phosphate/K/Mg → hypophosphataemia → arrhythmia, cardiac/respiratory failure, seizures. Manage: start at max 10 kcal/kg/day; increase slowly over 4-7 days; supplement thiamine + vitamin B + electrolytes

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Q20. Pre-Operative Nutritional Assessment and Optimisation [2025]

High-Risk Groups:

Screening Tools:

Pre-Operative Biochemistry:

Optimisation Strategies:

• First-line; 200 kcal/200 mL carton ×2-3 daily
• Minimum 7-10 days preoperatively; 2-4 weeks for major surgery

• Arginine + omega-3 fatty acids + glutamine + nucleotides
• 5-7 days preoperatively in malnourished patients undergoing major GI/oncological surgery
• Reduces infectious complications and length of stay

• If ONS insufficient; NG/NJ feeding for 10-14 days
• Severe malnutrition (albumin <20 g/L): delay surgery; feed aggressively

• Clear carbohydrate drinks (Nutricia PreOp): 800 mL evening before + 400 mL up to 2 hours before surgery
• Reduces insulin resistance; reduces PONV; attenuates catabolic response

• NRS-2002 ≥5 or albumin <30 g/L → delay 7-14 days and feed aggressively

Updated Fasting Guidelines (ERAS):

• Solids: 6 hours | Clear fluids/carbohydrate drinks: 2 hours before surgery
• Traditional "nil from midnight" is obsolete

Intraoperative Planning:

Multidisciplinary Team:

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Reference: All answers from Bailey and Love's Short Practice of Surgery, 28th Edition - Chapters 5, 6, 7, 15, 21, 25.

Exam Tip: Each answer above is structured for 15-minute writing. Use the bold headings as memory cues, the tables for structured marks, and lead with a 1-line definition or introduction to signal clarity to the examiner.