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SECTION A: NUTRITION

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Q1. Fluid Therapy in Burns (2014)

Pathophysiology of Fluid Loss

Estimation of Burn Area

• Head & neck: 9%; each upper limb: 9%; anterior trunk: 18%; posterior trunk: 18%; each lower limb: 18%; perineum: 1%
• For children: Lund and Browder chart (head proportionally larger)

Fluid Resuscitation Formulas

4 mL x weight (kg) x % TBSA burned = total fluid in 24 hours (Ringer's Lactate)

• Half given in first 8 hours from time of injury
• Remaining half over next 16 hours

0.5 mL x weight (kg) x % TBSA - given in 6 time periods (4h, 4h, 4h, 6h, 6h, 12h)

Fluid of Choice

• Ringer's Lactate - first 24 hours (crystalloid preferred)
• After 24 hours: colloids (albumin, FFP) + 5% dextrose added once capillary integrity partially restored
• Early colloid is controversial (leaky membrane in first 8-12h may worsen oedema)

Monitoring

• Urine output: 0.5-1 mL/kg/hr adults; 1 mL/kg/hr children
• CVP, BP, pulse, haematocrit, serum electrolytes

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Q2 & Q3. Parenteral Nutrition / TPN (2018, 2020)

Definition

Indications (Pye's Surgical Handicraft, Table 3.2)

Composition of TPN (Pye's Surgical Handicraft)

• 8.5% amino acids as nitrogen source
• 40 kcal/kg/day calories as:
  • 50% from 20% lipid (Intralipid)
  • 50% from 50% dextrose
• Additives: Na, K, Mg, Zn, Cl, phosphate, acetate, trace metals, vitamins

Routes of Administration

• Central venous catheter (CVC) - preferred; tip in SVC; allows hypertonic solutions (>900 mOsm/L)
• PICC line
• Peripheral TPN - only with isotonic solutions, short-term (<2 weeks)

Daily Requirements

Complications of TPN (Bailey & Love 28th Ed., Schwartz 11th Ed.)

• Hyperglycaemia (most common metabolic complication)
• Refeeding syndrome (hypophosphataemia, hypokalaemia, hypomagnesaemia)
• Electrolyte imbalances

• TPN-associated liver disease (cholestasis, fatty change, cirrhosis long-term)
• Gut mucosal atrophy and bacterial translocation
• Acalculous cholecystitis (bile stasis)

Monitoring

• Blood glucose q4-6h; daily electrolytes/urea/creatinine; twice weekly LFTs, albumin, TG, FBC

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Q4. Enteral Nutrition (10 marks, 2019)

Definition

Advantages over TPN

• Maintains gut mucosal integrity; prevents atrophy and bacterial translocation
• Stimulates intestinal motility; preserves GALT immune function
• Cheaper and safer; prevents acalculous cholecystitis

Routes (Pye's Surgical Handicraft)

1. Nasogastric tube (NGT) - fine-bore silicone rubber No. 7 gauge; most common
2. Nasojejunal tube - bypasses stomach; useful in gastroparesis
3. PEG (Percutaneous Endoscopic Gastrostomy) - long-term; placed endoscopically
4. Needle Catheter Jejunostomy (NCJ) - placed at laparotomy; 10 cm submucosal tunnel 30 cm from DJ flexure; for proximal obstruction/fistula/fragile anastomosis

Administration Tips (Pye's)

• Start at 1/4 to 1/2 strength to prevent cramps/diarrhoea
• Deliver via infusion pump (smoother delivery, fewer blockages)
• Confirm NGT position by X-ray before starting
• Correct severe hypoalbuminaemia first (100-200 mL 25% albumin parenterally) - hypoalbuminaemia impairs gastric emptying
• Weigh daily; monitor electrolytes and albumin twice weekly

Complications

• Aspiration pneumonia (most serious)
• Diarrhoea, abdominal distension, tube blockage/displacement
• Refeeding syndrome

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Q5. Post-op Fluid Balance in NBM Patient

Daily Baseline Requirements

• Water: 30-35 mL/kg/day (~2-2.5 L/day)
• Sodium: 70-100 mmol/day; Potassium: 70-100 mmol/day
• Glucose: minimum 50-100 g/day (prevent ketosis and protein catabolism)

Standard IV Regimen (Holliday-Segar / "2+1")

• 1L 0.9% NaCl + 20 mmol KCl over 8h
• 1L 5% Dextrose + 20 mmol KCl over 8h
• 1L 5% Dextrose + 20 mmol KCl over 8h

Additional Considerations

• Fever: +200-400 mL per °C above 37°C
• Drain/NGT/fistula losses replaced volume-for-volume (NG aspirate with NaCl; small bowel loss with Ringer's Lactate)
• Third-space losses in major abdominal surgery: 2-4 mL/kg/hr

Monitoring

• Fluid balance chart, hourly urine output (target 0.5 mL/kg/hr)
• Daily weight (most reliable), clinical examination, twice-daily electrolytes

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Q6. Physiology of Nutrition, Nutritional Assessment & Nutritional Support

Physiology of Nutrition

• Carbohydrates: 4 kcal/g; glucose is obligatory fuel for brain/RBCs; glycogen stores last only 24h
• Proteins: structural, enzymatic, immune roles; nitrogen balance = N intake - N output
• Fats: 9 kcal/g; essential fatty acids (linoleic, linolenic) cannot be synthesised

• Ebb phase (hours): decreased metabolic rate, conservation
• Flow phase (days-weeks): hypermetabolism, catabolism, gluconeogenesis, lipolysis
• Mediators: cortisol, glucagon, catecholamines, IL-1, IL-6, TNF-alpha

Nutritional Assessment

Techniques of Nutritional Support

1. Oral supplementation (first choice)
2. Enteral nutrition (when oral impossible - always preferred over parenteral)
3. Parenteral nutrition (when gut cannot be used)

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Q7. Electrolyte Disturbances in Surgical Conditions & Correction

Hyponatraemia (Na+ <135 mmol/L)

Na deficit = 0.6 x weight x (target Na - actual Na)

Hypokalaemia (K+ <3.5 mmol/L)

Hyperkalaemia (K+ >5.5 mmol/L)

1. Calcium gluconate 10 mL 10% IV - membrane stabilisation (immediate)
2. Insulin + Dextrose - 10U insulin in 50 mL 50% dextrose (onset 30 min)
3. Sodium bicarbonate - alkalosis shifts K intracellularly
4. Salbutamol 10-20 mg nebulised
5. Calcium resonium - removes K from body
6. Haemodialysis - definitive for renal failure

Metabolic Alkalosis (Prolonged vomiting / pyloric obstruction)

Metabolic Acidosis (Renal failure, fistulas, diarrhoea, sepsis)

Hypophosphataemia (Refeeding Syndrome)

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SECTION B: LAPAROSCOPY

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Ergonomics in Laparoscopic Surgery (2024, 2025) - 20 marks

• Elbows at 90°, shoulders relaxed, feet shoulder-width apart
• Table height adjusted so elbows are at 90° and shoulders at 120°
• Surgeon stands behind the telescope (optimal ergonomic orientation)

• Left and right hand trocars at least 10 cm apart
• Telescope between the two trocars, slightly posterior
• Target organ, left hand trocar, right hand trocar, and telescope form a diamond shape
• This creates equilateral triangles for optimal triangulation

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Q1 & Q10. SELS / SILS - Definition, Indications, CIE, Advantages, Disadvantages, Methods, Difficulties, Instruments

Definition

Indications

Contraindications (CIE)

• Morbid obesity; extensive previous abdominal surgery; peritonitis; large tumours; surgeon inexperienced in SILS

Methods of Access (Schwartz)

1. Multiple separate trocars through single umbilical skin incision - uses conventional instruments; disadvantage: extraction difficulty
2. Specialised multilumen port (TriPort, SILS Port, GelPOINT) through umbilical ring - faster access, better seal, instrument triangulation via port design; disadvantage: cost

Advantages

1. Best cosmesis - scar hidden in umbilicus
2. Less post-operative pain
3. Faster recovery and return to work
4. Fewer wound complications
5. Natural extraction site

Disadvantages

1. Crowded port - no triangulation; crossed-hands technique
2. Camera axis in-line with instruments - poor visualisation
3. Instrument clashing (extracorporeal and intracorporeal)
4. Limited retraction
5. Very steep learning curve
6. Higher cost (specialised ports + articulating instruments)
7. Conversion rate: 0-24% (cholecystectomy), 0-41% (appendicectomy), 0-33% (nephrectomy)

Instruments (Schwartz Table 14-4)

Difficulties

• Crossed-instrument technique; solid organ retraction (spleen); specimen extraction; obesity/tall patients limiting reach

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Q3. Advantages and Drawbacks of Laparoscopic Surgery

Advantages

1. Smaller incisions - better cosmesis
2. Less post-op pain, reduced analgesics
3. Earlier mobilisation - lower DVT/PE risk
4. Shorter hospital stay, faster return to work
5. Fewer wound complications (infection, hernia)
6. Reduced adhesion formation
7. Less blood loss
8. Magnified view - better visualisation of structures
9. Reduced post-op ileus
10. Preserved immune function vs open surgery

Disadvantages / Drawbacks

• No haptic (tactile) feedback
• 2D visualisation (standard)
• Restricted range of motion (fulcrum effect)
• Longer operative time on learning curve
• Expensive equipment and instruments

• Raised intra-abdominal pressure → decreased venous return and cardiac output
• CO2 absorption → hypercarbia, respiratory acidosis → requires capnography
• Phrenic nerve irritation → shoulder tip pain post-op
• Trendelenburg position → decreased FRC, aspiration risk

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Q4. Minilaparoscopy

• Uses 2-3 mm instruments (vs standard 5-10 mm)
• Also called needlescopic surgery
• Advantages: even less pain, better cosmesis, possible under local anaesthesia
• Disadvantages: fragile instruments, limited force transmission, fewer instrument types available
• Applications: diagnostic laparoscopy, microlaparoscopic cholecystectomy, gynaecology

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Q5. 3D Laparoscopy

Advantages

1. Restored depth perception and binocular vision
2. Faster performance of complex tasks (suturing, anastomosis)
3. Fewer errors during learning curve
4. Better for teaching trainees

Disadvantages

1. Higher cost; bulkier camera head
2. Headaches/nausea from glasses (some surgeons)
3. Advantage diminishes with surgical experience (experienced surgeons compensate via monocular cues)

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Q6. Diagnostic Laparoscopy

Indications by Category

• Gastric, pancreatic, hepatobiliary cancer - detect peritoneal/liver surface metastases invisible on CT
• Biopsy suspicious lesions; assess resectability before planned curative surgery

• Assess response to chemotherapy
• Detect recurrence post-curative resection

• Biopsy peritoneal nodules; culture ascites
• Diagnose TB peritonitis (caseous nodules, "violin string" adhesions, "putty" omentum)
• Distinguish TB from malignancy

• Acute abdomen of uncertain cause
• Chronic pelvic pain; suspected appendicitis
• Ascites of unknown origin; trauma assessment

Technique

• GA; 10-12 mmHg CO2 pneumoperitoneum
• 30° telescope for systematic survey: liver surface, stomach, duodenum, small bowel, colon, pelvis, para-aortic nodes
• Biopsy via 5 mm port

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Q7. Establishment of a Fully Equipped Laparoscopy & Endoscopy Unit (10 marks, 2013)

Laparoscopy Equipment

• HD/4K camera system + CCD sensor; xenon/LED light source
• CO2 insufflator with pressure monitoring
• Recording/image capture system; multiple monitors
• Veress needle; trocars (5, 10, 12 mm); 0° and 30° telescopes
• Dissectors, graspers, scissors; monopolar + bipolar electrosurgery
• Clip applicators; endoscopic linear staplers; irrigation/suction; specimen bags
• SILS ports (for single-incision procedures)

Endoscopy Equipment

• Flexible gastroscope and colonoscope; ERCP duodenoscope
• Biopsy forceps, snares, injection needles
• Argon Plasma Coagulator (APC)
• Capsule endoscopy workstation/reader
• Sterile processing unit (high-level disinfection for scopes - glutaraldehyde or OPA)

Staff & Infrastructure

• Trained surgeon + endoscopist; dedicated scrub nurse; biomedical engineer
• Proper ventilation (CO2 scavenging); emergency laparotomy set available
• Crash trolley and anaesthesia support

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Q8. Therapeutic Upper GI Endoscopy

Haemostasis

• Injection therapy (adrenaline 1:10,000)
• Thermal coagulation (BICAP, heater probe)
• Haemoclipping; APC
• Variceal band ligation; sclerotherapy

Luminal Procedures

• Balloon dilation (oesophageal strictures)
• SEMS (self-expanding metal stents) for obstruction
• EMR (Endoscopic Mucosal Resection) and ESD (Endoscopic Submucosal Dissection)

Biliary (ERCP)

• Sphincterotomy; CBD stone extraction (Dormia basket); biliary stenting

Others

• PEG placement; polypectomy; foreign body removal; POEM for achalasia

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Q9. Capsule Endoscopy (2017)

Principle

Specifications

• Battery: 8-12 hours; 2-6 frames/second; 140° field of view

Indications

1. Obscure GI bleeding (most common) - after negative upper and lower endoscopy
2. Suspected Crohn's disease (small bowel)
3. Small bowel tumours/polyps
4. NSAID enteropathy; coeliac disease monitoring
5. FAP/Lynch syndrome small bowel surveillance

Advantages

• Non-invasive (no sedation, anaesthesia, insufflation)
• Complete small bowel visualisation
• Outpatient; comfortable for patient

Disadvantages

1. No biopsy or therapeutic capability
2. Retention risk in strictures (use patency capsule first)
3. Incomplete study if battery dies before caecum
4. Cannot control/reposition capsule
5. Cost; requires expert review (up to 50,000 images)

Contraindications

• Known/suspected stricture or obstruction; cardiac pacemaker (relative); severe dysphagia; pregnancy (relative)

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