Surgery Revision Guide ✅

🔪 Surgery is anatomy plus physiology under time pressure. Start with: is the patient unstable?, is there sepsis, bleeding, ischaemia, obstruction or perforation?, and does this need theatre, radiology, ICU or conservative treatment? For exams and clinical work, the surgical mindset is simple: resuscitate first, diagnose in parallel, control the source, and reassess repeatedly.

✅ 1. Core Surgical Principles

🚨 1.1 ABCDE First

• A — Airway: obstruction, aspiration risk, cervical spine protection in trauma.
• B — Breathing: oxygenation, pneumothorax, haemothorax, flail chest, aspiration, sepsis-related respiratory failure.
• C — Circulation: haemorrhage, sepsis, dehydration, third-spacing, arrhythmia, shock.
• D — Disability: GCS/AVPU, pupils, glucose, pain, delirium, head injury.
• E — Exposure: abdomen, wounds, hernias, groins, back, perineum, temperature, safeguarding signs.

🧠 Exam pearl: In surgery, a CT scan is not a resuscitation tool. If the patient is unstable, manage ABCDE, call senior help and consider immediate source control rather than sending an unsafe patient to imaging.

🧪 1.2 Core Surgical Investigations

• FBC: anaemia, infection, platelets.
• U&E: dehydration, AKI, obstruction, vomiting-related electrolyte disturbance.
• LFTs: biliary obstruction, hepatitis, sepsis, liver injury.
• CRP: inflammation/infection trend, but can lag early.
• Coagulation: bleeding, liver disease, anticoagulation, theatre planning.
• Group and save/crossmatch: bleeding, trauma, ectopic, ruptured AAA, major surgery.
• VBG/ABG with lactate: shock, sepsis, ischaemia, respiratory failure.
• Urinalysis and pregnancy test where relevant.
• Imaging: X-ray, ultrasound, CT, MRI or interventional radiology depending on diagnosis and stability.

🧯 1.3 Source Control

• Drain pus: abscess, empyema, infected collections.
• Remove dead tissue: necrotising fasciitis, bowel necrosis, debridement.
• Stop bleeding: pressure, surgery, endoscopy, interventional radiology.
• Relieve obstruction: NG tube, catheter, stent, surgery, decompression.
• Repair perforation: bowel perforation, perforated ulcer, traumatic injury.

🚨 Safety pearl: Antibiotics help sepsis, but they do not replace source control. A perforated bowel, infected obstructed kidney or necrotising fasciitis needs mechanical control of the problem.

🧰 2. Perioperative Care

🩺 2.1 Pre-operative Assessment

• Clarify indication, urgency, expected benefit and alternatives.
• Assess comorbidities: cardiorespiratory disease, diabetes, CKD, anticoagulation, frailty, cognition, nutrition.
• Review medications: anticoagulants, antiplatelets, steroids, diabetic drugs, ACEi/ARB, SGLT2 inhibitors, immunosuppressants.
• Check allergies, airway risk, previous anaesthetic issues, VTE risk and infection risk.
• Optimise: fluids, electrolytes, anaemia, sepsis, glucose, pain, nutrition and consent.
• In emergency surgery, optimise what is possible without dangerous delay.

📝 2.2 Consent

• Explain diagnosis, uncertainty, treatment options and no-treatment option.
• Discuss material risks: those a reasonable person in the patient’s position would consider significant.
• Cover common and serious risks, including bleeding, infection, pain, scarring, VTE, organ injury, conversion to open surgery, stoma and death where relevant.
• Assess capacity and support shared decision-making.
• Document discussion clearly, including patient priorities and questions.

🛡️ 2.3 Post-operative Care

• ABCDE assessment for any deteriorating post-op patient.
• Common problems: bleeding, sepsis, atelectasis, pneumonia, PE, MI, AKI, ileus, urinary retention, delirium and pain.
• Monitor observations, urine output, drain output, wound, pain, bowels, glucose and bloods.
• Encourage mobilisation, VTE prophylaxis, breathing exercises and early nutrition where appropriate.
• Escalate early if tachycardia, hypotension, fever, rising lactate, oliguria, worsening pain or confusion.

🍽️ 3. Acute Abdomen

🔍 3.1 Surgical Abdominal Pain Approach

• Site: RUQ, epigastric, RIF, LIF, loin, suprapubic, generalised.
• Onset: sudden, gradual, colicky, constant, migrating.
• Associated symptoms: vomiting, distension, constipation, diarrhoea, bleeding, urinary symptoms, fever, jaundice.
• Peritonism: guarding, rebound, percussion tenderness, pain on movement.
• Shock or sepsis changes priority: resuscitate and call senior help.
• Pregnancy test in reproductive-age patients with abdominal pain.

📍 3.2 Pain Location Differentials

🧠 Exam pearl: Pain that becomes generalised with guarding suggests local inflammation has progressed to peritonitis. That is a surgical escalation point.

🪱 4. Appendicitis and Right Iliac Fossa Pain

• Appendicitis classically starts with vague periumbilical pain that migrates to the right iliac fossa.
• Associated features: anorexia, nausea, vomiting, low-grade fever and localised tenderness.
• Signs: McBurney point tenderness, guarding, rebound, Rovsing sign, psoas sign, obturator sign.
• Children, older adults and pregnancy can present atypically.
• Differentials: gastroenteritis, mesenteric adenitis, Crohn’s, Meckel’s diverticulitis, ovarian torsion/cyst, ectopic pregnancy, UTI, renal colic.
• Investigations: FBC, CRP, urine dip, pregnancy test, imaging depending on age/sex/local pathway.
• Management: analgesia, fluids, antibiotics if indicated, appendicectomy or conservative pathway depending on case and local policy.

⚠️ Clinical pearl: Vomiting before pain makes appendicitis less likely; pain before vomiting is more typical. But do not rely on one feature alone.

🪨 5. Gallstones and Biliary Surgery

NICE CG188 covers diagnosis and management of gallstone disease in adults, including gallbladder and common bile duct stones.

🪨 5.1 Biliary Colic

• Intermittent RUQ/epigastric pain, often after fatty meals, caused by transient cystic duct obstruction.
• Pain may radiate to right shoulder/scapula.
• Usually no fever or marked inflammatory response.
• Ultrasound shows gallstones; LFTs may be normal unless duct obstruction.
• Definitive management is usually elective laparoscopic cholecystectomy if symptomatic.

🔥 5.2 Acute Cholecystitis

• Persistent RUQ pain, fever, raised inflammatory markers and Murphy sign.
• Usually due to gallstone impaction in cystic duct.
• Management: analgesia, antibiotics, IV fluids, early laparoscopic cholecystectomy where suitable.
• High-risk patients may need gallbladder drainage.

🟡 5.3 Choledocholithiasis and Cholangitis

• Common bile duct stones can cause jaundice, cholestatic LFTs, pancreatitis or cholangitis.
• Cholangitis: fever, jaundice and RUQ pain; severe cases cause hypotension/confusion.
• Management: resuscitation, blood cultures, antibiotics and urgent biliary decompression, commonly ERCP.
• MRCP or EUS may be used to assess duct stones in stable patients.

🔥 5.4 Acute Pancreatitis

• Common causes: gallstones and alcohol.
• Features: severe epigastric pain radiating to back, vomiting, raised lipase/amylase.
• Management: fluids, analgesia, antiemetics, oxygen if needed, nutrition, severity assessment and treat cause.
• Complications: necrosis, pseudocyst, infected collections, ARDS, AKI, shock.
• Gallstone pancreatitis may need ERCP if cholangitis or persistent obstruction.

🚧 6. Bowel Obstruction and Ileus

🚧 6.1 Small Bowel Obstruction

• Features: colicky abdominal pain, vomiting, distension and constipation/obstipation.
• Common causes: adhesions, hernia, Crohn’s disease, tumour, volvulus.
• High obstruction causes early vomiting; distal obstruction causes more distension.
• Examine hernial orifices carefully.
• Initial management: nil by mouth, IV fluids, NG tube if vomiting/distended, analgesia, antiemetics, catheter/urine monitoring, CT to define cause and complications.
• Red flags for strangulation/ischaemia: fever, tachycardia, peritonism, continuous pain, raised lactate, metabolic acidosis.

🚧 6.2 Large Bowel Obstruction

• Features: abdominal distension, absolute constipation, pain, later vomiting.
• Common causes: colorectal cancer, volvulus, diverticular stricture.
• Caecal diameter matters because risk of perforation increases with marked distension.
• Management depends on cause: resuscitation, CT, decompression/stenting/surgery.

🌀 6.3 Volvulus

• Sigmoid volvulus: older/frail or neuropsychiatric patients, massive distension, “coffee bean” sign.
• Caecal volvulus: younger than sigmoid group, congenital mobility, obstruction.
• Sigmoid volvulus may be managed with endoscopic decompression if no peritonitis/ischaemia, followed by definitive planning.
• Peritonitis, perforation or ischaemia needs surgery.

🛌 6.4 Ileus

• Functional bowel paralysis without mechanical obstruction.
• Causes: post-op state, opioids, electrolyte disturbance, sepsis, inflammation, retroperitoneal pathology.
• Management: treat cause, reduce opioids, correct electrolytes, mobilise, NG tube if significant vomiting/distension.

🧱 7. Colorectal Surgery

🔥 7.1 Diverticulitis

• Inflammation/infection of diverticula, usually left-sided in Western populations.
• Features: left iliac fossa pain, fever, altered bowel habit, raised inflammatory markers.
• Complications: abscess, perforation, fistula, obstruction, stricture, bleeding.
• CT abdomen/pelvis helps confirm diagnosis and detect complications.
• Management ranges from oral antibiotics/observation to IV antibiotics, drainage or surgery depending on severity.

🎗️ 7.2 Colorectal Cancer

• Symptoms: change in bowel habit, rectal bleeding, iron deficiency anaemia, weight loss, abdominal pain, obstruction.
• Right-sided cancers often present with anaemia and occult bleeding.
• Left-sided cancers often present with altered bowel habit, visible bleeding or obstruction.
• Investigations: FIT in symptomatic pathways, colonoscopy with biopsy, CT staging, MRI rectum for rectal cancer.
• Management: surgery, chemotherapy, radiotherapy and stoma planning depending on site/stage.

🩸 7.3 Lower GI Bleeding

• Causes: diverticular bleeding, angiodysplasia, haemorrhoids, colorectal cancer, IBD, ischaemic colitis.
• Assess haemodynamic stability; massive fresh rectal bleeding can be from upper GI source.
• Investigations: FBC, clotting, group/crossmatch, CT angiography if active significant bleeding, endoscopy when appropriate.

🩹 7.4 Perianal Disease

• Haemorrhoids: painless bright red bleeding, itching, prolapse.
• Anal fissure: severe pain on defecation with bright bleeding; posterior midline common.
• Perianal abscess: painful swelling, fever; needs incision and drainage.
• Fistula-in-ano: chronic discharge/opening, often after abscess; consider Crohn’s disease if complex/recurrent.

🩸 8. Upper GI Surgery

🔥 8.1 Peptic Ulcer Complications

• Bleeding: haematemesis, melaena, anaemia, shock.
• Perforation: sudden severe epigastric pain, rigid abdomen, free air under diaphragm.
• Gastric outlet obstruction: vomiting, early satiety, weight loss, succussion splash.
• Management of perforation: resuscitation, antibiotics, PPI, urgent surgery or selected conservative approach in very specific cases.

🎗️ 8.2 Oesophagogastric Cancer

• Oesophageal cancer: progressive dysphagia, weight loss, regurgitation, hoarseness.
• Gastric cancer: weight loss, early satiety, dyspepsia, anaemia, vomiting.
• Risk factors: smoking, alcohol, Barrett’s oesophagus, obesity, H. pylori, atrophic gastritis, family history.
• Diagnosis: endoscopy with biopsy; staging with CT/PET/EUS/laparoscopy depending on tumour.
• Management: surgery, chemotherapy, radiotherapy, stenting or palliative care depending on stage/fitness.

🚑 8.3 Acute Mesenteric Ischaemia

• Classically causes severe pain out of proportion to examination early.
• Risk factors: AF, atherosclerosis, low-flow states, vasoconstrictors, thrombophilia.
• Late signs: peritonitis, bloody diarrhoea, shock, high lactate.
• Requires urgent CT angiography, resuscitation, broad-spectrum antibiotics and vascular/general surgical input.

🚨 Exam pearl: Pain out of proportion in the abdomen is mesenteric ischaemia until proven otherwise, especially in AF or vascular disease.

🧱 9. Hernias

• Hernia = protrusion of tissue through a defect in the containing wall.
• Reducible: contents can be returned.
• Incarcerated/irreducible: cannot be reduced.
• Obstructed: bowel lumen blocked within hernia.
• Strangulated: blood supply compromised — surgical emergency.

🚨 Safety pearl: A painful irreducible hernia with vomiting, fever, skin changes or systemic illness is strangulated until proven otherwise — urgent surgery review.

🩹 10. Skin, Soft Tissue and Breast Surgery

🦠 10.1 Abscess and Cellulitis

• Abscess: collection of pus; fluctuant, tender, localised swelling.
• Definitive treatment is incision and drainage when mature/appropriate.
• Antibiotics alone often fail if pus is not drained.
• Cellulitis: spreading skin infection; manage with antibiotics and treat portal of entry.
• Necrotising fasciitis: pain out of proportion, rapid progression, systemic toxicity, bullae/necrosis/crepitus; urgent debridement.

🎗️ 10.2 Breast Lump

• Triple assessment: clinical examination, imaging and tissue diagnosis.
• Benign causes: fibroadenoma, cyst, fat necrosis, abscess, mastitis.
• Malignancy red flags: hard irregular fixed lump, skin tethering, nipple inversion, blood-stained discharge, peau d’orange, axillary nodes.
• Inflammatory breast cancer can mimic mastitis but does not settle with antibiotics.

🍼 10.3 Mastitis and Breast Abscess

• Mastitis: painful red breast, fever, flu-like symptoms; common in breastfeeding.
• Continue milk removal if breastfeeding unless advised otherwise.
• Abscess: focal fluctuant mass or persistent symptoms despite antibiotics; ultrasound and drainage may be needed.

🧯 11. Vascular Surgery

🩸 11.1 Acute Limb Ischaemia

• Six Ps: pain, pallor, pulselessness, paraesthesia, paralysis, perishingly cold.
• Causes: embolus from AF, thrombosis on atherosclerotic disease, graft occlusion, trauma.
• Paralysis and anaesthesia indicate threatened limb and need immediate action.
• Management: urgent vascular referral, analgesia, IV heparin if not contraindicated, imaging/revascularisation depending on limb viability.

💥 11.2 Abdominal Aortic Aneurysm

• Risk factors: age, male sex, smoking, hypertension, family history.
• Rupture: abdominal/back pain, hypotension/collapse, pulsatile mass — classic triad often incomplete.
• Do not delay vascular surgery referral for imaging in unstable suspected rupture.
• Stable patients usually need CT angiography for planning.

🦵 11.3 Peripheral Arterial Disease

• Intermittent claudication: reproducible exertional muscle pain relieved by rest.
• Critical limb-threatening ischaemia: rest pain, tissue loss, gangrene or non-healing ulcer.
• Management: smoking cessation, antiplatelet/statin, exercise therapy, diabetes/BP control, revascularisation if severe.

🩸 11.4 Varicose Veins and Venous Disease

• Venous insufficiency causes aching, heaviness, oedema, eczema, pigmentation and ulcers.
• Venous ulcers usually occur around the gaiter area and need compression if arterial supply adequate.
• Check ABPI before compression therapy.

🚑 12. Trauma: Major Trauma and ATLS Principles

NICE NG39 covers rapid identification and early management of major trauma in pre-hospital and hospital settings, with the aim of reducing death and disability from serious injury.

🚨 12.1 Trauma Primary Survey

• C-spine: protect cervical spine when mechanism/risk suggests injury.
• Airway: obstruction, facial trauma, blood/vomit, GCS impairment.
• Breathing: tension pneumothorax, open pneumothorax, massive haemothorax, flail chest.
• Circulation: haemorrhage control, pelvic binder, tourniquet/pressure, IV/IO access, major haemorrhage protocol.
• Disability: GCS, pupils, glucose, limb movement.
• Exposure: fully examine front/back while preventing hypothermia.

🩸 12.2 Haemorrhagic Shock

• In trauma, shock is haemorrhage until proven otherwise.
• Bleeding sites: chest, abdomen, pelvis, long bones, external bleeding and floor.
• Management: direct pressure/tourniquet, pelvic binder, blood products, tranexamic acid if within appropriate timeframe, warming and rapid source control.
• Avoid excessive crystalloid causing dilutional coagulopathy and hypothermia.
• Use balanced transfusion guided by major haemorrhage protocol.

🫁 12.3 Life-Threatening Chest Injuries

🦴 12.4 Pelvic and Long Bone Trauma

• Pelvic fractures can cause massive occult haemorrhage.
• Apply pelvic binder early if pelvic injury suspected in unstable trauma.
• Femoral shaft fractures can bleed significantly into thigh.
• Open fractures require antibiotics, tetanus assessment, sterile dressing, splintage and urgent orthopaedics.

🧊 12.5 Trauma Triad of Death

• Hypothermia, acidosis and coagulopathy worsen each other.
• Prevention: warming, haemorrhage control, balanced transfusion, avoid excess crystalloid, correct calcium and clotting abnormalities.

🚨 Exam pearl: The “floor” is a hidden bleeding site — a trauma patient can lose their circulating volume externally before arrival.

🧠 13. Neurosurgery and Head Injury

NICE NG232 covers assessment and early management of head injury in babies, children, young people and adults, including when urgent imaging or specialist referral is needed.

🧠 13.1 Head Injury Assessment

• Record mechanism, loss of consciousness, amnesia, vomiting, seizure, anticoagulants/antiplatelets, alcohol/drugs and safeguarding concerns.
• Assess GCS with components, pupils, focal neurology, skull signs and cervical spine risk.
• Check glucose if reduced consciousness.
• Repeated observations matter because deterioration can occur after an initially lucid period.
• Escalate for falling GCS, unequal pupils, new focal deficit, repeated vomiting, seizure or signs of skull fracture.

🩸 13.2 Extradural, Subdural and Subarachnoid Blood

🧠 13.3 Raised Intracranial Pressure

• Features: headache, vomiting, papilloedema, reduced consciousness, sixth nerve palsy.
• Cushing response: hypertension, bradycardia and irregular breathing — late sign.
• Management principles: airway/oxygenation, avoid hypotension, head elevation, treat seizures/fever, urgent imaging and neurosurgical input.
• Hyperosmolar therapy or decompression may be needed in specialist settings.

🧠 13.4 Concussion

• Mild traumatic brain injury with transient neurological dysfunction.
• Symptoms: headache, dizziness, nausea, fatigue, poor concentration, memory problems, sleep disturbance, mood change.
• Give clear return precautions and graduated return to work/sport/school.
• Second impact before recovery can be dangerous; avoid contact sport until medically cleared.

🚨 Safety pearl: A falling GCS after head injury is an emergency. Protect airway, prevent hypoxia/hypotension and involve neurosurgery/trauma team early.

🧠 14. Spine, Cauda Equina and Neurosurgical Infection

🚨 14.1 Cauda Equina Syndrome

• Compression of lumbosacral nerve roots causing bladder, bowel, sexual and saddle sensory dysfunction.
• Red flags: urinary retention, reduced urinary sensation, saddle anaesthesia, faecal incontinence, bilateral sciatica, progressive weakness.
• Requires emergency MRI and spinal surgical referral.
• Do not reassure based only on normal anal tone; symptoms and bladder function matter.

🧱 14.2 Spinal Cord Compression

• Causes: metastatic cancer, epidural abscess, trauma, disc prolapse, haematoma.
• Features: back pain, limb weakness, sensory level, hyperreflexia, bladder/bowel dysfunction.
• Malignant cord compression often causes night/rest pain and progressive neurology.
• Urgent MRI whole spine and specialist input are needed.

🦠 14.3 Brain Abscess and Subdural Empyema

• Can arise from sinusitis, otitis media, dental infection, endocarditis, neurosurgery or immunosuppression.
• Features: headache, fever, focal neurology, seizure, raised ICP.
• Management: urgent imaging, blood cultures, IV antibiotics and neurosurgical drainage depending on size/site.

💧 14.4 Hydrocephalus and Shunts

• Hydrocephalus causes ventriculomegaly from CSF flow/absorption problem.
• Features: headache, vomiting, papilloedema, reduced consciousness; infants may have increasing head circumference/bulging fontanelle.
• VP shunt complications: blockage, infection, over-drainage.
• Shunt malfunction can deteriorate rapidly and needs urgent neurosurgical review.

🧪 15. Surgical Sepsis and Antibiotics

• Surgical sepsis often needs source control: drain, debride, resect, decompress or repair.
• Sepsis signs: fever/hypothermia, tachycardia, tachypnoea, hypotension, confusion, oliguria, raised lactate.
• Take cultures if this does not delay antibiotics.
• Use antibiotics according to local policy and likely source: biliary, bowel, urinary, skin/soft tissue, chest, line.
• Reassess after antibiotics: if still deteriorating, ask “where is the undrained pus or uncontrolled source?”

🚨 16. Surgical Emergencies

📚 17. OSCE / Exam Pearls

• Always assess ABCDE before narrowing the diagnosis.
• Pregnancy test is essential in reproductive-age abdominal pain.
• Pain out of proportion suggests ischaemia or necrotising infection.
• Vomiting + distension + absolute constipation suggests bowel obstruction.
• Peritonism means urgent surgical review.
• Never forget hernial orifices in bowel obstruction.
• In trauma, shock is haemorrhage until proven otherwise.
• A falling GCS after head injury is a neurosurgical emergency.
• Bilateral sciatica plus bladder/saddle symptoms is cauda equina until proven otherwise.
• Antibiotics do not replace source control.

📌 18. Quick Differentials Table

📚 References

• NICE. Major trauma: assessment and initial management. NG39.
• NICE. Head injury: assessment and early management. NG232.
• NICE. Gallstone disease: diagnosis and management. CG188.
• NICE Clinical Knowledge Summary. Acute abdominal pain assessment.
• Royal College of Surgeons guidance should be checked for emergency general surgery standards and local surgical pathways.
• Local trauma network, neurosurgical, vascular, antimicrobial, major haemorrhage and perioperative policies should always be followed.

⚠️ Disclaimer

This article is for medical education and exam revision. Clinical decisions should follow current local surgical, trauma, neurosurgical, vascular, antimicrobial, radiology, perioperative and major haemorrhage protocols, senior advice, NICE guidance and specialist network pathways. Surgical emergencies such as ruptured AAA, perforation, mesenteric ischaemia, strangulated hernia, necrotising fasciitis, major trauma, head injury deterioration and cauda equina syndrome require urgent senior input.