General Surgery

The abdomen, and everything that presents through it.

• General surgery owns the acute abdomen: appendicitis, gallstones, obstruction, hernias and perforation, the diseases that arrive through the emergency department at 3 a.m.
• The specialty's core skill is the theatre decision: who needs an operation, who needs a scan, and who needs resuscitation before either.
• Two shared ideas run through most of its operations: the acute abdomen method, and what it takes for a bowel anastomosis to heal. Learn both once and the individual operations organise themselves.
• The rhythm is take, list, ward: overnight referrals become a morning operating list, and the afternoons belong to the post-operative abdomen and its trends.

X-ray

What should I notice?

• Right lower quadrant pain

  “The ED calls: 22-year-old, periumbilical pain now settled in the right iliac fossa, off food, low-grade fever.”

  • The migration story is the diagnosis: visceral T10 pain at the umbilicus, then parietal pain where the appendix actually lies.
  • Who needs imaging and who does not: a classic story in a young man may go to theatre on the story alone; ultrasound first in the young woman.
  • The differential fans out by demographics: ovarian pathology, mesenteric adenitis, Crohn's, caecal tumours at the other end of life.

  Live it as a case Open appendectomy

• Right upper quadrant pain

  “Fatty-food pain for months, now constant for 18 hours with a positive Murphy's sign and a white count of 14.”

  • Place the patient on the gallstone spectrum: colic (pain alone), cholecystitis (pain plus inflammation), cholangitis (pain plus sepsis plus jaundice).
  • Ultrasound answers the gallbladder; the liver panel asks whether a stone has reached the common duct.
  • Timing is the modern question: index-admission cholecystectomy beats sending an inflamed gallbladder home to wait.

  Live it as a case Laparoscopic cholecystectomy

• Distension, vomiting, absolute constipation

  “Colicky central pain, a tympanitic abdomen, and a virgin abdomen is nowhere to be seen: two previous laparotomies.”

  • Adhesions, hernia, malignancy: the causes in order, and the groins examined before any scan is booked.
  • Drip and suck is a treatment with a timer: nasogastric decompression and fluids, with reassessment scheduled, not hoped for.
  • The signs that end the trial: peritonism, rising lactate, fever, or a CT showing a closed loop. Strangulation does not wait.

  Live it as a case Small bowel resection & anastomosisEmergency laparotomy

• The groin lump

  “A lump above and medial to the pubic tubercle, there for months, now suddenly tender and irreducible.”

  • Reducible and comfortable is a clinic conversation about elective repair; tender and irreducible is an emergency.
  • Irreducible, obstructed, strangulated: three words in escalating order, and the examination that separates them.
  • The femoral hernia rule: smaller, more medial-looking, more often in women, and far more likely to strangulate, so it is always repaired.

  Live it as a case Open inguinal hernia repair (Lichtenstein)

• Haematemesis and melaena

  “Coffee-ground vomiting overnight, now fresh blood, melaena on the glove, and a heart rate that outruns the blood pressure.”

  • Resuscitate before you diagnose: two large cannulas, blood products by ratio, and the massive transfusion protocol has a threshold, not a mood.
  • Endoscopy is both the diagnosis and usually the treatment; surgery is the plan for the bleed endoscopy cannot hold.
  • The duodenal ulcer that bleeds posteriorly has eroded the gastroduodenal artery: anatomy that explains both the torrent and the operation.

  Live it as a case