Surgical conditions for MRCS Part A

What the paper tends to test

• Questions typically ask for the single most appropriate investigation or first step in a common presentation — a breast lump, a groin lump, a change in bowel habit, a painful swollen leg, haematuria, a thyroid nodule.
• Expect hernia questions in Paper 2 to shift from anatomy to management: which hernia needs prompt repair, what an irreducible or strangulated hernia looks like, and how a femoral hernia is approached.
• Vascular questions test the ankle–brachial pressure index, the classification of limb ischaemia, when an aneurysm is repaired and the management of acute limb ischaemia and venous thromboembolism.
• Orthopaedic questions ask you to recognise septic arthritis, osteomyelitis, a primary bone tumour, cauda equina syndrome and the paediatric hip conditions by age.
• Breast questions follow triple assessment and the referral pathway for a symptomatic patient, and ask which benign condition needs no further treatment.
• Endocrine and head and neck lines test the work-up of a thyroid nodule, a parathyroid adenoma, an adrenal mass and a neck lump, and the red flags of head and neck cancer.
• Cancer questions test the principles of adjuvant and neoadjuvant therapy, performance status, and the management of the common palliative symptoms.

Classic traps and discriminators

• Cauda equina syndrome — bilateral sciatica, saddle anaesthesia, urinary retention or incontinence and reduced anal tone — needs an urgent MRI the same day and decompression; waiting for the picture to become complete is the wrong answer.
• Femoral hernias are commoner in women than in men, but the inguinal hernia is still the commonest groin hernia in women. A femoral hernia strangulates readily through the narrow femoral ring and is repaired promptly, electively or as an emergency, rather than watched.
• In septic arthritis the joint is held still and any passive movement is painful; the joint is aspirated before antibiotics where possible and washed out in theatre, and Staphylococcus aureus is the commonest organism at every age beyond the neonatal period.
• An ABPI below 0.9 indicates peripheral arterial disease and below about 0.5 critical limb ischaemia, but a value above 1.3 in a diabetic or elderly patient reflects calcified, incompressible vessels and is not reassuring — use toe pressures or the Doppler waveform instead.
• Thyroid nodules are assessed by ultrasound (U1–U5) and fine-needle aspiration cytology (Thy1–Thy5); cytology cannot distinguish a follicular adenoma from a follicular carcinoma, because the diagnosis depends on capsular and vascular invasion, which is why a Thy3f result leads to diagnostic hemithyroidectomy.
• A child with a limp and hip pain: transient synovitis is the commonest cause between 3 and 8 years but septic arthritis must be excluded (fever, refusal to weight-bear, raised inflammatory markers and white cell count); Perthes’ disease presents at about 4–8 years and slipped capital femoral epiphysis in the overweight adolescent of 10–15.

Interactive 3D: Inguinal canal & hernia anatomy

Drag to rotate, tap the hotspots, press play.

Also in this domain: Calot's triangle & the biliary tree (coming soon), Circle of Willis (coming soon), Axilla & breast lymphatics (coming soon)

Free revision notes

Surgical conditions questions, answered