The Major have spoken!

Thanks to Major (Dr.) Ngoo for his contribution. Gun-salute!

Question for Part II (Viva) Ms

Principles of surgery tables (i) and (ii)

1. Scenario: 70 years old man PR bleed came to you. Whilst assessing him, the patient developed torrential PR bleed. You are preparing to take him to OT for emergency total colectomy. Patient’s daughter came and asked about (a) her father’s prognosis, (b) whether you can guarantee that his father will recover.

2. You said no guarantee. So she said no need to go for OT because the patient is already old and unlikely to survive anyway. So what do YOU want to do now?

3. So you would still proceed with emergency surgery. But her daughter would not consent it. What next?

4. So you would get 2 consents from senior consultants for the patient. But your anaesthetist would not agree to consent. Furthermore, your anaesthetist is agreeable with the patient’s daughter, that is, no need surgery. What next?

5. Ok the patient survived and thanked you for saving him. Tell me the body’s physiology of this patient when he was losing blood per-rectally (Answer: discuss Baskett’s classification of shock…read Prof Mike Wyatt’s article in Surgery International published just before exams).

1. You are a senior consultant. Your elective OT has listed a 7 y/o boy for herniotomy, a 70 y/o Diabetic man for some surgery, and two other middle-aged ladies for operations too. Tell me the principles of organizing the OT list.

2. You said pre-operative work-up must be done. What is the concern here? (Answer: make it safe for surgery) and how do you address the concern? (Answer: tell all the characteristics of Safe Surgery initiative by WHO)

3. Now, how would you prepare the patients individually? (Answer: focus more on diabetic man, whether he has good DM control, diet-controlled, OHA-controlled, or insulin-controlled DM).

4. How would you prioritise?

5. Why would you prioritise?

6. Why should a young boy go before an elderly diabetic man? If you do not list the boy as the first in the list, what difficulties will your run into?

7. Can you prioritise the diabetic man instead, and if so, give your reasons.

1. Tell me in what situations of trauma that patients can be managed conservatively?

2. In what situation of abdominal trauma would you consider conservative management?

3. Tell me about the grading of solid organ injury and how you would re-act to it.

4. So a patient with abdominal trauma came to you, how would you assess for bleeding intra-abdominally and how this would influence your management (what parameters come to mind and how do you address this).

5. What would make you go for operative management subsequently?

1. As a surgeon, what influences your surgical incision. Tell me the principles of creating a surgical wound.

2. You commonly encounter surgical patients needing dialysis. Tell me, in what situations would dialysis be required.

3. You said renal failure. Can you tell me about renal failure, how you would assess for it and what are the implications of renal failure?

4. What types of dialysis do you know of and how do you choose.

5. You said haemodialysis through a femoral access. Tell me what are the complications associated with central venous catheterization.

6. The patient ended up needing a long-term haemodialysis. How would you go about this?

7. Where do you want to create your haemodialysis access?

8. What are the principles of creating a haemodialysis access?

Pathology Table

If given picture slides, start with, “I can see (describe like you see an alien)…”

Questions using picture slides – this is variable

1. A man’s buttock with a huge swelling (describe). It drained pus. What are the possibilities? Who gets this type of swelling? What is the possible micro-organism? What are the other more sinister causes of this swelling ? (Answer: psoas abscess, tuberculous spinal abscess)

2. Bilobar structure joined in the middle, lobulated (Dx: thyroid gland, multinodular goiter)

   1. What is this and why do you say so?

   2. So you say it is a multinodular goiter, what is your management?

   3. You want to offer total thyroidectomy. What are the complications?

   4. What if you do a subtotal thyroidectomy ?

3. Interjected question

   1. You mention tumour thrombus. What is your understanding of it?

   2. Give other examples where you get tumour thrombus apart from renal carcinoma

Using picture slides – this is variable

1. bladder calculi and prostate gland (identify the specimens and mention why)

   1. What is the relationship?

   2. What is the effect of bladder outlet obstruction?

   3. What is the effect of bladder calculi?

2. CT scan (please describe >> cystic lesion of the right kidney, loss of architecture of the left kidney)

   1. What do you think this is?

   2. How do you diagnose renal cell carcinoma? (Answer: change in Hounsfield unit on CT scan by 20-25, pre and post contrast)

   3. What treatment would you offer assuming that the contralateral kidney is normal?

Non-picture slide question:

1. What is an incidentaloma and give some examples.

2. How would you go about investigating for one?

3. What would suggest to you that an incidentaloma needs to be treated?

Operative table:

As I describe the procedure, he will intercept and focus on fine nitty, gritty details.

1. How do you perform a femoral embolectomy ?

2. How do you consent the patient for the surgery?

3. What sizes of Fogarty’s catheter would you prepare and how do you prepare it?

4. So you would obtain proximal and distal control. What would you be using ?

   1. So you said vascular loops. How do you apply them? Are you going to use vascular clamps?

   2. How do you keep your loops taut?

5. Hold on, before you perform the arteriotomy, would you not want systemic heparinisation? What dose of heparin ?

6. What arteriotomy incision would you make and why?

   1. So you choose a longitudinal incision, why not a transverse?

   2. So what is the problem with a transverse incision?

   3. What is the problem with a longitudinal incision?

7. So you have opened up the vessel, and you said you will assess from proximal inflow but usually there will be poor inflow anyway, otherwise you will not end up with an acute limb ischaemia. What catheter size would you choose for proximal embolectomy?

   1. How about distally?

   2. And how much air or water are you inflating the balloon catheter with?

8. Would you be satisfied after removing the emboli?

1. Describe how you would go about a performing a proximal ureterolithotomy.

2. How do you identify the 12^th rib?

3. Do you muscle cut or muscle split?

4. So you have seen the ureter and you said that you want to apply distal and proximal control. Is that really necessary?

   1. Ok I agree with proximal control but why do you think it is important?

   2. How about distal control, is it necessary?

   3. Now you have removed the stone, what else would you do?

   4. You said you want to insert a ureteric stent, which type and how do you place it?

   5. How are you going to manage the stent?

Good luck !

KS Ngoo
Nov 2010