ERN Surgery UG

8/13/2019 ERN Surgery UG

1/12

Essential Revision Notes inSurgery for Medical Students


2/12

Contents

v

Contributors vii

Editors Preface ix

About this book xi

1Principles of Surgery 1

Irfan Halim, Amir Halim, Akash Sharma

2Surgical Pathology 11

Shahzad Raja

3Peri-operative Care and Anaesthetics 65

Saima Saeed

4Abdominal Surgery 77

Irfan Halim, Rajib Das, Nirooshun Rajendran,

Seyed MM Ameli Renani, Ibraheim El-Daly

5Orthopaedics and Trauma Surgery 145

Naveed Shaikh, Ibraheim El-Daly

6Head, Neck and Neurosurgery 167

Ibraheim El-Daly

7Breast Surgery 207

Irfan Halim

8Endocrine Surgery 219

Rajib Das


3/12

Contents

vi

9Plastic Surgery 235

Shelain Patel

10Cardiac Surgery 247

Shahzad Raja, Giles D Dreyfus

11Thoracic Surgery 265

Shahzad Raja, Giles D Dreyfus

12Vascular Surgery 275

Ahmed Farhan Haq

13Urology 295

Barnaby Garner Chappell, Karim Jamal

Revision Index 313


4/12

CONTENTS

Principles of surgery Chapter 1

1.1 Introduction to surgery 2

1.1.1 Learning surgery

1.1.2 Diagnosing surgical patients

1.1.3 Surgical examinations

1.2 Surgical methodology 3

1.2.1 Incisions

1.2.2 Sutures

1.2.3 Drains

1.2.4 Attending operations

1.3 Peri-operative surgical care 6

1.3.1 Preparing for surgery

1.3.2 Informed consent

1.3.3 Communication

1.3.4 Post-operative review

1.3.5 Post-operative complications


5/12

Principles of surgery

2

1.1 INTRODUCTION TO SURGERY

1.1.1 Learning surgeryYour first exposure to surgery and to seeing patients being cutopen on the operating table will usually occur in your first

clinical year. Your experiences of surgery may be varied,

depending on your surgical firm, and the teaching quality can

range anywhere from excellent to an unacceptable waste of

time. Often this diversity in teaching can motivate or dishearten

you about a genuinely exciting subject. This section aims to

provide advice on how you can maximise your clinical learning

experience in surgery.

My personal advice on learning surgery is to start early, even

before joining a surgical firm. Some points that you should

follow routinely include:

Speak to students already on the firm before joining

Establish a rapport with the surgical team you are joining

Get a good surgical textbook for theory and one for

examinations. Read them at least once properly and then

as needed. My personal recommendations are:

Theory Lecture Notes in General Surgeryby Ellis et al

Examination Introduction to Symptoms and Signs of

Surgical Diseaseby Browse et al

Attend all the teaching offered regularly

Use free time to explore clinical experience (theatres,

clinics, clerking)

Stick to good teachers and spend time with them regularly

Try to clerk and present as many patients as possibleHave doctors demonstrate clinical signs and examination

techniques to you

Have doctors observe the way you examine and present

patients

Scrub in to as many cases as possible

Try to observe patients and cases from other surgical firms

with permission

Learn relevant procedures and skills from day 1

Do not be put off if doctors are too busy to teach you. Use

self-directed learning here

Read further about clinical cases encountered during the

day

Never be disheartened by doctors who treat you in anunacceptable manner. This is common in surgery and

actually means nothing to you in the long run. Do not let

them take you off your path to learning surgery. Be good

and proper as a student

It is not difficult to follow the above points if these are built

into a routine. They will not always apply, but their aim is to

make your surgical experience fulfilling and your exams much

easier. For those of you pursuing surgery in the future, you will

be building upon these skills. For those of you pursuing other

specialties, this may be the last opportunity for you to explore

and learn surgery and become comfortable with assessingsurgical patients.

Surgery is fun. Surgery is challenging. Surgery requires an

engaged mind with a skilled hand. Learn it, apply it, teach it!

1.1.2 Diagnosing surgical patientsDiagnosing patients involves:

History

Examination

Investigation

Every patient being seen for the first time should have a history

taken and an examination performed as the minimum in

diagnosing conditions. The only exception to this rule not being

followed is in the acute state where a critically ill patient may

require resuscitation and stabilisation first before reverting to

the thorough clinical history and detailed examination when

appropriate.

There is no good substitute for taking a thorough history when

seeing patients for the first time. Regardless of your own level

of surgical expertise, it is best to start taking full histories to

obtain as much information as possible. Later on, as the student

or junior doctor becomes more experienced, a focused and

targeted history can be a more efficient means of assessment.

This is required during busy times such as in the outpatient

clinics and emergency departments.

Although this book is intended as purely a revision guide to

surgery, no apology is made for recapping the very important

history-taking section below, which is vital in any patient being

assessed.

History taking follows a standard approach anywhere in the

world and comprises the following:

Introduction

Presenting complaint

History of the presenting complaint

Past medical/surgical history

Medications and allergiesFamily history

Social history

Systems review

Relevant sections such as immunisations, obstetric history and

developmental milestones may be added as required, depending

on the patient.


6/12

Surgical methodology

3

One of the commonest presenting symptoms in surgery as well

as medicine is that of pain. In general surgery, abdominal pain

is part of most disease processes in combination with other

symptoms. The SOCRATES approach to ascertaining a historyin patients presenting with abdominal pain allows for an easy

and thorough assessment. This method is covered further in

Chapter 4 and can also be applied to other common presenting

complaints.

If you find it difficult to take histories, it is probably best to

learn it via a combination of books, videos and personal

observations of more senior doctors. Most importantly, though,

is the self-directed practice of history taking with patients

one-on-one. There is no substitute for this and it should be

done with as many patients as possible. Once the full history is

mastered, you should aim to make this more efficient by taking

it in less time, or taking a more focused approach. Presenting

histories is also equally important as this often alerts you towhat you are doing right and what you are missing out. Many

medical students of mine have taken a near-perfect history

and presented it to me, often forgetting a single key question

in the presenting complaint (eg forgetting to ask about dysuria

or last menstrual period in a young woman with abdominal

pain). Another great thing about taking and presenting

histories is that it can be done before having learnt any

examinations.

1.1.3 Surgical examinationsSurgical examinations are slightly different from the standard

medical examinations applied in a general clerking, although

the same principles apply, such as inspect, palpate, percuss

and auscultate. Different conditions are focused upon in

examination settings. Also, different examination algorithms

exist for assessing particular surgical conditions and these

must be learnt in order to complete any patients surgical

assessment.

Examples of surgical examinations include:

Abdominal examination

Vascular arterial examination (usually lower limbs and

systemic)

Vascular venous examination (lower limbs)

Lump examination

Ulcer examination

Breast examination

Neck/thyroid examination

Hernia/groin-lump examination

Scrotal examination

Joint examination

Genuine effort should be made to learn these examinations as

they are easy to learn and perform as well as appearing in

every surgical exam! These are best learnt from surgical

outpatient clinic settings as well as from emergency patients

admitted on-take and elective surgical patients awaiting a

surgical procedure (eg a patient awaiting a thyroidectomywith a palpable goitre).

Some chapters of this book cover an outline of the relevant

surgical examinations as a revision tool, but this is not the

books main focus. There are many excellent textbooks to read

in conjunction with practising and performing examinations

under supervision. It is the supervision by and feedback from

different doctors that will enhance your diagnostic skills, by

learning how to pick up signs and combine the clinical

assessment with a history. Demonstration of normal signs in

addition to key signs is needed to learn them properly. How

can you be expected to recognise an abnormal breath or heart

sound if you dont yet know what a normal one sounds like?

1.2 SURGICAL METHODOLOGY

1.2.1 IncisionsRecognition and identification of surgical incisions is a key

element of inspection in a clinical examination. The organ

being operated on dictates the incision choice, in addition to

other factors listed below:

Site depends on which organ is being operated on

Size access to the organ dictates size of incision

Orientation follow Langers line to allow for better

healing and cosmesisSurrounding tissues healthy and non-infected tissues

Anatomy of site underlying structures that may need

avoiding (eg nerves and arteries)

Cosmesis hidden scar (eg inframammary scar for breast

implants)

With the advent of laparoscopic surgery, large incisions are

now disappearing and nowadays scars as small as 512 mm

are located in various sites around the abdomen. The

combination of sites of these incisions can give a clue to the

laparoscopic operation performed, although it is beyond the

scope of undergraduate and early postgraduate teaching to

learn these.

The most common incisions are shown and listed below, along

with potential organs that may have been operated on through

them (Figure 1.1, Table 1.1).


7/12


4

Figure 1.1: Common abdominal incisions

ASIS

Lateral

border of

abdominus

rectus

muscle

(1) Mid-line incision through linea alba

(2) Sub-umbilical incision(3) Para-median incision

(4) Para-rectal Battles incision

(5) Kochers incision(6) Double Kochers (rooftop) incision

(7) Transverse muscle-cutting incision(8) McBurneys/Gridiron incision

(8a) Rutherford Morrison incision(9) Lanz incision

(10) Pfannenstiel incision(11) Transverse incision

(12) Thoraco-abdominal incision

1

2

34

5 6

7

8

8a

910

11

12

Table 1.1 Common incisions

Organ Approach Organ Approach

Oesophagus

Upper thoracic

Mid thoracic

Lower thoracic

Abdominal

Stomach

Liver

Biliary tree

Pancreas

Duodenum

Small

intestine

Cervical

Right 4/5 postero-lateral thoracotomy

Right 5/6/7 postero-lateral thoracotomy

Right 5/6/7 postero-lateral thoracotomyLeft 6/7 postero-lateral thoracotomyLeft thoracoabdominal

Left thoracoabdominalRooftop

Upper midline

Left thoracoabdominalRooftopUpper midline

Right thoracoabdominal

RooftopUpper midlineRight paramedianKocherTransverse

Rooftop

Upper midlineRight paramedianKocherTransverse

MidlineParamedianTransverse

Colon

Appendix

Rectum

Uterus, ovaries

Aorta

Iliac vessels

Bladder

Kidney

Adrenal

glands

MidlineRight paramedianRight transverseRutherfordMorrisonGridiron

GridironLanz

MidlineLeft paramedianLeft transverse

MidlineLeft paramedianLeft transversePerineal

MidlinePfannenstiel

MidlineTransverse

MidlineTransverse

RutherfordMorrisonLower midlinePfannenstiel

Midline

Kocher12th rib incision


8/12

Surgical methodology

5

1.2.2 SuturesSutures are used in surgery to appose tissue edges that have

been cut, as well as to tie off structures and provide secure

ligation. Sutures may be found attached to needles or on theirown as ties.

Many different materials can be used to suture and there is

much commercial competition between differing suture

brands. At the undergraduate level, a basic understanding and

classification of sutures is provided here with examples.

Sutures may be absorbable or non-absorbable

Sutures may be synthetic or natural

Sutures may be monofilament or braided

Absorbable suturesare used for tissues that heal quickly, such

as bowel anastomosis, skin suturing, ligation of vessels and

mesentery and stoma creation. These sutures are understood

to provide initial strength to achieve their purpose and then todegrade and dissolve over time by natural processes within the

human body. Examples include Vicryl, Monocryl, Dexon, PDS

and catgut (no longer used).

Non-absorbable suturesare used for tissues that heal slowly.

They retain strength for a longer period of time to allow greater

healing to occur (eg abdominal wall closure). They also cause

less tissue reaction compared with absorbable sutures so they

have some cosmetic advantage (exception is silk, which causes

an inflammatory reaction). Examples include steel wire

(sternotomy closure), nylon, silk, Prolene and PTFE. Although it

is often assumed that non-absorbable sutures do not absorb

within the body as their title suggests, this is not often thecase and almost all suture materials (except steel) lose their

strength and absorb over time. The main difference is the

length of time which may elapse before a non-absorbable

suture is dissolved (months to many years) as compared to an

absorbable suture (weeks to months).

Synthetic suturesinclude Dexon, Vicryl, PDS, nylon, Prolene

and PTFE.

Natural suturesinclude catgut and silk.

Monofilament sutureshave a single filament and are easier

to pass through tissues. They do not have braids in them in

which infection can reside so they are less of an infection

source. Disadvantages include the fact that they are slipperyand difficult to knot due to the stiffness. Knots may not hold

as securely because of this and lead to inadequate closures.

Braided sutures have multiple filaments running through

them. Examples include Dexon, Vicryl, silk and nylon. They have

the advantage of providing a more secure closure. They can

cause more of a tissue reaction than monofilaments and also

harbour bacteria between the braids, leading to infections.

1.2.3 DrainsDrains are used in various parts of the body to drain and collect

air or fluids that can accumulate in compartments around the

body. Some indications for usage of drains include but are notlimited to:

Wound drain (eg post-thyroidectomy or mastectomy)

Abscess cavity drainage (eg corrugated drain)

Abdominal drainage for ascites or post-operatively to

check for blood, bile, urine, or anastomotic leakage

Chest drain for air, effusion, blood, or rarely chyle

Ventricular drains (eg external ventricular drains following

subarachnoid haemorrhage)

Drains come in many forms and varieties. Drains are best

classified into:

Open or closed drains

Open drainsallow drainage into dressings or a stomabag through gravity or natural flow. Often, just making

an incision into a superficial collection creates an open

drain which can then be dressed appropriately. This is

more often used in heavily infected cases or where a

natural fistula has already formed. A corrugated drain is

an example of an open drain.

Closed drainsallow drainage of substances into a bag

or bottle. As this is a closed system, infections are less

likely to develop. A Robinsons drain is an example of a

closed drain.

Suction or non-suction drains

Suction drainshelp to collapse down wound cavities

and drain them. If vacuum is applied, this can also helpwound healing. Examples include Redivac drains, sump

drains with suction and Vac dressings. Never apply a

suction drain in a brain ventricle.

Non-suction drainsare usually used in the brain

ventricles or abdominal cavities post-operatively or for

chest drains generally. They allow for natural collection

of fluids, air, or other content as necessary within the

body cavity.

1.2.4 Attending operationsIt is a privilege as a student to be allowed to scrub in and assist

a surgical procedure. This allows you to appreciate the anatomy

and pathology of the surgical procedure and to feel part of theteam involved in caring for a surgical patient.

Scrubbing-inAlways ask permission of the most senior surgeon if you can

scrub up in the procedure to observe. If allowed to, make sure

you learn the appropriate technique for scrubbing up from the

theatre sister or surgeon. Once this has been learned properly

and practised a few times, it should become a natural act


9/12


6

provided it has been practised regularly as well. Try to wear a

mask at all times with visor protection. This is to ensure that no

bodily fluids get splashed onto your eyes and into your mouth.

This is extremely common in surgery and following thesesimple measures can save a lot of unnecessary distress. The

standard rule for hand washing is to scrub up for 5 minutes for

the first scrub of the day and for 3 minutes between subsequent

cases. The closed gloving technique is preferred over the open

one, although it is best to learn both for comparison and

personal choice.

Scrub brushes should not be used as they promote bacteria on

the skin and also irritate the skins surface. They can be used if

necessary on the fingertips and nails, but they should not be

used on skin. An appropriate glove size should also be checked

prior to scrubbing up to allow for smooth assisting. Try to

double-glove as much as possible to ensure universal

precautions are carried out in every patient regardless of whothey are and the nature of their operation. The human

immunodeficiency virus (HIV) and hepatitis status of most

surgical patients is not known and there is no point risking

your life and career over something that could have been

avoided. This advice is no different from asking all drivers to

wear seatbelts whilst driving regardless of where and when

they drive. If the law didnt insist on it, would all drivers neglect

the seatbelt?

AssistingAssisting in an operation can be exciting as it allows you access

to view the operation upfront. It can also be boring, tiring and

may not give you the view and angle you wanted to see theoperation from. In certain cases, it is not always ideal to scrub

up to get the best view and remaining unscrubbed also allows

you freedom of movement within the case. Always follow the

lead of the senior surgeon and do not ever risk the life and

well-being of the patient by interfering or not following orders.

You may often have to provide retraction for long periods of

time in a particular stance and this can get painful for anyone.

If there is a particular discomfort, it is best to ask politely for a

break to readjust at the right moment in a surgical case. This

allows you to carry on doing your job well and does not put the

patient at any risk.

The operating roomWhen you are in the operating room you should notice that

there are many things in this new environment that you

havent encountered before. Firstly, the people around the

operating room have particular, defined job roles and you

should introduce yourself to them so that they know how to

help you and how you may be able to help them. Always try to

assist them in any way possible, including the transferring of

patients. They will, in return, teach you how to scrub and assist

in cases, and teach you about the operating room environment.

In other moments when you are not assisting or learning, it is

advisable to introduce yourself to the anaesthetist as well, who

can teach you a lot. Many skills such as cannulation, intubation,central venous pressure (CVP) and arterial line insertion, lumbar

puncture (LP)/spinal and ventilation can be learnt in a short

time. Topics such as physiology and pharmacology can also be

applied really well during the anaesthetic course and it is an

asset to learn from these doctors as well. Rules include:

Do not touch anything unless you know what you are

doing

Stay off the green sterile field unless you are scrubbed and

sterile

Always wear a mask as a student, even if not assisting

Be polite to everyone and introduce yourself to make your

own life easier

Help out at all timesUse every free moment to learn in the operating room, ask

questions appropriately, take a surgical textbook to read

on the side, read through patient notes and learn from

anaesthetists

Thank everyone for taking the time to accommodate you

and for teaching you

Post-operative careAs a junior doctor, it is good practice to see the patient in the

recovery room as they wake up. Many vital signs can be

monitored here and on occasion a patient who may have to go

back to the operating theatre can be recognised by following

good clinical judgement (eg excess bleeding from a drain sitein the recovery room, or blood-soaked dressings). After

recovery, it is also advisable to see the patient on the ward at

the end of an operating list or between cases if possible. This

allows you to see the patient recovering and to speak to them

about what happened during surgery. This helps in building

rapport through communication and often allows you to speak

to any family members at the same time so that any concerns

are alleviated. If you get into this practice as a student, it

becomes part of your good clinical practice and routine and

makes you feel part of the surgical team. Students often spend

more time with patients talking to them than the doctors

looking after them. If a rapport has been established pre-

operatively, the patient may expect to see the student aftersurgery as a friendly face who cares about their well-being.

1.3 PERI-OPERATIVE SURGICAL CARE

1.3.1 Preparing for surgeryWhen preparing for surgery, many things need to be considered

in advance. It is surprising to see how often most of these


10/12

Peri-operative surgical care

7

things can go wrong. The following need consideration and

addressing well before undertaking surgery on any patient:

Ensuring appropriate indication for surgery

Ensuring that the patient wishes to go ahead with surgeryEnsuring appropriate setting and facilities (eg ITU,

laparoscopic unit, anaesthetists with special skills)

Full clerking of patient and identification of any special

needs, medications or investigations

Liaising with anaesthetists, theatre staff and the

consultant/registrar about the cases

Ordering and submitting the theatre list with appropriate

case load and mix

Ordering any special equipment well in advance of surgery

Ensuring all investigations are adequate and results acted

upon in the week before surgery

Ensuring all patients have a bed on the wards or are

admitted pre-operativelyEnsuring that all patients have been consented and

marked appropriately (if necessary)

Ensuring that all the patients notes and scans are

available well in advance (few days) of the operation

Ensuring that any special adjuncts have been addressed on

the day (ITU bed, surgical equipment, blood products, etc)

Making sure that an appropriate time has elapsed since

the patient last ate or drank

Ensuring that the anaesthetist and theatres are aware of

the patients location (ward)

Although these points seem like a long list of chores, they

often become second nature to the junior doctor once they areestablished on a surgical firm. For those who are still finding

their way, there is never any harm in reverting back to the

above checklist.

1.3.2 Informed consentInformed consent should be sought before undertaking any

investigation, treatment, screening, or research on a patient.

All patients have a right to information about their condition

and any options for further investigation and management

plans. They also have the right to refuse any investigation or

treatment offered to them at any time, even after a consent

form has been signed. Acting against a patients wishes can be

regarded as assault. Most informed consent applies tocompetent patients who can:

Understand the information given to them

Retain the information

Contemplate the information

It is good practice to ask if patients have understood the

information and if they have any further questions of their

own before proceeding.

Different laws apply for patients deemed incompetent and for

children:

For children under 16 years parents should consent to

treatment. If a child is deemed competent and understandsthe risks and benefits of treatment, they can consent to

treatment even if their parents refuse. The converse is also

true if a competent child refuses treatment, but the

parents wish for it, then treatment may be given. A court

order can be obtained in life-threatening cases where both

child and parent refuse treatment.

For incompetent adults (including temporary and transient

incompetence) the doctrine of necessity applies, where a

physician can act in the patients best interests.

Informed consent can be implied or acquired. Informed consent

is implied in situations where there are no major complications

resulting from it. A good example is when a doctor cannulatesa patient or takes blood from them; no consent form is signed

for the procedure or investigation. Any situation in which a

major complication can arise should ideally have a signed

consent form. This happens to be a grey area in most hospitals

for intermediate ward procedures such as CVP line insertions,

chest drains and LPs, which all have well-defined major

complications listed. They are often treated as no different

from any other ward procedure provided the appropriate

precautions are taken and the procedure is discussed with the

patient in the usual manner.

Informed consent in all other situations should include:

Details of the clinical condition, including prognosisManagement options

Explanation of any proposed procedures

Risks, benefits, side-effects and complications which may

arise from it

Common (>1%) and serious complications and risks

should be discussed

The doctor responsible for their treatment

An opportunity for the patient and family members to ask

any questions

Normally, the consent forms provided these days in most

hospitals have sections laid out which comply with the above

points (except the last one) and can easily be gone through in

a stepwise approach. Remember that patients may changetheir minds at any stage, even after signing the consent form.

Consent should ideally be obtained by the doctor performing

the procedure although it can be delegated to an appropriate

team member of sufficient seniority and knowledge.


11/12


8

1.3.3 CommunicationCommunication is regarded as the most important part of any

aspect of patient care. It is extensively taught and examined

nowadays in the medical school curriculum. It is very brieflyrecapped in this section and the following skills should be

learnt well as part of learning in surgery. They are only included

here to remind you of the skills necessary and are not expanded

upon any further in this book.

Informed consent

Explaining common procedures for a lay person to

understand (eg gastroscopy, hernia repair, magnetic

resonance imaging (MRI) scan)

Breaking bad news (eg post- or peri-operative death)

Dealing with angry patients (eg cancelling their operation

due to lack of beds or overbooked lists)

Communicating with foreign-language-speaking patients

(eg use of translators, family, etc)

1.3.4 Post-operative reviewThe first post-operative review of a patient should ideally be

done in the recovery area of theatres as the patient is waking

up from anaesthesia. In reality, time pressures and other cases

may prevent a surgeon from seeing a patient in recovery for

review. It is good clinical practice to see all post-operative

patients after the operating list has finished on the same

evening. A quick ward round can be done to assess the patients

for any potential problems as well as communicate with the

patient as to the progress made by the surgical procedure.

Analgesics and antibiotics can be given as well as permission toeat and drink as appropriate. Blood tests can also be ordered

for the next morning during this round.

During the subsequent daily ward rounds it is important to

monitor the surgical patient carefully to ensure that they are

on the path to recovery from their surgical procedure. The aims

of the ward round are to:

Identify and address any problems reported by the patient

or nursing staff

Check routine observations:

Temperature

Heart rate

Blood pressureRespiratory rate

O2saturations

Blood glucose (diabetics)

Fluid balance

Input

Output

Nutritional status ladder

Sips of water

30 ml/60 ml/90 ml per hour of water

Clear free fluids

Free fluids (anything liquid)

Soft light dietLight diet

Full diet

Check analgesic control

Examine the patient

Cardiorespiratory

Abdomen

Wound

Calves for deep vein thrombosis (DVT)

Inspect the wound and drains

Note future date for suture removal

Drains (eg nasogastric tube, catheter, cavity drains,

lines)

Check blood and imaging results and compare withprevious results

Communicate findings

To patient (and relatives)

To own team

To nurses and other allied health professionals (eg

physiotherapist, dietitian)

Document findings

Clear legible and accurate notes

1.3.5 Post-operative complicationsPost-operative complications occur frequently. They may be

easily categorised by timing or by cause:

Timing

Immediate (within 24 hours of surgery)

Early (occur up to 30 days for outpatients or during the

inpatient stay)

Late (post-discharge or more than 30 days post-op)

Cause

General complications of surgery (haemorrhage,

infection, DVT)

Specific operative complication (eg anastomotic leak)

Complications as a result of patient co-morbidities (eg

cardiac failure)

The commonest causes of post-operative complications in

general are found in Section 3.3. I would highly recommendreading that section to familiarise yourself with a description

of the commonest post-operative complications.

Complications should also be learnt which are specific to the

procedure being performed (eg common bile duct injury during

laparoscopic cholecystectomy). Although this is a post-

graduate topic, some knowledge is tested in the written exams

as well as in OSCEs.


12/12

Peri-operative surgical care

9

The goal of a junior doctor in the post-operative period is to

recognise complications early and prevent their progress by

initiating appropriate management.

REFERENCES

Burnand K, Thomas W, Black J, Browse N. 2005. Browses

Introduction to the Symptoms and Signs of Surgical Disease.London: Hodder Arnold.

Ellis H, Calne R Y. 2002. Lecture Notes on General Surgery, 10th

revised edition. Oxford: Blackwell Science.

Documents

ERN Surgery UG