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MRCS a ESSENTIAL REVISION NOTES Book 2 MRCS A ESSENTIAL REVISION NOTES BOOK 2 Edited by Claire Ritchie Chalmers BA PhD FRCS Catherine Parchment Smith BSc MBChB FRCS MRCS ERN VOL 1 prelims.indd 1 8/19/2016 11:05:26 AM © 2016 Pastest Ltd Egerton Court Parkgate Estate Knutsford Cheshire WA16 8DX Telephone: 01565 752000 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the prior permission of the copyright owner. First published 2012, reprinted 2015, 2016 ISBN: 978 1 905 63583 2 eISBN: 978 1 909 49115 1 MobiPocket 978 1 908 18571 6 ePUB A catalogue record for this book is available from the British Library. The information contained within this book was obtained by the author from reliable sources. However, while every effort has been made to ensure its accuracy, no responsibility for loss, damage or injury occasioned to any person acting or refraining from action as a result of information contained herein can be accepted by the publishers or author. Pastest Online Revision, Books and Courses Pastest provides online revision, books and courses to help medical students and doctors maximise their personal performance in critical exams and tests. Our in- depth understanding is based on over 40 years’ experience and the feedback of recent exam candidates. Resources are available for: Medical school applicants and undergraduates, MRCP, MRCS, MRCPCH, DCH, GPST, MRCGP, FRCA, Dentistry, and USMLE Step 1. For further details contact: Tel: 01565 752000 Fax: 01565 650264 www.pastest.com [email protected] Text prepared in the UK by Carnegie Book Production, Lancaster Printed and bound in the UK by Bell & Bain Limited, Glasgow MRCS ERN VOL 1 prelims.indd 2 8/19/2016 12:10:03 PM Contents Acknowledgements v Preface v Picture Permissions vi Contributors vii Introduction ix Chapter 1 – Abdominal Surgery 1 Catherine Parchment Smith, Arin K. Sara and Ravinder S. Vohra Chapter 2 – Breast Surgery 337 Jenny McIlhenny and Ritchie Chalmers Chapter 3 – Cardiothoracic Surgery 397 George Tse and Sai Prasad Chapter 4 – Endocrine Surgery 465 Nicholas E Gibbins and Sylvia Brown Chapter 5 – Head and Neck Surgery 521 Nicholas E Gibbins Chapter 6 – Neurosurgery (Elective) 593 Paul Brennan iii MRCS ERN VOL 1 prelims.indd 3 8/19/2016 11:05:26 AM Chapter 7 – Transplant Surgery 627 Karen S Stevenson Chapter 8 – Urological Surgery 647 Mary M Brown Chapter 9 – Vascular Surgery 729 Sam Andrews Abbreviations 803 Bibliography 807 Index 809 iv MRCS ERN VOL 1 prelims.indd 4 8/19/2016 11:05:26 AM C HAPTER 1 Abdominal Surgery CHAPTER 1 Catherine Parchment Smith, Arin K. Saha and Ravinder S. Vohra 1. Abdominal wall and hernias 3 3.9 Congenital abnormalities of 1.1 Anterior abdominal wall 3 the duodenum 106 1.2 Hernias 10 3.10 Other conditions of the 1.3 Complications of hernias 31 stomach and duodenum 107 2. Oesophagus 37 4. Liver and spleen 110 2.1 Anatomy and physiology of the 4.1 Anatomy of the liver 110 oesophagus 37 4.2 Physiology of the liver 115 2.2 Pain and difficulty swallowing 40 4.3 Jaundice 120 2.3 Gastro-oesophageal reflux 4.4 Portal hypertension 127 disease 44 4.5 Clinical evaluation of liver 2.4 Hiatus hernia 48 disease 131 2.5 Motility disorders 49 4.6 Cirrhosis 133 2.6 Oesophageal perforation 51 4.7 Liver masses 134 2.7 Other benign oesophageal 4.8 Liver infections 137 disorders 53 4.9 Liver cysts 138 2.8 Barrett’s oesophagus 53 4.10 The spleen 139 2.9 Oesophageal carcinoma 55 5. Biliary tree and pancreas 144 3. Stomach and duodenum 60 5.1 Anatomy of the biliary system 144 3.1 Anatomy of the stomach 60 5.2 Physiology of the biliary tree 147 3.2 Anatomy of the duodenum 64 5.3 Gallstones 150 3.3 Physiology of the upper GI tract 66 5.4 Other disorders of the biliary 3.4 Peptic ulceration 77 tree 159 3.5 Complications of peptic 5.5 Anatomy of the pancreas 161 ulceration 89 5.6 Physiology of the pancreas 162 3.6 Gastric carcinoma 96 5.7 Pancreatitis 164 3.7 Gastritis 105 5.8 Pancreatic carcinoma 168 3.8 Congenital abnormalities of 5.9 Other pancreatic tumours 173 the stomach 106 5.10 Other disorders of the pancreas 174 1 ERN 2012.indb 1 8/17/2016 2:29:56 PM 6. Acute Abdomen 176 8. Large bowel 242 6.1 Acute abdominal pain 176 8.1 Symptoms of non-acute 6.2 Common acute abdominal abdominal disorders 242 emergencies 182 8.2 Anatomy and physiology of the 6.3 Intestinal obstruction 195 colon 259 6.4 Peritonitis 205 8.3 Diagnosis of colorectal disease 263 6.5 Stomas 215 8.4 Inflammatory bowel disease 269 8.5 Benign colorectal tumours 280 7. Small bowel 222 8.6 Colorectal cancer 289 7.1 Anatomy and physiology of 8.7 Other colorectal conditions 307 the small bowel 222 7.2 Imaging and investigating the 9 Perianal conditions 310 small bowel 226 9.1 Anatomy and physiology of 7.3 Intestinal fistulas 227 the rectum and anus 310 7.4 Tumours of the small bowel 230 9.2 Haemmorhoids 313 7.5 Bleeding from the small bowel 234 9.3 Anal fissures 318 7.6 Intestinal ischaemia 235 9.4 Anorectal abscesses 319 7.7 Diverticula of the small bowel 238 9.5 Anorectal fistulas 322 7.8 Infectious enteritis 239 9.6 Pilonidal sinus 324 7.9 Radiation small-bowel injury 240 9.7 Pruritus ani 325 7.10 Short-bowel syndrome 240 9.8 Rectal prolapsed 327 7.11 Short-bowel bypass 241 9.9 Proctalgia fugax 330 9.10 Faecal incontinence 330 9.11 Anal cancer 333 9.12 Sexually transmitted anorectal infections 334 2 ERN 2012.indb 2 8/17/2016 2:29:56 PM S ECTION 1 Abdominal wall and hernias CHAPTER 1 1.1 Anterior abdominal wall Superficial fascia (Scarpa’s fascia) Layers of the abdominal wall • Absent above and laterally • Fuses with deep fascia of leg inferior to inguinal ligament Learning point • Very prominent in children (can even be mistaken for external oblique!) When you make an incision in the • Continuous with Colles’ fascia over perineum anterior abdominal wall you will go (forms tubular sheath for penis/clitoris and through several layers: sac-like covering for scrotum/labia) • Skin • Subcutaneous fat • Superficial fascia Muscles • Deep fascia (vestigial) • Muscles (depending on incision) Learning point • Transversalis fascia • Extraperitoneal fat The muscles you’ll pass through depend • Peritoneum on the incision site: • External oblique • Internal oblique Skin • Rectus abdominis The skin has horizontal Langer’s lines over the • Transversus abdominis abdomen. Dermatomes are also arranged in • Pyramidalis transverse bands. • Rectus sheath Deep fascia This is a vestigial thin layer of areolar tissue over muscles. 3 ERN 2012.indb 3 8/17/2016 2:29:56 PM Abdominal Surgery • External oblique is a large sheet of muscle the nerves enter the sheath laterally and CHAPTER 1 fibres running downwards from lateral run towards the midline (so are disrupted in to medial like a ‘hand in your pocket’. Battle’s incision – see Figure 1.3) Medially, the external oblique becomes • Linea alba is a fibrotendinous raphe running a fibrous aponeurosis which lies over the vertically in the midline between the left rectus abdominis muscle (see below), and right rectus abdominis muscles. It is forming part of the anterior rectus sheath formed by the fusion of the external oblique, • Internal oblique is a second large sheet internal oblique and transversus abdominis of muscle fibres lying deep to the external aponeuroses. They fuse in an interlocking/ oblique and at right angles to it. Medially, interdigitating structure through which it forms a fibrous aponeurosis which splits epigastric hernias may protrude. The linea to enclose the middle portion of rectus alba provides an avascular and relatively abdominis as part of the anterior and bloodless plane through which midline posterior rectus sheath laparotomy incisions are made. It is easier • Transversus abdominis is the third large to begin a laparotomy incision above the sheet of muscle lying deep to the internal umbilicus, where the linea alba is wider, oblique and running transversely. Medially, thicker and better defined than below the it forms a fibrous aponeurosis which umbilicus contributes to the posterior rectus sheath • Pyramidalis is a small (4 cm long) lying behind rectus abdominis unimportant muscle arising from the pubic • Rectus abdominis and its pair join at the crest and inserting into the linea alba. It linea alba in the midline to form a wide lies behind the anterior rectus sheath in strap that runs longitudinally down the front of rectus abdominis. This is the only anterior abdominal wall. It lies within the muscle you go through in your lower rectus sheath formed by the aponeuroses midline laparotomy incision and it is not of the three muscles described above. It is as bloodless as the linea alba which it attached to the anterior rectus sheath, but underlies not to the posterior rectus sheath, by three tendinous insertions. These insertions are at the level of the xiphisternum, umbilicus Rectus sheath and halfway between (giving the ‘six-pack’ appearance in well-developed individuals!). Learning point The blood supply of rectus abdominis is through the superior epigastric artery (a terminal branch of the internal thoracic Any incision over rectus abdominis will artery) and the inferior epigastric artery (a go through the anterior rectus sheath. branch of the external iliac artery) which Arrangement of the rectus sheath is best anastomose to form a connection between considered in three sections: the subclavian and external iliac systems • Above the level of the costal margin (Fig.
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