General Surgery — MCQs
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A 36-year-old man presents with a 48-hour history of worsening right iliac fossa pain, fever of 38.5°C, and vomiting. Blood tests show WCC 16.8 × 10⁹/L, CRP 185 mg/L. CT abdomen with contrast demonstrates an inflamed appendix with a 6 cm pericaecal collection and surrounding fat stranding. He is haemodynamically stable. What is the most appropriate initial management strategy?
A 54-year-old woman with newly diagnosed Duke's B (T3 N0 M0) sigmoid colon adenocarcinoma is being counselled about treatment options. The tumour is located 30 cm from the anal verge with no evidence of obstruction or perforation. Her past medical history includes well-controlled hypertension. What is the most appropriate initial management for this patient?
A 67-year-old man presents with a firm, irreducible lump in his left groin that has been present for several hours. He reports severe pain and nausea. On examination, the lump is tender, erythematous, and cannot be reduced. His observations show temperature 37.9°C, heart rate 105 bpm, blood pressure 145/88 mmHg. Which anatomical structure forms the medial boundary of the femoral canal?
A 49-year-old woman undergoes colonoscopy for investigation of iron deficiency anaemia. A 3.5 cm circumferential tumour is identified in the descending colon. Biopsy confirms moderately differentiated adenocarcinoma. Staging CT shows locally advanced tumour adherent to the anterior abdominal wall with stranding but no definite invasion. There are no distant metastases. At MDT discussion, what is the most appropriate management approach?
A 73-year-old man with known familial adenomatous polyposis (FAP) who had subtotal colectomy with ileorectal anastomosis 15 years ago presents for routine surveillance. Flexible sigmoidoscopy reveals extensive rectal polyps and biopsy of the largest polyp shows high-grade dysplasia. He also reports mild faecal incontinence (Cleveland Clinic score 8/20). What is the most appropriate definitive management?
A 31-year-old man presents to the emergency department with sudden onset severe right-sided groin pain radiating to the testis that began 4 hours ago while lifting weights. On examination, there is a tender, firm, non-reducible mass in the right groin above the inguinal ligament, with overlying skin erythema. The right testis appears normal. He reports having a longstanding groin lump that usually reduces. Heart rate is 105 bpm, blood pressure 138/82 mmHg, temperature 37.6°C. What is the most appropriate immediate management?
A 57-year-old man undergoes surveillance colonoscopy 18 months after curative resection of a pT3N1 sigmoid adenocarcinoma. He had completed adjuvant chemotherapy with FOLFOX. The colonoscopy identifies a 12 mm pedunculated polyp in the ascending colon. Histology shows a well-differentiated adenocarcinoma within the polyp with invasion into the stalk (Haggitt level 3), clear margins (>2mm), no lymphovascular invasion, and favourable histological grade. What is the most appropriate management?
Which of the following statements best describes the anatomical relationship between the inferior epigastric artery and the different types of inguinal hernias?
During elective open right hemicolectomy for caecal adenocarcinoma, the surgeon notes multiple small white nodules throughout the peritoneum. Frozen section confirms metastatic adenocarcinoma. The patient is otherwise well with good performance status. The primary tumour is still resectable without technical difficulty. What is the most appropriate intraoperative decision?
A 24-year-old woman presents with acute right iliac fossa pain and pyrexia. Ultrasound findings show an appendix diameter of 8mm, non-compressible, with surrounding free fluid and a small amount of pericaecal inflammatory change. Blood tests show WCC 13.2 × 10⁹/L and CRP 45 mg/L. She is haemodynamically stable. A pregnancy test is negative. What is the most appropriate management approach?
General Surgery UK Medical PG Practice Questions and MCQs
Question 201: A 36-year-old man presents with a 48-hour history of worsening right iliac fossa pain, fever of 38.5°C, and vomiting. Blood tests show WCC 16.8 × 10⁹/L, CRP 185 mg/L. CT abdomen with contrast demonstrates an inflamed appendix with a 6 cm pericaecal collection and surrounding fat stranding. He is haemodynamically stable. What is the most appropriate initial management strategy?
- A. Immediate laparoscopic appendicectomy
- B. Immediate open appendicectomy
- C. Conservative management with IV antibiotics and percutaneous drainage, with interval appendicectomy at 6-8 weeks (Correct Answer)
- D. Conservative management with IV antibiotics alone, with interval appendicectomy at 6-8 weeks
- E. Immediate right hemicolectomy
Explanation: ***Conservative management with IV antibiotics and percutaneous drainage, with interval appendicectomy at 6-8 weeks*** - The presence of a **large pericaecal collection (6 cm)** and a **haemodynamically stable** patient are key indicators for initial conservative management to allow resolution of acute inflammation. - **Percutaneous drainage** is crucial for collections larger than 3-5 cm, effectively draining the abscess and preparing for a safer **interval appendicectomy** after 6-8 weeks. *Immediate laparoscopic appendicectomy* - Performing immediate surgery on an **established appendix abscess** carries a high risk of **bowel injury** due to friable, inflamed tissues, particularly the caecum and terminal ileum. - Severe inflammation makes tissue planes indistinct, increasing the likelihood of conversion to open surgery and **postoperative complications**. *Immediate open appendicectomy* - Similar to the laparoscopic approach, immediate open surgery in the presence of a **6 cm collection** is associated with high **intraoperative difficulties** and **postoperative morbidity**, including potential **enterocutaneous fistulas**. - For a stable patient with an **appendiceal mass or abscess**, conservative management is generally preferred to allow the acute inflammatory process to subside. *Conservative management with IV antibiotics alone, with interval appendicectomy at 6-8 weeks* - While antibiotics are essential, a **6 cm abscess** is generally too large to resolve effectively with **IV antibiotics alone**, increasing the risk of treatment failure and prolonged hospitalization. - **Percutaneous drainage** is a critical component for successful conservative management of large collections, as it physically removes purulent material, which antibiotics alone cannot achieve. *Immediate right hemicolectomy* - This is a radical surgical intervention primarily reserved for cases with confirmed or highly suspected **malignancy** or extensive **caecal necrosis** not amenable to simpler resection. - It is an overly aggressive and unnecessary initial management strategy for a stable patient with a drainable **appendiceal abscess** without evidence of malignancy.
Question 202: A 54-year-old woman with newly diagnosed Duke's B (T3 N0 M0) sigmoid colon adenocarcinoma is being counselled about treatment options. The tumour is located 30 cm from the anal verge with no evidence of obstruction or perforation. Her past medical history includes well-controlled hypertension. What is the most appropriate initial management for this patient?
- A. Neoadjuvant chemotherapy followed by sigmoid colectomy
- B. Neoadjuvant chemoradiotherapy followed by sigmoid colectomy
- C. Primary sigmoid colectomy with extended lymphadenectomy (Correct Answer)
- D. Endoscopic mucosal resection
- E. Primary radiotherapy followed by reassessment
Explanation: ***Primary sigmoid colectomy with extended lymphadenectomy*** - For **Stage II (Duke's B) colon cancer** (T3 N0 M0) located in the **sigmoid colon**, the standard of care is **upfront surgical resection** with clear margins. - An **extended lymphadenectomy** (sampling at least 12 lymph nodes) is crucial for accurate pathological staging and curative intent in these cases. *Neoadjuvant chemotherapy followed by sigmoid colectomy* - **Neoadjuvant chemotherapy** is not the standard initial management for **resectable Stage II colon cancer**; it is typically reserved for locally advanced T4b tumors or those with high-risk features for downstaging. - The primary role of chemotherapy in resected Stage II colon cancer is **adjuvant** (post-operative), particularly if high-risk features are identified on pathology. *Neoadjuvant chemoradiotherapy followed by sigmoid colectomy* - **Neoadjuvant chemoradiotherapy** is a treatment paradigm primarily used for **locally advanced rectal cancer** (tumors within 12-15 cm of the anal verge), not for sigmoid colon cancer. - **Radiation therapy** is generally avoided in colon cancer due to the mobility of the intraperitoneal colon, which increases the risk of radiation-induced enteritis. *Endoscopic mucosal resection* - **Endoscopic mucosal resection (EMR)** is only appropriate for **superficial lesions**, such as benign polyps or very early **T1 mucosal cancers** without evidence of deep invasion. - This patient has a **T3 tumor** (invading through the muscularis propria), which requires a formal oncological resection to address the significant risk of **lymph node metastasis**. *Primary radiotherapy followed by reassessment* - **Radiotherapy alone** is not a curative modality for colon adenocarcinoma and is not a substitute for surgery in resectable cases. - This approach would not achieve adequate local tumor control nor address the crucial need for **lymph node evaluation** for proper staging and to guide further management.
Question 203: A 67-year-old man presents with a firm, irreducible lump in his left groin that has been present for several hours. He reports severe pain and nausea. On examination, the lump is tender, erythematous, and cannot be reduced. His observations show temperature 37.9°C, heart rate 105 bpm, blood pressure 145/88 mmHg. Which anatomical structure forms the medial boundary of the femoral canal?
- A. Inguinal ligament
- B. Femoral vein
- C. Lacunar ligament (Correct Answer)
- D. Pectineal ligament
- E. Iliopubic tract
Explanation: ***Lacunar ligament***- The **lacunar ligament** (Gimbernat's ligament) forms the **medial boundary** of the femoral canal and is a triangular extension of the inguinal ligament.- Its **sharp, rigid edge** is clinically significant as it is often the structure that **strangulates** the contents of a femoral hernia.*Inguinal ligament*- The **inguinal ligament** (Poupart's ligament) forms the **anterior (superior)** boundary of the femoral canal.- It runs from the **anterior superior iliac spine (ASIS)** to the **pubic tubercle** and serves as the superior roof of the femoral opening.*Femoral vein*- The **femoral vein** forms the **lateral boundary** of the femoral canal within the femoral sheath.- Compression of this vein can occur when a large **femoral hernia** protrudes through the canal, though it does not form the medial edge.*Pectineal ligament*- The **pectineal ligament** (Cooper's ligament) forms the **posterior boundary** (floor) of the femoral canal.- It is a tough fibrous band that lies over the **pectineal line** of the pubic bone.*Iliopubic tract*- The **iliopubic tract** is a thickened band of the fascia transversalis that runs deep to the inguinal ligament.- While important in laparoscopic **hernia repairs**, it contributes to the posterior wall of the inguinal canal and not the primary medial boundary of the femoral canal.
Question 204: A 49-year-old woman undergoes colonoscopy for investigation of iron deficiency anaemia. A 3.5 cm circumferential tumour is identified in the descending colon. Biopsy confirms moderately differentiated adenocarcinoma. Staging CT shows locally advanced tumour adherent to the anterior abdominal wall with stranding but no definite invasion. There are no distant metastases. At MDT discussion, what is the most appropriate management approach?
- A. Proceed directly to left hemicolectomy with en-bloc abdominal wall resection if adherent (Correct Answer)
- B. Neoadjuvant chemotherapy with FOLFOX followed by reassessment and surgery
- C. Diagnostic laparoscopy to assess resectability before definitive surgery
- D. Neoadjuvant radiotherapy 45 Gy over 5 weeks followed by surgery
- E. PET-CT scan to better characterise the abdominal wall involvement
Explanation: ***Proceed directly to left hemicolectomy with en-bloc abdominal wall resection if adherent***- For **locally advanced colon cancer** (T4b) where the tumor is adherent to an adjacent structure, the gold standard is **primary surgery** with **en-bloc resection** of the involved abdominal wall to achieve **R0 margins**.- Attempting to separate the tumor from the abdominal wall is contraindicated, as it risks **tumor seeding** and positive margins if the adherence is malignant, even in the absence of definite invasion on CT.*Neoadjuvant chemotherapy with FOLFOX followed by reassessment and surgery*- Unlike rectal cancer, **upfront surgery** remains the standard of care for colon cancer, even when locally advanced and resectable.- **Neoadjuvant chemotherapy** is typically reserved for metastatic disease or specific clinical trials, while **adjuvant chemotherapy** is given post-resection for T4 disease to improve survival.*Diagnostic laparoscopy to assess resectability before definitive surgery*- While diagnostic laparoscopy can detect occult peritoneal metastases, the CT scan already indicates the tumor is likely resectable but requires a **multi-visceral/wall resection**.- An **open approach** is often anticipated for an en-bloc abdominal wall resection, making a prior diagnostic laparoscopy less likely to alter the immediate surgical plan, and it carries the risk of delaying definitive treatment.*Neoadjuvant radiotherapy 45 Gy over 5 weeks followed by surgery*- **Radiotherapy** is a standard treatment for **rectal cancer** due to its fixed anatomical position, but it is not routinely used for colon cancer.- This is primarily because of the risk of **radiation enteritis** in mobile small bowel loops, and primary surgical resection is superior for achieving local control in descending colon adenocarcinoma.*PET-CT scan to better characterise the abdominal wall involvement*- A **PET-CT** scan is not typically indicated for the local staging of colon cancer as it does not reliably distinguish between **inflammatory stranding** and **malignant invasion** of the abdominal wall better than a high-quality CT.- Regardless of whether the adherence is inflammatory or neoplastic (as CT shows stranding but no definite invasion), the surgical management remains **en-bloc resection** to ensure complete tumor removal, thus a PET scan would not alter the management plan.
Question 205: A 73-year-old man with known familial adenomatous polyposis (FAP) who had subtotal colectomy with ileorectal anastomosis 15 years ago presents for routine surveillance. Flexible sigmoidoscopy reveals extensive rectal polyps and biopsy of the largest polyp shows high-grade dysplasia. He also reports mild faecal incontinence (Cleveland Clinic score 8/20). What is the most appropriate definitive management?
- A. Intensive endoscopic polypectomy sessions every 3 months
- B. Completion proctectomy with end ileostomy (Correct Answer)
- C. Radiofrequency ablation of the rectal polyps
- D. Increase dose of sulindac or celecoxib and repeat surveillance in 6 months
- E. Transanal endoscopic microsurgery (TEMS) for the largest polyps
Explanation: ***Completion proctectomy with end ileostomy***- In **Familial Adenomatous Polyposis (FAP)**, the discovery of **high-grade dysplasia** in the retained rectum is a definitive indication for surgical removal due to the extremely high risk of progression to **rectal cancer**.- While an ileal pouch-anal anastomosis (IPAA) is an alternative, this patient’s baseline **faecal incontinence** (Cleveland Clinic score 8/20) makes a permanent **end ileostomy** the most appropriate functional choice to ensure quality of life.*Intensive endoscopic polypectomy sessions every 3 months*- This approach is insufficient because **high-grade dysplasia** represents a failure of endoscopic management and is an absolute indication for surgery.- Endoscopic surveillance is only appropriate when polyps are small, few in number, and show no signs of **advanced histology** or dysplasia.*Radiofrequency ablation of the rectal polyps*- Ablation is not a standard or validated treatment for diffuse **adenomatous polyposis** in the rectum and carries a high risk of incomplete treatment.- It does not address the underlying **genetic predisposition** of the rectal mucosa to undergo further malignant transformation.*Increase dose of sulindac or celecoxib and repeat surveillance in 6 months*- While **NSAIDs** like sulindac can reduce the number and size of polyps, they cannot reliably reverse **high-grade dysplasia** or replace surgical intervention.- Delaying surgery for 6 months in the presence of dysplasia significantly increases the risk of interval **adenocarcinoma** development.*Transanal endoscopic microsurgery (TEMS) for the largest polyps*- **TEMS** is designed for the excision of a specific, localized lesion, but it is not effective for managing the **extensive rectal polyps** seen in FAP.- This technique would leave behind other high-risk mucosa, necessitating eventual **radical proctectomy** anyway.
Question 206: A 31-year-old man presents to the emergency department with sudden onset severe right-sided groin pain radiating to the testis that began 4 hours ago while lifting weights. On examination, there is a tender, firm, non-reducible mass in the right groin above the inguinal ligament, with overlying skin erythema. The right testis appears normal. He reports having a longstanding groin lump that usually reduces. Heart rate is 105 bpm, blood pressure 138/82 mmHg, temperature 37.6°C. What is the most appropriate immediate management?
- A. Attempt gentle manual reduction with analgesia and sedation
- B. Emergency surgical exploration and hernia repair within 6 hours (Correct Answer)
- C. Urgent ultrasound of the groin and testis to assess blood flow
- D. CT abdomen and pelvis with intravenous contrast
- E. Admit for observation with analgesia and reassess in 6 hours
Explanation: ***Emergency surgical exploration and hernia repair within 6 hours*** - The presence of a **tender, firm, non-reducible mass** in the groin, severe pain, and **overlying skin erythema**, along with systemic signs like **tachycardia** and mild fever, are classic indicators of a **strangulated hernia**. - **Immediate surgical exploration** is crucial within **4-6 hours** to prevent irreversible **bowel necrosis**, perforation, and sepsis, which are life-threatening complications. *Attempt gentle manual reduction with analgesia and sedation* - Manual reduction is **contraindicated** when there are clear signs of strangulation (e.g., **skin erythema**, tenderness, non-reducibility), as it risks reducing **ischemic or necrotic bowel** into the abdomen, leading to peritonitis. - Such attempts can also cause **reduction-en-masse**, where the hernia sac is reduced with its contents still incarcerated, masking the true emergency. *Urgent ultrasound of the groin and testis to assess blood flow* - While ultrasound can assess hernia contents and blood flow, it should **not delay definitive surgical intervention** in a patient with a clear clinical picture of a **strangulated hernia**. - The time-sensitive nature of bowel ischemia means that **clinical suspicion** should directly lead to surgical management without waiting for imaging. *CT abdomen and pelvis with intravenous contrast* - A CT scan would introduce **unnecessary and critical delays** in a situation requiring immediate surgical intervention to salvage potentially compromised bowel. - CT is typically more useful for complex or atypical presentations of abdominal pain or hernias, not for a straightforward clinical diagnosis of strangulation. *Admit for observation with analgesia and reassess in 6 hours* - **Observation is inappropriate and dangerous** in suspected strangulated hernia, as it allows time for **bowel ischemia** to progress to irreversible **gangrene** and perforation. - The patient's systemic signs (tachycardia, mild fever) demand urgent escalation of care, not delayed reassessment, due to the high risk of sepsis.
Question 207: A 57-year-old man undergoes surveillance colonoscopy 18 months after curative resection of a pT3N1 sigmoid adenocarcinoma. He had completed adjuvant chemotherapy with FOLFOX. The colonoscopy identifies a 12 mm pedunculated polyp in the ascending colon. Histology shows a well-differentiated adenocarcinoma within the polyp with invasion into the stalk (Haggitt level 3), clear margins (>2mm), no lymphovascular invasion, and favourable histological grade. What is the most appropriate management?
- A. Right hemicolectomy within 4-6 weeks
- B. Endoscopic surveillance colonoscopy in 3 months
- C. Repeat colonoscopy with attempt at further endoscopic resection of the stalk base
- D. Adjuvant chemotherapy with capecitabine for 6 months
- E. Endoscopic surveillance colonoscopy in 12 months with standard metachronous surveillance protocol (Correct Answer)
Explanation: ***Endoscopic surveillance colonoscopy in 12 months with standard metachronous surveillance protocol*** - This **malignant polyp (pT1)** meets all criteria for definitive endoscopic management: **clear margins (>1mm)**, well-differentiated grade, no **lymphovascular invasion**, and **Haggitt level 3** (invasion limited to the stalk). - Because the risk of **lymph node metastasis** is exceptionally low (<2%) with these favorable features, surgical resection is unnecessary, and the patient follows standard **metachronous cancer surveillance**. *Right hemicolectomy within 4-6 weeks* - Radical surgery is not indicated because the polyp was completely excised with **clear margins** and lacked high-risk features like **lymphovascular invasion** or poor differentiation. - **Haggitt level 4** (invasion into the bowel wall submucosa) or **Kikuchi Sm3** would warrant resection, but level 3 in a pedunculated polyp does not. *Endoscopic surveillance colonoscopy in 3 months* - While some localized protocols suggest early site checks, standard guidelines for a completely excised **pT1 cancer** with favorable features and clear margins usually integrate into the **12-month surveillance** cycle. - A 3-month check is more appropriate if there was **piecemeal resection** or uncertainty regarding the completeness of the endoscopic excision. *Repeat colonoscopy with attempt at further endoscopic resection of the stalk base* - This intervention is unnecessary because the pathology confirmed **clear margins (>2mm)**, indicating the cancer was entirely removed during the initial procedure. - Further resection of the base would provide no additional oncological benefit and increases the risk of **perforation** or complications. *Adjuvant chemotherapy with capecitabine for 6 months* - Adjuvant chemotherapy is strictly reserved for **Stage III (node-positive)** or high-risk **Stage II** colon cancer; it has no role in **Stage I (T1N0)** disease. - The patient has already received **FOLFOX** for his previous sigmoid cancer, and there is no evidence that further chemotherapy prevents recurrence of a completely excised **pT1 lesion**.
Question 208: Which of the following statements best describes the anatomical relationship between the inferior epigastric artery and the different types of inguinal hernias?
- A. Both direct and indirect inguinal hernias occur lateral to the inferior epigastric artery
- B. Direct inguinal hernias occur lateral to the inferior epigastric artery, while indirect hernias occur medial to it
- C. Direct inguinal hernias occur medial to the inferior epigastric artery, while indirect hernias occur lateral to it (Correct Answer)
- D. The inferior epigastric artery passes through the deep inguinal ring between direct and indirect hernias
- E. Femoral hernias occur medial to the inferior epigastric artery and below the inguinal ligament
Explanation: ***Direct inguinal hernias occur medial to the inferior epigastric artery, while indirect hernias occur lateral to it*** - **Direct inguinal hernias** protrude through **Hesselbach's triangle**, an area of weakness in the posterior wall of the inguinal canal, which is bounded laterally by the **inferior epigastric artery**. - **Indirect inguinal hernias** follow the path of the **spermatic cord** or round ligament, entering the **deep inguinal ring**, which is anatomically located **lateral** to the inferior epigastric vessels. *Both direct and indirect inguinal hernias occur lateral to the inferior epigastric artery* - This statement is incorrect because the **inferior epigastric artery** serves as a crucial anatomical landmark that differentiates between direct and indirect inguinal hernias. - While **indirect hernias** are lateral to this artery, **direct hernias** are found medial to it. *Direct inguinal hernias occur lateral to the inferior epigastric artery, while indirect hernias occur medial to it* - This statement reverses the correct anatomical relationship; **indirect inguinal hernias** are lateral, originating from the deep inguinal ring, whereas **direct inguinal hernias** are medial, pushing through Hesselbach's triangle. - Misunderstanding this relationship can lead to errors in surgical repair and clinical diagnosis. *The inferior epigastric artery passes through the deep inguinal ring between direct and indirect hernias* - The **inferior epigastric artery** runs superiorly in the preperitoneal space, along the medial border of the **deep inguinal ring**, but does not pass through it. - The **deep inguinal ring** is an opening in the transversalis fascia, situated lateral to the artery, serving as the entrance for the spermatic cord (or round ligament) into the inguinal canal. *Femoral hernias occur medial to the inferior epigastric artery and below the inguinal ligament* - While **femoral hernias** occur **below the inguinal ligament**, their primary anatomical relationship is to the **femoral canal** and the **femoral vein**, typically found medial to the femoral vein. - The **inferior epigastric artery** is a landmark for inguinal hernias and is located superior to the inguinal ligament, making its direct relation to femoral hernia location less central.
Question 209: During elective open right hemicolectomy for caecal adenocarcinoma, the surgeon notes multiple small white nodules throughout the peritoneum. Frozen section confirms metastatic adenocarcinoma. The patient is otherwise well with good performance status. The primary tumour is still resectable without technical difficulty. What is the most appropriate intraoperative decision?
- A. Abandon the operation and close the abdomen for systemic chemotherapy
- B. Proceed with right hemicolectomy and take peritoneal biopsies (Correct Answer)
- C. Perform right hemicolectomy and debulk as much peritoneal disease as possible
- D. Convert to palliative bypass procedure only
- E. Perform right hemicolectomy, complete cytoreductive surgery, and hyperthermic intraperitoneal chemotherapy (HIPEC)
Explanation: ***Proceed with right hemicolectomy and take peritoneal biopsies***- Resecting the **primary tumor** is the preferred approach as it prevents future **obstruction, bleeding, or perforation**, even in the presence of metastatic disease.- **Peritoneal biopsies** provide essential histological confirmation and mapping of the disease extent to guide future systemic or cytoreductive therapies.*Abandon the operation and close the abdomen for systemic chemotherapy*- Leaving the **primary tumor** in situ places the patient at a high risk of developing **intestinal obstruction** or terminal complications while on chemotherapy.- This approach is generally reserved for patients with an **unresectable** primary or those who are medically unfit for the procedure.*Perform right hemicolectomy and debulk as much peritoneal disease as possible*- Extensive **debulking** for colorectal peritoneal metastases is not the standard of care as it does not improve survival compared to systemic therapy alone.- Unlike ovarian or appendiceal cancers, **colorectal carcinomatosis** requires a specific, planned approach rather than unplanned intraoperative debulking.*Convert to palliative bypass procedure only*- A **bypass procedure** is only indicated if the primary tumor is technically **unresectable**, which is not the case in this scenario.- Bypass leaves the **caecal adenocarcinoma** in place, failing to address potential issues like tumor-related bleeding or chronic anemia.*Perform right hemicolectomy, complete cytoreductive surgery, and hyperthermic intraperitoneal chemotherapy (HIPEC)**- **HIPEC** is a highly specialized procedure that requires careful **patient selection**, specialized equipment, and multidisciplinary team (MDT) discussion.- It is not appropriate to initiate an unplanned **cytoreductive surgery** and HIPEC during a routine elective hemicolectomy without prior consent and preparation.
Question 210: A 24-year-old woman presents with acute right iliac fossa pain and pyrexia. Ultrasound findings show an appendix diameter of 8mm, non-compressible, with surrounding free fluid and a small amount of pericaecal inflammatory change. Blood tests show WCC 13.2 × 10⁹/L and CRP 45 mg/L. She is haemodynamically stable. A pregnancy test is negative. What is the most appropriate management approach?
- A. Conservative management with intravenous antibiotics and interval appendicectomy at 6-8 weeks
- B. Immediate laparoscopic appendicectomy (Correct Answer)
- C. CT abdomen and pelvis before deciding on management
- D. Discharge with oral antibiotics and review in 48 hours
- E. Observation for 24 hours then reassess imaging and inflammatory markers
Explanation: ***Immediate laparoscopic appendicectomy***- The patient presents with clinical features (acute right iliac fossa pain, pyrexia, raised WCC and CRP) and **ultrasound findings** (8mm non-compressible appendix, free fluid, pericaecal inflammation) highly suggestive of **acute appendicitis**.- **Laparoscopic appendicectomy** is the gold standard treatment for acute appendicitis, offering minimal invasiveness and allowing for exclusion of **gynaecological pathology** in young women.*Conservative management with intravenous antibiotics and interval appendicectomy at 6-8 weeks*- This approach is primarily reserved for patients with an **appendiceal mass** or phlegmon, typically presenting after several days of symptoms with a contained inflammatory process.- The patient's presentation is acute, suggesting **uncomplicated appendicitis**, where immediate surgical intervention is generally preferred over a delayed approach.*CT abdomen and pelvis before deciding on management*- **Ultrasound findings are diagnostic** for appendicitis in this young, thin patient, making further imaging with CT unnecessary and exposing her to **ionizing radiation**.- CT is usually reserved for cases with **equivocal ultrasound findings**, suspected complications like abscess, or where the diagnosis remains uncertain despite initial imaging.*Discharge with oral antibiotics and review in 48 hours*- Discharging a patient with confirmed **acute appendicitis** is inappropriate and unsafe due to the high risk of **appendiceal perforation**, peritonitis, and subsequent severe morbidity.- Acute appendicitis requires urgent **inpatient management** and often surgical intervention to prevent progression and complications.*Observation for 24 hours then reassess imaging and inflammatory markers*- This patient has definitive clinical and imaging evidence of acute appendicitis; therefore, delaying surgery for **observation** increases the risk of **appendiceal rupture** and subsequent complications like sepsis.- Observation is typically considered only for patients with **equivocal diagnosis** or mild, resolving symptoms, which is not the case here.
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