A 31-year-old man presents with a 26-hour history of right iliac fossa pain that initially started periumbilically. He has vomited three times and has anorexia. On examination, temperature is 37.8°C, heart rate 92 bpm, blood pressure 128/76 mmHg. There is tenderness and guarding in the right iliac fossa. Blood tests show white cell count 13.8 × 10⁹/L with neutrophilia. Alvarado score is calculated as 8. What is the most appropriate next step in management?
Q52
A 63-year-old man undergoes colonoscopy for investigation of a positive faecal immunochemical test. A 3.5 cm circumferential tumour is identified at 25 cm from the anal verge in the sigmoid colon. Biopsies confirm moderately differentiated adenocarcinoma. Staging CT chest, abdomen and pelvis shows the primary tumour with thickening of the bowel wall, three enlarged local lymph nodes but no distant metastases. Which classification system provides the most comprehensive prognostic information for treatment planning in colorectal cancer?
Q53
A 56-year-old man presents to the surgical outpatient clinic with a 6-month history of a painless right groin swelling that enlarges on standing and straining, and reduces when lying down. On examination, you identify a mass that extends into the scrotum. During assessment of the hernia, you apply pressure over the deep inguinal ring and ask the patient to cough. The hernia does not reappear. What is the most likely diagnosis?
Q54
A 44-year-old woman presents to the emergency department with a 22-hour history of worsening right iliac fossa pain, nausea, and fever. On examination, she has tenderness and guarding in the right iliac fossa. Her white cell count is 15.2 × 10⁹/L and C-reactive protein is 78 mg/L. CT abdomen and pelvis shows an inflamed appendix with surrounding fat stranding. She undergoes laparoscopic appendicectomy. What is the most common anatomical layer that forms the outer longitudinal muscle layer of the appendix?
Q55
A 78-year-old man with known hereditary non-polyposis colorectal cancer (Lynch syndrome) presents with iron deficiency anaemia (Hb 82 g/L). Colonoscopy identifies a 4.5 cm ulcerated mass in the transverse colon. Biopsy confirms adenocarcinoma with high microsatellite instability (MSI-H). Staging CT shows no metastases but incidentally notes three 8-12 mm polyps in the ascending colon. Which surgical procedure is most appropriate?
Q56
A 29-year-old woman at 16 weeks gestation presents to the emergency department with a 24-hour history of lower abdominal pain, initially central but now localised to the right lower quadrant. She has vomited once and has a temperature of 37.6°C. Examination reveals tenderness in the right flank and right lumbar region. Blood tests show WCC 13.1 × 10⁹/L and CRP 38 mg/L. Urinalysis is normal. What is the most appropriate initial imaging investigation?
Q57
A 63-year-old woman presents with a 10-week history of altered bowel habit (increased frequency), intermittent rectal bleeding, and 6 kg weight loss. Digital rectal examination reveals a firm, ulcerated mass on the anterior wall 7 cm from the anal verge. Rigid sigmoidoscopy confirms a circumferential tumour. Biopsy shows adenocarcinoma. Staging CT chest/abdomen/pelvis shows no distant metastases. MRI pelvis shows a T3 tumour with threatened circumferential resection margin (CRM <1 mm) and 3 enlarged perirectal lymph nodes. What is the most appropriate treatment strategy?
Q58
A 35-year-old male manual labourer presents with a 4-month history of a painless right groin swelling that appears when standing and disappears when lying down. On examination with the patient standing, there is a 3 cm swelling in the right groin above and medial to the pubic tubercle. A cough impulse is present. The swelling reduces easily when the patient lies supine. He has no significant past medical history and his BMI is 24 kg/m². What is the most appropriate definitive management?
Q59
A 52-year-old man undergoes colonoscopy for change in bowel habit. A 25 mm flat polyp is identified in the caecum. Following attempted endoscopic mucosal resection, the polyp is removed piecemeal. Histology shows a tubulovillous adenoma with high-grade dysplasia. The resection is reported as complete but margins cannot be assessed due to piecemeal resection and cautery artefact. There is no evidence of invasive malignancy. What is the most appropriate next step in management?
Q60
A 46-year-old man presents to the emergency department with a 30-hour history of right iliac fossa pain, fever (38.4°C), and leucocytosis (WCC 18.2 × 10⁹/L). CT scan shows an inflamed appendix (diameter 12 mm) with surrounding fat stranding and a 5 cm × 4 cm pericaecal fluid collection. He is haemodynamically stable and tolerating oral fluids. What is the most appropriate initial management strategy?
General Surgery UK Medical PG Practice Questions and MCQs
Question 51: A 31-year-old man presents with a 26-hour history of right iliac fossa pain that initially started periumbilically. He has vomited three times and has anorexia. On examination, temperature is 37.8°C, heart rate 92 bpm, blood pressure 128/76 mmHg. There is tenderness and guarding in the right iliac fossa. Blood tests show white cell count 13.8 × 10⁹/L with neutrophilia. Alvarado score is calculated as 8. What is the most appropriate next step in management?
A. Proceed directly to laparoscopic appendicectomy (Correct Answer)
B. Request CT abdomen and pelvis before surgical intervention
C. Perform diagnostic laparoscopy
D. Commence antibiotics and observe for 24 hours
E. Arrange ultrasound scan of the abdomen
Explanation: ***Proceed directly to laparoscopic appendicectomy***
- An **Alvarado score of 8** indicates a high probability of acute appendicitis, and in a young male with classic clinical findings, definitive surgical management is the priority.
- The presentation of **migratory pain**, anorexia, fever, and **leucocytosis with neutrophilia** provides sufficient diagnostic certainty to bypass imaging and avoid delays that could lead to perforation.
*Request CT abdomen and pelvis before surgical intervention*
- While **CT imaging** has high sensitivity, it is typically reserved for equivocal cases (Alvarado score 4–6) or populations with higher diagnostic uncertainty seperti the elderly.
- Unnecessary imaging in a clear clinical case can lead to **delay in treatment** and increased healthcare costs without changing the management outcome.
*Perform diagnostic laparoscopy*
- This implies an exploratory procedure, but since the clinical diagnosis is highly likely, the intent should be **therapeutic appendicectomy** from the outset.
- **Laparoscopic appendicectomy** is the gold standard for both confirming the diagnosis and removing the inflamed appendix simultaneously.
*Commence antibiotics and observe for 24 hours*
- Delaying surgery for observation increases the risk of progression to **gangrenous appendicitis** or **free perforation** in a patient who already has localized guarding.
- While some uncomplicated cases are managed conservatively, a high **Alvarado score** and clinical systemic signs like tachycardia and fever mandate surgical intervention.
*Arrange ultrasound scan of the abdomen*
- Ultrasound is often user-dependent and is primarily useful in **pediatric patients** or **pregnant women** to avoid ionizing radiation.
- In an adult male where the clinical picture is classic, an **ultrasound** is unlikely to add valuable information and may yield a false negative.
Question 52: A 63-year-old man undergoes colonoscopy for investigation of a positive faecal immunochemical test. A 3.5 cm circumferential tumour is identified at 25 cm from the anal verge in the sigmoid colon. Biopsies confirm moderately differentiated adenocarcinoma. Staging CT chest, abdomen and pelvis shows the primary tumour with thickening of the bowel wall, three enlarged local lymph nodes but no distant metastases. Which classification system provides the most comprehensive prognostic information for treatment planning in colorectal cancer?
A. Dukes classification
B. Modified Astler-Coller classification
C. TNM staging system (Correct Answer)
D. Jass classification
E. Vienna classification
Explanation: ***TNM staging system***- The **TNM system** (Tumor, Node, Metastasis) is the global gold standard for colorectal cancer, offering the most granular detail regarding **depth of invasion**, nodal involvement, and metastases.- It provides superior **prognostic accuracy** compared to legacy systems and is essential for determining the need for **adjuvant chemotherapy** and surgical planning.*Dukes classification*- This is an older system (A-D) that is less precise; it has been largely **superseded** by TNM because it does not account for the number of affected lymph nodes or different T stages.- It lacks the **stratification** required for modern multidisciplinary team decisions and therapeutic protocols.*Modified Astler-Coller classification*- An extension of the original Dukes system that specifically focuses on the **extent of bowel wall penetration** and lymph node status.- While more detailed than Dukes, it remains less comprehensive than **TNM** and is no longer the standard for oncology reporting.*Jass classification*- This system focuses on **histological features** such as tumor lymphocytic infiltration and growth patterns rather than anatomical spread alone.- It is primarily used in a **research context** and does not provide the standardized anatomical staging necessary for initial treatment planning.*Vienna classification*- This classification is used specifically for the **standardization of terminology** in gastrointestinal epithelial neoplasia (epithelial dysplasia).- It is helpful for categorizing **precancerous lesions** and early mucosal changes but is not a staging system for invasive **adenocarcinoma**.
Question 53: A 56-year-old man presents to the surgical outpatient clinic with a 6-month history of a painless right groin swelling that enlarges on standing and straining, and reduces when lying down. On examination, you identify a mass that extends into the scrotum. During assessment of the hernia, you apply pressure over the deep inguinal ring and ask the patient to cough. The hernia does not reappear. What is the most likely diagnosis?
A. Direct inguinal hernia
B. Indirect inguinal hernia (Correct Answer)
C. Femoral hernia
D. Spigelian hernia
E. Obturator hernia
Explanation: ***Indirect inguinal hernia***
- This hernia passes through the **deep inguinal ring** and often descends into the **scrotum**, following the path of the spermatic cord.
- A positive **internal ring occlusion test** (the hernia does not reappear when pressure is applied over the deep ring) is pathognomonic for an **indirect hernia**.
*Direct inguinal hernia*
- Arises through **Hesselbach's triangle**, which is medial to the **inferior epigastric vessels**, and rarely enters the scrotum.
- In the **internal ring occlusion test**, a direct hernia will still bulge through despite pressure on the deep inguinal ring.
*Femoral hernia*
- Located **inferior and lateral** to the pubic tubercle, passing through the **femoral canal** rather than the inguinal canal.
- More common in **females** and carries a much higher risk of **incarceration** and strangulation due to the rigid boundaries of the femoral ring.
*Spigelian hernia*
- Occurs through the **Spigelian fascia** (aponeurosis of the transversus abdominis) at the **semilunar line**.
- Typically presents as a lateral abdominal wall bulge rather than a groin or scrotal swelling.
*Obturator hernia*
- Protrudes through the **obturator foramen** and is often non-palpable until it causes **bowel obstruction**.
- Often presents with the **Howship-Romberg sign**, where pain radiates to the inner knee due to compression of the obturator nerve.
Question 54: A 44-year-old woman presents to the emergency department with a 22-hour history of worsening right iliac fossa pain, nausea, and fever. On examination, she has tenderness and guarding in the right iliac fossa. Her white cell count is 15.2 × 10⁹/L and C-reactive protein is 78 mg/L. CT abdomen and pelvis shows an inflamed appendix with surrounding fat stranding. She undergoes laparoscopic appendicectomy. What is the most common anatomical layer that forms the outer longitudinal muscle layer of the appendix?
A. The taeniae coli converge at the base of the appendix to form a complete longitudinal layer (Correct Answer)
B. The appendix has three distinct taeniae coli throughout its entire length
C. The outer longitudinal layer is derived from the greater omentum
D. The appendix has no longitudinal muscle layer, only circular muscle
E. The longitudinal layer is formed by the mesoappendix
Explanation: ***The taeniae coli converge at the base of the appendix to form a complete longitudinal layer***
- On the caecum, three **taeniae coli** (anterior, posteromedial, and posterolateral) converge at the base of the appendix to form a continuous **outer longitudinal muscle layer**.
- This anatomical landmark is crucial in surgery, as surgeons follow the taeniae to their convergence point to reliably locate a **retrocecal** or hidden appendix.
*The appendix has three distinct taeniae coli throughout its entire length*
- While the caecum possesses three distinct muscular bands, they fuse at the **base of the appendix** to become a uniform layer.
- The appendix itself does not have **taeniae**, distinguishing its muscular architecture from the rest of the colon.
*The outer longitudinal layer is derived from the greater omentum*
- The **greater omentum** is a peritoneal fold (mesentery) and does not contribute to the direct **muscularis externa** of the gastrointestinal tract.
- The muscular layers of the appendix are intrinsic to the organ wall and originate from the **mesoderm-derived** muscular layer of the embryonic midgut.
*The appendix has no longitudinal muscle layer, only circular muscle*
- The appendix, like other parts of the GI tract, possesses both an **inner circular** and an **outer longitudinal** muscle layer.
- The presence of a **complete longitudinal layer** is actually a defining feature that distinguishes the appendiceal wall from the haustrated colon.
*The longitudinal layer is formed by the mesoappendix*
- The **mesoappendix** is a triangular fold of peritoneum that carries the **appendicular artery** and nerves.
- It is an extrinsic support structure and does not form part of the **tunica muscularis** or the longitudinal muscle layer.
Question 55: A 78-year-old man with known hereditary non-polyposis colorectal cancer (Lynch syndrome) presents with iron deficiency anaemia (Hb 82 g/L). Colonoscopy identifies a 4.5 cm ulcerated mass in the transverse colon. Biopsy confirms adenocarcinoma with high microsatellite instability (MSI-H). Staging CT shows no metastases but incidentally notes three 8-12 mm polyps in the ascending colon. Which surgical procedure is most appropriate?
A. Extended right hemicolectomy to include the transverse colon lesion and ascending colon polyps
B. Segmental transverse colectomy with separate polypectomy of ascending colon lesions
C. Total colectomy with ileorectal anastomosis (Correct Answer)
D. Right hemicolectomy for the transverse colon cancer with planned colonoscopic polypectomy at 3 months
E. Subtotal colectomy with ileosigmoid anastomosis
Explanation: ***Total colectomy with ileorectal anastomosis***- In patients with **Lynch syndrome** (HNPCC) and confirmed colorectal cancer, a **total colectomy** is the preferred surgical approach due to the significantly high lifetime risk of developing **metachronous colorectal cancer** in the remaining colon.- This procedure effectively removes the index **transverse colon adenocarcinoma** and the synchronous **ascending colon polyps**, while minimizing the risk of future primary tumors by resecting the entire at-risk colonic mucosa.*Extended right hemicolectomy to include the transverse colon lesion and ascending colon polyps*- This procedure addresses the current cancer and polyps but leaves the entire **descending and sigmoid colon** intact, which remains at high risk for future cancers in **Lynch syndrome**.- While removing existing lesions, it fails to provide adequate prophylactic benefit against subsequent **metachronous cancers**, which is a primary concern in Lynch syndrome management.*Segmental transverse colectomy with separate polypectomy of ascending colon lesions*- This approach is entirely inadequate for **Lynch syndrome** patients, as it only removes the current cancer and polyps without addressing the underlying **high risk for future colorectal cancers** throughout the colon.- It would necessitate extremely intensive and frequent **colonoscopic surveillance** with a high likelihood of developing new cancers requiring further surgery.*Right hemicolectomy for the transverse colon cancer with planned colonoscopic polypectomy at 3 months*- This option is insufficient as it delays the management of **synchronous polyps** and provides only a limited resection, leaving a substantial amount of **at-risk colon** in a patient with **Lynch syndrome**.- The standard of care for **Lynch syndrome** with colorectal cancer is an extended resection to reduce the cumulative risk of future cancers, not a segmental resection with delayed polypectomy.*Subtotal colectomy with ileosigmoid anastomosis*- While a **subtotal colectomy** is a more extensive resection than hemicolectomy, leaving the **sigmoid colon** in place still carries a significant risk of developing **metachronous colorectal cancer** in that segment.- For optimal risk reduction in **Lynch syndrome**, a **total colectomy with ileorectal anastomosis** is generally preferred over ileosigmoid anastomosis to minimize the remaining at-risk colonic mucosa.
Question 56: A 29-year-old woman at 16 weeks gestation presents to the emergency department with a 24-hour history of lower abdominal pain, initially central but now localised to the right lower quadrant. She has vomited once and has a temperature of 37.6°C. Examination reveals tenderness in the right flank and right lumbar region. Blood tests show WCC 13.1 × 10⁹/L and CRP 38 mg/L. Urinalysis is normal. What is the most appropriate initial imaging investigation?
A. Transvaginal ultrasound scan
B. CT abdomen and pelvis with intravenous contrast
C. MRI abdomen and pelvis without contrast (Correct Answer)
D. Transabdominal ultrasound of right iliac fossa
E. No imaging required, proceed directly to diagnostic laparoscopy
Explanation: ***MRI abdomen and pelvis without contrast***
- **MRI without contrast** is the preferred imaging modality for suspected appendicitis in pregnant patients (16 weeks gestation) when ultrasound is inconclusive, as it avoids **ionizing radiation** and gadolinium exposure.
- It provides high sensitivity and specificity for identifying the appendix, which may be **displaced superiorly** and laterally by the gravid uterus, aligning with the patient's right flank and lumbar pain.
*Transvaginal ultrasound scan*
- This investigation is primarily used to evaluate **gynecological pathology** in early pregnancy, such as ectopic pregnancy or ovarian torsion.
- It would not be effective for visualizing the appendix at **16 weeks gestation**, as the appendix is displaced out of the pelvis by the enlarging uterus, and the pain is not pelvic.
*CT abdomen and pelvis with intravenous contrast*
- CT is highly accurate but involves **ionizing radiation**, presenting a potential risk of childhood malignancy or developmental issues for the fetus.
- It is generally reserved as a last resort in pregnancy if **MRI is unavailable** or contraindicated and the clinical suspicion is high.
*Transabdominal ultrasound of right iliac fossa*
- While often a first-line step for suspected appendicitis, its sensitivity decreases significantly in pregnancy due to the **displaced appendix** and difficulty visualizing it through the gravid uterus.
- In this scenario, where pain is localized to the **right flank/lumbar region** rather than the iliac fossa, a standard RIF ultrasound is less likely to be diagnostic.
*No imaging required, proceed directly to diagnostic laparoscopy*
- Proceeding directly to surgery without imaging in pregnant patients is associated with an unacceptably high **negative appendicectomy rate**.
- Preoperative imaging is strongly recommended to confirm the diagnosis and avoid the risks of **general anesthesia** and surgery to the fetus unless there are signs of peritonitis or hemodynamic instability.
Question 57: A 63-year-old woman presents with a 10-week history of altered bowel habit (increased frequency), intermittent rectal bleeding, and 6 kg weight loss. Digital rectal examination reveals a firm, ulcerated mass on the anterior wall 7 cm from the anal verge. Rigid sigmoidoscopy confirms a circumferential tumour. Biopsy shows adenocarcinoma. Staging CT chest/abdomen/pelvis shows no distant metastases. MRI pelvis shows a T3 tumour with threatened circumferential resection margin (CRM <1 mm) and 3 enlarged perirectal lymph nodes. What is the most appropriate treatment strategy?
A. Immediate total mesorectal excision (TME) with adjuvant chemotherapy
B. Long-course neoadjuvant chemoradiotherapy, followed by TME, followed by adjuvant chemotherapy (Correct Answer)
C. Short-course neoadjuvant radiotherapy (5 × 5 Gy), followed immediately by TME
D. Neoadjuvant chemotherapy alone, followed by TME and adjuvant chemoradiotherapy
E. Transanal endoscopic microsurgery (TEMS) followed by adjuvant chemoradiotherapy
Explanation: ***Long-course neoadjuvant chemoradiotherapy, followed by TME, followed by adjuvant chemotherapy***- The patient has **locally advanced rectal cancer** (T3, N1) with a **threatened circumferential resection margin (CRM <1 mm)**. This clinical scenario strongly indicates the need for **tumour downstaging** to achieve a curative R0 resection and minimize local recurrence.- **Long-course chemoradiotherapy** (LCRT) is the preferred neoadjuvant strategy for rectal cancers with threatened margins, as it provides maximal **tumour regression and downsizing**, thereby improving the likelihood of a negative surgical margin at the time of **total mesorectal excision (TME)**, followed by adjuvant chemotherapy for node-positive disease.*Immediate total mesorectal excision (TME) with adjuvant chemotherapy*- Proceeding directly to **TME** with a **threatened CRM** (less than 1 mm) carries a very high risk of a **positive surgical margin** and subsequent **local recurrence**.- Neoadjuvant treatment is standard of care for locally advanced rectal cancer to downstage the tumour and improve the chances of a **complete (R0) resection**.*Short-course neoadjuvant radiotherapy (5 × 5 Gy), followed immediately by TME*- While **short-course radiotherapy** (SCRT) improves local control, it does not allow for significant **tumour downstaging** before surgery, which is crucial when the CRM is threatened.- For tumours with a **threatened CRM**, LCRT with a delayed TME (typically 8-12 weeks post-radiotherapy) is generally superior for achieving sufficient tumour regression and clearing the margin.*Neoadjuvant chemotherapy alone, followed by TME and adjuvant chemoradiotherapy*- **Radiotherapy** is a critical component of neoadjuvant therapy for locally advanced rectal cancer to reduce the risk of **local pelvic recurrence** and achieve tumour downstaging.- **Neoadjuvant chemotherapy alone** is currently not the standard of care for T3 N1 rectal cancer, especially with a threatened CRM, as it lacks the local control benefits of radiation.*Transanal endoscopic microsurgery (TEMS) followed by adjuvant chemoradiotherapy*- **TEMS** is an organ-preserving technique indicated only for **early T1 rectal cancers** without high-risk features like nodal involvement or deep invasion.- This patient has a **T3, N1, circumferential tumour** with a threatened CRM, which necessitates a formal **total mesorectal excision (TME)** for adequate oncological clearance and is beyond the scope of TEMS.
Question 58: A 35-year-old male manual labourer presents with a 4-month history of a painless right groin swelling that appears when standing and disappears when lying down. On examination with the patient standing, there is a 3 cm swelling in the right groin above and medial to the pubic tubercle. A cough impulse is present. The swelling reduces easily when the patient lies supine. He has no significant past medical history and his BMI is 24 kg/m². What is the most appropriate definitive management?
A. Laparoscopic totally extraperitoneal (TEP) repair (Correct Answer)
B. Laparoscopic transabdominal preperitoneal (TAPP) repair
C. Open mesh repair (Lichtenstein technique)
D. Open tissue repair (Shouldice technique)
E. Conservative management with observation only
Explanation: ***Laparoscopic totally extraperitoneal (TEP) repair*** - This patient presents with a **reducible inguinal hernia** and is a young, fit **manual labourer**, making him an ideal candidate for **laparoscopic repair**. - **TEP repair** is favored as it offers a **faster recovery**, a quicker return to heavy work, and a lower incidence of **chronic groin pain** by avoiding entry into the peritoneal cavity. *Laparoscopic transabdominal preperitoneal (TAPP) repair* - TAPP involves entering the **peritoneal cavity**, which carries a small but increased risk of **visceral injury** or adhesion formation compared to the extraperitoneal approach of TEP. - While effective, TAPP is generally considered for **recurrent hernias**, bilateral repairs, or when the anatomy is complex, whereas TEP is often preferred for primary unilateral cases. *Open mesh repair (Lichtenstein technique)* - Although a widely used and effective method, the **Lichtenstein technique** typically leads to a **longer recovery period** and delayed return to full activity for manual laborers compared to laparoscopic options. - It can also be associated with a slightly higher incidence of **chronic post-surgical pain** due to the more extensive open dissection and potential nerve entrapment. *Open tissue repair (Shouldice technique)* - The **Shouldice technique** is a non-mesh suture repair, which is technically demanding and generally has a **higher recurrence rate** compared to mesh-based repairs. - It is typically reserved for cases where **mesh is contraindicated**, such as in contaminated fields, rather than being a first-line option for primary repair in a healthy individual. *Conservative management with observation only* - Conservative management is generally recommended for **asymptomatic** or minimally symptomatic hernias, or in patients with significant **comorbidities** that make surgery high-risk. - For a symptomatic **manual labourer**, surgical repair is indicated to prevent complications like **incarceration** or **strangulation** and to allow a full and safe return to his profession.
Question 59: A 52-year-old man undergoes colonoscopy for change in bowel habit. A 25 mm flat polyp is identified in the caecum. Following attempted endoscopic mucosal resection, the polyp is removed piecemeal. Histology shows a tubulovillous adenoma with high-grade dysplasia. The resection is reported as complete but margins cannot be assessed due to piecemeal resection and cautery artefact. There is no evidence of invasive malignancy. What is the most appropriate next step in management?
A. Repeat colonoscopy at 3 months to assess for residual disease, with re-resection if required (Correct Answer)
B. CT staging followed by right hemicolectomy
C. Immediate right hemicolectomy without further imaging
D. MRI pelvis to assess depth of invasion followed by surgical planning
E. Repeat colonoscopy at 12 months with no immediate intervention
Explanation: ***Repeat colonoscopy at 3 months to assess for residual disease, with re-resection if required***
- For **large polyps** (>20 mm) with **high-grade dysplasia** removed via **piecemeal EMR**, inability to assess **clear margins** makes **early surveillance** mandatory to check for recurrence.
- Clinical guidelines recommend a **three-month follow-up colonoscopy** to inspect the scar site and perform further **endoscopic treatment** if residual adenomatous tissue is identified.
*CT staging followed by right hemicolectomy*
- **Staging imaging** and radical surgery are not indicated because histology showed **high-grade dysplasia** but no evidence of **invasive malignancy**.
- Surgery is reserved for cases where endoscopic management fails or invasive cancer with **high-risk features** is confirmed on pathology.
*Immediate right hemicolectomy without further imaging*
- This would be **over-treatment** for a benign tubulovillous adenoma and carries significant surgical **morbidity and mortality** risks.
- **Organ-preserving** endoscopic management is the preferred strategy as long as there is no evidence of deep invasion.
*MRI pelvis to assess depth of invasion followed by surgical planning*
- **MRI pelvis** is used primarily for the staging of **rectal cancer** to assess the mesorectal fascia and is not used for **caecal polyps**.
- Since the lesion was located in the **caecum**, this imaging modality is anatomically inappropriate for assessing depth of invasion.
*Repeat colonoscopy at 12 months with no immediate intervention*
- Waiting **12 months** is too long for a piecemeal resection of a high-grade lesion, as it increases the risk of residual tissue progressing to **invasive carcinoma**.
- Standard surveillance for **large non-pedunculated colorectal polyps** (LNPCPs) requires a shorter interval of **2-6 months** for the first check.
Question 60: A 46-year-old man presents to the emergency department with a 30-hour history of right iliac fossa pain, fever (38.4°C), and leucocytosis (WCC 18.2 × 10⁹/L). CT scan shows an inflamed appendix (diameter 12 mm) with surrounding fat stranding and a 5 cm × 4 cm pericaecal fluid collection. He is haemodynamically stable and tolerating oral fluids. What is the most appropriate initial management strategy?
A. Immediate laparoscopic appendicectomy with drainage of abscess
B. Immediate open appendicectomy via right iliac fossa incision
C. Intravenous antibiotics with CT-guided drainage of the abscess, followed by interval appendicectomy at 6-8 weeks (Correct Answer)
D. Intravenous antibiotics alone with interval appendicectomy at 6-8 weeks if abscess resolves
E. Intravenous antibiotics with percutaneous drainage only, with no planned interval appendicectomy
Explanation: ***Intravenous antibiotics with CT-guided drainage of the abscess, followed by interval appendicectomy at 6-8 weeks***- For a hemodynamically stable patient with a well-formed **appendiceal abscess** larger than **3-4 cm**, initial non-operative management with **antibiotics** and **percutaneous drainage** is the preferred strategy.- This approach allows for resolution of inflammation, making a subsequent **interval appendicectomy** safer with reduced risk of complications like bowel injury or fecal fistula.*Immediate laparoscopic appendicectomy with drainage of abscess*- Acute surgical intervention for a contained **appendiceal abscess** is associated with higher rates of **complications** (e.g., bowel injury, conversion to open, fistula formation) due to significant inflammation and friability.- This approach is typically reserved for patients with signs of **generalized peritonitis**, hemodynamic instability, or failure of conservative management.*Immediate open appendicectomy via right iliac fossa incision*- Similar to laparoscopic, immediate open surgery on an **appendiceal phlegmon** or abscess carries higher morbidity, including increased **wound infection** and longer hospital stays.- The goal of initial non-operative management is to convert a complex inflammatory process into a simpler surgical case at a later, less acute stage.*Intravenous antibiotics alone with interval appendicectomy at 6-8 weeks if abscess resolves*- While antibiotics are crucial, a **5 cm × 4 cm abscess** is a significant collection that requires physical drainage for effective resolution and to prevent treatment failure.- Relying solely on antibiotics for a large abscess (>3-5 cm) has a higher likelihood of requiring subsequent intervention due to inadequate source control.*Intravenous antibiotics with percutaneous drainage only, with no planned interval appendicectomy*- While some advocate for omitting interval appendicectomy after successful non-operative management, it is generally recommended to prevent **recurrent appendicitis** (up to 20% risk) and to **exclude underlying malignancy**, especially in older patients or atypical presentations.- Skipping interval appendicectomy means missing an opportunity to thoroughly examine the appendix and surrounding structures for other pathologies.
