Find the Complete Guide here
Clinical Station 1
You are asked to see a 67 year old retired architect who had a right hemicolectomy through a right paramedial incision for caecal carcinoma. Post operatively, he had a prolonged period for paralytic ileus requiring passage of an NG tube for suction and IV fluids. He passed flatus on day 6 post operatively. Despite this, his notes suggest ongoing abdominal distension. On day ten post operatively, after transfer to a general surgical ward, he suffered a prolonged episode of coughing and called the nurses because of pain in his abdomen and some pink 'watery' fluid coming from his wound. You are called to assess him
Discuss your initial management of this patient.
Over the phone I would ensure that the essential initial steps had been taken, asking for his observations, the patient’s symptoms and their current state, and assessing what level of input was needed. If he were deteriorating, I would ask them to get further help, for instance putting out a medical emergency call if appropriate, before immediately attending to the patient.
I would proceed by assessing the patients airway, breathing and circulation, ensuring that he was haemodynamically stable. Providing the patient was conscious, I would reassure the gentleman and ensure that appropriate analgesia was prescribed. I would then contact my senior colleagues as this patient would need to be returned to theatre for wound exploration under a general anaesthetic before complete rupture could occur.
I would proceed by assessing the patients airway, breathing and circulation, ensuring that he was haemodynamically stable. Providing the patient was conscious, I would reassure the gentleman and ensure that appropriate analgesia was prescribed. I would then contact my senior colleagues as this patient would need to be returned to theatre for wound exploration under a general anaesthetic before complete rupture could occur.
The ‘pink fluid sign’ described here is produced by blood tinged serous peritoneal exudate, which oozes through the weakened abdominal wound. This can progress over a number of days. It is a warning sign that precedes complete wound dehiscence.
You leave the patient to try and contact your registrar. However, you are then called to a cardiac arrest which you have to attend. You return to the patient 90 minutes later to find a distressed patient complaining of a ‘lump coming from his stomach. The patient is in moderate discomfort.
You leave the patient to try and contact your registrar. However, you are then called to a cardiac arrest which you have to attend. You return to the patient 90 minutes later to find a distressed patient complaining of a ‘lump coming from his stomach. The patient is in moderate discomfort.
How could this patient be most effectively managed at this stage?
This patient will need immediate transfer to theatre. "The patient has suffered a wound dehiscence. I would assess their airway, breathing and circulation and treat as required. The patient would likely be extremely distressed and I would reassure the patient. I would give intravenous morphine, both as a sedation and preanaestheic medication, together with an antiemetic to prevent opiate induced retching that could result in more bowel escaping from the abdomen. I would ensure my consultant was aware and prepare the patient for theatre. I would not attempt to reduce the bowel. The rigidity of the abdominal wall would not allow this and it would be extremely painful. I would cover the exposed viscera with a sterile towel or large dressing soaked in warm normal saline and keep this in place with a bandage if necessary. I would then fast-bleep my registrar immediately and ready the patient for surgery. This would include ensuring that a valid group and save or crossmatch was available and that an anaesthetist and emergency theatre was made available.
What Factors could be Responsible for this Emergency?
There are preoperative, operative and postoperative factors that may be responsible. Preoperative factors that impair normal wound healing include diabetes and poorly controlled blood sugar, Vitamin C deficiency, protein deficiency, uraemia, jaundice and anaemia.
Operative factors may be due to surgical error or poor technique. Using the wrong suture material, placing sutures too close to the wound edge, poorly tied knots with the ends cut too close to, or indeed through the knot can all lead to wound dehiscence. Post operatively anything that increases pressure in the abdomen such as obesity or a chronic cough can put pressure on the abdominal wound.
You don't have to mention all the possible factors, but its good to break it down into sections, demonstrating that you have an organised mind and can think logically about a surgical problem
Operative factors may be due to surgical error or poor technique. Using the wrong suture material, placing sutures too close to the wound edge, poorly tied knots with the ends cut too close to, or indeed through the knot can all lead to wound dehiscence. Post operatively anything that increases pressure in the abdomen such as obesity or a chronic cough can put pressure on the abdominal wound.
You don't have to mention all the possible factors, but its good to break it down into sections, demonstrating that you have an organised mind and can think logically about a surgical problem
What is the best way to suture an abdominal wound?
A mass closure technique should be used. All layers of the abdominal wall apart from the skin and subcutaneous tissue are picked up a minimum of 1cm from the wound edge on either side and the sutures inserted 1 cm or less apart. The skin is closed as a separate layer. This gives the maximal strength to the abdominal wound, reducing the risk of dehiscence.
Suture material used to repair an abdominal wound should be non absorbable (eg: nylon) or only slowly absorbable (eg: PDS) material and should not be too fine. Size 1 is commonly used.
Suture material used to repair an abdominal wound should be non absorbable (eg: nylon) or only slowly absorbable (eg: PDS) material and should not be too fine. Size 1 is commonly used.
What is Jenkins Rule?
It is a rule for closure of the abdominal wound. It states that for a continuous suture, the length of suture used should be at least four times the length of the wound with sutures 1cm apart and with 1cm bites of the wound edge
How should this wound be repaired?
Repair should be carried out using interrupted nylon sutures, which are passed through all layers of the abdominal wall, including the skin. The sutures should be held open until all are inserted and then tied ‘seriatim’- (ie: one after the other in series), taking care not to damage underlying viscera.
If the deep layer of the abdominal wound gives way, but the skin sutures stay intact, what would be resultant diagnosis?
Incisional Hernia
Advice
This is typical of the clinical station asked at the core surgical interview. It requires some clinical knowledge, but is mainly testing that you are a safe doctor, and know to ask for senior support early. We like the way this candidate gets into the scenario and says exactly what he would do in real life. You do assess the severity of a patient over the phone, and need to know the observations in order to assess whether you are capable of dealing with the situation as it is, or whether more help is required. This candidate is also direct with his answers, which suits the question and answer style at the interview. It is not like an old school viva where they want you to list the 10 causes of clubbing using a surgical sieve, rather the interviewers have certain questions to get through. Therefore you should be structured in how you answer but also direct and to the point. Being wooly will waste time and not present a confident knowledgeable candidate. So say what you would do, and then stop. If they want more, then they will ask you further questions. The interviewers are genuinely there to help you, and will do their best to prompt you in the right direction
Clinical stations were previously weighted the most heavily (50%), although this year they have indicated that each will be worth 1/3. Regardless it is important to do well in this station. Unfortunately it is the hardest to predict as they can pick on any speciality and choose a scenario. Luckily, the scenario has to be a commonly encountered one, so that everyone applying has got a good chance of having dealt with something similar if they have focused on developing their core surgical clinical skills during foundation training as expected of those applying. As a result, you can get together with peers, and perhaps a supportive registrar or consultant who can advice you on common surgical scenarios that you should be able to manage. If they come up, having gone through a similar scenario with your peers or seniors is a massive advantage on the day, and will allow you to deal with the subtle differences and twists that an interviewer can throw in. We have included several commonly asked clinical questions in the Guide to the Core Surgical Interview to try to facilitate your practice and make suggestions on how best to answer them when you are under the pressure of an interview situation.