Question 1 · Surgical Oncology · Hardest level
A 63-year-old man with well-controlled hypertension is investigated for two months of epigastric pain and 6 kg of weight loss. Endoscopy is normal. Contrast-enhanced computed tomography with a pancreatic protocol shows a 3 cm hypodense mass in the pancreatic head. The tumour abuts the superior mesenteric vein over 200 degrees of its circumference, with a short segment of vein narrowing but a reconstructible contour, and there is no arterial contact. There is no distant disease. Serum CA 19-9 is 620 U/mL. He has an Eastern Cooperative Oncology Group performance status of 0 and normal biliary drainage.
- AProceed directly to pancreaticoduodenectomy with planned venous resection and reconstruction
- BClassify the tumour as borderline resectable and give neoadjuvant systemic therapy with restaging before surgery
- CClassify the tumour as locally advanced and treat with definitive chemoradiotherapy alone
- DPerform a diagnostic laparoscopy and, if negative, proceed to a double bypass without resection
- EPerform total pancreatectomy to guarantee a negative pancreatic transection margin
Show the answer and the reasoning
Correct answer: B — Classify the tumour as borderline resectable and give neoadjuvant systemic therapy with restaging before surgery
Venous contact exceeding 180 degrees with a reconstructible vein and no arterial involvement defines borderline resectable disease, for which neoadjuvant systemic therapy followed by restaging is the current standard.
Why: Borderline anatomy predicts a high margin-positive rate if the patient goes straight to theatre. Neoadjuvant therapy treats occult micrometastatic disease and selects out those whose biology declares itself early. A markedly raised CA 19-9 reinforces the concern about systemic disease. Restaging after therapy identifies the patients who will genuinely benefit from a Whipple procedure.
Option A: Upfront resection in borderline anatomy raises the R1 rate and exposes rapid progressors to a major operation for no benefit.
Option C: Definitive chemoradiotherapy alone is reserved for truly locally advanced unresectable disease, usually with arterial encasement.
Option B: Correct — the anatomy is borderline and neoadjuvant therapy with restaging is the accepted route.
Option D: Bypass without an attempt at cure abandons a potentially resectable tumour in a fit man with no jaundice.
Option E: Total pancreatectomy does not address the venous margin, which is where the risk lies, and causes brittle diabetes.
Venous contact over 180 degrees with a reconstructible vein and no arterial involvement is borderline resectable pancreatic cancer, and the correct next step is neoadjuvant therapy with restaging, not immediate resection.
NCCN Guidelines, pancreatic adenocarcinoma
Question 2 · Benign Hepatopancreatobiliary Disease · Hardest level
A 38-year-old woman is undergoing laparoscopic cholecystectomy for a third episode of biliary colic. Preoperative magnetic resonance cholangiopancreatography showed a 2 cm stone impacted in Hartmann's pouch, extrinsic narrowing of the common hepatic duct, and a short segment where the gallbladder and duct appeared to share a wall over roughly one third of the duct circumference. Bilirubin was 62 µmol/L. At operation the hepatocystic triangle is a dense fibrotic mass and no plane can be developed between the gallbladder infundibulum and the common hepatic duct. Blood loss is minimal and she is stable. Which is the most appropriate intraoperative decision?
- AContinue laparoscopic dissection of the hepatocystic triangle until the cystic duct is unequivocally identified
- BClip and divide the structure entering the gallbladder that appears most likely to be the cystic duct, then complete the cholecystectomy
- CAbandon the operation, close, and refer for endoscopic stone extraction with no further surgery
- DPerform a top-down dissection from the fundus to define the anatomy from above
- EConvert to open, perform subtotal cholecystectomy leaving the posterior wall adherent, remove the stone, and repair or drain the duct defect with hepatobiliary input
Show the answer and the reasoning
Correct answer: E — Convert to open, perform subtotal cholecystectomy leaving the posterior wall adherent, remove the stone, and repair or drain the duct defect with hepatobiliary input
This is Mirizzi syndrome with a cholecystocholedochal fistula, and safety lies in converting and performing a subtotal cholecystectomy rather than pursuing a plane that does not exist.
Why: The gallbladder wall has eroded into the duct, so the two structures share a wall by definition. Persisting with dissection in this plane is how the duct is transected. Subtotal cholecystectomy removes the stone and the diseased anterior wall while leaving the posterior wall on the duct. The residual defect needs formal repair or controlled drainage, and this is a decision to take with hepatobiliary help, not alone.
Option A: Continued dissection in a frozen triangle with a fistula is precisely the manoeuvre that produces a Strasberg E injury.
Option B: Clipping the structure that looks most likely to be the cystic duct is the classical mechanism of major bile duct injury.
Option E: Correct — convert, go subtotal, and manage the duct defect with specialist input.
Option C: Endoscopic extraction cannot remove a 2 cm stone impacted in Hartmann's pouch with a fistula.
Option D: A top-down approach still ends at the fused infundibulum and duct, and offers no protection here.
In Mirizzi syndrome with a cholecystocholedochal fistula there is no safe plane between gallbladder and duct: convert, perform subtotal cholecystectomy and manage the duct defect deliberately.
SAGES multi-society safe cholecystectomy guideline, 2020 (Surg Endosc 2020;34:2827-2855); Strasberg classification of bile duct injury
Question 3 · Breast Disease · Hardest level
A 43-year-old woman undergoes wide local excision of a 26 mm grade 2 invasive carcinoma of no special type in the left breast with sentinel node biopsy. She was clinically and sonographically node-negative before surgery and had no neoadjuvant therapy. Whole-breast radiotherapy is planned and she has consented to it. The tumour is oestrogen receptor positive and HER2 negative, with no ink on tumour at any margin. Final histology reports three sentinel nodes retrieved, two of which contain macrometastases measuring 4 mm and 7 mm, with no extranodal extension. She is otherwise fit with no comorbidity and is 43 years old and premenopausal.
- ANo further axillary surgery; proceed to whole-breast radiotherapy and systemic therapy
- BReturn to theatre for completion level III axillary lymph node dissection
- CCompletion mastectomy with axillary dissection because two nodes are involved
- DRe-excision of the sentinel node bed only, without a formal dissection
- EAxillary dissection deferred until after adjuvant chemotherapy is completed
Show the answer and the reasoning
Correct answer: A — No further axillary surgery; proceed to whole-breast radiotherapy and systemic therapy
She meets the criteria under which completion axillary dissection can be safely omitted, so no further axillary surgery is required.
Why: The relevant criteria are a T1 or T2 tumour, one or two positive sentinel nodes, breast-conserving surgery, planned whole-breast radiotherapy and no neoadjuvant chemotherapy. She satisfies every one of them. Omitting dissection in this group does not compromise overall survival or locoregional control. It avoids lymphoedema, shoulder morbidity and sensory loss.
Option B: Completion dissection adds substantial arm morbidity without a survival or regional control benefit in exactly this patient group.
Option A: Correct — every eligibility criterion for omitting completion dissection is satisfied here.
Option C: The margins are clear and there is no indication to convert a successful conservation to mastectomy.
Option D: Re-excising the sentinel node bed is neither a recognised operation nor an adequate axillary clearance.
Option E: Deferring dissection until after chemotherapy does not remove its morbidity and is not a recognised strategy in this setting.
Completion axillary dissection may be omitted for one or two positive sentinel nodes only when the tumour is T1 to T2, the patient had breast-conserving surgery with planned whole-breast radiotherapy, and no neoadjuvant chemotherapy was given.
ESMO Clinical Practice Guidelines, early breast cancer
Question 4 · Trauma and Damage Control · Hardest level
A 29-year-old man sustains a shotgun wound to the left thigh at close range. The wound is in the medial thigh at the level of the adductor canal. The limb distal to the injury is cool and pale, there is no palpable popliteal or pedal pulse, and the ankle brachial index on that side cannot be recorded. Sensation over the dorsum of the foot is reduced. There is an obvious mid-shaft femoral fracture on the plain film. He is haemodynamically normal after two units of blood. There are no other injuries. Theatre is available now.
- AImmediate operative exploration with vascular shunt insertion, then skeletal fixation, then definitive repair
- BCT angiography of the limb before any operative intervention
- CDefinitive vein graft reconstruction first, followed by external fixation of the femur
- DExternal fixation of the femur first, then reassessment of the pulses before deciding on exploration
- ESystemic heparinisation and serial vascular observation with repeat ankle brachial index
Show the answer and the reasoning
Correct answer: A — Immediate operative exploration with vascular shunt insertion, then skeletal fixation, then definitive repair
Hard signs of vascular injury with a combined fracture mean theatre now, with a temporary shunt placed before the bone is fixed.
Why: Absent pulses with a cool pale limb are hard signs and require exploration, not imaging. In a combined vascular and skeletal injury the shunt restores perfusion within minutes and keeps the ischaemic clock from running while the orthopaedic team works. Fixing the bone first means an hour or more of continued ischaemia. Definitive repair is performed after fixation, when limb length is settled and the graft will not be torn or kinked.
Option B: Imaging delays revascularisation in a limb with hard signs where the diagnosis is already made.
Option A: Correct — shunt first restores flow, then fixation, then definitive repair at settled limb length.
Option C: A definitive graft placed before fixation risks disruption or inappropriate length once the femur is reduced.
Option D: Fixing the femur first adds substantial ischaemic time to a limb that is already threatened.
Option E: Anticoagulation and observation do not reperfuse an occluded artery and will cost the limb.
In combined vascular and skeletal limb injury, insert a temporary vascular shunt first, then fix the skeleton, then perform definitive vascular repair — perfusion should never wait for orthopaedic fixation.
ACS Committee on Trauma — Advanced Trauma Life Support, 11th edition (2025)
Question 5 · Vascular Surgery for the General Surgeon · Intermediate
A 62-year-old woman with type 2 diabetes of twenty years and end-stage renal failure attends the diabetic foot clinic. She has a two-centimetre ulcer over the plantar aspect of the left first metatarsal head, present for seven weeks, with surrounding callus but no erythema, fluctuance or discharge. She is apyrexial. Pedal pulses are impalpable. Ankle-brachial pressure index measures 1.4 on the left and 1.5 on the right. Monofilament sensation is absent to the mid-foot. Plain radiographs show no bone destruction and inflammatory markers are normal.
- AMeasure toe pressure or transcutaneous oxygen tension, as the ankle index is falsely elevated by medial calcification
- BReport the ankle-brachial index as normal and treat the ulcer as purely neuropathic with offloading alone
- CStart empirical broad-spectrum antibiotics and repeat radiographs in two weeks for suspected osteomyelitis
- DRefer directly for below-knee amputation given the duration of ulceration and dialysis dependence
- EArrange CT angiography of the lower limbs as the first investigation of perfusion
Show the answer and the reasoning
Correct answer: A — Measure toe pressure or transcutaneous oxygen tension, as the ankle index is falsely elevated by medial calcification
An ankle-brachial index above 1.3 in a diabetic dialysis patient is uninterpretable, so perfusion must be assessed with toe pressure or transcutaneous oximetry.
Why: Medial arterial calcification makes the tibial vessels non-compressible. The cuff then records an artefactually high pressure that can conceal severe occlusive disease. Digital arteries are usually spared, so a toe pressure remains valid. A toe pressure below 30 mmHg defines chronic limb-threatening ischaemia and mandates urgent vascular referral for revascularisation planning.
Option B: Calling a value of 1.4 normal is the classic trap; it is a marker of calcification, not of good flow.
Option A: Correct — toe pressure or transcutaneous oxygen tension bypasses the non-compressible tibial vessels.
Option C: There is no erythema, fever or raised inflammatory markers, so blind antibiotics treat a diagnosis she does not yet have.
Option D: Amputation before perfusion has even been measured forfeits a foot that revascularisation may well save.
Option E: Angiography is a roadmap for intervention, not the first-line physiological test, and carries contrast risk.
In diabetes or renal failure an ankle-brachial index above 1.3 means non-compressible calcified vessels and must never be read as normal; use toe pressure or transcutaneous oximetry instead.
ESVS guidelines, chronic limb-threatening ischaemia and diabetic foot
Question 6 · Emergency General Surgery · Intermediate
A 44-year-old woman presents with 30 hours of periumbilical pain that has shifted to the right iliac fossa, anorexia and two episodes of vomiting. She is haemodynamically stable, temperature 37.9°C, with localised right iliac fossa tenderness and no guarding elsewhere. White cell count is 14.2 x10^9/L and CRP is 62 mg/L. Contrast-enhanced CT shows a 12 mm appendix with periappendiceal fat stranding, no extraluminal gas, no free fluid and no collection. She has no significant comorbidity, is not pregnant, and asks whether she can avoid an operation because she is due to travel for work. Which is the most appropriate management?
- AProceed directly to emergency laparoscopic appendicectomy without further discussion, as surgery is the only accepted treatment
- BAdmit for intravenous antibiotics and arrange interval appendicectomy in eight weeks in all cases
- CDischarge on oral antibiotics with no follow-up arrangement, as recurrence is rare after a single episode
- DRequest an urgent MRI abdomen before committing to any treatment pathway
- EDiscuss antibiotic-first non-operative management and laparoscopic appendicectomy as alternatives, and agree a plan by shared decision-making
Show the answer and the reasoning
Correct answer: E — Discuss antibiotic-first non-operative management and laparoscopic appendicectomy as alternatives, and agree a plan by shared decision-making
This is uncomplicated appendicitis on CT, and current guidance treats antibiotic-first management and appendicectomy as two defensible options to be chosen with the patient.
Why: The CT shows no perforation, no gas and no abscess, so this is uncomplicated disease. Antibiotics alone succeed in a substantial proportion of such patients, but a meaningful minority recur and come to appendicectomy later. Appendicectomy is definitive but carries operative and anaesthetic risk. The choice therefore turns on the patient's own priorities, and the conversation must be documented.
Option A: Appendicectomy is a reasonable choice, but presenting it as the only option ignores an established alternative for uncomplicated disease.
Option E: Correct — it offers both evidence-based pathways and makes the decision jointly, which is what guidance requires.
Option B: Interval appendicectomy is a strategy for complicated disease managed non-operatively, not a routine follow-on after antibiotics for uncomplicated appendicitis.
Option C: Discharging without arranged review abandons a patient who has a real risk of failure or recurrence.
Option D: MRI adds nothing when a diagnostic CT has already been obtained in a non-pregnant adult, and delays treatment.
In CT-confirmed uncomplicated appendicitis, antibiotic-first management and appendicectomy are both acceptable, and the choice belongs to a documented shared decision with the patient.
WSES — Diagnosis and treatment of acute appendicitis — Jerusalem guidelines, 2025 edition (JAMA Surg 2026;161:283-295, PMID 41604201)
Question 7 · Bariatric and Metabolic Surgery · Intermediate
A 61-year-old man with type 2 diabetes of eight years' duration, previously requiring 78 units of insulin daily plus metformin, undergoes uncomplicated laparoscopic Roux-en-Y gastric bypass. His body mass index before surgery was 38 kg/m2 and his HbA1c was 8.1 per cent. Insulin was withheld on the morning of surgery. By the third post-operative day, taking free fluids only, his capillary glucose readings sit between 5.1 and 7.4 mmol/L with no insulin and no oral hypoglycaemic agent, and his recorded weight has fallen by 2 kg. He asks why his diabetes has improved before he has lost any meaningful weight.
- AResection of the ghrelin-producing gastric fundus has directly restored beta-cell function
- BThe improvement is entirely explained by the 2 kg of weight already lost and the fall in visceral fat
- CRapid delivery of undigested nutrients to the distal small bowel augments postprandial GLP-1 and peptide YY secretion, enhancing insulin release
- DCarbohydrate is malabsorbed within the biliopancreatic limb, so less glucose reaches the circulation
- EThis reflects the peri-operative fast and will reverse once he resumes a solid diet
Show the answer and the reasoning
Correct answer: C — Rapid delivery of undigested nutrients to the distal small bowel augments postprandial GLP-1 and peptide YY secretion, enhancing insulin release
The early glycaemic improvement after gastric bypass is an incretin effect, not a weight-loss effect.
Why: Nutrients reach the distal small bowel undiluted and undigested, driving L-cell secretion of GLP-1 and peptide YY. This amplifies glucose-stimulated insulin secretion within days of surgery. Acute energy restriction contributes by reducing hepatic fat and hepatic glucose output, but it does not explain the magnitude or the durability of the change. Sustained remission later depends on weight loss and improved peripheral insulin sensitivity.
Option A: The fundus is excluded rather than resected in a bypass, and ghrelin changes modulate appetite rather than restore beta-cell function.
Option B: Two kilograms, largely fluid, cannot account for withdrawal of 78 units of insulin.
Option C: Correct because the hindgut incretin response operates immediately and is the mechanism that distinguishes bypass from equivalent dieting.
Option D: The biliopancreatic limb carries no food, and a standard bypass causes little true carbohydrate malabsorption.
Option E: Fasting alone would not maintain euglycaemia off all agents, and in practice the improvement persists as he progresses to solids.
Glycaemic control improves within days of Roux-en-Y gastric bypass through enhanced GLP-1 and peptide YY secretion from the distal gut, before any weight-dependent mechanism can operate.
ADA Standards of Care, metabolic surgery for type 2 diabetes
Question 8 · Skin, Soft Tissue and Necrotising Infection · Basic
A 31-year-old woman presents to the emergency department with a four-day history of a painful swelling in the left axilla. She is otherwise well, takes no regular medication and is a non-smoker. On examination there is a 4 cm tender, fluctuant, erythematous swelling with a small central punctum and surrounding induration extending about 1 cm beyond the swelling. She is apyrexial, heart rate 88 beats per minute, blood pressure 118/72 mmHg. White cell count is 11.2 × 10⁹/L and C-reactive protein 46 mg/L. There is no cellulitis of the arm, no lymphangitis and no crepitus. What is the most appropriate management?
- AIncision and drainage of the abscess, with deroofing and irrigation of the cavity
- BOral flucloxacillin for seven days with review in the surgical outpatient clinic
- CUltrasound-guided needle aspiration and oral co-amoxiclav
- DUrgent contrast-enhanced computed tomography of the chest wall and axilla
- EWide local excision of the axillary skin with primary closure
Show the answer and the reasoning
Correct answer: A — Incision and drainage of the abscess, with deroofing and irrigation of the cavity
A fluctuant, well-localised cutaneous abscess is drained. Antibiotics do not resolve a collection of pus.
Why: Fluctuance plus a punctum means an established cavity. Antibiotics penetrate pus poorly, so drainage is the definitive treatment. In a systemically well patient with only a narrow rim of surrounding erythema, adjunctive antibiotics add little and are not routinely required. Send a pus swab so that a recurrence can be treated on culture data rather than guesswork.
Option A: Correct — drainage removes the pus, and deroofing prevents premature closure over a residual cavity.
Option B: Antibiotics alone leave the collection undrained and the patient returns worse in forty-eight hours.
Option C: Needle aspiration of a loculated cutaneous abscess has a high recurrence rate compared with formal drainage.
Option D: Cross-sectional imaging adds nothing when the diagnosis is clinically obvious and superficial.
Option E: Excisional surgery is an operation for recurrent hidradenitis, not for a first acute abscess.
A fluctuant cutaneous abscess is treated by drainage; antibiotics are an adjunct for surrounding cellulitis or systemic features, never a substitute.
WSES guidance on skin and soft tissue infections
Question 9 · Perioperative Care, ERAS and Patient Safety · Basic
A 34-year-old woman with no comorbidity is admitted for an elective open repair of a symptomatic umbilical hernia scheduled as the second case on the afternoon list, expected to start at about 14:00. She telephoned the preassessment nurse the previous evening and was told nothing to eat or drink from midnight. On the ward round at 11:00 she is thirsty, has a dry mouth and a headache, and asks whether she may have a drink. She has no diabetes, no history of reflux, no gastric surgery and is on no medication that delays gastric emptying. The anaesthetist confirms a general anaesthetic with a laryngeal mask.
- AContinue strict nil by mouth until she goes to theatre and give 1 litre of intravenous crystalloid
- BAllow a light breakfast now because the case is not until the afternoon
- CAllow clear fluids, including a carbohydrate drink, up to two hours before the anticipated start of surgery
- DAllow sips of water only, no more than 30 mL per hour, until she goes to theatre
- EMove her to the start of the list to shorten the fasting period and keep her nil by mouth
Show the answer and the reasoning
Correct answer: C — Allow clear fluids, including a carbohydrate drink, up to two hours before the anticipated start of surgery
She should be offered clear fluids, including a preoperative carbohydrate drink, until two hours before the expected start of surgery.
Why: The evidence-based fasting rule is six hours for solids and two hours for clear fluids. Midnight fasting for an afternoon list produces fourteen hours without oral fluid and no safety benefit. Prolonged fasting worsens thirst, headache, insulin resistance and patient experience. Carbohydrate loading is a core preoperative ERAS element in a patient with no diabetes and no gastric emptying disorder.
Option A: Intravenous fluid treats the dehydration but perpetuates an unnecessary fasting rule and adds a cannula and cost for no gain.
Option C: Correct — it matches the two-hour clear fluid rule and delivers the ERAS carbohydrate element safely.
Option B: Solids require six hours, so a light breakfast at 11:00 would not clear before a 14:00 start.
Option D: Rationing water to sips has no physiological basis and leaves her dehydrated and symptomatic.
Option E: Reordering the list to accommodate an outdated fasting instruction fixes the symptom and not the error.
Clear fluids are permitted until two hours before anaesthesia and solids until six hours; midnight fasting for an afternoon list is an avoidable harm, not a safety measure.
ERAS Society, enhanced recovery guideline for elective colonic surgery — preoperative fasting and carbohydrate loading
Question 10 · Surgical Critical Care · Basic
A 37-year-old woman with no significant past medical history presents to the emergency department with two days of increasing right loin pain, rigors and vomiting. She is drowsy but rousable. Temperature is 39.1°C, pulse 126 beats per minute, blood pressure 82/48 mmHg and respiratory rate 28 per minute. Urine dipstick shows nitrites and leucocytes. Ultrasound shows a dilated right renal pelvis with a 9 mm stone at the pelviureteric junction. Lactate is 4.2 mmol/L and creatinine 186 µmol/L. Two large-bore cannulae are in place. Which is the most appropriate next step?
- ATransfer immediately for percutaneous nephrostomy before antibiotics, so that pus can be sent for culture first
- BStart a noradrenaline infusion through a peripheral cannula and restrict fluids to 500 mL to avoid pulmonary oedema
- CGive intravenous antibiotics and observe for six hours, deferring drainage if the blood pressure improves
- DTake blood cultures, start broad-spectrum intravenous antibiotics and begin a 30 mL/kg crystalloid infusion, then arrange urgent ureteric decompression
- EArrange emergency ureteroscopy and laser fragmentation of the stone to achieve definitive clearance in one procedure
Show the answer and the reasoning
Correct answer: D — Take blood cultures, start broad-spectrum intravenous antibiotics and begin a 30 mL/kg crystalloid infusion, then arrange urgent ureteric decompression
This is septic shock from an obstructed infected kidney; the immediate priorities are cultures, antibiotics and fluid resuscitation, with decompression arranged urgently in parallel.
Why: An obstructed infected system will not sterilise on antibiotics alone. Source control is therefore mandatory. But resuscitation and antimicrobials should not wait for the interventional suite. They run alongside the referral, not after it.
Option D: Correct — it delivers the sepsis bundle and secures source control without either step delaying the other.
Option A: Withholding antibiotics to obtain a drainage specimen delays treatment in a patient who is already shocked.
Option B: Vasopressors before any meaningful volume replacement treat the number rather than the hypovolaemia driving it.
Option C: A six-hour observation period in obstructive pyonephrosis with shock risks irreversible deterioration.
Option E: Ureteroscopy in an infected obstructed system raises intrarenal pressure and can precipitate overwhelming bacteraemia.
In sepsis from an obstructed urinary tract, antibiotics and fluids do not substitute for decompression, and decompression does not justify delaying antibiotics — both happen at once.
Surviving Sepsis Campaign — International guidelines for sepsis and septic shock, 2026 (Intensive Care Med 2026;52:863-936)