General Surgery — 5-min cram sheet
_Built from the gen-surg disease index. Deck-faithful._
Buzzword → answer (the vignette reflex)
- Red currant jelly stool → Intussusception (pathognomonic in children <3 yrs)
- Coffee bean / bent inner tube on AXR → Sigmoid volvulus
- Bird's beak / ace of spades on barium enema → Sigmoid volvulus (pathognomonic)
- Coiled spring on contrast/air enema → Intussusception (diagnostic AND therapeutic)
- Target sign on USS/CT → Intussusception
- Caecum displaced to LUQ / comma / kidney bean gas shadow → Caecal volvulus
- Whirlpool / swirl sign on CT (mesenteric vessels wrapped around axis) → volvulus (pathognomonic)
- Free air under diaphragm on erect CXR → perforated hollow viscus → urgent laparotomy
- Restless patient who can't find a comfortable position → Ureteric colic (peritonitis = lies completely still)
- Below and lateral to pubic tubercle → Femoral hernia (inguinal = above + medial)
- Seat belt sign (horizontal abdominal ecchymosis) → mesenteric avulsion / small-bowel injury
- Howship–Romberg sign (medial thigh pain) → Obturator hernia
- Pneumobilia on AXR → gallstone ileus (a cause of SBO)
- Sausage-shaped mass in right hypochondrium → Intussusception
Sign / imaging → diagnosis
| Sign / finding | Points to |
| Red currant jelly PR stool | Intussusception (children) |
| Coiled spring (contrast enema) / claw sign (barium, on reduction) | Intussusception |
| Target / sausage mass (USS) | Intussusception |
| Coffee bean / bent inner tube (AXR) | Sigmoid volvulus |
| Bird's beak / ace of spades (barium) | Sigmoid volvulus (pathognomonic) |
| Caecum in LUQ; comma/kidney bean; ace of spades on barium | Caecal volvulus |
| Whirlpool / swirl sign (CT) | Volvulus (pathognomonic) |
| Pneumobilia (AXR) | Gallstone ileus |
| Valvulae conniventes (cross full lumen), central, dilated >3 cm | Small bowel (SBO) |
| Haustra (don't cross full width), peripheral | Large bowel (LBO) |
| Pneumatosis intestinalis / mesenteric oedema-stranding (CT) | Bowel ischaemia / strangulation |
| Mesenteric swirling (CT), post gastric bypass | Internal hernia (Roux-en-Y SBO) |
| Free air under (right) diaphragm, erect CXR | Perforated hollow viscus |
| Rigler's sign (gas both sides of bowel wall, AXR) | Pneumoperitoneum / perforation |
| Microcytic anaemia | Large-bowel malignancy |
| Restless, can't lie still + loin-to-groin pain + haematuria | Ureteric colic |
| Board-like rigidity + silent abdomen + free air | Generalised peritonitis (perforation) |
| RUQ tenderness = cholecystitis · RIF = appendicitis · LIF = diverticulitis | Localised peritonitis |
| Malgaigne's bulging (soft strain bulge, poor wall tone) | Direct inguinal hernia (→ needs mesh) |
| Howship–Romberg (medial thigh pain) | Obturator hernia |
| Sister Mary Joseph nodule (periumbilical) | Metastatic deposit |
| Corona mortis / Circle of Death (aberrant obturator artery on lacunar ligament) | Catastrophic bleed risk in femoral repair |
| Lead-pipe + loss of haustra + backwash ileitis | Ulcerative colitis |
| String sign + cobblestone + skip lesions | Crohn's |
| High-riding prostate / blood at meatus | Urethral injury → do NOT catheterise |
Criteria / staging / scores at a glance
- Hernia severity (ascending): Reducible → Irreducible (incarcerated) → Obstructed (lumen occluded, no vascular compromise) → Strangulated (vascular: venous → arterial) → Loss of domain (viscera lost "right of abode").
- Nyhus (groin hernia): I = indirect, normal internal ring · II = indirect, dilated ring, intact posterior wall · III = posterior-wall defect (IIIA direct, IIIB indirect/sliding, IIIC femoral) · IV = recurrent (IVA direct, IVB indirect, IVC femoral, IVD combined).
- Mesh position (Int'l Hernia Collaboration): A Onlay · B Inlay · C Retrorectus · D Preperitoneal · E Intraperitoneal. Primary fascial repair up to 50% recurrence; tension-free mesh 2–10%.
- ABCs of bowel obstruction: A = Adhesions (commonest SBO) · B = Bulge/hernia · C = Cancer (commonest LBO).
- 3/6/9 rule (AXR dilation): small bowel >3 cm · large bowel up to 6 cm · caecum up to 9 cm.
- SBO high-risk findings → operate: significant leucocytosis; lactic acidosis (normal lactate does NOT exclude venous ischaemia); closed loop; bowel dilation >3 cm; pneumatosis intestinalis; free air; mesenteric oedema.
- Gastrografin protocol (adhesional SBO): contrast fails to reach caecum by 24–48 h → conservative will fail → operate.
- Laparotomy indications — obstruction: cause needs surgery (hernia, colonic carcinoma); no improvement on conservative; strangulation/peritonitis; tachycardia + pyrexia + tenderness → operate whatever the cause. Resuscitate FIRST.
- Laparotomy — blunt trauma: haemodynamic instability despite resuscitation; +ve FAST/DPL + instability; peritonism; hollow-viscus injury (free air); diaphragm rupture; expanding/pulsatile retroperitoneal haematoma.
- Laparotomy — penetrating trauma: instability; evisceration; peritonitis; hollow-viscus/vascular injury; gunshot wounds nearly always. Stab = selective (peritoneal signs → laparotomy; stable no signs → local wound exploration).
- Retroperitoneal haematoma zones (blunt): Zone I (central) always explore · Zone II (flank/renal) only if expanding/pulsatile · Zone III (pelvic) do NOT open (releases tamponade).
- 3R trauma framework: Resuscitate (IV upper limbs only, ABC) → Reassess (repeat ABCDE) → Re-evaluate (operate vs observe). Never remove embedded FB in field.
- Caecal vs sigmoid volvulus: sigmoid = >80% of colonic volvulus, older (~5th decade / avg 60), anticlockwise, central; caecal = <40 yrs, women, clockwise, LUQ. Caecal dilation >10 cm + tenderness → impending perforation.
- Incisional hernia: mesh recurrence 2–10% vs up to 50% primary suture; incidence 10–50% after open laparotomy; small defect <3 cm → primary closure.
- Inguinal hernia numbers: 75% of all abdominal hernias are inguinal; 75% of inguinal are indirect.
- Acute abdomen: symptoms <8 days (>8 days probably not lethal); ~1 in 10 presentations is a true surgical emergency.
Discriminators that decide questions
- SBO vs LBO — vomiting early vs late; distension central vs peripheral; bowel sounds hyperaudible tinkling vs may be absent; main cause adhesions/hernia vs malignancy; adhesions cause SBO but NEVER LBO alone.
- Indirect vs direct inguinal hernia — lateral vs medial to inferior epigastric vessels; congenital (patent processus vaginalis) vs always acquired; deep-ring occlusion controls the indirect (no bulge on cough) but a direct still bulges medially through Hesselbach's triangle.
- Inguinal vs femoral hernia — above inguinal ligament + medial to pubic tubercle vs below ligament + lateral to pubic tubercle; femoral has the narrow ring → highest strangulation risk of all hernias; suspect occult femoral in an elderly woman (60–80) with SBO and no prior surgery.
- Caecal vs sigmoid volvulus — clockwise vs anticlockwise; caecum to LUQ vs sigmoid central; younger women vs older men; caecal has NO endoscopic role → right hemicolectomy, sigmoid = endoscopic detorsion first.
- Ureteric colic vs peritonitis — colic = restless patient who can't lie still (colicky = hollow-viscus obstruction); peritonitis = lies completely still, guarding/rigidity, silent abdomen. (Richter's hernia is the trap: only the anti-mesenteric wall strangulates → ischaemia WITHOUT obstruction, so stool/flatus continue and presentation is delayed.)