• MRCS Part A - Sep 2019 Exam

Following an elective splenectomy in a 21-year-old man with thalassaemia, you are asked
by the discharge co-ordinating team to review a discharge summary detailing the operative
steps and subsequent treatment.
Which one of the following would be correct?

The splenic artery was ligated after the splenic vein and lifelong oral penicillin prophylaxis
should not be offered to patients

The splenic artery was ligated after the splenic vein and lifelong oral penicillin prophylaxis
should be offered to patients

The splenic artery was ligated before the splenic vein and lifelong oral penicillin
prophylaxis should be offered to patients

The splenic artery was ligated before the splenic vein and lifelong oral penicillin
prophylaxis should not be offered to patients

The splenic artery was ligated at the hilum and lifelong oral penicillin prophylaxis should
be offered to patients

Explanation
The splenic artery was ligated before the splenic vein and lifelong oral penicillin
prophylaxis should be offered to patients

The splenic artery is always divided before the vein. This prevents congestion of the spleen,
by leaving it with outflow. When the indication for splenectomy is haemorrhage from the
spleen, it also allows for ongoing autotransfusion of blood from the spleen. Current
guidelines dictate that, after splenectomy, lifelong prophylactic antibiotics should be
offered to patients considered at continued high risk of pneumococcal infection using oral
penicillins. Patients not at high risk should be counselled regarding the risks and benefits of
lifelong antibiotics and may choose to discontinue them. All patients should carry a supply
of appropriate antibiotics for emergency use.

The splenic artery was ligated after the splenic vein and lifelong oral penicillin prophylaxis
should not be offered to patients

The splenic artery is always divided before the vein. Penicillin prophylaxis must be offered
to patients who have undergone splenectomy.
The splenic artery was ligated after the splenic vein and lifelong oral penicillin prophylaxis
should be offered to patients

Although it is correct to say that penicillin prophylaxis should be offered to patients

undergoing splenectomy, the splenic vein should be divided after the artery is divided, as
there is risk of rupture during the procedure.

The splenic artery was ligated before the splenic vein and lifelong oral penicillin
prophylaxis should not be offered to patients

All patients should be offered penicillin prophylaxis; alternatively, macrolides may be

prescribed and this depends on local pneumococcal resistance patterns.

The splenic artery was ligated at the hilum and lifelong oral penicillin prophylaxis should
be offered to patients

The splenic artery can be ligated at the hilum, although dissection here puts the patient at
risk of pancreatic injury. The short gastric vessels need to be divided. In this scenario, the
splenic artery is usually ligated along the upper border of the tail of the pancreas. The
artery is ligated before the vein to minimise splenic engorgement.

•
 • MRCS Part A - Sep 2019 Exam

A 45-year-old woman undergoes hemicolectomy through a midline laparotomy incision.

You are asked to close the abdominal wall.
Which one is the most appropriate suture for this task?
Catgut
Poliglecaprone monofilament
Polydioxanone monofilamentPolyglactin braided
Polypropylene monofilament

Explanation
Polydioxanone monofilament
Polydioxanone is commonly used in loop form for closure of the abdominal wall – it is
sometimes known as loop poly(p-dioxanone) (PDS). It retains around 80% of its tensile
strength by 2 weeks post-use; and is not completely absorbed until 6 months, so providing
the wound support that an abdominal wound needs.
Catgut

Catgut is rarely used in current practice, due to higher rates of postoperative infection.
Poliglecaprone monofilament

This suture is also known as Monocryl. This is not an appropriate suture for abdominal
wall closure as it loses its tensile strength quickly – it loses about 40% of its tensile
strength within 14 days. The abdominal wall is subject to high stresses, strains and
tensions, and so a suture which retains its tensile strength for longer is needed.
Poliglecaprone is appropriate for closure of the skin as it is absorbed quickly and so less
likely leave skin-marks behind; it also elicits a low tissue reaction, which is less likely to
lead to infection and more likely to leave wound that heals with satisfactory cosmesis.
Polyglactin braided

This is known as Vicryl. It is used for soft tissue approximation and ligation. Because it is
braided and relatively slow to be absorbed (although not as slow as polydioxanone/PDS), it
should not be used in cutaneous wounds, as it is bulkier in comparison to a monofilament
suture, and remain reactive over time, leading to a higher risk of infection and
unsatisfactory cosmesis.
Polypropylene monofilament
Polypropylene, also known as Prolene, is used primarily for vascular and other
anastomoses. It non-absorbable, and withstands enzymes, and passes through tissues with
ease, which is why it used in these anastomoses. Polydioxanone has less plasticity than
polypropylene, which is why it is preferred in abdominal wall closure.

•
 • MRCS Part A - Sep 2019 Exam

A 56-year-old man is admitted for an open appendicectomy. While the consultant is

undertaking the pre-operative World Health Organization (WHO) checklist, it appears the
diathermy plate has not yet been applied.
Which one of the following options most accurately describes the principles of
surgical diathermy?
Coagulation is produced by a continuous current with a square wave form
Is always dangerous if the patient is touching earthed metal

Involves a high frequency current in the range of 30 MHz to 300 MHz

Is contraindicated in patients with a pacemakerWith bipolar diathermy two electrodes are

combined in the instrument as opposed to monopolar diathermy

Explanation
With bipolar diathermy two electrodes are combined in the instrument as opposed to
monopolar diathermy

Bipolar diathermy combines two electrodes and so a diathermy plate on the patient is not
needed if using only bipolar.
Coagulation is produced by a continuous current with a square wave form

Coagulation involves an interrupted pulse of current (50–100/s) and a square wave form,
whereas cutting is produced by a continuous current with a sinus wave form.
Is always dangerous if the patient is touching earthed metal

This is only the case for older diathermy machines. When using an older machine it is
important to ensure that the patient is not touching earthed metal. Most modern diathermy
machines do not have earth-referenced generators.

Involves a high frequency current in the range of 30 MHz to 300 MHz

Diathermy uses the heating effect of electrical current at a frequency of 400 kHz to 10 MHz.
Is contraindicated in patients with a pacemaker
Although diathermy can be used in a patient with a pacemaker, the pad of the monopolar
diathermy should be positioned well away from the pacemaker. Bipolar diathermy which
combines two electrodes in the forceps does not interfere with pacemakers as the current
does not travel through the patient and may be more suitable.

•
 • MRCS Part A - Sep 2019 Exam

You are assisting in a sentinel node biopsy for a patient with known breast cancer. You
have difficulty locating the sentinel node but do so with a combination of blue dye and
radioisotope.
Which one of the following statements is correct?
At least 10 nodes must be sampled to give an accurate nodal stage

Sentinel node biopsy involves identifying the first four nodes of a basin through which the
majority of lymph from the breast drains

Lymphoscintigraphy can be performed up to one week in advance of the procedureBlue

dye is contraindicated in pregnancyThere is a high incidence of brachial plexus traction
following sentinel node

Explanation
Blue dye is contraindicated in pregnancy
Currently, the use of blue dye is not recommended during sentinel node biopsy in patients
who are pregnant.
At least 10 nodes must be sampled to give an accurate nodal stage
Sentinel node biopsy involves identifying the first nodes that drain the primary tumour and
is usually 1–2 nodes but can be more.

Sentinel node biopsy involves identifying the first four nodes of a basin through which the
majority of lymph from the breast drains

Sentinel node biopsy involves identifying the first nodes that drain the primary tumour.
Lymphoscintigraphy can be performed up to one week in advance of the procedure
Lymphoscintigraphy needs to be done on the day of the surgery; the isotopes used have a
half-life of just a few hours.
There is a high incidence of brachial plexus traction following sentinel node
The axilla simply needs to be exposed during sentinel node biopsy, and there is no need to
place the arm under great traction.

•
 • MRCS Part A - Sep 2019 Exam

You are assisting in a free flap reconstruction of the breast. The consultant allows you to
isolate the vascular pedicle so the free flap can be performed.
Which one of the following recipient vessels is commonly used in the
microanastomosis?
Subclavian arteryInternal mammary arteryAxillary artery
Thoracodorsal artery
Serratus branch of thoracodorsal artery

Explanation
Internal mammary artery
The internal mammary vessels are found underneath the medial 2–4th ribs, which are
resected during the procedure. These vessels are ideally located to receive the perforator
vessels from the free flap. It is possible to use recipient vessels other than the internal
mammary artery, such as those based on the thoracodorsal axis. However the dissection is
harder. Examples of free flaps used in breast reconstruction include deep inferior
epigastric perforator flap (DIEP flap) and the superior gluteal artery perforator flap (SGAP
flap).
Subclavian artery
The subclavian artery is not an ideal recipient vessel as it located relatively far away from
where the free flap will sit, ie on the chest. This may put the microanastomosis under too
much tension.
Axillary artery

It may be possible to use the axillary artery, but the dissection of this vessel is technically
challenging due to the proximity of the brachial plexus to it. Damage to the vessel will also
put the distal blood supply of the upper limb at risk.
Thoracodorsal artery

This artery supplies a latissimus dorsi flap that can be used for breast reconstruction.
However this is not a free flap, but regional flap
Serratus branch of thoracodorsal artery
The serratus branch of the thoracodorsal artery supplies what is known as a serratus
muscle flap. It is similar to the latissimus dorsi flap in that it is a regional flap that may be
used in breast reconstruction.

•
 • MRCS Part A - Sep 2019 Exam

An 84-year-old man with multiple co-morbidities presents with severe abdominal pain
looking very unwell. Blood gas reveals a severe metabolic acidosis and a computed
tomography (CT) scan confirms a diverticular perforation, but the extent of abdominal
contamination is unclear. A diagnostic laparoscopy is performed to assess if the patient can
avoid a laparotomy at present. This shows a purulent peritonitis, but no
faecalcontamination.
How would this be classified?
Hinchey I
Hinchey II
Hinchey III
Hinchey IV
Hinchey V

Explanation
Hinchey III

Hinchey III describes the presence of pus in the abdominal cavity (purulent peritonitis) as
described in this case. It is sometimes possible for cases with purulent peritonitis to be
managed laparoscopically and through inserting a drain. It may then be possible to perform
the appropriate resection later as an elective procedure and stoma formation may not be
necessary.
Hinchey I

The Hinchey classification is used for colonic perforation secondary to diverticular disease.
It is divided into four descriptions. Hinchey I describes localised (paracolic) abscesses. It
can be subdivided into 1a – phlegmon, or 1b – presence of pericolic or mesenteric abscess.
Hinchey II

Hinchey II describes the presence of pelvic abscesses.

Hinchey IV

Hinchey IV describes faeculent peritonitis. This usually requires surgical management, in

the form of a Hartman’s procedure, where the affected segmented would be resected and
the proximal end of the colon be brought out as an end stoma.
Hinchey V
There is no stage V in the Hinchey classification.
 • MRCS Part A - Sep 2019 Exam

During a daycase operating list, a 56-year old man, weighing 84 kg, asks you to repair his
direct left inguinal hernia under a local anaesthetic. You agree.

What would be the most appropriate anaesthetic and dose to use with this man?

100 ml 0.25% bupivacaine with 1:200 000 adrenaline

67 ml of 0.5% bupivacaine

67 ml 0.25% bupivacaine

100 ml 0.25% bupivacaine with 1:20 000 adrenaline

50 ml of 1% lidocaine

Explanation
67 ml 0.25% bupivacaine

The maximum safe dose of bupivacaine with or without adrenaline is 2 mg/kg. Therefore
the maximum dose of bupivacaine for an 84 kg man would be 168 mg. Using the formula '1
ml of 1% drug contains 10 mg', 16.8 ml of 1% drug, or 67.2 ml of 0.25% drug (ie in this
case) will be needed.

100 ml 0.25% bupivacaine with 1:200 000 adrenaline

The maximum safe dose of bupivacaine with or without adrenaline is 2 mg/kg. The
maximum volume of 0.25% to be used in this case is 67 ml.

67 ml of 0.5% bupivacaine

The maximum safe dose of bupivacaine with or without adrenaline is 2 mg/kg. The
maximum volume of 0.5% to be used in this case is 34 ml.

100 ml 0.25% bupivacaine with 1:20 000 adrenaline

The maximum safe dose of bupivacaine with or without adrenaline is 2 mg/kg. Therefore
the maximum volume of 0.25% to be used in this case is 67 ml. However, the concentration
of adrenaline used is 1:200 000, not 1:20 000

50 ml of 1% lidocaine
The maximum dose of 1% lidocaine for this man would be 25 ml.

•
 • MRCS Part A - Sep 2019 Exam

You are being taken through a carpal tunnel decompression by your consultant and are
prepping the patient with the operating room staff.
Which one of the following should you be aware of when applying a tourniquet?

Can be safely for up to 3 h at a time

Can be safely applied to cause a pressure exceeding 300 mmHgCan cause focal
demyelination of peripheral nervesUsually produce an axonotmesisIs not suitable for
procedures under local anaesthesia

Explanation
Can cause focal demyelination of peripheral nerves
The most common effect on peripheral nerves is neuropraxia. Mechanical effects of
compression and ischaemia cause focal demyelination.

Can be safely for up to 3 h at a time

Tourniquets should not be applied for longer than 1.5–2 h. If the tourniquet needs to be
used for longer, it should be deflated for an interval of 5 min, before re-applying pressure.
Can be safely applied to cause a pressure exceeding 300 mmHg
The pressure of tourniquets should not exceed 300 mmHg.
Usually produce an axonotmesis
‘Axonotmesis’ means disruption of the axons while the nerve sheath remains intact. It
usually occurs when there is a severe crush or stretch injury.
Is not suitable for procedures under local anaesthesia
Tourniquets can be used for procedures being done under local anaesthetic, however they
may become uncomfortable so should only be used for short procedures.

•
 • MRCS Part A - Sep 2019 Exam

A 71-year-old heavy smoker is listed for a left posterolateral thoracotomy for resection of a
tumour.
How should he be positioned on the table?
Left lateral positionProne

Trendelenburg position

Right lateral position

Supine

Explanation
Right lateral position

Posterolateral thoracotomy is performed most commonly with the patient in a full lateral
position. The skin incision extends from a point two fingerbreadths below the inferior
angle of the scapula, posteriorly to a point halfway between the spine of the scapula and
the vertebral column, and anteriorly following the line of the rib for a variable distance. The
latissimus dorsi is routinely divided but the serratus anterior is usually spared. The chest is
entered through the fifth intercostal space, which is counted as starting below the first rib.
So the fifth space lies below the fifth rib. The intercostal muscles are divided from the
superior border of the rib below the intercostal space, to be entered to avoid injury to the
neurovascular bundle lying just inferior to each rib.
Left lateral position
As the surgery is being performed on the left side, this would not be appropriate; they
should be placed on their right side with the left side uppermost.
Prone

Having the patient lying flat on their front is not appropriate for this type of surgery. It
would not allow access to the left thoracic cavity, and would pose multiple problems with
management of the airway.

Trendelenburg position

The Trendelenburg position, with the feet higher than the head by up to 30° is not used to
allow access to the left thoracic cavity.
Supine

A posterolateral thoracotomy is typically performed in a lateral position

•
 • MRCS Part A - Sep 2019 Exam

Your consultant leaves you to close the skin wound after performing an open reduction and
internal fixation (ORIF) of a fractured distal radius. He asks you to close with
a subcuticularstitch.
Which one of the following is an acceptable suture in this area?

2-0 Vicryl

3-0 silk

4-0 Ethilon

4-0 Monocryl

5-0 Prolene

Explanation
4-0 Monocryl

The ideal suture should produce minimal tissue reaction, have adequate tensile strength to
support wound healing and not cut through tissue. In this scenario, a dissolvable suture
should be used to place a subcuticular suture.

2-0 Vicryl

This is a large diameter, and Vicryl can produce a prominent tissue reaction.
3-0 silk
The suture should absorbable – silk is not absorbable and would have to be removed; it
would also produce a significant tissue reaction.

4-0 Ethilon

Ethilon is not absorbable, and may also produce a tissue reaction.

5-0 Prolene

Prolene is not absorbable, and would have to be removed. A suture at 5–0 strength would
probably not be heavy enough to hold the relatively thick skin of the arm.
 • MRCS Part A - Sep 2019 Exam

You are performing a zone 2 repair of a flexor tendon on a patient right middle finger.
Which one of the following is the best needle to use?
Blunt point needleConventional cutting needleReverse cutting needleRound body
needleTaper cutting needle

Explanation
Round body needle
When repairing a tendon it is important not to cut through the tissues as they may be
damaged leading to fraying of the edges and rupture. A round bodied needle does not cut
the tissue as it passes through.
Blunt point needle
A blunt point needle would not pass through the tendon with ease.
Conventional cutting needle
This needle would cut through the tissues, leaving the tendon vulnerable to further
rupture.
Reverse cutting needle
This needle would cut through the tissues, leaving the tendon vulnerable to further
rupture.
Taper cutting needle

This needle would cut through the tissues, leaving the tendon vulnerable to further
rupture.

•
 • MRCS Part A - Sep 2019 Exam

A 78-year old man presents with an infected dehisced sternal wound following a coronary
artery bypass graft (CABG). He undergoes debridement and application of dressing.
Which one of the following dressings is most suitable?
Alginate
Foam dressing
Hydrocolloid
Hydrogel
Negative pressure topical dressings

Explanation
Negative pressure topical dressings
This is a difficult scenario, and often patients have co-morbidities that delay or complicate
wound healing. Negative pressure dressings apply a constant pressure to the wound to
reduce extravascular and interstitial fluid, while promoting cellular proliferation. Once the
wound has been covered with a layer of granulation tissue other reconstructive methods,
such as skin grafting, can be carried out with the knowledge that there is a clean bed
without bacterial contamination.
Alginate

Alginate dressings are derived from seaweed, and are of use in wounds that secrete fluid,
including infected wounds. However, in this setting, this may not be the best option.
Alginate dressings are useful in chronic, shallow wounds, such as venous ulcers.
Foam dressing

Foam is useful for wounds that are wet. In this scenario, it would be best combined with
negative pressure.
Hydrocolloid

Hydrocolloid dressings should be used in clean wounds.

Hydrogel

Hydrogel dressings are useful in dry wounds, as they provide moisture. They are not
indicated in wounds with heavy exudate/discharge.

•
 • MRCS Part A - Sep 2019 Exam

You are performing a repair of a spaghetti wrist on a patient who has had his arm
trapped in heavy machinery.
In this situation what is the maximum continuous tourniquet time you should use?

Less than 2 h

Less than 4 h

Less than 6 h

There is no maximum
This depends on his response to deep sedation

Explanation
Less than 2 h

Ideally, a tourniquet should not be applied for longer than 1.5–2 h.

Less than 4 h

Ideally, a tourniquet should not be applied for longer than 1.5–2 h. This patient has already
suffered a degree of ischaemia to his arm, as it was trapped in machinery.

Less than 6 h

Ideally, a tourniquet should not be applied for longer than 1.5–2 h.

There is no maximum

A tourniquet should not be applied for longer than 1.5–2 h before damage due to ischaemia
and compression occurs.
This depends on his response to deep sedation
Sedation does not affect the length of time for which the tourniquet should be applied. In
prolonged operations, surgeons will reduce the tourniquet every 2 h for a period of up to
15 min to establish re-perfusion.

•
 • MRCS Part A - Sep 2019 Exam

A 36-year-old woman undergoes bilateral breast reduction. A drain is inserted before

closure.
What is the purpose of inserting a drain?
To assist in wound healing
To keep an eye on amount of exudate being released from the surgical site

To minimise the risk of postoperative seroma or haematoma formation

To reduce infection ratesTo seal off the environment from outside bacterial invasion

Explanation
To minimise the risk of postoperative seroma or haematoma formation

The use of drains remains controversial, and prolonged drain insertion can lead to an
increased risk of infection. They can be used in combination with low-grade suction to
remove blood excess from a cavity. They can also prevent haematoma or seroma. Large
amounts of blood in the drain bag can indicate ongoing bleeding.
To assist in wound healing

A drain will not speed wound healing.

To keep an eye on amount of exudate being released from the surgical site
There is no clinical reason to record the amount of exudate released from a surgical site.
To reduce infection rates
A drain is an infection risk, especially if kept in for a prolonged time.
To seal off the environment from outside bacterial invasion
Drains will not prevent bacteria from entering the wound; in fact, they may act as a vector
for them. The use of drains remains controversial, and prolonged drain insertion can lead
to an increased risk of infection. They can be used in combination with low-grade suction to
remove blood excess from a cavity. Large amounts of blood in the drain bag can indicate
ongoing bleeding.

•
 • MRCS Part A - Sep 2019 Exam

A 60 kg woman is undergoing lipofilling. The consultant wants to ensure she is comfortable

and administers local anaesthetic.
What is the maximum volume of 1% lidocaine with adrenaline that can be
administered?

30 ml

35 ml

42 ml

62 ml

70 ml

Explanation
42 ml

The maximum dose of lidocaine without adrenaline is 3 mg/kg, and with adrenaline this is
7 mg/kg; 1% lidocaine contains 10 mg/ml, and 2% 20 mg/ml. The maximum dose of
lidocaine with adrenaline in a 60 kg patient is 420 mg, which equates to 42 ml.

30 ml

This dose is too low. The maximum dose is 420 mg, which is 42 ml of 1% lidocaine.

35 ml

This dose is too low. The maximum dose is 420 mg, which is 42 ml of 1% lidocaine.

62 ml

This dose is too high. The maximum dose is 420 mg, which is 42 ml of 1% lidocaine.

70 ml

This dose is too high. The maximum dose is 420 mg, which is 42 ml of 1% lidocaine.
 • MRCS Part A - Sep 2019 Exam

You are completing the World Health Organisation (WHO) checklist before starting an
inguinal hernia repair under general anaesthetic. You have just asked ‘Is the diathermy
plate correctly applied?’
Which one of the following is true regarding the use of surgical diathermy?

The plate must be placed on a limb

The plate is required for use with bipolar machines

If care is not taken, diathermy may cause full thickness burns if the plate becomes wet

Plate position should be checked by the theatre sister/ scrub nurse

The plate should cover a minimum area of 20 cm2

Explanation
If care is not taken, diathermy may cause full thickness burns if the plate becomes wet

When the plate becomes wet its contact with the skin is partially lost. This causes heat
generation as there is no appropriate exit for the current to pass safely and results in burns.
Incorrect use of the diathermy plate is the commonest cause of diathermy burns.

The plate must be placed on a limb

It may be placed on the trunk or the limbs and should avoid bony prominences, scar tissue,
metal work and hairy surfaces.

The plate is required for use with bipolar machines

A diathermy plate is only required when using monopolar. When using monopolar the high
frequency current passes through the patient from the active electrode and is returned via
the diathermy plate. In bipolar surgery the current passes between the forceps to complete
the electrical circuit and there is no need for a diathermy plate.

Plate position should be checked by the theatre sister/ scrub nurse

While the theatre sister/scrub nurse often apply the diathermy plate, the overall
responsibility of plate position lies with the operating surgeon.

The plate should cover a minimum area of 20 cm2

The plate should cover a minimum surface area of 70 cm2.

•
 • MRCS Part A - Sep 2019 Exam

You are briefing your scrub sister on which scalpel you would like for your ‘lumps and
bumps’ list.
Which one of the following blades are correctly paired with its likely use?

The correct scalpel for excision of minor cutaneous lesions is a number 15 blade

The correct scalpel for an arteriotomy for example of the aorta is a number 10 blade

The correct scalpel for a small arteriotomy for example of a coronary artery is a number 10
blade

The correct scalpel for dissection in the abdomen is a number 10 blade

The correct scalpel for a laparotomy incision is a number 15 blade

Explanation
The correct scalpel for excision of minor cutaneous lesions is a number 15 blade

The number 15 blade has a small curved cutting edge and is the most popular blade shape
ideal for making short and precise incisions. It is utilised in a variety of surgical procedures
including the excision of a skin lesion or recurrent sebaceous cyst.

The correct scalpel for an arteriotomy for example of the aorta is a number 10 blade

To make this stab incision an elongated triangular blade with a strong pointed tip, the
number 11 blade, would be more suitable. It is used in various procedures such as the
creation of incisions for chest drains, opening the aorta and removing calcifications in the
aortic or mitral valves.

The correct scalpel for a small arteriotomy for example of a coronary artery is a number 10
blade

The number 10 blade with its curved cutting edge is used generally for making incisions in
skin and muscle. However, the number 15 blade has a small curved cutting edge and is
ideal for making short and precise incisions. It is utilised in a variety of surgical procedures
including opening coronary arteries.

The correct scalpel for dissection in the abdomen is a number 10 blade

When dissecting in the abdomen it is important to have precise controlled movements
which is best suited for a number 15 blade which has a small curved cutting edge.

The correct scalpel for a laparotomy incision is a number 15 blade

To make a laparotomy incision a number 10 blade would be more suitable with its curved
cutting edge compared with the small number 15 blade more suitable for short precise
incisions.

•
 • MRCS Part A - Sep 2019 Exam

You are undertaking a teaching session for some of the student operating department
professionals (ODPs)
Which one of the following statements best describes how the bipolar diathermy
machine works?

The bipolar diathermy machine uses a low current at very high frequency and low voltage,
which is passed through the patient’s tissue using two electrodes to complete the circuit

The bipolar diathermy machine uses a high current at very high frequency and high
voltage, which is passed through the patient’s tissue using two electrodes to complete the
circuit

The bipolar diathermy machine uses a low current at very low frequency and high voltage,
which is passed through the patient’s tissue using two electrodes to complete the circuit

The bipolar diathermy machine uses a low current at very high frequency and high voltage,
which is passed through the patient’s tissue using two electrodes to complete the circuit

The bipolar diathermy machine uses a low current at very low frequency and low voltage,
which is passed through the patient’s tissue using two electrodes to complete the circuit

Explanation
The bipolar diathermy machine uses a low current at very high frequency and low voltage,
which is passed through the patient’s tissue using two electrodes to complete the circuit

Diathermy is used for cutting tissues and for haemostasis. The bipolar diathermy machine
uses a low current at very high frequency and low voltage. The current passes between two
limbs of diathermy forceps only, with no need for patient plate electrode. Bipolar
diathermy is inherently safer than other settings but cannot be used to touch other
instruments to transfer current. Bipolar diathermy is useful for surgery to extremities:
scrotum, penis or on digits.

The bipolar diathermy machine uses a high current at very high frequency and high
voltage, which is passed through the patient’s tissue using two electrodes to complete the
circuit

A high current results in cutting, which is not the use of bipolar diathermy.

The bipolar diathermy machine uses a low current at very low frequency and high voltage,
which is passed through the patient’s tissue using two electrodes to complete the circuit
The bipolar diathermy machine is passed through the patient’s tissue using a low current
but at a very high frequency and low voltage. A high frequency is required to enable energy
to pass through the patient’s tissue with minimal neuromuscular stimulation and no risk of
electrocution.

The bipolar diathermy machine uses a low current at very high frequency and high voltage,
which is passed through the patient’s tissue using two electrodes to complete the circuit

The bipolar diathermy machine uses low current at a very high frequency but low voltage
to cause coagulation. Using high voltage causes fulguration – coagulating and charring the
tissue over a wide area.

The bipolar diathermy machine uses a low current at very low frequency and low voltage,
which is passed through the patient’s tissue using two electrodes to complete the circuit

During bipolar diathermy a low current passes between the forceps tips. It uses high
frequency to prevent neuromuscular stimulation or electrocution and a low voltage.

•
 • MRCS Part A - Sep 2019 Exam

You are assisting in laser cataract surgery using a neodymium-yttrium aluminium

garnet (Nd:YAG) laser. You ensure that you and the theatre staff wear protective goggles
and adhere to all safety precautions.
To what class of laser does this type of laser belong?
12

3R

3B

Explanation
4
Lasers are classified according to their degree of hazard. Class 4 lasers are the most
hazardous. They can burn the skin and cause permanent damage to the eye by direct,
diffuse or indirect beam viewing. They also pose a fire risk. Most medical lasers, which
includes Nd:YAG are class 4. Protective glasses should be worn when using the laser.
1
A class 1 laser is safe under all conditions of normal use, a laser printer is an example of a
class 1 laser in use.
2
Class 2 lasers are limited to a maximum output power and must have a wavelength
between 400 and 700 nm. A person whose eyes are exposed to a class 2 laser will be
naturally protected by their involuntary blink response. Examples of class 2 lasers include
laser pointers and barcode scanners.

3R

Class 3R lasers are higher powered than classes 1 and 2. The laser beams exceed the
maximal permissible exposure and your body is not able to protect itself from these lasers.
Therefore, they have the potential to cause eye injuries although this risk is low in
unintentional exposure as exposure is usually short. Some laser pointers are class 3R lasers
with others belonging to class 2.

3B
Class 3B lasers have sufficient power to cause eye injury and minor skin injuries from both
direct beam and reflections. Examples include lasers used for physiotherapy treatment and
research lasers.

•
 • MRCS Part A - Sep 2019 Exam

You are assisting in a femoro-distal bypass and the consultant asks you what would be the
most appropriate suture to select for the distal anastomosis to the tibial artery.
What suture would you select?

Polyester 6-0

Poliglecaprone 4-0

Polyglycolic acid 6-0

Polypropylene 6-0

Silk 4-0

Explanation
Polypropylene 6-0

For a vascular anastomosis a smooth running suture, a monofilament, with a size suitable
for the size of the vessel is required. Polypropylene is a monofilament and for this
anastomosis to the tibial artery a 6-0 or 7-0 would be a suitable size.

Polyester 6-0

Polyester is a polyfilament and would not give a smooth running suture required for a
vascular anastomosis. The size of the suture should be related to the size of the vessel with
2-0 and 3-0 suitable for the aorta and for this anastomosis to the tibial artery a 6-0 or 7-0
would be a suitable size.

Poliglecaprone 4-0

Poliglecaprone (Monocryl) is a monofilament, which would give the smooth running suture
required for a vascular anastomosis. However, the size of the suture should be related to
the size of the vessel with a 4-0 being more appropriate for the iliac vessels. For this
anastomosis to the tibial artery a 6-0 or 7-0 would be a more suitable size.

Polyglycolic acid 6-0

Polyglycolic acid (Dexon) is a polyfilament and would not give a smooth running suture
required for a vascular anastomosis. The size of the suture should be related to the size of
the vessel with 2-0 and 3-0 suitable for the aorta and for this anastomosis to the tibial
artery a 6-0 or 7-0 would be a suitable size.

Silk 4-0

Silk is a polyfilament and would not give a smooth running suture required for a vascular
anastomosis. A 4-0 would also be too large for the size of this vessel. For this anastomosis
to the tibial artery a 6-0 or 7-0 would be a more suitable size.

•
 • MRCS Part A - Sep 2019 Exam

A knee arthroscopy is performed on a 30-year-old man with no medical problems, and the
consultant prefers to use a tourniquet. This enables the arthoscopy to be bloodless and
relatively little sterile fluids is required to keep the joint inflated as it is not becoming blood
stained
Which type of tourniquet would be best for this procedure?
Double cuff pneumaticElasticNon-pneumaticRubberSingle cuff pneumatic

Explanation
Single cuff pneumatic
Tourniquets are commonly used in orthopaedic surgery. Knee arthroscopy can be
performed without tourniquet or with a single cuff pneumatic tourniquet. Pneumatic
tourniquets have a number of safety features and can be inflated to different pressures.
Double cuff pneumatic
Double cuff pneumatic tourniquets are used in orthopaedic surgery but mostly when a
regional block, eg Bier’s Block has been given. In a double cuff inflation and deflation of
each can be controlled separately to allow a switch from proximal to distal after local
anaesthetic injection. When the distal cuff is inflated the local anaesthetic is then effective
to prevent pain caused by the inflated cuff.
Elastic
An elastic tourniquet is an example of a non-pneumatic tourniquet. Therefore, there is a
fixed pressure which would not be suitable for a knee arthroscopy and is more commonly
used in venepuncture.
Non-pneumatic
Tourniquets can be broadly divided into two types: non-pneumatic, (non-inflatable) and
pneumatic. Examples of non-pneumatic tourniquets include elastic and rubber tourniquets,
which are commonly used in venepuncture and surgery on digits. These would not be
suitable for a knee arthroscopy as they give a fixed pressure to which there is limited
control.
Rubber
A rubber tourniquet is an example of a non-pneumatic tourniquet. These give a fixed
pressure which would not be suitable for a knee arthroscopy and are more commonly used
in venepuncture.

•
 • MRCS Part A - Sep 2019 Exam

You are performing an open reduction and plate fixation of a distal radius fracture.
Which one of the following maximum tourniquet pressure and tourniquet time
would you consider to be the most safe and effective for a tourniquet placed on the
proximal part of the arm?

Pressure: 350 mmHg/time: 120 min

Pressure: 150 mmHg/time: 90 min

Pressure: 50 mmHg above diastolic blood pressure/time: 60 min

Pressure: 100 mmHg above diastolic blood pressure/time: 90 min

Pressure: 50 mmHg above systolic blood pressure/time: 60 min

Explanation
Pressure: 50 mmHg above systolic blood pressure/time: 60 min

A pressure of 50 mmHg above systolic blood pressure would be just above arterial
pressure and therefore be suitable to prevent blood from obscuring the surgical field while
also minimising the risk of vascular damage, thrombosis, soft-tissue and nerve injury. A
tourniquet time of 60 min would be safe, beyond 2 h there is a higher risk of injury. It is
also good practice to release the tourniquet before suturing the wound to identify the
bleeding vessels and so prevent post-operative haemorrhage.

Pressure: 350 mmHg/time: 120 min

Tourniquets, even when used in an appropriate manner, can cause injury. A tourniquet
used at pressures of greater than 250 mmHg in the upper limb and/or for more than 2 h
increases the risk of vascular damage, thrombosis, soft-tissue injury and nerve injury. If
more than 2 h is required the tourniquet should be deflated for 5 min during every 30 min
of inflation time.

Pressure: 150 mmHg/time: 90 min

Tourniquet pressure should be just above arterial pressure. While 150 mmHg would be
enough for some individuals it would not work for all. If the pressure is too low then the
operating field would be obscured by bleeding. At the correct pressure it would be safe to
leave a tourniquet for 90 minutes in the upper limb.
Pressure: 50 mmHg above diastolic blood pressure/time: 60 min

The tourniquet pressure should be just above arterial pressure – systolic blood pressure
not diastolic blood pressure; 50 mmHg above diastolic pressure is unlikely to be sufficient
and bleeding would obscure the operating field. It would be safe to leave a tourniquet for
60 min in the upper limb.

Pressure: 100 mmHg above diastolic blood pressure/time: 90 min

The tourniquet pressure should be just above arterial pressure to prevent bleeding
obscuring the field of view and also not be too great to cause injury. While, 100 mmHg for
many people would likely fulfil both of these criteria it is not the best answer for calculating
tourniquet pressure. At the correct pressure it would be safe to leave a tourniquet for 90
min in the upper limb, beyond 2 h there is a higher risk of vascular damage, thrombosis,
soft-tissue and nerve injury.

•
 • MRCS Part A - Sep 2019 Exam

You are observing your consultant ablate a large exophytic oesophageal lesion using a
laser. You ensure you adhere to the laser safety protocols, the lesion is successfully excised
and the patient has a successful outcome.
Which one of the following is true regarding the neodymium-yttrium aluminium
garnet (Nd-YAG) laser?

It is fully portable and can be used in any theatre environment

It is principally used for tattoo removal

It has a role in the curative treatment of oesophageal carcinoma

It has very little tissue penetration

It requires compulsory eye protection by the user

Explanation
It requires compulsory eye protection by the user

The Nd-YAG laser is a class 4 laser and therefore classified as the most hazardous. It can
burn the skin and cause permanent damage to the eye by direct, diffuse or indirect beam
viewing. Protective glasses must be worn when using the laser.

It is fully portable and can be used in any theatre environment

The Nd-YAG laser must be used in a designated theatre that is clearly identified as a ‘laser
controlled area’ with warning signs placed at every entry point. It should only be used by
those trained to do so. It has the potential to burn the skin and cause permanent damage to
the eye by direct, diffuse or indirect beam viewing.

It is principally used for tattoo removal

The Nd-YAG laser can be used in tattoo removal but it is not its principle use. In tattoo
removal its 1064 nm wavelength makes it ideal for removing black or dark tattoos. It has
many other medical applications including the ablation of benign or malignant lesions such
as vascular skin lesions and in the palliative treatment of oesophageal carcinoma.

It has a role in the curative treatment of oesophageal carcinoma

The Nd-YAG laser has many medical applications. In upper gastrointestinal surgery the
major applications include control of haemorrhage and also in the palliative treatment of
oesophageal cancer to reduce symptoms relating to obstruction.
It has very little tissue penetration
The wavelength of the laser determines the depth of penetration, the lower the wavelength
the less tissue penetration. The Nd-YAG laser has a wavelength of 1064 nm, one of the
greatest, and penetrates tissue deeply (3–5 mm).

•
 • MRCS Part A - Sep 2019 Exam

You are assisting your consultant on a breast reduction when you ask if a drain should be
inserted at the end of the procedure.
Which one of the following regarding surgical drains is correct?

Drains of the peritoneal cavity always prevent the accumulation of fluid

Drains of the pleural cavity must always be connected to an underwater seal drain

Drains prevent a haematoma

Drains may result in the formation of a fistula

Drains should be performed through the main wound

Explanation
Drains may result in the formation of a fistula

Surgical drains, whether tubular or ribbon, form channels along which fluids travel to the
skin surface, these may form fistulae. For example after colorectal surgery an uncommon
but significant complication is the formation of an enterocutaneous fistula.

Drains of the peritoneal cavity always prevent the accumulation of fluid

Intraperitoneal drains are of doubtful benefit, and cannot be relied upon to drain intra-
abdominal fluid.

Drains of the pleural cavity must always be connected to an underwater seal drain

Drainage of the pleural cavity requires a closed system, usually an underwater seal drain.
Alternatively a disposable flutter valve system or continuous wall suction may be used and
these do not require an underwater seal.
Drains prevent a haematoma
Simply placing a drain in a space does not prevent haematoma formation, a meticulous
surgical technique to ensure haemostasis will reduce haematoma rates. However, gentle
suction drains will aid the closure of cavities after evacuation of haematoma.
Drains should be performed through the main wound
Surgical drains can be placed in the wound (eg Yeates drain) but usually require a separate
stab incision.
 • MRCS Part A - Sep 2019 Exam

You are assisting your consultant on a breast reduction and he quizzes the medical student
on suture type and material. Whilst this is happening you close the skin with a subcuticular
suture using non-absorbable suture materal.
Of the following, which one is an example of these sutures?

Polydioxanone sulphate

Polygalactin 910Polyglycolic acidPolyglyconate

Polypropylene

Explanation
Polypropylene

Polypropylene or ‘Prolene’ is an example of a non-absorbable suture, as are silk, nylon,

polyester (eg ‘Dacron’), PVDF (polyvinylidene fluoride – eg ‘Novafil’) and steel.

Polydioxanone sulphate

Polydioxanone sulphate also known as PDS is an absorbable suture.

Polygalactin 910
Polygalactin 910 also known as Vicryl is an absorbable suture.
Polyglycolic acid
Polyglycolic acid (Dexon) is a monofilament absorbable suture.
Polyglyconate
Also known as Monocryl is an absorbable suture.

•
 • MRCS Part A - Sep 2019 Exam

You are positioning a patient for left breast mastectomy. During this stage, the theatre
nurse asks you if you want a diathermy.
Which one of the following statements is correct regarding how diathermy works?
Heat is generated by the passage of high-frequency alternating current through body
tissuesHeat is generated by the passage of low-frequency alternating current through body
tissue

Heat is produced and required of up to 10000 oC

Heat is produced and required of up to 100 oC

Currents of up to 400 mA are safe at frequencies of 500kHz to 10 MHz

Explanation
Heat is generated by the passage of high-frequency alternating current through body
tissues
Diathermy is used for cutting tissues and for haemostasis.
Heat is generated by the passage of low-frequency alternating current through body tissue
The heat from diathermy is generated by the passage of high-frequency alternating current.

Heat is produced and required of up to 10000 oC

The heat produced is not this high, the concentrated current produces high heat up to 1000
°C.

Heat is produced and required of up to 100 oC

Locally concentrated current produces high heat up to 1000°C.

Currents of up to 400 mA are safe at frequencies of 500kHz to 10 MHz
Currents of up to 500 mA are safe at frequencies of 400 kHz to 10 MHz.

•
 • MRCS Part A - Sep 2019 Exam

A 91-year-old woman is admitted to hospital with an infected diabetic foot ulcer. The
nursing staff ask advice on which type of dressing to use.
Which one of the following dressings would you advise?
An alginate dressingA hydrogel dressing

An iodine-based dressing

An occulsive dressing

No dressing required

Explanation
An iodine-based dressing

Iodine-based dressings are effective in the management of infected and exuding wounds,
particularly diabetic foot ulcers, as it has bacteriocidal qualities.
An alginate dressing
Alginate dressings are highly absorbent, have haemostatic properties and are useful in
packing cavities. They are useful in the management of exudative wounds. However, it is
only bacteriostatic, as opposed to bacteriocidal.
A hydrogel dressing
Hydrogels retain moisture or provide rehydration, and so are more useful in dry, necrotic
wounds. This patient is likely to have a very wet wound with a large volume of exudate.

An occulsive dressing

Occlusive dressings should be avoided in infected wounds as they can worsen the infection
by retaining the exudate and causing maceration of the surrounding skin.
No dressing required
This patient needs dressings to help treat the infection, promote healing, and to allow them
to lead as normal a life as possible.

•
 • MRCS Part A - Sep 2019 Exam

You are asked by your consultant to directly close the abdominal skin wound following an
open cholecystectomy. There is concern about wound contamination after slight bile
spillage earlier in the operation. He leaves the choice of sutures to you.
What properties would you look for?

A non-absorbable biological braided multifilament coated in wax such as silk

A non-absorbable, synthetic monofilament such as Prolene™

A non-absorbable, synthetic multifilament such as Dacron™

An absorbable, coated synthetic homopolymer such as Dexon™

An absorbable synthetic copolymer coated with calcium stearate, glycolide and lactide such
as Vicryl™

Explanation
A non-absorbable, synthetic monofilament such as Prolene™

In cases of possible wound contamination (ie in this scenario), non-absorbable

monofilament sutures carry the lowest infection risk and can be removed easily if the
wound becomes infected in the early postoperative period. Staples are a good alternative.
Prolene™ (polypropylene) sutures in addition are generally used in a vascular anastomosis,
and cosmetically important scars as it does not produce much of a tissue reaction. Smooth
(monofilament) sutures are best for running stitches (eg vascular surgery) because they
slide easily through tissues.

A non-absorbable biological braided multifilament coated in wax such as silk

It is thought that multifilament sutures are more likely to be a vector for bacteria, and so
should be avoided in potentially contaminated wounds.

A non-absorbable, synthetic multifilament such as Dacron™

Multifilament sutures should be avoided in potentially contaminated wounds. Examples of

monofilament sutures are polydioxanone sutures (PDS) and Prolene™; Vicryl™ is a
polyfilament suture. Silk, linen and cotton are biological, multifilament, non-absorbable
sutures.

An absorbable, coated synthetic homopolymer such as Dexon™

Non-absorbable sutures, rather than absorbable sutures, are used for tissues that heal
more slowly (eg abdominal wall closure).

An absorbable synthetic copolymer coated with calcium stearate, glycolide and lactide such
as Vicryl™

Non-absorbable sutures are used for tissues that heal more slowly (eg abdominal wall
closure); Vicryl is also multifilament, and so thought to harbour bacteria. Absorbable
sutures are used for tissues that heal quickly such as bowel anastomosis.

•
 • MRCS Part A - Sep 2019 Exam

At the start of a routine procedure your scrub nurse asks you if you would like to use
diathermy.
What is the most common cause of diathermy burns?
Careless techniqueIncorrect placement of patient plate electrodeUse of bipolar
diathermyUse of diathermy on appendages (eg penis)
Use of diathermy on large bowel

Explanation
Incorrect placement of patient plate electrode
The most common cause of an accidental diathermy burn is the incorrect application of the
diathermy plate on the patient. The principles of safe pad placement are as follows:

• The pad should be placed close to the operative site.

• It should be placed away from prosthetic implants eg metal hips.
• It should be placed on a well vascularised muscular area eg the thigh, and the area
should be shaved.
• There must be good contact between the pad and the skin to prevent fluids from
seeping in-between.

Careless technique
Diathermy burns can be caused by careless technique, but fortunately this option is not the
most common cause.
Use of bipolar diathermy
Bipolar diathermy is considered to be safer and avoids the need for a diathermy plate.
However, burns can still be caused by carelessness.
Use of diathermy on appendages (eg penis)

Monopolar diathermy should not be used on end organs such as the penis, but bipolar
diathermy can be used safely.
Use of diathermy on large bowel
Diathermy can be used on the large bowel, provided it is used purposefully eg creating
enterotomy for staplers, or to open the bowel to create a stoma. The safe use
of diathermyincludes ensuring that the patient is not touching earthed metal (older
machines). Avoiding the pooling of inflammable agents (alcohol, inflammable gases); using
the lowest practicable power setting; not using monopolar on narrow pedicles such
as the penis, digits, dissected tissue block, spermatic cord; placing the plate away from
metallic implants (eg prosthetic hips).

•
 MRCS Part A - Sep 2019 Exam

An 18-month-old boy presents with a painful ulcerated haemangioma and is listed

for lasertherapy.
Which one of the following statements regarding the mechanism of action of lasers is
correct?

Lasers produce a low-voltage monochromatic beam of energy

Lasers routinely absorb red pigments such as in blood vessels

The amplitude defines the penetration depth of the light through the tissue

The wavelength defines the penetration depth of the light through the tissueWater is a
common lasing medium

Explanation
The wavelength defines the penetration depth of the light through the tissue
This is because the skin has a range of chromophores which have scattering and absorption
coefficients that wavelength dependent. Laser is an acronym for ‘light amplification by the
stimulated emission of radiation’.

Lasers produce a low-voltage monochromatic beam of energy

Lasers produce a highly directional monochromatic and in-phase (coherent) beam of

electromagnetic radiation.
Lasers routinely absorb red pigments such as in blood vessels
The absorption of red pigment depends on the wavelength of the laser.

The amplitude defines the penetration depth of the light through the tissue

It is the wavelength that defines the penetration of depth.

Water is a common lasing medium
The lasing medium is commonly gaseous (eg carbon dioxide) or crystalline
(egneodymium/yttrium–aluminium garnet, NdYAG)

•
 • MRCS Part A - Sep 2019 Exam

A 3-month-old boy presents with bile-stained vomit and abdominal tenderness. A plain X-
ray is normal. A barium enema reveals mid-gut malrotation with volvulus.
What will be the best treatment option?

Urgent laparotomy, rotate the volvulus anticlockwise, return the small bowel to the left of
the abdomen and the caecum and colon to the right and perform an appendicectomy

Urgent laparotomy, rotate the volvulus anticlockwise, return the small bowel to the right of
the abdomen and the caecum and colon to the left and perform an appendicectomy

Urgent laparotomy, rotate the volvulus clockwise, return the small bowel to the left of the
abdomen and the caecum and colon to the right

Urgent laparotomy, rotate the volvulus clockwise, return the small bowel to the left of the
abdomen and the caecum and colon to the right and perform an appendicectomy

Urgent laparotomy, rotate the volvulus clockwise, return the small bowel to the right of the
abdomen and the caecum and colon to the left and perform an appendicectomy

Explanation
Urgent laparotomy, rotate the volvulus anticlockwise, return the small bowel to the right of
the abdomen and the caecum and colon to the left and perform an appendicectomy

This is the correct summary of the Ladd procedure, which is the treatment for mid-
gutmalrotation with volvulus. The patient in the scenario has malrotation and volvulus
neonatorum. During normal embryogenesis, the bowel herniates into the base of the
umbilical cord and rapidly elongates. As it returns to the abdominal cavity, it undergoes a
complex 270 degree anticlockwise rotation, resulting in the duodenojejunal (DJ) flexure
normally located to the left of the midline (at the level of L1 vertebral body) and the
terminal ileum located in the right iliac fossa. This results in a broad mesentery running
obliquely down from the DJ flexure to the caecum, and prevents rotation around the
superior mesenteric artery (SMA). In malrotation, this does not occur and as a result the
mesentery has a short root, which allows it to act as a pedicle [through which the SMA and
superior mesenteric vein (SMV) pass] around which volvulus can occur. Surgical treatment
for malrotation remains the Ladd procedure – reduction of any volvulus, division of
mesenteric bands, placement of the small and large bowel on the right and left of the
abdomen respectively, and appendicectomy. A laparoscopic approach is becoming more
common. When mid-gut volvulus is present, this is usually seen as a clockwise direction
twist and is reduced by twisting in a counterclockwise direction, usually requiring two or
three twists of the bowel. Once this is done it is possible to decide whether the bowel
remains viable. The best outcomes are achieved when no or only a small area of
gangrenous bowel is discovered and resection/primary anastomosis performed. Grossly
necrotic bowel will require resection followed by primary anastomosis or diversion of the
faecal stream with a proximal stoma formation depending on circumstances. The next step
is identification and relief of any extrinsic obstruction to the duodenum and a check that no
intrinsic obstruction remains by passing an nasogastric tube (NG) tube through the
duodenum. The small and large bowel are replaced on the right and left of the abdomen
respectively and appendicectomy is performed to avoid any future difficulty in the
diagnosis of appendicitis at a later date due to the normal anatomical placement of the
appendix having been disrupted.

Urgent laparotomy, rotate the volvulus anticlockwise, return the small bowel to the left of
the abdomen and the caecum and colon to the right and perform an appendicectomy

The small bowel needs to be returned to the right of the abdomen, and the caecum and
colon to the left.

Urgent laparotomy, rotate the volvulus clockwise, return the small bowel to the left of the
abdomen and the caecum and colon to the right

This is incorrect, because it does not describe the need for an appendicectomy, the volvulus
needs to be rotated anticlockwise; and the small bowel needs to be returned to the right of
the abdomen, and the caecum and colon to the left.

Urgent laparotomy, rotate the volvulus clockwise, return the small bowel to the left of the
abdomen and the caecum and colon to the right and perform an appendicectomy

This is incorrect, because the volvulus needs to be rotated anticlockwise; and the small
bowel needs to be returned to the right of the abdomen, and the caecum and colon to the
left.

Urgent laparotomy, rotate the volvulus clockwise, return the small bowel to the right of the
abdomen and the caecum and colon to the left and perform an appendicectomy

This is incorrect because the volvulus needs to be rotated anticlockwise.

•
 • MRCS Part A - Sep 2019 Exam

A 3-month-old girl presents with bile-stained vomit, abdominal tenderness and rectal
bleeding. Subsequent imaging suggests malrotation and mid-gut volvulus.
Intraoperatively,the small bowel is found to be ischaemic.
What is the best treatment option?

If less than 50 cm of viable bowel is found, excise all the ischaemic bowel

If less than 50 cm of viable bowel is found, untwist the bowel, return it to the abdomen and
close

If less than 50 cm of viable bowel is found, untwist the bowel, return it to the abdomen and
perform a second look laparotomy

If more than 50 cm of viable bowel is found, untwist the bowel, return it to the abdomen
and close

If more than 50 cm of viable bowel is found, untwist the bowel, return it to the abdomen
and perform a second look laparotomy

Explanation
If less than 50 cm of viable bowel is found, untwist the bowel, return it to the abdomen and
perform a second look laparotomy

This is the correct response; the second look laparotomy allows for assessment of the
bowel and therefore preservation of more length.

If less than 50 cm of viable bowel is found, excise all the ischaemic bowel

The patient has malrotation and volvulus neonatorum. The abdominal tenderness and
rectal bleeding are signs that there is bowel ischaemia. Urgent laparotomy is required.
Once the volvulus has been derotated, and the bowel returned to the abdomen the
ischaemic bowel needs to be dealt with. Efforts should be made to give a chance for the
bowel to reperfuse as in a young patient excision of such a large amount of small bowel will
lead to debilitating morbidity.

If less than 50 cm of viable bowel is found, untwist the bowel, return it to the abdomen and
close

This is not correct, as a second look laparotomy will be required.

If more than 50 cm of viable bowel is found, untwist the bowel, return it to the abdomen
and close

If there is more than 50 cm of viable bowel remaining the ischaemic section can be excised;
a primary anastomosis can be created and the abdomen closed without a need for second
look.

If more than 50 cm of viable bowel is found, untwist the bowel, return it to the abdomen
and perform a second look laparotomy

If there is more than 50 cm of viable bowel remaining the ischaemic section can be excised
and the ends anastomosed; there should be no need for a second look.

•
 • MRCS Part A - Sep 2019 Exam

You are assisting in surgical exploration of a testicular torsion.

If the testis is viable, how should the fixation be performed?

Both testes should be invaginated in the tunica vaginalis and sutured to the midline septum
with non-absorbable sutures

Both testes should be invaginated in the tunica vaginalis and sutured to the midline septum
with absorbable sutures

Both testes should be invaginated in the internal spermatic fascia and sutured to the
midline septum with non-absorbable suturesBoth testes should be invaginated in the
cremasteric fascia and sutured to the midline septum with absorbable suturesBoth testes
should be invaginated in the dartos fascia and sutured to the midline septum with non-
absorbable sutures

Explanation
Both testes should be invaginated in the tunica vaginalis and sutured to the midline septum
with non-absorbable sutures

The treatment of a torted testis that is viable is to suture both testes to the midline with
non-absorbable sutures, having invaginated the testes in the tunica vaginalis. Usually three
point fixation of each testis should be performed with a stitch medially, laterally and
inferiorly.

Both testes should be invaginated in the tunica vaginalis and sutured to the midline septum
with absorbable sutures

Non-absorbable sutures should be used to maintain the fixation for life.

Both testes should be invaginated in the internal spermatic fascia and sutured to the
midline septum with non-absorbable sutures
Both testes should be invaginated to the tunica vaginalis.
Both testes should be invaginated in the cremasteric fascia and sutured to the midline
septum with absorbable sutures
The invagination should be to the tunica vaginalis with non-absorbable sutures.
Both testes should be invaginated in the dartos fascia and sutured to the midline septum
with non-absorbable sutures
Both testes should be invaginated to the tunica vaginalis. The layers of the scrotum are
skin, dartos fascia and muscle, external spermatic fascia, cremasteric fascia, internal
spermatic fascia, tunica vaginalis and tunica albuginea.

• .
 • MRCS Part A - Sep 2019 Exam

An 87-year-old patient with perforated diverticular disease undergoes

a lengthy laparotomy. The anaesthetists are concerned about maintaining the patient’s
temperature during the operation.
Which one of the following would be most effective in reducing heat loss from the
patient and maintain core body temperature during the procedure?
Humidification of inspired gasesLavage with warm salineMaintaining the environmental
temperature at 20 ºC

Use of a heated blanket set at 35 ºC

Use of warm saline soaked packs to cover the bowel

Explanation
Use of a heated blanket set at 35 ºC

Anaesthesia obtunds the normal mechanisms of heat production, so the patient is

vulnerable to hypothermia from conductive, convective and evaporative heat loss. Using a
Bair Hugger (heated blanket) acts to warm the patient rather than reduce losses and can be
on three settings low (32 ± 3°C), medium (38 ± 3°C) and high (43 ± 3°C). However, it is
effective in maintaining the patient’s temperature, and so has to be considered the most
superior method.
Humidification of inspired gases
Humidification of inspired gases works to raise/maintain the core temperature, rather than
to reduce the heat loss from a patient.
Lavage with warm saline
Using warmed infusions raises/maintains the core temperature of a patient, rather than
minimising heat losses.
Maintaining the environmental temperature at 20 ºC
Theatre temperature is usually maintained between 22°C and 24°C (but may need to be
higher for neonatal surgery).

Use of warm saline soaked packs to cover the bowel

This is one way of minimising heat loss, however, the packs will rapidly lose their warmth,
and so is it not the most effective way.
 • MRCS Part A - Sep 2019 Exam

You are performing the approach for a thyroidectomy.

Which one of the following options is correct regarding this approach?
The ansa cervicalis is seen readilyThe anterior jugular veins should be divided

The flaps raised should be deep to platysma

The incision is made vertically at the level of the cricoidThe strap muscles are commonly
divided

Explanation
The flaps raised should be deep to platysma

The flaps must be raised deep to platysma, which lies superficially to the target planes.
The ansa cervicalis is seen readily
The ansa cervicalis embedded in the carotid sheath is not usually sought, unlike the
recurrent laryngeal nerves.
The anterior jugular veins should be divided
The anterior jugular veins are typically paired veins running vertically along bilateral
symmetrical paramedian lines in the superficial layer of the deep cervical fascia. To gain
access to the strap muscles, and subsequently the surgical thyroid capsule, the fascia must
be divided in the midline (ie between the paired anterior jugular veins, which are
subsequently retracted laterally).
The incision is made vertically at the level of the cricoid
The incision in thyroidectomy is made following the skin creases at about 4 cm above the
sternoclavicular joints.
The strap muscles are commonly divided
The majority of surgeons rarely divide strap muscles (namely the sternothyroid muscle at
its insertion on the thyroid cartilage) to gain exposure to the superior pole during
thyroidectomy; they can usually be retracted out of the way.