FRCS General Surgery Section 1 (Part A) — Questions and Answers

Question 1: In a patient with a large ventral hernia, which mesh position has the lowest recurrence rate?

Intraperitoneal underlay
Retromuscular (Rives-Stoppa: posterior to rectus muscle, preperitoneal) (Correct answer)
Onlay (above the anterior rectus sheath)
Inlay (within the defect, suture to fascial edges)

Correct answer: Retromuscular (Rives-Stoppa: posterior to rectus muscle, preperitoneal)

The retromuscular (Rives-Stoppa) technique, placing mesh posterior to the rectus muscle in the retromuscular plane, achieves the lowest recurrence rates for complex ventral hernias. The mesh is held in place by intra-abdominal pressure and avoids direct bowel contact, reducing adhesion risk.

Question 2: What does the Montgomery ruling (2015) require regarding informed consent?

Written consent forms can replace verbal discussion
Consent must always be obtained by a consultant surgeon
Patients must be informed of any risks a reasonable patient would want to know about, not merely what the clinician considers material (Correct answer)
Consent is only valid if signed 24 hours before surgery

Correct answer: Patients must be informed of any risks a reasonable patient would want to know about, not merely what the clinician considers material

Montgomery v Lanarkshire Health Board (2015) replaced the Bolam-based approach to consent with a patient-centred standard: clinicians must disclose all material risks that a reasonable patient in that patient's position would want to know. This shifts the standard from 'what doctors consider material' to 'what patients consider material'.

Question 3: What is the oxygen content of arterial blood (CaO2) in a patient with Hb 150 g/L, SaO2 98%, and PaO2 13 kPa?

Approximately 250 ml/L
Approximately 100 ml/L
Approximately 200 ml/L (Correct answer)
Approximately 150 ml/L

Correct answer: Approximately 200 ml/L

CaO2 = (Hb x 1.34 x SaO2) + (PaO2 x 0.023). With Hb 150 g/L: (150 x 1.34 x 0.98) + (13 x 0.023) = 196.9 + 0.3 = approximately 197 ml/L, which rounds to approximately 200 ml/L. The dissolved oxygen contribution is minimal compared to haemoglobin-bound oxygen.

Question 4: A patient taking clopidogrel requires an elective total hip replacement. According to UK guidelines, how many days before surgery should clopidogrel ideally be stopped?

14 days
3 days
1 day
7 days (Correct answer)

Correct answer: 7 days

Clopidogrel irreversibly inhibits the P2Y12 ADP receptor on platelets for the platelet's lifespan (7-10 days). UK guidelines (NICE, AAGBI) recommend stopping clopidogrel 7 days before elective surgery to allow sufficient new platelet production. The decision must balance bleeding risk against thrombotic risk, particularly in patients with recent coronary stents.

Question 5: Which clotting factor has the shortest half-life and is therefore the earliest indicator of synthetic liver failure?

Factor V
Factor VII (Correct answer)
Factor X
Factor VIII

Correct answer: Factor VII

Factor VII has the shortest half-life of approximately 4–6 hours and is dependent on vitamin K and hepatic synthesis. The PT/INR, which is sensitive to Factor VII, is the most sensitive early indicator of hepatic synthetic failure and is incorporated into prognostic scoring (Child-Pugh, MELD, King's College Criteria).

Question 6: In a clinical trial, the number needed to treat (NNT) is calculated as 10. What does this mean?

10 patients need to receive the treatment for 1 additional patient to benefit (Correct answer)
The relative risk reduction is 10%
The treatment is effective in 10% of patients
10 patients will be harmed for every patient who benefits

Correct answer: 10 patients need to receive the treatment for 1 additional patient to benefit

NNT = 1/ARR (absolute risk reduction). An NNT of 10 means that for every 10 patients treated, 1 additional patient benefits compared to the control group. It is derived from the absolute risk reduction, not relative risk reduction. Lower NNT values indicate more effective treatments. NNT is clinically more meaningful than relative risk reduction as it provides a direct measure of treatment impact in absolute terms.

Question 7: The anatomical landmark for the femoral nerve during femoral vessel exposure in vascular surgery is its location relative to the femoral artery. Where does it lie?

Medial to the femoral artery within the femoral sheath
Lateral to the femoral artery, outside the femoral sheath (Correct answer)
Anterior to the femoral artery
Posterior to the femoral vein

Correct answer: Lateral to the femoral artery, outside the femoral sheath

The femoral nerve lies lateral to the femoral artery outside the femoral sheath, in the iliacus groove. The femoral sheath contains only the femoral artery, vein, and canal (lymphatics). Knowledge of this anatomy prevents femoral nerve injury during femoral artery exposure.

Question 8: Which Clostridium species is the primary causative organism of gas gangrene (clostridial myonecrosis)?

Clostridium difficile
Clostridium botulinum
Clostridium tetani
Clostridium perfringens (Correct answer)

Correct answer: Clostridium perfringens

Clostridium perfringens produces alpha-toxin (phospholipase C), which destroys cell membranes and is the primary virulence factor in gas gangrene.

Question 9: What is the number needed to treat (NNT) if a treatment reduces the absolute risk of complication from 20% to 15%?

15
20 (Correct answer)
5
10

Correct answer: 20

NNT = 1 / absolute risk reduction (ARR). ARR = 20% − 15% = 5% = 0.05. NNT = 1/0.05 = 20. This means 20 patients must be treated for one additional patient to avoid the complication. Lower NNT values indicate greater treatment efficacy.

Question 10: What is the difference between relative risk reduction (RRR) and absolute risk reduction (ARR)?

ARR is the percentage reduction in event rate between treatment and control groups; RRR is ARR divided by control event rate (Correct answer)
RRR is always smaller than ARR
ARR is only used for negative outcomes; RRR for positive outcomes
They are the same measure expressed differently

Correct answer: ARR is the percentage reduction in event rate between treatment and control groups; RRR is ARR divided by control event rate

ARR = control event rate − treatment event rate (e.g., 20% − 15% = 5%). RRR = ARR / control event rate (5%/20% = 25%). RRR appears more impressive than ARR but is less clinically meaningful because it does not reflect baseline risk. Both are needed alongside NNT for full interpretation.

Question 11: What is neoadjuvant therapy in the context of surgical oncology?

Palliative systemic therapy when surgery is not possible
Treatment given before surgery to downstage the tumour and improve surgical outcome (Correct answer)
Adjuvant treatment given after surgery to reduce recurrence
Biological therapy targeting specific receptor mutations given intraoperatively

Correct answer: Treatment given before surgery to downstage the tumour and improve surgical outcome

Neoadjuvant therapy (chemotherapy, radiotherapy, or chemoradiotherapy) is given before surgery to reduce tumour size, downstage disease, improve resectability, and potentially sterilise micrometastases. Examples include FLOT chemotherapy before gastric cancer surgery and long-course chemoradiotherapy before rectal cancer surgery.

Question 12: A patient who is a competent adult refuses an amputation that is likely to save their life from gas gangrene. What is the surgeon's legal and ethical obligation?

Respect the refusal, ensure the patient has full information, document extensively, and seek ethics support (Correct answer)
Perform the amputation as the patient's life is at stake
Obtain a court order to override the refusal
Proceed with surgery after 48 hours to allow the patient to reconsider

Correct answer: Respect the refusal, ensure the patient has full information, document extensively, and seek ethics support

A competent adult's refusal of treatment is legally and ethically binding, even when it results in death. The surgeon must ensure the decision is informed, not subject to undue influence, and made with capacity. Detailed documentation, ethics consultation, and support for the patient and family are essential.

Question 13: Keloid scarring differs from hypertrophic scarring in which key way?

Keloid scars remain within the original wound boundary; hypertrophic scars extend beyond it
Hypertrophic scars occur only in dark skin; keloid scars occur in any skin type
Keloid scars regress spontaneously; hypertrophic scars do not
Hypertrophic scars remain within wound margins; keloid scars extend beyond the original wound boundary (Correct answer)

Correct answer: Hypertrophic scars remain within wound margins; keloid scars extend beyond the original wound boundary

Keloid scars grow beyond the original wound boundary and may continue to enlarge over time; they do not regress spontaneously and are more common in darker skin types and in certain anatomical sites (sternum, shoulders, earlobes). Hypertrophic scars remain within the wound margins and may regress with time.

Question 14: Which organism is the most common cause of wound infection in colorectal surgery?

Bacteroides fragilis (Correct answer)
Pseudomonas aeruginosa
Escherichia coli
Staphylococcus aureus

Correct answer: Bacteroides fragilis

Bacteroides fragilis is the most common organism isolated in post-operative wound infections following colorectal surgery. It is a Gram-negative anaerobe from the colonic flora. Broad-spectrum prophylaxis (e.g., metronidazole plus cephalosporin) covers both aerobic and anaerobic bowel flora.

Question 15: A patient has signed a consent form but during surgery a new finding is discovered that requires an additional procedure not discussed preoperatively. The patient is unconscious. What is the appropriate action?

Perform the additional procedure as you have the patient on the table
Ask the patient's next of kin for consent by telephone
Document the finding and close — complete the additional procedure at a subsequent operation
Only perform the additional procedure if it is immediately necessary to save life or prevent serious harm (Correct answer)

Correct answer: Only perform the additional procedure if it is immediately necessary to save life or prevent serious harm

Consent is specific to what was discussed and agreed preoperatively. Under anaesthesia, the patient cannot consent to additional procedures. The additional procedure should only be performed without consent if it is immediately necessary to save life or prevent serious harm, and if delaying poses unacceptable risk. Non-urgent procedures should be deferred.

Question 16: Which fungal organism is most commonly responsible for invasive fungal infections in immunosuppressed or critically ill surgical patients?

Aspergillus fumigatus
Candida albicans (Correct answer)
Histoplasma capsulatum
Cryptococcus neoformans

Correct answer: Candida albicans

Candida albicans is the most common fungal pathogen in immunocompromised and critically ill patients, particularly those with prolonged central venous catheterisation or broad-spectrum antibiotic use.

Question 17: A 30-year-old woman presents with a firm, mobile 3 cm breast lump. Excision biopsy shows a well-circumscribed lesion with a leaf-like pattern of stromal overgrowth covered by epithelium. What is the most likely diagnosis?

Phyllodes tumour (Correct answer)
Fat necrosis
Fibroadenoma
Invasive ductal carcinoma

Correct answer: Phyllodes tumour

Phyllodes tumour (cystosarcoma phyllodes) shows a characteristic leaf-like (phyllodes) architecture with stromal hypercellularity projecting into epithelium-lined clefts. It is classified as benign, borderline, or malignant based on stromal cellularity, mitotic activity, and margins. Unlike fibroadenomas, phyllodes tumours have a tendency for local recurrence and require wide excision with clear margins.

Question 18: A patient loses 1500 ml of blood acutely. According to the ATLS classification, this represents which class of haemorrhagic shock?

Class III (Correct answer)
Class I
Class IV
Class II

Correct answer: Class III

Class III haemorrhage represents 30-40% blood volume loss (approximately 1500-2000 ml in a 70 kg adult). It is characterised by tachycardia, hypotension, tachypnoea, reduced urine output, and altered mental status. Crystalloid and blood transfusion are typically required.

Question 19: A patient develops deep vein thrombosis 5 days post-operatively despite receiving prophylactic LMWH. Platelet count has dropped from 250 to 80 x10^9/L. What is the most likely diagnosis?

Immune thrombocytopenic purpura
Heparin-induced thrombocytopenia type II (HIT) (Correct answer)
Dilutional thrombocytopenia
Disseminated intravascular coagulation

Correct answer: Heparin-induced thrombocytopenia type II (HIT)

HIT type II is an immune-mediated prothrombotic condition caused by antibodies against the heparin-PF4 complex. It typically presents 5-10 days after heparin exposure with a >50% drop in platelet count and paradoxical thrombosis (DVT, PE, arterial thrombosis). The 4T score assesses probability. All heparin must be stopped immediately and an alternative anticoagulant (argatroban, fondaparinux, or danaparoid) started.

Question 20: Which cells are the primary effector cells of innate immunity?

CD4+ and CD8+ T lymphocytes
B lymphocytes and plasma cells
Natural killer T cells exclusively
Neutrophils and macrophages (Correct answer)

Correct answer: Neutrophils and macrophages

Neutrophils and macrophages are the principal effector cells of innate immunity, providing immediate non-specific defence through phagocytosis and release of inflammatory mediators.

Question 21: What is the most important preoperative investigation before major elective surgery in a patient with known ischaemic heart disease?

Resting 12-lead ECG and cardiology review with functional assessment (Correct answer)
Chest X-ray
Routine blood tests only
Exercise tolerance test regardless of functional capacity

Correct answer: Resting 12-lead ECG and cardiology review with functional assessment

Perioperative cardiac assessment requires determining the patient's functional capacity (METs), current cardiac status, and any reversible ischaemia. ACC/AHA and UK guidelines recommend cardiology review, resting ECG, and if intermediate or high risk, further evaluation with stress testing or cardiac imaging to guide optimisation and anaesthetic planning.

Question 22: Which principle describes the surgical approach to ensuring adequate lymph node harvest in cancer surgery?

Lymph nodes are sampled only if enlarged on preoperative imaging
En bloc resection with regional lymphadenectomy removes the primary tumour and its regional lymph node drainage field together (Correct answer)
Radical excision is only performed for Stage IV cancer
Sentinel node biopsy replaces all lymphadenectomy in GI cancer surgery

Correct answer: En bloc resection with regional lymphadenectomy removes the primary tumour and its regional lymph node drainage field together

En bloc resection removes the primary tumour along with its regional lymphatic drainage field in continuity. This achieves both local disease control and accurate pathological staging. In colorectal, gastric, and oesophageal surgery, adequate lymph node harvest (e.g., D2 gastrectomy) affects staging accuracy and survival.

Question 23: A surgeon notices a colleague appears intoxicated in the operating theatre. According to GMC Good Medical Practice, what is the surgeon's primary duty?

Raise a concern to protect patient safety (Correct answer)
Report only to the colleague's defence union
Discuss privately with the colleague after the procedure
Ignore it unless a patient is directly harmed

Correct answer: Raise a concern to protect patient safety

GMC Good Medical Practice (2024) states that doctors must raise concerns if they believe patient safety is at risk, including concerns about a colleague's fitness to practise. The duty to protect patients takes precedence over professional loyalty. Concerns should be raised with a senior colleague, clinical director, or through the organisation's reporting mechanisms. Failure to raise concerns may itself constitute a fitness to practise issue.

Question 24: Which sterilisation method is most appropriate for heat-sensitive surgical equipment such as fibreoptic endoscopes?

Dry heat oven at 160°C for 2 hours
Ethylene oxide (ETO) gas sterilisation (Correct answer)
Glutaraldehyde high-level disinfection only
Autoclaving at 134°C for 3 minutes

Correct answer: Ethylene oxide (ETO) gas sterilisation

Ethylene oxide gas achieves sterilisation at low temperatures (37–63°C) and is therefore suitable for heat-sensitive equipment that would be damaged by autoclaving.

Question 25: During a Whipple's procedure (pancreaticoduodenectomy), which structure defines the plane of resection in assessing portal vein involvement?

The common bile duct
The gastroduodenal artery
The portal vein/superior mesenteric vein confluence (Correct answer)
The hepatic artery

Correct answer: The portal vein/superior mesenteric vein confluence

Resectability in pancreatic head cancer is determined by the relationship of the tumour to the superior mesenteric vein (SMV) and portal vein (PV). The SMV-PV confluence lies in the groove between the uncinate process and the neck of the pancreas; tumour involvement of this vessel indicates a technically demanding or borderline resection.

Question 26: Which antibiotic is currently the first-line treatment for severe Clostridioides (Clostridium) difficile infection?

Oral vancomycin or fidaxomicin (Correct answer)
IV metronidazole
IV ciprofloxacin
Oral amoxicillin-clavulanate

Correct answer: Oral vancomycin or fidaxomicin

Oral vancomycin or fidaxomicin is the recommended first-line treatment for C. difficile infection; oral vancomycin achieves very high intraluminal concentrations without systemic absorption.

Question 27: What is the most common electrolyte abnormality following prolonged nasogastric suction?

Hypocalcaemia
Hypokalaemia with metabolic alkalosis (Correct answer)
Hypernatraemia
Hyperkalaemia

Correct answer: Hypokalaemia with metabolic alkalosis

Prolonged nasogastric suction removes gastric fluid rich in HCl and KCl. This causes hypochloraemic, hypokalaemic metabolic alkalosis. Potassium is lost both directly in gastric juice and via secondary renal wasting (increased aldosterone secretion in response to hypovolaemia further promotes K+ loss).

Question 28: A breast cancer patient is found to have a sentinel lymph node biopsy positive for macrometastasis. What is the implication?

Immediate systemic chemotherapy and no surgery
No further axillary surgery is needed
The result should be ignored if the primary was <1 cm
Axillary lymph node dissection or axillary radiotherapy should be considered (Correct answer)

Correct answer: Axillary lymph node dissection or axillary radiotherapy should be considered

Sentinel lymph node biopsy (SLNB) positive for macrometastasis (>2 mm) typically warrants completion axillary lymph node dissection (ALND) or axillary radiotherapy (ACOSOG Z0011, AMAROS trials have refined criteria). The decision depends on tumour characteristics, patient fitness, and planned systemic therapy.

Question 29: Which type of hypersensitivity reaction is responsible for anaphylaxis?

Type II (cytotoxic)
Type I (IgE-mediated) (Correct answer)
Type III (immune complex)
Type IV (delayed)

Correct answer: Type I (IgE-mediated)

Anaphylaxis is a Type I (immediate) hypersensitivity reaction mediated by IgE antibodies bound to mast cells and basophils, triggering rapid degranulation.

Question 30: What is the concept of 'surgical margins' in oncological surgery, and why does an R0 resection matter?

R0 means open surgery; R1 means laparoscopic surgery was used
R0 means microscopically clear margins; R1 means microscopic residual disease; R2 means macroscopic residual disease (Correct answer)
R0 means the tumour was benign; R1 means it was borderline malignant
R0 means no lymph nodes are removed; R1 means lymphadenectomy was performed

Correct answer: R0 means microscopically clear margins; R1 means microscopic residual disease; R2 means macroscopic residual disease

The R classification describes completeness of surgical resection: R0 = complete resection with microscopically clear margins (curative intent achieved); R1 = microscopic residual tumour at margins; R2 = macroscopic residual tumour. R0 resection is the primary determinant of long-term cure in solid organ malignancies.

Question 31: In the primary survey of a trauma patient (ATLS), after addressing airway with cervical spine control, what is the next priority?

Exposure with environmental control
Disability (neurological assessment)
Circulation with haemorrhage control
Breathing and ventilation (Correct answer)

Correct answer: Breathing and ventilation

The ATLS primary survey follows the ABCDE sequence: Airway (with C-spine protection), Breathing (and ventilation), Circulation (with haemorrhage control), Disability (neurological status), and Exposure (with environmental control). After securing the airway, assessment of breathing is the next priority — look for tension pneumothorax, open pneumothorax, flail chest, and massive haemothorax, which are immediately life-threatening.

FRCS General Surgery Section 1 (Part A)

The FRCS General Surgery Section 1 is the written component of the Fellowship of the Royal Colleges of Surgeons examination, assessing applied surgical science knowledge at the level of a newly appointed consultant surgeon across anatomy, physiology, pathology, and surgical principles.

Questions

35 min

Time Limit

70%

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