FRCS Principles of Surgery-in-General 2 — Questions and Answers
Question 1: During consent for surgery, which element is NOT required for the consent to be legally valid in the UK?
- The patient must sign a written consent form for all procedures (Correct answer)
- The patient must have capacity to make the decision
- The patient must be given sufficient information about risks and benefits
- The consent must be given voluntarily without coercion
Correct answer: The patient must sign a written consent form for all procedures
In UK law, consent does not always require a written form to be legally valid — verbal consent is sufficient for many minor procedures. The three legal requirements are: capacity (the patient can understand, retain, weigh, and communicate their decision), information (Montgomery ruling 2015 — material risks that a reasonable patient would consider significant), and voluntariness (free from coercion). Written consent provides documentary evidence but is not a legal requirement for validity.
Question 2: 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)
- Discuss privately with the colleague after the procedure
- Ignore it unless a patient is directly harmed
- Report only to the colleague's defence union
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 3: Which wound closure technique is most appropriate for a contaminated abdominal wound following surgery for faecal peritonitis?
- Delayed primary closure (Correct answer)
- Primary closure with drain
- Immediate primary closure with skin staples
- Skin grafting
Correct answer: Delayed primary closure
Delayed primary closure (DPC) is the recommended approach for contaminated or dirty wounds. The wound is left open initially, packed with saline-soaked dressings, and inspected at 3-5 days. If the wound bed is clean and granulating, it is then formally closed. This reduces surgical site infection rates from approximately 30-40% (with primary closure of contaminated wounds) to 5-10%.
Question 4: A 65-year-old patient scores 3 on the ASA Physical Status Classification. What does this indicate?
- A patient with severe systemic disease (Correct answer)
- A patient with mild systemic disease
- A normal healthy patient
- A moribund patient not expected to survive 24 hours
Correct answer: A patient with severe systemic disease
ASA classification: I = healthy; II = mild systemic disease (e.g., well-controlled hypertension, BMI 30-40); III = severe systemic disease (e.g., poorly controlled diabetes, COPD, BMI >40, active hepatitis, history of MI/CVA >3 months); IV = severe systemic disease that is a constant threat to life; V = moribund, not expected to survive without surgery; VI = brain-dead organ donor. ASA III carries significantly increased perioperative risk.
Question 5: 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 treatment is effective in 10% of patients
- 10 patients will be harmed for every patient who benefits
- The relative risk reduction is 10%
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 6: Which suture material is most appropriate for closing the linea alba in an emergency midline laparotomy?
- Slowly absorbable monofilament (e.g., PDS/polydioxanone) (Correct answer)
- Rapidly absorbable braided (e.g., polyglactin/Vicryl)
- Non-absorbable braided (e.g., silk)
- Non-absorbable monofilament (e.g., nylon)
Correct answer: Slowly absorbable monofilament (e.g., PDS/polydioxanone)
The STITCH trial (2015) and subsequent evidence support mass closure of midline laparotomies with a slowly absorbable monofilament suture such as PDS (polydioxanone), using a small-bite technique (5-8 mm from the wound edge, 5 mm apart) with a suture-to-wound-length ratio of at least 4:1. PDS maintains tensile strength for 6-8 weeks, matching the critical wound healing period. Monofilament reduces infection risk compared to braided sutures.
FRCS Principles of Surgery-in-General 2
During consent for surgery, which element is NOT required for the consent to be legally valid in the UK?