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The Royal Australasian College of Surgeons

GENERAL SURGERY FELLOWSHIP EXAMINATION

CANDIDATE GUIDE

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INDEX

1.  INTRODUCTION AND ADVICE FOR CANDIDATE PREPARATION ............................ 3 

1.1  Examiners' expectations .................................................................................................. 3 

1.2  Criteria to sit the Fellowship Examination ........................................................................ 3 

1.3  The role of the surgical supervisor ................................................................................... 4 

1.4  Preparation for Fellowship Examination .......................................................................... 4 

1.5  Practice examinations ...................................................................................................... 4 

1.6  Standards to be aimed for in rehearsal ............................................................................ 4 

1.7  "Last minute" preparation ................................................................................................. 5 

1.8  The challenged candidate ................................................................................................ 5 

2.  CURRICULUM ................................................................................................................. 5 

2. 1 Suggested Reading ......................................................................................................... 6 

2.2  Images ............................................................................................................................. 6 

2.3  Written examinations ....................................................................................................... 6 

2.3.1  Written paper 1 - spot test questions (25 questions in two hours) .............................. 6 

2.3.2  Written paper 2 - short answers paper (eight questions in two hours plus reading time) ............................................................................................................................ 7 

2.3.3  Marking of written papers ............................................................................................ 8 

3.  CLINICAL EXAMINATIONS ......................................................................................... 19 

3.1  The examination venues ................................................................................................ 19 

3.2  Viva sequence ............................................................................................................... 19 

3.2.1  Clinical 1 - medium-long clinical cases (two patients, 45 minutes) ........................... 19 

3.2.2  Clinical 2 - short clinical cases (four to six patients/disorders plus a scenario in 45 minutes) ..................................................................................................................... 21 

3.2.3  Vivas .......................................................................................................................... 22 

4.  THE MEETING OF THE SPECIALTY COURT IN GENERAL SURGERY ................... 23 

4.1  Collation of the candidate's assessments ...................................................................... 23 

4.2  Discussion of selected candidate's performances ......................................................... 23 

5.  THE SPECIALTY COURT IN GENERAL SURGERY ................................................... 24 

5.1  Senior examiner ............................................................................................................. 24 

5.2  Examiner assessor ........................................................................................................ 24 

5.3  Candidate awareness of inner working of the fellowship assessment ........................... 24 

5.4  Unfair activities ............................................................................................................... 24 

5.5  Candidate review ........................................................................................................... 24 

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1.3 The role of the surgical supervisor

The potential candidate must seek the advice of the surgical supervisor about his or her chances of passing the Fellowship. If the surgical supervisor believes that any aspect of the candidate's preparation, experience, balance, insight, comprehension, confidence or wellness were not of a standard sufficient for the candidate to have a high chance of passing, the surgical supervisor should guide the candidate to participating in a later examination. The candidate should present for the exit assessment only after these shortcomings have been rectified according to the supervisor's expectations.

1.4 Preparation for Fellowship Examination

The candidate should prepare for the Royal Australasian College of Surgeons Fellowship Examination by fulfilling all training criteria according to the curriculum. This will provide a broad basis of surgical knowledge, surgical practice and understanding of professional and social values held in Australian and New Zealand. The candidate should ensure that preparation involves both physical and mental wellness, which includes working safe hours to achieve wise sleep hygiene.

It is useful to form study groups to improve the balance of opinions and comprehension. Even if a candidate feels isolated or embarrassed, it is necessary to provoke a change in behaviour patterns, as networking is a very important development in successful candidature and professional development. In preparing, the candidate should understand that training should provide breadth and depth of practice in surgery. However, within three months of the examination, it is necessary to prepare in a strategic fashion. Successful candidates shift to a strategic approach in the final stages of preparation for examination. Strategies of the successful candidate include:

setting out a detailed timetable for coverage of selected, critical topics. The timetable should include the timing of the study period, the duration, the content, the method of study (for example, reading, practice examination, study group) and objectives rehearsal of assessment methods past papers review quarantining of study period (for example, 5.30am-6.30am) study group participation without fail or excuse.

1.5 Practice examinations A key component of the strategic approach to an examination is participation in simulation. Simulation improves performance, reduces mistakes, diminishes stress, facilitates comprehension and clarifies objectives. Candidates should practice reading short answer questions and writing short answer questions, practice intermediate length patient assessment (outpatients clinics), practice clinical scenarios and practice short assessments. Each practice should be supervised, observed, assessed and reviewed. A clear grasp of the time involved in each examination must be established. It is worthwhile seeking the help of different assessors of performance to gain a balanced feedback. 1.6 Standards to be aimed for in rehearsal Assistance in preparation will be provided through this website, where examples of written questions and examples of written responses will provide evidence of the standard required for Fellowship success. In reviewing the answers to both written and oral questions, the candidate should have provided evidence of preparation, depth of knowledge, priorities, comprehension, judgement, organisation, methods, clarity, responsibility, wisdom and insight into cost-effectiveness, risk benefit ratio, and evidence-based medicine. A candidate may have vast knowledge and accurate recall; however, if peripheral or trivial issues are raised before critically important issues, understanding is not revealed, and the performance will be judged to be below standard. Excellent examples of appropriate answers may be found in the Advanced Trauma Life Support (ATLS), Early Management of Severe Trauma (EMST), Care of the Critically Ill Surgical Patient (CCrISP) and Definitive Surgery for Trauma Care Course (DSTC) manuals.

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2. 1 Suggested Reading

Breast Surgery The Breast: Comprehensive Management of Benign and Malignant Diseases (ISBN: 9781416052210), 4th edition, by K.I. Bland & E.M. Copeland Breast Surgery: A Companion to Specialist Surgical Practice (ISBN: 9780702030123), 4th edition by M.J. Dixon.

Colorectal Surgery The ASCRS Textbook of Colon and Rectal Surgery (ISBN: 9780387248462) by D.E. Beck, B.G. Wolff, J.W. Fleshman, and S.D. Wexner A Companion to Surgical Specialties: Colorectal Surgery (ISBN: 9780702030109), 4th Edition by R.K.S. Phillips.

Endocrine Surgery The Textbook of Endocrine Surgery (ISBN 0721601391), 2nd Edition, by Clark / Duh / Kebebew. Elselvier-Saunders, Philadelphia, 2005. Transplantation Surgery Transplantation Surgery (ISBN: 9780702021466), by J.L. Forsythe. Trauma Surgery Trauma (ISBN: 9780071469128), 4th edition, by D. Feliciano, K. Mattox, and E. Moore. 2.2 Images Clinical assessment requires recognition of physical appearance and the appearance of normal and abnormal plain X-rays, CAT scans, ultrasounds, MRI, arteriograms and histology. These images are examinable. Trainees should acquire knowledge of image interpretation throughout training. Although the Fellowship is not a degree in radiology, it is necessary to emphasise the importance of assessment of the images by clinicians for complete patient evaluation. Therefore, reproduction of images may be presented in written paper 1, the clinical examinations, surgical anatomy, operative surgery and pathology and critical care as a means of assessment. 2.3 Written examinations

These examinations consist of two (2) different two (2) hour papers which are to be sat one (1) month before the vivas and clinical examinations. The main objective of the written examinations is to test the breadth of the candidate's training. The questions cover all aspects of the curriculum. The questions will usually evaluate clinical management and decision- making; however, aspects of pathophysiology, pathology, intensive care, surgical anatomy, operative surgery or images may be included. An applied anatomical or pathological question without management may be included. Questions on emergency disorders should be expected.

2.3.1 Written paper 1 - spot test questions (25 questions in two hours)

The candidate will sit this paper on the morning of the written examination. A 51-page booklet labelled Fellowship Examination in General Surgery Written Paper I Spot Test Questions will be presented with 25 questions of equal value to be completed in two hours. The answers are to be written in the space provided beneath the components of the questions. The illustrations to which the questions relate will be presented on the opposite (left) side of the answer page. Some written information is available on the illustration page, which may be relevant to the question. Do not write a formal essay in response. Usually there are four or five linked questions which cover the subject of the illustration provided. The format of the questions in the first written paper may be, for example:

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Question 1 - What is the diagnosis and differential diagnosis? Question 2 - What is the aetiology of the condition? Question 3 - What is the pathogenesis of the lesion? Question 4 - What operative procedure is recommended? Question 5 - What is the long-term prognosis?

Expect many variations and be sure to answer the question concisely and precisely. Do not make any answer perfunctory. Do not underestimate the importance of predispositions, associations, aetiology or pathogenesis. Do not write an essay.

While each of the 25 questions may appear to demand a different magnitude of commitment, it is the intended that it would require approximately four-and-a-half minutes to respond to the set of four or five questions. In addition, each sub question on the spot illustration may require a variable response time. However, the marks are evenly distributed.

Assessment of management of acute surgical disorders The Fellowship Examination does not readily examine emergency management. Therefore, efforts are made on both of the written papers to try to test the knowledge of emergency patient management. Consequently approximately 50% of the spot questions will be on major and minor emergency disorders. 2.3.2 Written paper 2 - short answers paper (eight questions in two hours plus reading time)

On the afternoon of the same day, the candidate will sit paper 2. Candidates will be presented with an examination answer booklet and an examination question paper. The question paper may be turned over five minutes before starting time. There are eight (8) questions, all are compulsory. These questions may be read (very carefully) in the perusal time. No entry is permitted on the examination booklet at this time. Each question should be answered precisely and concisely. Do not write in essay format.

Answer format

Plan carefully. Clear setting out of the response provides evidence of care. Often a vast amount of information is required to be organised into a short response, which should be set out in point form, in algorithm form or in very brief note form. It is highly unlikely that the candidate will achieve success with a conventional formal essay format.

Where applicable measurements, doses, illustrations, graphs or tables may be used to answer the question, keep in mind that none of the above can be generated successfully in the examination without practice; therefore it is necessary to practice the above techniques carefully to ensure correct labelling and clarity.

Be sure to check the examination paper for eight questions. If there are fewer than eight questions check the reverse side or look for a second question sheet.

Many resources may be required to write a balanced answer. It is not necessary to provided references; however referencing evidence based medicine reports may be relevant. A useful guide to the setting out of algorithms for surgical management may be found in the textbook Surgical decision-making 5th Edition, publisher Elsevier Saunders, edited by McIntyre, Stiegmann and Eiseman. A well set out algorithm provides the clearest evidence of a candidate's comprehension of the point of the question presented. Examples of the format can be found below.

Time management Be determined that each question is answered in 15 minutes or less. Failing to answer a question is a great disadvantage. It is preferable to answer the questions in the order of presentation; however, if one question appears to be very challenging, leave it until the end of

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the paper, but ensure that you allow 15 minutes to tackle the question and label each question number clearly on the front of the answer booklet. Clarity of writing contributes handsomely to the likelihood of passing. Capitals for headings and underlining for vital elements of the response will also help to ensure that the examiner credits your understanding and values. Headings and tables clarify answers. Examination book photocopying

As the written paper is photocopied for distribution to several examiners, it is necessary for the candidate to use a black writing device which provides dense and continuous lines. Black fountain pen, black ink ball writers (for example, Jetstream Mitsubishi 1.0mm pen) will provide clear reproduction. Black biros are less legible. Coloured writing will not reproduce well.

Source of questions All questions are created by the examiners and the examiners will write model answers which will be discussed, evaluated and modified to fulfil the expectations of the clearly expressed objectives of the Fellowship Examination. The expectations of the examiners will be limited to that which is achievable within the 15 minutes in point format.

Written paper quality control

Every effort is made to ensure that the questions are well set out and clearly expressed. However, steps are taken to ensure that the candidate has the opportunity to seek clarification of a question from the invigilator (it would be unwise of the general surgical candidate to write answers to the orthopaedic paper). It is necessary to carefully check the point of the question, carefully check that all questions are answered and double check there are no omissions.

Written examination supplies The candidate is obliged to provide all of the necessary supplies for the examinations, including several appropriate pens, ruler, rubber, sweets, analgesics, cushion and jumper. However mobile telephones, PDAs, reference material or iPods are not permitted. You should be allowed fully two hours of writing time. Should you have concerns, these issues must be raised with the invigilator at the time, if possible. 2.3.3 Marking of written papers

Marking of spot test answer paper Written paper 1 questions are marked as a pass or fail. The candidate must pass 20 questions to pass this paper. A candidate who passes 23 or more questions will be ranked 9.5. A pass in 20-22 questions will be ranked at 9.0 for the paper. A candidate who passes 16 questions will be ranked 8.5, borderline fail. A candidate who passes only 15 questions is ranked at 8.0 which is a clear fail.

Marking of short answers

The examiner will mark each short answer according to the following outline: 1. a complete answer which is clearly set out with appropriate priorities, logical sequence

and no major error of omission or commission - Score 9.5 2. an almost complete answer, well set out with appropriate priorities with minor omissions

and no serious errors of commission - Rank 9 (a pass) 3. an answer which is not clear and which has one major error of commission, of omission

or failure in prioritisation - Score 8.5 (borderline fail) 4. an answer with multiple gaps and more than one major error of omission or commission

or lack of priorities - Rank 8 (fail)

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Marking guidelines for overall score for paper 2 (short answer paper)

1. A candidate who scores 3 x 9.5 or more and no score below 9 - Rank 9.5. 2. A candidate who scores 6 x 9 and 2 x 8.5 or 7x 9 or 1 x 8 - Rank 9 (pass). 3. A candidate who scores 4 x 9, 3 x 8.5 and 1 x 8 - Rank 8.5 (borderline fail). 4. A candidate who scores more than 1 x 8 or more than 4 x 8.5 - Rank 8 (clear fail).

Therefore a candidate who leaves out one question must pass all other questions.

Model answers for written papers

Set out below are example questions and model answers offered for the spot test question paper and the short essay question paper. All model answers are ranked at the level of 9 (pass). Examples of Spot test questions: Example 1: Spot question 1 - illustration of mass on medial aspect of thigh of left lower limb 20 x 10cm Caption - "This 70-year-old woman presented with a large painless mass in her left quadriceps." Spot question 1 - answers

1. What is the most likely diagnosis? Liposarcoma or rhabdomyosarcoma Metastasis. Benign tumour (lipoma) much less likely

2. What investigations would you undertake for this patient? Triple phase CT scan of the thigh, abdomen, chest; MRI of the thigh. Oncology consultant guided open biopsy of mass.

3. What are the principals of management? 1. Assess the patient. 2. Assess the stage of the primary, secondary and nodes, and lungs. 3. Identify the nature of the lesion (histology). 4. Collaborative multiple speciality consultation, involving sarcoma specialist, orthopaedic

surgeon, radiologist, radiotherapist, rehabilitation specialist, patient relatives and referring doctor, following by compartmental clearance or radical wide excision including, if neurotropism is present, the adjacent neurovascular bundle. Primary closure. Radiotherapy. No chemotherapy.

Example 2: Spot question 2 - illustration of hepatic arteries Caption - "This is a coeliac access angiogram demonstrating an anatomical anomaly." Spot question 2 – answers

1. What is the anomaly? Left hepatic artery arising from left gastric artery.

2. Approximately how frequently does it occur? Approximately 12% of people.

3. In what operations is it relevant? Proximal or distal partial gastrectomy; or total gastrectomy, liver resections, oesophageal resections.

4. What are the likely consequences of failure to recognise it? Division of the left hepatic artery may lead to major bleeding. With ligation of the artery abscess formation in the liver infarction of the entire left lobe of the liver may occur, which could produce a severe inflammatory response syndrome.

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Example 3: Spot question 3 - illustration of dry, severe perianal necrotizing fasciitis Caption - "This is a 55-year-old man who presents to hospital very unwell with an increasing painful perianal area."

Spot question 3 - answers

1. What is the diagnosis? Horseshoe ischiorectal abscess with associate necrotising fasciitis (Fournier's gangrene).

2. What is pathology? The pathogenesis is necrotising fasciitis due to mixed anaerobe and aerobic bacterial infection which is associated with rapid progression of infarction of fat and overlying skin. Untreated, this disease leads rapidly to death. The usual organisms include haemolytic streptococcus.

3. What is the treatment? Emergency resuscitation, triple antibiotics, oxygen, rapid transfer to theatre for wide excision of necrotic tissue, culture and intensive care management followed by general anaesthetic and re-excision in 24 hours. Patient and relative counselling essential as the disease is deadly and disfiguring. Reconstruction will be required later. Colostomy may be required.

Examples of Short answers paper

Question 1

A 52-year-old male presents following a haematemesis. He had been resuscitated at a small hospital and arrives in your casualty department with a pulse rate of 104 and a blood pressure of 100 over 70. Two weeks ago he had been endoscoped and found to have an ulcer in the duodenal cap. He is on no medication apart from Omeprazole.

Outline your management of this patient.

The following are two different (2) examples of model answers for question 1. Some practice is required to produce the second format as an algorithm or flow diagram.

Question 1 - model answer

This patient is a high risk patient. After initial resuscitation involving IV fluids, bloods are sent off for urgent cross match, full blood analysis, Us & Es and LFTs. If patient becomes unstable in the emergency department, blood transfusion is commenced using grouped and cross matched blood or O-negative blood.

Arrangements are made for a definitive diagnosis to be obtained via gastroscopy. The patient is taken to theatre and airway protection is managed and intubation. An upper GI endoscopy is carried out to identify the bleeding spot.

The history suggests the likely bleeding point is the duodenal ulcer seen two weeks before. If this is still bleeding, then the ulcer is injected with adrenaline or a bipolar probe or gold probe is used to stop the bleeding. Other things used include heater probes which are monopolar or endoscopic clips. The bipolar probe has the advantage that it can inject and burn at the same time.

At endoscopy an antral biopsy for histopathology +/- urease test needs to be taken though HP testing may be falsely - ve if pt is on PPI. Even if -ve will probably receive HP eradication therapy at some stage.

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o Liver USS or CT: yearly intervals to five years o CXR or Pulmonary CT: yearly intervals to five years.

Family screening

1. Establish family history of colorectal, breast and endometrial cancers. 2. Review histopathology specimen for immunohistochemical evidence of microsatellite

instability (MSI) where available. 3. If high risk on the basis of family history or MSI, consider referral to clinical geneticist.

Intensive screening of first degree relatives in this group includes: o colonoscopy three-five yearly from app. 43 years of age o mammography/PAP smears in female relatives in case of suspected/confirmed

HNPCC. 4. If no apparent family history still recommend close follow-up of first degree relatives by means

of three-five yearly colonoscopy.

Question 3

A 50-year-old female undergoes a laparotomy for an acute small bowel obstruction due to adhesions. Postoperatively on day seven she develops an entero-cutaneous fistula through the wound. The patient is well and does not have generalised peritonitis.

Outline the non-operative and operative principles of management.

Question 3 - model answer

Principles of management

Peritonitis excluded, therefore immediate laparotomy not required and aim to treat conservatively in the first instance.

Identify and treat any sites of sepsis. This will involve CT scanning with oral and intravenous contrast and CT or ultrasound guided percutaneous drainage of any intra-abdominal collections. Any collections should be sent for microscopy and culture. If organisms are grown, appropriate antibiotics should be prescribed according to sensitivity testing.

Careful fluid balance is required. Careful monitoring of input and output including the fistula volume over 24 hours, urine output and status of hydration. Careful replacement of fluids and electrolytes is essential, including Na+, K+, Cl-, Ca2+, Mg2+, MCO5.

Maintain adequate nutritional support. In the first instance this will be with total parenteral nutrition. However, later enteral feeding, if possible, is preferable to ensure the gut mucosa does not become atrophic. Enteral feeding has a trophic effect on the bowel, preserves the immune system and prevents bacterial translocation. Therefore electrolyte solutions, elemental feeding and enteric feeding with fine bore enteral tubes may all have a role.

Skin protection is important. Stomal therapists should be involved and high quality stomal products.

Exclude distal obstruction as this will prevent a fistula from spontaneously closing. A small bowel contrast follow through study may be required an/or a retrograde distal bowel contrast study may be required.

Investigate the fistula with a fistulogram. A fistula with a long narrow tract is more likely to close than a fistula with a short wide tract.

Classify the fistula into high or low output. High output is defined as greater than 500ml per 24 hours.

Aim to reduce the fistula output with anti-motility drugs, for example, Loperamide and Codeine. A trial of Octreotide for several days may be helpful. Use of electrolyte solutions and elemental feeding will reduce bowel content.

Surgery for non-healing fistulas. The timing of surgery will be when nutrition and sepsis are under control and distal obstruction is excluded. It is important to delay surgical intervention for as long as possible to reduce intro-abdominal adhesions and to be certain that spontaneous closure will not occur. This will usually equate to a six month period. The principles of surgery are as follows:

o laparotomy o resection of involved bowel and skin

Page | 13

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Question 4

A 50-year-old man has presented with a 3cm diameter firm lump in the left lobe of the thyroid gland. Thyroid function is normal. Fine needle aspiration cytology of the 3cm diameter lump shows definite papillary carcinoma.

Describe any further investigations you would wish to undertake. Discuss the principles of the surgical treatment of this condition. (Do not give operative

surgery details.) Enumerate the advantages of the proposed operation you have chosen. Indicate your plan for follow-up treatment. Discuss the prognosis for this patient.

Question 4 - model answer

Further preoperative investigations. This patient is a male over 50 with a 3cm diameter papillary cancer and therefore is at greater risk of local and systemic recurrence.

o A chest X-ray as a base line should at least be undertaken to exclude pulmonary metastases.

o A calcium level as a base line is important to monitor for postoperative hypercalcaemia.

o Serum thyroglobulin as a base line will be important for postoperative monitoring. o A preoperative vocal cord check is mandatory to assess normal bilateral recurrent

laryngeal nerve function prior to surgery.

Surgery The preferred operation is total thyroidectomy with central lymph node neck clearance, Levels VI and VII. Level VI lymph nodes are those nodes in the tracheoesophageal grooves on each side of the neck below the inferior thyroid artery, extending down to the thyrothymic ligament and anterior to the recurrent laryngeal nerves.

Level VII dissection is associated with cervical thymectomy and associated lymph nodes.

A lesser resection such as lobectomy with excision of pyramidal lobe and isthmus would not be regarded as adequate treatment. The reason being this patient has a higher risk of recurrent disease and will benefit from radio-iodine scanning and treatment and thyroxin suppression. This is not possible if the remaining thyroid lobe is in-situ.

The advantages of total thyroidectomy with central lymph node clearance for this patient over a lesser thyroid resection, therefore, are: 1. treats multicentric papillary carcinoma, which is a not uncommon problem 2. allows radio-iodine scanning and abatement of any residual thyroid tissue and any

suspected metastatic disease in lymph nodes 3. allows thyroxin suppression 4. allows follow-up with serum thyroglobulin, which should be close to 0 5. reduces the local recurrence rate in the neck, specifically by the central lymph node

dissection 6. probably improves survival in this high risk group of patients.

Follow-up Radio-iodine scanning should be undertaken at six weeks. The patient should not be put on Thyroxine in the immediate postoperative period so that the radio-iodine scanning can be undertaken.

Thyroxine should be prescribed in a dose to cause TSH suppression to a value of less than 0.01. Serum thyroglobulin should be monitored. The patient will be followed closely and will probably have a six month, then yearly radio-iodine scan at least for the first few years.

Page | 15

If cancer is confined to thyroid, five-year survival 97%. If cancer is metastatic in 50 yr, five-year survival 70%.

Question 5

A 50-year-old female is investigated for vague abdominal pain of one month's duration with ultrasound by her local doctor.

The ultrasound has demonstrated a probable, roughly 5 x 4 x 3cm diameter solid retroperitoneal mass, positioned in the pre-aortic region below the level of the pancreas.

List the possible differential diagnoses and discuss your further investigation of the patient. Do not include details of clinical assessment (do not detail the history and examination).

Question 5 - model answer

Differential diagnoses

1. Lymphoma 2. Secondary metastases in lymph node, for example bowel, ovary, melanoma, panaceas 3. Soft tissue sarcoma 4. Desmoid tumour 5. Rare benign soft tissue tumours 6. Phaeochromocytoma of organ of Zuckerkandl

Further investigations

Review the ultrasound images with a radiologist, ascertain the site of the lesion, whether it is cystic, solid or mixed, its vascularity, whether it is regular or irregular, assess whether any other features have been noted, for example liver lesions.

Further imaging o CT scan of the abdomen with intravenous and oral contrast to further delineate the exact

site of the mass, its possible organ of origin and its characteristic features. The site, the size, the regularity, local invasion of structures, density and associated features may give an indication as to whether this is an underlying benign or malignant mass. It will also help clarify whether the lesion is retroperitoneal or within the mesentery of the small bowel or intraperitoneal. This distinction is of significance in further investigation.

o CT scan of chest should be undertaken to exclude pulmonary metastases. o MRI may be required at a later stage if the lesion is felt to be resectable and to assess

involvement of major vascular structures, for example the aorta, inferior vena cava and superior mesenteric artery.

o PET scanning to detect metastatic disease elsewhere, which could therefore influence a decision as to whether or not to proceed to major resection of the retroperitoneal mass.

o Angiography. o Endoscopy with gastroscopy and colonoscopy is unlikely to be helpful if the imaging, as

previously mentioned, clearly establishes the lesion as in the pre-aortic area. However, if secondary lymph nodes disease from a carcinoma of the stomach or colon is a possibility, then it may be appropriate.

Tumour markers. CEA, alpha-feto protein, beta HCG, CA 125, CA 19.9 may provide a clue to conditions such as secondary pancreatic cancer, a germ-cell tumour metastasising from the ovary or metastatic colon cancer. An elevated LDH may suggest lymphoma.

General assessment of full blood examination, urea, creatinine, electrolytes, liver function tests, ESR and CRP will give information about possible generalised disease processes and the possibility that if this mass is malignant metastatic disease is present elsewhere.

In this site, one rare possibility is a phaeochromocytoma of the organ of Zuckerkandl, and therefore a secreting phaeo should be excluded before biopsy is undertaken because of the risk or precipitation of a hypertensive crisis. This screening is best undertaken with a 24-hour urine collection for catecholamines (adrenaline, noradrenaline and dopamine).

Page | 16

Coagulation studies, INR and KPPT should be undertaken prior to any biopsy procedure.

Biopsy to obtain histology is required. If possible, this is preferably undertaken with a core biopsy in preference to fine needle aspiration cytology. Appropriately taken core biopsies providing an adequate amount of tissue, handles by the pathologist directly and dealt with appropriately, i.e. including flow cytometry, imprint studies and appropriate immunohistochemistry, may well establish the diagnosis in sufficient detail without needing to resort to an open biopsy at laparotomy. On occasions, however, open biopsy at laparotomy will be required; however, if this is the case and resection is possible, one should aim to proceed to resection at the time of the open incisional biopsy.

On occasions laparoscopy may be considered as part of the investigation prior to a definitive laparotomy.

Question 6

A 21-year-old man suffers blunt abdominal trauma in the course of a football match. He presents with abdominal and left shoulder tip pain. PR = 120, BP = 140/90. The abdominal CT scan is reported as follows: major disruption of spleen with mid segment not perfused. Some free intraperitoneal blood seen around spleen. Liver and pancreas intact. Left kidney normal. No free gas. No other injuries seen. Probable Grade III to IV injury.

Outline his management, covering the common scenarios that might be encountered.

Question 6 - model answer

Salient points - splenic disruption without obvious free rupture; haemodynamically stable.

1. Immediate management o Oxygen via Hudson's mask 15L/min. o Appropriate resuscitation including establishment of IV access, check HB level,

arrange X-match, administer analgesia. o Limited screening for rib fractures, pneumothorax, urological trauma, hollow organ

rupture (including CXR, urinalysis).

2. Non-operative management o Despite the extensive splenic disruption, the splenic capsule is robust in young

people and surgery might be avoided. o Rest in bed including insertion of urinary catheter. o Close monitoring of PR, BP hourly in high dependency unit. o Monitor Hb and transfuse to keep Hb > 9.09m/L. o Anti-bacterial immunisation in case of later urgent need for splenectomy (includes

cover for Haemophilus, Pneumococcus and Meningococcus). o Follow CT appearances (at three-five days and immediately pre-discharge). o If haemodynamically stable and Hb also stable at 10 days, consider discharge; must

minimise risk of re-injury and be aware of risk of delayed rupture.

Follow-up including CAT scan abdomen. Return to contact sport only once CT appearances have normalised (usually four-six weeks).

3. Operative management o Required in event of sudden haemodynamic instability OR progressive fall in Hb level

with need for repeated transfusion. o Preoperative thrombo-embolic and antibiotic prophylaxis are mandatory. o Anti-bacterial immunisation as above. o Splenic conservation - partial splenectomy, splenic repair - unlikely in view of

substantial (Grave Iv) disruption on CT scan. o Formal splenectomy most likely - spleen is often auto-mobilised by the haematoma but

usual care to avoid injury to pancreatic tail and gastric fundus should be highlighted. Thorough laparotomy to examine other organs for possible injury is essential.

4. Arteriogram and embolization of bleeding artery

Page | 17

o Long-term immunisation (five yearly) and antibiotic prophylaxis (penicillin for first post-op month and to cover for surgical and dental procedures).

Question 7

A 67-year-old female presents with a strangulated left femoral hernia requiring urgent operation. She has a prosthetic mitral valve for which, among other medications she takes Warfarin. Her INR on admission is 4.6. Outline your management of her coagulation status.

Question 7 - model answer

1. This patient requires urgent reversal of the Warfarin effect and the aim is to reduce the INR to 1.5 or less. Vitamin K takes up to 24 hours to achieve its full effect and therefore has a very limited or no role in this situation. Warfarin should be ceased.

2. The patient's management should be provided in consultation with a haematologist. The patient will require intravenous administration of one or both of: o Prothrombinex - HT - this contains coagulation factors II, IX and X and low levels of

factor VII. It is a prothrombin complex concentrate. The dose appropriate to this situation is 50 IU/kg - vials contain 400 IU and so 6-8 vials will be necessary

o fresh frozen plasma - this contains factors II, VII, IX and X and due to the low levels of factor VII in prothrombinex it should be administered together with prothrombinex. Once thawed, approximately three bags will be required initially.

3. If Vitamin K is administered, it should be at a low dose (for example, 1mg intravenously) as higher doses will interfere with the therapeutic effect of Warfarin once it is re-introduced post operatively.

4. After the administration of the prothrombinex and/or FFP the INR should be checked and further doses given if the INR still exceeds 1.5.

5. Operation is conducted with INR of 1.5.

6. Post operatively this patient is at high risk of thrombosis of her prosthetic valve. It may take up to five days to achieve the full effect of Warfarin once it is re-introduced.

7. The anticoagulant effect of Warfarin depends primarily on its ability to inhibit the production of prothrombin (factor II). Factor II has a half life of 60-72 hours and as it takes two half lives to clear factor II, Warfarin will take about five days to achieve its full effect. Therefore this patient will require bridging therapy with Heparin.

8. If there is no post-operative bleeding, Heparin should be commenced 12-24 hours post operatively, either intravenous unfractionated Heparin (aim APTT 1.5x normal).

9. Re-commence Warfarin as soon as possible post operatively. The dose of 5mg is ideal as higher doses are not recommended. Heparin can be withdrawn 48 hours after the target INR is reached.

10. Cardiology review is recommended.

Reference Warfarin reversal: consensus guidelines on behalf of the Australasian Society of Thrombosis and Haemostasis MJA Vol 181, No 9, 1 November 2004

Question 8

Describe the anatomy of the axillary vein, including its important surgical relationships seen during axillary dissection. Describe the steps in your technique of identifying the axillary vein at the time of axillary dissection.

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Question 8 - model answer

Definition The axillary vein is formed by the venae-comitantes of the branchial artery joining the basilic vein at the lower border of the teres major on the posterior wall of the axilla. It then courses upwards on the medial side of the axillary artery and leaves the axilla by passing through the apex of the axilla anterior to the third part of the subclavian artery at the outer border of the first rib, as the subclavian vein. Tributaries The tributaries of the first part of the vein, that above pectoralis minor, include the cephalic vein which enters by piercing the clavi-pectoral fascia. The second part has tributaries from the acromiothoracic region including the important medial pectoral vein which runs with the medial pectoral nerve. The lateral thoracic vein runs just above the lower border of pectoralis minor and is related to the pectoral lymph nodes. The third part of the vein below the pectoralis minor has three tributaries; the subscapular vein which runs with the subscapular artery and the nerve to latissimus dorsi. This structure runs down on the posterior wall of the axilla. There are also anterior and posterior circumflex humeral vessels as tributaries of the third part of the vein. Relations The nerve to serratus anterior runs posteriorly in the axilla on the medial wall, deep to the

fascia on serratus anterior and runs behind the axillary vein. The medial cutaneous nerve of the arm is a branch of the medial cord of the brachial plexus and runs down on the medial side of the axillary vein and supplies skin over the front and medial side of the arm. This structure is at risk of damage during axillary dissection.

The medial cutaneous nerve of the forearm runs between the axillary vein and artery and therefore should not be at risk during axillary dissection, given that axillary dissection should be confined to the axillary contents inferior and medical to the axillary vein.

The thoracodorsal nerve or nerve to latissimus dorsi runs behind the axillary vein and is initially medical and posterior to the subscapular artery. The two structures then run down to the latissimus dorsi. Preserve these structures during axillary dissection to ensure neurovascular supply to the latissimus dorsi muscle which may be required at a late date for either rotation or free flap myocutaneous reconstruction.

Surgical approach Identification of the axillary vein at axillary dissection is achieved through a transverse skin crease incision deepened subcutaneous tissue. The outer border of pectoralis major and then pectoralis minor are in turn identified and the fascia overlying is divided. The fascia of the lateral border of the pectoralis minor (the suspensory ligament of the axilla) is divided and this allows entry into the axilla proper. The axillary artery is identified b y palpation and hence, medial to this, it will be possible to find the axillary vein behind the pectoralis minor muscle. The fascia over the inferior and medial border of the axillary vein is gently divided. This allows correct and safe identification of the axillary vein and allows axillary dissection to proceed. The important structures which should be preserved during axillary dissection are: the tissues, superior and lateral to the axillary vein the nerve to latissimus dorsi the subscapular pedicle the nerve to serratus anterior the medial pectoral nerve the medial cutaneous nerve of the arm the intercostobrachial nerve.

Page | 19

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Page | 20

Objectives In each instance the candidate should introduce himself carefully to the patient, should conduct an orderly, predictable and gentle bedside assessment. The candidate should comment on important positives and important negative physical findings as the examination progresses. Should the candidate have consultation difficulties during this part of the assessment, it will be obvious to the examiners and this will be taken in to consideration when assessments are made. The history taking may be continued during the physical examination. One of the assessments may be longer than the other.

The candidate will then be assessed on aspects including rapport, gentleness, organisation, insight, efficiency, quality, accuracy and comprehensiveness of the bedside assessment. The candidate will also be assessed on objectivity, consistency of conclusions with physical findings, quality differential diagnosis and strategy, interpretation of investigations, understanding and comprehension of the patient's clinical syndromes, their clinical decision-making, and the quality of the patient or relative's advice and counselling.

Competencies The examiners participating in this assessment will be evaluating the candidate's competencies. Competencies are made up of knowledge, skills, attitude and values. The standard assessment model applied in these examinations is the general surgical inpatient or outpatient. A satisfactory achievement in this standard assessment is that which would ensure the careful, thorough and successful care of the patient with his or her illnesses in an Australian or New Zealand environment. In this assessment, observation by the examiners is very important but also judgements may be inferred because this assessment is not measurement based but judgement based. There is scope for interpretation and individual variation. (For example, when a candidate's recommended management is at variance to the examiners judgement, the candidate will be given credit for the recommendations if there is a sound reason and the recommendations are safe, predictable, cost effective and well understood by the candidate.)

Examiner's strategies and obligations

The examiners wish to facilitate the assessment of the candidate's standard of practice to certify competence. The examiners therefore will raise issues for definition and discussion. In doing so the examiners are obliged to ask straightforward questions on basic or common issues. The candidate will not face tricks or traps in the assessment.

If the examiner asks the same question twice, it may be that the answer was not heard. Alternatively and more importantly, it is likely that the examiner is inviting the candidate to correct a major mistake. Be sure to grasp this opportunity to maintain standards when the examiner presents this offer. Be sure to know that examiners do not initiate bluffs as" it is forbidden.

The following is an example of the examiner providing the candidate with opportunities to reach competency in surgical practice.

A common scenario for the candidate is the challenge of appropriate management of a patient with a colostomy or an intestinal fistula.

If the candidate recommends surgical closure, the examiner will ask the candidate if there are any essential steps required to be completed before surgery.

If the candidate omits the required study of the distal bowel to prove patency and freedom from disease, the examiner will ask the candidate if there are any steps in preparation for theatre which may reduce the risk of leakage of the anastomosis. The examiner has asked two questions in the hope of confirming the candidate's understanding of the importance of distal patency.

Page | 21

Assessment

At the end of the two assessments, the examiners will be able to make a sound assessment of the contribution that the candidate could make to the quality of care of the patient with an elective surgical disorder with or without co-morbidities. The examiners will identify a global mark which will be declared as 9.5 for outstanding, 9 for a clear pass, 8.5 for a borderline fail and 8 for an outright fail. This global mark will be derived from the two components of the examination. If the examiners' assessments differ a discussion follows, the examiner who has the higher mark is then obliged to explain to the examiner who has marked the candidate down, why the candidate should have a higher ranking. The examiner awarding the higher ranking will be given generous opportunity to develop the case for the higher ranking for the candidate. The examiner who provides the lower ranking is obliged to provide very accurate, precise and reliable evidence for the lower ranking. This examiner may present on areas of serious commission, for example intubating a patient with an unstable cervical spine or serious errors of omission or flaws in priority rankings.

Other issues which would be considered worthy of concern would be if the candidate caused the patient discomfort or anguish or was unhygienic.

See Appendix 1 for the assessment scoring template

At the conclusion of the medium-long cases the final agreed single mark is awarded. The document identifying the candidate's final mark is carefully signed, dated and countersigned by the examiners. This document is then forwarded to the clerk of the court.

Other surgeons present at examination

On occasions, these important examinations will be observed by the censor-in-chief. On occasions the examiners will be under review by the senior examiner who will not participate in the examination. Only the assessments of the two appointed examiners will be permitted to be discussed before the final mark is awarded. The observers and the assessor will not participate in the assessment or questioning.

3.2.2 Clinical 2 - short clinical cases (four to six patients/disorders plus a scenario in 45 minutes)

In this section of the examination, the candidate will be expected to assess four to six patients. These patients will be carefully selected by the Registrar to the Court of Examiners and by the delegated organisers. These patients are fully informed of their role. The disorders are predictable and restricted to the range of disorders outlined in the syllabus which are associated with signs. The assessment almost always involves a regional examination. Patients with head and neck lumps, ulcers and deformities, patients with skin lesions, breast lesions, abdominal signs, hernias, peripheral vascular disease, neurological disorders such as Horner's will be assessed. On occasions, patients with nasogastric tubes, colostomies, catheters, drains, wounds or appliances may participate.

Objectives The candidate should formally introduce him or herself to the patient, announce clearly but sensitively, both positive and important negative findings and materially demonstrate patient care and infection control strategies. The candidate would be expected to assess the patient and discuss the findings as the examination progresses. The candidate should make accurate observations, well reasoned deductions and conclusions about patient signs without causing patient alarm. The entire introduction, establishment of rapport, bedside assessment, observations, deductions, conclusions and recommendations should be completed in five to seven minutes, after which the candidate will complete hand decontamination and start the assessment of the next patient. The candidate will complete this part in 30 minutes. As patients may have a number of disorders or signs the number of patients

Page | 22

assessed does not correlate with success or otherwise. One volunteer patient in a past examination had a Horner's Syndrome recurrent laryngeal N palsy, brachial plexus palsy and a thyroid mass representing almost one complete assessment session.

The scenario

After washing his or her hands, the candidate then will be made comfortable in front of a monitor screen where a case scenario will be projected starting with the history and physical signs progressing to laboratory tests followed by imaging, followed by the formulation of a management strategy. The candidate may be asked about consenting or patient advice at this stage. It is likely that this scenario will be of an emergency nature or will progress to requiring emergency management. The scenario will continue with the development of further issues which may be progression of the disease, the development of surgical complications, the onset of co-morbidity set backs or the development of other iatrogenic setbacks. The candidate will be required to assess these new developments, set in motion a plan of management and once again, make deductions from investigations of the patient's new scenario. This assessment will be completed in 15 minutes. This pattern is not unlike that presented in the CCrISP training format. However, the scenario is captured in digital format rather than a role playing actor. Each examiner will assess the candidate's ability to think comprehensively and in an orderly fashion when faced with progression of serious emergency developments. The candidate should demonstrate understanding, comprehension, organisation, insight and prioritisation in this segment of the examination. At the end of 45 minutes this examination is concluded.

Assessment

Once again, the examiners will award a global mark for each patient's assessment and scenario performed. This score will then convert to a global mark for the entire 45 minutes. This mark will follow the closed marking system once again of 9.5 for excellent, 9 for a clear pass, 8.5 for borderline fail and 8 for an outright fail. An 8 will be awarded to a candidate who is unable to satisfy the examiner's standards in two or more of the assessments. Four borderline scores will be converted to 8.5.

3.2.3 Vivas

Surgical anatomy (approximately six sections in 25 minutes)

The candidate will be expected to travel to an anatomy department to undergo examination in anatomy of the head and neck, chest, abdomen, pelvis and limbs over a period of 25 minutes. Two examiners will question the candidate on the anatomy of CT scans of the neck, abdomen or pelvis. Arteriograms of the abdomen, neck or limbs may be presented for assessment. The candidate will then be examined on regional anatomy as demonstrated by wet specimens of the head and neck, axilla, upper limb, abdomen, pelvis and lower limb. The emphasis of the questions is on clinically relevant anatomy and operative surgical anatomy, for example, the anatomical variations of the blood supply to the liver or the distribution of the facial nerve in the parotid gland. The candidate would be expected to know the consequences of misadventure resulting in an injury to an artery or nerve. The candidate would be marked on each of the six sections individually by the examiner. If the examiners disagreed, the examiner awarding the higher mark would be given a lengthy opportunity to justify the awarding of the higher mark. The closed marking system is employed.

Operative surgery (approximately five scenarios in 30 minutes)

The candidate will be introduced to two new examiners. The examiners will take it in turn to raise the subject of a surgical disorder and asked the candidate to outline the operative strategy and the management of that surgical disorder. The disorder to be considered for surgery may be emergency or elective. The candidate may be expected to give an account of the preparation, consenting, consideration of co-morbidities, modification of strategies, positioning of patient, apparatus required for surgery, risk benefit ratios and options. However, in most instances the examiner will be most interested in assessing the objectives of the operation and the candidate's understanding of the operation that the candidate would recommend for the disorder

Page | 23

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Page | 24

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L SURGER

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Page | 25

comment that they enjoyed the examinations, that the examinations were a fair and relevant test and that the examinations form an integral part of their learning of the practice of General Surgery. Some candidates have reported that they felt that every effort they had made to prepare for examination proved to be justified as they felt that anything less than devotion to their work would have led to an inferior and unacceptable performance. Passing candidates also recognised that the task is vast and time may not be enough to achieve the recognised standards. The solution to such a challenge for most candidates is networking through study groups where shared knowledge, attitudes, experience and insight accelerate learning making it more memorable, more organised and more readily retrieved.

Video training

It is important for candidates to recognise that videoing of practice clinicals and practice vivas will provide very profound and durable feedback. Perhaps, in time video evaluation of candidates of clinical activities or surgical procedures will be included in a portfolio to be submitted to the College. However, videoing of candidate performance should be seen as a very powerful training tool. Videoing will not be carried out in the examination. In the future, videoing may prove to be an important quality control for examinations. It may be possible that candidates will be able to request video recording of the formal Fellowship Examination.

Examinations of the future

The RACS Fellowship Examination is constantly under review. Changes will be introduced. However, any change must be conveyed to all candidates six months before the date of the written examination.

Acknowledgements

I would like to acknowledge the stimulus, guidance and enthusiasm of the Senior Examiner, Mr Richard Cade, in developing the knowledge base of the General Surgical Fellowship for dissemination to candidates. If Richard's ambition can be achieved in part through this document, we will see that the success rate of Fellowship candidates will approach 100%. I would also like to acknowledge the help of my fellow examiners and Dr Wendy Crebbin, Manager of Education Development and Research Department of the Royal Australasian College of Surgeons for her kindness and dedication in providing guidance and supervision of this Fellowship initiative.

Disclaimer

Should you have concerns about the contents of this material please do not hesitate to contact me as this is the first draft of a living document. It is hoped that this guide will be quickly modified and expanded to meet the many critical needs of the candidates according to the standards of the College Fellowship and the expectations of the members of the Court of Examiners.

Author

Daryl R Wall Director of General Surgery Associate Professor of Surgery University of Queensland Princess Alexandra Hospital Ipswich Rd Woolloongabba QLD 4102

Page | 26

APPENDIX 1

General Surgery Scoring Template

CLINICAL VIVAS IN GENERAL SURGERY SCORING TEMPLATE

Excellent Satisfactory Unsatisfactory

Basic Science: Clear and concise All components accurately identified and addressed Accurate use of medical terminology

Basic Science: Clearly outlined Most components accurately identified and addressed All of the significant areas addressed

Basic Science: Unclear, Confusion in interpretation Mistakes made in identifying some of the central features One or more of the significant areas omitted

Diagnosis: Thorough exploration of all pertinent issues Focused description of key features

Diagnosis: Exploration appropriate for the patient and condition Description includes most features

Diagnosis: Inadequate exploration Description is unclear or includes inaccuracies

Investigations: Most appropriate investigations identified Purposes for the investigations clearly explained in

relation to the case Detailed and accurate analysis of data from investigations

Investigations: Investigations identified are generally appropriate Able to justify selection of investigations for the case Accurate analysis of data from investigations

Investigations: Investigations identified are inadequate /inappropriate Justification of tools give little or no recognition of the

specifics of the case Analysis of investigative data is unclear or inadequate

Differential diagnosis: Full range of alternatives identified and considered Clear prioritizing of alternatives based on all information Decisions underpinned by most current knowledge

Differential diagnosis: Most possible alternatives identified and considered Able to justify possible alternatives from evidence Acknowledges the clinical implications

Differential diagnosis: Most likely alternatives not identified or considered Confusion in the interpretation of evidence Clinical implications are inappropriate

Treatment: Most appropriate treatment(s) selected Selected treatment(s) clearly justified based on all

relevant data and current knowledge Management plan is safe, ethical and fiscally responsible

Treatment: Selected treatment is likely to be successful Reasons for selection of treatment are logical, defensible

and culturally appropriate Management plan is safe and ethically responsible

Treatment: Selected treatment is unlikely to be successful Justification of selected treatment is inadequate or flawed Management plan is inadequate or flawed

On-going Management: Prognosis includes all relevant information All potential on-going needs identified and planned for in

a manner which meets the needs of the patient Relevant support from other professionals identified

On-going Management: Prognosis addresses the most likely outcomes On-going management regime planned and appropriate

for the patient Some consideration given to other professional support

On-going Management: Prognosis is inadequate or inappropriate Components of the management regime are inadequate On-going management is unlikely to meet the needs of

the patient

CANDIDATE NUMBER: SCORE:

Scoring Parameters

9.5 the candidate must have been assessed as EXCELLENT against AT LEAST THREE QUARTERS OF THE CRITERIA INCLUDING AT LEAST ONE CRITEION IN EACH CATEGORY 9.0 the candidate must have been assessed as EXCELLENT against AT LEAST HALF OF THE CRITERIA INCLUDING AT LEAST ONE CRITEION IN EACH CATEGORY 8.5: the candidate must have met MORE THAN TWO THIRDS of the criteria AT LEAST at a SATISFACTORY LEVEL 8.0 if the candidate has ONE THIRD, OR MORE, of marks in the UNSATISFACTORY category – that is automatically a FAIL

Marked by Date: