Free FRCS (Gen Surg) practice questions

The principle is that poor preoperative glycaemic control predicts surgical site infection, anastomotic and wound failure, longer stay and death, and that it is modifiable before elective surgery. UK guidance from the Centre for Perioperative Care and the Joint British Diabetes Societies advises that an HbA1c of 69 mmol/mol (8.5%) or more should prompt referral for optimisation and deferral of elective surgery where it is safe to wait. A value of 48 mmol/mol is the diagnostic threshold for diabetes and 58 mmol/mol a common treatment-intensification target, so both are too strict; 86 and 100 mmol/mol would allow operating with clearly poor control. Reference: Centre for Perioperative Care, Guideline for Perioperative Care for People with Diabetes Mellitus Undergoing Elective and Emergency Surgery (2021).

The principle is that the standards now measure what matters to the patient, a timely answer and timely treatment, not the first appointment. Since October 2023 NHS England has used three standards: the 28-day Faster Diagnosis Standard, by which a patient referred urgently or from screening should have cancer diagnosed or ruled out and be told; a 31-day standard from the decision to treat to the first treatment; and a 62-day standard from urgent referral, screening or consultant upgrade to the first treatment. The two-week-wait standard for first being seen was retired at the same time, although the term persists in clinical speech. Seven days is not a national standard. Scotland, Wales and Northern Ireland publish their own. Reference: NHS England, Changes to cancer waiting times standards from 1 October 2023.

This is diabetic ketoacidosis presenting as an acute abdomen. Ketoacidosis itself causes abdominal pain, guarding, a neutrophil leucocytosis and a modest rise in amylase, and the abdominal signs track the severity of the acidosis. The priority is fluid resuscitation and fixed-rate insulin; pain that resolves as the acidosis corrects needs no further surgical work-up, whereas pain that persists once the pH has recovered, or that occurs with only mild acidosis, should prompt a search for a surgical precipitant. Immediate CT or operation in an unresuscitated patient is hazardous and usually unnecessary. Bicarbonate is not recommended. Reference: Joint British Diabetes Societies, Management of diabetic ketoacidosis in adults (2023); Umpierrez G and Freire AX, J Crit Care 2002.

This is a ruptured or symptomatic abdominal aortic aneurysm until proved otherwise: new abdominal or loin pain in an older smoker with a large aneurysm on bedside ultrasound. NICE advises immediate bedside aortic ultrasound and, once an aneurysm is shown, immediate discussion with the regional vascular service, because survival depends on time to a centre that can repair it. CT angiography is valuable for planning but must not delay referral, and many patients are best scanned at the receiving unit. Ultrasound cannot exclude retroperitoneal rupture, so a formal scan adds nothing. Renal colic is the classic misdiagnosis. Observation in a hospital that cannot operate risks unheralded collapse. Reference: NICE NG156, Abdominal aortic aneurysm: diagnosis and management (2020).

Children compensate for haemorrhage by tachycardia and intense peripheral vasoconstriction, so systolic pressure is preserved until a large proportion of the blood volume has been lost: ATLS teaches that it may not fall until 30% has gone, and that frank hypotension signifies decompensated shock with loss of around 45%, shortly before bradycardia and arrest. This boy is already in compensated shock. Narrowing of the pulse pressure, weak or absent peripheral pulses, cool mottled limbs with prolonged capillary refill, and oliguria are all earlier consequences of vasoconstriction and reduced organ perfusion, and should trigger blood-product resuscitation and a search for the source. Reference: ATLS Student Course Manual, 10th edition (2018), chapter on trauma in children.

This is a haemodynamically stable blunt splenic injury with a contained vascular lesion (contrast blush or pseudoaneurysm). Stability makes non-operative management appropriate, but a blush is the strongest predictor that observation alone will fail, so angioembolisation is added to raise the splenic salvage rate. Observation alone or simply repeating the CT leaves a lesion with a high risk of delayed rupture untreated. Laparotomy, whether for splenectomy or splenorrhaphy, is reserved for haemodynamic instability, peritonitis or failed non-operative management, and sacrifices or risks a spleen that can usually be saved. Reference: Coccolini F et al., WSES classification and guidelines for splenic trauma, World J Emerg Surg 2017.

Unproven gastro-oesophageal reflux disease: the endoscopy is normal and the response to a proton pump inhibitor is incomplete, so pathological acid exposure has to be shown objectively before an irreversible operation. Ambulatory pH (or pH-impedance) monitoring after stopping acid suppression for about a week measures acid exposure time and symptom association, and is the strongest predictor of a good surgical result. Testing on treatment answers a different question, why symptoms persist in proven reflux. A barium study shows anatomy but neither proves nor excludes reflux. Gastric emptying studies are reserved for prominent nausea, vomiting or bloating. Biopsies of normal mucosa do not quantify reflux. Reference: Gyawali CP et al., Lyon Consensus 2.0, Gut 2024; NICE CG184.

This is non-dysplastic long-segment Barrett's oesophagus. Cancer risk rises with segment length, so NICE and the British Society of Gastroenterology recommend high-resolution endoscopic surveillance every 2–3 years for segments of 3 cm or longer, and every 3–5 years for segments shorter than 3 cm that contain intestinal metaplasia; within those ranges the interval is adjusted for age, sex, smoking and family history. Six-monthly endoscopy is for indefinite or newly found low-grade dysplasia, not for non-dysplastic mucosa. Annual endoscopy adds cost and risk without evidence of benefit. Ten years is far too long for a long segment. Reference: NICE NG231, Barrett's oesophagus and stage 1 oesophageal adenocarcinoma (2023).

This is uncomplicated acute calculous cholecystitis in a fit patient. NICE recommends early laparoscopic cholecystectomy, within one week of diagnosis, and randomised trials such as ACDC show lower morbidity, shorter stay and lower cost than initial antibiotics with delayed surgery, without more conversions or bile duct injuries. Delaying for 6–12 weeks exposes her to readmission with further cholecystitis, pancreatitis or duct stones, and operating in the fibrotic phase is no easier. Surgery only on recurrence leaves a diseased gallbladder in a fit patient. Cholecystostomy is for those unfit for surgery. MRCP is not indicated with normal liver tests and a normal duct. Reference: NICE CG188 (2014); Gutt CN et al., Ann Surg 2013 (ACDC).

This is severe acute pancreatitis (organ failure beyond 48 hours) in a patient who cannot meet her needs by mouth. NICE recommends enteral nutrition for severe or moderately severe disease, started within 72 hours of presentation, with parenteral nutrition only if the enteral route fails or is contraindicated; the gut is working here. Nasogastric feeding with a polymeric feed is as well tolerated as nasojejunal feeding and can start at once, whereas an endoscopic nasojejunal tube and elemental feeds add delay and cost without benefit unless gastric stasis develops. Central or peripheral parenteral nutrition carries more infective complications, and a week of starvation worsens outcome. Reference: NICE NG104, Pancreatitis (2018, updated 2020); IAP/APA evidence-based guidelines, Pancreatology 2013.

This is a large non-pedunculated colorectal polyp (20 mm or more) with every feature of a benign lesion: granular surface, no depression and a regular pit pattern. UK guidance is that such lesions are discussed by a complex polyp team and treated endoscopically as first-line, because mucosal resection in expert hands clears over 90% with far less morbidity and mortality than colectomy. Right hemicolectomy for a benign polyp is over-treatment unless endoscopic removal fails or is not feasible. Wedge resection is a second-line combined procedure. Observation leaves a lesion with a substantial risk of progression, and ablation alone gives no histology and incomplete treatment. Reference: Rutter MD et al., BSG/ACPGBI guidelines for the management of large non-pedunculated colorectal polyps, Gut 2015.

This is an early rectal cancer in which the choice between local excision and total mesorectal excision turns on the depth of invasion within the bowel wall. MRI is the standard local staging test because it shows the mesorectal fascia, nodes and extramural venous invasion, but it separates T1 from T2 poorly. Endorectal ultrasound resolves the layers of the rectal wall and is the better test when MRI suggests disease amenable to local excision. Diffusion-weighted MRI helps with response assessment, not wall layers. PET-CT and CT colonography add nothing to T staging, and repeat biopsies sample the surface without measuring depth. Reference: Glynne-Jones R et al., ESMO rectal cancer guidelines, Ann Oncol 2017; Colorectal Surgery: A Companion to Specialist Surgical Practice 7e.

This is a simple breast cyst, an aberration of normal involution that peaks in the decade before the menopause. When imaging shows a simple cyst, the aspirate is not bloodstained and the lump resolves completely, no further action is needed: cytology of ordinary cyst fluid has a negligible yield of cancer and generates false-positive atypia, so the fluid is discarded. Cytology or biopsy is indicated when the fluid is uniformly bloodstained, a mass persists after aspiration or imaging shows an intracystic or solid component. Scheduled repeat ultrasound is unnecessary, as she can return if a lump recurs, and many cysts refill harmlessly. Excision of a simple cyst is not indicated. Reference: Dixon JM (ed.), Breast Surgery: A Companion to Specialist Surgical Practice, 6th edn; Willett AM et al., Best practice diagnostic guidelines (2010).

This is invasive lobular carcinoma, which infiltrates as single files of discohesive cells with little stromal reaction, so mammography and ultrasound commonly underestimate its size and miss multifocal or contralateral disease. NICE recommends MRI of the breast for invasive lobular cancer when breast-conserving surgery is being considered, and when clinical and imaging size disagree, as here; it lowers the risk of involved margins and re-operation. CT and PET-CT stage distant disease and are not indicated in a clinically early, node-negative cancer. Tomosynthesis adds little to the assessment of extent in lobular disease. The diagnosis is already secure, so a larger-volume biopsy would not change the plan. Reference: NICE NG101, Early and locally advanced breast cancer (2018, updated 2025); Dixon JM (ed.), Breast Surgery: A Companion to Specialist Surgical Practice, 6th edn.

The picture is lymphoma, probably classical Hodgkin lymphoma, which cytology cannot diagnose or subtype. The pathologist needs nodal architecture as well as immunohistochemistry, flow cytometry and molecular studies, so the standard is excision of a whole, representative node, taking the largest abnormal node rather than the most convenient; image-guided core biopsy is an accepted alternative only when excision would be hazardous. A repeat aspirate has the same limitation, and scattered Reed-Sternberg cells in a reactive background are easily missed. PET-CT stages lymphoma once histology is known and does not replace tissue. Bone marrow examination is no longer routine in Hodgkin lymphoma staged by PET-CT. Six weeks of observation delays a curable diagnosis in a patient with B symptoms. Reference: British Society for Haematology guideline on first-line management of classical Hodgkin lymphoma (2022); Royal College of Pathologists dataset for lymphoma specimens.

The differential is primary hyperparathyroidism against familial hypocalciuric hypercalcaemia (FHH): mild hypercalcaemia with an inappropriately normal PTH fits both, and the family history raises the suspicion of FHH. NICE advises measuring urinary calcium excretion to separate them; a calcium:creatinine clearance ratio below 0.01 points to FHH, a benign autosomal dominant disorder of the calcium-sensing receptor in which parathyroidectomy does not help. Gene sequencing confirms FHH but follows a low urinary ratio, not precedes it. Ultrasound and sestamibi are for planning an operation once the diagnosis and the decision to operate are made, not for diagnosis. DEXA assesses end-organ damage in confirmed disease. Reference: NICE NG132, Hyperparathyroidism (primary): diagnosis, assessment and initial management (2019).

The principle is that a groin hernia in a woman should be repaired by a method that covers the whole myopectineal orifice. Femoral hernias are much more frequent in women, are often mistaken for inguinal hernias before operation, and account for a large share of 'recurrences' after open anterior repair in women, many of which are femoral hernias that were missed. A laparoscopic preperitoneal mesh (TEP or TAPP) inspects and covers the inguinal and femoral orifices together and is recommended by the international guidelines for all women. Lichtenstein, Shouldice and plug repairs leave the femoral canal unprotected. Watchful waiting is not advised in women because of the higher risk of a femoral hernia and of strangulation. Reference: HerniaSurge Group, International guidelines for groin hernia management, Hernia 2018.

The picture is tacrolimus toxicity: tremor, hyperkalaemia and acute nephrotoxicity from afferent arteriolar vasoconstriction. Tacrolimus has a narrow therapeutic index and is metabolised by cytochrome P450 3A4 and transported by P-glycoprotein. Macrolides such as clarithromycin and erythromycin, azole antifungals, diltiazem and grapefruit juice inhibit this pathway and can raise trough levels several-fold within days. Amoxicillin, co-amoxiclav and doxycycline have no significant interaction. Rifampicin is an enzyme inducer and does the opposite, lowering tacrolimus levels and risking rejection. A trough level should be checked and the dose reduced or withheld. Reference: British National Formulary, tacrolimus interactions; Forsythe JLR (ed.), Transplantation: A Companion to Specialist Surgical Practice, 6e.

Pyloric stenosis is a medical emergency and never a surgical one. Loss of gastric acid produces a hypochloraemic, hypokalaemic metabolic alkalosis; an alkalotic infant compensates by hypoventilating and is at risk of apnoea after anaesthesia. The deficit is replaced with sodium chloride, glucose and added potassium over 24–48 hours, and pyloromyotomy follows only when bicarbonate (below about 28 mmol/L) and chloride (above about 100 mmol/L) are corrected. Operating in two hours ignores this. Hypotonic 0.18% saline supplies too little chloride and risks hyponatraemia, and potassium alone is not the end-point. Acetazolamide worsens potassium loss. Atropine is not standard UK treatment. Reference: Bailey & Love's Short Practice of Surgery 28e; Core Topics in General and Emergency Surgery (Companion series) 6e.

A dorsal hooded foreskin with a ventrally placed meatus is hypospadias, often with chordee. Repair is carried out by a paediatric urologist, usually between 6 and 18 months, and the preputial skin is the tissue used to reconstruct the urethra or to cover the repair, so circumcision by any technique is contraindicated until the surgeon who will do the repair has decided the foreskin is not needed. The family should be referred and told that a circumcised appearance can usually be achieved at the repair. Distal position of the meatus does not change this. Isolated distal hypospadias carries no increased risk of urinary infection or upper tract anomaly, so neither prophylactic circumcision nor routine renal ultrasound is indicated. Reference: Bailey & Love's Short Practice of Surgery 28e; Royal College of Surgeons of England, Commissioning guide: foreskin conditions (2013).