Free UKMLA surgery questions with explanations

C. Laparoscopic ventral mesh rectopexy

Operations for rectal prolapse are divided into abdominal and perineal approaches. Abdominal rectopexy, now usually performed laparoscopically with a ventral mesh, fixes the rectum to the sacrum and gives the lowest recurrence rate and the best improvement in continence, so it is the operation of choice in patients fit for a general anaesthetic. Perineal operations such as Delorme's mucosal sleeve resection and the Altemeier perineal rectosigmoidectomy avoid the abdomen and are chosen for frail or elderly patients, at the cost of a higher recurrence rate. Anal encirclement narrows the anus without correcting the prolapse and is now rarely used.

B. Bell-clapper deformity

In the bell-clapper deformity the tunica vaginalis attaches high on the spermatic cord and completely surrounds the testis and epididymis, so the testis hangs freely like a clapper in a bell and can rotate on the cord. This intravaginal torsion is the type seen in adolescents and adults, and because the variant is usually present on both sides the contralateral testis is fixed at the time of exploration. A patent processus vaginalis predisposes to hernia and hydrocele rather than torsion, and neonatal torsion is a different, extravaginal process in which the whole tunica and testis twist before the tunica has fused to the scrotal wall.

E. Refer to paediatric surgery for orchidopexy

Most testes that are undescended at birth come down spontaneously in the first months, driven by the postnatal (mini-puberty) testosterone surge; descent after six months is unlikely. A testis still undescended at the 4 to 5 month review should therefore be referred to paediatric surgery, to be seen by 6 months, with the aim of orchidopexy by 12 months of age, because the higher temperature outside the scrotum progressively damages the germ cells and reduces later fertility, and an orchidopexied testis is easier to examine for malignancy. Ultrasound adds nothing when the testis is palpable, as it does not change the need for surgery, and it is unreliable for locating an impalpable testis. Hormonal treatment has poor success and is not used in UK practice.

A. Invasive ductal carcinoma

The combination of new nipple inversion, bloodstained discharge, a hard irregular retroareolar mass and palpable axillary lymphadenopathy in a middle-aged woman is the classic presentation of invasive breast carcinoma, most commonly invasive ductal carcinoma (no special type), which accounts for approximately 75% of invasive breast cancers. Urgent 2-week-wait referral is indicated for any woman aged 30 and over with an unexplained breast lump, and from age 50 and over for suspicious nipple changes.

A. Laparoscopic right adrenalectomy

Primary aldosteronism has two main causes with different treatments: a unilateral aldosterone-producing adenoma, cured by removing that gland, and bilateral adrenal hyperplasia, managed with a mineralocorticoid receptor antagonist for life. CT alone cannot make the distinction because non-functioning nodules are common, so adrenal venous sampling is used to prove that the aldosterone comes from the side with the nodule. With lateralisation confirmed, laparoscopic adrenalectomy corrects the hypokalaemia in almost all patients, cures or improves the hypertension in most, and spares a young man decades of drug therapy; surgery also gives better long-term cardiovascular and renal outcomes than medical treatment for unilateral disease.

E. Thoracic duct injury (chylothorax)

Milky white fluid in the chest drain following oesophagectomy is highly suggestive of chylothorax due to intraoperative thoracic duct injury, but empyema and pseudochylothorax look identical and chyle may be clear in a fasted patient, so the diagnosis is confirmed by a drain fluid triglyceride level above 1.24 mmol/L (>110 mg/dL). The thoracic duct runs adjacent to the oesophagus and is vulnerable during mediastinal dissection, particularly at the level of the diaphragmatic hiatus.

B. Goserelin

GnRH agonists such as goserelin induce a hypo-oestrogenic state that shrinks fibroids by 30–50% over 3–4 months and produces amenorrhoea, allowing haemoglobin to recover with concurrent iron therapy. Pre-operative GnRH analogue use before hysterectomy or myomectomy is supported where fibroid size or anaemia is a concern, typically for 3–4 months prior to surgery. Add-back HRT may be considered if treatment exceeds 6 months to mitigate hypo-oestrogenic side effects.

A. Internal anal sphincter spasm and ischaemia

Anal fissure pain is driven by reflex spasm of the internal anal sphincter, which raises resting anal pressure and reduces blood flow to the posterior midline anoderm (already the most poorly perfused area), producing ischaemia that both causes pain and prevents healing. This pathophysiology underpins first-line medical treatments (topical GTN, diltiazem) and botulinum toxin or lateral internal sphincterotomy, all of which reduce sphincter tone.

B. Incision and drainage, with excision of the cyst wall deferred until inflammation settles

A long-standing mobile lump that suddenly becomes hot, fluctuant and tender is an inflamed or abscessed epidermal cyst, usually from rupture of keratin into the dermis with secondary infection. A fluctuant collection needs draining, and the cyst wall is friable and difficult to remove intact while it is acutely inflamed, so attempting a formal excision at this stage risks incomplete removal and recurrence. The standard approach is incision and drainage now, then elective excision of the residual cyst wall once the inflammation has settled. Antibiotics alone do not drain a fluctuant collection.

A. A central punctum with the lump attached to the overlying skin

An epidermoid cyst arises from the follicular infundibulum within the dermis, so it is tethered to the skin and usually shows a central punctum through which cheesy keratinous material can be expressed. A lipoma sits in the subcutaneous fat beneath a freely mobile skin, and its lobulated surface, soft consistency and slippage sign all reflect encapsulated fat rather than a cyst wall. Both lumps are mobile over deeper structures, so mobility over muscle does not separate them.