A FRCS General Surgery station on MedMock, start to finish

Good morning. We'll discuss some clinical scenarios, including the evidence behind your management. The first: you're the consultant surgeon on call. A 68-year-old woman with type 2 diabetes and hypertension is admitted with two days of left iliac fossa pain that has become generalised. Her heart rate is 118 and her blood pressure 88 over 50 despite a litre of fluid, and her lactate is 4.2. She has generalised peritonism. Her CT shows free gas and free fluid throughout the abdomen and a thickened sigmoid colon with diverticula. How would you manage her?

She has perforated diverticulitis with generalised peritonitis and septic shock, so she needs resuscitation and source control, running in parallel. I'd see her myself straight away and involve the consultant anaesthetist and the critical care team now. For resuscitation: oxygen, large-bore access, blood cultures, and broad-spectrum intravenous antibiotics within the hour according to our sepsis guideline; further fluid in boluses against her response, but early vasopressors rather than large volumes of fluid, which means an arterial line and probably starting noradrenaline; a catheter to measure her urine output; and bloods including a gas, clotting and a group and save. I'd review the CT myself with the radiologist, looking at the extent of contamination and for anything that suggests a cancer. Source control means an emergency laparotomy tonight, and I wouldn't delay it to optimise her beyond resuscitation, because she won't improve until the source is controlled. I'd calculate her NELA risk, which will be well above 5%, so the consultant anaesthetist and I will both be in theatre, and she'll go to critical care afterwards. Then consent: I'd explain that she's very unwell, that the aim is to remove the perforated bowel and wash out her abdomen, that she's very likely to wake with a stoma, which may be permanent, and that she has a significant risk of dying, giving her the NELA estimate. And I'd want to know what matters to her, and whether she would want this operation.

Thank you. At laparotomy she has generalised purulent peritonitis and a perforated, inflamed sigmoid colon, with no faecal contamination. She's now on noradrenaline. What would you do?

This is Hinchey III disease. With her on noradrenaline, I want quick, definitive source control, so I'd do a Hartmann's procedure: resect the diseased sigmoid back to soft, healthy bowel, dividing distally on the upper rectum, close the rectal stump, bring out an end colostomy, and wash out the abdomen thoroughly. I wouldn't do a primary anastomosis in a patient who's shocked and on vasopressors, and I wouldn't do a laparoscopic lavage for her: it leaves the perforated colon in place, she needs the source removed, and the LOLA trial of lavage excluded haemodynamically unstable patients. If she became more unstable during the operation, with worsening acidosis or coagulopathy, I'd abbreviate it: resect the perforated segment, leave the bowel closed off in discontinuity, apply a temporary abdominal closure, and bring her back for a planned relook in 24 to 48 hours once she's been resuscitated on intensive care, deciding then between a stoma and an anastomosis. The specimen goes for histology, because a perforated cancer can look just like diverticulitis.

Thank you. Now suppose she were a fit 55-year-old with the same findings, but haemodynamically stable. Would you do anything differently, and what's the evidence?

Yes. I'd consider a sigmoid resection with primary anastomosis, and in this setting I'd usually add a defunctioning loop ileostomy. The evidence has moved away from routine Hartmann's for stable patients. In the DIVA arm of the LADIES trial, patients with Hinchey III or IV disease were randomised to Hartmann's or primary anastomosis: short-term morbidity and mortality were similar, but more patients were stoma-free at a year after primary anastomosis, and the authors concluded it's preferable in haemodynamically stable, immunocompetent patients under 85. The French DIVERTI trial also found similar mortality, with more stomas reversed after primary anastomosis. The other option in purulent peritonitis is laparoscopic lavage. The LOLA arm of LADIES was stopped early because of more adverse events in the lavage group. SCANDIV found more reoperations after lavage, and four sigmoid cancers were missed in patients treated by lavage. DILALA, comparing lavage with Hartmann's, found fewer patients needed a further operation within a year after lavage, largely because Hartmann's patients need their stoma reversed. NICE's advice is to offer either lavage or resection after discussing the risks and benefits with the patient, and to resect if there's faecal peritonitis. So lavage avoids a stoma for many patients, at the price of more early reintervention and a small risk of missing a cancer. For a fit 55-year-old I'd favour resection with primary anastomosis and a loop ileostomy, and whichever operation she had, she'd need her colon assessed afterwards to exclude a cancer.

Thank you. The second scenario. A 23-year-old man comes off his motorbike at speed and is brought to your major trauma centre. On arrival he's alert, his heart rate is 130 and his blood pressure 82 over 50. He's tender over the left lower ribs and the left upper quadrant. The trauma team leader asks you to take charge of his abdomen. What are your priorities?

He's in haemorrhagic shock until proved otherwise, and the spleen is the likeliest source, but I'd keep the chest, pelvis and retroperitoneum in mind. The trauma team leader runs the resuscitation and I'd work within it. That means the major haemorrhage protocol, giving plasma and red cells in a 1:1 ratio as NICE recommends, with no crystalloid while he's bleeding; tranexamic acid as soon as possible, because CRASH-2 showed it reduces death from bleeding when it's given early, and NICE advises against starting it more than 3 hours after injury unless there's evidence of hyperfibrinolysis; and a restrictive approach to volume, accepting a lower blood pressure until the bleeding is controlled, which is reasonable because there's no sign of a head injury. Blood products warmed, calcium replaced, and a switch from the fixed ratio to transfusion guided by coagulation results as soon as they're available. A pelvic binder stays on until a pelvic fracture is excluded. A chest X-ray and eFAST in the resuscitation room are there only to direct intervention. The key decision is whether he responds. If he does, he goes straight for a whole-body CT. If he doesn't, he goes straight to theatre for a damage control laparotomy, not to the scanner.

Thank you. He responds to blood: his heart rate falls to 100 and his blood pressure rises to 115 over 70. The CT shows a high-grade splenic laceration with a contrast blush within the spleen and a moderate haemoperitoneum, and no other significant injury. What would you do?

He's now a responder with an isolated high-grade splenic injury that's actively bleeding. In a responder, non-operative management is reasonable, but the blush means the bleeding needs stopping, so I'd ask the interventional radiologist to embolise now; NICE supports considering interventional radiology for arterial bleeding from a solid organ. That's a joint decision with the trauma team leader and the radiologist, and I'd consent him for a laparotomy and splenectomy at the same time, with theatre on standby. Afterwards he needs a monitored bed in a level 2 area, regular review by a senior surgeon, serial haemoglobin, and a clear rule that renewed instability means theatre. I'd explain the risks of non-operative management to him, including delayed bleeding. And even after embolisation, the current British Society for Haematology guideline counts him as at risk of infection from reduced splenic function, so he'd still need the vaccination advice.

Thank you. In the angiography suite, before the embolisation is finished, his blood pressure falls to 70 systolic and doesn't respond to blood. What now?

Non-operative management has failed, so he goes to theatre now for a laparotomy. Through a long midline incision I'd scoop out the clot, pack all four quadrants and let the anaesthetist catch up. Then I'd go to the spleen: mobilise it forwards and medially by dividing its lateral attachments, control the hilum and remove it. In an unstable patient I wouldn't try to save it. At the hilum I'd take care of the tail of the pancreas, and of the stomach when dividing the short gastric vessels. Then a full laparotomy for other injuries: the diaphragm, the left kidney, the pancreas, and the bowel and its mesentery. If he's cold, acidotic and coagulopathic, I'd abbreviate the operation: pack as needed, apply a temporary abdominal closure, and take him to intensive care to correct his physiology, with a planned relook in 24 to 48 hours. If there's any concern about the pancreatic tail, I'd leave a drain in the splenic bed.

Thank you. He recovers well after the splenectomy. What does he need before he goes home?

Protection against overwhelming post-splenectomy infection. Vaccination according to the Green Book: pneumococcal, meningococcal ACWY and meningococcal B, with a second dose of the B vaccine four weeks later, and an annual flu vaccine. After an emergency splenectomy the vaccines work better if they're given at least two weeks after the operation, but if there's a real risk he won't come back, he should have them before he leaves rather than miss them. He'll need a pneumococcal booster every five years. Antibiotic prophylaxis, usually phenoxymethylpenicillin, or a macrolide if he's allergic, for a duration guided by the British Society for Haematology guideline and his ongoing risk, and a standby course at home to start at the first sign of a fever while he seeks medical help. He needs the splenectomy card and leaflet, advice about travel, particularly the higher risk from malaria, and about animal and tick bites. And a clear discharge letter, so that his GP codes the splenectomy and calls him for his boosters.

Thank you. That's the end of the station.