Surgery: A Comprehensive Guide

Dr. Ammar Anwar
Class of 2019

If I were to make a list of the most terrifying subjects in MBBS, Surgery would surely top the list. Part of the reason is the fact that we are so used to studying subjects that eventually tie into Medicine, that the prospect of studying and passing a subject that is notorious for its difficult, heavy books and constantly increasing number of supplees scares us. While Surgery certainly appears to be different from the other subjects of final year, when you get down to studying it you'll find a lot of overlap between medicine and surgery. Most of the organ systems will eventually overlap, with the difference being their surgical procedures, of course.

''Bus aik aur saal parh lo, agay aish he aish hai'' 

You can overcome your fear of surgery by laying out a schedule and sticking to it. And to make a schedule, you need to know what topics need the most time and attention, which brings me to the first section of this post - "TOS".

1. Table of Specifications (TOS)

Surgery Table of Specifications Paper A
Paper A - General Surgery 

Surgery Paper B Table of Specifications
Paper B - Systemic Surgery

2. Detailed Breakdown

General Surgery Breakdown (Paper A)

1.       Principles of Surgery
  2 SEQs, 7 MCQs
  •         Metabolic response to injury
  •          Shock and blood transfusion
  •          Wounds, tissue repair, and scars
  •          Patient safety
  •          Surgical infection
  •          Surgery in the tropics
  •          Principles of laparoscopic and robotic surgery
  •          Surgical audit and clinical research
  •         Surgical ethics and law

2.       Perioperative Care
  2 SEQs, 7 MCQs
  •          Perioperative preparation
  •          Anesthesia and pain relief
  •         Care in the operating room
  •         Perioperative management of the high-risk surgical patient
  •         Nutrition and fluid therapy
  •         Postoperative care
  •         Day case surgery

3.       Trauma and Orthopedics
  2 SEQs, 8 MCQs
  •         Introduction to trauma
  •         Early assessment and management of trauma
  •          Emergency neurosurgery
  •         Neck and spine
  •         Maxillofacial trauma
  •         Torso trauma
  •          Extremity trauma
  •         Disaster surgery
  •         Plastic and reconstructive surgery

4.       Elective Orthopedics
 1 SEQs, 2 MCQs
  •         The spine
  •         Upper limb - Pathology, assessment, and management
  •         Hip and knee
  •         Foot and ankle
  •         Musculoskeletal tumors
  •         Infection of the bones and joints
  •         Pediatric orthopedics

5.       Conditions of the skin + Head & Neck
  1+1 SEQs, 2+2 MCQs
  •        Skin and subcutaneous tissue
  •         Pharynx, larynx, and neck
  •          Oropharyngeal cancer
  •         Disorders of the salivary glands

6.       Miscellaneous
 1 SEQs, 2 MCQs
  •         Burns
  •          Principles of Oncology
  •          Principles of Paediatric Surgery
  •         Elective neurosurgery
  •          Diagnostic Imaging
  •         Gastrointestinal Radiology
  •          Tissue Diagnosis

Systemic Surgery Breakdown (Paper B)

1.       Breast and Endocrine
               2 SEQs, 6 MCQs
  •         The thyroid and parathyroid glands
  •      The adrenal glands
  •         The breast
  •         Other endocrine tumors

2.       GIT + Hernia
  2+1 SEQs, 6+3 MCQs
  •        Abdominal wall, Hernia, and Umbilicus
  •         The peritoneum, omentum, mesentery and retroperitoneal space
  •         The esophagus
  •      Stomach and duodenum
  •         Bariatric surgery
  •        The small and large intestines
  •         Intestinal obstruction
  •         The vermiform appendix
  •         The rectum
  •         The anus and anal canal

3.       Hepatobiliary
  1 SEQs, 4 MCQs
  •          The liver
  • ·       The pancreas
  • ·       The gallbladder and bile ducts

4.       Vascular Surgery
  1 SEQs, 4 MCQs
  •         Arterial Disorders
  •         Venous Disorders
  •         Lymphatic Disorders

5.       Genitourinary
  1 SEQs, 2 MCQs
  •         The kidneys and ureters
  •         The urinary bladder
  •      The prostate and seminal vesicles
  •         Urethra and penis
  •         Testis and scrotum

6.       Miscellaneous
  2 SEQs, 5 MCQs
  •         Cardiac Surgery
  •         The Thorax
  •         Spleen
  •         Surgical Anatomy
  •         Gynecology

I'm guessing you had about as much fun reading this novel on marks distribution, as I had writing it.
P.S. I'm trying my best to make this boring blog interesting, ok? Bear with me.

3. Marks Distribution

Distribution for both Paper A and B is identical.

Written Exam

SEQs - 10 SEQs, 9 Marks Each = 90 Marks

MCQs - 30 MCQs, 1.5 Marks Each = 45 Marks

Total - 90+45 = 135 Marks (Total 270 Marks for 2 Papers overall)

Viva and OSCE

OSCE - 15 Stations, 2 Marks Each = 30 Marks

Short Cases - 2 Short Cases, 80 Marks Each = 160 Marks

Long Case - 1 Long Case = 120 Marks

Internal Assessment = 20 Marks

Total - 30+160+120+20 = 330 Marks

Maximum Score = 270 (Writtens) + 330 (Vivas, OSCE, Int. Assmt.) = 600 Marks

Note: Internal Assessment is based on your class test scores and counted with the aggregate marks of Clinical (Short and Long Cases) and OSCE, not the score of your written exams. Both Paper A and B are counted together in the final score, so you have to pass overall, not each written exam separately.

4. Important Stuff

-  Important Topics (Courtesy Dr. Romesa Qaiser Khan, Batch '18 - Via ZHCP Prof Guide For Final Year)

"For surgery, I did Bailey, Washington manual and Dogar. I'll make it easy for you and tell you the things you need to do from Bailey, otherwise, Dogar is 100% your ultimate guide and more than enough to pass. You won't have time to do Bailey or even retain it in prof so it's best to study Dogar and memorize all the criteria etc because they show up on the exam as it is. Dogar is NOT optional. 

From Bailey, do: 
  • Chapter 4 
  • Chapter 6 
  • Chapter 12 (especially memorize the checklist) 
  • Chapter 21 
  • Chapter 22 
  • ASIA scale on page 330 
  • Triage and Principles, pg 424 only from chapter 24 
  • Boxes from chapter 51 
  • Chapter 60 

From Dogar: EVERYTHING. 

-  Important Questions Systemic Surgery (Courtesy Dr. Muhammad Mohsin Ali, Batch '18)

5. Past Papers (Written)

6. Surgery Short Cases Made Easy

In your exam, you will be assigned two wards before OSCE. One will take your OSCE and Short Cases and the other will take your long case. Short Cases are usually two, one each taken by the internal and external examiner, but SSW and ESW sometimes put four short cases instead of the usual two, marks being equally divided among all of them.

Short cases are particularly daunting because you have to prove your clinical skills within 5 minutes or less. Add to that, the anxiety of not missing any step and the general fear of surgery, and it can easily be the noose around your neck on exam day.

BUT, short cases are a game of nerves and luck. Try to relax and remind yourself that this is just an exam, you have taken hundreds of exams like this before and you can easily do this too.

Short cases test your nerves and reflexes more than your knowledge.
Remember to relax and breathe. It's just an exam! 

For short cases, Dogar OSCE and Short Cases book is usually the go-to source, but in recent years Das Clinical Exam Videos have gained popularity because of their rich content that often obviates the need for Dogar Short Cases. If you're going with these videos, I'd highly recommend memorizing the second link mentioned below. These Short Case Examination Notes are based on Das videos and have been compiled by Dr. Musab Hussain (Batch '19), providing all the knowledge in the videos in a neatly arranged, written form. 

If you are doing only Dogar OSCE, I'd highly recommend watching these videos before reading the relevant cases from the book, because these videos are extremely high-yield.

What you're expected to know in short cases: Steps of examination, relevant topics from Systemic Surgery book, and proper protocol of approaching a patient. Examiners put special emphasis on the protocol, for instance covering the patient after you have completed the exam is an important part of your short case evaluation.

What to Study: 
Dogar OSCE is usually sufficient for Surgery OSCE. Stations that appear on your actual OSCE are a mix of the examples in this book and ward test stations (remember to note all your stations right after the ward test, it can help a lot in prof, like our OSCE on Day 3 was almost entirely ESW Ward Test OSCE).

Aside from the clinical scenarios, you have to memorize Instruments from the last section in Dogar OSCE. You can also learn instruments from this PDF compiled by our seniors.

Do not forget to learn the names and uses of various things you see in the ward but generally ignore, e.g. Vital Stats monitor and Bipolar Cautery Set that appeared in our OSCE, which was not mentioned in either of the two sources cited above.

8. Surgery Long Case

The ward that takes your long case is different from the one that takes your Short Case and OSCE as mentioned previously, e.g. our ward combinations were ESW/NSW and WSW/SSW. So if ESW is taking your Short Case and OSCE, NSW will take your Long Case and vice versa.

Long Cases are usually very straightforward. After completing your OSCE in Library Hall and Short Cases in the relevant ward, you're assigned your long case in the next ward. Remember that your mobile phones are taken before Short Case and returned after the long case is over, so chances of taking a peek at your phone to prepare for viva are slim. 

At your allotted bed, you should take your history and do the relevant systemic exam (don't forget GPE!). Afterward, there is a viva that is usually based around the case. This viva is sometimes split into two halves taken by separate examiners - for example in ESW and SSW long cases, internal and external both may take your viva. One examiner focuses on the pathophysiology and surgery, while the other focuses on specific ward management of the patient. 

All of this sounds scary, I know, but remember the golden rule of vivas "if you don't know the answer, don't say anything". Usually, we make things difficult for ourselves by blurting out a wrong answer and the entire viva then shifts to another topic altogether. So unless you're absolutely sure that what you're about to say is right, you should refrain from taking your viva on an unknown trajectory.

What you're expected to know in Long Cases: Pathophysiology, Surgical Management, Ward Management, possible courses of action for the patient in hypothetical scenarios, etc.

Where to study from: Dogar OSCE section on Long Cases, Dogar Systemic Surgery, Bailey and Love, Chapters on Fluids, Nutrition and Sutures from Dogar General Surgery. 

 Sometimes you forget basic anatomy, but issokay. At least your heart isn't in your stomach, right?

Tips for Surgery:

  • Surgery is just another subject, and if you treat it like Medicine, Paeds, and Gyne-Obs, you will likely score well in it too. The public fear of Surgery is much greater than the actual exam, and if you keep your calm, you can nail it.
  • Try to make a realistic schedule in prof prep leaves, and do not forget to assign days to Bailey only. Bailey, done selectively, is absolutely essential to pass surgery and only Dogar cannot cut it anymore because the surgery professors are onto us! This does not mean Dogar is optional. Dogar is dry and not very palatable, but also extremely necessary to form a base for the subject, which you can improve on by studying Bailey. 
  • If you are very short on time, please do not forget to do the chapter on Hernias from Bailey (I think it is Chapter 60). It is very high-yield and will save you from a lot of mistakes in the exam. I should mention here that if you are doing it from Bailey, you can skip the corresponding chapter from Systemic Dogar because there are some mistakes (particularly laparoscopic approaches to Hernia repair) that the professors know, and if you answer from Dogar, they will know you studied Dogar and that is frowned upon in our society. Better to keep your resources ambiguous. 
  • Try to incorporate past papers in your preparation schedule. Going through past papers can be weirdly helpful even if you are a person like me who does not want a free panic attack every time he looks at past papers. They can save you some marks on your exam, e.g. Fournier's gangrene appeared on our Paper B, and people who had done past papers got the diagnosis right.
  • Write something. Write whatever you know. If there is a single take-home message from this post, this is it. If you see a question that you do not know anything about, still write whatever you can in the answer. Always remember to never leave any question unattempted. Examiners will sometimes show leniency and award marks for your wrong answer, but they cannot give marks to a blank sheet of paper. On Paper A, we got almost 6 to 7 out of 10 questions that could not be answered only from Dogar, but we still wrote whatever we could! Even if it is ATLS in 6 out of 10 questions, you still have better chances of passing a difficult exam than blanking out and leaving questions unattempted.

Turn that C into A... Lekin parh kar...

Right now, we're in lockdown, and the future is uncertain. We don't know how this will affect our academic structure, but regardless, this is the prime time to study for your professionals. Everything you study now will end up helping you with your exams. Try to complete at least one subject, because the final professional is a long and tiresome test of your endurance and studying beforehand can make this journey a little less horrible.

Nevertheless, you have come so far, and you can make it through this too. So no matter if you see this post in May or October, my good wishes are with you. Go out there and break a leg!

Yeesh. All this talk about Surgery is giving me second-hand stress.  


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