Surgical mnemonics

• SSite: where exactly?
• OOnset: sudden or gradual?
• CCharacter: colicky, sharp, burning, dull
• RRadiation: to the back, shoulder tip, groin?
• AAssociated symptoms: vomiting, fever, jaundice
• TTime course: constant, coming and going, getting worse?
• EExacerbating and relieving factors
• SSeverity: score out of 10

💡 Sudden severe pain that is worst at onset suggests a perforation, a rupture or ischaemia. Colicky pain suggests a blocked tube: bowel, ureter or bile duct.

• SSite, Size, Shape (and Surface)
• CConsistency, Colour, Contour (the edge)
• TTenderness, Temperature, Transillumination
• FFluctuation and Fixation (to skin or deep structures)

💡 Finish every lump examination with the regional lymph nodes, and check whether it is pulsatile or reducible before you ever think about aspirating it.

• AAllergies
• MMedications, especially anticoagulants
• PPast medical history (and Pregnancy)
• LLast meal or drink
• EEvents leading to the injury or illness

💡 The last meal matters to the anaesthetist: a full stomach changes how the airway is secured.

• FFat
• FFluid (ascites)
• FFlatus (bowel obstruction)
• FFaeces
• FFetus
• FA “Fearsome” mass: tumour or a large organ

💡 Percussion separates them: tympanic for flatus, shifting dullness for fluid, dull and fixed for a mass.

• CCirrhosis
• CCrohn’s disease (and ulcerative colitis)
• CCoeliac disease
• CCancer of the GI tract

💡 Look at the hands first in every abdominal examination: clubbing, palmar erythema, Dupuytren’s, leuconychia and a liver flap.

• 4Eyes: four eyes (glasses) open to 4
• 5Verbal: the Jackson 5 talk up to 5
• 6Motor: a V6 engine moves up to 6
• 3The lowest possible score is 3, never 0

💡 Always report the three parts, for example E2 V3 M5, not just the total.

• MMigration of pain to the right iliac fossa (1)
• AAnorexia (1)
• NNausea or vomiting (1)
• TTenderness in the right iliac fossa (2)
• RRebound tenderness (1)
• EElevated temperature, 37.3 °C or more (1)
• LLeucocytosis over 10 (2)
• SShift to the left: neutrophils over 75% (1)

💡 T and L score 2 each, so the total is 10. A score below 5 makes appendicitis unlikely.

• WWound infection
• RResidual (pelvic) abscess
• AAdhesions
• PPortal pyaemia (pylephlebitis): rare but serious
• IIleus
• FFaecal fistula (stump leak)
• HHaemorrhage
• OObstruction from adhesions, later on
• TThromboembolism

💡 A swinging fever around day 5–7 with diarrhoea or rectal tenderness is a pelvic abscess until proven otherwise.

• 22% of people
• 22 feet (about 60 cm) from the ileocaecal valve
• 22 inches long
• 22 types of ectopic tissue: gastric and pancreatic
• 22 times as common in males
• 2Usually presents before age 2

💡 Painless rectal bleeding in a toddler: ectopic gastric acid ulcerates the neighbouring ileum. A technetium scan finds the gastric tissue.

• FForeign body (mesh, suture, drain)
• RRadiation
• IInfection or Inflammatory bowel disease
• EEpithelialisation of the track
• NNeoplasm
• DDistal obstruction
• SSteroids (and a Short track)

💡 Manage every fistula with SNAP: Sepsis control, Nutrition, Anatomy (define it), then Planned surgery.

• SSepsis: drain collections, treat infection
• NNutrition: often parenteral; protect the skin
• AAnatomy: define the fistula with imaging
• PPlan surgery, usually after months, if it does not close

💡 Most low-output fistulas close with conservative care once sepsis is controlled and nutrition is good.

• PPerforation
• AAbscess
• SStricture and obstruction
• HHaemorrhage
• FFistula (colovesical is commonest: pneumaturia)

💡 Grade perforated diverticulitis with Hinchey: I pericolic abscess, II distant abscess, III purulent peritonitis, IV faecal peritonitis.

• IPericolic abscess
• IIPelvic (or distant) abscess
• IIIPurulent peritonitis
• IVPoo: faecal peritonitis

💡 Grades III and IV need an emergency operation, classically Hartmann’s procedure for faecal peritonitis.

• 3Small bowel over 3 cm is dilated
• 6Colon over 6 cm is dilated
• 9Caecum over 9 cm is dilated (over 12 cm risks perforation)

💡 Small bowel has valvulae conniventes crossing the whole width; colon has haustra that do not cross completely.

• 33 o’clock: left lateral
• 77 o’clock: right posterior
• 1111 o’clock: right anterior
• •Positions with the patient in the lithotomy position

💡 They follow the branches of the superior rectal artery. Most anal fissures are at 6 o’clock (posterior midline); a lateral fissure suggests Crohn’s, HIV or cancer.

• 1Small bowel obstruction
• 2Gas in the biliary tree (pneumobilia)
• 3An ectopic gallstone, usually at the terminal ileum

💡 The stone passes through a cholecystoduodenal fistula. Classically an elderly woman with intermittent obstruction.

• IIdiopathic
• GGallstones
• EEthanol (alcohol)
• TTrauma
• SSteroids
• MMumps and other viruses
• AAutoimmune
• SScorpion venom
• HHypertriglyceridaemia, Hypercalcaemia, Hypothermia
• EERCP
• DDrugs: azathioprine, valproate, thiazides

💡 Gallstones and alcohol cause about 80%. Always look for the cause: ultrasound, triglycerides and calcium.

• PPaO₂ below 8 kPa
• AAge over 55
• NNeutrophils: white cells over 15
• CCalcium below 2 mmol/L
• RRenal: urea over 16 mmol/L
• EEnzymes: LDH over 600 or AST over 200
• AAlbumin below 32 g/L
• SSugar: glucose over 10 mmol/L

💡 Score within 48 hours. Three or more predicts a severe attack.

• FFemale
• FForty
• FFertile
• FFat
• FFair

💡 Useful but incomplete: add rapid weight loss (including after bariatric surgery), haemolysis and terminal ileal disease.

• 1Fever (with rigors)
• 2Jaundice
• 3Right upper quadrant pain
• +Reynolds’ pentad adds shock (hypotension)
• +and confusion

💡 Cholangitis needs antibiotics and biliary drainage, usually by ERCP, urgently if the patient is septic.

• •Jaundice plus a palpable, non-tender gallbladder
• •is unlikely to be due to gallstones
• •Think pancreatic head or distal bile duct cancer
• •Why: a stone-scarred gallbladder is fibrotic and cannot distend

💡 Exceptions examiners ask about: double impaction (one stone in the cystic duct and another in the CBD) and oriental cholangiohepatitis.

• 1The hepatocystic triangle is cleared of fat and fibrous tissue
• 2The lower third of the gallbladder is off the liver bed
• 3Only two structures enter the gallbladder: the cystic duct and the cystic artery

💡 If you cannot achieve it, stop: call for help, or do a subtotal cholecystectomy. Never clip what you cannot identify.

• CCystic duct
• CCommon hepatic duct
• LLiver (inferior surface) above
• •Contains the cystic artery and Lund’s (cystic) lymph node

💡 The original Calot’s triangle had the cystic artery as its upper border; the hepatocystic triangle uses the liver edge.

• AAlbumin
• BBilirubin
• CClotting (INR)
• DDistension: ascites
• EEncephalopathy

💡 Five items, 1–3 points each: class A 5–6, B 7–9, C 10–15. Creatinine is in MELD, not Child-Pugh.

• MRoof: 2 Muscles (internal oblique, transversus abdominis)
• AAnterior wall: 2 Aponeuroses (external oblique, plus internal oblique laterally)
• LFloor: 2 Ligaments (inguinal, lacunar medially)
• TPosterior wall: 2 Ts (Transversalis fascia, conjoint Tendon medially)

💡 Go round the canal clockwise from the top: superior, anterior, inferior, posterior = M, A, L, T.

• MDMedial to the inferior epigastric vessels = Direct
• LILateral to the inferior epigastric vessels = Indirect

💡 Direct hernias come through Hesselbach’s triangle. The distinction is made at surgery, not reliably by examination.

• RRectus abdominis: medial border
• IInferior epigastric vessels: lateral border
• PPoupart’s (inguinal) ligament: inferior border

💡 The site of direct inguinal hernias: weakness of the posterior wall (transversalis fascia).

• NNerve (femoral)
• AArtery (femoral)
• VVein (femoral)
• EEmpty space (the femoral canal)
• LLymphatics (Cloquet’s node)

💡 A femoral hernia comes through the femoral canal, below and lateral to the pubic tubercle, and strangulates easily.

• 33 arteries: testicular, cremasteric, artery to the vas
• 33 nerves: genital branch of genitofemoral, sympathetic fibres (and the ilioinguinal nerve, which runs on the cord)
• 33 other things: vas deferens, pampiniform plexus, lymphatics
• 33 coverings: external spermatic, cremasteric, internal spermatic fascia

💡 The ilioinguinal nerve is at risk in open hernia repair: injury causes numbness and chronic groin pain.

• AAmyand’s: contains the Appendix
• LLittre’s: contains a (Little) Meckel’s diverticulum
• RRichter’s: only the Rim of the bowel wall is trapped
• •Spigelian: through the linea semilunaris; obturator: thin elderly women

💡 A Richter’s hernia can strangulate without causing bowel obstruction, so it is easily missed.

• PPain
• PPallor
• PPulselessness
• PPerishing cold
• PParaesthesia
• PParalysis

💡 Paraesthesia and paralysis mean the limb is threatened and needs revascularisation within hours.

• 1Stasis of blood flow (immobility, surgery)
• 2Endothelial injury (trauma, surgery, lines)
• 3Hypercoagulability (cancer, pregnancy, oestrogen, thrombophilia)

💡 Every surgical patient ticks at least two boxes: that is why VTE prophylaxis is routine.

• 1Pain: abdomen, back or flank
• 2Pressure falls: hypotension or collapse
• 3Pulsatile, expansile abdominal mass

💡 Permissive hypotension: keep the systolic around 70–90 in a conscious patient, and get to theatre or EVAR fast.

• 1Buttock and thigh claudication
• 2Absent or weak femoral pulses
• 3Erectile dysfunction

💡 The occlusion is at the aortic bifurcation; collaterals develop slowly, so the leg is rarely acutely threatened.

• 1Pain out of proportion to the injury
• 2Pain on passive stretch of the muscles
• 3A tense, swollen compartment
• !Pulses are usually present: pulselessness is very late

💡 Delta pressure (diastolic minus compartment pressure) under 30 mmHg means fasciotomy.

• 1MEN 1, three Ps: Pituitary, Parathyroid, Pancreas
• 2AMEN 2A, two Ps and an M: Parathyroid, Phaeochromocytoma, Medullary thyroid
• 2BMEN 2B, one P and two Ms: Phaeochromocytoma, Medullary thyroid, Marfanoid habitus and mucosal neuromas

💡 MEN 2 is caused by RET mutations: carriers have a prophylactic thyroidectomy. Always exclude a phaeochromocytoma before neck surgery.

• BBones: pain, fractures, osteoporosis
• SStones: kidney stones, polyuria
• GAbdominal groans: pain, constipation, pancreatitis, ulcers
• MPsychic moans: tiredness, depression, confusion
• TAnd thrones: polyuria and thirst

💡 Primary hyperparathyroidism and malignancy cause about 90% of cases. Check the PTH.

• CConvulsions
• AArrhythmias (long QT)
• TTetany: Trousseau’s and Chvostek’s signs
• NNumbness: around the mouth, fingers and toes

💡 After a thyroidectomy, perioral tingling is often the first sign: check calcium and PTH.

• PPopular: the commonest thyroid cancer (about 80%)
• PPalpable nodes: spreads by lymphatics
• PPsammoma bodies and Orphan Annie nuclei on histology
• PPositive prognosis

💡 Contrast follicular cancer: spreads through the blood to bone and lung, and needs histology (capsular or vascular invasion) to diagnose.

• HHaematoma: airway emergency, open the wound at the bedside
• HHoarseness: recurrent laryngeal nerve injury
• HHypocalcaemia: parathyroid injury
• HHypothyroidism: lifelong thyroxine after total thyroidectomy
• HHyperthyroid storm: if the patient was not made euthyroid first

💡 Bilateral recurrent laryngeal nerve palsy causes stridor and may need a tracheostomy.

• 1010% bilateral
• 1010% extra-adrenal (paragangliomas)
• 1010% malignant
• !Updated: up to 40% are hereditary, not 10%

💡 Before surgery: alpha-blockade first (phenoxybenzamine), then beta-blockade, with good hydration.

• 1Clinical examination
• 2Imaging: ultrasound, plus mammography from about 40
• 3Tissue: core biopsy

💡 All three must agree. If any one is suspicious, the lump is investigated further.

• CCatastrophic haemorrhage
• AAirway with cervical spine protection
• BBreathing
• CCirculation with haemorrhage control
• DDisability: GCS, pupils, glucose
• EExposure and environment

💡 Treat each problem as you find it before moving on.

• AAirway obstruction
• TTension pneumothorax
• OOpen pneumothorax
• MMassive haemothorax
• FFlail chest
• CCardiac tamponade

💡 All are found and treated in the primary survey, mostly with a needle, a chest drain or a dressing.

• 1Hypotension
• 2Muffled heart sounds
• 3Raised JVP (distended neck veins)

💡 Neck veins may be flat if the patient is also bleeding. Diagnose with FAST; treat with pericardiocentesis or thoracotomy.

• 1On the floor: external bleeding
• 2Chest
• 3Abdomen
• 4Pelvis
• 5Long bones (femur)

💡 Chest X-ray, eFAST, pelvic X-ray and examination of the limbs find the source quickly.

• 1Hypothermia
• 2Acidosis
• 3Coagulopathy

💡 Each worsens the others. Damage-control surgery stops the bleeding and contamination, then warms and corrects the patient in ICU.

• 1Hypertension (widening pulse pressure)
• 2Bradycardia
• 3Irregular breathing

💡 A late, pre-terminal sign of brain herniation: call neurosurgery now.

• BBattle’s sign: bruising behind the ear
• RRaccoon (panda) eyes
• CCSF leak from the nose or ear
• e…and haemotympanum

💡 Never pass a nasogastric tube through the nose in a suspected base of skull fracture: use the mouth.

• BBlood cultures
• UUrine output: measure it
• FFluids: IV bolus
• AAntibiotics: IV, within the hour
• LLactate: measure it
• OOxygen to target saturations

💡 Three in, three out: give oxygen, fluids and antibiotics; take cultures, lactate and urine output.

• HHypotension: systolic 100 or less
• AAltered mental state
• TTachypnoea: breathing 22 or more a minute

💡 Two or more suggests a high risk of a poor outcome. It is not a screening tool on its own.

• 9Head and neck 9%
• 9Each arm 9%
• 18Front of trunk 18%, back of trunk 18%
• 18Each leg 18%
• 1Perineum 1%

💡 Do not count simple redness. The patient’s palm with fingers is about 1%. Children have bigger heads: use a Lund and Browder chart.

• WWind: day 1–2, atelectasis and pneumonia
• WWater: day 3–5, urinary infection
• WWound: day 5–7, wound infection or a leak
• WWalking: day 5 onward, DVT and PE
• WWonder drugs: any time, drug or transfusion reaction

💡 After bowel surgery, add a sixth W: Wound inside, the anastomotic leak. Tachycardia is often the first sign.

• PPain
• IInfection
• NNutrition
• CConstipation
• HHydration
• MMedication (opioids, sedatives, anticholinergics)
• EEnvironment (and Electrolytes)

💡 Also check for urinary retention and hypoxia. Screen older patients with the 4AT.

• 44 mL/kg/h for the first 10 kg
• 22 mL/kg/h for the next 10 kg
• 11 mL/kg/h for every kg above 20

💡 In adults, NICE uses 25–30 mL/kg/day of water, with about 1 mmol/kg/day of sodium, potassium and chloride.

• 66 hours: food (and formula or cow’s milk)
• 44 hours: breast milk
• 22 hours: clear fluids

💡 Many units now allow clear fluids until closer to surgery: follow local policy.

• 1Primary: during the operation
• 2Reactive: within 24 hours, as blood pressure rises or a ligature slips
• 3Secondary: 7–10 days later, from infection eroding a vessel

💡 Reactive bleeding often appears once the patient warms up and the blood pressure recovers.

• 1Sign in: before anaesthesia (identity, site, consent, allergies, airway)
• 2Time out: before the incision (team, procedure, antibiotics, imaging)
• 3Sign out: before leaving theatre (counts, specimens, problems)

💡 It reduces complications and deaths: a favourite OSCE and ethics question.

• DDiabetes
• IInfection
• DDrugs: steroids, chemotherapy
• NNutrition: protein, vitamin C, zinc
• TTissue ischaemia and smoking
• HHypoxia
• EExcess tension on the wound
• AAnother wound or foreign body nearby
• LLow temperature and radiation damage

💡 Many of these can be improved before elective surgery: stop smoking, control glucose, feed the patient.

• 1Colicky pain with drawing up of the legs, pale between attacks
• 2Redcurrant jelly stool (late)
• 3A sausage-shaped mass

💡 Peak age 6 months to 2 years. Ultrasound shows a target sign; treat with air enema reduction if there is no peritonitis.

• 1Projectile, non-bilious vomiting after feeds
• 2A hungry baby and an olive-shaped mass
• 3Hypochloraemic, hypokalaemic metabolic alkalosis

💡 Correct the fluids and electrolytes first; Ramstedt’s pyloromyotomy is not an emergency.

• !Bilious (green) vomiting = malrotation with volvulus until proven otherwise
• •Urgent upper GI contrast study
• •Emergency Ladd’s procedure to save the bowel

💡 The bowel can die within hours. Never wait to see if it settles.

• IStraight across the growth plate
• IIAbove: through the plate and the metaphysis (commonest)
• IIILower: through the plate and the epiphysis
• IVThrough: the metaphysis, plate and epiphysis
• VRammed: a crush injury of the plate

💡 Types III to V risk growth arrest and usually need an orthopaedic opinion.

• BBreast
• LLung
• TThyroid
• KKidney
• PProstate

💡 Kidney and thyroid metastases are lytic and very vascular; prostate metastases are sclerotic.

• AAsymmetry
• BBorder: irregular
• CColour: varied
• DDiameter over 6 mm
• EEvolving: changing size, shape or colour

💡 Breslow thickness (depth) is the most important prognostic factor once it is excised.

• 1IV antibiotics as soon as possible
• 2Tetanus status
• 3Photograph the wound, then cover it with a saline dressing
• 4Realign and splint; check neurovascular status
• 5Debridement in theatre

💡 Photograph first so the wound does not have to be uncovered again and again.

• TTumour: size or depth of the primary
• NNodes: regional lymph node spread
• MMetastasis: distant spread

💡 Prefix c = clinical, p = pathological, yp = after neoadjuvant treatment. Grade is separate.

• SSetting: private, seated, the right people
• PPerception: what do they already know?
• IInvitation: how much do they want to know?
• KKnowledge: warning shot, then plain words
• EEmotions: acknowledge and respond
• SStrategy and summary: the plan

💡 Pause after the news. Silence is part of the conversation.

• 33 relatives with a Lynch-associated cancer
• 2across 2 generations
• 11 diagnosed before the age of 50
• •and FAP excluded

💡 Many Lynch families miss these criteria: test every colorectal cancer for mismatch repair.

• 1Oncogene: one faulty copy, the accelerator is stuck on
• 2Tumour suppressor: two copies lost, the brakes fail (two hits)
• •Inherited cancers start with the first hit already present

💡 KRAS and HER2 are accelerators; TP53, APC and BRCA are brakes.

• ↑Potassium
• ↑Phosphate
• ↑Uric acid
• ↓Calcium (bound by the phosphate)

💡 Prevent with hydration and allopurinol or rasburicase before treating high-grade lymphoma or leukaemia.

• CEAColorectal
• 19-9Pancreas and bile ducts
• AFPLiver (HCC) and germ cell tumours
• 125Ovary
• PSAProstate
• CtCalcitonin: medullary thyroid

💡 For monitoring, not screening: a normal marker never excludes cancer.

• CCarcinomas: usually lymphatics first
• SSarcomas: usually blood, often to the lungs
• PPortal vein: GI cancers reach the liver
• TTranscoelomic: stomach, ovary and colon across the peritoneum

💡 Look for Virchow’s node, a Sister Mary Joseph nodule and Blumer’s shelf.