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Thank you for coming tonight. Um So I'm Lucy, I'm one of the FTSE at University Hospital of Wales. And tonight I'm going to be presenting uh mini teach on General Surgery for the mrcs. So I will just share my screen now. Okay. So hopefully you can all see the presentation now. So why general surgery with a focus on hip Otto pancreatic billary surgery? Bit of a mouthful, but general surgery is a huge topic for the MRCS which extends across both papers um of the part A and also part B. So, um, are lame to give a bit of a broad overview or a few different areas in this teach. Um I'm going to start off with anatomy for the first half and then the second half, I'll make it a bit more clinical and hopefully if you hang in there, um, it'll lighten up towards the end. I don't know about you guys, but for me, it was the anatomy that was really something that tested my resilience when I was preparing for my exam in September. So without further a do, that's start off with some questions. So, um, what I'd like you to do is please far away your answers in the chat thing with this exam, unlike our medical exams, is there really is no stupid answer. Uh And so the question is can be quite tough with multiple plausible sounding answers. So don't be afraid to get things wrong. And I haven't always picked the easiest bunch of questions as well. So starting off, um, during a whipple's procedure, the structure directly post Syria to the second part of the duodenum is injured whilst mobilizing this segment of the bow, which is the following is most like to have been injured. I'll give you a few seconds to answer this. Yeah. Um, just quickly before we move on. Um, what is a whipple's procedure? Anyone in the chat feel free to post also, can everyone in the chat hear me? Someone just post in the chat? Great. Um Fine. So a whipple's procedure is a pancreatic pancreatic oh Duodenal ectomy, which is an operation to remove the head of the pancreas. And first part of the duodenum as shown in this picture, um, as well as the gallbladder and the bile duct to treat a CIA of the head of pancreas. Okay. So, um, uh, haven't seen many answers to the question in the chat. So we'll move on. The answer is C so Kyle, um, of the right kidney. So essentially this brings us well, first concept in anatomy, which is the trans power look plane, which this answer is driving at. So the transpyloric plane is a really key level that is important because it's the level of multiple different important structures. And if you can use this level as a reference point, it's really helpful. It's equivalent to the L1 versatile level. And it's also halfway between the super sternal notch and the pubic symphysis. The all of these structured listed are, they're so key ones end of the spinal cord nights, costal cartilage, renal hilar, um the superior mesenteric artery, origin, portal pain, origin neck of pancreas, stomach pylorus gallbladder, fungus, um sphincter of oddi which surrounds the, which is a valve that controls the exit of the bile duct, uh pancreatic duct into the duodenum. And then we've got the second part of duodenum which this question is about. So, um going back to the question, the only catch here now is that all of these structures? In fact, our in our list and like the transpyloric plane. So this is where you need to just go that little bit further with your anatomy preparation. Um and start thinking about the relations and some of these structures. So the duodenum is a good one to get your hand up in terms of relations. Um It's a bit more complex, but actually, if you use some general rules of thumb, it can get you by in quite a lot of gi anatomy. So if you get used to the shape of the duodenum, it's like a C so with the first part, the top part. Um and like I said, my general, from really being behind the duodenum, you have mostly the major blood vessels, the kidneys and the psoas. Uh And in general, um So first part using that, you've got the portal vein, second part IBC, third part, you've got the aorta, fourth part being the inferior mesenteric vessels. And in general, it's the organs that lie in front of. So from right to left, you've got the liver, um you've got the liver and gallbladder, then the stomach, um then you've got the transverse colon that spans across all parts and the highlight of each kidney um either side. So I've just highlighted and bold a couple of exceptions to that rule. So the mecca of pancreas, yes, pancreas is an organ, but that just lies or sort of Nestle's in behind the first part of the duodenum and then the superior mesenteric artery. Yes, it's a vessel. But actually that overlies. So realize, anterior to the third part of the duodenum. So this is um an important slide as well as just going over this a few times because it does take a while to get your head around it, but does come up the thing that helps me remember the superior mesenteric artery just sneaking through. So it overlies the duodenum is something called superior mesenteric artery syndrome, which I've described in the image in the top right hand corner. Um So this is when loss of body fat means that the duodenum actually gets squished by the overlying superior mesenteric artery. Um So maybe that will help you remember that Little Pearler. Okay. So next question during a whipple's uh sorry, that was the question just answered. So, yeah, here, I've just um just showed that actually by using those concepts about the duodenum relations, you can answer this question, the fund assess of the gallbladder that lies anterior. Whereas this, this question is asking about posterior relations, um the hepatic portal vein again, that's first part and this is the second part, um superior mesenteric again, that's anterior and the third part Catholic Pylorus, that's anterior. I'm sure you get the gist. OK. Tricky question, right. So next one, which of the following does not form a boundary of calories triangle. So post your answers in the chat. So I know you're still with me. Okay. So we've got an E we've got an A. So the right answer is see. So important is these negative questions that can easily trip you up. So this one are asks which of the following does not form a boundary of Callus triangle. So first of all, why is culottes triangle? The cysto hepatic triangle important? Well, it's identified in a lap coli to identify and allow the safe ligation of the cystic duct and the cystic artery when you're taking out the gallbladder. So, a a deficiency in this diagram, a and B and D are all borders of calories triangle. Um E is actually where the cystic artery originates, but actually is a sign note can also just sneak in and be found within the triangle as well. But the key structure here is the cystic artery. So that's the contents of calories triangle. Okay. So here I'm just going to add in another anatomical concept, which is the celiac trunk and the way I've linked that is just because we've mentioned the cystic artery being a branch of the right hepatic artery, the right hepatic artery being a branch of what is eventually the common hepatic artery and the common hepatic artery we know is one of the main three branches of the celiac trunk along with the left gastric and the splenic artery. Now, the reason why I want to just highlight this is because these branches to come up. And uh you've got some key structures that come off these and anastomosis apart from the anastomosis. Um So just have a really good learn of this diagram and just remember the three main branches that I've outlined on this slide, common hepatic left gastric and Hispanic artery. Um Okay. So again, the celiac trunk being one of the three main branches off the abdominal aorta which apply the gi tract. I'd say the celiac trunk is the one that is worth concentrating on because again, it's got those three branches and sub branches with ridiculousness names that can be quite difficult to really get into your head. And in my mind, the superior mesenteric artery and the inferior mesenteric artery at one and L3 are just a bit more simple um to remember and has to have less branches with silly names. Um Again, I've just used this slide to highlight the different levels of the key branches. So um extending down is for which is where um there is the bifurcation of the aorta into the common, I'll yak arteries and again, the common I'll yaks then bifurcate further at L5 S one into the internal, an X L, I'll yaks on the left and right side. Okay. And then again, this just shows you the three main branches I mentioned. And um in general, there are branches off each main arteries and just knowing where the cut off points are for these um these different arteries. Okay. So next question, um A jaundiced 45 year old presents with some non ST hematemesis iss a gastroscopy reveals bleeding esophageal varices. Which of the following is true about the anatomy of the portal venous system. So, have a go again. This one is quite a tricky question. Okay. So the answer is b portal vein arises behind the neck of the pancreas. So before we go back over this question, I'll just explain some concepts about the portal venous system. So why is this important? Well, most of the blood from the abdominal organs goes into the hepatic portal vein and not directly into the IVC. So, essentially, you've got blood from the digestive organs and spleen. Um So that's the lower third of the esophagus to the anorectal junction, um is delivered to the hepatocytes via the capillary beds of the liver. And this blood is then absorbed. Um if the nutrients and toxins from the GI tract processed, then drained via the hepatic veins into the IBC. So, it's important to understand the key tributaries of the portal vein. The main ones being the S MVS of the superior mesenteric vein and the splenic vein. Um then the inferior mesenteric vein is actually a contributor to the splenic vein. So, going back to the question, a the origin of the portal vein lie superior to the origin of the superior superior mesenteric artery. Well, we know that's wrong because going back to our transpyloric plane, we know that the origin of the portal vein and superior mesenteric artery are at the same level. They both are at the transpyloric plane. Um B is possibly true because we know about the relations of the duodenum. We know that the vessels generally arise um lie behind the, the abdominal organs. Um And we know that the portal vein um arises at the similar level to the neck of the pancreas around the second part of duodenum. Um Even if we don't know that hopefully, um by method of deduction, you could consider that to be a plausible answer. So see, portable vein drains by the gi tract from the upper esophagus. The annual rectal junction. No, it's the lower esophagus. Um then the portal vein arises from the confluence of the splenic inferior mesenteric veins. Well, actually, it's the confluence of the splenic and the superior mesenteric veins and the inferior mesenteric going back to the last slide being a branch from the splenic. And then finally, portal vein lies anterior to the CBD and hepatic artery in the less momentum. Okay. So this last question, this list, last answer we haven't covered. So that is talking about something called the EpiPen loic foramen. Now they love aunts kit asking about this and the portal triad. So let me just go on to explain this last anatomical concept. And then we'll go on to something a little bit more fun and surgical. So essentially the portal triad. The three main tubes that enter the liver via deep fissure called the porter her pacis um include the hepatic artery that carries auction ated blood into her past sites. Um And then the portal vein which then carries blood with nutrients from the small intestine. And then third is the bile duct which carries the bioproducts away from the liver and into the dilatory and gallbladder. So, these three key structures, they sit within something called the hip Otto duodenal ligament that is also known as the free edge of the less momentum. So I'll talk about the a mentadent in the minute and, and how that's relevant. Essentially the reason why that, that bundle and um the ligament it lies within is really important is that this forms one of the borders of something called a cup Loic foramen or the Foramen of Winslow. So in fact, it's the forms the anterior border and in this diagram, the right, it's definitely worth learning the other borders of this foramen or this window um being the cord, it Chris Bolivar um superior Lee, first part of the duodenum inferior early and behind it is the IVC. So just to quickly remember as well is that this window or Framan can re remember does line between two great veins of the abdomen. So I'm talking about the portal vein and the IVC. So um what isn't showing well in this diagram is that the portal vein sits at the back of this portal triad. So yeah, actually, it is the thing that is a window between two veins that portal vein being at the back and nearest the Foramen. Um So what is this, the arraignment exactly? Well, it's a communicating cavity between the greater and the lesser sacks. Um So going a bit more into detail about these sacs. Um So essentially the uh greater a mentum is um uh this big fold of peritoneum attaches to organs also double uh double up as ligaments that hold organs together and channels for vessels. Um And then this. So this free edge of the lesser momentum. That makes sense that that's also acts as the hip Otto duodenum ligament that uh is also the channel for the portal triad. Um So essentially the lesser a mentum attached attaches the lesser curvature of the stomach and the liver. Um and then there's another ligament that's path that forms part of the lesser a mentum being the hepatic gastric ligament. Um Okay. So moving on, does anyone have any questions about any of those that and asked me before we move on to the more clinical questions? No. Okay. So next, I've mixed up the question format now. Um just to stop everyone falling asleep. So what I'd like you to do, I'll give you a bit longer for this one is go through quickly each other been yet and think about your uh spot diagnosis. I've given you some ideas, some inspiration on the right hand side. Um So you can apply any of those answers more than once to any of the questions or you might not apply any of those answers to any of the questions. So see how you get on and again, when you're done, feel free to post your answers in the chat. 21 or all of the questions. Can everyone still see the slides by the way? Okay. So first one, um first five year old male with right upper quadrant pain and vomiting. Um So, um the answer is cholangitis being an ascending bacterial infection of the biliary tree. Uh most commonly due to obstructive jaundice. So that leads me onto talking about shark owes triad. So, obstructive jaundice along with fever and right upper quadrant pain. Um Ren Woods pent had ads altered mental status and sepsis too. That triad say number two, a 50 year old male female with progressive jaundice and a powerful right upper quadrant mass. So this question is talking about gracias law which states that pain nous palpably in large gall bladder accompanies with mild jaundice is unlikely to be caused by gallstones, but indicative of a biliary obstruction. So that can either be from see a pancreas or gallbladder. Um OK. Next question, 68 year olds type two diabetic, right, upper quadrant tenderness develop septic shock. Um Ultrasound shows normal caliber bile duct, no gallstones in the gallbladder. So the answer here is a calculus cola cystitis. So again, another right upper quadrant pain and infection. Here, we've already talked about cholangitis. So that's where you get jaundice and obstructive picture because of the common bardack being blocked. So that's not mentioning this question. And there's no nothing to suggest there is any obstruction and we've also got a normal caliber piled up. So that's leaning more towards a cola cystitis rather than cholangitis. And then secondly, there aren't any stones in the gallbladder. So that is why this is an disease. Um Other causes of colecystitis can include trauma, vasculitis and in this case, type two diabetes, which can be associated with reduced um nerve innovations to the gallbladder. So it's not simulated to contract. So you get a build up of pressure within, um within the gallbladder. Um and then the bile salts become concentrated and predisposed to infection and information. So next is the 48 year old, two year history require recurrent, right, upper quadrant pain um emitted with small bowel obstruction that school stone ileus where you get a impacted gallstone that forms officially between the gallbladder and the duodenum. Um In other words, a Coehlo coli cysto enteric fistula, you can also get a fistula between the gallbladder and they're extra hepatic ducks. So, in these, in this case, um the impacted gallstones becomes large enough to actually compress the billary tree. So, hence the next question, um You get an obstructive picture of pale stools and dark urine and that's the only, um the only case or that this is a case where you can get that obstructive picture in the absence of the stone being, um being actually within the common bar duct. It can be within the gallbladder but large enough to compress extrinsic lee or externally the am billary tree. Um So that's a bit more highlighted in this diagram here. Hopefully mapping out visually, you can appreciate how we might fix some of these conditions. So in gallstone ileus, you typically we'll leave the gallbladder alone um and perform an enterostomy So you make a hole in the bow proximal to the impacted stone uh to fisher out um in less severe forms of um Maurizi syndrome, um which is where you get the extrinsic extrinsic compression of the um impacted gallstone um on billary tree. Um You might then before my cholecystectomy. Um but you can, because this condition can typically be a long course of information, um and a complication after um gallstones being there for a long time. Um Actually, often these uh this condition might be operated on with an open approach. So you can imagine you get very extensive adhesions, obscuring the calories triangle, which we mentioned earlier. So you can't safely do this procedure laparoscopically in all cases. Um as you might risk bile duct injury or massive hemorrhage. Okay. So, final question, 54 year old with right upper quadrant pain, nausea and vomiting has an ultrasound abdomen which reveals gallstones within a thickened wall gallbladder. There is gas overlying the harms pouch and common bile duct. What is the most appropriate step in her management? Okay. So the answer is d I'm going to use this question to reiterate the use of ultrasound as first line to um investigate suspected gallbladder gallstone pathology. So, there's three specific things that should be visualized. So the first um as a miss question is the presence of the gallstones or sludge, which can be a predisposition or precursor the stones. The second is the gallbladder war thickness, which indicates that there's been a lot of information. And then there's the third which is the biliary duct dilatation in which might indicate stones in the distal bile ducts or common bile duct. However, in this question, this third aspect isn't visualized properly, as it says in the stem that there is gas overlying the common bile duct. So this part is essential as it affects what you need to do in terms of your operative management. So for instants, if there's a colon cystitis, you might do an urgent lack choline within 72 hours. But if there's a C P CBD or common bile duct stone, you would not want to do that because even if you took the gallbladder out, you might not cause you might not solve the problem because you might have a remnants of the biliary tree with the stones still present. Um And that's not how you treat colon joe itis in the acute um stages. So, going straight for option e the hot lap coli um isn't the right answer. Um Be isn't either because we don't really know what condition we're dealing with and whether it's an indication for um for a lap coli. Um so a CT can as an answer, a can be performed as an adjunct um to investigate um coexisting pathology like trauma, treasury, tumor's or liver abscess, um or differentials like diverticulitis by pollen arthritis. Um But the major disadvantage is that you can't really have good sensitivity for diagnosing common bardack stones. So now we're left with E ERCP and M R C E P. So the key difference here is that E M R C P is just imaging whereas E ERCP can be both diagnostic and therapeutic. Um So we need a really good reason for B for doing an invasive procedure like any RCP. So the reason why M R C P is the right answer is because it gives you a second line of a better imaging. Um So you can understand what's going on and then if there is a stone in the distal billary structures or common bardot's, then you might then progress to an ERCP. Um And the advantage of an ERCP is that you can do a sphincterotomy or you can do stenting the same time uh as getting your um uh your diagnosis which might have to clear any obstruction. I will just mention a final um a final treatment mode that you might get in the MRCS, which is a P T C or a percutaneously transhepatic colon geography. Um And essentially that is an alternative to an ERCP. Um sometimes using settings where patient's are too sick to tolerate an ERCP um or where an ERCP can't be performed um to technically challenging for other reasons. Okay. So that concludes my talk, please feel free to post any questions in the chat. Um And otherwise I'll post the feedback form now. Okay. Does anyone have any questions at all? Um I can also answer any questions in general about the exam itself. Um So in collide, oh, Cola's thigh assist, does the stone form in the CBD or does it happen due to a stone from the gallbladder? That's a really good question actually. So, essentially, um from my understanding, the way a stone is formed is um due to bile stasis and you get um formation of the stone and the, the function of the gallbladder is storage of the bile. So, um, so the most likely source of a common bar duct stone is a stone that's worked its way from the gallbladder. From my understanding um into the