MRCS Picture Questions Book 3 MRCS Picture Questions Book 3 Edited by Tjun Tang MD MRCS Specialist Registrar in General & Vascular Surgery Eastern Deanery, UK Adrian Harris MD FRCSEd (GenSurg) Consultant Upper GI & Laparoscopic Surgeon Hinchingbrooke NHS Trust Hospital, Huntingdon, UK Senthil Nachimuthu MS MRCSEd Clinical Fellow in General Surgery Hinchingbrooke NHS Trust Hospital, Huntingdon, UK BV Praveen MS FRCS (Ed) FRCS (Eng) FRCS (Glas) FRCS (Ire) FRCS (Gen) Consultant Colorectal Surgeon Southend University Hospital Honorary Clinical Senior Lecturer Queen Mary University of London Associate DME, Eastern Deanery Examiner, Intercollegiate MRCS Examination Foreword by Pradip K Datta MS FRCS (Ed) FRCS (Eng) FRCS (Ire) FRCS (Glas) Senior Examiner and Council Member The Royal College of Surgeons of Edinburgh Radcliffe Publishing Ltd 18 Marcham Road Abingdon Oxon OX14 1AA United Kingdom www.radcliffe-oxford.com Electronic catalogue and worldwide online ordering facility. © 2010 Tjun Tang, Adrian Harris, Senthil Nachimuthu and BV Praveen Tjun Tang, Adrian Harris, Senthil Nachimuthu and BV Praveen have asserted their right under the Copyright, Designs and Patents Act 1998 to be identifi ed as the authors of this work. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopy- ing, recording or otherwise, without the prior permission of the copyright owner. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library. ISBN-13: 978 184619 108 4 Typeset by Pindar New Zealand (Egan Reid), Auckland, New Zealand Contents Foreword vii Preface viii List of contributors ix Acknowledgements x Section 1: Laparoscopic surgery 1 Section 2: GI endoscopy 39 Section 3: Colorectal surgery 77 Section 4: Urology 137 Section 5: Radiology for the surgical trainee 177 Reference 207 Index 209 Foreword It gives me great pleasure to write a foreword to be asked either in the MCQs or Final Assessment. the third volume in this series, not least because Some of the material is in such fi ne detail that I I have known Mr Praveen ever since his pre-Fel- dare say the book would also be useful for the lowship days shortly after he came to the UK in Higher Surgical Trainee preparing for the Exit the early 1990s. Now, as a Consultant Surgeon in FRCS examination. Southend, he has established himself as a good, As a person in the autumn of his surgical enthusiastic and committed surgical teacher. career, it gives me immense personal pleasure In this day and age surgical teachers are a rare to see this publication come to fruition – edited breed. If one was to ‘triage’ the responsibilities by very committed young teachers, ably sup- of a surgeon in the NHS, teaching would end up ported by several consultants and up and coming pretty low in the order of priorities – fi rst comes young surgeons who are setting out on the road service provision (and quite rightly too), then to a surgical vocation. ‘A picture is equal to a ‘number crunching’ of patients treated to keep thousand words’ – this adage is exemplifi ed by managers happy, private practice, research and the excellent pictures in this volume generously family. Praveen has been able to strike a superb contributed by many young surgeons. balance with considerable emphasis on teach- In writing this foreword, I must be careful not ing. This book is the outcome of the painstaking to stray into making it a ‘book review’; that must collection of clinical material over many years be somebody else’s job. All I can say is that the by the editors, aided by colleagues who have reader will fi nd the following pages a compelling contributed much towards this very worthwhile read. The quality of authorship is such that I will publication. be surprised if other books did not soon emerge Surgical trainees sometimes go from pillar to from the same stable. I wish the authors every post in search of good teaching. The MRCS train- success. ees should consider themselves lucky to have this book to prepare for the examination. As an Pradip K Datta examiner for the MRCS, I can assure the reader MS FRCS (Ed) FRCS (Eng) FRCS (Ire) FRCS (Glasg) that this book comprehensively covers every Senior Examiner and Council Member aspect of Surgery in General including pathology, The Royal College of Surgeons of Edinburgh and answers all questions that can conceivably September 2009 Preface It gives us great pleasure to present our book to them during their clinical practice. The combina- you. It is designed for candidates sitting both the tion of clinical photos and questions is perhaps new intercollegiate MRCS examination as well the best way to revise both the clinical aspects as the undergraduate clinical examinations in and the subject matter associated with them. It surgery. The method of presentation and topics is also believed that seeing clinical cases and are drawn from our own experiences during reading about them at the same time, reinforces preparation for our examinations. The book knowledge retention. provides visual revision material to reinforce Case selection is based not only upon the core subject matter. The questions are based editors’ experiences but also those of other distin- around a photograph or a set of pictures with guished clinicians in different subspecialties. All each question slightly more diffi cult than the contributors have been through the rigours of the previous one. MRCS examination and several are current inter- With the new European Working Time collegiate MRCS examiners. Typical examination Directive and the reduction in doctors’ hours, subject material and questions are presented. trainees may fi nd it more diffi cult to be exposed We hope you enjoy working your way through to all the different clinical cases. The MRCS this picture book and please do let us have your examination requires candidates to acquire valued comments. We wish you all the best in knowledge of the presentation and appearance your examinations and surgical career. of a wide range of surgical problems and we believe this book will assist students and trainees TT, AH, SN and BVP to acquire useful packages of information, not September 2009 only for examination purposes but also to help ‘The conditions necessary for the surgeon are four: fi rst, he should be learned; second, he should be expert; third, he must be ingenious; and fourth, he should learn to adapt himself.’ Guy de Chauliac, 1300–68 List of contributors MAJOR CONTRIBUTORS CONTRIBUTORS Sections 1 and 2 Mr Vamsi Velchuru Mr Szabolcs Gergely Clinical Fellow (General Surgery) Consultant Upper GI and Laparoscopic Surgeon James Paget NHS Trust Hospital, Great Hinchingbrooke NHS Trust Hospital, Yarmouth Huntingdon Mr Gerald David Clinical Fellow (General Surgery) Section 4 Mid Cheshire Hospitals NHS Foundation Trust, Mr Natarajan Sezhian Crewe Consultant Urologist James Paget NHS Trust Hospital, Great Dr Iain Au-Yong Yarmouth Specialist Registrar (Radiology) Nottingham Rotation Mr CJ Shukla Specialist Registrar (Urology) Norfolk & Norwich University Teaching Hospital, Norfolk Dr Min Yen Wong Specialist Registrar (Radiology) Norfolk & Norwich University Hospital, Norfolk