This document provides an overview of the field of surgery and key topics medical students will be asked about in their first week of a surgery rotation. It discusses hernias and varicose veins in depth, covering definitions, anatomy, classifications, examination techniques, and do's and don'ts. The document is intended to equip students with essential knowledge on common surgical conditions and expectations for their clinical work.

1. Surgery
Contents:
• What’s it all about?
• Conditions you will be asked about in your first week
• Hernia
• Varicose veins
• Do’s and don’ts
• History and examination
© Elsevier Ltd

2. What is it all about?
'Surgery' is often split into different specialties including general, breast, vascular, transplant,
orthopedic and trauma. It is linked to nearly every other specialty from pediatrics to care of the
elderly. The practice of surgery is separated into emergency and elective care. Patient care
covers emergency admission, operating room sessions, day-to-day inpatient care and outpatient
clinics.
Conditions you will be asked about in your first week
Favorites for surgery are varicose veins and hernias. Essential knowledge includes definition,
anatomy, examination and classification.
Hernia
A hernia is the abnormal protrusion of an organ or tissue through a weakness in the surrounding
structures. Hernias may be described as:
Reducible Easily put back
Irreducible Contents cannot be put back due to adhesions
Strangulated Contents are stuck and there is constriction of the tissues at the neck of
the hernia leading to reduced venous drainage and arterial occlusion.
Richter's Only part of the visceral wall is strangulated
Refer to Fig. 32.2 from Sweetland Crash Course Surgery
Types of hernia
Type Description Risk of
Strangulation
Incisional Herniation through an area weakened by a scar. Low
Umbilical Congenital defect of the abdominal wall seen in Low
infants as a swelling at the umbilicus
Paraumbilical Acquired defect above or below the umbilicus High
Epigastric Often small painful swelling in the midline of
abdomen above the umbilicus caused by a defect in
linea alba, usually contains extraperitoneal fat.
Femoral Herniation through the femoral canal which appears Highest
'below and lateral to the pubic tubercle'. More
common in women than men.
Inguinal Typically seen ‘above and medial to the pubic Low
tubercle’; swelling is caused by weakness in the
abdominal wall in the area of Hasselbach’s triangle.
Indirect -The most common Hernia, of which there are two
(inguinal) types. First, congenital, is caused by a patent High
processus vaginalis. Second, acquired, herniates
through deep ring and travels along the inguinal
canal within the coverings of the spermatic cord.

3. For anatomy, refer to Fig. 32.3 and Fig. 32.4 from Sweetland Crash Course Surgery.
Examination
Inspection:
• With patient standing, look for a swelling.
• Note position and involvement of scrotum.
• Look for scars- carefully check other side.
• Watch for cough impulse.
Palpation:
• Repeat cough impulse.
• Lie patient down.
• Decide type of hernia by position.
• Is it reduced or reducible?
• Is it inflamed or tender?
By the end of the history and examination you should have answered these questions:
• Does the patient have a hernia? (i.e. a swelling with a cough impulse)
• What type of hernia is it?
• Is it reducible?
• Is surgery appropriate?
Varicose Veins
Varicose veins are superficial veins that can be seen and are more tortuous and dilated than
normal. Varicose veins can be asymptomatic. Patients may complain of the unsightliness of the
veins. Other symptoms include aching, ankle swelling, dry and itchy skin, discoloration or
ulceration of the skin and vein rupture with bleeding.
Anatomy
The anatomy of the superficial leg veins and some understanding of the venous drainage of the
leg are essential.
If someone presents with varicose veins it is necessary to differentiate between problems of the
short and long (small and great) saphenous veins. This is done by knowledge of the anatomy.
Remember that veins drain from bottom to top and therefore refer to the anatomy in this direction.
Venous drainage of the leg is from the superficial veins to the deep veins. There are perforating
veins which join the two and have one way valves to prevent back flow. If these valves are faulty,
blood goes back into the superficial veins making them varicose.

4. Classification of varicose veins
Varicose veins can be broadly categorized into primary and secondary.
Primary:
These are common. The deep venous system is normal. The varicose veins are due to
incompetent valves either in the main venous junctions, i.e. the saphenofemoral, or in the
perforating veins. They can be considered idiopathic or familial. Varicose veins are worsened by
pregnancy, obesity, constipation or long periods of standing.
Secondary:
These are varicose veins caused by another pathological process. In the postphlebitic limb, the
deep veins are occluded and all or most of the venous return is in the superficial system causing
secondary varicosities. If there is re-canulization after a deep vein thrombosis, the venous
pressure in the deep system is increased (because the valves have been destroyed); this can
cause damage to the valves leading to secondary varicosities.
Examination
Inspection:
• The patient needs to be exposed - i.e. underwear, and standing in a good light.
• Get down low, sit on a stool if available.
• Inspect from the front and behind.
• Have one leg in front of the other to see the medial aspect of the limb.
• Look for distribution, scars (both legs, in groin and popliteal creases), venous flare,
edema, lipodermatosclerosis, ulceration.
Palpation:
Feel the veins, they might not be visible.
Feel for a cough impulse, just below the saphenofemoral junction.
Percussion:
Gently feel over the saphenous opening while tapping the varicosities, feeling the impulse
transmitted implies incompetent valves.
Trendelenburg’s Test
With the patient supine, lift the leg and milk out the blood. Either place your fingers over the
saphenofemoral junction or place a tourniquet around the limb. Keeping pressure on the limb,
have the patient stand. If there is no venous filling saphenofemoral incompetence is
demonstrated and the patient is very impressed! If there is filling of the veins the incompetence
must be lower down the limb. A similar test can be performed for short saphenous incompetence
although the best confirmation is with ultrasound. (Practice this examination technique!)

5. Do’s and Don’ts
• Attend ward rounds.
• Clerk inpatients on the ward and present them on ward rounds.
• Get to know the inpatients and follow their progress.
• Make presentations at meetings or discussions.
• Help out with ward duties.
• See outpatients at clinics, do history, examination, differential diagnosis and decide on
investigations.
• If possible see patients in emergency room.
• Attend surgeries to learn (not just to be present).
• Know the rules of the operating room. Make sure that you wear hat, mask and the correct
footwear before you enter the operating room. As a student ensure that you wear your
name badge and remove jewellery. If you are asked to scrub up, ask an experienced
member of surgical staff to show you how. This is important and best learned in the
operating suite.
• Spend your time wisely for your own gain.
• Try to enjoy it.
History and Examination
There are times when a full history and examination are required and you should practice this as
often as possible. Sometimes a consultant will expect this of you and you should offer a complete
history, examination, differential diagnosis and plan.
In the surgical unit, however, this might not always be required. For example for outpatients with
10 minute appointments, this is clearly not possible or appropriate. In this situation, think what
information is needed by the consultant:
• What is the problem?
• Is it surgical?
• What does the patient want done and why?
• Is surgery a possibility?
• Is the patient fit for surgery?
Author
Written by Nicola Campbell, University of Edinburgh , College of Medicine & Veterinary Medicine
© Elsevier Ltd