The 2027 General Surgery ST3 Interview Revision Platform: Question Bank, Live Practice and Mocks with Other Candidates

This is a potential surgical emergency: a frail 90-year-old with vomiting, distension and an irreducible groin lump has bowel obstruction from an incarcerated or strangulated groin hernia until proven otherwise — and in an elderly woman a femoral hernia is particularly likely, with a high risk of strangulation. If the bowel is compromised, delay risks perforation, sepsis and death, so she needs prompt senior review, resuscitation and probably urgent surgery.

Her frailty and dehydration raise her peri-operative risk, and her dementia means I'd assess capacity for this specific decision rather than assume she lacks it. Organisationally, I'd involve the on-call consultant surgeon and anaesthetist early, alert theatres and possibly ICU, and contact her next of kin or carers for collateral history and her known wishes.

I'd have her moved to resus and ask the team to start resuscitating while I attend: full observations and monitoring, two large-bore cannulas, bloods, IV fluids if she's dehydrated or hypotensive, analgesia and an antiemetic, and keep her nil by mouth.

On arrival I'd work through an A-to-E assessment. She's at high aspiration risk from vomiting and distension, so I'd protect the airway and involve anaesthetics if she's compromised, give oxygen if needed, and resuscitate her circulation with fluid boluses and frequent reassessment — in a frail patient I'd avoid both under-resuscitation and overload — checking lactate and inserting a catheter. I'd examine the abdomen and all hernial orifices, and I would not forcefully reduce the lump, as pushing ischaemic bowel back into the abdomen is dangerous.

Bloods: full blood count, U&Es, LFTs, CRP, clotting, glucose, a group and save or crossmatch, and a blood gas with lactate, plus an ECG. If she's stable and the diagnosis is uncertain, a CT abdomen and pelvis with contrast confirms the site and cause and assesses bowel viability — but I would not delay surgery for imaging if she's unstable or there are signs of strangulation.

For treatment: nil by mouth, IV fluids, careful analgesia and an antiemetic, an NG tube to decompress the stomach, a urinary catheter, and broad-spectrum IV antibiotics if strangulation, ischaemia or sepsis is suspected, alongside a VTE assessment and a medication review.

Likely urgent operative repair of the obstructed or strangulated hernia, and in a frail 90-year-old this should be consultant-led. That may mean groin exploration, assessment of bowel viability and hernia repair, with possible bowel resection or laparotomy depending on the findings.

I'd inform the consultant, anaesthetist and theatre coordinator early, make sure resuscitation and crossmatch are underway, use a risk tool such as NELA or P-POSSUM to communicate the risk, and plan her post-operative destination — ward, HDU or ICU — alongside an honest discussion about goals of care.

I'd assess her capacity for this specific decision at this time — dementia doesn't automatically mean she lacks it. If she has capacity, I'd explain the diagnosis, the operation, the risks and the alternatives, and that without surgery she risks bowel necrosis, sepsis and death, while being honest that surgery carries significant risk given her age and frailty. I'd also ask her permission before sharing information with her family.

If she lacks capacity, I'd make a best-interests decision with the consultant and MDT, checking for an advance decision or lasting power of attorney and consulting her family to understand her wishes — they inform the decision but don't consent on her behalf unless they hold health-and-welfare LPA. If surgery is immediately life-saving and she lacks capacity, it can proceed in her best interests, clearly documented.