General Surgery
Every diagnosis, condition, procedure, medication, abbreviation, and documentation framework you need to succeed on day one and beyond.
All diagrams on this page are sourced from published educational or institutional materials rather than AI generation. Each figure caption links to the original source, and the full diagram and guideline citations are collected in the references section at the bottom.
01 Surgical Anatomy — Abdomen & GI Tract
General surgery covers an enormous anatomic footprint: the entire gastrointestinal tract from the esophagus to the anus, the hepatobiliary system, the pancreas and spleen, the endocrine organs (thyroid, parathyroid, adrenals), the breast, the abdominal wall and hernias, and a significant share of skin, soft tissue, and trauma care. A general surgery scribe will hear anatomy named rapidly during both clinic consultations and operative dictations, and must be able to chart it accurately on the fly.
The Abdominal Quadrants & Regions
Abdominal pain and physical findings are routinely localized to one of four quadrants — right upper (RUQ), left upper (LUQ), right lower (RLQ), and left lower (LLQ) — or to one of nine anatomic regions (epigastric, umbilical, hypogastric/suprapubic, right/left hypochondriac, right/left lumbar/flank, right/left iliac/inguinal). RUQ pain points to the liver, gallbladder, and hepatic flexure; epigastric pain points to the stomach, pancreas, and duodenum; periumbilical migrating to RLQ is the classic appendicitis story; LLQ pain in an older adult raises diverticulitis; suprapubic pain raises bladder, pelvic, and sigmoid pathology.
Foregut, Midgut, Hindgut
The foregut (esophagus, stomach, duodenum to the ampulla of Vater, liver, gallbladder, pancreas, spleen) is supplied by the celiac trunk. The midgut (distal duodenum through the proximal two-thirds of the transverse colon) is supplied by the superior mesenteric artery (SMA). The hindgut (distal transverse colon, descending colon, sigmoid, rectum) is supplied by the inferior mesenteric artery (IMA). Knowing these territories is essential for understanding mesenteric ischemia and colonic resections.
Hepatobiliary Tree
Bile produced in the liver drains through the right and left hepatic ducts, which join to form the common hepatic duct. The cystic duct from the gallbladder joins it to form the common bile duct (CBD), which descends behind the duodenum and drains (with the pancreatic duct) through the ampulla of Vater into the second portion of the duodenum. The triangle bounded by the cystic duct, common hepatic duct, and liver edge is Calot's (the hepatocystic) triangle — the landmark surgeons call out during every cholecystectomy before clipping the cystic artery and cystic duct (the "critical view of safety").
Peritoneum & Retroperitoneum
The peritoneum is a serous membrane lining the abdominal cavity (parietal) and covering the organs (visceral). It creates potential spaces in which fluid, blood, pus, or tumor can accumulate: the subphrenic spaces, Morison's pouch (hepatorenal recess), the paracolic gutters, the pouch of Douglas (rectouterine or rectovesical). Retroperitoneal structures sit behind the peritoneum and include the kidneys, ureters, adrenal glands, pancreas (except the tail), duodenum (except the first part), ascending and descending colon, aorta, and IVC. Retroperitoneal bleeding and infection can be insidious because parietal peritoneal signs are absent.
Abdominal Wall & Inguinal Region
The abdominal wall is built in layers: skin, subcutaneous fat (Camper's and Scarpa's fascia), external oblique, internal oblique, transversus abdominis, transversalis fascia, preperitoneal fat, and peritoneum. In the midline the rectus abdominis muscles sit in the rectus sheath joined at the linea alba. The inguinal canal runs from the deep (internal) ring laterally to the superficial (external) ring medially and contains the spermatic cord in men (round ligament in women). Hesselbach's triangle (bounded by the inferior epigastric vessels, rectus lateral border, and inguinal ligament) is where direct inguinal hernias emerge; hernias lateral to the inferior epigastrics are indirect and traverse the internal ring.
Learn "right versus left" for every organ and every bowel segment cold. The surgeon will dictate "the hepatic flexure was mobilized" or "we took down the splenic flexure for tension-free anastomosis" and you must recognize immediately which segment of colon is being discussed. Mis-charted laterality is one of the most common scribe errors.
02 Scribe Documentation Framework
General surgery scribes document a mix of outpatient clinic consultations (new referrals, post-op follow-ups, surveillance), inpatient consults (ED calls, ward consults, ICU patients), and operative H&Ps. Each encounter type has its own rhythm, but they all follow SOAP structure at their core.
Chief Complaint: A short, focused reason for visit (e.g., "RLQ pain," "reducible right groin bulge," "colon cancer pre-op evaluation," "s/p lap chole POD#7 wound drainage").
HPI: Use OLDCARTS — onset, location, duration, character, aggravating/alleviating factors, radiation, timing, severity. For surgical abdominal pain, always capture migration (classic for appendicitis), relation to meals (gallbladder, PUD), bowel habits (obstruction, cancer, diverticulitis), bloody stools or melena, weight loss, fevers/chills, nausea/vomiting, last oral intake (for pre-op planning), and prior abdominal surgeries (adhesions!).
ROS: Problem-focused. Always document the pertinent GI review (abdominal pain, N/V, diarrhea, constipation, hematochezia, melena, dysphagia, early satiety, reflux, jaundice), constitutional (fever, weight loss, night sweats), and cardiopulmonary (relevant for pre-op risk).
PMHx/PSHx/Meds/Allergies/SHx/FHx: Prior abdominal operations matter enormously — always list each operation, approach (open vs laparoscopic), year, and surgeon if known. Anticoagulants (for operative planning), tobacco/alcohol (SSI and anastomotic risk), and family history of colon/breast/gastric cancer and polyposis syndromes are high-yield.
Vitals: Temperature, HR, BP, RR, SpO2, BMI. Document fever, tachycardia, hypotension (sepsis), and BMI (impacts approach and risk).
Abdominal Exam: Inspection (distension, scars, bruising, visible hernias), auscultation (bowel sounds present/absent/high-pitched), palpation (soft, tender, rebound, guarding, rigidity, masses, organomegaly, hernia reducibility), percussion (tympany, dullness, shifting dullness), and specific maneuvers (Murphy, McBurney, Rovsing, psoas, obturator, Carnett).
Results: CBC (WBC, Hgb, platelets), CMP (electrolytes, creatinine, liver enzymes, albumin, total/direct bilirubin), lipase, lactate, coagulation, type and screen. Imaging: CT abdomen/pelvis with contrast is the workhorse — document specific findings, not just "positive."
A numbered problem list with each diagnosis followed by an explicit plan: NPO status, IV fluids, antibiotics, imaging, consultations, operative planning, pain control, VTE prophylaxis, and disposition. Pre-op notes must include indication, proposed procedure (with laterality and approach), ASA class, informed consent discussion, and anesthesia plan.
Pre-Op H&P Specifics
Every pre-operative H&P must document the following in addition to standard SOAP: indication for surgery, proposed procedure (spelled out with laterality and approach), ASA physical status, functional status (METs, ability to climb two flights of stairs), cardiac risk assessment (RCRI, prior stents, EF if known), pulmonary status (smoking, home oxygen, recent exacerbations), bleeding and anticoagulation history, last oral intake, and informed consent discussion (risks, benefits, alternatives, all questions answered). A VTE risk assessment (Caprini score) and an SSI risk discussion are now standard at most centers.
Operative Note & Post-Op Note
Scribes often help populate the operative note from the surgeon's dictation. Key elements: pre-op diagnosis, post-op diagnosis, procedure performed, surgeon, assistants, anesthesia type, findings, specimens sent to pathology, estimated blood loss (EBL), IV fluids, urine output, drains placed (location, type, output), counts correct, disposition, and condition on transfer. The brief post-op note (POD #0) documents the immediate post-anesthesia status, vital signs, pain control plan, and any immediate complications.
When the surgeon is seeing a consult in the ED, listen specifically for three things: (1) peritoneal signs (rebound, guarding, rigidity) — these drive operative urgency; (2) hemodynamic stability; and (3) "time of last PO intake." Charting these three data points early makes the OR planning conversation with anesthesia go smoothly.
03 Appendicitis Acute Abdomen
Acute appendicitis is the most common surgical emergency in the United States, with a lifetime risk of approximately 7–8%. It is caused by luminal obstruction of the appendix — typically from a fecalith, lymphoid hyperplasia, or less commonly a tumor or parasite — leading to increased intraluminal pressure, venous congestion, bacterial overgrowth, inflammation, and ultimately gangrene and perforation if untreated.
Clinical Presentation
The classic history is periumbilical pain migrating to the right lower quadrant over 12–24 hours, accompanied by anorexia, nausea, low-grade fever, and mild leukocytosis. The migratory pain reflects the transition from visceral pain (referred to the umbilicus via T10 innervation) to somatic parietal peritoneal pain at McBurney's point (one-third of the way from the anterior superior iliac spine to the umbilicus). Atypical presentations are common in pregnancy, the elderly, and with retrocecal appendices.
McBurney's sign: Tenderness at McBurney's point. Rovsing's sign: RLQ pain with LLQ palpation. Psoas sign: Pain with right hip extension (retrocecal appendix irritating iliopsoas). Obturator sign: Pain with internal rotation of the flexed right hip (pelvic appendix). Dunphy's sign: RLQ pain worsened by coughing.
Workup
Labs typically show leukocytosis (WBC 10–18k) with left shift and sometimes mild CRP elevation. CT abdomen/pelvis with IV contrast is the gold-standard imaging (sensitivity >95%) and will show an enlarged appendix (>6 mm), wall thickening, periappendiceal fat stranding, appendicolith, or an abscess/phlegmon. In pregnant patients and young children, ultrasound is first-line, with MRI as a non-radiation backup. Scoring systems (Alvarado, AIR) exist but CT has largely replaced them at most centers.
Migration of pain to RLQ (1), Anorexia (1), Nausea/vomiting (1), Tenderness RLQ (2), Rebound tenderness (1), Elevated temperature (1), Leukocytosis (2), Shift of WBC to left (1). Total 10 points. Score <4: appendicitis unlikely. 5–6: possible, observe/image. 7–10: probable/definite appendicitis. Used less commonly now that CT is widely available, but still referenced in documentation.
Management
Standard management is laparoscopic appendectomy with peri-operative antibiotics (e.g., ceftriaxone + metronidazole or piperacillin-tazobactam). Uncomplicated appendicitis may be managed non-operatively with antibiotics alone in select patients (CODA trial, NEJM 2020), but recurrence is common and most surgeons still favor surgery. Perforated appendicitis with a walled-off abscess is often managed with percutaneous drainage and IV antibiotics followed by interval appendectomy 6–8 weeks later. Diffuse peritonitis requires urgent exploration.
Always document the time of symptom onset precisely. Perforation risk rises sharply after 36–48 hours of symptoms, and the surgeon and anesthesiologist will use this to prioritize OR timing.
04 Gallbladder & Biliary Disease Hepatobiliary
Biliary disease accounts for a huge share of general surgery volume. The common spectrum runs from asymptomatic cholelithiasis to biliary colic, acute cholecystitis, chronic cholecystitis, choledocholithiasis (stones in the common bile duct), ascending cholangitis, and gallstone pancreatitis.
Biliary Colic vs Acute Cholecystitis
Biliary colic is transient, post-prandial (classically after fatty meals) RUQ or epigastric pain that lasts minutes to a few hours, caused by a stone temporarily obstructing the cystic duct. Acute cholecystitis is sustained RUQ pain, fever, and leukocytosis caused by persistent cystic duct obstruction with gallbladder wall inflammation. A positive Murphy's sign (inspiratory arrest on deep RUQ palpation) is classic. Ultrasound shows gallstones, gallbladder wall thickening (>3–4 mm), pericholecystic fluid, and a sonographic Murphy's sign. HIDA scan confirms cystic duct obstruction when ultrasound is equivocal.
Grade I (Mild): Acute cholecystitis that does not meet the criteria for Grade II or III; no organ dysfunction; mild local inflammation.
Grade II (Moderate): Associated with any one of: WBC >18,000/mm³, palpable tender mass in RUQ, duration >72 hours, or marked local inflammation (gangrenous, emphysematous, pericholecystic abscess, hepatic abscess, biliary peritonitis).
Grade III (Severe): Associated with organ dysfunction in any of cardiovascular (hypotension requiring pressors), neurological (altered mental status), respiratory (PaO2/FiO2 <300), renal (oliguria, Cr >2.0), hepatic (INR >1.5), or hematologic (platelets <100,000). Citation: Tokyo Guidelines 2018 (TG18).
Choledocholithiasis & Cholangitis
Stones that migrate from the gallbladder into the common bile duct cause choledocholithiasis, signaled by a rising direct bilirubin, elevated alkaline phosphatase, and dilation of the CBD on ultrasound (>6 mm, or >8–10 mm post-cholecystectomy). If the stone remains impacted and infection develops, ascending cholangitis follows — classically Charcot's triad (RUQ pain, fever, jaundice) or the more ominous Reynolds' pentad (triad + hypotension + altered mental status). This is a surgical/GI emergency requiring IV antibiotics, fluid resuscitation, and urgent ERCP for biliary decompression.
Suspect cholangitis with (A) systemic inflammation (fever or labs), (B) cholestasis (jaundice or abnormal LFTs), and (C) imaging evidence of biliary dilation or stricture. Severity grading (mild/moderate/severe) parallels cholecystitis. Source: TG18 cholangitis criteria.
Chronic Cholecystitis & Biliary Dyskinesia
Chronic cholecystitis is the result of repeated episodes of biliary colic with gallstones, leading to a thickened, fibrotic gallbladder wall. Symptoms are intermittent rather than acute, and ultrasound shows cholelithiasis with a thickened wall but no acute findings. Biliary dyskinesia is functional gallbladder disease without stones — diagnosed when ultrasound is normal but HIDA scan shows a reduced ejection fraction (<35%) with CCK stimulation and classic symptoms. Both are managed with elective laparoscopic cholecystectomy.
Management
Symptomatic cholelithiasis and acute cholecystitis are managed with laparoscopic cholecystectomy, usually within 72 hours of presentation for acute cholecystitis. Choledocholithiasis is managed with preoperative ERCP + sphincterotomy + stone extraction followed by cholecystectomy, or with intraoperative cholangiogram and CBD exploration. For high-risk patients unfit for surgery, a percutaneous cholecystostomy tube can temporize acute cholecystitis.
05 Pancreatitis & Pancreatic Disease Hepatobiliary
Acute pancreatitis is one of the most common admissions in general surgery. The two leading causes are gallstones (~40%) and alcohol (~30%); the remainder include hypertriglyceridemia, hypercalcemia, medications, ERCP, trauma, and autoimmune pancreatitis. Diagnosis requires two of three: (1) characteristic epigastric pain radiating to the back, (2) lipase or amylase >3x upper limit of normal, or (3) cross-sectional imaging findings.
Mild: No organ failure, no local or systemic complications. Most common; self-limited.
Moderately severe: Transient organ failure (<48 hours) and/or local complications (peripancreatic fluid collection, pseudocyst, walled-off necrosis) and/or exacerbation of comorbidity.
Severe: Persistent organ failure (>48 hours), single or multi-organ. Mortality 30–50%. Citation: Banks PA et al., Revised Atlanta Classification.
Gallstone Pancreatitis
A stone transiently obstructs the ampulla of Vater, causing pancreatic duct obstruction and enzyme activation within the pancreas. After resolution of pancreatitis, the patient must undergo same-admission cholecystectomy to prevent recurrence, per PONCHO trial (Lancet 2015).
Management of acute pancreatitis is largely supportive: aggressive IV fluid resuscitation (lactated Ringer's 5–10 mL/kg/h initially), pain control, antiemetics, early enteral nutrition (within 24–48 hours when tolerated), and treatment of underlying cause. Antibiotics are not routinely indicated for sterile necrosis but are used for infected necrosis and cholangitis. Local complications include acute peripancreatic fluid collections, pancreatic pseudocysts (persisting >4 weeks with a defined wall), acute necrotic collections, and walled-off necrosis. Infected necrosis is managed with a step-up approach (percutaneous drainage, then minimally invasive necrosectomy if needed) rather than open necrosectomy whenever possible.
Chronic Pancreatitis & Pancreatic Cancer
Chronic pancreatitis presents with recurrent abdominal pain, exocrine insufficiency (steatorrhea, weight loss), and endocrine insufficiency (diabetes). Alcohol is the dominant cause. Pancreatic ductal adenocarcinoma is highly lethal and usually presents late with painless jaundice (head of pancreas tumor obstructing the CBD — classic Courvoisier's sign: palpable non-tender gallbladder with jaundice), weight loss, and new-onset diabetes. Workup includes CT pancreas protocol, MRCP, EUS with biopsy, and CA 19-9. Resectable tumors of the pancreatic head are treated with pancreaticoduodenectomy (Whipple procedure); body/tail tumors undergo distal pancreatectomy + splenectomy. NCCN staging and neoadjuvant therapy protocols guide management (NCCN Pancreatic Guidelines).
06 Gastric Disease & Peptic Ulcer Disease Foregut
Peptic ulcer disease (PUD) is mucosal ulceration of the stomach or duodenum caused by H. pylori infection or NSAID use. Most PUD is managed medically (PPI + H. pylori eradication), but general surgery is involved when complications occur: perforation, bleeding, or gastric outlet obstruction.
Sudden severe epigastric pain, rigid "board-like" abdomen, free air under the diaphragm on upright chest X-ray. This is a surgical emergency requiring urgent laparotomy or laparoscopy for Graham patch repair (omental patch over the perforation) and washout, plus treatment of the underlying ulcer with H. pylori eradication and PPI therapy.
Gastric Outlet Obstruction
Chronic duodenal ulcers with scarring, or antral/pyloric gastric cancer, cause obstruction with postprandial vomiting (non-bilious), early satiety, weight loss, and succussion splash on exam. Upper endoscopy is diagnostic; management is gastric decompression, correction of hypochloremic, hypokalemic metabolic alkalosis, and surgical bypass (gastrojejunostomy) or resection as indicated.
Gastric Cancer
Gastric adenocarcinoma is declining in incidence in the US but still common in East Asia. Risk factors include H. pylori, chronic atrophic gastritis, smoking, pickled foods, and family history. Presentation is often late: epigastric pain, weight loss, early satiety, melena, iron-deficiency anemia, or a left supraclavicular (Virchow's) node. Staging requires EGD with biopsy, CT chest/abdomen/pelvis, and endoscopic ultrasound; diagnostic laparoscopy is often done prior to resection to exclude peritoneal disease. Treatment is perioperative chemotherapy + subtotal or total gastrectomy with D1/D2 lymphadenectomy per NCCN Gastric Cancer Guidelines.
07 Foregut: GERD, Hiatal Hernia, Achalasia, Esophageal Cancer Foregut
GERD & Hiatal Hernia
Gastroesophageal reflux disease (GERD) results from lower esophageal sphincter incompetence, often in the setting of a hiatal hernia (herniation of the gastroesophageal junction and/or stomach through the diaphragmatic hiatus). Four types of hiatal hernia: Type I (sliding, most common), Type II (paraesophageal, GEJ remains below diaphragm but fundus herniates alongside), Type III (mixed sliding + paraesophageal), Type IV (additional organs — colon, spleen, small bowel — in the hernia sac). Symptomatic GERD unresponsive to PPIs or paraesophageal hernias with obstruction/volvulus (gastric volvulus) are referred for surgery. Nissen fundoplication (360° wrap) is standard; Toupet (270° posterior) and Dor (180° anterior) are partial wraps used when dysmotility is present. Workup includes EGD, barium swallow, pH monitoring, and manometry. Guidelines via SAGES hiatal hernia guidelines.
Achalasia
Failure of LES relaxation with absent peristalsis, caused by degeneration of inhibitory neurons in the myenteric plexus. Presents with progressive dysphagia to solids and liquids, regurgitation, and weight loss. Manometry is diagnostic ("integrated relaxation pressure" elevated, absent peristalsis). Treatment options: laparoscopic Heller myotomy with Dor fundoplication, per-oral endoscopic myotomy (POEM), or pneumatic dilation.
Esophageal Cancer
Two main histologies: adenocarcinoma (distal esophagus, associated with Barrett's and GERD, rising incidence in the US) and squamous cell carcinoma (mid esophagus, associated with smoking and alcohol). Presents with progressive dysphagia (solids first, then liquids), weight loss, and odynophagia. Workup: EGD + biopsy, EUS for T staging, CT chest/abdomen/pelvis, and PET-CT. Resection is by esophagectomy — transhiatal (Orringer), Ivor-Lewis (right thoracotomy + laparotomy), or McKeown (three-field with cervical anastomosis). Often preceded by neoadjuvant chemoradiation per NCCN Esophageal Cancer Guidelines.
08 Small & Large Bowel Obstruction, Ileus Acute Abdomen
Small Bowel Obstruction (SBO)
The most common cause of SBO in the US is adhesions from prior abdominal surgery, followed by hernias and tumors. Presentation: crampy abdominal pain, bilious or feculent vomiting, abdominal distension, obstipation, and high-pitched "tinkling" bowel sounds early (silent later). CT shows dilated small bowel loops (>3 cm) with a transition point and decompressed distal bowel. Management is NPO, NG tube decompression, IV fluids, and serial exams. Partial SBO often resolves non-operatively; complete or closed-loop obstructions, or any sign of strangulation (fever, tachycardia, peritonitis, leukocytosis, lactate elevation, mesenteric swirl, pneumatosis, portal venous gas), require urgent exploration.
Fever, tachycardia, peritonitis, rising lactate, bandemia, CT findings of bowel wall thickening, pneumatosis intestinalis, mesenteric edema, or portal venous gas. Closed-loop obstructions are at highest risk. Do not wait.
Large Bowel Obstruction (LBO)
LBO is most often caused by colorectal cancer (~60%), followed by sigmoid volvulus, diverticular stricture, and cecal volvulus. Patients present with distension, constipation, and crampy pain. A competent ileocecal valve creates a closed-loop obstruction with cecal dilation that can perforate (the cecum is the widest and thinnest segment — per Laplace's law). CT confirms LBO and usually identifies the cause. Sigmoid volvulus has a classic "coffee bean" sign and is often managed initially with endoscopic detorsion followed by elective sigmoidectomy. Obstructing colon cancers are managed with resection with or without stenting.
Closed-Loop Obstruction
A closed-loop obstruction is a special subtype in which both the proximal and distal ends of a bowel segment are obstructed — most commonly from an internal hernia, volvulus, or adhesive band. Because the trapped segment cannot decompress proximally, pressure rises rapidly, venous outflow obstructs, and the bowel progresses from congestion to ischemia to necrosis within hours. CT may show a U-shaped or C-shaped dilated loop with a radial arrangement of mesenteric vessels ("whirl sign"). This is a surgical emergency.
Ileus
Paralytic ileus is failure of peristalsis without mechanical obstruction, most commonly after abdominal surgery, with opioids, electrolyte disturbances (especially hypokalemia), or sepsis. Bowel sounds are absent. Management: NPO, NG tube if vomiting, correct electrolytes, minimize opioids, encourage ambulation, and time.
09 Mesenteric Ischemia Acute Abdomen
Mesenteric ischemia is rare but deadly — mortality for acute mesenteric ischemia remains 50–80% despite advances in diagnosis and treatment. Acute mesenteric ischemia (AMI) is classically described as "pain out of proportion to exam" — the patient has severe abdominal pain but a soft, non-tender abdomen early in the course because the visceral pain from ischemic bowel has not yet progressed to parietal peritoneal irritation.
Arterial embolism (~50%): Usually lodges in the SMA, often distal to the middle colic artery branch. Source is typically cardiac (atrial fibrillation, mural thrombus from recent MI, valvular disease, endocarditis). Presents with sudden severe pain.
Arterial thrombosis (~25%): Acute thrombosis on pre-existing atherosclerotic disease, usually at the SMA origin. Patients often have a preceding history of chronic mesenteric ischemia symptoms (post-prandial pain, food fear, weight loss).
Mesenteric venous thrombosis (~10%): Subacute presentation (days to weeks) in patients with hypercoagulable states, portal hypertension, or intra-abdominal inflammation.
Non-occlusive mesenteric ischemia (NOMI, ~15%): Low-flow state in critically ill patients (cardiogenic shock, pressors, cardiac surgery, dialysis). Diffuse splanchnic vasoconstriction without a focal occlusion.
Labs show leukocytosis, metabolic acidosis, and elevated lactate — but all three develop late, and normal lactate does not exclude early AMI. CT angiography of the abdomen is the gold standard and shows the occlusion or hypoperfusion plus secondary findings (bowel wall thickening, pneumatosis, portal venous gas, mesenteric edema). Management requires emergent laparotomy for bowel assessment with revascularization (endovascular thrombectomy/stenting, open embolectomy, or SMA bypass), resection of frankly necrotic segments, and a planned second-look operation 24–48 hours later to re-assess bowel viability. Chronic mesenteric ischemia presents with post-prandial abdominal pain ("intestinal angina"), food fear, and weight loss — usually from multi-vessel atherosclerotic disease involving at least two of the three mesenteric vessels (celiac, SMA, IMA). Treatment is endovascular stenting or open bypass.
10 Colorectal Disease & Colon Cancer Colorectal
Colorectal cancer (CRC) is the third most common cancer and second-leading cause of cancer death in the US. Most CRCs arise from adenomatous polyps via the classic adenoma-carcinoma sequence (APC → KRAS → p53). Screening is recommended starting at age 45 per USPSTF 2021 colorectal screening guidelines.
Presentation
Right-sided tumors present with occult bleeding, iron-deficiency anemia, and weight loss (stool is liquid and lumen wide — obstruction uncommon). Left-sided tumors present with change in bowel habits, crampy pain, and obstruction (stool is formed, lumen narrower). Rectal tumors present with hematochezia, tenesmus, narrowed caliber stool, and pelvic pain.
Workup & Staging
Colonoscopy with biopsy, CT chest/abdomen/pelvis, CEA level, and for rectal cancers a pelvic MRI and/or endorectal ultrasound. Staging is TNM. Management depends on stage and location per NCCN Colon Cancer Guidelines.
Cecum/ascending: Right hemicolectomy (ileocolic, right colic, right branch of middle colic).
Transverse: Extended right hemicolectomy or transverse colectomy.
Descending: Left hemicolectomy.
Sigmoid: Sigmoidectomy.
Upper/mid rectum: Low anterior resection (LAR) with total mesorectal excision (TME) and colorectal or coloanal anastomosis.
Low rectum (within 1–2 cm of anal sphincters): Abdominoperineal resection (APR) with permanent end colostomy.
Stage III colon cancer (node-positive) receives adjuvant chemotherapy (FOLFOX or CAPOX). Rectal cancer (stage II/III) often receives total neoadjuvant therapy (TNT) with chemoradiation plus chemotherapy before surgery.
11 Diverticulitis & Colonic Perforation Colorectal
Colonic diverticula are acquired outpouchings of mucosa and submucosa through weaknesses in the colonic wall, most commonly in the sigmoid colon. Diverticulitis is inflammation of a diverticulum, often from microperforation. Patients present with LLQ pain, fever, leukocytosis, and sometimes a palpable mass. CT is diagnostic and grades severity.
Stage I: Pericolic or mesenteric abscess (contained).
Stage II: Walled-off pelvic, intra-abdominal, or retroperitoneal abscess.
Stage III: Generalized purulent peritonitis (ruptured abscess, not communicating with bowel lumen).
Stage IV: Generalized fecal peritonitis (free perforation of colon).
Complications of chronic or recurrent diverticulitis include colovesical fistula (pneumaturia, fecaluria, recurrent UTIs — more common in men because the uterus provides a buffer in women), colovaginal fistula, coloenteric fistula, and strictures causing obstruction. Each of these is a firm indication for elective resection. Diverticular bleeding is usually painless, brisk, and self-limited but can be massive and is a common cause of LGIB.
Uncomplicated diverticulitis (Hinchey I or mild) is often managed with antibiotics as an outpatient or with brief admission. Abscesses >3–4 cm are drained percutaneously. Hinchey III/IV are surgical emergencies requiring laparoscopic lavage, Hartmann's procedure (sigmoidectomy + end colostomy + rectal stump), or primary anastomosis with diverting loop ileostomy. Elective sigmoidectomy is considered for recurrent attacks, complications (fistula, stricture), or immunocompromised patients. See ASCRS diverticulitis practice parameters.
12 Anorectal Disease Colorectal
Anorectal complaints are extremely common in general surgery clinic. The dentate (pectinate) line is the key anatomic landmark separating endoderm-derived (internal, insensate, portal venous drainage) from ectoderm-derived (external, richly innervated somatically, systemic venous drainage) tissue. This distinction explains why internal hemorrhoids bleed painlessly while external hemorrhoids are exquisitely painful when thrombosed.
Hemorrhoids: Engorged anal cushions. Internal (above dentate line, painless bleeding) graded I–IV: I = bleeding only, II = prolapse with spontaneous reduction, III = prolapse requiring manual reduction, IV = irreducible. External (below dentate line, painful if thrombosed). Management: fiber, sitz baths, topical therapies, banding for grade I–III internal, excisional hemorrhoidectomy for grade IV or thrombosed external.
Anal fissure: Linear tear in the anoderm, typically posterior midline, causing severe pain with defecation and bright red blood. First-line: sitz baths, fiber, topical nitroglycerin or diltiazem. Refractory: lateral internal sphincterotomy or botulinum toxin injection.
Perianal abscess: Infection of anal glands (cryptoglandular). Painful, fluctuant mass. Treatment: incision and drainage. Antibiotics are adjunctive only if cellulitis, immunocompromise, or systemic illness.
Anal fistula (fistula-in-ano): Chronic epithelialized tract from an anal crypt to perianal skin, often following an abscess. Classified by Parks (intersphincteric, transsphincteric, suprasphincteric, extrasphincteric). Treatment: fistulotomy for simple, LIFT or advancement flap for complex.
Pilonidal disease: Midline sacrococcygeal sinus with hair and debris. I&D for acute abscess; excision with primary closure or flap for chronic/recurrent disease.
13 Inflammatory Bowel Disease (Surgical) Colorectal
Crohn's disease (transmural, "skip lesions," any segment from mouth to anus, strictures and fistulas) and ulcerative colitis (mucosal, continuous from rectum proximally, limited to colon) both have surgical indications. Approximately 50–70% of Crohn's patients will ultimately require surgery, and roughly 20–30% of UC patients undergo colectomy during their disease course.
Crohn's Disease Surgery
Crohn's is not curable by surgery, and the principle of bowel preservation is paramount because of the long-term risk of short-bowel syndrome from repeated resections. Indications include: (1) strictures with obstructive symptoms, treated with limited resection or stricturoplasty (Heineke-Mikulicz, Finney, or Michelassi depending on length); (2) enteric fistulas (enterocutaneous, enteroenteric, enterovesical, enterovaginal); (3) intra-abdominal abscess, usually drained percutaneously first; (4) perforation with peritonitis; (5) hemorrhage not controlled endoscopically; and (6) medically refractory disease or dysplasia. The ileocecal region is the most common site of disease and ileocecectomy the most common operation.
Ulcerative Colitis Surgery
Because UC is limited to the colon, surgery is curative. Indications include medically refractory disease, steroid dependence, dysplasia or cancer, growth failure in children, and severe complications (toxic megacolon, perforation, massive hemorrhage). The gold-standard elective operation is the three-stage (or two-stage) total proctocolectomy with ileal pouch–anal anastomosis (IPAA / J-pouch), which preserves continence and avoids a permanent ostomy. Stage 1: total abdominal colectomy with end ileostomy (often the emergency operation). Stage 2: completion proctectomy with J-pouch creation and diverting loop ileostomy. Stage 3: ileostomy reversal 8–12 weeks later. Toxic megacolon (colonic dilation >6 cm with systemic toxicity) and fulminant colitis failing medical therapy require emergent total abdominal colectomy with end ileostomy, leaving the rectal stump for future reconstruction.
14 GI Bleeding (Surgical Management) Acute Abdomen
Most GI bleeding is managed medically and endoscopically, but general surgeons are consulted on every major bleed and are the backstop when less-invasive measures fail. The scribe's job is to capture the resuscitation timeline, transfusion counts, hemodynamic trends, and a running list of prior interventions.
Upper GI Bleeding (UGIB)
Defined as bleeding proximal to the ligament of Treitz. Presents with hematemesis (bright red or coffee-ground), melena (black tarry stools from digested blood), or occasionally hematochezia if the bleed is massive. Causes: peptic ulcer disease (most common), esophagogastric varices (portal hypertension), Mallory-Weiss tears, Dieulafoy lesion, gastric cancer, aortoenteric fistula (in patients with prior aortic graft), and erosive gastritis. Management follows a predictable sequence: (1) resuscitation with two large-bore IVs, crystalloid then blood products with massive transfusion protocol if needed; (2) PPI infusion (pantoprazole 80 mg bolus then 8 mg/h drip); (3) octreotide for suspected variceal bleeding; (4) urgent EGD for diagnosis and endoscopic hemostasis (clips, injection, thermal coagulation, banding for varices); (5) IR angiography with embolization if endoscopy fails; and (6) surgery (oversewing a bleeding vessel, Graham patch, partial gastrectomy) as the final backstop.
Lower GI Bleeding (LGIB)
Defined as bleeding distal to the ligament of Treitz. Usually presents as hematochezia (bright red blood per rectum) but a brisk UGIB can also present this way — NG lavage is sometimes used to exclude an upper source. Causes: diverticulosis (most common in adults; classically painless), angiodysplasia, hemorrhoids, colorectal cancer/polyps, ischemic colitis, inflammatory bowel disease, and post-polypectomy bleeding. Workup: stabilization, colonoscopy (therapeutic if source identified), CT angiography (requires active bleeding >0.3–0.5 mL/min) or tagged RBC scan for intermittent bleeding, and IR embolization. Surgery (segmental colectomy when the source is localized, or subtotal colectomy when it is not) is reserved for massive ongoing bleeding that cannot be controlled by endoscopy or IR, or when >6 units of blood are required.
15 Hernias — Inguinal, Femoral, Ventral, Incisional, Umbilical Abdominal Wall
Hernias are one of the highest-volume diagnoses in any general surgery clinic. A hernia is the protrusion of abdominal contents through a defect in the abdominal wall. Hernias may be reducible, incarcerated (non-reducible but not ischemic), or strangulated (incarcerated with vascular compromise — surgical emergency).
Indirect inguinal: Through the internal ring, lateral to inferior epigastrics, often congenital (patent processus vaginalis). Most common hernia overall.
Direct inguinal: Through Hesselbach's triangle (medial to inferior epigastrics), acquired, from abdominal wall weakness.
Femoral: Through the femoral canal, medial to the femoral vein. More common in women; higher incarceration risk — always repair.
Umbilical: Through the umbilical ring. Congenital in infants (most close spontaneously) or acquired in adults (obesity, multiparity, ascites).
Ventral/epigastric: Through the linea alba above the umbilicus.
Incisional: At the site of a prior surgical incision; classified by size and location (European Hernia Society).
Spigelian: Along the semilunar line at the lateral border of rectus; rare but high incarceration risk.
An incarcerated hernia is one that cannot be reduced into the abdominal cavity but is not ischemic — urgent repair is indicated but not an immediate emergency. A strangulated hernia is incarcerated AND ischemic (bowel or omentum) and is a true surgical emergency requiring immediate operation to prevent necrosis and perforation. Signs of strangulation include severe pain, fever, tachycardia, leukocytosis, skin changes over the hernia, and peritonitis.
Repair Approaches
Repair can be open (Lichtenstein tension-free mesh repair for inguinal; open mesh repair for ventral), laparoscopic (TAPP — transabdominal preperitoneal, or TEP — totally extraperitoneal for inguinal; IPOM — intraperitoneal onlay mesh for ventral), or robotic. Component separation (anterior or transversus abdominis release, TAR) is used for large ventral hernias requiring fascial reapproximation. Mesh choice (synthetic vs biologic, position) is guided by the contamination field and patient factors per HerniaSurge International Guidelines and SAGES ventral hernia guidelines.
Always document whether a hernia is reducible, what the size of the defect is (in cm, not "small/medium/large"), and whether there are any signs of incarceration (non-reducible, painful, skin changes) or strangulation (fever, tachycardia, skin discoloration, peritonitis). These details drive the urgency of the plan.
16 Breast Disease Breast/Endocrine
Breast disease is a major pillar of general surgery practice in most communities, accounting for a significant share of clinic volume. A scribe must be comfortable charting the full workup of a palpable mass, an imaging abnormality, and a new cancer diagnosis.
Benign Breast Disease
Common benign entities include fibrocystic changes, fibroadenomas (young women, firm, mobile, well-circumscribed), simple cysts (fluctuant, reproducible on ultrasound), intraductal papillomas (unilateral bloody nipple discharge), and mastitis/breast abscess (lactational or non-lactational). Workup of a palpable mass: ultrasound if <30, mammogram + ultrasound if ≥30; BI-RADS categorization drives biopsy decisions.
Breast Cancer
Breast cancer is the most common cancer in women and a leading cause of cancer death. Histologic types: invasive ductal carcinoma (IDC, most common), invasive lobular carcinoma (ILC), and in situ disease (DCIS, LCIS). Molecular subtyping drives treatment: ER/PR, HER2, and Ki-67. Screening mammography is recommended starting at age 40 per USPSTF 2024 breast cancer screening guidelines.
Breast-conserving surgery (lumpectomy): Wide local excision with negative margins + whole-breast radiation. Equivalent survival to mastectomy for early-stage disease.
Mastectomy: Simple (total) mastectomy, modified radical mastectomy (with axillary dissection), skin-sparing, or nipple-sparing. Often combined with immediate reconstruction.
Axillary staging: Sentinel lymph node biopsy (SLNB) for clinically node-negative disease; axillary lymph node dissection (ALND) for clinically positive nodes or heavy SLN burden.
Neoadjuvant chemotherapy is used for large tumors, triple-negative, HER2+, or to downstage for breast conservation. Adjuvant endocrine therapy (tamoxifen, aromatase inhibitors) for 5–10 years in ER+ disease. See NCCN Breast Cancer Guidelines.
17 Endocrine Surgery — Thyroid, Parathyroid, Adrenal Breast/Endocrine
Endocrine surgery is a distinct subspecialty within general surgery at most centers, but every general surgery scribe will chart thyroid, parathyroid, and adrenal cases.
Thyroid
Thyroid nodules are common; most are benign. Workup: TSH, neck ultrasound (TI-RADS scoring), and FNA biopsy of suspicious nodules (Bethesda classification I–VI). Thyroid cancers: papillary (most common, indolent, lymphatic spread), follicular (hematogenous), medullary (from C-cells, calcitonin, MEN2), and anaplastic (aggressive, elderly). Goiter (diffuse or multinodular) may require thyroidectomy for compressive symptoms, substernal extension, or concern for malignancy. Procedures: lobectomy vs total thyroidectomy +/- central or lateral neck dissection. Key post-op risks: recurrent laryngeal nerve injury (hoarseness), hypocalcemia (parathyroid injury), hematoma (airway emergency).
Parathyroid
Primary hyperparathyroidism (elevated calcium and PTH, usually from a single parathyroid adenoma) is the leading indication for parathyroidectomy. Localization with sestamibi scan, neck ultrasound, or 4D-CT. Minimally invasive parathyroidectomy with intraoperative PTH monitoring is standard. Secondary and tertiary hyperparathyroidism (renal failure) may require subtotal or total parathyroidectomy with autotransplantation.
Adrenal
Adrenal masses are often incidentalomas. Workup assesses for functional status (cortisol, aldosterone/renin, metanephrines) and malignancy risk (size, imaging characteristics — noncontrast Hounsfield units, washout). Functional tumors: pheochromocytoma (catecholamine-secreting, requires alpha-blockade before surgery), primary hyperaldosteronism (Conn's), Cushing's syndrome. Indications for adrenalectomy: functional tumors, suspicious imaging (>4 cm), or growth on surveillance. Laparoscopic or robotic adrenalectomy is standard.
18 Skin, Soft Tissue, Spleen & Trauma Soft Tissue/Trauma
Soft Tissue Infections
Cellulitis is managed medically. Abscesses require incision and drainage. Necrotizing soft tissue infection (NSTI, "necrotizing fasciitis") is a surgical emergency — rapid progression, pain out of proportion, skin discoloration, crepitus, bullae, systemic toxicity. LRINEC score suggests the diagnosis but is imperfect. Management is immediate aggressive surgical debridement, broad-spectrum antibiotics, and ICU-level supportive care. Fournier's gangrene is the perineal/genital variant.
Six lab values are summed: CRP ≥150 (4 pts), WBC >15 (1 pt) or >25 (2 pts), hemoglobin <13.5 (1 pt) or <11 (2 pts), sodium <135 (2 pts), creatinine >1.6 (2 pts), glucose >180 (1 pt). Score ≥6 is suggestive and ≥8 is highly suggestive of NSTI, but the gold standard remains surgical exploration — a normal LRINEC should not delay the OR if clinical suspicion is high. "Gray, dishwater-colored" fluid and easy digital dissection of fascial planes at exploration confirm the diagnosis.
Soft Tissue Masses & Melanoma
Lipomas, epidermal inclusion cysts, and abscesses make up most soft tissue masses. Concerning features (size >5 cm, deep, firm, growing, painful) warrant imaging (MRI) and biopsy to rule out soft tissue sarcoma. Sarcomas are managed at specialized centers with wide local excision +/- radiation. Melanoma is staged by Breslow depth and ulceration; management includes wide local excision (margins based on Breslow) and sentinel lymph node biopsy for lesions >0.8 mm or with high-risk features.
Splenectomy Indications
Traumatic splenic rupture, immune thrombocytopenic purpura (ITP) refractory to medical therapy, hereditary spherocytosis, splenic abscess/cyst, and some hematologic malignancies. Post-splenectomy patients require vaccination against encapsulated organisms (pneumococcus, meningococcus, H. influenzae) due to overwhelming post-splenectomy infection (OPSI) risk.
Trauma & Abdominal Compartment Syndrome
General surgeons staff trauma services at many centers. The ATLS primary survey (Airway, Breathing, Circulation, Disability, Exposure) guides initial resuscitation. FAST ultrasound screens for intra-abdominal fluid. Unstable blunt abdominal trauma with positive FAST → exploratory laparotomy. Penetrating abdominal injury with peritonitis, hypotension, or evisceration → laparotomy. Damage-control surgery with temporary abdominal closure may be used. Abdominal compartment syndrome is sustained intra-abdominal pressure >20 mm Hg with new organ dysfunction — treated with decompressive laparotomy.
Grade I: Subcapsular hematoma <10% surface area; capsular tear <1 cm depth.
Grade II: Subcapsular hematoma 10–50%; intraparenchymal hematoma <5 cm; laceration 1–3 cm, not involving trabecular vessel.
Grade III: Subcapsular hematoma >50% or expanding; ruptured subcapsular/parenchymal hematoma; intraparenchymal hematoma ≥5 cm; laceration >3 cm or involving trabecular vessel.
Grade IV: Laceration involving segmental or hilar vessels with devascularization >25%.
Grade V: Shattered spleen; hilar vascular injury with complete devascularization. Similar AAST scales exist for liver, kidney, pancreas, and other organs.
19 General Surgery Procedures — A to Z
This is the reference list of procedures you will hear named repeatedly. Each is performed open, laparoscopically, or robotically depending on the indication, patient factors, and surgeon preference.
| Procedure | Indication | Key Notes |
|---|---|---|
| Laparoscopic appendectomy | Acute appendicitis | Three-port technique; staple base; peri-op ABX |
| Laparoscopic cholecystectomy | Symptomatic cholelithiasis, cholecystitis | Critical view of safety; IOC if indicated |
| Open cholecystectomy | Severe inflammation, anatomy unclear | Conversion rate ~5% in acute cholecystitis |
| Cholecystostomy tube | High-risk patients with acute cholecystitis | Percutaneous IR drainage |
| Inguinal hernia repair (open Lichtenstein) | Inguinal hernia | Tension-free mesh |
| Laparoscopic inguinal hernia repair (TAPP, TEP) | Inguinal hernia, bilateral or recurrent | Preperitoneal mesh placement |
| Robotic hernia repair (TAPP, eTEP, rTAR) | Complex or recurrent hernias | Improved visualization and ergonomics |
| Umbilical/ventral hernia repair | Ventral wall hernia | Primary, mesh, or component separation |
| Component separation (TAR) | Large ventral hernia | Transversus abdominis release |
| Right hemicolectomy | Right-sided colon cancer, Crohn's | Ligate ileocolic, right colic, right branch middle colic |
| Left hemicolectomy | Descending colon lesions | Ligate left colic/IMA branch |
| Sigmoidectomy | Diverticulitis, sigmoid cancer, volvulus | Primary anastomosis vs Hartmann's |
| Low anterior resection (LAR) | Upper/mid rectal cancer | TME; often with diverting loop ileostomy |
| Abdominoperineal resection (APR) | Low rectal cancer | Permanent end colostomy |
| Total abdominal colectomy | UC, fulminant colitis, FAP | End ileostomy or IPAA |
| Small bowel resection | SBO, tumor, Crohn's, ischemia | Primary anastomosis usually feasible |
| Graham patch | Perforated duodenal ulcer | Omental patch over perforation |
| Gastrectomy (subtotal/total) | Gastric cancer, ulcer disease | D1/D2 lymphadenectomy; Roux-en-Y reconstruction |
| Esophagectomy (Ivor-Lewis, transhiatal, McKeown) | Esophageal cancer | High morbidity; specialized centers |
| Heller myotomy + Dor | Achalasia | Laparoscopic myotomy of LES |
| Nissen fundoplication | Refractory GERD, paraesophageal hernia | 360° wrap; Toupet/Dor for dysmotility |
| Whipple (pancreaticoduodenectomy) | Pancreatic head cancer, duodenal/ampullary tumors | Complex; multi-anastomosis |
| Distal pancreatectomy +/- splenectomy | Pancreatic body/tail lesions | Lap or robotic increasingly common |
| Splenectomy | Trauma, ITP, hematologic disease | Post-splenectomy vaccinations required |
| Adrenalectomy | Functional or suspicious adrenal mass | Laparoscopic/robotic standard |
| Thyroidectomy (lobectomy vs total) | Nodule, goiter, cancer | Watch RLN, parathyroids, hematoma |
| Parathyroidectomy | Primary hyperparathyroidism | Intraop PTH monitoring |
| Lumpectomy +/- SLNB | Early breast cancer | Adjuvant radiation required |
| Mastectomy (simple, MRM, skin/nipple-sparing) | Breast cancer | +/- immediate reconstruction |
| Sentinel lymph node biopsy | Clinically node-negative breast cancer, melanoma | Blue dye + radiotracer |
| Axillary lymph node dissection | Node-positive breast cancer | Risk of lymphedema |
| Exploratory laparotomy | Peritonitis, trauma, unclear dx | Midline incision, systematic exploration |
| Diagnostic laparoscopy | Staging, unclear abdominal pathology | Minimally invasive exploration |
| Loop ileostomy / colostomy creation | Diverting proximal to anastomosis | Usually reversed in 3–6 months |
| Ostomy closure/reversal | Planned reversal after healing | Check anastomosis with contrast study |
| Hemorrhoidectomy | Grade III/IV hemorrhoids | Ferguson (closed) vs Milligan-Morgan (open) |
| I&D perianal abscess | Perianal/perirectal abscess | Bedside or OR depending on complexity |
| Fistulotomy / LIFT / advancement flap | Anal fistula | Technique depends on tract anatomy |
NSQIP (the ACS National Surgical Quality Improvement Program) tracks outcomes across these procedures and generates patient-specific risk estimates used in shared decision-making and pre-op documentation. See ACS NSQIP risk calculator methodology.
20 Imaging, Labs & Diagnostics
Surgical decision-making is driven by imaging and lab data. A scribe who understands what each study shows and when it is ordered will anticipate the surgeon's next move and chart faster.
Imaging Modalities
CT abdomen/pelvis with IV contrast: Workhorse for acute abdomen. Diagnoses appendicitis, diverticulitis, SBO/LBO, mesenteric ischemia, abscess, perforation, and most tumors.
Right upper quadrant ultrasound: First-line for biliary disease — identifies stones, wall thickening, pericholecystic fluid, CBD dilation.
HIDA scan: Confirms cystic duct obstruction (non-filling gallbladder) in equivocal acute cholecystitis.
MRCP: Non-invasive imaging of the biliary and pancreatic ducts.
ERCP: Therapeutic — stone extraction, stent placement, sphincterotomy.
CT chest: Staging of GI and breast malignancies; PE evaluation.
PET-CT: Staging esophageal, colon, and some other cancers.
Mammography + breast ultrasound: Breast workup; BI-RADS categorization.
Upper GI series / barium enema: Anatomic and functional studies for GERD, hernia, motility.
FAST exam: Bedside trauma ultrasound — pericardial, Morison's, splenorenal, pelvic views.
Labs
Every general surgery patient needs: CBC (WBC for infection/inflammation, hemoglobin for bleeding, platelets), CMP (electrolytes, creatinine, glucose, liver enzymes, albumin, bilirubin), lipase (pancreatitis), lactate (ischemia/sepsis), coagulation studies (INR, PTT), and type and screen pre-operatively. Tumor markers: CEA (colon), CA 19-9 (pancreatic/biliary), CA 125 (ovarian), AFP (HCC).
21 Medications & ERAS Protocols
Timing: within 60 minutes of incision (120 min for vancomycin/fluoroquinolones). Per IDSA/SHEA surgical antimicrobial prophylaxis guidelines and CDC SSI prevention guidelines.
Clean (hernia, breast): Cefazolin 2 g (3 g if >120 kg).
Clean-contaminated GI: Cefazolin + metronidazole, cefoxitin, or ampicillin-sulbactam.
Colorectal: Oral neomycin + metronidazole or erythromycin day before, plus IV cefazolin + metronidazole or ertapenem.
Penicillin allergy: Vancomycin + gentamicin +/- metronidazole or clindamycin + gentamicin.
ERAS (Enhanced Recovery After Surgery) pathways emphasize opioid-sparing multimodal analgesia:
Scheduled acetaminophen 1 g IV/PO q6h (max 3–4 g/day).
NSAIDs (ketorolac 15–30 mg IV q6h, max 5 days; ibuprofen PO) — avoid in renal impairment, bleeding risk, anastomotic concerns.
Gabapentinoids (gabapentin, pregabalin) pre-op for selected cases.
Regional/neuraxial anesthesia: TAP blocks, epidural for open cases, paravertebral for breast.
Opioids for breakthrough: Oxycodone 5–10 mg PO q4h PRN, morphine/hydromorphone IV PCA when NPO. Wean aggressively.
Mechanical (sequential compression devices) + chemical (subcutaneous heparin 5000 units q8–12h or enoxaparin 40 mg daily, renal-adjusted). Higher doses for cancer patients or high Caprini score. Extended 28-day prophylaxis post-discharge for major abdominal/pelvic cancer surgery per ASCO and CHEST VTE guidelines.
Antiemetics: Ondansetron 4 mg IV, dexamethasone 4–8 mg IV, scopolamine patch, prochlorperazine, metoclopramide.
IV fluids: Balanced crystalloids (LR, Plasma-Lyte) preferred over normal saline for resuscitation; maintenance with D5 1/2 NS + KCl.
Electrolyte replacement: K+ (10 mEq IV raises ~0.1), Mg++ (2 g IV), phosphorus, calcium (especially post-thyroidectomy).
Bowel prep (colorectal): Mechanical (PEG, magnesium citrate) + oral antibiotics (neomycin + metronidazole or erythromycin) the day before.
PPIs: Pantoprazole 40 mg IV/PO daily; continuous drip 8 mg/h after bolus for high-risk upper GI bleeding.
Octreotide: Variceal bleeding, pancreatic fistula.
Pre-op and peri-op bleeding management requires knowing the reversal strategy for each common anticoagulant: warfarin (vitamin K, FFP, 4F-PCC), dabigatran (idarucizumab), apixaban/rivaroxaban (andexanet alfa or 4F-PCC), heparin (protamine), and antiplatelets (platelet transfusion in emergencies). Timing of when to hold and restart these medications is a frequent topic of clinic discussion.
The ERAS Society colorectal guidelines bundle pre-op carbohydrate loading, avoidance of prolonged fasting, goal-directed fluids, multimodal analgesia, early feeding, and early mobilization — dramatically reducing length of stay and complications.
22 Classification Systems
ASA I: Normal healthy patient.
ASA II: Mild systemic disease (controlled HTN, DM, obesity BMI 30–40, smoker, social drinker).
ASA III: Severe systemic disease with functional limitation (poorly controlled DM/HTN, COPD, BMI >40, active hepatitis, pacemaker, stable CAD).
ASA IV: Severe systemic disease that is a constant threat to life (recent MI/stroke <3 mo, ongoing ischemia, severe valve dysfunction, EF <40, sepsis, DIC, ARDS, ESRD not on scheduled dialysis).
ASA V: Moribund patient not expected to survive without the operation (ruptured AAA, massive trauma, intracranial bleed with mass effect, ischemic bowel with multi-organ dysfunction).
ASA VI: Declared brain-dead patient undergoing organ procurement. The suffix "E" is added for emergency surgery.
Grade I: Any deviation from normal post-op course without need for pharmacologic, surgical, endoscopic, or radiologic intervention (allowed: antiemetics, antipyretics, analgesics, diuretics, electrolytes, bedside wound opening).
Grade II: Requires pharmacologic treatment beyond Grade I, including blood transfusion and total parenteral nutrition.
Grade IIIa: Requires surgical, endoscopic, or radiologic intervention not under general anesthesia.
Grade IIIb: Requires intervention under general anesthesia.
Grade IVa: Life-threatening complication (including CNS) with single-organ dysfunction requiring ICU.
Grade IVb: Life-threatening complication with multi-organ dysfunction.
Grade V: Death of the patient. Citation: Dindo D, Demartines N, Clavien PA, Ann Surg 2004.
Points are assigned for age, BMI, cancer, prior VTE, surgery type, immobility, and many other factors. Low risk (0–1): early ambulation. Moderate (2): mechanical prophylaxis. High (3–4): mechanical + chemical prophylaxis. Highest (≥5): mechanical + chemical + consider extended-duration post-discharge. The Caprini score is the standard VTE assessment cited in most ERAS pathways and pre-op documentation.
In addition, this guide has already enumerated the Tokyo Guidelines for cholecystitis and cholangitis (Section 4), the Revised Atlanta Classification for pancreatitis severity (Section 5), the Hinchey Classification for diverticulitis (Section 11), and the AAST Organ Injury Scale (Section 18). Other routinely referenced systems include TNM staging for solid tumors, BI-RADS for breast imaging, Bethesda for thyroid cytology, and the Parks classification for anal fistulas.
23 Abbreviations, Physical Exam & Sample HPIs
Physical Exam Template
General: A&O x3, NAD vs in distress
CV: RRR, no m/r/g
Resp: CTA bilaterally, no respiratory distress
Abdomen: Inspection (scars, distension, visible hernia, ecchymosis); Auscultation (BS present/absent/high-pitched); Palpation (soft/rigid, tender/non-tender, localization, rebound, guarding, masses, hernia reducibility, hepatosplenomegaly); Percussion (tympany, dullness)
Special maneuvers: Murphy, McBurney, Rovsing, psoas, obturator, Carnett (as indicated)
Rectal: Tone, masses, tenderness, stool appearance (gross, heme-positive)
Wound (if present): Incision clean/dry/intact, no erythema/drainage/dehiscence, staples/sutures in place
Extremities: No edema, pulses intact, no calf tenderness
Abbreviations Master List
RUQ / LUQ / RLQ / LLQ — abdominal quadrants • GB — gallbladder • CBD — common bile duct • CHD — common hepatic duct • PD — pancreatic duct • SMA — superior mesenteric artery • IMA — inferior mesenteric artery • IVC — inferior vena cava • GEJ — gastroesophageal junction • LES — lower esophageal sphincter • SBO/LBO — small/large bowel obstruction • PUD — peptic ulcer disease • GERD — gastroesophageal reflux disease • IBD — inflammatory bowel disease • UC — ulcerative colitis • CD — Crohn's disease • CRC — colorectal cancer • DCIS/LCIS — ductal/lobular carcinoma in situ • IDC/ILC — invasive ductal/lobular carcinoma • HPT — hyperparathyroidism • NSTI — necrotizing soft tissue infection • ACS — abdominal compartment syndrome
Lap — laparoscopic • Lap chole — laparoscopic cholecystectomy • Lap appy — laparoscopic appendectomy • IOC — intraoperative cholangiogram • ERCP — endoscopic retrograde cholangiopancreatography • MRCP — magnetic resonance cholangiopancreatography • EGD — esophagogastroduodenoscopy • EUS — endoscopic ultrasound • LAR — low anterior resection • APR — abdominoperineal resection • TME — total mesorectal excision • IPAA — ileal pouch-anal anastomosis • TAPP/TEP — transabdominal preperitoneal / totally extraperitoneal • TAR — transversus abdominis release • SLNB — sentinel lymph node biopsy • ALND — axillary lymph node dissection • MRM — modified radical mastectomy • Ex-lap — exploratory laparotomy • Dx lap — diagnostic laparoscopy
NPO — nothing by mouth • NGT — nasogastric tube • JP — Jackson-Pratt drain • PPI — proton pump inhibitor • ABX — antibiotics • VTE — venous thromboembolism • DVT/PE — deep vein thrombosis / pulmonary embolism • SCDs — sequential compression devices • SSI — surgical site infection • CEA — carcinoembryonic antigen • CA 19-9 — pancreatic/biliary tumor marker • A&P — assessment and plan • POD # — post-op day number • s/p — status post • H&P — history and physical • ASA — American Society of Anesthesiologists • NSQIP — National Surgical Quality Improvement Program • ERAS — Enhanced Recovery After Surgery • TPN — total parenteral nutrition • D/C — discharge / discontinue
Sample HPIs
"Mr. [Name] is a 24-year-old previously healthy male who presents to the ED with 18 hours of progressive abdominal pain. Pain began as a vague periumbilical ache yesterday afternoon, became sharper and migrated to the right lower quadrant overnight, and is now 8/10, constant, worsened by movement and coughing. He has associated anorexia, nausea, and one episode of non-bloody non-bilious emesis. He denies diarrhea, dysuria, hematuria, or recent travel. Last oral intake was 6 hours ago. He has no prior abdominal surgeries. On exam, T 38.2°C, HR 108, BP 124/76. Abdomen with focal RLQ tenderness at McBurney's point with voluntary guarding; positive Rovsing's sign. Labs: WBC 14.8 with 86% neutrophils. CT abdomen/pelvis with IV contrast demonstrates a dilated (10 mm) appendix with periappendiceal fat stranding and a small fluid collection, consistent with acute appendicitis without frank perforation."
"Mrs. [Name] is a 52-year-old female with a history of obesity (BMI 34), type 2 diabetes, and prior episodes of biliary colic who presents with 2 days of persistent right upper quadrant pain radiating to the right scapula. The pain began after a fatty dinner and has not resolved despite rest, in contrast to her prior transient episodes. She has associated nausea, three episodes of non-bilious emesis, and subjective fevers. She denies jaundice, dark urine, or acholic stools. Exam: T 38.6°C, HR 102. Focal RUQ tenderness with a positive Murphy's sign. Labs: WBC 15.2, ALT 42, AST 38, total bilirubin 1.1, alk phos 128, lipase normal. RUQ ultrasound shows cholelithiasis with gallbladder wall thickening of 5 mm, pericholecystic fluid, and a sonographic Murphy's sign. CBD measures 4 mm, non-dilated. Findings consistent with acute cholecystitis, Tokyo Guidelines Grade II."
"Mr. [Name] is a 58-year-old male with a 6-month history of a right groin bulge that appears with straining and resolves when he lies down, referred by his PCP. The bulge is associated with mild dragging discomfort, worse at the end of the day and with heavy lifting at his construction job. He denies any episode of non-reducibility, severe pain, skin changes, nausea, or obstipation. No prior hernia repairs. PMHx notable for hypertension and 15-pack-year former smoker (quit 5 years ago). On exam, an easily reducible right inguinal hernia is palpable with Valsalva; the defect is approximately 2 cm and the hernia descends into the scrotum, consistent with indirect inguinal hernia. Left side is normal. We discussed observation versus elective repair, and the patient elected to proceed with laparoscopic TEP repair with mesh."
"Ms. [Name] is a 46-year-old premenopausal female (G2P2, last menstrual period 2 weeks ago) who presents for evaluation of a left breast lump she noticed on self-exam 3 weeks ago. She describes a firm, non-mobile mass in the upper outer quadrant, approximately 1.5 cm, non-tender, not associated with skin or nipple changes. No nipple discharge, no prior breast biopsies. Last screening mammogram was 14 months ago, reported as BI-RADS 1. Family history significant for mother diagnosed with breast cancer at age 61 (ER+). No BRCA testing previously. On exam, a firm, irregular 1.5 cm mass is palpable in the left upper outer quadrant, with no skin dimpling or nipple retraction; no axillary lymphadenopathy. Diagnostic mammogram and targeted left breast ultrasound obtained today demonstrate a hypoechoic, irregular 1.4 cm mass with posterior acoustic shadowing, BI-RADS 5. Ultrasound-guided core needle biopsy planned."
"Mr. [Name] is a 67-year-old male referred for surgical management of newly diagnosed sigmoid adenocarcinoma. He initially presented to his PCP with 3 months of altered bowel habits (alternating constipation and loose stools), intermittent hematochezia, and a 12-pound unintentional weight loss. Screening colonoscopy (first ever) revealed a near-obstructing, ulcerated mass at 25 cm from the anal verge; biopsy returned as moderately differentiated adenocarcinoma. Staging CT chest/abdomen/pelvis shows the sigmoid mass with pericolic fat stranding, 2 enlarged regional lymph nodes (up to 1.4 cm), and no distant metastasis. CEA 18.6 ng/mL (elevated). Clinical stage cT3N1M0. PMHx: HTN, hyperlipidemia, mild COPD. He remains functional (ECOG 1). We discussed laparoscopic sigmoid colectomy with primary anastomosis following mechanical + oral antibiotic bowel prep, and anticipated adjuvant chemotherapy pending final pathology. Consent obtained."
"Mrs. [Name] is a 71-year-old female s/p laparoscopic sigmoid colectomy with primary anastomosis (POD #5) for recurrent diverticulitis, now with worsening abdominal pain, low-grade fevers, and tachycardia since yesterday morning. Initial post-op course had been uneventful with return of bowel function on POD #3 and advancement to regular diet on POD #4. Today she reports diffuse abdominal pain (6/10), reduced oral intake, and chills. Vitals: T 38.7°C, HR 118, BP 96/58, SpO2 95% on room air. Abdomen distended, diffusely tender with voluntary guarding in the LLQ, no frank rigidity. Labs: WBC 18.6 with 14% bands, lactate 3.2, creatinine 1.5 (baseline 0.9). CT abdomen/pelvis with IV and oral contrast demonstrates free air, extraluminal contrast, and a fluid collection adjacent to the anastomosis — concerning for anastomotic leak. Plan: NPO, broad-spectrum antibiotics (piperacillin-tazobactam), IV fluid resuscitation, and emergent return to OR for exploratory laparotomy, washout, and likely Hartmann's procedure with end colostomy. Clavien-Dindo IIIb complication. Family updated."
24 References & Sources
Clinical Practice Guidelines
NCCN Clinical Practice Guidelines in Oncology: Colon Cancer.
NCCN Clinical Practice Guidelines in Oncology: Pancreatic Adenocarcinoma.
NCCN Clinical Practice Guidelines in Oncology: Breast Cancer.
NCCN Clinical Practice Guidelines in Oncology: Gastric Cancer.
NCCN Clinical Practice Guidelines in Oncology: Esophageal and Esophagogastric Junction Cancers.
HerniaSurge Group. International guidelines for groin hernia management. Hernia. 2018.
SAGES guidelines for laparoscopic ventral hernia repair.
SAGES guidelines for the management of hiatal hernia.
USPSTF. Screening for Colorectal Cancer. JAMA. 2021.
USPSTF. Screening for Breast Cancer (2024 update). JAMA. 2024.
ASHP/IDSA/SIS/SHEA clinical practice guidelines for antimicrobial prophylaxis in surgery.
ASCO VTE prophylaxis and treatment in patients with cancer: guideline update.
ERAS Society guidelines for perioperative care in elective colorectal surgery.
Landmark Clinical Trials & Publications
Diagram & Figure Sources
Figure 1: Components of the Digestive System. OpenStax College. CC BY 3.0.
Figure 2: Accessory Digestive Organs. OpenStax College. CC BY 3.0.
Figure 3: Stomach Anatomy. OpenStax College. CC BY 3.0.
Figure 4: Anatomy of the Small Intestine. OpenStax College. CC BY 3.0.
Figure 5: Anatomy of the Large Intestine. OpenStax College. CC BY 3.0.
Figure 6: Gallbladder, Liver, and Pancreas Location. Blausen Medical. CC BY 3.0.
Figure 7: Inguinal Hernia. Wikimedia Commons. Public domain.
General surgery is one of the broadest and busiest specialties you can scribe in. On any given day you may chart an appendicitis in the ED, a breast lump follow-up in clinic, a Whipple pre-op, a post-op check on a colectomy patient, and a trauma consult. The range is enormous, and the pace is fast.
The best general surgery scribes know the anatomy cold, anticipate the surgeon's documentation preferences, have the plan half-written before the attending walks out of the room, and can translate a rapid-fire operative dictation into a clean note without missing the laterality, the stapler size, the drain placement, or the estimated blood loss. They read the CT and the pathology report before the patient is seen. They know the difference between Hinchey I and III, between a TAPP and a TEP, between a LAR and an APR — not because memorization is fun, but because knowing the difference makes every note faster and more accurate.
This guide is your starting point. The mastery comes from doing the work in clinic and the OR every day. Welcome to general surgery.