Knowledge Area 3 | Core Surgical Skills

Knowledge Area 3 | Core Surgical Skills

(Aligned with RCOG Core Curriculum 2019)

Surgical competence is a core capability in Obstetrics and Gynaecology. The RCOG curriculum clearly outlines not only the procedural knowledge clinicians require, but also the decision-making, risk assessment, and non-technical skills that distinguish safe, effective practice. MRCOG Part 2 goes beyond textbook recall — it tests your ability to apply surgical knowledge through clinical reasoning, judgement under uncertainty, and escalation pathways.

What the Current RCOG Curriculum Expects

According to the RCOG Core Curriculum (2019, definitive document – updated 2021) Trainees must demonstrate:

• Understanding of indications, contraindications and expected outcomes of gynaecological/obstetric surgery
• Knowledge of surgical anatomy and physiology relevant to procedures
• Ability to recognise, prevent and manage complications
• Safe consent taking and documentation
• Knowledge of infection control, thromboprophylaxis, and enhanced recovery
• Effective non-technical skills (teamwork, communication, leadership)
• Evidence-based integration of guidelines (RCOG Green-tops, NICE, WHO)

Principles Underpinning Core Surgical Skills

Informed Consent (Ethics & Legal Framework)

• Consent is not a form — it is a process of shared decision-making. You must explain: Indications and alternatives; Expected benefits vs. risks; Possible complications; Impact on fertility and future pregnancies; Options if surgery fails or is abandoned
• For MRCOG exam, be able to justify your approach, handle patient reluctance, and document decision-making clearly.

Surgical Safety and Teamwork

• Safe surgery requires: WHO Surgical Safety Checklist; Clear roles and responsibilities; Effective handovers; Situational awareness
• Non-technical skills (communication, leadership, coordination) are repeatedly evaluated in exam scenarios.

Infection Prevention & Antibiotic Stewardship

• RCOG and NICE emphasize: SSI prevention (timely prophylaxis, skin preparation); Judicious antibiotic use; Peri-operative antimicrobial stewardship
• These are tested not as isolated facts but within scenarios where infection risk changes due to patient comorbidities.

Anaesthesia & Analgesia

• Understand: General, regional and local techniques; Patient selection for anaesthetic modality; Analgesic planning aligned with recovery goals
• You should be able to weigh risks and side-effects (e.g., epidural risks in coagulopathy).

Applied Surgical Anatomy & Science

• Examiners expect you to integrate anatomy and physiology into decisions:
  • Pelvic sidewall and ureteric course
  • Relationship of uterine vasculature to ligation sites
  • Layers of abdominal wall and implications for entry incisions
  • Variation in pelvic floor anatomy affecting repair
• Anatomy questions for Part 2 are not ‘what layer comes next?’ but ‘how does this anatomy influence your operation choice or complication risk?’.

Must-Know Surgical Procedures

The curriculum groups procedures into obstetric and gynaecological, both are tested through clinical scenarios that require indication, technique, complication handling and outcome planning.

Obstetric Procedures

Caesarean Section

• Indications (e.g., failure to progress, fetal compromise); Classification of urgency; Low transverse vs classical vs extensile incisions; Risks (haemorrhage, bladder injury, placenta accreta); Counselling about future pregnancies and VBAC
• Exam Tip: Be prepared to justify timing decisions, CS technique and responses to intra-operative complications.

Instrumental Birth (Forceps/Vacuum)

• Indications and prerequisites; Station and position assessment; Decision to abandon; Maternal and neonatal complications
• This is not just procedural but involves judgement about when and how it is safe to proceed.

Perineal Trauma Repair

• Classification and recognition; Repair principles for 3rd/4th degree tears; Anal sphincter repair techniques; Prevention strategies
• In exam, scenarios often describe continence issues — you must address both repair and future pelvic health.

Gynaecological Procedures

Diagnostic & Therapeutic Laparoscopy

• Entry techniques and safety; Energy modality selection; Adhesion prevention; Specimen retrieval; Management of inadvertent injuries
• Focus on safe access and complications rather than memorising energy settings.

Hysteroscopy

• Indications; Outpatient vs GA; Fluid management and related complications; Failed procedure strategies
• Exam questions often focus on decision-making when confronted with complications (fluid overload, perforation).

Laparotomy & Open Surgery

• Indications (e.g., large fibroids, malignancy staging); Tissue plane identification; Haemorrhage control
• Understand staged surgical planning and MDT involvement when necessary.

Amniocentesis & CV Sampling

• Indications; Complication risks; Patient counselling
• Procedural accuracy and complication management are emphasised.

Other Core Procedures

• MVA; Cystoscopy when required; Uterine artery embolisation (UAE); Robotic surgery principles
• Exam will test appropriateness and safety, not robotic console skills.

Complications & Crisis Management

MRCOG Part 2/3 scenarios are rich in complication management:

Haemorrhage

• Immediate recognition; Surgical and non-surgical steps; Use of uterotonics, tranexamic acid, balloon tamponade, uterine artery ligation

Injury to Visceral Structures

• Bladder, bowel, ureter; How to detect and repair intra-operatively; Post-operative implications

Thromboembolism

• Risk stratification; Prophylaxis and management
• Exam focus: When would you suspect this, how would your initial response change, and when do you escalate?

Decision-Making & MDT Care

• Knowledge Area 3 emphasises:
  • When to operate or when to refer
  • How to adjust plans for maternal comorbidities
  • Collaboration with anaesthetists, radiologists, critical care
• Part 2 expects justification of choices, not just recall.

MRCOG Exam Strategy

• Don’t memorise isolated steps — understand rationale and alternatives.
• Practice scenario questions that integrate surgical decisions with medical care.
• Justify your decisions using accepted guidelines.
• Highlight safety, escalation, documentation, and MDT involvement.
• Remember: The Part 2 exam tests clinical judgment and safe application, not rote surgical technique.

Important Topics to Cover
WHO	WHO Surgical Safety Checklist
RCOG	Instruments Surgical Sutures and Needles
TOG	Per-operative management of women on oral anticoagulants and antiplatelets agents undergoing gynaecological procedures 2020 Abdominal Incisions and Sutures in Obs & Gynae 2014 Importance of non-technical skills and risk reduction in Operation Theatre 2016
SIP	#39 Adhesion Prevention Agents in Obs & Gynae
NICE	NG180 Perioperative care in adults 2020 NG45 Routine pre-operative tests for elective surgery 2016 CG174 I/V fluid Therapy in adults in hospital 2013
Complications
SSI	WHO Surgical Site Infection Guideline 2018 NICE NG125 Surgical Site Infections: Prevention and treatment 2019
TOG	Thromboprophylaxis in gynaecology 2023 Surgical site infection in obstetrics & gynaecology 2021 Perioperative management of women on oral anticoagulants and antiplatelet agents undergoing gynaecological procedures 2020 Nerve injuries associated with gynaecological surgery 2014 The Perforated Uterus 2013
NICE	NG89 VTE in over 16s: reducing risk of hospital-acquired DVT/PE 2019
Infection	Antibiotic prophylaxis during obstetric and gynaecology surgery in adults (only do Charts)

Consent
PLEASE NOTE: As of July 2025, some of the previous RCOG Consent Advice documents have been archived, with redirection to the Getting It Right First Time (GIRFT) workspace on the FutureNHS platform.
CGA	#6 Obtaining Valid Consent #6b Obtaining Valid Consent for Complex Gynaecological Surgery
CA	#3 Female Sterilisation #5 Vaginal Surgery for Prolapse #10 Surgical Management of Miscarriage
TOG	Decision making framework in Gynaecology for patients who lack mental capacity 2018 Consent in clinical practice 2015

Enhanced Recovery
SIP	#36 Enhanced Recovery in Gynaecology
TOG	Enhanced Recovery Revisited 2025 Enhanced Recovery in gynaecology 2013

Anaesthesia/ Analgesia
SIP	#59 Antenatal and Postnatal Analgesia
TOG	Analgesia for labour 2015
TOG	Abdominal wall catheters for postoperative analgesia 2025
LA	Recommended Local Anaesthetic Doses (Adults)

Caesarean Section
GTG	#45 Birth after previous Caesarean Birth
NICE	Caesarean Section
CA	#7 Caesarean Section #12 C/S for Placenta Previa #14 Planned Caesarean Birth
GP	#11 Classification of Urgency of C/S
TOG	Gynaecological morbidity associated with CS niche 2020 Acute colonic pseudo-obstruction after CS 2019 Perimortem C/S- why, when and how 2018 Complications of C/S 2016 C/S at full dilatation 2014 Counselling women about risks of C/S delivery on future pregnancies 2014

Laparoscopy
GTG	#49 Preventing Entry-related Gynae Laparoscopic Injuries 2008
CA	#2 Diagnostic Laparoscopy #8 Laparoscopic Management of Tubal Ectopic Pregnancy
TOG	Life in the laparoscopic fast lane: evidence-based preoperative management and enhanced recovery in benign gynaecological laparoscopy 2021 Review of advanced energy devices for the minimal access gynaecologist 2021 Operative laparoscopy in advanced pregnancy beyond 20 weeks 2020 Vascular injury during laparoscopic gynaecological surgery 2020 Safe use of electrosurgery in gynaecological laparoscopic surgery 2020  Role of laparoscopic simulation training 2020 Preventing adhesions in laparoscopic surgery: role of anti-adhesion agents 2019 Surgical Smoke- what are the risks? 2019 Laparoscopic myomectomy: a review of alternatives, techniques and controversies 2018 Laparoscopy in Urogynaecology 2018 Methods of specimen removal from peritoneal cavity after laparoscopic excision 2013 Optimal laparoscopic ergonomics in gynaecology 2015 Urinary tract injuries in laparoscopic gynae surgery:prevention, recognition & management 2014

Hysteroscopy
GTG	#59 Outpatient Hysteroscopy 2024
NICE	IPG704 Hysteroscopic mechanical tissue removal for uterine fibroids 2021
CA	#1 Diagnostic Hysteroscopy Under GA 2008
GPP	Pain Relief and Informed Decision-Making for Outpatient Hysteroscopy 2023
TOG	BSGE/ESGE guideline on management of fluid dissension media in operative hysteroscopy 2018 Update in hysteroscopic Sterilization 2017 Failed hysteroscopy and further management strategies 2016 Ambulatory Hysteroscopy 2013

Hysterectomy
CA	#4 Abdominal Hysterectomy for Benign Conditions 2009 #13 Morcellation for myomectomy or hysterectomy 2024
TOG	Issues around vaginal vault closure 2019

Amniocentesis & CVS
GTG	#8 Amniocentesis and Chorionic Villous Sampling Summary Click Here
CA	#6 Amniocentesis

Perineal Tear
GTG	#29 Management of Third-and-Fourth-degree Perineal Tears
CA	#9 Repair of Third-and-Fourth- degree Perineal Tears following childbirth
TOG	Obstetrics pelvic floor and anal sphincter injuries 2012

Other Procedures
Cystoscopy	Cystoscopy for the gynaecologist: how to do a cystoscopy 2017
Robotic Surgery	SIP71 Robotic Surgery in Gynaecology 2022 TOG Robotic Surgery in gynaecology 2016
MVA	Manual Vacuum Aspiration 2015
UAE	Use of Uterine Artery Embolisation (UAE) in management of fibroids
Manchester Repair	Manchester repair (Fothergill’s operation) revisited 2021
Endometriosis	Excision of endometriosis – optimising surgical techniques 2021
vNOTES	vNOTES (vaginal Natural Orifice Transluminal Endoscopic Surgery): is this the future of gynaecological surgery? 2023
Hernia	Abdominal wall incision hernias: techniques to minimise the risks in open gynaecological surgery 2024

All the reading material, along with comprehensive summaries, is provided in our courses.