UPSC-CMS 2022 - Surgery Practice Questions

Q: Preoperative investigations done prior to surgery depend upon which of the following? 1. Type of surgery 2. Patient origin 3. Patient comorbidities 4. Experience of surgeon

1. Type of surgery. ***1. Type of surgery*** - The **type of surgery** is a primary determinant of preoperative investigations, as it defines the baseline assessment needed based on the procedure's complexity, invasiveness, and physiological stress. - Minor surgeries (e.g., superficial excisions) typically require minimal investigations, while major surgeries (e.g., cardiac, neurosurgery) mandate comprehensive cardiovascular, pulmonary, and hematological workups. - **Clinical Note:** In practice, preoperative investigations depend on BOTH the surgery type AND patient comorbidities working together, but this question likely seeks the most fundamental starting point. *3. Patient comorbidities* - **Patient comorbidities** are undeniably crucial in determining the extent and nature of preoperative investigations. - A patient with diabetes, hypertension, or cardiac disease requires additional specific investigations regardless of the surgery type. - However, the surgery type establishes the baseline framework, which is then modified based on comorbidities. *2. Patient origin* - **Patient origin** (geographical location, ethnicity) is generally not a direct determinant of preoperative investigation protocols. - While certain populations may have higher prevalence of specific conditions, investigations are based on individual patient assessment, not origin. *4. Experience of surgeon* - The **experience of the surgeon** does not alter the medical necessity or standard protocols for preoperative investigations. - Patient safety standards and investigation requirements remain consistent regardless of surgical expertise level.

Q: Which of the following is NOT included in Grade II acute cholecystitis as per 'Tokyo Consensus Guidelines for Severity'? 1. Elevated white cell count (> 18000/mm3) 2. Renal dysfunction 3. Duration > 72 hours 4. Marked local inflammation

2. Renal dysfunction. ***2. Renal dysfunction*** - **Renal dysfunction** is a criterion for **Grade III (severe)** acute cholecystitis, NOT Grade II, indicating systemic organ failure. - This represents a critical systemic complication requiring intensive care, distinct from the moderate severity markers of Grade II. *1. Elevated white cell count (> 18000/mm3)* - An elevated white blood cell count *greater than 18,000/mm³* **IS** a criterion for **Grade II (moderate)** acute cholecystitis. - This reflects a substantial systemic inflammatory response, categorizing it as a moderate severity finding. *3. Duration > 72 hours* - A duration of symptoms *greater than 72 hours* **IS** a defining criterion for **Grade II (moderate)** acute cholecystitis according to the **Tokyo Guidelines for severity assessment**. - This indicates a more prolonged inflammatory process, often associated with increased local complications. *4. Marked local inflammation* - **Marked local inflammation** **IS** a characteristic of **Grade II (moderate)** acute cholecystitis. - This criterion includes conditions such as pericholecystic abscess, hepatic abscess, gangrenous cholecystitis, or biliary peritonitis, indicating significant local complications.

Q: Which of the following is the FIRST step in triple assessment of breast lumps? 1. Clinical assessment 2. Radiological assessment 3. Histopathological assessment 4. Sentinel lymph node biopsy

Clinical assessment. ***Clinical assessment*** - The **first step** in triple assessment involves taking a thorough history and performing a physical examination to identify concerning features of a breast lump. - This step helps to guide the subsequent radiological and histopathological investigations. *Radiological assessment* - This is the **second step** of triple assessment and typically involves mammography, ultrasound, or MRI to characterize the lump's features and extent. - It provides imaging information but does not precede the initial clinical evaluation. *Histopathological assessment* - This is the **third step**, involving a biopsy (fine needle aspiration, core needle biopsy) to obtain tissue for microscopic examination and definitive diagnosis. - While crucial for diagnosis, it follows both clinical and radiological assessments in the triple assessment pathway. *Sentinel lymph node biopsy* - This procedure is performed to determine if **cancer cells have spread** to the regional lymph nodes, typically after a confirmed diagnosis of breast cancer. - It is not part of the initial diagnostic triple assessment for a breast lump but rather a staging procedure.

Q: Which of the following is the MOST reliable intraoperative feature of viable small bowel? 1. Visible peristalsis 2. Flabby intestinal musculature 3. Shiny appearance of small bowel wall 4. Visible pulsation in the mesenteric artery

1. Visible peristalsis. ***Visible peristalsis*** - The presence of **visible peristalsis** is the **MOST reliable indicator** of viable small bowel, demonstrating preserved neuromuscular function and tissue vitality. - Among the classical "3 Ps" of bowel viability (Peristalsis, Pulsation, Pink color), **peristalsis is the most direct indicator** as it confirms functional integrity of the bowel wall itself. - This indicates that the muscle layers of the intestine (longitudinal and circular) are functioning properly with intact innervation. *Shiny appearance of small bowel wall* - A **shiny serosa** is indeed a feature of viable bowel, indicating healthy, well-perfused tissue with an intact mesenteric surface. - However, it is a **less specific indicator** compared to peristalsis, as the appearance can be subjective and may not directly correlate with functional viability. *Visible pulsation in the mesenteric artery* - **Visible pulsation** in the mesenteric artery is one of the classical signs of viability and indicates blood flow to the vessel. - However, arterial pulsation alone **does not guarantee adequate tissue perfusion** or venous drainage, and ischemia can still occur despite pulsatile flow (e.g., venous thrombosis). - Peristalsis is more reliable as it confirms both adequate perfusion AND functional integrity. *Flabby intestinal musculature* - **Flabby intestinal musculature** indicates **non-viable bowel** with loss of tone, suggesting ischemia or necrosis. - Viable bowel typically feels **turgid and elastic** with good tone, not flabby.

Q: Which of the following is included in Ranson scoring system to predict the severity of acute pancreatitis at the time of admission? A. WBC count > 15 x 10^3/L B. Blood glucose > 200 mg/dL C. LDH > 350 units/L D. AST > 250 units/L

WBC count > 15,000/mm³. ***WBC count > 15,000/mm³*** - A **high white blood cell count** upon admission is one of the initial criteria in the Ranson scoring system indicating more severe inflammation [1]. - This parameter helps to assess the systemic inflammatory response in acute pancreatitis. *LDH > 350 units/L* - The Ranson criteria specify an **LDH level greater than 350 units/L** as a predictor of severity for acute pancreatitis, but it is assessed **at 48 hours after admission**, not at admission. - This value reflects ongoing tissue damage and enzyme release. *Blood glucose > 200 mg/dL* - A blood glucose level > 200 mg/dL is a criterion for the Ranson score, but it is assessed **at 48 hours after admission**, not at the time of admission. - This can indicate significant pancreatic damage impacting insulin production. *AST > 250 units/L* - While an elevated AST level can be present in acute pancreatitis, the specific Ranson criterion for AST is **> 250 units/L**, and it is assessed **at 48 hours after admission**, not upon admission. - This elevation can suggest hepatobiliary involvement or severe pancreatic necrosis.

Q: When the hernia extends between the layers of abdominal wall muscles and not directly through them, it is called

Spigelian hernia. ***Spigelian hernia*** - A **Spigelian hernia** occurs through a defect in the **Spigelian fascia**, extending between the transverse abdominis and internal oblique muscles. - It typically presents as a bulge between muscular layers, making it often **interparietal** and difficult to diagnose clinically due to its hidden nature. *Amyand's hernia* - This is a rare type of inguinal hernia that contains the **vermiform appendix** within the hernial sac. - It is notable for the potential complication of **appendicitis** within the hernia. *Richter's hernia* - A **Richter's hernia** involves only a portion of the circumference of the bowel wall becoming strangulated within the hernia orifice. - This can lead to **bowel necrosis** without complete obstruction, making diagnosis challenging. *Littre's hernia* - A **Littre's hernia** is characterized by the presence of a **Meckel's diverticulum** within the hernial sac. - It can occur in any hernia type (inguinal, femoral, umbilical) and carries a risk of diverticulitis or perforation.

Q: Which of the following are tension-free inguinal hernia repairs? 1. Stoppa's repair 2. Lichtenstein's repair 3. Laparoscopic TEP repair 4. Desarda's repair.

1, 2 and 3. ***1, 2 and 3*** - **Stoppa's repair**, **Lichtenstein's repair**, and **Laparoscopic TEP repair** are all considered tension-free methods because they use mesh to reinforce the inguinal floor without putting tension on the surrounding tissues. - The use of mesh in these repairs distributes the tension across a wider area, minimizing pain and recurrence rates compared to traditional tension-based repairs. - **Desarda's repair** is excluded because it is a tissue-based (non-mesh) technique that uses the external oblique aponeurosis, and is NOT classified as a tension-free repair. *2, 3 and 4* - This option incorrectly excludes **Stoppa's repair**, which is a widely recognized tension-free technique using a large prosthetic mesh in the preperitoneal space. - **Desarda's repair** is incorrectly included as it is a tissue-based repair without mesh, not a tension-free technique. *1, 3 and 4* - This option incorrectly excludes **Lichtenstein's repair**, which is the most commonly performed tension-free open mesh repair for inguinal hernias. - It involves placing a prosthetic mesh over the defect without suturing muscle or fascia under tension. - **Desarda's repair** is incorrectly included as it does not use mesh and is not classified as tension-free. *1, 2 and 4* - This option incorrectly excludes **Laparoscopic TEP repair**, which is a minimally invasive tension-free approach utilizing mesh to reinforce the posterior wall of the inguinal canal in the preperitoneal space. - **Desarda's repair** is incorrectly included; while it aims to be physiological and mesh-free, it is a tissue-based technique and not a tension-free repair.

Q: Which of the following are true about epidermal cyst? 1. It is lined by stratified squamous epithelium. 2. It is derived from hair follicle. 3. It contains keratin debris. 4. It is not fixed to the skin.

1, 2 and 3. ***1, 2 and 3*** - An **epidermal cyst** is indeed derived from the **infundibulum of a hair follicle**. - It is lined by **stratified squamous epithelium** and contains **keratin debris**, giving it a cheesy consistency. *1, 3 and 4* - While an epidermal cyst is lined by stratified squamous epithelium and contains keratin, it is often **fixed to the skin** due to its attachment to the follicular opening, making statement 4 incorrect. - The cyst's connection to the surface epithelium is a distinguishing feature, preventing it from being freely mobile. *1, 2 and 4* - Although statements 1 and 2 are true, statement 4, claiming it is not fixed to the skin, is generally **incorrect**. - Epidermal cysts typically have a punctum or small opening to the skin surface, indicating its attachment. *2, 3 and 4* - Statements 2 and 3 are correct, but statement 4, suggesting it is not fixed, is **false**. - The presence of a **central punctum**, which is common in epidermal cysts, signifies its epidermal origin and attachment to the skin.

Q: Anderson-Hynes plasty is a type of repair of

ureteropelvic junction. ***ureteropelvic junction*** - The **Anderson-Hynes pyeloplasty** is a widely used surgical procedure for the correction of a **ureteropelvic junction (UPJ) obstruction**. - It involves **excision of the stenotic or obstructed UPJ segment** and **reconstruction** to create a wide, funnel-shaped connection between the renal pelvis and the ureter. *lower ureter* - Repairs of the lower ureter, such as for distal ureteral strictures or reflux, typically involve procedures like ureteral re-implantation into the bladder or ureteroureterostomy, not the Anderson-Hynes plasty. - While these can address obstruction, the specific technique of Anderson-Hynes is designed for the UPJ. *glans penis* - The glans penis is part of the male external genitalia, and surgical repairs in this area, such as for hypospadias or strictures, are entirely unrelated to the ureter or kidney. - Surgical procedures for the glans penis would involve plastic and reconstructive techniques specific to the urethra and foreskin. *urinary bladder* - Repairs of the urinary bladder involve procedures for conditions like bladder diverticula, fistulae, or augmentation cystoplasty, which are distinct from managing obstructions in the upper urinary tract. - These procedures aim to restore bladder function and integrity, not to address blockages at the junction of the kidney and ureter.

Question 1

Preoperative investigations done prior to surgery depend upon which of the following?

1. Type of surgery
2. Patient origin
3. Patient comorbidities
4. Experience of surgeon

Accepted Answer

1. Type of surgery

Answer

4. Experience of surgeon

Answer

2. Patient origin

Answer

3. Patient comorbidities

Question 2

Which of the following is NOT included in Grade II acute cholecystitis as per 'Tokyo Consensus Guidelines for Severity'?

1. Elevated white cell count (> 18000/mm3)
2. Renal dysfunction
3. Duration > 72 hours
4. Marked local inflammation

Accepted Answer

2. Renal dysfunction

Answer

4. Marked local inflammation

Answer

3. Duration > 72 hours

Answer

1. Elevated white cell count (> 18000/mm3)

Question 3

Which of the following is the FIRST step in triple assessment of breast lumps?

1. Clinical assessment
2. Radiological assessment
3. Histopathological assessment
4. Sentinel lymph node biopsy

Accepted Answer

Clinical assessment

Answer

Radiological assessment

Answer

Sentinel lymph node biopsy

Answer

Histopathological assessment

Question 4

Which of the following is the MOST reliable intraoperative feature of viable small bowel?

1. Visible peristalsis
2. Flabby intestinal musculature
3. Shiny appearance of small bowel wall
4. Visible pulsation in the mesenteric artery

Accepted Answer

1. Visible peristalsis

Answer

3. Shiny appearance of small bowel wall

Answer

2. Flabby intestinal musculature

Answer

4. Visible pulsation in the mesenteric artery

Question 5

Which of the following is included in Ranson scoring system to predict the severity of acute pancreatitis at the time of admission?

A. WBC count > 15 x 10^3/L
B. Blood glucose > 200 mg/dL
C. LDH > 350 units/L
D. AST > 250 units/L

Accepted Answer

WBC count > 15,000/mm³

Answer

LDH > 350 units/L

Answer

Blood glucose > 200 mg/dL

Answer

AST > 250 units/L

Question 6

When the hernia extends between the layers of abdominal wall muscles and not directly through them, it is called

Accepted Answer

Spigelian hernia

Answer

Amyand's hernia

Answer

Richter's hernia

Answer

Littre's hernia

Question 7

Which of the following are tension-free inguinal hernia repairs?

1. Stoppa's repair
2. Lichtenstein's repair
3. Laparoscopic TEP repair
4. Desarda's repair.

Accepted Answer

1, 2 and 3

Answer

2, 3 and 4

Answer

1, 3 and 4

Answer

1, 2 and 4

Question 8

Which of the following are true about epidermal cyst?

1. It is lined by stratified squamous epithelium.
2. It is derived from hair follicle.
3. It contains keratin debris.
4. It is not fixed to the skin.

Accepted Answer

1, 2 and 3

Answer

1, 3 and 4

Answer

1, 2 and 4

Answer

2, 3 and 4

Question 9

Anderson-Hynes plasty is a type of repair of

Accepted Answer

ureteropelvic junction

Answer

lower ureter

Answer

glans penis

Answer

urinary bladder

UPSC-CMS 2022 — Surgery