UPSC-CMS 2009 - Surgery Practice Questions

Q: The following statements are correct about burst abdomen (abdominal dehiscence) except

Second dehiscence is very common. ***Second dehiscence is very common*** - This statement is incorrect. While **dehiscence** can recur, it is not considered "very common" after proper surgical repair and addressing risk factors. - The overall incidence of **abdominal dehiscence** ranges from 0.5% to 3%, and subsequent dehiscence, though possible, is less frequent than the initial event due to stricter prophylactic measures and more careful wound closure techniques. *Manage with nasogastric aspiration and intravenous fluids* - This is a crucial initial step for managing **burst abdomen**, as it helps to decompress the gastrointestinal tract and prevent vomiting. - **Intravenous fluids** are essential for maintaining hydration and electrolyte balance, especially if the patient is experiencing fluid loss through the exposed wound. *Cover the wound with sterile towel and perform emergency surgery* - Covering the exposed viscera with a **sterile, saline-soaked towel** is vital to prevent desiccation, infection, and further injury to the bowel. - **Emergency surgery** is necessary to debride the wound, inspect the abdominal contents, and perform a secure secondary closure of the abdominal wall layers. *Peak incidence is between 6th and 8th post operative day* - This timeframe is consistent with the typical healing progression of surgical wounds, where the tensile strength of the wound is still relatively low before collagen deposition is complete. - Factors like **infection**, **increased intra-abdominal pressure**, and poor nutritional status can contribute to wound breakdown during this critical period.

Q: A patient presents to the emergency department with pain and distension of abdomen and absolute constipation. What is the investigation of choice ?

Plain X-ray abdomen (Erect). ***Plain X-ray abdomen (Erect)*** - An erect plain X-ray of the abdomen is the initial and often diagnostic investigation for **bowel obstruction**, revealing **dilated bowel loops** and **air-fluid levels**. - It helps confirm the presence of obstruction and can sometimes indicate its location and severity, though it does not provide information about the cause. *Ultrasonography* - While ultrasound can detect **bowel dilation** and **peristalsis**, it is limited in visualizing the entire bowel and cannot reliably differentiate between various causes of obstruction. - It is more useful for assessing **extraluminal pathology** or **fluid collections** but less effective as a primary diagnostic tool for bowel obstruction. *Barium meal follow-through* - This study involves oral **barium administration** and serial X-rays to visualize the small bowel, but it is **contraindicated** in suspected bowel obstruction due to the risk of exacerbating the obstruction or causing **barium impaction**. - Its primary role is in evaluating chronic or partial obstructions, or malabsorption, not acute presentations with complete obstruction. *Colonoscopy* - **Colonoscopy** is an invasive procedure primarily used for diagnosis and treatment of **colonic pathology**, such as polyps, strictures, or bleeding. - It is **contraindicated** in acute, complete bowel obstruction due to the risk of **perforation** and is not the initial diagnostic choice for acute abdominal pain and absolute constipation.

Q: What is the investigation of choice in a patient with blunt abdominal trauma with hematuria ?

Contrast enhanced computed tomography. ***Contrast enhanced computed tomography*** - **Ureteral and renal injuries** are best evaluated using **CT with intravenous contrast**, which offers detailed anatomical information. - In cases of **blunt abdominal trauma with hematuria**, **CT with contrast** is the imaging modality of choice to assess for injuries to the urinary tract. *Ultrasonography of abdomen* - While useful in some abdominal injuries, **ultrasonography** does not provide sufficient detail for precise evaluation of the **renal parenchyma, collecting system, or ureteral integrity** in trauma. - It is often used as an initial screening tool but less effective than CT for confirming and staging urinary tract injuries. *Intravenous urogram* - An **intravenous urogram (IVU)** can identify some urinary tract injuries but is **less sensitive and specific** than modern CT scans. - It also provides **less anatomical detail** of associated soft tissue and vascular injuries compared to CT. *Retrograde urogram* - A **retrograde urogram** primarily visualizes the **lower urinary tract** (ureters and bladder) by injecting contrast directly into the ureters. - It is **invasive** and not the first-line investigation for **blunt abdominal trauma with hematuria**, especially for evaluating the kidneys themselves.

Q: Which one of the following is the treatment of choice in a child with inguinal hernia ?

Herniotomy alone. ***Herniotomy alone*** - In children, an **inguinal hernia** is typically an **indirect hernia** resulting from a persistent **patent processus vaginalis**. - **Herniotomy alone** (ligation and excision of the hernia sac) is sufficient because the posterior wall of the inguinal canal is usually strong and does not require reinforcement. *Shouldice operation* - The **Shouldice operation** is a **fascial repair** technique involving multiple layers of the posterior inguinal wall. - It is primarily used in **adults** for direct inguinal hernias or recurrent hernias, where the posterior wall is weakened. *Lichtenstein repair* - The **Lichtenstein repair** is a **tension-free mesh repair** method commonly performed in adults. - It involves placing a prosthetic mesh to reinforce the posterior wall of the inguinal canal, which is unnecessary and potentially problematic in growing children. *Bassini's repair* - **Bassini's repair** is a **tissue-based repair** that involves approximating the conjoined tendon to the inguinal ligament. - Like other adult repair techniques, it is associated with higher tension and risks of recurrence in adults due to underlying tissue weakness, and is not suitable for the physiological anatomy of a pediatric inguinal hernia.

Q: Match List-I with List-II and select the correct answer using the code given below the Lists: (Refer to the image for List-I and List-II)

A→4 B→1 C→2 D→3. ***A→4, B→1, C→2, D→3*** **Correct Matching:** **Tattooing (A) → Foreign particles like dirt, soot (4)** - Tattooing refers to permanent skin discoloration caused by **foreign pigment insertion** into the dermis - Commonly occurs accidentally after trauma with **dirt, soot, gunpowder, or other foreign particles** - The particles become embedded in the skin causing permanent discoloration **Keloid (B) → Outgrows boundaries of original wound (1)** - A keloid is a **prominent raised scar** that extends beyond the margins of the original injury - Results from excessive collagen deposition during abnormal wound healing - **Key feature**: Growth exceeds the boundaries of the original wound area **Dupuytren's contracture (C) → Contractures (2)** - Progressive fibrosis of the **palmar fascia** leading to finger contractures - Causes permanent flexion deformity, typically affecting the ring and little fingers - Results in functional limitation due to **contracture formation** **Basal cell carcinoma (D) → Not familial (3)** - Most common skin malignancy, typically **sporadic** rather than familial - Associated with UV exposure, fair skin, and immunosuppression - Unlike some other cancers, **typically not inherited** in familial patterns *Incorrect Options:* *A→2, B→3, C→4, D→1* - Incorrectly matches tattooing with contractures and Dupuytren's with foreign particles *A→3, B→4, C→1, D→2* - Incorrectly matches tattooing with non-familial trait and keloid with foreign particles *A→1, B→2, C→3, D→4* - Incorrectly matches tattooing with outgrowing boundaries and basal cell carcinoma with foreign particles

Q: Which of the following is the best indicator of prognosis of soft tissue sarcoma?

Tumour grade. ***Tumour grade*** - **Tumor grade** quantifies the degree of cellular differentiation, mitotic activity, and necrosis within the tumor, reflecting its aggressive potential. - A **higher tumor grade** is directly associated with a poorer prognosis, increased risk of local recurrence, and distant metastasis in soft tissue sarcomas. *Tumour size* - While larger tumor size (e.g., >5 cm) is generally associated with a worse prognosis, it is primarily a factor in **staging**, not the most critical prognostic indicator. - **Tumor grade** provides more fundamental information about the biological aggressiveness of the tumor cells regardless of their current size. *Nodal metastasis* - **Nodal metastasis** in soft tissue sarcomas is relatively uncommon (less than 5% of cases) compared to carcinomas, and its presence is a significant negative prognostic factor. - However, because it is rare, it doesn't serve as the *primary* indicator for the majority of sarcoma patients, where tumor grade is more universally applicable. *Histological type* - The **histological type** (e.g., liposarcoma, leiomyosarcoma) helps classify the sarcoma, but different subtypes can have a wide range of biological behavior. - While certain types may have a generally better or worse prognosis, the **grade** *within* that histological type is a more precise predictor of individual patient outcomes.

Q: Lympho-venous anastomosis is done for

Filarial lymphoedema. ***Filarial lymphoedema*** - **Lympho-venous anastomosis (LVA)** is a microsurgical technique used to bypass damaged lymphatic vessels and directly connect lymphatic channels to small veins. This procedure is primarily effective in treating **lymphedema due to lymphatic obstruction**, such as that caused by filarial infection. - In **filarial lymphoedema**, the lymphatic obstruction leads to accumulation of lymph fluid. LVA helps to restore lymphatic drainage, reducing limb swelling and improving symptoms, particularly in the early stages of the disease. *Cystic hygroma* - A **cystic hygroma** is a congenital lymphatic malformation, typically treated by surgical excision, sclerotherapy, or laser ablation. - It involves abnormally dilated lymphatic spaces and doesn't usually benefit from LVA, as the primary issue is malformation rather than obstruction requiring a bypass. *Malignant lymphoedema* - **Malignant lymphoedema** (secondary to cancer or its treatment) is often complicated by active tumor burden, radiation fibrosis, or extensive nodal involvement. - While LVA might be considered in carefully selected cases, its efficacy can be limited due to underlying cancer and the diffuse nature of the lymphatic damage, making it a less common primary indication compared to filarial lymphedema. *Lymphoid cyst* - A **lymphoid cyst** is a localized collection of lymph, often treated by aspiration, sclerotherapy, or surgical excision. - It is not a widespread lymphatic drainage disorder that would necessitate a bypass procedure like lympho-venous anastomosis.

Q: Which one of the following investigations is considered to be "Gold standard" technique for diagnosis of arterial occlusive disease ?

Digital Subtraction Angiography (DSA). ***Digital Subtraction Angiography (DSA)*** - **DSA** remains the gold standard for diagnosing arterial occlusive disease as it provides **high-resolution images** of the arterial lumen, accurately depicting stenoses and occlusions [1]. - It allows for precise localization and quantification of arterial lesions, which is crucial for treatment planning, especially for **interventional procedures** [1]. *Duplex imaging* - While useful for screening and follow-up, **duplex ultrasound** is operator-dependent and may not always provide the detailed anatomical information required for definitive diagnosis or pre-procedural planning, especially in complex cases. - It assesses blood flow and vessel patency but can be limited by factors such as patient body habitus, calcification, and bowel gas. *Doppler ultrasound blood flow detection* - **Doppler ultrasound** is an excellent tool for assessing blood flow characteristics and detecting changes indicative of arterial disease, but it provides less anatomical detail compared to angiography. - It is often used for **screening** and monitoring, but it does not offer the precise visualization of the arterial lumen needed to be a gold standard for diagnosis. *Treadmill* - A **treadmill test** (exercise stress test) is used to assess the functional impact of arterial occlusive disease, particularly **intermittent claudication**, by measuring the ankle-brachial index (ABI) after exertion. - It is a physiological test that indicates the presence and severity of flow-limiting lesions, but it does not provide anatomical information about the location or nature of the arterial occlusion.

Q: Which one of the following statements is not correct regarding thoracic outlet syndrome?

Radial nerve is involved. ***Radial nerve is involved*** - Thoracic outlet syndrome (TOS) primarily involves compression of the **brachial plexus** (specifically the lower trunk C8-T1), subclavian artery, or subclavian vein. - The **radial nerve** is derived from the posterior cord (C5-T1) of the brachial plexus, but the classic presentation of TOS does not typically involve isolated or predominant radial nerve symptoms. Instead, TOS symptoms more commonly affect the **ulnar nerve distribution** (C8-T1) due to compression of the lower trunk of the brachial plexus. *Resection of First rib is effective treatment* - **First rib resection** is a well-established surgical treatment option for thoracic outlet syndrome, aiming to decompress the neurovascular structures. - This procedure alleviates pressure on the **brachial plexus** and **subclavian vessels**, leading to symptom improvement in many patients. *It is associated with Horner's syndrome* - **Horner's syndrome** can be associated with thoracic outlet pathology, particularly tumors like **Pancoast tumors**, which can compress the sympathetic chain at the thoracic outlet. - While not a direct feature of typical TOS, conditions affecting the thoracic outlet region can impact the **cervical sympathetic ganglion** leading to Horner's syndrome (ptosis, miosis, anhidrosis). *It is a rare condition* - Thoracic outlet syndrome is generally considered a **relatively rare condition**, although its true incidence might be underestimated due to diagnostic challenges. - It is often a diagnosis of exclusion, requiring careful clinical evaluation and imaging to rule out other causes of **neck, shoulder, and arm pain**.

Question 1

The following statements are correct about burst abdomen (abdominal dehiscence) except

Accepted Answer

Second dehiscence is very common

Answer

Manage with nasogastric aspiration and intravenous fluids

Answer

Cover the wound with sterile towel and perform emergency surgery

Answer

Peak incidence is between 6th and 8th post operative day

Question 2

A patient presents to the emergency department with pain and distension of abdomen and absolute constipation. What is the investigation of choice ?

Accepted Answer

Plain X-ray abdomen (Erect)

Answer

Ultrasonography

Answer

Barium meal follow-through

Answer

Colonoscopy

Question 3

What is the investigation of choice in a patient with blunt abdominal trauma with hematuria ?

Accepted Answer

Contrast enhanced computed tomography

Answer

Ultrasonography of abdomen

Answer

Intravenous urogram

Answer

Retrograde urogram

Question 4

Which one of the following is the treatment of choice in a child with inguinal hernia ?

Accepted Answer

Herniotomy alone

Answer

Shouldice operation

Answer

Lichtenstein repair

Answer

Bassini's repair

Question 5

Match List-I with List-II and select the correct answer using the code given below the Lists:

(Refer to the image for List-I and List-II)

Accepted Answer

A→4  B→1  C→2  D→3

Answer

A→2  B→3  C→4  D→1

Answer

A→3  B→4  C→1  D→2

Answer

A→1  B→2  C→3  D→4

Question 6

Which of the following is the best indicator of prognosis of soft tissue sarcoma?

Accepted Answer

Tumour grade

Answer

Tumour size

Answer

Nodal metastasis

Answer

Histological type

Question 7

Lympho-venous anastomosis is done for

Accepted Answer

Filarial lymphoedema

Answer

Cystic hygroma

Answer

Malignant lymphoedema

Answer

Lymphoid cyst

Question 8

Which one of the following investigations is considered to be "Gold standard" technique for diagnosis of arterial occlusive disease ?

Accepted Answer

Digital Subtraction Angiography (DSA)

Answer

Duplex imaging

Answer

Doppler ultrasound blood flow detection

Answer

Treadmill

Question 9

Which one of the following statements is not correct regarding thoracic outlet syndrome?

Accepted Answer

Radial nerve is involved

Answer

Resection of First rib is effective treatment

Answer

It is associated with Horner's syndrome

Answer

It is a rare condition

UPSC-CMS 2009 — Surgery