General Surgery Principles Practice Questions

Q: In diabetic foot, which type of amputation is contraindicated?

Syme's amputation. **Explanation:** The correct answer is **Syme’s amputation**. **Why Syme’s Amputation is Contraindicated:** Syme’s amputation is a disarticulation of the ankle joint with the removal of the malleoli and the preservation of the heel pad. In diabetic patients, this procedure is generally contraindicated due to **peripheral arterial disease (PAD)** and **microangiopathy**. The success of a Syme’s amputation depends entirely on the viability and blood supply of the posterior tibial artery to the heel pad. Since diabetic patients often have calcified vessels and poor distal perfusion, the heel pad frequently fails to heal, leading to necrosis, infection, and the need for a higher level of amputation. Additionally, diabetic neuropathy can lead to "heel pad migration," making the stump unstable for weight-bearing. **Analysis of Other Options:** * **Ray Amputation:** Commonly performed in diabetics for localized gangrene of a toe and its corresponding metatarsal head. It is indicated if the infection is limited. * **Forefoot (Transmetatarsal) Amputation:** A viable option if the gangrene involves multiple toes but the midfoot has adequate perfusion. * **Below Knee Amputation (BKA):** This is the most common major amputation in diabetics. It is preferred over Syme’s because the vascularity at the calf level is usually superior, ensuring better wound healing and excellent prosthetic fitting. **Clinical Pearls for NEET-PG:** * **Gold Standard for Diabetic Foot Assessment:** The **Wagner Classification** is used to grade the severity of the ulcer. * **Most common site for diabetic foot ulcer:** Plantar aspect of the first metatarsophalangeal joint. * **Vascularity Check:** An **Ankle-Brachial Index (ABI)** < 0.5 or a toe pressure < 30 mmHg indicates poor healing potential for distal amputations. * **Syme’s Amputation** is ideally suited for **trauma** in non-diabetic young patients with good vascularity.

Q: Which of the following wounds is not typically considered untidy?

Incised wound. ### Explanation In surgical practice, wounds are broadly classified into **tidy** and **untidy** based on the mechanism of injury, the state of the tissue margins, and the presence of contamination. **1. Why "Incised Wound" is the Correct Answer:** An **incised wound** is the classic example of a **tidy wound**. It is caused by a sharp object (like a scalpel or glass) resulting in clean-cut, linear edges with minimal soft tissue damage. Because the blood supply to the wound edges remains intact and there is negligible devitalized tissue, these wounds can usually be closed primarily (Primary Intention) with excellent healing prospects. **2. Analysis of Incorrect Options (Untidy Wounds):** Untidy wounds are characterized by irregular edges, significant tissue destruction, and high contamination. * **Crushed Wound:** Caused by blunt force, leading to extensive deep tissue necrosis and impaired vascularity. * **Avulsed Wound:** Involves the tearing away of tissue layers (e.g., degloving), often compromising the blood supply to the skin flaps. * **Lacerated Wound:** Results from blunt trauma or shearing, producing jagged, irregular edges and often containing debris. **3. NEET-PG Clinical Pearls:** * **Management Difference:** Tidy wounds (Incised) can be closed immediately. Untidy wounds require thorough **debridement** (conversion of an untidy wound into a tidy one) before closure is considered. * **Rankin’s Classification:** Remember that "Untidy" wounds often have "the four Cs" of non-viable muscle: dark **C**olor, soft **C**onsistency, lack of **C**apillary bleeding, and failure to **C**ontract. * **High-Yield Fact:** A wound is considered "infected" if it contains $>10^5$ organisms per gram of tissue, a common complication in neglected untidy wounds.

Q: Which one of the following is a muscle-splitting incision?

Lanz. **Explanation:** The correct answer is **Lanz**, which is a classic example of a **muscle-splitting incision**. In surgery, muscle-splitting (or gridiron) incisions involve separating the muscle fibers along their natural direction rather than cutting across them. This preserves the integrity of the abdominal wall and results in better healing and less postoperative pain. * **Lanz Incision:** This is a transverse skin incision made at McBurney’s point, used primarily for appendectomy. It follows the Langer’s lines (skin tension lines) for a better cosmetic result. Like the McBurney (gridiron) incision, the underlying external oblique, internal oblique, and transversus abdominis muscles are split along their fibers. * **Kocher’s Incision:** This is a **muscle-cutting** subcostal incision used for open cholecystectomy or biliary surgery. The rectus abdominis muscle is divided. * **Rutherford-Morris (Rutherford-Morison) Incision:** This is an oblique muscle-cutting incision in the iliac fossa, commonly used for kidney transplants or access to the ureters. It involves cutting the oblique muscles. * **Pfannenstiel Incision:** This is a transverse incision used in pelvic surgery (e.g., C-sections). While the skin and rectus sheath are opened transversely, the rectus muscles are retracted laterally rather than split along their fibers; it is categorized as a **muscle-retracting** incision. **High-Yield Clinical Pearls for NEET-PG:** * **McBurney’s Incision:** The original muscle-splitting incision for appendectomy; it is oblique, whereas Lanz is transverse. * **Battle’s Incision:** A paramedian incision where the rectus muscle is retracted medially (muscle-retracting). * **Sanders’ Incision:** A variation of the Kocher’s incision used for better exposure in obese patients. * **Key Concept:** Muscle-splitting incisions (Lanz/McBurney) have a lower incidence of incisional hernia compared to muscle-cutting incisions.

Q: Acute paronychia is treated by which of the following procedures?

Incision and drainage. **Explanation:** **Acute paronychia** is a common localized infection of the lateral or proximal nail fold, most frequently caused by *Staphylococcus aureus*. The primary pathology involves a collection of pus (abscess) between the nail plate and the surrounding soft tissue. **Why Incision and Drainage (I&D) is correct:** The gold standard for treating any fluctuant abscess is **Incision and Drainage**. In acute paronychia, once suppuration (pus formation) occurs, conservative management with warm soaks or antibiotics is insufficient. An incision is made directly over the area of maximum fluctuation or along the nail fold (eponychium) to evacuate the pus, providing immediate pain relief and preventing the spread of infection to the nail bed or pulp space (felon). **Analysis of Incorrect Options:** * **B. Lifting the paronychium:** While a blunt probe can sometimes be used to separate the nail fold from the nail plate to release pus, it is considered a technique of drainage rather than a standalone procedure. Formal I&D is the definitive surgical principle. * **C. Partial nail excision:** This is typically reserved for cases where the infection has tracked underneath the nail plate (subungual abscess), but it is not the primary treatment for simple paronychia. * **D. Total nail excision:** This is an over-treatment for acute paronychia. It is generally indicated for chronic fungal infections or severe, recurrent ingrown toenails (onychocryptosis). **Clinical Pearls for NEET-PG:** * **Most common organism:** *Staphylococcus aureus* (Acute); *Candida albicans* (Chronic). * **Chronic Paronychia:** Defined as lasting >6 weeks; usually due to irritants/moisture. Treatment is avoidance of triggers and topical steroids (not antibiotics). * **Eponychia:** If the infection involves the entire proximal nail fold. * **Run-around abscess:** When paronychia extends from one lateral fold to the other across the base of the nail.

Q: What is the most common incision used for open general thoracic surgical procedures?

Median sternotomy. **Explanation:** The **Median Sternotomy** is the most common incision used for open general thoracic and cardiac surgical procedures. Its dominance in thoracic surgery is due to the excellent, wide exposure it provides to the heart, great vessels, and both pleural spaces. It is the standard approach for coronary artery bypass grafting (CABG), valve replacements, and mediastinal tumor resections (e.g., thymectomy). It is generally well-tolerated, associated with less postoperative pain compared to lateral incisions, and preserves pulmonary function better than a thoracotomy. **Analysis of Incorrect Options:** * **Anterior Thoracotomy:** Used primarily for emergency trauma (resuscitative thoracotomy) or limited access to the lung/pericardium. It offers restricted visualization compared to a sternotomy. * **Lateral Thoracotomy (Posterolateral):** While it is the "gold standard" for most **pulmonary** surgeries (lobectomy, pneumonectomy) and esophageal surgeries, it is not the most common incision for *general* thoracic/cardiac procedures overall. It is also associated with significant post-operative pain due to rib spreading and muscle transection. * **Transverse Thoracosternotomy (Clamshell Incision):** A bilateral incision used for double lung transplants or massive chest trauma. It is highly invasive and reserved for specific, complex cases. **Clinical Pearls for NEET-PG:** * **Most common incision for Cardiac Surgery:** Median Sternotomy. * **Best incision for Lung Resection:** Posterolateral Thoracotomy. * **Nerve at risk during Sternotomy:** The phrenic nerve (if dissecting near the pericardium). * **Sternal Dehiscence:** A serious complication of sternotomy, often associated with obesity, COPD, and diabetes. * **"Hemiclamshell":** A combination of a partial median sternotomy and an anterior thoracotomy.

Q: Punched-out edges are characteristic of which type of ulcer?

Syphilitic. **Explanation:** The characteristic appearance of an ulcer’s edge is a vital clinical clue in surgery. A **punched-out edge** (where the edge is vertical and the ulcer appears as if cut out with a punch) is the hallmark of a **Syphilitic (Gummatous) ulcer**. This occurs due to endarteritis obliterans, which causes localized ischemia and rapid tissue necrosis, leading to sharply defined margins. **Analysis of Options:** * **Syphilitic (Correct):** Typically seen in the tertiary stage of syphilis. These ulcers are painless, circular or "serpiginous," with a "wash-leather" slough at the base and characteristic punched-out edges. * **Tuberculosis:** Characterized by **undermined edges**. This happens because the disease process (caseous necrosis) destroys the subcutaneous tissue faster than the overlying skin. * **Rodent Ulcer (Basal Cell Carcinoma):** Characterized by **rolled-out (pearly) edges**. This is a slow-growing malignant ulcer that locally invades tissue but rarely metastasizes. * **Non-specific (Chronic/Venous):** Usually presents with **sloping edges**, indicating an attempt at healing where new epithelium grows over the granulation tissue. **NEET-PG High-Yield Pearls:** * **Punched-out edges** are also seen in **Trophic (Neuropathic) ulcers** (e.g., Diabetes, Leprosy) and **Arterial (Ischemic) ulcers**. * **Everted edges** are a classic sign of **Squamous Cell Carcinoma**. * **Wash-leather slough** is specifically associated with Syphilitic ulcers. * **Apple-jelly nodules** on the edge are characteristic of Lupus Vulgaris (Cutaneous TB).

Q: Which one of the following surgical procedures is considered to have a clean-contaminated wound?

Elective open cholecystectomy for cholelithiasis. ### Explanation The classification of surgical wounds is a high-yield topic for NEET-PG, based on the **CDC Surgical Wound Classification**, which predicts the risk of surgical site infection (SSI). **1. Why Option A is Correct:** An **elective open cholecystectomy** is classified as **Clean-Contaminated (Class II)**. This category includes procedures where a hollow viscus (respiratory, alimentary, genital, or urinary tract) is entered under controlled conditions and without unusual contamination. In this case, the biliary tract is entered, but since it is elective and for simple cholelithiasis (no acute inflammation or bile spill), it fits Class II. **2. Analysis of Incorrect Options:** * **Option B (Herniorrhaphy with mesh):** This is a **Clean (Class I)** wound. It is an elective procedure where no hollow viscus is entered, and there is no break in aseptic technique. * **Option C (Lumpectomy):** This is also a **Clean (Class I)** wound. Breast surgery and axillary dissections do not involve the respiratory or GI tracts. * **Option D (Appendectomy with abscess):** This is a **Dirty/Infected (Class IV)** wound. Any procedure involving a pre-existing clinical infection, perforated viscera, or pus/abscess falls into this category. (Note: A simple non-perforated appendectomy is Class II). **3. Clinical Pearls for NEET-PG:** * **Clean (Class I):** No inflammation, no entry into tracts. SSI risk: <2%. * **Clean-Contaminated (Class II):** Controlled entry into tracts. SSI risk: <10%. * **Contaminated (Class III):** Accidental open wounds, gross spillage from GI tract, or acute non-purulent inflammation (e.g., acute cholecystitis). SSI risk: 15-20%. * **Dirty (Class IV):** Traumatic wounds with devitalized tissue, fecal contamination, or established infection/abscess. SSI risk: Up to 40%.

Question 1

All of the following are true about hernia surgery except:

Accepted Answer

Surgery should not be done unless the patient becomes symptomatic.

Answer

Hernia in children is treated with herniotomy.

Answer

Absorbable mesh should not be used for surgery.

Answer

Surgery can be done using laparoscopy.

Question 2

In diabetic foot, which type of amputation is contraindicated?

Accepted Answer

Syme's amputation

Answer

Ray amputation

Answer

Forefoot amputation

Answer

Below knee amputation

Question 3

Which of the following wounds is not typically considered untidy?

Accepted Answer

Incised wound

Answer

Crushed wound

Answer

Avulsed wound

Answer

Lacerated wound

Question 4

Which one of the following is a muscle-splitting incision?

Accepted Answer

Lanz

Answer

Kocher's

Answer

Rutherford-Morris

Answer

Pfannensteil

Question 5

Which approach is safest for draining an axillary abscess?

Accepted Answer

Floor

Answer

Medial

Answer

Posterior

Answer

Lateral

Question 6

Acute paronychia is treated by which of the following procedures?

Accepted Answer

Incision and drainage

Answer

Lifting the paronychium

Answer

Partial nail excision

Answer

Total nail excision

Question 7

What is the most common incision used for open general thoracic surgical procedures?

Accepted Answer

Median sternotomy

Answer

Anterior thoracotomy

Answer

Lateral thoracotomy

Answer

Transverse thoracosternotomy

Question 8

Punched-out edges are characteristic of which type of ulcer?

Accepted Answer

Syphilitic

Answer

Tuberculosis

Answer

Rodent ulcer

Answer

Non-specific

Question 9

Which one of the following surgical procedures is considered to have a clean-contaminated wound?

Accepted Answer

Elective open cholecystectomy for cholelithiasis

Answer

Herniorrhaphy with mesh repair

Answer

Lumpectomy with axillary node dissection

Answer

Appendectomy with walled off abscess

Question 10

What is a complication of total parenteral nutrition (TPN)?

Accepted Answer

Hypochloremia

Answer

Congestive heart failure (CHF)

Answer

Metabolic acidosis

Answer

Leukopenia

General Surgery Principles — MCQs

General Surgery Principles — MCQs

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