General Surgery Principles Practice Questions

Q: A 25-year-old man with a history of road traffic injury presents to your clinic 4 months after the episode. His clinical presentation is shown in the image. What is the most likely diagnosis?

Normal scar. ***Normal scar*** - A **normal scar** appears as a flat, pale line, typically within the bounds of the original wound, as seen in the image after 4 months. - Histologically, a mature normal scar is characterized by **dense collagen bundles** arranged in parallel fashion, replacing the original dermis. *Keloid* - **Keloids** are characterized by **scar tissue growing beyond the boundaries of the original wound**, often appearing raised, firm, and reddish-purple. This is not seen in the image. - Histologically, keloids show irregularly arranged, **thick, hyalinized collagen bundles**, often with nodular formations and increased vascularity. *Hypertrophic scar* - A **hypertrophic scar** is elevated and red but remains **within the confines of the original wound**. Unlike keloids, they can often regress spontaneously. The image does not show an elevated or reddish scar. - Histologically, hypertrophic scars also feature **thick collagen bundles** but these are typically arranged **parallel to the epidermis** and are more organized than in keloids. *Wound contraction* - **Wound contraction** is a normal process during healing where the wound edges pull together, reducing the wound size. This is a process, not a final scar appearance. - While contraction occurs in all phases of wound healing, severe or excessive contraction can lead to **contractures**, which limit joint movement and are usually seen in extensive burns or chronic wounds.

Q: Which needle is shown below?

Vim-Silverman needle. ***Vim-Silverman needle*** - The image displays a needle with two prongs at the tip, which is characteristic of the **Vim-Silverman needle** used for **biopsy**. - This design allows for the capture of a tissue core between the prongs for microscopic examination. *Tru-cut needle* - A Tru-cut needle is also a biopsy needle, but it typically has a **single, cutting cannula** with a notch in its inner stylet. - Its design is different from the dual-pronged tip shown in the image. *Lumbar puncture needle* - A **lumbar puncture needle** (spinal needle) is used to access the subarachnoid space for cerebrospinal fluid (CSF) collection or drug administration. - It usually has a single, sharp bevel and a stylet, but lacks the biopsy collecting mechanism seen in the image. *Abraham's pleural biopsy needle* - **Abraham's pleural biopsy needle** is specifically designed for pleural biopsies and typically has a hook or a cutting edge that can be closed to obtain a tissue sample. - Its structure differs significantly from the bifurcated tip shown in the image.

Q: The commonest site of pressure sore is :

Heel. ***Heel*** - The **heel** is a common site for pressure sore development, especially in bedridden or immobile patients, due to sustained pressure on the bony prominence. - While less common as the *most* common site compared to the sacrum, it is still very frequently affected and can be equally severe. *Sacrum* - The **sacrum** is the *most common site* for pressure ulcers, particularly in individuals who are bed-bound or spend prolonged periods in a supine position. - This area experiences high pressure when lying on the back due to the body's weight pressing down on the bony prominence of the sacrum [1]. *Ischium* - The **ischial tuberosities** are common sites for pressure sores in individuals who are wheelchair-bound or spend extended periods in a seated position. - Pressure on this area is particularly high when sitting, making it vulnerable to tissue damage. *Occiput* - The **occiput** (back of the head) is a common site for pressure sores in infants, critically ill patients, or individuals who are supine for extended periods and unable to reposition their heads. - This is due to sustained pressure on the bony prominence of the skull against the mattress or support surface.

Q: Which of the following are the techniques commonly used to close the raw area after excision of a pilonidal sinus in order to avoid a midline wound? I. Limberg procedure II. Y-V plasty III. Z-plasty IV. Karydakis procedure Select the correct answer using the code given below :

I, II and IV. ***I, II and IV*** - The **Limberg procedure** (rhomboid flap) and **Karydakis flap** are the most widely established plastic surgical techniques used to close the defect after pilonidal sinus excision. - These techniques aim to **flatten the natal cleft** and move the scar away from the midline, reducing tension and recurrence rates. - **Y-V plasty** is less commonly used specifically for pilonidal sinus compared to Limberg and Karydakis procedures, though it can be employed for tissue advancement in selected cases. - This combination excludes Z-plasty, which is not a primary technique for pilonidal sinus closure. *II, III and IV* - While **Karydakis procedure** is indeed a standard technique, this option incorrectly includes **Z-plasty**, which is generally used for **scar revision** or releasing contractures rather than primary closure of large excisional defects. - It also excludes the **Limberg flap**, which is one of the most commonly used techniques worldwide for pilonidal sinus surgery. *I, III and IV* - This option incorrectly includes **Z-plasty** while excluding **Y-V plasty**. - Z-plasty is not a primary technique for closing pilonidal sinus defects as it doesn't provide adequate tissue coverage for large excisions. - The **Limberg and Karydakis procedures** are the mainstay techniques from this list. *I, II and III* - This combination incorrectly includes **Z-plasty** as a primary technique for closing the excisional defect. - It omits the **Karydakis procedure**, which is one of the most widely recognized and effective flaps for pilonidal disease with excellent outcomes. - The Karydakis flap specifically focuses on **modifying the natal cleft contour** and displacing the incision laterally for better healing and lower recurrence rates.

Q: Which of the following statements are correct regarding sutures in surgery? I. Barbed sutures have the advantage of eliminating the need for knots. II. Vertical mattress sutures help in eversion of wound edges. III. Aberdeen knot is used for continuous suturing. IV. Silk is preferred for subcuticular suturing. Select the answer using the code given below :

I, II and III. ***I, II and III*** - **I. Barbed sutures** have unidirectional or bidirectional barbs that grip tissue, negating the need for traditional knots to secure the suture line. This property can significantly **reduce operating time** and the volume of foreign material left in the wound. - **II. Vertical mattress sutures** are designed to achieve precise wound edge approximation and eversion, which are crucial for optimal healing and cosmesis, particularly in areas under tension or for thick skin. - **III. The Aberdeen knot** is a slip knot technique specifically designed to secure the end of a **continuous suture line** efficiently and reliably. It provides a flat, secure knot that minimizes bulk and is less prone to loosening. *I, II and IV* - While statements I and II are correct, statement IV is incorrect. **Silk is a braided, non-absorbable multifilament suture** that can cause significant tissue reaction. - It is generally not preferred for subcuticular suturing due to its increased risk of infection, visibility, and foreign body reaction compared to monofilament, absorbable sutures. *II, III and IV* - Statements II and III are correct, but statement IV is incorrect. **Silk is avoided for subcuticular closure** due to its inflammatory properties and potential for suture extrusion or sinus formation. - Subcuticular sutures typically use **absorbable monofilament sutures** (e.g., poliglecaprone 25 or polydioxanone) to minimize tissue reaction and achieve good cosmetic results. *I, III and IV* - Statements I and III are correct regarding barbed sutures and the Aberdeen knot, respectively. However, statement IV is incorrect because **silk suture is a non-absorbable, braided material that is highly reactive and not suitable for subcuticular placement**, where monofilament absorbable sutures are preferred for minimal tissue reaction and good cosmesis.

Q: Consider the following : I. Diabetes II. Hypertension III. Renal failure IV. Jaundice Which of the above are the risk factors for post-operative wound dehiscence?

I, III and IV. ***I, III and IV*** - **Diabetes** impairs wound healing through microvascular complications, neuropathy, and increased infection risk. - **Renal failure** (III) leads to uremia, malnutrition, and impaired collagen synthesis, all of which compromise wound integrity. - **Jaundice** (IV) is associated with impaired collagen synthesis, reduced fibroblast activity, and increased risk of infection, contributing to poor wound healing. *II, III and IV* - **Hypertension** (II) alone is not a direct risk factor for post-operative wound dehiscence; its complications (e.g., end-organ damage) might indirectly affect healing. - **Renal failure** (III) and **jaundice** (IV) are indeed significant risk factors, but the exclusion of diabetes makes this option incomplete. *I, II and III* - While **diabetes** (I) and **renal failure** (III) are major risk factors, **hypertension** (II) in isolation does not directly cause wound dehiscance. - This option incorrectly omits **jaundice** (IV), which is a known independent risk factor for impaired wound healing. *I, II and IV* - **Diabetes** (I) and **jaundice** (IV) are strong risk factors, but **hypertension** (II) does not directly contribute. - This option incorrectly excludes **renal failure** (III), which is a significant predisposing factor for wound dehiscence.

Q: Which of the following are included in common causes of mediastinal masses in superior and anterior mediastinum? I. Goitre II. Thymic tumour III. Neurogenic tumour Select the correct answer using the code given below :

I and II only. ***I and II only*** - **Goitre** (retrosternal thyroid extension) is a common cause of superior mediastinal masses. - **Thymic tumors** (thymoma, thymic carcinoma) are characteristically found in the anterior mediastinum. *I, II and III* - While goitre and thymic tumors are common in the superior and anterior mediastinum respectively, **neurogenic tumors** are typically found in the posterior mediastinum. - This option incorrectly includes neurogenic tumors with masses of the superior and anterior mediastinum. *II and III only* - This option correctly identifies **thymic tumors** for the anterior mediastinum but incorrectly includes **neurogenic tumors**, which are found in the posterior mediastinum. - It also omits **goitre**, which is a significant cause of superior mediastinal masses. *I and III only* - This option correctly identifies **goitre** as a superior mediastinal mass but incorrectly includes **neurogenic tumors**, which are typically located in the posterior mediastinum. - It incorrectly omits **thymic tumors**, which are a primary cause of anterior mediastinal masses.

Q: A 56-year-old male came with acute onset breathlessness and found to have pneumothorax. The resident doctor decided to insert an intercostal drain. Which one of the following sites is suitable for such a procedure?

Triangle of safety. ***Triangle of safety*** - The **triangle of safety** is the universally accepted site for safe **intercostal drain (chest tube)** insertion to treat **pneumothorax**. - Its boundaries help avoid injury to vital organs; it is bordered by the **anterior border of the latissimus dorsi**, the **lateral border of the pectoralis major**, and the **fifth intercostal space**. *Petit's triangle* - This anatomical landmark, also known as the **lumbar triangle**, is located in the **lumbar region** of the back. - It defines a weaker area in the abdominal wall and is a common site for **lumbar hernias**, not chest tube insertion for pneumothorax. *Hesselbach's triangle* - This triangle is located in the **groin region** and is an important anatomical landmark for **inguinal hernias**. - It is bordered by the inferior epigastric vessels, the lateral border of the rectus abdominis, and the inguinal ligament, and is entirely unrelated to chest procedures. *Triangle of auscultation* - The **triangle of auscultation** is a small region of the back, bordered by the **latissimus dorsi**, **trapezius**, and **medial border of the scapula**. - It is a thinner area of musculature, making it an ideal location for **listening to breath sounds** with a stethoscope, but it is not used for invasive procedures like chest tube insertion.

Q: The best measure of organ perfusion and the best monitor of adequacy of shock therapy is

urine output. ***urine output*** - **Urine output** is a direct and sensitive indicator of **renal blood flow** and, consequently, overall organ perfusion [1]. Adequate urine production (typically >0.5 mL/kg/hr) signifies that the kidneys are being sufficiently perfused, which generally correlates with adequate perfusion of other vital organs. - In the context of shock, improved urine output following therapy indicates effective restoration of **circulating blood volume** and microcirculation, making it an excellent monitor for treatment adequacy. *restoring blood pressure/pulse vital parameters* - While restoring **blood pressure** and **pulse** is a critical goal in shock management, these parameters alone do not always reflect true tissue perfusion [1]. A patient can have normalized blood pressure due to **vasoconstriction** while still experiencing inadequate microcirculatory flow and cellular hypoxia. - These vital signs are systemic indicators, and while essential, they don't provide the same granular insight into **organ-level perfusion** as urine output. *central venous pressure* - **Central venous pressure (CVP)** primarily reflects the **right heart's filling pressure** and overall intravascular volume status [1]. While CVP helps guide fluid resuscitation, it is not a direct measure of organ perfusion. - CVP can be influenced by various factors, including **cardiac function** and **intrathoracic pressure**, and a "normal" CVP does not guarantee adequate perfusion to all organs [1]. *pulmonary wedge pressure* - **Pulmonary wedge pressure (PWP)**, also known as pulmonary artery occlusion pressure, reflects the **left atrial pressure** and serves as an indicator of left ventricular preload [1]. - While PWP is useful in assessing **cardiac function** and guiding fluid management in specific types of shock [1] (e.g., cardiogenic shock), it is not a primary measure of global organ perfusion or a universal monitor for adequacy of shock therapy.

Q: A surgeon is about to start a laparoscopic procedure on a patient. The floor nurse asks the surgeon about the identity of the patient, site of the procedure to be performed and any anticipated critical events during the surgery. These questions are a part of the

WHO surgical safety checklist. **WHO surgical safety checklist** - The questions about patient identity, procedure site, and anticipated critical events are key components of the **"Sign In"** and **"Time Out"** sections of the **WHO Surgical Safety Checklist**. - This checklist is designed to improve **patient safety** by ensuring communication and adherence to essential steps before, during, and after surgery, thereby reducing surgical errors. *nurses safety checklist* - While nurses play a crucial role in patient safety, there isn't a universally recognized "nurses safety checklist" that specifically encompasses these exact comprehensive surgical verification steps. - The comprehensive framework described, with its specific questions, aligns more closely with the broader, interdisciplinary **WHO Surgical Safety Checklist**. *universal precautions checklist* - **Universal precautions** focus on preventing the transmission of bloodborne pathogens and other infectious agents by treating all bodily fluids as potentially infectious. - This checklist primarily addresses **infection control** measures and does not cover patient identification, surgical site verification, or critical event anticipation. *MCI patient safety checklist* - A "MCI patient safety checklist" is not a widely recognized or standardized medical safety protocol. - The scenario describes a standard, internationally adopted set of safety checks specifically for surgical procedures, which is the **WHO Surgical Safety Checklist**.

Question 1

A 25-year-old man with a history of road traffic injury presents to your clinic 4 months after the episode. His clinical presentation is shown in the image. What is the most likely diagnosis?

Accepted Answer

Normal scar

Answer

Keloid

Answer

Hypertrophic scar

Answer

Wound contraction

Question 2

Which needle is shown below?

Accepted Answer

Vim-Silverman needle

Answer

Tru-cut needle

Answer

Lumbar puncture needle

Answer

Abraham's pleural biopsy needle

Question 3

The commonest site of pressure sore is :

Accepted Answer

Heel

Answer

Sacrum

Answer

Ischium

Answer

Occiput

Question 4

Which of the following are the techniques commonly used to close the raw area after excision of a pilonidal sinus in order to avoid a midline wound?
I. Limberg procedure
II. Y-V plasty
III. Z-plasty
IV. Karydakis procedure

Select the correct answer using the code given below :

Accepted Answer

I, II and IV

Answer

II, III and IV

Answer

I, III and IV

Answer

I, II and III

Question 5

Which of the following statements are correct regarding sutures in surgery?
I. Barbed sutures have the advantage of eliminating the need for knots.
II. Vertical mattress sutures help in eversion of wound edges.
III. Aberdeen knot is used for continuous suturing.
IV. Silk is preferred for subcuticular suturing.

Select the answer using the code given below :

Accepted Answer

I, II and III

Answer

I, II and IV

Answer

II, III and IV

Answer

I, III and IV

Question 6

Consider the following :
I. Diabetes
II. Hypertension
III. Renal failure
IV. Jaundice

Which of the above are the risk factors for post-operative wound dehiscence?

Accepted Answer

I, III and IV

Answer

II, III and IV

Answer

I, II and III

Answer

I, II and IV

Question 7

Which of the following are included in common causes of mediastinal masses in superior and anterior mediastinum?
I. Goitre
II. Thymic tumour
III. Neurogenic tumour

Select the correct answer using the code given below :

Accepted Answer

I and II only

Answer

I, II and III

Answer

II and III only

Answer

I and III only

Question 8

A 56-year-old male came with acute onset breathlessness and found to have pneumothorax. The resident doctor decided to insert an intercostal drain. Which one of the following sites is suitable for such a procedure?

Accepted Answer

Triangle of safety

Answer

Petit's triangle

Answer

Hesselbach's triangle

Answer

Triangle of auscultation

Question 9

The best measure of organ perfusion and the best monitor of adequacy of shock therapy is

Accepted Answer

urine output

Answer

restoring blood pressure/pulse vital parameters

Answer

central venous pressure

Answer

pulmonary wedge pressure

Question 10

A surgeon is about to start a laparoscopic procedure on a patient. The floor nurse asks the surgeon about the identity of the patient, site of the procedure to be performed and any anticipated critical events during the surgery. These questions are a part of the

Accepted Answer

WHO surgical safety checklist

Answer

nurses safety checklist

Answer

universal precautions checklist

Answer

MCI patient safety checklist

General Surgery Principles — MCQs

General Surgery Principles — MCQs

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