General Surgery Principles — MCQs

General Surgery Principles Indian Medical PG Practice Questions and MCQs

Question 951: A 65-year-old male presents to the emergency department with acute respiratory distress, decreased breath sounds, and stony dullness to percussion on the right side. What is the initial management for this patient?

A. Echocardiogram
B. Pericardial window
C. Pericardiocentesis
D. Thoracentesis of the right chest cavity (Correct Answer)

Explanation: ***Thoracentesis of the right chest cavity*** - This patient presents with **acute respiratory distress**, **decreased breath sounds**, and **stony dullness to percussion** on the right side, which are classic signs of a **large pleural effusion**. - **Thoracentesis** (needle aspiration of pleural fluid) is the immediate intervention to relieve pressure on the lung, allow for re-expansion, and improve breathing. - This procedure provides both diagnostic information (analyzing pleural fluid) and therapeutic relief. *Pericardiocentesis* - This procedure is performed to drain fluid from the **pericardial sac** in cases of **cardiac tamponade** (Beck's triad: hypotension, muffled heart sounds, JVP elevation). - The patient's symptoms of decreased breath sounds, dullness to percussion, and unilateral findings point to a **pleural** issue, not a cardiac one. *Echocardiogram* - An **echocardiogram** is an imaging test used to visualize the heart's structure and function and assess for pericardial effusions. - While useful for diagnosis, it is **not an initial management step** to relieve acute respiratory distress caused by a pleural effusion. - In emergency settings with clear clinical signs, **therapeutic intervention takes priority** over diagnostic imaging. *Pericardial window* - A **pericardial window** is a surgical procedure to create an opening in the pericardium, typically for recurrent or loculated pericardial effusions. - This is a **definitive surgical treatment** and not an initial emergency management for acute respiratory distress from pleural pathology.

Question 952: A 70-year-old man presents with chest pain, diagnosed with coronary disease, and concurrently detected asymptomatic gallstones on ultrasonography. What is the most appropriate management strategy for gallstones in this patient?

A. Open cholecystectomy
B. Laparoscopic cholecystectomy
C. Oral dissolution agents
D. Conservative management with monitoring (Correct Answer)

Explanation: ***Conservative management with monitoring*** - Asymptomatic gallstones generally do not require surgical intervention due to the low risk of developing symptoms or complications and the potential risks of surgery in an elderly patient with **coronary artery disease**. - **Monitoring** for the development of symptoms such as biliary colic, cholecystitis, or pancreatitis is the recommended approach. *Open cholecystectomy* - This is a more invasive surgical procedure with a longer recovery time and higher risks compared to laparoscopic cholecystectomy. - It is typically reserved for complex cases or when laparoscopic surgery is contraindicated, neither of which applies to asymptomatic gallstones. *Laparoscopic cholecystectomy* - While this is the standard surgical treatment for **symptomatic gallstones**, it is not indicated for asymptomatic gallstones. - Performing elective surgery in an elderly patient with **coronary artery disease** for an asymptomatic condition would expose them to unnecessary surgical risks. *Oral dissolution agents* - These agents (e.g., **ursodeoxycholic acid**) are primarily effective for dissolving small, cholesterol-rich gallstones. - They have a low success rate, require prolonged treatment, and gallstones often recur after treatment cessation, making them unsuitable for routine management of asymptomatic gallstones.

Question 953: Which type of hernia is commonly associated with hydrocele?

A. Indirect inguinal hernia (Correct Answer)
B. Umbilical hernia
C. Direct inguinal hernia
D. Femoral hernia

Explanation: ***Indirect inguinal hernia*** - An **indirect inguinal hernia** occurs when there is a persistent **patent processus vaginalis**, the same embryological structure that can lead to a **hydrocele** if it closes incompletely distally. - Both conditions arise from the failure of the **processus vaginalis** to fully obliterate, allowing abdominal contents (for hernia) or peritoneal fluid (for hydrocele) to enter the inguinal canal or scrotum. *Direct inguinal hernia* - A **direct inguinal hernia** protrudes directly through **Hesselbach's triangle** and is an acquired weakness of the posterior wall of the inguinal canal, not related to the processus vaginalis. - It involves a different anatomical defect and does not share the same developmental origin as a hydrocele. *Femoral hernia* - A **femoral hernia** protrudes through the **femoral canal** below the inguinal ligament, a distinct anatomical pathway from the inguinal canal. - It is more common in women and is not embryologically linked to the formation of a hydrocele. *Umbilical hernia* - An **umbilical hernia** involves a protrusion through the **umbilical ring** due to incomplete closure of the abdominal wall at the umbilicus. - This type of hernia is entirely distinct in its anatomical location and developmental origin from both inguinal hernias and hydroceles.

Question 954: Which of the following is the MOST significant risk factor for inguinal hernia?

A. Hypertension
B. Cigarette smoking (Correct Answer)
C. Diabetes mellitus
D. Hypothyroidism

Explanation: ***Cigarette smoking*** - **Cigarette smoking** is strongly associated with an increased risk of inguinal hernia due to the breakdown of connective tissue and increased intra-abdominal pressure from chronic cough. - **Smoking** leads to impaired collagen synthesis and degradation of existing collagen, weakening the abdominal wall and predisposing to hernia formation. *Diabetes mellitus* - While **diabetes mellitus** can affect wound healing and increase the risk of surgical complications, it is not considered a primary direct risk factor for the development of an inguinal hernia itself. - The impact of **diabetes** on connective tissue strength is less direct and significant for hernia formation compared to factors like chronic cough from smoking. *Hypertension* - **Hypertension** is not a direct risk factor for the development of inguinal hernias. - There is no clear physiological mechanism linking elevated blood pressure to the weakening of the abdominal wall. *Hypothyroidism* - **Hypothyroidism** can be associated with an increased risk of certain types of hernias, particularly umbilical hernias, due to generalized weakness of connective tissue. - However, it is not considered the MOST significant risk factor for **inguinal hernias** specifically, which are more influenced by factors affecting intra-abdominal pressure and collagen integrity.

Question 955: Which of the following structures is not seen on bronchoscopy?

A. Trachea
B. Vocal cords
C. Subcarinal lymph nodes (Correct Answer)
D. First segmental division of bronchi

Explanation: ***Subcarinal lymph nodes*** - While the **carina** (the division of the trachea into the main stem bronchi) is clearly visible, the **lymph nodes** located beneath it are external to the airway and cannot be directly visualized during a standard bronchoscopy. - Visualization of lymph nodes typically requires imaging studies like CT scans or invasive procedures like **endobronchial ultrasound (EBUS)** with biopsy. *Trachea* - The **trachea** is the main airway tube and is fully visualized during the initial insertion and advancement of the bronchoscope. - Its rings, mucosa, and antegrade lumen are clearly inspected. *Vocal cords* - The **vocal cords** are located in the larynx, superior to the trachea, and are the first structures encountered and assessed during the intubation phase of a bronchoscopy. - Their movement and appearance are routinely checked to ensure proper bronchoscope insertion. *First segmental division of bronchi* - Bronchoscopy allows for the visualization of the **main bronchi** and their subsequent divisions down to the **segmental and subsegmental bronchi**. - The first division branches are readily accessible and are a common area for inspection and biopsy.

Question 956: Which of the following statements regarding indirect inguinal hernia is incorrect?

A. Inguinal herniotomy is the basic operation
B. Transillumination distinguishes it from hydrocele
C. Most common type of hernia
D. Always unilateral (Correct Answer)

Explanation: ***Always unilateral*** - While indirect inguinal hernias are more frequently unilateral, they can occur **bilaterally** in some patients. - The persistence of a **patent processus vaginalis** on both sides would predispose to bilateral herniation. *Most common type of hernia* - **Indirect inguinal hernias** are indeed the most common type of abdominal wall hernia, accounting for approximately two-thirds of all inguinal hernias. - This is due to their congenital origin from a **patent processus vaginalis**. *Inguinal herniotomy is the basic operation* - For children with indirect inguinal hernias, **inguinal herniotomy** (ligation and excision of the hernia sac) is the standard and often curative procedure. - In adults, a **hernioplasty** (repair with mesh) is usually performed, but simple herniotomy is suitable in specific cases. *Transillumination distinguishes it from hydrocele* - **Hydroceles** typically transilluminate (light passes through), indicating a fluid-filled sac. - An indirect inguinal hernia contains **bowel or omentum**, which does not transilluminate, thus helping to differentiate the two.

Question 957: All of the following are true regarding pilonidal sinus except:

A. Most commonly occurs in sacrococcygeal region
B. Obesity is a risk factor
C. tendency for recurrence
D. Seen predominantly in women (Correct Answer)

Explanation: ***Seen predominantly in women*** - Pilonidal sinus is **more prevalent in men** than in women, with a male-to-female ratio of about 3–4:1. - This higher incidence in males is often attributed to greater hairiness and occupational factors. *Most commonly occurs in sacrococcygeal region* - This is a **TRUE statement** - the sacrococcygeal region is the **most common site** for pilonidal sinus (>90% of cases). - While less commonly, pilonidal sinuses can also occur in other hairy areas such as the periumbilical region, axilla, and scalp (particularly in barbers). *Tendency for recurrence* - Pilonidal sinuses have a **high tendency for recurrence**, even after surgical intervention, especially with inadequate excision or conservative management. - Factors contributing to recurrence include presence of **remaining hair follicles** or insufficient removal of sinus tracts. *Obesity is a risk factor* - **Obesity** is a recognized risk factor for the development of pilonidal sinus. - Increased weight can lead to deeper gluteal clefts, increased sweating, and friction, which promote hair follicle damage and foreign body inflammatory reactions.

Question 958: A chest X-ray (CXR) of a patient is shown. What is the next step in management of this patient?

A. Ventilation perfusion scan
B. Bronchoalveolar lavage
C. High resolution CT scan
D. Exploratory laparotomy (Correct Answer)

Explanation: ***Exploratory laparotomy*** - The chest X-ray shows **free air under the diaphragm** on the right side, indicating **pneumoperitoneum**. - **Pneumoperitoneum** usually signifies a **perforated abdominal viscus**, a surgical emergency requiring immediate exploration to identify and repair the perforation. *Ventilation perfusion scan* - This scan is primarily used to diagnose **pulmonary embolism** and is not indicated for the current finding. - The chest X-ray does not show any signs suggestive of pulmonary embolism, such as a **Westermark sign** or a **Hampton hump**. *Bronchoalveolar lavage* - **Bronchoalveolar lavage (BAL)** is a diagnostic procedure used to retrieve fluid from the lower respiratory tract for analysis, typically for infections or inflammatory conditions. - It would not be helpful in evaluating **subdiaphragmatic free air**, which is an abdominal issue. *High resolution CT scan* - While a **CT scan** could further characterize the pneumoperitoneum, the presence of clear free air on a plain film warrants **immediate surgical intervention** rather than further imaging, especially in an acute setting. - A CT scan might be considered if the diagnosis is equivocal, but in this case, the finding is unequivocal and indicates an emergency.

Question 959: In which of the following conditions is splenectomy not indicated?

A. Trauma
B. Hereditary spherocytosis
C. Splenic abscess
D. Tuberculosis of the spleen (Correct Answer)

Explanation: ***Tuberculosis of the spleen*** - While splenic tuberculosis can occur, **medical management** with anti-tuberculosis drugs is typically the primary treatment, and splenectomy is usually not indicated unless there are complications like massive hemorrhage or rupture. - Splenectomy for tuberculosis **does not address the systemic nature** of the infection and carries risks without significant benefit in most cases. *Trauma* - **Splenic trauma** leading to hemorrhage or rupture is a common indication for splenectomy, especially in cases of severe injury. - Removal of the spleen can be **life-saving** to control bleeding and prevent hypovolemic shock. *Hereditary spherocytosis* - Splenectomy is the definitive treatment for **hereditary spherocytosis** to correct anemia and reduce hemolysis. - The spleen is responsible for **premature destruction of abnormally shaped red blood cells**, so its removal improves red blood cell survival. *Splenic abscess* - **Splenic abscesses** often require splenectomy, particularly if they are large, multiple, or do not respond to antibiotic therapy. - Removing the infected organ helps to **eliminate the source of infection** and prevent systemic complications like sepsis.

Question 960: Two weeks following the initial management of this patient's chylothorax, there is persistent accumulation of chyle in the pleural space. Which of the following procedures is appropriate management at this time?

A. Neck exploration for thoracic duct injury
B. Subdiaphragmatic ligation of the thoracic duct
C. Thoracotomy and ligation of the thoracic duct (Correct Answer)
D. Thoracotomy and repair of the thoracic duct injury

Explanation: ***Thoracotomy and ligation of the thoracic duct*** - This is the **standard surgical management** for persistent chylothorax that fails conservative treatment (typically after 2 weeks of chest tube drainage and nutritional management). - The procedure involves **right-sided thoracotomy** with ligation of the thoracic duct at or above the aortic hiatus (supradiaphragmatic level). - Ligation is preferred over repair because the **exact site of injury is often difficult to identify**, and ligation effectively stops the chyle leak by forcing lymphatic drainage through collateral pathways. - The thoracic duct is a **single, identifiable structure** at the level of the diaphragm, making supradiaphragmatic ligation technically feasible and effective. *Subdiaphragmatic ligation of the thoracic duct* - This is **not a standard surgical approach** for chylothorax management in major surgical practice. - The thoracic duct is typically accessed via **thoracotomy (supradiaphragmatic)** rather than through an abdominal/subdiaphragmatic approach. - Standard textbooks recommend **right thoracotomy with supradiaphragmatic thoracic duct ligation** as the definitive surgical treatment. *Neck exploration for thoracic duct injury* - Cervical approach is indicated only for **injuries in the neck region** (left supraclavicular area where the thoracic duct terminates). - This would not be appropriate for persistent chylothorax from thoracic injuries, which are more common. - The thoracic duct in the neck consists of **multiple small tributaries**, making surgical management more challenging. *Thoracotomy and repair of the thoracic duct injury* - Direct repair is technically **very difficult** due to the small caliber (2-3mm) and fragile nature of the thoracic duct. - The exact site of injury is often **not clearly identifiable** during surgery. - **Ligation is preferred over repair** because it has higher success rates, and collateral lymphatic channels can adequately handle lymphatic drainage after main duct ligation.

Practice by Chapter

Wound Healing and Care

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Surgical Infections

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Fluid and Electrolyte Management

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Nutrition in Surgical Patients

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Hemostasis and Blood Transfusion

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Surgical Instruments and Equipment

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Sutures and Stapling Devices

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Minimal Access Surgery Principles

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Surgical Complications

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Anesthesia Principles for Surgeons

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Surgical Oncology Principles

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Evidence-Based Surgery

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