FMGE 2024 - Surgery PYQs Practice Questions

Q: A 35-year-old woman, 10 years after mastectomy, notices gradual swelling and heaviness in her right upper limb without pain. On examination, bluish nodules on the skin with no infections are noted. What is the most likely cause of her symptoms?

Lymphangiosarcoma. ***Lymphangiosarcoma*** - The appearance of **bluish-purple cutaneous nodules** in a limb affected by long-standing **chronic lymphedema** (secondary to mastectomy and likely axillary dissection) is the classic presentation of **Stewart-Treves syndrome**, or post-mastectomy lymphangiosarcoma. - This is a rare, highly aggressive form of **angiosarcoma** arising from lymphatic endothelial cells in chronically static fluid, which aligns perfectly with the patient's history (10 years post-mastectomy). *Thoracic outlet syndrome* - This condition typically results from compression of the neurovascular bundle, causing symptoms like pain, paresthesias, weakness, or vascular changes (e.g., *Raynaud phenomenon*). - While mild edema can occur, it does not explain the significant history of chronic post-operative lymphedema or the development of highly specific **bluish cutaneous tumor nodules**. *Chronic venous insufficiency* - CVI typically affects the **lower limbs** and is characterized by edema, **skin hyperpigmentation**, and potential venous ulceration or stasis dermatitis, rather than post-mastectomy lymphedema. - The primary pathology here is lymphatic blockage following surgery, not incompetence of the venous valves, and CVI does not lead to the formation of sarcomatous skin nodules. *Recurrent breast cancer* - While recurrence can cause new lymphedema through **lymphatic obstruction**, the appearance of aggressive, rapidly growing **bluish vascular nodules** is highly suggestive of a secondary sarcoma (lymphangiosarcoma) rather than typical epithelial recurrence. - Recurrence often presents as a firm, ill-defined mass or local inflammatory changes, unlike the descriptive appearance of an **angiomatous tumor**. [Practice more Surgery PYQs on OnCourse]

Q: A patient presents with calf pain while walking a certain distance. The pain is severe enough that he must stop and rest before continuing. According to Boyd's grading, which of the following grades best describes this condition?

C. Grade 3. ***Correct: Grade 3*** - This grade signifies that the **claudication pain is severe enough to force the patient to stop and rest**, indicating moderately severe peripheral artery disease (PAD) - The distance the patient can walk before stopping is typically **short**, distinguishing it from less severe grades - This matches the clinical scenario where the patient "must stop and rest before continuing" *Incorrect: Grade 1* - This is the mildest form, where the patient experiences **claudication pain only after long distances** of walking - The pain is typically **not severe** and does not significantly interfere with regular walking pace or necessitate stopping - Patient can complete usual walking activities without stopping *Incorrect: Grade 2* - In this stage, pain occurs after a **moderate distance**, but the patient is usually able to continue walking by **slowing their pace** without immediately having to stop - It represents a mild to moderate level of **ischemia** induced by exercise - Key difference: patient can continue walking (albeit slowly) without complete rest *Incorrect: Grade 4* - This grade represents **critical limb ischemia (CLI)**, characterized by **pain at rest** and/or the presence of **ischemic ulcers or gangrene** - It is the most severe grade of PAD, often requiring urgent revascularization - Pain occurs even without walking [Practice more Surgery PYQs on OnCourse]

Q: Which of the following is not an indication for splenectomy?

Bone marrow failure. ***Bone marrow failure*** - In bone marrow failure (e.g., aplastic anemia), the spleen serves as an important site of **extramedullary hematopoiesis** (compensatory blood cell production outside the bone marrow) - Splenectomy would **remove this compensatory mechanism** and worsen the patient's condition - Therefore, bone marrow failure is a **contraindication**, not an indication for splenectomy *Hairy cell leukemia* - This is a chronic B-cell lymphoproliferative disorder with massive splenomegaly - Splenectomy is indicated when medical treatment fails or for symptomatic relief *Thrombocytopenia* - Immune thrombocytopenic purpura (ITP) is a classic indication for splenectomy - Performed when medical management (steroids, IVIG) fails - Spleen is the primary site of platelet destruction in ITP *Iatrogenic splenic trauma* - Intraoperative injury to the spleen during abdominal surgery - Splenectomy is indicated when hemostasis cannot be achieved or injury is severe (Grade IV-V) [Practice more Surgery PYQs on OnCourse]

Q: A patient underwent surgery for pilonidal sinus, which type of flap is used in this surgery?

Rhomboid flap. ***Rhomboid flap***- The **Limberg flap** is a classic type of rhomboid transposition flap widely used for closing the deep, large defect left after wide excision of a pilonidal sinus.- This flap provides excellent tissue coverage, shifts the scar away from the midline natal cleft, and significantly reduces tension, leading to lower rates of **recurrence**.*Advanced flap*- An advancement flap involves moving tissue linearly forward, which often results in high tension when used to close the typical wide, ovoid defect remaining after pilonidal sinus excision.- They are less suitable for deep and wide midline defects compared to rotational or transposition flaps because they do not effectively flatten the **natal cleft** or distribute tension laterally.*Rotational flap*- While rotational flaps (like the **Karydakis flap**) are effective for pilonidal disease by excising the disease and closing the defect laterally, the **Limberg flap** is specifically a rhomboid transposition flap and is arguably the most classic answer for a geometric local flap used in this surgery.- Simple rotational flaps might be used, but the effectiveness and precision provided by the rhomboid geometry for large defects make the Limberg (rhomboid) technique particularly notable.*Free flap*- **Free flaps** involve microsurgical anastomosis to connect tissue from a distant site, a level of surgical complexity unnecessary for standard pilonidal sinus reconstruction.- These flaps are reserved for very large, complex defects, often requiring coverage where local tissue has been destroyed by cancer or **osteomyelitis**, which is usually not the case in routine pilonidal surgery. [Practice more Surgery PYQs on OnCourse]

Q: Which nerve is most commonly injured during indirect inguinal hernia surgery?

Ilioinguinal nerve. ***Ilioinguinal nerve*** - This nerve travels superficial to the **external oblique aponeurosis** along the inguinal canal, making it extremely susceptible to direct trauma from surgical incisions, suture placement, or mesh fixation near the **pubic tubercle**. - Injury results in chronic pain and paresthesia (burning sensation) along its distribution, affecting the groin, lateral base of the penis/scrotum, and medial aspect of the thigh (**ilioinguinal neuralgia**). *Femoral nerve* - The femoral nerve lies deep to the **inguinal ligament** lateral to the femoral artery (part of the **NAVEL** bundle), a position deep and lateral to the primary operative field for indirect hernia repair. - Injury is rare in standard open inguinal hernia repair but can occur during deep retraction, or if the hernia dissection extends deeply and laterally below the inguinal ligament. *Genitofemoral nerve* - The genital branch traverses the inguinal canal within the **spermatic cord** and can be injured; however, the ilioinguinal nerve is more frequently involved due to its proximity to the surgical incision lines. - Injury to the genital branch specifically causes loss of the **cremaster reflex** and sensory loss over the anterior scrotum or labia. *Obturator nerve* - This nerve is located deep within the pelvis, passing through the **obturator canal** to supply the adductor muscles and medial thigh skin. - It is anatomically remote from the standard superficial and anterior approach required during routine indirect inguinal hernia repair. [Practice more Surgery PYQs on OnCourse]

Question 1

A 35-year-old woman, 10 years after mastectomy, notices gradual swelling and heaviness in her right upper limb without pain. On examination, bluish nodules on the skin with no infections are noted. What is the most likely cause of her symptoms?

Accepted Answer

Lymphangiosarcoma

Answer

Recurrent breast cancer

Answer

Thoracic outlet syndrome

Answer

Chronic venous insufficiency

Question 2

A patient presents with calf pain while walking a certain distance. The pain is severe enough that he must stop and rest before continuing. According to Boyd's grading, which of the following grades best describes this condition?

Accepted Answer

C. Grade 3

Answer

B. Grade 2

Answer

D. Grade 4

Answer

A. Grade 1

Question 3

Which of the following is not an indication for splenectomy?

Accepted Answer

Bone marrow failure

Answer

Hairy cell leukemia

Answer

Thrombocytopenia

Answer

Iatrogenic splenic trauma

Question 4

A patient underwent surgery for pilonidal sinus, which type of flap is used in this surgery?

Accepted Answer

Rhomboid flap

Answer

Free flap

Answer

Rotational flap

Answer

Advancement flap

Question 5

Which nerve is most commonly injured during indirect inguinal hernia surgery?

Accepted Answer

Ilioinguinal nerve

Answer

Genitofemoral nerve

Answer

Obturator nerve

Answer

Femoral nerve

FMGE 2024 — Surgery