FMGE 2025 - Surgery Practice Questions

Q: Given below are the steps of Damage control surgery. What is the correct sequence? 1. Control of hemorrhage and contamination 2. Temporary abdominal closure 3. Resuscitation in ICU 4. Definitive surgical repair

1,2,3,4. ***Correct Sequence: 1,2,3,4*** The correct sequence of Damage Control Surgery follows a systematic approach: **Step 1: Control of hemorrhage and contamination** - Initial abbreviated laparotomy to control life-threatening bleeding - Control contamination from hollow viscus injuries - Pack bleeding sites, ligate vessels, staple or resect perforated bowel - Goal: Stop bleeding and contamination rapidly **Step 2: Temporary abdominal closure** - Use temporary closure techniques (vacuum-assisted closure, Bogota bag, towel clip closure) - Prevents abdominal compartment syndrome - Avoids tension on abdominal wall in edematous/swollen abdomen - No attempt at definitive repairs **Step 3: Resuscitation in ICU** - Correct the "lethal triad": **hypothermia, acidosis, coagulopathy** - Optimize physiology with warming, volume resuscitation, blood products - Typically requires 24-48 hours of intensive care - Patient must be physiologically stable before returning to OR **Step 4: Definitive surgical repair** - Return to OR once hemodynamically stable and coagulopathy corrected - Perform definitive anastomoses, vascular repairs, reconstructions - Formal abdominal closure - May require multiple staged operations *Incorrect Option 3,1,2,4:* Starting with ICU resuscitation before controlling hemorrhage would be fatal *Incorrect Option 1,3,2,4:* Performing ICU resuscitation before temporary closure risks abdominal compartment syndrome *Incorrect Option 2,1,4,3:* Performing temporary closure before controlling hemorrhage is illogical **Clinical Pearl:** Damage control surgery is indicated in patients with physiologic exhaustion (hypothermia <35°C, pH <7.2, coagulopathy) where prolonged definitive surgery would be fatal.

Q: What is the most appropriate treatment for an 8cm chylolymphatic mesenteric cyst?

Enucleation. ***Enucleation*** - This is the standard surgical treatment for most **mesenteric cysts**, as it allows for complete removal of the cyst while preserving the adjacent bowel and its vital blood supply. - Successful **enucleation** has a very low recurrence rate and provides a definitive tissue diagnosis to rule out rare cases of malignancy. *Aspiration* - Aspiration is associated with a very high **recurrence rate** (50-100%) because the cyst-secreting lining is left behind. - It also carries risks of **infection**, **hemorrhage**, and leakage of cystic fluid causing chemical peritonitis, and it fails to provide a histological diagnosis. *Resection of the cyst along with the adjacent bowel* - This is an overly aggressive approach for a typically benign condition and should be avoided unless necessary to preserve **bowel viability**. - **Bowel resection** is reserved for cases where the cyst cannot be separated from the bowel wall or when the mesenteric blood supply is irrevocably compromised. *Conservative* - Conservative management is generally not recommended for symptomatic or large cysts (like this 8cm one) due to the risk of complications. - Potential complications include **intestinal obstruction**, **volvulus**, **torsion** of the cyst, **hemorrhage** into the cyst, or infection.

Q: A 30-year-old female presented with pain in the right upper quadrant of the abdomen after 4 days of cholecystectomy. On USG, it showed a significant collection in RUQ. What will you do further?

USG guided aspiration of content. ***USG guided aspiration of content***- A significant, symptomatic intra-abdominal collection post-cholecystectomy (4 days) strongly suggests a localized **abscess**, **hematoma**, or **biloma**, demanding urgent **source control**.- **Percutaneous drainage** guided by ultrasound or CT is the gold standard, minimally invasive treatment for accessible, well-defined fluid collections in the immediate postoperative period.*Re-explore laparoscopically*- Surgical **re-exploration** is more invasive and is typically reserved for cases where percutaneous drainage fails, or if there is diffuse peritonitis or active bleeding.- Since the USG shows a localized collection, the less invasive **percutaneous approach** is the initial management choice.*Higher antibiotics*- Antibiotics alone are insufficient to manage a significant, symptomatic fluid collection, especially if it is an **abscess** (pus collection).- Drainage (source control) followed by appropriate antibiotics is the required sequence to prevent systemic infection and **sepsis**.*MRCP*- **MRCP** (Magnetic Resonance Cholangiopancreatography) is a diagnostic test primarily used to evaluate the **biliary tree** for leaks or strictures.- While biliary tree integrity is important, the immediate therapeutic priority for a defined, symptomatic collection is drainage, not further imaging, unless a large, high-pressure **biloma** is highly suspected and the patient is stable.

Q: A neonate has intestines protruding from the abdomen without any external covering. What will be your next line of management?

Cover the content with a Silo bag and wait. ***Cover the content with a Silo bag and wait*** - This presentation, where intestines protrude without a covering sac, is **gastroschisis**. The primary management for gastroschisis usually involves a **staged reduction** using a pre-formed **silo bag** (or pouch). - The silo allows the edematous bowel to gradually return into the abdominal cavity by gravity over several days, minimizing the risk of **abdominal compartment syndrome** and visceral ischemia that can occur with forced primary closure. *Surgical correction* - Immediate primary surgical closure is often difficult in gastroschisis because the infant's abdominal cavity is relatively small (**abdominal paucity**). - Forcing closure when the volume is too large can significantly elevate intra-abdominal pressure, potentially leading to **intestinal ischemia** or respiratory compromise. *Conservative management with higher antibiotics* - Gastroschisis is a surgical emergency requiring definitive intervention (closure or staged reduction); simple conservative management or antibiotics alone is insufficient. - While **antibiotics** are a necessary supportive measure to prevent infection of the exposed bowel, they do not address the underlying anatomical defect or the risk of desiccation and mechanical injury. *Cover with NS-soaked gauze* - Covering the exposed bowel with warm, **NS-soaked gauze** is an essential immediate stabilization step during resuscitation and transport, protecting the viscera and minimizing fluid and heat loss. - However, the **silo bag** is considered the definitive method for long-term protection and **staged reduction** in cases where primary surgical repair is not feasible, making it the superior choice for the next line of management.

Q: After an RTA patient has severe Maxillofacial trauma with SpO2 80% at room air, and the patient cannot be intubated or ventilated, what should be your immediate step for this?

Cricothyrotomy. ***Cricothyrotomy***- This is the required immediate intervention in a "Cannot Intubate, Cannot Ventilate" (**CICV**) scenario, especially when severe maxillofacial trauma makes standard intubation impossible.- The SpO2 of **80%** indicates impending respiratory arrest and the urgent need for a definitive surgical airway below the level of obstruction/injury.*Tracheostomy*- A tracheostomy is a more complex surgical procedure that takes significantly longer than a **cricothyrotomy** and is not suitable in a crashing patient with immediate, life-threatening hypoxia.- It is typically reserved for elective or planned long-term airway management, not for initial **emergency airway access** in trauma.*ICD insertion*- An ICD (Intercostal Drain) insertion is used to treat **pneumothorax** or **hemothorax**, which addresses pulmonary/chest issues, not the primary problem of failed upper airway management due to maxillofacial trauma.- While chest injuries may coexist, airway management (A in **ATLS**) always takes immediate priority over breathing management (B) when the former is compromised to this extent.*Do suction and again try intubation*- The scenario explicitly states the patient **cannot be intubated or ventilated**, suggesting that maximal attempts, possibly including suctioning, have already failed or are deemed futile due to massive trauma/distortion.- Repeating futile attempts only prolongs the period of severe **hypoxia** (SpO2 80%), increasing the risk of cardiac arrest and neurologic damage.

Q: A 13-year-old male was brought to OPD with pain right side testes after being hit by a cricket ball 2 hours back. On examination, severe testicular pain and an absent cremasteric reflex. What is the next step?

Surgical exploration. ***Surgical exploration*** - This patient presents with **severe testicular pain** and **absent cremasteric reflex**, which has approximately **99% positive predictive value for testicular torsion** - The combination of these clinical findings constitutes a **surgical emergency** requiring **immediate scrotal exploration** without delay for imaging - **Time is critical**: testicular salvage rates are >90% if detorsion occurs within 6 hours, dropping to ~50% at 6-12 hours and <10% after 12 hours - In cases with **high clinical suspicion** (classic presentation with absent cremasteric reflex), imaging should **NOT delay surgical intervention** - Standard of care: proceed directly to the operating room for exploration and detorsion *USG Arterial Doppler* - While Doppler ultrasound can assess testicular blood flow, it is indicated only when the **diagnosis is equivocal** or clinical findings are unclear - Doppler has significant limitations: false negatives occur with intermittent or partial torsion, and arranging the study delays definitive treatment - In this case with **pathognomonic clinical findings** (absent cremasteric reflex + severe pain), imaging would inappropriately delay life-saving surgery - **"Time is testicle"** - every minute of delay reduces the chance of testicular salvage *USG Venous Doppler* - Venous Doppler is not the appropriate imaging modality for suspected testicular torsion - Arterial blood flow assessment is more relevant than venous drainage in diagnosing ischemia - However, with classic clinical presentation, neither imaging modality should delay surgical exploration *NSAIDS* - Administering analgesics alone is inappropriate management for suspected testicular torsion - Pain control does not address the underlying vascular compromise and will lead to **testicular loss** - NSAIDs may mask symptoms and create false reassurance while ischemic damage progresses

Q: A 30-year-old male presented to EMT with H/o Penetrating chest trauma. On examination, severe tracheal deviation was present. What is the immediate step of management?

Needle decompression. ***Needle decompression*** - The presence of **tracheal deviation** in a patient with penetrating chest trauma is a hallmark sign of a **tension pneumothorax**, a life-threatening condition that requires immediate intervention. - Needle decompression is the emergent, life-saving procedure performed to relieve the intrathoracic pressure by allowing the trapped air to escape, thereby correcting the mediastinal shift and restoring hemodynamic stability. *Chest X-ray* - A chest X-ray is a diagnostic tool used to confirm a pneumothorax but should **not** delay treatment in a hemodynamically unstable patient with clear clinical signs of tension. - Waiting for radiological confirmation in this emergency scenario can lead to cardiovascular collapse and death; the diagnosis is made clinically. *E-FAST* - The **Extended Focused Assessment with Sonography for Trauma (E-FAST)** can rapidly diagnose a pneumothorax at the bedside by showing an absence of **lung sliding**. - However, like a chest X-ray, it is a diagnostic step. In a patient with obvious signs of tension, proceeding directly to decompression is the priority over further imaging. *O2 support at 100%* - While supplemental oxygen is a crucial part of resuscitation in any trauma patient to treat hypoxia, it does not address the underlying mechanical problem. - The primary issue in a tension pneumothorax is the **compressive effect** of trapped air on the heart and great vessels, which can only be relieved by decompression.

Q: Identify the pathology in the child.

Umbilical Hernia. ***Umbilical Hernia*** - This is a protrusion of abdominal contents through a weak spot at the **umbilicus** (belly button), which is clearly depicted in the image. It occurs due to the incomplete closure of the umbilical ring after birth. - Umbilical hernias are very common in infants, particularly those born prematurely, and most resolve spontaneously without intervention by the age of 4-5 years. *Spigelian Hernia* - A Spigelian hernia occurs through the **Spigelian fascia**, located at the lateral edge of the rectus abdominis muscle, typically below the umbilicus. The bulge in the image is midline, not lateral. - This type of hernia is rare, especially in the pediatric population, and presents as a palpable mass on the side of the lower abdomen. *Inguinal Hernia* - An inguinal hernia involves the protrusion of abdominal contents through the **inguinal canal**, resulting in a bulge in the groin or scrotum. The location in the image is the umbilicus, not the groin. - While common in children, inguinal hernias are anatomically distinct and are located inferior and lateral to the umbilicus. *Femoral Hernia* - A femoral hernia occurs through the **femoral canal**, presenting as a bulge in the upper thigh, just below the inguinal ligament. This location is significantly different from the periumbilical bulge shown. - These hernias are rare in children and are more commonly seen in adult females due to the wider pelvis.

Q: A child comes after a train accident with stable vitals but a big laceration on the leg. Which triage category does the patient come under?

Yellow. ***Yellow (Correct Answer)*** - This category is used for casualties with **serious, non-life-threatening injuries** who require medical attention but whose treatment can be **delayed** for a few hours without causing immediate death or major morbidity. - A stable patient following trauma, despite having a **big laceration**, is categorized as Yellow because the immediate risk to life (indicated by **stable vitals**) is low, allowing for prioritized care after Red category patients are addressed. - The combination of **stable vitals + significant injury** = Yellow/Delayed category. *Red (Incorrect)* - This category is reserved for patients needing **immediate life-saving intervention** (within minutes), such as those with unstable vitals, airway obstruction, or uncontrolled severe hemorrhage leading to shock. - Since the patient has **stable vitals** (implying adequate circulation and respiration), they do not meet the criteria for immediate criticality required for the Red category. *Green (Incorrect)* - Green is assigned to the **'walking wounded'** or minor injuries like sprains, abrasions, or small cuts, where definitive treatment can be delayed indefinitely. - A **"big laceration"** implies a significant injury needing prompt management, ruling out the minor nature associated with the Green category. *Black (Incorrect)* - This category is for patients who are either confirmed **deceased** or have catastrophic injuries where survival is deemed highly unlikely (expectant categorization), and resources are better spent on higher priority patients. - Given the child has **stable vitals** and is salvageable with appropriate care, this category is inappropriate.

Q: A diabetic worker sustains a stab injury to the central region of his palm. After 3 days, he develops swelling, severe pain, and inability to extend his middle and ring fingers. Pus accumulation is suspected in one of the palmar spaces. Which of the following spaces is most likely involved?

B (Midpalmar space). ***B (Midpalmar space)*** - A stab wound to the central palm directly accesses the **midpalmar space**, which lies deep to the palmar aponeurosis and contains the flexor tendons for the middle, ring, and little fingers. - Infection and pus accumulation in this space lead to **flexor tenosynovitis**, causing severe pain, swelling, and inability to extend the middle and ring fingers, as their tendon sheaths are directly involved. *A (Hypothenar space)* - The **hypothenar space** is located on the ulnar side of the palm and is associated with the intrinsic muscles of the little finger. - An infection in this area would primarily cause swelling and tenderness over the hypothenar eminence and affect the **little finger**, not the middle and ring fingers. *C (Thenar space)* - The **thenar space** is on the radial side of the palm, containing the intrinsic muscles of the thumb and often the flexor tendon sheath of the index finger. - Infection here would cause significant swelling at the base of the thumb (thenar eminence) and primarily affect the function of the **thumb and index finger**. *D (Dorsal subaponeurotic space)* - This space is on the **dorsum (back) of the hand**, whereas the injury occurred on the palm. - While deep palmar space infections can cause significant dorsal swelling due to loose tissue, the primary site of pus collection from a palmar wound is a **palmar space**, not a dorsal one.

Question 1

Given below are the steps of Damage control surgery. What is the correct sequence?

1. Control of hemorrhage and contamination
2. Temporary abdominal closure
3. Resuscitation in ICU
4. Definitive surgical repair

Accepted Answer

1,2,3,4

Answer

3,1,2,4

Answer

1,3,2,4

Answer

2,1,4,3

Question 2

What is the most appropriate treatment for an 8cm chylolymphatic mesenteric cyst?

Accepted Answer

Enucleation

Answer

Aspiration

Answer

Conservative

Answer

Resection of the cyst along with the adjacent bowel

Question 3

A 30-year-old female presented with pain in the right upper quadrant of the abdomen after 4 days of cholecystectomy. On USG, it showed a significant collection in RUQ. What will you do further?

Accepted Answer

USG guided aspiration of content

Answer

Re-explore laparoscopically

Answer

MRCP

Answer

Higher antibiotics

Question 4

A neonate has intestines protruding from the abdomen without any external covering. What will be your next line of management?

Accepted Answer

Cover the content with a Silo bag and wait

Answer

Surgical correction

Answer

Cover with NS-soaked gauze

Answer

Conservative management with higher antibiotics

Question 5

After an RTA patient has severe Maxillofacial trauma with SpO2 80% at room air, and the patient cannot be intubated or ventilated, what should be your immediate step for this?

Accepted Answer

Cricothyrotomy

Answer

ICD insertion

Answer

Tracheostomy

Answer

Do suction and again try intubation

Question 6

A 13-year-old male was brought to OPD with pain right side testes after being hit by a cricket ball 2 hours back. On examination, severe testicular pain and an absent cremasteric reflex. What is the next step?

Accepted Answer

Surgical exploration

Answer

USG Venous Doppler

Answer

NSAIDS

Answer

USG Arterial Doppler

Question 7

A 30-year-old male presented to EMT with H/o Penetrating chest trauma. On examination, severe tracheal deviation was present. What is the immediate step of management?

Accepted Answer

Needle decompression

Answer

E-FAST

Answer

Chest X-ray

Answer

O2 support at 100%

Question 8

Identify the pathology in the child.

Accepted Answer

Umbilical Hernia

Answer

Inguinal Hernia

Answer

Femoral Hernia

Answer

Spigelian Hernia

Question 9

A child comes after a train accident with stable vitals but a big laceration on the leg. Which triage category does the patient come under?

Accepted Answer

Yellow

Answer

Black

Answer

Green

Answer

Red

Question 10

A diabetic worker sustains a stab injury to the central region of his palm. After 3 days, he develops swelling, severe pain, and inability to extend his middle and ring fingers. Pus accumulation is suspected in one of the palmar spaces. Which of the following spaces is most likely involved?

Accepted Answer

B (Midpalmar space)

Answer

A (Hypothenar space)

Answer

D (Dorsal subaponeurotic space)

Answer

C (Thenar space)

FMGE 2025 — Surgery