What is the preferred palliative surgical procedure for rectal prolapse in elderly patients who are unfit for more invasive surgery?
Which of the following stages of Breast Cancer corresponds to the following features: a breast mass of 6 x 3 cm, ipsilateral supraclavicular lymph node involvement, and distant metastasis that cannot be assessed?
Sentinel lymph node biopsy in carcinoma breast is done if -
Which of the following is a contraindication to breast conservation surgery?
Best prognostic factor for head injury is:
May-Thurner or Cockett syndrome involves:
Surgery in varicose veins is NOT attempted in the presence of which of the following?
During abdominal surgery under local anesthesia, the patient suddenly felt pain due to
Among the following, intraoperative sentinel lymph node detection in axilla can be done using
Which of the following statements is true about Marjolin's ulcer?
NEET-PG 2013 - Surgery NEET-PG Practice Questions and MCQs
Question 21: What is the preferred palliative surgical procedure for rectal prolapse in elderly patients who are unfit for more invasive surgery?
- A. Delorme's procedure
- B. Wells' procedure
- C. Thiersch's operation (Correct Answer)
- D. Low anterior resection
Explanation: ***Thiersch's operation*** - **Thiersch's operation** is a perineal procedure involving the placement of a **circum-anal cerclage** (a non-absorbable suture) around the anal canal to prevent external prolapse. - It is preferred in elderly or frail patients due to its **minimal invasiveness**, low operative risk, and suitability for local or regional anesthesia as a palliative measure for symptoms. *Delorme's procedure* - **Delorme's procedure** is a perineal approach that involves the **mucosal stripping** of the prolapsed rectum, plication of the muscularis, and re-anastomosis. - While less invasive than abdominal approaches, it is more complex than Thiersch's and may still carry higher operative risks for very frail patients. *Wells' procedure* - **Wells' procedure** (rectopexy via an abdominal approach) involves **mobilization of the rectum** and its fixation to the sacrum, often with a mesh. - This is a more invasive abdominal procedure with a higher operative risk, making it unsuitable for elderly patients unfit for major surgery. *Low anterior resection* - **Low anterior resection** is a major abdominal procedure primarily used for rectal cancer or severe inflammatory bowel disease, involving the **surgical removal of a segment of the rectum**. - It is a highly invasive procedure with significant morbidity and mortality, making it inappropriate for the palliative management of rectal prolapse in frail elderly patients.
Question 22: Which of the following stages of Breast Cancer corresponds to the following features: a breast mass of 6 x 3 cm, ipsilateral supraclavicular lymph node involvement, and distant metastasis that cannot be assessed?
- A. T4 N3 MX
- B. T4 N1 M1
- C. T4 N0 M0
- D. T3 N3c MX (Correct Answer)
Explanation: ***T3 N3c MX*** - A **breast mass of 6 x 3 cm** indicates a T3 tumor (tumor size > 5 cm). - **Ipsilateral supraclavicular lymph node involvement** is classified as N3c disease. **Distant metastasis that cannot be assessed** is denoted by MX. *T4 N3 MX* - A **T4 classification** is reserved for tumors with direct extension to the chest wall or skin, or inflammatory breast cancer, which is not mentioned here. - While N3c and MX are correct for the nodal and metastatic status, the T stage is inaccurate based on the provided tumor size. *T4 N1 M1* - A **T4 classification** is incorrect as the mass size alone (6 x 3 cm) does not meet T4 criteria. - **N1** denotes involvement of 1-3 axillary lymph nodes, which is less extensive than supraclavicular involvement (N3c). **M1** indicates confirmed distant metastasis, but the question states it "cannot be assessed" (MX). *T4 N0 M0* - **T4** is incorrect, as this stage is for direct chest wall/skin involvement or inflammatory breast cancer. - **N0** signifies no regional lymph node metastasis, contradicting the presence of supraclavicular lymph node involvement. **M0** indicates no distant metastasis, whereas the question specifies it cannot be assessed (MX).
Question 23: Sentinel lymph node biopsy in carcinoma breast is done if -
- A. LN palpable
- B. Breast lump with palpable axillary node
- C. Metastatic CA breast
- D. Breast mass but no lymph node palpable (Correct Answer)
Explanation: ***Breast mass but no lymph node palpable*** - Sentinel lymph node biopsy is primarily performed in patients with **clinically negative axillae** (no palpable lymph nodes) to assess for microscopic metastatic disease. - The goal is to avoid full axillary lymph node dissection if the sentinel nodes are negative, thus reducing the risk of **lymphedema** and other complications. *LN palpable* - If a lymph node is palpable, it is often considered **clinically suspicious** and may warrant a direct fine-needle aspiration (FNA) or core biopsy rather than a sentinel node biopsy. - A positive biopsy from a palpable node would typically lead directly to an **axillary lymph node dissection** or neoadjuvant therapy, as the sentinel node procedure offers less benefit in this scenario. *Breast lump with palpable axillary node* - Similar to a palpable LN, a **palpable axillary node** in the presence of a breast lump suggests established nodal involvement. - In such cases, **sentinel lymph node biopsy** is often not the initial step; rather, direct biopsy of the palpable node or upfront axillary dissection (sometimes after neoadjuvant treatment) is considered. *Metastatic CA breast* - In **metastatic breast cancer** (stage IV disease), the focus shifts to systemic treatment, and axillary lymph node dissection, including sentinel node biopsy, is generally not indicated for staging purposes. - The primary goal is palliative care or controlling systemic disease, not regional lymph node staging.
Question 24: Which of the following is a contraindication to breast conservation surgery?
- A. Presence of multicentric tumors (Correct Answer)
- B. Involvement of axillary lymph nodes
- C. Tumor size greater than 4 cm
- D. Presence of diffuse microcalcifications
Explanation: ***Presence of multicentric tumors*** - **Multicentric tumors** are defined as two or more discrete tumors in different quadrants of the breast, which cannot be removed with a single lumpectomy. - This condition is a contraindication for breast conservation surgery (BCS) because complete removal of all tumor foci while maintaining an acceptable cosmetic outcome is highly unlikely. *Involvement of axillary lymph nodes* - **Axillary lymph node involvement** is an important prognostic factor in breast cancer and influences adjuvant therapy decisions, but it is not a direct contraindication to BCS. - Patients with positive nodes often undergo axillary dissection or sentinel lymph node biopsy, followed by radiation and/or systemic therapy, which can be combined with BCS. *Tumor size greater than 4 cm* - While larger tumor size (e.g., >4-5 cm) can make achieving negative surgical margins and a good cosmetic outcome more challenging with BCS, it is not an absolute contraindication. - **Neoadjuvant chemotherapy** can often downstage larger tumors, making BCS a viable option for many patients. *Presence of diffuse microcalcifications* - **Diffuse microcalcifications** can sometimes indicate extensive ductal carcinoma in situ (**DCIS**) or invasive lobular carcinoma with a widespread component. - However, if the microcalcifications represent a single focus of disease that can be entirely excised with negative margins, BCS may still be an option, especially if guided by stereotactic biopsy and imaging.
Question 25: Best prognostic factor for head injury is:
- A. Glasgow coma scale (Correct Answer)
- B. Age
- C. Mode of injury
- D. CT
Explanation: ***Glasgow coma scale*** - The **Glasgow Coma Scale (GCS)** is a standardized tool used to assess the level of consciousness in head injury patients, providing an objective measure of neurological function. - A **lower GCS score** correlates with a greater severity of injury and poorer prognosis, making it the most reliable predictor of outcome. *Age* - While age can influence recovery, with **older patients generally having worse outcomes** due to less neural plasticity and pre-existing comorbidities, it is not the single best prognostic factor. - Younger patients often have better recovery potential, but their prognosis is still heavily dependent on the immediate severity of the brain injury. *Mode of injury* - The mode of injury (e.g., blunt trauma, penetrating injury) provides information about the mechanism and potential **types of injury**, but does not directly quantify the severity of brain damage or predict long-term outcomes as precisely as GCS. - While **high-impact injuries** tend to be more severe, the actual neurological deficit measured by GCS is a better indicator of prognosis. *CT* - **CT scans** are crucial for identifying specific neurological injuries like hemorrhage, edema, or fractures, which can guide immediate management. - However, the findings on a CT scan do not solely determine prognosis; a patient with a relatively normal CT can still have a poor outcome if their **GCS is low**, indicating widespread neuronal dysfunction not always visible on imaging.
Question 26: May-Thurner or Cockett syndrome involves:
- A. Left iliac vein compression (Correct Answer)
- B. Internal iliac artery obstruction
- C. Common iliac artery obstruction
- D. Internal iliac vein obstruction
Explanation: ***Correct: Left iliac vein compression*** - May-Thurner syndrome, also known as Cockett syndrome, specifically describes the **compression of the left common iliac vein** by the overlying right common iliac artery. - This anatomical compression can lead to **venous outflow obstruction**, increasing the risk of deep vein thrombosis (DVT) in the left leg. *Incorrect: Internal iliac artery obstruction* - This condition involves an artery and is unrelated to May-Thurner syndrome, which is a **venous compression disorder**. - Obstruction of the internal iliac artery would typically cause symptoms of **pelvic ischemia** or erectile dysfunction, not venous DVT. *Incorrect: Common iliac artery obstruction* - Obstruction of the common iliac artery is an **arterial occlusion** that would cause peripheral artery disease symptoms in the leg, such as claudication or rest pain. - It does not involve the compression of a vein by an artery, which is characteristic of May-Thurner syndrome. *Incorrect: Internal iliac vein obstruction* - While this is a venous issue, May-Thurner syndrome specifically involves the **common iliac vein**, not the internal iliac vein. - Obstruction of the internal iliac vein would typically present with symptoms related to pelvic venous congestion, distinct from the left lower extremity DVT associated with May-Thurner syndrome.
Question 27: Surgery in varicose veins is NOT attempted in the presence of which of the following?
- A. Deep vein thrombosis (Correct Answer)
- B. Multiple incompetent perforators
- C. Varicose veins with leg ulcer
- D. None of the above
Explanation: ***Deep vein thrombosis*** - **Surgery in varicose veins is absolutely contraindicated in the presence of DVT** (both acute and chronic) - In **acute DVT**, the deep venous system is already compromised, and removing superficial veins could further impair venous return and worsen the thrombotic state - In **chronic DVT with post-thrombotic syndrome**, the deep veins may be occluded or heavily damaged, and the superficial varicosities often serve as **crucial collateral vessels** to maintain venous drainage—their removal would be detrimental - Surgery should only be considered after complete resolution of acute DVT and adequate anticoagulation *Multiple incompetent perforators* - **NOT a contraindication**—incompetent perforators are actually a common indication for surgical treatment - Incompetent perforators contribute to venous insufficiency and recurrent varicose veins - Can be addressed surgically with **subfascial endoscopic perforator surgery (SEPS)** or endovenous ablation techniques - Their presence often indicates need for more comprehensive treatment alongside superficial venous surgery *Varicose veins with leg ulcer* - **NOT a contraindication**—venous leg ulcers are actually an **indication for varicose vein surgery** - Leg ulcers result from chronic venous hypertension due to venous insufficiency - Surgical treatment (saphenous vein ablation, ligation and stripping, or sclerotherapy) reduces venous hypertension and improves venous drainage - Surgery promotes ulcer healing and prevents recurrence when combined with appropriate wound care *None of the above* - Incorrect because **Deep Vein Thrombosis (DVT) is a well-established contraindication** to varicose vein surgery
Question 28: During abdominal surgery under local anesthesia, the patient suddenly felt pain due to
- A. Liver
- B. Parietal peritoneum (Correct Answer)
- C. Intestines
- D. Visceral peritoneum
Explanation: ***Parietal peritoneum*** - The **parietal peritoneum** is richly innervated by somatic nerves (**spinal nerves**), making it highly sensitive to pain, pressure, and temperature. - When stimulated during surgery, even under local anesthesia which might not completely block deeper somatic nerves or if the local block is inadequate, it can cause the patient to suddenly feel **sharp, localized pain**. *Liver* - The liver itself has very few pain receptors in its parenchyma; pain from the liver typically arises from stretching of its fibrous capsule (**Glisson's capsule**). - This pain is usually dull and poorly localized, not the sudden, sharp pain typically experienced during surgical manipulation. *Intestines* - The intestines are primarily innervated by the **autonomic nervous system** and are sensitive to distension and ischemia, causing visceral pain, which is typically dull, crampy, and poorly localized. - They are generally not sensitive to cutting or burning, which are common surgical manipulations. *Visceral peritoneum* - The **visceral peritoneum** covers abdominal organs and is innervated by the autonomic nervous system, similar to the organs it covers. - Like the intestines, it is sensitive to stretch and ischemia, producing diffuse, poorly localized visceral pain rather than sharp, localized pain from surgical incision or manipulation.
Question 29: Among the following, intraoperative sentinel lymph node detection in axilla can be done using
- A. Mammography
- B. Isosulfan blue dye (Correct Answer)
- C. MRI
- D. CT
Explanation: ***Correct Option: Isosulfan blue dye*** - **Isosulfan blue dye** is a vital dye used for **intraoperative visual identification** of sentinel lymph nodes in the axilla during breast cancer surgery - The dye is injected near the tumor site and **preferentially concentrates in lymphatic channels**, allowing the surgeon to visually trace the lymphatic drainage to the **first lymph node(s)** (sentinel nodes) receiving lymph flow - The sentinel nodes appear **blue-stained** and can be identified and excised for biopsy to determine lymph node status - **Alternative methods** include radioactive tracers like **Technetium-99m** or a combination of both (dual mapping technique) *Incorrect Option: Mammography* - Mammography is an **X-ray imaging technique** used for breast cancer screening and diagnosis to detect tumors and calcifications - It is a **pre-operative diagnostic tool**, not used for intraoperative sentinel lymph node detection - Cannot visualize or track lymphatic flow during surgery *Incorrect Option: MRI* - MRI (Magnetic Resonance Imaging) provides detailed anatomical assessment and staging of breast cancer pre-operatively - It is a **static imaging modality** that cannot be used for real-time intraoperative sentinel lymph node detection - Does not visualize lymphatic drainage or dye uptake during surgery *Incorrect Option: CT* - CT scans (Computed Tomography) provide cross-sectional images useful for assessing tumor size and metastatic spread - Not employed for **intraoperative sentinel lymph node detection** - Cannot track real-time lymphatic flow with dyes during surgery
Question 30: Which of the following statements is true about Marjolin's ulcer?
- A. Squamous cell carcinoma develops
- B. Slow growing lesion
- C. Develops in long standing scar
- D. All of the options (Correct Answer)
Explanation: ***All of the options*** - Marjolin's ulcer is a **malignant transformation** that occurs in chronic wounds and scars, which tend to be **long-standing**. - It most commonly leads to the development of **squamous cell carcinoma (SCC)**, and these lesions are generally **slow-growing**. *Squamous cell carcinoma develops* - This statement is true; the most common histological type of malignancy arising in a Marjolin's ulcer is **squamous cell carcinoma (SCC)**. - Less frequently, **basal cell carcinoma** or other sarcomas can also arise, but **SCC** is the predominant form. - The SCC arising in Marjolin's ulcer tends to be **more aggressive** than conventional SCC, with higher rates of **local invasion** and **metastasis**. *Slow growing lesion* - This statement is true; Marjolin's ulcer lesions typically exhibit a **slow growth rate** over an extended period. - This characteristic often contributes to delayed diagnosis, as patients may initially dismiss the changes as non-malignant wound complications. - The latency period can range from **years to decades** after the initial injury. *Develops in long standing scar* - This statement is true; Marjolin's ulcer is defined by its development in areas of **chronic inflammation**, such as **burn scars**, **pressure sores**, **venous stasis ulcers**, and other non-healing wounds. - The latency period for malignant transformation in such scars can range from years to decades, indicating a **long-standing** nature. - **Burn scars** are the most common site, accounting for the majority of cases.