NEET-PG 2020 — Surgery
23 Previous Year Questions with Answers & Explanations
What is the appropriate management for a male patient who presents to the hospital with abdominal pain from cholecystitis and is incidentally detected with an asymptomatic abdominal aortic aneurysm?
In a patient with parathyroid adenoma, how do we confirm the removal of the correct gland after surgery?
A pregnant female had meconium-stained liquor and underwent emergency LSCS. A few days later, her condition deteriorated, and an ultrasound showed edematous bowels. What is the most likely cause of her condition?
A middle-aged man presents with a swelling in the neck that has been present since childhood. The swelling has a bag or worm-like appearance and features a central black spot. Based on this description, what is the most likely diagnosis?
Which of the following is not a component of the Thoracoscore?
A 68-year-old asymptomatic male is found to have an abdominal aortic aneurysm (AAA) measuring 4.5 cm on routine ultrasound screening. What is the most appropriate management?
Which flap is commonly used in breast reconstruction?
A person reports 4 hours after having a clean wound without laceration. He had taken TT 10 years before. The next step in management is:
Which statement about retrosternal goiter is correct?
A patient after a heavy meal and episode of forceful vomiting presents with severe epigastric pain. On examination, there is tenderness and rigidity in the upper abdomen. X-ray shows pneumomediastinum. What is the most likely cause?
NEET-PG 2020 - Surgery NEET-PG Practice Questions and MCQs
Question 1: What is the appropriate management for a male patient who presents to the hospital with abdominal pain from cholecystitis and is incidentally detected with an asymptomatic abdominal aortic aneurysm?
- A. Immediate surgery
- B. Monitor till size reaches 55 mm (Correct Answer)
- C. Monitor till size reaches 45 mm
- D. USG monitoring till size of the aneurysm reaches 70 mm
Explanation: ***Monitor till size reaches 55 mm*** - For **asymptomatic abdominal aortic aneurysms (AAAs)** in male patients, elective repair is generally recommended when the aneurysm reaches 5.5 cm (55 mm) in diameter. - This size balances the risk of rupture against the risks associated with surgery. *Immediate surgery* - Immediate surgery is reserved for patients with a **symptomatic** or **ruptured AAA**, indicated by severe abdominal pain, hypotension, and a pulsatile mass. - An incidentally detected, asymptomatic AAA typically does not warrant emergency surgical intervention. *Monitor till size reaches 45 mm* - A 45 mm aneurysm in a male patient is typically managed with **regular surveillance** rather than immediate intervention. - The risk of rupture at this size is generally considered low enough to avoid the risks of elective surgery. *USG monitoring till size of the aneurysm reaches 70 mm* - Monitoring an AAA until it reaches 70 mm (7 cm) is **not safe practice** due to a significantly increased risk of rupture as the aneurysm grows beyond 5.5 cm. - Guidelines recommend intervention at 5.5 cm to prevent life-threatening rupture.
Question 2: In a patient with parathyroid adenoma, how do we confirm the removal of the correct gland after surgery?
- A. 50% reduction in PTH after 10 minutes (Correct Answer)
- B. 25% reduction in PTH after 10 minutes
- C. 25% reduction in PTH after 5 minutes
- D. 50% reduction in PTH after 5 minutes
Explanation: ***50% reduction in PTH after 10 minutes*** - Intraoperative **PTH monitoring** is crucial for confirming complete removal of hyperfunctioning parathyroid tissue during parathyroidectomy. - A successful surgery is indicated by a **≥50% drop** in PTH levels from the baseline (pre-excision) or highest post-excision level within **10 minutes** of gland removal. *25% reduction in PTH after 10 minutes* - A **25% reduction** in PTH after 10 minutes is generally considered **insufficient** to confirm successful removal of the hyperfunctioning gland. - This level of reduction may suggest incomplete removal or the presence of additional hypersecreting tissue. *25% reduction in PTH after 5 minutes* - While an initial drop may be observed, a **25% reduction after only 5 minutes** without further significant decline by 10 minutes is often not indicative of successful surgery. - The standard MIBI-scan-guided protocol or the Miami criteria require a more substantial and sustained drop. *50% reduction in PTH after 5 minutes* - A rapid and significant **50% reduction after 5 minutes** of excision is a good sign but the gold standard for intraoperative PTH monitoring typically requires the **10-minute post-excision** sample to confirm the sustained drop. - The **Miami Criteria**, a widely accepted protocol, uses the 10-minute post-excision time point as a critical determinant.
Question 3: A pregnant female had meconium-stained liquor and underwent emergency LSCS. A few days later, her condition deteriorated, and an ultrasound showed edematous bowels. What is the most likely cause of her condition?
- A. Adhesive intestinal obstruction
- B. Intra-abdominal abscess
- C. Paralytic ileus (Correct Answer)
- D. Intestinal perforation
Explanation: ***Paralytic ileus*** - **Paralytic ileus**, often called **postoperative ileus**, is a common complication after abdominal surgeries like **LSCS**, especially when associated with complications like meconium-stained liquor. - The combination of **meconium-stained liquor** (indicating fetal distress/inflammation) and **emergency LSCS** increases the risk for a prolonged inflammatory response post-surgery, leading to intestinal paralysis and **edematous bowels**. - Ultrasound findings of **edematous bowels** without signs of mechanical obstruction support this diagnosis. *Adhesive intestinal obstruction* - **Adhesive intestinal obstruction** usually occurs later, weeks to years after surgery, as **adhesions** form and contract. - While possible, it is less likely to present acutely a "few days later" after an initial surgery compared to **paralytic ileus**. *Intra-abdominal abscess* - An **intra-abdominal abscess** would typically cause localized pain, fever, and signs of infection with more focal findings on imaging. - The primary observation of **edematous bowels** points more directly to diffuse bowel dysfunction rather than a localized collection. *Intestinal perforation* - **Intestinal perforation** would present with acute peritonitis, free fluid/air on imaging, severe abdominal pain, and signs of sepsis. - While edematous bowels can be present, the clinical picture would be more dramatic with peritoneal signs rather than the subacute deterioration described here.
Question 4: A middle-aged man presents with a swelling in the neck that has been present since childhood. The swelling has a bag or worm-like appearance and features a central black spot. Based on this description, what is the most likely diagnosis?
- A. Cirsoid aneurysm
- B. Varicocele
- C. Plexiform neurofibroma (Correct Answer)
- D. Lymphangioma
Explanation: ***Plexiform neurofibroma*** - The description of a swelling since childhood with a **bag-of-worms appearance** and a **central black spot** is highly characteristic of a plexiform neurofibroma, a benign tumor of peripheral nerves. - These lesions are often associated with **neurofibromatosis type 1 (NF1)** and can grow quite large, causing cosmetic and functional concerns. - The **central black spot** represents pigmentation often seen in neurofibromas, particularly in NF1. *Cirsoid aneurysm* - A cirsoid aneurysm is a **congenital arteriovenous malformation** characterized by a tortuous mass of dilated blood vessels. - While it can manifest as a swelling, it typically presents with a **palpable thrill and audible bruit**, and its appearance is not usually described as having a central black spot. *Varicocele* - A varicocele is an **abnormal enlargement of the pampiniform plexus veins** in the scrotum, often described as a **bag of worms**, but it occurs exclusively in the scrotum. - It would not be found in the neck and does not feature a central black spot. *Lymphangioma* - A lymphangioma is a **benign malformation of the lymphatic system** that can present as a soft, compressible mass, often in the neck. - While present since childhood, its appearance is typically **cystic or multicystic** and does not usually have the distinct bag-of-worms texture or a central black spot described.
Question 5: Which of the following is not a component of the Thoracoscore?
- A. Surgery priorities
- B. ASA classifications
- C. Expected complications post-surgery (Correct Answer)
- D. Performance status
Explanation: ***Expected complications post-surgery*** - While patient risk assessment tools aim to predict surgical outcomes, the **Thoracoscore** specifically calculates risk based on present patient characteristics and surgical plan, not based on a list of expected complications. - Expected complications are a *result* of the risk score, not an input into its calculation. *ASA classifications* - The **American Society of Anesthesiologists (ASA) Physical Status Classification System** is a crucial component of the Thoracoscore, reflecting the patient's overall health status and comorbidity burden. - A higher ASA classification indicates greater surgical risk and contributes to the Thoracoscore calculation. *Surgery priorities* - **Surgery priority** (e.g., elective, urgent, emergency) is an important factor in the Thoracoscore, as urgent or emergent surgeries are associated with higher risk. - This parameter helps categorize the immediacy and complexity of the surgical intervention. *Performance status* - The patient's **performance status**, often assessed using scales like the Eastern Cooperative Oncology Group (ECOG) or Karnofsky, is a significant predictor of surgical outcome and is included in the Thoracoscore. - A lower performance status (indicating poorer functional capacity) increases the calculated surgical risk.
Question 6: A 68-year-old asymptomatic male is found to have an abdominal aortic aneurysm (AAA) measuring 4.5 cm on routine ultrasound screening. What is the most appropriate management?
- A. Ultrasound monitoring until size exceeds 70mm
- B. No treatment unless symptomatic
- C. Monitor regularly and consider surgery if size reaches 55mm or symptomatic (Correct Answer)
- D. Immediate surgical repair for all diagnosed aneurysms regardless of size
Explanation: ***Monitor regularly and consider surgery if size reaches 55mm or symptomatic*** - For **asymptomatic abdominal aortic aneurysms (AAA)** measuring less than 5.5 cm, **regular surveillance** with imaging (ultrasound or CT) is the appropriate management. - Elective surgical intervention (open repair or EVAR) is recommended when the aneurysm reaches **≥5.5 cm diameter** in men or **≥5.0 cm in women**, or if the patient becomes **symptomatic** (abdominal/back pain, tenderness). - Growth rate >1 cm/year is also an indication for repair. - The **55mm threshold** balances rupture risk against surgical mortality risk based on large randomized trials (UKSAT, ADAM). *Immediate surgical repair for all diagnosed aneurysms regardless of size* - This approach is **too aggressive** and not evidence-based. - Small AAAs (<5.5 cm) have low annual rupture rates (<1% for AAAs <5 cm), making elective surgery unjustified given operative mortality (2-5%). - Randomized trials showed **no survival benefit** from early repair of small AAAs. *Ultrasound monitoring until size exceeds 70mm* - The threshold of **70mm (7 cm) is dangerously high** and significantly increases rupture risk. - AAAs ≥5.5 cm have annual rupture rates of 3-15%, with mortality from rupture exceeding 80%. - The standard threshold for elective repair is **5.5 cm**, not 7 cm. *No treatment unless symptomatic* - This approach ignores **aneurysm size**, which is the primary predictor of rupture risk in asymptomatic patients. - Elective repair of large asymptomatic AAAs (≥5.5 cm) prevents rupture and improves survival compared to watchful waiting. - Any **symptomatic AAA** requires urgent evaluation regardless of size, as symptoms suggest impending rupture.
Question 7: Which flap is commonly used in breast reconstruction?
- A. DIEP based on deep inferior epigastric perforator vessels (Correct Answer)
- B. Gluteal flap based on superior gluteal artery
- C. Latissimus dorsi flap based on thoracodorsal artery
- D. TRAM based on transverse rectus abdominis muscle
Explanation: ***DIEP based on deep inferior epigastric perforator vessels*** - The **DIEP flap** is currently the **most preferred autologous flap** for breast reconstruction and is increasingly commonly used in modern practice. - It uses tissue from the lower abdomen, providing excellent volume and a natural-feeling breast mound, while being nourished by **deep inferior epigastric perforator vessels**. - Key advantage: **Muscle-sparing technique** that preserves the rectus abdominis muscle, minimizing abdominal wall morbidity compared to older techniques like TRAM. - Considered the **gold standard** for abdominal-based breast reconstruction. *Gluteal flap based on superior gluteal artery* - While gluteal flaps (like the **SGAP** based on the **superior gluteal artery**) are used for breast reconstruction, they are typically considered a secondary option when abdominal tissue is unavailable or unsuitable. - Harvesting can be more challenging and may result in a less ideal breast shape compared to abdominal flaps. - Less commonly used compared to abdominal-based flaps. *Latissimus dorsi flap based on thoracodorsal artery* - The **latissimus dorsi flap** is a reliable and commonly used option, particularly for smaller breasts or partial reconstruction. - However, it often requires an implant to achieve sufficient volume (not purely autologous reconstruction). - It involves transferring muscle from the back, which can lead to back weakness or contour deformities. - While frequently used, it is not the preferred choice when autologous tissue from the abdomen is available. *TRAM based on transverse rectus abdominis muscle* - The **TRAM flap** was historically a very common choice for breast reconstruction but involves taking a significant portion of the rectus abdominis muscle. - This leads to higher rates of abdominal wall weakness, hernias, or bulges compared to muscle-sparing techniques. - It is currently **less commonly used** than the DIEP flap due to its higher donor site morbidity and has been largely superseded by the DIEP technique.
Question 8: A person reports 4 hours after having a clean wound without laceration. He had taken TT 10 years before. The next step in management is:
- A. Single-dose TT (Correct Answer)
- B. No need for any vaccine
- C. Full course Tetanus vaccine to be given
- D. Full dose TT with TIG
Explanation: ***Single-dose TT*** - For a **clean wound** when the last **tetanus toxoid (TT)** was given **10 years ago**, a **booster dose** is indicated as the protective immunity duration is **10 years**. - **TT provides immunity for 10 years** for clean wounds; at the 10-year mark, the protective window has elapsed and requires a booster. *No need for any vaccine* - This would be correct only if the last TT dose was given **<10 years ago** (within the protective window). - At exactly **10 years**, the immunity has waned and a **booster is required** for continued protection against tetanus. *Full course Tetanus vaccine to be given* - A **complete primary series (3 doses)** is only indicated for patients who are **unimmunized** or have **unknown vaccination history**. - This patient has documented **prior TT immunization**, so only a **single booster dose** is needed, not a full course. *Full dose TT with TIG* - **Tetanus Immunoglobulin (TIG)** is reserved for **high-risk scenarios**: tetanus-prone wounds in patients with **inadequate immunization** (<3 doses) or **unknown vaccination status**. - For a **clean wound** with documented prior immunization, **TIG is unnecessary** and represents over-treatment.
Question 9: Which statement about retrosternal goiter is correct?
- A. Surgery should be avoided in all cases.
- B. CT chest is recommended for evaluation of retrosternal goiter. (Correct Answer)
- C. All patients require surgical intervention.
- D. Blood supply primarily comes from the thyroid arteries.
Explanation: ***CT chest is recommended for evaluation of retrosternal goiter.*** * A **CT chest** provides detailed imaging of the goiter's extent, its relationship to surrounding structures (trachea, esophagus, great vessels), and helps in surgical planning. * It can identify potential complications like **tracheal compression** or involvement of the superior mediastinum, which are crucial for management decisions. *All patients require surgical intervention.* * Surgical intervention is not universally required; it depends on the **size of the goiter**, presence and severity of compressive symptoms, and malignancy suspicion. * Small, asymptomatic retrosternal goiters may be managed conservatively with **monitoring**. *Blood supply primarily comes from the thyroid arteries.* * While the initial development of the goiter is from the thyroid gland, as it extends into the mediastinum, it can develop additional **blood supply from mediastinal vessels**. * This dual blood supply, sometimes including branches from the internal mammary or subclavian arteries, can make surgical ligation more complex. *Surgery should be avoided in all cases.* * Surgery is often necessary, especially in cases with **compressive symptoms** such as dyspnea, dysphagia, or stridor, or if there is concern for malignancy. * **Retrosternal goiters** can grow large and cause significant morbidity or even mortality due to airway obstruction, making surgery a vital treatment option.
Question 10: A patient after a heavy meal and episode of forceful vomiting presents with severe epigastric pain. On examination, there is tenderness and rigidity in the upper abdomen. X-ray shows pneumomediastinum. What is the most likely cause?
- A. Spontaneous rupture of the esophagus (Correct Answer)
- B. Penetrating injury to the esophagus
- C. Perforation of a peptic ulcer
- D. Rupture of an emphysematous bulla
Explanation: ***Spontaneous rupture of the esophagus*** - The combination of **post-emetic epigastric pain**, upper abdominal tenderness/rigidity, and **pneumomediastinum** is characteristic of Boerhaave syndrome, which is a **spontaneous transmural esophageal rupture**. - This rupture often occurs after a heavy meal or forceful vomiting, leading to a sudden increase in **intra-esophageal pressure**. *Penetrating injury to the esophagus* - While a penetrating injury could cause esophageal rupture and pneumomediastinum, the clinical scenario describes a **spontaneous event** following a meal, not trauma. - Absence of an external wound, trauma history, or foreign body ingestion makes this less likely. *Perforation of a peptic ulcer* - A perforated peptic ulcer would typically cause **severe, sudden onset epigastric pain** and **peritonitis**, but it would lead to **pneumoperitoneum** (free air in the abdomen) rather than pneumomediastinum. - While it could cause referred pain to the chest, the direct finding of air in the mediastinum points away from an isolated abdominal perforation. *Rupture of an emphysematous bulla* - Rupture of an emphysematous bulla would cause a **pneumothorax** or **pneumomediastinum**, but it would not typically present with severe epigastric pain and abdominal signs. - There would usually be a history of **lung disease** or smoking, and respiratory symptoms would be more prominent.