UPSC-CMS 2009 — Surgery
17 Previous Year Questions with Answers & Explanations
Which of the following is a scoring system for severity of wound infection, and is particularly useful for surveillance and research ?
Which one of the following statements is correct in case of squamous cell carcinoma of the lip?
Which one of the following is not a correct statement with reference to locally advanced carcinoma breast ?
Consider the following statements regarding splenectomy : 1. It corrects anemia in congenital hereditary spherocytosis. 2. Postponed until the age of 4 years if possible. 3. Polyvalent pneumococcal vaccine to be administered to all before the surgery. Which of the statements given above are correct ?
A young patient develops high grade fever with chills and rigors, mild jaundice and acute pain in the upper abdomen following cholecystectomy. On examination she was jaundiced, toxic, haemodynamically stable and having vague fullness upper abdomen. What is the most probable diagnosis ?
Consider the following with reference to the management of portal hypertension : 1. Infusion of vasopressin 2. General resuscitation 3. Devascularisation procedure 4. Endoscopic sclerotherapy What is the appropriate sequence in the line of management in the event of massive variceal bleeding in portal hypertension ?
A 50 year old diabetic patient with asymptomatic gallstone (> 3 cm) will be best treated by
Which of the following is not an indication for surgical intervention in acute pancreatitis?
The most common intraperitoneal abscess following peritonitis is
The following statements are correct about burst abdomen (abdominal dehiscence) except
UPSC-CMS 2009 - Surgery UPSC-CMS Practice Questions and MCQs
Question 1: Which of the following is a scoring system for severity of wound infection, and is particularly useful for surveillance and research ?
- A. Southampton grading system (Correct Answer)
- B. Apgar score
- C. Glasgow scoring system
- D. ASA classification
Explanation: ***Southampton grading system*** - The **Southampton grading system** is specifically designed for the **severity of wound infection**, offering a clear framework for classification based on clinical signs. - Its utility in **surveillance and research** stems from its structured and reproducible assessment, allowing for consistent data collection on wound healing and infection rates. *Apgar score* - The **Apgar score** is a rapid assessment of a **newborn's health** immediately after birth, evaluating heart rate, respiratory effort, muscle tone, reflex irritability, and color. - It is not used for assessing wound infection severity. *Glasgow scoring system* - The **Glasgow Coma Scale (GCS)** is used to assess the **level of consciousness** in a person following a brain injury, comprising eye opening, verbal, and motor responses. - It is not relevant to wound infection assessment. *ASA classification* - The **American Society of Anesthesiologists (ASA) Physical Status Classification System** is used to assess a patient's **overall health before surgery**, providing an indication of anesthetic risk. - It is not used for evaluating wound infection.
Question 2: Which one of the following statements is correct in case of squamous cell carcinoma of the lip?
- A. Lymph node metastases occur early
- B. Radiotherapy is considered inappropriate treatment for these lesions
- C. More than 90 per cent of cases occur on the upper lip
- D. Lesion often arises in the areas of persistent hyperkeratosis (Correct Answer)
Explanation: ***Lesion often arises in the areas of persistent hyperkeratosis*** - **Squamous cell carcinoma (SCC) of the lip** frequently originates from areas of **actinic cheilitis**, which presents as persistent hyperkeratosis due to chronic sun exposure. - This chronic irritation and dysplasia in hyperkeratotic lesions are known **precursor conditions** for SCC. *Lymph node metastases occur early* - While metastasis can occur in SCC of the lip, it typically does not occur **early**; the primary concern is **local invasion** before regional nodal involvement becomes significant. - The rate of **lymph node metastasis** is generally lower for SCC of the lip compared to other intraoral cancers and often occurs later in the disease course. *Radiotherapy is considered inappropriate treatment for these lesions* - **Radiotherapy** is a highly effective treatment for SCC of the lip, particularly for **small lesions** and in patients who are not surgical candidates, or as an adjuvant therapy. - It can achieve high cure rates with good cosmetic outcomes, making it a perfectly **appropriate treatment option**. *More than 90 per cent of cases occur on the upper lip* - The vast majority of **squamous cell carcinomas of the lip** (over 90%) occur on the **lower lip**, which is much more exposed to **solar radiation**. - The **upper lip** is less commonly affected due to its lesser exposure to chronic sun damage.
Question 3: Which one of the following is not a correct statement with reference to locally advanced carcinoma breast ?
- A. Patients are staged as T3 or T4 with any N, without distant metastasis (M0)
- B. It constitutes the bulk of patients of carcinoma breast in India
- C. Neoadjuvant chemotherapy downgrades the disease
- D. Radical Mastectomy is the treatment of choice (Correct Answer)
Explanation: *Patients are staged as T3 or T4 with any N, without distant metastasis (M0)* - **Locally advanced breast cancer (LABC)** is correctly defined as tumors that are **T3 or T4** or involve regional lymph nodes (**any N**) without distant metastasis (**M0**). - This statement is **correct** regarding LABC staging criteria. *It constitutes the bulk of patients of carcinoma breast in India* - This statement is **correct**. In India, approximately **50-60% of breast cancer patients present with locally advanced disease** at the time of diagnosis. - This is in stark contrast to Western countries where LABC represents less than 10% of cases. - The high prevalence is attributed to lack of screening programs, delayed presentation, limited awareness, and socioeconomic factors. *Neoadjuvant chemotherapy downgrades the disease* - This statement is **correct**. **Neoadjuvant chemotherapy (NACT)** is a cornerstone of LABC management. - NACT aims to **downstage** the tumor, making it more amenable to surgical resection and increasing the feasibility of breast-conserving surgery. - It also provides early treatment of micrometastases and serves as an in vivo test of tumor chemosensitivity. ***Radical Mastectomy is the treatment of choice*** - This statement is **INCORRECT** and is the correct answer to this negation question. - **Radical mastectomy (Halsted mastectomy)** involving removal of breast, pectoral muscles, and axillary nodes is **no longer the standard treatment** for LABC. - Modern treatment involves a **multimodal approach**: neoadjuvant chemotherapy followed by **modified radical mastectomy (MRM)** or breast-conserving surgery with radiation therapy. - MRM preserves the pectoral muscles, providing better functional and cosmetic outcomes while maintaining oncological safety.
Question 4: Consider the following statements regarding splenectomy : 1. It corrects anemia in congenital hereditary spherocytosis. 2. Postponed until the age of 4 years if possible. 3. Polyvalent pneumococcal vaccine to be administered to all before the surgery. Which of the statements given above are correct ?
- A. 1, 2 and 3 (Correct Answer)
- B. 1 and 3 only
- C. 2 and 3 only
- D. 1 and 2 only
Explanation: ***1, 2 and 3*** - **Splenectomy** is a definitive treatment for **hereditary spherocytosis**, as it removes the primary site of red blood cell destruction, thereby correcting the **anemia**. - Delaying splenectomy until after **4 years of age** reduces the risk of **overwhelming post-splenectomy infection (OPSI)**, allowing the child's immune system to mature. *Note: This reflects 2009 guidelines when this question was set. Current guidelines recommend postponing splenectomy until 5-6 years or even older (6-9 years) to further minimize OPSI risk.* - **Vaccination** against encapsulated bacteria like **Streptococcus pneumoniae** (using a polyvalent vaccine) is crucial before splenectomy to prevent severe infections, as the spleen plays a vital role in clearing these pathogens. *1 and 3 only* - This option is incorrect because it omits the important recommendation to **postpone splenectomy** until the child is older, which is a key part of managing hereditary spherocytosis in children. *2 and 3 only* - This option is incorrect because it fails to acknowledge that **splenectomy effectively corrects the anemia** in congenital hereditary spherocytosis by eliminating the site of premature red blood cell destruction, which is a primary indication for the procedure. *1 and 2 only* - This option is incorrect because it overlooks the critical need for **vaccination** against encapsulated bacteria **before splenectomy** to protect against life-threatening infections, a standard and essential practice.
Question 5: A young patient develops high grade fever with chills and rigors, mild jaundice and acute pain in the upper abdomen following cholecystectomy. On examination she was jaundiced, toxic, haemodynamically stable and having vague fullness upper abdomen. What is the most probable diagnosis ?
- A. Duodenal injury
- B. Acute Pancreatitis
- C. Localised collection of bile in peritoneal cavity (Correct Answer)
- D. Iatrogenic ligation of common bile duct
Explanation: ***Localised collection of bile in peritoneal cavity*** - The combination of **fever with chills and rigors**, **mild jaundice**, and **acute upper abdominal pain** developing post-cholecystectomy, along with a toxic appearance and vague upper abdominal fullness, strongly suggests a **localized bile leak** leading to a bile collection (biloma) and secondary infection. - **Bile leakage** can occur due to clips dislodging, an accessory duct injury, or cystic duct stump leak, and often presents as signs of **peritonitis** and **sepsis** if infected, causing the fever and rigors. *Duodenal injury* - A duodenal injury post-cholecystectomy would typically present with signs of **peritonitis**, **sepsis**, and potentially contents like bile or gastric acid in the drain, but **jaundice** would not be a prominent feature unless a separate biliary injury was also present. - While it could cause abdominal pain and fever, the specific presentation of **jaundice** and **vague fullness** without overt signs of free perforation makes it less likely than a bile collection. *Acute Pancreatitis* - **Acute pancreatitis** post-cholecystectomy is possible due to retained **gallstones** or **iatrogenic trauma** to the pancreatic duct, causing severe epigastric pain radiating to the back, nausea, and vomiting. - While it can cause jaundice in severe cases due to common bile duct compression, the primary abdominal finding is usually diffuse tenderness and rigidity rather than vague fullness, and the pattern of pain is often more characteristic. *Iatrogenic ligation of common bile duct* - **Iatrogenic ligation of the common bile duct** would cause **progressive jaundice**, **acholic stools**, and potentially **cholangitis** (fever, chills, abdominal pain), due to complete obstruction of bile flow. - However, while it explains jaundice and may cause fever, the presence of **rigors**, immediate post-operative onset of **fever**, and vague **abdominal fullness** suggesting a collection makes a bile leak with infection a more direct explanation for the acute picture.
Question 6: Consider the following with reference to the management of portal hypertension : 1. Infusion of vasopressin 2. General resuscitation 3. Devascularisation procedure 4. Endoscopic sclerotherapy What is the appropriate sequence in the line of management in the event of massive variceal bleeding in portal hypertension ?
- A. 3, 2, 1, 4
- B. 2, 1, 4, 3 (Correct Answer)
- C. 1, 4, 2, 3
- D. 4, 2, 1, 3
Explanation: ***Correct Option: 2, 1, 4, 3*** - The initial and most critical step in managing massive variceal bleeding is **general resuscitation** to stabilize the patient, including securing the airway, establishing IV access, and restoring blood volume. - After initial resuscitation, **infusion of vasopressin** or other vasoactive drugs (e.g., octreotide or somatostatin) is initiated to reduce portal pressure and control bleeding by causing splanchnic vasoconstriction. - Once the patient is stabilized and pharmacological agents are initiated, **endoscopic sclerotherapy** or band ligation is performed to directly control bleeding from the varices. - If initial measures fail, or in cases of chronic, recurrent bleeding not amenable to endoscopy, a **devascularization procedure** (e.g., portosystemic shunts, or surgical devascularization such as splenorenal shunt) becomes necessary as a definitive, but more invasive, treatment. *Incorrect Option: 3, 2, 1, 4* - **Devascularization procedures** are invasive surgical interventions and are generally considered a last resort for definitive management after less invasive methods have failed or are not suitable. - Starting with a devascularization procedure would bypass critical initial steps of **resuscitation** and immediate control of hemorrhage. *Incorrect Option: 1, 4, 2, 3* - This sequence incorrectly places **vasopressin infusion** and **endoscopic sclerotherapy** before **general resuscitation**. - Without proper resuscitation, the patient may not be stable enough to tolerate these interventions, and vital organ perfusion may be compromised, leading to a worse outcome. *Incorrect Option: 4, 2, 1, 3* - This sequence mistakenly places **endoscopic sclerotherapy** before **general resuscitation**, which is incorrect given the urgency of stabilizing a patient with massive bleeding. - While endoscopy is crucial for diagnosis and treatment, it must follow initial **resuscitation** to ensure patient safety and optimize the chances of success.
Question 7: A 50 year old diabetic patient with asymptomatic gallstone (> 3 cm) will be best treated by
- A. Early surgery (Correct Answer)
- B. Bile-salt treatment
- C. Waiting till it becomes symptomatic
- D. ESWL
Explanation: ***Early surgery*** - **Diabetic patients** with gallstones, especially those over 3 cm, have a higher risk of complications like **cholecystitis**, **cholangitis**, and even **gallbladder cancer**, justifying prophylactic cholecystectomy. - The risk of perioperative complications is lower than the risk associated with an acute gallstone event in a diabetic patient. *Bile-salt treatment* - This treatment is primarily used for **small cholesterol gallstones** in patients who are not surgical candidates. - It is ineffective for large gallstones (>3 cm) and calcified stones, and it carries a high recurrence rate. *Waiting till it becomes symptomatic* - In diabetic patients, waiting for symptoms can lead to more severe and **atypical presentations** of complications, which may be harder to manage. - Larger gallstones in diabetic patients pose a significantly increased risk of developing **gallbladder cancer**, making prophylactic removal beneficial. *ESWL (Extracorporeal Shock Wave Lithotripsy)* - **ESWL** is generally reserved for solitary, small (<2 cm), non-calcified gallstones in patients who refuse or are not candidates for surgery. - It is not effective for large gallstones (>3 cm) and carries risks of stone recurrence and fragmentation complications.
Question 8: Which of the following is not an indication for surgical intervention in acute pancreatitis?
- A. Diagnostic dilemma
- B. Pancreatic abscess
- C. Infected pancreatic necrosis
- D. Acute fluid collection (Correct Answer)
Explanation: ***Acute fluid collection*** - **Acute fluid collections** are common in acute pancreatitis and are often **sterile** and resolve spontaneously without intervention. - Early surgical intervention for uncomplicated acute fluid collections is generally **contraindicated** due to high morbidity and mortality. *Diagnostic dilemma* - When the diagnosis of acute pancreatitis is uncertain and other surgical emergencies, such as **perforated viscus** or **ischemic bowel**, cannot be ruled out, surgery may be necessary. - An **exploratory laparotomy** can help confirm the diagnosis and address any concurrent surgical pathology. *Pancreatic abscess* - A **pancreatic abscess** is a localized collection of pus in or near the pancreas, indicating **infected necrotic tissue**. - Surgical drainage and debridement are typically required to control the infection and prevent systemic sepsis. *Infected pancreatic necrosis* - **Infected pancreatic necrosis** is a severe complication of acute pancreatitis with high mortality, often requiring surgical debridement (necrosectomy). - While sterile necrosis may be managed conservatively, **infected necrosis** necessitates intervention to remove the source of infection.
Question 9: The most common intraperitoneal abscess following peritonitis is
- A. Pelvic (Correct Answer)
- B. Paracolic
- C. Subphrenic
- D. Interloop
Explanation: ***Pelvic*** - Due to **gravity**, inflammatory exudates and bacteria tend to accumulate in the lowest part of the peritoneal cavity, which is the **pelvis**. - The **pelvic peritoneum** has an excellent capacity for localizing infection, leading to a high incidence of abscess formation here. *Para colic* - While paracolic gutters can accumulate fluid, they are generally **less dependent** than the pelvis for universal collection of peritoneal fluid. - Abscesses in this region are common but not typically the *most common* overall compared to pelvic abscesses. *Subphrenic* - Subphrenic abscesses occur below the diaphragm, often associated with operations on the **upper abdomen** or liver/spleen injuries. - While a significant complication, they are less common than pelvic abscesses in general peritonitis. *Interloop* - Interloop abscesses form between loops of bowel, often due to localized inflammation and exudate. - These are common but tend to be **smaller** and **more scattered** than the large collections seen in the pelvis, making them less frequently the single most common site for a prominent abscess.
Question 10: The following statements are correct about burst abdomen (abdominal dehiscence) except
- A. Manage with nasogastric aspiration and intravenous fluids
- B. Cover the wound with sterile towel and perform emergency surgery
- C. Peak incidence is between 6th and 8th post operative day
- D. Second dehiscence is very common (Correct Answer)
Explanation: ***Second dehiscence is very common*** - This statement is incorrect. While **dehiscence** can recur, it is not considered "very common" after proper surgical repair and addressing risk factors. - The overall incidence of **abdominal dehiscence** ranges from 0.5% to 3%, and subsequent dehiscence, though possible, is less frequent than the initial event due to stricter prophylactic measures and more careful wound closure techniques. *Manage with nasogastric aspiration and intravenous fluids* - This is a crucial initial step for managing **burst abdomen**, as it helps to decompress the gastrointestinal tract and prevent vomiting. - **Intravenous fluids** are essential for maintaining hydration and electrolyte balance, especially if the patient is experiencing fluid loss through the exposed wound. *Cover the wound with sterile towel and perform emergency surgery* - Covering the exposed viscera with a **sterile, saline-soaked towel** is vital to prevent desiccation, infection, and further injury to the bowel. - **Emergency surgery** is necessary to debride the wound, inspect the abdominal contents, and perform a secure secondary closure of the abdominal wall layers. *Peak incidence is between 6th and 8th post operative day* - This timeframe is consistent with the typical healing progression of surgical wounds, where the tensile strength of the wound is still relatively low before collagen deposition is complete. - Factors like **infection**, **increased intra-abdominal pressure**, and poor nutritional status can contribute to wound breakdown during this critical period.