UPSC-CMS 2010 — Surgery

Q: The percutaneous PAIR therapy used in the treatment of uncomplicated hepatic hydatid cyst can be associated with the following complications, except

bradycardia. ***bradycardia*** - **Bradycardia is not a recognized primary complication** of percutaneous aspiration, injection, and re-aspiration (PAIR) therapy for hydatid cysts. - While bradycardia can occur as a **vasovagal response during any invasive procedure**, it is not specifically listed among the complications of PAIR therapy in standard medical literature. - The typical cardiovascular manifestation of anaphylaxis (a known PAIR complication) is **tachycardia**, not bradycardia. *hypotension* - **Hypotension** is a well-documented complication of PAIR therapy, occurring due to **anaphylactic reaction** from leakage of antigenic hydatid fluid into the circulation. - It can also result from **intra-abdominal hemorrhage** if a major vessel is inadvertently punctured during the procedure. *vomiting* - **Vomiting** can occur as part of a **systemic allergic reaction or anaphylaxis** triggered by the release of hydatid cyst contents. - It may also be a manifestation of peritoneal irritation if cyst contents leak into the peritoneal cavity. *anaphylaxis* - **Anaphylaxis** is the most feared and well-documented complication of PAIR therapy, caused by the release of **highly antigenic hydatid cyst fluid** (containing protoscolices and hydatid antigens) into the host's system. - This severe Type I hypersensitivity reaction can manifest with **hypotension, tachycardia, bronchospasm, urticaria, angioedema**, and in severe cases, cardiovascular collapse. - Prophylactic antihistamines and corticosteroids are often administered to minimize this risk. [Practice more Surgery PYQs on OnCourse]

Q: Trendelenburg's operation is done for

primary varicose veins. ***primary varicose veins*** - **Trendelenburg's operation** is the classical surgical procedure for **primary varicose veins of the lower limb** - It involves **high ligation of the long saphenous vein** at the saphenofemoral junction - Named after Friedrich Trendelenburg (1844-1924), this was historically the standard treatment for varicose veins - Modern variations include **flush ligation** and stripping of the saphenous vein - Now often replaced by minimally invasive techniques like **endovenous laser ablation (EVLA)** and **radiofrequency ablation (RFA)** *varicocele* - **Varicocele** is treated by operations like **Ivanissevich procedure**, **Palomo's operation**, or **laparoscopic varicocelectomy** - These involve ligation of the **testicular/gonadal veins**, not the saphenous vein - There is no established surgical technique for varicocele called "Trendelenburg's operation" - The confusion may arise from Trendelenburg's contributions to various surgical fields *deep vein thrombosis with varicose veins* - **Deep vein thrombosis (DVT)** is an acute condition requiring **anticoagulation therapy**, not surgical intervention like Trendelenburg's operation - Management focuses on preventing **pulmonary embolism** and post-thrombotic syndrome - Varicose veins may coexist but are addressed separately after DVT treatment *arteriovenous fistula* - **Arteriovenous fistula** represents an abnormal connection between artery and vein - Treatment involves **surgical repair**, **embolization**, or observation depending on etiology - This is unrelated to Trendelenburg's operation for venous insufficiency [Practice more Surgery PYQs on OnCourse]

Q: Which of the following does not alter the T stage in breast cancer?

Nipple retraction. ***Nipple retraction*** - Nipple retraction, while a significant clinical sign that can indicate an underlying malignancy, does **not alter the T stage** (tumor size and extent) of breast cancer. - It is considered a local sign of tumor proximity or involvement but does not classify the tumor into a T4 category according to AJCC TNM staging. - Nipple retraction may be seen with various T stages and is **not a criterion for upstaging**. *Pectoral muscle involvement* - **Important note**: Involvement of the **pectoralis muscle alone does NOT alter T stage** according to current AJCC TNM classification. - Only **chest wall involvement** (ribs, intercostal muscles, serratus anterior) qualifies as **T4b**. - This is a common point of confusion, but pectoralis muscle is **not considered chest wall** for staging purposes. *Skin ulceration* - **Skin ulceration** directly reflects tumor invasion through the skin of the breast. - This finding is a criterion for classifying the tumor as **T4b**, indicating advanced local disease. - Clearly **alters the T stage** regardless of tumor size. *Peau d'orange* - **Peau d'orange** (orange peel appearance) is caused by obstruction of dermal lymphatics by tumor cells, leading to **skin edema**. - This sign is a criterion for classifying the tumor as **T4b** (edema of the skin including peau d'orange). - Clearly **alters the T stage** and indicates advanced local disease. [Practice more Surgery PYQs on OnCourse]

Q: What is the most common hernia in females?

Inguinal hernia. ***Inguinal hernia*** - **Inguinal hernias** are the most common type of hernia in females, accounting for approximately **70% of all hernias** in women. - While less common in females than males, inguinal hernias still represent the majority of hernias in the female population. - They occur through the **inguinal canal** and can be either indirect (through the deep inguinal ring) or direct (through Hesselbach's triangle). - Present as a **bulge in the groin** above the inguinal ligament. *Femoral hernia* - **Femoral hernias** are the second most common hernia in females, accounting for approximately 30% of hernias in women. - They have a **higher female-to-male ratio** compared to inguinal hernias (femoral hernias are more common in women than men relatively). - Occur through the **femoral canal** below the inguinal ligament, medial to the femoral vein. - Higher risk of **strangulation** due to the rigid boundaries of the femoral ring. - This option is incorrect because despite being relatively more common in females than males, femoral hernias are still **less common than inguinal hernias** in the female population overall. *Spigelian hernia* - A rare type of hernia occurring through the **Spigelian aponeurosis**, lateral to the rectus abdominis muscle. - Not specifically more common in females and represents a small fraction of all hernias. *Obturator hernia* - A very rare hernia passing through the **obturator foramen**. - More common in elderly, thin females but still extremely rare overall. - May present with **Howship-Romberg sign** (inner thigh pain on hip extension/rotation) due to obturator nerve compression. [Practice more Surgery PYQs on OnCourse]

10 Previous Year Questions with Answers & Explanations

Questions

All Subjects Anatomy (6)Biochemistry (2)Community Medicine (24)ENT (1)Forensic Medicine (1)Internal Medicine (7)Microbiology (3)Obstetrics and Gynecology (28)Ophthalmology (1)Orthopaedics (1)Pathology (8)Pediatrics (4)Pharmacology (9)Physiology (2)Radiology (4)Surgery (10)

In carcinoma breast, adjuvant radiotherapy is indicated after modified radical mastectomy in all of the following, except

The percutaneous PAIR therapy used in the treatment of uncomplicated hepatic hydatid cyst can be associated with the following complications, except

Trendelenburg's operation is done for

Which of the following does not alter the T stage in breast cancer?

What is the most common hernia in females?

Dumping syndrome can occur after

With reference to Le Fort I fracture, consider the following statements : 1. Fracture line separates alveolus and palate from the facial skeleton. 2. Fracture line passes from the pyriform aperture. 3. Fracture line runs posteriorly to include pterygoid plates. 4. Fracture line passes through orbit. Which of the statements given above are correct?

Consider the following conditions in blunt trauma of the chest : 1. Flail chest 2. Drainage of 1 litre of blood from the chest tube 3. Cardiac tamponade 4. Rupture of oesophagus Which of the above are the indications of emergency thoracotomy?

A man falls astride a penetrating object. He develops retention of urine, perineal hematoma and bleeding from urinary meatus. The nature of injury would be

Q10

Renal carcinoma with solitary lung secondary is best treated by

UPSC-CMS 2010 - Surgery UPSC-CMS Practice Questions and MCQs

Question 1: In carcinoma breast, adjuvant radiotherapy is indicated after modified radical mastectomy in all of the following, except

A. more than four positive axillary lymph nodes
B. positive margins
C. tumour size more than 5 cm
D. ER, PR hormone receptor negative tumour (Correct Answer)

Explanation: ***ER, PR hormone receptor negative tumour*** - While **ER/PR negative** tumors (including triple-negative breast cancers) are often more aggressive and have higher recurrence rates, **adjuvant radiotherapy** post-mastectomy is primarily dictated by **local-regional anatomic and pathologic factors**, not solely by receptor status. - **ER/PR negative status is NOT a standalone indication** for post-mastectomy radiation therapy (PMRT) in guidelines. The decision for radiotherapy is based on **tumor burden, nodal involvement, and surgical margins**. - Receptor status influences systemic therapy choices but does not independently determine the need for radiotherapy after adequate surgical resection. *more than four positive axillary lymph nodes* - The presence of **four or more positive axillary lymph nodes** is one of the **strongest indications** for post-mastectomy radiation therapy. - This degree of nodal involvement significantly increases the risk of locoregional recurrence, and **PMRT is standard of care** in this scenario. - Guidelines consistently recommend radiotherapy to the chest wall and regional nodal basins when ≥4 nodes are positive. *positive margins* - **Positive surgical margins** after mastectomy indicate residual tumor cells along the resection edges, representing an **absolute indication** for adjuvant radiotherapy if re-excision is not feasible. - This is a **pathologic criterion** that directly indicates microscopic residual disease requiring radiation for local control. - PMRT significantly reduces local recurrence risk in this high-risk scenario. *tumour size more than 5 cm* - A **tumor size greater than 5 cm** (T3 classification) is an **established indication** for post-mastectomy radiation therapy, independent of nodal status. - This substantial tumor burden is associated with higher locoregional recurrence risk even after complete surgical resection. - **PMRT improves locoregional control** and overall outcomes in patients with T3 tumors.

Question 2: The percutaneous PAIR therapy used in the treatment of uncomplicated hepatic hydatid cyst can be associated with the following complications, except

A. hypotension
B. bradycardia (Correct Answer)
C. vomiting
D. anaphylaxis

Explanation: ***bradycardia*** - **Bradycardia is not a recognized primary complication** of percutaneous aspiration, injection, and re-aspiration (PAIR) therapy for hydatid cysts. - While bradycardia can occur as a **vasovagal response during any invasive procedure**, it is not specifically listed among the complications of PAIR therapy in standard medical literature. - The typical cardiovascular manifestation of anaphylaxis (a known PAIR complication) is **tachycardia**, not bradycardia. *hypotension* - **Hypotension** is a well-documented complication of PAIR therapy, occurring due to **anaphylactic reaction** from leakage of antigenic hydatid fluid into the circulation. - It can also result from **intra-abdominal hemorrhage** if a major vessel is inadvertently punctured during the procedure. *vomiting* - **Vomiting** can occur as part of a **systemic allergic reaction or anaphylaxis** triggered by the release of hydatid cyst contents. - It may also be a manifestation of peritoneal irritation if cyst contents leak into the peritoneal cavity. *anaphylaxis* - **Anaphylaxis** is the most feared and well-documented complication of PAIR therapy, caused by the release of **highly antigenic hydatid cyst fluid** (containing protoscolices and hydatid antigens) into the host's system. - This severe Type I hypersensitivity reaction can manifest with **hypotension, tachycardia, bronchospasm, urticaria, angioedema**, and in severe cases, cardiovascular collapse. - Prophylactic antihistamines and corticosteroids are often administered to minimize this risk.

Question 3: Trendelenburg's operation is done for

A. primary varicose veins (Correct Answer)
B. deep vein thrombosis with varicose veins
C. varicocele
D. arteriovenous fistula

Explanation: ***primary varicose veins*** - **Trendelenburg's operation** is the classical surgical procedure for **primary varicose veins of the lower limb** - It involves **high ligation of the long saphenous vein** at the saphenofemoral junction - Named after Friedrich Trendelenburg (1844-1924), this was historically the standard treatment for varicose veins - Modern variations include **flush ligation** and stripping of the saphenous vein - Now often replaced by minimally invasive techniques like **endovenous laser ablation (EVLA)** and **radiofrequency ablation (RFA)** *varicocele* - **Varicocele** is treated by operations like **Ivanissevich procedure**, **Palomo's operation**, or **laparoscopic varicocelectomy** - These involve ligation of the **testicular/gonadal veins**, not the saphenous vein - There is no established surgical technique for varicocele called "Trendelenburg's operation" - The confusion may arise from Trendelenburg's contributions to various surgical fields *deep vein thrombosis with varicose veins* - **Deep vein thrombosis (DVT)** is an acute condition requiring **anticoagulation therapy**, not surgical intervention like Trendelenburg's operation - Management focuses on preventing **pulmonary embolism** and post-thrombotic syndrome - Varicose veins may coexist but are addressed separately after DVT treatment *arteriovenous fistula* - **Arteriovenous fistula** represents an abnormal connection between artery and vein - Treatment involves **surgical repair**, **embolization**, or observation depending on etiology - This is unrelated to Trendelenburg's operation for venous insufficiency

Question 4: Which of the following does not alter the T stage in breast cancer?

A. Pectoral muscle involvement
B. Nipple retraction (Correct Answer)
C. Skin ulceration
D. Peau d'orange

Explanation: ***Nipple retraction*** - Nipple retraction, while a significant clinical sign that can indicate an underlying malignancy, does **not alter the T stage** (tumor size and extent) of breast cancer. - It is considered a local sign of tumor proximity or involvement but does not classify the tumor into a T4 category according to AJCC TNM staging. - Nipple retraction may be seen with various T stages and is **not a criterion for upstaging**. *Pectoral muscle involvement* - **Important note**: Involvement of the **pectoralis muscle alone does NOT alter T stage** according to current AJCC TNM classification. - Only **chest wall involvement** (ribs, intercostal muscles, serratus anterior) qualifies as **T4b**. - This is a common point of confusion, but pectoralis muscle is **not considered chest wall** for staging purposes. *Skin ulceration* - **Skin ulceration** directly reflects tumor invasion through the skin of the breast. - This finding is a criterion for classifying the tumor as **T4b**, indicating advanced local disease. - Clearly **alters the T stage** regardless of tumor size. *Peau d'orange* - **Peau d'orange** (orange peel appearance) is caused by obstruction of dermal lymphatics by tumor cells, leading to **skin edema**. - This sign is a criterion for classifying the tumor as **T4b** (edema of the skin including peau d'orange). - Clearly **alters the T stage** and indicates advanced local disease.

Question 5: What is the most common hernia in females?

A. Femoral hernia
B. Obturator hernia
C. Inguinal hernia (Correct Answer)
D. Spigelian hernia

Explanation: ***Inguinal hernia*** - **Inguinal hernias** are the most common type of hernia in females, accounting for approximately **70% of all hernias** in women. - While less common in females than males, inguinal hernias still represent the majority of hernias in the female population. - They occur through the **inguinal canal** and can be either indirect (through the deep inguinal ring) or direct (through Hesselbach's triangle). - Present as a **bulge in the groin** above the inguinal ligament. *Femoral hernia* - **Femoral hernias** are the second most common hernia in females, accounting for approximately 30% of hernias in women. - They have a **higher female-to-male ratio** compared to inguinal hernias (femoral hernias are more common in women than men relatively). - Occur through the **femoral canal** below the inguinal ligament, medial to the femoral vein. - Higher risk of **strangulation** due to the rigid boundaries of the femoral ring. - This option is incorrect because despite being relatively more common in females than males, femoral hernias are still **less common than inguinal hernias** in the female population overall. *Spigelian hernia* - A rare type of hernia occurring through the **Spigelian aponeurosis**, lateral to the rectus abdominis muscle. - Not specifically more common in females and represents a small fraction of all hernias. *Obturator hernia* - A very rare hernia passing through the **obturator foramen**. - More common in elderly, thin females but still extremely rare overall. - May present with **Howship-Romberg sign** (inner thigh pain on hip extension/rotation) due to obturator nerve compression.

Question 6: Dumping syndrome can occur after

A. Whipple's operation
B. Nissen fundoplication
C. Heller's operation
D. Billroth-II operation (Correct Answer)

Explanation: ***Billroth-II operation*** - This procedure involves a **gastrojejunostomy** where the stomach is connected directly to the jejunum, bypassing the duodenum. This design allows for rapid emptying of gastric contents into the small intestine. - The rapid transit of **hyperosmolar chyme** into the small bowel draws fluid into the lumen, leading to symptoms like abdominal pain, bloating, diarrhea, and vasomotor symptoms (e.g., palpitations, sweating) [1]. *Whipple's operation* - While it involves extensive gastrointestinal reconstruction, a **Whipple's operation** (pancreaticoduodenectomy) typically includes a gastrojejunostomy that is less prone to severe dumping than a Billroth II, as it often preserves a significant portion of the duodenum or creates a more controlled gastric outflow. - The primary aim of a Whipple is to resect the head of the pancreas, duodenum, gallbladder, and bile duct, with subsequent reconstruction involving multiple anastomoses, but usually not one specifically designed to rapidly empty into the jejunum without duodenal transit. *Nissen fundoplication* - This procedure is performed to treat **gastroesophageal reflux disease (GERD)** by wrapping the top of the stomach (fundus) around the lower esophagus to strengthen the lower esophageal sphincter. - It aims to prevent reflux, not to alter the rate of gastric emptying in a way that typically causes dumping syndrome. *Heller's operation* - **Heller's myotomy** is a surgical procedure to treat **achalasia**, a disorder where the lower esophageal sphincter fails to relax properly. It involves cutting the muscle fibers of the lower esophageal sphincter to facilitate the passage of food into the stomach. - This operation addresses a motility issue of the esophagus and generally does not affect gastric emptying in a manner that leads to dumping syndrome.

Question 7: With reference to Le Fort I fracture, consider the following statements : 1. Fracture line separates alveolus and palate from the facial skeleton. 2. Fracture line passes from the pyriform aperture. 3. Fracture line runs posteriorly to include pterygoid plates. 4. Fracture line passes through orbit. Which of the statements given above are correct?

A. 1 and 2 only
B. 2, 3 and 4
C. 1 and 3 only
D. 1, 2 and 3 (Correct Answer)

Explanation: ***Correct Answer: 1, 2 and 3*** - A **Le Fort I fracture** (floating palate fracture) involves a horizontal fracture line separating the **maxillary alveolus and hard palate** from the rest of the facial skeleton, confirming statement 1. - The fracture path includes the **pyriform aperture** anteriorly (statement 2) and extends posteriorly to involve the **pterygoid plates of the sphenoid bone** (statement 3). - Statement 4 is **incorrect** because Le Fort I fractures do **not** involve the orbit; this is a low-level fracture below the orbital floor. *Incorrect: 1 and 2 only* - This option is incomplete as it omits statement 3, which is a defining characteristic of Le Fort I fractures. - The fracture **must** extend posteriorly to include the **pterygoid plates** to be classified as a Le Fort I. *Incorrect: 2, 3 and 4* - Statement 4 is incorrect for a Le Fort I fracture. - Le Fort I fractures are located **inferiorly** and do **not** involve the orbital floor or walls. - Orbital involvement is characteristic of **Le Fort II** (pyramidal fracture) or **Le Fort III** (craniofacial dysjunction) fractures. *Incorrect: 1 and 3 only* - This option omits statement 2, which accurately describes the involvement of the **pyriform aperture** in Le Fort I fractures. - The fracture line **consistently** passes through the pyriform aperture anteriorly as it traverses the lower maxilla.

Question 8: Consider the following conditions in blunt trauma of the chest : 1. Flail chest 2. Drainage of 1 litre of blood from the chest tube 3. Cardiac tamponade 4. Rupture of oesophagus Which of the above are the indications of emergency thoracotomy?

A. 2 and 4 only
B. 1, 2, 3 and 4
C. 2, 3 and 4 only (Correct Answer)
D. 1, 2 and 3 only

Explanation: ***Correct: 2, 3 and 4 only*** **Emergency thoracotomy indications in blunt chest trauma:** **Drainage of 1 litre of blood from chest tube (Massive Hemothorax):** - Definite indication for emergency thoracotomy - Standard criteria: >1500 mL initial drainage OR >200-300 mL/hr for 2-4 consecutive hours - 1 liter initially approaches the threshold and indicates ongoing hemorrhage requiring surgical control **Cardiac tamponade:** - Life-threatening condition requiring immediate intervention - Initial management may include pericardiocentesis, but if patient is in extremis or pericardiocentesis fails, emergency thoracotomy is indicated - In the setting of blunt trauma with hemodynamic instability, thoracotomy may be necessary for definitive repair **Rupture of oesophagus:** - Though rare in blunt trauma, when it occurs it requires surgical repair via thoracotomy - While not always an immediate "emergency" in the resuscitation bay, it does require urgent surgical intervention once diagnosed - Can lead to mediastinitis and requires thoracotomy for repair and debridement *Incorrect: Flail chest (Statement 1)* - **Flail chest is NOT an indication for emergency thoracotomy** - Management is primarily conservative: adequate analgesia, pulmonary toilet, and respiratory support - Surgical rib fixation (ORIF) may be considered in select cases but this is different from emergency thoracotomy for hemorrhage or cardiac injury - Flail chest does not require opening the chest cavity emergently; it's a chest wall injury managed supportively *Incorrect: 2 and 4 only* - Excludes cardiac tamponade, which is a critical indication for thoracotomy in unstable patients *Incorrect: 1, 2, 3 and 4* - Incorrectly includes flail chest, which is not an indication for emergency thoracotomy *Incorrect: 1, 2 and 3 only* - Incorrectly includes flail chest - Excludes esophageal rupture which does require surgical thoracotomy when diagnosed

Question 9: A man falls astride a penetrating object. He develops retention of urine, perineal hematoma and bleeding from urinary meatus. The nature of injury would be

A. intraperitoneal rupture of bladder
B. rupture of bulbar urethra (Correct Answer)
C. rupture of membranous urethra
D. extraperitoneal rupture of bladder

Explanation: ***Rupture of bulbar urethra*** - An injury from falling astride a penetrating object, causing symptoms like **retention of urine**, **perineal hematoma**, and **bleeding from the urinary meatus**, is highly indicative of a **bulbar urethral rupture**. - The **bulbar urethra** is particularly vulnerable to crush injuries against the **pubic symphysis** in astride falls, leading to extravasation of urine and blood into the perineum. *Intraperitoneal rupture of bladder* - This typically occurs from a **direct blow to the lower abdomen** when the bladder is full, resulting in release of urine into the **peritoneal cavity**. - Symptoms would include generalized **abdominal pain**, **rebound tenderness**, and **peritonitis-like signs**, rather than localized perineal hematoma. *Rupture of membranous urethra* - A rupture of the **membranous urethra** is typically associated with **pelvic fractures** and is usually **above the urogenital diaphragm**. - While it can cause hematoma, the extravasation of urine and blood would more commonly track into the **retropubic space** and potentially the anterior abdominal wall, not primarily the perineum. *Extraperitoneal rupture of bladder* - This often results from **pelvic fractures** and is characterized by urine leaking into the **prevesical space**. - Symptoms include **suprapubic pain** and tenderness, but a perineal hematoma and meatal bleeding are less typical in isolation for this type of injury.

Question 10: Renal carcinoma with solitary lung secondary is best treated by

A. chemotherapy
B. surgery (Correct Answer)
C. immunotherapy
D. radiotherapy

Explanation: ***Surgery*** - For **renal cell carcinoma** with a **solitary lung metastasis**, surgical resection of both the primary tumor (nephrectomy) and the lung metastasis is often the preferred treatment and offers the best chance for long-term survival. - This approach is particularly effective when the patient has a good performance status, the primary tumor is controlled, and the metastasis is truly solitary and resectable. *Chemotherapy* - **Renal cell carcinoma** is classically considered **chemotherapy-resistant**, meaning traditional chemotherapy agents generally have limited efficacy. - While some newer targeted therapies and immunotherapies are used, conventional chemotherapy is not the first-line treatment for metastatic RCC, especially when surgical options are available. *Immunotherapy* - **Immunotherapy** (e.g., nivolumab, pembrolizumab) is a common treatment for advanced or metastatic renal cell carcinoma, particularly when surgery is not feasible or after recurrence. - However, for a **solitary resectable metastasis**, it is typically considered after surgery, or in cases where surgery is contraindicated, rather than as a primary curative approach. *Radiotherapy* - **Radiotherapy** has a limited role in the primary treatment of renal cell carcinoma due to its relative radioresistance, though it can be used for palliative purposes (e.g., pain control, brain metastases). - For a solitary lung metastasis, while **stereotactic body radiation therapy (SBRT)** might be considered in select cases where surgery is not possible, surgical resection remains the gold standard for resectable lesions.