UPSC-CMS 2012 - Surgery Practice Questions

Q: Which one of the following nerves is vulnerable to injury while conducting an appendicectomy through the McBurney's incision ?

Ilio-inguinal nerve. ***Ilio-inguinal nerve*** - The **ilio-inguinal nerve** runs anterior to the **quadratus lumborum muscle** and enters the **transversus abdominis muscle**, lying between it and the internal oblique muscle. It is especially vulnerable at the lateral edge of the **rectus abdominis.** - **McBurney's incision**, which is an **oblique incision** in the **right lower quadrant**, may damage the ilioinguinal nerve as it exits the deep inguinal ring. *Subcostal nerve* - The **subcostal nerve** is the ventral ramus of **T12**, and it runs inferior to the **12th rib**. - It usually lies significantly superior to the **McBurney’s incision** site, making injury unlikely during this specific procedure. *Lateral cutaneous nerve of the thigh* - The **lateral cutaneous nerve of the thigh** arises from the **lumbar plexus (L2-L3)** and innervates the skin of the lateral thigh. - It traverses near the **anterior superior iliac spine**, which is not typically within the primary field of a **McBurney’s incision**. *Genitofemoral nerve* - The **genitofemoral nerve** originates from the **L1 and L2 spinal nerves** and descends retroperitoneally. - It is located deep and medial to the region of **McBurney’s incision**, making direct injury during this superficial abdominal incision less probable.

Q: What is the most appropriate surgical procedure for duodenal atresia?

Duodenoduodenostomy. ***Duodenoduodenostomy*** - This procedure involves **reconnecting the two ends of the duodenum** after resecting the atretic (blocked) segment. - It is specifically designed to bypass the obstruction caused by **duodenal atresia**, restoring normal intestinal continuity. *Ramstedt's operation* - This procedure is a **pyloromyotomy** performed for **pyloric stenosis**, where the thickened muscle of the pylorus is incised, not for duodenal atresia. - It addresses a narrowing at the exit of the stomach, not an obstruction within the small intestine itself. *Duodenojejunostomy* - This involves connecting the **duodenum to the jejunum**, typically used when a large segment of the duodenum is affected or there is a need to bypass a pathological area. - While technically feasible, **duodenoduodenostomy is preferred for isolated duodenal atresia** due to its more anatomical reconstruction. *Gastroduodenostomy* - This procedure connects the **stomach to the duodenum**, primarily performed after a partial gastrectomy (e.g., Billroth I) or for gastric outlet obstruction. - It is **not indicated for duodenal atresia**, as it does not address the congenital blockage within the duodenum.

Q: All of the following signs are considered in Alvarado score for acute appendicitis except

Rectal tenderness. ***Rectal tenderness*** - While rectal tenderness can be a sign of appendicitis, it is **not included in the Alvarado score**. The Alvarado score focuses on more direct indicators of peritoneal irritation and systemic response. - The score is composed of symptoms like **migratory right iliac fossa pain**, anorexia, nausea/vomiting, and signs like right iliac fossa tenderness, rebound tenderness, elevated temperature, leukocytosis and shift to the left. *Elevated temperature* - An **elevated body temperature** (fever) is a recognized component of the Alvarado score, indicating a systemic inflammatory response. - This sign contributes one point to the total score. *Rebound tenderness* - **Rebound tenderness** in the right lower quadrant is a crucial sign of peritoneal irritation and is explicitly included in the Alvarado score. - This clinical finding contributes one point to the total score. *Right iliac fossa tenderness* - **Tenderness in the right iliac fossa** (RLQ tenderness) is a primary clinical sign of appendicitis and is a significant component of the Alvarado score. - This sign contributes two points to the total score, reflecting its importance.

Q: A 30-year-old patient developed haematuria following a blunt injury to the abdomen. The patient is haemodynamically stable. However, the ultrasonographic examination reveals a perirenal collection which measures 4 x 4 cm. The patient is best managed by

Nonoperative management. ***Nonoperative management*** - The patient is **haemodynamically stable** with a contained, relatively small **perirenal collection (4x4 cm)**, indicating that the bleeding is likely self-limiting. - **Conservative management** involving observation, bed rest, and serial imaging is the standard approach for most blunt renal injuries in stable patients. *Percutaneous nephrostomy and drainage of the haematoma* - This approach is generally reserved for patients with significant **urinary extravasation**, **infected collections**, or ongoing bleeding despite conservative measures, which are not described here. - Draining a sterile haematoma without addressing the source of bleeding can also pose a risk of infection without clear benefit in a stable patient. *Renal angiography and embolisation of the bleeding vessel* - **Angioembolization** is typically indicated for patients with **persistent active bleeding** despite conservative management, or for those who become **haemodynamically unstable**. - In a stable patient with a contained haematoma, this invasive procedure is not the initial best step. *Immediate laparotomy and repair of the renal injury* - **Laparotomy** and surgical repair are indicated for **haemodynamically unstable patients**, large or expanding retroperitoneal haematomas, or injuries involving the renal pedicle or major collecting system. - Given the **haemodynamic stability** and contained haematoma, immediate surgery is overly aggressive and unnecessary.

Q: Inhalation injury most commonly results in which of the following to the bronchial tree?

Chemical burn to the bronchial tree. ***Correct: Chemical burn to the bronchial tree*** - Inhalation injuries predominantly involve **toxic gases and chemicals** (carbon monoxide, cyanide, aldehydes, acids) produced during fires, which cause **chemical burns** to the bronchial tree - The bronchial mucosa is highly susceptible to chemical irritants, leading to **mucosal inflammation, edema, sloughing, and bronchospasm** - Chemical injury to the tracheobronchial tree is the **hallmark of significant inhalation injury** - Clinical features include wheezing, carbonaceous sputum, and progressive respiratory distress *Incorrect: Thermal burn to the bronchial tree and lungs* - **Thermal burns rarely extend beyond the larynx** to the lower airways due to the **efficient heat dissipation** by the upper airway structures - The high heat capacity of the upper airway mucosa and cooling effect of inspired air protect the bronchial tree and lungs from direct thermal injury - Exception: superheated steam can occasionally reach lower airways, but this is uncommon *Incorrect: Chemical burn to the lungs* - While chemical irritants can reach the alveoli and cause **secondary pneumonitis or ARDS**, the question specifically asks about the **bronchial tree** - The **primary site of chemical injury** from inhalation is the airway (bronchial tree), not the pulmonary parenchyma - Lung injury is typically a delayed complication rather than the immediate result *Incorrect: Thermal burn to the upper airway* - Thermal injury primarily affects the **supraglottic structures** (nasopharynx, oropharynx, larynx), not the bronchial tree - While thermal burns to the upper airway are common in inhalation injury, the question asks specifically about the **bronchial tree** - Upper airway thermal injury and lower airway chemical injury are distinct components of inhalation injury

Q: A patient is diagnosed to have a Stage T3a carcinoma of the prostate. Clinically, this implies

Extraprostatic extension through the prostatic capsule. ***Extraprostatic extension through the prostatic capsule*** - **T3a prostate cancer** indicates **extraprostatic extension** of the tumor, meaning it has grown beyond the boundaries of the prostate capsule [1]. - This stage specifically denotes microscopic or macroscopic extension through the capsule but without involvement of seminal vesicles or other adjacent structures [1]. *Involvement of the pelvic wall* - **Pelvic wall involvement** signifies a more advanced stage, typically **T4**, where the tumor has invaded adjacent organs or structures beyond the seminal vesicles. - This description goes beyond the definition of a T3a tumor, which is contained within the immediate periprostatic tissue. *Involvement of the seminal vesicles* - **Seminal vesicle invasion** is classified as **T3b** in the TNM staging system for prostate cancer, differentiating it from T3a [1]. - T3a specifically excludes seminal vesicle involvement, focusing solely on extraprostatic extension [1]. *Involvement of both the lobes but the disease is limited to within the prostatic capsule* - **Involvement of both lobes** while remaining within the prostatic capsule is characteristic of a **T2c** stage prostate cancer. - T3a implies extension *beyond* the capsule, which contradicts the statement that the disease is limited to within it.

Question 1

Which one of the following nerves is vulnerable to injury while conducting an appendicectomy through the McBurney's incision ?

Accepted Answer

Ilio-inguinal nerve

Answer

Subcostal nerve

Answer

Lateral cutaneous nerve of the thigh

Answer

Genitofemoral nerve

Question 2

A truck driver hit his chest against the steering wheel and sustained multiple rib fractures. His vitals are stable; however, the injured side of the chest shows paradoxical movement. The chest X-ray shows no evidence of haemothorax or pneumothorax but there is a large pulmonary contusion. The most appropriate treatment will be

Accepted Answer

Immediate operative stabilisation

Answer

Insertion of an intrathoracic drain

Answer

Stabilisation of fractured ribs with towel clips

Answer

Tracheostomy, mechanical ventilation and positive end-expiratory pressure ventilation

Question 3

What is the most appropriate surgical procedure for duodenal atresia?

Accepted Answer

Duodenoduodenostomy

Answer

Ramstedt's operation

Answer

Duodenojejunostomy

Answer

Gastroduodenostomy

Question 4

All of the following signs are considered in Alvarado score for acute appendicitis except

Accepted Answer

Rectal tenderness

Answer

Elevated temperature

Answer

Rebound tenderness

Answer

Right iliac fossa tenderness

Question 5

A 30-year-old patient developed haematuria following a blunt injury to the abdomen. The patient is haemodynamically stable. However, the ultrasonographic examination reveals a perirenal collection which measures 4 x 4 cm. The patient is best managed by

Accepted Answer

Nonoperative management

Answer

Percutaneous nephrostomy and drainage of the haematoma

Answer

Renal angiography and embolisation of the bleeding vessel

Answer

Immediate laparotomy and repair of the renal injury

Question 6

Inhalation injury most commonly results in which of the following to the bronchial tree?

Accepted Answer

Chemical burn to the bronchial tree

Answer

Thermal burn to the bronchial tree and lungs

Answer

Chemical burn to the lungs

Answer

Thermal burn to the upper airway

Question 7

A patient is diagnosed to have a Stage T3a carcinoma of the prostate. Clinically, this implies

Accepted Answer

Extraprostatic extension through the prostatic capsule

Answer

Involvement of the pelvic wall

Answer

Involvement of the seminal vesicles

Answer

Involvement of both the lobes but the disease is limited to within the prostatic capsule

UPSC-CMS 2012 — Surgery