UPSC-CMS 2013 — Surgery
17 Previous Year Questions with Answers & Explanations
A 25-year-old patient has 5 x 5 cm amoebic abscess in right lobe of liver. He is febrile and has pain in right hypochondrium. His primary management would include:
The surgical complications of typhoid fever include all of the following except :
Treatment of choice for acute femoral artery embolism is :
The most common early sign of increasing intracranial pressure in the victim of head injury is :
Surgical treatment for a 40-years old lady with 3 x 3 cm. papillary carcinoma thyroid with level III enlarged lymph nodes is :
Splenectomy is best indicated for :
A retained stone in CBD (common bile duct) diagnosed by T-tube cholangiogram is best treated by :
All of the following statements regarding gallstones are true except :
A 65-year-old patient presents with obstructive jaundice and 15 kg weight loss. An ultrasound shows a 4 cm mass in the head of the pancreas with dilated bile ducts. Further work up includes a helical CT scan. The study shows several lesions consistent with metastasis in the right and left lobes of the liver and encasement of gastroduodenal artery. The most appropriate treatment would be:
Laparoscopic instruments are best sterilized by :
UPSC-CMS 2013 - Surgery UPSC-CMS Practice Questions and MCQs
Question 1: A 25-year-old patient has 5 x 5 cm amoebic abscess in right lobe of liver. He is febrile and has pain in right hypochondrium. His primary management would include:
- A. Laparotomy and drainage
- B. Administration of antibiotic and observation
- C. Ultra-sound guided aspiration
- D. Ultra-sound guided placement of pigtail catheter (Correct Answer)
Explanation: ***Ultra-sound guided placement of pigtail catheter*** - For an **amoebic liver abscess** of 5x5 cm with **significant symptoms** (fever and pain), **catheter drainage combined with anti-amoebic therapy** is indicated. - While medical therapy alone may suffice for smaller or less symptomatic abscesses, this patient's **symptomatic presentation** warrants drainage to provide rapid relief, prevent complications, and ensure resolution. - **Pigtail catheter placement** allows for continuous drainage and is the preferred minimally invasive approach for abscesses requiring intervention. - This approach is safer than open surgery and more effective than single aspiration for complete evacuation. *Laparotomy and drainage* - **Open surgical drainage** is reserved for complicated cases such as **ruptured abscesses**, peritonitis, or failure of percutaneous drainage. - For an uncomplicated 5x5 cm abscess, laparotomy is overly invasive and carries higher morbidity compared to image-guided percutaneous techniques. *Administration of antibiotic and observation* - **Anti-amoebic medications** (metronidazole) are essential for treating amoebic liver abscesses and must be given in all cases. - However, for a **5x5 cm abscess with fever and pain**, medical therapy alone may be insufficient for rapid symptom resolution. - The size (at the threshold of 5 cm) combined with symptomatic presentation justifies **drainage in addition to medical therapy** to prevent complications like rupture or secondary infection. - Observation alone without drainage in a symptomatic patient of this size risks delayed resolution and potential complications. *Ultra-sound guided aspiration* - **Single aspiration** may be considered for diagnostic purposes or in selected cases. - However, for a 5x5 cm abscess, **aspiration may require multiple procedures** for complete evacuation, and there's risk of inadequate drainage. - **Pigtail catheter drainage** is preferred over aspiration as it allows **continuous drainage**, reduces the need for repeat procedures, and has higher success rates for abscesses of this size.
Question 2: The surgical complications of typhoid fever include all of the following except :
- A. Acute pancreatitis (Correct Answer)
- B. Splenic abscess
- C. Acute cholecystitis
- D. Perforation peritonitis
Explanation: ***Acute pancreatitis*** - While typhoid fever can rarely involve the pancreas, **acute pancreatitis** is **not** considered a typical *surgical complication* of typhoid fever. - Pancreatic involvement, when it occurs, is generally mild and does not require surgical intervention. - This is the correct answer as it is NOT a recognized surgical complication. *Splenic abscess* - **Splenic abscess** is a rare but recognized complication of typhoid fever, resulting from hematogenous spread. - When present, it may require **percutaneous drainage** or **splenectomy** due to the risk of rupture. - Note: More common splenic manifestation is splenomegaly, not abscess. *Acute cholecystitis* - **Acute cholecystitis** is a well-recognized surgical complication of typhoid fever. - The gallbladder can serve as a chronic reservoir for **Salmonella Typhi**, leading to inflammation and stone formation. - This may require **cholecystectomy** in severe or recurrent cases. *Perforation peritonitis* - **Intestinal perforation**, particularly of the **terminal ileum**, is the **most common and serious** surgical complication of typhoid fever. - Occurs in approximately **1-3%** of cases, typically in the 2nd-3rd week of illness. - This leads to **peritonitis**, a life-threatening condition requiring **urgent laparotomy and surgical repair**.
Question 3: Treatment of choice for acute femoral artery embolism is :
- A. Immediate embolectomy (Correct Answer)
- B. Warfarin
- C. Embolectomy after rest for few days
- D. Heparin
Explanation: ***Immediate embolectomy*** - **Acute femoral artery embolism** is a medical emergency that requires prompt intervention to restore blood flow and prevent limb ischemia. - **Early surgical embolectomy** is the treatment of choice to physically remove the clot and immediately re-establish perfusion. *Warfarin* - **Warfarin** is an anticoagulant used for *long-term prevention* of future embolic events, but it is not effective for acute clot removal. - Its therapeutic effect is delayed, making it unsuitable for the immediate treatment of an acute embolism. *Embolectomy after rest for few days* - Delaying embolectomy for several days would lead to **irreversible tissue damage** and potential limb loss due to prolonged ischemia. - Time is critical in acute arterial occlusions, and immediate intervention is paramount. *Heparin* - **Heparin** is an anticoagulant used to *prevent further clot propagation* and reduce the risk of re-embolization. - While it can be initiated as an adjunct, it does not dissolve the existing embolus quickly enough to be the sole treatment for an acute limb-threatening obstruction.
Question 4: The most common early sign of increasing intracranial pressure in the victim of head injury is :
- A. Change of level of consciousness (Correct Answer)
- B. Contralateral pupillary dilation
- C. Ipsilateral pupillary dilatation
- D. Hemiparesis
Explanation: ***Change of level of consciousness*** - A **deterioration in the level of consciousness** is often the earliest and most sensitive indicator of increasing intracranial pressure (ICP) following a head injury. - This change can manifest as **confusion, lethargy, drowsiness, or difficulty arousing** the patient. *Contralateral pupillary dilation* - **Contralateral pupillary dilation** typically occurs later in the progression of increased ICP, often indicating brainstem compression. - This sign suggests a more advanced and severe stage of brain herniation. *Ipsilateral pupillary dilatation* - **Ipsilateral pupillary dilation** is a classic sign of **uncal herniation**, which occurs as increased ICP pushes the temporal lobe. - While a critical sign, it is generally not the earliest indicator and suggests significant mass effect on the oculomotor nerve. *Hemiparesis* - **Hemiparesis**, or weakness on one side of the body, is a **focal neurological deficit** that can result from direct brain injury or compression. - It usually appears later than changes in the level of consciousness and may not be the initial symptom of rising ICP, especially if the pressure increase is diffuse.
Question 5: Surgical treatment for a 40-years old lady with 3 x 3 cm. papillary carcinoma thyroid with level III enlarged lymph nodes is :
- A. Total thyroidectomy with radical neck dissection
- B. Total thyroidectomy with post-operative radio-iodine ablation
- C. Total thyroidectomy with excision of involved nodes
- D. Total thyroidectomy with functional neck dissection (Correct Answer)
Explanation: ***Total thyroidectomy with functional neck dissection*** - For **papillary thyroid carcinoma** with **level III lymph node involvement**, the standard approach is **total thyroidectomy** with **therapeutic lateral neck dissection** (functional/modified radical neck dissection). - **Level III nodes** are part of the **lateral compartment** (levels II-IV), requiring formal **compartment-oriented dissection** rather than selective node excision for adequate oncological clearance. *Total thyroidectomy with excision of involved nodes* - **"Excision of involved nodes"** is not standard terminology in thyroid surgery and **"berry-picking"** individual nodes is generally not recommended for therapeutic purposes. - **Compartment-oriented dissection** is preferred over selective node removal as it provides better oncological outcomes and staging accuracy. *Total thyroidectomy with radical neck dissection* - **Radical neck dissection** involves removal of cervical lymph node levels I-V along with the **sternocleidomastoid muscle**, **internal jugular vein**, and **spinal accessory nerve**. - This extensive procedure is reserved for cases with **extensive extranodal extension** or when these structures are directly involved, causing significant morbidity. *Total thyroidectomy with post-operative radio-iodine ablation* - **Radioiodine ablation** is an **adjuvant therapy** used after thyroidectomy to destroy remaining thyroid tissue and microscopic disease. - This option doesn't address the **surgical management** of enlarged lymph nodes, which is specifically what the question asks about.
Question 6: Splenectomy is best indicated for :
- A. Cirrhosis liver with portal hypertension
- B. Sickle cell disease
- C. Hereditary spherocytosis (Correct Answer)
- D. Gaucher's disease
Explanation: ***Hereditary spherocytosis*** - Splenectomy is a curative treatment for **hereditary spherocytosis** as it removes the primary site of red blood cell destruction. - It alleviates **anemia** and prevents complications such as **gallstones** by reducing hemolysis. *Cirrhosis liver with portal hypertension* - In cirrhosis with **portal hypertension**, splenectomy is generally not the primary treatment and may even worsen portal hypertension in some cases. - Management focuses on treating the underlying **liver disease** and its complications, such as **variceal bleeding**. *Sickle cell disease* - Splenectomy is generally avoided in **sickle cell disease** due to the increased risk of **overwhelming post-splenectomy sepsis** and other complications. - The primary approach is supportive care to manage crises, pain, and prevent infections. *Gaucher's disease* - **Gaucher's disease** involves the accumulation of glucocerebroside in various organs, including the spleen, often leading to **splenomegaly**. - Treatment primarily involves **enzyme replacement therapy (ERT)** and substrate reduction therapy, with splenectomy reserved for rare cases of severe symptoms unresponsive to medical therapy.
Question 7: A retained stone in CBD (common bile duct) diagnosed by T-tube cholangiogram is best treated by :
- A. Endoscopic papillotomy (Correct Answer)
- B. Re-exploration of common bile duct
- C. Extra corporeal shock wave lithotripsy
- D. Dissolution therapy
Explanation: ***Endoscopic papillotomy*** - This procedure, typically performed via an **ERCP**, allows for the removal of **retained common bile duct stones** in a less invasive manner than re-exploration. - It involves incising the **sphincter of Oddi** to facilitate stone extraction or spontaneous passage, especially when a **T-tube** is already in place, making access easier. *Re-exploration of common bile duct* - This is a more invasive surgical procedure with higher risks compared to endoscopic approaches. - Re-exploration is generally reserved for cases where **endoscopic techniques fail** or where there are specific contraindications to endoscopy. *Extra corporeal shock wave lithotripsy* - **ESWL** is primarily used for **kidney stones** and sometimes for large pancreatic or gallbladder stones that are difficult to access endoscopically. - Its effectiveness in fragmenting **CBD stones**, especially when a T-tube is present, is limited, and fragments may still obstruct the duct. *Dissolution therapy* - This therapy involves administering **ursodeoxycholic acid** to dissolve cholesterol stones. - It is a **slow process** and is generally ineffective for pigmented stones or for promptly resolving symptomatic or **obstructive retained CBD stones**.
Question 8: All of the following statements regarding gallstones are true except :
- A. They can cause intestinal obstruction
- B. They are mostly radio opaque (Correct Answer)
- C. They can lead to acute cholangitis by slipping into the common bile duct
- D. Mixed stones are the commonest type
Explanation: ***They are mostly radio opaque*** - Only about **10-20% of gallstones** are sufficiently calcified to be visible on a plain abdominal radiograph. - The majority of gallstones, especially **cholesterol stones**, are radiolucent and are best visualized by ultrasound. *They can cause intestinal obstruction* - This statement is true. A large gallstone can erode through the gallbladder wall into the small intestine, typically the duodenum, leading to a gallstone ileus. - **Gallstone ileus** is a rare form of mechanical bowel obstruction caused by a gallstone impaction, usually in the terminal ileum. *They can lead to acute cholangitis by slipping into the common bile duct* - This statement is true. Gallstones can migrate from the gallbladder into the **common bile duct (CBD)**, obstructing bile flow and leading to **choledocholithiasis**. - Obstruction of the CBD by gallstones, especially with superimposed bacterial infection, can cause **acute cholangitis**. *Mixed stones are the commonest type* - This statement is true. **Mixed gallstones**, which contain a combination of cholesterol, calcium salts, and bilirubin, are the most prevalent type of gallstones. - Pure cholesterol stones and pure pigment stones (black or brown) are less common than mixed stones.
Question 9: A 65-year-old patient presents with obstructive jaundice and 15 kg weight loss. An ultrasound shows a 4 cm mass in the head of the pancreas with dilated bile ducts. Further work up includes a helical CT scan. The study shows several lesions consistent with metastasis in the right and left lobes of the liver and encasement of gastroduodenal artery. The most appropriate treatment would be:
- A. Total pancreatectomy
- B. Biliary and gastric bypass
- C. Pancreaticoduodenectomy (Whipple procedure)
- D. Endoscopic stenting of bile duct (Correct Answer)
Explanation: **_Endoscopic stenting of bile duct_** - The presence of **distant liver metastases** and **vascular encasement** makes the disease inoperable and renders curative surgery impossible. - **Endoscopic stenting** offers effective palliation for **obstructive jaundice**, improving quality of life by relieving symptoms such as itching and nausea, and preventing cholangitis. *Total pancreatectomy* - This is an **extensive surgical procedure** suitable for resectable pancreatic head tumors without metastatic disease. - It is **highly morbid** and not indicated in the presence of **liver metastases** and **vascular encasement**, as it would not be curative and carries significant risks. *Biliary and gastric bypass* - This procedure aims to relieve both **biliary obstruction** and potential gastric outlet obstruction, which can occur from pancreatic head tumors. - While it addresses symptoms, it is still a **surgical intervention** with associated risks and is generally reserved for patients with a longer life expectancy or when endoscopic stenting is unsuccessful or unfeasible. It is not the most appropriate initial palliative step given the metastatic disease. *Pancreaticoduodenectomy (Whipple procedure)* - The **Whipple procedure** is the standard curative surgical treatment for **resectable pancreatic head cancers**. - However, the patient's presentation with **liver metastases** and **gastroduodenal artery encasement** indicates unresectable disease, making this procedure inappropriate and potentially harmful.
Question 10: Laparoscopic instruments are best sterilized by :
- A. Autoclaving (Correct Answer)
- B. Ethylene oxide
- C. Hot air oven
- D. 2% Glutaraldehyde
Explanation: ***Autoclaving*** - **Autoclaving** remains the gold standard for sterilizing **heat-stable** laparoscopic instruments (e.g., reusable trocars, simple graspers, scissors without delicate components). - Uses **moist heat** (steam at 121-134°C under pressure) to kill all microorganisms including spores, achieving complete sterilization. - **Advantages**: Rapid cycle time (15-30 minutes), cost-effective, no toxic residues, widely available. - **Limitation**: Many modern laparoscopic instruments contain heat-sensitive components (fiber optic cables, cameras, delicate optics) that may be damaged by repeated autoclaving. *Ethylene oxide* - **Ethylene oxide (EtO)** is the preferred method for **heat-sensitive** laparoscopic equipment including telescopes, cameras, and instruments with complex electronics. - Provides complete sterilization at low temperatures (37-63°C), making it ideal for delicate optics and plastics. - **Disadvantages**: Requires 8-12 hours for aeration to remove toxic residues, is a known **carcinogen**, needs special facilities and ventilation, and has longer cycle times (12-24 hours total). *Hot air oven* - Uses **dry heat** (160-180°C for 1-2 hours) suitable for glassware, oils, and powders. - **Not suitable** for laparoscopic instruments due to high temperatures damaging plastics, rubber, and optical components, and poor penetration into lumens. - Less efficient than moist heat sterilization. *2% Glutaraldehyde* - **2% Glutaraldehyde** provides **high-level disinfection** (20-30 minutes) or sterilization (10 hours contact time) for heat-sensitive instruments. - Commonly used for routine processing of laparoscopic equipment between cases when full sterilization is not required. - **Disadvantages**: Prolonged immersion time needed for sterilization, toxic fumes requiring ventilation, does not kill all spores reliably in short contact times, and is primarily a disinfectant rather than a practical sterilant. **Note**: Modern practice increasingly uses low-temperature sterilization methods (hydrogen peroxide plasma, peracetic acid systems) for heat-sensitive laparoscopic equipment, combining the benefits of complete sterilization with protection of delicate instruments.