UPSC-CMS 2014 — Surgery
21 Previous Year Questions with Answers & Explanations
Indications of TURP for Benign Prostatic Hyperplasia (BPH) include: 1. Urinary flow rate of less than 10 mL/second 2. Residual volume of urine >100 mL 3. Serum level of prostatic specific antigen >10 ng/mL 4. Trabeculated Urinary bladder Select the correct answer using the code given below:
Tongue fixation in a patient with carcinoma tongue is staged as
The following procedures are recommended for palliation in a patient with obstructive jaundice due to unresectable carcinoma of head of pancreas except:
Which of the following are contraindications to salvaging accidentally injured spleen during operation? 1. Labile blood pressure 2. Presence of intraperitoneal infection 3. Pre-existing splenic disease 4. Age below 50 years Select the correct answer using the code given below:
Treatment of choice for annular pancreas is
In a patient of gastric outlet obstruction nutritional support is best delivered by:
The following nerves are blocked for repairing inguinal hernia by local anaesthetic except:
Traumatic haemothorax is best managed by:
Which of the following statements about mesh skin grafts is not correct?
The following operative procedure can result in neurogenic voiding dysfunction except:
UPSC-CMS 2014 - Surgery UPSC-CMS Practice Questions and MCQs
Question 1: Indications of TURP for Benign Prostatic Hyperplasia (BPH) include: 1. Urinary flow rate of less than 10 mL/second 2. Residual volume of urine >100 mL 3. Serum level of prostatic specific antigen >10 ng/mL 4. Trabeculated Urinary bladder Select the correct answer using the code given below:
- A. 2, 3 and 4
- B. 1, 2 and 3
- C. 1, 3 and 4
- D. 1, 2 and 4 (Correct Answer)
Explanation: ***1, 2 and 4*** - Urinary flow rate **< 10 mL/s**, **residual urine volume > 100 mL**, and the presence of a **trabeculated bladder** (indicating chronic bladder outlet obstruction) are all relevant indications for considering TURP in BPH. - These findings collectively suggest significant **obstruction** and potential complications of BPH that may warrant surgical intervention. *2, 3 and 4* - This option incorrectly includes a **PSA level > 10 ng/mL** as an indication for TURP, which is primarily a marker for **prostate cancer screening** and not a direct surgical indication for BPH. - While an elevated PSA might prompt further investigation (e.g., biopsy), it doesn't alone necessitate TURP for BPH symptoms. *1, 2 and 3* - This option also incorrectly includes **PSA level > 10 ng/mL** as an indication for TURP. - The other two points (low flow rate and high residual volume) are appropriate indications, but the inclusion of PSA makes this option incorrect. *1, 3 and 4* - This option includes **PSA level > 10 ng/mL** as an indication for TURP, which is incorrect. - Additionally, it omits **residual urine volume > 100 mL**, which is a significant indicator of obstruction and a common reason for considering TURP.
Question 2: Tongue fixation in a patient with carcinoma tongue is staged as
- A. T1
- B. T2
- C. T3
- D. T4 (Correct Answer)
Explanation: ***T4*** - **Tongue fixation** in carcinoma of the tongue indicates advanced local disease classified as **T4a stage** according to AJCC TNM staging. - This finding suggests invasion of **extrinsic tongue muscles**, which causes loss of tongue mobility and represents moderately advanced local disease. - T4a tumors invade through cortical bone, involve the inferior alveolar nerve, floor of mouth, or skin of face, or in the case of tongue, involve deep extrinsic muscles causing fixation. *T1* - **T1 tumors** are small lesions measuring **≤2 cm** in greatest dimension with **depth of invasion (DOI) ≤5 mm**. - They are superficial without invasion of deep structures or causing any functional impairment like tongue fixation. *T2* - **T2 tumors** measure **≤2 cm with DOI >5 mm and ≤10 mm**, OR **>2 cm but ≤4 cm with DOI ≤10 mm**. - While larger than T1, they do not involve deep extrinsic muscles or cause tongue fixation. *T3* - **T3 tumors** are defined as tumors **>4 cm** OR **any tumor with DOI >10 mm**. - Although T3 indicates larger tumor size and deeper invasion, **tongue fixation** specifically indicates T4a stage due to involvement of extrinsic tongue musculature.
Question 3: The following procedures are recommended for palliation in a patient with obstructive jaundice due to unresectable carcinoma of head of pancreas except:
- A. Cholecystojejunostomy with jejunojejunostomy with gastrojejunostomy
- B. Hepaticojejunostomy with gastrojejunostomy
- C. Choledochoduodenostomy with gastrojejunostomy
- D. Choledochoduodenostomy, gastrojejunostomy with pancreaticojejunostomy (Correct Answer)
Explanation: ***Choledochoduodenostomy, gastrojejunostomy with pancreaticojejunostomy*** - **Pancreaticojejunostomy is NOT indicated** in palliative surgery for unresectable pancreatic cancer. - This procedure is used to anastomose the **pancreatic remnant** after **resection** (as in Whipple procedure), not in bypass operations. - Palliation focuses on **relieving biliary and gastric outlet obstruction** without performing pancreatic anastomosis, making this combination inappropriate for palliative care. *Cholecystojejunostomy with jejunojejunostomy with gastrojejunostomy* - **Cholecystojejunostomy** diverts bile flow from the gallbladder to the jejunum, relieving biliary obstruction when the cystic duct is patent. - **Gastrojejunostomy** relieves gastric outlet obstruction, a common complication of pancreatic head cancer. - This represents a valid **triple bypass** palliative approach. *Hepaticojejunostomy with gastrojejunostomy* - **Hepaticojejunostomy** creates a bypass between the common hepatic duct and the jejunum, effectively relieving biliary obstruction. - **Gastrojejunostomy** manages or prevents gastric outlet obstruction. - This **double bypass** is a standard palliative procedure for unresectable pancreatic head cancer. *Choledochoduodenostomy with gastrojejunostomy* - **Choledochoduodenostomy** directly bypasses the biliary obstruction by connecting the common bile duct to the duodenum. - **Gastrojejunostomy** addresses gastric outlet obstruction from duodenal compression by the tumor. - This **double bypass** is another widely accepted palliative approach.
Question 4: Which of the following are contraindications to salvaging accidentally injured spleen during operation? 1. Labile blood pressure 2. Presence of intraperitoneal infection 3. Pre-existing splenic disease 4. Age below 50 years Select the correct answer using the code given below:
- A. 1, 2 and 3 (Correct Answer)
- B. 1, 3 and 4
- C. 2, 3 and 4
- D. 1, 2 and 4
Explanation: ***1, 2 and 3*** - **Labile blood pressure** (1) indicates ongoing hemodynamic instability, making splenic salvage risky due to the potential for further hemorrhage and the need for immediate control. - **Presence of intraperitoneal infection** (2) makes splenic salvage dangerous as the injured spleen provides a niche for bacterial proliferation, increasing the risk of abscess formation and sepsis. - **Pre-existing splenic disease** (3) such as lymphoma or significant architectural changes, can compromise the spleen's integrity and function, making successful and safe salvage unlikely. *1, 3 and 4* - This option incorrectly includes age below 50 years as a contraindication. **Age below 50 years** (4) is generally not a contraindication to splenic salvage; in fact, younger patients, especially children, often have a greater imperative for splenic preservation due to higher risks of **overwhelming post-splenectomy infection (OPSI)**. - While choices 1 and 3 are correct contraindications, choice 4 is not. *2, 3 and 4* - This option incorrectly includes age below 50 years as a contraindication. **Labile blood pressure** (1) is a critical contraindication but is omitted. - Choices 2 and 3 are valid contraindications, but excluding the crucial factor of hemodynamic instability makes this option incomplete. *1, 2 and 4* - This option correctly identifies **labile blood pressure** (1) and **intraperitoneal infection** (2) as contraindications but incorrectly includes **age below 50 years** (4). - It also omits **pre-existing splenic disease** (3), which is another significant reason to avoid salvage.
Question 5: Treatment of choice for annular pancreas is
- A. Resection
- B. Pyloromyotomy
- C. Gastrojejunostomy
- D. Duodenoduodenostomy (Correct Answer)
Explanation: ***Duodenoduodenostomy*** - This procedure bypasses the **annular pancreatic constriction** by creating an anastomosis between two healthy segments of the **duodenum**, restoring normal flow. - It's preferred because it avoids manipulation or resection of the pancreatic tissue itself, which can lead to complications such as **pancreatitis** or **fistula formation**. *Resection* - Direct resection of the **annular pancreas** is generally avoided due to the high risk of **pancreatitis**, **fistulae**, and injury to the **biliary duct** or **main pancreatic duct**. - The abnormal pancreatic tissue is often intimately associated with the **duodenal wall**, making its complete removal difficult and dangerous. *Pyloromyotomy* - This procedure involves incising the muscle layer of the **pylorus** and is typically used for conditions like **pyloric stenosis**. - It does not address the obstruction caused by an annular pancreas around the **duodenum**. *Gastrojejunostomy* - This procedure involves creating a connection between the **stomach** and the **jejunum** to bypass a distal duodenal or pyloric obstruction. - While it can relieve gastric outlet obstruction, it does not directly address the obstruction in the **proximal duodenum** caused by an **annular pancreas**.
Question 6: In a patient of gastric outlet obstruction nutritional support is best delivered by:
- A. Enteral nutrition by Ryles tube
- B. Jejunostomy (Correct Answer)
- C. Gastrostomy
- D. Parenteral nutrition
Explanation: ***Jejunostomy*** - In **gastric outlet obstruction**, the stomach cannot empty properly, making gastric feeding routes (like Ryles tube or gastrostomy) ineffective. - A **jejunostomy** allows direct delivery of **enteral nutrition** into the jejunum, bypassing the obstructed stomach and duodenum. *Enteral nutrition by Ryles tube* - A **Ryles tube** delivers nutrition into the stomach, which is obstructed in this condition, leading to **stasis** and **vomiting**. - This method would be ineffective and potentially dangerous due to the inability of gastric contents to pass beyond the obstruction. *Gastrostomy* - A **gastrostomy** involves placing a tube directly into the stomach, which is still part of the obstructed system. - Feeding via gastrostomy would lead to accumulation of feed in the stomach, mimicking the issues with oral feeding or a Ryles tube. *Parenteral nutrition* - **Parenteral nutrition** is a viable option for nutritional support but is generally considered a second-line therapy after **enteral routes** fail or are contraindicated. - **Enteral feeding**, when possible (as with jejunostomy), is preferred due to lower cost, reduced risk of infection, and better maintenance of gut integrity.
Question 7: The following nerves are blocked for repairing inguinal hernia by local anaesthetic except:
- A. Ilio-inguinal
- B. Femoral (Correct Answer)
- C. Genito-femoral
- D. Ilio-hypogastric
Explanation: ***Femoral*** - The **femoral nerve** primarily innervates the anterior thigh muscles and provides sensory supply to the anterior thigh and medial leg; its block is not typically required for **inguinal hernia repair**. - Blocking the femoral nerve would primarily affect **motor function** of the quadriceps and sensation in the distribution of the saphenous nerve, which is not the surgical field for an inguinal hernia. *Ilio-inguinal* - The **ilio-inguinal nerve** provides sensation to the inguinal region, scrotum/labia majora, and the medial aspect of the thigh, making its block essential for anesthesia during **inguinal hernia repair**. - It lies in the **inguinal canal** and is typically targeted with local anesthetic to cover the incision site and surgical area. *Genito femoral* - The **genitofemoral nerve** has both genital and femoral branches, providing sensation to the scrotum/labia majora and a small area of the femoral triangle, respectively, and is therefore often included in an **inguinal block**. - Its blockade helps to cover the sensory innervation of the **spermatic cord** and a portion of the inguinal region, contributing to effective pain control. *Ilio-hypogastric* - The **ilio-hypogastric nerve** provides sensory innervation to the suprapubic and gluteal regions, and its blockade is important for covering the **upper part of the surgical incision** for an inguinal hernia repair. - It runs parallel to the ilio-inguinal nerve and is often blocked concurrently to ensure **comprehensive analgesia** of the abdominal wall.
Question 8: Traumatic haemothorax is best managed by:
- A. Use of streptokinase
- B. Intercostal tube drainage (Correct Answer)
- C. Open drainage
- D. Aspiration of blood from pleural cavity
Explanation: ***Intercostal tube drainage*** - **Intercostal tube drainage** is the most effective initial management for traumatic haemothorax as it allows continuous evacuation of blood and re-expansion of the lung. - It helps in quantifying blood loss, preventing clot formation, and improving respiratory mechanics by reducing pleural space compression. *Use of streptokinase* - **Streptokinase** is a fibrinolytic agent used to break down clots, but its primary role is in established, organized haemothoraces (fibrothorax) and is not the acute management for traumatic haemothorax. - Administering streptokinase in acute bleeding can worsen haemorrhage and is contraindicated in the immediate post-traumatic period. *Open drainage* - **Open drainage**, typically via thoracotomy, is reserved for massive haemothorax (e.g., >1500 mL initially or >200 mL/hr for 2-4 hours) or ongoing severe bleeding that cannot be controlled by tube thoracostomy. - It is a more invasive procedure with higher risks and is not the first-line management for all traumatic haemothoraces. *Aspiration of blood from pleural cavity* - **Aspiration of blood from the pleural cavity** (thoracentesis) can be diagnostic but is often insufficient for adequately draining a traumatic haemothorax, especially if there is ongoing bleeding or significant clot formation. - It is often reserved for small, uncomplicated haemothoraces or for diagnostic purposes, not as the definitive management in trauma.
Question 9: Which of the following statements about mesh skin grafts is not correct?
- A. They allow egress of fluid collections under the graft.
- B. They permit coverage of large areas.
- C. They “take” satisfactorily on granulating bed.
- D. They contract to the same degree as a grafted sheet of skin. (Correct Answer)
Explanation: ***They contract to the same degree as a grafted sheet of skin.*** - This statement is incorrect because **meshed skin grafts** undergo **greater primary and secondary contraction** compared to unmeshed, full-thickness sheet grafts. - The fenestrations in the meshed graft allow for stretching and expansion, but this also contributes to increased contraction as the graft heals and remodels. *They allow egress of fluid collections under the graft.* - The **fenestrations** created by the meshing process provide small openings that facilitate the **drainage of seroma or hematoma** from beneath the graft. - This feature is crucial for graft survival as fluid accumulation can lift the graft, impairing nutrient diffusion and leading to graft failure. *They permit coverage of large areas.* - Meshing a skin graft allows it to be **expanded to cover an area up to 1.5 to 9 times larger** than the original harvested skin. - This is particularly useful in managing **large burn wounds** or extensive skin defects where donor sites are limited. *They “take” satisfactorily on granulating bed.* - Meshed grafts tend to tolerate **less ideal recipient beds**, such as those with some granulation tissue or minor contamination, better than sheet grafts. - The fenestrations allow for drainage and better adherence, which can compensate for a suboptimal underlying bed.
Question 10: The following operative procedure can result in neurogenic voiding dysfunction except:
- A. Ureterolithotomy (Correct Answer)
- B. Radical hysterectomy
- C. Abdominoperineal resection
- D. Retroperitoneal lymph node dissection
Explanation: **Ureterolithotomy** - This procedure involves removing kidney stones from the **ureter** and generally does not involve dissection near the pelvic nerves responsible for bladder function. - It is a **localized procedure** that avoids the extensive pelvic dissection associated with damage to the **autonomic nerves controlling voiding**. *Radical hysterectomy* - This procedure involves the removal of the **uterus, cervix, parametrium, and a portion of the vagina**, which frequently necessitates extensive dissection in the pelvic area. - The dissection can injure the **pelvic plexus nerves**, leading to neurogenic bladder dysfunction. *Abdominoperineal resection* - This surgery involves removing the **rectum and anus**, requiring extensive dissection through the pelvic floor. - This procedure carries a significant risk of damaging the **inferior hypogastric plexus and sacral nerves**, which are crucial for bladder control. *Retroperitoneal lymph node dissection* - This procedure involves dissecting lymph nodes in the **retroperitoneal space**, especially in cases of testicular cancer. - While primarily affecting ejaculation, extensive or misplaced dissection can also impact the **sympathetic and parasympathetic efferent nerves originating from the pelvic plexus** that contribute to bladder function.