UPSC-CMS 2017 — Surgery
23 Previous Year Questions with Answers & Explanations
An eight year old male child complains of severe pain in right testis. The most probable diagnosis is
Which one of the following statements is NOT correct regarding Gastroschisis?
Heineke‐Mikulicz operation is done for:
A 32 year old female underwent laparoscopic cholecystectomy which was difficult. On her second post operative day, she develops jaundice. Her LFT parameters show serum bilirubin 6.8 mg/dL; direct bilirubin 5.6 and indirect bilirubin 1.2 mg/dL; and serum alkaline phosphatase 1226 IU/L. She is most likely suffering from obstructive jaundice due to:
A 23-year-old male riding his motorcycle meets with a road accident. He is tachypnoeic with HR 110/min and BP 112/74 mmHg. On examination, he appears pale and has tenderness over the left side of chest with dullness to percussion. There is slight mediastinal shift to the opposite side. Abdominal examination is unremarkable. Most probably he is suffering from:
Mondor’s disease is
Anderson‐Hynes operation is performed for:
Which one of the following is the most important selection criteria for obesity surgery?
A 45 year old underwent surgery for rectal prolapse. At present, he complains of sexual dysfunction which is probably due to the injury of:
A 40 year old man, with a history of a reducible left groin swelling of two years, comes with severe pain over left groin. The swelling is now non-reducible and is very tender to touch. The most probable treatment plan for this patient would be:
UPSC-CMS 2017 - Surgery UPSC-CMS Practice Questions and MCQs
Question 1: An eight year old male child complains of severe pain in right testis. The most probable diagnosis is
- A. Acute epididymo-orchitis
- B. Torsion of right testis (Correct Answer)
- C. Strangulated Inguinal hernia
- D. Undescended testis
Explanation: ***Torsion of right testis*** - **Testicular torsion** typically presents with sudden onset **severe unilateral testicular pain** in pre-pubertal boys, as described. - This condition is an emergency requiring prompt surgical intervention to preserve testicular viability, making it the most probable diagnosis for severe pain in a child's testis. *Acute epididymo-orchitis* - While causing testicular pain, **epididymo-orchitis** typically has a more gradual onset and is often associated with symptoms like **fever** and **dysuria**, which are not mentioned. - It usually occurs in older adolescents or adults and is less common in an 8-year-old without predisposing factors like a urinary tract infection. *Strangulated Inguinal hernia* - A **strangulated inguinal hernia** would present with an acutely painful, irreducible groin or scrotal swelling, often accompanied by signs of **bowel obstruction**. - While it can cause pain radiating to the testis, primary severe testicular pain without a palpable groin mass points away from this diagnosis. *Undescended testis* - An **undescended testis** (cryptorchidism) is a condition where the testis has not descended into the scrotum; it typically presents as an empty scrotum or a palpable mass in the inguinal canal. - It is usually **painless** unless undergoing torsion or developing malignancy, and severe acute pain as the primary symptom would be unusual for an uncomplicated undescended testis.
Question 2: Which one of the following statements is NOT correct regarding Gastroschisis?
- A. Gut has herniated through a defect to right of umbilicus
- B. Normally limited to midgut
- C. It is a ruptured exomphalos (Correct Answer)
- D. There is no covering membrane
Explanation: ***It is a ruptured exomphalos*** - This statement is incorrect because **gastroschisis** and **exomphalos (omphalocele)** are distinct congenital abdominal wall defects, and gastroschisis is not a ruptured form of exomphalos. - Gastroschisis involves a **full-thickness abdominal wall defect** with direct extrusion of bowel, while exomphalos involves herniation of abdominal contents into the base of the umbilical cord, covered by a membrane. *Gut has herniated through a defect to right of umbilicus* - Gastroschisis is typically characterized by a **paraumbilical defect**, almost always located to the **right of the umbilical cord**. - This anatomical location is a key differentiator from exomphalos, where the defect is at the central umbilical ring. *Normally limited to midgut* - The herniated contents in gastroschisis are predominantly the **small bowel (midgut)**, though other organs like the large bowel, stomach, or liver can occasionally be involved. - The limited involvement of other organs is a differentiating factor from an exomphalos, which can contain a wider array of abdominal viscera. *There is no covering membrane* - A defining feature of gastroschisis is the **absence of a peritoneal sac or covering membrane** over the herniated intestines. - This lack of protection exposes the bowel to amniotic fluid, leading to inflammation and a thickened, matted appearance of the bowel loops.
Question 3: Heineke‐Mikulicz operation is done for:
- A. Pyloric stenosis (Correct Answer)
- B. Ureteric stricture
- C. Urethral stricture
- D. Stricture common bile duct
Explanation: ***Pyloric stenosis*** - The Heineke-Mikulicz pyloroplasty is a surgical procedure specifically designed to relieve obstruction in cases of **pyloric stenosis**. - This operation involves a **longitudinal incision** of the pylorus followed by a **transverse closure**, effectively widening the pyloric channel. *Ureteric stricture* - Ureteric strictures are typically treated with procedures like **ureteroplasty** (e.g., using a Foley Y-V plasty for ureteropelvic junction obstruction) or ureteral stenting, not the Heineke-Mikulicz operation. - The Heineke-Mikulicz technique is not anatomically or functionally suitable for the repair of a ureter, which is a muscular tube with distinct functions. *Urethral stricture* - Urethral strictures are managed by **urethroplasty**, which includes various techniques such as excision and primary anastomosis, or augmentation using grafts (e.g., buccal mucosa). - The Heineke-Mikulicz technique is not employed for the treatment of urethral strictures, which have different anatomical and surgical considerations. *Stricture common bile duct* - Common bile duct strictures are usually treated with procedures like **choledochoduodenostomy** or **choledochojejunostomy** (bile duct bypass) or endoscopic techniques like balloon dilation and stent placement. - The Heineke-Mikulicz operation is a pyloroplasty that is not applicable to the common bile duct, given its different anatomical location and physiological role.
Question 4: A 32 year old female underwent laparoscopic cholecystectomy which was difficult. On her second post operative day, she develops jaundice. Her LFT parameters show serum bilirubin 6.8 mg/dL; direct bilirubin 5.6 and indirect bilirubin 1.2 mg/dL; and serum alkaline phosphatase 1226 IU/L. She is most likely suffering from obstructive jaundice due to:
- A. Hepatocellular carcinoma
- B. Carcinoma gallbladder
- C. Carcinoma head of pancreas
- D. Bile duct injury (Correct Answer)
Explanation: ***Bile duct injury*** - The patient developed jaundice two days after a "difficult" laparoscopic cholecystectomy, which is a common context for **iatrogenic bile duct injury**. - The lab results show **predominantly direct (conjugated) hyperbilirubinemia** and a significantly **elevated alkaline phosphatase**, highly indicative of extrahepatic **obstructive jaundice**. *Hepatocellular carcinoma* - This is unlikely given the **acute onset of jaundice** two days post-surgery; hepatocellular carcinoma typically presents with a more ** insidious onset** and features of chronic liver disease. - While it can cause obstructive jaundice, it is usually due to large masses compressing bile ducts or tumor thrombus in the portal vein, which doesn't fit the immediate postoperative timing. *Carcinoma gallbladder* - Gallbladder carcinoma can cause obstructive jaundice by invading or compressing the bile ducts, but it usually presents with more **chronic symptoms** and is rare in a 32-year-old. - The acute onset immediately following surgery makes an **iatrogenic cause** much more probable than a newly diagnosed cancer. *Carcinoma head of pancreas* - Pancreatic head carcinoma causes **obstructive jaundice** by compressing the common bile duct, but similar to other cancers, it presents more chronically with **weight loss**, **abdominal pain**, and potentially **pancreatitis**. - An acute presentation **post-cholecystectomy** in a young patient is not typical for this diagnosis.
Question 5: A 23-year-old male riding his motorcycle meets with a road accident. He is tachypnoeic with HR 110/min and BP 112/74 mmHg. On examination, he appears pale and has tenderness over the left side of chest with dullness to percussion. There is slight mediastinal shift to the opposite side. Abdominal examination is unremarkable. Most probably he is suffering from:
- A. Tension pneumothorax
- B. Subcutaneous emphysema
- C. Haemothorax (Correct Answer)
- D. Tracheal rupture
Explanation: **Haemothorax** - **Dullness to percussion** on the left side of the chest, combined with symptoms of **hypovolemia** (pale, HR 110/min, BP 112/74 mmHg), strongly suggests blood accumulation in the pleural space. - **Slight mediastinal shift** to the opposite side is consistent with a large volume of blood pushing the mediastinum, though it's typically more pronounced in tension pneumothorax. *Tension pneumothorax* - Characterized by **hyperresonance** to percussion, not dullness, as air accumulates in the pleural space. - Would present with marked **tracheal deviation**, **severe respiratory distress**, and often severe hypotension due to impaired cardiac output. *Subcutaneous emphysema* - Identified by **crepitus** (crackling sensation) on palpation due to air in the subcutaneous tissues. - While it can be associated with chest trauma, it does not explain the dullness to percussion or the systemic signs of blood loss. *Tracheal rupture* - Typically presents with **severe subcutaneous emphysema**, **dyspnea**, **hoarseness**, and possibly a **pneumomediastinum**. - Does not directly cause dullness to percussion in the pleural space or explain the significant signs of blood loss.
Question 6: Mondor’s disease is
- A. Multiple breast cysts
- B. Eczema of nipple and areola
- C. Thrombophlebitis of superficial veins of breast (Correct Answer)
- D. Lymphangitis of mammary lymphatics
Explanation: ***Thrombophlebitis of superficial veins of breast*** - Mondor's disease is characterized by **thrombophlebitis**, which is inflammation and clotting, of the **superficial veins of the breast** and sometimes the chest wall. - It often manifests as a **palpable, tender cord-like structure** under the skin. *Multiple breast cysts* - This condition involves the presence of **fluid-filled sacs** within the breast tissue, which can be palpable but do not present as a classic cord-like structure. - Cysts are typically smooth, mobile, and can fluctuate in size with the **menstrual cycle**, unlike Mondor's disease. *Eczema by nipple and areola* - This refers to an **inflammatory skin condition** affecting the **nipple and areola**, characterized by redness, itching, scaling, and sometimes oozing. - It is a **dermatological issue** and does not involve vascular clotting or a palpable cord. *Lymphangitis of mammary lymphatics* - **Lymphangitis** is the inflammation of **lymphatic vessels**, often presenting as red streaks and tenderness. - While it can affect the breast, it involves the **lymphatic system** rather than the superficial venous system and would not typically present as a thrombosed vessel.
Question 7: Anderson‐Hynes operation is performed for:
- A. Pseudo-pancreatic cyst
- B. Achalasia cardia
- C. Pelvi-ureteric junction obstruction (Correct Answer)
- D. Pyloric stenosis
Explanation: ***Pelvi-ureteric junction obstruction*** - The **Anderson-Hynes pyeloplasty** is a widely used surgical procedure to correct obstruction at the **pelvi-ureteric junction (PUJ)**. - This operation involves **resecting the stenotic (narrowed) or obstructed part of the renal pelvis and ureter** and then rejoining the healthy segments to restore normal urine flow. *Pseudo-pancreatic cyst* - Management of a **pseudopancreatic cyst** typically involves percutaneous drainage, endoscopic transmural drainage, or surgical cyst-gastrostomy or cyst-jejunostomy. - The **Anderson-Hynes operation** is not indicated for this condition, which is a complication of pancreatitis. *Achalasia cardia* - **Achalasia cardia** is a disorder of esophageal motility, primarily treated with procedures like **Heller myotomy** (surgical cutting of the lower esophageal sphincter muscle) or pneumatic dilation. - The **Anderson-Hynes procedure** is entirely unrelated to the esophagus or its disorders. *Pyloric stenosis* - **Pyloric stenosis** in infants is generally treated with a **Ramstedt pyloromyotomy**, which involves surgically incising the hypertrophied pyloric muscle without opening the mucosa. - This condition involves the stomach outlet, and therefore, the **Anderson-Hynes operation** is not relevant.
Question 8: Which one of the following is the most important selection criteria for obesity surgery?
- A. BMI 35 without any co-morbid disease
- B. BMI > 40 (Correct Answer)
- C. BMI 30 with co-morbid disease
- D. BMI 30
Explanation: ***BMI > 40*** - A **Body Mass Index (BMI) greater than 40 kg/m²** is generally the primary and most significant criterion for considering obesity surgery. - This category of obesity, often referred to as **morbid obesity**, carries severe health risks that surgery is deemed necessary to mitigate. *BMI 35 without any co-morbid disease* - While a **BMI of 35 kg/m²** is considered severe obesity, standing alone without significant comorbidities, it is not typically the strongest indication for bariatric surgery. - Surgery is usually recommended for this group if there are also **obesity-related comorbidities** like diabetes or hypertension. *BMI 30 with co-morbid disease* - A **BMI of 30 kg/m²** falls into the category of obesity class I, and while comorbidities are present, bariatric surgery is generally not recommended at this stage. - Lifestyle interventions, medication, and non-surgical approaches are typically tried first for individuals with a BMI of 30, even with comorbidities. *BMI 30* - A **BMI of 30 kg/m²** without any mention of comorbidities is considered obesity class I. - This level is usually managed through lifestyle modifications, diet, exercise, and sometimes pharmacotherapy, rather than surgical intervention.
Question 9: A 45 year old underwent surgery for rectal prolapse. At present, he complains of sexual dysfunction which is probably due to the injury of:
- A. Pelvic autonomic nerves (Correct Answer)
- B. Urinary bladder
- C. Rectum
- D. Inferior mesenteric artery
Explanation: ***Pelvic autonomic nerves*** - Surgical procedures in the **pelvic region**, such as for rectal prolapse, carry a risk of damaging the **pelvic autonomic nerves**, which are crucial for sexual function. - Injury to these nerves can lead to various forms of **sexual dysfunction**, including erectile dysfunction in men, due to impaired nerve signaling to the genital organs. *Urinary bladder* - While the urinary bladder is anatomically close to the rectum, direct injury to the bladder itself during rectal prolapse surgery typically leads to **urinary symptoms** (e.g., incontinence, retention), not primarily sexual dysfunction. - Though bladder dysfunction can indirectly impact sexual activity, it's not the direct cause of primary sexual dysfunction following injury in this context. *Rectum* - The surgery is performed on the rectum, and while complications can occur, direct injury to the rectal wall itself primarily results in issues such as **fecal incontinence, bleeding, or infection**. - The rectum's primary role is in digestion and defecation, and its injury does not directly cause sexual dysfunction unrelated to nerve damage. *Inferior mesenteric artery* - The **inferior mesenteric artery (IMA)** supplies blood to the distal colon and rectum, and its injury during surgery would primarily lead to **ischemia or necrosis** of the supplied bowel segments. - While a severely compromised blood supply could have systemic effects, direct injury to the IMA is not a direct or common cause of sexual dysfunction.
Question 10: A 40 year old man, with a history of a reducible left groin swelling of two years, comes with severe pain over left groin. The swelling is now non-reducible and is very tender to touch. The most probable treatment plan for this patient would be:
- A. Hot fomentation of groin area
- B. Oral antibiotics
- C. Continue conservative management
- D. Prepare for emergency surgery (Correct Answer)
Explanation: ***Prepare for emergency surgery*** - The sudden onset of **severe pain**, non-reducibility, and tenderness in a pre-existing reducible groin swelling strongly suggests **incarceration** or **strangulation** of a hernia. - **Strangulation** is a surgical emergency due to the risk of **ischemic bowel injury**, requiring immediate surgical intervention. *Hot fomentation of groin area* - This offers no therapeutic benefit for an incarcerated or strangulated hernia and may delay necessary surgical intervention, leading to **worse patient outcomes**. - It would be inappropriate for a condition that poses a risk of **bowel necrosis**. *Oral antibiotics* - While infection could be a secondary complication of bowel necrosis, antibiotics alone will not resolve the mechanical obstruction or relieve the **ischemia**. - They do not address the primary problem of **hernia incarceration** or strangulation. *Continue conservative management* - Conservative management is suitable for **reducible hernias** that are asymptomatic or mildly symptomatic, but not for acute, painful, and non-reducible hernias. - Continuing conservative management in this setting would lead to **bowel strangulation** and potential **peritonitis** or sepsis.