During laparoscopic inguinal hernia repair, in the ‘triangle of doom’, the following are true EXCEPT:
All are rare types of lateral hernia of abdominal wall, EXCEPT:
A 35 year old female had laparoscopic ventral hernia repair using polypropylene mesh in January 2015. In June 2015, she is again admitted with features of subacute intestinal obstruction and is managed conservatively. She continues to have recurrent colicky pain after that. Most probably she is suffering from:
Which of the following is NOT correct for breast abscess?
A 35 year old man presents to Emergency with acute onset pain abdomen radiating to whole abdomen and abdominal distension for one day. On examination, he has tenderness and guarding all over abdomen with pulse rate of 100/m and BP 116/84 mmHg. Chest X-ray erect position shows gas under bilateral domes of diaphragm. Probably he is suffering from:
A 70 year old man comes to Emergency with pain lower abdomen and not passing urine for eight hours. He has a past history of urgency, hesitancy and frequency of urine. On examination, he has a lump up to the umbilicus which is slightly tender. What is the next step of management?
‘Swiss cheese defects’ of anterior abdominal wall after exploratory laparotomy is best seen while doing:
A 35 year old male patient comes to casualty with acute pain abdomen; and on examination found to have cold, clammy extremities, sunken eyes, dry tongue, thready pulse, drawn and anxious face with abdominal guarding and rigidity. This clinical picture indicates:
Which of these is a palliative shunt procedure created between the left subclavian artery and pulmonary artery to treat cyanotic congenital heart disease?
A young male is undergoing emergency surgery for a clinical diagnosis of acute appendicitis. Intraoperatively minimal pus was found but the appendix was normal. What is the next step of management?
UPSC-CMS 2017 - Surgery UPSC-CMS Practice Questions and MCQs
Question 11: During laparoscopic inguinal hernia repair, in the ‘triangle of doom’, the following are true EXCEPT:
- A. Vas deferens on medial side
- B. Base by iliac vessels
- C. Cord structures on lateral side (Correct Answer)
- D. Dangerous area for dissection
Explanation: ***Cord structures on lateral side*** - This statement is somewhat **ambiguous** and is considered the EXCEPT answer in this context. - The **spermatic cord** contains multiple structures, and different components form **both boundaries** of the triangle of doom: - The **vas deferens** (a cord structure) forms the **medial** boundary - The **gonadal vessels** (testicular artery and pampiniform plexus, also cord structures) form the **lateral** boundary - In the context of this question, "cord structures" likely refers to the **bulk of the cord or vas deferens**, which is positioned **medially**, making the lateral positioning statement incorrect as commonly taught. *Vas deferens on medial side* - The **vas deferens** forms the **medial border** of the triangle of doom. - This is a key anatomical landmark used to identify the triangle during laparoscopic inguinal hernia repair. *Base by iliac vessels* - The **external iliac artery and vein** form the **base (inferior border)** of the triangle of doom. - These are the most dangerous structures in this region—injury can lead to catastrophic hemorrhage. *Dangerous area for dissection* - The triangle of doom is aptly named because it contains **critical vascular structures** including the **external iliac vessels** and **deep circumflex iliac artery**. - **Aggressive dissection, stapling, or tack placement** in this area can cause life-threatening vascular injury or damage to the **femoral branch of the genitofemoral nerve**.
Question 12: All are rare types of lateral hernia of abdominal wall, EXCEPT:
- A. Spigelian
- B. Obturator
- C. Inferior lumbar (Correct Answer)
- D. Superior lumbar
Explanation: ***Inferior lumbar*** - While still considered rare, **inferior lumbar hernias** (also known as **Petit's hernias**) are relatively more common among the listed lateral hernias. - They occur through the **inferior lumbar triangle** (Petit's triangle), bounded by the latissimus dorsi, external oblique, and iliac crest. - Among lumbar hernias, inferior lumbar hernias comprise approximately **20-25%** of cases, making them less rare than superior lumbar hernias. *Spigelian* - **Spigelian hernias** are rare lateral hernias occurring through the **Spigelian aponeurosis** (fascia of transversus abdominis muscle lateral to the rectus abdominis). - Account for only **0.12-2%** of all abdominal wall hernias. - Often **interparietal** (between muscle layers), making clinical diagnosis difficult. *Obturator* - **Obturator hernias** are extremely rare, accounting for **0.05-0.4%** of all hernias. - Protrude through the **obturator canal** in the pelvis. - More common in elderly, emaciated women and often present as small bowel obstruction. - **Note:** Technically a pelvic hernia rather than an abdominal wall hernia, but included in rare lateral hernia classifications. *Superior lumbar* - **Superior lumbar hernias** (also known as **Grynfeltt-Lesshaft hernias**) are the rarest type, comprising only **1-2%** of all abdominal wall hernias. - Occur through the **superior lumbar triangle** (Grynfeltt's triangle), bounded by the 12th rib, erector spinae, and internal oblique. - More prone to incarceration than inferior lumbar hernias.
Question 13: A 35 year old female had laparoscopic ventral hernia repair using polypropylene mesh in January 2015. In June 2015, she is again admitted with features of subacute intestinal obstruction and is managed conservatively. She continues to have recurrent colicky pain after that. Most probably she is suffering from:
- A. Recurrence of hernia
- B. New hernia
- C. Acute appendicitis
- D. Bowel adhesion to mesh (Correct Answer)
Explanation: ***Bowel adhesion to mesh*** - The patient's history of **laparoscopic ventral hernia repair** using polypropylene mesh, followed by recurrent colicky pain and a subacute intestinal obstruction, strongly suggests **adhesion formation involving the mesh and bowel**. - **Polypropylene mesh** is known to induce an inflammatory response, leading to scar tissue formation and potential adhesion to nearby organs, which can cause chronic pain and obstruction. *Recurrence of hernia* - While hernia recurrence is possible, the presentation primarily with **recurrent colicky pain** and a single episode of **subacute intestinal obstruction** is less characteristic of a simple recurrence, which often presents with a palpable bulge or more direct obstructive symptoms. - The conservative management of the obstruction episode further suggests a non-strangulated or irreducible recurrence, which would typically warrant surgical intervention if severely symptomatic. *New hernia* - A new hernia is unlikely given the history of a recent repair at a different site, unless specified. - The symptoms are more directly attributable to complications related to the previous surgery and the implanted mesh. *Acute appendicitis* - **Acute appendicitis** typically presents with right lower quadrant pain, fever, and leukocytosis, which are not described in the patient's symptoms of recurrent colicky pain and subacute obstruction. - The onset of symptoms months after a hernia repair, and their chronic, recurrent nature, makes acute appendicitis an improbable diagnosis.
Question 14: Which of the following is NOT correct for breast abscess?
- A. Antibiotic is given if pus is already present
- B. A counterincision is made in the dependant part (Correct Answer)
- C. Drainage of abscess by a radial incision
- D. Dressings are changed frequently
Explanation: ***A counterincision is made in the dependant part*** - For breast abscesses, making a **counterincision** is generally *not* the standard practice unless there are specific, complex circumstances requiring additional drainage. - The primary goal is to **incise and drain** the abscess in one go, without the need for additional counterincisions. *Antibiotic is given if pus is already present* - **Antibiotics** are typically initiated *before* pus formation and continue **post-drainage** to manage infection. - If pus is already present, drainage is the primary treatment, but antibiotics are also necessary to treat the underlying infection and prevent recurrence. *Drainage of abscess by a radial incision* - **Radial incisions** are the preferred method for draining breast abscesses as they align with the natural **ductal architecture** of the breast. - This approach minimizes damage to milk ducts and reduces the risk of **fistula formation** while promoting better cosmetic outcomes. *Dressings are changed frequently* - **Frequent dressing changes** (e.g., daily or every shift) are crucial for managing an open wound after abscess drainage. - This helps to remove **exudate**, monitor for signs of infection, and ensure proper **wound healing** by allowing the cavity to heal from the inside out.
Question 15: A 35 year old man presents to Emergency with acute onset pain abdomen radiating to whole abdomen and abdominal distension for one day. On examination, he has tenderness and guarding all over abdomen with pulse rate of 100/m and BP 116/84 mmHg. Chest X-ray erect position shows gas under bilateral domes of diaphragm. Probably he is suffering from:
- A. Acute pancreatitis
- B. Appendicular perforation
- C. Ruptured liver abscess
- D. Gastric perforation (Correct Answer)
Explanation: ***Gastric perforation*** - The presence of **bilateral pneumoperitoneum** (gas under both domes of diaphragm) on erect chest X-ray is **pathognomonic for hollow viscus perforation**, with gastric/duodenal perforations being the most common cause. - The clinical presentation of **acute onset generalized abdominal pain**, **tenderness and guarding all over abdomen**, combined with bilateral free air perfectly matches **gastric perforation**. *Acute pancreatitis* - Typically presents with severe **epigastric pain radiating to the back**, often with elevated **serum amylase/lipase**, but does **NOT cause pneumoperitoneum**. - While severe pancreatitis can cause peritonitis, it involves **inflammatory exudate** rather than free air under the diaphragm. *Appendicular perforation* - Usually presents with **localized right iliac fossa pain** initially before generalizing, unlike the immediate generalized presentation described. - Though perforation can cause pneumoperitoneum, it's **less likely to cause prominent bilateral free air** compared to upper GI perforations. *Ruptured liver abscess* - Would typically have a preceding history of **fever, right upper quadrant pain**, and systemic signs of infection before rupture. - Rupture releases **purulent material and exudate** into the peritoneum rather than free air, so **pneumoperitoneum would not be present**.
Question 16: A 70 year old man comes to Emergency with pain lower abdomen and not passing urine for eight hours. He has a past history of urgency, hesitancy and frequency of urine. On examination, he has a lump up to the umbilicus which is slightly tender. What is the next step of management?
- A. Per urethral catheterise the patient (Correct Answer)
- B. Get an urgent USG
- C. Start antibiotics
- D. Per rectal examination
Explanation: ***Per urethral catheterise the patient*** - The patient presents with **acute urinary retention**, indicated by the inability to pass urine for eight hours and a tender palpable bladder up to the umbilicus. - **Catheterization** is the immediate and most effective way to relieve bladder distension, pain, and prevent potential kidney damage. *Get an urgent USG* - While a **ultrasound** can confirm bladder distention and identify underlying causes, it is not the immediate priority. - Relieving the obstruction takes precedence over diagnostic imaging in **acute urinary retention**. *Start antibiotics* - There are no specific signs of infection (e.g., fever, dysuria) to necessitate **immediate antibiotic administration**. - While urinary retention can increase the risk of infection, **antibiotics** should be reserved for confirmed infections or as prophylaxis after catheterization in high-risk patients. *Per rectal examination* - A **per rectal examination** would be performed as part of the initial assessment to evaluate the prostate in a male patient with urinary symptoms. - However, it does not directly address the immediate need to relieve the **urinary obstruction** in acute retention.
Question 17: ‘Swiss cheese defects’ of anterior abdominal wall after exploratory laparotomy is best seen while doing:
- A. Open inguinal hernia repair
- B. Laparoscopic ventral hernia repair (Correct Answer)
- C. Open ventral hernia repair
- D. Laparoscopic inguinal hernia repair
Explanation: ***Laparoscopic ventral hernia repair*** - During **laparoscopic ventral hernia repair**, the surgeon has an **intra-abdominal view** of the anterior abdominal wall. - This allows for direct visualization of multiple, small fascial defects ("Swiss cheese defects") from an old laparotomy incision from the inside. - The **panoramic view** from within the peritoneal cavity enables comprehensive assessment of the entire abdominal wall, making it the best approach to identify scattered defects. *Open inguinal hernia repair* - This approach focuses on the **inguinal canal** and does not provide an adequate view of the entire anterior abdominal wall. - It is performed through an **external incision**, making it difficult to detect multiple small defects throughout the rectus sheath. *Open ventral hernia repair* - While an **open ventral hernia repair** addresses a defect in the anterior abdominal wall, the exposure is typically confined to the immediate area of the hernia. - It may not offer the comprehensive intra-abdominal view necessary to identify scattered "Swiss cheese defects" across a wider area of the fascia. *Laparoscopic inguinal hernia repair* - This procedure primarily involves repairing an **inguinal hernia**, with visualization focused on the inguinal region and the posterior aspect of the groin. - It does not provide the broad intra-abdominal perspective needed to assess for general anterior abdominal wall defects or "Swiss cheese defects" away from the repair site.
Question 18: A 35 year old male patient comes to casualty with acute pain abdomen; and on examination found to have cold, clammy extremities, sunken eyes, dry tongue, thready pulse, drawn and anxious face with abdominal guarding and rigidity. This clinical picture indicates:
- A. Acute cholecystitis
- B. Local peritonitis
- C. Diffuse late peritonitis (Correct Answer)
- D. Diffuse early peritonitis
Explanation: ***Diffuse late peritonitis*** - The combination of **cold, clammy extremities**, **thready pulse**, **sunken eyes**, **dry tongue**, and an **anxious face** points to significant **systemic inflammatory response syndrome (SIRS)** and **hypovolemic shock**, which are characteristic of late-stage peritonitis. - **Abdominal guarding and rigidity** indicate widespread peritoneal irritation, and the systemic signs confirm that this is a late-stage, diffuse process, rather than localized or early. *Acute cholecystitis* - While it causes **acute pain in the abdomen**, it is typically localized to the **right upper quadrant** and does not usually present with the severe systemic signs of **shock** described (e.g., cold extremities, thready pulse) unless complications like perforation have occurred. - The generalized abdominal guarding and rigidity suggest a more diffuse inflammatory process beyond a single inflamed organ. *Local peritonitis* - This condition involves inflammation of a specific area of the peritoneum, leading to **localized tenderness**, guarding, and rebound tenderness, but typically **without the widespread systemic signs of shock and severe hypovolemia** seen in this patient. - The description of a "drawn and anxious face" and global signs of shock indicate a more widespread, serious condition. *Diffuse early peritonitis* - **Early diffuse peritonitis** would present with generalized abdominal pain, guarding, and rigidity, but the severe systemic signs of **shock** (e.g., cold, clammy extremities, thready pulse, sunken eyes) are usually not as pronounced or absent. - The patient's presentation with **profound signs of hypovolemia and systemic compromise** indicates a more advanced, "late" stage of the disease where fluid shifts and septic shock are already established.
Question 19: Which of these is a palliative shunt procedure created between the left subclavian artery and pulmonary artery to treat cyanotic congenital heart disease?
- A. Waterston's shunt
- B. Lieno renal shunt
- C. Gott’s shunt
- D. Blalock-Taussig shunt (Correct Answer)
Explanation: **Blalock-Taussig shunt** - This procedure creates a **systemic-to-pulmonary artery shunt** by anastomosing a systemic artery (often the **subclavian artery**) to the pulmonary artery, increasing **pulmonary blood flow**. - It is a palliative measure for **cyanotic congenital heart diseases** where there is reduced pulmonary blood flow, such as **Tetralogy of Fallot**. *Waterston's shunt* - This is an older, no longer commonly used palliative shunt connecting the **ascending aorta to the right pulmonary artery**. - It was associated with a high incidence of complications, including **pulmonary overcirculation** and **pulmonary vascular disease**. *Lieno renal shunt* - This refers to a shunt created between the **splenic vein (lienal vein)** and the **left renal vein**. - It is primarily used to treat **portal hypertension** by decompressing the portal venous system, not congenital heart disease. *Gott's shunt* - This involves a **temporary bypass shunt** often used during **thoracic aortic surgery** to protect the spinal cord from ischemia. - It maintains blood flow to the distal aorta during aortic clamping and is not related to congenital heart disease palliation.
Question 20: A young male is undergoing emergency surgery for a clinical diagnosis of acute appendicitis. Intraoperatively minimal pus was found but the appendix was normal. What is the next step of management?
- A. Close the abdomen without doing anything
- B. Search for perforated Meckel’s diverticulum (Correct Answer)
- C. Right hemicolectomy
- D. Appendectomy
Explanation: ***Search for perforated Meckel's diverticulum*** - When the appendix appears normal despite a strong clinical suspicion of appendicitis and **minimal pus** is present, it is crucial to investigate for alternative causes of **right lower quadrant pain** and localized peritonitis. - A **Meckel's diverticulum** is the most common congenital anomaly of the gastrointestinal tract (present in ~2% of population) and can mimic appendicitis when inflamed or perforated, necessitating a thorough search in such scenarios. - Standard practice: Examine the **terminal ileum up to 2 feet proximal to the ileocecal valve** to identify Meckel's diverticulum. *Close the abdomen without doing anything* - Closing the abdomen without identifying the source of the minimal pus and the patient's symptoms would be an **incomplete and potentially negligent** approach. - Doing so risks leaving an **undiagnosed and untreated problem**, which could lead to severe complications such as ongoing sepsis or perforation. *Right hemicolectomy* - **Right hemicolectomy** is an extensive surgical procedure typically reserved for conditions like large bowel obstructions, advanced tumors, or severe inflammatory bowel disease. - Performing a right hemicolectomy based on minimal pus and a normal appendix would be an **overly aggressive and inappropriate response** without a clear indication. *Appendectomy* - While an **incidental appendectomy** of a normal-appearing appendix is sometimes performed to prevent future diagnostic confusion, this alone **does not address the immediate problem**. - The critical error here is **failing to identify the source of the pus** that was found intraoperatively. Simply removing a normal appendix leaves the underlying pathology untreated. - The presence of pus mandates a thorough exploration to find its source—most commonly a **Meckel's diverticulum** in this clinical scenario.