UPSC-CMS 2017 - Surgery Practice Questions

Q: A 45 year old underwent surgery for rectal prolapse. At present, he complains of sexual dysfunction which is probably due to the injury of:

Pelvic autonomic nerves. ***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.

Q: 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:

Prepare for emergency surgery. ***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.

Q: During laparoscopic inguinal hernia repair, in the 'triangle of doom', the following are true EXCEPT:

Cord structures on lateral side. ***Cord structures on lateral side*** - This statement is **incorrect** - the **spermatic cord structures** (specifically the **vas deferens**) form the **medial boundary**, not the lateral boundary of the triangle of doom. - The **lateral boundary** is formed by the **testicular/gonadal vessels** (testicular artery and pampiniform plexus), which are separate from the main cord structures. *Vas deferens on medial side* - The **vas deferens** correctly forms the **medial border** of the triangle of doom during laparoscopic inguinal hernia repair. - This is a crucial anatomical landmark that surgeons use to identify and avoid the dangerous triangle. *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**. *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** requiring immediate vascular repair.

Q: All are rare types of lateral hernia of abdominal wall, EXCEPT:

Inferior lumbar. ***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.

Q: 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:

Bowel adhesion to mesh. ***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.

Q: Which of the following is NOT correct for breast abscess?

A counterincision is made in the dependant part. ***A counterincision is made in the dependant part*** - **Counterincisions** are generally *not* required for breast abscesses as a single **radial incision** is usually sufficient for adequate drainage. - Making additional incisions can damage the **ductal architecture** and increase the risk of **fistula formation** and poor cosmetic outcomes. *Dressings are changed frequently* - **Frequent dressing changes** are essential after abscess drainage to remove **exudate** and monitor healing progress. - This prevents secondary infection and allows the cavity to heal from the **inside out** properly. *Antibiotic is given if pus is already present* - **Antibiotics** are indicated even when pus is present, as they treat the underlying **bacterial infection** and prevent spread. - They work synergistically with surgical drainage to ensure complete resolution and prevent **recurrence**. *Drainage of abscess by a radial incision* - **Radial incisions** are the gold standard as they follow the natural **ductal pattern** of the breast tissue. - This approach minimizes damage to **milk ducts** and provides better cosmetic results compared to circumferential incisions.

Q: 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:

Gastric perforation. ***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**.

Q: 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?

Per urethral catheterise the patient. ***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.

Q: ‘Swiss cheese defects’ of anterior abdominal wall after exploratory laparotomy is best seen while doing:

Laparoscopic ventral hernia repair. ***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.

Q: 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:

Diffuse late peritonitis. ***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 1

A 45 year old underwent surgery for rectal prolapse. At present, he complains of sexual dysfunction which is probably due to the injury of:

Accepted Answer

Pelvic autonomic nerves

Answer

Urinary bladder

Answer

Rectum

Answer

Inferior mesenteric artery

Question 2

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:

Accepted Answer

Prepare for emergency surgery

Answer

Hot fomentation of groin area

Answer

Oral antibiotics

Answer

Continue conservative management

Question 3

During laparoscopic inguinal hernia repair, in the 'triangle of doom', the following are true EXCEPT:

Accepted Answer

Cord structures on lateral side

Answer

Vas deferens on medial side

Answer

Base by iliac vessels

Answer

Dangerous area for dissection

Question 4

All are rare types of lateral hernia of abdominal wall, EXCEPT:

Accepted Answer

Inferior lumbar

Answer

Spigelian

Answer

Obturator

Answer

Superior lumbar

Question 5

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:

Accepted Answer

Bowel adhesion to mesh

Answer

Recurrence of hernia

Answer

New hernia

Answer

Acute appendicitis

Question 6

Which of the following is NOT correct for breast abscess?

Accepted Answer

A counterincision is made in the dependant part

Answer

Antibiotic is given if pus is already present

Answer

Drainage of abscess by a radial incision

Answer

Dressings are changed frequently

Question 7

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:

Accepted Answer

Gastric perforation

Answer

Acute pancreatitis

Answer

Appendicular perforation

Answer

Ruptured liver abscess

Question 8

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?

Accepted Answer

Per urethral catheterise the patient

Answer

Get an urgent USG

Answer

Start antibiotics

Answer

Per rectal examination

Question 9

‘Swiss cheese defects’ of anterior abdominal wall after exploratory laparotomy is best seen while doing:

Accepted Answer

Laparoscopic ventral hernia repair

Answer

Open inguinal hernia repair

Answer

Open ventral hernia repair

Answer

Laparoscopic inguinal hernia repair

Question 10

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:

Accepted Answer

Diffuse late peritonitis

Answer

Acute cholecystitis

Answer

Local peritonitis

Answer

Diffuse early peritonitis

UPSC-CMS 2017 — Surgery