UPSC-CMS 2018 — Surgery
23 Previous Year Questions with Answers & Explanations
All of the following statements are correct about vasectomy EXCEPT:
Following are the factors for increased risk of wound infection EXCEPT:
A 22 year old young man came with history of occasional bleeding per rectum. On colonoscopy, numerous sessile polyps were seen in descending and sigmoid colon. On family history his elder brother was operated for thyroid malignancy. The young man should be advised:
Gastric conduit after oesophageal resection is based upon:
A 70 year old male having comorbidities presents with benign appearing parotid tumour. The best option is:
Mainstay of an accurate diagnosis of pancreatic injury following blunt abdominal trauma is:
Pancreatic pseudocysts developing complications are best managed by?
Which one of the following regarding absorbable meshes is NOT true?
Which one of the following is NOT a surgical modality for management of femoral hernia?
“Triangle of Doom” dissected and seen during Laparoscopic inguinal hernia repair is bounded by all EXCEPT:
UPSC-CMS 2018 - Surgery UPSC-CMS Practice Questions and MCQs
Question 1: All of the following statements are correct about vasectomy EXCEPT:
- A. No Scalpel Vasectomy (NSV) was first developed in China.
- B. It is less time consuming than tubectomy
- C. It increases the incidence of testicular cancer (Correct Answer)
- D. Additional contraception should be used for 3 months after vasectomy
Explanation: ***It increases the incidence of testicular cancer*** - Research has consistently shown **no causal link** between vasectomy and an increased risk of testicular cancer. - The reported incidence of testicular cancer in men who have undergone vasectomy is similar to that in the general population. *No Scalpel Vasectomy (NSV) was first developed in China.* - The **no-scalpel vasectomy (NSV)** technique was indeed developed in China by Dr. Li Shunqiang in 1974. - This method involves a smaller puncture incision rather than a traditional scalpel incision, leading to fewer complications. *It is less time consuming than tubectomy* - Vasectomy is generally a **simpler, less invasive, and quicker procedure** than tubectomy (female sterilization). - Tubectomy often requires general anesthesia and a more complex surgical approach, making it more time-consuming overall. *Addition contraception should be used for 3 months after vasectomy* - It takes approximately **3 months or 20 ejaculations** for all residual sperm to be cleared from the reproductive tract after a vasectomy. - Therefore, additional contraception is crucial during this period until a **sperm analysis (semen analysis)** confirms azoospermia (absence of sperm).
Question 2: Following are the factors for increased risk of wound infection EXCEPT:
- A. Good blood supply (Correct Answer)
- B. Metabolic diseases (diabetes, uraemia)
- C. Immunosuppression
- D. Malnutrition
Explanation: ***Good blood supply*** - A **robust blood supply** is crucial for wound healing as it delivers **oxygen, nutrients, and immune cells** to the injured site, actively preventing infection. - Good perfusion means that the tissues can effectively **clear bacteria** and support the local immune response, thereby **decreasing the risk** of wound infection. *Metabolic diseases (diabetes, uraemia)* - **Diabetes** impairs wound healing through mechanisms like **peripheral neuropathy**, **vasculopathy**, and compromised immune function, greatly increasing infection risk. - **Uraemia** in kidney failure leads to a buildup of toxins that can **suppress the immune system** and impair cellular function, making patients more susceptible to infections. *Immunosuppression* - **Immunosuppression**, whether due to chronic illness, medications (e.g., corticosteroids), or immunodeficiency, significantly **weakens the body's defense mechanisms**. - A compromised immune system is less able to **identify, target, and eliminate invading pathogens**, leading to a higher incidence of wound infections. *Malnutrition* - **Malnutrition**, particularly deficiencies in protein, vitamin C, and zinc, can severely **impair collagen synthesis**, immune function, and overall tissue repair. - Inadequate nutritional status hinders the body's ability to **mount an effective immune response** and regenerate tissues, creating an environment ripe for infection.
Question 3: A 22 year old young man came with history of occasional bleeding per rectum. On colonoscopy, numerous sessile polyps were seen in descending and sigmoid colon. On family history his elder brother was operated for thyroid malignancy. The young man should be advised:
- A. Prophylactic anterior resection
- B. Prophylactic panproctocolectomy (Correct Answer)
- C. Surveillance colonoscopy every 6 months
- D. Colonoscopic removal of all polyps
Explanation: ***Prophylactic panproctocolectomy*** - This patient presents with multiple sessile polyps in the descending and sigmoid colon, along with a family history of **thyroid malignancy** in his brother. This constellation of findings is highly suggestive of **Familial Adenomatous Polyposis (FAP)**, specifically **Gardner syndrome**, which is a variant of FAP associated with extracolonic manifestations like thyroid tumors. - Due to the high risk of **colorectal cancer** development in FAP (nearly 100% by age 40 without intervention), **prophylactic panproctocolectomy** is the recommended treatment to prevent progression to malignancy. *Prophylactic anterior resection* - An anterior resection typically involves removing only a segment of the colon, which would be insufficient for a patient with FAP, as polyps can develop throughout the entire colon and rectum. - This procedure would leave a significant portion of the colon at risk for **neoplastic transformation**, necessitating further surgeries or intense surveillance. *Surveillance colonoscopy every 6 months* - While surveillance is crucial in risk assessment, for diagnosed FAP, particularly with symptomatic polyps and a family history suggestive of a syndrome, surveillance alone is inadequate due to the **high and inevitable risk of cancer**. - Delaying definitive surgical intervention would expose the patient to a very high probability of developing **colorectal carcinoma**. *Colonoscopic removal of all polyps* - Given the presence of **numerous sessile polyps**, endoscopic polypectomy would be impractical, incomplete, and would likely miss microscopic or nascent lesions. - This approach offers only temporary management and does not address the underlying genetic predisposition to continuous polyp formation and high malignancy risk.
Question 4: Gastric conduit after oesophageal resection is based upon:
- A. Short gastric vessels and Vasa brevia
- B. Right Gastroepiploic artery (Correct Answer)
- C. Left gastric artery
- D. Right gastric artery
Explanation: ***Right Gastroepiploic artery*** - The **right gastroepiploic artery** is the primary arterial supply preserved when fashioning a gastric conduit for esophageal replacement. - This artery provides the main blood supply to the **greater curvature of the stomach**, which forms the basis of the conduit, ensuring its viability. *Short gastric vessels and Vasa brevia* - The **short gastric vessels** are typically ligated and divided during gastric conduit creation to mobilize the stomach for upward transposition. - These vessels supply the fundus and upper part of the greater curvature, which are often either resected or lose their primary blood supply, making them unsuitable as the sole basis for the conduit. *Left gastric artery* - The **left gastric artery** is usually ligated during oesophageal resection to facilitate gastric mobilization and conduit creation. - It supplies the lesser curvature and upper part of the stomach, but its division is necessary to free the stomach for transposition into the chest or neck. *Right gastric artery* - The **right gastric artery** supplies the lesser curvature of the stomach and is often ligated or preserved with care, but it is not the primary vessel relied upon for the blood supply of the gastric conduit. - Its contribution to the overall conduit's blood supply is secondary to the robust flow from the right gastroepiploic artery.
Question 5: A 70 year old male having comorbidities presents with benign appearing parotid tumour. The best option is:
- A. Tumour enucleation
- B. Radio therapy
- C. Aspiration biopsy confirmation
- D. Superficial Parotidectomy (Correct Answer)
Explanation: ***Superficial Parotidectomy*** - This is the **standard surgical treatment** for benign parotid tumors, even in elderly patients with comorbidities, as it offers the best balance of **low recurrence risk** and **preservation of facial nerve function**. - The procedure removes the superficial lobe of the parotid gland, where most benign tumors are located, and allows for **intraoperative facial nerve monitoring**. *Tumour enucleation* - This procedure has a **higher risk of tumor recurrence** as it does not remove a cuff of healthy tissue around the tumor. - It also has a greater chance of **facial nerve injury** due to the lack of clear dissection planes. *Radio therapy* - Radiotherapy is generally reserved for **malignant parotid tumors** or as an adjuvant therapy after incomplete resection of high-grade malignancies. - It carries risks of **xerostomia**, radiation-induced fibrosis, and potential secondary malignancies, making it less suitable for benign conditions. *Aspiration biopsy confirmation* - While an aspiration biopsy (Fine Needle Aspiration Cytology, FNAC) is crucial for **preoperative diagnosis**, it is not a treatment option. - It helps in planning the definitive surgical approach but does not address the tumor itself.
Question 6: Mainstay of an accurate diagnosis of pancreatic injury following blunt abdominal trauma is:
- A. USG abdomen
- B. MRI abdomen
- C. Computed Tomogram (Correct Answer)
- D. Diagnostic peritoneal lavage
Explanation: ***Computed Tomogram*** - **CT scan** is the **imaging modality of choice** for evaluating solid organ injuries, including the pancreas, following blunt abdominal trauma due to its rapid acquisition and high resolution. - It effectively identifies signs of pancreatic injury such as **lacerations**, **hematoma**, **peripancreatic fluid**, and **transection of the pancreatic duct**. *USG abdomen* - **Ultrasound** has limited utility in diagnosing pancreatic injury due to the gland's **retroperitoneal location** and frequent overlying bowel gas obfuscating views. - While useful for rapid assessment of free fluid, it is **not sensitive enough** to reliably detect subtle pancreatic parenchymal damage. *MRI abdomen* - **MRI** provides excellent soft tissue contrast but is typically **time-consuming** and less accessible than CT in acute trauma settings, making it impractical for initial evaluation. - It may be used for **further characterization** of an injury, especially ductal involvement, if CT findings are equivocal or in stable patients. *Diagnostic peritoneal lavage* - **Diagnostic peritoneal lavage (DPL)** is primarily used to detect **hemoperitoneum** or rupture of hollow viscous organs, but it is **not specific for pancreatic injury**. - A positive DPL can indicate intra-abdominal injury but doesn't localize the source, and it has largely been replaced by focused assessment with sonography for trauma (FAST) and CT scans.
Question 7: Pancreatic pseudocysts developing complications are best managed by?
- A. Conservative treatment
- B. Surgery (Correct Answer)
- C. Radiologically guided interventions
- D. External drainage
Explanation: ***Surgery*** - When pancreatic pseudocysts develop **complications** (infection, hemorrhage, rupture, gastric outlet/biliary obstruction), definitive management is required. - Surgical internal drainage procedures (**cyst-gastrostomy**, **cyst-jejunostomy**, or **cyst-duodenostomy**) provide durable treatment by creating a permanent communication between the mature pseudocyst and the GI tract. - Surgery is particularly indicated when the pseudocyst has a **mature wall (>6 weeks)**, is **large (>6 cm)**, or when endoscopic approaches are not feasible or have failed. - While endoscopic drainage (EUS-guided) is increasingly used as first-line therapy, surgery remains the gold standard for complicated pseudocysts requiring definitive management, especially with complex anatomy or failed minimally invasive approaches. *Conservative treatment* - Conservative management with observation, pain control, and nutritional support is appropriate only for **asymptomatic, small (<6 cm)**, and **uncomplicated pseudocysts** with high likelihood of spontaneous resolution. - Once complications develop, conservative treatment is **inadequate** and poses risks of further deterioration. *Radiologically guided interventions* - Percutaneous drainage may be used for **infected pseudocysts** or as a temporizing measure, but carries high risk of **external fistula formation** (25-50%) and **recurrence**. - Does not provide internal drainage and is generally less effective than surgical or endoscopic internal drainage for complicated pseudocysts. - Not considered definitive management when complications are present. *External drainage* - External percutaneous catheter drainage is primarily a **temporizing measure** for critically ill patients or infected pseudocysts not amenable to other approaches. - High risk of **pancreaticocutaneous fistula** formation and does not address the underlying pancreatic duct communication. - Requires subsequent definitive management in most cases; not appropriate as primary treatment for complicated pseudocysts.
Question 8: Which one of the following regarding absorbable meshes is NOT true?
- A. They show very good results as collagen deposition is maximum (Correct Answer)
- B. They are made of polyglycolic acid fibre
- C. They are used to buttress sutured repair
- D. They are used in temporary abdominal wall closure
Explanation: ***They show very good results as collagen deposition is maximum*** - Absorbable meshes are **resorbed by the body** over time, leading to less collagen deposition compared to non-absorbable meshes, which provide a permanent scaffold for tissue integration. - While they can be useful in certain situations, the statement implies **superior results due to maximum collagen deposition**, which is contradictory to their nature and purpose in situations where permanent reinforcement is needed. *They are made of polyglycolic acid fibre* - Many absorbable meshes, such as **Dexon** and **Vicryl**, are indeed made from synthetic polymers like **polyglycolic acid (PGA)** or polylactic acid (PLA). - These materials are designed to be **hydrolyzed and absorbed** by the body. *They are used to buttress sutured repair* - Absorbable meshes can be used to **reinforce a primary suture line** in contaminated fields or when there is concern for tissue breakdown. - They provide **temporary support** while the native tissue heals. *They are used in temporary abdominal wall closure* - In cases of **abdominal compartment syndrome** or severe contamination, absorbable meshes may be used for **temporary closure** of the abdominal wall. - This allows for staged repair and reduces the risk of infection often associated with permanent meshes in these scenarios.
Question 9: Which one of the following is NOT a surgical modality for management of femoral hernia?
- A. The canal ring narrowing operation (Lytle’s) (Correct Answer)
- B. Lotheissen's (Inguinal) operation
- C. The low approach (Lockwood)
- D. The high approach (Mc Evedy)
Explanation: ***The canal ring narrowing operation (Lytle’s)*** - The **Lytle's operation** is a technique primarily used for the repair of **inguinal hernias**, specifically to reinforce the posterior wall of the inguinal canal, not for femoral hernias. - It involves repairing the **transversalis fascia** and strengthening the deep inguinal ring area. *Lotheissen's (Inguinal) operation* - This approach involves reducing the **femoral hernia sac** from above and repairing the defect through an **inguinal incision**. - It allows for exploration of the **inguinal canal** and is often used in cases of difficulty reducing the hernia or when a concomitant inguinal hernia is suspected. *The low approach (Lockwood)* - The **Lockwood operation** involves approaching the femoral hernia directly from **below the inguinal ligament** through a groin crease incision. - This method is straightforward for simple, uncomplicated femoral hernias. *The high approach (Mc Evedy)* - The **McEvedy approach** involves a **vertical incision** made above the inguinal ligament, providing excellent access to the **preperitoneal space** and the femoral canal. - This approach is particularly useful for **strangulated femoral hernias** as it allows for better visualization of compromised bowel and wider repair of the defect.
Question 10: “Triangle of Doom” dissected and seen during Laparoscopic inguinal hernia repair is bounded by all EXCEPT:
- A. Vas deferens
- B. Gonadal vessels
- C. Cord structures
- D. Peritoneal fold (Correct Answer)
Explanation: ***Peritoneal fold*** - The "Triangle of Doom" is an important anatomical landmark in **laparoscopic inguinal hernia repair** that contains critical vascular structures vulnerable to injury. - The **peritoneal fold** does not form a boundary of the Triangle of Doom, making this the correct answer to the EXCEPT question. - The triangle lies in the preperitoneal space and is not bounded by peritoneal reflections. *Vas deferens* - The **vas deferens** forms the **medial boundary** of the Triangle of Doom. - It courses from the internal ring into the pelvis and is a crucial landmark during dissection. - Injury can result in **infertility**, particularly if bilateral damage occurs. *Gonadal vessels* - The **gonadal vessels (testicular/ovarian vessels)** form the **lateral boundary** of the Triangle of Doom. - These vessels run parallel to the vas deferens and are at risk during lateral dissection. - The triangle's base is formed by the **iliac vessels** (external iliac artery and vein). *Cord structures* - The **cord structures** (including vas deferens and gonadal vessels) pass through or form the boundaries of the Triangle of Doom. - Within this triangle lie the **external iliac artery and vein** and the **femoral branch of the genitofemoral nerve**. - **Clinical significance**: Inadvertent stapling or dissection in this area can cause life-threatening **vascular injury** or nerve damage. **Note**: This should not be confused with the "Triangle of Pain" which is bounded laterally by the **inferior epigastric artery** and contains the lateral femoral cutaneous nerve and femoral branch of genitofemoral nerve.