UPSC-CMS 2019 — Surgery
16 Previous Year Questions with Answers & Explanations
All of the following are risk factors for an increased risk of wound infection EXCEPT:
Gentleman of 56 years underwent laparoscopic left hemicolectomy for diagnosed left colonic carcinoma. Histopathology revealed the tumour to be invading submucosa and muscularis propria. Among the 16 regional lymph nodes harvested, 2 were positive for malignant deposits. His staging as per AJCC will be:
Indications for carotid endarterectomy in symptomatic patients are all of the following EXCEPT:
A policeman of 45 years presented with Lipodermatosclerosis over lower medial aspect of left leg, along with a healed venous ulcer. As per the CEAP (Clinical-etiology-anatomy-pathophysiology) classification his clinical classification will be:
What is true about the management of a corrosive injury of oesophagus?
A 48 year old male with the history of chronic duodenal ulcer presented in surgical emergency with the complaints of sudden severe pain in the abdomen. At presentation: Pulse = 120/m, BP = 90/60 mm of Hg Abdomen: Tenderness (+), Rigidity (+), Guarding (+) Respiratory Rate: 20/m X-ray: Gas under right dome of diaphragm The probable diagnosis is:
A young sports person presented in surgical emergency with the complaints of severe pain in the groin area, extending into the scrotum and upper thigh. The pain is debilitating and he is not able to exercise. On examination there is tenderness in the region of Inguinal canal and pubic tubercle. He is probably suffering from:
Ventral hernia includes all EXCEPT:
Diaphragmatic injury is suspected in a 50 year old gentleman with history of blunt abdominal trauma, having a normal chest X-ray. He is best managed by:
Urinary bladder can be injured in all of the following operations EXCEPT:
UPSC-CMS 2019 - Surgery UPSC-CMS Practice Questions and MCQs
Question 1: All of the following are risk factors for an increased risk of wound infection EXCEPT:
- A. Hypertension (Correct Answer)
- B. Cancer
- C. Jaundice
- D. Obesity
Explanation: ***Hypertension*** - **Hypertension** itself is not a direct risk factor for wound infection, unlike conditions that impair immunity, tissue perfusion, or healing. - While uncontrolled hypertension can contribute to broader cardiovascular issues, it does not inherently increase the likelihood of **bacterial contamination** or **impaired immune response** in a wound. *Cancer* - Patients with **cancer** often have compromised immune systems due to the disease itself or as a result of treatments like **chemotherapy** or **radiation**, increasing susceptibility to infections. - **Malnutrition** and overall debilitation associated with advanced cancer can also impair wound healing and immune function. *Jaundice* - **Jaundice** (hyperbilirubinemia) is associated with impaired immune function, particularly a reduction in phagocytic activity and cellular immunity, making patients more prone to infections. - High bilirubin levels can also interfere with **collagen synthesis** and wound tensile strength, contributing to delayed healing and increased infection risk. *Obesity* - **Obesity** is a significant risk factor for wound infection due to poor vascularity of adipose tissue, which leads to reduced oxygen delivery and antibiotic penetration to the wound site. - The presence of large skin folds can also create a **moist environment** conducive to bacterial growth, and increased tension on wound edges can impair healing.
Question 2: Gentleman of 56 years underwent laparoscopic left hemicolectomy for diagnosed left colonic carcinoma. Histopathology revealed the tumour to be invading submucosa and muscularis propria. Among the 16 regional lymph nodes harvested, 2 were positive for malignant deposits. His staging as per AJCC will be:
- A. T2, N1, M0 (Correct Answer)
- B. T2, N1, M1
- C. T1, N1, M0
- D. T1, N0, M0
Explanation: ***T2, N1, M0*** - The tumor invades the **muscularis propria** but not through it, which is classified as **T2** in the AJCC staging for colorectal cancer. - The presence of **2 positive regional lymph nodes** (out of 16 harvested) is classified as **N1** disease. **M0** indicates no distant metastasis. *T2, N1, M1* - While the **T2** and **N1** classifications are correct for this case, **M1** signifies the presence of **distant metastasis**, which is not indicated in the provided information. - The staging is based on the **available pathological findings only**, which do not mention any distant spread. *T1, N1, M0* - **T1** classification indicates that the tumor invades the **submucosa** but not the muscularis propria, which contradicts the information that the tumor invaded the **muscularis propria**. - Although **N1** and **M0** are consistent with the provided information regarding lymph nodes and distant metastasis, the **T-stage is incorrect**. *T1, N0, M0* - **T1** is incorrect as the tumor invaded the **muscularis propria**. - **N0** is incorrect as there were **2 positive regional lymph nodes** which indicates nodal involvement.
Question 3: Indications for carotid endarterectomy in symptomatic patients are all of the following EXCEPT:
- A. Persistent hypertension (Correct Answer)
- B. Hemianopia
- C. Dysphasia
- D. Monocular blindness
Explanation: ***Persistent hypertension*** - **Hypertension** is a **risk factor** for carotid artery disease but is not a direct indication for carotid endarterectomy in symptomatic patients. - Carotid endarterectomy aims to treat **carotid stenosis** causing neurological symptoms, not to manage blood pressure. *Hemianopia* - **Hemianopia** is a **visual field defect** that can be caused by cerebral ischemia resulting from carotid artery stenosis, making it a neurological symptom indicating potential benefit from endarterectomy. - It suggests that the **carotid artery** is supplying an area of the brain that could be at risk for stroke. *Dysphasia* - **Dysphasia** (difficulty with speech) is a classic **neurological symptom** of cerebral ischemia, often associated with carotid artery stenosis affecting the dominant hemisphere. - This symptom strongly indicates that the patient's **carotid disease** is causing clinically significant effects, warranting consideration of endarterectomy. *Monocular blindness* - **Amaurosis fugax**, or transient monocular blindness, is a **transient ischemic attack (TIA)** symptom caused by emboli from the carotid artery reaching the retinal artery. - It is a significant **warning sign** of impending stroke and is a strong indication for carotid endarterectomy in symptomatic patients with appropriate stenosis.
Question 4: A policeman of 45 years presented with Lipodermatosclerosis over lower medial aspect of left leg, along with a healed venous ulcer. As per the CEAP (Clinical-etiology-anatomy-pathophysiology) classification his clinical classification will be:
- A. C5 (Correct Answer)
- B. C4b
- C. C6
- D. C4a
Explanation: **C5 (healed venous ulcer)** - The CEAP classification for **C5** indicates the presence of a **healed venous ulcer**, which matches the patient's presentation of a healed ulcer. - The associated **lipodermatosclerosis** is a skin change often preceding or accompanying venous ulcers. *C4b (lipodermatosclerosis, atrophie blanche)* - **C4b** represents **lipodermatosclerosis** and **atrophie blanche**, which are skin changes due to chronic venous insufficiency. - While the patient has lipodermatosclerosis, the presence of a *healed ulcer* further elevates the classification to C5, as it signifies a more advanced stage of venous disease. *C6 (active venous ulcer)* - **C6** denotes an **active, open venous ulcer**. - The patient's ulcer is explicitly stated as "healed," making C6 an incorrect classification. *C4a (pigmentation or eczema)* - **C4a** refers to skin changes such as **pigmentation** or **venous eczema**. - While the patient might have some pigmentation associated with lipodermatosclerosis, the presence of a *healed ulcer* indicates a more severe clinical stage than C4a.
Question 5: What is true about the management of a corrosive injury of oesophagus?
- A. Early skilled endoscopy is a must (Correct Answer)
- B. Broad spectrum antibiotics should be started as soon as possible
- C. Immediate surgery with oesophagectomy is advisable
- D. Immediate NG tube insertion and gastric lavage should be performed
Explanation: ***Early skilled endoscopy is a must*** - **Early endoscopy** within 12-24 hours is crucial to assess the extent and depth of corrosive injury - Helps determine severity (Grade I-III burns) and guide further management - Identifies patients needing aggressive treatment vs. conservative management - **Contraindicated** only in suspected perforation or severe respiratory distress *Broad spectrum antibiotics should be started as soon as possible* - **Prophylactic antibiotics are NOT routinely recommended** for corrosive injuries - Risk of promoting antibiotic resistance without proven benefit - Antibiotics indicated only when signs of infection present: **fever, leukocytosis, or suspected perforation** *Immediate surgery with oesophagectomy is advisable* - **Immediate oesophagectomy is NOT standard management** - Reserved for severe complications: **perforation, extensive necrosis, mediastinitis, or uncontrolled bleeding** - Most patients initially managed conservatively with supportive care - Surgery considered only if conservative measures fail *Immediate NG tube insertion and gastric lavage should be performed* - **Both are CONTRAINDICATED** in corrosive ingestions - **Gastric lavage** can induce vomiting, causing re-exposure of esophagus and risking perforation - **NG tube insertion** can traumatize damaged esophageal mucosa and cause perforation - Management focuses on NBM (nil by mouth), fluid resuscitation, and pain control
Question 6: A 48 year old male with the history of chronic duodenal ulcer presented in surgical emergency with the complaints of sudden severe pain in the abdomen. At presentation: Pulse = 120/m, BP = 90/60 mm of Hg Abdomen: Tenderness (+), Rigidity (+), Guarding (+) Respiratory Rate: 20/m X-ray: Gas under right dome of diaphragm The probable diagnosis is:
- A. Acute appendicitis
- B. Perforation Peritonitis (Correct Answer)
- C. Acute Pancreatitis
- D. Acute Myocardial infarction
Explanation: ***Perforation Peritonitis*** - The patient's history of **chronic duodenal ulcer**, sudden severe abdominal pain, signs of **peritonitis** (**tenderness, rigidity, guarding**), and especially the X-ray finding of **gas under the right dome of the diaphragm** (indicating **pneumoperitoneum**) are all classic for a perforated viscus. - The **tachycardia** (Pulse = 120/m) and **hypotension** (BP = 90/60 mm Hg) further suggest a systemic inflammatory response syndrome (SIRS) or even **septic shock** due to peritonitis. *Acute appendicitis* - This typically presents with peri-umbilical pain migrating to the right lower quadrant, with localized tenderness and guarding, not diffuse peritonitis. - **Gas under the diaphragm** is not a feature of uncomplicated appendicitis but occurs with perforation of a hollow viscus. *Acute Pancreatitis* - While it can cause severe abdominal pain and signs of peritonitis, the pain often radiates to the back and is associated with elevated pancreatic enzymes. - **Gas under the diaphragm** is not a typical finding in acute pancreatitis unless there's a complication like colonic perforation. *Acute Myocardial infarction* - Though an MI can present with epigastric pain, it would not typically cause **diffuse abdominal tenderness, rigidity, guarding**, or **pneumoperitoneum**. - The primary symptoms would generally involve chest discomfort, and diagnostic tests would show cardiac enzyme elevation and EKG changes.
Question 7: A young sports person presented in surgical emergency with the complaints of severe pain in the groin area, extending into the scrotum and upper thigh. The pain is debilitating and he is not able to exercise. On examination there is tenderness in the region of Inguinal canal and pubic tubercle. He is probably suffering from:
- A. Inguinal hernia
- B. Femoral hernia
- C. Varicocele
- D. Sportsman hernia (Correct Answer)
Explanation: ***Sportsman hernia*** - The presentation of severe, debilitating groin pain extending to the scrotum and upper thigh, especially in a young sports person, is highly characteristic of a **sportsman's hernia** (also known as athletic pubalgia or Gilmore's groin). - This condition involves a **tear or weakening** of the posterior inguinal wall or associated musculature, leading to chronic groin pain exacerbated by physical activity. *Inguinal hernia* - This typically presents with a **visible bulge** in the groin that may or may not be painful, often increasing with straining but usually not as debilitating without incarceration. - While pain can extend to the scrotum, the primary complaint is usually the bulge and the pain is frequently relieved by lying down, unlike the chronic, activity-related pain described. *Femoral hernia* - A femoral hernia usually presents as a **lump below the inguinal ligament**, often more common in women, and can be easily confused with lymphadenopathy or a saphena varix. - While it can cause pain, it is less likely to produce the widespread, debilitating pain described as a primary symptom without signs of complications like incarceration. *Varicocele* - A varicocele is a condition of **enlarged veins within the scrotum** and typically presents as a "bag of worms" sensation or dull ache in the scrotum, often worse after standing for prolonged periods. - The pain is usually scrotal and not described as severe, debilitating groin pain extending to the upper thigh with tenderness in the inguinal canal, as seen in this case.
Question 8: Ventral hernia includes all EXCEPT:
- A. Inguinal hernia (Correct Answer)
- B. Umbilical hernia
- C. Epigastric hernia
- D. Para-umbilical hernia
Explanation: ***Inguinal hernia*** - An **inguinal hernia** is a protrusion of abdominal contents through the **inguinal canal**, located in the groin region. - It is **NOT a ventral hernia** because it occurs through the inguinal canal in the groin, not through the anterior abdominal wall directly. - Inguinal hernias are classified separately as **groin hernias**, distinct from ventral hernias. *Umbilical hernia* - An **umbilical hernia** occurs through a defect in the **umbilical ring** at the umbilicus. - This is a **true ventral hernia** as it protrudes directly through the anterior abdominal wall at the umbilicus. - Common in infants and adults, especially in conditions that increase intra-abdominal pressure. *Epigastric hernia* - An **epigastric hernia** involves protrusion of preperitoneal fat or peritoneum through a defect in the **linea alba** between the xiphoid process and the umbilicus. - This is a **ventral hernia** because it occurs directly in the anterior abdominal wall through the midline. *Para-umbilical hernia* - A **para-umbilical hernia** occurs through a defect in the **linea alba** adjacent to, but not directly through, the umbilical cicatrix. - This is classified as a **ventral hernia** due to its location in the anterior abdominal wall near the umbilicus.
Question 9: Diaphragmatic injury is suspected in a 50 year old gentleman with history of blunt abdominal trauma, having a normal chest X-ray. He is best managed by:
- A. CECT abdomen
- B. Diagnostic peritoneal lavage and proceed
- C. Upper GI contrast study
- D. Diagnostic laparoscopy (Correct Answer)
Explanation: ***Diagnostic laparoscopy*** - **Diagnostic laparoscopy** is the **most sensitive and specific method** for detecting diaphragmatic injuries, especially when initial imaging like X-ray is normal but suspicion remains high after blunt trauma. - It allows **direct visualization** of the diaphragm for tears, herniation of abdominal contents, and associated visceral injuries, enabling simultaneous repair. *CECT abdomen* - While a **CECT abdomen** can show some diaphragmatic injuries, its sensitivity is **limited, especially for small tears**. - It may identify associated organ damage but might miss non-displaced diaphragmatic ruptures, particularly in the acute phase. *Diagnostic peritoneal lavage and proceed* - **Diagnostic peritoneal lavage (DPL)** is primarily used to detect intra-abdominal hemorrhage or viscus perforation, not specifically diaphragmatic injury. - A positive DPL (indicating bleeding) does not directly localize diaphragmatic trauma. *Upper GI contrast study* - An **Upper GI contrast study** is useful for diagnosing a **herniated stomach or small bowel** into the thoracic cavity in chronic or delayed presentations of diaphragmatic injury. - It is **less effective for acute detection** of diaphragmatic tears without significant herniation and does not allow for direct visualization or repair.
Question 10: Urinary bladder can be injured in all of the following operations EXCEPT:
- A. Surgery for rectum
- B. Inguinal hernia repair (Correct Answer)
- C. Inguinal lymph node dissection
- D. Hysterectomy
Explanation: ***Inguinal hernia repair*** - While theoretically possible, bladder injury during **inguinal hernia repair** is exceedingly rare, often less than 1% as the bladder is not typically in the direct field of dissection. - The surgical approach for inguinal hernias generally involves layers superficial to the bladder, making direct injury much less common than in pelvic surgeries. - Rare cases occur with **sliding hernias** where the bladder may form part of the hernia sac wall. *Surgery for rectum* - **Anterior resection of the rectum** or abdominoperineal resection involves dissecting close to the bladder's posterior and inferior aspects, particularly the **bladder base** and **ureteral entries**. - Procedures like low anterior resection for rectal cancer pose a significant risk due to the **proximity of the bladder** to the surgical field in the pelvis. *Inguinal lymph node dissection* - **Inguinal lymph node dissection** is primarily a superficial groin procedure involving removal of superficial and deep inguinal nodes. - While bladder injury is **theoretically possible** if dissection extends unusually deep or medially toward the retropubic space, this is **extremely rare** in standard practice. - The risk is significantly lower than pelvic operations but higher than standard inguinal hernia repair due to the extent of dissection. *Hysterectomy* - During a **hysterectomy** (removal of the uterus), the bladder lies anterior and inferior to the uterus and cervix, making it highly susceptible to injury. - The dissection planes for detaching the bladder from the lower uterine segment and cervix pose a substantial risk, especially during **total abdominal hysterectomy** or **vaginal hysterectomy**. - This is one of the **most common** causes of iatrogenic bladder injury.