UPSC-CMS 2020 — Surgery
20 Previous Year Questions with Answers & Explanations
Indications for fasciotomy in compartment syndrome include all EXCEPT:
Which one of the following statements is NOT correct regarding Necrotising Soft Tissue infections?
Which type of surgery is laparoscopic cholecystectomy classified as?
A 50-year old lady underwent uneventful bariatric surgery for morbid obesity. On the third post operative day, she develops breathlessness and pulmonary embolism is suspected. The next investigation to confirm the diagnosis will be:
A patient operated for a parotid gland tumour developed symptoms of sweating and erythema (flushing) over the region of surgical excision while eating. The probable diagnosis is:
All of the following are sequelae of peptic ulcer surgery EXCEPT:
'Swiss cheese defects' are seen during laparoscopic repair of:
Valentino's syndrome is:
Structure not forming boundaries of the "Triangle of doom" seen during laparoscopic inguinal hernia surgery dissection is:
Left Internal Mammary Artery (LIMA) has become the conduit of choice for Left Anterior Descending (LAD) artery during coronary artery bypass grafting because:
UPSC-CMS 2020 - Surgery UPSC-CMS Practice Questions and MCQs
Question 1: Indications for fasciotomy in compartment syndrome include all EXCEPT:
- A. Compartment pressure > 30 mm Hg
- B. Distal sensory disturbance
- C. Palpable distal pulses (Correct Answer)
- D. Pain on passive movement of affected muscles
Explanation: ***Palpable distal pulses*** - The presence of **palpable distal pulses is NOT an indication for fasciotomy** and does not rule out compartment syndrome. - **Vascular compromise is a late sign** in compartment syndrome - pulses often remain palpable even with significant nerve and muscle ischemia. - Fasciotomy decisions should be based on **clinical signs** (pain, sensory changes) and **pressure measurements**, not the presence of pulses. - This is the correct answer because it is NOT an indication for the procedure. *Compartment pressure > 30 mm Hg* - **Absolute indication for fasciotomy** when compartment pressure exceeds 30 mmHg, or when the **delta pressure** (diastolic BP minus compartment pressure) is less than 30 mmHg. - This pressure level impairs capillary perfusion and leads to tissue ischemia. *Distal sensory disturbance* - **Early and reliable indication** for fasciotomy showing nerve ischemia. - Paresthesia or numbness in the distribution of nerves running through the affected compartment indicates neurological compromise from elevated intracompartmental pressure. *Pain on passive movement of affected muscles* - **Most sensitive and earliest clinical sign** of compartment syndrome (part of "the 6 P's"). - Pain on passive stretch is typically **out of proportion to the injury** and indicates underlying muscle ischemia. - This is a clear indication for fasciotomy.
Question 2: Which one of the following statements is NOT correct regarding Necrotising Soft Tissue infections?
- A. Treatment consists of wide local excision and appropriate antibiotics
- B. They are monomicrobial in nature (Correct Answer)
- C. Tissue biopsy is required for culture and diagnosis
- D. Crepitus, skin blistering and focal skin gangrene are typical presenting features
Explanation: ***They are monomicrobial in nature*** - Necrotizing soft tissue infections (NSTIs) are predominantly **polymicrobial**, involving a mix of aerobic and anaerobic bacteria. - While some cases can be monomicrobial (e.g., due to *Streptococcus pyogenes* or *Clostridium perfringens*), the statement that they *are* monomicrobial is generally false. *Treatment consists of wide local excision and appropriate antibiotics* - This statement is **correct**. **Aggressive surgical debridement** (wide local excision) to remove all necrotic tissue is the cornerstone of treatment for NSTIs. - **Broad-spectrum antibiotics** are also essential to cover the polymicrobial nature of these infections, but they are insufficient without surgical intervention. *Tissue biopsy is required for culture and diagnosis* - This statement is **correct**. While the diagnosis is primarily clinical, **tissue biopsy** for gram stain, culture, and histopathology is crucial for identifying the causative organisms and guiding definitive antibiotic therapy. - This helps differentiate NSTIs from other severe soft tissue infections and improves treatment accuracy. *Crepitus, skin blistering and focal skin gangrene are typical presenting features* - This statement is **correct**. These are classic signs of advanced necrotizing soft tissue infections. - **Crepitus** indicates gas production by bacteria, **skin blistering** (bullae) suggests dermal involvement, and **focal skin gangrene** is a direct sign of tissue necrosis, all pointing to the severity and rapid progression of NSTIs.
Question 3: Which type of surgery is laparoscopic cholecystectomy classified as?
- A. Clean contaminated (Correct Answer)
- B. Dirty
- C. Contaminated
- D. Clean
Explanation: ***Clean contaminated*** - This classification applies to surgeries that involve a **viscus** (e.g., gallbladder, gastrointestinal tract, respiratory tract) but with **no unusual contamination** encountered. - While the gallbladder contains bile, which harbors bacteria, in an uncomplicated laparoscopic cholecystectomy, spillage is controlled, and there's no pre-existing infection. *Dirty* - This category is reserved for procedures performed in the presence of **established infection**, such as an abdominal abscess or perforated viscus with gross spillage. - There is evidence of **pus** or a **perforated hollow viscus** encountered during the operation. *Contaminated* - This classification is used when there is a **major break in sterile technique** or a significant spillage from the gastrointestinal contents or infected bile. - It also includes procedures where **acute, non-purulent inflammation** is encountered, or an open, traumatic wound is less than 4 hours old. *Clean* - These are procedures in which there is **no inflammation**, the gastrointestinal, genitourinary, or respiratory tracts are **not entered**, and there is no break in aseptic technique. - Examples include breast biopsies, hernia repairs without bowel resection, and thyroidectomies.
Question 4: A 50-year old lady underwent uneventful bariatric surgery for morbid obesity. On the third post operative day, she develops breathlessness and pulmonary embolism is suspected. The next investigation to confirm the diagnosis will be:
- A. MR angiography
- B. Echocardiography
- C. Duplex venography
- D. CT pulmonary angiography (Correct Answer)
Explanation: ***CT pulmonary angiography*** - **CT pulmonary angiography (CTPA)** is the **gold standard** for diagnosing pulmonary embolism due to its high sensitivity and specificity in visualizing pulmonary arteries. - It rapidly provides detailed images of the pulmonary vasculature, allowing for the direct visualization of **thrombi** within the vessels. *MR angiography* - **MR angiography (MRA)** can be used for diagnosing pulmonary embolism but is generally less available and often takes longer than CTPA. - It is usually reserved for patients with contraindications to CT, such as **renal impairment** or **iodine allergy**, which are not indicated in this case. *Echocardiography* - **Echocardiography** can help assess the **right ventricular strain** caused by pulmonary embolism, but it is not diagnostic for the embolism itself. - It is more useful in evaluating the **hemodynamic impact** of the PE and ruling out other cardiac causes of breathlessness. *Duplex venography* - **Duplex venography** (or ultrasound of the lower extremities) is used to detect **deep vein thrombosis (DVT)** in the legs. - While DVT is a common cause of pulmonary embolism, this investigation does not directly visualize the embolism in the **pulmonary arteries**.
Question 5: A patient operated for a parotid gland tumour developed symptoms of sweating and erythema (flushing) over the region of surgical excision while eating. The probable diagnosis is:
- A. Sialadenitis
- B. Parotid gland fistula
- C. Frey's syndrome (Correct Answer)
- D. Chronic wound infection
Explanation: ***Frey's syndrome*** - **Frey's syndrome**, also known as auriculotemporal syndrome, is characterized by gustatory sweating and flushing in the preauricular or temporal region during mastication (eating). - This occurs due to aberrant regeneration of damaged postganglionic parasympathetic fibers that previously supplied the parotid gland. These fibers mistakenly reinnervate sweat glands and blood vessels in the skin, leading to sweating and flushing when salivary stimulation occurs. *Sialadenitis* - **Sialadenitis** is inflammation of a salivary gland, typically presenting with pain, swelling, and sometimes fever, and is not directly linked to sweating while eating. - It is usually caused by infection or obstruction, and its symptoms would not be localized to the surgical excision site with flushing and sweating upon eating. *Parotid gland fistula* - A **parotid gland fistula** involves the leakage of saliva through an opening in the skin, which would manifest as continuous or intermittent salivary drainage, not sweating and flushing. - This condition is a direct communication between the parotid duct or gland parenchyma and the skin surface. *Chronic wound infection* - A **chronic wound infection** would present with persistent pain, redness, warmth, swelling, and possibly purulent discharge at the surgical site. - Sweating and flushing specifically triggered by eating are not characteristic symptoms of a wound infection.
Question 6: All of the following are sequelae of peptic ulcer surgery EXCEPT:
- A. Dumping syndrome
- B. Bilious vomiting
- C. Increased appetite (Correct Answer)
- D. Diarrhoea
Explanation: ***Increased appetite*** - **Increased appetite** is generally not a sequela of peptic ulcer surgery; patients commonly experience *early satiety* or *anorexia* due to faster gastric emptying and altered nutrient absorption. - Surgical alterations to the GI tract often lead to changes in hunger and satiety signals, typically *reducing desire for large meals* rather than increasing appetite. *Dumping syndrome* - **Dumping syndrome** is a common sequela, particularly after gastrectomy or vagotomy, due to *rapid emptying* of undigested food into the small intestine. - Symptoms include abdominal pain, nausea, diarrhea, and vasomotor symptoms like palpitations and sweating, often occurring post-prandially. *Bilious vomiting* - **Bilious vomiting** can occur, especially after gastrectomy or gastrojejunostomy, when *bile refluxes* into the gastric remnant and is subsequently vomited. - This is often due to an *altered anatomical arrangement* that allows bile to enter the stomach more easily. *Diarrhoea* - **Diarrhea** is a frequently reported complication, often resulting from *accelerated gastric emptying*, *bacterial overgrowth* in the small intestine, or *loss of vagal innervation*. - It can be chronic and significantly impact quality of life due to malabsorption or rapid transit of chyme.
Question 7: 'Swiss cheese defects' are seen during laparoscopic repair of:
- A. Ventral hernia
- B. Inguinal hernia (Correct Answer)
- C. Obturator hernia
- D. Femoral hernia
Explanation: ***Inguinal hernia*** - **Swiss cheese defects** refer to multiple small defects in the **transversalis fascia** seen in some cases of direct inguinal hernias. - These defects require careful identification and repair during **laparoscopic inguinal hernia repair** to prevent recurrence. *Ventral hernia* - Ventral hernias are typically located on the **anterior abdominal wall**, often at previous surgical incision sites. - The term **Swiss cheese defects** is not commonly used to describe the fascial defects associated with ventral hernias. *Obturator hernia* - An **obturator hernia** protrudes through the obturator foramen and is a rare type of pelvic hernia. - The pattern of fascial defects described as **Swiss cheese** is unrelated to this type of hernia. *Femoral hernia* - A **femoral hernia** protrudes through the femoral canal, inferior to the inguinal ligament. - This type of hernia involves a distinct anatomical defect, which does not typically present as multiple small holes referred to as **Swiss cheese defects**.
Question 8: Valentino's syndrome is:
- A. Pain over left shoulder in left hypochondriac collection
- B. Pain on per-vaginal examination in pelvic abscess
- C. Pain in right iliac fossa in perforated peptic ulcer (Correct Answer)
- D. Pain over left groin in perirenal collection
Explanation: ***Pain in right iliac fossa in perforated peptic ulcer*** - **Valentino's syndrome** (also known as **Valentino's sign**) specifically describes the clinical presentation of **right iliac fossa (RIF) pain** in patients with a **perforated peptic ulcer**. - This occurs when gastric or duodenal contents from the perforation track down along the **right paracolic gutter** due to gravity and peritoneal fluid flow, accumulating in the RIF and causing **localized peritonitis**. - This can **mimic acute appendicitis** clinically, making it an important differential diagnosis. - Named after Rudolph Valentino, the famous actor who died from complications of a perforated gastric ulcer. *Pain over left shoulder in left hypochondriac collection* - This describes **Kehr's sign**, which is referred pain to the left shoulder due to **diaphragmatic irritation** from blood or fluid in the left upper quadrant (e.g., splenic rupture, subphrenic abscess). - Caused by irritation of the phrenic nerve (C3-C5), which also supplies sensation to the shoulder. - This is **not** Valentino's syndrome. *Pain on per-vaginal examination in pelvic abscess* - Cervical excitation pain or adnexal tenderness on vaginal examination suggests **pelvic pathology** such as pelvic inflammatory disease, ectopic pregnancy, or pelvic abscess. - This finding is unrelated to Valentino's syndrome, which involves upper GI perforation with RIF pain. *Pain over left groin in perirenal collection* - Groin pain from perirenal pathology may occur with conditions like renal calculi, pyelonephritis, or perinephric abscess. - This is not associated with Valentino's syndrome, which has a specific anatomical pattern related to peptic ulcer perforation.
Question 9: Structure not forming boundaries of the "Triangle of doom" seen during laparoscopic inguinal hernia surgery dissection is:
- A. Spermatic cord vessels
- B. Vas deferens
- C. Peritoneum
- D. Inferior epigastric artery (Correct Answer)
Explanation: ***Inferior epigastric artery*** - The **inferior epigastric artery** does NOT form a boundary of the **"Triangle of Doom"** during laparoscopic inguinal hernia repair. - Instead, it forms the **lateral boundary of Hesselbach's triangle** and the **medial boundary of the "Triangle of Pain"** (another important anatomical landmark containing the lateral femoral cutaneous nerve and genitofemoral nerve). - The Triangle of Doom is bounded by the **vas deferens medially**, the **spermatic vessels (gonadal vessels) laterally**, and the **peritoneal reflection inferiorly**. *Spermatic cord vessels* - The **spermatic vessels (testicular artery and pampiniform plexus)** form the **lateral boundary** of the **"Triangle of Doom."** - This triangle contains the **external iliac artery and vein**, which pose significant risk of major hemorrhage if injured. - Careful identification of these vessels is crucial to avoid devastating vascular complications. *Vas deferens* - The **vas deferens** forms the **medial boundary** of the **"Triangle of Doom."** - This structure runs within the spermatic cord and must be carefully preserved to prevent male infertility. - Injury to the vas deferens during dissection can result in permanent reproductive consequences. *Peritoneum* - The **peritoneum (peritoneal reflection)** forms the **base/inferior boundary** of the **"Triangle of Doom."** - This serous membrane provides the anatomical floor of the triangle during laparoscopic visualization. - Understanding the peritoneal boundaries helps surgeons safely navigate this high-risk anatomical area.
Question 10: Left Internal Mammary Artery (LIMA) has become the conduit of choice for Left Anterior Descending (LAD) artery during coronary artery bypass grafting because:
- A. Atherosclerosis is never seen in this vessel
- B. It is very easy to harvest
- C. It is close to LAD
- D. Long term patency rates are superior (>90% at 10 years) (Correct Answer)
Explanation: ***Long term patency rates are superior (>90% at 10 years)*** - The superior **long-term patency rates** (over 90% at 10 years) of the **Left Internal Mammary Artery (LIMA)** when anastomosed to the **Left Anterior Descending (LAD) artery** are the primary reason for it being the conduit of choice. - This excellent patency is attributed to its **endothelial** properties and **resistance to atherosclerosis**, contributing to improved patient outcomes and survival. *Atherosclerosis is never seen in this vessel* - While the LIMA is significantly **more resistant to atherosclerosis** compared to saphenous veins, it is not entirely immune. - Atherosclerosis can still occur in the LIMA, though it is far less common and less severe than in other graft conduits. *It is very easy to harvest* - Harvesting the LIMA requires a skilled surgical technique and is **not considered "very easy."** - It involves careful dissection to preserve the conduit's integrity and includes potential complications like **sternal wound infections** due to altered blood supply. *It is close to LAD* - While the anatomical proximity of the LIMA to the LAD is a favorable factor, making the anastomosis geographically convenient, it is **not the primary reason** for its widespread use. - The primary driving factor is the superior long-term patency, which directly impacts patient morbidity and mortality.