UPSC-CMS 2022 — Surgery
14 Previous Year Questions with Answers & Explanations
Which of the following vital structures in the axilla should always be preserved in modified radical mastectomy?
The most common metabolic abnormality associated with gastric outlet obstruction is
Which of the following is the PRIMARY factor that predisposes to the development of incisional hernia?
Which of the following statements regarding a patient of liver trauma are correct? 1. Liver is the most common organ injured following abdominal trauma. 2. Surgical exploration (laparotomy) is required in haemodynamically unstable patients and patients with free intraperitoneal fluid on FAST. 3. Contrast enhanced CT abdomen should be done in haemodynamically stable patients. 4. Blunt injuries have a higher mortality as compared to penetrating injuries.
Triaging is done to prioritize the treatment in case of trauma and the patients are colour coded. The yellow colour code signifies
Hypotension in an unconscious head injury patient is most commonly due to
Preoperative investigations done prior to surgery depend upon which of the following? 1. Type of surgery 2. Patient origin 3. Patient comorbidities 4. Experience of surgeon
Which of the following is NOT included in Grade II acute cholecystitis as per 'Tokyo Consensus Guidelines for Severity'? 1. Elevated white cell count (> 18000/mm3) 2. Renal dysfunction 3. Duration > 72 hours 4. Marked local inflammation
Which of the following is the FIRST step in triple assessment of breast lumps? 1. Clinical assessment 2. Radiological assessment 3. Histopathological assessment 4. Sentinel lymph node biopsy
Which of the following is the MOST reliable intraoperative feature of viable small bowel? 1. Visible peristalsis 2. Flabby intestinal musculature 3. Shiny appearance of small bowel wall 4. Visible pulsation in the mesenteric artery
UPSC-CMS 2022 - Surgery UPSC-CMS Practice Questions and MCQs
Question 1: Which of the following vital structures in the axilla should always be preserved in modified radical mastectomy?
- A. Intercostobrachial nerves
- B. Nerve to serratus anterior
- C. Nerve to latissimus dorsi
- D. Axillary vein (Correct Answer)
Explanation: ***Axillary vein*** - The **axillary vein** is the only structure that must be preserved in **all cases** of modified radical mastectomy without exception. - It is a major conduit for venous return from the upper limb; its injury or sacrifice would cause **severe venous congestion** and **marked lymphedema** of the arm, representing a major surgical complication. - Unlike the nerves listed below, there is **no acceptable clinical scenario** where the axillary vein can be intentionally sacrificed during MRM. *Intercostobrachial nerves* - The **intercostobrachial nerves** provide sensation to the axilla and medial aspect of the arm. - While their preservation minimizes **postoperative numbness** and discomfort, they are **frequently sacrificed** during level II axillary dissection to achieve adequate lymph node clearance. - Their sacrifice is an accepted consequence of thorough axillary dissection. *Nerve to serratus anterior (Long thoracic nerve)* - The **long thoracic nerve** innervates the serratus anterior muscle, which is crucial for scapular stability. - Its injury causes **winged scapula**, significantly impairing shoulder movement. - While preservation is **attempted and highly desirable**, it may need to be sacrificed if there is **direct tumor involvement** or to achieve adequate oncologic clearance. - Preservation is the goal but not absolute in all cases. *Nerve to latissimus dorsi (Thoracodorsal nerve)* - The **thoracodorsal nerve** innervates the latissimus dorsi muscle, important for shoulder function and potential breast reconstruction. - While preservation is **strongly preferred**, it may need to be sacrificed if there is **lymph node involvement along its course** or direct tumor invasion. - Like the long thoracic nerve, preservation is attempted but not guaranteed in all cases. **Key Distinction:** The question asks what "should **always** be preserved" - the axillary vein is the only structure where preservation is absolute and non-negotiable. The motor nerves (long thoracic and thoracodorsal) are critical structures that surgeons attempt to preserve, but their sacrifice may be necessary for oncologic reasons in some cases.
Question 2: The most common metabolic abnormality associated with gastric outlet obstruction is
- A. hyperchloraemic alkalosis
- B. hypochloraemic acidosis
- C. hyperchloraemic acidosis
- D. hypochloraemic alkalosis (Correct Answer)
Explanation: ***Hypochloraemic alkalosis*** - Gastric outlet obstruction leads to **persistent vomiting of gastric contents**, rich in **hydrochloric acid (HCl)**. - The loss of HCl causes a decrease in plasma chloride (**hypochloraemia**) and an increase in bicarbonate, leading to **metabolic alkalosis**. - This is the **classic metabolic abnormality** seen in pyloric stenosis and other causes of gastric outlet obstruction. *Hyperchloraemic alkalosis* - This is an incorrect combination of electrolyte and acid-base disturbances; hyperchloraemia typically accompanies **acidosis**, not alkalosis. - Hyperchloraemic alkalosis would imply an excess of chloride and base, which does not result from the vomiting of acidic gastric contents. *Hypochloraemic acidosis* - Hypochloraemia can occur with acidosis (e.g., from severe diarrhea with bicarbonate loss), but the primary acid-base disturbance in gastric outlet obstruction is **alkalosis** due to hydrogen ion loss. - Vomiting primarily causes a loss of acid, leading to an increase in blood pH, not a decrease. *Hyperchloraemic acidosis* - This condition is often seen in situations like **renal tubular acidosis** or with the administration of large amounts of **saline solutions**, where chloride intake is high and bicarbonate is lost or diluted. - It specifically does not occur with the loss of highly acidic gastric contents, which would decrease chloride levels and increase pH.
Question 3: Which of the following is the PRIMARY factor that predisposes to the development of incisional hernia?
- A. Immunocompromised patient
- B. Malnutrition
- C. Non-absorbable suture material
- D. Postoperative wound infection (Correct Answer)
Explanation: ***Postoperative wound infection*** - **Postoperative wound infection** is the **PRIMARY and most important modifiable risk factor** for incisional hernia development, increasing the risk by **2-4 fold**. - Infection causes **tissue necrosis**, **fascial disruption**, and **impaired collagen synthesis**, directly compromising the structural integrity of the wound closure. - The inflammatory response and proteolytic enzymes released during infection destroy newly formed collagen and prevent proper fascial healing. - This is consistently cited in major surgical textbooks (Sabiston, Schwartz) as the leading preventable cause of incisional hernias. *Malnutrition* - While malnutrition impairs wound healing by reducing collagen synthesis and tissue strength, it acts as a **background predisposing factor** rather than the primary cause [1]. - Protein deficiency affects overall tissue quality but typically requires additional factors (like infection) to result in hernia formation [1]. - Nutritional optimization is important perioperatively but is less directly causative than acute wound complications. *Immunocompromised patient* - Immunocompromise increases susceptibility to infection and impairs healing, but it is an indirect risk factor [1]. - The mechanism primarily operates through **increased infection risk** rather than being an independent primary cause [1]. *Non-absorbable suture material* - Suture material choice affects long-term stability and may influence chronic pain or foreign body reactions. - Current evidence shows **continuous non-absorbable sutures** are actually preferred for fascial closure to reduce hernia risk [1]. - This is a technical consideration but not a primary predisposing factor compared to wound complications.
Question 4: Which of the following statements regarding a patient of liver trauma are correct? 1. Liver is the most common organ injured following abdominal trauma. 2. Surgical exploration (laparotomy) is required in haemodynamically unstable patients and patients with free intraperitoneal fluid on FAST. 3. Contrast enhanced CT abdomen should be done in haemodynamically stable patients. 4. Blunt injuries have a higher mortality as compared to penetrating injuries.
- A. 1. Liver is the most common organ injured following abdominal trauma.
- B. 2. Surgical exploration (laparotomy) is required in haemodynamically unstable patients and patients with free intraperitoneal fluid on FAST.
- C. 4. Blunt injuries have a higher mortality as compared to penetrating injuries.
- D. 3. Contrast enhanced CT abdomen should be done in haemodynamically stable patients. (Correct Answer)
Explanation: ***3. Contrast enhanced CT abdomen should be done in haemodynamically stable patients.*** - A **contrast-enhanced CT abdomen** is the diagnostic study of choice for **hemodynamically stable patients** with suspected liver trauma, as it accurately quantifies injury and guides management. - It helps in grading the liver injury, identifying active extravasation, and detecting associated injuries, thus determining the need for operative versus non-operative management. *1. Liver is the most common organ injured following abdominal trauma.* - While the liver is frequently injured in abdominal trauma, the **spleen** is actually the most commonly injured solid organ in cases of **blunt abdominal trauma**. - The liver is the second most commonly injured solid organ, but its large size and fragile nature make it highly susceptible to injury. *2. Surgical exploration (laparotomy) is required in haemodynamically unstable patients and patients with free intraperitoneal fluid on FAST.* - **Hemodynamically unstable patients** with suspected abdominal trauma often require **surgical exploration (laparotomy)**, but the presence of **free intraperitoneal fluid on FAST** alone does not automatically necessitate laparotomy in stable patients. - Free fluid on FAST in a stable patient can represent blood or other fluid, and further imaging like CT is needed to assess the source and extent of injury before surgical intervention. *4. Blunt injuries have a higher mortality as compared to penetrating injuries.* - **Penetrating injuries** (e.g., stab wounds, gunshot wounds) generally have a **higher mortality rate** than blunt injuries due to the direct damage to vital structures and risk of massive hemorrhage and infection. - While blunt injuries can be severe, they often lead to less direct and immediate damage to major vessels and organs compared to penetrating trauma.
Question 5: Triaging is done to prioritize the treatment in case of trauma and the patients are colour coded. The yellow colour code signifies
- A. non-urgent
- B. urgent (Correct Answer)
- C. immediate
- D. unsalvageable
Explanation: ***urgent*** - The **yellow (urgent)** code indicates that the patient requires medical attention within a few hours, but their condition is not immediately life-threatening. - These patients are stable enough to wait for treatment after more critical patients have been addressed but still need significant care soon. *non-urgent* - **Green (non-urgent)** code is for patients with minor injuries or conditions that can wait for extended periods for treatment. - They typically have stable vital signs and minimal risk of deterioration. *immediate* - **Red (immediate)** code signifies patients with life-threatening injuries or conditions requiring immediate intervention to save life or limb. - These are the highest priority patients who need attention within minutes. *unsalvageable* - **Black (unsalvageable/deceased)** code is for patients who are either deceased or have injuries so severe that survival is unlikely even with immediate medical intervention. - These patients are given palliative care if alive, or their bodies are managed if deceased.
Question 6: Hypotension in an unconscious head injury patient is most commonly due to
- A. intracerebral haemorrhage
- B. associated injuries of abdomen or chest (Correct Answer)
- C. extradural haemorrhage
- D. pontine haemorrhage
Explanation: ***associated injuries of abdomen or chest*** - **Hypotension** in an unconscious head injury patient is rarely caused by the head injury itself, as the brain cannot lose enough blood to cause systemic hypotension. - Therefore, other concurrent injuries, such as **intra-abdominal or intrathoracic hemorrhage**, are the most common cause of hypotension in this setting, requiring a thorough secondary survey. *intracerebral haemorrhage* - While intracerebral hemorrhage can lead to increased intracranial pressure and neurological deterioration, it generally does not cause **systemic hypotension** on its own. - The volume of bleeding within the brain is typically insufficient to result in clinically significant **blood loss** leading to shock. *extradural haemorrhage* - An extradural hematoma involves bleeding between the **dura mater** and the skull, often from a ruptured middle meningeal artery. - It primarily causes increased intracranial pressure and **neurological symptoms**, but like other cranial hemorrhages, it's not a common cause of **systemic hypotension**. *pontine haemorrhage* - A pontine hemorrhage is a severe form of stroke affecting the **brainstem**, leading to rapid neurological decline and often coma. - While devastating, its effect on blood pressure is typically through **autonomic dysfunction**, which can cause hypertension or profound bradycardia, but not usually **hypotension** due to blood loss.
Question 7: Preoperative investigations done prior to surgery depend upon which of the following? 1. Type of surgery 2. Patient origin 3. Patient comorbidities 4. Experience of surgeon
- A. 4. Experience of surgeon
- B. 1. Type of surgery (Correct Answer)
- C. 2. Patient origin
- D. 3. Patient comorbidities
Explanation: ***1. Type of surgery*** - The **type of surgery** is a primary determinant of preoperative investigations, as it defines the baseline assessment needed based on the procedure's complexity, invasiveness, and physiological stress. - Minor surgeries (e.g., superficial excisions) typically require minimal investigations, while major surgeries (e.g., cardiac, neurosurgery) mandate comprehensive cardiovascular, pulmonary, and hematological workups. - **Clinical Note:** In practice, preoperative investigations depend on BOTH the surgery type AND patient comorbidities working together, but this question likely seeks the most fundamental starting point. *3. Patient comorbidities* - **Patient comorbidities** are undeniably crucial in determining the extent and nature of preoperative investigations. - A patient with diabetes, hypertension, or cardiac disease requires additional specific investigations regardless of the surgery type. - However, the surgery type establishes the baseline framework, which is then modified based on comorbidities. *2. Patient origin* - **Patient origin** (geographical location, ethnicity) is generally not a direct determinant of preoperative investigation protocols. - While certain populations may have higher prevalence of specific conditions, investigations are based on individual patient assessment, not origin. *4. Experience of surgeon* - The **experience of the surgeon** does not alter the medical necessity or standard protocols for preoperative investigations. - Patient safety standards and investigation requirements remain consistent regardless of surgical expertise level.
Question 8: Which of the following is NOT included in Grade II acute cholecystitis as per 'Tokyo Consensus Guidelines for Severity'? 1. Elevated white cell count (> 18000/mm3) 2. Renal dysfunction 3. Duration > 72 hours 4. Marked local inflammation
- A. 2. Renal dysfunction (Correct Answer)
- B. 4. Marked local inflammation
- C. 3. Duration > 72 hours
- D. 1. Elevated white cell count (> 18000/mm3)
Explanation: ***2. Renal dysfunction*** - **Renal dysfunction** is a criterion for **Grade III (severe)** acute cholecystitis, NOT Grade II, indicating systemic organ failure. - This represents a critical systemic complication requiring intensive care, distinct from the moderate severity markers of Grade II. *1. Elevated white cell count (> 18000/mm3)* - An elevated white blood cell count *greater than 18,000/mm³* **IS** a criterion for **Grade II (moderate)** acute cholecystitis. - This reflects a substantial systemic inflammatory response, categorizing it as a moderate severity finding. *3. Duration > 72 hours* - A duration of symptoms *greater than 72 hours* **IS** a defining criterion for **Grade II (moderate)** acute cholecystitis according to the **Tokyo Guidelines for severity assessment**. - This indicates a more prolonged inflammatory process, often associated with increased local complications. *4. Marked local inflammation* - **Marked local inflammation** **IS** a characteristic of **Grade II (moderate)** acute cholecystitis. - This criterion includes conditions such as pericholecystic abscess, hepatic abscess, gangrenous cholecystitis, or biliary peritonitis, indicating significant local complications.
Question 9: Which of the following is the FIRST step in triple assessment of breast lumps? 1. Clinical assessment 2. Radiological assessment 3. Histopathological assessment 4. Sentinel lymph node biopsy
- A. Radiological assessment
- B. Sentinel lymph node biopsy
- C. Histopathological assessment
- D. Clinical assessment (Correct Answer)
Explanation: ***Clinical assessment*** - The **first step** in triple assessment involves taking a thorough history and performing a physical examination to identify concerning features of a breast lump. - This step helps to guide the subsequent radiological and histopathological investigations. *Radiological assessment* - This is the **second step** of triple assessment and typically involves mammography, ultrasound, or MRI to characterize the lump's features and extent. - It provides imaging information but does not precede the initial clinical evaluation. *Histopathological assessment* - This is the **third step**, involving a biopsy (fine needle aspiration, core needle biopsy) to obtain tissue for microscopic examination and definitive diagnosis. - While crucial for diagnosis, it follows both clinical and radiological assessments in the triple assessment pathway. *Sentinel lymph node biopsy* - This procedure is performed to determine if **cancer cells have spread** to the regional lymph nodes, typically after a confirmed diagnosis of breast cancer. - It is not part of the initial diagnostic triple assessment for a breast lump but rather a staging procedure.
Question 10: Which of the following is the MOST reliable intraoperative feature of viable small bowel? 1. Visible peristalsis 2. Flabby intestinal musculature 3. Shiny appearance of small bowel wall 4. Visible pulsation in the mesenteric artery
- A. 3. Shiny appearance of small bowel wall
- B. 2. Flabby intestinal musculature
- C. 4. Visible pulsation in the mesenteric artery
- D. 1. Visible peristalsis (Correct Answer)
Explanation: ***Visible peristalsis*** - The presence of **visible peristalsis** is the **MOST reliable indicator** of viable small bowel, demonstrating preserved neuromuscular function and tissue vitality. - Among the classical "3 Ps" of bowel viability (Peristalsis, Pulsation, Pink color), **peristalsis is the most direct indicator** as it confirms functional integrity of the bowel wall itself. - This indicates that the muscle layers of the intestine (longitudinal and circular) are functioning properly with intact innervation. *Shiny appearance of small bowel wall* - A **shiny serosa** is indeed a feature of viable bowel, indicating healthy, well-perfused tissue with an intact mesenteric surface. - However, it is a **less specific indicator** compared to peristalsis, as the appearance can be subjective and may not directly correlate with functional viability. *Visible pulsation in the mesenteric artery* - **Visible pulsation** in the mesenteric artery is one of the classical signs of viability and indicates blood flow to the vessel. - However, arterial pulsation alone **does not guarantee adequate tissue perfusion** or venous drainage, and ischemia can still occur despite pulsatile flow (e.g., venous thrombosis). - Peristalsis is more reliable as it confirms both adequate perfusion AND functional integrity. *Flabby intestinal musculature* - **Flabby intestinal musculature** indicates **non-viable bowel** with loss of tone, suggesting ischemia or necrosis. - Viable bowel typically feels **turgid and elastic** with good tone, not flabby.