UPSC-CMS 2023 — Surgery

Q: Tidy wounds inflicted by sharp instruments and containing no devitalised tissues are expected to heal by

Primary healing. ***Primary healing*** - This mode of healing occurs in **clean, surgically incised, or sharply cut wounds** with minimal tissue loss and edges that can be approximated. - Features include minimal scarring and rapid re-epithelialization without granulation tissue formation. *Skin grafting* - This is a surgical procedure used to cover large wounds where **primary closure is not possible** or to repair areas with significant tissue loss. - It involves transplanting skin from one area of the body to another, not a natural healing process for tidy wounds. *Secondary healing* - This occurs in wounds with **significant tissue loss, infection, or edges that cannot be approximated**, requiring the formation of granulation tissue to fill the defect. - It results in a larger scar and takes longer to heal compared to primary healing. *Formation of contracture* - **Wound contracture** is a process that occurs during secondary healing, where myofibroblasts pull the wound edges together, leading to a reduction in wound size. - While it's a part of the healing process for certain wounds, it is not the primary mode of healing for tidy, sharp wounds and can lead to functional impairment if severe. [Practice more Surgery PYQs on OnCourse]

Q: A patient has a 6-cm breast tumor with mobile, clinically positive, ipsilateral axillary lymph nodes and no evidence of distant metastasis. The stage of the breast cancer is

Stage IIb. ***Stage IIb*** - A 6-cm tumor (T3) in the presence of mobile, clinically positive, ipsilateral axillary lymph nodes (N1) and no distant metastasis (M0) fits the criteria for **Stage IIB** according to the AJCC 8th edition TNM classification. - The TNM classification defines T3 as a tumor >5 cm and N1 as metastasis to **ipsilateral movable axillary lymph nodes**. - **T3N1M0 = Stage IIB** definitively. *Stage IIIa* - Stage IIIA would require **T3 with N2 nodes** (fixed/matted axillary nodes or clinically detected internal mammary nodes without axillary involvement), or **T0-T2 with N2**, or **T4 with N1**. - N2 nodes refer to **fixed/matted axillary nodes** or internal mammary nodes, which are not described here. - The patient has **N1 nodes** (mobile), not N2. *Stage IIIb* - Stage IIIB would involve **T4 disease** (tumor of any size with direct extension to chest wall or skin involvement like ulceration, ipsilateral satellite nodules, or inflammatory breast cancer). - The given tumor does not show signs of **locally advanced disease** such as chest wall invasion or skin involvement. *Stage I* - Stage I describes **small tumors** (T1, ≤2 cm) with no lymph node involvement (N0) or micrometastases only (N1mi). - The tumor size of 6 cm and presence of **clinically evident axillary lymph node involvement** preclude a Stage I diagnosis. [Practice more Surgery PYQs on OnCourse]

Q: A 40-year old alcoholic male complains of acute pain in the epigastrium associated with vomiting for the last 10 days. On clinical examination, he is found to have a mass in the epigastrium. The most likely diagnosis is

Pancreatic pseudocyst. **Pancreatic pseudocyst** - The presence of an **epigastric mass** in an **alcoholic male** with acute epigastric pain and vomiting for 10 days is highly suggestive of a pancreatic pseudocyst, which commonly develops after **acute pancreatitis**. - Pseudocysts are collections of **pancreatic fluid** encased by a non-epithelial inflammatory wall, often presenting as a palpable mass within days to weeks after an acute episode. - The **alcoholic history** and **acute presentation** strongly support this diagnosis. *Carcinoma of head of the pancreas* - While pancreatic carcinoma can cause epigastric pain, **vomiting** and an **acute course** over 10 days are less typical. - It is usually associated with **weight loss**, **jaundice** (if the head is involved), and a more insidious onset. *Perforated peptic ulcer with sub-hepatic abscess* - A perforated peptic ulcer presents with **sudden, severe epigastric pain** that rapidly worsens, often with signs of **peritonitis** and acute abdomen. - A sub-hepatic abscess would typically be accompanied by **fever**, **leukocytosis**, and signs of sepsis. *Hepatoma in left lobe of liver* - A hepatoma would usually present with a **liver mass**, potentially **jaundice**, weight loss, and abnormal liver function tests, rather than an acute onset of severe epigastric pain and vomiting. - The mass would typically be felt in the **right upper quadrant** or epigastrium, but the clinical picture does not align with an acute pancreatic process. [Practice more Surgery PYQs on OnCourse]

Q: In acute pancreatitis, surgery is indicated in which one of the following conditions?

Infected pancreatic necrosis. ***Infected pancreatic necrosis*** - **Infected pancreatic necrosis** is a severe complication of acute pancreatitis requiring surgical or percutaneous debridement (necrosectomy) to remove infected tissue and prevent sepsis. - The presence of infection in necrotic tissue significantly increases morbidity and mortality, making intervention crucial. *Acute pseudocyst* - An acute pseudocyst is usually managed conservatively and only requires intervention if it is **symptomatic**, rapidly expanding, or becomes infected. - Surgical drainage is typically reserved for large, symptomatic, or complicated pseudocysts that persist beyond 6 weeks. *Acute fluid collection* - **Acute fluid collections** are generally self-limiting and resolve without intervention. - They are typically asymptomatic and represent an early stage of fluid accumulation, often preceding pseudocyst formation. *Sterile pancreatic necrosis* - **Sterile pancreatic necrosis** is usually managed with supportive care, as surgical intervention in the absence of infection does not improve outcomes and may increase complications. - The key distinction is the absence of infection—surgery is indicated only when necrosis becomes infected. [Practice more Surgery PYQs on OnCourse]

Q: Consider the following findings with reference to a diagnostic peritoneal lavage (DPL) in a case of abdominal trauma : 1. 10 ml of gross blood on aspiration 2. W.B.C. count more than 500/cu mm 3. Amylase level more than 175 IU/dL 4. R.B.C. count more than 100,000/cu mm The criteria for a positive DPL are :

1, 2, 3 and 4. ***1, 2, 3 and 4*** - A **positive DPL** is indicated by any of these findings: gross blood on aspiration (≥10 mL), WBC count >500/mm³, amylase level >175 IU/dL, or RBC count >100,000/mm³. - All four criteria listed are standard indicators for a positive DPL, suggesting significant intra-abdominal injury requiring further intervention. *1 and 2 only* - While **gross blood aspiration** and an **elevated WBC count** are indeed criteria for a positive DPL, this option is incomplete as it omits other critical indicators. - A **high amylase level** and **RBC count >100,000/mm³** are also definitive signs of a positive DPL. *3 and 4 only* - Although an **elevated amylase level** and a **high RBC count** are valid criteria, this option is insufficient because it excludes the important findings of gross blood aspiration and an elevated WBC count. - A comprehensive assessment requires considering **all definitive indicators** for a positive DPL. *1, 2 and 3 only* - This option includes gross blood aspiration, elevated WBC count, and elevated amylase level, which are all positive indicators. - However, it incorrectly excludes an **RBC count >100,000/mm³**, which is a crucial and widely accepted criterion for a positive DPL. [Practice more Surgery PYQs on OnCourse]

24 Previous Year Questions with Answers & Explanations

Questions

All Subjects Anatomy (8)Biochemistry (3)Community Medicine (52)Dermatology (1)Forensic Medicine (2)Internal Medicine (29)Microbiology (4)Obstetrics and Gynecology (66)Ophthalmology (2)Orthopaedics (1)Pathology (9)Pediatrics (6)Pharmacology (3)Physiology (10)Psychiatry (1)Radiology (6)Surgery (24)

Tidy wounds inflicted by sharp instruments and containing no devitalised tissues are expected to heal by

A patient has a 6-cm breast tumor with mobile, clinically positive, ipsilateral axillary lymph nodes and no evidence of distant metastasis. The stage of the breast cancer is

A 40-year old alcoholic male complains of acute pain in the epigastrium associated with vomiting for the last 10 days. On clinical examination, he is found to have a mass in the epigastrium. The most likely diagnosis is

In acute pancreatitis, surgery is indicated in which one of the following conditions?

Consider the following findings with reference to a diagnostic peritoneal lavage (DPL) in a case of abdominal trauma : 1. 10 ml of gross blood on aspiration 2. W.B.C. count more than 500/cu mm 3. Amylase level more than 175 IU/dL 4. R.B.C. count more than 100,000/cu mm The criteria for a positive DPL are :

Following radical surgery for the carcinoma of breast, reconstruction of the breast can be performed by using the following procedures except

A Wolfe graft is a

The indications for surgery in patients with pulmonary tuberculosis include all of the following except

In a patient with stage T1 (tumor invading lamina propria) transitional cell carcinoma of the urinary bladder, the recommended treatment is

Q10

A localized nodule of squamous cell carcinoma in the vocal cord is best treated by

UPSC-CMS 2023 - Surgery UPSC-CMS Practice Questions and MCQs

Question 1: Tidy wounds inflicted by sharp instruments and containing no devitalised tissues are expected to heal by

A. Primary healing (Correct Answer)
B. Skin grafting
C. Secondary healing
D. Formation of contracture

Explanation: ***Primary healing*** - This mode of healing occurs in **clean, surgically incised, or sharply cut wounds** with minimal tissue loss and edges that can be approximated. - Features include minimal scarring and rapid re-epithelialization without granulation tissue formation. *Skin grafting* - This is a surgical procedure used to cover large wounds where **primary closure is not possible** or to repair areas with significant tissue loss. - It involves transplanting skin from one area of the body to another, not a natural healing process for tidy wounds. *Secondary healing* - This occurs in wounds with **significant tissue loss, infection, or edges that cannot be approximated**, requiring the formation of granulation tissue to fill the defect. - It results in a larger scar and takes longer to heal compared to primary healing. *Formation of contracture* - **Wound contracture** is a process that occurs during secondary healing, where myofibroblasts pull the wound edges together, leading to a reduction in wound size. - While it's a part of the healing process for certain wounds, it is not the primary mode of healing for tidy, sharp wounds and can lead to functional impairment if severe.

Question 2: A patient has a 6-cm breast tumor with mobile, clinically positive, ipsilateral axillary lymph nodes and no evidence of distant metastasis. The stage of the breast cancer is

A. Stage IIIb
B. Stage I
C. Stage IIb (Correct Answer)
D. Stage IIIa

Explanation: ***Stage IIb*** - A 6-cm tumor (T3) in the presence of mobile, clinically positive, ipsilateral axillary lymph nodes (N1) and no distant metastasis (M0) fits the criteria for **Stage IIB** according to the AJCC 8th edition TNM classification. - The TNM classification defines T3 as a tumor >5 cm and N1 as metastasis to **ipsilateral movable axillary lymph nodes**. - **T3N1M0 = Stage IIB** definitively. *Stage IIIa* - Stage IIIA would require **T3 with N2 nodes** (fixed/matted axillary nodes or clinically detected internal mammary nodes without axillary involvement), or **T0-T2 with N2**, or **T4 with N1**. - N2 nodes refer to **fixed/matted axillary nodes** or internal mammary nodes, which are not described here. - The patient has **N1 nodes** (mobile), not N2. *Stage IIIb* - Stage IIIB would involve **T4 disease** (tumor of any size with direct extension to chest wall or skin involvement like ulceration, ipsilateral satellite nodules, or inflammatory breast cancer). - The given tumor does not show signs of **locally advanced disease** such as chest wall invasion or skin involvement. *Stage I* - Stage I describes **small tumors** (T1, ≤2 cm) with no lymph node involvement (N0) or micrometastases only (N1mi). - The tumor size of 6 cm and presence of **clinically evident axillary lymph node involvement** preclude a Stage I diagnosis.

Question 3: A 40-year old alcoholic male complains of acute pain in the epigastrium associated with vomiting for the last 10 days. On clinical examination, he is found to have a mass in the epigastrium. The most likely diagnosis is

A. Carcinoma of head of the pancreas
B. Perforated peptic ulcer with sub-hepatic abscess
C. Hepatoma in left lobe of liver
D. Pancreatic pseudocyst (Correct Answer)

Explanation: **Pancreatic pseudocyst** - The presence of an **epigastric mass** in an **alcoholic male** with acute epigastric pain and vomiting for 10 days is highly suggestive of a pancreatic pseudocyst, which commonly develops after **acute pancreatitis**. - Pseudocysts are collections of **pancreatic fluid** encased by a non-epithelial inflammatory wall, often presenting as a palpable mass within days to weeks after an acute episode. - The **alcoholic history** and **acute presentation** strongly support this diagnosis. *Carcinoma of head of the pancreas* - While pancreatic carcinoma can cause epigastric pain, **vomiting** and an **acute course** over 10 days are less typical. - It is usually associated with **weight loss**, **jaundice** (if the head is involved), and a more insidious onset. *Perforated peptic ulcer with sub-hepatic abscess* - A perforated peptic ulcer presents with **sudden, severe epigastric pain** that rapidly worsens, often with signs of **peritonitis** and acute abdomen. - A sub-hepatic abscess would typically be accompanied by **fever**, **leukocytosis**, and signs of sepsis. *Hepatoma in left lobe of liver* - A hepatoma would usually present with a **liver mass**, potentially **jaundice**, weight loss, and abnormal liver function tests, rather than an acute onset of severe epigastric pain and vomiting. - The mass would typically be felt in the **right upper quadrant** or epigastrium, but the clinical picture does not align with an acute pancreatic process.

Question 4: In acute pancreatitis, surgery is indicated in which one of the following conditions?

A. Infected pancreatic necrosis (Correct Answer)
B. Acute pseudocyst
C. Acute fluid collection
D. Sterile pancreatic necrosis

Explanation: ***Infected pancreatic necrosis*** - **Infected pancreatic necrosis** is a severe complication of acute pancreatitis requiring surgical or percutaneous debridement (necrosectomy) to remove infected tissue and prevent sepsis. - The presence of infection in necrotic tissue significantly increases morbidity and mortality, making intervention crucial. *Acute pseudocyst* - An acute pseudocyst is usually managed conservatively and only requires intervention if it is **symptomatic**, rapidly expanding, or becomes infected. - Surgical drainage is typically reserved for large, symptomatic, or complicated pseudocysts that persist beyond 6 weeks. *Acute fluid collection* - **Acute fluid collections** are generally self-limiting and resolve without intervention. - They are typically asymptomatic and represent an early stage of fluid accumulation, often preceding pseudocyst formation. *Sterile pancreatic necrosis* - **Sterile pancreatic necrosis** is usually managed with supportive care, as surgical intervention in the absence of infection does not improve outcomes and may increase complications. - The key distinction is the absence of infection—surgery is indicated only when necrosis becomes infected.

Question 5: Consider the following findings with reference to a diagnostic peritoneal lavage (DPL) in a case of abdominal trauma : 1. 10 ml of gross blood on aspiration 2. W.B.C. count more than 500/cu mm 3. Amylase level more than 175 IU/dL 4. R.B.C. count more than 100,000/cu mm The criteria for a positive DPL are :

A. 1 and 2 only
B. 3 and 4 only
C. 1, 2 and 3 only
D. 1, 2, 3 and 4 (Correct Answer)

Explanation: ***1, 2, 3 and 4*** - A **positive DPL** is indicated by any of these findings: gross blood on aspiration (≥10 mL), WBC count >500/mm³, amylase level >175 IU/dL, or RBC count >100,000/mm³. - All four criteria listed are standard indicators for a positive DPL, suggesting significant intra-abdominal injury requiring further intervention. *1 and 2 only* - While **gross blood aspiration** and an **elevated WBC count** are indeed criteria for a positive DPL, this option is incomplete as it omits other critical indicators. - A **high amylase level** and **RBC count >100,000/mm³** are also definitive signs of a positive DPL. *3 and 4 only* - Although an **elevated amylase level** and a **high RBC count** are valid criteria, this option is insufficient because it excludes the important findings of gross blood aspiration and an elevated WBC count. - A comprehensive assessment requires considering **all definitive indicators** for a positive DPL. *1, 2 and 3 only* - This option includes gross blood aspiration, elevated WBC count, and elevated amylase level, which are all positive indicators. - However, it incorrectly excludes an **RBC count >100,000/mm³**, which is a crucial and widely accepted criterion for a positive DPL.

Question 6: Following radical surgery for the carcinoma of breast, reconstruction of the breast can be performed by using the following procedures except

A. Silicone implants
B. Transversus abdominis muscle flap (TRAM flap)
C. Latissimus dorsi flap (LD flap)
D. Deltopectoral flap (Correct Answer)

Explanation: ***Deltopectoral flap*** - The **deltopectoral flap**, also known as the Bakamjian flap, is primarily used for **head and neck reconstruction**, particularly for defects in the pharynx, esophagus, or oral cavity. - It involves tissue from the shoulder and chest wall, but its design and vascular supply make it unsuitable for **breast reconstruction** after radical mastectomy, which requires significantly more volume and different tissue characteristics. *Silicone implants* - **Silicone implants** are a common method for breast reconstruction, offering a less invasive option than flap procedures. - They are placed either beneath the pectoral muscle or subcutaneously to restore breast volume and shape. *Transversus abdominis muscle flap (TRAM flap)* - The **TRAM flap** is a widely used and versatile autologous tissue reconstruction method, utilizing tissue from the lower abdomen to create a new breast mound. - It can be either pedicled (retaining its original blood supply) or free (requiring microvascular anastomosis), providing a natural-feeling and long-lasting reconstruction. *Latissimus dorsi flap (LD flap)* - The **latissimus dorsi (LD) flap** involves transferring muscle, fat, and skin from the back to the chest to reconstruct the breast. - It is particularly useful for smaller breasts or when combined with an implant, and it can provide good aesthetic results with reliable blood supply.

Question 7: A Wolfe graft is a

A. Partial thickness skin graft
B. Pinch skin graft
C. Pedicle graft
D. Large full thickness skin graft (Correct Answer)

Explanation: ***Large full thickness skin graft*** - A **Wolfe graft** is a type of **large full-thickness skin graft** that includes the epidermis and entire dermis. - Due to its full thickness, it provides better cosmetic results and less contracture compared to split-thickness grafts, but requires optimal **vascularization** at the recipient site. - The term "Wolfe graft" specifically refers to the **large size** of the full-thickness graft, distinguishing it from smaller grafts. *Partial thickness skin graft* - A **partial-thickness skin graft** (also known as a split-thickness skin graft) includes the epidermis and only a portion of the dermis. - While easier to harvest and more likely to **take** in less ideal recipient beds, they are known for more contraction and a less cosmetic appearance. *Pinch skin graft* - A **pinch graft** is a small, conical piece of skin, including the epidermis and dermis, taken by pinching the skin. - These grafts are generally less aesthetically pleasing, have limited applications, and are often used for small, non-cosmetic defects. *Pedicle graft* - A **pedicle graft** (or flap) is a section of tissue that remains attached to its original site at one or more points, maintaining its own **blood supply**. - Unlike a free graft, it is not completely detached from the donor site, allowing for transfer of more complex tissues like muscle or bone.

Question 8: The indications for surgery in patients with pulmonary tuberculosis include all of the following except

A. Drug-resistant chronic tuberculous abscess
B. Severe life-threatening haemoptysis
C. AFB positive sputum with normal chest CT scan (Correct Answer)
D. Aspergilloma within a tuberculous cavity with recurrent haemoptysis

Explanation: ***AFB positive sputum with normal chest CT scan*** - This scenario typically indicates **early or uncomplicated pulmonary tuberculosis** that is responsive to standard antitubercular drug therapy. - A normal chest CT scan suggests the absence of significant cavitations, extensive lung damage, or other structural abnormalities that would necessitate surgical intervention. *Drug-resistant chronic tuberculous abscess* - **Drug resistance** and the presence of a **chronic tuberculous abscess** make medical management difficult and often ineffective. - Surgical resection can remove the source of infection, facilitate cure, and prevent further dissemination of drug-resistant organisms. *Severe life-threatening haemoptysis* - **Severe or life-threatening haemoptysis** in TB patients often arises from eroded pulmonary vessels within cavitary lesions. - Surgical intervention (e.g., lobectomy, pneumonectomy) is critical to control bleeding and prevent fatal outcomes when conservative measures fail. *Aspergilloma within a tuberculous cavity with recurrent haemoptysis* - An **aspergilloma (fungal ball)** developing in a pre-existing tuberculous cavity can cause **recurrent haemoptysis** due to erosion of blood vessels by the fungus. - Surgical resection is often the definitive treatment to remove the aspergilloma and prevent further bleeding.

Question 9: In a patient with stage T1 (tumor invading lamina propria) transitional cell carcinoma of the urinary bladder, the recommended treatment is

A. Radiation therapy
B. Systemic chemotherapy
C. Radical cystectomy
D. Trans urethral resection of bladder tumour (TURBT) (Correct Answer)

Explanation: ***Trans urethral resection of bladder tumour (TURBT)*** - For **stage 1 (confined to mucosa and submucosa) transitional cell carcinoma** of the urinary bladder, TURBT is the primary and often curative treatment. - This procedure allows for both diagnostic staging and complete resection of visible tumors. *Radiation therapy* - **Radiation therapy** is generally reserved for more advanced stages or for patients who are not surgical candidates. - It is often used in combination with chemotherapy or as a palliative measure, not typically as monotherapy for early-stage disease. *Systemic chemotherapy* - **Systemic chemotherapy** is typically indicated for advanced, metastatic bladder cancer or as neoadjuvant/adjuvant therapy in muscle-invasive disease. - It is not the primary treatment for early-stage, non-muscle invasive bladder cancer. *Radical cystectomy* - **Radical cystectomy** is a major surgical procedure involving removal of the entire bladder and surrounding structures. - It is reserved for **muscle-invasive bladder cancer** or recurrent high-grade non-muscle invasive bladder cancer that has failed conservative treatments.

Question 10: A localized nodule of squamous cell carcinoma in the vocal cord is best treated by

A. Cryosurgery
B. Radiotherapy
C. Laser therapy (Correct Answer)
D. Surgical excision

Explanation: ***Laser therapy (Transoral Laser Microsurgery)*** - **CO2 laser excision** is an excellent first-line treatment for localized T1a squamous cell carcinoma of the vocal cord, offering **>90% cure rates**. - Advantages include: **precise tumor removal**, immediate pathological assessment with margin evaluation, **excellent voice preservation**, and shorter treatment duration compared to radiotherapy. - **Transoral laser microsurgery (TLM)** allows for cord-sparing procedures that maintain vocal function while achieving complete oncological resection. *Radiotherapy* - **Important Note:** **Radiotherapy is EQUALLY effective** as laser therapy for early T1 glottic cancer, with comparable **5-year local control rates (>90%)** and voice quality outcomes. - Both laser surgery and radiotherapy are **guideline-recommended first-line treatments** (NCCN, ESMO guidelines). - Choice between the two depends on tumor characteristics (anterior commissure involvement), patient preference, institutional expertise, and functional outcomes. - In examination contexts, laser therapy may be preferred as it provides histopathological confirmation and is often considered more definitive for "localized nodules." *Cryosurgery* - **Cryosurgery** is rarely used for vocal cord lesions due to **unpredictable tissue destruction**, potential for severe **vocal cord scarring**, and inability to obtain tissue for pathological margin assessment. - Not a standard treatment option for laryngeal cancer. *Surgical excision* - This term is ambiguous as **laser excision IS a form of surgical excision**. - If referring to **open surgical approaches** (laryngofissure, cordectomy via external approach), these are more invasive than transoral laser surgery and are reserved for larger tumors or salvage situations. - Traditional "cold steel" endoscopic excision is less precise than laser and can cause more trauma and scarring.