FMGE 2023 - Surgery Practice Questions

Q: Which of the following procedures has the highest risk of causing the recurrence of duodenal ulcers?

Highly selective vagotomy. ***Highly selective vagotomy***- ***Highly selective vagotomy*** (or parietal cell vagotomy) denervates only the acid-producing parietal cell mass, reducing basal and maximal acid output less intensely than other procedures. This procedure preserves the innervation of the **gastric antrum** and **pylorus**, maintaining physiological motility but resulting in the highest reported **ulcer recurrence rate** (historically 10-20%).*Gastrectomy*- A subtotal **gastrectomy** involves physically removing the portion of the stomach (body and/or antrum) responsible for acid or gastrin production, leading to a drastic reduction in acid load and a very low recurrence rate. This procedure is generally associated with the highest rates of **post-gastrectomy syndromes** (e.g., afferent loop syndrome, dumping syndrome) compared to vagotomy alone.*Truncal vagotomy*- **Truncal vagotomy** divides the main vagus trunks, causing near-maximal reduction of cephalic-phase acid secretion but requires mandatory **drainage procedures** (**pyloroplasty** or gastrojejunostomy) due to resulting gastric atony. The profound reduction in acid output achieved by this method gives it a significantly lower recurrence rate than highly selective vagotomy.*Gastro-jejunostomy*- **Gastro-jejunostomy** (often referring to the creation of a stoma between the stomach and jejunum) is typically performed as the **drainage procedure** necessary after truncal vagotomy, allowing food egress when the pylorus is dysfunctional. While effective in preventing stasis, a gastro-jejunostomy carries a specific risk of **marginal ulceration** (anastomotic ulceration) but the overall rate of recurrence for the combined operation is low.

Q: Elective splenectomy is preferred in which of the following conditions?

Hereditary spherocytosis. ***Hereditary spherocytosis***- It is the preferred elective treatment because the inherited structural defect in the red blood cell membrane leads to the sequestration and destruction of the rigid **spherocytes** primarily by the **spleen**. - Splenectomy significantly reduces hemolysis and corrects chronic anemia, but it is typically delayed until the child is over 5 years old to reduce the risk of **post-splenectomy sepsis**.*G6PD deficiency-Glucose-6-phosphate dehydrogenase deficiency*- This condition causes episodic hemolysis (typically **intravascular**) triggered by **oxidative stress** (drugs, fava beans, infection), not continuous extravascular hemolysis reliant on the spleen.- The mainstay of management is identifying and **avoiding oxidant triggers**; splenectomy is not indicated as it does not address the underlying enzymatic deficiency or the mechanism of hemolysis.*Paroxysmal nocturnal hemoglobinuria*- PNH is characterized by complement-mediated cytotoxicity due to lack of **GPI-anchored proteins** (CD55, CD59) on RBCs, leading to **intravascular hemolysis**.- Treatment involves targeted therapies like **complement inhibitors** (e.g., **eculizumab**) or **hematopoietic stem cell transplant**; splenectomy is usually ineffective and potentially harmful.*Hairy cell leukemia*- This is a **B-cell malignancy** effectively treated with chemotherapy using **purine analogs** (e.g., **cladribine**), which is the standard first-line approach for symptomatic disease.- Splenectomy may be considered for massive symptomatic **splenomegaly** or severe **refractory cytopenias**, but it is a secondary intervention and not the preferred elective treatment for the condition itself.

Q: A man came with complaints of recurrent discharge and pain due to lesions around the anus for 3 years. A diagnosis of fistula-in-ano is made. What is the gold standard investigation for this condition?

MRI. ***MRI*** - **Gold standard investigation** for fistula-in-ano for preoperative assessment - Provides **superior soft tissue contrast** and multiplanar imaging capabilities - Accurately delineates the **fistula tract, internal and external openings** - Detects **secondary tracts, horseshoe extensions, and abscesses** - Helps in **Parks classification** (intersphincteric, trans-sphincteric, suprasphincteric, extrasphincteric) - Essential for **surgical planning** and predicting recurrence risk - MRI with fat suppression sequences (T2-weighted) provides best visualization *Fistulogram* - Outdated investigation with **limited accuracy** (40-50%) - Cannot adequately assess sphincter involvement or secondary tracts - Invasive and uncomfortable for the patient - Risk of extravasation and infection *USG (Endoanal/Transperineal Ultrasound)* - Useful adjunct but **not gold standard** - Operator-dependent with limited field of view - Difficulty visualizing high or complex fistulas - Less accurate for secondary extensions *CECT* - Not routinely used for fistula-in-ano assessment - **Inferior soft tissue resolution** compared to MRI - Radiation exposure - Limited differentiation of sphincter anatomy

Q: Identify the given instrument.

Linear stapler. ***Linear stapler*** - The instrument shown has a long shaft with two jaws that apply staples in a straight line, which is characteristic of a **linear stapler**. - It is primarily used in **abdominal** and **thoracic surgery** for transecting tissue or closing internal organs like the stomach, intestines, or lung parenchyma. *Skin stapler* - A **skin stapler** is a much smaller, handheld device used exclusively for closing skin incisions externally and has a distinctly different appearance. - It applies single, wide staples and is not used for internal tissue anastomosis or transection. *Circular stapler* - A **circular stapler** has a round head at the distal end designed to create a circular, end-to-end anastomosis, typically in **colorectal** or **esophageal** surgery. - The instrument in the image lacks this circular head and is designed for a linear staple line. *Curved stapler* - This term most commonly refers to a **circular stapler** or a **curved linear cutter**, which has a curved head to facilitate access in locations like the pelvis. - The instrument shown has straight jaws, not a curved head, and is designed for creating a straight line of staples.

Q: A patient was brought to the emergency department following a road traffic accident. Skin grafting was done wherein the graft was taken from the same person. Which type of graft is it?

Autograft. ***Autograft*** - An **autograft** is a type of graft where tissue is transplanted from one site to another on the **same individual**, which matches the clinical scenario described. - This is the most common type of skin graft because there is no risk of an **immunological rejection** by the recipient's body, as the tissue is genetically identical. *Xenograft* - A **xenograft** (or heterograft) involves the transplantation of tissue between individuals of **different species**, such as using pig skin for a temporary burn dressing on a human. - This is incorrect as the graft was taken from the patient themselves, not from an animal source. *Allograft* - An **allograft** (or homograft) is a graft of tissue between two genetically **non-identical individuals** of the **same species**, such as a cadaveric skin graft. - This is not the correct answer because the donor and recipient are the same person, not two different people. *Isograft* - An **isograft** (or syngeneic graft) is a tissue transplant between two genetically **identical individuals**, specifically **identical twins**. - While isografts also avoid immune rejection, this is incorrect because the graft was from the patient's own body, not from their identical twin.

Q: A male patient presented with a sudden onset tearing type of chest pain radiating to the back, shortness of breath, and nausea. CT chest image is given. What is the most appropriate next step in the management of this patient?

Esmolol and urgent surgery. ***Esmolol and urgent surgery*** - The CT image shows an intimal flap in the ascending aorta, confirming a **Stanford Type A aortic dissection**. This is a surgical emergency requiring immediate intervention. - The initial management goals are to lower heart rate and blood pressure to reduce aortic wall shear stress. This is achieved with intravenous **beta-blockers** (like **esmolol**), followed by urgent surgical repair. *Urgent surgery* - While surgery is the definitive treatment, it should not be performed without first medically stabilizing the patient. - Failure to control **blood pressure** and **heart rate** pre-operatively increases the risk of dissection propagation or aortic rupture during induction of anesthesia or the surgical procedure itself. *Wait and watch* - A **Type A aortic dissection** is a life-threatening condition with a very high mortality rate (approximately 1-2% per hour for the first 48 hours) if left untreated. - Delaying treatment drastically increases the risk of fatal complications such as **cardiac tamponade**, **acute aortic regurgitation**, or **malperfusion syndromes**. *Blood transfusion* - Blood transfusion is not the primary treatment unless the patient is hemodynamically unstable due to massive hemorrhage from an aortic rupture. - The priority is to prevent rupture and further dissection through **hemodynamic control** and definitive **surgical repair**, not to replace blood volume unless significant loss has already occurred.

Q: A 32-year-old patient who is a chronic tobacco chewer presents with a whitish lesion on the gingivobuccal sulcus for 7 months. What is the next best step in the management of this condition?

Local excision and biopsy. ***Local excision and biopsy*** - The clinical presentation of a persistent white patch in a chronic tobacco user is highly suspicious for **oral leukoplakia**, which is a **premalignant** condition. A **biopsy** is mandatory to establish a definitive histological diagnosis and rule out dysplasia or **squamous cell carcinoma**. - An **excisional biopsy** for a localized lesion is both diagnostic and therapeutic, as it removes the potentially malignant tissue and allows for microscopic examination. *Avoid smoking; wait and watch* - While smoking cessation is a critical part of management, a "wait and watch" approach is inappropriate for a lesion that has persisted for 7 months due to the significant risk of underlying malignancy. - Delaying a definitive diagnosis could allow a potential early-stage cancer to progress, leading to a worse prognosis. *Steroidal injection* - Steroids are used to treat **inflammatory** or **autoimmune** oral lesions like oral lichen planus or pemphigus vulgaris, not potentially neoplastic conditions like leukoplakia. - Using steroids could mask the progression of the lesion and delay the diagnosis of a malignancy. *Sclerotherapy* - Sclerotherapy is a treatment used for **vascular lesions**, such as **hemangiomas** or venous malformations, where a sclerosing agent is injected to cause thrombosis and fibrosis. - This modality is completely inappropriate for an **epithelial** lesion like leukoplakia.

Q: A 32-year-old female undergoes emergency laparotomy for perforation peritonitis. Which of the following is the surest sign of wound dehiscence?

Copious sero-sanguinous discharge. ***Copious sero-sanguinous discharge*** - An abrupt increase in **sero-sanguinous fluid** (often described as salmon-colored or pink-brown) soaking the dressing is the **surest clinical sign** of underlying fascial dehiscence. - This discharge represents peritoneal fluid leaking through the broken-down **fascial closure**, usually preceding full **evisceration**. - Typically occurs 5-10 days post-operatively and is the most specific early warning sign. *Rebound tenderness* - **Rebound tenderness** is a sign of **peritonitis** or intra-abdominal inflammation, which is related to the primary pathology (perforation) but not a direct sign of **fascial integrity loss**. - If present post-operatively, it usually indicates persistent or recurrent **intra-abdominal sepsis**, abscess, or ongoing peritonitis. *Hemorrhage* - **Hemorrhage** (frank bleeding) indicates vascular injury or a defect in **hemostasis**, not mechanical failure of the fascial layer itself. - Significant wound bleeding is common in the immediate post-operative period but is not the specific pathognomonic finding for **wound dehiscence**. *Hypotension* - **Hypotension** is a non-specific sign of severe systemic compromise, such as **sepsis**, **hypovolemic shock**, or ongoing internal bleeding. - Although a major dehiscence could lead to sepsis and subsequent hypotension, it is not the initial or most **specific indicator** of the structural breakdown of the wound.

Q: Four patients were brought to the casualty after sustaining trauma. Which of the following is the correct match among the following?

Gaze palsy is - Midbrain lesion. ***Gaze palseis-Mid brain lesion***- **Vertical gaze palsies** are commonly associated with lesions affecting the **midbrain**, particularly the **pretectal area** and the rostral interstitial nucleus of the **medial longitudinal fasciculus (riMLF)**.- Trauma or increased intracranial pressure leading to compression in this region, such as in **Parinaud syndrome**, can result in impaired upward or downward gaze.*Extradural hemorrhage (EDH)- Pin point pupil*- An **EDH** typically causes rapid mass effect and subsequent **uncal herniation**, leading to compression of the **oculomotor nerve (CN III)** and resulting in a fixed, **dilated pupil** (mydriasis) ipsilateral to the lesion.- **Pinpoint pupils** are classically associated with damage to the descending sympathetic pathways in the **pons** (pontine hemorrhage) or opioid overdose.*Penetrating injury to eustachian tube- CSF otorrhea*- **CSF otorrhea** (leakage of CSF from the ear) occurs due to a tear in the dura mater and the **temporal bone**, specifically involving the **petrous segment** and tympanic membrane rupture.- Injury to the **Eustachian tube** primarily connects the middle ear to the nasopharynx; damage here would typically cause air leak or middle ear bleeding, not primary CSF leakage through the external auditory canal.*Penetrating injury to eye- Battle sign*- **Battle sign** is ecchymosis (bruising) over the **mastoid process** and is a hallmark clinical indicator of a **basilar skull fracture**, usually involving the middle cranial fossa (temporal bone).- Penetrating injuries to the eye are associated with localized ocular trauma (e.g., globe rupture, hyphema) but are not typically linked to this specific sign of underlying skull base injury.

Question 1

Genetic testing for BRCA 1/BRCA 2 is indicated for all of the following except:

Accepted Answer

Breast cancer diagnosed in a postmenopausal female >50 years of age

Answer

Breast and ovarian cancer

Answer

Male breast cancer

Answer

Bilateral breast cancer

Question 2

Which of the following procedures has the highest risk of causing the recurrence of duodenal ulcers?

Accepted Answer

Highly selective vagotomy

Answer

Gastro-jejunostomy

Answer

Gastrectomy

Answer

Truncal vagotomy

Question 3

Elective splenectomy is preferred in which of the following conditions?

Accepted Answer

Hereditary spherocytosis

Answer

Hairy cell leukemia

Answer

Paroxysmal nocturnal hemoglobinuria

Answer

G6PD deficiency

Question 4

A man came with complaints of recurrent discharge and pain due to lesions around the anus for 3 years. A diagnosis of fistula-in-ano is made. What is the gold standard investigation for this condition?

Accepted Answer

MRI

Answer

Fistulogram

Answer

USG

Answer

CECT

Question 5

Identify the given instrument.

Accepted Answer

Linear stapler

Answer

Curved stapler

Answer

Circular stapler

Answer

Skin stapler

Question 6

A patient was brought to the emergency department following a road traffic accident. Skin grafting was done wherein the graft was taken from the same person. Which type of graft is it?

Accepted Answer

Autograft

Answer

Isograft

Answer

Xenograft

Answer

Allograft

Question 7

A male patient presented with a sudden onset tearing type of chest pain radiating to the back, shortness of breath, and nausea. CT chest image is given. What is the most appropriate next step in the management of this patient?

Accepted Answer

Esmolol and urgent surgery

Answer

Urgent surgery

Answer

Blood transfusion

Answer

Wait and watch

Question 8

A 32-year-old patient who is a chronic tobacco chewer presents with a whitish lesion on the gingivobuccal sulcus for 7 months. What is the next best step in the management of this condition?

Accepted Answer

Local excision and biopsy

Answer

Steroidal injection

Answer

Sclerotherapy

Answer

Avoid smoking; wait and watch

Question 9

A 32-year-old female undergoes emergency laparotomy for perforation peritonitis. Which of the following is the surest sign of wound dehiscence?

Accepted Answer

Copious sero-sanguinous discharge

Answer

Rebound tenderness

Answer

Hypotension

Answer

Hemorrhage

Question 10

Four patients were brought to the casualty after sustaining trauma. Which of the following is the correct match among the following?

Accepted Answer

Gaze palsy is - Midbrain lesion

Answer

b.Penetrating injury to eustachian tube- CSF otorrhea

Answer

c.Penetrating injury to eye- Battle sign

Answer

a.Extradural hemorrhage (EDH)- Pin point pupil

FMGE 2023 — Surgery