Which of the following is a contraindication to breast conservation surgery?
Best prognostic factor for head injury is:
May-Thurner or Cockett syndrome involves:
Surgery in varicose veins is NOT attempted in the presence of which of the following?
During abdominal surgery under local anesthesia, the patient suddenly felt pain due to
Among the following, intraoperative sentinel lymph node detection in axilla can be done using
Indication for sentinel node biopsy is:
Which of the following statements is true about Marjolin's ulcer?
In which of the following conditions is neurosurgery not indicated?
Which of the following is an example of a clean surgery?
NEET-PG 2013 - Surgery NEET-PG Practice Questions and MCQs
Question 21: Which of the following is a contraindication to breast conservation surgery?
- A. Presence of multicentric tumors (Correct Answer)
- B. Involvement of axillary lymph nodes
- C. Tumor size greater than 4 cm
- D. Presence of diffuse microcalcifications
Explanation: ***Presence of multicentric tumors*** - **Multicentric tumors** are defined as two or more discrete tumors in different quadrants of the breast, which cannot be removed with a single lumpectomy. - This condition is a contraindication for breast conservation surgery (BCS) because complete removal of all tumor foci while maintaining an acceptable cosmetic outcome is highly unlikely. *Involvement of axillary lymph nodes* - **Axillary lymph node involvement** is an important prognostic factor in breast cancer and influences adjuvant therapy decisions, but it is not a direct contraindication to BCS. - Patients with positive nodes often undergo axillary dissection or sentinel lymph node biopsy, followed by radiation and/or systemic therapy, which can be combined with BCS. *Tumor size greater than 4 cm* - While larger tumor size (e.g., >4-5 cm) can make achieving negative surgical margins and a good cosmetic outcome more challenging with BCS, it is not an absolute contraindication. - **Neoadjuvant chemotherapy** can often downstage larger tumors, making BCS a viable option for many patients. *Presence of diffuse microcalcifications* - **Diffuse microcalcifications** can sometimes indicate extensive ductal carcinoma in situ (**DCIS**) or invasive lobular carcinoma with a widespread component. - However, if the microcalcifications represent a single focus of disease that can be entirely excised with negative margins, BCS may still be an option, especially if guided by stereotactic biopsy and imaging.
Question 22: Best prognostic factor for head injury is:
- A. Glasgow coma scale (Correct Answer)
- B. Age
- C. Mode of injury
- D. CT
Explanation: ***Glasgow coma scale*** - The **Glasgow Coma Scale (GCS)** is a standardized tool used to assess the level of consciousness in head injury patients, providing an objective measure of neurological function. - A **lower GCS score** correlates with a greater severity of injury and poorer prognosis, making it the most reliable predictor of outcome. *Age* - While age can influence recovery, with **older patients generally having worse outcomes** due to less neural plasticity and pre-existing comorbidities, it is not the single best prognostic factor. - Younger patients often have better recovery potential, but their prognosis is still heavily dependent on the immediate severity of the brain injury. *Mode of injury* - The mode of injury (e.g., blunt trauma, penetrating injury) provides information about the mechanism and potential **types of injury**, but does not directly quantify the severity of brain damage or predict long-term outcomes as precisely as GCS. - While **high-impact injuries** tend to be more severe, the actual neurological deficit measured by GCS is a better indicator of prognosis. *CT* - **CT scans** are crucial for identifying specific neurological injuries like hemorrhage, edema, or fractures, which can guide immediate management. - However, the findings on a CT scan do not solely determine prognosis; a patient with a relatively normal CT can still have a poor outcome if their **GCS is low**, indicating widespread neuronal dysfunction not always visible on imaging.
Question 23: May-Thurner or Cockett syndrome involves:
- A. Left iliac vein compression (Correct Answer)
- B. Internal iliac artery obstruction
- C. Common iliac artery obstruction
- D. Internal iliac vein obstruction
Explanation: ***Correct: Left iliac vein compression*** - May-Thurner syndrome, also known as Cockett syndrome, specifically describes the **compression of the left common iliac vein** by the overlying right common iliac artery. - This anatomical compression can lead to **venous outflow obstruction**, increasing the risk of deep vein thrombosis (DVT) in the left leg. *Incorrect: Internal iliac artery obstruction* - This condition involves an artery and is unrelated to May-Thurner syndrome, which is a **venous compression disorder**. - Obstruction of the internal iliac artery would typically cause symptoms of **pelvic ischemia** or erectile dysfunction, not venous DVT. *Incorrect: Common iliac artery obstruction* - Obstruction of the common iliac artery is an **arterial occlusion** that would cause peripheral artery disease symptoms in the leg, such as claudication or rest pain. - It does not involve the compression of a vein by an artery, which is characteristic of May-Thurner syndrome. *Incorrect: Internal iliac vein obstruction* - While this is a venous issue, May-Thurner syndrome specifically involves the **common iliac vein**, not the internal iliac vein. - Obstruction of the internal iliac vein would typically present with symptoms related to pelvic venous congestion, distinct from the left lower extremity DVT associated with May-Thurner syndrome.
Question 24: Surgery in varicose veins is NOT attempted in the presence of which of the following?
- A. Deep vein thrombosis (Correct Answer)
- B. Multiple incompetent perforators
- C. Varicose veins with leg ulcer
- D. None of the above
Explanation: ***Deep vein thrombosis*** - **Surgery in varicose veins is absolutely contraindicated in the presence of DVT** (both acute and chronic) - In **acute DVT**, the deep venous system is already compromised, and removing superficial veins could further impair venous return and worsen the thrombotic state - In **chronic DVT with post-thrombotic syndrome**, the deep veins may be occluded or heavily damaged, and the superficial varicosities often serve as **crucial collateral vessels** to maintain venous drainage—their removal would be detrimental - Surgery should only be considered after complete resolution of acute DVT and adequate anticoagulation *Multiple incompetent perforators* - **NOT a contraindication**—incompetent perforators are actually a common indication for surgical treatment - Incompetent perforators contribute to venous insufficiency and recurrent varicose veins - Can be addressed surgically with **subfascial endoscopic perforator surgery (SEPS)** or endovenous ablation techniques - Their presence often indicates need for more comprehensive treatment alongside superficial venous surgery *Varicose veins with leg ulcer* - **NOT a contraindication**—venous leg ulcers are actually an **indication for varicose vein surgery** - Leg ulcers result from chronic venous hypertension due to venous insufficiency - Surgical treatment (saphenous vein ablation, ligation and stripping, or sclerotherapy) reduces venous hypertension and improves venous drainage - Surgery promotes ulcer healing and prevents recurrence when combined with appropriate wound care *None of the above* - Incorrect because **Deep Vein Thrombosis (DVT) is a well-established contraindication** to varicose vein surgery
Question 25: During abdominal surgery under local anesthesia, the patient suddenly felt pain due to
- A. Liver
- B. Parietal peritoneum (Correct Answer)
- C. Intestines
- D. Visceral peritoneum
Explanation: ***Parietal peritoneum*** - The **parietal peritoneum** is richly innervated by somatic nerves (**spinal nerves**), making it highly sensitive to pain, pressure, and temperature. - When stimulated during surgery, even under local anesthesia which might not completely block deeper somatic nerves or if the local block is inadequate, it can cause the patient to suddenly feel **sharp, localized pain**. *Liver* - The liver itself has very few pain receptors in its parenchyma; pain from the liver typically arises from stretching of its fibrous capsule (**Glisson's capsule**). - This pain is usually dull and poorly localized, not the sudden, sharp pain typically experienced during surgical manipulation. *Intestines* - The intestines are primarily innervated by the **autonomic nervous system** and are sensitive to distension and ischemia, causing visceral pain, which is typically dull, crampy, and poorly localized. - They are generally not sensitive to cutting or burning, which are common surgical manipulations. *Visceral peritoneum* - The **visceral peritoneum** covers abdominal organs and is innervated by the autonomic nervous system, similar to the organs it covers. - Like the intestines, it is sensitive to stretch and ischemia, producing diffuse, poorly localized visceral pain rather than sharp, localized pain from surgical incision or manipulation.
Question 26: Among the following, intraoperative sentinel lymph node detection in axilla can be done using
- A. Mammography
- B. Isosulfan blue dye (Correct Answer)
- C. MRI
- D. CT
Explanation: ***Correct Option: Isosulfan blue dye*** - **Isosulfan blue dye** is a vital dye used for **intraoperative visual identification** of sentinel lymph nodes in the axilla during breast cancer surgery - The dye is injected near the tumor site and **preferentially concentrates in lymphatic channels**, allowing the surgeon to visually trace the lymphatic drainage to the **first lymph node(s)** (sentinel nodes) receiving lymph flow - The sentinel nodes appear **blue-stained** and can be identified and excised for biopsy to determine lymph node status - **Alternative methods** include radioactive tracers like **Technetium-99m** or a combination of both (dual mapping technique) *Incorrect Option: Mammography* - Mammography is an **X-ray imaging technique** used for breast cancer screening and diagnosis to detect tumors and calcifications - It is a **pre-operative diagnostic tool**, not used for intraoperative sentinel lymph node detection - Cannot visualize or track lymphatic flow during surgery *Incorrect Option: MRI* - MRI (Magnetic Resonance Imaging) provides detailed anatomical assessment and staging of breast cancer pre-operatively - It is a **static imaging modality** that cannot be used for real-time intraoperative sentinel lymph node detection - Does not visualize lymphatic drainage or dye uptake during surgery *Incorrect Option: CT* - CT scans (Computed Tomography) provide cross-sectional images useful for assessing tumor size and metastatic spread - Not employed for **intraoperative sentinel lymph node detection** - Cannot track real-time lymphatic flow with dyes during surgery
Question 27: Indication for sentinel node biopsy is:
- A. Palpable axillary lymph node
- B. Metastasis
- C. Mass > 5 cm
- D. Non-palpable axillary lymph node (Correct Answer)
Explanation: ***Non-palpable axillary lymph node*** - **Sentinel lymph node biopsy (SLNB)** is indicated when there is no clinical evidence of axillary lymph node involvement, meaning the nodes are **non-palpable**. - Its purpose is to identify micrometastases that would not be detectable by physical examination, staging the cancer more accurately and guiding further treatment. *Palpable axillary lymph node* - A **palpable axillary lymph node** suggests macroscopic nodal involvement, usually requiring a fine needle aspiration (FNA) or core needle biopsy for diagnosis. - If positive, these patients typically proceed directly to **axillary lymph node dissection (ALND)** rather than SLNB. *Mass > 5 cm* - The size of the primary tumor (e.g., > 5 cm) is a factor in staging but does not, in itself, preclude or indicate SLNB. - While larger tumors have a higher risk of nodal involvement, the decision for SLNB still hinges on the clinical status of the axilla (palpable vs. non-palpable nodes). *Metastasis* - If **distant metastasis** is confirmed, the focus shifts to palliative care and systemic treatment, making a regional staging procedure like SLNB less relevant or unnecessary. - SLNB is used for staging early-stage cancer to detect regional spread, not when widespread disease is already established.
Question 28: Which of the following statements is true about Marjolin's ulcer?
- A. Squamous cell carcinoma develops
- B. Slow growing lesion
- C. Develops in long standing scar
- D. All of the options (Correct Answer)
Explanation: ***All of the options*** - Marjolin's ulcer is a **malignant transformation** that occurs in chronic wounds and scars, which tend to be **long-standing**. - It most commonly leads to the development of **squamous cell carcinoma (SCC)**, and these lesions are generally **slow-growing**. *Squamous cell carcinoma develops* - This statement is true; the most common histological type of malignancy arising in a Marjolin's ulcer is **squamous cell carcinoma (SCC)**. - Less frequently, **basal cell carcinoma** or other sarcomas can also arise, but **SCC** is the predominant form. - The SCC arising in Marjolin's ulcer tends to be **more aggressive** than conventional SCC, with higher rates of **local invasion** and **metastasis**. *Slow growing lesion* - This statement is true; Marjolin's ulcer lesions typically exhibit a **slow growth rate** over an extended period. - This characteristic often contributes to delayed diagnosis, as patients may initially dismiss the changes as non-malignant wound complications. - The latency period can range from **years to decades** after the initial injury. *Develops in long standing scar* - This statement is true; Marjolin's ulcer is defined by its development in areas of **chronic inflammation**, such as **burn scars**, **pressure sores**, **venous stasis ulcers**, and other non-healing wounds. - The latency period for malignant transformation in such scars can range from years to decades, indicating a **long-standing** nature. - **Burn scars** are the most common site, accounting for the majority of cases.
Question 29: In which of the following conditions is neurosurgery not indicated?
- A. Subdural hematoma (SDH)
- B. Epidural hematoma (EDH)
- C. Diffuse axonal injury (DAI) (Correct Answer)
- D. Intracerebral hemorrhage
Explanation: ***Diffuse axonal injury (DAI)*** - Neurosurgery is generally **not indicated** for diffuse axonal injury because the primary damage involves widespread shearing of axons throughout the white matter, rather than a focal, surgically accessible lesion. - Management of DAI is primarily **supportive**, focusing on managing intracranial pressure and optimizing cerebral perfusion, as there is no specific surgical intervention to reverse the axonal damage. *Subdural hematoma (SDH)* - Surgical intervention, such as a **craniotomy** or **burr hole drainage**, is often indicated for acute or subacute subdural hematomas, especially when they are large, causing mass effect, or leading to neurological deterioration. - The goal of surgery is to **evacuate the blood clot** and relieve pressure on the brain. *Epidural hematoma (EDH)* - **Epidural hematomas** are typically surgical emergencies that require urgent craniotomy for evacuation of the hematoma to relieve pressure on the brain. - This is due to their rapid development and tendency to cause significant **mass effect** and brain herniation. *Intracerebral hemorrhage* - Neurosurgery may be indicated for certain types of **intracerebral hemorrhage (ICH)**, particularly those that are superficial, large, causing significant mass effect, or located in a surgically accessible area. - The decision for surgery often depends on the **size and location of the bleed**, the patient's neurological status, and the risk of further deterioration.
Question 30: Which of the following is an example of a clean surgery?
- A. Hernia surgery (Correct Answer)
- B. Cholecystectomy
- C. Rectal surgery
- D. Gastric surgery
Explanation: ***Hernia surgery*** - **Clean surgeries** involve no entry into hollow viscera (e.g., gastrointestinal, genitourinary, or respiratory tract) and are characterized by **no inflammation** or infection. Hernia repair typically fits this description. - The risk of **surgical site infection** (SSI) is usually less than 2% in clean cases, making it a benchmark for surgical infection control. *Gastric surgery* - This involves entry into the **gastrointestinal tract**, which is considered a **contaminated** or **clean-contaminated** procedure due to the presence of bacteria. - The risk of infection is higher than in clean surgeries, often requiring prophylactic antibiotics. *Cholecystectomy* - This procedure involves the **gallbladder**, which is part of the biliary system, often considered a **clean-contaminated** wound if bile spills or if there's no evidence of active infection. - If performed for **acute cholecystitis** (inflammation/infection), it would be classified as **contaminated** or **dirty**. *Rectal surgery* - This involves the **rectum**, which is part of the lower **gastrointestinal tract** and contains a high bacterial load. - Procedures involving the rectum are classified as **contaminated** or **dirty** due to the high risk of bacterial contamination.