NEET-PG 2024 - Surgery Practice Questions

Q: In the intraoperative image of congenital hernia repair, the structure marked by the red arrow is identified as which of the following?

Testicular vein. ***Testicular vein*** - The **testicular vein** is clearly visible within the **spermatic cord** structures, which are typically identified and often dissected during congenital hernia repair. - Its position coursing with the testicular artery and vas deferens is consistent with its anatomical location within the inguinal canal. *Femoral vein* - The **femoral vein** lies more inferiorly and medially within the femoral canal, distinct from the inguinal canal contents visualized in this image. - Identification of the femoral vein would be in the context of a femoral hernia repair, not typically a congenital (indirect inguinal) hernia. *Obturator vein* - The **obturator vein** is located deep within the pelvis, accompanying the obturator nerve and artery through the obturator foramen. - It is not typically encountered or visible during a standard open or laparoscopic inguinal hernia repair. *Inferior epigastric vein* - The **inferior epigastric vein** runs superiorly and medially, forming the medial border of the **inguinal triangle (Hesselbach's triangle)**. - While it's an important landmark in hernia repair (differentiating direct vs. indirect hernias), its anatomical position and trajectory are distinct from the structure indicated by the arrow, which is part of the spermatic cord.

Q: How does a skin graft receive nutrition on day 3 after transplantation?

Inosculation. ***Inosculation*** - **Inosculation** is the process where host capillaries directly connect with the graft's existing vessels (or newly formed ones) around day 2-3 post-transplantation. - This establishes blood flow and is the primary mechanism for **nutrient delivery** and waste removal by day 3. *Imbibition* - **Imbibition** is the initial phase (first 24-48 hours) where the graft passively absorbs nutrients from the recipient bed through diffusion. - While essential for initial survival, it is typically insufficient for sustained graft viability by day 3. *Neovascularization* - **Neovascularization** involves the formation of entirely new blood vessels into the graft, a process that typically begins after inosculation and continues for several days to weeks. - On day 3, while *initiation* of new vessel formation may be occurring, the main nutritional support is primarily from established connections through inosculation. *A & B* - While **imbibition** plays a role in the initial survival of the graft, by day 3, **inosculation** is the dominant and more effective mechanism for nutrient supply. - Therefore, selecting both A and B would be incorrect as imbibition's role diminishes significantly as inosculation progresses.

Q: A patient presents with constant chest pain, and the radiological finding is as shown in the image. What is the most appropriate management?

Surgical management. ***Surgical management*** - The chest X-ray shows a **widened mediastinum** and abnormal aortic contour, highly suggestive of **aortic dissection involving the ascending aorta (Type A)**. - **Type A aortic dissection** (involving the ascending aorta) is a **surgical emergency** requiring immediate operative repair to prevent life-threatening complications such as cardiac tamponade, acute aortic regurgitation, or rupture. - The constant chest pain with these radiological findings indicates urgent surgical intervention is the definitive management. *Vasodilator* - Vasodilators **alone** should never be used in aortic dissection as they can increase aortic wall shear stress and propagate the dissection. - They must always be preceded by beta-blockade to prevent reflex tachycardia. - Vasodilators do not address the structural defect requiring surgical correction in Type A dissection. *Beta blocker* - Beta-blockers are essential for **initial medical stabilization** to reduce heart rate (target <60 bpm) and blood pressure, thereby decreasing aortic wall stress (dP/dt). - However, in **Type A dissection**, beta-blockers alone do not address the structural defect and are used as a bridge to emergency surgery, not as definitive treatment. - For Type B dissections (descending aorta), medical management with beta-blockers may be definitive in uncomplicated cases. *Beta blocker plus vasodilator* - This combination represents optimal **medical management** for blood pressure and heart rate control in aortic dissection. - In **Type B (descending) aortic dissections**, this is often the definitive treatment for uncomplicated cases. - However, in **Type A dissections** (as indicated by the widened mediastinum suggesting ascending aortic involvement), this serves only as initial stabilization before **mandatory surgical repair**, not as definitive therapy. - Surgery cannot be delayed in Type A dissection due to high mortality risk (1-2% per hour).

Q: Identify the procedure shown in the image, which is performed in a patient with recurrent GERD.

Nissen fundoplication. ***Nissen fundoplication*** - The image clearly depicts the **fundus of the stomach** being wrapped completely around the lower esophagus and sutured in place, which is the hallmark of a **360-degree Nissen fundoplication**. - This procedure aims to strengthen the **lower esophageal sphincter (LES)** to prevent reflux in patients with recurrent GERD. *Partial gastrectomy* - This procedure involves the **surgical removal of a portion of the stomach** and is typically performed for conditions like gastric cancer or severe ulcers, not primarily for GERD. - The image shows the stomach intact and being wrapped, not resected. *Esophageal banding* - Esophageal banding is a procedure used to treat **esophageal varices** by placing elastic bands around dilated veins, not a surgical intervention for GERD that alters stomach anatomy. - The image shows a gastric maneuver, not banding of the esophagus. *Toupet fundoplication* - A Toupet fundoplication involves a **partial (270-degree) wrap** of the fundus around the esophagus, leaving a small portion unwrapped. - The image distinctly illustrates a **complete 360-degree wrap**, distinguishing it from a Toupet fundoplication.

Q: A patient presents with a penile lesion staged as T3, with clinically palpable lymph nodes. What is the most appropriate management?

Penectomy with deep ilioinguinal node dissection. ***Penectomy with deep ilioinguinal node dissection*** - A **T3 penile lesion** indicates invasion of the corpus cavernosum or corpus spongiosum, which is an aggressive stage requiring **radical local excision (penectomy)**. - **Clinically palpable lymph nodes** alongside a T3 tumor suggest nodal involvement (N1-N3), necessitating a **deep ilioinguinal lymph node dissection** to remove affected deeper lymph nodes that are not readily accessible by superficial dissection. *Penectomy* - While penectomy addresses the primary tumor, it does not manage the **clinically palpable lymph nodes**, which are crucial for staging and prognosis in advanced penile cancer. - This option would be insufficient given the documented **nodal involvement**, leading to likely recurrence and progression of the disease. *Penectomy with superficial node dissection* - This approach is inadequate for **palpable lymph nodes**, especially with a T3 lesion, because such nodes often indicate involvement of **deeper lymphatics (deep ilioinguinal)**. - Superficial dissection alone would likely leave residual disease, failing to properly stage and treat the extent of the cancer. *Chemoradiotherapy* - **Chemoradiotherapy** is typically reserved for patients who are not surgical candidates, or as a neoadjuvant/adjuvant therapy, not as primary treatment for a **T3 lesion with palpable nodes** where surgical intervention is the standard of care for optimal local and regional control. - While it may be used in certain settings, surgery (penectomy with lymph node dissection) offers the best chance for cure in this scenario.

Q: Tubectomy is typically performed on which part of the fallopian tube and why?

Isthmus - narrowest. ***Isthmus - narrowest*** - The **isthmus** is preferred for tubectomy because its **narrowest diameter** and thick muscular wall make it easier to ligate and minimize recanalization. - Its narrow lumen also reduces the chances of spontaneous rejoining and pregnancy, ensuring a more effective and permanent sterilization. *Ampulla - uniform thickness of muscle* - The **ampulla** is a wider, more distensible part of the fallopian tube, making it **less suitable for ligation** due to a higher risk of recanalization. - While tubular muscle thickness is a factor, the **ampulla's larger lumen** makes it less ideal for effective and permanent occlusion compared to the isthmus. *Ampulla - widest* - The **ampulla's wider diameter** increases the technical difficulty of creating a secure and permanent occlusion, as ligating a broad segment is less effective. - A wider lumen makes **spontaneous recanalization** more likely, compromising the contraceptive efficacy of the procedure. *Isthmus - uniform thickness of muscle* - While the isthmus does have a relatively **uniform and thick muscular wall**, it is the **narrowness of the lumen** that is the primary reason for its selection in tubectomy. - The consistency of its muscle is a contributing factor to its robustness, but the **small caliber** is key to preventing recanalization.

Q: A patient presents with fecal discharge from the umbilicus. What is the most likely diagnosis?

Patent vitelline duct. ***Patent vitelline duct*** - **Fecal discharge from the umbilicus** indicates a persistent communication between the **ileum** and the **umbilicus** through a patent vitelline (omphalomesenteric) duct. - This congenital anomaly represents a remnant of the **omphalomesenteric duct** that **completely failed to involute**, creating a **fistulous tract** allowing intestinal contents to exit through the umbilicus. - This is the **most complete form** of vitelline duct persistence (other forms include Meckel's diverticulum, fibrous band, or umbilical polyp). *Urachal fistula* - A urachal fistula occurs when the **urachus** remains patent, creating a connection between the **bladder** and the umbilicus. - While it can result in umbilical discharge, the discharge would be **urine**, not feces. *Omphalocele* - An omphalocele is a **congenital abdominal wall defect** where abdominal contents protrude into a sac at the base of the umbilicus. - It does not involve a fistulous communication with intestines causing fecal discharge, but rather a **herniation** of organs covered by a peritoneal membrane. *Gastroschisis* - Gastroschisis is a congenital anomaly characterized by the **protrusion of abdominal organs** directly into the amniotic cavity **without a covering sac**, usually to the **right of the umbilicus**. - Like omphalocele, it's a **herniation defect** presenting at birth and does not involve an abnormal fistulous connection causing fecal discharge from the umbilicus.

Q: Which of the following is not seen with ileal resections?

Cognitive improvement. ***Cognitive improvement*** - Ileal resections are associated with malabsorption of various nutrients, but they do not lead to **cognitive improvement**. In fact, nutrient deficiencies (particularly B12) can negatively impact cognitive function. - The effects of ileal resections are primarily related to **digestion** and **absorption**, causing symptoms like diarrhea, weight loss, and specific vitamin deficiencies, not enhanced brain function. - This is the **most obvious answer** to what is "not seen" with ileal resections. *Microcytic hypochromic anemia* - This type of anemia is caused by **iron deficiency**, which is **NOT a direct consequence** of ileal resection. - **Iron absorption** occurs primarily in the **duodenum and proximal jejunum**, not in the ileum. - Ileal resection typically causes **macrocytic anemia** (due to B12 deficiency), not microcytic anemia. - While microcytic anemia could occur indirectly from chronic blood loss in inflammatory bowel disease, it is not a characteristic feature of ileal resection itself. *Nuclear cytological asynchrony* - **Nuclear cytological asynchrony** (megaloblastic changes) is a **direct consequence** of **vitamin B12 deficiency**, which commonly results from terminal ileal resection. - The **terminal ileum** is the primary site for absorption of **vitamin B12** (cobalamin) bound to intrinsic factor. - This manifests as macrocytic anemia with characteristic bone marrow changes. *Neurological manifestation* - **Vitamin B12 deficiency**, resulting from impaired absorption after ileal resection, directly causes various **neurological symptoms**. - These include **peripheral neuropathy**, **subacute combined degeneration of the spinal cord** (posterior and lateral columns), paresthesias, ataxia, memory impairment, and cognitive changes. - Neurological symptoms may occur even before hematological changes become apparent.

Q: A nasal surgery was carried out with the incision shown in the image. What was the procedure likely carried out?

Open rhinoplasty. ***Open rhinoplasty*** - The image displays a **transcolumellar incision** (typically inverted V or W-shaped), which is the hallmark approach for **open rhinoplasty**. - This incision allows for direct visualization of the underlying nasal cartilages and bones, enabling precise reshaping of the nose. *Submucosal resection (SMR)* - SMR is a procedure to correct a **deviated nasal septum** by removing cartilage or bone from beneath the mucoperichondrial flaps. - It involves an **intranasal incision**, usually along the septal mucosa, not an external transcolumellar incision. *FESS (Functional Endoscopic Sinus Surgery)* - FESS is a minimally invasive procedure used to treat **chronic sinusitis** and other sinus conditions. - It is performed entirely **endoscopically through the nostrils**, with no external incisions on the nasal columella. *Caldwell-Luc's procedure* - This procedure accesses the **maxillary sinus** through an incision in the upper gum beneath the lip. - It is used for drainage of the maxillary sinus or removal of foreign bodies/tumors, and does not involve an external nasal incision.

Question 1

In the intraoperative image of congenital hernia repair, the structure marked by the red arrow is identified as which of the following?

Accepted Answer

Testicular vein

Answer

Femoral vein

Answer

Obturator vein

Answer

Inferior epigastric vein

Question 2

An elderly patient presents with a non-healing ulcerative lesion on the lower lip, as shown in the image. The lesion has been gradually enlarging over the past few months. Suspecting squamous cell carcinoma (SCC), what is the most appropriate method to obtain a biopsy for definitive diagnosis?

Accepted Answer

Incisional

Answer

Excisional

Answer

Deep tissue biopsy

Answer

Superficial biopsy from the border with normal tissue

Question 3

How does a skin graft receive nutrition on day 3 after transplantation?

Accepted Answer

Inosculation

Answer

Imbibition

Answer

Neovascularization

Answer

A & B

Question 4

A patient presents with constant chest pain, and the radiological finding is as shown in the image. What is the most appropriate management?

Accepted Answer

Surgical management

Answer

Vasodilator

Answer

Beta blocker

Answer

Beta blocker plus vasodilator

Question 5

Identify the procedure shown in the image, which is performed in a patient with recurrent GERD.

Accepted Answer

Nissen fundoplication

Answer

Partial gastrectomy

Answer

Esophageal banding

Answer

Toupet fundoplication

Question 6

A patient presents with a penile lesion staged as T3, with clinically palpable lymph nodes. What is the most appropriate management?

Accepted Answer

Penectomy with deep ilioinguinal node dissection

Answer

Penectomy

Answer

Penectomy with superficial node dissection

Answer

Chemoradiotherapy

Question 7

Tubectomy is typically performed on which part of the fallopian tube and why?

Accepted Answer

Isthmus - narrowest

Answer

Ampulla - uniform thickness of muscle

Answer

Ampulla - widest

Answer

Isthmus - uniform thickness of muscle

Question 8

A patient presents with fecal discharge from the umbilicus. What is the most likely diagnosis?

Accepted Answer

Patent vitelline duct

Answer

Urachal fistula

Answer

Omphalocele

Answer

Gastroschisis

Question 9

Which of the following is not seen with ileal resections?

Accepted Answer

Cognitive improvement

Answer

Microcytic hypochromic anemia

Answer

Nuclear cytological asynchrony

Answer

Neurological manifestation

Question 10

A nasal surgery was carried out with the incision shown in the image. What was the procedure likely carried out?

Accepted Answer

Open rhinoplasty

Answer

Submucosal resection (SMR)

Answer

FESS (Functional Endoscopic Sinus Surgery)

Answer

Caldwell-Luc's procedure

NEET-PG 2024 — Surgery