UPSC-CMS 2017 - Surgery Practice Questions

Q: All of the following statements are true for keloids EXCEPT:

True keloid does not spread into surrounding tissue. ***True keloid does not spread into surrounding tissue*** - This statement is **incorrect** as a defining characteristic of keloids is their tendency to **spread beyond the original wound boundaries**, invading surrounding healthy tissue. - This expansive growth differentiates keloids from hypertrophic scars, which remain confined to the site of injury. *The maturation and stabilization of the collagen fibrils is inhibited* - This statement is **true**. In keloids, there is an impairment in the normal maturation process of collagen, leading to an accumulation of **immature, disorganized collagen fibrils**. - This abnormal collagen synthesis and degradation contribute to the excessive and persistent fibrosis characteristic of keloids. *It is rarely seen in white skinned persons and is more common over the sternum* - This statement is **true**. Keloids are more prevalent in individuals with **skin of color (e.g., African, Hispanic, and Asian descent)** and are less common in Caucasians. - Common locations for keloids include the **sternum**, earlobes, shoulders, and upper back, areas under significant skin tension. *True keloid continues to become worse even after one year* - This statement is **true**. Unlike hypertrophic scars which may regress over time, keloids tend to be **persistent and progressive**, often continuing to grow and worsen in size and appearance even years after the initial injury. - They typically do not resolve spontaneously and may even recur after excision.

Q: Which of these is a palliative shunt procedure created between the left subclavian artery and pulmonary artery to treat cyanotic congenital heart disease?

Blalock-Taussig shunt. **Blalock-Taussig shunt** - This procedure creates a **systemic-to-pulmonary artery shunt** by anastomosing a systemic artery (often the **subclavian artery**) to the pulmonary artery, increasing **pulmonary blood flow**. - It is a palliative measure for **cyanotic congenital heart diseases** where there is reduced pulmonary blood flow, such as **Tetralogy of Fallot**. *Waterston's shunt* - This is an older, no longer commonly used palliative shunt connecting the **ascending aorta to the right pulmonary artery**. - It was associated with a high incidence of complications, including **pulmonary overcirculation** and **pulmonary vascular disease**. *Lieno renal shunt* - This refers to a shunt created between the **splenic vein (lienal vein)** and the **left renal vein**. - It is primarily used to treat **portal hypertension** by decompressing the portal venous system, not congenital heart disease. *Gott's shunt* - This involves a **temporary bypass shunt** often used during **thoracic aortic surgery** to protect the spinal cord from ischemia. - It maintains blood flow to the distal aorta during aortic clamping and is not related to congenital heart disease palliation.

Q: A young male is undergoing emergency surgery for a clinical diagnosis of acute appendicitis. Intraoperatively minimal pus was found but the appendix was normal. What is the next step of management?

Search for perforated Meckel’s diverticulum. ***Search for perforated Meckel's diverticulum*** - When the appendix appears normal despite a strong clinical suspicion of appendicitis and **minimal pus** is present, it is crucial to investigate for alternative causes of **right lower quadrant pain** and localized peritonitis. - A **Meckel's diverticulum** is the most common congenital anomaly of the gastrointestinal tract (present in ~2% of population) and can mimic appendicitis when inflamed or perforated, necessitating a thorough search in such scenarios. - Standard practice: Examine the **terminal ileum up to 2 feet proximal to the ileocecal valve** to identify Meckel's diverticulum. *Close the abdomen without doing anything* - Closing the abdomen without identifying the source of the minimal pus and the patient's symptoms would be an **incomplete and potentially negligent** approach. - Doing so risks leaving an **undiagnosed and untreated problem**, which could lead to severe complications such as ongoing sepsis or perforation. *Right hemicolectomy* - **Right hemicolectomy** is an extensive surgical procedure typically reserved for conditions like large bowel obstructions, advanced tumors, or severe inflammatory bowel disease. - Performing a right hemicolectomy based on minimal pus and a normal appendix would be an **overly aggressive and inappropriate response** without a clear indication. *Appendectomy* - While an **incidental appendectomy** of a normal-appearing appendix is sometimes performed to prevent future diagnostic confusion, this alone **does not address the immediate problem**. - The critical error here is **failing to identify the source of the pus** that was found intraoperatively. Simply removing a normal appendix leaves the underlying pathology untreated. - The presence of pus mandates a thorough exploration to find its source—most commonly a **Meckel's diverticulum** in this clinical scenario.

Q: A 35 year old woman presented with a lump in her upper abdomen for two months which was slightly increasing. She also complained of early satiety. She gave a history of acute severe pain in upper abdomen for which she was admitted in hospital for 10 days, about three months ago. On examination, the mass was firm, smooth surfaced and not moving with respiration. She was most likely suffering from:

Pseudocyst pancreas. Pseudocyst pancreas - The history of **acute severe upper abdominal pain** followed by a progressively enlarging, firm, smooth-surfaced upper abdominal mass points strongly towards a pancreatic pseudocyst, a common complication of **pancreatitis** [1]. - **Early satiety** can occur due to the mass effect of the pseudocyst compressing the stomach [1]. *Cancer colon* - A rapidly growing upper abdominal mass is **not a typical presentation** of colon cancer, which usually presents with changes in bowel habits, rectal bleeding, or weight loss. - Colon cancer does not typically cause a history of **acute, severe generalized abdominal pain** preceding mass formation in this manner. *Splenic cyst* - While a splenic cyst could present as an abdominal mass, it is **less likely to follow a history of acute severe abdominal pain** (unless trauma-related). - A history of acute pancreatitis is a strong indicator away from a splenic cyst as the primary diagnosis [1]. *Cancer stomach* - Gastric cancer can present with early satiety and an upper abdominal mass, but the specific history of **acute severe pain followed by a mass** is less characteristic of gastric cancer's typical insidious onset. - The "firm, smooth surfaced, not moving with respiration" description, especially in the context of prior pancreatitis, is more aligned with a **pancreatic pseudocyst** [1].

Q: Pringle's manoeuvre is done to stop bleeding at:

Hepatoduodenal ligament. ***Hepatoduodenal ligament*** - **Pringle's manoeuvre** involves clamping the **hepatoduodenal ligament** to temporarily occlude the hepatic artery and portal vein, which are the main blood supply to the liver. - This maneuver is used during **liver surgery** to control or prevent bleeding from the liver parenchyma. *Splenic artery* - The **splenic artery** supplies the spleen and is not directly occluded by Pringle's manoeuvre. - Bleeding from the splenic artery would require direct clamping or **ligation** of that vessel, not compression of the hepatoduodenal ligament. *Renal artery* - The **renal artery** supplies the kidney and is located in the retroperitoneum, far from the liver and the hepatoduodenal ligament. - Pringle's manoeuvre has no effect on blood flow to the kidneys. *Left gastric artery* - The **left gastric artery** supplies the stomach and is a branch of the celiac trunk, which is proximal to the points of compression in Pringle's manoeuvre. - While it is part of the systemic circulation, Pringle's manoeuvre is specific to the blood supply entering the liver via the hepatoduodenal ligament, not individual gastric vessels.

Q: Which of the following is NOT a symptom of atherosclerotic occlusive disease at the bifurcation of aorta (Leriche syndrome)?

Claudication of the calf. ***Claudication of the calf*** - In Leriche syndrome, the occlusion is at the **aortic bifurcation**, affecting blood flow to the iliac arteries and their branches, typically presenting with **buttock and thigh claudication** [1]. - **Calf claudication** alone is usually indicative of more distal occlusive disease, such as in the popliteal or tibial arteries, and not typically the primary or most characteristic symptom of Leriche syndrome [1]. *Sexual impotence* - **Atherosclerotic occlusive disease** at the aortic bifurcation often reduces blood flow to the internal iliac arteries, which supply the penile arteries. - This results in **erectile dysfunction** due to insufficient blood supply during erection, making sexual impotence a characteristic symptom of Leriche syndrome. *Claudication of the buttock and thigh* - The partial or complete blockage of the **aortic bifurcation** impairs blood flow to both common iliac arteries, leading to ischemia in the major muscle groups of the buttocks and thighs [1]. - This **ischemia** manifests as pain, cramping, or fatigue during exercise, which is relieved by rest, making it a classic symptom of Leriche syndrome [1]. *Gangrene localised to the feet* - Severe and chronic **ischemia** resulting from significant atherosclerotic occlusion at the aortic bifurcation can lead to critical limb ischemia, especially in the lower extremities [1]. - Reduced blood flow to the feet can cause tissue necrosis, ultimately leading to **gangrene**, particularly in advanced stages of Leriche syndrome [1].

Q: Vocal cord palsy after thyroid surgery is due to injury to:

Recurrent laryngeal nerve. ***Recurrent laryngeal nerve*** - The **recurrent laryngeal nerves** innervate all intrinsic muscles of the larynx except the cricothyroid muscle, which are responsible for vocal cord movement. - Injury to this nerve during thyroid surgery leads to **vocal cord palsy**, causing hoarseness or aphonia. *Vagus nerve* - The **vagus nerve** is the main trunk from which the recurrent laryngeal nerve branches, but direct injury to the vagus itself is less common in thyroid surgery and would cause widespread symptoms beyond just vocal cord palsy. - Vagus nerve injury would also affect other structures in the neck, thorax, and abdomen, reflecting its broad autonomic and motor functions. *Superior laryngeal nerve* - The **superior laryngeal nerve** innervates the **cricothyroid muscle** (external branch) and provides sensation to the supraglottic larynx (internal branch). - Damage to this nerve causes changes in vocal pitch (due to paralysis of the cricothyroid muscle, which tenses the vocal cords) and problems with voice modulation, but not complete vocal cord paralysis. *Ansa cervicalis* - The **ansa cervicalis** innervates the infrahyoid muscles (strap muscles), which depress the hyoid bone and larynx. - Injury to the ansa cervicalis would affect neck movement and swallowing, but not directly cause vocal cord palsy.

Question 1

All of the following statements are true for keloids EXCEPT:

Accepted Answer

True keloid does not spread into surrounding tissue

Answer

The maturation and stabilization of the collagen fibrils is inhibited

Answer

It is rarely seen in white skinned persons and is more common over the sternum

Answer

True keloid continues to become worse even after one year

Question 2

Which of these is a palliative shunt procedure created between the left subclavian artery and pulmonary artery to treat cyanotic congenital heart disease?

Accepted Answer

Blalock-Taussig shunt

Answer

Waterston's shunt

Answer

Lieno renal shunt

Answer

Gott’s shunt

Question 3

A young male is undergoing emergency surgery for a clinical diagnosis of acute appendicitis. Intraoperatively minimal pus was found but the appendix was normal. What is the next step of management?

Accepted Answer

Search for perforated Meckel’s diverticulum

Answer

Close the abdomen without doing anything

Answer

Right hemicolectomy

Answer

Appendectomy

Question 4

In a 65 year old, double contrast barium enema shows cancer of colon with an apple core appearance. Colonoscopic biopsy shows adenocarcinoma. What will be the next step of management?

Accepted Answer

CECT to stage disease

Answer

Surgery

Answer

Radiotherapy

Answer

Chemotherapy

Question 5

A 35 year old woman presented with a lump in her upper abdomen for two months which was slightly increasing. She also complained of early satiety. She gave a history of acute severe pain in upper abdomen for which she was admitted in hospital for 10 days, about three months ago. On examination, the mass was firm, smooth surfaced and not moving with respiration. She was most likely suffering from:

Accepted Answer

Pseudocyst pancreas

Answer

Cancer colon

Answer

Splenic cyst

Answer

Cancer stomach

Question 6

Pringle's manoeuvre is done to stop bleeding at:

Accepted Answer

Hepatoduodenal ligament

Answer

Splenic artery

Answer

Renal artery

Answer

Left gastric artery

Question 7

Which of the following is NOT a symptom of atherosclerotic occlusive disease at the bifurcation of aorta (Leriche syndrome)?

Accepted Answer

Claudication of the calf

Answer

Sexual impotence

Answer

Claudication of the buttock and thigh

Answer

Gangrene localised to the feet

Question 8

Vocal cord palsy after thyroid surgery is due to injury to:

Accepted Answer

Recurrent laryngeal nerve

Answer

Vagus nerve

Answer

Superior laryngeal nerve

Answer

Ansa cervicalis

UPSC-CMS 2017 — Surgery