UPSC-CMS 2020 - Surgery Practice Questions

Q: Left Internal Mammary Artery (LIMA) has become the conduit of choice for Left Anterior Descending (LAD) artery during coronary artery bypass grafting because:

Long term patency rates are superior (>90% at 10 years). ***Long term patency rates are superior (>90% at 10 years)*** - The superior **long-term patency rates** (over 90% at 10 years) of the **Left Internal Mammary Artery (LIMA)** when anastomosed to the **Left Anterior Descending (LAD) artery** are the primary reason for it being the conduit of choice. - This excellent patency is attributed to its **endothelial** properties and **resistance to atherosclerosis**, contributing to improved patient outcomes and survival. *Atherosclerosis is never seen in this vessel* - While the LIMA is significantly **more resistant to atherosclerosis** compared to saphenous veins, it is not entirely immune. - Atherosclerosis can still occur in the LIMA, though it is far less common and less severe than in other graft conduits. *It is very easy to harvest* - Harvesting the LIMA requires a skilled surgical technique and is **not considered "very easy."** - It involves careful dissection to preserve the conduit's integrity and includes potential complications like **sternal wound infections** due to altered blood supply. *It is close to LAD* - While the anatomical proximity of the LIMA to the LAD is a favorable factor, making the anastomosis geographically convenient, it is **not the primary reason** for its widespread use. - The primary driving factor is the superior long-term patency, which directly impacts patient morbidity and mortality.

Q: A 50-year old male with significant smoking history presented in the surgical emergency with sudden severe breathlessness. Chest X-ray shows right sided Pneumothorax. The appropriate management requires:

Right chest drain of size 8-14 Fr. ***Right chest drain of size 8-14 Fr*** - **Secondary spontaneous pneumothorax (SSP)** in a smoker with severe breathlessness requires **chest drain insertion** as first-line treatment to evacuate trapped air and allow lung re-expansion. - A **small-bore chest drain (8-14 Fr)** is preferred as it provides effective drainage with reduced patient discomfort and lower complication rates compared to large-bore tubes. *Oxygen by face mask* - **Oxygen therapy** is supportive care that may accelerate **pleural air resorption** but does not actively remove trapped air from the pleural space. - It is **insufficient as primary treatment** for symptomatic pneumothorax, especially in secondary spontaneous pneumothorax which requires active intervention. *Aspiration of air with 16-18 G cannula* - **Needle aspiration** is typically reserved for **primary spontaneous pneumothorax** in young, healthy patients or as emergency decompression for tension pneumothorax. - In **secondary spontaneous pneumothorax** (especially with underlying lung disease from smoking), chest drain insertion is preferred over needle aspiration due to higher success rates and lower recurrence. *Mechanical ventilation* - **Positive pressure ventilation** can worsen pneumothorax by increasing **intrathoracic pressure** and potentially converting simple pneumothorax to tension pneumothorax. - Mechanical ventilation is only indicated if patient develops **respiratory failure** despite appropriate pneumothorax management or in cases of hemodynamic instability.

Q: Which one of the following statements regarding Felon is NOT correct?

It is a painless condition. ***It is a painless condition*** - A **felon** is an abscess within the distal phalanx (fingertip) confined by fibrous septa, making it an extremely **painful** and tense infection due to increased pressure. - The severe pain is a hallmark symptom, distinguishing it from a painless condition, and is caused by the pus accumulating in a confined space. *It is common in diabetics* - **Felons** (and other soft tissue infections) are indeed more common in individuals with **diabetes mellitus** due to impaired immune function and compromised circulation. - This makes diabetics more susceptible to infections and can also lead to more severe outcomes. *Incision and drainage is the treatment of choice* - For a **felon**, **surgical incision and drainage** is the primary treatment to relieve pressure, evacuate pus, and prevent serious complications like osteomyelitis or necrosis. - This procedure typically involves a longitudinal or hockey-stick incision to access the infected compartment. *There is infection of the finger tip between specialised fibrous septa* - A **felon** is an infection, typically bacterial, located in the closed compartments of the fingertip's distal pulp, which are separated by **fibrous septa**. - These septa connect the skin to the periosteum, creating multiple small, enclosed spaces that can become acutely infected and filled with pus.

Q: Which of the following statements regarding lymphoedema following breast cancer treatment are correct? 1. Incidence has decreased due to rarely combined therapy of axillary LN dissection and radiotherapy 2. Precipitating cause like LN metastasis is a major determinant 3. The condition is often painful 4. Oedematous limb is susceptible to bacterial infection Select the correct answer using the code given below:

1, 2 and 4. ***Correct: 1, 2 and 4*** **Statement 1 is correct:** The incidence of post-treatment lymphoedema has decreased primarily due to the shift from routine **axillary lymph node dissection (ALND)** to **sentinel lymph node biopsy (SLNB)**. The combined therapy of ALND and radiotherapy, historically a major risk factor, is now rarely used, significantly reducing lymphoedema incidence. **Statement 2 is correct:** The presence of **lymph node metastases** is a major precipitating factor as it necessitates more extensive surgery (ALND) and/or radiation therapy, increasing the risk of lymphatic damage and subsequent lymphoedema. **Statement 4 is correct:** The oedematous limb has impaired lymphatic drainage leading to reduced immune surveillance and skin changes, making it highly **susceptible to bacterial infections** like cellulitis and erysipelas. *Statement 3 is incorrect:* Lymphoedema itself is typically **not acutely painful** but may cause a feeling of heaviness, tightness, or discomfort. Pain usually indicates complications such as bacterial infection (cellulitis), not the lymphoedema itself. Therefore, statements 1, 2, and 4 are correct, making option **"1, 2 and 4"** the correct answer.

Q: Which one of the following is NOT a risk factor for development of venous thrombosis in surgical patients?

Male gender. ***Male gender*** - While there may be slight differences in **VTE incidence** between sexes, male gender is **not considered an independent risk factor** for venous thrombosis in surgical patients; rather, other comorbidities or specific surgical procedures are more influential. - Risk factors like **age, obesity, and pregnancy** are well-established and significantly increase the risk of thrombosis, unlike male gender. *Age > 60 years* - **Advancing age** is a significant risk factor for venous thrombosis due to age-related changes in coagulation factors, endothelial function, and reduced mobility. - Older patients undergoing surgery have a higher likelihood of developing **deep vein thrombosis (DVT)** and **pulmonary embolism (PE)**. *Obesity (BMI > 30 kg/m2)* - **Obesity** is a well-established risk factor for venous thrombosis due to chronic inflammation, endothelial dysfunction, and increased procoagulant factors. - Obese surgical patients have a higher risk of **VTE** compared to those with a normal BMI. *Pregnancy* - **Pregnancy** is a hypercoagulable state due to hormonal changes, increased coagulation factors, and venous stasis, significantly increasing the risk of venous thrombosis. - The risk of VTE is elevated throughout pregnancy and the **postpartum period**, especially after surgical interventions like Cesarean sections.

Q: Which one of the following is NOT a complication of massive blood transfusion?

Hyperthermia. ***Hyperthermia*** - **Hypothermia** is a more common complication of massive blood transfusion due to the administration of large volumes of cold blood products. - While theoretical, hyperthermia in this context would be rare and not a direct complication of the blood components themselves, unless equipment malfunction or infection occurs. [1] *Hyperkalemia* - Stored red blood cells **leak potassium** as they age, leading to higher potassium levels in the transfusion product. - Rapid infusion of large volumes can overwhelm the body's compensatory mechanisms, resulting in **elevated serum potassium**. *Hypocalcaemia* - **Citrate**, an anticoagulant used in blood storage, binds to ionized calcium in the recipient's blood. - Massive transfusions can lead to significant citrate accumulation, causing a drop in **ionized calcium levels**. *Coagulopathy* - Massive transfusions dilute clotting factors and platelets, which are not proportionally replaced in standard transfusion protocols. - This dilution can lead to impaired **hemostasis** and increased bleeding tendencies. [1]

Q: Stage III "Pressure sore" is full thickness skin loss extending:

into subcutaneous tissue but not through fascia. ***into subcutaneous tissue but not through fascia*** - A **Stage III pressure ulcer** involves **full-thickness skin loss** with damage or necrosis of **subcutaneous tissue** that may extend down to, but **NOT through**, the underlying fascia. - The ulcer presents as a **deep crater** with or without undermining of adjacent tissue, slough, or eschar. - **Muscle, tendon, and bone are NOT visible or directly palpable** in Stage III ulcers. *through subcutaneous tissue into fascia* - This description is **too deep** for Stage III; fascia penetration indicates **Stage IV**. - Stage III extends **to** the fascia but does **not penetrate through** it. *through subcutaneous tissue into fascia and muscles* - This is the definition of a **Stage IV pressure ulcer**, not Stage III. - **Muscle exposure** indicates full-thickness tissue loss beyond the subcutaneous layer and signifies Stage IV. *through subcutaneous tissue into fascia, muscles and bone* - This is also **Stage IV** (most severe form with bone, tendon, or muscle exposure). - **Bone exposure** is pathognomonic of Stage IV pressure ulcers and never occurs in Stage III.

Q: During subclavian vein puncture in a surgical ward suddenly a patient developed severe breathlessness. On auscultation breath sound was absent and the ipsilateral chest was tympanitic on percussion. The probable diagnosis is:

Iatrogenic pneumothorax. ***Iatrogenic pneumothorax*** - The sudden onset of breathlessness after **subclavian vein puncture** points towards an iatrogenic cause due to accidental pleural injury. - **Absent breath sounds** and **tympanitic percussion** on the ipsilateral side are classic signs of air in the pleural space. *Tension pneumothorax* - While it shares features of pneumothorax, **tension pneumothorax** would typically present with **tracheal deviation**, severe hypotension, and signs of cardiovascular collapse due to mediastinal shift. - The description lacks these critical signs of hemodynamic instability and significant mediastinal compression. *Spontaneous pneumothorax* - **Spontaneous pneumothorax** occurs without any preceding trauma or medical procedure, usually due to rupture of subpleural blebs. - The history of a recent **subclavian vein puncture** makes an iatrogenic cause much more likely than a spontaneous event. *Iatrogenic hemothorax* - **Iatrogenic hemothorax** would also be a complication of subclavian vein puncture, but it would present with **dullness to percussion** instead of tympany, and signs of hypovolemic shock if severe. - The **tympanitic percussion** directly indicates the presence of air, not blood, in the pleural cavity.

Q: Which of the following is NOT a tissue repair surgery for inguinal hernia repair?

Stoppa's repair. ***Stoppa's repair*** - Stoppa's repair is a type of **giant prosthetic reinforcement of the visceral sac (GPRVS)**, which involves placing a large sheet of **synthetic mesh** in the preperitoneal space to buttress the entire myopectineal orifice. - This technique is primarily a **mesh repair** and thus not considered a pure tissue repair method. *Bassini's repair* - This is a classic **tissue repair** method where the conjoint tendon is sutured to the inguinal ligament, reinforcing the posterior wall of the inguinal canal. - It involves using the patient's own tissues without the implantation of synthetic mesh. *Shouldice repair* - Considered a gold standard among **tissue repairs**, it involves a multi-layered reconstruction of the posterior wall of the inguinal canal by approximating the transversalis fascia, conjoint tendon, and iliopubic tract. - The Shouldice repair also avoids the use of mesh. *Desarda repair* - This is a newer **tissue repair** method that utilizes a strip of the external oblique aponeurosis to create a new posterior wall for the inguinal canal. - It is promoted as a tension-free repair that does not use foreign mesh materials.

Q: Which one of the following type of meshes is recommended for intraperitoneal use in abdominal wall hernia?

Tissue separating meshes. ***Correct: Tissue separating meshes*** - These meshes are designed with a **non-adherent barrier** on one side to prevent visceral adhesions when placed intraperitoneally. - They are essential for intraperitoneal hernia repair to avoid complications like **bowel obstruction** or **fistula formation**. - Examples include **Parietex Composite, Proceed, and Composix** meshes. *Incorrect: Light weight, porous meshes* - While generally preferred for tension-free repair due to reduced foreign body reaction, they **lack an anti-adhesive barrier** for intraperitoneal use. - Their direct contact with abdominal viscera can lead to **adhesion formation**, which is a significant complication. *Incorrect: Absorbable meshes* - These meshes are intended for temporary support and are eventually broken down and absorbed by the body. - Their complete absorption means they **do not provide long-term reinforcement** or prevent hernia recurrence, which is crucial for permanent repair. *Incorrect: Heavy weight, porous meshes* - These meshes are associated with a **higher foreign body reaction**, leading to more inflammation, pain, and mesh contraction. - They also **lack the necessary anti-adhesive coating** for safe intraperitoneal placement, increasing the risk of visceral adhesions.

Question 1

Left Internal Mammary Artery (LIMA) has become the conduit of choice for Left Anterior Descending (LAD) artery during coronary artery bypass grafting because:

Accepted Answer

Long term patency rates are superior (>90% at 10 years)

Answer

Atherosclerosis is never seen in this vessel

Answer

It is very easy to harvest

Answer

It is close to LAD

Question 2

A 50-year old male with significant smoking history presented in the surgical emergency with sudden severe breathlessness. Chest X-ray shows right sided Pneumothorax. The appropriate management requires:

Accepted Answer

Right chest drain of size 8-14 Fr

Answer

Mechanical ventilation

Answer

Aspiration of air with 16-18 G cannula

Answer

Oxygen by face mask

Question 3

Which one of the following statements regarding Felon is NOT correct?

Accepted Answer

It is a painless condition

Answer

It is common in diabetics

Answer

Incision and drainage is the treatment of choice

Answer

There is infection of the finger tip between specialised fibrous septa

Question 4

Which of the following statements regarding lymphoedema following breast cancer treatment are correct?

1. Incidence has decreased due to rarely combined therapy of axillary LN dissection and radiotherapy
2. Precipitating cause like LN metastasis is a major determinant
3. The condition is often painful
4. Oedematous limb is susceptible to bacterial infection

Select the correct answer using the code given below:

Accepted Answer

1, 2 and 4

Answer

1, 3 and 4

Answer

2, 3 and 4

Answer

1, 2 and 3

Question 5

Which one of the following is NOT a risk factor for development of venous thrombosis in surgical patients?

Accepted Answer

Male gender

Answer

Age > 60 years

Answer

Obesity (BMI > 30 kg/m2 )

Answer

Pregnancy

Question 6

Which one of the following is NOT a complication of massive blood transfusion?

Accepted Answer

Hyperthermia

Answer

Hyperkalemia

Answer

Hypocalcaemia

Answer

Coagulopathy

Question 7

Stage III "Pressure sore" is full thickness skin loss extending:

Accepted Answer

into subcutaneous tissue but not through fascia

Answer

through subcutaneous tissue into fascia, muscles and bone

Answer

through subcutaneous tissue into fascia

Answer

through subcutaneous tissue into fascia and muscles

Question 8

During subclavian vein puncture in a surgical ward suddenly a patient developed severe breathlessness. On auscultation breath sound was absent and the ipsilateral chest was tympanitic on percussion. The probable diagnosis is:

Accepted Answer

Iatrogenic pneumothorax

Answer

Tension pneumothorax

Answer

Spontaneous pneumothorax

Answer

Iatrogenic hemothorax

Question 9

Which of the following is NOT a tissue repair surgery for inguinal hernia repair?

Accepted Answer

Stoppa's repair

Answer

Bassini's repair

Answer

Shouldice repair

Answer

Desarda repair

Question 10

Which one of the following type of meshes is recommended for intraperitoneal use in abdominal wall hernia?

Accepted Answer

Tissue separating meshes

Answer

Absorbable meshes

Answer

Heavy weight, porous meshes

Answer

Light weight, porous meshes

UPSC-CMS 2020 — Surgery