UPSC-CMS 2023 - Surgery Practice Questions

Q: The best cosmetic result following breast reconstruction is achieved with :

Transverse rectus abdominis myocutaneous flap. ***Transverse rectus abdominis myocutaneous flap*** - The **TRAM flap** offers excellent aesthetic outcomes by utilizing the patient's own **abdominal tissue**, providing a natural look and feel that mimics breast tissue. - This method results in a soft, pliable breast mound with good long-term stability and can provide a **simultaneous abdominoplasty** effect. *Latissimus dorsi flap* - While a viable option, the **latissimus dorsi flap** is typically smaller and may require an **implant** to achieve adequate breast volume, potentially leading to a less natural result than a TRAM flap. - It uses tissue from the back, which can leave a noticeable scar and may cause **weakness in the shoulder** or back. *Silicone gel implant with reconstruction* - Implants can provide good cosmetic results but carry risks such as **capsular contracture**, rupture, and the need for future revisions, which can affect long-term satisfaction. - They do not offer the same **natural feel or warmth** as autologous tissue reconstruction, as the reconstructed breast is not made of living tissue. *Acellular dermal matrix flap* - **Acellular dermal matrix (ADM)** is often used as an adjunct in implant-based reconstruction to support and reinforce the breast tissue, rather than as a primary reconstructive flap for optimal cosmetic results. - While it aids in tissue expansion and support, it does not provide the **volume or natural contour** that an autologous flap like the TRAM can achieve on its own.

Q: Which of the following statements with regard to Colorectal Carcinoma are correct ? 1. Left-sided Colorectal Carcinoma presents with bleeding per rectum. 2. Right-sided Colorectal Carcinoma presents with iron deficiency anaemia. 3. Right-sided Colorectal Carcinoma is more common as compared to the left-sided Colorectal Carcinoma. 4. Colonoscopy is the investigation of choice for suspected Colorectal Carcinoma. Select the correct answer using the code given below :

1, 2 and 3. ***1, 2 and 4*** - **Left-sided colorectal carcinoma** often presents with **bleeding per rectum** due to its proximity to the anus [1]. - **Right-sided colorectal carcinoma** is more likely to cause insidious blood loss, leading to **iron deficiency anemia** [1]. - **Colonoscopy** is considered the **gold standard** for diagnosing colorectal carcinoma due to its ability to visualize the entire colon and allow for biopsy [1]. *2, 3 and 4* - While statements 2 and 4 are correct, statement 3 is incorrect. **Left-sided colorectal carcinoma is more common** than right-sided colorectal carcinoma [1]. - Right-sided lesions more generally cause anemia, and colonoscopy is the appropriate investigation of choice [1]. *1, 2 and 3* - Statements 1 and 2 are correct. However, statement 3 is incorrect; **left-sided colorectal carcinoma has a higher incidence** compared to right-sided colorectal carcinoma [1]. - Bleeding per rectum is characteristic of left-sided lesions while iron deficiency anemia for right-sided lesions [1]. *1, 3 and 4* - While statements 1 and 4 are correct, statement 3 is incorrect. **Left-sided colorectal carcinoma is more prevalent** than right-sided colorectal carcinoma [1]. - Clinical presentation with bleeding per rectum is typical for left-sided cancers, and colonoscopy is the definitive diagnostic tool [1].

Q: While managing oesophageal perforations, which of the following factors favour non-operative management? 1. Perforation by a flexible endoscope 2. Contained perforation without free communication 3. Perforation with a small septic load 4. Perforation of the abdominal oesophagus Select the correct answer using the code given below:

1, 2 and 3. ***1, 2 and 3*** - **Perforation by a flexible endoscope** often results in smaller, less destructive perforations due to the instrument's flexibility, making non-operative management feasible if other favorable conditions are met. - **Contained perforation without free communication** implies that the leak is localized and not actively spreading into surrounding tissues, reducing the risk of widespread mediastinitis or peritonitis. - **Perforation with a small septic load** indicates minimal contamination, which simplifies management and improves the chances of successful non-operative treatment through antibiotics and supportive care. *1, 3 and 4* - This option correctly identifies factors 1 and 3, but **perforation of the abdominal esophagus** is generally treated surgically due to the high risk of widespread peritonitis and severe sepsis. - While smaller perforations are more manageable, the anatomical location in the abdominal cavity predisposes to rapid and severe contamination. *2, 3 and 4* - This option correctly includes factors 2 and 3 that favor non-operative management but incorrectly suggests that **perforation of the abdominal esophagus** is managed non-operatively. - The high risk of peritonitis from an abdominal oesophageal perforation often necessitates surgical intervention to prevent severe complications. *1, 2 and 4* - This option correctly identifies factors 1 and 2 but mistakenly includes **perforation of the abdominal esophagus** as a factor favoring non-operative management. - Abdominal oesophageal perforations are high-risk situations generally requiring early surgical repair to prevent life-threatening complications.

Q: A Sengstaken-Blakemore tube is used for the management of :

Variceal bleeding. ***Variceal bleeding*** - A **Sengstaken-Blakemore tube** is specifically designed with gastric and esophageal balloons to apply direct pressure and tamponade **bleeding esophageal varices**, a common complication of portal hypertension. - It is utilized as a temporary measure to control severe hemorrhage when endoscopic interventions fail or are unavailable. *Corrosive poisoning* - Management of corrosive poisoning focuses on **supportive care**, pain management, and preventing further injury; a Sengstaken-Blakemore tube is not indicated. - Using such a tube could potentially worsen esophageal damage or perforation in corrosive injuries. *Tension pneumothorax* - A tension pneumothorax is a **thoracic emergency** requiring immediate **needle decompression** or chest tube insertion. - A Sengstaken-Blakemore tube is an upper gastrointestinal device and has no role in managing pulmonary conditions. *Asphyxia* - Asphyxia involves a lack of oxygen and is managed by establishing an **open airway**, providing ventilation, and addressing the underlying cause. - A Sengstaken-Blakemore tube is irrelevant to the treatment of asphyxia.

Q: A young 28-year-old male was operated for duodenal ulcer perforation peritonitis. After having recovered well for five days, he developed high fever with chills and symptoms of toxemia. He developed right shoulder tip pain and intractable hiccoughs. The most likely diagnosis is :

Subphrenic abscess. ***Subphrenic abscess*** - The development of **high fever with chills**, **toxemia**, **right shoulder tip pain**, and **intractable hiccups** following a duodenal ulcer perforation repair strongly suggests a subphrenic abscess. - **Diaphragmatic irritation** by the abscess causes referred shoulder pain (due to phrenic nerve irritation) and hiccups. *Right lobe liver abscess* - While a liver abscess can cause fever and chills, **shoulder tip pain** and **hiccups** are less typical compared to a subphrenic abscess, unless the abscess is very superficial and irritating the diaphragm. - A liver abscess often presents with **right upper quadrant pain** and hepatomegaly, which are not mentioned. *Surgical site infection* - A surgical site infection would typically manifest with **localized pain**, **redness**, **swelling**, and possibly **pus discharge** at the incision site, rather than referred shoulder pain or intractable hiccups. - While it can cause fever and toxemia, the specific constellation of symptoms points away from a superficial wound infection. *Postoperative peritonitis* - Postoperative peritonitis would present with more generalized **abdominal pain**, **distension**, **tenderness**, and potentially signs of evolving **sepsis** or **organ dysfunction**. - While it can cause fever and toxemia, the distinct symptoms of **shoulder tip pain** and **hiccups** are less characteristic of diffuse peritonitis.

Q: In seat belt syndrome the most common site of bleeding is from :

Mesentery. ***Mesentery*** - In **seat belt syndrome**, the **mesentery** is the **most common site of bleeding** due to the unique mechanism of injury. - Sudden deceleration causes **shearing forces** at fixed points where the small bowel and mesentery are compressed against the posterior abdominal wall and spine by the lap belt. - This results in **mesenteric tears**, **hematomas**, and **vascular injuries** (mesenteric vessels are particularly vulnerable), leading to significant intra-abdominal hemorrhage. - **Mesenteric injury** occurs in approximately **20-30%** of seat belt syndrome cases, making it the predominant source of bleeding. *Bowel* - While **bowel injuries** (perforation, transection, intramural hematoma) do occur in seat belt syndrome and are clinically significant, they are typically **second in frequency** to mesenteric injuries. - Bowel perforation occurs in about 15-20% of cases and may present with delayed symptoms. - The bowel injury often occurs in conjunction with mesenteric tears due to the same deceleration mechanism. *Spleen* - Splenic injury is less commonly associated with the specific compression mechanism of seat belt syndrome. - The spleen is more typically injured in direct blunt trauma to the left upper quadrant from side impacts or direct blows. - Not the characteristic injury pattern seen with lap belt restraint. *Liver* - Liver injuries are more often associated with direct forceful impacts to the right upper quadrant or generalized severe blunt abdominal trauma. - The typical seat belt mechanism with lap belt compression does not preferentially injure the liver. - Less common in the classical seat belt syndrome presentation.

Q: A 47-year-old man comes to Surgery OPD with history of recurrent episodes of UTI. He gives history of the urine being frothy and occasionally having bubbles. The probable diagnosis is :

Colovesical fistula. ***Colovesical fistula*** - The presence of **pneumaturia (gas/bubbles in urine)** and **frothy urine** is pathognomonic of colovesical fistula, indicating abnormal communication between the colon and bladder with gas passage from bowel to bladder. - **Recurrent UTIs** occur in >50% of cases due to constant contamination of the bladder with fecal bacteria. - Other features include **fecaluria** (fecal matter in urine) - though less common than pneumaturia. - Most commonly caused by diverticular disease (65%), followed by colorectal cancer and Crohn's disease. *Tubercular cystitis* - While it can cause recurrent UTIs and bladder irritation, it does not typically present with **pneumaturia** or frothy urine. - Presents with sterile pyuria, dysuria, hematuria, and frequency. - Diagnosis requires identification of *Mycobacterium tuberculosis* in urine culture or bladder biopsy. *Urethrocutaneous fistula* - This involves an abnormal communication between the urethra and the skin, leading to urine leakage onto the skin surface. - Does not cause gas to enter the bladder or result in **pneumaturia**. - May cause recurrent UTIs if fistula leads to inadequate bladder emptying, but not the presenting features. *Anaerobic bacterial infection* - Although anaerobic bacteria can cause UTIs, they do not produce sufficient gas to cause **pneumaturia** without an underlying anatomical defect. - **Pneumaturia** is a mechanical sign indicating an abnormal connection with a gas-containing organ (colon), not merely infection.

Q: A patient with head injury with a Glasgow Coma Scale of 10 is classified as :

Moderate injury. ***Moderate injury*** - A Glasgow Coma Scale (GCS) score between **9 and 12** is classified as a **moderate head injury**. - Patients in this range often present with initial loss of consciousness, post-traumatic amnesia, or neurological deficits. *Mild injury* - A **mild head injury** is characterized by a GCS score of **13-15**. - These patients typically have a brief or no loss of consciousness and may experience symptoms like headache or dizziness. *Severe injury* - A **severe head injury** is indicated by a GCS score of **3-8**. - Patients with severe head injuries are often comatose and require urgent medical intervention. *Minor injury* - "Minor injury" is not a standard medical classification for head trauma based on the GCS. - The closest GCS classification would be for **mild head injury**.

Q: Which of the following are the common complications associated with enteral nutrition in postoperative patients ? 1. Tube malposition, displacement 2. Diarrhoea, constipation 3. Predisposition to systemic sepsis 4. Electrolytic imbalance Select the correct answer using the code given below :

1, 2 and 3. ***1, 2 and 3*** - **Tube malposition/displacement** is a common mechanical complication (10-15% incidence), which can lead to ineffective feeding or aspiration into the respiratory tract. - **Diarrhoea and constipation** are frequent gastrointestinal complications (10-20% incidence), occurring due to formula intolerance, rapid infusion rates, or altered gut motility in postoperative patients. - **Predisposition to systemic sepsis**: While enteral nutrition itself has lower infection risk than parenteral nutrition, complications like **aspiration pneumonia** (from tube malposition), **contaminated formula**, and **prolonged ileus** can predispose to severe infections and sepsis in postoperative patients. This is particularly relevant when enteral feeding is improperly managed. *1, 2 and 4* - This combination includes **electrolyte imbalances** (hypokalemia, hypophosphatemia, hypomagnesemia), which are indeed common metabolic complications requiring monitoring. - However, in the context of postoperative patients, the infection risk (sepsis) from aspiration and feeding-related complications is considered a more significant acute complication than electrolyte disturbances, which are generally manageable with proper monitoring and formula adjustment. *1, 3 and 4* - This option incorrectly excludes **diarrhoea and constipation**, which are among the **most common complications** of enteral nutrition, occurring in 10-20% of patients. - GI complications are a primary reason for enteral feeding intolerance and cannot be omitted. *2, 3 and 4* - This option incorrectly omits **tube malposition/displacement**, which is the most important **mechanical complication** directly related to the enteral feeding method. - Without proper tube placement verification, feeding cannot be safely administered, making this a critical complication to recognize.

Question 1

The best cosmetic result following breast reconstruction is achieved with :

Accepted Answer

Transverse rectus abdominis myocutaneous flap

Answer

Latissimus dorsi flap

Answer

Silicone gel implant with reconstruction

Answer

Acellular dermal matrix flap

Question 2

Which of the following statements with regard to Colorectal Carcinoma are correct ?

1. Left-sided Colorectal Carcinoma presents with bleeding per rectum.
2. Right-sided Colorectal Carcinoma presents with iron deficiency anaemia.
3. Right-sided Colorectal Carcinoma is more common as compared to the left-sided Colorectal Carcinoma.
4. Colonoscopy is the investigation of choice for suspected Colorectal Carcinoma.

Select the correct answer using the code given below :

Accepted Answer

1, 2 and 3

Answer

2, 3 and 4

Answer

1, 2 and 4

Answer

1, 3 and 4

Question 3

While managing oesophageal perforations, which of the following factors favour non-operative management?

1. Perforation by a flexible endoscope

2. Contained perforation without free communication

3. Perforation with a small septic load

4. Perforation of the abdominal oesophagus

Select the correct answer using the code given below:

Accepted Answer

1, 2 and 3

Answer

1, 3 and 4

Answer

2, 3 and 4

Answer

1, 2 and 4

Question 4

A Sengstaken-Blakemore tube is used for the management of :

Accepted Answer

Variceal bleeding

Answer

Corrosive poisoning

Answer

Tension pneumothorax

Answer

Asphyxia

Question 5

A young 28-year-old male was operated for duodenal ulcer perforation peritonitis. After having recovered well for five days, he developed high fever with chills and symptoms of toxemia. He developed right shoulder tip pain and intractable hiccoughs. The most likely diagnosis is :

Accepted Answer

Subphrenic abscess

Answer

Right lobe liver abscess

Answer

Surgical site infection

Answer

Postoperative peritonitis

Question 6

In seat belt syndrome the most common site of bleeding is from :

Accepted Answer

Mesentery

Answer

Bowel

Answer

Spleen

Answer

Liver

Question 7

A 47-year-old man comes to Surgery OPD with history of recurrent episodes of UTI. He gives history of the urine being frothy and occasionally having bubbles. The probable diagnosis is :

Accepted Answer

Colovesical fistula

Answer

Tubercular cystitis

Answer

Urethrocutaneous fistula

Answer

Anaerobic bacterial infection

Question 8

A patient with head injury with a Glasgow Coma Scale of 10 is classified as :

Accepted Answer

Moderate injury

Answer

Mild injury

Answer

Severe injury

Answer

Minor injury

Question 9

Which of the following are the common complications associated with enteral nutrition in postoperative patients ?

1. Tube malposition, displacement
2. Diarrhoea, constipation
3. Predisposition to systemic sepsis
4. Electrolytic imbalance

Select the correct answer using the code given below :

Accepted Answer

1, 2 and 3

Answer

1, 2 and 4

Answer

1, 3 and 4

Answer

2, 3 and 4

UPSC-CMS 2023 — Surgery