Colorectal Surgery Practice Questions

Q: Local excision in rectal cancer is done in all, except:

T2 cancer or any lymph node involvement. ***T2 cancer or any lymph node involvement*** - Local excision is typically reserved for **early-stage rectal cancers (T1 tumors)** where the risk of lymph node metastasis is very low and there is **no lymph node involvement**. - **T2 tumors** (invasion into muscularis propria) carry a significantly higher risk of lymph node metastasis (10-20%) and are generally **not suitable for local excision**, requiring radical resection instead. - **Any lymph node involvement** (even in T1 disease) is an **absolute contraindication** to local excision, as it indicates metastatic spread requiring comprehensive lymphadenectomy through radical resection. *Within 6 cm of anal verge* - This refers to the **location within the rectum** and accessibility for transanal approaches. - Rectal tumors within 6-8 cm of the anal verge are **suitable for local excision** techniques like transanal endoscopic microsurgery (TEM) or transanal minimally invasive surgery (TAMIS) if they meet other criteria (T1, N0, favorable histology). *Lesion <4 cm* - **Tumor size <3-4 cm** is one of the favorable criteria for local excision. - Smaller tumors are more amenable to complete excision with adequate margins and are associated with lower risk of lymph node metastasis. *Involvement of <40% circumference* - The **circumferential involvement** of the rectal wall is an important factor for technical feasibility. - Tumors involving **<30-40% of the circumference** are suitable for local excision, allowing adequate margin resection and primary closure without compromising rectal function or causing stenosis.

Q: Most important disadvantage of cryosurgery for hemorrhoids is:

Profuse watery discharge. ***Profuse watery discharge*** - **Profuse, foul-smelling watery discharge** is the **most important and troublesome disadvantage** of cryosurgery for hemorrhoids. - Results from **tissue necrosis and sloughing** following freezing, lasting **2-3 weeks** post-procedure. - This persistent discharge is **socially distressing**, requires frequent dressing changes, and is the primary reason cryosurgery has **largely fallen out of favor** in modern practice. - The severity and duration of this complication makes it more problematic than other side effects. *Pain* - While postoperative discomfort does occur, pain after cryosurgery is **generally not more severe** than with other hemorrhoid procedures. - The freezing effect can actually cause **temporary nerve damage** that may reduce immediate pain sensation. - Pain is manageable with standard analgesics and is **not the defining disadvantage** of this technique. *Infection* - Infection is **uncommon** with cryosurgery as the ultra-cold temperatures have some **antibacterial effect**. - Not a characteristic or major complication of this specific technique. *Hemorrhage* - Cryosurgery actually has a **lower risk of immediate bleeding** compared to excisional hemorrhoidectomy. - The freezing causes **vasoconstriction and thrombosis** of small vessels, reducing acute blood loss. - Delayed bleeding can rarely occur when eschar separates, but this is not the most significant disadvantage.

Q: A young male patient presents with complete rectal prolapse and no history of previous surgeries. The surgery of choice is:

Abdominal rectopexy. ***Abdominal rectopexy*** - **Abdominal rectopexy** is considered the surgery of choice for **complete rectal prolapse** in young, fit patients due to its superior long-term results in terms of recurrence rates. - This procedure involves addressing the prolapse via an abdominal approach, often by fixing the rectum to the sacrum, and may include sigmoid resection if there is a redundant colon. *Delorme's procedure* - This is a **perineal approach** that involves plication of the prolapsed rectal mucosa and muscle. - It is generally favored in **elderly** or **frail patients** due to its lower morbidity, but it has a higher recurrence rate compared to abdominal approaches. *Anterior resection* - **Anterior resection** is primarily a procedure for removing a diseased segment of the **left colon or rectum**, typically for cancer or diverticular disease. - While it may be combined with rectopexy if a redundant sigmoid colon is present, it is not the primary or sole treatment for rectal prolapse itself. *Goodsall's procedure* - **Goodsall's rule** is a principle used to predict the internal opening of an anal fistula based on the external opening's location, and **Goodsall's procedure** is not a named surgical technique for rectal prolapse. - This option appears to be a distractor, as there is no specific surgical procedure for rectal prolapse named after Goodsall.

Q: Most common site of chronic fissure in the anus is

Posterior. ***Posterior*** - The **posterior midline** is the most common site for anal fissures due to it being less well-supported and poorly vascularized, making it susceptible to trauma during defecation. - The internal anal sphincter pulls the anoderm in the posterior midline, making it the most common site of injury and fissure formation in both sexes. *Anterior* - While anterior fissures can occur, they are much less common than posterior fissures, accounting for a smaller percentage of all chronic fissures. - Anterior fissures are more common in women due to the different angles of the anterior anal canal in relation to the vaginal introitus, but still less frequent than posterior ones. *Anterolateral* - Fissures rarely occur in an anterolateral position. Anal fissures typically appear in the midline anteriorly or posteriorly. - This location is not anatomically predisposed to the same degree of trauma or stress experienced by the anterior or posterior midline during defecation. *Lateral* - **Lateral fissures** are uncommon and should raise suspicion for other underlying conditions, such as **inflammatory bowel disease** (Crohn's disease), tuberculosis, or malignancy [1]. - The anal canal's support and vascularization are generally better in the lateral aspects, making primary fissure formation here less likely.

Q: Procedure of choice in ulcerative colitis with acute perforation is

Total colectomy and ileostomy. ***Total colectomy and ileostomy*** - **Acute perforation** in ulcerative colitis is a life-threatening emergency requiring immediate and definitive surgical management. - **Total colectomy** removes the diseased colon, preventing further perforation and systemic toxicity, with an ileostomy providing fecal diversion. *Defunctioning ileostomy* - A defunctioning ileostomy alone would not address the actively perforated and inflamed colon, leaving the source of sepsis intact. - This procedure leads to potentially fatal **peritoneal contamination** and ongoing inflammation. *Closure of perforation* - Direct closure of a colonic perforation in the context of acute ulcerative colitis is generally contraindicated due to the **fragile, inflamed, and friable bowel tissue**, which is prone to dehiscence. - This approach carries a high risk of **re-perforation** and persistent sepsis. *Proximal diversion colostomy* - A proximal diversion colostomy, similar to a defunctioning ileostomy, fails to remove the diseased and perforated segment of the colon. - It would not prevent the continued leakage of bowel contents from the perforation site into the **abdominal cavity**, leading to severe peritonitis.

Question 1

Local excision in rectal cancer is done in all, except:

Accepted Answer

T2 cancer or any lymph node involvement

Answer

Involvement of <40% circumference

Answer

Lesion <4 cm

Answer

Within 6 cm of anal verge

Question 2

Most important disadvantage of cryosurgery for hemorrhoids is:

Accepted Answer

Profuse watery discharge

Answer

Pain

Answer

Infection

Answer

Hemorrhage

Question 3

A patient with a non-obstructing carcinoma of the sigmoid colon is being prepared for elective resection. To minimize the risk of postoperative infectious complications, what should be included in your planning?

Accepted Answer

A single preoperative parenteral dose of antibiotic effective against aerobes and anaerobes may provide initial coverage.

Answer

Postoperative administration for 5 to 7 days of parenteral antibiotics effective against aerobes and anaerobes

Answer

Postoperative administration for 2 to 4 days of parenteral antibiotics effective against aerobes and anaerobes

Answer

Avoidance of oral antibiotics to prevent emergence of Clostridioides difficile

Question 4

A young male patient presents with complete rectal prolapse and no history of previous surgeries. The surgery of choice is:

Accepted Answer

Abdominal rectopexy

Answer

Delorme's procedure

Answer

Anterior resection

Answer

Goodsall's procedure

Question 5

Most common site of chronic fissure in the anus is

Accepted Answer

Posterior

Answer

Answer

Anterolateral

Answer

Lateral

Question 6

Procedure of choice in ulcerative colitis with acute perforation is

Accepted Answer

Total colectomy and ileostomy

Answer

Defunctioning ileostomy

Answer

Closure of perforation

Answer

Proximal diversion colostomy

Colorectal Surgery — MCQs

Colorectal Surgery — MCQs

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