General Surgery Principles — MCQs

General Surgery Principles Indian Medical PG Practice Questions and MCQs

Question 91: All of the following are true about tumors associated with BRCA-1 except:

A. Hormone receptor positive (Correct Answer)
B. Poorly differentiated
C. Chromosome 17
D. Early age onset

Explanation: **Explanation:** The correct answer is **A (Hormone receptor positive)** because BRCA-1 associated breast cancers are characteristically **Triple Negative** (ER negative, PR negative, and HER2/neu negative). **1. Why Option A is the correct answer (The Exception):** BRCA-1 mutations are associated with a specific molecular phenotype known as "Basal-like" carcinoma. Unlike sporadic breast cancers or BRCA-2 mutations, BRCA-1 tumors typically lack estrogen and progesterone receptors. Therefore, they do not respond to hormonal therapies like Tamoxifen or Aromatase inhibitors. **2. Analysis of Incorrect Options:** * **B. Poorly differentiated:** BRCA-1 tumors are histologically aggressive. they are typically high-grade (Grade 3), show a high mitotic index, and often exhibit pushing margins and lymphocytic infiltration. * **C. Chromosome 17:** The BRCA-1 gene is located on the long arm of **Chromosome 17 (17q21)**. (Note: BRCA-2 is on Chromosome 13q12). * **D. Early age onset:** Hereditary breast cancers present significantly earlier than sporadic cases, often in the 30s or 40s. **Clinical Pearls for NEET-PG:** * **BRCA-1 vs. BRCA-2:** BRCA-1 has a higher risk of **Ovarian cancer** (up to 40%) compared to BRCA-2 (up to 20%). BRCA-2 is more strongly associated with **Male breast cancer** and is typically **ER/PR positive**. * **Prophylaxis:** Bilateral Salpingo-oophorectomy (BSO) reduces the risk of ovarian cancer by 80-90% and also significantly reduces breast cancer risk if performed pre-menopausally. * **Associated Tumors:** BRCA-1 is also linked to prostate and colon cancers, while BRCA-2 is linked to pancreatic, prostate, and gallbladder cancers.

Question 92: Burst abdomen occurs most commonly on which postoperative day?

A. 2nd day
B. 7th day (Correct Answer)
C. 4th day
D. 9th day

Explanation: **Explanation:** **Burst Abdomen (Abdominal Wound Dehiscence)** is a serious postoperative complication where the layers of the abdominal wall separate, leading to the protrusion of viscera. **Why 7th Day is Correct:** The peak incidence of burst abdomen occurs between the **6th and 8th postoperative days** (most commonly the **7th day**). This timing is critical because of the "lag phase" in wound healing. During the first week, the wound relies entirely on the mechanical strength of the sutures. By day 7, the initial fibrin clot is weakening, but the synthesis of new collagen (which provides tensile strength) has not yet reached a sufficient level to withstand intra-abdominal pressure. **Analysis of Incorrect Options:** * **2nd Day:** Too early for dehiscence. At this stage, the inflammatory phase is dominant, and the primary sutures are at their maximum holding strength. * **4th Day:** While the wound is vulnerable, the peak breakdown usually occurs slightly later when metabolic demands and factors like postoperative ileus or coughing (increasing intra-abdominal pressure) have exerted cumulative stress. * **9th Day:** By this time, the proliferative phase is well underway, and collagen deposition has begun to significantly increase the wound's tensile strength, making dehiscence less likely than on day 7. **High-Yield Clinical Pearls for NEET-PG:** * **Serosanguinous discharge:** The most important clinical "warning sign" (herald sign) of an impending burst abdomen is a pinkish, serosanguinous discharge from the wound. * **Risk Factors:** Malnutrition (hypoalbuminemia), anemia, obesity, malignancy, and conditions that increase intra-abdominal pressure (chronic cough, vomiting, or distension). * **Management:** Immediate management involves covering the bowel with sterile saline-soaked gauze, followed by urgent surgical re-closure (usually using **tension-sutures** or "interrupted mass closure").

Question 93: An 8-month-old boy has impalpable undescended testes. What is the next step in management?

A. Reassurance
B. Ultrasound abdomen and scrotum
C. MRI abdomen
D. Laparoscopy (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. Laparoscopy** The management of undescended testes (UDT) depends on whether the testis is palpable or impalpable. In this case, the 8-month-old boy has **impalpable** testes. **Diagnostic Laparoscopy** is the "Gold Standard" for managing impalpable testes. It serves a dual purpose: 1. **Diagnostic:** It identifies the presence, location (intra-abdominal vs. absent), and morphology of the testis. 2. **Therapeutic:** If an intra-abdominal testis is found, definitive surgery (Laparoscopic Orchiopexy or Fowler-Stephens procedure) can be performed in the same sitting. --- ### Why the other options are incorrect: * **A. Reassurance:** Spontaneous descent of the testis is rare after **6 months** of age. Since the child is 8 months old, surgical intervention is indicated to prevent complications like infertility and malignancy. * **B. Ultrasound (USG):** While commonly used, USG has very low sensitivity (approx. 45%) for locating impalpable testes. A negative USG does not rule out an intra-abdominal testis; therefore, it should not delay definitive management. * **C. MRI:** Although more accurate than USG, MRI is expensive, requires sedation in infants, and does not offer the therapeutic advantage that laparoscopy provides. --- ### High-Yield Clinical Pearls for NEET-PG: * **Timing of Surgery:** The ideal age for Orchiopexy is **6 to 12 months** (latest by 18 months). * **Most Common Site:** The most common site for an undescended testis is the **Inguinal Canal**. * **Vanishing Testis Syndrome:** If laparoscopy reveals blind-ending spermatic vessels above the internal ring, it confirms an absent testis (monorchism). * **Malignancy Risk:** Orchiopexy does not eliminate the risk of testicular cancer (Seminoma is most common), but it makes the testis accessible for clinical screening. * **Hormonal Therapy:** HCG or GnRH analogues are generally not recommended as primary treatment for UDT.

Question 94: Which type of hernia is most prone to reoccur after primary repair?

A. Femoral
B. Epigastric
C. Spigelian
D. Incisional (Correct Answer)

Explanation: **Explanation:** **Incisional hernias** have the highest recurrence rates among all abdominal wall hernias, often cited between **10–50%** depending on the repair technique (primary suture vs. mesh). The underlying medical concept is that an incisional hernia occurs through a pre-existing surgical scar, which represents a zone of permanent structural weakness. Unlike primary hernias, the surrounding fascia is often attenuated, poorly vascularized, and has altered collagen metabolism, making primary suture repair prone to "cheese-wiring" and subsequent failure. **Analysis of Incorrect Options:** * **Femoral Hernia:** While these have the highest risk of **strangulation** due to the rigid boundaries of the femoral canal, their recurrence rate after proper repair (e.g., McVay’s or mesh plug) is significantly lower than incisional hernias. * **Epigastric Hernia:** These occur through small defects in the linea alba. While they have a moderate recurrence rate if multiple small defects are missed, they generally heal well because they occur in "virgin" tissue. * **Spigelian Hernia:** These are rare interstitial hernias occurring through the Spigelian aponeurosis. Because the surrounding fascia is usually healthy and the defect is small, recurrence after surgical repair is uncommon. **Clinical Pearls for NEET-PG:** * **Gold Standard Repair:** For incisional hernias, **mesh repair** (Laparoscopic or Open) is mandatory for defects >2 cm to reduce recurrence. * **Most Common Site:** The most common site for an incisional hernia is a **midline vertical incision**. * **Risk Factors:** Obesity, wound infection (the single most important factor), and smoking significantly increase recurrence risk. * **Richter’s Hernia:** Frequently involves the femoral ring; only a portion of the bowel wall is entrapped.

Question 95: Where does a femoral hernia present relative to the pubic tubercle?

A. Below and lateral (Correct Answer)
B. Above and medial
C. Below and medial
D. Above and lateral

Explanation: **Explanation:** The anatomical relationship between a hernia and the **pubic tubercle** is the definitive clinical landmark used to differentiate a femoral hernia from an inguinal hernia. **1. Why "Below and Lateral" is Correct:** The femoral canal lies within the femoral sheath, located inferior to the inguinal ligament. The medial boundary of the femoral ring is the lacunar ligament, which attaches to the pectineal line of the pubis. Anatomically, the femoral canal (and thus a femoral hernia) emerges through the saphenous opening, which is situated **below and lateral** to the pubic tubercle. **2. Why the Other Options are Incorrect:** * **Above and Medial:** This describes the presentation of an **Inguinal Hernia** (both direct and indirect). The superficial inguinal ring lies superior and medial to the pubic tubercle. * **Below and Medial / Above and Lateral:** These positions do not correspond to the standard anatomical exit points of common groin hernias. **Clinical Pearls for NEET-PG:** * **The "Rule of Thumb":** If you can feel the pubic tubercle and the lump is above/medial, it’s inguinal; if it’s below/lateral, it’s femoral. * **Demographics:** Femoral hernias are more common in **females** (due to a wider pelvis), though inguinal hernias remain the most common hernia overall in both sexes. * **Complications:** Femoral hernias have the **highest risk of strangulation** (approx. 40%) because of the rigid, narrow boundaries of the femoral canal (lacunar ligament medially). * **Management:** Unlike asymptomatic inguinal hernias, all femoral hernias should be repaired surgically upon diagnosis due to the high risk of incarceration.

Question 96: A mesenteric cyst typically moves in relation to the mesentery in which of the following ways?

A. Moves parallel to the mesentery
B. Moves perpendicular to the mesentery (Correct Answer)
C. Is a secondary tumor
D. Is fixed and immobile

Explanation: **Explanation:** The characteristic mobility of a mesenteric cyst is a classic clinical sign known as **Tillaux’s Sign**. This sign is fundamental in differentiating mesenteric masses from other intra-abdominal swellings. **1. Why Option B is Correct:** Mesenteric cysts are located between the two layers of the mesentery. The mesentery is attached to the posterior abdominal wall along a line running from the left side of the second lumbar vertebra to the right sacroiliac joint (the root of the mesentery). Because of this anatomical tethering, the cyst can be moved freely in a direction **perpendicular** to the line of the mesenteric attachment (i.e., from right to left). However, its movement is restricted along the longitudinal axis (parallel) of the mesentery because it is anchored by the root. **2. Why the other options are incorrect:** * **Option A:** Movement parallel to the mesentery is restricted by the root of the mesentery and the tension of the superior mesenteric vessels. * **Option C:** Mesenteric cysts are typically primary lesions (often lymphatic in origin, like cystic lymphangiomas) rather than secondary tumors (metastases), though secondary malignant involvement of the mesentery can occur. * **Option D:** A fixed and immobile mass usually suggests a retroperitoneal tumor (e.g., sarcoma) or a malignancy that has infiltrated the posterior abdominal wall. **Clinical Pearls for NEET-PG:** * **Tillaux’s Sign:** A triad consisting of a fluctuant swelling in the umbilical region, great mobility in a plane perpendicular to the mesentery, and a zone of resonance (tympanitic note) all around the cyst due to surrounding bowel loops. * **Most common site:** The mesentery of the **ileum** is the most frequent location. * **Treatment of choice:** Complete **enucleation** is preferred. If the blood supply to the adjacent bowel is compromised, bowel resection with end-to-end anastomosis is required.

Question 97: What is the recommended timing for pneumococcal vaccination prior to splenectomy?

A. 2 weeks (Correct Answer)
B. 1 week
C. 3 days
D. 1 month

Explanation: **Explanation:** The primary concern following a splenectomy is **Overwhelming Post-Splenectomy Infection (OPSI)**, most commonly caused by encapsulated organisms like *Streptococcus pneumoniae*. To prevent this, immunization is mandatory. **1. Why 2 weeks is the correct answer:** The goal of preoperative vaccination is to allow the body sufficient time to mount an adequate humoral immune response (antibody production) before the lymphoid tissue of the spleen is removed. Studies show that a minimum of **14 days (2 weeks)** is required to achieve peak antibody titers. If the surgery is elective, the vaccines should be administered at least 2 weeks prior. If the splenectomy is emergent (e.g., trauma), the vaccines should be given **2 weeks after** the procedure to avoid the period of post-traumatic immunosuppression. **2. Why other options are incorrect:** * **1 week / 3 days:** These durations are insufficient for the B-cells in the splenic follicles to undergo clonal expansion and produce protective levels of IgG antibodies. * **1 month:** While waiting longer is not harmful, 2 weeks is the established clinical standard that balances surgical scheduling with immunological efficacy. **Clinical Pearls for NEET-PG:** * **Target Organisms:** The "Big Three" vaccines required are against *S. pneumoniae*, *Haemophilus influenzae* type b (Hib), and *Neisseria meningitidis*. * **Annual Requirement:** Patients should also receive the annual Influenza vaccine. * **Re-vaccination:** Pneumococcal boosters are typically recommended every 5 years. * **Prophylaxis:** In addition to vaccines, lifelong prophylactic antibiotics (usually Penicillin V) are often recommended, especially in children.

Question 98: The Karydakis procedure is used for which condition?

A. Pilonidal sinus (Correct Answer)
B. Fistula in ano
C. Coccydynia
D. Haemorrhoids

Explanation: **Explanation:** The **Karydakis procedure** is a specialized surgical technique used for the management of **Pilonidal Sinus Disease (PNS)**. The primary goal of this procedure is to prevent recurrence by addressing the mechanical factors that cause the condition. It involves an asymmetrical elliptical excision of the sinus tract followed by the mobilization of a medial skin flap to shift the surgical scar away from the midline (the natal cleft). By flattening the deep groove of the natal cleft, it reduces friction, moisture, and the tendency for hair to penetrate the skin—the hallmark pathophysiology of PNS. **Analysis of Options:** * **A. Pilonidal Sinus (Correct):** As described, the Karydakis flap is a "midline-offloading" procedure specifically designed to treat chronic or recurrent pilonidal disease. * **B. Fistula in ano:** This is treated via fistulotomy, fistulectomy, or sphincter-sparing procedures like LIFT (Ligation of Intersphincteric Fistula Tract) or VAAFT. * **C. Coccydynia:** This refers to pain in the coccyx, usually managed conservatively with NSAIDs and cushions, or in refractory cases, via coccygectomy. * **D. Haemorrhoids:** Surgical treatments include Milligan-Morgan (open) or Ferguson (closed) hemorrhoidectomy, and Stapled Hemorrhoidopexy (MIPH). **High-Yield Clinical Pearls for NEET-PG:** * **Bascom’s Procedure:** Another "off-midline" technique for pilonidal sinus involving small lateral incisions. * **Limberg Flap:** A rhomboid transposition flap used for complex pilonidal disease; it also aims to move the scar away from the midline. * **Z-plasty:** Sometimes used to flatten the natal cleft in PNS management. * **Pathogenesis:** Remember that PNS is an **acquired** condition (not congenital) caused by "drilling" of hair into the skin.

Question 99: What is true about Richter's hernia?

A. Meckel's diverticulum is the content.
B. Only a part of the bowel wall enters the hernia. (Correct Answer)
C. The appendix is the content.
D. The viscus forms the wall of the hernia.

Explanation: ### Explanation **Richter’s Hernia** is a specific type of hernia where only a **portion of the circumference** of the bowel wall (usually the antimesenteric border) becomes incarcerated within the hernial sac. **1. Why the Correct Answer is Right:** In Richter’s hernia, the entire lumen of the bowel is not involved. Because the intestinal continuity is maintained, the patient may not present with classic signs of intestinal obstruction (like absolute constipation or vomiting) despite the presence of strangulation. This makes it clinically dangerous, as diagnosis is often delayed until gangrene or perforation occurs. **2. Analysis of Incorrect Options:** * **Option A (Meckel’s diverticulum):** This describes **Littre’s Hernia**. While it also involves a portion of the bowel, it specifically refers to the presence of a Meckel’s diverticulum in the sac. * **Option C (Appendix):** This describes **Amyand’s Hernia** (appendix in an inguinal sac) or **De Garengeot Hernia** (appendix in a femoral sac). * **Option D (Viscus forms the wall):** This describes a **Sliding Hernia** (Hernia en glissade), where an extraperitoneal organ (like the cecum or bladder) forms part of the wall of the hernial sac. **3. Clinical Pearls for NEET-PG:** * **Most Common Site:** The **Femoral canal** is the most frequent site for Richter’s hernia, followed by the inguinal canal and incisional hernias. * **Key Feature:** Strangulation can occur without clinical signs of bowel obstruction. * **High-Yield Fact:** It is more common in elderly patients and carries a high mortality rate due to delayed presentation and rapid progression to gangrene. * **Management:** Immediate surgical intervention is required; if the bowel wall is non-viable, resection and anastomosis are performed.

Question 100: How will you drain the abscess shown below?

A. Hilton method
B. Non dependent drainage
C. Cruciate incision (Correct Answer)
D. Antibiotics only

Explanation: ***Cruciate incision*** - **Cruciate incision** (cross-shaped) is the gold standard for draining **ischiorectal and perianal abscesses** as it provides excellent drainage and prevents premature closure. - The **four flaps** created allow complete evacuation of pus and facilitate proper healing from the base upward, reducing recurrence rates. *Hilton method* - **Hilton's method** uses **blunt dissection** and is reserved for abscesses near vital structures like the **anal sphincter** to avoid injury. - This method is **not suitable** for large ischiorectal abscesses as it provides inadequate drainage and higher recurrence rates. *Non dependent drainage* - **Non-dependent drainage** creates an opening at a higher level, leading to **poor gravitational drainage** and pus accumulation. - This approach is **contraindicated** in perianal abscesses as it promotes **incomplete evacuation** and abscess reformation. *Antibiotics only* - **Antibiotics alone** cannot penetrate the **avascular abscess cavity** effectively and fail to evacuate the formed pus collection. - **Surgical drainage** is mandatory for any formed abscess as per the principle **"pus anywhere must come out"** - antibiotics are only adjunctive therapy.

Practice by Chapter

Wound Healing and Care

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Surgical Infections

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Fluid and Electrolyte Management

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Nutrition in Surgical Patients

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Hemostasis and Blood Transfusion

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Surgical Instruments and Equipment

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Sutures and Stapling Devices

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Minimal Access Surgery Principles

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Surgical Complications

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Anesthesia Principles for Surgeons

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Surgical Oncology Principles

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Evidence-Based Surgery

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