General Surgery Principles — MCQs

General Surgery Principles Indian Medical PG Practice Questions and MCQs

Question 151: What is extrapleural pneumonectomy?

A. Removal of one lobe of the lung
B. Removal of a complete lung
C. Removal of the pleura of one lung
D. Removal of an affected lung with its pleura and part of the diaphragm (Correct Answer)

Explanation: ### Explanation **Extrapleural Pneumonectomy (EPP)** is a radical surgical procedure primarily indicated for **Malignant Pleural Mesothelioma (MPM)**. Unlike a standard pneumonectomy, EPP involves the "en bloc" resection of the entire affected lung along with the parietal and visceral pleura, the ipsilateral hemidiaphragm, and the pericardium. The goal is to achieve macroscopic complete resection of the tumor, which characteristically spreads along the pleural surfaces. **Analysis of Options:** * **Option A (Removal of one lobe):** This is termed a **Lobectomy**, the standard treatment for localized non-small cell lung cancer (NSCLC). * **Option B (Removal of a complete lung):** This is a **Pneumonectomy**. While EPP includes this, a simple pneumonectomy does not involve the diaphragm or pericardium. * **Option C (Removal of the pleura):** This is known as **Pleurectomy/Decortication (P/D)**. It is a lung-sparing alternative to EPP used in mesothelioma patients with lower performance status. **High-Yield Clinical Pearls for NEET-PG:** * **Primary Indication:** Malignant Pleural Mesothelioma (epithelioid subtype has the best prognosis). * **Tri-modality Therapy:** EPP is often part of a regimen including neoadjuvant chemotherapy and adjuvant radiotherapy. * **Complications:** High morbidity rates; common issues include cardiac arrhythmias, respiratory failure, and "post-pneumonectomy syndrome." * **Anatomy:** Reconstruction of the diaphragm and pericardium using synthetic patches (e.g., Gore-Tex) is required following the resection.

Question 152: Splenosis means

A. Infection of the spleen
B. Presence of an accessory spleen
C. Rupture of the spleen and distribution of its tissue on the peritoneum (Correct Answer)
D. A non-functioning spleen

Explanation: **Explanation:** **Splenosis** is an acquired condition characterized by the autotransplantation of splenic tissue onto various surfaces, most commonly the peritoneum, following splenic trauma or surgery (splenectomy). 1. **Why Option C is correct:** When the splenic capsule ruptures (due to trauma) or during surgical manipulation, viable splenic pulp cells are released into the abdominal cavity. These fragments "seed" onto the serosal surfaces, develop a new blood supply from the surrounding tissues, and grow into functional nodules. Unlike the original spleen, these nodules lack a formal capsule and are supplied by local vessels rather than the splenic artery. 2. **Why the other options are incorrect:** * **Option A:** Infection of the spleen is termed a **Splenic Abscess**. * **Option B:** An **Accessory Spleen (Splenunculus)** is a congenital condition where splenic tissue is found at distinct sites (usually the splenic hilum) due to failure of fusion during embryogenesis. It has a normal splenic artery supply and a capsule. * **Option C:** A non-functioning spleen is referred to as **Asplenia** (congenital) or **Functional Hyposplenism** (often seen in Sickle Cell Anemia due to repeated infarctions/autosplenectomy). **High-Yield Clinical Pearls for NEET-PG:** * **Site:** Most common in the peritoneum, but can occur in the thorax (pleural splenosis) if the diaphragm is also ruptured. * **Function:** Splenotic nodules are functional and can provide some immune protection, often leading to the absence of "Howell-Jolly bodies" on a peripheral smear even after a total splenectomy. * **Diagnosis:** Often an incidental finding on CT; however, **Heat-damaged Tc-99m labeled RBC scan** is the gold standard for confirming splenic tissue. * **Clinical Significance:** It is usually asymptomatic but can be mistaken for metastatic nodules or endometriosis during imaging or laparoscopy.

Question 153: Which of the following is NOT part of personal protective equipment?

A. Face mask
B. Gloves
C. Lab coat (Correct Answer)
D. Goggles

Explanation: In the context of surgical practice and infection control, **Personal Protective Equipment (PPE)** refers to specialized clothing or equipment worn by healthcare workers to protect themselves from infectious materials or bodily fluids. ### Why "Lab Coat" is the Correct Answer While a lab coat is a common piece of professional attire, it is **not** classified as PPE in a clinical or surgical setting. Standard lab coats are typically made of permeable cotton or polyester, which can soak up fluids and harbor pathogens, potentially acting as a **fomite**. In contrast, PPE must provide a barrier. In high-risk or surgical environments, a lab coat is replaced by a **fluid-resistant sterile gown**, which is true PPE. ### Analysis of Other Options * **Gloves (B):** These are the most essential component of PPE, protecting the hands from blood-borne pathogens and preventing the cross-contamination of surgical sites. * **Face Mask (A):** Masks protect the wearer’s mucous membranes (nose and mouth) from splashes and prevent the transmission of respiratory droplets to the patient. * **Goggles (D):** Eye protection is a critical part of "Standard Precautions" to prevent conjunctival exposure to blood or body fluid splashes during procedures. ### NEET-PG Clinical Pearls * **Standard Precautions:** The principle that all blood and body fluids are treated as potentially infectious. PPE is the cornerstone of these precautions. * **Donning Sequence (Putting on):** Gown → Mask → Goggles/Face Shield → Gloves. * **Doffing Sequence (Taking off):** Gloves → Goggles → Gown → Mask (Gloves are removed first as they are the most contaminated). * **N95 Masks:** Required specifically for **aerosol-generating procedures** (e.g., intubation, bronchoscopy) or when dealing with airborne infections like Tuberculosis or COVID-19.

Question 154: All of the following are true about primary bacterial peritonitis, EXCEPT:

A. Ascitic fluid polymorphonuclear leukocyte (PMN) count > 250 cells/mm³ is diagnostic.
B. Microbiology of primary bacterial peritonitis is distinctive.
C. Some patients may be totally asymptomatic.
D. It usually does not respond to routine antimicrobial therapy. (Correct Answer)

Explanation: **Explanation:** Primary Bacterial Peritonitis (PBP), also known as **Spontaneous Bacterial Peritonitis (SBP)**, is an infection of the peritoneal fluid without an evident intra-abdominal source of sepsis. It typically occurs in patients with pre-existing ascites due to cirrhosis or nephrotic syndrome. **Why Option D is the Correct Answer (The False Statement):** Unlike secondary peritonitis (which requires surgical intervention), SBP **responds well to routine antimicrobial therapy**. The standard of care is intravenous third-generation cephalosporins (e.g., Cefotaxime). Surgery is contraindicated in SBP and can be fatal; therefore, the statement that it "does not respond to routine antimicrobial therapy" is incorrect. **Analysis of Incorrect Options (True Statements):** * **Option A:** An ascitic fluid **PMN count > 250 cells/mm³** is the gold standard diagnostic criterion. It indicates a significant inflammatory response even if cultures are negative (Culture-Negative Neutrocytic Ascites). * **Option B:** The microbiology is **distinctive** because it is typically **monomicrobial**. The most common organisms are enteric Gram-negative bacilli (*E. coli* is #1, followed by *Klebsiella*). In contrast, secondary peritonitis is usually polymicrobial. * **Option C:** Clinical presentation varies widely. While many present with fever and abdominal pain, some patients are **totally asymptomatic**, and the diagnosis is only caught during routine paracentesis. **NEET-PG High-Yield Pearls:** * **Most common organism:** *Escherichia coli*. * **Diagnosis:** PMN count > 250/mm³ (Absolute Neutrophil Count). * **Treatment of choice:** Cefotaxime (3rd Gen Cephalosporin). * **Prophylaxis:** Norfloxacin or Trimethoprim-sulfamethoxazole is used in high-risk patients to prevent recurrence. * **Differentiating from Secondary Peritonitis:** Use **Runyon’s Criteria** (Secondary peritonitis usually has low glucose <50mg/dL, high LDH, and high protein >1g/dL in ascitic fluid).

Question 155: Elective splenectomy is indicated in which of the following conditions?

A. Hereditary spherocytosis (Correct Answer)
B. G6PD deficiency
C. Beta thalassemia
D. Sickle cell anemia

Explanation: **Explanation:** **Hereditary Spherocytosis (HS)** is the most common indication for elective splenectomy among the options provided. In HS, a defect in red blood cell (RBC) membrane proteins (like spectrin or ankyrin) leads to the formation of spherical, rigid cells. These spherocytes are prematurely trapped and destroyed by splenic macrophages in the cords of Billroth. Splenectomy is **curative** for the anemia because it removes the primary site of hemolysis, significantly extending RBC lifespan, even though the underlying membrane defect persists. **Why the other options are incorrect:** * **G6PD Deficiency:** This is an enzyme defect leading to episodic hemolysis triggered by oxidative stress (e.g., fava beans, drugs). The hemolysis is primarily intravascular or occurs throughout the reticuloendothelial system; splenectomy has no therapeutic role. * **Beta Thalassemia:** Splenectomy is not a primary treatment. It is reserved only for specific complications, such as massive splenomegaly causing mechanical discomfort or severe hypersplenism that significantly increases transfusion requirements. * **Sickle Cell Anemia:** Most patients undergo "autosplenectomy" by early childhood due to repeated splenic infarctions. Elective splenectomy is rarely indicated except in cases of acute splenic sequestration crisis. **High-Yield Clinical Pearls for NEET-PG:** * **Timing:** Elective splenectomy should ideally be delayed until after age 5–6 to reduce the risk of **Overwhelming Post-Splenectomy Infection (OPSI)**. * **Prophylaxis:** Patients must receive vaccinations against encapsulated organisms (*S. pneumoniae, H. influenzae, N. meningitidis*) at least **2 weeks before** elective surgery. * **Post-op Blood Picture:** Look for **Howell-Jolly bodies**, Pappenheimer bodies, and Heinz bodies on a peripheral smear. * **Associated Condition:** Always check for **gallstones** (pigment stones) via ultrasound before HS surgery; a concomitant cholecystectomy may be required.

Question 156: What is the ideal treatment of alveolar osteitis after dental extraction?

A. Topical antibiotics
B. Systemic antibiotics
C. Debridement of socket and sedative dressing (Correct Answer)
D. Curettage to induce fresh bleeding

Explanation: **Explanation:** **Alveolar Osteitis**, commonly known as **"Dry Socket,"** is a painful condition occurring 3–5 days post-extraction due to the premature lysis or loss of the blood clot. This exposes the underlying alveolar bone to oral fluids and bacteria, leading to localized osteitis. **Why Option C is Correct:** The primary goal of treatment is **pain management** and promoting secondary intention healing. The standard protocol involves: 1. **Gentle Debridement:** Irrigating the socket with warm saline to remove food debris and necrotic tissue. 2. **Sedative Dressing:** Placing a medicated dressing (typically **Zinc Oxide Eugenol** or Alvogyl) into the socket. Eugenol acts as a local anesthetic and obtundent, providing immediate relief from the characteristic radiating pain. **Why Other Options are Incorrect:** * **A & B (Antibiotics):** Dry socket is primarily a physical loss of the clot leading to inflammation, not a systemic or localized infection requiring antibiotics. They do not provide pain relief or accelerate healing in this context. * **D (Curettage):** This is **contraindicated**. Aggressive curettage to induce bleeding can spread the localized inflammation into the deeper bone, potentially causing true osteomyelitis. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Smoking (most common), oral contraceptives, traumatic extraction, and mandibular third molar extractions. * **Clinical Feature:** Severe, throbbing pain radiating to the ear, accompanied by a foul odor (halitosis) and an empty-looking socket. * **Pathophysiology:** Increased **fibrinolysis** (plasminogen conversion to plasmin) which dissolves the clot. * **Management:** It is a self-limiting condition; treatment is purely symptomatic.

Question 157: Which type of transplantation requires all cellular components to be irradiated prior to transfusion?

A. Heart
B. Liver
C. Bone marrow (Correct Answer)
D. Lung

Explanation: **Explanation:** The correct answer is **Bone marrow (C)**. The underlying medical concept is the prevention of **Transfusion-Associated Graft-Versus-Host Disease (TA-GVHD)**. In bone marrow transplantation, the recipient is severely immunocompromised due to conditioning regimens (chemotherapy/radiation). If non-irradiated blood products are transfused, viable donor T-lymphocytes can recognize the recipient's HLA antigens as foreign and mount an immune attack against the host's tissues (skin, liver, and bone marrow). Since the recipient’s immune system is suppressed, it cannot reject these donor cells. **Irradiation** (usually 25-30 Gy) inactivates donor T-lymphocytes by causing DNA cross-linking, preventing them from proliferating without affecting the function of red cells or platelets. **Why other options are incorrect:** * **Heart, Liver, and Lung (A, B, D):** While these are solid organ transplants requiring immunosuppression, the risk of TA-GVHD is significantly lower compared to hematopoietic stem cell transplants. Standard protocols for solid organ transplants do not routinely mandate irradiation of all cellular components unless the patient is undergoing specific high-intensity T-cell depleting therapy (like ATG). **High-Yield Clinical Pearls for NEET-PG:** * **Indications for Irradiated Blood:** Bone marrow/Stem cell transplant recipients, patients with Hodgkin lymphoma, intrauterine transfusions, and directed donations from first-degree relatives. * **TA-GVHD Mortality:** Unlike chronic GVHD, TA-GVHD is nearly always fatal (mortality >90%) due to profound bone marrow aplasia. * **Shelf Life:** Irradiation shortens the shelf life of RBCs to 28 days due to increased potassium leakage from the cells.

Question 158: Cock's peculiar tumour is described as:

A. An infected sebaceous cyst (Correct Answer)
B. A malignant tumour of the scalp
C. A metastatic lesion of the scalp
D. An indicator of underlying osteomyelitis

Explanation: **Explanation:** **Cock’s Peculiar Tumour** is a clinical entity where a long-standing **sebaceous cyst of the scalp** undergoes infection and ulceration. The correct answer is **Option A**. 1. **Why Option A is Correct:** When a sebaceous cyst on the scalp becomes infected, it can rupture and form an ulcerated, exuberant mass of granulation tissue. This proliferative growth mimics a fungating squamous cell carcinoma (hence "peculiar"), but it remains a benign, inflammatory complication of a sebaceous cyst. 2. **Why Other Options are Incorrect:** * **Option B & C:** Although it clinically resembles a malignant or metastatic lesion due to its raw, fungating appearance, it is pathologically benign. It does not arise from malignant transformation or distant spread. * **Option D:** While infection is present, it is localized to the dermis and subcutaneous tissue; it is not typically associated with underlying bone infection (osteomyelitis). **High-Yield Clinical Pearls for NEET-PG:** * **Common Site:** Almost exclusively found on the **scalp**. * **Clinical Appearance:** It presents as a foul-smelling, vascular, and ulcerated swelling that looks like a "cauliflower." * **Differential Diagnosis:** Must be differentiated from **Squamous Cell Carcinoma (SCC)**. The presence of a punctum or a history of a slow-growing cyst favors Cock’s tumour. * **Management:** Wide local excision is the treatment of choice. * **Pathology:** Histology shows inflamed granulation tissue and remnants of the sebaceous cyst wall; it is **not** a true neoplasm.

Question 159: What is the most sensitive investigation for acute appendicitis?

A. Ultrasound (USG)
B. Computed Tomography (CT) (Correct Answer)
C. Magnetic Resonance Imaging (MRI)
D. Abdominal Radiography

Explanation: ### Explanation **1. Why Computed Tomography (CT) is the Correct Answer:** Contrast-enhanced CT (CECT) of the abdomen and pelvis is the **gold standard** and the **most sensitive (94–98%)** and specific investigation for acute appendicitis. Its high diagnostic accuracy is due to its ability to clearly visualize the appendix (diameter >6 mm), wall thickening, periappendiceal fat stranding, and complications like phlegmon or abscess. It significantly reduces the rate of "negative appendectomies." **2. Analysis of Incorrect Options:** * **Ultrasound (USG):** While often the **initial investigation of choice** (especially in children and pregnant women) due to lack of radiation, it is highly operator-dependent and has lower sensitivity (approx. 86%), especially in obese patients or those with retrocecal appendices. * **Magnetic Resonance Imaging (MRI):** MRI is highly sensitive but is not the primary investigation due to high cost and limited availability. It is reserved as the **investigation of choice for pregnant women** when USG is inconclusive. * **Abdominal Radiography:** X-rays have very low sensitivity. While they may show a "fecalith" (appendicolith) in 10% of cases, they are primarily used to rule out other pathologies like intestinal obstruction or hollow viscus perforation. **3. NEET-PG High-Yield Pearls:** * **Most common cause of acute appendicitis:** Fecalith (adults); Lymphoid hyperplasia (children). * **Clinical Diagnosis:** Acute appendicitis remains primarily a clinical diagnosis based on the **Alvarado Score** (MANTRELS). * **Investigation of Choice (General):** CT Scan. * **Investigation of Choice (Pregnancy/Children):** Ultrasound (1st line); MRI (2nd line in pregnancy). * **Most common position of the appendix:** Retrocecal (74%). * **McBurney’s Point:** Located at the junction of the lateral 1/3rd and medial 2/3rd of the line joining the umbilicus to the Right Anterior Superior Iliac Spine (ASIS).

Question 160: Facial nerve injury occurs during parotid surgery. What is the best management?

A. Immediate repair (Correct Answer)
B. Repair after 1 week
C. Repair after waiting for partial recovery of the nerve
D. Do nothing and refer to a higher center

Explanation: **Explanation:** The facial nerve is the most critical structure encountered during parotidectomy. If the nerve is accidentally transected during surgery, **Immediate primary repair** (Option A) is the gold standard of management. **Why Immediate Repair is Correct:** 1. **Anatomical Alignment:** The nerve ends are fresh, easily identifiable, and have not yet retracted or been obscured by postoperative scarring and fibrosis. 2. **Distal Stimulation:** For up to 72 hours post-injury, the distal segment of the nerve can still be stimulated using a nerve stimulator (due to Wallerian degeneration not being complete), making it easier to locate the distal branches. 3. **Better Outcomes:** Primary neurorrhaphy (end-to-end anastomosis) or immediate cable grafting (using the great auricular or sural nerve) provides the best functional recovery. **Why Other Options are Incorrect:** * **Option B & C:** Delaying repair (delayed primary or secondary repair) leads to stump retraction, muscle atrophy, and dense fibrosis, which significantly complicates the surgery and worsens the prognosis for facial symmetry. * **Option D:** While complex cases may require expertise, "doing nothing" is negligent. The best window for repair is intraoperative. **NEET-PG High-Yield Pearls:** * **Most common nerve injured** in parotid surgery: Facial nerve (specifically the marginal mandibular branch). * **Most common benign tumor:** Pleomorphic adenoma (requires Superficial Parotidectomy). * **Landmarks to identify Facial Nerve:** Tragal pointer (nerve is 1cm deep and slightly anterior/inferior), Tympanomastoid fissure, and the Posterior belly of the digastric muscle. * **Frey’s Syndrome:** A late complication of parotidectomy due to aberrant regeneration of auriculotemporal nerve fibers. Diagnosis: Minor’s Starch-Iodine test.

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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