General Surgery Principles — MCQs

General Surgery Principles Indian Medical PG Practice Questions and MCQs

Question 171: Foley catheter is used for:

A. Suprapubic drainage
B. Acute limb ischaemia (Correct Answer)
C. Cardiac angioplasty
D. Intraventricular drainage

Explanation: **Explanation:** The correct answer is **Acute limb ischaemia**. While Foley catheters are synonymous with urinary drainage, this question tests the knowledge of specialized variants and their cross-disciplinary applications in surgery. **1. Why Acute Limb Ischaemia is correct:** In the context of acute limb ischaemia, a specialized version of the Foley catheter—the **Fogarty Embolectomy Catheter**—is the gold standard for performing a surgical embolectomy. It is a balloon-tipped catheter inserted into an artery; the balloon is inflated distal to the thrombus and then withdrawn, "dragging" the clot out to restore perfusion. In many emergency settings or exams, the term "Foley" is used broadly to refer to balloon-tipped catheters used for such mechanical extractions. **2. Analysis of Incorrect Options:** * **A. Suprapubic drainage:** While a Foley can be used for suprapubic cystostomy, the preferred and specific catheter for long-term suprapubic drainage is the **Malecot or Pezzer catheter** (self-retaining without a balloon). * **C. Cardiac angioplasty:** This requires high-pressure non-compliant balloons (e.g., **PTCA catheters**) to dilate stenotic coronary arteries. A standard Foley balloon is low-pressure and would be ineffective. * **D. Intraventricular drainage:** This is performed using an **External Ventricular Drain (EVD)** or a ventricular shunt. A Foley catheter is too large and lacks the necessary pressure-monitoring compatibility for neurosurgical use. **High-Yield Clinical Pearls for NEET-PG:** * **Fogarty Catheter Sizes:** Usually measured in French (F). Commonly 3F-4F for the femoral artery and 5F-6F for larger vessels. * **Balloon Inflation:** Always inflate the embolectomy balloon with **saline or air** gently to avoid intimal damage or arterial rupture. * **Urinary Foley:** The balloon size is typically 5-10 ml; however, for post-prostatectomy hemostasis, a 30 ml balloon is used to apply pressure to the prostatic bed.

Question 172: What is the most common site for pressure sores?

A. Ischium (Correct Answer)
B. Greater trochanter
C. Sacrum
D. Heel

Explanation: **Explanation:** Pressure sores (decubitus ulcers) occur due to prolonged ischemia caused by external pressure exceeding capillary perfusion pressure (approximately 32 mmHg). The distribution of these ulcers depends heavily on the patient's position. **Why Ischium is correct:** The **ischial tuberosity** is the most common site for pressure sores overall. This is because the highest pressure intensities in the body are recorded over the ischium while in the **sitting position**. Since many patients at risk (such as those with paraplegia) spend significant time in wheelchairs, the ischium remains the most frequent site of involvement. **Analysis of Incorrect Options:** * **Sacrum:** This is the most common site for patients in the **supine (lying down) position**. While very frequent in hospital-bed-bound patients, statistically, the ischium leads in overall prevalence across all patient populations (including chronic wheelchair users). * **Greater Trochanter:** This is the most common site for patients in the **lateral decubitus (side-lying) position**. * **Heel:** This is a common site in supine patients, particularly those with peripheral vascular disease or diabetes, but it ranks lower in frequency than the sacrum or ischium. **High-Yield Clinical Pearls for NEET-PG:** * **Order of Frequency:** Ischium (24%) > Sacrum (23%) > Greater Trochanter (15%) > Heel (8%). * **Grading:** Pressure sores are classified into 4 stages (Stage I: Non-blanchable erythema; Stage IV: Full-thickness loss with exposed bone/tendon/muscle). * **Management:** The gold standard for prevention is frequent repositioning (every 2 hours). For surgical closure, **myocutaneous flaps** are preferred over skin grafts due to better padding and blood supply.

Question 173: Interparietal hernia at the level of the arcuate line and lateral border of the rectus is called?

A. Spigelian hernia (Correct Answer)
B. Lumbar hernia
C. Richter’s hernia
D. Epigastric hernia

Explanation: ### Explanation **Correct Answer: A. Spigelian hernia** A **Spigelian hernia** is a type of interparietal hernia that occurs through the **Spigelian fascia** (the aponeurosis of the transversus abdominis muscle). * **Anatomy:** It is bounded laterally by the **linea semilunaris** (lateral border of the rectus muscle) and medially by the rectus sheath. * **Location:** The vast majority occur at or below the **arcuate line** (Spigelian hernia belt), where the posterior rectus sheath is absent, creating a point of potential weakness. * **Mechanism:** It is "interparietal" because the hernial sac often dissects between the internal oblique and external oblique aponeurosis, making it difficult to diagnose on physical examination as there is often no obvious external bulge. **Analysis of Incorrect Options:** * **B. Lumbar hernia:** Occurs through the posterior abdominal wall in either the superior (Grynfelt-Lesshaft) or inferior (Petit) lumbar triangles. * **C. Richter’s hernia:** A specific type of hernia where only a **portion of the circumference** of the bowel wall is trapped. It does not refer to a specific anatomical location like the Spigelian fascia. * **D. Epigastric hernia:** Occurs through the **linea alba** in the midline, anywhere between the xiphoid process and the umbilicus. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** Clinical diagnosis is difficult; **Ultrasound or CT scan** is the gold standard for confirmation. * **Risk of Strangulation:** High, due to the narrow, rigid neck of the defect. * **Treatment:** Surgical repair is always indicated (open or laparoscopic) because of the high risk of incarceration. * **Key Landmark:** The intersection of the arcuate line and the linea semilunaris is the most common site.

Question 174: Pseudoeschar formation is seen with which of the following agents?

A. Silver Nitrate
B. Silver sulfadiazine (Correct Answer)
C. Sulfamylon
D. Mafenide acetate

Explanation: **Explanation:** **Silver sulfadiazine (SSD)** is the most commonly used topical antibacterial agent in burn care. Its hallmark clinical feature is the formation of a **pseudoeschar**—a thick, grayish-white, gelatinous layer formed by the interaction of the cream with wound exudate. Unlike a true eschar (dead tissue), a pseudoeschar can be easily debrided or washed away during dressing changes. **Analysis of Options:** * **Silver sulfadiazine (B):** Correct. It is painless, has broad-spectrum activity (including *Pseudomonas*), but its main drawback is the formation of pseudoeschar which can sometimes harbor bacteria if not cleaned properly. * **Silver Nitrate (A):** This agent does not form a pseudoeschar. Instead, it causes **black staining** of the skin and dressings. Its major clinical side effects are electrolyte imbalances (hyponatremia, hypochloremia) due to leaching. * **Mafenide acetate / Sulfamylon (C & D):** These are the same agent. Mafenide is highly effective for deep penetration (especially in ear burns/cartilage), but it is notorious for causing **metabolic acidosis** (via carbonic anhydrase inhibition) and pain on application. It does not form a pseudoeschar. **High-Yield Clinical Pearls for NEET-PG:** * **Silver Sulfadiazine:** Can cause transient **leukopenia** (neutropenia) within 2-3 days of therapy; it is contraindicated in patients with sulfa allergies and in newborns (risk of kernicterus). * **Mafenide Acetate:** The drug of choice for **burns over cartilage** and heavily colonized wounds due to its superior tissue penetration. * **Silver Nitrate (0.5%):** Known for causing "blackening" and potential methemoglobinemia.

Question 175: What is the best method to monitor intracranial pressure?

A. Intraventricular catheter (Correct Answer)
B. Subarachnoid bolt
C. Intraparenchymal catheter
D. Epidural catheter

Explanation: **Explanation:** Monitoring intracranial pressure (ICP) is critical in managing severe traumatic brain injury and neurosurgical emergencies. **Why Intraventricular Catheter is the Correct Answer:** The **Intraventricular Catheter (Ventriculostomy)** is considered the **Gold Standard** for ICP monitoring. Its primary advantage is that it allows for both accurate pressure measurement and **therapeutic drainage of cerebrospinal fluid (CSF)** to acutely lower ICP. It is calibrated against an external transducer, making it the most reliable and accurate method available. **Analysis of Incorrect Options:** * **Subarachnoid Bolt (Richmond Bolt):** This is less invasive than a ventricular catheter as it does not penetrate the brain parenchyma. However, it is prone to clogging with debris or brain tissue and cannot be used to drain CSF, making it less accurate and versatile. * **Intraparenchymal Catheter:** These use fiberoptic or strain-gauge technology. While they provide accurate pressure readings and are easy to insert, they are expensive, prone to "measurement drift" (loss of accuracy over time), and do not allow for CSF drainage. * **Epidural Catheter:** These are placed between the skull and the dura. They are the least invasive but also the **least accurate**, as the dura acts as a buffer, often leading to inconsistent readings. **NEET-PG High-Yield Pearls:** * **Normal ICP:** 5–15 mmHg. Treatment is usually initiated when ICP >20–22 mmHg. * **Cerebral Perfusion Pressure (CPP):** MAP – ICP. Goal is typically maintained between 60–70 mmHg. * **Reference Point:** For an intraventricular catheter, the transducer should be leveled at the **Foramen of Monro** (approximated by the external auditory meatus). * **Complication:** The most significant risk of an intraventricular catheter is **infection (ventriculitis)**.

Question 176: Cystic hygroma is best described as which of the following?

A. Lymphangioma (Correct Answer)
B. Hemangioma
C. A condition that follows filariasis
D. Malignant

Explanation: **Explanation:** **Cystic Hygroma** is a congenital malformation of the lymphatic system, specifically classified as a **macrocystic lymphangioma**. It occurs due to the failure of the primary lymphatic sacs to establish a connection with the venous system, leading to the sequestration of lymphatic tissue and subsequent cystic dilatation. * **Why Option A is correct:** Cystic hygroma is the most common type of lymphangioma. It typically presents at birth or by age two as a soft, painless, compressible, and brilliantly **transilluminant** mass, most commonly located in the posterior triangle of the neck. * **Why Option B is incorrect:** Hemangiomas are benign tumors of vascular endothelium (blood vessels), not lymphatics. While they can also present in infancy, they do not typically show the same degree of transillumination as cystic hygromas. * **Why Option C is incorrect:** Lymphatic obstruction following filariasis (caused by *Wuchereria bancrofti*) leads to acquired lymphedema or elephantiasis, not congenital cystic hygromas. * **Why Option D is incorrect:** Cystic hygromas are inherently **benign** lesions. However, they can be clinically challenging due to their tendency to infiltrate local structures (nerves and vessels) and potential for rapid enlargement if infected or if hemorrhage occurs within the cyst. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Left side of the neck (Posterior triangle). * **Pathognomonic sign:** Brilliantly transilluminant (due to clear serous fluid). * **Association:** Frequently associated with chromosomal anomalies like **Turner syndrome** and Down syndrome. * **Treatment of choice:** Surgical excision is preferred; however, **Sclerotherapy** (using agents like OK-432 or Bleomycin) is an effective alternative for large, unresectable lesions.

Question 177: Following an oral surgical procedure, the surgical site is covered with a gauze wetted with saline because:

A. Saline promotes local hemostasis at the site.
B. Saline decreases the tendency of the clot to get embedded in gauze mesh. (Correct Answer)
C. Saline has localized anti-inflammatory action.
D. Saline accelerates the healing of the wound.

Explanation: **Explanation:** The primary reason for using saline-moistened gauze following oral surgery is to **prevent the blood clot from adhering to the gauze fibers.** When dry gauze is placed over a surgical site, the blood undergoes coagulation within the mesh of the fabric. Upon removal, the dry gauze pulls away the newly formed fibrin clot, leading to secondary bleeding, delayed healing, or complications like alveolar osteitis (dry socket). Wetting the gauze with saline creates a non-adherent interface, ensuring the clot remains undisturbed in the socket when the dressing is changed or removed. **Analysis of Incorrect Options:** * **Option A:** Saline is an isotonic solution and does not possess intrinsic vasoconstrictive or pro-coagulant properties. Hemostasis is achieved via mechanical pressure, not the saline itself. * **Option C:** Saline is chemically inert and does not have pharmacological anti-inflammatory properties. * **Option D:** While a moist environment is generally favorable for wound healing, saline itself does not "accelerate" the biological process of tissue repair; it simply protects the existing physiological repair mechanism (the clot). **High-Yield Clinical Pearls for NEET-PG:** * **Alveolar Osteitis (Dry Socket):** The most common complication after tooth extraction, caused by the premature loss or disintegration of the blood clot. Using moist gauze helps prevent this by preserving the clot. * **Wet-to-Dry Dressings:** In general surgery, these are used for mechanical debridement. However, in oral surgery, the goal is **protection**, hence the gauze is kept moist to avoid debridement of the essential clot. * **Isotonicity:** 0.9% Normal Saline is used because it is isotonic to body fluids, preventing cellular dehydration or lysis at the wound site.

Question 178: Which of the following is true about chronic wounds?

A. Found in diabetes mellitus (Correct Answer)
B. Always require surgical treatment
C. May be associated with vascular compromise
D. Monofilament sutures prevent infection

Explanation: **Explanation:** Chronic wounds are defined as wounds that fail to proceed through an orderly and timely series of events to produce anatomic and functional integrity within 3 months. **Why Option A is Correct:** Diabetes mellitus is a classic cause of chronic wounds (diabetic foot ulcers). The pathophysiology is multifactorial, involving **microangiopathy** (impaired capillary exchange), **neuropathy** (loss of protective sensation leading to repetitive trauma), and **impaired leukocyte function**, which delays the inflammatory phase of healing and increases infection risk. **Analysis of Incorrect Options:** * **Option B:** Not all chronic wounds require surgery. Many are managed conservatively with optimized glycemic control, offloading, compression therapy (for venous ulcers), and advanced dressings (e.g., hydrocolloids, silver dressings). * **Option C:** While many chronic wounds *are* associated with vascular compromise (e.g., arterial or venous ulcers), the question asks for a definitive "true" statement. Option A is a more direct clinical association, though Option C is often a contributing factor. (Note: In some versions of this question, "all of the above" might be used if C is framed as a common etiology). * **Option D:** While monofilament sutures (like Prolene) have a lower risk of harboring bacteria compared to braided sutures (like Silk), they do not "prevent" infection in a chronic wound. In fact, primary closure with sutures is generally contraindicated in infected or heavily colonized chronic wounds. **High-Yield Clinical Pearls for NEET-PG:** * **The "Time" Rule:** A wound is typically labeled chronic if it hasn't healed in **4–12 weeks**. * **Marjolin’s Ulcer:** A crucial high-yield fact—any chronic wound (especially burn scars or osteomyelitis sinuses) undergoing malignant transformation into **Squamous Cell Carcinoma** is called a Marjolin’s ulcer. * **Commonest Cause:** Globally, the most common cause of chronic leg ulcers is **Venous Insufficiency** (70%), followed by arterial disease and diabetes.

Question 179: Which of the following is NOT a feature of a pilonidal sinus?

A. Common in young males
B. Abscess formation
C. Jack knife position is used for surgery
D. Recurrence is uncommon (Correct Answer)

Explanation: **Explanation:** **Pilonidal Sinus (PNS)** is a chronic inflammatory condition occurring in the natal cleft, primarily caused by the penetration of hair into the skin, leading to a foreign body reaction and track formation. **Why Option D is the correct answer:** Recurrence is actually a **hallmark characteristic** of pilonidal sinus disease. Recurrence rates are high (ranging from 10% to 40% depending on the surgical technique) due to factors like persistent hair growth, inadequate excision of tracks, presence of deep natal clefts, and poor postoperative hygiene. Therefore, the statement "Recurrence is uncommon" is false. **Analysis of Incorrect Options:** * **Option A:** PNS is most **common in young males** (late teens to 20s). This is attributed to thicker body hair, increased sweat production, and deeper natal clefts compared to females. * **Option B:** **Abscess formation** is the most common acute presentation. If the sinus track becomes infected and drainage is blocked, a painful pilonidal abscess develops, requiring incision and drainage. * **Option C:** The **Jack-knife (Kraske) position** is the standard surgical position. The patient is prone with hips flexed and buttocks taped apart to provide optimal exposure of the sacrococcygeal area. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Obesity, sedentary lifestyle ("Jeep Rider’s Disease"), and hirsutism. * **Pathogenesis:** It is an **acquired** condition (Karydakis theory), not congenital. * **Surgical Procedures:** * *Bascom’s Procedure:* For simple disease. * *Karydakis Flap/Limberg Flap:* Transposition flaps used to flatten the natal cleft and reduce recurrence. * **Primary Treatment:** Wide local excision with primary closure or healing by secondary intention.

Question 180: All are true about epigastric hernia except?

A. Contents bulge in the epigastric region
B. Cough impulse is positive
C. The most common structure herniating is omentum (Correct Answer)
D. Can be confused with the pain of peptic ulcer

Explanation: **Explanation:** An epigastric hernia occurs through a defect in the **linea alba** between the xiphoid process and the umbilicus. **1. Why Option C is the Correct Answer (The "Except" statement):** Contrary to common belief, the most common content of an epigastric hernia is **extraperitoneal fat** (preperitoneal fat), not the omentum. The defect in the linea alba is usually very small (often less than 1 cm), which allows fat to protrude but is frequently too narrow for a peritoneal sac or omentum to enter. Therefore, the statement that omentum is the most common content is incorrect. **2. Analysis of Other Options:** * **Option A:** True. These hernias occur in the midline of the epigastrium. * **Option B:** True. Like most abdominal wall hernias, a cough impulse is typically present, though it may be difficult to elicit if the hernia is small, incarcerated, or composed of tense fat. * **Option D:** True. Epigastric hernias often present with localized pain and tenderness. Because of the location, the referred pain can mimic **peptic ulcer disease** or gallbladder disease, leading to diagnostic confusion. **Clinical Pearls for NEET-PG:** * **Gender Predominance:** More common in **males** (3:1 ratio), typically aged 20–50 years. * **Clinical Presentation:** Often presents as a small, painful lump. Pain is exacerbated by straining or coughing. * **Multiple Defects:** In about 20% of cases, multiple defects are present; always palpate the entire linea alba. * **Management:** They do not resolve spontaneously. Surgical repair (herniotomy and primary closure) is the treatment of choice.

Practice by Chapter

Wound Healing and Care

Practice Questions

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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