General Surgery Principles — MCQs

General Surgery Principles Indian Medical PG Practice Questions and MCQs

Question 251: All of the following are true about sportsman's hernia except:

A. Has inguinal pain
B. Sac is palpable (Correct Answer)
C. IOC is MRI
D. Laparoscopic inguinal hernia surgery

Explanation: **Explanation:** **Sportsman’s Hernia** (also known as Gilmore’s Groin or Athletic Pubalgia) is a clinical syndrome characterized by chronic groin pain. Despite the name, it is **not a true hernia** because there is no actual defect in the abdominal wall and no protrusion of a peritoneal sac. 1. **Why Option B is correct:** Since there is no actual herniation of intra-abdominal contents, there is **no palpable sac**. The condition involves a tear or strain of the soft tissues (muscles, tendons, or ligaments) in the groin area, specifically the posterior inguinal wall or the insertion of the rectus abdominis. 2. **Why Option A is incorrect:** Inguinal pain is the hallmark symptom. It is typically unilateral, exercise-induced, and aggravated by sudden movements like kicking, twisting, or sprinting. 3. **Why Option C is incorrect:** **MRI** is the Investigation of Choice (IOC) as it can identify bone marrow edema in the pubic symphysis, muscle tears (adductor longus or rectus abdominis), and help rule out other causes of groin pain. 4. **Why Option D is incorrect:** If conservative management (rest and physiotherapy) fails, surgical intervention is indicated. Both open and **laparoscopic inguinal hernia repairs** (using mesh to reinforce the posterior wall) are standard treatments to stabilize the groin. **Clinical Pearls for NEET-PG:** * **Pathophysiology:** Often involves a "tug-of-war" imbalance between the strong adductor muscles and weak abdominal muscles. * **Physical Exam:** Pain is often elicited by resisted adduction or a resisted sit-up. * **Differential Diagnosis:** Must be distinguished from Osteitis Pubis (inflammation of the pubic symphysis).

Question 252: Which of the following is NOT an indication for PAIR treatment in a hydatid cyst?

A. Size > 5 cm
B. Multiloculated cyst
C. Cyst in lung
D. Recurrence after surgery (Correct Answer)

Explanation: **Explanation:** **PAIR (Puncture, Aspiration, Injection, Re-aspiration)** is a minimally invasive technique used for managing Hydatid cysts (Echinococcus granulosus). The correct answer is **Option D**, as recurrence after surgery is actually a **primary indication** for PAIR, not a contraindication. **Why Option D is the correct answer:** Recurrent cysts after surgical intervention are often difficult to manage with repeat surgery due to adhesions and altered anatomy. PAIR is highly effective and preferred in such cases. **Analysis of Incorrect Options (Contraindications for PAIR):** * **Option A (Size > 5 cm):** While PAIR is generally used for cysts > 5 cm (WHO stages CE1 and CE3a), very large cysts or those with specific complications may require surgery. However, size alone is an indication, not a contraindication. * **Option B (Multiloculated cyst):** This is a **relative contraindication**. PAIR is difficult in multiloculated cysts (WHO stage CE2) because the scolicidal agent cannot reach all daughter cysts effectively. Surgery or medical management is preferred. * **Option C (Cyst in lung):** This is an **absolute contraindication**. PAIR is never performed on pulmonary hydatid cysts due to the high risk of cyst rupture into the bronchial tree, leading to anaphylaxis or suffocation, and the negative pressure in the thorax which prevents the cavity from collapsing. **High-Yield Clinical Pearls for NEET-PG:** * **WHO Classification:** PAIR is best for **CE1** (unilocular) and **CE3a** (detached membranes) stages. * **Scolicidal Agents:** Commonly used agents include **20% Hypertonic saline** (most common) or 95% Ethanol. * **Medical Cover:** Always start **Albendazole** (10-15 mg/kg/day) at least 4 days before and continue for 4 weeks after PAIR to prevent secondary hydatidosis. * **Absolute Contraindications:** Lung/Brain cysts, superficially located cysts (risk of rupture), and inactive/calcified cysts (CE4/CE5).

Question 253: In a lumbar sympathectomy, the sympathetic chain in its usual position is likely to be confused with which of the following structures?

A. Ureter
B. Psoas minor (Correct Answer)
C. Genitofemoral nerve
D. Ilioinguinal nerve

Explanation: **Explanation:** In a lumbar sympathectomy, the sympathetic chain is located in the retroperitoneal space, lying on the anterolateral aspect of the lumbar vertebral bodies, medial to the psoas major muscle. **Why Psoas Minor is the correct answer:** The **Psoas minor tendon** is the structure most commonly confused with the sympathetic chain during surgery. This is because the Psoas minor (present in about 60% of the population) has a long, thin, glistening tendon that lies on the anterior surface of the Psoas major. To differentiate them, surgeons use the **"Pluck Test"**: when the sympathetic chain is picked up with a hook, it feels rigid and gives a characteristic "snap" due to its attachments (rami communicantes), whereas a tendon is more elastic and does not have these lateral attachments. **Analysis of Incorrect Options:** * **Ureter:** While the ureter is a retroperitoneal structure, it is more lateral and anterior. It is easily identified by its characteristic **peristalsis** when touched. * **Genitofemoral nerve:** This nerve emerges on the anterior surface of the Psoas major but is much thinner and runs more laterally than the sympathetic chain. * **Ilioinguinal nerve:** This nerve emerges from the lateral border of the Psoas major and runs across the quadratus lumborum, far from the vertebral bodies where the chain is located. **High-Yield Clinical Pearls for NEET-PG:** * **Level of Surgery:** For Buerger’s disease or peripheral vascular disease of the lower limb, the **L2, L3, and L4** ganglia are typically removed. * **Avoid L1:** The L1 ganglion is preserved in bilateral procedures to prevent **loss of ejaculation** (retrograde ejaculation). * **Landmark:** The right sympathetic chain is partially covered by the **Inferior Vena Cava (IVC)**, while the left chain is lateral to the **Aorta**.

Question 254: Which of the following is NOT a complication of peritonitis?

A. Cardiac failure (Correct Answer)
B. Residual abscess
C. Endotoxic shock
D. Bone marrow suppression

Explanation: **Explanation:** Peritonitis is a severe inflammatory process of the peritoneum, typically resulting from infection or chemical irritation. The systemic response to peritonitis is characterized by a massive release of inflammatory mediators and significant fluid shifts. **Why Cardiac Failure is the correct answer:** While peritonitis causes significant cardiovascular stress, **Cardiac Failure** is not a direct or typical complication of the disease process itself. Instead, peritonitis leads to **hypovolemia** (due to third-space fluid loss) and **septic shock**, which results in a high-output state or peripheral vasodilation rather than primary pump failure. Unless the patient has a pre-existing cardiac condition, the heart usually maintains its intrinsic function while struggling to compensate for low systemic vascular resistance. **Analysis of other options:** * **Residual Abscess:** This is a common local complication. Infected fluid can collect in dependent areas like the subphrenic space or the Pouch of Douglas, leading to localized abscess formation. * **Endotoxic Shock:** Gram-negative bacteria (common in gut perforation) release lipopolysaccharides (endotoxins), triggering a systemic inflammatory response syndrome (SIRS) and septic shock. * **Bone Marrow Suppression:** Severe, prolonged sepsis associated with peritonitis can lead to toxic suppression of the bone marrow, manifesting as leukopenia or thrombocytopenia. **NEET-PG High-Yield Pearls:** * **Most common cause of primary peritonitis:** *Streptococcus pneumoniae* (in children) or *E. coli* (in adults with cirrhosis). * **Most common cause of secondary peritonitis:** Perforation of a hollow viscus (e.g., Peptic ulcer or Appendix). * **Clinical Hallmark:** "Board-like" abdominal rigidity and rebound tenderness. * **Radiology:** Upright X-ray showing "pneumoperitoneum" (gas under the diaphragm) is the gold standard for diagnosing perforation.

Question 255: What percentage of burns in a child involve the head region?

A. 10%
B. 20% (Correct Answer)
C. 30%
D. 40%

Explanation: In pediatric burn assessment, the **Rule of Nines** used for adults is modified because children have a disproportionately larger head and smaller lower extremities compared to adults. ### Why 20% is Correct According to the **Lund and Browder chart** (the most accurate method for pediatric surface area calculation), the head of a newborn or infant accounts for approximately **18-19%** of the Total Body Surface Area (TBSA). In clinical practice and for standardized examinations like NEET-PG, this is rounded to **20%**. As the child grows, the head's relative surface area decreases by 1% for every year of age, while the legs increase in percentage. ### Explanation of Incorrect Options * **A (10%):** This is closer to the adult value. In adults, the head and neck represent only **9%** of the TBSA. * **C & D (30% & 40%):** These values significantly overestimate the cranial surface area. Even in a neonate, the head does not exceed 20% of the total body surface. ### High-Yield Clinical Pearls for NEET-PG * **The "1% Rule":** For children, subtract 1% from the head for every year over age 1 and add 0.5% to each leg. By age 10, a child’s proportions closely resemble an adult's. * **Palmar Method:** The patient’s entire palm (including fingers) represents approximately **1% TBSA**. This is useful for small or patchy burns. * **Fluid Resuscitation:** The **Parkland Formula** (4ml x kg x %TBSA) is used, but in children, **maintenance fluids** (using the 4-2-1 rule) must be added to the resuscitation volume to prevent hypoglycemia and electrolyte imbalance. * **Critical Area:** Any burn involving the face/head in a child is considered a major burn due to the risk of airway involvement and cosmetic deformity.

Question 256: A 15-year-old girl, a regular swimmer, presents with sudden onset of abdominal pain, abdominal distension, and a fever of 39°C, along with obliteration of liver dullness. What is the most probable diagnosis?

A. Ruptured typhoid ulcer (Correct Answer)
B. Primary bacterial peritonitis
C. Ruptured ectopic pregnancy
D. Urinary tract infection with pelvic inflammatory disease

Explanation: ### Explanation **Correct Answer: A. Ruptured typhoid ulcer** The clinical presentation of sudden onset abdominal pain, distension, high-grade fever (39°C), and **obliteration of liver dullness** is a classic triad for **pneumoperitoneum** resulting from a hollow viscus perforation. In the context of a young patient in an endemic region, a ruptured typhoid ulcer is the most likely cause. Typhoid fever (caused by *Salmonella typhi*) leads to hyperplasia and subsequent necrosis of **Peyer’s patches** in the terminal ileum. Perforation typically occurs during the **third week** of the illness. The loss of liver dullness (Gas under the diaphragm) confirms the presence of free intraperitoneal air. **Why other options are incorrect:** * **B. Primary Bacterial Peritonitis (PBP):** Usually occurs in patients with pre-existing ascites (e.g., cirrhosis or nephrotic syndrome). It presents with diffuse pain but **does not** cause obliteration of liver dullness, as there is no hollow viscus perforation. * **C. Ruptured Ectopic Pregnancy:** While it causes sudden abdominal pain and shock, it typically presents with signs of internal hemorrhage (anemia, hypotension) rather than high-grade fever and pneumoperitoneum. * **D. UTI with PID:** These conditions cause pelvic pain and fever but do not result in free intraperitoneal air or the acute surgical abdomen seen here. **High-Yield Clinical Pearls for NEET-PG:** * **Site of Typhoid Perforation:** Usually within **45–60 cm** of the ileocaecal valve. * **Most Common Site of GI Perforation (Overall):** Duodenal ulcer (first part). * **Radiological Sign:** The most sensitive sign for perforation is **"Gas under the right dome of the diaphragm"** on an erect X-ray chest/abdomen. * **Management:** Typhoid perforation is a surgical emergency requiring resuscitation followed by primary closure or ileostomy.

Question 257: A 25-year-old male patient presents with a bony expansile swelling of the right body of the mandible and mild paresthesia of the right inferior alveolar nerve. An OPG shows a multilocular radiolucency without root resorption. What is the management of an odontogenic keratocyst?

A. Marsupialization
B. Enucleation
C. Enucleation with peripheral ostectomy (Correct Answer)
D. Resection and radiation

Explanation: **Explanation:** The **Odontogenic Keratocyst (OKC)**, now often referred to as a Keratocystic Odontogenic Tumor, is known for its aggressive local behavior and high recurrence rate (up to 30-60% with simple treatment). This high recurrence is due to the presence of **"daughter cysts"** or "satellite cysts" in the thin, friable epithelial lining and the surrounding bony wall. 1. **Why Option C is correct:** **Enucleation with peripheral ostectomy** (or Carnoy’s solution application) is the gold standard. Simple enucleation leaves behind microscopic satellite cysts. Peripheral ostectomy involves removing a 1–2 mm layer of bone from the cavity margin using a burr, effectively eliminating these satellite cysts and significantly reducing recurrence rates. 2. **Why other options are incorrect:** * **Marsupialization (A):** This involves decompression to reduce the size of the cyst. While it preserves vital structures, it is rarely used as a definitive treatment for OKC because it leaves the aggressive lining in situ. * **Enucleation (B):** Simple enucleation alone has an unacceptably high recurrence rate for OKCs. * **Resection and Radiation (D):** While radical resection (segmental mandibulectomy) is definitive, it is often considered over-treatment for a benign lesion in a young patient. **Radiation is never indicated** for OKC as it is a benign pathology and carries a risk of secondary malignancy. **High-Yield Pearls for NEET-PG:** * **Radiology:** Classically presents as a multilocular "soap bubble" or "honeycomb" radiolucency. Unlike Ameloblastoma, OKC typically causes **minimal expansion** and **rarely causes root resorption**. * **Syndromic Association:** Multiple OKCs are a hallmark of **Gorlin-Goltz Syndrome** (Nevoid Basal Cell Carcinoma Syndrome), associated with PTCH gene mutations. * **Aspiration:** Characteristically shows a "cheesy" or "creamy" white aspirate (keratin) with low soluble protein levels (<4g/dL).

Question 258: All are included in the Child-Turcotte-Pugh classification except?

A. Bilirubin
B. Ascites
C. INR
D. ALP (Correct Answer)

Explanation: The **Child-Turcotte-Pugh (CTP) score** is a clinical tool used to assess the prognosis of chronic liver disease, primarily cirrhosis. It predicts mortality and the necessity for liver transplantation. ### Why ALP is the Correct Answer **Alkaline Phosphatase (ALP)** is a marker of cholestasis or bone turnover but is **not** a component of the CTP classification. While liver enzymes (ALT/AST/ALP) indicate liver injury, they do not accurately reflect the liver's functional reserve or synthetic capacity, which is what the CTP score aims to measure. ### Explanation of Other Options The CTP score consists of five parameters (mnemonic: **ABCDE**): * **A - Albumin:** Reflects the synthetic function of the liver. * **B - Bilirubin:** Indicates the liver's excretory function. * **C - Coagulation (INR/Prothrombin Time):** Reflects the synthesis of vitamin K-dependent clotting factors. * **D - Distension (Ascites):** Assessed via physical exam or ultrasound (None, Mild, Moderate/Severe). * **E - Encephalopathy:** Graded based on clinical severity (None, Grade 1-2, Grade 3-4). ### High-Yield Clinical Pearls for NEET-PG * **Scoring:** Each parameter is scored from 1 to 3. The total score ranges from **5 to 15**. * **Classification:** * **Class A (5–6 points):** Least severe, 100% 1-year survival. * **Class B (7–9 points):** Moderate severity. * **Class C (10–15 points):** Most severe, ~45% 1-year survival. * **CTP vs. MELD:** While CTP is bedside-friendly, the **MELD score** (Model for End-Stage Liver Disease) is now preferred for transplant allocation. MELD uses objective values: **Bilirubin, Creatinine, and INR** (and recently Sodium). * **Surgical Significance:** Patients with Child Class C are generally considered poor candidates for elective non-transplant surgery due to high perioperative mortality.

Question 259: All of the following are true about lymphedema EXCEPT:

A. Prevalence of 0.1-2%
B. Interstitial fluid accumulation
C. Severe lymphedema if limb volume increases by more than 40%
D. Primary lymphedema typically sets in by age of 2 (Correct Answer)

Explanation: **Explanation:** Lymphedema is a chronic condition characterized by the accumulation of protein-rich **interstitial fluid** due to impaired lymphatic drainage. **Why Option D is the Correct Answer (The False Statement):** Primary lymphedema is classified based on the age of onset, and it rarely sets in by age 2. The most common form is **Lymphedema Praecox**, which typically appears during puberty or adolescence (up to age 35) and accounts for 80% of primary cases. Only *Lymphedema Congenita* (e.g., Milroy’s disease) is present at birth or within the first two years of life, making the statement that it "typically" sets in by age 2 incorrect. **Analysis of Other Options:** * **Option A:** The global prevalence of lymphedema is estimated to be between **0.1% and 2%**, making it a significant clinical entity. * **Option B:** The fundamental pathophysiology involves the failure of the lymphatic system to remove high-molecular-weight proteins, leading to increased oncotic pressure and **interstitial fluid accumulation**. * **Option C:** Lymphedema severity is often graded by limb volume increase: Mild (<20%), Moderate (20–40%), and **Severe (>40%)**. **NEET-PG High-Yield Pearls:** * **Most common cause worldwide:** Filariasis (*Wuchereria bancrofti*). * **Most common cause in developed countries:** Secondary to malignancy or its treatment (e.g., post-mastectomy axillary lymph node dissection). * **Stemmer’s Sign:** Inability to pinch the skin on the dorsal surface of the base of the second toe; a pathognomonic clinical finding. * **Stewart-Treves Syndrome:** A rare, dreaded complication where lymphangiosarcoma develops in a limb with long-standing chronic lymphedema.

Question 260: Which of the following is not a sign of appendicitis?

A. Rovsing's sign
B. Murphy's sign (Correct Answer)
C. Obturator sign
D. Psoas sign

Explanation: **Explanation:** The correct answer is **B. Murphy's sign**. **Why Murphy's sign is the correct answer:** Murphy’s sign is the classic clinical indicator for **Acute Cholecystitis**, not appendicitis. It is elicited by asking the patient to take a deep breath while the clinician maintains pressure in the right upper quadrant (over the gallbladder). As the liver descends, the inflamed gallbladder strikes the examining fingers, causing the patient to catch their breath (inspiratory arrest). **Analysis of incorrect options (Signs of Appendicitis):** * **A. Rovsing's sign:** Indirect tenderness. Pressing in the Left Lower Quadrant (LLQ) causes pain in the Right Lower Quadrant (RLQ) due to the displacement of gas and peritoneal irritation. * **C. Obturator sign:** Pain on internal rotation of the flexed right hip. This indicates an inflamed **pelvic appendix** irritating the obturator internus muscle. * **D. Psoas sign:** Pain on passive extension of the right hip. This indicates a **retrocecal appendix** irritating the iliopsoas muscle. **High-Yield Clinical Pearls for NEET-PG:** * **McBurney’s Point:** The point of maximum tenderness, located 1/3rd of the distance from the ASIS to the umbilicus. * **Sherren’s Triangle:** Formed by the umbilicus, ASIS, and pubic symphysis; hyperesthesia in this area suggests appendicitis. * **Alvarado Score (MANTRELS):** A clinical scoring system where a score of ≥7 is highly suggestive of appendicitis. * **Gold Standard Imaging:** Contrast-enhanced CT (CECT) is the most accurate investigation, though Ultrasound is the initial choice in children and pregnant women.

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