General Surgery Principles — MCQs

General Surgery Principles Indian Medical PG Practice Questions and MCQs

Question 261: The composition of which of the following intravenous fluids most closely resembles that of plasma?

A. Isotonic saline
B. 1/5th isotonic saline
C. 4.3% dextrose
D. Lactated Ringer's solution (Correct Answer)

Explanation: **Explanation:** The goal of fluid resuscitation is to maintain physiological homeostasis. **Lactated Ringer’s (LR) solution**, also known as Hartmann's solution, is considered the most "physiological" crystalloid because its electrolyte composition and osmolarity closely mimic human plasma. **Why Lactated Ringer's is Correct:** * **Electrolytes:** Unlike normal saline, LR contains potassium (4 mEq/L) and calcium (3 mEq/L) in concentrations similar to plasma. * **Buffer:** It contains **Sodium Lactate**, which is metabolized by the liver into bicarbonate, helping to maintain acid-base balance and preventing the hyperchloremic metabolic acidosis often seen with large volumes of saline. * **Osmolarity:** Its osmolarity (approx. 273 mOsm/L) is closer to plasma (285–295 mOsm/L) than other common crystalloids. **Why Other Options are Incorrect:** * **Isotonic Saline (0.9% NaCl):** Contains supra-physiological levels of Chloride (154 mEq/L vs. plasma 100 mEq/L). Large volumes lead to hyperchloremic metabolic acidosis. * **1/5th Isotonic Saline:** This is a hypotonic solution used primarily in pediatric maintenance fluids; it does not resemble plasma and can cause cellular swelling. * **4.3% Dextrose:** This is essentially free water once the glucose is metabolized. It is used to treat dehydration but does not provide the electrolyte support required for plasma volume expansion. **High-Yield NEET-PG Pearls:** * **Fluid of Choice:** LR is the fluid of choice for **burns (Parkland Formula)** and **hemorrhagic shock**. * **Contraindication:** Avoid LR in patients receiving blood transfusions in the same line (Calcium in LR can bind to Citrate anticoagulant, causing **clotting**). * **Metabolism:** Avoid LR in severe liver failure as the liver cannot convert lactate to bicarbonate, potentially worsening lactic acidosis.

Question 262: Which procedure is indicated for the management of recurrent ranula?

A. Incision and drainage
B. Aspiration
C. Excision (Correct Answer)
D. Sclerosant injection

Explanation: **Explanation:** A **ranula** is a clinical term for a mucocele occurring in the floor of the mouth, typically arising from the **sublingual gland**. It results from either mucus extravasation (due to ductal trauma) or mucus retention. **Why Excision is the Correct Answer:** The definitive management for a recurrent ranula is the **complete excision of the cyst along with the offending sublingual gland**. Since the sublingual gland is a spontaneous secretor, leaving it in situ provides a continuous source of mucus, leading to high recurrence rates. While "marsupialization" is often the first-line treatment for simple ranulas, **excision of the sublingual gland** is the gold standard for recurrent or "plunging" (diving) ranulas to ensure a permanent cure. **Why Other Options are Incorrect:** * **Incision and Drainage (A):** This provides only temporary symptomatic relief. The wound heals quickly, but the underlying secretory gland remains, leading to almost 100% recurrence. * **Aspiration (B):** Aspiration is purely diagnostic (to confirm the presence of "snail-track" mucus). It is never a definitive treatment as the fluid re-accumulates rapidly. * **Sclerosant Injection (D):** While agents like OK-432 or Bleomycin are sometimes used in specialized cases (especially for plunging ranulas in patients unfit for surgery), they are not the standard primary surgical indication for recurrent cases. **NEET-PG High-Yield Pearls:** * **Anatomy:** Ranulas are located lateral to the midline in the floor of the mouth (unlike dermoid cysts, which are midline). * **Plunging Ranula:** Occurs when the mucus extravasates through or around the **mylohyoid muscle** into the submandibular space, presenting as a neck swelling. * **Diagnosis:** Usually clinical; "blue-domed" appearance. MRI is the imaging of choice to see the "tail sign" in plunging ranulas. * **Complication:** The most significant risk during excision is injury to the **lingual nerve** or the **Wharton’s duct**.

Question 263: Which of the following is true about abdominal compartment syndrome?

A. Intra-abdominal pressure > 15 cm H2O
B. Decreased urine output (Correct Answer)
C. Increased renal blood flow
D. Decreased venous return

Explanation: **Abdominal Compartment Syndrome (ACS)** is defined as a sustained intra-abdominal pressure (IAP) **> 20 mmHg** (not cm H2O) associated with new-onset organ dysfunction. ### **Explanation of Options** * **Correct Answer: Decreased urine output (B):** Oliguria is one of the earliest signs of ACS. Increased IAP causes direct compression of the renal parenchyma and renal veins. This leads to a decrease in renal perfusion pressure and glomerular filtration rate (GFR), eventually resulting in acute kidney injury. * **Incorrect (A):** The threshold for ACS is **> 20 mmHg**. While Intra-abdominal Hypertension (IAH) starts at ≥ 12 mmHg, ACS requires the higher threshold of 20 mmHg plus organ failure. * **Incorrect (C):** Renal blood flow is **decreased**, not increased, due to the mechanical compression of vessels and reduced cardiac output. * **Incorrect (D):** This is a tricky distractor. While ACS **decreases venous return** from the lower extremities (due to IVC compression), the question asks for the "most true" clinical manifestation or hallmark. In many exam patterns, the physiological hallmark of ACS is the systemic effect on organ perfusion, specifically the renal and respiratory systems. *Note: If this were a "multiple correct" style, D would also be physiologically true; however, in NEET-PG, the clinical manifestation of oliguria is the classic diagnostic trigger.* ### **High-Yield Clinical Pearls for NEET-PG** 1. **Gold Standard Measurement:** Indirect measurement via **intra-vesical (bladder) pressure** using a Foley catheter (Transducer technique). 2. **Abdominal Perfusion Pressure (APP):** Calculated as MAP minus IAP. Target APP should be **> 60 mmHg** for survival. 3. **Respiratory Effects:** Elevation of the diaphragm leads to decreased lung compliance, increased peak airway pressure, and hypercapnia. 4. **Management:** Initial medical management (NG decompression, prokinetics); definitive treatment is **decompressive laparotomy** (leaving the abdomen open with a Bogota bag or VAC).

Question 264: Which of the following is NOT a medical indication for circumcision?

A. Non-retractile foreskin (Correct Answer)
B. Paraphimosis
C. Recurrent balanoposthitis
D. Recurrent urinary tract infections

Explanation: **Explanation:** The correct answer is **A. Non-retractile foreskin**. In pediatric surgery, it is crucial to distinguish between **physiologic phimosis** and **pathologic phimosis**. At birth, the inner surface of the prepuce is naturally adherent to the glans, making the foreskin non-retractile. This is a normal developmental stage. By age 3, about 90% of boys will have a retractile foreskin, and this percentage increases with age. Therefore, a simple non-retractile foreskin in an asymptomatic child is not a medical indication for surgery; it requires only observation and hygiene. **Analysis of Incorrect Options:** * **Paraphimosis (B):** This is a surgical emergency where the foreskin is trapped behind the glans, causing venous congestion and edema. While initial management involves manual reduction, circumcision is indicated to prevent recurrence. * **Recurrent Balanoposthitis (C):** Chronic or recurrent inflammation of the glans (balanitis) and prepuce (posthitis), often seen in diabetic patients or those with poor hygiene, is a definitive indication for circumcision. * **Recurrent Urinary Tract Infections (D):** In children with underlying urological abnormalities (like posterior urethral valves or high-grade VUR), circumcision is indicated as it significantly reduces the bacterial colonization of the preputial space, lowering the risk of ascending UTIs. **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Indication:** Pathologic phimosis (scarring of the preputial orifice, often due to *Balanitis Xerotica Obliterans* or BXO). * **BXO:** The most common cause of pathological phimosis; it appears as a white, scarred, thickened prepuce. * **Contraindication:** Never perform circumcision in patients with **Hypospadias**, as the prepuce is required for future reconstructive surgery (chordee correction or urethroplasty).

Question 265: If the caecum is involved as a part of the wall of a hernial sac and is not its content, then it will be known as:

A. Richter's hernia
B. Spigelian hernia
C. Sliding hernia (Correct Answer)
D. Interstitial hernia

Explanation: ### Explanation **Correct Answer: C. Sliding Hernia (Hernie en Glissade)** A **Sliding Hernia** occurs when a retroperitoneal organ (most commonly the **caecum** on the right or the **sigmoid colon** on the left) drags its overlying peritoneum with it as it descends through the hernial orifice. Consequently, the organ itself forms a portion of the **posterior wall of the sac**, rather than being free content within the sac. This is a crucial surgical distinction because an inadvertent incision into the "sac" on its posterior aspect can result in accidental injury to the bowel. **Analysis of Incorrect Options:** * **A. Richter’s Hernia:** This involves the protrusion of only a **portion of the bowel wall circumference** through the defect. It can lead to strangulation without causing complete intestinal obstruction. * **B. Spigelian Hernia:** This is a ventral hernia occurring through the **linea semilunaris** (at the level of the arcuate line), lateral to the rectus abdominis muscle. * **D. Interstitial Hernia:** Here, the hernial sac lies **between the layers of the abdominal wall** (e.g., between the external and internal oblique muscles) rather than protruding into the subcutaneous tissue. **High-Yield Clinical Pearls for NEET-PG:** * **Most common organs involved:** Bladder (often in direct inguinal hernias), Caecum (right side), and Sigmoid colon (left side). * **Surgical Caution:** Never open a hernial sac from the posterior side; always open it anteriorly to avoid injuring the sliding component. * **Demographics:** Sliding hernias are more common in elderly males and are almost always associated with **indirect inguinal hernias**. * **Diagnosis:** Often suspected clinically when a large, long-standing hernia cannot be completely reduced.

Question 266: When the rectum is inflated with air through a rectal tube, pain and tenderness occur in the right iliac fossa in case of appendicitis. What is this sign known as?

A. Aaron's sign
B. Battle's sign
C. Bastedo's sign (Correct Answer)
D. McBurney's sign

Explanation: ### Explanation **Correct Answer: C. Bastedo's sign** **Bastedo’s sign** is a clinical sign used in the diagnosis of chronic or subacute appendicitis. It is elicited by inserting a rectal tube and inflating the colon with air (insufflation). As the air distends the cecum, it causes movement and irritation of the inflamed appendix, leading to referred pain and tenderness in the **right iliac fossa (RIF)**. This is based on the principle that mechanical distension of the bowel proximal to the site of inflammation will provoke localized peritoneal irritation. #### Analysis of Incorrect Options: * **A. Aaron’s sign:** Refers to referred pain or distress in the epigastrium or precordial region upon continuous firm pressure over McBurney’s point. It is indicative of appendicitis. * **B. Battle’s sign:** This is an extra-abdominal sign characterized by ecchymosis (bruising) over the mastoid process. It is a classic indicator of a **basilar skull fracture** (middle cranial fossa). * **D. McBurney’s sign:** This is the most common sign of acute appendicitis, defined as deep tenderness at McBurney’s point (located 1/3rd of the distance from the ASIS to the umbilicus). #### NEET-PG High-Yield Pearls: * **Rovsing’s Sign:** Pain in the RIF when the Left Iliac Fossa is palpated (due to shift of gas). * **Psoas Sign:** Pain on extension of the right hip (indicates a **retrocecal** appendix). * **Obturator Sign:** Pain on internal rotation of the flexed right hip (indicates a **pelvic** appendix). * **Sherren’s Triangle:** An area of hyperesthesia formed by the umbilicus, ASIS, and symphysis pubis; its presence suggests impending perforation.

Question 267: Complications of total parenteral nutrition include all except?

A. Hyperglycemia
B. Hypoglycemia
C. Hypochloremic alkalosis (Correct Answer)
D. Electrolyte abnormalities

Explanation: **Explanation:** Total Parenteral Nutrition (TPN) is a complex intravenous solution that bypasses the gastrointestinal tract. While life-saving, it is associated with significant metabolic, mechanical, and infectious complications. **Why Hypochloremic Alkalosis is the Correct Answer:** TPN is more commonly associated with **Hyperchloremic Metabolic Acidosis**. This occurs because the crystalline amino acids used in TPN formulations often contain chloride salts (like lysine hydrochloride). When these are metabolized, they release excess chloride ions and hydrogen ions, leading to a drop in pH. Hypochloremic alkalosis is typically seen in conditions like persistent vomiting or gastric suctioning, not as a direct result of TPN administration. **Analysis of Incorrect Options:** * **Hyperglycemia (A):** The most common metabolic complication. It occurs due to high glucose infusion rates, stress-induced insulin resistance, or rapid initiation of TPN. * **Hypoglycemia (B):** Usually occurs as "rebound hypoglycemia" if TPN is discontinued abruptly, as the pancreas takes time to downregulate high insulin secretion. * **Electrolyte Abnormalities (D):** TPN frequently causes shifts in potassium, magnesium, and phosphate. A classic example is **Refeeding Syndrome**, characterized by profound hypophosphatemia, hypokalemia, and hypomagnesemia. **High-Yield Clinical Pearls for NEET-PG:** * **Most common TPN complication:** Hyperglycemia. * **Most common electrolyte abnormality in Refeeding Syndrome:** Hypophosphatemia. * **Hepatobiliary complication:** Cholestasis and cholelithiasis (due to lack of enteral stimulation and gallbladder stasis). * **Infectious:** Catheter-related bloodstream infections (CRBSI), most commonly by *Staphylococcus aureus* or *Candida*. * **Essential Fatty Acid Deficiency (EFAD):** Presents as dry, scaly rash (alopecia) if lipid emulsions are omitted.

Question 268: Which of the following investigations is generally NOT indicated in the management of an obstructed inguinal hernia?

A. Aspiration of the sac for diagnosis
B. X-ray abdomen (Correct Answer)
C. Ultrasound (USG) abdomen
D. Early surgical intervention

Explanation: **Explanation:** In the management of an **obstructed inguinal hernia**, the diagnosis is primarily **clinical**, and the condition is a surgical emergency. **Why Option B (X-ray Abdomen) is the correct answer:** While an X-ray might show dilated bowel loops or air-fluid levels, it is **not routinely indicated** because it does not change the management plan. A clinical diagnosis of obstruction in a known hernia is sufficient to proceed to surgery. Relying on imaging can cause a dangerous delay in treatment, increasing the risk of bowel ischemia and gangrene. **Analysis of other options:** * **A. Aspiration of the sac:** This is **strictly contraindicated**. Attempting to aspirate the sac can lead to bowel perforation, fecal peritonitis, and the introduction of infection into the peritoneal cavity. (Note: While the question asks what is *not indicated*, X-ray is the "standard" textbook answer for unnecessary imaging, whereas aspiration is a "procedural contraindication"). * **C. Ultrasound (USG) abdomen:** USG is often used in doubtful cases to differentiate a hernia from other groin swellings (like hydrocele or lymphadenopathy) or to assess the viability of the contents (Doppler), though it is not mandatory. * **D. Early surgical intervention:** This is the **gold standard** management. Once obstruction is diagnosed, the patient must be resuscitated and taken for emergency surgery to prevent strangulation. **High-Yield Pearls for NEET-PG:** * **Clinical Triad of Obstruction:** Irreducibility, colicky abdominal pain/vomiting, and constipation. * **Strangulation vs. Obstruction:** Strangulation is a surgical emergency where the blood supply is compromised; the hallmark is **exquisite tenderness** and skin discoloration over the hernia site. * **Taxis:** Manual reduction (Taxis) is **contraindicated** in strangulated hernias as it may return gangrenous bowel into the abdomen ("reduction-en-masse").

Question 269: A 50-year-old man presents with complaints of a painful tender mass situated one-third of the way between the xiphisternum and umbilicus. What is the likely diagnosis?

A. Omphalocele
B. Epigastric hernia (Correct Answer)
C. Spigelian hernia
D. Fibrosarcoma of the abdominal wall

Explanation: ### Explanation **Correct Answer: B. Epigastric hernia** **Why it is correct:** An **epigastric hernia** occurs through a defect in the **linea alba** (the midline raphe) between the xiphisternum and the umbilicus. It is caused by the protrusion of extraperitoneal fat (and occasionally a peritoneal sac containing omentum) through small apertures where blood vessels pierce the fascia. * **Clinical Presentation:** It typically presents as a small, firm, and exquisitely tender lump. The pain is often disproportionate to the size of the hernia because the protruding fat becomes incarcerated or strangulated through a very narrow fascial defect. The location described—one-third of the way between the xiphisternum and umbilicus—is the classic site for these hernias. **Why the other options are incorrect:** * **A. Omphalocele:** This is a congenital midline defect where abdominal contents protrude through the **umbilical ring**, covered by a sac (amnion and peritoneum). It is seen in neonates, not 50-year-old adults. * **C. Spigelian hernia:** This occurs through the *linea semilunaris* at the level of the *arcuate line* (lateral to the rectus muscle). It is located in the **lower abdomen**, lateral to the midline, not between the xiphoid and umbilicus. * **D. Fibrosarcoma:** While it can present as a mass, it is usually a slow-growing, painless, firm-to-hard mass. It does not typically present with the acute tenderness and specific midline localization characteristic of an epigastric hernia. **High-Yield NEET-PG Pearls:** * **"Fatty Hernia of the Linea Alba":** Another name for epigastric hernia when only extraperitoneal fat is involved. * **Symptom Mimicry:** Epigastric hernias can mimic peptic ulcer disease or gallbladder pain; always palpate the midline for a small, tender lump. * **Gender:** More common in males (3:1 ratio), often in athletic middle-aged men. * **Management:** Unlike umbilical hernias in children, epigastric hernias do not resolve spontaneously and require surgical repair due to the high risk of incarceration.

Question 270: Skin grafting is performed on a wound using skin taken from an identical twin brother. What type of skin graft is this called?

A. Isograft (Correct Answer)
B. Allograft
C. Autograft
D. Xenograft

Explanation: ### Explanation The correct answer is **Isograft (Option A)**. **1. Why Isograft is correct:** An **Isograft** (also known as a syngeneic graft) refers to the transfer of tissue between individuals who are genetically identical, such as **monozygotic (identical) twins**. Because the donor and recipient share the same Major Histocompatibility Complex (MHC) antigens, the recipient’s immune system does not recognize the graft as foreign. Consequently, there is no graft rejection, and long-term immunosuppression is not required. **2. Why the other options are incorrect:** * **Autograft (Option C):** This involves tissue transferred from one site to another on the **same individual** (e.g., taking a split-thickness skin graft from the thigh to cover a burn on the arm). This is the most common type of graft. * **Allograft (Option B):** Also called a homograft, this is a transfer between genetically different members of the **same species** (e.g., human to human). These require immunosuppression to prevent rejection. * **Xenograft (Option D):** Also called a heterograft, this involves tissue transfer between **different species** (e.g., porcine/pig skin or bovine valves used in humans). These are often used as temporary biological dressings. **3. NEET-PG High-Yield Pearls:** * **Order of Immunogenicity:** Xenograft > Allograft > Isograft/Autograft. * **First Set Rejection:** Occurs in 7–10 days in an unsensitized recipient. * **Second Set Rejection:** Occurs in 3–4 days (accelerated) due to pre-existing memory T-cells. * **Hyperacute Rejection:** Occurs within minutes to hours due to pre-formed ABO or HLA antibodies. * **Skin Graft Survival:** Relies on three stages: **Plasmatic imbibition** (first 24–48h), **Inosculation** (48–72h), and **Revascularization** (day 4 onwards).

Practice by Chapter

Wound Healing and Care

Practice Questions

Surgical Infections

Practice Questions

Fluid and Electrolyte Management

Practice Questions

Nutrition in Surgical Patients

Practice Questions

Hemostasis and Blood Transfusion

Practice Questions

Surgical Instruments and Equipment

Practice Questions

Sutures and Stapling Devices

Practice Questions

Minimal Access Surgery Principles

Practice Questions

Surgical Complications

Practice Questions

Anesthesia Principles for Surgeons

Practice Questions

Surgical Oncology Principles

Practice Questions

Evidence-Based Surgery

Practice Questions

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free