General Surgery Principles Practice Questions

Q: Which of the following statements about surgical wounds is incorrect?

Incision of an abscess is considered a contaminated wound.. ### Explanation The classification of surgical wounds is a high-yield topic based on the **CDC Surgical Wound Classification**, which predicts the risk of postoperative surgical site infection (SSI). #### Why Option B is Incorrect (The Correct Answer) Incision and drainage of an abscess is classified as a **Dirty (Class IV)** wound, not a contaminated wound. Dirty wounds involve clinical infection, perforated viscera, or old traumatic wounds with retained devitalized tissue. Since an abscess contains active pus and established infection, it falls into this highest risk category. #### Analysis of Other Options * **Option A:** In **Clean (Class I)** surgeries (e.g., hernia repair, thyroidectomy), the respiratory, alimentary, or genitourinary tracts are not entered. Prophylactic antibiotics are generally not required unless a prosthetic implant is used. * **Option C:** A **Clean-Contaminated (Class II)** wound involves controlled entry into a hollow viscus. However, if there is a major break in technique or **gross spillage** of contents (like stomach or biliary contents), it is upgraded to a **Contaminated (Class III)** wound. * **Option D:** The expected infection rate for Clean-Contaminated wounds, when proper technique and prophylaxis are used, is typically **between 3% and 10%**. #### NEET-PG High-Yield Pearls * **Clean (Class I):** No inflammation; no tracts entered. SSI risk: <2%. * **Clean-Contaminated (Class II):** Controlled entry into tracts (e.g., elective cholecystectomy, appendectomy). SSI risk: 3–10%. * **Contaminated (Class III):** Accidental wounds, gross spillage, or acute non-purulent inflammation. SSI risk: 10–20%. * **Dirty (Class IV):** Pus present, perforated viscera (e.g., perforated diverticulitis). SSI risk: 20–40%.

Q: Which of the following is a non-absorbable suture?

Polypropylene. **Explanation:** The classification of suture materials into **absorbable** and **non-absorbable** is a fundamental concept in surgery, determined by whether the body’s tissues can degrade and digest the material over time. **1. Why Polypropylene is Correct:** **Polypropylene (Prolene)** is a synthetic, monofilament, **non-absorbable** suture. It is biologically inert and maintains its tensile strength indefinitely because it is not degraded by host enzymes or hydrolysis. It is the material of choice for vascular anastomoses, abdominal wall closure (linea alba), and subcuticular skin closure due to its high tensile strength and low tissue reactivity. **2. Why the other options are incorrect:** * **Polyglycolic acid (Dexon):** This is a synthetic, braided, **absorbable** suture. It is degraded via **hydrolysis** and typically loses its tensile strength within 3–4 weeks. * **Collagen:** This is a natural **absorbable** suture derived from the submucosa of sheep intestine or serosa of cattle. It is degraded by **proteolytic enzymatic digestion**. "Catgut" is the most common example of a collagen-based suture. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism of Degradation:** Natural sutures (Silk, Catgut) are degraded by **proteolysis**, whereas synthetic sutures (Vicryl, PDS, Dexon) are degraded by **hydrolysis**. * **Suture of Choice:** * **Vascular surgery:** Polypropylene (due to its plasticity and low friction). * **Biliary/Urinary tract:** Absorbable sutures (to prevent them from acting as a nidus for stone formation). * **Infected wounds:** Monofilament (like Nylon or Prolene) is preferred over braided (like Silk or Vicryl) to prevent bacterial "wicking." * **Steel:** The strongest non-absorbable suture, often used for sternal closure.

Q: Splenectomy is contraindicated in which of the following hemolytic anemias?

Stomatocytosis. **Explanation:** **1. Why Stomatocytosis is the Correct Answer:** Hereditary Stomatocytosis (specifically the overhydrated subtype) is a rare hemolytic anemia where the red cell membrane is abnormally permeable to cations. Splenectomy is **contraindicated** in these patients because it is associated with a life-threatening risk of **severe thromboembolic complications** (such as portal vein thrombosis and pulmonary hypertension). Unlike other hemolytic anemias, the clinical benefit of splenectomy in stomatocytosis is minimal compared to the high risk of fatal clotting events. **2. Why the Other Options are Incorrect:** * **Hereditary Elliptocytosis (Option B):** Splenectomy is the treatment of choice for patients with symptomatic, severe hemolysis or significant anemia. It effectively increases the lifespan of the elliptical red cells. * **Sickle Cell Disease (Option C):** While patients often undergo "autosplenectomy" due to repeated infarcts, surgical splenectomy is indicated in specific cases such as **acute splenic sequestration crisis** or hypersplenism. It is not contraindicated; rather, it can be life-saving in these acute scenarios. **Clinical Pearls for NEET-PG:** * **Hereditary Spherocytosis:** Splenectomy is the **gold standard** treatment (usually performed after age 5-6 to reduce sepsis risk). * **Post-Splenectomy Sepsis (OPSI):** Most commonly caused by *Streptococcus pneumoniae*. Vaccination against encapsulated organisms (Pneumococcus, Meningococcus, H. influenzae) should be given 2 weeks before elective surgery. * **Peripheral Smear Finding:** Look for **Howell-Jolly bodies** post-splenectomy, which indicate absent splenic filtration. * **Absolute Contraindication:** Splenectomy should never be performed in asymptomatic patients or those with mild compensation where the risks of surgery outweigh the benefits.

Q: In an adult patient with pleural effusion, what is the most appropriate site for thoracentesis?

7th intercostal space in the midaxillary line. ### Explanation **Correct Answer: B. 7th intercostal space in the midaxillary line** Thoracentesis (pleural tap) is performed to remove fluid from the pleural space. The goal is to select a site that is low enough to access gravity-dependent fluid but high enough to avoid injury to the diaphragm and abdominal viscera (liver/spleen). The **7th to 9th intercostal spaces** between the **midaxillary line and the posterior axillary line** are the preferred sites. At the midaxillary line, the 7th intercostal space provides a safe window above the diaphragmatic reflection while ensuring the needle enters the widest part of the costodiaphragmatic recess. **Analysis of Incorrect Options:** * **Option A (5th ICS, Midclavicular line):** This site is too high for efficient fluid drainage and carries a risk of injuring the heart (on the left) or the lung parenchyma. * **Option C (2nd ICS, Midclavicular line):** This is the classic site for **needle decompression of a tension pneumothorax**, not for pleural effusion. * **Option D (10th ICS):** This is too low. The diaphragm typically rises to the level of the 8th–10th ribs posteriorly during expiration; inserting a needle here poses a high risk of penetrating the diaphragm and causing intra-abdominal injury (liver or spleen laceration). **NEET-PG High-Yield Pearls:** * **The "Safe Zone":** Always insert the needle **immediately above the rib (superior border)** to avoid the neurovascular bundle (Intercostal vein, artery, and nerve), which runs in the costal groove at the inferior border of the rib. * **Positioning:** The patient should ideally be sitting upright, leaning forward. * **Fluid Limit:** To avoid re-expansion pulmonary edema, do not remove more than **1,000–1,500 mL** of fluid in a single session. * **Gold Standard:** Ultrasound-guided thoracentesis is now preferred over the "blind" clinical approach to minimize complications like pneumothorax.

Q: Which of the following muscles is not incised during a posterolateral thoracotomy?

Pectoralis major. **Explanation:** The **posterolateral thoracotomy** is the most common surgical approach for major lung resections (lobectomy/pneumonectomy) and esophageal surgeries. The incision typically begins midway between the spine and the scapula, curves around the scapular tip, and follows the line of the rib (usually the 5th intercostal space) toward the anterior axillary line. **Why Pectoralis Major is the correct answer:** The **Pectoralis major** is an anterior chest wall muscle. Its origin is on the clavicle, sternum, and upper ribs, and it inserts into the humerus. Since the posterolateral incision stays posterior to the anterior axillary line, the pectoralis major is never encountered or incised. **Analysis of incorrect options:** * **Latissimus dorsi:** This is the largest muscle of the back and the first major muscle layer encountered. It must be divided (incised) to gain access to the deeper structures. * **Serratus anterior:** Located on the lateral chest wall, its posterior fibers are often divided or retracted during this procedure to expose the ribs. * **Intercostals:** To enter the pleural cavity, the intercostal muscles (external, internal, and innermost) in the specific intercostal space must be incised. **High-Yield Clinical Pearls for NEET-PG:** * **Muscle-Sparing Thoracotomy:** Modern variations aim to retract rather than divide the latissimus dorsi and serratus anterior to reduce post-operative pain. * **Nerve at Risk:** The **Long Thoracic Nerve** (supplying serratus anterior) and the **Thoracodorsal Nerve** (supplying latissimus dorsi) are at risk if the dissection is too extensive. * **Anterior Thoracotomy:** This is the approach where the Pectoralis major *would* be incised (used for trauma or cardiac access).

Q: What is the preservative used for this suture material?

isopropyl alcohol. ***Isopropyl alcohol*** - **Catgut sutures** are preserved in **isopropyl alcohol** to maintain their sterility and prevent bacterial contamination during storage. - **Isopropyl alcohol (70%)** provides effective antimicrobial action while maintaining the **tensile strength** and flexibility of the catgut material. *Saline* - **Saline** lacks antimicrobial properties and would not provide adequate preservation for long-term storage of suture materials. - Storage in saline could lead to **bacterial growth** and **degradation** of the catgut suture material over time. *Ethanol* - **Ethanol** can cause excessive dehydration and **hardening** of catgut sutures, making them brittle and difficult to handle. - Unlike **isopropyl alcohol**, ethanol may compromise the **flexibility** and handling characteristics of the suture material. *Formalin* - **Formalin** is a tissue fixative used for histopathological specimens, not for preserving surgical suture materials. - Formalin would cause **cross-linking** and **hardening** of the catgut protein, making it unsuitable for surgical use.

Q: In a patient with lung cancer, which of the following is a contraindication for surgical resection?

Malignant pleural effusion. ### Explanation In the management of Non-Small Cell Lung Cancer (NSCLC), determining resectability is crucial. The presence of a **Malignant Pleural Effusion (Option A)** signifies that the tumor has disseminated within the pleural cavity. According to the TNM staging system (8th edition), this is classified as **M1a (Stage IV)** disease. Surgical resection is generally contraindicated in Stage IV because the disease is systemic rather than localized, and surgery does not offer a survival benefit or curative potential in this setting. **Analysis of Incorrect Options:** * **Hilar Lymphadenopathy (Option B):** This corresponds to N1 nodal involvement. While it indicates a higher stage (Stage II), it is not a contraindication to surgery; these patients typically undergo lobectomy with lymph node dissection. * **Consolidation of one lobe (Option C):** This is often a secondary effect of bronchial obstruction by the tumor (obstructive pneumonitis). As long as the tumor itself is resectable, consolidation limited to the lobe or even the entire lung is not a contraindication. * **Involvement of the visceral pleura (Option D):** This is classified as T2 disease. It indicates local extension but remains localized to the lung structure, making it amenable to surgical resection. **NEET-PG High-Yield Pearls:** * **Absolute Contraindications to Surgery (The "STOP" Criteria):** * **S:** Superior Vena Cava (SVC) Syndrome. * **T:** Tracheal involvement or Carina involvement (less than 2cm from carina). * **O:** Outside metastasis (Distant metastasis, including Malignant Pleural Effusion). * **P:** Paralysis of the Left Vocal Cord (indicates Recurrent Laryngeal Nerve involvement) or Phrenic nerve. * **PFT Criteria:** A predicted post-operative FEV1 of **<800ml** or **<30-40%** of predicted is generally a contraindication to pneumonectomy.

Q: What is the most common tumour of the posterior mediastinum?

Neurogenic tumour. The mediastinum is anatomically divided into compartments, each characterized by specific resident structures and associated pathologies. **Correct Answer: A. Neurogenic tumour** Neurogenic tumours are the most common primary mediastinal tumours overall, and specifically, they account for over **90% of posterior mediastinal masses**. They arise from the intercostal nerves (e.g., Schwannomas, Neurofibromas) or the sympathetic chain (e.g., Ganglioneuromas, Neuroblastomas). Because the paravertebral sulcus is located in the posterior compartment, these nerve-derived tumours are almost exclusively found here. **Explanation of Incorrect Options:** * **B. Thymoma:** This is the most common primary tumour of the **anterior mediastinum**. While it is the most common mediastinal tumour in adults overall, its location is strictly pre-vascular. * **C. Cyst:** Bronchogenic or pericardial cysts are most frequently found in the **middle mediastinum**. While enteric cysts can occur posteriorly, they are far less common than neurogenic tumours. * **D. Lymphoma:** Lymphomas typically present in the **anterior or middle mediastinum** (associated with lymph node chains). They are rarely isolated to the posterior compartment. **High-Yield Clinical Pearls for NEET-PG:** * **Mnemonic for Anterior Mediastinal Masses (4 Ts):** **T**hymoma, **T**eratoma (Germ cell tumours), **T**errible Lymphoma, and **T**hyroid (Retrosternal goiter). * **Middle Mediastinum:** Predominantly characterized by lymphadenopathy and developmental cysts. * **Posterior Mediastinum:** Think "Nerves." Schwannoma is the most common type in adults. * **Imaging Gold Standard:** Contrast-Enhanced CT (CECT) is the initial investigation of choice, but MRI is superior for evaluating spinal canal involvement in posterior tumours ("Dumbbell tumours").

Q: A 20-year-old female presents to the casualty with right iliac fossa pain, local guarding, and tenderness. Which of the following management interventions should NOT be done?

None of the above. **Explanation:** The clinical presentation of right iliac fossa (RIF) pain, local guarding, and tenderness in a young female is highly suggestive of **Acute Appendicitis** or an acute surgical abdomen. The management of such cases follows the standard surgical principle of "stabilize and prepare for potential surgery." **1. Why "None of the above" is correct:** All the interventions listed (A, B, and C) are standard, appropriate management steps for a patient with a suspected acute abdomen. Therefore, none of them are contraindicated. **2. Analysis of Options:** * **Nil Orally (NPO):** This is the most critical initial step. It prevents aspiration during potential emergency anesthesia and rests the bowel. * **Intravenous Glucose/Fluids:** Since the patient is NPO and may have lost fluids due to vomiting or decreased intake, IV fluids (often Dextrose-Normal Saline) are essential to maintain hydration and electrolyte balance. * **Pethidine (Analgesia):** Historically, there was a myth that analgesics "mask" the signs of peritonitis. Modern surgical teaching (and ATLS guidelines) emphasizes that providing pain relief (like Pethidine or Morphine) does **not** interfere with the diagnosis and is humane. It reduces patient distress and may actually make the physical exam easier by reducing voluntary guarding. **Clinical Pearls for NEET-PG:** * **Analgesia in Acute Abdomen:** Opioids do not mask physical signs or delay diagnosis; they are recommended once a preliminary evaluation is done. * **Pethidine vs. Morphine:** Pethidine was traditionally preferred in biliary colic due to the belief it causes less spasm of the Sphincter of Oddi, though recent evidence suggests little clinical difference. * **Most common cause of RIF pain in young females:** Acute appendicitis, but always rule out ectopic pregnancy (order a UPT) and ovarian torsion.

Question 1

Which of the following statements about surgical wounds is incorrect?

Accepted Answer

Incision of an abscess is considered a contaminated wound.

Answer

No antibiotics are required in clean surgery.

Answer

Spillage of stomach contents converts a clean-contaminated case to a contaminated case.

Answer

In clean-contaminated wounds, the infection rate is less than 10%.

Question 2

Which of the following is a non-absorbable suture?

Accepted Answer

Polypropylene

Answer

Polyglycolic acid

Answer

Collagen

Answer

All

Question 3

Splenectomy is contraindicated in which of the following hemolytic anemias?

Accepted Answer

Stomatocytosis

Answer

Elliptocytosis

Answer

Sickle cell disease

Answer

All of the above

Question 4

In an adult patient with pleural effusion, what is the most appropriate site for thoracentesis?

Accepted Answer

7th intercostal space in the midaxillary line

Answer

5th intercostal space in the midclavicular line

Answer

2nd intercostal space adjacent to the sternum

Answer

10th intercostal space adjacent to the vertebral column

Question 5

From the surgery performed, what is the gold standard investigation used to diagnose this condition?

Accepted Answer

CECT

Answer

Ultrasound

Answer

MRI

Answer

Laparotomy

Question 6

Which of the following muscles is not incised during a posterolateral thoracotomy?

Accepted Answer

Pectoralis major

Answer

Serratus anterior

Answer

Latissimus dorsi

Answer

Intercostals

Question 7

What is the preservative used for this suture material?

Accepted Answer

isopropyl alcohol

Answer

saline

Answer

ethanol

Answer

formalin

Question 8

In a patient with lung cancer, which of the following is a contraindication for surgical resection?

Accepted Answer

Malignant pleural effusion

Answer

Hilar lymphadenopathy

Answer

Consolidation of one lobe

Answer

Involvement of the visceral pleura

Question 9

What is the most common tumour of the posterior mediastinum?

Accepted Answer

Neurogenic tumour

Answer

Thymoma

Answer

Cyst

Answer

Lymphoma

Question 10

A 20-year-old female presents to the casualty with right iliac fossa pain, local guarding, and tenderness. Which of the following management interventions should NOT be done?

Accepted Answer

None of the above

Answer

Intravenous glucose

Answer

Pethidine 100 mg intramuscularly

Answer

Nil orally

General Surgery Principles — MCQs

General Surgery Principles — MCQs

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