General Surgery Principles Practice Questions

Q: A 60-year-old male came with bleeding per rectum and was diagnosed to have carcinoma colon. The patient underwent extended hemicolectomy. Identify the instrument the surgeon is using: (AIIMS Nov 2016)

Monopolar cautery. ***Monopolar cautery*** - Monopolar electrosurgery passes high-frequency current from the active pencil electrode through the patient to a return electrode for cutting or coagulation.

Q: What is the most likely diagnosis based on the image provided? The patient had a snake bite at this site 5 years ago, which left a chronic non-healing ulcer/scar that has now developed into the lesion shown.

Marjolin's ulcer. ***Marjolin's ulcer*** - This is a **squamous cell carcinoma** developing in a chronic wound, burn scar, or chronic inflammatory lesion, often after a long latent period (like the 5 years post-snake bite). The image shows a **fungating, ulcerative lesion** consistent with a malignant transformation in a chronic wound. - The history of a **snake bite 5 years ago** that resulted in a persistent chronic ulcer/scar indicates a pre-existing chronic wound site, making Marjolin's ulcer the most probable diagnosis for a subsequent malignant change. *Bazin's ulcer* - Bazin's ulcer, also known as **erythema induratum**, is a chronic, recurrent panniculitis typically affecting the calves of young to middle-aged women. - It is associated with **tuberculosis**, presenting as tender, subcutaneous nodules that can ulcerate, which doesn't match the image or history. *Martorell's ulcer* - This is a form of **ischemic ulcer** caused by severe, uncontrolled hypertension, leading to microangiopathy and skin necrosis, usually on the anterior and lateral aspects of the lower leg. - While it presents as a painful ulcer, it is not typically associated with chronic trauma or previous wounds like a snake bite and lacks the fungating appearance shown. *Meleney's ulcer* - Meleney's ulcer, or **progressive bacterial synergistic gangrene**, is a rare, severe skin infection characterized by painful, undermined ulcers with a necrotic center. - It usually develops post-surgery or trauma and involves a synergistic bacterial infection, which is not suggested by the chronic nature (5 years) or the appearance of the lesion in the image.

Q: A 60-year-old male patient with a history of weight gain and polyuria presents with the following lesion. What is the most possible diagnosis?

Diabetic ulcer. ***Diabetic ulcer*** - The patient's history of **weight gain** and **polyuria** suggests uncontrolled diabetes mellitus, a common cause of foot ulcers. - **Diabetic ulcers** can appear at various locations on the foot, including the dorsum, and are typically painless due to neuropathy and impaired protective sensation, and can be complicated by poor wound healing, as seen in the image. *Buruli's ulcer* - Buruli's ulcer is a **necrotizing skin disease** caused by *Mycobacterium ulcerans*, typically found in tropical and subtropical regions. - While it causes large, deep ulcers, the patient's symptoms (weight gain, polyuria) are not characteristic of this infection. *Venous ulcer* - **Venous ulcers** occur due to chronic venous insufficiency and are typically found on the **medial malleolus**, often associated with edema, hyperpigmentation, and lipodermatosclerosis. - The lesion's appearance and location, along with the patient's systemic symptoms, do not align with a classic venous ulcer. *Meleney's ulcer* - **Meleney's ulcer** (also known as progressive bacterial synergistic gangrene) is a rare, painful, and rapidly progressive ulceration of the skin and subcutaneous tissue. - It usually follows surgical procedures or trauma and is characterized by a necrotic center with a spreading red margin, which doesn't fully match the provided image or patient history.

Q: A patient presents with a mass on the volar-radial aspect of the wrist. On examination, the mass is soft, mobile, and nonpulsatile. Ultrasound with Doppler shows a nonvascular subcutaneous fatty lesion. What is the most likely diagnosis?

Lipoma. ***Lipoma*** - The image displays a soft, mobile, nonpulsatile, and **well-demarcated subcutaneous mass** on the volar-radial aspect of the wrist, which is characteristic of a lipoma. Ultrasound features show a subcutaneous fat-density lesion consistent with lipoma. - Lipomas are **benign tumors** composed of mature fat cells and are one of the most common soft tissue tumors, often occurring on the trunk, neck, upper thighs, upper arms, and forearms. *Radial artery aneurysm* - A radial artery aneurysm would typically present as a **pulsatile mass** in the anatomical course of the radial artery, and would often involve symptoms of vascular compression or compromise. - The mass in the image does not visibly appear to be pulsatile, and it is located on the volar-radial aspect of the wrist, directly over the course of the radial artery. *Liposarcoma* - Liposarcomas are **malignant tumors** that can be difficult to distinguish from lipomas clinically, but they are generally larger, firmer, deeper, and may show rapid growth or cause pain. - While they are composed of fat cells, the visual appearance of this lesion is more consistent with a benign growth. Imaging (MRI) and biopsy would be needed for definitive diagnosis. *Enchondroma* - An enchondroma is a **benign cartilaginous tumor** that arises within the bone, most commonly in the small bones of the hands and feet. - It would not typically present as a visible, soft tissue mass on the surface, but rather as an intraosseous lesion, sometimes causing bone expansion or pathological fractures.

Q: A diabetic patient presents with a plantar foot ulcer. On examination, the ulcer is located beneath the second and third metatarsal heads, has a punched-out appearance with a surrounding callus, shows no signs of active infection, has minimal exudate, and probing does not reach bone. There is no fever, no erythema extending beyond the wound margin, and initial plain radiographs show no bony changes. All are correct about the image shown below except:

Grade 5 ulcer. ***Grade 5 ulcer*** - The Wagner grading system for diabetic foot ulcers ranges from 0 to 5. A **Grade 5 ulcer** specifically refers to **extensive gangrene** involving the entire foot, which is not depicted in the image. - The ulcer shown is more consistent with a lesser grade, likely involving full-thickness skin loss but without widespread gangrene. *Neuropathic ulcer* - The image shows a **classic neuropathic ulcer** on the plantar aspect of the foot, characterized by a **punched-out appearance** with surrounding callused skin. - These ulcers are common in diabetic patients due to peripheral neuropathy and repetitive trauma to pressure points. *Hydrocolloid dressings* - **Hydrocolloid dressings** are appropriate for managing wounds that are **clean, noninfected, and have minimal to moderate exudate**, as these dressings help create a moist wound environment conducive to healing. - They are often used for neuropathic ulcers that have been debrided, show no signs of active infection, and have suitable exudate levels. *MRI is preferred if osteomyelitis remains clinically suspected despite initial evaluation* - Deep or chronic foot ulcers, especially in diabetic patients, carry a significant risk of **osteomyelitis**, an infection of the bone. - **MRI** is the **most sensitive imaging modality** for detecting osteomyelitis and is indicated when there is **clinical suspicion of osteomyelitis after initial evaluation** (e.g., persistent wound, positive probe-to-bone test, or inconclusive plain radiographs), rather than being required routinely for every neuropathic ulcer.

Q: All are true about the lesion shown below except:

Remains confined within the original wound margins. ***Remains confined within the original wound margins*** - Keloids are characterized by growth that **extends beyond the original wound boundaries**, unlike hypertrophic scars which remain within the wound margins. - This spreading beyond the original injury site is a defining feature of keloids. *Claw like process* - Keloids are well-known for their **claw-like extensions** or finger-like projections that spread beyond the original wound boundaries. - This characteristic growth pattern helps differentiate keloids from hypertrophic scars, which remain within the wound margins. *Develops at vaccination sites* - Keloids have a propensity to form at sites of skin injury, including piercings, surgical incisions, and **vaccination sites**. - This is a common predisposing factor, particularly in individuals with a genetic predisposition to keloid formation. *Collagen bundles are present* - Histologically, keloids are characterized by the presence of **thick, haphazardly arranged collagen bundles** in the dermis. - This excessive and disorganized deposition of collagen is a hallmark of keloid pathology.

Q: Identify these two surgical instruments.

Artery forceps and needle holder. ***Artery forceps and needle holder*** - The instrument on the **left** is an **artery forcep** (straight hemostat), recognizable by its straight, serrated jaws and often used for clamping or dissecting vessels. - The instrument on the **right** is a **needle holder**, characterized by its short, sturdy jaws with serrations (often cross-hatched) designed to firmly grip a needle during suturing. *Thumb forceps and sponge holder* - The instruments shown are **ring-handled clamps with ratchets**, not thumb forceps which are tweezer-like. - A sponge holder (e.g., Foerster clamp) typically has **fenestrated** (ring-shaped) jaws for grasping sponges, which is not depicted. *Sponge holder and Allis forceps* - While one might resemble a variant of a sponge holder, it does not perfectly match the typical **fenestrated jaws** of a Foerster sponge clamp. - An **Allis forcep** has rows of interlocking teeth at the tips, which are not visible on either instrument shown. *Needle holder and ovum forceps* - While one instrument is correctly identified as a needle holder, the other is not an **ovum forcep**. - **Ovum forceps** (or ovum clamps) have large, fenestrated, often curved jaws designed for grasping and removing placental tissue or polyps from the uterus.

Q: All are true about the lesion shown below except:

Spontaneous regression is common. ***Spontaneous regression is common*** - Keloids generally **persist** rather than regress spontaneously. - Unlike some other skin lesions, keloids do **not** resolve on their own and tend to remain or even continue to grow over time without treatment. - Management typically requires active intervention such as intralesional corticosteroid injections, surgical excision, silicone sheeting, or other therapies, as spontaneous resolution is not expected. *Claw like process* - The image shows a **keloid**, which is characterized by its tendency to grow **beyond the boundaries of the original wound**, often forming **claw-like extensions**. - This **exuberant growth** into surrounding normal tissue is a **key differentiating feature** of keloids compared to hypertrophic scars, which remain within the original wound boundaries. *Develops at vaccination sites* - Keloids commonly develop at sites of **skin trauma**, including **vaccination sites**, piercings, acne, and surgical incisions. - The **deltoid region**, where many vaccinations are administered, is a frequent location for keloid formation, especially in **predisposed individuals** (more common in darker skin types and with genetic predisposition). *Collagen bundles are present* - Keloids are composed of **abnormally dense and disorganized collagen bundles** in the dermis, particularly **Type I and Type III collagen**. - Histologically, they show **thick, hyalinized collagen fibers** arranged in a haphazard fashion, extending into the subcutaneous fat, which distinguishes them from normal scars.

Q: What type of suture is this?

Purse string suture. ***Purse string suture*** - The image shows a suture placed in a **circular pattern** around a wound opening, which can be **tightened like a drawstring** to close the defect. - This technique is characteristic of a **purse-string suture**, commonly used to close circular openings or to reduce the size of a defect for easier closure. *Pare's suture* - This is not a recognized or standard surgical suture technique. - Suture names are typically associated with their creators (e.g., Halsted) or their specific pattern/function (e.g., mattress, purse-string). *Halsted's suture* - Refers to a type of **interrupted mattress suture** or a principle of meticulous surgical technique, not a specific circular closing suture like the one pictured. - Halsted's sutures are typically used for strong wound closure and **eversion of wound edges**. *Vertical mattress interrupted suture* - This suture involves a "far-far, near-near" pattern, passing deep then superficial on each side of the wound, resulting in **strong closure** and **wound edge eversion**. - It consists of **individual, non-continuous stitches** (interrupted) and its appearance is distinct from the encircling pattern shown.

Q: Identify these two surgical instruments.

Needle holder and artery forceps. **Needle holder and artery forceps** - The instrument on the left is a **needle holder**, which has short, robust jaws with a cross-hatch pattern for secure gripping of surgical needles, and a ratcheted handle to lock the needle in place. - The instrument on the right is a **curved artery forceps (hemostat)**, characterized by its serrated jaws and a locking mechanism, designed for clamping vessels to control bleeding. *Thumb forceps and sponge holder* - **Thumb forceps** are non-locking instruments held like a pen, used for grasping tissue, and are not depicted here. - A **sponge holder** (also known as Foerster sponge forceps) typically has large, fenestrated jaws to hold surgical sponges, which is different from either of the instruments shown. *Sponge holder and Allis forceps* - As mentioned, a **sponge holder** is distinct and not shown in the image. - **Allis forceps** have multiple fine teeth that interlock to hold tissue firmly but atraumatically, which differs from the jaw patterns seen in these instruments. *Needle holder and ovum forceps* - While a **needle holder** is correctly identified on the left, the instrument on the right is not an **ovum forceps**. - **Ovum forceps** (or ovum polyp forceps) are used in gynecology, often having wide, fenestrated, cup-shaped jaws for grasping tissue during uterine procedures.

Question 1

A 60-year-old male came with bleeding per rectum and was diagnosed to have carcinoma colon. The patient underwent extended hemicolectomy. Identify the instrument the surgeon is using: (AIIMS Nov 2016)

Accepted Answer

Monopolar cautery

Answer

Ligasure vessel ligating system

Answer

Harmonic scalpel

Answer

Hyfrecator

Question 2

What is the most likely diagnosis based on the image provided? The patient had a snake bite at this site 5 years ago, which left a chronic non-healing ulcer/scar that has now developed into the lesion shown.

Accepted Answer

Marjolin's ulcer

Answer

Bazin's ulcer

Answer

Martorell's ulcer

Answer

Meleney's ulcer

Question 3

A 60-year-old male patient with a history of weight gain and polyuria presents with the following lesion. What is the most possible diagnosis?

Accepted Answer

Diabetic ulcer

Answer

Buruli's ulcer

Answer

Venous ulcer

Answer

Meleney's ulcer

Question 4

A patient presents with a mass on the volar-radial aspect of the wrist. On examination, the mass is soft, mobile, and nonpulsatile. Ultrasound with Doppler shows a nonvascular subcutaneous fatty lesion. What is the most likely diagnosis?

Accepted Answer

Lipoma

Answer

Radial artery aneurysm

Answer

Liposarcoma

Answer

Enchondroma

Question 5

A diabetic patient presents with a plantar foot ulcer. On examination, the ulcer is located beneath the second and third metatarsal heads, has a punched-out appearance with a surrounding callus, shows no signs of active infection, has minimal exudate, and probing does not reach bone. There is no fever, no erythema extending beyond the wound margin, and initial plain radiographs show no bony changes. All are correct about the image shown below except:

Accepted Answer

Grade 5 ulcer

Answer

Neuropathic ulcer

Answer

Hydrocolloid dressings

Answer

MRI is preferred if osteomyelitis remains clinically suspected despite initial evaluation

Question 6

All are true about the lesion shown below except:

Accepted Answer

Remains confined within the original wound margins

Answer

Collagen bundles are present

Answer

Claw like process

Answer

Develops at vaccination sites

Question 7

Identify these two surgical instruments.

Accepted Answer

Artery forceps and needle holder

Answer

Thumb forceps and sponge holder

Answer

Sponge holder and Allis forceps

Answer

Needle holder and ovum forceps

Question 8

All are true about the lesion shown below except:

Accepted Answer

Spontaneous regression is common

Answer

Claw like process

Answer

Develops at vaccination sites

Answer

Collagen bundles are present

Question 9

What type of suture is this?

Accepted Answer

Purse string suture

Answer

Pare's suture

Answer

Halsted's suture

Answer

Vertical mattress interrupted suture

Question 10

Identify these two surgical instruments.

Accepted Answer

Needle holder and artery forceps

Answer

Thumb forceps and sponge holder

Answer

Sponge holder and Allis forceps

Answer

Needle holder and ovum forceps

General Surgery Principles — MCQs

General Surgery Principles — MCQs

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