General Surgery Principles Practice Questions

Q: A 56-year-old male came with acute onset breathlessness and found to have pneumothorax. The resident doctor decided to insert an intercostal drain. Which one of the following sites is suitable for such a procedure?

Triangle of safety. ***Triangle of safety*** - The **triangle of safety** is the universally accepted site for safe **intercostal drain (chest tube)** insertion to treat **pneumothorax**. - Its boundaries help avoid injury to vital organs; it is bordered by the **anterior border of the latissimus dorsi**, the **lateral border of the pectoralis major**, and the **fifth intercostal space**. *Petit's triangle* - This anatomical landmark, also known as the **lumbar triangle**, is located in the **lumbar region** of the back. - It defines a weaker area in the abdominal wall and is a common site for **lumbar hernias**, not chest tube insertion for pneumothorax. *Hesselbach's triangle* - This triangle is located in the **groin region** and is an important anatomical landmark for **inguinal hernias**. - It is bordered by the inferior epigastric vessels, the lateral border of the rectus abdominis, and the inguinal ligament, and is entirely unrelated to chest procedures. *Triangle of auscultation* - The **triangle of auscultation** is a small region of the back, bordered by the **latissimus dorsi**, **trapezius**, and **medial border of the scapula**. - It is a thinner area of musculature, making it an ideal location for **listening to breath sounds** with a stethoscope, but it is not used for invasive procedures like chest tube insertion.

Q: The best measure of organ perfusion and the best monitor of adequacy of shock therapy is

urine output. ***urine output*** - **Urine output** is a direct and sensitive indicator of **renal blood flow** and, consequently, overall organ perfusion [1]. Adequate urine production (typically >0.5 mL/kg/hr) signifies that the kidneys are being sufficiently perfused, which generally correlates with adequate perfusion of other vital organs. - In the context of shock, improved urine output following therapy indicates effective restoration of **circulating blood volume** and microcirculation, making it an excellent monitor for treatment adequacy. *restoring blood pressure/pulse vital parameters* - While restoring **blood pressure** and **pulse** is a critical goal in shock management, these parameters alone do not always reflect true tissue perfusion [1]. A patient can have normalized blood pressure due to **vasoconstriction** while still experiencing inadequate microcirculatory flow and cellular hypoxia. - These vital signs are systemic indicators, and while essential, they don't provide the same granular insight into **organ-level perfusion** as urine output. *central venous pressure* - **Central venous pressure (CVP)** primarily reflects the **right heart's filling pressure** and overall intravascular volume status [1]. While CVP helps guide fluid resuscitation, it is not a direct measure of organ perfusion. - CVP can be influenced by various factors, including **cardiac function** and **intrathoracic pressure**, and a "normal" CVP does not guarantee adequate perfusion to all organs [1]. *pulmonary wedge pressure* - **Pulmonary wedge pressure (PWP)**, also known as pulmonary artery occlusion pressure, reflects the **left atrial pressure** and serves as an indicator of left ventricular preload [1]. - While PWP is useful in assessing **cardiac function** and guiding fluid management in specific types of shock [1] (e.g., cardiogenic shock), it is not a primary measure of global organ perfusion or a universal monitor for adequacy of shock therapy.

Q: A surgeon is about to start a laparoscopic procedure on a patient. The floor nurse asks the surgeon about the identity of the patient, site of the procedure to be performed and any anticipated critical events during the surgery. These questions are a part of the

WHO surgical safety checklist. **WHO surgical safety checklist** - The questions about patient identity, procedure site, and anticipated critical events are key components of the **"Sign In"** and **"Time Out"** sections of the **WHO Surgical Safety Checklist**. - This checklist is designed to improve **patient safety** by ensuring communication and adherence to essential steps before, during, and after surgery, thereby reducing surgical errors. *nurses safety checklist* - While nurses play a crucial role in patient safety, there isn't a universally recognized "nurses safety checklist" that specifically encompasses these exact comprehensive surgical verification steps. - The comprehensive framework described, with its specific questions, aligns more closely with the broader, interdisciplinary **WHO Surgical Safety Checklist**. *universal precautions checklist* - **Universal precautions** focus on preventing the transmission of bloodborne pathogens and other infectious agents by treating all bodily fluids as potentially infectious. - This checklist primarily addresses **infection control** measures and does not cover patient identification, surgical site verification, or critical event anticipation. *MCI patient safety checklist* - A "MCI patient safety checklist" is not a widely recognized or standardized medical safety protocol. - The scenario describes a standard, internationally adopted set of safety checks specifically for surgical procedures, which is the **WHO Surgical Safety Checklist**.

Q: Which of the following are true about epidermal cyst? 1. It is lined by stratified squamous epithelium. 2. It is derived from hair follicle. 3. It contains keratin debris. 4. It is not fixed to the skin.

1, 2 and 3. ***1, 2 and 3*** - An **epidermal cyst** is indeed derived from the **infundibulum of a hair follicle**. - It is lined by **stratified squamous epithelium** and contains **keratin debris**, giving it a cheesy consistency. *1, 3 and 4* - While an epidermal cyst is lined by stratified squamous epithelium and contains keratin, it is often **fixed to the skin** due to its attachment to the follicular opening, making statement 4 incorrect. - The cyst's connection to the surface epithelium is a distinguishing feature, preventing it from being freely mobile. *1, 2 and 4* - Although statements 1 and 2 are true, statement 4, claiming it is not fixed to the skin, is generally **incorrect**. - Epidermal cysts typically have a punctum or small opening to the skin surface, indicating its attachment. *2, 3 and 4* - Statements 2 and 3 are correct, but statement 4, suggesting it is not fixed, is **false**. - The presence of a **central punctum**, which is common in epidermal cysts, signifies its epidermal origin and attachment to the skin.

Q: Which of the following is the PRIMARY factor that predisposes to the development of incisional hernia?

Postoperative wound infection. ***Postoperative wound infection*** - **Postoperative wound infection** is the **PRIMARY and most important modifiable risk factor** for incisional hernia development, increasing the risk by **2-4 fold**. - Infection causes **tissue necrosis**, **fascial disruption**, and **impaired collagen synthesis**, directly compromising the structural integrity of the wound closure. - The inflammatory response and proteolytic enzymes released during infection destroy newly formed collagen and prevent proper fascial healing. - This is consistently cited in major surgical textbooks (Sabiston, Schwartz) as the leading preventable cause of incisional hernias. *Malnutrition* - While malnutrition impairs wound healing by reducing collagen synthesis and tissue strength, it acts as a **background predisposing factor** rather than the primary cause [1]. - Protein deficiency affects overall tissue quality but typically requires additional factors (like infection) to result in hernia formation [1]. - Nutritional optimization is important perioperatively but is less directly causative than acute wound complications. *Immunocompromised patient* - Immunocompromise increases susceptibility to infection and impairs healing, but it is an indirect risk factor [1]. - The mechanism primarily operates through **increased infection risk** rather than being an independent primary cause [1]. *Non-absorbable suture material* - Suture material choice affects long-term stability and may influence chronic pain or foreign body reactions. - Current evidence shows **continuous non-absorbable sutures** are actually preferred for fascial closure to reduce hernia risk [1]. - This is a technical consideration but not a primary predisposing factor compared to wound complications.

Q: Match List-I with List-II and select the correct answer using the code given below the Lists: (Refer to the image for List-I and List-II)

A→4 B→1 C→2 D→3. ***A→4, B→1, C→2, D→3*** **Correct Matching:** **Tattooing (A) → Foreign particles like dirt, soot (4)** - Tattooing refers to permanent skin discoloration caused by **foreign pigment insertion** into the dermis - Commonly occurs accidentally after trauma with **dirt, soot, gunpowder, or other foreign particles** - The particles become embedded in the skin causing permanent discoloration **Keloid (B) → Outgrows boundaries of original wound (1)** - A keloid is a **prominent raised scar** that extends beyond the margins of the original injury - Results from excessive collagen deposition during abnormal wound healing - **Key feature**: Growth exceeds the boundaries of the original wound area **Dupuytren's contracture (C) → Contractures (2)** - Progressive fibrosis of the **palmar fascia** leading to finger contractures - Causes permanent flexion deformity, typically affecting the ring and little fingers - Results in functional limitation due to **contracture formation** **Basal cell carcinoma (D) → Not familial (3)** - Most common skin malignancy, typically **sporadic** rather than familial - Associated with UV exposure, fair skin, and immunosuppression - Unlike some other cancers, **typically not inherited** in familial patterns *Incorrect Options:* *A→2, B→3, C→4, D→1* - Incorrectly matches tattooing with contractures and Dupuytren's with foreign particles *A→3, B→4, C→1, D→2* - Incorrectly matches tattooing with non-familial trait and keloid with foreign particles *A→1, B→2, C→3, D→4* - Incorrectly matches tattooing with outgrowing boundaries and basal cell carcinoma with foreign particles

Q: Consider the following statements regarding splenectomy : 1. It corrects anemia in congenital hereditary spherocytosis. 2. Postponed until the age of 4 years if possible. 3. Polyvalent pneumococcal vaccine to be administered to all before the surgery. Which of the statements given above are correct ?

1, 2 and 3. ***1, 2 and 3*** - **Splenectomy** is a definitive treatment for **hereditary spherocytosis**, as it removes the primary site of red blood cell destruction, thereby correcting the **anemia**. - Delaying splenectomy until after **4 years of age** reduces the risk of **overwhelming post-splenectomy infection (OPSI)**, allowing the child's immune system to mature. *Note: This reflects 2009 guidelines when this question was set. Current guidelines recommend postponing splenectomy until 5-6 years or even older (6-9 years) to further minimize OPSI risk.* - **Vaccination** against encapsulated bacteria like **Streptococcus pneumoniae** (using a polyvalent vaccine) is crucial before splenectomy to prevent severe infections, as the spleen plays a vital role in clearing these pathogens. *1 and 3 only* - This option is incorrect because it omits the important recommendation to **postpone splenectomy** until the child is older, which is a key part of managing hereditary spherocytosis in children. *2 and 3 only* - This option is incorrect because it fails to acknowledge that **splenectomy effectively corrects the anemia** in congenital hereditary spherocytosis by eliminating the site of premature red blood cell destruction, which is a primary indication for the procedure. *1 and 2 only* - This option is incorrect because it overlooks the critical need for **vaccination** against encapsulated bacteria **before splenectomy** to protect against life-threatening infections, a standard and essential practice.

Q: Splenectomy is best indicated for :

Hereditary spherocytosis. ***Hereditary spherocytosis*** - Splenectomy is a curative treatment for **hereditary spherocytosis** as it removes the primary site of red blood cell destruction. - It alleviates **anemia** and prevents complications such as **gallstones** by reducing hemolysis. *Cirrhosis liver with portal hypertension* - In cirrhosis with **portal hypertension**, splenectomy is generally not the primary treatment and may even worsen portal hypertension in some cases. - Management focuses on treating the underlying **liver disease** and its complications, such as **variceal bleeding**. *Sickle cell disease* - Splenectomy is generally avoided in **sickle cell disease** due to the increased risk of **overwhelming post-splenectomy sepsis** and other complications. - The primary approach is supportive care to manage crises, pain, and prevent infections. *Gaucher's disease* - **Gaucher's disease** involves the accumulation of glucocerebroside in various organs, including the spleen, often leading to **splenomegaly**. - Treatment primarily involves **enzyme replacement therapy (ERT)** and substrate reduction therapy, with splenectomy reserved for rare cases of severe symptoms unresponsive to medical therapy.

Q: Splenectomy is indicated in all of the following conditions, except

Hydatid cyst of the spleen. ***Hydatid cyst of the spleen*** - **Splenectomy** is generally **NOT indicated** as first-line treatment for uncomplicated **hydatid cysts** of the spleen. - The primary concern is the **risk of spillage of cyst contents**, which can lead to **anaphylactic shock** or **disseminated echinococcosis** (secondary hydatid disease). - **Conservative organ-preserving approaches** are strongly preferred, including **PAIR** (Puncture, Aspiration, Injection, Reaspiration, and Drainage) or **pericystectomy** (removing cyst with its pericyst while preserving spleen). - Splenectomy may only be considered in complicated cases (rupture, secondary infection, or inability to preserve spleen tissue), but it is NOT a routine indication. *Hereditary spherocytosis* - **Splenectomy** is the **definitive treatment** for **hereditary spherocytosis** to reduce hemolysis and alleviate symptoms like anemia, jaundice, and splenomegaly. - The spleen is the primary site of destruction of the abnormally shaped red blood cells, so its removal significantly prolongs red blood cell lifespan. - Typically performed after age 5-6 years to reduce infection risk. *Idiopathic thrombocytopenic purpura* - **Splenectomy** is indicated in cases of **chronic refractory ITP** that do not respond to medical therapy (e.g., corticosteroids, IVIG, rituximab). - The spleen is the primary site of **platelet destruction** and **autoantibody production** against platelets in ITP. - Splenectomy achieves remission in approximately 60-70% of patients with chronic ITP. *Myelofibrosis* - **Splenectomy** may be indicated in **myelofibrosis** for severe, symptomatic **splenomegaly** causing debilitating pain, early satiety, cachexia, or mechanical complications. - Also indicated for refractory cytopenias requiring frequent transfusions or severe portal hypertension. - It can alleviate pressure symptoms and reduce the metabolic demands of a massively enlarged spleen, improving quality of life.

Question 1

A 56-year-old male came with acute onset breathlessness and found to have pneumothorax. The resident doctor decided to insert an intercostal drain. Which one of the following sites is suitable for such a procedure?

Accepted Answer

Triangle of safety

Answer

Petit's triangle

Answer

Hesselbach's triangle

Answer

Triangle of auscultation

Question 2

The best measure of organ perfusion and the best monitor of adequacy of shock therapy is

Accepted Answer

urine output

Answer

restoring blood pressure/pulse vital parameters

Answer

central venous pressure

Answer

pulmonary wedge pressure

Question 3

A surgeon is about to start a laparoscopic procedure on a patient. The floor nurse asks the surgeon about the identity of the patient, site of the procedure to be performed and any anticipated critical events during the surgery. These questions are a part of the

Accepted Answer

WHO surgical safety checklist

Answer

nurses safety checklist

Answer

universal precautions checklist

Answer

MCI patient safety checklist

Question 4

Which of the following are true about epidermal cyst?

1. It is lined by stratified squamous epithelium.
2. It is derived from hair follicle.
3. It contains keratin debris.
4. It is not fixed to the skin.

Accepted Answer

1, 2 and 3

Answer

1, 3 and 4

Answer

1, 2 and 4

Answer

2, 3 and 4

Question 5

Which of the following is the PRIMARY factor that predisposes to the development of incisional hernia?

Accepted Answer

Postoperative wound infection

Answer

Immunocompromised patient

Answer

Malnutrition

Answer

Non-absorbable suture material

Question 6

Match List-I with List-II and select the correct answer using the code given below the Lists:

(Refer to the image for List-I and List-II)

Accepted Answer

A→4  B→1  C→2  D→3

Answer

A→2  B→3  C→4  D→1

Answer

A→3  B→4  C→1  D→2

Answer

A→1  B→2  C→3  D→4

Question 7

Consider the following statements regarding splenectomy :

1. It corrects anemia in congenital hereditary spherocytosis.
2. Postponed until the age of 4 years if possible.
3. Polyvalent pneumococcal vaccine to be administered to all before the surgery. Which of the statements given above are correct ?

Accepted Answer

1, 2 and 3

Answer

1 and 3 only

Answer

2 and 3 only

Answer

1 and 2 only

Question 8

Splenectomy is best indicated for :

Accepted Answer

Hereditary spherocytosis

Answer

Cirrhosis liver with portal hypertension

Answer

Sickle cell disease

Answer

Gaucher's disease

Question 9

Splenectomy is indicated in all of the following conditions, except

Accepted Answer

Hydatid cyst of the spleen

Answer

Hereditary spherocytosis

Answer

Idiopathic thrombocytopenic purpura

Answer

Myelofibrosis

Question 10

Which of the following statements is true regarding wound contracture ?

Accepted Answer

It is the function of specialised fibroblasts that contain actin myofilaments

Answer

Bacterial colonization of a wound slows the process of contraction

Answer

It may account for a 40% decrease in the size of a wound

Answer

It is a primary process affecting the closure of sutured wounds

General Surgery Principles — MCQs

General Surgery Principles — MCQs

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