General Surgery Principles Practice Questions

Q: A 40 year old man presented with a flat 1x1cm scaly, itchy black mole on the front of thigh. Examination did not reveal any inguinal lymphodenopathy. The best course of management would be:

Excision biopsy. ***Excision biopsy*** - A **flat, scaly, itchy, black mole** is highly suspicious for **melanoma**, and an excision biopsy provides the most accurate histopathological diagnosis and depth assessment. - This procedure removes the entire lesion with a narrow margin of normal-appearing skin, allowing for comprehensive evaluation of its nature and determining further management. *FNAC of lesion* - **Fine needle aspiration cytology (FNAC)** is generally used for evaluating palpable masses or lymph nodes, not primary skin lesions like a suspicious mole. - It provides only cellular samples, making it difficult to assess architectural features, depth of invasion, or determine definitive malignancy in skin lesions. *Incision biopsy* - An **incision biopsy** involves removing only a partial sample of the lesion, which can lead to sampling error and an inaccurate diagnosis if the most aggressive part is missed. - For suspected melanoma, an incomplete biopsy can compromise subsequent staging and definitive treatment planning. *Wide excision with inguinal lymphadenectomy* - This is an **overly aggressive initial approach** before a definitive diagnosis of melanoma and its stage has been established. - **Wide excision** is typically performed after an excision biopsy confirms melanoma and determines its depth, while **lymphadenectomy** is indicated for confirmed lymph node involvement.

Q: Which of the following suture materials has the least tissue reaction?

Stainless steel. ***Stainless steel*** - **Stainless steel** is a **monofilament** suture with the **lowest tissue reactivity** due to its inert nature. - It is often used in situations requiring maximal strength and minimal biological interaction, such as abdominal wall closure or orthopedic procedures. *Silk* - **Silk** is a **multifilament, natural, non-absorbable** suture and is known for its **moderate tissue reactivity** due to its braided structure and organic origin. - While it provides good knot security, its reactivity makes it unsuitable for areas where minimal foreign body reaction is paramount. *Cotton / Linen* - **Cotton and linen** sutures are **natural, multifilament, non-absorbable** materials that exhibit significant **tissue reactivity**. - Their fibrous nature can lead to considerable inflammatory response and are rarely used in modern surgical practice. *Chromic catgut* - **Chromic catgut** is a **natural, absorbable** suture treated with chromium salts to prolong its absorption time, but it still triggers a **significant inflammatory response** as it is absorbed by enzymatic digestion. - Its high tissue reactivity makes it less ideal for situations requiring minimal foreign body reaction compared to synthetic or metallic sutures.

Q: Which of the following statements is not correct regarding sebaceous cyst?

Treatment is incision and drainage. ***Treatment is incision and drainage*** - The standard treatment for a sebaceous cyst (more accurately an **epidermoid cyst** or **pilar cyst**) is **surgical excision** of the entire cyst wall to prevent recurrence. - **Incision and drainage** only provides temporary relief by emptying the contents but leaves the cyst wall intact, leading to a high chance of the cyst refilling. *Found on hairy areas of the body* - This statement is generally correct as sebaceous cysts often arise from hair follicles and are common in **hair-bearing areas** like the scalp, face, neck, and trunk. - They occur due to the accumulation of **sebum** and keratin within a blocked or damaged sebaceous gland or hair follicle. *Not found on palms and soles* - This statement is correct because **palms and soles** generally **lack sebaceous glands** and hair follicles, hence sebaceous cysts are typically not found in these locations. - Cysts found in these areas are more likely to be **ganglion cysts** or other types of epidermal inclusion cysts. *It has a punctum* - This statement is often correct; many sebaceous cysts (especially epidermoid cysts) have a visible **central punctum** which represents the occluded pore from which the cyst originated. - This punctum is a **key diagnostic feature** and can sometimes exude a cheesy, foul-smelling material.

Q: Good surgical practice and surgical ethics include all EXCEPT:

Experiment without consent. ***Experiment without consent*** - Performing an experiment or research procedure on a patient **without proper informed consent** is a direct violation of medical ethics and good surgical practice. - Even well-designed clinical research requires **explicit patient consent**, **ethics committee approval**, and adherence to principles of *non-maleficence* and *beneficence*. - Conducting any experimental procedure without consent violates patient autonomy and the fundamental ethical principle of **informed consent**. *Confidentiality* - **Confidentiality** is a cornerstone of patient care, ensuring that patient information is protected and disclosed only with proper consent or legal requirement. - Maintaining confidentiality is an essential component of good surgical practice and medical ethics. *Informed consent* - **Informed consent** is a fundamental ethical and legal requirement before any medical procedure, ensuring the patient understands the *risks, benefits, alternatives*, and prognosis. - It upholds the principle of *patient autonomy*, allowing individuals to make decisions about their own healthcare. *Respect autonomy* - **Respect for autonomy** means acknowledging and upholding a patient's right to *make their own decisions* about their medical care, free from coercion. - This principle guides processes like obtaining informed consent and respecting a patient's choices, even if they differ from the medical professional's recommendation, as long as the patient is competent.

Q: A young sports person presented in surgical emergency with the complaints of severe pain in the groin area, extending into the scrotum and upper thigh. The pain is debilitating and he is not able to exercise. On examination there is tenderness in the region of Inguinal canal and pubic tubercle. He is probably suffering from:

Sportsman hernia. ***Sportsman hernia*** - The presentation of severe, debilitating groin pain extending to the scrotum and upper thigh, especially in a young sports person, is highly characteristic of a **sportsman's hernia** (also known as athletic pubalgia or Gilmore's groin). - This condition involves a **tear or weakening** of the posterior inguinal wall or associated musculature, leading to chronic groin pain exacerbated by physical activity. *Inguinal hernia* - This typically presents with a **visible bulge** in the groin that may or may not be painful, often increasing with straining but usually not as debilitating without incarceration. - While pain can extend to the scrotum, the primary complaint is usually the bulge and the pain is frequently relieved by lying down, unlike the chronic, activity-related pain described. *Femoral hernia* - A femoral hernia usually presents as a **lump below the inguinal ligament**, often more common in women, and can be easily confused with lymphadenopathy or a saphena varix. - While it can cause pain, it is less likely to produce the widespread, debilitating pain described as a primary symptom without signs of complications like incarceration. *Varicocele* - A varicocele is a condition of **enlarged veins within the scrotum** and typically presents as a "bag of worms" sensation or dull ache in the scrotum, often worse after standing for prolonged periods. - The pain is usually scrotal and not described as severe, debilitating groin pain extending to the upper thigh with tenderness in the inguinal canal, as seen in this case.

Q: Which one of the following type of meshes is recommended for intraperitoneal use in abdominal wall hernia?

Tissue separating meshes. ***Correct: Tissue separating meshes*** - These meshes are designed with a **non-adherent barrier** on one side to prevent visceral adhesions when placed intraperitoneally. - They are essential for intraperitoneal hernia repair to avoid complications like **bowel obstruction** or **fistula formation**. - Examples include **Parietex Composite, Proceed, and Composix** meshes. *Incorrect: Light weight, porous meshes* - While generally preferred for tension-free repair due to reduced foreign body reaction, they **lack an anti-adhesive barrier** for intraperitoneal use. - Their direct contact with abdominal viscera can lead to **adhesion formation**, which is a significant complication. *Incorrect: Absorbable meshes* - These meshes are intended for temporary support and are eventually broken down and absorbed by the body. - Their complete absorption means they **do not provide long-term reinforcement** or prevent hernia recurrence, which is crucial for permanent repair. *Incorrect: Heavy weight, porous meshes* - These meshes are associated with a **higher foreign body reaction**, leading to more inflammation, pain, and mesh contraction. - They also **lack the necessary anti-adhesive coating** for safe intraperitoneal placement, increasing the risk of visceral adhesions.

Q: Stage III "Pressure sore" is full thickness skin loss extending:

into subcutaneous tissue but not through fascia. ***into subcutaneous tissue but not through fascia*** - A **Stage III pressure ulcer** involves **full-thickness skin loss** with damage or necrosis of **subcutaneous tissue** that may extend down to, but **NOT through**, the underlying fascia. - The ulcer presents as a **deep crater** with or without undermining of adjacent tissue, slough, or eschar. - **Muscle, tendon, and bone are NOT visible or directly palpable** in Stage III ulcers. *through subcutaneous tissue into fascia* - This description is **too deep** for Stage III; fascia penetration indicates **Stage IV**. - Stage III extends **to** the fascia but does **not penetrate through** it. *through subcutaneous tissue into fascia and muscles* - This is the definition of a **Stage IV pressure ulcer**, not Stage III. - **Muscle exposure** indicates full-thickness tissue loss beyond the subcutaneous layer and signifies Stage IV. *through subcutaneous tissue into fascia, muscles and bone* - This is also **Stage IV** (most severe form with bone, tendon, or muscle exposure). - **Bone exposure** is pathognomonic of Stage IV pressure ulcers and never occurs in Stage III.

Q: Which one of the following is NOT a complication of massive blood transfusion?

Hyperthermia. ***Hyperthermia*** - **Hypothermia** is a more common complication of massive blood transfusion due to the administration of large volumes of cold blood products. - While theoretical, hyperthermia in this context would be rare and not a direct complication of the blood components themselves, unless equipment malfunction or infection occurs. [1] *Hyperkalemia* - Stored red blood cells **leak potassium** as they age, leading to higher potassium levels in the transfusion product. - Rapid infusion of large volumes can overwhelm the body's compensatory mechanisms, resulting in **elevated serum potassium**. *Hypocalcaemia* - **Citrate**, an anticoagulant used in blood storage, binds to ionized calcium in the recipient's blood. - Massive transfusions can lead to significant citrate accumulation, causing a drop in **ionized calcium levels**. *Coagulopathy* - Massive transfusions dilute clotting factors and platelets, which are not proportionally replaced in standard transfusion protocols. - This dilution can lead to impaired **hemostasis** and increased bleeding tendencies. [1]

Q: A 50-year old male with significant smoking history presented in the surgical emergency with sudden severe breathlessness. Chest X-ray shows right sided Pneumothorax. The appropriate management requires:

Right chest drain of size 8-14 Fr. ***Right chest drain of size 8-14 Fr*** - **Secondary spontaneous pneumothorax (SSP)** in a smoker with severe breathlessness requires **chest drain insertion** as first-line treatment to evacuate trapped air and allow lung re-expansion. - A **small-bore chest drain (8-14 Fr)** is preferred as it provides effective drainage with reduced patient discomfort and lower complication rates compared to large-bore tubes. *Oxygen by face mask* - **Oxygen therapy** is supportive care that may accelerate **pleural air resorption** but does not actively remove trapped air from the pleural space. - It is **insufficient as primary treatment** for symptomatic pneumothorax, especially in secondary spontaneous pneumothorax which requires active intervention. *Aspiration of air with 16-18 G cannula* - **Needle aspiration** is typically reserved for **primary spontaneous pneumothorax** in young, healthy patients or as emergency decompression for tension pneumothorax. - In **secondary spontaneous pneumothorax** (especially with underlying lung disease from smoking), chest drain insertion is preferred over needle aspiration due to higher success rates and lower recurrence. *Mechanical ventilation* - **Positive pressure ventilation** can worsen pneumothorax by increasing **intrathoracic pressure** and potentially converting simple pneumothorax to tension pneumothorax. - Mechanical ventilation is only indicated if patient develops **respiratory failure** despite appropriate pneumothorax management or in cases of hemodynamic instability.

Q: Which type of surgery is laparoscopic cholecystectomy classified as?

Clean contaminated. ***Clean contaminated*** - This classification applies to surgeries that involve a **viscus** (e.g., gallbladder, gastrointestinal tract, respiratory tract) but with **no unusual contamination** encountered. - While the gallbladder contains bile, which harbors bacteria, in an uncomplicated laparoscopic cholecystectomy, spillage is controlled, and there's no pre-existing infection. *Dirty* - This category is reserved for procedures performed in the presence of **established infection**, such as an abdominal abscess or perforated viscus with gross spillage. - There is evidence of **pus** or a **perforated hollow viscus** encountered during the operation. *Contaminated* - This classification is used when there is a **major break in sterile technique** or a significant spillage from the gastrointestinal contents or infected bile. - It also includes procedures where **acute, non-purulent inflammation** is encountered, or an open, traumatic wound is less than 4 hours old. *Clean* - These are procedures in which there is **no inflammation**, the gastrointestinal, genitourinary, or respiratory tracts are **not entered**, and there is no break in aseptic technique. - Examples include breast biopsies, hernia repairs without bowel resection, and thyroidectomies.

Question 1

A 40 year old man presented with a flat 1x1cm scaly, itchy black mole on the front of thigh. Examination did not reveal any inguinal lymphodenopathy. The best course of management would be:

Accepted Answer

Excision biopsy

Answer

FNAC of lesion

Answer

Incision biopsy

Answer

Wide excision with inguinal lymphadenectomy

Question 2

Which of the following suture materials has the least tissue reaction?

Accepted Answer

Stainless steel

Answer

Silk

Answer

Cotton / Linen

Answer

Chromic catgut

Question 3

Which of the following statements is not correct regarding sebaceous cyst?

Accepted Answer

Treatment is incision and drainage

Answer

Found on hairy areas of the body

Answer

Not found on palms and soles

Answer

It has a punctum

Question 4

Good surgical practice and surgical ethics include all EXCEPT:

Accepted Answer

Experiment without consent

Answer

Confidentiality

Answer

Informed consent

Answer

Respect autonomy

Question 5

A young sports person presented in surgical emergency with the complaints of severe pain in the groin area, extending into the scrotum and upper thigh. The pain is debilitating and he is not able to exercise. On examination there is tenderness in the region of Inguinal canal and pubic tubercle. He is probably suffering from:

Accepted Answer

Sportsman hernia

Answer

Inguinal hernia

Answer

Femoral hernia

Answer

Varicocele

Question 6

Which one of the following type of meshes is recommended for intraperitoneal use in abdominal wall hernia?

Accepted Answer

Tissue separating meshes

Answer

Absorbable meshes

Answer

Heavy weight, porous meshes

Answer

Light weight, porous meshes

Question 7

Stage III "Pressure sore" is full thickness skin loss extending:

Accepted Answer

into subcutaneous tissue but not through fascia

Answer

through subcutaneous tissue into fascia, muscles and bone

Answer

through subcutaneous tissue into fascia

Answer

through subcutaneous tissue into fascia and muscles

Question 8

Which one of the following is NOT a complication of massive blood transfusion?

Accepted Answer

Hyperthermia

Answer

Hyperkalemia

Answer

Hypocalcaemia

Answer

Coagulopathy

Question 9

A 50-year old male with significant smoking history presented in the surgical emergency with sudden severe breathlessness. Chest X-ray shows right sided Pneumothorax. The appropriate management requires:

Accepted Answer

Right chest drain of size 8-14 Fr

Answer

Mechanical ventilation

Answer

Aspiration of air with 16-18 G cannula

Answer

Oxygen by face mask

Question 10

Which type of surgery is laparoscopic cholecystectomy classified as?

Accepted Answer

Clean contaminated

Answer

Dirty

Answer

Contaminated

Answer

Clean

General Surgery Principles — MCQs

General Surgery Principles — MCQs

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