General Surgery Principles Practice Questions

Q: A 65-year-old diabetic woman develops a surgical site infection 5 days after elective cholecystectomy. She has poorly controlled diabetes (HbA1c 10.2%), is obese (BMI 35), and was on chronic steroids for rheumatoid arthritis. Which factor most likely contributed to her delayed wound healing?

Hyperglycemia impairing neutrophil function. ***Hyperglycemia impairing neutrophil function*** - **Poorly controlled diabetes** leads to hyperglycemia, which significantly impairs **neutrophil chemotaxis**, phagocytosis, and bacterial killing. - This compromised immune response directly increases the risk of **surgical site infections** and delayed wound healing by reducing the body's ability to clear pathogens. - With an **HbA1c of 10.2%**, this patient has severe chronic hyperglycemia, making this the most direct and significant contributor to the acute SSI. *Steroid use preventing inflammation* - **Chronic steroid use suppresses the immune system** and **impairs collagen synthesis**, which are indeed risk factors for delayed wound healing. - However, in this specific scenario, the impact of severe hyperglycemia on acute immune function (neutrophil impairment) is a more *direct* and *most likely* contributor to the *surgical site infection* within 5 days, rather than the chronic effects of steroids. *Advanced age alone* - While **advanced age** can be associated with some delay in wound healing due to reduced cellular regeneration and vascularity, it is typically a less potent factor than severe systemic metabolic disorders like **uncontrolled diabetes**. - Compared to the profound immune dysfunction caused by hyperglycemia, age alone is not the *most likely* primary contributor to this acute infection. *Obesity causing mechanical stress* - **Obesity** contributes to increased surgical complexity, poor vascularization in adipose tissue, and higher rates of **wound dehiscence** and infection due to increased skin tension and impaired drug penetration. - While it is a significant risk factor, the **acute impairment of bacterial clearance** due to hyperglycemia is a more direct and immediate cause of the *infection* itself, rather than just delayed healing or dehiscence from mechanical stress.

Q: The image shows a Negative Pressure Wound Therapy (NPWT) dressing applied to a patient's wound. What is the standard NPWT pressure setting commonly used to promote wound healing?

-125 mm Hg. ***-125 mm Hg*** - **Negative Pressure Wound Therapy (NPWT)** uses controlled subatmospheric (negative) pressure to promote wound healing. - The most commonly used pressure setting is **-125 mm Hg**, which has been extensively validated in clinical studies. - This pressure level effectively promotes granulation tissue formation, reduces edema, removes exudate, and increases blood flow to the wound bed. - **-75 to -125 mm Hg** is the typical therapeutic range, with -125 mm Hg being the standard setting for most wound types. *-60 to -80 mm Hg* - This represents a **lower negative pressure range** that, while within the broader NPWT spectrum, is below the standard -125 mm Hg setting. - Lower negative pressures may be used in specific sensitive wound types but are not the standard setting for most wounds. - The standard -125 mm Hg provides more effective granulation tissue formation and exudate removal than this lower range. *-130 mm Hg* - This is slightly above the standard -125 mm Hg setting used in NPWT. - While close to the standard, -130 mm Hg would be at the higher end and might increase patient discomfort without additional benefit over -125 mm Hg. - The standard validated setting remains -125 mm Hg for most wound types. *-80 to -100 mm Hg* - These negative pressure values are within the lower end of the NPWT therapeutic range but are not the standard setting. - NPWT at -80 to -100 mm Hg may be used in certain clinical scenarios but does not represent the most commonly validated standard setting. - The standard -125 mm Hg setting is preferred for optimal wound healing outcomes in most patients.

Q: A 78-year-old immobile patient presents with a pressure ulcer on the sacral area, as shown in the image below. How would you grade this bedsore?

Unstageable pressure injury. *Stage 1* - A Stage 1 pressure ulcer is characterized by **non-blanchable erythema** of intact skin, typically over a bony prominence. - There is no break in the skin, which is not what is visible in the image. *Stage 2* - A Stage 2 pressure ulcer involves **partial-thickness skin loss** presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. - The depth and tissue involvement shown in the image are far more extensive than a Stage 2 ulcer. *Stage 3* - A Stage 3 pressure ulcer involves **full-thickness tissue loss** where subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. - Because the wound base is obscured by slough and eschar, the image cannot distinguish Stage 3 from Stage 4 until the base is exposed and the true depth is determined. *Stage 4* - A Stage 4 pressure ulcer involves **full-thickness tissue loss** with visible **bone, tendon, or muscle**. - The wound base in this image is obscured by slough and eschar, so Stage 4 cannot be confirmed from this image alone. ***Unstageable pressure injury*** - The image shows **full-thickness tissue loss** in which the base of the ulcer is covered by **slough and/or eschar**, obscuring the true depth of the wound. - Because the wound bed cannot be visualized, the ulcer cannot be accurately staged until the slough or eschar is removed. - This is the **correct answer** as the obscured wound base is the defining feature of an unstageable pressure injury.

Q: Which of the following conditions most commonly presents with free gas under the diaphragm (pneumoperitoneum) on imaging?

Secondary. ***Correct: Secondary*** - **Gas under the diaphragm** is a classic sign of a **perforated viscus**, which is a severe form of **secondary peritonitis**. - Secondary peritonitis typically arises from the **rupture or perforation of an abdominal organ**, allowing gas and contents to leak into the peritoneal cavity. *Incorrect: Tertiary* - **Tertiary peritonitis** refers to persistent or recurrent peritonitis after seemingly adequate surgical and antibiotic treatment for primary or secondary peritonitis. - It is associated with **immunocompromised states** or **low-virulence organisms** and does not typically present with free gas under the diaphragm. *Incorrect: Retained stone* - A **retained stone** (e.g., gallstone, renal stone) can cause obstruction or inflammation but does not directly lead to **gas under the diaphragm**. - While it might indirectly lead to perforation if neglected, it's not the most common direct cause of **free peritoneal gas**. *Incorrect: Primary* - **Primary peritonitis** (also known as spontaneous bacterial peritonitis) occurs without an apparent source of contamination within the abdominal cavity, often in patients with ascites and **liver cirrhosis**. - It is characterized by bacterial infection of the ascitic fluid but does not involve a perforated viscus or **free gas under the diaphragm**.

Q: A surgeon examined a case of hernia and was able to retract the hernial sac on examination but not the contents. Identify the type of hernia depicted in the image.

Reduction en masse. ***Reduction en masse*** - This occurs when the **hernia sac** is reduced into the abdomen but the contents remain incarcerated within the sac, still outside the peritoneal cavity. The image clearly depicts the sac being pushed back, while the bowel loop within it remains constricted at the neck. - This is a dangerous situation because the **incarcerated bowel** is not visible externally, yet remains at risk of strangulation and is often unrecognized. *Sliding hernia* - A sliding hernia involves a portion of the **retroperitoneal organ** (like the colon or bladder) forming part of the posterior wall of the hernia sac. - This typically occurs gradually, and the sac itself is not mistakenly reduced without its contents while the contents remain trapped. *Incarcerated hernia* - An incarcerated hernia means the contents of the hernia sac are **trapped** and cannot be manually reduced back into the abdominal cavity. - While the image shows incarcerated contents, the specific problem here is that the *sac* has been reduced without its contents, which is a particular complication rather than just general incarceration. *Maydl's hernia* - Maydl's hernia (also known as a W-hernia) describes a scenario where **two loops of bowel** are contained within the hernia sac, with a connecting loop of bowel located within the abdominal cavity, forming a 'W' shape. - The illustration shows only one loop of bowel within the sac and does not suggest the specific 'W' configuration or intra-abdominal strangulation of the connecting segment.

Q: You are suturing a laceration in the ER using the interrupted suturing technique. What is the angle of needle placement?

90 degrees. ***90 degrees*** - Placing the needle at a **90-degree angle** to the skin surface ensures that the suture comes out perpendicular to the skin edge, creating an **eversion of the wound edges**. - This perpendicular entry allows for an equal amount of tissue to be grasped on both sides of the wound, promoting proper **wound approximation** and healing. *80 degrees* - An 80-degree angle, while close, would not provide the ideal **perpendicular entry** needed to properly evert the wound edges. - This slight deviation from 90 degrees could lead to less precise **tissue approximation** and potentially an inverted wound edge. *70 degrees* - A 70-degree angle is too shallow and would result in the suture entering the wound more tangentially, leading to **inverted wound edges**. - **Inverted wound edges** hinder optimal healing and can result in a less aesthetically pleasing scar. *60 degrees* - A 60-degree angle is significantly too shallow, which would cause the suture to be placed too superficially and horizontally, resulting in **poor wound edge eversion**. - This angle would make it difficult to adequately appose the deeper dermal layers, compromising **tensile strength** and increasing the risk of scar formation.

Q: Marjolin's ulcer is:-

Squamous cell carcinoma from scar. ***Squamous cell carcinoma from scar*** - A Marjolin's ulcer is a rare but aggressive form of squamous cell carcinoma (SCC) that arises in areas of previously traumatized, chronically inflamed, or scarred skin. - Common sites include burn scars, chronic osteomyelitis tracts, pressure ulcers, and venous ulcers. - Typically has a long latency period (average 30-35 years after initial injury). - Characterized by higher rates of local recurrence and metastasis compared to conventional SCC. *Adenoma of scar* - An adenoma is a benign tumor of glandular origin and is not typically associated with scar tissue or malignant transformation in this context. - The malignancy arising in a scar is usually carcinoma, not adenoma. *Amoebic ulcer* - An amoebic ulcer is caused by the parasite *Entamoeba histolytica* and typically affects the colon, presenting as dysentery. - It is not a type of malignant transformation within a pre-existing scar. *Tubercular ulcer* - A tubercular ulcer is a manifestation of tuberculosis, often affecting the skin or mucous membranes and caused by *Mycobacterium tuberculosis*. - This is an infectious process and not a malignant transformation of scar tissue.

Q: Most common immediate complication after splenectomy?

Hemorrhage. **Hemorrhage** - **Hemorrhage** is the most common immediate complication due to the spleen's rich blood supply and its close proximity to major vessels such as the **splenic artery and vein**. - Surgical trauma, inadequate ligation, or dislodgment of ligatures can lead to significant blood loss post-splenectomy. *Fistula* - Fistula formation, such as a **pancreatic fistula**, can occur but is less common immediately post-splenectomy compared to hemorrhage. - This complication typically develops due to injury to the **pancreatic tail** during splenic dissection, leading to leakage of pancreatic enzymes. *Bleeding from gastric mucosa* - Bleeding from the **gastric mucosa** (e.g., from stress ulcers or gastritis) is a potential complication after any major surgery but is not the most common immediate complication specific to splenectomy. - While the stomach is in close proximity, direct injury to the gastric mucosa causing significant bleeding is less frequent than hemorrhage from the splenic bed. *Pancreatitis* - **Pancreatitis** can be a severe complication of splenectomy, resulting from injury to the **pancreatic tail** during the procedure. - While it can manifest immediately, its incidence is generally lower than that of hemorrhage.

Q: Degloving injury is -

Avulsion injury. ***Avulsion injury*** - A **degloving injury** is a severe type of **avulsion wound** where a large section of skin and subcutaneous tissue is completely torn away from the underlying muscle and fascia. - This injury can expose bone, muscle, or other internal structures due to the forceful tearing process. *Blunt injury* - **Blunt injuries** result from impact with a dull object, causing contusions, hematomas, or fractures without necessarily breaking the skin or tearing away large sections of tissue. - While a blunt force can cause a degloving injury, the term "blunt injury" describes the *mechanism* rather than the specific type of wound characterized by tissue avulsion. *Surgeon made wound* - A **surgeon-made wound** refers to an incision created purposefully during a medical procedure, which is a controlled and precise cut to access deeper tissues. - Degloving injuries are accidental, traumatic wounds, not intentional surgical incisions. *Lacerated wound* - A **lacerated wound** is a tear in the skin and underlying tissue, often caused by a blunt object or shearing force, resulting in irregular edges. - While both involve tearing, a laceration doesn't typically involve the extensive separation and removal of an entire layer of skin and subcutaneous tissue characteristic of degloving.

Question 1

A 65-year-old diabetic woman develops a surgical site infection 5 days after elective cholecystectomy. She has poorly controlled diabetes (HbA1c 10.2%), is obese (BMI 35), and was on chronic steroids for rheumatoid arthritis. Which factor most likely contributed to her delayed wound healing?

Accepted Answer

Hyperglycemia impairing neutrophil function

Answer

Steroid use preventing inflammation

Answer

Advanced age alone

Answer

Obesity causing mechanical stress

Question 2

A 55-year-old diabetic woman develops necrotizing fasciitis of the perineum following a minor gynecologic procedure. She has septic shock, multiorgan failure, and extensive tissue necrosis. Her family requests 'everything be done,' but her prognosis is poor. Evaluate the ethical and medical approach to her care.

Accepted Answer

Extensive debridement with time-limited trial of intensive care

Answer

Transfer to another facility for second opinion

Answer

Limited surgical intervention with family counseling about prognosis

Answer

Palliative care transition with comfort measures only

Question 3

The image shows a Negative Pressure Wound Therapy (NPWT) dressing applied to a patient's wound. What is the standard NPWT pressure setting commonly used to promote wound healing?

Accepted Answer

-125 mm Hg

Answer

-80 to -100 mm Hg

Answer

-130 mm Hg

Answer

-60 to -80 mm Hg

Question 4

A 78-year-old immobile patient presents with a pressure ulcer on the sacral area, as shown in the image below. How would you grade this bedsore?

Accepted Answer

Unstageable pressure injury

Answer

Stage 3

Answer

Stage 2

Answer

Stage 1

Answer

Stage 4

Question 5

Which of the following conditions most commonly presents with free gas under the diaphragm (pneumoperitoneum) on imaging?

Accepted Answer

Secondary

Answer

Tertiary

Answer

Retained stone

Answer

Primary

Question 6

A surgeon examined a case of hernia and was able to retract the hernial sac on examination but not the contents. Identify the type of hernia depicted in the image.

Accepted Answer

Reduction en masse

Answer

Sliding hernia

Answer

Incarcerated hernia

Answer

Maydl's hernia

Question 7

You are suturing a laceration in the ER using the interrupted suturing technique. What is the angle of needle placement?

Accepted Answer

90 degrees

Answer

80 degrees

Answer

70 degrees

Answer

60 degrees

Question 8

Marjolin's ulcer is:-

Accepted Answer

Squamous cell carcinoma from scar

Answer

Adenoma of scar

Answer

Amoebic ulcer

Answer

Tubercular ulcer

Question 9

Most common immediate complication after splenectomy?

Accepted Answer

Hemorrhage

Answer

Fistula

Answer

Bleeding from gastric mucosa

Answer

Pancreatitis

Question 10

Degloving injury is -

Accepted Answer

Avulsion injury

Answer

Blunt injury

Answer

Surgeon made wound

Answer

Lacerated wound

General Surgery Principles — MCQs

General Surgery Principles — MCQs

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