General Surgery Principles Practice Questions

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.

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 ideal negative pressure range commonly used for NPWT 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. *60-80 mm Hg* - This represents **positive pressure**, not negative pressure used in NPWT. - NPWT requires subatmospheric (below atmospheric) pressure, denoted by the negative sign. - Positive pressures in this range would be used in compression therapy for venous insufficiency, not vacuum-assisted wound closure. *130 mm Hg* - This is a **positive pressure** value and does not apply to NPWT. - NPWT uses negative (suction) pressure, not positive compression. - If interpreted as -130 mm Hg, this would be at the higher end and might increase patient discomfort without additional benefit over -125 mm Hg. *80-100 mm Hg* - These are **positive pressure** values not used in NPWT. - NPWT specifically requires negative pressure (vacuum/suction) to work effectively. - This range would be excessively high even for compression therapy and inappropriate for NPWT.

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?

Stage 4. *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. - The visible structures in the image suggest involvement beyond the subcutaneous fat layer, distinguishing it from a Stage 3 ulcer. ***Stage 4*** - The image shows **full-thickness tissue loss** with visible **bone, tendon, or muscle**, indicating a Stage 4 pressure ulcer. - There is also evidence of **slough and eschar** in the wound bed, which is consistent with severe tissue damage extending beyond the subcutaneous fat. - This is the **correct answer** as the exposed deeper structures are pathognomonic for Stage 4.

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.

Question 1

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 2

Which type of surgery is laparoscopic cholecystectomy classified as?

Accepted Answer

Clean contaminated

Answer

Dirty

Answer

Contaminated

Answer

Clean

Question 3

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 4

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 5

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

Accepted Answer

-125 mm Hg

Answer

60-80 mm Hg

Answer

130 mm Hg

Answer

80-100 mm Hg

Question 6

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

Stage 4

Answer

Stage 1

Answer

Stage 2

Answer

Stage 3

Question 7

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 8

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 9

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 10

Marjolin's ulcer is:-

Accepted Answer

Squamous cell carcinoma from scar

Answer

Adenoma of scar

Answer

Amoebic ulcer

Answer

Tubercular ulcer

General Surgery Principles — MCQs

General Surgery Principles — MCQs

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