General Surgery Principles Practice Questions

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.

Q: Which of the following is the triad of complications of massive blood transfusion?

Acidosis, hypothermia, coagulopathy. ***Acidosis, hypothermia, coagulopathy*** - **Massive blood transfusion** can lead to **metabolic acidosis** due to the citrate in stored blood, which is metabolized to bicarbonate and consumed. - Stored blood is cold, which can cause patient **hypothermia**, while **coagulopathy** arises from dilution of clotting factors and platelets [1]. *Hypocalcemia, hypothermia, coagulopathy* - While **hypocalcemia** can occur due to **citrate toxicity** binding calcium, it is not considered one of the primary components of the classic triad. - The classic triad focuses on the most immediate and profound threats: acidosis, hypothermia, and coagulopathy. *Hyperkalemia, metabolic acidosis, and cardiac arrhythmias* - **Hyperkalemia** can occur due to the release of potassium from lysed red blood cells in stored blood, especially with older units. - However, **cardiac arrhythmias** are a *consequence* of these electrolyte imbalances and not a primary component of the classic triad itself. *Alkalosis, hyperthermia, coagulopathy* - **Alkalosis** is not typically a direct complication; **acidosis** is more common due to the metabolic burden of citrate and hypoperfusion. - **Hypothermia** is a more prominent issue than hyperthermia, as transfused blood is stored cold.

Q: All are absolute indications for amputation except,

Frost bite. ***Frost bite*** - While severe **frostbite** can lead to amputation, it is not an absolute indication as initial management often involves **rapid rewarming**, observation, and conservative measures to preserve tissue. - Amputation is typically considered only after the full extent of tissue damage is clear, and conservative treatments have failed or severe infection develops. *Buerger's gangrene* - **Buerger's disease (thromboangiitis obliterans)** is a progressive inflammatory obliterative disease of small and medium-sized arteries and veins, mainly affecting the limbs. - **Gangrene** in Buerger's disease is often severe and progressive, frequently leading to **autoamputation** or surgical amputation to prevent spread and manage pain. *Gas gangrene* - **Gas gangrene** is a rapidly progressive and life-threatening infection caused by Clostridium species, which produces toxins and gas in tissues. - It necessitates urgent and aggressive treatment, including **radical débridement** or **amputation** to remove infected tissue and prevent sepsis. *Diabetic gangrene* - **Diabetic gangrene** arises from severe peripheral artery disease and neuropathy in diabetic patients, compromising blood supply and sensation. - The compromised blood flow and presence of infection often result in tissue necrosis requiring **amputation** to prevent further spread of infection and systemic complications.

Q: If suture marks are to be avoided, skin sutures should be removed by:

1 week. ***Correct: 1 week*** - Skin sutures are typically removed around **7 days (1 week)** to prevent the formation of **track marks** or permanent scarring along the suture lines. - By this time, sufficient wound healing has occurred for the incision to withstand normal tension, reducing the risk of **dehiscence**. - This timing balances adequate healing with minimal scarring, especially important for cosmetically sensitive areas like the face and neck. *Incorrect: 72 hours* - Removing sutures after only **72 hours (3 days)** is generally too early, as the wound may not have acquired enough tensile strength, increasing the risk of **wound dehiscence**. - While this might minimize suture marks, the primary concern is proper wound healing and closure before suture removal. *Incorrect: 3 weeks* - Leaving sutures in for **3 weeks** is significantly longer than necessary and will almost certainly result in prominent **suture marks** due to epithelialization around the suture material. - Prolonged presence of sutures can also increase the risk of **infection** and foreign body reactions. *Incorrect: 2 weeks* - While sometimes appropriate for areas of high tension or slower healing (e.g., joints, back), **2 weeks** often leads to more noticeable **suture marks** compared to removal at 1 week, particularly in cosmetically sensitive areas. - The goal is to remove sutures as soon as the wound is stable enough to minimize scar formation.

Q: Massive blood transfusion complications include all except -

Hypernatremia. ***Hypernatremia*** - **Massive blood transfusions** typically involve transfusing red blood cells suspended in solutions like normal saline, which is **isotonic** or slightly hypotonic, or solutions containing **citrate**, which is metabolized in the liver to bicarbonate. - Therefore, hypernatremia is **not expected** and, in fact, hyponatremia can occur in some circumstances due to dilution or impaired sodium excretion in severely ill patients. *Hypothermia* - **Refrigerated blood products** are typically stored at 1-6°C; rapid infusion of large volumes of these cold products can significantly lower the patient's core body temperature, leading to **hypothermia**. - Hypothermia can worsen **coagulopathy** and cardiac arrhythmias, which are serious complications in critically ill or hemorrhaging patients. *Hyperkalemia* - As red blood cells are stored, there is a gradual leakage of **potassium** from intracellular to extracellular compartments due to reduced activity of the **Na+/K+ ATPase pump**. - During massive transfusion, the infusion of large volumes of blood with elevated extracellular potassium can lead to significant **hyperkalemia**, especially in patients with impaired renal function. *Hypocalcemia* - **Citrate** is an anticoagulant used in blood storage that binds to **ionized calcium** in the patient's blood, effectively chelating it. - Rapid infusion of large amounts of citrated blood can overwhelm the liver's capacity to metabolize citrate, leading to a significant drop in ionized calcium levels and consequently **hypocalcemia**.

Q: Delayed wound healing is seen in all except-

Hypertension. ***Hypertension*** - While **severe or uncontrolled hypertension** with microvascular complications may theoretically affect tissue perfusion, hypertension **alone is not classically listed** among the primary independent causes of delayed wound healing in standard surgical teaching. - Unlike the other options, hypertension is **not a direct metabolic or local tissue factor** that impairs the wound healing cascade. - The major recognized factors causing delayed wound healing are infection, metabolic disorders (diabetes, malnutrition), malignancy, and immunosuppression—hypertension does not fall into these classical categories. *Diabetes* - **Hyperglycemia** impairs neutrophil function, reduces collagen synthesis, and causes **microvascular disease** that reduces oxygen and nutrient delivery to wounds. - **Diabetic neuropathy** prevents early wound detection, and peripheral vascular disease further compromises healing. - Diabetes is one of the **most important systemic causes** of chronic non-healing wounds. *Infection* - **Bacterial colonization** prolongs the inflammatory phase and prevents progression to proliferation and remodeling. - Pathogens produce **proteases and toxins** that destroy granulation tissue, consume oxygen, and create a hostile wound environment. - Infection is a **local factor** that directly impairs all phases of wound healing. *Malignancy* - **Cancer-associated cachexia** and malnutrition deprive the body of resources needed for tissue repair. - Tumors can **directly invade** wound sites, and cancer treatments (chemotherapy, radiation) impair cellular proliferation and angiogenesis. - Malignancy creates a **systemic catabolic state** unfavorable for healing.

Q: All these are techniques to decrease scarring except:

Late removal of sutures. ***Late removal of sutures*** - **Late removal of sutures** can lead to permanent suture marks and increased scarring, as the epithelial cells grow down the suture track. - This increases the foreign body reaction and the duration of inflammation, ultimately worsening the cosmetic outcome. *Tension-free suturing* - **Tension-free suturing** minimizes mechanical stress on the wound edges, which is crucial for optimal healing and reduced scar formation. - Reduced tension prevents excessive inflammation and tissue ischemia, leading to a flatter, less noticeable scar. *Finer suture materials* - Using **finer suture materials** reduces the amount of foreign body reaction, which is a key factor in scar formation. - Smaller caliber sutures cause less tissue trauma and inflammation, resulting in a more aesthetically pleasing scar. *Debridement* - **Debridement** removes necrotic tissue, foreign bodies, and devitalized tissue from the wound, which are sources of chronic inflammation and impaired healing. - By creating a clean wound bed, debridement promotes healthy granulation tissue and reduces the risk of excessive scarring.

Q: Wound healing is delayed by all of the following EXCEPT?

Debridement. ***Debridement*** - **Debridement** is the medical removal of **dead, damaged, or infected tissue** to improve the healing potential of the remaining healthy tissue. - By removing impediments to healing, debridement actually **facilitates wound healing**, rather than delaying it. *Presence of foreign bodies* - The presence of **foreign bodies** (e.g., dirt, glass, sutures that are causing a reaction) in a wound can act as a **persistent irritant**, leading to chronic inflammation. - This ongoing inflammatory response can **impair the normal progression of wound healing**, often prolonging the healing process. *Trauma* - Severe or repeated **trauma** to a healing wound can disrupt the delicate new tissue formation, such as **granulation tissue** and **epithelium**. - This disruption can lead to **re-injury**, increased inflammation, and a significant delay in the wound's progression through its healing phases. *Excessive tissue manipulation* - **Excessive tissue manipulation** during surgery or wound care can cause further damage to surrounding healthy tissues and blood vessels. - This can increase wound edema, create more dead space, and release inflammatory mediators, all of which can **impede the healing process**.

Q: Best skin disinfectant for central line insertion is?

Chlorhexidine. ***Chlorhexidine*** - **Chlorhexidine gluconate** with alcohol is highly recommended for **skin antisepsis** prior to central venous catheter insertion due to its rapid and persistent antimicrobial activity. - It effectively reduces the risk of **catheter-related bloodstream infections (CRBSIs)** by targeting a broad spectrum of bacteria. *Povidone iodine* - While effective, **povidone iodine** has a slower onset of action and is less persistent compared to chlorhexidine, making it less ideal for this specific procedure. - Its efficacy can be reduced in the presence of organic material, and it may cause **skin irritation** in some patients. *Cetrimide* - **Cetrimide** is a cationic surfactant with antiseptic properties but is generally considered less potent and less widely recommended than chlorhexidine for surgical skin preparation. - It is more commonly found in preparations for cleaning wounds rather than for **major invasive procedures** like central line insertion. *Alcohol* - **Alcohol** provides rapid antisepsis and has a broad spectrum of activity, but its effect is not persistent and it is volatile, leading to quick evaporation. - Its efficacy is enhanced when combined with other agents, such as chlorhexidine, rather than being used alone for **central line insertion**.

Question 1

Most common immediate complication after splenectomy?

Accepted Answer

Hemorrhage

Answer

Fistula

Answer

Bleeding from gastric mucosa

Answer

Pancreatitis

Question 2

Degloving injury is -

Accepted Answer

Avulsion injury

Answer

Blunt injury

Answer

Surgeon made wound

Answer

Lacerated wound

Question 3

Which of the following is the triad of complications of massive blood transfusion?

Accepted Answer

Acidosis, hypothermia, coagulopathy

Answer

Hypocalcemia, hypothermia, coagulopathy

Answer

Hyperkalemia, metabolic acidosis, and cardiac arrhythmias

Answer

Alkalosis, hyperthermia, coagulopathy

Question 4

All are absolute indications for amputation except,

Accepted Answer

Frost bite

Answer

Buerger's gangrene

Answer

Gas gangrene

Answer

Diabetic gangrene

Question 5

If suture marks are to be avoided, skin sutures should be removed by:

Accepted Answer

1 week

Answer

72 hours

Answer

3 weeks

Answer

2 weeks

Question 6

Massive blood transfusion complications include all except -

Accepted Answer

Hypernatremia

Answer

Hypothermia

Answer

Hyperkalemia

Answer

Hypocalcemia

Question 7

Delayed wound healing is seen in all except-

Accepted Answer

Hypertension

Answer

Malignancy

Answer

Infection

Answer

Diabetes

Question 8

All these are techniques to decrease scarring except:

Accepted Answer

Late removal of sutures

Answer

Tension-free suturing

Answer

Finer suture materials

Answer

Debridement

Question 9

Wound healing is delayed by all of the following EXCEPT?

Accepted Answer

Debridement

Answer

Presence of foreign bodies

Answer

Trauma

Answer

Excessive tissue manipulation

Question 10

Best skin disinfectant for central line insertion is?

Accepted Answer

Chlorhexidine

Answer

Povidone iodine

Answer

Cetrimide

Answer

Alcohol

General Surgery Principles — MCQs

General Surgery Principles — MCQs

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