General Surgery Principles Practice Questions

Q: Which of the following muscles is cut in posterolateral thoracotomy?

Latissimus dorsi. ***Latissimus dorsi*** - The **latissimus dorsi** is the **largest muscle divided** during a standard posterolateral thoracotomy incision. - It is the **most superficial** of the divided muscles and is routinely cut to allow access to the deeper structures and ribs required for entry into the thoracic cavity. - This is the **primary muscle** identified with this surgical approach. *Serratus anterior* - The **serratus anterior** is also typically **divided** (along with latissimus dorsi) in a posterolateral thoracotomy. - However, latissimus dorsi is considered the **more characteristic** muscle of this approach due to its larger size and more superficial position. - Preservation when possible is important for shoulder function (scapular protraction and superior rotation). *Rhomboids* - The **rhomboid muscles** (major and minor) lie deeper, beneath the trapezius, and are **not typically cut** in a standard posterolateral thoracotomy. - They remain protected and are involved in **scapular retraction** and downward rotation. *Pectoralis major* - The **pectoralis major** muscle is a large chest muscle located **anteriorly** and is **not involved** in a posterolateral thoracotomy approach. - This muscle is relevant in anterior thoracotomy approaches, where it's involved in **adduction, medial rotation**, and flexion of the humerus.

Q: Which of the following is a PRIMARY indication for negative pressure wound therapy (NPWT)?

Bed sore in sacrum after debridement. ***Bed sore in sacrum after debridement*** - **Negative pressure wound therapy (NPWT)** is a **primary, well-established indication** for pressure ulcers (bedsores) after debridement. - NPWT promotes **granulation tissue formation**, **wound contraction**, and prepares the wound bed for closure. - It effectively reduces **exudate** and bacterial load, making it a **first-line adjunctive therapy** for clean pressure ulcers. - **Strong evidence base** supports its use in this indication, particularly for Stage III-IV pressure ulcers post-debridement. *After amputation* - NPWT can be used in selected post-amputation cases to manage residual limb wounds or surgical site complications. - However, it is **not a primary or routine indication** but rather a **secondary/adjunctive option** for specific complications. - The main post-amputation focus is limb shaping, prosthetic preparation, and infection prevention. *Chronic osteomyelitis wound* - NPWT serves as **adjunctive therapy** for osteomyelitis wounds after surgical debridement to manage exudate. - The **primary treatment** for chronic osteomyelitis is aggressive **surgical debridement** and prolonged **antibiotic therapy**. - NPWT is supportive but **not the primary therapeutic modality** for this condition. *After split skin graft* - NPWT can be used post-grafting as a **graft bolster** to ensure adherence and optimal take. - While effective, this is a **specialized application** rather than a primary indication. - Traditional tie-over dressings remain standard in many settings, with NPWT reserved for complex cases.

Q: In flap method of amputation, which structure is kept shorter than the level of amputation?

Bone. ***Bone*** - In the **flap method of amputation**, the bone is intentionally cut **shorter** than the soft tissue flaps (typically 2-3 cm proximal to the planned skin closure level). - This allows the **muscle and skin flaps** to be closed over the end of the bone without tension, providing good padding and a well-contoured stump for prosthesis fitting. - This is the **primary structural principle** of flap amputation technique. *Nerves* - **Nerves** are typically cut sharply under gentle traction and allowed to retract proximally (usually 5-10 cm proximal to bone level) to prevent **neuroma formation** and phantom limb pain. - While nerves are indeed cut shorter, the **bone** is the structure specifically beveled shorter **for the purpose of flap closure**, which is what the question asks. *Vessels* - **Vessels** (arteries and veins) are ligated and divided at a level that ensures **hemostasis** and allows for proper flap closure. - They are handled for vascular control, not specifically kept shorter than the bone for shaping the stump. *Muscles* - **Muscles** are usually beveled and sewn to each other (myoplasty) or to the periosteum (myodesis) over the bone end to provide a well-padded, functional stump. - Muscles form the **flap itself** and are **longer than the bone**, not shorter, as they must cover and cushion it.

Q: During hysterectomy, dissection through the broad ligament most commonly risks injury to which structure?

Ureter. ***Ureter*** - During a hysterectomy, especially when dissecting deeply within the **broad ligament** to ligate the uterine artery, the **ureter** is at high risk of injury due to its close anatomical proximity. - The ureter passes just **inferior to the uterine artery** (water under the bridge), making it vulnerable during clamping and ligation of the uterine vessels. *Transverse colon* - The transverse colon is located much higher in the abdomen and is not typically within the surgical field of a hysterectomy unless there is **extensive adhesion formation** or a very unusual approach. - Injury to the transverse colon is highly **unlikely** during an uncomplicated hysterectomy through the broad ligament. *Bladder* - The bladder is anterior to the uterus and is more commonly at risk of injury when dissecting the **vesicouterine fold** or during mobilization of the anterior vaginal wall. - While a common site of injury in hysterectomy, it is less directly related to dissection within the **broad ligament** itself, which is more lateral to the bladder's dome. *Urethra* - The urethra is the terminal portion of the urinary tract and is located much more **inferiorly and anteriorly**, within the pelvic floor and distal to the surgical field for uterine removal. - Injury to the urethra is extremely rare during a routine hysterectomy and would imply a significant **surgical misadventure** far from the broad ligament.

Q: In the acute management of ecchymosis and hematoma, which thermal modality is most appropriate?

Intermittent ice pack. ***Intermittent ice pack*** - An **intermittent ice pack** is the cornerstone of acute thermal management for ecchymosis and hematoma, reducing **swelling** and **inflammation**. - Cold application causes **vasoconstriction**, minimizing further bleeding into tissues and providing **analgesia** by numbing the affected area. - Intermittent application (15-20 minutes on, 20-30 minutes off) prevents tissue damage while maximizing therapeutic benefit. - Part of the **RICE protocol** (Rest, Ice, Compression, Elevation) for acute soft tissue injuries. *Continuous ice pack* - **Continuous ice pack** application can cause **tissue damage**, including frostbite, nerve injury, and skin necrosis. - Prolonged vasoconstriction impairs tissue perfusion and delays healing by limiting oxygen and nutrient delivery. - Should be avoided in favor of intermittent application. *Pressure and pack* - While **compression/pressure** is indeed an important component of acute hematoma management, this option refers to the mechanical intervention rather than the thermal modality asked in the question. - Pressure dressings are used **in conjunction with** ice application, not as an alternative thermal treatment. - The question specifically asks about thermal modality, making ice the correct answer. *Intermittent hot pack* - **Heat application** in the acute phase causes **vasodilation**, which would increase blood flow and exacerbate bleeding. - This would worsen swelling and hematoma formation in the initial 24-48 hours post-injury. - Heat therapy is reserved for the later stages (after 48-72 hours) to promote healing and reduce chronic inflammation.

Q: Neurofibromatosis presents as all of the following except -

Lymphadenovarix. ***Lymphadenovarix*** - **Lymphadenovarix** is a rare condition characterized by the abnormal dilation of lymphatic vessels, forming a varicose appearance, and is not a feature of neurofibromatosis. - It is often associated with lymphatic obstruction or congenital lymphatic malformations, unrelated to neural crest cell anomalies. *Von Recklinghausen's disease* - This is an older name for **Neurofibromatosis type 1 (NF1)**, which is the most common form of neurofibromatosis. - NF1 is a **genetic disorder** that causes tumors to grow on nerve tissue, as well as various skin and bone abnormalities. *Elephantiasis neuromatodes* - This term refers to a severe form of **plexiform neurofibroma** that causes extensive overgrowth of skin and subcutaneous tissues, leading to a thickened, elephant-like appearance. - It is a significant and disfiguring manifestation of **Neurofibromatosis Type 1**. *Plexiform neuroma* - A **plexiform neuroma** is a pathognomonic feature of **Neurofibromatosis Type 1 (NF1)**, consisting of a diffuse neurofibroma that involves multiple nerve fascicles. - These tumors can be extensive, involve deep tissues, and are associated with a risk of **malignant transformation** to malignant peripheral nerve sheath tumors (MPNST). [1]

Q: Bedsore is an example of:

Trophic ulcer. ***Trophic ulcer*** - A **bedsore**, also known as a **decubitus ulcer**, is a classic example of a **trophic ulcer** because it results from impaired nutrition and blood supply to the tissues due to prolonged pressure. - **Trophic ulcers** generally arise from a disrupted nerve supply, prolonged pressure, or inadequate circulation, leading to tissue breakdown and poor healing. *Venous ulcer* - **Venous ulcers** are caused by venous insufficiency, where blood pools in the veins, leading to increased pressure and tissue damage, typically found in the lower legs. - They are characterized by **brawny edema**, hyperpigmentation, and usually appear irregular with a shallow base. *Post thrombotic ulcer* - A **post-thrombotic ulcer** is a specific type of venous ulcer that develops following a **deep vein thrombosis (DVT)**, damaging the venous valves and leading to chronic venous insufficiency. - It presents with symptoms similar to other venous ulcers but has a clear history of DVT as a predisposing factor. *Tropical ulcer* - **Tropical ulcers** are typically found in tropical and subtropical regions and are caused by a combination of minor trauma and bacterial infection (often **Fusobacterium species** and **Treponema pallidum pertenue**). - They are characterized by rapid onset, a painful, foul-smelling appearance, and often result in significant tissue destruction.

Q: Polyglactin 910 suture material ("Vicryl") is a / an

Absorbable synthetic suture. ***Absorbable synthetic suture*** - **Polyglactin 910**, marketed as **Vicryl**, is a **synthetic copolymer** of glycolide and lactide that undergoes hydrolysis in the body. - This hydrolysis leads to its eventual reabsorption over 56-70 days, classifying it as an **absorbable** material. - Vicryl maintains tensile strength for approximately 21 days before being fully absorbed. *Absorbable natural suture* - Natural absorbable sutures, such as **catgut** (plain and chromic), are derived from animal tissues and are absorbed enzymatically within the body. - **Polyglactin 910** is **synthetic**, not natural, despite being absorbable. *Non-absorbable synthetic suture* - Non-absorbable synthetic sutures (e.g., **nylon**, **polypropylene**, **polyester**) retain their tensile strength and remain in the body indefinitely or require removal. - Vicryl is designed to be **absorbed** over time through hydrolysis, distinguishing it from non-absorbable types. *Non-absorbable natural suture* - Examples of non-absorbable natural sutures include **silk** and **cotton**, which are derived from natural sources and are not reabsorbed by the body. - Polyglactin 910 is both **synthetic** and **absorbable**, making this option incorrect.

Q: A case of spontaneous pneumothorax with significant breathlessness comes to you. What will be the initial treatment of choice?

Needle aspiration. ***Needle aspiration*** - **Needle aspiration** is the initial treatment of choice for a **spontaneous pneumothorax**, especially if it is large or causing significant symptoms, as it quickly relieves pressure. - This procedure involves inserting a small needle and catheter into the pleural space to evacuate air, allowing the lung to re-expand. *ICD* - **Intercostal chest drain (ICD)** insertion is typically reserved for larger pneumothoraces, those failing needle aspiration, or recurrent cases. - While effective, it is a more invasive procedure than initial needle aspiration. *IPPV* - **Intermittent positive pressure ventilation (IPPV)** is a form of mechanical ventilation applied in cases of severe respiratory failure, not as an initial treatment for a stable spontaneous pneumothorax. - Administering positive pressure can worsen a pneumothorax if not carefully monitored and managed. *Wait and watch* - A "wait and watch" approach is only appropriate for very **small, asymptomatic spontaneous pneumothoraces** (typically < 1-2 cm from the chest wall). - For symptomatic or larger pneumothoraces, intervention is necessary to prevent further complications and improve respiratory function.

Question 1

Which of the following muscles is cut in posterolateral thoracotomy?

Accepted Answer

Latissimus dorsi

Answer

Serratus anterior

Answer

Rhomboids

Answer

Pectoralis major

Question 2

Which of the following is a PRIMARY indication for negative pressure wound therapy (NPWT)?

Accepted Answer

Bed sore in sacrum after debridement

Answer

After amputation

Answer

Chronic osteomyelitis wound

Answer

After split skin graft

Question 3

In flap method of amputation, which structure is kept shorter than the level of amputation?

Accepted Answer

Bone

Answer

Nerves

Answer

Vessels

Answer

Muscles

Question 4

During hysterectomy, dissection through the broad ligament most commonly risks injury to which structure?

Accepted Answer

Ureter

Answer

Transverse colon

Answer

Bladder

Answer

Urethra

Question 5

In the acute management of ecchymosis and hematoma, which thermal modality is most appropriate?

Accepted Answer

Intermittent ice pack

Answer

Continuous ice pack

Answer

Pressure and pack

Answer

Intermittent hot pack

Question 6

A patient has a lacerated, untidy wound of the leg and attended the casualty department after 2 hours. His wound should be:

Accepted Answer

Debrided and sutured secondarily

Answer

Debrided and sutured immediately

Answer

Sutured immediately

Answer

Cleaned and dressed

Question 7

Neurofibromatosis presents as all of the following except -

Accepted Answer

Lymphadenovarix

Answer

Von Recklinghausen's disease

Answer

Elephantiasis neuromatodes

Answer

Plexiform neuroma

Question 8

Bedsore is an example of:

Accepted Answer

Trophic ulcer

Answer

Venous ulcer

Answer

Post thrombotic ulcer

Answer

Tropical ulcer

Question 9

Polyglactin 910 suture material ("Vicryl") is a / an

Accepted Answer

Absorbable synthetic suture

Answer

Absorbable natural suture

Answer

Non-absorbable synthetic suture

Answer

Non-absorbable natural suture

Question 10

A case of spontaneous pneumothorax with significant breathlessness comes to you. What will be the initial treatment of choice?

Accepted Answer

Needle aspiration

Answer

ICD

Answer

IPPV

Answer

Wait and watch

General Surgery Principles — MCQs

General Surgery Principles — MCQs

On this page

Practice by Chapter

Want unlimited practice?