General Surgery Principles — MCQs

A 36-year-old patient is undergoing mediastinoscopy with biopsy. During the procedure, several lymph node biopsies are taken. Pathologic examination reveals normal lymphoid tissue replaced by a mixed population of cells including histiocytes, lymphocytes, monocytes, plasma cells, and eosinophils. Interspersed among these cells are infrequent large binucleate cells with prominent eosinophilic nucleoli. Immunophenotyping shows these cells are positive for CD15 and CD30. What is the most likely diagnosis for these CD15 and CD30 positive cells?

Q476Medium

A 15-year-old male presents with pain in the inguinal area and lower abdomen. He has tenderness over a non-reducible swelling with a negative cough impulse. What is the most likely diagnosis?

Q477Easy

Which of the following wounds is not typically considered untidy?

Q478Easy

Which one of the following is a muscle-splitting incision?

Q479Medium

According to the Hippocrates-Nelson method, what pressure is applied for the reduction of a dislocated mandible?

Q480Medium

An 85-year-old gentleman complains of leg pain while lying down, which lessens when he hangs the foot out of bed. What is the most likely cause?

General Surgery Principles Indian Medical PG Practice Questions and MCQs

Question 471: Which of the following are considered blood components products?

A. Whole blood
B. Platelets
C. Fresh frozen plasma
D. All of the above (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. All of the above**. In transfusion medicine, a distinction is made between **Whole Blood** and **Blood Components**. Blood components are the specific therapeutic constituents derived from whole blood through centrifugal separation. 1. **Whole Blood (A):** While it is the raw material, it is also classified as a blood product. It contains red cells, plasma, and stable clotting factors. Its use is now largely limited to cases of massive hemorrhage or autologous transfusion. 2. **Platelets (B):** These are components separated from whole blood (Random Donor Platelets) or via apheresis (Single Donor Platelets). They are essential for managing thrombocytopenia or platelet dysfunction. 3. **Fresh Frozen Plasma (FFP) (C):** This is the liquid portion of blood frozen within 8 hours of collection. It contains all coagulation factors and is the component of choice for correcting multiple factor deficiencies (e.g., liver disease, DIC, or Warfarin reversal). **Why "All of the above" is correct:** Modern surgical practice follows the principle of **"Component Therapy,"** where patients receive only the specific part of the blood they lack. This maximizes the utility of a single unit of donated blood and reduces the risk of volume overload and transfusion reactions. **High-Yield Clinical Pearls for NEET-PG:** * **Storage Temperatures:** RBCs (2–6°C), Platelets (20–24°C with constant agitation), FFP (below -18°C). * **Shelf Life:** RBCs (35–42 days depending on preservative), Platelets (5 days), FFP (1 year). * **Cryoprecipitate:** A component derived from FFP, rich in Fibrinogen, Factor VIII, Factor XIII, and von Willebrand factor. * **Universal Donor:** O-negative for RBCs; AB-positive for Plasma.

Question 472: Which of the following is not an approach for inguinal hernia repair?

A. Bassini's
B. Lotheissen (Correct Answer)
C. Lichtenstein's
D. Desarda

Explanation: ### Explanation The correct answer is **B. Lotheissen**. **Why Lotheissen is the correct answer:** The **Lotheissen procedure** is a surgical approach specifically designed for **femoral hernia** repair, not inguinal hernia. It involves a supra-inguinal approach where the transversalis fascia is opened to access the femoral canal from above. While it utilizes the same regional anatomy, its primary objective is the closure of the femoral ring. **Analysis of Incorrect Options:** * **Bassini’s Repair:** A classic "tissue-based" (non-mesh) repair for inguinal hernias. It involves suturing the conjoint tendon (internal oblique and transversus abdominis) to the inguinal ligament. * **Lichtenstein’s Repair:** The current **gold standard** for inguinal hernia surgery. It is a "tension-free" repair using a synthetic mesh to reinforce the posterior wall of the inguinal canal. * **Desarda Repair:** A modern non-mesh technique where a strip of the external oblique aponeurosis is used to reinforce the posterior wall. It is an alternative for patients who cannot afford or tolerate mesh. **High-Yield Clinical Pearls for NEET-PG:** * **McVay’s Repair:** A procedure that can address **both** inguinal and femoral hernias by suturing the conjoint tendon to Cooper’s ligament. * **Shouldice Repair:** The most effective non-mesh (tissue) repair with the lowest recurrence rate; it involves a four-layer imbrication of the transversalis fascia. * **Nerve Injury:** The **ilioinguinal nerve** is the most commonly injured nerve during open inguinal hernia repair, leading to numbness over the scrotum/labia and medial thigh. * **Gold Standard:** Lichtenstein (Open) and TEP/TAPP (Laparoscopic) are the preferred modern approaches.

Question 473: What is the most common syndrome associated with cleft palate?

A. Pierre Robin sequence (Correct Answer)
B. Stickler syndrome
C. Treacher Collins syndrome
D. Downs syndrome

Explanation: **Explanation:** The correct answer is **Pierre Robin sequence (PRS)**. While many syndromes feature cleft palate, PRS is the most frequently associated clinical entity [2]. It is defined as a **sequence** because one initial structural defect (micrognathia) leads to a cascade of events: the small mandible forces the tongue to remain high in the oral cavity (glossoptosis), which physically prevents the palatal shelves from fusing, resulting in a **U-shaped cleft palate** [2]. **Analysis of Options:** * **Pierre Robin sequence:** Characterized by the triad of micrognathia, glossoptosis, and airway obstruction [1], [2]. The associated cleft palate is typically U-shaped rather than V-shaped. * **Stickler syndrome:** This is a connective tissue disorder and is actually the most common *syndromic cause* of Pierre Robin sequence itself [2]. However, in the context of general surgical associations, PRS remains the primary answer. * **Treacher Collins syndrome:** An autosomal dominant disorder of craniofacial development (1st and 2nd branchial arches). While cleft palate occurs in about 30% of cases, it is less common than in PRS. * **Downs syndrome:** Primarily associated with macroglossia and dental anomalies; cleft palate is not a hallmark feature. **High-Yield Clinical Pearls for NEET-PG:** * **Rule of 10s for Cleft Lip Repair:** 10 weeks of age, 10 lbs weight, 10 g/dL Hemoglobin [1]. * **Timing:** Cleft lip is usually repaired at **3–6 months**, while cleft palate is repaired at **9–18 months** (to allow for maxillary growth but before significant speech development). * **Muscle Involvement:** In cleft palate, the **Levator veli palatini** is the most important muscle that requires surgical repositioning to ensure proper velopharyngeal function.

Question 474: What is true about the hyperplastic type of tuberculosis?

A. Swallowed infected sputum is the cause
B. Highly virulent compared to ulcerative type
C. Serosa studded with tubercles
D. Pulled up caecum (Correct Answer)

Explanation: Abdominal tuberculosis primarily manifests in two forms: **Ulcerative** and **Hyperplastic**. Understanding the distinction between these is high-yield for NEET-PG. ### **Explanation of the Correct Option** **D. Pulled up caecum:** In the hyperplastic type, there is significant chronic inflammation and transmural fibrosis of the ileocaecal region. As the fibrous tissue contracts, it causes the caecum to shrink and be displaced superiorly and laterally. This "pulled up caecum" is a classic radiological and surgical finding, often associated with an obtuse ileocaecal angle. ### **Analysis of Incorrect Options** * **A. Swallowed infected sputum:** This is the primary cause of the **Ulcerative type**, usually secondary to active pulmonary TB. The Hyperplastic type is typically caused by the ingestion of low-virulence organisms (like *Mycobacterium bovis*) in unpasteurized milk or in individuals with high host resistance. * **B. Highly virulent:** The hyperplastic type occurs in patients with **high host resistance** and low organism virulence. In contrast, the ulcerative type is seen in patients with low resistance and high-virulence organisms, leading to multiple transverse ulcers. * **C. Serosa studded with tubercles:** This is a characteristic feature of **Peritoneal Tuberculosis** (specifically the "wet" or ascitic type), not the localized hyperplastic intestinal type. ### **Clinical Pearls for NEET-PG** * **Most Common Site:** The ileocaecal region is the most common site for intestinal TB due to the abundance of Peyer's patches and physiological stasis. * **Radiology:** Look for the **"Stierlin Sign"** (rapid emptying of the inflamed segment) and **"Kantor’s String Sign"** (narrowing of the terminal ileum) on Barium studies. * **Differential Diagnosis:** Hyperplastic TB closely mimics **Crohn’s Disease**. A key differentiator is that TB often involves the ileocaecal valve (making it incompetent), whereas Crohn’s often spares it. * **Management:** The mainstay is Anti-Tubercular Therapy (ATT). Surgery (e.g., Limited Resection or Right Hemicolectomy) is reserved for complications like obstruction or perforation.

Question 475: A 36-year-old patient is undergoing mediastinoscopy with biopsy. During the procedure, several lymph node biopsies are taken. Pathologic examination reveals normal lymphoid tissue replaced by a mixed population of cells including histiocytes, lymphocytes, monocytes, plasma cells, and eosinophils. Interspersed among these cells are infrequent large binucleate cells with prominent eosinophilic nucleoli. Immunophenotyping shows these cells are positive for CD15 and CD30. What is the most likely diagnosis for these CD15 and CD30 positive cells?

A. Aschoff cells
B. Langhans giant cells
C. Megakaryocytes
D. Reed-Sternberg cells (Correct Answer)

Explanation: ### Explanation The clinical presentation and histopathology described are classic for **Hodgkin Lymphoma (HL)**. **1. Why the Correct Answer is Right:** The "infrequent large binucleate cells with prominent eosinophilic nucleoli" are the pathognomonic **Reed-Sternberg (RS) cells**. Their appearance is often described as **"owl’s eye"** nuclei. The background of mixed inflammatory cells (lymphocytes, histiocytes, eosinophils) represents the characteristic reactive inflammatory milieu of HL. Crucially, the immunophenotype **CD15+ and CD30+** is the gold standard marker for RS cells in Classical Hodgkin Lymphoma (except for the nodular lymphocyte-predominant subtype, which is CD20+). **2. Why the Incorrect Options are Wrong:** * **Aschoff cells (A):** These are pathognomonic for **Acute Rheumatic Carditis**. They are enlarged macrophages found within Aschoff bodies in the myocardium, often showing "caterpillar" nuclei (Anitschkow cells). * **Langhans giant cells (B):** These are multinucleated giant cells with nuclei arranged in a **horseshoe pattern** at the periphery. They are characteristic of granulomatous inflammation, most notably **Tuberculosis**. * **Megakaryocytes (C):** These are large bone marrow cells responsible for platelet production. While they are large and multinucleated, they do not express CD15/CD30 and are not associated with the specific inflammatory background described. **3. High-Yield Clinical Pearls for NEET-PG:** * **Bimodal Age Distribution:** HL typically peaks in the 20s and again after age 50. * **Staging:** The **Ann Arbor Staging System** is used; the most important prognostic factor is the stage at presentation. * **Mediastinal Mass:** HL often presents as asymptomatic lymphadenopathy or a mediastinal mass on CXR. * **Alcohol-induced pain:** A rare but specific symptom where lymph nodes become painful after alcohol consumption. * **Markers:** RS cells are typically **CD15+, CD30+, and CD45–**.

Question 476: A 15-year-old male presents with pain in the inguinal area and lower abdomen. He has tenderness over a non-reducible swelling with a negative cough impulse. What is the most likely diagnosis?

A. Strangulated hernia (Correct Answer)
B. Testicular torsion
C. Scrotal abscess
D. Femoral hernia

Explanation: ### Explanation **Correct Answer: A. Strangulated hernia** The clinical triad of a **non-reducible swelling**, **absence of cough impulse**, and **tenderness** in the inguinal region is classic for a strangulated hernia. In strangulation, the blood supply to the herniated contents is compromised. The resulting edema and pressure within the hernial sac lead to the loss of expansile cough impulse (as the sac is no longer in free communication with the peritoneal cavity) and significant pain/tenderness. In a 15-year-old male, an indirect inguinal hernia is the most common type due to a patent processus vaginalis. **Why other options are incorrect:** * **B. Testicular torsion:** While it presents with acute pain, the swelling is typically confined to the scrotum (not the inguinal canal). The "Prehn’s sign" is negative, and the testis is often high-riding or transversely oriented. * **C. Scrotal abscess:** This usually follows epididymo-orchitis. While tender and swollen, it is associated with inflammatory signs like skin redness, warmth, and often a high-grade fever, rather than an inguinal mass with loss of cough impulse. * **D. Femoral hernia:** These are extremely rare in young males (more common in elderly females). They present below and lateral to the pubic tubercle, whereas inguinal hernias are above and medial. **NEET-PG High-Yield Pearls:** * **Irreducibility vs. Strangulation:** Irreducibility means the contents cannot be returned to the abdomen; strangulation means the blood supply is cut off (a surgical emergency). * **Cough Impulse:** It is lost in both **incarcerated** and **strangulated** hernias. * **Richter’s Hernia:** Only a part of the bowel wall is trapped; it may strangulate without causing complete intestinal obstruction. * **Maydl’s Hernia:** "W" shaped loop where the gangrenous portion lies inside the abdomen.

Question 477: Which of the following wounds is not typically considered untidy?

A. Incised wound (Correct Answer)
B. Crushed wound
C. Avulsed wound
D. Lacerated wound

Explanation: ### Explanation In surgical practice, wounds are broadly classified into **tidy** and **untidy** based on the mechanism of injury, the state of the tissue margins, and the presence of contamination. **1. Why "Incised Wound" is the Correct Answer:** An **incised wound** is the classic example of a **tidy wound**. It is caused by a sharp object (like a scalpel or glass) resulting in clean-cut, linear edges with minimal soft tissue damage. Because the blood supply to the wound edges remains intact and there is negligible devitalized tissue, these wounds can usually be closed primarily (Primary Intention) with excellent healing prospects. **2. Analysis of Incorrect Options (Untidy Wounds):** Untidy wounds are characterized by irregular edges, significant tissue destruction, and high contamination. * **Crushed Wound:** Caused by blunt force, leading to extensive deep tissue necrosis and impaired vascularity. * **Avulsed Wound:** Involves the tearing away of tissue layers (e.g., degloving), often compromising the blood supply to the skin flaps. * **Lacerated Wound:** Results from blunt trauma or shearing, producing jagged, irregular edges and often containing debris. **3. NEET-PG Clinical Pearls:** * **Management Difference:** Tidy wounds (Incised) can be closed immediately. Untidy wounds require thorough **debridement** (conversion of an untidy wound into a tidy one) before closure is considered. * **Rankin’s Classification:** Remember that "Untidy" wounds often have "the four Cs" of non-viable muscle: dark **C**olor, soft **C**onsistency, lack of **C**apillary bleeding, and failure to **C**ontract. * **High-Yield Fact:** A wound is considered "infected" if it contains $>10^5$ organisms per gram of tissue, a common complication in neglected untidy wounds.

Question 478: Which one of the following is a muscle-splitting incision?

A. Kocher's
B. Rutherford-Morris
C. Pfannensteil
D. Lanz (Correct Answer)

Explanation: **Explanation:** The correct answer is **Lanz**, which is a classic example of a **muscle-splitting incision**. In surgery, muscle-splitting (or gridiron) incisions involve separating the muscle fibers along their natural direction rather than cutting across them. This preserves the integrity of the abdominal wall and results in better healing and less postoperative pain. * **Lanz Incision:** This is a transverse skin incision made at McBurney’s point, used primarily for appendectomy. It follows the Langer’s lines (skin tension lines) for a better cosmetic result. Like the McBurney (gridiron) incision, the underlying external oblique, internal oblique, and transversus abdominis muscles are split along their fibers. * **Kocher’s Incision:** This is a **muscle-cutting** subcostal incision used for open cholecystectomy or biliary surgery. The rectus abdominis muscle is divided. * **Rutherford-Morris (Rutherford-Morison) Incision:** This is an oblique muscle-cutting incision in the iliac fossa, commonly used for kidney transplants or access to the ureters. It involves cutting the oblique muscles. * **Pfannenstiel Incision:** This is a transverse incision used in pelvic surgery (e.g., C-sections). While the skin and rectus sheath are opened transversely, the rectus muscles are retracted laterally rather than split along their fibers; it is categorized as a **muscle-retracting** incision. **High-Yield Clinical Pearls for NEET-PG:** * **McBurney’s Incision:** The original muscle-splitting incision for appendectomy; it is oblique, whereas Lanz is transverse. * **Battle’s Incision:** A paramedian incision where the rectus muscle is retracted medially (muscle-retracting). * **Sanders’ Incision:** A variation of the Kocher’s incision used for better exposure in obese patients. * **Key Concept:** Muscle-splitting incisions (Lanz/McBurney) have a lower incidence of incisional hernia compared to muscle-cutting incisions.

Question 479: According to the Hippocrates-Nelson method, what pressure is applied for the reduction of a dislocated mandible?

A. Downward pressure on molars.
B. Backward pressure on the mandible.
C. Downward pressure on the mandible.
D. Both downward pressure on molars and backward pressure on the mandible. (Correct Answer)

Explanation: ### Explanation The **Hippocrates-Nelson method** is the most common manual technique used for the reduction of an anterior mandibular dislocation. The goal of this procedure is to overcome the spasm of the muscles of mastication (masseter and temporalis) and guide the condyle back over the articular eminence into the glenoid fossa. **Why Option D is Correct:** The procedure involves a two-step coordinated movement: 1. **Downward pressure on molars:** The clinician places gloved thumbs on the lower molar teeth (protected by gauze) and applies steady downward pressure. This distracts the condyle inferiorly, clearing the articular eminence. 2. **Backward pressure on the mandible:** Once the condyle is cleared, the mandible is pushed posteriorly (backward) to seat the condyle back into the mandibular fossa. **Analysis of Incorrect Options:** * **Options A & C:** While downward pressure is the crucial first step to unlock the joint, it is insufficient on its own. Without the subsequent posterior guidance, the mandible will not return to its anatomical position. * **Option B:** Applying only backward pressure is dangerous and ineffective, as the condyle remains "locked" in front of the articular eminence; forcing it backward without downward distraction can cause trauma to the joint or teeth. **Clinical Pearls for NEET-PG:** * **Direction of Dislocation:** Mandibular dislocation is almost always **anterior**. * **Mechanism:** Usually occurs due to excessive mouth opening (yawning, dental procedures, or trauma). * **Safety Tip:** Always wrap your thumbs in thick gauze before the procedure. As the reduction occurs, the "snap-back" action caused by masseter spasm can lead to an accidental bite injury to the clinician. * **Post-reduction care:** Advise the patient to avoid wide mouth opening for 1–2 weeks and use a Barton bandage if necessary.

Question 480: An 85-year-old gentleman complains of leg pain while lying down, which lessens when he hangs the foot out of bed. What is the most likely cause?

A. Psychiatric illness
B. Peripheral vascular disease (Correct Answer)
C. L4-L5 disc prolapse
D. Osteoarthritis of the knee

Explanation: ### Explanation The clinical presentation described is a classic manifestation of **Rest Pain**, a hallmark of advanced **Peripheral Vascular Disease (PVD)** or Chronic Limb-Threatening Ischemia (CLTI). **1. Why Peripheral Vascular Disease is correct:** Rest pain occurs when the resting blood flow is insufficient to meet the metabolic demands of the tissues (Fontaine Stage III or Rutherford Category 4). It typically occurs at night because the beneficial effect of gravity is lost when the patient is supine, and the blood pressure naturally drops during sleep. Hanging the foot over the edge of the bed uses **gravity** to assist arterial flow to the distal extremities, thereby partially relieving the ischemic pain. **2. Why the other options are incorrect:** * **Psychiatric illness:** While chronic pain can have psychological components, the specific relief obtained by postural changes (hanging the foot) points toward a clear physiological/mechanical cause. * **L4-L5 disc prolapse:** This typically causes radiculopathy (sciatica). While pain may worsen when lying down in certain positions, it is usually relieved by the fetal position or specific spinal alignments, not by hanging the foot to increase perfusion. * **Osteoarthritis of the knee:** This pain is primarily "mechanical"—worse with weight-bearing and movement, and generally relieved by rest, which is the opposite of this patient's presentation. **3. High-Yield Clinical Pearls for NEET-PG:** * **Fontaine Classification:** Stage I (Asymptomatic), II (Intermittent Claudication), III (Rest Pain), IV (Ulceration/Gangrene). * **Buerger’s Test:** A positive test involves "vascular angle" (pallor on elevation) and "dependent rubor" (dusky redness when hanging the limb), confirming PVD. * **Leriche Syndrome:** A triad of claudication (buttock/thigh), impotence, and absent femoral pulses due to aortoiliac occlusion. * **Ankle-Brachial Index (ABI):** Rest pain is typically associated with an ABI **< 0.4**.

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Surgical Infections

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Surgical Instruments and Equipment

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Sutures and Stapling Devices

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Minimal Access Surgery Principles

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