General Surgery Principles — MCQs

A 25-year-old female presents with a diffuse, non-progressive, and non-tender swelling of the right maxilla, measuring approximately 2 x 1.5 cm, extending from the canine to the first molar region. Radiography reveals a ground glass appearance of the bone in the affected area. What is the appropriate surgical treatment?

Q675Easy

The remodelling phase of wound healing is characterized by:

Q676Easy

According to the CEAP classification, what does a healed venous ulcer represent?

Q677Easy

What is the most common site for an intra-abdominal abscess following a laparotomy?

Q678Medium

Which of the following diseases is effectively treated by splenectomy and does not typically present with splenomegaly?

Q679Easy

Trophic ulcers are caused by all of the following except?

Q680Easy

Lockwood repair is performed for which condition?

General Surgery Principles Indian Medical PG Practice Questions and MCQs

Question 671: No-touch technique of suturing should be undertaken to reduce the risk of what?

A. Hematoma formation
B. Needle stick injuries (Correct Answer)
C. Abscess formation
D. None of the above

Explanation: ### Explanation The **"No-touch technique"** is a critical safety protocol in the operating theater designed primarily to prevent **Needle Stick Injuries (NSIs)** and the subsequent transmission of blood-borne pathogens (such as HIV, Hepatitis B, and Hepatitis C). #### Why the Correct Answer is Right: The technique involves using instruments (like needle holders and forceps) to handle the needle at all times, ensuring that the surgeon’s or assistant’s fingers never come into direct contact with the sharp end of the needle. By eliminating manual manipulation of the needle during loading, suturing, or disposal, the risk of accidental percutaneous injury is significantly minimized. This is a key component of **Universal Precautions**. #### Why Incorrect Options are Wrong: * **A. Hematoma formation:** Hematomas are caused by inadequate intraoperative hemostasis or the failure to ligate bleeding vessels. While proper suturing technique (tension and spacing) affects wound healing, the "no-touch" aspect specifically refers to sharps safety, not the physiological control of bleeding. * **C. Abscess formation:** Abscesses result from bacterial contamination or retained foreign bodies. While sterile technique prevents infection, the "no-touch" rule is a provider-safety measure rather than a primary method for reducing surgical site infections (SSIs). #### High-Yield Clinical Pearls for NEET-PG: * **Neutral Zone Technique:** This is a related concept where a designated area (e.g., a kidney tray) is used to pass sharps between the scrub nurse and the surgeon to avoid hand-to-hand transfer. * **Double Gloving:** Reduces the risk of inner glove perforation and decreases the volume of blood transferred during an NSI by up to 95%. * **Post-Exposure Prophylaxis (PEP):** In case of an NSI, the site should be washed with soap and water (do not scrub or squeeze). PEP for HIV should ideally be started within **2 hours** (and no later than 72 hours).

Question 672: Elective cholecystectomy is classified as which type of surgical procedure?

A. Clean-contaminated (Correct Answer)
B. Clean
C. Dirty
D. Contaminated

Explanation: ### Explanation The classification of surgical wounds is based on the **CDC Surgical Wound Classification**, which predicts the risk of postoperative surgical site infections (SSI). **Why Clean-contaminated is correct:** A **Clean-contaminated (Class II)** wound is defined as a procedure where a hollow viscus (respiratory, alimentary, genital, or urinary tract) is entered under controlled conditions and without unusual contamination. In an **elective cholecystectomy**, the biliary tract (part of the alimentary system) is intentionally entered. Since there is no evidence of active infection (acute inflammation) or major break in technique, it falls into this category. The expected infection rate is 3–11%. **Why the other options are wrong:** * **Clean (Class I):** These are uninfected operative wounds in which no inflammation is encountered and the respiratory, alimentary, genital, or urinary tracts are **not** entered (e.g., Hernioplasty, Thyroidectomy). * **Contaminated (Class III):** These involve open, fresh, accidental wounds or procedures with a major break in sterile technique or gross spillage from the GI tract. Acute non-purulent inflammation (e.g., Cholecystitis with bile spillage) falls here. * **Dirty (Class IV):** These involve old traumatic wounds with retained devitalized tissue or existing clinical infection/perforation (e.g., Perforated peptic ulcer, abscess drainage). **High-Yield Clinical Pearls for NEET-PG:** * **Appendectomy:** Elective/Incidental is **Clean-contaminated**; Inflamed is **Contaminated**; Perforated is **Dirty**. * **Prophylactic Antibiotics:** Usually indicated for Clean-contaminated and Contaminated cases. For Clean cases, they are only used if a prosthetic implant is being placed (e.g., Mesh). * **Vaginal Hysterectomy:** Always Clean-contaminated (vagina is colonized).

Question 673: Klippel-Trenaunay syndrome is associated with which of the following?

A. Varicose veins (Correct Answer)
B. Arteriovenous malformations
C. Aortic aneurysm
D. Lymphedema

Explanation: **Explanation:** **Klippel-Trenaunay Syndrome (KTS)** is a rare congenital vascular anomaly characterized by a classic triad of clinical features. Understanding this triad is essential for identifying the correct answer: 1. **Capillary Malformations:** Typically presenting as a "Port-wine stain." 2. **Venous Malformations:** Most commonly manifesting as **Varicose veins** (often in an atypical distribution, such as the lateral aspect of the limb, known as the *Servelle-Martorell vein*). 3. **Soft tissue and Bony Hypertrophy:** Leading to limb overgrowth (macrodactyly or limb length discrepancy). **Why the correct answer is right:** Varicose veins (Option A) are a core component of the KTS triad. These veins are often present from birth or early childhood and result from venous dysplasia or deep vein abnormalities. **Why other options are incorrect:** * **Arteriovenous malformations (Option B):** This is the most important distractor. If AVMs (high-flow lesions) are present along with the KTS triad, the condition is termed **Parkes-Weber Syndrome**. KTS is strictly a low-flow vascular malformation. * **Aortic aneurysm (Option C):** There is no established clinical association between KTS and aortic aneurysms. * **Lymphedema (Option D):** While lymphatic hypoplasia can occur in KTS, it is not a primary diagnostic feature compared to the classic venous malformations. **Clinical Pearls for NEET-PG:** * **Flow Type:** KTS is a **low-flow** malformation; Parkes-Weber is **high-flow**. * **Diagnosis:** Primarily clinical; however, **Duplex Ultrasound** is the initial investigation of choice to assess the venous system. * **Management:** Mostly conservative (compression stockings). Surgery is reserved for complications due to the high risk of recurrence and deep venous system anomalies.

Question 674: A 25-year-old female presents with a diffuse, non-progressive, and non-tender swelling of the right maxilla, measuring approximately 2 x 1.5 cm, extending from the canine to the first molar region. Radiography reveals a ground glass appearance of the bone in the affected area. What is the appropriate surgical treatment?

A. Total excision of the lesion
B. Curettage of the area with extraction of the involved teeth
C. Surgical cosmetic recontouring only (Correct Answer)
D. Surgical excision followed by radiotherapy

Explanation: ### Explanation The clinical presentation of a slow-growing, painless, diffuse maxillary swelling with a characteristic **"ground glass" appearance** on radiography is pathognomonic for **Fibrous Dysplasia**. **1. Why "Surgical cosmetic recontouring" is correct:** Fibrous dysplasia is a benign, self-limiting skeletal developmental anomaly where normal bone is replaced by fibrous connective tissue and poorly formed trabeculae. In most cases, the lesion stabilizes after skeletal maturity. Since it is not a true neoplasm and is poorly demarcated from surrounding healthy bone, radical excision is unnecessary and technically difficult. The primary goal of treatment is functional and aesthetic; therefore, **surgical recontouring (shaving the bone)** is the treatment of choice once the lesion has stabilized. **2. Why the other options are incorrect:** * **Total excision (A):** This is avoided because the lesion merges imperceptibly with normal bone, making complete removal highly mutilating without clinical benefit. * **Curettage (B):** Curettage is associated with a high recurrence rate in fibrous dysplasia and is generally ineffective for managing the diffuse expansion of the maxilla. * **Radiotherapy (D):** Radiotherapy is **strictly contraindicated** in fibrous dysplasia as it significantly increases the risk of malignant transformation into osteosarcoma. **3. Clinical Pearls for NEET-PG:** * **Radiographic Sign:** "Ground glass" or "Orange peel" appearance due to fine, non-aligned bone trabeculae. * **Histology:** "Chinese letter" pattern of trabeculae (C-shaped or Y-shaped) without osteoblastic rimming. * **McCune-Albright Syndrome:** Triad of Polyostotic fibrous dysplasia, Café-au-lait spots (Coast of Maine borders), and precocious puberty. * **Monostotic vs. Polyostotic:** The monostotic form (involving one bone) is more common, with the maxilla being the most frequently affected bone in the craniofacial region.

Question 675: The remodelling phase of wound healing is characterized by:

A. Type I collagen replacing Type IV collagen
B. Type III collagen being replaced by Type I collagen (Correct Answer)
C. Type IV collagen replacing Type I collagen
D. Type I collagen replacing Type III collagen

Explanation: ### Explanation Wound healing occurs in three overlapping phases: **Inflammatory, Proliferative, and Remodeling.** **1. Why the correct answer is right:** The **Remodeling (Maturation) phase** is the longest stage, beginning around the 3rd week and lasting up to a year or more. During the earlier proliferative phase, **Type III collagen** (granulation tissue) is laid down rapidly because it is flexible and easy to produce. However, it lacks structural strength. During remodeling, Type III collagen is degraded by matrix metalloproteinases (MMPs) and replaced by **Type I collagen**, which is more robust and organized. This "collagen switch" increases the tensile strength of the wound. **2. Why the incorrect options are wrong:** * **Options A & C:** **Type IV collagen** is primarily found in the **basal lamina** (basement membrane). It is not the primary collagen involved in the bulk structural replacement of the dermis during wound contraction and maturation. * **Option D:** This is the inverse of the physiological process. Type I is the "mature" collagen; replacing it with Type III would result in a weaker, more primitive scar. **3. NEET-PG High-Yield Clinical Pearls:** * **Tensile Strength:** At 1 week, a wound has only ~3% of its original strength. By 3 weeks, it reaches ~20%. After remodeling (1 year), it reaches a maximum of **70-80%**; it never returns to 100% of pre-injury strength. * **Collagen Types:** Remember **"Type One is Bone (and strong skin)"** and **"Type Three is Thre-e (Granulation/Early tissue)."** * **Vitamin C:** Essential for the hydroxylation of proline and lysine residues during collagen synthesis; deficiency leads to scurvy and poor wound healing. * **Zinc:** A necessary cofactor for MMPs involved in the remodeling phase.

Question 676: According to the CEAP classification, what does a healed venous ulcer represent?

A. C2
B. C3
C. C4
D. C5 (Correct Answer)

Explanation: The **CEAP classification** is the international standard for describing chronic venous disorders. It stands for **C**linical, **E**tiological, **A**natomical, and **P**athophysiological. ### Why C5 is the Correct Answer The Clinical (C) component of the classification is based on objective signs of venous disease. **C5** specifically denotes **skin changes with a healed venous ulcer**. In contrast, an active ulcer is classified as C6. This distinction is vital for tracking disease progression and treatment efficacy. ### Explanation of Incorrect Options * **A. C2 (Varicose Veins):** Represents dilated, tortuous subcutaneous veins ≥3 mm in diameter. There are no skin changes or ulcers at this stage. * **B. C3 (Edema):** Represents swelling of the lower limb without secondary skin changes like pigmentation or eczema. * **C. C4 (Skin Changes):** Represents skin changes secondary to venous hypertension (e.g., C4a: pigmentation/eczema; C4b: lipodermatosclerosis/atrophie blanche). While these often precede ulcers, no ulcer has occurred yet. ### High-Yield Clinical Pearls for NEET-PG * **C0:** No visible or palpable signs of venous disease. * **C1:** Telangiectasias or reticular veins (<3 mm). * **C6:** **Active** venous ulcer (the most severe clinical stage). * **Corona Phlebectatica:** A fan-shaped pattern of small veins at the ankle, now considered a sign of early C4 disease. * **Management Tip:** The gold standard for treating venous ulcers (C5/C6) is **compression therapy** (e.g., Unna boot or multi-layer bandages), provided the Arterial Brachial Index (ABI) is >0.5.

Question 677: What is the most common site for an intra-abdominal abscess following a laparotomy?

A. Subhepatic (Correct Answer)
B. Subphrenic
C. Pelvic
D. Paracolic

Explanation: **Explanation:** The correct answer is **Subhepatic (A)**. Intra-abdominal abscesses are a significant postoperative complication, typically occurring due to localized contamination or persistent infection. **Why Subhepatic is correct:** The **subhepatic space** (specifically the right subhepatic space, also known as **Morison’s Pouch**) is the most dependent part of the upper abdominal cavity when a patient is in the supine position. Due to the natural contours of the peritoneum and the effects of gravity, infected peritoneal fluid and inflammatory exudates preferentially track into and collect in this space. Following general laparotomies (especially those involving the gallbladder, stomach, or duodenum), this is statistically the most frequent site for abscess formation. **Analysis of Incorrect Options:** * **Subphrenic (B):** While the subphrenic spaces (between the diaphragm and liver/spleen) are common sites for collections, they are less frequent than the subhepatic space. Subphrenic abscesses often present with referred shoulder pain due to diaphragmatic irritation (phrenic nerve). * **Pelvic (C):** The pelvis is the most dependent part of the *entire* peritoneal cavity when upright. While pelvic abscesses are common after lower abdominal surgeries (like appendicitis or colorectal surgery), they are not the most common site overall following general laparotomy. * **Paracolic (D):** The paracolic gutters serve as conduits for the flow of fluid between the upper and lower abdomen but are rarely the primary site of a localized abscess compared to the potential spaces. **NEET-PG High-Yield Pearls:** * **Morison’s Pouch:** The most dependent part of the upper abdomen; it is the first place fluid is sought during a **FAST** (Focused Assessment with Sonography for Trauma) scan. * **Clinical Presentation:** Postoperative abscesses typically present with a "swinging" pyrexia (hectic fever), localized pain, and leukocytosis. * **Gold Standard Investigation:** **CT scan** with oral and IV contrast is the investigation of choice for diagnosing intra-abdominal abscesses. * **Management:** The standard of care is **percutaneous image-guided drainage** (USG or CT-guided) combined with targeted antibiotics.

Question 678: Which of the following diseases is effectively treated by splenectomy and does not typically present with splenomegaly?

A. Sickle cell disease
B. Idiopathic thrombocytopenic purpura (Correct Answer)
C. Aplastic anaemia
D. Thalassemia

Explanation: **Explanation:** The correct answer is **Idiopathic Thrombocytopenic Purpura (ITP)**. **1. Why ITP is the correct answer:** In ITP, anti-platelet IgG antibodies (produced in the spleen) coat the platelets, leading to their premature destruction by splenic macrophages. Splenectomy is a highly effective second-line treatment because it removes both the primary site of antibody production and the main site of platelet sequestration. Crucially, the spleen in ITP is **not typically enlarged**; if significant splenomegaly is present, a clinician should investigate alternative diagnoses like leukemia or lymphoma. **2. Analysis of Incorrect Options:** * **Sickle Cell Disease:** While splenectomy may be indicated for acute sequestration crises, these patients typically undergo **autosplenectomy** (shrunken, fibrotic spleen) by adulthood due to repeated infarctions. It is not a primary "treatment" for the underlying disease. * **Aplastic Anaemia:** This is a bone marrow failure syndrome. Splenectomy has no role in its management, as the pathology lies in the marrow's inability to produce cells, not their peripheral destruction. * **Thalassemia:** Splenectomy is often indicated for Thalassemia Major to reduce transfusion requirements, but these patients characteristically present with **massive splenomegaly** due to extramedullary hematopoiesis and secondary hypersplenism. **3. NEET-PG High-Yield Pearls:** * **Most common indication for elective splenectomy:** ITP. * **Most common indication for emergency splenectomy:** Trauma (Splenic rupture). * **Vaccination Protocol:** Post-splenectomy patients must be vaccinated against encapsulated organisms (*S. pneumoniae, H. influenzae, N. meningitidis*) ideally 2 weeks before elective surgery or 2 weeks after emergency surgery. * **Peripheral Smear Findings:** Look for **Howell-Jolly bodies**, Pappenheimer bodies, and Heinz bodies post-splenectomy.

Question 679: Trophic ulcers are caused by all of the following except?

A. Syringomyelia
B. Varicose veins (Correct Answer)
C. Leprosy
D. Prolonged recumbency

Explanation: ### Explanation The core concept behind a **trophic ulcer** is a lack of nutrition to the tissues resulting from **denervation** (loss of sensory/nerve supply) or **prolonged pressure**. **1. Why Varicose Veins is the correct answer:** Varicose veins lead to **Venous Ulcers** (Gaiter’s ulcers), not trophic ulcers. The pathophysiology involves venous hypertension and valvular incompetence, leading to blood stasis and fibrin cuff formation. Unlike trophic ulcers, venous ulcers are typically painful, associated with skin changes like lipodermatosclerosis and hemosiderin staining, and occur in areas with intact sensation. **2. Analysis of Incorrect Options (Causes of Trophic Ulcers):** * **Syringomyelia:** This is a neurological condition causing a "dissociated sensory loss." The loss of pain and temperature sensation leads to repetitive unnoticed trauma, resulting in trophic ulcers (typically in the upper limbs). * **Leprosy:** The most common cause of trophic ulcers in India. It involves peripheral nerve destruction (e.g., tibial nerve), leading to an insensitive foot. Constant pressure on bony prominences during walking causes tissue necrosis. * **Prolonged Recumbency:** This leads to **Pressure Sores (Decubitus ulcers)**, which are a subtype of trophic ulcers. Constant pressure on areas like the sacrum or heels exceeds capillary perfusion pressure, causing ischemic necrosis. ### NEET-PG High-Yield Pearls: * **Classic Site:** Trophic ulcers occur at pressure-bearing, denervated areas (e.g., the ball of the great toe, heel, or ischial tuberosity). * **Characteristics:** They are typically **painless**, "punched out" in appearance, and have a non-mobile base fixed to underlying bone. * **Management Principle:** The most important step in treating a trophic ulcer is **offloading** (removing pressure), often via a Total Contact Cast (TCC). * **Other Causes:** Diabetes Mellitus (Diabetic foot), Tabes dorsalis, and Spina bifida.

Question 680: Lockwood repair is performed for which condition?

A. Appendicitis
B. Femoral hernia (Correct Answer)
C. Deep vein thrombosis
D. Sigmoid volvulus

Explanation: **Explanation:** **Lockwood’s infra-inguinal approach** is a classic surgical technique used for the repair of a **femoral hernia**. In this procedure, the incision is made directly over the femoral swelling, below and parallel to the inguinal ligament. It is primarily indicated for elective cases or when the diagnosis of a femoral hernia is certain. The repair involves reducing the hernial sac and approximating the inguinal ligament to the pectineal (Cooper’s) ligament using non-absorbable sutures to close the femoral canal. **Analysis of Incorrect Options:** * **Appendicitis:** Managed via appendectomy (e.g., McBurney’s or Lanz incision). While a femoral hernia can occasionally contain the appendix (De Garengeot hernia), Lockwood repair refers specifically to the hernia repair technique, not the treatment for primary appendicitis. * **Deep Vein Thrombosis (DVT):** This is a medical/vascular condition managed with anticoagulants or thrombolysis, not a surgical "repair" like Lockwood’s. * **Sigmoid Volvulus:** Managed via sigmoidoscopic detorsion or resection (e.g., Hartmann’s procedure), not a groin-based hernia repair. **High-Yield Clinical Pearls for NEET-PG:** * **Three Approaches to Femoral Hernia:** 1. **Lockwood:** Infra-inguinal (Low) approach. 2. **Lotheissen:** Trans-inguinal approach (through the posterior wall of the inguinal canal). 3. **McEvedy:** High/Supra-inguinal approach (vertical incision; best for strangulated hernias as it provides better exposure to the bowel). * Femoral hernias are more common in **females** and have the **highest risk of strangulation** among all hernias due to the narrow, rigid boundaries of the femoral canal.

Practice by Chapter

Wound Healing and Care

Practice Questions

Surgical Infections

Practice Questions

Fluid and Electrolyte Management

Practice Questions

Nutrition in Surgical Patients

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Hemostasis and Blood Transfusion

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Surgical Instruments and Equipment

Practice Questions

Sutures and Stapling Devices

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Minimal Access Surgery Principles

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Surgical Complications

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Anesthesia Principles for Surgeons

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Surgical Oncology Principles

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Evidence-Based Surgery

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