General Surgery Principles Practice Questions

Q: A 34-year-old male undergoes an open appendectomy for acute appendicitis. The choice of incision was McBurney's incision. Postoperatively, after a few days, he presents with pain and bulging in the right lower quadrant, which is diagnosed as an indirect inguinal hernia. Which nerve injury during the appendectomy is most likely responsible for this complication?

Ilioinguinal nerve. ***Ilioinguinal nerve*** - The **ilioinguinal nerve** (L1) runs between the internal oblique and transversus abdominis muscles in the inguinal region and passes through the superficial inguinal ring - During **McBurney's incision** (muscle-splitting incision at McBurney's point), the ilioinguinal nerve is at risk of injury as it traverses the layers of the anterior abdominal wall - **Mechanism of hernia formation:** Injury to the ilioinguinal nerve causes denervation and atrophy of the internal oblique and transversus abdominis muscles, which weakens the posterior wall of the inguinal canal - This muscular weakness predisposes to **indirect inguinal hernia** formation through the internal inguinal ring - **Classic presentation:** Pain and bulging in the inguinal region post-appendectomy *Pudendal nerve* - Arises from S2-S4 and runs through the **pelvis and perineum** (pudendal canal) - Not at risk during appendectomy as it is far from the surgical field - Injury would cause perineal sensory loss and sphincter dysfunction, not hernia *Genitofemoral nerve* - Runs on the psoas muscle and divides into genital and femoral branches - While the genital branch passes through the inguinal canal, injury typically causes **sensory loss** in the groin and scrotum/labia - Does **not** cause motor weakness or hernia formation *Femoral nerve* - Runs beneath the **inguinal ligament** in the femoral triangle - Not at risk during McBurney's incision - Injury would cause quadriceps weakness and loss of knee extension, not hernia

Q: The given image shows an ulcer. Identify the marked structure.

Edge. ***Edge*** - The marked structure represents the side of the ulcer, connecting the **margin** to the **floor**, which is correctly termed the **edge**. - The characteristics of the edge (e.g., sloping, punched-out, undermined) are crucial for determining the ulcer's etiology, such as in **tuberculous ulcers** (undermined) or **malignant ulcers** (everted). *Margin* - The **margin** is the area of skin immediately surrounding the ulcer, essentially the "rim" on the surface. - The arrow is pointing into the crater of the ulcer, not the tissue around its periphery. *Floor* - The **floor** is the bottom, visible surface of the ulcer crater itself. - The marked structure is the wall leading down to the floor, not the floor itself. *Base* - The **base** is the tissue deep to the ulcer, upon which it rests, and is typically assessed by palpation for induration. - It is not a visible structure on inspection, unlike the edge which is clearly marked in the diagram.

Q: A 25-year-old patient presents to the surgical OPD with a painless left inguinal reducible mass. On examination cough impulse is positive. After further investigations, the patient is diagnosed with an inguinal hernia. What is the surgical management of this patient?

b.Hernioplasty. ***Hernioplasty***- **Hernioplasty**, which utilizes a prosthetic mesh (e.g., **Lichtenstein technique**), is the universally accepted standard for repairing adult inguinal hernias to achieve a tension-free repair.- This method provides a **tension-free repair** of the posterior inguinal wall, leading to significantly lower recurrence rates compared to traditional suture repairs.*Herniotomy*- **Herniotomy** involves only the excision of the hernia sac and is typically reserved for **indirect inguinal hernias in children**, where the muscle wall is robust.- In an adult, failing to repair the inherent weakness of the **inguinal canal floor** after sac removal results in an unacceptably high risk of hernia recurrence.*Wait and watch*- This approach is mainly reserved for **elderly or comorbid patients** with minimally symptomatic or asymptomatic reducible hernias who are considered high risk for surgery.- For a fit 25-year-old, surgery is recommended to prevent future potentially life-threatening complications like **strangulation** or chronic pain.*Emergency laparotomy*- A full **laparotomy** is an extensive abdominal incision utilized for exploring the acute abdomen or managing complicated intra-abdominal sepsis.- This procedure is unnecessary as the hernia is described as **reducible** and **painless**, indicating an elective repair is warranted, not an emergency exploration.

Q: Identify the given instrument.

Linear stapler. ***Linear stapler*** - The instrument shown has a long shaft with two jaws that apply staples in a straight line, which is characteristic of a **linear stapler**. - It is primarily used in **abdominal** and **thoracic surgery** for transecting tissue or closing internal organs like the stomach, intestines, or lung parenchyma. *Skin stapler* - A **skin stapler** is a much smaller, handheld device used exclusively for closing skin incisions externally and has a distinctly different appearance. - It applies single, wide staples and is not used for internal tissue anastomosis or transection. *Circular stapler* - A **circular stapler** has a round head at the distal end designed to create a circular, end-to-end anastomosis, typically in **colorectal** or **esophageal** surgery. - The instrument in the image lacks this circular head and is designed for a linear staple line. *Curved stapler* - This term most commonly refers to a **circular stapler** or a **curved linear cutter**, which has a curved head to facilitate access in locations like the pelvis. - The instrument shown has straight jaws, not a curved head, and is designed for creating a straight line of staples.

Q: Elective splenectomy is preferred in which of the following conditions?

Hereditary spherocytosis. ***Hereditary spherocytosis***- It is the preferred elective treatment because the inherited structural defect in the red blood cell membrane leads to the sequestration and destruction of the rigid **spherocytes** primarily by the **spleen**. - Splenectomy significantly reduces hemolysis and corrects chronic anemia, but it is typically delayed until the child is over 5 years old to reduce the risk of **post-splenectomy sepsis**.*G6PD deficiency-Glucose-6-phosphate dehydrogenase deficiency*- This condition causes episodic hemolysis (typically **intravascular**) triggered by **oxidative stress** (drugs, fava beans, infection), not continuous extravascular hemolysis reliant on the spleen.- The mainstay of management is identifying and **avoiding oxidant triggers**; splenectomy is not indicated as it does not address the underlying enzymatic deficiency or the mechanism of hemolysis.*Paroxysmal nocturnal hemoglobinuria*- PNH is characterized by complement-mediated cytotoxicity due to lack of **GPI-anchored proteins** (CD55, CD59) on RBCs, leading to **intravascular hemolysis**.- Treatment involves targeted therapies like **complement inhibitors** (e.g., **eculizumab**) or **hematopoietic stem cell transplant**; splenectomy is usually ineffective and potentially harmful.*Hairy cell leukemia*- This is a **B-cell malignancy** effectively treated with chemotherapy using **purine analogs** (e.g., **cladribine**), which is the standard first-line approach for symptomatic disease.- Splenectomy may be considered for massive symptomatic **splenomegaly** or severe **refractory cytopenias**, but it is a secondary intervention and not the preferred elective treatment for the condition itself.

Q: Identify the knot?

Surgeon's knot. ***Surgeon's knot*** - The image displays the characteristic first throw of a **Surgeon's knot**, which involves looping the suture end twice (a **double throw** or double twist) instead of once. - This double throw is designed to increase friction, preventing slippage when securing vascular pedicles or tissues under **high tension** before completing the knot with a second single throw. *Granny's knot* - A **Granny's knot** is formed by two consecutive throws made in the same direction, meaning the second throw does not reverse the first. - This design causes the knot to lie obliquely, making it inherently weak and prone to **slipping** or untying, especially under tension. *Reef knot* - Also known as a **Square knot**, a Reef knot consists of two consecutive throws made in **opposite directions** (e.g., right-over-left followed by left-over-right). - It is a secure knot when used correctly, but it uses only a single twist for the first throw, unlike the double twist shown in the image. *Double Knot* - "Double knot" is a generalized or imprecise term; while a Surgeon's knot involves a double twist, this term does not precisely describe the unique **structure and function** of the knot shown. - The image specifically illustrates the deliberate **two consecutive wraps** in the first throw, which precisely defines the specialized technique of the Surgeon's knot.

Q: What is correct regarding this suture?

Monofilament. ***Monofilament*** - **Monofilament** sutures consist of a single strand, which minimizes tissue drag and reduces the risk of harboring **bacteria** and subsequent wound infection. - This structure is typical for materials like **Prolene** (Polypropylene) and **Nylon**, prized for their low friction and use in delicate or contaminated fields. *Non absorbable* - This describes the **fate** of the suture (remaining permanently in the body) but not its structure; non-absorbable sutures can be either **monofilament** (e.g., Nylon) or multifilament (e.g., Silk). - While many important sutures are non-absorbable, it is a property independent of whether the suture is single-stranded. *Braided multifilament* - This refers to sutures made of multiple intertwined strands, which is the structural opposite of a **monofilament**. - Multifilament sutures typically offer better knot security but have increased tissue drag and potential for **capillarity** (wicking action). *Collagen derived* - This refers to the material source, specifically **catgut** (made from sheep or cow intestine), which is an absorbable natural material. - Catgut is absorbable and rapidly loses its tensile strength; 'monofilament' describes the physical form and is not exclusive to this biologic material.

Q: A patient underwent surgery for a reducible groin swelling. The image shows the layers of the hernia sac identified intraoperatively. Using the reference table below that enumerates the covering layers of inguinal hernias, identify the type of hernia shown: | Indirect inguinal hernia | Direct inguinal hernia | | :--: | :--: | | - Extraperitoneal tissue - Internal spermatic fascia - Cremasteric fascia - External spermatic fascia - Skin | - Extraperitoneal tissue - Fascia transversalis - Conjoint tendon (in medial direct hernia) - Cremaster fascia (in lateral direct hernia) - External spermatic fascia - Skin |

Direct inguinal hernia. ***Direct inguinal hernia*** - The image shows presence of **fascia transversalis** in the hernia sac, which is **characteristic of direct inguinal hernia** - Direct hernia protrudes through **Hesselbach's triangle**, medial to the inferior epigastric vessels - It herniates directly through the **posterior wall of the inguinal canal** due to weakness in the transversalis fascia - Covered by fascia transversalis, not by all three layers of spermatic fascia *Indirect inguinal hernia* - Would pass through the **internal inguinal ring** lateral to inferior epigastric vessels - Covered by **internal spermatic fascia** (from transversalis fascia), cremasteric fascia, and external spermatic fascia - Does NOT have direct contact with fascia transversalis as shown in the image *Femoral hernia* - Protrudes through the **femoral canal** below the inguinal ligament - More common in females, located in the femoral triangle - Would not show the anatomical layers described for inguinal hernias *Spigelian hernia* - Occurs through the **spigelian fascia** (aponeurotic layer between rectus abdominis and semilunar line) - Located lateral to the rectus muscle, typically below the level of umbilicus - Not associated with the inguinal canal anatomy shown

Question 1

A 34-year-old male undergoes an open appendectomy for acute appendicitis. The choice of incision was McBurney's incision. Postoperatively, after a few days, he presents with pain and bulging in the right lower quadrant, which is diagnosed as an indirect inguinal hernia. Which nerve injury during the appendectomy is most likely responsible for this complication?

Accepted Answer

Ilioinguinal nerve

Answer

Pudendal nerve

Answer

Genitofemoral nerve

Answer

Femoral nerve

Question 2

The given image shows an ulcer. Identify the marked structure.

Accepted Answer

Edge

Answer

Base

Answer

Floor

Answer

Margin

Question 3

A 25-year-old patient presents to the surgical OPD with a painless left inguinal reducible mass. On examination cough impulse is positive. After further investigations, the patient is diagnosed with an inguinal hernia. What is the surgical management of this patient?

Accepted Answer

b.Hernioplasty

Answer

a.Herniotomy

Answer

c.Wait and watch

Answer

d.Emergency laparotomy

Question 4

Identify the given instrument.

Accepted Answer

Linear stapler

Answer

Curved stapler

Answer

Circular stapler

Answer

Skin stapler

Question 5

Elective splenectomy is preferred in which of the following conditions?

Accepted Answer

Hereditary spherocytosis

Answer

Hairy cell leukemia

Answer

Paroxysmal nocturnal hemoglobinuria

Answer

G6PD deficiency

Question 6

Which of the following statements regarding Vacuum-Assisted Closure (VAC) therapy is correct?
1. It promotes granulation tissue formation
2. It reduces interstitial and periwound edema
3. It drains excessive exudate
4. It increases local blood flow

Accepted Answer

All correct

Answer

1 and 3 correct

Answer

2 and 4 correct

Answer

1, 2, 3 correct

Question 7

Identify the knot?

Accepted Answer

Surgeon's knot

Answer

Double Knot

Answer

Reef knot

Answer

Granny's knot

Question 8

What is correct regarding this suture?

Accepted Answer

Monofilament

Answer

Collagen derived

Answer

Non absorbable

Answer

Braided multifilament

Question 9

A patient underwent surgery for a reducible groin swelling. The image shows the layers of the hernia sac identified intraoperatively. Using the reference table below that enumerates the covering layers of inguinal hernias, identify the type of hernia shown: | Indirect inguinal hernia | Direct inguinal hernia | | :--: | :--: | | - Extraperitoneal tissue
- Internal spermatic
fascia
- Cremasteric fascia
- External spermatic
fascia
- Skin | - Extraperitoneal tissue
- Fascia transversalis
- Conjoint tendon (in medial
direct hernia)
- Cremaster fascia (in
lateral direct hernia)
- External spermatic fascia
- Skin |

Accepted Answer

Direct inguinal hernia

Answer

Indirect inguinal hernia

Answer

Femoral hernia

Answer

Spigelian hernia

Question 10

All are correct about the procedure performed in the patient except:

Accepted Answer

Skin incision is a vertical midline incision from cricoid cartilage to suprasternal notch

Answer

Skin incision is not sutured to prevent surgical emphysema

Answer

Tracheal incision is a transverse incision starting from the first tracheal ring

Answer

Performed under general anesthesia in infants

General Surgery Principles — MCQs

General Surgery Principles — MCQs

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