General Surgery Principles Practice Questions

Q: Contents of the inguinal hernia sac are displayed intraoperatively and appendix is seen at 7 o'clock. What is the diagnosis?

Amyand hernia. ***Amyand hernia*** - An **Amyand hernia** is a rare type of inguinal hernia that contains the **vermiform appendix** within the hernia sac. - The discovery of the appendix, as shown in the image, within an inguinal hernia sac definitively identifies this as an Amyand hernia. *Richter hernia* - A **Richter's hernia** occurs when only a portion of the circumference of the bowel wall becomes incarcerated in the hernia sac. - It does not specifically involve the appendix and is characterized by the potential for **strangulation without obstruction**. *Pantaloons hernia* - A **pantaloons hernia** (or saddlebag hernia) is a combined direct and indirect inguinal hernia, with the inferior epigastric vessels located between the two sacs. - It describes the anatomical configuration of the hernia sacs rather than the contents within them. *Maydl's hernia* - **Maydl's hernia** (or W-hernia) occurs when two loops of bowel are contained within the hernia sac, with a connecting loop lying within the abdominal cavity. - This type of hernia is particularly dangerous due to the high risk of **strangulation of the intervening loop** of bowel.

Q: A 35-year-old patient presents with a painless swelling at the umbilicus that has been gradually increasing in size over the past 6 months. The swelling increases on coughing and straining. On examination, there is a reducible bulge at the umbilicus. What is the likely diagnosis?

Umbilical hernia. ***Umbilical hernia*** - The image clearly displays a bulge at the **umbilicus**, which is characteristic of an umbilical hernia. - This type of hernia occurs when abdominal contents protrude through a weakness in the **umbilical ring**. - The clinical presentation of a **reducible swelling that increases with coughing** is pathognomonic of a hernia. - Umbilical hernias are common in adults and are associated with increased intra-abdominal pressure. *Epigastric hernia* - An epigastric hernia occurs in the **midline** between the **xiphoid process** and the umbilicus. - The location of the bulge in the image is specifically at the umbilicus, not superior to it. - These typically present as small, often tender nodules in the epigastric region. *Spigelian hernia* - A Spigelian hernia protrudes through the **Spigelian fascia**, which is lateral to the rectus abdominis muscle, typically at the **arcuate line**. - This location is **lateral**, distinct from the periumbilical region shown in the image. - These are rare and often difficult to palpate due to their interparietal nature. *Paraumbilical hernia* - A paraumbilical hernia occurs **adjacent to the umbilicus** through the linea alba, rather than directly through the umbilical ring. - While close in location, the image shows a hernia **directly at the umbilicus**, not beside it. - Paraumbilical hernias are more common in adults, while true umbilical hernias through the ring can occur in both children and adults.

Q: What is the functional capability of the instrument shown in the image?

Used for both cutting and coagulation. ***Used for both cutting and coagulation*** - The image displays a **bipolar electrosurgical forceps**, which is specifically designed to deliver **high-frequency electrical current** for both cutting and coagulating tissue. - The electrical energy is localized between the two tips of the forceps, allowing for precise tissue manipulation with minimal collateral damage and reducing the risk of current spread to other parts of the body. *Used for coagulation* - While this instrument is excellent for **coagulation**, its capabilities extend beyond just stopping bleeding. - It can also be used for **cutting tissue efficiently** by using a different electrical waveform or power setting. *Used for cutting* - This instrument is indeed used for **cutting tissue**, but it also has the critical function of **coagulation**. - Restricting its description to only cutting would be incomplete and overlook its dual utility in surgery. *Cannot be used in patient with artificial valves* - Bipolar electrosurgery is generally considered **safe for patients with pacemakers, ICDs, or artificial valves** because the current is confined between the two tips of the instrument. - This localized current flow **minimizes the risk of interference** with implanted medical devices, unlike monopolar electrosurgery which has a greater risk of current dispersion.

Q: A 30-year-old patient presents with abdominal pain, fever, nausea, vomiting and respiratory distress. On admission BP=80/40 mm Hg and pulse rate is 120 BPM. The following CXR was performed. What is the immediate management? (AIIMS May 2016)

IV fluids and antibiotics followed by laparotomy. ***IV fluids and antibiotics followed by laparotomy*** - The imaging shows **free air under the diaphragm** (pneumoperitoneum), confirming a perforated viscus. The patient is also in **septic shock** (low blood pressure, high heart rate, fever, abdominal pain), requiring immediate resuscitation with **IV fluids and broad-spectrum antibiotics** to stabilize before surgery. - While definitive management is surgical, **resuscitation** must precede laparotomy in an unstable patient to improve outcomes from septic shock. *Immediate laparotomy* - Performing an immediate laparotomy without prior resuscitation in a patient with **septic shock** (BP 80/40, HR 120) significantly increases surgical risk and mortality. - The patient's **hemodynamic instability** must be addressed first to withstand the stress of surgery. *Intravenous fluids* - While critical for initial resuscitation in septic shock, **IV fluids alone** are insufficient as the definitive management for a perforated viscus. - The source of sepsis (perforation) must be addressed surgically, and **antibiotics** are essential to combat the infection. *Intravenous potassium* - There is no indication in the clinical presentation or image for **intravenous potassium administration**. - This intervention is used for treating **hypokalemia**, which is not mentioned as a concern here, and does not address the underlying pathology.

Q: What type of suture is this?

Purse string suture. ***Purse string suture*** - The image shows a suture placed in a **circular pattern** around a wound opening, which can be **tightened like a drawstring** to close the defect. - This technique is characteristic of a **purse-string suture**, commonly used to close circular openings or to reduce the size of a defect for easier closure. *Pare's suture* - This is not a recognized or standard surgical suture technique. - Suture names are typically associated with their creators (e.g., Halsted) or their specific pattern/function (e.g., mattress, purse-string). *Halsted's suture* - Refers to a type of **interrupted mattress suture** or a principle of meticulous surgical technique, not a specific circular closing suture like the one pictured. - Halsted's sutures are typically used for strong wound closure and **eversion of wound edges**. *Vertical mattress interrupted suture* - This suture involves a "far-far, near-near" pattern, passing deep then superficial on each side of the wound, resulting in **strong closure** and **wound edge eversion**. - It consists of **individual, non-continuous stitches** (interrupted) and its appearance is distinct from the encircling pattern shown.

Q: Identify these two surgical instruments.

Artery forceps and needle holder. **Artery forceps and needle holder** - The instrument on the left is an **artery forceps (hemostat)**, characterized by its serrated jaws and a locking mechanism, designed for clamping vessels to control bleeding. - The instrument on the right is a **needle holder**, which has short, robust jaws with a cross-hatch pattern for secure gripping of surgical needles, and a ratcheted handle to lock the needle in place. *Thumb forceps and sponge holder* - **Thumb forceps** are non-locking instruments held like a pen, used for grasping tissue, and are not depicted here. - A **sponge holder** (also known as Foerster sponge forceps) typically has large, fenestrated jaws to hold surgical sponges, which is different from either of the instruments shown. *Sponge holder and Allis forceps* - As mentioned, a **sponge holder** is distinct and not shown in the image. - **Allis forceps** have multiple fine teeth that interlock to hold tissue firmly but atraumatically, which differs from the jaw patterns seen in these instruments. *Needle holder and ovum forceps* - While a **needle holder** is correctly identified on the right, the instrument on the left is not an **ovum forceps**. - **Ovum forceps** (or ovum polyp forceps) are used in gynecology, often having wide, fenestrated, cup-shaped jaws for grasping tissue during uterine procedures.

Q: The following suture material gets absorbed in how many days?

90 days. **90 days** - The image displays **Vicryl suture**, which is a **braided, absorbable suture** material made of polyglactin 910. - Vicryl typically retains tensile strength for about 2-3 weeks and is **completely absorbed** by hydrolysis in approximately **60 to 90 days**. *7 days* - Sutures that absorb in roughly 7 days, like **plain gut**, have a much **faster absorption profile** and are usually reserved for rapidly healing tissues. - Vicryl maintains its strength much longer and is used for tissues requiring more prolonged support, such as muscle repair. *21 days* - While Vicryl retains sufficient tensile strength for about **21 days (3 weeks)**, this refers to the period it provides adequate wound support, not its complete absorption time. - Complete absorption of Vicryl takes significantly longer than 21 days. *Non-absorbable* - **Non-absorbable sutures**, such as nylon or polypropylene, are designed to remain in the tissue permanently or until physically removed. - Vicryl's composition and mode of degradation (hydrolysis) clearly classify it as an **absorbable suture**.

Q: The method of ulcer healing shown below generates a pressure of: (Recent NEET Pattern 2016-17)

Minus 125 mm Hg. ***Minus 125 mm Hg*** - The image depicts **Negative Pressure Wound Therapy (NPWT)**, also known as vacuum-assisted closure (VAC), which applies subatmospheric pressure to promote wound healing. - The standard therapeutic pressure for NPWT is **-125 mmHg**, which aids in wound contraction, granulation tissue formation, removal of exudate, and increased blood flow to the wound bed. - This pressure setting is well-established in clinical practice and supported by surgical literature. *Minus 100 cm of water* - While this represents negative pressure, **mmHg is the standard unit** used for measuring and reporting NPWT pressure settings, not cm H₂O. - Converting -100 cm H₂O to mmHg yields approximately -73.5 mmHg, which is lower than the commonly effective therapeutic pressure range for NPWT. *Plus 100 cm of water* - This indicates **positive pressure**, whereas NPWT fundamentally relies on **negative (subatmospheric) pressure** to achieve its therapeutic effects. - Positive pressure would not facilitate wound fluid removal, tissue contraction, or granulation tissue formation as intended by NPWT. *Plus 125 cm of water* - This represents **positive pressure**, which contradicts the core mechanism of action of **Negative Pressure Wound Therapy**. - Positive pressure would push against the wound rather than creating the suction needed to draw out exudate and promote wound closure.

Q: Which is correct about the suture material shown in the image?

Absorbed by phagocytosis and enzymatic degradation. ***Absorbed by phagocytosis and enzymatic degradation*** - This description is characteristic of **natural absorbable sutures**, such as **catgut** (which appears to be depicted by the golden, multi-filament material with a needle). Catgut is absorbed by the body's enzymatic processes and macrophage activity. - This type of absorption is a key feature distinguishing natural absorbable sutures from synthetic ones (which are absorbed by hydrolysis) and non-absorbable sutures. *It is less reactive* - Natural absorbable sutures like catgut are generally associated with a **higher inflammatory reaction** in tissues compared to synthetic absorbable sutures due to their proteinacious nature. - The body's immune system recognizes these natural proteins, leading to a more pronounced foreign body response. *Derived from cat gut mucosa* - **Catgut sutures** are indeed derived from the sub-mucosal layer of the sheep or goat **intestine**, not the mucosa itself. - The term "catgut" is historical and misleading, as it is not derived from cats. *Used for bowel anastomosis* - While absorbable sutures are used for bowel anastomosis, the use of **plain catgut** (which the image suggests due to its color and appearance) is generally not preferred for critical anastomoses due to its variable and rapid absorption time, which can compromise wound strength before healing is complete. - **Chromic catgut** or synthetic absorbable sutures (like Vicryl or PDS) with more predictable absorption profiles are typically favored for bowel anastomoses.

Q: Which retractor is shown in the image?

Deaver retractor. ***Deaver retractor*** - The Deaver retractor is easily identifiable by its distinct **flat, C-shaped, curved blade** at one end and a **long handle with a fenestrated grip**. - It is commonly used in deep abdominal and thoracic procedures to **retract organs and tissues**, providing excellent exposure. *Morris retractor* - The Morris retractor typically features a **curved blade** that is less pronounced than a Deaver and often includes a **fenestrated handle**. - However, its blade is generally **flatter and broader** compared to the distinctive C-shape of the Deaver. *Langenbeck retractor* - A Langenbeck retractor is characterized by a **small, L-shaped blade** and a handle, designed for retracting small incisions and delicate tissues. - Its blade is significantly smaller and has a **sharper, angled bend** compared to the broad, C-shaped blade shown. *Doyen retractor* - The Doyen retractor, also known as a Doyen rib raspatory, is typically used to **retract ribs** and protect lung tissue during thoracic surgeries. - It has a distinctive **hooked end** or a spoon-like blade, which is quite different from the broad, curved blade in the image.

Question 1

Contents of the inguinal hernia sac are displayed intraoperatively and appendix is seen at 7 o'clock. What is the diagnosis?

Accepted Answer

Amyand hernia

Answer

Richter hernia

Answer

Pantaloons hernia

Answer

Maydl's hernia

Question 2

A 35-year-old patient presents with a painless swelling at the umbilicus that has been gradually increasing in size over the past 6 months. The swelling increases on coughing and straining. On examination, there is a reducible bulge at the umbilicus. What is the likely diagnosis?

Accepted Answer

Umbilical hernia

Answer

Epigastric hernia

Answer

Spigelian hernia

Answer

Paraumbilical hernia

Question 3

What is the functional capability of the instrument shown in the image?

Accepted Answer

Used for both cutting and coagulation

Answer

Used for coagulation

Answer

Used for cutting

Answer

Cannot be used in patient with artificial valves

Question 4

A 30-year-old patient presents with abdominal pain, fever, nausea, vomiting and respiratory distress. On admission BP=80/40 mm Hg and pulse rate is 120 BPM. The following CXR was performed. What is the immediate management? (AIIMS May 2016)

Accepted Answer

IV fluids and antibiotics followed by laparotomy

Answer

Immediate laparotomy

Answer

Intravenous fluids

Answer

Intravenous potassium

Question 5

What type of suture is this?

Accepted Answer

Purse string suture

Answer

Pare's suture

Answer

Halsted's suture

Answer

Vertical mattress interrupted suture

Question 6

Identify these two surgical instruments.

Accepted Answer

Artery forceps and needle holder

Answer

Thumb forceps and sponge holder

Answer

Sponge holder and Allis forceps

Answer

Needle holder and ovum forceps

Question 7

The following suture material gets absorbed in how many days?

Accepted Answer

90 days

Answer

7 days

Answer

21 days

Answer

Non-absorbable

Question 8

The method of ulcer healing shown below generates a pressure of: (Recent NEET Pattern 2016-17)

Accepted Answer

Minus 125 mm Hg

Answer

Minus 100 cm of water

Answer

Plus 100 cm of water

Answer

Plus 125 cm of water

Question 9

Which is correct about the suture material shown in the image?

Accepted Answer

Absorbed by phagocytosis and enzymatic degradation

Answer

It is less reactive

Answer

Derived from cat gut mucosa

Answer

Used for bowel anastomosis

Question 10

Which retractor is shown in the image?

Accepted Answer

Deaver retractor

Answer

Morris retractor

Answer

Langenbeck retractor

Answer

Doyen retractor

General Surgery Principles — MCQs

General Surgery Principles — MCQs

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