General Surgery Principles Practice Questions

Q: A 35 year old male patient comes to casualty with acute pain abdomen; and on examination found to have cold, clammy extremities, sunken eyes, dry tongue, thready pulse, drawn and anxious face with abdominal guarding and rigidity. This clinical picture indicates:

Diffuse late peritonitis. ***Diffuse late peritonitis*** - The combination of **cold, clammy extremities**, **thready pulse**, **sunken eyes**, **dry tongue**, and an **anxious face** points to significant **systemic inflammatory response syndrome (SIRS)** and **hypovolemic shock**, which are characteristic of late-stage peritonitis. - **Abdominal guarding and rigidity** indicate widespread peritoneal irritation, and the systemic signs confirm that this is a late-stage, diffuse process, rather than localized or early. *Acute cholecystitis* - While it causes **acute pain in the abdomen**, it is typically localized to the **right upper quadrant** and does not usually present with the severe systemic signs of **shock** described (e.g., cold extremities, thready pulse) unless complications like perforation have occurred. - The generalized abdominal guarding and rigidity suggest a more diffuse inflammatory process beyond a single inflamed organ. *Local peritonitis* - This condition involves inflammation of a specific area of the peritoneum, leading to **localized tenderness**, guarding, and rebound tenderness, but typically **without the widespread systemic signs of shock and severe hypovolemia** seen in this patient. - The description of a "drawn and anxious face" and global signs of shock indicate a more widespread, serious condition. *Diffuse early peritonitis* - **Early diffuse peritonitis** would present with generalized abdominal pain, guarding, and rigidity, but the severe systemic signs of **shock** (e.g., cold, clammy extremities, thready pulse, sunken eyes) are usually not as pronounced or absent. - The patient's presentation with **profound signs of hypovolemia and systemic compromise** indicates a more advanced, "late" stage of the disease where fluid shifts and septic shock are already established.

Q: During laparoscopic inguinal hernia repair, in the ‘triangle of doom’, the following are true EXCEPT:

Cord structures on lateral side. ***Cord structures on lateral side*** - This statement is somewhat **ambiguous** and is considered the EXCEPT answer in this context. - The **spermatic cord** contains multiple structures, and different components form **both boundaries** of the triangle of doom: - The **vas deferens** (a cord structure) forms the **medial** boundary - The **gonadal vessels** (testicular artery and pampiniform plexus, also cord structures) form the **lateral** boundary - In the context of this question, "cord structures" likely refers to the **bulk of the cord or vas deferens**, which is positioned **medially**, making the lateral positioning statement incorrect as commonly taught. *Vas deferens on medial side* - The **vas deferens** forms the **medial border** of the triangle of doom. - This is a key anatomical landmark used to identify the triangle during laparoscopic inguinal hernia repair. *Base by iliac vessels* - The **external iliac artery and vein** form the **base (inferior border)** of the triangle of doom. - These are the most dangerous structures in this region—injury can lead to catastrophic hemorrhage. *Dangerous area for dissection* - The triangle of doom is aptly named because it contains **critical vascular structures** including the **external iliac vessels** and **deep circumflex iliac artery**. - **Aggressive dissection, stapling, or tack placement** in this area can cause life-threatening vascular injury or damage to the **femoral branch of the genitofemoral nerve**.

Q: A 40 year old man, with a history of a reducible left groin swelling of two years, comes with severe pain over left groin. The swelling is now non-reducible and is very tender to touch. The most probable treatment plan for this patient would be:

Prepare for emergency surgery. ***Prepare for emergency surgery*** - The sudden onset of **severe pain**, non-reducibility, and tenderness in a pre-existing reducible groin swelling strongly suggests **incarceration** or **strangulation** of a hernia. - **Strangulation** is a surgical emergency due to the risk of **ischemic bowel injury**, requiring immediate surgical intervention. *Hot fomentation of groin area* - This offers no therapeutic benefit for an incarcerated or strangulated hernia and may delay necessary surgical intervention, leading to **worse patient outcomes**. - It would be inappropriate for a condition that poses a risk of **bowel necrosis**. *Oral antibiotics* - While infection could be a secondary complication of bowel necrosis, antibiotics alone will not resolve the mechanical obstruction or relieve the **ischemia**. - They do not address the primary problem of **hernia incarceration** or strangulation. *Continue conservative management* - Conservative management is suitable for **reducible hernias** that are asymptomatic or mildly symptomatic, but not for acute, painful, and non-reducible hernias. - Continuing conservative management in this setting would lead to **bowel strangulation** and potential **peritonitis** or sepsis.

Q: Paralytic ileus is a type of:

Adynamic obstruction. ***Adynamic obstruction*** - **Paralytic ileus** is characterized by the absence of normal peristaltic movement of the bowel, leading to a functional or **adynamic obstruction** without a physical blockage. - This condition often results from factors like **abdominal surgery**, electrolyte imbalances, or certain medications, which disrupt neural control over intestinal motility. *Inflammatory obstruction* - An **inflammatory obstruction** implies a physical blockage or narrowing of the bowel lumen due to inflammation, such as in **Crohn's disease** or diverticulitis. - While inflammation can contribute to ileus, the primary mechanism of paralytic ileus is a lack of motility, not a physical inflammatory mass blocking the lumen. *Drug-induced obstruction* - While certain drugs, such as **opioids** or **anticholinergics**, can *cause* paralytic ileus by reducing gut motility, the term "drug-induced obstruction" is typically used when the drug directly creates a physical obstruction. - In the context of ileus, drugs induce a *functional* impairment rather than a physical **luminal blockage**. *Dynamic obstruction* - **Dynamic obstruction** refers to a *physical blockage* of the bowel, such as a **volvulus**, **intussusception**, or an **hernia**, where the bowel is actively trying to overcome the obstruction (hence "dynamic"). - In contrast, paralytic ileus involves a *lack* of active bowel movement, classifying it as an adynamic, rather than dynamic, obstruction.

Q: Which of the following are types of wound healing? 1. Primary Intention 2. Secondary Intention 3. Tertiary Intention 4. Quaternary Intention

1, 2 and 3. ***1, 2 and 3*** - These options correctly identify the three recognized types of **wound healing** in surgical practice. - **Primary intention (healing by first intention)**: Clean wounds with approximated edges, minimal tissue loss, heals with minimal scarring (e.g., surgical incisions). - **Secondary intention (healing by second intention)**: Wounds with significant tissue loss that heal by granulation tissue formation, wound contraction, and epithelialization (e.g., pressure ulcers, large traumatic wounds). - **Tertiary intention (delayed primary closure)**: Contaminated wounds initially left open for 3-5 days, then closed after infection risk decreases. *1, 2 and 4* - This option incorrectly includes **"Quaternary Intention,"** which is **not a recognized classification** in wound healing. - Only primary, secondary, and tertiary intention are standard types described in surgical textbooks. *2, 3 and 4* - This option omits **"Primary Intention,"** the most common type of wound healing for clean surgical incisions. - It also incorrectly includes "Quaternary Intention," which does not exist in wound healing classification. *1, 3 and 4* - This option omits **"Secondary Intention,"** a crucial healing process for wounds with substantial tissue loss that cannot be primarily closed. - "Quaternary Intention" is not a valid wound healing type and represents a distractor in this question.

Q: The following nerves are blocked for repairing inguinal hernia by local anaesthetic except:

Femoral. ***Femoral*** - The **femoral nerve** primarily innervates the anterior thigh muscles and provides sensory supply to the anterior thigh and medial leg; its block is not typically required for **inguinal hernia repair**. - Blocking the femoral nerve would primarily affect **motor function** of the quadriceps and sensation in the distribution of the saphenous nerve, which is not the surgical field for an inguinal hernia. *Ilio-inguinal* - The **ilio-inguinal nerve** provides sensation to the inguinal region, scrotum/labia majora, and the medial aspect of the thigh, making its block essential for anesthesia during **inguinal hernia repair**. - It lies in the **inguinal canal** and is typically targeted with local anesthetic to cover the incision site and surgical area. *Genito femoral* - The **genitofemoral nerve** has both genital and femoral branches, providing sensation to the scrotum/labia majora and a small area of the femoral triangle, respectively, and is therefore often included in an **inguinal block**. - Its blockade helps to cover the sensory innervation of the **spermatic cord** and a portion of the inguinal region, contributing to effective pain control. *Ilio-hypogastric* - The **ilio-hypogastric nerve** provides sensory innervation to the suprapubic and gluteal regions, and its blockade is important for covering the **upper part of the surgical incision** for an inguinal hernia repair. - It runs parallel to the ilio-inguinal nerve and is often blocked concurrently to ensure **comprehensive analgesia** of the abdominal wall.

Q: Which of the following suture materials has the least tissue reaction?

Stainless steel. ***Stainless steel*** - **Stainless steel** is a **monofilament** suture with the **lowest tissue reactivity** due to its inert nature. - It is often used in situations requiring maximal strength and minimal biological interaction, such as abdominal wall closure or orthopedic procedures. *Silk* - **Silk** is a **multifilament, natural, non-absorbable** suture and is known for its **moderate tissue reactivity** due to its braided structure and organic origin. - While it provides good knot security, its reactivity makes it unsuitable for areas where minimal foreign body reaction is paramount. *Cotton / Linen* - **Cotton and linen** sutures are **natural, multifilament, non-absorbable** materials that exhibit significant **tissue reactivity**. - Their fibrous nature can lead to considerable inflammatory response and are rarely used in modern surgical practice. *Chromic catgut* - **Chromic catgut** is a **natural, absorbable** suture treated with chromium salts to prolong its absorption time, but it still triggers a **significant inflammatory response** as it is absorbed by enzymatic digestion. - Its high tissue reactivity makes it less ideal for situations requiring minimal foreign body reaction compared to synthetic or metallic sutures.

Q: In a case of obstructed hernia, strangulation is suggested by which of the following? 1. Presence of shock 2. Pain is never completely absent 3. Localised tenderness is associated with rebound tenderness 4. Pain persists despite conservative management 5. An external hernia becomes tense, tender, irreducible, with recent increase in size Select the correct answer using the code given below:

1, 2, 3, 4 and 5. ***1, 2, 3, 4 and 5*** - All listed options (presence of **shock**, persistent pain, **localized and rebound tenderness**, failure of conservative management, and a **tense, tender, irreducible hernia** with recent size increase) are classic indicators of **hernia strangulation**. - **Strangulation** is a surgical emergency where the blood supply to the herniated tissue is compromised, leading to **ischemia** and potential **necrosis**, requiring immediate intervention. *1, 2, 4 and 5 only* - This option incorrectly omits **localized tenderness associated with rebound tenderness**, which is a crucial sign of peritoneal irritation and impending or established strangulation. - While other signs are accurate, the absence of this specific finding makes the option incomplete for a comprehensive understanding of strangulation. *1, 2, 3, 4 only* - This option misses the critical clinical sign of an **external hernia becoming tense, tender, irreducible, with a recent increase in size**, which is a direct and often visible sign of strangulation. - The physical examination findings of the hernia itself are paramount in diagnosing strangulation. *1, 3 and 5 only* - This option omits two significant indicators: **pain is never completely absent** (implying continuous, severe pain) and **pain persists despite conservative management**. - Continuous pain and refractoriness to treatment highlight the progressive and severe nature of strangulation.

Question 1

A 35 year old male patient comes to casualty with acute pain abdomen; and on examination found to have cold, clammy extremities, sunken eyes, dry tongue, thready pulse, drawn and anxious face with abdominal guarding and rigidity. This clinical picture indicates:

Accepted Answer

Diffuse late peritonitis

Answer

Acute cholecystitis

Answer

Local peritonitis

Answer

Diffuse early peritonitis

Question 2

During laparoscopic inguinal hernia repair, in the ‘triangle of doom’, the following are true EXCEPT:

Accepted Answer

Cord structures on lateral side

Answer

Vas deferens on medial side

Answer

Base by iliac vessels

Answer

Dangerous area for dissection

Question 3

A 40 year old man, with a history of a reducible left groin swelling of two years, comes with severe pain over left groin. The swelling is now non-reducible and is very tender to touch. The most probable treatment plan for this patient would be:

Accepted Answer

Prepare for emergency surgery

Answer

Hot fomentation of groin area

Answer

Oral antibiotics

Answer

Continue conservative management

Question 4

In Hernia repair, polypropylene suture is used because

Accepted Answer

It is a synthetic monofilament non-absorbable suture with low tissue reaction and high tensile strength

Answer

It is a synthetic monofilament undyed absorbable suture with high tissue reaction and low tensile strength

Answer

It is a synthetic monofilament undyed non absorbable suture with high tissue reaction and which degrades at 15-20% per year

Answer

It is a synthetic braided dyed absorbable suture with low tissue reaction and high tensile strength

Question 5

Paralytic ileus is a type of:

Accepted Answer

Adynamic obstruction

Answer

Inflammatory obstruction

Answer

Drug induced obstruction

Answer

Dynamic obstruction

Question 6

Which one of the following regarding absorbable meshes is NOT true?

Accepted Answer

They show very good results as collagen deposition is maximum

Answer

They are made of polyglycolic acid fibre

Answer

They are used to buttress sutured repair

Answer

They are used in temporary abdominal wall closure

Question 7

Which of the following are types of wound healing?

1. Primary Intention
2. Secondary Intention
3. Tertiary Intention
4. Quaternary Intention

Accepted Answer

1, 2 and 3

Answer

1, 2 and 4

Answer

2, 3 and 4

Answer

1, 3 and 4

Question 8

The following nerves are blocked for repairing inguinal hernia by local anaesthetic except:

Accepted Answer

Femoral

Answer

Ilio-inguinal

Answer

Genito-femoral

Answer

Ilio-hypogastric

Question 9

Which of the following suture materials has the least tissue reaction?

Accepted Answer

Stainless steel

Answer

Silk

Answer

Cotton / Linen

Answer

Chromic catgut

Question 10

In a case of obstructed hernia, strangulation is suggested by which of the following?

1. Presence of shock
2. Pain is never completely absent
3. Localised tenderness is associated with rebound tenderness
4. Pain persists despite conservative management
5. An external hernia becomes tense, tender, irreducible, with recent increase in size

Select the correct answer using the code given below:

Accepted Answer

1, 2, 3, 4 and 5

Answer

1, 2, 4 and 5 only

Answer

1, 2, 3, 4 only

Answer

1, 3 and 5 only

General Surgery Principles — MCQs

General Surgery Principles — MCQs

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