General Surgery Principles Practice Questions

Q: You are suturing a laceration in the ER using the interrupted suturing technique. What is the angle of needle placement?

90 degrees. ***90 degrees*** - Placing the needle at a **90-degree angle** to the skin surface ensures that the suture comes out perpendicular to the skin edge, creating an **eversion of the wound edges**. - This perpendicular entry allows for an equal amount of tissue to be grasped on both sides of the wound, promoting proper **wound approximation** and healing. *80 degrees* - An 80-degree angle, while close, would not provide the ideal **perpendicular entry** needed to properly evert the wound edges. - This slight deviation from 90 degrees could lead to less precise **tissue approximation** and potentially an inverted wound edge. *70 degrees* - A 70-degree angle is too shallow and would result in the suture entering the wound more tangentially, leading to **inverted wound edges**. - **Inverted wound edges** hinder optimal healing and can result in a less aesthetically pleasing scar. *60 degrees* - A 60-degree angle is significantly too shallow, which would cause the suture to be placed too superficially and horizontally, resulting in **poor wound edge eversion**. - This angle would make it difficult to adequately appose the deeper dermal layers, compromising **tensile strength** and increasing the risk of scar formation.

Q: A patient undergoes spinal surgery at the L4-L5 level. During the procedure, which of the following ligaments must be divided first to access the spinal canal?

Ligamentum flavum. ***Ligamentum flavum*** - The **ligamentum flavum** connects the laminae of adjacent vertebrae and forms the posterior boundary of the spinal canal, making it the first ligament encountered anteriorly after removing the lamina. - While performing a posterior approach **laminectomy**, the ligamentum flavum is typically divided or removed to gain access to the neural structures within the spinal canal. *Nuchal ligament* - The **nuchal ligament** is located in the cervical spine and provides attachment for muscles, extending from the external occipital protuberance to the spinous process of C7. - It is not present at the **L4-L5 level** and therefore plays no role in lumbar spinal surgery. *Anterior longitudinal ligament* - The **anterior longitudinal ligament** runs along the anterior surfaces of the vertebral bodies and intervertebral discs. - It would be encountered during an **anterior surgical approach** to the spine, not a posterior approach to access the spinal canal. *Supraspinous ligament* - The **supraspinous ligament** connects the tips of the spinous processes and is the most superficial ligament posteriorly. - While it is incised during a posterior approach, it is **superficial to the lamina** and ligamentum flavum; therefore, the lamina and ligamentum flavum must be removed or divided first to access the canal.

Q: A 33-year-old woman comes to the emergency department because of a 1-hour history of severe pelvic pain and nausea. She was diagnosed with a follicular cyst in the left ovary 3 months ago. The cyst was found incidentally during a fertility evaluation. A pelvic ultrasound with Doppler flow shows an enlarged, edematous left ovary with no blood flow. Laparoscopic evaluation shows necrosis of the left ovary, and a left oophorectomy is performed. During the procedure, blunt dissection of the left infundibulopelvic ligament is performed. Which of the following structures is most at risk of injury during this step of the surgery?

Ureter. ***Ureter*** - The **infundibulopelvic ligament** (also known as the suspensory ligament of the ovary) contains the **ovarian artery and vein** and is in close proximity to the ureter as it crosses the pelvic brim. - During dissection or clamping of this ligament, especially in an emergency setting or when anatomy is distorted (e.g., by an enlarged ovary or edema), the **ureter** is highly susceptible to injury. *Bladder trigone* - The **bladder trigone** is the smooth triangular region at the base of the bladder, formed by the openings of the ureters and the internal urethral orifice. - It is not directly adjacent to the infundibulopelvic ligament and is therefore at a comparably lower risk of injury during dissection of this ligament. *Uterine artery* - The **uterine artery** travels within the cardinal ligament and supplies the uterus; it is located more medially and inferiorly within the broad ligament. - While important in pelvic surgery, it is not in the immediate vicinity of the infundibulopelvic ligament dissection itself. *Kidney* - The **kidneys** are retroperitoneal organs located much higher in the abdominal cavity, far superior to the pelvis. - They are not at risk of direct injury during pelvic surgery involving the infundibulopelvic ligament.

Q: Most common immediate complication after splenectomy?

Hemorrhage. **Hemorrhage** - **Hemorrhage** is the most common immediate complication due to the spleen's rich blood supply and its close proximity to major vessels such as the **splenic artery and vein**. - Surgical trauma, inadequate ligation, or dislodgment of ligatures can lead to significant blood loss post-splenectomy. *Fistula* - Fistula formation, such as a **pancreatic fistula**, can occur but is less common immediately post-splenectomy compared to hemorrhage. - This complication typically develops due to injury to the **pancreatic tail** during splenic dissection, leading to leakage of pancreatic enzymes. *Bleeding from gastric mucosa* - Bleeding from the **gastric mucosa** (e.g., from stress ulcers or gastritis) is a potential complication after any major surgery but is not the most common immediate complication specific to splenectomy. - While the stomach is in close proximity, direct injury to the gastric mucosa causing significant bleeding is less frequent than hemorrhage from the splenic bed. *Pancreatitis* - **Pancreatitis** can be a severe complication of splenectomy, resulting from injury to the **pancreatic tail** during the procedure. - While it can manifest immediately, its incidence is generally lower than that of hemorrhage.

Q: Best method to evaluate bone defect is

Sounding. ***Sounding*** - **Sounding** involves inserting a periodontal probe into the bone defect to measure its depth and morphology, providing a direct and accurate assessment. - This method is particularly useful for evaluating the **clinical attachment loss** and the configuration of intrabony defects. *Use of Florida probe* - The **Florida probe** is a computerized periodontal probe used for precise measurement of probing depths and clinical attachment levels. - While accurate for soft tissue measurements, it does not directly assess bone defects or their morphology. *Bitewing radiograph* - **Bitewing radiographs** are primarily used to detect interproximal caries and assess the alveolar bone level. - They provide a two-dimensional image and are not ideal for evaluating the three-dimensional morphology or true depth of bone defects. *IOPA* - **Intraoral periapical (IOPA) radiographs** show the entire tooth, including the apex and surrounding bone. - While they can reveal some bony changes, they offer a two-dimensional view and may underestimate the extent of bone loss, especially around the roots, due to superimposition.

Q: Myodesis is employed in amputations for all of the following indications except:

Ischemia. ***Ischemia*** - **Ischemia** is the primary exception where myodesis is often contraindicated or avoided - In ischemic limbs, compromised blood supply limits muscle viability and healing capacity - Poor vascularity prevents adequate muscle-to-bone integration and increases risk of wound complications - Simple myoplasty (muscle-to-muscle suturing) or guillotine-type procedures are often preferred in severe ischemia to ensure primary healing - The priority is achieving a viable stump rather than optimal functional reconstruction *Trauma* - Trauma is one of the **best indications** for myodesis when adequate healthy tissue is available - Creates a stable, functional residual limb with better proprioception for prosthetic fitting - Muscle-to-bone attachment provides superior control and reduces phantom limb pain - Standard technique in traumatic amputations with good soft tissue coverage *Tumor* - Myodesis can be performed in oncological amputations if surgical margins allow - While oncological clearance is the priority, functional reconstruction with myodesis is still pursued when feasible - Modern limb-sparing principles encourage maintaining function alongside adequate resection *Children* - Children are **excellent candidates** for myodesis - Promotes better skeletal growth and long-term functional adaptation - Maintains soft tissue bulk and provides stable base for prosthetic use as the child grows - Helps prevent muscle atrophy and improves quality of life

Q: Massive blood transfusion complications include all except -

Hypernatremia. ***Hypernatremia*** - **Massive blood transfusions** typically involve transfusing red blood cells suspended in solutions like normal saline, which is **isotonic** or slightly hypotonic, or solutions containing **citrate**, which is metabolized in the liver to bicarbonate. - Therefore, hypernatremia is **not expected** and, in fact, hyponatremia can occur in some circumstances due to dilution or impaired sodium excretion in severely ill patients. *Hypothermia* - **Refrigerated blood products** are typically stored at 1-6°C; rapid infusion of large volumes of these cold products can significantly lower the patient's core body temperature, leading to **hypothermia**. - Hypothermia can worsen **coagulopathy** and cardiac arrhythmias, which are serious complications in critically ill or hemorrhaging patients. *Hyperkalemia* - As red blood cells are stored, there is a gradual leakage of **potassium** from intracellular to extracellular compartments due to reduced activity of the **Na+/K+ ATPase pump**. - During massive transfusion, the infusion of large volumes of blood with elevated extracellular potassium can lead to significant **hyperkalemia**, especially in patients with impaired renal function. *Hypocalcemia* - **Citrate** is an anticoagulant used in blood storage that binds to **ionized calcium** in the patient's blood, effectively chelating it. - Rapid infusion of large amounts of citrated blood can overwhelm the liver's capacity to metabolize citrate, leading to a significant drop in ionized calcium levels and consequently **hypocalcemia**.

Q: What is an absolute indication for surgery in disc prolapse?

Cauda equina syndrome. ***Cauda equina syndrome*** - **Cauda equina syndrome** is a neurological emergency characterized by compression of the cauda equina nerves, leading to symptoms like **saddle anesthesia**, bowel/bladder dysfunction, and severe neurological deficits, necessitating immediate surgical decompression. - Delay in surgery for **cauda equina syndrome** can result in permanent neurological damage, making it an *absolute indication* for surgical intervention within **48 hours**. *Recurrent episodes of sciatica* - While recurrent **sciatica** can be debilitating and may eventually warrant surgery, it is typically managed conservatively initially and is not considered an *absolute emergency* for surgery. - Surgical intervention in recurrent **sciatica** is usually considered when conservative treatments fail over 6-12 weeks, but it is a *relative indication*, not an immediate requirement. *Progressive motor weakness despite conservative management* - **Progressive motor weakness** is a serious concern and represents a *relative indication* for surgery, especially if documented over serial examinations. - Unlike **cauda equina syndrome**, which requires immediate surgery, progressive weakness allows for a brief period of conservative management and surgical planning, though surgery should not be unduly delayed if weakness continues to progress. *Pain not relieved by complete rest* - **Pain not relieved by rest** is a common symptom of disc prolapse and can be an indication for surgery after failed conservative management, but it is not an *absolute emergency* like **cauda equina syndrome**. - This type of pain often indicates discogenic pain or nerve root compression but can often be managed with medications, physical therapy, or injections before surgical consideration.

Q: Delayed wound healing is seen in all except-

Hypertension. ***Hypertension*** - While **severe or uncontrolled hypertension** with microvascular complications may theoretically affect tissue perfusion, hypertension **alone is not classically listed** among the primary independent causes of delayed wound healing in standard surgical teaching. - Unlike the other options, hypertension is **not a direct metabolic or local tissue factor** that impairs the wound healing cascade. - The major recognized factors causing delayed wound healing are infection, metabolic disorders (diabetes, malnutrition), malignancy, and immunosuppression—hypertension does not fall into these classical categories. *Diabetes* - **Hyperglycemia** impairs neutrophil function, reduces collagen synthesis, and causes **microvascular disease** that reduces oxygen and nutrient delivery to wounds. - **Diabetic neuropathy** prevents early wound detection, and peripheral vascular disease further compromises healing. - Diabetes is one of the **most important systemic causes** of chronic non-healing wounds. *Infection* - **Bacterial colonization** prolongs the inflammatory phase and prevents progression to proliferation and remodeling. - Pathogens produce **proteases and toxins** that destroy granulation tissue, consume oxygen, and create a hostile wound environment. - Infection is a **local factor** that directly impairs all phases of wound healing. *Malignancy* - **Cancer-associated cachexia** and malnutrition deprive the body of resources needed for tissue repair. - Tumors can **directly invade** wound sites, and cancer treatments (chemotherapy, radiation) impair cellular proliferation and angiogenesis. - Malignancy creates a **systemic catabolic state** unfavorable for healing.

Q: MC site of injury to the ureter during a hysterectomy is:

Site of crossing by the uterine artery. ***Site of crossing by the uterine artery*** - This is the most common site of ureteral injury during a hysterectomy because the **ureter** and the **uterine artery** cross paths in close proximity. The ureter passes *under* the uterine artery, making it vulnerable to **ligation or transection** during clamping or cutting of the artery. - The phrase "water under the bridge" is a common mnemonic used to remember this relationship, where **water (ureter)** passes under the **bridge (uterine artery)**. *In the ovarian fossa* - While the ureter is in proximity to the ovarian vessels, injury in the ovarian fossa is more common during procedures like **oophorectomy** or **pelvic lymph node dissection**, not typically hysterectomy. - The ureter can be injured here if it's mistaken for a blood vessel during **ligament ligation** or when securing the ovarian pedicle. *At the pelvic brim* - Injury at the pelvic brim is less common during a hysterectomy, though it can occur during procedures that involve **dissection of the great vessels** or extensive pelvic lymphadenectomy. - At this point, the ureter crosses the **iliac vessels**, which might be relevant in procedures like radical hysterectomy with lymph node dissection, but not a standard total hysterectomy. *As it enters the bladder* - Although the terminal portion of the ureter is close to the bladder, injury at its entry point into the bladder during a hysterectomy is not the most common site. - This area is more often at risk during procedures involving the **bladder itself**, such as cystectomy or extensive dissection of the bladder base for endometriosis.

Question 1

You are suturing a laceration in the ER using the interrupted suturing technique. What is the angle of needle placement?

Accepted Answer

90 degrees

Answer

80 degrees

Answer

70 degrees

Answer

60 degrees

Question 2

A patient undergoes spinal surgery at the L4-L5 level. During the procedure, which of the following ligaments must be divided first to access the spinal canal?

Accepted Answer

Ligamentum flavum

Answer

Nuchal ligament

Answer

Anterior longitudinal ligament

Answer

Supraspinous ligament

Question 3

A 33-year-old woman comes to the emergency department because of a 1-hour history of severe pelvic pain and nausea. She was diagnosed with a follicular cyst in the left ovary 3 months ago. The cyst was found incidentally during a fertility evaluation. A pelvic ultrasound with Doppler flow shows an enlarged, edematous left ovary with no blood flow. Laparoscopic evaluation shows necrosis of the left ovary, and a left oophorectomy is performed. During the procedure, blunt dissection of the left infundibulopelvic ligament is performed. Which of the following structures is most at risk of injury during this step of the surgery?

Accepted Answer

Ureter

Answer

Bladder trigone

Answer

Uterine artery

Answer

Kidney

Question 4

Most common immediate complication after splenectomy?

Accepted Answer

Hemorrhage

Answer

Fistula

Answer

Bleeding from gastric mucosa

Answer

Pancreatitis

Question 5

Best method to evaluate bone defect is

Accepted Answer

Sounding

Answer

Use of Florida probe

Answer

Bitewing radiograph

Answer

IOPA

Question 6

Myodesis is employed in amputations for all of the following indications except:

Accepted Answer

Ischemia

Answer

Tumor

Answer

Children

Answer

Trauma

Question 7

Massive blood transfusion complications include all except -

Accepted Answer

Hypernatremia

Answer

Hypothermia

Answer

Hyperkalemia

Answer

Hypocalcemia

Question 8

What is an absolute indication for surgery in disc prolapse?

Accepted Answer

Cauda equina syndrome

Answer

Recurrent episodes of sciatica

Answer

Pain not relieved by complete rest

Answer

Progressive motor weakness despite conservative management

Question 9

Delayed wound healing is seen in all except-

Accepted Answer

Hypertension

Answer

Malignancy

Answer

Infection

Answer

Diabetes

Question 10

MC site of injury to the ureter during a hysterectomy is:

Accepted Answer

Site of crossing by the uterine artery

Answer

In the ovarian fossa

Answer

At the pelvic brim

Answer

As it enters the bladder

General Surgery Principles — MCQs

General Surgery Principles — MCQs

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