General Surgery Principles — MCQs

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?

Q845

Most common immediate complication after splenectomy?

Q846

Best method to evaluate bone defect is

Q847

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

Q848

Massive blood transfusion complications include all except -

Q849

What is an absolute indication for surgery in disc prolapse?

Q850

Delayed wound healing is seen in all except-

General Surgery Principles Indian Medical PG Practice Questions and MCQs

Question 841: A surgeon examined a case of hernia and was able to retract the hernial sac on examination but not the contents. Identify the type of hernia depicted in the image.

A. Reduction en masse (Correct Answer)
B. Sliding hernia
C. Incarcerated hernia
D. Maydl's hernia

Explanation: ***Reduction en masse*** - This occurs when the **hernia sac** is reduced into the abdomen but the contents remain incarcerated within the sac, still outside the peritoneal cavity. The image clearly depicts the sac being pushed back, while the bowel loop within it remains constricted at the neck. - This is a dangerous situation because the **incarcerated bowel** is not visible externally, yet remains at risk of strangulation and is often unrecognized. *Sliding hernia* - A sliding hernia involves a portion of the **retroperitoneal organ** (like the colon or bladder) forming part of the posterior wall of the hernia sac. - This typically occurs gradually, and the sac itself is not mistakenly reduced without its contents while the contents remain trapped. *Incarcerated hernia* - An incarcerated hernia means the contents of the hernia sac are **trapped** and cannot be manually reduced back into the abdominal cavity. - While the image shows incarcerated contents, the specific problem here is that the *sac* has been reduced without its contents, which is a particular complication rather than just general incarceration. *Maydl's hernia* - Maydl's hernia (also known as a W-hernia) describes a scenario where **two loops of bowel** are contained within the hernia sac, with a connecting loop of bowel located within the abdominal cavity, forming a 'W' shape. - The illustration shows only one loop of bowel within the sac and does not suggest the specific 'W' configuration or intra-abdominal strangulation of the connecting segment.

Question 842: You are suturing a laceration in the ER using the interrupted suturing technique. What is the angle of needle placement?

A. 80 degrees
B. 70 degrees
C. 60 degrees
D. 90 degrees (Correct Answer)

Explanation: ***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.

Question 843: 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?

A. Nuchal ligament
B. Anterior longitudinal ligament
C. Supraspinous ligament
D. Ligamentum flavum (Correct Answer)

Explanation: ***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.

Question 844: 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?

A. Bladder trigone
B. Uterine artery
C. Kidney
D. Ureter (Correct Answer)

Explanation: ***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.

Question 845: Most common immediate complication after splenectomy?

A. Fistula
B. Bleeding from gastric mucosa
C. Pancreatitis
D. Hemorrhage (Correct Answer)

Explanation: **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.

Question 846: Best method to evaluate bone defect is

A. Use of Florida probe
B. Sounding (Correct Answer)
C. Bitewing radiograph
D. IOPA

Explanation: ***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.

Question 847: Myodesis is employed in amputations for all of the following indications except:

A. Ischemia (Correct Answer)
B. Tumor
C. Children
D. Trauma

Explanation: ***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

Question 848: Massive blood transfusion complications include all except -

A. Hypothermia
B. Hyperkalemia
C. Hypernatremia (Correct Answer)
D. Hypocalcemia

Explanation: ***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**.

Question 849: What is an absolute indication for surgery in disc prolapse?

A. Recurrent episodes of sciatica
B. Cauda equina syndrome (Correct Answer)
C. Pain not relieved by complete rest
D. Progressive motor weakness despite conservative management

Explanation: ***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.

Question 850: Delayed wound healing is seen in all except-

A. Hypertension (Correct Answer)
B. Malignancy
C. Infection
D. Diabetes

Explanation: ***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.

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

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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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