General Surgery Principles — MCQs

General Surgery Principles Indian Medical PG Practice Questions and MCQs

Question 851: MC site of injury to the ureter during a hysterectomy is:

A. In the ovarian fossa
B. At the pelvic brim
C. As it enters the bladder
D. Site of crossing by the uterine artery (Correct Answer)

Explanation: ***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 852: Which of the following is a non-self-retaining handheld retractor?

A. Mollison's mastoid retractor
B. Davis retractor (Correct Answer)
C. Jansen's mastoid retractor
D. Lempert's endaural retractor

Explanation: ***Davis Retractor*** - The **Davis retractor** is a **handheld retractor** primarily used in procedures like tonsillectomy to retract the tongue and soft palate, and requires continuous manual holding. - It does not have a locking mechanism or self-retaining features, distinguishing it from retractors designed to stay in place once positioned. *Mollison's mastoid retractor* - The **Mollison's mastoid retractor** is a **self-retaining retractor** commonly used in mastoid surgery. - It features ratcheted arms that lock into position, allowing it to hold tissue apart without continuous manual assistance. *Jansen's mastoid retractor* - The **Jansen's mastoid retractor** is another **self-retaining retractor** with a spring-loaded or ratcheted mechanism. - This design allows it to maintain tissue retraction in mastoid and ear surgeries without requiring a surgeon's constant hold. *Lempert's endaural retractor* - The **Lempert's endaural retractor** is a **self-retaining retractor** specifically designed for endaural approaches to the middle ear. - Its design includes sharp prongs and a flexible but stable frame that anchors in tissue, providing continuous retraction.

Question 853: All these are techniques to decrease scarring except:

A. Late removal of sutures (Correct Answer)
B. Tension-free suturing
C. Finer suture materials
D. Debridement

Explanation: ***Late removal of sutures*** - **Late removal of sutures** can lead to permanent suture marks and increased scarring, as the epithelial cells grow down the suture track. - This increases the foreign body reaction and the duration of inflammation, ultimately worsening the cosmetic outcome. *Tension-free suturing* - **Tension-free suturing** minimizes mechanical stress on the wound edges, which is crucial for optimal healing and reduced scar formation. - Reduced tension prevents excessive inflammation and tissue ischemia, leading to a flatter, less noticeable scar. *Finer suture materials* - Using **finer suture materials** reduces the amount of foreign body reaction, which is a key factor in scar formation. - Smaller caliber sutures cause less tissue trauma and inflammation, resulting in a more aesthetically pleasing scar. *Debridement* - **Debridement** removes necrotic tissue, foreign bodies, and devitalized tissue from the wound, which are sources of chronic inflammation and impaired healing. - By creating a clean wound bed, debridement promotes healthy granulation tissue and reduces the risk of excessive scarring.

Question 854: Wound healing is delayed by all of the following EXCEPT?

A. Presence of foreign bodies
B. Trauma
C. Excessive tissue manipulation
D. Debridement (Correct Answer)

Explanation: ***Debridement*** - **Debridement** is the medical removal of **dead, damaged, or infected tissue** to improve the healing potential of the remaining healthy tissue. - By removing impediments to healing, debridement actually **facilitates wound healing**, rather than delaying it. *Presence of foreign bodies* - The presence of **foreign bodies** (e.g., dirt, glass, sutures that are causing a reaction) in a wound can act as a **persistent irritant**, leading to chronic inflammation. - This ongoing inflammatory response can **impair the normal progression of wound healing**, often prolonging the healing process. *Trauma* - Severe or repeated **trauma** to a healing wound can disrupt the delicate new tissue formation, such as **granulation tissue** and **epithelium**. - This disruption can lead to **re-injury**, increased inflammation, and a significant delay in the wound's progression through its healing phases. *Excessive tissue manipulation* - **Excessive tissue manipulation** during surgery or wound care can cause further damage to surrounding healthy tissues and blood vessels. - This can increase wound edema, create more dead space, and release inflammatory mediators, all of which can **impede the healing process**.

Question 855: To minimize ureteric damage, the following preoperative and operative precautions may be taken except:

A. Ureter should not be dissected off the peritoneum for a long distance
B. Cystoscopy (Correct Answer)
C. Bladder should be pushed downwards and outwards while the clamps are placed near the angles of vagina
D. Direct visualization during surgery

Explanation: ***Cystoscopy*** - **Cystoscopy** with or without ureteric catheterization can be used as an adjunct in some complex pelvic surgeries, but it is **not considered a primary or routine preventive measure** during most surgeries where ureteric injury risk exists. - While **intraoperative cystoscopy** may help identify ureters or detect injury post-operatively, it is more of a **diagnostic/confirmatory tool** rather than a direct anatomical protective measure during the surgical dissection itself. - Compared to the other listed options, cystoscopy is the **least direct method** of preventing mechanical ureteric injury during the actual surgical dissection and clamping phases. - The other three options represent **direct anatomical protective techniques** employed during surgery. *Ureter should not be dissected off the peritoneum for a long distance* - This is a crucial **surgical principle** to prevent ureteric injury. - Extensive dissection of the ureter from the peritoneum compromises its **blood supply** from adventitial vessels. - Maintaining peritoneal attachments preserves **vascularity** and reduces risk of **ischemic injury** and subsequent necrosis. *Bladder should be pushed downwards and outwards while the clamps are placed near the angles of vagina* - This is an important **anatomical displacement technique** in pelvic surgery. - The ureters course near the **lateral vaginal fornices** (approximately 2 cm lateral to the cervix). - Repositioning the bladder helps displace the ureters away from surgical **clamps, sutures, and electrocautery** applied to vaginal angles. - This maneuver provides a **safety margin** during cardinal ligament and uterosacral ligament procedures. *Direct visualization during surgery* - **Direct visualization** is the gold standard for ureteric protection during surgery. - Allows the surgeon to **identify anatomical location** and confirm ureter position before clamping or ligating. - Essential in complex pelvic procedures with **distorted anatomy** (endometriosis, adhesions, malignancy). - May involve identification of the ureter at the **pelvic brim** and tracing it through the surgical field.

Question 856: What is the advantage of fiberoptic bronchoscopy over rigid bronchoscopy?

A. Better airway control
B. Good view (Correct Answer)
C. Foreign body removal
D. In a sick child, it can be passed through an endotracheal tube

Explanation: ***Good view*** - Fiberoptic bronchoscopy offers a **flexible scope** that can navigate smaller and more tortuous airways, providing **superior visualization of the entire bronchial tree**, including distal segments and subsegmental bronchi that are inaccessible to rigid bronchoscopy. - This is the **primary and most fundamental advantage** of fiberoptic over rigid bronchoscopy, enabling better diagnostic capability for peripheral lesions, biopsies, and brushings. - The flexible nature allows visualization of **upper lobe bronchi** and other angulated airways that rigid scopes cannot reach. *Better airway control* - This is an advantage of **rigid bronchoscopy, not fiberoptic**. - Rigid bronchoscopy provides superior airway control, especially in massive hemoptysis or large foreign body aspiration, allowing direct ventilation and suctioning through the scope. - Fiberoptic bronchoscopy does not offer the same level of **airway stabilization** or ability to ventilate directly. *Foreign body removal* - This is an advantage of **rigid bronchoscopy, not fiberoptic**. - Rigid bronchoscopy is preferred for foreign body removal, particularly larger or sharply angled objects, due to its larger working channel and ability to introduce robust grasping instruments. - While small foreign bodies can sometimes be removed with a fiberoptic scope, the **limited working channel** makes this challenging. *In a sick child, it can be passed through an endotracheal tube* - This is **also an advantage** of fiberoptic bronchoscopy, particularly useful in critically ill or intubated patients. - However, compared to the **superior visualization** (which is the core defining advantage used in all clinical scenarios), this is a **situational advantage** limited to intubated patients. - The question asks for "the advantage" (singular), making **superior view/visualization** the best answer as it represents the primary reason fiberoptic bronchoscopy was developed and is widely used.

Question 857: The incision in which rectus abdominis muscle is cut transversely is :

A. Maylard (Correct Answer)
B. Kerr
C. Pfannenstiel
D. All of the options

Explanation: ***Correct Answer: Maylard*** - The **Maylard incision** is a transverse incision that cuts through the **rectus abdominis muscles** transversely to provide excellent access to the pelvis. - This incision is commonly used in **gynecological oncology** and pelvic surgeries requiring extensive exposure. - By cutting (transecting) the rectus muscles, it provides superior lateral access compared to muscle-splitting techniques. *Incorrect: Kerr* - The **Kerr incision** is a transverse abdominal incision that typically involves **splitting, rather than cutting**, the rectus abdominis muscles. - It is often used for operations such as a **lower segment Cesarean section**, similar in concept to a Pfannenstiel incision. - The muscles are separated along their fibers, not cut transversely. *Incorrect: Pfannenstiel* - The **Pfannenstiel incision** is a low transverse incision in the skin and subcutaneous tissue, with the **rectus abdominis muscles separated vertically in the midline** rather than cut transversely. - This incision offers **good cosmetic results** and is commonly used for **Cesarean sections** and pelvic procedures. - The rectus sheath is incised transversely, but the muscles themselves are separated, not cut. *Incorrect: All of the options* - This option is incorrect because **only the Maylard incision** specifically involves transecting (cutting) the rectus abdominis muscles transversely. - The Kerr and Pfannenstiel incisions involve either separating or splitting the rectus muscles along their fibers, not cutting them transversely.

Question 858: For a midline incision in the abdomen, length of suture required is:

A. 3 times the length of incision
B. 4 times the length of incision (Correct Answer)
C. 2 times the length of incision
D. 5 times the length of incision

Explanation: ***4 times the length of incision*** - The standard recommendation for interrupted abdominal fascial closure is to use a **suture-to-wound length ratio** of approximately **4:1**. - This ratio ensures sufficient material for adequate fascial apposition, overlapping bites, and knots, which are crucial for preventing wound dehiscence. *3 times the length of incision* - A 3:1 suture-to-wound ratio might be insufficient for secure fascial closure, potentially leading to increased tension on the suture lines and a **higher risk of dehiscence**. - This ratio could be considered for very specific continuous closure techniques, but it's generally not recommended for standard interrupted closures. *2 times the length of incision* - A 2:1 ratio is generally considered **inadequate** for most fascial closures, especially in the abdomen. - This ratio would likely result in insufficient suture material, leading to very large bites and an insecure closure, significantly increasing the risk of **wound dehiscence** and **herniation**. *5 times the length of incision* - While it ensures enough material, a 5:1 ratio suggests using **excessive suture material** which might extend operating time. - Using significantly more suture than necessary offers no proven benefit in terms of wound security and can sometimes introduce more foreign material into the wound.

Question 859: Venous air embolism during surgery is seen with

A. Lateral position
B. Supine position
C. Sitting position (Correct Answer)
D. Prone position

Explanation: ***Sitting position*** - In the **sitting position** (e.g., for posterior fossa surgery), the surgical site is often above the level of the heart, creating a negative pressure gradient in the veins. - This **negative pressure** can draw air into opened veins if they are not adequately occluded, leading to a venous air embolism. *Lateral position* - While air embolism can occur in various positions if venous sinuses are open, the **lateral position** does not inherently create the same significant negative pressure gradient as the sitting position relative to the heart. - Risk is generally lower compared to positions where the surgical field is significantly elevated above the heart. *Supine position* - In the **supine position**, the surgical field is typically at or below heart level, which minimizes the likelihood of a negative pressure gradient in the veins. - This position is generally considered to have a **lower risk** for venous air embolism compared to upright positions. *Prone position* - The **prone position** can also increase central venous pressure if abdominal compression occurs, making venous air embolism less likely due to a positive venous pressure. - Although other surgical complications can arise, a venous air embolism is **not a classic risk** specifically associated with the prone position from a negative pressure standpoint.

Question 860: Whitehead's varnish in gauze is used to arrest bleeding from:

A. Bleeding from capillaries.
B. Bleeding from bone. (Correct Answer)
C. Bleeding from skin.
D. All of the options.

Explanation: ***Bleeding from bone*** - **Whitehead's varnish** contains **iodoform and benzoin** (iodoform in benzoin compound tincture), which have an **astringent and antiseptic** effect. - When applied to bleeding bone surfaces, it helps to **coagulate proteins** and promote **mechanical tamponade**, thereby arresting bleeding. - Commonly used in **oral and maxillofacial surgery** to control bleeding from bone cavities. *Bleeding from capillaries* - Capillary bleeding is usually **minor and self-limiting**, often controlled by **direct pressure** or simple absorbents. - Whitehead's varnish is typically reserved for more persistent bleeding from bony surfaces, not superficial capillaries. *Bleeding from skin* - Skin bleeding generally responds well to **direct pressure, simple dressings**, or **topical coagulants** if needed. - Whitehead's varnish is not a primary therapeutic agent for cutaneous bleeding; its formulation is specifically aimed at managing bone bleeding. *All of the options* - While it might theoretically have some effect on other types of bleeding, its **primary and specifically indicated use** is for bleeding from bone. - Applying it to all forms of bleeding would be **ineffective** or **inappropriate** given more conventional and targeted treatments available for capillary and skin bleeding.

Practice by Chapter

Wound Healing and Care

Practice Questions

Surgical Infections

Practice Questions

Fluid and Electrolyte Management

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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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