General Surgery Principles — MCQs

General Surgery Principles Indian Medical PG Practice Questions and MCQs

Question 861: Abdominal compartment syndrome is characterized by the following except:

A. Hypotension due to decrease in venous return
B. Oliguria due to ureter obstruction (Correct Answer)
C. Hypoxia due to increased peak inspiratory pressure
D. Hypercarbia and respiratory acidosis

Explanation: ***Oliguria due to ureter obstruction*** - **Oliguria** in abdominal compartment syndrome is primarily due to **renal hypoperfusion** caused by increased intra-abdominal pressure compressing renal vasculature and reducing kidney blood flow, **not ureter obstruction**. - Increased intra-abdominal pressure can also cause direct **renal parenchymal compression** and activation of neurohormonal mechanisms, leading to reduced urine output. *Hypotension due to decrease in venous return* - Increased intra-abdominal pressure compresses the **inferior vena cava**, leading to reduced **venous return** to the heart. - This decreased preload results in a lower cardiac output and subsequent **hypotension**. - This is a **true characteristic** of abdominal compartment syndrome. *Hypoxia due to increased peak inspiratory pressure* - Elevated intra-abdominal pressure pushes the diaphragm upwards, leading to reduced **lung compliance** and **tidal volume**. - This increases the **peak inspiratory pressure** required to ventilate the lungs and can result in **hypoxia**. - This is a **true characteristic** of abdominal compartment syndrome. *Hypercarbia and respiratory acidosis* - The combination of **diaphragmatic splinting** and **reduced lung compliance** leads to impaired ventilation. - This causes inadequate carbon dioxide excretion, resulting in **hypercarbia** (elevated CO2) and subsequent **respiratory acidosis**. - This is a **true characteristic** of abdominal compartment syndrome.

Question 862: EUSOL solution used in treatment of venous ulcer contains all except

A. Boric acid
B. Sodium hydroxide (Correct Answer)
C. Calcium hydroxide
D. Sodium hypochlorite

Explanation: ***Sodium hydroxide*** - EUSOL (Edinburgh University Solution of Lime) solution is an antiseptic solution that traditionally contains equal parts of **bleaching powder (chlorinated lime)** and **boric acid**, dissolved in water. - **Sodium hydroxide** is not a component of the standard EUSOL solution formulation. *Boric acid* - **Boric acid** is a key ingredient in EUSOL solution, contributing to its antiseptic and mild astringent properties. - It helps to buffer the solution and enhance its stability. *Calcium hydroxide* - **Calcium hydroxide** is a component of **chlorinated lime**, which is used to generate sodium hypochlorite within the solution. - It is an indirect ingredient, as part of the bleaching powder. *Sodium hypochlorite* - **Sodium hypochlorite** is the active antiseptic agent formed when chlorinated lime reacts with water. - It provides the primary antimicrobial action against bacteria in wounds.

Question 863: The gold standard for definitive wound coverage in open wounds requiring tissue replacement is:

A. Traditional dressings
B. Synthetic skin substitutes
C. Skin grafting (Correct Answer)
D. Biological dressings

Explanation: ***Skin grafting*** - **Skin grafting** involves transplanting healthy skin from one area of the body to another to cover a wound. This is the **gold standard for definitive wound coverage** in open wounds requiring tissue replacement. - It provides **viable, vascularized tissue** that can permanently integrate with the wound bed, making it superior for large or deep wounds where other methods are insufficient. - Both **split-thickness skin grafts (STSG)** and **full-thickness skin grafts (FTSG)** are used depending on the wound characteristics and requirements. *Traditional dressings* - While essential for initial wound care, **traditional dressings (e.g., gauze)** primarily provide a protective barrier and absorb exudate, but they do not contribute to definitive tissue replacement for open wounds. - They are considered a staple for **temporary management** and healing by secondary intention, but not the "gold standard" for *replacing* lost tissue. *Synthetic skin substitutes* - These are **engineered materials** designed to mimic some functions of skin, providing a temporary or permanent cover. - While useful for **wound healing acceleration** or as a temporary bridge for grafting, they are not universally considered the **gold standard for definitive tissue replacement** in all open wounds as they may lack full integration or viability compared to native tissue. *Biological dressings* - These include materials derived from human or animal tissue (e.g., **allografts, xenografts**) that serve as temporary wound coverings. - Biological dressings help **prepare the wound bed** and promote healing but are often resorbed or rejected and typically need to be replaced by a permanent solution like skin grafting for definitive closure.

Question 864: Tensile strength of a wound becomes normal after:

A. Never (Correct Answer)
B. 6 months
C. 4 months
D. 6 weeks

Explanation: ***Never*** - A healed wound, even after complete maturation, only achieves about **80% of the original tissue's tensile strength** - The process of scar formation involves the realignment of collagen fibers and increased cross-linking, but it can **never perfectly replicate** the pre-injury tissue architecture and strength - This is a fundamental principle of wound healing - scar tissue is structurally different from normal tissue *6 months* - By 6 months, a wound's tensile strength has typically reached its **maximum potential** of approximately 80%, but this is still less than 100% of the original tissue's strength - This period marks the end of the significant remodeling phase, where collagen fibers are reorganized and strengthened *4 months* - At 4 months, the wound is still undergoing substantial **remodeling and strengthening**, achieving approximately 70-80% of eventual tensile strength - While considerable strength is gained by this time, further improvements continue for several more months *6 weeks* - At 6 weeks, the wound has achieved about **50-70% of its eventual tensile strength** - This stage is characterized by increased collagen deposition and cross-linking, making the wound clinically strong, but it is far from its maximum or normal strength

Question 865: For a lacerated wound, delayed primary suturing is done within:

A. 24 hr
B. 48 hr (Correct Answer)
C. 36 hr
D. 50 hr

Explanation: ***48 hr*** - **Delayed primary closure (DPC)** is typically performed **between 48 hours and 7 days** after the initial injury, with **48 hours representing the earliest threshold** for this technique. - At 48 hours, the wound has passed the acute inflammatory phase, bacterial load has been reduced through initial wound care, and the tissue can be assessed for readiness to close. - This method is used for **contaminated or potentially infected wounds** where immediate closure would risk infection, allowing time for wound cleaning and monitoring. - While optimal DPC is often performed at **3-5 days**, 48 hours marks the transition from primary to delayed primary closure. *24 hr* - This timeframe represents **primary closure**, where clean, uncontaminated wounds are sutured immediately or within the first 24 hours of injury. - At 24 hours, contaminated wounds have not had sufficient time for bacterial load reduction and inflammatory response assessment. *36 hr* - While 36 hours represents a delay from immediate closure, it falls short of the **minimum 48-hour threshold** typically required for delayed primary closure. - This intermediate timeframe does not allow adequate wound assessment and bacterial load reduction. *50 hr* - Although 50 hours falls within the DPC window (48 hours to 7 days), the question asks for the timeframe within which DPC is done, and **48 hours is the established earliest/minimum threshold**. - While DPC can certainly be performed at 50 hours, 48 hours is the standard benchmark cited in surgical literature as the beginning of the DPC window.

Question 866: Howship-Romberg sign is seen in

A. Spigelian hernia
B. Femoral hernia
C. Inguinal hernia
D. Obturator hernia (Correct Answer)

Explanation: ***Obturator hernia*** - The **Howship-Romberg sign** is characterized by **medial thigh pain** on hip extension, adduction, and internal rotation, which is indicative of an obturator hernia. - This symptom arises from compression of the **obturator nerve** as it passes through the obturator canal alongside the hernia sac. *Spigelian hernia* - A Spigelian hernia presents as a **ventrolateral abdominal wall defect**, typically between the rectus abdominis muscle and linea semilunaris. - It usually causes localized pain and a palpable lump but does not involve **obturator nerve compression**. *Femoral hernia* - A femoral hernia manifests as a bulge in the **groin region** below the inguinal ligament, often presenting as an emergent strangulated hernia. - While it can cause groin pain, it does not typically involve the **obturator nerve** or present with the **Howship-Romberg sign**. *Inguinal hernia* - Inguinal hernias are common, presenting as a bulge in the groin, either **direct or indirect**, above the inguinal ligament. - Symptoms include a palpable mass and discomfort, but not the specific **medial thigh pain** associated with obturator nerve compression.

Question 867: Which of the following muscles is cut in posterolateral thoracotomy?

A. Serratus anterior
B. Latissimus dorsi (Correct Answer)
C. Rhomboids
D. Pectoralis major

Explanation: ***Latissimus dorsi*** - The **latissimus dorsi** is the **largest muscle divided** during a standard posterolateral thoracotomy incision. - It is the **most superficial** of the divided muscles and is routinely cut to allow access to the deeper structures and ribs required for entry into the thoracic cavity. - This is the **primary muscle** identified with this surgical approach. *Serratus anterior* - The **serratus anterior** is also typically **divided** (along with latissimus dorsi) in a posterolateral thoracotomy. - However, latissimus dorsi is considered the **more characteristic** muscle of this approach due to its larger size and more superficial position. - Preservation when possible is important for shoulder function (scapular protraction and superior rotation). *Rhomboids* - The **rhomboid muscles** (major and minor) lie deeper, beneath the trapezius, and are **not typically cut** in a standard posterolateral thoracotomy. - They remain protected and are involved in **scapular retraction** and downward rotation. *Pectoralis major* - The **pectoralis major** muscle is a large chest muscle located **anteriorly** and is **not involved** in a posterolateral thoracotomy approach. - This muscle is relevant in anterior thoracotomy approaches, where it's involved in **adduction, medial rotation**, and flexion of the humerus.

Question 868: During cardiopulmonary resuscitation, cardiac massage is given over:

A. Mid third of sternum
B. Upper third of sternum
C. Precordium
D. Lower third of sternum (Correct Answer)

Explanation: ***Lower third of sternum*** - Correct hand placement for **cardiac compressions** is on the **lower half of the sternum**, approximately at the junction of the middle and lower thirds. - Position: **Center of the chest**, 2 finger breadths above the xiphoid process, which corresponds anatomically to the lower third area. - This placement ensures optimal compression of the heart between the sternum and spine, maximizing **cardiac output** during CPR according to **AHA and ERC guidelines**. *Mid third of sternum* - Compressing only the mid-third (middle of sternum) is **too high** for optimal cardiac compression. - This placement is above the ideal position and results in **less effective blood flow** during resuscitation. *Upper third of sternum* - Compressing the upper third of the sternum is **highly ineffective** for cardiac compression. - Can lead to injuries such as **fractures of the clavicle** or upper ribs without achieving adequate cardiac compression. *Precordium* - **Precordium** refers to the general area over the heart, but it is **not precise enough** for effective CPR hand placement. - This vague anatomical term doesn't provide the specific landmark needed for proper compression technique.

Question 869: In flap method of amputation, which structure is kept shorter than the level of amputation?

A. Bone (Correct Answer)
B. Nerves
C. Vessels
D. Muscles

Explanation: ***Bone*** - In the **flap method of amputation**, the bone is intentionally cut **shorter** than the soft tissue flaps (typically 2-3 cm proximal to the planned skin closure level). - This allows the **muscle and skin flaps** to be closed over the end of the bone without tension, providing good padding and a well-contoured stump for prosthesis fitting. - This is the **primary structural principle** of flap amputation technique. *Nerves* - **Nerves** are typically cut sharply under gentle traction and allowed to retract proximally (usually 5-10 cm proximal to bone level) to prevent **neuroma formation** and phantom limb pain. - While nerves are indeed cut shorter, the **bone** is the structure specifically beveled shorter **for the purpose of flap closure**, which is what the question asks. *Vessels* - **Vessels** (arteries and veins) are ligated and divided at a level that ensures **hemostasis** and allows for proper flap closure. - They are handled for vascular control, not specifically kept shorter than the bone for shaping the stump. *Muscles* - **Muscles** are usually beveled and sewn to each other (myoplasty) or to the periosteum (myodesis) over the bone end to provide a well-padded, functional stump. - Muscles form the **flap itself** and are **longer than the bone**, not shorter, as they must cover and cushion it.

Question 870: During hysterectomy, dissection through the broad ligament most commonly risks injury to which structure?

A. Transverse colon
B. Ureter (Correct Answer)
C. Bladder
D. Urethra

Explanation: ***Ureter*** - During a hysterectomy, especially when dissecting deeply within the **broad ligament** to ligate the uterine artery, the **ureter** is at high risk of injury due to its close anatomical proximity. - The ureter passes just **inferior to the uterine artery** (water under the bridge), making it vulnerable during clamping and ligation of the uterine vessels. *Transverse colon* - The transverse colon is located much higher in the abdomen and is not typically within the surgical field of a hysterectomy unless there is **extensive adhesion formation** or a very unusual approach. - Injury to the transverse colon is highly **unlikely** during an uncomplicated hysterectomy through the broad ligament. *Bladder* - The bladder is anterior to the uterus and is more commonly at risk of injury when dissecting the **vesicouterine fold** or during mobilization of the anterior vaginal wall. - While a common site of injury in hysterectomy, it is less directly related to dissection within the **broad ligament** itself, which is more lateral to the bladder's dome. *Urethra* - The urethra is the terminal portion of the urinary tract and is located much more **inferiorly and anteriorly**, within the pelvic floor and distal to the surgical field for uterine removal. - Injury to the urethra is extremely rare during a routine hysterectomy and would imply a significant **surgical misadventure** far from the broad ligament.

Practice by Chapter

Wound Healing and Care

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Surgical Infections

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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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