General Surgery Principles Practice Questions

Q: A 70-year-old man presents with chest pain, diagnosed with coronary disease, and concurrently detected asymptomatic gallstones on ultrasonography. What is the most appropriate management strategy for gallstones in this patient?

Conservative management with monitoring. ***Conservative management with monitoring*** - Asymptomatic gallstones generally do not require surgical intervention due to the low risk of developing symptoms or complications and the potential risks of surgery in an elderly patient with **coronary artery disease**. - **Monitoring** for the development of symptoms such as biliary colic, cholecystitis, or pancreatitis is the recommended approach. *Open cholecystectomy* - This is a more invasive surgical procedure with a longer recovery time and higher risks compared to laparoscopic cholecystectomy. - It is typically reserved for complex cases or when laparoscopic surgery is contraindicated, neither of which applies to asymptomatic gallstones. *Laparoscopic cholecystectomy* - While this is the standard surgical treatment for **symptomatic gallstones**, it is not indicated for asymptomatic gallstones. - Performing elective surgery in an elderly patient with **coronary artery disease** for an asymptomatic condition would expose them to unnecessary surgical risks. *Oral dissolution agents* - These agents (e.g., **ursodeoxycholic acid**) are primarily effective for dissolving small, cholesterol-rich gallstones. - They have a low success rate, require prolonged treatment, and gallstones often recur after treatment cessation, making them unsuitable for routine management of asymptomatic gallstones.

Q: Which type of hernia is commonly associated with hydrocele?

Indirect inguinal hernia. ***Indirect inguinal hernia*** - An **indirect inguinal hernia** occurs when there is a persistent **patent processus vaginalis**, the same embryological structure that can lead to a **hydrocele** if it closes incompletely distally. - Both conditions arise from the failure of the **processus vaginalis** to fully obliterate, allowing abdominal contents (for hernia) or peritoneal fluid (for hydrocele) to enter the inguinal canal or scrotum. *Direct inguinal hernia* - A **direct inguinal hernia** protrudes directly through **Hesselbach's triangle** and is an acquired weakness of the posterior wall of the inguinal canal, not related to the processus vaginalis. - It involves a different anatomical defect and does not share the same developmental origin as a hydrocele. *Femoral hernia* - A **femoral hernia** protrudes through the **femoral canal** below the inguinal ligament, a distinct anatomical pathway from the inguinal canal. - It is more common in women and is not embryologically linked to the formation of a hydrocele. *Umbilical hernia* - An **umbilical hernia** involves a protrusion through the **umbilical ring** due to incomplete closure of the abdominal wall at the umbilicus. - This type of hernia is entirely distinct in its anatomical location and developmental origin from both inguinal hernias and hydroceles.

Q: Which of the following structures is not seen on bronchoscopy?

Subcarinal lymph nodes. ***Subcarinal lymph nodes*** - While the **carina** (the division of the trachea into the main stem bronchi) is clearly visible, the **lymph nodes** located beneath it are external to the airway and cannot be directly visualized during a standard bronchoscopy. - Visualization of lymph nodes typically requires imaging studies like CT scans or invasive procedures like **endobronchial ultrasound (EBUS)** with biopsy. *Trachea* - The **trachea** is the main airway tube and is fully visualized during the initial insertion and advancement of the bronchoscope. - Its rings, mucosa, and antegrade lumen are clearly inspected. *Vocal cords* - The **vocal cords** are located in the larynx, superior to the trachea, and are the first structures encountered and assessed during the intubation phase of a bronchoscopy. - Their movement and appearance are routinely checked to ensure proper bronchoscope insertion. *First segmental division of bronchi* - Bronchoscopy allows for the visualization of the **main bronchi** and their subsequent divisions down to the **segmental and subsegmental bronchi**. - The first division branches are readily accessible and are a common area for inspection and biopsy.

Q: Which of the following is the MOST significant risk factor for inguinal hernia?

Cigarette smoking. ***Cigarette smoking*** - **Cigarette smoking** is strongly associated with an increased risk of inguinal hernia due to the breakdown of connective tissue and increased intra-abdominal pressure from chronic cough. - **Smoking** leads to impaired collagen synthesis and degradation of existing collagen, weakening the abdominal wall and predisposing to hernia formation. *Diabetes mellitus* - While **diabetes mellitus** can affect wound healing and increase the risk of surgical complications, it is not considered a primary direct risk factor for the development of an inguinal hernia itself. - The impact of **diabetes** on connective tissue strength is less direct and significant for hernia formation compared to factors like chronic cough from smoking. *Hypertension* - **Hypertension** is not a direct risk factor for the development of inguinal hernias. - There is no clear physiological mechanism linking elevated blood pressure to the weakening of the abdominal wall. *Hypothyroidism* - **Hypothyroidism** can be associated with an increased risk of certain types of hernias, particularly umbilical hernias, due to generalized weakness of connective tissue. - However, it is not considered the MOST significant risk factor for **inguinal hernias** specifically, which are more influenced by factors affecting intra-abdominal pressure and collagen integrity.

Q: All of the following are true regarding pilonidal sinus except:

Seen predominantly in women. ***Seen predominantly in women*** - Pilonidal sinus is **more prevalent in men** than in women, with a male-to-female ratio of about 3–4:1. - This higher incidence in males is often attributed to greater hairiness and occupational factors. *Most commonly occurs in sacrococcygeal region* - This is a **TRUE statement** - the sacrococcygeal region is the **most common site** for pilonidal sinus (>90% of cases). - While less commonly, pilonidal sinuses can also occur in other hairy areas such as the periumbilical region, axilla, and scalp (particularly in barbers). *Tendency for recurrence* - Pilonidal sinuses have a **high tendency for recurrence**, even after surgical intervention, especially with inadequate excision or conservative management. - Factors contributing to recurrence include presence of **remaining hair follicles** or insufficient removal of sinus tracts. *Obesity is a risk factor* - **Obesity** is a recognized risk factor for the development of pilonidal sinus. - Increased weight can lead to deeper gluteal clefts, increased sweating, and friction, which promote hair follicle damage and foreign body inflammatory reactions.

Q: Which of the following statements regarding indirect inguinal hernia is incorrect?

Always unilateral. ***Always unilateral*** - While indirect inguinal hernias are more frequently unilateral, they can occur **bilaterally** in some patients. - The persistence of a **patent processus vaginalis** on both sides would predispose to bilateral herniation. *Most common type of hernia* - **Indirect inguinal hernias** are indeed the most common type of abdominal wall hernia, accounting for approximately two-thirds of all inguinal hernias. - This is due to their congenital origin from a **patent processus vaginalis**. *Inguinal herniotomy is the basic operation* - For children with indirect inguinal hernias, **inguinal herniotomy** (ligation and excision of the hernia sac) is the standard and often curative procedure. - In adults, a **hernioplasty** (repair with mesh) is usually performed, but simple herniotomy is suitable in specific cases. *Transillumination distinguishes it from hydrocele* - **Hydroceles** typically transilluminate (light passes through), indicating a fluid-filled sac. - An indirect inguinal hernia contains **bowel or omentum**, which does not transilluminate, thus helping to differentiate the two.

Q: A chest X-ray (CXR) of a patient is shown. What is the next step in management of this patient?

Exploratory laparotomy. ***Exploratory laparotomy*** - The chest X-ray shows **free air under the diaphragm** on the right side, indicating **pneumoperitoneum**. - **Pneumoperitoneum** usually signifies a **perforated abdominal viscus**, a surgical emergency requiring immediate exploration to identify and repair the perforation. *Ventilation perfusion scan* - This scan is primarily used to diagnose **pulmonary embolism** and is not indicated for the current finding. - The chest X-ray does not show any signs suggestive of pulmonary embolism, such as a **Westermark sign** or a **Hampton hump**. *Bronchoalveolar lavage* - **Bronchoalveolar lavage (BAL)** is a diagnostic procedure used to retrieve fluid from the lower respiratory tract for analysis, typically for infections or inflammatory conditions. - It would not be helpful in evaluating **subdiaphragmatic free air**, which is an abdominal issue. *High resolution CT scan* - While a **CT scan** could further characterize the pneumoperitoneum, the presence of clear free air on a plain film warrants **immediate surgical intervention** rather than further imaging, especially in an acute setting. - A CT scan might be considered if the diagnosis is equivocal, but in this case, the finding is unequivocal and indicates an emergency.

Q: In which of the following conditions is splenectomy not indicated?

Tuberculosis of the spleen. ***Tuberculosis of the spleen*** - While splenic tuberculosis can occur, **medical management** with anti-tuberculosis drugs is typically the primary treatment, and splenectomy is usually not indicated unless there are complications like massive hemorrhage or rupture. - Splenectomy for tuberculosis **does not address the systemic nature** of the infection and carries risks without significant benefit in most cases. *Trauma* - **Splenic trauma** leading to hemorrhage or rupture is a common indication for splenectomy, especially in cases of severe injury. - Removal of the spleen can be **life-saving** to control bleeding and prevent hypovolemic shock. *Hereditary spherocytosis* - Splenectomy is the definitive treatment for **hereditary spherocytosis** to correct anemia and reduce hemolysis. - The spleen is responsible for **premature destruction of abnormally shaped red blood cells**, so its removal improves red blood cell survival. *Splenic abscess* - **Splenic abscesses** often require splenectomy, particularly if they are large, multiple, or do not respond to antibiotic therapy. - Removing the infected organ helps to **eliminate the source of infection** and prevent systemic complications like sepsis.

Q: Splenectomy is most useful in:

Hereditary spherocytosis. ***Hereditary spherocytosis*** - Splenectomy is a definitive treatment for **hereditary spherocytosis** as it removes the primary site where abnormally shaped **spherocytes** are selectively destroyed. - While it does not cure the genetic defect, it significantly reduces **hemolysis** and **anemia**, improving quality of life. *Thrombocytopenia* - Splenectomy can be considered for certain types of **immune thrombocytopenia (ITP)** that are refractory to medical therapy, but it is not the most common or initial treatment. - In ITP, the spleen is a major site of **platelet destruction** and **antibody production**, making splenectomy a potential option in selected cases. *Henoch-Schönlein purpura* - **Henoch-Schönlein purpura** (now known as **IgA vasculitis**) is a **self-limiting vasculitis** that primarily affects small blood vessels and typically resolves with supportive care. - Splenectomy plays no role in the management of **Henoch-Schönlein purpura** as the pathophysiology does not involve splenic dysfunction or destruction of blood cells. *Sickle cell anemia* - Splenectomy is generally **contraindicated** in **sickle cell anemia** patients beyond early childhood, as most older patients experience **autosplenectomy** due to recurrent sickling and infarction. - In very young children, splenectomy might be considered for recurrent **splenic sequestration crises**, but this is not a common or universally applied treatment.

Question 1

A 70-year-old man presents with chest pain, diagnosed with coronary disease, and concurrently detected asymptomatic gallstones on ultrasonography. What is the most appropriate management strategy for gallstones in this patient?

Accepted Answer

Conservative management with monitoring

Answer

Open cholecystectomy

Answer

Laparoscopic cholecystectomy

Answer

Oral dissolution agents

Question 2

Which type of hernia is commonly associated with hydrocele?

Accepted Answer

Indirect inguinal hernia

Answer

Umbilical hernia

Answer

Direct inguinal hernia

Answer

Femoral hernia

Question 3

Which of the following structures is not seen on bronchoscopy?

Accepted Answer

Subcarinal lymph nodes

Answer

Trachea

Answer

Vocal cords

Answer

First segmental division of bronchi

Question 4

Which of the following is the MOST significant risk factor for inguinal hernia?

Accepted Answer

Cigarette smoking

Answer

Hypertension

Answer

Diabetes mellitus

Answer

Hypothyroidism

Question 5

All of the following are true regarding pilonidal sinus except:

Accepted Answer

Seen predominantly in women

Answer

Most commonly occurs in sacrococcygeal region

Answer

Obesity is a risk factor

Answer

tendency for recurrence

Question 6

Which of the following statements regarding indirect inguinal hernia is incorrect?

Accepted Answer

Always unilateral

Answer

Inguinal herniotomy is the basic operation

Answer

Transillumination distinguishes it from hydrocele

Answer

Most common type of hernia

Question 7

A chest X-ray (CXR) of a patient is shown. What is the next step in management of this patient?

Accepted Answer

Exploratory laparotomy

Answer

Ventilation perfusion scan

Answer

Bronchoalveolar lavage

Answer

High resolution CT scan

Question 8

In which of the following conditions is splenectomy not indicated?

Accepted Answer

Tuberculosis of the spleen

Answer

Trauma

Answer

Hereditary spherocytosis

Answer

Splenic abscess

Question 9

Two weeks following the initial management of this patient's chylothorax, there is persistent accumulation of chyle in the pleural space. Which of the following procedures is appropriate management at this time?

Accepted Answer

Thoracotomy and ligation of the thoracic duct

Answer

Neck exploration for thoracic duct injury

Answer

Subdiaphragmatic ligation of the thoracic duct

Answer

Thoracotomy and repair of the thoracic duct injury

Question 10

Splenectomy is most useful in:

Accepted Answer

Hereditary spherocytosis

Answer

Thrombocytopenia

Answer

Sickle cell anemia

Answer

Henoch-Schönlein purpura

General Surgery Principles — MCQs

General Surgery Principles — MCQs

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