Surgical Complications — MCQs

10 questions

Complications of sling procedures (TVT) for USI are all except:

Which of the following is the LEAST significant risk factor for postoperative pulmonary complications?

A patient who met with an accident presented to the emergency department, he lost 25% of his total blood volume approximately, blood pressure is normal. He/she will be classified under which class of hypovolemic shock?

A 55-year-old male, known smoker, complains of calf pain while walking. He experiences calf pain while walking but can continue walking with effort. Which grade of claudication does this patient fall under?

Which one of the following is not a part of the Revised Trauma score -

A 45 year old underwent surgery for rectal prolapse. At present, he complains of sexual dysfunction which is probably due to the injury of:

A surgeon is about to start a laparoscopic procedure on a patient. The floor nurse asks the surgeon about the identity of the patient, site of the procedure to be performed and any anticipated critical events during the surgery. These questions are a part of the

A patient presents with an umbilical mass, which was previously reducible but has now become irreducible with discharge coming out, as shown in the image. What is the most appropriate management?

A surgeon examined the case of hernia. Forcefully reduces the sac in abdominal cavity, without actually pushing back the contents. Identify type of hernia with the image given.

Q10

In a female with appendicitis in pregnancy, treatment of choice is

Surgical Complications Indian Medical PG Practice Questions and MCQs

Question 1: Complications of sling procedures (TVT) for USI are all except:

A. Obturator nerve injury is about 10% (Correct Answer)
B. Overactive bladder in about 7% cases
C. Injury to bladder and wound haematoma
D. Sling erosion particularly with polytetrafluoroethylene (Goretex)

Explanation: ***Obturator nerve injury is about 10%*** ✓ **CORRECT ANSWER (NOT a complication of TVT)** - **Obturator nerve injury** is exceedingly rare during **TVT (Tension-free Vaginal Tape)** procedures, which use a retropubic approach through the space of Retzius. - This complication is primarily associated with **TOT (Trans-Obturator Tape)** procedures where the tape passes near the obturator foramen, not with standard retropubic TVT. - The incidence of obturator nerve injury in TVT is essentially negligible (<0.1%), nowhere near 10%. *Overactive bladder in about 7% cases* - **De novo overactive bladder (OAB)** symptoms or worsening of pre-existing OAB can occur in 3-15% of patients after TVT procedures, with 7% being a commonly cited figure. - This occurs due to changes in bladder neck support, urethral kinking, or irritation from the sling material. *Injury to bladder and wound haematoma* - **Bladder injury/perforation** occurs in 2-5% of TVT cases due to the retropubic passage of needles close to the bladder, which is why intraoperative cystoscopy is routinely performed. - **Wound hematoma** can occur at the vaginal or suprapubic incision sites as a common surgical complication from tissue dissection and bleeding. *Sling erosion particularly with polytetrafluoroethylene (Goretex)* - **Sling erosion** into the vagina or urethra is a documented complication of synthetic slings, with rates of 0.5-3% for modern materials. - **Polytetrafluoroethylene (Goretex)**, an older first-generation mesh material, was associated with significantly higher rates of erosion (up to 10%) and infection compared to modern monofilament polypropylene meshes, which is why it has been largely discontinued for sling procedures.

Question 2: Which of the following is the LEAST significant risk factor for postoperative pulmonary complications?

A. Age >70
B. Patient with 7 pack years of smoking
C. Upper abdominal surgery
D. BMI>30 (Correct Answer)

Explanation: ***BMI>30*** - While **obesity (BMI >30)** is associated with some surgical risks, it is generally considered a less significant independent risk factor for postoperative pulmonary complications compared to other factors like age, smoking, and surgical site. - The impact of obesity on pulmonary function is complex and varies depending on the type of surgery and presence of comorbid conditions like **sleep apnea**. *Age >70* - **Advanced age (>70)** is a significant independent risk factor due to decreased physiological reserve, reduced pulmonary function (e.g., decreased lung elasticity, impaired cough reflex), and increased prevalence of comorbidities. - Older patients are more susceptible to **atelectasis**, **pneumonia**, and **respiratory failure** postoperatively. *Patient with 7 pack years of smoking* - Even a relatively low cumulative smoking history of **7 pack-years** can impair mucociliary clearance, increase bronchial secretions, and cause airway inflammation, significantly increasing the risk of pulmonary complications. - Smoking compromises lung function and increases the risk of **bronchospasm** and infection. *Upper abdominal surgery* - **Upper abdominal surgery** is a significant risk factor because incisions close to the diaphragm interfere with diaphragmatic movement, leading to reduced lung volumes, impaired cough, and increased risk of **atelectasis** and **pneumonia**. - Pain from the incision further restricts deep breaths and coughing, contributing to pulmonary complications.

Question 3: A patient who met with an accident presented to the emergency department, he lost 25% of his total blood volume approximately, blood pressure is normal. He/she will be classified under which class of hypovolemic shock?

A. Class II (Correct Answer)
B. Class I
C. Class III
D. Class IV

Explanation: ***Class II*** - A 25% blood loss (within the **15-30% range**), with **blood pressure remaining normal**, categorizes this patient into **Class II hypovolemic shock**. - In Class II, compensatory mechanisms such as increased **heart rate** and **peripheral vasoconstriction** maintain systolic blood pressure despite significant volume loss. - Patients typically present with **tachycardia (100-120 bpm)**, **narrowed pulse pressure**, mild **anxiety**, and **normal systolic BP**. *Class I* - Class I shock involves **minimal blood loss** (up to 15%), with blood loss <750 mL in adults. - Patients in Class I typically present with **normal vital signs** and minimal to no clinical symptoms. - The 25% blood loss exceeds the threshold for Class I classification. *Class III* - Class III shock is characterized by blood loss of **30-40%** (1500-2000 mL in adults). - This level of loss typically results in **decreased systolic blood pressure**, **marked tachycardia (120-140 bpm)**, **confusion**, and clinical instability. - The patient's normal blood pressure and 25% loss are **below the threshold** for Class III shock. *Class IV* - Class IV shock involves massive blood loss of **greater than 40%** (>2000 mL in adults). - Presents with profound **hypotension**, **severe tachycardia (>140 bpm)**, **altered consciousness**, and **imminent cardiovascular collapse**. - This patient's normal blood pressure and stable condition are inconsistent with Class IV shock.

Question 4: A 55-year-old male, known smoker, complains of calf pain while walking. He experiences calf pain while walking but can continue walking with effort. Which grade of claudication does this patient fall under?

A. Grade I (Mild claudication)
B. Grade II (Moderate claudication) (Correct Answer)
C. Grade III (Severe claudication)
D. Grade IV (Ischemic rest pain)

Explanation: ***Grade II (Moderate claudication)*** - **Grade II claudication** is characterized by **intermittent claudication** where the patient experiences pain while walking but can **continue walking with effort**. - This level of claudication reflects a moderate degree of peripheral arterial disease, where blood flow is sufficiently compromised to cause pain with exertion but not severe enough to force immediate cessation of activity. - The patient in this scenario can continue ambulation despite discomfort, which is the defining feature of this grade. *Grade I (Mild claudication)* - **Grade I claudication** involves discomfort or pain that the patient can **tolerate without significantly altering their gait or pace**. - In this stage, the pain is minimal, and the patient may perceive it as a dull ache or mild fatigue rather than true pain. - Walking can continue without significant effort or limitation. *Grade III (Severe claudication)* - **Grade III claudication** is marked by pain that is **severe enough to stop the patient from walking within a short distance** (typically less than 200 meters). - The pain forces the patient to rest and recover before they can resume walking. - This represents significant functional limitation in daily activities. *Grade IV (Ischemic rest pain)* - **Grade IV**, also known as **critical limb ischemia**, involves **pain even at rest**, especially in the feet or toes, often worsening at night when the limb is elevated. - This stage indicates severe arterial obstruction and is frequently associated with **ulcers, non-healing wounds, or gangrene**. - This represents advanced peripheral arterial disease requiring urgent intervention. **Note:** This grading system is a simplified clinical classification. The standard medical classifications for peripheral arterial disease are the **Fontaine classification** (Stages I-IV) and **Rutherford classification** (Categories 0-6).

Question 5: Which one of the following is not a part of the Revised Trauma score -

A. Systolic blood pressure
B. Glasgow coma scale
C. Respiratory rate
D. Pulse rate (Correct Answer)

Explanation: ***Pulse rate*** - The **Revised Trauma Score (RTS)** uses three physiological parameters: **Glasgow Coma Scale (GCS)**, **Systolic Blood Pressure (SBP)**, and **Respiratory Rate (RR)**. - **Pulse rate** is not a component of the calculated RTS, although it is an important vital sign in trauma assessment. *Systolic blood pressure* - **Systolic blood pressure** is a crucial component of the RTS, reflecting the patient's hemodynamic stability. - It is assigned a coded value (0-4) based on its measurement, with lower values indicating poorer prognosis. *Glasgow coma scale* - The **Glasgow Coma Scale (GCS)** assesses the patient's level of consciousness and neurological status. - It is a key element of the RTS, providing insight into the severity of head injury or overall neurological compromise. *Respiratory rate* - **Respiratory rate** is included in the RTS for its ability to reflect the adequacy of ventilation and overall physiological distress. - Abnormal respiratory rates (too high or too low) are assigned lower coded values, indicating more severe injury.

Question 6: A 45 year old underwent surgery for rectal prolapse. At present, he complains of sexual dysfunction which is probably due to the injury of:

A. Pelvic autonomic nerves (Correct Answer)
B. Urinary bladder
C. Rectum
D. Inferior mesenteric artery

Explanation: ***Pelvic autonomic nerves*** - Surgical procedures in the **pelvic region**, such as for rectal prolapse, carry a risk of damaging the **pelvic autonomic nerves**, which are crucial for sexual function. - Injury to these nerves can lead to various forms of **sexual dysfunction**, including erectile dysfunction in men, due to impaired nerve signaling to the genital organs. *Urinary bladder* - While the urinary bladder is anatomically close to the rectum, direct injury to the bladder itself during rectal prolapse surgery typically leads to **urinary symptoms** (e.g., incontinence, retention), not primarily sexual dysfunction. - Though bladder dysfunction can indirectly impact sexual activity, it's not the direct cause of primary sexual dysfunction following injury in this context. *Rectum* - The surgery is performed on the rectum, and while complications can occur, direct injury to the rectal wall itself primarily results in issues such as **fecal incontinence, bleeding, or infection**. - The rectum's primary role is in digestion and defecation, and its injury does not directly cause sexual dysfunction unrelated to nerve damage. *Inferior mesenteric artery* - The **inferior mesenteric artery (IMA)** supplies blood to the distal colon and rectum, and its injury during surgery would primarily lead to **ischemia or necrosis** of the supplied bowel segments. - While a severely compromised blood supply could have systemic effects, direct injury to the IMA is not a direct or common cause of sexual dysfunction.

Question 7: A surgeon is about to start a laparoscopic procedure on a patient. The floor nurse asks the surgeon about the identity of the patient, site of the procedure to be performed and any anticipated critical events during the surgery. These questions are a part of the

A. nurses safety checklist
B. WHO surgical safety checklist (Correct Answer)
C. universal precautions checklist
D. MCI patient safety checklist

Explanation: **WHO surgical safety checklist** - The questions about patient identity, procedure site, and anticipated critical events are key components of the **"Sign In"** and **"Time Out"** sections of the **WHO Surgical Safety Checklist**. - This checklist is designed to improve **patient safety** by ensuring communication and adherence to essential steps before, during, and after surgery, thereby reducing surgical errors. *nurses safety checklist* - While nurses play a crucial role in patient safety, there isn't a universally recognized "nurses safety checklist" that specifically encompasses these exact comprehensive surgical verification steps. - The comprehensive framework described, with its specific questions, aligns more closely with the broader, interdisciplinary **WHO Surgical Safety Checklist**. *universal precautions checklist* - **Universal precautions** focus on preventing the transmission of bloodborne pathogens and other infectious agents by treating all bodily fluids as potentially infectious. - This checklist primarily addresses **infection control** measures and does not cover patient identification, surgical site verification, or critical event anticipation. *MCI patient safety checklist* - A "MCI patient safety checklist" is not a widely recognized or standardized medical safety protocol. - The scenario describes a standard, internationally adopted set of safety checks specifically for surgical procedures, which is the **WHO Surgical Safety Checklist**.

Question 8: A patient presents with an umbilical mass, which was previously reducible but has now become irreducible with discharge coming out, as shown in the image. What is the most appropriate management?

A. Umbilical excision
B. Umbilical excision with mesh hernioplasty (Correct Answer)
C. Mesh hernioplasty
D. Conservative

Explanation: ***Umbilical excision with mesh hernioplasty*** - The presence of an **irreducible umbilical mass with discharge** indicates a complicated umbilical hernia, likely with **incarceration, strangulation, or infection**. - Management requires **excision of compromised tissue** (umbilicus and surrounding necrotic/infected skin) followed by **hernia defect repair**. - **Mesh hernioplasty** provides strong, durable reinforcement and prevents recurrence. - **Note:** In heavily contaminated fields, primary tissue repair or biologic mesh may be preferred over synthetic mesh, or staged repair may be considered. However, if contamination is minimal after debridement, mesh repair can be performed in the same setting. *Umbilical excision* - While **excision of the compromised umbilical skin and necrotic tissue** is necessary due to the discharge (suggesting infection or necrosis), **excision alone does not address the underlying hernia defect**. - Simply excising the umbilicus without repairing the hernia would lead to **persistent hernia or recurrence**. *Mesh hernioplasty* - A mesh hernioplasty alone is appropriate for **uncomplicated, reducible umbilical hernias** to reinforce the abdominal wall. - However, it **does not account for the irreducibility and skin changes/discharge**, which necessitate **excision of potentially infected or necrotic tissue** first. - Placing mesh without addressing the compromised tissue would risk ongoing infection and mesh complications. *Conservative* - **Conservative management** is reserved for **asymptomatic, reducible umbilical hernias** in adults (especially if small) or for infants where spontaneous closure can occur. - An **irreducible mass with discharge** signifies an **acute surgical emergency** (incarceration, strangulation, or infection) requiring **urgent surgical intervention**, not observation.

Question 9: A surgeon examined the case of hernia. Forcefully reduces the sac in abdominal cavity, without actually pushing back the contents. Identify type of hernia with the image given.

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

Explanation: ***Reduction en masse*** - **Reduction en masse** is a dangerous complication that occurs during attempted hernia reduction where the entire hernia sac, along with its incarcerated contents, is pushed back into the abdominal cavity. - The key feature is that **the contents remain trapped within the sac** after reduction, creating a false sense of successful reduction. - The scenario explicitly describes this: "forcefully reduces the sac... without actually pushing back the contents" - this is the textbook definition of reduction en masse. - This complication is dangerous because the incarcerated/strangulated bowel remains undetected inside the abdomen, potentially leading to **peritonitis and bowel necrosis**. - The hernia defect appears reduced externally, but the obstruction persists internally. *Incarcerated hernia* - An **incarcerated hernia** is the state where hernia contents are trapped and cannot be reduced back into the abdominal cavity. - This represents the **pre-existing condition** before the forceful reduction attempt was made. - While incarceration may have been present initially, the question asks about the outcome after the surgeon "forcefully reduces the sac" - this action creates a reduction en masse. *Sliding hernia* - A **sliding hernia** involves a retroperitoneal organ (colon, bladder, ovary) forming part of the hernia sac wall itself. - This is a structural variant unrelated to the reduction complication described in the scenario. *Maydl's hernia* - **Maydl's hernia** (W-hernia or retrograde strangulation) involves a loop of bowel where both ends remain in the abdomen while the intermediate segment is trapped in the hernia sac. - The strangulated segment is the intra-abdominal portion, not the part in the sac. - This is a specific type of hernia content configuration, not related to the reduction complication described.

Question 10: In a female with appendicitis in pregnancy, treatment of choice is

A. Surgery after delivery
B. Continue pregnancy with medical Rx
C. Abortion with appendectomy
D. Surgery at earliest (Correct Answer)

Explanation: ***Surgery at earliest*** - **Appendicitis** in pregnancy is a surgical emergency requiring prompt intervention to prevent maternal and fetal complications such as **peritonitis**, **sepsis**, and **preterm labor**. - Delaying surgery significantly increases the risk of **appendiceal rupture**, which can lead to higher rates of fetal loss and maternal morbidity. *Surgery after delivery* - Delaying surgery until after delivery is **contraindicated** because acute appendicitis requires immediate treatment. - The risk of **perforation** and subsequent complications for both mother and fetus is unacceptably high if left untreated. *Continue pregnancy with medical Rx* - **Medical management alone** is not an appropriate treatment for acute appendicitis during pregnancy. - Antibiotics may temporarily mask symptoms but do not treat the underlying **inflammation** or prevent **rupture** of the appendix. *Aboion with appendectomy* - **Abortion** is not indicated as a primary treatment for appendicitis in pregnancy. - The goal is to safely remove the inflamed appendix while preserving the pregnancy, unless there are severe, uncontrollable complications threatening the mother's life where abortion might be considered in extreme circumstances.

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