Microsurgical Techniques — MCQs
Most sensitive method of monitoring cardiovascular ischemia in the perioperative period is -
Which one of the following is not a wound closure technique?
What type of graft or dressing is used to cover the post-burn wound shown in the image?
Longitudinal incision with Z-plasty closure is used in which of the following?
Vacuum assisted closure is contraindicated in which of the following conditions -
Which flap is commonly used in breast reconstruction?
Radial Nerve injury of this type recovers with conservative management
Blood loss during major surgery is best estimated by:
What is the treatment of choice in a patient with Crohn’s disease, where inflamed appendix was found on exploration?
Which of the following statements are correct regarding sutures in surgery? I. Barbed sutures have the advantage of eliminating the need for knots. II. Vertical mattress sutures help in eversion of wound edges. III. Aberdeen knot is used for continuous suturing. IV. Silk is preferred for subcuticular suturing. Select the answer using the code given below :
Microsurgical Techniques Indian Medical PG Practice Questions and MCQs
Question 1: Most sensitive method of monitoring cardiovascular ischemia in the perioperative period is -
- A. NIBP
- B. ECG
- C. Pulse oximeter
- D. TEE (Correct Answer)
Explanation: ***TEE*** - **Transesophageal echocardiography (TEE)** is the most sensitive method for detecting perioperative myocardial ischemia because it can visualize **regional wall motion abnormalities** and changes in **ventricular function** much earlier than ECG. - **Ischemia** directly impairs the contractility of the affected myocardium, leading to subtle changes in wall motion that TEE can identify. *NIBP* - **Non-invasive blood pressure (NIBP)** monitoring can detect **hemodynamic changes** (like hypotension or hypertension) that may precede or accompany ischemia. - However, these changes are **non-specific** and occur relatively late, making NIBP a less sensitive indicator of early ischemia. *ECG* - **Electrocardiography (ECG)** monitors the electrical activity of the heart and can detect **ST-segment changes** indicative of ischemia. - While useful, ECG changes may appear later than wall motion abnormalities, and **silent ischemia** can be missed if the leads are not optimally placed or if the ischemia does not produce significant electrical changes. *Pulse oximeter* - A **pulse oximeter** measures **oxygen saturation** in the peripheral blood. - It is primarily used to assess **respiratory function** and tissue oxygenation, and it does not directly monitor myocardial ischemia or cardiac function.
Question 2: Which one of the following is not a wound closure technique?
- A. Composite graft
- B. Vascular graft (Correct Answer)
- C. Partial thickness skin graft
- D. Musculocutaneous flap
Explanation: ***Vascular graft*** - A **vascular graft** is a tube-like structure used to bypass or replace a diseased or damaged blood vessel. - Its primary purpose is to **restore blood flow**, not to close a wound on the body surface or replace missing tissue. *Partial thickness skin graft* - A **partial thickness skin graft** involves transplanting the epidermis and a portion of the dermis to cover a wound. - This is a common and effective technique for **wound closure**, particularly for large surface area wounds or burns. *Composite graft* - A **composite graft** is a graft consisting of multiple tissue types, such as skin, cartilage, and fat, often used for reconstruction. - This is a direct method of **wound closure** and tissue replacement, particularly in areas requiring structural support and soft tissue coverage. *Musculocutaneous flap* - A **musculocutaneous flap** involves the transfer of skin, subcutaneous tissue, and an underlying muscle to cover a wound. - This is a versatile **wound closure technique** that provides robust soft tissue coverage and blood supply to complex defects.
Question 3: What type of graft or dressing is used to cover the post-burn wound shown in the image?
- A. Split thickness skin graft (Correct Answer)
- B. Full thickness skin graft
- C. VAC dressing
- D. Normal saline dressing
Explanation: ***Split thickness skin graft*** - The image shows a **meshed pattern** on the skin graft, which is characteristic of a **split-thickness skin graft** that has been expanded to cover a larger area. - This type of graft consists of the epidermis and a portion of the dermis, making it more flexible and able to **"take" more reliably** on various wound beds, commonly used for burn wounds. *Full thickness skin graft* - A **full-thickness skin graft** includes the entire epidermis and dermis and typically does not have a meshed appearance. - They are used for smaller defects where cosmesis is a priority, but have a **lower take rate** than split-thickness grafts, making them less suitable for large burn wounds. *VAC dressing* - A **VAC (Vacuum-Assisted Closure) dressing** is a system that applies negative pressure to a wound to promote healing and is not a skin graft itself. - It involves a foam or gauze dressing sealed with an adhesive film, connected to a vacuum pump, which is not what is depicted in the image. *Normal saline dressing* - A **normal saline dressing** is a simple wet-to-dry or wet-to-wet dressing for wound care, involving gauze soaked in normal saline. - This is a basic wound management technique and does not involve grafting or have the characteristic meshed appearance seen in the image.
Question 4: Longitudinal incision with Z-plasty closure is used in which of the following?
- A. Hand surgery (Correct Answer)
- B. Thyroid surgery
- C. Breast reconstruction surgery
- D. Hernia repair surgery
Explanation: ***Hand surgery*** - **Z-plasty** is frequently employed in hand surgery to **lengthen constricted scars** or to **reorient tension lines**, especially across joints or creases. - This technique helps to improve **range of motion** and prevent contractures that can severely impair hand function following injury or surgery. *Breast reconstruction surgery* - While various flap techniques are used in breast reconstruction, the primary incision or closure does not typically involve a **longitudinal incision with Z-plasty**. - Procedures often focus on re-shaping and volume replacement using **tissue flaps** or implants, or linear scar realignment for aesthetic purposes. *Thyroid surgery* - Thyroidectomy typically involves a **transverse incision** in the neck (a **Kocher collar incision**) to minimize visible scarring and follow natural skin folds. - **Z-plasty** is not a standard technique for closing the primary incision in thyroid surgery. *Hernia repair surgery* - Hernia repair usually involves a **linear or curvilinear incision** in the groin or abdominal wall, followed by direct closure or mesh placement. - The goal is strong tissue repair, and **Z-plasty** is not used as a closure method for the primary incision in hernia repair.
Question 5: Vacuum assisted closure is contraindicated in which of the following conditions -
- A. Chronic osteomyelitis
- B. Large amount of necrotic tissue with eschar (Correct Answer)
- C. Abdominal wound
- D. Surgical wound dehiscence
Explanation: ***Large amount of necrotic tissue with eschar*** - The presence of a large amount of **necrotic tissue** and **eschar** is a contraindication for VAC therapy because it prevents effective contact between the foam and viable tissue, impairing wound healing. - Eschar acts as a physical barrier, trapping bacteria and hindering the proper function of negative pressure by preventing uniform pressure distribution and fluid removal from the wound bed. *Chronic osteomyelitis* - While chronic osteomyelitis can be challenging, VAC therapy can sometimes be used as an **adjunctive treatment** after surgical debridement to manage the wound and promote granulation tissue formation. - It helps in controlling infection and closing the wound by removing exudates, reducing edema, and improving blood flow. *Abdominal wound* - VAC therapy is commonly used for **abdominal wounds**, especially after damage control surgery or in cases of open abdomen management. - It facilitates closure by promoting granulation, reducing edema, and protecting the abdominal contents. *Surgical wound dehiscence* - **Surgical wound dehiscence** is a common indication for VAC therapy, as it helps to manage the open wound, promote granulation tissue, and prepare the wound for eventual secondary closure or grafting. - VAC therapy reduces surgical site infections, removes exudates, and enhances tissue perfusion, leading to better wound healing outcomes.
Question 6: Which flap is commonly used in breast reconstruction?
- A. DIEP based on deep inferior epigastric perforator vessels (Correct Answer)
- B. Gluteal flap based on superior gluteal artery
- C. Latissimus dorsi flap based on thoracodorsal artery
- D. TRAM based on transverse rectus abdominis muscle
Explanation: ***DIEP based on deep inferior epigastric perforator vessels*** - The **DIEP flap** is currently the **most preferred autologous flap** for breast reconstruction and is increasingly commonly used in modern practice. - It uses tissue from the lower abdomen, providing excellent volume and a natural-feeling breast mound, while being nourished by **deep inferior epigastric perforator vessels**. - Key advantage: **Muscle-sparing technique** that preserves the rectus abdominis muscle, minimizing abdominal wall morbidity compared to older techniques like TRAM. - Considered the **gold standard** for abdominal-based breast reconstruction. *Gluteal flap based on superior gluteal artery* - While gluteal flaps (like the **SGAP** based on the **superior gluteal artery**) are used for breast reconstruction, they are typically considered a secondary option when abdominal tissue is unavailable or unsuitable. - Harvesting can be more challenging and may result in a less ideal breast shape compared to abdominal flaps. - Less commonly used compared to abdominal-based flaps. *Latissimus dorsi flap based on thoracodorsal artery* - The **latissimus dorsi flap** is a reliable and commonly used option, particularly for smaller breasts or partial reconstruction. - However, it often requires an implant to achieve sufficient volume (not purely autologous reconstruction). - It involves transferring muscle from the back, which can lead to back weakness or contour deformities. - While frequently used, it is not the preferred choice when autologous tissue from the abdomen is available. *TRAM based on transverse rectus abdominis muscle* - The **TRAM flap** was historically a very common choice for breast reconstruction but involves taking a significant portion of the rectus abdominis muscle. - This leads to higher rates of abdominal wall weakness, hernias, or bulges compared to muscle-sparing techniques. - It is currently **less commonly used** than the DIEP flap due to its higher donor site morbidity and has been largely superseded by the DIEP technique.
Question 7: Radial Nerve injury of this type recovers with conservative management
- A. Crush injury
- B. Chemical injury
- C. Neurotmesis
- D. Neuropraxia (Correct Answer)
Explanation: ***Neuropraxia*** - **Neuropraxia** is a mild form of nerve injury involving demyelination without axonal disruption, allowing for complete recovery with conservative management. - The nerve's electrical conduction is temporarily blocked, but the **axon** and its supporting structures remain intact. *Crush injury* - Crush injuries often result in more severe nerve damage, ranging from **axonotmesis** to **neurotmesis**, generally requiring more than conservative management for recovery. - The extensive compression and potential tissue damage can lead to significant axonal disruption and scar tissue formation, impeding nerve regeneration. *Chemical injury* - Chemical injuries can cause varying degrees of nerve damage, often resulting in **axonopathy** or demyelination, which may or may not recover with conservative management. - The extent of damage is highly dependent on the type and concentration of the chemical, and the duration of exposure. *Neurotmesis* - **Neurotmesis** involves complete transection of the nerve, including the axon and surrounding connective tissue sheaths, making spontaneous recovery highly unlikely. - Surgical intervention, such as **nerve repair** or grafting, is typically required for any functional recovery.
Question 8: Blood loss during major surgery is best estimated by:
- A. Transesophageal USG Doppler
- B. Visual assessment
- C. Suction bottles (Correct Answer)
- D. Cardiac output by thermodilution
Explanation: ***Suction bottles*** - Measuring the volume of fluid collected in **suction bottles** (after subtracting irrigating fluid) provides a direct and quantifiable estimate of blood loss. - This method is widely used in surgery due to its **simplicity and relative accuracy** for assessing blood collected from the surgical field. *Transesophageal USG Doppler* - This technique primarily assesses **cardiac function** and **blood flow dynamics**, not directly quantifying blood loss. - While it can indicate hypovolemia, it doesn't provide a precise measurement of the volume of blood lost. *Visual assessment* - **Visual estimation** of blood loss by surgical staff is notoriously inaccurate and can lead to significant underestimation or overestimation. - It is highly subjective and depends on factors like lighting, the color of the blood-soaked materials, and individual experience. *Cardiac output by thermodilution* - **Thermodilution** is used to measure cardiac output, which can reflect hemodynamic status and help guide fluid resuscitation. - It does not directly quantify the amount of blood lost but rather assesses the **body's response** to blood loss.
Question 9: What is the treatment of choice in a patient with Crohn’s disease, where inflamed appendix was found on exploration?
- A. Appendectomy
- B. Closing the abdomen and starting medical treatment
- C. Right hemicolectomy
- D. Ileo–colic resection and anastomosis (Correct Answer)
Explanation: ***Ileo-colic resection and anastomosis*** - This is the treatment of choice when an inflamed appendix is found during exploration in a patient with Crohn's disease, as the disease typically affects the **terminal ileum** and **right colon**. - The inflamed appendix is often a manifestation of Crohn's disease involving the **cecal base** and surrounding bowel. - **Ileo-colic resection** ensures removal of the diseased segment, including the inflamed appendix and involved bowel, thereby preventing future complications such as **fistulas** (risk up to 65% with simple appendectomy) and **strictures**. - If the cecal base is involved with Crohn's disease, simple appendectomy is contraindicated due to poor healing and high fistula risk. *Appendectomy* - Performing a simple appendectomy in the context of Crohn's disease carries a high risk of **fistula formation** and **poor wound healing** due to the underlying inflammatory process. - When the disease involves the **base of the appendix** and surrounding **cecum** (which is common), appendectomy alone is insufficient and dangerous. - Appendectomy may only be considered safe if the cecal base is completely **normal and uninvolved**, which is uncommon in this clinical scenario. *Closing the abdomen and starting medical treatment* - While medical treatment is crucial for managing Crohn's disease, an **inflamed appendix** found during exploration suggests an acute process that requires **surgical intervention**. - Delaying surgery by closing the abdomen could lead to complications such as **perforation** and **peritonitis**, especially if inflammation is severe. - Medical therapy alone is insufficient for acute complications requiring exploration. *Right hemicolectomy* - Right hemicolectomy is a more extensive resection than necessary for most cases of ileocecal Crohn's disease with appendiceal involvement. - **Ileo-colic resection** (removing terminal ileum, cecum, and ascending colon up to the hepatic flexure) is adequate and preferred as it is less extensive while addressing the pathology. - Right hemicolectomy would be reserved for more extensive colonic involvement beyond the typical ileocecal distribution.
Question 10: Which of the following statements are correct regarding sutures in surgery? I. Barbed sutures have the advantage of eliminating the need for knots. II. Vertical mattress sutures help in eversion of wound edges. III. Aberdeen knot is used for continuous suturing. IV. Silk is preferred for subcuticular suturing. Select the answer using the code given below :
- A. I, II and IV
- B. II, III and IV
- C. I, II and III (Correct Answer)
- D. I, III and IV
Explanation: ***I, II and III*** - **I. Barbed sutures** have unidirectional or bidirectional barbs that grip tissue, negating the need for traditional knots to secure the suture line. This property can significantly **reduce operating time** and the volume of foreign material left in the wound. - **II. Vertical mattress sutures** are designed to achieve precise wound edge approximation and eversion, which are crucial for optimal healing and cosmesis, particularly in areas under tension or for thick skin. - **III. The Aberdeen knot** is a slip knot technique specifically designed to secure the end of a **continuous suture line** efficiently and reliably. It provides a flat, secure knot that minimizes bulk and is less prone to loosening. *I, II and IV* - While statements I and II are correct, statement IV is incorrect. **Silk is a braided, non-absorbable multifilament suture** that can cause significant tissue reaction. - It is generally not preferred for subcuticular suturing due to its increased risk of infection, visibility, and foreign body reaction compared to monofilament, absorbable sutures. *II, III and IV* - Statements II and III are correct, but statement IV is incorrect. **Silk is avoided for subcuticular closure** due to its inflammatory properties and potential for suture extrusion or sinus formation. - Subcuticular sutures typically use **absorbable monofilament sutures** (e.g., poliglecaprone 25 or polydioxanone) to minimize tissue reaction and achieve good cosmetic results. *I, III and IV* - Statements I and III are correct regarding barbed sutures and the Aberdeen knot, respectively. However, statement IV is incorrect because **silk suture is a non-absorbable, braided material that is highly reactive and not suitable for subcuticular placement**, where monofilament absorbable sutures are preferred for minimal tissue reaction and good cosmesis.
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