Surgical Resection Principles — MCQs
The commando operation is:
Which one of the following is not a principle followed in the management of missile injuries?
Local excision in rectal cancer is done in all, except:
Which statement is incorrect about the pathology of the bone tumor?
Which of the following is NOT an indication for postoperative radiotherapy in a case of carcinoma endometrium?
A patient scheduled for elective inguinal hernia surgery has a history of myocardial infarction (MI) and underwent coronary artery bypass grafting (CABG). What should be included in the preoperative assessment?
What is the treatment of choice for a patient presenting with carcinoma of the rectum and obstruction in an emergency setting?
After undergoing surgery, for carcinoma of colon, a patient developed single liver metastasis of 2 cm. What would be the next treatment?
A 35-year-old HIV-positive woman (CD4 count 180/μL, on HAART) develops extensive perianal condyloma acuminata resistant to conventional treatments. HPV typing shows type 16. What is the most appropriate management approach?
Which of the following is most radiosensitive tumor?
Surgical Resection Principles Indian Medical PG Practice Questions and MCQs
Question 1: The commando operation is:
- A. Abdomino-perineal resection of the rectum for carcinoma
- B. Extended radical mastectomy
- C. Disarticulation of the hip for gas gangrene of the leg
- D. Excision of carcinoma of the tongue, the floor of the mouth, part of the jaw and lymph nodes en bloc (Correct Answer)
Explanation: ***Excision of carcinoma of the tongue, the floor of the mouth, part of the jaw and lymph nodes en bloc*** - The **Commando operation** specifically refers to a radical surgical procedure for advanced head and neck cancers, typically involving the **tongue**, **floor of the mouth**, and often requiring removal of a portion of the **mandible (jaw)** and a **neck dissection (lymph nodes en bloc)**. - This extensive, single-block resection aims to provide wide margins for large or invasive tumors in the oral cavity. *Abdomino-perineal resection of the rectum for carcinoma* - This procedure, known as **APR**, is a common surgery for low rectal cancers but is not referred to as a "Commando operation." - It involves the removal of the rectum and anus through both abdominal and perineal incisions, usually resulting in a permanent colostomy. *Extended radical mastectomy* - **Extended radical mastectomy** involves the removal of the breast, axillary lymph nodes, and potentially some chest wall muscles, but it is a procedure for breast cancer and not related to head and neck surgery, nor is it termed a "Commando operation." - This operation is a historically significant, though less common, approach to breast cancer management. *Disarticulation of the hip for gas gangrene of the leg* - **Hip disarticulation** is an amputation procedure at the hip joint for severe conditions like gas gangrene or extensive trauma and is not known as a "Commando operation." - This is an emergency or salvage procedure aimed at preventing further spread of infection or disease.
Question 2: Which one of the following is not a principle followed in the management of missile injuries?
- A. Excision of all dead muscles
- B. Removal of foreign bodies
- C. Leaving the wound open
- D. Removal of fragments of bone (Correct Answer)
Explanation: ***Removal of fragments of bone*** - While large, easily accessible bone fragments that are likely to cause future complications (e.g., nerve compression) might be removed, the general principle in missile injuries is **not to routinely remove all bone fragments**. - Small, embedded bone fragments often act as a scaffold for healing and may not pose a significant threat if sterile, and aggressive removal can cause further trauma. *Excision of all dead muscles* - This is a fundamental principle in the management of missile injuries to prevent **infection** and promote healing. - **Debridement** of all non-viable tissue, including dead muscle, is crucial to remove potential sources of bacterial growth and toxins. *Removal of foreign bodies* - This is also a crucial principle to prevent **infection**, **inflammation**, and potential long-term complications. - Foreign bodies like bullet fragments, clothing, or dirt can introduce bacteria and hinder wound healing. *Leaving the wound open* - This is a standard practice for most missile wounds, especially those with significant tissue damage or contamination, to allow for **drainage** and prevent **compartment syndrome**. - **Delayed primary closure** may be performed after a few days if the wound is clean and free of infection, but initial closure is generally avoided.
Question 3: Local excision in rectal cancer is done in all, except:
- A. Involvement of <40% circumference
- B. Lesion <4 cm
- C. Within 6 cm of anal verge
- D. T2 cancer or any lymph node involvement (Correct Answer)
Explanation: ***T2 cancer or any lymph node involvement*** - Local excision is typically reserved for **early-stage rectal cancers (T1 tumors)** where the risk of lymph node metastasis is very low and there is **no lymph node involvement**. - **T2 tumors** (invasion into muscularis propria) carry a significantly higher risk of lymph node metastasis (10-20%) and are generally **not suitable for local excision**, requiring radical resection instead. - **Any lymph node involvement** (even in T1 disease) is an **absolute contraindication** to local excision, as it indicates metastatic spread requiring comprehensive lymphadenectomy through radical resection. *Within 6 cm of anal verge* - This refers to the **location within the rectum** and accessibility for transanal approaches. - Rectal tumors within 6-8 cm of the anal verge are **suitable for local excision** techniques like transanal endoscopic microsurgery (TEM) or transanal minimally invasive surgery (TAMIS) if they meet other criteria (T1, N0, favorable histology). *Lesion <4 cm* - **Tumor size <3-4 cm** is one of the favorable criteria for local excision. - Smaller tumors are more amenable to complete excision with adequate margins and are associated with lower risk of lymph node metastasis. *Involvement of <40% circumference* - The **circumferential involvement** of the rectal wall is an important factor for technical feasibility. - Tumors involving **<30-40% of the circumference** are suitable for local excision, allowing adequate margin resection and primary closure without compromising rectal function or causing stenosis.
Question 4: Which statement is incorrect about the pathology of the bone tumor?
- A. Tumor has distinct margin
- B. Tumor arises from epiphyseal to metaphyseal region
- C. Eccentric lesion
- D. Chemotherapy is the treatment of choice for all bone tumors. (Correct Answer)
Explanation: ***Tumor has distinct margin*** - A **distinct margin** often indicates a benign tumor, while malignant tumors typically show **infiltrative margins**. - In bone tumors, particularly malignant ones, the lack of clear demarcation is a key pathological feature. *Chemotherapy is the treatment of choice* - While chemotherapy may be used for certain **malignant bone tumors**, it is not the first-line treatment for most bone tumors [1]. - The primary treatment is often **surgical excision**, especially for localized lesions [1]. *Tumor arise from epiphyseal to metaphyseal region* - While some tumors can originate in these areas, many actually arise from the **diaphyseal** region in bone tumors like osteosarcoma. - This option misrepresents the common locations where various tumors develop, as osteochondromas tend to develop near the epiphyses of limb bones [2]. *Eccentric lesion* - Many bone tumors do indeed present as **eccentric lesions**, especially benign ones like **osteochondromas**. - However, this feature does not apply universally, as some malignant tumors can also be **central or infiltrative** in nature. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 673-674. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Osteoarticular And Connective Tissue Disease, pp. 672-673.
Question 5: Which of the following is NOT an indication for postoperative radiotherapy in a case of carcinoma endometrium?
- A. Positive lymph nodes
- B. Endocervical involvement
- C. Myometrial invasion >1/2 thickness
- D. Tumor positive for estrogen receptors (Correct Answer)
Explanation: ***Tumor positive for estrogen receptors*** - A tumor being **positive for estrogen receptors** indicates a potential responsiveness to **hormonal therapy**, rather than an indication for postoperative radiotherapy. - While it guides treatment decisions, it does not suggest a need for radiation to reduce local recurrence risk, unlike other high-risk features. *Myometrial invasion >1/2 thickness* - **Deep myometrial invasion (>1/2 thickness)** is a significant **risk factor for recurrence** and metastases in endometrial carcinoma. - Radiotherapy is often indicated in such cases to improve **local control** and reduce recurrence. *Positive lymph nodes* - The presence of **positive lymph nodes** signifies regional spread of the cancer. - This is a strong indication for **adjuvant therapy**, including radiotherapy, to target residual disease and prevent recurrence. *Endocervical involvement* - **Endocervical stromal invasion** indicates a more aggressive tumor that has extended beyond the endometrium. - This finding is associated with a higher risk of **locoregional recurrence**, making postoperative radiotherapy a crucial component of treatment to improve outcomes.
Question 6: A patient scheduled for elective inguinal hernia surgery has a history of myocardial infarction (MI) and underwent coronary artery bypass grafting (CABG). What should be included in the preoperative assessment?
- A. History + c/e + routine labs + V/Q scan
- B. History + c/e + routine labs
- C. History + c/e + routine labs + stress test (Correct Answer)
- D. History + c/e + routine labs + angiography to assess graft patency
Explanation: ***History + c/e + routine labs + stress test*** - A **stress test** is crucial in patients with a history of MI and CABG to assess **myocardial ischemia** and functional capacity, guiding perioperative management. - This evaluation helps determine the patient's **cardiac risk** for non-cardiac surgery and the need for further cardiac optimization. *History + c/e + routine labs + angiography to assess graft patency* - **Coronary angiography** is an invasive procedure and is generally not indicated as a routine preoperative assessment unless there are new, significant cardiac symptoms or signs of **graft dysfunction**. - Assessing graft patency through angiography carries risks and would only be justified if there were strong clinical indications suggesting acute or severe **cardiac ischemia**. *History + c/e + routine labs* - While critical for any preoperative assessment, **routine history, physical examination, and basic laboratory tests** are insufficient for a patient with a significant cardiac history like MI and CABG. - This approach would **underestimate the cardiac risk** and might miss undetected ischemia, leading to adverse perioperative cardiac events. *History + c/e + routine labs + V/Q scan* - A **ventilation-perfusion (V/Q) scan** is primarily used to diagnose **pulmonary embolism** or assess regional lung function. - It does not provide information about myocardial ischemia or cardiac functional capacity, making it **irrelevant** for assessing cardiac risk in this clinical scenario.
Question 7: What is the treatment of choice for a patient presenting with carcinoma of the rectum and obstruction in an emergency setting?
- A. Total colectomy
- B. Hartmann's procedure (Correct Answer)
- C. Defunctioning colostomy
- D. Left hemi-colectomy
Explanation: ***Hartmann's procedure*** - In an emergency setting with **obstructing carcinoma of the rectum**, Hartmann's procedure is the **treatment of choice**. - This procedure involves **resection of the tumor** with formation of an **end colostomy** and closure of the distal rectal stump. - It achieves **dual objectives**: relieves the obstruction AND removes the primary tumor, allowing proper oncological staging and planning of adjuvant therapy. - While more extensive than simple diversion, it is the **standard emergency operation** for obstructing left-sided and rectal cancers in patients who can tolerate resection. - The colostomy can be reversed later after adjuvant treatment (if needed), though many remain permanent. *Defunctioning colostomy* - A proximal diverting colostomy only diverts the fecal stream without addressing the primary tumor. - This is a **temporizing measure**, not definitive treatment, and leaves the malignancy in situ. - It may be considered in **highly unstable patients** or for purely **palliative** intent when resection is not feasible. - Requires a second major operation for definitive tumor resection, increasing overall morbidity. *Total colectomy* - This involves removing the entire colon and is performed for conditions like **familial adenomatous polyposis** or **synchronous colon cancers**. - Not indicated for isolated rectal cancer with obstruction. - Would be excessively extensive and carry unnecessary morbidity in this setting. *Left hemi-colectomy* - This procedure removes the left colon (descending and sigmoid) but typically does not include the rectum. - Not appropriate for **rectal cancer**, as it would not address the primary pathology. - Used for tumors of the descending or sigmoid colon, not rectum.
Question 8: After undergoing surgery, for carcinoma of colon, a patient developed single liver metastasis of 2 cm. What would be the next treatment?
- A. Radio frequency ablation
- B. Chemo-radiation
- C. Acetic acid injection
- D. Resection (Correct Answer)
Explanation: ***Resection*** - For a **single, resectable liver metastasis** from colorectal carcinoma, surgical **resection offers the best chance of cure** and is the gold standard of treatment. - The size of the metastasis (2 cm) is well within the criteria for surgical removal, and the absence of multiple lesions or widespread disease makes it a prime candidate for curative surgery. *Radio frequency ablation* - **RFA** is typically considered for patients with **unresectable liver metastases** or those who are not surgical candidates. - While it can be effective for small lesions, it is generally preferred when resection is not possible due to factors like lesion location (e.g. adjacent to major vessels), patient comorbidities, or multiple lesions. *Chemo-radiation* - **Chemoradiation** is more commonly used in the treatment of the **primary colorectal cancer** itself, especially in locally advanced rectal cancer, or for palliative purposes in metastatic disease. - It is **not the primary curative treatment** for an isolated, resectable liver metastasis. *Acetic acid injection* - **Acetic acid injection** is a form of **chemical ablation** and is sometimes used for small liver tumors, particularly hepatocellular carcinoma. - It is generally considered **less effective and less predictable** than RFA or surgical resection for colorectal liver metastases and is not the preferred treatment for a resectable lesion.
Question 9: A 35-year-old HIV-positive woman (CD4 count 180/μL, on HAART) develops extensive perianal condyloma acuminata resistant to conventional treatments. HPV typing shows type 16. What is the most appropriate management approach?
- A. HPV vaccination
- B. Interferon therapy
- C. Continue conservative management with topical imiquimod
- D. Wide surgical excision with histopathological examination (Correct Answer)
Explanation: ***Wide surgical excision with histopathological examination*** - This is the most appropriate management due to the **extensive, treatment-resistant perianal condyloma acuminata** in an **HIV-positive patient with HPV type 16**, which carries a higher risk of **malignant transformation**. - **Surgical excision** allows for complete removal of the lesions and provides tissue for **histopathological examination** to rule out **dysplasia or squamous cell carcinoma**. *HPV vaccination* - While important for prevention, **HPV vaccination** is generally less effective as a primary treatment for **established, extensive lesions**, especially with existing infection. - It primarily aims to prevent new infections and may have some benefit in preventing recurrence, but it won't resolve the current burden of disease. *Interferon therapy* - **Interferon therapy** can be used for severe, recurrent, or difficult-to-treat warts, but its efficacy is variable and generally considered a **second-line or adjunctive treatment**. - Given the patient's **immunosuppressed status** and **resistance to conventional treatments**, a more definitive approach is needed. *Continue conservative management with topical imiquimod* - The patient has already demonstrated **resistance to conventional treatments**, suggesting that continued topical therapy with **imiquimod** is unlikely to be effective. - In an HIV-positive individual with **extensive lesions and high-risk HPV type 16**, waiting for a response to conservative therapy could delay definitive management and potentially increase the **risk of malignant progression**.
Question 10: Which of the following is most radiosensitive tumor?
- A. Medulloblastoma (Correct Answer)
- B. Teratoma
- C. Craniopharyngioma
- D. Astrocytoma
Explanation: ***Medulloblastoma*** - **Medulloblastomas** are highly radiosensitive tumors, meaning they are very responsive to **radiation therapy**. - They originate in the **cerebellum** and are often treated with craniospinal irradiation. *Teratoma* - **Teratomas** contain a variety of tissues from all three germ layers and have variable radiosensitivity depending on their composition. - Mature teratomas are generally **radioresistant**, while immature teratomas can be more sensitive, but typically less so than medulloblastomas. *Craniopharyngioma* - **Craniopharyngiomas** are benign tumors that are generally less radiosensitive than medulloblastomas. - While radiation therapy can be part of their treatment, they often require **surgical resection** due to their location near vital structures. *Astrocytoma* - The radiosensitivity of **astrocytomas** varies significantly with their grade; low-grade astrocytomas are generally less radiosensitive. - High-grade astrocytomas (e.g., glioblastoma) are often treated with radiation, but their overall prognosis remains challenging due to their infiltrative nature and inherent **radioresistance** compared to medulloblastomas.
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free