UPSC-CMS 2018 - Surgery Practice Questions

Q: Indication of Coronary artery bypass grafting (CABG) is:

Triple vessel disease. ***Triple vessel disease*** - **Triple vessel disease** (significant stenosis in all three major coronary arteries: LAD, LCx, and RCA) is a **Class I indication for CABG** with the highest level of evidence. - CABG provides **superior long-term outcomes** compared to PCI in triple vessel disease, with better survival rates, reduced need for repeat revascularization, and more complete revascularization. - This is particularly true in patients with **diabetes** or **reduced LV function**. *More than 70% stenosis of proximal left anterior interventricular artery* - While **proximal LAD stenosis >70%** can be treated with CABG (Class IIa indication), it is often managed successfully with **PCI** (drug-eluting stents). - The choice between CABG and PCI for isolated proximal LAD disease depends on anatomy, patient comorbidities, and surgical risk factors. *More than 50% stenosis of critical left main stem* - **Left main coronary artery stenosis >50%** is actually a **Class I indication for CABG** per ACC/AHA and ESC/EACTS guidelines. - However, in the context of this question comparing multiple scenarios, **triple vessel disease** represents a more universally accepted and broader indication with the strongest evidence base for CABG superiority over PCI. - Modern guidelines do allow PCI for selected left main cases (low SYNTAX score, ostial/shaft lesions), whereas triple vessel disease more consistently favors CABG. *Deranged Stress Echocardiography report* - A **positive stress echocardiography** indicates inducible myocardial ischemia but is a **diagnostic finding**, not a specific indication for the revascularization method. - Further evaluation with **coronary angiography** is required to determine the anatomical extent of CAD and guide the choice between CABG, PCI, or medical management.

Q: Which one of the following is NOT correct regarding Adenocarcinoma of the kidney ?

It always presents with haematuria. ***It always presents with haematuria*** - This statement is incorrect because **renal cell carcinoma** (adenocarcinoma of the kidney) often remains asymptomatic until a late stage, meaning **hematuria** is not always present, especially in early disease [1]. - While hematuria is a common symptom in later stages, occurring in about 60% of cases, its absence does not rule out the diagnosis, and many tumors are found incidentally [1]. *It may be associated with Pyrexia of unknown origin* - **Renal cell carcinoma** can produce various paraneoplastic syndromes, including **pyrexia of unknown origin (PUO)** [2]. - The tumor may release **pyrogenic cytokines** that lead to unexplained fever, making this a recognized systemic manifestation. *Renal vein extention may embolize to lungs* - **Renal cell carcinoma** has a propensity to invade the **renal vein** and extend into the inferior vena cava. - Tumor thrombi can then break off and travel to the lungs, resulting in **pulmonary embolism** of tumor cells or even macroscopic tumor emboli. *It is also called Grawitz tumour* - **Grawitz tumor** is an older, historical term used to refer to **renal cell carcinoma**, particularly the clear cell subtype. - This name originated from Paul Grawitz, who first described the tumor's histological features.

Q: Which one of the following regarding abdominal pediatric surgery is correct?

Incision can be closed with absorbable suture. ***Incision can be closed with absorbable suture*** - **Absorbable sutures** are commonly used in pediatric abdominal surgery for closing deeper layers and sometimes skin, as they degrade over time and do not require removal. - This is particularly beneficial in children to avoid the trauma and discomfort of suture removal and to promote good cosmetic outcomes. *Transverse abdominal incision is always used* - While **transverse incisions** are often preferred in pediatric abdominal surgery for their good cosmetic results and lower incidence of incisional hernias, they are not *always* used. - Other incisions, such as **vertical midline incisions**, may be utilized depending on the surgical exposure required, the specific pathology, or the surgeon's preference. *Bowel must be always anastomosed in double layer* - **Bowel anastomoses** in pediatric surgery can be performed using either a **single-layer** or **double-layer** technique. - The choice depends on surgeon preference, the specific bowel segment involved, and the patient's condition, with both methods demonstrating comparable outcomes in many situations. *Skin over abdomen can never be closed with subcuticular sutures* - **Subcuticular sutures** are frequently used for skin closure in pediatric abdominal surgery, especially for their excellent cosmetic results and to avoid external suture removal. - This technique places the suture material under the skin surface, minimizing scarring and being well-suited for a child's healing skin.

Q: Allen's test is used in cardiac surgery for:

When radial artery harvest is planned. ***When radial artery harvest is planned*** - **Allen's test** is performed to assess the patency of the **ulnar artery** and ensure adequate collateral circulation to the hand before harvesting the radial artery. - A positive test (indicating good collateral flow) is crucial to prevent **hand ischemia** if the radial artery is removed. *To select finger prick for blood glucose estimation* - Finger prick sites for **blood glucose estimation** are chosen based on adequate capillary blood flow and patient comfort, not by Allen's test. - Allen's test is specifically for evaluating **arterial patency** and collateral circulation, which is irrelevant for routine fingersticks. *To check warmth of hands* - Checking the **warmth of hands** is a basic clinical assessment for peripheral perfusion but does not involve Allen's test. - Allen's test is a dynamic test of **vascular competence**, not a static thermal assessment. *For evaluation of AV fistula* - **AV fistula evaluation** involves assessing patency, thrill, and bruit, and is typically done using physical examination and Doppler ultrasound. - Allen's test is not used for this purpose, as it assesses **collateral arterial flow** to a digit, not the patency of an arteriovenous connection.

Q: In a lateral facial wound, if facial nerve injury is suspected, it should be:

Primary repair should be attempted. ***Primary repair should be attempted*** - **Early surgical repair** of facial nerve injuries, ideally within the first 72 hours, offers the best chance for **functional recovery**. - **Primary repair** involves direct reapproximation and meticulous suturing of the severed nerve ends under magnification. *Left alone* - Leaving a suspected facial nerve injury untreated can lead to **permanent facial paralysis** and significant functional and aesthetic deficits. - The facial nerve has a limited capacity for spontaneous regeneration, especially after a **complete transection**. *Secondary repair using microscope gives best result* - While microscopic techniques are crucial for nerve repair, **secondary repair** (performed weeks or months after the injury) generally yields poorer outcomes compared to primary repair. - **Scar tissue formation** and **nerve end retraction** make secondary repair more challenging and less effective. *Skin and subcutaneous flaps to be raised to cover the cut ends* - This approach addresses wound closure but **does not repair the underlying nerve injury**, leading to persistent motor deficits. - Covering the nerve ends without repair would still result in **facial paralysis** as the nerve fibers cannot reconnect across the gap.

Q: Mallory-Weiss tear causing haematemesis is seen over:

Gastroesophageal junction. ***Gastroesophageal junction*** - Mallory-Weiss tears are **linear mucosal lacerations** typically located at the **gastroesophageal junction**, where the esophagus meets the stomach. - These tears are caused by sudden increases in **intra-abdominal pressure**, often due to forceful retching or vomiting, leading to bleeding. *Oesophagus* - While located close, Mallory-Weiss tears are specifically at the **junction**, not generally throughout the esophageal body. - **Esophageal varices** are a more common cause of hematemesis originating from the esophagus itself, distinct from Mallory-Weiss tears. *Anterior wall of stomach* - Tears in the anterior wall of the stomach are less common and typically associated with other conditions like **ulcers** or **trauma**, not the characteristic forceful vomiting seen in Mallory-Weiss syndrome. - The unique anatomical stress at the **gastroesophageal junction** during retching makes it the preferred site for Mallory-Weiss lacerations. *Fundus of stomach* - Tears in the fundus are rare in the context of Mallory-Weiss syndrome; the fundus is usually affected by other conditions such as **gastric ulcers** or **gastric varices**. - The biomechanical forces that cause Mallory-Weiss tears are concentrated where the **esophageal and gastric mucosa meet**, not primarily in the fundus.

Q: Sleeve Gastrectomy done for Morbid obesity is a:

Restrictive procedure. ***Restrictive procedure (Correct Answer)*** - A **sleeve gastrectomy** involves removing a large portion of the stomach (approximately 75-80%), leaving a banana-shaped "sleeve," which significantly **reduces stomach volume**. - This reduction in volume **restricts** the amount of food a patient can consume at one time, leading to early satiety and weight loss. - It is classified as a **purely restrictive** bariatric procedure. *Mildly restrictive and mainly malabsorptive* - While there is some malabsorption due to faster gastric emptying, the primary mechanism of weight loss in sleeve gastrectomy is **restriction**, not malabsorption. - Procedures like **Roux-en-Y gastric bypass** are considered both restrictive and malabsorptive. *Reversible procedure* - Sleeve gastrectomy involves the **irreversible removal** of a significant part of the stomach. - Unlike devices like the **adjustable gastric band**, it cannot be undone or reversed. *Malabsorptive procedure only* - Sleeve gastrectomy does not significantly alter the **intestinal tract** to cause malabsorption. - Procedures that are primarily **malabsorptive**, such as **biliopancreatic diversion with duodenal switch**, involve bypassing large sections of the small intestine.

Q: Pre-operative Nutrition Screening in a patient with morbid obesity planned for Gastric Bypass includes all EXCEPT:

Serum Insulin. ***Serum Insulin*** - While relevant to **diabetes** and metabolic health, routine **pre-operative insulin screening** is not standard for gastric bypass. - Nutritional screening focuses on identifying and correcting deficiencies that could complicate surgery or post-operative recovery. *Serum Vitamin B12* - Patients undergoing **gastric bypass** are at high risk for **Vitamin B12 deficiency** due to altered absorption in the bypassed stomach and small intestine. - Pre-operative screening is essential to identify and replete deficiencies to prevent post-operative neurological complications. *Serum Calcium* - **Malabsorption of calcium** is a known risk after gastric bypass due to changes in the digestive tract. - Pre-operative **calcium levels** are crucial for bone health assessment and to guide supplementation strategies. *Serum Magnesium* - **Magnesium deficiency** can occur post-gastric bypass due to malabsorption. - Pre-operative screening helps to identify existing deficiencies, which can impact cardiac function and neuromuscular health.

Q: In postoperative care the long term risks after Bariatric Surgery include all EXCEPT:

Deep Vein Thrombosis. ***Deep Vein Thrombosis*** - Deep Vein Thrombosis (DVT) is a significant **short-term (early) complication** of bariatric surgery, primarily in the **immediate postoperative period**, due to immobility and hypercoagulability. - While prophylaxis is crucial, DVT is not typically considered a **long-term risk** that persists for years after surgery. *Vitamin and Micronutrient depletion syndromes* - Bariatric surgery procedures, especially those involving malabsorption (e.g., Roux-en-Y gastric bypass), can lead to chronic deficiencies in **fat-soluble vitamins (A, D, E, K)**, **B12**, **iron**, and **calcium** due to altered absorption. - These depletion syndromes are a well-documented **long-term risk** requiring lifelong supplementation and monitoring. *Weight regain* - Despite initial significant weight loss, a substantial number of patients experience some degree of **weight regain** in the long term, typically peaking 2-5 years post-surgery. - This is a common and critical **long-term risk** that often necessitates ongoing lifestyle modifications and monitoring. *Protein Calorie Malnutrition* - Certain bariatric procedures (e.g., biliopancreatic diversion with duodenal switch) can lead to severe **malabsorption of protein and calories**, resulting in protein-calorie malnutrition (PCM). - PCM is a serious and persistent **long-term risk** that requires careful dietary management and sometimes additional medical interventions.

Q: Hilton's method of Incision and drainage of abscess has the advantage of:

Avoids injury to underlying vessels and nerves. ***Avoids injury to underlying vessels and nerves*** - Hilton's method involves blunt dissection with an artery forceps once the skin incision is made, allowing the surgeon to **feel important structures** and push them aside. - This technique is particularly useful in areas with **numerous neurovascular bundles**, such as the axilla or neck, minimizing the risk of iatrogenic damage. *Complete drainage of pus* - While Hilton's method facilitates drainage, it doesn't inherently guarantee **complete drainage** more than other proper incision and drainage techniques. - The effectiveness of drainage primarily depends on the **size and location of the incision** relative to the abscess cavity. *Heals without scar* - Any surgical incision, including those made using Hilton's method, will result in some degree of **scar formation**. - The method prioritizes safety over cosmetic outcomes, and the nature of the scar depends on **wound healing** and **surgical closure**. *Provides irrigation* - Irrigation is a separate step often performed after the incision and drainage to **flush out debris** and reduce bacterial load. - Hilton's method itself is a technique for making the incision and gaining access to the abscess, not for **intraoperative irrigation**.

Question 1

Indication of Coronary artery bypass grafting (CABG) is:

Accepted Answer

Triple vessel disease

Answer

More than 70% stenosis of proximal left anterior interventricular artery

Answer

More than 50% stenosis of critical left main stem

Answer

Deranged Stress Echocardiography report

Question 2

Which one of the following is NOT correct regarding Adenocarcinoma of the kidney ?

Accepted Answer

It always presents with haematuria

Answer

It may be associated with Pyrexia of unknown origin

Answer

Renal vein extention may embolize to lungs

Answer

It is also called Grawitz tumour

Question 3

Which one of the following regarding abdominal pediatric surgery is correct?

Accepted Answer

Incision can be closed with absorbable suture

Answer

Transverse abdominal incision is always used

Answer

Bowel must be always anastomosed in double layer

Answer

Skin over abdomen can never be closed with subcuticular sutures

Question 4

Allen's test is used in cardiac surgery for:

Accepted Answer

When radial artery harvest is planned

Answer

To select finger prick for blood glucose estimation

Answer

To check warmth of hands

Answer

For evaluation of AV fistula

Question 5

In a lateral facial wound, if facial nerve injury is suspected, it should be:

Accepted Answer

Primary repair should be attempted

Answer

Left alone

Answer

Secondary repair using microscope gives best result

Answer

Skin and subcutaneous flaps to be raised to cover the cut ends

Question 6

Mallory-Weiss tear causing haematemesis is seen over:

Accepted Answer

Gastroesophageal junction

Answer

Oesophagus

Answer

Anterior wall of stomach

Answer

Fundus of stomach

Question 7

Sleeve Gastrectomy done for Morbid obesity is a:

Accepted Answer

Restrictive procedure

Answer

Mildly restrictive and mainly malabsorptive

Answer

Reversible procedure

Answer

Malabsorptive procedure only

Question 8

Pre-operative Nutrition Screening in a patient with morbid obesity planned for Gastric Bypass includes all EXCEPT:

Accepted Answer

Serum Insulin

Answer

Serum Vitamin B12

Answer

Serum Calcium

Answer

Serum Magnesium

Question 9

In postoperative care the long term risks after Bariatric Surgery include all EXCEPT:

Accepted Answer

Deep Vein Thrombosis

Answer

Vitamin and Micronutrient depletion syndromes

Answer

Weight regain

Answer

Protein Calorie Malnutrition

Question 10

Hilton's method of Incision and drainage of abscess has the advantage of:

Accepted Answer

Avoids injury to underlying vessels and nerves

Answer

Complete drainage of pus

Answer

Heals without scar

Answer

Provides irrigation

UPSC-CMS 2018 — Surgery