INI-CET 2026 - Surgery Practice Questions

Q: A prostatic biopsy report reveals a Gleason score of 8 (4 + 4). What is the corresponding Grade Group classification of this tumor?

Grade Group 4. ***Grade Group 4*** - The current **Grade Group** system for prostate cancer consolidates Gleason scores into five groups; a **Gleason score of 8** corresponds directly to **Grade Group 4**. - The **International Society of Urological Pathology (ISUP)** developed this system to simplify prognosis and clinical decision-making based on biopsy specimens. *Grade Group 2* - This grade group refers to a **Gleason score of 3 + 4 = 7**. - It represents a **favorable intermediate-risk** tumor with 3 as the primary pattern. *Grade Group 3* - This classification corresponds to a **Gleason score of 4 + 3 = 7**. - It indicates a higher risk profile than Group 2, as the **predominant pattern is 4**. *Grade Group 5* - This group is assigned to **Gleason scores 9 and 10**. - It represents the most aggressive tumors with the highest potential for **distant metastasis** and poorer prognosis.

Q: A 55-year-old patient presents to the emergency department with abdominal pain, distension, and vomiting. Imaging confirms a diagnosis of cecal volvulus. Which of the following risk factors is responsible for 50-70% of cecal volvulus cases?

Previous abdominal surgery. ***Previous abdominal surgery*** - **Previous abdominal surgery** is the most common predisposing factor for cecal volvulus, as resulting **adhesions** create a fixed point around which the cecum can twist. - Between 50% and 70% of patients diagnosed with this condition have a history of prior operative procedures on the abdomen. *High-fiber diet* - While high fiber intake can influence bowel motility, it is not a primary established risk factor for the mechanical torsion seen in a volvulus. - Dietary factors are generally more associated with conditions like diverticulosis rather than volvulus formation. *Lactulose abuse* - Lactulose administration can cause bowel distension and gas but is not a recognized direct cause of anatomic volvulus. - It is typically used for hepatic encephalopathy or constipation and has no documented link to the high incidence rates requested. *Female sex* - While age and certain anatomical variations may correlate, female sex is not the causative risk factor responsible for the majority of cases. - Cecal volvulus is frequently associated with a congenital **hypermobile cecum** (lack of peritoneal attachment), which is an anatomical predisposition rather than gender-dependent.

Q: A 65-year-old male with diabetes mellitus presents with purulent rectal discharge and is diagnosed with fistula-in-ano. Surgical management is planned. Which of the following procedures is considered internal anal sphincter-preserving?

Fistulectomy. ***Fistulectomy*** - A **fistulectomy** involves the complete excision of the **fistula tract** from its internal to its external opening, sparing the surrounding healthy **anal sphincter complex** when performed correctly. - It is the traditional standard for simple, low-lying **fistulae-in-ano** where the sphincter muscle involvement is minimal or superficial, thus preserving continence. *LIFT (Ligation of Intersphincteric Fistula Tract)* - The **LIFT** procedure is specifically designed to isolate and ligate the fistula tract in the **intersphincteric plane**. - While it preserves the sphincter, it is distinct from a formal **fistulectomy** and is often used for complex or **transphincteric fistulas** to avoid sphincter division. *FiLaC (Fistula-tract Laser Closure)* - **FiLaC** is a minimally invasive, sphincter-sparing technique that uses a **radial laser probe** to destroy the epithelial lining of the fistula tract. - It promotes healing of the tract from the inside out without requiring the division or excision of the **anal sphincter** muscles. *VAAFT (Video-Assisted Anal Fistula Treatment)* - **VAAFT** utilizes an **endoscope** (fistuloscope) to visualize the tract and fulgurate it under direct vision. - This procedure allows for the identification of lateral tracts and abscess cavities while strictly preserving the **anal sphincter** integrity.

Q: Which of the following clinical features best distinguishes mechanical small bowel obstruction from paralytic ileus?

Colicky abdominal pain. ***Colicky abdominal pain*** - In **mechanical small bowel obstruction (SBO)**, the bowel proximal to the obstruction undergoes vigorous peristaltic contractions in an attempt to overcome the lumen blockage, resulting in characteristic **high-pitched** and periodic **colicky pain**. - Conversely, a **paralytic ileus** is marked by a complete cessation of peristaltic activity due to neurogenic or myogenic failure, resulting in an abdomen that is typically silent, without the peristaltic rushes that cause severe colicky pain. *Tachycardia* - **Tachycardia** is a non-specific sign and a common clinical finding in both **mechanical SBO** and **paralytic ileus**, often secondary to dehydration, electrolyte imbalances, or systemic distress. - Because it can occur in both conditions as a result of hypovolemia or metabolic disturbance, it does not serve as a reliable differentiating feature. *Vomiting* - **Vomiting** is a hallmark symptom of both conditions, occurring as bowel contents accumulate proximal to the obstruction or as the gut fails to propel contents forward in an ileus. - While the severity may vary based on the level of obstruction, it does not reliably distinguish between the two entities on its own. *Abdominal distension* - **Abdominal distension** is a generalized sign of both **SBO** and **paralytic ileus**, occurring as air and fluid accumulate within the non-propulsive or obstructed bowel segments. - It is a common clinical finding in any setting of bowel dysfunction and cannot be used to differentiate the mechanical cause from the functional motility failure of an ileus.

Q: A patient is planned for elective colon surgery. What is the ideal timing for administration of prophylactic parenteral antibiotics?

1 hour before skin incision. ***1 hour before skin incision*** - Administering prophylactic antibiotics within **60 minutes** prior to the initial incision ensures adequate **tissue concentration** at the time of potential bacterial contamination. - Giving the dose too early risks the drug level dropping before the surgery begins, while giving it too late fails to protect during the highest risk period. *30 minutes before surgery* - While this timing falls within the acceptable window, it is not the **optimal** or widely recommended target compared to the 60-minute benchmark. - Depending on the specific antibiotic (e.g., **vancomycin** or **fluoroquinolones**), 30 minutes may not be sufficient for full infusion prior to incision. *2 hours before surgery* - Administering antibiotics 2 hours preoperatively significantly increases the risk that peak **serum levels** will be missed during the critical window of contamination. - Prolonged time intervals prior to incision are associated with higher rates of **surgical site infections (SSIs)**. *4 hours before surgery* - This duration is far too early; the drug will likely be cleared or metabolized below the **minimum inhibitory concentration (MIC)** required to prevent infection by the time the incision is made. - Prolonged preoperative administration does not provide additional benefit and may contribute unnecessarily to **antibiotic resistance**.

Q: A young patient presents with recurrent fever and constitutional symptoms. Evaluation reveals a mediastinal mass and biopsy confirms lymphoma. In the staging system, 'X' is mentioned. What does 'X' denote?

Bulky or large tumor mass. ***Bulky or large tumor mass*** - In the Ann Arbor staging system for lymphoma, the suffix **'X'** is utilized to denote a **bulky disease**. - This is defined as a mass greater than **10 cm** in maximum dimension or a mass that occupies more than one-third of the **transthoracic diameter** on a chest radiograph. *Extranodal spread of disease* - The suffix **'E'** is used to designate **extranodal involvement**, indicating localized extralymphatic tissue disease adjacent to a known lymph node site. - This does not refer to the size of the tumor mass, but rather the anatomical location of the disease process. *Presence of systemic symptoms* - The suffixes **'A'** (absence) and **'B'** (presence) are used to indicate the status of **systemic symptoms** like fever, night sweats, and significant weight loss. - These are known as **'B' symptoms** and are crucial for prognosis, but they do not relate to the anatomical size of the tumor. *Tumor present on both sides of the diaphragm* - This finding is represented by the stage **Stage III** designation in the Ann Arbor classification. - It describes the **anatomic extent** of the disease geographically rather than the specific tumor burden or bulk.

Q: In which type of constipation are stimulant laxatives contraindicated or should be avoided?

Spastic constipation. ***Spastic constipation*** - In this condition, the bowel hyperactivates causing **painful spasms** and cramping; therefore, **stimulant laxatives** are contraindicated as they increase peristalsis and worsen the spasm. - Management typically involves **antispasmodics** and dietary adjustments rather than motility-enhancing agents. *Habitual constipation* - This type results from poor dietary habits and ignoring the urge to defecate, often requiring **lifestyle modifications** such as increased fiber and fluid intake. - Mild stimulant laxatives may sometimes be used as a last resort, but they are not the primary treatment of choice. *Atonic constipation* - This presents with a **hypotonic colon** characterized by sluggish motility, where stimulant laxatives can be beneficial to promote movement. - It is often associated with aging, chronic laxative abuse, or neurological disorders where the bowel lacks the tone to propel contents. *Post-operative constipation* - Often caused by **anesthesia** or **post-surgical ileus**, which requires careful management of intestinal motility. - While caution is advised to prevent bowel perforation, stimulant laxatives are sometimes cautiously used if there is no evidence of obstruction.

Q: A 40-year-old female with progressive left flank pain, no mass or fever. What is the next best step?

Ultrasound followed by non-contrast CT. ***Ultrasound followed by non-contrast CT*** - In a non-pregnant patient with classic symptoms of suspected **urolithiasis** (flank pain without systemic signs of infection), initial imaging often involves low-dose **non-contrast CT (NCCT)** of the abdomen and pelvis as the study of choice, - However, to minimize radiation exposure in appropriate clinical settings, an initial **ultrasound** can identify hydronephrosis; if the diagnosis remains uncertain or if complications are suspected, a **non-contrast CT** remains the gold standard to pinpoint stone size and location. *CECT followed by MRI* - **Contrast-enhanced CT (CECT)** is not typically indicated as the first step for suspected kidney stones because intravenous contrast can obscure small stones on the scan. - **MRI** is generally reserved for special populations like pregnant patients or those where radiation must be strictly avoided, and it is not the primary diagnostic tool for stone detection. *Contrast-enhanced CT abdomen* - **Intravenous contrast** is not required to diagnose nephrolithiasis and may actually make stones harder to visualize, as iodine density can mimic stone high-density appearance. - This study is more appropriate if one is ruling out vascular abnormalities, complex masses, or bowel pathology, rather than evaluating for uncomplicated flank pain. *Non-contrast CT followed by contrast CT* - An initial **non-contrast CT** is sufficient to diagnose most cases of nephrolithiasis; performing a follow-up **contrast CT** exposes the patient to unnecessary, excessive radiation and contrast-related risks. - **Contrast enhancement** should only be added if there is a suspicion of alternative pathologies (like complex cysts, tumors, or renal infarction) after the initial NCCT results are reviewed.

Question 1

A prostatic biopsy report reveals a Gleason score of 8 (4 + 4). What is the corresponding Grade
Group classification of this tumor?

Accepted Answer

Grade Group 4

Answer

Grade Group 2

Answer

Grade Group 3

Answer

Grade Group 5

Question 2

A 55-year-old patient presents to the emergency department with abdominal pain, distension,
and vomiting. Imaging confirms a diagnosis of cecal volvulus. Which of the following risk factors is
responsible for 50-70% of cecal volvulus cases?

Accepted Answer

Previous abdominal surgery

Answer

High-fiber diet

Answer

Lactulose abuse

Answer

Female sex

Question 3

A 65-year-old male with diabetes mellitus presents with purulent rectal discharge and is
diagnosed with fistula-in-ano. Surgical management is planned. Which of the following procedures
is considered internal anal sphincter-preserving?

Accepted Answer

Fistulectomy

Answer

LIFT

Answer

FiLaC

Answer

VAAFT

Question 4

Which of the following clinical features best distinguishes mechanical small bowel obstruction
from paralytic ileus?

Accepted Answer

Colicky abdominal pain

Answer

Tachycardia

Answer

Vomiting

Answer

Abdominal distension

Question 5

A patient is planned for elective colon surgery. What is the ideal timing for administration of
prophylactic parenteral antibiotics?

Accepted Answer

1 hour before skin incision

Answer

30 minutes before surgery

Answer

2 hours before surgery

Answer

4 hours before surgery

Question 6

A young patient presents with recurrent fever and constitutional symptoms. Evaluation reveals a
mediastinal mass and biopsy confirms lymphoma. In the staging system, 'X' is mentioned. What
does 'X' denote?

Accepted Answer

Bulky or large tumor mass

Answer

Extranodal spread of disease

Answer

Presence of systemic symptoms

Answer

Tumor present on both sides of the diaphragm

Question 7

In which type of constipation are stimulant laxatives contraindicated or should be avoided?

Accepted Answer

Spastic constipation

Answer

Habitual constipation

Answer

Atonic constipation

Answer

Post-operative constipation

Question 8

A 40-year-old female with progressive left flank pain, no mass or fever. What is the next best
step?

Accepted Answer

Ultrasound followed by non-contrast CT

Answer

CECT followed by MRI

Answer

Contrast-enhanced CT abdomen

Answer

Non-contrast CT followed by contrast CT

Question 9

Assertion (A): In a patient with scrotal swelling, examination of the superficial inguinal lymph
nodes should always be performed. Reason (R): Most lymphatic drainage from scrotal skin goes to
the superficial inguinal lymph nodes. Choose the correct option:

Accepted Answer

Both A and R are true, and R is the correct explanation of A

Answer

Both A and R are true, but R is not the correct explanation of A

Answer

A is true, but R is false

Answer

A is false, but R is true

INI-CET 2026 — Surgery