Free Questions

Free MCQs in Surgery

Facial nerve pointers

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Q) What is the most consistent anatomical landmark of the facial nerve?

A) Anterior border of the posterior belly of the digastric muscle.
B) Posterior border of the posterior belly of the digastric muscle.
C) Superior border of the posterior belly of the digastric muscle.
D) Inferior border of the posterior belly of the digastric muscle.

Ans C) Superior border of the posterior belly of the digastric muscle.

Why This Landmark Matters: The superior aspect of the posterior belly of the digastric muscle serves as a reliable intraoperative landmark for locating the facial nerve. Understanding this landmark can enhance surgical precision and reduce complications.

Key Anatomical Landmarks for Facial Nerve Identification:

  1. Posterior Belly of the Digastric Muscle:
    • The facial nerve is located about 2 to 4 mm inferior to the tympanomastoid suture line, making the superior border of the posterior belly a consistent guide.
  2. Tragal “Pointer” (of Conley):
    • The tragal cartilage, found in front of the ear, provides a helpful reference. The facial nerve lies approximately 1 cm deep, slightly anterior and inferior to this point, making it an essential landmark during dissection.
  3. Tendon of the Posterior Belly of the Digastric Muscle:
    • The attachment of the digastric muscle to the mastoid bone conceals the facial nerve about 1 cm deep. Careful dissection in this area is crucial to uncover this hidden structure.
  4. Tympanomastoid Suture/Fissure:
    • This area within the temporal bone marks another critical point for identifying the facial nerve, which is situated about 6-8 mm deep.
  5. Styloid Process:
    • Located laterally to the styloid process, the facial nerve resides in proximity, making it a significant marker during surgical approaches.

Conclusion: Understanding the superior border of the posterior belly of the digastric muscle as the most consistent anatomical landmark of the facial nerve is essential for safe surgical practice. Mastering these landmarks not only enhances surgical outcomes but also promotes patient safety.

Ivor Lewis Esophagectomy leak

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Q)  After Ivor Lewis esophagectomy, on postoperative day 5 (POD 5), bile is seen in the chest tube.

The patient presents with a heart rate of 120 bpm, a temperature of 101°F, and blood pressure of 100/70 mmHg. What is the next appropriate step in management?

 a) Stenting
b) Colonic replacement of gastric conduit
c) IV antibiotics
d) Conduit excision and esophageal diversion

Correct Answer: d) Conduit excision and esophageal diversion

In patients who develop a completely necrotic conduit post-esophagectomy, the risk of sepsis is high. These patients often require urgent surgical intervention. Upon confirming conduit necrosis, the conduit must be resected, and the patient should undergo diversion, which includes:

  • End esophagostomy
  • Venting gastrostomy
  • Feeding jejunostomy

It is crucial to maintain as much length of the remaining esophagus as possible to facilitate future reconstructive procedures.

Key Points:

  • Postoperative Day 5: Critical time for monitoring complications after esophagectomy.
  • Symptoms of Concern: Tachycardia, fever, and hypotension may indicate sepsis or other complications.
  • Surgical Intervention: Timely recognition and management are vital for patient outcomes.

For further reading, refer to Schakelford’s Surgical Anatomy of the Gastrointestinal Tract.

Schakelford page 477

Lung cancer

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Q) A 73 year male, old heavy smoker presents with haemoptysis.

On examination he is cachectic and shows evidence of clubbing. Imaging shows a main bronchial tumour with massive mediastinal lymphadenopathy together with widespread visceral metastases.

Which of the following variant is likely in him?

( Theme from mock test 12- 24) 

a)  Adenocarcinoma
B.  Small cell lung cancer
C. Large cell lung cancer
D. Squamous cell carcinoma

  • Patient: 73-year-old male, heavy smoker
  • Symptoms: Hemoptysis, cachexia, clubbing
  • Imaging: Main bronchial tumor with massive mediastinal lymphadenopathy and widespread visceral metastases

Likely Variant:

B. Small cell lung cancer (SCLC) is the most likely diagnosis.

Rationale:

  • Small Cell Lung Cancer: This type of cancer is strongly associated with heavy smoking and is characterized by aggressive behavior and early metastasis. Most patients present with disseminated disease, as seen in this case.
  • Clinical Features: The combination of hemoptysis, cachexia, and clubbing aligns well with SCLC, which can also lead to various paraneoplastic syndromes.
  • Other Tumors:
    • Adenocarcinoma: More common in never smokers and typically peripheral, not fitting the profile here.
    • Squamous Cell Carcinoma: Generally grows slower and is also typically centrally located, but not usually associated with such widespread metastasis at presentation.
    • Large Cell Lung Cancer: While it can be aggressive, it’s less commonly associated with extensive lymphadenopathy and visceral metastases compared to SCLC.

Thyroid storm

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Q) 40 year old lady was on anti thyroid medications which she stopped for 2 weeks.

She presented in emergency with high grade fever and hypotension. ( Thyroid Storm) .

What is not a part of further management?

a) Oxygen

b) Beta blockers

c) Radio active Iodine

d) Lugol's idodine

Thyroid MCqs

Ans c

Explanation:
In the management of a thyroid storm, radioactive iodine (RAI) is not used. RAI is a predisposing factor for thyroid storm, not a treatment. The management includes beta blockers, oxygen and hemodynamic support, IV Lugol iodine, PTU (propylthiouracil), and corticosteroids.

Grades of Splenic Injury – Image based Question

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Q) 45 year old male with road side accident and fracture of 3 ribs on left side.

CT scan of the abdomen is shown below. Out of the five grades of splenic injury What is the grade  in him ?

Splenic Injury grades

 

 

 

 

 

a) Grade II

b) Grade III

c) Grade IV

d) Grade V 

Take the practice MCQ tests  ( Some are free). Others are for Premium Members

Take the free image based mock test 

Ans b Grade III

Grade 1
Subcapsular haematoma <10% of surface area
Parenchymal laceration <1 cm depth Capsular tear
Grade 2
Subcapsular haematoma 10–50% of surface area; Intraparenchymal haematoma <5 cm
Parenchymal laceration 1–3 cm
Grade 3
Subcapsular haematoma >50% surface area; ruptured subcapsular or intraparenchymal haematoma ≥5 cm Parenchymal laceration >3 cm depth
Grade 4
Any injury in the presence of a splenic vascular
injury or active bleeding confned within the splenic
capsule
Parenchymal laceration involving segmental or hilar
vessels producing >25% devascularisation
Grade 5
Any injury in the presence of splenic vascular injurya
with active bleeding extending beyond the spleen
into the peritoneum – shattered spleen
Vascular injury is defined as a pseudoaneurysm or arteriovenous fistula and appears as a focal collection of vascular contrast that decreases in attenuation with delayed imaging.
Active bleeding from a vascular injury presents as vascular contrast, focal or diffuse, that
increases in size or attenuation in the delayed phase

THE vs TTE

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Q) Trans Hiatal Esophagectomy ( THE)  vs Trans Thoracic Esophagectomy ( TTE)  which is not true? ( Question asked in all AIIMS and INI exams since 2017) 

a) Leak rates are more with TTE 

b) Pulmonary complication is more with TTE

c) Side to side stapler anastomosis has less leaks than open two layer suturing

d) THE can be done through minimally invasive surgery

Esophagus Mock test  1

Esophagus Mock test 2 

Ans c

Pulmonary complications  are 57% with TTE 27% with  THE  ( SKF 409)

Anastomotic leak 16% TTE and 14% THE ( not significant) subclinical leak slightly more in THE

Option D is correct

Cardiac complications, Vocal cord paralysis , wound infection, chyle leak are all more with TTE

Blackmon et al. published a propensity-matched analysis comparing outcomes between side-to-side stapled anastomosis, end-to-end circular stapled anastomosis, and handsewn,
with no significant difference in leak rate noted.  ( SKF page 475)

SKF page 409

Ulcerative colitis Surgery in Young female

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Q) Which surgery would be preferred to be done in young unmarried  female with steroid refractory Ulcerative colitis  and 15 bloody bowel movements per day?

a) TPC with IPAA

b) TPC with EI ( end ileostomy) 

c) TAC with EI ( end ileostomy) 

d) TAC with IRA ( Ileo rectal anastomosis)

#AIIMS 2022 April 

Ans b

The risk of infertility following IPAA was estimated to be approximately 50% compared with 15% among medically treated patients.
Given these data, many surgeons advocate for a three-stage procedure in which subtotal colectomy with end ileostomy is performed and IPAA is deferred until childbearing is
completed.

Medullary thyroid cancer – Management

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Q) 42 year old Male patient with 1 cm nodule in Right side of Thyroid.

Biopsy shows medullary carcinoma. No neck nodes are seen on USG. What is the management

a) Total thyroidectomy

b) Total thyroidectomy with central node dissection

c) Total thyroidectomy with lateral and central neck dissection

d) Right hemithyroidectomy

Thyroid MCQs 

Thyroid Mock test 1 

Thyroid Mock test 2 

Thyroid 3 

Ans b 

Medullary thyroid carcinoma is associated with a risk of nodal involvement, even if neck nodes are not visible on ultrasound. A total thyroidectomy is recommended to remove the affected thyroid tissue, and central neck dissection is indicated to address potential lymphatic spread.

Total thyroidectomy

  • While a total thyroidectomy is necessary for medullary thyroid carcinoma (MTC) to remove the entire gland, it does not include the assessment and potential removal of central lymph nodes, which can harbor metastases. Given the risk of lymphatic spread with MTC, central node dissection is recommended.

c) Total thyroidectomy with lateral and central neck dissection

  • This option is more extensive than typically required for a 1 cm medullary carcinoma without evidence of lymph node involvement. While MTC can spread to lateral nodes, the primary recommendation is to start with central node dissection unless there are clinical signs or imaging suggesting lateral node involvement. A more conservative approach is often favored unless there's clear evidence of lateral disease.

d) Right hemithyroidectomy

  • A hemithyroidectomy would only remove half of the thyroid gland and is inadequate for managing MTC. Since MTC can be bilateral and has the potential for multifocality, a total thyroidectomy is the standard of care to ensure complete removal of the cancerous tissue.

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