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Free MCQs in Surgery

Timing of cholecystectomy in biliary pancreatitis

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Q) What is true regarding timing of cholecystectomy in biliary pancreatitis ?

a) Cholecystectomy should be done before discharge in severe pancreatitis to prevent recurrent attacks

b) Cholecystectomy should be done in same admission as pancreatitis when severe disease is excluded

c) Early cholecystectomy has been shown to have more complications than interval cholecystectomy

d) Early cholecystectomy increases technical complications

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Questions on Bile ducts?

 Ans b

"Poncho trial " answers this question of timing of cholecystectomy in biliary pancreatitis 

Early cholecystectomy (just before discharge, when the patient has recovered and severe disease excluded), compared to interval cholecystectomy, effectively reduces---

  1. The rate of recurrent gallstone-related complications in patients with mild biliary pancreatitis,
  2. low added risk of complications.

Evidence on the timing of cholecystectomy in severe pancreatitis is scarce. Cholecystectomy is recommended after all signs of pancreatic necrosis have been resolved or if they persist more than 6 weeks

  • Cholecystectomy during the same admission is recommended for patients with mild biliary pancreatitis to prevent recurrent attacks.
  • In cases of severe pancreatitis, surgery is generally delayed until the inflammation subsides.
  • Studies have shown that early cholecystectomy during the same admission for mild to moderate biliary pancreatitis does not increase complications compared to delayed or interval cholecystectomy.

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Skin grafting

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Q) In preop evaluation before placing skin graft over wounded area…bacterial colony count must be less than

a) 10000
b) 100000
c) 1000000
d) 10000000

ans b)  10 raise to the power 5

In advanced surgical practice, the bacterial colony count is a critical factor when considering the placement of a skin graft over a wounded area. The threshold for bacterial contamination in the wound is typically 100,000 colony-forming units (CFU) per gram of tissue. If the bacterial count exceeds this limit, the risk of postoperative infection, graft failure, and delayed healing increases significantly.

This threshold is based on several key factors:

  • Wound infection: A bacterial count above 100,000 CFU per gram is associated with a high risk of wound infection, which can lead to graft failure.
  • Graft survival: A sterile or minimally contaminated wound is crucial for graft take. Any significant bacterial load can compromise the graft's survival due to the impaired healing environment.

Prerequisites for skin grafting:
The recipient site should be assessed for potential bacterial load, blood supply,
presence of devitalized tissue, and exposed vital structures.
Donor site availability
Perform recipient site tissue culture if history or concern for infection (counts <100000
CFU/g tissue for most pathogens required before grafting).

Presence of group a beta heamolytic streptococci is absolute contraindication for skin grafting
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Skin grafting cultures

Highly selective vagotomy

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False about Highly Selective Vagotomy? | Gastric Surgery MCQs
Q) False about highly selective vagotomy? (# Gastric Surgery MCQS) (# Questions on Esophagus)
a) Highly selective vagotomy divides the vagus nerves supplying the acid-producing portion of the stomach
b) Incidence of postoperative complications is lower.
c) The criminal nerve of Grassi should be severed
d) Crow's feet nerves are severed till below the GE junction

Ans - d

Highly Selective Vagotomy (HSV) only divides the last part of the nerves which supply the part of stomach which produces acid.
Anterior and posterior nerves of Latarjet are found and their terminal branches are severed from 7 cm proximal to the pylorus to 5 cm above the GE junction
Motor function of the stomach is not affected
Criminal nerve of Grassi is branch of posterior Vagus. It should be sought and cut. This nerve derives its name from the common mistake done during vagotomy. This nerve is often missed and responsible for recurrence of symptoms of Peptic ulcer disease. MOre

Vagus Nerve branches

  • Anterior trunk: Gives branch to liver GB and bile duct and goes along the lesser curvature as the anterior nerve of Latarjet
  • Posterior trunk: Sends branches to the celiac plexus and continues along the posterior aspect of the lesser curvature as the posterior nerve of Latarjet.
  • Criminal Nerve of Grassi: The first branch of the posterior trunk, innervates the gastric fundus. Failure to divide this nerve during an acid-reducing surgery can lead to recurrent ulcers
  • Crows Foot: The most distal branches of the anterior and posterior trunks and provides innervation to the antro-pyloric region. These branches are spared in a highly selective vagotomy (HSV)

Parasympathetics are vagally mediated using acetylcholine as the primary neurotransmitter.

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Post Whipple’s Bleeding

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Free MCQ
Q) A 50-year-old male undergoes Whipple pancreaticoduodenectomy. On post-op day 4, he develops fever, tachycardia, and pain. Ultrasound shows a collection in the lesser sac, which is drained percutaneously. On post-op day 10, 100 ml of frank blood is noted in the drain. What is the next best step?
✅ Correct Answer: a. CT angiography

🔍 Explanation:
This is an extraluminal bleed on the 10th POD, likely due to a pancreatic fistula. The earlier POD 4 symptoms indicate a leak, which can lead to pseudoaneurysm formation. CT angiography is crucial to identify the bleeding source and evaluate for vascular injury or pseudoaneurysm, which may be amenable to embolization.

- Emergency laparotomy is reserved for unstable patients or failed embolization.
- Flushing the drain or observation are inappropriate and potentially harmful in the setting of active bleeding.

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Tumor lysis syndrome

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Q)Tumor lysis  syndrome which is not seen? (# Electrolytes MCQ) 

a. Hyperkalemia

b Hypocalcemia

c. Hypophosphatemia

d. Hyperuricemia

Ans is c

This syndrome  releases, various intracellular  metabolites such as uric acid, potassium and phosphorous which overwhelm the excretory capacities of the kidney.

The metabolic anomalies are

Hyperuricemia

Hyperkalemia

Hyperphosphatemeia

Hypocalcemia

It mostly occurs in poorly differentiated leukemias and lymphomas

Other facts

Tumor Lysis Syndrome Tumor lysis syndrome (TLS) is a life-threatening condition that can occur when cancer cells die. As the cells die, they release their contents into the bloodstream, which can lead to a number of complications.

TLS is most likely to occur in people with rapidly growing cancers, such as leukemia, lymphoma, and multiple myeloma. It can also occur in people with solid tumors, such as breast cancer, lung cancer, and pancreatic cancer.

 

Corrosive Stricture esophagus

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Q) Which modality has no part in management of corrosive injury of esophagus? 

a) Repeated Endoscopies routinely

b) Esophagectomy in some cases

c) Early emergency surgery routinely

d) Steroid use routinely

Corrosive stricture esophagus mcqs

C

In corrosive injury of the esophagus, routine early emergency surgery is generally not indicated. The primary approach involves stabilization, assessing the extent of injury, and supportive care. Surgery is reserved for specific complications, such as perforation or severe necrosis.

Other than the need for emergency surgery for bleeding or perforation, elective oesophageal resection should be deferred for at least 3 months until the fibrotic phase has been established.

Oesophageal replacement is usually required for very long or multiple strictures. Resection can be difficult because of perioesophageal inflammation in these patients.

Regular endoscopic examinations are the best way to assess stricture development .

Significant stricture formation occurs in about 50% of patients with extensive mucosal damageo Corrosives can cause significant pharyngolaryngeal oedema

In unusual circumstances, e.g. with extensive necrosis after corrosive ingestion, emergency oesophagectomy may be necessary.

Questions on Esophagus 

Alkali and acidic injuries to the esophagus, both leading causes of corrosive stricture of the esophagus, differ in their effects due to distinct chemical reactions with tissue.

 Mechanism of Injury

  • Alkali Injuries: Ingested alkalis (e.g., drain cleaners) cause liquefactive necrosis, where tissue rapidly breaks down. This process allows alkalis to penetrate deep into the esophageal layers, often causing severe, widespread injury that extends to adjacent tissues. As a result, alkali injuries frequently lead to extensive scarring and stricture formation over time, significantly impacting the esophageal lumen.
  • Acidic Injuries: Acids like hydrochloric acid cause coagulative necrosis, resulting in protein denaturation and an eschar formation. This eschar limits acid penetration depth, typically causing more superficial injury compared to alkalis. However, mucosal damage can still be severe, leading to ulceration and potential esophageal stricture over time, especially if the injury affects the lower esophagus.

Haemorrhoidectomy

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Q) 57 year old male come to the surgery clinic with bleeding PR. He is diagnosed with Haemarrhoids . What is  not an indication of haemorrhoidectomy 

a) Persistent Second degree haemorrhoid 5 days after sclerotherapy

b) 3rd degree haemorrhoid

c) Fibrosed  haemorrhoid

d)  Interno-external haemorrhoids when the external haemorrhoid is well defined.

Ans a

Haemorrhoids can persist for 10 days after sclerotherapy

The indications for haemorrhoidectomy include:

● third- and fourth-degree haemorrhoids;

● second-degree haemorrhoids that have not been cured by non-operative treatments;

● fibrosed haemorrhoids;

● interno-external haemorrhoids when the external haemorrhoid is well defined.

Four degrees of haemorrhoids ●●

First degree – bleed only, no prolapse ●●

Second degree – prolapse but reduce spontaneously ●●

Third degree – prolapse and have to be manually reduced ●●

Fourth degree – permanently prolapsed

MCQS on Rectum

Right gastroepiploic vein

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Q) Right gastroepiploic vein drains into
A. Splenic vein
B. Left gastric vein
C. Portal vein
D. Superior mesenteric vein

ANswer is free

D

SMV

Veins of SMV
Right gastro epiploic vein

The right gastroepiploic vein is a significant blood vessel located in the abdomen. It runs parallel to the right gastroepiploic artery and is an essential part of the venous drainage system of the stomach.

Originating from the greater curvature of the stomach, this vein receives blood from various branches, including the short gastric veins. As it continues its course, it eventually joins with the superior mesenteric vein, contributing to the portal venous system. Understanding the anatomy and function of the right gastroepiploic vein is crucial for medical professionals in diagnosing and treating related conditions, ensuring proper circulation and overall digestive health.

The right gastroepiploic vein is essential in many surgical procedures:

  • Gastric Bypass and Gastric Cancer Surgery: The RGEV may require ligation or resection in gastrectomy procedures. Surgeons should be cautious of potential bleeding risks and the implications for vascular flow.
  • Coronary Artery Bypass Grafting (CABG): Surgeons often use the right gastroepiploic artery as a graft, though the associated vein is also considered during CABG preparation due to its proximity and importance.
  • Trauma and Emergency Surgery: Understanding Right gastroepiploic vein anatomy aids in identifying bleeding sources, especially in abdominal injuries.

Questions on Liver 

Surgery Anatomy

Pseudoachalasia

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Q) Most common cause of  pseudoachalasia is ?

(a) Benign tumors of esophagus

(b) Chagas disease

(c) Caustic injury

(d) Adenocarcinoma of cardia

d

Pseudoachalasia is an achalasia-like disorder that is usually produced by adenocarcinoma of the cardia

Other uncommon causes are

 1.benign tumours at this level.

2, Tumors of bronchus, pancreas

It  is a condition that mimics the symptoms of achalasia, but is caused by a different underlying problem. The most common cause  is  malignancy in the gastroesophageal junction (GEJ), which is the area where the esophagus meets the stomach. Other possible causes of pseudoachalasia include:

  • Esophageal stricture
  • Chagas disease
  • Radiation therapy to the chest
  • Aortic aneurysm
  • Thyroid cancer

Pseudoachalasia presents in an identical manner to idiopathic achalasia with progressive dysphagia to solids and liquids, retrosternal pain, regurgitation of undigested foods and weight loss.

The main difference between pseudoachalasia and achalasia is that it  is often associated with other symptoms, such as abdominal pain, vomiting, and weight loss.

The diagnosis is made through a combination of clinical evaluation, upper endoscopy, and esophageal manometry. Upper endoscopy can help to rule out a malignancy in the GEJ, and esophageal manometry can help to confirm the diagnosis of achalasia. In some cases, a CT scan or MRI of the chest may be needed to further evaluate the cause of pseudoachalasia.

Pseudoachalasia

Questions MCQs on Esophagus 

Case report 

Marjolin Ulcer

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Q) 35 year old male has come with Marjolin ulcer if the leg. True about Marjolin's ulcer is ?

a) Lymphatic spread is common

b) They are painful

c) Aggressive and fast growing tumors

d) Squamous cell carcinoma is the most common type

d. squamous cell carcinoma

When a SCC or BCC occurs in a long standing scar, it is called marjolin's ulcer.

Marjolin's type of ulcer is a malignant change that can occur in any long standing ulcer (ie venous ulcer)

Scar tissue is devoid of lymphatics, so no lymphatic spread. Lymphatic spread can still occur when it invades normal tissue. also nerve endings are not in scar tissue, so pain is a late feature

They are slow growing tumors but have propensity for distal metastasis  and squamous cell carcinoma is the most common type. Slow growth is again due to avascular characteristic

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