Free Questions

Free MCQs in Surgery

Gall bladder stone with obstruction

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A 65-year-old male presents with abdominal pain, vomiting, and a history of multiple episodes of cholecystitis. X ray image is given below.What is the most likely diagnosis?

Gall stone and intesinal obstruction

A. Acute cholecystitis
B. Gallstone ileus
C. Small bowel volvulus
D. Duodenal perforation

Answer: B. Gallstone ileus

Explanation:
Rigler's Triad consists of pneumobilia, small bowel obstruction, and an ectopic gallstone, which is diagnostic of gallstone ileus. This condition occurs when a gallstone enters the bowel through a biliary-enteric fistula, leading to mechanical obstruction.

A large gallstone (>2.5 cm) erodes through the gallbladder wall, creating a cholecysto-enteric fistula (most commonly into the duodenum).

The stone enters the bowel and may cause obstruction, most often at the ileocecal valve due to its narrow lumen.

The presence of air in the biliary tree (pneumobilia) results from communication between the biliary and intestinal tracts.

Surgery Instrument

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Q) Identify the instrument

a) Craniotome

b) Hudson Brace

c) Humby's knife

d) CUSA

Ans b

The Hudson brace is a manually operated surgical drill used in neurosurgery and orthopedic procedures. It consists of a hand-cranked mechanism with interchangeable drill bits for trephination or skull perforation.

Puzzle people by Thomas Starzl

Axillary lymoh node dissection in ca breast

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Q) Which of the following statements is most accurate regarding axillary lymph node dissection (ALND) in breast cancer staging?

a) Level I and level II ALND requires the removal of at least 10 lymph nodes for accurate staging, and level III nodes should always be included in the dissection, regardless of the presence of gross disease in levels I and II.

b) The axillary dissection should include tissue from levels I and II, with a focus on the area inferior to the axillary vein, extending laterally to the latissimus dorsi muscle and medially to the pectoralis minor muscle, when there is no gross disease in level II nodes.

c) Level III nodes should be dissected in all cases of breast cancer for accurate staging, as they are always involved in metastatic spread.

d) Level I and level II ALND can be skipped in cases of clinically negative axilla, as there is no need for lymph node evaluation in the absence of suspicion of metastasis

Ans b) The axillary dissection should include tissue from levels I and II, with a focus on the area inferior to the axillary vein, extending laterally to the latissimus dorsi muscle and medially to the pectoralis minor muscle, when there is no gross disease in level II nodes.

 

In breast cancer surgery, axillary lymph node dissection (ALND) is used to evaluate the extent of cancer spread to the lymph nodes and to help stage the disease. The following key points should be noted:

Why Option b is correct:

  • Level I and II ALND are typically performed when there is a need to stage the axilla, and it is crucial to remove lymph nodes from these levels to accurately assess the presence of metastatic cancer. The dissection should focus on the tissue inferior to the axillary vein, from the latissimus dorsi muscle laterally to the medial border of the pectoralis minor muscle. This area corresponds to the levels I and II nodes.
  • If there is no gross disease detected in the level II nodes, further dissection into level III nodes is generally not needed. This ensures a more selective approach, avoiding unnecessary complications associated with dissection of more extensive lymph node regions.

Why the other options are incorrect:

  • Option a): While 10 lymph nodes are often considered the minimum number for accurate staging, level III nodes should not always be included in ALND unless there is gross disease detected in levels I and II. Dissecting level III nodes in the absence of disease is not routine practice due to the increased risk of complications.
  • Option c): Level III nodes are not routinely dissected in all cases. They are only considered when there is gross disease in level I and II nodes. This step is generally reserved for cases where there is clinically evident disease, as level III nodes are more challenging to access and carry a higher risk of complications.
  • Option d): In cases of clinically negative axilla, ALND may not be necessary, but for accurate staging and treatment decisions, lymph node evaluation (such as with sentinel lymph node biopsy or ALND) is still important. Skipping the dissection entirely without any evaluation is not appropriate, as there may be microscopic disease in the axillary nodes that could influence prognosis and treatment planning.

Causes of Constipation in childhood

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Q) A 4-year-old child presents with a history of infrequent, hard stools associated with painful defecation. There is no history of vomiting, fever, or blood in the stool. On examination, there is a palpable fecal mass in the left lower abdomen, and the anal tone is normal. What is the most likely diagnosis? # Theme from Mock test 32

A) Hirschsprung disease
B) Functional constipation
C) Intussusception
D) Anal fissure

Ans b

Functional constipation is the most common cause of constipation in children. It is characterized by hard stools, infrequent bowel movements, and often associated with painful defecation leading to stool withholding.

It is diagnosed clinically based on the Rome IV criteria, with no evidence of an organic cause.

Why the other options are incorrect:

A) Hirschsprung disease:

  • Typically presents in infancy with failure to pass meconium within 48 hours, abdominal distension, and bilious vomiting. The anal tone may be increased, and rectal examination may reveal an explosive release of stool.

C) Intussusception:

  • Presents with intermittent, severe abdominal pain, vomiting, and "currant jelly stools." A palpable "sausage-shaped" mass is found in the abdomen, not a fecal mass.

D) Anal fissure:

  • Can cause painful defecation, but it is usually associated with streaks of bright red blood on the stool and pain during defecation, without palpable fecal masses.

Breast cancer TNBC

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Q) Which of the following patients with operable breast cancer is the most appropriate candidate for preoperative systemic therapy?

A) A patient with ER-positive, HER2-negative breast cancer with a 1 cm tumor and clinically node-negative disease who desires breast conservation

B) A patient with HER2-positive breast cancer with a 3 cm primary tumor and clinically node-positive disease

C) A patient with triple-negative breast cancer with a 1 cm tumor and clinically node-negative disease who prefers mastectomy

D) A patient with ER-positive, HER2-positive breast cancer with a 1.5 cm tumor and no lymph node involvement

Correct Answer: B) A patient with HER2-positive breast cancer with a 3 cm primary tumor and clinically node-positive disease

Preoperative systemic therapy is generally recommended for:

  1. HER2-positive or triple-negative breast cancer when the tumor is ≥cT2 (≥2 cm) or clinically node-positive (cN1).
  2. Patients with a large tumor relative to breast size who desire breast-conserving surgery.
  3. Patients with clinically node-positive disease (cN+) who may achieve node-negative (cN0) status with systemic therapy.

Option B meets these criteria with both HER2-positive disease and clinically node-positive status, making the patient an ideal candidate for preoperative systemic therapy.

Choice A: A patient with ER-positive, HER2-negative breast cancer with a 1 cm tumor and clinically node-negative disease who desires breast conservation
  • Explanation: This patient has an ER-positive, HER2-negative tumor that is small (1 cm) and clinically node-negative. These characteristics indicate a low risk of aggressive disease, and preoperative systemic therapy is typically not necessary for small, low-risk tumors. In this case, surgery would likely be the primary treatment option, followed by adjuvant therapy if needed.

Choice C: A patient with triple-negative breast cancer with a 1 cm tumor and clinically node-negative disease who prefers mastectomy

  • Explanation: Although this patient has triple-negative breast cancer (TNBC), the tumor size is only 1 cm and clinically node-negative. Preoperative systemic therapy is generally reserved for larger tumors (≥cT2) or node-positive disease in TNBC cases to improve outcomes or allow breast conservation. In this scenario, with a small, node-negative tumor, the preferred approach might be surgery first, as systemic therapy may not offer substantial additional benefits.

Choice D: A patient with ER-positive, HER2-positive breast cancer with a 1.5 cm tumor and no lymph node involvement

  • Explanation: This patient has HER2-positive breast cancer, but the tumor size is only 1.5 cm, which is below the ≥cT2 threshold for recommending preoperative systemic therapy. Additionally, the absence of lymph node involvement (cN0) indicates a lower burden of disease. While HER2-positive patients often benefit from systemic therapy, a neoadjuvant (preoperative) approach may not be necessary unless the tumor or nodal status meets certain thresholds (≥cT2 or ≥cN1).

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.

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

Rationale:

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

 

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