Free Questions

Free MCQs in Surgery

Facial nerve pointers

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Q) The most consistent anatomical landmark of the facial nerve is the
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

Facial nerve identification:

  •  Posterior belly of the digastric
  • Mastoid tip
  • Tragal pointer
  • Tympanomastoid suture line are key anatomical landmarks.
  • The nerve lies 2 to 4 mm inferior to the tympanomastoid suture line. The most consistent intraoperative landmark is the superior aspect of the posterior belly
    of the digastric.
  1. Tragal “Pointer” (of Conley):
    • Imagine the tragal cartilage—the little bump in front of your ear. Well, the facial nerve lies approximately 1 cm deep and slightly anterior and inferior to this “pointer.” As you dissect the tragal cartilage from the parotid fascia, it takes on a bluntly pointed shape—hence the name. This unassuming landmark is vital for safe surgery.
  2. Tendon of Posterior Belly of Digastric Muscle:
    • Picture the posterior belly of the digastric muscle attaching to the mastoid bone. The facial nerve lies about 1 cm deep to this attachment. During surgery, gently separate the tail of the parotid gland from the sternocleidomastoid muscle and uncover this hidden treasure.
  3. Tympanomastoid Suture/Fissure:
    • Deep within the temporal bone, where the mastoid meets the vaginal portion of the tympanic ring (fancy, right?), lies the facial nerve. It’s about 6-8 mm deep to this suture. Think of it as the nerve’s secret hideout.
  4. Styloid Process:
    • Lateral to the styloid process, you’re getting warmer! The facial nerve hangs out nearby. It’s like a VIP lounge for nerves.

Ivor Lewis Esophagectomy leak

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Q) After Ivor Lewis esophagectomy, on POD 5 , bile is seen in chest tube. Patient's heart rate is 120,  temp is 101 degree F, BP is 100/70. What will be the next step?

a) Stenting

b) Colonic replacement of gastric conduit

c) IV antibiotics 

d) Conduit excision and  Esophageal diversion

Ans  d

Patients with a completely necrotic conduit are most often septic and brought to the operating room for emergent exploration.

If conduit necrosis is confirmed,   then the conduit must be resected and the patient
should be diverted with an end esophagostomy, venting gastrostomy, and feeding jejunostomy. Care should be
taken to maintain the longest possible length of remaining
esophagus to facilitate future reconstruction

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

Ans  b

 Small cell lung cancer
Small cell carcinoma is associated with disseminated disease at presentation in the majority of cases. Most cases occur in the main airways and paraneoplastic features are common

Adenocarcinomas are the most common tumour type present in never smokers. They are usually located at the periphery.

Squamous cell carcinomas are reported to be more slow growing and are typically centrally located

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

This is Thyroid storm. radio active iodine is a predisposing factor and not part of management 

Predisposing factors for thyroid storm are 

  1. Cessation of anti thyroid medications
  2. Infection
  3. Thyroid or non thyroid surgery in untreated thyrotoxicosis
  4. Trauma in patients with untreated thyrotoxicosis.
  5. Amiodarone
  6. Iodinated contrast agents
  7. RAI therapy

Management is 

  1. Beta blockers
  2. Oxygen and hemodynamic support
  3. IV Lugol iodine
  4. PTU
  5. Corticosteroids

The symptoms of thyroid storm are more intense and severe than typical hyperthyroidism symptoms. They can include severe fever, rapid and irregular heartbeat (tachycardia), elevated blood pressure, restlessness, confusion, agitation, tremors, excessive sweating, nausea, vomiting, diarrhea, dehydration, and in severe cases, even delirium, seizures, and coma.

Schwartz page 1638

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
Bailey 1224 

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 

Colon

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.
SKF 8th page 1936
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