14 General Surgery

AIIMS NOVEMBER 2017 5. Elderly male presents with a ulcerative lesion on the dorsum
of nose since 2 years as shown in the given picture, which
1. A 53 year old man is admitted with a history of CVA 2 days bleeds on touch. What is most likely diagnosis?
ago. Patient is drowsy with minimal response and weakness
of left side. CT picture is shown as in the figure. What will be
your next line of management?

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a. Aspirin and clopidogrel

b. Mannitol
SURG PLATE 55
c. Decompressive surgery
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d. Mechanical thrombectomy a. Marjolin’s ulcer

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b. Basal cell carcinoma

2. Which of the following is the best guide to measure fluid
c. Dermatofibrosarcoma
resuscitation in shock? (AIIMS Nov. 2017, Nov. 2015)
d. Nevus
a. CVP
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b. Urine output 6. A person sustained Road Traffic Accident is found lying

c. Oxygen saturation on road and is conscious. All of following can be done for
d. Systemic BP transportation of the patient EXCEPT:
a. Strap head, chest and pelvis on spine board
3. Modified Shock Index formula is?
b. Put him in lateral position on stretcher to prevent
a. Heart rate/Systolic BP
aspiration
b. Heart rate/Diastolic BP
c. Talk to patient while he is on board
c. Heart rate/Mean arterial pressure
d. Roll him on stretcher like a log roll
d. Heart rate/Pulse rate
7. In a School bus accident, as per the guidelines of Triage;
4. A person presents in emergency with history of traumatic
which of the following child will you attend first on priority?
head injury. On examination he was found to have moving
a. Child with airway obstruction
all limbs spontaneously and obeys commands, uttering
b. Child with shock
inappropriate words and opens eye on painful stimuli. His
c. Child with flail chest
GCS would be?
d. Child with severe head injury
a. 3
b. 10 8. French in Foley’s Catheter refers to?
c. 11 a. Outer circumference b. Inner circumference
d. 13 c. Outer diameter d. Inner radius
772 Section I  •  Subject-wise MCQs and Answers with Explanations

9. Which of the following is not a part of Preoperative patient 16. Which layer involved in blister formation in a superficial
surgical Checklist? partial thickness burn?
a. Oral consent b. Doctor’s signature a. Epidermis b. Dermis
c. Site marking d. Confirming patient identity c. Papillary dermis d. Reticular dermis
10. After cholecystectomy gallbladder specimen is shown below. 17. Length of insertion of Nasogastric tube is best measured by?
Identify the condition? a. Tip of Nose to ear to umbilicus
b. Tip of Nose to ear to Xiphoid process
c. Mouth to ear to Umbilicus
d. Mouth to ear to midway between xiphisternum and
umbilicus

AIIMS MAY 2017

18. Pancreatic cancer has highest association with?
a. Peutz-Jeghers syndrome b. Hereditary pancreatitis
c. FAP d. FAMMM syndrome
19. Kraissl’s lines are?
a. Point of maximum tension in a fracture
SURG PLATE 56A
b. Point of tension in hanging
a. Cancer gallbladder b. Cholesterolosis c. Collagen and elastin lines in stab injury

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c. Strawberry gallbladder d. Polyps in gallbladder d. Relaxed tension lines in skin
11. Most common presentation of Abdominal Desmoid tumor 20. A 30-year-old female was admitted to casualty with history

is?
a. Fever
c. Abdominal mass
b. Abdominal pain
d. Rectal prolapse
Ea of head trauma in a RTa. Her eye opens to pain, moans,
localizes towards the pain on left-hand and away from
the pain on right hand, both the legs in extended posture.
ed
Calculate her GCS?
12. A 10 year old child with pain and mass in right lumbar
a. 3 b. 7
region with no fever, with right hip flexed and X ray shows
c. 9 d. 11
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Spine changes. Most probable diagnosis is?

a. Pyelonephritis 21. A 30-year-old female with history of burns involving abdomen,
b. Psoas abscess both limbs and back and presented after 8 hours which of the
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c. Retrocecal Appendicitis following is the formula for calculation of fluid infusion?

d. Torsion of Right Undescended testis a. 4 ml/kg × %TBSA for first 8 hours then 2 ml/kg × %TBSA
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for next 16 hours

13. Most appropriate method of checking the patency of the
b. 2 ml/kg × %TSBA
ICD tube?
c. 4 ml/kg × %TSBA
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a. By checking continuous air bubbles coming out of the

d. 5 ml/kg × %TSBA
underwater drain
b. By checking the movement of air water column in the tube 22. A 21-year-old male presents with soft tissue swelling front
during respiration of neck moves with deglutition and protrusion of tongue?
c. By checking position of the tube on chest X ray
d. By auscultation
14. Following a blunt trauma abdomen patient had renal
laceration for which he was operated. Now after 1 week
patient is hemodynamically stable and asymptomatic. There
after 2 days patient developed Urinoma. Patient was stable
and No fever. How will you manage the patient?
a. Percutaneous nephrostomy
b. Surgical exploration and repair
c. Urethral stenting
d. Wait and watch
15. Best management of 4 cm size renal staghorn calculus?
a. ESWL SURG PLATE 54
b. PCNL
c. Intra renal repair surgery a. Thyroglossal cyst b. Branchial cyst
d. Open pyelolithotomy c. Cystic hygroma d. Cervical lymphadenopathy

AIIMS Nov 2013–May 2011

AIIMS (Nov 2017–May 2014) Questions with Explanations Covered in Volume II (Available Separately)
780 Section I  •  Subject-wise MCQs and Answers with Explanations

108. A 12-year-old girl presents with nodular goiter. Which 111. The most serious complication of prolonged sitting position
of the following statements regarding her evaluation and is?
management is incorrect? a. Venous air embolism
a. 99 m-Tc scan should be performed to determine whether b. Dysrhythmias
the nodules are hypofunctioning or hyperfunctioning c. Hypotension
b. Functional thyroid nodules are usually benign d. Nerve palsies
c. All nodules >4 cm should be resected irrespective of
112. An elderly male presents 2 months after renal trans­
cytology
plantation with nephropathy. Which of the following can be
d. FNAC should be performed for all nodules >1 cm in
a viral etiological agent?
diameter
a. Polyoma virus BK
109. The first priority in management of a case of head injury b. Human herpes virus type 6
with open fracture of shaft of femur is? c. Hepatitis C
a. Neurosurgery consultation d. Human papilloma virus
b. Give IV fluids
113. Neurogenic shock is characterized by? 
c. Intubation
 (AIIMS May 2014, Nov 2013)
d. Splintage of fracture
a. Hypertension and tachycardia
110. Which of the following is not an etiological factor for b. Hypertension and bradycardia
pancreatitis? c. Hypotension and tachycardia
a. Abdominal trauma d. Hypotension and bradycardia
b. Hyperlipidemia

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c. Islet cell hyperplasia
d. Germline mutations in the cationic trypsinogen gene

Ea
ANSWERS WITH EXPLANATIONS
ed
AIIMS NOVEMBER 2017 frequent non-invasive blood pressure monitoring and hourly
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urine output measurements. Most patients will need more

1. Ans. (c)  Decompressive surgery aggressive invasive monitoring, including central venous
pressure and invasive blood pressure monitoring
Ref: Netter’s Neurology By H. Royden Jones, Jr., Jayashri
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Bailey states “Ultimately, the goal of treatment is to restore

Srinivasan, Gregory J. Allam, Richard A. Baker 2nd ed Page 209
cellular and organ perfusion. Ideally, therefore, monitoring of
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The patient is having a low GCS, with CT showing significant organ perfusion should guide the management of shock. The
edema in the Middle Cerebral Artery territory (at least >50%) best measures of organ perfusion and the best monitor of the
and compressed ventricle. In such cases brain herniation adequacy of shock therapy remains the urine output”
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is impending and need to be referred for decompressive

Monitoring of Patient in Shock
neurosurgery.
Minimal Additional Modalities
Note
ECG Central venous pressure
The only independent radiologic predictor of fatal Pulse oximetry Invasive blood pressure
brain swelling was involvement of >50 percent of Blood pressure Cardiac output
the MCA territory on head CT Urine output Base deficit and serum lactate
Central Venous Pressure
The STATE criteria may be useful
•• Score – GCS<8 Patients whose state of shock is not rapidly corrected with a
•• Time <48 h small amount of fluid should have central venous pressure
•• Age < 60 yrs monitoring and continuous blood pressure monitoring
•• Territory infarct > 150 cm3 or >50% MCA territory through an arterial line. Low CVP always means hypovolemia,
•• Expectancy of life is high but high CVP can signify either over expansion of blood
volume or cardiac failure. There is no ‘normal’ central venous
2. Ans. (b)  Urine output pressure (CVP) for a shocked patient, and reliance cannot
be placed on an individual pressure measurement to assess
Ref: Bailey 26th ed page 17, British Journal of Anesthesia volume status. Some patients may require a CVP of 5 cm H2O,
whereas some may require a CVP of 15 cm H2O or higher.
Shock Monitoring
Further, ventricular compliance can change from minute to
The minimum standard for monitoring of the patient in shock minute in the shocked state, and CVP is a poor reflection of
is continuous heart rate and oxygen saturation monitoring,

AIIMS (Nov 2017–May 2014)

 GENERAL SURGERY  •  Answers with Explanations 781
end diastolic volume (preload). CVP measurements should be 6. Ans. (b)  Put him in lateral position on stretcher to prevent
assessed dynamically as response to a fluid challenge. A fluid aspiration
bolus (250– 500 mL) is infused rapidly over 5–10 minutes. The
normal CVP response is a rise of 2–5 cmH2O which gradually Ref: Sabiston 20th edition page 415, Bailey 26th ed page 304, 330
drifts back to the original level over 10–20 minutes. Patients All polytrauma patients should be considered to sustain
with no change in their CVP are empty and require further Cervical spine injury unless proven otherwise. I.e. Full spine
fluid resuscitation. Patients with a large, sustained rise in CVP precautions must be observed until it is confirmed that
have high preload and an element of cardiac insufficiency or the patient’s vertebral column is intact, either by physical
volume overload. examination and clinical findings or by radiologic confirmation
Resuscitation requires appropriate fluid management and when warranted.
is dependent on the cause of shock and the time course of •• The cervical spine is stabilized by fitting the patient with a
the illness. For example, in hypovolaemic shock with a low hard cervical collar
CVP, fluid replacement is required. In contrast, in cardiogenic •• A patient with a spinal injury should be strapped to a spine
shock due to left-sided heart failure (i.e. with a raised CVP), board and the head fixed to the board with tape.
diuretic therapy with fluid restriction may be indicated. To
complicate matters further, cardiogenic shock due to right-
sided heart failure (i.e. also with a raised CVP) may require
fluid administration to ensure adequate filling of, and cardiac
output from, the left side of the heart! The time course of the
disease is also important. For example, at the onset of septic
shock, fluid replacement is essential, but, if acute respiratory

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distress syndrome develops later, fluid restriction is necessary
to prevent pulmonary oedema. (Ref: Oxford Desk Reference:
Acute Medicine edited by Richard Leach, Kevin Moore, Derek
Bell) Ea
3. Ans. (c)  Heart Rate/Mean Arterial pressure
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Ref: Sabiston 20th Ed Page 52
•• Shock Index is defined as Heart rate divided by Systolic BP.
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•• Shock Index is known as hemodynamic stability indicator •• The thoracic, lumbar, and sacral segments of the spine are
in Shock cases. protected by maintaining the patient in the supine position
•• Modified Shock Index ( MSI) includes Diastolic BP also and at all times by strapping on spine board.
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defined as heart rate divided by •• If the patient is to be moved, strict log roll technique is used.
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Percussion and auscultation should be performed on both

Mean Arterial Pressure
the front and back of the chest wall after log rolling. Once
•• MAP= Systolic Pressure+ ( 2 X Diastolic Pressure) divided the patient has been evaluated anteriorly, a log roll should
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by 3 be performed to inspect the back. A total of 5 people are

•• High MSI indicates- Hypodynamic state required to perform spinal Log roll
•• Low MSI indicates- Hyperdynamic state
•• MSI is better indicator than SI to predict the mortality in
shock

4. Ans. (c)  11
Ref: Bailey 26th Ed Pg 321
This is a pretty straightforward question.
EVM score = Eye opening 2+ Verbal 3 + Motor 6 = 11
See details of Glasgow coma scoe in Surgery AIIMS NOV 2015

5. Ans. (b)  Basal cell carcinoma

Ref: Harrison 19th ed page 500, Schwartz 9th ed chapter 16

See SURG PLATE 55

Basal cell cancer (BCC) or Rodent Ulcer often occurs on the

face above a line joining the angle of the mouth and the ear
lobe.

GENERAL SURGERY
782 Section I  •  Subject-wise MCQs and Answers with Explanations

7. Ans. (a)  Child with airway obstruction

Ref: Miller’s 8th Ed Pg 2476, Trauma: Resuscitation, Perioperative Management, and Critical Care by William C. Wilson, Pg 73
The options in this question are very close. See division into triage groups below:

Triage Groups in Mass Casualty Incidents

With the aid of triage tags or colored flags, the patients are sorted into four groups.
Triage Tag Assessment of Treatments Needed Types of Injuries
Green (minor) Minor injuries with no immediate need of treatment Wounds
Psychologic support is needed Minor fractures
Patients can walk
Yellow (delayed) Urgent treatment is needed Fractures, joint injuries
No vital threat is present Amputation, major blood loss
Burns
Red (immediate) Vital threat is immediate Respiratory insufficiency, shock
Brain trauma
Burns with immediate vital threat

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Abdominal trauma
Black (expectant) Patients are dead or moribund Respiratory arrest, cardiac arrest
Ea Head injuries with dismal prognosis
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Triage categories
EXPECTANT Black triage tag color DELAYED Yellow Triage Tag Color
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•• Victim unlikely to survive-given severity of injuries, level •• Victim’s transport can be delayed
of available care, or both •• Includes serious and potentially life-threatening
•• Palliative care and pain relief should be provided injuries, but status not expected to deteriorate
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significantly
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IMMEDIATE Red Triage Tag Color MINOR Green Triage Tag Color
•• Victim can be helped by immediate intervention and •• Victim with relatively minor injuries
transport •• Status unlikely to deteriorate over day
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•• Requires medical attention within minutes for survival(up •• May be able to assist in own care: “Walking Wounded”
to 60)
•• Includes compromises to patient’s Airway, Breathing,
circulation

As we can see, except for Option (D) Child with Severe Head injury; all other options fall under the red, that is, immediate group. Now,
we go further into the details of triage protocols.
There are a few protocols designed for primary triage in adults and paediatric patients. The protocols for adults are START (Simple
Triage And Rapid Treatment).

AIIMS (Nov 2017–May 2014)

 GENERAL SURGERY  •  Answers with Explanations 783

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The protocols for paediatric patients are JumpSTART, Paediatric trauma tape (PTT). JumpSTART is one of the most common protocols.
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GENERAL SURGERY
784 Section I  •  Subject-wise MCQs and Answers with Explanations

There is an algorithm for secondary triage, that is, after arrival in the hospital.
It involves categorisation of patients into 3 categories: ones who will survive despite no treatment, those who will not survive despite
treatment, and those who may survive with immediate treatment. Obviously, the last group is given top priority.

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Physiological Predictors
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Category 1 Category 2 Category 3 Category 4 Category 5

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Immediate 30 mimutes 30 mimutes 60 mimutes 120 mimutes

Airway Obstructed/partially Patent Patent Patent Patent
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obstructed
Breathing Severe respiratory Moderate respiratory Mild respiratory No respiratory No respiratory
distress/absent distress distress distress distress
respiration/
hypoyentilation
Circulation Severe Moderate Mild haemodynamic No haemodynamic No haemodynamic
haemodynamic haemodynamic compromise compromise compromise
conpromise/absent compromise
criculation
Uncontrolled
haemorrhage
Disability GSC < 9 GCS 9–12 GCS > 12 Normal GCS Normal GCS

AIIMS (Nov 2017–May 2014)

 GENERAL SURGERY  •  Answers with Explanations 785

8. Ans. (c)  Outer diameter Also Know

Gauge Size
Ref: The ICU book by Paul Marino 4th Ed Pg 17; Vascular
For hollow needles, peripheral catheters,infusion channels of
Medicine and Endovascular Interventions by Thom W. Rooke
multilumen catheters.
Pg 126; Urology Instrumentation - A Comprehensive Guide by
Varies inversely with outside diameter (i.e., the higher the
Ravindra B Sabnis 1st Ed Pg 116
gauge size, the smaller the outside diameter)
French Size
9. Ans. (b)  Doctor’s signature
•• Synonymous with Charriere size (CH)
•• The French scale begins at zero, and each increment of one Ref: WHO surgical safety checklist 1st Ed 2008 guidelines;
French unit represents an increase of ⅓ (0.33) millimeter in Textbook of Anesthesia for Postgraduates By TK Agasti Pg 313
outer diameter: i.e., “Informed consent is essential in the preoperative checklist.
•• French size × 0.33 = outside diameter (mm). Verbal consent may be accepted in life threatening or emergency
•• E.g: 5 French units in size will have an outer diameter of 5 situations but written consent is always preferable” Hence we
× 0.33 = 1.65 mm. can not say the Oral consent is not a part of checklist. The WHO
checklist does not differentiate between types of consent.

Surgical Safety Checklist

Before induction of anaesthesia Before skin incision Before patient leaves operating room
Sign In Time Out Sign Out

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•• Patient has confirmed •• Confirm all team members have Nurse verbally confirms with the team:
ƒƒ Identity introduced themselves by name and •• The name of the procedure recorded
ƒƒ Site
ƒƒ Procedure
ƒƒ Consent
role Ea •• That instrument, sponge and
needle counts are correct (or not
Applicable)
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•• Site marked/not applicable •• Surgeon, anaesthesia professional •• How the specimen is labelled
•• And nurse verbally confirm (Including patient name)
•• Whether there are any equipment
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ƒƒ Patient
ƒƒ Site problems to be addressed
ƒƒ Procedure
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•• Anaesthesia safety check completed Anticipated critical events

•• Surgeon reviews: what are the critical
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or unexpected steps, operative

duration, anticipated blood loss?
•• Anaesthesia team reviews: are there
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any patient-specific concerns?

•• Nursing team reviews: has sterility
(including indicator results) been
confirmed? Are there equipment
issues or any concerns?
•• Pulse oximeter on patient and
functioning
Does patient have a: Has antibiotic prophylaxis been given •• Surgeon, anaesthesia professional
Known allergy? within the last 60 minutes? and nurse review the key concerns
•• No •• Yes for recovery and management of
•• Yes •• Not applicable this patient
Difficult airway/aspiration risk? Is essential imaging displayed?
•• No •• Yes
•• Yes, and equipment/assistance •• Not applicable
available
Risk of > 500 ml blood loss (7Ml/kg in
children)?
•• No
•• Yes, and adequate intravenous access
•• And fluids planned

GENERAL SURGERY
786 Section I  •  Subject-wise MCQs and Answers with Explanations

10. Ans. (d)  Polyps in Gallbladder pregnancy or possibly a small haematoma of the abdominal
wall, appears to be an aetiological factor. They can occur in
Ref: Sternberg’s surgical pathology 5th ed page 1614, Bailey 26th cases of familial adenomatous polyposis (FAP).
ed page 1108 Clinical features: Patients with desmoid tumors present with
a painless enlarging mass. Local symptoms may arise from
See SURG PLATE 56A compression of adjacent organs or neurovascular structures.
Magnetic resonance imaging (MRI) provides information
Gallbladder polyp is the best possible answer. Gallbladder regarding the extent of the disease and its relationship to intra-
cancer is mostly a Histopathological diagnosis and from abdominal organs.
gross specimen it is difficult to ascertain as Gallbladder
cancer. Moreover it can develop in Gallbladder Polyps, Stones Treatment
etc. Also in gallbladder cancer specimen mostly Radical Unless the tumour is excised widely, with a surrounding margin
Cholecystectomy with segmental Liver resection is given in of at least 2.5 cm of healthy tissue, recurrence commonly takes
history (Mostly but not necessarily) place. After removal of a large tumour, repair of the defect in
the abdominal wall by nylon mesh is required. These tumours
11. Ans. (c)  Abdominal mass are moderately radiosensitive. (Intraperitoneal desmoids are
best left alone when possible.)
Ref: Sabiston 20th ed Page 765, 1073, Devita 10th ed page 1485
Schwartz 9th edn Page 1065
12. Ans. (b)  Psoas Abscess
Desmoid Tumour Ref: Bailey 26th ed Page 985, SRB Manual of Surgery 4th ed page
A desmoid tumour is a tumour arising in the musculoaponeurotic 769

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structures of the abdominal wall, especially below the level of This question is based on the clinical judgement and
the umbilicus. It is a completely unencapsulated fibroma and is differential diagnosis of Right Lumbar mass and pain. Site of
so hard that it creaks when it is cut.
Aetiology
Ea pain and Mass are often overlapping into different regions of
the abdomen and can not be relied upon completely. Hip flexed
attitude is given that means hip extension is painful, this points
About 80% of cases occur in women, many of whom have borne
ed
towards Appendicitis irritating Psoas muscle or Psoas Abscess.
children, and the neoplasm occurs occasionally in scars of old No fever points towards non infectious pathology or Cold
hernial or other abdominal operation wounds. Consequently, abscess. Psoas Cold abscess is the best fit in this case.
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trauma, for example the stretching of the muscle fibres during

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Pyelonephritis Psoas abscess Retrocaecal Appendicitis Torsion of Right Unde-

scended testis
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Age Any 83% under 30 years Young Young

Pain in right Loin/Lumbar pain Rt Iliac fossa, Back/Lumbar Rt Iliac fossa/Lumbar pain. RIF pain not related to
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Lumbar region not related to Hip pain. Relieved on Hip flexion, Relieved on Hip flexion, Hip movement
with Hip movement Increased on extension due Increased on extension due
flexion to Psoas muscle spasm to Psoas muscle spasm.
Mass in right Lumbar Lump Lump RIF/LIF smooth, non Lump RIF Undescended testis can
Lumbar region mobile, not moving with present as Lumbar, Iliac
respiration. Non tender fossa, Inguinal mass
locally in Cold abscess
Fever Present Present (Absent in Cold Present Absent (uncommon)
abscess)
Spine change Lumbosacral scoliosis Spine may show Gibbus, Lumbosacral scoliosis with No spine changes
on X-ray with concavity to the Tenderness, Paraspinal concavity to the right
right spasm and restricted
movement.

AIIMS (Nov 2017–May 2014)

 GENERAL SURGERY  •  Answers with Explanations 787

Note
Swellings that are cross fluctuant
1. Ranula
2. Psoas abscess
3. Compound palmar ganglion
4. Bilocular hydrocele

13. Ans. (b)  By checking the movement of air water column in

the tube during respiration
Ref: Bailey 26th edition Page 355
The chest tube is connected to a closed chest drainage system,
which allows for air or fluid to be drained, and prevents air or
fluid from entering the pleural space. The system is airtight to
prevent the inflow of atmospheric pressure. This chamber has
a one-way valve that allows air to exit the pleural cavity during
exhalation but does not allow it to re-enter during inhalation
due to the pressure in the chamber. The water-seal chamber
must be filled with sterile water and should be checked

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regularly. The water in the water-seal chamber should rise with
inhalation and fall with exhalation (this is called tidaling),
which demonstrates that the chest tube is patent. Continuous
bubbling may indicate an air leak, and newer systems have a
measurement system for leaks the higher the number, the
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greater the air leak. 14. Ans. (d)  Wait and Watch
ed
Ref: Smith Urology page 17th ed page 125, Sabiston 20th ed page 2091
ICD Monitoring
Campbell 10th ed page 1178- Persistent urinary extravasation
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Drainage Underwater Assessment and can result in urinoma, perinephric infection, and even renal loss.
collection seal chamber Management of Air leak These patients are initially administered systemic antibiotics
chamber and carefully observed with appropriate antibiotics. In a high
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Tidaling Bubbling percentage, the extravasation resolves spontaneously. Should

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it persist, placement of an internal ureteral stent often corrects

Yes Yes Indicates patient air leak the problem. A nonoperative approach with careful observation
(pneumothorax) usually results in a functional renal unit. Perinephric abscess rarely
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occurs after renal injury, but persistent urinary extravasation

No No Indicates lung re expansion
and urinoma are the typical precursors. Percutaneous drainage
or obstruction by kinks or
offers a good initial method of management of perinephric
clots
abscess, followed by surgical drainage if necessary.
No Yes Indicates possible Extravasating urine is collected near the urinary tract and may
connection or system air manifest as:
leak •• Free fluid, also called urinary ascites, if the fascial planes are
disrupted (less frequently in renal tears)
Yes No Observed with
•• Acute spread to local tissues
pneumonectomy or
•• Encapsulated fluid collection surrounding by a fibrous capsule
decreased lung compliance
resulting from chronic tissue irritation by urine (urinoma)

GENERAL SURGERY
788 Section I  •  Subject-wise MCQs and Answers with Explanations

Treatment other to decompress the collecting system in order to

•• Small urinomas can reabsorb spontaneously. Should it facilitate urinary drainage
persist, placement of an internal ureteral stent often corrects •• In cases of persistent leakage from the collecting system,
the problem placement of a nephrostomy catheter, usually with a ureteral
•• If urinoma is larger or if the patient developed septic stent or nephroureterostomy catheter, is warranted in order
fever, drainage is Mandatory. The drainage catheter can be to promote primary healing of the collecting system.
positioned under US or CT guidance in the most dependent •• If hemodynamically unstable, surgical exploration and
portion of a urinoma. Percutaneous techniques of catheter repair is warranted.
drainage eliminate the need for open surgical revision •• When surgical exploration for renal trauma is indicated,
in most cases. Insertion of a small (6–10F) catheter (with it is recommended to use a transabdominal approach and
numerous side holes) is usually sufficient. early exploration of the renal hilum and vasculature before
•• If urinoma do not reduce its volume, a percutaneous exploring the retroperitoneum
nephrostomy catheter may be placed in addition to the

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Indications of Surgical Intervention in Renal Trauma

Absolute Indications Relative Indications
•• Persistent, life-threatening hemorrhage •• Large laceration of the renal pelvis or avulsion of the ureteropelvic junction
from probable renal injury •• Coexisting bowel or pancreatic injuries
•• Renal pedicle avulsion (grade V injury) •• Persistent urinary leakage, postinjury urinoma, or perinephric abscess with
•• Expanding, pulsatile, or uncontained failed percutaneous or endoscopic management
retroperitoneal hematoma •• Abnormal intraoperative one-shot IV urogram
•• Devitalized parenchymal segment with associated urine leak
•• Complete renal artery thrombosis of both kidneys or of a solitary kidney
when renal perfusion appears preserved
•• Renal vascular injuries after failed angiographic management
•• Renovascular hypertension

AIIMS (Nov 2017–May 2014)

 GENERAL SURGERY  •  Answers with Explanations 789

15. Ans. (b)  PCNL a primary percutaneous stone debulking by PCNL followed
by ESWL of any inaccessible, residual infundibulo calyceal
Ref: Campbell 10th ed page 1364, Smith Urology 17th ed page stone extensions or fragments. After ESWL a secondary
114, Bailey 26th ed page 1294 percutaneous procedure (PCNL) is performed. These various
Latest treatment of large Staghorn calculus is “Sandwich stages are usually separated by 1 or 2 days. Stone-free rates for
technique”- Using both PCNL and ESWL, but it must be combined therapy are similar to those obtained by PNL alone
reviewed as primary PCNL only as per Campbell Urology or by open surgery. The management of patients with staghorn
Campbell states: “The use of multiple endourologic stones by a combined approach must be viewed as primarily
techniques for the treatment of patients with staghorn stones percutaneous in nature, with ESWL being used only as an
is referred to as combination therapy or “sandwich therapy.” adjunct to minimize the number of access points required”
The most frequently used multimodal regimen consisted of

Treatment Modalities for Nephrolithiasis

Treatment Indications Advantages Limitations Complications
Extracorporeal Mainly used for renal Minimally invasive Requires spontaneous passage Ureteral obstruction
shock wave and proximal ureteral Outpatient procedure of fragments, Less effective in by stone fragments,
lithotripsy (ESWL) stones <2 cm patients with morbid obesity or Perinephric hematoma
hard stones
Ureteroscopy Ureteral stones Definitive Outpatient Invasive, May be difficult to Ureteral stricture or
procedure clear fragments, Commonly injury

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requires postoperative ureteral
stent, laser fiber is passed

Ea through the scope, and energy

is delivered to fragment the
calculus
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Ureterorenoscopy Renal stones <2 cm Definitive Outpatient Same as above Ureteral stricture or
procedure injury
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Percutaneous Mainly used for Definitive Invasive (various energy Bleeding Injury to
nephrolithotomy Renal stones >2 cm sources (laser, ultrasound) are collecting system,
(PCNL) (including Staghorn used to fragment large renal Injury to adjacent
S

calculus) Proximal calculi) structures

ureteral stones >2 cm
IM

Footnote:
•• Ninety-five percent of stones 4 mm or smaller in size pass spontaneously. Patients may be given up to 4 weeks to pass a
partially obstructing stone without permanent renal damage.
AI

•• Smaller stones (up to 6 mm) may cause severe symptoms, such as flank pain and nausea, but typically pass without intervention
beyond supportive care.
•• Calculi ≥7 mm are more likely to become impacted or to have a prolonged passage through the ureter. For this reason,
intervention at the time of presentation is preferred for larger stones (except cases where the calculus is in the very distal ureter)
•• Stone removal is indicated for stones with a diameter between 6-7 mm but can be delayed and shall be tailored as per needs.

16. Ans. (c)  Papillary dermis

Ref: Bailey 26th ed page 390

Degree of Burn Injuries

Degree Level of Injury Clinical Features Treatment Outcome
1 degree burns
st
Limited to the Skin is painful and red, There are Epidermal (1 degree)
st

epidermis no blisters. Heal spontaneously burnsrequire only

in 3 to 4 days symptomatic treatment.
Superficial Limited to the dermal They appear red, warm, Tetanus prophylaxis Epithelialization in
partial layers of the skin, edematous, and blistered, often Cleaning (e.g., with 7–21 days
thickness involve the papillary with denuded, moist, mottled chlorhexidine gluconate)
burns dermis red or pink epithelium.
Contd…

GENERAL SURGERY
790 Section I  •  Subject-wise MCQs and Answers with Explanations

Blanch to touch, very painful. Topical agent (e.g., 1% Hypertrophic scar

Such burns frequently arise from silver sulfadiazine) rare
brief contact with hot surfaces, Sterile gauze dressingc Return of full
liquids, flames, or chemicals.Heal Physical therapy function
in 7–14 days Splints as necessary
2nddegree burns

Deep partial Limited to the Blisters present, do not blanch As for superficial partial- Epithelialization in
thickness dermal layers of to touch, Less sensitive to pain, thickness burns 21–60 days in the
burns the skin,involve the but remain painful to pinprick, Early surgical excision absence of surgery
reticular dermis and hairs may be easily plucked out. and skin grafting an Hypertrophic scar
thus can damage Heals in 21–60 days (Some says option common
some dermal 14 to 35 days) , Hypertrophic Earlier return of
appendages (e.g., scar common function with
nerves, sweat glands, surgical therapy
or hair follicles).
3rd degree Involve all layers Blisters may be absent, Painless, As for superficial partial- Functional
burns of the skin and insensate dry surface that may thickness burns limitation more
some subcutaneous appear either white and leathery Wound excision and frequent
tissue, all the skin or charred and cracked, with grafting at earliest Hypertrophic scar
appendages, including exposure of underlying fat feasible time mainly at graft
hair follicles and margins

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sweat and sebaceous
Full-thickness burns

glands, and sensory

fibers for touch,
pain, temperature,
and pressure are
Ea
ed
destroyed
4thdegree Also involve fascia, Same as above, Deep structures
burns muscle, and bone. like muscles and bones are also
M

They often result from visible.

prolonged contact
with thermal sources
S

or high electrical
IM

current.
# Only definitive method of differentiating superficial and deep partial-thickness burns is by length of time to heal
* Some textbooks have not mentioned Fourth degree burns separately
AI

AIIMS (Nov 2017–May 2014)

 GENERAL SURGERY  •  Answers with Explanations 791

17. Ans. (b)  Tip of Nose to ear to Xiphoid process NG Tube in children: The placement of a NG tube in children
is often difficult. Their large tonsils and adenoids may hinder
Ref: Emergency Medicine Procedures 2nd ed by Eric F. Reichman the passage. These tissues are soft, easily injured, and may bleed
ch 58 as the NG tube is passed. The tongue, large by comparison with
Nasogastric (NG) intubation is one of the commonly performed adults, may push into the oropharynx and impede passage of
procedures in the Emergency Department. Its use as a conduit the NG tube. Their nostrils and nasal passage are quite small
into the stomach. The method most frequently used to measure and limit the size of NG tube that may be passed.
correct length of the NG tube prior to insertion is the distance
from nose to ear to xiphisternum (NEX). Estimate the length AIIMS MAY 2017
of the tube needed to reach the stomach by measuring the tube
either from the tip of the nose to the earlobe and down to the 18. Ans. (a)  Peutz-Jeghers syndrome
xiphoid process or from the tip of the nose to the umbilicus.
Controversy exists regarding measurement of the length of Ref: Sabiston 20th Ed Pg 1541-1543, Robbins 9th ed page 593
the NG tube to be inserted. Two most common methods of
Name Defect Risk of pancre-
measurement are:
atic cancer
•• From the nose tip to the earlobe and then to the end of the
xiphoid process (NEX) Peutz-Jeghers STK11 gene mutation 100 fold
•• From the nose tip to the earlobe and then to a point midway syndrome increased risk
between Xiphoid process and umbilicus.
Hereditary Mutation in cationic 50 fold
pancreatitis trypsinogen PRSS1 increased risk

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gene
Cystic fibrosis CFTR gene mutation 30 fold

Ea
FAMMM syndrome CDKN2A gene mutation
increased risk
20 fold
increased risk
ed
Hereditary breast BRCA 2 gene mutation 10 fold
and ovarian cancer increased risk
M

Lynch syndrome MLH1 gene mutation 8 fold increased

risk
S

FAP APC gene mutation 4 fold increased

risk
IM

Familial pancreatic Unknown gene 18 fold

cancer increased risk
AI

19. Ans. (d)  Relaxed tension lines in skin

Ref: Grabb and Smith’s Plastic Surgery 7th page 1 – 3
This question refers to the cutaneous lines meant for incision
in plastic surgery so as to avoid scarring. The three best line
Fig: Two methods of NG tube insertion
systems known are:

Line Systems in Plastic Surgery

Line Description
Langer’s line Langer’s lines, sometimes called cleavage lines, are topological lines drawn on a map of the human body. They
were described by Karl Langer who studied these lines by producing wounds with a spike on fresh cadaver.
He investigated directional variations in the mechanical and physical properties of skin and produced a series
of diagrams depicting lines of cleavage in the skin and showed that the orientation of these lines correspond
to the natural orientation of collagen fibers in the dermis, and are generally parallel to the orientation of the
underlying muscle fibers. Wounds against langer Lines generally have poor cosmetic outcome. These lines
represent skin tension in rigor mortis but frequently do not relate to the lines of choice in making elective
incisions. Indeed Langer’s lines often run at right angles to the RSTLs in the face.
Contd…

GENERAL SURGERY
792 Section I  •  Subject-wise MCQs and Answers with Explanations

Kraissl’s lines Kraissl’s lines are essentially exaggerated wrinkle lines obtained by
studying the loose skin of elderly faces whilst contracting the muscles
of facial expression. These lines for the most part correspond to RSTLs,
but slight variation exists on the face, especially on the lateral side of
the nose, the lateral aspect of the orbit, and the chin. Kraissl’s lines
coincides with wrinkle lines, although not always, and tend to be
perpendicular to the muscle action.
Borge’s Relaxed Tension is present in all directions in the skin but mainly in one direction,
skin tension lines which follows the relaxed skin tension lines (RSTLs) first described by
Borges. Relaxed skin tension lines (RSTLs) are those which correspond to
the directional pull (which forms furrows) when the skin is relaxed: they
do not always correspond to wrinkle lines. The tension across the RSTL is
constant even during sleep but can be altered (increased, decreased or
abolished) by underlying muscle contraction. The direction of the RSTLs
can be determined by pinching the skin in different directions. Pinching
at right angles to the RSTLs will result in fewer and higher furrows than
pinching parallel to these lines

20. Ans. (c)  9 Galveston 5000 mL/m2 burned None None

sy
Ref: Bailey 26th ed page 312, Schwartz 10th ed page 168–170 (pediatric) area + 1500 mL/m2
total area
See table of Glasgow Coma Scale Score in Surgery AIIMS
NOV 2015 Ea
Footnote:
•• In children with burns over 10% TBSA and adults with burns over
15% TBSA, consider the need for intravenous fluid resuscitation.
ed
E = Eye opening = Eye opens to pain = 2 •• Fluid of choice for burn resuscitation in first 24 hours is Ringer
V = Verbal = Moans = Unintelligible sounds = 2 lactate
M = Motor = Localizes towards pain on left is M5 and •• Fluid of choice for burn resuscitation in children below 20 kg
M

withdrawal on right is M4 (best score is taken so M5) = 5 or younger than 2 years in first 24 hours is Ringer lactate with
So total GCS score = 2 + 2 + 5 = 9 (Moderate head injury) 5% dextrose
•• Fluid of choice for burn resuscitation after 24 hours is colloids
S

21. Ans. (c)  4 ml/kg × %TSBA •• If oral fluids are to be used, salt must be added.
•• Both mafenide and silver sulfadiazine have antibacterial
IM

Ref: Bailey 26th ed page 390 – 392, Sabiston 20th ed page 513 –
514, http://dghs.gov.in/WriteReadData/userfiles/file/Practical_ properties against pseudomonas and are used in management
handbook-revised_Karoon.pdf of burns.
AI

Option (A) is designed to confuse you. One that 4 ml/kg ×

BSA% is divided into 2 halves, one half for first 4 hours and 22. Ans. (a)  Thyroglossal cyst
another half for next 16 hours from the time of burn. Secondly Ref: Bailey’s 25th Ed page 729
8 hours have already passed so that calculation will exceed
24 hours and should not be applied. Hence simply 4 ml/kg × See SURG PLATE 54 KEY
TBSA% should be the answer.
The most commonly used fluid resuscitation formula for This is a classical case scenario of Thyroglossal cyst. There are
burns is Parkland formula. many midline neck swellings that moves with deglutition but
only one out of them also moves with protrusion of tongue.
Resuscitation Formulas
23. Ans. (c)  McBurney point tenderness
Formula Crystalloid volume Colloid volume Free water
Ref: Bailey 26th ed page 1202 – 1203, Schwartz 10th ed page
Parkland 4 mL/kg per % TBSA None None 1243-48, Sabiston 20th ed page 1297 - 1302
Brooke burn
(1/2 in first 8 hours See SURG PLATE 53 KEY
and another 1/2 in
next 16 hours) Options A, B, and C are related to acute appendicitis
Option (D) Ballance’s sign is fixed dullness on the left flank
Brooke 1.5 mL/kg per % TBSA 0.5 mL/kg per % 2.0 L
with shifting dullness in the right flank. This is seen in rupture
burn TBSA burn
of spleen.
Contd…

AIIMS (Nov 2017–May 2014)

 General Surgery

SURG PLATE 1 These catheters are often of a larger diameter (20-24 Fr.) to allow for
large chunks of debris to pass through it.
•• Following a transurethral resection of the prostate, a large (24 Fr.)
three-way Foley catheter with 30 cc balloon is used to maintain
hemostasis
•• Used for bladder irrigation/lavage and clot removal.

Indications for Urethral Catheterization

•• Acute and chronic urinary retention.
•• Maintain a continuous outflow of urine for patients with voiding
difficulties, as a result of neurological disorders that cause

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paralysis or loss of sensation affecting urination.
•• Need for accurate measurements of urinary output in critically
ill patients.
Ea
•• Perioperative use for selected surgical procedures.
•• Patients undergoing urological surgery or other surgery on
contiguous structures of the genitourinary tract.
ed
•• Anticipated prolonged duration of surgery.
•• Need for intra-operative monitoring of urinary output.
SURG PLATE 1 KEY •• To assist in healing of open sacral or perineal wounds in incontinent
M

patients.
•• Patient requires prolonged immobilisation (e.g. potentially
The name comes from the designer, Frederic Foley, a surgeon unstable thoracic or lumbar spine, multiple traumatic injuries
S

working in Boston, Massachusetts in the 1930s. The French scale or such as pelvic fractures).
French gauge system is commonly used to measure the size (out-
IM

•• To allow bladder irrigation/lavage. (3 way catheter)

side diameter) of a catheter. It is most often abbreviated as Fr, but •• To facilitate continence and maintain skin integrity (when
can often abbreviated as FR or F. The outer diameter of the catheter conservative treatment methods have been unsuccessful).
in millimeters can be determined by dividing the French size by 3;
AI

•• To improve comfort for end of life care if needed.

that is 1 F = 1/3 mm outer diameter. The standard male catheter •• Management of intractable incontinence.
length of 41-45 cm can be used for males and females, but a shorter
female length of 25 cm can be more comfortable and discrete for Contraindications for Urethral Catheterization
some women. •• Acute prostatitis
•• Suspicion of urethral trauma
Change Frequency
•• Latex Foley catheter: 4 weekly change
•• Silicon Foley catheter: 8–12 week change
SURG PLATE 2
Two Way Foley’s Catheter (A)
It is a flexible self retaining indwelling catheter that is often passed
through the urethra and into the bladder. Side channel is used to
inflate the balloon so that it is kept indwelling and main channel is to
hook the drainage bag. Balloon capacity is typically 5-50 ml (5 ml for
retaining catheter, 30-50 ml for hemostasis).

Three-Way Catheters (B)

Also called haemostatic catheters, these are generally thicker cathe-
ters with an extra channel to be used to flush the bladder. Through
this tube, it is possible to inject water (i.e. NaCl 0.9%) into the blad-
der to be able to flush it continuously in order to clean the bladder
of blood cloths or other debris, for instance after prostate surgery.
1208 Section II  •  Subject-wise Color Plates

Some tube with radio-opaque line, marked at 40, 50, 60 and

SURG PLATE 2 KEY 70 cm from the tip for accurate placement.

Nasogastric Tube (RYLES) Marking At Corresponds to

First marking 40 cm Gastroesophageal junction
Indications/Uses
2 marking
nd
50 cm Body of the stomach
•• To decompress stomach during upper abdominal surgeries
•• To decompress stomach in intestinal obstruction 3rd marking 60 cm Pyloric region of stomach
•• To decompress stomach postoperative 4th marking 70 cm Duodenum
•• For gastric lavage (14-18 French Catheter is typically used for
suction, while enteral feeding tubes may be smaller 8 French).
Size in FR Color Code
•• For administration of medications or enteral feeding—when the
patient is unable to swallow (8 French) 8 Blue
•• To monitor gastric bleeding. 10 Black
Contraindications 12 White
•• Skull base fractures 14 Green
•• Facial fractures 16 Orange
•• Obstructed airway
18 Red

sy
•• Oesophageal varices
•• Clotting disorder 20 Yellow
Technique
Estimate the length of the tube to be inserted. Do this by measuring
the NG tube from the tip of the nose, to the earlobe and then to the
Ea SURG PLATE 3
ed
xiphisternum.
Lubricate the tip of the tube and begin to insert through one of the
nostrils. If any resistance is encountered change to the other nostril.
M

Ask the patient to take a mouthful of water and as they swallow

advance the tube to the desired length.
S

How to confirm its placement in stomach?

•• Greenish grey fluid on aspiration confirms that the tube is in
IM

stomach.
•• Inject 50 ml of air into the tube and listen for gurgling sound in
the epigastrium.
AI

•• pH readings should be between 1 and 5.5 for feeding to commence

safely.
A
•• Chest X-ray confirmation of placement is mandatory prior to
instilling material such as medications or tube feedings down an
NG tube.
Size
•• NG tube (for adult patients)—14-18 French
•• NG tube (for pediatric patients)—In pediatric patients, the correct
tube size varies with the patient’s age; to find the correct size (in
French), add 16 to the patient’s age in years and then divide by
2, so that for an 8-year-old child, for example, the correct size is
12 French ([8 + 16]/2 = 12)
Length
105-120 cm.
Parts
Manufactured from non-toxic, non-irritant medical grade PVC.
Four lateral eyes (to avoid blockage).
Tip of the tube contains lead or stainless steel shots to make it
radiopaque and heavier for easy introduction. B

AIIMS
 GENERAL SURGERY  • Color Plates 1209
Complications
•• Aspiration is probably the most frequent major complication.
The greatest risk of aspiration occurs during insertion. The risk
of aspiration can be minimized by evacuating the stomach prior
to tube placement.
•• Asphyxiation is caused by proximal migration of the tube and
can be prevented with endotracheal intubation. If tube migration
results in airway obstruction, cutting across all the tube lumens
just distal to the points of bifurcation allows immediate extraction
of the entire tube.
•• Esophageal perforation or rupture can occur with inflation of a
gastric balloon that is inadvertently placed in the esophagus or
can be secondary to esophageal mucosal necrosis that results
from excessive or prolonged inflation of the esophageal balloon.
•• Minor complications include pain, pharyngeal and gastroesopha-
geal erosions and ulcers caused by local pressure effects, pressure
necrosis of the nose, lips, tongue, and hiccups.

SURG PLATE 4

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C

SURG PLATE 3 KEY Ea

ed
Sengstaken–Blakemore Tube
A double-balloon tamponade system was developed by Sengstaken
and Blakemore for Balloon tamponade of bleeding esophageal
M

varices.

Parts
S

See PLATE 3B
IM

Indications
•• Acute life-threatening bleeding from esophageal or gastric varices
AI

that does not respond to medical therapy (including endoscopic

hemostasis and vasoconstrictor therapy)
•• Acute life-threatening bleeding from esophageal or gastric varices
when endoscopic hemostasis and vasoconstrictor therapy are
unavailable. SURG PLATE 4 KEY
Contraindications
Myer’s Vein Stripper
•• Recent surgery that involved the esophagogastric junction
•• Known esophageal stricture. Varicose vein stripper is used for stripping varicose veins of long and
short saphenous system.
Clinical Pearls
Parts
•• In most cases, the esophageal balloon is not inflated during the
initial placement of the tube. Never inflate the esophageal balloon •• 1 meter long flexible wire with detachable heads
before the gastric balloon. •• Fixed or detachable handle on one end
•• Keep a pair of scissors near the patient at all times in case the •• Various sized detachable olive on other end.
balloons migrate superiorly and obstruct the airway. The whole Sterilization
tube can be cut and removed.
By autoclaving.
•• Direct pressure from the tube can cause mucosal ulceration.
Perform frequent examinations to ensure that the tube is not Uses
placing excessive force on any given surface. Stripping varicose veins of long and short saphenous system second-
•• Generally, the esophageal tamponade tube is a temporizing ary to ligation and division of saphenofemoral or saphenopopliteal
measure and should not be left in place for more than 24 hours. junction.

GENERAL SURGERY
1210 Section II  •  Subject-wise Color Plates

SURG PLATE 5 SURG PLATE 6 KEY

Bard Parker’s Handle and Surgical Blades

•• BP handle one end is narrow to attach blades
•• Handle shaft is grooved or serrated for better grip
•• Number of handle written on shaft (say 3, 4, 5, 7) to attach with
different sized of blades
•• BP handle is reusable and sterilized by autoclaving
•• Surgical blades are detachable and disposable
•• Blade No. 10, 11, 12, 15 fits to BP handle number 3 and 5
SURG PLATE 5 KEY •• Blade number 18, 19, 20, 21, 22, 23, 24 fits to BP handle No. 4
•• Surgical blades No. 20 to 24 have wide shaft, and are used to make
Kelly’s Proctoscope larger incisions for laparotomy, mastectomy, etc. or for sharp
dissections to raise skin flaps
Indication •• Surgical blade No. 15 has narrow shaft and is used to make
•• Diagnostic: Piles, polyps, strictures, etc. smaller skin incisions and excesions of sebaceous cyst and lipoma,
•• Therapeutic: To inject sclerosant in prolapsed piles, cryotherapy venesection, etc.

sy
for piles, polypectomy, biopsy for carcinoma rectum and anal •• Surgical balde No. 11 has oblique edge with sharp pointed tip
canal. (AKA Stab knife), used commonly for abscess drainage, drain
Parts
Conican shape with proximal diameter more than distal, so as to illu-
minate the light at the required site. Obturator is the inner part for
Ea insertion, etc.

SURG PLATE 7
ed
easy insertion of proctoscope.

Types
M

Illuminating or nonilluminating.

Technique
S

•• Do digital rectal examination first

•• Proctoscope with obturator is inserted into the anal canal in the
IM

direction towards the umblicus

•• Obturator is removed and proctoscope is withdrawn
AI

•• During the course of withdrawal, any pathology is looked for.

Contraindication
Fissure in ano.

SURG PLATE 6
SURG PLATE 7 KEY

Needle Holding Forceps

•• Blades having criss cross or transverse serrations of needle holding
•• Blade length is smaller than haemostatic foceps
•• Blade have a central groove unlike haemostatic forceps
•• Modified box joint

AIIMS