SURGERY JIPMER MAY 2018

1. In Carcinoma head of pancreas, Nausea & vomiting is due to

a) External Compression of duodenum
b) Portal vein infiltration
c) Proliferation infiltration of tumor into duodenum
d) Chemotherapy related

Ans: A
Reference: Blumgarts 6th ed; pg. 979; Sabiston 20th ed; pg. 1544
Explanation:

• Pancreatic adenocarcinoma develops in the ductal cells and are called Ductal Adenocarcinoma.
• They most commonly occur on the Right side, ie, Head and Uncinate Process (60-70%) than left side,
ie, Body and Tail of pancreas (20-25%)
• Features of Carcinoma Head of Pancreas are
▪ Jaundice 75%
▪ Weight loss 51%
▪ Abdominal pain 39%
▪ Nausea/vomiting 13%
▪ Pruritus 11%
▪ Fever 3%
▪ Gastrointestinal bleeding 1%
• For tumors at the body and tail of pancreas, Pain(most common) and weight loss are the presenting
features as they present at a late advanced stage
• Regarding Nausea and vomiting, they occur due to tumor extrinsic compression of duodenum C loop
presenting a state of Gastric outlet obstruction.
• In unresectable cases, these patients should be offered Endoluminal duodenal metal stent as
palliation.

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2. According to AJCC 8th edition, Staging of 2cm size Pancreatic cancer if it involves portal vein is?
a) T1
b) T2
c) T3
d) T4

Ans: A
Reference: AJCC 8th edition manual, pg. 340-344
Explanation:

AJCC 8th edition has brought the following changes with regard to carcinoma pancreas
• T1 is subdivided into T1a, T1b and T1c based on size
• T2 and T3 are categorized based on size and not on extrapancreatic involvement anymore
• T4 is a radiological staging done by the relationship to vessels
• Nodal staging has N1 and N2 subdivisions unlike before N1 alone

Tx No primary tumor could not be assessed Nx Regional nodes cannot be assessed

T0 No evidence of primary tumor N0 No regional nodes
Tis Carcinoma in situ includes Pan-IN 3, IPMN with
high risk features
T1 Tumor < or = 2 cm in greatest dimension N1 One to three regional lymph nodes
T1a - < or = 0.5cm
 T1b – 0.5 to 1 cm
T1c – 1.0 to 2.0 cm
T2 Tumor > 2cm but < or = 4 cm N2 Four or more lymph nodes
T3 Tumor > 4cm in greatest dimension M0 No distant metastases
T4 Tumor any size involvement of celiac axis, superior M1 Distant metastases
mesenteric artery and common hepatic artery

• Portal vein or SMV involvement will not change the staging as per AJCC 7 and AJCC 8 th
edition. Staging Decided based on the Tumor size only.
• Borderline resectable lesion is lesion involvement > 180 degrees of PV/SMV or <180 degree
involvement of Coeliac axis/SMA.

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3. Liver tunneling procedure not done for which segment?

a) I
b) IV
c) V
d) VIII

Ans: C
Reference: Blumgart’s 6th edition Page 1705.
Explanation:

This is even high standard for MCh Preparatory exams.

In short, there are several difficulties in planning resections in liver as you cannot imagine. Just the criteria
for liver resection based on size alone not sufficient in planning. Finer details like its proximity to secondary
and tertiary portobiliary radicles and hepatic vein is necessary to guide liver resection.

Common liver resections are Right and Left hepatectomy and its extended versions based on the segments
removed.

New Terminologies and their removed segments

Procedure Name Removed Liver segments
Right hemihepatectomy Segments 5, 6, 7 and 8
Left hemihepatectomy Segments 2, 3 and 4
Right trisectionectomy Segments 4, 5, 6, 7 and 8
Left lateral sectionectomy Segment 2 and 3
Left trisectionectomy Segments 2,3, 4, 5 and 8

High Level Resections or Named liver resections with limitations to specific conditions based on the extent of
involvement in Hilar cholangiocarcinoma and Colorectal metastases and certain forms of HCC in unusual
locations like involving caudal lobe.

Taj Mahal Resection Segments IVa, V and I (caudate lobe) removed (hence the shape of
For Hilar cholangiocarcinoma Taj Mahal dome)

Dumbbell Form Resection Segments IVb, I (caudate lobe) and partial Segment V resection
For Cholangiocarcinoma about the right hepatic pedicle
Mini-Mesohepatectomy (MMH) For lesions involving the Middle hepatic vein at caval confluence
(not involving caudate lobe)
Liver Tunnel Procedure Segments I, IV and VIII are removed as part of parenchymal
(if caudate lobe involved as in above preserving liver surgery for selected liver tumors which are
condition) involving Middle hepatic vein along with Caudate lobe
 Liver Hanging Manoeuvre (LHM) It uses a tape between the anterior surface of Retrohepatic IVC and
liver surface to help in better lifting of the liver and efficient
vascular control if Anterior Approach for liver resection is planned
(it is the preferred procedure nowadays as it is a no-touch
technique)

Figure A represents the typical lesion needing Liver Tunnel Procedure ( CV- Communicating veins)
Figure B represents the post-operative resection including MHV.

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4. Pancreatic ascites. When to do surgery?

a) Symptomatic
b) Recurrent ascites following abdominal drainage
c) Not responding to medical therapy
d) Leak from the stented duct

Ans: D
Reference: Sabiston 20th ed; pg. 1531
Explanation:

• Pancreatic ascites is nowadays a rare entity occurs due to complete disruption of the pancreatic duct
leading to significant accumulation of fluid
• Common causes include following acute pancreatitis with duct disruption, chronic pancreatitis with
ductal obstruction with pseudocyst rupture and trauma causes.
• Features include abdominal distension due to free fluid abdomen.
• Diagnostic paracentesis shows elevated amylase and lipase levels suggesting pancreatic duct leak.
• Initial management includes therapeutic paracentesis and endoscopic placement of pancreatic stent
across the disruption.
• Failure of this stenting, mandates surgical exploration which involves distal pancreatectomy and
closure of the proximal stump.

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5. Best graft for infra-inguinal approach bypass?

a) Dacron
b) PTFE
c) Polyester
d) Autologous vein
Ans: D
Reference: Sabiston 20th ed; pg. 1774-1775
Explanation:

• Bypass surgeries are done for peripheral arterial occlusive diseases which are several enough (ie,
more than rest pain) and not eligible for Endovascular approaches (ie, TASC C or D lesions meaning
long segment occlusive disease or occlusion at trifurcation or bifurcation of vessels)
• Another important criteria for bypass is, there should be sufficient length of normal distal vessel to
allow for bypass anastomoses.
• For Bypass, two most common conduits used are
▪ PTFE (Polytetrafluroethylene) – synthetic graft, used for larger vessels like iliac and
axillary vessels
▪ Autologous vein (most commonly saphenous vein) – Autograft, so innate
antithrombotic properties, most preferred for infrainguinal bypass as they size
match well, better patency rates than PTFE
▪ Other graft is Dacron (polyethylene terephthalate or polyester) used in Aortic
aneurysm repair
• Saphenous vein used should be reversed, as they have valves which allow unidirectional flow. So
saphenous vein should be reversed (turned upside down) for bypass to allow any interruption to
blood flow. (Reversed saphenous vein graft)

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6. Best graft for aortic dissection

a) Dacron
b) Autologous vein
c) Autologous artery
d) PTFE

Ans: A
Reference: Sabiston 20th ed; pg. 1730
Explanation:

• Aortic dissection occurs when there is a defect in the intimal layer which permits blood to create
false channel within the aortic wall between media and adventitia.
• Stanford classification is most commonly used
• Type A (any involvement of ascending aorta) – surgical emergency
• Type B dissection mostly treated with Hypertensive control followed by endovascular stenting called
TEVAR (thoracic endovascular aneurysm repair)
• As mentioned above, all aortic surgeries are replaced with a synthetic graft – Dacron (woven/knitted
polyester) sutured with 2-0 polypropylene

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7. True about Splenunculi

a) It is encapsulated
b) MC site is tail of pancreas
c) Often single
d) Have more red pulp than spleen

Ans: A
Reference: Bailey and love, 27th ed; pg. 1178
Explanation:
 • Splenunculi or Accessory spleen is the most common of all splenic anomalies accounting for 10-30%
of population
• Formed due to incomplete fusion of embryologic splenic tissue during 5 th week leading to the
formation of accessory spleen, which is more common or always on the left side of abdomen.
• It is encapsulated just like the normal spleen and contains normal splenic tissue and are more
commonly identified during radiological investigations and intraoperatively for other conditions
• They are mostly multiple, located in the hilum of spleen (50%), tail of pancreas (30%)
• They are more prone for torsion and needs emergency resection in such cases.

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8. Not True regarding Sub Dural hematoma

a) Occurs on both sides
b) X ray not visible
c) Surgery can be done
d) Unilateral surgery

Ans: A
Reference: Bailey and love, 27th ed; pg. 334-335
Explanation:

• Subdural hematoma is collection of blood between the dura and arachnoid layers of the meninges
• Causes being Trauma leading to acute subdural hematoma and in elderly, even trivial trauma causes
bleed who are on anticoagulation
• Usually diagnosed with Non contrast CT brain which differentiates acute from chronic subdural
hematoma
• Acute subdural hematoma have characteristic finding of hyperdense concavo-convex lesion on side
of the brain with or without midline shift
• In acute conditions, urgent surgical evacuation is needed in the form of craniotomy or craniectomy.
• Those presenting with chronic subdural hematomas, anticoagulation should be reversed by Vitamin
K and steroids as conservative options. If severe, can undergo burr hole procedure to evacuate the
clot.

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9. Not a Temporary embolization agent is

a) Collagen
b) Gel foam
c) Thrombin
d) Onyx

Ans: D
Reference: Interventional Radiology Journal, Internet
Explanation:

• Embolization is an intentional endovascular occlusion of either an artery or vein and it is an

interventional radiological procedure.
• There are several agents discovered and each has its own merits and limitations based on the nature
of the agent, and the need for occlusion.
• General categorization of embolic agents are
 • Temporary embolization agents are used only for temporary occlusion of bleeding vessels which
allows recanalization in weeks, so not used in fistulas or tumors. They are used in traumatic
parenchymal bleeds from liver or spleen
• Permanent embolization agents are commonly used. Uses are
• Mechanical embolic agents like Coils and plugs used for focal vascular abnormalities like traumatic
bleeds or aneurysms
• Flow directed embolic agents are Liquid agents, Particulate agents which are used in AV
malformations, tumors etc.

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10. Examine the picture carefully. Diagnosis?

a) Ganglion
b) Dupuytren’s contracture
c) Fibromatosis
d) Rheumatoid nodule

Ans: C
Reference: Internet
Explanation: Orthopaedics question

• The above picture shows a plantar nodule in the concavity of the arch of the foot
• This rules out Ganglion, Rheumatoid nodule and Dupuytren’s disease which are associated with hand
• Plantar fascial fibromatosis or Ledderhose disease is similar to dupuytren’s disease in the hand.
• Both are fibrosing diseases causing fibrosing contracture of the plantar aponeurosis (as in
Ledderhose) leading to formation of nodules, which are painless.
 • After a period of time, this hinders with gait as it is situated most commonly at the height of arch of
foot.
• Needs excision before tendon shortening occurs.

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11. False about Pseudomyoxma peritonei is

a) Recurrence after surgery
b) Refractory to drugs
c) Hyperthermic intraperitoneal chemotherapy is treatment option
d) Most commonly associated with appendiceal tumour

Ans: B
Reference: Sabiston 20th ed; pg. 1080 & Bailey 27th ed; pg. 1316
Explanation:

• Pseudomyxoma peritonei is a rare condition which describes mucinous ascites arising from a
ruptured ovarian or appendiceal carcinoma.
• First described by Fraenkel, condition typically has progressive peritoneal tumor deposits, mucinous
ascites, omental cake and ovarian involvement in females
• Most commonly associated with appendiceal tumor
• Occurs most commonly in patients who are 40 to 50 years of age and occurs in equal frequency in
both males and females
• Risk of developing pseudomyxoma peritonei following removal of appendix harbouring epithelial
tumor is 9%, non mucinous neoplasm is 3% and 30% with mucinous adenocarcinoma
• Current accepted treatment is Cytoreductive surgery with Heated or Hyperthemia Intra Peritoneal
Chemotherapy (CRS + HIPEC) which includes omentectomy, stripping of involved peritoneum,
resection of involved organs and appendicectomy.
• The survival rates after CRS + HIPEC increased from 20 to 30% to 55% nowadays.

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12. True about Visceral aneurysm

a) Splenic artery is commonly involved
b) Hepatic aneurysm is operated irrespective of symptoms
c) Splenic artery aneurysm is most commonly followed by trauma
d) True aneurysms are more common nowadays with increasing abdominal trauma

Ans: A
Reference: Blumgarts 6th ed; pg. 1905 and Maingot’s abdominal operations; pg. 1245
Explanation:

Splenic artery aneurysm Hepatic artery aneurysm

Most common visceral aneurysm 60% Second most common 20%
Female predominance 1:4 Male predominance 2:1
Associated with Cirrhosis, Portal hypertension Associated with congenital or acquired factors
and pancreatitis
Mean age at presentation 62 years Mean age at presentation 60 years
Majority are solitary, extrahepatic 80% and true
aneurysms
Pseudoaneurysms occur following trauma Pseudoaneurysms occur following trauma, iatrogenic
procedures
 Risk of rupture: Most common site is Common hepatic 63% > right
Females hepatic 28% and then left hepatic
Pregnant women HAAs have the highest risk of rupture – false aneurysm,
Aneurysms > 2cm multiple aneurysm, more than 2 cm
All aneurysms > 2cm even if asymptomatic
needs intervention
Most common site of rupture – Intraperitoneal Most rupture intraperitoneally, but intrahepatic
rupture aneurysms rupture – Quincke’s triad – pain, jaundice and
hemobilia
Proximal lesions – Resection of aneurysm and Extrahepatic aneurysm:
end to end anastomoses Proximal to GDA – ligated
Distal lesions – Laparoscopic splenectomy Distal to GDA – aneurysmectomy and revascularization
Intrahepatic aneurysm
Percutaneous angioembolization

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13. Increases in D-dimer levels are noticed in immediate post-operative period. Most appropriate
cause is
a) DVT
b) Pulmonary embolism
c) DIC
d) Normal

Ans: A
Reference: Sabiston 20th ed; pg. 295
Explanation:

• D dimer is a degradation product of a cross linked fibrin blood clot.

• Increased levels are typically elevated in patients with acute thromboembolism
• D- dimer will increase only if thrombus has occurred and also with fibrinolysis.
• Presence of D-dimers in the circulation may serve as a marker of thrombosis or other conditions in
which a significant activation of the fibrinolytic system is present.
• Elevated D dimer should be followed by Venous Duplex ultrasound of the extremities for diagnosing
DVT.
• If there is a homogenous hypoechoic clot, without compressibility of the vein and absence of flow
across it confirms the diagnosis
• Initial treatment is with Low molecular weight heparin Enoxaparin 1.5mg/kg/day subcutaneous
twice daily along with Warfarin 5mg on day 1, 5 mg on day 2 and then 10 mg thereafter.
• Heparin overlap to be given for 5 days, as the anticoagulant action of warfarin takes 5 doses.
• Maintain INR 2.5 for DVT for 3 months, once recanalization of vein occurs, anticoagulants can be
withheld.

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14. Management of CA breast in 2nd trimester- all except? (repeat May 2017)
a) Chemotherapy Doxorubicin + Cyclophosphamide + 5FU
b) Mastectomy
c) Focal 3D
d) Breast conservative surgery is a valid option

Ans: C
Reference: Sabiston 20th ed; pg. 2059-2060
Explanation:
BREAST CANCER AND PREGNANCY

• Radiotherapy definitely avoided

• Chemotherapy avoided in first trimester, risk of teratogenicity is 10 to 25% and in second and third
trimesters its 1.3%
• After first trimester, sentinel node biopsy can be done safely
• Breast conserving therapy is becoming option nowadays in late 2nd trimester and 3rd trimester,
where neoadjuvant chemotherapy is given to downsize tumor and BCS done in third trimester along
with C section followed by RT after delivery

First trimester Mastectomy with axillary dissection

Second trimester Mastectomy with axillary dissection or sentinel node axillary staging
Neoadjuvant chemotherapy followed by Breast conservation surgery and RT post
delivery
Third trimester Mastectomy or BCS followed by RT post delivery

• Important considerations:
• Trastuzumab avoided in pregnancy
• Methotrexate avoided
• Chemotherapy drugs should not be given after 35 weeks of gestation – cause
myelosuppression in newborn

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15. ACR-TIRADS scan for thyroid nodule characteristics include all except
a) Margin
b) Echogenicity
c) Vascularity
d) Shape

Ans: C
Ref: ACR-TIRADS journal
Explanation: