MPMSU MBBS Surgery 2022 Paper 1 questions with their answers

A. Closed Wounds

• Contusion: Minor or major soft tissue injury without skin break. Skin discoloration due to blood collection.
• Abrasion: Epidermis scraped off exposing dermis. Painful due to exposed nerve endings. Requires cleaning, antibiotics, dressings.
• Haematoma: Blood collection post-injury. Seen in bleeding disorders (e.g., haemophilia).
  Types: Subcutaneous, Intramuscular, Intra-articular, Subperiosteal.
  Small: Absorbs naturally.
  Large: May need aspiration and compression. Can get infected.

B. Open Wounds

• Incised Wounds: From sharp objects (knife, blade, glass). Sharp edges, less contaminated. Primary suturing ideal.
• Lacerated Wounds: From blunt injury (fall/RTA). Jagged edges with crushed tissue, haematoma or necrosis. Treated by excision + suturing (within 6 hrs).
• Penetrating Wounds: From stab injuries (abdomen). May appear small externally but can injure internal organs. Observation and exploration recommended.
• Crushed/Contused Wounds: Blunt trauma (run over, collapse, industry). Dangerous—risk of bleeding, necrosis, gas gangrene. Requires thorough debridement.

• Tidy Wounds: Incised, clean, minimal tissue loss.
• Untidy Wounds: Crushed, avulsed, contaminated, with devitalised tissue and loss.

• Acute Wounds: Stab wounds, RTAs, blast injuries.
• Chronic Wounds: Leg ulcers, pressure sores.

• Primary Intention: Clean incised wound (e.g., surgical). Heals with a neat, thin scar.
• Secondary Intention: Infected/discharging wounds or with skin loss. Heals with ugly scar.

1. Inflammatory Phase (Lag Phase)
   Release of inflammatory mediators (histamine from platelets, mast cells, granulocytes).
   Increased capillary permeability.
   Kinins, prostaglandins attract WBCs and fibroblasts.
   First 48 hrs: PMNs remove dead/necrotic tissue.
2. Proliferative Phase (Collagen Phase)
   3rd–5th day: PMNs decrease, monocytes increase (specialised scavengers).
   Fibroblasts appear → Protocollagen → Collagen (needs O₂, Fe²⁺, Vitamin C).
   Granulation tissue forms from fibroplasia + capillary budding.
   Fibroblasts secrete proteoglycans (ground substance) → Binds collagen.
   Epithelialisation: From wound edges by basal cells (within 48 hrs). Also from skin appendages in wounds with skin loss. Surface cells keratinise gradually.
3. Remodelling Phase (Maturation Phase)
   Starts after day 4, ends ~day 14.
   Myofibroblasts contract wound → Reduces defect size.
   Contraction better over loose skin (back, gluteal), poor over shin, malleolus.
   Delayed by corticosteroids, irradiation, chemo.
4. Scar Formation Phase
   Increased fibroplasia and collagen deposition.
   Devascularisation.
   Continued epithelialisation.
   Ingrowth of lymphatics and nerve fibres.
   Collagen remodelling → Scar (cicatrisation).

A. General Factors

• Age: Faster in children; slow in elderly (↓ dermal collagen, disorganised fibres).
• Debilitation: Malnutrition → ↓ Vitamin C → ↓ Collagen. Zinc deficiency → Delayed healing (rare, seen in burns, trauma, cirrhosis).
• Diabetes Mellitus: ↓ Healing due to microangiopathy, atherosclerosis, ↓ phagocytosis, ↑ bacterial proliferation, ↓ immunity.
• Jaundice/Uraemia: Delayed fibroblastic repair.
• Cytotoxic Drugs & Malignancy: Delay healing.
• Generalised Infection: Pus delays healing.
• Corticosteroids: Early use delays healing via anti-inflammatory action. Later use is safe.
• Malnutrition: Affects healing, intestinal leaks, wound dehiscence. Albumin <2 g/dL → Poor healing.

B. Local Factors

• Poor Blood Supply: Shin wounds heal slow; facial wounds heal fast.
• Local Infection:
  Destroys sutures and granulation tissue.
  Bacterial load >10⁵/mg tissue or β-hemolytic streptococci → No healing.
  Collagen synthesis ↓; Collagenolysis ↑.
  Give antibiotics within 2 hrs.
• Haematoma: Promotes infection.
• Faulty Wound Closure Technique.
• Suturing Under Tension.
• Hypoxia:
  ↓ Macrophage and fibroblast function.
  ↓ Collagen synthesis.
  Anaemia → ↓ angiogenesis, ↓ collagen.
  Smoking → Vasoconstriction + ↑ CO.
• Ionising Radiation: Endothelial injury → Endarteritis → Atrophy, fibrosis.
• Foreign Body: Delays healing.

I. Developmental Swellings

• Thyroglossal cyst
• Lingual thyroid
• Ectopic thyroid
• Thyroglossal fistula
• Pyramidal lobe enlargement

II. Inflammatory Conditions

• Acute thyroiditis – Suppurative (bacterial)
• Subacute thyroiditis – De Quervain’s thyroiditis (granulomatous)
• Chronic thyroiditis:
  • Hashimoto's thyroiditis (autoimmune)
  • Riedel’s thyroiditis (fibrous)

III. Non-neoplastic Goitres

• Diffuse simple goitre
  • Puberty goitre
  • Physiological goitre
• Multinodular goitre
• Colloid goitre
• Toxic goitre
  • Diffuse toxic (Graves’ disease)
  • Toxic multinodular goitre
  • Toxic adenoma

IV. Neoplastic Swellings

• Benign Tumours: Follicular adenoma
• Malignant Tumours:
  • Papillary carcinoma
  • Follicular carcinoma
  • Medullary carcinoma
  • Anaplastic carcinoma
  • Primary lymphoma of thyroid
  • Metastatic deposits to thyroid (rare)

V. Others / Miscellaneous

• Thyroid cyst
• Amyloid goitre
• Sarcoidosis involving thyroid
• Parasitic cysts (rare)

• Common in females. Female: male ratio is 10:1. Seen in the age group of 20–40 years.
• Long duration of swelling in front of the neck, dyspnoea due to tracheomalacia and dysphagia are the presenting features.
• The gland is nodular, firm in consistency and both the lobes are enlarged. Hard areas may suggest calcification and soft areas, necrosis.
• Sudden increase in size with pain is mainly due to haemorrhage in a nodule.

Investigations

1. Complete blood picture (CBP), routine urine examination and fasting and postprandial blood sugar to rule out diabetes mellitus.
2. X-ray of the neck: Anteroposterior and lateral view
   • To look for compression of trachea—to check feasibility of intubation during anaesthesia
   • To rule out retrosternal extension—soft tissue shadow seen
   • Calcification in long-standing MNG
3. Flexible laryngoscopy is done to see vocal cord mobility (this has replaced indirect laryngoscopy).
4. Ultrasonography
   • High frequency ultrasound is a very useful investigation especially in cases of solitary nodule
   • Even in multinodular goitres, ultrasound-guided FNAC can be done
   • It can also detect clinically impalpable lymph nodes in the neck (suggest malignancy)
   • Inexpensive, easily done and often the first investigation in thyroid swellings
5. Fine needle aspiration cytology (FNAC)
   • Done in suspected hard nodule of multinodular goitre
   • Simple and useful to detect malignancy
   • Since treatment is often total thyroidectomy and ultrasound can rule out malignancy, FNAC is done only in suspicious cases
6. CT scan
   • When you suspect retrosternal extension, doubtful resectability, or large lymph nodes in the neck
   • May also show intrathoracic lymph nodes

• Puberty goitre: 0.1 g to 0.2 mg of thyroxine
• Iodine deficiency goitre: Use iodised salt, sea food, milk, egg, etc.
• Goitrogens: Avoid cabbage, drugs

1. Total thyroidectomy
   • The choice today provided complications like recurrent laryngeal nerve paralysis and hypocalcaemia can be avoided
   • Desirable in high volume centres with experienced surgeons
   • Offers permanent and quick cure
2. Subtotal thyroidectomy
   • Parts of right and left lobes and entire isthmus are removed in flush with tracheal surface
   • Leaves a little tissue in the tracheoesophageal groove to protect recurrent laryngeal nerve and parathyroid gland
3. Dunhill procedure
   • Total lobectomy on one side and subtotal lobectomy on the other side when one lobe is completely replaced with nodules and a few nodules on the other side

• Some surgeons give 0.1 mg thyroxine for 2–5 years to suppress TSH stimulation
• Risks of long-term thyroxine therapy:
  • Osteoporosis
  • Atrial fibrillation
  • Increased morbidity and mortality from cardiovascular disease
• Patients should be informed about these complications

These are the most common causes of cervical lymphadenopathy.

• Viral Infections: Common cold (rhinovirus), Influenza, Mononucleosis (Epstein-Barr virus), HIV, Herpes simplex virus (HSV), Adenovirus (respiratory infections), Cytomegalovirus (CMV)
• Bacterial Infections: Streptococcal pharyngitis (strep throat), Tuberculosis (TB), Cat scratch disease (Bartonella henselae), Tonsillitis or abscess, Diphtheria, Non-tuberculous mycobacteria
• Fungal Infections: Histoplasmosis, Coccidioidomycosis, Blastomycosis

• Autoimmune Disorders: Systemic lupus erythematosus (SLE), Rheumatoid arthritis, Sarcoidosis
• Malignant Causes: Lymphoma (Hodgkin's and Non-Hodgkin's), Leukemia, Metastatic cancer (e.g., from head and neck, breast, lung, or gastrointestinal cancers)
• Reactive Lymphadenopathy: Lymph nodes react to a local or systemic infection, inflammation, or trauma

• Medications: Drug-induced lymphadenopathy (e.g., phenytoin, allopurinol, sulfonamides)
• Kikuchi Disease: A rare, self-limited condition often associated with fever
• Rheumatic Fever: Can cause swollen lymph nodes as part of systemic inflammation

Anti-tubercular Drugs (ATT) are essential in treating lymph node tuberculosis (TBLN).

First-line drugs for drug-sensitive TB: Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), Ethambutol (E), and Streptomycin (S).

TBLN management is based on drug susceptibility and patient history.

• a. Drug-Sensitive Tuberculosis (DST)
  • Intensive Phase (IP): 2 months – HRZE (Isoniazid, Rifampicin, Pyrazinamide, Ethambutol)
  • Continuation Phase (CP): 5 months – HRE (Isoniazid, Rifampicin, Ethambutol)
• b. Previously Treated Cases
  • IP: 2 months of HRZE + 1 month of HRZE
  • CP: 5 months of HRE

• a. MDR-TB (Resistance to Rifampicin and Isoniazid)
  • IP: 6–9 months – Kanamycin, Levofloxacin, Pyrazinamide, Ethambutol, Cycloserine, Ethionamide
  • CP: 18 months – Levofloxacin, Ethambutol, Cycloserine, Ethionamide
  • Note: If sensitive to Isoniazid but resistant to Rifampicin, add Isoniazid in both phases
• b. Isoniazid Mono-Resistance
  • IP: 3–6 months – Kanamycin, Levofloxacin, Rifampicin, Pyrazinamide, Ethambutol
  • CP: 6 months – Levofloxacin, Rifampicin, Pyrazinamide, Ethambutol

Individualized Treatment: Based on drug sensitivity testing results.

• HIV is a significant risk factor for extrapulmonary TB
• PLHIV have higher risk of tuberculous lymphadenitis
• Nodes often symmetrical, multiple, with higher mycobacterial load
• Response to treatment is similar, but higher recurrence and death rates in PLHIV
• Chest radiography may show pulmonary TB along with TBLN

• Common sites: Cervical (63.3%), Mediastinal (26.7%), Axillary (8.3%)
• Descending order: Cervical (64.9%), Axillary (27%), Mediastinal (8%)
• Types of involvement:
  • Only cervical: 63.6%
  • Cervical + axillary + inguinal: 15.1%
  • Hilar nodes only: 6%
  • Only inguinal: 3%
  • Axillary + inguinal: 3%
  • Axillary + abdominal + hilar: 3%

• Biopsy: Wedge biopsy from lymph node edge for diagnosis
• Aspiration: Non-dependent aspiration of cold abscess/pus. Send sample for AFB staining and Ziehl-Neelsen stain
• Excision: For persistent lymph node enlargement despite ATT
• Sinus/fistula tract excision: Required if sinus or draining fistula forms

• Acute pelvic conditions
• Ovarian diseases
• Tubal pregnancy
• Infertility
• Staging of malignancy
• Biopsy from the tumours
• In chronic pain abdomen where ultrasound, endoscopies, barium studies are negative, diagnostic laparoscopy is useful
• Needle laparoscopy (2 mm sized) is becoming popular, especially for diagnostic purposes

• Laparotomy is avoided
• Once diagnosis is made, therapeutic procedure can also be carried out in the same sitting

a. Major (ABO) Incompatibility

• Caused by mismatched transfusion (technical errors: sampling, labeling, dispatch)
• Leads to intravascular haemolysis

Clinical Features:

• Haematuria
• Bilateral loin pain
• Fever, chills, rigors
• Oliguria → Acute Tubular Necrosis (ATN)

Treatment:

• Stop transfusion; send blood bag for recheck
• Repeat coagulation profile
• IV fluids, monitor urine output
• Check urine for hemoglobin
• Diuresis: Inj. Furosemide 20–40 mg IV / Mannitol 20% 100 mL IV
• Hemodialysis if renal failure
• Cardiovascular support if unstable

b. Minor Incompatibility

• Extravascular haemolysis; occurs 2–21 days post-transfusion
• Due to antibodies to minor antigens

Features:

• Malaise, jaundice, fever
• Usually mild

Treatment:

• Supportive only

a. Febrile Non-Haemolytic Reaction (FNHR):

• Sensitization to donor WBCs/platelets
• Fever, no haemolysis
• Prevent: Use leukocyte-depleted blood / 20–40 µm filters

b. Allergic Reaction:

• Due to plasma proteins
• Features: Rash, chills, rigors
• Rx: Inj. Chlorpheniramine maleate 10 mg IV

c. TRALI (Transfusion-Related Acute Lung Injury):

• Occurs within 6 hrs
• Caused by antileukocyte antibodies → neutrophil aggregation in lungs → non-cardiogenic pulmonary oedema

Features:

• Mild dyspnoea to ARDS
• Rx: Supportive (O2, fluids); resolves in 24–48 hrs

d. Congestive Cardiac Failure (CCF):

• Risk ↑ in rapid transfusion in chronic anaemia

Rx:

• Slow transfusion
• Inj. Furosemide 20 mg IV
• Prefer packed cells over whole blood

• Diseases transmitted: Hepatitis B/C, HIV, Malaria, Syphilis
• Risk ↑ with multiple transfusions/emergency transfusions
• Prevention: Mandatory screening before transfusion

Definition:

• > 1 blood volume in 24 hrs / >10 units in 24 hrs
• > 4 units RBC/hr with ongoing bleeding
• > 500 mL in 5 mins with instability

Common Causes:

• Trauma, PPH, major surgery

Massive Transfusion Protocol (MTP):

• Inform blood bank early
• Initial cross-match + 2 units PRBC
• Blood released in boxes (components mix)
• Stop MTP when bleeding stops

Monitoring:

• Acid-base status
• Hb, Platelet count
• PT, aPTT, Fibrinogen
• Serum Calcium

• Infective gangrene of subcutaneous tissue
• Organism: Staphylococcus aureus
• Common in diabetics, immunocompromised, or post-radiotherapy patients

• Nape of neck (most common)
• Back, shoulders (due to coarse skin and poor vascularity)

• Begins as folliculitis → perifolliculitis
• Rapid spread in diabetics → necrosis of subcutaneous fat
• Forms intercommunicating abscesses → open via multiple sieve-like openings
• Cribriform appearance = pathognomonic
• Eventually forms a crateriform ulcer with central slough

• Typically seen in diabetic patients
• Severe pain & swelling (esp. nape of neck)
• Fever with chills, rigors
• Red-hot, angry looking surface
• Indurated margins
• Central softening → vesicles → rupture with pus discharge
• Cribriform appearance → Late stage: crateriform ulcer

• Diabetic ketoacidosis (DKA)
• Extensive skin necrosis
• Septicaemia / Toxaemia

• Causative organism: Cocci (Staph aureus)
• Abscesses: Communicating
• Surface: Red-hot like Coal
• Appearance: Cribriform → Crateriform ulcer
• Type: Cutaneous Gangrene
• Drug of Choice: Cloxacillin
• Comorbidity: Control Diabetes
• Surgery: Cruciate Incision

Medical:

• Control diabetes (injectable insulin)
• Antibiotics:
• MSSA: Cloxacillin, flucloxacillin, erythromycin, cephalosporins
• MRSA: Vancomycin IV
• Improve general condition

Surgical:

• If no pus or signs of healing → No incision
• If pus present → Cruciate incision
• Excise skin flaps
• Drain pus, break loculi
• Remove slough, irrigate
• Heal by secondary intention

• Embedded toenail; exact etiology unclear
• May have family history
• Excessive trimming of nails can contribute

• Nail grows into surrounding soft tissue
• Infection occurs → granulation tissue formation
• Leads to pain, discomfort, and unsightly appearance

• Painful, especially when walking
• Disturbing and unsightly appearance
• Granulation tissue may pout from the nail margin

1. Conservative Management

• Dressings with antiseptic agents (e.g., iodine)
• Copper sulphate for granulation tissue
• Antibiotics for infection control

2. Surgical Management

• Partial nail removal (under local anaesthesia)
• Apply phenol to the nailbed base to prevent regrowth
• Healing time: 10–15 days

3. Radical Surgery

• Zadik’s or Fowler’s operation:
• Expose lateral spike and germinal matrix
• Incise lateral skin margin and root of the nail

• Patients with ischemic or non-ischemic cardiomyopathy
• LVEF ≤ 35%
• NYHA Class II or III symptoms
• On optimal medical therapy

• Survivors of cardiac arrest due to:
• Ventricular fibrillation (VF)
• Hemodynamically unstable ventricular tachycardia (VT)
• Not due to a reversible cause

• Vacuum therapy
• Vacuum sealing
• Topical negative pressure therapy

• Removes blood/serous fluid from wounds or post-op sites
• Promotes faster wound healing

• Open-cell foam inserted into wound
• Drain with multiple lateral holes placed
• Sealed with transparent adhesive membrane over wound + surrounding skin
• Drain connected to vacuum system → fluid drawn into a collection bag
• Membrane prevents air/bacterial entry, maintains partial vacuum

• Negative pressure effects:
• Removes interstitial fluid → ↓ oedema
• ↑ local blood flow
• ↓ bacterial load
• Mechanical stretch on cells → ↑ protein & matrix synthesis → ↑ cell proliferation
• Pressure range: 25–200 mmHg (controlled via microprocessor unit)
• Can be continuous or intermittent

• Chronic ulcers: Venous, diabetic, post-necrotising fasciitis
• Open fractures
• Soft tissue defects:
• Sacral pressure ulcers
• Traumatic wounds
• Infected defects post-fixation of lower limb fractures
• Burns and wounds in perineum, hand, axilla

• Untreated osteomyelitis (treat first, then VAC)
• Internal fistula
• Necrotic tissue with eschar
• Malignancy within the wound area

The Rule of Nine is a clinical method used to estimate the Total Body Surface Area (TBSA) affected by burns in adults.

• Head and neck: 9%
• Each upper limb: 9% (4.5% front + 4.5% back)
• Each lower limb: 18% (9% front + 9% back)
• Anterior trunk: 18%
• Posterior trunk: 18%
• Perineum: 1%

(When enteral nutrition is not possible or contraindicated for ≥7–10 days)

• High-output GI fistulas (duodenal, biliary, pancreatic)
• Major abdominal surgeries (liver, pancreas, biliary tract, colon)
• Severe pancreatitis
• Short bowel syndrome
• Bowel ischemia or obstruction
• Severe peritonitis or ileus
• Massive GI bleeding
• Hemodynamic instability
• High risk of aspiration
• Hyperemesis gravidarum
• Multiorgan failure
• Severe burns
• Head injury
• Severe sepsis or multiple trauma

• Cardiac failure
• Blood dyscrasias
• Altered fat metabolism