MPMSU MBBS Surgery 2023 Paper 1 questions with their answers

Breast cancer is a multifactorial malignant disease involving genetic, hormonal, and environmental factors.

Non-Modifiable Risk Factors:

• Gender – Female > Male
• Age – Risk increases after 50 years
• Genetic mutations – BRCA1, BRCA2, TP53
• Hormonal – Early menarche, late menopause, prolonged estrogen exposure
• Race – Caucasians higher risk; African-Americans have aggressive subtypes
• Personal history – Prior breast cancer or benign breast lesions

Modifiable Risk Factors:

• Reproductive – Nulliparity, late first childbirth, no breastfeeding
• Lifestyle – Obesity, alcohol, sedentary lifestyle, high-fat diet
• Hormonal therapy – Long-term estrogen-progestin use
• Radiation – Prior chest wall radiation (e.g., Hodgkin lymphoma)

• Lump – Hard, irregular, immobile mass in breast
• Skin – Peau d'orange, dimpling, ulceration
• Nipple – Retraction, bloody or serous discharge
• Lymph nodes – Axillary or supraclavicular lymphadenopathy
• Pain – Late presentation, often painless initially

Defined as a tumor between 2–5 cm with or without mobile ipsilateral axillary nodes, but no distant metastasis.

1. Surgery:

• Breast-Conserving Surgery (BCS): Wide local excision with margins
• Mastectomy: In large or multifocal tumors
• + Sentinel lymph node biopsy or axillary dissection if nodes involved

2. Radiotherapy:

• Post-BCS: Whole breast irradiation
• Post-Mastectomy: Chest wall + regional lymph nodes if indicated

3. Chemotherapy:

• Adjuvant: Based on grade, nodal status (e.g., Doxorubicin + Paclitaxel)
• Neoadjuvant: If tumor large, to facilitate BCS

4. Hormonal Therapy (ER/PR+ tumors):

• Tamoxifen: For premenopausal women
• Aromatase Inhibitors: (Letrozole, Anastrozole) for postmenopausal

5. Targeted Therapy:

• HER2+ tumors: Trastuzumab ± Pertuzumab

6. Adjuvant Therapy:

• Planned based on tumor biology, grade, and node status
• Can include chemotherapy, hormonal, or targeted therapy

7. Follow-Up:

• Clinical exam + imaging (mammogram/USG/MRI)
• Serum markers (CA 15-3, CEA) in select cases

• Peripheral Neuropathy: Loss of protective sensation, dry skin due to autonomic neuropathy, and motor imbalance causing pressure points.
• Peripheral Vascular Disease: Poor healing due to involvement of small and medium arteries.
• Immunopathy: Impaired neutrophil function leads to delayed immune response.
• Foot Deformities: Charcot’s joints, hammer toes → abnormal pressure points → callus → ulcer.
• External Factors: Trauma, burns, nail cutting injury, improper footwear.

• Ulceration: Painless, located at pressure points, surrounded by callus, slough and foul-smelling discharge.
• Infection: Cellulitis, abscess, osteomyelitis – caused by Staph. aureus, Streptococci, anaerobes, gram-negative bacilli.
• Ischaemia: Cold foot, absent pulses, gangrene, delayed capillary refill.
• Charcot's Joint: Swollen, warm, painless foot with joint deformity.

• Glycaemic Control: Insulin, oral hypoglycaemics, and diet.
• Infection Control: Culture-based antibiotics, incision & drainage, sequestrectomy if osteomyelitis.

• Ulcer with slough: Debridement
• Healing ulcer: Skin grafting or reverse sural flap
• Abscess: Incision and drainage
• Gangrenous toe: Disarticulation
• Involvement of metatarsals: Forefoot amputation
• Spreading cellulitis: Below/above knee amputation
• Cellulitis + gangrene: Revascularisation

• Grade 1: Removal of slough, callus, blisters
• Grade 2: + Necrotic skin, subcutaneous tissue
• Grade 3: + Tendons, fascia, retinaculum
• Grade 4: + Infected muscle
• Extent (E): E1 (1 site), E2 (2 sites), E3 (3 sites)
• Repetition (R): R0 (no repeat), R1, R2, etc.

• Negative pressure therapy for large infected ulcers
• Removes fluid, reduces oedema, promotes granulation
• Indications: Diabetic ulcers, pressure sores, necrotising fasciitis
• Contraindications: Untreated osteomyelitis, necrotic eschar, malignancy

• Economical alternative to VAC
• Plastic sheet with intermittent suction

• Duplex USG: PSV ratio >2 = significant stenosis
• Angiography: Gold standard
• Short lesions: Balloon angioplasty ± stent
• Long lesions: Popliteal to tibial/pedal bypass with saphenous vein
• Even after revascularisation: 35% amputation, 2-year patency ~70%

• No barefoot walking; use microcellular rubber footwear
• Inspect foot daily, keep dry
• Trim nails carefully, avoid home remedies for corns
• Control sugars and avoid hot water baths (neuropathy)
• Triple Assessment: Look (ulcer/infection), Feel (pulses), Test (sensation)

• Biotherapy using sterile maggots to remove necrotic tissue
• Effective in MRSA and chronic non-healing wounds

• DKA with septicaemia
• Electrolyte imbalance
• Silent myocardial infarction

1. Simple Goitre

• Puberty goitre
• Colloid / Iodine deficiency goitre
• Multinodular goitre

2. Toxic Goitre

• Graves’ disease (Diffuse toxic goitre)
• Secondary thyrotoxicosis in MNG
• Toxic nodule (Autonomously functioning)

3. Neoplastic Goitre

• Benign: Follicular adenoma
• Malignant:
  • Well-differentiated: Papillary, Follicular carcinoma
  • Poorly differentiated: Anaplastic carcinoma
  • Parafollicular origin: Medullary carcinoma
  • Lymphatic origin: Non-Hodgkin’s lymphoma
• Secondary (Metastatic):
  • Renal cell carcinoma
  • Breast carcinoma
  • Malignant melanoma

4. Thyroiditis

• Granulomatous thyroiditis
• Autoimmune thyroiditis
• Riedel’s thyroiditis

5. Other Rare Causes

• Thyroid cyst
• Acute bacterial thyroiditis
• Thyroid abscess
• Amyloid goitre

1. Definition:

Palpable discrete swelling in an otherwise normal thyroid gland.

2. Clinical Evaluation

• Age, gender, duration, rapid growth
• Symptoms: hoarseness, dysphagia, pressure symptoms
• Radiation exposure or family history

3. Investigations

• Thyroid profile: TSH, T3, T4
• Ultrasound neck: cystic vs solid, echogenicity
• FNAC (Bethesda classification)
• Radionuclide scan: hot vs cold nodule
• CT/MRI if retrosternal extension

4. Bethesda Classification (FNAC)

• I. Non-diagnostic: Repeat FNAC
• II. Benign: Observe
• III. Atypia/FLUS: Repeat FNAC / lobectomy
• IV. Follicular neoplasm: Lobectomy
• V. Suspicious: Lobectomy / Total thyroidectomy
• VI. Malignant: Total thyroidectomy

5. Treatment A. Benign Nodule

• Observation if small and asymptomatic
• Hemithyroidectomy if symptomatic or suspicious

B. Toxic Nodule

• Antithyroid drugs
• Radioiodine ablation
• Hemithyroidectomy in young patients

C. Malignant/Suspicious Nodule

• Total thyroidectomy ± neck dissection
• Radioiodine therapy
• TSH suppression with thyroxine

Abdominal Compartment Syndrome is a sustained intra-abdominal pressure (IAP) >20 mmHg with or without abdominal perfusion pressure (APP) <60 mmHg, associated with new organ dysfunction or failure.

• Ranges from 0–5 mmHg
• Shows phasic variation with respiration

• Grade I: IAP 12–15 mmHg
• Grade II: IAP 16–20 mmHg
• Grade III: IAP 21–25 mmHg
• Grade IV: IAP >25 mmHg

Elevated IAP compromises organ perfusion leading to multi-organ dysfunction.

Systems affected:

• Pulmonary: Intractable hypoxia, ARDS
• Cardiovascular: Cardiac insufficiency, arrest
• Renal: Oliguria, anuria, acute renal failure
• CNS: Cerebral edema, anoxia

A. Diminished Abdominal Wall Compliance:

• Tight closure post abdominal surgery
• Massive hernia reduction
• Obesity (central)
• Burns/trauma
• Prone positioning, HOB >30°

B. Increased Intraluminal Contents:

• Gastroparesis
• Acute gastric dilatation
• Ileus
• Colonic pseudo-obstruction

C. Increased Abdominal Contents:

• Ascites
• Haemoperitoneum
• Pneumoperitoneum
• Liver dysfunction
• Laparoscopy

• Measured in mmHg (1 mmHg = 1.36 cm H₂O)
• Measured at end-expiration in supine position
• Zeroed at mid-axillary line at iliac crest
• Use ≤25 ml saline in bladder
• Wait 30–60 sec post-instillation for detrusor relaxation

Medical Management:

• Close hemodynamic monitoring
• Blood transfusion as needed
• Nutritional support (IV/TPN)
• Treat underlying cause

Surgical Management:

I. Temporary Abdominal Closure (TAC)

• Skin-only closure with towel clips
• Dual-layer Mesh: Vicryl (inner), Prolene (outer)
• PTFE Mesh (ePTFE) – antimicrobial + promotes tissue ingrowth
• Bogotá Bag: Sterile irrigation bag sutured to wound margin
  • Transparent, allows inspection
  • Prevents evisceration
  • Useful in ischemic bowel resections
• VAC Therapy: Negative pressure system
  • Removes inflammatory debris
  • Used in open abdomen and severe pancreatitis

II. Definitive Abdominal Closure

• Primary closure (non-absorbable suture, layer-wise)
• Synthetic mesh
• Biologic mesh
• Component separation
• Plastic surgical reconstruction (if needed)

Paget’s disease of the breast is a rare form of breast cancer that typically involves the nipple and the areola. It is characterized by the presence of eczema-like changes of the nipple skin, which may be associated with an underlying breast malignancy, most commonly invasive ductal carcinoma.

Etiology:

The exact cause remains unclear, but it is believed to result from the spread of malignant cells from an underlying breast carcinoma to the skin of the nipple and areola.

Pathophysiology:

It is associated with infiltration of Paget cells (malignant cells) into the epidermis of the nipple. These cells are derived from the underlying ductal carcinoma.

Risk Factors:

• Age (usually seen in women over 50)
• Family history of breast cancer
• History of other breast diseases

Nipple Changes:

• Eczematous, scaly, or ulcerated appearance of the nipple and areola
• Often with itching, burning, or pain

Discharge:

• Bloody or serous discharge from the nipple is common.

Lumps:

• A palpable mass may be present, indicating underlying breast cancer.

Occasionally:

• In advanced cases, ulceration or thickening of the nipple skin can occur.

• Invasive Paget's Disease: Involves underlying invasive carcinoma, typically invasive ductal carcinoma.
• Non-invasive Paget's Disease: Limited to the nipple and areola, without invasive cancer. It is rare.

Clinical Examination:

• Thorough breast examination, including palpation of the breast and lymph nodes.

Mammography:

• Used to detect underlying breast cancer.

Ultrasound:

• Helps assess the size, location, and nature of any breast mass.

Biopsy:

• A skin biopsy of the nipple is crucial for diagnosis, revealing Paget cells.

Histopathology:

• Confirmation of Paget's disease is based on the presence of large, pale cells (Paget cells) in the epidermis.

• Eczema: A benign skin condition that may mimic the eczema-like lesions of Paget’s disease.
• Contact Dermatitis: Another inflammatory condition that affects the nipple.
• Infection: Nipple infection or abscess can cause nipple discharge and skin changes.

Surgical Management:

• Wide Local Excision: Removal of the nipple, areola, and underlying breast tissue if there is an invasive carcinoma.
• Mastectomy: Total mastectomy may be needed if the carcinoma is widespread or multifocal.

Radiotherapy:

• May be used after surgery if the margins are positive or for more localized cases of Paget’s without invasive cancer.

Chemotherapy and Hormonal Therapy:

• Indicated if invasive carcinoma is present, based on receptor status (e.g., estrogen receptor-positive, HER2 status).

Sentinel Lymph Node Biopsy:

• Performed to assess lymph node involvement.

Collection of pus in the pleural space is called empyema.

It is the end-stage result of pleural effusion and infection.

Examples:

• Following haemothorax
• Lung abscess
• Pneumonia

In India: Tuberculosis is an important cause.

Other Causes:

• Oesophageal perforations (iatrogenic/spontaneous)
• Rupture of:
  • Subphrenic abscess
  • Hydatid cyst
  • Amoebic liver abscess

Classical Progression (Post-pneumonia):

1. Exudative phase: Pleural effusion
2. Fibropurulent stage: Thickening of fluid
3. Organising phase: Lung covered by thick cortex

• History of fever diagnosed as pneumonia or tuberculosis
• Chest pain, breathlessness
• Tenderness over chest
• Toxic features in acute empyema (especially children)
• Presence of thick pus with thick cortex of fibrin/coagulum over lung

Chest X-ray:

• May show lung collapse
• Tracheal deviation
• Evidence of pneumonia/tuberculosis

Pleural Fluid Aspiration and Analysis:

• Shows exudate (in pneumonia)
• Send for bacterial culture

CT Scan:

• May show split pleura sign
• Helps detect tuberculous spine

Video-Assisted Thoracoscopic Surgery (VATS):

• 3–4 ports
• Minimal incision, less pain, fast recovery
• Can perform:
  • Drainage
  • Pleural biopsy
  • Talc pleurodesis
  • Debridement
  • Intercostal tube drainage (ICD)

Rib Resections and Drainage via Window – Eloisier’s Method Decortication:

• More radical
• Via thoracotomy
• Involves debridement and excision of thick lung cortex to allow lung expansion
• Done by posterolateral thoracotomy

• Toxicity, septic shock, multiorgan failure if untreated
• Damage to lung → may need lobectomy or pneumonectomy

A lucid interval is a temporary period of regained consciousness after an initial loss of consciousness, followed by subsequent neurological deterioration.

It is classically seen in epidural (extradural) hematoma, where a patient loses consciousness due to head trauma, regains it (lucid phase), and then deteriorates as the hematoma expands.

• Haemolytic reactions:
  • Major incompatibility (ABO mismatch): Intravascular haemolysis → haematuria, loin pain, renal failure.
  • Minor incompatibility: Mild jaundice, fever due to extravascular haemolysis.
• Non-haemolytic reactions:
  • Febrile reaction: Sensitization to WBCs → fever.
  • Allergic reaction: Urticaria, chills; responds to antihistamines.
  • TRALI (Transfusion-Related Acute Lung Injury): Non-cardiogenic pulmonary edema due to antileukocyte antibodies.
  • CCF (Congestive Cardiac Failure): From rapid transfusion in chronic anaemics.

Universal precautions are a set of practices used to prevent transmission of blood-borne pathogens (like HIV, HBV, HCV) in healthcare settings.

• Use of gloves, masks, goggles, and gowns when handling blood or body fluids.
• Hand hygiene before and after patient contact.
• Safe disposal of sharps (needles/blades) in puncture-proof containers.
• Avoid recapping needles.
• Proper disinfection and sterilization of instruments and surfaces.
• Immediate action and reporting after needle-stick injuries.

A hypertrophic scar is a type of scar that results from prolonged inflammation during wound healing, characterized by thickened, raised tissue.

• Occurs due to prolonged inflammatory phase of wound healing.
• Does not worsen after 6 months.
• Nontender and non-vascular.
• Limited to the boundaries of the original wound or incision, but rises above the skin.
• Itching, if present, is mild.

• Stockings, armlets, or elastic bandages to reduce scar formation.
• Excision if necessary.
• Silicone gel application.
• Topical retinoids.

A thyroglossal cyst is a congenital cyst that arises from the thyroglossal duct, which extends from the foramen caecum at the base of the tongue to the isthmus of the thyroid gland.

• Common in females, presenting as a painless, midline swelling, typically around ages 15–30.
• Cyst is soft, cystic, and fluctuating, with negative transillumination.
• Characteristic mobility: moves with deglutition, protrusion of the tongue, and sideways motion.

• Preoperative thyroid scan is required to check for functioning thyroid tissue.
• Sistrunk operation – Excision of the cyst along with the thyroglossal duct and part of the hyoid bone is the standard treatment.

A life-threatening condition caused by a valvular air leak from the lung leading to increased intrapleural pressure, lung collapse, and mediastinal shift, reducing venous return and ventilation.

• Sudden onset dyspnoea, tachypnoea
• Tachycardia
• Tracheal shift to opposite side
• Tympanic percussion note
• Absent breath sounds on affected side

• Immediate needle thoracocentesis in 2nd intercostal space, midclavicular line
• Followed by intercostal chest drain insertion connected to an underwater seal
• Do not wait for chest X-ray