MPMSU MBBS Surgery 2023 Paper 2 questions with their answers

1. Genital Warts (Buschke-Löwenstein Tumour)

Giant condyloma acuminatum, exophytic and cauliflower-like.

Can mimic squamous cell carcinoma; may have malignant foci.

2. Erythroplasia of Queyrat

Red, raw lesion on glans or inner prepuce.

Considered carcinoma in situ (intraepithelial neoplasia).

3. Leukoplakia

Persistent patch on glans or prepuce.

Unlike oral leukoplakia, not always white. May progress to malignancy.

4. Bowen’s Disease

Eczematous plaque on penile skin; carcinoma in situ variant.

May evolve into invasive squamous cell carcinoma.

Lack of Circumcision

Smegma accumulation leads to chronic irritation → dysplasia → carcinoma.

Common in uncircumcised males (e.g., Hindus, Christians).

Rare in Muslims and Jews due to early circumcision.

Phimosis

Causes smegma retention and chronic inflammation.

HPV Infection

Especially HPV 16 and 18, associated with high-risk squamous cell carcinoma.

Poor Hygiene

Contributes to chronic irritation and inflammation.

Smoking

Increases risk of penile cancer.

T – Primary Tumour

Tx: Primary tumour cannot be assessed

T0: No evidence of primary tumour

Tis: Carcinoma in situ (Erythroplasia of Queyrat)

Ta: Non-invasive verrucous carcinoma

T1a: Invades subepithelial tissue; no LVI; well/moderate grade

T1b: Subepithelial invasion with LVI or poor differentiation

T2: Invades corpus spongiosum with/without urethra

T3: Invades corpus cavernosum with/without urethra

T4: Invades adjacent structures (prostate, scrotum, pubic bone)

N – Regional Lymph Nodes

Nx: Regional lymph nodes cannot be assessed

N0: No lymph node metastasis

N1: Single, unilateral inguinal node, mobile

N2: Multiple or bilateral superficial inguinal nodes, mobile

N3: Fixed inguinal/pelvic nodes, or deep inguinal nodes

M – Distant Metastasis

M0: No distant metastasis

M1: Distant metastasis present

I. Treatment of Primary Tumour

Stage I (Tis, Ta, T1a):

Circumcision (if confined to prepuce)

Partial Penectomy (if glans involved; 2 cm margin required)

Organ-preserving options:

Topical 5-FU or imiquimod for Tis

Laser ablation (CO₂/Nd:YAG)

Mohs microsurgery

Radiation therapy (for Tis or inoperable cases)

Stage II (T1b, T2):

Partial Penectomy if ≥2.5 cm penile length preserved

Total Penectomy + Perineal Urethrostomy if proximal spread

Complications of Perineal Urethrostomy:

Ammoniacal dermatitis (requires scrotal elevation during urination)

Stricture formation (dilated by Hegar’s dilators)

Stage III (T3 or regional nodes):

Surgical resection (partial/total penectomy) + Ilioinguinal block dissection

Stage IV (T4 or distant mets):

Chemoradiotherapy (cisplatin + ifosfamide + paclitaxel)

II. Management of Inguinal Lymph Node Metastasis

1. Clinical Node Negative (cN0):

Low-grade Tis/T1: Observe or SLNB

High-grade or deeply invasive lesions: Superficial node dissection

2. Palpable Nodes:

Treat primary first

Give 4–6 weeks of antibiotics to exclude infection

If nodes regress: Observe

If nodes persist: FNAC or Modified Inguinal Block Dissection (Catalona)

3. SLNB (Sentinel Lymph Node Biopsy):

Isosulphan blue dye injected at primary site

Helps avoid unnecessary block dissection

Positive node: Complete Ilioinguinal dissection

III. Role of Radiotherapy

Indications:

Organ preservation in early-stage disease

Medically unfit or surgery refusal

Palliative intent in fixed nodal disease

Types:

External RT (40–60 Gy; includes inguinal & pelvic nodes)

Interstitial RT (Iridium/Tantalum implants)

Complication:

Radionecrosis of penis

IV. Chemotherapy

Used in advanced or metastatic disease

Regimen: Cisplatin + Ifosfamide + Paclitaxel

Cause of Death

Erosion of femoral vessels by fungating inguinal lymph node masses → fatal hemorrhage

A. Hematological Causes:

• 1. Hemolytic anaemias
  • Hereditary spherocytosis
  • Thalassaemia major
  • Sickle cell anaemia
  • Autoimmune haemolytic anaemia
• 2. Leukemias & Lymphomas
  • Chronic myeloid leukemia (CML)
  • Chronic lymphocytic leukemia (CLL)
  • Hairy cell leukemia
  • Hodgkin’s and Non-Hodgkin’s lymphoma
• 3. Myeloproliferative Disorders
  • Polycythemia vera
  • Idiopathic myelofibrosis

B. Infective Causes:

• 1. Bacterial: Subacute bacterial endocarditis, Typhoid
• 2. Viral: Infectious mononucleosis, CMV, Hepatitis
• 3. Parasitic: Malaria, Kala-azar (Leishmaniasis), Hydatid cyst

C. Congestive Causes (Portal Hypertension):

• Cirrhosis of liver
• Splenic vein thrombosis

D. Storage Disorders:

• Gaucher’s disease
• Niemann-Pick disease

E. Autoimmune & Other Causes:

• Felty’s syndrome (RA + splenomegaly + neutropenia)
• Sarcoidosis
• Amyloidosis
• SLE
• Wiskott-Aldrich syndrome

A. Always Indicated:

• Primary splenic tumour
• Hereditary spherocytosis

B. Usually Indicated:

• Primary hypersplenism
• Chronic idiopathic thrombocytopenic purpura (ITP)
• Splenic vein thrombosis
• Splenic abscess

C. Sometimes Indicated:

• Splenic injury (especially Grade III–V trauma)
• Autoimmune haemolytic anaemia
• Congenital elliptocytosis with haemolysis
• Non-spherocytic congenital haemolytic anaemia
• Hodgkin’s disease (with refractory anaemia)
• Thrombotic thrombocytopenic purpura (TTP)
• Idiopathic myelofibrosis
• Splenic artery aneurysm
• Wiskott-Aldrich syndrome
• Gaucher’s disease

D. Rarely Indicated:

• Chronic leukemia
• Thalassaemia major
• Sickle cell anaemia
• Felty’s syndrome
• Hairy cell leukemia

Choledocholithiasis refers to the presence of one or more stones within the common bile duct (CBD).

• 1. Primary CBD Stones:
  • Formed within the CBD or intrahepatic bile ducts
  • Typically multiple, pigment stones, or mixed stones
  • Causes include:
    • Infections or parasitic infestation (e.g., Clonorchis sinensis)
    • Congenital conditions (e.g., Caroli’s disease, choledochal cyst)
    • Biliary dyskinesia
    • Diabetes, malnutrition
• 2. Secondary CBD Stones:
  • Originate from the gallbladder and lodge in the CBD (commonly in the supraduodenal part)
  • Usually cholesterol stones
  • Can enlarge over time and lead to complications like cholangitis

Definition:
Infection of the biliary tract due to obstruction, commonly caused by CBD stones.

Causative Organisms:
E. coli, Klebsiella, Pseudomonas, Enterococci, Proteus
Anaerobes: Bacteroides, Clostridium perfringens

Common Causes:

• Choledocholithiasis
• Biliary strictures
• Biliary tract neoplasms
• Pancreatic pseudocyst, chronic pancreatitis
• Sphincter of Oddi dysfunction
• Post-ERCP in cases of obstructive jaundice

• Biliary colic
• Jaundice
• Fever with chills and rigors (Charcot’s triad)
• Upper abdominal tenderness
• In severe cases: Reynolds' pentad:
  • Pain
  • Fever
  • Jaundice
  • Shock
  • Altered mental status

Blood Tests:

• Leukocytosis
• Elevated conjugated bilirubin
• Increased alkaline phosphatase

Imaging:

• Ultrasound: Detects dilated CBD and stones
• CT Scan
• ERCP: Diagnostic and therapeutic
• MRCP: Non-invasive alternative for diagnosis

• 1. Medical:
  • IV fluids and resuscitation
  • Intravenous broad-spectrum antibiotics
• 2. Endoscopic:
  • ERCP with sphincterotomy and stone extraction
  • Stenting in case of strictures
• 3. Percutaneous:
  • PTBD in high biliary obstructions where ERCP is not feasible
• 4. Surgical:
  • Laparotomy with CBD exploration and T-tube insertion
  • Used when endoscopic or percutaneous methods fail or are contraindicated

A. Acute Complications:

• Perforation – surgical emergency
• Hematemesis and/or Melaena – due to bleeding ulcer

B. Subacute Complications:

• Residual intra-abdominal abscess – due to sealed perforation or inadequate treatment

C. Chronic Complications:

• Gastric Outlet Obstruction (Pyloric stenosis) – due to scarring or inflammation
• Teapot Deformity – structural change in the stomach due to chronic scarring
• Hourglass Contracture – constriction of the stomach forming two chambers
• Penetration into Pancreas – ulcer erodes into the pancreas causing pain
• Carcinoma of Stomach – long-standing gastric ulcers can undergo malignant change

Introduction:

• More common in males (M:F = 8–10:1 in India)
• Anterior duodenal ulcers tend to perforate; posterior ulcers tend to bleed
• Posterior gastric ulcers may perforate into the lesser sac
• Precipitating factors: smoking, alcohol, NSAIDs, steroids
• Etiologies:
  • NSAID-induced – elderly, both sexes
  • H. pylori infection – younger males, chronic dyspepsia
• Mortality rate: 5–10%; up to 20–30% in elderly with gastric ulcer
• Golden window for surgery: within 6 hours

• 1. Stage of Chemical Peritonitis (0–4 hours):
  • Sudden severe epigastric or RUQ pain
  • Guarding, rigidity, rebound tenderness (Blumberg’s sign)
  • Absent liver dullness (pneumoperitoneum)
  • Silent bowel sounds
  • Tachycardia, normal BP initially
• 2. Stage of Reaction (3–6 hours):
  • Temporary relief due to peritoneal fluid secretion
  • Signs worsen: tachycardia >120/min, hypotension, dehydration
  • Shifting dullness, paralytic ileus
• 3. Stage of Bacterial Peritonitis (>6 hours):
  • Bacterial contamination → sepsis and shock
  • Hippocratic facies (sunken cheeks, dry tongue)
  • High fever, cold extremities, feeble pulse
  • Marked distension, tenderness, rigidity

• CBC & Electrolytes: Assess anemia, sepsis, dehydration
• Erect X-ray abdomen/chest: Free gas under diaphragm
• CT Scan with contrast: Detects pneumoperitoneum, fluid collection, site of perforation

• A – Aspiration:
  • Ryle’s tube to decompress stomach
• B – Blood Grouping & Cross-matching:
  • Prepare for resuscitation and surgery
• C – Charts & Catheterisation:
  • Monitor vitals, Foley’s catheter for urine output
• D – Drugs:
  • Triple IV antibiotics:
  • Ampicillin 500 mg IV 6 hourly
  • Gentamicin 60–80 mg IV 8 hourly
  • Metronidazole 500 mg IV 8 hourly
  • Cephalosporins if needed
• E – Exploratory Laparotomy:
  • Midline incision, identify and close perforation
  • Omental (Graham’s) patch, thorough peritoneal lavage
  • Insert drain (remove in 3–5 days)
  • Gastrectomy for large/stable ulcers; Vagotomy + GJ deferred in acute phase
• F – Fluids:
  • Aggressive IV fluids to treat dehydration
  • Continue until bowel sounds return

• Anti-ulcer medications
• Endoscopy after 2 months:
  • If ulcer persists → H. pylori eradication
  • If symptoms persist → Elective surgery (e.g., Vagotomy + GJ)

Also called Tropical Abscess. It is the most common extraintestinal manifestation of amoebiasis, caused by Entamoeba histolytica.

• Caused by Entamoeba histolytica infection spreading from the intestine via portal circulation.
• Right lobe is commonly involved due to:
  • Streamline phenomenon (blood flow favors right branch)
  • Larger size and greater blood supply
• Liquefactive necrosis leads to sterile, anchovy sauce-like pus (chocolate-brown, odorless).
• Amoebae are usually found in the wall, not the pus.
• Gallbladder is rarely involved (bile is toxic to amoebae).

• Common in adult males, especially alcoholics (20–40 years).
• Symptoms:
  • Right hypochondriac pain
  • Fever (low-grade; high if secondarily infected)
  • Anorexia, malaise, weight loss
• Thoracic signs (if extension to diaphragm): Cough, dyspnea, pleuritic pain, shoulder tip pain.
• Signs: Tender hepatomegaly, intercostal edema, occasional jaundice (~15%).

• Blood: Leukocytosis, raised ESR, ↑ ALP
• Ultrasound: First-line; shows hypoechoic lesion(s)
• CT scan: For complex/multiple abscesses
• Serology: ELISA for amoebic antibodies
• Aspiration: Anchovy sauce pus confirms diagnosis; used if non-responsive to drugs or diagnostic doubt

• 1. Medical Management:
  • Metronidazole: 750 mg TID × 10 days (or 800 mg TID PO)
  • Followed by luminal amoebicide: Diloxanide furoate (500 mg TID × 10 days)
• 2. Indications for Aspiration:
  • Left lobe abscess (risk of rupture into pericardium)
  • Thin rim of liver tissue (<10 mm)
  • Imminent rupture or persistent pain
  • Failure to respond to drugs in 48–72 hours
  • Uncertainty in diagnosis
• 3. Surgical Management:
  • For ruptured abscess into peritoneum or pleural cavity
  • Laparotomy with drainage

• Rupture into:
  • Pleural cavity → empyema
  • Peritoneum → peritonitis
  • Pericardium → cardiac tamponade
  • Stomach or colon → internal fistula
• Secondary bacterial infection
• Chronicity or relapse

The most common renal fusion abnormality. It occurs when the caudal ends of the metanephric blastema fuse in the midline prior to the 6th week of intrauterine life. This fusion prevents normal kidney rotation and ascent, resulting in the characteristic horseshoe-shaped kidney.

• Occurs due to overcrowding in the pelvis by large umbilical arteries during early development.
• Fusion typically occurs at the lower poles of both kidneys, resulting in the horseshoe shape.
• Rarely, upper polar fusion may occur, leading to a reverse horseshoe kidney.

• Spina bifida
• Congenital hemivertebra
• Turner’s syndrome
• Cleft lip and cleft palate

• Occurs in 1 in 500 live births, with a male preponderance (M:F = 2:1).
• Can remain asymptomatic for many years.
• A palpable mass can be felt below and to the right and left of the umbilicus or in the umbilical region.
• Recurrent urinary tract infections (UTIs) due to angulated ureters over the kidney isthmus.
• Increased susceptibility to hydronephrosis due to ureter angulation.
• Rovsing’s sign: Hyperextension of the spine results in abdominal pain, nausea, or vomiting due to stretching of the kidney capsule.

• 1. Ultrasonography (USG): To locate the kidneys and assess any anatomical abnormalities.
• 2. IVU: Upper and middle calyces are directed laterally, while the lower calyx is directed medially where fusion occurs — characteristic of horseshoe kidney.
• 3. CT Scan or Isotope Renogram: Confirmatory tests to evaluate kidney function and structure.

• Treatment is only indicated when complications arise.
• Stone Removal or Hydronephrosis Repair: Performed as in standard procedures.
• Aortic Aneurysm Repair: The isthmus may need to be divided during surgery.

• Mild to moderate symptoms
• Post-void residual urine < 150 ml
• Flow rate > 15 ml/sec

• Avoid alcohol
• Avoid delaying micturition

• 1. 5α-Reductase Inhibitors:
  • Finasteride 5 mg/day
  • Dutasteride 0.5 mg/day
  • Use: Large prostates
  • SE: ↓ Libido, impotence
• 2. α-Adrenergic Blockers:
  • Tamsulosin, Terazosin, Silodosin
  • Use: Small prostate (<40 g)
  • SE: Postural hypotension, retrograde ejaculation
• 3. Combination Therapy: For large glands

• Acute or chronic retention
• Post-void residual > 200 ml
• Severe LUTS
• Complications: Recurrent infection, haematuria, bladder stones, hydronephrosis

• 1. TURP (Transurethral Resection of Prostate):
  • Gold standard
  • Uses 1.5% glycine for irrigation
  • SE: TURP syndrome, incontinence, retrograde ejaculation (15%), impotence (5–10%)
• 2. Transvesical Prostatectomy (Frayer’s):
  • Indication: Prostate >100 g, bladder stones
  • Bladder opened extraperitoneally
  • Foley bulb inflated for haemostasis
  • Uses Malecot catheter
  • SE: Haemorrhage, urethral stricture
• 3. Retropubic Prostatectomy (Millin’s):
  • Bladder not opened
  • Prostate excised via extraperitoneal route
• 4. Perineal Prostatectomy (Young’s):
  • Obsolete technique

• Holmium:YAG Laser: Suitable for large glands or bleeding tendency
• Intraurethral Stents: Used in unfit surgical candidates (ASA IV)

• Cleft lip results from abnormal development of the median nasal and maxillary process.
• Cleft palate is due to failure of fusion of the two palatine processes.

• I. Central: Very rare; due to failure of fusion of two median nasal processes.
• II. Lateral: Most common type; due to imperfect fusion of maxillary process with median nasal process.
  • Can be unilateral or bilateral.
• III. Complete or Incomplete:
  • Complete: Extends to the floor of the nose.
  • Incomplete: Does not extend up to the nostril.
• IV. Simple or Compound:
  • Compound: Associated with cleft in the alveolus.

• 80% are unilateral.
• 60% are associated with cleft palate.
• Nostril may be widened.
• Maldevelopment or malalignment of teeth is common.

• Sucking: Usually not affected, but bottle feeding may be difficult.
• Speech: Some degree of dysarticulation (speech difficulty) may be present.

• Doppler ultrasound is a non-invasive diagnostic technique based on the Doppler principle.
• An ultrasound beam is directed at blood vessels, and frequency changes in the reflected beam, caused by moving blood, are converted into audible signals.

• Detects pulses even when they are clinically not palpable.
• Assesses blood flow.
• Measures Ankle Brachial Pressure Index (ABI).
• Differentiates between ischemic and neurogenic claudication.

• Tuberculous lymphadenitis is an extrapulmonary manifestation of tuberculosis where the lymph nodes become infected with Mycobacterium tuberculosis, leading to enlargement, matting, and abscess formation.

• Common Presentation: Painless, gradually enlarging lymph nodes, typically in the cervical region (scrofula).
• Systemic Symptoms: Fever, weight loss, night sweats, and fatigue.
• Advanced Stages: Cold abscess formation due to caseating necrosis of lymph nodes, resulting in soft, fluctuant swelling.

• Basal cell carcinoma (BCC) is the most common malignant skin tumour, originating from the basal cells of the pilosebaceous adnexa.
• It occurs exclusively on the skin, typically presenting as a slow-growing neoplasm that becomes a chronic ulcer, persisting for many years.
• Metastasis is extremely rare, and death from this disease is uncommon. However, in some cases, it can present as a locally penetrating, ulcerative, and destructive lesion.

• The majority of lesions are located on the face, above an imaginary line extending from the lobule of the ear to the angle of the mouth.

• Inner canthus of the eye
• Outer canthus of the eye
• Eyelids
• Bridge of the nose
• Around the nasolabial fold

• Cystic Hygroma is a congenital lymphatic malformation caused by the failure of lymphatic vessels to connect with major lymph sacs.
• It appears as a soft, cystic swelling filled with lymphatic fluid.

• Presentation: Often seen in infancy or early childhood, though it can present at birth or rarely before birth.
• Location: Commonly found in the lateral neck (posterior triangle), groin, and buttocks.
• Appearance: Soft, fluctuant, and transilluminant due to clear lymph fluid.
• Size Variation: Swelling may increase with crying or straining due to increased intra-thoracic pressure.

• Surgical Excision: Preferred treatment to remove all cystic loculi and prevent recurrence.
• Careful dissection is required, especially to avoid extending into muscle planes.

• To evaluate renal function and detect any pathology in kidneys, ureters, or bladder.
• To assess anatomical variations of the renal system.

• Fat-free diet and Dimol tablets for 2–3 days before procedure.
• No oral fluids 6 hours prior to the procedure.
• Injection of 20–40 ml sodium diatrizoate (contrast dye) via the median cubital vein.

• Renal failure, iodine allergies, and multiple myeloma.
• Dehydration, sickle cell anemia, hyperuricemia.

• Diagnosing congenital abnormalities, stones, hydronephrosis, and renal tumors.
• Assessing pelvicalyceal system and urinary tract obstructions.

Invagination of one segment of the intestine into another (usually proximal into distal).

• Simple: Ileocolic (most common), ileoileal, colocolic.
• Compound: Ileo-ileocolic.
• Retrograde: Jejunogastric (rare, complication of gastrojejunostomy).

• Recent viral infections (e.g., respiratory)
• Cystic fibrosis
• Henoch-Schönlein purpura
• Coeliac disease

• Common in male infants (6–9 months).
• Symptoms: Abdominal pain, red currant jelly stools, vomiting, constipation.
• Signs: Sausage-shaped mass, Dance’s sign (emptiness in RIF), visible peristalsis.

• Ultrasound: Target sign, doughnut sign.
• CT scan: Sausage-shaped mass, blood vessels within bowel lumen.
• Barium enema: Claw (pincer) ending or meniscus sign.

• Conservative: Hydrostatic reduction (50–70% success), air contrast enema (avoid in gangrene).
• Surgical: Laparotomy and manual reduction; resection if gangrenous.
• Recurrent cases: Managed with ileocolic anastomosis.

Abnormal accumulation of cerebrospinal fluid (CSF) in the ventricles due to imbalance between CSF production and absorption, leading to ventricular dilatation.

• Overproduction: Rare; e.g., choroid plexus papilloma.
• Decreased absorption/Obstruction: Infections, hemorrhage, aqueductal stenosis, tumors.

• Communicating: Obstruction in subarachnoid space.
• Non-communicating (Obstructive): Blockage within ventricular system.

• Infants: Enlarged head, bulging fontanelles, sun-setting sign, delayed milestones.
• Children/Adults: Headache, vomiting, papilledema, abducens palsy, altered consciousness.

• Medical: Acetazolamide, furosemide.
• Surgical: Removal of cause or CSF diversion via shunt (e.g., VP shunt).

Abnormal rotation of the stomach along its axis (between cardia and pylorus), leading to obstruction.

• Organo-axial: Common in elderly (horizontal twist).
• Mesenterico-axial: Common in children (vertical twist).
• Combined

• Idiopathic (65%)
• Secondary to hiatus hernia, diaphragmatic eventration, adhesions

Acute or chronic recurrent (more common)

• Gastric gangrene
• Perforation
• Bleeding

• Plain X-ray – Retrocardiac gas shadow
• Barium meal, CT abdomen

• Untwisting + anterior gastropexy
• Gastrojejunostomy or gastrectomy if gangrenous
• Correct underlying cause (e.g., hiatus hernia, eventration)