Surgery - General Flashcards
SUR - 1.1
A surgery is performed with diagnostic intent:
A) if the nature of the disease cannot be otherwise confirmed
B) if no further costly investigations can be carried out
C) if the patient refuses to undergo any other therapeutic intervention
D) in the majority of the surgical interventions
ANSWER
A) if the nature of the disease cannot be otherwise confirmed
EXPLANATION
We perform a surgery with diagnostic intent if the diagnosis could not be established with any of the preoperative non-invasive and invasive diagnostic modalities, and further diagnostic progress can only be achieved by surgical exploration of the patient.
SUR - 1.2
A surgery is considered curative:
A) in all the cases
B) if the cause of the disease can be completely eliminated with the surgery
C) if it is not aimed to prevent a disease
D) when peritoneal carcinomatosis is found
ANSWER
B) if the cause of the disease can be completely eliminated with the surgery
EXPLANATION
A surgery is considered curative if both the preoperative examinations and the surgical exploration confirms that the target lesion (e.g. a cancer with its metastases, if any) can be completely removed. Do not forget; however, that it’s the outcome of the disease that will ultimately determine the radicality of the surgery.
SUR - 1.3
All these methods are used to prevent thromboembolic complications in the perioperative period, except one:
A) Na-heparin
B) Colfarit (acidum acetylsalicylicum)
C) Ca-heparin
D) compression stockings
ANSWER
B) Colfarit (acidum acetylsalicylicum)
EXPLANATION
One of the most frequent complications after a surgical intervention is thromboembolization (with an average risk of around 20-30% after abdominal surgeries, and 50-60% after major orthopedic and trauma surgeries). Thromboembolic prophylaxis should be carried out in patients at a high risk (e.g. history of thrombosis or myocardial infarction, elderly people, obesity, undergoing long surgery). Methods include medical therapy: conventional and low-molecular-weight heparin administered subcutaneously (started before the surgery!), and physical modalities: early mobilization, use of compression stockings, pillowing up the lower extremities. Acetylsalicylic acid (e.g. Colfarit) decreases the risk of thromboembolism by inhibiting platelet aggregation. Its effect starts around 15 minutes after administration and lasts for 3-7 days. Its side effects (e.g. bleeding complications) cannot be suspended and the patient may require platelet transfusion, thus these drugs are not suitable for preoperative prophylaxis.
SUR - 1.4
All those means, methods and interventions with which we try to prevent the contamination of the pathogens are collectively called as:
A) disinfection
B) asepsis
C) antisepsis
D) sterilization
ANSWER
B) asepsis
EXPLANATION
All those interventions, actions and methods with which we try to prevent the contamination of the pathogens are collectively called asepsis. To reach this goal, all the instruments and materials we use during an intervention must be made free of germs (sterilization). Antisepsis means all the actions taken against the already present contamination, which can be most effectively achieved by disinfection. (See also SEB-1.65.)
SUR - 1.5
Principles of the modern antibiotic therapy:
A) broad-spectrum antibiotics are given in the proper dose
B) antibiotic treatment is always targeted
C) carefully selected antibiotics are given in the proper dose for the proper time
D) carefully selected antibiotics are given in the proper dose for the longest possible time
ANSWER
C) carefully selected antibiotics are given in the proper dose for the proper time
EXPLANATION
Ideally antibiotic treatment should always be targeted. However, this is rarely the case due to time constraints or the unavailability of a culture sample. Thus, targeted antibiotic therapy is started only if possible, in other cases we use a broad-spectrum antibiotic agent against the presumed pathogen for the required period of time.
SUR - 1.7
Which of the following solutions CANNOT be used for disinfection of the skin around the wound?
A) iodine
B) petrol
C) alcohol
D) sublimate
ANSWER
B) petrol
EXPLANATION
Iodine, alcohol and sublimate are antibacterial by nature (see also SEB-1.4.), while benzol has no such effect. Benzol, however, is a good solvent of fats and thus can be used for removing dirt.
SUR - 1.8
Instruments used before any invasive intervention have to be:
A) disinfected using H2O2 solution
B) disinfected using a solution containing alcohol and tensides or invert soap
C) sterilized (e.g. autoclave or gas sterilization, radiation sterilization)
D) sterilized (e.g. ultraviolet or infrared light)
ANSWER
C) sterilized (e.g. autoclave or gas sterilization, radiation sterilization)
EXPLANATION
We call a medical intervention invasive if it penetrates a natural barrier of the body. Such barriers include: Skin, mucosa, openings of the hollow viscera (e.g. pharynx, urethra, anus, vagina, Eustachian tube, etc.). Any instrument used for an invasive medical intervention has to be sterilized to prevent the pathogens from entering the already vulnerable area. The accepted methods of sterilizing are steam sterilization in an autoclave, or gas sterilization using ethylene dioxide or formaldehyde. Single-use instruments are factory sterilized using irradiation. Boiling or dry heat sterilization usually cannot eliminate all the germs. Ultraviolet or infrared light has sterilizing effect. For non-invasive intervention we can use disinfected or sterilized instruments (see also SEB-1.4.).
SUR - 1.9
After any invasive intervention, the used instruments have to be:
A) rinsed under running water using soap and brush
B) soaked for disinfection and removal of blood residues
C) sterilized in a dry heat sterilizer
D) disassembled and sterilized
ANSWER
B) soaked for disinfection and removal of blood residues
EXPLANATION
Instruments used for invasive interventions (see also SEB-1.13.) can be contaminated with pathogens from the patient or the hospital environment. Their inner or outer surfaces can come into contact with body fluids (e.g. blood, lymph, stool, etc.) which dry or clot there. The proteins in these fluids can also clot and get precipitated by the agents used for disinfection. Pathogen within these protein traps may be resistant to the effects of sterilizing. Thus, soaking should be done with chemicals that – usually enzymatically - dissolve blood and the precipitated proteins. The temperature and duration of soaking depends on the chemicals used. After soaking, machine washing, ultrasound or manual cleaning is done, followed by reassembly and testing. Some of these steps require manual workforce. To protect the cleaning staff, soaking and pre-disinfection should be performed at the same cleaning session or consecutively. Answer A does not match the desired workflow at all. Answer C is partially correct, but it misses the step before sterilizing and also only mentions a single method of sterilizing. Answer D refers only to later steps of the workflow and misses the step before sterilizing. The term “after use” in the question is best answered by option B.
SUR - 1.10
Clinical signs of bleeding, except:
A) tachycardia
B) drop of blood-pressure
C) dry mouth
D) polyuria
ANSWER
D) polyuria
EXPLANATION
Decrease of circulating blood volume after a major bleeding leads to hypotension, which – through different compensating mechanisms of the body – often leads to tachycardia and development of dry mouth. A bleeding patient is weak, may feel dizzy or collapse; the parasympathetic condition, polyuria is the least characteristic finding during a major bleeding.
SUR - 1.11
Which is the most probable cause of a gastrointestinal bleeding presenting in the form of hematemesis?
A) recto-sigmoid cancer
B) duodenal cancer
C) erosive gastritis
D) hemorrhagic enteritis
ANSWER
C) erosive gastritis
EXPLANATION
The duodenojejunal ligament (Treitz) acts as a division line between the frequent bleeding sources of the gastrointestinal tract. Any GI bleeding proximal to this will lead to hematemesis or melena, while more distal bleeding sources will only lead to rectal bleeding, usually melena. Thus, in the case of hematemesis, esophageal or gastroduodenal bleeding sources are the most obvious targets. From these bleeding sources erosive gastritis is frequent, while a duodenal cancer is a rare disease. Erosions of the gastric mucosa usually develop quickly but may also heal quickly. Its underlying pathomechanism is not yet fully understood, but a sudden increase in the acid output seems an important risk factor, which in turn can be caused by stress or other processes in the central nervous system
SUR - 1.12
Which is the most frequent cause of primary hyperparathyroidism?
A) parathyroid hyperplasia
B) parathyroid adenoma
C) parathyroid cancer
D) chronic renal failure
ANSWER
B) parathyroid adenoma
EXPLANATION
Primary or autonomous hyperparathyroidism is based on an uncontrolled increase in the parathyroid hormone production, and in the majority of the cases (85-90%) is the result of a solitary parathyroid adenoma. In only 10-15% of the cases do we find multiple adenomas or hyperplasia of all the glands. From the solitary masses 1-3% turns out to be carcinoma. In patients undergoing hemodialysis due to chronic renal failure secondary hyperparathyroidism may develop, since the excessive loss of calcium from the kidneys will lead to compensatory feedback mechanisms.
SUR - 1.13
From the following options which symptom is NOT characteristic of primary hyperparathyroidism?
A) hypercalcemia
B) oliguria
C) short QT interval
D) hypophosphatemia
ANSWER
B) oliguria
EXPLANATION
The clinical signs of primary hyperparathyroidism (pHPT) include general muscle weakness, bone pain, nausea, vomiting, constipation, abdominal pain, polydipsia, polyuria and increased blood pressure. Characteristic laboratory parameters are hypercalcemia (dominantly high ionized calcium levels), high serum intact parathormone levels, hypophosphatemia, hypercalciuria, increased alkaline phosphatase and one can see short QT intervals on the ECG. In the case of pHPT densitometry reveals decreased mineral content of the bones and X-Ray usually shows subperiosteal demineralization in the fingers, skull and vertebrae, while density of the spongiosa may even be higher. Kidney stones often develop - in 5-10% of the recurrent or bilateral cases (even up to 15% for calcium stones) its pHPT laying in the background.
SUR - 1.14
The development of metastases in malignant diseases:
A) correlates with the size of the cancer
B) correlates with the time elapsed from the appearance of the cancer
C) depends on the biologic characteristics of the cancer and does not correlate with its volume
D) depends on the location of the primary cancer
ANSWER
C) depends on the biologic characteristics of the cancer and does not correlate with its volume
EXPLANATION
Certain malignancies – depending on their biologic nature – develop metastases early. Metastases are usually associated with an advanced disease stage. Sometimes huge, locally advanced tumors do not give distant metastases, while in other cases the presence of multiple metastases dominates the clinical picture and often the small primary cancer is discovered only later. It can also happen that despite a histologically confirmed metastasis the occult primary cancer will never be identified.
SUR - 1.15
Generally speaking, the aim of lymph node dissection in malignant diseases is:
A) to eliminate the pathways of further lymphatic
B) to remove the regional metastases as best as possible
C) to improve the lymphatic drainage of the involved tissues
D) to make the radical removal of the primary cancer possible
ANSWER
B) to remove the regional metastases as best as possible
EXPLANATION
The main principle of oncologic surgery is to get the body rid of the tumor mass as radically as possible. To achieve this goal, surgical resection should be performed with an ample safety margin, together with the en-bloc removal of the regional lymph nodes alongside the main lymphatic pathways and any regional cancer spreading. This is even more important in the case of cancers which are likely to spread via the lymphatics.
SUR - 1.16
Select the correct (most appropriate) answer.
A) Fibroadenoma is the most common benign lesion of the breast in hormonally active women.
B) Fibroadenomas never turn malignant.
C) Fibroadenomas are never removed surgically, cytological examination is enough.
D) Fibrocystic breast lesion (mastopathy) is very common in non-lactating women.
ANSWER
A) Fibroadenoma is the most common benign lesion of the breast in hormonally active women.
EXPLANATION
Benign lesions of the breasts include fibroadenomas which are the most frequent benign lesion in hormonally active women. Fibroadenomas – arising from the epithelial layer – are usually palpable, well defined, mobile firm lesions.
SUR - 1.17
Select the correct (most appropriate) answer.
A) The TNM score has only a limited role in the staging of breast cancer; other classifications are becoming more important
B) About 80% of all breast cancers are invasive ductal carcinomas
C) About 70-80% of all breast cancers are invasive lobular carcinomas
D) The proportion of ductal and lobular breast carcinomas is roughly the same (45–45%)
ANSWER
B) About 80% of all breast cancers are invasive ductal carcinomas
SUR - 1.18
Which type of hernia is the most prone to incarceration?
A) femoral hernia with a wide orifice
B) complex ventral incisional hernia
C) inguinal hernia with a narrow orifice
D) non-reducible umbilical hernia
ANSWER
C) inguinal hernia with a narrow orifice
EXPLANATION
Hernia incarceration is most frequent in hernias with a narrow orifice. In conditions where the abdominal pressure is increased, any kind of hernia is more prone to incarceration. The question focused on the ‘narrow orifice’, as compared to the ‘multilocular’ and ‘wide orifice’ hernias.
SUR - 1.19
The most frequent type of surgery of the repair of an inguinal hernia is:
A) Fabricius surgery
B) Kocher surgery
C) Nissen–Rosetti surgery
D) Lichtenstein surgery
E) Bassini-Kirschner surgery
ANSWER
D) Lichtenstein surgery
EXPLANATION
Today the most widely accepted inguinal hernia repair is the tension-free Lichtenstein surgery which comes with the lowest recurrence rate. Previously the standard technique was the Bassini surgery, which was not tension-free, and the rate of recurrence could be as high as 10-15%
SUR - 1.20
During a laparoscopic surgical intervention
A) the abdominal cavity is inflated with oxygen
B) the increased intra-abdominal pressure has to be taken into account when considering the indication of surgery
C) any intraoperative bleeding complication necessitates a conversion to open procedure
D) antibiotic prophylaxis is compulsory before every surgery
ANSWER
B) the increased intra-abdominal pressure has to be taken into account when considering the indication of surgery
EXPLANATION
Answer A: For filling up the abdominal cavity such gas must be used which is inert and non-flammable so that electrocautery devices can be safely used. Thus, it cannot contain oxygen. The most commonly used gas is CO2, although xenon is currently also recommended, particularly in oncologic surgery. Answer C: An intraoperative bleeding can often be managed by laparoscopic means, e.g. using small clips or electrocautery device on the bleeders. Obviously, a clean operating field and good visualization is a must. If the bleeding cannot be laparoscopically controlled, we have to convert to an open procedure immediately. Answer D: Antibiotic prophylaxis before laparoscopic surgeries follows the same principles as of the open surgical procedures. That is, antibiotics are not administered in an obligatory way, but rather selectively before the presumably contaminated (e.g. perforated appendicitis, bowel resection) or long surgeries (e.g. pancreatic resection).
SUR - 1.21
During a laparoscopic hernia repair:
A) The defect of the abdominal wall is covered by a synthetic mesh
B) The defect of the abdominal wall is closed by plastic clips
C) The hernia contents are pushed back into the abdominal cavity from the outside
D) The defect of the abdominal wall is actually not closed
ANSWER
A) The defect of the abdominal wall is covered by a synthetic mesh
EXPLANATION
The two most commonly used laparoscopic inguinal hernia repair is the transabdominal preperitoneal (TAPP) and the total extraperitoneal (TEP) approach. During both procedures we place a mesh between the peritoneum and the abdominal wall covering the defect(s). The hernia orifice cannot be closed by clips. Before covering the effect, the hernia contents are pulled back into the abdominal cavity from the inside.
SUR - 1.22
Which one of the following statements is not true for abdominal abscesses?
A) often caused by perforation of some hollow viscera
B) treatment is primarily surgical exploration + drainage
C) drainage of the abscess can be done percutaneously with US, CT or MR guidance
D) interintestinal abscesses only develop on basis of Crohn’s disease
ANSWER
D) interintestinal abscesses only develop on basis of Crohn’s disease
EXPLANATION
Intra-abdominal abscesses can be rather diverse based on their location and origin. An inter-intestinal abscess – accumulation of pus in a cavity confined by bowels – is just a type of this disease family. The general treatment principle for any kind of abscess is the exploration of the purulent cavity, letting out all the pus and keeping the cavity open until its healing. Surgical exploration or percutaneous drainage with some form of imaging guidance are both commonly accepted techniques.
SUR - 1.23
Which of the following statements is true?
A) Hernia repairs are categorized as clean-contaminated surgeries
B) The average suppuration rate after clean-contaminated surgeries is around 5-15%
C) The average suppuration rate after clean-contaminated surgeries is <8-22%.
D) The average suppuration rate after clean-contaminated surgeries is >2-8%.
ANSWER
D) The average suppuration rate after clean-contaminated surgeries is >2-8%.
EXPLANATION
We consider a surgery clean-contaminated if the gastrointestinal, genitourinary and/or respiratory tracts are opened under controlled conditions without significant. After such surgeries the risk of infection is inevitably increased, regardless of how careful the surgical manipulation or isolation of the operating field was.
SUR - 1.24
Which of the following signs is the least characteristic of a pancreatic cancer?
A) loss of appetite
B) asymptomatic jaundice
C) newly discovered diabetes
D) fever
ANSWER
D) fever
EXPLANATION
Malignant diseases of the exocrine pancreas will also eventually affect the endocrine function (islet cells) due to the transformation of the pancreatic tissue. Thus, clinical signs of the growing pancreatic mass can be general (loss of appetite, fatigue, weakness), but a sudden onset of diabetes mellitus should be an alarming sign, too. A cancer in the head of the pancreas often infiltrates the intrapancreatic part of the common bile duct, gradually leading to the development of jaundice. As compared to the stone-related, rapidly developing, symptomatic jaundice, malignant jaundice is usually painless. In cancer patients fever is a less characteristic sign, but may develop in complicated cases (e.g. biliary obstruction in a head of the pancreas cancer leading to cholangitis or even hepatic abscess).
SUR - 1.25
Relatives of a 63-year-old male patient discover jaundice on him. All of the following presumed diagnoses are reasonable, except one:
A) infective hepatitis
B) pancreatic cancer
C) chronic pancreatitis
D) Crigler–Najjar syndrome
E) choledocholithiasis
ANSWER
D) Crigler–Najjar syndrome
EXPLANATION
Based on the clinical data and etiology (alcohol abuse), the patient can have liver cirrhosis, some form of chronic hepatitis or chronic pancreatitis. Painless jaundice is often caused by a head of the pancreas cancer (see also SEB-1.29.). Similarly, an acquired infective hepatitis or even choledocholithiasis cannot be ruled out. Crigler-Najjar syndrome, however, is a fetal metabolic disorder leading to hyperbilirubinemia (see also SEB-1.169. - 1.180.).
SUR - 1.26
The most common pathway of metastatic spreading in colonic cancer is:
A) via the inferior mesenteric vein
B) via the portal vein
C) lymphogenic spreading
D) intraluminar spreading
ANSWER
C) lymphogenic spreading
EXPLANATION
Colorectal cancer has the potential to give hematogenous metastases when penetrating the vessels of the bowel-wall as they grow. The major supplying vessels of the colon – e.g. both the superior and inferior mesenteric veins – both reach the liver via the portal vein. In colorectal cancer, however, the most common means of spreading is through the lymphatics. If the cancer infiltrates all layers of the colonic wall, lymphatic spreading is present in 90% of the cases.
SUR - 1.27
What do we call as neoadjuvant chemotherapy?
A) irradiation administered during the surgery
B) cytostatic treatment administered after the surgery
C) cytostatic treatment administered before the surgery
D) cytostatic treatment administered during the surgery
ANSWER
C) cytostatic treatment administered before the surgery
EXPLANATION
Neoadjuvant chemotherapy means cytostatic treatment administered before a surgical intervention. In certain types of cancer (e.g. primary liver, colorectal, breast, stomach, etc.) neoadjuvant treatment may reduce the size of the cancer and slow its spreading. In some cases, an otherwise inoperable cancer becomes surgically resectable. Chemotherapy can be systemic or local (e.g. selective chemoperfusion of the supplying artery of the given organ).
SUR - 1.28
Proper treatment of a furuncle on the face:
A) incision, excochleation
B) expression of the pus
C) moist packing and antibiotics
D) excision
ANSWER
C) moist packing and antibiotics
EXPLANATION
The venous system of the face has a direct connection with the basilar plexus in the head. Thus, any facial infection has to be treated with special care. Incision and excision are often unfavorable due to cosmetic reasons. The popular ‘self-made popping’ is strictly contraindicated.
SUR - 1.29
Which histologic type of the thyroid cancer has generally the best prognosis?
A) medullary cancer
B) papillary cancer
C) follicular cancer
D) anaplastic cancer
ANSWER
B) papillary cancer
EXPLANATION
From the thyroid cancers the papillary type grows very slowly and is rare to give metastases. Thus, the papillary type is considered the most ‘benign’ of the malignant cancers.
SUR - 1.30
Primary varicosity:
A) develops always after deep vein thrombosis
B) is a result of superficial thrombophlebitis
C) is always treated surgically
D) is a hereditary, degenerative condition of the superficial veins
ANSWER
D) is a hereditary, degenerative condition of the superficial veins
EXPLANATION
Primary varicosity is a hereditary, degenerative process which manifests eventually over the time. It is based on the gradual weakening of the mesenchymal tissue; the main predisposing factors are age, unhealthy lifestyle, obesity, pregnancy, etc. Based on the severity of the disease, treatment can be conservative or surgical.
SUR - 1.31
The Perthes test:
A) assesses the condition of the valves in the greater saphenous vein
B) assesses the rate of blood flow towards the deep veins
C) is a sign of deep-vein thrombosis when dorsalflexion of the foot induces calf pain
D) if negative, phlebography has to be performed next
ANSWER
B) assesses the rate of blood flow towards the deep veins
EXPLANATION
The Perthes test is a clinical test for assessing the patency of the deep femoral vein. After placing a rubber compression band on the leg of the standing patient (under the knee or sometimes also unto the thighs -, he/she is asked to walk for some time. Emptying (collapse) of the superficial veins means a good flow towards the deep veins – this we call a negative Perthes test. If the test is positive, further evaluation tests (e.g. venous Doppler US, phlebography) are needed when planning a varicectomy. (Other references in the question A: Trendelenburg test, C: Homan’s sign).
SUR - 1.32
In which disease is it most common to find an enlarged, palpable gallbladder?
A) Klatskin tumor
B) papilla of Vater carcinoma
C) cancer in the body of the pancreas
D) hepaticolithiasis
ANSWER
B) papilla of Vater carcinoma
EXPLANATION
In the case of a hilar or intrahepatic Klatskin tumor or biliary tract stone, the obstruction is proximal to the gallbladder, thus the gallbladder can empty freely. If the cancer is in the body of the pancreas, the distal bile duct is usually not compressed, and the gallbladder is cannot be palpated. The characteristic „Courvoisier sign” is most often present in head of the pancreas or papilla of Vater malignancies.
SUR - 1.33
All of these lesions can be drained by ultrasonic guidance, except one:
A) pancreas pseudocysts
B) retention cysts of the liver
C) meningeal cysts
D) retroperitoneal cysts
E) hydatid cysts
ANSWER
C) meningeal cysts
EXPLANATION
Ultrasound guided percutaneous puncture and drainage is a commonly accepted method for the treatment of various fluid accumulations in the abdominal cavity, retroperitoneum or in certain organs. Recently even hydatid cysts (liver Echinococcus cysts) can be drained by interventional radiological means. A meningeal cyst is located in the skull; thus, it cannot be routinely punctured.
SUR - 1.34
What is the definition of an in situ cancer?
A) if the tumor grows towards the lumen of an organ
B) if the tumor does not penetrate the serosal layer of the organ
C) if the tumor is confined to one tissue layer of the organ
D) if the tumor does not give regional metastases
ANSWER
C) if the tumor is confined to one tissue layer of the organ
EXPLANATION
During carcinogenesis the tumor mass develops in one of the tissue layers of the given organ or tissue. This first stage we call an in situ cancer. Further expansion through the wall of the organ can happen towards the lumen of the organ (endophytic) or towards the outer surface (exophytic). There is no correlation between the size of the cancer and its tendency to give metastases (see also SEB-1.19. and SEB-1.149.).
SUR - 1.35
Select the examples of an absolute indication of surgery:
1) an injury that is so severe that the life of the patient can only be saved with a surgical intervention
2) deepening jaundice
3) intestinal obstruction
4) certain cases of gallstone disease
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
ANSWER
C) 2nd and 4th answers are correct
EXPLANATION
Answer 1 and 3: Vital (immediate) indication of surgery usually refers to perforation of a hollow viscera with consequent peritonitis, major acute bleeding, bowel incarceration, or any other medical condition where the life of the patient can only be saved with an immediate surgery. In such cases delaying the surgical intervention can lead to irreversible organ damage, development of sepsis and eventually death. Answer 2 and 4: Absolute surgical indication means that the disease is to be treated surgically – although not necessarily immediately -, otherwise permanent organ damage may develop, and the process may lead to the death of the patient. Cholelithiasis in itself is not an absolute indication, but it may lead to pancreatitis, cholangitis, cholecystitis and perforation and as such, a symptomatic cholelithiasis is considered an absolute surgical indication (see also SEB-1.42. and SEB-1.81., 1.82., 1.83., 1.84.).
SUR - 1.36
A surgery is performed by vital indication in the case of:
1) incarcerated hernia with signs of intestinal obstruction
2) perforation of a hollow abdominal viscera
3) ruptured aortic aneurysm
4) bleeding from a superficial vein on the lower extremity
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
ANSWER
A) 1st, 2nd and 3rd answers are correct
EXPLANATION
In the case of an immediate, vital indication of surgery the timing is essential (e.g. gastrointestinal perforation, acute major bleeding, etc.). The life of the patient can only be saved by an immediate intervention, there are no other treatment options, nor there is time to thoroughly investigate the patient. If possible, the vital parameters have to be stabilized, obviously (see also SEB-1.41.).
SUR - 1.37
Possible causes of a complete postoperative abdominal wound disruption:
1) protein deficiency
2) improper surgical technique
3) postoperative abdominal distension
4) early mobilization
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
ANSWER
A) 1st, 2nd and 3rd answers are correct
EXPLANATION
Wound dehiscence is the consequence of several predisposing factors and usually develops on the 5-8. postoperative day. It happens most often in cachectic patients, but adiposity, protein loss, the presence of ascites or sudden postoperative intra-abdominal pressure changes (e.g. coughing) or improper surgical technique is also a risk factor. Often wound suppuration lay in the background. Early mobilization is, however, not a predisposing factor. Dehiscence is often preceded by clear-bloody discharge from the wound. In the case of a total disruption, abdominal viscera may prolapse. Treatment is urgent reoperation. After suppuration and dehiscence, closure of the abdominal cavity can be challenging.
SUR - 1.38
Anastomotic leakage is one of the most serious complications after a gastrointestinal surgery. The following factors play a role in the prevention of it:
1) antibiotics administered in therapeutic dose
2) the created anastomosis should be free of tension
3) at least two layers of suture should be made for the anastomosis
4) only tissues (e.g. bowel ends) with good blood supply should be approximated
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
ANSWER
C) 2nd and 4th answers are correct
EXPLANATION
A fundamental principle of gastrointestinal surgery is that a reliable bowel anastomosis should have good blood supply, should not be under tension and the placement of sutures must be perfect. The type of anastomosis (manual or instrumental, one layer or two layers, etc.) is secondary. Antibiotic treatment will not prevent the development of anastomotic insufficiency (see also SEB-1.123.).
SUR - 1.40
We are speaking of radical (R0) resection if:
1) both the surgeon and the pathologist states that there is no residual tumor left behind
2) the tumor can be physically resected but histological assessment confirms microscopic residual tumor
3) the tumor can be physically resected but metastatic lymph nodes are left behind
4) there is a visible tumor mass left behind at the end of the surgery
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 1st answer is correct
E) all of the answers are correct
ANSWER
D) only 1st answer is correct
SUR - 1.41
Clinical signs of an incarcerated hernia:
1) the hernia becomes swollen and rigid
2) the hernia becomes painful
3) signs of bowel obstruction
4) the hernia cannot be reduced to the abdominal cavity
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
ANSWER
E) all of the answers are correct
EXPLANATION
An incarcerated hernia most often presents as a tender, non-reducible mass and the symptoms develop fairly rapidly. If there are bowels in the hernia sac, clinical signs of bowel obstruction can be seen. If left untended, incarceration will lead to perforation of the affected bowel loop and eventually peritonitis will develop.
SUR - 1.42
Characteristics of the lateral/indirect inguinal hernia:
1) it is less prone to incarceration
2) can cause intermittent groin pain
3) it never extends into the scrotum
4) it is often congenital
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
ANSWER
C) 2nd and 4th answers are correct
EXPLANATION
Lateral (indirect) inguinal hernias are especially prone to incarceration since the hernia has to pass through the long, curvy and relatively narrow inguinal canal. Medial (direct) hernias, on the other hand, has only a short hernial sac – if any -, and their orifice is usually wide. The characteristic intermittent pain or discomfort associated with inguinal hernias is caused by the stretching of the mesentery of the trapped bowel loop. Lateral hernias often develop in the persisting tunica vaginalis (congenital hernia) and thus the hernia sac can reach the scrotum itself (inguinoscrotal hernia) (see also SEB-1.23.).
SUR - 1.43
Benefits of a laparoscopic surgery over an open procedure include:
1) less postoperative pain
2) shorter hospital stay
3) faster recovery
4) better exposure of the abdominal cavity
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
ANSWER
A) 1st, 2nd and 3rd answers are correct
EXPLANATION
During a laparoscopic surgery we make small – 5-10mm long – incisions on the abdomen to introduce the surgical instruments. The integrity of the abdominal wall is only minimally disrupted, thus postoperative pain is small. Since the abdominal cavity is not opened up, the peritoneum does not come into contact with the outside air and surgical manipulation is less likely to irritate the peritoneum, leading to a decreased risk of postoperative bowel paralysis – a common condition after open procedures. The patient can be mobilized and discharged from the hospital earlier. Overall, laparoscopic surgeries are a much smaller burden on the patients. The only real disadvantage of the laparoscopic approach is the limited ability to explore the abdominal cavity. Since the surgeon cannot feel around with his/her hands among the viscera, the small and less obvious lesions can stay undetected. If in doubt, the surgeon can increase the efficacy of exploration by using intraoperative laparoscopic ultrasound scan (see also SEB-1.125. and SEB-1.134.).
SUR - 1.44
What are those areas where the laparoscopic surgical approach has the most obvious benefits?
1) gallstone disease
2) inguinal hernia
3) gastroesophageal reflux disease (GERD)
4) adrenal adenoma
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
ANSWER
E) all of the answers are correct
EXPLANATION
Laparoscopic approach is ideal in those cases when the intervention is relatively uncomplicated and technically not too challenging, still requiring a long incision for proper exposure. All the answers meet these criteria. By performing a laparoscopic surgery, we can minimize tissue damage and still achieve the same results as of an open procedure.
SUR - 1.45
Choose the correct (most appropriate) answer(s).
1) The average suppuration rate after a contaminated surgery does not exceed 20%.
2) An emergency subtotal gastric resection performed due to a bleeding ulcer is considered a contaminated surgery.
3) Biliary tract surgeries are considered contaminated only if the bile is confirmed to be bacterially infected.
4) No antibiotic prophylaxis is needed before a contaminated surgery since antibiotics should only be administered based on the culture reports.
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
ANSWER
A) 1st, 2nd and 3rd answers are correct
EXPLANATION
A surgery is considered contaminated – for example – if we open a purulent mass or fluid accumulation, open the large bowels during a scheduled surgery. The risk of postoperative septic complications can reach 10-20 percent even with antibiotic prophylaxis administered. Thus, preoperative antibiotic prophylaxis is absolutely indicated in these cases.
SUR - 1.46
Choose the correct (most appropriate) answer(s).
1) Staphylococcus species are often found in samples taken from purulent skin infections and abdominal abscesses.
2) Anaerobic bacteria can also cause septic skin lesions.
3) Furuncles most often develop from Staphylococcus infection.
4) Folliculitis is the purulent inflammation of the hair follicles.
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
ANSWER
E) all of the answers are correct
EXPLANATION
Answers 1., 2. and 3. are correct and general enough in themselves. Answer 4. is also an adequate definition.
SUR - 1.47
When diabetes mellitus is diagnosed, the further investigations has to be carried out:
1) quantitative glucose assessment from collected urine
2) sugar profile assessment
3) glucose acetone assessment from fragmented urine using test strips
4) glucose tolerance test
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
ANSWER
A) 1st, 2nd and 3rd answers are correct
EXPLANATION
The commonly accepted diagnostic method of an asymptomatic diabetes mellitus or decreased glucose tolerance is the glycated hemoglobin test and the glucose tolerance test. In manifest diabetes mellitus they are unnecessary to be performed. To determine or adjust the required amounts of antidiabetic agents in diabetic patients, a complete glucose profile has to be the set up (measuring the serum glucose levels at different times and after meals, fractioned urine glucose and acetone tests and assessment of daily glucose loss (see also SEB-1.169.—1.180.).
SUR - 1.48
If a patient develops jaundice, which of the following investigations would you perform first?
1) abdominal CT
2) MR cholangiography
3) HIDA scan
4) abdominal ultrasound
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
ANSWER
D) only 4th answer is correct
EXPLANATION
Being cheap, non-invasive, widely-available and involving no irradiation, abdominal ultrasound is the first choice of imaging study in the case of a suspected biliary obstruction. Other, more sophisticated imaging options are reserved for answering specific clinical questions.
SUR - 1.49
The following diseases can mimic the signs of acute abdomen:
1) diabetes mellitus
2) porphyrin metabolism disorders
3) lead poisoning
4) steroid administration
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
ANSWER
A) 1st, 2nd and 3rd answers are correct
EXPLANATION
Diabetic ketoacidosis leads to the loss of fluids and electrolytes. As a result of the severe metabolic disorder, vomiting and gastric paralysis can develop, which – together with the muscle cramps coming from exsiccosis – can easily mimic the signs of acute abdomen. Thorough diagnostic investigations, careful assessment of the laboratory parameters, and proper treatment is of utmost importance. However, in diabetic patients acute inflammatory abdominal diseases can develop with minimal or atypical clinical signs. Congenital or acquired porphyrin metabolic disorders or lead toxicity can also cause strong, colic abdominal pain. A thorough evaluation of the personal and family history of the patient must be done in all the cases.
SUR - 1.50
After which surgeries do we have to administer drug replacement therapy?
1) partial thyroid resection
2) total pancreatectomy
3) subtotal gastric resection
4) total gastrectomy
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
ANSWER
C) 2nd and 4th answers are correct
EXPLANATION
After a total pancreatectomy the patient inevitably becomes diabetic due to removal of all the islet cells (islets of Langerhans). After a total gastrectomy the complete loss of intrinsic factor production – required for the proper absorption of vitamin B12 – necessitates postoperative parenteral vitamin B12 substitution. After a partial thyroid or gastric resection hormone replacement is not always needed.
SUR - 1.51
Postoperative thyrotoxic crisis
1) it can develop after the surgery of hyperthyroidism
2) it can develop after the surgery of hypothyroidism
3) it is a life-threatening condition
4) recovery can occur spontaneously
5) rarely develops with adequate preoperative medication
A) 1, 2 and 3 answers are correct
B) 1, 3 and 4 answers are correct
C) 1, 4 and 5 answers are correct
D) 1, 3 and 5 answers are correct
E) 2, 3 and 4 answers are correct
ANSWER
D) 1, 3 and 5 answers are correct
EXPLANATION
Most severe complication of hyperthyroidism is thyrotoxic crisis, which can occur spontaneously in untreated cases or if the treatment is inadequate (e.g. neglected preparation before surgery). It is a severe, life-threatening condition which demands immediate specific treatment.
SUR - 1.52
Absolute indication of tracheostomy
1) prolonged intubation
2) bilateral paresis of the recurrent laryngeal nerve
3) polyp of the vocal cord
4) destructive trauma of the larynx
5) severe laryngeal edema
A) 1, 2, 4 and 5 answers are correct
B) all of the answers are correct
C) 2 and 4 answers are correct
D) 1, 3 and 4 answers are correct
E) 2, 4 and 5 answers are correct
ANSWER
A) 1, 2, 4 and 5 answers are correct
EXPLANATION
Cricothyrotomy (coniotomy) is a common method to ensure the permeability of the respiratory tract in case of the occlusive conditions of the larynx. Permanent usage of orotracheal tubes can cause the irreversible destruction of vocal cords. To prevent this damage tracheostomy is necessary in case of extended mechanical ventilation.
SUR - 1.53
Principle conditions of primary wound healing
1) tight wound suture
2) good blood supply
3) sterile wound dressing
4) intact innervation
5) viable wound edges
A) 1, 2 and 3 answers are correct
B) 1, 4 and 5 answers are correct
C) 2, 3 and 4 answers are correct
D) 2, 3 and 5 answers are correct
ANSWER
D) 2, 3 and 5 answers are correct
EXPLANATION
Intact wound edges and good blood supply is necessary to achieve primary wound healing. Tight wound suture causes ischemia. It is necessary to cover the wound with sterile dressing at least 24 hours. Meanwhile a serous protection layer can develop between the wound edges which protects the body from desiccation and also gives protection against bacterial invasion. Intact innervation does not take part directly in wound healing.
SUR - 1.54
Sign of wound infection
1) wound is covered with dry slough
2) hyperemia of the wound edges
3) edema of the wound edges
4) suffusion around the wound
5) septic fever
A) 1, 2 and 3 answers are correct
B) 1, 4 and 5 answers are correct
C) 2, 3 and 4 answers are correct
D) 2, 3 and 5 answers are correct
ANSWER
D) 2, 3 and 5 answers are correct
EXPLANATION
Clump occurs from the bleeding of wound edges. After desiccation it forms cinder which is not pathological. First sign of wound infection is local inflammation, which can be seen as hyperemia and edema of wound edges. Septic fever can occur if abscess develop without the ability of spontaneous pus depletion. Suffusion is a flat-long bruise in the subcutaneous tissue without containing pus.
SUR - 1.55
Characteristics of steam sterilization
1) the process is done at above 1 Atm pressure and above 105 °C temperature
2) vacuum pumps suck out air before the chamber is filled with pressurized steam
3) to ensure sterility indicators should be taped on medical packaging
4) Surgical instruments should be placed in aluminum foil package
5) after the process the chamber should be cleaned with sodium hypochlorite (bleach)
A) 1, 2 and 3 answers are correct
B) 1, 3 and 4 answers are correct
C) 2, 3 and 5 answers are correct
D) 3, 4 and 5 answers are correct
ANSWER
A) 1, 2 and 3 answers are correct
EXPLANATION
Function of autoclave depends on the effect of pressurized saturated steam. The minimal effective pressure is 1.1 Atm, and the most commonly used maximum limit of over-pressure is 2.5 Atm. In order to preserve saturation and avoid cooling air is needed to be removed before filling the chamber with steam. Sterilization is signed for user by coloration of an indicator. Coloration of an indicator is used to sign whether the sterilization process and bagging of loaded instruments is completed (see also SEB-1.4.).
SUR - 1.56
In case of lacerated wound which involves the gluteal muscle
1) wound edges should be excised
2) prophylactic antibiotics (in this case Sulfaguanidine) should be administered
3) wound cavity should be rinsed with H2O2-solution
4) the wound should only be closed if a drain tube is left in the cavity
5) wound closure should be done with running intracutaneous suture
A) 1, 2, 4 and 5 answers are correct
B) all of the answers are correct
C) 2 and 4 answers are correct
D) 1, 3 and 4 answers are correct
ANSWER
D) 1, 3 and 4 answers are correct
EXPLANATION
Excision of wound edges and cleaning of wound cavity (debridement) is compulsory. Diluted H2O2 (at least 3%) is appropriate for cleaning and disinfection. In spite of the previous processes wound cavity should be considered contaminated so leaving a tube in the cavity is mandatory for preventing an abscess. Sulphaguanidine is not suitable for wound management because of its spectrum of activity and because it is a non-absorbable material. Intracutaneous running suture tightly closes the wound which is unfavorable because watertight closure should be avoided. Infected wound should be closed loosely or just converge the edges or treated it in a totally opened state.
SUR - 1.57
Tetanus prophylaxis is mandatory:
1) erysipelas
2) congelation
3) gunshot wound
4) bite wound
5) hydradenitis
A) 1, 2 and 3 answers are correct
B) 1, 3 and 4 answers are correct
C) 2, 3 and 4 answers are correct
D) 3, 4 and 5 answers are correct
ANSWER
C) 2, 3 and 4 answers are correct
EXPLANATION
Tetanus prophylaxis is mandatory in every type of lacerated, bitten or gunshot wounds. In these cases the skin is damaged and soft tissues are contaminated (see also SEB-1.11). Tetanus prophylaxis is also necessary in case of congelation because of the extensive soft tissue damage. Antibiotics are notable for treating inflamed skin lesions.
SUR - 1.58
Requirements of primary wound healing
1) debridement
2) good blood supply
3) intact innervation
4) Donati-type suturing
5) proper macrophage function
A) 1, 2, 4 and 5 answers are correct
B) all of the answers are correct
C) 2 and 4 answers are correct
D) 1, 2 and 5 answers are correct
E) 2, 4 and 5 answers are correct
ANSWER
D) 1, 2 and 5 answers are correct
EXPLANATION
Criteria of primary wound healing: sharp wound edges, non-tight edges, lack of foreign or contaminated parts in the cavity. Appropriate blood supply of the damaged area and its surrounding is pivotal for complete and primary wound healing (see also SEB-1.63. and SEB-1.66).
SUR - 1.59
Steps of wound management
1) analgesia
2) tetanus prophylaxis
3) wound excision
4) wound cleaning
5) wound closure, dressing
A) 2–1–4–3–5
B) 3–1–4–5–2
C) 4–1–3–5–2
D) 2–4–3–1–5
ANSWER
C) 4–1–3–5–2
EXPLANATION
The first step in the management of open wounds is removing rough contaminations. The next step is disinfection the site of local anesthesia and inject local anesthetics. Lacerated wound edges should be excised then closed (suture- clips- or sticking with or without leaving a tube) if criteria of closure are fulfilled. Tetanus prophylaxis is mandatory after wound dressing (see also SEB- 1.66., 1.67., 1.68.)
SUR - 1.60
Local signs of wound infection
1) bulge
2) innervation problem
3) hyperemia
4) functional problems
5) local tetanic spasm
A) 1, 2, 4 and 5 answers are correct
B) all of the answers are correct
C) 1, 3 and 4 answers are correct
D) 1, 2 and 5 answers are correct
E) 2, 4 and 5 answers are correct
ANSWER
C) 1, 3 and 4 answers are correct
EXPLANATION
Classic signs of inflammation published by Galenus are tumor, rubor, calor, dolor and functio laesa, which means bulge, erythema, warm, pain and loss of function, often subfebrility or fever. 1. 3. and 4. are wrong choices so the best answer is C.
