MPMSU MBBS Surgery 2024 Paper 2 questions with their answers

The clinical picture suggests acute intestinal obstruction with possible peritonitis or sepsis. This is a surgical emergency and requires prompt diagnosis, resuscitation, and intervention to prevent complications like bowel ischemia or septic shock.

• Acute Intestinal Obstruction: Obstructing colonic carcinoma, strangulated hernia, volvulus, adhesions.
• Perforation peritonitis: Duodenal ulcer, typhoid/TB, malignancy.
• Mesenteric ischemia: Embolic/thrombotic cause.
• Acute pancreatitis with paralytic ileus.

• History: Fever with chills, severe abdominal pain, absolute constipation, vomiting, past history of surgeries/hernias/malignancy.
• General exam: Toxic look, dehydration, fever, tachycardia, hypotension.
• Abdominal exam: Distension, visible peristalsis, guarding/rigidity, absent bowel sounds, tympanic percussion, DRE findings.

• Bloods: CBC, urea/creatinine, electrolytes, CRP, procalcitonin, amylase/lipase, blood culture, ABG.
• Imaging:
  • X-ray abdomen: air-fluid levels, dilated loops, pneumoperitoneum.
  • Ultrasound: free fluid, bowel loops, mass/herniation.
  • CECT abdomen: gold standard for cause/site of obstruction, ischemia, perforation, abscess.
  • Chest X-ray & ECG: pre-op assessment.

• Initial Resuscitation:
  • Airway & oxygen.
  • IV fluids (NS/RL), central line if needed.
  • Nasogastric decompression.
  • Foley catheter for output monitoring.
  • IV antibiotics – piperacillin-tazobactam + metronidazole.
  • IV analgesia.
• Definitive Management:
  • Obstruction: Conservative in early cases. Surgery if strangulated or no response in 24–48 hrs. Options: adhesiolysis, hernia repair, derotation of volvulus, tumor resection/anastomosis/stoma.
  • Peritonitis/Perforation: Emergency laparotomy, Graham’s patch, resection, peritoneal lavage + drain.
  • Colorectal malignancy: Left – Hartmann’s; Right – hemicolectomy.
• Post-op Care: ICU support, fluid/electrolyte management, antibiotics, vitals monitoring, early mobilization, DVT prophylaxis.

• Septic shock
• Bowel gangrene
• Anastomotic leak
• Electrolyte imbalance
• Wound infection, burst abdomen
• ARDS, renal failure

Acute Calculous Cholecystitis

Rationale: Right subcostal pain radiating to the shoulder, nausea, vomiting, and tenderness are classical features of acute cholecystitis, likely due to gallstones.

• Perforated peptic ulcer: Sudden severe pain, guarding, rigidity, obliteration of liver dullness, air under diaphragm on X-ray.
• Acute pancreatitis: Epigastric pain radiating to back, right hypochondrium tenderness, elevated serum amylase/lipase.
• High retrocaecal appendicitis: Mimics cholecystitis; inflammation near subhepatic area.
• Amoebic liver abscess: Tender enlarged liver; more common in alcoholic males.
• Basal lobar pneumonia: Referred pain to right hypochondrium; confirmed via chest X-ray.

• Blood Tests: Total WBC (↑ in inflammation), blood/urine sugar (diabetes screen).
• Plain X-ray Abdomen (Erect): 10% gallstones are radio-opaque; rule out perforation (air under diaphragm).
• Ultrasound Abdomen: Investigation of choice. Shows gallstones (posterior shadow), GB wall thickening (>5–6 mm), pericholecystic fluid, Murphy’s sign.
• HIDA/PIPIDA Scan: Non-visualisation of GB → acute cholecystitis. Helpful in acalculous cases.
• CT Scan: For complications (e.g., perforation, CBD stones) or inconclusive USG.

• I. Conservative Treatment (60–70% cases):
  • Admission, Ryle’s tube aspiration.
  • Analgesics & antispasmodics: Inj. Morphine + Atropine.
  • IV antibiotics: Cefazolin / Cefuroxime / Amikacin.
  • NPO for 2–3 days, followed by soft diet.
  • Elective cholecystectomy after 6 weeks (indicated in elderly, diabetics, comorbidities, frozen Calot’s triangle).
• II. Early Cholecystectomy (within 48–72 hrs):
  • Done if diagnosis is clear, comorbidities under control.
  • Laparoscopic cholecystectomy preferred by experienced surgeons.
  • Advantage: Avoids second admission, quicker recovery.
• III. Emergency Cholecystostomy (5% cases):
  • Indications: Sepsis, shock, high fever, acalculous cholecystitis, perforation.
  • Procedure: Drain pus/necrotic tissue via pig-tail or Malecot catheter. Cholecystectomy done 6–8 days later.

• Mortality: 3–5%
• Poor prognostic factors: Diabetes, age >60, cardiopulmonary disease, uncontrolled sepsis

Mesh repair is the most preferred surgical technique for incisional hernias, particularly in obese, multiparous females with large fascial defects and poor abdominal wall tone. It provides a tension-free, non-absorbable suture-based repair using synthetic mesh.

• Large incisional hernias
• Obese patients
• Multiparous women
• Poor muscle tone
• Recurrent hernias

• 1. Onlay Mesh Repair:
  • Mesh placed over anterior rectus sheath in subcutaneous plane.
  • Technically simple but requires wide flap dissection.
• 2. Sublay (Retromuscular) Mesh Repair:
  • Mesh placed between posterior rectus sheath and rectus muscle.
  • Preferred due to lower seroma and recurrence rates.
  • Not possible below arcuate line (no posterior sheath).

• 1. Incision and Exposure: Previous incision reopened; scar excised; flaps raised to expose muscles.
• 2. Identification of Sac: Hernial sac dissected and opened; contents reduced; redundant omentum excised.
• 3. Sac Management: Sac excised; peritoneum closed to avoid mesh contact.
• 4. Mesh Placement:
  • Mesh (Prolene/Marlex) placed tension-free with 5 cm overlap in all directions.
  • Secured using non-absorbable sutures.
  • Onlay: Mesh in subcutaneous plane over anterior sheath.
  • Sublay: Mesh between posterior sheath and rectus muscle.

• Mesh: Prolene / Marlex (non-absorbable)
• Sutures: Non-absorbable (e.g., Prolene)

• Seroma formation (most common)
• Wound infection
• Mesh infection
• Recurrence (due to inadequate overlap or persistent tension)

• Tension-free closure
• Low recurrence rate
• Suitable for large defects
• Durable and strong repair

A longitudinal tear in the lower end of the anal canal. It is one of the most painful anal conditions, commonly seen in young adults.

• 90% occur posteriorly (midline) → due to relative ischaemia.
• Initiated by hard stool → tear → pain → sphincter spasm → constipation → chronic fissure.
• Anterior fissures: Common in elderly women due to pelvic floor damage during childbirth.
• Acute fissures in females may occur after vaginal delivery.

• Severe burning pain during and after defaecation (lasting 30–60 min).
• Constipation with passage of hard pellet-like stool.
• Fresh bleeding per rectum:
  • Drop: Fissure in ano
  • Splash: Haemorrhoids
  • Slimy blood: Carcinoma
• Sentinel pile: Skin tag at the lower end of the fissure.
• Perianal abscess: May coexist and worsen pain.

• F: Faeces (hard)
• I: Ischaemia
• S: Sphincter hypertonia
• S: Surgical procedures (e.g., haemorrhoidectomy)
• U: Underlying diseases (Crohn’s, STDs)
• R: Repeated childbirth
• E: Enthusiastic use of ointments/laxatives

• 1. Inspection: Longitudinal tear and sentinel pile seen on separating buttocks.
• 2. Per Rectal Examination: Sphincter spasm present. Done only with lignocaine jelly.
• 3. Proctoscopy: Contraindicated due to severe pain.

• I. Conservative Measures:
  • High-fibre diet to soften stool and prevent constipation.
  • Warm Sitz baths.
  • Topical lignocaine gel for analgesia.
  • Metronidazole or antibiotics in case of secondary infection.
• II. Medications to Relax Sphincter:
  • 1. Glyceryl Trinitrate (0.2%): Increases local blood flow and relieves spasm. Side effect: headache. Recurrence in 50% cases.
  • 2. Botulinum Toxin Injection: Causes temporary sphincter paresis. Avoids permanent damage. Costly; risk of thrombosis/sepsis.
  • 3. Calcium Channel Blockers: Nifedipine or Diltiazem (oral/topical 2%).
• Note: Fissures away from the midline → Suspect Crohn’s disease, STDs, or trauma.
• III. Surgical Treatment:
  • 1. Lateral Internal Sphincterotomy (Notaras): Procedure of choice. Internal sphincter divided laterally (right or left). Avoids incontinence if limited to fissure length.
  • 2. Fissurectomy + Advancement Flap: For chronic non-healing fissures. Rhomboid flap used. Longer healing time.
  • 3. Lord’s Anal Dilatation: No longer recommended. Blunt division of sphincter fibres. High risk of incontinence, especially in females.

When the descent of the testis is arrested somewhere in its normal pathway to the scrotum, it is called undescended testis.

• Testis develops in the retroperitoneum from the genital tubercles.
• Descent is guided by the gubernaculum.
• Descent timeline:
  • 7th month – Reaches deep inguinal ring
  • 8th month – Enters inguinal canal
  • 9th month – Reaches superficial inguinal pouch
• Normally reaches the scrotum by full term.
• Processus vaginalis sac surrounds the testis during descent; failure to obliterate can lead to hernia/hydrocoele.

• Muscular hypotonia – e.g., prune-belly syndrome, Down’s syndrome.
• Gubernaculum dysfunction – improper guidance during descent.
• Deficiency of maternal HCG – hormonal defect.
• Familial – genetic predisposition.
• Retroperitoneal adhesions – anatomical blockage.

• Right side more commonly affected.
• Bilateral in 20% of cases.
• Cryptorchidism: Both testes are impalpable.
• Retractile testis:
  • Palpable at root of scrotum; testis can be brought down manually.
  • Usually self-resolves by 1–2 years of age.
  • Squatting helps assessment.

• T: Trauma – Increased risk of injury and pain.
• E: Epididymo-orchitis – Can mimic acute abdomen.
• S: Sterility – Irreversible damage starts by 2 years, infertility by 12 years.
• T: Torsion – Twisting of the testis.
• I: Indirect inguinal hernia – Common association.
• S: Seminoma – Increased risk of testicular malignancy.

• 1. Orchidopexy: Surgical fixation of testis into the scrotum.
  • Can be open or laparoscopic; one-stage or two-stage (Fowler-Stephens technique).
  • Stage I: Divide spermatic vessels.
  • Stage II: After collateral supply forms, place testis in scrotum.
  • Ideal timing:
    • Bilateral – 6 months to 1 year
    • Unilateral – up to 4 years
  • Steps:
    • Explore inguinal canal, mobilize testis, divide adhesions.
    • Fix testis in a dartos pouch using nonabsorbable sutures.
    • Excise hernial sac if present.
• 2. Orchidectomy: Removal of testis if undescended after age 14 (cancer risk).
• 3. Ombredanne’s Procedure: Transfer testis to opposite scrotum via scrotal septum and fix in dartos pouch.
• 4. Silber’s Procedure: Microvascular division and reanastomosis of testicular vessels.

Tuberculous peritonitis is a form of peritoneal tuberculosis that can present acutely or chronically. It is marked by intense exudation and manifests in various pathological forms like ascitic, loculated, fibrous, and purulent types.

• 1. Ascitic Form (Generalized Variety):
  • Common in: Children and young adults
  • Features: Abdominal distension, doughy feel, positive shifting dullness
  • Omentum: Palpable, rolled-up, nodular mass
  • Ascitic fluid: Lymphocyte-rich
  • Differentials: Pseudocyst of pancreas, mesenteric cyst, retroperitoneal cyst
• 2. Loculated or Encysted Form:
  • Common in: Adults
  • Features: Localized ascitic fluid, no shifting dullness
  • Caused by: Matted coils of intestine and omentum sealing off the fluid
• 3. Fibrous Peritonitis (Plastic Form):
  • Features: No ascites, dense adhesions and fibrosis
  • Presentation: Distension, intestinal matting, strictures, bowel obstruction
  • Complications: Blind loop syndrome, steatorrhea, emaciation, risk during laparotomy
• 4. Purulent Form:
  • Cause: Spread from genital TB (e.g. tuberculous salpingitis)
  • Presentation: Acute peritonitis with tubercles, pus, cold abscesses
  • Management: Laparotomy + drainage + ATT
  • Prognosis: Poor due to risk of toxaemia and faecal fistula
  • Association: Polyserositis syndrome (pleural/pericardial effusions)

Primary cause: Reactivation of latent tubercular focus in the peritoneum

Predisposing factors:

• Cirrhosis
• HIV infection
• Diabetes mellitus
• Malignancy
• Peritoneal dialysis (CAPD)

• 1. Ascitic Fluid Analysis:
  • Appearance: Pale-straw colored
  • Cell count: Lymphocyte-predominant exudate
  • Surface: Tubercles may be visible
• 2. Imaging:
  • Ultrasound: Loculated fluid, matted intestines, abscesses
  • CT Scan: Detects fibrosis, adhesions, and tubercles

• 1. Anti-tuberculous Therapy (ATT):
  • Drugs: Rifampicin, Isoniazid, Pyrazinamide, Ethambutol (RHZE)
  • Duration: 6–9 months
• 2. Surgical Management:
  • Laparotomy for pus drainage (purulent form)
  • Bowel resections for strictures or perforations

• Intestinal obstruction
• Fistula formation
• Peritonitis
• Polyserositis syndrome (pleural/pericardial effusion)

• Malignant tumour of the kidney in children, also called nephroblastoma.
• Composed of blastemal, epithelial, and connective tissue elements (bone, cartilage, muscle).
• Typically arises from one pole of the kidney, distorting its shape.
• Grossly greyish-white or pinkish-white; resembles brain tissue; may have haemorrhage or necrosis.
• Microscopy: Connective tissue (cartilage, spindle cells), smooth/striated muscle, epithelial components.
• 5% are bilateral; occurs in familial and non-familial forms.

• Affects both genders, most common between 2–4 years.
• Better prognosis if diagnosed before 1 year; rare after 7 years.
• Presents as abdominal distension from enlarged, nodular kidney.
• Haematuria indicates tumour rupture into renal pelvis – poor prognosis.
• Low-grade fever due to tumour necrosis and pyrogens.
• Rapid deterioration of health is common.

• USG: Detects solid renal mass, assesses other kidney.
• CT Scan: Evaluates extent and adjacent involvement.
• IVP / CECT Urogram: Shows calyceal distortion and opposite kidney function.
• FNAC: Confirms diagnosis preoperatively.

• Neuroblastoma (most common differential)
• Retroperitoneal tumours
• Adrenal tumours

Differentiating from Neuroblastoma:

• Calcification: Common in neuroblastoma (85%), rare in Wilms’ (15%)
• Intraspinal extension: Seen in neuroblastoma, rare in Wilms’
• Wilms’ invades renal vessels (aorta/IVC); neuroblastoma rarely does
• Wilms’ is intrarenal; neuroblastoma displaces kidney
• Neuroblastoma more often crosses midline
• HVA/VMA elevated in neuroblastoma, not in Wilms’

• Local: Direct renal capsule invasion
• Lymphatic: Hilar, para-aortic, mediastinal, left supraclavicular nodes
• Haematogenous: Lungs, liver, bones, brain
• Vascular: Tumour thrombus in renal vein/IVC

Initial step: Correct anaemia before definitive therapy

1. Localised Tumour (Kidney/Perirenal tissue):
   • Radical nephrectomy
   • Chemotherapy (6 months): Actinomycin D + Vincristine
2. Locally Advanced Tumour (Beyond capsule or lymph nodes):
   • Radical nephrectomy
   • Local radiotherapy
   • Chemotherapy (15 months): Actinomycin D + Vincristine
3. Unresectable Tumour:
   • Confirm diagnosis with FNAC
   • Preoperative radiotherapy (1000 cGy) or chemotherapy
   • Nephrectomy once operable
   • Post-op chemo: Actinomycin D, Vincristine, Doxorubicin
4. Bilateral Wilms’ Tumour:
   • Radical nephrectomy (larger tumour)
   • Partial nephrectomy (smaller side – preserve renal tissue)
   • Chemotherapy post-op
   • If inoperable: Chemotherapy + Radiotherapy
   • Long-term risks of radiotherapy: Growth disturbances, cardiac & pulmonary toxicity

A gallbladder polyp is a mucosal growth projecting into the lumen of the gallbladder. Most are benign and incidentally detected on imaging, especially ultrasonography.

• Seen in ~5% of patients undergoing routine abdominal USG
• Found in ~10% of cholecystectomy specimens

• Cholesterol polyps: Most common; benign, non-neoplastic
• Adenomyomatosis: Benign hyperplastic lesion
• Adenomatous polyps: True neoplastic polyps with malignant potential
• Inflammatory polyps
• Hyperplastic polyps

• Often asymptomatic
• If symptomatic: RUQ pain, nausea, or biliary colic-like symptoms

• Echogenic lesion without acoustic shadowing
• Pedunculated polyps: Usually small (<10 mm)
• Sessile polyps: Tend to be larger, higher malignancy risk
• Multiple polyps in ~30% of cases

• Polyp size >10 mm
• Sessile morphology
• Age >60 years
• Associated gallstones
• Multiple polyps
• Symptomatic presentation

• Ultrasound: First-line modality
• CT scan: If malignancy suspected
• MRI/MRCP: For select cases with uncertain findings

• Indications for cholecystectomy:
  • Polyp >10 mm
  • Symptomatic patient
  • Sessile morphology
  • Multiple polyps
  • Associated gallstones
  • Age >60 years
• Laparoscopic cholecystectomy is the treatment of choice
• Histological examination is essential to confirm benign nature and exclude malignancy
• Polyps <10 mm without risk factors: Monitor with serial USG

• Most polyps are benign
• Early diagnosis of malignant polyps improves outcomes
• Gallbladder cancer overall carries poor prognosis

Use Ryle’s tube aspiration to rest the gut, especially if vomiting is present.

• Purgatives are contraindicated as they may cause perforation.

• Record temperature, pulse, respiration, and diameter of the mass
• Swinging temperature and increased mass size suggest an appendicular abscess

• Use broad-spectrum antibiotics to cover:
  • Gram-positive organisms
  • Gram-negative organisms
  • Anaerobic organisms

• Initial exploratory laparotomy is avoided
• Indications for surgery:
  • No improvement in condition
  • Suspected abscess
  • Doubtful diagnosis

• Nil orally for a few days
• IV fluids to manage and correct dehydration

Torsion testis refers to the twisting of the spermatic cord leading to compromised blood supply to the testis. It is a urological emergency.

• Bell clapper deformity – High tunica vaginalis investment
• Inversion of testis – Lies horizontally or upside down
• Long spermatic cord
• Cremasteric muscle contraction – Can trigger torsion during straining
• Extravaginal torsion – Seen in neonates
• Intravaginal torsion – Common in ages 12–18 years

• Sudden, severe pain in groin or lower abdomen
• Nausea and vomiting
• Empty, oedematous hemiscrotum
• High-riding, tender testis – Deming’s sign
• Prehn’s sign: Pain increases on elevation
• Angell’s sign: Horizontal lie of opposite testis

• Manual detorsion – Should be attempted within 1 hour
• Emergency surgical exploration:
  • Viable testis: Perform orchidopexy
  • Gangrenous testis: Perform orchidectomy
• Contralateral orchidopexy – To prevent future torsion
• Doppler USG – A useful diagnostic aid

An anatomical area of the lower anterior abdominal wall, bounded by three key landmarks, important in the pathogenesis of inguinal hernias.

• Medially: Lateral border of rectus abdominis
• Laterally: Inferior epigastric artery
• Inferiorly: Inguinal ligament

• Direct inguinal hernia: Occurs through Hesselbach’s triangle (medial to inferior epigastric artery)
• Indirect inguinal hernia: Occurs lateral to inferior epigastric artery

A true congenital diverticulum of the small intestine, arising from the antimesenteric border of the ileum, due to persistence of the vitellointestinal duct.

• Seen in 2% of the population
• 2 inches long
• Located 2 feet from the ileocaecal valve
• 2 types of ectopic mucosa: gastric (commonest), pancreatic
• Presents commonly in <2 years of age
• 2 times more common in males

• Massive painless rectal bleeding (melaena or maroon-colored)
• Acute diverticulitis – mimics appendicitis
• Perforation – can cause generalised peritonitis
• Intestinal obstruction – due to band or volvulus
• Intussusception, chronic pain due to peptic ulceration
• Neoplasms – e.g. Carcinoid, GIST
• Hernia of Littre – when Meckel’s is present in a hernial sac

• 99mTc-pertechnetate scan: Detects ectopic gastric mucosa, especially in children
• Small bowel enema: May detect wide-mouthed diverticulum (rarely used)

• Symptomatic or complicated: Surgical resection with adjacent ileum
• Incidental finding: Left alone if wide-mouthed & asymptomatic, but must be documented

An anatomical triangle dissected during cholecystectomy to safely identify and ligate the cystic artery—important to avoid bile duct injury.

• Lateral: Cystic duct (and gallbladder)
• Medial: Common hepatic duct
• Superior: Inferior surface of right lobe of liver

A clinical guideline used to predict the internal opening of an anal fistula based on the position of its external opening.

• External opening is in the anterior half of the anus.
• Located within 3.75 cm from the anal verge.
• The fistulous tract usually follows a straight (radial) path to the anal canal.

• External opening is in the posterior half of the anus.
• Typically follows a curved or indirect path.
• May form a horseshoe-shaped fistula.
• May communicate with the opposite side of the anus.

• Occurs in low socio-economic groups, poor hygiene.
• Follows perianal abscess, urogenital instrumentation, or minor scrotal trauma (cut/scratch).

Microaerophilic Streptococci, Staphylococci, E. coli, Clostridium welchii.

Classified under necrotising fasciitis.

• Sudden painful scrotal swelling, fever, toxicity.
• Rapid progression to gangrene with exposed testis.
• May extend to perineum, penis, abdominal wall.

• Start broad-spectrum antibiotics: Metronidazole, Gentamicin, Ampicillin.
• Urgent excision of gangrenous skin.
• Grafting or thigh implantation for exposed testis.

A congenital tubuloembryonic dermoid cyst arising from the thyroglossal duct, extending from foramen caecum to thyroid isthmus.

1. Subhyoid – Most common
2. Thyroid cartilage level – 2nd most common
3. Suprahyoid – Gives a double chin look
4. Foramen caecum – Rare
5. Cricoid level
6. Floor of mouth

• Midline painless cystic swelling
• Moves with swallowing and tongue protrusion (due to hyoid attachment)
• Seen in young adults (15–30 yrs)
• Soft/fluctuant, non-transilluminant
• Slight deviation at thyroid cartilage level

• Thyroid scan before surgery – To rule out ectopic thyroid
• Sistrunk operation – Excision of cyst, entire tract, and central part of the hyoid bone

• Primary splenic tumour
• Hereditary spherocytosis

• Primary hypersplenism
• Chronic ITP (Idiopathic Thrombocytopenic Purpura)
• Splenic vein thrombosis
• Splenic abscess

• Splenic injury
• Autoimmune haemolytic anaemia
• Elliptocytosis with haemolysis
• Congenital nonspherocytic haemolytic anaemia
• Hodgkin’s disease with anaemia
• TTP (Thrombotic Thrombocytopenic Purpura)
• Idiopathic myelofibrosis
• Splenic artery aneurysm
• Wiskott-Aldrich syndrome
• Gaucher’s disease

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