Sample Pages of Surgery Sixer

Contents
Preface ix
Acknowledgements xi
Recent Pattern Questions 2019 At a Glance xix
Sample Video Questions xxii
SECTION 1 GENERAL SURGERY
Chapter 1. Basic Concepts in Surgery---------------------------------------------------------------------------------------------3–32

Theory--------------------------------------------------------------------------------------------------------------------------------------- 3
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Image-Based Questions------------------------------------------------------------------------------------------------------------------- 15
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Answers of Image-Based Questions----------------------------------------------------------------------------------------------------- 16
Multiple Choice Questions--------------------------------------------------------------------------------------------------------------- 17
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Answers with Explanations of Multiple Choice Questions--------------------------------------------------------------------------- 24
Chapter 2. General Surgery Principles, Perioperative Care and Recent Advances--------------------------------------- 33–80
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Theory-------------------------------------------------------------------------------------------------------------------------------------- 33
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Image-Based Questions------------------------------------------------------------------------------------------------------------------- 56
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Answers of Image-Based Questions----------------------------------------------------------------------------------------------------- 58
Multiple Choice Questions--------------------------------------------------------------------------------------------------------------- 60
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Answers with Explanations of Multiple Choice Questions--------------------------------------------------------------------------- 68

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Chapter 3. Trauma (Including-Recent ATLS 10th Edition Updates)-------------------------------------------------------81–135

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Theory-------------------------------------------------------------------------------------------------------------------------------------- 81
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Image-Based Questions------------------------------------------------------------------------------------------------------------------105
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Answers of Image-Based Questions----------------------------------------------------------------------------------------------------109

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Multiple Choice Questions--------------------------------------------------------------------------------------------------------------111

Answers with Explanations of Multiple Choice Questions--------------------------------------------------------------------------122
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Chapter 4. Transplant---------------------------------------------------------------------------------------------------------- 137–162

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Theory-------------------------------------------------------------------------------------------------------------------------------------137
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SECTION 2 HEAD, NECK, THYROID AND BREAST
Chapter 5. Oral Cavity and Malignancy------------------------------------------------------------------------------------- 165–183

Theory-------------------------------------------------------------------------------------------------------------------------------------165
Surgery Sixer for NBE
Chapter 6. Salivary Gland Swellings------------------------------------------------------------------------------------------ 185–200

Theory-------------------------------------------------------------------------------------------------------------------------------------185
Chapter 7. Swellings/Pathology in Head and Neck------------------------------------------------------------------------- 201–218

Theory-------------------------------------------------------------------------------------------------------------------------------------201
Chapter 8. Thyroid-------------------------------------------------------------------------------------------------------------- 219–256
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Theory-------------------------------------------------------------------------------------------------------------------------------------219
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Chapter 9. Breast---------------------------------------------------------------------------------------------------------------- 257–304

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Theory-------------------------------------------------------------------------------------------------------------------------------------257
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SECTION 3 GASTRO INTESTINAL TRACT

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Chapter 10. Esophagus----------------------------------------------------------------------------------------------------------- 307–349

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Theory-------------------------------------------------------------------------------------------------------------------------------------307
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Image-Based Questions -----------------------------------------------------------------------------------------------------------------325

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Chapter 11. Stomach and Duodenum (Including Bariatric Surgery and Upper GI Hemorrhage)------------------- 351–401
Theory-------------------------------------------------------------------------------------------------------------------------------------351
Chapter 12. Small and Large Bowel (Including Appendix and Stomas)-------------------------------------------------- 403–479
Theory-------------------------------------------------------------------------------------------------------------------------------------403
xiv Answers with Explanations of Multiple Choice Questions--------------------------------------------------------------------------457
Contents
Chapter 13. Rectum and Anus (Includes Lower GI and Obscure GI Bleeding)----------------------------------------- 481–506
Theory-------------------------------------------------------------------------------------------------------------------------------------481
Chapter 14. Miscellaneous Conditions in Abdomen (Includes HERNIA in Detail)------------------------------------ 507–538

Theory-------------------------------------------------------------------------------------------------------------------------------------507
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SECTION 4 HEPATOBILIARY AND PANCREATIC SURGERY
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Chapter 15. Gallbladder and Biliary System---------------------------------------------------------------------------------- 541–588
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Theory-------------------------------------------------------------------------------------------------------------------------------------541
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Chapter 16. Liver (Including Portal Hypertension)------------------------------------------------------------------------- 589–630

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Theory-------------------------------------------------------------------------------------------------------------------------------------589
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Chapter 17. Pancreas------------------------------------------------------------------------------------------------------------- 631–673

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Theory-------------------------------------------------------------------------------------------------------------------------------------631
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Chapter 18. Spleen---------------------------------------------------------------------------------------------------------------- 675–688

Theory-------------------------------------------------------------------------------------------------------------------------------------675
xv
SECTION 5 SPECIALITY SURGERIES
Chapter 19. Urology—Part 1: (Kidney and Ureter)-------------------------------------------------------------------------- 691–732

Theory-------------------------------------------------------------------------------------------------------------------------------------691
Chapter 20. Urology—Part 2: Lower Urinary System (Bladder, Prostate, Urethra, Testis and Penis)---------------- 733–793
Theory-------------------------------------------------------------------------------------------------------------------------------------733
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Chapter 21. Cardiothoracic Surgery (Including Lung, Pleura and Heart)----------------------------------------------- 795–827
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Theory-------------------------------------------------------------------------------------------------------------------------------------795
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Chapter 22. Vascular Surgery (Arterial, Venous and Lymphatic System)------------------------------------------------ 829–870
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Theory-------------------------------------------------------------------------------------------------------------------------------------829
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Chapter 23. Plastic Surgery and Burns (Including Skin Lesions)---------------------------------------------------------- 871–897
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Theory-------------------------------------------------------------------------------------------------------------------------------------871
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Chapter 24. Neurosurgery (Excluding Head Injury)------------------------------------------------------------------------ 899–922

Theory-------------------------------------------------------------------------------------------------------------------------------------899
xvi
Contents
Chapter 25. Oncosurgery-------------------------------------------------------------------------------------------------------- 923–950

Theory-------------------------------------------------------------------------------------------------------------------------------------923
Chapter 26. Pediatric Surgery--------------------------------------------------------------------------------------------------- 951–965

Theory-------------------------------------------------------------------------------------------------------------------------------------951
Chapter 27. Endocrine Surgery (MEN Syndrome, Parathyroid and Adrenal Glands)---------------------------------- 967–986
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Theory-------------------------------------------------------------------------------------------------------------------------------------967
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SECTION 6 FINAL OVER ry

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Chapter 28. General Surgical Instruments----------------------------------------------------------------------------------- 989–1002

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Chapter 29. Last Minute Tables---------------------------------------------------------------------------------------------- 1003–1011

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Chapter 30. AJCC 8th Edition Updates-------------------------------------------------------------------------------------- 1013–1016

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Chapter 31. PGI Chandigarh Questions (2017, 2018 Question Papers)----------------------------------------------- 1017–1040
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xvii
Basic Concepts
in Surgery 1
ONE LINERS
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Basic Points in Surgery
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• Most common type of Shock: Hypovolemic shock
• The best parameter to monitor/guide tissue perfusion:* Urine output
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• The best method to manage shock with fluids: pulmonary capillary wedge pressure (PCWP)* > central venous pressure (CVP) monitor*
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• The most dangerous complication after (CVP) line: Pneumothorax
• Most common complication of central venous line: Catheter-related sepsis*
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• On total parenteral nutrition (TPN) weight gain starts from 7th day.
• Most common cause of death in surgical patients: Shock
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• Blood pressure is maintained and falls after 30–40% of circulating volume has been lost.
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• Hypovolemic shock is characterized by low blood pressure (BP), tachycardia, acidosis and oliguria**
• Blood loss in class II hemorrhagic shock is 15–30%**
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• Neurogenic shock is characterized by hypotension and bradycardia.

• Plasma expanders are used in septic shock**
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• Reactionary hemorrhage occurs within 24 hours

• Secondary hemorrhage occurs after 7–14 days of injury
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• Most common coagulopathy in surgical patient is thrombocytopenia.

• The most common artery for cannulation is radial artery.
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• Post-dural puncture headache is typically bifront or occipital

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Blood and Blood Products

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• Hematocrit is the best indicator for need of blood transfusion*

• Massive blood transfusion means transfusion of whole blood volume (E.g. 5 liters in adult)
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• Hemoglobin level of <6 g/dL is indication of transfusion for asymptomatic, not actively bleeding and patient not undergoing major surgery.
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• Blood group O is universal donor, AB is universal recipient

• Cryoprecipitate is a source of fibrinogen ,VIII factor and Von Willebrand factor
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• Cryoprecipitate is stored at -40°C

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• Rosenthal’s syndrome is due to deficiency of Factor XI

• Half - life of factor VIII is 8–12 hours
• Blood platelets in stored blood do not remain functional after 24 hours
• Platelets can be stored at (20°C–24°C) for 5 days**
• Blood grouping and cross-matching is must prior to infusion of Dextran.
• Massive blood transfusion is defined as whole blood volume in 24 hours
• Maximum storage of blood with citrate-phosphate-dextrose with adenine (CPDA) is 35 days.
• One unit of fresh blood rises the HB% concentration by 1 gm%
• Most common blood transfusion reaction is febrile nonhemolytic transfusion reaction.
Overview of Chapter
•• Nutrition
•• Shock, Fluids, Acid Base Balance and Electrolytes Imbalance
•• Blood Transfusion and Blood Products
Section 1  General Surgery
NUTRITION IN SURGERY
NUTRITIONAL ASSESSMENT
Laboratory Techniques
yy Albumin (though not much useful in acute setting)
yy Hypoalbuminemia is an indicator of poor prognosis following surgery (Less than 30 g/L)
Body weight and Anthropometry
yy Body mass index (BMI) < 18.5 indicates nutritional impairment.
yy BMI <15 indicates severe mortality.
yy Midarm circumference, Skin fold thickness are indirect measurements of protein stores.
Bailey's 27/e update
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Clinical:
Malnutrition Universal Screening Tool (MUST): Clinical assessment tool of malnutrition
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BMI Weight loss in 3–6 months Acute disease effect
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>20 <5% Add a score of 2 if there is reduced
18.5- 20 5–10% intake >5 days
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<18.5 >10%
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Count all scores
Estimate the risk of undernutrition
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O 1 2 or more
Low Medium risk High risk
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Routine clinical care Observe Treat

Visit hospital every week Document dietary and fluid intake for Refer to dietician
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3 days once in Hospital

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INDICATIONS FOR ARTIFICIAL NUTRITION

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yy Any patient who has sustained > 7 days of inadequate intake

yy Any patient who is anticipated to have no intake for > 7 days.
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Modes of Nutrition (Table 1 and Fig. 1)

Table 1: Modes of nutrition
Enteral Nutrition Parenteral Nutrition

Nutrition Given via Gastrointestinal Nutrition Given via Veins
Tract
•• Sip feeding •• Peripheral parenteral
•• Tube feeding •• Central parenteral
Nasogastric tube (Ryles tube)
Nasojejunal tube
Feeding gastrostomy (PEG)
Feeding Jejunostomy .
Fig. 1: Modes of nutrition

Abbreviations: PEG, percutaneous endoscopic gastrostomy; TPN, total
parenteral nutrition
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Theory
Chapter 1  Basic Concepts in Surgery

M ust K now High Yield Extra Edge:
•• Threshold for platelet transfusion = 10,000 cells/ µL
Effects of storage of whole blood: •• For invasive procedure minimum platelet count must be
•• Reduction in pH** 50,000
•• Raise in potassium concentration** •• For Surgeries minimum platelet count must be 1 lakh*
•• Progressive reduction of red cell content of 2, 3 di
phosphoglycerate which results in decrease in oxygen
Trending Tremors....
carrying capacity.
•• Loss of platelet function in whole blood within 48 hours of
donation
•• Reduction of factor VIII to 10-20% of normal in 48 hours Topic 1: Ryles Tube (Nasogastric Tube)
•• Coagulation factors VII and IX are stable in storage*
yy Ryles tube length ranges from standard 105 cm to even 120 cms.
yy It is coated with radiopaque line to facilitate its identification
Massive Blood Transfusion
through X rays.
It is defined as transfusion of greater than patient’s total blood
volume in 24 hours or as acute administration of more than half It is of two types:
the patient’s estimated blood volume over a few hours.
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yy Fine bored tubes (8 -12 Fr) preferred for enteral feedings, which
requires prolonged use to be tolerated by nasal mucosa
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Complications of Massive Transfusion
yy Large bore tubes (14Fr or more) for decompression and lavage
yy Coagulopathy
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(Levin or Ewald tube)
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yy Hypocalcemia* (due to binding of ionized calcium by citrate
used as anticoagulant) Selecting the length to be inserted in an adult and
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yy Hyperkalemia* (due to RBC lysis) children:
yy Hypomagnesemia
yy Hypothermia ry
yy NEX method (in adults) – Nose to Ear to Xiphisternum
yy Nose to around ear lobe and to umbilicus
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yy Volume overload
yy NEMU (preferred in children) – Nose to Ear lobe to Mid point
yy Dilutional thrombocytopenia
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between xiphoid and Umbilicus

yy Decreased oxygen delivery (due to decrease in 2, 3 DPG)
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yy Metabolic alkalosis (even though the stored blood contains pH- Indications Contraindications
6.3, because of massive transfusion sodium citrate is metabolized •• Decompression in GOO, Bowel •• Kerosene poisoning
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in liver to sodium bicarbonate) obstruction •• Skull base fracture

yy Rare- Metabolic Acidosis*
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•• Feeding purposes •• Unstable cervical spine

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•• Lavage in some poisoning injury

Table 20: Blood components, storage temperature and their •• Aspiration for diagnostic •• Gastroesophageal varices,
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shelf-life purposes uncontrolled hemorrhage

•• Administration of medications •• Untreated coagulopathy
Blood components Temperature of Shelf life
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storage
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Technique:
Whole blood 1-6°C 35 days
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yy Choose larger nostril, lubricate nostril with Lidocaine and also

the tube
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Packed cells 42 days

yy Measure length to be inserted
Platelets 20-24°C 5 days
yy Patient in high fowler position or upright position with neck
FFP - 40°C 2 years flexed** during negotiation into nasopharynx.
Cryoprecipitate -30°C 2 years
Once desired length mark has reached, confirm its
position by:
yy Auscultating with stethoscope in epigastric region by
Platelet Transfusion:
simultaneously pushing air in an empty syringe through the
•• Volume- 50 mL
external port of tube
•• Stored at room temperature*
yy Look for reflux of gastric contents in the tube
•• Survive only for 5 days*
•• 1 unit has- 5,000–10,000 platelets* yy Aspiration of secretion and test with litmus paper for pH (Most
•• ABO compatibility is not needed for platelet and FFP* ideal method**)
•• Blood pack containing platelets will not be functioning after yy ET CO2 measuring
24 hours.
Contd...
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Image-Based Questions

1. Which is the ideal position to insert the below tube 3. Identify the use of the tube shown here:
(AIIMS May 2018, AIIMS Nov 2018 )
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a. Sitting with neck extended
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b. Supine with neck flexed
c. Supine with neck extended a. Venous cannulation
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d. Sitting with neck flexed b. Feeding Gastrostomy by surgery
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c. PEG
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d. Feeding jejunostomy
2. Identify the fluid bag shown here:
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4. Identify the use of the tube shown here:
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a. Jejunostomy bag with milk

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b. Albumin
a. Feeding tube b. Central venous catheter
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c. TPN
d. Astymin c. Ryle tube d. PEG tube
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5. How long can we store the blood product shown below?
a. 1 month b. 1 year
c. 2 years d. 6 weeks 15
Answers of Image-Based Questions

1. Ans. (d) Sitting with neck flexed
Ref. Clinical Practical Procedures for Doctors, pg. 123-128;

Medscape (Nasogastric tube placement
•• Ideal position to insert the Ryles Tube is sitting with Neck
flexed or Fowler position.
2. Ans. (c) TPN
3. Ans. (c) PEG

•• PEG – percutaneous endoscopic gastrostomy is an
endoscopic method of inserting gastrostomy tube for
patients who cannot take oral diet.
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•• For those who need Ryle’s tube for more than 4 weeks we
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will put PEG tube.
•• Infection around the PEG tube is a common complication. X-ray showing naso jejunal tube in position*
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4. Ans. (a) Feeding tube 5.
Ans. (c) 2 years
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•• This is a fine bore (3 mm diameter) feeding tube inserted via •• Fresh frozen plasma is shown here. It should be stored at
the nose into stomach (nasogastric feeding) or into Jejunum -40°C.
(Naso jejunal feeding) for enteral nutrition*
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•• It can be stored for 2 years. (Shelf life)
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•• The position of the tube should be checked using plain
abdominal radiography.
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Multiple Choice Questions

11. One French (F) size of angiographic catheter corresponds
MOST RECENT PATTERN QUESTIONS to: (PGI November 2017)
2017, 2018 AND 2019 a. 0.33 mm b. 0.133 inch
c. 0.013 inch d. 0.057 inch
1. Which of the following corresponds to Grade 3 Hemorrhage? e. 1.67 mm
(AIIMS May 2018) 12. Best guide for the management of resuscitation is:
a. <15% b. 15-30% (AIIMS Nov 2017)
c. 30-40% d. >40% a. CVP b. Urine output
2. Colour of 16 French Foley’s catheter c. Blood pressure d. Saturation of oxygen
(AIIMS November 2018) 13. Modified shock index formula is: (AIIMS Nov 2017)
a. Orange b. Yellow a. Heart rate / Systolic BP
c. Red d. Blue b. Heart rate / Diastolic BP
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3. A person with massive diarrhea and dehydration presented c. Heart rate/ Mean arterial pressure
to emergency room. What is the best size of cannula to
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d. Pulse rate/ Systolic BP
infuse maximum fluids (AIIMS November 2018) 14. 22 Gauge IV cannula color (AIIMS Nov 2017)
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a. Grey b. Green a. Green b. Gray
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c. Blue d. Pink c. Blue d. Pink
4. Refeeding Syndrome – Lab values to be monitored are all
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15. Which of the following is considered balanced resuscitation?
except (Recent Pattern June 2018) (AIIMS Nov 2017)
a. Calcium b. Magnesium
c. Phosphate d. Ammonium

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b. Maintaining pH by ensuring acid base are balanced
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5. Side effect of massive blood transfusion are all except c. Maintaining permissible hypotension to avoid bleeding
(Recent Pattern June 2018) d. Maintaining airway breathing and circulation
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a. Hypothermia b. Hypocalcemia 16. Nasogastric tube length is measured by: (AIIMS Nov 2017)
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c. Hypomagnesemia d. Hypokalemia a. Nose to ear to midpoint between xiphisternum and umbi-

6. TPN is indicated in all except (Recent Pattern June 2018) licus
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a. Short bowel syndrome b. Nose to ear to xiphoid process

b. Burns
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c. Nose to umbilicus
c. Sepsis
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d. Nose to ear to pubic symphysis

d. Enterocutaneous fistula 17. A patient requiring total parenteral nutrition for more than Ans.
7. All the following are included in qSOFA Criteria Except
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a month via central venous catheter. All are done, except: 1. c

(JIPMER Pattern December 2018) (JIPMER May 2017) 2. a
a. Respiratory rate b. Mental status a. Change central venous catheter tube every two weeks 3. a
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c. Hypotension d. Urine Output routinely

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4. d
8. Maintenance level of Mixed Venous Oxygen Saturation in b. LFT, BUN must be done weekly once 5. d
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shock must be (Recent Pattern 2019) c. Electrolytes must be checked every 2–3 days once 6. c
a. >70%. b. 50-70%
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d. Sudden glucose intolerance is an early sign of sepsis 7. d

c. 40-50% d. < 40%
8. b
9. True statement regarding surviving sepsis guideline:
9. b
(PGI Chandigarh Nov 2016)
a. Activated protein C is useful
OLD EXAM PATTERN QUESTIONS 10. c
11. a
b. q SOFA should be assessed in case of prolong stay of
NUTRITION IN SURGERY 12. b
patient in ICU
13. c
c. Suggest against the use of IV immunoglobulins in patients 18. Preferred route for giving TPN for a patient for < 14 days 14. c
with sepsis and there is no other use of central vein: 15. c
d. Recommend the use of erythropoietin for treatment of (Recent Pattern 2017) 16. b
anemia associated with sepsis a. EJV b. IJV 17. a
e. Recommend empiric broad-spectrum therapy c. Peripheral Vein d. PICC 18. c
10. French in Foley’s Catheter refers to (AIIMS Nov 2017) 19. Which of the following is not an indication of TPN? 19. c
a. Outer circumference measurement (Recent Pattern 2015)
b. Inner circumference measurement a. Acute pancreatitis
c. Diameter of catheter b. Enterocolic fistula
d. Lumen size c. Chronic liver disease
d. Fecal fistula
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Answers with Explanations of Multiple Choice Questions

1. Ans. (c) 30-40% 5. Ans. (d) Hypokalemia

Ref: Bailey and Love, 27 ed; pg. 19; Sabiston 20 ed; pg. 50 .
th th
Ref: Bailey and Love 27th Edition Page 22, Surgery Sixer 3rd
•• Grade 3 Shock is 30-40% Blood loss. Edition Page 12
Complications of Massive Blood Transfusion ( > 10 units
2. Ans. (a) Orange packed cells in 24 hours)
Ref: Catheter Care Guidelines Decreased things:
•• Commonly used 16 Fr Foley’s is Orange color •• Hypocalcemia
•• Hypomagnesemia
3. Ans. (a) Grey •• Hypothermia
Ref: Surgery Sixer 3rd Edition Page 10 •• Dilutional Thrombocytopenia
•• Coagulopathy
•• This is a repeat Question, Highest flow per minute is seen
•• Decreased 2,3 DPG and hence Oxygen delivery
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in Orange> Grey venflons. The flow rate is 200 ml/minute
in Grey Venflon. Increased Things:
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•• Dear friends Please don’t misunderstand what cannula •• Hyper kalemia
is used commonly.. Here they are asking which cannula
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•• Metabolic Alkalosis
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carries maximum flow, hence go with Grey** •• Volume overload
Gauge Color Catheter •• Iron overload ( in people who receive long term Blood
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Code transfusions)
External Length Flow Rate
Diameter
"mm"
"mm" "mL/min"
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6. Ans. (c) Sepsis
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Ref. Bailey and Love 27th edition Page 287, Ref. Surgery Sixer 3rd
G 14 Orange 2.1 45 270
Edition Page 5
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G 16 Gray 1.8 45 200

•• Indication of parenteral nutrition in ‘sepsis’ is under
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G 17 White 1.5 45 140 intensive study but not proven so far to be effective ,
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G 18 Green 1.3 45 85 however in the above options it is the best Choice.

G 20 Pink 1.1 33 55
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7. Ans. (d) Urine Output

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G 22 Blue 0.9 25 33
Ref: 2016, Third Sepsis Consensus Guidelines
G 24 Yellow 0.7 19 18
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Quick Sequential Organ Failure Assessment (SOFA) score

G 26 Violet 0.6 19 10
qSOFA (Quick SOFA) Criteria Points
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4. Ans. (d) Ammonium
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Respiratory rate ≥ 22/min 1

Ref: Bailey and Love 27th edition Page 288, Surgery Sixer 3rd
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Change in mental status 1

Edition Page 6
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Systolic blood pressure ≤ 100 mmHg 1

Refeeding Syndrome
q SOFA score, consists of only three components that are each
•• Characterised by severe fluid and electrolyte shifts in allocated one point. A qSOFA score of ≥2 points indicates organ
malnourished patients undergoing refeeding* dysfunction. Score > 2 carries 10% mortality
•• It can occur with Enteral and Parenteral nutrition ( MC with
TPN) 8. Ans. (b) 50-70%
•• Lab values: Hypophosphatemia, Hypocalcemia,
Ref: Surgery Sixer 3rd Edition Page 8
Hypomagnesemia*
(Mneumonic-CPM Low) Mixed Venous Oxygen Saturation:
•• Risk factors: Alcohol, Severe malnutrition, Anorexia,
•• This is a measure of oxygen returning to heart from body
Prolonged fasting*
after delivery and extraction by tissues.
•• Treatment: Avoid Overfeeding*
•• Normal Value- 50-70%
•• Deliver calories slowly*
•• In cardiogenic shock and Hypovolemic shock, the tissues
•• Electrolyte imbalance needs to corrected*
takes up more oxygen and hence value is low < 50%
•• In Septic and Distributive shock , the tissues takes up less
oxygen and hence more oxygenated blood returns to heart
and hence value is high > 70%
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High Yield Facts

Bailey's 27/e update Brain injury

Stages of Damage Control Surgery: •• Most common cause of brain injuries in the young – Road
Stage Procedure traffic accidents
•• Most common cause of brain injuries in the elderly – Falls
I Select the patient •• Monro Kellie doctrine – Any increase in the volume of
II Control haemorrhage, Contamination intracranial contents (from blood or edema) results in an
III ICU resuscitation elevation of Intracranial pressure (ICP) with an associated
decrease in the volume of other tissues, such as the brain
IV Definitive repairs parenchyma and cerebrospinal fluid (Fig. 2).
V Closure of abdomen
Indications of Damage Control Surgery **
Anatomical:
•• Difficult to achieve haemostasis
•• Complex injury like liver, pancreas etc
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•• Combined solid, hollow, vascular injuries
•• Inaccessible major venous like Retrohepatic IVC injury
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•• Non operative control of other injuries in more demand like
pelvic fracture
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•• Time consuming procedure anticipated.
Physiological:
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•• Temperature < 34 deg
•• pH <7.2
•• Se. Lactate > 5 mmol/l (N = 2.5) ry
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•• PT >16 S
•• PTT >60 S
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•• > 10 units transfused

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•• Systolic BP < 90 mm Hg for > 60 Seconds

Environmental:
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•• Operating time > 60 minutes

•• Inability to approximate abdominal incision
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•• Relook of abdomen needed.

Fig. 2: Monro Kellie doctrine
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yy Elevated ICP only worsens cerebral perfusion and oxygenation,

Procedures in DCS which results in further edema.
yy Cause of Morbidity in Brain injuries – Intraparenchymal
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Arterial injuries Interposition PTFE graft

contusion and Cerebral edema.
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Venous injuries Preferentially ligated yy Normal Cerebral blood flow is 55mL/min, CPP = MAP – ICP
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Hepatic injuries Perihepatic packing yy Cerebral perfusion pressure (CPP:70 mm Hg) = Mean arterial
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Translobar gunshot Balloon catheter tamponade pressure (MAP: 90mm Hg) – Intracranial pressure (ICP:20mm
wounds of liver Hg)
yy Cushing’s Triad : Hypertension, Bradycardia and Irregular
Bleeding pulmonary Wedge resection using stapler
respiration seen in Cerebellar tonsil herniation through foramen
injuries
magnum compressing vasomotor and respiratory centres.
Penetrating pulmonary Pulmonary tractotomy yy Kernohan-Woltman Notch Phenomenon: Ideally in any bleed,
injuries there will be contralateral hemiparesis due to pressure over
Cardiac injuries Pledgeted repair pyramidal tract in ipsilateral side. But when there is massive
Pancreatic injuries Packed and evaluation of ductal bleed with midline shift, the contralateral pyramidal tract will be
integrity later compressed by tentorium cerebelli causing Ipsilateral Weakness
(False Localising sign).
Urologic injuries Catheter diversion
yy In moderate or severe TBI, there is associated cervical spine
Small GI injuries Rapid Whipstitch using prolene and injury in 10% of cases.
temporary closure of abdomen yy Priapism is a strong predictor of severe cord injury even in
intubated patients
yy Midline shift of >5mm is considered an indication for evacuation.
yy Steroid administration has no role in the management of TBIs*
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Bailey's 27/e update

Disaster Surgery- New Chapter in 27th Edition Bailey and Love
Major Disaster
•• Most common cause of death in Earthquake – Crush injuries
•• Most common cause of death in Volcanoes – Suffocation
•• Most common cause of death in Tsunami – Drowning
Type of treatment given in field Hospitals:
Examples Further management
First Aid Suture, Dressing, Splinting etc Review in Local Hospital
Emergency care of Life •• ET tube insertion After Damage control surgery refer to
threatening Injuries •• Tracheostomy Main hospitals
•• Tension Pneumothorax treatment
•• Stop external haemorrhage
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•• Relieve Extradural hematoma
•• Emergency Thoracotomy
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•• Laparotomy for internal hemorrhage
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Care of Non life threatening •• Debridement of wounds Transfer to Base hospitals for further
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injuries Initially •• Reduction of fractures and dislocations management
•• External Fixator
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•• Vascular repairs
Principles of debridement and initial wound care: ry

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•• Generous exposure of tissues via skin and fascia
•• Identify neurovascular bundles
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•• Excise devitalized tissues

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•• Foreign body removal

•• Major vessels repair
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•• Skeletal stabilization with Fixators

•• Apply tags to tendons and nerves and don’t repair now.
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•• Leave wound open for delayed primary closure of wound

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•• Don’t do tight dressings

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•• Elevation of damaged limb

Trauma Related Issues in General Surgery
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Limb Salvage:
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•• Mangled Extremity Severity Score is used to decide the limb salvage.

•• If performed in time Vascular repairs can salvage most Acutely Ischemic limbs.
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•• Majority of patients who reach in 24 hours to tertiary centre have Limb Salvage.
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•• Limb is unlikely to survive if vascular repair of major vessels is delayed for more than 4-6 hours**
Tetanus:
•• Prevention: 0.5 ml TT Intra muscular , Grossly contaminated patients also receive 250-500 Units of Anti tetanus Globulin IM.
•• Clinical Tetanus- 3000- 10000 Units of ATG should be administered.
•• IV administration of Penicillin is given for 10-14 days.
•• Patients managed in ICU free from any sensory stimuli**
•• Overall mortality rate= 45%
•• Prognosis depends on Incubation period and Time from First symptom to first tetanic spasm. (Shorter intervals have bad prognosis**)
Necrotising Fascitis:
•• Organisms- Beta Hemolytic streptococci and occasionally Staphylococcus aureus** and may be caused by polymicrobial infections
also.
•• Rate of progression is dramatic with mortality around 70%
•• Diagnosis is made by Clinical methods.
•• Creatinine Kinase levels are elevated , Biopsy from fascial layers confirms diagnosis**
Contd...
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Section 3  Gastro Intestinal Tract
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Fig. 7: Borrmann classification (Operated by Dr Rajamahendran)

S
Laurens Classification
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Table 7: Laurens Classification

s
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Histology Intestinal Diffuse

Pa
Areas of intestinal metaplasia Normal gastric mucosa

Early cancer Protruding Flat (depressed/excavated)
e
Infiltration Localized Diffuse

pl
Hematogenous metastasis is common** Lymphatic and transcoelomic spread is

m
more common**
Sa
Peritoneal dissemination Infrequent Frequent

Hepatic metastasis Nodular Diffuse
Sex incidence Males more common Females more common
Age incidence Elderly Young
Group A - +
Pernicious anemia - +
Genetic predisposition - +
H. pylori association + -
Prognosis Good Bad*
Pathology Gland formation + Poor differentiated Signet Ring cells.
Most common in distal stomach Most common in proximal stomach
Genetics* APC gene mutation** Decreased E- Cadherin**
P53 and P16 inactivation P53 and P16 inactivation
Microsatellite instability
358
Liver
(Including Portal Hypertension)
16
ONE LINERS
/e
Investigations of choice:
,4
• Hepatic venography showing Spider web appearance- Budd Chiari syndrome*
• Caudate lobe Hypertrophy (Central Hot Spot)- Budd Chiari Syndrome*
r
• Water Lilly appearance- Hydatid Cyst*
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• Rosette Like appearance/ Calcification- Hydatid cyst*
• Tumor of liver which appears as hot spot in Sulphur colloid scan- FNH*
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• Tumor of liver which shows slow enhancement on CECT scan- Hemangioma*
• Hemangioma on T2 weighted MRI- Light Bulb Sign**
• Tumor of liver showing central stellate scar on CECT scan- FNH**
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• The only tumor which has normal kupffer cell and hence visible on Sulphur colloid scan is – FNH**
• Early enhancement with early wash out on CECT in liver is seen in HCC*
• Cystic lesion of liver with septations which are enhancing in contrast- Cystic Adenocarcinoma liver*
ur
Benign points:
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• Most common cause of Portal hypertension- Cirrhosis

• Most common cause of Intrahepatic Presinusoidal PHT- Schistosomiasis*
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• Hepatic stellate cells (ito cells)*contain high lipid content and it’s major function is to store vitamin A and synthesize extracellular collagen.
• Grade B- Modified Child scoring is 7-9**
s
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• Normal Portal Vein Pressure: 5-10 mmHg**

• Commonest cause of Sinistral PHT- Chronic Pancreatitis**
• Sengstaken Blakemore tube has 4 lumens**
Pa
• Esophageal balloon inflated with air up to 40 mm Hg

• Stomach Balloon inflated with Air up to 300 mL.
e
• Maximum time to have SB tube in compression is 12 hours*

pl
• TIPS is intrahepatic shunt between PV and HV.

• TIPS is nonselective shunt and hence risk of encephalopathy*
m
• Linton Shunt (Conventional/Proximal Splenorenal Shunt)- Non selective shunt of liver*

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• Warren Shunt (Distal splenorenal shunt)- Selective shunt**

• Rex Shunt- Shunt between SMV and Left portal vein in EHPVO** (More physiological treatment for EHPVO babies)
• Most common cause of Budd Chiari syndrome in India- membranous web in IVC**
• Most common cause of BCS in West- Hepatic vein thrombosis due to Polycythemia*
• Most common cause of pyogenic liver abscess in western countries- E. coli**
• Most common cause of pyogenic liver abscess in India/Asia- Klebsiella*
• Most common route for liver abscess infection- Pyogenic** MC cause of Isolated Gastric varices- Splenic vein thrombosis
• Most common cause of veno-occlusive disease- Bone marrow Transplant in West.
• Most common complication of Amoebic liver abscess- Rupture into peritoneal cavity
• Most common complication of Hydatid cyst liver- Rupture into the Biliary tree.
• Multiple macro abscess is seen in Biliary origin of abscess*
• Klebsiella pyogenic liver abscess will produce Endopthalmitis in 3% cases*
• MC lobe affected in Liver in Hydatid cyst – Right lobe (segment 7 and 8)
• Gharbi classification is for Liver hydatid cyst*
• Scolicidal agent used in Hydatid cyst PAIR- 20% hypertonic saline**, 0.5% Silver nitrate, 95% ethanol, Absolute alcohol, Mebendazole
• Kassbach merit syndrome- Huge hemangioma producing Thrombocytopenia and CCF**
Malignant points:
• Most common malignant tumor in liver- Mets (MC from Colorectal)
• Most common Primary malignant tumor in Liver- HCC
• Most common Primary tumor in childhood- Hepatoblastoma**
Contd...
Section 4  Hepatobiliary and Pancreatic Surgery
• Most common Benign tumor- Hemangioma

• Most common benign tumor in young females on OCP- Hepatic adenoma*
• Adenoma has risk of malignant change and needs excision*
• AFP is the tumor marker used to monitor recurrence in HCC after surgery*
• Latest tumor marker for HCC- PIVKA**
• Staging used for HCC- Okuda Staging, Barcelona staging**
• Fibro lamellar variety of HCC tumor marker- Neurotensin B**
• Milan Criteria** for Liver transplantation in Cirrhosis going for HCC- (Transplant can be indicated for tumors < 5 cm, 2-3 lesions <3 cm size,
No extrahepatic spread)*
• Sorafenib** (Multi kinase Inhibitor) ** is DOC of inoperable and metastatic HCC.
• Resection is the best treatment of HCC. After resection Future Liver remnant (FLR) must be 40% in cirrhotic liver and 25% in normal liver*
• Calcified hepatic metastases are seen in Mucinous Adenocarcinoma of colon*> Ovarian Carcinoma.
BASIC POINTS IN LIVER yy Right liver–segments 5, 6, 7, 8

yy Left liver–segments 1, 2, 3, 4
yy Largest organ in the body yy Caudate lobe is segment 1.
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yy Bare area- posterior surface yy Reidel’s lobe- a tongue like extension from the right liver
,4
yy 5 SURFACES- anterior, posterior, right, superior and inferior. inferiorly.
yy Left hepatic duct has longest extra hepatic course*- 2 cm is yy Segments to the left of falciparum segment-segment 2 and 3*
r
accessible outside liver. yy CAUDATE LOBE* is the lobe that is not affected in Budd Chiari
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yy Relations** in the porta hepatitis from behind forwards- Portal syndrome and cirrhosis of liver because of its direct drainage into
vein (posterior), Hepatic artery (left) and Hepatic ducts (right)
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IVC.
(Fig. 1) yy Quadrate lobe is the fourth lobe*
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Types of Hepatectomy: (Couinaud naming)
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•• Aberrant right hepatic artery* arises from superior •• Removal of segments 2–4 (Left hepatectomy)
•• Removal of segments 5–8 (Right hepatectomy)
ur
mesenteric artery and runs posterior to the pancreas head.

•• Replaced or accessory left hepatic artery* arises from left •• Removal of segments 5–8 along with 4 (Extended right
S
gastric artery. hepatectomy)

•• Removal of segments 2–4 along with 5 and 8 (Extended left
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•• An accessory cystic artery*can originate from gastroduodenal

or proper common hepatic artery. hepatectomy)
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Brisbane 2000 is the latest naming for hepatectomy:

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•• Right hemihepatectomy = 5–8

FUNCTIONAL ANATOMY (COUINAUD’S •• Right Trisectionectomy = Extended Right hepatectomy = 4, 5-8
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•• Left hemihepatectomy = 2–4

SEGMENTS) (FIG. 2) •• Left trisectionectomy = Extended Left hepatectomy = 2, 3, 4,
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yy Cantle's Line (Cholecysto Caval Line)- Imaginary line running 5 and 8

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from Gallbladder Fossa to right side of IVC. •• Left lateral hepatectomy = 2, 3 removal
m
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Fig. 1: Portal triad relations Fig. 2: Liver segments

590
Section 5  Speciality Surgeries

10. The ideal material used for Femoro Popliteal shunt is:
MOST RECENT PATTERN QUESTIONS a. PTFE (Recent Pattern 2018)
2017 2018 AND 2019 b. Reverse saphenous vein
c. Polypropylene
1. A patient presents with heaviness of leg with veins of d. Dacron
diameter less than 1 mm over the posterior part of the calf- 11. False elevation of ABPI is seen in: (Recent Pattern 2018)
Under CEAP, classification it comes under: a. DVT
a. C1 b. C2 (Recent Pattern 2019) b. Acute limb ischemia
c. C3 d. C0 c. Chronic venous insufficiency
2. False about Deep Vein thrombosis is: d. Calcified vessel walls
(Recent Pattern 2019) 12. Abdominal aortic aneurysm is operated when the size is
a. Leg pain is most common symptom more than: (Recent Pattern 2018)
/e
b. Bilateral DVT is common a. 35 mm
,4
c. Some People present 1st time with Pulmonary embolism b. 45 mm
d. Clinical Evaluation is most reliable c. 55 mm
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3. A patient had retrograde pelvic thrombophlebitis and it
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d. 65 mm
progressed to Bilateral Ileofemoral Occlusion and now the 13. In Lumbar sympathectomy which root value is spared:
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presentation will be: (Recent Pattern June 2018) a. L1 (JIPMER Nov 2017 Pattern)
a. Blue leg b. White leg b. L2
c. Red leg d. Purple leg
4. Most commonly used graft for repair of Aorta is:

ry c. L3
d. L4
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(JIPMER December 2018 Pattern) 14. Klippel Trenanauy syndrome associated with all except:
ur
a. Autologous vein b. Autologous Artery a. Port wine stain (JIPMER Nov 2017 Pattern)
c. Dacron d. PTFE b. Varicose veins
S
5. Best graft for infra-inguinal approach bypass: c. Limb lengthening

(JIPMER May 2018 Pattern Question)
of
d. Fused vertebra
a. Dacron b. PTFE 15. A surgery done in pelvis, which vein has high chances to go
s
c. Polyester d. Autologous vein for DVT? (JIPMER Nov 2017 Pattern)

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6. Best graft for aortic dissection: a. Iliac vein

Ans. (JIPMER May 2018 Pattern Question) b. Femoral vein
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1. a a. Dacron b. Autologous vein c. Calf vein

2. d c. Autologous artery d. PTFE d. IVC
7. True about Visceral aneurysm: 16. Oliver’s sign is seen in: (JIPMER Nov 2017 Pattern)
e
3. b
(JIPMER May 2018 Pattern Question)
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4. c a. Ascending aortic aneurysm

5. d a. Splenic artery is commonly involved b. Arch of aorta aneurysm
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6. a b. Hepatic aneurysm is operated irrespective of symptoms c. Descending aortic aneurysm

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7. a c. Splenic artery aneurysm is most commonly followed by d. Aortic dissection

8. a trauma 17. Most common site of venous ulcer in varicose vein:
9. d d. True aneurysms are more common nowadays with a. Gluteal (Recent Question 2017 )
10. b increasing abdominal trauma b. Medial malleolus
11. d 8. Increases in D-dimer levels are noticed in immediate post- c. Lateral malleolus
12. c operative period. Most appropriate cause is: d. Popliteal fossa
13. a (JIPMER May 2018 Pattern Question) 18. Most common source of thrombi for pulmonary
14. d a. DVT b. Pulmonary embolism embolization: (Recent Question 2017)
15. c c. DIC d. Normal a. Anterior tibial vein
16. b 9. Patients with phlebographically confirmed deep vein b. Posterior tibial vein
17. c thrombosis of the calf: (UPSC 2018) c. Femoral vein
18. c a. Can expect asymptomatic recovery if treated promptly d. Popliteal vein
with anticoagulant
b. May be effectively treated with low-dose heparin
c. May be effectively treated with pneumatic compression
stockings
d. Are at risk for significant pulmonary embolism
850
Chapter 23  Plastic Surgery and Burns (Including Skin Lesions)

1. Name the pathology seen in scalp 4. Name the method shown here to calculate the percentage
of burns:
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,4
a. Dermoid b. Sebaceous cyst
c. Hemangioma d. Metastasis
r
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2. What is the name of this flap shown here?
(AIIMS November 2018)
ry
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Age in years 0 1 5 10 15 Adult

A Head 9 8 6 5 4 3
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A B B Thigh 2 3 4 4 4 4
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C leg 2 2 3 3 3 3
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a. Rhomboidal Flap
b. Rotational Flap a. Rule of 9
Pa
c. Transposition Flap b. Lund and Browder chart

d. Advancement Flap c. Berkow formula
e
d. Palm rule
pl
m
3. What is the use of this Instrument shown below? 5. What is the degree of this burn shown below?
Sa
(AIIMS November 2018)
a. 1st degree
b. 2nd degree
a. To take Skin Graft b. To take Bone Graft c. 3rd degree
c. To take muscle graft d. To take tendon Graft d. d. 4th degree
881
Last Minute Tables 29
Table 1: Named Operations
Name Disease
Palomo Operation Varicocele testis
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Palma Operation Deep Vein Thrombosis
,4
Nesbitt Operation Peyronies Disease
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Gray hack Shunt operation Priapism
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Dennis Brown Operation Hypospadias
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Anderson Hynes Operation Congenital Pelvi Ureteric Junction Obstruction
Hellers Cardiomyotomy Achalasia Cardia
POEM Achalasia Cardia ry
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Stretta Procedure GERD- RFA ablation of LES
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Nissen Fundoplication 360 degree posterior wrap for GERD

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Belsey Mark 4 Operation Thoracic Type of Fundoplication

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Ivor Lewis Operation Transthoracic - Subtotal Radical Esophagectomy for Cancer Esophagus
Orringer Operation Transhiatal Esophagectomy
s
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Sistrunk operation Thyroglossal cyst

Patey’s Operation Modified Radical mastectomy for cancer breast
Pa
Hadfield Operation Conical Excision of ducts for Duct Ectasia

Duhamel, Swensen and Soave Operations Rectal pull through for Hirschsprung disease
e
pl
Bishop Koop operation Meconium Ileus

m
Frey procedure Chronic Calcific Pancreatitis

Sa
Whipple operation Head of pancreas and Periampullary cancers

Kasai procedure Extrahepatic Biliary atresia
Ladd’s Procedure Midgut volvulus/Malrotation of gut
Milligan Morgan operation Hemorrhoidectomy (open method)
Longo Procedure Stapled Hemorrhoidopexy
Strong Procedure** Superior Mesentric Artery Syndrome
Table 22: New drugs for Cancers in Surgery

Section 6  Final Over
Drug Cancer
Ixabepilone Anthracyclines and Taxanes resistant Breast cancer
Lapatinib Second line Her-2 neu therapy for breast cancer
Sunitinib •• Advanced RCC
•• Refractory metastatic breast cancer
•• Imatinib resistant GIST
Sorafenib Unresectable HCC
Silpencal-T Castrate resistant Prostate cancer
Geftinib Adenocarcinoma lung in non smoking females
Table 23: Clinical Findings in Trauma
Finding Name of the sign

Middle cranial fossa fracture causing Bruising behind ear Battle sign
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Unilateral shifting dullness in splenic trauma Balance sign
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Referred pain to left shoulder in splenic trauma Kehr’s sign
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Periumbilical pigmentation in Hemorrhagic pancreatitis Cullen sign
Loin pigmentation in hemorrhagic pancreatitis Grey Turner Sign
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Yellow discoloration around umbilicus due to CBD rupture Ransohoff’s Sign
Table 24: Radio sensitivity Tissue ry

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Blood Cell:
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•• Most radiosensitive Lymphocyte

•• Least radiosensitive
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Platelet
Tissue:
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•• Most Radiosensitive Bone marrow

•• Least Radiosensitive Nervous Tissue
s
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Organs:
•• Most Radiosensitive abdominal organ Kidney
Pa
•• Most Radioresistant Organ Vagina

•• Most Common mucosa affected by RT Intestine
e
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Table 25: Storage of Blood Components

m
Sa
Blood component Temperature of storage Shelf life

Whole blood 1-6 deg C 35 days
Packed cells 1-6 deg C 42 days
Platelets 20-24 deg C 5 days
FFP - 40 deg C 2 years
Cryoprecipitate -30 deg C 2 years
Table 26: Burns Points
Grade of Burns Clinical Findings Healing

1 Degree
st
Painful erythema Heals without scar in 7 days
2 Degree- Superficial
nd
Painful Blisters Heals without Scar in 14 days
2rd Degree- Deep Painless Blisters Heals with Scar in 3-5 weeks
3 Degree Burns
rd
Painless Eschar Severe scar and contracture
1010
AJCC 8th Edition
Updates 30
AUTHOR’S INTRODUCTION
American Joint Committee on Cancer started AJCC staging 1st Edition in 1977, Since then based on the advances and enrolment from
various cancer surgeons, physicians have made so many changes and the 8th Edition got released by 2018.
/e
AJCC 8th edition is not yet updated by Bailey, Sabiston or Schwartz. However some Institute exams like JIPMER, AIIMS will
purposefully ask questions from the changes made in 7th and 8th Edition.
,4
However from MBBS student to MS to MCh, at all stages in my academic period, if you ask me the toughest to remember and recall
r
is Cancer staging. Yes it will be tough for all…
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If you ask me what are all the stagings that must be remembered by heart for exams from General Surgery Syllabus, I will give the list
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below:
1. Cancer of Breast
2. Cancer of Oral cavity
ry
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3. Cancer of Colorectum
4. Cancer of Stomach
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I have enlisted the AJCC 8th Edition and have also highlighted the changes made from 7th to 8th edition at each place. It’s up to you
S
to read or leave 1-2 questions that may come in Exam.

of
yy N2a- Metastasis in single node, greater than 3 cm but not larger

CANCER OF ORAL CAVITY
s
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than 6 cm in greatest dimension, (> 3cm to < 6cm) No Extra

nodal Extension (ENE- Negative)
AJCC 8th Edition Oral Cancer Staging
Pa
yy N2b- Metastasis in Multiple Ipsilateral nodes, None larger than

6 cm. ENE Negative.
T staging: N2c- Metastasis in Bilateral or Contralateral nodes, none larger
e
yy
pl
than 6 cm, ENE Negative.

yy Tis- Carcinoma in Situ
yy N3a- Metastasis in a Lymph node larger than 6 cm in greatest
m
yy T1 – Tumor in greatest dimension < 2cm and DOI <5mm

dimension, ENE Negative
yy T2 – Tumor < 2cm and DOI >5mm but < 10mm or Tumor >2cm
Sa
yy N3b- Metastasis in any size node with ENE+ve (Newly added

but <4 cm and DOI < 10 mm
point in AJCC)**
yy T3 – Tumor more than 4 cm or any size with DOI > 10 mm
yy T4 a – Invasion into adjacent structures like cortical bone, Inferior
Alveolar nerve, Floor of mouth or Skin of Nose and Chin in Lip
M staging:
cancer and Skin of Face in Oral cancer. yy M1- Metastasis +
yy T4 b – Invasion into masticator space, pterygoid plates, carotid
sheath or encases Internal Carotid Artery Stage Grouping:
yy Extrinsic muscle invasion is not considered as T4 nowadays yy Stage 1- T1N0M0
yy Stage 2- T2 N0 M0
N staging: yy Stage 3- T3N0M0, T1-3 N1M0
yy N1- Metastasis in single node < 3cm in greatest dimension with yy Stage 4A- Any T4a, Any N2 case
no Extra nodal Extension (ENE- Negative) yy Stage 4B- Any T4b, Any N3 case
yy Stage 4C- Any M1 case
PGI Chandigarh
Questions
(2017, 2018 Question Papers)
31
AUTHOR’S INTRODUCTION
PGI Chandigarh is one Unique pattern Exam with totally different type of pattern, needs committed preparation from last 2-3 years papers of
PGI Exams. Most of the questions are Undergraduate standard and asked from Standard books only. In this Exam you must know what not to
/e
mark rather than knowing what to mark because most of them miss the seat only because of Negative marks. The number of students writing
this exam every year is very less when compared to other Exams, due to travel related factors, less number of seats, fear of writing exam just
,4
before NEET etc.
r
For all the reasons above, we have decided to remove the entire PGI Chandigarh Question paper contents from all the chapter and added
xe
only last 2 year papers in this section. Hence, if you want an Extra Edge and If you are PGI Aspirant you can go through this section for Surgery.
We advise you to read PGI Chandigarh review by Dr. Manoj Choudhary under CBS publications for detailed preparation of PGI Chandigarh
Si
Exams.
ry
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of
d. Resection of unprepared bowel

MOST RECENT PATTERN QUESTIONS e. Hysterectomy
s
2016, 2017 AND 2018 4. True about Opsite wound dressing: (PGI May 2018)
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a. Wound can be visualized Ans.

b. Permeable to gases
Pa
1. a,b
SECTION 1: GENERAL SURGERY c. Permeable to water
d. Impermeable to bacteria d,e
1. True about elastic compression stockings in venous
e
e. Increased wound contraction 2. a,b,c

pl
insufficiency: (PGI May 2018) 5. Feature of compartment syndromes include(s) 3. b,d

a. Elastic compression stocking’s cause dynamic sequential 4. a,b,d
m
(PGI May 2018)

compression of leg veins a. Swollen fingers b. Pallor 5. a,b
Sa
b. Improve venous circulation of leg c. Paraesthesia d. Pain on passion flexion c,d

c. Compression occur maximum at calf e. Pain on active flexion 6. a,e
d. Worn in the morning and taken off at night before bedtime 6. Feature of 10-0 suture in comparison to 1-0 suture (made up 7. a,c,e
e. Worn even after ulcer heals to prevent recurrence of same material): (PGI May 2018)
2. Not true about frost bite: (PGI May 2018) a. Smaller diameter
a. Trench foot is a type of frostbite of foot b. More tensile strength
b. Initial treatment is rewarming c. More elasticity and plasticity
c. On face it is superficial and on extremities severe form d. More chance of tissue reaction
occurs e. Less chance of tissue reaction
d. Autoamputation may occur in severe cases 7. Steps taken to prevent post-operative infection include(s):
e. In First and second degree frostbite affected part show (PGI May 2018)
redness and edema a. Antibiotic is given at time of induction of anesthesia
3. Which of the following is/are examples of contaminated b. Shaving hair is better than clipping
wound: (PGI May 2018) c. Preoperative skin preparation with alcohol-based solutions
a. Resection of intestinal fistula d. Start antibiotic at least 1 day preoperatively
b. Ruptured appendix surgery e. Prevent perioperative hypothermia
c. Inguinal hernia repair surgery

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Contents

Chapter 1. Basic Concepts in Surgery---------------------------------------------------------------------------------------------3–32

Answers with Explanations of Multiple Choice Questions--------------------------------------------------------------------------- 68

Chapter 3. Trauma (Including-Recent ATLS 10th Edition Updates)-------------------------------------------------------81–135

Answers of Image-Based Questions----------------------------------------------------------------------------------------------------109

Multiple Choice Questions--------------------------------------------------------------------------------------------------------------111

Chapter 4. Transplant---------------------------------------------------------------------------------------------------------- 137–162

Answers of Image-Based Questions----------------------------------------------------------------------------------------------------154

SECTION 2 HEAD, NECK, THYROID AND BREAST

Chapter 5. Oral Cavity and Malignancy------------------------------------------------------------------------------------- 165–183

Chapter 6. Salivary Gland Swellings------------------------------------------------------------------------------------------ 185–200

Chapter 7. Swellings/Pathology in Head and Neck------------------------------------------------------------------------- 201–218

Chapter 8. Thyroid-------------------------------------------------------------------------------------------------------------- 219–256

Chapter 9. Breast---------------------------------------------------------------------------------------------------------------- 257–304

Answers of Image-Based Questions----------------------------------------------------------------------------------------------------276

Multiple Choice Questions--------------------------------------------------------------------------------------------------------------277

SECTION 3 GASTRO INTESTINAL TRACT

Chapter 10. Esophagus----------------------------------------------------------------------------------------------------------- 307–349

Image-Based Questions -----------------------------------------------------------------------------------------------------------------325

Answers of Image-Based Questions----------------------------------------------------------------------------------------------------327

Multiple Choice Questions--------------------------------------------------------------------------------------------------------------328

Chapter 14. Miscellaneous Conditions in Abdomen (Includes HERNIA in Detail)------------------------------------ 507–538

Chapter 16. Liver (Including Portal Hypertension)------------------------------------------------------------------------- 589–630

Multiple Choice Questions--------------------------------------------------------------------------------------------------------------613

Chapter 17. Pancreas------------------------------------------------------------------------------------------------------------- 631–673

Answers of Image-Based Questions----------------------------------------------------------------------------------------------------650

Multiple Choice Questions--------------------------------------------------------------------------------------------------------------651

Chapter 18. Spleen---------------------------------------------------------------------------------------------------------------- 675–688

SECTION 5 SPECIALITY SURGERIES

Chapter 19. Urology—Part 1: (Kidney and Ureter)-------------------------------------------------------------------------- 691–732

Multiple Choice Questions--------------------------------------------------------------------------------------------------------------850

Answers with Explanations of Multiple Choice Questions--------------------------------------------------------------------------859

Answers of Image-Based Questions----------------------------------------------------------------------------------------------------884

Multiple Choice Questions--------------------------------------------------------------------------------------------------------------885

Chapter 24. Neurosurgery (Excluding Head Injury)------------------------------------------------------------------------ 899–922

Chapter 25. Oncosurgery-------------------------------------------------------------------------------------------------------- 923–950

Chapter 26. Pediatric Surgery--------------------------------------------------------------------------------------------------- 951–965

SECTION 6 FINAL OVER ry

Chapter 28. General Surgical Instruments----------------------------------------------------------------------------------- 989–1002

Chapter 29. Last Minute Tables---------------------------------------------------------------------------------------------- 1003–1011

Chapter 30. AJCC 8th Edition Updates-------------------------------------------------------------------------------------- 1013–1016

• Neurogenic shock is characterized by hypotension and bradycardia.

• Reactionary hemorrhage occurs within 24 hours

• Most common coagulopathy in surgical patient is thrombocytopenia.

• Post-dural puncture headache is typically bifront or occipital

Blood and Blood Products

• Hematocrit is the best indicator for need of blood transfusion*

• Blood group O is universal donor, AB is universal recipient

• Cryoprecipitate is stored at -40°C

• Rosenthal’s syndrome is due to deficiency of Factor XI

Bailey's 27/e update

Routine clinical care Observe Treat

3 days once in Hospital

INDICATIONS FOR ARTIFICIAL NUTRITION

yy Any patient who has sustained > 7 days of inadequate intake

Modes of Nutrition (Table 1 and Fig. 1)

Enteral Nutrition Parenteral Nutrition

Fig. 1: Modes of nutrition

Chapter 1  Basic Concepts in Surgery

between xiphoid and Umbilicus

in liver to sodium bicarbonate) obstruction •• Skull base fracture

•• Feeding purposes •• Unstable cervical spine

•• Lavage in some poisoning injury

5. Best graft for infra-inguinal approach bypass: c. Limb lengthening

c. Polyester d. Autologous vein for DVT? (JIPMER Nov 2017 Pattern)