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DRIEMS General Surgery - Internal Assessment Examination II

Complete Answers with Explanations

Q.1. Answer in One Sentence (10 x 1 marks)

a) Full form of NOTES

Natural Orifice Transluminal Endoscopic Surgery - a technique where operations are performed by passing an endoscope through a natural body orifice (mouth, vagina, anus) to access internal organs without external skin incisions.

b) Name of the needle used for Pneumoperitoneum in Laparoscopic Surgery

Veress needle (also written Veress needle) - a spring-loaded needle with a blunt inner stylet that retracts on contact with the peritoneum, used to insufflate CO2 into the peritoneal cavity safely.

c) Which gas is used commonly for Pneumoperitoneum & why?

Carbon dioxide (CO2) is used because it is rapidly absorbed across the peritoneal membrane into the circulation, is non-combustible (safe with electrocautery), is physiologically metabolized by the body buffers and lungs, and is relatively inexpensive. (Schwartz's Surgery)

d) What is the diameter of the umbilical port in Lap Surgery?

10-12 mm - the umbilical (primary) port is a 10 mm or 12 mm port used to introduce the laparoscope. It is typically placed at the umbilicus.

e) Where is the location of Palmer's point?

Palmer's point is located 3 cm below the left subcostal margin in the midclavicular line (left upper quadrant). It is an alternative entry site for Veress needle insertion, especially in patients with previous abdominal surgeries or adhesions, as it is generally free from adhesions. - Berek & Novak's Gynecology

f) Which port is made first in Lap Choli operation?

The umbilical (epigastric) port - the first port (10 mm) is placed at the umbilicus under direct vision (open Hasson technique or closed Veress technique) to introduce the laparoscope before other working ports are placed.

g) What is the maximum flow rate of CO2 gas while doing Pneumoperitoneum?

Maximum flow rate is 1 L/min during initial insufflation (to detect correct placement); the typical working flow rate during laparoscopy is up to 6 L/min, with an intra-abdominal pressure maintained at 12-15 mmHg.

h) Which size port in Lap Surgery does not require suture closure?

Ports of 5 mm or less do not require fascial suture closure. Ports of 10 mm and above (especially 12 mm) require closure of the fascial defect to prevent port-site hernias.

i) When does Polydioxanone (PDS) suture get completely absorbed?

PDS (Polydioxanone) suture gets completely absorbed by hydrolysis in approximately 180-210 days (6 months). It retains 70% of its tensile strength at 2 weeks and 25% at 6 weeks.

j) What is the method of sterilization of disposable articles like syringes, plastic tubes, etc.?

Gamma irradiation (radiation sterilization) - disposable articles made of plastic/rubber that cannot withstand heat are sterilized using gamma rays from Cobalt-60. Ethylene oxide (EtO) gas is also used as an alternative for heat-sensitive items.

Q.2. Answer in Short (10 x 1 marks)

a) What is the normal value of total serum bilirubin?

Normal total serum bilirubin = 0.3-1.0 mg/dL (up to 1.2 mg/dL)
  • Direct (conjugated) bilirubin: 0-0.3 mg/dL
  • Indirect (unconjugated) bilirubin: 0.1-0.8 mg/dL
  • Jaundice becomes clinically visible (scleral icterus) when bilirubin exceeds 2.5-3 mg/dL

b) Which intrahepatic enzyme is responsible for conjugation of bilirubin?

UDP-glucuronosyltransferase (UGT1A1) - this enzyme in hepatocytes conjugates unconjugated (fat-soluble) bilirubin with glucuronic acid to form water-soluble bilirubin diglucuronide (direct bilirubin), which is then excreted in bile. Deficiency of this enzyme causes Gilbert's syndrome and Crigler-Najjar syndrome.

c) Enumerate the sites of Porto-caval anastomosis

The sites of portosystemic (porto-caval) anastomoses are:
  1. Lower oesophagus - left gastric (portal) with azygos (systemic) - varices
  2. Anorectal junction - superior rectal (portal) with middle/inferior rectal (systemic) - haemorrhoids
  3. Umbilicus - para-umbilical veins (portal) with epigastric veins (systemic) - caput medusae
  4. Retroperitoneum - veins of Retzius (portal tributaries with renal/lumbar veins)
  5. Bare area of liver - hepatic veins with phrenic/intercostal veins

d) Minimum quantity of blood required to produce melaena

Approximately 50-100 mL of blood in the upper GI tract is required to produce melaena. The dark tarry stool results from bacterial degradation of haemoglobin to haematin as blood passes through the bowel. It typically indicates an upper GI bleed (proximal to ligament of Treitz).

e) Which chemical is used to prepare chromic catgut?

Chromic acid (chromic salt/chromium trioxide) - plain catgut is treated with chromic acid salts, which cross-link the collagen fibres. This delays absorption from 10-14 days (plain) to 21-28 days (chromic catgut) by making it more resistant to enzymatic digestion.

f) What are the constituents of EUSOL?

EUSOL = Edinburgh University Solution Of Lime Constituents:
  • Chlorinated lime (bleaching powder) - 12.5 g
  • Boric acid - 12.5 g
  • Distilled water - 1 litre It contains hypochlorous acid as the active antiseptic agent (0.25% available chlorine). Used for wound irrigation and desloughing.

g) Where is the site of placement of Chevron incision?

Chevron (rooftop/bilateral subcostal) incision is placed bilaterally below both costal margins (typically 2 cm below the costal margins) meeting in the midline, forming a "V" or chevron shape. It is used for upper abdominal surgeries such as liver transplantation, Whipple's procedure (pancreaticoduodenectomy), bilateral adrenalectomy, and major hepatic resections.

h) What amount of pressure is employed for sterilization by Autoclaving?

15 psi (pounds per square inch) at 121°C for 15-20 minutes for standard autoclaving (gravity displacement).
  • For flash (pre-vacuum) autoclave: 30 psi at 134°C for 3-4 minutes.
  • Autoclaving works by moist heat (steam under pressure) - the most reliable method of sterilization.

i) Which benign tumour is common in superficial Parotid gland?

Pleomorphic adenoma (mixed parotid tumour) - it accounts for 70-80% of all parotid tumours and is most common in the superficial lobe. It is a benign, slow-growing, painless, firm, lobulated swelling. Although benign, it has malignant potential and is treated by superficial parotidectomy (not enucleation, to prevent recurrence).

j) What is the normal pressure in Portal vein?

Normal portal vein pressure = 5-10 mmHg (up to 12 mmHg)
  • The hepatic venous pressure gradient (HVPG) = 3-5 mmHg normally
  • Portal hypertension is diagnosed when HVPG exceeds 10 mmHg (clinically significant)
  • HVPG >12 mmHg is associated with risk of variceal bleeding (Mulholland & Greenfield's Surgery; Sleisenger & Fordtran's GI & Liver Disease)

Q.3. Write Short Notes (5 x 2 marks)

a) Amelanotic Melanoma

  • A variant of malignant melanoma that lacks the usual brown/black pigment (melanin), making it pink, red, or flesh-coloured.
  • Accounts for approximately 2-8% of all melanomas.
  • Clinically deceptive - often mistaken for pyogenic granuloma, basal cell carcinoma, squamous cell carcinoma, or inflammatory lesion, leading to delayed diagnosis.
  • Diagnosis is often delayed - in up to 25% of nail/subungual melanomas, the tumour is amelanotic.
  • Histologically, melanocytes are present but lack pigment. Immunohistochemistry (S-100, HMB-45, Melan-A) is used to confirm the diagnosis.
  • Prognosis is generally worse than pigmented melanoma due to late presentation and advanced stage at diagnosis.
  • Treatment: Wide local excision with adequate margins (1-2 cm depending on Breslow thickness), sentinel lymph node biopsy. (Fitzpatrick's Dermatology; Dermatology 2-Volume Set 5e)

b) Barrett's Oesophagus

  • Definition: Replacement of the normal stratified squamous epithelium of the lower oesophagus with columnar (intestinal-type) metaplasia - specifically, specialised intestinal metaplasia with goblet cells.
  • Cause: Long-standing gastro-oesophageal reflux disease (GORD) - chronic acid/bile exposure causes metaplastic change.
  • Length: Short segment (<3 cm) and long segment (>3 cm).
  • Significance: Barrett's is a pre-malignant condition with a 0.5%/year risk of progression to oesophageal adenocarcinoma.
  • Diagnosis: Endoscopy with biopsies (Prague C&M criteria for classification).
  • Management:
    • PPI therapy for acid suppression
    • Endoscopic surveillance every 3-5 years (no dysplasia) to every 6 months (high-grade dysplasia)
    • Endoscopic ablation (radiofrequency ablation - RFA) or mucosal resection for dysplastic Barrett's
    • Surgery (oesophagectomy) for invasive adenocarcinoma

c) Rodent Ulcer (Basal Cell Carcinoma - BCC)

  • Rodent ulcer is the classic presentation of Basal Cell Carcinoma (BCC) - the most common skin cancer.
  • Site: Most commonly on the face, especially around the nose, inner canthus of eye, nasolabial fold ("H-zone" of face).
  • Clinical features:
    • Starts as a pearly, translucent nodule with telangiectasiae
    • Central ulceration with characteristic rolled (everted) pearly edges
    • Slow-growing, locally invasive ("rodent" - gnaws away tissue)
    • Rarely metastasises but causes extensive local destruction
  • Types: Nodular (commonest), superficial, morphoeic (sclerosing), pigmented.
  • Treatment: Surgical excision with 4-5 mm margins; Mohs micrographic surgery for recurrent/morphoeic types; radiotherapy; topical 5-FU or imiquimod for superficial BCC.

d) Feeding Jejunostomy

  • Definition: A surgical procedure where a tube is inserted into the jejunum (third part of small bowel, 30-40 cm from Duodenojejunal flexure) to provide enteral nutritional support.
  • Indications:
    • Oesophageal/gastric cancer - when oral feeding is impossible
    • After major upper GI surgery (oesophagectomy, total gastrectomy, pancreaticoduodenectomy)
    • Prolonged ileus or delayed gastric emptying
    • Severe maxillofacial injuries
    • Neurological dysphagia
  • Types: Witzel jejunostomy (tunnelled), needle-catheter jejunostomy, Roux-en-Y feeding jejunostomy.
  • Advantages over TPN: Maintains gut mucosal integrity, prevents bacterial translocation, cheaper, fewer line sepsis complications.
  • Complications: Tube blockage, dislodgement, jejunostomy site infection, aspiration, diarrhoea, volvulus around the tube.

e) Glasgow Coma Scale (GCS)

  • Developed by Teasdale and Jennett (1974) at the University of Glasgow.
  • Objectively assesses level of consciousness using three parameters:
ComponentResponseScore
Eye Opening (E)Spontaneous4
To voice3
To pain2
None1
Verbal Response (V)Oriented5
Confused4
Inappropriate words3
Incomprehensible sounds2
None1
Motor Response (M)Obeys commands6
Localizes pain5
Withdraws4
Abnormal flexion (decorticate)3
Extension (decerebrate)2
None1
  • Total score: 3-15; scored as E+V+M
  • GCS 15 = fully conscious; GCS 3 = deepest coma
  • Severe head injury: GCS ≤ 8; Moderate: 9-12; Minor: 13-15
  • GCS ≤ 8 - intubation usually required (Gray's Anatomy for Students; Rosen's Emergency Medicine)

Q.4. Write the Differential Diagnosis (5 x 2 marks)

a) Fever with Chill & Rigor

  1. Malaria (periodic rigors - tertian in P.vivax, quartan in P.malariae)
  2. Pyaemia / Septicaemia - bacteraemia with metastatic abscesses
  3. Cholangitis (Charcot's triad: fever+jaundice+RUQ pain) - biliary obstruction with infection
  4. Pyelonephritis / Urinary tract infection
  5. Liver abscess (amoebic or pyogenic)
  6. Infective endocarditis
  7. Lymphoma (Pel-Ebstein fever)
  8. Kala-azar (visceral leishmaniasis)
  9. Typhoid fever (step-ladder fever, no rigors typically)
  10. Drug reactions / transfusion reactions

b) Ulcers with raised, swollen & everted margin

  1. Carcinoma (squamous cell carcinoma - most common cause of everted edge ulcer)
  2. Basal Cell Carcinoma - rolled pearly edges
  3. Marjolin's ulcer - malignant change in chronic scar/venous ulcer
  4. Fungating tumour
  5. Tertiary syphilis (gumma - but classically has punched-out edges)
Key: Raised, everted (rolled-out), indurated edges = malignant ulcer

c) Vomiting without nausea

  1. Raised intracranial pressure (ICP) - projectile vomiting without preceding nausea (brain tumour, meningitis, subarachnoid haemorrhage)
  2. Vestibular disorders - labyrinthitis, Meniere's disease (vertigo + vomiting)
  3. Pyloric stenosis in infants (projectile, non-bilious vomiting)
  4. Cyclic vomiting syndrome
  5. Cannabis hyperemesis syndrome
  6. Psychogenic vomiting
  7. Posterior fossa tumours

d) Severe abdominal pain with minimum local signs on abdominal examination

  1. Acute pancreatitis - severe epigastric pain radiating to back, tenderness but often little guarding
  2. Mesenteric ischaemia - "pain out of proportion to signs"
  3. Aortic dissection / Leaking AAA - severe back/abdominal pain
  4. Renal colic / Ureteric colic - severe colic, minimal tenderness
  5. Diabetic ketoacidosis (DKA) - pseudo-peritonitis
  6. Porphyria
  7. Sickle cell crisis
  8. Early intestinal obstruction (before peritonism sets in)
  9. Retroperitoneal pathology (psoas abscess, haematoma)
  10. Tabes dorsalis (tabetic crises)

e) Recurrent Jaundice

  1. Choledocholithiasis (recurrent common bile duct stones - most common surgical cause)
  2. Carcinoma of head of pancreas (progressive obstructive jaundice, Courvoisier's sign)
  3. Cholangiocarcinoma (Klatskin tumour at hilum)
  4. Stricture of bile duct (post-operative, post-inflammatory)
  5. Primary sclerosing cholangitis (PSC)
  6. Haemolytic anaemia (recurrent haemolytic crises - hereditary spherocytosis, G6PD deficiency)
  7. Gilbert's syndrome (benign, triggered by fasting/illness)
  8. Dubin-Johnson syndrome / Rotor syndrome
  9. Chronic liver disease / Cirrhosis (with intermittent decompensation)
  10. Recurrent cholangitis (Caroli's disease)

Q.5. Answer Briefly (5 x 2 marks)

a) HLA (Human Leucocyte Antigen)

  • HLA = Human Leucocyte Antigen system - the Major Histocompatibility Complex (MHC) in humans, located on chromosome 6p21.3.
  • Encodes cell-surface proteins that present antigens to T-lymphocytes - central to immune recognition of "self vs non-self."
  • Classes:
    • Class I (HLA-A, B, C): present on all nucleated cells; present antigens to CD8+ cytotoxic T cells
    • Class II (HLA-DR, DP, DQ): present on antigen-presenting cells (macrophages, B cells, dendritic cells); present antigens to CD4+ helper T cells
  • Surgical importance:
    • Transplantation: HLA matching between donor and recipient reduces rejection risk (kidney, bone marrow transplants)
    • Blood transfusion: HLA antibodies cause febrile non-haemolytic transfusion reactions
    • Disease associations: HLA-B27 (ankylosing spondylitis), HLA-DR3/DR4 (Type 1 DM), HLA-DR2 (SLE)

b) Definition of Massive Blood Transfusion

Massive blood transfusion is defined as the transfusion of:
  • >10 units of packed red blood cells (PRBC) in 24 hours, OR
  • Replacement of one entire blood volume (approximately 5 L in an adult) in 24 hours, OR
  • >4 units of PRBC in 1 hour with ongoing need
Complications of massive transfusion (SHOT - acronym):
  • Hypothermia (cold blood)
  • Hypocalcaemia (citrate chelates calcium)
  • Hyperkalaemia
  • Dilutional coagulopathy
  • Metabolic acidosis
  • Transfusion-related acute lung injury (TRALI)
Current practice: Damage Control Resuscitation - transfuse PRBCs : FFP : Platelets in a 1:1:1 ratio.

c) BMI Formula + Calculation for 80 kg, 4.5 feet height

Formula: $$\text{BMI} = \frac{\text{Weight (kg)}}{\text{Height (m)}^2}$$
Calculation:
  • Weight = 80 kg
  • Height = 4.5 feet = 4.5 × 0.3048 = 1.3716 m
  • BMI = 80 ÷ (1.3716)² = 80 ÷ 1.8813 = ~42.5 kg/m²
Classification:
  • <18.5 = Underweight
  • 18.5-24.9 = Normal
  • 25-29.9 = Overweight
  • 30-34.9 = Obese Class I
  • 35-39.9 = Obese Class II
  • ≥40 = Morbidly Obese (Class III) ← This patient falls here

d) Parkland Formula + Calculation for 50 kg, 40% burns

Parkland Formula: $$\text{Fluid in 24 hrs} = 4 \times \text{Weight (kg)} \times % \text{TBSA burn}$$
(Only partial thickness burns and full-thickness burns are included; superficial/first-degree burns excluded)
Calculation:
  • = 4 × 50 × 40
  • = 8,000 mL (8 litres) of Ringer's Lactate in 24 hours
Administration schedule:
  • First 8 hours: give half = 4,000 mL (from time of injury, not from time of arrival)
  • Next 16 hours: give remaining half = 4,000 mL
Note: ABLS 2011 acknowledges the Parkland formula can lead to fluid over-resuscitation ("fluid creep"). Urine output (0.5-1 mL/kg/hr) is the best guide to adequacy. (Tintinalli's Emergency Medicine; Sabiston Textbook of Surgery)

e) Formula to calculate drops per minute to infuse IV fluid in 24 hours

Formula:
$$\text{Drops per minute} = \frac{\text{Volume (mL)} \times \text{Drop factor}}{\text{Time (minutes)}}$$
  • Standard IV giving set: Drop factor = 20 drops/mL
  • Blood/colloid giving set: Drop factor = 15 drops/mL
  • Burette/paediatric set: Drop factor = 60 drops/mL
Example - to give 1000 mL in 8 hours using standard giving set:
  • Time = 8 × 60 = 480 minutes
  • Drops/min = (1000 × 20) ÷ 480 = 41.6 ≈ 42 drops/minute
For the Parkland formula patient above (8000 mL over 24 hours):
  • 4000 mL over 8 hours (first half): = (4000 × 20) ÷ 480 = 167 drops/min (or use infusion pump at 500 mL/hr)
  • 4000 mL over 16 hours (second half): = (4000 × 20) ÷ 960 = 83 drops/min
Sources: Schwartz's Principles of Surgery 11e, Bailey & Love's Short Practice of Surgery, Sabiston Textbook of Surgery, Sleisenger & Fordtran's GI & Liver Disease, Tintinalli's Emergency Medicine, Gray's Anatomy for Students, Berek & Novak's Gynecology, Fitzpatrick's Dermatology
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