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MBBS 3rd Professional Surgery Paper - Complete Answers

Bailey & Love's Short Practice of Surgery, 28th Edition

SECTION A - MCQs (Answers with Rationale)

Q	Answer	Rationale (Bailey & Love)
1	(c) Cortisol	"Diabetes of injury" is driven by cortisol (glucocorticoid surge). Cortisol causes insulin resistance + gluconeogenesis, keeping blood glucose elevated despite high insulin levels postoperatively.
2	(b) 30 days	CDC/NHSN defines SSI as infection occurring within 30 days of the operative procedure at or near the surgical site. (If implant involved, extends to 90 days.)
3	(a) Dobutamine	Cold shock = low CO, high SVR (cardiogenic/obstructive pattern). Dobutamine is a positive inotrope that increases cardiac output without excessive vasoconstriction - first-line inotrope. Noradrenaline further increases SVR and worsens cold shock.
4	(d) Remodeling	Bailey & Love: Remodelling phase involves continuous collagen turnover - Type III collagen (provisional) is progressively replaced by stronger Type I collagen. Remodelling begins at ~3 weeks and continues for up to 2 years.
5	(b) Echinococcus granulosus	Hydatid cyst shows: (a) double contour/double wall sign - endocyst separating from pericyst, (b) "water lily" sign - collapsed endocyst floating in cyst fluid, (c) "snowstorm" appearance on USG - all pathognomonic of Echinococcus granulosus.
6	(c) Inferior surface of the liver	Calot's triangle boundaries: medially - common hepatic duct, laterally - cystic duct, superiorly - inferior surface of the liver (visceral peritoneum/liver bed). Cystic artery and Hartmann's node lie within this triangle.
7	(a) Regional lymph node involvement	TNM Staging: T = primary Tumour, N = regional lymph Node involvement, M = distant Metastasis.
8	(b) Tachycardia	Bailey & Love (Table 2.2): In Class II haemorrhage (~15-30% blood loss), compensated shock - BP is maintained, tachycardia is the earliest and most sensitive indicator. Urine output decreases in moderate/severe shock; hypotension is a late sign.
9	(c) Cystoscopy	For painless total haematuria in a smoker (high risk of bladder Ca), cystoscopy is the gold standard - directly visualises the bladder mucosa and allows biopsy. CT urography complements but cystoscopy remains definitive.
10	(d) Extradural Haematoma	The "Lucid Interval" - brief period of consciousness followed by rapid deterioration - is the classic hallmark of Extradural Haematoma (EDH), due to arterial bleed (middle meningeal artery) with initial compensation then rapid decompensation.
11	(c) 31%	Rule of Nines: Entire right arm = 9%, Anterior trunk = 18%, Genitalia = 1%. Total = 9 + 18 + 1 = 28%. Wait - let me recalculate: Right arm = 9%, Anterior trunk = 18%, Genitalia = 1% = 28%. Answer (b) 28%.
12	(c) Medullary Carcinoma	Medullary thyroid carcinoma (MTC) arises from parafollicular C-cells, secretes Calcitonin, and is associated with MEN 2A (MTC + phaeochromocytoma + hyperparathyroidism) and MEN 2B (MTC + phaeochromocytoma + mucosal neuromas).
13	(d) Lymphatic obstruction	"Peau d'orange" (skin dimpling like orange peel) in breast cancer is caused by dermal lymphatic obstruction - lymph oedema tethers the skin via Cooper's ligaments, creating the characteristic pitting. Cooper's ligament contraction causes skin dimpling/retraction, not peau d'orange.
14	(b) Core Biopsy/FNAC	Triple Assessment = 1. Clinical examination, 2. Imaging (mammogram/USG), 3. Pathology (FNAC or Core Biopsy). Sensitivity/specificity approaches 100% when all three are concordant.
15	(a) Saphenofemoral junction incompetence	Trendelenburg Test: tourniquet applied at the thigh above SFJ. If veins fill from above when tourniquet released = SFJ incompetence. If veins fill from below before tourniquet release = perforator incompetence.
16	(d) Vesicoureteric junction (VUJ)	Most common site for ureteric calculus to lodge = VUJ (~70%). Other narrow points: PUJ and crossing of iliac vessels. VUJ is the narrowest point of the ureter.
17	(a) Acute Epididymo-orchitis	Prehn's sign = relief of pain on elevation of the scrotum. Positive (pain relieved) in epididymo-orchitis. Negative (pain NOT relieved or worsens) in testicular torsion - a useful clinical differentiator.
18	(b) Pre-formed cytotoxic antibodies	Hyperacute rejection occurs within minutes to hours due to pre-formed anti-donor antibodies (ABO incompatibility or pre-sensitised HLA antibodies). These cause immediate complement activation and vascular thrombosis.
19	(d) Carbon Dioxide (CO₂)	CO₂ is used for pneumoperitoneum because: (a) non-combustible, (b) highly soluble in blood (absorbed quickly if embolism), (c) cheap, (d) readily available. Its high solubility makes it safe even if inadvertent gas embolism occurs.
20	(c) "Do no harm"	Four principles of surgical ethics: Autonomy (patient choice), Beneficence (do good), Non-maleficence (do no harm), Justice (fair resource distribution).

SECTION B - Short Answers

Q1. Shock - Define, Classify, Clinical Features, Pathophysiology & Management of Haemorrhagic Shock (10 marks)

Definition

Shock is a systemic state of low tissue perfusion that is inadequate for normal cellular respiration, leading to anaerobic metabolism and lactic acidosis. (Bailey & Love, Ch. 2)

Classification

Type	CO	SVR	Cause
Hypovolaemic	↓	↑	Haemorrhage, dehydration, burns
Cardiogenic	↓	↑	MI, dysrhythmia, myocardial injury
Obstructive	↓	↑	Tamponade, tension pneumothorax, PE
Distributive	↑	↓	Sepsis, anaphylaxis, neurogenic
Endocrine	variable	variable	Adrenal insufficiency, thyroid crisis

Haemorrhagic Shock - ATLS Classification

Class	Blood loss	BP	HR	Urine output	GCS
I	<750 mL (<15%)	Normal	<100	>30 mL/hr	Normal
II	750-1500 mL (15-30%)	Normal	100-120	20-30 mL/hr	Anxious
III	1500-2000 mL (30-40%)	↓	120-140	5-15 mL/hr	Confused
IV	>2000 mL (>40%)	Severe ↓	>140	<5 mL/hr	Unconscious

Pathophysiology

Blood loss → ↓ preload → ↓ cardiac output
Baroreceptors activated → sympathetic surge → tachycardia + vasoconstriction
RAAS activated → Na/water retention
ADH released → water retention
Cells switch to anaerobic metabolism → lactic acidosis
Capillary leak → tissue oedema
Organ failure if uncorrected

Management - Damage Control Resuscitation

Airway + Breathing: Secure airway; O₂ supplementation
2 large-bore IV lines: At least 14G in antecubital fossa
Bloods: FBC, U&E, crossmatch, coagulation, lactate, ABG
Fluids: Warm crystalloids initially; move quickly to blood products
DCR principle: Ratio 1:1:1 - packed RBC : FFP : Platelets
Permissive hypotension: Target SBP 80-90 mmHg until surgical haemorrhage control
Control haemorrhage: Surgical/angioembolisation
Correct "Lethal Triad": Hypothermia + Acidosis + Coagulopathy
Monitor: Urine output (>0.5 mL/kg/hr), lactate clearance, CVP, MAP

Q2a. Factors that Delay Wound Healing

(Bailey & Love, Summary Box 3.1, Ch. 3)

Local Factors:

Skin tension / wound under tension
Tissue hypoxia and ischaemia
Vascular insufficiency
Lymphoedema
Wound contamination / infection
Foreign bodies in wound
Haematoma / seroma
Previous radiotherapy (obliterative endarteritis)

Systemic Factors:

Advancing age
Obesity
Malnutrition (esp. protein, Vit C, Zinc deficiency)
Smoking (nicotine causes vasoconstriction)
Diabetes mellitus (reduces collagen deposition, impairs neutrophil function)
Immunocompromised states (HIV, steroids, chemotherapy)
Connective tissue disorders (Ehlers-Danlos)
Jaundice + Uraemia (impair collagen synthesis)

Q2b. Varicose Veins - Clinical Features & Surgical Management

Clinical Features

Symptoms: Aching, heaviness, throbbing, itching in lower limbs; worse on standing, relieved by elevation. Ankle swelling.

Signs:

Dilated, tortuous subcutaneous veins (GSV/SSV territory)
Skin changes: eczema, lipodermatosclerosis, haemosiderin pigmentation, atrophie blanche
Complications: superficial thrombophlebitis, ulceration (gaiter area), bleeding

Tests:

Trendelenburg test (SFJ incompetence)
Duplex ultrasound - gold standard for mapping reflux

Surgical Management

Conservative: Compression hosiery, lifestyle modification (weight loss, avoid prolonged standing)
Endovenous ablation (first-line if suitable anatomy):
- Endovenous laser ablation (EVLA)
- Radiofrequency ablation (RFA)
Ultrasound-guided foam sclerotherapy (UGFS)
Surgery: High saphenous ligation + stripping (if endovenous not suitable)
Avulsions: Multiple stab phlebectomy for tributary varices

Q2c. Rule of Nines & Early Excision and Grafting in Burns

Rule of Nines (Wallace's Rule)

Area	Adult TBSA
Head & Neck	9%
Each arm	9%
Anterior trunk	18%
Posterior trunk	18%
Each leg	18%
Genitalia/perineum	1%
Total	100%

Lund & Browder chart is more accurate, especially in children.

Fluid Resuscitation (Parkland Formula)

4 mL x weight (kg) x %TBSA burned (2nd + 3rd degree only)

Half in first 8 hours from time of burn
Half in next 16 hours

Importance of Early Excision and Grafting

Reduces infection - devitalised tissue is a culture medium
Reduces systemic inflammatory response and sepsis
Reduces hospital stay and reduces mortality
Improves functional outcome - less contracture formation
Deep partial and full thickness burns: excise within 48-72 hours, then split skin graft (SSG)
Early coverage restores skin barrier function

Q2d. Minimal Access Surgery (Laparoscopy) - Principles & Advantages

Principles

Pneumoperitoneum created with CO₂ (12-15 mmHg intra-abdominal pressure)
Veress needle or Hasson (open) technique for port entry
Optical trocar (10-12 mm) for camera (30° laparoscope)
Additional working ports (5-10 mm) for instruments
Surgeon operates using monitor image (magnified 4-5×)

Physiological Effects of CO₂ Pneumoperitoneum

↑ Intra-abdominal pressure → ↓ venous return, ↓ CO
CO₂ absorbed → hypercapnia, respiratory acidosis (managed by ventilator adjustments)
Port-site complications: hernia, haematoma

Advantages

MAS	Open Surgery
Smaller incisions	Large wounds
Less pain	More analgesia needed
Faster recovery/discharge	Prolonged hospital stay
Less wound infection	Higher SSI rate
Less adhesion formation	Higher adhesion risk
Better cosmesis	Scarring
Less blood loss	More blood loss

Common Applications

Cholecystectomy, appendicectomy, hernia repair, colonic resection, anti-reflux surgery, bariatric surgery, nephrectomy.

SECTION B - Q3 Very Short Notes

(a) Surgical Audit

Systematic review of surgical practice comparing actual outcomes against defined standards, with implementation of change to close the audit cycle. Used to improve quality of care, reduce complications, and identify outliers.

(b) Two Indications for Blood Transfusion

Acute haemorrhage with haemodynamic instability (Class III/IV shock)
Symptomatic anaemia (Hb <8 g/dL in surgical patients, or <7 g/dL in stable patients) causing cardiorespiratory compromise

(c) Marjolin's Ulcer

Squamous cell carcinoma (SCC) arising in a chronic wound or scar - classically in old burn scars, venous ulcers, or sinus tracts. Features: painless (scar has no nerves), everted edges, indurated base, may have foul discharge. Slow-growing, late metastasis but aggressive when it does.

(d) Secondary Thyrotoxicosis

Hyperthyroidism arising in a pre-existing multinodular goitre (Plummer's disease) when nodules autonomously secrete thyroid hormone - often triggered by iodine excess (e.g. amiodarone, contrast media). Unlike Graves' disease, no exophthalmos, no autoimmune basis.

(e) Two Crystalloid Solutions Used in Fluid Resuscitation

Normal Saline (0.9% NaCl) - isotonic, risk of hyperchloraemic metabolic acidosis with large volumes
Hartmann's Solution (Lactated Ringer's) - balanced crystalloid, more physiological, preferred in trauma

SECTION C

Q1a. Glasgow Coma Scale (GCS) - Definition & Calculation (3 marks)

GCS Components

Component	Response	Score
Eye Opening (E)	Spontaneous	4
	To voice	3
	To pain	2
	None	1
Verbal (V)	Oriented	5
	Confused	4
	Inappropriate words	3
	Sounds	2
	None	1
Motor (M)	Obeys commands	6
	Localises pain	5
	Withdraws	4
	Flexion (decorticate)	3
	Extension (decerebrate)	2
	None	1

Total range: 3 (worst) - 15 (normal)

For this patient (unconscious, dilated right pupil):

E1 (no eye opening) + V1 (no verbal) + M1-2 (no/extension) = GCS ~3-4
Unilateral dilated pupil = ipsilateral uncal herniation (CN III compression) - indicates raised ICP / herniation

Interpretation

13-15 = Mild TBI
9-12 = Moderate TBI
≤8 = Severe TBI (intubate - "can't protect airway")

Q1b. Initial Management of Traumatic Brain Injury (4 marks)

Primary Survey - ABCDE

A: Secure airway with C-spine precautions; if GCS ≤8, intubate
B: 100% O₂; maintain SpO₂ >95%; avoid hypoxia (PaO₂ <60 mmHg doubles mortality)
C: Maintain MAP ≥80 mmHg; avoid hypotension (SBP <90 mmHg = secondary injury)
D: GCS, pupils, limb movements; Blood glucose
E: Expose, temperature control

Specific TBI Measures

Elevate head 30° (reduces ICP)
Mannitol 20% (0.25-1 g/kg IV) or hypertonic saline - osmotic decompression of brain
Hyperventilate briefly if herniation signs (pCO₂ 35-40, target 30-35 if coning)
Treat seizures - IV phenytoin/levetiracetam
Avoid hyperthermia (increases metabolic demand)
Blood glucose control (avoid hypo and hyperglycaemia)
Neurosurgical referral - for any significant intracranial lesion
ICP monitoring if GCS ≤8 with CT abnormality

Secondary Injury Prevention

Avoid the "Deadly Ds": Desaturation, Dehydration, Depressed BP, Distended bladder, Delayed seizure treatment.

Q1c. Indications for CT Scan in Head Injury (3 marks)

(NICE/ATLS Guidelines as referenced in Bailey & Love)

CT Head within 1 hour if:

GCS <13 at any point
GCS 13-14 at 2 hours post-injury
Suspected open/depressed skull fracture
Focal neurological deficit
Seizure after injury
Signs of basal skull fracture (Battle's sign, raccoon eyes, CSF rhinorrhoea/otorrhoea, haemotympanum)
Vomiting ≥2 episodes
Age ≥65 with any LOC or amnesia
Dangerous mechanism (pedestrian vs vehicle, fall >1 metre)
Coagulopathy (including anticoagulant use)
Loss of consciousness + amnesia (any duration) in high-risk patients

Q2a. Breaking Bad News & Informed Consent in Oral Cancer

Breaking Bad News - SPIKES Protocol

S - Setting: Private, quiet room; patient with family/support
P - Perception: "What do you already know about your condition?"
I - Invitation: "How much would you like to know?"
K - Knowledge: Give information in simple, clear language; avoid jargon; pause frequently
E - Empathy: Acknowledge patient's reaction; allow silence; offer support
S - Summary/Strategy: Summarise, outline next steps, offer follow-up

Informed Consent for Radical Surgery

Patient must be told:

Diagnosis and proposed procedure (e.g. composite resection, neck dissection, free flap reconstruction)
Risks specific and general (bleeding, infection, fistula, nerve injury, speech/swallowing changes, disfigurement)
Benefits (potentially curative, disease control)
Alternatives (radiotherapy, palliative care)
Consequences of not operating
Patient must have capacity (understand, retain, weigh, communicate)
Consent must be voluntary - no coercion
Document in writing; witness present

Q2b. Solitary Thyroid Nodule - Diagnostic Approach

History & Examination

Duration, change in size, dysphagia, hoarseness, dyspnoea
Risk: young male, radiation exposure, family history MTC/MEN
Examine: hard, irregular, fixed = malignant; cervical lymphadenopathy

Triple Assessment

Clinical - history + examination
Imaging - Ultrasound neck (size, echogenicity, calcification, margins, vascularity - TIRADS scoring)
Cytology/Pathology - FNAC (first line) or core biopsy if FNAC inconclusive

Bethesda Classification (FNAC Result)

I (non-diagnostic) → II (benign) → III (atypia of undetermined significance) → IV (follicular neoplasm) → V (suspicious malignancy) → VI (malignant)

Additional Investigations

TFTs: TSH, T3, T4 (hyperfunctioning nodule unlikely to be malignant)
Calcitonin if suspected MTC
Tc-99m scan: Hot nodule (autonomous, rarely malignant), Cold nodule (20% malignant risk)
CT chest/neck: If retrosternal extension or metastasis suspected

Management Based on FNAC

Bethesda II: observe/follow-up
Bethesda IV-VI: hemithyroidectomy or total thyroidectomy
Bethesda III: repeat FNAC or diagnostic hemithyroidectomy

Q2c. Buerger's Disease (TAO) - Clinical Features & Management

Definition

Thromboangiitis Obliterans - segmental inflammatory vasculitis of small and medium vessels of extremities, exclusively in smokers.

Clinical Features

Young male smoker (<45 years), lower limb > upper limb
Rest pain and intermittent claudication
Superficial migratory thrombophlebitis (pathognomonic - occurs in 40%)
Raynaud's phenomenon
Digital ischaemia - gangrene of fingers/toes; often starts at tips
Cold, pale/cyanotic extremities; reduced/absent peripheral pulses
Buerger's test: Pallor on elevation, hyperaemia on dependency
Ankle-brachial index (ABI): <0.9

Investigations

Angiography/CT angiography: "Corkscrew" collaterals, segmental occlusions, no calcification, healthy proximal vessels
ESR, ANA, ANCA (to exclude other vasculitides)
Allen's test for upper limb involvement

Management

Stop smoking ABSOLUTELY - the only proven intervention to halt progression
Wound care for ulcers; antibiotics for infection
Vasodilators: Iloprost (prostacyclin analogue) IV - improves rest pain and ulcer healing
Sympathectomy (lumbar for lower, cervical for upper limb) - reduces vasospasm
Amputation - if gangrene is irreversible (often digital; avoid major amputation if possible)
No role for arterial reconstruction (vessels too small and diseased)

Q2d. Immunosuppression in Renal Transplantation

Principles

Prevent rejection while minimising infection and malignancy risk. Most protocols use triple therapy.

Standard Triple Therapy

Drug	Class	Mechanism
Tacrolimus (or Ciclosporin)	Calcineurin inhibitor	Blocks IL-2 production → inhibits T-cell proliferation
Mycophenolate mofetil (MMF)	Antimetabolite	Inhibits purine synthesis → blocks lymphocyte proliferation
Prednisolone	Corticosteroid	Anti-inflammatory; inhibits cytokine production

Induction Therapy (at time of transplant)

Basiliximab (IL-2 receptor antagonist) - blocks initial T-cell activation
Anti-thymocyte globulin (ATG) - in high-risk patients

Types of Rejection & Treatment

Hyperacute (minutes-hours): pre-formed antibodies; untreatable, graft removal
Acute cellular (days-months): T-cell mediated; treat with high-dose methylprednisolone IV
Chronic (months-years): both cellular + humoral; ongoing immunosuppression modification

Side Effects

Tacrolimus: nephrotoxicity, neurotoxicity, diabetes
Steroids: HTN, DM, osteoporosis, Cushingoid
MMF: GI upset, bone marrow suppression
All: increased risk of infections (CMV, PCP) and malignancy (skin cancer, lymphoma)

Q3 Very Short Notes (Section C)

(a) Golden Hour in Trauma

The first 60 minutes after major trauma when definitive treatment is most effective in preventing death. During this period, reversible causes of death (haemorrhage, airway obstruction, tension pneumothorax) must be identified and treated. It emphasises rapid transport, ATLS primary survey, and early surgical intervention.

(b) Two Complications of Thyroidectomy

Recurrent Laryngeal Nerve (RLN) injury - unilateral: hoarseness; bilateral: stridor, respiratory distress (emergency airway needed)
Hypoparathyroidism - inadvertent removal/devascularisation of parathyroids → hypocalcaemia (perioral tingling, carpopedal spasm, Chvostek's/Trousseau's sign; treat with calcium + Vit D)

Other important complications: haematoma (airway emergency), thyroid storm, hypothyroidism.

(c) Day Case Surgery

Surgical procedure in which the patient is admitted and discharged on the same day (no overnight stay). Criteria: ASA I-II, BMI <35, no significant comorbidities, adequate home support, within 1 hour of hospital. Advantages: reduced cost, lower infection risk, faster recovery.

(d) Two Screening Methods for Breast Cancer

Mammography - primary screening tool; 2-yearly for women 50-70 years (UK NHS programme)
Clinical Breast Examination (CBE) - particularly in younger women and low-resource settings

MRI used in high-risk women (BRCA1/2 mutation carriers).

(e) Sentinel Lymph Node

The first lymph node (or group of nodes) in the regional lymphatic basin to receive drainage from a primary tumour. It is identified intraoperatively using blue dye (e.g. Patent Blue V) ± Tc-99m radiolabelled colloid (gamma probe). If the sentinel node is histologically negative, the rest of the nodal basin is very unlikely to contain metastasis, avoiding full axillary clearance (and its morbidity: lymphoedema, nerve injury) in clinically node-negative breast cancer.

All answers based on Bailey & Love's Short Practice of Surgery, 28th Edition (ISBN 9780367548117).---

Quick Reference - MCQ Answer Key

Q	Answer
1	(c) Cortisol
2	(b) 30 days
3	(a) Dobutamine
4	(d) Remodeling
5	(b) Echinococcus granulosus
6	(c) Inferior surface of the liver
7	(a) Regional lymph node involvement
8	(b) Tachycardia
9	(c) Cystoscopy
10	(d) Extradural Haematoma
11	(b) 28% (9% arm + 18% anterior trunk + 1% genitalia)
12	(c) Medullary Carcinoma
13	(d) Lymphatic obstruction
14	(b) Core Biopsy/FNAC
15	(a) Saphenofemoral junction incompetence
16	(d) Vesicoureteric junction (VUJ)
17	(a) Acute Epididymo-orchitis
18	(b) Pre-formed cytotoxic antibodies
19	(d) Carbon Dioxide
20	(c) "Do no harm"

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