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  • Question 1 - A 63 year old man presents with recurrent colicky abdominal pain. A CT...

    Incorrect

    • A 63 year old man presents with recurrent colicky abdominal pain. A CT scan demonstrates a hernia lateral to the rectus muscle at the level of the arcuate line. What type of hernia would this be classified as?

      Your Answer: Incisional

      Correct Answer: Spigelian

      Explanation:

      A Spigelian hernia (or lateral ventral hernia) is a hernia through the Spigelian fascia, which is the aponeurotic layer between the rectus abdominis muscle medially, and the semilunar line laterally. These are generally interparietal hernias, meaning that they do not lie below the subcutaneous fat but penetrate between the muscles of the abdominal wall; therefore, there is often no notable swelling.

      Spigelian hernias are usually small and therefore risk of strangulation is high. Most occur on the right side. (4th–7th decade of life.) Compared to other types of hernias they are rare.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
      2
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  • Question 2 - A 27-year-old builder presents with a reducible swelling in the right groin, it...

    Incorrect

    • A 27-year-old builder presents with a reducible swelling in the right groin, it is increasing in size and has not been operated on previously. What is the best course of action?

      Your Answer: Laparoscopic Bassini repair

      Correct Answer: Open Lichtenstein repair

      Explanation:

      The patient has a right groin hernia since he has a reducible lump and a history of carrying heavy objects.
      Inguinal hernias present with a reducible lump in the groin.
      A third of patients scheduled for surgery have no pain, and severe pain is uncommon (1.5% at rest and 10.2% on movement).
      Inguinal hernias are at risk of irreducibility or incarceration, which may result in strangulation and obstruction; however, unlike with femoral hernias, strangulation is rare.
      Inguinal hernias are often classified as direct or indirect, depending on whether the hernia sac bulges directly through the posterior wall of the inguinal canal (direct hernia) or passes through the internal inguinal ring alongside the spermatic cord, following the coursing of the inguinal canal (indirect hernia).

      Surgery is the only curative treatment.
      If patients with asymptomatic inguinal hernia are medically fit, they should be offered repair
      Mesh repair is associated with the lowest recurrence rates of hernia
      Laparoscopic repair is suggested for recurrent and bilateral inguinal hernias, though it may also be offered for primary inguinal hernia repair
      The EuraHS recommendations:
      – For Primary unilateral Hernia: Mesh repair, Lichtenstein or endoscopic repair are recommended. Endoscopic repair only if expertise is available.
      – Primary bilateral: Mesh repair, Lichtenstein or endoscopic.
      – Recurrent inguinal hernia: Mesh repair, modifying the technique with respect to the previous technique.
      – If previously anterior: Consider open preperitoneal mesh or endoscopic approach (if expertise is present).
      – If previously posterior: Consider an anterior mesh

      In inguinal hernia tension-free repair, synthetic non-absorbable flat meshes (or composite meshes with a non-absorbable component) should be used.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
      5
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  • Question 3 - A 36 year old woman who smokes heavily arrives at the clinic complaining...

    Incorrect

    • A 36 year old woman who smokes heavily arrives at the clinic complaining of frequent stools and crampy abdominal pain that has been occurring for some time. She undergoes colonoscopy (which is macroscopically normal) and several pan colonic biopsies are taken. Histologic analysis reveals a thickened sub apical collagen layer and increased lymphocytes in the lamina propria. Which of the following diagnosis is most likely?

      Your Answer:

      Correct Answer: Microscopic colitis

      Explanation:

      Microscopic colitis is an inflammation of the large intestine (colon) that causes persistent watery diarrhoea. The disorder gets its name from the fact that it’s necessary to examine the colon tissue under a microscope to identify it, since the tissue may appear normal with a colonoscopy or flexible sigmoidoscopy. It is characterised by normal endoscopic appearances, microscopic features of colonic inflammation and thickening of the sub epithelial collagen layer. Features such as granulomas are absent. It is the normal endoscopic appearance that makes the other options less likely.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
      0
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  • Question 4 - A 26-year-old woman presents with right iliac fossa pain and history of some...

    Incorrect

    • A 26-year-old woman presents with right iliac fossa pain and history of some bloodstained vaginal discharge. On examination, she has diffuse lower abdominal tenderness and is afebrile with a heart rate of 97 bpm and blood pressure of 120/70 mmHg.

      Considering these signs and symptoms, what should be the most appropriate course of action?

      Your Answer:

      Correct Answer: Abdominal and pelvic USS

      Explanation:

      The history of bloodstained vaginal discharge and lower abdominal tenderness makes ectopic pregnancy a strong possibility. Therefore, a pregnancy test (for beta hCG) and abdominal and pelvic USS should be performed. If the beta HCG is high, that is an indication for intrauterine pregnancy. If it is not, then an ectopic pregnancy is likely, and surgery should be considered.

      Generally, the differential diagnosis of right iliac fossa (RIF) pain includes:
      1. Appendicitis
      2. Crohn’s disease
      3. Mesenteric adenitis
      4. Diverticulitis
      5. Meckel’s diverticulitis
      6. Perforated peptic ulcer
      7. Incarcerated right inguinal or femoral hernia
      8. Bowel perforation secondary to caecal or colon carcinoma
      9. Gynaecological causes—pelvic inflammatory disease/salpingitis/pelvic abscess/ectopic pregnancy/ovarian torsion/threatened or complete abortion
      10. Urological causes—ureteric colic/urinary tract infection/Testicular torsion
      11. Other causes—tuberculosis/typhoid/ infection with herpes zoster

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
      0
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  • Question 5 - A 39 year old man with a long standing inguinal hernia inquires about...

    Incorrect

    • A 39 year old man with a long standing inguinal hernia inquires about the risk of strangulation over the next year if he decides not to have surgery done. He is seen with a small, direct inguinal hernia. Which percentage matches with the likely risk of strangulation over the year?

      Your Answer:

      Correct Answer:

      Explanation:

      Indirect inguinal hernias have a higher risk of strangulation. The risk of strangulation and obstruction is lowest for direct inguinal hernias as they have a wide neck, which can often be monitored and managed conservatively. A study conducted showed that the cumulative probability of strangulation for inguinal hernias was 2.8 per cent, rising to 4.5 per cent after 2 years.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
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  • Question 6 - A 60 year old woman develops an enterocutaneous fistula which is high output...

    Incorrect

    • A 60 year old woman develops an enterocutaneous fistula which is high output following a recent stricturoplasty. Her medical history shows that she has been suffering from small bowel Crohn's disease for the past 17 years. A small bowel follow through shows it to be 14 cm from the DJ flexure and her overlying skin is becoming excoriated. What is the most appropriate course of action?

      Your Answer:

      Correct Answer: Commence TPN and octreotide

      Explanation:

      Total parenteral nutrition (TPN) is usually indicated with suspected gastric, duodenal, or small-bowel fistula. When the fistula output is very high, discontinuance of oral intake is recommended because oral intake stimulates further losses of fluids, electrolytes, and protein via the fistula. A decrease in fistula output frequently occurs with the initiation of TPN.

      Volume depletion from a proximal high-output fistula can be controlled with the use of the long-acting somatostatin analogue octreotide, which acts by inhibiting GI hormones. The administration of octreotide reportedly diminishes fistula output, but whether it shortens the time required for fistula closure remains to be determined.
      Draus et al recommended a 3-day trial of octreotide, maintaining that if the fistula output is reduced during this time, then administration of the drug should be continued. Two meta-analyses showed that somatostatin and its analogues decreased the time for fistula closure and increased the closure rate.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
      0
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  • Question 7 - A 32-year-old woman is vomiting persistently following a laparoscopic appendicectomy for a perforated...

    Incorrect

    • A 32-year-old woman is vomiting persistently following a laparoscopic appendicectomy for a perforated gangrenous appendicitis. Imaging shows some dilated small bowel loops.

      What should be the most appropriate course of action?

      Your Answer:

      Correct Answer: Insertion of wide bore nasogastric tube

      Explanation:

      This patient is likely to have paralytic ileus and the administration of antiemetic drugs, in this situation, will have no effect. It is, therefore, important to decompress the stomach with a wide bore nasogastric tube.

      Paralytic ileus is the obstruction of the intestine due to paralysis of the intestinal muscles. It commonly occurs after an abdominal surgery. Irrespective of the cause, paralytic ileus causes constipation, abdominal distention, nausea, and vomiting. It is a severe condition because if left untreated, an ileus can cut off blood supply to the intestines and cause tissue death.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
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  • Question 8 - A 28-year-old woman is admitted with a 48-hour history of worsening pain in...

    Incorrect

    • A 28-year-old woman is admitted with a 48-hour history of worsening pain in the right iliac fossa. She has also been feeling nauseous and has vomited twice. On examination, there is marked tenderness in the right iliac fossa with localised guarding. Vaginal examination is unremarkable and urine dipstick (including beta hCG) is negative. Her blood reports show WCC of 13.5 x 10^9/L and CRP of 70 mg/dL.

      What should be the most appropriate course of action?

      Your Answer:

      Correct Answer: Laparoscopic appendicectomy

      Explanation:

      The most likely diagnosis is appendicitis. The negative vaginal examination (and therefore by definition, the absence of cervical excitation) makes pelvic inflammatory disease unlikely. Given the raised inflammatory markers, the correct course of action is to proceed with surgery. In females, there are considerable advantages of undertaking this laparoscopically as it allows evaluation of the pelvic viscera. Imaging with ultrasound is unlikely to alter management as it has a false negative rate, and given the context of the clinical findings, surgery is likely to occur in any case. Whilst a CT scan would allow for an accurate preoperative diagnosis, it carries a significant radiation dose and again, is unlikely to alter management.

      Differential diagnosis of right iliac fossa (RIF) pain includes:
      1. Appendicitis
      2. Crohn’s disease
      3. Mesenteric adenitis
      4. Diverticulitis
      5. Meckel’s diverticulitis
      6. Perforated peptic ulcer
      7. Incarcerated right inguinal or femoral hernia
      8. Bowel perforation secondary to caecal or colon carcinoma
      9. Gynaecological causes—pelvic inflammatory disease/salpingitis/pelvic abscess/Ectopic pregnancy/Ovarian torsion/threatened or complete abortion
      10. Urological causes—ureteric colic/urinary tract infection/Testicular torsion
      11. Other causes—tuberculosis/typhoid/ infection with herpes zoster

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
      0
      Seconds
  • Question 9 - A 24 year old female is rushed to the emergency room after complaining...

    Incorrect

    • A 24 year old female is rushed to the emergency room after complaining of pain in the lower abdomen. She is diffusely tender on examination and a laparoscopy is performed. Multiple fine adhesions are seen between the liver and abdominal wall during the operation. However, her appendix is normal. Which of the following is her diagnosis?

      Your Answer:

      Correct Answer: Fitz Hugh Curtis Syndrome

      Explanation:

      Answer: Fitz Hugh Curtis syndrome

      Fitz-Hugh-Curtis syndrome is a rare disorder that occurs almost exclusively in women. It is characterized by inflammation of the membrane lining the stomach (peritoneum) and the tissues surrounding the liver (perihepatitis). The muscle that separates the stomach and the chest (diaphragm), which plays an essential role in breathing, may also be affected. Common symptoms include severe pain in the upper right area (quadrant) of the abdomen, fever, chills, headaches, and a general feeling of poor health (malaise). Fitz-Hugh-Curtis syndrome is a complication of pelvic inflammatory disease (PID), a general term for infection of the upper genital tract in women. Infection is most often caused by Neisseria gonorrhoeae and Chlamydia trachomatis.

      Fitz-Hugh-Curtis syndrome is characterized by the onset of sudden, severe pain in the upper right area of the abdomen. Pain may spread to additional areas including the right shoulder and the inside of the right arm. Movement often increases pain. The upper right area may be extremely tender.

      Additional symptoms may occur in some cases including fever, chills, night sweats, vomiting and nausea. Some affected individuals may develop headaches, hiccupping, and a general feeling of poor health (malaise).

      Some affected individuals may have symptoms associated with pelvic inflammatory disease including fever, vaginal discharge, and lower abdominal pain. Lower abdominal pain may precede, follow, or occur simultaneously with upper abdominal pain.

      Most cases of Fitz-Hugh-Curtis syndrome are caused by infection with the bacterium Chlamydia trachomatis, which causes Chlamydia or the organism Neisseria gonorrhoeae, which causes gonorrhoea. Chlamydia and gonorrhoea are common sexually transmitted diseases (STDs). Researchers believe that more cases of Fitz-Hugh-Curtis syndrome are caused by infection with Chlamydia trachomatis than with Neisseria gonorrhoeae.

      The exact process by which such infections cause Fitz-Hugh-Curtis syndrome (pathogenesis) is not completely understood. Some researchers believe that it occurs because of infection of the liver and surrounding tissue, which may result from bacteria traveling from the pelvis directly to the liver or via the bloodstream or lymphatic system. Fitz-Hugh-Curtis syndrome is characterized by the developed of string-like, fibrous scar tissue (adhesions) between the liver and the abdominal wall or the diaphragm.

      Laparoscopy is the gold standard for diagnosing FHCS and PID. In the setting of PID, laparoscopy can show oedema with exudates on tubal surfaces, ectopic pregnancy, or tubo-ovarian abscess. FHCS can be diagnosed directly via visualization of adhesions between the diaphragm and liver or liver and the anterior abdominal wall.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
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  • Question 10 - A 13 month old baby was taken to the hospital after his father...

    Incorrect

    • A 13 month old baby was taken to the hospital after his father saw that he had periorbital oedema for two days. He is seen by the doctor and noted to have facial oedema and a tender distended abdomen. His temperature is 39.1 and his blood pressure is 91/46 mmHg. There is also clinical evidence of poor peripheral perfusion. What is the diagnosis?

      Your Answer:

      Correct Answer: Spontaneous bacterial peritonitis

      Explanation:

      Answer: Spontaneous bacterial peritonitis

      The presence of periorbital and facial oedema with normal blood pressure in this toddler indicates that he has nephrotic syndrome. Nephrotic syndrome can be associated with a series of complications that can affect an individual’s health and quality of life:
      Spontaneous bacterial peritonitis can develop where there is ascites present. This is a frequent development in children but very rarely found in adults.

      Spontaneous bacterial peritonitis (SBP) is the development of a bacterial infection in the peritoneum, despite the absence of an obvious source for the infection. It is specifically an infection of the ascitic fluid – an increased volume of peritoneal fluid. Ascites is most commonly a complication of cirrhosis of the liver. It can also occur in patients with nephrotic syndrome. SBP has a high mortality rate.

      The diagnosis of SBP requires paracentesis, a sampling of the peritoneal fluid taken from the peritoneal cavity. If the fluid contains large numbers of white blood cells known as neutrophils (>250 cells/µL), infection is confirmed and antibiotics will be given, without waiting for culture results. In addition to antibiotics, infusions of albumin are usually administered.

      Signs and symptoms of spontaneous bacterial peritonitis (SBP) include fevers, chills, nausea, vomiting, abdominal pain and tenderness, general malaise, altered mental status, and worsening ascites. Thirteen percent of patients have no signs or symptoms. In cases of acute or chronic liver failure SBP is one of the main triggers for hepatic encephalopathy, and where there is no other clear causal indication for this, SBP may be suspected.

      These symptoms can also be the same for a spontaneous fungal peritonitis (SFP) and therefore make a differentiation difficult. Delay of diagnosis can delay antifungal treatment and lead to a higher mortality rate.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
      0
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  • Question 11 - A 33 year old man with fulminant ulcerative colitis underwent a subtotal colectomy....

    Incorrect

    • A 33 year old man with fulminant ulcerative colitis underwent a subtotal colectomy. Which type of stoma would most likely be fashioned?

      Your Answer:

      Correct Answer: End ileostomy

      Explanation:

      Subtotal colectomy is resection of the entire right, transverse, left and part of the sigmoid colon. The rectal stump is closed and an end ileostomy fashioned in the right iliac fossa.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
      0
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  • Question 12 - A 17 year old girl is taken to the hospital with a 10...

    Incorrect

    • A 17 year old girl is taken to the hospital with a 10 hour history of pelvic pain. Her last normal menstrual cycle was 14 days ago and she is otherwise well. Her abdomen was soft with mild suprapubic pain on examination. What is the underlying cause?

      Your Answer:

      Correct Answer: Mittelschmerz

      Explanation:

      Answer: Mittelschmerz

      Mittelschmerz is midcycle abdominal pain due to leakage of prostaglandin-containing follicular fluid at the time of ovulation. It is self-limited, and a theoretical concern is treatment of pain with prostaglandin synthetase inhibitors, which could prevent ovulation. The pain of mittelschmerz usually occurs in the lower abdomen and pelvis, either in the middle or to one side. The pain can range from a mild twinge to severe discomfort and usually lasts from minutes to hours. In some cases, a small amount of vaginal bleeding or discharge might occur. Some women have nausea, especially if the pain is very strong.
      Diagnosis of pelvic pain in women can be challenging because many symptoms and signs are insensitive and nonspecific. As the first priority, urgent life-threatening conditions (e.g., ectopic pregnancy, appendicitis, ruptured ovarian cyst) and fertility-threatening conditions (e.g., pelvic inflammatory disease, ovarian torsion) must be considered.
      Many women never have pain at ovulation. Some women, however, have mid-cycle pain every month, and can tell by the pain that they are ovulating.
      As an egg develops in the ovary, it is surrounded by follicular fluid. During ovulation, the egg and the fluid, as well as some blood, are released from the ovary. While the exact cause of mittelschmerz is not known, it is believed to be caused by the normal enlargement of the egg in the ovary just before ovulation. Also, the pain could be caused by the normal bleeding that comes with ovulation.
      Pelvic inflammatory disease can be ruled out if the patient is not sexually active.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
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  • Question 13 - A 4 year old boy is rushed to the A&E department and admitted...

    Incorrect

    • A 4 year old boy is rushed to the A&E department and admitted with lethargy and abdominal pain. On examination, he is febrile, temperature 38.2oC, pulse rate is 121 and blood pressure is 101/62. His abdomen is soft but there is some right sided peritonism. His WCC is 14 and urinalysis is positive for leucocytes but is otherwise normal. Which of the following is the best course of action?

      Your Answer:

      Correct Answer: Take to theatre for appendicectomy within 6 hours

      Explanation:

      The definitive treatment for appendicitis is appendectomy. An appendectomy, also spelled appendicectomy, is a surgical operation in which the vermiform appendix is removed. Appendectomy is normally performed as an urgent or emergency procedure to treat acute appendicitis.

      Appendectomy may be performed laparoscopically (as minimally invasive surgery) or as an open operation. Laparoscopy is often used if the diagnosis is in doubt, or in order to leave a less visible surgical scar.
      The classic history of anorexia and vague periumbilical pain, followed by migration of pain to the right lower quadrant (RLQ) and onset of fever and vomiting, is observed in fewer than 60% of patients. Children with appendicitis do not localize in the same way as adults and often the diagnosis is difficult and all too often made late. If the appendix perforates, an interval of pain relief is followed by development of generalized abdominal pain and peritonitis.

      Laboratory findings may increase suspicion of appendicitis but are not diagnostic. The minimum laboratory workup for a patient with possible appendicitis includes a white blood cell (WBC) count with differential and urinalysis. Liver function tests and amylase and lipase assessments are helpful when the aetiology is unclear. Baseline blood urea nitrogen and creatinine are needed prior to intravenous contrast CT scanning. The WBC count becomes elevated in approximately 70-90% of patients with acute appendicitis.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
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  • Question 14 - A 3 month old baby boy is taken to the hospital for recurrent...

    Incorrect

    • A 3 month old baby boy is taken to the hospital for recurrent colicky abdominal pain and intermittent intestinal obstruction. The transverse colon is herniated into the thoracic cavity, through a mid line defect and this is shown when imaging is done. What is the cause of this defect?

      Your Answer:

      Correct Answer: Morgagni hernia

      Explanation:

      Morgagni hernias are one of the congenital diaphragmatic hernias (CDH), and are characterized by herniation through the foramen of Morgagni. When compared to Bochdalek hernias, Morgagni hernias are:
      -anterior
      -more often right-sided (,90%)
      -small
      -rare (,2% of CDH)
      -at low risk of prolapse

      Only ,30% of patients are symptomatic. Newborns may present with respiratory distress at birth similar to a Bochdalek hernia. Additionally, recurrent chest infections and gastrointestinal symptoms have been reported in those with previously undiagnosed Morgagni hernia.
      The image of the transverse colon is herniated into the thoracic cavity, through a mid line defect and this indicates that it is a Morgagni hernia since the foramen of a Morgagni hernia occurs in the anterior midline through the sternocostal hiatus of the diaphragm, with 90% of cases occurring on the right side.

      Clinical manifestations of congenital diaphragmatic hernia (CDH) include the following:
      Early diagnosis – Right-side heart; decreased breath sounds on the affected side; scaphoid abdomen; bowel sounds in the thorax, respiratory distress, and/or cyanosis on auscultation; CDH can often be diagnosed in utero with ultrasonography (US), magnetic resonance imaging (MRI), or both

      Late diagnosis – Chest mass on chest radiography, gastric volvulus, splenic volvulus, or large-bowel obstruction

      Congenital hernias (neonatal onset) – Respiratory distress and/or cyanosis occurs within the first 24 hours of life; CDH may not be diagnosed for several years if the defect is small enough that it does not cause significant pulmonary dysfunction

      Congenital hernias (childhood or adult onset) – Obstructive symptoms from protrusion of the colon, chest pain, tightness or fullness the in chest, sepsis following strangulation or perforation, and many respiratory symptoms occur.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
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  • Question 15 - A 30-year-old male presents with a recurrent inguinal hernia on the left side...

    Incorrect

    • A 30-year-old male presents with a recurrent inguinal hernia on the left side of his abdomen and a newly diagnosed inguinal hernia on the right side. What is the best course of action?

      Your Answer:

      Correct Answer: Bilateral laparoscopic TEP repair

      Explanation:

      Risk factors for Recurrent Inguinal Hernia with a moderate level of evidence include the presence of a sliding hernia, a diminished collagen type I/III ratio, increased systemic matrix metalloproteinase levels, obesity and open hernia repair under local anaesthesia by general surgeons.
      The incorrect surgical technique is likely the most important reason for recurrence after primary IH repair.

      According to the guidelines:
      – Laparo-endoscopic recurred inguinal hernia repair is strongly recommended after failed anterior tissue or Lichtenstein repair (evidence: moderate; recommendation: strong).
      – Anterior repair is recommended after a failed posterior repair (evidence: moderate; recommendation: strong).
      – An expert hernia surgeon should repair a recurrent Inguinal Hernia after failed anterior and posterior repair. Choice of technique depends on patient and surgeon specific factors (evidence: low; recommendation: strong upgraded).

      The EHS guidelines recommended for bilateral primary inguinal hernia repair, either a bilateral Lichtenstein or endoscopic approach.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
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  • Question 16 - A 30-year-old man is undergoing surgery for a left inguinal hernia. During the...

    Incorrect

    • A 30-year-old man is undergoing surgery for a left inguinal hernia. During the operation, the sac is opened to reveal a large Meckel's diverticulum.

      What type of hernia is this?

      Your Answer:

      Correct Answer: Littre's hernia

      Explanation:

      Hernia containing Meckel’s diverticulum is termed as Littre’s hernia.

      Hernias occur when a viscus or part of it protrudes from within its normal anatomical cavity. A Littre’s hernia is an abdominal wall hernia that involves the Meckel’s diverticulum which is a congenital outpouching or bulge in the lower part of the small intestine and is a leftover of the umbilical cord.

      Management of Littre’s hernia includes resection of the diverticulum followed by herniorrhaphy.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
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  • Question 17 - A 39-year-old man is admitted with a tender mass in the right groin,...

    Incorrect

    • A 39-year-old man is admitted with a tender mass in the right groin, fever, and sweating. He is on multi-drug therapy for HIV infection. On examination, a tender swelling is noted in his right groin. The pain is exacerbated by hip extension.

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Psoas abscess

      Explanation:

      The patient has a primary psoas abscess.

      Psoas (or iliopsoas) abscess is a collection of pus in the iliopsoas muscle compartment. It may arise via contiguous spread from adjacent structures or by the haematogenous route from a distant site. Psoas abscesses may be either primary or secondary. Primary cases often develop in the immunosuppressed and may occur as a result of haematogenous spread. Secondary cases may occur as a complication of intra-abdominal diseases such as Crohn’s disease.

      Patients usually present with lower back pain and if the abscess is extensive, a mass that may be localised to the inguinal region or femoral triangle. In most cases, the diagnosis can be made clinically. Where it is not clear, an ultrasound scan is often the most convenient investigation.

      Smaller collections may be percutaneously drained. If the collection is larger, or the percutaneous route fails, then surgery (via a retroperitoneal approach) should be performed.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
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  • Question 18 - An 11 month old baby boy is taken to the clinic with a...

    Incorrect

    • An 11 month old baby boy is taken to the clinic with a history of a right groin swelling. A photograph on the father's mobile phone, shows what looks like an inguinal hernia. What is the most appropriate course of action?

      Your Answer:

      Correct Answer: Undertake an open inguinal herniotomy

      Explanation:

      Answer: Undertake an open inguinal herniotomy

      Inguinal hernia is a type of ventral hernia that occurs when an intra-abdominal structure, such as bowel or omentum, protrudes through a defect in the abdominal wall. Inguinal hernias do not spontaneously heal and must be surgically repaired because of the ever-present risk of incarceration. Generally, a surgical consultation should be made at the time of diagnosis, and repair (on an elective basis) should be performed very soon after the diagnosis is confirmed.

      The infant or child with an inguinal hernia generally presents with an obvious bulge at the internal or external ring or within the scrotum. The parents typically provide the history of a visible swelling or bulge, commonly intermittent, in the inguinoscrotal region in boys and inguinolabial region in girls. The swelling may or may not be associated with any pain or discomfort.

      Open herniotomy is its standard treatment against which all alternative modalities of treatment are evaluated. It is credited with being easy to perform, having a high success rate, and low rate of complications.
      The use of prosthetic mesh in these patients is rare, however not uncalled for. Laparoscopic inguinal herniotomy is significantly associated with longer operative time for unilateral cases and a reduction in metachronous hernia development when compared to open inguinal herniotomy. There was a trend towards higher recurrence rate for laparoscopic repairs and shorter operative time for bilateral cases. A well conducted randomized controlled trial is warranted to compare both approaches.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
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  • Question 19 - A 22-year-old male presents with a 10-day history of right-sided abdominal pain. Prior...

    Incorrect

    • A 22-year-old male presents with a 10-day history of right-sided abdominal pain. Prior to this, he was well. On examination, he has a low-grade fever and a palpable mass in the right iliac fossa. The rest of his abdomen is soft. An abdominal USS demonstrates matted bowel loops surrounding a thickened appendix. What is the best course of action?

      Your Answer:

      Correct Answer: Manage conservatively with antibiotics

      Explanation:

      The patient mostly has an appendicular mass.
      At present, the treatment of choice for uncomplicated acute appendicitis in adults continues to be surgical. The inflammation in acute appendicitis may sometimes be enclosed by the patient’s own defence mechanisms, by the formation of an inflammatory phlegmon or a circumscribed abscess. The management of these patients is controversial. An immediate appendectomy may be technically demanding. The exploration often ends up in an ileocecal resection or a right-sided hemicolectomy. Recently, the conditions for conservative management of these patients have changed due to the development of computed tomography and ultrasound, which has improved the diagnosis of enclosed inflammation and made drainage of intra-abdominal abscesses easier. New efficient antibiotics have also given new opportunities for nonsurgical treatment of complicated appendicitis. The traditional management of these patients is nonsurgical treatment followed by interval appendectomy to prevent a recurrence. The need for interval appendectomy after successful nonsurgical treatment has recently been questioned because the risk of recurrence is relatively small.
      In patients with suspicion of contained appendiceal inflammation, based on a palpable mass or long duration of symptoms, the diagnosis should be confirmed by imaging techniques, especially CT scan. The patient should receive primary nonsurgical treatment with antibiotics and abscess drainage as needed. After successful nonsurgical treatment, no interval appendectomy is indicated in some cases, but the patient should be informed about the risk of recurrence especially in the presence of appendicolith. The risk of missing another underlying condition (cancer or CD) is low, but motivates a follow-up with a colon examination and/or a CT scan or US, especially in patients above the age of 40 years.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
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  • Question 20 - A 1 day old baby girl is born with severe respiratory compromise. She...

    Incorrect

    • A 1 day old baby girl is born with severe respiratory compromise. She is seen to have a scaphoid abdomen and an absent apex beat. Which anomaly does this baby have?

      Your Answer:

      Correct Answer: Bochdalek hernia

      Explanation:

      Answer: Bochdalek hernia

      A Bochdalek hernia is one of two forms of a congenital diaphragmatic hernia, the other form being Morgagni hernia. A Bochdalek hernia is a congenital abnormality in which an opening exists in the infant’s diaphragm, allowing normally intra-abdominal organs (particularly the stomach and intestines) to protrude into the thoracic cavity. In the majority of patients, the affected lung will be deformed, and the resulting lung compression can be life-threatening. Bochdalek hernias occur more commonly on the posterior left side (85%, versus right side 15%).

      In normal Bochdalek hernia cases, the symptoms are often observable simultaneously with the baby’s birth. A few of the symptoms of a Bochdalek Hernia include difficulty breathing, fast respiration and increased heart rate. Also, if the baby appears to have cyanosis (blue-tinted skin) this can also be a sign. Another way to differentiate a healthy baby from a baby with Bochdalek Hernia, is to look at the chest immediately after birth. If the baby has a Bochdalek Hernia it may appear that one side of the chest cavity is larger than the other and or the abdomen seems to be scaphoid (caved in).

      Situs inversus (also called situs transversus or oppositus) is a congenital condition in which the major visceral organs are reversed or mirrored from their normal positions. The normal arrangement of internal organs is known as situs solitus while situs inversus is generally the mirror image of situs solitus. Although cardiac problems are more common than in the general population, most people with situs inversus have no medical symptoms or complications resulting from the condition, and until the advent of modern medicine it was usually undiagnosed. In the absence of congenital heart defects, individuals with situs inversus are homeostatically normal, and can live standard healthy lives, without any complications related to their medical condition. There is a 5–10% prevalence of congenital heart disease in individuals with situs inversus totalis, most commonly transposition of the great vessels. The incidence of congenital heart disease is 95% in situs inversus with levocardia.

      Cystic fibrosis is a progressive, genetic disease that causes persistent lung infections and limits the ability to breathe over time. In people with CF, mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene cause the CFTR protein to become dysfunctional. When the protein is not working correctly, it’s unable to help move chloride — a component of salt — to the cell surface. Without the chloride to attract water to the cell surface, the mucus in various organs becomes thick and sticky. In the lungs, the mucus clogs the airways and traps germs, like bacteria, leading to infections, inflammation, respiratory failure, and other complications.

      Necrotizing enterocolitis (NEC) is a medical condition where a portion of the bowel dies. It typically occurs in new-borns that are either premature or otherwise unwell. Symptoms may include poor feeding, bloating, decreased activity, blood in the stool, or vomiting of bile.
      The exact cause is unclear. Risk factors include congenital heart disease, birth asphyxia, exchange transfusion, and premature rupture of membranes. The underlying mechanism is believed to involve a combination of poor blood flow and infection of the intestines. Diagnosis is based on symptoms and confirmed with medical imaging.

      Morgagni hernias are one of the congenital diaphragmatic hernias (CDH), and is characterized by herniation through the foramen of Morgagni. When compared to Bochdalek hernias, Morgagni hernias are:
      -anterior
      -more often right-sided (,90%)
      -small
      -rare (,2% of CDH)
      -at low risk of prolapse

      Only ,30% of patients are symptomatic. New-borns may present with respiratory distress at birth similar to a Bochdalek hernia. Additionally, recurrent chest infections and gastrointestinal symptoms have been reported in those with previously undiagnosed Morgagni hernia.
      The image of the transverse colon is herniated into the thoracic cavity, through a mid line defect and this indicates that it is a Morgagni hernia since the foramen of a Morgagni hernia occurs in the anterior midline through the sternocostal hiatus of the diaphragm, with 90% of cases occurring on the right side.

      Clinical manifestations of congenital diaphragmatic hernia (CDH) include the following:

      Early diagnosis – Right-side heart; decreased breath sounds on the affected side; scaphoid abdomen; bowel sounds in the thorax, respiratory distress, and/or cyanosis on auscultation; CDH can often be diagnosed in utero with ultrasonography (US), magnetic resonance imaging (MRI), or both
      Late diagnosis – Chest mass on chest radiography, gastric volvulus, splenic volvulus, or large-bowel obstruction
      Congenital hernias (neonatal onset) – Respiratory distress and/or cyanosis occurs within the first 24 hours of life; CDH may not be diagnosed for several years if the defect is small enough that it does not cause significant pulmonary dysfunction
      Congenital hernias (childhood or adult onset) – Obstructive symptoms from protrusion of the colon, chest pain, tightness or fullness the in chest, sepsis following strangulation or perforation, and many respiratory symptoms occur.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
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  • Question 21 - A male teenager is taken to the A&E department with lower abdominal discomfort....

    Incorrect

    • A male teenager is taken to the A&E department with lower abdominal discomfort. For the last several months, he has been having intermittent right iliac fossa pain. A negative colonoscopy and gastroscopy for iron deficiency anaemia are seen in his past medical history notes. He states that the pain is worse after eating. Tests show that his inflammatory markers are normal. What is the likely diagnosis?

      Your Answer:

      Correct Answer: Meckel's diverticulum

      Explanation:

      Answer: Meckel’s diverticulum

      Meckel’s diverticulum is the most common congenital malformation of the gastrointestinal tract (present in 2%-4% of population) due to persistence of the congenital vitello-intestinal duct. Bleeding from Meckel’s diverticulum due to ectopic gastric mucosa is the most common clinical presentation, especially in younger patients, but it is rare in the adult population. This is due to the persistence of the proximal part of the congenital vitello-intestinal duct. It is a true diverticulum, typically located on anti-mesenteric border, and contains all three coats of intestinal wall with its separate blood supply from the vitelline artery. Meckel’s diverticulum is lined mainly by the typical ileal mucosa as in the adjacent small bowel. However, ectopic gastric, duodenal, colonic, pancreatic, Brunner’s glands, hepatobiliary tissue and endometrial mucosa may be found, usually near the tip. The main mechanism of bleeding is the acid secretion from ectopic mucosa, leading to ulceration of adjacent ileal mucosa. It is possible that the recurrent intussusception may cause trauma, inflammation, mucosal erosion and bleeding. The pathogenic role of Helicobacter pylori in the development of gastritis and bleeding in the ectopic gastric mucosa is still debatable. NSAIDs’ effect on the ectopic gastric mucosa is yet to be proved. Bleeding from Meckel’s diverticulum can cause the iron deficiency anaemia, but it may also cause megaloblastic anaemia due to the bacterial overgrowth and vitamin B12 deficiency as a result of the dilatation and stasis in adjacent obstructed ileal loop. The presence of bleeding with hypoalbuminemia and low ferritin due to ongoing slow unrecognized bleeding may lead to the diagnosis of inflammatory bowel disease.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
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  • Question 22 - A 50 year old man develops a colocutaneous fistula after having reversal of...

    Incorrect

    • A 50 year old man develops a colocutaneous fistula after having reversal of a loop colostomy fashioned for the defunctioning of an anterior resection. Pre-operative Gastrografin enema showed no distal obstruction or anastomotic stricture. Which of the following is the most appropriate course of action?

      Your Answer:

      Correct Answer: Provide local wound care and await spontaneous resolution

      Explanation:

      Containment of fistula output and skin protection should be instituted as soon as the diagnosis is made as it will decrease local skin excoriation and inflammation, pain and infection. While low output fistulas may be controlled with a simple absorbent dressing, complex fistulas often require advanced techniques including barrier creams, powders, and sealants to protect the skin from auto-digestion as well as bridging for fistula isolation, topographical enhancements, and complex pouching systems with or without sump drainage
      Fistulas arising from the oesophagus, duodenal stump after gastric resection, pancreaticobiliary tract, and jejunum are more likely to close without operative intervention. Additionally, those with long tracts and small enteric wall defects are associated with higher spontaneous closure rates. Fistulas in the colon show favourable rates of spontaneous resolution.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
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  • Question 23 - A 15 year old girl is taken to the A&E after complaining of...

    Incorrect

    • A 15 year old girl is taken to the A&E after complaining of right iliac fossa pain which started suddenly. She is well other than having some right iliac fossa tenderness but no guarding. She has no fever and the urinary dipstick result is normal. Her last menstrual cycle was 14 days ago which was also normal and the pregnancy test done is negative. What is the most likely underlying condition?

      Your Answer:

      Correct Answer: Mittelschmerz

      Explanation:

      Answer: Mittelschmerz

      Mittelschmerz is midcycle abdominal pain due to leakage of prostaglandin-containing follicular fluid at the time of ovulation. It is self-limited, and a theoretical concern is treatment of pain with prostaglandin synthetase inhibitors, which could prevent ovulation. The pain of mittelschmerz usually occurs in the lower abdomen and pelvis, either in the middle or to one side. The pain can range from a mild twinge to severe discomfort and usually lasts from minutes to hours. In some cases, a small amount of vaginal bleeding or discharge might occur. Some women have nausea, especially if the pain is very strong.
      Diagnosis of pelvic pain in women can be challenging because many symptoms and signs are insensitive and nonspecific. As the first priority, urgent life-threatening conditions (e.g., ectopic pregnancy, appendicitis, ruptured ovarian cyst) and fertility-threatening conditions (e.g., pelvic inflammatory disease, ovarian torsion) must be considered.
      Many women never have pain at ovulation. Some women, however, have mid-cycle pain every month, and can tell by the pain that they are ovulating.
      As an egg develops in the ovary, it is surrounded by follicular fluid. During ovulation, the egg and the fluid, as well as some blood, are released from the ovary. While the exact cause of mittelschmerz is not known, it is believed to be caused by the normal enlargement of the egg in the ovary just before ovulation. Also, the pain could be caused by the normal bleeding that comes with ovulation.
      Pelvic inflammatory disease can be ruled out if the patient is not sexually active.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
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  • Question 24 - A 9 year old boy is admitted with right iliac fossa pain and...

    Incorrect

    • A 9 year old boy is admitted with right iliac fossa pain and an appendicectomy is to be performed.
      Which of the following incision is the best for this procedure?

      Your Answer:

      Correct Answer: Lanz

      Explanation:

      Answer: Lanz

      The Lanz and Gridiron incisions are two incisions that can be used to access the appendix, predominantly for appendectomy.

      Both incisions are made at McBurney’s point (two-thirds from the umbilicus to the anterior superior iliac spine). They involve passing through all of the abdominal muscles, transversalis fascia, and then the peritoneum, before entering the abdominal cavity.

      The Lanz incision is a transverse incision, whilst the Gridiron incision is oblique (superolateral to inferomedial). Due to its continuation with Langer’s lines, the Lanz incision produces much more aesthetically pleasing results with reduced scarring.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
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  • Question 25 - An 18-year-old male is admitted with a three-month history of intermittent pain in...

    Incorrect

    • An 18-year-old male is admitted with a three-month history of intermittent pain in the right iliac fossa. He suffers from episodic diarrhoea and has lost two kilograms of weight. On examination, he is febrile and has right iliac fossa tenderness.

      What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Inflammatory bowel disease

      Explanation:

      A history of weight loss and intermittent diarrhoea makes inflammatory bowel disease (IBD) the most likely diagnosis. Conditions such as appendicitis and infections have a much shorter history. Although Meckel’s diverticulum can bleed and cause inflammation, it seldom causes marked weight loss. Irritable bowel syndrome (IBS) presents with alternating episodes of constipation and diarrhoea along with abdominal pain, bloating, and gas.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
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  • Question 26 - A 26-year-old female presents to her GP complaining of a two day history...

    Incorrect

    • A 26-year-old female presents to her GP complaining of a two day history of right upper quadrant pain, fever and a white vaginal discharge. She has seen the GP twice in 12 weeks complaining of pelvic pain and dyspareunia. What is the most likely cause?

      Your Answer:

      Correct Answer: Pelvic inflammatory disease

      Explanation:

      Pelvic inflammatory disease (PID) is an infectious and inflammatory disorder of the upper female genital tract, including the uterus, fallopian tubes, and adjacent pelvic structures. Infection and inflammation may spread to the abdomen, including perihepatic structures (Fitz-Hugh−Curtis syndrome). The classic high-risk patient is a menstruating woman younger than 25 years who has multiple sex partners, does not use contraception, and lives in an area with a high prevalence of sexually transmitted disease (STD).
      PID is initiated by an infection that ascends from the vagina and cervix into the upper genital tract. Chlamydia trachomatis is the predominant sexually transmitted organism associated with PID. Of all acute PID cases, less than 50% test positive for the sexually transmitted organisms such as Chlamydia trachomatis and Neisseria gonorrhoea.
      Other organisms implicated in the pathogenesis of PID include Gardnerella vaginalis (which causes bacterial vaginosis (BV), Haemophilus influenzae, and anaerobes such as Peptococcus and Bacteroides species. Laparoscopic studies have shown that in 30-40% of cases, PID is polymicrobial.
      The most common presenting complaint is lower abdominal pain. Abnormal vaginal discharge is present in approximately 75% of cases. Unanticipated vaginal bleeding, often postcoital, is reported in about 40% of cases. Temperature is higher than 38°C (found in 30% of cases), nausea, and vomiting manifest late in the clinical course of the disease. Abnormal uterine bleeding is present in more than one-third of patients.
      Right upper quadrant tenderness, especially if associated with jaundice, may indicate associated Fitz-Hugh−Curtis syndrome.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
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