INI-CET High Yield Questions for Surgery

Mastering the INI-CET demands a strategic approach to preparation, with an emphasis on high-yield topics proving to be a successful tactic. This blog zeroes in on exactly that – a curated list of high-yield questions in Surgery that are highly likely to appear on the INI-CET. By acquainting yourself with these questions and their detailed explanations, you'll deepen your understanding of Surgery concepts, enhancing your confidence and readiness for exam day.

1. A 30-year-old woman was admitted to the post-op unit following a total thyroidectomy for medullary carcinoma 3 days ago. During the morning round, a junior resident in the surgical department noticed the finding shown in the image. Which of the following is the most probable cause for this condition?

A. Hypothyroidism

B. Parathyroid insufficiency

C. Nerve damage during surgery

D. Infection

Option B: Parathyroid insufficiency

• The image above demonstrates a Carpopedal spasm by inflating the sphygmomanometer above systolic blood pressure for 3 minutes (Trousseau's sign). It is due to hypocalcemia caused by parathyroid insufficiency in a patient with total thyroidectomy.
• Total thyroidectomy can also lead to loss of parathyroid glands. This results in decreased effects of parathyroid hormone, leading to hypocalcemia as a complication of the surgery.
• Hypocalcemia most commonly occurs on the second to the fifth day of surgery.

Options A, C, and D: Hypothyroidism, Nerve damage during surgery and Infection do not lead to carpopedal spasm.

2. Which of the following conditions does not exhibit the given histological findings?

A. Follicular carcinoma of the thyroid

B. Papillary carcinoma of the thyroid

C. Meningioma

D. Serous cystadenocarcinoma of the ovary

Correct Option

Option A: Follicular carcinoma of the thyroid

• The given image shows Psammoma bodies. Psammoma bodies are not seen in follicular carcinoma of the thyroid.
• Follicular carcinoma shows follicles with a lumen devoid of colloid. The hallmark is the presence of capsular and vascular invasion. 

Options B, C, and D: Papillary carcinoma of the thyroid, Meningioma, and Serous cystadenocarcinoma of the ovary exhibit Psammoma bodies.

3. A 46-year-old female gives a vague history of occasional mild abdominal pain. Her CT scan revealed the findings shown in the given image. How will you manage this case?

A. Reassurance and conservative management

B. Cholecystectomy

C. Left Hepatectomy

D. Extended left Hepatectomy

Option B: Cholecystectomy

• The given image shows calcification of the walls of the gallbladder, also known as the Porcelain Gallbladder. 
• Early laparoscopic cholecystectomy is the treatment of choice in patients with porcelain gallbladder, even in asymptomatic patients (due to the high incidence of development of carcinoma gallbladder).

Option A, C, and D are not used to manage porcelain gallbladder.

4. A 71-year-old male was referred to the surgery department by his family physician for an incidental finding of a gallstone. The patient denied any abdominal pain, nausea, vomiting, or jaundice. What is the treatment of choice for this patient?

A. Observation

B. Ursodeoxycholic acid

C. Cholecystectomy

D. Lithotripsy

Option A: Observation  

• Since only 1% of patients with asymptomatic stones develop complications, prophylactic cholecystectomy is not warranted in asymptomatic patients.
• Most patients with gallstones are asymptomatic, often being identified at the time of abdominal imaging for other reasons or during laparotomy.
• Symptomatic patients present with typical symptoms of postprandial right upper quadrant pain (biliary colic) caused by a stone obstructing the cystic duct
• Medical treatment of gallstones is generally unsuccessful and is rarely used. Options include dissolution with oral bile salt therapy, contact dissolution, which requires cannulation of the gallbladder, and infusion of organic solvent, and extracorporeal shock wave lithotripsy.
• Hence treatment of silent gallstones is observation.
• Because patients with mild symptoms have a low rate of complications from gallstones (1%–3%/year),observation and dietary and lifestyle changes are appropriate in this population. Patients with more severe or recurrent symptoms have a higher rate of complications of the disease (7%/year), so elective laparoscopic cholecystectomy is warranted.

Option B: Ursodeoxycholic acid

• Ursodeoxycholic acid can be used as a medical therapy in carefully selected patients with functional gallbladder radiolucent stones <10 mm in diameter.
• Stones are dissolved in 50% of patients within 6 months to 2 years.  
• However, stones >10mm in size rarely dissolve.
• This patient is asymptomatic.
• Therefore, she is not a candidate for any surgical or medical management.

Option C: Cholecystectomy 

• Cholecystectomy is not indicated in asymptomatic patients.
• Therefore, this option is incorrect.

Option D: Lithotripsy

• Lithotripsy of bile duct stones is highly effective and can be considered in patients in whom primary endoscopic or surgical stone removal fails.
• This patient is asymptomatic, lithotripsy is not done.

5. A 30-year-old man is diagnosed with carcinoma of the head of the pancreas. The doctors decide to resect the tumour by the procedure shown in the image below. What is the most common complication of the procedure shown in the image?

A. Delayed gastric emptying

B. Bleeding

C. Exocrine insufficiency

D. Anastomotic leak

Option A: Delayed gastric emptying

• The most common complication of Whipple's procedure is Delayed gastric emptying.
• Whipple procedure — also known as a pancreaticoduodenectomy — is a complex operation to remove the head of the pancreas, the first part of the duodenum, the gallbladder and the bile duct. The Whipple procedure treats tumours and other disorders of the pancreas, intestine and bile duct.
• This procedure is associated with significant postoperative morbidity, rates of which range from 20% to 50%
• Indications for Whipple procedure
  • Cancer located at the head of the pancreas
  • The pancreatic neuroendocrine tumours (PNETs)
  • The gastrointestinal stromal tumour (GIST)
  • The intraductal papillary mucinous neoplasms (IPMN)
  • Periampullary cancer which includes distal bile duct cholangiocarcinoma (DBDC)
  • The Adenocarcinoma of the ampulla of Vater

complication:

Complications are-

• Delayed gastric emptying (19%)
• Pancreatic fistula (14%)
• Infection (intra-abdominal abscess wound infection, cholangitis, pancreatitis , pneumonia)
• Bile leak
• Mortality is 3%

Option B: Bleeding

• Bleeding mainly occurs from the stump of the gastroduodenal artery after a Whipple procedure, but it is not the most common complication, as it occurs in only 10% of patients.

Option C: Exocrine insufficiency

• Exocrine insufficiency is common after the Whipple procedure, but its incidence is less than that of delayed gastric emptying as the pancreatic tissue is mostly preserved except the head of the pancreas.

Option D: Anastomotic leak

• The anastomotic leak may present as a bile leak with increasing pain in the abdomen with LFTs bilirubin increasing, but its incidence is less than that of gastric emptying.

Also Read: INI-CET Previous Year Question Papers

6. A 40-year-old female who has had a history of smoking for the past 15 years comes to the OPD with complaints of dilated, tortuous veins in her right leg for the past five months. Doppler reveals a saphenofemoral junction and perforator incompetence in the right lower limb. For her disease, the doctor prescribed injection sclerotherapy. What is the size of the veins that can be treated by sclerotherapy?

A. 8 mm

B. <3 mm

C. 4 mm

D. 6 mm

Option B:< 3 mm

• In this case, the patient has dilated tortuous veins, which are suggestive of varicose veins.
• Diameter 4-5 mm - varicose, 1-4 mm reticular vein, <1mm -telangiectasia
• The varicose veins are dilated tortuous veins. In this, there is a weakening of vessel valves.
• It is caused due to prolonged standing and walking, which causes increased pressure in veins.
• The gold standard treatment for the varicose vein is Endothermal ablation.
• Surgery done for the varicose vein is Trendelenburg operation.
• For intermediate sizes, sclerotherapy and laser therapy are done.
• Sclerotherapy is useful for dealing with minor varicosities (<3 mm) and recurrences in the calf and lower leg.
• The amount of sclerosants used in the treatment of varicose veins is 0.5 ml.

Option A: 8 mm

• Sclerotherapy cannot be used for veins of 8mm.
• Surgery is usually done for large-sized veins.

Option C: 4 mm

• 4 mm is a larger size to treat with sclerotherapy.
• Endothermal ablation can be done.

Option D: 6 mm

• Sclerotherapy cannot be used for veins of 6mm.
• Surgery is usually done for large-sized veins.

7. A 1-year-old boy is brought in by his parents to the surgery department with complaints of a progressive increase in head circumference for the last six months. They also report a delay in speech and difficulty in coordinating movements. His examination findings reveal developmental delay, low tone (hypotonia), and poor coordination. His MRI brain reveals hydrocephalus. A diagnosis of Dandy-Walker syndrome is made. Which of the following statements about the syndrome is true?

A. Most common anterior fossa malformation

B. Consists of a cystic expansion of the 4th ventricle in the posterior fossa and midline cerebellar hypoplasia

C. Managed by removal of the cystic cavity

D. Most common manifestation is microcephaly

Correct Option B - Consists of a cystic expansion of the 4th ventricle in the posterior fossa and midline cerebellar hypoplasia:

• Dandy Walker syndrome:
  • Characterized by developmental failure of the roof of the 4th ventricle during embryogenesis.
  • It consists of a cystic expansion of the fourth ventricle in the posterior fossa and midline cerebellar hypoplasia.
  • Prevalence: 1 per 30,000 live births.
  • The triad of Dandy-Walker malformation.
    • Hypoplasia of vermis
    • Cephalad rotation of the vermian remnant and cystic dilatation of the 4th ventricle extending posteriorly
    • Enlarged posterior fossa with circular-lambdoid inversion.
  • Clinical features include:
    • Macrocephaly (80% cases); associated with hydrocephalus (90% cases).
    • Infants present with a rapid increase in head size and prominent occiput.
    • Transillumination of the skull may be positive.
    • Most children have evidence of long-tract signs (spasticity), cerebellar ataxia, and delayed motor and cognitive milestones, probably due to the associated structural anomalies.
  • Associations:
    • CNS abnormalities are present in 70% of cases (i.e. agenesis of the posterior cerebellar vermis and corpus callosum)
    • Cortical dysplasia
    • Polymicrogyria
  • MRI Brain is the investigation of choice.
  • Treatment: Managed by shunting the cystic cavity.

Incorrect Options:

Option A - Most common anterior fossa malformation:

• Dandy-Walker malformation is the most common posterior fossa malformation.

Option C - Managed by removal of the cystic cavity:

• The shunting of the cystic cavity manages Dandy-Walker syndrome.

Option D - Most common manifestation is microcephaly:

• Most common manifestation of Dandy-Walker syndrome is macrocephaly.

8. What cellular changes are most likely to occur in an 84-year-old man with prostate cancer and vertebral lesions treated with dexamethasone and external beam radiation?

A. Formation of pyrimidine dimers

B. Generation of hydroxyl radicals

C. Disruption of microtubule assembly

D. Formation of DNA crosslinks

Correct Option B - Generation of hydroxyl radicals:

• Ionising radiation is a form of radiation that contains enough energy to liberate electrons from atomic orbit, which ionizes them.
• Light in the X-ray spectrum or higher has sufficient energy to ionize atoms, which can create free radicals which damages the cells of body.
• Ionising radiation (e.g., gamma irradiation, x-ray) causes ionization of the water component of cells and the resultant generation of hydroxyl radicals. Hydroxyl radicals are reactive oxygen species that attack the DNA backbone and bases.
• These reactions cause DNA single-strand breaks and, most deleteriously, double-strand breaks, which are very difficult for the cell to repair, leading to cell death. 

• The radiosensitivity of cells varies with the cell cycle phase. The image here shows the phases in which radiation results in chromosome aberration (yellow), apoptosis (blue), or mitotic arrest (green).
• Cells in the G2 and M phases demonstrate the highest radiosensitivity, whereas cells in the G1 and S phases generally show radioresistance.

Incorrect Options:

Option A - Formation of pyrimidine dimers:

• Non-ionising radiation (e.g., UV radiation) causes covalent binding between adjacent pyrimidines, leading to dimer formation (most commonly thymine dimers).
• These dimers create bulky helix distortions, impairing regular base pairing during replication, which increases the risk of developing mutations. Non-ionizing radiation is not used for external beam radiation therapy for cancer; instead, it is the causative agent for skin cancers.

Option C - Disruption of microtubule assembly:

• Vinca alkaloids (e.g., vincristine, vinblastine) are chemotherapeutic agents that disrupt microtubule assembly by binding to β-tubulin.
• This disruption prevents the formation of the mitotic spindle, causing cell cycle arrest. Vinca alkaloids are most commonly used to treat solid tumors, leukemias, and lymphomas.

Option D - Formation of DNA crosslinks:

• The formation of DNA crosslinks is the mechanism by which alkylating chemotherapeutic agents (e.g., cyclophosphamide, busulfan) destroy malignant cells.
• The presence of DNA crosslinks results in impaired DNA replication of the malignant cells. Alkylating agents are used for various malignancies, including brain tumors, leukemias, and lymphomas. 

9. An 82-year-old male patient with chronic diabetes mellitus has infected wounds on the lower part of the leg. The patient and his family opted for self-treatment with maggots. The maggots that can be used for wound therapy are?

A. Black soldier fly larvae

B. Housefly larvae

C. Green bottle fly larvae

D. Bluebottle fly larvae

Correct Option C - Green bottle fly larvae:

• Maggot debridement therapy, also known as larvae debridement, treats chronic wounds.
• Sterile maggots of the green bottle fly are used.
• The flies used most often for maggot therapy are blow files of Calliphoridae.
• The blow fly species used most commonly is Lucilia sericata, the common green bottle fly.
• Maggots can be directly placed over the wound with a dressing covering them to keep them moist and prevent them from escaping.
• Maggots have the following actions:
  • Debridement: helps in the removal of necrotic and infected tissue. It can debride the wound in a day or two.
  • Disinfection: maggots release secretions that have antimicrobial activity and thus can inhibit or kill infecting bacteria
  • Acceleration of wound healing: granulation tissue is stimulated after the wound has been debrided.
• This therapy's primary advantage is that maggots separate the necrotic dead tissue from the healthy tissue, making surgical debridement easier.

Incorrect Options:

Option A - Black soldier fly larvae:

• The black soldier fly larvae can be used as food for fish, poultry, and pigs.
• It converts organic waste into high-quality nutrient food.
• In humans, it is an excellent source of protein.

Option B - Housefly larvae:

• Housefly larvae are used to biodegrade manure.
• It helps break down and recycle organic matter.

Option D - Bluebottle fly larvae:

•  It is essential in aiding the breakdown of dead animal carcasses.

10. A 30-year-old woman weighing 50 kg comes to the Burn Institute 1.5 hours after a flame burns her head, trunk, and limbs. The total burnt area is 50% TBSA (total body surface). How much lactate Ringer's solution have to be infused for fluid resuscitation in this patient in the first 8 hours of injury?

A. 5 litres

B. 2.5 litres

C. 7 litres

D. 8 litres

Correct Option B: 2.5 litres:

Resuscitation Formula	Crystalloid volume	Colloid Volume	Free water
Parkland	2 mL / Kg per % TBSA	None	None

From the given question:

• % BSA= 50 %
• Body wt. (kg) = 50 kg
  • Total fluid volume= 2ml x kg body weight x %BSA
    • Therefore, 2 mL x 50 kg x 50 = 5000 mL or 5L
    • 50% is given in first 8 hours and next 50% in next 16 hours. Thus, 2.5L should be given in the first 8 hours and 2.5 litres in the next 16 hours

Incorrect Options: 

• Option A, C & D are incorrect.

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