ABDOMINAL WALL and ACUTE ABDOMEN Multiple Choice Questions and Answers pdf :-
1. The most common hernia in females is:
A. Femoral hernia.
B. Direct inguinal hernia.
C. Indirect inguinal hernia.
D. Obturator hernia.
E. Umbilical hernia.
DISCUSSION: Indirect inguinal hernias are the most common hernia in both females and males. Femoral hernias are more common in females than in males.
2. Which of the following statements regarding unusual hernias is incorrect?
A. An obturator hernia may produce nerve compression diagnosed by a positive Howship-Romberg sign.
B. Grynfeltt’s hernia appears through the superior lumbar triangle, whereas Petit’s hernia occurs through the inferior lumbar triangle.
C. Sciatic hernias usually present with a painful groin mass below the inguinal ligament.
D. Littre’s hernia is defined by a Meckel’s diverticulum presenting as the sole component of the hernia sac.
E. Richter’s hernia involves the antimesenteric surface of the intestine within the hernia sac and may present with partial intestinal obstruction.
DISCUSSION: Sciatic hernias usually present with intestinal obstruction or a mass in the gluteal or infragluteal region.
3. Staples may safely be placed during laparoscopic hernia repair in each of the following structures except:
A. Cooper’s ligament.
B. Tissues superior to the lateral iliopubic tract.
C. The transversus abdominis aponeurotic arch.
D. Tissues inferior to the lateral iliopubic tract.
E. The iliopubic tract at its insertion onto Cooper’s ligament.
DISCUSSION: Placement of staples inferior to (below) the lateral iliopubic tract may result in injury to the lateral femoral cutaneous nerve or the genitofemoral nerve. Staples should also not be placed within the triangle of doom, owing to the risk of major vascular injury.
4. The following Nyhus classification of hernias is correct except for:
A. Recurrent direct inguinal hernia—Type IVa.
B. Indirect inguinal hernia with a normal internal inguinal ring—Type I.
C. Femoral hernia—Type IIIc.
D. Direct inguinal hernia—Type IIIa.
E. Indirect inguinal hernia with destruction of the transversalis fascia of Hesselbach’s triangle—Type II.
DISCUSSION: An indirect inguinal hernia with destruction of the transversalis fascia of Hesselbach’s triangle is classified as a Type IIIb hernia. Also classified as Type IIIb hernias are sliding, pantaloon, and massive scrotal hernias. Type II hernia is an indirect inguinal hernia with a dilated internal ring but without displacement of the inferior deep epigastric vessels or destruction of the transversalis fascia of Hesselbach’s triangle.
5. Which of the following statements about the causes of inguinal hernia is correct?
A. Excessive hydroxyproline has been demonstrated in the aponeuroses of hernia patients.
B. Obliteration of the processus vaginalis is a contributing factor for the development of an indirect inguinal hernia.
C. Physical activity and athletics have been shown to have a protective effect toward the development of inguinal hernias.
D. Elevated levels of circulating serum elastalytic activity have been demonstrated in patients with direct herniation who smoke.
E. The majority of inguinal hernias are acquired.
DISCUSSION: A correlation between cigarette smoking and an inguinal hernia formation has been demonstrated. Elevated circulating serum elastalytic activity and free active unbound neutrophil elastase has been detected in smokers.
6. The following statements about the repair of inguinal hernias are true except:
A. The conjoined tendon is sutured to Cooper’s ligament in the Bassini hernia repair.
B. The McVay repair is a suitable option for the repair of femoral hernias.
C. The Shouldice repair involves a multilayer, imbricated repair of the floor of the inguinal canal.
D. The Lichtenstein repair is accomplished by prosthetic mesh repair of the inguinal canal floor in a tension-free manner.
E. The laparoscopic transabdominal preperitoneal (TAPP) and totally extraperitoneal approach (TEPA) repairs are based on the preperitoneal repairs of Cheattle, Henry, Nyhus, and Stoppa.
DISCUSSION: The Bassini repair is accomplished by high ligation of the hernia sac followed by suturing the conjoined tendon and the internal oblique muscle to the inguinal ligament.
7. Which of the following statements concerning the abdominal wall layers are correct?
A. Scarpa’s fascia affords little strength in wound closure.
B. The internal abdominal oblique muscles have fibers that continue into the scrotum as cremasteric muscles.
C. The transversalis fascia is the most important layer of the abdominal wall in preventing hernias.
D. The lymphatics of the abdominal wall drain into the ipsilateral axillary lymph nodes above the umbilicus and into the ipsilateral superficial inguinal lymph nodes below the umbilicus.
8. Which of the following congenital abnormalities are correctly defined?
A. Omphalocele represents a defect in the abdominal wall lateral to the umbilical cord.
B. The herniated viscera associated with omphaloceles are usually covered with a membranous sac.
C. An umbilical polyp is a small excrescence of omphalomesenteric duct mucosa that is retained in the umbilicus.
D. Meckel’s diverticulum results when the intestinal end of the omphalomesenteric duct persists and represents a true diverticulum.
9. The following statement(s) is/are true concerning the indications for treatment of an inguinal hernia.
a. Most adult hernias will remain stable in size, therefore delay seldom affects the technical aspects of a surgical repair
b. There is a direct correlation between the length of time that a hernia is present and the risk of major complications
c. The morbidity and mortality associated with emergent operation due to hernia complications is significantly greater than for elective repair of the identical hernia
d. A truss maintains a hernia in the reduced state, therefore, minimizing the risk of incarceration and strangulation
Answer: b, c
10. Which of the following statement(s) is/are true concerning the diagnosis and management of epigastric hernias?
a. A large peritoneal sac containing abdominal viscera is common
b. At the time of surgical repair, a careful search for other defects should be performed
c. Recurrent epigastric hernias after simple closure is uncommon
d. Patients with symptoms of a painful midline abdominal mass frequently will contain incarcerated small bowel
11. The following statement(s) is/are true concerning neurovascular structures in the inguinal region.
a. The inferior epigastric artery and vein run upward in the preperitoneal fat posterior to the transversalis fascia close to the lateral margin of the internal inguinal ring
b. The iliohypogastric and ilioinguinal are motor and sensory nerves in the inguinal region which lie beneath the external oblique aponeurosis
c. The ilioinguinal nerve runs anterior to the spermatic cord in the inguinal canal and at the superficial inguinal ring, branches into the sensory supply to the pubic region and the upper scrotum or labium majoris
d. The genital branch of the genitofemoral nerve is a sensory nerve only to the upper thigh and genital area
Answer: b, c
12. In advising a patient preoperatively of potential complications of operative treatment of an inguinal hernia, which of the following statement(s) is/are true?
a. Severe symptoms due to sensory nerve entrapment or injury can occur
b. The most common vascular structure injured during the course of a groin hernia repair is the femoral artery
c. Recurrent hernia after primary groin repair should occur in less than 10% of cases
d. Wound infection increases the risk of recurrent hernia
Answer: a, c, d
13. Chylous ascites is the accumulation of chyle within the peritoneal cavity. Which of the following statement(s) is/are true concerning chylous ascites?
a. The cisterna chyli lies at the anterior surface of the first and second lumbar vertebrae and receives lymphatic fluid from the mesenteric lymphatics
b. Chylous ascites is most commonly associated with abdominal lymphoma
c. Paracentesis and analysis of chylous fluid typically reveals elevated triglycerides, protein, and leukocyte levels with cytologic analysis reflecting the underlying presence of malignancy
d. Treatment of chylous ascites with dietary manipulation will be successful in most cases
e. The mortality rate in adults with chylous ascites is in excess of 50%
Answer: a, b, e
14. Which of the statement(s) is/are true concerning laparoscopic hernia repair?
a. General anesthesia is required
b. Either an abdominal or preperitoneal approach is possible
c. The use of prosthetic mesh is required in all variations
d. Long-term results suggest that the laparoscopic approach is equal or better than traditional repairs
Answer: a, b, c
15. A 28-year-old woman with a history of an appendectomy presents with a nontender palpable mass in the right lower quadrant abdominal incision. The following statement(s) is/are true concerning the diagnosis and management of this patient.
a. The best diagnostic test involves imaging of the abdominal wall by either CT or MRI
b. Resection of the mass with a 2 cm margin is usually adequate
c. Low dose radiation is a suitable alternative to surgery for primary treatment
d. Re-resection for recurrence will likely have a higher rate of recurrence than for primary resection
16. Which of the following statement(s) is/are true concerning repair of inguinal hernias?
a. The Bassini repair approximates the transversus abdominis aponeurosis and transversalis fascia and the shelving edge of the inguinal ligament.
b. The Bassini repair is an adequate repair for a femoral hernia
c. A relaxing incision is important for repairs of direct and large indirect inguinal hernias to prevent excessive tension in the closure
d. An advantage to the use of prosthetic material is the mesh incites formation of scar tissue to further increase tensile strength provided by the mesh alone
Answer: a, c, d
17. The following statement(s) is/are true concerning the epidemiology of inguinal hernias.
a. Inguinal hernias occur with a male-to-female ratio of about 7:1
b. Femoral and umbilical hernias are more common in women, with a female-to-male ratio of 4:1
c. The frequency of inguinal hernias increases with age
d. Almost all umbilical hernias occur in the pediatric age group
Answer: a, c
18. A 77-year-old multiparous female presents with a bowel obstruction. She has no previous abdominal operations and no abdominal wall hernias can be detected. In addition to her abdominal symptoms, she reports pain in her right medial thigh. The following statement(s) is/are true concerning her diagnosis and management.
a. Expectant management with nasogastric suction and IV fluid replacement is indicated
b. A right groin approach is indicated for exploration and repair of the presumed hernia
c. The use of a polypropylene mesh will likely be necessary for repair
d. A correct diagnosis can usually be made by visualizing an external mass in the upper, medial thigh
19. The following statement(s) is/are true concerning umbilical hernias in adults.
a. Most umbilical hernias in adults are the result of a congenital defect carried into adulthood
b. A paraumbilical hernia typically occurs in multiparous females
c. The presence of ascites is a contraindication to elective umbilical hernia repair.
d. Incarceration is uncommon with umbilical hernias
20. Retroperitoneal fibrosis is a fibrosing condition of retroperitoneum, which is of significance as it generally encompasses the ureters and eventually causes hydronephrosis and kidney damage. Which of the following statement(s) is/are true concerning this condition?
a. The majority of cases are idiopathic in nature
b. A history of use of methysergide for treatment of migraine headaches would be significant
c. There is no known association of malignancy with retroperitoneal fibrosis
d. The disease occurs more commonly in women than in men
Answer: a, b
21. The following statement(s) is/are true concerning the anterior abdominal wall musculature.
a. The lateral musculature of the abdominal wall consists of three muscle layers. These are, from external to internal, the external oblique, the transversus abdominis, and the internal oblique muscles
b. The transversalis fascia lies on the deep side of the transversus muscle and extends to form an essentially complete fascial envelope of the abdominal cavity
c. Above the semicircular line, the internal oblique aponeurosis splits into posterior and anterior laminae
d. The rectus abdominis muscles originate on the ribs superiorly and on the pubis inferiorly and are clearly distinct throughout their entire length
Answer: b, c
22. A 48-year-old woman maintained on Warfarin for a history of cardiac valvular replacement and a history of recent upper respiratory infection presents with severe abdominal pain exacerbated by movement. Her physical examination shows tenderness in the right paramedian area with voluntary guarding but no peritoneal signs. The following statement(s) is/are true concerning the diagnosis and management of this patient.
a. Urgent laparotomy should be performed because of concern for arterial mesenteric embolus
b. The correct diagnosis could likely be made by CT scan and operation avoided
c. The status of her anticoagulation should be checked and if her prothrombin time is excessively prolonged, correction is necessary
d. If untreated, hemodynamic instability is common
Answer: b, c
23. True statements concerning the diagnosis and management of retroperitoneal fibrosis include:
a. Most patients present with dull, non-colicky back, flank, or abdominal pain
b. Evidence of impaired renal function with an elevated blood urea nitrogen is common
c. The diagnosis is most commonly suggested by intravenous pyelography although contrast studies with CT scan or MRI are useful in further defining the disease
d. Most patients can be managed nonoperatively
e. The prognosis for nonmalignant retroperitoneal fibrosis is grim with progression of disease until death occurring in most patients
Answer: a, b, c
24. The following statement(s) is/are true concerning incarceration of an inguinal hernia.
a. All incarcerated hernias are surgical emergencies and require prompt surgical intervention
b. Attempt at reduction of an incarcerated symptomatic hernia is generally considered safe
c. Vigorous attempts at reduction of an incarcerated hernia may result in reduction en masse with continued entrapment and possible progression to obstruction or strangulation
d. Incarcerated hernias frequently cause both small and large bowel obstruction
Answer: b, c
25. A careful history is necessary in all patients being considered for inguinal hernia repair. Symptoms which deserve investigation and appropriate treatment prior to proceeding with inguinal hernia repair include:
a. Chronic cough
b. Urinary hesitancy and straining
c. Change in bowel habit
d. A specific episode of muscular straining with associated discomfort
Answer: a, b, c
ABDOMINAL WALL and ACUTE ABDOMEN Interview Questions and Answers ::
26. The following statement(s) is/are true concerning abdominal incisional hernias.
a. Large incisional hernias are associated with a high recurrence rate when closed primarily
b. A large potential space remains anterior to the abdominal wall closure in most patients indicating a need for postoperative wound drainage
c. The use of prosthetic mesh can often be avoided by employing relaxing incisions in the anterior fascia parallel to the midline
d. Incisional hernias are frequently associated with a tissue deficit either due to chronic retraction and scarring or the result of tissue necrosis from either infection or tension at the initial closure
Answer: a, b, c, d
27. Which of the following structures are derived from the external oblique muscle and its aponeurosis?
a. The inguinal or Poupart’s ligament
b. The lacunar ligament
c. The superficial inguinal ring
d. The conjoined tendon
Answer: a, b, c
28. A number of special circumstances exist in the repair of inguinal hernias. The following statement(s) is/are correct.
a. Simultaneous repair of bilateral direct inguinal hernias can be performed with no significant increased risk of recurrence
b. The preperitoneal approach may be appropriate for repair of a multiple recurrent hernia
c. A femoral hernia repair can best be accomplished using a Bassini or Shouldice repair
d. Management of an incarcerated inguinal hernia with obstruction is best approached via laparotomy incision
29. Which of the following statements concerning intraperitoneal fluid collections are correct?
A. Ascites occurs when either the peritoneal fluid secretion rate increases or the absorption rate decreases.
B. Accumulation of lymph within the peritoneal cavity usually results from trauma as tumor involving the intra-abdominal lymphatic structures.
C. Choleperitoneum (intraperitoneal bile) generally occurs following biliary surgery, but spontaneous perforation of the bile duct has been reported.
D. The most common cause of hemoperitoneum is trauma to the liver or spleen.
30. The following statement about peritonitis are all true except:
A. Peritonitis is defined as inflammation of the peritoneum.
B. Most surgical peritonitis is secondary to bacterial contamination.
C. Primary peritonitis has no documented source of contamination and is more common in adults than in children and in men than in women.
D. Tuberculous peritonitis can present with or without ascites.
31. True or false?
A. Mesenteric cysts are most often due to congenital lymphatic spaces that gradually fill with lymph.
B. Mesenteric cysts usually present as abdominal masses accompanied by pain, nausea, or vomiting.
C. Mesenteric cysts are best treated by marsupialization.
D. Omental cysts are frequently asymptomatic unless they undergo torsion.
Answer: A-TRUE, B-TRUE, C-FALSE, D-TRUE
32. Which of the following statements about acute salpingitis are true?
A. The disease rarely occurs after menopause.
B. Gonococcal infection is most common.
C. There is minimal cervical tenderness to palpation.
D. Vaginal discharge occurs rarely.
33. Acute appendicitis is most commonly associated with which of the following signs?
A. Temperature above 104؛ F.
B. Frequent loose stools.
C. Anorexia, abdominal pain, and right lower quadrant tenderness.
D. White blood cell count greater than 20,000 per cu. mm.
34. Which of the following most often initiates the development of acute appendicitis?
A. A viral infection.
B. Acute gastroenteritis.
C. Obstruction of the appendiceal lumen.
D. A primary clostridial infection.
35. The diagnosis of acute appendicitis is most difficult to establish in:
A. Persons aged 60 and older.
B. Women aged 18 to 35.
C. Infants younger than 1 year.
D. Pregnant women.
36. Once a diagnosis of acute appendicitis has been made and appendectomy decided upon, which of the following is/are true?
A. Prophylactic antibiotics should be administered.
B. Prophylactic antibitics are not necessary unless there is evidence of perforation.
C. If the appendix is not ruptured and not gangrenous, antibiotics may be discontinued after 24 hours.
D. Multiple antibiotics are in all cases preferable to a single agent.
37. The best type of x-ray to locate free abdominal air is:
A. A posteroanterior view of the chest.
B. A flat and upright view of the abdomen.
C. Computed tomograph (CT) of the abdomen.
D. A lateral decubitus x-ray, right side up.
38. The most helpful diagnostic radiographic procedure in small bowel obstruction is:
A. CT of the abdomen.
B. Contrast study of the intestine.
C. Supine and erect x-rays of the abdomen.
D. Ultrasonography of the abdomen.
39. The most commonly used imaging method for diagnosis of acute cholecystitis is:
A. CT of the abdomen.
B. Ultrasonography of the gallbladder.
C. Oral cholecystogram.
D. Radionuclide (HIDA) scan of the gallbladder.
40. Acute salpingitis occurs most often:
A. After menopause.
B. In patients with unilateral lower abdominal pain.
C. During the menstrual cycle.
D. In patients with cervical tenderness and vaginal discharge.
41. Meckel’s diverticulitis most often occurs in the:
A. Proximal jejunum.
B. Distal jejunum.
C. Proximal ileum.
D. Distal ileum.
42. A patient is seen in the emergency room with reproducible right lower quadrant tenderness. The approximate incidence of finding a normal appendix on right lower quadrant exploration in similar nonselected patients is which of the following:
43. Of adult patients presenting to the emergency room for evaluation of acute abdominal pain, which one of the following answers includes the most common diagnoses?
a. Urologic problems, cholelithiasis, pelvic inflammatory disease
b. Mittelschmerz, appendicitis, ureterolithiasis
c. Nonspecific abdominal pain, appendicitis, intestinal obstruction
d. Appendicitis, pelvic inflammatory disease, perforated ulcer
44. Nonsurgical causes of acute abdominal pain may include which of the following?
b. Adrenal insufficiency
d. Diabetic ketoacidosis
Answer: b, c, d
45. Which of the following cause visceral pain from the abdominal organs?
a. Stretching and contraction
b. Traction, compression, torsion
d. Certain chemicals
Answer: a, b, d
46. Factors which may influence the clinical presentation of intraabdominal pathology include which of the following?
b. Oral anticoagulants
d. HIV infection
Answer: a, b, c, d
47. Prospective studies have shown incidental appendectomy to be advantageous in which of the following patient groups?
a. Children undergoing staging laparotomy for malignancy who are then to enter chemotherapy
b. HIV infected patients
c. Patients over 50 years of age
d. Patients with spinal cord injuries
e. None of the above
48. Visceral pain is typically:
a. Well localized
c. Mediated via spinal nerves
d. Perceived to be in the midline
49. True statements regarding the pathophysiology of acute appendicitis include which of the following:
a. Fecaliths are responsible for the disease process in approximately 30% of adult patients
b. Lymphoid hyperplasia is a rare cause of appendicitis in young patients
c. Clostridium difficile is implicated as a pathogenic organism
d. Carcinoid tumors account for approximately 5% of all cases of acute appendicitis
50. A 26-year old woman in her first trimester of pregnancy presents with a 2-day history of right lower quadrant pain and fever. Physical examination reveals a tender, palpable, right lower quadrant mass. There is no evidence of peritonitis or systemic sepsis. Laboratory evaluation is remarkable for mild leukocytosis, and abdominal ultrasound demonstrates an inflammatory mass but no evidence of abscess. As the surgeon on call, your recommendation would be:
b. Intravenous hydration, antibiotic prophylasis, and urgent appendectomy
c. Intravenous hydration, antibiotics, bowel rest, and interval appendectomy in 4 to 6 weeks
d. Intravenous hydration, antibiotics, and appendectomy if no improvement in 12 to 24 hours
e. Intravenous hydration, antibiotics, and interval appendectomy when fever has subsided, leukocyte count has returned to normal, and the patient is pain free
f. Emergent obstetrical consultation for evaluation and treatment of possible ectopic pregnancy
51. True statements regarding appendiceal neoplasms include which of the following?
a. Carcinoid tumors of the appendix less than 1.5 cm are adequately treated by simple appendectomy
b. Appendiceal carcinoma is associated with secondary tumors of the GI tract in up to 60% of patients
c. Survival following right colectomy for a Dukes’ stage C appendiceal carcinoma is markedly better than that for a similarly staged colon cancer at 5 years
d. Mucinous cystadenocarcinoma of the appendix is adequately treated by simple appendectomy, even in patients with rupture and mucinous ascites
e. Up to 50% of patients with appendiceal carcinoma have metastatic disease, with the liver as the most common site of spread