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RACS GSSE practice questions

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Question 1General Surgery

A 24-year-old man has a 2 cm freely mobile indirect inguinal hernia. Which structure lies immediately lateral to the inferior epigastric vessels at the deep inguinal ring?

  1. The deep inguinal ring Correct answer.
  2. The femoral ring
  3. The superficial inguinal ring
  4. The lacunar ligament

Explanation

The deep inguinal ring lies lateral to the inferior epigastric vessels and is the entry point of an indirect hernia. The superficial ring is a defect in the external oblique aponeurosis and lies medially and inferiorly. Indirect hernias enter through the deep ring, lateral to the inferior epigastric vessels.

Question 2General Surgery

A 30-year-old woman has a tender 3 cm mass in the right groin below the inguinal ligament and medial to the femoral vein. Which diagnosis is most likely?

  1. Indirect inguinal hernia
  2. Obturator hernia
  3. Spigelian hernia
  4. Femoral hernia Correct answer.

Explanation

A femoral hernia passes through the femoral canal, which lies below the inguinal ligament and medial to the femoral vein. Inguinal hernias lie above and medial to the pubic tubercle. Obturator hernias present deep in the medial thigh and are not groin masses.

Question 3General Surgery

A 55-year-old man presents with a painful irreducible groin swelling and vomiting for 6 hours. What is the most appropriate immediate management?

  1. Manual reduction and discharge
  2. Urgent surgical exploration Correct answer.
  3. Ultrasound-guided aspiration
  4. Elective hernia repair in 6 weeks

Explanation

An irreducible painful hernia with vomiting suggests incarceration with possible strangulation, which requires urgent surgical exploration. Delay risks bowel ischaemia and perforation. Elective repair is inappropriate for an acute obstructed hernia.

Question 4General Surgery

Which nerve is at greatest risk of injury during open inguinal hernia repair within the spermatic cord?

  1. Femoral nerve
  2. Genital branch of the genitofemoral nerve Correct answer.
  3. Obturator nerve
  4. Ilioinguinal nerve

Explanation

The genital branch of the genitofemoral nerve runs within the spermatic cord and is at risk during dissection of the cord. The ilioinguinal nerve lies on the cord but outside it. The femoral and obturator nerves are not in the operative field.

Question 5General Surgery

A 40-year-old woman has a 1 cm firm, tender lump at the lateral edge of the areola with no fluctuation. Which diagnosis is most likely?

  1. Periductal mastitis Correct answer.
  2. Lactiferous duct ectasia
  3. Fibroadenoma
  4. Phyllodes tumour

Explanation

Periductal mastitis typically presents as a tender periareolar mass, often with a history of smoking, and may progress to abscess or fistula. Fibroadenomas are usually painless and mobile. Duct ectasia tends to cause nipple discharge in older women.

Question 6General Surgery

A 52-year-old woman has a 2 cm breast cancer. Sentinel node biopsy is planned. Which statement about sentinel node biopsy is correct?

  1. It requires removal of all axillary nodes
  2. It replaces breast surgery
  3. It identifies the first draining node with blue dye or radioisotope Correct answer.
  4. It is contraindicated in clinically node-negative disease

Explanation

Sentinel node biopsy uses blue dye, radioisotope, or both to identify the first draining axillary node, allowing axillary staging with less morbidity than full dissection. It is standard in clinically node-negative disease. It does not replace breast surgery.

Question 7General Surgery

Which feature on mammography is most suggestive of malignancy?

  1. Well-circumscribed oval mass
  2. Spiculated mass with pleomorphic microcalcifications Correct answer.
  3. Diffuse symmetrical density
  4. Simple cyst on ultrasound

Explanation

Spiculation and pleomorphic clustered microcalcifications are classic malignant mammographic features. Well-circumscribed oval masses and simple cysts are usually benign. Diffuse symmetrical density has no focal malignant significance.

Question 8General Surgery

A 60-year-old man has painless visible haematuria. What is the most appropriate first-line investigation?

  1. Urine cytology alone
  2. Repeat urinalysis in 3 months
  3. Flexible cystoscopy and upper tract imaging Correct answer.
  4. Renal biopsy

Explanation

Painless visible haematuria in an older adult requires exclusion of urothelial malignancy with cystoscopy and upper tract imaging. Cytology alone has insufficient sensitivity. Repeat urinalysis delays diagnosis.

Question 9General Surgery

A 25-year-old man has sudden severe right testicular pain with a high-riding testis and absent cremasteric reflex. What is the most appropriate next step?

  1. Ultrasound before any intervention
  2. Immediate scrotal exploration Correct answer.
  3. Reassurance and outpatient review
  4. Antibiotics and analgesia

Explanation

Testicular torsion is a surgical emergency; immediate exploration allows detorsion and fixation and preserves testicular viability. Ultrasound must not delay surgery when the clinical picture is convincing. Antibiotics treat epididymitis, not torsion.

Question 10General Surgery

Which finding best distinguishes testicular torsion from epididymo-orchitis?

  1. Gradual onset
  2. Absent cremasteric reflex Correct answer.
  3. Dysuria
  4. Fever

Explanation

An absent cremasteric reflex strongly supports torsion, whereas it is usually preserved in epididymo-orchitis. Fever and dysuria favour infection. Gradual onset favours inflammation rather than torsion.

Question 11General Surgery

A 45-year-old man has a 4 cm renal mass with tumour thrombus extending into the inferior vena cava below the hepatic veins. Which management is most appropriate?

  1. Radical nephrectomy with thrombectomy Correct answer.
  2. Systemic chemotherapy alone
  3. Percutaneous ablation
  4. Observation alone

Explanation

Renal cell carcinoma with IVC thrombus below the hepatic veins is resectable by radical nephrectomy with thrombectomy. Observation and ablation are inadequate for locally advanced disease. Renal cell carcinoma is chemotherapy-resistant.

Question 12General Surgery

A 70-year-old man has a 3 cm bladder tumour invading the muscularis propria. Which treatment offers the best chance of cure?

  1. Observation
  2. Radical cystectomy with urinary diversion Correct answer.
  3. Transurethral resection alone
  4. Intravesical BCG alone

Explanation

Muscle-invasive bladder cancer is best treated with radical cystectomy with urinary diversion, often with neoadjuvant cisplatin-based chemotherapy. Transurethral resection and intravesical BCG are treatments for non-muscle-invasive disease. Observation is inappropriate.

Question 13General Surgery

Which is the most common cause of acute pancreatitis in developed countries?

  1. Infection
  2. Gallstones Correct answer.
  3. Hypertriglyceridaemia
  4. Trauma

Explanation

Gallstones and alcohol are the leading causes of acute pancreatitis in developed countries, with gallstones being the most common overall. Hypertriglyceridaemia, trauma, and infection are less frequent causes.

Question 14General Surgery

A 55-year-old man with severe acute pancreatitis develops fever and a fluid collection at 4 weeks. What is the most appropriate next step?

  1. Oral antibiotics and discharge
  2. Observation for 6 months
  3. Immediate open necrosectomy
  4. CT-guided drainage Correct answer.

Explanation

A walled-off collection after 4 weeks with sepsis is best managed initially by minimally invasive drainage, such as CT-guided percutaneous drainage. Open necrosectomy is reserved for failure of less invasive measures. Observation and discharge are unsafe.

Question 15General Surgery

Which finding on CT is the strongest predictor of severe acute pancreatitis?

  1. Pancreatic necrosis Correct answer.
  2. Small pancreatic size
  3. Mild peripancreatic fat stranding
  4. Gallstones

Explanation

Pancreatic necrosis on contrast-enhanced CT is strongly associated with severe acute pancreatitis and increased mortality. Gallstones indicate aetiology rather than severity. Mild fat stranding alone is typical of mild disease.

Question 16General Surgery

A 65-year-old woman has painless obstructive jaundice and a palpable gallbladder. Which diagnosis is most likely?

  1. Cholangitis
  2. Gallstone in the cystic duct
  3. Acute cholecystitis
  4. Pancreatic head carcinoma Correct answer.

Explanation

Painless obstructive jaundice with a palpable, non-tender gallbladder suggests malignant distal biliary obstruction, often pancreatic head carcinoma. Gallstones in the cystic duct do not cause jaundice. Cholecystitis and cholangitis are painful and usually febrile.

Question 17General Surgery

Which tumour marker is most useful in monitoring colorectal cancer?

  1. CA 125
  2. CEA Correct answer.
  3. CA 19-9
  4. AFP

Explanation

Carcinoembryonic antigen (CEA) is used to monitor response and recurrence in colorectal cancer. CA 19-9 is used mainly for pancreatic cancer. AFP is used for hepatocellular carcinoma and germ cell tumours.

Question 18General Surgery

A 60-year-old man has a 2 cm low rectal adenocarcinoma 4 cm from the anal verge. Which operation is most appropriate?

  1. Right hemicolectomy
  2. Hartmann procedure
  3. Abdominoperineal excision Correct answer.
  4. Anterior resection

Explanation

A low rectal tumour within about 5 cm of the anal verge usually requires abdominoperineal excision with a permanent end colostomy to achieve clear margins. Anterior resection is used for higher rectal tumours. Hartmann procedure and right hemicolectomy are not appropriate for low rectal cancer.

Question 19General Surgery

A 30-year-old man has a right-sided indirect inguinal hernia and a history of cryptorchidism. Which complication is most strongly associated with cryptorchidism?

  1. Testicular malignancy Correct answer.
  2. Epididymal cyst
  3. Hydrocele
  4. Varicocele

Explanation

Undescended testes are associated with an increased risk of testicular malignancy, even after orchidopexy. Hydroceles and epididymal cysts are common and not specifically linked. Varicoceles occur more on the left and are unrelated to cryptorchidism.

Question 20General Surgery

A 45-year-old woman has a 3 cm thyroid nodule with fine-needle aspiration showing papillary carcinoma. Which treatment is most appropriate?

  1. Total thyroidectomy Correct answer.
  2. Radioactive iodine alone
  3. Observation
  4. Antithyroid drugs

Explanation

Papillary thyroid carcinoma is treated surgically with total or near-total thyroidectomy, followed by risk-adapted radioiodine and TSH suppression. Observation is inappropriate for confirmed malignancy. Radioiodine alone and antithyroid drugs do not treat the tumour.

Question 21General Surgery

Which nerve is at risk during ligation of the inferior thyroid artery in thyroid surgery?

  1. Hypoglossal nerve
  2. Facial nerve
  3. Accessory nerve
  4. Recurrent laryngeal nerve Correct answer.

Explanation

The recurrent laryngeal nerve runs close to the inferior thyroid artery and is at risk during ligation. Injury causes vocal cord paresis and hoarseness. The facial, hypoglossal, and accessory nerves are not in the thyroid bed.

Question 22General Surgery

A 35-year-old woman has a 3 cm firm, painless, mobile breast mass. Core biopsy shows a fibroadenoma. What is the most appropriate management?

  1. Chemotherapy
  2. Mastectomy
  3. Radiotherapy
  4. Excision or observation with follow-up Correct answer.

Explanation

Fibroadenomas are benign and may be observed or excised if large, symptomatic, or the diagnosis is uncertain. Mastectomy, radiotherapy, and chemotherapy are treatments for malignancy.

Question 23General Surgery

A 70-year-old man has a pulsatile abdominal mass. Which investigation is most appropriate to confirm an abdominal aortic aneurysm?

  1. Colonoscopy
  2. CT angiography Correct answer.
  3. Plain abdominal radiograph
  4. Barium enema

Explanation

CT angiography accurately confirms the presence, size, and extent of an abdominal aortic aneurysm and guides intervention. Plain radiographs are insensitive. Barium enema and colonoscopy are irrelevant to vascular diagnosis.

Question 24General Surgery

A 65-year-old smoker has rest pain and a non-healing ulcer on the toes with absent pedal pulses. Which investigation is most appropriate to assess severity?

  1. Venous duplex
  2. MRI spine
  3. Nerve conduction studies
  4. Ankle-brachial pressure index Correct answer.

Explanation

Ankle-brachial pressure index assesses the severity of peripheral arterial disease and helps guide revascularisation. Venous duplex, spinal MRI, and nerve conduction studies address unrelated conditions.

Question 25General Surgery

A 50-year-old woman has a 1 cm hard, fixed breast lump with peau d'orange. What is the most appropriate next step?

  1. Antibiotics alone
  2. Triple assessment with core biopsy Correct answer.
  3. Excision biopsy without imaging
  4. Reassurance

Explanation

A hard fixed lump with peau d'orange suggests locally advanced breast cancer and requires triple assessment: clinical examination, imaging, and core biopsy. Excision without imaging is inappropriate. Antibiotics treat infection, not malignancy.

Question 26General Surgery

A 24-year-old man presents with a 6-hour history of central abdominal pain that has migrated to the right iliac fossa. He has anorexia and low-grade fever. Which clinical sign, when present, most supports the diagnosis of acute appendicitis?

  1. Hyperactive bowel sounds throughout the abdomen
  2. Generalised guarding with board-like rigidity
  3. Rebound tenderness at McBurney's point Correct answer.
  4. Pain on passive extension of the right hip

Explanation

Localised rebound tenderness over McBurney's point reflects focal parietal peritoneal irritation from an inflamed appendix. It is a classic sign of localised peritonism and supports appendicitis over non-surgical causes of right iliac fossa pain. Generalised rigidity suggests a perforated viscus rather than uncomplicated appendicitis.

Question 27General Surgery

A 68-year-old man has a large, irreducible, painful left inguinal swelling with overlying erythema and vomiting. Which feature most strongly indicates strangulation requiring emergency surgery?

  1. Presence of a reducible component
  2. Absence of cough impulse alone
  3. A history of the hernia for many years
  4. Systemic toxicity with skin changes over the hernia Correct answer.

Explanation

Strangulation is suggested by systemic toxicity, skin erythema, and severe pain in an irreducible hernia, indicating compromised bowel perfusion. These findings mandate urgent resuscitation and operative exploration. Absence of cough impulse simply indicates irreducibility and does not itself prove vascular compromise.

Question 28General Surgery

A 55-year-old woman has a 2 cm firm mass in the left breast. Core biopsy shows invasive ductal carcinoma. Which receptor status is most important in determining whether she is eligible for trastuzumab-based therapy?

  1. Progesterone receptor status
  2. Human epidermal growth factor receptor 2 status Correct answer.
  3. Oestrogen receptor status
  4. Ki-67 proliferation index

Explanation

Trastuzumab is a monoclonal antibody directed against HER2, so overexpression or amplification of HER2 is the prerequisite for its use. Hormone receptor status guides endocrine therapy, and Ki-67 informs prognosis and chemotherapy decisions but does not select anti-HER2 treatment.

Question 29General Surgery

A 70-year-old man is admitted with a 12-hour history of absolute constipation, distension, and vomiting. Abdominal radiograph shows multiple dilated small bowel loops with valvulae conniventes and a paucity of gas distally. Which is the most appropriate initial investigation to identify the transition point?

  1. Barium meal and follow-through
  2. Diagnostic laparoscopy
  3. Water-soluble contrast enema
  4. Computed tomography of the abdomen with intravenous contrast Correct answer.

Explanation

Contrast-enhanced CT is the imaging modality of choice in suspected small bowel obstruction because it identifies the transition point, the cause, and features of strangulation such as reduced wall enhancement. It also guides decisions between operative and non-operative management. Plain films confirm obstruction but poorly localise the level or cause.

Question 30General Surgery

A 62-year-old man has a 5 cm abdominal aortic aneurysm. Which diameter threshold generally warrants elective repair in men?

  1. 7.0 cm
  2. 3.0 cm
  3. 4.0 cm
  4. 5.5 cm Correct answer.

Explanation

Elective repair of an asymptomatic infrarenal abdominal aortic aneurysm is generally offered when the maximum diameter reaches about 5.5 cm in men, because the rupture risk rises steeply above this size. Smaller aneurysms are usually managed with surveillance imaging. Women are often considered for repair at a slightly smaller diameter.

Question 31General Surgery

A 48-year-old woman has a solitary 4 cm thyroid nodule. Fine-needle aspiration is reported as suspicious for malignancy. Which is the most appropriate next step in management?

  1. Repeat fine-needle aspiration in 6 months
  2. Radioactive iodine ablation
  3. Diagnostic hemithyroidectomy for histology Correct answer.
  4. Observation with annual ultrasound

Explanation

A cytologically suspicious thyroid nodule requires surgical excision to obtain definitive histology, usually by diagnostic hemithyroidectomy or lobectomy. The extent of completion surgery is then determined by the final histopathology. Repeat aspiration or observation would delay diagnosis of a possible malignancy.

Question 32General Surgery

A 30-year-old man has a small 1 cm well-differentiated rectal neuroendocrine tumour confined to the submucosa, with no lymph node involvement. Which treatment is most appropriate?

  1. Endoscopic or local surgical resection with clear margins Correct answer.
  2. Abdominoperineal resection
  3. Watchful waiting without intervention
  4. Systemic chemotherapy

Explanation

Small, well-differentiated rectal neuroendocrine tumours confined to the submucosa and without nodal disease can be managed by complete local excision, often endoscopically, provided clear margins are achieved. More radical resection is reserved for larger or invasive tumours with nodal involvement.

Question 33General Surgery

A 58-year-old man with cirrhosis presents with haematemesis. Endoscopy shows bleeding oesophageal varices. Which agent should be given early to reduce portal pressure while awaiting definitive therapy?

  1. Terlipressin Correct answer.
  2. Intravenous vitamin K
  3. Oral propranolol
  4. Intravenous proton pump inhibitor

Explanation

Terlipressin is a vasopressin analogue that splanchnic vasoconstriction reduces portal venous pressure and is given early in acute variceal bleeding. It is combined with prophylactic antibiotics and endoscopic therapy. Non-selective beta-blockers are used for prophylaxis, not for the acute bleed.

Question 34General Surgery

A 45-year-old man has a deep partial-thickness burn to 20% of his total body surface area after a house fire. Which formula is used to estimate his initial 24-hour fluid resuscitation requirement?

  1. Glasgow-Blatchford score
  2. Ranson criteria
  3. Child-Pugh score
  4. Parkland formula Correct answer.

Explanation

The Parkland formula estimates 24-hour crystalloid requirements as 4 mL/kg per percent of total body surface area burned, with half given in the first 8 hours from the time of injury. It guides initial resuscitation in major burns. The other scores are unrelated to burn fluid therapy.

Question 35General Surgery

A 35-year-old woman has a 2 cm simple cyst in the right breast, confirmed on ultrasound with no solid component or internal vascularity. She is asymptomatic. What is the most appropriate management?

  1. Excisional biopsy
  2. Reassurance and no further intervention Correct answer.
  3. Aspiration and discard of the fluid without cytology
  4. Mastectomy with sentinel node biopsy

Explanation

A simple breast cyst with typical ultrasound features and no solid component or vascularity is benign and requires only reassurance. Aspiration is reserved for symptomatic or complex cysts, and cytology is not needed for simple cysts.

Question 36General Surgery

A 40-year-old man has a 3 cm duodenal ulcer with active spurting bleeding at endoscopy. Which endoscopic therapy is most appropriate?

  1. Nasogastric tube with observation
  2. Oral proton pump inhibitor alone
  3. Combination therapy with adrenaline injection plus a thermal or mechanical method Correct answer.
  4. Injection of adrenaline alone

Explanation

For actively bleeding peptic ulcers, combination endoscopic therapy using adrenaline injection plus a second modality such as a clip or thermal probe reduces rebleeding and improves outcomes. Adrenaline alone is less effective and is not recommended as monotherapy.

Question 37General Surgery

A 50-year-old man has a 4 cm gastric adenocarcinoma on the lesser curvature with no evidence of distant metastasis. Which is the most appropriate surgical approach?

  1. Endoscopic mucosal resection alone
  2. Wedge resection of the stomach
  3. Proximal gastrectomy without lymph node dissection
  4. Subtotal or total gastrectomy with regional lymphadenectomy Correct answer.

Explanation

Resectable gastric cancer is treated by gastrectomy with regional lymphadenectomy (usually D2) to achieve clear margins and accurate staging. Wedge or limited resections are inadequate for invasive adenocarcinoma because they compromise oncological clearance and nodal staging.

Question 38General Surgery

A 55-year-old woman develops severe epigastric pain and bilious vomiting. CT shows a 3 cm mass at the ampulla of Vater with dilated pancreatic and biliary ducts. Which is the most appropriate operation for a resectable ampullary carcinoma?

  1. Distal pancreatectomy
  2. Pancreaticoduodenectomy Correct answer.
  3. Enucleation of the ampulla
  4. Total pancreatectomy with splenectomy

Explanation

Pancreaticoduodenectomy (Whipple procedure) is the standard resection for resectable ampullary and periampullary malignancies because it removes the tumour with adequate margins and regional nodes. Enucleation is inadequate for carcinoma, and distal pancreatectomy does not address the ampullary region.

Question 39General Surgery

A 28-year-old man has a 2 cm non-pulsatile, tender swelling in the left scrotum, separate from the testis, which transilluminates. What is the most likely diagnosis?

  1. Testicular torsion
  2. Spermatocele Correct answer.
  3. Varicocele
  4. Hydrocele

Explanation

A spermatocele is a cystic, transilluminating swelling arising from the epididymis, separate from the testis, and may be tender when inflamed. Hydroceles also transilluminate but surround the testis rather than being a discrete separate swelling.

Question 40General Surgery

A 65-year-old man has a 2 cm distal ureteric stone with severe colic and a creatinine of 250 micromol/L. Ultrasound shows moderate hydronephrosis. Which management is most appropriate?

  1. Extracorporeal shock wave lithotripsy
  2. Observation with analgesia and repeat imaging in 2 weeks
  3. Urgent decompression with ureteric stent or percutaneous nephrostomy Correct answer.
  4. Medical expulsive therapy with tamsulosin alone

Explanation

Obstructing stones with renal impairment or infection require urgent decompression by ureteric stent or percutaneous nephrostomy to preserve renal function and drain infection. Definitive stone treatment is then performed electively. Expulsive therapy and lithotripsy are inappropriate in the presence of significant obstruction and impaired renal function.

Question 41General Surgery

A 70-year-old man has a 3 cm muscle-invasive bladder tumour. He is fit for surgery. Which treatment offers the best oncological outcome?

  1. Neoadjuvant chemotherapy followed by radical cystectomy Correct answer.
  2. Partial cystectomy with surveillance
  3. Intravesical BCG
  4. Transurethral resection alone

Explanation

Muscle-invasive bladder cancer is best treated with neoadjuvant cisplatin-based chemotherapy followed by radical cystectomy, which improves survival compared with cystectomy alone. Transurethral resection and intravesical BCG are treatments for non-muscle-invasive disease.

Question 42General Surgery

A 60-year-old man has a 2 cm low rectal adenocarcinoma 4 cm from the anal verge, with no evidence of metastasis. Which operation is most appropriate?

  1. Anterior resection
  2. Abdominoperineal resection Correct answer.
  3. Hartmann procedure
  4. Local excision with clear margins

Explanation

A low rectal cancer within about 5 cm of the anal verge usually requires abdominoperineal resection with a permanent end colostomy to achieve adequate distal clearance. Anterior resection is used for higher tumours where a stapled anastomosis is feasible.

Question 43General Surgery

A 45-year-old woman has a 1 cm hard, fixed right breast lump with peau d'orange. What is the most appropriate next step?

  1. Mammography alone with no tissue sampling
  2. Excision under local anaesthetic
  3. Core needle biopsy of the breast mass Correct answer.
  4. Reassurance and review in 6 months

Explanation

A hard, fixed mass with peau d'orange is highly suspicious for locally advanced breast cancer and requires tissue diagnosis by core needle biopsy to confirm histology and receptor status. Imaging alone cannot establish the diagnosis.

Question 44General Surgery

A 50-year-old man has a 3 cm mid-rectal cancer. MRI shows tumour extending through the muscularis propria into the mesorectum with involved mesorectal nodes. Which treatment sequence is most appropriate?

  1. Neoadjuvant chemoradiotherapy followed by total mesorectal excision Correct answer.
  2. Defunctioning colostomy alone
  3. Local excision followed by observation
  4. Immediate anterior resection without neoadjuvant therapy

Explanation

Locally advanced rectal cancer with mesorectal invasion and nodal involvement is treated with neoadjuvant chemoradiotherapy followed by total mesorectal excision, which improves local control. Total mesorectal excision is the standard surgical technique to reduce local recurrence.

Question 45General Surgery

A 3-day-old boy has bilious vomiting and a scaphoid abdomen. Abdominal radiograph shows a double-bubble sign with no distal gas. What is the most likely diagnosis?

  1. Hirschsprung disease
  2. Malrotation with midgut volvulus
  3. Hypertrophic pyloric stenosis
  4. Duodenal atresia Correct answer.

Explanation

Bilious vomiting in a neonate with a double-bubble sign and no distal gas is characteristic of duodenal atresia. The absence of distal gas distinguishes it from causes of distal obstruction. Malrotation with volvulus is a surgical emergency but does not typically produce a double bubble.

Question 46General Surgery

A 35-year-old woman has a 2 cm firm, painless, mobile breast mass. Core biopsy shows a fibroadenoma. What is the most appropriate management?

  1. Excisional biopsy of the mass
  2. Mastectomy
  3. Radiotherapy to the breast
  4. Reassurance with clinical and imaging follow-up Correct answer.

Explanation

A biopsy-proven fibroadenoma in a young woman with concordant clinical and imaging findings can be managed conservatively with reassurance and follow-up. Excision is reserved for large, symptomatic, or discordant lesions.

Question 47General Surgery

A 60-year-old man has a 2 cm low rectal adenocarcinoma. Which lymph node group is most likely to be involved first by lymphatic spread?

  1. Para-aortic nodes
  2. External iliac nodes
  3. Superficial inguinal nodes
  4. Mesorectal nodes Correct answer.

Explanation

Rectal cancer drains initially to the mesorectal lymph nodes, which is why total mesorectal excision is central to surgical treatment. Inguinal and external iliac nodes are involved only with tumours extending below the dentate line or with advanced disease.

Question 48General Surgery

A 65-year-old man has a 4 cm renal mass with tumour thrombus extending into the inferior vena cava below the hepatic veins. Which management is most appropriate?

  1. Observation with serial imaging
  2. Partial nephrectomy alone
  3. Radical nephrectomy with thrombectomy Correct answer.
  4. Systemic targeted therapy alone

Explanation

A renal cell carcinoma with level II inferior vena cava thrombus below the hepatic veins is managed by radical nephrectomy with caval thrombectomy, often with cardiothoracic or vascular surgical support. This offers the best chance of cure or disease control.

Question 49General Surgery

A 55-year-old man has a 4 cm pancreatic head adenocarcinoma with no vascular involvement or metastasis. Which operation is most appropriate?

  1. Pancreaticoduodenectomy Correct answer.
  2. Bypass gastrojejunostomy alone
  3. Enucleation of the tumour
  4. Distal pancreatectomy

Explanation

Resectable pancreatic head adenocarcinoma is treated by pancreaticoduodenectomy (Whipple procedure), which removes the tumour with adequate margins and regional nodes. Bypass alone is reserved for unresectable or metastatic disease.

Question 50General Surgery

A 60-year-old woman has a 3 cm unilocular cystic lesion in the tail of the pancreas. Endoscopic ultrasound shows a mucinous cyst with mural nodules and a main duct component. Which management is most appropriate?

  1. Aspiration and drainage
  2. Surgical resection Correct answer.
  3. Chemotherapy alone
  4. Observation with annual MRI

Explanation

Mucinous pancreatic cysts with mural nodules or main duct involvement have a significant risk of malignant transformation and should be resected. Surveillance is reserved for small cysts without high-risk features.