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OMSB General Surgery (OEGS) study materials
OMSB General Surgery (OEGS) study resources

OMSB General Surgery (OEGS) practice questions

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Question 1General Surgery (OMS B specialty training program content)

A 45-year-old man presents with a 6-hour history of periumbilical pain that migrated to the right iliac fossa, associated with anorexia and low-grade fever. On examination there is tenderness and guarding at McBurney's point. Which single finding most reliably supports the diagnosis of acute appendicitis in this context?

  1. Pain migration from periumbilical region to right iliac fossa Correct answer.
  2. Rebound tenderness localized to the right iliac fossa
  3. Low-grade fever of 37.8°C
  4. Presence of Rovsing's sign

Explanation

The classic migration of visceral periumbilical pain to somatic right iliac fossa pain reflects the transition from appendiceal distension to parietal peritoneal irritation and is the most characteristic historical feature of acute appendicitis. Other signs are supportive but less specific individually.

Question 2General Surgery (OMS B specialty training program content)

A 62-year-old woman has a 3 cm firm, painless breast mass with skin dimpling. Which feature on history most increases the likelihood of malignancy rather than a benign lesion?

  1. Bilateral cyclical mastalgia
  2. Mobility of the mass within the breast tissue
  3. Nipple discharge that is green and multiductal
  4. Mass fixed to underlying structures with peau d'orange Correct answer.

Explanation

Fixation to underlying structures and peau d'orange indicate tumor invasion of Cooper's ligaments and dermal lymphatic obstruction, both strongly associated with malignancy. Benign lesions such as fibroadenomas are typically mobile and well circumscribed.

Question 3General Surgery (OMS B specialty training program content)

A 30-year-old man sustains a stab wound to the left anterior chest. He is hypotensive with distended neck veins and absent breath sounds on the left with tracheal deviation to the right. What is the most appropriate immediate management?

  1. Immediate needle decompression followed by tube thoracostomy Correct answer.
  2. Emergency thoracotomy in the resuscitation room
  3. CT scan of the chest with contrast
  4. Urgent pericardiocentesis

Explanation

The triad of hypotension, distended neck veins, and absent breath sounds with contralateral tracheal shift indicates tension pneumothorax, a clinical diagnosis requiring immediate needle decompression followed by tube thoracostomy. Delay for imaging risks cardiac arrest.

Question 4General Surgery (OMS B specialty training program content)

A 55-year-old man with a 20-year history of gastroesophageal reflux presents with progressive dysphagia and unintentional weight loss. Which investigation is most appropriate to establish the diagnosis?

  1. Upper gastrointestinal endoscopy with biopsy Correct answer.
  2. 24-hour esophageal pH monitoring
  3. Esophageal manometry
  4. Barium swallow

Explanation

Progressive dysphagia with weight loss in a patient with chronic reflux raises concern for esophageal adenocarcinoma, and endoscopy with biopsy provides both direct visualization and histological confirmation. Functional studies do not diagnose malignancy.

Question 5General Surgery (OMS B specialty training program content)

A 70-year-old man presents with painless jaundice and a palpable, non-tender gallbladder (Courvoisier's sign). Which diagnosis is most likely?

  1. Gallstone impaction in the cystic duct
  2. Acute cholecystitis
  3. Choledocholithiasis with cholangitis
  4. Periampullary or pancreatic head malignancy Correct answer.

Explanation

Courvoisier's law states that a palpable, non-tender gallbladder in the presence of painless jaundice is unlikely to be due to stones and suggests malignant obstruction, typically at the pancreatic head or periampullary region. Chronic stone disease usually produces a fibrotic, non-distensible gallbladder.

Question 6General Surgery (OMS B specialty training program content)

A 25-year-old man has a 2 cm indirect inguinal hernia. Which anatomical structure forms the posterior wall of the inguinal canal?

  1. External oblique aponeurosis
  2. Transversalis fascia Correct answer.
  3. Inguinal ligament
  4. Internal oblique muscle

Explanation

The posterior wall of the inguinal canal is formed by the transversalis fascia, reinforced medially by the conjoint tendon. The anterior wall is the external oblique aponeurosis, and the inferior border is the inguinal ligament.

Question 7General Surgery (OMS B specialty training program content)

A 48-year-old woman has right upper quadrant pain, fever, and jaundice. Ultrasound shows a dilated common bile duct with stones. What is the most appropriate initial management for choledocholithiasis with cholangitis?

  1. Endoscopic retrograde cholangiopancreatography with sphincterotomy Correct answer.
  2. Emergency open common bile duct exploration
  3. Elective laparoscopic cholecystectomy in six weeks
  4. Percutaneous transhepatic cholangiography

Explanation

ERCP with sphincterotomy and stone extraction is the first-line treatment for choledocholithiasis, particularly with cholangitis, because it decompresses the biliary tree without the morbidity of open surgery. Cholecystectomy follows once the patient has stabilized.

Question 8General Surgery (OMS B specialty training program content)

A 35-year-old woman has a solitary thyroid nodule. Which finding on fine-needle aspiration is most consistent with papillary thyroid carcinoma?

  1. Abundant colloid with benign follicular cells
  2. Follicular cells with capsular invasion
  3. Orphan Annie eye nuclei and psammoma bodies Correct answer.
  4. Sheets of uniform parafollicular cells

Explanation

Papillary thyroid carcinoma characteristically shows nuclear clearing (Orphan Annie eye nuclei), grooves, pseudoinclusions, and psammoma bodies. These nuclear features are the diagnostic hallmark and distinguish it from follicular neoplasms.

Question 9General Surgery (OMS B specialty training program content)

A 60-year-old man with a history of alcohol abuse presents with hematemesis and melena. He is tachycardic and hypotensive. After initial resuscitation, what is the most appropriate next step?

  1. Immediate surgery for gastrectomy
  2. Start oral proton pump inhibitor and discharge
  3. Barium meal study
  4. Upper endoscopy within 24 hours after stabilization Correct answer.

Explanation

In acute upper gastrointestinal bleeding, endoscopy after hemodynamic stabilization allows identification and endoscopic hemostasis of the bleeding source. Urgent surgery is reserved for failure of endoscopic and medical therapy.

Question 10General Surgery (OMS B specialty training program content)

A 28-year-old man has a penetrating abdominal wound with evisceration of omentum. He is hemodynamically stable. What is the most appropriate management?

  1. Local wound exploration and discharge if fascia intact
  2. Exploratory laparotomy Correct answer.
  3. CT scan with oral contrast and observation
  4. Diagnostic peritoneal lavage

Explanation

Evisceration after penetrating abdominal trauma is an indication for exploratory laparotomy because of the high likelihood of significant intra-abdominal injury. Hemodynamic stability does not obviate the need for operative exploration in this setting.

Question 11General Surgery (OMS B specialty training program content)

A 65-year-old woman has a 4 cm abdominal aortic aneurysm. Which diameter threshold generally warrants elective repair in a fit patient?

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

Explanation

Elective repair of an infrarenal abdominal aortic aneurysm is generally recommended at a diameter of 5.5 cm or greater, or when the growth rate exceeds 1 cm per year, because rupture risk rises steeply above this size. Smaller aneurysms are managed with surveillance.

Question 12General Surgery (OMS B specialty training program content)

A 40-year-old woman has a 1 cm papillary thyroid carcinoma confined to one lobe with no lymph node involvement. What is the most appropriate surgical management?

  1. Total thyroidectomy with central neck dissection
  2. Observation with annual ultrasound
  3. Radioactive iodine ablation without surgery
  4. Lobectomy alone Correct answer.

Explanation

For a low-risk papillary thyroid carcinoma of 1 to 4 cm confined to one lobe without nodal disease, lobectomy alone is acceptable and avoids the morbidity of total thyroidectomy. Total thyroidectomy is reserved for bilateral disease, larger tumors, or nodal involvement.

Question 13General Surgery (OMS B specialty training program content)

A 50-year-old man presents with a painful, swollen left leg after prolonged immobilization. Doppler ultrasound confirms a proximal deep vein thrombosis. Which is the most appropriate initial anticoagulation strategy?

  1. Low-molecular-weight heparin or a direct oral anticoagulant Correct answer.
  2. Systemic thrombolysis
  3. Immediate inferior vena cava filter
  4. Aspirin alone

Explanation

Proximal deep vein thrombosis is treated with therapeutic anticoagulation, typically low-molecular-weight heparin or a direct oral anticoagulant, to prevent propagation and pulmonary embolism. Thrombolysis and caval filters are reserved for specific high-risk situations.

Question 14General Surgery (OMS B specialty training program content)

A 3-year-old boy has a 2 cm umbilical hernia that remains reducible. What is the most appropriate management?

  1. Injection sclerotherapy
  2. Observation until age 4 to 5 years Correct answer.
  3. Immediate surgical repair
  4. Truss application

Explanation

Most pediatric umbilical hernias close spontaneously by age 4 to 5 years, so observation is appropriate for a reducible defect smaller than 1.5 to 2 cm. Surgery is reserved for persistence beyond this age, incarceration, or a very large defect.

Question 15General Surgery (OMS B specialty training program content)

A 58-year-old man has a biopsy-proven adenocarcinoma of the sigmoid colon with no distant metastases. Which principle best guides the extent of surgical resection?

  1. En bloc resection with adequate margins and regional lymphadenectomy Correct answer.
  2. Resection of the tumor with a 1 cm margin only
  3. Resection limited to the mucosa
  4. Segmental resection without lymph node clearance

Explanation

Oncological resection of colon cancer requires en bloc removal of the tumor with adequate proximal and distal margins and clearance of the regional lymphatics to allow accurate staging and improve survival. Lymph node yield of at least 12 nodes is a quality indicator.

Question 16General Surgery (OMS B specialty training program content)

A 22-year-old man has a 1 cm indirect inguinal hernia. Which structure passes through the deep inguinal ring in an indirect hernia?

  1. Femoral canal
  2. Directly through the posterior wall medial to the inferior epigastric vessels
  3. Contents of the inguinal canal lateral to the inferior epigastric vessels Correct answer.
  4. Inferior epigastric vessels

Explanation

Indirect inguinal hernias enter the deep ring lateral to the inferior epigastric vessels and travel within the inguinal canal. Direct hernias protrude through the posterior wall medial to these vessels, and femoral hernias pass below the inguinal ligament.

Question 17General Surgery (OMS B specialty training program content)

A 35-year-old woman has a 2 cm thyroid nodule with a cytology result of follicular neoplasm (Bethesda IV). What is the most appropriate next step?

  1. Repeat fine-needle aspiration in one year
  2. Total thyroidectomy with central neck dissection
  3. Radioactive iodine therapy
  4. Diagnostic hemithyroidectomy for histological assessment Correct answer.

Explanation

Bethesda IV follicular neoplasm cannot be distinguished from follicular carcinoma on cytology because the diagnosis depends on capsular or vascular invasion. Diagnostic hemithyroidectomy provides the necessary histology.

Question 18General Surgery (OMS B specialty training program content)

A 70-year-old woman with atrial fibrillation on warfarin presents with a 12-hour history of acute mesenteric ischemia and peritoneal signs. What is the most appropriate management?

  1. Endoscopic evaluation of the small bowel
  2. Thrombolysis alone
  3. Immediate exploratory laparotomy with bowel resection Correct answer.
  4. Observation with serial abdominal examinations

Explanation

Acute mesenteric ischemia with peritoneal signs indicates transmural infarction, and immediate laparotomy with resection of non-viable bowel is required. Delay increases mortality from sepsis and short bowel syndrome.

Question 19General Surgery (OMS B specialty training program content)

A 45-year-old man has a 3 cm soft tissue mass in the thigh. Which finding most suggests a soft tissue sarcoma rather than a benign lipoma?

  1. Rapid growth and size greater than 5 cm Correct answer.
  2. Superficial location and mobility
  3. Long-standing stable size
  4. Homogeneous fat signal on MRI

Explanation

Soft tissue sarcomas are suggested by rapid growth, size greater than 5 cm, deep location, and heterogeneity on imaging. Benign lipomas are typically slow-growing, superficial, and homogeneous on MRI.

Question 20General Surgery (OMS B specialty training program content)

A 60-year-old man has a chronic anal fissure at the posterior midline. What is the most appropriate first-line surgical treatment after failed medical therapy?

  1. Seton placement
  2. Lateral internal sphincterotomy Correct answer.
  3. Anterior sphincterotomy
  4. Fissurectomy alone

Explanation

Lateral internal sphincterotomy is the standard surgical treatment for chronic anal fissure refractory to medical therapy, relieving sphincter spasm while preserving continence. Fissurectomy alone has higher recurrence.

Question 21General Surgery (OMS B specialty training program content)

A 55-year-old woman has a 5 cm pancreatic head mass with jaundice and weight loss. Which factor most strongly predicts resectability?

  1. Tumor confined to the pancreas without vascular encasement Correct answer.
  2. Involvement of the superior mesenteric artery
  3. Elevated CA 19-9 alone
  4. Presence of hepatic metastases

Explanation

Resectability of pancreatic head adenocarcinoma requires absence of distant metastasis and no arterial encasement (superior mesenteric artery or celiac axis). Tumors confined to the pancreas without vascular involvement are potentially resectable.

Question 22General Surgery (OMS B specialty training program content)

A 40-year-old man has recurrent peptic ulceration with diarrhea and multiple duodenal ulcers. Fasting gastrin is markedly elevated and a secretin stimulation test shows a paradoxical rise. What is the most likely diagnosis?

  1. Crohn's disease of the duodenum
  2. Antral G-cell hyperplasia
  3. Zollinger-Ellison syndrome Correct answer.
  4. Helicobacter pylori infection

Explanation

Markedly elevated fasting gastrin with a paradoxical rise after secretin stimulation is diagnostic of Zollinger-Ellison syndrome, usually due to a gastrinoma. H. pylori and antral G-cell hyperplasia do not produce a positive secretin test.

Question 23General Surgery (OMS B specialty training program content)

A 65-year-old man with cirrhosis has refractory ascites and a Child-Pugh score of 10. Which finding most strongly contraindicates creation of a transjugular intrahepatic portosystemic shunt?

  1. Splenomegaly
  2. Hepatic encephalopathy refractory to medical therapy Correct answer.
  3. Portal hypertension with ascites
  4. Recurrent variceal bleeding

Explanation

Severe or refractory hepatic encephalopathy is a major contraindication to TIPS because shunting increases delivery of ammonia-rich blood past the liver and worsens encephalopathy. TIPS is often used for refractory ascites or variceal bleeding in appropriate candidates.

Question 24General Surgery (OMS B specialty training program content)

A 30-year-old woman has a 2 cm thyroid nodule and cytology showing medullary thyroid carcinoma. Which additional investigation is most important?

  1. Serum calcitonin and RET proto-oncogene testing Correct answer.
  2. Serum thyroglobulin
  3. Anti-thyroid peroxidase antibodies
  4. Thyroid uptake scan

Explanation

Medullary thyroid carcinoma arises from parafollicular C cells and is associated with MEN 2 syndromes, so calcitonin levels and RET proto-oncogene mutation analysis are essential for diagnosis and family screening. Thyroglobulin is a marker for differentiated thyroid cancer.

Question 25General Surgery (OMS B specialty training program content)

A 50-year-old man has a gunshot wound to the abdomen with hemodynamic instability. Which is the most appropriate immediate management?

  1. Immediate exploratory laparotomy Correct answer.
  2. CT scan with contrast
  3. Focused assessment with sonography for trauma followed by observation
  4. Diagnostic peritoneal lavage

Explanation

Penetrating abdominal trauma with hemodynamic instability mandates immediate exploratory laparotomy to control hemorrhage and contamination. Imaging and diagnostic adjuncts are reserved for stable patients.

Question 26General Surgery (OMS B specialty training program content)

A 30-year-old man sustains a blunt splenic injury in a road traffic crash. He is hemodynamically stable and CT shows a grade III laceration with no active contrast extravasation. What is the most appropriate initial management?

  1. Immediate splenectomy
  2. Nonoperative management with monitoring in a facility capable of immediate laparotomy Correct answer.
  3. Splenic artery embolization in all grade III injuries
  4. Diagnostic peritoneal lavage to decide on laparotomy

Explanation

Hemodynamically stable patients with blunt splenic injury and no active contrast blush are managed nonoperatively with close monitoring, serial examination, and ready access to the operating theatre. Splenic salvage preserves immune function and avoids unnecessary surgery.

Question 27General Surgery (OMS B specialty training program content)

A 55-year-old woman has a firm, painless breast mass. Core biopsy shows invasive ductal carcinoma. Which receptor profile most directly determines eligibility for trastuzumab-based therapy?

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

Explanation

Trastuzumab is a monoclonal antibody directed against the HER2 receptor and is effective only in tumors with HER2 overexpression or amplification. Hormone receptors and Ki-67 guide endocrine therapy and prognostication but do not predict trastuzumab benefit.

Question 28General Surgery (OMS B specialty training program content)

A 68-year-old man has a 3 cm ulcerated lesion on the lower lip with palpable submental nodes. Biopsy shows squamous cell carcinoma. Which feature of this tumor most strongly predicts regional nodal metastasis?

  1. Depth of invasion and perineural involvement Correct answer.
  2. Male sex of the patient
  3. Tumor diameter of 3 cm
  4. Presence of keratin pearls on histology

Explanation

In cutaneous and lip squamous cell carcinoma, depth of invasion, perineural invasion, poor differentiation, and recurrent disease are the strongest predictors of nodal spread. Tumor size alone and histological keratinization are weaker predictors.

Question 29General Surgery (OMS B specialty training program content)

A 45-year-old man has a 2 cm mass in the tail of the pancreas found incidentally. He is asymptomatic. Endoscopic ultrasound with fine-needle aspiration is nondiagnostic. Which tumor marker is most useful in the workup of a suspected pancreatic neuroendocrine tumor?

  1. Alpha-fetoprotein
  2. CA 19-9
  3. Carcinoembryonic antigen
  4. Chromogranin A Correct answer.

Explanation

Chromogranin A is a neuroendocrine secretory protein and serves as the main circulating marker for pancreatic neuroendocrine tumors. It supports diagnosis and monitoring but is not specific enough to replace histology.

Question 30General Surgery (OMS B specialty training program content)

A 62-year-old man has a 6 cm infrarenal abdominal aortic aneurysm with a neck unsuitable for endovascular repair. He is otherwise fit. Which open operative approach gives the most direct exposure for proximal control?

  1. Bilateral subcostal incision
  2. Left thoracoabdominal incision
  3. Retroperitoneal flank incision Correct answer.
  4. Midline transperitoneal laparotomy

Explanation

A left retroperitoneal approach provides excellent exposure of the infrarenal aorta and facilitates proximal control without entering the peritoneal cavity. It is particularly useful in hostile abdomens and in obese patients.

Question 31General Surgery (OMS B specialty training program content)

A 24-year-old man has a firm 1 cm nodule in the tail of the epididymis. Ultrasound shows a solid lesion distinct from the testis. Which feature most reliably distinguishes an epididymal adenomatoid tumor from a malignancy?

  1. Presence of a hydrocele on ultrasound
  2. Elevated serum alpha-fetoprotein
  3. Benign histology with mesothelial origin on excision Correct answer.
  4. Bilateral involvement of the epididymis

Explanation

Adenomatoid tumors are the most common benign tumors of the epididymis and arise from mesothelial cells; diagnosis is confirmed histologically after excision. Tumor markers are normal and imaging alone cannot exclude malignancy.

Question 32General Surgery (OMS B specialty training program content)

A 58-year-old woman has a 4 cm proximal humerus metastasis from breast cancer with intractable pain despite radiotherapy. Which surgical option offers the best durable pain control and function?

  1. Intramedullary nailing with cement augmentation Correct answer.
  2. Shoulder arthrodesis
  3. Above-elbow amputation
  4. Curettage and bone grafting alone

Explanation

For a painful proximal humeral metastasis with structural compromise, intramedullary nailing with cement augmentation stabilizes the bone, relieves pain, and preserves limb function. Amputation is reserved for uncontrollable complications.

Question 33General Surgery (OMS B specialty training program content)

A 35-year-old woman has a 3 cm simple hepatic cyst found on ultrasound. She is asymptomatic with normal liver function. What is the most appropriate management?

  1. Laparoscopic deroofing
  2. Observation without intervention Correct answer.
  3. Percutaneous aspiration and sclerotherapy
  4. Formal hepatic resection

Explanation

Asymptomatic simple hepatic cysts require no treatment; they are benign and rarely cause complications. Intervention is reserved for symptomatic cysts, rapid enlargement, or diagnostic uncertainty.

Question 34General Surgery (OMS B specialty training program content)

A 70-year-old man has a chronic nonhealing ulcer on the medial malleolus with surrounding hyperpigmentation and edema. Ankle-brachial index is 0.7. Which factor most strongly impairs healing in this venous ulcer?

  1. Patient age
  2. Coexisting arterial insufficiency Correct answer.
  3. Chronic venous hypertension
  4. Presence of lipodermatosclerosis

Explanation

An ankle-brachial index of 0.7 indicates significant arterial insufficiency, which compromises perfusion and impairs healing of a venous ulcer. Compression therapy, the mainstay of venous ulcer treatment, must be used cautiously in this setting.

Question 35General Surgery (OMS B specialty training program content)

A 28-year-old woman has a 2 cm firm mass in the submandibular region. Fine-needle aspiration suggests pleomorphic adenoma. Which surgical principle is most important to prevent recurrence?

  1. Observation with serial ultrasound
  2. Removal with a margin of normal surrounding gland tissue Correct answer.
  3. Enucleation of the tumor capsule
  4. Incision and drainage of the gland

Explanation

Pleomorphic adenomas are prone to recurrence if the capsule is ruptured, so excision with a cuff of normal gland tissue is recommended. Enucleation risks spillage of tumor cells and multifocal recurrence.

Question 36General Surgery (OMS B specialty training program content)

A 50-year-old man has a 5 cm mass in the left lobe of the liver with imaging features of hepatocellular carcinoma and a background of hepatitis B cirrhosis. Which finding most strongly precludes curative resection?

  1. Portal vein invasion by tumor thrombus Correct answer.
  2. Tumor diameter of 5 cm
  3. Child-Pugh class A cirrhosis
  4. Serum alpha-fetoprotein of 200 ng/mL

Explanation

Macroscopic portal vein invasion by tumor thrombus indicates advanced disease with poor prognosis and generally precludes curative resection or transplantation. Tumor size and elevated alpha-fetoprotein alone are less decisive in a patient with preserved liver function.

Question 37General Surgery (OMS B specialty training program content)

A 40-year-old woman has a 1 cm papillary thyroid microcarcinoma confined to one lobe with no nodal disease. She has no history of radiation and no family history. What is the most appropriate management?

  1. Total thyroidectomy with central neck dissection
  2. Radioactive iodine ablation without surgery
  3. Lobectomy alone
  4. Active surveillance with serial ultrasound Correct answer.

Explanation

For low-risk papillary thyroid microcarcinoma without nodal or extrathyroidal disease, active surveillance is an accepted option supported by contemporary guidelines. Surgery remains an alternative but is not mandatory for every microcarcinoma.

Question 38General Surgery (OMS B specialty training program content)

A 65-year-old man has a 3 cm renal mass with a level II inferior vena cava thrombus. He is otherwise fit. Which factor most strongly determines operability and surgical planning?

  1. Presence of a contralateral renal cyst
  2. Serum creatinine level
  3. Cranial extent of the thrombus Correct answer.
  4. Tumor histologic subtype

Explanation

The cranial extent of the tumor thrombus determines the operative approach, the need for vascular bypass or cardiopulmonary bypass, and the overall surgical risk. Level II thrombus remains below the hepatic veins and is generally resectable without bypass.

Question 39General Surgery (OMS B specialty training program content)

A 60-year-old woman has a 3 cm mass in the body of the stomach. Endoscopic ultrasound shows a hypoechoic lesion arising from the muscularis propria, and biopsy confirms gastrointestinal stromal tumor. Which feature best predicts malignant potential?

  1. Patient age at diagnosis
  2. Tumor size and mitotic rate Correct answer.
  3. Tumor location within the stomach
  4. Presence of Helicobacter pylori

Explanation

Risk stratification of gastrointestinal stromal tumors is based on tumor size and mitotic index, with anatomic site as a secondary modifier. These factors guide the decision for adjuvant imatinib therapy.

Question 40General Surgery (OMS B specialty training program content)

A 45-year-old man has a 2 cm soft tissue mass in the thigh. Which finding on imaging most suggests a benign lipoma rather than a liposarcoma?

  1. Homogeneous fat signal with thin septa Correct answer.
  2. Nodular enhancement after contrast
  3. Thick irregular septa within the mass
  4. Peritumoral edema

Explanation

A benign lipoma shows homogeneous fat signal on MRI with thin septa and no significant enhancement. Thick septa, nodular enhancement, and peritumoral edema raise concern for atypical lipomatous tumor or liposarcoma.

Question 41General Surgery (OMS B specialty training program content)

A 55-year-old man has a 4 cm descending colon adenocarcinoma with no metastases. During laparoscopic resection, which principle most reduces the risk of anastomotic recurrence?

  1. Placement of an intraperitoneal drain
  2. Routine intraoperative colonic lavage
  3. Use of a stapled rather than handsewn anastomosis
  4. Ligation of the inferior mesenteric artery at its origin with adequate lymphadenectomy Correct answer.

Explanation

High ligation of the inferior mesenteric artery with complete mesocolic excision and adequate lymphadenectomy improves oncologic clearance and reduces local recurrence. Anastomotic technique and lavage do not substitute for adequate oncologic resection.

Question 42General Surgery (OMS B specialty training program content)

A 70-year-old woman has a 5 cm pancreatic head mass with jaundice and weight loss. Which factor most strongly predicts resectability?

  1. Tumor differentiation on biopsy
  2. Absence of superior mesenteric artery encasement Correct answer.
  3. Presence of a biliary stent
  4. Serum CA 19-9 level

Explanation

Resectability of pancreatic head cancer depends on the relationship of the tumor to the superior mesenteric artery and vein and the portal vein. Arterial encasement indicates locally advanced, unresectable disease.

Question 43General Surgery (OMS B specialty training program content)

A 32-year-old woman has a 1 cm firm, mobile mass in the right breast. Ultrasound shows a well-circumscribed hypoechoic lesion, and core biopsy shows fibroadenoma. She is asymptomatic. What is the most appropriate management?

  1. Radiotherapy to the breast
  2. Bilateral mastectomy
  3. Excisional biopsy
  4. Observation with clinical follow-up Correct answer.

Explanation

A biopsy-proven fibroadenoma that is concordant with imaging and asymptomatic can be observed safely with clinical follow-up. Excision is reserved for symptomatic, growing, or discordant lesions.

Question 44General Surgery (OMS B specialty training program content)

A 30-year-old woman has a 2 cm thyroid nodule with cytology showing medullary thyroid carcinoma. Which additional investigation is most important before surgery?

  1. Thyroid peroxidase antibodies
  2. Serum thyroglobulin
  3. Serum calcitonin and RET proto-oncogene testing Correct answer.
  4. Radioactive iodine uptake scan

Explanation

Medullary thyroid carcinoma arises from parafollicular C cells, and calcitonin is the key tumor marker. RET proto-oncogene testing identifies hereditary multiple endocrine neoplasia type 2, which changes the extent of surgery and triggers family screening.

Question 45General Surgery (OMS B specialty training program content)

A 40-year-old man has recurrent peptic ulceration with diarrhea and multiple duodenal ulcers. Fasting gastrin is markedly elevated. Which localizing investigation is most appropriate after biochemical confirmation?

  1. Computed tomography of the abdomen with somatostatin receptor imaging Correct answer.
  2. Upper gastrointestinal endoscopy with biopsy
  3. Serum chromogranin A measurement
  4. Barium meal study

Explanation

Biochemically confirmed Zollinger-Ellison syndrome requires tumor localization, and multiphasic CT combined with somatostatin receptor imaging is the preferred approach. Endoscopy confirms ulcers but does not localize the gastrinoma.

Question 46General Surgery (OMS B specialty training program content)

A 55-year-old woman has a 5 cm mass in the pancreatic body with imaging showing abutment of the superior mesenteric artery of less than 180 degrees without encasement. Which classification best describes this tumor?

  1. Metastatic
  2. Resectable
  3. Borderline resectable Correct answer.
  4. Locally advanced unresectable

Explanation

Tumor abutment of the superior mesenteric artery of less than 180 degrees without encasement defines borderline resectable disease. Such tumors may be treated with neoadjuvant therapy before attempted resection.

Question 47General Surgery (OMS B specialty training program content)

A 45-year-old man has hematemesis and melena with a known history of alcohol abuse. He is tachycardic and hypotensive. After initial resuscitation, which step is most appropriate before endoscopy?

  1. Immediate surgical portosystemic shunt
  2. Prophylactic antibiotic administration and vasoactive therapy Correct answer.
  3. Balloon tamponade as first-line treatment
  4. Transjugular intrahepatic portosystemic shunt

Explanation

In suspected variceal hemorrhage, resuscitation should be accompanied by prophylactic antibiotics and vasoactive drugs such as octreotide before endoscopy, which improves outcomes and reduces mortality.

Question 48General Surgery (OMS B specialty training program content)

A 60-year-old man has a 3 cm mass in the right colon with biopsy-proven adenocarcinoma, and staging shows no distant metastases. He undergoes right hemicolectomy. Which factor most strongly determines the need for adjuvant chemotherapy?

  1. Presence of a synchronous polyp
  2. Lymph node status Correct answer.
  3. Tumor location within the right colon
  4. Patient's body mass index

Explanation

Nodal involvement is the strongest determinant of recurrence risk and the principal indication for adjuvant chemotherapy in resected colon cancer. Tumor location and body mass index do not drive this decision.

Question 49General Surgery (OMS B specialty training program content)

A 35-year-old woman has a 2 cm thyroid nodule with cytology showing follicular neoplasm. She undergoes diagnostic lobectomy, and histology shows capsular invasion without vascular invasion. Which factor most strongly predicts recurrence?

  1. Presence of a follicular adenoma in the opposite lobe
  2. Serum thyroid-stimulating hormone level
  3. Patient's family history of goiter
  4. Degree of capsular invasion and tumor size Correct answer.

Explanation

In follicular thyroid carcinoma, the extent of capsular invasion and tumor size determine the risk of recurrence and guide completion thyroidectomy and radioiodine decisions. Vascular invasion further increases risk.

Question 50General Surgery (OMS B specialty training program content)

A 45-year-old man is brought to the emergency department after a stab wound to the left anterior chest. He is hypotensive with distended neck veins and absent breath sounds on the left. Which is the most appropriate immediate intervention?

  1. Urgent CT scan of the chest with contrast
  2. Immediate tube thoracostomy in the fifth intercostal space at the anterior axillary line
  3. Emergency department thoracotomy
  4. Needle decompression in the second intercostal space at the midclavicular line Correct answer.

Explanation

The presentation of hypotension, distended neck veins, and absent breath sounds after penetrating chest trauma indicates tension pneumothorax, a clinical diagnosis requiring immediate needle decompression before any imaging. Decompression is followed by definitive tube thoracostomy. Delay for imaging risks cardiovascular collapse.