SMLE Surgery 3 — Questions and Answers
Question 1: A 30-year-old male involved in a motor vehicle accident presents with hypotension and a positive FAST examination. Where is the most likely site of fluid accumulation detected by FAST?
- Pericardial space
- Morrison's pouch (hepatorenal recess) (Correct answer)
- Left paracolic gutter
- Pelvis
Correct answer: Morrison's pouch (hepatorenal recess)
Morrison's pouch (hepatorenal recess) is the most dependent part of the peritoneal cavity in the supine position and is the most common site where free fluid accumulates in blunt abdominal trauma. It is the most sensitive FAST window.
Question 2: A 45-year-old female presents with a thyroid nodule. Fine needle aspiration cytology (FNAC) shows Bethesda category V (suspicious for malignancy). What is the recommended management?
- Repeat FNAC in 6 months
- Lobectomy or total thyroidectomy (Correct answer)
- Radioactive iodine therapy
- Observation with serial ultrasound
Correct answer: Lobectomy or total thyroidectomy
Bethesda category V carries a malignancy risk of 60-75%. Surgery (lobectomy for diagnostic purposes or total thyroidectomy) is recommended. The extent of surgery depends on risk factors, nodule size, and patient preference.
Question 3: A patient develops deep vein thrombosis (DVT) on postoperative day 5 after a total hip replacement. According to Virchow's triad, which factor is most directly related to this patient's risk?
- Endothelial injury from surgery
- Venous stasis from immobilisation (Correct answer)
- Hypercoagulability from factor V Leiden
- Dehydration from fasting
Correct answer: Venous stasis from immobilisation
While all three components of Virchow's triad (stasis, endothelial injury, hypercoagulability) contribute, venous stasis from postoperative immobilisation is the most significant modifiable risk factor in this setting. Early mobilisation and pharmacological prophylaxis are essential.
Question 4: A 70-year-old male presents with left lower quadrant pain, fever, and leucocytosis. CT shows pericolic fat stranding and a small abscess around the sigmoid colon. What is the initial management?
- Emergency sigmoid colectomy
- IV antibiotics and CT-guided percutaneous drainage (Correct answer)
- Colonoscopy
- Oral antibiotics and outpatient follow-up
Correct answer: IV antibiotics and CT-guided percutaneous drainage
Complicated diverticulitis with a small abscess (Hinchey stage I-II) is initially managed with IV antibiotics and CT-guided percutaneous drainage if the abscess is accessible (>3 cm). Surgery is reserved for failed conservative management or complications.
Question 5: During a right hemicolectomy, which vessel is ligated at its origin to achieve adequate lymph node clearance for caecal carcinoma?
- Superior mesenteric artery
- Ileocolic artery (Correct answer)
- Middle colic artery
- Inferior mesenteric artery
Correct answer: Ileocolic artery
For caecal carcinoma, the ileocolic artery is the primary feeding vessel and is ligated at its origin from the superior mesenteric artery to achieve central lymph node clearance, which is essential for adequate oncological resection.
Question 6: A 28-year-old woman presents with a painful, fluctuant swelling near the anus at the 5 o'clock position. What is the most appropriate management?
- Oral antibiotics and sitz baths
- Incision and drainage (Correct answer)
- Fistulotomy
- MRI pelvis
Correct answer: Incision and drainage
A fluctuant, painful perianal swelling is a perianal abscess requiring incision and drainage under local or general anaesthesia. Antibiotics alone are insufficient as the pus needs to be drained. Follow-up is needed to watch for fistula formation.
SMLE Surgery 3
A 30-year-old male involved in a motor vehicle accident presents with hypotension and a positive FAST examination.
Where is the most likely site of fluid accumulation detected by FAST?