# Exam Recall Series (NEET-PG '25) - Surgery

https://www.youtube.com/watch?v=85A8WD3AdGg

[00:00] Hello everyone, I'm Dr. Dhan Kandelwal, your Maro surgery faculty, and I'll be discussing the recently conducted knee PG exam surgery questions.
[00:09] Now these are the questions which we've recalled based on what students have told us in various forums.
[00:13] So there might be some uh options which might be a bit different.
[00:18] If they are, please do write them in the comment section and we'll be happy to correct them.
[00:21] Now my analysis of the paper was uh that it was an easy to an moderate paper, more towards the side of easy.
[00:30] And given the type of paper which had come, you please expect that there'll be very high cut offs this time as well.
[00:38] Also that means one more thing that with every one question correct or every one question wrong, ranks are going to fluctuate quite a lot.
[00:47] So maybe one question wrong can drop your rank by thousands.
[00:50] Right?
[00:53] So be ready for that and you would see that in a very short uh range of uh scores all the important ranks would be decided.
[01:00] Having said that.
[01:03] Let's focus on the questions which were asked.
[01:05] I've divided them into sections.
[01:07] The first I'm going to talk about endocrine surgery questions.
[01:11] This was a question with a patient with hypertensive episodes and an MRI showing a supra renal mass is planned for surgery.
[01:18] Again, like I've been saying, whenever you given such questions please try to visualize the key words in your mind.
[01:26] So the key words are hypertensive episodes, mass, 24-hour urine showing metanephrine elevated levels.
[01:33] So I think with this the diagnosis is extremely clear to us.
[01:38] We are dealing with a case of pheochromocytoma.
[01:43] Now pheochromocytoma, you know these patients, the problem is that they can land up in hypertensive crisis which is why we need to control the blood pressure in them.
[01:55] Now you know in these patients that we always have to achieve alpha blockade followed by beta blockade.
[02:04] Right.
[02:07] We never do beta blockade first because if you do beta blockade first that would lead to unopposed alpha action that would lead to vasoconstriction because alpha would lead to vasoconstriction and that can trigger a hypertensive crisis.
[02:21] So we need either a combined blockade or alpha followed by beta blockade.
[02:24] And in these patients we use phoxyenzamine in these patients.
[02:29] Also the traditional teaching is that uh you can give alpha blockade first right and you continue to increase the dose till postural hypotension develops right till the patient starts developing postural hypotension.
[02:47] Now then we can add a beta blocker if tachicardia is there.
[02:56] If tachicardia is there then you can add a beta blocker.
[02:59] This is the traditional teaching.
[03:00] You can give a combined blockade also.
[03:02] The correct answer here.
[03:05] Is phoxybenzamine.
[03:09] The next question, there were two questions from thyroid conditions.
[03:13] One was a complication of the surgery; one was a diagnosis which you had to make.
[03:17] A malignant neck swelling was surgically removed from a patient and the image is shown below.
[03:21] What will the patient likely present with 2 to 3 days after the procedure?
[03:27] You can see here that both the lobes of thyroid and the isthmus is there.
[03:32] So this is most likely a specimen of total thyroidectomy which has been performed for a condition of thyroid.
[03:41] Now they are asking which thyroid complication would manifest 2 to 3 days later.
[03:45] Right.
[03:46] Deviation of the angle of the mouth is usually not seen with thyroid.
[03:50] This would be seen with marginal mandibular nerve which is usually in salivary gland tumors or salivary gland surgery.
[03:57] This has been asked many times in the exam.
[03:59] Marginal mandibular nerve or the ramus mandibularis leads to deviation of the.
[04:05] Angle of the mouth.
[04:07] Hoarseness of voice which is due to RLN or ELN injury.
[04:11] This would present immediately after surgery.
[04:13] Migratory thrombophlebitis again is not a complication of thyroid surgery.
[04:18] So even by elimination you can reach to the answer of carpopedal spasm.
[04:21] And we know that hypoparathyroidism which gives rise to hypocalcemia and predisposes to carpopedal spasm usually manifests 48 to 72 hours later.
[04:35] So one of the complications is hypoparathyroidism.
[04:36] And we know that the most common cause of hypoparathyroidism is vascular insult to the parathyroid gland during surgery.
[04:44] And what is the blood supply of the parathyroid glands that has also been asked in the exam?
[04:51] It is from the branches of the inferior thyroid artery.
[04:53] So vascular insult to the parathyroid glands leads to hypoparathyroidism.
[05:00] And as you can see the symptoms manifest 48 to 72 hours later the earliest.
[05:06] Symptom is peroral numbness.
[05:08] Patient would say that I'm feeling numb around the mouth.
[05:10] Then there is tingling and paristhesas.
[05:14] Then there can be tetany and you can have the classical two signs.
[05:16] You can have carpedal spasm.
[05:18] Right?
[05:18] Carpoed spasm which is known as the Trousseau sign and you can even have the Chvostek sign.
[05:27] Chvostek sign is when you tap over the facial nerve.
[05:30] When you tap over the facial nerve there is facial spasm and both these signs occur due to neuromuscular hyperexitability.
[05:43] The next question was a 45-year-old man with a midline neck swelling comes with odinophagia and dyspnea.
[05:50] The swelling showed cells with variations in size and morphology.
[05:53] A amyloid deposit was seen and the swelling was positive for IHC markers like TTF-1, synaptophysin and chromogranin.
[06:03] What is the diagnosis?
[06:05] So I think so there's just one key word.
[06:07] Which I'm sure has been covered in surgery and pathology both, that amyloid rich stroma is a classical feature of medullary thyroid cancer.
[06:20] So wherever you see FNAC shows amyloid or the biopsy specimen after surgery shows amyloid, we know we are dealing with a medullary thyroid cancer.
[06:28] Again a straightforward question.
[06:30] Uh, I don't think so this was this could have been much easier than this if you could identify the word amyloid.
[06:38] We know papillary thyroid cancer is the most common thyroid cancer and this has the best prognosis as well.
[06:47] And the key words which you will usually see with papillary are radiation exposure.
[06:54] Follicular is the second most common thyroid cancer.
[06:56] And the classical keyword which we see with follicular is a pre-existing thyroid swelling or a multinodular goiter and a rapid increase in size.
[07:08] So medullary thyroid cancer we know it arises from the parafollicular C cells which are derived from the neural crest.
[07:16] And there is an intermediary body known as ultimobranchial body which will give rise to these cells and these cells secrete the tumor marker for this tumor that is calcitonin.
[07:27] It can be sporadic or familial.
[07:29] Familial we know is seen with MEN 2 syndrome and the most aggressive medullary thyroid cancer seen with MEN 2B.
[07:37] Patients will come with a thyroid swelling or they can come with diarrhea, sweating and hypertension as well and it can spread both via lymphatic and hematogenous routes.
[07:48] Hematogenous spread is most common to the liver.
[07:51] And the classical slide you can see when you see the slide you will see this pinkish material and this pinkish material is amyloid and this is how we clinch the diagnosis of medullary thyroid cancer.
[08:06] This is a question which I think so has been asked in all the exams right from.
[08:10] FMG to INIC to nepg.
[08:13] This is a patient who's come with a breast lump and the biopsy confirms it to be cancer.
[08:18] They had given a clinical image and we know this sign is the peau d'orange sign, right, this reddish appearance of the skin in a patient with cancer.
[08:27] This is peau d'orange and this occurs due to involvement of subdermal lymphatics.
[08:31] Right?
[08:35] This occurs due to involvement of the subdermal or the superficial lymphatics.
[08:39] Now if only this is present in less than one-third, right, then we just say it is skin involvement, right, we're going to say T4B.
[08:47] But if it is present in more than one-third of the skin of the breast, then we call it inflammatory breast cancer or T4D.
[08:59] So as the students recollect, this was involving more than one-third of the breast.
[09:04] And if it involves more than one-third of the breast, this is going to be T4D or inflammatory breast cancer.
[09:13] That would be the correct answer.
[09:15] We know that inflammatory breast cancer is the most aggressive type of breast tumor.
[09:23] The TNM staging of breast and oral cancer is extremely important for the exam and you should remember it.
[09:27] T1 is carcinoma in situ.
[09:31] This only includes DCIS and Paget's.
[09:35] We know that lobular carcinoma in situ is no longer an in situ lesion.
[09:39] T1 is less than or equal to 2 cm.
[09:43] T2 is 2 to 5.
[09:45] T3 is more than five.
[09:47] Most of the questions in all the exams are asked regarding T4.
[09:49] T4A is involvement of chest wall.
[09:53] And I want you to remember here that chest wall would only be the ribs, serratus anterior and the intercostal muscles.
[10:03] We don't include the pectoral muscle involvement here.
[10:06] T4B, like I said, is involvement of skin which is either through direct infiltration, ulceration.
[10:15] Pudorange or satellite nodules.
[10:19] T4 C is A + B and T4D is inflammatory cancer which I've told you is involving more than one/ird of the breast skin.
[10:29] So those are the questions regarding endocrine surgery.
[10:31] Moving on to the git questions.
[10:33] A 45year-old male comes with a female or male I think.
[10:37] So some said female, some said male.
[10:40] So it can be made accordingly.
[10:43] Whatever uh you think was correct, please do let us know in the options as well.
[10:46] Presented with difficulty in swallowing and weight loss.
[10:50] X-ray gives the findings along with bronchiactic changes.
[10:54] What is the investigation of choice?
[10:57] So in such questions you know your mind is immediately drawn to the image and all of us know this image of a berium swallow which is showing showing gradual tapering.
[11:09] We know this is the bird's beak appearance and this bird's beak appearance is seen in acalasia cardia.
[11:17] Which we know is the most common motility disorder these days of the esophagus.
[11:23] It is the most common motility disorder and we know that for motility disorders the investigation of choice is high resolution manometry.
[11:31] Right?
[11:31] Manometry would be done to clinch the diagnosis of this condition and that we can easily make out in these patients because of the bird's beak appearance.
[11:41] Right?
[11:43] You can see the gradual tapering.
[11:45] Also in these patients an endoscopy should always be done to rule out cancer.
[11:50] Right?
[11:50] To rule out cancer we should do an endoscopy.
[11:52] But to confirm or clinch the diagnosis it would rely on the manometric findings.
[11:59] You know echalasia means failure to relax and the lower esophadial sphincter fails to relax in these patients.
[12:06] There can be various types of echalasia.
[12:08] Primary echlesia is due to loss of ganglion cells.
[12:10] Secondary this has also been asked is secondary to shaga's disease which is due to trapanoo.
[12:17] Vigorous achalasia is rapidly progressive.
[12:19] Pseudoachalasia is seen in malignancy, which is why we should always do an endoscopy, like I said, to rule out a cancer or a growth which might be mimicking achalasia.
[12:29] And AAA is Allgrove syndrome, in which achalasia can also be seen.
[12:38] Patients come with dysphagia, weight loss, which is what was written in the question stem, and regurgitation.
[12:45] Due to regurgitation, there can be aspiration; that is why bronchiectatic changes were also mentioned in the question.
[12:54] And we know that initially the dysphagia is more to liquids than to solids, and then it becomes solids equal to liquids.
[13:03] So this is the bird's beak appearance, and you can see the gradual tapering in the bird's beak appearance.
[13:10] Another question which has been asked in the NEET PG exam, this was around 3 or 4 years back, was regarding one of the types of achalasia.
[13:16] Now according to the
[13:18] Chicago classification, which is the classification for motility disorders, there are three types of acalasias.
[13:24] Type one is the classicalia.
[13:27] You don't need to remember a lot of details because they will mention the findings.
[13:30] Just some key words I want you to remember.
[13:34] There are 100% failed peristalsis with DCI.
[13:37] DCI is distal contractile index.
[13:41] This is one of the values which we study when we are doing manometry.
[13:45] So there is failed paristelsis in the body of the esophagus.
[13:50] DCI is less than 100.
[13:53] Right?
[13:55] Type two is with esophasial compression.
[13:57] So again 100% failed perists and it will be mentioned in the question stem pan esophasial pressurization with more than 20% of swallows.
[14:05] Type three is [ __ ].
[14:08] This is what was asked in the nepg exam and you can see here no normal peristalis and they will mention premature [ __ ] contractions right?
[14:18] With a DCI more than 450.
[14:21] And another question which has been asked in INICT is that it is for type three achalasia that the surgery which is known as POEM right which is peroral endoscopic myotomy.
[14:32] This is useful for type three achalasia.
[14:36] Right.
[14:40] Works best in type three achalasia and conditions.
[14:42] Which of the following image depicting bile duct injury is shown and which type is depicted on the Strasberg classification?
[14:51] So Strasberg has been asked previously in INIC.
[14:53] In they had asked about type C Strasberg.
[14:56] Here they are showing a leak from the cystic duct stump.
[14:59] Right?
[15:01] They're showing a leak from the cystic duct stump.
[15:03] And this would be a right.
[15:06] This is going to be a type A kind of a injury.
[15:09] You can see that cystic duct leak or leaks from small ducts in the liver bed is Strasberg A.
[15:18] Occlusion of aberrant right.
[15:21] Hippatic duct.
[15:21] Right.
[15:21] So aberant right hippatic duct if it is occluded it is B.
[15:26] If there is a leak from an aberant right hippatic duct, it will become C.
[15:28] This is what was asked in INICT.
[15:31] A lateral injury to the CBD less than 50% circumference is D.
[15:36] And other injuries are classified from E1 to E5.
[15:40] These E1 to E5 have not been asked in the exam.
[15:43] You need to remember A to D of Strasburg as now it has been asked in two exams.
[15:48] The other classification is the bismouth classification.
[15:51] Now whenever we are suspecting a leak another question which is asked in the exam is how will you confirm the diagnosis of a leak if you're suspecting a leak post the surgery will it be MRCP which is magnetic resonance colangio pancreatic or ERCP which is endoscopic retrograde colangopancotic?
[16:16] And a lot of times students get confused here.
[16:18] Please remember to confirm the diagnosis we first do a noninvasive.
[16:23] Modality that is MR MRCP magnetic resonance collangio pancreatic.
[16:28] And here you can see that this die is leaking out here right there is a leak which can be seen.
[16:34] So the diagnosis will be confirmed by MRCP.
[16:36] ERCP can be done if we want to do a stenting across that leak or a cut.
[16:42] Right?
[16:42] But we will not do ERCP first.
[16:44] To confirm, we will do MRCP.
[16:48] Please remember that.
[16:52] This was a classical question.
[16:52] If you've been to your MBPS wards, if you presented a case of an abdominal lump or obstructive jaundice, you could have answered this very easily.
[16:59] There is an elderly male coming with epigastric pain, anorexia, weight loss, right?
[17:03] And jaundice since 2 years.
[17:07] He has scratch marks all over the body.
[17:10] What does that imply?
[17:12] That this is type of an obstructive jaundice, which is why itching or scratch marks are there.
[17:15] And the key word is gallbladder was palpable, smooth and non-tender.
[17:23] Now we know, we've read about perampary cancers.
[17:27] As we know perampillary cancers are a group of four cancers which arise within 2 cm of the ampula and all of these cancers have a similar presentation.
[17:40] Right, they present with obstructive jaundice with a palpable gallbladder.
[17:45] Right, present with obstructive jaundice with a palpable gallbladder and out of these four the most common is carcinoma head of pancreas.
[17:56] So if you have a tumor here, this is carcinoma head of pancreas.
[18:01] This is going to block the CBD, right?
[18:04] So that is why the patient is having obstructive jaundice and when it blocks the CBD, the CBD will be dilated and the gallbladder will be distended.
[18:14] This satisfies the kverier's law, right?
[18:17] This satisfies the kverzia's law and that is why you will see this kind of a finding in a patient with carcinoma.
[18:26] Head of pancreas.
[18:30] Now why can't this be CHB?
[18:30] CHB is going to come with a gallbladder mass, right?
[18:33] Gallbladder mass does not retain the shape of gallbladder.
[18:42] Does not retain the pyriform shape of the gallbladder.
[18:48] Does not retain shape of gallbladder and in GB mass jaundice is in GB cancer jaundice is a late finding whereas in patients with obstructive jaundice due to periampullary cancers jaundice is an early finding.
[19:02] Hepatocellular cancer will not come with a palpable GB.
[19:07] Again, jaundice is going to be late.
[19:09] And choledocholithiasis, you know, choledocholithiasis means that a stone which was in the gallbladder.
[19:16] If this stone comes here and it blocks the CBD, this can also cause jaundice.
[19:22] But it will not cause a palpable gallbladder.
[19:25] No palpable.
[19:28] Why?
[19:31] Because before the stone comes down, it would have caused inflammatory fibrosis.
[19:35] It would have caused shrinking of the gallbladder, fibrosis of the gallbladder, which is why you're not going to see a dilated or a descended GB here.
[19:45] Fine.
[19:45] So, this is a classical MBS case round question.
[19:50] I'm sure everyone would have got this correct.
[19:56] Which type of anal fistula is seen in the image here?
[19:59] So you know there is a Parks classification.
[20:01] This has been asked many times in the exam and this is the internal sphincter.
[20:05] This is the external sphincter.
[20:07] You can see that the track here is running is approximately at the level of the dentate line and is running between the two sphincters.
[20:15] So this is inter sphincteric type which is the most common type of perianal fistula.
[20:25] Now you know that the investigation of choice here is MRI.
[20:27] It is an MRI.
[20:27] MR.
[20:31] fishog MRI is the investigation of
[20:33] choice and based on that you will have
[20:35] the parks classification. Like I've said
[20:38] if the tract runs in between the two
[20:40] sphincters that is inter sphincteric.
[20:42] This is the most common type.
[20:46] Transferric is when it traverses both
[20:48] the sphincter then it is transfinctic.
[20:51] Supra sphincteric is when it goes above
[20:53] the sphincters and extras sphincteric is
[20:56] a high fistula which is going through
[20:59] the levator ni and it is opening above
[21:03] the ano rectal ring. It is a high
[21:05] fistula and these are the fish where you
[21:09] know we cannot we should do siton
[21:11] treatment. We should not do a fishotomy
[21:13] fishctomy because that can give rise to
[21:16] incontinence. So these facial we manage
[21:19] with high fish we manage with siton.
[21:24] In a patient with Ial resection she
[21:27] comes with fatigue and hemoglobin is 8
[21:30] g% MCV is 110.
[21:34] Peripheral smear shows macroitic anemia.
[21:38] Right? This is a simple question. We
[21:40] know that in the terminal illium is
[21:43] where B12 will be maximally absorbed.
[21:47] Right? And so if there is terminal ilial
[21:50] resection or ilial resection then it
[21:53] will lead to B12 deficiency. Similarly
[21:56] if gastric resection is done intrinsic
[21:59] factor is reduced that can also give
[22:02] rise to B12 deficiency and
[22:04] megalloplastic anemia.
[22:06] So here the correct answer is going to
[22:08] be B12 deficiency. That is the correct
[22:11] answer in this question. This has been
[22:13] asked both as ial resection also and
[22:16] postgastric resection. Which is why you
[22:19] know that after any biatric surgery that
[22:22] is weight loss surgery or gastric
[22:24] resections iron deficiency anemia is the
[22:28] most common and one more type of anemia
[22:31] which can occur is B12 deficiency
[22:33] anemia. There
[22:37] another GI question. A 42 year old lady
[22:40] has a non-specific right upper quadrant
[22:42] pain. Again the tumor is excised and the
[22:44] cross-section is shown below. So you can
[22:47] see this cross-section of the tumor
[22:49] shows a central stelate scar and we know
[22:53] central stelate scar in liver is seen in
[22:56] focal nodular hyperplasia. If it was
[22:59] kidney central celate scar in the kidney
[23:02] is seen in enkoytoma
[23:06] encoytoma or chromophobc but in the
[23:10] liver it is seen in focal nodular
[23:13] hyperplasia
[23:14] usually focal nodular hyperlasia or FNH
[23:17] we don't resect these tumors we keep
[23:19] them under observation
[23:21] and the ideology is decreased blood
[23:23] supply these focal nodular hypoplasia
[23:27] lesions have hippatosytes and bile duct
[23:30] structures and cuffer cells which is why
[23:33] they will show a hot spot on technesium
[23:36] 99 scanning. When you do a CT you are
[23:40] going to see this central stelate scar.
[23:43] Now this central celate scar is nothing
[23:44] but a dilated arterial a dilated central
[23:47] arterial which is there which is
[23:49] visualized as a central stilate scar and
[23:52] the management is conservative. We are
[23:54] usually not resecting these FNH lesions.
[23:57] They are benign and they don't show
[23:59] malignant conversion.
[24:02] A patient presents with carcinoma near
[24:04] the anal opening. Which of the following
[24:07] lymph nodes are most likely to be
[24:09] involved here? Now you know that
[24:15] there is the anal verge through which
[24:18] fecal matter will come out. The anal
[24:20] verge.
[24:22] Then 2 to 2 and 1/2 cm above the anal
[24:26] verge is the dentate line
[24:29] which is the watershed region and again
[24:33] 2 and 1/2 cm above that is the anorrect
[24:36] rectal ring where the levator ni slings
[24:39] around the rectum rectum and the anal
[24:42] canal right so the dentate line below
[24:45] the dentate line below the dentate line
[24:48] you know there is somatic
[24:51] nervous supply which That is why pain is
[24:53] felt. That is why if you have to do any
[24:56] banding of hemorrhoids or sclerotherapy,
[24:57] we do it above the dentate line or we
[25:00] fire the stapler above the dentate line.
[25:02] Right? Also below the dentate line, it
[25:05] goes to the superficial inguinal lymph
[25:07] nodes. Right? Which is the correct
[25:10] answer here. Superficial inguinal lymph
[25:12] nodes. Above the dentate line, you know
[25:15] there is autonomic supply, nervous
[25:17] supply, which is why pain is not felt.
[25:21] And that is why I told you the
[25:22] interventions are done above and the
[25:24] lymph nodes are ultimately first they're
[25:28] going to be along the vessels and then
[25:30] eventually they land up in the parototic
[25:33] region right so there are various levels
[25:35] but eventually they are going to land up
[25:36] in the parotic levels. So here the
[25:39] correct answer is superficial inguinal
[25:41] lymph nodes which is why if you have an
[25:43] anal cancer which which is usually which
[25:46] can be a squamous cell carcinoma there
[25:49] we are going to examine the superficial
[25:50] inguinal lymph nodes and you know that
[25:52] these patients are treated with the
[25:54] nigros regime that has also been asked
[25:56] in nepg previously nigro regime for anal
[25:59] cancer is combined cheo radiation
[26:03] is combined cheo radiation and the
[26:06] advantage of nigro regime is that this
[26:08] can help in shrinking the tumor and we
[26:11] can avoid a surgery because if I have to
[26:14] do a surgery in this patient invariably
[26:16] it would be an APR abdominal perennial
[26:20] resection which means the patient would
[26:22] land up with a permanent colosttomy
[26:25] lifelong so if we can avoid that by
[26:29] niguro's regime that is good for the
[26:31] patient so Niger's regime which is
[26:33] combined chemo radiation for anal
[26:36] cancers has also also been asked
[26:39] previously.
[26:42] Coming to the general surgery questions,
[26:44] identify the type of suture material
[26:46] given in the image. So they had given
[26:48] poly dioxon PDS, right? PDS or poly
[26:52] dioxon. We know that PDS is a synthetic
[26:57] absorbable suture and this synthetic
[27:00] absorbable suture dissolves in 180 days.
[27:04] Right? Vikril which is polyglactin
[27:07] dissolves in 60 to 90 days. This
[27:10] dissolves in 180 days. And PDS is a
[27:13] monoilament suture means it's a single
[27:16] thread. The advantage being that less
[27:19] chances of infection. Braided sutures.
[27:22] Braided sutures like silk is braided.
[27:25] Cotton is braided.
[27:28] Right? Silk, cotton, these are braided
[27:30] sutures. So these sutures
[27:34] even vril is braided. So these sutures
[27:37] what is going to happen? There are
[27:38] multiple threads there and in these
[27:40] multiple threads what can happen?
[27:42] Bacteria can grow in the crevices. So
[27:44] there can be increased rates of
[27:46] infection. So that is one of the
[27:48] advantages of monofilament sutures. But
[27:51] the disadvantage of monofilament suture
[27:53] is it is difficult to handle. Right? It
[27:55] keeps on opening up. So you have to take
[27:57] more knots to secure it. Where is PDS
[28:02] used? PDS is used for CBD repair.
[28:06] It is used for CBD repair. You can use
[28:08] it for bowel repair or bowel anastemosis
[28:11] as well. So there was a question where
[28:14] you have to identify the knot and in the
[28:17] NEPG exam they've previously asked about
[28:19] reef knot and a granny's knot as well.
[28:22] This time the correct answer was
[28:23] surgeon's knot. surgeons not you know
[28:26] that we take two throws
[28:29] that is followed by a single throw right
[28:33] some of you might have taken this during
[28:35] internship I'm sure not some everyone
[28:38] who sutured has taken this during
[28:39] internship during internship you would
[28:41] have wrapped the thread two times around
[28:43] the needle holder then crossed and then
[28:45] wrapped it once and then crossed right
[28:48] so that exactly is a surgeon's knot
[28:50] which you were taking so two times
[28:52] followed by one time is a surgeon's knot
[28:55] and this is a secure knot which usually
[28:58] does not open up easily. The next
[29:00] question was a patient came with
[29:02] odinophasia and cervical lympodinitis.
[29:06] On examination there was an ulcerated
[29:08] growth present in the base of the tongue
[29:10] which was found to be squamous
[29:12] carcinoma. What is the most common
[29:14] organism associated with squamous
[29:17] carinoma of the oral cavity and
[29:19] oroparangel region? We know the correct
[29:21] answer is human papilloma virus. Right?
[29:25] So you know that the virus which is
[29:27] associated with oral and oroparangel
[29:29] regions uh is the human papilloma virus.
[29:32] Human papilloma virus is also associated
[29:35] with cervical cancer. Epstein bar virus
[29:38] is also associated with nasoparangial
[29:41] cancers
[29:43] right with nasoparangel cancers but not
[29:46] with oral and oroparangel cancers. So
[29:49] EBV is with nasoparangel cancer. You
[29:52] should know the correct answer here is
[29:53] human papilloma virus. Then there was a
[29:56] question regarding hernia. This was a
[29:57] straightforward question which has been
[29:59] asked many times. A newborn is admitted
[30:01] to the niku after 24 hours with severe
[30:04] respiratory distress. What is the
[30:06] diagnosis given in the x-ray? Right? So
[30:10] you can see in the X-ray you can see
[30:12] that the bowel loops are all in the
[30:14] thoracic cavity and they are on the left
[30:18] side there on the left side you can see
[30:21] bowel loops in the thoracic cavity which
[30:23] is ultimately led to compression of the
[30:26] lungs on the other side and the lung has
[30:28] not developed on the same side. So this
[30:31] is classical of congenital diaphragmatic
[30:33] hernia.
[30:35] These days congenital diaphragmatic
[30:37] hernas are usually picked up in the
[30:38] prenatal ultrasounds right but a lot of
[30:41] ladies coming from villages those who
[30:43] are not getting antiatal checkups done
[30:45] there it is detected after delivery and
[30:48] typically the child will come with a
[30:50] scafoid abdomen
[30:52] you're going to get a scafoid abdomen
[30:54] and respiratory distress because all the
[30:57] bowel cavity or all the bowel is in the
[31:00] thoracic cavity now we know that there
[31:02] are two types is the most common which
[31:05] is left to posterolateral which is what
[31:07] we could see in the image. It was on the
[31:10] left side and this is due to defective
[31:12] development of the pluroparonial canal
[31:14] membrane and the usual structures which
[31:18] go up are the stomach and the spleen.
[31:22] Morgan is right anteromedial. Right.
[31:26] Right anteromedial. And this is due to
[31:28] the defective central tendon of the
[31:31] diaphragm. And
[31:34] transverse colon is the structure which
[31:36] herniates upwards here. Most commonly
[31:39] these children they usually die due to
[31:42] most common cause of death in them is
[31:44] pulmonary hypoplasia.
[31:48] And you know bag and mask ventilation is
[31:50] not done in these children. This is the
[31:52] most common cause of death.
[31:55] Second most common cause of death is
[31:57] pulmonary hypertension. And like I've
[32:00] said bag and mask ventilation is not
[32:02] done in these children. That is been
[32:04] asked in the exam as well.
[32:07] A 15year-old girl comes with a painless
[32:10] swelling which is gradually progressed
[32:12] over one year. What is the diagnosis?
[32:15] You can see that there is a classical
[32:17] swelling in the outer canthus of the eye
[32:21] or on the outer side of the eye. Right?
[32:25] Outer side of the eye.
[32:28] And this is a classical location for
[32:32] sequestration
[32:34] dermmoid cyst. You know as the two
[32:36] plates fuse if some tissue is left there
[32:39] it can form a dermmoid cyst. The
[32:42] classical locations are the outer side
[32:44] of the eye and the post oricular region
[32:48] and the post oricular region. So the
[32:51] diagnosis of this question is primarily
[32:54] based on the location on the site which
[32:58] is the classical site. Okay. Now hema
[33:03] would be a compressible swelling that
[33:05] has not been mentioned. Osteoma will be
[33:08] a bony hard swelling. Right. Lacrimmal
[33:11] gland masses would usually be lower
[33:13] close to the uh eye you would find them.
[33:17] The primary diagnosis of this is based
[33:19] on the site. Now one thing which is uh
[33:22] which has been asked long time back and
[33:24] it is a clinical correlate which all of
[33:26] you should remember that the management
[33:28] here is excision. But there is one
[33:31] precaution which we need to take. We
[33:33] should always rule out intraranial
[33:36] extension whenever we are excising a
[33:38] dermmoid cyst. So always rule out an
[33:41] intraranial extension before you do
[33:43] surgery of these lesions.
[33:47] Moving on to the questions that are
[33:48] asked in trauma. You had a 25-year-old
[33:51] male who came to the emergency with a
[33:54] stab injury in the right iliac region.
[33:57] Few hours later he developed
[33:59] hypotension, abdominal tenderness and
[34:02] peritonitis. What is the next best
[34:05] management?
[34:07] Right? Please remember if the patient
[34:10] has developed peritonitis and this is a
[34:12] stab injury. You know there are two main
[34:14] mechanisms. One is a blunt injury and
[34:16] other one is penetrating injury.
[34:18] Penetrating injury peritonitis
[34:21] nothing is to be done. These patients
[34:24] will be wheeled in straight to the
[34:25] theater. Right? You prepare them as soon
[34:27] as possible and you take them to the
[34:29] theater for an emergency lipotomy.
[34:32] Right?
[34:33] So penetrating trauma if it is
[34:35] superficial to the paronium we do local
[34:38] exploration and then if the patient is
[34:40] stable I'm going to send the patient for
[34:42] the CT but if there is peronial breach
[34:45] that means peritonitis is there or the
[34:48] um is hanging out like this you get a
[34:51] patient like this where the um is out
[34:53] even if the patient is stable still you
[34:55] need to do leprotomy so peritonitis um
[34:59] hanging out bile staining of the
[35:00] dressing patient would go for a lip
[35:03] brtomy straight away. You're not doing
[35:04] any investigations.
[35:06] If it was blunt trauma, right? Blunt
[35:10] trauma, you know, in a stable patient,
[35:14] blunt trauma, you have unstable patient,
[35:18] then we do fast, right? Which is focus
[35:21] assessment, sonogram. In trauma and in a
[35:25] stable patient, we will do CCT.
[35:29] But this is a case of stab injury,
[35:31] penetrating injury, peritonitis is
[35:33] there. Patient straight away goes for a
[35:34] liprotomy. So always when you encounter
[35:37] such questions, please read the
[35:39] mechanism of injury and then see what
[35:41] all parameters they have given.
[35:44] A 30-year-old lady underwent the
[35:46] procedure shown in the image following a
[35:48] burn injury. So the hint which they gave
[35:49] you was a burn injury and you can see
[35:52] these cuts which have been made. I think
[35:54] so in the exam there were cuts which
[35:56] were made on the chest and the abdomen
[35:58] as well. in the exam image. I might be
[36:00] wrong. Uh you can write down in the
[36:02] comment section and let us know. So
[36:04] these cuts which are made these are done
[36:07] in circumferential burns and this is
[36:11] known as estarottomy.
[36:13] Now eschar is thickened tissue which is
[36:16] left after burns. So is thickened
[36:18] tissue. Now if this thickened tissue is
[36:20] there, this thickened tissue can give
[36:22] rise to compartment syndrome or can
[36:24] hamper breathing. So we need to cut this
[36:27] right. We need to cut it in
[36:29] circumferential burn patients so that
[36:32] the patient does not develop a
[36:33] compartment syndrome. Fine. This
[36:37] escarottomy is done till the deep fasia.
[36:40] You have to insize the deep fasia and
[36:44] you will prevent the development of
[36:46] compartment syndrome by doing this. So
[36:48] go cut till the deep fasia. You cut the
[36:51] deep fasia as well then only it'll be
[36:53] adequate. There are certain precautions
[36:56] which need to be taken. You don't need
[36:58] to remember where the incisions are
[37:00] made. They have not been asked in any
[37:02] exam. But in this table of Bailey, they
[37:05] have mentioned that extend the wound
[37:07] beyond the deep burn. You should dither
[37:10] them the significant bleeding vessels
[37:13] and because this can be bloody, you
[37:16] should apply a hemostatic dressing.
[37:19] Right? The main aim here is to release
[37:22] the wound. Right? It is not done to save
[37:25] the artery. It is to release and to
[37:27] prevent compartment syndrome.
[37:30] A 25-year-old following a road traffic
[37:33] accident with head injury has come to
[37:35] the ER and CT scan shows normal
[37:38] findings. CT shows normal finding after
[37:40] road traffic accident but the patient
[37:42] dies within 3 hours. Autopsy shows
[37:46] particular hemorrhages in the corpus
[37:47] colossum and focal lesions in the brain
[37:50] stem with retraction ball appearance in
[37:52] the internal capsule. What is the
[37:55] diagnosis? So this is classical. Patient
[37:58] comes with RTA CT is normal but the
[38:01] patient's GCS is not improving or the
[38:04] patient dies. This is classical of
[38:06] diffuse axonal injury which is the most
[38:08] severe type of brain injury which can
[38:11] occur and this occurs due to shearing
[38:13] force between the gray and the white
[38:15] matter. Patient will be in coma but CT
[38:18] is normal. That is why the investigation
[38:20] of choice here is MRI which can show
[38:23] punctate bleeding which is what was
[38:25] mentioned in the question stem.
[38:27] You can see these punctate bleeding and
[38:30] on autopsy you can see retraction ball
[38:32] appearance as well. This has the worst
[38:36] prognosis amongst all the head injuries.
[38:42] So following a building collapse a male
[38:44] patient was brought with copious amount
[38:46] of debris in the mouth and following
[38:49] that a procedure was done. Um the
[38:52] procedure was where they were showing a
[38:54] needle being put in the neck here.
[38:57] Right? This might not be the actual
[39:00] image shown in the exam. Uh do let us
[39:02] know if this was similar or it was
[39:04] different and we'll be happy to correct
[39:05] it. But what I could gather from
[39:08] questions was that it was an image going
[39:12] a needle going into the neck which is
[39:14] done which is needle criccoyroidtomy.
[39:17] Right? which is needle criccoyroidtomy
[39:22] and this is an emergency airway right
[39:25] this is an emergency airway which we can
[39:27] achieve very quickly and this I'm sure
[39:30] has um become popular because of the
[39:33] series called good doctor and in the
[39:35] first season first episode this is what
[39:37] that person does at the airport a needle
[39:39] cricothyroidtomy so this is a quick way
[39:42] to achieve airway but this only works
[39:45] for 20 to 30 minutes right So 20 to 30
[39:48] minutes it will give you but because
[39:50] it's such a narrow it's such a small
[39:52] opening you have to convert it into a
[39:55] tracheiotomy or a meaningful airway
[39:57] later on. So it can be used for
[39:59] effective ventilation for 6 hours. No
[40:01] just 20 to 30 minutes. It is used to
[40:04] measure CVP. No work of breathing is
[40:07] more than bag and mask ventilation. No.
[40:11] And it is followed by a tracheio. Yes.
[40:15] because this is only useful for 20 to 30
[40:17] minutes after which the patient develops
[40:19] CO2 retention. So you get those 20
[40:21] minutes to do a tracheosttomy.
[40:25] A patient presented with the following
[40:27] findings in the lower limb. Identify the
[40:29] true statement regarding the condition.
[40:31] Right? So you could clearly see varicose
[40:34] veins here. You could clearly see
[40:36] varicose veins
[40:39] and in these varicose veins
[40:43] they had asked which is the true
[40:44] statement. Scarotherapy is the treatment
[40:46] of choice. We know that scarotherapy is
[40:49] done for thread veins and dermal flares
[40:52] right is done for thread veins and
[40:54] dermal flares. And these are veins which
[40:57] are less than 1 mm in diameter. These
[41:00] you can see are well-formed varicose
[41:02] veins which are more than 3 mm. So you
[41:04] would not do sclerotherapy here. C6 is
[41:08] an active ulcer.
[41:11] We can't see any ulcer. So this is
[41:13] wrong. Pelvic tumor is a cause of
[41:17] varicose veins but not the most common
[41:19] cause of varicose veins. They can
[41:21] develop eczema and pigmentation. That is
[41:23] the correct answer here. Again I don't
[41:26] think so. This is a difficult question.
[41:28] Right? Some students were saying that
[41:29] the options were challenging. I don't
[41:31] think so. The options for any of the
[41:33] questions till now have been
[41:35] challenging. They were straightforward
[41:36] questions. If you've read surgery, if
[41:39] you've revised it, you could have
[41:40] answered majority of the questions which
[41:43] were asked in the exam. And I really
[41:45] wouldn't be surprised if the topper got
[41:48] all surgery questions correct. That's
[41:49] how uh easy the surgery questions were.
[41:53] So these are varicose veins which are
[41:55] more than 3 mm in diameter. Thread veins
[41:59] or dermal flares are less than 1 millm
[42:02] and you have reticular veins which are
[42:04] between 1 to 3 mm.
[42:06] Corona flectasia this is malol flare. It
[42:10] is a fan shaped pattern of telling
[42:12] jectesic veins less than 1 mm and you
[42:15] can see that it is for these veins which
[42:17] are less than 1 mm that foam
[42:18] scarotherapy is being done. You can see
[42:20] foam sclerotherapy is done for less than
[42:22] 1 mm.
[42:25] A trophy blanche is a depigmented area
[42:28] surrounded by dilated veins. This is
[42:30] this can again be a complication of
[42:32] varicose veins. Lipotermatosclerosis
[42:36] and pigmentation. This pigmentation is
[42:38] due to hemocidarine deposition.
[42:40] Lipottomatosclerosis
[42:42] what happens is that the fat obliterates
[42:44] and there is contraure of the tendoacles
[42:47] and this can give rise to the inverted
[42:49] champagne bottle appearance which you
[42:51] can see here in this image. And this is
[42:54] also a complication of varicose veins.
[42:57] Ulceration of course along the medial
[42:59] malulus. This is known as the gator
[43:02] area. This is a classical area where
[43:06] varicose ulcers of venus ulcers forms
[43:08] and this was asked in the recently
[43:09] conducted in IICT exam.
[43:12] This is the CAP classification which you
[43:15] would need to remember for the exam
[43:17] because this there was a phase when all
[43:20] examiners all exams ask about CAP
[43:23] classification right so C 0 is no
[43:26] visible signs C1 is tellingic or
[43:29] reticular veins which I've already told
[43:31] you telling are less than 1 millm
[43:34] reticular are 1 to 3 mm varicose veins
[43:38] are more than 3 mm C2 C3 is edema
[43:42] C4 A is pigmentation or eczema. C4 P B
[43:46] is lipodomatus sclerosis or atrophy
[43:49] blanche. I've shown you the images. C4C
[43:52] is corona flabasia. C5 is a healed ulsa.
[43:55] C6 is an active ulcer. This
[43:58] classification we need to remember for
[44:00] the exam.
[44:05] So usually there are questions regarding
[44:07] ulcers in nepg. This time they had asked
[44:09] a question where they had shown an image
[44:11] of a hand. You could see that the hand
[44:14] is inflamed
[44:17] right and you could see gangrine or
[44:20] blackish discoloration of the digits
[44:24] and you know that gang which is there
[44:27] with super added infection. This is
[44:29] usually wet gangarine. Dry gangarine you
[44:33] will have a well demarcated line of
[44:35] demarcation. The area tissue would be
[44:38] dry. This you can see is inflamed.
[44:42] Reord's phenomena we know occurs due to
[44:45] vasos spasm. And here you will you are
[44:49] going to get the classical sequence
[44:51] white blue red change would be there in
[44:55] the hand the color of the hand and it is
[44:58] linked with vasospasm. This has been
[45:00] asked previously in the nepg exam. This
[45:03] time they had asked about gangarene. You
[45:05] know gangarine can be dry gangarine or
[45:07] wet gangarine. Dry gangarine is
[45:09] desiccated tissue by gradual slowing of
[45:12] blood. When there's gradual slowing of
[45:13] blood, you usually have a good line of
[45:16] demarcation. You can see here you will
[45:18] have a good line of demarcation. You can
[45:20] see a very clear line of demarcation
[45:23] here in dry gangrine
[45:26] and in the bone the stump would be
[45:28] conical. Venus gangrine occurs sorry vet
[45:32] gangrian occurs by two methods either
[45:34] venus blockade or super added infection
[45:36] like in this case it looks more like
[45:38] super added infection
[45:41] poor line of demarcation you cannot see
[45:43] the line of demarcation properly in wet
[45:45] gangarene and if infection spreads this
[45:49] line of demarcation can spread
[45:51] proximally as well
[45:54] now this time in the nepg exam there was
[45:57] only one question from Urology last year
[46:00] if you recolct it was a urology heavy
[46:03] paper this time there was only one
[46:05] question from urology uh some students
[46:07] said that there was one uh image
[46:09] regarding intravenous euroggram as well
[46:12] I could not get that question maybe that
[46:15] would be covered in uh radiology right
[46:18] so you had a 8-year-old child who' come
[46:21] with progressive fimosis and a wide
[46:24] sclerotic lesion on the pennis a wide
[46:27] sclerotic lesion on the pennis what is
[46:30] the diagnosis
[46:32] now paraphyimosis let's look at one
[46:35] option at a time because this I feel is
[46:38] the only question which was a bit tricky
[46:41] where you had to use your elimination
[46:44] power to come to the diagnosis otherwise
[46:46] all the surgery questions were
[46:48] straightforward okay so paraphyimosis
[46:50] happens when there is a tight fork skin
[46:55] when there is a tight fork skin which
[46:57] forms a constriction ring around the
[47:02] which forms a constriction ring around
[47:04] the penis.
[47:06] Right? So we can't see anything of that
[47:08] sort here in paraphymosis. The entire
[47:11] penis is swollen and there is a
[47:13] constriction ring around the penis.
[47:16] Hypospadas. Hypospadius you know is the
[47:19] most common
[47:21] congenital eurogenital anomaly. And here
[47:24] you will have the urethral opening will
[47:26] be ventrally placed. The urethral
[47:29] opening you can see is going to be this
[47:32] is normal. This would be ventrally
[47:34] placed. It'll be placed below and you
[47:36] can get a hooded peruse. So this is also
[47:39] not looking like hypospadius
[47:44] mial stenosis and balonitis erotic
[47:46] obliterance.
[47:48] Now yes the opening of the urethra
[47:51] appears senos here. I'm not doubting
[47:53] that. Right? So some people would have
[47:55] gone for miatal stenosis but the key
[47:57] thing which you had to read here was the
[47:59] wide sclerotic lesion. This white
[48:02] sclerotic fibrootic kind of a lesion is
[48:04] classically seen in balonitis zerotica
[48:07] obliterance and this balonitis erotica
[48:10] obliterance is a risk factor for penile
[48:14] cancer as well. So this is the only
[48:16] question where you had to eliminate and
[48:18] you had to slightly um use your
[48:21] knowledge to eliminate the other
[48:23] options. So this was the question which
[48:25] was asked from urology and that brings
[48:28] us uh to the end of the questions which
[48:30] were asked in surgery in nepg. If you
[48:34] feel that there were any more questions
[48:36] and I have not included in this
[48:38] discussion, please do write in the
[48:40] comment section and we'll be happy to
[48:42] add them later on in the section. Also,
[48:46] um after seeing the last 2 three years
[48:49] where every nepg exam is either
[48:50] postponed, prepped, postponed again,
[48:53] this kind of saga continues, there are
[48:55] delays in the counseling. It is my
[48:58] humble request to all of you who are
[49:00] watching this video that please please
[49:02] appear for the INIC exam right it is a
[49:05] most standard exam happens on time
[49:08] result comes on time counseling happens
[49:10] on time and with more and more as
[49:13] opening up with more post-graduate seats
[49:15] opening up in these central institutes
[49:17] please prepare for INIC as well don't
[49:20] just keep it as an exam um which only
[49:24] toppers give no that is not the case
[49:26] anyone who studies hard and diligently
[49:29] can crack the INIC exam. So, please do
[49:32] fill in the form if you don't make it in
[49:35] need PG or if you're watching this video
[49:38] for future preparation. Don't skip out
[49:40] on the INIC exam. Also, this paper was a
[49:44] clear reflection
[49:46] of how good your MCQ skills and your
[49:49] reading skills for those MCQs are. So,
[49:52] please make MCQ solving a habit, right?
[49:55] It should not be a start stop kind of a
[49:57] method. MCQs are what are going to get
[50:00] you through the exam. So make it a
[50:02] habit. Make sure that you don't while
[50:05] you're preparing for the exams, you
[50:06] don't spend a single day where you don't
[50:09] solve MCQs. If there are any further
[50:11] questions which you have, please do
[50:13] write in write them in the comment
[50:14] section. I'll be happy to answer them.
[50:16] Thank you.