General Surgery Prometric exam questions

The General Surgery exam in every GCC country

From each regulator's own exam pages; anything a regulator does not publish says so. Assessment mode also depends on your licence title, so confirm your route on your eligibility notice.

12 worked General Surgery practice questions

Original exam-style questions from the bank, spread across the blueprint domains. They are not real or recalled exam questions. Try each one, then open the answer for the rationale and reference. None of them appear in the free mock exam, so reading them will not spoil it.

1. Question 1 · Hepatobiliary, Pancreas and Spleen

   Histology after a routine laparoscopic cholecystectomy for gallstones reports adenocarcinoma invading the perimuscular connective tissue but not beyond the serosa (T2), with a negative cystic duct margin. Staging CT shows no metastases. What is the recommended management?

   1. AObservation with 6-monthly CT surveillance, as cholecystectomy alone is adequate for T2 disease
   2. BAdjuvant chemoradiotherapy without further surgery
   3. CRadical re-resection: liver resection of segments IVb/V (or wedge with adequate margin) plus portal lymphadenectomy
   4. DExtended right hepatectomy with pancreaticoduodenectomy in all cases
   Show answer and explanation

   Correct answer: C. Radical re-resection: liver resection of segments IVb/V (or wedge with adequate margin) plus portal lymphadenectomy

   T1a tumours confined to the lamina propria are adequately treated by cholecystectomy alone, but T1b and all T2 tumours require re-resection because of high rates of residual disease and nodal involvement; the standard is a segment IVb/V liver resection with portal (hepatoduodenal ligament) lymphadenectomy, with bile duct excision only if the cystic duct margin is positive. Surveillance alone under-treats T2 disease, and adjuvant therapy does not replace resection. Hepatopancreatoduodenectomy is not routine and is reserved for highly selected extensive disease.

   Reference: NCCN Clinical Practice Guidelines in Oncology: Biliary Tract Cancers (2024); AJCC Cancer Staging Manual, 8th edition

2. Question 2 · Acute Abdomen and Gastrointestinal Bleeding

   At laparotomy for a strangulated obstruction, a 25 cm segment of ileum is released from a constricting adhesive band. It is dusky and non-peristaltic. After the band is divided the mesentery is covered with warm packs for 10-15 minutes. Which finding most reliably indicates that the segment is viable and can be left in situ?

   1. AReturn of a pink colour to the serosal surface alone
   2. BAbsence of gross perforation on inspection
   3. CReturn of peristalsis with palpable pulsation in the adjacent mesenteric arcade
   4. DA soft, non-oedematous bowel wall on palpation
   Show answer and explanation

   Correct answer: C. Return of peristalsis with palpable pulsation in the adjacent mesenteric arcade

   The accepted intraoperative triad for viability is restoration of normal colour, return of visible peristalsis in the segment, and palpable pulsation in the terminal mesenteric arcade close to the bowel; return of peristalsis with arterial pulsation is the most reliable of these. Colour alone is unreliable because congested bowel may pink up transiently while remaining infarcted, and neither absence of perforation nor wall texture predicts subsequent necrosis. Where doubt persists, fluorescein or indocyanine green fluorescence, or a planned relook laparotomy, should be used rather than accepting equivocal bowel.

   Reference: Bailey & Love's Short Practice of Surgery, 28th edition (2023); ACS Principles of Emergency General Surgery (2022)

3. Question 3 · Perioperative Care, Anaesthesia, Pain and Surgical Complications

   A 46-year-old man with severe acute pancreatitis in the ICU has a tensely distended abdomen, peak airway pressures of 42 cmH2O, urine output of 5 mL/h despite adequate filling, and a bladder pressure of 28 mmHg. He has already had nasogastric decompression, neuromuscular blockade, sedation and diuretic-assisted fluid removal without improvement. What is the definitive management?

   1. AIncrease intravenous crystalloid to improve renal perfusion
   2. BStart continuous veno-venous haemofiltration to reduce intra-abdominal pressure
   3. CDecompressive laparotomy with temporary abdominal closure
   4. DPercutaneous drainage of the pancreatic bed regardless of collections
   Show answer and explanation

   Correct answer: C. Decompressive laparotomy with temporary abdominal closure

   This is established abdominal compartment syndrome refractory to all medical measures, and decompressive laparotomy with a temporary abdominal closure such as negative pressure therapy is the definitive treatment that immediately restores visceral, renal and respiratory function. Further aggressive crystalloid worsens visceral oedema and raises intra-abdominal pressure further. Haemofiltration may help volume removal but does not reliably decompress an acutely tense abdomen. Percutaneous drainage is useful only when there is a substantial drainable ascitic or peripancreatic collection, and should not delay decompression when none is present.

   Reference: Kirkpatrick AW et al., WSACS consensus guidelines, Intensive Care Medicine 2013; IAP/APA Evidence-based guidelines for the management of acute pancreatitis

4. Question 4 · Colorectal, Appendix and Perianal Surgery

   A 34-year-old man has a caecal adenocarcinoma. Immunohistochemistry shows loss of MSH2 and MSH6 staining, and germline testing confirms a pathogenic MSH2 mutation. There is no evidence of metastatic disease. What is the most appropriate operation?

   1. ASegmental caecal resection with a 5 cm margin
   2. BTotal colectomy with ileorectal anastomosis
   3. CStandard right hemicolectomy alone
   4. DTotal proctocolectomy with permanent end ileostomy
   Show answer and explanation

   Correct answer: B. Total colectomy with ileorectal anastomosis

   Lynch syndrome carries a high risk of metachronous colorectal cancer after segmental resection (reported at 16-45 per cent), so an extended resection, most often total colectomy with ileorectal anastomosis, is recommended for a young patient with a colonic index cancer, followed by lifelong annual endoscopic surveillance of the retained rectum. Segmental caecal resection or a standard right hemicolectomy leaves substantial at-risk colon. Total proctocolectomy is generally reserved for an index rectal cancer or for patients unable to comply with rectal surveillance, since it costs bowel function unnecessarily in this setting.

   Reference: NCCN Guidelines: Genetic/Familial High-Risk Assessment: Colorectal, 2023; ASCRS Clinical Practice Guidelines for the Management of Inherited Polyposis and Hereditary Nonpolyposis Colorectal Cancer, 2017

5. Question 5 · Fluid, Electrolyte, Acid-Base and Surgical Nutrition

   A malnourished 61-year-old man with alcohol dependence is admitted for an elective hernia repair. He is mildly confused but not fitting. Serum sodium is 108 mmol/L and has probably been low for several weeks. Which correction strategy minimises the risk of osmotic demyelination syndrome?

   1. ACorrect to a sodium of 135 mmol/L within the first 24 hours using 3% saline
   2. BInfuse 3% saline at a rate that raises sodium by 0.5 mmol/L per hour continuously until sodium reaches 130 mmol/L
   3. CLimit the total rise to no more than 8 mmol/L in the first 24 hours, with re-lowering using desmopressin and free water if this is exceeded
   4. DGive 0.9% saline at 250 mL/hour with no sodium monitoring for 12 hours
   Show answer and explanation

   Correct answer: C. Limit the total rise to no more than 8 mmol/L in the first 24 hours, with re-lowering using desmopressin and free water if this is exceeded

   In chronic hyponatraemia with high-risk features (sodium below 105 mmol/L, alcoholism, malnutrition, hypokalaemia, liver disease) correction should not exceed about 8 mmol/L in 24 hours, and inadvertent overcorrection should be actively reversed with desmopressin and hypotonic fluid. Correcting to normal within 24 hours, or a sustained 0.5 mmol/L/hour rise (which equates to 12 mmol/L per day), both exceed safe limits and risk central pontine myelinolysis. Unmonitored isotonic saline in a patient at risk is unsafe because autocorrection can be abrupt once any volume deficit is repaired.

   Reference: Verbalis JG et al., Diagnosis, Evaluation and Treatment of Hyponatremia: Expert Panel Recommendations, American Journal of Medicine 2013

6. Question 6 · Surgical Infection, Sepsis and Antimicrobial Stewardship

   A theatre nurse who never responded to hepatitis B vaccination (documented anti-HBs less than 10 mIU/mL after two full courses) sustains a percutaneous injury from a patient who is HBsAg positive. What is the correct post-exposure management for hepatitis B?

   1. AHepatitis B vaccine booster alone
   2. BHepatitis B immunoglobulin alone as a single dose, with no further action
   3. CTwo doses of hepatitis B immunoglobulin one month apart (or HBIG plus revaccination), given as soon as possible after exposure
   4. DNo prophylaxis, as non-responders are naturally protected
   Show answer and explanation

   Correct answer: C. Two doses of hepatitis B immunoglobulin one month apart (or HBIG plus revaccination), given as soon as possible after exposure

   A documented non-responder to two complete vaccine series exposed to an HBsAg-positive source should receive hepatitis B immunoglobulin as soon as possible, with a second dose one month later (or HBIG plus initiation of revaccination), because further vaccine alone is unlikely to produce protective antibody. A booster alone is inadequate in a proven non-responder. A single HBIG dose without a plan for the second dose or revaccination leaves incomplete cover. Non-response indicates susceptibility, not protection. There is no effective post-exposure prophylaxis for hepatitis C, which is managed by serial testing with early antiviral treatment if seroconversion occurs.

   Reference: CDC/ACIP Updated Recommendations for the Management of Hepatitis B Virus Occupational Exposures, MMWR 2013 and 2018 update

7. Question 7 · Professionalism, Ethics, Patient Safety and Evidence-Based Surgery

   A 34-year-old Jehovah's Witness woman with capacity requires urgent laparotomy for a ruptured ectopic pregnancy. Her haemoglobin is 62 g/L. She signs an advance refusal of all blood components including red cells, but accepts cell salvage and tranexamic acid. Intraoperatively she becomes profoundly anaemic. What is the correct course of action?

   1. ARespect the refusal, continue surgical haemostasis, cell salvage, tranexamic acid and haemoglobin-sparing measures, and escalate to critical care
   2. BTransfuse packed red cells because her life is now in immediate danger
   3. CAsk her husband to authorise transfusion on her behalf
   4. DTransfuse under general anaesthesia and inform her afterwards, documenting the clinical necessity
   Show answer and explanation

   Correct answer: A. Respect the refusal, continue surgical haemostasis, cell salvage, tranexamic acid and haemoglobin-sparing measures, and escalate to critical care

   A valid, applicable advance refusal made by an adult with capacity is legally and ethically binding even when refusal is likely to result in death; the treating team must honour it and maximise permitted bloodless strategies such as meticulous haemostasis, cell salvage, tranexamic acid, oxygen delivery optimisation and iron/erythropoietin postoperatively. A spouse cannot override a competent adult's advance decision. Covert transfusion is a battery and a serious professional breach.

   Reference: Association of Anaesthetists, Management of Anaesthesia for Jehovah's Witnesses (2005, updated guidance); NICE NG24 Blood Transfusion (2015)

8. Question 8 · Upper GI, Foregut and Bariatric/Metabolic Surgery

   Ten weeks after sleeve gastrectomy a 29-year-old woman with persistent vomiting for 3 weeks, who has not taken her prescribed supplements, presents with confusion, horizontal nystagmus and an unsteady gait. What is the most important immediate treatment?

   1. AIntravenous 50% dextrose to correct presumed hypoglycaemia
   2. BIntravenous high-dose thiamine before administering any glucose-containing fluids
   3. CIntramuscular vitamin B12 1000 micrograms
   4. DUrgent CT brain before any therapy is given
   Show answer and explanation

   Correct answer: B. Intravenous high-dose thiamine before administering any glucose-containing fluids

   The triad of confusion, ophthalmoplegia or nystagmus and ataxia after prolonged post-bariatric vomiting is Wernicke encephalopathy from thiamine deficiency, which must be treated empirically with parenteral high-dose thiamine without waiting for confirmation. Giving glucose first precipitates or worsens the encephalopathy by consuming the residual thiamine. Vitamin B12 deficiency does not cause this acute syndrome, and imaging must not delay treatment of a time-critical, reversible condition.

   Reference: ASMBS Integrated Health Nutritional Guidelines (2017 update); Royal College of Physicians / NICE guidance on Wernicke encephalopathy

9. Question 9 · Breast and Endocrine Surgery

   A 32-year-old woman at 14 weeks gestation is diagnosed with a 3 cm node-positive invasive ductal carcinoma. Which management statement is correct?

   1. AAnthracycline-based chemotherapy can be given after the first trimester, while radiotherapy and endocrine therapy are deferred until after delivery
   2. BTermination of pregnancy is required before any oncological treatment can begin
   3. CTrastuzumab is safe throughout pregnancy and should be started immediately if HER2-positive
   4. DRadiotherapy may be given safely in the second trimester with abdominal shielding
   Show answer and explanation

   Correct answer: A. Anthracycline-based chemotherapy can be given after the first trimester, while radiotherapy and endocrine therapy are deferred until after delivery

   Anthracycline and taxane chemotherapy is considered acceptable from the second trimester onward, whereas radiotherapy, endocrine therapy (tamoxifen) and anti-HER2 agents are deferred until after delivery because of fetal toxicity; trastuzumab causes oligohydramnios and is contraindicated in pregnancy. Surgery, including mastectomy, can be performed safely in any trimester. Termination does not improve maternal oncological outcome and is not a requirement.

   Reference: ESMO Clinical Practice Guidelines: Cancer, Pregnancy and Fertility (Annals of Oncology, 2020); NCCN Breast Cancer Guidelines (2024)

10. Question 10 · Subspecialty Surgery (Vascular, Paediatric, Thoracic, Plastic) and Transplantation

    Three weeks after kidney transplantation, a patient's creatinine rises from 110 to 210 micromol/L. Doppler shows a patent artery and vein with no collection, tacrolimus trough is within target, and biopsy demonstrates interstitial mononuclear infiltrate with tubulitis but no C4d staining and no donor-specific antibodies. What is the most appropriate first-line treatment?

    1. APlasma exchange with intravenous immunoglobulin
    2. BReduction of tacrolimus dose and observation
    3. CPulsed high-dose intravenous methylprednisolone
    4. DImmediate graft nephrectomy
    Show answer and explanation

    Correct answer: C. Pulsed high-dose intravenous methylprednisolone

    Tubulitis with an interstitial mononuclear infiltrate and negative C4d and donor-specific antibodies is acute T-cell mediated (cellular) rejection, and first-line treatment is pulsed high-dose corticosteroids, with anti-thymocyte globulin reserved for steroid-resistant or severe (vascular, Banff grade II-III) rejection. Plasma exchange with IVIG and anti-CD20 therapy treat antibody-mediated rejection, which would show C4d deposition, peritubular capillaritis and circulating donor-specific antibodies. Simply lowering the calcineurin inhibitor would worsen rejection, and nephrectomy is not indicated for a treatable, reversible cellular rejection episode.

    Reference: KDIGO Clinical Practice Guideline for the Care of Kidney Transplant Recipients (2009); Banff 2019 update on allograft pathology

11. Question 11 · Hernia, Abdominal Wall, Skin and Soft Tissue

    A 52-year-old man with a 2.2 mm truncal melanoma undergoes sentinel lymph node biopsy which shows a 0.4 mm micrometastatic deposit in one axillary node. Staging CT shows no distant disease. Based on current evidence, what should be recommended?

    1. AImmediate completion axillary lymph node dissection, which improves melanoma-specific survival
    2. BNodal ultrasound surveillance with consideration of adjuvant systemic therapy, as completion dissection does not improve melanoma-specific survival
    3. CAdjuvant radiotherapy to the axilla in place of any further surgery or systemic therapy
    4. DObservation alone with no imaging follow-up as micrometastasis carries no prognostic significance
    Show answer and explanation

    Correct answer: B. Nodal ultrasound surveillance with consideration of adjuvant systemic therapy, as completion dissection does not improve melanoma-specific survival

    The MSLT-II and DeCOG-SLT trials showed that immediate completion lymph node dissection after a positive sentinel node increases regional disease control and lymphoedema but does not improve melanoma-specific survival, so structured nodal ultrasound surveillance with discussion of adjuvant systemic therapy (checkpoint inhibitors or targeted therapy) is now standard. Routine adjuvant axillary radiotherapy is reserved for selected high-risk extracapsular disease and is not a substitute for systemic therapy. Sentinel node micrometastasis upstages the patient and is prognostically important, so observation without follow-up is inappropriate.

    Reference: Faries MB et al., Completion Dissection or Observation for Sentinel-Node Metastasis in Melanoma (MSLT-II), New England Journal of Medicine (2017); NCCN Guidelines, Melanoma: Cutaneous (2023)

12. Question 12 · Fluid, Electrolyte, Acid-Base and Surgical Nutrition

    A 40-year-old man has 55 cm of jejunum ending in a jejunostomy after extensive resection for mesenteric ischaemia. He has been dependent on home parenteral nutrition for 18 months despite optimised oral rehydration solution, high-dose loperamide and a proton pump inhibitor. Which additional therapy is most likely to reduce his parenteral nutrition requirement?

    1. ALong-acting octreotide
    2. BCholestyramine
    3. CMetoclopramide
    4. DTeduglutide, a glucagon-like peptide-2 analogue
    Show answer and explanation

    Correct answer: D. Teduglutide, a glucagon-like peptide-2 analogue

    Teduglutide is a GLP-2 analogue that promotes intestinal mucosal growth and slows transit, and randomised trials have shown reduced parenteral support volume and, in some patients, weaning from parenteral nutrition in short bowel syndrome with intestinal failure. Octreotide reduces secretions modestly but is not recommended for long-term use because it may impair adaptation and cause gallstones. Cholestyramine binds bile salts and is used for bile-salt diarrhoea in patients with a retained colon, and would worsen fat malabsorption here; metoclopramide is prokinetic and would increase output.

    Reference: Pironi L et al., ESPEN Guideline on Chronic Intestinal Failure in Adults, Clinical Nutrition (2016, updated 2023); Jeppesen PB et al., STEPS trial, Gastroenterology 2012

General Surgery reference books and guidelines

Every question in this bank names the textbook or guideline its answer rests on. These are the sources our General Surgery questions cite most often - the reading list to revise from alongside the bank.

Where your regulator publishes a reading list, use the editions it names. Exam questions are not taken from any one book.