Free General Surgery mock test

General Surgery sample questions with answers

10 more original exam-style General Surgery questions, worked in full. They are not real or recalled exam questions, and none of them is in the mock above or on the bank page, so sit the mock first if you have not.

1. Question 1 · Upper GI, Foregut and Bariatric/Metabolic Surgery

   Fourteen months after Roux-en-Y gastric bypass a 45-year-old smoker who takes ibuprofen for back pain develops burning epigastric pain and intermittent haematemesis. Endoscopy shows an ulcer at the gastrojejunal anastomosis. Which management plan is most appropriate?

   1. ARevision of the gastrojejunostomy as first-line therapy
   2. BSmoking cessation, stopping NSAIDs, high-dose PPI with sucralfate, and H. pylori testing and treatment
   3. CCorticosteroids to reduce anastomotic inflammation
   4. DReversal of the bypass to normal anatomy
   Show answer and explanation

   Correct answer: B. Smoking cessation, stopping NSAIDs, high-dose PPI with sucralfate, and H. pylori testing and treatment

   Marginal ulceration is strongly associated with smoking, NSAID use, H. pylori and a large pouch or gastrogastric fistula, so first-line therapy removes the causative factors and provides high-dose acid suppression with a mucosal protectant. Most ulcers heal with this approach. Revisional surgery is reserved for perforation, uncontrolled bleeding, stricture, gastrogastric fistula or ulcers refractory to prolonged medical therapy, and corticosteroids would impair healing.

   Reference: ASMBS Clinical Issues Committee Position Statement on Marginal Ulceration (2020)

2. Question 2 · Breast and Endocrine Surgery

   A 27-year-old woman has a diffusely infiltrating lobular breast carcinoma. Her father had diffuse gastric cancer at 45 and a paternal aunt had lobular breast cancer at 40. Which germline mutation is most likely?

   1. ATP53 (Li-Fraumeni syndrome)
   2. BPTEN (Cowden syndrome)
   3. CCDH1 (hereditary diffuse gastric cancer syndrome)
   4. DSTK11 (Peutz-Jeghers syndrome)
   Show answer and explanation

   Correct answer: C. CDH1 (hereditary diffuse gastric cancer syndrome)

   Germline CDH1 (E-cadherin) mutation causes hereditary diffuse gastric cancer and confers a markedly increased risk of lobular breast carcinoma, exactly the family pattern described. Li-Fraumeni (TP53) typically produces sarcoma, early breast cancer, adrenocortical carcinoma and brain tumours; Cowden syndrome features hamartomas, macrocephaly and thyroid and endometrial cancers; Peutz-Jeghers causes mucocutaneous pigmentation and hamartomatous polyps.

   Reference: International Gastric Cancer Linkage Consortium updated clinical practice guidelines for hereditary diffuse gastric cancer (Lancet Oncology, 2020); NCCN Genetic/Familial High-Risk Assessment (2024)

3. Question 3 · Subspecialty Surgery (Vascular, Paediatric, Thoracic, Plastic) and Transplantation

   On the fourth day after orthotopic liver transplantation, a recipient develops a sudden rise in aspartate and alanine transaminases to over 2000 U/L, a rising lactate and a swinging fever. Bile drainage from the T-tube has become watery. Which complication should be suspected first and how should it be investigated?

   1. AAcute cellular rejection; proceed directly to pulsed steroids
   2. BHepatic artery thrombosis; perform urgent Doppler ultrasound with a view to angiography and re-exploration
   3. CPrimary biliary anastomotic stricture; arrange elective ERCP in 2 weeks
   4. DCytomegalovirus hepatitis; start intravenous ganciclovir
   Show answer and explanation

   Correct answer: B. Hepatic artery thrombosis; perform urgent Doppler ultrasound with a view to angiography and re-exploration

   Early hepatic artery thrombosis is a graft-threatening emergency because the transplanted biliary tree depends entirely on arterial inflow, so it presents with abrupt transaminase elevation, sepsis, bile leak or ischaemic biliary injury within the first days to weeks. Immediate Doppler ultrasound is the first-line investigation, with confirmatory CT or catheter angiography and urgent surgical or endovascular revascularisation, or listing for re-transplantation if the graft is not salvageable. Acute cellular rejection typically occurs from around day 5-10 with a more modest, mixed enzyme rise and should be biopsy-proven before treatment, CMV hepatitis is a later complication, and an anastomotic stricture would produce a cholestatic rather than a fulminant hepatocellular picture.

   Reference: EASL Clinical Practice Guidelines on Liver Transplantation (J Hepatol 2016, updated 2024); AASLD Practice Guidance on Evaluation for Liver Transplantation

4. Question 4 · Hernia, Abdominal Wall, Skin and Soft Tissue

   A 78-year-old renal transplant recipient has a 3 cm, poorly differentiated cutaneous squamous cell carcinoma on the cheek invading to 7 mm depth with perineural involvement on biopsy. Which statement about management is most appropriate?

   1. AExcise with a 4 mm margin, since the anatomical site mandates tissue conservation
   2. BThis is a high-risk tumour requiring wide excision with margin control (for example Mohs or staged excision), nodal assessment and multidisciplinary discussion about adjuvant radiotherapy
   3. CTreat with topical 5-fluorouracil because immunosuppression precludes surgery
   4. DPerform an elective ipsilateral parotidectomy and neck dissection in all such cases regardless of imaging
   Show answer and explanation

   Correct answer: B. This is a high-risk tumour requiring wide excision with margin control (for example Mohs or staged excision), nodal assessment and multidisciplinary discussion about adjuvant radiotherapy

   Size over 2 cm, depth beyond 6 mm, poor differentiation, perineural invasion, a high-risk site and immunosuppression all mark this as a high-risk cutaneous squamous cell carcinoma, which requires wide excision with histological margin control (Mohs or staged excision), staging of the draining parotid and cervical nodes, and MDT consideration of adjuvant radiotherapy. A 4 mm margin is only adequate for small low-risk lesions. Topical 5-fluorouracil treats actinic keratoses and Bowen disease, not invasive carcinoma. Elective nodal surgery is not performed indiscriminately without clinical or radiological evidence of nodal disease.

   Reference: British Association of Dermatologists guidelines for the management of people with cutaneous squamous cell carcinoma, British Journal of Dermatology (2020); NCCN Guidelines, Squamous Cell Skin Cancer (2023)

5. Question 5 · Shock, Haemostasis, Transfusion and Coagulation

   A 59-year-old woman with Gram-negative septic shock after a biliary drainage procedure is oozing from all venepuncture sites. Platelets are 38 x 10^9/L, INR 2.1, aPTT prolonged, fibrinogen 0.8 g/L and D-dimer markedly elevated. Which management step is most important?

   1. AStart therapeutic heparin infusion for all patients with this laboratory pattern
   2. BGive tranexamic acid to inhibit the fibrinolysis driving the bleeding
   3. CAggressive source control and antimicrobial therapy, with component replacement guided by bleeding
   4. DWithhold all blood products until the fibrinogen falls below 0.5 g/L
   Show answer and explanation

   Correct answer: C. Aggressive source control and antimicrobial therapy, with component replacement guided by bleeding

   This is disseminated intravascular coagulation from sepsis, and the single most effective intervention is treating the precipitant with source control and antibiotics; component support (platelets, fibrinogen/cryoprecipitate, plasma) is given to patients who are bleeding or about to undergo a procedure rather than for laboratory numbers alone. Heparin is reserved for predominantly thrombotic DIC, antifibrinolytics are generally avoided in DIC because they may precipitate microvascular thrombosis, and withholding products from an actively bleeding patient is unsafe.

   Reference: British Society for Haematology Guidelines for the Diagnosis and Management of Disseminated Intravascular Coagulation (2009, updated); ISTH DIC scoring system

6. Question 6 · Trauma and Surgical Critical Care

   A trauma patient has the following Abbreviated Injury Scale scores: head 4, chest 3, abdomen 2, extremity 2 and external 1. What is the Injury Severity Score?

   1. A25
   2. B29
   3. C34
   4. D21
   Show answer and explanation

   Correct answer: B. 29

   The Injury Severity Score is the sum of the squares of the highest Abbreviated Injury Scale scores in the three most severely injured of the six body regions, giving 4 squared plus 3 squared plus 2 squared, which is 16 + 9 + 4 = 29. The lower extremity and external scores beyond the top three are not included. An Injury Severity Score above 15 defines major trauma, and any single region scoring 6 automatically makes the total 75.

   Reference: Baker and colleagues, The Injury Severity Score, Journal of Trauma, 1974; ATLS Student Course Manual, 10th edition, American College of Surgeons, 2018

7. Question 7 · Hepatobiliary, Pancreas and Spleen

   A general surgeon recognises a complete common bile duct transection intraoperatively during laparoscopic cholecystectomy at a district hospital. There is no hepatobiliary surgeon available and it is 2 a.m. The patient is stable. What is the most appropriate action?

   1. AAttempt an immediate laparoscopic end-to-end anastomosis over a T-tube to restore continuity
   2. BLigate both duct ends, close the abdomen, and arrange elective referral in 6 weeks
   3. CPlace a subhepatic drain, avoid further dissection, close, and transfer urgently to a specialist hepatobiliary unit
   4. DPerform a choledochoduodenostomy to the duodenum as a rapid definitive reconstruction
   Show answer and explanation

   Correct answer: C. Place a subhepatic drain, avoid further dissection, close, and transfer urgently to a specialist hepatobiliary unit

   Outcomes after bile duct injury are best when definitive repair is performed by a specialist hepatobiliary surgeon; an inexperienced attempt at reconstruction substantially increases stricture, re-operation and long-term morbidity. Controlled external drainage with no further dissection preserves ductal length and vascularity and allows safe transfer. Simple ligation without drainage risks biliary sepsis, and choledochoduodenostomy in this setting is technically inappropriate and prone to tension and cholangitis.

   Reference: Multi-society (SAGES/AHPBA/IHPBA/SSAT/EAES) Consensus on Prevention of Bile Duct Injury, Ann Surg (2020)

8. Question 8 · Acute Abdomen and Gastrointestinal Bleeding

   A 47-year-old man with Child-Pugh class B cirrhosis has oesophageal variceal bleeding controlled by band ligation, but he had presented with a hepatic venous pressure gradient of 24 mmHg and active bleeding at endoscopy. He has no overt encephalopathy and no hepatocellular carcinoma. Which strategy offers the greatest reduction in rebleeding and mortality?

   1. ARepeat banding sessions at 2-weekly intervals alone
   2. BPre-emptive (early) TIPS within 72 hours of the index bleed
   3. CDistal splenorenal shunt surgery within 1 week
   4. DLong-term terlipressin infusion
   Show answer and explanation

   Correct answer: B. Pre-emptive (early) TIPS within 72 hours of the index bleed

   Pre-emptive TIPS placed within 72 hours in high-risk patients (Child-Pugh C up to 13 points, or Child-Pugh B with active bleeding at endoscopy, or HVPG above 20 mmHg) significantly reduces treatment failure, rebleeding and mortality compared with standard drug plus endoscopic therapy. Banding alone with beta-blockade is standard secondary prophylaxis in lower-risk patients but is inferior here. Surgical shunts are largely historical, reserved for TIPS failure or unavailability, and long-term vasoconstrictor infusion is neither feasible nor evidence-based.

   Reference: Baveno VII Consensus Workshop on portal hypertension (2022); Garcia-Pagan et al., Early TIPS in variceal bleeding, New England Journal of Medicine (2010)

9. Question 9 · Perioperative Care, Anaesthesia, Pain and Surgical Complications

   Three days after an uneventful laparoscopic sigmoid colectomy in which monopolar hook diathermy was used extensively through a metal cannula, the patient develops peritonitis and CT shows free intraperitoneal gas with fluid adjacent to a small bowel loop remote from the anastomosis. Which mechanism best explains this delayed injury?

   1. ADirect mechanical laceration by the hook at the time of dissection
   2. BInsulation failure or capacitive coupling of the monopolar instrument causing an unseen out-of-view thermal injury
   3. CArgon beam plume contamination of the peritoneum
   4. DLocal anaesthetic toxicity of the port-site infiltration
   Show answer and explanation

   Correct answer: B. Insulation failure or capacitive coupling of the monopolar instrument causing an unseen out-of-view thermal injury

   Delayed presentation of a bowel perforation remote from the operative field several days after laparoscopy with monopolar energy is characteristic of a thermal injury from insulation failure along the instrument shaft or capacitive coupling through a metal cannula, which occurs outside the surgeon's field of view and causes coagulative necrosis that perforates later. A direct mechanical laceration would usually be recognised at operation or present with early peritonitis. Argon plume and local anaesthetic infiltration do not perforate bowel. Prevention includes shaft inspection, avoiding mixed metal-plastic cannula systems, low power settings and active electrode monitoring.

   Reference: SAGES Fundamental Use of Surgical Energy (FUSE) manual, 2nd edition; Wu MP et al., American Journal of Surgery 2000

10. Question 10 · Colorectal, Appendix and Perianal Surgery

    A 45-year-old man has a recurrent fistula-in-ano. Examination under anaesthesia and MRI confirm a high transsphincteric track that encircles more than a third of the external anal sphincter, with an internal opening at the dentate line posteriorly and no active sepsis. He has normal baseline continence. Which is the most appropriate definitive strategy?

    1. ALaying open the entire track by fistulotomy
    2. BCore-out fistulectomy with primary sphincter reconstruction as first choice in all cases
    3. CLong-term antibiotics with no surgery
    4. DDrainage with a loose seton followed by a sphincter-preserving procedure such as LIFT or an endorectal advancement flap
    Show answer and explanation

    Correct answer: D. Drainage with a loose seton followed by a sphincter-preserving procedure such as LIFT or an endorectal advancement flap

    A high transsphincteric fistula involving a substantial proportion of the external sphincter cannot be laid open without a significant risk of faecal incontinence, so the accepted approach is to control sepsis with a loose draining seton and then perform a sphincter-preserving operation such as ligation of the intersphincteric fistula tract (LIFT) or a mucosal advancement flap. Fistulotomy is appropriate only for low, simple, submucosal or low transsphincteric tracks with minimal sphincter involvement. Antibiotics alone do not heal an epithelialised track, and routine fistulectomy with sphincter reconstruction is a specialised salvage option rather than a first-line strategy.

    Reference: Parks AG, Gordon PH, Hardcastle JD. A classification of fistula-in-ano. British Journal of Surgery, 1976; ASCRS Clinical Practice Guidelines for Anorectal Abscess and Fistula-in-Ano, 2022