VIVA VOCE

Compilation of
Questions for
Masters of General
Surgery
1st Edition

By

Dr. Zairul Azwan Mohd Azman

MD (UKM), MS (UKM)

TABLE OF CONTENTS

ACKNOWLEDGEMENT

VIVA VOCE JUNE 2013, UKM MEDICAL CENTRE

PRINCIPAL OF SURGERY TABLE 1 AND 2

OPERATIVE TABLE
PATHOLOGY TABLE

3
7
9

VIVA VOCE NOVEMBER 2012, UM MEDICAL CENTRE

11

PRINCIPAL OF SURGERY TABLE 1 AND 2

OPERATIVE TABLE
PATHOLOGY TABLE

11
13
14

VIVA VOCE NOVEMBER 2010, USM KUBANG KERIAN

15

PRINCIPAL OF SURGERY TABLE 1 AND 2

OPERATIVE TABLE
PATHOLOGY TABLE

15
18
20

ACKNOWLEDGEMENT

I would like to take the opportunity to express my appreciation to those who have
contributed to the making of this question bank.
Any suggestions or comments can be emailed to me at zairulazwan@gmail.com .
All the best in the upcoming exams and dont forget to write to me about your viva
experience J.

Houseman
(egg)

Medical
Officer
(pupa)

Masters
Student
(larva)

VIVA VOCE JUNE 2013, UKM MEDICAL CENTRE

Contributors:
Dr. Yusra, Dr. Falah, Dr. Aini Ibrahim, Dr. Adel, Dr. Ruhi, Dr. Faiz, Dr. Rusdi

PRINCIPAL OF SURGERY TABLE 1 AND 2

Examiners pair 1:
UM and USM
1.

How to setup up an operating theatre?

2.

Tell about the modalities of sterilization?

3.

How to perform cholecystectomy?

a.

Talk about the advantages and disadvantages of open and laparoscopic

cholecystectomy and also their complications.

Examiners pair 2:
UM and KKM
1.

Scenario: An elderly patient came in with abdominal pain. After history talking
and physical examination a diagnosis of perforated gastric ulcer were made.
a.
b.
c.

What is your initial management?

What is your choice of operative technique?
Discuss about post operative care and your concern for an elderly
patient.

2.

Definition of neoplasm, differences between normal cell, benign and malignant

cell. The microscopic and macroscopic features.

3.

What is screening?
a.
b.

What screening tests are available and their sensitivity and specificity
of each test mentioned.
What is an acceptable screening test?

Examiners pair 3:
UM and external examiner

1.

What is shock?

2.

What are the types of shock?

3.

Talk about the pathophysiology of septic and haemorrhagic shock.

4.

Scenario: An elderly man with diabetis mellitus and ischemic heart disease just
had surgery for bleeding ulcer, noted in ICU to have a BP 90/60 and PR
120bpm.
a.
b.
c.

Do you consider this as shock?

What are the causes you think for him to have this BP reading?
What would you do?

5.

Tell me about consent.

6.

Talk about the principles of organ transplant in Malaysia.

7.

What are the advancements in endoscopy?

Examiners pair 4:
1.

Tell me about preoperative preparation for a patient with diabetes mellitus on

insulin going for surgery.

2.

Talk about sliding scale and GIK regime.

Examiners pair 5:
UKM and external examiner
1.

Scenario: A case of polytrauma, patient came to you with head injury. CT-scan
brain showed no intra-cerebral bleed.
a.
b.
c.

Talk about Glasgow Coma Scale (GCS) monitoring in ward.

Tell me regarding fluid management for head injury patient.
What is the pathophysiology of cerebral edema post head injury?

2.

You saw a patient in clinic going for an elective laparoscopic cholecystectomy.

She wanted a more or less better scar. What are the options she has?

3.

You are doing a complex laparoscopic surgery, which will be finishing in hours.
What are the complications related to prolonged pneumoperitoneum?

4.

Topic: Burn injury.

a.
b.
c.

5.

How do you manage a patient who came in casualty with burns injury?
How do you know the burn patient has inhalational injury?
What is the mechanism of fluid loss in burns patient?

What is your opinion on crystalloid and colloid in initial resuscitation?

Examiners pair 6:
1.

Talk about day care surgery.

2.

Talk about palliative care.

3.

Talk about minimally invasive surgery.

4.

Talk about brain death.

5.

General questions about cancer.

a.
b.
c.
d.
e.

What are the factors causing cancer?

Talk about screening and tumour markers?
Tell me the difference about definitive versus palliative resection.
Tell me the difference about neo-adjuvant versus adjuvant therapy.
What are radiotherapy, chemotherapy and targeted therapy?

6.

What is prophylaxis antibiotic?

7.

Statistic questions:
a.
b.
c.
d.
e.

What is evidence base medicine?

What is level of evidence?
How to conduct a randomized controlled trial?
How to calculate a sample size?
What is meta-analysis?

Examiners pair 7:
UKM and KKM
1.

Topic: Blood transfusion.

a.
b.
c.

2.

Scenario: A patient was diagnosed of esophageal cancer with a history of

prolonged dysphagia. You plan for an elective surgery for this patient.
a.

What is massive blood transfusion and its problem?

Talk about transfusion reaction.
Talk about blood products.

Talk about perioperative management and nutrition support for this

patient.

Examiners pair 8:
UM and UKM
1.

Talk about the principals of diathermy usage.

2.

Talk about the principals of laparoscopic surgery.

3.

Scenario: You saw a 50 years old patient in clinic with a pelvic mass plan for
surgery.
a.

How do you prepare this patient?

(Cardiac risk, nutritional support, dvt, baseline assessment, etc)

Examiners pair 9:
KKM and UM
1.

Tell me about high-risk consent.

2.

Tell me about surgical site infection rate for each type of wound.

3.

What do you know about prophylactic antibiotics?

4.

Tell me about audit.

5.

Describe briefly about nosocomial infection.

6.

Topic: MRSA.
a.
b.

7.

What do you know about MRSA and vancomycin resistant?

What are the steps to be taken if a carrier of MRSA is detected among
your staff?

Topic: Liver abscess.

a.
b.
c.

How do you manage a liver abscess?

What are the common organisms?
How do you culture these organisms?

OPERATIVE TABLE
Examiners pair 1:
UKM and KKM
1.

Given a scenario of a patient involve in a motor vehicle accident. He sustained

hepatic injury, which requires emergency surgery.
a.
b.
c.
d.

What type of operation will you choose?

How to prepare the operating theatre and requirements for this surgery?
Tell me how do you perform the operation?
Would you ask for intubation first or prep and drape first?

2.

Discuss about four-quadrant packing during laparotomy.

3.

Tell me ways of stopping bleeding from liver injury and how to manage it?

4.

How to perform a left adrenalectomy for pheochromocytoma?

Examiners pair 2:
UM & KKM
1.

Describe how to do an axillary lymph node dissection?

2.

Tell me what will you consent this patient prior to surgery (axillary lymph node
dissection)?

3.

Where is the landmark of incision in detail? In particular the borders of axilla

dissection.

4.

Describe the course of inter-costobrachial nerve and why is it on injuring the

thoracodorsal nerve patient will only get weakness but not paralysis?

5.

Describe in detail how do you perform an inguinal hernia repair.

a.
b.

6.

Types of repair?
Why do you ligate the superficial epigastric vein?

If you are doing an obstructed inguinal hernia and on opening of the sac you see
blood coming out what will you do?

Examiners pair 3:
UKM and KKM

1.

How do you perform a femoral embolectomy?

2.

Talk about the principles of anti-reflux surgery.

3.

You have a patient with stomach cancer, how do you perform a total
gastrectomy?

4.

Describe to me about sistrunk procedure/surgery and its complications.

5.

Describe how do you perform a small bowel resection for a small bowel
tumour?

PATHOLOGY TABLE
Examiners pair 1:
UKM and USM
1.

Image: Omphalocele.
a.
b.
c.

2.

Image: Gallbladder with gallstone.

a.

3.

Describe the pathology of cholecystitis and gallstone formation?

Image: Gangrenous lower limb with dry and wet areas due to snake bite.
a.
b.
c.

4.

What is your diagnosis?

How to manage this condition?
How do you cover the expose structure?

Describe the lesion.

What group/type of venom causes this condition?
Example of a snake that produce this type of venom.

Image: X-ray film of a barium swallow with bird's beak appearance.

a.
b.
c.

What is your diagnosis?

Any confirmatory test to your diagnosis?
What are the treatment options?

Examiners pair 2:
UKM and Academy of Medicine
Candidates are required to describe the images, pathophysiology and brief management.

1.

Image: Appendix mucocele.

2.

Image: Acute ischemic limb.

3.

Image: CT-scan abdomen showing hydronephrosis followed by an axial cut at

bladder level showing BPH and irregular bladder wall.

4.

Image: Colonoscopy image of a fungating tumour.

5.

Image: Perianal region with multiple external opening and previous scar
(complex fistula-in-ano).

6.

Image: CT-scan brain showing cerebral concussion and subdural haemorrhage.

7.

Image: OGDS image showing oesophageal varices.

Examiner pair 3:
USIM and UKM
1.

Talk about wound healing.

2.

Image: Specimen of a kidney with a growth renal cell carcinoma.

a) Describe what you see.
b) What is your diagnosis?
c) How do you manage this patient?

Examiners pair 4:
UKM and Academy of Medicine
1.

Image: Specimen of a resected sigmoid or an anterior resection.

a)

2.

Image: Specimen of a right hepatectomy.

a)
b)
c)
d)

3.

Describe the role of neoadjuvant in rectal cancer.

Describe the findings.

How do you diagnose hepatocellular carcinoma (hcc)?
What are the features of hcc in CT-scan?
What are the principles management of hcc?

Report: Histopathological examination report for invasive ductal carcinoma of

breast.
a) Comment on the report.
b) How do you manage?

4.

Report: Histopathological examination report for ductal carcinoma in situ.

a) Comment on the report.
b) How do you manage?

VIVA VOCE NOVEMBER 2012, UM MEDICAL CENTRE

Contributor:
Dr. Afirul

PRINCIPAL OF SURGERY TABLE 1 AND 2

Examiners pair 1:
KKM and external examiner
1.

Scenario: A patient had undergone a control damage surgery last night. You are
reviewing this patient today and noted a low urine output:
a.
b.

2.

Tell me about the hazards in the operating theatre.

3.

Define quality of life.

4.

Define palliative care.

5.

Define level of care.

6.

What are the criteria of an ICU admission?

7.

Talk about types of respiratory failure.

8.

Tell me the blood results that will suggest a respiratory failure.

9.

Topic: Statistics.
a.
b.
c.
d.

11

What is your diagnosis at this point? Why?

Any differential diagnosis?

What is mean?
What is median?
What is mod?
What are the advantages using median as compare to mean?

Examiners pair 2:
UPM, KKM and external examiner
1.

Scenario: You have a patient that as undergone an anterior resection with a

defunctioning ileostomy.
a.
b.
c.
d.
e.
f.
g.

2.

What do you look for during your rounds the next day?
A few days later you noticed he developed fever. What do you think?
What are the signs to suggest an anastomotic leak?
What blood investigations would you order?
What imaging modalities would you request?
Why a ct-scan? What if patient developed an acute renal failure?
Lastly you decided to push him for surgery, intraoperative findings
revealed a gangrenous descending colon. What procedure will you
perform?

Scenario: A patient with a rectosigmoid cancer was admitted for an elective

anterior resection on Monday. While doing rounds during the weekend you
noticed his left leg was swollen.
a.
b.
c.
d.
e.
f.
g.
h.

What is your diagnosis?

What are your differential diagnoses?
If you suspected a deep vein thrombosis, what will you do?
When do you decide to do an ultrasound and what are you looking for?
Describe findings in ultrasound that would suggest a higher risk of
developing pulmonary embolism.
Describe the guidelines for prophylaxis of deep veins thrombosis.
When would you reschedule this patient surgery and why?
Topic: Inferior vena cava (IVD) filter.
i.
ii.
iii.

Describe types of IVC filter.

Where would you deploy the IVC filter?
When are you going to remove the IVC filter?

OPERATIVE TABLE

Examiners pair 1:
UKM and UM
1.

Scenario: You have seen a patient with varicose veins and plan for an elective
high saphenous vein ligation surgery.
a) What are the preoperative preparations?
b) What are the complications of this surgery?
c) Describe the postoperative care for this patient.

2.

Scenario: A patient came in with an acute intestinal obstruction due to a midtransverse colon tumour?
a)
b)
c)
d)
e)
f)

3.

Describe the initial management.

What surgery would you do?
Explain how would you do an extended right hemicolectomy?
If the tumour is at the splenic flexure will it change your choice of
resection and why?
What are your concerns about performing a left hemicolectomy?
Describe what is a watershed area?

Topic: Bowel anastomosis

a) Explain the principles of bowel anastomosis.
b) Described type of sutures used in bowel anastomosis.

13

PATHOLOGY TABLE

Examiners pair 1:
UM and USM
1.

Image: Specimen of a gastrectomy and right hemicolectomy on a same patient.

a.
b.
c.
d.
e.
f.
g.
h.
i.

2.

Describe your findings. (Linitis plastica on the gastrectomy specimen

and a constricted ulcer on the right hemicolectomy specimen)
What is the most likely diagnosis?
What is the differential diagnosis? What if the patient is female what
will be the differential diagnosis?
Talk bout Laurens classification.
Which type has the poorest prognosis?
What surgery would you perform in a diffuse type of stomach cancer?
Draw all stations of the stomach lymph nodes.
Describe the TNM classification for stomach cancer.
What will be the prognosis of a patient with locally advance stomach
cancer?

Image: Specimen of a laparoscopic cholecystectomy with presence of calculi in

the gallbladder.
a.
b.
c.
d.

Describe your findings.

What type of stone/calculi do you think this is?
What is the commonest stone/calculi in our population?
Describe how to perform a laparoscopic cholecystectomy.
i.
ii.

Where are the locations of the laparoscopic ports?

Describe about Calots triangle.

VIVA VOCE NOVEMBER 2010, USM KUBANG KERIAN

Contributors:
Dr. Ngoo, Dr. Zairul

PRINCIPAL OF SURGERY TABLE 1 AND 2

Examiners pair 1:
UKM and external examiner
1.

Scenario: 70 years old man came in with per-rectal bleeding. Whilst assessing
him, the patient developed torrential per-rectal bleed. You are preparing to take
him in for emergency total colectomy. Patients daughter came and asked about
i.

Her fathers prognosis and whether you can guarantee that his
father will recover.

b) You said no guarantee. Hearing this the daughter refuse to give consent
since her father is already old and unlikely to survive anyway.
i.
c)

What do you want to do now?

So you would still want to proceed with emergency surgery. But her
daughter would not consent it (I suppose the patient could not give
consent for himself).
i.

What next?

d) You explained that you would get 2 consents from senior consultants
for the patient. But your anaesthetist would not agree to consent.
Furthermore, your anaesthetist is agreeable with the patients daughter,
that is, no need surgery.
i.
e)

What next?

After lengthy discussion consent was finally obtained, patient survived

and thanked you for saving him.

15

i.

Tell me the bodys physiology changes of this patient when he

was losing blood per-rectally. Discuss Basketts classification
of shock

2.

Scenario: You are a senior consultant. Your elective operating theatre has listed
a 7 years old boy for herniotomy, a 70 years old diabetic man for some surgery,
and two other middle-aged ladies for operations too.
a)

Tell me the principles of organizing the list.

b) How would you prepare the patients individually?

c)

How would you prioritise?

d) Why would you prioritise?

e)

Why should a young boy go before an elderly diabetic man? If you do

not list the boy as the first in the list, what difficulties will your run
into?

f)

Can you prioritise the diabetic man instead, and if so, give your
reasons.

3.

Tell me in what situations of trauma that patients can be managed

conservatively.

4.

In what situation of abdominal trauma would you consider conservative

management?

5.

Tell me about the grading of solid organ injury and how would you re-act to it.

6.

A patient with abdominal trauma came to you, how would you assess for
bleeding intra-abdominally and how this would influence your management.
a)

7.

What would make you go for operative management subsequently?

As a surgeon, what influences your surgical incision? Tell me the principles of

creating a surgical wound.

8.

You commonly encounter surgical patients needing dialysis. Tell me, in what
situations would dialysis be required.
a)

You said renal failure. Can you tell me about renal failure, how you
would assess for it and what are the implications of renal failure?

b) What types of dialysis do you know of and how do you choose?

c)

You said haemodialysis through a femoral access. Tell me what are the
complications associated with central venous catheterization.

d) The patient ended up needing a long-term haemodialysis. How would

you go about this?
e)

Where do you want to create your haemodialysis access?

f)

What are the principles of creating a haemodialysis access?

Examiners pair 2:
USM and KKM
1.

Topic: Retroperitoneal hematoma.

a)

How to classify abdominal trauma? Blunt versus penetrating injury.

b) Tell me about the zones in retroperitoneal hematoma.

c)

What are the structures in each zone?

d) How do you manage for each zone?

e)

When do you decide go in for emergency surgery or just observe the

patient?

2.

Topic: Abdominal wound dehiscence and burst abdomen.

a)

How do you classify wound dehiscence?

b) What clinical signs to indicate that wound is dehisce?

c)
3.

How to manage?

Scenario: Patient post emergency laparotomy for a perforated gastric ulcer

developed fever.
a)

Talk about post op fever.

b) How to investigate and manage?

4.

Scenario: A patient post total thyroidectomy.

a)

When do you stop carbimazole and propanolol? Why?

b) Patient complain of numbness, what would you checked?

c)

How do you treat hypocalcemia for this patient?

d) What are the complications of hypocalcemia?

5.

Topic: Body response to injury/surgery.

a)

Talked about the erb and flow phase, what happen during these phase?

b) Postoperative intravenous fluid (IVD), to give either all normal saline

or a mixture of normal saline and dextrose saline, why?

17

OPERATIVE TABLE

Examiners pair 1:
KKM and USM
1.

Topic: Femoral embolectomy.

a.

How do you perform a femoral embolectomy?

b.

How do you consent the patient for the surgery?

c.

What sizes of Fogartys catheter would you prepare and how do you
prepare it?

d.

So you would obtain proximal and distal control. What would you be
using?

e.

So you said vascular loops. How do you apply them? Are you going to
use vascular clamps?

f.

How do you keep your loops taut?

g.

Hold on, before you perform the arteriotomy, would you not want
systemic heparinisation?
1.

What dose of heparin?

h.

What arteriotomy incision would you make and why?

i.

So you choose a longitudinal incision, why not a transverse?

j.

So what is the problem with a transverse incision?

k.

What is the problem with a longitudinal incision?

l.

So you have opened up the vessel, and you said you will assess from
proximal inflow but usually there will be poor inflow anyway,
otherwise you will not end up with an acute limb ischaemia. What
catheter size would you choose for proximal embolectomy?

m. How about distally?

2.

n.

And how much air or water are you inflating the balloon catheter with?

o.

Would you be satisfied after removing the emboli?

Topic: Proximal ureterolithotomy.

a.

Describe how you would go about a performing a proximal

ureterolithotomy.

b.

How do you identify the 12th rib?

c.

Do you muscle cut or muscle split?

d.

So you have seen the ureter and you said that you want to apply distal
and proximal control. Is that really necessary?

e.

Ok I agree with proximal control but why do you think it is important?

f.

How about distal control, is it necessary?

g.

Now you have removed the stone, what else would you do?

h.

You said you want to insert a ureteric stent, which type and how do you
place it?

i.

How are you going to manage the stent?

Examiners pair 2:
KKM and UM
1.

Scenario: Patient came with an obstructed sigmoid tumour. You plan to bring
him in for emergency surgery.

2.

a.

How will you take consent for the surgery from this patient?

b.

What is an informed consent?

c.

Discuss about Hartmanns procedure or a defunctioning colostomy.

How do you perform a hemithyroidectomy?

a.

3.

19

What to look for post operative?

Topic: Sutures.
a.

Definition.

b.

How do you classify sutures?

c.

Give example.

d.

Where does a catgut suture come from?

e.

Which part of a sheep does catgut comes from?

f.

Where does silk sutures comes from?

PATHOLOGY TABLE
Examiners pair 1:
1.

Image: A mans buttock with a huge swelling. It drained pus.

a.

Describe the findings.

b.

What are the possibilities?

c.

Who gets this type of swelling?

d.

What is the possible micro-organism?

e.

What are the other more sinister causes of this swelling?

(Answer: psoas abscess, tuberculous spinal abscess)

2.

Image: A bilobar structure joined in the middle, lobulated (thyroid gland,

multinodular goiter).

3.

4.

a.

What is this and why do you say so?

b.

So you say it is a multinodular goiter, what is your management?

c.

You want to offer total thyroidectomy. What are the complications?

d.

What if you do a subtotal thyroidectomy?

Image: Bladder calculi and prostate gland

a.

Identify the specimens and mention why.

b.

What is the relationship?

c.

What is the effect of bladder outlet obstruction?

d.

What is the effect of bladder calculi?

Image: CT-scan of a cystic lesion of the right kidney, loss of architecture of the
left kidney.
a.

Describe the findings.

b.

How do you diagnose renal cell carcinoma on ct-scan?

c.

What treatment would you offer assuming that the contralateral kidney
is normal?

5.

What is an incidentaloma and give some examples?

a.

How would you go about investigating for one?

b.

What would suggest to you that an incidentaloma needs to be treated?

Examiners pair 2:
UKM and USM
1.

Image: Abdominal X-ray film of dilated small bowel with intussusception of

small bowel.
a)

Why you say this is small bowel?

b) Causes of intussusception?
2.

Image: Specimen of a resected small bowel with 3 polypoidal lesions.

a)

Describe the picture.

b) What are the possible associated diseases?

3.

Image: Specimen of a partial gastrectomy.

a)

4.

What are the possible reasons of gastrectomy?

Image: Specimen of a cut opened stomach with an ulcer on the mucosa

a)

Describe and show the edges of the ulcer.

b) How to do classify stomach cancer?

c)
5.

What is Borrmann and Laurens classification?

Image: Hip X-ray with multiple lytic lesion and pathological fracture neck of
femur.
a)

6.

What are the most likely primaries? (in men and women)

Image: MRCP film

a)

Delineate the anatomy.

b) What is the most likely diagnosis? (cholangiocarinoma)

7.

Image: Specimen of a resected abdominal aortic aneurysm

a)

How many ways to classify an aneurysm?

b) What are the differences between a true and false aneurysm?

c)

21

Tell me the causes of an abdominal aortic aneurysm.

8.

Image: Gangrene leg.

a)

Describe the gangrene and the edges.

b) How do you investigate and manage?

c)

If this were due to snakebite, what type of snake would cause it?

d) What type of venom i.e. neurotoxic, myotoxic or hemotoxic?