Surgery Specimen Viva Voce Examination Question And Answers

Specimens

Tuberculous (TB) Lymphadenitis

Question 1. What is this specimen?
Answer: Specimen of lymph nodes which are matted. The cut surface shows caseation. Hence, it is tuberculous lymphadenitis.

Question 2. What is the microscopic picture?
Answer: Central caseation surrounded by epithelioid cells, Langhans’ type of giant cells.

Read And Learn More: Surgery of Urology Notes

Question 3. What are the stages of TB lymphadenitis?
Answer:

• Stage of lymphadenitis
• Stage of matting
• Stage of cold abscess
• Stage of collar stud abscess
• Stage of sinus formation

Question 4. Why is matting seen in TB lymphadenitis?
Answer: It is because of periodontitis

Question 5. What is the treatment of cold abscess?
Answer: Nondependent aspiration by using a wide bore needle, to avoid sinus formation.

Lymphoma

Question 1. What is the diagnosis?
Answer: Multiple lymph nodes which are discrete and not matted. The Cut surface does not show caseation. It is homogenous. Hence, this is a specimen of Hodgkin’s lymphoma.

Question 2. How do you confirm the diagnosis?
Answer: Lymph node biopsy

Question 3. What is the microscopic picture?
Answer: Cellular pleomorphism: Lymphocytes, histiocytes, eosinophils, monocytes with giant cells containing mirror image nuclei—Reed-Sternberg cell.

Question 4. What are the common lymph nodes involved in Hodgkin’s lymphoma?
Answer: Cervical, axillary, para-aortic, iliac and inguinal lymph nodes.

Question 5. Is Waldeyer’s ring involvement seen in Hodgkin’s lymphoma?
Answer: No, it is usually seen in non-Hodgkin’s lymphoma.

Specimen Of Hemiglossectomy With Hemimandibulectomy

Question 1. What is this specimen?
Answer: Specimen showing growth arising from the tongue and infiltrating the mandible.

Question 2. What is the diagnosis?
Answer: Advanced carcinoma tongue

Question 3. Is radiotherapy indicated in this situation?
Answer: No, because the chances of radionecrosis of the mandible are high.

Question 4. What type of X-ray is taken to look for involvement of the mandible?
Answer: Orthopantomogram

Question 5. What is Commando’s operation?
Answer: Hemiglossectomy with excision of the floor of the mouth, hemimandibulectomy, with radical block dissection of the neck done in a single stage, with en bloc removal.

Chronic Gastric Ulcer

Question 1. What is this specimen?
Answer: Specimen of the stomach showing rugosity of the stomach. There is a deep ulcer crater along the lesser curvature.

Question 2. What is the diagnosis?
Answer: Benign gastric ulcer

Question 3. Why is it a benign gastric ulcer?
Answer: Since the rugae are of converging type, it is a benign gastric ulcer.

Question 4. How do you rule out malignancy in a gastric ulcer?
Answer: Endoscopic biopsy

Question 5. What is the incidence of gastric ulcer turning into malignancy?
Answer: 0.5 to 2%

Linitis Plastica

Question 1. What is this specimen?
Answer: Specimen of the stomach showing loss of normal rugosity. There is a nodular extensive infiltrating lesion along the entire length of the stomach.

Question 2. What is the diagnosis?
Answer: Linitis plastica—leather bottle stomach.

Question 3. What is linitis plastica?
Answer: It is an extensive fibrosis involving the entire submucosa of the stomach initially and involves other layers later.

Question 4. What is the treatment for linitis plastica?
Answer: Radical total gastrectomy

Question 5. What is the D2 prognosis?
Answer: Very poor

Intussusception

Question 1. What is this specimen?
Answer: Specimen of intestine showing one portion of bowel invaginated within the other.

Question 2. What is the diagnosis?
Answer: Intussusception

Question 3. What is the common type of intussusception?
Answer: Ileocolic

Question 4. What are the parts of intussusception?
Answer: Intussusceptum, intussuscipiens, neck and apex.

Question 5. What is the treatment in children?
Answer:

• Hydrostatic reduction or operative reduction.
• If there is gangrene—resection followed by end-to-end anastomosis

Carcinoma Rectum

Question 1. What is this specimen?
Answer: Specimen of rectum showing ulceroproliferative growth in the middle of the rectum. The specimen also shows the entire rectum and anal canal.

Question 2. What is the diagnosis?
Answer: Carcinoma rectum

Question 3. What is this surgery?
Answer: Abdominoperineal resection (excision) (APR). In this operation, the entire rectum, anal canal, part of the sigmoid colon, fat, fascia, lymphatics and regional nodes are removed en bloc followed by permanent colostomy in the left iliac fossa.

Question 4. What are the indications for APR?
Answer: Growth in the lower rectum wherein the sphincter cannot be saved.

Question 5. What is the position of the patient during APR?
Answer: Supine with lithotomy called Lloyd Davis position.

Gangrenous Appendicitis

Question 1. What is this specimen?
Answer: It is an appendicectomy specimen showing blackish discolouration of the appendix.

Question 2. What factors cause gangrene of the appendix?
Answer: Gangrenous appendicitis occurs usually in elderly patients, where there is decreased vascularity due to atherosclerosis. It can also occur when the lumen is blocked due to faecolith, thereby causing ischaemia.

Question 3. What is the one simple investigation which is useful in diagnosing appendicitis?
Answer: Total WBC count. Above 10,000 cells/cu mm of blood with increased neutrophil count.

Question 4. What are the complications of acute appendicitis?
Answer:

• Appendicular mass (in untreated cases)
• Perforation with an abscess
• Perforation with generalised peritonitis
• Pylephlebitis, portal pyaemia
• Septicaemia, gram-negative shock

Question 5. How do you treat an appendicular mass?
Answer: Conservative line, Oschner-Sherren regime— liquid and semisolid diet, antibiotics, intravenous fluids, etc.

Carcinoma Ascending Colon

Question 1. What is this specimen?
Answer: Specimen of the terminal ileum, caecum and right colon with removal of involved lymph nodes and fat fascia. Nowadays, only 4–6 cm of ileum is removed.

Question 2. What is the surgery?
Answer: Right radical hemicolectomy done for growth in the ascending colon.

Question 3. How do you identify the colon?
Answer: Taenia coli and appendix are seen. The colon has a larger diameter compared to the small intestine.

Question 4. What are the investigations?
Answer: Barium enema will show persistent filling defects. However, colonoscopy is the investigation because the growth can be visualised and a biopsy can be taken.

Question 5. What do you mean by limited resection?
Answer: It is done for ileocaecal tuberculosis wherein the diseased segment is removed.

Meckel’s Diverticulum

Question 1. What is the specimen?
Answer: Resected specimen of intestine showing a diverticulum. Hence, it is a Meckel’s diverticulum.

Question 2. Why is it a Meckel’s diverticulum?
Answer: Because it is a single diverticulum arising from the antimesenteric border of the intestine.

Question 3. What are common symptoms?
Answer: Bleeding per rectum, abdominal pain due to inflammation, intestinal obstruction and peritonitis due to perforation.

Question 4. What is the cause and what are the types of bleeding?
Answer: Ulcer in the ectopic gastric mucosa. Bleeding can be occult, in small quantities or rarely can be massive.

Question 5. How do you diagnose Meckel’s diverticulum?
Answer: Radio-nuclear (99mTc pertechnetate) scan is helpful when there is active bleeding.

Polycystic Kidney

Question 1. What is this specimen?
Answer:

• Specimen of the kidney with multiple cystic lesions.
• The entire kidney is involved.

Question 2. What is the diagnosis?
Answer: Polycystic kidney

Question 3. Why do you say it is polycystic kidney?
Answer:

• The kidney is grossly enlarged
• The outer surface is bosselated
• Multiple cysts are present

Question 4. What are the clinical features of polycystic kidney?
Answer:

• Women: 30–50 years
• Bilateral renal mass
• Hypertension

• Haematuria
• Renal failure

Question 5. What is the treatment?
Answer:

• If there is no renal failure, control hypertension.
• If there is renal failure—dialysis followed by renal transplantation.

Renal Cell Carcinoma

Question 1. What is this specimen?
Answer:

• Specimen of the kidney, because it is reniform shaped, ureter and calyces, are seen.
• In the upper pole, there is the destruction of the calyces with a solid mass. The Cut surface is smooth.

Question 2. What is the diagnosis?
Answer: Renal cell carcinoma.

Question 3. What is the microscopic picture?
Answer: Cuboidal or polyhedral clear cells with deeply stained rounded nuclei—clear cell carcinoma. Sometimes, dark cells can coexist. In some cases, the walls of blood vessels are lined by tumour cells.

Question 4. How does it spread?
Answer: Lymphatic and blood spread

Question 5. What are the primary malignant tumours which spread by blood?
Answer: Renal cell carcinoma, follicular carcinoma thyroid, carcinoma prostate, carcinoma breast, bronchogenic carcinoma.

Hydronephrosis

Question 1. What is this specimen?
Answer: Specimen of the kidney with ureter showing dilatation of pelvicalyceal system. Calyces are club-shaped.

Question 2. What is the diagnosis?
Answer: Hydronephrosis—probably due to a pelvic-ureteric junction (PUJ) obstruction.

Question 3. Why PUJ obstruction?
Answer: Ureter is not dilated

Question 4. What are the common causes of obstruction at PUJ?
Answer:

• Stone in the pelvis
• Aberrant vessels—a lower polar artery or vein arising from the main vessels in an aberrant position obstructs the upper ureter.
• PUJ dyskinesia—occurs due to incoordination between neuromuscular impulses and pelvis.

Question 5. What is the treatment of PUJ dyskinesia?
Answer: Anderson-Hynes pyeloplasty.

Carcinoma Penis

Question 1. What is this specimen?
Answer: Specimen of the penis, showing the glans. The prepuce is cut open showing the growth.

Question 2. What is the diagnosis?
Answer: Partial amputation done for carcinoma penis

Question 3. What are the indications for partial amputation of the penis?
Answer: Growth confined to the glans penis or to the prepuce.

Question 4. If a shaft is involved, what is the treatment?
Answer: Total amputation of the penis followed by perineal urethrostomy.

Question 5. What are the complications of perineal urethrostomy?
Answer: Bleeding, dermatitis and stenosis. The stenosis should be dilated by using Hegar’s dilators.

Seminoma Testis

Question 1. What is this specimen?
Answer: Specimen of testis showing spermatic cord. Cut surface of the testis is smooth and homogenous with a tumour in the upper part.

Question 2. What is the diagnosis?
Answer: Seminoma

Question 3. Why not a teratoma?
Answer: In a teratoma, the cut surface is not homogenous.

Question 4. How does seminoma spread?
Answer: Mainly by lymphatics.

Question 5. What type of orchidectomy is done for testicular tumours and why?
Answer: High orchidectomy, through an inguinal incision. If the scrotum is incised, chances of an alternate pathway of lymphatics opening up are high. Hence, inguinal exploration is the choice.

Cholecystectomy For Gallstones

Question 1. What is this specimen?
Answer: Cholecystectomy specimen.

Question 2. What is the diagnosis?
Answer: Multiple stones are present within the lumen— the diagnosis is probably chronic cholecystitis.

Question 3. Why do you say it is a gallbladder?
Answer: It is pear-shaped with a fundus, body and a narrow portion—cystic area.

Question 4. What is Hartmann’s pouch?
Answer: It is the distal angulated portion of the gallbladder wherein a stone commonly lodges.

Question 5. What are the common symptoms of gallstones?
Answer: Flatulent dyspepsia, gallstone colic, and acute and chronic cholecystitis are common symptoms of gallstones. Mucocoele, empyema, perforation and gallstone pancreatitis are other complications.

Hydatid Cyst

Question 1. What is this specimen?
Answer: Specimen of laminated membranes—this layer is also called ectocyst. It is thick and elastic resembling onion skin appearance.

Question 2. What is the diagnosis?
Answer: Hydatid cyst—mostly liver

Question 3. What are the other layers of hydatid cysts?
Answer:

The outermost layer is called the adventitial layer which blends firmly with liver tissue. The middle layer is the ectocyst, also called the laminated membrane. The inner layer is the germinal epithelium, also called the endocyst within which brood capsules and daughter cysts are present.

Question 4. What is the drug for hydatid disease?
Answer: Albendazole 400 mg, a day for 15 days followed by no drug for 15 days. Then restart the cycle. Such treatment may have to continue for 6 months depending on the response rate.

Question 5. What are the common complications of hydatid cyst of the liver?
Answer: Infection, rupture, calcification, cholangitis with jaundice are a few complications.

Radical Gastrectomy Including Removal Of The Colon

Question 1. What is the specimen?
Answer: Specimen of the stomach with transverse colon.

Question 2. Why stomach and colon?
Answer: It has lesser curvature and greater curvature— pylorus, body and proximal stomach. The colon is the immediate structure below the stomach.

Question 3. What does it show?
Answer: Exophytic growth infiltrating the colon

Question 4. What is the final diagnosis?
Answer: Most probably it is carcinoma stomach infiltrating the transverse colon.

Question 5. What is the best investigation in such cases to identify local infiltration?
Answer: CT scan

Lipoma

Question 1. What is this specimen?
Answer: Specimen of lipoma

Question 2. Why do you say it is lipoma?
Answer: It is lobular, yellow in colour

Question 3. What is the most common site and type of lipoma?
Answer: Flank is the commonest site. Single and subcutaneous variety is the commonest type.

Question 4. What are the common complications of lipoma?
Answer: Liposarcoma and intussusception

Question 5. Which type of lipoma gives rise to intussusception?
Answer: Submucosal type

Malignant Melanoma

Question 1. What is this specimen?
Answer: Specimen of foot showing a large ulcerated growth in the sole of the foot.

Question 2. What is the diagnosis and why do you say so?
Answer: Malignant melanoma because the lesion is pigmented.

Question 3. What is the most common type of malignant melanoma?
Answer: Superficial spreading is the first followed by nodular variety.

Question 4. What are the staging systems available for this condition?
Answer: Clark’s level of invasion and Breslow’s thickness are important staging systems in addition to TNM staging.

Question 5. What are the ABCDE of melanoma?
Answer:

• Asymmetry
• Border irregular
• Colour variegation
• Diameter >6 mm
• Elevation

Thyroidectomy Specimen

Question 1. What is this specimen?
Answer: Specimen of thyroid gland showing both lobes and Isthmus.

Question 2. What is the diagnosis and why do you say so?
Answer: Probably it is a subtotal thyroidectomy specimen— surgery is done for multinodular goitre.

Question 3. What is the commonest type of malignancy of the thyroid gland?
Answer: Papillary carcinoma—63%. 2nd common type is follicular carcinoma thyroid.

Question 4. What is the surgical treatment for well-differentiated carcinoma thyroid gland?
Answer: Most centres follow total thyroidectomy. If the patient is in the low-risk category, a lobectomy can be done.

Question 5. What blood investigation is useful in the follow-up period of papillary carcinoma thyroid gland?
Answer: Thyroglobulin

Wide Excision Specimen Of Skin

Question 1. What is this specimen?
Answer: Specimen of skin which has been excised with normal skin. Hence, wide excision specimen.

Question 2. What is the diagnosis and why do you say so?
Answer: Probably it is a squamous cell carcinoma because edges are everted.

Question 3. What are the common sites of squamous cell carcinoma skin?
Answer: Areas with chronic irritation, e.g. Kangri cancer in the abdominal wall, chimney sweepers cancer, etc.

Question 4. What are the common precancerous lesions for squamous cell carcinoma?
Answer: Leukoplakia, Bowen’s disease, chronic irritation and scar tissues, etc.

Question 5. What do you call squamous cell carcinoma arising in scar tissue?
Answer: Marjolin’s ulcer

Whipple’s Pancreaticoduodenectomy

Question 1. What is this specimen?
Answer: Specimen showing distal stomach, duodenum, proximal jejunum and pancreatic head.

Question 2. What is the name of this operation?
Answer: Whipple’s pancreaticoduodenectomy

Question 3. Why is it done?
Answer: Mostly due to periampullary carcinoma

Question 4. How can you get a histopathological diagnosis?
Answer: Endoscopic biopsy

Question 5. Is there any other indication for Whipple’s surgery?
Answer: Pancreatic head mass—doubt exists between chronic pancreatitis and carcinoma head pancreas. The provided experience of the surgeon is good.

Right Hemicolectomy For Carcinoma Caecum

Question 1. What is this specimen?
Answer: Specimen showing distal ileum, caecum, part of the ascending colon and a few lymph nodes

Question 2. What is the name of this operation?
Answer: Limited colectomy

Question 3. Why is it done?
Answer: Mostly due to ileo-caecal tuberculosis

Question 4. Why do you say so?
Answer: Stricture is seen in the terminal ileum

Question 5. What was the indication for surgery?
Answer: Acute intestinal obstruction

Splenectomy Specimen

Question 1. What is this specimen?
Answer: Specimen showing spleen with laceration of the diaphragmatic surface.

Question 2. Why laceration?
Answer: Blunt injury is the most common cause of ruptured spleen.

Question 3. What will be the clinical manifestation?
Answer: Bleeding

Question 4. What other surgery can be done for bleeding?
Answer: Partial splenectomy or selenography

Question 5. What is the dangerous complication after splenectomy?
Answer: Opportunistic post-splenectomy infections

Useful Tips:

• Please look into the specimen carefully
• Please see both sides of the specimen
• Think which is the most likely organ involved
• Think what is the probable diagnosis