MyPasTest » MRCS A Online - Jan Exam 2015
18. Surgical Specialities; Cardiothoracic Surgery (26Qs)
-------------------------------------------------------------------------------------------------------------------
01. Theme: Thoracic incisions
A Median sternotomy
B Posterolateral thoracotomy
C Clamshell thoracotomy
D Anterior thoracotomy.
For each of the following situations select the most useful surgical incision. Each option may be used
Page
once, more than once, or not at all. 1237
Scenario 1
Aortic transection at the junction of the aortic arch with descending thoracic aorta
A - Median sternotomy« YOUR ANSWER
B - Posterolateral thoracotomy« CORRECT ANSWER.
The junction of the aortic arch with the descending thoracic aorta is the commonest site of aortic
transection, often after a deceleration injury. The aorta is found in the posterior mediastinum and is best
approached via a left posterolateral thoracotomy.
Scenario 2
Stab wound to the right ventricle
B - Posterolateral thoracotomy« YOUR ANSWER
A - Median sternotomy« CORRECT ANSWER.
The right ventricle is the most anterior chamber of the heart and is thus most easily accessed via a
median sternotomy.
Scenario 3
Bilateral penetrating chest injuries with lung parenchymal lacerations
C - Clamshell thoracotomy« CORRECT ANSWER.
Bilateral penetrating lung injuries will often need wide exposure to be appropriately repaired. Access to
both lungs is feasible via a median sternotomy, but a clamshell thoracotomy gives the best access to
both hemithoraces.
02. An 86-year-old man is diagnosed with a 2cm lung squamous cell carcinoma confined to the anterior
bronchopulmonary segment of the right upper lobe, its staging is T1N0M0 suggesting curative surgery is
an option. He is a life-long smoker. Which of the following is the most desirable therapeutic option?
Single best answer - select one answer only.
Chemotherapy« YOUR ANSWER
Pnuemonectomy
Radiotherapy
Sleeve lobectomy
Wedge resection« CORRECT ANSWER.
Sleeve lobectomy describes the resection of a lobe and a portion of the main stem bronchus with re-
implantation of the distal bronchus. It is often performed for centrally located lesions and especially
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail:
, MyPasTest » MRCS A Online - Jan Exam 2015
18. Surgical Specialities; Cardiothoracic Surgery (26Qs)
-------------------------------------------------------------------------------------------------------------------
favourable for patients with limited cardiopulmonary reserve. Wedge resections can be performed with
video-assisted thorascopic surgery (VATS). Studies comparing lobectomy with wedge resection in non-
small cell lung cancer (NSCLC) have shown that 5-year survival rate with wedge resection to be lower
than with lobectomy however in older patients with poor lung function this may be a better option.
Chemotherapy is used in the neoadjuvant or adjuvant setting in curable lung cancer. Radiotherapy may
be used in the treatment of small cell lung cancer (SCLC).
Page
03. Theme: Aortic bypass grafting 1238
A Aorto-bifemoral bypass
B Axillo-bifemoral bypass
C Left iliac angioplasty
D Left iliac angioplasty and femoral cross-over
E Femoral to femoral cross-over.
For each of the patients described below, select the most likely diagnosis from the list of options above.
Each option may be used once, more than once or not at all. You may believe that more than one
diagnosis is possible but you should choose the ONE most likely diagnosis.
Scenario 1
A 55-year-old farmer presents to the vascular outpatient clinic with pain in his legs whilst walking. He claudicates
at 50 m but has no rest pain. Angiogram reveals complete occlusion of lower aorta, with patent femoral vessels.
A - Aorto-bifemoral bypass« CORRECT ANSWER.
Scenario 2
A 79-year-old male presents to the vascular outpatient clinic with inability to walk long distances. He also
complains of occasional rest pain. He has emphysema for which he is on home oxygen. Angiogram reveals
complete occlusion of the aorta with patent femoral vessels.
B - Axillo-bifemoral bypass« CORRECT ANSWER.
Scenario 3
A 43-year-old postman presents to the emergency department with acute onset claudication in both feet. He is fit
and well, and is a non-smoker. He is determined to go back to work. He has an aortic bifurcation block with good
femoral run off on both sides.
C - Left iliac angioplasty« YOUR ANSWER
A - Aorto-bifemoral bypass« CORRECT ANSWER.
It is always best to perform an aorto bifemoral bypass graft if possible. This has the highest patency rate
of any bypass procedures to the femoral vessels. An axillo-bifemoral bypass graft should only be
considered in the very poor, high-risk surgical patient who has critical ischaemia. It is contraindicated in
those patients with claudication.
Axillo-bifemoral bypass is suitable in high-risk patients because it is an extra-abdominal procedure unlike
an aorto-femoral bypass which involves laparaotomy and quite extensive surgery of the aorta. Obviously
this is a major procedure and hence not suitable in elderly high risk patients. In contrast, axillo-bifemoral
bypass is a low risk procedure (a straight forward graft from the axillary to the femoral artery) and hence
suitable in medically unfit/compromised patients who have/or who are in risk of developing critical
ischaemia.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail:
, MyPasTest » MRCS A Online - Jan Exam 2015
18. Surgical Specialities; Cardiothoracic Surgery (26Qs)
-------------------------------------------------------------------------------------------------------------------
04. A 47-year-old man presents to the hospital with a two-month history of night sweats and weight loss.
Blood culture grows a haemophilus species from two different peripheral venous samples. On
examination a pan-systolic murmur is present. Increasingly there are signs of left heart strain. What
procedure may this patient require if his condition deteriorates? Single best answer - select one answer
only.
Trans-catheter aortic valve implantation« YOUR ANSWER Page
Mitral valvuloplasty 1239
Mechanical aortic valve replacement
Biological aortic valve replacement
Mechanical mitral valve replacement« CORRECT ANSWER.
Pan-systolic (holo-systolic) murmurs are usually due to regurgitation, such as mitral regurgitation,
tricuspid regurgitation, or ventricular septal defect (VSD). This patient has a clinical history consistent
with bacterial endocarditis with a HACEK organism and mitral valve damage causing regurgitation. The
National Institute of Clinical Excellence (NICE) recommends Trans-catheter aortic valve implantation
(TAVI) for patients with aortic stenosis who are considered to be unsuitable for surgical aortic valve
replacement (NICE interventional procedures guidance [IPG421]).
Percutaneous mitral balloon valvuloplasty (PMBV) has become the treatment of choice for mitral stenosis
in some patients who are unfit for mitral valve replacement. There are a variety of biological valves, most
are made from cow or pig tissue, and their advantage is the reduced risk of thromboembolism.
Mechanical valves offer the greatest life span and are the treatment of choice for younger patients.
05. Theme: Lung and oesophageal cancer
A Computed tomography (CT)-guided biopsy
B Mediastinoscopy
C Rigid bronchoscopy
D Exploratory thoracotomy.
For each of the following situations select the most useful next step in management. Each option may be
used once, more than once, or not at all.
Scenario 1
A 73-year-old female smoker presented with a persistent cough. A chest radiograph revealed a suspicious lesion
in the periphery of the left upper zone. Flexible bronchoscopy was unremarkable. A CT scan confirms the
presence of a spiculated mass in the left upper lobe and also reveals some enlarged left paratracheal lymph
nodes.
A - Computed tomography (CT)-guided biopsy« CORRECT ANSWER.
This patient requires a tissue diagnosis. Peripheral lesions may not be seen via flexible bronchoscopy but
are amenable to CT-guided biopsy.
Scenario 2
A 64-year-old man with a known right upper lobe squamous cell carcinoma is shown to have a tumour abutting
the superior vena cava on CT scan. There is also an enlarged right hilar lymph node, but no other sign of
metastatic disease.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail:
18. Surgical Specialities; Cardiothoracic Surgery (26Qs)
-------------------------------------------------------------------------------------------------------------------
01. Theme: Thoracic incisions
A Median sternotomy
B Posterolateral thoracotomy
C Clamshell thoracotomy
D Anterior thoracotomy.
For each of the following situations select the most useful surgical incision. Each option may be used
Page
once, more than once, or not at all. 1237
Scenario 1
Aortic transection at the junction of the aortic arch with descending thoracic aorta
A - Median sternotomy« YOUR ANSWER
B - Posterolateral thoracotomy« CORRECT ANSWER.
The junction of the aortic arch with the descending thoracic aorta is the commonest site of aortic
transection, often after a deceleration injury. The aorta is found in the posterior mediastinum and is best
approached via a left posterolateral thoracotomy.
Scenario 2
Stab wound to the right ventricle
B - Posterolateral thoracotomy« YOUR ANSWER
A - Median sternotomy« CORRECT ANSWER.
The right ventricle is the most anterior chamber of the heart and is thus most easily accessed via a
median sternotomy.
Scenario 3
Bilateral penetrating chest injuries with lung parenchymal lacerations
C - Clamshell thoracotomy« CORRECT ANSWER.
Bilateral penetrating lung injuries will often need wide exposure to be appropriately repaired. Access to
both lungs is feasible via a median sternotomy, but a clamshell thoracotomy gives the best access to
both hemithoraces.
02. An 86-year-old man is diagnosed with a 2cm lung squamous cell carcinoma confined to the anterior
bronchopulmonary segment of the right upper lobe, its staging is T1N0M0 suggesting curative surgery is
an option. He is a life-long smoker. Which of the following is the most desirable therapeutic option?
Single best answer - select one answer only.
Chemotherapy« YOUR ANSWER
Pnuemonectomy
Radiotherapy
Sleeve lobectomy
Wedge resection« CORRECT ANSWER.
Sleeve lobectomy describes the resection of a lobe and a portion of the main stem bronchus with re-
implantation of the distal bronchus. It is often performed for centrally located lesions and especially
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail:
, MyPasTest » MRCS A Online - Jan Exam 2015
18. Surgical Specialities; Cardiothoracic Surgery (26Qs)
-------------------------------------------------------------------------------------------------------------------
favourable for patients with limited cardiopulmonary reserve. Wedge resections can be performed with
video-assisted thorascopic surgery (VATS). Studies comparing lobectomy with wedge resection in non-
small cell lung cancer (NSCLC) have shown that 5-year survival rate with wedge resection to be lower
than with lobectomy however in older patients with poor lung function this may be a better option.
Chemotherapy is used in the neoadjuvant or adjuvant setting in curable lung cancer. Radiotherapy may
be used in the treatment of small cell lung cancer (SCLC).
Page
03. Theme: Aortic bypass grafting 1238
A Aorto-bifemoral bypass
B Axillo-bifemoral bypass
C Left iliac angioplasty
D Left iliac angioplasty and femoral cross-over
E Femoral to femoral cross-over.
For each of the patients described below, select the most likely diagnosis from the list of options above.
Each option may be used once, more than once or not at all. You may believe that more than one
diagnosis is possible but you should choose the ONE most likely diagnosis.
Scenario 1
A 55-year-old farmer presents to the vascular outpatient clinic with pain in his legs whilst walking. He claudicates
at 50 m but has no rest pain. Angiogram reveals complete occlusion of lower aorta, with patent femoral vessels.
A - Aorto-bifemoral bypass« CORRECT ANSWER.
Scenario 2
A 79-year-old male presents to the vascular outpatient clinic with inability to walk long distances. He also
complains of occasional rest pain. He has emphysema for which he is on home oxygen. Angiogram reveals
complete occlusion of the aorta with patent femoral vessels.
B - Axillo-bifemoral bypass« CORRECT ANSWER.
Scenario 3
A 43-year-old postman presents to the emergency department with acute onset claudication in both feet. He is fit
and well, and is a non-smoker. He is determined to go back to work. He has an aortic bifurcation block with good
femoral run off on both sides.
C - Left iliac angioplasty« YOUR ANSWER
A - Aorto-bifemoral bypass« CORRECT ANSWER.
It is always best to perform an aorto bifemoral bypass graft if possible. This has the highest patency rate
of any bypass procedures to the femoral vessels. An axillo-bifemoral bypass graft should only be
considered in the very poor, high-risk surgical patient who has critical ischaemia. It is contraindicated in
those patients with claudication.
Axillo-bifemoral bypass is suitable in high-risk patients because it is an extra-abdominal procedure unlike
an aorto-femoral bypass which involves laparaotomy and quite extensive surgery of the aorta. Obviously
this is a major procedure and hence not suitable in elderly high risk patients. In contrast, axillo-bifemoral
bypass is a low risk procedure (a straight forward graft from the axillary to the femoral artery) and hence
suitable in medically unfit/compromised patients who have/or who are in risk of developing critical
ischaemia.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail:
, MyPasTest » MRCS A Online - Jan Exam 2015
18. Surgical Specialities; Cardiothoracic Surgery (26Qs)
-------------------------------------------------------------------------------------------------------------------
04. A 47-year-old man presents to the hospital with a two-month history of night sweats and weight loss.
Blood culture grows a haemophilus species from two different peripheral venous samples. On
examination a pan-systolic murmur is present. Increasingly there are signs of left heart strain. What
procedure may this patient require if his condition deteriorates? Single best answer - select one answer
only.
Trans-catheter aortic valve implantation« YOUR ANSWER Page
Mitral valvuloplasty 1239
Mechanical aortic valve replacement
Biological aortic valve replacement
Mechanical mitral valve replacement« CORRECT ANSWER.
Pan-systolic (holo-systolic) murmurs are usually due to regurgitation, such as mitral regurgitation,
tricuspid regurgitation, or ventricular septal defect (VSD). This patient has a clinical history consistent
with bacterial endocarditis with a HACEK organism and mitral valve damage causing regurgitation. The
National Institute of Clinical Excellence (NICE) recommends Trans-catheter aortic valve implantation
(TAVI) for patients with aortic stenosis who are considered to be unsuitable for surgical aortic valve
replacement (NICE interventional procedures guidance [IPG421]).
Percutaneous mitral balloon valvuloplasty (PMBV) has become the treatment of choice for mitral stenosis
in some patients who are unfit for mitral valve replacement. There are a variety of biological valves, most
are made from cow or pig tissue, and their advantage is the reduced risk of thromboembolism.
Mechanical valves offer the greatest life span and are the treatment of choice for younger patients.
05. Theme: Lung and oesophageal cancer
A Computed tomography (CT)-guided biopsy
B Mediastinoscopy
C Rigid bronchoscopy
D Exploratory thoracotomy.
For each of the following situations select the most useful next step in management. Each option may be
used once, more than once, or not at all.
Scenario 1
A 73-year-old female smoker presented with a persistent cough. A chest radiograph revealed a suspicious lesion
in the periphery of the left upper zone. Flexible bronchoscopy was unremarkable. A CT scan confirms the
presence of a spiculated mass in the left upper lobe and also reveals some enlarged left paratracheal lymph
nodes.
A - Computed tomography (CT)-guided biopsy« CORRECT ANSWER.
This patient requires a tissue diagnosis. Peripheral lesions may not be seen via flexible bronchoscopy but
are amenable to CT-guided biopsy.
Scenario 2
A 64-year-old man with a known right upper lobe squamous cell carcinoma is shown to have a tumour abutting
the superior vena cava on CT scan. There is also an enlarged right hilar lymph node, but no other sign of
metastatic disease.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail:
