Pediatric Surgery Basics

Pediatric Surgery Basics Indian Medical PG Question 1: In neonatal resuscitation, which of the following is the most effective indicator of successful ventilatory effort?

• A. Rise in heart rate (Correct Answer)
• B. Air entry
• C. Chest rise
• D. Colour change

Pediatric Surgery Basics Explanation: ***Rise in heart rate*** - A **rapid increase in heart rate** is the most sensitive and immediate indicator that ventilation is effectively delivering oxygen to the neonate. - An increase in heart rate signifies improved oxygenation and circulatory response, which are the primary goals of resuscitation. *Air entry* - While **air entry** indicates that air is moving into the lungs, it does not guarantee effective gas exchange or systemic oxygenation. - Unequal or diminished air entry can occur even with some chest movement, and it is less reliable than heart rate for assessing overall improvement. *Chest rise* - **Visible chest rise** suggests that air is moving into the lungs, but it can be misleading if the volume is insufficient or if the air is not effectively reaching the alveoli for gas exchange. - **Gastric inflation** can also cause chest rise, masquerading as effective ventilation without significant clinical improvement. *Colour change* - **Improvement in skin color** (e.g., pinking up) is a slower and less reliable indicator of effective ventilation, as it can be influenced by peripheral perfusion and environmental factors. - **Cyanosis** may persist even after adequate ventilation begins, and relying solely on color can delay necessary interventions if other, more immediate signs are not improving.

Pediatric Surgery Basics Indian Medical PG Question 2: A 6-month-old child presents with an umbilical hernia measuring 3 cm in diameter. What is the management protocol?

• A. Immediate surgical repair
• B. Elective surgery at 5 years of age
• C. Hernioplasty for repair
• D. Observation until 2 years of age, then surgery if unresolved (Correct Answer)

Pediatric Surgery Basics Explanation: ***Observation until 2 years of age, then surgery if unresolved*** - Most **umbilical hernias** in infants and young children **resolve spontaneously** by the age of 2 years, making observation the initial management for uncomplicated cases. - Surgical intervention is typically considered if the hernia persists beyond **2-4 years of age**, is symptomatic, or demonstrates features of incarceration regardless of age. *Immediate surgical repair* - Immediate surgery is reserved for cases with **incarceration** or **strangulation**, which are not indicated by a "symptomatic" hernia in this context. - Given the high rate of spontaneous closure, most umbilical hernias do not require urgent intervention. *Elective surgery at 5 years of age* - Waiting until 5 years of age to consider surgery might delay treatment for some children whose hernias are unlikely to close spontaneously after the age of 2-4 and could lead to prolonged parental anxiety. - The general consensus is to recommend surgery if the hernia persists beyond **2-4 years**, rather than a fixed age of 5. *Hernioplasty for repair* - While hernioplasty is the surgical technique for repair, the question asks about the overall management protocol, which includes initial observation. - Applying this term as an immediate solution for a 6-month-old's uncomplicated umbilical hernia would bypass the recommended period of **conservative management**.

Pediatric Surgery Basics Indian Medical PG Question 3: A 1-week-old previously healthy infant presents to the emergency room with the acute onset of bilious vomiting. The abdominal plain film in the emergency department (A) and the barium enema done after admission (B) are shown. Which of the following is the most likely diagnosis for this patient?

• A. Hypertrophic pyloric stenosis
• B. Acute appendicitis
• C. Jejunal atresia
• D. Malrotation with volvulus (Correct Answer)

Pediatric Surgery Basics Explanation: ***Malrotation with volvulus*** - The acute onset of **bilious vomiting** in a 1-week-old infant is a **surgical emergency** and highly suggestive of intestinal obstruction, with malrotation with volvulus being a critical consideration. - The barium enema image (B) shows the **ligament of Treitz** located to the right of the midline, indicating **intestinal malrotation** and a **corkscrew pattern** of the duodenum, which is pathognomonic for **midgut volvulus**. *Hypertrophic pyloric stenosis* - Typically presents with **non-bilious projectile vomiting** and palpable **pyloric olive mass**, usually appearing between 3 to 6 weeks of age, not at 1 week with bilious vomiting. - Imaging would reveal an **elongated, narrowed pyloric channel** (string sign) and thickened pyloric muscle, not the findings seen in the barium study. *Acute appendicitis* - This is an **extremely rare diagnosis** in a 1-week-old infant and typically presents with localized pain, fever, and leukocytosis, which are not the primary symptoms described. - Acute appendicitis would not explain the **bilious vomiting** or the specific findings on the barium study related to intestinal rotation. *Jejunal atresia* - Presents with bilious vomiting and abdominal distension, often diagnosed prenatally or shortly after birth due to proximal dilation and distal collapse of the bowel. - While it causes obstruction, the barium study in jejunal atresia would show a **blind-ending jejunum** and not the distinct malrotation and volvulus features (e.g., corkscrew sign, abnormal Treitz location).

Pediatric Surgery Basics Indian Medical PG Question 4: Which one of the following regarding abdominal pediatric surgery is correct?

• A. Transverse abdominal incision is always used
• B. Bowel must be always anastomosed in double layer
• C. Skin over abdomen can never be closed with subcuticular sutures
• D. Incision can be closed with absorbable suture (Correct Answer)

Pediatric Surgery Basics Explanation: ***Incision can be closed with absorbable suture*** - **Absorbable sutures** are commonly used in pediatric abdominal surgery for closing deeper layers and sometimes skin, as they degrade over time and do not require removal. - This is particularly beneficial in children to avoid the trauma and discomfort of suture removal and to promote good cosmetic outcomes. *Transverse abdominal incision is always used* - While **transverse incisions** are often preferred in pediatric abdominal surgery for their good cosmetic results and lower incidence of incisional hernias, they are not *always* used. - Other incisions, such as **vertical midline incisions**, may be utilized depending on the surgical exposure required, the specific pathology, or the surgeon's preference. *Bowel must be always anastomosed in double layer* - **Bowel anastomoses** in pediatric surgery can be performed using either a **single-layer** or **double-layer** technique. - The choice depends on surgeon preference, the specific bowel segment involved, and the patient's condition, with both methods demonstrating comparable outcomes in many situations. *Skin over abdomen can never be closed with subcuticular sutures* - **Subcuticular sutures** are frequently used for skin closure in pediatric abdominal surgery, especially for their excellent cosmetic results and to avoid external suture removal. - This technique places the suture material under the skin surface, minimizing scarring and being well-suited for a child's healing skin.

Pediatric Surgery Basics Indian Medical PG Question 5: Which of the following surgeries is contraindicated below 12 years of age?

• A. SMR (Correct Answer)
• B. Rhinoplasty
• C. Septoplasty
• D. Antral puncture

Pediatric Surgery Basics Explanation: ***SMR (Submucous Resection of the septum)*** - SMR procedure involves removing a significant portion of the **septal cartilage and bone**, which is crucial for nasal growth. - Performing SMR before 12 years of age can lead to severe **facial growth disturbances**, such as a saddle nose deformity, due to interference with the septal growth plate. *Rhinoplasty* - While rhinoplasty is generally delayed until nasal growth is complete (around 15-16 years old for girls, 16-17 for boys), it is not absolutely contraindicated structurally before 12 in the same way SMR is. - The concern is primarily about final aesthetic outcome and patient maturity, not direct damage to major growth centers. *Septoplasty* - **Septoplasty** can be performed in younger children for severe nasal obstruction, especially if it significantly impacts breathing or sleep. - It involves reshaping or repositioning the **septal cartilage and bone** with minimal removal, preserving growth potential. *Antral puncture* - **Antral puncture** (or antral lavage) is a procedure to drain the maxillary sinus and can be performed at any age when indicated for sinusitis. - It does not interfere with facial growth as it targets the sinus cavity walls and does not involve the nasal septum.

Pediatric Surgery Basics Indian Medical PG Question 6: What is the most appropriate method for administering asthma treatment to an infant under one year of age?

• A. MDI with Mask (no spacer)
• B. Nebulizer therapy
• C. MDI with Spacer (no mask)
• D. MDI with Spacer and Mask (Correct Answer)

Pediatric Surgery Basics Explanation: ***MDI with Spacer and Mask*** - For infants and young children, a **metered-dose inhaler (MDI)** used with a **spacer** and a **well-fitting mask** is the **most appropriate** method for delivering asthma medication. - The spacer helps to reduce the velocity of the aerosol and allows the infant to inhale the medication over several breaths, while the mask ensures the medication is delivered to the airways without significant loss. - This method is **portable**, **convenient**, and **cost-effective** for routine outpatient management. *MDI with Spacer (no mask)* - While a spacer is crucial for optimizing drug delivery from an MDI, an infant cannot effectively seal their lips around a spacer mouthpiece for proper inhalation. - This method would result in significant **medication loss** and insufficient dose delivery to the lungs. *MDI with Mask (no spacer)* - An MDI used directly with a mask without a spacer leads to inefficient drug delivery due to the **high velocity** of the aerosol spray. - The medication impinges on the back of the throat and face, reducing the amount that reaches the small airways. *Nebulizer therapy* - Nebulizers are also an **acceptable and effective option** for infants, particularly in acute settings or when families find them easier to use. - However, they are **time-consuming** (typically 10-15 minutes per treatment), require a power source or batteries, and are less portable than MDI systems. - For **routine outpatient management**, an MDI with spacer and mask is generally **preferred** due to its convenience, portability, and comparable efficacy when used correctly.

Pediatric Surgery Basics Indian Medical PG Question 7: Consider the following features: 1. Visible gastric peristalsis 2. Bilious vomiting 3. Palpable tumour 4. Melena Which of these is/are feature/features of infantile hypertrophic pyloric stenosis?

• A. 1 and 3 only (Correct Answer)
• B. 2 and 4
• C. 4 only
• D. 1, 2 and 3

Pediatric Surgery Basics Explanation: ***1 and 3 only*** - **Visible gastric peristalsis** is a classic sign of pyloric stenosis, as the stomach attempts to overcome the obstruction. - A **palpable olive-shaped mass** (the hypertrophied pylorus) in the epigastrium is a hallmark physical finding. *2 and 4* - **Bilious vomiting** indicates an obstruction **distal** to the ampulla of Vater (duodenum or beyond), whereas pyloric stenosis is gastric outlet obstruction and typically causes **non-bilious vomiting**. - **Melena** (black, tarry stools) indicates upper gastrointestinal bleeding, which is not a typical feature of pyloric stenosis. *4 only* - **Melena** is not a feature of pyloric stenosis; it indicates upper gastrointestinal bleeding. - Pyloric stenosis primarily causes gastric outlet obstruction, leading to forceful, **non-bilious vomiting** and dehydration. *1, 2 and 3* - While **visible gastric peristalsis** and a **palpable tumour** are characteristic, **bilious vomiting** is not. - Vomiting in pyloric stenosis is typically **non-bilious** because the obstruction is proximal to the entry of bile into the duodenum.

Pediatric Surgery Basics Indian Medical PG Question 8: According to IMNCI guidelines, what is the definition of fast breathing in a 5-month-old child?

• A. ≥40 breaths per minute
• B. More than 30 breaths per minute
• C. ≥50 breaths per minute (Correct Answer)
• D. ≥60 breaths per minute

Pediatric Surgery Basics Explanation: ***≥50 breaths per minute*** - For infants aged **2-12 months**, fast breathing is defined as a respiratory rate of **≥50 breaths per minute** according to **WHO IMNCI guidelines**. - A 5-month-old falls in this age category, making this the correct threshold for identifying **pneumonia** and severe acute respiratory infections. - This cutoff is critical for **early detection** and appropriate management in primary care settings. *≥40 breaths per minute* - This is the cutoff for fast breathing in children aged **12 months to 5 years**, not for infants. - Using this lower threshold for a 5-month-old would result in **missing cases** of pneumonia that require treatment. *More than 30 breaths per minute* - This respiratory rate is normal for older children and adults and is **far below** the threshold for tachypnea in infants. - Infants have a naturally **higher baseline respiratory rate** due to smaller lung volumes and higher metabolic demands. *≥60 breaths per minute* - While this rate indicates significant respiratory distress, it **exceeds** the IMNCI definition of fast breathing for this age group. - Using this higher threshold would delay recognition and treatment of pneumonia, leading to **worse outcomes**.

Pediatric Surgery Basics Indian Medical PG Question 9: Neonate is brought at 3 weeks of age, with projectile vomiting. USG was performed and is shown below. When can the abdominal mass in this condition be best palpated?

• A. During feeding (Correct Answer)
• B. In umbilical area
• C. In epigastric area
• D. In Right upper quadrant

Pediatric Surgery Basics Explanation: ***During feeding*** - In **hypertrophic pyloric stenosis**, the characteristic **"olive" mass** formed by the thickened pylorus is most easily palpable **during feeding or immediately after vomiting**. - During this time, the infant’s abdominal muscles are relaxed, making palpation of the mass in the **epigastrium (right upper quadrant)** more successful. *In umbilical area* - The umbilical area is typically where **omphaloceles** or **umbilical hernias** are found, not the pyloric mass. - The pylorus is located much higher in the epigastric region, to the right of the midline. *In epigastric area* - While the pyloric mass is located in the **epigastric area**, palpation is more difficult when the infant is crying or agitated. - The question asks when it can be *best* palpated, emphasizing the conditions under which it is most detectable. *In Right upper quadrant* - The pylorus is indeed located in the **right upper quadrant/epigastrium**. - However, the optimal timing for palpation is during feeding or after vomiting, as the infant's abdomen is relaxed at that point.

Pediatric Surgery Basics Indian Medical PG Question 10: An infant brought to the clinic with non-bilious projectile vomiting. The investigation of choice includes:

• A. Sigmoidoscopy
• B. Abdominal ultrasonography (Correct Answer)
• C. Barium meal
• D. Flexible Endoscopy

Pediatric Surgery Basics Explanation: ***Abdominal ultrasonography*** - **Abdominal ultrasonography** is the **investigation of choice** for **hypertrophic pyloric stenosis** presenting with non-bilious projectile vomiting in infants. - It is **non-invasive**, avoids **radiation exposure**, and has high sensitivity and specificity (>95%). - USG demonstrates a **thickened pyloric muscle** (>3 mm), **elongated pyloric channel** (>15-17 mm), and **absent or reduced passage of gastric contents** through the pylorus. - The characteristic **"target sign"** or **"doughnut sign"** on transverse view and **"cervix sign"** on longitudinal view are diagnostic. *Barium meal* - A **barium meal** (upper GI series) can demonstrate the characteristic **"string sign"** or **"shoulder sign"** in pyloric stenosis, showing a narrowed pyloric channel. - However, it is **not the first-line investigation** due to **radiation exposure**, being more time-consuming, and less practical in sick infants. - It may be used when **USG is inconclusive** or unavailable, but has been largely replaced by ultrasound in modern practice. *Flexible Endoscopy* - **Flexible endoscopy** is an **invasive procedure** and is not the first-line diagnostic tool for pyloric stenosis in infants. - It may be considered in atypical cases to rule out other diagnoses like **gastroesophageal reflux disease (GERD)**, **esophagitis**, or **gastritis**. *Sigmoidoscopy* - **Sigmoidoscopy** examines the **lower gastrointestinal tract** (sigmoid colon and rectum) and is completely **irrelevant** to the diagnosis of non-bilious projectile vomiting. - This presentation indicates an **upper GI pathology** (pyloric stenosis), not a lower GI condition. - Sigmoidoscopy is used for conditions like **inflammatory bowel disease** or **rectal bleeding**.

Pediatric Surgery Basics Flashcard 1 of 8

Question: Immediate steps of management of a baby with CDH is to _____ and insert a NG tube

Answer: intubate

Pediatric Surgery Basics Flashcard 2 of 8

Question: Annular pancreas may cause _____ obstruction and billious vomiting

Answer: duodenal

Pediatric Surgery Basics Flashcard 3 of 8

Question: What is the classification of the following type of jejunoileal atresia? _____

Answer: Type IIIb

Pediatric Surgery Basics Flashcard 4 of 8

Question: Left-sided congenital diaphragmatic hernias are _____ common than the right

Answer: more

Pediatric Surgery Basics Flashcard 5 of 8

Question: Bladder extrophy may present with a characteristic _____ gait

Answer: broad-based

Pediatric Surgery Basics Flashcard 6 of 8

Question: _____ is the most common anomaly associated with gastroschisis

Answer: Intestinal atresia

Pediatric Surgery Basics Flashcard 7 of 8

Question: Congenital diaphragmatic hernia is associated with lung _____ and a scaphoid abdomen

Answer: hypoplasia

Pediatric Surgery Basics Flashcard 8 of 8

Question: USG criteria for diagnosing CHPS: Pyloric thickness of more than _____ mm or a Pyloric length greater than 15 to 18 mm in the presence of functional gastric outlet obstruction

Answer: 3 to 4