Pediatric Surgery — MCQs

Pediatric Surgery Indian Medical PG Practice Questions and MCQs

Question 111: Which of the following procedures is NOT performed in a case of Hirschsprung's disease?

A. Swenson's operation
B. Duhamel's operation
C. Fasanella-Servat procedure (Correct Answer)
D. Soave's operation

Explanation: **Explanation:** Hirschsprung’s disease (Congenital Aganglionic Megacolon) is characterized by the absence of ganglion cells in the myenteric and submucosal plexuses. The definitive treatment involves a "pull-through" procedure to remove the aganglionic segment and bring functional, ganglionated bowel down to the anus. **Why Option C is Correct:** The **Fasanella-Servat procedure** is an ophthalmic surgery used to treat **mild ptosis**. It involves the excision of the superior border of the tarsus, the lower border of the Müller muscle, and the overlying conjunctiva. It has no relevance to pediatric surgery or the gastrointestinal tract. **Why the Other Options are Incorrect:** The following are the three classic definitive pull-through operations for Hirschsprung’s disease: * **Swenson’s Operation (A):** The original procedure involving proctectomy and end-to-end anastomosis. It requires full dissection of the rectum close to the pelvic nerves. * **Duhamel’s Operation (B):** A "retro-rectal" approach where the ganglionic bowel is brought down behind the rectum, creating a side-to-side anastomosis. This avoids anterior pelvic dissection. * **Soave’s Operation (D):** An "endorectal" pull-through where the rectal mucosa is stripped, and the ganglionic bowel is pulled through the remaining muscular cuff, protecting pelvic nerves. **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Rectal suction biopsy (shows absence of ganglion cells and hypertrophied nerve bundles). * **Most Common Site:** Rectosigmoid region (Short-segment disease). * **Modern Trend:** Transanal Endorectal Pull-Through (TEPT) is now frequently performed as a single-stage minimally invasive procedure. * **Associated Condition:** Down Syndrome (Trisomy 21) is seen in approximately 10% of cases.

Question 112: What is the primary treatment for Hirschsprung's disease?

A. Colostomy
B. Excision of the aganglionic segment (Correct Answer)
C. Colectomy
D. Sodium chloride wash

Explanation: **Explanation:** **Hirschsprung’s Disease (Congenital Aganglionic Megacolon)** is characterized by the absence of ganglion cells (Meissner’s and Auerbach’s plexuses) in the distal bowel, starting from the internal anal sphincter and extending proximally. This results in a functional obstruction because the aganglionic segment remains in a state of tonic contraction. **Why the Correct Answer is Right:** The definitive treatment is the **excision of the aganglionic segment** followed by a "pull-through" procedure. The goal is to remove the non-functional, aperistaltic segment and anastomose the normally ganglionated proximal bowel to the anus. Common surgical techniques include the **Swenson, Duhamel, and Soave procedures.** **Why Other Options are Wrong:** * **Colostomy (A):** This is a temporary, stabilizing measure used in neonates with enterocolitis or massive colonic dilation to decompress the bowel before definitive surgery. It does not treat the underlying pathology. * **Colectomy (C):** Total colectomy is only indicated in rare cases of "Total Colonic Aganglionosis." In standard Hirschsprung’s (which usually involves the rectosigmoid), removing the entire colon is unnecessary and leads to significant morbidity. * **Sodium chloride wash (D):** Rectal irrigations with normal saline are used for preoperative bowel preparation or emergency decompression in Hirschsprung-associated enterocolitis (HAEC), but they are not curative. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Full-thickness rectal biopsy (shows absence of ganglion cells and hypertrophied nerve bundles). * **Histochemistry:** Increased **Acetylcholinesterase (AChE)** staining is a classic diagnostic marker. * **X-ray Finding:** A "transition zone" between the narrow aganglionic distal segment and the dilated proximal colon. * **Associated Condition:** Strongly associated with **Down Syndrome** (Trisomy 21).

Question 113: What is the standard treatment for congenital hydrocele?

A. Herniotomy (Correct Answer)
B. Excision of sac
C. Eversion of sac
D. Jaboulay procedure

Explanation: **Explanation:** The standard treatment for congenital hydrocele is **Herniotomy**. **1. Why Herniotomy is the Correct Answer:** Congenital hydrocele is caused by a **patent processus vaginalis (PPV)**—a failure of the communication between the peritoneal cavity and the scrotum to obliterate. Because the underlying pathology is a persistent communication (similar to an indirect inguinal hernia), the treatment must involve the high ligation and division of this sac at the level of the internal inguinal ring. This procedure is called a **Herniotomy**. Unlike adult hydroceles, most congenital hydroceles are "communicating" and often resolve spontaneously by age 1–2; surgery is indicated if they persist beyond this age. **2. Why Other Options are Incorrect:** * **Excision of sac (Lord’s Procedure), Eversion of sac (Lord’s/Jaboulay), and Jaboulay procedure:** These are surgical techniques used for **primary vaginal hydroceles in adults**. In adults, the hydrocele is caused by an imbalance in fluid secretion and absorption within the tunica vaginalis, not a patent communication. Performing these scrotal-approach surgeries in a child would fail to address the PPV and carries a risk of injuring the vas deferens or cord structures. **Clinical Pearls for NEET-PG:** * **Approach:** Congenital hydrocele/hernia is always approached via an **inguinal incision**, whereas adult hydrocele is approached via a **scrotal incision**. * **Observation:** Most congenital hydroceles are managed conservatively until **12–24 months of age** as they may resolve spontaneously. * **Associated Condition:** If the hydrocele is "encysted" in the cord, it is known as an **Encysted Hydrocele of the Cord**. * **Key Difference:** In children, the sac is the cause; in adults, the fluid dynamics are the cause.

Question 114: What is the treatment for recurrent rectal prolapse in children?

A. Thiersh wiring
B. Digital reposition
C. Excision
D. Ripstein's operation (Correct Answer)

Explanation: ### **Explanation** Rectal prolapse in children is most commonly a self-limiting condition, often associated with malnutrition, chronic constipation, or parasitic infections. However, when conservative management fails and the prolapse becomes **recurrent or persistent**, surgical intervention is required. **1. Why Ripstein’s Operation is Correct:** Ripstein’s operation is a **posterior proctopexy**. It involves mobilizing the rectum and fixing it to the sacral promontory using a prosthetic mesh. This procedure restores the normal posterior fixation of the rectum and prevents the intussusception process that leads to prolapse. In the context of recurrent cases where conservative measures have failed, abdominal pexy procedures like Ripstein’s are considered definitive surgical treatments. **2. Why Other Options are Incorrect:** * **Thiersch Wiring:** This involves placing a perianal silver wire or silicone loop to narrow the anal orifice. It is generally reserved for elderly, frail patients who cannot tolerate major surgery. It is rarely used in children due to high infection rates and the risk of fecal impaction. * **Digital Reposition:** This is the **initial management** for an acute episode of prolapse. While necessary for immediate reduction, it does not treat the underlying cause of *recurrent* prolapse. * **Excision:** Rectal resection (e.g., Altemeier’s procedure) is typically reserved for adults with full-thickness prolapse or incarcerated segments. It is avoided in children due to the risk of pelvic nerve injury and functional complications. **NEET-PG High-Yield Pearls:** * **Most common cause** of rectal prolapse in children worldwide: Malnutrition and chronic diarrhea. * **Association:** In developed countries, always rule out **Cystic Fibrosis** (sweat chloride test) in a child with rectal prolapse. * **First-line treatment:** Conservative (high-fiber diet, stool softeners, and treating the underlying cause). * **Sclerotherapy:** Injection of 5% phenol in almond oil or hypertonic saline is a common minimally invasive option for recurrent cases before proceeding to major surgery like Ripstein's.

Question 115: Which among the following is the latest classification for Wilms tumor based on surgical and pathologic findings?

A. NWTS V (Correct Answer)
B. CIOS
C. CHIDC
D. All of the above

Explanation: **Explanation:** **1. Why NWTS V is Correct:** The **National Wilms Tumor Study (NWTS)** group, now part of the **Children’s Oncology Group (COG)**, provides the gold-standard staging system used globally. **NWTS V** is the most recent iteration of this classification. It is a **surgical-pathologic staging system**, meaning the stage is determined based on findings during surgery and the subsequent histopathological examination of the specimen *before* the administration of chemotherapy (unlike the SIOP system used in Europe, which uses post-chemotherapy findings). **2. Why Other Options are Incorrect:** * **CIOS & CHIDC:** These are not recognized medical acronyms for staging systems in pediatric oncology. They are likely "distractor" options designed to test the candidate's specific knowledge of the NWTS nomenclature. * **SIOP (Société Internationale d’Oncologie Pédiatrique):** While not listed as an option, it is the other major classification system. It differs from NWTS V because it utilizes preoperative chemotherapy and stages the tumor based on post-treatment findings. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most Common Presentation:** An asymptomatic abdominal mass (often discovered by a parent while bathing the child). * **NWTS V Staging Highlights:** * **Stage I:** Tumor limited to the kidney; excised intact. * **Stage II:** Tumor extends beyond the kidney but is completely excised. * **Stage III:** Residual non-hematogenous tumor confined to the abdomen (e.g., lymph node involvement or peritoneal spill). * **Stage IV:** Hematogenous metastases (most common site: **Lungs**). * **Stage V:** Bilateral renal involvement at diagnosis. * **Prognostic Factor:** The most important histological prognostic factor is the presence of **anaplasia** (unfavorable histology). * **Associated Syndromes:** WAGR, Denys-Drash, and Beckwith-Wiedemann syndromes.

Question 116: Which of the following congenital anomalies is more common in occurrence: isolated cleft palate, isolated cleft lip, or cleft lip and palate?

A. Cleft palate only
B. Cleft lip only
C. Cleft lip and palate (Correct Answer)
D. All of the above have equal occurrence

Explanation: **Explanation:** The distribution of orofacial clefts follows a specific epidemiological pattern. **Cleft lip with or without cleft palate (CL±P)** is etiologically distinct from **isolated cleft palate (CP)**. Among these, the combination of **Cleft Lip and Palate (CLP)** is the most frequent presentation. **Why Option C is Correct:** Statistically, approximately **45-50%** of cases present as combined Cleft Lip and Palate. Isolated Cleft Palate accounts for about **30%**, and isolated Cleft Lip is the least common at approximately **20-25%**. This occurs because the embryological fusion of the primary palate (lip and premaxilla) and the secondary palate (hard and soft palate) are closely timed; a significant insult during primary palate formation often persists to affect the secondary palate. **Why Other Options are Incorrect:** * **Option A (Cleft Palate only):** While common, it occurs in roughly 1 in 1,500–2,000 births. It is more frequently associated with syndromic presentations (e.g., Pierre Robin Sequence) compared to CLP. * **Option B (Cleft Lip only):** This is the rarest of the three main types. It results from the failure of the maxillary process to fuse with the medial nasal process. * **Option D:** The occurrences are not equal; there is a clear hierarchy in frequency (CLP > CP > CL). **High-Yield Clinical Pearls for NEET-PG:** * **Gender Predilection:** Cleft Lip (+/- Palate) is more common in **males**, whereas isolated Cleft Palate is more common in **females**. * **Laterality:** Isolated cleft lip is most commonly **unilateral** and occurs more frequently on the **left side**. * **Rule of 10s (for Cheiloplasty):** 10 weeks of age, 10 lbs weight, and 10 g/dL Hemoglobin. * **Surgical Timing:** Cleft lip repair (Cheiloplasty) is usually done at **3 months**; Cleft palate repair (Palatoplasty) is done at **6–12 months** (before significant speech development).

Question 117: Apple peel bowel with loss of dorsal mesentery is a feature of which type of ileal atresia?

A. Type 1
B. Type 2
C. Type 3 (Correct Answer)
D. Type 4

Explanation: **Explanation:** The correct answer is **Type 3b**. In the Grosfeld classification of intestinal atresia, Type 3 is divided into two subtypes, with Type 3b specifically characterized by the "Apple Peel" or "Christmas Tree" deformity. **1. Why Type 3 is correct:** Intestinal atresia is primarily caused by an **in-utero vascular accident** (ischemic insult). In **Type 3b**, a large mesenteric defect occurs due to the occlusion of the superior mesenteric artery. This results in: * A large gap between the proximal and distal bowel ends. * **Loss of dorsal mesentery.** * The distal small bowel survives by receiving retrograde blood supply from the ileocolic or right colic artery, causing it to coil around its tenuous blood supply, resembling an **apple peel**. **2. Why other options are incorrect:** * **Type 1:** Characterized by an intraluminal septum (web) with intact muscularis and mesentery. There is no gap or loss of mesentery. * **Type 2:** Two blind ends connected by a fibrous cord. The mesentery remains intact. * **Type 3a:** Features a V-shaped mesenteric defect with a complete separation of blind ends, but it lacks the characteristic spiral "apple peel" distal segment. * **Type 4:** Defined by multiple "string of beads" atresias. **Clinical Pearls for NEET-PG:** * **Most common site:** Ileum > Jejunum. * **Duodenal Atresia:** Unlike ileal atresia, this is caused by a failure of **recanalization** (not vascular insult) and is strongly associated with **Down Syndrome** and the "Double Bubble" sign. * **Prognosis:** Type 3b has a higher morbidity due to prematurity, low birth weight, and significantly shortened bowel length (Short Bowel Syndrome).

Question 118: Which of the following statements regarding Hirschsprung's disease are true?

A. Sometimes found in adults
B. Dilated segment involved
C. Auerbach's plexus absent (Correct Answer)
D. Sometimes involves the small intestine

Explanation: ### Explanation: Hirschsprung’s Disease (Congenital Aganglionic Megacolon) **1. Why Option C is Correct:** Hirschsprung’s disease is characterized by the **absence of ganglion cells** in both the **Auerbach’s (myenteric)** and **Meissner’s (submucosal)** plexuses. This occurs due to the failure of neural crest cells to migrate cranio-caudally during the 5th to 12th weeks of gestation. The absence of these inhibitory neurons leads to a permanent state of contraction in the affected segment, resulting in functional intestinal obstruction. **2. Analysis of Incorrect Options:** * **Option A:** While rare "adult Hirschsprung" cases exist, it is primarily a **pediatric diagnosis**, typically presenting in the neonatal period with failure to pass meconium within 48 hours. * **Option B:** In this disease, the **aganglionic segment is narrow/contracted**. The **dilated segment** is actually the proximal, normal colon that undergoes hypertrophy to push stool past the obstruction. * **Option C vs D:** While total colonic aganglionosis can occur, involvement of the small intestine is extremely rare (Zuelzer-Wilson syndrome). Option C is the definitive pathological hallmark and the most accurate statement. **3. High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Rectal Suction Biopsy (shows absence of ganglion cells and increased **Acetylcholinesterase** staining). * **Most Common Site:** Rectosigmoid region (Short-segment disease). * **Associated Condition:** Down Syndrome (Trisomy 21) is seen in ~10% of cases. * **Clinical Sign:** "Blast sign" or "Squirt sign" (explosive release of gas/stool on digital rectal exam). * **Surgical Procedures:** Duhamel, Soave, and Swenson procedures are the classic definitive repairs.

Question 119: A part of the adjacent intestine will be removed in which of the following conditions?

A. Enterogenous cyst (Correct Answer)
B. Chylolymphatic cyst
C. Dermoid cyst
D. Mesothelial cyst

Explanation: ***Enterogenous cyst*** - **Enterogenous (duplication) cysts** share the **muscularis propria** and blood supply with the adjacent intestine, making separate excision impossible. - **En-bloc resection** with adjacent bowel segment is mandatory to prevent complications like bowel perforation or ischemia. *Chylolymphatic cyst* - These are **lymphatic malformations** that develop independently of the intestinal wall and have separate vascular supply. - Can be **excised completely** without removing adjacent bowel as they don't share muscular layers with intestine. *Dermoid cyst* - **Teratomatous cysts** containing ectoderm-derived tissues that develop as separate entities from intestinal structures. - Have **independent blood supply** and capsule, allowing complete excision without bowel resection. *Mesothelial cyst* - Arise from **peritoneal mesothelium** and are located in the mesentery without intimate connection to bowel wall. - Can be **enucleated safely** as they don't share structural components with the adjacent intestine.

Question 120: Which of the following is NOT true about hernia in children?

A. Conservative management is done until the patient is asymptomatic. (Correct Answer)
B. In children, hernia treatment is performed with herniotomy.
C. Absorbable mesh is not used.
D. Long-standing hernias increase the chances of incarceration.

Explanation: **Explanation:** In pediatric surgery, the pathophysiology of an inguinal hernia differs significantly from adults. It is almost always an **indirect inguinal hernia** caused by a **patent processus vaginalis (PPV)** rather than a weakness in the abdominal wall. **1. Why Option A is the correct (False) statement:** Unlike umbilical hernias, which often close spontaneously, pediatric inguinal hernias **never resolve on their own**. There is no role for conservative management. Once diagnosed, surgical intervention is indicated promptly because the risk of **incarceration** (especially in infants) is high. Waiting until symptoms worsen increases the risk of bowel gangrene or gonadal ischemia. **2. Analysis of other options:** * **Option B:** The standard treatment is **Herniotomy** (High ligation of the sac). Since the defect is a patent tube (PPV) and not a muscular weakness, simple ligation and excision of the sac are sufficient. * **Option C:** **Mesh is not used** in children. The inguinal canal grows as the child matures; a mesh would interfere with this growth and is unnecessary since there is no posterior wall defect to reinforce. * **Option D:** It is a clinical fact that the longer a hernia remains unrepaired, the higher the cumulative risk of incarceration and strangulation. **Clinical Pearls for NEET-PG:** * **Most common side:** Right side (due to later descent of the right testis). * **Silk Glove Sign:** A palpable sensation of two layers of the empty hernial sac rubbing together over the spermatic cord. * **Emergency:** If a hernia is irreducible, it is a surgical emergency. * **Gold Standard:** High ligation of the sac at the level of the internal ring (Mitchell Banks or Ferguson technique).

Practice by Chapter

Neonatal Physiology

Practice Questions

Congenital Anomalies Overview

Practice Questions

Neonatal Intestinal Obstruction

Practice Questions

Necrotizing Enterocolitis

Practice Questions

Hirschsprung's Disease

Practice Questions

Anorectal Malformations

Practice Questions

Pediatric Hernias

Practice Questions

Pyloric Stenosis

Practice Questions

Biliary Atresia

Practice Questions

Pediatric Tumors

Practice Questions

Congenital Diaphragmatic Hernia

Practice Questions

Pediatric Trauma

Practice Questions

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