Pediatric Surgery — MCQs

A 16-year-old boy presents with acute onset of severe abdominal pain that began while playing basketball. He has a history of undescended testis that was surgically corrected at age 8. Physical examination shows a tender mass in the left lower quadrant. What is the most likely diagnosis and underlying mechanism?

Q260

A 4-year-old boy presents with sudden onset of severe abdominal pain and vomiting. On examination, he has a palpable mass in the right upper quadrant and bloody stools. Ultrasound shows a 'target sign' in the right abdomen. What is the most likely diagnosis and appropriate initial management?

Pediatric Surgery Indian Medical PG Practice Questions and MCQs

Question 251: Which of the following are correct for herniation via foramen of Morgagni? 1. It occurs posteriorly in chest. 2. Transverse colon is the commonest content. 3. Defect is between sternal and costal attachments. 4. It is a type of congenital hernia. Select the answer using the code given below.

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

Explanation: ***2, 3 and 4*** - The **foramen of Morgagni** hernia (also known as a parasternal or retrosternal hernia) is a type of **congenital diaphragmatic hernia (CDH)** - statement 4 is **correct**. - The defect is located in the **anterior diaphragm**, specifically between the **sternal and costal attachments** - statement 3 is **correct**. - The **transverse colon** is indeed a common content (most common visceral organ), though omentum is actually the most frequent overall content - statement 2 is considered **correct** in clinical practice. - Statement 1 is **incorrect** as Morgagni hernias occur **anteriorly**, not posteriorly. *1, 3 and 4* - This option incorrectly includes statement 1, which claims the herniation occurs **posteriorly** in the chest. - **Morgagni hernias** are **anterior** diaphragmatic defects (parasternal location). - Posterior diaphragmatic hernias are **Bochdalek hernias**, not Morgagni hernias. *1, 2 and 4* - This option is incorrect because statement 1 states the hernia occurs **posteriorly**, which is wrong. - **Morgagni hernias** are located in the **anterior diaphragm** between sternal and costal attachments. - While statements 2 and 4 are correct, the inclusion of statement 1 makes this option incorrect. *1, 2 and 3* - This option is incorrect because statement 1 claims the hernia occurs **posteriorly**, which is inaccurate. - **Morgagni hernias** are **anterior** defects, representing only 2-3% of congenital diaphragmatic hernias. - The key distinguishing feature is the anterior parasternal location, not posterior.

Question 252: Which one of the following is the treatment of choice in a child with inguinal hernia ?

A. Shouldice operation
B. Lichtenstein repair
C. Herniotomy alone (Correct Answer)
D. Bassini's repair

Explanation: ***Herniotomy alone*** - In children, an **inguinal hernia** is typically an **indirect hernia** resulting from a persistent **patent processus vaginalis**. - **Herniotomy alone** (ligation and excision of the hernia sac) is sufficient because the posterior wall of the inguinal canal is usually strong and does not require reinforcement. *Shouldice operation* - The **Shouldice operation** is a **fascial repair** technique involving multiple layers of the posterior inguinal wall. - It is primarily used in **adults** for direct inguinal hernias or recurrent hernias, where the posterior wall is weakened. *Lichtenstein repair* - The **Lichtenstein repair** is a **tension-free mesh repair** method commonly performed in adults. - It involves placing a prosthetic mesh to reinforce the posterior wall of the inguinal canal, which is unnecessary and potentially problematic in growing children. *Bassini's repair* - **Bassini's repair** is a **tissue-based repair** that involves approximating the conjoined tendon to the inguinal ligament. - Like other adult repair techniques, it is associated with higher tension and risks of recurrence in adults due to underlying tissue weakness, and is not suitable for the physiological anatomy of a pediatric inguinal hernia.

Question 253: The treatment of choice for congenital hypertrophic pyloric stenosis is :

A. Duodenojejunostomy
B. Heller's operation
C. Ramstedt's operation (Correct Answer)
D. Gastrojejunostomy

Explanation: ***Ramsted's operation*** - **Ramstedt pyloromyotomy** is the definitive surgical treatment for **congenital hypertrophic pyloric stenosis**. - This procedure involves a longitudinal incision through the serosa and muscular layers of the hypertrophied pylorus, stopping short of the mucosa, to relieve the obstruction. *Duodenojejunostomy* - This procedure involves connecting the **duodenum to the jejunum**, typically performed to bypass an obstruction or resection in the distal duodenum or pancreas. - It is not indicated for **pyloric stenosis**, which is an obstruction at the gastric outlet. *Heller's operation* - Also known as **Heller myotomy**, this procedure is used to treat **achalasia**, a disorder affecting the esophagus. - It involves cutting the muscle fibers of the lower esophageal sphincter to facilitate food passage into the stomach, which is unrelated to **pyloric hypertrophy**. *Gastrojejunostomy* - This surgical procedure creates a connection between the **stomach and the jejunum**, bypassing the duodenum. - It is typically performed for conditions like **duodenal obstruction** or distal gastric tumors, not for primary pyloric muscle hypertrophy.

Question 254: What is the most appropriate surgical procedure for duodenal atresia?

A. Ramstedt's operation
B. Duodenojejunostomy
C. Duodenoduodenostomy (Correct Answer)
D. Gastroduodenostomy

Explanation: ***Duodenoduodenostomy*** - This procedure involves **reconnecting the two ends of the duodenum** after resecting the atretic (blocked) segment. - It is specifically designed to bypass the obstruction caused by **duodenal atresia**, restoring normal intestinal continuity. *Ramstedt's operation* - This procedure is a **pyloromyotomy** performed for **pyloric stenosis**, where the thickened muscle of the pylorus is incised, not for duodenal atresia. - It addresses a narrowing at the exit of the stomach, not an obstruction within the small intestine itself. *Duodenojejunostomy* - This involves connecting the **duodenum to the jejunum**, typically used when a large segment of the duodenum is affected or there is a need to bypass a pathological area. - While technically feasible, **duodenoduodenostomy is preferred for isolated duodenal atresia** due to its more anatomical reconstruction. *Gastroduodenostomy* - This procedure connects the **stomach to the duodenum**, primarily performed after a partial gastrectomy (e.g., Billroth I) or for gastric outlet obstruction. - It is **not indicated for duodenal atresia**, as it does not address the congenital blockage within the duodenum.

Question 255: Which one of the following statements is NOT correct regarding Gastroschisis?

A. Gut has herniated through a defect to right of umbilicus
B. Normally limited to midgut
C. It is a ruptured exomphalos (Correct Answer)
D. There is no covering membrane

Explanation: ***It is a ruptured exomphalos*** - This statement is incorrect because **gastroschisis** and **exomphalos (omphalocele)** are distinct congenital abdominal wall defects, and gastroschisis is not a ruptured form of exomphalos. - Gastroschisis involves a **full-thickness abdominal wall defect** with direct extrusion of bowel, while exomphalos involves herniation of abdominal contents into the base of the umbilical cord, covered by a membrane. *Gut has herniated through a defect to right of umbilicus* - Gastroschisis is typically characterized by a **paraumbilical defect**, almost always located to the **right of the umbilical cord**. - This anatomical location is a key differentiator from exomphalos, where the defect is at the central umbilical ring. *Normally limited to midgut* - The herniated contents in gastroschisis are predominantly the **small bowel (midgut)**, though other organs like the large bowel, stomach, or liver can occasionally be involved. - The limited involvement of other organs is a differentiating factor from an exomphalos, which can contain a wider array of abdominal viscera. *There is no covering membrane* - A defining feature of gastroschisis is the **absence of a peritoneal sac or covering membrane** over the herniated intestines. - This lack of protection exposes the bowel to amniotic fluid, leading to inflammation and a thickened, matted appearance of the bowel loops.

Question 256: An eight year old male child complains of severe pain in right testis. The most probable diagnosis is

A. Acute epididymo-orchitis
B. Torsion of right testis (Correct Answer)
C. Strangulated Inguinal hernia
D. Undescended testis

Explanation: ***Torsion of right testis*** - **Testicular torsion** typically presents with sudden onset **severe unilateral testicular pain** in pre-pubertal boys, as described. - This condition is an emergency requiring prompt surgical intervention to preserve testicular viability, making it the most probable diagnosis for severe pain in a child's testis. *Acute epididymo-orchitis* - While causing testicular pain, **epididymo-orchitis** typically has a more gradual onset and is often associated with symptoms like **fever** and **dysuria**, which are not mentioned. - It usually occurs in older adolescents or adults and is less common in an 8-year-old without predisposing factors like a urinary tract infection. *Strangulated Inguinal hernia* - A **strangulated inguinal hernia** would present with an acutely painful, irreducible groin or scrotal swelling, often accompanied by signs of **bowel obstruction**. - While it can cause pain radiating to the testis, primary severe testicular pain without a palpable groin mass points away from this diagnosis. *Undescended testis* - An **undescended testis** (cryptorchidism) is a condition where the testis has not descended into the scrotum; it typically presents as an empty scrotum or a palpable mass in the inguinal canal. - It is usually **painless** unless undergoing torsion or developing malignancy, and severe acute pain as the primary symptom would be unusual for an uncomplicated undescended testis.

Question 257: 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)

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.

Question 258: An infant presented in the surgical OPD with complaints of a unilateral swelling in the neck. The swelling was soft, cystic, partially compressible and brilliantly transilluminant. The most probable diagnosis is

A. Branchial fistula
B. Branchial cyst
C. Thyroglossal cyst
D. Cystic Hygroma (Correct Answer)

Explanation: ***Cystic Hygroma*** - A **cystic hygroma (lymphangioma)** is a congenital malformation of the lymphatic system, typically presenting in infants as a soft, compressible, and **brilliantly transilluminant** neck mass. - The hallmark feature is **brilliant transillumination** due to the clear lymphatic fluid within the multiloculated cystic spaces. - Commonly located in the **posterior triangle of the neck** (75%) or submandibular region, though can occur anywhere in the neck. - The presentation of a soft, cystic, partially compressible, and brilliantly transilluminant unilateral neck swelling in an infant is classic for cystic hygroma. *Branchial cyst* - A **branchial cyst** arises from incomplete obliteration of the branchial apparatus during embryonic development. - Typically presents in **older children or young adults** (late childhood to third decade), not commonly in infancy. - Located in the **lateral neck** along the anterior border of the sternocleidomastoid muscle. - While it can be soft and cystic, **brilliant transillumination is not a hallmark feature** of branchial cysts, making this less likely in an infant with this classic presentation. *Branchial fistula* - A **branchial fistula** is an abnormal tract connecting the skin to the pharynx, presenting with a small external opening that may discharge mucus or saliva. - It is **not a cystic swelling** and does not present with transillumination, as it is a communicating tract rather than a closed cystic mass. *Thyroglossal cyst* - A **thyroglossal cyst** is a **midline neck swelling** that moves with protrusion of the tongue and swallowing, reflecting its embryonic origin from the thyroglossal duct. - The question specifically mentions a **unilateral swelling**, which rules out thyroglossal cyst as it characteristically occurs in the midline.

Question 259: A 16-year-old boy presents with acute onset of severe abdominal pain that began while playing basketball. He has a history of undescended testis that was surgically corrected at age 8. Physical examination shows a tender mass in the left lower quadrant. What is the most likely diagnosis and underlying mechanism?

A. Testicular cancer from previous cryptorchidism
B. Testicular torsion from previous surgery
C. Appendicitis from athletic activity
D. Inguinal hernia from increased activity (Correct Answer)

Explanation: ***Inguinal hernia from increased activity*** - The acute onset of **severe abdominal pain** during physical activity (basketball) and the presence of a **tender mass in the left lower quadrant** are highly suggestive of an incarcerated inguinal hernia. - Previous undescended testis and subsequent surgery, especially if a **patent processus vaginalis** remained, can predispose to inguinal hernia formation, which can acutely manifest with strenuous activity. *Testicular cancer from previous cryptorchidism* - While a history of cryptorchidism increases the risk of testicular cancer, it typically presents as a **painless testicular mass** or swelling, not acute severe abdominal pain with a tender mass in the lower quadrant. - The onset of symptoms in this case is acute and directly related to physical activity, which is less consistent with the usually gradual progression of testicular cancer. *Testicular torsion from previous surgery* - Testicular torsion presents with **sudden, severe unilateral scrotal pain**, often radiating to the groin or abdomen, and typically involves a high-riding, tender testis. The pain is not primarily abdominal unless referred. - While some surgical procedures can alter testicular fixation, the pain being described as a **tender mass in the left lower quadrant** points more towards an abdominal or groin wall issue rather than direct testicular torsion. *Appendicitis from athletic activity* - Appendicitis typically presents with **periumbilical pain** that migrates to the **right lower quadrant (McBurney's point)**, often accompanied by **anorexia, nausea, and vomiting**. - The location of the tender mass in the **left lower quadrant** and the acute onset during physical activity make appendicitis less likely as the primary diagnosis.

Question 260: A 4-year-old boy presents with sudden onset of severe abdominal pain and vomiting. On examination, he has a palpable mass in the right upper quadrant and bloody stools. Ultrasound shows a 'target sign' in the right abdomen. What is the most likely diagnosis and appropriate initial management?

A. Appendicitis; emergent appendectomy
B. Pyloric stenosis; pyloromyotomy
C. Malrotation with volvulus; emergent surgery
D. Intussusception; pneumatic reduction (Correct Answer)

Explanation: ***Intussusception; pneumatic reduction*** - The classic triad of **intermittent severe abdominal pain**, **vomiting**, and **bloody (currant jelly) stools** in a young child, along with a **palpable right upper quadrant mass** and an ultrasound **'target sign'**, is highly indicative of intussusception. - **Pneumatic reduction** (or hydrostatic) is the initial management choice in hemodynamically stable patients without signs of perforation, as it is often successful and avoids surgery. *Incorrect: Appendicitis; emergent appendectomy* - While appendicitis causes abdominal pain and vomiting, it typically presents with **periumbilical pain migrating to the right lower quadrant** and usually does not feature a palpable mass or currant jelly stools. - The ultrasound finding of a **'target sign'** is specific to intussusception, not appendicitis. *Incorrect: Pyloric stenosis; pyloromyotomy* - Pyloric stenosis typically causes **non-bilious projectile vomiting** in infants (usually 2-8 weeks old) due to hypertrophy of the pyloric muscle. - It does not involve severe abdominal pain, palpable mass in the right upper quadrant, or bloody stools. *Incorrect: Malrotation with volvulus; emergent surgery* - Malrotation with volvulus also causes sudden onset abdominal pain and vomiting, often **bilious**, due to intestinal obstruction and ischemia. - While it requires emergent surgery, the presence of a **palpable mass** and the specific **ultrasound 'target sign'** are more characteristic of intussusception than volvulus.

Practice by Chapter

Neonatal Physiology

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Congenital Anomalies Overview

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Neonatal Intestinal Obstruction

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Necrotizing Enterocolitis

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Hirschsprung's Disease

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Anorectal Malformations

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Pediatric Hernias

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Pyloric Stenosis

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Biliary Atresia

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Pediatric Tumors

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Congenital Diaphragmatic Hernia

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Pediatric Trauma

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