Pediatric Surgery Practice Questions

Q: A 16-year-old competitive swimmer presents with recurrent shoulder dislocation. MRI shows a Bankart lesion and significant bone loss. His coach wants him to return to competition quickly, his parents are concerned about long-term function, and the patient wants to continue swimming. Evaluate the management approach that best addresses all stakeholder concerns.

Latarjet procedure for bone loss with extended recovery. ***Latarjet procedure for bone loss with extended recovery*** - The **Latarjet procedure** addresses both the **Bankart lesion** and significant **bone loss** on the glenoid, which is crucial for preventing future dislocations in a high-risk athlete. - While it requires an **extended recovery** (typically 4-6 months), this approach offers the best long-term stability, satisfying the parents' concern for long-term function and ultimately allowing the patient to return to competitive swimming. - This procedure transfers the coracoid process to the glenoid, providing both a bony buttress and dynamic sling effect from the conjoint tendon. *Temporary activity restriction with delayed surgical decision* - This approach fails to address the underlying **structural instability** and significant bone loss, making future dislocations highly probable, especially in a competitive swimmer. - Delaying surgery prolongs the patient's time away from sport and does not adequately address the goal of a definitive, long-term solution. *Conservative management with physical therapy* - In a young, athletic individual with **recurrent dislocations**, a Bankart lesion, and **significant bone loss**, conservative management is highly unlikely to provide adequate stability to prevent recurrence. - This would not allow the patient to safely return to high-demand activities like competitive swimming. *Open Bankart repair with 4-6 month recovery period* - While an **open Bankart repair** addresses the labral lesion, it does not adequately manage the **significant bone loss**, which is a major risk factor for re-dislocation in this patient population. - The risk of recurrent instability remains high with failure rates of 20-30% in athletes with bone loss, making this a less durable solution for a competitive swimmer.

Q: A patient presents with fecal discharge from the umbilicus. What is the most likely diagnosis?

Patent vitelline duct. ***Patent vitelline duct*** - **Fecal discharge from the umbilicus** indicates a persistent communication between the **ileum** and the **umbilicus** through a patent vitelline (omphalomesenteric) duct. - This congenital anomaly represents a remnant of the **omphalomesenteric duct** that **completely failed to involute**, creating a **fistulous tract** allowing intestinal contents to exit through the umbilicus. - This is the **most complete form** of vitelline duct persistence (other forms include Meckel's diverticulum, fibrous band, or umbilical polyp). *Urachal fistula* - A urachal fistula occurs when the **urachus** remains patent, creating a connection between the **bladder** and the umbilicus. - While it can result in umbilical discharge, the discharge would be **urine**, not feces. *Omphalocele* - An omphalocele is a **congenital abdominal wall defect** where abdominal contents protrude into a sac at the base of the umbilicus. - It does not involve a fistulous communication with intestines causing fecal discharge, but rather a **herniation** of organs covered by a peritoneal membrane. *Gastroschisis* - Gastroschisis is a congenital anomaly characterized by the **protrusion of abdominal organs** directly into the amniotic cavity **without a covering sac**, usually to the **right of the umbilicus**. - Like omphalocele, it's a **herniation defect** presenting at birth and does not involve an abnormal fistulous connection causing fecal discharge from the umbilicus.

Q: In the intraoperative image of congenital hernia repair, the structure marked by the red arrow is identified as which of the following?

Testicular vein. ***Testicular vein*** - The **testicular vein** is clearly visible within the **spermatic cord** structures, which are typically identified and often dissected during congenital hernia repair. - Its position coursing with the testicular artery and vas deferens is consistent with its anatomical location within the inguinal canal. *Femoral vein* - The **femoral vein** lies more inferiorly and medially within the femoral canal, distinct from the inguinal canal contents visualized in this image. - Identification of the femoral vein would be in the context of a femoral hernia repair, not typically a congenital (indirect inguinal) hernia. *Obturator vein* - The **obturator vein** is located deep within the pelvis, accompanying the obturator nerve and artery through the obturator foramen. - It is not typically encountered or visible during a standard open or laparoscopic inguinal hernia repair. *Inferior epigastric vein* - The **inferior epigastric vein** runs superiorly and medially, forming the medial border of the **inguinal triangle (Hesselbach's triangle)**. - While it's an important landmark in hernia repair (differentiating direct vs. indirect hernias), its anatomical position and trajectory are distinct from the structure indicated by the arrow, which is part of the spermatic cord.

Q: A child presents to the OPD with the finding shown in the image. When should the first surgical repair be performed?

3 months. ***3 months*** - Surgical repair of **cleft lip** is typically performed around **3 months of age** based on current practice guidelines. - The traditional **"Rule of 10s"** (10 weeks old, 10 pounds weight, 10 g/dL hemoglobin) has evolved to **3-6 months** as the optimal timing window, with **3 months** being most common. - Early repair helps with **feeding difficulties**, improves cosmesis, and facilitates normal **parent-infant bonding** while optimizing surgical outcomes. *6 months* - While 6 months is within the acceptable range for cleft lip repair, **3 months is preferred** as the optimal timing in most centers. - Delaying repair to 6 months may impact feeding mechanics and parental bonding, though outcomes remain good. - This timing is **earlier** than the recommended window for **cleft palate repair** (9-18 months). *12 months* - **Cleft palate repair** is typically performed around **9-18 months of age**, with 12 months being a common target to optimize speech development. - Performing **cleft lip repair** at 12 months is significantly **delayed** and would miss the benefits of earlier intervention for feeding, cosmesis, and bonding. *18 months* - 18 months is at the **upper limit** for **cleft palate repair** to minimize speech development issues. - This age is **too late** for the first surgical repair of a cleft lip, which should be performed in early infancy (3-6 months).

Q: The metabolic derangement in congenital pyloric stenosis is -

Hypochloremic alkalosis. ***Hypochloremic alkalosis*** - **Pyloric stenosis** causes persistent vomiting of stomach contents, leading to the loss of **hydrochloric acid (HCl)** and subsequent **hypochloremia** and **metabolic alkalosis**. - The body's compensatory mechanisms are limited: with volume depletion, the kidneys prioritize sodium retention over acid-base balance, leading to **paradoxical aciduria** (excretion of H+ to retain Na+), which perpetuates the alkalosis. *Hyperchloremic alkalosis* - **Hyperchloremia** is an elevated chloride level, which is not characteristic of pyloric stenosis as profound vomiting leads to significant **chloride loss**. - While alkalosis is present, it is specifically **hypochloremic** due to the loss of gastric acid. *Hyperchloremic acidosis* - **Hyperchloremic acidosis** is often seen in conditions like **renal tubular acidosis** or **diarrhea**, where there is a loss of bicarbonate or retention of chloride, and is not associated with gastric outlet obstruction. - This condition involves a low pH (acidosis) and high chloride, which contradicts the clinical picture of pyloric stenosis characterized by high pH (alkalosis) and low chloride. *Hypochloremic acidosis* - This combination is rare and typically seen in conditions like very severe **diarrhea** with significant fluid and electrolyte loss alongside certain renal dysfunctions. - In pyloric stenosis, the primary acid-base disturbance is **alkalosis** due to the loss of gastric acid, not acidosis.

Q: All of the following are true about congenital hypertrophic pyloric stenosis except

Metabolic acidosis occurs. ***Metabolic acidosis occurs*** - Due to persistent **vomiting** from pyloric stenosis, there is a significant loss of **hydrochloric acid (HCl)** from the stomach. - This loss of gastric acid leads to **hypochloremic metabolic alkalosis** rather than acidosis. *More common in males* - **Pyloric stenosis** has a clear male predominance, with a male-to-female ratio of about 4:1. - This gender disparity is a well-established epidemiological feature of the condition. *RamStedt Pyloromyotomy is the treatment of choice* - The **Ramstedt pyloromyotomy** is the definitive surgical procedure for congenital hypertrophic pyloric stenosis. - This procedure involves incising the hypertrophied muscle of the pylorus while leaving the mucosa intact, thus relieving the obstruction. *Non Bilious vomiting is seen* - The vomiting in pyloric stenosis is typically **non-bilious** because the obstruction is proximal to the **ampulla of Vater**, where bile enters the duodenum. - Vomiting usually occurs forcefully (projectile) after feeding.

Q: Investigation of choice for Posterior urethral valves?

Micturating Cystourethrography (MCU). ***Micturating Cystourethrography (MCU)*** - The **Micturating Cystourethrography (MCU)** is the gold standard for diagnosing posterior urethral valves (PUV) as it directly visualizes the posterior urethra during voiding. - It classically shows a **dilated posterior urethra** with a narrow opening at the level of the valves, often accompanied by **vesicoureteral reflux** and bladder wall abnormalities. *Ultrasound* - **Antenatal ultrasound** can suggest PUV by showing bilateral **hydronephrosis**, a dilated bladder, and thick-walled bladder with a "keyhole sign" (dilated posterior urethra). - However, ultrasound alone **cannot definitively diagnose** the valves or rule out other causes of obstruction. *Retrograde urethrography* - **Retrograde urethrography (RGU)** involves injecting contrast against the flow of urine, which can mask the presence of posterior urethral valves, as they are typically obstructive to antegrade flow. - While RGU can highlight urethral strictures and other anterior urethral pathologies, it is **not ideal** for visualizing posterior urethral valves. *Intravenous Pyelography* - **Intravenous Pyelography (IVP)** assesses kidney function and the collecting system, but it provides **limited detailed visualization** of the urethra itself. - While it might show features of obstructive uropathy like **hydronephrosis** or delayed excretion, it cannot directly confirm the presence or location of posterior urethral valves.

Question 1

A 3-year-old child presents with congenital diaphragmatic hernia requiring repair. Preoperative echocardiogram shows severe pulmonary hypertension with suprasystemic pressures. The pediatric surgeon recommends immediate repair, while the cardiologist suggests optimizing pulmonary pressures first. Evaluate the optimal timing and approach.

Accepted Answer

Medical optimization of pulmonary hypertension then early repair

Answer

Surgical repair with intraoperative ECMO support

Answer

ECMO support with delayed surgical repair

Answer

Delay surgery until pulmonary pressures normalize

Question 2

A 16-year-old competitive swimmer presents with recurrent shoulder dislocation. MRI shows a Bankart lesion and significant bone loss. His coach wants him to return to competition quickly, his parents are concerned about long-term function, and the patient wants to continue swimming. Evaluate the management approach that best addresses all stakeholder concerns.

Accepted Answer

Latarjet procedure for bone loss with extended recovery

Answer

Temporary activity restriction with delayed surgical decision

Answer

Conservative management with physical therapy

Answer

Open Bankart repair with 4-6 month recovery period

Question 3

A patient presents with fecal discharge from the umbilicus. What is the most likely diagnosis?

Accepted Answer

Patent vitelline duct

Answer

Urachal fistula

Answer

Omphalocele

Answer

Gastroschisis

Question 4

In the intraoperative image of congenital hernia repair, the structure marked by the red arrow is identified as which of the following?

Accepted Answer

Testicular vein

Answer

Femoral vein

Answer

Obturator vein

Answer

Inferior epigastric vein

Question 5

A child presents to the OPD with the finding shown in the image. When should the first surgical repair be performed?

Accepted Answer

3 months

Answer

6 months

Answer

12 months

Answer

18 months

Question 6

A 6-month-old child presents with an umbilical hernia measuring 3 cm in diameter. What is the management protocol?

Accepted Answer

Observation until 2 years of age, then surgery if unresolved

Answer

Immediate surgical repair

Answer

Elective surgery at 5 years of age

Answer

Hernioplasty for repair

Question 7

The metabolic derangement in congenital pyloric stenosis is -

Accepted Answer

Hypochloremic alkalosis

Answer

Hyperchloremic alkalosis

Answer

Hyperchloremic acidosis

Answer

Hypochloremic acidosis

Question 8

All of the following are true about congenital hypertrophic pyloric stenosis except

Accepted Answer

Metabolic acidosis occurs

Answer

More common in males

Answer

RamStedt Pyloromyotomy is the treatment of choice

Answer

Non Bilious vomiting is seen

Question 9

Investigation of choice for Posterior urethral valves?

Accepted Answer

Micturating Cystourethrography (MCU)

Answer

Ultrasound

Answer

Retrograde urethrography

Answer

Intravenous Pyelography

Question 10

A child presented with intermittent episodes of left sided flank pain. Ultrasonography reveals large hydronephrosis with dilated renal pelvis and cortical thinning with a normal ureter. Kidney differential function was observed to be 19%. Which of the following is the best management?

Accepted Answer

Pyeloplasty

Answer

Endopylostomy

Answer

Nephrectomy

Answer

External drainage

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

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