Pediatric Surgery Practice Questions

Q: What is the definitive treatment for Tetralogy of Fallot (TOF)?

Complete repair. ***Complete repair*** - **Complete repair** is the definitive treatment for TOF, addressing all four anatomical defects. This typically involves closing the **ventricular septal defect (VSD)** and relieving the **right ventricular outflow tract (RVOT) obstruction**. - This procedure usually occurs between 3 to 6 months of age, or earlier if the child experiences severe cyanosis or hypercyanotic spells. *Modified Blalock-Taussig shunt* - The **Modified Blalock-Taussig shunt** is a palliative procedure, not a definitive one. It creates a connection between a systemic artery (often the subclavian) and the pulmonary artery. - This shunt increases **pulmonary blood flow** in infants with severe cyanosis, bridging them to a time when definitive repair can be safely performed. *Fontan procedure* - The **Fontan procedure** is a surgical intervention used for complex congenital heart defects with a **single functional ventricle**, such as hypoplastic left heart syndrome. - It reroutes systemic venous return directly to the pulmonary arteries, bypassing the non-functional ventricle, which is not the primary issue in TOF. *Glenn shunt* - The **Glenn shunt** (or superior cavopulmonary connection) is another palliative procedure, typically performed as the second stage in single-ventricle repair strategies. - It connects the **superior vena cava** to the **pulmonary artery**, diverting upper body venous blood directly to the lungs, and allowing the single ventricle to pump only systemic blood. This is not applicable as a definitive solution for TOF.

Q: All are features of congenital megacolon except:

Large bulky stools. ***Large bulky stools*** - Patients with **congenital megacolon** (Hirschsprung disease) typically have difficulty passing stool, leading to small, pellet-like stools or significant constipation, not large bulky stools. - The absence of **ganglion cells** in the affected segment prevents proper relaxation and propulsion, resulting in stool retention and a narrow, spastic segment. *Pseudodiarrhoea* - **Pseudodiarrhoea** can occur in congenital megacolon when liquid stool bypasses the impaction, leading to overflow incontinence. - This symptom is often mistaken for true diarrhea but is characteristic of severe constipation. *Tight anal ring* - A **tight anal ring** on digital rectal examination is a classic finding in Hirschsprung disease due to the spastic, aganglionic segment extending down to the internal anal sphincter. - This spasticity prevents normal relaxation of the internal anal sphincter. *Failure to thrive* - **Failure to thrive** is a common complication of congenital megacolon due to chronic constipation, poor nutrient absorption secondary to bowel stasis, and recurrent enterocolitis. - Chronic poor feeding and malabsorption contribute to inadequate weight gain and growth.

Q: What is the most common complication occurring in tracheostomy in children? (March 2004)

Infection. ***Infection*** - **Infection** is among the most frequent complications in pediatric tracheostomy, occurring in the immediate postoperative period and throughout the tracheostomy course. - Can manifest as **stoma infections** (cellulitis, wound breakdown), **tracheitis**, **pneumonia**, or **mediastinitis**. - The constant presence of an open wound, bypassed upper airway defenses, and need for frequent suctioning create ongoing infection risk. - **Clinical significance**: While some studies cite difficult decannulation as more common, infection remains the most clinically significant early complication requiring active management. *Difficult decannulation* - A very common complication in pediatric tracheostomy, with some studies suggesting it may be the **most frequent** long-term issue. - Children's airways are more prone to **granulation tissue formation**, **suprastomal collapse**, and **tracheomalacia**. - Occurs in **prolonged tracheostomy** cases, often requiring multiple attempts or surgical intervention. - Frequency varies by underlying indication and duration of cannulation. *Difficult weaning* - Refers to challenges in **ventilator weaning** rather than a direct tracheostomy complication. - More related to the **underlying respiratory or neurological condition** necessitating tracheostomy. - A management challenge rather than a procedural complication. *Stenosis* - **Tracheal or subglottic stenosis** is a serious **late complication** occurring in 10-15% of pediatric cases. - Results from **chronic irritation**, **granulation tissue**, cartilage injury, or improper tube size. - While severe when it occurs, its overall incidence is **lower than infection or decannulation issues**.

Q: A newborn suffering from perforated necrotizing enterocolitis is having very poor general condition. He is currently stabilized on ventilator. Which of the following should be done in the management of this patient?

Peritoneal drainage. ***Peritoneal drainage*** - In a newborn with **perforated necrotizing enterocolitis (NEC)** and **poor general condition**, peritoneal drainage is the preferred initial surgical approach to address sepsis while avoiding major abdominal surgery. - This procedure involves draining accumulated fluid and pus from the peritoneal cavity, reducing intra-abdominal pressure and systemic inflammation in a medically unstable patient. *Resection and anastomosis* - **Resection and primary anastomosis** is a more extensive surgical procedure that carries higher risks in a globally unstable neonate. - This surgery is typically reserved for more stable patients or as a secondary procedure once the patient's condition has improved following initial decompression. *Conservative treatment* - **Conservative treatment** alone is insufficient and inappropriate for **perforated necrotizing enterocolitis**, as perforation implies the need for surgical intervention to address peritonitis and sepsis. - Delaying surgical management in perforation can lead to rapid deterioration, severe sepsis, and increased mortality. *Stabilization with membrane oxygenator and defer surgery* - While an **extracorporeal membrane oxygenator (ECMO)** might be used for respiratory or cardiovascular support in severe cases, it does not address the underlying **perforation and peritonitis**. - **Deferring surgery** for perforation is not an option as surgical source control is necessary to manage the acute peritonitis and sepsis, even if the patient is on ECMO.

Q: The commonest cause of intestinal obstruction in children is –

Intussusception. ***Intussusception*** - **Intussusception** is the most common cause of intestinal obstruction in children, especially in infants between 6 months and 3 years of age. - It occurs when one segment of the intestine telescopes into an adjacent segment, leading to obstruction and potentially compromising blood supply. *Adhesions* - **Adhesions** are bands of scar tissue that can form after abdominal surgery and are a common cause of intestinal obstruction in adults. - While they can occur in children, they are generally less common as a primary cause of obstruction compared to intussusception, especially in infants. *Hernia* - **Hernias**, particularly incarcerated inguinal hernias, can cause intestinal obstruction in children. - Although common, hernias are not the single most frequent cause of intestinal obstruction across all pediatric age groups compared to intussusception. *Volvulus* - **Volvulus** refers to the twisting of a loop of intestine around its mesentery, often associated with intestinal malrotation. - It is a serious cause of intestinal obstruction in children and infants, but less common than intussusception, though it carries a higher risk of intestinal ischemia.

Q: A 12-year-old male is admitted to the hospital with profuse rectal bleeding but appears to be free of any associated pain. Which of the following is the most common cause of severe rectal bleeding in the pediatric age group?

Ileal (Meckel) diverticulum. ***Ileal (Meckel) diverticulum*** - **Meckel's diverticulum** is the most common congenital anomaly of the gastrointestinal tract, present in approximately 2% of the population. - It is the **most common cause of painless, profuse rectal bleeding** in the pediatric age group, typically presenting with brick-red or maroon stools. - The bleeding results from **peptic ulceration of the ileal mucosa** adjacent to ectopic (heterotopic) gastric mucosa within the diverticulum, which secretes acid. - Diagnosis is often confirmed with a **Technetium-99m pertechnetate scan** (Meckel's scan), which detects ectopic gastric mucosa. *External hemorrhoids* - External hemorrhoids typically present with **pain, itching, and a palpable perianal lump**, especially when thrombosed. - While they can cause bleeding, it is usually **minimal and bright red**, not the profuse rectal bleeding described in this case. - Hemorrhoids are **uncommon in children** and usually associated with chronic constipation or straining. *Internal hemorrhoids* - Internal hemorrhoids can cause **painless bleeding**, but this typically manifests as bright red blood coating the stool or dripping into the toilet bowl. - The bleeding is usually **minor and intermittent**, not profuse or life-threatening. - They are **much less common in the pediatric population** compared to adults and are not a typical cause of significant hemorrhage in children. *Diverticulosis* - Colonic diverticulosis is predominantly a **disease of older adults** (typically >40 years of age) related to dietary factors and increased intraluminal pressure. - It is **extremely rare in the pediatric age group** and would not be a primary consideration in a 12-year-old. - While diverticulosis can cause significant painless bleeding in adults, its occurrence in children is highly unlikely.

Q: The ideal timing of radiotherapy for Wilms tumour after surgery is:

Within 10 days. ***Within 10 days*** - For patients with **Wilms tumour** requiring adjuvant radiotherapy, treatment should ideally commence within **10 days following surgery**. - This prompt initiation minimizes the time for any residual microscopic disease to proliferate and potentially spread, optimizing local control and overall outcome. *Any time after surgery* - This timing is too broad and does not adhere to the recommended protocol for Wilms tumour, which emphasizes early post-operative radiotherapy. - Delaying radiotherapy beyond the recommended window can increase the risk of tumour recurrence and negatively impact prognosis. *Within 2 weeks* - While 2 weeks is a relatively short timeframe, **10 days** is the more precise and **ideal window** for initiating radiotherapy according to established protocols for Wilms tumour. - Waiting up to 2 weeks (14 days) might still introduce an unnecessary delay compared to the optimal 10-day goal. *Within 3 weeks* - A delay of up to **3 weeks** is considered suboptimal and potentially risky, as it allows a longer period for any remaining tumour cells to regrow. - This interval significantly deviates from the **evidence-based guidelines** for timely adjuvant therapy in Wilms tumour management.

Q: A 7-year-old female who is somewhat obese is brought to the emergency department because of a soft lump above the buttocks. Upon physical examination you note the lump is located just superior to the iliac crest unilaterally on the left side. The protrusion is deep to the skin and pliable to the touch. Which of the following is the most probable diagnosis?

Herniation at the lumbar triangle (of Petit). ***Herniation at the lumbar triangle (of Petit)*** - This hernia occurs through the **lumbar triangle of Petit**, which is bounded by the **latissimus dorsi**, **external oblique**, and **iliac crest**. - Its location just **superior to the iliac crest** and unilateral presentation align with the description of a lumbar hernia, often presenting as a soft, pliable lump. *Indirect inguinal hernia* - This type of hernia protrudes through the **deep inguinal ring** and often descends into the scrotum or labia, a location not consistent with a lump above the buttocks. - It is typically associated with a **patent processus vaginalis**, more common in infants and young children, but the described location differs significantly. *Tumor of the external abdominal oblique muscle* - While possible, a **tumor** would likely present with different characteristics, such as being firm, fixed, and potentially painful, rather than a soft, pliable protrusion. - The described soft and pliable characteristics are more indicative of a hernia involving abdominal contents rather than a solid muscle mass. *Direct inguinal hernia* - A direct inguinal hernia protrudes through the **Hesselbach's triangle** and appears medially to the inferior epigastric vessels, typically presenting as a bulge in the groin area. - Its location in the **anterior abdominal wall**, near the pubic tubercle, makes it inconsistent with a lump found superior to the iliac crest.

Q: 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?

Malrotation with volvulus. ***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).

Question 1

What is the definitive treatment for Tetralogy of Fallot (TOF)?

Accepted Answer

Complete repair

Answer

Modified Blalock-Taussig shunt

Answer

Fontan procedure

Answer

Glenn shunt

Question 2

All are features of congenital megacolon except:

Accepted Answer

Large bulky stools

Answer

Pseudodiarrhoea

Answer

Tight anal ring

Answer

Failure to thrive

Question 3

A 13-year-old boy has a 3-day history of low-grade fever, symptoms of upper respiratory infection, and a sore throat. A few hours before his presentation to the emergency room, he has an abrupt onset of high fever, difficulty swallowing, and poor handling of his secretions. He indicates that he has a marked worsening in the severity of his sore throat. His pharynx has a fluctuant bulge in the posterior wall. A soft tissue radiograph of his neck is shown. Which of the following is the most appropriate initial therapy for this patient?

Accepted Answer

Surgical consultation for incision and drainage under general anesthesia

Answer

Narcotic analgesics

Answer

Rapid streptococcal screen

Answer

Trial of oral penicillin V

Question 4

What is the most common complication occurring in tracheostomy in children? (March 2004)

Accepted Answer

Infection

Answer

Difficult decannulation

Answer

Difficult weaning

Answer

Stenosis

Question 5

A newborn suffering from perforated necrotizing enterocolitis is having very poor general condition. He is currently stabilized on ventilator. Which of the following should be done in the management of this patient?

Accepted Answer

Peritoneal drainage

Answer

Resection and anastomosis

Answer

Conservative treatment

Answer

Stabilization with membrane oxygenator and defer surgery

Question 6

The commonest cause of intestinal obstruction in children is –

Accepted Answer

Intussusception

Answer

Adhesions

Answer

Hernia

Answer

Volvulus

Question 7

A 12-year-old male is admitted to the hospital with profuse rectal bleeding but appears to be free of any associated pain. Which of the following is the most common cause of severe rectal bleeding in the pediatric age group?

Accepted Answer

Ileal (Meckel) diverticulum

Answer

External hemorrhoids

Answer

Internal hemorrhoids

Answer

Diverticulosis

Question 8

The ideal timing of radiotherapy for Wilms tumour after surgery is:

Accepted Answer

Within 10 days

Answer

Any time after surgery

Answer

Within 2 weeks

Answer

Within 3 weeks

Question 9

A 7-year-old female who is somewhat obese is brought to the emergency department because of a soft lump above the buttocks. Upon physical examination you note the lump is located just superior to the iliac crest unilaterally on the left side. The protrusion is deep to the skin and pliable to the touch. Which of the following is the most probable diagnosis?

Accepted Answer

Herniation at the lumbar triangle (of Petit)

Answer

Indirect inguinal hernia

Answer

Tumor of the external abdominal oblique muscle

Answer

Direct inguinal hernia

Question 10

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?

Accepted Answer

Malrotation with volvulus

Answer

Hypertrophic pyloric stenosis

Answer

Acute appendicitis

Answer

Jejunal atresia

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

On this page

Practice by Chapter

Want unlimited practice?