Pediatric Surgery Practice Questions

Q: In a child with confirmed intussusception, what is the first-line therapeutic procedure?

Pneumatic reduction under fluoroscopy. ***Pneumatic reduction under fluoroscopy*** - This is the **first-line therapeutic procedure** for intussusception in hemodynamically stable children without peritoneal signs. - Uses air pressure to un-telescope the bowel segments, with success rates of **70-90%** in appropriately selected cases. - Performed under fluoroscopic or **ultrasound guidance** (ultrasound preferred in many centers to avoid radiation). - Contraindications include peritonitis, perforation, and shock. *Exploratory laparotomy* - Reserved as **second-line treatment** when pneumatic reduction fails (occurs in 10-30% of cases). - Also indicated when there are contraindications to reduction: **peritonitis, perforation, bowel necrosis**, or hemodynamic instability. - Allows manual reduction or bowel resection if necrotic segments are present. *Observation and supportive care* - Supportive measures (IV fluids, NG decompression, antibiotics) are **adjunctive** but not definitive treatment. - Intussusception requires **prompt intervention** as it can rapidly progress to bowel ischemia, necrosis, and perforation. - Observation alone is inadequate and risks serious complications. *Abdominal ultrasound only* - Ultrasound is the **gold standard for diagnosis**, showing the characteristic "target sign" or "pseudokidney sign." - However, it is **diagnostic only** and does not treat the intussusception. - Diagnosis must be followed by therapeutic intervention (reduction or surgery).

Q: A 6-year-old child presents with fever, abdominal pain, and a positive McBurney's sign. What is the most likely diagnosis?

Acute appendicitis. ***Acute appendicitis*** - The classic presentation of **fever, abdominal pain**, and a **positive McBurney's sign** in a child strongly indicates acute appendicitis. - **McBurney's sign** refers to tenderness at McBurney's point, which is 2/3 of the way from the umbilicus to the anterior superior iliac spine, a hallmark of appendiceal inflammation. *Gastroenteritis* - While it can cause fever and abdominal pain, **gastroenteritis** is typically associated with **vomiting and diarrhea**, which are not mentioned here. - It does not present with a localized sign like **McBurney's tenderness**. *Meckel's diverticulitis* - **Meckel's diverticulitis** can mimic appendicitis but typically presents with **painless rectal bleeding** due to ectopic gastric mucosa or occasionally with periumbilical pain. - It is less commonly associated with a distinct McBurney's sign. *Intussusception* - **Intussusception** is characterized by sudden onset of intermittent, severe **colicky abdominal pain**, often with **currant jelly stools** (blood and mucus) and a palpable sausage-shaped mass, not typically McBurney's sign. - It is also more common in infants and toddlers, though it can occur in older children.

Q: Treatment of congenital hydrocephalus is -

Ventriculoperitoneal shunt. ***Ventriculoperitoneal shunt*** - A **ventriculoperitoneal shunt** is the most common and effective treatment for congenital hydrocephalus, diverting excess **cerebrospinal fluid (CSF)** from the ventricles to the peritoneal cavity for absorption. - This surgical procedure aims to reduce **intracranial pressure** and prevent further brain damage caused by CSF accumulation. *Stereotactic radiosurgery* - This minimally invasive technique primarily treats **tumors** or **vascular malformations** in the brain, delivering high-dose radiation precisely. - It does not address the underlying **CSF flow obstruction** or **absorption issues** characteristic of hydrocephalus. *Diuretics* - Diuretics like **acetazolamide** can reduce CSF production, offering temporary or adjunctive treatment for certain forms of hydrocephalus, but they are generally **insufficient** as a primary treatment for congenital hydrocephalus. - They do not address the large-volume fluid accumulation or **obstruction** that typically requires surgical intervention in congenital cases. *Radiotherapy* - **Radiotherapy** uses radiation to destroy cancer cells and is primarily used in the treatment of **brain tumors**. - It is not a treatment for **congenital hydrocephalus**, as it does not resolve the issues of CSF accumulation or reabsorption.

Q: Most common impacted foreign body in esophagus in children is

Coin. ***Coin:*** - **Coins** are the most frequently encountered foreign bodies ingested by children, often becoming lodged in the esophagus due to their shape and size. - The **cricopharyngeal muscle** or the **aortic arch** are common impaction sites for coins in the esophagus. *Food product:* - While food products can cause esophageal obstruction in children, they are more often associated with **strictures** or underlying esophageal motility disorders. - **Smaller, chewable food items** are less likely to cause a complete or prolonged impaction compared to smooth, solid objects like coins. *Crayon:* - **Crayons** are typically made of wax and pigment, making them relatively soft and less likely to cause complete esophageal obstruction or retain a fixed position. - Their irregular shape and friable nature mean they might be more easily dislodged or pass through compared to a rigid coin. *Marble:* - **Marbles** can certainly become impacted in the esophagus, and their smooth, spherical shape poses a risk of complete obstruction. - However, they are **less commonly ingested** by children compared to coins, which are more readily available and often mistaken as playthings.

Q: What is the most appropriate surgical treatment for a large omphalocele?

Silo placement with gradual reduction. ***Silo placement with gradual reduction*** - For **large/giant omphaloceles**, **silo placement** (spring-loaded silo or Silastic pouch) with **gradual reduction** is the most appropriate modern approach when primary closure is not feasible. - The silo allows for **progressive reduction of the visceral contents** back into the abdominal cavity over several days to weeks, allowing the abdominal domain to expand gradually. - This technique **minimizes intra-abdominal pressure**, reduces risk of **abdominal compartment syndrome**, and avoids respiratory and cardiovascular compromise. - The silo is progressively tightened, and once contents are reduced, definitive fascial and skin closure is performed. *Staged closure using PTFE mesh* - **PTFE mesh** or prosthetic patch repair is an alternative for large omphaloceles but is typically a **secondary option**. - It is used when silo reduction fails or for complex cases requiring reinforcement of the abdominal wall. - Mesh may be associated with complications like infection, adhesions, and need for future hernia repair. *Primary closure of the defect* - **Primary closure** is reserved for **small omphaloceles** (typically <5 cm) where the abdominal contents can be reduced and the fascial defect closed without tension. - Attempting primary closure in a **large omphalocele** can lead to **abdominal compartment syndrome** with increased intra-abdominal pressure, causing respiratory distress, renal failure, and bowel ischemia. *None of the options* - This option is incorrect as silo placement with gradual reduction is a well-established and appropriate surgical treatment for large omphaloceles.

Q: What is the best treatment for cystic hygroma?

Surgical excision. ***Surgical excision*** - **Complete surgical excision** is the **gold standard and definitive treatment** for cystic hygroma, offering the best chance of cure and lowest recurrence rate. - Surgery aims for **complete removal** of the lesion while preserving vital structures like nerves and blood vessels in the neck region. - **Timing**: Ideally performed between **18-24 months of age** or earlier if causing airway compromise or rapid growth. - Modern microsurgical techniques have significantly reduced complications like nerve injury. *Sclerotherapy* - **Sclerotherapy** (using agents like OK-432, doxycycline, or bleomycin) is a **second-line or adjunct treatment**, particularly useful for **macrocystic lesions**. - It is considered when complete surgical excision is difficult, for residual disease post-surgery, or in poor surgical candidates. - Has **variable success rates** (60-100% for macrocystic, lower for microcystic) and **higher recurrence** compared to complete excision. *Radiotherapy* - **Radiotherapy has NO role** in the treatment of cystic hygroma as these are benign lymphatic malformations. - Risk of **radiation-induced malignancies** and tissue damage in pediatric patients makes it contraindicated. *Chemotherapy* - **Chemotherapy is NOT indicated** for cystic hygroma as these are **benign congenital lymphatic malformations**, not malignant tumors. - Chemotherapy targets rapidly dividing malignant cells and has no effect on lymphatic malformations.

Q: A 10-year-old male presents with a smooth swelling near superficial inguinal ring, which moves downwards when the testicle is pulled downwards. Diagnosis -

Encysted hydrocele of the cord. ***Encysted hydrocele of the cord*** - An **encysted hydrocele of the cord** manifests as a smooth swelling near the superficial inguinal ring, which is connected to the testicle and thus moves downwards when the testicle is pulled. - This condition arises from the **incomplete obliteration of the processus vaginalis**, leading to a localized fluid collection along the spermatic cord. *Inguinal hernia* - An **inguinal hernia** usually presents with a swelling that can be *reduced* (pushed back into the abdomen) and typically has a **cough impulse**. - While it can be near the inguinal ring, its connection to the testicle is less direct, and pulling the testicle would not typically move the swelling downwards in the same manner. *Congenital hydrocele* - A **congenital hydrocele** involves fluid surrounding the testicle within the tunica vaginalis, often communicating with the peritoneal cavity, causing the scrotum to swell. - It would typically cause a *generalized scrotal swelling* rather than a localized swelling near the superficial inguinal ring that moves with testicular traction. *Varicocele* - A **varicocele** is characterized by a "bag of worms" sensation due to dilated veins in the pampiniform plexus. - It typically appears as a swelling *above the testicle* and does not move downwards when the testicle is pulled, nor is it a smooth, fluid-filled swelling.

Q: Which one of the following is the most clinically significant consequence of undescended testis?

Has a higher incidence of malignancy. ***Has a higher incidence of malignancy*** - **Undescended testes** (cryptorchidism) are associated with a significantly increased risk of developing **germ cell tumors**, particularly seminomas. - While other complications exist, the lifelong risk of **testicular cancer** represents the most serious clinical consequence. *Usually does not descend spontaneously at puberty.* - Spontaneous descent is most likely to occur by **6 months of age**; descent after this period, and particularly at puberty, is rare. - Waiting until puberty for descent is an outdated and potentially harmful approach due to the **increased risk of malignancy** and impaired fertility. *Orchidopexy should be performed if no descent occurs by 6 months of age.* - While early intervention is crucial, the current recommendation is to perform **orchidopexy if spontaneous descent does not occur by 6-12 months of age**. - Performing surgery earlier than 6 months is generally not recommended, as some testes may still descend spontaneously within this timeframe. *Leads to impaired sperm production due to higher internal body temperature.* - The higher temperature within the abdominal cavity or inguinal canal does indeed **impair spermatogenesis**, leading to reduced fertility. - However, while significant, **infertility** is generally considered a less immediate and life-threatening concern compared to the risk of **testicular malignancy**.

Q: In Kernahan's striped 'Y' classification, what is the main reference point?

Incisive foramen. ***Incisive foramen*** - The **incisive foramen** is the central point in the Kernahan's striped 'Y' classification for cleft lip and palate. - This classification system uses the **incisive foramen** as a boundary to distinguish between primary and secondary palatal defects. *Soft palate* - While the **soft palate** can be affected in cleft conditions, it is not the main reference point for the Kernahan's striped 'Y' classification. - Defects of the **soft palate** are part of the secondary palate, but the classification's division hinges on the incisive foramen. *Hard palate* - The **hard palate** is divided into primary and secondary parts by the incisive foramen, making the foramen the key anatomical landmark in this classification. - Defects in the **hard palate** can occur, but the classification system doesn't use the entire hard palate as its primary reference. *Third molar* - The **third molar** is irrelevant to the Kernahan's striped 'Y' classification of cleft lip and palate. - This classification focuses on midfacial structures and palatal development, not on tooth development or position.

Question 1

In a child with confirmed intussusception, what is the first-line therapeutic procedure?

Accepted Answer

Pneumatic reduction under fluoroscopy

Answer

Exploratory laparotomy

Answer

Observation and supportive care

Answer

Abdominal ultrasound only

Question 2

A neonate presented with fever, lethargy, abdominal distension, vomiting, and constipation. What is the most likely diagnosis?

Accepted Answer

Hirschsprung disease

Answer

Volvulus neonatorum

Answer

Intestinal atresia

Answer

Necrotizing enterocolitis

Question 3

A 6-year-old child presents with fever, abdominal pain, and a positive McBurney's sign. What is the most likely diagnosis?

Accepted Answer

Acute appendicitis

Answer

Gastroenteritis

Answer

Meckel's diverticulitis

Answer

Intussusception

Question 4

Treatment of congenital hydrocephalus is -

Accepted Answer

Ventriculoperitoneal shunt

Answer

Diuretics

Answer

Radiotherapy

Answer

Stereotactic radiosurgery

Question 5

Most common impacted foreign body in esophagus in children is

Accepted Answer

Coin

Answer

Food product

Answer

Marble

Answer

Crayon

Question 6

What is the most appropriate surgical treatment for a large omphalocele?

Accepted Answer

Silo placement with gradual reduction

Answer

Staged closure using PTFE mesh

Answer

Primary closure of the defect

Answer

None of the options

Question 7

What is the best treatment for cystic hygroma?

Accepted Answer

Surgical excision

Answer

Radiotherapy

Answer

Chemotherapy

Answer

Sclerotherapy

Question 8

A 10-year-old male presents with a smooth swelling near superficial inguinal ring, which moves downwards when the testicle is pulled downwards. Diagnosis -

Accepted Answer

Encysted hydrocele of the cord

Answer

Inguinal hernia

Answer

Congenital hydrocele

Answer

Varicocele

Question 9

Which one of the following is the most clinically significant consequence of undescended testis?

Accepted Answer

Has a higher incidence of malignancy

Answer

Usually does not descend spontaneously at puberty

Answer

Orchidopexy should be performed if no descent occurs by 6 months of age

Answer

Leads to impaired sperm production due to higher internal body temperature.

Question 10

In Kernahan's striped 'Y' classification, what is the main reference point?

Accepted Answer

Incisive foramen

Answer

Soft palate

Answer

Hard palate

Answer

Third molar

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

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