Pediatric Surgery Practice Questions

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

Herniotomy alone. ***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.

Q: The treatment of choice for congenital hypertrophic pyloric stenosis is :

Ramstedt's operation. ***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.

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

Duodenoduodenostomy. ***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.

Q: Consider the following statements in respect of congenital hypertrophic pyloric stenosis: 1. The condition is more common in males. 2. The investigation of choice is ultrasonography. 3. Hypertrophy is maximal in the pre pyloric region. 4. Projectile vomiting is seen in this condition. Which of the statements given above are correct?

1, 2 and 4 only. ***1, 2 and 4 only*** - **Statement 1 is CORRECT**: Congenital hypertrophic pyloric stenosis (CHPS) is more common in males with a male-to-female ratio of approximately 4-5:1. - **Statement 2 is CORRECT**: Ultrasonography is the investigation of choice for CHPS, being non-invasive and accurate in measuring pyloric muscle thickness (>3 mm) and pyloric length (>15 mm). - **Statement 3 is INCORRECT**: The hypertrophy is maximal in the **pyloric muscle** (circular muscle layer of the pylorus), NOT in the pre-pyloric region. This is a key anatomical distinction. - **Statement 4 is CORRECT**: Projectile non-bilious vomiting typically occurring 30-60 minutes after feeding is the hallmark clinical presentation of CHPS. *3 only* - Incorrect because statement 3 is false (hypertrophy is in the pylorus, not pre-pyloric region), while statements 1, 2, and 4 are all true. *2, 3 and 4 only* - Incorrect because it includes statement 3, which is false. The maximal hypertrophy occurs in the **pyloric canal**, not the pre-pyloric region. *1 and 2 only* - Incomplete as it omits statement 4 about projectile vomiting, which is a cardinal feature of CHPS and is definitely correct.

Q: What is the most common cause of gastric outlet obstruction in a 4-week-old baby?

Congenital hypertrophic pyloric stenosis. ***Congenital hypertrophic pyloric stenosis*** - This condition involves thickening of the **pyloric muscle**, leading to a narrowed outflow tract from the stomach. - It classically presents in infants around **2-6 weeks of age** with **projectile, non-bilious vomiting** and a palpable **olive-shaped mass** in the epigastrium. *Foreign body* - While possible, foreign body ingestion is an **uncommon cause** of gastric outlet obstruction in a 4-week-old infant. - Infants within this age range are typically **not mobile** or exploring their environment in a way that would lead to frequent foreign body ingestion. *Annular pancreas* - This is a rare congenital anomaly where pancreatic tissue completely encircles the **duodenum**, causing obstruction. - Although it can cause gastric outlet obstruction, it is **less common** than pyloric stenosis as the cause in this age group. *Duodenal atresia* - This condition is a complete blockage of the duodenum and typically presents with **bilious vomiting** within the **first 24-48 hours of life**. - The onset of symptoms in a 4-week-old, especially with non-bilious vomiting, makes duodenal atresia a less likely diagnosis.

Q: Which of these is a palliative shunt procedure created between the left subclavian artery and pulmonary artery to treat cyanotic congenital heart disease?

Blalock-Taussig shunt. **Blalock-Taussig shunt** - This procedure creates a **systemic-to-pulmonary artery shunt** by anastomosing a systemic artery (often the **subclavian artery**) to the pulmonary artery, increasing **pulmonary blood flow**. - It is a palliative measure for **cyanotic congenital heart diseases** where there is reduced pulmonary blood flow, such as **Tetralogy of Fallot**. *Waterston's shunt* - This is an older, no longer commonly used palliative shunt connecting the **ascending aorta to the right pulmonary artery**. - It was associated with a high incidence of complications, including **pulmonary overcirculation** and **pulmonary vascular disease**. *Lieno renal shunt* - This refers to a shunt created between the **splenic vein (lienal vein)** and the **left renal vein**. - It is primarily used to treat **portal hypertension** by decompressing the portal venous system, not congenital heart disease. *Gott's shunt* - This involves a **temporary bypass shunt** often used during **thoracic aortic surgery** to protect the spinal cord from ischemia. - It maintains blood flow to the distal aorta during aortic clamping and is not related to congenital heart disease palliation.

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

It is a ruptured exomphalos. ***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.

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

Torsion of right testis. ***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.

Q: Which one of the following regarding abdominal pediatric surgery is correct?

Incision can be closed with absorbable suture. ***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.

Q: 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

Cystic Hygroma. ***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 1

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

Accepted Answer

Herniotomy alone

Answer

Shouldice operation

Answer

Lichtenstein repair

Answer

Bassini's repair

Question 2

The treatment of choice for congenital hypertrophic pyloric stenosis is :

Accepted Answer

Ramstedt's operation

Answer

Duodenojejunostomy

Answer

Heller's operation

Answer

Gastrojejunostomy

Question 3

What is the most appropriate surgical procedure for duodenal atresia?

Accepted Answer

Duodenoduodenostomy

Answer

Ramstedt's operation

Answer

Duodenojejunostomy

Answer

Gastroduodenostomy

Question 4

Consider the following statements in respect of congenital hypertrophic pyloric stenosis:

1. The condition is more common in males.

2. The investigation of choice is ultrasonography.

3. Hypertrophy is maximal in the pre pyloric region.

4. Projectile vomiting is seen in this condition.
Which of the statements given above are correct?

Accepted Answer

1, 2 and 4 only

Answer

3 only

Answer

2, 3 and 4 only

Answer

1 and 2 only

Question 5

What is the most common cause of gastric outlet obstruction in a 4-week-old baby?

Accepted Answer

Congenital hypertrophic pyloric stenosis

Answer

Foreign body

Answer

Annular pancreas

Answer

Duodenal atresia

Question 6

Which of these is a palliative shunt procedure created between the left subclavian artery and pulmonary artery to treat cyanotic congenital heart disease?

Accepted Answer

Blalock-Taussig shunt

Answer

Waterston's shunt

Answer

Lieno renal shunt

Answer

Gott’s shunt

Question 7

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

Accepted Answer

It is a ruptured exomphalos

Answer

Gut has herniated through a defect to right of umbilicus

Answer

Normally limited to midgut

Answer

There is no covering membrane

Question 8

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

Accepted Answer

Torsion of right testis

Answer

Acute epididymo-orchitis

Answer

Strangulated Inguinal hernia

Answer

Undescended testis

Question 9

Which one of the following regarding abdominal pediatric surgery is correct?

Accepted Answer

Incision can be closed with absorbable suture

Answer

Transverse abdominal incision is always used

Answer

Bowel must be always anastomosed in double layer

Answer

Skin over abdomen can never be closed with subcuticular sutures

Question 10

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

Accepted Answer

Cystic Hygroma

Answer

Branchial fistula

Answer

Branchial cyst

Answer

Thyroglossal cyst

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

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