Pediatric Surgery Practice Questions

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: 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: 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: Commonest site of hypospadias is:

Glanular/Coronal. ***Glanular/Coronal*** - The most common location for the ectopic urethral opening in hypospadias is **glanular** or **coronal** (distal type). - This accounts for approximately **65-70%** of all hypospadias cases. - The urethral meatus opens on or just proximal to the glans penis. *Scrotum* - This represents a more **severe form** of hypospadias, where the urethral opening is located on the scrotum. - While it occurs, it is far **less common** than the distal forms. - Classified as **proximal hypospadias**. *Perineum* - **Perineal hypospadias** is the **most severe** form, with the urethral opening located in the perineum (between the scrotum and anus). - This is a **rare occurrence** and often associated with other urogenital anomalies. - Also classified as **proximal hypospadias**. *Mid-penile* - **Mid-shaft hypospadias** involves the urethral opening being located along the mid-portion of the penile shaft. - While more common than scrotal or perineal, it is **less frequent** than the distal (glanular/coronal) types. - Classified as **middle hypospadias**.

Q: A child presents with a scrotal swelling that disappears when lying down and reappears when standing or crying. What is the most likely diagnosis?

Indirect inguinal hernia. ***Indirect inguinal hernia*** - This presentation, where a **scrotal swelling disappears upon lying down** and reappears with increased intra-abdominal pressure (standing, crying), is classic for an **indirect inguinal hernia**. - The hernia sac passes through the **patent processus vaginalis**, allowing abdominal contents to descend into the scrotum. - The **reducibility** of the swelling is the key diagnostic feature. *Congenital hydrocele* - A **congenital hydrocele** is typically a collection of **peritoneal fluid** within the processus vaginalis that does not usually reduce spontaneously. - While it can be transilluminable, its size does not typically fluctuate as dramatically with position or straining. - Hydroceles are **non-reducible** and **painless**. *Varicocele* - A **varicocele** is an abnormal dilation of the **pampiniform plexus veins** within the scrotum. - It usually feels like a "bag of worms" and **enlarges with standing** or Valsalva maneuver, but does not typically reduce completely when lying down in the same way an indirect hernia does. - More common in **adolescents**, typically on the **left side**. *Testicular torsion* - **Testicular torsion** presents with **acute onset** severe scrotal pain and swelling, not a chronic reducible swelling. - The affected testis is typically **tender**, **elevated**, and has an **abnormal lie** (horizontal orientation). - This is a **surgical emergency** requiring immediate intervention, unlike the gradual, painless, reducible presentation described.

Q: At what age is surgical treatment for congenital hydrocele recommended if it fails to resolve?

2 years. ***2 years*** - Congenital hydroceles often resolve spontaneously by the age of **1 year**. - If a congenital hydrocele persists beyond **2 years of age**, surgical repair is typically recommended to prevent complications and address the patent processus vaginalis. *1 year* - While many congenital hydroceles resolve spontaneously by **1 year of age**, surgical intervention is not immediately recommended at this point if it persists. - Waiting until age 2 allows for further opportunity for spontaneous resolution before considering surgery. *3 years* - Waiting until **3 years of age** to intervene for a persistent hydrocele is generally considered too late. - This delay can increase the risk of complications such as **inguinal hernia** or discomfort. *4 years* - Surgical treatment for a congenital hydrocele should be performed well before **4 years of age** if it has not resolved spontaneously. - Prolonged persistence increases the likelihood of discomfort, cosmetic concerns, and potential for associated **inguinal hernia**.

Q: At what age do symptoms of midgut volvulus most commonly present?

1 week. ***1 week*** - **Midgut volvulus** is a surgical emergency where the intestine twists around the **superior mesenteric artery**, typically due to **intestinal malrotation**. - Approximately **50% of cases present within the first week of life**, making this the most common timeframe for symptom onset. - Classic presentation includes **bilious vomiting** in a neonate, which requires urgent surgical evaluation. - The volvulus causes arterial occlusion leading to **bowel ischemia** and potential necrosis if not promptly treated. *Within 24 hours* - While some cases present within the first 24 hours of life, this represents a subset of cases rather than the typical presentation timeframe. - The teaching emphasizes that 50% present in the **first week**, not specifically the first day. *2-3 days* - This falls within the first week and represents a reasonable timeframe for presentation. - However, when considering the **most typical** presentation period, the first week as a whole is the more accurate teaching point. *2-3 weeks* - While 75% of cases present within the **first month of life**, the peak incidence is earlier. - Presentation at 2-3 weeks is possible but less common than presentation in the first week. - Most standard references emphasize the **first week** as the critical period for presentation.

Q: At what age is orchidopexy for an incompletely descended testis typically performed?

1 year. ***1 year*** - Orchidopexy is typically recommended between **6 and 12 months** of age to prevent long-term complications like **infertility** and **malignancy**. - Performing the surgery at this age maximizes the chances of **normal testicular development** and reduces the risk of germ cell destruction. *At birth* - It is generally not performed at birth because **spontaneous descent** can still occur within the first few months of life. - Early intervention is usually reserved for specific conditions like **testicular torsion**. *2 years* - Waiting until 2 years of age is considered **too late**, as prolonged exposure to higher abdominal temperatures can cause **irreversible damage** to the testicular tissue. - This delay increases the risk of **compromised fertility** and a higher incidence of **testicular cancer**. *5 years* - Performing orchidopexy at 5 years is significantly **too late**, leading to a high risk of **infertility** and a severely increased risk of **testicular cancer**. - By this age, the potential for normal testicular development is greatly diminished.

Q: At what age is cleft palate ideally repaired?

At 1 year of age. ***At 1 year of age*** - Repair at this age allows for adequate palatal growth while minimizing interference with **speech development**. - Performing the surgery around 12 months provides a balance between avoiding early anesthetic risks and preventing significant **speech pathology**. *At 5 months of age* - Repair at this early age carries a higher risk of **anesthetic complications** and may interfere with future **midfacial growth**. - It also provides less time for the infant to gain weight and for the tissues to strengthen, increasing the risk of **dehiscence**. *Before school age* - While it's important to repair before school to avoid social and psychological issues, waiting this long can lead to significant and potentially **irreversible speech articulation problems**. - Corrective speech therapy may be more challenging and less effective if primary repair is delayed beyond the critical period for speech development. *At 6 to 8 years of age* - This age is far too late for initial cleft palate repair, as significant **speech deficits** and compensatory articulation patterns would have already developed. - Delaying repair until this age would necessitate extensive and often less successful **speech therapy** and potentially multiple corrective surgeries.

Question 1

What is the best treatment for cystic hygroma?

Accepted Answer

Surgical excision

Answer

Radiotherapy

Answer

Chemotherapy

Answer

Sclerotherapy

Question 2

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 3

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 4

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 5

Commonest site of hypospadias is:

Accepted Answer

Glanular/Coronal

Answer

Scrotum

Answer

Perineum

Answer

Mid-penile

Question 6

A child presents with a scrotal swelling that disappears when lying down and reappears when standing or crying. What is the most likely diagnosis?

Accepted Answer

Indirect inguinal hernia

Answer

Testicular torsion

Answer

Varicocele

Answer

Congenital hydrocele

Question 7

At what age is surgical treatment for congenital hydrocele recommended if it fails to resolve?

Accepted Answer

2 years

Answer

3 years

Answer

4 years

Answer

1 year

Question 8

At what age do symptoms of midgut volvulus most commonly present?

Accepted Answer

1 week

Answer

2-3 days

Answer

2-3 weeks

Answer

Within 24 hours

Question 9

At what age is orchidopexy for an incompletely descended testis typically performed?

Accepted Answer

1 year

Answer

At birth

Answer

2 years

Answer

5 years

Question 10

At what age is cleft palate ideally repaired?

Accepted Answer

At 1 year of age

Answer

At 5 months of age

Answer

Before school age

Answer

At 6 to 8 years of age

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

On this page

Practice by Chapter

Want unlimited practice?