Pediatric Surgery Practice Questions

Q: What is the surgical procedure for undescended testis?

Undescended testis. The surgical procedure for an undescended testis (UDT) is **Orchidopexy** (or Orchiopexy). The primary goal is to mobilize the testis and fix it within the scrotal sac to preserve fertility potential and allow for early detection of malignancy. ### **Explanation of Options:** * **A. Undescended Testis (Correct):** Also known as Cryptorchidism, this occurs when the testis fails to descend into the scrotum. Surgery is ideally performed between **6 to 12 months of age**. If the testis is palpable, an inguinal orchidopexy is done; if non-palpable, laparoscopy is the gold standard for diagnosis and management (e.g., Fowler-Stephens procedure). * **B. Ectopic Testis:** This refers to a testis that has descended through the inguinal canal but diverted to an abnormal site (most commonly the superficial inguinal pouch). While it also requires orchidopexy, it is distinct from UDT because it has left the normal path of descent. * **C. Retractile Testis:** This is a normal variant caused by an overactive cremasteric reflex. The testis can be manually brought down into the scrotum and stays there without tension. **No surgery is required**; it only needs periodic observation. * **D. Testicular Torsion:** This is a surgical emergency involving the twisting of the spermatic cord. The procedure required is **Emergency Exploration and Detorsion** with bilateral orchidopexy (to prevent recurrence). ### **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of UDT:** Inguinal canal. * **Most common site of Ectopic testis:** Superficial inguinal pouch (Lockwood’s ligament theory). * **Complications of UDT:** Infertility (most common), Testicular Malignancy (most common is **Seminoma**), Inguinal Hernia, and Torsion. * **Orchidopexy** reduces the risk of torsion and infertility but **does not eliminate** the risk of malignancy; it only makes the testis accessible for screening.

Q: Duhamel's operation is indicated for which of the following conditions?

Hirschsprung's disease. **Explanation:** **Hirschsprung’s Disease (Correct Answer):** Hirschsprung’s disease is characterized by the absence of ganglion cells in the myenteric and submucosal plexuses, leading to a functional bowel obstruction. The surgical management aims to bypass or remove the aganglionic segment. **Duhamel’s procedure** (Retrorectal Pull-through) is one of the classic definitive surgeries. In this technique, the normal ganglionic colon is pulled down behind the rectum (retrorectal space) and anastomosed side-to-side with the rectum. This creates a "neorectum" that preserves the sensory function of the anterior rectal wall while providing a functional posterior wall. **Incorrect Options:** * **Meconium Ileus:** This is a manifestation of Cystic Fibrosis where thick, inspissated meconium obstructs the terminal ileum. Management involves Gastrografin enemas or surgeries like Bishop-Koop or Santulli enterostomy. * **Annular Pancreas:** This is a congenital anomaly where a ring of pancreatic tissue encircles the duodenum. The treatment of choice is a bypass procedure, typically a **Duodenoduodenostomy**. * **Imperforate Anus:** Part of the Anorectal Malformation (ARM) spectrum. The gold standard surgical repair is the **Posterior Sagittal Anorectoplasty (PSARP)**, also known as the Pena procedure. **High-Yield Clinical Pearls for NEET-PG:** * **Other Surgeries for Hirschsprung’s:** Swenson (End-to-end), Soave (Endorectal pull-through), and the modern Transanal Endorectal Pull-through (TEPT). * **Gold Standard Diagnosis:** Rectal Suction Biopsy (shows absence of ganglion cells and hypertrophied nerve bundles). * **Duhamel’s Advantage:** It is technically easier than Swenson’s and avoids extensive pelvic dissection, reducing the risk of injury to pelvic nerves (preserving bladder and sexual function).

Q: What is the most common site of meningomyelocele?

Lumbosacral. **Explanation:** **Meningomyelocele** is the most common and severe form of open neural tube defect (spina bifida cystica), characterized by the herniation of both the meninges and the spinal cord through a vertebral defect. **Why Lumbosacral is Correct:** The neural tube closes in a bidirectional manner, starting in the cervical region and progressing cranially and caudally. The **caudal neuropore** (the tail end) is the last part of the neural tube to close, typically around the 26th day of gestation. Because this area is the final site of closure, it is most susceptible to developmental failures. Consequently, approximately **75-80%** of all meningomyeloceles occur in the **lumbosacral region**. **Analysis of Incorrect Options:** * **Cranial:** Defects in the cranial region lead to conditions like *encephalocele* or *anencephaly*. While serious, these are statistically less common than spinal defects. * **Thoracic:** While meningomyeloceles can occur in the thoracic spine, they are much rarer than lumbosacral lesions. Thoracic lesions are often associated with more profound neurological deficits and kyphosis. **NEET-PG High-Yield Pearls:** * **Associated Malformation:** Almost all cases of lumbosacral meningomyelocele are associated with **Arnold-Chiari Malformation Type II** (downward displacement of cerebellar tonsils) and subsequent hydrocephalus. * **Screening:** Elevated **Alpha-fetoprotein (AFP)** in maternal serum and amniotic fluid is a key screening marker. * **Prevention:** Periconceptional intake of **Folic acid (400 mcg/day)** significantly reduces the incidence. * **Clinical Sign:** Look for a "tuft of hair," birthmark, or dimple in cases of *spina bifida occulta* (the mildest form).

Q: Intussusception usually begins from which anatomical location?

Terminal ileum. **Explanation:** Intussusception is the telescoping of a proximal segment of the bowel (intussusceptum) into an adjacent distal segment (intussuscipiens). **1. Why Terminal Ileum is Correct:** The most common type of intussusception is **Ileocolic (75-90% of cases)**. It typically originates at or near the **terminal ileum**, just proximal to the ileocecal valve. This area is anatomically prone to intussusception due to the abundance of lymphoid tissue (Peyer’s patches) in the terminal ileum. In children, viral infections often cause lymphoid hyperplasia, which acts as a "pathological lead point," allowing the terminal ileum to prolapse into the cecum. **2. Analysis of Incorrect Options:** * **Jejunum (A):** While jejuno-jejunal intussusception can occur, it is rare and usually associated with specific lead points like Henoch-Schönlein purpura or postoperative states. * **Colon (B):** Colo-colic intussusception is less common in children and, when present, is often associated with a distinct lead point like a polyp or malignancy. * **Rectum (D):** The rectum is a fixed retroperitoneal structure and is the endpoint of the intussusceptum (prolapse through the anus), not the site of origin. **3. Clinical Pearls for NEET-PG:** * **Classic Triad:** Intermittent abdominal pain, "currant jelly" stools, and a palpable sausage-shaped mass (usually in the right upper quadrant). * **Dance’s Sign:** Emptiness in the right iliac fossa. * **Diagnosis:** Ultrasound is the gold standard (**Target or Donut sign**). * **Treatment:** Non-operative reduction using **Air or Hydrostatic (Barium/Saline) enema** is the first-line treatment if there are no signs of peritonitis or perforation.

Q: Hypochloremic alkalosis is seen in which of the following conditions?

Congenital hypertrophic pyloric stenosis. **Explanation:** **Congenital Hypertrophic Pyloric Stenosis (CHPS)** is the classic cause of **Hypochloremic, Hypokalemic Metabolic Alkalosis with Paradoxical Aciduria**. The underlying mechanism involves persistent non-bilious projectile vomiting, leading to a significant loss of gastric juice. Gastric juice is rich in Hydrochloric acid (HCl), Potassium (K+), and Water. * **Hypochloremia:** Loss of Cl⁻ ions from gastric acid. * **Alkalosis:** Loss of H⁺ ions leads to an increase in serum bicarbonate. * **Paradoxical Aciduria:** To conserve volume (due to dehydration), the kidney reabsorbs Na⁺ in exchange for H⁺ in the distal tubule (once K⁺ stores are depleted), resulting in acidic urine despite systemic alkalosis. **Incorrect Options:** * **Achalasia Cardia:** While vomiting/regurgitation occurs, it involves undigested food that has not yet mixed with gastric acid; thus, it does not typically cause significant electrolyte disturbances. * **Ureterosigmoidostomy:** This leads to **Hyperchloremic Metabolic Acidosis** because the colonic mucosa reabsorbs Chloride in exchange for Bicarbonate. * **Diarrhea:** This typically results in **Hyperchloremic Metabolic Acidosis** due to the massive loss of bicarbonate-rich intestinal secretions. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Triad:** Projectile non-bilious vomiting, palpable "olive-shaped" mass in the epigastrium, and visible gastric peristalsis. * **Investigation of Choice:** Ultrasound (Criteria: Pyloric muscle thickness >4mm, Pyloric canal length >14mm). * **Management:** Initial priority is correction of dehydration and electrolyte imbalance (Normal Saline is the fluid of choice). Definitive surgery is **Ramstedt’s Pyloromyotomy**.

Question 1

What is the surgical procedure for undescended testis?

Accepted Answer

Undescended testis

Answer

Ectopic testis

Answer

Retractile testis

Answer

Testicular torsion

Question 2

Duhamel's operation is indicated for which of the following conditions?

Accepted Answer

Hirschsprung's disease

Answer

Meconium ileus

Answer

Annular pancreas

Answer

Imperforate anus

Question 3

What is the most common site of meningomyelocele?

Accepted Answer

Lumbosacral

Answer

Cranial

Answer

Thoracic

Answer

None of the above

Question 4

What is a major indication for orthognathic surgery before puberty?

Accepted Answer

Ankylosis of the mandible

Answer

Transverse deficiency of the maxilla

Answer

Prognathic mandible

Answer

Hyperdivergent facial pattern with anterior open bite

Question 5

Intussusception usually begins from which anatomical location?

Accepted Answer

Terminal ileum

Answer

Jejunum

Answer

Colon

Answer

Rectum

Question 6

A 4-year-old child presented with a solitary painless mass on the neck. The parents reported that the mass would usually swell and become tender during episodes of upper respiratory tract infection. On examination, a smooth, nontender, fluctuant mass was observed along the lower one third of the anteromedial border of the sternocleidomastoid muscle, situated between the muscle and the overlying skin. Following CECT neck, the question is: The described structure develops due to the failure of obliteration of which embryonic component?

Accepted Answer

Second pharyngeal cleft

Answer

Second pharyngeal pouch

Answer

Second pharyngeal arch

Answer

Third pharyngeal cleft

Question 7

What is most characteristic of congenital hypertrophic pyloric stenosis?

Accepted Answer

The pyloric tumor is best felt during feeding

Answer

Affects the first-born female child

Answer

The patient is commonly marasmic

Answer

Loss of appetite occurs early

Question 8

Which statement regarding congenital umbilical hernia is false?

Accepted Answer

Protrusion of abdominal contents through a paraumbilical defect

Answer

Covered by a peritoneal sac

Answer

Herniated viscera may include stomach and bowel

Answer

Occurs in term babies

Question 9

Hypochloremic alkalosis is seen in which of the following conditions?

Accepted Answer

Congenital hypertrophic pyloric stenosis

Answer

Achalasia cardia

Answer

Ureterosigmoidostomy

Answer

Diarrhea

Question 10

Recurrent intussusception occurs in about what percentage of cases?

Accepted Answer

5-10%

Answer

Less than 1%

Answer

1-5%

Answer

10-20%

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

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