Pediatric Surgery Practice Questions

Q: Which of the following are correct for herniation via foramen of Morgagni? 1. It occurs posteriorly in chest. 2. Transverse colon is the commonest content. 3. Defect is between sternal and costal attachments. 4. It is a type of congenital hernia. Select the answer using the code given below.

2, 3 and 4. ***2, 3 and 4*** - The **foramen of Morgagni** hernia (also known as a parasternal or retrosternal hernia) is a type of **congenital diaphragmatic hernia (CDH)** - statement 4 is **correct**. - The defect is located in the **anterior diaphragm**, specifically between the **sternal and costal attachments** - statement 3 is **correct**. - The **transverse colon** is indeed a common content (most common visceral organ), though omentum is actually the most frequent overall content - statement 2 is considered **correct** in clinical practice. - Statement 1 is **incorrect** as Morgagni hernias occur **anteriorly**, not posteriorly. *1, 3 and 4* - This option incorrectly includes statement 1, which claims the herniation occurs **posteriorly** in the chest. - **Morgagni hernias** are **anterior** diaphragmatic defects (parasternal location). - Posterior diaphragmatic hernias are **Bochdalek hernias**, not Morgagni hernias. *1, 2 and 4* - This option is incorrect because statement 1 states the hernia occurs **posteriorly**, which is wrong. - **Morgagni hernias** are located in the **anterior diaphragm** between sternal and costal attachments. - While statements 2 and 4 are correct, the inclusion of statement 1 makes this option incorrect. *1, 2 and 3* - This option is incorrect because statement 1 claims the hernia occurs **posteriorly**, which is inaccurate. - **Morgagni hernias** are **anterior** defects, representing only 2-3% of congenital diaphragmatic hernias. - The key distinguishing feature is the anterior parasternal location, not posterior.

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.

Question 1

A 5-year-old male child comes with a left sided scrotal swelling which has no cough impulse and does not reduce on compression or lying down but the parents give a definite history that swelling is absent in the morning and comes by in the evening. The best treatment is :

Accepted Answer

Herniotomy

Answer

Eversion of sac

Answer

To leave it alone (masterly inactivity)

Answer

Hernioplasty

Question 2

Which of the following are correct for herniation via foramen of Morgagni?

1. It occurs posteriorly in chest.
2. Transverse colon is the commonest content.
3. Defect is between sternal and costal attachments.
4. It is a type of congenital hernia. Select the answer using the code given below.

Accepted Answer

2, 3 and 4

Answer

1, 3 and 4

Answer

1, 2 and 4

Answer

1, 2 and 3

Question 3

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 4

The treatment of choice for congenital hypertrophic pyloric stenosis is :

Accepted Answer

Ramstedt's operation

Answer

Duodenojejunostomy

Answer

Heller's operation

Answer

Gastrojejunostomy

Question 5

What is the most appropriate surgical procedure for duodenal atresia?

Accepted Answer

Duodenoduodenostomy

Answer

Ramstedt's operation

Answer

Duodenojejunostomy

Answer

Gastroduodenostomy

Question 6

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 7

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 8

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 9

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 10

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

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

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