Pediatric Surgery Practice Questions

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.

Q: Which one of the following parts of intussusception is most susceptible to ischaemia and perforation?

Apex. ***Apex*** - The **apex** is the **leading edge** (distal tip) of the intussusceptum that protrudes furthest into the intussuscipiens. - It is the **most distal point** from its blood supply and experiences the **greatest degree of vascular compromise**. - The apex suffers from **pressure necrosis** due to compression against the intussuscipiens and maximal venous congestion. - This makes it the **most susceptible site for ischemia, necrosis, and perforation** in intussusception. - Clinically, when perforation occurs, it is **most commonly at the apex**. *Neck* - The **neck** is the constricted point where the intussusceptum enters the intussuscipiens. - While the neck does compress the **mesentery and blood vessels**, causing venous outflow obstruction that affects the entire intussusceptum, it is not itself the most susceptible site for perforation. - The neck causes the ischemia, but the apex suffers the most from it. *Intussuscipiens* - The **intussuscipiens** is the **outer receiving segment** that engulfs the intussusceptum. - Its blood supply remains relatively intact as it is not invaginated. - It is **not susceptible** to ischemia in the same way as the invaginated segment. *Intussusceptum* - The **intussusceptum** refers to the **entire invaginated inner segment**. - While the whole intussusceptum can become ischemic, the question asks for the **specific part** most susceptible. - Within the intussusceptum, the **apex is the most vulnerable point** for ischemia and perforation.

Q: A 16-year-old boy presents with acute onset of severe abdominal pain that began while playing basketball. He has a history of undescended testis that was surgically corrected at age 8. Physical examination shows a tender mass in the left lower quadrant. What is the most likely diagnosis and underlying mechanism?

Inguinal hernia from increased activity. ***Inguinal hernia from increased activity*** - The acute onset of **severe abdominal pain** during physical activity (basketball) and the presence of a **tender mass in the left lower quadrant** are highly suggestive of an incarcerated inguinal hernia. - Previous undescended testis and subsequent surgery, especially if a **patent processus vaginalis** remained, can predispose to inguinal hernia formation, which can acutely manifest with strenuous activity. *Testicular cancer from previous cryptorchidism* - While a history of cryptorchidism increases the risk of testicular cancer, it typically presents as a **painless testicular mass** or swelling, not acute severe abdominal pain with a tender mass in the lower quadrant. - The onset of symptoms in this case is acute and directly related to physical activity, which is less consistent with the usually gradual progression of testicular cancer. *Testicular torsion from previous surgery* - Testicular torsion presents with **sudden, severe unilateral scrotal pain**, often radiating to the groin or abdomen, and typically involves a high-riding, tender testis. The pain is not primarily abdominal unless referred. - While some surgical procedures can alter testicular fixation, the pain being described as a **tender mass in the left lower quadrant** points more towards an abdominal or groin wall issue rather than direct testicular torsion. *Appendicitis from athletic activity* - Appendicitis typically presents with **periumbilical pain** that migrates to the **right lower quadrant (McBurney's point)**, often accompanied by **anorexia, nausea, and vomiting**. - The location of the tender mass in the **left lower quadrant** and the acute onset during physical activity make appendicitis less likely as the primary diagnosis.

Q: A 4-year-old boy presents with sudden onset of severe abdominal pain and vomiting. On examination, he has a palpable mass in the right upper quadrant and bloody stools. Ultrasound shows a 'target sign' in the right abdomen. What is the most likely diagnosis and appropriate initial management?

Intussusception; pneumatic reduction. ***Intussusception; pneumatic reduction*** - The classic triad of **intermittent severe abdominal pain**, **vomiting**, and **bloody (currant jelly) stools** in a young child, along with a **palpable right upper quadrant mass** and an ultrasound **'target sign'**, is highly indicative of intussusception. - **Pneumatic reduction** (or hydrostatic) is the initial management choice in hemodynamically stable patients without signs of perforation, as it is often successful and avoids surgery. *Incorrect: Appendicitis; emergent appendectomy* - While appendicitis causes abdominal pain and vomiting, it typically presents with **periumbilical pain migrating to the right lower quadrant** and usually does not feature a palpable mass or currant jelly stools. - The ultrasound finding of a **'target sign'** is specific to intussusception, not appendicitis. *Incorrect: Pyloric stenosis; pyloromyotomy* - Pyloric stenosis typically causes **non-bilious projectile vomiting** in infants (usually 2-8 weeks old) due to hypertrophy of the pyloric muscle. - It does not involve severe abdominal pain, palpable mass in the right upper quadrant, or bloody stools. *Incorrect: Malrotation with volvulus; emergent surgery* - Malrotation with volvulus also causes sudden onset abdominal pain and vomiting, often **bilious**, due to intestinal obstruction and ischemia. - While it requires emergent surgery, the presence of a **palpable mass** and the specific **ultrasound 'target sign'** are more characteristic of intussusception than volvulus.

Q: What is the diagnosis based on the image shown?

Umbilical fistula. ***Umbilical fistula*** - The image shows a **patent vitelline duct (omphalomesenteric duct)**, which creates a direct connection between the umbilicus and the ileum, visible as an umbilical fistula. - This condition presents with **fecal discharge from the umbilicus** or **umbilical prolapse of intestinal mucosa**. *Ileal diverticulum* - An ileal diverticulum, such as a **Meckel's diverticulum**, is a blind pouch protruding from the ileum, usually not communicating with the umbilicus. - It would typically be noted as an **outpouching of the ileal wall**, without an external opening at the umbilicus unless complicated by rupture. *Urachal cyst* - A urachal cyst is a remnant of the **urachus**, which connects the bladder to the umbilicus during fetal development. - It would be located **between the umbilicus and the bladder** and contain urine or serous fluid, not intestinal contents. *Omphalocele* - An omphalocele is a **congenital abdominal wall defect** where abdominal organs protrude into the base of the umbilical cord. - The defect is **covered by a membrane**, and it involves herniation of abdominal contents, not a fistula with the intestine.

Q: A patient presents with fecal discharge from the umbilicus. What is the most likely diagnosis?

Patent vitelline duct. ***Patent vitelline duct*** - **Fecal discharge from the umbilicus** indicates a persistent communication between the **ileum** and the **umbilicus** through a patent vitelline (omphalomesenteric) duct. - This congenital anomaly represents a remnant of the **omphalomesenteric duct** that **completely failed to involute**, creating a **fistulous tract** allowing intestinal contents to exit through the umbilicus. - This is the **most complete form** of vitelline duct persistence (other forms include Meckel's diverticulum, fibrous band, or umbilical polyp). *Urachal fistula* - A urachal fistula occurs when the **urachus** remains patent, creating a connection between the **bladder** and the umbilicus. - While it can result in umbilical discharge, the discharge would be **urine**, not feces. *Omphalocele* - An omphalocele is a **congenital abdominal wall defect** where abdominal contents protrude into a sac at the base of the umbilicus. - It does not involve a fistulous communication with intestines causing fecal discharge, but rather a **herniation** of organs covered by a peritoneal membrane. *Gastroschisis* - Gastroschisis is a congenital anomaly characterized by the **protrusion of abdominal organs** directly into the amniotic cavity **without a covering sac**, usually to the **right of the umbilicus**. - Like omphalocele, it's a **herniation defect** presenting at birth and does not involve an abnormal fistulous connection causing fecal discharge from the umbilicus.

Q: A child presents to the OPD with the finding shown in the image. When should the first surgical repair be performed?

3 months. ***3 months*** - Surgical repair of **cleft lip** is typically performed around **3 months of age** based on current practice guidelines. - The traditional **"Rule of 10s"** (10 weeks old, 10 pounds weight, 10 g/dL hemoglobin) has evolved to **3-6 months** as the optimal timing window, with **3 months** being most common. - Early repair helps with **feeding difficulties**, improves cosmesis, and facilitates normal **parent-infant bonding** while optimizing surgical outcomes. *6 months* - While 6 months is within the acceptable range for cleft lip repair, **3 months is preferred** as the optimal timing in most centers. - Delaying repair to 6 months may impact feeding mechanics and parental bonding, though outcomes remain good. - This timing is **earlier** than the recommended window for **cleft palate repair** (9-18 months). *12 months* - **Cleft palate repair** is typically performed around **9-18 months of age**, with 12 months being a common target to optimize speech development. - Performing **cleft lip repair** at 12 months is significantly **delayed** and would miss the benefits of earlier intervention for feeding, cosmesis, and bonding. *18 months* - 18 months is at the **upper limit** for **cleft palate repair** to minimize speech development issues. - This age is **too late** for the first surgical repair of a cleft lip, which should be performed in early infancy (3-6 months).

Q: Match the following 1. Hirschsprung's disease 2. Posterior urethral valve 3. Choledochal cyst 4. Intussusception A. Jaundice B. Currant jelly stools C. Distended abdomen D. Oligohydramnios

1-C, 2-D, 3-A, 4-B. ***Correct Answer: 1-C, 2-D, 3-A, 4-B*** **Correct Associations:** - **Hirschsprung's disease (1) → Distended abdomen (C)**: Congenital absence of ganglion cells in the distal bowel leads to functional obstruction and subsequent abdominal distension. This is a hallmark presentation in neonates and infants. - **Posterior urethral valve (2) → Oligohydramnios (D)**: Urethral obstruction in utero prevents normal fetal urine output, resulting in decreased amniotic fluid (oligohydramnios). This can be detected on prenatal ultrasound. - **Choledochal cyst (3) → Jaundice (A)**: Congenital dilatation of the bile ducts causes biliary obstruction, presenting with jaundice as part of the classic triad (jaundice, abdominal mass, and pain). - **Intussusception (4) → Currant jelly stools (B)**: Telescoping of bowel causes mucosal ischemia and venous congestion, leading to bloody mucoid stools with characteristic "currant jelly" appearance. This is a pathognomonic feature. *Incorrect: 1-C, 2-D, 3-B, 4-A* - Incorrectly associates choledochal cyst with currant jelly stools (which is specific to intussusception) and intussusception with jaundice (which indicates biliary pathology). *Incorrect: 1-A, 2-D, 3-B, 4-C* - Wrongly links Hirschsprung's disease with jaundice instead of its characteristic abdominal distension, and misidentifies intussusception's primary feature. *Incorrect: 1-D, 2-C, 3-A, 4-B* - Swaps the associations between Hirschsprung's disease and PUV. Oligohydramnios is specific to urinary tract obstruction (PUV), not intestinal pathology (Hirschsprung's).

Question 1

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 2

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

Question 3

Which one of the following parts of intussusception is most susceptible to ischaemia and perforation?

Accepted Answer

Apex

Answer

Neck

Answer

Intussuscipiens

Answer

Intussusceptum

Question 4

A 16-year-old boy presents with acute onset of severe abdominal pain that began while playing basketball. He has a history of undescended testis that was surgically corrected at age 8. Physical examination shows a tender mass in the left lower quadrant. What is the most likely diagnosis and underlying mechanism?

Accepted Answer

Inguinal hernia from increased activity

Answer

Testicular cancer from previous cryptorchidism

Answer

Testicular torsion from previous surgery

Answer

Appendicitis from athletic activity

Question 5

A 4-year-old boy presents with sudden onset of severe abdominal pain and vomiting. On examination, he has a palpable mass in the right upper quadrant and bloody stools. Ultrasound shows a 'target sign' in the right abdomen. What is the most likely diagnosis and appropriate initial management?

Accepted Answer

Intussusception; pneumatic reduction

Answer

Appendicitis; emergent appendectomy

Answer

Pyloric stenosis; pyloromyotomy

Answer

Malrotation with volvulus; emergent surgery

Question 6

A 3-year-old child presents with congenital diaphragmatic hernia requiring repair. Preoperative echocardiogram shows severe pulmonary hypertension with suprasystemic pressures. The pediatric surgeon recommends immediate repair, while the cardiologist suggests optimizing pulmonary pressures first. Evaluate the optimal timing and approach.

Accepted Answer

Medical optimization of pulmonary hypertension then early repair

Answer

Surgical repair with intraoperative ECMO support

Answer

ECMO support with delayed surgical repair

Answer

Delay surgery until pulmonary pressures normalize

Question 7

What is the diagnosis based on the image shown?

Accepted Answer

Umbilical fistula

Answer

Ileal diverticulum

Answer

Urachal cyst

Answer

Omphalocele

Question 8

A patient presents with fecal discharge from the umbilicus. What is the most likely diagnosis?

Accepted Answer

Patent vitelline duct

Answer

Urachal fistula

Answer

Omphalocele

Answer

Gastroschisis

Question 9

A child presents to the OPD with the finding shown in the image. When should the first surgical repair be performed?

Accepted Answer

3 months

Answer

6 months

Answer

12 months

Answer

18 months

Question 10

Match the following

1. Hirschsprung's disease
2. Posterior urethral valve
3. Choledochal cyst
4. Intussusception

A. Jaundice
B. Currant jelly stools
C. Distended abdomen
D. Oligohydramnios

Accepted Answer

1-C, 2-D, 3-A, 4-B

Answer

1-C, 2-D, 3-B, 4-A

Answer

1-A, 2-D, 3-B, 4-C

Answer

1-D, 2-C, 3-A, 4-B

Pediatric Surgery — MCQs

Pediatric Surgery — MCQs

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