Childhood Surgery

Question 1

Rectal prolapse in children

Answer 1

Mostly secondary to constipation- treat with laxatives

Occasionally injection of sclerosant - rarely a thiersch procedure

Question 2

Treatment for duodenal atrasia

Answer 2

Duodenoduodenostomt

Question 3

Cryptorchidism (congenital undescended testis)

Answer 3

Fail to descend by 3 months - normally down by 6 months
Linked to:
Patent processus vaginalis
Abnormal epididymis
Cerebral palsy
Mental retardation
Wilms tumour
Abdominal wall defects (e.g. gastroschisis, prune belly syndrome)

Treatment is orchidopexy at 6-18minths

Question 4

Intestinal malrotstion

Answer 4

Mid gut volvulus-

US the SMA lies to the left of the SMV in normal anatomy)

In upper GI contrast series the DJ flexure is normal sited to left of the vertebral bodies

Treated by a Ladds procedure - division of bands and bowel returned in rotated (small bowel on right, large bowel on left, caecum in LUQ)

Question 5

Malrotation and volvulus

Answer 5

Bilious vomiting in first few days of life
Scaphoid abdomen
Few abdominal signs
Diagnosed with USS and upper Gl contrast study
Treated with Ladd’s procedure
May be fatal if missed

Question 6

Diaphragmatic hernia

Answer 6

Major hernias occur through Boxkdalek defects (usually left sided)
Significant herniation of abdominal contents may occur
Associated pulmonary hypoplasia may lead to poor developmental outcomes
Diagnosed on CXR at birth (of more often, antenatally)
Treated by laparotomy/ thoracotomy and repair

Question 7

Tracheo-
esophageal fistula

Answer 7

Varying anomalies from esophageal atresias through to a variety of fistulas
“H’ type fistulas, though rare, are easily overlooked and may present later
Feeding difficulties and cyanotic spells may be seen
Early surgery is the mainstay of treatment

Question 8

Congenital hernias

Answer 8

These include exomphalos and gastroschisis
Usually diagnosed antenatally and managed in tertiary units

Question 9

Inguinal hernias

Answer 9

Usually occur secondary to PPV
Indirect
Easily strangulate and therefore should be repaired within a few days of diagnosis

Question 10

Hirschprungs
disease

Answer 10

First suspected when a child fails to pass meconium in 48 hours
Abdominal distension is seen and diagnosis made by suction rectal biopsy
Treated initially by washouts and then subsequent pull through at 6 months of age
High incidence of NEC

Question 11

Necrotising
enterocolitis

Answer 11

Patchy necrosis and subsequent perforation of the small or large bowel in neonates (often those who are unwell or premature)
Often settle with conservative management, though may develop subsequent strictures
The deteriorating infant will require laparotomy and stoma formation

Question 12

What percentage of people with Meckles will develop symptoms

Answer 12

Approx 5%

Of these 30% will encounter bleeding

Question 13

Paediatric umbilical hernia

Answer 13

Most umbilical hernias will resolve with non operative management and surgery under the age of 2 is not justified

Question 14

Paraumbilical hernias

Answer 14

Seldom resolve spontaneous and require surgical repair

Question 15

Omphalitis

Answer 15

Infection of the umbilicus
Most comman bacteria is Staph aureus
Serious condition as may rapidly spread through the umbilical vessels
Risk of portal Pyramus and portal vein thrombosis

Question 16

Investigation for meckels diverticulum

Answer 16

Laparoscopy > nuclear scintigraphy> CT enteroclysis> CT scan > Us scan > small bowel contrast study

Technetium 99m pertechnetate nuclear scan

Question 17

NEC in term babies

Answer 17

Rare and should always prompt search for hirschprungs disease

Question 18

Persistent urachus

Answer 18

Usually presents with yellow liquid at umbilicus during raises intra-abdominal pressure

Associated with posterior urethral valves

Question 19

Thyroglossal cyst

Answer 19

• Located in the anterior triangle, usually in the midline and below the hyoid (65% cases)
•Derived from remnants of the thyroglossal duct
• Thin walled and anechoic on USS (echogenicity suggests infection of cyst)

Question 20

Branchial cyst

Answer 20

• Six branchial arches separated by branchial clefts
• Incomplete obliteration of the branchial apparatus may result in cysts, sinuses or fistulae
• 75% of branchial cysts originate from the second branchial cleft
• Usually located anterior to the sternocleidomastoid near the angle of the mandible
• Unless infected the fluid of the cyst has a similar consistency to water and is anechoic on USS

Question 21

Dermoid cysts

Answer 21

• Derived from pleuripotent stem cells and are located in the midline
• Most commonly in a suprahyoid location
• They have heterogeneous appearances on imaging and contain variable amounts of calcium and fat

Question 22

Thyroid gland

Answer 22

• True thyroid lesions are rare in children and usually represent thyroglossal cysts or tumours like lymphoma

Question 23

Lymphatic malformations

Answer 23

• Usually located posterior to the sternocleidomastoid
• Cystic hygroma result from occlusion of lymphatic
channels
• The painless, fluid filled, lesions usually present prior to the age of 2
• They are often closely linked to surrounding structures and surgical removal is difficult
• They are typically hypochoic on USS

Question 24

Infantile haemangioma

Answer 24

• May present in either triangle of the neck
• Grow rapidly initially and then will often spontaneously regress
• Plain x-rays will shows a mass lesion, usually containing calcified phleboliths
• As involution occurs the fat content of the lesions increases

Question 25

Lymphadenopathy

Answer 25

. Located in either tridigle of the neck
• May be reactive or neoplastic
• Generalised lymphadenopathy usually secondary to infection in children (very common)