Paediatric Surgery

Question 1

Peak age for intussusception

Answer 1

3 months to 2 years old

Question 2

What is hypospadias

Answer 2

Urethral opening is proximal to normal meatus on the glans due to failure of completion of urethral tubularisation

Question 3

What is chordee?

Answer 3

Ventral curvature of the shaft of the penis, most apparent in erection. Only marked in the most severe form of hypospadias

Question 4

What does hypospadias consist of

Answer 4

Ventral urethral meatus, hooded dorsal foreskin, chordee

Question 5

How to manage hypospadias?

Answer 5

Surgery before 2 years of to produce a terminal urethral meatus, straight erection and a normal looking penis

Question 6

What is the spiral/corkscrew sign indicative of and where is it located

Answer 6

Midgut volvulus, at the duodenojejunal junction

Question 7

Tests for intussusception

Answer 7

IV resus and Analgesia first!
AXR: absence of cecal gas, crescent sign, dilated small bowel, target sign
ABD US: target sign and pseudo kidney sign
Contrast/gas enema: CI if peritonitis, perf, shock
FBC, FBG, U&E, blood group and hold

Question 8

Immediate management of intussusception

Answer 8

2 large bore cannula 
NBM 
Analgesia 
O2 
If in shock: bolus NS 
Monitor signs of shock: urine output, VS

Question 9

Definitive management of intussusception

Answer 9

Air enema
If perf/bowel obstruction: insert NG tube
Consider IV cefazolin/metronidazole
Other options: USG guided saline solution
If above fails: surgical reduction

Question 10

Features of intussusception

Answer 10

Paroxysmal severe colicky pain and pallor
May refuse feeding
Vomiting
Sausage-shaped mass in abdomen
Red-currant jelly stool
Abdominal distention, tenderness, guarding, shock

Question 11

When does malrotation and volvulus present and when does it occur in gestation

Answer 11

Within 1st few days but potentially up to 2 weeks, 8-10 weeks gestation

Question 12

How to test for malrotation and volvulus

Answer 12

Oral contrast study Of upper GI

Abdominal U/S

Question 13

Hirschsprung’s disease clinical features

Answer 13

Failure to pass meconium within 24 hours of life

Constipation, poor feeding, +/- bilious vomiting, abdominal distention, Squirt sign on PR exam

Question 14

Tests for Hirschsprung’s

Answer 14

Rectal suction biopsy
Abd X Ray - distended large bowel, fluid levels
FBC TRO enterocolitis

Question 15

Necrotizing enterocolitis features

Answer 15

Rapidly progressing distention, tenderness, vomiting, fever, watery foul smelling diarrhoea, blood on DRE.

Question 16

Managing pyloric stenosis

Answer 16

NBM
NG tube if profuse vomiting continues
IV rehydration
Delay surgery till hydration, electrolyte levels and acid base disturbance corrected
- monitor VBG and electrolytes 6 holy initially
- aim for full correction in 48 hours
Pyloromyotomy

Question 17

How to investigate pyloric stenosis

Answer 17

U&E, VBG, abdominal U/S

Question 18

When does pyloric stenosis present and what are its clinical features

Answer 18

2-6 weeks of chronological age
Vomiting which gets more frequent and forceful and eventually is projectile, soon after feeding and non-bilious, can have blood
Child often hungry afterwards until dehydration curbs that
Weight loss if delayed presentation

Question 19

Classification of undescended testis

Answer 19

Retractile: can manipulate into scrotum without tension but retracts into the inguinal region after because the cremasteric muscle pulls it up. Needs follow-up but usually it resides in the scrotum permanently

Palpable: in the groin but not in scrotum, sometimes ectopic

Impalpable: may be in inguinal canal, intra-abdominal or absent

Question 20

Tests for undescended testis

Answer 20

Ultrasound: in children with bilateral impalpable testes to verify internal pelvic organs
Hormonal: for bilateral impalpable tested, can confirm testicular tissue by recording rise in serum testosterone to IM injection of HCG, may require endocrine review
Laparoscopy: test of choice.

Question 21

Management of undescended testis

Answer 21

Orchidopexy by 1-2 y/o because

• fertility (testis needs to be in scrotum below body temperature)
• malignancy (is greater, greatest in intra-abdominal)
• cosmetic and psychological
• must do abdominal ultrasound and serum tumor markers beforehand

Question 22

How to manage inguinal hernia in infant

Answer 22

Try reducing by administering opioids and sustained gentle compression, delay surgery for 24-48 hours to allow odema to resolve

If reduction impossible/associated with undescended testis, emergency surgery needed

Question 23

Hydrocoele management

Answer 23

It resorbs and tunica vaginalis closes spontaneously in first year

Consider surgical referral for repair if present after 2 years

Question 24

Cause of inguinal hernia and hydrocoele

Answer 24

Patent processes vaginalis

Question 25

Varicocoele management

Answer 25

Refer to surgery when symptomatic, impaired testicular growth and infertility

Question 26

Testicular torsion management

Answer 26

Need early surgical consult because it will infarct in 8-12 hours
Clear fluids until surgical review

Question 27

Torsion hydatid peak onset, classic sign, management

Answer 27

11 years old

Blue dot sign - necrotic appendage seen thru skin

Analgesia, rest
Pain resolves in 2-12 days, should lessen by 48 hours
Usually requires surgical exploration, can excise torted areas

Question 28

Epididymoorchitis management

Answer 28

Urine MCS + PCR for chlamydia and gonorrhea
Antibiotics: IV benpen + gentamicin if systemically unwell/young infant
PO Co-trimoxazole if we’ll
Slow to resolve, may have weeks of gradually subsiding scrotal discomfort and swelling
Second episode: do renal tract US/MCU

Question 29

Testicular or epidydymal rupture

Answer 29

Surgical review in ALL testicular trauma unless testis clearly felt to be normal and without significant tenderness