Surgery 5

Question 1

What are useful investigations for undescended testes?

Answer 1

o Ultrasound- identifying testes in the inguinal canal in obese boys, cannot distinguish between an intra-abdominal or absent testis  it is performed in children with bilateral impalpable testes to verify internal pelvic organs
o Hormonal- for bilateral impalpable testes, the presence of testicular tissue can be confirmed by recording a rise in serum testosterone in response to intramuscular injections of human chorionic gonadotrophin (HCG)- may require specialist endocrine review
o Laparoscopy- the investigation of choice for the impalpable testis- under anaesthesia, inguinal examination is first carried out to check that the testis is not in the inguinal canal

Question 2

How is a circumcision carried out?

Answer 2

Under GA as a day case
Healing takes up to 10 days
Complications- bleeding and infection

Question 3

What is the management for labial adhesions?

Answer 3

• Asymptomatic adhesions can be left alone and will often lyse spontaneously
• If there is perineal soreness or urinary irritation, treatment with topical oestrogen treatment applied sparingly twice a day for 1–2 weeks often dissolves the adhesions
• Active separation of the adhesions under anaesthesia is sometimes required

Question 4

What are associated conditions and drugs of cleft palate?

Answer 4

o	Anticonvulsant therapy
o	Isotretinoin
o	Patau syndrome
o	Other chromosomal disorders
Pierre Robin 
Smoking, alcohol, obesity, lack of folate and hypertension in mother

Question 5

When is cleft palate surgically repaired?

Answer 5

Can be within 1st week of life for cosmetic reasons

palate is usually repaired at several months of age

Question 6

How does a diaphragmatic hernia present?

Answer 6

1 per 2000
most frequently caused by failure of one or both of the pleuroperitoneal membranes to close the pericardioperitoneal canals, in that case, the peritoneal and pleural cavities are continuous with one another along the posterior body wall
this hernia allows abdominal viscera to enter the pleural cavity
• In 85 to 90% of cases the hernia is on the left side- intestinal loops, stomach, spleen and part of the liver enter the thoracic cavity
the abdominal viscera in the chest push the heart anteriorly and compress the lungs, which are commonly hypoplastic

Question 7

What are the signs of a diaphragmatic hernia?

Answer 7

o Cyanosis shortly after birth
o Tachypnoea
o Tachycardia
o Asymmetry of the chest wall
o Absent breath sounds on one side of the chest (usually the left)
o Bowel sounds audible over the chest wall
o The abdomen feels ‘less full’ on palpation
o A shift of cardiac sounds
o Signs of pneumothorax

Question 8

What is the management for a diaphragmatic hernia?

Answer 8

sedation, paralysis, endotracheal intubation and mechanical ventilation with 100% O2 therapy- NGT placement and avoiding bag-valve-mask ventilation
Surgery by a few days, primary suture or insertion of a prosthetic patch
• Fluids are restricted to 40ml/kg for the first 24 hours, with an extra 10ml/kg being added until the 7th day-
NG or IV feeding should also be started

Question 9

What is the management for a severe diaphragmatic hernia?

Answer 9

May have pulmonary hypoplasia
• Severely affected infants have chronic lung disease- these children may require prolonged therapy of supplemental oxygen and diuretics
• These children may also require ventilation whilst their lungs recover
• Intermediate mandatory ventilation is used to wean the child off ventilation and can take up to 6 weeks

Question 10

What is the acute management for OA and TOF?

Answer 10

• The baby should be kept warm and disturbed as little as possible- standard IV fluids started
• The upper oesophageal pouch should be aspirated regularly by oropharyngeal suction or a Replogle tube
• Pre-operative antibiotics are not required unless there is evidence of aspiration pneumonia
• Babies who require mechanical ventilation must be referred urgently for surgery because gas will escape down the TOF and produce progressive gastric distension- which impairs ventilation further, ultimately leading to gastric perforation

Question 11

What are the complications of surgery for OA and TOF?

Answer 11

o Anastomotic leak
o Anastomotic stricture
o Gastro- oesophageal
o Recurrent fistula

Question 12

What is the follow up for OA and TOF?

Answer 12

• Respiratory morbidity in the early years after OA/TOF repair is relatively high, particularly in the winter months- consider admitting these children during respiratory infections
• Obstruction of the oesophagus by food boluses is common in toddlers and young children after OA repair-
usually, it is caused by meat that has not been chewed- refer for urgent oesophagoscopy

Question 13

What is gastroschisis?

Answer 13

The bowel protrudes through a defect in the anterior abdominal wall, adjacent to the umbilicus, and there is no covering sac- it is not associated with other congenital abnormalities
Greater risk of dehydration and protein loss- wrap in clingfilm
1 in 3000
Associated with intestinal atresias (10%)

Question 14

What is the management for gastroschisis?

Answer 14

Cover exposed bowel with clingfilm 
NG tube
IV dextrose- colloid support 
AXR is unnecessary 
Surgery- silo is reduced serially over a period of 1-2 weeks 
Total parenteral nutrition

Question 15

What is exomphalos (omphalocele)?

Answer 15

The abdominal contents protrude through the umbilical ring, covered with a transparent sac formed by the amniotic membrane and peritoneum- it is often associated with other major congenital abnormalities
o Exomphalos major: defect >5cm diameter
o Exomphalos minor: defect <5cm diameter

Question 16

What are the malformations associated with exomphalos?

Answer 16

Found in 50% of cases 
Chromosomal defects- trisomies 18, 13, 21 and Turner’s syndrome
Cardiac defects (septak and tetralogy of fallot) 
Syndromes- BWS (beckwith Wiedemann syndrome)

Question 17

What is a urachus?

Answer 17

Fibrous remnant of the allantois is persistent- this is normally a canal that joins the urinary bladder of the fetus with the umbilical cord
• This will lead to leakage of urine from the umbilicus and needs surgical removal
• There are four anatomical cases:
o Urachal cyst – no connection between umbilicus and bladder
o Urachal fistula – a free connection between them
o Urachal diverticulum – bladder out pouching
o Urachal sinus – pouch opens towards umbilicus

Question 18

What is bladder exstrophy?

Answer 18

Congenital abnormality in which part of the urinary bladder is present outside the body
• It is due to a failure of the abdominal wall to close during development and leads to the anterior bladder protruding
• Treatment here is surgical correction.

Question 19

What is associated with anorectal malformations?

Answer 19

Cardiac defects- VSD/TOF
o	Tracheo-oesophageal anomalies
o	Duodenal atresia
o	Malrotation
o	Hirschsprung disease
•	Sacral/spinal problems are associated- especially with high anomalities, vaginal and uterine problems are common

Question 20

What is the surgical management for anorectal malformations?

Answer 20

• If feeds have been started they should be stopped and an NG tube passed to empty the stomach
• Fluids will be given via a peripheral cannula
X-ray
Small dose of antibiotics continued for several months
• Low anomalities are treated with an anoplasty: this is where the anus is exposed under the skin- this will need serial dilators passing through the new hole regularly to prevent initial stenosis
• High anomalities will require a temporary colostomy initially- several weeks after this operation, when the child is feeding again, the bowel will be imaged to assess its anatomy, then an appropriate operation will occur to form a new anus