Surgery

Question 1

6 month old with umbilical hernia

a. refer for a repair now
b. reassure
c. surgery is indicated if it doesn’t resolve until 2 years old

Answer 1

b. reassure

Question 2

Surgical abdomen, what do you do?

a. Send patient for a CT scan
b. bolus and give analgesia

Answer 2

b. bolus and give analgesia
● Stabilization before surgical intervention
● Aggressive fluid resuscitation + support cardiovascular function IMMEDIATELY
● IV Abx

Question 3

Baby with acute scrotal swelling that transilluminates, testes is red, irritable but well except for mild tachycardia, afebrile, diagnosis:

a. testicular torsion
b. epidydimitis
c. inguinal hernia
d. acute hydrocele

Answer 3

c. inguinal hernia – hernia in children can transilluminate
* a. testicular torsion - most common cause of testicular pain in boys 12 years and older, uncommon in boys less than 10 years old

Question 4

Baby with scrotal swelling, 1 episode of vomiting, non reducible on exam, active bowel sounds, approach?

a. U/S scrotum
b. Abdominal xray
c. Radionuclear scan
d. Consult surgery

Answer 4

d. Consult surgery
- incarcerated inguinal hernia
Most non reducible inguinal hernias in children, unless tx, rapidly progress to strangulation with potential infarction of hernia content or intestinal obstruction

Question 5

Smooth, firm, tubular mass in scrotum that transilluminates, not febrile, irritable for a week. Discomfort with examination, testes palpable and are distinct from this mass.
Not reducible, no vomiting.
a. incarcerated inguinal hernia
b. acute non-communicating hydrocoele
c. epididymitis
d. testicular torsion

Answer 5

b. acute non-communicating hydrocoele

Question 6

13 y.o. presents with 3 day history of gradually worsening scrotal pain. On exam, you note tenderness at the superior pole of the right testis, with a bluish discolouration at the tip. Most appropriate next step in management:

a) testicular U/S with dopplers
b) testicular nuclear scan
c) urethral swab for chlamydia
d) supportive care and reassurance

Answer 6

d) supportive care and reassurance
- torsion of appendix testis
- Will resolve in 3-10 days (bed rest x24h and NSAIDs)

Question 7

3mo, pale, intermittent pain, vomiting, tachycardia, investigations

a. AXR
b. Air enema fluoro
c. UGI series
d. Contrast study

Answer 7

b. Air enema fluoro

- intussusception

Question 8

Newborn with trisomy 21, non-bilious vomiting after feeds. What’s the test?

a. Abdominal ultrasound
b. Barium swallow with follow through
c. Abdominal Xray
d. observe for now

Answer 8

c. Abdominal Xray

- look for double bubble (duodenal atresia)

Question 9

Infant who has cyclic crying, now presents appearing more lethargic. Abdo is distended. Best test?

a. supine AXR film
b. air enema
c. colonoscopy
d. CT abdomen

Answer 9

b. air enema

• intussusception
• air enema preferred over contrast as less risk perforation

Question 10

Older infant, respiratory symptoms. CXR shows diaphragmatic hernia or diaphragmatic eventration.
What is the MOST diagnostic test?
a. surgical exploration
b. diaphragm fluoroscopy
c. U/S
d. MRI

Answer 10

c. U/S - correct answer if you think picture is of eventration
- elevation of one hemidiaphragm on AP CXR; lateral
shows normal posterior attachment of both hemidiaphragms
- if diagnostic uncertainty, can get U/S which will show minimal or paradoxical diaphragm movement with breathing
d. MRI - correct answer if you think picture is of hernia
- Morgagni hernias can be diagnosed later/incidentally
- AP film shows structure behind heart and lateral shows the mass is retrosternal
- diagnosis confirmed by chest CT or MRI

Question 11

Picture of a baby that looks like this (eventration of bowel lateral to umbilicus with no overlying membrane). What is an associated defect?

a. intestinal atresia
b. cardiac anomalies
c. renal anomalies
d. mental retardation

Answer 11

a. intestinal atresia
- gastroschisis - 1/10 babies have intestinal atresia, not associated with other congenital anomalies, unlike omphalocele