Surgery

Question 1

Undescended testes at 8 month, what to do next ?

A. Refer to surgery
B. Ultrasound

Answer 1

A. Refer to surgery

Surgical treatment of undescended testes is recommended as soon as possible after four months of age for congenitally undescended testes and definitely should be completed before the child is two years old. And children with testicular ascent later in childhood, surgery generally should be performed within six months of identification. Spontaneous dissent rarely, if ever occurs after six months of age. Treatment before two years, ideally before one year of age is associated with improved testicular growth and fertility potential.

Question 2

8 month old with 3cm umbilical hernia. No strangulation.

A. Continue to monitor
B. Refer at 2y.o if still persistent

Answer 2

A. Continue to monitor

Surgery is not indicated unless the hernia persists past age 4 to 5 years old, becomes strangulated, or becomes progressively larger after age 1 to 2 years old

Question 3

You examine an eight-month-old infant and find the right testicle is not palpable in the scrotum. What is the most important next step?
A. Reassess in two months
B. Refer to Surgery
C. Order an ultrasound to locate the testicle
D.refer to endocrinology

Answer 3

B. Refer to surgery

Question 4

A three-month-old male infant presents to the emergency department with a one-month history of spit ups and a 2 day history of projectile vomiting. His last two vomits were bilious. On exam, he looks dehydrated and unwell. His abdomen is distended, nontender, with no palpable masses. What diagnostic test would most likely reveal the underlying abnormality?

A. Abdominal ultrasound
B. Barium enema
C. Upper G.I. series
D. Abdominal x-ray (anterioposterior and lateral)

Answer 4

C. Upper GI series - this would likely reveal the actual diagnosis. This sounds like malrotation with volvulus

Most present in first year of life with over 50% presenting in the first month of life. You see bilious emesis in a acute bowel obstruction. Diagnosis may be suggested by ultrasound but it’s confirmed by contrast radiographic studies. Abdominal x-ray is nonspecific. Barium enema shows malposition of the caecum but is normal in 20% of cases. Upper G.I. series is the imaging test of choice and gold standard in the evaluation and diagnosis of volvulus and malrotation.

Question 5

Newborn baby born with the refractory hypoglycemia and attached photo showing an omphalocele. What is he most at risk for?

A. Hirschprung’s disease
B. Wilm’s tumor
C. Hypothyroid

Answer 5

B. Wilm’s Tumor

This is an omphalocele and the clue is the refractory hypoglycemia which apparently makes you think of Beckwith- Wiedeman syndrome which is a\w Wilm’s Tumor

Question 6

17-year-old female presents with a small firm lump in her breast. What is the most likely cause

A. Fibrocystic changes
B. Fibroadenoma

Answer 6

B. Fibroadenoma

The most common solid mass in adolescent girls is the fibroadenoma. Fibroadenomas are most often located in the upper outer quadrant of the breast. The average size is 2 to 3 cm, and 10 to 25% of patients have multiple lesions. The physical exam is usually diagnostic because these lesions are well circumscribed, rubbery, mobile, nontender. In equivocal cases, ultrasound would be helpful in making a diagnosis. Mammography is not indicated in the adolescent patient. Can enlarge during menstrual cycle, responsive to estrogen. Can just observe but should ultrasound Q6 to 12 months

Question 7

5 month old with vomiting for six hours intermittently, has had three or four episodes of flexion and extension of arms and legs, drowsy after, abdomen is distended, which test will reveal diagnosis?

A. EEG
B. CT abdomen
C. Ultrasound abdomen
D. Abdominal x-ray

Answer 7

C. Ultrasound abdomen

Intussusception

Question 8

Adolescent girl with scoliosis has undergone spinal surgery. She presents with bilious vomiting for the last few days. What is the etiology?

A. Bowel adhesions
B. Superior mesenteric artery syndrome
C.malrotation with volvulus
D.pancreatitis

Answer 8

B. Superior mesenteric syndrome

SMA syndrome results from compression of the 3rd duodenal segment by the artery against the aorta. Malnutrition or catabolic states are the most common causes but also extra abdominal compression, mesenteric tension with ileoanal pouch anastomosis. Risk factors include: thin, prolonged bedrest, abdominal surgery, exaggerated lumber lordosis. Classic example is teenager who is underweight and undergoes surgery for scoliosis and starts vomiting one to two weeks after. Presents with intermittent epigastric pain, anorexia, nausea and vomiting. Upper G.I. series is best for diagnosis. Treatment with positioning, prokinetics, NG tube feeding, surgery

Question 9

Photo of G-tube site (shows granulation). What would you do ?

A. Oral abx
B. Consult surgery
C. Silver nitrate cautery
D. Reassure

Answer 9

C. Silver nitrite cautery

Question 10

Teen with firm systemically enlarged thyroid. Negative for thyroid antibodies. What next?

A. Follow-up in 6 month
B. Do ultrasound
C. Biopsy

Answer 10

A. Follow-up in 6 months

Simple goiter. Takes about in endo.

B. Generally don’t need to U/S goiter, only if distinct nodule
C. Don’t biopsy a goiter

Simple Goiter: a few children with euthyroid goiters have simple goiters, a condition of unknown cause not associated with hypothyroidism or hyperthyroidism and not caused by inflammation or Neoplasia. More common in girls, peak incidence before and during puberty. Levels of TSH are normal or low, Scintiscans are normal and thyroid antibodies are absent. Differentiation from lymphocytic thyroiditis might not be possible without a biopsy, a biopsy is usually not indicated. Patient should be reevaluated periodically, because some have antibody negative lymphocytic thyroiditis and therefore at risk for changes in thyroid function. Natural history is to decrease in size.

Question 11

Peritonitis, what to do next ?

Answer 11

A. Bolus and analgesia

Primary peritonitis: source of infection originates outside of the abdomen, seeds via hematogenous, lymphatic, or transmural spread. Treat with broad spectrum IV antibiotics for example cefotaxime for 10 to 14 days. Usually only one organism is isolated in primary.

Secondary peritonitis: Arises from the abdominal cavity. Most often results from entry of enteric bacteria into the peritoneal cavity through a necrotic defect in the wall of the intestine or other viscous as a result of obstruction or infarction or after rupture of an intra-abdominal visceral abscess. It most commonly follows perforation of the appendix.
- need to stabilize the patient before surgical intervention: with fluid resuscitation and abx
- secondary peritonitis is typically polymocrobial: E.coli, klebsiella, bacteroides, enterococci - treat with amp/gent/flagyl OR piptazo
- surgery to repair perforated viscous should proceed after pt is stabilized on abx
-

Question 12

A 1 month old boy is diagnosed with pyloric stenosis. He has severe metabolic alkalosis, bicarbonate 34. What do you do ?

A. Operate immediately
B. Give HCL
C. Give K bolus
D. Give large amounts of chlorinated fluid IV

Answer 12

D. Give large amounts of chlorinated fluids

Question 13

Picture of gastroschisis. What is this associated with ?

A. Intestinal atresia
B. Cardiac defect
C. Renal defects

Answer 13

A. Intestinal atresia
- the vast majority of associated abnormalities are GI in nature; but small mi Keith of children also have cardiac defects.

Question 14

1 year old with rectal abscess. Management ?

A. Systemic abx
B. Excision by surgery
C. I&D

Answer 14

Answer: likely C. I& D.

Treatment is rarely indicated in infants with no predisposing disease because the condition is often self limited. Even in cases of fistulization, conservative management with observation is advocated because the fistula often disappear spontaneously. Antibiotics are not useful in these patients. When dictated by patient discomfort, abscesses may be drained under local anesthesia.
Nelson’s

Question 15

Unwell boy, tense abdomen. What do you do after calling surgery

A. Bolus and analgesia
B. Bolus and CT scan
C. IV antibiotics

Answer 15

Answer: likely C, IV abx - but ideally bolus and IV abx

Initial management of the patient with Gastro intestinal perforation includes IV fluid therapy, NPO and broad-spectrum antibiotics. Drainage, gastrostomy, and feeding jejunostomy may be appropriate depending upon the level of perforation. Monitoring should initially take place in ICU. Administration of IV PPI is appropriate for those suspected to have upper G.I. perforation. Patients with intestinal perforation can have severe volume depletion and electrolyte abnormalities. Surgical management of patients with free perforation should be expedited to minimize such derangements.

Question 16

A 13 y.o girl is seen with abdominal pain of 24h duration.She rates it as a 10 out of 10 pain. She has a fever. On exam there is diffusely tender abdomen and guarding. You call general surgery. In the meantime, what is your management?

A. Blood culture and sensitivity and antibiotics
B.IV fluid bolus and analgesia
C. IV fluid bolus and CT abdomen
D. IV fluid bolus and IV antibiotics

Answer 16

Answer: D vs A. Tricky question, I suppose depends on if they describe any haemodynamic instability in which case definitely bolus. But naturally would do blood culture and sensitivity before giving antibiotics in any case why would they make us choose between them

Question 17

An eight-month-old child is admitted for viral gastroenteritis. The child has intermittent episodes of screaming and vomiting. On exam, the child is pale and lethargic. Which of the following investigation is most useful in diagnosis of this patient?

A. AXR
B.Serum lactate
C. Air enema

Or

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

A. Supine abdominal x-ray film
B. Air enema
C. Colonoscopy
D. CT abdomen

Answer 17

Answer: best test is abdominal U/S but if not an option air enema - likely B

Patients with a typical presentation or characteristic findings on radiography, may proceed directly to non-operative reduction using hydrostatic (contrast or saline) or pneumatic air enema, performed under either sonographic or fluoroscopic guidance. In these cases the procedures both diagnostic and therapeutic. Often the diagnosis is unclear at presentation and initial work up May include abdominal ultrasound or abdominal plain films provided that do not significantly delay the definitive treatment.

Question 18

What is the most common complication after gastoschisis repair?

A. Bowel obstruction
B. Abdominal compartment syndrome

Answer 18

B. Abdominal compartment syndrome

Question 19

What is the most likely complication of a ruptured appendicitis?

A. Bowel obstruction
B. Abscess in the abdomen
C. Wound infection
D. Enterocutaneous fistula

Answer 19

Answer B. Abscess in the abdomen

Once significant inflammation and necrosis occur, the appendix is at risk for perforation, which leads to localized abscess formation or diffuse peritonitis

Question 20

A 3 week old is brought to the ER because of repeated projectile vomiting after each feed. What to find on lab work ?

A. Hyponatremia
B .hyperkalemia
C. Hypochloremia
D. Metabolic acidosis

Answer 20

Answer C. Hypochloremia

Pyloric stenosis get hypochloremia, metabolic alkalosis (low CL, lowK, high bicarbonate) Na is either high or low

Question 21

A baby and X-ray done and it is not clear if it is diaphragmatic eventration or actually diaphragmatic hernia. What is the best initial investigation to differentiate?

A. Ultrasound
B. Diaphragmatic fluoroscopy
C. Surgical exploration
D .MRI

Or

5 y.o with cough and fever. Crackles on the RLL. CXR shows either diaphragmatic eventration vs hernia. What is the next test for diagnosis ?
A. Diaphragmatic fluoroscopy
B.Ultrasound
C. Exploratory laparotomy
D. MRI

Answer 21

Answer A,B ultrasound - to look to see if diaphragm is moving (moves in eventration)

B is old answer but on resp answers

Question 22

1 month old baby irritable, not feeding well, vomited once, distended abdomen. On exam VSS except mild tachycardia. There is a mass in the right scrotal, form and non-reducible. Does not tranilluminate. What is the next step?

A. Ultrasound
B. Urgent surgical consultation
C. Nuclear scan
D. Testicular Doppler

Answer 22

Answer B. Urgent surgical consult

Incarcerated hernia needs emergent reduction manually or surgery. Can do it manually unless the child appears extremely ill and has signs of peritonitis, intestinal obstruction or toxicity from gangrenous bowel. Often these kids are crying, irritable, vomiting and abdominal distention can develop. They have firm inguinal mass, usually tender and surrounded by edema with erythema.

Incarcerated cannot be reduced by manipulation
Strangulation - vascular compromise of incarcerated hernia caused by progressive edema from venous and lymphatic obstruction. Can lead to necrosis and perforation.
Imaging isnt helpful in this situation, need to reduce it.

Question 23

10 month old irritable. Acute onset of red scrotal swelling. Parents had noted on and off swelling in the past few days. Today irritable, VSS, mild tachycardia. On exam right red swollen and transilluminate as well. What is the diagnosis?

A. Epididymitis
B. Testicular torsion
C. Acute hydrocele
D. Incarcerated hernia

Answer 23

Controversial question:

Answer B- hydrocele can happen at the time of torsion but could also be hernia. Urology lecture said B

Incarcerated hernia - (as per nephrologist at MAc)

Transilluminates = fluid filled sac
Hydrocele = delayed closure of patent processes vaginalis or fluid trapped at time of testicular assent. Common in newborns. Can happen later spontaneously or secondary to infection, torsion, trauma, tumor. Transilluminate, cystic, irreducible, non-tender

Epididymitis- Inflammation of epididymitis.
Testicular torsion - causes severe pain and vomiting. The affected testicle is typically swollen, tender, and retracted toward the external ring. The cremasteroc reflex is absent on the affected side.

Question 24

Six-year-old boy presents with severe abdominal pain, 8/10. Heart rate 150, blood pressure 120/80, abdomen is rigid. You immediately call the surgeons; what is your next step?

A. Culture and start IV antibiotics
Be. IV bolus of 20 mL/kg NS and arrange for urgent CT abdomen
C. Ultrasound the abdomen
D. IV bolus of 20 mls/kilogram NS and analgesia

Answer 24

Controversial
A. Culture and start IV antibiotics. Our group is going with A A as we don’t think analgesia is a good idea

Vs

D. IV bolus 20cc/kg NS and analgesia

Peritonitis - needs culture, iV abx, fluid resuscitation, general surgery

Question 25

What is true about intussusception?

A. Meckel’s diverticulum is the most common lead point
B. 75% of cases are idiopathic
C. Most patients present with red current jelly stools

Answer 25

Answer B: closest to being right - 75% are ideopathic

The classic triad of pain, palpable sausage shaped abdominal mass and bloody jelly stool is seen in less than 30% of patients.
90% of cases are idiopathic.
60% of infants pass a stool containing red blood and mucus, the current jelly stool.
Blood is generally passed in the first 12 hours, but at times not for 1-2 days and frequently not at all.
In typical cases, there is sudden onset in a previously well child, of severe paroxysmal colicky pain that recurs at frequent intervals and is accompanied by straining efforts with legs and knees flexed and loud cries. In 2 to 8% of patients recognizable lead points for intussusception are found: Meckel’s diverticulum, intestinal polyps, neurofibroma

Question 26

2 week old girl with rectal bleeding. HR220, BP 60/35, abdomen tense and sensitive. What is your next step in your diagnostic approach ?

A. Call general surgery
B. Abdominal ultrasound
C. IV antibiotics
D.  Abdominal x-ray
E. Barium meal with small bowel follow-through

Answer 26

Controversial

A. Call general surgery vs D. Abdominal X-ray. Wording is next diagnostic approach - therefore calling surgery is not diagnostic. Would get X-ray first

Me - disagree - baby is sick and imaging is not priority!! Stabilize and call general surgery

NEC vs malrotation with volvulus

NEC - more likely to have rectal bleeding, but this usually occurs in preterm growing babies not term babies. Diagnosis based on x-ray or ultrasound.

When malrotation is complicated by volvulus, it is a potentially life-threatening condition and requires emergent evaluation and treatment. If the patient has volvulus with signs of systemic decompensation for example hematemesis, hematochezia, abdominal distention, peritonitis and shock, no additional evaluation is needed. The patient should be rapidly resuscitated and immediately taken to surgery for exploration.

Question 27

15-year-old status post therapeutic abortion. Sudden onset of respiratory distress, chest pain. On exam, bilateral crackles. She is coughing blood. What is the best test;

A. ECG
B. Pulmonary angiography
C. Chest x-ray
D. Pulmonary VQ scan
E. Leg Doppler’s
F. CT scan

Answer 27

B. Pulmonary angiography

Symptoms of pulmonary embolism include shortness of breath, pleuritic chest pain, cough, hemoptysis, fever, and in the case of massive PE, hypotension and right heart failure. Spiral CT is used most frequently for the diagnosis of PE. CT PA is the gold standard for diagnosis.

Question 28

Omphalocele. What do you tell the nurse to do ?

A. Elective surgery
B. Dry dressing
C. Wet dressing
D. Topical Flamazine

Answer 28

C. Wet dressing

Cover viscera with sterile Saline soaked gauze and cellophane wrap or plastic bag

Question 29

One month old has progressive non-bilious vomiting. On exam has a small palpable olive in the right upper quadrant. Most likely lab abnormalities:

A. Metabolic acidosis
B. Respiratory acidosis
C. Hypokalemia
D. Alkalotic urine hypernatremia

Answer 29

C. Hypokalemia

Pyloric stenosis - hypochloric metabolic alkalosis. K is normal or low

Question 30

Umbilical hernia, what to do?
A.Take a coin and strap it down
B. May resolve in 24 months
C. Do surgery right now or else the hernia will incarcerate

Answer 30

B. May resolve in 24 months

Question 31

A previously healthy 15-year-old boy has cramping umbilical pain. After several hours, the pain shifts to the right lower quadrant and becomes constant. He vomit several times and is brought to the emergency department. The abdomen is tender on palpation on the right lower quadrant. Findings on chest and abdominal x-ray films are normal. Leucocyte count is 15,000 mm, which of the following is the most appropriate initial management?

A. A CT scan of the abdomen
B. IV hydration
C. Surgical exploration of the abdomen
D. U/S of the abdomen

Answer 31

B. IV hydration

Appendicitis is a clinical diagnosis so this kid ultimately need surgery but this is generally considered semi elective for example within 24 to 48 hours of diagnosis. The initial management includes IV fluids and pain medications. Ultrasound is not needed unless a diagnosis is uncertain.

Question 32

Blunt abdominal trauma. One reason to take patient to OR for laparotomy.

Answer 32

• persistent shock despite fluid and blood.

Absolute indications:

1. Perforation from a hollow viscous injury demonstrated as penumoperitoneum
2. Intrabdominal bleeding and more than half the patient’s blood volume demonstrated as persistent or recurring hemodynamic instability, despite crystalloid infusion and blood transfusion, especially when accompanied by abdominal distension.

Regardless of the procedure the following remain indications for surgical exploration in children with blunt abdominal trauma:

• hemodynamic instability
• replacement of > 40ml/kg blood products
• peritonitis
• free intraperitoneal air or extravasated contrast on imaging
• clinical deterioration during observation

Question 33

List three indications for urgent surgical referral for endoscopic removal of an esophageal foreign body.

Answer 33

1. Unsure when the foreign body was ingested >24h
2. Button battery
3. Signs of complete blockage of esophagus ie; can’t swallow secretions

Urgent intervention is indicated if any of the following warning signs are present:

1. When the ingested object is sharp, long > 5 cm, or a super absorbent polymer, and is in the oesophagus or stomach.
2. When the ingested object is a high powered magnet or magnets
3. When a disk battery is in the oesophagus and in some cases in the stomach
4. When the patient shows signs of airway compromise
5. When there is evidence of near complete oesophageal obstruction for example patient cannot swallow secretions.
6. When there are signs or symptoms suggesting inflammation or intestinal obstruction (ie; fever, abdominal pain, or vomiting) - not for this question
7. If object is still in the esophagus after 24h

Question 34

Photo of double bubble sign

A. What does this X-ray show?
B. What is the diagnosis ?
C. What underlying condition is this disorder most commonly associated with ?
D. Now this child has Left axis deviation on ECG. What is the most likely heart lesion ?

Answer 34

A. What does the X-ray show?
- double bubble sign
B. What is the diagnosis ?
- duodenal atresia
C. What underlying condition is this disorder most commonly associated with ?
- T21
D. What is the most likely heart lesion ?
- AVSD

Most common congenital heart disease in T21 is AVSD. ECG shows leftward and superior QRS axis deviation.
Two causes of left axis deviation 1) AVSD and 2) tricuspid atresia from hypoplastic right ventricle

Question 35

A. Name 2 situations where air enema for intussusception would be unsuccessful.

B. Name 2 contraindications to air enema for intussusception

Answer 35

Children less than one year, especially those less than three months
Children above five years increased risk for pathological lead point
Signs of intestinal obstruction on plane films
Success is more likely of intussusception idiopathic with no identified lead point

B. Contraindications to give air Adema
Intestinal perforation
Clinical instability or shock
Prolonged duration of symptoms above three days

Question 36

Surgeon asks for a consult on two of his patients for elective surgeries the next morning. Please give fluid type and rate for:

A. 14y.o boy (50kg) NPO from midnight for inguinal hernia repair

B. 2 month old (5kg) NPO from midnight for inguinal hernia repair

Answer 36

A. 14 y.o 50kg
- IV D5W 0.9% NS + 20KCL at 90cc/h

B. 2mo old 5kg

• IV D5W 0.9% NS + 20KCL at 20cc/h

Question 37

3 y.o with bite on his cheek. List 4 characteristics of the bite that would have an impact on the management of this patient.

Answer 37

4 characteristics with impact on management 
1. Type of bite - animal vs human
2. Type of animal ie; cat vs bat
3. Signs of surrounding infection -
Red, hot, swollen, fever, pus
4. Location of bite
5. Size of bite
6. Any other injuries
7. Actively bleeding
8. Neurovascularly intact or not 

We often repair face wounds for cosmetic purposes

1. Bite came from an animal with suspected or confirmed rabies for example may need rabies IG or vaccine.
2. Bite came from a human with confirmed or suspected hepatitis B or HIV for example may need HepB vaccine or HBIG
3. Bite happened < 24 hours ago versus > 24 hours ago may impact whether you close it.
4. Signs of infection including erythema, swelling pus and fever
5. Complex facial laceration may require plastic surgery
6. Other: deep puncture wound from cat may need antibiotics prophylaxis, though a facial laceration probably needs abx anyway, patient immunocompromised, patient unimmunized (may need tetanus)

Question 38

Description of a baby with a reducible hernia. When should he be referred for surgery for repair ?

Answer 38

What type of hernia are we talking about ?

Umbilical hernia:
- surgery is not advised unless the hernia persists to the age 4-5y.o, causes symptoms, becomes strangulated or becomes progressively larger after the age of 1-2years.

Inguinal hernia

1. Inguinal hernia does not resolve spontaneously and early repair eliminates the risk of incarceration
2. The timing depends on several factors including age, general condition of the patient and comorbid conditions
3. In infants younger than one year old repair should be prompt within 2 to 3 weeks because as many as 70% of incarcerated inguinal hernia’s requiring emergency operation occur in infants younger than 11 months.
4. The incidence of complications associated with elective hernia repair include intestinal injury, testicular atrophy, recurrent hernia and wound infection are low and are less than 1% but rise up to 20% if it is performed at the time of incarceration

Question 39

A six-year-old boy presents with severe abdominal pain and vomiting. On examination his abdomen is tender and he is tense and guarding. What three things do you do for management?

Answer 39

3 management

1. Insert IV and give IV fluid/bolus
2. Pain medication with IV morphine
3. Call general surgery and keep NPO

Other

1. Abdominal x-ray/ultrasound +/- CT scan
2. Blood work (CBC, culture, lytes, Cr), urinalysis + start abx

Me - I disagree with the above

1. IV fluid bolus and maintenance
2. NPO
3. Culture and IV abx
4. Surgery consult

Question 40

2019Q: A 17 month old boy is going for elective orchidopexy today. When he shows up he has a fever of 38.2 and copious yellow nasal discharge. He has intermittent cough but otherwise appears well. Can he have his surgery?

A. Yes
B. Yes, but he needs to be observed overnight
C. No, wait until his symptoms resolve
D. No wait until 6 weeks after his symptoms resolve

Answer 40

D. No, wait until 6 weeks after this symptoms resolve

Up to date it’s 2-4weeks after symptoms resolve but can have reactive airways until 6 weeks post URTI

Pts with fever >38C or a wet cough should postpone elective procedures until 2-4weeks after symptoms subside