Surgery

Question 1

How does an inguinal hernia (usually indirect) present?

Answer 1

usually caused by a persistently patent
processus vaginalis (PPV), a remnant of peritoneal invagination, and emerges from the deep inguinal ring through the inguinal canal
Most common in preterm infants
A lump in the groin, which may extend into the scrotum or labium. They are usually asymptomatic but may be intermittent aka visible during straining

Question 2

What is incarceration?

Answer 2

Pain, intestinal obstruction, damage to the testis (if becomes strangulated). Sometimes the ovary becomes incarcerated within a hernia.
Lump is tender and infant may be irritable and may vomit

Question 3

What is the management for an inguinal hernia?

Answer 3

Herniotomy with division and ligation of PPV.
Beyond 3 months it can be safely performed as a day case
Taxis: gentle compression in the line of the inguinal canal with good analgesia. Used to reduce hernia.
Most hernias can be ‘taxied’ and then surgery can be planned for a suitable time when any oedema has settled and the child isn’t acutely unwell.
Reduction impossible: emergency surgery as high risk of bowel/testis compromise

Question 4

What is a hydrocele?

Answer 4

Same underlying anatomy as a hernia, but
the PPV is not wide enough to form an inguinal hernia. A collection of fluid forms within PV, producing inguinal or scrotal swelling
Usually asymptomatic and can appear blue

Question 5

How does a hydrocele present on examination?

Answer 5

it is usually possible to feel the testis. Sometimes the hydrocele is separate from the testis in the cord. They usually transilluminate
If you can ‘get above it’- hydrocele

Question 6

What is the management for a hydrocele?

Answer 6

Usually resolve spontaneously as PV closes within months after birth.
Surgery may be considered if hydrocele persists beyond 2 years of age
Much less common in girls

Question 7

How does a varicocele present?

Answer 7

scrotal swelling comprising dialted (varicose) testicular veins. It occurs in up to 15% of (pubertal) boys
More common on the left side (drainage of gonadal vein into the left renal vein)
Asympotmatic, may cause a dull ache

Question 8

What does a varicocele look like on examination?

Answer 8

Bluish colour and feel like ‘a bag of worms’. Sometimes

the testis is smaller or softer than normal

Question 9

What is the management for a varicocele?

Answer 9

Conservative if asymptomatic.

Occlusion of gonadal veins can be achieved by surgical ligation (lap through the groin) or by radiological embolization

Question 10

How do undescended testis present?

Answer 10

present in up to 5% of newborn term infants, but more common in premature infants (22%). By 3 months of age only 1% are still undescended.
Palpable undescended testes (cannot be manipulated into the scrotum

Question 11

What are the other presentations of undescended testis?

Answer 11

Ectopic= can be palpated below the external inguinal ring but outside the scrotum
Impalpable testis= may be in the inguinal canal, but cannot be identified or it may be interabdominal or absent. Laparoscopy allows both diagnosis and treatment.
Bilateral impalpable testes= karytotyping to exclude disorders of sex development
Retractile testis- can be manipulated into the scrotum with ease and without tension

Question 12

What is the management for undescended testis?

Answer 12

orchidopexy (before 2 years of age) is performed for the following reasons:
Cosmetic
o Reduced risk of torsion and trauma compared to groin location
o Fertility (the testis needs to be in the scrotum, below body temperature, in order to allow spermatogenesis). More important in bilateral undescended testes.
There is some evidence suggesting that delaying orchidopexy beyond 2 years of age adversely affects testicular development
o Malignancy
Orchidopexy should be performed before or around the age of 1 as to minimise chances of spontaneous descent and to improve hormonal function and testicular growth.

Question 13

How does torsion of the testis present?

Answer 13

commonest in post-pubertal boys, presents at birth in newborns (perinatal)
sudden onset pain in the groin, lower abdomen or scrotum. Vomiting may be present
redness and oedema of the scrotal skin with absent cremasteric reflex (elicited by stroking
medial thigh)

Question 14

What needs to be excluded when diagnosing testicular torsion?

Answer 14

MUST distinguish from an incarcerate hernia. If no evidence of fever then the cause of scrotal pain is more likely to be mechanical (so torsion rather than epididymo-orchitis)
Surgical exploration in any acute scrotal presentation is mandatory
In perinatal testicular torsion, testicular loss is almost inevitable

Question 15

What is torsion of appendix testis?

Answer 15

Testicular appendage = a paramesonephric remnant usually located on the upper pole of the testis
Affects prepubertal boys, more common than torsion
Pain evolves over days, not as intense as torsion

Question 16

How is torsion of appendix testis diagnosed?

Answer 16

Scrotal exploration and excision of the appendage is often needed as it cannot be differentiated reliably from testicular torsion.

Question 17

What is the management for torsion of appendix testis?

Answer 17

if a ‘blue dot’ can be seen through the scrotal skin and pain is controlled with analgesia, surgery may not be necessary.

Question 18

How does epididymo-orchitis present?

Answer 18

Commoner in infants and small children and more likely with a pre-existing urological or anorectal malformation
Start empirical antibiotics

Question 19

What are the investigations for epididymo-orchitis?

Answer 19

May be indistinguishable from torsion so scrotal exploration is often needed.
Doppler USS of flow pattern in testicular blood vessels may allow differentiation, but must not delay surgical exploration if torsion remains a possibility
Urine sample
Pus collected at operation

Question 20

How does appendicitis present?

Answer 20

Anorexia
Vomiting (usually only a few times)
Abdominal pain, initially central and colicky (appendicular midgut colic), but then localising to the right iliac fossa (from localised peritoneal inflammation)
Flushed face with oral fetor
Low-grade fever 37.2–38°C
Abdominal pain aggravated by movement, e.g. on walking, coughing, jumping, bumps on the road during a car journey
Persistent tenderness with guarding in the right iliac fossa (McBurney’s point)

Question 21

How does appendicitis differ in school children?

Answer 21

More difficult diagnosis
Faecoliths are more common and can be seen on a plain abdominal X-ray- inspissated faecal mass
Perforation may be rapid as the omentum is less well developed and fails to surround the appendix- the signs are easy to underestimate at this age
With a retrocaecal appendix, localised guarding may be absent- in a pelvic appendix there may be few abdominal signs

Question 22

How can bowel sounds be categorised?

Answer 22

o Mechanical obstruction- produces active, high pitched, hyperactive bowel sounds
o Peristalsis- may be increased in the upper abdomen and decreased in the lower
o With time peristaltic waves and bowel sounds disappear

Question 23

What can small bowel obstruction be caused by?

Answer 23

o	Atresia or stenosis of the duodenum
o	Atresia or stenosis of the jejunum or ileum
o	Malrotation or Volvulus
o	Meconium ileus
o	Meconium plug

Question 24

What can large bowel obstruction be caused by?

Answer 24

o Hirschsprung disease

o Rectal atresia