Surgery

Question 1

At which month is it very unlikely for an undescended testicle to descend?

Answer 1

4 months

Question 2

What are the complications or risks of an undescended testicle?

Answer 2

• Poor testicular growth
• Testicular malignancy (peak age 15-45 years, most common = seminoma)
  
  • 4x higher in the undescended testis, less common if orchiopexy <10yo but risk still exists
  • Adolescents should be instructed in testicular self-examinations
• Associated hernia
• Torsion of the cryptorchid testis
• Infertility

Question 3

What are indications for surgical repair of an umbilical hernia?

Answer 3

• Hernia persists to 4 to 5 years of age
• Causes symptoms
• Becomes strangulated
• Becomes progressively larger after 1-2 years

Question 4

What is the best investigation for breast mass in teens?

What is the most common etiology?

What is the management for this issue?

Answer 4

Ultrasound → mammogram NOT indicated

Fibroadenoma

Management: observe 2 menstrual cycles or until adulthood, 10% will regress. Serial US to monitor.

FNA indication: >5cm (risk of giant fibroadenoma, cystosarcoma phylloides)

Question 5

At what age is intussusception mostly seen?

Answer 5

• Most common cause of intestinal obstruction between 5 months and 3 years
• Approximately 80% of cases occur <2 years of age; rare in neonates
• M>F (3:1)
• Ileo-colic (90%) > ceco-colic > ileo-ileal

Question 6

What are the classic clinical presenting symptoms?

Answer 6

• Sudden onset of severe paroxysmal colicky pain accompanied by straining and flexed knees
• Progressively weaker and lethargic, as well shock-like state with fever and peritonitis
• Vomiting, may be bilious
• Red currant jelly stool in 60% of infants; may more commonly be bloody
• “Sausage-shaped” RUQ mass in 30% of patients
• Classic triad of paroxysmal pain, palpable sausage-shaped RUQ abdominal mass and currant jelly stool present in <30% of affected patients

Question 7

What are the contraindications to air enema for intussusception?

Answer 7

• Prolonged intussusception
• Signs of shock
• Peritoneal irritation / peritonitis
• Intestinal perforation
• Pneumatosis intestinalis

Question 8

What is the most common associated anomaly with gastroschisis?

Answer 8

Intestinal atresia

Question 9

What are the differences between non-communicating and communicating hydroceles?

Answer 9

• Non communicating - fixed amount of fluid and the tract has closed off; common in newborns and rare > 1 year → conservative, typically self-resolves (surgery if persistent at 18mo)
• Communicating - persistence or delayed closure of the processus vaginalis but smaller so doesn’t cause hernia. Fluid amounts change with gravity and throughout the day → can be corrected in 1st if truly changing volumen

Question 10

What are indications for emergent or urgent removal of foreign bodies in the esophagus?

Answer 10

• Signs of airway compromise
• Symptoms consistent with esophageal obstruction
• Button battery in the esophagus
• Sharp or long (>5cm) objects in the esophagus or stomach
• High-powdered magnets
• Intestinal obstruction
• FB impacted in the esophagus for >24h or an unknown period

Question 11

What is the peak age of appendicitis?

Answer 11

• Most common non-traumatic surgical emergency in children
• 1 in 1000 kids per year
• 20-25% perforated on presentation
• Peak incidence: 11-12yo (⅓ present < 18y)
• Lifetime risk: 7% female, 9% male

Question 12

What is the sensitivity and specificity for ultrasound vs. CT scan in appendicitis?

Answer 12

• US - non compressible appendix, abscess
  
  • Sensitivity 85%, specificity > 90%
• CT scan - ALARA principle
  
  • Sensitivity 95%, specificity 94%