Surgical Cases

Question 1

What is a hydatid of Morgagni? How does it present?

Answer 1

• Most common at 11 years or less as oestrogen surge affects receptors here. Torted of the testicular appendage - blue dot sign and pain!
• DDx - testicular torsion, appendicitis

Question 2

When is testicular torsion most common. How is it definitely managed?

Answer 2

• 13-16
• Surgical exploration and fixation (of both testes)

Question 3

Which testicle is a varicocoele more likely to occur in?

Answer 3

Left

Question 4

What is a differential for a paediatric bilaterally swollen scrotum?

Answer 4

• Nephrotic syndrome
• Idiopathic scrotal oedema (~ allergy)

Question 5

How can an undescended testis be distinguished clinically from an absent testis?

Answer 5

• Size - the remaining testis will compensate if the other is absent, but not if it’s just undescended

Question 6

What are the most common causes of ambiguous genitalia? What work-up is needed in these situations?

Answer 6

• Congenital adrenal hypoplasia and androgen insensitivity syndrome
• UEC, BSL (looking for adrenal crisis signs - low Na, glucose, high K)
• Urine collection
• Pelvic ultrasound - adrenals, gonads, uterus/tubes
• Serum progesterone (increased in CAH), testosterone, adrenal steroids
• Chromosomal analysis

Question 7

What is a sacrococcygeal teratoma?

Answer 7

• Congenital cancer that can rapidly turn malignant. Polyp at sacrococcygeal junction - red flag. Requires immediate referral - emergency

Question 8

What is a cystic hygroma? Where is it normally found?

Answer 8

• A lymphatic anomaly usually centred over the anterior triangle in the neck. Transilluminable, more common in children with chromosomal abnormalities e.g. T21

Question 9

What is the cause of a dermoid cyst? Where are they commonly found? What else is commonly found here in infants?

Answer 9

• Skin trapped between two fusing bony plates that forms a lump of skin secretions and peeled skin
• Commonly at the external angle
• Strawberry naevus/haemangiomas

Question 10

What is a thyroglossal cyst? How is it treated? What presents similarly to it?

Answer 10

• Descent of the thyroid leaves a track lined with respiratory epithelium - usually ending up close to the hyoid bone. Excision is necessary (of the cyst, track and part of the hyoid) as infection is likely
• DDx - neck abscess (erythema of this is limited by deep cervical fascia)

Question 11

What is difference between gastroschisis and exomphalos/omphalocoele? How are they managed?

Answer 11

• Gastroschisis - abdominal wall defect to the right of the umbilicus with uncovered bowel extrusion (urea and ammonia cause chemical peritonitis)
• Exomphalos - protrusion of the intestines through the cord attachment (covered by membranes)
• Babies need protection from heat loss and dehydration (glad wrap exposed bowel) before definitive surgery

Question 12

What is the presentation of a paediatric volvulus?

Answer 12

• Previously well child with sudden-onset bright green vomiting and no sepsis. Volvulus until proven otherwise, this can cause gut necrosis and is an emergency

Question 13

What causes Hirschsprung’s disease and how does it present? How is it managed?

Answer 13

• Loss of ganglion cells in enteric plexus.
• Delayed meconium (beyond 24 hours) and vomiting around day 3, abdominal distension. PR examination (stretch on anus) leads to reflex bowel contraction and a squirt.
• Removal of dysfunctional segment required.