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ABS Pediatric Surgery study materials
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ABS Pediatric Surgery practice questions

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Question 1Fetal and prenatal surgical conditions

In fetal congenital diaphragmatic hernia, where is the defect most commonly located?

  1. Right posterolateral diaphragm
  2. Left posterolateral diaphragm Correct answer.
  3. Central tendinous diaphragm
  4. Anterior retrosternal diaphragm

Explanation

Most congenital diaphragmatic hernias are Bochdalek defects, which occur posterolaterally and are far more frequent on the left. The left-sided predominance reflects later closure of the left pleuroperitoneal canal. Anterior retrosternal defects are Morgagni hernias and are uncommon.

Question 2Fetal and prenatal surgical conditions

Which congenital pulmonary airway malformation (CPAM) subtype is encountered most frequently?

  1. Type I Correct answer.
  2. Type IV
  3. Type 0
  4. Type II

Explanation

CPAM type I is the most common subtype and consists of one or more large macrocysts. Type II lesions have smaller uniform cysts, and type III lesions are bulky and microcystic. Type 0 and type IV are rare.

Question 3Fetal and prenatal surgical conditions

A fetus has an anterior abdominal wall defect with bowel protruding and no covering membrane, and maternal serum alpha-fetoprotein is elevated. Which diagnosis is most consistent?

  1. Umbilical hernia
  2. Prune belly syndrome
  3. Omphalocele
  4. Gastroschisis Correct answer.

Explanation

Gastroschisis is a full-thickness paraumbilical defect without a membranous sac, so bowel is directly exposed to amniotic fluid. Alpha-fetoprotein is typically elevated because fetal tissue is exposed. Omphalocele, by contrast, is covered by peritoneum and amnion.

Question 4Fetal and prenatal surgical conditions

Which cranial ultrasound findings are most characteristic of fetal myelomeningocele?

  1. Dandy-Walker malformation and mega cisterna magna
  2. Holoprosencephaly and absent cavum septum pellucidum
  3. Lemon sign and banana sign Correct answer.
  4. Agenesis of the corpus callosum and colpocephaly

Explanation

Myelomeningocele is associated with Chiari II malformation, which produces scalloping of the frontal bones (lemon sign) and downward curvature of the cerebellum (banana sign). These findings reflect altered cerebrospinal fluid dynamics and hindbrain herniation. They are classic prenatal markers of open spinal dysraphism.

Question 5Fetal and prenatal surgical conditions

Which fetal gastrointestinal obstruction most typically presents with polyhydramnios and a double bubble sign?

  1. Jejunoileal atresia
  2. Hirschsprung disease
  3. Meconium ileus
  4. Duodenal atresia Correct answer.

Explanation

Duodenal atresia obstructs proximal to the ampulla or just distal to it, causing a dilated stomach and proximal duodenum that appear as a double bubble. Because the fetus cannot swallow and absorb amniotic fluid normally, polyhydramnios develops. Jejunoileal atresia tends to produce multiple dilated loops rather than a double bubble.

Question 6Fetal and prenatal surgical conditions

Which tumor is the most common congenital germ cell tumor diagnosed in the fetus and newborn?

  1. Sacrococcygeal teratoma Correct answer.
  2. Neuroblastoma
  3. Congenital mesoblastic nephroma
  4. Hepatoblastoma

Explanation

Sacrococcygeal teratoma is the most common congenital germ cell tumor and the most common tumor of the newborn. It arises at the coccyx and can grow rapidly, causing high-output cardiac failure or hydrops. Neuroblastoma is common in infancy but is not a germ cell tumor.

Question 7Fetal and prenatal surgical conditions

A fetal lung lesion has a CPAM volume ratio (CVR) of 2.0. This value is most associated with which outcome?

  1. Need for immediate postnatal lobectomy
  2. Increased risk of hydrops fetalis Correct answer.
  3. Low risk of hydrops
  4. Spontaneous regression without intervention

Explanation

A CVR greater than 1.6 identifies fetuses with a substantially increased risk of developing hydrops fetalis. These fetuses require close surveillance because hydrops may prompt prenatal intervention. A CVR below 1.6 is associated with a much lower risk of hydrops.

Question 8Fetal and prenatal surgical conditions

The MOMS trial compared prenatal with postnatal repair of myelomeningocele. Which statement best summarizes its primary finding?

  1. Prenatal repair eliminated the need for ventriculoperitoneal shunting
  2. Prenatal repair improved survival to discharge
  3. Prenatal repair reduced shunt placement and improved motor function Correct answer.
  4. Prenatal repair reduced the rate of preterm birth

Explanation

The MOMS trial showed that prenatal repair decreased the need for ventriculoperitoneal shunting at 12 months and improved motor outcomes at 30 months. It also increased the risks of preterm birth and uterine dehiscence. These trade-offs frame prenatal counseling.

Question 9Fetal and prenatal surgical conditions

In fetal congenital diaphragmatic hernia, which finding on prenatal imaging most strongly predicts a poor prognosis?

  1. Right-sided defect
  2. Polyhydramnios alone
  3. Liver herniation into the thorax Correct answer.
  4. Presence of a stomach bubble in the abdomen

Explanation

Liver herniation into the chest is a strong predictor of severe pulmonary hypoplasia and worse survival in CDH. The herniated liver displaces mediastinal structures and is associated with a larger effective defect. Stomach position and lung size also contribute to risk stratification.

Question 10Fetal and prenatal surgical conditions

Fetoscopic tracheal occlusion (FETO) for severe congenital diaphragmatic hernia is most commonly associated with which complication?

  1. Maternal pulmonary edema
  2. Fetal intracranial hemorrhage
  3. Fetal tracheal stenosis requiring neonatal dilation
  4. Preterm premature rupture of membranes Correct answer.

Explanation

Preterm premature rupture of membranes is the most frequent complication of FETO and often limits the duration of occlusion. Preterm labor and chorioamnionitis also occur. These risks are central to selecting candidates for the procedure.

Question 11Fetal and prenatal surgical conditions

A fetus with a large microcystic CPAM develops hydrops. Which initial therapy is most appropriate?

  1. Thoracentesis of the cyst
  2. Percutaneous sclerotherapy
  3. Maternal betamethasone Correct answer.
  4. Immediate open fetal lobectomy

Explanation

Maternal betamethasone is first-line therapy for a microcystic CPAM complicated by hydrops because it can reduce lesion size and resolve hydrops. Fetal surgery is reserved for steroid failures or very severe disease. Macrocystic lesions may instead be treated with thoracoamniotic shunting.

Question 12Fetal and prenatal surgical conditions

Bronchopulmonary sequestration is best distinguished from CPAM by which feature?

  1. Association with hydrops
  2. Location in the lower lobes
  3. Systemic arterial supply Correct answer.
  4. Presence of a cystic component

Explanation

Bronchopulmonary sequestration has an anomalous systemic arterial supply, usually from the descending aorta. CPAM lacks this systemic feeding vessel. The two lesions can coexist as hybrid lesions, so identifying systemic supply is key.

Question 13Fetal and prenatal surgical conditions

A fetus has a large unilateral pleural effusion with mediastinal shift and hydrops. Which intervention is most appropriate?

  1. Early delivery at 32 weeks
  2. Thoracoamniotic shunt Correct answer.
  3. Serial amniocentesis
  4. Maternal indomethacin

Explanation

A large pleural effusion causing mediastinal shift and hydrops is treated with thoracoamniotic shunting to decompress the chest and improve venous return. This may reverse hydrops and allow the pregnancy to continue. Serial thoracentesis is an alternative but is less durable.

Question 14Fetal and prenatal surgical conditions

What is the definitive prenatal treatment for twin-twin transfusion syndrome?

  1. Fetoscopic laser photocoagulation Correct answer.
  2. Maternal beta-blocker therapy
  3. Serial amnioreduction
  4. Selective fetal reduction

Explanation

Fetoscopic laser photocoagulation ablates placental vascular anastomoses and addresses the underlying pathophysiology of twin-twin transfusion syndrome. It improves survival and reduces neurologic morbidity compared with amnioreduction. Amnioreduction is a temporizing measure.

Question 15Fetal and prenatal surgical conditions

Which prenatal ultrasound finding is most characteristic of posterior urethral valves?

  1. Dilated bladder with keyhole sign Correct answer.
  2. Absent bladder
  3. Normal bladder with unilateral hydronephrosis
  4. Bilateral multicystic dysplastic kidneys

Explanation

Posterior urethral valves obstruct the urethra, producing a distended bladder and a dilated posterior urethra that creates the keyhole sign. Oligohydramnios and bilateral hydronephrosis often accompany it. The keyhole appearance is a classic prenatal clue.

Question 16Fetal and prenatal surgical conditions

Which fetus with lower urinary tract obstruction is the best candidate for vesicoamniotic shunting?

  1. Oligohydramnios with anuria and abnormal fetal urine electrolytes
  2. Oligohydramnios and normal fetal urine studies Correct answer.
  3. Polyhydramnios with a normal bladder
  4. Bilateral renal dysplasia with absent amniotic fluid

Explanation

Vesicoamniotic shunting is offered when there is oligohydramnios from bladder outlet obstruction but fetal urine studies suggest preserved renal function. Normal urine electrolytes and low beta-2 microglobulin favor a good candidacy. Fetuses with evidence of irreversible dysplasia are not good candidates.

Question 17Fetal and prenatal surgical conditions

The EXIT (ex utero intrapartum treatment) procedure is most clearly indicated for which fetal condition?

  1. Cervical teratoma with airway compression Correct answer.
  2. Isolated left congenital diaphragmatic hernia
  3. Small sacrococcygeal teratoma without hydrops
  4. Type I CPAM without hydrops

Explanation

EXIT maintains placental circulation while the fetal airway is secured, which is most valuable when a neck mass compresses or obstructs the airway. Large cervical teratomas and other causes of congenital high airway obstruction are classic indications. The procedure allows controlled intubation or tracheostomy before cord clamping.

Question 18Fetal and prenatal surgical conditions

A fetus with meconium ileus on prenatal ultrasound should raise suspicion for which condition?

  1. Cystic fibrosis Correct answer.
  2. Biliary atresia
  3. Duodenal web
  4. Hirschsprung disease

Explanation

Meconium ileus is strongly associated with cystic fibrosis because abnormal chloride transport produces thick, inspissated meconium. Prenatal findings include echogenic bowel and dilated loops. Newborns may present with failure to pass meconium and abdominal distension.

Question 19Fetal and prenatal surgical conditions

A fetal ovarian cyst is noted at 32 weeks and shows a fluid-debris level with a twisted pedicle. What is the most appropriate management?

  1. Maternal hormone therapy
  2. Prenatal aspiration of the cyst
  3. Postnatal surgical resection Correct answer.
  4. Observation until after delivery

Explanation

A fluid-debris level and twisted pedicle suggest torsion or hemorrhage, which are complications of a fetal ovarian cyst. These complicated cysts are managed with postnatal surgical resection. Simple, uncomplicated cysts may be observed.

Question 20Fetal and prenatal surgical conditions

A fetus with a sacrococcygeal teratoma develops high-output cardiac failure and hydrops at 24 weeks. Which management is most appropriate?

  1. Maternal digoxin alone
  2. Open fetal surgical resection Correct answer.
  3. Expectant management until term
  4. Serial amnioinfusion

Explanation

Hydrops from a sacrococcygeal teratoma reflects high-output failure caused by arteriovenous shunting within the tumor. Open fetal resection or other fetal intervention may be offered to reverse hydrops. Without intervention, mortality is very high.

Question 21Fetal and prenatal surgical conditions

In fetal congenital diaphragmatic hernia, which measure best predicts the severity of pulmonary hypoplasia?

  1. Cord blood gas at delivery
  2. Amniotic fluid index
  3. Fetal stomach position
  4. Observed-to-expected LHR Correct answer.

Explanation

The observed-to-expected lung-to-head ratio (o/e LHR) quantifies the contralateral lung area relative to head circumference and gestational age. Lower o/e LHR values correlate with more severe pulmonary hypoplasia and worse outcomes. It is used to stratify severity and consider fetal intervention.

Question 22Fetal and prenatal surgical conditions

In the MOMS trial, which outcome was more frequent in the prenatal-repair group?

  1. Ability to walk independently
  2. Delivery before 37 weeks Correct answer.
  3. Occurrence of Chiari II malformation
  4. Need for ventriculoperitoneal shunt at 12 months

Explanation

Prenatal repair increased the rate of preterm delivery before 37 weeks, along with uterine dehiscence and need for cesarean delivery. These maternal and obstetric risks are a major trade-off. The trial also showed reduced shunt placement and improved motor outcomes.

Question 23Fetal and prenatal surgical conditions

A fetus shows bilaterally enlarged echogenic lungs, a flattened or inverted diaphragm, and hydrops. Which diagnosis is most likely?

  1. Left congenital diaphragmatic hernia
  2. Bilateral CPAM with hydrops
  3. Bilateral bronchopulmonary sequestration
  4. High airway obstruction syndrome Correct answer.

Explanation

Congenital high airway obstruction syndrome (CHAOS) causes retained lung fluid, producing symmetrically enlarged, echogenic lungs and a flattened or inverted diaphragm. Hydrops may develop from impaired venous return. The findings are bilateral and symmetric, which helps distinguish CHAOS from unilateral lung lesions.

Question 24Fetal and prenatal surgical conditions

Which fetal urine marker best predicts poor renal prognosis in lower urinary tract obstruction?

  1. Beta-2 microglobulin > 6 mg/L Correct answer.
  2. Urine calcium > 8 mg/dL
  3. Urine sodium > 100 mEq/L
  4. Urine osmolality > 200 mOsm/kg

Explanation

Elevated fetal urine beta-2 microglobulin reflects impaired glomerular filtration and tubular function and predicts poor postnatal renal outcome. It is used with other urine indices such as sodium, osmolality, and calcium when selecting candidates for vesicoamniotic shunting. Persistently abnormal values suggest irreversible renal damage.

Question 25Fetal and prenatal surgical conditions

Which maternal complication is most associated with open fetal surgery?

  1. Gestational diabetes
  2. Preeclampsia
  3. Uterine dehiscence Correct answer.
  4. Placenta previa

Explanation

Open fetal surgery requires a hysterotomy, which creates a uterine scar and risks dehiscence in the current or a subsequent pregnancy. Preterm labor and preterm premature rupture of membranes are also common. These maternal risks are central to counseling and to the preference for minimally invasive approaches when feasible.

Question 26Neonatal surgery

A preterm infant with feeding intolerance and bloody stools has an abdominal radiograph that shows gas within the bowel wall. What is this finding called?

  1. Pneumoperitoneum
  2. Pneumatosis Correct answer.
  3. Ground-glass opacity
  4. Double bubble

Explanation

Intramural gas, or pneumatosis intestinalis, is a radiographic hallmark of necrotizing enterocolitis. It reflects gas produced by bacteria within the bowel wall after mucosal injury. Pneumoperitoneum indicates free intraperitoneal air, which is a later complication.

Question 27Neonatal surgery

A 2-day-old newborn has bilious vomiting and an abdominal radiograph showing a dilated stomach and proximal duodenum with no distal bowel gas. Which diagnosis is most likely?

  1. Malrotation with volvulus
  2. Hirschsprung disease
  3. Hypertrophic pyloric stenosis
  4. Duodenal atresia Correct answer.

Explanation

The double-bubble sign with absent distal gas is classic for complete duodenal obstruction, most often duodenal atresia. Duodenal atresia is associated with Down syndrome and often presents on the first day of life. Malrotation can also cause bilious vomiting but usually shows some distal gas unless volvulus is complete.

Question 28Neonatal surgery

Which anatomic pattern is the most common form of esophageal atresia?

  1. H-type tracheoesophageal fistula without atresia
  2. Proximal tracheoesophageal fistula with distal atresia
  3. Isolated esophageal atresia without fistula
  4. Proximal atresia with distal fistula Correct answer.

Explanation

More than 80% of esophageal atresia cases consist of a blind proximal esophageal pouch and a distal esophagus that communicates with the trachea. This pattern explains the early feeding intolerance, choking, and respiratory symptoms. Isolated atresia and H-type fistulas are less common.

Question 29Neonatal surgery

Which abdominal wall defect in a newborn is most strongly associated with chromosomal abnormalities?

  1. Patent urachus
  2. Omphalocele Correct answer.
  3. Gastroschisis
  4. Umbilical hernia

Explanation

Omphalocele is associated with chromosomal anomalies such as trisomy 13, 18, and 21, and with Beckwith-Wiedemann syndrome. Gastroschisis is generally isolated and not strongly linked to karyotypic abnormalities. This difference influences prenatal counseling and postnatal evaluation.

Question 30Neonatal surgery

A 5-week-old infant with projectile nonbilious vomiting has a hypochloremic, hypokalemic metabolic alkalosis. Which diagnosis best explains these findings?

  1. Diaphragmatic hernia
  2. Malrotation with volvulus
  3. Duodenal atresia
  4. Hypertrophic pyloric stenosis Correct answer.

Explanation

Repeated vomiting of gastric contents in pyloric stenosis loses hydrogen and chloride, producing a hypochloremic metabolic alkalosis. Potassium is also depleted because of renal compensation and poor intake. Bilious vomiting and a double bubble point instead to duodenal obstruction.

Question 31Neonatal surgery

Which test is the most reliable for confirming Hirschsprung disease in a neonate?

  1. Anorectal manometry
  2. Abdominal ultrasound
  3. Rectal biopsy Correct answer.
  4. Contrast enema

Explanation

Rectal suction biopsy showing absence of ganglion cells and hypertrophic nerve trunks is the diagnostic standard. Contrast enema can suggest a transition zone but may be normal in the neonatal period. Manometry is useful in older children and is difficult in newborns.

Question 32Neonatal surgery

A 3-week-old former preterm infant has a reducible right inguinal hernia. What is the most appropriate management?

  1. Application of a truss
  2. Observation until 1 year of age
  3. Repair within days to weeks Correct answer.
  4. Immediate emergency laparotomy

Explanation

Inguinal hernias in infants carry a high risk of incarceration because the processus vaginalis is narrow. Repair is therefore scheduled soon after diagnosis, often before discharge in preterm infants. A truss is not used in infants because it can injure the skin and gonads.

Question 33Neonatal surgery

Meconium ileus in a newborn is most commonly associated with which condition?

  1. Duodenal atresia
  2. Malrotation
  3. Hirschsprung disease
  4. Cystic fibrosis Correct answer.

Explanation

Meconium ileus results from abnormally thick, sticky meconium and is strongly associated with cystic fibrosis. The diagnosis is suggested by distal small bowel obstruction and a soap-bubble appearance on plain film. Hirschsprung disease and atresia cause different patterns of neonatal obstruction.

Question 34Neonatal surgery

A newborn with prenatally diagnosed congenital diaphragmatic hernia is in respiratory distress. Which initial maneuver is most appropriate?

  1. Intubate gently and decompress stomach Correct answer.
  2. Bag-mask ventilation with high pressures
  3. Immediate surgical repair before stabilization
  4. Placement of a chest tube on the affected side

Explanation

Infants with CDH have pulmonary hypoplasia, and positive-pressure bag-mask ventilation can distend the stomach and worsen lung compression. Early intubation allows controlled ventilation, and nasogastric decompression reduces bowel distention. Surgery is delayed until physiologic stabilization.

Question 35Neonatal surgery

A 5-day-old presents with bilious vomiting. Upper gastrointestinal contrast study shows the duodenojejunal junction located to the right of the spine. What is the next best step?

  1. NG feeding
  2. Contrast enema
  3. Observe and feed
  4. Urgent Ladd procedure Correct answer.

Explanation

Malposition of the duodenojejunal junction indicates malrotation, and bilious vomiting raises concern for midgut volvulus. The infant should undergo urgent Ladd procedure after volume resuscitation to prevent bowel necrosis. Delay increases the risk of short bowel syndrome.

Question 36Neonatal surgery

In a preterm infant with necrotizing enterocolitis, which finding is the strongest indication for surgical intervention?

  1. Thrombocytopenia
  2. Pneumatosis intestinalis
  3. Pneumoperitoneum Correct answer.
  4. Grossly bloody stools

Explanation

Pneumoperitoneum indicates full-thickness bowel perforation and is an absolute indication for laparotomy or peritoneal drainage. Pneumatosis and bloody stools are common medical-stage findings that do not alone mandate surgery. Thrombocytopenia can accompany NEC but is nonspecific.

Question 37Neonatal surgery

In fetal congenital diaphragmatic hernia, which prenatal finding is associated with a worse prognosis?

  1. Polyhydramnios
  2. Liver up in the chest Correct answer.
  3. Stomach in abdomen
  4. Left-sided defect

Explanation

Liver herniation into the chest is a marker of larger defect size and more severe pulmonary hypoplasia. It correlates with lower survival and greater need for ECMO. The side of the defect and polyhydramnios are less predictive.

Question 38Neonatal surgery

A newborn with suspected esophageal atresia has excessive oral secretions and choking with the first feed. What is the most appropriate initial management?

  1. Perform immediate primary esophageal repair
  2. Initiate oral feeds with thickened formula
  3. Place a nasogastric tube into the stomach and feed
  4. Keep NPO and suction the proximal pouch Correct answer.

Explanation

The immediate priorities are preventing aspiration and stabilizing the infant. A Replogle tube or intermittent suction decompresses the blind proximal pouch, and the infant remains NPO. Repair is planned after evaluation for associated anomalies and respiratory stabilization.

Question 39Neonatal surgery

A neonate with bilious vomiting is found at laparotomy to have jejunoileal atresia. Which operative approach is standard?

  1. Resection with primary anastomosis Correct answer.
  2. Ladd procedure with appendectomy
  3. Duodenoduodenostomy for duodenal atresia
  4. Gastrostomy placement without resection

Explanation

Jejunoileal atresia is managed by resecting the dilated, dysmotile proximal segment and the atretic segment, followed by primary anastomosis. This restores continuity and avoids leaving a poorly functioning segment. Duodenoduodenostomy is used for duodenal atresia, not jejunoileal atresia.

Question 40Neonatal surgery

A newborn has a large sacrococcygeal teratoma. What is the cornerstone of definitive treatment?

  1. Complete resection with coccygectomy Correct answer.
  2. Chemotherapy alone
  3. Serial ultrasound surveillance without surgery
  4. Needle biopsy with observation and repeat imaging

Explanation

Complete surgical resection with removal of the coccyx is the standard because residual coccyx increases local recurrence. Preoperative evaluation focuses on tumor vascularity and risk of hemorrhage. Chemotherapy is reserved for malignant or recurrent disease.

Question 41Neonatal surgery

A newborn with a small omphalocele is stable and has no respiratory distress. Which initial management is most appropriate?

  1. Immediate primary closure in the delivery room
  2. Silver sulfadiazine and pressure dressing
  3. Protect the sac and evaluate for anomalies Correct answer.
  4. Rupture the sac to inspect the bowel

Explanation

An intact omphalocele sac should be protected from desiccation and infection while the infant is evaluated for chromosomal and cardiac anomalies. Small defects may be closed primarily after stabilization, but immediate delivery-room closure is not routine. Rupturing the sac exposes the bowel and increases infection risk.

Question 42Neonatal surgery

A 4-week-old infant has projectile nonbilious vomiting and a palpable olive-shaped mass in the epigastrium. Which initial diagnostic test is most appropriate?

  1. Abdominal ultrasound Correct answer.
  2. Serum electrolytes
  3. Upper gastrointestinal contrast series
  4. Abdominal plain radiograph

Explanation

Ultrasound is the preferred initial test for hypertrophic pyloric stenosis because it directly measures pyloric muscle thickness and channel length. It is noninvasive and highly sensitive. Electrolytes assess severity but do not confirm the diagnosis.

Question 43Neonatal surgery

A contrast enema in a neonate with Hirschsprung disease classically demonstrates which finding?

  1. A fixed narrowed segment with proximal dilation
  2. A double bubble in the duodenum
  3. A transition zone with proximal dilation Correct answer.
  4. A microcolon with meconium pellets

Explanation

The aganglionic distal segment remains contracted, while the normal proximal colon dilates, creating a transition zone. The rectum is typically narrow. A microcolon with meconium pellets suggests meconium ileus instead.

Question 44Neonatal surgery

A 6-week-old infant has persistent jaundice, acholic stools, and direct hyperbilirubinemia. Which operation is the initial definitive treatment for biliary atresia?

  1. Cholecystectomy alone
  2. Liver transplantation as the first operation
  3. Exploratory laparotomy without contrast studies
  4. Kasai portoenterostomy Correct answer.

Explanation

Kasai portoenterostomy restores bile flow by anastomosing a Roux-en-Y loop to the transected porta hepatis. It is most successful when performed before 60 days of life. Liver transplantation is reserved for failure of the Kasai procedure or advanced cirrhosis.

Question 45Neonatal surgery

A newborn with gastroschisis has eviscerated bowel at delivery. Which initial measure is most appropriate?

  1. Begin oral feeds to stimulate bowel function
  2. Attempt forceful reduction of the bowel
  3. Immediate primary closure in delivery room
  4. Cover bowel with warm saline gauze and IV fluids Correct answer.

Explanation

Eviscerated bowel loses heat and fluid rapidly, so the initial priority is covering it with warm, moist sterile gauze and providing fluid resuscitation. The defect is then assessed for staged or primary closure. Immediate closure in the delivery room is not routine.

Question 46Neonatal surgery

A newborn boy has an imperforate anus with a visible perineal fistula. Which statement about management is correct?

  1. The condition is always associated with Down syndrome
  2. A permanent colostomy is always required
  3. A low lesion may be treated with a perineal anoplasty Correct answer.
  4. No further evaluation of the urinary tract is needed

Explanation

Low anorectal malformations with a perineal fistula can often be repaired via a limited perineal anoplasty. High lesions usually require a divided colostomy and later pull-through. All infants need evaluation for associated anomalies, including renal and spinal defects.

Question 47Neonatal surgery

Which ventilation strategy is preferred in a newborn with congenital diaphragmatic hernia before surgical repair?

  1. High peak inspiratory pressures to recruit collapsed lung
  2. Immediate high-frequency ventilation for every infant
  3. Gentle ventilation with permissive hypercapnia Correct answer.
  4. Hyperventilation targeting a PaCO2 below 25 mm Hg

Explanation

Gentle ventilation minimizes barotrauma to hypoplastic lungs and accepts permissive hypercapnia. High peak pressures increase the risk of pneumothorax and worsen outcomes. High-frequency ventilation is used selectively for infants who fail conventional ventilation.

Question 48Neonatal surgery

Which feature best distinguishes spontaneous intestinal perforation from necrotizing enterocolitis in a preterm infant?

  1. Grossly bloody stools and anemia
  2. Pneumatosis intestinalis on film
  3. Perforation without pneumatosis Correct answer.
  4. Diffuse abdominal tenderness

Explanation

Spontaneous intestinal perforation typically presents as an isolated ileal perforation without the pneumatosis or diffuse bowel inflammation of NEC. It often occurs in extremely low birth weight infants during the first week. Pneumatosis strongly favors NEC.

Question 49Neonatal surgery

After resection of a sacrococcygeal teratoma in a newborn, which factor most increases the risk of local recurrence?

  1. Residual coccyx Correct answer.
  2. Large tumor size
  3. Female sex
  4. Cystic tumor consistency

Explanation

The coccyx is the site of origin, and leaving it behind is the strongest risk factor for local recurrence. Complete resection includes the coccyx. Tumor size and cystic components affect surgical difficulty but are not the main recurrence determinant.

Question 50Neonatal surgery

During a Ladd procedure for malrotation, which sequence of steps is correct?

  1. Detorse, perform duodenoduodenostomy, place cecum right
  2. Detorse, divide bands, widen mesentery, place cecum left Correct answer.
  3. Divide bands, detorse, place cecum right, close mesentery
  4. Resect all bowel, widen mesentery, place cecum left upper

Explanation

The Ladd procedure begins with counterclockwise detorsion of the volvulus to restore perfusion. Ladd bands are divided, the mesentery is widened, and the cecum is positioned in the left lower quadrant to reduce recurrent volvulus. Routine appendectomy is often performed.