Paediatrics for FRCS (Gen Surg)

Pyloric stenosis is a medical emergency and never a surgical one. Loss of gastric acid produces a hypochloraemic, hypokalaemic metabolic alkalosis; an alkalotic infant compensates by hypoventilating and is at risk of apnoea after anaesthesia. The deficit is replaced with sodium chloride, glucose and added potassium over 24–48 hours, and pyloromyotomy follows only when bicarbonate (below about 28 mmol/L) and chloride (above about 100 mmol/L) are corrected. Operating in two hours ignores this. Hypotonic 0.18% saline supplies too little chloride and risks hyponatraemia, and potassium alone is not the end-point. Acetazolamide worsens potassium loss. Atropine is not standard UK treatment. Reference: Bailey & Love's Short Practice of Surgery 28e; Core Topics in General and Emergency Surgery (Companion series) 6e.

A dorsal hooded foreskin with a ventrally placed meatus is hypospadias, often with chordee. Repair is carried out by a paediatric urologist, usually between 6 and 18 months, and the preputial skin is the tissue used to reconstruct the urethra or to cover the repair, so circumcision by any technique is contraindicated until the surgeon who will do the repair has decided the foreskin is not needed. The family should be referred and told that a circumcised appearance can usually be achieved at the repair. Distal position of the meatus does not change this. Isolated distal hypospadias carries no increased risk of urinary infection or upper tract anomaly, so neither prophylactic circumcision nor routine renal ultrasound is indicated. Reference: Bailey & Love's Short Practice of Surgery 28e; Royal College of Surgeons of England, Commissioning guide: foreskin conditions (2013).