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Test Taking Tips

  • Remember typical ages at presentation for various congenital disorders that may manifest in a similar fashion (e.g., duodenal atresia vs. malrotation). The age of a neonate can clue you in to the probable diagnosis.

  • Many pediatric surgical disorders can be observed for possible resolution. Do not rush toward operative intervention. Examples include NEC, umbilical hernias, hernias, and MEN syndromes, where surgery is delayed until a certain age.

  • Familiarize yourself with imaging characteristics of frequently encountered conditions, as they are often included in the question stem, such as duodenal atresia, Hirschsprung, NEC (will typically show pneumatosis intestinalis or free intraperitoneal air), gastroschisis vs. omphalocele, intussusception.

Is bilious vomiting a surgical emergency in the newborn and why?

  • Yes! Must rule out malrotation with midgut volvulus in a patient with proximal obstruction because the gut can be strangulated (time = bowel).

  • Differential diagnosis (memorize this list—the ABSITE will point you toward one of these!): annular pancreas, malrotation, jejunoileal atresia, meconium ileus, meconium plug syndrome, duodenal web/atresia, Hirschsprung, hypoplastic left colon. Always remember one anomaly begets additional associated anomalies.

Meconium ileus is associated with what anomaly?

  • Cystic fibrosis

Duodenal atresia and malrotation are associated with what anomaly?

  • Down syndrome

What other abnormalities are associated with malrotation?

  • Diaphragmatic hernia, jejunoileal atresia, abdominal wall defects

Which abdominal wall defects are associated with malrotation?

  • Both omphalocele and gastroschisis

What is the first diagnostic study of choice to rule in malrotation with midgut volvulus?

  • Upper gastrointestinal contrast radiography (UGI) – Duodenal-jejunal junction should be to the left of the vertebral body on anteroposterior (AP) film to be considered normal

Surgical procedure for malrotation:

  • Ladd procedure: Counterclockwise rotation to detorse involved bowel: (1) divide peritoneal bands crossing the duodenum, (2) mobilization and position colon to the left, (3) mobilization and straightening of the duodenum so that it points inferiorly and position small bowel to the right, (4) broaden the base of the mesentery

  • Appendectomy (cecum is now on the left side of the abdomen, perhaps delaying the diagnosis of acute appendicitis)


Ladd procedure for malrotation. (A) Lysis of cecal and duodenal bands. (B) Broadening of the mesentery. (C) Appendectomy. (Reproduced with permission from Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz’s Principles of Surgery, 11th ed. New York, NY: McGraw Hill; 2019.)


Abdominal radiograph showing the “double-bubble” sign in a newborn infant with duodenal atresia. The 2 bubbles are numbered. (Reproduced with permission from Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz’s Principles of Surgery, 11th ed. New York, NY: ...

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