Surgery (Lecture Summaries)

Surgery Newborn Saliva bubbles à oesophageal atresia à NGT & CXR / AXR Bilious Vomiting à Intestinal obstruction à AXR Distended abdo + poor feeding à obstruction à AXR No Meconium after 48 hours à ? hirschsprungs à rectal biopsy Common Surgical Emergencies Malrotation - Green bilious vomiting – 6 hrs to act Obstruction – no Meconium in 24hrs = hirschsprungs Intussecption – All PR bleeds 6month – 2 yrs unless proven otherwise 60% occur 1m-1y (peak 4-9m, boys 50% more than girls) 90% are ileocolic or ileocaecal Constriction of mesentry à venous congestion + oedema à gangrene. Can à lumen obstruction Sx – rapid onset, draws up knees & screams, pale, rapid resolution. Increasing frequency of attacks, vomiting, mucous & blood PR (redcurrant jelly). Sometimes sausage shaped mass on examination Dx – US, air/barium enema will diagnose + treat 60-70%. Otherwise requires theatre Appendicitis In childhood is usually retrocaecal (70%) Psoas irritation à flexed hip with limp (appendix shuffle) Can also present with pyrexia & anorexia OE – furred tongue, foetid odour. RIF tenderness Rx – Abx fb surgery Inguinoscrotal Swelling – pain red swollen = testicular torsion Infantile hypertrophic pyloric stenosis 4x more common in boys. Usually present at 3-9 wks (upto 3m) Sx – projectile vomiting, visible peristalsis, palpable pyloric tumour “olive”. Hungry straight after vomiting. NEVER bilious, wt loss, oliguria, dehydration, jaundice Dx – metabolic alkalosis, hypocholoraemia, hyponatraemia, hypokalemia Rx – medical rehydration then surgical pyloromyotomy Empty Scrotum 2-4% = undescended at birth 1-2% remain undescended at 1yr Spontaneous descent will not occur after 1 year Testis should be 1o below body temp Maldescent - Should be pulled into scrotum by gubernaculums (1st trimester due to Mullerian inhibiting factor, 3rd trimester due to testosterone). 4% incidence ½ will descend by 6 months ¼ by 12 months à Remaining 1% require investigation after 12 months. Commonly assoc with indirect inguinal hernia Ectopic - Incorrect attachment of gubernaculum - 3 possible sites – perineum, femoral triangle, root of penis Atrophy - Usually due to torsion à necrosis, remnants can be found Agenesis - Never developed, no trace can be found Retractile = NORMAL - palpable, can be pulled into scrotum WITHOUT TENSION If non palpable à EUA, laparoscopy, orchidoplexy Risks to leaving intra-abdominally – torsion, malignancy (x10), easier to palpate for malignancy, poor fertility, cosmetic, trauma (if in perineum) Acute Scrotum 90% = torsion of cyst of Morgiani = blue spot on trans-illumination 5% = epididymo-orchitis / Orchitis / Epididymitis / Dysuria, frequency and discharge. Due to mumps or other infection. Increased blood flow on Doppler 3% = Torsion of testis (1/4000) - high lying, decreased blood flow on Doppler (blood flow ok) Discoloured skin, acute pain, must act within 6 hrs 2% = Acute Idiopathic Scrotal Oedema – idiopathic, resolves spontaneously over 2-3 days Hydrocele / Hernia Due to patent processus vaginalis (usually closes in 1st yr), otherwise required ligation & drainage Hydrocele – patent processus vaginalis allows fluid to enter scrotum. Blue hue to swelling, trans-illuminates (so can bowel). NOT reducible as narrow neck. Most resolve spontaneously by age 3 (80%). Remainder require ligation & drainage. Hernia – requires herniotomy = excision of sac NB: younger the child, faster it should be fixed Inguinal Hernia M:F = 9:1 70% Right sided, 25% left, 5% bilateral 3-% present in 1st year of life, if present in 1st year, 75% risk of incarceration Incarcerated hernia – check for bowel sounds etc. 10x more common in boys. 1/100. 30% incidence in prem babies Prepuce Physiological Phimosis - Usually adhered to glans until 4+yrs, Phimosis – scarring & stenosis, due to recurrent balanitis à ballooning & poor stream, Rx: circumcision Paraphimosis – only possible if moderate phimosis, Rx: reduction under anaesthesia Hypospadia 1/300, +FH Sx - urethral opening on ventral aspect (65% anterior, 15% middle, 20% posterior), Assoc with hooded foreskin, chordee, Rx: surgery to repair + circumcise to reduce UTI risk NB: if +1 undesc testis = 15% risk intersex, if bilat undesc = 30% risk intersex Circumcision ONLY for pathological phimosis (unusual at < 5 yrs) Occasionally for recurrent balantitis Complications include bleeding, infection, delayed healing, pain & damage to the glans Non retractile foreskin NORMAL until 3 years (90% retractile at 3 yrs) Separation is spontaneous Neck lumps Midline Dental root abscess à submental lymph nodes, can à fistula to skin with discharge Dermoid cyst – firm, don’t get infected Thyroglossal cyst – along tract from foramen caecum to isthmus. Move with tongue protrusion. Lined with squamous epithelium but can contain mucous secreting / respiratory epithelium. Often become infected à painful abscess. Rx is excision including middle portion of hyoid bone and complete tract Lateral Large matted lymph nodes – consider TB Bronchial Cyst – corner of jaw / upper end of auditory canal or lower end of SCM. Painless. Can discharge Cystic Hygroma – disorganised lymphatic system, variable growth and recession. Soft fluctuant lobulated mass in neck. Rx – excise