Female Pediatric Surgery

Pediatric Surgery Omphalocele 1:5000 abdominal wall defect (>2.5 cm) with extrusion of Sac covered viscera Prenatally Diagnosed with u/s; mostly Central amnion - wharton's jelly peritoneum Can be associated with other abnormalities like GIT, CVS, CNS, musculoskeletal -Can be part of pentology of Centrell → Diaphragmatic hernia Hydrocele has diurnal Variation in size Communicated hydrocele: Process vaginalis fails to close with small opening for fluid to Congenital move freely between Peritoneal Cavity through patent processus (if it progress and intestine fall sort hernia) non communicating hydrocele: fluid trapped in Tunica Vaginalis- MC -If Causes painless scrotal mass, ↑ in size when standing or valsalva (in communicating) other classifications: -Infantile hydrocele → saushing to the neck of scrotum. Confined above cetacuble -Encysted hydrocele swelling around Cord -treatment: mostly resolve spontaneously in 1 year Surgical repair if presistance > 2y or pain or Communicating or infection High ligation of patent process vaginalis Hydrocele Hernia bead like fuen vessel Irreducable Reducable Can get above swelling Can't feel borders -ve trans illumination has bowel sounds Cannot seperate testis from -ve trans illumination test swelling in non communicating -Content is more down No bowel sound sea saw sign in Communicating -Silk glove Sign Rubbing silk on silk (on spermatic cord) Hirschsprung's Disease (Congenital aganglionic bowel) Congenital absence of ganglion cells in Auerbach's (myenteric) and Meissner's (submucosal) plexus that result in intestinal obstruction. Due to arrest of migration of neural crest cells (cephalic-caudal migration) Most common cause of lower intestinal obstruction in neonates Can be Rectal, Rectosigmoid, entire colon More in male MC Failure to pass meconium in first 48h Intestinal obstruction -> abdominal Distention, Constipation, bilious vomiting Sepsis & infection Enterocolitis (most common cause of mortality) Complications: Hypertrophic pyloric stenosis, Hirschsprung's associated enterocolitis Diagnosis: AXR (obstruction above level of aganglionic cells), Rectal biopsy (Definitive Diagnosis), Barium enema (must include submucosa to know the level (transitional zone)) Treatment: Surgical resection of aganglionic segment + anastomosis of remaining colon. Pull-through procedure (transanal/ lap assisted) Strength: Imperforated anus Imperforated anus Lack of anal opening of proper location or size Due to failure of urinary & hind Gut system to separate Associated anomalies: VACTERL Treatment: High: colostomy Low: perineal anoplasty or dilation of fistula The higher the lesion the poorer prognosis Image Transcription Meckel's Diverticulum most frequent Congenital GI abnormality. 2% more in male < 2 years old Presence of omphalomesenteric (Vitelline) Duct (should disappear by 7th week of gestation) It arises from antemesenteric border of ileum (Most Common Remnant of vitelline duct that Connects yolk sac with primitive Gut) Contains heterotopic epithelium (gastric, colonic, pancreatic) A true diverticulum in that it contains all layers of bowel wall Can Cause Intermittent painless rectal bleeding Intestinal obstruction Diverticulitis Diagnosed by Meckel's scan (Scintigraphy) Treatment → Diverticular resection Intestinal Atresia It is failure of duodenum to recanalize during early Fetal life - mostly at ampulla of Vater If Jejunal/ileal acquired as result of vascular disruption (Eschemic necrosis & resorption of necrotic tissue) - creation of blind distal and proximal end associated with Down syndrome, esophageal atresia, imperforated anus. Cardiac and renal anomalies. Small for GA. CF, Polyhydramnios Causes Intrinsic Down syndrome Extrinsic Vascular obstruction Diagnosis AXR Double Bubble sign (air in stomach & duodenum) Distended bowel proximal to obstruction other inv: CBC, ABC, UBE Treatment fluid resuscitation NGT ABCD barium enema Surgery: Duodenal atresia: Side to side anastomosis (to avoid injury to bile & pancreatic duct) Colonic/Jejunal/ileal: Duodenostomy (DJ) Primary anastomosis Intussusception Obstruction Caused by bowel telescoping into the lumen of adjacent distal bowel MC in ileocecal Valve (payer's patches) *MC Cause of bowel obstruction in < 2y MC Cause due to enlarged payer's patch point (2m-24m) MC Cause due to Pathologic lead point Polyp mecki's diverticulum.CF, lymphoma IBD, HSP. if it's look for other Causes *mostly idiopathic. *Proceeded by Viral infection *Causes colikey abdominal pain - bilious Vomiting jelly stool (Currant) Bloody stool Dance's sign: RLQ mass in Bowel obstruction signs. aledominal film RLQ amply - Sausage shape mass in RUQ Falpradion. -Diagnosis: albdominal xray se bowel destruction signs) abdomenal Sandwich sign euls (targel sign/ donut san maneyment: Gosless RLQ (iliccecal) QPsudokidney sign) NG tumumestatre thesegule & Orgnatic Correct dehydration non operative, hydrostatic ar Reduction Vid air Contrast Succed-wpen reaching dialated loof Operative non oferative failed, enema (air or with peritonitis Resection of involved Colon Complianten Conticindications of hytrustalic reductions secondary intesoption - <3 or fluid) Arap sigh or perferatio Daanash thos Q Volvus (mid Cut) and malrotation ER failure of Gut to normally rotate around SMA (midad chutes 270° counter check wise und SMA) te rule with mal rotation cojum ends up in RUG. Qvery sick usually 1y of age. Present with sudden oncet abdominal Dotention billous vomiting (Biliou Vomiting ini infent Proven other wise) lethargy, skin mottling,, hyfordenia 15 malretation untill -Diagnosis: Scaphold becau affected pod Sever dehydration Bloody sted (late) abdomin Necrotizing Enterocolitis (NEC) Serious intestinal injury and necrosis following a combination of vascular, mucosal and toxic insult to relatively immature GI tract 1st week of life - most common GI ER in prematurity - leading to sepsis and shock Predisposing factors: Prematurity Artificial feeding (hyperosmolar) Stress (shock, hypoxia, RDS, apnea episodes, sepsis, PDA, polycythemia, endomethacin) Many, many other Pathophysiology: Splanchnic vasoconstriction with ↓ perfusion -> mucosal injury -> bacterial invasion Symptoms: Lethargy, feeding intolerance Fever or hypothermia Hypotension, apnea spells Skin necrosis (furunclection + late sign) GI: Abdominal distention, tenderness, vomiting, bloody diarrhea, hematochezia, redness of umbilical wall Diagnosis: CBC, ABG (leukocytosis & thrombocytopenia) - Blood culture (full septic screen) Coagulation profile KUB (LA) Pneumatosis intestinalis (gas within bowel wall) - pathognomonic intramural portal vein air (advanced disease) fixed, dilated intestinal loop - thickened wall Treatment: Primarily medical NPO IV fluid O2 or ventilator NGT Abx Scintigram, amylase Free air on abdomen revealing perforation (intraperitoneal air) Surgery indications: Free air abdomen revealing perforation Progressive peritoneal signs with peritonitis De-escalation with medical treatment Portal vein gas Fixed, dilated intestinal loop - thickened wall Surgical laparotomy Resection of necrotic bowel Drainage If surgical laparotomy: Resect necrotic bowel Drain Stoma Hernia is imp (see chapter) Radical Surgery Mortality 3-4% Morbidity: Postoperative pain Wound infection Hematoma Ileus Chronic pain Laparoscopic Surgery Mostly outpatient Earlier recovery Less pain Better cosmetic results Decreased hospital stay May require conversion to open surgery Hernia types Inguinal Femoral Umbilical Incisional Hiatus hernia Diaphragmatic hernia Risk factors Male sex Increasing age Obesity Smoking Chronic cough Constipation Pregnancy Ascites Family history Clinical presentation Painless lump May be reducible or irreducible May be painful if strangulated May cause bowel obstruction Diagnosis Clinical examination Ultrasound CT scan Treatment Surgical repair Laparoscopic or open Mesh repair 3m, hx exit & small wt, presented with enlarged scrotum and unrectibility Strangulated hernia → Clinical Diagnosis Resuscitation → Reduction under sedation → herniotomy InguinalInguinoscrotal hypertrophicPyloric stenosis GERD Duodenalatresia Volvulus Intussusception NEC (+ bleeding) meconiumplug meconiumilieusMeckel'sDiverticulum(Can Causebleeding) Hirschsprung disease Im per for at edanus fluid manegment: total blood volume of newborn 80 ml/kg first 10 kg → 4 cc/kg second 10 kg → 2 cc/kg every additional Kg → 1 cc/kg. minimal urin out put 1-2 mL/kg/h +D5NS (0.45% Nacl) 1st manegment in most cases: -ABC (IV fluid ressucitation) (20 mL/kg every 4 h) -GI decompression-NGT (apper) 40%, plasma transfusion, ventilation if needed repeat AXR 12-24h