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PEDIATRIC SURGERY

THE AMBULATORY SETTING


What is it?
• 2CO5 - Clinic code
• Mondays and Fridays 1:00 P.M.
• General pediatric surgery patients
(excluding primarily orthopedic,
cardiac, neurosurgical,
ophthalmologic,and plastic )
MANPOWER
• PEDIATRIC SURGERY FELLOWS
– Dr. Zsazsa Tuason – Senior Fellow
– Dr. Mabel Moreno – Junior Fellow
• GENERAL SURGERY RESIDENTS
• NURSE
• CONSULTANT ON DUTY
WHO ARE THE
PATIENTS?
• POSTOPERATIVE PATIENTS
Patients discharged from the
hospital after undergoing surgery
WHO ARE THE
PATIENTS?
• Patients referred from other clinics
for potential surgical management
PECULIARITIES
• Many cases are congenital in nature
• A number have been undergoing repeated
surgeries for certain conditions
• History is often obtained NOT from the
patient.
• Weight,height/length, and age are
important clinical data
PEDIATRIC CLEARANCE
• May be requested in some patients
for surgery
• CBC, CXR APL, urinalysis, fecalysis,
blood typing
• Other lab exams as needed
• Nutritional assessment is necessary
POST-OP FOLLOW UP
VISITS
• Check wound status – erythema, pain,
tenderness, fluctuance
• Remove sutures if necessary
• Advise regarding future expectations
• Return to normal activities
COMMON PEDIATRIC
SURGICAL CONDITIONS
INGUINOSCROTAL
CONDITIONS

• Indirect inguinal hernias


• Hydrocoeles
• Undescended testis
• Testicular tumors
• Hypospadias
INGUINAL HERNIAS
• Congenital or inborn but may manifest late
• Persistent patent processus vaginalis
• Bulging in the groin may extend to
scrotum,contains bowel or ovary
• Aggravated by conditions predisposing to
increased intraabdominal pressure
• More common in premature infants
ANATOMY REVIEW

PROCESSUS VAGINALIS

Peritoneal diverticulum
that extends through the
internal inguinal ring

CANAL OF NUCK
In females
EMBRYOLOGY
EMBRYOLOGY
EMBRYOLOGY
ANATOMY OF HYDROCOELES
& INDIRECT INGUINAL HERNIAS
DIFFERENCE BETWEEN
CONGENITAL HERNIA AND
HYDROCOELE
 DIAMETER OF PROCESSUS VAGINALIS
 CONTENT OF SAC

INDIRECT INGUINAL
HERNIA HYDROCOELE
IDENTIFICATION OF
HYDROCOELE
HISTORY
• Fluid in scrotum
• Two types
communicating – treat as hernia
non-communicating – if present at birth, may
spontaneously resolve until 1 year

PHYSICAL EXAMINATION
TRANSILLUMINATION
GUIDELINES IN MANAGEMENT
OF HYDROCOELE
 IF THE HYDROCOELE IS
NONCOMMUNICATING (EARLY ONSET WITH
NO CYCLIC CHANGES), IT MAY BE OBSERVED
FOR A YEAR

 IF THE HYDROCOELE IS COMMUNICATING


(CYCLIC CHANGES), REQUIRES OPERATIVE
REPAIR

HYDROCOELE - HYDROCOELOTOMY
IDENTIFICATION OF
INGUINAL HERNIAS
HISTORY
RECURRENT GROIN SWELLING
FIRST NOTED IN THE
1ST YEAR OF LIFE

PHYSICAL EXAMINATION
1. GROIN OR SCROTAL SWELLING, OFTEN
INITIATED BY STRAINING
2. IN FEMALES, MASS INDICATES THE OVARY
3. IN MALES, CHECK LOCATION OF THE TESTIS
GUIDELINES IN THE
MANAGEMENT OF
HERNIAS
• Operate as soon as diagnosed
• High risk for incarceration esp. in 1st year of
life
TREATMENT OF INDIRECT INGUINAL HERNIA
HERNIOTOMY (CHILDREN)
• Operation is HERNIOTOMY
which means the patent processus
vaginalis is ligated high at the
internal inguinal ring
HIGH LIGATION OF HERNIAL SAC
ONE WEEK AFTER HERNIOTOMY
UNDESCENDED TESTIS
• If bilateral, may require endocrine
workup
• Descent may still occur until 1 year
• Palpate for testes in groin, perineum,
other ectopic location
• May request for UTZ
• Operation is ORCHIDOPEXY
UNDESCENDED TESTIS
DEFINITION: TESTIS CANNOT BE
MANIPULATED TO THE BOTTOM
OF THE SCROTUM

ETIOLOGY
•HORMONAL
•MECHANICAL

DIFFERENTIAL DIAGNOSIS:
•RETRACTILE TESTIS
•ECTOPIC TESTIS
•TRUE UNDESCENDED TESTIS
Undescended testis
PROBLEMS OF CRYPTORCHIDISM
•STERILITY – DECREASED SPERMATOGENESIS
•MALIGNANT CHANGES
•HERNIA
•TRAUMA AND TORSION
•PSYCHOLOGICAL/EMOTIONAL

GOALS OF TREATMENT
•IMPROVE FERTILITY
•PREVENT TRAUMA AND TORSION
•TESTIS PALPABLE FOR EXAMINATION
•PSYCHOLOGICAL REASON
TREATMENT FOR
CRYPTORCHIDISM
ORCHIDOPEXY PRIOR TO 1 YEAR OF AGE
INGUINAL, STAGED OR LAPARASCOPIC
SURGERY

ROLE OF HORMONES STILL CONTROVERSIAL


 HCG OR LHRH ADMINISTRATION

 MAY BE USED FOR BILATERAL CASES


TESTICULAR TUMORS
• Often mistaken for hernias
• Solid scrotal mass
• Germ cell tumors, seminoma
• Palpate groin for lymphadenopathy
• Request ultrasound of abdomen, alpha
fetoprotein determination
• Operation is RADICAL ORCHIECTOMY
Testicular tumors
HYPOSPADIAS
• Abnormal location of urethral opening
• Anywhere from the glans penis to the
perineal area along the midline
• Usually associated with ventral
curvature of the penis -- chordee
HYPOSPADIAS
IMPERFORATE ANUS
• Spectrum of anomalies
• VACTERL association
• May have been missed in the
perinatal period

COUNT THE NUMBER OF HOLES!


Imperforate anus
IMPERFORATE ANUS
Important points:
• Passage of meconium per vagina or
urethra or abnormal opening
• Presence of other anomalies
• Completeness of sacrum
• Urinary continence
IMPERFORATE ANUS
Diagnostic work up:
• Invertogram – only for neonates without
obvious fistula
• Babygram – to check skeleton
• Evaluation of sacrum
• Ultrasound of the kidneys
• Urinalysis
• 2 D echocardiogram
TYPES OF
IMPERFORATE ANUS
HIGH - RECTAL POUCH
ABOVE LEVATOR ANI LOW - RECTAL POUCH
BELOW LEVATOR ANI
IMPERFORATE ANUS
S/P COLOSTOMY
• Distal colostogram using water
soluble contrast
• Evaluate perineum (sacrum , flat
bottom)
• Ask about urinary habits
TRANSVERSE LOOP COLOSTOMY
FOR IMPERFORATE ANUS
IMPERFORATE ANUS
• Use proper nomenclature in chart
Imperforate anus with anocutaneous
fistula, anovestibular fistula,
rectourethral fistula, rectovaginal
fistula
Cloacal malformation
IMPERFORATE ANUS
• Low types – may undergo anoplasty
without colostomy
• High type- diverting colostomy ,
followed by definitive operation at 4
– 6 months
• Cloaca – may require cystostomy or
vaginostomy
IMPERFORATE ANUS
Definitive surgery – PSARP
posterior sagittal anorectoplasty

Anal dilatation is commenced 10 days


post op to prevent stricture

Colostomy is closed 2 – 3 months later


HIRSCHSPRUNG’S
DISEASE
• Chronic constipation often starting
at birth
• May also have bouts of diarrhea
• Should be differentiated from
functional constipation
• Often with abdominal distension
DEFINITION OF
HIRSCHSPRUNG’S
DISEASE

CONGENITAL ABSENCE OF
PARASYMPATHETIC INNERVATION
OF THE INTESTINE
HIRSCHSPRUNG’S
DISEASE
Important points:
• First passage of meconium
• Poor weight gain
• Abdominal distension relieved with
suppositories or rectal stimulation
• Gush of air or feces on rectal exam
• Visible bowel loops
CLINICAL PRESENTATION
•DELAYED PASSAGE OF MECONIUM
MORE THAN 24 HOURS AFTER
BIRTH
•MAY PROGRESS TO MASSIVE
DISTENTION
•CHRONIC CONSTIPATION
•DIARRHEA FROM ENTEROCOLITIS
WITH DISTENTION AND
DEHYDRATION
•INTERMITTENT OBSTRUCTION RELIEVED
BY SUPPOSITORIES OR ENEMAS
ABDOMINAL
DISTENSION
DIAGNOSTIC STUDIES FOR
HIRSCHSPRUNG’S DISEASE
•BARIUM ENEMA
CONING OR TRANSITION ZONE

•ANORECTAL MANOMETRY

•RECTAL BIOPSY – ABSENT GANGLION


CELLS

•ACETYLCHOLINESTERASE
DETERMINATION
TRANSITION ZONE/CONING
ON BARIUM ENEMA
Hirschsprung’ s disease

Transition zone
HIRSCHSPRUNG’S
DISEASE
Patient population
• Virgin case, for rectal biopsy
• Candidate for primary pullthrough
• S/p colostomy, for pullthrough
• S/p pullthrough, for closure of
colostomy
• Complicated cases
HIRSCHSPRUNG’S
DISEASE
Salient points:
• Good history and PE
• Look for results of labs (rectal
biopsy, barium enema, distal
colonogram)
• Assess eligibility of child for
surgery
Post-colostomy
SOFT TISSUE MASSES
• Hemangiomas
• Lymphangiomas
• Ganglion cysts, Baker’s cysts
• Lipomas
• Epidermal inclusion cysts
• Subcutaneous abscesses
HEMANGIOMAS
Congenital reddish cutaneous masses
Spontaneous regression
Large ones – Kassabach Merritt synd
May have a feeding artery
Transient increase in size during the
first year of life
HEMANGIOMAS
Diagnostic : Physical exam
Others: CBC with platelet count
angiogram
ultrasound
HEMANGIOMAS
Management:
1. Observation
2. Oral steroids – prednisolone or
prednisone
3. Surgery – partial or complete
excision
4. Laser ablation
HEMANGIOMA

LYMPHANGIOMA
LYMPHANGIOMAS
• Cystic congenital masses due to
obstructed lymphatic channels
• Known as cystic hygromas
• Excision treatment of choice ( not
always possible)
• Limited use of intralesional
sclerosants
OTHER MASSES
• Ganglion cysts – excision, aspiration
• Abscesses – drainage
• Inclusion cysts – excision
• Teratomas
UMBILICAL PROBLEMS
• Abdominal wall defects which may
not be corrected at birth or
manifest late
• Hernias, polyps, urachal remnant,
omphalomesenteric duct remant
UMBILICAL HERNIA

PATENT URACHUS
ANAL FISTULA
• May start as a perianal abscess
• Communicating tract between anal
canal and skin due to a
cryptoglandular infection
• Operation: FISTULOTOMY or
FISTULECTOMY , often with
proctosigmoidoscopy
ANAL FISTULA AND
FISSURES
FISSURES
• common in constipated child, esp
after passage of large hard stool
• Located in midline, may cause blood
streaked stool
• Stool softeners, hot sitz bath, pain
meds
CLINICAL SIGNS OF ANAL
FISSURES
•BRIGHT RED BLEEDING

•STOOL COATED WITH BLOOD

•SPREADING BUTTOCKS REVEALS


FISSURE

•HEALS SPONTANEOUSLY ESPECIALLY


IF CONSTIPATION IS TREATED AND
PERIANAL HYGIENE IS MAINTAINED
REMEMBER!
• Be patient with children! Try to be as non-
threatening as possible.
• Establish rapport with both parents and
kids before doing anything (undressing,
palpating, wearing gloves)
• Obtain a good and pertinent history
before doing a physical exam.
THANK YOU!