Surgery

Pediatric Surgery
Erika Marie C. Gacus, MD
September 28, 2020

OUTLINE 6. Pay particular attention to the post-operative pediatric patient

• to avoid mortality and morbidity Post-operative monitoring is a
OVERVIEW ....................................................................................................... 1 must
PEDIATRIC SURGICAL THEMES: PITFALLS AND PEARLS ......................... 1
GENERAL CONSIDERATIONS
GENERAL CONSIDERATIONS........................................................................ 1
- Fluid and electrolyte balance
PEDIATRIC TUMORS ...................................................................................... 1 - Acid - base equilibrium
Lymphangioma ................................................................................................................ 1
Wilm’s Tumor................................................................................................................... 2
- Blood volume and blood replacement
Neuroblastoma ................................................................................................................ 2 - Enteral and parenteral nutrition
Sacrococcygeal Teratoma .............................................................................................. 2
- Venous access
NEONATAL SURGICAL CONDITIONS ........................................................... 3 o Common problem (one should recall all the veins in the
Congenital Diaphragmatic Hernia .................................................................................. 3 pediatric patient)
Esophageal Atresia ......................................................................................................... 3
Abdominal Wall Defects.................................................................................................. 3 - Thermoregulation
Gastroschisis ................................................................................................................... 4 o Preoperative: less muscle mass, less shivering, less heat
APPENDIX ........................................................................................................ 5 generation
- Pain control

OVERVIEW PEDIATRIC TUMORS

- Pediatric patients Lymphangioma
o the most taxing to monitor preoperatively - Lymphatic Malformations (Cystic Hygroma)
o different physiologic requirements compared to adult px - Etiology and Pathology
o cry when they don’t feel well o Sequestration or obstruction of developing lymph bowls
o role as a physician: o 1 in 12,000 births
• to learn to move one step ahead of this px o Common sites: posterior triangle of the neck, axilla, groin,
• to help and provide the needed care despite the mediastinum
obstacle o Cysts are lined by endothelium and filled with lymph
o Unilocular vs multiple cyst "infiltrating"
o May contain nests of vascular tissue
o Infections can occur, usually caused by Streptococcus or
Staphylococcus
o Detected prenatally thru ultrasound before 30 weeks AOG
o Large lesions may cause airway obstruction leading to
polyhydramnios
▪ EXIT procedure
- ex utero intrapartum technique
- baby is delivered prior to cutting of the
umbilical cord the airway of the baby is
secured and the mass is excised
- Treatment
o Sclerotherapy
o Cyst excision
Figure 1. Challenge of Pediatric Surgery

PEDIATRIC SURGICAL THEMES: PITFALLS AND PEARLS

1. Children are not little adults, but they are little people
• everything from their medication to their fluid requirements to
blood products should be based on their weights
2. Sick children whisper before they shout
• do not verbalize their complains
• small margin between stability and collapse
3. Always listen to the mother and father
• history is 2nd hand
4. Children suffer pain after surgery
• pain management is important post-operatively (it makes the
patient more compliant and cooperative)
• results in early feeding, early ambulation, early discharge, and
less complications
5. Pediatric tissue must be handled delicately and with profound
respect Figure 2. Lymphangioma

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 Surgery | Pediatric Surgery
Wilm’s Tumor Neuroblastoma
- The most common cause of primary malignant tumor of the - Third most common pediatric malignancy
kidney in the children - Advanced disease at time of presentation
- 1-5 years old - Overall survival rate is significantly lower
- May present as an asymptomatic mass in the flanks or upper - 2-4 years of age
abdomen - Tumor originates in the adrenal glands, posterior mediastinum, neck,
o Other symptoms include: pelvis or any sympathetic ganglion usually presents as
▪ hematuria asymptomatic abdominal mass
▪ hypertension
▪ obstipation Diagnostic Evaluation
▪ weight loss - Serum catecholamines
- 97% sporadic - Urine vanillylmandelic acid or homovanillic acid
- If (+) hereditary risk factor - Abdominal CT scan
o Early presentation - Chest Radiographs
o Bilateral tumors - Bone Marrow Biopsy
- Associated syndromes
o WAGR syndrome
Shimada Classification
▪ Wilm’s' Tumor, Aniridia, Genitourinary Abnormalities.
mental retardation - Favorable vs unfavorable histology
o Beckwith-Weidemann Syndrome
▪ Visceromegaly, macroglossia, hyperinsulinemic
hypoglycemia
- Management
o 2 management strategies:
o National Wilms' Tumor Study Group (NWTSG) in North
America
▪ Surgery followed by chemotherapy
o International Society of Pediatric Oncology (SIOP) in Europe
▪ Shrinking the tumor using preoperative chemotherapy
- Preoperative Diagnostics
o chest and abdominal CT scans
- Preoperative chemotherapy for special instances
o Bilateral involvement
o Inferior vena cava involvement extending above Hepatic veins
o Involvement in a solitary kidney Figure 5. International Neuroblastoma Staging System
- Management
o Radical nephroureterectomy
o Post-operative chemotherapy and/or radiotherapy

Figure 3. Stages of Wilm's Tumor

Figure 6. Neuroblastoma: Both kidneys are visualized

Sacrococcygeal Teratoma
- Teratoma
o composed of all three embryonic germ layers
o benign or malignant
o usually found in the midline structures
o mature vs immature
- May be prenatally diagnosed
- Presents as mass at sacral area
- Classified based on location and degree of intrapelvic extension
- May be benign or malignant
- Differential Diagnosis: Neural tumors, lipoma, myelomeningoceles
- Treatment: complete surgical excision
Figure 4. Stages of Wilm's Tumor
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 Surgery | Pediatric Surgery

Figure 7. Classification of Sacrococcygeal Teratoma

Type I Pure sacral mass; most common type

Figure 9. Sacrococcygeal Teratoma - Note: (+) Multiple Cystic Lucencies at the
Left Hemithorax, which is continuous with cystic lucencies at abdominal area -->
Type II 50% at sacral area; 50% intrapelvic area
Indication: Small Bowels

Majority of mass in the intrapelvic; small part in sacral Esophageal Atresia

Type III
area
- Esophagus and trachea share a common embryologic origin
- At 4 weeks AOG, a diverticulum progressively forms to a laryngo-
Type IV Completely intrapelvic
tracheal groove creating a separate trachea and esophagus
Table 1. Type I-IV Sacrococcygeal Teratoma Classification - Mnemonic VACTERL: vertebral anomalies, anorectal anomalies,
cardiac defects, TEF, renal anomalies, radial limb hyperplasia
- Signs and symptoms: excessive drooling, choking and coughing
immediately after feeding
- Diagnostic: inability to pass OGT into the stomach
- Treatment: primary repair; delayed staged repair

Figure 8. Sacrococcygeal Teratoma

NEONATAL SURGICAL CONDITIONS

Congenital Diaphragmatic Hernia
- Incomplete separation of the pleural and coelomic cavities at the
posterolateral aspects
- Posterolateral defect (Bochdalek Hernia) - most common
Figure 10. Esophageal Atresia: Note Non-passage of Dye to the Stomach
- Prenatally diagnosed
- Differential Diagnosis: Bronchopulmonary foregut malformation
Abdominal Wall Defects
- Treatment: Repair the diaphragmatic defect- done once the patient
is clinically stable - Abdominal wall is formed by 4 separate embryologic folds
(cephalic, caudal, right, left)
- Failure of closures:
o Cephalic fold → sternal defect
o Caudal fold → exstrophy of the bladder
o Lateral folds → omphalocele/gastroschisis

Omphalocele
- Abdominal wall defect in which the bowel and viscera are covered by
peritoneum and amniotic membrane
- Umbilical cord inserts into the sac
- Incidence: 1:5,000 live births
- Syndromes:
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 Surgery | Pediatric Surgery
o Exstrophy of the cloaca - Edematous Bowels Subsides 7-10 Days → Attempt of bowel
o Beckwith Weidemann reduction and primary wall repair
o Pentalogy of Cantrell
- Treatment: layer abdominal wall closure (if feasible- clinically stable)

Figure 11. Note Small Bowels and Liver are Visible

Gastroschisis
- Abdominal wall defect in which the intestinal contents freely
protrude
- Defect may be <4cm
- Defect is at the junction of the umbilicus and normal skin, almost
always right to the umbilicus
- Treatment: Layer abdominal closure

Figure 12. Gastroschisis: Note (+) Edematous Bowels --> Difficult to do immediate
bowel reduction and primary wall repair

Figure 13. Gastroschisis: Note Bowels Placed in a Temporary Silo Bag

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 APPENDIX

Figure 14. International Neuroblastoma Staging System

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