PEDIATRIC SURGERY-2022

No. : 1
Attendance: Obligatory
Type of lecture: theory
Place : College of medicine –Anbar University .
Date : 21 -Feb.- 2023.
Time : 12:30 – 01:30 PM.
Students: 5th year / college of medicine / Anbar University
By : Dr.Omar A. Ajaj- M.B.Ch.B. - F.I.C.M.S. -Associate professor-
pediatric surgeon.
E. mail : omarabd954@uoanbar.edu.iq

F.I.C.M.S
 Pediatric surgery: Deal with surgical problems in children
under the age of 14 years.
 Neonatal surgery: Deal with surgical problems in neonate
below 28 days of age & it deals mainly with congenital
malformations.
 Fetal surgery: Deal with some abnormalities in
intrauterine life, like; 1.Hydrocephalus, which if left without
drainage it will lead to increase in the size of head and
causing brain atrophy, putting a ventriculostomy catheter will
prevent atrophy of brain cortex and reduce head size making
vaginal delivery possible.
Causes of NIO

 1-High intestinal obstruction

At level of pylorus(stenosis, atresia)
At level of duodenum( atresia)
At level of jejunum( atresia,
Malrotation)
2- Low intestinal obstruction
 Intramural: meconium plug syndrome, Meconium
ileus

 Mural : Anorectal malformation or atresia(ilial or

colonic)
 Exramural: pelvic mass obstructing the rectum
(teratoma).
 Neurogenic & functional:Hirschsprung`s disease,
ileus, sepsis
Triad of clinical presentation in NIO

 1.Vomiting.
 2.Abdominal distention.
 3.Delayed passage of meconium(after 24 hrs.)
 4. bloody diarrhea indicating bowel ischemia or
necrosis.
 Early vomiting in the first 24 hours, late
distension indicates high obstruction.
 While the early distension, later onset of
vomiting indicates a lower obstruction.
Management

History
Examination
Investigation
Treatment
complications
Failure to recognize neonatal intestinal obstruction
can result in
 Aspiration,
 Sepsis,
 Bowel gangrene, Deat Passed away
 Perforation
 Enterocolitis.
Differential diagnosis for nonbilious
vomiting
 1- Non surgical causes such as gastroesophageal
reflux, increased intracranial pressure, and
metabolic disorders.
 2- Surgical causes include gastroesophageal reflux
disease, pyloric stenosis or atresia , antral web.
HYPERTROPHIC PYLORIC STENOSIS

 The condition is caused by hypertrophy of the

smooth circular muscle layer of the pyloric
muscle, obstructing the gastric outlet
 It occurs at a rate of 1 to 4 per 1,000 live births.
 4 : 1 male-to-female
Etiology

The cause of HPS is unknown, but

genetic and environmental factors
appear to play a large role in the
pathophysiology.
Environmental factors associated
with HPS include feeding(bottle),
exposure to erythromycin,
 Risk factors for HPS
- Family history,
- Gender(MALE)
- Younger maternal age,
- A first born infant.
Diagnosis

 The classic presentation of HPS is

nonbilious, forceful vomiting in a full-
term neonate who is between 2 and 8
weeks old.
 Palpable pylorus mass in 70–90%.
 Ultrasound (gold standard technique). The
diagnostic criteria for pyloric stenosis is a muscle
thickness ≥4 mm and a pyloric channel length
≥16 mm.
 Upper gastrointestinal series?
Treatment

 Resuscitation followed by pyloromyotomy.

 The metabolic derangement

Hypochloremic,
Hypokalemic,
Hyponatremic,
Metabolic alkalosis.
DUODENAL ATRESIA
 Occurs in 1 / 5000
 Etiology:
 Intrinsic: (is most common) believed to be caused by a
failure of recanalization of the fetal duodenum resulting in
complete obstruction.
 The extrinsic form of duodenal obstruction is due to defects
in the development of neighboring structures.
Type I atresias account for more than 90% of all
duodenal obstructions
Associated anomalies
VACTRAL
 Vertebral
 Anorectal
 Cardiac
 Tracheoesophageal
 Renal
 Atresia
 Limb
Diagnosis
 prenatal ultrasound.

 The classic presentation is that of bilious emesis

within the first hours of life in an otherwise stable
neonate.
 In neonates with duodenal atresia, the abdomen
is scaphoid.
 The diagnostic radiographic presentation of
duodenal atresia
 Plain abdomenal x-ray (that of a double bubble
sign with no distal bowel gas).
Treatment

 Appropriate resuscitation is required with

correction of fluid and electrolyte abnormalities,
and duodenoduodenostomy.
 Midgut maturation involves four stages:
 (1) Herniation;
 (2) Rotation;
 (3) Retraction;
 (4) Fixation.
Malrotation

Clinical disorders may arise when intestinal rotation either fails

to occur or is incomplete.
video
 The incidence of malrotation has been estimated at 1 in 6000
live births.
 Classic malrotation with midgut volvulus is often discovered
in a previously healthy term neonate.
 Sudden onset of bilious vomiting in a previously
healthy term neonate is the cardinal sign , and
malrotation with volvulus must be the presumed
diagnosis until proven otherwise.
 Physical examination findings will vary. Initially,
the patient have a scaphoid abdomen.
 Upper gastrointestinal contrast study remains the
gold standard, the contrast study may show the
„coil spring‟ or „corkscrew‟ configuration with
incomplete obstruction and the “beak” appearance
in the duodenum with complete Obstruction.
Treatment
 Patients with suspected or confirmed midgut
volvulus They should be aggressively resuscitated
and taken to the operating room for immediate
exploration.
Jejunoileal atresia
 Occurs in approximately 1 in 5,000 live
births.
 Etiology :The hypothesis that most cases of
jejunoileal atresia occur secondary to
vascular disruption during fetal life.
Classification
 Clinical presentation: Bilious emesis,
abdominal distention and mostly gray plugs
of mucus passed via the rectum.
 Diagnosis: Jejunal
atresia patients can
have a few(3-5) gas-
filled and fluid-
filled loops of small
bowel, but the
remainder of the
abdomen is gasless.
Treatment
 Resection of atretic segment, with
primary end-to-end anastomosis or
resection with stoma.