PEDIATRIC SURGERY

Musekhir siraj: 129

Ajmal: 128
Naveed: 130
 Pediatric Surgery
• It is a branch of surgery devoted to
surgical care and management of infants
and children
 Pediatric Population
• Premature infants
• Small for gestational age
• Term infants/appropriate for gestational age
• Post-mature infants
• Older children
• Adolescents
• (Fetus)
 General Principles
1. Sick children whisper before they shout.
2. Always listen to the mother and father.
3. Pediatric issue must be handled delicately.
4. Children suffer pain after surgery.
5. Pay particular attention to the postoperative
patient whose pain cannot be soothed by
standard analgesia
Surgical conditions in children
• Many unique to them
Congenital malformations
Neoplasms
Results of trauma
• Most are amenable to treatment thus offer
satisfaction of permanent cure
• Requires knowledge and awareness of differences
Diseases
Physiologic and psychologic responses in various
ages
• Some disease processes actually begin in-utero
during fetal development
• Some diseases are genetic
• History taking is more difficult
• Complete physical exam is crucial and
requires the consent of parents/guardians
 Fluids & Electrolytes
• Insensible loss greatly increased
– Greater surface area
– Exposure to radiant heat or bililights
• Greater metabolic activity increases water
requirement
• Margin between dehydration and fluid
overload is small
 Fluid Requirements
VOLUME CALCULATION :

Existing Deficit +
Normal Requirements +
Ongoing Losses
Maintenance:
first 10 kg 100 ml/kg/ day
second 10kg plus 50 ml/kg/ day
each added kg plus 20 ml/kg/ day
 Electrolyte Requirements
Depending on baseline measurements and
type/volume of ongoing loss, the i.v. fluid is adjusted, or
electrolytes are added to the fluid, in order to correct
deficits.
Daily Maintenance Requirements:
Na 2-4 mEq / kg / day;
principal volume regulator
K 1-3 mEq / kg / day;
consider urine output
Cl 2-4 mEq / kg / day
Ca 0.5-3 mEq / kg / day
Mg 0.5-1 mEq / kg / day
 Monitoring of Response

Clinical activity, appearance, capillary

refill, turgor, mucosa
Vital Signs,Heart rate, BP, pulse
Urine volume ( 2 ml / kg / hr )
concentration ( sp. gr. 1.010 )

Reestablishment of circulatory dynamics

is heralded by production of sustained
adequate urinary output.
 Blood Volume/ Replacement
Blood Volume Estimation
Group mL/kg
premature 85-100
term 85
>1 mo 75
3mo – older 70
Allowable blood loss should not be more than 10-
15%.
3kg neonate 250-300 cc TBV
blood loss should be <30 cc
 Operative Blood Loss
• Replaced when it exceeds 10% of vascular volume
– Ex. 20 ml in a 2-kg. Premature infant
• Because of high hematocrit (50-65) in newborns,
losses may be initially replaced with plasma
• Volume repletion in hypovolemic infant is best
accomplished by bolus therapy
– Infusion of 25 ml/kg at a time
– Well tolerated by elastic cardiovascular system of infant
 Nutrition/Metabolism

• Higher metabolic rate

– Rapid turnover of water & metabolites
– Higher oxygen consumption
• Need to grow
– Increased requirement for calories and fluid

When compounded by illness, the risks of

protein-calorie malnutrition are
considerable.
 Nutrition

• Normal infant growth requires 100 kcal/kg

of body weight/day
• Enteral route (via oral or tube feeding) is
most ideal and economical
• Total Parenteral Nutrition
– Profound effect on survival of infants
undergoing major intestinal surgery
 Caloric Requirements
• 0-10 kg body weight: 100 kcal/kg
• 10-20 kg body weight: 1000 kcal plus 50 kcal/kg
for each kg over 10 kg
• 20 kg and over: 1500 kcal plus 20 kcal/kg for each
kg over 20 kg
• Patient is growing and developing while he is
recovering from an injury or operation.
• Adjustments for Stress Factor:
– Sepsis: 130-160%
– Trauma: 120-150%
– Burns: up to 200%
 Heat Loss
• In adults • In infants
– Largely by radiation – More rapid because of
greater surface area to
body mass ratio
– Augmented by
deficiency of
subcutaneous fat and
immature sympathetic
nervous system
Venous Access for fluids/TPN
Peripheral IV
Cutdown
Umbilical
Intraosseus
Central line
 least invasive, least risky, least painful,
with least complications
 Pain Control

All pediatric patients undergoing surgery

should be given appropriate analgesia by
the appropriate route to control pain.
 Respiratory Care
• Respiratory problems common in young infants
after operation
– Neonates-obligatory nasal breather
– Intercostal muscles contribute little to ventilation
– Infants rely entirely on diaphragm
– Small infant airway easily compromised by edema or
secretions
– Poor cough and gag reflexes limit ability to mobilize
secretions
– CNS control of respiration is poor
• Periodic apneic spells in premature infants
Respiratory problems in children

• Accumulation of secretions
• Hypoventilation
• Atelectasis with respiratory acidosis

especially in patients with poor pain control

 Intra-operatively
• During the operative procedure:
• Fluid of choice should be that of the most dominant fluid
loss…
- Ex. 1. Elective procedure – herniotomy
- - insensible loss is the dominant fluid deficit
- - replacement with hypotonic fluids should be given
to replace free water and minimal electrolytes
-
- Ex. 2. Procedures in which there is significant major,
prolonged invasion of the abdominal and thoracic
cavity
- - replacement with balanced salt or blood products
variety should be chosen
- - importance of availability of blood products
 Postoperative Care
• Similar to those used in adults BUT..
– Modified for specific physiologic
limitations of immature patients
• Lability of infants
• Subtlety of signs of distress
Common Pediatric Surgical Conditions
I. Head & Neck
II. Respiratory
III. Esophageal
IV. Gastrointestinal
V. Hepatobiliary
VI. Abdominal Wall Defects
VIII. Genitourinary
IX. Tumors
X. Trauma
 Cystic Hygroma
- a.k.a. Lymphangioma, Lymphatic
Malformation (macro- or micro-)
- result of sequestration or obstruction of
developing lymph vessels
- most common sites: neck, axilla, groin,
mediastinum
- surgery is the treatment of choice
- sclerosing agents (OK-432) sometimes used
in solitary cysts
 Other common H&N conditions
• Lymphadenopathy
• Thyroglossal duct cysts
• Branchial cleft anomalies
Congenital Diaphragmatic Hernia

Manifestations:
- Severe respiratory distress within the
first hours/days of life
- Respiratory distress beyond neonatal
period (in some)
- Gastrointestinal obstructive
symptoms
- Scaphoid abdomen
- Bowel sounds in chest
 Congenital Diaphragmatic Hernia
Herniation of abdominal contents into the thoracic cavity due to a
defect in the diaphragm
1/5,000 to 1/2,000 live births
Types based on location of defect:
Bochdalek: posterolateral (70-85%)
Morgagni: anterior/retrosternal (<2%)
Hiatal: esophageal hiatus
Paraesophageal: adjacent to the esophageal hiatus
Etiology:
Failure of closure of the pleuroperitoneal canals (8 th week of
gestation)
 Esophageal Atresia
• Unable to swallow saliva, “excessive secretions”
noted shortly after birth
• Aspiration events may result in cough, tachypnea,
hypoxia
• If infant is fed, immediate regurgitation,
accompanied by choking/coughing/cyanosis
sometimes
• Successful passage of orogastric tube rules out the
diagnosis
• If tube does not pass beyond 9 to 13 cm from the
alveolar ridge, x-ray demonstrates atresia
 Classification of EA
1. EA with TEF –85%
2. Isolated EA –3-5%
3. Isolated TEF (H-type) –6%
4. EA with proximal fistula –2%
5. EA with fistulas to upper and lower
esophagus segments –3-5%

- may be associated w/ VACTERL anomalies

EA with distal TEF

• 85%
• proximal esophagus
dilated and thickened,
ends at T3
• anterior aspect of
esophagus and may
have partial common
wall with adjacent
trachea
 Intussusception

Most (90%) cases are idiopathic, rest have lead point

Incidence varies from 1-4 :1000 births
2/3 of cases occur before pxs 1st bday
80% occur before age 24 mo
Rare in pxs <3 mo and less common >36 mo
Present w/ crampy abdl pain, bleeding, abdl mass, vomiting
Currant-jelly stools occur in only about 50%
Dance sign- empty RLQ
Most are reducible (75%) by Barium, air or saline
Recurrence is 3-11% usually w/in 72 hours
Mortality is 1-3%
 Malrotation

- usually presents with bilious vomiting/

recurrent vomiting, failure to thrive
- index of suspicion should be high
- midgut volvulus and bowel gangrene may
develop
- diagnosis is best made by an upper GI
series
- surgery is called Ladd’s procedure
(adhesiolysis of Ladd’s bands +
appendectomy + bowel arrangement)
 Malrotation
Normal fixation of the bowel: Malrotation of the bowel may look like this:
 NEC
- disease of prematurity and LBW infants
- first sign is formula intolerance (vomiting,
residuals) after initiation of feeding
- abdominal distention and hematochezia
eventually follow
- bowel ischemia and gangrene are late signs
- may lead to bowel perforation and death
- despite severity of illness, survival rates
approach 80% in most series
- most cases are managed conservatively
 Intestinal Atresia
- usually present with vomiting and abdominal
distention
- varying levels of obstruction, degree
correlates roughly with level, commonly in the
jejunum and usually single (~90%)
- fetal mesenteric vascular accidents are likely
to be the cause of most cases
- treatment is surgical
 Duodenal Atresia

- incomplete canalization of duodenal lumen

- usuually present w/ bilious vomiting
- approx 1/3rd associated with Down’s Syndrome
 Acute Appendicitis

- incidence of perforation rises as age of px

decreases (~25% in adol, ~80% in <5yo)
- approx 52% of children perforate before seeing
a doctor, 70% are perforated before being seen
by a surgeon
- may differ in presentation from that of adults
- children may localize pain poorly
- physical examination is also relatively more
difficult
 Hirschsprung’s Disease
• also called congenital aganglionosis
• failure to pass meconium in the first 24 to 48
hours
• abdominal distention and vomiting in the neonate
• chronic constipation in older children
• malnutrition, failure to thrive
• abdominal distention, tympany
• bilious/fecaloid vomiting –late sign
• spasm of the rectum on digital examination
• characteristic forceful evacuation of gray liquid
stool at the time of rectal examination
 Hirschsprung’s Disease
• plain radiogragraph: air-filled, distended proximal
bowel that occupies most of the abdomen
• barium enema: transition zone (may be unreliable in
the newborn because the colon is not dilated enough
to show a transition zone)
• rectal manometry: absence of reflex anal relaxation
 Hirschsprung’s Disease
• rectal biopsy: definitive diagnosis
• suction rectal biopsy
• full-thickness biopsy
• absence of ganglion cells in the myenteric
and submucous plexuses
• increased staining of a cholinesterase stain
• presence of hypertrophied nerve bundles
• treatment is surgical in all cases, may be
staged
 Imperforate Anus
- approx 1 in 5000 births
- failure of descent of the urorectal septum
- broadly classified as “high” or “low”
- patients with a high type usually require a
preliminary colostomy
- diagnosis is not difficult but it is often
missed; check the perineum of newborns
- treatment is surgical reconstruction
 Biliary Atresia
- usually presents with jaundice, acholic stool
- obliterative process involving the common
duct, hepatic ducts, cystic duct and GB
- liver failure sets in if untreated
- Kasai procedure (hepatoportoenterostomy)
is known treatment, high success rate if done
before 8 wks of age
- liver transplantation is next option
 Choledochal Cyst
• Dilatation of the bile ducts
• Usually presents as pain, jaundice and a
palpable mass
• Ultrasound or CT confirms the diagnosis
• Treatment is surgical/resection
 Abdominal Wall Defects

- incidence is approx. 1 in 2000 births

- highly associated with prematurity
- detection in utero is important, with a search for
other congenital anomalies esp during 2nd trimester
- management is directed at correcting hypovolemia,
preventing hypothermia, monitoring for sepsis,
nutritional support
 Abdominal Wall Defects

- surgery is performed as soon as possible (primary

vs staged closure) to protect and cover the
bowels/exposed organs
- abdominal wall closure usually in 7-10 days
- associated with growth delay in the long-term
- usual complications are sepsis, NEC,
prolonged ileus, respiratory distress
 Abdominal Wall Defects
GASTROSCHISIS:
- from Greek for “belly cleft”
- generally thought is a result of intrauterine
occlusion of the R omphalomesenteric artery
resulting in disruption of the umbilical ring and
bowel herniation
- often assoc. with intestinal atresia
- mortality is around 10%
 Abdominal Wall Defects
OMPHALOCOELE:
- failure of migration and fusion of embryonic folds
- associated with several genetic syndromes, esp.
trisomies, and with cardiac anomalies
- survival depends on size, prematurity, sac rupture,
associated anomalies
- nonoperative closure is reserved for extremely
large defects or high-risk infants by promoting
epithelilization
- mortality ranges from 30-60%
 Abdominal Wall Defects
Gastroschisis Omphalocoele
Area lateral, R umbilical
Size small variable
Sac absent present
Cord absent present
Bowels inflamed normal-looking
Liver not exposed herniated
Atresia common rare
Strangulation inc. risk uncommon
Anomalies uncommon common
 Hernia of the Umbilical Cord

-usually < 4 cm in diameter and the sac should contain

only a few loops of intestines
-may be missed at birth and injury to the intestine can
be caused by careless clamping of the umbilical cord
 Prune Belly

- absent/deficient abdominal wall musculature; urinary tract

malformations, cryptorchidism
- also known as triad syndrome-
Eagle-Barrett syndrome
 Cloacal Exstrophy

- rare
- increased survival in recent years
- quite difficult to reconstruct.
- similar to bladder exstrophy in embryogenesis
 Inguinal Hernias

- patent processus vaginalis

- approximately 1-5% incidence
- male:female ratio is 6-10:1
- R>L>B
- incarceration exceeds 60%
in the first 6 months of life
 Comparison of hernias in children
and adults
Hernias in children Hernias in adults

Congenital Congenital &/or acquired

Indirect Indirect &/or direct

High ligation of sac High ligation of sac with

repair of floor
 Tumors in Children

Marked increase in survival because of

better imaging, new chemo agents, multi-
disciplinary approach, and newer protocols.
 Trauma

- most common environment is the home

- most lethal agent: motor vehicle
- causes of fatal unintentional injury varies:
< 1 yr: suffocation
1-4 yrs: drowning
5-9 yrs: vehicular accident
10-14 yrs: vehicular accident
 Trauma
- account for more almost half of all deaths,
more than cancer and infectious diseases
combined
- vehicular accidents is the most common
- consideration of unique requesits of
injured child improves outcome
- priorities of management are still ABCs
- special consideration are burns and child
abuse
- solution is not surgery but PREVENTION!