Pediatric surgery Introduction to pediatric surgery Anorectal malformation Colostomy Sacrococcygeal Teratoma Meckel’s Diverticulum Biliary Atresia Choledochal Cysts Approach to 2 days after birth vomiting Diaphragmatic hernia Use of NG tube

1. Mohammed Satar Jabbar (Medical Student-Kerbala college of Medicine-Iraq)
Contact: mohammed.s.al.graitti@gmail.com
Introduction to pediatric surgery
The difference between pediatric and adult
1) Wide abdomen
2) Most organs located in the abdomen
3) Respiration depend mostly on the diaphragm
4) Transverse abdominal incision gives access to a lot of organs
5) More vulnerable to heat loss (there will be cardiac standstill: the complete cessation
of ventricular contractions and ejection of blood by the heart)
6) More susceptible to hypoglycemia
7) Clotting disorder
8) Different in fluid that must be given
9) More susceptible to infection
10) Small incision, hemostasis
11) Post-operative take care about the HOT
12) Antibiotic: nephro/hepatotoxicity and hearing problem (care about dose and giving)
Anorectal malformation
Incidence
More in male
General classification
According to elevator ani muscle:
1) High (fistula with bladder and urethra, short colon, no isceo-rectal muscle or
shallow)
2) Intermediate (fistula in urethra, Most common)
3) Low (good prognosis, open in skin)
Note: prognosis: continence (isceo-rectal muscle)
Classification in male
Imperforate anus with recto-cutaneous fistula (perineal fistula)
Other names: perineal fistula, covered anus
Low type: opening + meconium
Prognosis: very good
Surgery: primary anoplasty
Imperforate anus with Recto-urethral fistula.
1) With recto-bulbar urethral fistula
2) With recto-prostatic urethral fistula
3) With recto-bladder neck fistula

2. Mohammed Satar Jabbar (Medical Student-Kerbala college of Medicine-Iraq)
Contact: mohammed.s.al.graitti@gmail.com
Imperforate anus without fistula
Rectal atresia
Classification in Female
Imperforate anus with recto-cutaneous fistula (perineal fistula)
Other names: perineal fistula, anterior displaced anus, covered anus
Low type: opening + meconium
Prognosis: very good
Surgery: primary anoplasty
Imperforate anus with Recto- vestibular fistula.
Opening: outside the hymen
Surgery: dilation then wait for 40 days then colostomy (early colostomy if vomiting,
abdominal distension)
Imperforate anus without fistula
Rectal atresia
Cloaca
Most severe complicated anomaly
Def.: urethra and vagina and rectum in one opening (too many variation)
Complex malformations
Clinical Presentation
1) no anal opening
2) failure to pass meconium
3) VACTERL stands for vertebral defects, anal atresia, cardiac defects (VSD and
teratology of fallot), tracheo-esophageal fistula, renal anomalies, and limb
abnormalities + down syndrome)
Diagnosis
Low type: perineal fistula
High type:
1) Invertogram: 12-24 hour put metallic substance in the possible site of anus + child
upside down + lateral view X-ray = more than 1 colostomy, high type, colostomy,
less than 1 primary anoplasty, low type.
2) Or do cross table
Relation to urine: green color urine = fistula with bladder or urethra (colostomy)
Types of colostomy
1) Loop colostomy

3. Mohammed Satar Jabbar (Medical Student-Kerbala college of Medicine-Iraq)
Contact: mohammed.s.al.graitti@gmail.com
2) End colostomy: for CA
3) Double barrel colostomy (used in imperforated anus)
Complication of colostomy
1) Bleeding
2) Infection
3) Prolapse
4) Hernia
5) Dehiscence
6) Stenosis
7) Skin excoriation
Site pf colostomy
1) Sigmoid
2) Transverse colon in HSD
Pediatric surgery
Sacrococcygeal Teratoma
Clinical Presentation
1) Prenatal discovery by ultrasound is becoming common
2) lesion may be in the retro rectal space and/or the retro peritoneum. In these cases,
patients will present with
A) Rectal pain
B) Constipation
C) Mass
Diagnosis
1) Made by physical examination
2) Ultrasonography is useful to determine the nature of the lesion (solid vs. cystic), the
presence of an intra-abdominal component, and the presence of liver involvement

4. Mohammed Satar Jabbar (Medical Student-Kerbala college of Medicine-Iraq)
Contact: mohammed.s.al.graitti@gmail.com
3) Alpha-fetoprotein (AFP) and beta human chorionic gonadotropin (beta-hCG) are
serum tumor markers associated with teratomas and should be obtained
preoperatively and followed postoperatively
Treatment
1) Should be completely excised
2) Complete removal of the intact tumor, ligation of the middle sacral artery, and
excision of the coccyx with the tumor
Meckel’s Diverticulum
Note
1) most common gastrointestinal tract anomaly
2) Two percent of the population is affected
3) twice as frequent in males
4) two feet from the ileocecal valve
5) two inches’ long
6) two centimeters wide
7) two types of mucosa often exist
8) two years of age the majority of symptoms
Clinical presentation
1) asymptomatic until complicated
2) bleeding (children less than 5) (episodic and painless) (require bleed transfusion)
3) obstruction (due to intussusception (50%) (before 10 years old), herniation, kinking
or volvulus)
4) inflammation (with or without perforation)
5) similar to acute appendicitis
6) The diagnosis is rarely made prior to laparotomy
Diagnosis
radio-labeled technetium scan
Treatment
1) operative intervention (simple diverticulectomy or by a partial ileal resection)
2) intravenous fluids or blood products is paramount
3) In young children, because of a life-long potential for complications and the low
morbidity with resection, an incidentally encountered Meckel’s diverticulum
probably should be resected
Biliary Atresia
Clinical Presentation
1) Jaundice (during first month)
2) Pale stool (during first month)
3) Dark urine
Diagnosis
1) LFT
2) Direct hyperbilirubinemia
3) HIDA or DESIDA (failure of traced excretion into the intestine after 24 hours)

5. Mohammed Satar Jabbar (Medical Student-Kerbala college of Medicine-Iraq)
Contact: mohammed.s.al.graitti@gmail.com
Preoperative
1) Vitamin K several days before operation
2) Oral kanamycin
3) Stop oral feeding 24-48 hours
4) Glycerin enemas
5) Broad spectrum antibiotics
Surgery
Roux-en-Y Portoenterostomy
Choledochal Cysts
Clinical presentation
1) Jaundice
2) Right upper quadrant Pain
3) Palpable mass
Diagnosis
1) LFT (elevated during the period of pain)
2) Elevated Direct hyperbilirubinemia
3) Elevated GGT
4) Elevated transaminase
5) Serum amylase and lipase (accompany pancreatic inflammation)
6) US (test of choice) (cystic dilation of CBD and gallbladder may be to CHD but not the
hepatic ducts)
Treatment
Cystic excision + Roux-en-Y hepaticojejunostomy
Approach to 2 days after birth vomiting
Hx:
1) Term/preterm
2) Normal vaginal/cesarean
3) Twins/single
4) Onset
5) Jaundice
6) Color
A) Milk
B) Frothy discharge
C) White (from the stomach)
D) Bilious (below ampulla of Vata)
7) Bottle feeding/breast feeding
8) Other things may be given to the neonate
Examination
1) Umbilical cord
2) Hernia
3) Anus
4) DRE

6. Mohammed Satar Jabbar (Medical Student-Kerbala college of Medicine-Iraq)
Contact: mohammed.s.al.graitti@gmail.com
Case: a neonate 2 days after delivery presented with bilious vomiting
D.D
1) IO
2) Duodenal atresia
3) HSD
4) Malrotation
5) Web (partial obstruction)
6) Volvulus
7) Diaphragmatic hernia
Management
1) NG
2) Fluid
3) Vitamin K
4) Erect AXR
Diaphragmatic hernia
Types
1) Bochdalek:
A) Left
B) Near the ribs
2) Morgagni
A) Retrosternal
Use of NG tube
1) Decompression
2) Type of fluid
3) Prevent aspiration