Pediatric Surgery Review

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  • Dilated small and large bowel loops, prominent transverse, descending, sigmoid
  • Pediatric Surgery Review

    1. 1. Paediatric Surgery ReviewPaediatric Surgery Review(for 6(for 6ththyear medical students)year medical students)Mustafa RedwanMustafa RedwanAssistant Lecturer of General &Assistant Lecturer of General &Paediatric SurgeryPaediatric SurgerySohag Faculty of MedicineSohag Faculty of Medicine20132013
    2. 2. OutlineOutline• Congenital Diaphragmatic Hernia (CDH)• Esophageal Atresia &/Tracheo-esophageal fistula(EA -TEF)• Congenital Hypertrophic Pyloric Stenosis(CHPS)• Intussuception• Meckel’s Diverticulum• Hirschsprung Disease (HSD)• Anorectal Malformations (ARM)• Intestinal Malrotation.
    3. 3. 1-Congenital Diaphragmatic1-Congenital DiaphragmaticHerniaHernia(CDH)(CDH)
    4. 4. • Herniation of abdominal contents into the chestthrough a congenital defect in the diaphragm.• Aetiology & Embryology: failure of fusion of theseptum transversum w the dorso-lateraldiaphragmatic processes(pleuro-peritonealmembranes)• Types :-Posterior (Bochdalek) 90% , lt 5x >Rt-Anterior (Morgagni)-Eventration (just weakness & upward eversion ofthe diaphragm with no actual defect)DefinitionDefinition
    5. 5. Schematic illustration of a left congenital diaphragmatichernia showing translocation of abdominal viscera througha posterolateral aperture into the chest.
    6. 6. -Ipsilateral lung hypoplasia & cyanosis-Contralateral lung compression-Pulmonary hypertension & Rt to Ltshunting(Persistent fetal circulation)-Ischemia of herniated bowelPathophysiology:Pathophysiology:
    7. 7. DiagnosisDiagnosis• Antenatal diagnosis:-Maternal polyhydramnios-U/S• After birth:Severe cases :immediate severe RD ,cyanosis & gaspingUnequal air entryShifted heart soundsScaphoid abdomenMild cases (delayed diagnosis)Recurrent chest infectionsAccidental auscultation of bowel sounds
    8. 8. InvestigationsInvestigations• Chest X-ray• Arterial Blood gases• Echocardiogram• Ultrasound• CT chest
    9. 9. DD:DD:• Other causes of respiratory distressMention…………?
    10. 10. ManagementManagement• Preop. Care:1-NG tube2-ET intubation & ventilation3-I.V fluids4-Warming5-NICU admission
    11. 11. Operation :Operation :1-Abdominal approach (Subcostal incision)2-Reduction of the content3-Repair of the defect
    12. 12. A.Schematic drawing of an unreduced left congenital diaphragmatic hernia as seenfrom the abdomen. B, The same hernia but now reduced, Sutures have been placedfor a primary repair. C, Completed primary repair of a left congenital diaphragmatichernia D, Repaired left congenital diaphragmatic hernia using prosthetic material.
    13. 13. Postop.Care:Postop.Care:Continued ventillatory support
    14. 14. 2-Esophageal Atresia &2-Esophageal Atresia &Tracheoesophageal FistulaTracheoesophageal Fistula(EA & TEF)(EA & TEF)
    15. 15. Definition:Definition:• Esophageal atresia (EA) is an interruption ordiscontinuity• Tracheoesophageal fistula (TEF) is an abnormalcommunication• EA may be present with or without a TEF.• TEF may be present with or without EA.
    16. 16. Aetiology:Aetiology:• Incomplete partitioning of primitive foregut
    17. 17. Types of EA & TEF:Types of EA & TEF:
    18. 18. PathophysiologyPathophysiology• Failure of swallowing….dehydration &hypoglycemia• Proximal obstruction….Aspiration• Distal fistula…..regurgitation of acid intothe stmoach……..Severe pneumonia
    19. 19. DiagnosisDiagnosis• Maternal history of polyhydramnios.• Excessive salivation, drooling ,coughing,chokingcyanosis during the first oral feeding.• Chemical and aspiration pneumonia• The inability to pass a nasogastric tube into the stomach• X-ray: -coiling of the tube in the upper mediastinum.-gastrointestinal gas ??• contrast study• TEF w/o atresia presents with recurrent aspiration
    20. 20. Search forSearch for {{ VACTERLVACTERL }}VertebralAnorectalCardiacTracheal Present in 50% of cases.EsophagealRenalLimbSo that,other investigations may be done asrequired e.g: abd. U/S ,Echo,X-ray spine…etc.
    21. 21. ManagementManagement1-Preoperative preparation1-Preoperative preparation•Oral feeding prohibited•Continuous suction•NICU admission:Supine and elevated to 30 ~ 40ºincubator,oxygen inhalation, Endotrachealtube distal to the TEF minimize the leak andpermit adequate ventilation.•I.V fluids and broad-spectrum antibiotics•Exclude VACTERL.•Urgent surgical repair after rapid preoperativepreparation
    22. 22. • Low-risk infants should get primary repair :• high-risk babies get gastrostomy• Rt thoracotomy through the 4thintercostal space.• Operation includes TEF ligation, transection, andrestoration with end-to-end anastamosis over aryle tube.• An ICT is inserted in the Rt pleural space.• POD 5-7 esophagram, if no leak, feed, removedrain.2-Operation2-Operation
    23. 23. ComplicationsComplications• Early complications :Anastamotic leak,recurrent TEF,tracheomalacia.• Late Complications :Anastamotic stricture (25%),reflux (50%),dysmotility (100%).
    24. 24. 3-Congenital Hypertrophic3-Congenital HypertrophicPyloric StenosisPyloric StenosisCHPSCHPS
    25. 25.  Common.Common. Between the ages of 2 and 8 weeks.Between the ages of 2 and 8 weeks.
    26. 26. PathophsiologyPathophsiology::-Muscular hypertrophy of all the layers of-Muscular hypertrophy of all the layers ofthe pylorus , most significant in the circularthe pylorus , most significant in the circularlayer, causing pyloric stenosis &layer, causing pyloric stenosis &-Gradual gastric outlet obstruction(GOO).-Gradual gastric outlet obstruction(GOO).-Repeated Vomiting….losses of …-Repeated Vomiting….losses of …-increased peristalsis-increased peristalsis
    27. 27. Diagnosis:Diagnosis:SymptomsSymptoms-Onset:2-3 weeks after birth (not since birth)-Onset:2-3 weeks after birth (not since birth)-Persistent Progressive Projectile Non-bilie stained-Persistent Progressive Projectile Non-bilie stainedvomiting.vomiting.-hungry baby…..Feeds vigorously-hungry baby…..Feeds vigorouslySigns:Signs:-General: dehydration, weight loss,oliguria,tinge of-General: dehydration, weight loss,oliguria,tinge ofjaundicejaundice-Abdominal :-Abdominal :distension of epigastrium,distension of epigastrium,Visible gastric peristalsisVisible gastric peristalsisPalpation of the pyloric tumorPalpation of the pyloric tumor (pathognomonic)
    28. 28. Investigations:Investigations:1-Ultrsound: Diagnostic in most cases1-Ultrsound: Diagnostic in most cases2-Barium meal: for cases with difficulty in diagnosis2-Barium meal: for cases with difficulty in diagnosis ::①①distention of the stomachdistention of the stomach②②strong gastric wavesstrong gastric waves③③elongated and narrow pyloric channel “String Sign”elongated and narrow pyloric channel “String Sign”④④delayed gastric emptyingdelayed gastric emptying3-Labs:3-Labs:- Na,K,Ca ,Cl- Na,K,Ca ,Cl-hypo-chloraemic metabolic alkalosis,-hypo-chloraemic metabolic alkalosis,- Indirect hyperbilirubinemia (glucuronyl transferase- Indirect hyperbilirubinemia (glucuronyl transferasedeficiency)deficiency)
    29. 29. Pyloric Stenosis--USPyloric Stenosis--US
    30. 30. Barium meal
    31. 31. Management:Management:1-Preoperative preparation:1-Preoperative preparation:-Good hydration by I.V fluids-Good hydration by I.V fluids-correction of electrolytes & metabolic-correction of electrolytes & metabolicalkalosisalkalosis
    32. 32. Ramstedt`s pyloromyotomyRamstedt`s pyloromyotomy-Transverse Rt upper abd. Incision-Transverse Rt upper abd. Incision-Intraoperative finding:-Intraoperative finding:Olive shaped mass which is:Olive shaped mass which is:22 ~~ 3cm in length,3cm in length,pale in colorpale in colorFeels like cartilage)Feels like cartilage)-Incision in the anterosuperior surface-Incision in the anterosuperior surface-Avoid perforation-Avoid perforation2-Operation:2-Operation:
    33. 33. CHPSCHPSDanger point
    34. 34. Pyloromyotomy (diagramatic)Pyloromyotomy (diagramatic)
    35. 35. Pyloromyotomy (Operative photos)Pyloromyotomy (Operative photos)Pyloromyotomy Completed
    36. 36. 3-Postoperative:3-Postoperative: Infants are usually maintained on I.V fluidsInfants are usually maintained on I.V fluidsfor few hours.for few hours. They are allowed to resume gradual oralThey are allowed to resume gradual oralfeeding at the same day and arefeeding at the same day and aredischarged within 24-48hdischarged within 24-48h
    37. 37. 4-INTUSSUSCEPTION
    38. 38. DEFINITION:• The Invagination or telescoping of a proximal segment of bowel(intussusceptum) into the lumen of a distal segment (intussuscipiens).Intussusceptum=proximal portionIntussuscipens=distal portion
    39. 39. INCIDENCE:• Second most common cause of acuteabdominal pain in children followingappendicitis• Found between 3 months to 2 years ofage, peaking at 5-7 months
    40. 40. AETIOLOGY: Idiopathic 90%(Most are ileocolic) Lead point <10%•Most common is Meckel’s diverticulum•Other possibilities : polyps, hemangiomas,lymphomas, cyst;appendix, intestinal neoplasm,submucosal hemorrhage associated withHenoch-Schönlein purpura, foreign body, ectopicpancreatic or gastric tissue, and intestinalduplication.Hypotheses of etiologies:……..
    41. 41. PATHOPHYSIOLOGY• The invaginated segment is carried distally byperistalsis.• Mesnetery and vessels become involved with theintraluminal loop and are squeezed within theengulfing segment causing venous congestion.• Types: enteroenteric, enterocolic, and colocolic.
    42. 42. DIAGNOSIS:1-CLINICALLY:• Cramping abdominal pain in an otherwise healthy child.• drawing the legs up during the pain episodes After sometime, the child becomes lethargic.• Vomiting.• Constipation although frequent bowel movements mayoccur with the onset of pain.• “currant jelly” stool :dark blood clots mixed with mucus,• An abdominal mass. & Signe de Dance
    43. 43. CLASSIC TRIAD:Colicky abdominal pain-pulling knees up to abdomenSausage shaped AbdominaMass-sausage shaped“Red Currant Jelly” or bloodystoolspresent in only 20-50% of cases
    44. 44. 2-IMAGING:1-Abdominal X-RayLow sensitivity, high false negative rateCan be negative in early ISUses:-Diagnosis of intussusception-Evaluating for risk of perforation before enema treatment-Diagnosis of other diseases (SBO, LBO, volvulus)•Radiographic signs of Intussusception:target signcrescent signabsent liver edge sign (also called absence of the subhepatic angle)bowel obstructionMay have a normal x-ray!
    45. 45. Where isthe targetsign?
    46. 46. Created by gastrapped betweentwo layers ofintestinal walltarget sign
    47. 47. • An abdominal film showingsigns of small bowelobstruction (multiple dilatedintestinal loops mainly in thecenter of the abdomen withvavulae coniventes)
    48. 48. • Erect film showing multiplefluid levels in the small bowel
    49. 49. plain abdominal films cannot be used torule out intussusceptionKEEP IN MIND…
    50. 50. 2-ULTRASOUND•Used to diagnose IS and prevent unnecessary enemasHigh sensitivity and specificityNo radiation exposureExclude other pathologies.•Findings:-target sign (transverse)-sandwich sign (longitudinal)
    51. 51. TARGET SIGNCentral hyperechoic region (C) surrounded by hypoechoic andhomogeneous edge (bowel wall)
    52. 52. TARGET SIGN
    53. 53. SANDWICH SIGNCylindrical hyperechoiccenter (C) thatcontinues fromintestinal lumen and issurrounded on bothsides by hypoechoicmesentary (M)
    54. 54. 3-BARIUM ENEMA
    55. 55. 4-CT SCAN• Target sign is also seen inCT.• Can also see a sausageshaped mass
    56. 56. MANAGEMENT:1-RESUCITATION & PREOP.PREP.:NPONG tubeI.V.fluidsBroad spectrum antibiotics.Blood transfusion.
    57. 57. 2-REDUCTION ENEMA:• When the clinical index of suspicion for intussusception is high,hydrostatic reduction by contrast agent or air enema is thediagnostic and therapeutic procedure of choice.• Types of enemas Pneumatic (air enema) Hydrostatic (fluid enema) Barium Enema (fluid with contrast)
    58. 58. Barium Enema:
    59. 59. 3-SURGERY:Exploration through a transverse supraumblical incision- Viable intestines:Reduction by milking (withappendectomy,excision of associated Meckel`sdiverticulum…)-Gangrenous loop: Resection of the affected segmentwith: -primary anastmosis-proximal ileostomy or colostomy and distalmucous fistula
    60. 60. Ileocecocolic intussusception containing viableloop treated by milking and appendictomy
    61. 61. Neglected ileocecal intussusception with gangrenousperforated intestines treated by resection and primaryanastmosis
    62. 62. 5-Hirschsprung’s Disease5-Hirschsprung’s Disease
    63. 63. Hirschsprung’s DiseaseHirschsprung’s Disease• Neurogenic form of intestinal obstruction• Absence of ganglion cells in the myentericand submucosal plexus• Failure in relaxation of the internal analsphincter and affected bowel• Upstream bowel becomes dilatedsecondary to distal obstruction
    64. 64. Pathogenesis:Pathogenesis:• Failure of neural crest cells to migrate caudally• Aganglionosis begins at anorectal line• 80% involve only rectosigmoid area• 10% extend proximal to splenic flexure• 10% involves the entire colon and part of smallbowel (Total colonic aganglionosis)• Rarely involves entire gastrointestinal tract
    65. 65. Presentation:Presentation:• Severe abdominal distention• 95% - failure to pass meconium in first 24hours life• Bilious vomiting• PR examination…gush of stools & gas• Older children - constipation, failure to thrive• 10-15% -Present with Hirschsprung’senterocolitis severe explosive diarrhea,fever ,dehydration and abd distension.
    66. 66. a neonate with Hirschsprung’s Disease
    67. 67. DiagnosisDiagnosis• Clinical• Abdominal plain X-rays• Barium Enema• Rectal Biopsies• Anal manometry
    68. 68. Hirschsprung’sHirschsprung’s
    69. 69. Abdominal X-ray (HSD)Abdominal X-ray (HSD)
    70. 70. HSDHSD
    71. 71. Barium EnemaBarium Enemashowing 3 differentshowing 3 differentzoneszones :-:--Spastic lower zone-Spastic lower zone-funnel shaped middle-funnel shaped middlezonezone-markedly dilated proximal-markedly dilated proximal(normal) colon(normal) colon
    72. 72. Barium EnemaBarium Enema• Less sensitive for detectingshort and ultrashort segment HSDtotal colon aganglionosis, anddisease of the newborn (Many newbornsdo NOT show definitive transition zone butonly delayed evacuation of contrast)
    73. 73. Rectal biopsyRectal biopsy• Submucosal suction biopsy–Meissner’s submucosal plexus• Full thickness rectal biopsy–Auerbach’s myenteric plexus• Acetylcholinesterase staining–increased staining of neurofibrils
    74. 74. Anorectal manometryAnorectal manometry• Absent rectoanal inhibitory reflex• Lack of internal anal sphincterrelaxation in response to rectalstretch
    75. 75. Management:Management:1-Definitive repair:1-Definitive repair:• Transanal Pull-through operations (in prone jack-knifeposition)The most commonly used is the Trans-analendorectal mucosal excision (Soave)A transanal approach is usually sufficent butabdominal incision is sometimes needed formobilization of long segment HSD or in olderchildren.• Laparoscopic assissted transanal pullthroughis a recent approach that uses laparoscopy formobilizing the colon , facilitating the procedureand avoiding bdominal incision.
    76. 76. Laparoscopic Assissted transanal pullthrough : the affectedsegment has been withdrawn through the anus after beingdissected free from its mesentry and blood vessels usinglaparoscopy
    77. 77. Operative complicationsOperative complications• Constipation.• Stricture Formation.• Leak at anastamosis.• Postop Enterocolitis.• Incontinence.
    78. 78. 2-Hirshsprung enterocolitis:• It`s is a medical emergency requiring:-Hospital admission and observation-NPO-I.V fluids-Broad spectrum antibiotics and metronidazole-Frequent colonic irrigation.• Surgery is indicated in cases of :-Failure of conservation.-Evidence of bowel perforationin the form of a leveling transverse or sigmoidloop colostomy.
    79. 79. 6-Meckel’s Diverticulum6-Meckel’s Diverticulum
    80. 80. Meckel’s DiverticulumMeckel’s Diverticulum (Disease of 2 )(Disease of 2 )• Found in 2% of the population.• Symptomatizes in only 2% of affected people.• Majority of symptomatic cases < 2yrs old• 2 feet from ileocecal valve.• About 2 inches in length.• contains 2 types of ectopic tissue: gastric and/orpancreatic.
    81. 81. Presentation:Presentation:• Painless GI Bleeding (50%)• Bowel Obstruction (30%)• Inflammation – diverticulitis (20%)
    82. 82. GI Bleeding:GI Bleeding:• Most common cause of bleeding inchildren• Painless, massive, usually self resolving• Due to mucosal ulceration from acidsecretion
    83. 83. Bowel ObstructionBowel Obstruction• Due to-Intussusception, (diverticulum is the lead point)-Mesodiverticular bands (connecting thediverticulum to the mesentry and kinking of theintestine or internal herniation)
    84. 84. Operative photo of a 4 years old child presented with intestinalobstruction.Exploration revealed a mesodiverticular band which was dividedfollowed by wedge excision of the Meckel`s diverticulum with primary repair
    85. 85. Meckel’s Diverticulitis:Meckel’s Diverticulitis:• Symptoms simulate acute appendicitis• Result of luminal obstruction, bacterialinvasion, progressive inflammation• Ectopic gastric mucosa predisposes• 30% incidence of perforations• Higher risk of peritonitis
    86. 86. TreatmentTreatment1-Symptomatic Meckel`s requires either :- Wedge excision with transverse repairof the intestinal wall.- Resection of the adjacent segment ofilieum with end to end anastmosis.
    87. 87. 2-Incidentally found Meckel`s: (duringoperation for another cause)-If healthy wall,wide based and of shortlength …..leave alone-If narrow based ,long ….excise
    88. 88. 7-Anorectal Malformations7-Anorectal Malformations
    89. 89. SynonymsSynonyms• imperforate anus• anorectal malformations• anorectal anomaly
    90. 90. FrequencyFrequency• Anorectal malformations occur in approximately 1 per 5000live births One of the most frequently encountered digestive tractabnormality Frequency is slightly higher in males compared with females Associated anomaly: urogenital,another gastrointestinal anomaly,cardiovascular, vertebra Arrest of the caudal descent of the urorectal septum toward thecloacal membrane during the fourth week and ending by theeighth week of gestation.
    91. 91. PC line: pubococcygeal lineI line: ischial line
    92. 92. TYPESTYPES• HIGH TYPE• LOW TYPE
    93. 93. Clinical Findings:Clinical Findings:• Findings are associated with a high malformation– A flat perineum, as evidenced by the lack of a midline glutealfold– absence of an anal dimple, indicates that the patient has poormuscles in the perineum.• Perineal signs found in patients with low malformationsinclude– the presence of meconium at the perineum,– a bucket-handle malformation– anal membrane (through which meconium is visible).
    94. 94. RADIOGRAPHY (INVERTOGRAM)RADIOGRAPHY (INVERTOGRAM)16-24 hours16-24 hours
    95. 95. A flat perineumA flat perineum
    96. 96. A flat perineum-GIRLA flat perineum-GIRL
    97. 97. Perineal fistulaPerineal fistula
    98. 98. bucket-handle malformationbucket-handle malformation
    99. 99. Imperforate anus with rectovesical fistula
    100. 100. Imperforate anus with rectourethral fistula
    101. 101. Associated malformationsAssociated malformations• The following associated anomalies canoccur separately or as VACTERLassociations:– Esophageal atresia– Duodenal atresia– Ventricular or atrioseptal defects– Tetrology of Fallot– Hirschsprungs disease
    102. 102. Surgical Treatment:Surgical Treatment:• Colostomy versus Definitive repair
    103. 103. COLOSTOMYCOLOSTOMY)Sigmoid colostomy with distal mucousfistula(
    104. 104. Definitive repairDefinitive repair1-Anoplasty :– Rectoperineal fistula– Covered anus– Bucket-handle malformation
    105. 105. • Posterior Sagittal Ano-Recto Plasty (PSARP)
    106. 106. 8-Intestinal Malrotation
    107. 107. a group of congenital anomalies resulting fromabnormal intestinal rotation and fixation
    108. 108.  Week 6~8: Herniation of midgut into the umbilical cordwith a 180 degree of counterclockwise rotation along theaxis of superior mesenteric artery Week 10: Return to the abdominal cavity with a final 90degree of rotation to complete the 270-degreecounterclockwise rotation
    109. 109.  Nonrotation and Incomplete rotation: abnormal positioning ofthe proximal small bowel and the cecum Duodenum compressed by abnormal peritoneal band(Ladd’sband): high incomplete extrinsic obstruction Midgut volvulus: torsion of the narrow mesenteric pedicleproduces an acute closed-loop intestinal obstruction andvascular strangulation. Proximal jejunum fused to the ascending colon by anomalousperitoneal attachments
    110. 110. Newborn with: Emesis : bilious, intermittent , occur at 3-5 days after birth orasymptomatic Abdominal distention: confined in epigastrium or diffuse to the fullabdomen in bowel necrosis Stool: normal meconium or bloody stool with volvulus and necrosisChildren and infant: asymptomatic since birth, intermittent orsudden onset of intestinal obstruction
    111. 111.  1-Plain X-ray : double-bubble sign 2-Barium meal follow through : incompleteduodenal obstruction; ligament of Treitz not to the left ofthe midline; abnormal position of the proximal jejunalloops to the right of the midline 3-Barium enema: cecum in the upper or left abdomen
    112. 112. TreatmentTreatmentPrinciples:-Asymptomatic malrotationmost recommend surgical treatmentsome believe operation only necessary in young children-High intestinal obstructionoperated on promptly, but not necessarily emergently-Volulus with sign of bowel necrosis: immediate operation
    113. 113. Ladd′s operation )or Procedure(: Untwisting: Volvulus is always clockwise so thesmall bowel must be rotated in a counterclockwisefashion. Division of Ladd’s bands. Broadening of the base of the mesentry. Redistribution of small bowel to the right and colonto the left of the abdominal cavity Appendictomy: to avoid misdiagnosis ofappendicitis later on.
    114. 114. Ladd′s Procedure
    115. 115.  O`neil textbook of pediatric surgery. Rob & Smith operative pediatric surgery. Shwartz principles of surgery. Kasr Al-Aini Introduction to surgery.
    116. 116. Thank You(mustafa_redwan@yahoo.com)

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