DD

1. ILMU BEDAH ANAK
( PEDIATRIC
SURGERY )
Poerwadi, Pediatric Surgeon
Departement of Surgery / Division of Pediatric Surgery,
Soetomo Teaching Hospital / Medicine Faculty, Airlangga Uni
S U R A B A Y A

2. Special Considerations
NEONATE
CHILDREN ADULT MINI
STRES
MATURATION
ADAPTATION
GROWTH
ENLARGEMENT
SIZE AND SHAPE
BODY SURFACE
BODY CAPACITY
EQUIPMENT.
 PATTERN DISEASE
 CONGENITAL ANOMALY
 PERI OPERATIVE CARE
 SURGICAL TECHNIC
 POST OPERATIVE CARE

3.  Physiologic .
 Anatomy.
 Pediatric Surgical cases .
 Pattern diseases &
 Problem of the neonates and children.
Newborn .. Neonate …Infant…Children…Toddler.. Adult …Geriatric
Congen Congen Congen Infect Hormonal Infect Degener
Infetion Infect Neoplasma
 FETAL SURGERY .
 NEONATAL SURGERY .
 PEDIATRIC SURGERY.
 HISTORY :
 Pediatric Surgery ……. 1881 ……… Hirschsprung
 ….. 1956 Grobs ………… Swenson
Unique& Characteristicsaspect of neonates and children :

4. PROBLEMS
Newborn MEDICAL PROBLEM :
Adaptation
Maturation
Physiology
Pattern of disease
Examinations
SPECIAL PROBLEM :
1. Facilities.
2. Transportation
3. Pre operative management
4. Intra operative managemant.
5. Post operative management
INFANT
NEONATE
CHILDREN
TODDLER
COMMON PROBLEM :
1.Ethical Problem.
2.Sociocultural Problem.
3.Economics Problem
4.Law.

5. 1. Early diagnosis of surgical conditions :
DIFFICULT !!!
- Baby and child cannot complain delay
- Difficulties and risk of Diagnostic
procedure
- The Equipment : age and BW
- Different pattern of disease with adult.

6. 6
TARGET:
MUST KNOW :
1. Common Cases.
2. Emergency Cases.
3. Initial Asassement and Resuscitation.
4. Referral & Transportation.
NICE KNOW :
 Resuscitation …. Live threatening: ABC
References :
 Prem Puri & Michael Höllwarth : PEDIATRIC SURGERY, © Springer-
Verlag Berlin Heidelberg 2006
 Steven Teich MD, Donna A. Caniano MD : Reoperative Pediatric
Surgery , © Humana Press 2008

7. Neonatal surgical problems often present
as EMERGENCIES !!!:
- Rapid stabilization and transfer .
- Proper initial management is crucial .
- Multi organ systems most commonly
affected .

8. 1.1. Airway Obstruction :
a. Choanal Atresia.
b. Robin Sequence Disease.
c. Pierre Robin Syndrome.
d. Laryngeal & tracheal anomali.
e. Oesofageal Atresia +/- Fistel .
f. Cystic Hygroma.
g. Infection
SURGICAL EMERGENCY CASES
IN NEWBORN AND CHILD :
1. Immediately, life-threatening :

9. Congenital Diphragmatic Hernia
a. Esophageal Atresia & tracheoesophageal fistula
b. Congenital diaphragmatic hernia.
c. Abdominal distention
d. Evisceratio Diafragma.
e. Pneumothorax
f. Hematothorax.
1.2. Respiratory Disorder :

10. 1.3. Circulatory :
a. Congestive heart Diseases.
b. Intussuseption.
c. Strangulated hernia,
d. Haemorrhagic shock.
e. Volvulus

11. 1.4.Infection :
a. Appendicitis
b. Peritonitis.
c. NEC.

12. 1.5. OTHERS :
a. Anorectal Malformations without fistel.
b. Omphalocel.
d. Gastroschizis.
e. Sacrocoxygeal Teratoma.

13. Urgent :
1. Infantile hypertrophic pylorus stenosis.
2. Duodenal Obstruction (duodenal atresia,
malrotation, annular pancreas )
3. Billiar Atresia.
4. Choledochal cyst.
5. Inguinal Hernia.
6. Small intestine atresia.
7. Anorectal Malformation with adequate
fistel.
8. Hirschsprung Disease.

14. MANAGEMENT
General Management :
To resuscitated Stable conditions
To make Optimal conditions
To maintaining optimal conditions

15. Clear ET
Oxygenation
Ventilation prevent
barotrauma
aspiration ( NGT )
venous access
Central ?. MONITORING
perfusion, ECG, HR, Urine
nvironment ( temperatur control )
RESUSCISATION
B
A irway
Circulation
E
ISABILITY  others congen anomalies ?
d

16. NEWBORN AND CHILD SURGICAL
EMERGENCY CASES AND PROBLEMS
Kind of
Disease PROBLEM
MANAGEMENT
DIAGNOSTIC Preoperative
Care
Transportation OPERATION
Technic Timing
1
Esophageal
Atresia
Unknown,
Aspiration,
Pneumoni,
SGA, other
anomalies
NGT insertion
Babygram
Fasting,
NGT insert &
suction,
trendelenburg
position.
Thermo regul
Trendelenburg po
sition &
Thermoregulation
Gastrostomi
Anastomosis
Cito
Urgent
2
Diafragmatic
Hernia
Respratory
distress ,
SGA
Thorax foto,
with NGT
inserting
NGT insertion,
Oxigenation.... /
Respirator
Tilt ( left position /
Upper right )
Repair of
diaphragmatic
deffect
Urgent
( Resp was
controlled )
3
Rupture
Omfalocel &
Gastroschizis
Hypothermia,
thiny abdomi
nal cavity,
Short gut.
Easy Thermoregula
tion, water &
electrolit resus
citation &
infection
control
Thermoregulation Silastoplasty Cito
4
Duodenal
obstruction
Delayed,
catabolic state
Plain foto:
Double buble.
Colon inloop
Water &
electrolit resus
citation
Thermoregulation Laparotomi :
-Ladd’s procedr
-Duodeno - duo
denostomi -
Duodenoplasty
Urgent

17. Kind of
Disease PROBLEM
MANAGEMENT
DIAGNOSTIC Preoperative
Care
TRANSPORTATI
ON
OPERATION
Technic TIMING
5
Small intest
obstruction
Abdominal
distention
Sphlancnic
compartement,
Aspiration,
Respir distress
Catabolic state
Abd plain photo
Colon inloop
Water &
electrolit
resuscitation
Thermoregulation Ileostomy,
Delayed
anastomosis
Urgent
6
Intussuception
Strangulation,
Intestinal obs-
truction,
Delayed
Trias
Colon inloop
Water &
electrolit
resuscitation
Thermoregulation Reposition :
Non operative
( new )
Operative
Cito
7
Strangulated
Hernia
Strangulation
Recidif
Clinical sign
Water &
electrolit
resuscitation
Sedativum.
Thermoregulation
Fowler position
Conservative
( new )
Fail :
operation
Cito
8
NEC Unkwon
Delayed
Sepsis
Cinical sign
Abd plain photo
Culture : blood &
peritoneal fluid
Water &
electrolit
resuscitation
Fasting,
Decompresion,
TPN,
Antibiotika
Thermoregulation Conservative
( new )
Fail :
operation
( perforation )
Cito

18.  Indirect 99%
 1% to 3% of all children
 3% to 5% in preterm baby
 R 60% L 30% Bilateral 10-15%
 Males to females ratio is 6:1
 Present as bulge in the groin,
scrotum, or labia.
 A reliable history is sufficient to
make the diagnosis, even if the
hernia cannot identify.
 An incarcerated inguinal hernia
presents as a mass in the labia or
scrotum that does not reduce
spontaneously.
Inguinal hernia

19. Attempt manual reduction
(use sedation if necessary);
emergency surgery if unsuccessful.
What embryological events
account for this abnormality?
Failure of the processus vaginalis to
close (it remains patent).
 What are your
recommendations to the parents?
The hernia should be repaired
( URGENT );
the parents should be warned
about possible incarceration.
 If at the time of your examination
the child were irritable and the
mass irreducible,
what would be your approach?

20.  NOTE.
 Inguinal hernia is common in males because the testis
descend and make the procesus vaginalis more wider.
 Hernia; Swelling start from above so when the patient
cough you can feel the swelling from above and below.
(Inguinoscrotal)
 Hydrocele; Fluid accumulate only below and no swelling
above (scrotal swelling only).
 You must treat it to prevent strangulation
 Experienced doctors knows how to reduce it in 95% of
cases. So after you reduce it do the operation in the next
day.
(Important):

21. Hydrocele
 It is a collection of fluid in the
tunica vaginalis.
 Localized to the scrotum.
 Fluctuation of the scrotal size
during the day.
 Types: communicating &
noncommunicating
 Transillumination : +
 Do not aspirate !!!
 Treatment: Observation for 1 to 2
years of age, before
recommending repair.

22. ESOFAGEAL
ATRESIA
( EA )
EA … WITH or WITHOUT
FISTULA TO TRACHEA.

23. GEJALA KLINIK :
IBU HAMIL DGN HYDRAMNION / POLYHYDRAMNION.
 TERSEDAK, BATUK, SESAK NAFAS,
CYANOSIS.
 DYSPHAGIA ------- PERHATIAN !!! :
 JANGAN DIBERI MINUM !!!
BAYI LAHIR HYPERSALIVASI &
SALIVA BERBUIH.

24. PASANG NGT ---- TIDAK BISA MASUK.
BUAT FOTO POLOS : Babygram
FOTO DGN KONTRAS ???
----- HATI - HATI !!!
SYARAT :
KONTRAS HARUS WATER SOLUBEL.
TERSEDIA ALAT PENGHISAP.
VOLUME KONTRAS
Associated Anomaly
Cardiovacular 35%
Gastrointestinal 15%
Neurologic 5%
Genitourinary 5%
Skeletal 2%
VACTERLsyndrome 25%
Overall incidence 50-70%

25. Gastric tube No. 10 F
dimasukkan melalui
mulut tidak bisa
mencapai lambung
Tube tidak bisa
masuk lebih 10 cm
dari gusi. (Jangan
dipaksa masuk
nares merusak
nasal)

26. Memakai soft tube
kaliber kecil
melingkar

27. Type B Type C Type D Type E
Bentuk – bentuk Pathology: Vogt
Type A

28.  HISAP TERUS GT YG TERPASANG & SALIVA YG KELUAR, AWAS!!!....
JANGAN DIBERIKAN NAFAS BANTUAN DGN MASKER.
 PUASAKAN & PASANG I .V. LINE , BERIKAN OKSIGEN MASK.
 SEGERA RUJUK ATAU GASTROSTOMY , BILA MAMPU.
 SIKAP BEDAH LANJUT SESUAI KRITERIA “ WATERSTONE “
 MENGOBATI PNEUMONITIS DGN BROAD SPECTRUM AB
 BERIKAN 1 MG VIT.K.
GASTROS
TOMY
MANAGEMENT

29. “ KRITERIA WATERSTONE “
PARAMETER :
BERAT BADAN( gram) >// 2500 1800 – 2500 <// 1800
KONDISI PARU BAIK SEDANG JELEK
KELAINAN LAIN NIHIL + / - ++
A B C

30. CONGENITAL DIPHRAGMATIC HERNIA
INSIDEN :
1 DARI 45.000 KELAHIRAN
K L I N I S :
1. PRENATAL DIAGNOSIS : POLY HYDRAMNION …..
USG .
2. DISTRESS NAFAS PADA BAYI (UNCOMPENSATED ).
3. GANGGUAN PARU / INFEKSI BERULANG PADA
ANAK ( COMPENSATED ).
4. GERAKAN DADA KANAN : < , SUARA NAFAS
HILANG , IKTUS KORDIS PINDAH KEKANAN ,
BISING USUS PADA CAV THORAX KANAN , PERUT
SCAPHOID.

31. MANAGEMENT :
1. DIAGNOSIS :
 BERDASARKAN GEJALA KLINIS .
 PEMERIKSAAN PENUNJANG :
 THORAX FOTO : GAMBARAN USUS PADA RONGGA
DADA , MEDIASTINUM TERDORONG KESISI KONTRA
LATERAL , ATELEKTASIS / HYPOPLASIA PARU
IPSILAT.
 ANALISA GAS DARAH ( MENENTUKAN PROGNOSE & THERAPY ).
2. THERAPY :
TERGANTUNG DERAJAD GANGGUAN RESPIRASINYA :
* PERBAIKI DULU RESPIRASINYA :
 RESPIRATOR ??? … HATI – HATI … BAROTRAUMA
!!!!.
 ECMO (Extra Corporeal Membrane Oxygenation )
…. TEPAT .

34. Causes:
Congenital/ inflammatory/ malignancy
Age : newborn, infant, child
Level : Upper, mid, lower gut
Internal/external
Types :
 Simple
 Strangulation
Bowel Obstruction
Age specific:
Newborn…infant : congenital
Children : intusception , Meckel’s,
adhesions appendicitis
( “febrile obstruction”)

35. Four cardinal signs of
intestinal obstruction
in neonate
1. Antenatal
polyhydramnios
2. Bilious vomiting
3. Delayed passage of
meconium (> 24 hrs)
4. Gastric residual > 30 cc
Cardinal sign in adult
1. Vomiting
2. Abdominal pain
3. Abdominal distension
4. Obstipation/ constipation
LEVEL of obstructions
Esofagus :
Drolling
Abd not dist
Stomach :
Vomitus
projectile, clear
 Abd. Not dist
Smal inst :
 vom , yelw
 abd: dist
Large inst :
 Vom: fecal
 abd: dist

37. Perioperative Management
 Fundamental rule: Resuscitation of
losses/maintenance/ongoing
 Urine output best measure of adequate resuscitation
 ? Need for central monitoring
…… Bolus: crystaloid : 20 cc/kg
… Monitoring : BP, heart rate, urine output, saturation
 Antibiotics if any viscus opened, cardiac issues,
immunosuppresed (newborn)
 Steroids: if on previously/deficiency (stress dose
physiology)
 Gastric tube (Decompression)
 Keep patient warm

38. GASTRIC OUTLET
OBSTRUCTION
ETIOLOGI :
A . CONGENITAL : atresia , septum,
stenosis anthrum pyloricum.
B . ACQUIRED :
 Infantile Hypertrophic Pylorus Stenosis ( IHPS ).
C . MAKANAN : Phyto Bezoir & PiloBezoir

39. GEJALA KLINIK :
1. MUNTAH , JERNIH , SESUAI DIMINUM, MENYEMPROT
2. TIDAK KEMBUNG , CONTOUR & STEIFUNG LAMBUNG : +
3. TEST PROVOKASI : +
4. FOTO POLOS PERUT :
……..SINGLE BUBLE…. :
 SEGERA SETELAH LAHIR : …CONGENITAL : ATRESIA /
SEPTUM ANTHRUM PYLORICUM U.G.I. : - Kontras STOP
( ATRESIA )  Hati- hati
ASPIRASI !!!
 Umur 3 MGG - 6 MGG : IHPS ( teraba mass, USG : mass + )
U.G.I foto : STRIGN / UMBRELLA SIGN / SHOULDER SIGN
IHPS

40. GASTRIC WAVE
SINGLE BUBLE
STRING SIGN
UMBRELLA SIGN

41. INFANTILE HYPERTROPHIC PYLORUS
STENOSIS
PYLOROMYOTOMY
FREDET RAMSTEDT WEBER

42. Be Aware !!! of Child with
Bilious (Green) Vomiting

43. OBSTRUKSI DUODENUM
GEJALA KLINIK :
 Ibu poly hydramnion.
 Muntah : tidak menyemprot, walau
puasa,
jumlah banyak , warna hijau / putih.
 Retensi cairan lambung ( hijau ).
 Tidak kembung.
 Meko terlambat .
ETIOLOGY :
 M A L R O T A S I ………… EKSTRINSIK.
 A T R E S I A, S E P T U M, S T E N O S I S
…… INTRINSIK.
 P A N C R E A S A N N U L A R
E…EKSTRINSIK.

44. MANAGEMENT OBSTRUKSI DUODENUM :
DIAGNOSIS :
1. BERDASARKAN GEJALA KLINIK OBSTR DUODENUM.
2. FOTO POLOS ABDOMEN :

45. MALROTATION
COLON INLOOP / BARIUM ENEMA :
 PERHATIKAN POSISI CAECUM / APPENDIX
 ADAKAH “ MICRO COLON “ / NORMAL COLON .
Caecum

46. OMPHALOCELE = EXOMPHALOS
Keluarnya organ intra peritoneal melewati “ umbilcal
cord “ yang dilapisi membran amnion
E M B R Y O G E N E S I S : GANGGUAN PERTUMBUHAN
DINDING ABDOMEN
KLINIS :
MASSA DI UMBILICAL CORD
BERISI USUS, DILAPISI MEMBRAN AMNION
TALI PUSAT DIPUNCAK MASSA
CAVUM ABDOMEN SCAPHOID
OMFALOKE
L
UTUH
KECIL : < 3 Cm.
SEDANG : 3 - 5 Cm.
BESAR : > 5 Cm Atau HEPAR KELUAR

47. OMFALOKEL PECAH

48. THERAPY :
OMFALOKEL UTUH : KONSERVATIF
1. PERTAHANKAN KEUTUHANNYA.
2. CEGAH INFEKSI
3. RANGSANG GRANULASI
4. OMFALOKEL BESAR : - GANTUNG
- SUSPENSI.
5. MEDIKAMENTOSA .
.
OPERASI, SETELAH GRANULASI SEMPURNA

49. G A S T R O S C H I S I S
KELUARNYA ORGAN INTRA PERITONEAL
MELEWATI DEFECT PARAUMBILICAL,
TANPA DILAPISI MEMBRAN AMNION
EMBRYOGENESIS :
PERTUMBUHAN DINDING ABDOMEN NORMAL ,
TERJADI DEFECT KARENA GANGGUAN
VASKULARISASI DINDING ABDOMEN.
GASTROSISIS THORACAL

51. K L I N I S :
1. NEONATUS TERLIHAT VISCERA BERADA DILUAR PERUT.
2. TANPA DILAPISI MEMBRAN AMNION .
3. LETAKNYA PARA UMBILIKAL .
4. USUS YG DILUAR DINDINGNYA MENEBAL(PERITONITIS KIMIAWI )
DD:
OMFALOKEL PECAH & GASTROSCHISIS
1. TEMPAT DEFECT UMBILICAL CORD PARAUMBILICAL
2. TALI PUSAT DIPUNCAK KANTONG POSISI NORMAL
3. MEMBRAN AMNION SISA – SISA ROBEK TIDAK ADA.
4. PERITONITIS KIMIAWI TIDAK ADA / JARANG HEBAT .
5. RONGGA PERUT KECIL NORMAL .
6. VISCERA YG KELUAR USUS + SERING HEPAR HEPAR JARANG

52. GANGGUAN PERKEMBANGAN DUCTUS
OMPHALO ENTERICUS
1. DUCTUS OMPHALO ENTERICUS PERSISTENT : EKSISI
2. OMPHALO ENTERICUS FIBROSIS : EKSISI
3. SINUS OMPHALO ENTERICUS +/- GRANULOMA : EKSISI
4. OMPHALO ENTERIC CYST : EKSISI
5. URACHUS PERSISTENT : EKSISI
6. HERNIA UMBILICALIS : KONSERVATIF
.
URINE
FESES

53. Embryogenesis duktus omphaloenterikus
OMPHALO ENTERICUS FIBROSIS
DUCTUS OMPHALO ENTERICUS PERSISTENT
OMPHALO ENTERIC CYST

54. MENGANDUNG MUKOSA LAMBUNG….ULKUS ..
BERDARAH.
GEJALA KLINIS DIVERTKEL MECKEL ;
Sesuai komplikasi yang ditimbulkannya , sering asymptomatis.
SIKAP :
BILA MENEMUKAN DIVERTIKEL MECKEL
HARUS DIRESEKSI
7. DIVERTIKEL MECKEL :
 1 meter dari ileocaecal junction .
 mempunyai vaskularisasi tersendiri.
PENYULIT : + / - …. @ VOLVULUS
@ INVAGINASI
@ INFEKSI
@ PERFORASI
@ HEMATOSESIA :

55. HERNIA UMBILIKALIS
 Benjolan kistus di umbilikus
 Menonjol waktu menangis /
hilang waktu ditekan
 Embryologi : gagal menutupnya umbilical ring.
 Wanita > pria , kulit berwarna > kulit putih ,
prematutur >
 Berhubungan dgn metabolisme Mucopolysaccharide
( Hurler's Syndrome (gargoylism).
Therapy:
KONSERVATIF
Menutup usia 3bl – 1thn pada 90% kasus
Menutup pada usia 5 tahun pada 95% kasus
OPERASI :
Gagal nutup usia > 5 thn
Defek > 2 cm
Kosmetik
Inakerserata ( jarang ).

56. Perut kembung ?
?PATHOLOGIS
? SEBAB
? BEDAH

57. ABDOMINAL DISTENTION

58. A. BAYI
1. KELAINAN BAWAAN :
1.1. OBSTRUKSI USUS DISTAL
a. Atresia usus halus.
b. Mekonium ileus.
c. Volvulus neonatorum.
d. Penyakit Hirschsprung.
e. Malformasi Ano Rektal.
1.2. Infeksi : NEC

59. B. Anak
1. Proses Strangulasi :
1.1. Intususepsi.
1.2. Hernia inkarserata.
2. Infeksi :
2.1. Appendisitis +/- perforasi.
2.2. Typhoid + perforasi.
2.3. Perforasi lambung.
2.4. Inflamatory bowel disease.
3. Kelainan Bawaan :
3.1. Penyakit Hirschsprung.
3.2. Megakolon sekunder
4. Lain- lain : adynamic ileus.

60. OBSTRUKSI USUS HALUS
 K L I N I S :
 SIFAT : TIDAK MENYEMPROT ,
WALAU PUASA
 KWALITAS : KUNING SEPERTI FESES .
 KWANTITAS : BANYAK .
 KEMBUNG : HEBAT .
 OBSTIPASI : YA .
 ETIOLOGY :
1. EXTRINSIC :
- Atresia Yeyuno-ileal.
- Volvulus neonatorum.
2. INTRINSIK :
- mekonium ileus.
MUNTAH !!!

61. Embryogenesis
Second trimester :
 Gangg vacuolisasi
 Vascular accident
(Barnard)
FotoPolos
TypePathology

62. MANAGEMENT :
1. D I A G N O S I S :
 BERDASARKAN GEJALA KLINIS .
 PEMERIKSAAN PENUNJANG :
1. FOTO POLOS PERUT ( SCRENING ) :
 DILATASI USUS HALUS .
 AIR / FLUID LEVEL : +++
 TIDAK TERLIHAT GAMBARAN COLON.
 GROUND GLASS APPEARANCE ( mec ileus )
 PNEUMO PERITONEUM ( PERFORASI !! ).

64. 2. COLON INLOOP / BARIUM ENEMA :
MIKRO COLON : ATRESIA
ROSARIO SIGN : MECONIUM ILEUS .
LONG SEGMENT / TOTAL AGANGLIONIS
COLON.

65.  MANAGEMENT :
THERAPY :
 PUASA , PASANG NGT , INFUS .
 KOREKSI DEFISIT CAIRAN & ELEKTROLIT
 LAPAROTOMY
* PRIMER ANASTOMOSIS .
* DELAYED ANASTOMOSIS .
* LAIN - LAIN .

66. MEKONIUM ILEUS
THERAPY :
1. KONSERVATIF :
( BILA TANPA PENYULIT ).
PUASA , PASANG NGT ,
IRIGASI GASTROGRAFIN 76% .
KOREKSI DEFISIT CAIRAN &
ELEKTROLIT ( INFUS ) .
2. OPERASI :
( BILA KONSERV GAGAL /
ADA PENYULIT ):
LAPAROTOMY : Bishopkoop Proc /
Santuli Proc/ Mikulick proc.

67. NECROTIZING ENTERO COLITIS ( N E C )
SEJARAH : ?????? MISTERI KEGAWATAN BAYI
( 1891 )
……… 100 Thn TERLUPAKAN.
1. CRUZE & SNYDER ( 1961 ) : NEC
2. HERENDEEN & KING ( 1963 ) ; JELAS / KLINIS.

68. INCIDENCE :
BAYI – BAYI RESIKO TINGGI :
NEC..MENINGKAT
 BBLR < 1500 Gram .
 HYPOXIA …UMUM : distres
nafas
…LOKAL : perut
kembung
 HYPOTHERMIA .
 MUCOSAL INYURY :
• Early feeding ,
• hyperviscous feeding ,
• kembung berkepanjangan .
TRANSLOKASI KUMAN
INTRA LUMEN
( E. Coli , Klebsiella , Pseudomonas ,
Enterobachter , Salmonella , Clostridia ) .
NEC

69. K L I N I S :
 BAYI RESIKO TINGGI
 LEMAH , TDK MAU MINUM .
 MUNTAH SANG AT BERBAU & KERUH
…….. KEMBUNG .
 HEMATOSESIA ……… OLIGOURIA .
Selulitis dinding perut

70. 5. TANDA - TANDA PERITONITIS :
 PERUT KEMBUNG .
 MENGKILAP , KEMERAHAN , KREPITASI …. AWAS !!! : PERFORASI
6. TANDA - TANDA SEPSIS :
 D . I . C , PETECHIAE .
 GRANULOCITOPENIA .
MANAGEMENT :
DIAGNOSIS :
1 . ADANYA GEJALA KLINIS .
2 . LAB ( GRANULOCITOPENIA , CRP , CULTUR ).
3 . FOTO POLOS PERUT ; DAPAT DIULANG TIAP 8 Jam .
 LOOP USUS YANG MENETAP .
 KESURAMAN CAVUM ABDOMEN .
 PNEUMATOSIS INTESTINALIS ------ PN MEDIASTINALIS .
 PNEUMA PORTA ------ PNEUMO PERITONEUM ( PERFORASI ).

71. PNEUMATOSIS
INTESTINALIS

72. 2. THERAPY :
 STADIUM AWAL : KONSERVATIF …..
 PUASA TOTAL ……. Total Parenteral Nutrition .
 DECOMPRESI USUS : NGT , RECTAL TUBE …. Irigasi .
 KOREKSI DEFISIT CAIRAN & ELEKTROLIT, THROMB, ALB & GLOB ).
 OKSIGENASI ( O2 , Hb , SIRKULASI / PERFUSI JARINGAN ) .
 ANTIBIOTIKA ( Ampi + Amino + Metroni atau Cefalo III +
Metro )
 MONITORING KETAT ( KLINIS , LAB & RADIOLOGIS ).
 STADIUM LANJUT : LAPAROTOMY
 BUAT STOMA ( ILEOSTOMY ) .
 EXTERIORISASI ( BILA SDH PERFORASI ).

73. PENY HIRSCHSPRUNG =
MEGACOLON CONGENITUM

74. ETIOLOGI & PATOFISIOLOGI
Tonjolan neural neuroblast
berhenti
Tidak berganglion
Tidak berganglion
Spasme
Gangguan pengosongan
Hypertrofi/ hyperplasi
Dilatasi
Enterokolitis

75. INCIDENCE : 1 DARI 5000 KELAHIRAN.
KLINIS :
1. IBU POLYHYDRAMNION .
2. GANGGUAN DEFAEKASI : ACUTE , RECURRENT , CHRONIS .
TERGANTUNG PANJANG / PENDEK SEGMENT AGANGLIONER
 MEKONIUM TERLAMBAT KELUAR ( NEONATUS ) …… PANJANG
 OBSTIPASI ( ANAK - ANAK ). …….. PENDEK
3. VOMITING : HIJAU Atau RETENSI CAIRAN LAMBUNG ( NGT
)
4. KEMBUNG : ++
a. ACUT ( NEONATUS ) …. PIPA REKTUM & BILAS KOLON BERULANG
b. CHRONIS ( ANAK ) :
- TERABA KOLON MENEBAL .
- TERABA MASS ( SKIBALA ) .
5. ENTEROKOLITIS BERULANG ( ANAK ).
6. COLOK DUBUR :
- UDARA & FESES MENYEMPROT ( BAYI )
- SKIBALA DIATAS JARI ( ANAK ).

76. MANAGEMENT :
1. DIAGNOSE :
 GEJALA KLINIK .
 RADIOLOGY :
 FOTO POLOS PERUT : DILATASI USUS + , FECAL MATERIAL
COLON DOMINAN , REKTUM KOSONG.
 BARIUM ENEMA : KOLON DILATASI …. MENYEMPIT ….. SPASME
( SEPERTI GAMBARAN EKOR TIKUS ) .
 MANOMETRI : TEKANAN MENINGKAT .
 BIOPSI :
- INCI ONAL BIOPSY : SWENSON .
- SUCHTION BIOPSY : NOBLET
P.A ; H.E Atau HISTOCHEMISTRY .

77. FOTO POLOS PERUT
FAECALOM
ZONA TRANSIS
AGANGLIONER
FOTO BARIUM ENEMA

79. 2. THERAPY :
A . KONSERVATIF : BAYI ……PASANG RECTAL TUBE &
WASH OUT BERKALA DGN NORMAL SALINE , 38 ” C
B . OPERATIF :
BAYI : OPERASI DEFINITIF SATU TAHAP :
TRANS ANAL ENDORECTAL PULL THROUGH
LONG SEGMENT :
1. COLOSTOMY ……… DIVERSION FESES.
2. DEFINITIF : PULL THROUGH PROCEDURES ………..
 ENDORECTAL PULLTHOUGH : SOAVE’S PROCEDURE.
 RETRORECTAL PULLTHROUGH : DUHAMEL’S PROCEDURE.
 RESCTION & ANASTOMOSIS : SWENSON’S PROCEDURE .
REHBEIN’S PROCEDURE.

80. MACAM – MACAM TEHNIK OPERASI HIRCSHSPRUNG

81. ANORECTAL MALFORMATION
(AMR )
ANUS MEMBRANOSUS LOW HIGH
LOW FISTULAS HIGHFISTULAS
PATHOLOGY :
 A. WITHOUT FISTULA : Imperforated Anus ( Atresia Ani ) :
 With fistula

82. Perineal inspection
FISTEL ?
MALE FEMALE
Urinalysis:
Meko +
Without Fistel
( Atresia recti ):
- Anal membran.
Tx : cross incission
- Invertogram :
Low ( < 1 cm ):
Tx: L.PSARP
With Fistel :
A. Low Fistel :
- Perineal fistel.
Tx. Cut back inscision.
- Anterior anus.
- Bucket handle.
Tx: Min Anusplasty
With fistel
A. Low fistel :
-Perineal fistel
-Anterior anus.
-Bucket handle
-Anovestib/H
type
B. High Fistel :
- Recto vesical
- Recto urethral
B. High ( > 1 cm )
B. High Fistel :
- Recto vaginal
- Cloaca
Tx :
-Colostomy
-PSARP
Decision-making
in newborn with AMF

83.  EXAMINATIONS :
 LAB : URINE SEDIMENT ( MALE ).
 IMAGING :
 WITHOUT FISTULA :
* USG ( EARLY ).
* INVERTOGRAM ( WANGENTEEN - RICE ) :
> 12 Hrs.
Associated Anomalies : VACTERL
( Vertebra Anus Cardio Trakhea Esofagus Renal Limb)

84. THERAPY :
 ANUS MEMBRANACEUS : Cross Incision
 VESTIBULAR ANUS :
ADEQUAT…. DILATATION
NOT ADEQUAT : CUTBACK Incision
* Low Imporf Anus : LIMITED . P . S . A . R . P.
* High Imperf Anus : COLOSTOMY ….. P . S . A . R . P
Postero Sagital Ano Recto Plasty

85. ANOCUTAN FISTULA
KLOAKA
ANUS MEMBRAN

86. BUCKET HANDLE
ANUS VESTIBULARIS
INSISI CUTBACK

87. ATRESIA ANI ( PRIA )
FISTEL ANOKUTAN
MECONIUM PADA URINE
ATRESIA ANI( WANITA )
ECTOPIC ANUS
ANOVESTIBULAR
FISTULA

88. PERDARAHAN SALURAN CERNA
1. PERDARAHAN SALURAN CERNA ATAS :
HEMATEMESIS & MELENA .
2. PERD SAL CERNA TENGAH :
HEMATOSESIA .
3. PERD SAL CERNA BAWAH : DARAH
SEGAR.
K L I N I S :
• MUNTAH DARAH SEGAR , BERGUMPAL .
• IKUT PENCERNAAN ……… MELENA .
HEMATEMESIS & MELENA

89. Berak darah bercampur feses.
ETIOLOGY :
1. ULKUS DUODENI .
2. DIVERTIKEL DUODENI .
3. DIVERTIKEL MECKEL .
4. INVAGINASI ( INTUSUSEPSI ).
5. N . E . C
K L I NI S :
1. GEJALA LAIN TERGANTUNG KELAINAN PRIMER.
2. FESES BERCAMPUR DARAH ( MERAH TUA SEPERTI BATA ).
H E M A T O S E S I A

90.  INVAGINASI = INTUSSUSEPSI
MASUKNYA SEGMENT USUS PROXIMAL KE USUS DISTAL.
ETIOLOGY : ???? PADA ANAK- ANAK ,
PERUBAHAN POLA MAKAN .
INFEKSI / INFLAMASI / ALERGI .
DEWASA ( JARANG )… CARI PENYEBABNYA !!! .
INSIDEN : 3 Bln - 9 Bln.
PATHOFISIOLOGY :
LEAD POINT / SEGMENTAL PARALYSIS ---- HYPERPERISTALTIK
PROXIMALNYA .
MASUK

92. MANAGEMENT :
1. DIAGNOSA :
 KLINIS
 PENUNJANG : BARIUM ENEMA :
2. THERAPY :
 REPOSISI :
- NON OPERATIVE ……. BARU .
- OPERATIVE : BILA SDH ADA PENYULIT / GAGAL
LAPAROTOMY : REPOSISI SECARA MILKING .
“ T R I A S “
K L I N I S :
MASS
 DIAGNOSTIK
 Therapy

93. ETIOLOGY :
1. FISSURA ANI .
2. POLIP RECTI .
F I S S U R A A N I
ETIOLOGY : FESES KERAS.
KLINIS :
1. DEFEKASI DGN FESES YG KERAS .
2. NYERI WAKTU DEFEKASI , DARAH MENEMPEL PD FESES ….
MENETES
3. TRIAS ( ULKUS + HYPERTROFI PAPIL + SENTINAL TAG )
PADA JAM 12 .
4. AWAS !!! DILARANG MELAKUKAN COLOK DUBUR !!!
THERAPY :
• KONSERVATIF
• OPERATIVE ( SPHINCTEROTOMY )… BILA KONSERV GAGAL .
PERDARAHAN PERANUM ( SEGAR )

94. POLYP RECTI
ADANYA TUMOR BERTANGKAI DARI MUKOSA REKTUM AKIBAT
RADANG MENAHUN / JARINGAN GRANULASI .
INSIDEN :
ANAK ,,,,,,,,, JARANG < 1 Thn , SERING UMUR 2 - 8 Thn .
KLINIS :
1. BERAK DARAH SEGAR MENETES ,, TIDAK “ SAKIT .
2. KELUAR TONJOLAN / DAGING LEWAT ANUS .
3. COLOK DUBUR : TERABA POLYP , SERING PADA JAM 12 .
THERAPY : POLYPECTOMY / LIGASI .

96. PendekatanDiagnosis Tumor Abdomen
Pada Anak
Tumor ganas pada anak : 2% dari seluruh kasus onkologi.
bahkan keluhan belum timbul walaupun tumor telah dapat diraba
(sifat rongga perut yang yang longgar, sehingga bila ada massa di
dalamnya, dapat tumbuh sampai cukup besar tanpa mengganggu
organ di sekitarnya)
Tumor Abdomen Anak : diagnosis sulit ... terlambat
Dini ....tidak memberikan keluhan, ....
Neuroblastoma,
Tumor Wilms,
Teratoma,
Tumor ovarium,
Limfoma abdomen,
Hepatoma.
SERING !!!

97. Abdomen hanya sekitar 1-2%
SERING letaknya retroperitoneal.
Teratoma abd 29% berasal dari ovarium.
Teratoma retroperitoneal DD/ :
tumor Wilms,
neuroblastoma.
Foto polos abdomen : kalsifikasi, gigi, tulang dan lain-lain.
Teratoma
Tumor yang berasal dari sel germinativum
Dapat timbul di mana–mana.
AFP,
BHCG

98. KLINIS :
Tumor abdomen
Hematuria
Hypertensi
Febris
anemia
aniridia
hemihipertrofi
Gejala klinis
IVP
USG
CT Scan
Tumor marker : tidak ada
DIAGNOSIS :
Nefroblastoma
(Tumor Wilms’)
Neoplasma
dari parenchim ginjal

99. NEUROBLASTOMA
 Diagnosis dini tumor ini sulit.
Stadium lanjut
 Angka kematiannya tinggi.
Katekol
amin
 Hypertensi
 Fkushing
 Banyak keringat
 Demam
KLINIS
Gejala klinis
Foto polos perut
USG
IVP
CT scan
DIAGNOSIS
Imunohistokimia:
neurofilament,
synaptophysin
neuron specific enolase (NSE)
PA :

100. CONCLUSION
Surgical Problems in Newborn baby and children :
Complex
Newbornbaby is not miniatur of adult, physiology
maturity,
disease patern,
growth and development,
Identifications
stabilisation,
diagnosis,

101. Selamat BELAJAR!!!
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102. TERIMAKASIH