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3/6/12
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Pediatric General Surgery
Professor General & Thoracic Surgery
Topics for discussion
• What makes Pediatric Surgery unique? • Neonatal intestinal obstruction • Abdominal wall defects • Inguinal hernias • Appendicitis • Malignancies
Why is it different from adult surgery?
• Different diseases • Responses to surgery and trauma • Physiology • Cure vs. Palliation • Family dynamics • Ability to take a history • True general surgery
Physiology
• Children are not little adults • Problems and physiologic maturity vary at
different ages
Surgical Newborns
• Common Symptoms – Vomiting – Abdominal distension – Bloody stool – Respiratory distress
Neonatal Intestinal Obstruction
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Esophagus
Stomach
Colon Small
intestine
Duodenum
Esophagus
Stomach
Colon Small
intestine
Duodenum
Esophageal Atresia
Tracheoesophageal Fistula (TEF) and Esophageal Atresia (EA)
• VACTERL Anomalies • Coiled tube in the
proximal pouch • Air distally in the
stomach and GI tract • Outcome:
– 85-90% survival – 100% without
associated anomalies
Associated Defects
VACTERL
Repair of TEF and EA
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Repair of TEF and EA Repair of TEF and EA
Esophagus
Stomach
Colon Small
intestine
Duodenum
Pyloric stenosis
• Metabolic abnormality: – Hypokalemic – Hypochloremic – Metabolic alkalosis
• Paradoxic aciduria
Fredet Ramstad Pyloromyotomy
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Esophagus
Stomach
Colon Small
intestine
Duodenum
Beware the child that vomits green
Double Bubble
Duodenal atresia
Annular pancreas
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Normal Rotation
Malrotation
• Better term is absence of normal rotation
• Normal “anchor points” are absent
Effect of no anchor point
Volvulus
Ladd’s Procedure
L - aparotomy A - ppendectomy D - ivide bands D - eliver bowel to sides
End of Ladd’s Procedure
Small bowel on Right
Large bowel on Left
Appendectomy
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Esophagus
Stomach
Colon Small
intestine
Duodenum
Intestinal Atresia
• Presumed to be vascular accident in utero leading to infarction of portion(s) of bowel
Ileocolic Intussusception
• Small bowel telescopes through the ileocecal valve leading to obstruction
• Mesentery is caught in the process leading to ischemia
Red currant jelly stools
Contrast Enema Reduction
• Air or liquid is used to push the bowel back thereby reducing the intussusception
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Esophagus
Stomach
Colon Small
intestine
Duodenum
Hirschsprung’s Disease
• Etiology: arrest in migration of ganglion cells from the neural crest -> absence of ganglion cells in Auerbach’s and Meissner’s plexus’
• Pathology: spastic contraction, no relaxation, functional obstruction
Imperforate Anus
• Associated Anomalies – Spinal / Sacral (most common) – Urogenital – VACTERL association
Imperforate anus
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Imperforate anus
Perineal/Vestibular Fistula
Posterior Sagittal Anorectoplasty
Abdominal Wall Defects
In utero
Gastroschisis
• Associated anomalies much less common – Malrotation (all) – Short bowel – Intestinal atresia
• Hypothermia and hypovolemia are of greatest concern
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Omphalocele
• Anomalies in 50% – Trisomy 13, 18, 21 – Beckwith-
Wiedemann Syndrome
– Cardiac, Skeletal, GU, Neurologic
– Intestinal tract • Cloacal extrophy,
Pentalogy of Cantrell Place infant in warm saline bag
Silicone Ventral Wall Defect Silo Bag “Peel” on bowel
Staged closure of gastroschisis Omphalocele
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Omphalocele Omphalocele
Omphalocele
Inguinal Hernias
Inguinal Hernia
• 5% incidence in full term infants
• M:F 10:1 • Risks:
– Incarceration (30% in first 6 months for term; 60% in first 6 months for premie)
– Infarcation (Low incidence (1%)
• Fix when found
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Appendicitis
• Appendix is a vestigial organ in RLQ
• Obstruction of the lumen may lead to swelling
Appendicitis
• Appendix is a vestigial organ in RLQ
• Obstruction of the lumen may lead to swelling
• Pressure in the lumen builds leading to ischemia
Appendicitis
• Appendix is a vestigial organ in RLQ
• Obstruction of the lumen may lead to swelling
• Pressure in the lumen builds leading to ischemia
• Ultimately, necrosis of the wall will lead to perforation and leakage of infected contents
Appendicitis
• Typical history in only ~50%
• Pain poorly localized – Children < 4 years – Retrocecal location
• Perforation – 12-15 hours, younger
children – 24 hours, 25% – 36 hours, 50% – 48 hours, 80%
Appendicitis
• ~1% Mortality • 5% incidence pelvic
abscess • <1% incidence post-
operative bowel obstruction
Pediatric Malignancies
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10 Most Common Cancers
Adult Cancers 1. Melanoma 2. Colorectal adenocarcinoma 3. Breast adenocarcinoma 4. Prostate adenocarcinoma 5. Lung adenocarcinoma 6. Pancreatic adenocarcinoma 7. Thyroid carcinoma 8. Leukemia 9. Endometrial carcinoma 10. Renal cell carcinoma
Childhood Cancers 1. Leukemia 2. CNS tumors 3. Neuroblastoma 4. Nephroblastoma 5. Lymphoma 6. Retinoblastoma 7. Sarcomas 8. Bone Tumors 9. Hepatoblastoma 10. Germ Cell Tumors
Neuroblastoma
• Most common abdominal malignancy of childhood
• Often will surround major vessels thereby making surgery challenging
Nephroblastoma (Wilms Tumor)
• Most common malignant renal tumor of childhood
• Combination of surgery, chemotherapy, and radiotherapy
Hepatoblastoma
• Most common malignant lesion of the liver in childhood
• Complete resection is the most important aspect of therapy
Pediatric Surgery
• “Our scope is the skin and its contents”
• “The last true general surgeon”
• “Children are not little adults”
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