Intestinal obstruction Intestinal obstruction

in childrenin children Symptoms: Symptoms: Bilious vomiting Bilious vomiting Abdominal distention Abdominal distention Colicky abdominal painColicky abdominal painObstipation (failure of meconium passing) Obstipation (failure of meconium passing)

Prenatal Diagnosis Prenatal Diagnosis Polyhydramnios Polyhydramnios Intestinal distention Intestinal distention Double bubble sign Double bubble sign Familial history (FC, HD) Familial history (FC, HD)

Post natal diagnosis Post natal diagnosis Bilious vomiting Bilious vomiting Abdominal distention (not in Abdominal distention (not in

volvulus, upper obstruction)volvulus, upper obstruction)

Upper or lower obstruction Upper or lower obstruction Meconium passing? (24-48h, 99%)Meconium passing? (24-48h, 99%) Fluid or meconium in scrotum Fluid or meconium in scrotum Abdominal cystic mass Abdominal cystic mass

Intestinal obstruction Intestinal obstruction evaluation evaluation

Plain abdominal Xray (flat and Plain abdominal Xray (flat and upright) upright)

Double bubble sign, triple bubble Double bubble sign, triple bubble sign, multiple air fluid level sign, multiple air fluid level

Calcification Calcification Upper GI study (upper obstruction)Upper GI study (upper obstruction) Barium enema Barium enema

Complications of intestinal Complications of intestinal obstruction obstruction

Volume loss (decreased intake, fluid Volume loss (decreased intake, fluid retention)retention)

Metabolic acidosis (ischemia, low Metabolic acidosis (ischemia, low glucose)glucose)

Hypothermia Hypothermia Respiratory distress (distention, Respiratory distress (distention,

elevation of diaphragm)elevation of diaphragm) Infection (sepsis) Infection (sepsis)

Treatment Treatment GI rest (NG tube, NPO)GI rest (NG tube, NPO) Resuscitation Resuscitation

IV fluid 10 ml/kg, glucose, bicarbonateIV fluid 10 ml/kg, glucose, bicarbonate warming warming Oxygenation Oxygenation Antibiotics Antibiotics Surgery Surgery

Esophageal atresia Esophageal atresia Congenital anomaly Congenital anomaly Upper pouch obstruction Upper pouch obstruction Lower part connected to trachea Lower part connected to trachea Multiple congenital anomaliesMultiple congenital anomalies V A C TE R LV A C TE R LVertebralVertebral anus cardiac anus cardiac tracheo renal limbs tracheo renal limbs

esophagealesophageal

atresiaatresia

Esophageal atresia Esophageal atresia Symptoms Symptoms Excess salivation Excess salivation Feeding intolerance Feeding intolerance Choking Choking Cyanosis Cyanosis Atelectasis, pneumoniaAtelectasis, pneumonia Abdominal distention Abdominal distention Polyhydramnios Polyhydramnios

Esophageal atresiaEsophageal atresia

Early diagnosis Early diagnosis Diagnosis before starting diet Diagnosis before starting diet Chest x ray Chest x ray Passing of large catheter (14-Passing of large catheter (14-

16french) 16french) EchocardiographyEchocardiography Ultra sonography Ultra sonography Abdominal x ray (air less abdomen)Abdominal x ray (air less abdomen)

Treatment Treatment

Pure Esophageal atresia Pure Esophageal atresia

Long gap, gastrostomy, Long gap, gastrostomy, esophagostomyesophagostomy

Common typeCommon type

type A, B, C type A, B, C H fistula H fistula

Duodenal obstruction Duodenal obstruction

Duodenal atresia Duodenal atresia Duodenal web Duodenal web Duodenal stenosis Duodenal stenosis Annular pancreas Annular pancreas Midgut volvulus Midgut volvulus

Duodenal obstructionDuodenal obstruction Poly hydramniosPoly hydramnios Prematurity Prematurity Downs syndrome (30%)Downs syndrome (30%) Pre duodenal portal vein Pre duodenal portal vein Double bubble signDouble bubble sign Upper GI study Upper GI study

Treatment Treatment Resuscitation Resuscitation Surgery Surgery

Doudeno-doudenostomy Doudeno-doudenostomy

doudeno-jejenostomydoudeno-jejenostomy Antibiotics Antibiotics

Small bowel atresia Small bowel atresia Jejunal atresia Jejunal atresia Ileal atresia Ileal atresia Types I mucosal Types I mucosal Types II atresia without mesentric gap Types II atresia without mesentric gap Types III a atresia with mesentric gap Types III a atresia with mesentric gap

Types III b apple peel deformity Types III b apple peel deformity Types IV multiple Types IV multiple

Meconium ileus Meconium ileus Hereditary (autosomal recessive )Hereditary (autosomal recessive ) Previous history Previous history Calcification Calcification Meconial cystic mass Meconial cystic mass No air fluid level up to 24-48hNo air fluid level up to 24-48h Abdominal protrusion Abdominal protrusion Soap bubble appearance Soap bubble appearance No meconium passing No meconium passing

Hirschsprung’s disease Hirschsprung’s disease 1/5000 live birth1/5000 live birth 80% in boys 80% in boys Mostly in left colon Mostly in left colon Aganglionosis Aganglionosis Lower GI obstruction Lower GI obstruction Barium enema (microcolon, Barium enema (microcolon,

transitional zone)transitional zone) Colostomy (operation later)Colostomy (operation later)

Midgut volvulus Midgut volvulus Malrotation Malrotation Narrow mesentery Narrow mesentery Healthy neonate Healthy neonate Sudden onset Sudden onset Rapid deterioration Rapid deterioration Metabolic acidosis Metabolic acidosis True emergency True emergency Barium study Barium study

Omphaloecele Omphaloecele Congenital defect in umbilicus Congenital defect in umbilicus Amniotic membrane Amniotic membrane Chromosomal anomalies Chromosomal anomalies GI anomaly (less common)GI anomaly (less common) Umblical cord hernia Umblical cord hernia Giant omphaloecele Giant omphaloecele Hypothermia Hypothermia

OmphaloeceleOmphaloecele Small surgery Small surgery Large silo reduction, mercurochrome, Large silo reduction, mercurochrome,

surgery surgery

Gastroschisis Gastroschisis True emergency True emergency Defect in right side of umblicus Defect in right side of umblicus More GI anomaly More GI anomaly Hypothermia Hypothermia No sac (amniotic membrane) No sac (amniotic membrane)

Intussusception Intussusception Telescopic invaginationTelescopic invagination Below 2 years old (9-12m) Below 2 years old (9-12m) Unknown etiology (90%)Unknown etiology (90%) 10% lead point 10% lead point Lymphiod hyperplasia Lymphiod hyperplasia More after URI More after URI

Symptoms and signs Symptoms and signs Vomiting Vomiting Colicky abdominal pain Colicky abdominal pain Pallor Pallor Abdominal mass Abdominal mass Currant jelly stool Currant jelly stool RectorrhagiaRectorrhagia Intestinal obstruction Intestinal obstruction

Treatment of Treatment of Intussusception Intussusception

Wind colicWind colic Gastroenteritis Gastroenteritis Enema (barium, air, saline)Enema (barium, air, saline) Surgery Surgery

Meckel’s diverticula Meckel’s diverticula Complete diverticula Complete diverticula

(30cm-1m) (30cm-1m) Band Band Cyst Cyst Patent omphalo mesentric duct Patent omphalo mesentric duct

Meckel’s diverticula Meckel’s diverticula complications complications

Diverticula Diverticula

diveticulitis, bleedingdiveticulitis, bleeding Band internal hernia Band internal hernia Cyst infection Cyst infection Patent omphalomesentric duct Patent omphalomesentric duct

fistula fistula

Congenital Hypertrophic Congenital Hypertrophic pyloric stenosis pyloric stenosis

1/450 live birth1/450 live birth 85% boys 85% boys Unknown Unknown 2-4 weeks after birth 2-4 weeks after birth 20% familial history 20% familial history

Congenital Hypertrophic Congenital Hypertrophic pyloric stenosispyloric stenosis

Non bilious vomiting Non bilious vomiting Projectile vomitingProjectile vomiting Gastric pristalsis Gastric pristalsis Coffee ground material Coffee ground material Olive mass Olive mass Infrequent stool Infrequent stool Metabolic alkalosis Metabolic alkalosis

Congenital Hypertrophic Congenital Hypertrophic pyloric stenosispyloric stenosis

Treatment Treatment

Fluid and electrolyte correction Fluid and electrolyte correction

Pyloromyotomy Pyloromyotomy

Imperforate anus Imperforate anus Low type Low type Intermadiate type Intermadiate type High typeHigh type Intestinal obstruction Intestinal obstruction VACTERL anomaly VACTERL anomaly Anoplasty Anoplasty Colostomy Colostomy

Acute appendicitisAcute appendicitisAnatomy Anatomy

IntrapelvicIntrapelvic retrocecalretrocecalretroileal retroileal retrosical retrosical

intraperitunealintraperituneal Cause Cause

obstructionobstructionworm in fes. worm in fes. vegetable seeds vegetable seeds

tumorstumors

PathologyPathologyobstructionobstruction

increased intraluminal pressure increased intraluminal pressure

over growth of organismover growth of organism

Stage of inflammationStage of inflammationearly inflammed early inflammed

supporative supporative

gangrenousgangrenous

perforatedperforated

Complication Complication

Complications Complications

peritonitisperitonitis

intraperituneal abcess intraperituneal abcess

portal phlebitis portal phlebitis

Appendicular mass Appendicular mass

Phlegmon (plastrum)Phlegmon (plastrum)

diagnosis diagnosis

treatment treatment

conseravativeconseravative

surgery surgery

Inguinal hernea Inguinal hernea AnatomyAnatomy

Patent processuse vaginalis Patent processuse vaginalis

Incidence Incidence premature premature

termterm DiagnosisDiagnosis

Bulging Bulging Silk glove sign Silk glove sign

Cord thickeningCord thickening

Inguineal hernia (complications)Inguineal hernia (complications)

Incarceration Incarceration

Strangulation Strangulation

Testis and ovary necrosis Testis and ovary necrosis

Intestinal obstruction Intestinal obstruction

Undescended testis Undescended testis

Definition Definition Incidence Incidence

Premature Premature TermTerm

Types Types Intra abdominal Intra abdominal intra canalicular intra canalicular high scrotalhigh scrotal

ectopicectopic

Undescended testisUndescended testis

Age of operation Age of operation

Complications Complications tursion tursion

trauma trauma

infertility infertility

malignancymalignancy

ConstipationConstipation

Definition Definition

Causes Causes functional functional

Hirschsprong’s disease Hirschsprong’s disease

dietarydietary

neuronal dysplasia neuronal dysplasia

Functional constipation Functional constipation

Age Age

CausesCausesHard stool Hard stool

FissureFissure

Symtoms Symtoms

Behavior Behavior

Functional constipation Functional constipation

Treatment Treatment

Conservative Conservative Diet Diet

Stool softenerStool softener

OperativeOperativePosterior myectomy Posterior myectomy

Diaphragmatic herniaDiaphragmatic hernia

Respiratory distressRespiratory distress Increased A-P chest diameterIncreased A-P chest diameter Scaphoid abdomenScaphoid abdomen Abnormal chest X-RayAbnormal chest X-Ray

Gastric volvulusGastric volvulus

Rare in childrenRare in children 51% <1 year51% <1 year 26% <1 month26% <1 month Organoaxial or mesentroaxialOrganoaxial or mesentroaxial

Heyperthrophic pyloric stenosisHeyperthrophic pyloric stenosis

Hypertrophic pyloric stenosis: Hypertrophic pyloric stenosis: incidence and pathogenesisincidence and pathogenesisAn acquired condition; tends to have An acquired condition; tends to have familial predisposition. familial predisposition. Male:Female 4-6:1 Male:Female 4-6:1 Hypertrophy of pyloric muscle leads Hypertrophy of pyloric muscle leads to obstruction of the lumen to obstruction of the lumen Cause of hypertrophy not known, but Cause of hypertrophy not known, but excessive activity of nitric oxide excessive activity of nitric oxide neuronsneurons is likely is likely

Pyloric stenosis: clinicalPyloric stenosis: clinical Peak incidence 3-10 weeks of age Peak incidence 3-10 weeks of age Progressive, non-bilious vomiting Progressive, non-bilious vomiting Dehydration Dehydration Loss of HCl leads to Loss of HCl leads to

hypochloremic alkalosis hypochloremic alkalosis Pyloric mass “olive” is palpable Pyloric mass “olive” is palpable

in 80% with careful examin 80% with careful exam

How to feel the oliveHow to feel the olive Child must have an empty stomach Child must have an empty stomach

– examine immediately after vomiting, or examine immediately after vomiting, or – empty stomach with 10 Fr tube empty stomach with 10 Fr tube

Easiest when child is calm Easiest when child is calm Palpate gently, with a sliding Palpate gently, with a sliding

motion, in mid-epigastrium, motion, in mid-epigastrium, allowing underlying tissues to roll allowing underlying tissues to roll beneath fingersbeneath fingers

Duodenal stenosisDuodenal stenosis

Birth injuriesBirth injuries

HeadHead Cephale hematoma,caput succedaneumCephale hematoma,caput succedaneum Intraventricular hemorrhageIntraventricular hemorrhage Subdural hematomaSubdural hematoma LimbLimb Clavicle Fx,humerus,femor Fx Clavicle Fx,humerus,femor Fx Nerve injuriesNerve injuries Erb palsy,facial palsyErb palsy,facial palsy Visceral injury (spleen,liver)Visceral injury (spleen,liver)

Vomiting in first week of lifeVomiting in first week of life

Mecanical intestinal obs.Mecanical intestinal obs.

Cerebral birth injuryCerebral birth injury

InfectionsInfections

Functional intestinal obstractionsFunctional intestinal obstractions

GERDGERD

Mecanical intestinal obstructionsMecanical intestinal obstructions

Duodenal atresiaDuodenal atresia Jujeno ileal atresiaJujeno ileal atresia MalrotationMalrotation Meconium ileusMeconium ileus Hirschsprung’s diseaseHirschsprung’s disease Small left colon syndromSmall left colon syndrom Meconium plug syndronmMeconium plug syndronm Imperforate anusImperforate anus

Imperforate anusImperforate anus

Low typeLow type Covered anus,ectopic anus,prineal fistulaCovered anus,ectopic anus,prineal fistula Intermediate typeIntermediate type Anorectal Anorectal

stenosis,rectovaginal&rectourethral fistulastenosis,rectovaginal&rectourethral fistula High type High type

Respiratory problem in newbornRespiratory problem in newborn

Upper obstructionUpper obstruction Micrognethia,choanal atresiaMicrognethia,choanal atresia Congenital laryngeal stridorCongenital laryngeal stridor Sub glotic stenosisSub glotic stenosis Intra thorasic conditionsIntra thorasic conditions esophageal atresiaesophageal atresia Tension syndrom(diphragmatic hernia,lung Tension syndrom(diphragmatic hernia,lung

cyst,lubar emphysema,CHD,vascular ring)cyst,lubar emphysema,CHD,vascular ring)

HerniasHernias InguinalInguinal

Premature neonate>Premature neonate>25%25%

Rt >LtRt >Lt 1/50 boys,1/500 girls1/50 boys,1/500 girls

SignificanceSignificance

obstraction of the bowelobstraction of the bowel Symptoms Symptoms

inguinal bulginginguinal bulging

silk glove singsilk glove sing

Cord thickeningCord thickening

Parents historyParents history

Time of oprationsTime of oprations

Early after diagnosisEarly after diagnosis

Even in prematureEven in premature

ComplicationsComplications

IncarcerationIncarceration

StrangulationStrangulation

TreatmentTreatment

ReductionReduction

oprationopration

Omphalocele(exomphalos)Omphalocele(exomphalos)

Abnormal abdominal wall Abnormal abdominal wall constructionconstruction

Early in gestational ageEarly in gestational age Other congenital or chorosomal Other congenital or chorosomal

abnormalityabnormality Emergency situationEmergency situation

GastroschasisGastroschasis

Congenital hernia of the gutCongenital hernia of the gut

Through the opening of abdominal wallThrough the opening of abdominal wall Late in gestational ageLate in gestational age Rupture of Rt umblical veinRupture of Rt umblical vein No suc or membraneNo suc or membrane GI atresiaGI atresia No other congenital abnormalityNo other congenital abnormality

ConstipationConstipation

2 or 3 times defecation per week2 or 3 times defecation per week Hard stoolHard stool Painful defecationPainful defecation CausesCauses

functional constipationfunctional constipation

anal stenosis or ectopic anusanal stenosis or ectopic anus

hirschsprung’s diseasehirschsprung’s disease

INDIND

Functional constipationFunctional constipation

Late onsetLate onset Absence of previous historyAbsence of previous history Full rectumFull rectum SoilageSoilage FissureFissure Abdominal mass (feces)Abdominal mass (feces) Fear of defecationFear of defecation

Genital anomaliesGenital anomalies

HypospediasHypospedias

failure of forming anterior urethrafailure of forming anterior urethra

abnormal prepuceabnormal prepuce

Glandular,penial,penoscrotal,perinalGlandular,penial,penoscrotal,perinal

Opration 3-4 years oldOpration 3-4 years old

Head and neck diseaseHead and neck disease

Cystic hygromaCystic hygroma Branchial cyst and sinusBranchial cyst and sinus Thyroglossal cystThyroglossal cyst Tongue tieTongue tie

Umbilical&femoral herniaUmbilical&femoral hernia

Time of oprationTime of opration

ObservationObservation

Scurotal swellingsScurotal swellings

HerniaHernia HydroceleHydrocele Cord hydroceleCord hydrocele Torsion of testisTorsion of testis Epididym orchitisEpididym orchitis Tumor of testisTumor of testis

Rectal bleeding & problemsRectal bleeding & problems

Anal fissureAnal fissure Rectal prolapsRectal prolaps Rectal polypRectal polyp Meckel’s diverticulumMeckel’s diverticulum Blood dyscrasiaBlood dyscrasia

Umbilical problemsUmbilical problems

Umbilical herniaUmbilical hernia Paraumbilical herniaParaumbilical hernia Umbilical granulomaUmbilical granuloma Umbilical sinusUmbilical sinus Umbilical polypUmbilical polyp Ectopic tissueEctopic tissue Patent urachusPatent urachus

Undesnded testisUndesnded testis

ClassificationClassification

DiagnosisDiagnosis

Diffrentional diagnosis Diffrentional diagnosis

Time of oprationTime of opration

Esophageal atresia and Esophageal atresia and tracheoesophageal fistulatracheoesophageal fistula

Ali. Bahador M.DAli. Bahador M.D

Namaze hospital Namaze hospital

Shiraz IRANShiraz IRAN

Esophageal atresiaEsophageal atresia

Anatomic variations Anatomic variations A.A. Common type 85% (distal fistula) Common type 85% (distal fistula)

B.B. Atresia alone no fistula 6%Atresia alone no fistula 6%

C.C. Proximal fistula no distal fistula 2%Proximal fistula no distal fistula 2%

D.D. Proximal and distal fistula 1%Proximal and distal fistula 1%

E.E. No atresia with tracheoesophageal No atresia with tracheoesophageal fistula H or N fistula 6%fistula H or N fistula 6%

Esophageal atresiaEsophageal atresiaDiagnosis Diagnosis Antenatal US shows maternal polyhydraminos, small Antenatal US shows maternal polyhydraminos, small

stomach, distended upper esophageal pouch, stomach, distended upper esophageal pouch, abnormal swallowing, associated anomaliesabnormal swallowing, associated anomalies

Clinical diagnosis Clinical diagnosis excessively drooling, syanosis, respiratory infection, excessively drooling, syanosis, respiratory infection, chokingchoking

passing OG tube > 10 French passing OG tube > 10 French rarely Ba. Study is needed rarely Ba. Study is needed gasless obdomengasless obdomen

Recurrent respiratory infection, cough during eating, Recurrent respiratory infection, cough during eating, choke, abdominal distention, H fistula, at age of choke, abdominal distention, H fistula, at age of more than 3 monthsmore than 3 months

Esophageal atresiaEsophageal atresia Associated anomalies Associated anomalies

VACTERL VACTERL

trisomy 18 and 21 trisomy 18 and 21 7%7%

CHDCHD 25 25 Urinary tract Urinary tract 2222 Vertebral anomaly Vertebral anomaly 1515 GI anomaly GI anomaly 2222 CHARGE 2% (Colobomata, Heart mal. CHARGE 2% (Colobomata, Heart mal.

Choanal atresia, Retardation, Genital Choanal atresia, Retardation, Genital hypoplasia, Ear anomalies) hypoplasia, Ear anomalies)

Management of Management of Esophageal atresiaEsophageal atresia

Initial management Initial management prevent prevent hypotermia hypotermia wraping, wraping, warmer warmer

asphyexia asphyexia tube in upper tube in upper pouch pouch

aspiration pneumoniaaspiration pneumoniagastrostomy gastrostomy

hypoxiahypoxia oxygenation oxygenation

Operative Management of Operative Management of Esophageal atresiaEsophageal atresia

Waterstone classification Waterstone classification

A. normal wt. , no pneumonia, no major A. normal wt. , no pneumonia, no major anomalyanomaly

early surgical treatment early surgical treatment

B. severe pneumonia B. severe pneumonia

gastrostomy, jejunostomy, antibiotics gastrostomy, jejunostomy, antibiotics

delay operation delay operation

C. low wt. , major anomaly, pneumonia C. low wt. , major anomaly, pneumonia

staged operation staged operation

Operative Management of Operative Management of Esophageal atresiaEsophageal atresia

Esophageal atresia without Esophageal atresia without fistula fistula

gastrostomy for feeding gastrostomy for feeding

esophageal substitute esophageal substitute Right thoracotomy Right thoracotomy

division of fistula division of fistula

release of upper pouch release of upper pouch

end to end anastomosis end to end anastomosis

Complications Complications Anastomotic Leakage Anastomotic Leakage

fever, sepsis, pleural effusionfever, sepsis, pleural effusion

Ba. StudyBa. Study Anostomotic stricture Anostomotic stricture

Dilation, check for GERD Dilation, check for GERD

revision if neededrevision if needed GERD GERD

common finding needs medical common finding needs medical treatment treatment

no responsive needs surgeryno responsive needs surgery

ComplicationsComplications Recurrence of fistula Recurrence of fistula

cough during feeding, aspiration, cough during feeding, aspiration, chokingchoking Tracheo-bronchial malacia Tracheo-bronchial malacia

Rule out vascular ring, GERD Rule out vascular ring, GERD tachypnia, cyanosis, choking, feeding tachypnia, cyanosis, choking, feeding difficulties difficulties treatment: observation treatment: observation aortopexy aortopexy tracheostomytracheostomystentstent

H. Fistula H. Fistula Different clinical spectrum from Different clinical spectrum from

eso. Atrasia (cyanotic attacks, eso. Atrasia (cyanotic attacks, aspiration pneumonia, abdominal aspiration pneumonia, abdominal distention, distention,

At level TAt level T11 to T to T33 or higher or higher Bronchoscopy, esophagoscopy, Bronchoscopy, esophagoscopy,

Barium study, with fluoroscopy, Barium study, with fluoroscopy, CT Scan CT Scan

Cervical approch Cervical approch

Tracheal anomalies Tracheal anomalies Congenital tracheal stenosisCongenital tracheal stenosis

(complete tracheal rings) (complete tracheal rings) in trachea or bronchus or both in trachea or bronchus or both > 50% segmental stenosis > 50% segmental stenosis severe respiratory distress to severe respiratory distress to

subtle subtle symptoms, stridor, cough, symptoms, stridor, cough, altrations altrations of cry, wheezing of cry, wheezing rhonchi, respiratory rhonchi, respiratory distress or distress or sudden death. sudden death.

Tracheal anomaliesTracheal anomaliesAssociate anomaly:Associate anomaly: esophageal, esophageal,

cardiac, skeletal, GU. 50% vascular cardiac, skeletal, GU. 50% vascular ring (Echo. Angiography) ring (Echo. Angiography)

DiagnosisDiagnosis Contrast study Contrast study

endoscope endoscope

AP radiography an fluoroscopy AP radiography an fluoroscopy

CT Scan (more precise) 3D image construction CT Scan (more precise) 3D image construction MRIMRI

Tracheal anomaliesTracheal anomaliesTreatment Treatment Tracheal resection Tracheal resection less than five less than five

rings rings Patch tracheoplasty Patch tracheoplasty (cartilage (cartilage

dura pericardium dura pericardium Slide tracheoplasty Slide tracheoplasty (choice (choice

procedure)procedure)

Balloon dilatation Balloon dilatation

Tracheal anomaliesTracheal anomaliesTrachemoalacia and Trachemoalacia and

bronchomalaciabronchomalacia weakening of trachea or bronchi weakening of trachea or bronchi no sufficient rigidity, localized or no sufficient rigidity, localized or diffusediffuse

CausesCauses Extrinsic pressure, vascular Extrinsic pressure, vascular

rings, rings, unknown, eso. Atresia, unknown, eso. Atresia, mediastinal mediastinal mass, prolonged mass, prolonged intubation, intubation, interstitial long diseaseinterstitial long disease

Tracheal anomaliesTracheal anomaliesDiagnostic evaluation Diagnostic evaluation

AP. RadiographyAP. Radiography

cinefluoroscopy cinefluoroscopy

bronchoscopy best method with bronchoscopy best method with spontaneous breathing spontaneous breathing

Ba. Study, angiography for Ba. Study, angiography for vascular vascular rings rings

Tracheal anomaliesTracheal anomaliesTreatmentTreatment

observationobservation

trachael suspension trachael suspension (aortopexy) (aortopexy)

stent stent

Hemangiomas of trachea Hemangiomas of trachea

Symptoms and signs Symptoms and signs Stridor, airway obstruction Stridor, airway obstruction

subglotic locations most subglotic locations most common common

first 6 months first 6 months

50% cutaneous hemangiomas 50% cutaneous hemangiomas

F > M (2 times)F > M (2 times)

Hemangiomas of tracheaHemangiomas of trachea Diagnosis Diagnosis

broncoscopy broncoscopy biopsy is dangerous biopsy is dangerous

Treatment Treatment observation (tracheotomy may observation (tracheotomy may

needed) needed) steroids (systemic, intralesional)steroids (systemic, intralesional)laser ablation laser ablation scloresing agentsscloresing agentsembolization embolization interfron alfa2a interfron alfa2a surgery surgery

Tracheal anomaliesTracheal anomalies Esophageal bronchus Esophageal bronchus

recurrent pulmonary infection recurrent pulmonary infection collapsed, infiltration of lung, collapsed, infiltration of lung,

cavtation, cavtation, cystformationcystformation

abnormal arterial and venous supplyabnormal arterial and venous supply Tracheobronchial biliary fistula Tracheobronchial biliary fistula

bile stained sputum bile stained sputum

Tracheal webs Tracheal webs Bronchial atresia Bronchial atresia Bronchial stenosis (acquired) Bronchial stenosis (acquired)

Undescended Undescended testistestis

Ali Bahador M.DAli Bahador M.D

Pediatric surgery ward Pediatric surgery ward

Shiraz IRANShiraz IRAN

Impalpable testisImpalpable testis24% of UDT24% of UDT39% distal to the ring 39% distal to the ring 41% atrophic or absent 41% atrophic or absent 20% intra abdominal 20% intra abdominal

Ectopic testis Ectopic testis perineal perineal upper thighupper thighfemoral femoral cross ectopiacross ectopia

Intra abdominal Intra abdominal AnorchiaAnorchia

unilateralunilateralbilateral bilateral

Diagnostic tests Diagnostic tests

Exam: warm room, warm hand, Exam: warm room, warm hand, not be hurried, cross legged not be hurried, cross legged position, to hand exam. position, to hand exam.

Diff. diag: retractile testis Diff. diag: retractile testis

pressure on femoral artery pressure on femoral artery

exam exam

Diagnostic test Diagnostic test

Ultra sonography Ultra sonography

frequent used frequent used

high rate of misdiagnosis high rate of misdiagnosis

US positive or negative needs US positive or negative needs surgery surgery

unuseful in most cases unuseful in most cases

US after complete exam.US after complete exam.

Diagnostic testDiagnostic test CT Scan CT Scan

more accurate but not 100%more accurate but not 100% MRI MRI

selected cases (obese child)selected cases (obese child)

routine radiologic evaluation not routine radiologic evaluation not suffiently accurate not cost justifiable suffiently accurate not cost justifiable

Laparoscopy Laparoscopy

selective in certain casesselective in certain cases

Orchiopexy Methods Orchiopexy Methods Routine orchiopexy Routine orchiopexy Fowler – stephen’s method Fowler – stephen’s method

one stage one stage two stage two stage

Staged orchiopexy Staged orchiopexy Microvascular orchiopexy (auto Microvascular orchiopexy (auto

transplantation) transplantation) Laparoscopic (fowler - stephen’s) Laparoscopic (fowler - stephen’s)

one stage one stage two stage two stage

Unilateral impalpable testisUnilateral impalpable testis Inguinal approch Inguinal approch Testis & peritoneal tongue present Testis & peritoneal tongue present

no internal ring is opened no internal ring is opened (most cases)(most cases)

No testis, no small tongue of No testis, no small tongue of peritoneum internal ring is opened, peritoneum internal ring is opened, intra peritoneal exploration intra peritoneal exploration

Traction on testis to evaluate the Traction on testis to evaluate the type of orchiopexy type of orchiopexy

Unilateral impalpable testis Unilateral impalpable testis Standard incision Standard incision Lateral extension (Larok maneuver) Lateral extension (Larok maneuver)

Good mobilization Good mobilization Possible orchiopexy almost in all Possible orchiopexy almost in all

casescases No laparoscopy is needed No laparoscopy is needed If other testis is normal, too short If other testis is normal, too short

vessels one stage fowler - vessels one stage fowler - stephen’s procedurestephen’s procedure

Bilateral impalpable testisBilateral impalpable testis Inguinal explorationInguinal exploration

midline trans or pre peritoneal midline trans or pre peritoneal approach, rectus transection, new approach, rectus transection, new internal ring, trans peritoneal internal ring, trans peritoneal exploration exploration

Rationale for primary laparoscopyRationale for primary laparoscopy one side fowler - stephen’s procedureone side fowler - stephen’s procedureother side delayed operation other side delayed operation both side staged operation both side staged operation fowler – stephen’s or staged fowler – stephen’s or staged operation operation

Bilateral impalpable testisBilateral impalpable testis Laparoscopy Laparoscopy

testis within 2.5cm of internal ring able testis within 2.5cm of internal ring able to mobilize in scrotom without vascular to mobilize in scrotom without vascular ligation ligation

Older boy better than small Older boy better than small Two high intra abdominal testes need Two high intra abdominal testes need

primary clipping then staged orchiopexy primary clipping then staged orchiopexy (open or laparoscopic)(open or laparoscopic)

One intra abdominal testis needs One intra abdominal testis needs laparoscopic or microvascular orchiopexy laparoscopic or microvascular orchiopexy

Vanishing testis Vanishing testis Spermatic blind end vessels (sine qua Spermatic blind end vessels (sine qua

non) non) Spermatic goes up, surgical point, Spermatic goes up, surgical point,

end of operation end of operation vasal artery followed the vas, vasal artery followed the vas,

continue the operation (divergence) continue the operation (divergence) Blind end vas, continue the operation Blind end vas, continue the operation Blind end of vessels shows Blind end of vessels shows

calcification, hemosiderosis, calcification, hemosiderosis, hyalinised tissuehyalinised tissue

Impalpable testis Impalpable testis 432 cases432 cases

LaparoscopyLaparoscopy

Help full in 10% Help full in 10% If is with treatment may help full If is with treatment may help full

in 27% in 27% Help full in reoperative casesHelp full in reoperative cases ExperiencesExperiences Need of prosthesisNeed of prosthesis Success 89% one stage Success 89% one stage

95% two stage95% two stage

Laparoscopic for Laparoscopic for Undescended testisUndescended testis

20% impalpable (1/4 1/3 intra abdominal)20% impalpable (1/4 1/3 intra abdominal) Minor complication 4% Minor complication 4% Major complication 1% Major complication 1% Selective or routine? Selective or routine? Routine use for diagnosis is not warranted Routine use for diagnosis is not warranted

Unless diagnosis an treatment as well Unless diagnosis an treatment as well Selective: not cost effective or patient Selective: not cost effective or patient

friendly, many an necessary laparoscopy, friendly, many an necessary laparoscopy, routine ing. exploration provide the same routine ing. exploration provide the same resultresult

Fowler – stephen’s method Fowler – stephen’s method

InguinalInguinal LaparoscopicLaparoscopic Bevan 1903Bevan 1903

fowler – stephen’s 1959 vascular fowler – stephen’s 1959 vascular anatomy anatomy

Brendler & wolfson high ligation Brendler & wolfson high ligation Clatworthy epigastric vessels Clatworthy epigastric vessels

and floor of canal be left intactand floor of canal be left intact

Fowler – stephen’s methodFowler – stephen’s method

Leave medial peritoneal strip to Leave medial peritoneal strip to attach the vas attach the vas

Not a salvage procedure Not a salvage procedure High lagating of the vessels High lagating of the vessels No injury to the vasal arteryNo injury to the vasal artery

No Fowler – stephen’s No Fowler – stephen’s method method

Short vas Short vas Hypoplastic testis Hypoplastic testis Segmental vas atresia Segmental vas atresia None attached epididymis None attached epididymis Un certain blood suplly Un certain blood suplly

Atrophy 20% in one stage Atrophy 20% in one stage

10% in two stage10% in two stage

Microvascular orchiopexy Microvascular orchiopexy

Donor inferior epigastric vessels Donor inferior epigastric vessels High transection of spermatic High transection of spermatic

vessels vessels Absolute invecation: solitary Absolute invecation: solitary

intra abdominal testis, intra abdominal testis, contralateral atrophy after contralateral atrophy after orchiopexy orchiopexy

Success 55-100% (80%)Success 55-100% (80%)

Staged orchiopexy Staged orchiopexy

In two stages In two stages First stage testis fixed with non First stage testis fixed with non

absorbable suture absorbable suture Two stage 4-6% Two stage 4-6% When no other procedures are When no other procedures are

appropriate success 82-90%appropriate success 82-90% 195 cases 18 cases performed staged 195 cases 18 cases performed staged

orchiopexyorchiopexy 2/18 (11.1%) showed 2/18 (11.1%) showed atrophy follow up 9m. – 3yrs atrophy follow up 9m. – 3yrs

Principle of orchiopexy Principle of orchiopexy

Unilatral inguinal approch Unilatral inguinal approch Bilatral laparoscopy or inguinal Bilatral laparoscopy or inguinal

approch approch Anorchia, HCG test Anorchia, HCG test

high LH, FSH, positive HCG testhigh LH, FSH, positive HCG test