Pediatric Surgery

Mark Perna

1/5/2010

Disclaimer

Competitive 2 year surgical fellowship in 55minutes– Obviously gross overview

Pediatric Trauma

Increased Risk for Head Trauma and Burns HR and RR are best signs of shock (not

BP) Solid Organ Injury can most often

nonoperatively Bone non brittle

– Set up for contusions Nonaccidental Trauma

– Duty to report

Pediatric Trauma

Seat Belt Sign and Abd Pain– Small Bowel Injury

Handle Bar Injury and abd pain– Pancreatic Injury

Handle Bar Injury with profuse vomiting – Duodenal Hematoma

General Concepts

Differences in Vital Signs Prone to hypothermia and hypoglycemia Fluid Bolus - 20 ml/kg (times 2) Transfusion- 10ml/kg

Most appropriate vitals for 3 day newborn HR SBP RR Sat 95 110 30 94 190 60 45 98 160 50 40 100 120 95 20 92

General Concept

Nutritional Requirements– Neonates 90-120 kcal/kg– Children 70-90kcal/kg– Adolescents 30-60kcal/kg– Adults 25 kcal/kg

Protein Requirements– Neonates 2-3 g/kg– Infants 1-5 –2 g/kg – Children 1-1.5 g/kg

General Concepts Urine Output

– Neonates 2 cc/kg/hr– Infants 1.5 cc/kg/hr– Children 1 cc/kg/hr– Adult 0.5 cc/kg/hr

Fluids Management– 4 cc/kg/hr (for first 10kg)– 2 cc/kg/hr (for second 10 kg)– 1 cc/kg/hr (for remaining weight)

General Concepts- Radiology

U/S often the most helpful study– Abdomen– Cost– Low Risk

Xray and Contrasted xrays CT MRI

PICU

SIMV ventilatory support– FIO2

Oscillatory Vent Jet Vent ECMO

Neck – High Yield Cervical Lymphadenopathy

– Most likely viral– Tender versus Nontender– Unresolving think of more rare causes

• Cat-Scratch, TB, Lymphoma

Thyroglossal Ducts Cyst– Midline– From the foramen cecum– Sistrunk procedure

Brachial Cleft Cyst– Off midline – 2nd cleft most common– Excision

Thoracic - High Yield Bronchogenic Cysts Congential Lobar Emphysema-

– Failure of development bronchus cartilage Congential cystic adenoid malformation

– Alveolar structure not developed, but does communicate with airway

Pulmonary Sequestration– Lung tissue with systemic arterial supply

• Intralobar – Venous drainage to pulm circ• Extralobar- Venous drainage to systemic circ

Anterior Mediastenal Mass– Thymoma, Teratoma, Terrible Lymphoma, Thyroid

Tracheoesophageal Fistula

What syndrome is associated with TE fistula Vertebral Anal Cardiac TE fistula Renal Limb dysplasia

Vomiting Nonbilious

– GERD– Allergies

Projectile– Pyloric Stenosis

Bloody– UG Bleed

Bilious– Broad Differential– Always abnormal, Generally Serious– Quick Elevation

Pediatric Bowel Obstructions -

Pyloric Stenosis– 3 in 1000, generally male, first born– Projectile Vomiting, Nonbilious– Palpable Olive– US diagnosis– Tx??

• Fredet-Ramstedt pyloromyotomy

Electrolytes

Na K CL CO2 Urine pH

Pediatric Bowel Obstructions

Duodenal Atresia – Failure of Recannulization of bowel– “Double Bubble”– Associated with Down’s and VACTERL– Tx

• Doudeno-doudneostomy

Pediatric Bowel Obstructions

Intestinal Atresia– Intrauterine vascular accident– Polyhydramnios– Tx

• Tapered jejunoplasty

– Short Gut Syndrome

Pediatric Bowel Obstructions

Malrotation (Common) Always on Boards!!– Bilious vomiting, Abd distention, acidosis– Obstruction from Ladd’s band across the

duodenum or Midgut volvulus– Tx-

• Counterclockwise reduction of midgut volvulus

• Lysis of Ladd’s Bands

• Appendectomy

Pediatric Bowel Obstructions

Meconium Ileus – Inspissated meconium– 90% will have CF. Get Sweat Test!!– “soap bubble” appearance

• Tx- Nonoperative first– Gastrograffin enemas (Meglumine Diatrizoate)

– Ileostomy, resection

Pediatric Bowel Obstructions

Meconium Plug Syndrome– Stool balls in the rectum– Almost never operative– Tx

• Time

• Enema

Pediatric Bowel Obstructions

Hirshbrung’s – Absence in parasympathetic ganglion cell in

distal colon– Dx with Suction Rectal Biopsy– Toxic enterocolitis– Tx

• Sauve

• Swenson

• Duhamel

Pediatric Bowel Obstructions

Intussusception– Telescoping of bowel– Currant jelly stools– Lead point usually not identified in kids– Dx US or Barium enema

• Tx– Barium enema

– Air enema

– Exploratory Lap and Reduction

Pediatric Bowel Obstructions

Imperforate Anus– High versus Low– US can diagnose– Associated abnormalities

Abdominal Wall Defects Umbilical hernia

– Common– AF children– Most close on there own

• Don’t mistake for diastasis rectus

Omphalocele– Covered in a sac of chorium, Wharton’s jelly, peritoneum– Associated abnormalities

Gastroschisis– Bare bowel and abdominal contents– No congenital defects work up necessary – Cover and keep warm

• Hypothermia, Bowel Bag, Reduce in OR

What GI abnormality seen with gastroschisis

Small Bowel Atresias– 11% of the time

What is Cantrell syndrome?

Omphalocele Diagphramatic hernia Pericardial Defect Cardiac Defects Sternal Defects

NEC

Most common pediatric surgery emergency Low flow state = Bowel ischemia

– Distention, bloody stools, perforation, sespis• Follow Serial Abx Xray

• Na

• Platelets

• CO2

• Temps

Tx- Laparotomy versus abdominal drain

Inguinal Hernia versus Hydrocele

Common– More common in prematurity with high risk of

incarceration Anatomic Location

– Medial versus Lateral Congential versus Aquired

– Tx • High Ligation of Sac• Laproscopic Repair

What test does a child need with bilateral direct hernia repair?

Sweat Chloride Test

Jaundice

Cholestatic Jaundice Biliary Atresia

– Portoenterostomy Choledochal Cyst

– Type I- Fusiform Enlargement– Type 2- Diverticular-like– Type 3- Distal Common Duct– Type 4- Extra and Intrahepatic Dilation– Type 5- Intrahepatic (Caroli Disease)

Solid Abdominal Tumors

Wilms tumor– Most common intraabd tumor– Staging

• Group I - Limited to kidney, completely excised

• Group II- Extends past kidney, completely excised

• Group III- Extends past kidney, not excised

• Group IV- Hematogenous metastasis

• Group V- Bilateral tumors

Solid Abdominal Tumors

Neuroblastoma– Neuro crest cells– Most common solid organ tumor– Staging

• Stage I- Tumor limited to organ of origin

• Stage II- Regional spread, not across midline

• Stage III- Tumor extending across midline

• Stage IV- Distant Metastasis