Pediatric surgical notes

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Dr. Ali M AhmadMBBCh, MS, MD, MRCS-Ed, EBPSAssociate Pediatric Surgery; KAAUH_ PNUSurgical Notes

First: Acidosis Or Alkalosis {Look at the pH}Second: Metabolic Or Respiratory {Look at the Pco2}Third: respiratory & renal compensationNormal ABG valuespH 7.35 to 7.45paCO2 36 to 44 mm HgHCO3 22 to 26 mEq/LPaO2 80 100 mmhg (Age dependent)1- ABG Interpretation

2-Pleural Fluid in Empyma1- Early Stage/acute : Thin serous or cloudy fluid, sterilepH < 7.2Glucose < 40 mg /dLLDH >1000 IU/dLProtein > 2.5 g /dLWBC > 500 /LSpecific gravity greater than 1.018

2- intermediate stage / Fibrino - purulent Thicker, opaque fluid or fluid with positive cultures

3- late stage/ OrganizingAn organizing peel with entrapment of the lung

Esophageal FBs tend to lodge in areas of physiologic narrowing, such as the upper esophageal sphincter (cricopharyngeus muscle), the level of the aortic arch, and the lower esophageal sphincter .

Objects that appear in the middle portion of the esophagus are more likely to represent esophageal pathology, such as a stricture. Similarly, children presenting with food bolus impaction commonly have underlying esophageal pathology (eg, a stricture) directly responsible for the impaction 3-Foreign Body ingestion

Sharp objects may perforate the esophagus, resulting in neck swelling, crepitus, or pneumomediastinum .

Erosion into the aorta also has been reported, causing life-threatening gastrointestinal bleeding .

Occasionally FBs may be retained in the distal gastrointestinal tract, where they can cause delayed complications.

Disk batteries:A disk or "button" battery lodged in the esophagus is a medical emergency.

Contact of the flat esophageal wall with both poles of the battery conducts electricity, which can rapidly result in liquefaction necrosis and perforation of the esophagus.

Retained batteries also can cause problems by the leakage of caustic material (generally batteries contain a heavy metal like mercury, silver, lithium, and a strong hydroxide of sodium or potassium)

Sharp-pointed objects: The most common sharp-pointed objects ingested by children are straight pins, needles, and straightened paper clips; these represent 5 to 30 percent of swallowed objects .

Sharp-pointed objects lodged in the esophagus represent a medical emergency because of a high risk of perforation (15 to 35 percent) .

When lodged in the hypo pharynx, they can cause a retropharyngeal abscess

If the object is in the stomach or proximal duodenum, it also should be removed promptly, using a flexible endoscope. The risk of a complication caused by a sharp-pointed object passing through the gastrointestinal tract is as high as 35 percent .

Sharp objects that pass beyond the reach of a flexible endoscope and then cause symptoms will require surgical intervention

Clinical Presentation: nonspecific and suggests high intestinal obstruction

Presents as a triad of A sudden onset of severe epigastric pain,Intractable retching with emesis (without vomiting). Inability to pass a tube into the stomach4- Gastric Volvulus

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Organ axial Volvulus

Mesentero-axial Volvulus

Mesentero-axial Volvulus

5- Alimentary tract duplicationsFound anywhere along GI

Share Common wall & vascular supply.

Either cystic or tubular structures

Due to: aberrant recanalization of the alimentary tract lumen

CT chest, esophagus duplication

Esophageal duplication cysts

Usually intramuralNoncommunicatingCystic lesionsMostly located to the right side of the esophagus

Total colonic duplications

All colon tubularAntimesenteric Communicates proximally with the normal bowel.

If communicates distally, no treatment is necessary.If not communicate distally, a communication must be establishedif a small communication is present, this opening may need to be enlarged

Lower esophagus may be obvious, distending with each inspiration as it lies in the lower posterior mediastinum.

Close proximity of the vagus nerve to the lower esophagus aids in its identification.

6- TEF & Azygous vein is ligated and divided.

7- Lt LL Bronchopulmonary Sequestration

8- Mediastinum

9- Process Vaginalis

10- Laparoscopic exploration to view the contralateral IH

The cribriform fascia and fat layers are incised, exposing the femoral hernia sac.

Note that the femoral sac protrudes into the femoral canal (Langenbeck) Infra-inguinal repair

11-Femoral Hernia

12-Umbilical Hernia (Smile Incision)

13-Omphalocele (Staged Repair) Liver usually not fully reducible so need to do Undermining the skin

1- Skin is closed over the abdominal viscera, producing a ventral hernia that can be repaired 612 months later

2-Prosthetic closure of the fascia defect over polyethylene or Silastic sheeting to prevent adhesion of the viscera to the prosthetic material.

46-week intervals the wound can be reopened and the skin dissected from the prosthesis

3- Spring-loaded silo

is placed underneath the fascial defect after the herniated bowel is placed within it

14- GERDAnatomic:length and pressure of the lower esophageal sphincter;the intra-abdominal segment of the esophagus;the gastroesophageal angle (angle of His);the lower esophageal mucosal rosette;the phrenoesophageal membrane;the diaphragmatic hiatal pinchcock effect.

Physiologic:Coordinated effective peristaltic clearance of the distal esophagus;Normal gastric emptyingNORMAL MECHANISMS PREVENTING REFLUX

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Barium EsophagogramEsophageal pH monitoringEsophageal manometry..Endoscopy and biopsyScintiscanningInvestigations for GERD

Anatomy of the esophagus (e.g.. Strictures)Function of the Esophagus (Peristaltic & clearance)Presence of a hiatus herniaEvidence of gastric outlet obstructionDegree of GERDgrade I: Distal esophagusGrade II: Thoracic esophagusgrade III: Cervical esophagusgrade IV: Continuous refluxgrade V: Aspiration into tracheobronchial treeBarium Esophagogram

Number of Reflux episodes (pH falls below 4)Duration of each Reflux episode

Number of episodes lasting more than 5 minutesTotal duration of reflux {percentage of recording time}24 h Esophageal pH monitoring pH of less than 4 is regarded as significant

Grade I: Erythema of mucosaGrade II: Friability of mucosaGrade III: Ulcerative esophagitisGrade IV: Stricture.Endoscopy and biopsy (degree of esophagitis)

Wound infectionRespiratory: pneumonia or atelectasisDysphagia: wrap too long or too tight.Recur GER: either fundo disruption or herniationGas bloat, retching, and dumping are usually transient.Paraesophageal hernia: inadequate approximation or disruption of the crural repair.Adhesion intestinal obstruction is particularly common if an additional intra-abdominal procedure such as gastrostomy, incidental appendectomy, or correction of malrotationComplications Post Fundoplication

Dilated esophagusAbsence of stripping wavesIncoordinated contractionObstruction GE junction gives rise to the classical rat-tail deformity of funnelling and narrowing of the distal esophagus.

15- AchalasiaBarium swallow

LES: High-pressure (>30 mmHg)Failure LE relaxation in response to swallowingAbsence of propulsive peristalsisIncoordinated tertiary contractions in the body of the esophagus

Esophageal Manometry

Janeway Gastrostomy

The stapler is employed to tubularize the gastric wall.

The gastric tube is brought out away from the incision

If the open technique is used, or through one of the port sites if it is performed laparoscopically16- Gastrostomy

Barium Meal (Rarely Used)

string sign of the narrow elongated pyloric canal

Delayed gastric emptying

Gastric hyperperistalsis

17- IHPS

US in HPSpyloric channel >17 mm in length pyloric thickness >4 mm.

TYPE I (MEMBRANE)18- Bowel Atresia

TYPE II (BLIND ENDS JOINED BY A FIBROUS CORD)

TYPE IIIA (DISCONNECTED BLIND ENDS)

TYPE IIIB (APPLE PEEL, CHRISTMAS TREE)

TYPE IV (MULTIPLE ATRESIA)

Ensure good Postop function

The proximal distended and hypertrophied intestine must be liberally resected {1015 cm} even if it appears viable

23 cm distal intestine resected oblique fish mouthResection

Tapering duodenojejunoplasty or enteroplasty:

This surgical procedure is indicated for bowel-length preservation, especially in type III b atresia and for high jejunal atresias

Tapering

Plication or infolding enteroplasty:

antimesenteric intestinal plication involves infolding of up to half or more of the intestinal circumference into the lumen over an extended length

Plication 1

Antimesenteric seromuscular stripping and inversion plication: Plication 2

Uncomplicated meconium ileus

Distal 1530 cm ileum is filled with meconium pellets, which adherent to the bowel wall.

Proximal ileum filled with thick, putty-like meconium & dilates 3 4 cm in diameter

Microcolon: because meconium has not yet entered this segment of bowel

19- Meconium Diseases

Complicated MI includeBowel VolvulusBowel atresiaBowel perforationGiant cystic meconium peritonitis.

Uncomplicated meconium ileus1-BISHOPKOOP PROCEDUREDistal bowel is brought out as an end Ileostomy

Uncomplicated meconium ileus2- SANTULLIBLANC ENTEROSTOMY Proximal bowel is brought out

Uncomplicated meconium ileus3- PRIMARY RESECTION AND ANASTOMOSIS

Uncomplicated meconium ileus4- TUBE ENTEROSTOMY

20- NEC

Proxi