Pediatric surgical notes

Dr. Ali M AhmadMBBCh, MS, MD, MRCS-Ed, EBPS

Associate Pediatric Surgery; KAAUH_ PNU

Surgical Notes

1. First: Acidosis Or Alkalosis {Look at the pH}2. Second: Metabolic Or Respiratory {Look at the

Pco2}3. Third: respiratory & renal compensation

Normal ABG values• pH 7.35 to 7.45• paCO2 36 to 44 mm Hg• HCO3 22 to 26 mEq/L• PaO2 80 – 100 mmhg (Age dependent)

1- ABG Interpretation

2-PLEURAL FLUID IN EMPYMA1- Early Stage/acute : Thin serous or cloudy fluid, sterile

pH < 7.2 Glucose < 40 mg /dL LDH >1000 IU/dL Protein > 2.5 g /dL WBC > 500 /µL Specific 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 1. A sudden onset of severe epigastric pain,2. Intractable retching with emesis (without

vomiting). 3. Inability to pass a tube into the stomach

4- Gastric Volvulus

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 intramural• Noncommunicating• Cystic lesions• Mostly located to the right side of the esophagus

Total colonic duplications

• All colon tubular• Antimesenteric • Communicates proximally with the normal bowel.

• If communicates distally, no treatment is necessary.

• If not communicate distally, a communication must be established

• if 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 6–12 months later

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

• 4–6-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- GERD

Anatomic:1. length and pressure of the lower esophageal

sphincter;2. the intra-abdominal segment of the esophagus;3. the gastroesophageal angle (angle of His);4. the lower esophageal mucosal rosette;5. the phrenoesophageal membrane;6. the diaphragmatic hiatal pinchcock effect.

Physiologic:7. Coordinated effective peristaltic clearance of the distal

esophagus;8. Normal gastric emptying

NORMAL MECHANISMS PREVENTING REFLUX

1.Barium Esophagogram2.Esophageal pH monitoring3.Esophageal manometry..4.Endoscopy and biopsy5.Scintiscanning

Investigations for GERD

1.Anatomy of the esophagus (e.g.. Strictures)2.Function of the Esophagus (Peristaltic &

clearance)3.Presence of a hiatus hernia4.Evidence of gastric outlet obstruction5.Degree of GERD

o grade I: Distal esophaguso Grade II: Thoracic esophaguso grade III: Cervical esophaguso grade IV: Continuous refluxo grade V: Aspiration into tracheobronchial tree

Barium Esophagogram

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

Number of episodes lasting more than 5 minutes

Total duration of reflux {percentage of recording time}

24 h Esophageal pH monitoring pH of less than 4 is regarded as significant

1.Grade I: Erythema of mucosa2.Grade II: Friability of mucosa3.Grade III: Ulcerative esophagitis4.Grade IV: Stricture.

Endoscopy and biopsy (degree of esophagitis)

Wound infectionRespiratory: pneumonia or atelectasis

Dysphagia: wrap too long or too tight.

Recur GER: either fundo disruption or herniation

Gas 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 malrotation

Complications Post Fundoplication

• Dilated esophagus• Absence of stripping waves

• Incoordinated contraction

• Obstruction GE junction gives rise to the classical ‘rat-tail’ deformity of funnelling and narrowing of the distal esophagus.

15- Achalasia

Barium swallow

1.LES: High-pressure (>30 mmHg)

2.Failure LE relaxation in response to swallowing

3.Absence of propulsive peristalsis

4.Incoordinated 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 laparoscopically

16- Gastrostomy

Barium Meal (Rarely Used)

• ‘string sign’ of the narrow elongated pyloric canal

• Delayed gastric emptying

• Gastric hyperperistalsis

17- IHPS

US in HPS• pyloric 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 {10–15 cm} even if it appears viable

• 2–3 cm distal intestine resected oblique ‘fish mouth’

Resection

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 15–30 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 include1. Bowel Volvulus2. Bowel atresia3. Bowel perforation4. Giant cystic meconium

peritonitis.

Uncomplicated meconium ileus1-BISHOP–KOOP PROCEDURE

Distal bowel is brought out as an end Ileostomy

Uncomplicated meconium ileus2- SANTULLI–BLANC ENTEROSTOMY

Proximal bowel is brought out

Uncomplicated meconium ileus3- PRIMARY RESECTION AND

ANASTOMOSIS

Uncomplicated meconium ileus4- TUBE ENTEROSTOMY

20- NEC

Proximal jejunostomyPan-intestinal disease

• allows decompression and defunctioning of the diseased intestine but does not remove gangrenous segments and may permit continued bacterial

• translocation.

• high morbidity and mortality rates should be carefully considered

21- ARM

(Bianchi 1980) Longitudinal

22- intestinal lengthening

(Kimura 1993)Isolate bowel segment

22- intestinal lengthening

(Kim et al. 2003)Serial transverse

entrostomy

22- intestinal lengthening

23- Complications of Choledochal cysts

• Should be resected by inguinal orchiectomy

• Patients >10 years Should undergo ipsilateral retroperitoneal lymph node dissection.

• Patients <10 years May be followed by thin-cut CT scans to evaluate nodal status.

• Positive nodes are radiated

24- Paratesticular Rhabdomyosarcoma

25- ‘Damage control’ strategy in exsanguinating trauma patient