Common Pediatric Surgery Conditions

General info:

  • Maintenance fluids:
    • First 10 kgs -> 4 cc\kg
    • Second 10 kgs -> 2 cc\kg
    • Every additional kg (past 20 kgs) -> 1 cc\kg
    • What is the maintenance IV fluids used for children? D5 1\4 NS + 20 mEq KCL
  • Minimum UO: 1-2 mL\kg\hr
  • Blood volume: 85 cc\kg

Esophageal atresia with tracheo-esophageal fistula: 

  • Failure of complete separation of trachea from esophagus


  1. Esophageal atresia w\out TEF
  2. Proximal esophageal atresia w\ proximal TEF
  3. Proximal esophageal atresia w\ distal TEF (most common)
  4. Proximal esophageal atresia w\ proximal + distal TEF
  5. “H-type” TEF w\out esophageal atresia


  • Postnatal:
    • Excessive salivary secretions
    • Respiratory distress\chocking\regurgitation after first feeding
  • Prenatal:
    • Preterm
    • Polyhydramnios


  • AXR + NGT: coiled NGT in upper esophagus
  • Gas in stomach = w\ TEF. No gas in stomach = w\out TEF


  • Suction blind pouch (NPO\TPN)
  • Prophylactic abx (amp\gent)
  • Surgical repair; thoracotomy:
    • Ligation of TEF
    • Anastomosis of 2 ends of esophagus


Congenital diaphragmatic hernia: 

  • Incomplete formation of diaphragm -> defect -> abdominal organs herniate
  • Can lead to pulmonary hypoplasia + pulmonary HTN


  • Bochdalek: posterolateral (most common, L>R)
  • Morgagni: anterior parasternal


  • Respiratory distress
  • Scaphoid abdomen


  • Prenatal US and polyhydramnios
  • CXR: bowel gas pattern in hemithorax + mediastinal shift


  • ET + NGT
  • If stable -> surgical repair: hernia reduction \ patch
  • If unstable -> NO +\- ECMO -> then surgery

Pulmonary sequestration: 

  • Nonfunctioning lung tissue that receives its own blood supply from system circulation + doesn’t communicate w\ normal tracheobronchial airway


Interlobar Extralobar
·   W\in normal lung

·   Covered by normal visceral pleura

·   Drained by pulmonary veins

·   Associated w\ infection

·   Rx: lobectomy


·   Separated from normal lung

·   Covered by its own pleura

·   Drained by systemic veins

·   Associated w\ diaphragmatic hernia

·   Rx: surgical resection

Pediatric surgery conditions 6


  • Anterior abdominal wall defect (usually Rt to umbilicus) -> antenatal bowel evisceration
  • No peritoneal sac


  • Prenatal: US + ↑ AFP


  • NGT decompression
  • IVF, TPN, broad-spectrum abx
  • Surgical reduction of viscera + abdominal closure (+\- Silastic silo)

Pediatric surgery conditions 7


  • Umbilical ring defect -> herniation of abdominal contents (including liver)
  • Covered by a sac: outer layer of amnion + inner layer of peritoneum
  • Associated w\ other anomalies + malrotation of the gut


  • Prenatal: US + ↑ AFP


  • NGT decompression
  • IVF, TPN, broad-spectrum abx
  • Surgical repair; depends on the size:
    • Small: closure of defect primarily
    • Medium: close skin + repairs hernia later
    • Large: staged closure using Silastic silo

Pyloric stenosis: 

  • Gastric outlet obstruction due to hypertrophy of the pyloric muscle


  • Age: (“3 to 3”) 3 wks after birth to 3 mos
  • Vomiting: nonbilious (b\c prox to ampulla of vater) + projectile + postprandial
  • Hungary after vomiting
  • Palpable midepigastric\RUQ pyloric mass (“olive”)


  • US: > 3 mm thick, > 14 mm long (remember Pylorus = Pi ‘π’ = 14)
  • Radiographic contrast series: signs >>


  • A medical emergency, not a surgical emergency
  • NGT, fluids, electrolytes
  • D5 1\2 NS + KCL
  • Ramstedt pyloromyotomy (divide circular fibres of pylorus w\out entering gastric lumen)

Marotation \ Midgut volvulus:

  • Incomplete 270° counter clockwise bowel rotation during fetal development -> vascular compromise
  • Cecum ending up being up in the RUQ -> Ladd’s bands (fibrous bands) -> cross over duodenum and cause obstruction


  • Age: 1st year
  • Sudden bilious vomiting (b\c distal to ampulla of vater)
  • Abdominal distension and lethargy
  • Late signs: hypovolemia and bloody stool


  • AXR: double-bubble (air in stomach and duodenum)


  • Surgical emergency!
  • Ladd procedure:
    • Reduction w\counter clockwise rotation
    • Ligation of Ladd’s bands
    • Appendectomy

Pediatric surgery conditions 12

Intestinal atresia: 

  • Obstruction of duodenum due to failure of recanalization or an ischemic insult during development
  • Associated w\ Down syndrome


  • Premature + LBW
  • Bilious emesis
  • Abdominal distension
  • Failure to pass meconium in the first 24 hrs


  • Prenatal: US -> polyhydramnios
  • AXR: dilated bowel loops due to obstruction + “double-bubble” sign
  • Contrast enema: unused “microcolon”


  • IVF, NGT, NPO, IV abx
  • Surgery: duodenoduodenostomy or duodenojejunostomy


  • Invagination of one portion of bowel into itself “telescoping”
  • Most common site? Terminal ileum: ileocecal -> ascending colon
  • Usually caused by a “lead point” -> viral infection (enterovirus in summer, rotavirus in winter) -> hypertrophied Peyer’s patches, Meckel’s diverticulum


  • Age: < 2 yrs (most common cause of bowel obstruction in toddlers)
  • Triad:
    1. Abdominal pain: intermittent + colicky
    2. Bilious vomiting
    3. Currant jelly stool
  • Neuro: shock-like, seizure-like, apnea
  • RUQ mass -> sausage shaped + Dance’s sign (absence of bowel in RLQ)


  • AXR: signs of obstruction
  • US: “Target” or “Donut” sign + “Pseudo-kidney” sign


  • IVF, NGT, NPO, IV abx
  • Air or barium enema -> reduce w\ hydrostatic pressure
    • Contraindications to barium enema: peritonitis, perforation, profound shock
  • If unsuccessful -> laparotomy + manual reduction “milking”

Meckel’s diverticulum: 

  • Persistent vitelline duct remnant -> true diverticulum (all 3 layers of the intestines)
  • Occurs on antimesenteric border of ileum w\in 60 cm of ileocecal valve


  • Intermittent rectal bleeding (painless): caused by ulceration of adjacent tissue from ectopic gastric mucosa
  • Intestinal obstruction: “lead point” to intussusception and volvulus
  • Diverticulitis: mimics appendicitis


  • Meckel’s scan (scintigraphy) -> uptake by ectopic gastric mucosa


  • Surgical resection

Hirschsprung’s disease: 

  • Congenital absence of parasympathetic ganglion cells in the Auerbach (myenteric) + Meissner (submucosal) plexi -> intestinal obstruction
  • Most commonly Rectosegmoid
  • Most common cause of lower intestinal obstruction in neonates


  • Failure to pass meconium > 24 hrs
  • Abdominal distension
  • Bilious vomiting
  • Constipation\overflow diarrhea


  • AXR: dilated colon
  • Barium enema:
    • “Transition point” -> narrow rectum + dilated prox colon
    • Retained colonic barium > 24 hrs
  • Confirmatory: suction biopsy


  • IVF, NGT, IV abx
  • Surgery: diverting colostomy or definitive repair

Pediatric surgery conditions 17


  • Arises from neural crest cells -> adrenal medulla (most commonly), paraaortic ganglia, post mediastinum, neck
  • Metabolically active -> release of catecholamines


  • Age < 4 yrs
  • Abdominal mass and pain
  • Fever, failure to thrive
  • Hypertension
  • Horner syndrome (if primary cervical tumour)


  • Urinary catecholamines


  1. Limited to one organ (origin) -> resection
  2. Extends beyond origin but doesn’t cross midline -> resection + chemo
  3. Crosses midline -> resection + chemo
  4. Metastasis -> resection + aggressive chemo\radio

Pediatric surgery conditions 18

Wilm’s tumor: 

  • Nephroblastoma; embryonal tumour of renal origin

Associated syndromes:

  • WAGR (Wilm’s, Aniridia, GU anomalies, mental Retardation)
  • Beckwith-Weidmann syndrome (hemihypertrophy, macroglossia, organomegaly)
  • Denys-Drash (Wilm’s, pseudohermaphroditism, glomerulopathy)


  • Triad:
    1. Flank mass (painless)
    2. Haematuria
    3. Hypertension


  1. Limited to kidney
  2. Extends beyond kidney -> invades capsule and perirenal tissue
  3. Non-haematogenous metastasis
  4. Haematogenous metastasis -> lung, brain, distal nodes
  5. Involves both kidneys

Inguinal hernia: 

  • Indirect inguinal hernia -> due to patent processus vaginalis
  • Most commonly in infancy (< 1yr), incidence decrease with age


  • Painless swelling, not confined to the scrotum
  • Cough\crying impulse
  • “Thick cord sign” + “Silk glove sign”
  • Complications: incarcerated, bowel obstruction, strangulation


  • Fluid-filled sac -> due to patent processus vaginalis


  • Asymptomatic, no signs\sx of hernia (cough impulse or obstruction)
  • Can get above it, but can’t feel the testis
  • Non-reducible
  • Positive trans-illumination

Types and management:

  • Non-communicating: fixed in size, gradually disappear -> observe + surgery in 1-2 yrs
  • Communicating: increase in size at the end of the day, small in size when the baby is relaxed\in early morning -> surgery at any age

Umbilical hernia: 

  • Due to failure of closure of umbilical ring -> central defect in linea alba


  • Rarely incarcerate, and therefore doesn’t cause abdominal pain
  • Reduction is contraindicated


  • Close spontaneously w\in 3 yrs + if the defect is < 1 cm -> only observe
  • Surgical repair indicated if:
    • Defect > 2 cm
    • Child > 3-5 yrs

Undescended testis: 

  • Can lead to torsion, hernia, germ cell tumours, infertility
  • Treatment: orchidopexy + herniotomy at 6-12 mo

Testicular torsion: 


  • Testicular or abdominal pain
  • Scrotum: tender, high riding, erythema
  • Absent cremasteric reflex
  • Time is essential; if firm and not too painful -> infarcted


  • Bilateral orchiopexy

Appendix testis torsion: 

  • Mild acute scrotal pain, no abdominal pain, baby is not toxic
  • Infarction of the appendix of the testis -> blue dot sign
  • Self-limiting

Pediatric surgery conditions 19

Ambiguous genitalia: 

  • Need to rule out congenital adrenal hyperplasia
  • Do karyotyping and US

Thyroglossal duct cyst: 

  • Remnant of the embryological migration of the thyroid from the base of the tongue -> foramen cecum -> migrates down to the root of the neck along thyroglossal duct


  • Midline infrahyoid structure -> moves w\ swallowing and tongue protrusion
  • Cysts can become infected and drained -> can develop into sinus or fistula


  • Sistrunk procedure: surgical excision of the gland remnant + entire tract to foramen cecum + central portion of hyoid bone (to minimize recurrence)

Branchial cleft anomalies: 

  • Remnant of primitive branchial clefts -> the epithelium forms a sinus tract between skin of ant neck and: pharynx (2nd cleft) or external auditory canal (1st cleft)


  • 2nd cleft (most common): lateral to midline (along ant border of sternocleidomastoid)


  • Abx if infected + surgical excision of cyst and entire tract (step-ladder incision)

Congenital torticollis \ Sternocleidomastoid tumor:

  • Inflammation or birth trauma -> fibrosis -> head tilt


  • Plagiocephaly: craniofacial deformity
  • Fascial asymmetry and squint
  • Scoliosis and ipsilateral atrophy of trapezius


  • Early -> physiotherapy
  • Late -> surgical release

Lymphangioma = Cystic hygroma: 

  • Benign tumour of lymphatic origin caused by sequestration or obstruction of developing lymphatics


  • Most commonly -> post triangle of the neck (> Lt side), axilla, groin
  • Complications: compression, haemorrhage, infection, lymphatic leak, chylothorax


  • Prenatal: US


  • Conservative excision + unroofing of remaining cyst
  • Sclerotherapy


  • Most common tumor of infancy
  • Usually spontaneously regress


  • Medical: propranolol, steroids
  • Surgery: indications:
    • Dangerous location
    • Large\rapidly growing
    • Local complication


  • Painless, spherical, mucous-containing cyst in the floor of the mouth

Pediatric surgery conditions 20



Download the PDF version: here


  • Dr Alnamshan’s lecture
  • Step up for the surgery clerkship
  • Monte Reid

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