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

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Esophageal atresia with tracheo-esophageal fistula: 

• Failure of complete separation of trachea from esophagus

Types:

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

Presentation:

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

Diagnosis:

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

Treatment:

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

 

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Congenital diaphragmatic hernia: 

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

Types:

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

Presentation:

• Respiratory distress
• Scaphoid abdomen

Diagnosis:

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

Treatment:

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

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Pulmonary sequestration: 

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

Types:

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

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Gastroschisis: 

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

Diagnosis:

• Prenatal: US + ↑ AFP

Treatment:

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

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Omphalocele:

• 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

Diagnosis:

• Prenatal: US + ↑ AFP

Treatment:

• 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

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Pyloric stenosis: 

• Gastric outlet obstruction due to hypertrophy of the pyloric muscle

Presentation:

• 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”)

Diagnosis:

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

Treatment:

• 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)

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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

Presentation:

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

Diagnosis:

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

Treatment:

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

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Intestinal atresia: 

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

Presentation:

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

Diagnosis:

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

Treatment:

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

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Intussusception: 

• 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

Presentation:

• 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)

Diagnosis:

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

Treatment:

• 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”

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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

Presentation:

• 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

Diagnosis:

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

Treatment:

• Surgical resection

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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

Presentation:

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

Diagnosis:

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

Treatment:

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

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Neuroblastoma:

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

Presentation:

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

Diagnosis:

• Urinary catecholamines
• CT, MRI, MIBG

Stages:

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

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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)

Presentation:

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

Stages:

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

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Inguinal hernia: 

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

Presentation:

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

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Hydrocele:

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

Presentation:

• 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

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Umbilical hernia: 

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

Presentation:

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

Treatment:

• 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

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Undescended testis: 

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

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Testicular torsion: 

Presentation:

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

Treatment:

• Bilateral orchiopexy

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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

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Ambiguous genitalia: 

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

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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

Presentation:

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

Treatment:

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

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Branchial cleft anomalies: 

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

Presentation:

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

Treatment:

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

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Congenital torticollis \ Sternocleidomastoid tumor:

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

Presentation:

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

Treatment:

• Early -> physiotherapy
• Late -> surgical release

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Lymphangioma = Cystic hygroma: 

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

Presentation:

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

Diagnosis:

• Prenatal: US

Treatment:

• Conservative excision + unroofing of remaining cyst
• Sclerotherapy

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Hemangiomas: 

• Most common tumor of infancy
• Usually spontaneously regress

Treatment:

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

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Rannula:

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

 

 

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Download the PDF version: here

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References: 

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