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

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

 


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

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

Pediatric surgery conditions 6


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)

Pediatric surgery conditions 7


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

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)

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: 1st 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

Pediatric surgery conditions 12


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

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”

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

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

Pediatric surgery conditions 17


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

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)

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

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

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

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

Undescended testis: 

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

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

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

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)

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)

Presentation:

  • 2nd 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)

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

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

Hemangiomas: 

  • Most common tumor of infancy
  • Usually spontaneously regress

Treatment:

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

Rannula:

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

Pediatric surgery conditions 20

 

 


Download the PDF version: here


References: 

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

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