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:
- Esophageal atresia w\out TEF
- Proximal esophageal atresia w\ proximal TEF
- Proximal esophageal atresia w\ distal TEF (most common)
- Proximal esophageal atresia w\ proximal + distal TEF
- “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 |
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)
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
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:
- Abdominal pain: intermittent + colicky
- Bilious vomiting
- 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
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:
- Limited to one organ (origin) -> resection
- Extends beyond origin but doesn’t cross midline -> resection + chemo
- Crosses midline -> resection + chemo
- Metastasis -> resection + aggressive chemo\radio
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:
- Flank mass (painless)
- Haematuria
- Hypertension
Stages:
- Limited to kidney
- Extends beyond kidney -> invades capsule and perirenal tissue
- Non-haematogenous metastasis
- Haematogenous metastasis -> lung, brain, distal nodes
- 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
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
Download the PDF version: here
References:
- Dr Alnamshan’s lecture
- Step up for the surgery clerkship
- Monte Reid