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PEDI A TRIC SU R GICAL REV I EW D r . M. B e t t ol l i

PEDI A TRIC SU R GICAL REV I EW D r . M. B e t t ol l i De p artme n t of G en e ral P ediatr i c Surg er y Chi l dren ’ s Hospi t al of E a s t ern O nt ar i o , Ot t awa. 8 t h ,. Apr i l. 2011. Objecti v es. • •. Her n ias Acu t e abdomen/Bo w el - T r auma - Ap p endic i t i s

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PEDI A TRIC SU R GICAL REV I EW D r . M. B e t t ol l i

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  1. PEDIATRICSURGICALREVIEW Dr.M.Bettolli Departmentof GeneralPediatric Surgery Children’sHospitalof EasternOntario, Ottawa 8th, April 2011

  2. Objectives • • Hernias Acute abdomen/Bowel -Trauma -Appendicitis -Midgutvolvulus -Intussusception Pyloricstenosis obstruction •

  3. Inguinal Hernias Embriologyandanatomy: Testisdescendinto thescrotum duringthe 7thmonthinutero insidetheprocesusvaginalis(PV) The PVbeginsto obliterateafter birth(close 1yr of life) Failure to obliterate: Procesus Vaginalis Cystofthe cord (encystedhydro.) Communicating hydrocele Inguinal hernia Complete inguinalhernia Hydrocele

  4. Inguinal Hernias Incidence: The commonestconditionrequiringSx duringchildhood It variesdirectlyw/thedegreeofprematurity -Prematures10-30% -Terms3-5% Nearly all ing.hernias inchildrenareindirect Entitiesassociatedw/an↑incidence: -Cryptorchidism -CF -Ascitis, VP shunts, PDcatheters -Abdwalldefects -Conectivetissuedisorders, congenitalhipdislocation -Mucopolisacaridosis -Meningomyeolocele

  5. Inguinal Hernias Clinicalpresentation: Most herniasare asymptomatic Inguinalbulgingorswellingw/straining Oftenfound byparents or pediatritianon routineexamination Phys.Ex.: - valsalvamaneuvers - silk glove sign - always exam theoppositeside - confirmpositionofbothtestes Acommonscenario:“Normalexaminationw/asuggestiveHx” Returnfor a 2ndexam Digitalphoto Options?

  6. Inguinal Hernias Diferentialdiagnosis: • Hydrocele:cystic,irreducible,transiluminate, painless,the upper limitis easilydemonstrable • Retractileor undescendedtestis • Femoralhernias and directhernias are rare • Inguinallymphnodes

  7. Inguinal Hernias Treatment: Surgery Timing:bowelincarceration inprematures issignificantly ↑(threefolds)* Ideally,repair herniabefore discharge *EinS.H. etalJPS2006May;41(5):980-6

  8. Inguinal Hernias Complications: Incarceration: -fussy orinconsolableinfant w/ -intermittentabd pain -tense, tender sweelingatthe -externaling.ring Strangulation:redness,indurationoverlyingthe lump,peritoniticsigns Diferentialdiagnosis: Cystof the cord:-mayappear suddenly,not tenderness -happyinfant -redness aftermanipulation Torsion ofan undescendedtestis:absence of testison thesameside Lymphadenitisorlocal inguinalabscess “Overall90-95% ofincarceratedherniascanbesuccessfullyreduced” The incidenceoftesticularatrophyisto 2-3% inthispatients

  9. • Abdominalpainisoneofthemostcommoncomplaintsin Acuteabdomen &Bowel obstruction childhood FrequentlyrequiresurgentevaluationintheofficeorER Thechallengeistoidentifythoseptsw/seriousorpotentiallylife- threateningconditions(e.g.appendicitisorbowelobstruction) ThelikelyDxisoften suggestedbythe child's ageandclinical features Signsofobstruction,Hxofpriorabd.surgery,andperitoneal irritationareclinicalfeaturesassociatedw/seriousintraabdominal conditionsthatrequirepromptDxandTt. • • • •

  10. Causesof life threateningabdpainby age Acute abdomen &Bowel obstruction Neonates Volvulus NEC Adhesions 2mo– 2 Trauma Incarcerated hernia yrs 2yrs– 5 Trauma Appendicitis yrs >5yrs Appendicitis Trauma Perforatedulcer Adhesions Hemolyticuremic syndr. Primary bacterial peritonitis Intussusception Foreignbody ingestion Adhesions Hemolyticuremic syndr. Primarybacterial peritonitis Intussusception Foreignbody ingestion HD Adhesions Hemolyticuremic Syndr.

  11. Evaluation: Acuteabdomen &Bowel obstruction The firstgoalistoidentifylife-threateningconditionsthat require emergent interventions History: -Historyoftrauma -Priorabdominalsurgery -Fever -Vomiting -Locationoftheabdominal pain -Patternofsymptoms -Lastmenstrualperiod&sexualactivity (pubertalgirls)

  12. Characteristicsof abdominal pain: Acuteabdomen &Bowel obstruction -< 2 yrs,symptomssuch us drawingthelegsuporinconsolability -The preschoolchild may beable to describepain &symptoms -> 5 yrs, can typicallycharacterizethe onset, frequency,duration, and locationoftheirsymptoms SpecificDx associatedw/characteristicpatternsof pain: AppendicitisPeriumbilical,migratingto theRLQ Appendicealrupture(early),ovarian torsionAcute,severe, focal IntussusceptionIntermittent,colicky GastroenteritisDiffuseor vague CholecystitisRightupperquadrant Gastritis, gastriculcerdiseaseEpigastric PancreatitisSteady periumbilicalpain,oftenradiatingto theback

  13. Associatedsymptoms: Acuteabdomen &Bowel obstruction Fever,children w/abdominalpainfrequentlyhave fever Vomiting, andabdominalpain(inthe absenceofdiarrhea)should becarefullyevaluatedforlife-threateningconditions… -Volvulusmust beexcludedwhenbiliousemesisandapparent abdominalpain -Intussusceptionvomiting(initiallynon-bilious)mayoccur followingepisodesofpain -Small bowelobstructionresultof postoperativeor postinflammatoryadhesions -Appendicitisnausea&vomitingaretypicallypresent Diarrhea,usuallynota surgicalabdomen,unless perf.appendix

  14. Pastmedicalhistory: Acuteabdomen &Bowel obstruction -Bowelobstructionfrom adhesions duepriorabdominalsurgery -Ptsw/Hirschsprung Diseasecan develop obstructionand fulminant enterocolitis -Primarybacterialperitonitisoccursw/increased frequency amongchildren w/nephrotic syndrome -Diabetic pts, ketoacidosis w/abdpain

  15. Imaging: Acuteabdomen &Bowel obstruction -Essentialcomponentoftheevaluationinchildren w/ acute abdominalpain andconcerningclinicalfetaures: Trauma Masses Peritonealirritation Distension Signsofobstruction Focal tenderness

  16. -Children w/ abdominal painwhohave sustainedtraumamust Acute abdomen:Abd. Trauma be carefullyevaluatedforintraabdominalinjuries -MVA, MVpedestriancollisions,falls,and child abuse are mechanismstypically associatedw/ significantinjury -Althoughabdominalinjuries are 30%more commonthan thoracic injuries,they are 40%lesslikelytobe fatal -Historically,adultsurgeonsunfamiliarw/ the nonoperative management ofsolid organinjuries raiseddoubtsabout the wisdom ofthis approach

  17. Acute abdomen:Abd. Trauma Most solidvisceralinjuriesare successfullytreatednonoperatively, kidneys(98%),spleen(95%),andliver(90%)

  18. Acute abdomen:A.Appendicitis The mostcommonacute surgicalconditionin children Thelifetimeriskofappendicitis is≅8.7%forboys&6.7%forgirls Perforation ratesashighas 82%inchildren <5yrs and nearly 100% of1-yrolds Clinicalpresentation: -Anorexia and vagueperiumbilicalpain -Migrationofperiumbilicalpainto the RLQ -Nausea leading tovomiting follows the onsetofpain -Diarrheamore commonlyseenw/perf.appendicitis,alsomore commonin infants and toddlers

  19. Acute abdomen:A. Physicalfindings: Appendicitis -TendernessRLQ (McBurney’spoint) -Guardingorrigidity -Reboundtenderness -Palpablemass(delayedDx) -Lowgradefever -Urinarysymptoms Lab findings: Mildelevationofthe leukocytecount(11,000to16,000) Neutrophilia and lymphopenia “Childrenoften presentw/widedeviations from the classic picture”

  20. Acute abdomen:A.Appendicitis Radiologicimaging: -X-rays: may demonstratea fecalithin5-15%ofPts -US: fluid-filled,noncompressibleappendix diameter> 6 mm appendicolith periappendicealorpericecalfluid ↑periappendiceal echogenicitycausedbyinflammation Hyperhemia -CT: operator dependent,and extremelyaccurate (sen&esp 95%) lifetimeriskofa fatalradiation-induced malignancyis0.18%fora 1-yochild -MRI:extremelyaccurate,butimpractical

  21. Acute abdomen:A.Appendicitis Treatment: Surgery Medicalmanagement:-Delay presentationorDx(>5days) -Ptclinicallystable -MassRLQ -Percutaneous drain

  22. Bowelobstruction -bilevomiting Neonatal bowelobstruction -abd.distension -failuretopass meconium Severalcongenitalanomaliesofthegutcancauseneonatal bowelobstruction: -Duodenalobstruction:Duodenalatresia/web,annular pancreas -Bowel atresia:most commonDtl ileum, rare in the colon -NEC -Malrotationw/midgut volvulus -Hirschsprung’sdisease -Meconiumileus,meconiumplug -Bowel duplications -Imperforateanus

  23. Bowelobstruction Clinicalfindings •Bile-stainedvomitinginthe neonatal period alwaysissignificant Must beevaluatedcarefully(is indicativeofbowelobstruction) •Abdominaldistensionis lessspecific •Neonateswithbowelobstructiondonotpassmeconium three exceptions:-HD (may passstoolsw/stimulation) -Meconiumileus(passsome stickypellets) -Malrotationw/ volvulus (delay ppt)

  24. Bowelobstruction Imaging: Plainx-rayis very useful: distension ofthe gutw/ fluid levels Levelofthe obstructionmay berelatedtothe numberoffluidlevels Ileal atresia,HD Doublebuble Jejunal atresia

  25. Bowelobstruction Imaging: UGI are usefulforincomplete highobstructions Contrast enema isasuitable forlowobstructions Midgutvolvulus Meconium ileus

  26. Bowelobstruction Generaltreatment: •Transport: isaparticularlystressfultimeand the metabolic problems shouldbe correctedbeforetransfer •NGtubeismandatory •Resuscitation:-fluid replacement -glucosereplacement -correctionofacidosis •Hypothermia:is a majorrisktothe sickneonate •Sepsis:riskofsepsisw/neonatal BO IVAbxare startedafter cultures are taken

  27. Bowel obstruction: Midgut volvulus The normalmesenteryofthesmall bowelhas awidebase from the angleofTreitztothe cecum

  28. Bowel obstruction: In malrotation,theangle ofTreitzand thececumliesidebyside Midgut volvulus The narrowbase ofthe mesentery allowsthe gutto twist aroundthe superiormesentericvessels

  29. Bowel obstruction: Midgut volvulus Clinicalfeatures: Healthy fulltermbabywhoiswellforthe firstfewdaysoflife, develop feedingdifficultiesw/bilevomiting Early stage,the abdomenissoft and not distended The diagnosisshouldbe made atthisstage (UrgentUGI) Bloodper rectum andabdominal distensionw/tendernessare late featuresand indicate majorgut ischaemia Treatment: Urgent surgeryis required (otherwisegangreneof the duodenumto therightcolon)

  30. Bowel obstruction: Intussusception One ofthemost frequentcausesofBOininfants &toddlers 1st and 2ndyrsof lifeandis Theincidenceishighestinthe Uncommonbelow3 mo ofageandafter3 yrsof life Most patients arewellnourished,healthyinfants Clinicalpresentation: -Youngchildw/intermittent,crampyabdominalpain associated w/“currant jelly” stools -Between thepainfulepisodes,thechildmay appear comfortableorfall asleep -The childmay stiffenandpullthelegs upto the abdomen -Lethargyor alteredconsciousness canbethe primary symptom -Astheobstructionworsensbiliousemesis&worseningabdo distention infants) minal

  31. Bowel obstruction: Intussusception Physicalexamination: Vitalsigns are usuallynormalin theearlystage Duringpainlessintervals,the childlookcomfortable& Phys.Ex.willbe unremarkable The benignclinical appearancemay lead to anerroneous Dx (constipationor gastroenteritis) A massmightbe palpable anywherein the abdomen orevenvisualized Onrectalexamination,blood-stainedmucusor blood may beencountered Prolapseof theintussusceptumthroughtheanus isa grave sign

  32. Bowel obstruction: Intussusception Diagnosis: -AbdominalX-rays: normal, non-specificor reveala SBO w/air-fluidlevelsindilatedsmallbowel d usually isthe1st ussusceptionis -U/S: confirmed Dxan Investigationwhenint suspected

  33. Bowel obstruction: Treatment: Nonoperativemanagement: -NGtubeto decompress thestomach -NPO -IVfluidresuscitation Intussusception -Complete bloodcellcountand electrolytes

  34. Bowel obstruction: Nonoperativemanagement: Intussusception Colonenema • Airreduction (1st line of treatment)successrate 75-94%,perf. rate0.16- 2.8% • Ifsuccessfuladmit for 24hs(recurrence rate 10-12%)

  35. Bowel obstruction: Intussusception Operative management: Openapproach Lapapproach • •

  36. History: Pyloric Stenosis 4weeksoldmale Fullterm 3dayshistoryofvomiting

  37. Nonbiliousvomiting Pyloric Stenosis Progressive….. Projectile

  38. Pyloric Stenosis Differentialdiagnosis: • • • • Pyloricstenosis Feedingintolerance GER Infections: – – – UTI CNS GI

  39. Pyloric Stenosis Hydration: -Fontanels -Eyes -Mucousmembranes -Skinturgor -Urinaryoutput

  40. Pyloric Stenosis Findingsonabdominalexam: • • • Gastricdistention Gastricperistalticwaves Pyloricolive

  41. Pyloric Stenosis Whatwould you Priorities -Rehydration do now? -Correctionof electrolyte& metabolicabnormalities (metabolicalkalosis,↓Na, ↓Cl,↓K) -Confirmdiagnosis

  42. Ultrasound Pyloric Stenosis 3mm >15mm >14mm

  43. Pyloric Stenosis Surgical correction Pyloromyotomy -Alkalosiscorrected rehydrated normal electrolytes Preoperativeinform parentsabout expectedpostopvomiting

  44. O.pyloromyotomy L. pyloromyotomy

  45. END!

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