Pediatric Surgery
Epiglottitis
H. Influenza is most common organism
A lateral xray may show edema of the epiglottis
(bird’s beak)
Orotracheal intubation should be performed in the
OR so that an open tracheostomy can be done if
needed.
Never nasotracheally intubate a child because the
angle between the superior and inferior glottis is
too large.
Tracheoesophageal Fistula
A newborn infant has excessive salivation,
choking, and regurgitation with feeding.
Results from abnormal ingrowth of ectodermal
ridges during the 4th week of gestation.
25-40% of neonates are premature, low bith
weight.
A maternal history of polyhydramnios is common
50% of neonates with TEF have an associated
anomaly (cardiovascular most common)
GI malformation
GU anomalies
Tracheoesophageal Fistula
Proximal and distal TEF
Diagnosis
Inability to pass nasogastric tube
CXR to deternime length of esophageal gap
Abdominal Xray with air in the stomach excludes
esophageal atresia
Treatment
Right thoracotomy thru 4th intercostal space
Proximal esophagus blood supply is from
thyrocervical trunk
Tracheoesophageal Fistula
Distally supplied by more tenuous
intercostals
Operation includes TEF ligation,
transection, and restoration with end-to-end
anastamosis.
POD 5-7 esophagram, if no leak, feed,
remove drain.
Tracheoesophageal Fistula
Early complications include:
Anastamotic leak, recurrent TEF,
tracheomalacia.
Late Complications include:
Anastamotic stricture (25%), reflux (50%),
dysmotility (100%).
Proximal atresia with distal TEF most
common.
Immunoglobulins
Which immunoglobulin is secreted in breast
milk?
Which immunoglobulin does not cross
blood brain barrier?
IGA is most common antibody in breast
milk, the gut, saliva, bodily secretions.
IGM is large and does not cross the
placenta.
Resuscitation
An 8 year old boy presents following a
bicycle crash with a ruptured spleen.What is
the best indicator of early shock?
Tachycardia in childhood is defined as a
heart rate >150 for a neonate, >120 in the
first year, >100 after one year. It is the best
indicator of shock.
Fluid resuscitation in children:
Resuscitation
20cc/kg crystalloid bolus for trauma
If shock persists after a second bolus, give
blood at 10cc/kg
Children have a lower GFR in comparison
to adults.
Malrotation
A healthy infant presents with bilious
vomiting, abdominal distension, and shock.
A surgical emergency, bilious vomiting in a
newborn is malrotation until proven
otherwise.
Malrotation
During 6-12 week of gestation, the intestine
undergoes evisceration, elongation, and
eventual return to the abdominal cavity in a
270 degree counterclockwise rotation with
fixation.
Malrotation is associated with abnormal
rotation and fixation.
Malrotation
Ladds bands extend from the colon to the
duodenum, causing duodenal obstruction
and biliary emesis.
Midgut volvulus refers to the narrow based
mesentery twisting around the SMA
(usually clockwise).
This results in obstruction and vascular
compromise.
Malrotation
Most develop symptoms in first month of
life.
If patient stable do UGI series (gold
standard).
See bird’s beak in third part of duodenum
Ligament of Treitz is right of midline.
Malrotation
Midgut volvulus is a surgical emergency.
Volume resuscitation is essential.
If patient in shock, no studies are warranted.
Malrotation
Immediate exploration to avoid loss of
small bowel and resultant SBS, death.
Surgical treatment is the Ladd’s
procedure.
This consists of division of bands,
correction of malrotation, restoration of
broad based mesentery, appendectomy
(because it is in the wrong place in LUQ).
Duodenal Atresia
A newborn full term neonate with Down’s
syndrome had bilious vomiting during the first day
of life. The abdominal exam is normal.
Duodenal atresia. Malrotation can present
similarly but less common.
Failure of recanalization during 8-10th week of
gestation.
Presents in first 24hrs of life.
Trisomy 21 is present in about 25%
Characterized by bilious emesis
Abdominal distension is absent
Duodenal Atresia
Check for patent anus
Rule out anorectal anomalies
Abdominal x-ray reveals double bubble sign:
Air in the stomach, and 1st and 2nd portions of
duodenum.
If there is no distal air, the diagnosis is secure.
If there is distal air, and urgent UGI needed to rule
out midgut volvulus.
Surgical treatment is a duodenoduodenostomy.
Jejunoileal Atresia
A 3 day old infant has bilious vomiting,
abdominal distension.
Differential includes:
Duodenal atresia
Malrotation
Meconium ileus
Imperforate anus
Hirchsprungs
Jejunoileal Atresia
Jejunoileal atresia is caused by an in utero
vascular accident.
Presents within first 2-3 days
Associated with Cystic Fibrosis in 10%
Jejunoileal Atresia
Abdominal distension is usually present with
distal atresia.
Abd. X-ray demonstrates multiple distended loops
of bowel with A-F levels
Contrast enema demonstrates a micro colon and
no reflux into dilated intestines.
Multiple areas of involvement in 10%.
Surgical correction involves end-to –end
anastamosis. Preserve length to prevent SBS.
Colonic Atresia
Caused by in utero mesenteric vascular accident.
Similar to above in presentation
Abdominal distention present
X-rays show obstructive picture
Contrast enema shows microcolon with a cut off
in proximal colon.
Surgical correction involves end-to-end
anastamosis.
Intestinal atresia can be associated with
gastrochisis.
Meconium Ileus
A newborn with cystic fibrosis presents with mild
abdominal distension. An X-ray demonstrates a
ground glass appearing mass on the right side of
the abdomen.
A gastrograffin enema may be all that is needed to
treat meconium ileus, complicated cases may need
surgery.
Caused by obstruction of terminal ileum with
meconium.
Meconium Ileus
15% have CF
Simple MI can be treated with enemas.
Complex MI requires enterotomy, resection,
evacuation.
Mucomyst enemas can be used for this. (Nacetylcysteine)
Hirchsprung’s Disease
A full-term neonate has bilious emesis during first
and second days of life. The abdomen is
distended. X-rays show dilated loops of small
bowel. A contrast enema reveals a narrow rectum,
compared to the sigmoid. The baby failed to
evacuate the contrast the following day.
A bedside suction rectal biopsy at least 2cm above
dentate line is the gold standard test.
Hirchsprung’s Disease
Failure of the normal migration of neural
crest cells.
Absent ganglia in the myenteric and
submucosal plexus.
The absence always occurs in the distal
rectum and extends proximally.
80-85% localized to rectosigmoid.
Hirchsprung’s Disease
Diagnostic work-up includes:
Contrast enema showing a contracted
rectum with dilated bowel above.
Failure to evacuate contrast 24h later can be
diagnostic.
Hirchsprung’s Disease
Rectal biopsy is required to confirm
absence of ganglion cells and nerve
hypertrophy.
Surgical treatment:
Soave endo-rectal pull through with
removal of the diseased distal bowel with
coloanal anastamosis
Hirchsprung’s Disease
Children who present acutely ill may need
staged procedure with colostomy.
Need to do intraoperative frozen section to
help determine the anatomic location of
transition zone.
Imperforate Anus
Anus absent or misplaced
Usually form anterior fistulous tract
Associated with coloanal deformity
Imperforate Anus
Divided into high and low malformations
with respect to the levators.
High: fistula to bladder, vagina, or urethra,
are treated with colostomy and posterior
sagital anorectoplasty (PSARP), and
genitourinary reconstruction if necessary.
Low: PSARP
Imperforate Anus
Preop anal dilatation may be needed to
prevent stricture.
A colostomy is generally not needed to treat
a low (below levator) imperforate anus.
NEC
A 7 day old premature infant has emesis,
abdominal distension, and bloody stools.
Differential includes:
NEC
Malrotation
NEC
More common in premature infants after
initiation of feeding.
Abdominal x-ray often reveals pneumotosis
intestinalis or portal vein air.
Treatment is conservative: NPO, NGT,
antibiotics, serial x-rays.
Medical management is successful in 50%
of cases.
NEC
Surgical treatment for :
Free air
Abdominal wall erythema, cellulitis
Worsening acidosis
Hyperkalemia
Palpable mass
Worsening distension
Overall deterioration
NEC
Surgery often involves resection of affected
intestine and creation of and end ileostomy and
mucous fistula.
If the neonate survives, reverse around 4-6 weeks
later after a contrast study rules out strictures.
NEC is the most common cause of SBS in
childhood
Abdominal erythema is an indication for surgery!
Hypertrophic Pyloric Stenosis
A 4 week old infant presents with non-bilious
vomiting and hypochloremic, hypokalemic,
metabolic alkalosis.
Idiopathic thickening and elongation of the
pylorus causing GOO.
Age is 3-6 weeks (1 month of age)
Initially fed normally then projectile vomiting.
An “olive” is palpated in 50%
Hypertrophic Pyloric Stenosis
Mild jaundice in 5% due to reduced glucoronyl
transferase activity
Dx is confirmed by US
Pyloric diameter > 1.4 cm
Pyloric wall >0.4cm
Pyloric channel > 1.6cm
Ramstedt pyloromyotomy is treatment of choice
(open or laparoscopic).
Surgery is not an emergency (resuscitate).
Intussusception
A healthy 11 month boy presents with sudden
emesis, crampy abdominal pain, bloody stools.
Intussusception is most common cause of
intestinal obstruction in early childhood and
classically present between ages 3 months and 3
years.
Air contrast enema is diagnostic and therapeutic.
Intussusception
Most occur before age of two.
Etiology is thought to be lymphoid hyperplasia in
terminal ileum after a viral illness.
Proximal bowel (intussusceptum) invaginates into
the distal bowel (intussuscipien) causing swelling,
obstruction, and possible vascular compromise.
Controlled air contrast enema is successful in 90%
Intussusception
Indications for surgery:
Enema not success
Third episode
Peritonitis
Intussusception
Surgery involves reduction, appendectomy, and
bowel resection for pathology.
Recurrence after radiographic or surgical
treatment is 5%.
Lead point present in 10% of cases (increases with
age)
Meckel’s diverticulum is most common lead point
In adults it is malignancy!
Currant jelly stool!
Meckel’s Diverticulum
A healthy 2 year old presents with painless bloody
stools.
Patent vitelline duct
True diverticulum
Located on anti-mesenteric border
A technetium-99 scan can assist with diagnosis
and localization.
Segmental resection is indicated for symptoms.
Rule of twos:
Meckel’s Diverticulum
2% of population
2% symptomatic
2 times more in males
2 feet from valve
2 years of age or less
2 presentations (bleeding or obstruction)
2 tissue types (pancreatic, gastric)
Most common cause of bleeding in children.
Biliary Atresia
A 1 month old infant has acholic stools and
persistent jaundice.
Jaundice in the newborn that persists >2
weeks is no longer considered physiologic.
Early diagnosis is critical (before 2 months)
to prevent progressive liver damage.
Biliary Atresia
Hallmarks:
Bile duct proliferation
Cholestasis with plugging
Inflammatory cell infiltrate
Progression to cirrhosis
Biliary Atresia
Must rule out hepatocellular dysfunction
due to infectious, metabolic, hematologic,
or genetic disoders.
Elevated conjugated bilirubin?
Elevated unconjugated bilirubin?
Biliary Atresia
Ultrasound helps to determine bile duct size
and if a gallbladder is present.
Bile ducts are not enlarged in atresia
If atresia is suspected do mini RUQ incision
for local exploration and biopsy.
Initial goal is to establish diagnosis!
Biliary Atresia
If gallbladder is present do cholangiogram.
If cholangiogram demonstrates a patent but
hypoplastic biliary system, the incision is
closed.
Biliary Atresia
If a patent GB or biliary tract cannot be
identified, the incision is elongated and a
Kasai procedure is performed:
portoenterostomy.
The fibrotic GB and extrahepatic biliary
tree is dissected to the porta hepatis and
resected.
Biliary Atresia
A Roux-en-Y is created and the roux jejunal
limb is sutured to the porta hepatis to help
reestablish bile flow from the minute bile
ducts.
Liver transplant is reserved for
progression to liver disease, failed Kasai,
cases where delayed diagnosis.
Gastrochisis
A neonate is born with an abdominal waal
defect to the right of the umbilicus. The
eviscerated intestines appear thickened and
do not have a peritoneal covering.
Caused by intrauterine rupture of umbilical
vein. (1 vein 2 arteries)
Gastrochisis
Eviscerated intestines have no covering
2-5 cm defect to right of umbilicus
Intestines are thickened, edematous and
foreshortened.
Associated anomalies are uncommon (except
intestinal atresia in 10-15%)
Perioperative management includes volume, NGT,
confirmation of bowel viability and protective
dressings.
Gastrochisis
Treatment:
Attempt primary reduction, if unsuccessful,
use a silo.
A silo allows for a bedside staged closure to
be followed by primary closure.
During exploration confirm presence or
absence of atresia.
Post-op ileus common, TPN life saving.
Omphalocele
A baby is born with an abdominal wall
defect. The exposed intestines have an
intact peritoneal covering and appear
normal.
Omphalocele is associated with 40-80%
incidence of another congenital anomaly!
Defect thru umbilicus, 4-10cm defect.
Covered, normal appearing.
Omphalocele
Associated anomalies
Cardiac most common
Pericardial, sternal, diaphragmatic
Musculoskeletal
GI,GU
Beckwith-Weidmann syndrome
(omphalocele, hyperinsulinema,
macroglossia)
Omphalocele
Perioperative management includes volume,
NGT, ID other anomalies.
Primary reduction is optimal, but if defect
too large, then staged closure.
Outcomes related more to associated
anomalies than to the omphalocele itself.
Congenital Diaphragmatic Hernia
A few hours after birth, a newborn develops
dyspnea, cyanosis, retractions.
Two types:
Bochdalek (posterolateral) most common,
80% on left
Morgnani (anteromedial)
CXR shows loops of intestine or gastric
bubble in chest. NGT helps in diagnosis.
Congenital Diaphragmatic Hernia
Resuscitate, stabilize first!
May require ECMO
Beware of contralateral PTX due to aggressive
ventilation.
Surgical repair is done through subcostal incision,
with reduction of organs, closure of defect.
Primary repair is optimal but may need patch to
avoid tension.
Neuroblastoma
A 2 year old boy complains of belly pain and lack
of appetite. Physical reveals a large abdominal
mass.
Most common malignant solid tumor in children.
Derived from neural crest tissue
May arise anywhere along sympathetic ganglia.
Most common in adrenal medulla (50%)
Neuroblastoma
Age 1-2 years
Extends across midline
Ocular involvement may present as raccoon eyes.
Calcifications on x-ray
Elevated catecholamines, VMA, metanephrines.
Due to production of hormones, children may
present with flushing, HTN, watery diarrhea,
periorbital ecchymosis.
Neuroblastoma
Age at presentation is major prognostic factor.
Less than 1 year >70% survival
Older than 1 year <35% survival
Good prognostic features:
Tumors with <10 copies of N-myc gene
Aneuploid tumors
Low mitosis index
Normal LDH and catecholamine levels.
Neuroblastoma
Rarely mets
If able, surgical excision is treatment of
choice, chemo may be beneficial.
The N-myc gene is associated with
neuroblastoma!
Wilm’s Tumor (Nephroblastoma)
Second most common solid tumor in
children.
Mass palpable and HTN, hematuria
Derived from kidney
3-4 years of age
Rare to extend across midline
Wilm’s Tumor (Nephroblastoma)
No x-ray calcifications
Prognosis based on tumor grade
Mets to bone and lung
Primary surgical excision very important
Neoadjuvant chemo for large tumors
Overall survival is good (85%)
Wilm’s tumors replace renal parenchyma on CT
scans whereas Neuroblastoma displaces it.
Hepatoblastoma
A 7 year old boy presents with precocious
puberty and elevated Alfa fetal protein.
Most common liver tumor in children.
Liver cancer variant (better prognosis than
hepatocellular ca in adults)
Beta HCG release results in puberty
AFP elevated
Surgical resection is treatment of choice.
Mediastinal Masses in Children
A 7 year old girl presents with dysphagia.
A CT scan reveals a mediastinal mass.
Most common is T-Cell lymphoma
Teratoma
Tumor (neuroblastoma, neurofibroma,
neuroganglionoma, germ-cell tumors).
Most Common Malignancy in
Children?
Leukemia
Hernia
A 14 month old presents with incarcerated
right inguinal hernia. What do you do?
Reduce, admit, do semielective repair in
future.
High ligation and division of sac.
Elective repair to avoid reincarceration
(16%)
Hernia
10-30% incidence of contralateral inguinal hernia.
Watch out for a normal ovary in an inguinal
hernia in females.
Umbilical hernias occur in 10-30% of live births
Incarceration very rare
If less than 2cm, frequently close spontaneously,
closure and repair should be delayed until age of
4.
If larger than 2cm, repair at time of diagnosis.