Paediatric Surgery Flashcards
Biliary atresia - Jaundice in infants:
Colour of stools and urine…
Associated with…
> 14 days in term infants (>21 days in pre term infants)
Pale stool, yellow urine (colourless in babies)
Associated with cardiac malformations, polysplenia, situs inversus
Biliary atresia - Surgical Treatment with.
Jaundice > 14 days
Increased conjugated bilirubin
Roux-en-Y portojejunostomy (Kasai procedure).
If Kasai procedure fails or late recognition, a liver transplant becomes the only option.
Bilious vomiting in neonates ALL…
Few hours after birth - Duodenal atresia - Duoduodenostomy. Double bubble AXR
Around 24 hours of birth - Jejunal/ ileal atresia - Laparatomy + primrary resection/ Air -fluid level AXR.
Around 24-48 hours - Meconium ileus - surgical decompression, PR contrast or NG NAC. Fluid level AXR. Sweat test for CF.
Usually 3-7 days after birth - Malrotation with volvulus - Ladd’s procedure
The second week of life - Necrotising enterocolitis - Conservative and supportive for non perforated cases, laparotomy and resection in cases of perforation of ongoing clinical deterioration
Bronchogenic cysts
anomalous development of the ventral foregut
lie near the midline and most frequently occur in the region of the carina
maybe asymptomatic or present with respiratory symptoms early in the neonatal period.
maybe detected on conventional chest radiography as a midline spherical mass or cystic structure
Once the diagnosis is suspected a CT scan should be performed
Thoracoscopic resection is the ideal treatment. Very young babies can be operated on once they reach six weeks of age.
Cyanotic Congenital heart disease
Most Common…
TTTP
Tetralogy of Fallot
Transposition of the great arteries (TGA)
Tricuspid atresia
Pulmonary valve stenosis
Ayanotic Congenital heart disease
Most Common…
Ventricular septal defects (VSD) - most common, accounts for 30% Atrial septal defect (ASD) Patent ductus arteriosus (PDA) Coarctation of the aorta Aortic valve stenosis
Inguinal hernia in children
hernia sac is often a remnant of
ernia sac is often a remnant of the processus vaginalis and association with undescended testis is recognised
Inguinal hernia in children
Type and timing of presentation
Treatment..
Most common in the first few weeks of life. Nearly all will be indirect hernias. The treatment of which is inguinal herniotomy. Formal repair using meshes is not required because the posterior wall of the canal is usually intact.
BL tendency- offer BL exploration in females but not in males (risk of cord and testicular injury)
Fix on next available list!
Embryogenesis the intestine
4th week - into abdomen via umbilcus
270 degree clockwise twist
ligament of Treitz lies to the left of the spine and the caecum in the right lower quadrant.
Malrotation with volvulus - Ladd’s procedure
Usually 3-7 days after birth
Billous vomiting
an abdominal ultrasound scan to determine the relationship between the superior mesenteric artery and vein (normally SMA lies to the left of the SMV
Ladds procedure - division of adhesional bands - appendicectomy as caecum is replaced in upper left
Intraoperative fluid management
Neonates should receive
Other children should receive
Neonates should receive glucose 10% during surgery - at a rate of 60ml/Kg/day.
Other children should receive isotonic crystalloid.
Pyloric stenosis
2-6 weeks of life
30mins after feeding - Projectile non-bile stained vomitin, mass in RUQ
Treatment: Ramstedt pyloromyotomy (open or laparoscopic)
M>F
5-10% Family history in parents
Intussusception
6-9 months age - Telescoping bowel
Proximal to or at the level of, ileocaecal valve
Colicky pain, diarrhoea and vomiting, sausage shaped mass, red jelly stool.
Treatment: reduction with air insufflation
Hirschsprung’s disease
Absence of ganglion cells from myenteric and submucosal plexuses
Occurs in 1/5000 births
Full-thickness rectal biopsy for diagnosis
Delayed passage of meconium and abdominal distension
Treatment is with rectal washouts initially, thereafter an anorectal pull through procedure
Oesophageal atresia
Associated with tracheo-oesophageal fistula and polyhydramnios
May present with choking and cyanotic spells following aspiration
VACTERL associations
Cherry red rectile polyps
Juvenile polyps may occur as part of the familial polyposis coli syndromes. The lesions, which are hamartomas, are often cherry red if they protrude externally.
Umbilical vessels
The arteries are continuous with the internal iliac arteries (medial umbilical ligaments) and the vein is continuous with the falciform ligament (ductus venosus)
Omphalitis
infection of the umbilicus - Staphylococcus aureus is the commonest cause
cherry red lesions surrounding the umbilicus, they may bleed on contact and be a site of seropurulent discharge.
Umbilical granuloma - often respond favorably to chemical cautery with topically applied silver nitrate.
urinary discharge from the umbilicus
persistence of the urachus which attaches to the bladder. They are associated with other urogenital abnormalities.
umbilical discharge that discharges small bowel content
Persistent vitello-intestinal duct
Complete persistence of the duct is a rare condition. Much more common is the persistence of part of the duct (Meckels diverticulum). Persistent vitello-intestinal ducts are best imaged using a contrast study to delineate the anatomy and are managed by laparotomy and surgical closure.
dermatological condition in which scarring of the foreskin occurs leading to phimosis
Balanitis xerotica obliterans
This is a dermatological condition in which scarring of the foreskin occurs leading to phimosis. It is rare below the age of 5 years. Treatment is usually with circumcision.
Tetralogy of Fallot typically presents at around…
Most common CHD, typically presents at around 1-2 months, although may not be picked up until the baby is 6 months old.
ventricular septal defect (VSD)
right ventricular hypertrophy
right ventricular outflow tract obstruction, pulmonary stenosis
overriding aorta
Other features
causes a right-to-left shunt
ejection systolic murmur due to pulmonary stenosis (the VSD doesn’t usually cause a murmur)
a right-sided aortic arch is seen in 25% of patients
chest x-ray shows a ‘boot-shaped’ heart, ECG shows right ventricular hypertrophy
Management
surgical repair is often undertaken in two parts
cyanotic episodes may be helped by beta-blockers to reduce infundibular spasm
AT BIRTH, most common cyanotic heart disease presentation is…
at birth transposition of the great arteries is the more common lesion as patients with TOF generally present at around 1-2 months
Commonest cause of infravesical outflow obstruction in males…
Posterior urethral valves
high emptying pressures in utero, the child may develop renal parenchymal damage. This translates to renal impairment noted in 70% of boys at presentation.
Treatment is with bladder catheterisation. Endoscopic valvotomy is the definitive treatment of choice with cystoscopic and renal follow up.
Most common cause of UTI and management
E-Coli accounts for 80% cases.
important to establish whether there is underlying urinary stasis or vesico-ureteric reflux
Pyrexia lasting for more than 3 days mandates urine testing.
> 2 UTI’s (or 1 in males) in a 6 month period should prompt further testing.
Voiding cystourethrograms show the greatest anatomical detail and is the ideal first line test in males; isotope cystography has a lower radiation dose and is the first line test in girls.
USS should also be performed. Renal cortical scintigraphy should be performed when renal scarring is suspected.
Long obstructed breech delivery
Developmental dysplasia of the hip
Perthes
Age
Imaging
Sclerosis Catarall Staging
Perthes – 5-12 – MRI hip – Fem head sclerosis Catarall Stage 2
Achondroplasia inheritance
Achondroplasia – sporadic autosomal dominant (dwarfism, fibroblast growth factor)
Small round yellow nodule within the inguinal canal
Small round yellow nodule within the inguinal canal – Adrenal Rest
Scrotal swelling – indirect inguinal hernia - treatment is
inguinal herniotomy w/o mesh
Scrotal skin -
5/0 vicryl rapide
Bilious vomiting in neonates - surgical emergency -
intestinal malrotation and volvulus until proven otherwise - upper GI contrast study - Ladds
Types intussusception types
Ileo-ileal intussusception – laparotomy
Ileocolic – susage shaped mass, legs up crying, sufflation for ilio-colic
3 month hemiscrotum swelling – spermatic cord
Rhabdomyosarcoma
6 month old, firm testicular mass, weight loss
Rhabdomyosarcoma – malignant tumour (teratoma’s are benign)
Scream attacks
Think intussusception
2 months – elevated conjugated bilirubin + jaundice
2 months – elevated conjugated bilirubin + jaundice = biliary atresia – roux-en-y portojejunostomy
For paediatric laparotomy -
For laparotomy - Transverse supra umbilical abdominal incision
Umbilical hernia, age to fix..
Umbilical hernia – fix after 3 years of age
Neonate spinal cord termination
Neonate spinal cord termination – L3 (Adults L1)
cyanotic episodes worse on feeding. Improvement when the baby cries
Choanal atresia cyanotic episodes worse on feeding. Improvement when the baby cries or use of oropharyngeal airway.
D1 cyanotic when feeding or crying
TPA (TOF most common overall)
Management of Patent Processus Vaginalis hydrocele
Lords or Jabouley Procedure
Viral illness + abnormal gait
X > WCC 12 + ESR 40 > Y
Septic Arthritis > WCC 12 + ESR 40 > Transient tenosynovitis
(Septic: T >38.5 + Inability to weigh bear)
Rickets – Low Vit D
Features…
- Osteomalacia – femur/tib bowing,
- Costochondral thickening,
- Harrisons transverse chest sulcus, large head
Ligamentum teres femoris –
Ligamentum teres femoris – femur blood supply (acetabula notch to fovea)
Smooth RIF swelling, systemically well
Smooth RIF swelling, systemically well – mesenteric cyst
Most common brain tumour in kids
Most common brain tumour in kids
- Astrocytoma
Congenital undescended testis – no descent by..
Congenital undescended testis – no descent by 3 months!
2yo with high output ileostomy – IVF using..
0.9% NaCl with K+
Polyhydramnious + Cyanotic episodes =
oesophageal atresia
Kasai procedure for biliary atresia – survoval at 5 years
45% survival after 5 years
Transverse colon herniation through anterior midline defect
Morgagni hernia
Cherry red lesion , post defecation bleeding
Cherry red lesion , post defecation bleeding – juvenile polyp
Neuroblastoma – lesions are…
Neuroblastoma – lytics lesions
Unilateral cleft lip - incomplete…
nasolabial muscle ring fusion
Massive painless bleeding – otherwise well,
Meckels’s!
4yo sorethroat + thick grey membrane
diptheria
Direct hernia strangulation risk
Direct hernia strangulation risk <5% over a year
Bilious vomiting in neonates…
Few hours after birth
- Duodenal atresia - Duoduodenostomy. Double bubble AXR
Bilious vomiting in neonates…
Around 24 hours of birth
Jejunal/ ileal atresia - Laparatomy + primrary resection/ Air -fluid level AXR.
Bilious vomiting in neonates…
Around 24-48 hours
Meconium ileus - surgical decompression, PR contrast or NG NAC. Fluid level AXR. Sweat test for CF.
Bilious vomiting in neonates…
Usually 3-7 days after birth
Malrotation with volvulus - Ladd’s procedure
Bilious vomiting in neonates…
The second week of life
Necrotising enterocolitis - Conservative and supportive for non perforated cases, laparotomy and resection in cases of perforation of ongoing clinical deterioration
