Paeds Surgery Flashcards
What is a infantile haemangioma?
A birthmark made up of blood vessels which develops from 4-6 weeks of life
Who are infantile haemangiomas more common in?
Caucasian premature girls
What is a superficial haemangioma?
It is a haemangioma that is on the surface of the skin and bright red/purple
What are deep haemangiomas?
Haemangioma in the fat layer- purple,blue or even skin colour if deep enough under the skin layer
Mixed haemangioma
Both superficial and deep components
What are the 3 phases of infantile haemangioma?
- rapidly growing phase(first few weeks or months)
- plateau phase- at 8 months
- involution phase-after 1 year they start to turn from red, purple to grey
Where are haemangiomas more common?
- scalp
- face
- neck
How do they initially present?
As a single red bruise/bump
When do we worry about internal haemangiomas?
When there are 6 skin haemangiomas and more
What is the typical size and shape of haemangiomas?
Vary from oval and round and 1mm to 20 cm
What special investigations do you do?
- Skin biopsy
- Doppler US
- MRI can make diagnosis if atypical looking
What is the treatment of haemangiomas dependant on?
- age
- size of the lesion
- how rapidly it’s growing
- the location(if it threatens life-airway and liver)
- complications
What is the treatment options for haemangiomas?
- observation
- propanolol(A b-blocker that vasocontricts and causes a colour change and softening of haemangioma within 24 hours)
- surgery
- Laser therapy
- oral corticosteroids
- Intralesional corticosteroids
- Topical steroids
What are the complications of haemangiomas?
Complications occur in 25% of pts
- inteference with organ function eg. eyes,and diaper area
- ulceration-the skin around a haemangioma is raw and shiny and can scar easily and can get infections easily
- Bleeding if cut or injured
What are the adverse reactions of propanolol?
- Hypotension
- Hypoglycaemia
- bradycardia
- bronchospasm
What is omphacocele?
It is congenital herniation of the abdominal contents through the umbilical ring
How does omphalococele develop?
By the intra-abdominal contents not closing into the abdomen at the 11-1th week of development
What is the hernia covered with?
Peritoneum/whartons jelly and transparent amniotic membrane
How can exomphalos be classified?
Minor: less than 5cm in sheath diameter
Major: More than 5 cm in sheath diameter
What is the presentation of babies with exomphalos?
They present with asoociated abnormalities, a defect through the umbilical ring, bowel covered in a membrane,
What is Beckwith Wiedeman syndrome?
- Hypoglycaemia
- Exomphalos
- Macroglossia(large tongue)
- macrosomia(large baby)
- organomegaly
- increased risk of nephroblastoma/hepatoblastoma
What chromosomal abnormalities does exomphalos present with?
Trisomy 13,18,21
What other congenital anomalies does omphalocele present with?
- prematurity
- malrotation in 100%
- cardiac and urogenital problems
What is the initial management of exomphalos?
Put in an IV line to combat the hypoglycameia(12-15% dextrose maintenance fluid)
What is the initial mamagement of a baby with exomphalos?
- Keep baby warm
- normal feeds unless going into theatre
- give antibiotics(penicllin and gentamycin)
- cover the abdominal contents with silk tie
What surgical options are there with exomphalos?
Primary closure:
Done under general anaesthesia in theatre
The membrane is removed and the contents reduced and sheath closed then skin closed
What is the delayed secondary closure for exomphalos?
This is when the baby has a ruptured sac or the sheath is too big. A silastic sac is placed over the aread and reduced twice a day until 3-10 days later
What does non-operative management of exomphalos consist of?
It is reserved for patients with cardiac issues that are not fit for surgery
We wait for the membrane to completely dry out and granulation tissue forms
The agents used for this include:
1% mercurochrome
H&E stain
Gentian violet(dye used to treat ringworms/athletes foot etc.)
Complications of exomphalos?
Infection and septic complications
Rupture of the sac
Hypoglycaemia
What is gastroschisis?
congenital condition where the abdominal contents are protruding outside of the anterior abdominal wall-lateral to the umbilical ring.
Not covered in a membrane
What are the risk factors for gastroschisis?
- Young mother <20 years old
- Drug abuse-Tik(vasoconstrictor)
- cigarette smoker
What is the clinical presentation of a baby with gastroschisis?
- They present with protruding bowel
- No membrane surrounding the bowel
- To the right of the umbilicus with an opening of 1-2 cm
What is the initial management of a patient with gastroschisis?
ABCDE!
- Put in a nasogastric tube
- Give feeds TPN and nil by mouth
- IV fluids- normal fluids plus 10% extra of neonatalyte
- If the baby presented to the hospital late give 10-20ml/kg IV crystalloid (NaCl 0.9%) to combat the dehydration
- Protect the bowel by covering it with plastic eg clingwrap
- Avoid ischaemia of the bowel by making sure the mesentery does not coil
- enlarge to opening by injecting local anaesthetic and cutting 1cm left laterally - Transfer the baby to a tertiary hospital ASAP
What is the definitive management of gastroschisis?
- Primary reduction and surgical closure of the sheath is recommended
- Delayed Secondary closure can be done if the abdomen of the baby is too small for the abdominal contents to fit- in this case a silo bag is placed and the closure re-attempted at 5-10 days later
- The baby must be TPN because the bowel activity only begins 2-4 weeks after the ileus - If there is atresia then repair of that 3 weeks is expected
What are the complications of gastroschisis?
Death
Central venous line infection
Necrotizing enterocolitis
Define a hernia
It is the protrusion of an organ through its cavity when a defect occurs in its cavity wall
Inguinal hernia?
It is the out-pouching of abdminal contents out of the inguinal canal
What is the prossesus vaginalis?
It is the embryonic outpouching of peritoneum along the pathway of the testicles. It is 20% as adults, 40% for 2 year olds and 80% at birth
What causes groin hernias 99% of the time?
Opened processus vaginalis
What other contents other than abdominal contents do groin hernias have?
Ovaries in girls and someimes bladder
What is a fluid hernia/hydrocele?
The fluid from the abdomen collecing in the testicles
Is the incidence of bilateral hernias more common in girls or boys?
Girls- 75%
How does a baby with a hernia present with?
Increasing inguinal mass with coughing/vasalva
Relaible hx from mom
Bowel obstruction symptoms- constipation and vomiting
What are the clinical findings on inspection of an inguinal hernia?
- There is a swelling in the groin that is either reducible/not reducible
- red, swollen, tender
- transillumination if hydrocele
What are the clinical signs on palpation of an inguinal hernia?
- silk sign where it feels like silk when you rub the processus vaginalis
- palpation of bowel in the inguinal canal
- swelling
- cannot get above the mass (for a hydrocele you can get above the mass)
- swollen lymphnodes as masses below the inguinal canal
What are the clinical signs that you would auscultate for in an inguinal hernia?
Gurgling sounds
What is the diff diagnosis of inguinal hernia?
- Hydrocele
- varicocele
- Testicular torsion
- undescended testes
- Buried testes
- Hydrocele of the cord
What is an incarcerated/obstructed hernia?
It is a hernia where the abdominal contents continue to be outside the abdominal cavity
What is an irreducible hernia?
It is a hernia that ca be pushed back into the cavity
How do incarcerated hernias present?
- pain
- swelling in inguinal canal
- vomiting
- cannot get above the mass
- sudden onset
What is a strangulated hernia?
It is a hernia that is obstructed where ischaemia and necrosis occur
What are the clinical signs of a strangulated hernia?
It is an emergency- painful,redness, oedema above the mass, tenderness
This requires resuscitation and surgery ASAP
What complications can inguinal hernias cause?
- incarcerated hernia
- strangulated hernia
- speticaemia and septic shock
- full thickness necrosis
- testicular infarction in 10% of obstructed hernias
What is the operation of choice in children with an uncomplicated hernia?
Herniotomy
Is age important when deciding when to do the herniotomy?
No it isn’t because the younger the child is(neonates) the higher the risk of complications
What is the Mx of an incarcerated hernia?
- Conservative treatement first to prevent possible infection, haematoma,recurrent hernia and damage to the vas dederens
- Give 1mg/kg of ketamine as sedation
- Resuscitation and nasogastric tube is commenced
- Once reduced wait 24-48 hours to do the surgery
What is the Mx of patients with a strangulated hernia?
- Active resusciation is NB- electrolyte correction, IV fluids,broad spectrum Antibiotics
- Resection of ischaemic bowel and a primary anastomses
- Herniotomy
- ICU postoperatively