Common problems in paediatric surgery.pptx
- 1. Common paediatric surgical problems Speaker : Dr.Md.Mokarabin(Robin) Asst. Professor & Head Dept of Paediatric Surgery , SHMCJ
- 2. Introduction All encountered surgical conditions in paediatric age group, mostly surgically correctable congenital anomalies. Requires specialized knowledge & expertise, concentration of facilities including the sophisticated support services of anesthesia, laboratories facilities , imaging & nursing care.
- 3. contd Antenatal & postnatal checkups are helpful. Outcome depends on time on attention , evaluation , resuscitations including pre , peri & postoperative care.
- 4. Antenatal Diagnosis Possibilities : - Extremes of maternal age. - Primi gravida. - High multiparous mothers. - Low socioeconomics - Smoker mother - Diabetic & hypertensive mother.
- 5. Indicator: Polyhydramnios - GIT anomaly. Oligohydramnios Renal anomaly
- 6. Pregnancy profile USG Capable of detects a wide range of fetal anomalies during pregnancy. Fetal ECHO. Maternal serum level of AFP. Amniocentesis Endoscopy
- 7. Post-natal Revealed anomalies - detected by routine physical examinations. Concealed anomalies - by recognition of clinical presentation like vomiting , failure to or delayed passes of meconium, respiratory distress with or without cyanotic spell, failure to or difficult micturation , rectal bleeding & abdominal masses .
- 8. Diagnostic tools Clinical presentation Laboratory investigations USG Plain & contrast imaging including CT & MRI. Endoscopy
- 9. NEONATAL INTESTINAL OBSTRUCTION Neonatal intestinal obstruction presents with a triad of bilious vomiting, abdominal distension and failure to pass meconium. It is an urgent condition that requires the immediate involvement of a team of Paediatric Surgeons and Neonatologist for perioperative management.
- 10. EVALUATION BY CLINICAL EXAMINATION NEONATAL INTESTINAL OBSTRUCTION INSPECT PERINEUM ANAL OPENING ANAL OPENING NOT ANAL OPENING PRESENT PRESENT IN SITU ABSENT (IMPERFORATE ANUS) NORMAL SITE NORMAL CALIBRE STENOSED LOOK FOR ECTOPIC SITE COVERED ANUS. - ANTERIORLY PLACED ANUS - RECTOVAGINAL FISTULA - RECTOVESTIBULAR FISTULA - ANOVESTIBULAR FISTULA.
- 11. Anal opening present in normal site Gentle introduction of lubricated plain rubber catheter no 5 FR. Not pass beyond the limit 2-3cm-Rectal atresia. Pass more than 5-6cm & then withdraw catheter. Look for tip of catheter. If tip of catheter contain meconium- Hirschsprungs disease, meconium ileus disease. If tip of catheter not contain meconium only mucus & blood Intestinal atresia.
- 12. DIAGNOSIS Antenatal: - Maternal polyhydramnios - Maternal USG - Family history of HPD or Cystic fibrosis Postnatal : - Plain X Ray abdomen - Abdominal / Transperineal USG - Invertogram - Contrast imaging study of upper & lower GIT - Laboratory Investigations
- 13. Management Resuscitation by NPO , N/G suction, I/V fluid, I/V antibiotic. Definitive treatment : According cause either in a single or staged procedure
- 17. Anorectal malformation. A perineum without an anal opening described as imperforate, embraces a number of anomalies. Mostly communicate by a fistulaurinary/genital, skin. Incidence :1 in 5000 live birth ,more in male. Outcome depends on associated anomalies which is more common in high varieties.
- 18. EVALUATION BY CLINICAL EXAMINATION ANORECTAL MALFORMATION INSPECT PERINEUM ANAL OPENING ANAL OPENING NOT ANAL OPENING PRESENT PRESENT IN SITU ABSENT (IMPERFORATE ANUS) NORMAL SITE NORMAL CALIBRE STENOSED LOOK FOR ECTOPIC SITE COVERED ANUS. - ANTERIORLY PLACED ANUS - RECTOVAGINAL FISTULA - RECTOVESTIBULAR FISTULA - ANOVESTIBULAR FISTULA.
- 19. Diagnosis. History Clinical examination Investigation : a) Invertogram : - pouch-perenial distence - sacral anomaly/agenesis - vertebral anomaly b) Cross table lat. prone invertogram : safer more informative.
- 20. Contd Transperenial USG : pouch-perineal distance. To asses : Hb%, Serum creatinine, Serum electroyte, Blood glucose, Urine analysis, CxR, Echocardiography.
- 21. Management. Resuscitation : Low ---Anorectoplasty High--- Staged procedure: single procedure, PSARP/ ASARP/ Abdominoperenial pull through.
- 27. INFANTILE HYPERTROPHIC PYLORIC STENOSIS(IHPS) Commonest cause of vomiting in infant, severe in nature, usually commences between 3 to 6 weeks of age in an other wise well baby. Vomiting is non bilious and projectile Olive shaped mass in the epigastrium Severe dehydration & electrolyte imbalance leads to metabolic alkalosis
- 28. Diagnosis mostly obvious. Imaging studies of upper GIT are helpful. Needs urgent evaluation & surgical intervention which is very simple & permanent relief, other wise fatal outcome will be the result.
- 29. CLINICAL PRESENTATION Usual presentation is with severe non bilious, projectile vomiting which starts 3 - 6 weeks of age in an other wise well baby, rarely 10 days to 11 weeks. Vomitus contains only milk the child is active & hungry. Readiness & ability to feed immediately after vomiting. Constipation, jaundice & failure to thrive.
- 30. DIAGNOSIS Mostly by clinical presentation USG of upper GIT shows Olive shaped mass in epigastrium. Increase pyloric length mean 22 mm (range is 16-28 mm);normal length is 14mm Diameter of pyloric canal mean 16mm(range is 12-22 mm);normal is less than12 mm.
- 31. Upper GIT contrast study shows large gastric residue, delayed gastric empting, "string sign & pyloric canal is elongated. CBC, S creatinin , S electrolytes .
- 34. TREATMENT Correction of nutrition, fluid & electrolytes are the utmost part of treatment. Pyloromyotomy Fredet-Ramstedts pyloromyotomy. Complications: Perforation of duodenum. Incomplete pyloromyotomy
- 36. POST-OPERATIVE CARE Trial feeds are given after 12 hours & when these are retained, milk feed are started & the baby is usually discharged on 3rd or 4th post- operative day.
- 37. Inguinoscrotal swelling in children Commonest surgical condition encountered in children The duration & extent of the swelling can vary. The swelling can be either acute or insidious in onset Either congenital or acquired Accurate anatomical knowledge helps making correct diagnosis
- 38. D/D of inguinoscrotal swelling Onset of swelling Acute Insidious* - torsion testes site - Inguinal hernia - torsion appendages - Hydrocele - epididymo-orchitis - Testicular tumour - inguinal lymphadenitis Inguinal scrotal lymphadenitis - Torsion - epididymo-orchitis scrotal support Reduction of pain No relief epididymo orchitis Torsion testis
- 39. Torsion testis(contd) Insidious(contd) Clearly felt Not felt Site Torsion of appendages Torsion testis Inguinal only with Scrotal inguinoscrotal * +ve cough impulse Hernia - Hydrocele - Hernia - Tumour - Hydrocele Flactuation & Transillumination +ve - ve Hydrocele * Tumour
- 40. Hydrocele* Inguinoscrotal* - hernia Testis - hydrocele felt separately can`t felt spt cuogh impulse Reduction, transillumination encysted congenital flactuation hydrocele hydrocele cough impulse +ve flactuation +ve can be reduced transillumination +ve Hernia Hydrocele
- 41. INVESTIGATION Hb , TC, DC, BT, CT S Creatinin Chest - x - ray USG of inguinoscrotal region
- 42. Treatment Hernia: - Herniotomy as soon as diagnosed Hydrocele : - Neonates & Infants - wait & observe - Older children - Herniotomy + open the sac distally
- 49. Child with abnormal urinary opening Lower Abdominal wall Normal Deficit Hypospadias - Extrophy of Epispadias bladder Urethral - Cloacal extrophy duplication Urethral opening Mucosa Dorsal aspect ventral aspect Two urethral - only bladder - Bladder & of the penis of the penis openings mucosa colonic mucosa - Two ureteric - Two ureteric Epispadias Hypospadias Urethral openings openings and duplication - Two Intestinal openings Extrophy of bladder Cloacal extrophy
- 50. Hypospadias Hypospadias is a developmental anomaly characterized by a urethral meatus that opens on the ventral aspect of the penis, proximal to the end of the glans. Commonest congenital anomalies of the male genitalia occuring in 1 in 300 male birth.
- 51. Causes ventral curvature of the shaft of the penis more marked during erection. Deficiency in ventral aspect of the prepuce producing an unsightly dorsal hood of redundant skin. Meatus usually narrow may causes back pressure effect in the upper urinary system. Early treatment reduce morbidity, relief parent`s worries & anxiety
- 52. Imaging studies of urinary system, renal function tests & urinalysis are helpful to detect associated anomalies or co-existing morbidities.
- 53. Anatomy of the defect. Abnormal location of the meatus on the ventral surface of the penis Meatal stenosis Chordee.
- 54. Problems. Due to chordee stream of urine is deflected and splayed Difficulties in voiding in posterior variant of hypospadias Painful erection and interfere in sexual act leading to infertility
- 55. Associated anomalies. Inguinal hernia Undescended testes Upper urinary tract anomalies Enlarge prostatic utricle
- 56. Treatment. Aim : - straitening of the penis - placing the meatus at tip of the glans symmetric conical shaped - satisfactory cosmetic skin coverage Time: - preschool going age - meatotomy at any age after birth if needed Treatment modalities : - Orthoplasty & urethroplasty either in a single or stage procedure depends on types of hypospadias in various procedures.
- 60. Epispadias Relatively uncommon in which the urethra opens on the dorsal aspect of the penis Usually associated with exstrophy of the bladder, dorsal chordee is a coexisting problem Surgical reconstruction in a single or stage procedures at pre school going age
- 62. Exstrophy bladder Anterior abdominal wall & anterior wall of urinary bladder deficit, posterior wall of the urinary bladder with two ureteric orifices exposed Symphysis pubis apart from each other Anteriorly placed anus Epispadias with dorsal chordee and small/ micro penis in male , bifid clitoris and missing of roof of the urethra in female
- 63. Bilateral Undescended testis in male and bilateral direct Inguinal hernia in both sexes are associated Surgery is challenging and stage procedures
- 64. Cloacal exstrophy Most severe form of abdominal wall defect in which omphalocele superiorly, posterior walls of the hemi bladder on either side with central inter position of bowel, Symphysis pubis apart from each other Epispadias with dorsal chordee and small/ micro penis in male , bifid clitoris and missing of roof of the urethra in female Imperforate anus
- 65. Successful treatment requires an aggressive multispecialty effort