PEDIATRIC SURGICAL

REVIEW

Dr. M.
Bettolli
Department of General Pediatric
April 8th,
2011 Surgery
Childrens Hospital of Eastern
Ontario, Ottawa
 Objective

Hernias
s
Acute obstructio
abdomen/Bowel
n
-Trauma
-Appendicitis
-Midgut volvulus
-Intussusception
Pyloric stenosis
 Inguinal

Hernias
Testis descend into the scrotum during the 7th month in

utero
The PV begins to obliterate after birth 1 yr of
Embriology and anatomy:
inside the procesus vaginalis (PV)
(close life)
Failure to

obliterate:
Procesus
Vaginalis

Hydrocel Communicatin Inguina Complete Cyst of the cord

e g l inguinal (encysted
 Inguinal
Incidence
The commonest condition requiring Sx during
:childhood Hernias
It varies directly w/ the degree of
prematurity
- Prematures 10-30%
- Terms 3-5%
Nearly
Entitiesall ing. hernias in children
associated w/ an are indirect
-Cryptorchidism
incidence:
-CF
-Ascitis, VP shunts, PD catheters
-Abd wall defects
-Conective tissue disorders, congenital hip
dislocation
-Mucopolisacaridosis
-Meningomyeolocele
 Inguinal
Most hernias are asymptomatic
Hernias
Inguinal bulging or swelling w/ straining
Often found by parents or pediatritian on routine
Clinical
examination presentation:
Phys. Ex.: - valsalva maneuvers
- silk glove sign
- always exam the opposite side
- confrm position of both testes

A common scenario: Normal examination w/a

Options? Return for a 2nd
suggestive Hx
exam

Digital photo
 Inguinal

Hernias
Hydrocele: cystic, irreducible,
Diferential diagnosis:
transiluminate,
Retractile or undescended
painless, the upper limit is easily
testis
Femoral hernias and direct hernias are
demonstrable

rare
Inguinal lymph

nodes
 Inguina Hernia
Treatment
Surgery
:Timing: bowel l s
incarceration
in prematures is
signifcantly
(threefolds)*

Ideally, repair hernia

before
discharge

*Ein S.H. et al JPS 2006 May;41(5):980-6

 Inguinal
Incarceration -fussy or inconsolable infant

:
Hernias
w/
Complications:
-intermittent abd pain
-tense, tender sweeling
Strangulation: redness, induration overlying the lump, peritonitic
at the
signs -external ing. ring
Diferential
Cyst of the cord: diagnosis:
-may appear suddenly, not tenderness

-happy infant

-redness after manipulation

Torsion of an undescended testis: absence of testis on
the same side
Lymphadenitis or local inguinal abscess
Overall 90-95% of incarcerated hernias can be successfully
Acute abdomen & Bowel
Abdominal pain is one of the most common complaints in

obstruction

childhood
Frequently requires urgent evaluation in the offce or
ER
The challenge is to identify those pts w/ serious or
potentially life- threatening conditions (e.g.
appendicitis or bowel obstruction)
The likely Dx is often suggested by the child's age
and clinical
features
Signs of obstruction,Hx of prior abd. surgery, and
peritoneal irritation are clinical features associated w/
serious intraabdominal conditions that require
prompt Dx and Tt.
Acute abdome & Bowel
Causes of life threatening abd pain by age
n obstruction
Neonate 2mo 2 yrs 2yrs yrs >5
Trauma
s Incarcerat 5 yrs
Volvulus ed hernia Intussusception
Trauma Appendicitis
NEC Intussusception Trauma
Foreign body
Appendiciti
Adhesio Foreign body Perforated
ns ingestion
s ulcer
ingestion Adhesions
Adhesions
HD Hemolytic
Hemolytic uremic
Adhesions syndr.
uremic
Hemolytic Primary
syndr.
uremic bacterial
Primary
Syndr. peritonitis
bacterial
Acute abdomen & Bowel
Evaluation:
obstruction
The frst goal is to identify life-threatening conditions

that
require emergent interventions

History:
-History of trauma
-Prior abdominal surgery
-Fever
-Vomiting
-Location of the abdominal pain
-Pattern of symptoms
-Last menstrual period & sexual activity
(pubertal girls)
Acute abdomen & Bowel
Characteristics of abdominal pain:
obstruction
-< 2 yrs, symptoms such us drawing the legs up or

inconsolability
-The preschool child may be able to describe pain &
symptoms
-> 5 yrs, can typically characterize the onset,
Specific Dx associated w/ characteristic patterns of
frequency, duration,
pain:
and location
Appendicitis of their symptoms
Periumbilical, migrating to the RLQ

Appendiceal rupture (early), ovarian torsion Acute, severe,

focal

Intussusception Intermittent, colicky

Gastroenteritis Diffuse or vague

Cholecystitis Right upper quadrant

Acute abdomen & Bowel
Associated symptoms:
obstruction
Fever, children w/ abdominal pain frequently have fever
Vomiting, and abdominal pain (in the absence of
diarrhea) should
be carefully evaluated for life-threatening
conditions
-Volvulus must be excluded when bilious emesis
and apparent
abdominal pain
-Intussusception vomiting (initially non-bilious )
may occur
following episodes of pain
-Small bowel obstruction result of
Diarrhea, usually not a surgical abdomen, unless
postoperative or
perf.appendix
postinflammatory adhesions
Acute abdomen & Bowel
Past medical history:
obstruction
-Bowel obstruction from adhesions due prior abdominal

surgery
-Pts w/ Hirschsprung Disease can develop obstruction

and
fulminant
-Primary enterocolitis
bacterial peritonitis occurs w/ increased

frequency
among
-Diabeticchildren w/ nephrotic
pts, ketoacidosis w/abd syndrome

pain
Acute abdomen & Bowel
Imaging:
obstruction
-Essential component of the evaluation in children

w/
acute abdominal pain and concerning
Traum
clinical fetaures:
Masses a
Peritoneal

irritation
Distensio
Signs of
n
Focal obstruction
tenderne
ss
Acute abdomen: Abd.
-Children w/ abdominal pain who have sustained trauma must

Trauma
be carefully evaluated for intraabdominal

injuries
-MVA, MV pedestrian collisions, falls, and child abuse

are
mechanisms typically
-Although abdominal associated
injuries w/ common
are 30% more
significant injury
than
thoracic injuries,
-Historically, they areunfamiliar
adult surgeons 40% lessw/likely
the to be
fatal
nonoperative

management of solid organ injuries raised

doubts about the wisdom of this approach
 Acute abdomen: Abd.

Trauma
Most solid visceral injuries are successfully treated
non operatively, kidneys (98%), spleen (95%), and
liver (90%)
 Acute abdomen: A.

Appendicitis
The most common acute surgical condition in children

-Anorexia andrisk
The lifetime vague periumbilical
of appendicitis is pain
8.7% for boys & 6.7% for
-Migration of periumbilical pain to the RLQ
girls
-Nausea leading to vomiting follows the onset of
pain
Perforation rates as high as 82% in children <5 yrs and nearly
-Diarrhea
100% more commonly seen w/ perf.
appendicitis, also more common in infants and
of 1-yr olds
toddlers
Clinical presentation:
Acute abdomen: Appendiciti

A.
-Tenderness RLQ (McBurneys s
point)
Physical
-Guarding orfndings:
rigidity

-Rebound tenderness

-Palpable mass (delayed Dx)

Lab
-Low grade fever
Mild elevation of the leukocyte count (11,000 to
fndings:
-Urinary symptoms
16,000)

Children often
Neutrophilia present w/
and lymphopenia wide deviations from

the
Acute abdomen: A.

Appendicitis
-X-rays: may demonstrate a fecalith in 5-15% of Pts

-US: fluid-flled, noncompressible appendix

Radiologic
diameter >imaging:
6 mm

appendicolith

periappendiceal or pericecal fluid

periappendiceal echogenicity caused by

- operator dependent, and extremely accurate (sen&esp
lifetime risk of a fatal radiation-induced malignancy is 0.18%
inflammation
CT: 95%)
for aHyperhemia

1-yo child

-MRI: extremely accurate, but impractical

 Acute abdomen: A.

Appendicitis
Treatment:
Surgery
Medical management: -Delay presentation or Dx
(>5days)
-Pt clinically stable

-Mass

RLQ

-Percutaneous drain
 Bowel
Neonatal bowel -abd. distension
obstruction obstruction
-failure to pass

-bile
thevomiting
meconium
Several congenital anomalies of gut can cause

neonatal

bowel obstruction:

- Duodenal obstruction: Duodenal

atresia/web, annular pancreas
- Bowel atresia: most common Dtl ileum, rare
in the colon
- NEC

- Malrotation w/ midgut volvulus

- Hirschsprungs disease
 Bowel

obstruction
Bile-stained vomiting in the neonatal period always is

signifcant
Clinical fndings
Must be evaluated carefully (is indicative of bowel

obstruction)

Abdominal distension is less specifc

Neonates with bowel obstruction do not pass
meconium
three exceptions: - HD (may pass stools
w/stimulation)
- Meconium ileus (pass some sticky

pellets)
 Bowel
Imaging:
Plain x-ray is very useful: distension of the gut w/ fluid
levels obstruction
Level of the obstruction may be related to the number of fluid

levels

Double Ileal atresia, HD

Jejunal
 Bowel
Imaging:
UGI are useful for Contrast enema is a
incomplete obstruction suitable
high obstructions
Midgut for low obstructions
volvulus

Meconium

ileus
 Bowel

obstruction
Transport: is a particularly stressful time and the

metabolic
General treatment:
problems should be corrected before transfer

NG tube is mandatory
Resuscitation: -fluid replacement
-glucose replacement

-correction of acidosis

Hypothermia: is a major risk to the sick neonate

Sepsis: risk of sepsis w/ neonatal BO IV Abx are
started after cultures are taken
Bowel obstruction: Midgut

volvulus
The normal mesentery of
the small bowel has a wide
base from the angle of
Treitz to the cecum
Bowel Midgut

obstruction:
In malrotation, the angle of
Treitz and the cecum lie side
by side
volvulus
The narrow base of the
mesentery allows the gut to
twist around the superior
mesenteric vessels
Bowel obstruction: Midgut

volvulus
Healthy full term baby who is well for the first few days of

life,
Clinical features:
develop feeding diffculties w/ bile vomiting
Early stage, the abdomen is soft and not
distended
Blood per rectum and
The diagnosis should be made at this stage
abdominal
(Urgent UGI)
distension w/ tenderness are

late

features and indicate major

gut

ischaemia
Bowel obstruction:

Intussusception
The incidence is highest in
Uncommon
the below 3 mo of age and
1st and 2nd yrs of life and

is after 3 yrs of
life
One of the most frequent causes of BO in infants & toddlers
Most patients are well nourished, healthy
infants
-Young child w/ intermittent, crampy abdominal pain
Clinical presentation:
associated w/ currant jelly stools

-Between the painful episodes, the child may appear

comfortable or fall asleep infants)

-The child may stiffen and pull the legs up to the abdomen minal

-Lethargy or altered consciousness can be the primary

symptom
-As the obstruction worsens bilious emesis &
worsening abdo distention
Bowel obstruction:

Intussusception
Vital signs are usually normal in the early stage
During painless intervals, the child look
comfortable &
Physical examination:
Phys. Ex. will be unremarkable
The benign clinical appearance may lead to
an erroneous Dx
(constipation or gastroenteritis)
A mass might be palpable anywhere in
the abdomen
or even visualized
On rectal examination, blood-stained
mucus or blood
may be encountered
Prolapse of the intussusceptum through the
Bowel obstruction:

Intussusception
Diagnosis:
-Abdominal X-rays: normal, non- specifc or reveal a
SBO w/ air-fluid levels in dilated small bowel

d usually is the
-U/S: confrmed Dx
1st
an
ussusception is
Investigation when

int
Bowel Intussusceptio

obstruction: n
Treatment:
Nonoperative management:
-Complete blood cell count and
-NG tube to decompress the
stomach
electrolytes
-NPO
-IV fluid resuscitation
 Bowel Intussusceptio

obstruction:
Colon
n
Air reduction(1st line
Nonoperative
enema
of treatment) success
management:
rate

75-94%, perf. rate 0.16-

If successful admit
2.8%
24hs (recurrence
for
rate

10-12%)
Bowel Intussusceptio

obstruction:
Operative n
manageme

Open
nt:

approach
Lap
approach
 PyloricStenosi
History:
s
4 weeks old male
Full term
3 days history of
vomiting
 Pyloric
Non bilious vomiting
Stenosis
Progressive

..

Projectile
 Pyloric

Stenosis
Pyloric stenosis

Feeding
Differential diagnosis:

intolerance

GER

Infections:

UTI
CN

S
GI
 PyloricStenosi
Hydration: s
-Fontanels
-Eyes
-Mucous
membranes
-Skin turgor
-Urinary output
 Pyloric

Stenosis
Gastric distention

Findings on abdominal
Gastric peristaltic
waves
exam:
Pyloric olive
 PyloricStenosi

What would s now?

do

you
Priorities
-Correction of electrolyte & metabolic

abnormalities
-Rehydration
(metabolic alkalosis, Na, Cl, K)

-Confrm diagnosis
 PyloricStenosi
Ultrasound
s
3mm
>15mm

>14mm
 PyloricStenosi
Surgical s
Pyloromyotomy
correction
-Alkalosis
corrected
rehydrated
Preoperative
normal inform parents about
expected post op vomiting
electrolytes
O.
L.
pyloromyotomy
pyloromyotomy
END!