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Pediatric surgery is a sub speciality of surgery pertaining to patients ranging from new-borns to 18 years of age. It comes with its own challenges that differentiate it from other surgeries. Whether it is the small size of babies and children to be operated or dealing with their responses to illness or surgery, every aspect of Pediatric Surgery needs special attention. Hence, there is a rationale for a dedicated division for Paediatric Surgery.
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Neonatal surgical Emergencies Dr Prashant Jain Sr Consultant Ped. Surgery & Ped Urology Dr BLKSS Hospital
Gastro-Intestinal Abdominal wall defects Respiratory distress
Intestinal Obstruction Bilious Vomiting Abdominal distension Failure to pass meconium
Neonatal Intestinal Obstruction Abdominal Distension +/- Bilious vomiting +/- fail to pass meconium Bilious Vomiting +/- fail to pass meconium Upper GI Obstruction Small or large bowel Jejunal/ileal/colonic atresia Meconium ileus Anorectal malformation Hirschsprung’s Disease Duodenal Atresia Malrotation
PASSAGE OF MECONIUM • CANNOT RULE OUT OBSTRUCTION • CAN PASS EVEN IN CASES OF ATRESIA
Causes Intestinal atresia Malrotation with or without Midgut volvulus Meconium ileus Meconium Peritonitis Ano-Rectal Malformation Hirschsprung’s Disease
CASE Term male child 2.7 Kg discharged after delivery Passed meconium Antenatal history normal Presented at day 5 with yellowish vomiting Admitted and managed conservatively
Exploratory Laparotomy MALROTATION WITH MID GUT VOLVULUS
Malrotation is a TRUE SURGICAL EMERGENCY • X-Ray • Upper GI study • USG
Volvulus Malrotation Normal Acute Intestinal Obstruction Recurrent abdominal pain and vomiting
CASE Bilious vomiting Antenatal scan: Polyhydramnios Down’s Syndrome
Duodenal Atresia Double Bubble
CASE Bilious vomiting/aspirates Mild upper abdominal distension Antenatal H/O of Polyhydramnios Triple Bubble D/D: Jejunal Atresia
CASE Multiple air fluid level • Bilious vomiting/aspirates • Progressive abdominal distension D/D • Ileal atresia • NEC • Total colonic aganglionosis • Meconium Ileus Ileal Atresia
CASE Colonic Atresia
CASE • Abdominal distension from birth • Antenatal scan: Echogenic and dilated bowel • X-ray
Abdominal distension since birth Meconium ileus Meconium peritonitis/ascites Abdominal lump Ascites
Meconium Ileus • Gastrograffin enema
CASE Term male Newborn Antenatal scan s/o echogenic bowel Bilious aspirates & not passed meconium Abdominal distension since birth
Ano-Rectal Malformation Vestibular Fistula Anteriorly placed anus Bucket Handle deformity Anocutaneous Fistula
Ano-Rectal Malformation Perineal Examination No Fistula Fistula 24 hrs Anoplasty or Pull through after 3mths Cross table Xray Colostomy Pull through after 3 months
Hirschsprung’s Disease Aganglionosis can extend to variable distance • Short segment – Classical Rectosigmoid (60-70%) • Long Segment (15-20%) • Total colonic aganglionosis (5-10%) • Ultrashort segment
Presentation • Characteristically disease of full term newborn • History of constipation dating back to newborn period • 95% of newborns defecate in first 24 hrs of life • Abdominal distension • Poor feeding • Failure to thrive
Investigations • Barium Enema • Rectal Biopsy
Definitive Pull through for Hirschsprung’s Disease • Single stage at age 3-6 months • Two stage at 6-12 months after colostomy
Primary Laparoscopic Assisted Pull through
A new born with respiratory distress • Day 1, Term 39 wks, delivered in Sonepat • Antenatal scan: Polyhydramnios • Respiratory distress • Intubated and transferred in BLK CONGENITAL DIAPHRAGMATIC HERNIA
Congenital Diaphragmatic Hernia Cardio-Pulmonary Stabilisation (Pulmonary Hypoplasia + Hypertension) Minimal Barotrauma • Conventional Ventilation • High frequency ventilation • ECMO Invasive & Noninvasive monitoring
Day 1 • Respiraory acidosis (Ph 7.26/PO2 118/Pco2 47/Hco3 20.1) • Assisted control ventilation – Fio2 100% – PIP/PEEP: 15/5 • Dopamine and Adrenaline (Mean 50mm Hg) • Cardiac Echo: Mild Pulmonary Hypertension
Day 2 • One episode of desaturation • Respiratory acidosis • Shifted on HFO MAP 14 Fio2 100% Delta P 30 • Stable
Day 3 • Desaturated • Rt Pneumothorax- Drained • Stable
Post Operative Course • Stable on ventilator (PSV) • Had collpase/ consolidation of Rt Lung….managed conservatively • Extubated on POD 9 • Discharged on POD 13 • Asymptomatic now at 3 months
A new born with respiratory distress Cystic adenomatoid malformation
Air filled cystic spaces: Congenital Cystic Adenomatoid Malformation
Respiratory distress CONGENITAL LOBAR EMPHYSEMA
CCAM Pneumatocoel CDH
CLE CLE pneumothorax