Children with Surgical Disorders

1. Children with Surgical Disorders Dr. S. Nishan Silva (MBBS)

2. Congenital Abnormalities • Malformation of the Central Nervous System • Myelomeningocele • Congenital Hydrocephalus • Malformations of the Gastrointestinal Tract • Cleft Lip and Cleft Palate • Anorectal Malformations • Imperforated Anus • Pyloric Stenosis • Intersusception • Hirschsprung’s Disease

3. Other… • Urinary system related ( covered later) • Hypospedias • Phimosis • Upper urinary track • Hydrocoele • Other

4. Myelomeningocele • 1st 28 days of pregnancy • Associated problems • Hydrocephalus • Other spinal cord / M/S system disorders • Syringomyelia • Hip dislocation • Causes • Folic Acid • Heriditory?

6. Clinical Manifestations • Can be seen after birth • Defect is related to the anatomical level • Bowel bladder incontinance • Sensory deficit • Paralysis • Infection risk

9. Vertebral arch Hair tuft Dura Skin Subarachnoid space with CSF Spinal cord Muscle Vertebral bodies Spina bifida occulta Meningocele Skin Dura Open spinal cord Spinal cord (displaced) Nerve roots Subarachnoid space with CSF Spinal ganglia (Anencephaly in the head) Meningomyelocele Myelocele

12. Diagnosis (tests) • MRI • USS • CT • Myelography • Perinatal diagnosis • Anomaly scan • Alpha feto protein in maternal blood and amniotic fluid

13. Management • Multidisciplinary approach • Surgery – Early • Protect till surgery • Special care and positioning • Prevent infections - ? Antibiotics • Supportive care – bowel bladder, physical therapy

14. Hydrocephalus • CSF block • SOL • Infection • Injury • Or CSF overproduction • Fluid accumulating in the cerebral ventricals • Skull expands

15. Clinical Manifestations • Increased OFC • Bulging fontanel • Suture seperation • Cracked pot sound on percussion • Setting sun sign • Poor feeding / frequent vomitting / altered consciousness, limb weakness – lowerlimbs more

18. Management • The relief of hydrocephalus • Ventriculo-peritoneal shunt - younger • Ventriculo- atrial shunt - older • Lumbo – peritoneal shunt • Treatment of complications • Infections • Mechanical obstructions • Displacement with growth • Perforations • Ensure proper development

20. Nursing care • Perioperative • Check for raised ICP daily • OFC daily • Observe for behavioral change • Assist with nutritional needs • Postoperative • Positioning – prevent pressure on valve • Raised ICP – pupil dilatation, hypertension • Peritonitis ? • IP/OP chart • Family support

21. Cleft Lip / Cleft Palate • Cleft lip , uni/bilateral • May be associated with cleft palate, nasal maldevelopments, maxillary anomalies • CL can see clearly. CP not. So, check carefully. Use a gloved finger in baby’s mouth. • CL surgery – early • CP delayed till 12-18 months to use natural shaping of the palate. • When CP is associated there may be a speech defect. • Feeding done in an upright position.

22. Face formation contd.. Note the junction of the frontal and maxillary processes: Three weeks Nasolacrimal groove duct Site of cleft lip Eight weeks CIBA Clinical Symposia, Vol. 28, No. 3, CIBA-GEIGY, 1976 Before We Are Born, 5th Ed., Saunders, 1998

23. Varieties of Cleft Lip & Palate Cleft lip Cleft secondary palate Complete cleft of primary and secondary palates Cleft primary palate--partial Secondary- complete Primary- partial Partial cleft of secondary Total cleft of primary palate

26. Post operative • Lip protection device, arm restrainer, check suture line carefully. • Continue to feed upright • CP repair – keep the child on abdomen initially. Packing will be removed in 2-3 days. • Care to feed only soft foods. • Educate on mouth guards, mouth care • Guidance for speech therapy

27. Cleft Lip and Palate Repair

28. Anorectal malformations • Forms of Imperforated anus • Genitourinary anomalies • Cloacal exstrophy

29. Cloacal exstrophy

30. Imperforated Anus

32. A flat perineum

33. A flat perineum-GIRL

34. Perineal fistula

35. bucket-handle malformation

36. Diagnosis • External physical findings • Patency • Fistula • Meconium track • Radiography • USS

37. RADIOGRAPHY-INVERTOGRAM16-24 hours

38. Management • Low category, with good muscles, well innervated – Manual dilatation • High or Intermediate categories – Elective repair with sigmoid colostomy – at 6-12 months

39. Manual dilatation

40. Nursing Considerations • Suspicion – No passage of stools within first 24 hours • Pre-operative care • Gastric decompression • IV fluids • Post-operative care – usual • Skin care – Zinc oxide, hydrocolloid dressing • Cleansing skin • Position for minimal contamination • Family support

41. Causes for intestinal obstruction

42. Pyloric stenosis • Gastric outlet obstruction due to circular muscle of the pylorus thickening • Mostly between 2weeks to 2 months • Features • Onset around 3rd week • Vomiting • Projectile vomiting • Hungry again • Stool changes • Constipation • Weight loss, lethargy

45. Treatment • Relief of obstruction • Called – Pyloromyotomy

46. Nursing considerations • Perioperative • Hydration – IP/OP • Electrolyte correction • Stomach decompression through NG - amount • Perioperative • IP/OP • Vital signs • NG – amount • Feeding – after 24 hours – start with clear fluid

47. Pyloromyotomy

48. Pyloromyotomy Completed

49. Intussuception • Telescoping of bowels • 3-12 months • Inflammation of payers patches, tumors etc cause

50. Clinical manifestations • Sudden severe pain – crying • Abdominal distension • Bloody stools – Red current jelly like • Billious vomiting • Lethargy • Shallow breathing • Grunting • Disgnosis • USS – sausage shape appearance of a bowel segment