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Pediatric Surgery

Pediatric Surgery. Mark Perna 1/5/2010. Disclaimer. Competitive 2 year surgical fellowship in 55minutes Obviously gross overview. Pediatric Trauma. Increased Risk for Head Trauma and Burns HR and RR are best signs of shock (not BP) Solid Organ Injury can most often nonoperatively

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Pediatric Surgery

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  1. Pediatric Surgery Mark Perna 1/5/2010

  2. Disclaimer • Competitive 2 year surgical fellowship in 55minutes • Obviously gross overview

  3. Pediatric Trauma • Increased Risk for Head Trauma and Burns • HR and RR are best signs of shock (not BP) • Solid Organ Injury can most often nonoperatively • Bone non brittle • Set up for contusions • Nonaccidental Trauma • Duty to report

  4. Pediatric Trauma • Seat Belt Sign and Abd Pain • Small Bowel Injury • Handle Bar Injury and abd pain • Pancreatic Injury • Handle Bar Injury with profuse vomiting • Duodenal Hematoma

  5. General Concepts • Differences in Vital Signs • Prone to hypothermia and hypoglycemia • Fluid Bolus - 20ml/kg (times 2) • Transfusion- 10ml/kg

  6. Most appropriate vitals for 3 day newborn • HR SBP RR Sat • 95 110 30 94 • 190 60 45 98 • 160 50 40 100 • 120 95 20 92

  7. General Concept • Nutritional Requirements • Neonates 90-120 kcal/kg • Children 70-90kcal/kg • Adolescents 30-60kcal/kg • Adults 25 kcal/kg • Protein Requirements • Neonates 2-3 g/kg • Infants 1-5 –2 g/kg • Children 1-1.5 g/kg

  8. General Concepts • Urine Output • Neonates 2 cc/kg/hr • Infants 1.5 cc/kg/hr • Children 1 cc/kg/hr • Adult 0.5 cc/kg/hr • Fluids Management • 4 cc/kg/hr (for first 10kg) • 2 cc/kg/hr (for second 10 kg) • 1 cc/kg/hr (for remaining weight)

  9. General Concepts- Radiology • U/S often the most helpful study • Abdomen • Cost • Low Risk • Xray and Contrasted xrays • CT • MRI

  10. PICU • SIMV ventilatory support • FIO2 • Oscillatory Vent • Jet Vent • ECMO

  11. Neck – High Yield • Cervical Lymphadenopathy • Most likely viral • Tender versus Nontender • Unresolving think of more rare causes • Cat-Scratch, TB, Lymphoma • Thyroglossal Ducts Cyst • Midline • From the foramen cecum • Sistrunk procedure • Brachial Cleft Cyst • Off midline • 2nd cleft most common • Excision

  12. Thoracic - High Yield • Bronchogenic Cysts • Congential Lobar Emphysema- • Failure of development bronchus cartilage • Congential cystic adenoid malformation • Alveolar structure not developed, but does communicate with airway • Pulmonary Sequestration • Lung tissue with systemic arterial supply • Intralobar – Venous drainage to pulm circ • Extralobar- Venous drainage to systemic circ • Anterior Mediastenal Mass • Thymoma, Teratoma, Terrible Lymphoma, Thyroid

  13. Tracheoesophageal Fistula

  14. What syndrome is associated with TE fistula • Vertebral • Anal • Cardiac • TE fistula • Renal • Limb dysplasia

  15. Vomiting • Nonbilious • GERD • Allergies • Projectile • Pyloric Stenosis • Bloody • UG Bleed • Bilious • Broad Differential • Always abnormal, Generally Serious • Quick Elevation

  16. Pediatric Bowel Obstructions - • Pyloric Stenosis • 3 in 1000, generally male, first born • Projectile Vomiting, Nonbilious • Palpable Olive • US diagnosis • Tx?? • Fredet-Ramstedt pyloromyotomy

  17. Electrolytes • Na K CL CO2 Urine pH

  18. Pediatric Bowel Obstructions • Duodenal Atresia • Failure of Recannulization of bowel • “Double Bubble” • Associated with Down’s and VACTERL • Tx • Doudeno-doudneostomy

  19. Pediatric Bowel Obstructions • Intestinal Atresia • Intrauterine vascular accident • Polyhydramnios • Tx • Tapered jejunoplasty • Short Gut Syndrome

  20. Pediatric Bowel Obstructions • Malrotation (Common) Always on Boards!! • Bilious vomiting, Abd distention, acidosis • Obstruction from Ladd’s band across the duodenum or Midgut volvulus • Tx- • Counterclockwise reduction of midgut volvulus • Lysis of Ladd’s Bands • Appendectomy

  21. Pediatric Bowel Obstructions • Meconium Ileus • Inspissated meconium • 90% will have CF. Get Sweat Test!! • “soap bubble” appearance • Tx- Nonoperative first • Gastrograffin enemas (Meglumine Diatrizoate) • Ileostomy, resection

  22. Pediatric Bowel Obstructions • Meconium Plug Syndrome • Stool balls in the rectum • Almost never operative • Tx • Time • Enema

  23. Pediatric Bowel Obstructions • Hirshbrung’s • Absence in parasympathetic ganglion cell in distal colon • Dx with Suction Rectal Biopsy • Toxic enterocolitis • Tx • Sauve • Swenson • Duhamel

  24. Pediatric Bowel Obstructions • Intussusception • Telescoping of bowel • Currant jelly stools • Lead point usually not identified in kids • Dx US or Barium enema • Tx • Barium enema • Air enema • Exploratory Lap and Reduction

  25. Pediatric Bowel Obstructions • Imperforate Anus • High versus Low • US can diagnose • Associated abnormalities

  26. Abdominal Wall Defects • Umbilical hernia • Common • AF children • Most close on there own • Don’t mistake for diastasis rectus • Omphalocele • Covered in a sac of chorium, Wharton’s jelly, peritoneum • Associated abnormalities • Gastroschisis • Bare bowel and abdominal contents • No congenital defects work up necessary • Cover and keep warm • Hypothermia, Bowel Bag, Reduce in OR

  27. What GI abnormality seen with gastroschisis • Small Bowel Atresias • 11% of the time

  28. What is Cantrell syndrome? Omphalocele • Diagphramatic hernia • Pericardial Defect • Cardiac Defects • Sternal Defects

  29. NEC • Most common pediatric surgery emergency • Low flow state = Bowel ischemia • Distention, bloody stools, perforation, sespis • Follow Serial Abx Xray • Na • Platelets • CO2 • Temps • Tx- Laparotomy versus abdominal drain

  30. Inguinal Hernia versus Hydrocele • Common • More common in prematurity with high risk of incarceration • Anatomic Location • Medial versus Lateral • Congential versus Aquired • Tx • High Ligation of Sac • Laproscopic Repair

  31. What test does a child need with bilateral direct hernia repair? • Sweat Chloride Test

  32. Jaundice • Cholestatic Jaundice • Biliary Atresia • Portoenterostomy • Choledochal Cyst • Type I- Fusiform Enlargement • Type 2- Diverticular-like • Type 3- Distal Common Duct • Type 4- Extra and Intrahepatic Dilation • Type 5- Intrahepatic (Caroli Disease)

  33. Solid Abdominal Tumors • Wilms tumor • Most common intraabd tumor • Staging • Group I - Limited to kidney, completely excised • Group II- Extends past kidney, completely excised • Group III- Extends past kidney, not excised • Group IV- Hematogenous metastasis • Group V- Bilateral tumors

  34. Solid Abdominal Tumors • Neuroblastoma • Neuro crest cells • Most common solid organ tumor • Staging • Stage I- Tumor limited to organ of origin • Stage II- Regional spread, not across midline • Stage III- Tumor extending across midline • Stage IV- Distant Metastasis

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