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Pediatric General Surgery

Professor General & Thoracic Surgery

Topics for discussion

• What makes Pediatric Surgery unique? • Neonatal intestinal obstruction • Abdominal wall defects •  Inguinal hernias • Appendicitis • Malignancies

Why is it different from adult surgery?

•  Different diseases •  Responses to surgery and trauma •  Physiology •  Cure vs. Palliation •  Family dynamics •  Ability to take a history •  True general surgery

Physiology

•  Children are not little adults •  Problems and physiologic maturity vary at

different ages

Surgical Newborns

•  Common Symptoms – Vomiting – Abdominal distension – Bloody stool – Respiratory distress

Neonatal Intestinal Obstruction

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Esophagus

Stomach

Colon Small

intestine

Duodenum

Esophagus

Stomach

Colon Small

intestine

Duodenum

Esophageal Atresia

Tracheoesophageal Fistula (TEF) and Esophageal Atresia (EA)

•  VACTERL Anomalies •  Coiled tube in the

proximal pouch •  Air distally in the

stomach and GI tract •  Outcome:

–  85-90% survival –  100% without

associated anomalies

Associated Defects

VACTERL

Repair of TEF and EA

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Repair of TEF and EA Repair of TEF and EA

Esophagus

Stomach

Colon Small

intestine

Duodenum

Pyloric stenosis

•  Metabolic abnormality: –  Hypokalemic –  Hypochloremic –  Metabolic alkalosis

•  Paradoxic aciduria

Fredet Ramstad Pyloromyotomy

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Esophagus

Stomach

Colon Small

intestine

Duodenum

Beware the child that vomits green

Double Bubble

Duodenal atresia

Annular pancreas

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Normal Rotation

Malrotation

•  Better term is absence of normal rotation

•  Normal “anchor points” are absent

Effect of no anchor point

Volvulus

Ladd’s Procedure

L - aparotomy A - ppendectomy D - ivide bands D - eliver bowel to sides

End of Ladd’s Procedure

Small bowel on Right

Large bowel on Left

Appendectomy

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Esophagus

Stomach

Colon Small

intestine

Duodenum

Intestinal Atresia

•  Presumed to be vascular accident in utero leading to infarction of portion(s) of bowel

Ileocolic Intussusception

•  Small bowel telescopes through the ileocecal valve leading to obstruction

•  Mesentery is caught in the process leading to ischemia

Red currant jelly stools

Contrast Enema Reduction

•  Air or liquid is used to push the bowel back thereby reducing the intussusception

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Esophagus

Stomach

Colon Small

intestine

Duodenum

Hirschsprung’s Disease

•  Etiology: arrest in migration of ganglion cells from the neural crest -> absence of ganglion cells in Auerbach’s and Meissner’s plexus’

•  Pathology: spastic contraction, no relaxation, functional obstruction

Imperforate Anus

•  Associated Anomalies – Spinal / Sacral (most common) – Urogenital – VACTERL association

Imperforate anus

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Imperforate anus

Perineal/Vestibular Fistula

Posterior Sagittal Anorectoplasty

Abdominal Wall Defects

In utero

Gastroschisis

•  Associated anomalies much less common –  Malrotation (all) –  Short bowel –  Intestinal atresia

•  Hypothermia and hypovolemia are of greatest concern

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Omphalocele

•  Anomalies in 50% –  Trisomy 13, 18, 21 –  Beckwith-

Wiedemann Syndrome

–  Cardiac, Skeletal, GU, Neurologic

–  Intestinal tract •  Cloacal extrophy,

Pentalogy of Cantrell Place infant in warm saline bag

Silicone Ventral Wall Defect Silo Bag “Peel” on bowel

Staged closure of gastroschisis Omphalocele

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Omphalocele Omphalocele

Omphalocele

Inguinal Hernias

Inguinal Hernia

•  5% incidence in full term infants

•  M:F 10:1 •  Risks:

–  Incarceration (30% in first 6 months for term; 60% in first 6 months for premie)

–  Infarcation (Low incidence (1%)

•  Fix when found

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Appendicitis

Appendicitis

•  Appendix is a vestigial organ in RLQ

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Appendicitis

•  Appendix is a vestigial organ in RLQ

•  Obstruction of the lumen may lead to swelling

Appendicitis

•  Appendix is a vestigial organ in RLQ

•  Obstruction of the lumen may lead to swelling

•  Pressure in the lumen builds leading to ischemia

Appendicitis

•  Appendix is a vestigial organ in RLQ

•  Obstruction of the lumen may lead to swelling

•  Pressure in the lumen builds leading to ischemia

•  Ultimately, necrosis of the wall will lead to perforation and leakage of infected contents

Appendicitis

•  Typical history in only ~50%

•  Pain poorly localized –  Children < 4 years –  Retrocecal location

•  Perforation –  12-15 hours, younger

children –  24 hours, 25% –  36 hours, 50% –  48 hours, 80%

Appendicitis

•  ~1% Mortality •  5% incidence pelvic

abscess •  <1% incidence post-

operative bowel obstruction

Pediatric Malignancies

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10 Most Common Cancers

Adult Cancers 1.  Melanoma 2.  Colorectal adenocarcinoma 3.  Breast adenocarcinoma 4.  Prostate adenocarcinoma 5.  Lung adenocarcinoma 6.  Pancreatic adenocarcinoma 7.  Thyroid carcinoma 8.  Leukemia 9.  Endometrial carcinoma 10.  Renal cell carcinoma

Childhood Cancers 1.  Leukemia 2.  CNS tumors 3.  Neuroblastoma 4.  Nephroblastoma 5.  Lymphoma 6.  Retinoblastoma 7.  Sarcomas 8.  Bone Tumors 9.  Hepatoblastoma 10.  Germ Cell Tumors

Neuroblastoma

•  Most common abdominal malignancy of childhood

•  Often will surround major vessels thereby making surgery challenging

Nephroblastoma (Wilms Tumor)

•  Most common malignant renal tumor of childhood

•  Combination of surgery, chemotherapy, and radiotherapy

Hepatoblastoma

•  Most common malignant lesion of the liver in childhood

•  Complete resection is the most important aspect of therapy

Pediatric Surgery

•  “Our scope is the skin and its contents”

•  “The last true general surgeon”

•  “Children are not little adults”

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