Common Problems in Pediatric Surgery

Paisarn Vejchapipat, MD PhD FACSPediatric Surgery Unit, Department of Surgery, Faculty of Medicine, Chulalongkorn University

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www.pedsurgery.md.chula.ac.th

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Pediatric Surgery contents for MD Basic knowledge

Head & Neck lesions

Diaphragm & lungs

GIT newborn

GIT infants & children

Biliary diseases

Abdominal wall

Inguinal and genitalia

Tumors

Trauma

Common Problems

OPD cases

IPD cases

Pediatric Surgery: OPD

Tongue tie Dermoid cyst Preauricular sinus 2nd Branchial cleft cyst Thyroglossal duct cyst Cystic hygroma Torticollis

Pediatric Surgery: OPD

Umbilical hernia Indirect inguinal hernia Hydrocele Undescended testis Labial fusion Phimosis Hypospadias Buried penis

Umbilical hernia

Most patients have spontaneous closure before 3 years of age

Treatment: umbilicoplasty if persistent after 3 years

Indirect inguinal hernia

Indirect inguinal hernia

Treatment: herniotomy

Lap hernia repair

Hydrocele

Hydrocele with ascites

Hydrocele of spermatic cord

Treatment

Communicating hydrocele

Non-communicating hydrocele

Hydrocele of cord

Vaginal hydrocele

Processus vaginalis ligation

Spontaneous resolution (within 2 years),

If not hydrocelectomy

Undescended Testis

D/Dx Undescended testis Retractile testis Ectopic testis Testicular atrophy Anorchia

Retractile testis

Ectopic testis

Untreated undescended testis

Possibility of indirect inguinal hernia Risk of testicular torsion Risk of infertility Malignant potentials Prone to trauma Psychological aspects

Treatment for undescended testis

Orchiopexy Inguinal testis Intra-abdominal testis Ectopic testis

Torsion of Testis

Phimosis and Posthitis

Paraphimosis

Paraphimosis

Indications for circumcision

Pathologic phimosis Paraphimosis Posthitis Preputial “pearls” Redundant foreskin Prevention of UTI Trauma Religious belief

Common Problems at IPD GI anomalies

Esophageal atresia Hypertrophic pyloric stenosis Duodenal atresia Jejuno-ileal atresia Malrotation Hirschsprung’s disease Imperforate anus

Abdominal wall defects

Congenital Abdominal Wall Defect

Gastroschisis Omphalocele

Embryology

GASTROSCHISIS Vascular accident Congenital weakening

OMPHALOCELE Failure of migration

and fusion of embryonic folds; cephalic, caudal, lateral folds

Epidemiology GASTROSCHISIS

Young maternal age Low socioeconomic Use of aspirin, Ibuprofen,

pseudoephridine

OMPHALOCELE 30% chromosomal

anomaly; trisomy 13, 18

Over all incidence ~ 1:3000 live birth

Associated Anomalies GASTROSCHISIS

15% Malrotation Intestinal atresia

OMPHALOCELE 50-80% other

malformations; Cardiac, Genitourinary Musculoskeletal Beckwith-Weidemann

syndrome Neural tube malformation Pentalogy of Cantrell

Cesarean Section

No evidences to decrease incidence of bowel injury, birth injury, or infection

Recommended in giant omphalocele

Giant Omphalocele

Omphalocele 3 layers sac coverage

Peritoneum, Wharton’s jelly, amnion

Early management same as Gastroschisis Require less fluid resuscitation

Initial evaluation of other malformations

Treatment dependent on SIZE of the lesion

Prognosis dependent on associated anomalies

Treatment

Early management 1. Sterile protection

2. Hypothermia prevention

3. Adequate fluid resuscitation

4. Antibiotic administration

Initial management

Initial management

Abdominal closure

Primary fascial closure

Artifical sac closure

Skin flap closure

Non-operative management (for omphalocele)

Primary fascial closure

Artificial sac closure

Artificial sac closure

Artificial sac closure

Artifical sac closure

Artificial sac closure

Skin flap closure

Non-operative treatment (for omphalocele)

Conclusions Common problems in pediatric surgery

OPD casesIPD cases

Understanding of these conditions is essential for the prognosis of these babies