Pediatric surgery
• Pediatric Surgery: deals with surgical problems in children under the age
of 14 years.
• Neonatal Surgery: deals with surgical problems in neonate below 28a
days of age .It deals mainly with congenital malformations.
• Fetal Surgery :deals with some abnormalities in the intrauterine life ,like
urinary obstruction or Hydrocephalus or Sacrococcygeal taratoma .Such
abnormalities if its left without intervention it may lead to further
deterioration in the general condition of the fetus. For example :
1-Hydrocephalus in Utero :if left without drainage it may lead to increase
in size of head and atrophy of the brain tissue .Putting catheter will
prevent cortical atrophy & reduce the size of the head making vaginal
delivery possible.
2-Bladder Neck Obstruction :will lead to Hydroureter & Hydronephrosis
with impaired renal function . Putting a catheter in the bladder or making
a cystostomy in the intrauterine life may prevent renal function
deterioration.
3- Sacrococcygeal taratoma :It may cause poor fetal development or what
is called stealing phenomenon of fetal blood .
What is the main presenting symptoms that bring the parents to the pediatric
surgeon :
1-Gross congenital abnormalities.
2-Vomiting.
3-Dyspnoea .
4-Urinary retention.
5-Jaundice
6-Constipation (failure of passing meconium).
7-Abdominal distention.
Congenital Abnormalities
Some congenital abnormalities are obvious at birth ,e.g: Meningocele,
Sacrococcygeal taratoma,Cleft lip&palate,…..
Other anomalies may reveal themselves within 24 hours such as
Esophageal atresia or Diaphragmatic hernia . Other anomalies present
after 24 hours like Intestinal atresia (when the baby starts to have oral
feeding),or Urinary retention or anuria.
Some anomalies may reveal itself several weeks after birth e.g:Biliary
atresia ,Pyloric stenosis.
Other anomalies may show themselves months or years later like
:Congenital Hydronephrosis or Congenital polycystic kidney …
Some anomalies may reveal itself several weeks after birth e.g:Biliary
atresia ,Pyloric stenosis.
Other anomalies may show themselves months or years later like
:Congenital Hydronephrosis or Congenital polycystic kidney …
Vomiting in neonates
Vomiting is one of the most common symptoms in neonate. Vomiting may
be non significant: causes could be over or little feeding, or
significant if it is persistent, projectile, bile or blood stained, or if it is
associated with weight loss.
Bile stained vomiting should be considered . due to intestinal obstruction
until prove other wise
Causes of vomiting:
• -Non surgical conditions :
1) Neonatal infections like septicemia ,meningitis :the vomiting is
associated with pallor ,convulsions or twitching ,hypothermia
,cyanosis ….
2) Adrenogenital syndrome :abnormal genitalia, salt losing metabolic
disturbances.
3) Gastroenteritis ,gastritis ,urinary tract infection may occur in the late
neonatal period &infancy .
4) Milk allergy (very rare)
5) Feeding mismanagement.
• surgical conditions:
1) Neonatal intestinal obstruction .
2) Sphenicteric disorders at either ends of the stomach , Congenital
hypertrophic pyloric stenosis ,Gastro-esophageal reflux
3) Cerebral birth injury(head injury)increased ICP(rare).
4) Necrotising Enterocolitis.
Neonatal intestinal obstruction
The pathological types of obstruction is as follow:
1) In the lumen
2) In the wall of the bowel
3) Extrinsic
4) Neurogenic
The effects of intestinal obstruction:
1-Secondary pathological changes
-Hypertrophy of muscle coat
-Marked dilatation of the bowel above the obstruction
-Collapsed distal segment (microcolon).
2-Additional effects :
- -Fluid & electrolytes loss :extrinsic (vomiting)
intrinsic(to the bowel & peritoneal cavity)
- -Disturbances of acid base balance :acidosis or alkalosis
- -Respiratory distress (abdominal distention).
Local changes at the site of obstruction:
- -Ischemia,
- -Perforation if perforation occur in utero it leads to meconium peritonitis .
Clinical features :
There is a triad of clinical findings :
1-Vomiting ,abdominal distention, abnormal or retained meconium.
2-Rectal examination
3-General examination (fontanel, skin ,body temperature).
Investigations
It has 2 objectives
1-To confirm the diagnosis
2-To determine the extent and severity of the physiological disturbances
to do proper preoperative resuscitation. So we have :
-Diagnostic investigations (plain X-ray ,contrast enema)
-Assessment investigations(Hb, pcv, platelet count,S-electrolytes, acid -
base balance ,ph, Pco2, bicarbonates. Cultures of Blood ,nasopharyngs,
umbilicus&sites of sepsis .
Causes of neonatal intestinal obstruction:
1-Duodenal obstruction :
-Intramural: Duodenal mambrane
-Mural: stenosis or atresia
-Exramural:anular pancreas ,band of Ladd
2- Small bowel obstruction :
-Intramural :meconium ileus
-Mural:atresia,stenosis
-Exramural :volvulus neonatorum
3-Large bowel (colonic)obstruction:
-Intramural: meconium plug syndrome
-Mural : stenosis or atresia,Hirschsprung`s disease
-Exramural pelvic mass obstructing the rectum (teratoma).
4-Neurogenic & functional : Hirschsprung`s disease, ileus, sepsis.
1-Atresia
: Duodenum,Small intestine, Colon, Rectum, Anal atresia .
Type I: Membranous (thich membrane)
Type II: Missing segment of the bowel .
Type III: Missing segment of the bowel & mesentery.
Type IV: Multiple segment atresia.
The bowel proximal to the atresia is hugely distended and it's muscular
coat is hypertrophied ,it's tip is ballooned.
The Bowel distal to the atresia including the colon and rectum is unused
,collapsed ,(i.e microcolon).
Treatment:
Excision of reasonable length of the proximal bowel including the
ballooned segment to:
Have proper anastomasis (less dispropotion).
To remove the tip which has poor blood supply .
To have area with good peristalsis .
In cases of membranous duodenal obstruction -Duodenotomy with
excision of part of the membrane is done .
In cases of Anular pancreas Duodeno-duodenostomy is done.
2-Malrotation and Volvulus Neonatorum:
The return of fetal alimentary canal from the extra embryonic coelom into
the abdomen occurs during the 10
th
week of intrauterine life ,then the
bowel undergoes rotation and fixation at certain points by attachments of
it's mesentery to the posterior abdominal wall .
When there is arrest or incomplete rotation or less commonly deviation
from normal rotation ,It's called malrotation or malfixation .
The Commonest abnormality when the small intestine (midgut) from the
duodenojejunal junction to the caecum has a very narrow mesenteric
attachment to the posterior abdominal wall based arround the superior
mesenteric vessel .The caecum and appendix is situated at the right
hypochondrium and abnormally fixed by avascular band or sheet of
peritoneum running laterally across the second part of duodenum.
These abnormalities lead to 2 different types of presentations:
- volvulus of midgut >>>strangulation .
- Duodenal obstruction >>>by bands of Ladd .
3-Meconium Ileus :
Meconium Ileus is the intestinal obstructive variant of cystic fibrosis (CF)
or mucoviscoidosis .
About 10-20 % of infants with CF present with intestinal obstruction
related to meconium ileus . Cystic fibrosis affects all the exocrine and
mucus secreting glands in the baby (not only the pancreas). It's a complex
disorder of the respiratory and digestive systems.
Pathology:
dilated segment of ileum containing impacted black-green meconium
.Proximal to this segment there are several loops of hypertrophied bowel
distended with fluid .Distal to the obstruction there is a few separated
gray white globular pellets in the distal ileum .
Clinically
abdominal distension ,vomiting , &failure of passing meconium .
Investigation:
Plain X-ray :multiple air fluid level .
Treatment:
Rehydration, Broad spectrum antibiotics(including staphylococcus) .
Gastrographin enema under fluoroscopy .
Surgery:-Enterostomy & removal of meconium.
-Resection with end to end anastomosis .
-Bishob Koop anastomosis.
4-Meconium Plug Syndrome
Present with the same triad :
1) Abdominal distension .
2) Vomiting
3) Delayed passage of meconium.
This is due to inspissated plug of mucous at the distal end the meconium
column in the rectum .
P-R is normal unlike Hirschsprung's disease in which the anal canal is tight.
P-R is therapeutic and can relieve the obstruction and the plug is passed with
large amount of meconium and gases .
Plain X-ray is normal in the early stage ,fluid levels at the late stage .
Contrast study is normal and can relieve the obstruction.
Rectal biopsy: is needed when we are in doubt to distinguish between
Hirschsprung's disease& meconium Plug Syndrome