1
Fifth stage
Surgery
Lec-1
.د
اسامة
13/12/2015
Introduction to pediatric surgery
Pediatric surgery Is a subspecialty of surgery involving the surgery of fetuses, infants,
children, adolescents
Pediatric patients includes different age groups:-.
1-Fetus …….during pregnancy.
2-Neonate in the 1
st
month of life.
A-Preterm baby born before 37 weeks of gestation.
B-Term baby born between 38-42 weeks of gestation.
C-Post term baby born after 42 weeks of gestation.
3-Infant in the first year of life.
4-Todller …………2 to 4 years of age.
5-Preschool age 4-6 year
6-School age child 6-12 year
7-Adoloscent 12-18 years.
Are pediatric patients are just small adult?
No, because there is a lot of differences between pediatric and adult which includes
differences in anatomy , physiology and physical and psychological responses to illnesses.
Specific physiological problems of newborn:-
A-Hypoglycemia:-
The fetus maintains a blood glucose level value 70-80% of maternal value by facilitated
diffusion across the placenta.
Clinical signs of hypoglycemia:-
Are non specific and may include a weak and high pitch cry ,cyanosis ,apnea ,jitteriness
,apathy, seizures, abnormal eye movement ,temperature instability ,hypotonia ,and weak
suck .
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When there is hypoglycemia ,Glucose level generally below 40 mg /dl.
Treatment: - An hourly 1-2 ml of 10% glucose is given intravenously.
Rarely hydrocortisone ,glucagon ,or somatostatine is used to treat persistent
hypoglycemia.
B-Thermoregulation: -
Newborn have difficulty maintaining constant deep body temperature because of
1-Their relatively large surface area.
2-Poor thermal regulation.
3-Small mass to act as a heat sink.
Infant produce heat by increasing their metabolic activity by non-shivering thermo genesis
,by using their brown fat unlike adult.
Brown fat thermo genesis may render inactive by vasopressors, by anesthetic agents, and
through nutritional depletion.
What is the bad effect of hypothermia?
How we can prevent hypothermia in a newborn baby during operation?
1-Keep the theater temp. between 24-28 C
2-Using special electrically heated Blanket .
3-Covering of extremities by cotton
4-Using worm I.V.F and Blood.
5-Using worm anesthetic gases.
C-Blood volume:-
Total RBC volume is at its highest point at delivery.
Estimated blood volume for premature infants is 85-100 mL/kg
Estimated blood volume for term neonate is 80- 85 mL/kg
Estimated blood volume for three month to adult is 70 mL/kg
How much the blood volume for 3 kg. neonate?
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D-Fluid and electrolyte
Infants can retain water and sodium but cannot excrete excessive water and sodium.
As a rule of thumb, the daily fluid requirements can be approximated too:
Premature 120-150 cc/kg/24 hrs
Neonates (term) 100 cc/kg/24 hrs
Infants >10 kg 1000 cc+ 50 cc/kg/24 hrs.
High intravenous therapy can lead to :-
1-heart Failure
2-Patent dactus arteriosus
3- Bronchopulmonary dysplasia
4-Enterocolitis
5-Intraventricular hemorrhage.
Anatomical differences between infant and older children and adult
A-Differences between abdomen of infant and that of older children and adult:-
Characteristics of the abdomen of infant are
1-The shape of the abdomen is square if compared to the shape of adults abdomen which
is rectangular.
2-The compliant rib cage and wide sub costal angle facilitate access to the upper abdominal
organs and diaphragm.
3-The rectus muscle is wider and extends further laterally.
4-The liver is relatively larger and occupies most of upper abdomen and epigastrium.
5-The umbilicus is low and nearer the pubic symphysis .
6-The bladder is intraabdominal and extend up to umbilicus ,therefore there is limited
space below the umbilicus. While in adult is in the pelvis.
Therefore,Transverse supraumblical inscion is suitable for most of laparatomies in
pediatric while longitudinal inscion is suitable for adult
Anatomical differences between trachea and thorax of infant and that of older children
and adult:-
Thoracotomy:-
In infants and young children differs from the procedure in adults. The chest of the infant is
compliant and relatively short in its longitudinal axis so a lateral transverse incision,
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entering the chest through the fifth intercostals space, is suitable for most operations. It is
not necessary to remove or transect a rib. The posterior incision, which curves upwards
around the scapula, is rarely required.
The trachea:-
The trachea of neonate is 5mm diameter only which mean it may easily occluded( eg. By
thick mucus)
Fetal surgery:-
Advances in radiology and sampling techniques have given clinician increasingly accurate
methods to make diagnosis of prenatal anomalies.
There are many advantages of antenatal diagnosis ,the out come of many conditions is
improved by prior Knowledge of the congenital anomaly, and other anomaly is corrected
surgically (Fetal surgery)
How to access the fetus:-
Access to the fetus can be gained by one of three general methods:-
1-US-guided percutaneous intervention.
2-Fetoscopically guided intervention.
3-Direct open hysterotomy.
The observation that the fetal incisions heal without scarring has provided new insights into
the biology of wound healing and has stimulated efforts to mimic the fetal process
postnatally.
Timing surgical procedures:-
Inguinal hernia?
• Inguinal hernias do not spontaneously heal and must be surgically repaired because
of the risk of incarceration.
Generally, a surgical consultation should be made at the
time of diagnosis, and repair (on an elective basis) should be performed very soon
after the diagnosis is confirmed (within one week)