Topics for discussion

Pediatric General Surgery

Professor
General & Thoracic Surgery

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

What makes Pediatric Surgery unique?

Neonatal intestinal obstruction
Abdominal wall defects
Inguinal hernias
Appendicitis
Malignancies

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

Esophagus

Esophagus

Stomach

Duodenum

Colon

Stomach

Duodenum

Colon

Small

intestine

Small

intestine

Tracheoesophageal Fistula (TEF) and

Esophageal Atresia (EA)

Esophageal Atresia

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

Repair of TEF and EA

Repair of TEF and EA

Pyloric stenosis
Esophagus

Duodenum

Stomach

Colon

Small

intestine

Metabolic
abnormality:
Hypokalemic
Hypochloremic
Metabolic alkalosis
Paradoxic aciduria

Fredet Ramstad Pyloromyotomy

Beware the child that vomits

green

Esophagus

Stomach

Duodenum

Colon

Small

intestine

Duodenal atresia

Double Bubble

Annular pancreas

Malrotation
Better term is absence
of normal rotation
Normal anchor
points are absent

Normal Rotation

Effect of no anchor point

Volvulus

Ladd s Procedure

Small bowel

on Right

Large bowel

on Left

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

Appendectomy

End of Ladd s Procedure

Intestinal Atresia
Esophagus

Stomach

Duodenum

Colon

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

Small

intestine

Ileocolic Intussusception
Small bowel
telescopes through
the ileocecal valve
leading to obstruction
Mesentery is caught in
the process leading to
ischemia

Contrast Enema Reduction

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

Red currant jelly stools

Esophagus

Stomach

Duodenum

Colon

Small

intestine

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

Perineal/Vestibular Fistula

Imperforate anus

Posterior Sagittal Anorectoplasty

Abdominal Wall Defects

Gastroschisis
Associated anomalies
much less common
Malrotation (all)
Short bowel
Intestinal atresia
Hypothermia and
hypovolemia are of
greatest concern

In utero

Omphalocele
Anomalies in 50%
Trisomy 13, 18, 21
BeckwithWiedemann
Syndrome
Cardiac, Skeletal,
GU, Neurologic
Intestinal tract
Cloacal extrophy,
Pentalogy of Cantrell

Silicone Ventral Wall Defect Silo Bag

Staged closure of gastroschisis

Place infant in warm saline bag

Peel on bowel

Omphalocele

Omphalocele

Omphalocele

Inguinal Hernias

Omphalocele

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

Appendicitis
Appendicitis

Appendix is a vestigial
organ in RLQ

Appendicitis

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

Appendix is a vestigial
organ in RLQ
Obstruction of the
lumen may lead to
swelling
Pressure in the lumen
builds leading to
ischemia

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 postoperative bowel
obstruction

Pediatric Malignancies

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