1. PEDIATRIC SURGICAL REVIEW
Dr. M. Bettolli
Department of General Pediatric Surgery
Children’s Hospital of Eastern Ontario, Ottawa
April
8th,
2011

2. Objectives Hernias obstruction • Acute abdomen/Bowel -Trauma
-Appendicitis
-Midgut volvulus
-Intussusception
Pyloric stenosis
obstruction •

3. Inguinal Hernias Failure to obliterate: Embriology and anatomy:
Testis descend into the scrotum during the 7th month in utero
inside the procesus vaginalis (PV)
The PV begins to obliterate after birth (close
1 yr of life)
Failure to obliterate:
Procesus
Vaginalis
Hydrocele
Communicating
hydrocele
Inguinal
hernia
Complete
inguinal hernia
Cyst of the cord
(encysted hydro.)

4. Inguinal Hernias Incidence: Entities associated w/ an ↑incidence:
The commonest condition requiring Sx during childhood
It varies directly w/ the degree of prematurity
- Prematures 10-30%
- Terms 3-5%
Nearly all ing. hernias in children are indirect
Entities associated w/ an ↑incidence:
-Cryptorchidism
-CF
-Ascitis, VP shunts, PD catheters
-Abd wall defects
-Conective tissue disorders, congenital hip dislocation
-Mucopolisacaridosis
-Meningomyeolocele

5. Inguinal Hernias
Clinical presentation:
Most hernias are asymptomatic
Inguinal bulging or swelling w/ straining
Often found by parents or pediatritian on routine examination
Phys. Ex.: - valsalva maneuvers
- silk glove sign
- always exam the opposite side
- confirm position of both testes
A common scenario: “Normal examination w/a suggestive Hx”
Options?
Return for a 2nd exam
Digital photo

6. Inguinal Hernias • Hydrocele: cystic, irreducible, transiluminate,
Diferential diagnosis: •
Hydrocele: cystic, irreducible, transiluminate,
painless, the upper limit is easily demonstrable •
Retractile or undescended testis •
Femoral hernias and direct hernias are rare •
Inguinal lymph nodes

7. Inguinal Hernias Treatment: Surgery Ideally, repair hernia before
Timing: bowel incarceration
in prematures is significantly
↑(threefolds)*
Ideally, repair hernia before
discharge
*Ein S.H. et al JPS 2006 May;41(5):980-6

8. Inguinal Hernias -fussy or inconsolable infant w/
Complications:
Incarceration:
-fussy or inconsolable infant w/
-intermittent abd pain
-tense, tender sweeling at the
-external ing. ring
Strangulation: redness, induration overlying the lump, peritonitic signs
Diferential diagnosis:
Cyst of the cord: -may appear suddenly, not tenderness
-happy infant
-redness after manipulation
Torsion of an undescended testis: absence of testis on the same side
Lymphadenitis or local inguinal abscess
“Overall 90-95% of incarcerated hernias can be successfully reduced”
The incidence of testicular atrophy is to 2-3% in this patients

9. Acute abdomen & Bowel obstruction
• Abdominal pain is one of the most common complaints in
Acute abdomen & Bowel obstruction
childhood
Frequently requires urgent evaluation in the office or ER
The challenge is to identify those pts w/ serious or potentially life- threatening conditions (e.g. appendicitis or bowel obstruction)
The likely Dx is often suggested by the child's age and clinical
features
Signs of obstruction,Hx of prior abd. surgery, and peritoneal irritation are clinical features associated w/ serious intraabdominal conditions that require prompt Dx and Tt. • • •

10. Acute abdomen & Bowel obstruction Neonates 2mo – 2 yrs 2yrs – 5 yrs
Causes of life threatening abd pain by age
Acute
abdomen
& Bowel obstruction
Neonates
Volvulus NEC Adhesions
2mo – 2
Trauma Incarcerated hernia
yrs
2yrs – 5
Trauma
Appendicitis
yrs
>5 yrs
Appendicitis Trauma Perforated ulcer Adhesions
Hemolytic uremic syndr.
Primary bacterial
peritonitis
Intussusception
Foreign body
ingestion
Adhesions
Hemolytic uremic
syndr.
Primary bacterial
peritonitis
Intussusception
Foreign body
ingestion HD
Adhesions
Hemolytic uremic
Syndr.

11. Acute abdomen & Bowel obstruction
Evaluation:
Acute abdomen & Bowel obstruction
The first goal is to identify life-threatening conditions that
require emergent interventions
History:
-History of trauma
-Prior abdominal surgery
-Fever
-Vomiting
-Location of the abdominal pain
-Pattern of symptoms
-Last menstrual period & sexual activity (pubertal girls)

12. Acute abdomen & Bowel obstruction
Characteristics of abdominal pain:
Acute abdomen & Bowel obstruction
-< 2 yrs, symptoms such us drawing the legs up or inconsolability
-The preschool child may be able to describe pain & symptoms
-> 5 yrs, can typically characterize the onset, frequency, duration,
and location of their symptoms
Specific Dx associated w/ characteristic patterns of pain:
Appendicitis Periumbilical, migrating to the RLQ
Appendiceal rupture (early), ovarian torsion  Acute, severe, focal
Intussusception  Intermittent, colicky
Gastroenteritis  Diffuse or vague
Cholecystitis  Right upper quadrant
Gastritis, gastric ulcer disease  Epigastric
Pancreatitis Steady periumbilical pain, often radiating to the back

13. Acute abdomen & Bowel obstruction
Associated symptoms:
Acute abdomen & Bowel obstruction
Fever, children w/ abdominal pain frequently have fever
Vomiting, and abdominal pain (in the absence of diarrhea) should
be carefully evaluated for life-threatening conditions…
-Volvulus must be excluded when bilious emesis and apparent
abdominal pain
-Intussusception  vomiting (initially non-bilious ) may occur
following episodes of pain
-Small bowel obstruction result of postoperative or
postinflammatory adhesions
-Appendicitis nausea & vomiting are typically present
Diarrhea, usually not a surgical abdomen, unless perf.appendix

14. Acute abdomen & Bowel obstruction
Past medical history:
Acute abdomen & Bowel obstruction
-Bowel obstruction from adhesions due prior abdominal surgery
-Pts w/ Hirschsprung Disease can develop obstruction and
fulminant enterocolitis
-Primary bacterial peritonitis occurs w/ increased frequency
among children w/ nephrotic syndrome
-Diabetic pts, ketoacidosis w/abd pain

15. Acute abdomen & Bowel obstruction
Imaging:
Acute abdomen & Bowel obstruction
-Essential component of the evaluation in children w/
acute abdominal pain and concerning clinical fetaures:
Trauma
Masses
Peritoneal irritation
Distension
Signs of obstruction
Focal
tenderness

16. Acute abdomen: Abd. Trauma
-Children w/ abdominal pain who have sustained trauma must
Acute abdomen: Abd. Trauma
be carefully evaluated for intraabdominal injuries
-MVA, MV pedestrian collisions, falls, and child abuse are
mechanisms typically associated w/ significant injury
-Although abdominal injuries are 30% more common than
thoracic injuries, they are 40% less likely to be fatal
-Historically, adult surgeons unfamiliar w/ the nonoperative
management of solid organ injuries raised doubts about the wisdom of this approach

17. Acute abdomen: Abd. Trauma
Most solid visceral injuries are successfully treated non operatively, kidneys (98%), spleen (95%), and liver (90%)

18. Acute abdomen: A. Appendicitis
The most common acute surgical condition in children
The lifetime risk of appendicitis is ≅8.7% for boys & 6.7% for girls
Perforation rates as high as 82% in children <5 yrs and nearly 100%
of 1-yr olds
Clinical presentation:
-Anorexia and vague periumbilical pain
-Migration of periumbilical pain to the RLQ
-Nausea leading to vomiting follows the onset of pain
-Diarrhea more commonly seen w/ perf. appendicitis, also more common in infants and toddlers

19. Acute abdomen: A. Appendicitis Lab findings:
Physical findings:
Appendicitis
-Tenderness RLQ (McBurney’s point)
-Guarding or rigidity
-Rebound tenderness
-Palpable mass (delayed Dx)
-Low grade fever
-Urinary symptoms
Lab findings:
Mild elevation of the leukocyte count (11,000 to 16,000)
Neutrophilia and lymphopenia
“Children often present w/ wide deviations from the
classic picture”

20. Acute abdomen: A. Appendicitis
Radiologic imaging:
-X-rays: may demonstrate a fecalith in 5-15% of Pts
-US: fluid-filled, noncompressible appendix
diameter > 6 mm
appendicolith
periappendiceal or pericecal fluid
↑periappendiceal echogenicity caused by inflammation
Hyperhemia
-CT:
operator dependent, and extremely accurate (sen&esp 95%)
lifetime risk of a fatal radiation-induced malignancy is 0.18% for a
1-yo child
-MRI: extremely accurate, but impractical

21. Acute abdomen: A. Appendicitis
Treatment:
Surgery
Medical management: -Delay presentation or Dx (>5days)
-Pt clinically stable
-Mass RLQ
-Percutaneous drain

22. Bowel obstruction Neonatal bowel obstruction -abd. distension
-bile vomiting
Neonatal bowel obstruction
-abd. distension
-failure to pass meconium
Several congenital anomalies of the gut can cause neonatal
bowel obstruction:
- Duodenal obstruction: Duodenal atresia/web, annular pancreas
- Bowel atresia: most common Dtl ileum, rare in the colon
- NEC
- Malrotation w/ midgut volvulus
- Hirschsprung’s disease
- Meconium ileus, meconium plug
- Bowel duplications
- Imperforate anus

23. three exceptions: - HD (may pass stools w/stimulation)
Bowel obstruction
Clinical findings
• Bile-stained vomiting in the neonatal period always is significant
Must be evaluated carefully (is indicative of bowel obstruction)
• Abdominal distension is less specific
• Neonates with bowel obstruction do not pass meconium
three exceptions: - HD (may pass stools w/stimulation)
- Meconium ileus (pass some sticky pellets)
- Malrotation w/ volvulus (delay ppt)

24. Bowel obstruction Imaging:
Plain x-ray is very useful: distension of the gut w/ fluid levels
Level of the obstruction may be related to the number of fluid levels
Ileal atresia, HD
Double buble
Jejunal atresia

25. Bowel obstruction Imaging: high obstructions
UGI are useful for incomplete
high obstructions
Contrast enema is a suitable
for low obstructions
Midgut volvulus
Meconium
ileus

26. Bowel obstruction
General treatment:
•Transport: is a particularly stressful time and the metabolic
problems should be corrected before transfer
•NG tube is mandatory
•Resuscitation: -fluid replacement
-glucose replacement
-correction of acidosis
•Hypothermia: is a major risk to the sick neonate
•Sepsis: risk of sepsis w/ neonatal BO IV Abx are started after cultures are taken

27. Bowel obstruction: Midgut volvulus
The normal mesentery of the small bowel has a wide base from the angle of Treitz to the cecum

28. Bowel obstruction: Midgut volvulus
In malrotation, the angle of Treitz and the cecum lie side by side
Midgut volvulus
The narrow base of the mesentery allows the gut to twist around the superior mesenteric vessels

29. Bowel obstruction: Midgut volvulus
Clinical features:
Healthy full term baby who is well for the first few days of life,
develop feeding difficulties w/ bile vomiting
Early stage, the abdomen is soft and not distended
The diagnosis should be made at this stage (Urgent UGI)
Blood per rectum and abdominal
distension w/ tenderness are late
features and indicate major gut
ischaemia
Treatment:
Urgent surgery is required (otherwise gangrene of the duodenum to the right colon)

30. Bowel obstruction: Intussusception
One of the most frequent causes of BO in infants & toddlers
The incidence is highest in the
1st
and 2nd yrs of life and is
Uncommon below 3 mo of age and after 3 yrs of life
Most patients are well nourished, healthy infants
Clinical presentation:
-Young child w/ intermittent, crampy abdominal pain
associated w/ “currant jelly” stools
-Between the painful episodes, the child may appear
comfortable or fall asleep
-The child may stiffen and pull the legs up to the abdomen
-Lethargy or altered consciousness can be the primary symptom
-As the obstruction worsens bilious emesis & worsening abdo distention
infants)
minal

31. Bowel obstruction: Intussusception
Physical examination:
Vital signs are usually normal in the early stage
During painless intervals, the child look comfortable &
Phys. Ex. will be unremarkable
The benign clinical appearance may lead to an erroneous Dx
(constipation or gastroenteritis)
A mass might be palpable anywhere in the abdomen
or even visualized
On rectal examination, blood-stained mucus or blood
may be encountered
Prolapse of the intussusceptum through the anus is a
grave sign

32. Bowel obstruction: Intussusception
Diagnosis:
-Abdominal X-rays: normal, non- specific or reveal a
SBO w/ air-fluid levels in dilated small bowel
d usually is the 1st
ussusception is
-U/S: confirmed Dx an
Investigation when int
suspected

33. Bowel obstruction: Intussusception
Treatment:
Nonoperative management:
-NG tube to decompress the stomach
-NPO
-IV fluid resuscitation
Intussusception
-Complete blood cell count and electrolytes

34. Bowel obstruction: Intussusception Colon enema • Air reduction (1st
Nonoperative management:
Intussusception
Colon enema
• Air reduction
(1st
line
of treatment) success rate
75-94%, perf. rate 0.16-
2.8% •
If successful admit for
24hs (recurrence rate
10-12%)

35. Bowel obstruction: Intussusception Operative Open approach management:•
Open approach
Lap approach

36. Pyloric Stenosis 4 weeks old male History: Full term
3 days history of vomiting

37. Non bilious vomiting
Pyloric Stenosis
Progressive…..
Projectile

38. Pyloric Stenosis Pyloric stenosis Differential diagnosis: UTI •
Feeding intolerance
GER
Infections: –
UTI
CNS GI

39. Pyloric Stenosis -Fontanels Hydration: -Eyes -Mucous membranes
-Skin turgor
-Urinary output

40. Pyloric Stenosis Gastric distention Findings on abdominal exam: •
Gastric peristaltic waves
Pyloric olive

41. Pyloric Stenosis What would you do now? Priorities
-Rehydration
do now?
-Correction of electrolyte & metabolic abnormalities
(metabolic alkalosis, ↓Na, ↓Cl, ↓K)
-Confirm diagnosis

42. Ultrasound
Pyloric
Stenosis
3mm
>15mm
>14mm

43. Pyloric Stenosis Surgical correction Pyloromyotomy
-Alkalosis corrected
rehydrated
normal electrolytes
Preoperative inform
parents about
expected post op vomiting

44. O. pyloromyotomy
L. pyloromyotomy

45. END!