Emergencies In Pediatric Surgery

Emergencies in Pediatric Surgery Dr.Vivek Gharpure

Consultant Pediatric Surgeon Children’s Surgical Hospital Aurangabad MITHRI, CIDCO, Aurangabad Government Medical College, Aurangabad Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer

E A & T E F Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer

CONGENITAL DIPHRAGMATIC HERNIA

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EXOMPHALOS MAJOR

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GASTROSCHISIS

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D O U B O D E N A L

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S T R U C T I O N

IMPERFORATE ANUS Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer

IMPERFORATE ANUS Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer

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CONGENITAL MEGAOLON

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Emergencies in Pediatric Surgery • Upper Gastrointestinal Hemorrhage • Lower gastrointestinal Hemorrhage • Ulcerative Colitis • Obstructive cholangiopathy/Cholangitis Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer

Emergencies in Pediatric Surgery

• Torsion testis • Inguinal hernia • Upper airway obstruction • Pulmonary anomalies causing respiratory distress • Ambiguous genitalia • Empyema

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Upper Gastrointestinal Hemorrhage • Portal hypertension • Stress ulcer • Erosive gastritis

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Upper Gastrointestinal Hemorrhage Portal hypertension

• Secondary to portal vein thrombosis/portal cavernoma • Massive upper gi hemorrhage Surgery vs. sclerotherapy • Surgery preferred because permanent cure recurrence rare small size endoscopes not available everywhere

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Upper Gastrointestinal Hemorrhage Mesocaval Mesocaval H graft with jugular vein Lienorenal Choice of shunt immaterial but directed by size of vessel Ultrasound scan useful Doppler not reliable as operator dependant and too many variables Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer

Upper Gastrointestinal Hemorrhage

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Distal Lienorenal Shunt (Selective)

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Upper Gastrointestinal Hemorrhage •26 patients •2 years to 14 years •Lienorenal 11 •Mesocaval 7 •Mesocaval H graft 8 •Mortality Nil •Follow-up •Encephalopathy – none •Rebleed 4/26 Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer

Lower GI Bleed • • • •

Vascular Malformation Inflammatory bowel disease Polypoid disease Intussusception

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Ulcerative colitis • Failure to respond to conservative treatment • Refractory anemia • Growth failure

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Ulcerative colitis • Total colectomy • Ileal j pouch construction • Pullthrough • Covering ileostomy • Ileostomy closure Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer

Lower GI Bleed

Vascular Malformation

3

Right hemicolectomy

Ulcerative colitis

4

Polyposis coli

2

Total colectomy With ileoanal pullthrough Jpouch Total colectomy With ileoanal jpouch pullthrough

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Cholangiopathy • Extrahepatic Biliary atresia • Choledocal cyst • Bile sludge • cholangitis Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer

Obstructive Cholangiopathy

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Obstructive Cholangiopathy

• EHBA repair before 8 weeks has best outcome • All babies require exploration and operative cholangiogram for confirmation of diagnosis and intervention • Trial of steroids/other drugs only delays the inevitableleads to poor outcome • Surgery feasible/safe • Although surgery not required in emergency, emergency work-up is required.

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Obstructive Cholangiopathy Choledocal cyst • Complete excision of cyst • Hepatico-docho-jejunostomy roux-en-Y Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer

Obstructive Cholangiopathy EHBA

32

10

4

Choledocal cyst 18

18

16

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Torsion testis

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Torsion testis • Ultrasound and color Doppler not reliable • Testicular isotope scan reliable • Wasting time in doing investigations can make the difference between two testes and oneDr Simon T Elliott, Consultant Radiologist UK • Auto-immune damage to other testis additional risk Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer

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Inguinal hernia • All hernias must be repaired within one week of diagnosis • Youngest patient with inguinal hernia 3 days old • Smallest 1.8 kg • OPD procedure no night in hospital • Two doses of antibiotic • No hernia ever goes away • Masterly inactivity- dangerous Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer

Upper Airway Obstruction

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Cystic Hygroma and Hemangioma

• bleeding/infection can cause sudden increase in size and respiratory obstruction • Surgery on placental support if antenatal diagnosis

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Pulmonary disease • Congenital lobar emphysema • Foreign body • Cystic adenomatoid malformation • Empyema

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Pulmonary disease

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Pulmonary disease Lobectomy Cyst excision Deroofing

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Pulmonary disease •Pre-operative bronchoscopy if necessary •Good anesthesia management •Adequate and appropriate instruments •Appropriate suture material •Blood available •Ventilatory support if necessary •Post-operative chest physiotherapy, suction, bronchoscopy if necessary •Intercostal tube management in small babies Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer

Empyema

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•Early intercostal drainage and continuous suction •Incidence of organized empyema reduced •Fewer patients require decortication •Reduced hospital stay •Reduced antibiotic requirement •Reduced long term disability and chest wall deformity •Must be done by surgeons as decision making required even after insertion of the tube.

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Empyema ICD

36

Decortication

8

ICD with suction

32

Decortication

4

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S I G N I F I C A N T

Ambiguous genitalia

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A m b i g u o u s

G e n i t a l i a

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A m b i g u o u s

G e n i t a l i a

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A m b i g u o u s

G e n i t a l i a

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Intersex

•Presence of y chromosome determines male sex •Gonad develops from yolk sac into testis/ovary •Leydig cells secretes testosterone under influence of pituitary •Local testosterone leads to stabilization of wolfian ducts •Sertoli cells secrete mullerian inhibiting substance - causes atrophy of mullerian ducts •Testosterone converted to di-hydro testosterone by genital skin with 5 αreductase •Absence of 5 αreductase- external genitalia does not virilize Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer

E x t e r n a l F e m a le

N o r m a l f e m a le

In te rn a l O rg a n s FEM ALE E x t e r n a l M a le

C .A .H .

M u lle r ia n d u c t s p re s e n t

P .M .D .s y n d ro m e

M u lle r ia n d u c t s absent

N o r m a l M a le

E x t e r n a l M a le In te rn a l O rg a n s M ALE E x t e r n a l F e m a le

O v a ry and T e s t is

O v o t e s t is / o v o t e s t is / s tre a k g o n a d

T e s t ic u la r f e m in iz a t io n

E x t e r n a l M a le

T r u e h e r m a p h r o d it e

E x t e r n a l F e m a le

T r u e h e r m a p h r o d it e

E x t e r n a l F e m a le E x t e r n a l M a le

M ix e d g o n a d a l d y s g e n e s is

M ix e d g o n a d a l d y s g e n e s is

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Intersex

Persistent Mullerian duct syndrome • Testes. Virilization. Uterus and tubes present. Male Pseudo-vaginal perineoscrotal hypospadias • Hypospadias with vagina-like structure in prostatic urethra. Male 5 αreductase deficiency • Small penis, testes present. Male Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer

Intersex • • • • • •

Chromosomal sex Gonadal sex Genotypic sex Phenotypic sex Psychological sex Social sex

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Intersex • • • • • •

First question boy/girl? Must be answered immediately Any delay suspicious People have long memories Therefore Confirmation of sex becomes emergency

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Intersex

Only god can make a fully functional erectile penis Only god can make a functioning uterus Surgeon can make a neo-vagina Someone can donate sperm Someone can donate egg Fertilization can be carried out exutero

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Intersex No one can see the internal sex organs For satisfactory sexual life, external organs necessary If uterus present- reconstruct as female If penis present- reconstruct as male Any size penis can be removed if uterus and ovaries present; as in CAH New vagina can be created with sigmoid/ileum

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•Blunt more common than penetrating •Liver and spleen injuries common •DO NOT OPERATE ON ALL BLUNT TRAUMAS •97% patients can have their spleens after splenic injuries •45% patients do not require intervention for liver injuries •Associated injuries can be picked up from lavage and x-ray Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer

Abdominal Trauma Criteria for successful conservative treatment Stable patient with pulse pressure>20 mm Hg Heart rate <120/min Good capillary refill Unstable patient stabilizes with up to 40ml/kg of RL Unstable patient stabilizes with upto 20ml/kg No other intraabdominal injury x-ray/lavage Remains stable for 24 hours on this regime Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer

Abdominal Trauma Conservative treatment

Must be carried out by surgeon and not by physician Frequent observation by same surgeon and not by different doctors OT ready for immediate laparotomy if necessary Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer

Abdominal Trauma

Laparotomy for trauma Massive hemorrhage as peritoneal tamponade released Be ready for vena-cava bypass Compression of viscus Pringle maneuver Cross clamping of aorta at diaphragmatic hiatus Management of coagulopathy/metabolic derangement/infection Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer

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