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
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F
CONGENITAL DIPHRAGMATIC HERNIA
EXOMPHALOS MAJOR
GASTROSCHISIS
D O
U B
O S
D T
E R
N U
A C
L T
I
O
N
IMPERFORATE ANUS
IMPERFORATE ANUS
CONGENITAL MEGAOLON
Emergencies in
Pediatric Surgery
• Upper Gastrointestinal
Hemorrhage
• Lower gastrointestinal Hemorrhage
• Ulcerative Colitis
• Obstructive
cholangiopathy/Cholangitis
Emergencies in
Pediatric Surgery
• Torsion testis
• Inguinal hernia
• Upper airway obstruction
• Pulmonary anomalies causing
respiratory distress
• Ambiguous genitalia
• Empyema
Upper Gastrointestinal
Hemorrhage
• Portal hypertension
• Stress ulcer
• Erosive gastritis
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
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
Hemorrhage
Distal Lienorenal Shunt
(Selective)
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
Lower GI Bleed
• Vascular Malformation
• Inflammatory bowel disease
• Polypoid disease
• Intussusception
Ulcerative colitis
• Failure to respond to
conservative treatment
• Refractory anemia
• Growth failure
Ulcerative colitis
• Total colectomy
• Ileal j pouch
construction
• Pullthrough
• Covering ileostomy
• Ileostomy closure
Lower GI Bleed
Vascular 3 Right
Malformation hemicolectomy
Ulcerative colitis 4 Total colectomy

With ileoanal
pullthrough J-
pouch
Polyposis coli 2 Total colectomy
With ileoanal j-
pouch
pullthrough
Cholangiopathy
• Extrahepatic Biliary atresia
• Choledocal cyst
• Bile sludge
• cholangitis
Obstructive
Cholangiopathy
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 inevitable-
leads to poor outcome
• Surgery feasible/safe
• Although surgery not required in emergency,
emergency work-up is required.
Obstructive
Cholangiopathy
Choledocal cyst
• Complete excision of cyst
• Hepatico-docho-jejunostomy
roux-en-Y
Obstructive
Cholangiopathy
EHBA 32 10 4
Choledocal cyst 18 18 16
Torsion testis
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
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
Upper Airway
Obstruction
Cystic Hygroma and
Hemangioma
• bleeding/infection can cause sudden
increase in size and respiratory
obstruction
• Surgery on placental support if
antenatal diagnosis
Pulmonary disease
• Congenital lobar emphysema
• Foreign body
• Cystic adenomatoid malformation
• Empyema
Pulmonary disease
Pulmonary disease
Lobectomy
Cyst excision
Deroofing
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
Empyema
•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.
Empyema
S
ICD 36 I
G
Decortication 8 N
I
F
ICD with suction 32 I

C
A
Decortication 4 N
T
Ambiguous genitalia
A G
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b n
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u a
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u i
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A G
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b n
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u a
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A G
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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
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 .M .D .s y n d ro m e
p re s e n t
E x t e r n a l M a le
M u lle r ia n d u c t s
N o r m a l M a le
In te rn a l O rg a n s absent
M ALE
E x t e r n a l F e m a le T e s t ic u la r
f e m in iz a t io n
O v a ry 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
and
T e s t is
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
M ix e d g o n a d a l
O v o t e s t is / o v o t e s t is / E x t e r n a l F e m a le d y s g e n e s is
s tre a k g o n a d
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
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
Intersex
• Chromosomal sex
• Gonadal sex
• Genotypic sex
• Phenotypic sex
• Psychological sex
• Social sex
Intersex
• First question boy/girl?
• Must be answered immediately
• Any delay suspicious
• People have long memories
• Therefore
• Confirmation of sex becomes
emergency
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 ex-
utero
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
•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
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
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
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

Emergencies in Pediatric Surgery

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ICD with suction 32 I

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