Pediatric Surgery

Testicular Torsion

2017-04-07T23:27:00.003-07:00

INTRODUCTION:

Testicular torsion or torsion of the testis is twisting of testis leading to occlusion of blood vessels which if not diagnosed and operated can lead to testicular necrosis. It is one of the important cause of acute scrotum and is a surgical emergency.

ETIOLOGY:

There is bi-modal distribution in the age:

Neonatal age group- Extravaginal testicular torsion: Entire spermatic cord twists around its axis.

Adolescents- Intravaginal testicular torsion: because of abnormal fixation of testis with epididymis (Bell-clapper deformity), torsion of spermatic cord occurs within tunica vaginalis

SYMPTOMS:

1. Acute scrotal pain

2. Nausea/Vomiting

3. Pain in lower abdomen radiating to testis

4. previous H/O similar type of pain swelling

ON EXAMINATION:

- high degree of suspicion

- firm, high lying testis with tenderness

- transverse orientation of testis

- absence of cremasteric reflex

- scrotal edema

INVESTIGATION:

If there is high index of suspicion, prompt surgical exploration is mandatory.

In doubtful situation Color Doppler US study

TREATMENT:

Bilateral orchiopexy:

Detorsion of the affected testis with orchiopexy/ orchiectomy depending upon the situation. At the same time other testis is also fixed as it has high chances of undergoing torsion

Klippel-Feil syndrome

2015-05-29T20:02:00.002-07:00

Introduction:
Klipple-Feil Syndrome is a congenital malformation.It is first described by Maurice Klippel and Andre Feil in 1912.68% found in females. It may be because of problem in the early neural tube development.

Features:
1.short webbed neck
2,fused cervical vertebrae
3. secondary torticollis
4. facial asymmetry
5.low hairline

Frequency:
1 in 42000 live births

Types:
Type I - Single-level fusion
Type II - Multiple, noncontinuous fused segments
Type III - Multiple, contiguous fused segments

Associated anomalies:
Cleft palate
deafness
ventricular septal defect
rib defects
fetal alcohol syndrome
syringomyelia
scoliosis
cervical meningomyelocele
Sprengel anomaly

Presentation:
short neck
Decreased neck movements (ROM)
Facial asymmetry
toticollis

Investigations:
Lateral flexion-extension radiographs of the cervical spine
CT scan of cervical spine/whole spine
Ultrasonography for renal anomalies

Management:
Hyper-mobility of upper cervical spine are at risk of developing neurologic development, While hyper-mobility of lower cervical spine are exposed to early degenerative disease and its consequences.
Syptomatic spinal fusion my require decompression

Hepatoblastoma

2013-02-04T05:33:00.000-08:00

Introduction:
The liver is a large, very important organ situated in the right upper quadrant of abdomen. The normal functions of the liver in the body are:

To help store nutrients from food
To break down and remove harmful chemicals from the body
To build chemicals that the body needs to stay healthy.

Hepatoblastoma: The most common type of liver cancer in children is Hepatoblastoma. it occurs most frequently in infants or very young children between 2 months and 2 year.

Symptoms:

Lump in the abdomen (most common)

Reduced appetite

lethargy

nausea / vomiting

Pain in abdomen

Jaundice

Investigations:The following minimal investigations are proposed to diagnose hepatoblastoma

Tumor markers- serum AFP

CT scan of abdomen with Ct guided FNAC or Biopsy

X-ray ches/CT Chest

Complete blood count

Biochem profile

Treatment:

Surgery & chemotherapy are two treatment options

Surgery: Liver resection according to the location & extent of the tumor. It will be either

Rt hepatectomy

Lt hepatectomy

Extended Rt or Lt hepatectomy

Bi or trisegmentectomy

If liver resection is not possible because of multicentric disease then liver transplant is the only treatment of option.

Chemotherapy:
Chemotherapy is given before or after surgery. Surgery is done either as a sandwich surgery (in between cycles of chemotherapy) or it is done at the start & then chemotherapy is given.

The drugs used in chemotherapy are

Cisplatin

Doxorubicin

Vincristine

5-Fluorouracil

Ksharsutra for fistula in ano

2013-01-31T06:12:00.000-08:00

Ksharsutra is barbouslinen No.20 coated with latex of ‘EUPHORBIA NERIFOLYA’ ash of
‘ACHYRANTHUS ASPERA’and dried powder of ‘TURMERIC’.

It has antibacterial, antifungal, anti-inflammatory, antioxidant, anticoagulant properties.

How it is used-

Under general anesthesia fistula site is probed

Tract delineated by methylene blue and hydrogen peroxide

Internal opening is identified

Ksharsutra passed through the probe

Knot tied and kept

Re application of Ksharsutra is done after 10 days

Ksharsutra cut through the fistula over a span of 3 weeks

Wound healed well with secondary intention

Ksharsutra performs chemical cauterization

Complications are less

It can avoid incontinence, stricture and bleeding

High cure rate

Early ambulation and early discharge

Average cutting time 0.78 to 1 cms/week

Palatal abscesses

2013-01-28T14:35:00.000-08:00

Hard palate is the partition between the nose and floor of the mouth. Embryologically, hard palate is formed by the palatine process of maxilla and the horizontal plate of the palatine bone. Anterior portion of the hard palate contains irregular ridges which help during feeding. Hard palate continues posteriorly in a soft portion called soft palate.

Abscesses of hard palate are known. The etiology may be trauma, ulceration, secondarily infected nasopalatine cyst or infected tooth. The line of treatment will be antibiotics and anti-inflammatory followed by incision and drainage.

Vesicoureteral reflux (VUR)

2012-12-20T23:04:00.001-08:00

Introduction:

Vesicoureteral reflux (VUR) represents one of the most significant risk factors for acute pyelonephritis in children

Spontaneous resolution of VUR occurs in 78–90% of grades I–III VUR that is diagnosed during evaluation of antenatal hydronephrosis.

Grades IV and V may spontaneously resolve but usually require surgical intervention

Classification of vesicoureteral reflux (VUR)

Grade I- Reflux of urine in non dilated ureter

Grade II- Reflux of urine into a non dilated pelvis

Grade III- Reflux of urine into a dilated ureter up to the renal pelvis with possible blunting of calyceal fornices.

Grade IV- Reflux of urine into a grossly dilated ureter with moderate blunting of the calyces.

Grade V- Reflux of urine into a massively dilated and tortuous ureter with loss of the papillary impressio.

Management:

The objectives in the current treatment
the prevention of episodes of acute pyelonephritis with its associated morbidity and mortality.

to prevent the scarring of the kidney associated with vesicoureteral reflux (reflux nephropathy), which increases the risk of hypertension and renal failure.

Indications for surgical treatment

1.Breakthrough febrile UTIs despite adequate antibiotic prophylaxis
2. Severe reflux (grade V or bilateral grade IV) that is unlikely to spontaneously resolve,especially if renal scarring is present
3.Poor compliance with medications or surveillance programs
4.Poor renal growth or function or appearance of new scars.

Surgical management of VUR : Ureteric Reimplantation:

Principle-Reconstruction of the ureterovesical junction (UVJ) to create a lengthened submucosal tunnel for the ureter,which functions as a one-way valve as the bladder fills

Types of Surgical repair:

Cohen procedure
Politano-Leadbetter
Lich-Gregoir,
Psoas hitch technique

Surgical management of Ureteropelvic junction (UPJ) obstruction:

2012-12-18T01:29:00.002-08:00

The goals in treating patients with ureteropelvic junction (UPJ) obstruction are to improve renal drainage and to maintain or improve renal function.

Surgical Treatment:

Endopyelotomy,
Open pyeloplasty
Laparoscopic pyeloplasty
Robotic-assisted laparoscopic pyeloplasty.

The principles of surgical repair:

Formation of a funnel
Dependent drainage
Watertight anastomosis
Tension-free anastom

Types of pyeloplasty

Anderson-Hynes dismembered pyeloplasty
Foley Y-V plasty
Culp and DeWeerd
Scardino and Prince

Endopyelotomy

1. The stricture should be short (< 1.5 cm), and no crossing vessels should be defined on imaging
2. An endopyelotomy incision is performed through the area of obstruction with a laser, electrocautery, or endoscopic scalpel.
3. This is followed by prolonged ureteral stenting, for a period of 4-8 weeks.
4. When open pyeloplasty fails, endopyelotomy is particularly useful

Laparoscopic pyeloplasty

This procedure is replacing open pyeloplasty as the criterion standard with 95% success rates.Significant learning curve associated with laparoscopic suturing

Complications:

Complications from open surgical pyeloplasty include UTI and pyelonephritis,urinary extravasation and leakage, recurrent ureteropelvic junction (UPJ) obstruction, or stricture formation.

Intestinal malrotation in children

2012-10-31T00:19:00.000-07:00

Types of Intestinal Malrotation

Nonrotation: Bowel returns to coelom.It fails to rotate.Result will be Small bowel to the right & Colon to the left

Reversed rotation:It is rare anomaly.There is 90 clockwise rotation around SMA, as a result of which Cecum & transverse colon comes dorsal to SMA while duodenum anterior to SMA

Incomplete rotation: There is premature arrest of normal rotation so that Ladd’s bands forms causing duodenal obstruction.Base of the mesentery is narrow which can cause to clockwise rotation.

Clinical features:

The newborn presented with bilious vomiting, haematemesis & haematochezia.

In older children, Either they wll be asymptomatic or intermittent abdominal complaints or acute obstructive symptoms &
signs of impending abdominal catastrophe.

Diagnosis:

A.X-ray abdomen in erect position- 1.Paucity of gas in the X-ray abdomen 2. Only gastric air-fluid level seen or there will double bubble appearance.

B. Upper GI studies:1.Right-sided DJ junction 2. proximal jejunal loops 3. Dilated stomach s/o incomplete obstruction of the duodenum.
4. Midgut volvulus - Corkscrew appearance.

C.Ultrasound doppler: There will be either vertical orientation or left-right inversion of SMA & SMV.

D.CT Scan of the abdomen: 1.Alteration of SMA & SMV orientation. 2. DJ & small bowel loops seen on right side of the spine. 3. large bowel is seen on left side of the abdomen. 4. there will be signs s/o duodenal obstruction.

Management: Ladd's procedure.Step 1.- lysis of ladd's bands & many other adhesivebands. 2.Mesenteric base widening 3. straightening of duodenum. 4. appendicectomy 5. Placing small bowel on right side of abdomen while large bowel on the left side of the abdomen.

Liver injury grading system

2012-06-21T23:23:00.000-07:00

The AAST Liver injury grading system is as follows

grade I :
- haematoma : sub capsular, < 10% surface area
- laceration : capsular tear, < 1cm depth

grade II :
- haematoma: sub capsular, 10 - 50% surface area
- haematoma : intraparenchymal < 10cm diameter
- laceration: capsular tear, 1 - 3cm depth, < 10cm length

grade III :
- haematoma : sub capsular, > 50% surface area, or ruptured with active bleeding
- haematoma : intraparenchymal > 10 cm diameter
- laceration : capsular tear, > 3 cm depth

grade IV :
- haematoma : ruptured intraparenchymal with active bleeding
- laceration : parenchymal distruption involving 25 - 75% hepatic lobes or
- 1 - 3 segments (within one lobe)

grade V :
- laceration : parenchymal distruption involving >75% helpatic lobe or
- > 3 segments (within one lobe)
- vascular : juxtahepatic venous injuries (IVC, major hepatic vein)

grade VI : vascular : hepatic avulsion

Umbilical hernia in children

2012-03-18T09:52:00.000-07:00

Introduction: Umbilical hernias in children result from a weakness in the abdominal wall that is present at birth.

Clinical Presentation: Generally, Parents notice a bulge at the umbilicus,which increases in size as the child cries, strains, coughs.It reduces spontaneously when the child goes to sleep or clam down.

Investigations: Its clinical diagnosis & does not require any further test if there are no other signs.

Treatment: 1. Reassurance- If the child is less than 2 years, small defect & no h/o irreducibility then just reassurance is needed (90% of umbilical hernia resolute spontaneously)

2. Indications for surgical repair-1. Age is more than 2 years 2. The defect is more than 1.5 cm.3.If there is h/o irreducibility or obstruction.

Sacrococcygeal Teratoma

2012-02-07T06:32:00.000-08:00

Sacrococcygeal teratoma is the tumor arising in sacrococcygeal region.It is the commonest tumor found in newborns. It is also seen in infants, children & very rarely in adults. The SCT is more common in girls than boys with ratio of 3:1. The routine use of prenatal ultrasound has made the diagnosis early during fetal life.

Symptoms:
1. Sacral mass
2. Mass in the abdomen & perineum
3. Distension of abdomen
4. Displacement of anus due to sacral mass
5. Constipation
6. Sacral sinus.

Classification: Altaman's classification
Type 1- Entirely outside
Type 2- Mostly outside
Type 3-Mostly inside
Type 4- Entirely inside

Diagnosis:
1. Prenatal Ultrasound- Solid/ cystic mass occupying abdomen as well as perineum
2. CT Scan abdomino-pelvic region/ MRI abdomino-pelvic region
3. Tumor markers- AFP or Alfafetoproteins

Treatment:
1. Surgical excision in benign or mature teratoma
2. Associated with chemotherapy in malignant or immature teratoma

Chemotherapy:
Bleomycin, Etoposide & Cisplatin (BEP) protocol is the commonest first line protocol used.

Prognosis- Good if complete surgical excision is done along with removal of coccyx.

Germ Cell Tumor

2012-02-06T09:54:00.000-08:00

Introduction:
Germ Cell Tumors are the neoplasm arising from primordial germ cells which produces specialized cells in the body like sperm and egg cells. With the recent advances in cisplatin based chemotherapy, the cure rate of germ cell tumors is increased if diagnosed in early stages. It frequently occurs in three modal peaks of life, infancy, 25-40 yrs and around 60 yrs.

Sites:
Testes
Ovaries
Paratesticular area
Abdomen (retroperitoneum)
Mediastinum
Brain

Types:
Malignant GCTs: The tumors such as yolk sac tumors, choriocarcinoma, and immature tearatomas encompass this type. The elevated tumor markers, rapid growth signifies malignant transformation.

Benign GCTs: Teratomas are benign tumors. They have characteristic appearance where there are teeth, bone, hair is found inside the tumor.

Symptoms:
Painless scrotal mass
Abdominal mass
Abdominal pain
Breathlessness
Sacral mass
Mediastinal mass

Investigations:
Tumor markers like AFP, β-HCG, LDH
Biopsy
CT Scan/ MRI

Treatment:
Surgery: The location of the tumor may influence the need for surgery. When possible, the first choice is usually to try and remove the entire tumor. This can be enough to cure most teratomas and immature teratomas. The coccyx needs to be removed in case of sacrococcygeal teratomas.

Chemotherapy: BEP (Bleomycin, Etoposide & Cisplatin) is the first line chemotherapy for the malignant germ cell tumors. This tumors are very much chemosensitive & the fall in tumor marker gives the idea about the response. If the complete resection is not possible initially then neoadjuvant chemotherapy is advisable.

Radiotherapy: It is indicated as a local therapy when the surgery is not possible.

Prognosis:
The 5-year survival rate is about 95% in germ cell tumors.

Phimosis

2012-02-05T09:11:00.000-08:00

Phimosis is narrowing of prepucial opening. In infancy, prepucial skin is adherent to the glans.Over the period it gets separated. This is physiological phimosis. Pathological phimosis generally occurs in older children because of repeated infection also called as balanoposthitis.

The child will present with urinary complaints like crying during micturition, redness at glans/meatus, ballooning of prepuceal skin while micturating, repeated urinary tract infection, failure to thrive.

Circumcision is the procedure of choice where the excess prepucial skin is cut under local/general anesthesia.In some religions like muslim, it is done as a ritual custom.

It is day care procedure & within 8-10 days child recovers & wound dries up. The sutures are absorbable like catgut, vicryl rapid etc.Oral antibiotics, analgesics,local ointment & local sitz bath is required after the procedure. Complications are immediate bleeding, recurrent adhesion (if the excess skin is not cut adequately), excess cutting of the prepucial skin, meatal stenosis etc.

Hodgkin's Disease

2012-02-03T22:25:00.000-08:00

Introduction:

Hodgkin’s disease is a cancer of the lymphatic system. It is also called as Hodgkin’s lymphoma. Hodgkin’s disease accounts for 5% of cancers diagnosed in children. It is rare before the age of five years. The number of cases increases significantly in the second decade of life.

Symptoms:

1. enlarged lymph nodes, called lymphadenopathy
(Painless, firm, rubbery, and movable)
2. loss of appetite
3. loss of weight
4. fever
5. lethargy
6. lump in abdomen
7. pain in abdomen
8. itching
9. night sweat
10. cough or breathlessness.

Investigations:

1. X-ray Chest
2. Ultrasonography / CT scan of abdomen
3. lymph node biopsy
4. Complete Blood Count (specially ESR)
5. Biochemistry ( specific- LDH, β2 macroglobulin, serum albumin)
6. Bone marrow / Bone scan in advanced stage
7. PET scan

Treatment:

Hodgkin’s disease is treated with chemotherapy & radiotherapy. The surgery is done only for the diagnosis.

Chemotherapy:

The following drugs are used
1. Adriamycin
2. Bleomycin
3. Vinblastine
4. Dacarbazine

Radiotherapy:

Radiotherapy is used after 4 or 6 cycles of chemotherapy.

Prognosis: Excellent. 5 year survival rate is >85%.

Sacrococcygeal Teratoma

2012-02-03T09:47:00.000-08:00

Sacrococcygeal teratoma is the tumor arising in sacrococcygeal region & it is the commonest tumor found in newborns. It is also seen in infants, children & very rarely in adults. The SCT is more common in girls than boys with ratio of 3:1. The routine use of prenatal ultrasound has made the diagnosis early during fetal life.

Symptoms:
1. Sacral mass
2. Mass in the abdomen & perineum
3. Distension of abdomen
4. Displacement of anus due to sacral mass
5. Constipation
6. Sacral sinus.

Classification: Altaman's classification
Type 1- Entirely outside
Type 2- Mostly outside
Type 3-Mostly inside
Type 4- Entirely inside

Diagnosis:
1. Prenatal Ultrasound- Solid/ cystic mass occupying abdomen as well as perineum
2. CT Scan abdomino-pelvic region/ MRI abdomino-pelvic region
3. Tumor markers- AFP or Alfafetoproteins

Treatment:
1. Surgical excision in benign or mature teratoma
2. Associated with chemotherapy in malignant or immature teratoma

Chemotherapy:
Bleomycin, Etoposide & Cisplatin (BEP) protocol is the commonest first line protocol used.

Prognosis- Good if complete surgical excision is done along with removal of coccyx.

Thyroglossal duct cyst/Fistula

2011-10-02T11:14:00.000-07:00

Introduction: The thyroglossal duct cyst is the most common congenital neck mass.

Clinical Presentation:

1. Painless mid-line neck swelling
2. Discharging sinus.
3. Painful mass (in c/o infected thyroglossal cyst)

Clinical diagnosis: Mid-line neck swelling moves with swallowing & also moves with protrusion of tongue.

Investigations:
1. Thyroid hormone tests T3,T4,TSH
2. Ultrasonography
3. Thyroid scan to rule out ectopic thyroid tissue.
Beside these tests, other optional tests are
4. CT/MRI
5. Fine needle aspiration cytology
6. Fistulography

Management:

Sistrunk procedure: Principle- excision of cyst along with fistulous tract extending up to the foramen caecum with central portion of hyoid bone (through which the tract goes)

In case of infected thyroglossal cyst, the preoperative antibiotic course is given & then the procedure carried out once the infection settles down.

Cystic Hygroma

2011-07-06T05:50:00.000-07:00

Introduction: Cystic hygroma or lymphangioma occurs because of faulty development of lymph vessels.There is either sequestration or obstruction of the developing vessels.It occurs 1 in 12000 of births every year.
Commonest sites are:
Posterior triangle of the neck
Axilla
Groin
Mediastinum
(though it can occur anywhere in the body)
Age at presentation:
It may appear at birth or can rapidly increase in size over first few months of life.Generally it is disease of infants.
Diagnosis:
Prenatal Ultrasonography
swelling at the time of delivery
Complications:
If the swelling is very large,it can cause compression over the trachea & airway compromise
Infection
Hemorrhage
Treatment:
Injection sclerotherapy
Surgical excision
Principle of surgery:
Total removal of all gross disease without damaging vital structures.
Recurrence rate: 20% with subtotal excision.

Anterior Abdominal Wall Defects

2011-03-27T00:34:00.000-07:00

Introduction:

Most common congenital Anterior abdominal wall defects are Omphalocele & Gastroschisis.Combined incidence is 1:2000.It occurs equally in males & females.

Etiology:
Omphalocele: Failure of lateral & caudal folds to unite (which forms anterior abdominal wall) causes intestines to remain outside the body wall.
Gastroschisis: Abnormal involution of right umbilical vein resulting in the mesenchymal defects at the junction of the body stalk & body wall.
Pathology:
Omphalocele: There is anterior midline defect at the base of the umbilicus through which abdominal viscera herniates into an avascular hernial sac composed of peritoneum, wharton's jelly & amnion.

Presence or absence of liver in the sac differentiates between large & small omphalocele respectively.
Gastroschisis: There is a defect in the abdominal wall either on right (commonest) or left side of umbilicus without membranous sac.
Diagnosis:
Antenatal: Ultrasonography
Maternal serum AFP
Acetyl Cholinesterase
Amniocentesis & Chromosomal analysis
Postnatal: Clinical & Ultrasonography
Associated Syndromes:
1) Cantrell Pentalogy: Epigastric omphalocele, Anterior diaphragmatic hernia, Sternal cleft,
Ectopia cordis, Cardiac anomaly.

2) Beckwith Wiedemann syndrome: Exomphalos, macroglossia, gigantism

3) Trisomy syndrome

4) Prune belly Syndrome
Associated Conditions:
Intestinal malrotation, Meckel's diverticulum, Treacheo-esophageal Fistula, Undescended testis,
Small bowel atresia.
Management: Conservative (omphalocele):

1) Topical application of escharotic agents
2) Delayed external compressive reduction of omphalocele
Surgical management:
1) Primary closure of anterior abdominal wall defect
2) Staged silo closure
3) Skin flap closure( ventral hernia)
4) Repair using synthetic grafts

Acute appendicities

2010-02-04T11:43:00.000-08:00

One 16 yrs old female presented with sudden, severe pain around umbilicus along with gastric vomiting. Later on the pain shifted to right side of lower abdomen. She started having frequency of urination. Looking at her condition she was directly admitted in surgical ward. The plain x-ray abdomen showed 2-3 air fluid levels in right lower part of x ray. rest of the parts were normal. Ultrasonography abdomen showed swollen, tubular & tender structure in right iliac fossa.There were dilated bowel loops & minimal fluid in the same site, most probably appendicitis (whenever the ultrasonologist can see the appendix that means it is acutely inflamed, otherwise in majority of the cases, appendix could not be located & there is only probe tenderness). Both the ovaries & adnexae were normal (this is very important in female patients). Total leukocyte counts were high with predominance of neutrophils (S/O infection).

As it was the case of acute appendicitis, patient was immediately taken for surgery. On exploration there was long, inflamed, swollen appendix going into pelvis. There were lot of bowel adhesions & whole area was edematous. But there was no perforation. Rest of the bowel was normal. Ovaries were normal. Appendix removed after ligating & cutting appendicular mesentery. Abdomen sutured in layers.

Patient was kept nil by mouth for 24 hours till abdomen became soft, she passed flatus & bowel sounds became normal. She was started on oral fluids followed by solids & discharged on third day.Subcuticular suture removed on day 7. The wound was perfectly healed.

Small Intestinal obstruction

2010-02-03T23:11:00.000-08:00

A 4 yrs old child is presented with vomiting & pain in abdomen. Initially, vomiting were whitish/or food taken then later on vomitings became yellowish. The child was having severe pain in abdomen. Abdomen was distended. There was tenderness (pain on palpation) all over abdomen. Bowel peristalsis were sluggish.

X-ray abdomen in standing position revealed multiple air fluid levels. Ultrasonography abdomen shows dilated bowel loops with sluggish peristalsis. Minimal fluid was present in peritoneal cavity.All these investigations typically suggestive of intestinal obstruction.

Child was posted for surgery.On exploration there was small intestinal volvulus with a band crossing & obstructing.The band was nothing but a part of small intestine. Once the volvulus derotated & small intestinal band released, obstruction relieved. Some portion of bowel involved in volvulus was looking bluish & preischaemic. After putting hot mops, giving 100% oxygen, the bowel color changed. After inspecting all intestine and other structures in abdomen, abdomen closed in layers.

The child was kept nil by mouth for 48 hours within this period the bowel sounds returned & child passes gases. Then slowly water, liquids introduced & once child started tolerating soft died the child was discharged.

Hirschsprung's Disease

2009-05-26T21:11:00.000-07:00

One 7 months old female child presented with distension of abdomen and intermittent enterocolitis since birth. When I saw the child, she was weighing 4.3 kg which was far less than expected weight for her age. Her abdomen was distended with gas and I could see visible bowel loops. After doing per rectal examination, when I removed my finger, there was gush of liquid stool came with explosion.

This is typical of what it is called as Hirschsprung's disease. In this disease, there is problem in the innervation of part or whole large intestine or rarely extending small intestine. There is absence of ganglion cells in the affected part of intestine (Ganglion cells are required for proper peristalsis of intestine). The child presents with delayed passage of meconium, enterocolitis and distension of abdomen in the neonatal period while chronic constipation and distension of abdomen are presenting features in the older children.

Barium enema & full thickness rectal biopsy are the modalities of diagnosis. Treatment is decompression with colostomy and later pull through procedure or primary pull through procedure.

Meckel's Diverticulum

2009-05-25T22:27:00.000-07:00

Introduction: Meckel's diverticulum is the diverticulum present on the antimesenteric border of terminal part of small intestine also called as ileum. It does not present in all individuals. It is a presistence of vitellointestinal duct in the abdomen.

There is unique 'The rule of two' i.e. Meckel's diverticulum is present in 2% of population, it is 2" long and it is 2 feet away from ileocaecal junction (junction where small intestine joins large intestine).

Clinical presentation:
1. Bleeding per rectum- profuse & painless bleeding
2. Intestinal obstruction- leadiing to vomiting, pain & abdominal distension
3. Infection- symtoms mimicking appendicitis

Diagnosis:
In majority of cases it is diagnosed at exploration when the child is being operated for appendicitis. When it presents as bleeding per rectum then Meckel's scan or RBC tagged scan is useful. Barium meal follow through can also sometimes diagnoses Meckel's Diverticulum.

Managment: Laparoscopic or open Meckel's diverticulectomy is the standard of care. In case of appendicectomy, it is worthwhile to trace aprroximately 2 feet of ileum from ileocaecal junction to rule out uncomplicated Meckel's diverticulum.

Diagnosis of Swine Flu

2009-05-13T05:18:00.000-07:00

For diagnosis of swine influenza A infection, respiratory specimen would generally need to be collected within the first 4 to 5 days of illness (when an infected person is most likely to be shedding virus). However, some persons, especially children, may shed virus for 10 days or longer.

Sample Collection & Laboratory Diagnosis

· Preferred respiratory samples Nasal, Nasopharyngeal & throat swab

· Collection- on vaccine transport media

· Availability- with area & regional coordinator

· Storage of Samples : should be at 2-8⁰C until can be placed at -70⁰C.

· Transportation of Samples : dry ice in triple packaging. All samples should be labeled clearly and include patient’s complete information

· Laboratory biosafety measures should be followed for collections, storage, packaging and courier/ shipping of influenza samples.

· Available Laboratory tests:

- Rapid Antigen Tests: not as sensitive as other available tests.

- RT-PCR, Virus isolation, Virus Genome Sequencing, Four-fold rise in swine influenza A (H1N1) virus specific neutralizing antibodies

Treatment of Wilms' tumor

2009-05-11T02:42:00.000-07:00

Wilms' tumor is the commonest kidney tumor in childhood. It is also called nephroblastoma.

Treatment for wilms' tumor is multidisciplinary.It includes surgery, chemotherapy & radiotherapy

Surgery- includes radical nephrectomy with lymph node sampling

Chemotherapy- combination of drugs like Vincristine / Actinomycin- D/ Cyclophosphamide.

Radiotherapy- is given to the flank in advanced disease or to the chest if there are metastasis.

Prognosis:This is one of the most curable cancer. the cure rate is more than 80% with multimodality treatment.

Other tumors of kidney in childhood
1. Clear cell sarcoma
2. Rhabdoid tumor
3. Renal cell carcinoma
4. Primitive neuroectodermal tumor
5. Infantile osteoid producing kidney tumor.

Laparoscopic Appendicectomy

2009-05-08T22:42:00.000-07:00

First laparoscopic appendicectomy was performed by Dr Kurt Semm (A German gynecologist) & Dr Philippe Mouret (A French surgeon & gynecologist) in beginnings of1980's.

Laparoscopic instruments required for appendictomy:
1. Trocar & Cannula
2. Telscope
3. Grasping forceps
4. Dissector
5. Monopolar/ Bipolar cautery/ Harmonic scalpel
6. Clip applicator with clips
7. Endoloop introducer with endoloops
8. Suction cannula

Surgical procedure:
1. Hasson's/ open technique- umbilical port for camera
2. Suprapubic & Left side of abdomen in line with umbilical port for working instruments
3. Telescope introduced through umbilical port by Hasson's technique
4. CO2 insufflation done & pressure kept at 8-10 mm Hg
5. Working ports introduced
6. Appendix visualized in RIF by moving away all the small bowel loops
7. Trendelenberg's position with left tilt given
8. Appendix tip grasped & mesoappendix either cauterized & endoclips are put
9. Endoloops introduced at the base of appendix & appendix is cut in between the loops
10. Appendix removed through the umbilical port after checking haemostasis.

Pediatric Surgery

Testicular Torsion

Klippel-Feil syndrome

Hepatoblastoma

Ksharsutra for fistula in ano

Palatal abscesses

Vesicoureteral reflux (VUR)

Surgical management of Ureteropelvic junction (UPJ) obstruction:

Intestinal malrotation in children

Types of Intestinal Malrotation

Nonrotation: Bowel returns to coelom.It fails to rotate.Result will be Small bowel to the right & Colon to the left

Reversed rotation:It is rare anomaly.There is 90 clockwise rotation around SMA, as a result of which Cecum & transverse colon comes dorsal to SMA while duodenum anterior to SMA

Incomplete rotation: There is premature arrest of normal rotation so that Ladd’s bands forms causing duodenal obstruction.Base of the mesentery is narrow which can cause to clockwise rotation.

Clinical features:

The newborn presented with bilious vomiting, haematemesis & haematochezia.

In older children, Either they wll be asymptomatic or intermittent abdominal complaints or acute obstructive symptoms & signs of impending abdominal catastrophe.Diagnosis:

A.X-ray abdomen in erect position- 1.Paucity of gas in the X-ray abdomen 2. Only gastric air-fluid level seen or there will double bubble appearance.

B. Upper GI studies:1.Right-sided DJ junction 2. proximal jejunal loops 3. Dilated stomach s/o incomplete obstruction of the duodenum.4. Midgut volvulus - Corkscrew appearance.

C.Ultrasound doppler: There will be either vertical orientation or left-right inversion of SMA & SMV.

D.CT Scan of the abdomen: 1.Alteration of SMA & SMV orientation. 2. DJ & small bowel loops seen on right side of the spine. 3. large bowel is seen on left side of the abdomen. 4. there will be signs s/o duodenal obstruction.

Management: Ladd's procedure.Step 1.- lysis of ladd's bands & many other adhesivebands. 2.Mesenteric base widening 3. straightening of duodenum. 4. appendicectomy 5. Placing small bowel on right side of abdomen while large bowel on the left side of the abdomen.

Liver injury grading system

Umbilical hernia in children

Sacrococcygeal Teratoma

Germ Cell Tumor

Phimosis

Hodgkin's Disease

Sacrococcygeal Teratoma

Thyroglossal duct cyst/Fistula

Cystic Hygroma

Anterior Abdominal Wall Defects

Acute appendicities

Small Intestinal obstruction

Hirschsprung's Disease

Meckel's Diverticulum

Diagnosis of Swine Flu

Treatment of Wilms' tumor

Laparoscopic Appendicectomy

In older children, Either they wll be asymptomatic or intermittent abdominal complaints or acute obstructive symptoms &
signs of impending abdominal catastrophe.

Diagnosis:

B. Upper GI studies:1.Right-sided DJ junction 2. proximal jejunal loops 3. Dilated stomach s/o incomplete obstruction of the duodenum.
4. Midgut volvulus - Corkscrew appearance.