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Chapter 12
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Paediatric surgery
Principles of managing paediatric surgical cases 424
Acute abdominal emergencies—overview 426
Oesophageal atresia 428
Pyloric stenosis 430
Malrotation and volvulus 432
Intussusception 434
Hirschsprung’s disease 436
Rare causes of intestinal obstruction 438
Abdominal wall defects 440
Necrotizing enterocolitis (NEC) 442
Inguinal hernia and scrotal swellings 444
Other childhood hernias 446
Prepuce (foreskin) and circumcision 448
Undescended testis 450
Solid tumours of childhood 452
Neck swellings 454
423
CHAPTER 12 Paediatric surgery
424424
Principles of managing paediatric
surgical cases
Key facts
• Children are not small adults.
• Children come in different sizes; always obtain a weight before starting
treatment.
• Fluids and drug doses depend on body weight.
• Babies and children have different differential diagnoses from adults.
• Children often differ from adults in physiology and anatomy (see
Table 12.1).
• Babies and young children have diffi culty communicating symptoms.
Special problems with babies
• Thermoregulation is impaired (immature sweating, high surface area to
body weight increases rate of heat loss). Prone to hypothermia.
• Minimal glycogen stores. Prone to acute hypoglycaemia.
• Principal breathing pattern is diaphragmatic. Prone to breathing
diffi culties with abdominal distension.
• Immature body physiology. Much less biological functional reserve than
adults; acute disturbances of physiology more serious with less room
for error.
• May not metabolize drugs as expected.
Intravenous fl uids
Maintenance fl uids (see Box 12.1)
Box 12.1 Paediatric fl uid regimen
• 4mL/kg/h total fl uid for each of the fi rst 10kg of weight (0–10kg).
• 2mL/kg/h total fl uid for each of the next 10kg of weight (11–20kg).
• 1mL/kg/h total fl uid for each subsequent kg of weight (over 21kg)
• Always calculate fl uid and sodium requirements according to weight.
• Remember to add glucose, especially for neonates.
• Adjust the fl uid regimen according to clinical setting for neonates and
premature babies.
Resuscitation fl uids
• Crystalloids or colloids can be given as resuscitation fl uids.
• Mild dehydration—10mL/kg bolus; repeat as necessary.
• Moderate dehydration—20mL/kg bolus; repeat as necessary.
PRINCIPLES OF MANAGING PAEDIATRIC SURGICAL CASES
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Table 12.1 Basic physiological parameters in children
Neonates Adolescents
Blood volume (mL/kg) 80 30–40
Oral fl uid intake (mL/kg/day) 150 30–40
Daily Na+ intake (mmol/kg) 2–3 1–2
Daily K+ intake (mmol/kg) 2–3 1
Systolic BP (mmHg) 40–50 100–120
Resting pulse rate (bpm) 120–160 70–80
425
CHAPTER 12 Paediatric surgery
426426
Acute abdominal emergencies—
overview
Key facts
• Whatever the cause (see Fig. 12.1), these typically present with signs
and symptoms of either peritonitis or intestinal obstruction.
• Features of peritonitis are often diffi cult to elicit in babies.
• Cardinal features of obstruction are:
Vomiting.•
Abdominal distension.•
Failure to pass meconium.•
Pain.•
Vomiting in children
• Vomiting is common in newborns and is often entirely benign. May be
due to:
Overfeeding.•
Rapid feeding.•
Air swallowing (inadequate winding).•
• Vomiting may be due to metabolic causes (inborn errors of
metabolism, acidosis) or infections (UTI, chest infection, meningitis).
• Bile-stained vomiting should never be ignored.
Abdominal distension Most pronounced in distal obstruction and less so in
proximal causes of obstruction.
Failure to pass meconium
• Term babies should pass meconium within 36h.
• Babies with proximal obstruction or atresia may still pass meconium.
Pain May be diffi cult to assess in babies. Typical features are going off
feeds, lethargy, erratic heart rate.
Diagnostic features
History
• Family/genetic history for cystic fi brosis (CF). Meconium ileus.
• Premature birth. Necrotizing enterocolitis.
• Time of onset related to birth. The more proximal the obstruction,
the earlier the presentation.
Examination
• Blood in vomit or stool may indicate necrotic bowel.
• Degree of distension. Most pronounced with distal obstruction.
Investigations
• Plain AXR may show diagnostic features.
‘Double bubble sign’• . Duodenal atresia or malrotation.
‘Ground glass’• . Meconium ileus.
Multiple loops of small bowel• . Distal obstruction.
Intramural gas• (‘pneumatosis intestinalis’). Necrotizing enterocolitis.
Free air• . Intestinal perforation.
• Abdominal ultrasound. Abdominal mass. Intussusception, tumour,
duplication cyst.
ACUTE ABDOMINAL EMERGENCIES—OVERVIEW
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427427
Congenital oesophageal
Incarcerated inguinal hernia
problems
Duodenal atresia
Volvulus
Exomphalos
Gastnoschisis
Ileal adhesion
Meconium ileus
Antral web
Pyloric stenosis (>3wks)
Jejunal atresia
Hirschsprung’s disease
Meconium plug
Small left colon
syndrome
Anorectal
malformation
Fig. 12.1 Causes of acute abdominal emergencies in babies and infants.
CHAPTER 12 Paediatric surgery
428
Oesophageal atresia
Key facts
• Congenital abnormality of the formation of the upper aerodigestive
tract (UADT), resulting in partial or complete interruption of the
oesophageal lumen (see Fig. 12.2).
• Often associated with other congenital abnormalities (VACTERL).
Clinicopathological features
• May be diagnosed on prenatal ultrasound. Features include maternal
polyhydramnios, absent stomach bubble, associated abnormalities.
• Post-natal diagnosis relies on features of persistent salivary drooling,
regurgitation of all feeds, and cyanosis with feeding.
• Failure to pass NGT into stomach.
• Tracheo-oesophageal fi stula in isolation unusual. Presents with
recurrent aspiration/chest infections.
Diagnosis and treatment
• Plain AXR and thorax. NGT coiled in oesophagus.
• Presence of stomach gas suggests tracheo-distal oesophageal fi stula.
• Plain X-ray spine. Associated congenital abnormalities.
• Echocardiography. Associated cardiac abnormalities.
Medical treatment
• Nurse head-up.
• NBM and continuous Replogle (oro-oesophageal) tube.
• Antibiotics for possible aspiration pneumonia.
Surgical treatment
• Isolated atresia.
Gastrostomy for feeding + continuous drainage of upper pouch.•
Delayed closure of defect (may require interposition graft if a long •
segment involved).
• Atresia with tracheo-oesophageal fi stula. Ligation of fi stula and primary
closure of oesophageal defect.
• Isolated tracheo-oesophageal fi stula. Ligation of fi stula (through neck).
OESOPHAGEAL ATRESIA
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Type C
87%
429
Type A
8%
Fig. 12.2 Classifi cation of oesophageal atresia. Type C (III), distal fi stula; type A
(I), atresia without fi stula; type E (V), H-type fi stula.
Type E
4%
CHAPTER 12 Paediatric surgery
430
Pyloric stenosis
Key facts (children)
• Incidence 3 in 1000 live births.
• Increased familial risk (family history).
• It typically occurs in fi rst born boys (♂:♀, 4:1).
Pathological features There is hypertrophy of the pyloric smooth
muscle in early infancy, which occurs at about 3–6 weeks.
Clinical features
• Classical projectile, forceful vomiting (secondary gastritis may cause
bloodstaining).
• Persisting vomiting.
• Sometimes a history of excessive positing and gastro-oesophageal
refl ux.
• Baby appears active and hungry, especially after vomiting.
• Small, green, starvation stools passed infrequently.
• Weight gain is poor.
• Dehydration with hypochloraemic alkalosis gradually supervenes in
untreated, established condition.
• Baby usually looks well in early state.
• Dehydration, pallor, underweight only in advanced condition.
• Epigastric fullness with left-to-right gastric peristaltic wave.
• Test feed is usually performed to palpate a pyloric ‘tumour’ (see
Box 12.2).
Diagnosis and investigations
• If pyloric ‘tumour’ is felt, no radiological investigations are necessary
prior to surgery.
• Ultrasound shows thickened (>4mm), elongated (>16mm) pyloric
muscle and increased muscle to lumen ratio with decreased movement
of fl uid through narrow canal (term infants).
• Barium meal (rarely necessary) shows an enlarged stomach, increased
gastric peristalsis, and elongated, narrowed pyloric canal.
• Electrolytes and capillary blood gases (d Na
and pH).
Treatment
• Resuscitation with IV rehydration.
• Correct hypovolaemia with 10mL/kg 0.9% saline.
• Correct hypochloraemic alkalosis and hypokalaemia (may take
24–48h)—0.45% sodium chloride/5% dextrose with added potassium
chloride at a rate of 120–150mL/kg/24h.
• NGT drainage to prevent aspiration of vomited secretions.
Surgical treatment
• Pyloromyotomy (division of pyloric muscle fi bres without opening of
bowel lumen).
Done via right upper quadrant incision, periumbilical, or •
laparoscopically.
+
, d K+, d Cl–, base excess,
PYLORIC STENOSIS
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Caution not to open mucosa and avoid the prepyloric vein (‘of •
Mayo’).
Start feeding within 4–6h post-operatively and increase to full •
volume by 24h.
Box 12.2 How to perform a test feed
• Undress baby (leaving loose nappy) and place on carer’s lap with
head elevated.
• Sit opposite baby and carer; position baby so head is to examiner’s
right.
• Begin feeding (breast or bottle). With active suckling, the abdominal
wall relaxes.
• Palpate with left hand (middle fi nger).
• Begin above umbilicus and feel into RUQ under liver edge.
• Wait to feel appearance of olive-sized, fi rm, mobile lump in angle
between liver edge and upper right rectus muscle (contracted
pyloric muscles).
• As stomach infl ates with air and milk, pylorus becomes more
diffi cult to feel—aspiration of NGT may help.
431
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