Pediatric Surgery: core knowledge for Pediatric residents Part 1 of 2 [updated June 2016] MCMASTER DIVISION OF PEDIATRIC SURGERY: DR. KAREN BAILEY DR. BRIAN CAMERON DR. PETER FITZGERALD DR. HELENE FLAGEOLE DR. MARK WALTON
RCPSC objectives for pediatrics residents: 1. Principles of pre-operative assessment. 2. Principles of indications for appropriate surgical referrals (today s discussion). 3. Principles of preoperative management, including fluids, steroids and antibiotics. 4. Principles of postoperative management including pain management. [you should learn about 1,3,4 on your rotation]
[from RCPSC objectives] assess and appropriately refer Hernias (umbilical, inguinal, incarcerated, and hydroceles). Acute abdomen (appendicitis, trauma). Abscess (perianal, subcutaneous). Acute scrotal pain (testicular torsion and its differential). [?Urology lecture] Next time: Bowel obstruction (pyloric stenosis, malrotation/volvulus, intussusception).
PART 1 OF 2 Discussion topics: Inguinal hernia Testicular torsion Undescended testis Umbilical hernia Umbilical remnants Meckel s diverticulum Appendicitis Pediatric trauma Head and neck lumps Other lumps and bumps Perianal abscess GI foreign bodies We won t get through everything but the slides will be available.
CASE 1: How do you tell the difference between a Hernia and a Hydrocele?
Processus Vaginalis
Hernia or hydrocele? Both due to patent processus vaginalis Hydroceles: transilluminate, you can palpate the cord above it, but often can t feel the testis Hernias: usually can be reduced are painful if incarcerated DO NOT DO ROUTINE ULTRASOUND
HERNIA: refer when diagnosed urgent surgery. HYDROCELE: most resolve within 18 months elective repair Hydrocele of the cord (NOT a third testicle!)
Incarcerated hernia Occurs in 15-30% Usually in infants < 1 (85%)
Reducing an incarcerated hernia Wrong way Right way Unilateral frog-leg manoevre.?sedation?admit?risk of strangulation
Hernias in females (10%) Increased risk of incarceration in females Femoral hernias are less common than inguinal hernias, even in girls
Differential diagnosis of incarcerated hernia Hydrocele acutely swollen during URTI Retractile testis Varicocoele (bag of worms) Acute scrotum: testicular torsion Torsion of the appendix testis Acute Lymphadenitis
Scrotum impalpable testis Can it be manipulated into the scrotum? it s retractile. U/S not useful. If inguinal or impalpable, refer by 8 months of age
Scrotum: testicular torsion Neonatal torsion Pubertal torsion In newborn: usually happens perinatally and testis is necrotic by time of diagnosis. Controversy re need to pexy other side. If suspected: Doppler US of testis And emergency surgery. ALWAYS EXAMINE SCROTUM
Umbilical hernia MOST DON T need surgery: Refer after age 3 Other abdominal wall bulges: What s this one? but some do What about this?
Infantile umbilical POLYP s Granuloma Urachal remnant Vitelline duct remnant
Not always just what meets the eye:
Case study #1 History: 2 year old boy, previously well, brought to ER after passing 2 large maroon-colored stools. He denies abdo pain. While waiting, passes a third one and is brought into resuscitation room. Exam: He is pale, cool, restless. P 160, BP 80/40, T 36.1 Wt 10kg. Abdomen scaphoid & soft, fresh clots in the diaper.
CASE 1 cont d: In next 10 min., he should have all the following EXCEPT: A- Large-bore IV and 200 ml warm NS bolus B- NG tube and aspiration stomach contents C- CBC, Xmatch, coag. Studies D- AXR
CASE 1: The NG aspirate does not contain blood. The most likely cause of bleeding is: A- Bleeding esophageal varices B- Intussusception C- Meckel s diverticulum D- Colonic polyp E- Duodenal ulcer
After 40cc/kg of crystalloid, HR down to 130, perfusion is better. Which test is most likely to reveal source of bleeding? A- Mesenteric angiography B- Technetium-99 scan C- Flexible EGD D- Colonoscopy E- Tagged red cell scan
Meckel Scan Sensitivity approx 85% Specificity approx 95% Tc99m has an affinity for gastric mucosa Imaging is enhanced by pentagastrin or histamine given 24-48hrs prior to enhance uptake and inhibit intra-luminal release
About Meckel s: which is false? A- They are true diverticula B- Diverticulitis, mimicking appendicitis, is the commonest presentation C- Heterotopic gastric tissue is found in 75% of symptomatic patients D- A Littre s hernia is an inguinal hernia containing a Meckel s
Meckel s Ectopic tissue found in 50% of cases Gastric 60 to 85% Pancreatic acinar 6 to 16% Other duodenal, pancreatic islet, colonic, hepatobiliary, etc. Small Intestine Stomach Pancreatic
Which statement is TRUE regarding Surgery for Meckel s diverticulum? A- usually occurs before age 5 B- may be done laparoscopically C- consists of either diverticulectomy or small bowel resection D- may not be indicated if Meckel s found incidentally at laparotomy E- All of the above
Rule of Two s Affects 2% of the population Common age at clinical presentation is 2yrs Average of 2 inches in length Found within 2 feet of the ileocecal valve Approximately 2% develop a complication over the course of their lives present in 3 ways: bleeding, bowel obstruction, inflammation
Case study #2 History: A 3.5 yo boy has abdo. pain X 36 hours. Vomits X2, has a loose BM. Mom gives Pepto-Bismol and outs him to bed. Next day, pain intense on R side. He walks slowly, holding his R side. Exam: Listless, lying still: T 38.4, P 118, RR 40. Abdomen tender everywhere, worse RLQ, + guarding/rebound WBC 19 000, Urine neg., CXR normal
What are the most reliable symptoms of appendicitis? Initial pain site inconsistent Followed by anorexia, nausea or 1-2 vomits in 93-96% Migration of pain to RLQ in only 32-69% Doubt appendicitis if: no anorexia/nausea/vomiting Symptoms >72hr without perforation/abscess
The most important single finding in making dx of appendicitis in a child is: A- Periumbilical pain that migrates to RLQ B- Persistent RLQ abdominal tenderness C- Rebound tenderness D- Right-sided tenderness on rectal exam. E- WBC > 12 000
The most important single finding in making dx of appendicitis in a child is: A- Periumbilical pain that migrates to RLQ B- Persistent RLQ abdominal tenderness C- Rebound tenderness D- Right-sided tenderness on rectal exam. E- WBC > 12 000
What are the most reliable signs of appendicitis? Persistent localized tenderness in 96+% Other physical signs are less reliable. Rovsings, obturator, psoas signs etc. *Repeated exam over time by same person
Is the Pediatric Appendicitis Score useful?
Investigations for?appendicitis Essential?: CBC + diff Leukocytosis is sensitive but non-specific Optional: urinalysis, electrolytes, amylase, b-hcg Abdominal x-rays Ultrasound becoming essential!
When are abdominal x-rays useful? Gastroenteritis/mesenteric adenitis Ie. Vomiting++ / distension Constipation: Rx dulcolax suppository Clinically uncertain; fecalith in 10% Bowel obstruction NB chest x-ray
Ultrasound: blind-ending, non-compressible, thickened (>8mm) bowel, may have appendicolith/fecalith 95% sensitive/specific
What is the role for CT in diagnosis of appendicitis? Not in skinny children ultrasound is best If?abscess Or if obese and diagnosis uncertain
In children < 2 years of age with appy, the incidence of perforation noted at surgery is: A- > 80% B- 50% C- 30% D- < 20%
Any Pediatric trauma questions?
Identify congenital neck masses: A: Thyroglossal Duct cyst B/C: Branchial Cleft cysts D: Cystic Hygroma E: F: Sternomastoid tumor congenital torticollis Thyroid
What is it? Cystic hygroma = Lymphangioma Thyroglossal Duct Cyst or Dermoid Cyst Branchial cleft sinus
Lump in sternomastoid at 3 weeks of age? Congenital muscular torticollis: Diagnosis: Head turns up and away from affected muscle Palpable mass (fibrosis) in most babies at 3-6 weeks. Treatment: Passive stretching exercises, rarely surgery Complications: Facial or skull asymmetry Prognosis: excellent
Vs Subacute: Cat-scratch Atypical Mycobacterium What s this neck mass? A surgeon s most satisfying operation: Draining pus! Acute Lymphadenitis Causes: Strep/Staph
OTHER LUMPS AND BUMPS OTHER LYMPH NODES IN NECK WHEN TO REFER? PILOMATRICOMA INGROWN TOENAILS PILONIDAL SINUS PERIANAL ABSCESS GI FOREIGN BODIES TUBES AND LINES CHEST WALL DEFORMITIES
Pilomatricoma
Ingrown toenails
Pilonidal sinus
Perianal abscess
Perianal abscess PEDIATRICS Volume 120, Number 3, September 2007
GI Foreign bodies