Pediatric Surgery congenital inguinal hernia

Inguinal Hernia

Definition

Congenital inguinal hernia is invariably an indirect hernia due to nonclosure of processus vaginalis.

Objectives

•   To reduce the contents of hernia

•   To suture ligate the processus vaginalis at the deep ring.

Position

Supine.

Anesthesia

General with endotracheal intubation.

Procedure

   1.  A 2-3 cm long inguinal skin crease incision.

   2.  Divide the superficial and the deep layers of subcutaneous tissue.

   3.  Divide external aponeurosis in line of its fibers.

   4.  Identify the hernial sac and separate it from the cremaster muscle.

   5.  Identify and separate the spermatic vessels and the vas.

   6.  Isolate the hernial sac upto the deep ring.

   7.  Ensure complete reduction of the hernial contents.

   8.  Suture ligate the neck of the sac.

   9.  Wide open the mouth of the sac distally.

10.  Ensure scrotal placement of the testis.

11.  Close the inguinal wound in layers.

Instruments

General pediatric set.

Sutures

•   Catgut       3/0, 4/0

•   Silk             3/0

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Pediatric Surgery Malrotation Midgut

Malrotation of Midgut

Definition

In an incomplete rotation of the bowel during early development of the baby leading to:

•   Short and narrow base of the mesentery, resulting in frequent to volvulus

•   Duodenal obstruction due to the abnormal fibrous bands stretched across it from the parieties to the colon.

Objectives

•   To release the fibrous bands (Bands of Ladd) in front of the duodenum

•   Widen the base of the mesentery to prevent volvulus.

Position

Supine.

Anesthesia

General with endotracheal intubation.

Procedure

1.  Right transverse upper abdominal incision—5 cm long.

2.  Divide the subcutaneous tissue and muscles.

3.  Retract the liver superiorly.

4.  Identify and divide the fibrous bands in front of the duodenum with cautery.

5.  Release the small bowel to make the duodenum and the jejunum in one line and wider the base of the mesentery.

6.  Check the free flow of air from the stomach to the jejunum.

7.  Place the small bowel in the right abdomen.

8.  Place the large bowel to the left side of abdomen.

9.  Close the abdominal wound in layers.

Instruments

General pediatric set.

Sutures

•   Catgut       4/0

•   Silk             4/0

•   Nylon                     5/0

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Pediatric Surgery esophageal atresia

Esophageal Atresia

Definition

In cases of developmental defect of the esophagus, the upper pouch is large and blind. The lower pouch is thin and communicates with the bronchus, in most cases.

Objectives

•   To disconnect the fistula from the bronchus

•   To anastomose the upper with the lower pouch.

Position

Lateral, with the left chest along the table.

Anesthesia

General with endotracheal intubation.

Procedure

   1.  Right posterolateral thoracotomy—5 cm long.

   2.  Divide subcutaneous tissue and intercostal muscles.

   3.  Mobilize parietal pleura upto mediastinum.

   4.  Retract the ribs with Finochietto retractor.

   5.  Divide the azygos vein between ligatures.

   6.  Identify the lower pouch and divide it from the bronchus.

   7.  Suture the fistulous opening in the bronchus.

   8.  Mobilize the upper pouch upto the neck.

   9.  Anastomose the upper and the lower pouches—tension free.

10.  Drain the extrapleural space by an under water seal bottle.

11.  Approximate the ribs with the pericostal sutures.

12.  Close the wound in layers.

Instrument

•   General pediatric set

•   Special:

     a.  Finochietto chest retractor

     b.  Malleable retractors

     c.  Right angled artery forceps

     d.  Long thumb forceps

     e.  Long needle holder

     f.   Red rubber catheter #6

     g.  Feeding tube # 6.

Sutures

•   4/0 Catgut 

•   4/0, 5/0       Silk

•   5/0              Prolene

•   5/0              Nylon.

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Pediatric Surgery Congenital diaphragmatic hernia

Congenital Diaphragmatic Hernia

Mostly a left sided hernia, through a defect in the dome of the diaphragm, pushing the abdominal viscera into the chest.

Problems

•   Respiratory distress due to lung compression

•   Associated ipsilateral lung hypoplasia

•   Poorly developed abdominal cavity.

Objectives

•   Reduce the hernial contents to abdomen

•   Repair the defect in the diaphragm

•   Allow slow expansion of the hypoplastic lung

•   Increase the space in the abdominal cavity.

Position

Supine with a folded towel under the lower chest.

Anesthesia

•   General with endotracheal intubation

•   Face-mask inhalation of gases-contraindicated.

Procedure

   1.  Subcostal incision 5-7 cm long and 1 cm below the costal margin.

   2.  Divide subcutaneous tissue and muscles with cautery.

   3.  Open the peritoneum.

   4.  Reduce the contents (stomach, intestine, colon, spleen) from the chest.

   5.  Retract left lobe of the liver medially.

   6.  Retract the stomach, intestine and spleen inferiorly.

   7.  Identify the defect in the diaphragm.

   8.  Mobilize the edges of the defect.

   9.  Drain the left chest under water seal.

10.  Suture the defect in 2 layers (double breasting) with 4/0 silk.

11.  Stretch the abdominal muscles, if required.

12.  Avoid undue resistance to breathing.

Options

1. Gastrostomy for abdominal decompression.

2. Marlex mesh to repair the large defects of the diaphragm.

3. Creation of a ventral hernia to prevent respiratory distress.

4. Elective postoperative ventilation to assist in respiration.

Instruments

General pediatric set.

Special

•   Red rubber catheter (#8)                 1

•   Under-water seal bottle, tubes and         1
connector

•   Marlex or prolene mesh.

Sutures

•   4/0 Catgut 1

•   4/0 Silk                   2

•   4/0 Nylon    1

Any questions be sent to drmmkapur@gmail.com  

All older posts are stored in archive for accessand reiew

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To create consumer/provider enagement visit www.surginstruatlas.blogspot.com 

www.drmmkapur.blogspot.com                   www.surgseminar.blogspot.com  

Also available now on android & smartphones same internet address

Complete set of blogs & precepts available at distance  learning support Tryselfcar