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

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Pediatric surgery Intestinal Obstruction 1

Surgery for Intestinal Obstruction

Definition

In cases of intestinal obstruction due to developmental defect the newborns, resulting in:

•   Abdominal distension

•   Bilious vomiting

•   Constipation.

Objectives

•   To respect the adynamic and the dilated proximal bowel

•   To restore intestinal continuity, with or without an external stoma.

Position

Supine (with an overhead warmer).

Anesthesia

General with endotracheal intubation.

Procedure

1.  Transverse abdominal muscle cutting incision 7-10 cm long between the umbilicus and the xiphoid process.

2.  Open the peritoneal cavity.

3.  Identify the site of obstruction.

4.  Resect or taper the grossly dilated proximal segment of the bowel.

5.  Make a cutback for 2 cm on the antimesenteric side of distal narrow segment of the bowel.

6.  Make a single layer anastomosis with 5/0 silk interrupted sutures between the proximal and the distal bowel segments.

7.  Ensure distal patency of the small and large bowel.

Options

1. Bishop-Coop Chimney instead of primary anastomosis.

2.  Exteriorization of proximal and distal ends of bowel.

3.  Plication of the dilated proximal bowel.

Instruments

General pediatric set.

Sutures

•   4/0 Catgut              2

•   5/0 Silk                               2

•           5/0 Nylon                    1

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Pediatric Surgery Hypospadius 2 urethroplasty

Urethroplasty

Procedure

1.  Hold the glans with a silk stay suture.

2.  Mark the incision with a marking ink or pen.

3.  Make a ‘U’ shape incision on the ventral surface of the penis around the meatus.

4.  Roll it into a tube over a # 6 feeding tube.

5.  Make the water tight urethra with PDS.

6.  Approximate subcutaneous tissue with catgut.

7.  Close skin with interrupted nylon suture.

8.  Apply compression penile dressing.

Options

1.  Single stage urethroplasty, if no chordee.

2.  Multistage procedures, if associated with:

     •   Chordee

     •   Torsion of phallus.

Instruments

General Pediatric Surgical Set

Special instruments

•   Fine scissors                                      1 (Fig. 21.4)

•   Fine tissue forceps                           2 (Fig. 21.5)

•   Skin hooks                                        2

•   Measuring scale                                1

•   Marking ink/pen                               1

•   Silastic/PVC catheter                        # 6, 8

Sutures

•   5/0 PDS/Dexon                                 1

•   5/0 Catgut                                         1

•   4/0 Silk                                               1

•   5/0 Nylon                                           1

Any questions be sent to drmmkapur@gmail.com  

All older posts are stored in archive for accessand reiew

Thosewho follow may post contributions to the site,please writo tp address above.

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 Tryselfcare.