Pediatric Surgery Appendectomy

Appendectomy

Definition

In cases of acute appendicitis or as an interval appendectomy procedure.

Objectives

•   To remove the appendix to prevent complications

•   Invert the appendiceal stump.

Position

Supine.

Anesthesia

General with endotracheal intubation.

Procedure

1.  A 5 cm long skin crease incision of McBurney’s point on right side.

2.  Open the peritoneal cavity by separating muscles.

3.  Identify and grasp the appendix.

4.  Identify and ligate the appendicular artery.

5.  Define the base of appendix from all sides.

6.  Crush and ligate the appendix near its base.

7.  Invaginate the stump within the purse string suture.

8.  Assess for Meckel’s diverticulum, if any.

9.  Close the wound in layers.

Instruments

•   General pediatric surgical set.

Suture

•   3/0 Catgut                         2

•   4/0 Silk                               1

•   4/0 Nylon                1.

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Pediatric Surgery Hydrcaphelos

Surgery for Hydrocephalus

Definition

In cases of big head with ventricular dilatations due to excessive accumulation of cerebrospinal fluid in the brain resulting in rise in intracranial pressure in conditions of:

•   Congenital acqueductal stenosis

•   Associated meningomyelocele

•   Complications of pyogenic and tubercular meningitis.

Objectives

•   To drain the exess of CSF from ventricles to the peritoneal cavity

•   To reduce the intracranial tension

•   To insert a ventriculoperitoneal silastic shunt.

Position

•   Supine with neck extended and rotated to the left side

•   Pinna stapped in front of tragus.

Anesthesia

General.

Procedure

   1.  A curved scalp incision, 5 cm long, above and behind the pinna over the parietal eminence.

   2.  Incise and reflect the periosteum.

   3.  Make one cm sized burr hole with a trephine.

   4.  Cauterize the dura to make a tiny hole.

   5.  Insert the ventricular catheter to ensure CSF flow.

   6.  Prevent excessive CSF drainage.

   7.  Open the peritoneal cavity in the right subcostal region.

   8.  Make a subcutaneous tunnel from the head to the abdominal wound.

   9.  Place the lower end of the shunt in the pelvis or the suprahepatic space.

10.  Close all wounds in 2 layers.

Options

1.  Ventriculoatrial shunt instead of ventriculoperitoneal.

2.  Choice of an indigenous or an imported shunt.

Special Instruments

•   General pediatric surgical set

•   Special instruments include:

     a.  Trephine (1 cm)                           1 (Fig. 17.26)

     b.  Brain needle and cannula           1 (Fig. 13.47)

     c.  Periosteal elevators                      2

     d.  Guarded clamps                           2

     e.  Mastoid retractors                        2 (Fig. 21.3)

     f.   Ventriculoperitoneal shunt        1

     g.  CSF sample bottles                     3

     h.  Red rubber catheter # 10            1

Sutures

•   4/0 Catgut                                          2

•   5/0 Nylon                                           1

•   4/0 Silk                                               2

•   1/0 Silk                                               1

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Pediatric Surgery Undescended Testis

Surgery for Undescended Testis

Definitions

In cases of maldevelopment of testis, resulting in unilateral or bilateral maldescent of testis.

Objectives

To bring and keep the testis in the scrotum by the age of two years or so to:

•   Prevent trauma and torsion 

•   Detect malignancy of testis early 

•   Improve fertility.

Position

Supine.

Anesthesia

General with endotracheal intubation.

Procedure

1.  Open the inguinal canal through skin crease. 

2.  Divide the cremasteric muscle fibers.

3.  Isolate the spermatic cord with testis.

4.  Detach the testis from the gubernacular attachments at the lower end.

5.  Separate and suture ligate the hernial sac.

6.  Mobilize in the retroperitoneal space if required to achieve the length of the spermatic vessels.

7.  Fix the testis in the extradartos pouch without any tension.

8.  Close the wound in layers.

Options

•   Two stage procedure, if the spermatic vessels are short

•   Simultaneous orchiopexy, if bilateral maldescent.

Sutures

•   4/0 Catgut              1

•   3/0 Catgut                         1

•   4/0 Nylon                1

•   3/0 Silk 

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Pediatric Surgery Wilms Tumor

Surgery for Wilms’ Tumor

Definition

In cases of abnormal and uncontrolled growth of kidney(s) in children, resulting in:

•   Non-functioning of the kidney

•   Spread of tumor locally as well as to lungs

•   Deterioration in general health.

Objectives

•   Removal of the entire tumor including the affected kidney

•   Staging of the tumor, lymph nodes sampling

•   Histopathological grading of tumor

•   Supplement with chemotherapy and radiotherapy, to prevent recurrence.

Position

Supine, with a towel under the loin.

Anesthesia

General with endotracheal.

Procedure

   1.  Large transverse abdominal skin incision over the tumor.

   2.  Divide the muscles.

   3.  Open the peritoneal cavity.

   4.  Reflect the colon medially.

   5.  Define and ligate the renal vessels.

   6.  Free the tumor from all sides.

   7.  Leave the adrenal gland, if not involved.

   8.  Ligate the ureter as low down as possible.

   9.  Remove the kidney with the tumor.

10.  Avoid any tumor rupture/spill.

11.  Assess the other kidney and biopsy the lymph nodes if any.

12.  Close the abdominal wound in layers.

Options

1.  Renal preserving surgery, if feasible.

2.  Minimal surgery if bilateral disease.

3.  Biopsy only, if an extensive and fixed tumor.

Instruments

General pediatric surgical set.

Sutures

•   3/0 Catgut             2

•   3/0 Silk                               4

•   2/0 Silk                               4

•           4/0 Nylon 

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Cardiovascular Surgery CABG

Coronary Artery Bypass Graft

Objective

•   To open chest

•   To expose heart

•   To connect aorta to coronary artery (CA) with a vein or internal mammary artery so as to bypass block in CA. 

Position

Supine.

Anesthesia

General.

Procedure

   1.  Catheterization cleaning of chest and both legs.

   2.  Draping the chest and both legs. 

   3.  Skin incision with 20 No. blade saw and cable for sternotomy Finochietto retractor for sternum. 

   4.  Cautery for pericardiotomy pericardial retraction sutures 2/0 atro silk. 

   5.  Internal mammary artery or saphenous vein dissected after sternotomy if desired by surgeons. 

   6.  Saphenous vein graft is taken from the leg, graft check in heparanized saline. 

   7.  Bleeders tied with 4/0 silk hemostatic clips applied for hemostasis marking suture of 4/0 Surgilene is done on distal end. 

   8.  Thigh is closed with 0 Vicryl suture with 3/0 Surgilene.

   9.  Cannulation. 

10.  2-0 T2 is used for aortic purse string. No. 12 blade and No. 11 blade for incision on aorta, aortic cannula tie suture 2/0 atro silk. Connect the arterial line. 

11.  Becks clamp to clamp SVC and connect with arterial line. Incision with 12 No. blade purse string with 4/0 C2 Tevdek. SVC cannula is connected venous line. 

12.  Purse string with 4/0 T3 insertion of cardioplegia needle and 3 way connection. Ice cold ringer lactate. 

13.  Internal mammary artery or sephanous vein dissection. 

14.  Patient goes on bypass. Aorta is cross clamped. Cooling upto 27°C heart stop. Dissect the coronary vessel by Pott’s scissors. Distal end of saphenous vein 6/0 Proximal end of coronary artery with 6/0 prolene suture needle. 

15.  All the grafts are sutured to the aorta in same manner. 

16.  Pacing wire and BP heart rate. ECG maintained.

17.  Venous line clamp. Remove the cannulae and tie with silk. 

18.  Decannulation. 

19.  Aortic cannula is removed a stitch of 2-0 T2 is taken. 

20.  Sponge and instrument count. 

21.  Steel wires are used for sternum closure.

22.  Bandage the legs; elasto crepe bandage. 

23.  Dressing with betadine.

Instruments

•   Cleaning set 

•   Cardiac set 

•   Open heart special set 

•   Open heart vascular set 

•   Open heart water seal 

•   Coronary set.

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