Pediatric Surgery Intussusception

Intussusception

Definition

In case of entry of the ileum with its mesentery into the colon intussusception resulting in a mechanical bowel obstruction.

Objectives

•   To open the abdomen to inspect the bowel

•   To reduce the intussusception and relieve obstruction

•   To resect and anastomose, if the bowel has become gangrenous.

Position

Supine.

Anesthesia

General with endotracheal intubation.

Procedure

   1.  Right transverse upper abdominal 7-8 cm long incision.

   2.  Avoid the subcutaneous tissues and muscles.

   3.  Open the peritoneal cavity.

   4.  Identify the intussusception mass.

   5.  Suck out the peritoneal fluid, if any.

   6.  Reduce the intussusception by “milking” from distal to proximal side, without injury to the bowel.

   7.  Resect and anastomoses the bowel, if it fails to reduce completely or found gangrenous.

   8.  Check for free flow of intestinal contents.

   9.  Check for any associated lesion, i.e. lymphoma Meckles diverticulum.

10.  Close the abdominal wound in layers.

Instruments

General pediatric set.

Sutures

•   Catgut       2/0, 3/0, 4/0

•   Silk             3/0, 4/0

•   Nylon         4/0

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Pediatric surgery Ano-Rectal malfomations

Anorectal Malformation

Definition

In cases of development defect of anus, babies are born with imperforate anus and with or without abnormal fistulous connections.

Objectives

•   To bring the bowel down at the anal site

•   To preserve the sphincteric mechanism for anal continence.

Position

•   Prone with buttocks raised at 45 degree angle

•   Pass Folley’s catheter into the bladder before positioning.

Anesthesia

General with endotracheal intubation.

Procedure

   1.  A midline incision from sacrococcygeal region to the proposed anal site.

   2.  Divide the subcutaneous tissue and the sphincteric muscle complex strictly in midline with a fine tipped diathermy.

   3.  Hook and divide the puborectalis muscle fibers in the midline.

   4.  Open the rectum in the midline, between the stay sutures.

   5.  Identify, isolate and suture the fistula.

   6.  Lengthen the rectum by dividing the fibrovascular bands.

   7.  Place the neorectum through the sphincter muscle complex, checking with muscle stimulator.

   8.  Fix neoanus at the anal site.

   9.  Close the bifurcated coccyx.

10.  Close the midline wound in layers.

Instruments

General pediatric set.

Special

•   Muscle stimulator                             1

•   Mastoid retractor                               2

•   Right angled artery forceps             2

Sutures

•   Vickryl                    4/0, 5/0

•   Catgut       4/0

•   Nylon                     4/0.

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Pediatric Surgery Colostomy

Colostomy

Definition

Colostomy is a temporary procedure required to relieve obstruction of large bowel in babies mostly with:

•   Anorectal malformations and

•   Hirschsprung’s disease.

Objective

•   Temporary fecal diversion

•   Temporary decompression of bowel.

Position

•   Supine, for right transverse colostomy for babies with Hirschsprung’s disease

•   Supine, with a folded towel under the left iliac region for sigmoid colostomy in babies with anorectal malformations.

Anesthesia

General with endotracheal intubation.

Procedure

1.  A transverse muscle cutting incision, 5 cm long at the proposed toma site.

2.  Open the peritoneal cavity.

3.  Identify the colon.

4.  Free the transverse colon from the omentum.

5.  Make a spur of the colon.

6.  Fix the colon with the peritoneum and the abdominal wall muscles in layers.

7.  Deflate the colon with a catheter around a purse string.

8.  Open the colon for 2 to 3 cm along the tinea coli.

Instruments

General set.

Sutures

•   Catgut                   4/0, 3/0

•   Silk                         4/0

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Pediatric surgery abdomonal wall defects

Abdominal Wall Defects

Definition

In babies with congenital umbilical wall defect gastroschisis and ruptured omphalocele.

Objectives

•   To reduce the bowel inside the abdominal cavity

•   To close the defect primarily if feasible

•   To increase the abdominal cavity by a pouch, if required.

Position

Supine.

Anesthesia

General with endotracheal intubation.

Procedure

1.  Enlarge the defect transversely in the case of gastroschisis.

2.  Excise the remaining sac in the case of ruptured omphalocele and enter the abdominal cavity.

3.  Stretch the anterior abdominal wall. Try to close the defect in layers, if feasible.

4.  Create a pouch of marlex or prolene mesh.

5.  Suture the pouch all around the defect in 2 layers.

6.  Clamp the excess of pouch to force reduce the bowel into the abdominal cavity in stages.

Instruments

General pediatric set.

Sutures

•   Catgut                   4/0

•   Nylon                                 3/0

•   Marlex mesh.

Any questions be sent to drmmkapur@gmail.com  

All older posts are stored in archive for accessand reiew

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