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

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Pediatric surgery Hypospadias 1 cordee correction

Hypospadias

Definition

In cases of developmental defect of urethra, leading to position­ing of the urinary meatus proximally on the ventral surface of penis and also resulting in:

•   Distortion of the penis (chordee) 

•   Misdirected urinary stream 

•   Possible difficulty in reproductive functions later.

Objectives

•   To correct chordee if present 

•   Reconstruction of urethra from opening to tip.

Position

Supine.

Anesthesia

General with endotracheal intubation.

Chordee Correction

Procedure

1.  Hold the glans with stay sutures.

2.  Inject normal saline in glans to check chordee.

3.  Excise the fibrous cord, if any.

4.  Readjust the prepuce on the ventral surface.

5.  Advance the prepucial skin to the edges of the navicular fossa.

6.  Close the wound in 2 layers.

7.  Drain the bladder with a urethral catheter

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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.

Any questions be sent to drmmkapur@gmail.com  

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