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Flashcards in Paediatric Surgery Deck (68)
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Management of appendicitis

Fluid resuscitation bolus 10-20ml/kg 0.9NaCl
Opiate analgesia


Aetiology of indirect inguinal hernia

Wide patent processes vaginalis permits passage of bowel into inguinal canal/scrotum


Presentation of inguinal hernia in child

Groin pain, unsettled infant, groin swelling (intermittency/variation in size, +/- reducible), obstruction causing vomiting, colicky abdominal pain, dehydration
Groin swelling that cannot get above extending from inguinal ring to scrotum/labia
Increase in abdominal pressure e.g. Palpating/cough/laugh may evoke a reduced hernia


Management of paediatric inguinal hernia

Reducible hernia: elective hernia tony at next available opportunity, safety net tell patient signs of inarceration/obstruction

Irreducible: consider need for IV resuscitation if dehydrated, timely manual reduction if no signs of peritonitis or sepsis followed by repair within 24-48h after settling of swelling. Emergency surgery if failure of manual reduction, clinical deterioration, peritonism or sepsis


Features of hydrocele

Bluefish hue
Can get above mass (I.e. Scrotal)
Non tender
Non reducible


Management of hydrocele

80% boys have at birth, 90% will resolve spontaneously by 2y therefore:
Defer elective surgery until after 2y
Same procedure as a herniotomy
Simple aspiration contrindicated


Differential diagnosis for acute scrotum in a child

Testicular torsion (commonest in pubertal)
Torsion of testicular appendages
Epididymoorchitis (commonest prepubertal)
Benign idiopathic scrotal oedema
Incarcerated inguinal hernia
Rare:HSP, leukaemia


Surgical referral guidelines for acute scrotum

Any boy with high suspicion of testicular torsion
Any boy whom an alternative diagnosis to testicular torsion cannot be made with confidence


Features of testicular torsion

Abrupt onset, unilateral, severe testicular pain
Abdominal pain, nausea,vomiting
Wide based gait, normal abdominal exam, erythematous oedematous hemiscrotum, absent cremasteric reflex, firm diffusely tender testicle, affected testicle sitting higher in scrotum or bell clapper (transverse lie) of scrotum - right testis usually slightly higher


Management of testicular torsion

Manual de torsion if emergency surgery unavoidably delayed (e.g. Presentation in remote setting) - successful in 70%, only a time buying procedure, definitive treatment still surgery

Surgical de torsion


Clinical presentation of Epididymo-orchitis

Testicular pain (less severe than than torsion events)
+/- Lower urinary tract symptoms
Inflamed hemiscrotum
Normal testis
Prehn's manoeuvre positive (pain relieved by elevation of scrotum above pubis symphysis)


Management of Epididymo-orchitis

If diagnosis certain:
Oral fluids


Clinical features of pyloric stenosis

Increasing frequency projectile vomiting, non bile stained, postprandial
Feeds readily after vomiting
+/- failure to thrive/weight loss
+/- dehydration, sepsis

Visible peristalsis left to right across epigastrium
Pyloric mass typically olive shaped in RUQ adjacent to liver edge


Management of pyloric stenosis

Not surgical emergency, dehydration may become medical emergency

Immediate: nil by mouth, fluid bolus
Correction of hydration and electrolyte disturbance, aim to correct over 24-48h
Surgical management: pyloromyotomy after electrolyte and acids base disturbance has been corrected


Differentials for acute abdomen in a child

Non specific abdominal pain
Mesenteric adenitis
Midgut malrotation with volvulus
Irreducible/incarcerated inguinal hernia
Testicular torsion
Meckels diverticulitis/ bleeding diverticulitis
Bacterial enterocolitis


What is an omphalocele (exomphalos)

A midline abdominal wall defect at the base of the umbilical cord, containing umbilical contents under a membrane of amnion and peritoneum (abdominal contents protrude into the umbilical cord)


Immediate and definitive management of omphalocele

Sterile wrap of bowel
NG tube to decompress stomach
Stabilise airway and ensure adequate ventilation
Establish IV access

surgery: primary closure if


Abnormalities associated with omphalocele

Aneuploidy (T18, T13)
Additional GI anomalies
Cardiac defects (in up to 50%)
GU anomalies
Orofacial clefts
Neural tube defects
Diaphragm defects


What is gastroschisis

A full-thickness paraumbilical abdominal wall defect associated with evisceration of bowel without any covering membrane (to the R of the midline)


Duodenal atresia presentation and diagnosis

Abdominal distension present at birth and progressive
Bilious vomiting beginning in first 24 hours of life
"Double bubble" sign on abdominal x-ray (dilation of stomach and proximal duodenum with gas)


Management of duodenal atresia

Withhold feeds, NG tube for decompression, fluid resuscitation, correct metabolic anomalies, broad spectrum Abx (ampicillin + gentamycin)
Surgical repair


VACTERL associated congenital anomalies

Vertebral defects
Anal atresia
Cardiac defects
Tracheo-oesophageal fistula +
Esophageal atresia
Renal defects
Limb hypoplasia


Causes of meconium retention

Hirschsprung disease
Meconium plug syndrome
Meconium ileus
Anorectal malformations
Intestinal atresia


Presentation and diagnosis of oesophageal atresia

Usually picked up on antenatal USS (polyhydramnios, small stomach, etc.)
Excessive drooling/mucousy
Need for suction and resuscitation at birth
Cyanosis during feeds
Rattling respiration, frothy white bubbles of mucus in nostrils/lips within minutes of birth
Try to introduce an OG tube - arrests 10cm from lips
Thoracic/Abdo xray: air in stomach and small bowel (=TOF) - allows to assess for associated anomalies e.g. vertebral or rib, right-sided aortic arch


Management of oesophageal atresia

Echo: identify any cardiac lesions
Renal USS: exclude bilateral renal agenesis (if patient has not passed urine)
Early genetic consultation
Early complete correction (TOF division, reconstruction of end-to-end oesophagus)


Varicocele (definition, epidemiology, aetiology)

A collection of dilated, tortuous veins in the pampiniform plexus surrounding the spermatic cord
present in 10-25% of adolescents, 85-95% are left sided due to L spermatic vein entering left renal vein at right angle whereas R enters IVC at more obtuse angle
Secondary causes: IVC obstruction (thrombosis, abdominal mass e.g. retroperitoneal tumour, lymphadenopathy)


Presentation of varicocele

May be asymptomatic OR dull ache/fullness in scrotum upon standing
Examination: visible distention around spermatic cord on standing (grade III) palpable "bag of worms" in scrotum (grade I if only with valsalva)


Indications for IVC ultrasonography in setting of varicocele

Suspicion of IVC obstruction: Right-sided varicocele, acute onset, persistence in supine position (grade III)


Management of varicocele

Usually conservative
Surgical ligation or testicular vein embolisation, indications:
Affected testicle volume less than unaffected (>10-15% or 2mL difference)
Symptomatic varicocele (pain, heaviness, swelling)
bilateral varicoceles


Types of testicular cancers

Testicular Germ cell tumours (95%)
Nonseminomatous germ cell tumours (embryonal carcinoma, teratoma, choriocarcinoma/trophoblastic tumour, yolk sac/endodermal sinus tumour, mixed germ cell tumours)

Sex cord-stromal tumours:
Leydig cell tumours (2%) sertoli cell tumours, granulosa cell tumours, mixed types