PAEDIATRIC SURGERY

Part 3
INTESTINAL ATRESIA

● ATRESIA - failure of vacoulisation of intestine from solid

core stage.
● Range of anatomical variants
○ Stenosis
○ Mucosal web(windsock deformity)
○ Two ends separated by fibrotic band
○ Complete separation with resultant gap
● Association - prematurity, down syndrome, maternal
polyhydramnios, malrotation, annular pancreas, biliary
atresia
● Proximal bowel - dilated
● Distal bowel - collapsed
● Duodenal atresia - double bubble appearance
● Jejunal atresia - triple bubble appearance
● Sx - kimuras duodeno-duodenostomy
○ Jejuno-jejunal anastomosis
MALROTATION OF GUT

● 1 in 6000 live births

● Rotation of gut -
○ 4th week - midgut herniates out of coelomic cavity
○ 10th week - intestine begins to migrate back into
abdominal cavity- counter clockwise 270° rotation
○ 12th week - complete and colon fixed to
retroperitoneum
● Newborn with bilious vomiting - MALROTATION UNLESS
PROVEN
● Complete malrotation - most common
○ Midgut suspended over a narrow SMA stalk

● Midgut volvulus - surgical emergency - ischemic bowel

loops
● Upper GI contrast series - diagnostic study of choice

● Gold standard - laparotomy or diagnostic laparoscopy

● Sx - LADD’S PROCEDURE
○ Eviscerate small bowel & confirm diagnosis
○ See ladd’s bands and divide them
○ Mesentry wide no chance of volvulus
○ Do appendicectomy
NECROTISING ENTEROCOLITIS

● Most common surgical emergency in neonatal period

● Ischemia , bacteria and enteral feeding
● Prematurity
● Most common cause of short bowel syndrome
● Acute abdominal wall cellulitis, distention, tenderness
● Xray - pneumatosis intestinalis(intramural gas)
● Medical MX - 50% cases
● Pneumoperitoneum - absolute indication of surgery
● Unstable babies - bedside peritoneal drain placement
SHORT BOWEL SYNDROME

● Inadequate length of functional intestine to sustain normal

enteral nutrition
● Due to massive bowel resection
○ Intestinal atresia
○ NEC
○ Gastroschisis
Bianchi procedure. STEP
MECONIUM ILEUS

● Misnomer
● As a part of cystic fibrosis
● 1 in 1000 to 2000 live births
● 3 cardinal signs :
○ Generalized abdominal distention
○ Bilious emesis
○ Failure to pass meconium
● X-ray - dilated bowel loops with relatively absent air.
● MX - N acetyl cysteine - breaks disulfide bonds in
meconium
● Sx is mainstay
● Mc site - terminal ileum
○ Proximal incision : milk the meconium
○ Check for other sites of obstruction
HIRSCHSPRUNG DISEASE

● Absence of ganglion cells in myenteric and meissners

plexus
● 1 in 5000 live births
● Males more effected - 4x
● Functional obstruction
● Rectosigmoid - 80% cases
● Entire colony - 8%
● Symptoms - abdominal distention and failure to pass
meconium in first 24 hrs of life
● Enterocolitis - mc cause of death in children.
● Diagnostic test - contrast enema study
○ Narrow calibre distal rectum with a transition zone +
dilated proximal colony
● Manometry
● Gold standard - rectal biopsy
● Sx - treatment of coice
● Swenson - aganglionic bowel removed + colo anal
anastomosis
● Soave - endorectal. Mucosal dissection via transanal
approach
INTUSSUSCEPTION

● Part of intestine telescopes into itself

● Lead points :
○ Prayers patches
○ Appendix
○ Meckels diverticulum
● 6 months - 2 years
● Pain abdomen, inconsolable cry
● Red currant jelly stool
● Inv - xray abdomen
● Ultrasound abdomen - target sign or bulls eyes
appearance
● Mx- resuscitation followed by surgery
● Non operative - hydrostatic enema
● Air enema