– Pediatric Surgery

Foregut – lungs, esophagus, stomach, pancreas, liver, gallbladder, bile duct, and duodenum proximal to ampulla

Midgut – duodenum distal to ampulla, small bowel, and large bowel to distal ⅓ of transverse colon

Hindgut – distal ⅓ of transverse colon to anal canal

Midgut rotates 270 degrees counterclockwise normally

Low birth weight < 2,500 g; premature < 37 weeks

Immunity at birth – IgA from mother’s milk; IgG crosses the placenta

#1 cause of childhood death – trauma

• Trauma bolus – 20 cc/kg X 2, then give blood 10 cc/kg

• Tachycardia – best indicator of shock (neonate > 150; < 1 year > 120; rest > 100)

• Want urine output > 2–4 cc/kg/hr

• Children (< 6 months) only have 25% the GFR capacity of adults – poor concentrating ability

↑ alkaline phosphatase in children compared with adults → bone growth

Umbilical vessels – 2 arteries and 1 vein

MAINTENANCE INTRAVENOUS FLUIDS

4 cc/kg/hr for 1st 10 kg

2 cc/kg/hr for 2nd 10 kg

1 cc/kg/hr for everything after that

CONGENITAL CYSTIC DISEASE OF THE LUNG

Pulmonary sequestration

• Lung tissue has anomalous systemic arterial supply (thoracic aorta or abdominal aorta through inferior pulmonary ligament)

• Have either systemic venous or pulmonary vein drainage

• Extra-lobar – more likely to have systemic venous drainage (azygous system)

• Intra-lobar – more likely to have pulmonary vein drainage

• Do not communicate with tracheobronchial tree

• Most commonly presents with infection; can also have respiratory compromise or an abnormal CXR

• Tx: lobectomy

Congenital lobar overinflation (emphysema)

• Cartilage fails to develop in bronchus, leading to air trapping with expiration

• Vascular supply and other lobes are normal (except compressed by hyperinflated lobe)

• Can develop hemodynamic instability (same mechanism as tension PTX) or respiratory compromise

• LUL most commonly affected

• Tx: lobectomy

Congenital cystic adenoid malformation

• Communicates with airway

• Alveolar structure is poorly developed, although lung tissue is present

• Symptoms: respiratory compromise or recurrent infection

• Tx: lobectomy

Bronchiogenic cyst

• Most common cysts of the mediastinum; usually posterior to the carina

• Are extra-pulmonary cysts formed from bronchial tissue and cartilage wall

• Usually present with a mediastinal mass filled with milky liquid

• Can compress adjacent structures or become infected; have malignant potential

• Occasionally are intra-pulmonary

• Tx: resect cyst

MEDIASTINAL MASSES IN CHILDREN

Neurogenic tumors (neurofibroma, neuroganglioma, neuroblastoma) – most common mediastinal tumor in children; usually located posteriorly

Respiratory symptoms, dysphagia – common to all mediastinal masses regardless of location

Anterior – T cell lymphoma, teratoma, and other germ cell tumors (most common type of anterior mediastinal mass in children), thyroid CA

Middle – T cell lymphoma, teratoma, cyst (cardiogenic or bronchiogenic)

Posterior – T cell lymphoma, neuroblastoma, neurogenic tumor

Thymoma is rare in children

CHOLEDOCHAL CYST

Need to resect – risk of cholangiocarcinoma, pancreatitis, cholangitis, and obstructive jaundice; caused by reflux of pancreatic enzymes into the biliary system in utero

LYMPHADENOPATHY

Usually acute suppurative adenitis associated with URI or pharyngitis

If fluctuant → FNA, culture and sensitivity, and antibiotics; may need incision and drainage if it fails to resolve

• Chronic causes – cat scratch fever, atypical mycoplasma

Asymptomatic – antibiotics for 10 days → excisional biopsy if no improvement

• This is lymphoma until proved otherwise

Cystic hygroma (lymphangioma) – usually found in lateral cervical regions in neck; gets infected; is usually lateral to the sternocleidomastoid (SCM) muscle

• Tx: resection

DIAPHRAGMATIC HERNIAS AND CHEST WALL

Overall survival 50%

Increased on left side (80%); can have severe pulmonary HTN

80% have associated anomalies (cardiac and neural tube defects mostly; malrotation)

Diagnosis can be made with prenatal ultrasound

Symptoms: respiratory distress

CXR – bowel in chest

Tx: high-frequency ventilation; inhaled nitric oxide; may need ECMO

• Stabilize these patients before operating on them

• Need to reduce bowel and repair defect ± mesh (abdominal approach)

• Look for visceral anomalies (run the bowel)

Bochdalek’s hernia – most common, located posteriorly

Morgagni’s hernia – rare, located anteriorly

Pectus excavatum (sinks in) – sternal osteotomy, need strut; performed if causing respiratory symptoms or emotional stress

Pectus carinatum (pigeon chest) – strut not necessary; repair for emotional stress

BRANCHIAL CLEFT CYST

Leads to cysts, sinuses, and fistulas

1st branchial cleft cyst – angle of mandible; may connect with external auditory canal

• Often associated with facial nerve

2nd branchial cleft cyst (most common) – on anterior border of mid-SCM muscle

• Goes through carotid bifurcation into tonsillar pillar

3rd branchial cleft cyst – lower neck, medial to or through the lower SCM

Tx for all branchial cysts: resection

THYROGLOSSAL DUCT CYST

From the descent of the thyroid gland from the foramen cecum

May be only thyroid tissue patient has

Presents as a midline cervical mass

Goes through the hyoid bone

Tx: excision of cyst, tract, and hyoid bone (at least the central portion)

HEMANGIOMA

Appears at birth or shortly after

Rapid growth during first 6–12 months of life, then begins to involute

Tx: observation – most resolve by age 7–8

If lesion has uncontrollable growth, impairs function (eyelid or ear canal), or is persistent after age 8 → can treat with oral steroids → laser or resection if steroids are not successful