MEDICAL SCHOOL LECTURE A process by which the notes of the lecturer are transferred to the notes of the student, without passing through the mind of either

SURGERY IN THE PEDIATRIC PATIENT Spectrum of diseases Atypical presentation Different approaches Different physiology Technical issues Psychosocial issues

Newborn baby with bilious vomiting

6 year old girl 5 day history of abdominal pain and vomiting

INTESTINAL OBSTRUCTION Newborn –congenital malformations, CF Toddler –intussusception, incarcerated hernia, Meckels band School age –Appendicitis, adhesions Adolescent –Adhesions, Crohns

2 year old male with right retroperitoneal mass

Wilms tumour

Newborn male with right retroperitoneal mass

RENAL/ADRENAL MASS Newborn –Hydronephrosis, dysplastic kidney, adrenal hemorrhage, mesoblastic nephroma Toddler –Wilms tumour, neuroblastoma School age –Ganglioneuroma Adolescent –Renal cell carcinoma

OTHER EXAMPLES Rectal bleeding Increased intracranial pressure Fractures Vascular malformations Cardiac failure

Nine year old Portugese boy, small for age 3 week history of crampy abdominal pain 2 day history of right lower quadrant pain Admitted to hospital, noted to be anemic No change for 3 days Taken to operating room

Diagnosis of “ileitis” and appendicitis Pathology consistent with Crohn disease Treated medically

PRESENTATION OF IBD IN CHILDREN MAY BE ATYPICAL Growth failure Delayed onset of puberty Anemia Nonspecific abdominal pain or diarrhea Recurrent anal fistulae or fissures

Most children have not read the textbook

PRENATAL DIAGNOSIS

Abdominal wall defects Diaphragmatic hernia CCAM and pulmonary sequestration Hydrocephalus and myelomeningocele Congenital heart disease Cleft lip and palate Amniotic band syndrome Renal anomalies and posterior urethral valves Spinal and skeletal abnormalities

FETAL DIAGNOSIS: OPTIONS Termination Deliver at term

FETAL DIAGNOSIS: OPTIONS Change mode of delivery Termination Deliver at term

FETAL DIAGNOSIS: OPTIONS Change mode of delivery Change timing of delivery Termination Deliver at term

FETAL DIAGNOSIS: OPTIONS Change mode of delivery Change site of delivery Change timing of delivery Termination Deliver at term

FETAL DIAGNOSIS: OPTIONS Change mode of delivery Change site of delivery Change timing of delivery Fetal intervention Termination Deliver at term

FETAL SURGERY Lethal anomalies –Bladder outlet obstruction with oligohydramnios

FETAL SURGERY Lethal anomalies –Diaphragmatic hernia

FETAL SURGERY Non-lethal anomalies –Myelomeningocele

FETAL SURGERY Non-lethal anomalies –Myelomeningocele –Amniotic band syndrome –Cleft lip and palate?

DIFFERENT APPROACHES

12 year old boy hit by car

1 month old baby with incarcerated hernia

Severely burned child Newborn with necrotizing fasciitis PHYSIOLOGY

PHYSIOLOGICAL DIFFERENCES BETWEEN CHILDREN AND ADULTS Fluid requirements, calcium, blood sugar Temperature control Immune system, sepsis Intraabdominal pressure Postoperative complications

Neuroblastoma Stage IV-S

TECHNICAL ISSUES Children are smaller Anatomical differences Tissues are more fragile (be dainty) “One false move, and the patient pays for it for eighty years”

Smaller LAPAROSCOPY IN CHILDREN: TECHNICAL ISSUES

Smaller Thinner abdominal wall LAPAROSCOPY IN CHILDREN: TECHNICAL ISSUES

Smaller Thinner abdominal wall Rounder abdomen Smaller peritoneal cavity More prominent liver, spleen, bladder Horizontal orientation of stomach LAPAROSCOPY IN CHILDREN: TECHNICAL ISSUES

DIAGNOSING PERITONITIS IN THE CHILD Rapport prior to examination Diversionary tactics Facial expression and body position Percussion tenderness Surreptitious palpation Limitation of specific activities

CASE Ten year old boy with chronic renal failure Steroid-induced osteoporosis, myopathy, cataracts Hospital admission every 1-2 months

EFFECT OF CHRONIC ILLNESS ON FAMILY DYNAMICS Father left when illness began Child shifted between parents in different cities Cadaveric renal transplant, complicated by rejection During hospitalization, sibling alone with Aunt Over 4-year illness, missed two years of school

PSYCHOSOCIAL ISSUES Body image and sexuality Control and independence Effect of chronic illness on well siblings and parents School Development of social skills and interactions