1. 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

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

4. Newborn baby with bilious vomiting

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

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

9. 2 year old male with right retroperitoneal mass

10. Wilms tumour

11. Newborn male with right retroperitoneal mass

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

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

14. 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

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

16. 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

17. Most children have not read the textbook

18. PRENATAL DIAGNOSIS

19. 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

20. FETAL DIAGNOSIS: OPTIONS Termination Deliver at term

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

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

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

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

25. FETAL SURGERY Lethal anomalies –Bladder outlet obstruction with oligohydramnios

26. FETAL SURGERY Lethal anomalies –Diaphragmatic hernia

27. FETAL SURGERY Non-lethal anomalies –Myelomeningocele

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

29. DIFFERENT APPROACHES

30. 12 year old boy hit by car

31. 1 month old baby with incarcerated hernia

32. Severely burned child Newborn with necrotizing fasciitis PHYSIOLOGY

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

34. Neuroblastoma Stage IV-S

35. 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”

36. Smaller LAPAROSCOPY IN CHILDREN: TECHNICAL ISSUES

37. Smaller Thinner abdominal wall LAPAROSCOPY IN CHILDREN: TECHNICAL ISSUES

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

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

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

44. 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

45. 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