intestinal obstruction in children symptoms: bilious vomiting abdominal distention colicky abdominal...
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Intestinal obstruction Intestinal obstruction
in childrenin children Symptoms: Symptoms: Bilious vomiting Bilious vomiting Abdominal distention Abdominal distention Colicky abdominal painColicky abdominal painObstipation (failure of meconium passing) Obstipation (failure of meconium passing)
Prenatal Diagnosis Prenatal Diagnosis Polyhydramnios Polyhydramnios Intestinal distention Intestinal distention Double bubble sign Double bubble sign Familial history (FC, HD) Familial history (FC, HD)
Post natal diagnosis Post natal diagnosis Bilious vomiting Bilious vomiting Abdominal distention (not in Abdominal distention (not in
volvulus, upper obstruction)volvulus, upper obstruction)
Upper or lower obstruction Upper or lower obstruction Meconium passing? (24-48h, 99%)Meconium passing? (24-48h, 99%) Fluid or meconium in scrotum Fluid or meconium in scrotum Abdominal cystic mass Abdominal cystic mass
Intestinal obstruction Intestinal obstruction evaluation evaluation
Plain abdominal Xray (flat and Plain abdominal Xray (flat and upright) upright)
Double bubble sign, triple bubble Double bubble sign, triple bubble sign, multiple air fluid level sign, multiple air fluid level
Calcification Calcification Upper GI study (upper obstruction)Upper GI study (upper obstruction) Barium enema Barium enema
Complications of intestinal Complications of intestinal obstruction obstruction
Volume loss (decreased intake, fluid Volume loss (decreased intake, fluid retention)retention)
Metabolic acidosis (ischemia, low Metabolic acidosis (ischemia, low glucose)glucose)
Hypothermia Hypothermia Respiratory distress (distention, Respiratory distress (distention,
elevation of diaphragm)elevation of diaphragm) Infection (sepsis) Infection (sepsis)
Treatment Treatment GI rest (NG tube, NPO)GI rest (NG tube, NPO) Resuscitation Resuscitation
IV fluid 10 ml/kg, glucose, bicarbonateIV fluid 10 ml/kg, glucose, bicarbonate warming warming Oxygenation Oxygenation Antibiotics Antibiotics Surgery Surgery
Esophageal atresia Esophageal atresia Congenital anomaly Congenital anomaly Upper pouch obstruction Upper pouch obstruction Lower part connected to trachea Lower part connected to trachea Multiple congenital anomaliesMultiple congenital anomalies V A C TE R LV A C TE R LVertebralVertebral anus cardiac anus cardiac tracheo renal limbs tracheo renal limbs
esophagealesophageal
atresiaatresia
Esophageal atresia Esophageal atresia Symptoms Symptoms Excess salivation Excess salivation Feeding intolerance Feeding intolerance Choking Choking Cyanosis Cyanosis Atelectasis, pneumoniaAtelectasis, pneumonia Abdominal distention Abdominal distention Polyhydramnios Polyhydramnios
Esophageal atresiaEsophageal atresia
Early diagnosis Early diagnosis Diagnosis before starting diet Diagnosis before starting diet Chest x ray Chest x ray Passing of large catheter (14-Passing of large catheter (14-
16french) 16french) EchocardiographyEchocardiography Ultra sonography Ultra sonography Abdominal x ray (air less abdomen)Abdominal x ray (air less abdomen)
Treatment Treatment
Pure Esophageal atresia Pure Esophageal atresia
Long gap, gastrostomy, Long gap, gastrostomy, esophagostomyesophagostomy
Common typeCommon type
type A, B, C type A, B, C H fistula H fistula
Duodenal obstruction Duodenal obstruction
Duodenal atresia Duodenal atresia Duodenal web Duodenal web Duodenal stenosis Duodenal stenosis Annular pancreas Annular pancreas Midgut volvulus Midgut volvulus
Duodenal obstructionDuodenal obstruction Poly hydramniosPoly hydramnios Prematurity Prematurity Downs syndrome (30%)Downs syndrome (30%) Pre duodenal portal vein Pre duodenal portal vein Double bubble signDouble bubble sign Upper GI study Upper GI study
Treatment Treatment Resuscitation Resuscitation Surgery Surgery
Doudeno-doudenostomy Doudeno-doudenostomy
doudeno-jejenostomydoudeno-jejenostomy Antibiotics Antibiotics
Small bowel atresia Small bowel atresia Jejunal atresia Jejunal atresia Ileal atresia Ileal atresia Types I mucosal Types I mucosal Types II atresia without mesentric gap Types II atresia without mesentric gap Types III a atresia with mesentric gap Types III a atresia with mesentric gap
Types III b apple peel deformity Types III b apple peel deformity Types IV multiple Types IV multiple
Meconium ileus Meconium ileus Hereditary (autosomal recessive )Hereditary (autosomal recessive ) Previous history Previous history Calcification Calcification Meconial cystic mass Meconial cystic mass No air fluid level up to 24-48hNo air fluid level up to 24-48h Abdominal protrusion Abdominal protrusion Soap bubble appearance Soap bubble appearance No meconium passing No meconium passing
Hirschsprung’s disease Hirschsprung’s disease 1/5000 live birth1/5000 live birth 80% in boys 80% in boys Mostly in left colon Mostly in left colon Aganglionosis Aganglionosis Lower GI obstruction Lower GI obstruction Barium enema (microcolon, Barium enema (microcolon,
transitional zone)transitional zone) Colostomy (operation later)Colostomy (operation later)
Midgut volvulus Midgut volvulus Malrotation Malrotation Narrow mesentery Narrow mesentery Healthy neonate Healthy neonate Sudden onset Sudden onset Rapid deterioration Rapid deterioration Metabolic acidosis Metabolic acidosis True emergency True emergency Barium study Barium study
Omphaloecele Omphaloecele Congenital defect in umbilicus Congenital defect in umbilicus Amniotic membrane Amniotic membrane Chromosomal anomalies Chromosomal anomalies GI anomaly (less common)GI anomaly (less common) Umblical cord hernia Umblical cord hernia Giant omphaloecele Giant omphaloecele Hypothermia Hypothermia
OmphaloeceleOmphaloecele Small surgery Small surgery Large silo reduction, mercurochrome, Large silo reduction, mercurochrome,
surgery surgery
Gastroschisis Gastroschisis True emergency True emergency Defect in right side of umblicus Defect in right side of umblicus More GI anomaly More GI anomaly Hypothermia Hypothermia No sac (amniotic membrane) No sac (amniotic membrane)
Intussusception Intussusception Telescopic invaginationTelescopic invagination Below 2 years old (9-12m) Below 2 years old (9-12m) Unknown etiology (90%)Unknown etiology (90%) 10% lead point 10% lead point Lymphiod hyperplasia Lymphiod hyperplasia More after URI More after URI
Symptoms and signs Symptoms and signs Vomiting Vomiting Colicky abdominal pain Colicky abdominal pain Pallor Pallor Abdominal mass Abdominal mass Currant jelly stool Currant jelly stool RectorrhagiaRectorrhagia Intestinal obstruction Intestinal obstruction
Treatment of Treatment of Intussusception Intussusception
Wind colicWind colic Gastroenteritis Gastroenteritis Enema (barium, air, saline)Enema (barium, air, saline) Surgery Surgery
Meckel’s diverticula Meckel’s diverticula Complete diverticula Complete diverticula
(30cm-1m) (30cm-1m) Band Band Cyst Cyst Patent omphalo mesentric duct Patent omphalo mesentric duct
Meckel’s diverticula Meckel’s diverticula complications complications
Diverticula Diverticula
diveticulitis, bleedingdiveticulitis, bleeding Band internal hernia Band internal hernia Cyst infection Cyst infection Patent omphalomesentric duct Patent omphalomesentric duct
fistula fistula
Congenital Hypertrophic Congenital Hypertrophic pyloric stenosis pyloric stenosis
1/450 live birth1/450 live birth 85% boys 85% boys Unknown Unknown 2-4 weeks after birth 2-4 weeks after birth 20% familial history 20% familial history
Congenital Hypertrophic Congenital Hypertrophic pyloric stenosispyloric stenosis
Non bilious vomiting Non bilious vomiting Projectile vomitingProjectile vomiting Gastric pristalsis Gastric pristalsis Coffee ground material Coffee ground material Olive mass Olive mass Infrequent stool Infrequent stool Metabolic alkalosis Metabolic alkalosis
Congenital Hypertrophic Congenital Hypertrophic pyloric stenosispyloric stenosis
Treatment Treatment
Fluid and electrolyte correction Fluid and electrolyte correction
Pyloromyotomy Pyloromyotomy
Imperforate anus Imperforate anus Low type Low type Intermadiate type Intermadiate type High typeHigh type Intestinal obstruction Intestinal obstruction VACTERL anomaly VACTERL anomaly Anoplasty Anoplasty Colostomy Colostomy
Acute appendicitisAcute appendicitisAnatomy Anatomy
IntrapelvicIntrapelvic retrocecalretrocecalretroileal retroileal retrosical retrosical
intraperitunealintraperituneal Cause Cause
obstructionobstructionworm in fes. worm in fes. vegetable seeds vegetable seeds
tumorstumors
PathologyPathologyobstructionobstruction
increased intraluminal pressure increased intraluminal pressure
over growth of organismover growth of organism
Stage of inflammationStage of inflammationearly inflammed early inflammed
supporative supporative
gangrenousgangrenous
perforatedperforated
Complication Complication
Complications Complications
peritonitisperitonitis
intraperituneal abcess intraperituneal abcess
portal phlebitis portal phlebitis
Appendicular mass Appendicular mass
Phlegmon (plastrum)Phlegmon (plastrum)
diagnosis diagnosis
treatment treatment
conseravativeconseravative
surgery surgery
Inguinal hernea Inguinal hernea AnatomyAnatomy
Patent processuse vaginalis Patent processuse vaginalis
Incidence Incidence premature premature
termterm DiagnosisDiagnosis
Bulging Bulging Silk glove sign Silk glove sign
Cord thickeningCord thickening
Inguineal hernia (complications)Inguineal hernia (complications)
Incarceration Incarceration
Strangulation Strangulation
Testis and ovary necrosis Testis and ovary necrosis
Intestinal obstruction Intestinal obstruction
Undescended testis Undescended testis
Definition Definition Incidence Incidence
Premature Premature TermTerm
Types Types Intra abdominal Intra abdominal intra canalicular intra canalicular high scrotalhigh scrotal
ectopicectopic
Undescended testisUndescended testis
Age of operation Age of operation
Complications Complications tursion tursion
trauma trauma
infertility infertility
malignancymalignancy
ConstipationConstipation
Definition Definition
Causes Causes functional functional
Hirschsprong’s disease Hirschsprong’s disease
dietarydietary
neuronal dysplasia neuronal dysplasia
Functional constipation Functional constipation
Age Age
CausesCausesHard stool Hard stool
FissureFissure
Symtoms Symtoms
Behavior Behavior
Functional constipation Functional constipation
Treatment Treatment
Conservative Conservative Diet Diet
Stool softenerStool softener
OperativeOperativePosterior myectomy Posterior myectomy
Diaphragmatic herniaDiaphragmatic hernia
Respiratory distressRespiratory distress Increased A-P chest diameterIncreased A-P chest diameter Scaphoid abdomenScaphoid abdomen Abnormal chest X-RayAbnormal chest X-Ray
Gastric volvulusGastric volvulus
Rare in childrenRare in children 51% <1 year51% <1 year 26% <1 month26% <1 month Organoaxial or mesentroaxialOrganoaxial or mesentroaxial
Heyperthrophic pyloric stenosisHeyperthrophic pyloric stenosis
Hypertrophic pyloric stenosis: Hypertrophic pyloric stenosis: incidence and pathogenesisincidence and pathogenesisAn acquired condition; tends to have An acquired condition; tends to have familial predisposition. familial predisposition. Male:Female 4-6:1 Male:Female 4-6:1 Hypertrophy of pyloric muscle leads Hypertrophy of pyloric muscle leads to obstruction of the lumen to obstruction of the lumen Cause of hypertrophy not known, but Cause of hypertrophy not known, but excessive activity of nitric oxide excessive activity of nitric oxide neuronsneurons is likely is likely
Pyloric stenosis: clinicalPyloric stenosis: clinical Peak incidence 3-10 weeks of age Peak incidence 3-10 weeks of age Progressive, non-bilious vomiting Progressive, non-bilious vomiting Dehydration Dehydration Loss of HCl leads to Loss of HCl leads to
hypochloremic alkalosis hypochloremic alkalosis Pyloric mass “olive” is palpable Pyloric mass “olive” is palpable
in 80% with careful examin 80% with careful exam
How to feel the oliveHow to feel the olive Child must have an empty stomach Child must have an empty stomach
– examine immediately after vomiting, or examine immediately after vomiting, or – empty stomach with 10 Fr tube empty stomach with 10 Fr tube
Easiest when child is calm Easiest when child is calm Palpate gently, with a sliding Palpate gently, with a sliding
motion, in mid-epigastrium, motion, in mid-epigastrium, allowing underlying tissues to roll allowing underlying tissues to roll beneath fingersbeneath fingers
Duodenal stenosisDuodenal stenosis
Birth injuriesBirth injuries
HeadHead Cephale hematoma,caput succedaneumCephale hematoma,caput succedaneum Intraventricular hemorrhageIntraventricular hemorrhage Subdural hematomaSubdural hematoma LimbLimb Clavicle Fx,humerus,femor Fx Clavicle Fx,humerus,femor Fx Nerve injuriesNerve injuries Erb palsy,facial palsyErb palsy,facial palsy Visceral injury (spleen,liver)Visceral injury (spleen,liver)
Vomiting in first week of lifeVomiting in first week of life
Mecanical intestinal obs.Mecanical intestinal obs.
Cerebral birth injuryCerebral birth injury
InfectionsInfections
Functional intestinal obstractionsFunctional intestinal obstractions
GERDGERD
Mecanical intestinal obstructionsMecanical intestinal obstructions
Duodenal atresiaDuodenal atresia Jujeno ileal atresiaJujeno ileal atresia MalrotationMalrotation Meconium ileusMeconium ileus Hirschsprung’s diseaseHirschsprung’s disease Small left colon syndromSmall left colon syndrom Meconium plug syndronmMeconium plug syndronm Imperforate anusImperforate anus
Imperforate anusImperforate anus
Low typeLow type Covered anus,ectopic anus,prineal fistulaCovered anus,ectopic anus,prineal fistula Intermediate typeIntermediate type Anorectal Anorectal
stenosis,rectovaginal&rectourethral fistulastenosis,rectovaginal&rectourethral fistula High type High type
Respiratory problem in newbornRespiratory problem in newborn
Upper obstructionUpper obstruction Micrognethia,choanal atresiaMicrognethia,choanal atresia Congenital laryngeal stridorCongenital laryngeal stridor Sub glotic stenosisSub glotic stenosis Intra thorasic conditionsIntra thorasic conditions esophageal atresiaesophageal atresia Tension syndrom(diphragmatic hernia,lung Tension syndrom(diphragmatic hernia,lung
cyst,lubar emphysema,CHD,vascular ring)cyst,lubar emphysema,CHD,vascular ring)
HerniasHernias InguinalInguinal
Premature neonate>Premature neonate>25%25%
Rt >LtRt >Lt 1/50 boys,1/500 girls1/50 boys,1/500 girls
SignificanceSignificance
obstraction of the bowelobstraction of the bowel Symptoms Symptoms
inguinal bulginginguinal bulging
silk glove singsilk glove sing
Cord thickeningCord thickening
Parents historyParents history
Time of oprationsTime of oprations
Early after diagnosisEarly after diagnosis
Even in prematureEven in premature
ComplicationsComplications
IncarcerationIncarceration
StrangulationStrangulation
TreatmentTreatment
ReductionReduction
oprationopration
Omphalocele(exomphalos)Omphalocele(exomphalos)
Abnormal abdominal wall Abnormal abdominal wall constructionconstruction
Early in gestational ageEarly in gestational age Other congenital or chorosomal Other congenital or chorosomal
abnormalityabnormality Emergency situationEmergency situation
GastroschasisGastroschasis
Congenital hernia of the gutCongenital hernia of the gut
Through the opening of abdominal wallThrough the opening of abdominal wall Late in gestational ageLate in gestational age Rupture of Rt umblical veinRupture of Rt umblical vein No suc or membraneNo suc or membrane GI atresiaGI atresia No other congenital abnormalityNo other congenital abnormality
ConstipationConstipation
2 or 3 times defecation per week2 or 3 times defecation per week Hard stoolHard stool Painful defecationPainful defecation CausesCauses
functional constipationfunctional constipation
anal stenosis or ectopic anusanal stenosis or ectopic anus
hirschsprung’s diseasehirschsprung’s disease
INDIND
Functional constipationFunctional constipation
Late onsetLate onset Absence of previous historyAbsence of previous history Full rectumFull rectum SoilageSoilage FissureFissure Abdominal mass (feces)Abdominal mass (feces) Fear of defecationFear of defecation
Genital anomaliesGenital anomalies
HypospediasHypospedias
failure of forming anterior urethrafailure of forming anterior urethra
abnormal prepuceabnormal prepuce
Glandular,penial,penoscrotal,perinalGlandular,penial,penoscrotal,perinal
Opration 3-4 years oldOpration 3-4 years old
Head and neck diseaseHead and neck disease
Cystic hygromaCystic hygroma Branchial cyst and sinusBranchial cyst and sinus Thyroglossal cystThyroglossal cyst Tongue tieTongue tie
Umbilical&femoral herniaUmbilical&femoral hernia
Time of oprationTime of opration
ObservationObservation
Scurotal swellingsScurotal swellings
HerniaHernia HydroceleHydrocele Cord hydroceleCord hydrocele Torsion of testisTorsion of testis Epididym orchitisEpididym orchitis Tumor of testisTumor of testis
Rectal bleeding & problemsRectal bleeding & problems
Anal fissureAnal fissure Rectal prolapsRectal prolaps Rectal polypRectal polyp Meckel’s diverticulumMeckel’s diverticulum Blood dyscrasiaBlood dyscrasia
Umbilical problemsUmbilical problems
Umbilical herniaUmbilical hernia Paraumbilical herniaParaumbilical hernia Umbilical granulomaUmbilical granuloma Umbilical sinusUmbilical sinus Umbilical polypUmbilical polyp Ectopic tissueEctopic tissue Patent urachusPatent urachus
Undesnded testisUndesnded testis
ClassificationClassification
DiagnosisDiagnosis
Diffrentional diagnosis Diffrentional diagnosis
Time of oprationTime of opration
Esophageal atresia and Esophageal atresia and tracheoesophageal fistulatracheoesophageal fistula
Ali. Bahador M.DAli. Bahador M.D
Namaze hospital Namaze hospital
Shiraz IRANShiraz IRAN
Esophageal atresiaEsophageal atresia
Anatomic variations Anatomic variations A.A. Common type 85% (distal fistula) Common type 85% (distal fistula)
B.B. Atresia alone no fistula 6%Atresia alone no fistula 6%
C.C. Proximal fistula no distal fistula 2%Proximal fistula no distal fistula 2%
D.D. Proximal and distal fistula 1%Proximal and distal fistula 1%
E.E. No atresia with tracheoesophageal No atresia with tracheoesophageal fistula H or N fistula 6%fistula H or N fistula 6%
Esophageal atresiaEsophageal atresiaDiagnosis Diagnosis Antenatal US shows maternal polyhydraminos, small Antenatal US shows maternal polyhydraminos, small
stomach, distended upper esophageal pouch, stomach, distended upper esophageal pouch, abnormal swallowing, associated anomaliesabnormal swallowing, associated anomalies
Clinical diagnosis Clinical diagnosis excessively drooling, syanosis, respiratory infection, excessively drooling, syanosis, respiratory infection, chokingchoking
passing OG tube > 10 French passing OG tube > 10 French rarely Ba. Study is needed rarely Ba. Study is needed gasless obdomengasless obdomen
Recurrent respiratory infection, cough during eating, Recurrent respiratory infection, cough during eating, choke, abdominal distention, H fistula, at age of choke, abdominal distention, H fistula, at age of more than 3 monthsmore than 3 months
Esophageal atresiaEsophageal atresia Associated anomalies Associated anomalies
VACTERL VACTERL
trisomy 18 and 21 trisomy 18 and 21 7%7%
CHDCHD 25 25 Urinary tract Urinary tract 2222 Vertebral anomaly Vertebral anomaly 1515 GI anomaly GI anomaly 2222 CHARGE 2% (Colobomata, Heart mal. CHARGE 2% (Colobomata, Heart mal.
Choanal atresia, Retardation, Genital Choanal atresia, Retardation, Genital hypoplasia, Ear anomalies) hypoplasia, Ear anomalies)
Management of Management of Esophageal atresiaEsophageal atresia
Initial management Initial management prevent prevent hypotermia hypotermia wraping, wraping, warmer warmer
asphyexia asphyexia tube in upper tube in upper pouch pouch
aspiration pneumoniaaspiration pneumoniagastrostomy gastrostomy
hypoxiahypoxia oxygenation oxygenation
Operative Management of Operative Management of Esophageal atresiaEsophageal atresia
Waterstone classification Waterstone classification
A. normal wt. , no pneumonia, no major A. normal wt. , no pneumonia, no major anomalyanomaly
early surgical treatment early surgical treatment
B. severe pneumonia B. severe pneumonia
gastrostomy, jejunostomy, antibiotics gastrostomy, jejunostomy, antibiotics
delay operation delay operation
C. low wt. , major anomaly, pneumonia C. low wt. , major anomaly, pneumonia
staged operation staged operation
Operative Management of Operative Management of Esophageal atresiaEsophageal atresia
Esophageal atresia without Esophageal atresia without fistula fistula
gastrostomy for feeding gastrostomy for feeding
esophageal substitute esophageal substitute Right thoracotomy Right thoracotomy
division of fistula division of fistula
release of upper pouch release of upper pouch
end to end anastomosis end to end anastomosis
Complications Complications Anastomotic Leakage Anastomotic Leakage
fever, sepsis, pleural effusionfever, sepsis, pleural effusion
Ba. StudyBa. Study Anostomotic stricture Anostomotic stricture
Dilation, check for GERD Dilation, check for GERD
revision if neededrevision if needed GERD GERD
common finding needs medical common finding needs medical treatment treatment
no responsive needs surgeryno responsive needs surgery
ComplicationsComplications Recurrence of fistula Recurrence of fistula
cough during feeding, aspiration, cough during feeding, aspiration, chokingchoking Tracheo-bronchial malacia Tracheo-bronchial malacia
Rule out vascular ring, GERD Rule out vascular ring, GERD tachypnia, cyanosis, choking, feeding tachypnia, cyanosis, choking, feeding difficulties difficulties treatment: observation treatment: observation aortopexy aortopexy tracheostomytracheostomystentstent
H. Fistula H. Fistula Different clinical spectrum from Different clinical spectrum from
eso. Atrasia (cyanotic attacks, eso. Atrasia (cyanotic attacks, aspiration pneumonia, abdominal aspiration pneumonia, abdominal distention, distention,
At level TAt level T11 to T to T33 or higher or higher Bronchoscopy, esophagoscopy, Bronchoscopy, esophagoscopy,
Barium study, with fluoroscopy, Barium study, with fluoroscopy, CT Scan CT Scan
Cervical approch Cervical approch
Tracheal anomalies Tracheal anomalies Congenital tracheal stenosisCongenital tracheal stenosis
(complete tracheal rings) (complete tracheal rings) in trachea or bronchus or both in trachea or bronchus or both > 50% segmental stenosis > 50% segmental stenosis severe respiratory distress to severe respiratory distress to
subtle subtle symptoms, stridor, cough, symptoms, stridor, cough, altrations altrations of cry, wheezing of cry, wheezing rhonchi, respiratory rhonchi, respiratory distress or distress or sudden death. sudden death.
Tracheal anomaliesTracheal anomaliesAssociate anomaly:Associate anomaly: esophageal, esophageal,
cardiac, skeletal, GU. 50% vascular cardiac, skeletal, GU. 50% vascular ring (Echo. Angiography) ring (Echo. Angiography)
DiagnosisDiagnosis Contrast study Contrast study
endoscope endoscope
AP radiography an fluoroscopy AP radiography an fluoroscopy
CT Scan (more precise) 3D image construction CT Scan (more precise) 3D image construction MRIMRI
Tracheal anomaliesTracheal anomaliesTreatment Treatment Tracheal resection Tracheal resection less than five less than five
rings rings Patch tracheoplasty Patch tracheoplasty (cartilage (cartilage
dura pericardium dura pericardium Slide tracheoplasty Slide tracheoplasty (choice (choice
procedure)procedure)
Balloon dilatation Balloon dilatation
Tracheal anomaliesTracheal anomaliesTrachemoalacia and Trachemoalacia and
bronchomalaciabronchomalacia weakening of trachea or bronchi weakening of trachea or bronchi no sufficient rigidity, localized or no sufficient rigidity, localized or diffusediffuse
CausesCauses Extrinsic pressure, vascular Extrinsic pressure, vascular
rings, rings, unknown, eso. Atresia, unknown, eso. Atresia, mediastinal mediastinal mass, prolonged mass, prolonged intubation, intubation, interstitial long diseaseinterstitial long disease
Tracheal anomaliesTracheal anomaliesDiagnostic evaluation Diagnostic evaluation
AP. RadiographyAP. Radiography
cinefluoroscopy cinefluoroscopy
bronchoscopy best method with bronchoscopy best method with spontaneous breathing spontaneous breathing
Ba. Study, angiography for Ba. Study, angiography for vascular vascular rings rings
Tracheal anomaliesTracheal anomaliesTreatmentTreatment
observationobservation
trachael suspension trachael suspension (aortopexy) (aortopexy)
stent stent
Hemangiomas of trachea Hemangiomas of trachea
Symptoms and signs Symptoms and signs Stridor, airway obstruction Stridor, airway obstruction
subglotic locations most subglotic locations most common common
first 6 months first 6 months
50% cutaneous hemangiomas 50% cutaneous hemangiomas
F > M (2 times)F > M (2 times)
Hemangiomas of tracheaHemangiomas of trachea Diagnosis Diagnosis
broncoscopy broncoscopy biopsy is dangerous biopsy is dangerous
Treatment Treatment observation (tracheotomy may observation (tracheotomy may
needed) needed) steroids (systemic, intralesional)steroids (systemic, intralesional)laser ablation laser ablation scloresing agentsscloresing agentsembolization embolization interfron alfa2a interfron alfa2a surgery surgery
Tracheal anomaliesTracheal anomalies Esophageal bronchus Esophageal bronchus
recurrent pulmonary infection recurrent pulmonary infection collapsed, infiltration of lung, collapsed, infiltration of lung,
cavtation, cavtation, cystformationcystformation
abnormal arterial and venous supplyabnormal arterial and venous supply Tracheobronchial biliary fistula Tracheobronchial biliary fistula
bile stained sputum bile stained sputum
Tracheal webs Tracheal webs Bronchial atresia Bronchial atresia Bronchial stenosis (acquired) Bronchial stenosis (acquired)
Undescended Undescended testistestis
Ali Bahador M.DAli Bahador M.D
Pediatric surgery ward Pediatric surgery ward
Shiraz IRANShiraz IRAN
Impalpable testisImpalpable testis24% of UDT24% of UDT39% distal to the ring 39% distal to the ring 41% atrophic or absent 41% atrophic or absent 20% intra abdominal 20% intra abdominal
Ectopic testis Ectopic testis perineal perineal upper thighupper thighfemoral femoral cross ectopiacross ectopia
Intra abdominal Intra abdominal AnorchiaAnorchia
unilateralunilateralbilateral bilateral
Diagnostic tests Diagnostic tests
Exam: warm room, warm hand, Exam: warm room, warm hand, not be hurried, cross legged not be hurried, cross legged position, to hand exam. position, to hand exam.
Diff. diag: retractile testis Diff. diag: retractile testis
pressure on femoral artery pressure on femoral artery
exam exam
Diagnostic test Diagnostic test
Ultra sonography Ultra sonography
frequent used frequent used
high rate of misdiagnosis high rate of misdiagnosis
US positive or negative needs US positive or negative needs surgery surgery
unuseful in most cases unuseful in most cases
US after complete exam.US after complete exam.
Diagnostic testDiagnostic test CT Scan CT Scan
more accurate but not 100%more accurate but not 100% MRI MRI
selected cases (obese child)selected cases (obese child)
routine radiologic evaluation not routine radiologic evaluation not suffiently accurate not cost justifiable suffiently accurate not cost justifiable
Laparoscopy Laparoscopy
selective in certain casesselective in certain cases
Orchiopexy Methods Orchiopexy Methods Routine orchiopexy Routine orchiopexy Fowler – stephen’s method Fowler – stephen’s method
one stage one stage two stage two stage
Staged orchiopexy Staged orchiopexy Microvascular orchiopexy (auto Microvascular orchiopexy (auto
transplantation) transplantation) Laparoscopic (fowler - stephen’s) Laparoscopic (fowler - stephen’s)
one stage one stage two stage two stage
Unilateral impalpable testisUnilateral impalpable testis Inguinal approch Inguinal approch Testis & peritoneal tongue present Testis & peritoneal tongue present
no internal ring is opened no internal ring is opened (most cases)(most cases)
No testis, no small tongue of No testis, no small tongue of peritoneum internal ring is opened, peritoneum internal ring is opened, intra peritoneal exploration intra peritoneal exploration
Traction on testis to evaluate the Traction on testis to evaluate the type of orchiopexy type of orchiopexy
Unilateral impalpable testis Unilateral impalpable testis Standard incision Standard incision Lateral extension (Larok maneuver) Lateral extension (Larok maneuver)
Good mobilization Good mobilization Possible orchiopexy almost in all Possible orchiopexy almost in all
casescases No laparoscopy is needed No laparoscopy is needed If other testis is normal, too short If other testis is normal, too short
vessels one stage fowler - vessels one stage fowler - stephen’s procedurestephen’s procedure
Bilateral impalpable testisBilateral impalpable testis Inguinal explorationInguinal exploration
midline trans or pre peritoneal midline trans or pre peritoneal approach, rectus transection, new approach, rectus transection, new internal ring, trans peritoneal internal ring, trans peritoneal exploration exploration
Rationale for primary laparoscopyRationale for primary laparoscopy one side fowler - stephen’s procedureone side fowler - stephen’s procedureother side delayed operation other side delayed operation both side staged operation both side staged operation fowler – stephen’s or staged fowler – stephen’s or staged operation operation
Bilateral impalpable testisBilateral impalpable testis Laparoscopy Laparoscopy
testis within 2.5cm of internal ring able testis within 2.5cm of internal ring able to mobilize in scrotom without vascular to mobilize in scrotom without vascular ligation ligation
Older boy better than small Older boy better than small Two high intra abdominal testes need Two high intra abdominal testes need
primary clipping then staged orchiopexy primary clipping then staged orchiopexy (open or laparoscopic)(open or laparoscopic)
One intra abdominal testis needs One intra abdominal testis needs laparoscopic or microvascular orchiopexy laparoscopic or microvascular orchiopexy
Vanishing testis Vanishing testis Spermatic blind end vessels (sine qua Spermatic blind end vessels (sine qua
non) non) Spermatic goes up, surgical point, Spermatic goes up, surgical point,
end of operation end of operation vasal artery followed the vas, vasal artery followed the vas,
continue the operation (divergence) continue the operation (divergence) Blind end vas, continue the operation Blind end vas, continue the operation Blind end of vessels shows Blind end of vessels shows
calcification, hemosiderosis, calcification, hemosiderosis, hyalinised tissuehyalinised tissue
Impalpable testis Impalpable testis 432 cases432 cases
LaparoscopyLaparoscopy
Help full in 10% Help full in 10% If is with treatment may help full If is with treatment may help full
in 27% in 27% Help full in reoperative casesHelp full in reoperative cases ExperiencesExperiences Need of prosthesisNeed of prosthesis Success 89% one stage Success 89% one stage
95% two stage95% two stage
Laparoscopic for Laparoscopic for Undescended testisUndescended testis
20% impalpable (1/4 1/3 intra abdominal)20% impalpable (1/4 1/3 intra abdominal) Minor complication 4% Minor complication 4% Major complication 1% Major complication 1% Selective or routine? Selective or routine? Routine use for diagnosis is not warranted Routine use for diagnosis is not warranted
Unless diagnosis an treatment as well Unless diagnosis an treatment as well Selective: not cost effective or patient Selective: not cost effective or patient
friendly, many an necessary laparoscopy, friendly, many an necessary laparoscopy, routine ing. exploration provide the same routine ing. exploration provide the same resultresult
Fowler – stephen’s method Fowler – stephen’s method
InguinalInguinal LaparoscopicLaparoscopic Bevan 1903Bevan 1903
fowler – stephen’s 1959 vascular fowler – stephen’s 1959 vascular anatomy anatomy
Brendler & wolfson high ligation Brendler & wolfson high ligation Clatworthy epigastric vessels Clatworthy epigastric vessels
and floor of canal be left intactand floor of canal be left intact
Fowler – stephen’s methodFowler – stephen’s method
Leave medial peritoneal strip to Leave medial peritoneal strip to attach the vas attach the vas
Not a salvage procedure Not a salvage procedure High lagating of the vessels High lagating of the vessels No injury to the vasal arteryNo injury to the vasal artery
No Fowler – stephen’s No Fowler – stephen’s method method
Short vas Short vas Hypoplastic testis Hypoplastic testis Segmental vas atresia Segmental vas atresia None attached epididymis None attached epididymis Un certain blood suplly Un certain blood suplly
Atrophy 20% in one stage Atrophy 20% in one stage
10% in two stage10% in two stage
Microvascular orchiopexy Microvascular orchiopexy
Donor inferior epigastric vessels Donor inferior epigastric vessels High transection of spermatic High transection of spermatic
vessels vessels Absolute invecation: solitary Absolute invecation: solitary
intra abdominal testis, intra abdominal testis, contralateral atrophy after contralateral atrophy after orchiopexy orchiopexy
Success 55-100% (80%)Success 55-100% (80%)
Staged orchiopexy Staged orchiopexy
In two stages In two stages First stage testis fixed with non First stage testis fixed with non
absorbable suture absorbable suture Two stage 4-6% Two stage 4-6% When no other procedures are When no other procedures are
appropriate success 82-90%appropriate success 82-90% 195 cases 18 cases performed staged 195 cases 18 cases performed staged
orchiopexyorchiopexy 2/18 (11.1%) showed 2/18 (11.1%) showed atrophy follow up 9m. – 3yrs atrophy follow up 9m. – 3yrs
Principle of orchiopexy Principle of orchiopexy
Unilatral inguinal approch Unilatral inguinal approch Bilatral laparoscopy or inguinal Bilatral laparoscopy or inguinal
approch approch Anorchia, HCG test Anorchia, HCG test
high LH, FSH, positive HCG testhigh LH, FSH, positive HCG test
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