Acquired surgical abnormalities

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Acquired surgical abnormalities

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Acquired surgical abnormalities

• Pyloric stenosis
• Intussusception
• Undescended Testes
• Meckel's diverticulum
• Testicular Torsion
• Hypospadias

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Key points

• Symptoms suggestive
• of surgical disease
• Diagnosis and treatment
• The operative approach
• for common surgical
• problem

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Pyloric stenosis
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Pyloric stenosis Definition
  Pyloric stenosis refers to a narrowing of
the passage between the stomach and the small
intestine. The condition, which affects infants
during the first several weeks of life, can be
corrected effectively with surgery
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Pyloric stenosis Description

• Infantile hypertrophic pyloric stenosis (IHPS) is
  a common cause of gastric outlet obstruction in
  infants
• The prevalance of IHPS ranges from 1.5 to 4.0 in
  1000 live births among Whites but is less
  prevalent in African-Americans and Asians  

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Pyloric stenosis Description

• The occurrence of IHPS has been associated with
  several variables, including both environmental
  and familial factors
• The cause of IHPS is now thought to be by a
  mechanism other than a developmental defect

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Pyloric stenosis Description
  The appearance of the pylorus in IHPS is that
of an enlarged, pale muscle mass usually
measuring 2 to 2.5 cm in length and 1 to 1.5 cm
in diameter.
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Pyloric stenosis Description
  Histologically the mucosa and adventitia are
normal. There is marked muscle hypertrophy
primarily involving the circular layer, which
produces partial or complete luminal occlusion
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Pyloric stenosis Description
  There is evidence of a genetic
predisposition to the development of IHPS. In
addition to the variability among races and the
clear male predominance, there appears to be an
increased risk to first-born infants with a
positive family history and certain ABO blood
types .
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Pyloric stenosis symptoms

• The typical presentation of an infant with IHPS
  is the onset of nonbilious vomiting at 2 to 8
  weeks of age with a peak occurrence at 3 to 5
  weeks of age.
• Initially the vomiting may not be frequent or
  forceful, but over several days it progresses to
  nearly every feeding and becomes forceful
  (projectile).

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Pyloric stenosis symptoms

• On occasion, there may be blood in the emesis
  appearing as a brownish discoloration or as a
  coffee-ground appearance as a result of gastritis
  or esophagitis
• Infant with IHPS remain hungry after vomiting and
  are otherwise not ill-appearing or febrile

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Pyloric stenosis symptoms

• A significant delay in diagnosis leading to
  severe dehydration, however, results in a
  lethargic infant
• Some infants have diarrhea (starvation stools)
  and are thought to have gastroenteritis

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Pyloric stenosis Symptoms

• Approximately 2 to 5 of infants have jaundice
  associated with indirect hyper-bilirubinemia.
  This is believed to be secondary to glucuronyl
  transferase deficiency

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Pyloric stenosis Diagnosis

• Cardinal features of IHPS
• No bilious projectile vomiting
• Visible peristaltic waves in the left upper
  abdomen
• Hypochloremic, hypokalemic metabolic alkalosis

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Pyloric stenosis Diagnosis
Ultrasonography has become the most common
imaging technique for the diagnosis of IHPS under
optimal circumstances, this technique can be
reliable.
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Pyloric stenosis Diagnosis

• The most commonly used criteria for a positive
  ultrasound study
• a pyloric muscle thickness of 4 mm or more
• a pyloric channel length of 16 mm or more

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Pyloric stenosis Diagnosis
A barium upper gastrointestinal (UGI)
examination is highly effective in making the
diagnosis of IHPS and should demonstrate an
elongated pyloric channel and indentation on the
antral outline, which are indirect findings of
pyloric muscle enlargement .
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Pyloric stenosis Treatment
Pyloric stenosis can be cured with a surgical
procedure called a pyloromyotomy.
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INTUSSUSCEPTION
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INTUSSUSCEPTIONDEFINITION

• Telescoping of a proximal segment of the
  intestine (intussusceptum) into a distal segment
  (intussuscipiens)

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INTUSSUSCEPTION EPIDEMIOLOGY

• Incidence 2 - 4 / 1000 live births
• Usual age group 3 months - 3 years
• Greatest incidence 6-12 months
• Male predominance (1.5-2 1)
• No clear hereditary association
• No seasonal distribution
• Frequently preceded by viral infection
• URI, ADENOVIRUS

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INTUSSUSCEPTIONPATHOPHYSIOLOGY

• Precipitating mechanism unknown
• Obstruction of intussusceptum mesentery
• Venous and lymphatic obstruction
• Third spacing of fluid into bowel wall
• Ischemic necrosis occurs in both intussusceptum
  and intussuscipiens
• Pathologic bacterial translocation

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INTUSSUSCEPTIONCLINICAL CHARACTERISTICS

• Early Symptoms
• PAROXYSMAL ABDOMINAL PAIN
• SEPARATED BY PERIODS OF APATHY
• POOR FEEDING AND VOMITING
• Late Symptoms
• WORSENING VOMITING, BECOMING BILIOUS
• ABDOMINAL DISTENTION
• HEME POSITIVE STOOLS
• FOLLOWED BY CURRANT JELLY STOOL
• DEHYDRATION (PROGRESSIVE)
• Unusual Symptoms
• DIARRHEA

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INTUSSUSCEPTION PHYSICAL EVALUATION

• Moderately to severely ill
• Irritable, limited movement
• Most are at least 5-10 dehydrated
• 80 have palpable abdominal masses
• Paucity of bowel sounds
• Rectal examination (blood, mass)
• Abdominal rigidity, poor perfusion
• Knocked Out syndrome

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INTUSSUSCEPTION RADIOGRAPHIC EVALUATION

• Plain radiographs (acute abdominal series)
• Plain films suggestive in majority, but cannot
  rule out diagnosis
• PAUCITY OF LUMINAL AIR IN RLQ
• SMALL BOWEL DISTENTION, AIR FLUID LEVELS
• LUMINAL AIR CUTOFFS (CECUM, TRANSVERSE COLON)
• SOFT TISSUE MASS IN RUQ OR MIDABDOMEN
• Suggestive clinical symptoms and compatible or
  nonspecific plain films should undergo evaluation
  with air or barium enema

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INTUSSUSCEPTION TREATMENT

• Obstructive surgical emergency
• Pediatric surgeon notified immediately
• Supportive Therapy
• INITIATE IV ACCESS
• AGGRESSIVE FLUID RESUSCITATION
• CBC, ELECTROLYTES, COAGS TYPE CROSS
• NASOGASTRIC TUBE PLACEMENT AND DRAINAGE
• ANTIBIOTICS IF ISCHEMIC BOWEL SUSPECTED
• Arrange radiographic evaluation
• Physician should accompany patient
• FREQUENT MONITORING OF FLUID STATUS

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INTUSSUSCEPTION REDUCTION

• Radiographic
• HYDROSTATIC
• (BARIUM, WATER SOLUBLE CONTRAST)
• Operative
• MANUAL
• RESECTION AND REANASTAMOSIS

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INTUSSUSCEPTIONPNEUMATIC REDUCTION

• Theoretical Advantages
• LESS INFLAMMATION IF PERFORATION OCCURS
• Method
• TIGHT ANAL SEAL
• AIR INSUFFLATION LIMITED TO MAXIMUM RESTING
  PRESSURE OF 120 mmHg
• MAXIMUM PRESSURE MAINTAINED FOR 3 MIN
• USUALLY 3 ATTEMPTS AT REDUCTION
• Success Rate (75-90)
• MUST OBSERVE AIR IN THE TERMINAL ILEUM
• LESS RECURRENCES (5-10)
• LOW PERFORATION RATE (1)

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INTUSSUSCEPTION HYDROSTATIC REDUCTION

• Method
• SEDATION VARIABLE
• DILUTE BARIUM NOT gt 100 cm ABOVE PT
• AVOID COMPRESSION OF ABDOMEN
• Success Rate (65-85)
• INTUSSUSCEPTUM MOVES BACKWARD THROUGH ILEOCECAL
  VALVE
• TERMINAL ILEUM MUST BE FILLED
• PATIENTS SYMPTOMS RESOLVE
• Complication Rate
• PERFORATION IN 1-2
• RECURRENCE IN 8-20

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INTUSSUSCEPTION NON-OPERATIVE REDUCTION
CONTRAINDICATIONS

• Absolute Contraindications
• PERITONEAL SIGNS
• SUSPECTED PERFORATION
• Relative Contraindications
• SYMPTOMS gt 24-48 HRS
• RECTAL BLEEDING
• POOR PROGNOSTIC INDICATORS

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INTUSSUSCEPTION FAILURE OF NON-OPERATIVE REDUCTION

• Factors associated with failure
• SYMPTOMS gt 48 HRS
• RECTAL BLEEDING
• SMALL BOWEL OBSTRUCTION RADIOGRAPHICALLY
• ILEOILEOCOLIC OR SMALL BOWEL TYPES
• PRESENCE OF MECHANICAL LEAD POINT
• AGE lt 3 MONTHS
• Operative Reduction

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INTUSSUSCEPTION POST-REDUCTION TREATMENT

• Admit patient for 24 hours
• May attempt feeding within 12 hrs
• Return to fluoroscopy for suspected recurrence
  (occurs in 4)
• CONSIDER PATHOLOGIC LEAD POINT
• SCHEDULE MECKELS SCAN, ? ABDOMINAL CT
• May also recur up to one year
• Need to follow as outpatient

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Meckel's diverticulum
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Meckel's diverticulum Definition
Meckel's diverticulum is a congenital pouch
(diverticulum) approximately two inches in length
and located at the lower (distal) end of the
small intestine. It was named for Johann F.
Meckel, a German anatomist who first described
the structure.
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Meckel's diverticulum Description
The diverticulum is most easily described as a
blind pouch that is a remnant of the
omphalomesenteric duct or yolk sac that nourished
the early embryo. It contains all layers of the
intestine and may have ectopic tissue present
from either the pancreas or stomach.
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Meckel's diverticulum Description
The rule of 2s is the classical description.
It is located about 2 ft from the end of the
small intestine, is often about 2 in in length,
occurs in about 2 of the population, is twice as
common in males as females, and can contain two
types of ectopic tissue-stomach or pancreas. Many
who have a Meckel's diverticulum never have
trouble but those that do present in the first
two decades of life and often in the first two
years.
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Meckel's diverticulum Description

• Three major complications
• Inflammation or infection
• Bleeding
• Obstruction

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Meckel's diverticulum  Causes and symptoms
Meckel's diverticulum is not hereditary. It is
a vestigial remnant of the omphalomesenteric
duct, an embryonic structure that becomes the
intestine. As such, there is no genetic defect or
abnormality.
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Meckel's diverticulum  Causes and symptoms
Symptoms usually occur in children under 10
years of age. There may be bleeding from the
rectum, pain and vomiting, or simply tiredness
and weakness from unnoticed blood loss.
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Meckel's diverticulum  Causes and symptoms
It is common for a Meckel's diverticulum to be
mistaken for the much more common disease
appendicitis. If there is obstruction, the
abdomen will distend and there will be cramping
pain and vomiting.
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Meckel's diverticulum  Diagnosis
The situation may be so acute that surgery is
needed on an emergency basis. This is often the
case with bowel obstruction. With heavy bleeding
or severe pain, whatever the cause, surgery is
required. The finer points of diagnosis can be
accomplished when the abdomen is open for
inspection during a surgical procedure. This
situation is called an acute abdomen.
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Meckel's diverticulum  Diagnosis
If there is more time (not an emergency
situation), the best way to diagnose Meckel's
diverticulum is with a nuclear scan. A
radioactive isotope injected into the bloodstream
will accumulate at sites of bleeding or in
stomach tissue. If a piece of stomach tissue or a
pool of blood shows up in the lower intestine,
Meckel's diverticulum is indicated.
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Meckel's diverticulum Treatment
A Meckel's diverticulum that is causing
discomfort, bleeding, or obstruction must be
surgically removed. This procedure is very
similar to an appendectomy.
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Meckel's diverticulum  Prognosis
The outcome after surgery is usually excellent.
The source of bleeding, pain, or obstruction is
removed so the symptoms also disappear. A
Meckel's diverticulum will not return.
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Undescended Testes
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Undescended Testes Definition
Also known as cryptorchidism, undescended
testes is a congenital condition characterized by
testicles that do not extend to the scrotum.
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Undescended Testes Description
In the fetus, the testes are in the abdomen.
As development progresses they migrate downward
through the groin and into the scrotum. This
event takes place late in fetal development,
during the eighth month of gestation.
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Undescended Testes Description
Thirty percent of premature boys have testes
that have not yet made the full descent. Only
3-4 of full-term baby boys have undescended
testes, and half of those complete the journey by
the age of three months.
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Undescended Testes Description
Eighty percent of all undescended testes cases
naturally correct themselves during the first
year of life. Undescended testes that are not
corrected can lead to sterility and an increased
risk of testicular cancer.
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Undescended Testes Causes and symptoms
The cause of undescended testes is presently
unknown, however its symptoms are quite apparent.
One or all of the testicles can be undescended,
therefore the testicles appear to be either
missing or lopsided.
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Undescended Testes  Diagnosis
The newborn examination always checks for
testes in the scrotum. It they are not found, a
search will be conducted, but not necessarily
right away. In most cases, the testes will drop
into place later. If the testes are present at
all, they can be anywhere within a couple inches
of the appropriate spot.
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Undescended Testes  Diagnosis
In 5 of cases, one testis is completely
absent. In 10, the condition occurs on both
sides. Presence of undescended testes is
indicated by measuring the amount of gonadotropin
hormone in the blood.
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Undescended Testes Treatment
Once it is determined that the testes will not
naturally descend, surgery becomes necessary. The
procedure is called an orchiopexy and is
relatively simple once the testes are located.
The surgery is usually performed when the boy is
between one to two years old.
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Undescended Testes  Prognosis
Undescended testes must be treated to
eliminate the increased risk of testicular cancer
and the possibility of sterility. Undescended
testes are twice as likely to develop cancer. Ten
percent of all testicular cancers are in
undescended testes.
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Testicular Torsion
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Testicular Torsion Definition
Testicular torsion is the twisting of a testis
(testicle) on its connection.
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Testicular Torsion Description
The testes are suspended in the scrotum by a
single bundle of tissues that also carries the
blood supply to and from the testes. If the
testicle rotates, the bundle kinks, and the blood
supply is shut off. The resulting situation is an
emergency because the testis will die within
hours if the blood supply is not restored.
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Testicular Torsion Causes and symptoms
Some testes hang in such a way that they twist
more easily than others. Nearly all torsions
happen to adolescent males--between the ages of
12 and 18--because their testes enlarge by a
factor of five to six during puberty. A larger
testis is more likely to twist. Torsion can also
occur in a newborn.
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Testicular Torsion Causes and symptoms

• Symptoms of testicular torsion
• Sudden severe pain in the scrotum
• Swelling
• Nausea and vomiting.

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Testicular Torsion  Diagnosis
A nuclear scan of the scrotum may be performed.
In this procedure, a tiny amount of radioactive
fluid is injected into the blood and detected as
it flows through the scrotum and testicles.
Torsion is indicated if the radioactive fluid
does not flow through the sore testis. Ultrasound
scan accompanied by a contrast agent can also be
used to diagnose testicular torsion.
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Testicular Torsion Treatment
Surgery must be performed within 24 hours to
ensure the health of the affected testis. During
the procedure, the surgeon untwists the cord and
secures the testis in place so that it cannot
rotate again. The other testicle should also be
secured to deter future testicular torsion. This
procedure is called orchiopexy.
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Testicular Torsion  Prognosis
If the torsion is relieved within 24 hours, the
testis will recover normal blood flow and
function
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Hypospadias
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Hypospadias Definition
Hypospadias is a congenital defect, primarily
of males, in which the urethra opens on the
underside (ventrum) of the penis. The
corresponding defect in females is an opening of
the urethra into the vagina and is rare.
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Hypospadias Description
In a male, the external opening of the urinary
tract (external meatus) is normally located at
the tip of the penis. In a female, it is normally
located between the clitoris and the vagina.
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Hypospadias Description
In males with hypospadias, the urethra opens
on the inferior surface or underside of the
penis. In females with hypospadias, the urethra
opens into the cavity of the vagina.
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Hypospadias

• Abnormal urethral
• Chordee venteral fibrosis
• Abnormal foreskin

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Hypospadias Description
During the embryological development of
males, a groove of tissue folds inward and then
fuses to form a tube that becomes the urethra.
Hypospadias occurs when the tube does not form or
does not fuse completely.
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Hypospadias Description
Hypospadias in males generally occur alone.
Because it represents incomplete development of
the penis, some experts think that insufficient
male hormone may be responsible for hypospadias.
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Hypospadias Description
In males, the incidence of hypospadias is
approximately one per 250 to 300 live births.
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Hypospadias Causes and symptoms
Hypospadias are congenital defects of the
urinary tract. This means that they occur during
intrauterine development. There is no genetic
basis for the defects. Specific causes for
hypospadias are not known. This means that blood
relatives do not have increased chances of
developing them.
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Hypospadias Causes and symptoms
Hypospadias is usually not associated with
other defects of the penis or urethra. In males,
it can occur at any site along the underside of
the penis. In females, the urethra exits the body
in an abnormal location. This is usually due to
inadequate length of the urethra.
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Hypospadias Causes and symptoms
Hypospadias is associated with difficulty in
assigning gender to babies. This occurs when
gender is not obvious at birth because of
deformities in the sex organs.
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Hypospadias  Diagnosis
Male external urinary tract defects are
discovered at birth during the first detailed
examination of the newborn. Female urethral
defects may not be discovered for some time due
to the difficulty in viewing the infant vagina.
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Hypospadias Treatment
Surgery is the treatment of choice for
hypospadias .All surgical repairs should be
undertaken early and completed without delay.
This minimizes psychological trauma.
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Hypospadias Treatment
In males with hypospadias, one surgery is
usually sufficient to repair the defect. With
more complicated hypospadias (more than one
abnormally situated urethral opening), multiple
surgeries may be required.
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Hypospadias  Prognosis
With adequate surgical repair, most males with
simple hypospadias can lead normal lives with a
penis that appears and functions in a normal
manner. This includes fathering children. Females
with simple hypospadias also have normal lives,
including conceiving and bearing children.
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Thank You!