Early erythromytin

exposure (*13 d old)

right gastric

contraction

unnecessary

Pyloromyotomy,open

(Ramstedt vs.tiansumbilical or

laparoscopic approach) isthe

definitive treatment

Alternative therapies such as

IPR wait or atropine impractical

due to long time course of effect

“waves"after

feeding

Congenital

Diaphragmatic

Hernias

3 types:

Posterolateral

(Bochdalek)

Left-sided (85%)

Right-sided (13%)

Bilateral,rare,

often fatal

1in 2000 to 5000live Combinations of smal bowel.

large bowel,stomach,and

Presents vnthn hours solid viscera (spleen,liver)may Cyanosis

of life althoughsome herniate into thorax

cases of delayed

presentation

Early respiratory

distress

Decreasedair

entry r bowel

soundsinthe

Scaphoid abdomen chest

Prenatal diagnosis (hsp

’

acedheart

sounds

Prenatal USMRI Intubatei'ventilate

Orogastric suction

Period of respiratory

Better outcomes in

later presentations

Neurodevelopmental

stabilization due to associated impairment

pulmonary hypoplasia (may

require extracorporeal

membrane oxygenation)

Scxgical repair after stable by andscoliotic defects as

hernia reduction and closure ol potenbal complications

diaphragmatic defect open vs. of thoracotomy

thoracoscopic vs.laparoscopic long-term surveillance

nth or without prosthetic or for potential recurrence

muscular patch

depending on sice of defect

births ABO

CXR (bowel loopsin

hemithorax.shifted

heart)

Echocardiography

Genetic consultation

if warranted

Hearing defrat(40%)

Varying degrees of puhnonary AssocatedGERD

hypoplasia and pulmonary

»10= areassociated hypertension possible

with other congenital

anomalies

M-F MSKdefects chest wall

Prenatal diagnosis

common Anterior IMorgagm)

Fibre to thrive

Chronic lung disease if

severe hypoplasia

Hiatus

1-3%of population

M:F-3:1

Present most

Failure of vitelline duetto

regress 5-7 wkrncrfero:

50% containheterotopic

Tenderness and

distension (lower

abdomen) near

umbilicus

Stabilize,resectionby

laparotomy or laparoscopy t

incidental appendectomy

Meckel's

Diverticulum

Most common

remnant ol vitelline

duct that connects

yolk sac with

primitive midgut

BRBPR (heterotopic

gastric mucosa in

Meckel'scausing

frequently during first tissue (e.g. gastric mucosa. mucosal ulceration

5 yr of kfe ectopic pancreas):other andbleedingin

Symptomatic m 2% associated anomalies include adjacent small bowel

of cases omphalomesenteric fistula. mucosa)

umbilical sinus,umbilical cyst Abdominal

sepsis (Meckel’

s

AXR Resection curative

Meckel scan:scan

for ectopicgastric

mucosa with

technetium Tc99m

pertechnctateIV

(sensitivity 85%.

specificity 95%)

and fibrous band

diverticulitis ±

perforation)

Small bowel volvulus

aroundfibrous band

Intestinal obstruction

symptoms

Matrotation 1:500live txrttis failure of gut lonormally

1/3 present byInk rotatearoundSMA with

ofage.34by1mo associated abnormal intestinal rlabdomen

of age.90%bylyr attachments and anatom

positions *

Represent a spectrum of

Higher incidence rotational abnormalities

among patients with including complete noncardiac anomalies or rotation (which Isnot at

heterotaxy syndromes high-risk (or volvulus)

Cardinal sign:bilious Bilious drainage

emesis (especially fromNG tube

Tachycatdic.pale

nondistended) Diaphoretic

If bilious emesis with Flat abdomen

distended abdomen. Tenderness

consider surgical

exploration to raleout

volvulus

Rectal bleed(late/

ominous signs)

Intermittent

symptoms

AXR:obstruction

of proximal S80.

double-bubble

sign,intestinal wall

thickened

Immediate UGt

dilated duodenum,

duodenojejunal

segment (Ligament

of Treitz) right of

midline and not

fixed posteriorly

over spinalcolumn,

“corkscrew"sign

indicating volvulus

U/S:“whirlpool"

sign,abnormal SMA

SMV relationship

indicates UGI to

rule out rotational

anomalies

tv antibiotics

Fluid resuscitation

EMERGENUAPAROfOMYLadd

procedure:counterclockwise

reduction of midgut volvulus,

division of Ladd's bands,

division of peritoneal

attachments between cecum

and abdominal wall that

obstruct duodenum,broadening

of themesentery (open folded

mesentery likea book and

dhnde congenital adhesions),r

appendectomy

Positioning the bowel into nonrotation(SB0inright abdomen.

LS0inleft abdomen)

Mortality related to

length of bowel loss:

W% necrosis 100%

survivalrale.75%

of age necrosis 35%survival

M:F-1:1 rate

Recurrence 2-6%

r m

uJ

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GS7‘

IGeneral and Thoracic Surgery Toronto Notes 2023

Condition Epidemiology and Pathophysiology

Risk Factors

Clinical Features Physical Exam Investigations

and History

Treatment Prognosis

Gastroschisis 1:2000 live births Delect of abdominal wall near Hot associated with Hollow viscera Prenatal U/S

Antenatal diagnosis umbilicus,with free extrusion genetic syndromes |slomach. small Elevated MS AFP

common of intestine intoamniotic cavity 10% withintestinal and large bowels)

No specific environmental atresia Delect lateral

factor identified Some cases

Defect in embryogenesis associated with short right)

unclear bowel syndrome due Bowel may

be inflamed,

thickened.

NG lube decompression

IV fluids

IVanlibiotics

Keep viscera moist and

protected until surgical

reduction with primary

abdominal closure or staged

closure with silo

May have bowel dysmotility

requiring motility medications

>90% survival rale

Increased risk with

younger maternal

age andassodated

withIUGR

Rate slightly higher in

male infants

Smoking

to cord (usually

to antenatal volvulus

andnecrosisof

herniated bowel mailed,

foreshortened

Defect siie

variable

1:5000 live births

Antenatal diagnosis

common

Defect of abdominal wall and 30-70% associated

umbilical ring,with extrusion with genetic

of sac-covered viscera (amnion, syndromes (e.g.

Lower gestational age Wharton’s jelly,peritoneum) Pentalogy of

Increased maternal through the umbilicalring Cantrell,congenital

Duhamel's theory failure of heart disease,

body wall morphogenesis

Commonly associated with

rotational abnormalities of the Associated pulmonary

hypoplasia

Hollow viscera Prenatal Ur’S

(stomach,small Elevated MS AFP

and large bowels,

often liver)

Sac present with

cord attached

40- 70%survival rate

Higher survivalrales

most likely related to

antenatal mortality

of fetuses with giant

omphaloceles

Omphalocele NG tube decompression

IV fluids,IVanlibiotics

Small defect [<2cm):

Primary closure

Medium (2-4 cm) and large

(>4 cm) defects:silver

sulfadianne coupled with

compression dressing (toallow

eptlhelialitation and gradual

reduction) or Silon Silo Pouch,

followed by future repair tmesh

Repair if not spontaneously

closed by age 5

Earlier repair of large

“ptoboscoid"hernias with

extensive skin stretching may

be warranted lor cosmetic

reasons

Simple primary closure of

fascial defect

III

MF-1 5:1 Beckwith Wiedemann

syndrome,fnsomy 18)

intestine

Incidence 2-14%

Increases with

prematurity

Decreases with

Increasing age

UmbilicalHernias Majority

peritoneal and fascial layers asymptomatic

within umbilicus by 4 yr Majority (95%)

Hernia isperitoneum-linedand spontaneously resolve less common

abdominal wall

Incarccralionpriorlo herniasthaldo

ageSveryrarc not spontaneously

Mostsymptomsoccur resolve (e.g.

inlate adolescence or epigastric

hernias)

Most defects >1.5

cm in infancy

will not dose

spontaneously

Incidence 2-14% Duodenal failure ol bowel to Gastric distension Complete physical Conlrasl enema $ NP0

May be antenatally recanabre after endodermal and vomiting (usually Special attention UGI with small bowel NG tube decompression

diagnosed by dilated epithelium proliferation(wk bilious) to abdominal follow through(S8FI) Fluid resuscitation

bowelloopsor 8-10) Duodenal maybe exam,perineum. Group and screen IPN

‘

‘double-bubble"sign Jejunal/ileal acquired as a associated with andanus

on x-ray for duodenal result of vascular disruption » other anomalies Include evaluation surgery

atresia ischemic necrosis

*

resorption (tracheoesophageal of respiratory

of necrotic tissue -•blind distal fistula,cardiac. distressand

renal,and vertebral signs ol volume

Colonic mechanism unknown, anomalies).24-28% depiction

Ihoughl lobesimilar to small have Down syndrome Congenital

Jejunal/ileal within anomalies

2 d of birth,may be Jaundice

associated with CF

Colonic within3 d

of birth

Incomplete closure of Protrusion from

umbilicus

Different from

None if

uncomplicated

Rarely become

incarcerated

Low risk of recurrence

skin- covered by age 4

Sire of fascial defect

determines chances ol

spontaneous closure

adulthood

Long-term survival:

Duodenal 86%

Jejunal/ileal 84%

Colonic100%

Intestinal Atresia

INR andPIT if for Broad spectrum antibiotics

Duodenal

duodenoduodenostomy or

duodenojejunostomy

Jejunal/ileal primary

anastomosis:or if atresia

associated with short bowel

then may createend stoma

or defer surgery for bowel

lengthening procedures

Colonic primary anastomosis

Decreasedwith

increasing age and proximal ends

bowel atresia

1:5000births

M:F-3:1 to 4:1.

approaches1:1when resulting in aganghomc bowel spontaneously within Squirt/blast sign aganglionosisand

whole coloninvolved that (ails to perislalseand 48 h of life (95%pass

Canhave internal sphincter that fails to meconium within 24

aganglionosis of small relax (internal anal sphincter h,5% within 48h)

bowel as well achalasia) causing functional Symptoms of

Familial and partial mechanical

Hirschsprung's in <5% obstruction,respectively

of cases

Deled in migrationof

neurocrcst cells to intestine

Congenital

Aganglionic

Meirschsprung's

Disease

Failure to pass

meconium

t Abdominal Rectal biopsy (gold

standard) look for

Duhamel pull-through

procedure: surgicalresection ol near-normal anorectal

aganglionic intestinal segment function

and anastomosis ofremaining

intestine to anus

Either innewborn period

or staged if extensive

aganglionosis

Mosl have normal/

distension

neural hypertrophy Complications:

fecal incontinence

and constipation,

postoperative

enterocolitis (medical

emergency if

progresses to sepsis)

Contrast enema to

find narrowrectum

and transition cone

Anal manometry

unreliable ininfants

classic finding is

absence of redoanal

inhibitory reflex

bovrel obstruction:

abdominal distension,

constipation,bilious

emesis

Starts in the rectum and

variable involvement

proximally:REI mutation Enterocolitis/sepsis

failurelothrive

Cryptorchidism Most common

congenital

abnormality of the

GU tract

2-5%of termmales

moslol these descend

spontaneously by 6

moolage

1% ol males do

not spontaneously

descend

Suspect in

prematurity

Palpable testicle Scrotal

Descent is mediated by INSL3 within inguinal canal asymmetry

ortestidewhichcan Bi-annual

be milked down into testicular exam

hCG to stimulate testosterone

production and descent

Orchidopexy especially if

undescended byage

6 mo-2yr

Orchidopexy

Decreasedrisk of

torsion and blunt

trauma to testicle

No effect on malignant

potential of testicle

Descent can preserve

spermatogenesis rl

performed by1y»

Idiopathic Depends onageof

presentation

Older child:LH.FSH.

Mullerian inhibiting

the scrotum (called with palpation substance. hCG

retractile testis) Distinguish truly stimulation test

Occasionally no undescendcd lor gonadotropin

palpable testis as itis testis Irom production

intra abdominal retractile testis Infant:U/S. FSH.

Consider other (whichis “high" LH,karyotype,

congenital testis dueto MIS.17-hydrojcyabnormalities hyperactive progesterone

cremasteric If non-palpable:

muscles) exam under

and testosterone

Descent usuallybegins at

28 wk

i. J

anesthesia. +

exploratory

laparoscopy

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GS75 General and Thoracic Surgery Toronto Notes 2023

Condition Epidemiology and Pathophysiology

Risk Factors

Clinical Features Physical Exam Investigations

and History

Treatment Prognosis

Intussusception Most common cause Usually idiopathic

of bowel obstruction Usually startsat Ileocecal

between 6-36 mo junction

26:100.000 newborns Telescoping ol bowel intoitsell pain

causing an obstruction and

Pathologic lead vascular compromise

points:enlarged

Payer's patches due

to viral infections of

the Gl tract,polyps.

Meckel's diverticulum

CF.lymphoma andI8D

may increase risk

Abdominal exam AXR for signs of

Palpate

1«masses

(especially

sausage shaped

upper abdommal

mass) and

tenderness

Signs olbowel

obstruction:

distended

abdomen

Look for localized

peritonitis

which suggests

transmural

ischemia

Abdominal

distention

If peritonitis,consider operative 10%recurrence rale

If recurent - more

likely nonidiopathic

If successfully reduced

by enema in older

childrenallow 2 wk

resolution of edema

before performingSBFT

to ruleout pathologic

lead points

Acute onset

abdominal pain

Episodic "colicky"

bowel obstruction or management

perforation

U/S if suspect

pathology

Hon operative management

involves reduction via air

M:F-3:2 Vomitingt bilious

Abdominalmass

Currant- jelly stool

suggests mucosal

neuosisand

contrast enema

Operativeiedudion (open or

laparoscopically)

Resection of involved colon

if failure to leduce or bowel

sloughing appears compromised

Tracheoesophageal 1:3000 1:4600 Defect inthe lateral seplatron Varies with type of

Fistula (TEF) Typically occurs with ollive foregut into the

esophageal atresia esophagus and trachea causing May have history

connection between the of maternal

polyhydramnios

May present after

several months

(ifno associated

esophageal atresia)

of non-bilious

vomiting,coughing,

cyanosis withreeds,

respiratory distress,

recurrent pneumonia,

frothy bubbles of

mucus in mouth,and

nose that return after

suctioning

X-ray:anatomic Investigate for other congenital Complications:

abnormalities.HG anomalies

tube curled in pouch Early repair by surgical ligation reaebseaitways

loprevent lung damage and disease

maintain nutrition and growth Following repair:

esophageal stenosis

andstricturesat

repair site.GERD,

and poor swallowing

(i.e.dysphagia,

regurgitation)

Ml pneumonia,sepsis.

esophagus and trachea

Associated anomaliesin 50%:

VACTERL association

Inguinal Hernias 5%of all term

newborns

All infant hernias are indirect:

descent of intra-abdominal

2x risk andmore likely contents through the internal

bilateral if pre-term

M:F-4:1

low birth weight

increases risk

1/5 inguinal hernias

will become

incarceratedif patient

is «1yr

Incarcerationis more

common in females

Associated with other

conditions:androgen

insensitivity,

connective tissue

diseases

Palpate far

presentation:painless “bag of worms" standard

intermiltent mass

in groin,may also

note extensioninto varicocele

scrotum (scrotalmass Biannual

in absence of inguinal testicular exam • difficult)

massisa hydrocele) palpation along

IIincarcerated:

tender,vomiting,firm evaluate for any

mass,erythema then masses

cyanosis of mass may "Silk sign"

palpable

thickening of cord

Mass palpated

alexternal

inguinalringand

reducible through

inguinal canalinto

abdomen

Must always

try reduction

to confirm that

hernia is not

incarcerated

Physical exam isgold Manualreduction in the ER lo Risk of recurrence after

relieve acutesymptoms

suggests U/S only if physical For reducible hernia:repair

possible testicular exam uncertain within a few wk (if «1yr) vs.

(e.g. in small infants elective repair (rl >1yr)

where exam can be For incarcerated hernia:repair was incarcerated/

immediately (emergency) strangulated

Herniorrhaphy (laparoscopic or

open) definitive treatment by

reduction of herniated contents

and highligation of sac for

indirect hernias

Most common

surgicalreduction

<3%.higher if repair

done inpremature

infants or if hernia

inguinalring Ihrougha patent

tunica vaginalis

Inguinal hernia can be

reducible,incarcerated

lunreducible).or strangulated

inguinal canal to

be noted

Skin Lesions All inguinal hernias of infancy and

childhood require repair at the earliest

convenience: emergent repair if

• teePerinatology.08;Emergency Medicine.EK43;Plastic Surgery. PL5 incarcerated/strangulated

rt

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