Emergency Pediatric Surgery

ผศ. รวิศ เรืองตระกูล

สาขาวิชากุมารศัลยศาสตร
ภาควิชาศัลยศาสตร
Emergency Respiratory Conditions
„ Esophageal atresia
„ Diaphragmatic hernia
„ Diaphragmatic eventration
„ Pulmonary lesions
¾ Sequestration
¾ Emphysema

¾ Congenital cystic adenomatoid

malformation (CCAM)
 Esophageal atresia

„ Isolated esophageal atresia

„ Esophageal atresia with proximal TE fistula
„ Esophageal atresia with distal TE fistula
„ Esophageal atresia with double TE fistula
„ TE fistula without esophageal atresia
Esophageal atresia
Esophageal
atresia
with distal
TE fistula
 Esophageal atresia
with distal TE fistula

Associated anomaly
Pneumonia

Minor anomaly + Minor anomaly +

Major anomaly
Minor pneumonia Major pneumonia

Esophagoesophagostomy Correct cardiac dis

Gastrostomy
No gastrostomy Gastrostomy

Delayed Esophagoesophagostomy
 Esophageal atresia
without TE fistula
Access Gap
< 2 vertebra 2 – 5 vertebra > 5 vertebra

Gastrostomy at birth
Cervical esophagostomy
Esophagoesophagostomy Gastrostomy
Gastrostomy
At 3 weeks

Delayed
Esophagoesophagostomy Esophageal substitution
at 6 and 12 weeks

Failure to anastomosis
Diaphragmatic hernia
 Diaphragmatic hernia
Associated anomaly

Pre operative stabilization

Sedate, paralysis, FiO2 =1
High RR, Low tidal, Low PIP

Stable Unstable

Delayed repair when

High frequency
Pulmonary hypertension ECMO
Respirator
decreases

Delayed repair when

Pulmonary hypertension
decreases
Diaphragmatic eventration
Diaphragmatic eventration

Birth trauma
Branchial plexus injury
Fracture of clavicle

Unable to wean
Wean off respirator
Respirator
In 2 weeks
In 2 weeks

Plication Observe

Recurrence pneumonia
Diaphragmatic eventration

No Birth trauma

Respiratory No respiratory
Symptoms Symptoms

Plication Observe

Recurrence pneumonia
 Neonatal gut obstruction

Upper gut Lower gut

„ Polyhydramnios +++ +
„ Bilious vomiting +++ ++
„ Abdominal + +++
distention
„ Delayed passage + +++
of meconium
Neonatal gut obstruction
„ Abnormal vomiting
ΠBilious vomiting
ΠStomach content > 20 mL
ΠSick baby
ΠBody weight

„ Passages of meconium
Π90% in 24 hrs
Π96% in 48 hrs
 Upper gut obstruction

No abdominal distention

Retain OG tube

OG tube at 9 – 11 cm Abnormal vomiting

Esophageal atresia Plain abdomen X - ray

Double bubble with Multi-loop with

Double bubble
Distal air No distal bowel loop
Complete duodenal obstruction

Double bubble sign

 Upper Gut Obstruction
Plain abdominal X - ray

Double bubble Multi- loops with

Double bubble
With distal air no distal bowel loop

Duodenal
Upper GI study Jejunal atresia
Atresia

Duodenoduodenostomy Partial duodenal Jejunal resection

Duodenojejunostomy Obstruction End to back anastomos

Malrotation
Duodenal web
Annular pancreas
Duodenal stenosis
Lower Gut
Obstruction
 Lower Gut Obstruction
Saline irrigation

Pass meconium No meconium

Abdominal distention decreases Same abdominal distension

Ileal atresia
Hirschsprung’s disease
Colonic atresia
VS Meconium plug syndrome
Total colonic aganglionosis

+,- Barium enema

Observe
(Emergency)
Barium enema
Explor Lap
(elective)
Hirschsprung’s disease
 Anorectal Malformation
„ Low Type (Translevator)
Male - Anocutaneous fistula
Female - Anocutaneous fistula
- Anovestibular fistula
„ Intermediate Type - Anal agenesis +,- fistula
Male - recto- bulbar urethral fistula
Female - rectovaginal fistula
- rectovestibular fistula
„ High Type - Anorectal agenesis +,- fistula
Male - recto- prostatic urethral fistula
Female - rectovaginal fistula
 Anorectal Malformation
„ Fistula of low type anorectal malformation
Male – penoscrotal orifice to anal position
Female – posterior commissure of labia minora to
anal position

„ Visceral fistula (urethral fistula, vaginal fistula) are

always not low type anorectal malformation
Æ Sigmoid colostomy

„ Vestibular fistula
Ano-vestibular (low) VS recto-vestibular (intermediate)
 Male anorectal malformation
Fistula

Fistula between
Fistula
Penoscrotal junc Urethral fistula
Unseen
to anus

Low type Non low type Wait 18-24 hrs

Anoplasty Fistula
Colostomy
At birth Still unseen

Invertogram
Female anorectal malformation
Fistula

Fistula between
Fistula
Post comm of labia Vaginal fistula
Unseen
minora to anus

Low type Non low type Wait 18-24 hrs

Anoplasty Fistula
Colostomy
At birth Still unseen

Invertogram

Vestibular fistula See next slide

 Controversy of vestibular fistula

Probe Routine
Sigmoid
Anovestibular Rectovestibular Colostomy
Anoplasty
Sigmoid colostomy
At birth