小儿外科课件.ppt

1、Pediatric Surgery1ppt课件 Responsible for the treatment and prevention of surgical conditions in fetus 28 weeks of gestation to adolescent at puberty.Including the related basic medical theories and researches.2ppt课件精品资料 你怎么称呼老师？如果老师最后没有总结一节课的重点的难点，你是否会认为老师的教学方法需要改进？你所经历的课堂，是讲座式还是讨论式？教师的教鞭“不怕太阳晒，也不怕那风

2、雨狂，只怕先生骂我笨，没有学问无颜见爹娘”“太阳当空照，花儿对我笑，小鸟说早早早”精品资料 你怎么称呼老师？如果老师最后没有总结一节课的重点的难点，你是否会认为老师的教学方法需要改进？你所经历的课堂，是讲座式还是讨论式？教师的教鞭“不怕太阳晒，也不怕那风雨狂，只怕先生骂我笨，没有学问无颜见爹娘”“太阳当空照，花儿对我笑，小鸟说早早早”History of pediatric surgery Establishment of pediatric surgeryAboard:end of 1940s,Aboard:end of 1940s,China:beginning of 1950sChina

3、:beginning of 1950s specialties now include：general surgery neonate surgery orthopedics urology thoracic&cardiac surgery oncology neurosurgery7ppt课件小儿外科疑难重症临床中心小儿外科疑难重症临床中心 临床中心学科结构图临床中心学科结构图 微创外科中心微创外科中心 血液肿瘤中心血液肿瘤中心 肝病中心肝病中心 心血管中心心血管中心 遗尿中心遗尿中心 产瘫中心产瘫中心 神经外科8ppt课件 Defects in the abdominal wall(dia

4、phragmatic hernia,gastroschisis,omphalocele)Neurological system(brain,spinal cord,etc.)Cardiovascular and pulmonary abnormality Malformation of digestive system Malformation of urological and reproductive system Limbs and vertebra abnormality9ppt课件Congenital Posterolateral Diaphragmatic Hernia(CDH)J

5、One of most severe conditions of neonateJDefect in diaphragm during early fetal development J left side most commonly affected Jcontent of the hernia:small bowel colon spleen stomach liver,kidney,tail of pancreatic10ppt课件 【EmbryologyEmbryology】week89：division of coelomic cavity into the pleural and

6、peritoneal cavity by the diaphragm;a triangular area in the posterolateral site was left open.week1012：herniation occur through this opening into the pleural cavity at the return of midgut 11ppt课件 【pathophysiology】1、Hypoplasia of the lung Pulmonary weight (ipsilateral+contralateral)Alveoli number Hy

7、pertrophy of the media of pulmonary arteriole Resistance of the vesselsPulmonary hypertension Abdominal viscera into the thoracic cavity Compression of the lung,PaO2PaCO2 Acidosis,hypoxemia（PH7.30）Pulmonary vessels spasm Vessel resistance,right to left shunting through patent ductus arteries and for

8、amen ovale Aggravate acidosis and hypoxemia in the body circulation(fetal circulation syndrome)12ppt课件EmbryonicPseudoglandularCanalicularSaccularAlveolar06162636PostnatalWeeks GestationCDHBranching morphogenesisArterioles,Bronchioles,AlveoliGas Exchange13ppt课件diaphragmatic herniaClinical manifestati

9、ons：1，Severe respiratory distress，cyanosis,vomit 2，Breath sounds:diminished on the side of hernia 3，Heart sounds:deviated to the contralateral chest 4，Scaphoid abdomen14ppt课件【diagnosis diagnosis】Prenatal diagnosis Ultrasound:abdominal organ visible in the fetal chest15ppt课件diagnosis after birthX-ray

10、 film:uTypical air-filled stomach and bowels in the chest,which continues into the abdominal cavity.uDiaphram can not be seen at the affected side.uAbsence or scarcity of intestine in the abdominal cavity16ppt课件 In utero repair,N Engl J Me,2003 Prenatal Treatment for CDH 17ppt课件Treatment Before deli

11、very:cortisone could induce the maturation of pulmonary tissue Preoperative preparation:（1）mechanical ventilation with pure oxygen（2）nasogastric tube to decompress stomach and intestine（3）semi-supine and inclined to the ipsilateral side，keep warm（4）i.v.fuild,correction of acidosis (5）surgical repair

12、 18ppt课件omphalocele19ppt课件gastroschisis20ppt课件I期还纳法期还纳法21ppt课件I期还纳法期还纳法22ppt课件Congenital Esophageal Atresia with Tracheoesophageal FistulanIncidence:1/3000nassociated anomalies common nImpediment of recanalization and interruption of septation of trachea and esophagus 23ppt课件Congenital esophageal at

13、resia6，2，85，1。6Classification24ppt课件【clinical findings】1 1、drooling saliva,unable to swallow 2、cough and choke and may become cyanotic after feeding 3、chemical and aspiration pneumonia4、abdominal distention or scaphoid abdomen25ppt课件【diagnosis】1 1、prenatal diagnosis2、nasogastric tube can not reach s

14、tomach.3、X-ray film show the coiling of the tube in the upper mediastinum26ppt课件 Preoperative preparationnsupine and elevated to 3040nCatheter was put at the blind end of the esophagus for continuous drainagen oxygen inhalation,incubatorn i.v.fluid and broad-spectrum antibioticsnsurgical repair4Prog

15、nosis:98%100%survival rate for the last decade(aboard),all of the cases survived since 2002(our hospital).27ppt课件Hypertrophic Pyloric Stenosis【pathophsiology】1、olive shaped mass：length 23.5cm，thickness 0.40.6cm，pale in color with consistency of cartilage2、Muscular hypertrophy of all the layers of th

16、e pylorus,most significant in the circular layer,causing the stenosis28ppt课件Hypertrophic Pyloric Stenosis 【symptoms】1、projectile vomiting:onset:2-3 weeks after birth and progressive with time;vomitus:non-bilious milk and milk curds2、jaundice：deficiency in liver enzyme and compression of the biliary

17、tract3、overall condition:dehydration,weight lose,hypo-chloride metabolic alkalosis,oliguria 4、abdominal examination:distention of epigastrium,visible gastric waves,presence of a palpable pyloric tumor(unique physical sign)29ppt课件 【Diagnosis】1、Typical vomiting and mass in the epigastrium2、Ultrasound:

18、muscular thickness0.4cm，SD=thickness2/diameter503、GI for cases with difficulty in diagnosis：distention of the stomach strong gastric waves elongated and narrow pyloric channel delay in stomach emptying30ppt课件【Treatment】Surgery Surgery pyloromyotomy pyloromyotomy31ppt课件Intestinal Obstruction in the N

19、eonate32ppt课件【Etiology】1、Malrotation of midgut around the axis of superior mesenteric artery 2、Intestinal recanalization anomaly 3、Compromise of intestinal blood supply4、Arrest of the migration of neuroblast derived from neural crest of epiderm5、Viscosity of meconium:cystic fibrosis6、Maternal factor

20、s:infection,diabetes,pharmaceuticals 33ppt课件【Pathophysiology】1、Loss of fluid from emesis:dehydration,electrolyte disturbance,acid-base imbalance2、Aspiration and abdominal distention:chemical and bacterial pneumonia,apnea3、Dissemination of enterobacterium:ischemia,necrosis,perforation and sepsis 34pp

21、t课件【Clinical manifestation】Characters of neonate ileus:vBilious vomitingvAbdominal distentionvFailure to pass meconiumvGeneral condition：drowsy、hypomyotonia、tachypnea35ppt课件Common causes of neonate intestinal obstruction (Mechanic obstruction)Extrinsic：intestinal atresia and stenosis 40 annular panc

22、reas Malrotation 1015%intestinal duplication meconium peritonitis（adhesion）internal hernia,incarcerated external herniaIntussuception Intrinsic：meconium peritonitis milk curds obstrution meconium plug36ppt课件Functional obstruction Hirschsprungs disease 2530Necrotizing enterocolitis Left microcolon sy

23、ndromeInfectionMetabolic37ppt课件Intestinal Atresia and Stenosis38ppt课件【Clinical findings】1 1、V Vomiting onset:from first time of feeding to a few days after birth vomitus:bilious or feculent2、Abdominal distention high:confined to epigastrium low:full abdomen distention3、Failure to pass meconium:norma

24、lly meconium was passed within the first 24hrs of life and cleared in 2-3 days.4、General condition39ppt课件【Diagnosis】1 1、P Prenatal ultrasound2、Clinical findings:bilious vomiting 24-48hrs after birth abdominal distention failure to pass meconium3、X-ray：duodenal atresiaDouble bubble signjejunal atresi

25、atriple bubble signlow intestinal atresiamultiple air-fluid level40ppt课件Diagnosis(intestinal atresia)X-ray：supine for anteroposterior，erected for lateral41ppt课件【Treatment Treatment】The only option is surgery：intestinal septum excision Intestine resection and anastomosis42ppt课件Congenital Malrotation

26、of Intestine43ppt课件【Definition】Malrotation is the term used to define the group of congenital anomalies resulting from aberrant intestinal rotation and fixation【Embryology】Week 68:Herniation of midgut into the umbilical cord with a 180 degree of counterclockwise rotation along the axis of superior m

27、esenteric artery Week 10:Return to the abdominal cavity with a final 90 degree of rotation to complete the 270-degree counterclockwise rotation 44ppt课件Schematics of normal midgut rotation 45ppt课件【Pathology】Nonrotation and Incomplete rotation:abnormal positioning of the proximal small bowel and the c

28、ecumDuodenum compressed by abnormal peritoneal band(Ladds band):high incomplete extrinsic obstructionMidgut volvulus:torsion of the narrow mesenteric pedicle produces an acute closed-loop intestinal obstruction and vascular insufficiency.Proximal jejunum fused to the ascending colon by anomalous per

29、itoneal attachments46ppt课件MalrotationnPathology：Compression of duodenum Kinked and foreshortened proximal jejunum by peritoneal bandMidgut volvulus47ppt课件【Clinical manifestations】Emesis：bilious,intermittent，occur at 3-5 days after birth or asymptomatic Abdominal distention:confined in epigastrium,di

30、ffuse to the full abdomen in bowel necrosis Stool:normal meconium,bloody stool suggests volvulus and necrosis Newborn:normal meconium，intermittent vomiting after 3-5 days of birth，no abdominal distention,hard stool Children and infant：asymptomatic since birth,intermittent onset or sudden onset of vo

31、lvulus48ppt课件Clinical manifestations nSymptoms of volvulus:bloody vomitus and stool,abdominal tenderness49ppt课件【X-ray film】1、Plain X-ray film:double-bubble sign 2、barium enema:cecum in the upper or left abdomen 3、GI：incomplete duodenal obstruction;ligament of Treitz not to the left of the midline;ab

32、normal position of the proximal jejunal loops to the right of the midline50ppt课件TreatmentPrinciples：Asymptomatic malrotationmost recommend surgical treatment some believe operation only necessary in young childrenHigh intestinal obstruction operated on promptly,but not necessarily emergently Volulus

33、 with sign of bowel necrosis immediate operation 51ppt课件TreatmentTreatmentLadd s operation All volvulus is clockwise so the small bowel must be rotated in a counterclockwise fashion Expose duodenum by division of the Ladds bands Dissection additional peritoneal bands to convert the mesenteric pedicl

34、e to a wide plane Alignment of small bowel to the right and colon to the left of the abdominal cavity Appendectomy52ppt课件Hirschsprungs Disease Anatomy1 1、distended segment:proxiaml colon enlarged with muscular hypertrophy2、stenosis segment：distal colon spasm3、transitional segment：between distal and

35、proximal segments53ppt课件 Histology1、lack of ganglion cell in the neural plexus of the affected segment of intestine2、hypertrophied nerve trunk stain positive for acetylcholinesterase3、Disarray of adrenergic fibers54ppt课件【Pathophysiology】Arrest of cranial to caudal migration of neuroblasts derived fr

36、om neural crest precursors along the intestinal tract with vagal nerve fiber at 6-12 weeks of gestation,which results in aganglionosis of the distal bowel.1、spasm of affected segment no normal peristalsis2、internal sphincter spasm no normal defecation reflex 3、proximal bowel distended with histologi

37、c evidence of muscular hypertrophy 55ppt课件【clinical findings】Neonate：1、emesis：bilious or feculent 2、abdominal distention 3、delayed passage of meconium 4、rectal examination：tightness of internal sphincter,rectal emptiness，withdraw brings out meconium and gas 5、after bowel irrigation,temporary subsidi

38、ng of the symptomsChildren and infant：1、History of neonate constipation 2、Malnutrition,anemia 3、Chronic abdominal distention56ppt课件【Diagnosis】Barium enema Demonstration of a spasmodic distal intestinal segment with dilated proximal bowel Failure to evacuate barium from colon within 24hours simplicit

39、y of the method accuracy in neonate 80 not suitable for short segment type57ppt课件Anorectal ManometryAid diagnosis through identification of the rectoanal inhibitory reflex which is absent in the vast majority of children with Hirschsprungs diseaseDrawbacks:false-positive in older children due to mas

40、king of the relaxation response by contraction of the external sphincter58ppt课件Rectal biopsy()59ppt课件 Histologic staining of mucosa Increased AChE content in the nerve fibers of the lamina propria and muscularis mucosae Full-thickness Rectal Biopsy Complexity and complications,possible effect on fut

41、ure definitive surgery 60ppt课件【Complications】1 1、Enterocolitis Most frequently encountered and life-threatening:from constipation to diarrhea peritonitis and sepsis fever and abdominal distention digital exam：massive amount of odorant stool 2、Perforation Cecum peforation Bowel necrosis and perforati

42、on61ppt课件【Treatment】1 1、Colon irrigations:isotonic fluid one to two times a day Do not use water2、Colostomy：3、Surgical options Swenson Duhamal Rehbein Soave Neonatal surgery Laparoscopes Transanal pullthrough 62ppt课件Anorectal Malformations(ARMs)nOne of the most frequently encountered digestive tract

43、 abnormalitynFrequency is slightly higher in males compared with femalesnAssociated anomaly:urogenital,another gastrointestinal anomaly,cardiovascular,vertebranArrest of the caudal descent of the urorectal septum toward the cloacal membrane during the fourth week and ending by the eighth week of ges

44、tation.63ppt课件ARM classification Wingspread classification:according to the relative position of retal end to the elevater ani：high:above elevater ani intermediate:within elevater ani low:pass through elevater ani Further classification according to the fistula 64ppt课件PC line:pubococcygeal lineI lin

45、e:ischial line 65ppt课件ARM diagnosisnInvert-gram 12 hours after birth66ppt课件ARM treatmentAim：Rebuilt an anus with well functioning anal sphinctenHigh and intermediate imperforated anus colostomy at birth definitive surgery at 6-12months of agenLow imperforated anus Trans-perineal anoplasty after birt

46、h For female with fistula，Dilatation of fistula,anoplasty at 6-8 months 67ppt课件Key wordsKey words CDH pathophysiology and Clinical manifestations clinical findings of Congenital esophageal atresia symptoms and diagnosis of Hypertrophic Pyloric Stenosis(pyloromyotomy)Clinical manifestation of neonate intestinal obstruction Pathology of Congenital Malrotation of Intestine Histology and clinical findings of Hirschsprungs Disease Wingspread classification of Anorectal Malformations68ppt课件 Thank you！69ppt课件