Pediatric Surgery

Congenital as often as acquired, and every dose, tube and decision scaled to the child.

• Paediatric surgery treats children and neonates, where diseases are congenital as often as acquired: the malrotated gut, the hypertrophied pylorus, the hernia of a patent processus, and the emergencies unique to small bodies.
• Its alarm phrase is bilious vomiting: green vomit in a baby means malrotation with volvulus until proven otherwise, a diagnosis on which a midgut's survival depends.
• Children are not small adults: circulating volumes measured in hundreds of millilitres, weight-based everything, compensation that hides deterioration until late, and consent that involves families.
• Its own logic of urgency: some conditions that sound urgent are resuscitation-first (pyloric stenosis is never an emergency operation), while some that sound mild are theatre-tonight (the volvulus).

Ultrasound

What should I notice?

• The six-week-old with projectile vomiting

  “Forceful non-bilious vomiting after every feed for a week, a hungry baby losing weight, and a mother told twice it was reflux.”

  • Hypertrophic pyloric stenosis: the pylorus has thickened into an obstruction, classically in a firstborn boy around four to six weeks.
  • The biochemistry is the classic: vomiting stomach acid alone produces hypochloraemic, hypokalaemic metabolic alkalosis, and the blood gas is both diagnosis-support and readiness-meter.
  • Ultrasound measures the muscle and makes the diagnosis; the olive-shaped mass and visible peristalsis are the examination's version.

  Live it as a case Ramstedt pyloromyotomy

• The neonate with green vomit

  “A three-day-old, previously feeding well, vomits bile twice: the referring team notes a soft abdomen and normal observations.”

  • Bilious vomiting in a neonate is malrotation with volvulus until proven otherwise: the soft abdomen and normal observations exclude nothing, because the midgut can be twisting on its pedicle while the surface looks fine.
  • The upper GI contrast study is the urgent test, looking for the duodenojejunal flexure in the wrong place or the corkscrew of a volvulus: urgency is measured in hours.
  • The stakes are the whole midgut: the volvulus strangles the superior mesenteric artery, and delay is measured in centimetres of dead bowel and a lifetime of intestinal failure.

  Live it as a case Ladd's procedure for malrotation

• The screaming, drawing-up infant

  “A nine-month-old with episodes of inconsolable crying and leg-drawing, quiet and pale between, then a nappy with redcurrant-jelly stool.”

  • Intussusception: a bowel segment telescopes into its neighbour, classically ileocolic, at the classic age when lymphoid patches serve as lead points.
  • The episodic pattern is the story's signature, and the between-episode lethargy is itself a red flag, not reassurance.
  • Ultrasound makes the diagnosis (the target sign); air enema then makes the treatment, reducing most cases without surgery, with theatre informed and ready.

  Live it as a case

• The preterm baby with a distending abdomen

  “A 29-week preterm infant on the neonatal unit, day 12: feed intolerance, a distending shiny abdomen, and blood in the stool.”

  • Necrotising enterocolitis: the preterm gut's mucosal barrier fails, bacteria invade the wall, and the wall can necrose and perforate.
  • The X-ray vocabulary matters: pneumatosis intestinalis (gas in the bowel wall) confirms, portal venous gas escalates, and free gas declares perforation.
  • Management starts medical: stop feeds, decompress, antibiotics, and support in the incubator, with serial films and serial surgical review.

  Live it as a case

• The infant's groin swelling

  “A four-month-old with an intermittent groin swelling that appears on crying; today it is out, firm, and the baby is unsettled.”

  • An infant's inguinal hernia is a patent processus vaginalis, not a muscle weakness: the sac is congenital, the repair is herniotomy (ligate the sac), and no mesh is involved.
  • Infant hernias incarcerate at rates adult ones do not, which is why they are repaired promptly after diagnosis rather than watched.
  • The incarcerated hernia is first managed by skilled reduction (taxis) with analgesia: most reduce, earning a short admission and repair on that admission.

  Paediatric inguinal herniotomy