How to remember the position of the Bochdalek hernia?

Chapter 67 / Pediatric Surgery 531

Think: BOCH DA LEK “BACK TO

THE LEFT”

Large bowel

Spleen

Hernia

What are the effects on the lungs?

What inhaled agent is often used?

What is the treatment?

1.Pulmonary hypoplasia

2.Pulmonary hypertension

Inhaled nitric oxide (pulmonary vasodilator), which decreases the shunt and decreases pulmonary hypertension

NG tube, ET tube, stabilization, and if patient is stable, surgical repair; if patient is unstable: nitric oxide ECMO then to the O.R. when feasible

532 Section III / Subspecialty Surgery

Extralobar

What are the signs/ symptoms?

How is the diagnosis made?

What is the treatment of each type:

Extralobar?

Intralobar?

What is the major risk during operation for sequestration?

ABDOMEN

Sequestration not in the normal lung covered by its own pleura

Asymptomatic, recurrent pneumonia

CXR, chest CT, A-gram, U/S with Doppler flow to ascertain blood supply

Surgical resection

Lobectomy

Anomalous blood supply from below the diaphragm (can be cut and retracted into the abdomen and result in exsanguination!); always document blood supply by A-gram or U/S with Doppler flow

What is the differential diagnosis of pediatric upper GI bleeding?

What is the differential diagnosis of pediatric lower GI bleeding?

What is the differential diagnosis of neonatal bowel obstruction?

Gastritis, esophagitis, gastric ulcer, duodenal ulcer, esophageal varices, foreign body, epistaxis, coagulopathy, vascular malformation, duplication cyst

Upper GI bleeding, anal fissures, NEC (premature infants), midgut volvulus (usually children younger than 1 year), strangulated hernia, intussusception, Meckel’s diverticulum, infectious diarrhea, polyps, IBD, hemolytic uremic syndrome, Henoch-Schönlein purpura, vascular malformation, coagulopathy

Malrotation with volvulus, intestinal atresia, duodenal web, annular pancreas, imperforate anus, Hirschsprung’s disease, NEC, intussusception (rare), Meckel’s diverticulum, incarcerated hernia, meconium ileus, meconium plug, maternal narcotic abuse (ileus), maternal hypermagnesemia (ileus), sepsis (ileus)

What is the most common inguinal hernia in children?

What is an indirect inguinal hernia?

Indirect

Hernia lateral to Hesselbach’s triangle into the internal inguinal ring and down the inguinal canal (Think: through the abdominal wall indirectly into the internal ring and out through the external inguinal ring)

What type of hernia goes through Hesselbach’s triangle?

What is the incidence of indirect inguinal hernia in all children?

Direct hernia from a weak abdominal floor; rare in children (0.5% of all inguinal hernias)

3%

What is the incidence in premature infants?

What is the male to female ratio?

What are the risk factors for an indirect inguinal hernia?

Up to 30%

6:1

Male gender, ascites, V-P shunt, prematurity, family history, meconium ileus, abdominal wall defect elsewhere, hypo/epispadias, connective tissue disease, bladder exstrophy, undescended testicle, CF

534 Section III / Subspecialty Surgery

Which side is affected more commonly?

What percentage are bilateral?

What percentage have a family history of indirect hernias?

Right ( 60%)

15%

10%

What are the signs/ symptoms?

What is the silk glove sign?

Why should it be repaired?

How is a pediatric inguinal hernia repaired?

Groin bulge, scrotal mass, thickened cord, silk glove sign

Hernia sac rolls under the finger like the finger of a silk glove

Risk of incarcerated/strangulated bowel or ovary; will not go away on its own

High ligation of hernia sac (no repair of the abdominal wall floor, which is a big difference between the procedure in children vs. adults; high refers to high position on the sac neck next to the peritoneal cavity)

Which infants need overnight apnea monitoring/ observation?

What is the risk of recurrence after high ligation of an indirect pediatric hernia?

Premature infants; infants younger than 3 months of age

1%

Describe the steps in the repair of an indirect inguinal hernia from skin to skin.

Cut skin, then fat, then Scarpa’s fascia, then external oblique fascia through the external inguinal ring; find hernia sac anteriomedially and bluntly separate from the other cord structures; ligate sac high at the neck at the internal inguinal ring; resect sac and allow sac stump to retract into the peritoneal cavity; close external oblique; close Scarpa’s fascia; close skin

Define the following terms: Cryptorchidism

Hydrocele

Communicating hydrocele

Noncommunicating hydrocele

Can a hernia be ruled out if an inguinal mass transilluminates?

Chapter 67 / Pediatric Surgery 535

Failure of the testicle to descend into the scrotum

Fluid-filled sac (i.e., fluid in a patent processus vaginalis or in the tunica vaginalis around the testicle)

Hydrocele that communicates with the peritoneal cavity and thus fills and drains peritoneal fluid or gets bigger, then smaller

Hydrocele that does not communicate with the peritoneal cavity; stays about the same size

NO; baby bowel is very thin and will often transilluminate

What is the hernia sac made of?

Basically peritoneum or a patent processus vaginalis

What attaches the testicle to the scrotum?

How can the opposite side be assessed for a hernia intraoperatively?

Gubernaculum

Many surgeons operatively explore the opposite side when they repair the affected side

Laparoscope is placed into the abdomen via the hernia sac and the opposite side internal inguinal ring is examined

What is a Littre’s inguinal hernia?

What may a yellow/orange tissue that is not fat be on the spermatic cord/testicle?

Hernia with a Meckel’s diverticulum in the hernia sac

Adrenal rest