Beruflich Dokumente
Kultur Dokumente
Sandeep Agarwala
Tim J. Bradnock Editors
Basic Techniques in
Pediatric Surgery
An Operative Manual
1 23
Basic Techniques in Pediatric Surgery
Salvatore Cascio
Hock Lim Tan
(Associate Editors)
Basic Techniques
in Pediatric Surgery
An Operative Manual
123
Editors
Prof. Dr. Robert Carachi Mr. Tim J. Bradnock
University of Glasgow, The Royal Hospital for Sick Children,
The Royal Hospital for Sick Children, Sciennes Rd 9,
G3 8SJ, Glasgow, UK EH9 1LF, Edinburgh, UK
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The use of general descriptive names, registered names, trademarks, servicemarks, etc.in this publication does
not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective
laws and regulations and there fore free for general use.
While the advice and information in this book are believed to be true and accurate at the date of publication,
neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omis-
sions that may be made. The publisher makes no warranty, express or implied, with respect to the material
contained here in.
We would like to dedicate this book to our wives and children. An-
nette Carachi and their sons Peter, Michael Andrew and Philip.
Ranju Agarwala and their son and daughter Rishabh and Shreya.
Rachel Bradnock and their sons Henry and Toby. Mariagrazia Cas-
cio and their daughters Mariateresa and Costanza. Evelyn Tan and
their daughter Melanie and son Alexander.
We would also like to thank Mr. Bachem, Ms. Blasig and Ms.
Schröder from Springer who had an extremely difficult job and
made the book so colourful.
The final dedication is to Mrs Kay Byrne who was a faithful ac-
ademic secretary to the senior author of this book. She was respon-
sible for all the correspondence and collating of the manuscripts
which she has helped edit even after she retired.
vii
Foreword
The “Basic Techniques in Pediatric Surgery” is not just another book in the field. The manual
has been prepared to meet the basic need of the undergraduate and the postgraduate students
and the general paediatric surgeons with the operative and the postoperative basic details
related to various surgical procedures in children.
The authors of the manual are very senior and experienced paediatric surgeons from the
Royal Children Hospital, University of Glasgow, Glasgow (RC) and All India Institute of Med-
ical Sciences, New Delhi (SA). The scientific information is up-to-date, complete and authen-
tic. Significantly, the chapters have been contributed by the younger trainees in pediatric sur-
gery from the institutions of repute and these have been very well supervised by the senior au-
thors. All the authors are very much familiar with the surgical techniques described in the man-
ual and involved in the day to day actual planning in the preparation of the patients for surgery
or the operative and the postoperative care.
The manual of about 640 pages has covered various paediatric surgical problems with the
emphasis on preoperative, operative and the postoperative aspects. The manual has been di-
vided into various subsections covering the basic surgical techniques, anatomic and fundamen-
tal principles of paediatric surgery.
Being produced by “Springer” a well known name in the field of medical publications around
the world, the manual has maintained highest standard of publication. The language is simple
and easily understood. It is well supported by diagrams and figures.
I wish to compliment the contributors for the thought and the splendid job so well done in
producing a manual which was very much needed in the field. I am sure the manual would fill
the void. It would serve as a good companion to all the under and the postgraduate paediatric
surgical students working in various teaching and non teaching institutions in the developing
and the developed world. I strongly recommend the same to all the users in the specialty and
the institutional libraries around the world.
This operative manual is a joint venture between the Department of Surgical Paediatrics at
The Royal Hospital for Sick Children in Glasgow and the Department of Paediatric Sur-
gery, All India Institute of Medical Sciences (AIIMS) in New Delhi. A total of 67 paedi-
atric surgical trainees and consultant mentors have authored chapters for the book, with
additional contributions from leading paediatric surgeons from around the world, who are
well known for their expertise in a particular operation.
The operative manual aims to fill a niche in the surgical literature by providing concise, easy-
to-follow descriptions of 183 paediatric surgical operations and the basic operative techniques
that are required to perform them safely. The manual is intended to be something akin to a sur-
gical ‘cook-book’, in that it describes very clearly, in a step-by-step sequence, the component
parts of each operation. For ease of use, each chapter has been written in the same style, with
a succinct, well-illustrated description of the operative technique, followed by further sections
containing helpful tips and warning the reader about common pitfalls.
The operative manual covers the majority of operations and techniques that a paediatric sur-
gical trainee could expect to be involved with at any level from interested spectator to first as-
sistant and finally, principal operator. We are not suggesting that trainees should perform all the
operations included in this book, but we feel that no matter what their level of experience and
hence involvement in an operation, a trainee should always go into theatre armed with a ba-
sic understanding of the operative steps and sequence involved. We hope that the operative de-
scriptions in the manual will not only help trainees prepare for cases in theatre but also serve
as a useful revision tool for the FRCS (Paed Surg) exam and other Board exams worldwide.
The book starts with a ‘Basic Surgical Techniques’ section. This section takes the trainee
through the preparatory stages of an operation, covering topics such as the ‘WHO Safe Surgery
Checklist’, patient positioning, skin preparation and a ‘field guide’ to commonly employed sur-
gical instruments and their uses. Further chapters describe commonly used skin incisions and
some of the skills and techniques that trainees should develop in theatre. The remainder of the
book describes individual operations by organ system or anatomical region. The final chap-
ter of the book has been included to reflect the changes in the way in which paediatric surgi-
cal training is being delivered in the UK. This chapter provides the reader with an overview of
the new paediatric surgery syllabus, with special reference to the operative competencies that
should be developed by each stage of training. We hope that this will also be of interest to train-
ers in other countries.
It has not been our intention to provide information regarding underlying disease processes
or their management and outcome, as these topics have been well covered elsewhere. We have
excluded complex subspecialty surgery such as liver and bowel transplantation, neurosurgery,
complex reconstructive orthopaedic surgery, and cardiac surgery as these procedures are best
covered in large, specialist operative textbooks. Paediatric surgeons in the UK no longer per-
form some of the operations listed in the contents page. These cases are included for readers in
countries such as India and parts of Europe, where paediatric surgery remains more generalised.
x Preface
We are cognisant of the fact that in surgery as in life, there are many paths to the same end. We
do not profess that the operative techniques described in this book are the only way of achiev-
ing the intended outcomes of a procedure. The operative descriptions presented in this book are
included because they are safe and effective. Furthermore the descriptions have been enhanced
with tips and modifications, which have been learnt and developed by senior surgeons through
years of personal experience.
It has been a pleasure watching the operative manual evolve. We hope that you enjoy using
it and that it helps you to develop a sound understanding of the operative techniques and pro-
cedures which underpin this most rewarding of specialties.
Tim J. Bradnock and family Prof. Hock Lim Tam Salvatore Cascio
Preface xi
Consultants and trainees of “Department of Surgical Pediatrics, The Royal Hospital for Sick Children, G3 8SJ,
Glasgow, UK”
Contributing authors from the Department of Pediatric Surgery, All India Institute of Medical Sciences,
New Delhi, India
Contents
Iain Yardley ( )
Specialty Registrar in Paediatric Surgery,
Clinical Advisor, World Health Organisation Patient Safety
E-mail: iyardley@doctors.org.uk
Further Reading
Haynes et al (2009) A surgical safety checklist to reduce Weiser TG (2008) An estimation of the global volume
morbidity and mortality in a global population. N Eng of surgery: a modelling strategy based on available data.
J Med 360:491–499 Lancet 372:139–144
A2 Positioning 5
A 2Positioning A2
P. Sekaran and R. Carachi
The key to an ordered and successful day in the- xtended Neck for Head and Neck
E
atre is good communication among all the staff in- Surgery
volved. A briefing involving the surgeons, theatre
staff and anaesthetists should always take place The patient lies on their back with a roll placed
before starting the theatre list. It is good practice under the shoulders and the neck extended in the
to discuss each case that will be performed dur- midline. This position is adopted for operations on
ing the operating list. Important information that the neck, e.g. thyroid and thyroglossal cyst.
should be discussed for each patient includes sig-
nificant past medical history (e.g. malignant hy-
pertension), the optimal positioning on the table, Dorsal Position
the requirement for specialist equipment (e.g. fluo-
roscopy), the need for a diathermy pad, the site of The patient lies on their back on the operating ta-
the incision and whether antibiotics are required ble (Fig. 1). This is the position most commonly
perioperatively. Any anticipated difficulties should adopted in paediatric surgery. Arms should be
also be discussed. In conjunction with a briefing kept at the side of the patient, with the use of
at the start of the list, The World Health Organ- curved supports.
isation Safe Surgery Checklist has been shown to
reduce surgical morbidity and mortality and its
use for each case should be strongly encouraged Trendelenburg Position
(see Chap. A1).
The position of the patient is as fundamen- The patient is placed on the operating table in
tal as is the initial incision. Good positioning and the dorsal position, but the table is tilted with a
draping will allow optimal exposure of the oper- head-downwards slope (Fig. 2). The feet are now
ative field. For each position, any potential pres- at a higher level than the head. This increases
sure points where the skin overlies a bony prom- venous return from the body, but increases the
inence should be protected with additional pad- risk of aspiration of gastric contents and may
ding. In this chapter we discuss some of the com- hinder diaphragmatic excursion. The head-down
mon positions used in paediatric surgery. position can be used in central venous surgery to
fill the internal and external jugular veins, and in
pelvic surgery to displace the abdominal organs
out of the pelvis. In a laparoscopic appendectomy
the patient is usually positioned head down, with
a left lateral tilt to help mobilise the small bowel
from the pelvis and right iliac fossa, providing
optimal exposure of the caecum and appendix
Prabhu Sekaran () base.
Specialty Trainee in Paediatric Surgery In the reverse-Trendelenburg position (Fig. 3),
E-mail: Prabhu.sekaran@nhs.net
the patient is tilted in the opposite direction, so
Robert Carachi that the head and chest lay superior to the lower
Professor of Surgical Paediatrics limbs. This position may be used to facilitate ex-
E-mail: Robert.Carachi@glasgow.ac.uk posure of the upper abdomen during laparoscopy.
Fig. 1
Fig. 2
Fig. 3
A2 Positioning 7
Fig. 4
Fig. 5
The patient lies supine on the operating table. The patient is placed on their side with the arm
The thighs and knees are flexed and supported on the side of the incision, lying forward and over
on stirrups (Fig. 4). Additional padding should the face, supported on an armrest (Fig. 6). Care
be placed under the posterior compartment mus- should be taken to avoid dislodging the endotra-
cles of the legs to reduce the risk of pressure ul- cheal tube. The patient is secured to the edges of
ceration. The legs are secured onto the stirrups the table by using strong adhesive tape across the
with crepe bandaging. This position is routinely hips and shoulders to prevent the patient from
used for cystoscopy, as it provides good exposure rolling during the operation. This position may
of the perineum. be used for posterolateral thoracotomies and open
renal surgery.
Prone Position
Robert Carachi
Professor of Surgical Paediatrics
E-mail: Robert.Carachi@glasgow.ac.uk
Fig. 3 Fig. 4
Fig. 5
Tips
77 Allow time for alcohol-based solutions to evapo- 77 Be careful when removing drapes at the end of
rate before making your incision. the procedure not to dislodge the endotracheal
77 Think where you may need to access in unex- tube or intravenous lines.
pected circumstances – for a laparotomy prepare 77 Clean the patient before they wake up; seeing
from nipples to knees. blood can distress children.
Common Pitfalls
77 When draping, avoid moving the drapes from 77 Avoid pools of fluid near the diathermy. Be es-
dirty to clean. Always place the drapes well pecially careful with alcoholic preparation solu-
within the prepared area and move them from tions, as pools can ignite.
clean to dirty if required. 77 Be careful not to catch the patient’s skin in towel
clips.
10 A. Neilson and R. Carachi
The first Professor of Surgery at John Hopkins, Halstead pioneered many innovations in the
field of surgery: the surgical residency programmes, the careful and meticulous technique of
operating, the green surgical scrubs and the use of gloves in surgery. Halstead’s scrub nurse
was the able Caroline Hampton, for whom he had a soft spot. When he noticed that her
hands were raw and chaffed from the sterilizing liquid mercuric chloride, he acted. He had
the Goodyear Tyre and Rubber Company produce rubber protective gloves for her. Thereaf-
ter both Halstead and his surgical assistant started wearing gloves as well, and this became
the norm. Halstead went on to marry Ms. Hampton, and the surgical gloves have become
an effective tool in the surgical theatre.
A4 Surgical Instruments 11
A 4Surgical Instruments A4
B. Amjad
• Gallipots and kidney dish Fig. 4 Scalpel handle and disposable blades
– Surgical preparation dispensers
– Kidney dish used for handing instruments
and for collecting samples as well
• Duff towel clips
– Hold together the surgical drapes after they
have been laid out
Fig. 13 Langenbeck (left) and Durham (right) retractors Fig. 14 Malleable copper retractors (left) and Deaver re-
tractors (right)
Fig. 26 Straight and curved Kelly (or mosquito) artery forceps
A4 Surgical Instruments 17
• Subcutaneous tunnellers
– Available in a variety of forms
– Tunneller on the left in Fig. 39 for passing
ventriculoperitoneal catheters through the
subcutaneous tissues
– Instrument on the right in Fig. 39 for tun-
nelling central venous catheters
Fig. 36 Glasgow pattern rongeur (left) and Luer–Jansen Fig. 37 Pennybacker el-
rongeur compound action (right) evator (left) and Cobb spi-
nal elevator (right)
20 B. Amjad
H OWA R D KELLY
(1858 – 1943)
American surgeon and designer of the artery clip
Over the course of a stellar career he made many advances in the field of obstetrics and gyn-
aecology. A number of surgical procedures and instruments bear his name, including the
most common surgical instrument known: Kelly’s forceps or clamp, also called the mos-
quito or artery clip.
A5 Diathermy 21
A 5Diathermy A5
P. Sekaran and R. Carachi
Monopolar Diathermy
Tips
77 Only the surgeon with the active electrode 77 Learn to recognise the different diathermy alarm
should activate the diathermy. It is not a two-per- sounds and their meanings. Never ignore an
son job! Do not ask the assistant to depress the alarm.
pedal. 77 The postoperative checklist should include an in-
77 You should familiarise yourself with the inner spection of the diathermy plate site to ensure
workings of the diathermy machine – read the that there is no evidence of tissue injury.
manual. 77 Always clean the tip of the active electrode on a
77 Always check that the diathermy plate is applied scratch pad or moistened swab to remove any
correctly and is of an appropriate size. adherent tissue, which reduces its efficacy.
Common Pitfalls
77 Thermal injury is the most common risk of dia- 77 Ensure the patient is not touching ‘earthed’ metal
thermy, and it is usually the result of incorrect objects, which offer an alternative return route
placement of the diathermy plate. Always en- for diathermy current with localised heating over
sure proper placement of the diathermy plate a small surface area.
and check that no flammable liquids are present 77 Never use monopolar diathermy on append-
around the patient. Alcoholic skin preparations ages with an end-arterial supply, such as the pe-
burn with a clear flame, making them almost im- nis or testes, as the high current density gener-
possible to recognise until significant tissue dam- ated may compromise the arterial inflow, caus-
age has occurred. ing infarction.
77 Do not site the diathermy plate over a bony 77 Monopolar diathermy has the potential to reset
prominence or metal prosthesis and ensure that cardiac pacemaker programs or cause current
it has a good interface with the patient, free from to travel down the wires, burning the myocar-
interposed air or skin preparation. The tissue at dium and raising the pacemaker threshold. Dis-
the plate site should have good blood supply to cuss this with the patient’s cardiologist preopera-
disperse any heat generated. tively. If monopolar diathermy must be used, en-
77 The operating department practitioner (ODP) is sure there is a defibrillator in theatre and site the
usually responsible for attaching the diathermy diathermy plate as near to the active electrode
plate, but it is the surgeon’s responsibility to en- as possible. Bipolar diathermy is a safer option in
sure that this has been done safely prior to sur- this scenario.
gery.
A5 Diathermy 23
Fig. 2
Fig. 3
24 P. Sekaran and R. Carachi
Fig. 4
Fig. 5
Fig. 6
A5 Diathermy 25
H A RV E Y C US HI NG
(1869 – 1939)
American neurosurgeon and inventor of diathermy
A graduate of Harvard Medical School, Cushing trained under William Halstead at the
Johns Hopkins. He is considered the Father of American Neurosurgery and setup his unit at
the Peter Brent Bingham Hospital in Boston. His brilliant approach and hard work consid-
erably improved the outcome of neurosurgical patients. He used x-rays to diagnose brain tu-
mours and electrical stimuli to chart the human sensory cortex. Cushing’s disease and Cush-
ing’s syndrome are named after him.
The electrocautery device or monopolar and bipolar diathermy were developed by Cushing
and an inventor named William Bovie between 1914 and 1927. It was then used in 1927 by
Cushing to remove previously inoperable brain tumours.
Of note, Cushing is also the only physician to have won a Pulitzer Prize in Literature for
his Life of William Osler.
26 J. Currie
A6 A 6Local Anaesthesia
J. Currie
Local anaesthesia is extremely useful either as the 1. Levobupivacaine (l-bupivacaine) has a relatively
sole method of anaesthesia for minor surgery or slow onset of around 10 min, but is longer act-
as an adjunct to general anaesthesia. Well-placed ing, giving between 4 and 6 h of analgesia. The
local anaesthetic solution will allow the child to maximum dose is 2 mg/kg (1 mg/kg in an in-
wake pain-free and reduce postoperative analgesic fant <6 months old).
requirements. It is much easier to keep pain away 2. Lignocaine is more rapidly acting, having effect
than to take pain away. in 2 to 3 min. However, its duration of action
Blocking the pain pathway with local anaes- is only about an hour. The maximum dose is 3
thetic solution will also reduce the stress response mg/kg.
to surgery. 3. Prilocaine has roughly the same rapidity of on-
There are three commonly used anaesthetic so- set and duration of action as lignocaine. The
lutions: maximum dose is 5 mg/kilogram. Dose must
be based an optimal weight for height (BMI).
Tips
77 A useful technique is to combine lignocaine and 77 Where possible use a 10-ml syringe for your
l-bupivacaine. This gives rapid onset of action as blocks. This allows consistency in the ease of in-
well as long duration of analgesia. One per cent jection, the feel of the tissues and any loss of re-
lignocaine is available combined with 1:200,000 sistance. More pressure can be exerted at the
adrenalin. This can be used with the same vol- needle tip with a smaller syringe and less with
ume of l-bupivacaine to reduce bleeding due to the greater surface area of the plunger of a
the vasoconstrictive effect of adrenaline. In this larger-capacity syringe. Consistent ‘feel’ will al-
scenario, you should use half the maximum dose low for increased confidence and more consis-
of each drug. tent blocks.
Common Pitfalls
77 Inadvertent intravenous injection of local anaes- associated with l-bupivacaine can be intractable.
thetic agents can lead to side effects such as fit- Intravenous intralipid should be administered,
ting and ventricular arrhythmias. These com- as this binds to the drug, effectively reducing the
plications are less of a problem with prilocaine, blood levels.
which is metabolised by plasma enzymes. In the 77 Toxicity due to overdose or intravenous injection
case of lignocaine, these can usually be treated is usually heralded by side effects such as a tin-
symptomatically, but the ventricular arrhythmias gling sensation or numbness around the mouth
Indication Indications
This is a simple and very useful technique for an- This block can be used for analgesia for hernia re-
algesia for repair of superficial injuries. It is also pair and orchidopexy.
very useful when removing skin lesions. In adults
or in older co-operative children, this may be all Technique
that is required.
This technique can also be used in extremis for The aim is to block both the ilioinguinal and il-
operations such as appendicectomy, hernia repair iohypogastric nerves. The path of these nerves
or caesarean section. In these cases, analgesia is from the dorsal horn, takes them through the
administered at each layer of the surgical expo- three muscular layers of the anterior abdominal
sure. wall (Fig. 2). At the level of the anterior superior
iliac spine, the iliohypogastric nerve lies between
Technique the external and internal oblique muscles. At this
level, the ilioinguinal nerve lies deeper, between
Anaesthetic solution is administered in a double the internal oblique and transversus abdominus.
“V” (Fig. 1) around the wound or incision site, The traditional way to perform the block is to in-
raising a wheal with the solution. This is a very sert the needle perpendicularly and infiltrate lo-
simple technique. cal anaesthesia at these two levels. However a bet-
Tips
77 It is more comfortable for patient if after rais- 77 The line of anaesthetic solution can be advanced
ing the initial wheal further injections are made by injecting successfully through each wheal.
through that wheal, as it will be less painful.
Common Pitfalls
77 Innervation is generally from lateral to medial, so edge of the wound. Midline lesions are inner-
special attention should be given to the lateral vated bilaterally.
28 J. Currie
1. Aponeurosis of the
external oblique m.
2. External oblique m.
3. Internal oblique m.
4. Anterior superior iliac spine
5. Transversus abdominis m.
6. Iliohypogastric n.
1 7. Inguinal ligament
8. Ilioinguinal n.
9. Genital branch of the
2 genitofemoral n.
3 10. Spermatic cord
11. Pubic tubercle
4 12. Superficial inguinal ring
13. Inguinal hernia
5
6
7
8 13
9
10
11
12
Fig. 2 Inguinal block. The course of the ilioinguinal and iliohypogastric nerves
ter technique is to insert the needle at an angle of ate line, the external oblique becomes aponeurotic,
30°, one-finger’s breadth medial to the anterior and this denser tissue provides a very good end-
superior iliac spine. The needle is advanced par- point as the loss of resistance, as the needle ad-
allel to the inguinal ligament in a caudal direc- vances beyond it is easily felt. At this level, both
tion. A sudden loss of resistance or a ‘pop’ will nerves lie in the same plane between external and
be felt at the level of Scarpa’s fascia and again at internal oblique, and so injection here will give a
the external oblique aponeurosis. Below the arcu- reliable block.
Tips
77 The analgesic solution will track down into the helping to separate the tissue planes. If l-bupiva-
inguinal canal and hence be visible in the opera- caine is used, the analgesia obtained is usually
tive field during surgery. This confirms the posi- good enough and long enough that only simple
tion of the block and may indeed aid surgery by analgesics are needed thereafter.
Common Pitfalls
77 The inferior and medial aspects of the scro- tion of the wound will solve this problem. Spray-
tum are innervated by the genitofemoral nerve. ing local anaesthetic directly onto the wound
Hence a low incision for testicular fixation during has also been shown to be effective. This is not
orchidopexy will be painful, as this nerve will not necessary with a high scrotal incision.
be affected by an inguinal block. Local infiltra-
A6 Local Anaesthesia 29
Indication Indication
This is a very useful block for operations on a limb. This is a useful block for fractured ribs or ante-
Although most commonly used on the leg, it is rior chest wall trauma. It can also provide anal-
also effective for operations on the arm. It is also gesia for upper abdominal surgery.
effective for setting fractures of the upper limb,
such as Colles’ fracture. Technique
Tips
77 It is much easier to insert a cannula into the af- comes numb the lower cuff can be inflated and
fected limb before inflating the tourniquet. Once the upper cuff deflated. In the conscious patient
the limb is exsanguinated obtaining venous ac- this will be much more comfortable, as the cuff
cess is nearly impossible. Venous access should is now over the area of analgesia. If the patient
be obtained at another site in case of complica- is anaesthetised then both cuffs can be left in-
tions. flated to give a better tourniquet effect. The limb
77 A double-cuff tourniquet should be used. The will become very mottled and discoloured – this
technique is to inflate the upper cuff and then is normal.
inject the local anaesthetic. When the limb be-
Common Pitfalls
77 l-Bupivacaine should not be used, as serious side 77 The cuff should be let down slowly, pausing ev-
effects may be encountered as the drug enters ery 10 mmHg or so. This helps to reduce the ef-
the general circulation after cuff deflation. fects of flushing deoxygenated blood and lactic
acid into the general circulation.
30 J. Currie
Tips
Common Pitfalls
77 Careful aspiration is essential before injection, as your finger against the patient’s chest wall. Ad-
the artery and vein lie just above the nerve. This vancing the needle with a syringe attached fa-
will prevent inadvertent intravascular injection. cilitates detection of loss of resistance and pre-
The other major complication of pneumothorax vents entry of air into the pleura if it is acciden-
can be avoided by carefully advancing the nee- tally punctured.
dle whilst stabilising the shaft of the needle with
Indication
Technique
Tips
Fig. 6 Anatomy of the web space Fig. 7 Alternative technique for digital nerve blockade
32 J. Currie
Common Pitfalls
77 The digital arteries are end arteries so vasocon- 77 As always, when injecting around a neurovas-
stricting agents should never be used. cular bundle, care must be taken to avoid intra-
77 Care should be taken when injecting, as the vascular injection. Accidental vascular puncture
pressure caused by an excessive volume of lo- may lead to haematoma.
cal anaesthetic in the tissues can lead to vascu-
lar compromise. Use a 10-ml syringe for the cor-
rect feel.
Penile Block
Indication
Technique
Palpate the symphysis pubis. The injection is made sage through Scarpa’s fascia will usually be felt
on either side of the midline just below the sym- as a ‘give’ but this is membranous fascia, and so
physis pubis, slightly medially to the lateral edge the feel is inconsistent. Buck’s fascia will give a
of the base of the penis (Fig. 7). In an infant this ‘bounce’ (elastic tissue) and a more definite loss
will be approximately 0.5 cm from the midline. A of resistance (Fig. 8).
short-bevelled 23-gauge needle is ideal. The nee- Inject 0.1 ml/kg into the subpubic space, up to
dle is advanced caudally and slightly medially. Pas- a maximum of 5 ml each side.
Tips
77 The penis is a midline structure and is innervated other drugs to be added to the local anaesthetic.
bilaterally. It is important to inject both sides of A good example of this is the addition of 1 mcg/
the root. Anaesthetists often prefer to perform a kg clonidine, which considerably extends the
caudal block for penile surgery. With experience, duration of the block. This is the preferred tech-
this is more consistently effective and allows nique for hypospadias surgery.
Common Pitfalls
77 Careful aspiration is essential to avoid intravascu- 77 Never use a solution containing any vasocon-
lar injection. This is particularly important when strictive agent such as adrenalin.
smaller-gauge needles are used. Advancing the
needle too caudally can result in injection into
the corpus cavernosum or cause a haematoma
from puncture of the dorsal vessels.
34 L. McIntosh and A. H. B. Fyfe
A7 A7 Skin Lines and Wound Healing
L. McIntosh and A. H. B. Fyfe
• Lines of tension in the skin or cleavage lines • Wound healing involves a complex and chang-
are named after the Austrian anatomist Karl ing interplay between haemostatic, inflamma-
Langer, who first depicted them. They are re- tory, epithelial and connective tissue cells.
markably constant between individuals of sim- • Healing may be by primary or secondary inten-
ilar body habitus. In most areas of the body tion. The edges of incised (surgical) wounds re-
these correspond with the skin creases (Figs. 1 main in close apposition and heal by primary
and 2). intention. In cases of extensive loss of epithe-
• Skin lines are important when making and lium or subcutaneous tissue, wound contrac-
closing wounds. Ideally all wounds should be tion occurs with abundant formation of scar
made parallel to Langer’s lines to optimize the tissue to ‘plug’ the defect (secondary intention)
cosmetic outcome. Wounds made across the The final outcome in wound healing may be com-
lines of skin tension promote hypertrophic promised by a variety of systemic and local fac-
scarring. tors, all of which present the surgeon with an op-
• When the type of surgery necessitates crossing portunity for optimisation (Table 1).
Langer’s lines, oblique or S-shaped incisions
may improve cosmesis. Alternatively, Z-plas-
ties may be used.
Fig. 1
Alistair A. H. B. Fyfe
Consultant Paediatric Urologist
Fyfe7es@btinternet.com
Fig. 2
36 L. McIntosh and A. H. B. Fyfe
Local factor
Infection Meticulous aseptic technique
Principles
Atul J. Sabharwal
Consultant Paediatric and Neonatal Surgeon
Atul.Sabharwal@ggc.scot.nhs.uk
Tips
77 Always take great care to ensure that all intra-ab- 77 Similarly, on closure, ensure that none of your su-
dominal contents are well clear of your incision tures catches intra-abdominal structures, such as
as you enter the abdomen. omentum.
Common Pitfalls
77 Failure to identify and control the ligamentum 77 In the neonate, the incision should be a little less
teres may result in haemorrhage if its lumen is than a third of the way from umbilicus to xiphi-
still patent. sternum, as the neonatal liver is often large and
extends well down into the abdomen.
40 R. Partridge and A. J. Sabharwal
A9 A 9M idline Laparotomy
and Paramedian Incisions
R. Partridge and A. J. Sabharwal
Atul J. Sabharwal
Consultant Paediatric and Neonatal Surgeon
Atul.Sabharwal@ggc.scot.nhs.uk
• The underlying peritoneum is similarly elevated • The skin is closed with a running subcuticu-
between curved mosquito artery forceps and lar absorbable suture with or without adhesive
incised. strips.
• This incision in the linea alba is extended to the
length of the skin incision by using cutting mo-
nopolar diathermy on to the surgeon’s finger to Paramedian Incision
avoid damage to the intra-abdominal organs.
• A skin incision is made approximately 2 cm lat-
Closure erally to the midline.
• The anterior rectus sheath is then cleared of fat
• The linea alba is closed with a continuous, slow- and incised vertically.
absorbing or non-absorbable suture. • The rectus muscle retracted laterally.
• The knot should be buried to avoid nodule for- • The transversalis fascia and peritoneum (and
mation. posterior rectus sheath if upper incision) are
• A continuous absorbable subcutaneous suture opened between curved mosquito forceps.
is placed.
Fig. 3 Midline incision made down to the linea alba, Fig. 4 Linea alba and then peritoneum opened between
which is then cleared for ~1 cm each side clips
42 R. Partridge and A. J. Sabharwal
Tips
77 Near the umbilicus the peritoneum fuses with 77 Care should be taken to ensure that no tissue is
the linea alba, and they will be encountered as a interposed between the adjacent sides of linea
single layer. alba as it is closed.
77 It may be necessary to ligate and divide the lig-
amentum teres, depending on the exposure re-
quired.
Common Pitfalls
77 Always take great care to ensure that all intra-ab- 77 Similarly, on closure, ensure that none of your su-
dominal contents are well clear of your incision tures catches intra-abdominal structures, such as
as you enter the abdomen. omentum.
A10 Subcostal and Rooftop Incisions 43
A10 Subcostal and Rooftop Incisions A10
T. J. Bradnock and R. Carachi
Technique
Robert Carachi
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk
Closure
Fig. 3
A10 Subcostal and Rooftop Incisions 45
Indications Indications
Liver surgery and surgery to portal structures are Indications include liver surgery including trans-
indications for use of the rooftop incision. plantation and access to the diaphragmatic hia-
tuses.
Technique
Technique
• The skin incision is extended symmetrically
across the midline to parallel the contralateral • If this incision is planned initially, the bilateral
costal margin. subcostal incisions are usually made lower than
• The incision is deepened to peritoneum, as de- normal.
scribed above. • The linea alba is opened in the midline with
monopolar diathermy up to or through the xy-
Closure phoid process.
Fig. 4 Fig. 5
46 T. J. Bradnock and R. Carachi
Tips
77 Always use your assistant to best advantage to 77 Use a mass closure, in very premature neonates,
apply tension across the tissue being divided. where concern about integrity of individual mus-
77 The divided rectus abdominus is held by tendi- cle layers exists and when an old incision has
nous intersections superiorly and inferiorly to been re-opened.
the incision and retracts very little. Only the rec- 77 The incisions described in this chapter are effec-
tus sheath requires closure. tive because they do not deprive the rectus mus-
77 The isolated subcostal incision can be extended cles of their segmental innervation, which run
up to the xiphisternum to improve access to the with slightly downward obliquely from lateral to
diaphragm or distal oesophagus (‘hockey-stick’ medial direction. Avoid making an incision that
incision). is too oblique.
Common Pitfalls
77 The superior epigastric vessels lie posterior to 77 Ensure the suture line does not overlie costal
the lateral part of rectus abdominus. Be careful margin, as this will impair healing and cause dis-
to identify and control the vessels with ligatures comfort.
or coagulation. 77 Both the subcostal and rooftop incisions give op-
77 Inevitably the small eighth thoracic nerve is di- timal exposure in patients with wide subcostal
vided in a subcostal incision, but the larger ninth angles. In patients with a narrow subcostal angle,
nerve must be identified and preserved in the consider an upper midline incision.
lateral part of the wound, to prevent atrophy of 77 Avoid making bilateral subcostal incisions too
the rectus abdominus. obliquely, as the acute angle this generates may
result in devitalisation of the apical tissue inferior
to the incisions.
A11 Pfannenstiel Incision 47
A 1Pfannenstiel Incision A11
H. Said and R. Carachi
The Pfannenstiel incision provides access to pel- • Before incising the rectus sheath, the distance
vic organs including the urinary bladder, distal above the pubic symphysis should be checked
ureters, ovary and uterus. It offers good exposure, by palpation, to ensure it remains at least one-
without the need for division of the rectus muscles. finger’s breadth.
Technique
Fig. 2
Fig. 1
Robert Carachi
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk Fig. 3
nal oblique and transversus abdominus apo- muscles from the overlying sheath down to the
neuroses and muscles at each extremity. pubic symphysis (Fig. 4).
• The upper edge of the divided rectus sheath is • Take care to avoid the perforating branches of
grasped and elevated with curved mosquito for- the inferior epigastric vessels or to coagulate
ceps. Its midline attachment should be divided and divide them.
with monopolar diathermy extending cranially • The lower flap is mobilised caudally in the same
as far as the umbilicus (Fig. 3). way, as far as the pubic symphysis. Both pyram-
idalis muscles are elevated if well developed;
otherwise they are left attached to the rectus
muscles.
• The rectus and pyramidalis muscles are sep-
arated in the midline by using a combination
of sharp dissection and gentle spreading with
a curved clamp (Fig. 5), until the preperitoneal
and prevesical space is identified.
Fig. 4
Closure
Tips
77 Mark the incision before starting. 77 Leave adequate length of rectus sheath inferi-
77 Preoperatively, place a urinary catheter to empty orly.
the bladder.
Common Pitfalls
77 Inguinal canal injury may occur if the incision ex- 77 Inadvertent injury may occur to the urinary blad-
tends too laterally without curving cranially. der.
77 Injury to the rectus muscle and perforating
branches of the inferior epigastric vessels may
occur.
50 T. J. Bradnock and R. Carachi
A12 A 12Gridiron, Lanz
and Rutherford Morison Incisions
T. J. Bradnock and R. Carachi
Robert Carachi
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk
Closure
Lanz Incision
Fig. 4
52 T. J. Bradnock and R. Carachi
Tips
77 Opening the peritoneum vertically has the the- 77 If it is anticipated that the incision is likely to re-
oretical advantage of reducing the risk of inad- quire extension, it is best to make an oblique in-
vertently opening the rectus sheath and injur- cision, which can be easily extended laterally as a
ing the inferior epigastric vessels medially or cae- muscle-cutting incision.
cum laterally. 77 Maintain a low threshold for extending the orig-
inal incision as described above –‘many big mis-
takes are made through small holes’.
Common Pitfalls
77 Dissect the plane between the internal oblique 77 If a Rutherford Morison incision is used for renal
and transversus abdominus muscles carefully, transplantation, take great care to avoid opening
since the supplying the lower rectus abdominus the peritoneum, as this may allow residual dialy-
muscle and the skin of the lower abdominal wall sis fluid to compromise the operative field.
traverse this plane. Damage results in loss of sen- 77 A gridiron incision may result in damage to the
sation or atrophy and weakness of the lower rec- ilioinguinal or iliohypogastric nerves, which in-
tus muscle. creases the risk of subsequent inguinal hernia.
77 Be careful to avoid inadvertent damage to the
spermatic cord when making a Rutherford Mor-
ison incision. This may be avoided by medial re-
traction of the cord structures.
A13 Sutures and Their Uses 53
A13 Sutures and Their Uses A13
R. Kronfli and G. M. Walker
• Silk
• Ethibond
Gregor M. Walker
Consultant Paediatric and Neonatal Surgeon
Gregor.Walker@ggc.scot.nhs.uk
Tips
77 Use the finest size of suture possible that will pro- 77 Sutures should be removed at an early stage in
vide adequate strength. cosmetically important areas such as the face
and later over areas of increased skin tension,
such as joints.
Common Pitfalls
77 Give specific advice on suture care and/or re- 77 Consider alternative ways of wound closure, e.g.
moval to avoid confusion. glue, staples, SteriStrips.
• Knots must be tied firmly to avoid slipping. • It can be tied two-handed, one-handed or with
• All knots weaken the suture material signifi- instruments.
cantly, but applying excessive tension when ty- • The square knot is reliable for tying most su-
ing the knot will cause critical tissue or suture ture materials.
damage. • It involves two simple knots tied in opposite di-
• The knot should be as small as possible to avoid rections.
unnecessary tissue reaction. • The addition of a further half-hitch creates a
triple-throw knot, which is the standard knot-
tying method used in surgery.
Simple Knot
Robert Carachi
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk
Slipknot
Surgeon’s Knot
• It can be hand tied or instrument tied.
• The surgeon’s knot can be tied two-handed, • The slipknot involves simple knots formed
one-handed or with instruments. around a straight, taut suture end.
• It involves a double knot, followed by a simple • The knot can be advanced to the wound edge
knot in the opposite direction. and then tightened.
• A slipknot can be converted to a square knot
by applying tension to the opposite suture end
to the one that was held taut.
Fig. 4 Slipknot
Tips
77 Time should be taken to ensure knots are tied part of surgical practice. Ensure that you develop
accurately to ensure maximum strength. your understanding and mastery at an early
77 Understanding the basic units of knots, how to stage in your training.
tie them and when to use them is an essential
Common Pitfalls
77 Avoid tying a ‘granny’ knot, which may be 77 When tying deep in a body cavity, ensure you
formed by incorrectly laying down a square knot do not pull upwards while ‘snugging’ down the
(with two half-hitches in the same direction), as it knot, causing damage or avulsion of the tissues.
has the tendency to slip.
58 R. Kronfli and A. J. Sabharwal
A15 A 15Hand Tying
R. Kronfli and A. J. Sabharwal
The hand-tying technique described below is safe 7. Apply an even and adequate tension to com-
and effective in most situations. plete the first part of the knot.
• It is tied by using the left-hand. 8. Now take the lower suture with your thumb
• Because it only requires one hand, it can be tied and index finger and pass it under and over the
while holding an instrument in the right hand. ring finger of your left hand.
• Two-handed knots are slower to tie but are a 9. Hold the top strand of suture in your right
more secure alternative until you have mastered hand between thumb and index finger.
this technique. 10. Hook the middle finger of your left hand un-
• Mastery of the technique cannot be achieved der the strand held by your right hand.
through reading alone; a sound theoretical un- 11. While keeping hold of the left hand strand,
derstanding of the key steps involved will en- bend your left middle finger and pass it around
hance your practical skill development and pre- the distal end of left hand strand near to where
vent you picking up bad habits at an early stage. it is being held.
12. Pass the suture through the loop.
13. The knot is completed by pulling the right
One-Handed Square Knot hand strand towards yourself and moving
your left hand away (hands cross in the sagit-
1. Hold the top strand in your left hand between tal plane again).
the thumb and middle finger, with a loop over 14. Apply an even and adequate tension to ensure
index finger. the knot is tight.
2. Hold the bottom strand in your right hand be- 15. Repeat steps 1–7 for a three-throw knot or
tween your thumb and index finger. steps 1–14 for a four-throw knot.
3. While holding the suture, hook your left index
finger over the taught suture held by your right
hand.
4. Now hook your left index finger around the
distal suture, held between your left thumb and
middle finger.
5. While doing this move your right hand away
from yourself.
6. Pull the left hand strand through the loop to-
wards yourself, while moving your right hand
away (hands cross in the sagittal plane).
Atul J. Sabharwal
Consultant Paediatric and Neonatal Surgeon
Atul.Sabharwal@ggc.scot.nhs.uk
Tips
77 Ensure the knot is flat before tightening. 77 Practice wearing gloves and replicate different
77 To master the art of hand tying, there is no sub- scenarios, e.g. tying in a hole.
stitute for endless practice. Get used to the feel 77 Basic Surgical Techniques by R. M. Kirk is full of in-
of the suture material and what constitutes the valuable advice to enhance your practice – we
‘right’ amount of tension to apply. recommend it.
Common Pitfalls
77 Avoid cutting suture too short to enable a com- 77 A two-handed knot is safer for tying sutures in
fortable hand-tied knot to be performed. very delicate tissues, as it is easier to control and
77 Remember that the one-handed knot requires minimise tension on the threads.
two hands to tighten. Failure to use both hands
results in a slipknot and not a square knot (see
Chap. A14).
60 R. Kronfli and A. J. Sabharwal
A16 A 16Instrument Tying
R. Kronfli and A. J. Sabharwal
Fig. 2
Fig. 3
Fig. 4
62 R. Kronfli and A. J. Sabharwal
Fig. 5
Fig. 6
Fig. 7
A16 Instrument Tying 63
Tips
77 Instrument tying is useful when the ends of the 77 Always grasp the distal end of the suture to
suture material are short but in this situation, it avoid entanglement.
is imperative that you do not keep the short end 77 When tying tissues under tension, use your as-
under tension and tie a slipknot around it. sistant to keep the tissues in opposition until the
77 Pull the suture through as much as comfortably knot is tightened.
possible before tying the knot in order to avoid
wasting suture material.
Common Pitfalls
77 Be careful when handling sutures with the nee- 77 When using monofilament or tying tissues under
dle holder, as repeated grasping may compro- moderate tension, a double throw is required on
mise the strength of the suture. the first half-hitch, followed by a single throw on
77 Tension is more difficult to gauge when instru- the second half-hitch. This is called a surgeon’s
ment tying, compared with hand tying. Avoid ex- knot.
cessive tightening as the sutures may break.
64 O. Quaba and A. Hart
A17 A17 Repair of Vessels, Nerves and Tendons
O. Quaba and A. Hart
Introduction Technique
This chapter provides a basic overview of primary • Align stumps to avoid twisting and ensure ves-
vessel, nerve and tendon repair. All require ade- sel not so slack as to risk kinking.
quate exposure using extensile incisions that avoid • Release constricting/compressing soft tissues.
risk of flexion contracture (e.g. Bruner incision in • Trim to healthy adherent intima, excise further
the digits). Tourniquet control, hand table, accu- ~5 mm of adventitia.
rate haemostasis and self-retaining retractors are • Test proximal inflow/distal retrograde flow to
of benefit. ensure patency and flush with heparinised sa-
• Avoid scars overlying anastomoses and provide line.
good soft tissue envelope. • Use vessel dilator forceps to gently counteract
• Adequate debridement and prevention of in- spasm.
fection is critical. • Anastomosis – use 6/0 (brachial artery) to 10/0
• Use well-padded dressings and protective (digital artery) nylon/Prolene, depending on
splinting (tendon, 4–6 weeks; nerve, 3 weeks; calibre.
vessel 2 weeks). • Insert hardest stitch first (back wall), or if ves-
• Aim for controlled, early active mobilisation. sel can be rotated, triangulate first then fill in
gaps.
• Ensure needle enters vessel at 90°, following
Vessels curve of needle, full thickness bite ~3× the
thickness of vessel wall.
General Principles • Visualise lumen to ensure back wall not caught,
then pass suture through opposing vessel from
• Use magnification (loupes 4.0× are acceptable inside to outside.
for vessels >2 mm in diameter, microscope pre- • Gently knot (externally) avoiding tearing. Next
ferred) and meticulous tissue handling (no con- suture ~2–4 mm away.
tact on the intima, only grasp adventitia). • Irrigate lumen before closure.
• Keep vessels moist with heparinised saline (10 • Usually complete arterial and venous repairs
U/ml) and irrigate the wound bed. before removing clamps and applying topical
• A tension-free anastomosis is critical for pa- vasodilator (e.g. nifedipine)/warm packs.
tency – use a reverse vein graft, if a tension-free • Use soft (e.g. Penrose) drains.
repair cannot be achieved – approximate with • Postoperatively ensure that warming measures
a double microvascular clamp (e.g. Ackland) employed, patient is kept well perfused, and use
low-molecular-weight (LMW) heparin.
Andrew Hart
Consultant Plastic Surgeon
Andrew.Hart@ggc.scot.nhs.uk
Tendons
General Principles
Tips
77 Ensure comfortable setup for microsurgery, with 77 Bury core suture knot in tendon repair (avoid
good access, instruments and assistance. over tightening as this causes bunching).
77 Use wick spears to remove fluid from vessel lu- 77 Bury epitendinous suture knot by taking first bite
mens, or nerves. from inside; cut tendon face to outside.
77 Obtain skeletal stability and perform tendon re- 77 Monofilaments are more forgiving when ten-
pairs before vascular and nerve anastomoses. sioning a core suture, as they glide.
Common Pitfalls
Pressure
Direct pressure with a gauze swab is usually suf- Fig. 1 Diathermy applied to forceps – always ensure no
ficient to arrest minor bleeding. contact with the skin edge
Small vessels may be controlled with diathermy Larger vessels should be clipped – usually using
coagulation, either before they are divided or fol- curved mosquito forceps with the concaved tips
lowing accidental division. The vessel should be facing each other – the vessel divided with curved
grasped with non-toothed or curved mosquito dissecting scissors and a ligature placed beneath
forceps, and current should be applied to any part the forceps and tied (Figs. 2 and 3).
Robert Carachi
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk
Clips
Under-running
Stabilisation of Torrential
Fig. 2 Clipping and cutting a vessel Haemorrhage
Transfixion
Blood Products
Clot Removal
Tips
77 ‘Dab, don’t wipe’ – use dry swabs to dab an area, 77 When assisting, become skilled at helping to
but avoid ‘wiping’ across a surface, as this will dis- control haemostasis – in coordination with the
lodge small haemostatic clot, and may restart primary surgeon use non-tooth forceps to pick-
bleeding. up small bleeding vessels, to which monopolar
diathermy may be applied.
Common Pitfalls
77 Do not panic: apply direct pressure, clear the 77 Always be aware of the skin edges and other
area, identify the bleeding point and apply a suit- structures to which a metal instrument may con-
able technique to control it. duct current.
77 Never diathermy or clip blindly into a pool of
blood or fluid – it will not work, and may cause
damage.
70 R. Partridge and R. Carachi
A19 A 19Debridement
R. Partridge and R. Carachi
Robert Carachi
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk
Reconstruction
Fig. 2 The same child four months later, showing good Fig. 3 A hand which sus- Fig. 4 In theatre the true
result from split skin grafting tained a significant crush extent of the tissue damage
injury necessitated considerable
wound excision
Tips
77 “Irrigate, irrigate, irrigate” – to ensure that all par- 77 Infected or traumatised tissues are more acidic,
ticulate matter had been removed from the preventing the dissociation of local anaesthetics
wound. and limiting their effectiveness
77 In children, general anaesthesia is usually re-
quired for proper wound inspection and exci-
sion.
Common Pitfalls
77 Foreign material may have penetrated deep into 77 The true extent of the tissue injury is usually much
the wound. greater than it at first appears (Figs. 3 and 4).
77 Be careful not to miss damage to deeper struc-
tures such as muscles, bones, joints, nerves and
underlying cavities.
72 G. M. Walker and S. Ramsay
A20 A20 Management of Acute Thermal Injuries
in Children
G. M. Walker and S. Ramsay
The majority of thermal injuries in children are – Deep dermal – deep red/speckled, altered
scalds, typically affecting infants. Outcome is de- sensation, with or without blistering, slow
pendant on optimal early management and resus- capillary refill
citation. Large burns are best managed in burn – Full thickness – white or leathery (black in
centres with appropriate experience and multidis- flame burns), insensate, dry, no capillary re-
ciplinary teams. fill
• Obtain accurate weight.
Sharon Ramsay
Specialist Burns Nurse
Sharon.Ramsay@ggc.scot.nhs.uk
Fig. 1 Lund and Browder chart for assessment of TBSA affected in paediatric burns. Note age-related changes in pro-
portion of head and lower limbs to TBSA. Injury is drawn onto chart and proportions of each body part injured are
added together to give a %TBSA. NB: Erythema is not included in calculations
Fig. 2b
Tips
Common Pitfalls
Fig. 1
tempts at intravenous access lasting not more • May be used to establish venous access when
than 60 s should be made before recourse to IO attempts at percutaneous venipuncture have
access in a shocked child. failed. Its use in the resuscitation of critically
• As a rule, fluids or medications that can be
given centrally can be given by the IO route.
Technique
ill children when immediate vascular access is • Place one throw on the proximal ligature but
required has been replaced by IO cannulation. leave it untied. Elevating this ligature prevents
• Commonly used veins include the long saphe- back bleeding when the vein is opened.
nous vein (Fig. 4), the basilic or cephalic veins • If the vein is large, use an 11 blade to create a
at the antecubital fossa or the femoral vein. short longitudinal or transverse venotomy, tak-
• The long saphenous vein is most commonly ing care not to transect the vein. Alternatively,
used and can be readily accessed at the ankle in small veins the needle or catheter can be in-
because of its superficial location. serted directly into the exposed vein without
the need for a venotomy.
• Relax the proximal ligature to allow the tip of
the catheter to pass (Fig. 9).
• If a PICC line is inserted always confirm cor-
rect placement with fluoroscopy.
• If the position is satisfactory, secure the prox-
imal ligature around the vein and catheter.
• After aspirating and flushing the system with
normal saline, attach the intravenous tubing.
• Close the skin with interrupted absorbable su-
tures and simple dressing (Fig. 10).
Fig. 5 • Ensure the catheter is secure with additional
fixation sutures or dressing as required.
Technique: Long Saphenous Venous Cut-
Down
Fig. 6
Fig. 7
Fig. 8
Fig. 9
A21 Venepuncture, Intraosseous Access and Venous Cut-down 81
Fig. 10
Tips
77 In neonates, a ‘cold light’ may help delineate 77 If an IO needle is not available, a bone marrow or
small veins on the dorsum of the hand. spinal needle can be used as an alternative.
77 Avoid excessive squeezing of the limb or suc- 77 Alternative sites for IO access include the distal
tion with a syringe when obtaining blood sam- tibia proximal to the medial malleolus and the il-
ples, particularly in neonates and infants, as this iac crest.
leads to haemolysis of the blood and erroneous 77 Revise the anatomy of the vein and surrounding
blood results. tissues prior to attempting venous cut-down.
77 Whilst awaiting the x-ray to confirm the PICC
line position run an infusion of normal saline at
1 ml/h to prevent the line becoming occluded
with clot, which can happen rapidly.
Common Pitfalls
Procedure
Isolation of Vein
Tunnelling of Catheter
Types of Catheters
• Broviac/Hickman
• Single/multiple lumen
• Sizes 2.7–12 Fr
If a portacath is being inserted please follow the
additional steps described in Chap. A23.
Fig. 3
Venotomy
Confirmation of Position
Closure
Tips
77 Consider local anaesthetic infiltration when tun- 77 Venotomy can be closed around catheter with
neller is in situ to avoid inadvertent damage to ‘figure-8’ stitch if necessary using a fine vascular
catheter or intravenous administration. suture – do not use purse-string.
77 If catheter does not pass freely through venot- 77 If patient has had previous central lines, imag-
omy, consider malposition. ing of veins may be helpful with ultrasound scan
(USS) or a magnetic resonance (MR) venogram.
Common Pitfalls
77 Avoid making your incision too medial or too 77 Avoid cutting the line too short.
low. 77 Avoid piercing the line while closing the neck
77 Beware of the carotid artery and vagus nerve wound.
when dissecting within the carotid sheath.
77 When tunnelling, avoid bringing catheter out
too close to the vein as this can cause kinking of
the line.
A23 Percutaneous Insertion of Central Venous Lines and Portacaths 85
A 23Percutaneous Insertion A23
of Central Venous Lines and Portacaths
R. Kronfli and M. E. Flett
See Fig. 1.
• Supine
• Roll under scapulae
• Neck extended and turned 30° to contralateral
side
Tunnelling
Closure Portacath
• Neck wound is closed with absorbable suture. • Accessing vein is done as above described.
• Position should be confirmed radiologically be- • At tunnelling stage, make pocket for port sub-
fore use if possible. cutaneously.
• Absorbable suture is placed snug to wound • Tunnel, cut and flush the line as above.
around catheter at the exit site. • Attach to port.
• Non-absorbable suture to secure catheter at • Dilatation is done as above described.
exit site are placed. • Closure is as above; however port is secured to
fascia with non-absorbable suture.
• Site is closed with absorbable suture.
Other Common Sites
Types of Catheters
• Broviac/Hickman
• Single/multiple lumen
• Sizes 2.7–12 Fr
Tips
77 Use non-Luer lock syringe on ‘seeker’ needle to 77 If placing a port, consider patient characteristics
facilitate removal prior to inserting guide wire. prior to choosing site.
77 Consider local anaesthetic infiltration when tun- 77 If patient has had previous central lines, imaging
neller is in situ to avoid inadvertent damage to of veins may be helpful.
catheter or intravenous administration.
Common Pitfalls
77 Hold ‘seeker’ needle securely in place when re- 77 Avoid cutting the line too short.
moving syringe to avoid malposition. 77 Avoid piercing the line while closing the neck
77 When tunnelling, avoid bringing catheter out wound.
too close to the vein as this can cause kinking of
the line.
A24 Principles of Tumour Biopsy 87
A24 Principles of Tumour Biopsy A24
P. Hammond and C. A. Hajivassiliou
Principles Practice
Constantinos A. Hajivassiliou
Consultant Paediatric and Neonatal Surgeon
ch27z@udcf.gla.ac.uk
Fig. 2 ‘cocked’ spring (depth of biopsy may be determined with yellow ratchet)
Tips
77 Tumour tissue is friable with abnormal vascula- be adherent to the tumour and when collapsed
ture. Bleeding is common. Methods for tampon- may not be demonstrated on routine imaging
ade should be used as far as possible. modalities. Interposed loops of bowel are at risk
77 If in any doubt opt for biopsy under local vi- of damage during blind biopsy attempts.
sion, as viscera (especially loops of bowel) could
Common Pitfalls
77 Primary re-excision may be required if an inade- 77 Non-diagnostic biopsy is more likely if necrotic
quate excision biopsy is attempted. or non-solid elements are biopsied.
90 P. Hammond and C. A. Hajivassiliou
A25 A25 Skin and Muscle Biopsies
P. Hammond and C. A. Hajivassiliou
Fig. 1 Fig. 2
Constantinos A. Hajivassiliou
Consultant Paediatric and Neonatal Surgeon
ch27z@udcf.gla.ac.uk
Fig. 3 Fig. 4
Fig. 5
Tips
77 Avoid monopolar diathermy prior to removal of and/or skeletal deformities. These may necessi-
the sample as this may damage the sample tate the use of alternative muscles for biopsy if
77 Patients undergoing muscle or skin biopsy are access to the anterior thigh is problematic.
often quite ill and have associated neurological
Common Pitfalls
77 Ensure that an adequate mass (especially length) 77 Failure to achieve an adequate biopsy will ne-
of tissue is obtained, as multiple diagnostic tests cessitate a further general anaesthetic in a com-
may be performed on the specimen. plex patient.
92 J. Andrews and R. Carachi
A26 A26 Excision of Common Skin Lesions
J. Andrews and R. Carachi
• The degree of skin involvement determines the lesion, as they will retract into fat and be diffi-
incision: A, straight; B, elliptical; or C, wide el- cult to control.
liptical (Fig. 1). • Coagulate and divide the vessels safely using
• Mark the position of the intended skin inci- bipolar diathermy (Fig. 5).
sion. Try to make it along Langer’s lines (see • If a large elliptical incision was used, it can be
Chap. A7). helpful to undermine the skin to reduce tension
on the wound (Fig. 6).
• Closure – interrupted absorbable sutures to fat
and Scarpa’s fascia. A continuous subcuticular
absorbable suture to skin should be placed.
Fig. 1
• Use skin hooks or cats paw retractors to gen-
tly retract the edges of the incision (Fig. 2).
• Deepen the incision through subcutaneous fat
using dissecting scissors until the lesion is iden-
tified.
• It may be possible to grasp the capsule with
curved mosquito forceps to provide gentle trac-
tion (Fig. 3).
• Be particularly careful not to rupture the cap-
sule if the lesion is cystic.
• Dissect loose connective tissue off the lesion Fig. 2
using dissecting scissors or bipolar forceps
(Fig. 4).
• Avoid inadvertently tearing the feeding vessels,
which usually run into the deep aspect of the
Robert Carachi
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk Fig. 3
Fig. 4
Fig. 5
Fig. 6
94 J. Andrews and R. Carachi
Tips
77 Pilomatrixoma is often tethered to skin – an el- 77 If a cavity is present following excision, inter-
liptical incision should be made in these cases to rupted vertical mattress sutures help evert the
reduce the risk of recurrence. skin edges. If there is significant tension on the
77 Use deep interrupted absorbable sutures to wound, interrupted horizontal mattress sutures
obliterate the residual cavity after excision of reduce the risk of the sutures cutting out (Fig. 7).
larger lesions and consider using a pressure 77 Lipomas (rare in children) can usually be ‘shelled
dressing. Failure to do so increases the risk of out’ though a smaller incision than the lesion it-
haematoma or seroma formation. self. Avoid making a larger incision than is re-
quired.
Fig. 7
Common Pitfalls
77 Pyogenic granuloma – if feeding vessels are left 77 Viral warts – these are usually self-limiting and
behind, it will recur, so make sure you deal with can be treated with topical irritants, cryotherapy,
these. excision, curettage and bipolar electrocautery.
77 Epidermoid cyst – it is easy to cause the cyst wall The optimal method depends on the site and ex-
to rupture. If rupture occurs, curved mosquito tent of involvement. Always seek to minimise
forceps can be applied to contain the contents. scarring in exposed sites.
If sebum leaks into the wound, perform a thor-
ough washout followed by careful excision of
any residual capsule to prevent recurrence.
A27 Compartment Syndrome and Lower-Limb Fasciotomy 95
A 27Compartment Syndrome A27
and Lower-Limb Fasciotomy
J. S. Huntley
Indications
Fig. 2 Lower-limb cross-sectional anatomy with recommended skin and fascial incisions
A27 Compartment Syndrome and Lower-Limb Fasciotomy 97
Tips
Common Pitfalls
77 Delayed diagnosis (and therefore delayed treat- 77 Compartment syndrome does not usually affect
ment) is the commonest cause of a poor out- the distal pulses, so do not be reassured by their
come. presence.
77 Beware the unconscious patient in whom the 77 Remember the superficial peroneal nerve has a
cardinal clinical signs will not be evident. variable course.
77 The cardinal signs are also masked when nerve 77 If the muscle has already died, then compart-
blocks have been used or when there has been ment release may cause a reperfusion injury, al-
nerve injury. low access to infection. Compartmentectomy or
amputation may follow.
98 J. S. Huntley
A28 A 28Plastering
J. S. Huntley
Indication
Tips
77 Have enough extra assistants to hold the limb 77 Take care not to wind too tightly – the muslin of
correctly (one for arm/forearm; two for tibia/ a plaster cast is not distensible like an elastic ban-
lower limb) before you start. dage.
77 Have the ‘tails’ of the plaster rolls exposed before
you dip them (Fig. 1).
Common Pitfalls
77 Excessive padding can lead to a cast that slips, 77 Other risks for thermal injury are:
fails to maintain position and can cause skin ul- – If too many pl of cast are applied, e.g. folding
ceration. a posterior slab back on itself over the calf (in-
77 If the cast is too long this will restrict movement stead of cutting it) when it is realised to be too
at adjacent joints, e.g. with forearm casts, spe- long
cial attention should be paid to movement at the – Inappropriate molding (putting focal pressure
thumb and metacarpophalangeal joints. onto underlying tissue)
77 Foreign bodies under cast can cause ulceration. 77 If a cast is applied before limb swelling is com-
‘Plaster instructions’ issued to the patient/par- plete (e.g. if a tourniquet has been used), or if too
ents must emphasise that nothing should be in- forceful a mould is applied then there is the dan-
serted down the inside of the cast. ger of an extrinsic compartment syndrome. Pres-
77 Plaster burns can occur if the dipping temper- sure can be relieved by splitting the cast.
ature is too hot, i.e. more than lukewarm – re-
member that the plaster temperature rises
above the dipping temperature because the re-
action is exothermic.
A29 Traction and the Thomas Splint 101
A29 Traction and the Thomas Splint A29
J. S. Huntley
Indication
Operative Technique
Tips
77 A bandage roll is a useful spacer for the spreader 77 Elevating the foot of the bed may be necessary
plate of the traction tapes when the tapes are to provide partial counter-traction.
being applied.
Common Pitfalls
77 Skin traction is contraindicated if there are abra- 77 The ring must not be tight in the groin as there is
sions, lacerations or significant skin conditions. a real risk of pressure sore here.
104 J. S. Huntley
Indication
Operative Technique
Tips
77 It is useful to release the tourniquet before skin 77 Tourniquets should only be used on limbs with a
closure so that bleeding points can be identified normal blood supply.
and haemostasis obtained. 77 The pressure gauge should be checked regularly.
77 Record the tourniquet site, time and pressure as
well as the patient’s index blood pressure.
Common Pitfalls
77 External compression for exsanguination is con- 77 After tourniquet use, the limb swells significantly
traindicated in patients with a suspected infec- – beware of external compression by bandages/
tion or malignant lesion. splints/casts.
77 Do not rotate the tourniquet once applied, as 77 Skin damage or ‘tourniquet burns’ can occur
this may cause a shearing injury to the skin. when solutions have tracked under tourniquets.
77 An inadequately inflated tourniquet may func- 77 Two hours is the upper time-limit for tourniquet
tion as a ‘venous tourniquet’, blocking venous use.
outflow from the limb, though arterial inflow can
still occur. This situation is worse than no tourni-
quet at all.
A31 Drains and Drain Fixation Techniques 107
A31 Drains and Drain Fixation Techniques A31
R. Partridge and A. J. Sabharwal
• Drains may be placed in a variety of cavities to • Tie suture to the skin, leaving both tails long.
channel away fluids. • Wind each end around the tube once and tie
• They may be used to: again.
– Prevent a collection • Assistant should hold the tube upwards.
– Herald a collection • Threads are wound around tubing, advancing
– Drain an established collection along its length, ~1 mm with each wrap.
– Maintain a tract • A single throw is placed each time the threads
• Their role is debated however. cross (i.e. at each turn)
• They are often unreliable, cause discomfort, • Each throw should be tight enough to indent
and present a route for infection ingress. the tubing.
• Drains may use gravity, suction or capillary ef- • The tubing should be forced into a slightly tor-
fect. tuous shape; otherwise it is unlikely to have a
• A secure method of keeping them in place is firm enough grip and liable to slip.
essential.
Locking-Turns Technique
Dressings
Fixation Techniques
• Many dressing techniques have been described
• Wicks, corrugated and Yate drains may be se- to assist in the safe anchoring of drains.
cured with a simple stitch at the entry site. • Placing a dressing such that there is a ‘mesen-
• A safety pin may be used on the end of the tery’ of dressing holding the drain off the skin
drain to prevent it falling into the cavity. is thought to be advantageous
• Tube drains require a more elaborate fixation, • Conclusive evidence of benefit of one tech-
as below. nique over another is lacking.
Atul J. Sabharwal
Consultant Paediatric and Neonatal Surgeon
Atul.Sabharwal@ggc.scot.nhs.uk
Fig. 1 Wick-ganze/Penrose
Fig. 2 Corrugated
Tips
77 Suture choice: a non-absorbable suture should 77 Either monofilament or braided are accept-
be used. able, although a braded suture possibly provides
slightly superior grip on the tubing.
Common Pitfalls
Andrena Kelly
Clinical Nurse Educator
Andrena.Kelly@ggc.scot.nhs.uk
Yvonne Bennett
Clinical Nurse Specialist in Stoma Care
Yvonne.Bennett@ggc.scot.nhs.uk
Film dressings
Transparent, adhesive, va- Epithelialising
Iv 3000 pour permeable but imperme-
able to ingress of bacteria Lightly exuding
Op-site
Primary dressing for central and
Tegaderm peripheral intravenous lines
Anti-microbial dressings*
Acticoat A wide range of dressings im- Critically colonised or infected
pregnated or coated with sil- wounds including MRSA and VRE
Activon honey range ver, honey, iodine or PHMB
Burns
Inadine These products either inhibit growth
of or kill bacteria at the wound bed. *Silver and iodine can be absorbed
Iodoflex percutaneously and are not recom-
mended in neonates and infants
Silvercel younger than 6 months of age
Suprasorb x + PHMB
Urgotul ssd
Skin protectants
Provide a protective film over Use under adhesives to prevent
Cavilon range skin to prevent excoriation. skin stripping on removal
Must be used sparingly
Lbf no-sting barrier film Available in spray, foam ap- Periwound skin to pre-
plicators or cream vent excoriation
Nappy area
A32 Principles of Wound Management 113
Larvae
Larvae of the Lucilia sericata avail- Rapid and selective debride-
Biofoam dressing able in pots (larvae) or contained ment of devitalised tissue and
in a net dressing (biofoam). eradication of bacteria in a va-
Larvae (free-range maggots) riety of wounds in 3–5 days
Repeated applications may be
required in larger wounds
Topical negative pressure
Gauze or foam dressings occluded Cavity wounds
Renasys (Smith and Nephew) under a film and attached by tub-
ing to a negative pressure pump. Dehisced surgical wounds
Vacuum-assisted closure (KCI) Pressures of –50 to –75 mmHg are
appropriate for paediatric patients Flaps and grafts
Venturi (Talley)
Traumatic wounds
MODERATE/HIGH
COLONISED – the pres- Higher levels of Use of appropriate Thin hydrocolloid,
ence of multiplying micro- wound exudate dressings to absorb Non-adherent contact non-adhesive or
organisms in the wound Exudate may be higher levels of layer containing adhesive foam+
with no host reaction brownish in colour exudate and thus silver sulphadiazine retention bandage
Wound contin- reduce bacterial load Honey LOW EXUDATE
ues to heal Hydrofibre Simple absorbent
dressing + tape or
retention bandage
MODERATE/HIGH
CRITICAL COLONI- Delayed healing Reduce bacterial Non-adherent contact Non-adhesive or
SATION – numbers Unhealthy/friable load at wound layer containing adhesive foam+
of micro-organisms granulation tissue bed to allow silver sulphadiazine retention bandage
in the wound are at a Increased normal healing Honey LOW EXUDATE
critical level and without exudate/odour process to return Iodine products* Simple absorbent
intervention the wound Dusky/dull Hydrofibre dressing + tape or
will become infected wound bed retention bandage
Increased pain
MODERATE/HIGH
WOUND INFECTION – Erythema To reduce bacterial Honey Non-adhesive or
the presence of multiply- Increased pain levels at wound bed Iodine products* adhesive foam+
ing micro-organisms with Increased swelling and treat infection Silver alginate retention bandage
a subsequent host reaction Associated pyrexia Silver hydrofibre LOW EXUDATE
Increased exudate Simple absorbent
Increased dressing + tape or
malodour retention bandage
MODERATE/HIGH
The presence Remove non-viable Indications for use Non-adhesive or
POINTS TO REMEMBER of necrotic or tissue if appropriate, Wear time adhesive foam+
devitalised tissue seek advice if the How to apply and retention bandage
will increase the patient is diabetic remove safely Do not use two
bacterial burden or there is any arte- different types of an-
within the wound rial insufficiency timicrobials together
*Iodine should not
be used in patients
<6months old
116 A. Rodgers, A. Kelly and Y. Bennet
The perianal skin is vulnerable to excoriation af- complications including pain sepsis and delayed
ter abdominal surgery, and for use of antibiot- discharge from hospital. Table 4 summaries our
ics, in the immunocompromised patient. Meticu- management algorithm.
lous care of the skin in this region is vital to avoid
Napkin Care Guidelines
Normal Mild Moderate Severe Candidiasis
Erythema (redness). Erythema (redness) Erythema (redness) Bright red rash with satellite
No broken skin + small areas of large areas of lesions/pustules at margins. This
broken skin broken skin rash may extend onto groins and
skin folds. This may occur along
with excoriation
• Cleanse by irrigating with warm water +/- an Emollient and a 20ml syringe.
Passing Frequent Stools YES
• Pat intact skin dry
NO
• Cleanse with water and soft • Apply Cavilon spray twice • Apply Daktacort cream twice daily for 3 days then stop • DO NOT use Cavilon film if
cotton wipe daily • Apply Cavilon spray twice daily candidiasis present
• Pat dry • Apply 1% Ichthammol in zinc • Apply Orabase Paste and Yellow Soft Paraffin 50:50 mixture at each • Apply Clotrimazole 1% 3 times
• Apply yellow soft paraffin ointment at each nappy nappy change daily
• Use a gel core nappy and change • Use a gel core nappy and change frequently. If age/condition permits • Apply barrier cream according
change frequently or as soon • Use a gel core nappy and nurse exposed on an open nappy to mild/mod/severe guidance
as possible after soiling change frequently or as soon • If no improvement in 72 hours or rapid deterioration in skin contact as appropriate
as possible after soiling Tissue Viability Nurse/Dermatology/ Stoma Specialist Nurse • Consider oral Nystan
• Continue Clotrimazole 1% for
3 weeks even if symptoms
have resolved
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
Fig. 1
Fig. 2
B1 Layers of the Scalp and Suturing 123
Fig. 3
Fig. 4
Fig. 5
124 D. Datta and S. Agarwala
Tips
77 The scalp is highly vascular so pay close atten- sion across the suture line, but if excessive con-
tion to haemostasis. The use of local anaesthetic sider a rotational flap.
agents with adrenaline may help to reduce 77 For neurosurgical procedures make U-shaped
bleeding (see Chap. A6). flaps reflected on an inferior pedicle, based on
77 The thickness of the scalp skin allows some ten- the vascular anatomy.
Common Pitfalls
77 Inadequate debridement of devitalized tissue tion of the healing wound, resulting in a wide
predisposes to infection and poor wound heal- scar.
ing. 77 Always palpate the pericranium at the base
77 Failure to approximate the epicranial aponeuro- of the wound. Failure to do so may result in a
sis promotes haematoma formation and distrac- missed underlying depressed skull fracture.
B2 External and Internal Angular Dermoid Cyst 125
B2 External and Internal B2
Angular Dermoid Cyst
P. Sekaran and N. Brindley
The soft tissues of the face are formed by the fu- Operative Technique
sion of the frontal, maxillary and mandibular pro-
cesses. Dermoid cysts occur when skin elements • The incision is made just above or below the
become trapped along lines of embryological clo- lateral part of the eyebrow, overlying the cyst
sure. The external angle of the supraorbital ridge (Fig. 2).
is the most common site of occurrence (Fig. 1). • Alternatively, the incision can be hidden in the
superior palpebral fold.
Fig. 1 Fig. 2
Nicola Brindley
Consultant Paediatric and Neonatal Surgeon
Nicola.Brindley@ggc.scot.nhs.uk
ndoscopic-Assisted Excision of
E
External Angular Dermoid Cysts
Fig. 4
Closure
Fig. 5
B2 External and Internal Angular Dermoid Cyst 127
Tips
77 Always obtain preoperative MRI imaging for in- 77 MRI can be used selectively in patients with ex-
ternal angular and midline nasal dermoid cysts. ternal angular dermoid, with imaging reserved
for cases with suspicious features.
Common Pitfalls
77 Skull x-rays do not reliably exclude intracranial 77 Making the incision within the eyebrow dam-
extension. ages hair follicles and may distort the eyebrow,
77 If cyst rupture occurs during excision, irrigate the resulting in a poor cosmetic result.
cavity with normal saline to remove debris and
ensure that the entire cyst wall is excised to re-
duce the risk of recurrence.
128 P. A. M. Raine
B3 B3 Cleft Lip and Palate
P. A. M. Raine
Repair of a cleft lip confers not only cosmetic • Medial rotation flap and lateral advancement
and aesthetic benefits, but also functional ben- flap
efits. Speech, feeding and dental hygiene are all • Small columellar lengthening rotation flap
improved by normally functioning labial closure. • Detachment of orbicularis oris muscle fibres
Approximately 3 months of age is commonly ac- from abnormal insertions and careful recon-
cepted as the optimal time for lip repair. struction of sphincter function
• Repositioning of alar cartilages to achieve na-
Preoperative Preparation sal tip symmetry
• Closure with fine absorbable 5/0, 6/0 and 7/0
• Preoperative orthodontic care achieves better sutures
alignment of the maxillary segments and nar-
rowing of the cleft gap, which aids surgical clo- Bilateral Repair (Manchester Technique)
sure.
• Satisfactory weight gain, normal haemoglobin This repair is based on the above-stated principles.
and control of comorbidities are prerequisites • Complicated by the excessive anterior promi-
for surgery. Absence of oral, nasal, dental or nence of the premaxilla
upper respiratory tract infection is also neces- • Apposition of orbicularis oris fibres in midline
sary. • Straight line closure of lateral lip segments and
prolabium
Operative Technique
Fig. 3 Bilateral cleft lip repair Fig. 4 Completed bilateral cleft lip repair
130 P. A. M. Raine
Tips
Pitfall
Fig. 5 Soft palate cleft incisions Fig. 6 Furlow soft palate repair
B3 Cleft Lip and Palate 131
Fig. 7 Secondary cleft palate incisions Fig. 8 Langenbeck secondary cleft palate repair
Furlow Soft Palate Repair (Including Langenbeck Repair for Both Secondary and
Submucosa Cleft of Soft Palate) Primary Hard Palate Clefts
Tips
77 Avoid excessive mobilisation, which leads to in- for later orthodontic or secondary orthognathic
terference with jaw growth, disruption of man- surgery.
dibular/ maxillary arch relationship and the need
Pitfalls
• Be sure that the wound is appropriate for clo- • Traumatic wounds should be thoroughly
sure by primary intention and that you are the cleaned and any foreign bodies must be re-
right surgeon for the job – does it need a plas- moved – with adequate anaesthesia, a scrub-
tic maxillofacial or ear nose and throat (ENT) bing brush can be used initially, then irrigate
surgeon? with saline before closure (Fig. 1).
• Consider what type of anaesthesia is appro- • Identify and document the depth of the wound
priate (local anaesthetic or general anaesthetic – can you palpate a step in the skull table or see
[LA or GA]) – this often requires discussion a visible fracture?
with the parents. • It may be appropriate to debride the wound or
• Prepare the area, but be careful with prep near freshen ragged edges.
the eyes and mucous membranes – you may • General surgical principles require that trau-
need to irrigate the eyes with saline at the end. matic wounds should be closed with inter-
rupted non-absorbable sutures. In paediatrics
Fig. 1a–c
Fig. 2a,b
Carl F. Davis
Consultant Paediatric and Neonatal Surgeon
Carl.Davis@ggc.scot.nhs.uk
Fig. 3a, b
Tips
77 Use 5-0 or 6-0 sutures on the face. 77 Antibiotics are not generally indicated, but
77 A small dressing (e.g. a Steri-Strip) will keep a should be used for animal and human bites.
toddler’s fingers away from the wound (as will 77 For ear injuries, expedite coverage of exposed
glue). cartilage and minimise haematoma, consider re-
ferral to a specialist.
Common Pitfalls
77 Scalp lacerations in trauma can be multiple and 77 Local anaesthesia can distort the anatomy, par-
are easy to miss due to hair – examine thor- ticularly of the vermilion border or alar rim –
oughly for additional injuries before the proce- mark areas with indelible ink before infiltration,
dure. or infiltrate after closure if using GA.
134 R. Carachi
B5 B 5Ear Deformities
R. Carachi
Fig. 1
Fig. 2
Fig. 3
136 R. Carachi
Fig. 4
Fig. 6
Fig. 5
Tips
77 Avoid implantation as it can cause a dermoid. 77 Tape the head dressing to avoid slippage.
77 Haemostasis is necessary to avoid haematoma. 77 Leave dressing for 1 week before removal.
Common Pitfalls
Fig. 1
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
Tips
77 The distinction of polyotia from a skin tag rests 77 The accessory ear often has a substantial conchal
largely on size and a subjective level of resem- hollow and in these cases exploration reveals a
blance to a normal external ear. None is as large cartilage-lined cheek defect. This should be filled
as the normal auricle, nor is any a complete du- prior to skin closure with spare cartilage, and
plication. Some are a mirror image, and others may be achieved using excised cartilage from
are based on a different axis. the accessory ear.
Fig. 3
Tips
77 During the first branchial cleft cyst dissection 77 Dissection of sinus tract may be facilitated by
where the tract is leading up to or into external passing a probe or heavy nylon suture through
auditory meatus, injury to adjacent facial nerve is the tract.
to be avoided. Nerve stimulator is helpful during
dissection. (Fig. 7)
Common Pitfalls
77 Avulsion of the tract midway during dissection 77 Injury to the adjoining nerves and vessels if one
due to undue traction dissects away from the surface of the tract
140 S. Panda and S. Agarwala
Common Pitfalls
77 Injury to the facial nerve in attempting to excise 77 Too-tight closure of the skin, leading to wound
the deep portion of the cartilage breakdown and ugly scar formation
B7 Parotid Dissection 141
B 7Parotid Dissection B7
F. B. MacGregor
Operative Technique
Fig. 4
B7 Parotid Dissection 143
Tips
77 Remind the anaesthetist not to use muscle re- 77 Enhance haemostasis by elevating the head of
laxant. the bed and use adrenaline patties if there is
77 Take a brief rest after nerve trunk has been ex- small ooze around the nerve.
posed. 77 Use regular saline washes.
77 Careful haemostasis is vital so you can see the
fine branches of the nerve.
Common Pitfalls
77 Avoid repeated stimulation of the nerve as this 77 The main trunk is much more superficial than in
may cause temporary weakness. adults and it is at a higher level. The lower divi-
77 Avoid dissecting down a deep hole. sion runs very superficially over the angle of the
77 Open the wound widely to gain good access and mandible.
illumination when identifying the nerve.
77 A parotidectomy is more challenging in children
because the nerve is smaller and there is a lack of
development of the mastoid tip.
144 L. McIntosh and R. Carachi
B8 B 8R anula and Tongue-Tie
L. McIntosh and R. Carachi
Simple Ranula
Fig. 1
• General anaesthesia is used with oral or nasal • Make an incision directly over the gland with
endotracheal intubation. monopolar or bipolar diathermy (Fig. 3).
• Avoid muscle relaxation so that tongue move- • Alternatively, making an incision in the lingual
ment can be observed as an indicator of prox- gingival sulcus at the level of the first molar
imity to the motor nerve supply to the tongue. and raising a full-thickness mucoperiosteal flap
• Pack the hypopharynx with a gauze swab. gives good exposure.
• Good exposure can be achieved with a mouth • Well-encapsulated lesions should be removed
gag or small retractors. using dissecting scissors and bipolar diathermy,
• Place a silk stay suture through the tip of the without excising the gland. Loculated or rup-
tongue for retraction.
• Identify the paired submandibular (Wharton’s)
duct orifices, which lie immediately adjacent to
the lingual frenulum (Fig. 2).
• Cannulate the ipsilateral duct orifice with a lac-
rimal probe to avoid inadvertent injury.
• Place four stay sutures around the planned mu-
cosal incision (Fig. 3).
Robert Carachi
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk Fig. 3
Tips
77 Most tongue-ties are asymptomatic and do not 77 Breastfeeding immediately post–tongue-tie divi-
require division. sion may help achieve haemostasis.
77 The first-line treatment for difficulties establish- 77 Warn parents to expect a white strip of tissue to
ing breastfeeding should be with breastfeeding persist under the tongue for several days post–
support specialists. tongue-tie division.
77 Division of a tongue-tie may improve feeding in
bottle-fed neonates although there is currently
little evidence to support this.
Common Pitfalls
77 Use the approaches to a ranula described oppo- vical approach with excision of the submandibu-
site, to avoid inadvertent injury to the lingual or lar gland. Consider a computerized axial tomog-
hypoglossal nerves. raphy (CT) and/or magnetic resonance imaging
77 A ‘plunging’ ranula is a pseudocyst which oc- (MRI) and ear, nose and throat (ENT) referral.
curs due to mucous extravasation. Typically 77 Avoid allowing the infant to use a dummy imme-
they pervade deeply through the fascial planes diately post ranula excision as this may trauma-
of the neck. They may mimic congenital lym- tise the incision.
phatic malformations and usually require a cer-
B9 Excision of Thyroglossal Cyst and Fistula 147
B9 Excision of Thyroglossal Cyst and Fistula B9
N. Sugandhi and S. Agarwala
Fig. 2
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com Fig. 3
Fig. 4 Fig. 5
Tips
77 Avoid excessive traction of the fistulous tract. 77 Dissect carefully posterior to the body of hyoid
to avoid damage to the thyrohyoid membrane.
Common Pitfalls
77 Not removing a cylinder of tissue superior to the 77 Incomplete dissection of the tract to the base of
hyoid bone the tongue
B10 Lymph Node Biopsy 149
B10 Lymph Node Biopsy B10
A. Verma and S. Agarwala
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
Tips
77 Always revise the relevant regional anatomy 77 Sometimes multiple, large matted lymph nodes
prior to lymph node biopsy and be vigilant to are found, and it may only be possible to per-
avoid injuring the associated nerves and major form a wedge biopsy. This is best done with a
vessels. knife and not diathermy to avoid compromising
77 Retracting deep-seated nodes with Babcock’s the specimen.
forceps may be useful but be careful not to dis- 77 When approaching the jugulodigastric node,
tort the nodal architecture. make your incision at least 2.5 cm inferior to
the mandible to avoid the marginal mandibular
branch of the facial nerve (see below).
Common Pitfalls
77 Selecting a small node that may not be represen- 77 The upper part of the deep cervical chain of
tative of any pathology present can occur. lymph nodes, drain the tonsils and this is the
77 Not discussing the case with the pathologists most common site of nodal involvement in tu-
first. The node should always be sent intact and berculosis infection. The nodes may be inti-
fresh. mately related to the internal jugular vein and
77 The marginal mandibular branch of the facial caution should be taken to avoid major vessel in-
nerve passes behind the angle of the mandible jury during excision.
and runs forward less then 2 cm inferior to it be- 77 Infected lymph nodes underlying the cervical
fore passing over the body of the mandible to fascia may rupture to from an abscess, which
supply the circumoral musculature. It is vulnera- then drains out through the fascia into the sub-
ble during jugulodigastric lymph node excision. cutaneous tissue. This ‘collar-stud’ abscess causes
Damage results in a distorted smile and impaired a characteristic blue–purple discolouration of
movements of the lower lip. the overlying skin and is usually a feature of My-
77 Attempting to access a node deep to the sterno- cobacterium avium, intracellulare and scrofula-
cleidomastoid muscle without splitting or divid- ceum (MAIS) infection. This atypical mycobacte-
ing the muscle is possible. rium is found in soil and after entering the child’s
77 Performing a biopsy through an inadequate inci- mouth, it drains to the tonsillar or parotid nodes.
sion leading to excessive handling and crushing Untreated the abscess forms multiple sinuses,
of the biopsied tissue is also possible. It is impor- which then drain through the skin. Incision and
tant to preserve the nodal architecture for histo- drainage alone results in recurrence. Treatment
pathological diagnosis. is complete excision of the infected nodes and
subcutaneous tissue. Always send pus for rou-
tine and mycobacterial culture techniques.
B11 Principles of Surgery for Lymphatic Malformations 151
B1 Principles of Surgery B11
for Lymphatic Malformations
F. B. MacGregor
These malformations are usually found in areas involution of the cyst. In practice it is not always
of confluence of major lymphatic channels. The successful and can result in a systemic reaction
most common site is the head and neck region. A and severe skin breakdown. The resulting tissues
typical lesion consists of several dilated lymphatic are subsequently more fibrotic and therefore more
channels lined by a single layer of epithelium. Pre- challenging to operate on later. This technique is
natal diagnosis is common and the lesion is usu- most effective in macrocystic lesions, which are
ally obvious at birth although rarely, may present also the lesions that are more amenable to sur-
months or even years later. Lesions vary in size gery. Popular agents include ethanol and OK432.
and position within the head and neck and may be Microcystic disease is more challenging to ex-
composed of fluid filled microcysts or macrocysts, cise but is also less effectively treated with sclero-
often in combination. They tend to invest normal therapy. Conservative treatment may be appropri-
structures such as arteries, veins and nerves and ate. Because of the position of these lesions and
can involve muscle and salivary gland. These le- the fact that they are intimately related to nerves
sions can suddenly increase in size and depending and vessels, these can be at risk. In particular, the
on their position, may cause airway obstruction, marginal mandibular branch of the facial nerve
difficulty swallowing (because of enlarged tongue and the hypoglossal, vagus, phrenic and accessory
and abnormal floor of mouth) and severe defor- nerves can all be closely related to these lesions
mity in the head and neck region. and may be damaged during excision. It is there-
Treatment depends on the site of the lesion, fore important to remember that these are benign
the disability caused and the aesthetic concerns. lesions and the desire for complete excision should
Tracheostomy may be required to make an air- not take precedence over preservation of impor-
way safe prior to definitive treatment. Occasion- tant structures.
ally large malformations diagnosed prenatally re- Excision of a neck lesion is usually performed
quire management with an ex-utero intrapartum through a transverse skin incision at least 2 cm
treatment (EXIT) procedure to maintain oxy- below the mandible. The platysma is divided and
genation prior to a tracheostomy. In many situa- subplatysmal flaps are elevated to display the mal-
tions treatment consists of a series of staged op- formation. Sharp dissection proceeds carefully
erative procedures and sclerotherapy may be im- around the lymphatic malformation with dia-
plemented. In most cases where emergency inter- thermy to small bleeding vessels. Knowledge of
vention has not been required, surgery can wait the local anatomy is vital to preserve major ves-
until the child is 3–6 months old. sels and nerves. It is often useful to dissect down
Sclerotherapy involves aspiration of larger to the internal jugular vein and use it as a land-
cysts (usually under ultrasound control) and then mark. The lesion may need to be split to dissect
injecting the empty cyst with an irritative agent nerves. Identification is usually easier if the cysts
that causes an inflammatory reaction. This sub- remain intact although large tense cysts may even-
sequently encourages the walls to adhese, causing tually require aspiration during surgery to obtain
access to deeper structures. In the lower neck, be
careful to avoid damage to the thoracic duct (left)
Fiona B. MacGregor ()
and accessory thoracic duct (right). If these are
Consultant Paediatric Otolaryngologist damaged they should be repaired with 6.0 nylon
Fiona.MacGregor@ggc.scot.nhs.uk to avoid an ongoing chyle leak. Dissection supe-
Tips
77 Use a nerve monitor when excising lesions 77 Sudden increase in the size of these lesions may
around the parotid and remember to inform the be due to internal haemorrhage – check the in-
anaesthetist. fant’s haemoglobin as it may drop suddenly and
significantly.
Common Pitfalls
77 Do not be tempted to remove the drain too 77 Bulky–tongue base disease may make intuba-
early. The patient will get a collection. tion difficult and result in a challenging postop-
erative airway if the child does not have a trache-
ostomy.
B12 Tracheostomy 153
B 12Tracheostomy B12
C. Venkatakarthikeya and P. Sagar
Fig. 1
C.Venkatakarthikey ()
Assistant Professor
Department of Otorhinolaryngology
Prem Sagar
Senior Resident, Department of Otorhinolarnygology,
All India Institute of Medical Sciences, New Delhi 110029
sagardrprem@gmail.com
Fig. 2 Fig. 3
Tips
77 Always stay in the midline. 77 Keep the stay sutures until the tracheostomy
77 Always confirm the tubular structure to be tra- tract matures.
chea by aspirating before making any incision. 77 Postoperative chest x-rays help in identifying the
77 Palpate the trachea before each step; remember position of tracheostomy tube and complication
in children trachea is quite soft, unlike adults. like pneumothorax.
77 Remove any nasogastric tube prior to surgery as
it may give a false sense of trachea during pal-
pation.
Common Pitfalls
77 Excessive extension of the neck may expose the 77 Do not remove any tracheal tissue. Excision of
carotids and the pleura during the dissection. tracheal tissue to create an opening for the tra-
77 In children the trachea is soft and may be con- cheostomy leads to tracheal stenosis.
fused with the carotids. During palpation, sensi- 77 Always preserve the first cartilaginous ring and
tize yourself for any pulsation in nearby area. in small infants, the second ring as well.
B13 Torticollis 155
B 13Torticollis B13
A. Verma and S. Agarwala
Operative technique
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
Tips
77 Complete division of stermocleidomastoid along 77 Adequate post operative pain relief and early
with deep cervical fascia should always be per- neck physiotherapy should be done.
formed. 77 Ensure good hemostasis.
77 Sometimes few fibers of the anterior edge of the
trapezius may need to be divided. Avoid damage
to the nerve to trapezius in doing this.
Common Pitfalls
77 Inadequate division of the investing layer of 77 Doing the procedure of division of sternocleido-
deep cervical fascia around the muscle will lead mastoid when the cause of torticollis is some-
to persistence of the deformity. thing else, such as a vertebral anomaly.
B14 Burr Holes 157
B 14Burr Holes B14
R. Carachi
Our prehistoric ancestors made burr holes in the • Pressure is applied on the edges of the incised
skull, and there is archaeological evidence that wound and the galea is picked up using mos-
these early attempts were successful in saving lives. quito forceps and then flipped over the flap to
Burr holes in the skull can be a life-saving op- stop bleeding (the scalp is very vascular). (Fig. 2)
eration in a patient with a head injury when bleed- • A periosteal elevator is used to expose the skull
ing can cause rapid coning of the brain and death. bone; this is often accompanied with some ooz-
Although this is the domain of the neurosur- ing of blood. This is to allow a burr hole to be
geon, every surgeon should be able to carry out performed. (Fig. 2)
this life-saving procedure while waiting for the • A no. 10 blade is then rotated through the skull
neurosurgeon if necessary. in a vertical position until the outer table of
bone is breached and the inner table is pene-
trated. At this point the blade is swapped for the
Operative Technique tip of a curved mosquito forceps to open the
hole (Fig. 3a) and allow a bone nibbler to fur-
The area selected needs to be shaved, prepared ther open this area and expose the dura, which
and draped. should be glistening. Occasionally blood can be
• An incision is made in a curved fashion using seen beneath the dura if it is under pressure.
a no. 15 blade, often over the temporoparietal
region of the scalp and it is then incised down
to the bone through all the layers of the scalp.
(Fig. 1)
Fig. 3
Tips
77 Any bleeding from the bone can be stopped us- 77 The site of the incision will be determined by the
ing bone wax. nature of the injury and the preoperative imag-
ing.
Common Pitfalls
77 The skull bone may be very thin in infants and 77 Always double-check the side of the injury on
care must be taken not to penetrate the dura the preoperative imaging and mark it preopera-
whilst making the burr hole. tively to ensure that the correct side is chosen for
the operation.
B15 Ventriculoperitoneal Shunting for Hydrocephalus 159
B 15Ventriculoperitoneal Shunting B15
for Hydrocephalus
R. Carachi
John Holter – the pioneer who introduced the the surgeon to ensure that this positioning is cor-
shunt for hydrocephalus – developed a valve that rect before the operation starts.
has been effective for many years. There is a vast It is also the responsibility of the surgeon to
array of shunt systems now available on the mar- select the appropriate shunt device, the ventricu-
ket and their description is beyond the scope of lar cannula and peritoneal tubing. This is very of-
this chapter. ten determined by the personal preference of the
Ventriculoperitoneal (VP) shunting is carried surgeon and the length is determined by the im-
out in most centres by paediatric neurosurgeons aging available.
and should be in their domain; however, some The imaging via a computerized axial tomog-
paediatric surgical centres still carry out this pro- raphy (CT) scan should be on view in the theatre
cedure. Often the paediatric surgeon has to per- next to the patient for the surgeon to view when
form this procedure. attempting to insert the ventricular cannula into
The patient is anaesthetised, intubated and po- the ventricle.
sitioned as in Fig. 1. It is essential that the posi- The following rules should be applied to ensure
tioning of the patient establishes a straight hor- a reduced risk of perioperative infection, the big-
izontal line from the skull to the abdomen. This gest complication of this procedure.
is achieved by careful positioning and the use of
rolls under the patient. It is the responsibility of
Fig. 1
• A curvilinear incision is used over the scalp and • Pressure is applied to the edges of the incised
its position should not overlie the shunt system. wound and the galea is picked up using mos-
(Fig. 1) quito forceps and flipped over the flap to stop
• Different instruments must be used for the skin bleeding (the scalp is very vascular).
and for the rest of the operation. • A periosteal elevator is used to expose the skull
• No diathermy, either unipolar or bipolar, bone; this is often accompanied with some ooz-
should be used especially in small babies. ing of blood. This is to allow a burr hole to be
• A non-touch technique with minimal tissue performed.
handling should be used at all time. • A no. 10 blade is then rotated through the skull
• Double gloving and removal of the outer gloves in a vertical position until the outer table of
when handling the shunt system is advised. bone is breached and then the inner table is
• The shunt system should be tested and im- penetrated. At this point the blade is swapped
mersed in a antibiotic solution while awaiting for the tip of curved mosquito forceps to open
insertion. the hole and allow a bone nibbler to further
• Appropriate cleansing solution (Bethadine) open this area and expose the dura, which
should be used over the operating field after it should be glistening.
is cleared of any hair that may be present. • Using a dural right-angle hook the dura is
The first part of this operation is described under opened in a cruciate incision using a no. 11
Chap. B14 entitled ‘Burr Holes’. blade.
• The venticular catheder is then inserted in the
direction illustrated in Fig. 2 aiming for the
Operative Technique bridge of the nose to enter the ventricle.
Connection
at the scalp wound and the abdominal wound fluid (CSF) should be taken for culture and sen-
to ensure that the catheter is not contaminated. sitivity. The entire wound is then irrigated with
• The valve is fixed in position with a black silk antibiotic solution and the wound closed in the
stitch (000) in order to prevent it from sliding usual fashion.
out of position. A sample of cerebral spinal
Fig. 3
Tips
Common Pitfalls
77 There are many pitfalls and it is essential to test 77 The skull bone may be very thin in infants and
the shunt at the operation to ensure that it is care must be taken not to penetrate the dura
working properly. CSF must be taken for culture whilst making the burr hole.
and sent to the laboratory.
162 R. Carachi
J. W. H O LT ER
(1916 – 2003)
American scientist
John Holter was a tool maker working for a lock company in Connecticut when his son was
born with spina bifida. The boy went on to develop hydrocephalus and it sparked in his father
an urgent desire to find a cure. He therefore designed the first VP shunts to drain the cerebro-
spinal fluid. The early work was done in John’s garage, but he later built a company which not
only manufactured the VP shunts, but it also led research and trials in various aspects of the
condition and the production of these shunts. Working with Dr. Eugene Spitz he designed the
valved drainage system, that remains the basic principle behind valves to this day. Though he
was unable to help his own son, John Holter has provided help and hope to many thousands.
B16 Cervical Oesophagostomy 163
B 16Cervical Oesophagostomy B16
A. Sinha and S. Agarwala
Fig. 1 Fig. 2
• Using a diathermy, divide the subcutaneous tis-
sue and platysma in the line of the incision and • Mobilize the oesophagus circumferentially,
develop subplatysmal flaps superiorly and in- staying on its wall, and separate it from the
feriorly to expose the medial aspect of sterno- posterior surface of trachea.
cleidomastoid muscle (Fig. 2). • Loop the oesophagus with a sling and continue
• Retract the external jugular vein laterally or di- dissection inferiorly until the blind pouch is
vide it between ligatures. completely mobilized (Fig. 5).
• Incise the investing layer of deep cervical fascia
longitudinally at the medial edge of the sterno-
cleidomastoid muscle and dissect between the
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com Fig. 3
Fig. 5
Fig. 6
Fig. 7 Fig. 8
B16 Cervical Oesophagostomy 165
Tips
77 Maintain hemostasis at all time so that the 77 A Babcock’s forceps can be handy in circumfer-
planes and structures can be identified. entially holding the oesophagus without crush-
77 Attempt not to open the carotid sheath. ing its walls.
77 Remove the red rubber catheter before starting 77 The sternal head of the sternocleidomastoid can
to dissect the oesophagus from the trachea. be divided for better exposure.
Common Pitfalls
77 Injury to the adjoining structures such as: 77 Inadequate mobilization results in tension at the
– Major vessels in the carotid sheath suture line can lead to ischemia, retraction and
– Recurrent laryngeal nerve in the tracheo-oe- stenosis of the oesophagostomy.
sophageal groove 77 Sagging oesophagostomy can result in a J-
– Posterior surface of trachea while separating it pouch formation with resultant pooling of saliva
from the oesophagus and recurrent aspiration pneumonitis.
– Thoracic duct on the left side
166 A. Sinha and S. Agarwala
B17 B 17H-Type Tracheo-oesophageal Fistula
A. Sinha and S. Agarwala
Fig. 2
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
Tips
77 Bronchoscopy and cannulation of the fistula 77 Approach from the right is easier in H-type TEF
with a ureteric stent can be done prior to endo- cases.
tracheal intubation to facilitate identification of 77 The sternal head of the sternocleidomastoid can
the fistula. be divided for better exposure.
Common Pitfalls
77 Injury to the adjoining structures such as: - Thoracic duct on the left side
- Major vessels in the carotid sheath 77 Inability to identify the distal most edge of the
- Recurrent laryngeal nerve in the tracheo-oe- fistula and therefore incomplete repair on both
sophageal groove the sides
- Posterior surface of trachea while separating it
from the oesophagus
PAR T C
Spine and Limbs
C1 Spina Bifida 171
C 1Spina Bifida C1
M. Ragavan and M. Srinivas
Operative Technique
Fig. 2
the thoracolumbar fascia. Dissect as close to
the sac as possible without opening it.
• Place two stay sutures on the superior aspect
of the dura and open it in the midline between
stays without damaging the underlying neural
elements (Fig. 3).
• Using a nerve hook, work around the neural
elements, between them and the dura, to sep-
arate them from the dura and then divide the
Fig. 1 dura completely (Fig. 4). Place multiple fine
Prolene stay sutures on the edges of the dura.
• Apply drapes and suture them to the skin with • De-tether the spinal cord posteriorly and de-
3/0 black silk. tether the filum terminale between two stay su-
• Cover the anus with a large transparent, occlu- tures, and then release all the arachnoid adhe-
sive dressing. sions.
• Make a transverse elliptical incision circum- • Tubularize the neural placode, if open, using
scribing the base of the myelomeningocele interrupted, fine Prolene sutures (Fig. 5).
(Fig. 2). • Repair the dura using a continuous fine Prolene
• Deepen the incision at the lateral edge to reach suture (Fig. 6).
the thoracolumbar fascia. Dissect around the • Mobilize the thoracolumbar fascia from one
base of the sac in this layer, just superficial to side and use the erector spinae fascia to rein-
force the dural repair with interrupted Vicryl
M. Ragavan ()
Associate Professor sutures (Fig. 7).
Department of Pediatric Surgery, Narayana Medical Col- • Mobilize the subcutaneous tissue and skin to
lege & Superspeciality Hospital, Chinthareddypalem, Nel- achieve a tension-free closure.
lore, Andhra Pradesh 524002, India • Reconstruct the subcutaneous tissue with in-
dr_ragavan_2011@rediffmail.com
terrupted 2/0 Vicryl sutures, and the skin with
M. Srinivas a running, subcuticular Monocryl suture.
Additional Professor of Pediatric Surgery • A suction drain should be left beneath the sub-
srinivasem@hotmail.com cutaneous layer for 24 h.
Fig. 3
Fig. 4 Fig. 5
Fig. 6 Fig. 7
C1 Spina Bifida 173
Tips
Common Pitfalls
77 Incomplete de-tethering of the cord structures 77 Contamination of the intradural space with ex-
and the filum terminale may happen. cess blood is possible.
77 Attempting to reconstitute the neural tube 77 Damage to the cord or the nerve roots due to ex-
should not be attempted if the edges of the cess traction on the sac during dissection is pos-
placode do not easily come together, as this risks sible.
strangulation and pressure necrosis of the plac- 77 Skin and subcutaneous closure under tension
ode. can occur, leading to ischaemia and breakdown.
77 Tight dural closure leading to delayed ischaemia
and cerebral spinal fluid (CSF) leak can occur.
174 J. S. Huntley
C2 C2 Forearm Manipulation and Molded Cast
J. S. Huntley
Indication
Operative Technique
Manipulation
Fig. 1 Exaggeration of the deformity unlocks ‘locked’
Musculoskeletal tissues are visco-elastic, so that fractures
the mechanical response in stretching out of soft distal part, the fragments can then be re-en-
tissues depends not only on the force applied, but gaged in their proper relative positions as the
also on the length of time for which it is applied. deformity is reduced (Fig. 1).
Thus longitudinal traction with careful counter- • Greenstick fractures with an intact hinge re-
force, applied over the course of five minutes is quire correction by gentle pressure (Fig. 2).
helpful in disimpaction. • Plastic bowing requires considerable force ap-
All components of deformity (translation, an- plied in a three-point pattern over an extended
gulation, rotation and shortening) should be re- period to unbend (Fig. 3).
duced (check with the image intensifier). Rota-
tional deformity in radial fractures proximal to Casting
pronator teres may be reduced by supination,
whereas in those distal to pronator teres, a pro- • Usually an above elbow cast with the forearm
nation manoeuvre is likely to be required. in neutral is appropriate (sometimes a prona-
The manipulative technique varies according tion or supination position may be required).
to the fracture configuration: • Apply soft-roll sparingly along the arm (one-
• Off-ended and shortened fractures (the frag- ply, just overlapping) with extra to the promi-
ments are termed 'locked') require the frag- nences (Fig. 4).
ments to be unlocked by exaggeration of the • Dip the plaster until the bubbles stop appear-
deformity. After longitudinal translation of the ing. Bring the roll out of the water and remove
the excess.
Jim S. Huntley ()
• Roll the wet plaster circumferentially, with
Consultant Paediatric Orthopaedic Surgeon 'tucks' to allow smooth, economical and even
Jim.Huntley@ggc.scot.nhs.uk
Tips
77 Assess for rotational abnormality by match- 77 Hyndman’s cast ratio is a useful predictor of
ing the medullary and cortical diameters in the maintenance of reduction by a forearm cast –
neighbouring fracture fragments. the lateral diameter must be much less than the
77 When moulding, keep moving the hands to anteroposterior diameter (Fig. 7).
avoid sharp peak contact areas in the cast. 77 Fractures must be followed by radiographs in the
clinic so that if they lose reduction it is possible
to intervene before union.
Common Pitfalls
77 Too much padding is a recipe for cast slippage, 77 Do not accept a poor reduction, especially in the
loss of reduction and complications. child of 10 years or older, in whom the remodel-
ling capacity is far less.
178 J. S. Huntley
C3 C 3Distal Radius Wiring
J. S. Huntley
Operative Technique
Fig. 7 Lateral incision (1 cm) in mid-lateral line (avoid the Fig. 9 Two-wire construct
superficial radial nerve)
180 J. S. Huntley
Tips
77 Watch for the digits (especially thumb) moving, 77 The wires can be bent and cut, leaving a 1-cm
so that if the edge of a tendon is picked up by bent portion proud of the skin – this can be
the rotating K-wire, you can stop immediately. dressed with a swab or Betadine sponge. The
77 At the end, use the ‘tenodesis effect’ to check wires should be removed at 4 weeks (without
that there is no tethering or tendon rupture by anaesthetic).
freely flexing and extending the wrist and ob-
serving reciprocal movement at the digits.
Common Pitfalls
77 Avoid the superficial radial nerve below the lat- 77 Make sure you advance the wire at the appropri-
eral incision. ate angle to pick up contralateral cortex in the
proximal fragment.
C4 Forearm Diaphyseal Reduction and Fixation (Closed Wiring) 181
C4 Forearm Diaphyseal Reduction C4
and Fixation (Closed Wiring)
J. S. Huntley
Indication
Operative Technique
Tips
77 Although it is helpful to start the ulna K-wire on wire and advance ‘by feel’, as there is less chance
power, it is then better to use a chuck to grip the of a cortical perforation.
Common Pitfalls
77 Extensor pollicis longus rupture – make sure 77 Sometimes the described closed nailing is im-
you cut the titanium nail short, even off the cut possible because of interposed tissue, and the
edges so they are not sharp, and turn the edge fractures have to be opened to allow reduction.
away from the extensor pollicis tendon. 77 Infection – minimise the risk with prophylactic
antibiotics and meticulous technique.
184 J. S. Huntley
C5 C5 Displaced Supracondylar Humeral
Fracture
J. S. Huntley
• Prepare the whole arm. • Use 2.0-mm-diameter K-wires – the first entry
• Perform maintained gentle, longitudinal trac- point is on the distal part of the lateral condyle,
tion (with counter traction in the upper arm) engage the bone and drive the wire at 45° to the
with the elbow flexed 30° for 5 min (Fig. 2). transverse axis and in the coronal plane so that
it passes across the fracture site into the proxi-
mal fragment, engaging the contralateral cor-
tex.
Jim S. Huntley ()
• The second entry point is distal to the first in
Consultant Paediatric Orthopaedic Surgeon the gap between the lateral epicondyle and the
Jim.Huntley@ggc.scot.nhs.uk
Fig. 8 Exposure of ulnar nerve (running between 2 heads Fig. 9 Additional medial wire used when laterally sited
of flexor carpi ulnaris) allows safe placement of wire ones were not sufficient
through medial epicondyle under direct vision
Tips
77 Check the setup and make any adjustments [to sifier in the upright position – runs the danger of
allow the image intensifier to swing through for twisting the distal fragment off and losing the re-
a lateral view] before scrubbing. duction.
77 The facility to obtain the under-the-table lateral 77 Nerve (radial, ulnar, median and anterior interos-
view is good because otherwise rotating the arm seous) and vascular charting is important both
to obtain the lateral view – with the image inten- pre- and postoperatively.
Common Pitfalls
77 Tethering/puckering of the skin is important as elbow’. Reduce and stabilise the radius (usually
it indicates buttonholing of a proximal fragment wires) first and then treat the supracondylar frac-
spike through brachialis. This can be released ture as usual.
preoperatively by ‘milking’ the soft tissues down 77 Increasing pain postoperatively may indicate
over the spike. nerve entrapment and/or compartment syn-
77 Beware medial column comminution, especially drome.
in the less displaced fractures, that need to be re- 77 Though rare, beware compartment syndrome
duced at the initial longitudinal traction stage. which mandates fasciotomies to prevent mus-
Otherwise a cubitus varus (‘gunstock’ deformity) cle necrosis.
may result.
77 Higher energy injuries may produce an ipsilat-
eral radial fracture (usually distal) – the ‘floating
188 J. S. Huntley
C6 C6 Femoral Fracture and Spica Cast
J. S. Huntley
Indication
Fig. 1 Long leg cast
Femoral shaft fractures are indications for spica
casting. placement along the length of the leg, four- to
five-ply.
• Mold laterally and medially in the supracon-
Operative Technique dylar region.
• When this is set, transfer the patient to the spica
• Stabilise the limb by applying traction to the in- table (Fig. 2).
volved extremity with the patient's heel in one • Flex the hip to 50–90° and use the contralat-
hand and calf in the other and the knee flexed eral leg as a guide to rotation.
to 70–90°. • You have good rotational, angular and trac-
• Use two assistants to apply a long leg cast from tional control of the fracture because of the
the supramalleolar region to the level of the long leg cast.
fracture with a supracondylar mold (Fig. 1).
The first assistant should hold the femur in the
supracondylar region below the fracture, mov-
ing his/her hands to avoid indenting the cast.
The second assistant should apply the soft-roll
and cast.
• Dip the plaster until the bubbles stop appear-
ing. Bring the roll out of the water, and remove
the excess.
• Roll the wet plaster circumferentially, with
'tucks' to allow smooth, economical and even
Tips
77 Do not apply a below-knee cast first and then ex- to 90°) to cater for the flexion of the proximal
tend it, as the ridge is likely to dig into the calf fragment.
and may cause a sore or extrinsic compartment 77 Shortening of up to 1.5–2.0 cm is acceptable be-
syndrome. cause of the regional overgrowth that occurs
77 In more proximal fractures (e.g. subtrochanteric), post-fracture.
it may be necessary to flex the hip more (e.g. up
Common Pitfalls
Tips
77 The stability of the construct can be increased by 77 As well as the anteromedial pins used above, an-
– having more pins either side of the fracture teroposterior (sagittal) screws are also feasible as
(e.g. 3 rather than 2), long as care is taken to avoid posterior over-pen-
– increasing the distance between pins on one etration. These may be preferred by plastic sur-
side of the fracture, and geons wanting access to both sides of the sagit-
– moving the bar (and its articulations) closer to
tal plane.
the skin.
Common pitfalls
Indication
Septic arthritis is an indication for the washout Fig. 1 Lateral incisions for suprapatellar and infrapatellar
procedure. portals
Operative Technique
Tips
77 In the anterior approach to the hip, use the ASIS gluteus medius to be (reassuringly) well lateral to
and the femoral pulse as landmarks. You should the femoral pulse.
find the intervals of TFL to sartorius and rectus to 77 A tag suture to the TFL:sartorius interval can be
useful if a secondary washout is required.
Common Pitfalls
77 For the anterior approach to the hip, avoid mak- 77 Take care not to damage the articular cartilage
ing your incision too high. when making either the parapatellar approach
in the knee, or incising the capsule of the hip.
C9 Syndactyly 195
C 9Syndactyly C9
O. Quaba and J. J. R. Kirkpatrick
Principles
Classification
Operative Technique
• Use a proximally based dorsal trapezoidal flap, • These are Dorsal and palmar triangular flaps
extending two thirds of the length of the prox- with matched zigzag incisions.
imal phalanx (Fig. 1). • The dorsal flaps are designed with the base of
• Mark the position of the web space on the pal- flaps broadly centred over the PIP and distal in-
mar side. terphalangeal (DIP) joints of one finger (Fig. 1).
• The metacarpophalangeal joint (MCPJ) crease • The palmar flaps are based opposite the dorsal
is often present; if not, the correct web space flaps (mirror images) with bases centred over
position is usually midway between the distal the opposite PIP and DIP joints to allow for
palmar crease and the proximal interphalan- interdigitation (Fig. 2).
geal (PIPJ) crease (Fig. 2). • The flaps should extend from the midline of
one digit to the midline of the other digit.
Omar Quaba ()
Specialist Registrar in Plastic Surgery
omarquaba@hotmail.com
James J. R. Kirkpatrick
Consultant Plastic Surgeon
J.Kirkpatrick@nhs.net
Fig. 3
Fig. 2
• Raise the dorsal flaps first, identifying interdig- • Buck–Gramcko flaps are used to recreate the
ital connective tissue. lateral nail folds along the contiguous borders
• Next, raise the palmar flaps, identifying and of the digits in complete syndactyly (Fig. 3).
preserving the neurovascular bundles (use lon- • If complex, cut bony union using an osteo-
gitudinal spreading with scissors). tome.
• Separate the digits from distal to proximal • Raise these flaps before the terminal parts of
while protecting the neurovascular bundles. the digit are separated.
• Note that the digital artery bifurcation may be
more distal than normal – this may limit the
depth of the web (division of a proper digital Full-Thickness Skin Grafts
artery may be required – with obvious caveats!).
• Intraneural dissection of the common digital • Full-thickness skin grafts are usually required,
nerve may be required to overcome a restric- except in some cases of simple, incomplete syn-
tion created by distal nerve bifurcation. dactyly.
• The best donor site is the groin crease, or lower
Defat the Flaps abdomen if a large graft is required.
• Trimming excess fat from the flaps increases pli- Suture Choice
ability and may reduce potential need for skin
grafts. 6/0 Vicryl Rapide is the preferred suture.
• Excise interdigital fat, taking care around the
neurovascular bundles.
C9 Syndactyly 197
Tips
77 Early release is indicated for digits of unequal 77 Suture flaps loosely, with small bites.
length to correct alignment/ allow unimpeded 77 Use an assistant to distract the fingertips with
growth (e.g. first and fourth web). skin hooks (or use temporary silk sutures
77 Do not release adjacent webs simultaneously through the pulps).
due to risk of ischaemia.
Common Pitfalls
77 Tight suture of flaps compromising flap viability 77 Skin graft taken from future hair bearing pubic
(use a skin graft if required) area resulting in future hair growth in the web
space
198 D. Datta and S. Agarwala
C10 C 10Polydactyly
D. Datta and S. Agarwala
Fig. 4a,b
Fig. 5a,b
Fig. 6a–c
C10 Polydactyly 201
Tips
77 In the postoperative period, provide support 77 When the extra finger arises from a metacar-
with a splint, keeping the wrist in extension with pal or phalanx, always trim the bone to avoid a
maintenance of the thumb wave. swelling which may over grow later.
77 The functional thumb is usually small and de- 77 Discard a little over half the width from both
formed, so make best use of tissue from both thumbs; otherwise during alignment an inevita-
thumbs to construct a functionally active, cor- ble gap will make the thumb more bulky.
rectly aligned thumb.
Common Pitfalls
Fig. 1 Fig. 2
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
Tips
77 Avoid raising fascial flaps, so as not increase the 77 Deep sutures may be placed in the tumour, cov-
width of the excision later on. ering an area wider than the intended biopsy,
77 Take the biopsy from a firm or hard part of the before excising a wedge for biopsy. These su-
tissue. tures can then be approximated to close the bi-
77 Never take the biopsy from a soft or fluctuant opsy ‘bed’ and achieve haemostasis.
part of the tumour, as this reflects underlying ne- 77 Avoid using diathermy while taking a wedge of
crotic material. the tumour tissue, as this may render the speci-
men nondiagnostic.
Common Pitfalls
77 Avoid making a transverse incision for two rea- 77 Biopsying from a soft, necrotic area should not
sons: First, the incision should be parallel to the be done.
neurovascular bundles and second, the entire bi-
opsy scar must be easily included in the incision
during definitive surgery.
204 P. Sekaran and C. F. Davis
C12 C 12Ingrown Toenail
P. Sekaran and C. F. Davis
Fig. 1
For a first presentation, simple avulsion of the • An assistant holds the leg, elevating the foot off
nail may be curative. Nail avulsion involves ex- the bed, whilst the surgeon prepares the entire
cision of the body of the nail plate from its pri- skin of the foot paying close attention to the
mary attachments, the nail bed and the proximal web spaces and extending superiorly beyond
nail fold (PNF). the ankle.
• A sterile drape is then placed on the trolley un-
der the foot and a further drape folded into a
triangular configuration, wrapped around the
mid-foot and held in place with a towel clip.
• A torniquet can be used but must be visible
(Ring torniquets should be avoided)
Prabhu Sekaran () • Curved mosquito forceps are gradually in-
Specialty Trainee in Paediatric Surgery serted under the distal central portion of the
Prabhu.sekaran@nhs.net
nail and used to bluntly dissect the nail plate
Carl F. Davis from the underlying bed.
Consultant Paediatric and Neonatal Surgeon • Once the nail is free proximally and distally, it is
Carl.Davis@ggc.scot.nhs.uk grasped with Mosquito forceps and rolled from
side to side until the nail can be lifted free from • The patient is positioned and prepared as de-
the lateral nail folds (LNFs). scribed for nail avulsion and a tourniquet ap-
• Any adjacent granulation tissue is sharply ex- plied.
cised with a blade or scissors. • Straight iris scissors are used to undermine the
• The avulsed nail should be carefully inspected nail plate laterally on the affected side.
to ensure it is completely removed. • The undermined portion of nail plate is then
• A Mepitel, blue gauze and crepe bandage dress- divided longitudinally with straight iris scissors
ing is applied after removal of the tourniquet, through the full proximal extent of the plate
ensuring that the skin at the end of the (Fig. 3).
• Postoperatively, the patient should be advised • The free portion of nail is avulsed with straight
to avoid narrow shoes and to cut the nail square Mosquito forceps by rolling the nail away from
(not back at the lateral corners). Despite this, the LNF.
recurrence rates are high following simple avul- • Local curettage with a Volkmann spoon or
sion. If the condition recurs, the nail bed (or curved Mosquito forceps (Fig. 4) should be
part of it) should be ablated surgically or chem- performed to remove granulation tissue from
ically, with phenol. the LNF and nail bed.
• Apply a small amount of cotton wool to the
Wedge excision of the nail and partial nail bed to keep it dry whilst applying soft yel-
phenolisation of the nail matrix low paraffin around the surrounding soft tis-
sues to protect them from the phenol (Fig. 5).
• The nail matrix is the germinative epithelium • A supersaturated solution of 88 % phenol on
that forms the nail plate (Fig. 2). A wedge ex- preprepared cotton-tip applicators (often need
cision removes the diseased (in-growing) por- to be reduced in bulk for small children) is ap-
tion of the nail plate and the phenol applied plied to the nail matrix for 2 min (Fig. 6) be-
topically to the matrix denatures proteins re- fore neutralisation with 70 % isopropyl alcohol
sulting in chemical matricectomy. The aim of (white spirit).
surgery is to narrow the nail plate preventing • Remove the tourniquet.
recurrent ingrowth into the LNFs. • Apply dressing as before.
Fig. 3 Fig. 4
206 P. Sekaran and C. F. Davis
Zadek’s procedure.
Fig. 6
C12 Ingrown Toenail 207
Tips
77 Do not fold the Mepitel dressing, as this prevents 77 Postoperatively the patient should be encour-
exudative fluid release and makes removal of the aged to elevate the foot and limit activity, to en-
dressing difficult. courage healing and reduce pain and swelling.
77 Following Zadek’s procedure, pain can be signif- 77 A district nurse should visit the patient at home
icant. A ring block of l-Bupivacaine established to change the dressing after 24 h.
immediately after surgery provides extended 77 Follow-up with a podiatrist may help reduce re-
pain relief for 8–12 hours. currence.
Common Pitfalls
77 Always record the tourniquet time on a board in 77 The nail matrix extends laterally into lateral ma-
theatre. It is your responsibility to ensure it has trix horns – always ensure these areas are fully
been removed at the end of the case. excised or covered with phenol to prevent recur-
77 Always ensure that the nail bed is dry and blood- rent nail spicule formation.
less before applying phenol. Blood deactivates 77 Surgical matricectomy should extend onto the
phenol. periosteum of the distal phalanx, but take care
to avoid damaging the insertion of the extensor
tendon on the distal portion of this bone.
PAR T D
Thorax
D1 Chest Tube Insertion 211
D 1Chest Tube Insertion D1
D. Datta and S. Agarwala
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
Fig. 1
Fig. 2 Fig. 3
D1 Chest Tube Insertion 213
Tips
77 Ensure the correct side of the chest is marked 77 An oblique tunnel reduces the risk of pneumo-
prior to the procedure. thorax on removing the tube.
77 Careful preoperative clinical and radiological 77 The site of chest drain insertion should be mod-
evaluation (chest x-ray with or without ultra- ified according to whether there is a loculated
sound) is important to confirm the nature of the pleural effusion, empyema or pneumothorax. In
collection and the optimal site for drainage. general, basal chest drains are better for drain-
77 Start counting ribs from sternal angle which is ing fluid whilst apical chest drains are better for
the site of attachment of second rib. draining air.
77 After infiltrating local anaesthesia, aspirate the 77 Tailor the chest tube size to the pathology. Gen-
pleural space at the proposed site of chest drain erally, larger-diameter tubes (16–24 Fr) are re-
insertion to confirm the diagnosis, the nature quired for complicated effusions or haemotho-
(and viscosity) of the fluid and the correct inser- rax, and smaller tubes (10–16 Fr) for pneumo-
tion site. thorax.
77 During blunt dissection of the intercostal space 77 Post-procedure, obtain an anterior–posterior
with a curved haemostat, hold your index finger (AP) chest x-ray to check correct positioning of
near the tip of the instrument to guard against the drain and to exclude any complications.
sudden entry into the pleural cavity and injury to 77 If multiple chest tubes are to be placed, as may
lung parenchyma. be the case in loculated pleural effusions, empy-
77 Always enter the intercostal space adjacent to ema or pneumothorax, each chest tube should
the upper border of the rib below, to avoid injury be connected to its own underwater seal system.
to the neurovascular bundle which runs beneath
the lower border of rib.
Common Pitfalls
77 Purse-string sutures at the exit site are not neces- 77 Occasionally, tube displacement will cause a side
sary to prevent air entrainment during drain re- hole to come to lie outside the chest. The chest
moval and do not result in a satisfactory wound. drain will cease to drain and any pneumothorax
Older, cooperative children can perform a Val- will reaccumulate as air is drawn into the pleu-
salva manoeuvre during removal to prevent air ral space.
entrainment, and in younger children the tube is 77 Ongoing bubbling from the chest tube is indica-
removed during expiration before immediately tive of an ongoing air leak. Consider the need for
covering the exit site with an occlusive dressing. adding suction to the system to encourage lung
77 Ensure the end of the tube connected to the re-expansion and never clamp a bubbling tube.
chest drain remains underwater at all times to 77 Re-expansion pulmonary oedema occurs when
prevent air being drawn into the chest on inspi- a massive pleural effusion is drained too quickly.
ration. Clamp the chest tube for 1 h after each 10-ml/kg
77 A patent chest tube correctly sited in the pleural aliquot of fluid is drained.
space will be ‘swinging’. In other words, the fluid
in the tubing will move towards the chest on in-
spiration and away from the chest on expiration.
If this is not observed, consider whether the tube
is blocked or the collection is completely drained
and the lung fully expanded.
214 R. Partridge and G. Haddock
D2 D 2Thoracotomy
R. Partridge and G. Haddock
Principle Technique
• The infant chest is quite short longitudinally. • Incision from anterior axillary fold just inferior
• A posterolateral approach through the fifth to level of nipple, to below scapula tip poste-
intercostal space allows good exposure of riorly, then curving cranially up to erector spi-
the lung, oesophagus, mediastinum and dia- nae
phragm. • Steps as show in Figs. 2–4
• Carefully place a Finochietto (rib spreader) re-
tractor under the ribs and open slowly.
Positioning • Use a pledget mounted on curved mosquito
forceps to depress the parietal pleura and un-
• Place the patient in a lateral position with arm derlying lung, while safely dividing the remain-
up over face, on armrest or padding. ing intercostal muscles using monopolar dia-
• Place a bolster pad under back at nipple level, thermy.
as shown below. • For an extrapleural approach (e.g. for an oe-
sophageal atresia repair), a moistened pledget
mounted on curved mosquito forceps should
be used to sweep the parietal pleura anteriorly
and medially to develop the extrapleural plane.
• If a transpleural approach is used, the pleura is
opened whilst the anaesthetist withholds pos-
itive-pressure ventilation. This manoeuvre al-
lows air to enter the pleural space and the lung
to collapse.
Fig. 1
Closure
See to Fig. 5.
• Three to four pericostal heavy, absorbable su-
tures are placed around the ribs and gently ap-
proximated.
• Avoid tying the pericostal sutures too tightly,
as this promotes rib fusion.
• Repair of intercostal muscles is not essential.
Roland Partridge () • Close the other muscles in anatomical layers
Specialty Trainee in Paediatric Surgery using interrupted absorbable sutures, ensuring
rolandpartridge@nhs.net
the muscle edges are aligned.
Graham Haddock
Consultant Paediatric and Neonatal Surgeon
Ghaddock@udcf.gla.ac.uk
Alternative Incisions
Axillary Thoracotomy
Median Sternotomy
Fig. 5
D2 Thoracotomy 217
Tips
77 Long-acting local anaesthetic should be instilled 77 In older children, it may be preferable to en-
to the intercostal nerve region prior to closure of ter the pleural space through the periosteal bed
the wound. of the fifth rib. Use monopolar diathermy to di-
77 Mark the tip of the scapula before the arm is el- vide the rib. Inadequate exposure may necessi-
evated. tate partial (posterior) or complete rib excision in
this setting.
Common Pitfalls
77 Beware of the long thoracic nerve, that runs near 77 If placing a drain, site it in the mid-axillary line
the anterior border of serratus anterior. Try to two rib spaces below the incision to avoid the
preserve the serratus anterior wherever possible patient lying on tube postoperatively (see Chap.
to avoid inadvertent division of the nerve and D1).
winging of the scapula. 77 Stabilise with sandbags and tape.
77 Avoid fracturing the ribs when the retractor 77 Mark the scapula tip.
placed by mobilising the ribs both anteriorly and 77 Prep and drape, leaving nipple, lower scapula,
posteriorly. spine and costal margin visible as landmarks.
218 A. Sinha and S. Agarwala
D3 D 3Empyema
A. Sinha and S. Agarwala
Fig. 1
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
Fig. 2
Fig. 3
220 A. Sinha and S. Agarwala
Fig. 4
Fig. 7
Fig. 6
Tips
77 Place a large-bore nasogastric tube in the oe- 77 At times the visceral pleural peel may be so
sophagus to identify it during separation of the densely adherent to the lungs that it may prove
peel posteriorly. impossible to separate it without causing signif-
77 In critically ill patients with complicated empy- icant air leak. In such cases multiple criss-cross
ema who may not tolerate thoracoscopy or pro- incisions through the peel may ‘release’ its con-
longed open debridement, rib excision and tube stricting effect and allow the lung to re-expand
drainage is sometimes necessary (Fig. 3). (Fig. 7).
77 For localized empyema, the intercostal space 77 Postoperative pain relief is extremely impor-
used for the incision can be tailored according to tant to encourage the patient to breathe well.
the location. Epidural analgesia is a good option for such pa-
tients.
77 Proper postoperative chest physiotherapy and
good care of the intercostals drains is the key to
optimising lung re-expansion postoperatively.
Common Pitfalls
77 Ensure your incision is long enough to allow ade- 77 Injury to mediastinal structures or the subcla-
quate working space in a chronically contracted vian vein in an attempt to separate the peel over
thorax. Occasionally rib resection may be re- these structures is possible.
quired.
77 Separation of the peel in the wrong plane may
lead to multiple deep parenchymal tears.
222 D. Datta and S. Agarwala
D4 D4 Bronchoscopy and Removal
of Foreign Body
D. Datta and S. Agarwala
Preoperative Preparation
Anaesthetic Care
• Introduce the telescope into the broncho- • Occasionally, if the FB is small and not too fria-
scope and advance slowly down the trachea, ble, it can be withdrawn with the optical forceps
constantly keeping the lumen in view to avoid through the lumen of the bronchoscope. Usu-
pushing the FB distally. ally, the FB is too large, and the entire bron-
• Position the distal end of bronchoscope 1–2 choscope and optical FB forceps must be re-
cm away from the FB. trieved as a single unit.
• The surgeon maintains the position of the • Following removal of the FB, introduce the
bronchoscope whilst the scrub nurse removes bronchoscope again and use the telescope to
the telescope and attaches the glass eyepiece. perform a thorough examination of the trachea
• Introduce the appropriate optical FB forceps and bronchi, including the uninvolved side.
into the bronchoscope. • This can be performed with a rigid or fibre-op-
• Once the tip of the optical forceps clears the tic bronchoscope and is vital to exclude resid-
end of the bronchoscope, gently open the ual/additional FBs and to aspirate retained se-
forceps and grasp the FB firmly but without cretions.
crushing it. • Additional or residual FBs should be removed
• Align the FB with the vocal cords. as described above.
• Remove the bronchoscope under vision, in-
specting the vocal cords.
Tips
7 The elective retrieval of aspirated FB should not 7 Exuberant granulation tissue in cases of long-
be initiated without ensuring a full range of sizes standing foreign bodies (especially common
and variety of instrumentation is available. It is with peanuts) can lead to haemorrhage dur-
good to check the grasping forceps outside the ing attempted retrieval. The granulation tissue
patient before commencing the procedure. can be touched with a small adrenaline soaked
7 Straightening of the right or left mainstem bron- pledget to decrease vascularity and control
chus can be facilitated by turning the head to oozing.
the contralateral side. 7 A large, obstructing FB in the larynx or upper tra-
7 Avoid applying excessive force to prevent frag- chea can be brought back to the laryngeal inlet
mentation of FB. Peanuts are particularly suscep- using a Fogarty embolectomy catheter enabling
tible to this and should be handled carefully. retrieval with McGill’s forceps.
7 Sharp foreign bodies should, if possible, be re-
moved, sheathed within the lumen of broncho-
scope to avoid mucosal injury or perforation.
Common Pitfalls
7 Avoid mechanical ventilation as this may force 7 Application of undue force when grasping a
the FB distally creating a ‘ball-valve’ obstruction. long-standing, organic FB may result in fragmen-
7 The use of an excessively large bronchoscope, tation into multiple pieces.
a prolonged procedure and multiple introduc- 7 Failure to do a complete examination of the dis-
tions lead to oedema of the vocal cords and per- tal airways may lead to a retained residual FB.
sistence of postoperative stridor and respiratory 7 If the view is completely obscured by bleeding
distress. from chronic granulation tissue, it may be safer
to stop the procedure, and try a further attempt
at retrieval after 2–3 days.
224 P. Goel and S. Agarwala
D5 D 5Oesophageal Atresia
and Tracheo-oesophageal Fistula
P. Goel and S. Agarwala
Fig. 1
Fig. 5 Fig. 6
226 P. Goel and S. Agarwala
Fig. 7
Fig. 8
D5 Oesophageal Atresia and Tracheo-oesophageal Fistula 227
Tips
77 It is important to separate the pleura adequately 77 The lung retraction should be relieved intermit-
from the ribs above and below to prevent it from tently to allow expansion of the lung to prevent
tearing when the chest retractor is applied. atelectasis.
77 The fistula should be divided as close to the
trachea as possible to prevent formation of a
pouch.
Common Pitfalls
77 Misidentification of the right bronchus or the 77 Missing a small tracheal rent caused during the
aorta (in case of a right sided aortic arch) as the upper pouch mobilization
lower oesophageal pouch 77 Improper anastomosis in which the mucosa has
77 Attempting to dissect the upper pouch without been missed
dividing the fascia over it
RO B E RT E. GROS S
(1905 – 1988)
American paediatric surgeon
Robert E. Gross was the first William E. Ladd Professor at Harvard Medical School. As a young man
he read Cushing’s biography of William Osler and resolved to be a physician. He was a pioneer in the
field of cardiac surgery of childhood, and was the first to safely ligate a patent ductus arteriosus in a
child. He also developed the classification system for oesophageal Atresia, that now bears his name. In
addition to these achievements, he not only co-wrote “the text book of paediatric surgery” with Ladd
but also established the paediatric surgical residency at Children’s Hospital, and was thus responsible
for the training of a generation of paediatric surgeons who later on became leaders in this field.
228 N. Sugandhi and S. Agarwala
D6 D 6R ight Pneumonectomy
N. Sugandhi and S. Agarwala
Fig. 1
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
Fig. 2
• Reflect the pleura laterally to expose the supe- Repair the transected bronchial end with in-
rior pulmonary vein (Fig. 1). Dissect to enter terrupted Prolene sutures applied in a ‘figure-
the perivascular plane. 8’manner.
• Delineate the main trunk and then continue • Alternatively, the bronchus may be secured by
dissection distally to expose the three branches applying and stapling device (Fig. 3).
of the superior pulmonary vein (Fig. 1). • Check for the integrity of the bronchial closure
• Doubly ligate all these three branches and then by dipping the end into a pool of saline and
ligate the trunk of the vein with a thick silk su- asking the anaesthetist to apply positive pres-
ture (Fig. 1). sure.
• Divide the three branches between the ligatures. • Ensure haemostasis, place an appropriately
• Retract the lower lobe of the lung anteriorly sized intercostal drain and close the chest in
and superiorly to identify the inferior pulmo- layers.
nary ligament.
• Divide the inferior pulmonary ligament from
the diaphragm to the lower margin of the in-
ferior pulmonary vein. Many small vessels in
this ligament will need to be cauterized.
• Dissect the inferior pulmonary vein as de-
scribed for superior pulmonary vein. This also
usually has three branches which can be dealt
with as for the superior pulmonary vein (Fig 2).
• Retract the lung anteriorly and elevate it from
the mediastinum to identify the right main
bronchus in the superior portion of the pul-
monary hilum (Fig. 3).
• Secure the two bronchial arteries on it surface
and enter the peribronchial plane.
• Apply a bronchial clamp on the bronchus, tran-
sect it with a knife and remove the specimen. Fig. 3
230 N. Sugandhi and S. Agarwala
Tips
77 In cases of severe bronchiectasis with the lung 77 The trunk of the inferior pulmonary vein is just
and the thoracic cage severely collapsed, it is anterior to the oesophagus which can be easily
worthwhile opening the chest through the peri- identified by a thick orogastric catheter placed in
osteal bed of the resected fifth rib. the oesophagus by the anaesthetist.
77 Pulmonary artery and veins have a very poorly 77 The site of bronchial transaction should be as
developed media and hence need careful han- high as possible to avoid leaving too-long a
dling and ligation. bronchial stump which is prone to collection and
77 The vascular ligatures can be done in many dif- repeated infections.
ferent ways and can also be done with vascu- 77 The procedure is same for left pneumonectomy.
lar staplers. During ligation of the veins and the
arteries, all the branches and the main trunk
should be ligated separately and then the
branches should be divided to prevent slipping
of the ligature.
Common Pitfalls
77 Injury to the stump of the superior pulmonary 77 Leaving too-long a bronchial stump will lead to
artery while dissecting the main bronchus as the recurrent infections and may cause stump blow
artery is just on the anteromedially surface of the out and a bronchopleural fistula.
bronchus can occur.
D7 Right Upper Lobectomy 231
D7 R ight Upper Lobectomy D7
N. Sugandhi and S. Agarwala
Fig. 1
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
• Apply three ligatures to the superior two • Dissect proximally on the artery to identify its
branches and divide between the distal two lig- first branch, that is given off posteriorly to the
atures keeping the proximal vein with double superior segment of the lower lobe (Fig. 2).
ligatures. The middle lobe tributary (lingular • Also identify the branch to the middle lobe,
lobe on the left side) is the inferior most tribu- that is given off anteriorly (to the lingual on
tary and this needs to be preserved if the mid- the left side), just opposite the branch to the
dle lobe is being preserved (Fig. 1). superior segment (Fig. 2).
• Identify the interlobar fissure by retracting the • Continue dissection proximally in the fissure to
lower lobe inferiorly and upper lobe superiorly. identify the posterior segmental branch to the
• Begin dissection at the point of convergence of posterior segment of the upper lobe (Fig. 2).
the horizontal and the oblique fissures. Apply three ligatures to this branch and divide
• Identify the inferior division of the right pul- between the distal two ligatures.
monary artery at this point and enter its peri- • In case the fissure is incomplete, the lung is re-
vascular plane. tracted anteriorly and the pleural incision com-
pleted to complete the division of the fissure.
• Retract the lung anteriorly and elevate it from
the mediastinum to identify the right main
bronchus in the superior portion of the pul-
monary hilum.
• Continue this dissection to identify the right
upper lobe bronchus (Fig. 3).
• Apply a bronchial clamp on the upper lobe
bronchus, transect it with a knife and remove
the specimen.
• Repair the transected bronchial end with in-
terrupted Prolene sutures applied in a figure
of eight manner.
• Alternatively, the bronchus may be secured by
Fig. 2 applying and stapling device.
• Check for the integrity of the bronchial closure
by dipping the end into a pool of saline and
asking the anaesthetist to apply positive pres-
sure.
• Ensure expansion and collapse of the remain-
ing pulmonary lobes, especially the middle
lobe.
• Ensure haemostasis and place an appropriate
size intercostal drain and close the chest in lay-
ers.
Fig. 3
D7 Right Upper Lobectomy 233
Tips
77 Often the apical vein overlies the apical branch 77 Posterior segmental artery to the posterior seg-
of the artery and may need to be divided before ment of the upper lobe requires separate liga-
the artery itself can be reached. tion as it arises separately from the inferior pul-
77 The posterior wall of the superior pulmonary monary artery. There may be more than three
vein is in intimate relation to the inferior divi- arteries supplying the upper lobe.
sion of the pulmonary artery and damage to this 77 The inferior division of the pulmonary artery is
should be avoided when dissecting the superior aligned in the direction of the horizontal fissure
pulmonary vein. and not at right angles to it.
77 During ligation of the superior pulmonary vein
the tributary from the middle lobe must be iden-
tified and preserved.
Common Pitfalls
77 Compromise to the main bronchus will lead to 77 Leaving too-long a bronchial stump will lead to
postoperative collapse. Manual lung inflation recurrent infections and may cause stump blow
should be used to be certain that the main bron- out and a bronchopleural fistula.
chus is not compromised before dividing the up-
per lobe bronchus.
234 N. Sugandhi and S. Agarwala
D8 D8 R ight Lower Lobectomy
N. Sugandhi and S. Agarwala
Operative Technique
Fig. 2
Tips
77 The arterial division and the bronchial division to 77 The inferior division of the pulmonary artery is
the superior segment of the lower lobe should aligned in the direction of the horizontal fissure
be dealt with separately or else it would lead to and not at right angles to it.
a compromise to the middle lobe arterial supply 77 The horizontal fissure between the upper and
and aeration. lower lobes may be complete and this leaves
77 The posterior wall of the superior pulmonary middle lobe free to undergo torsion on its pedi-
vein is in intimate relation to the inferior divi- cle. The middle lobe in such a situation should be
sion of the pulmonary artery and damage to this secured to the upper lobe either with sutures or
should be avoided when dissecting the inferior with a stapling device.
division of the pulmonary artery in the fissure. 77 The middle lobe may become free and prone to
volvulus and hence may need to be fixed with
sutures or staplers to the upper lobe.
Common Pitfalls
77 Compromise to the middle lobe bronchus will 77 Leaving too-long a bronchial stump will lead to
lead to postoperative collapse. Manual lung in- recurrent infections and may cause stump blow
flation should be used to be certain that the out and a bronchopleural fistula.
main bronchus is not compromised before divid-
ing the bronchus to the superior segment of the
lower lobe.
D9 Wedge Resection 237
D 9Wedge Resection D9
N. Sugandhi and S. Agarwala
Operative Procedure
Fig. 2
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com Fig. 3
Fig. 6
Fig. 4
Fig. 7
Fig. 5
Tips
77 For lesions that are peripheral but not near the 77 For very small peripherally located lesions: The
fissures, grasp the lesion with a Duval’s lung for- lesion may be grasped with Duval’s forceps and
ceps (Fig. 3) and deflate the lung. Draw out the a stapling device (Figs. 5 and 6) or transfixation
lesion and then apply a stapling devise as shown suture placed at the base and the lesion excised
(Fig. 4). (Fig. 7).
Common Pitfalls
Carl F. Davis
Consultant Paediatric and Neonatal Surgeon
Carl.Davis@ggc.scot.nhs.uk
Procedure for VA Cannulation sition the tip of arterial cannula one third of
distance between sternal notch and xyphoid.
• Split the sternomastoid with blunt dissection, • Release clamp until cannula fills with blood
exposing the carotid sheath. and tie down silk ligatures to secure within the
• Open the carotid sheath and identify the artery (Fig. 3).
RCCA.
• Administer IV heparin (50 IU/kg).
• Control the RCCA with 2/0 silk ligatures (Fig.
1) and at least 90 s following heparin injection,
tie the cranially placed ligature and clamp the
RCCA caudally.
RCCA
RIJV
Fig. 3 Arterial cannula secured over silicone. RIJV is now
controlled with silk ties
• Secure the cannulae and connect to ECLS cir- Procedure for Open VV Cannulation
cuit, ensuring a bubbleless technique by irriga-
tion with saline (Fig. 5). • Split sternomastoid with blunt dissection, ex-
posing the carotid sheath.
• Open the carotid sheath and identify the RIJV.
• Administer IV heparin (50 IU/kg).
• Control the RIJV with two 2/0 silk ties, and at
least 90 s following the heparin injection, tie the
cranially placed ligature and clamp the RIJV
caudally.
• Perform a venotomy with a size no. 11 blade.
• Advance a lubricated, clamped, venous can-
nula though the venotomy aiming to position
the tip half way between the sternal notch and
xyphoid – put pressure on liver as before to fill
Fig. 5 Both cannulae secured (note clamps in place before the cannula.
connecting to circuit) • Repeat for femoral vein if two cannulae tech-
nique required.
rocedure for Percutaneous VV
P • Secure cannula(e) and connect to ECLS cir-
Cannulation cuit, ensuring a bubbleless technique by irri-
gation of saline.
In most cases, VV cannulation can be performed
percutaneously using the Seldinger technique.
Decannulation from ECLS
• Position as above. RIJV can be identified using
anatomical or ultrasound techniques. • Preparation and positioning techniques are as
• Access the RIJV using a 21-G needle and ad- for insertion.
vance a 0.018-in (0.045 cm) guide wire into • If the vein was percutaneously accessed, the
the vein. Ensure correct placement by echo- cannula should be removed during inspiratory
cardiography or radiological identification of hold, followed by direct pressure over the ve-
guide wire in RA. notomy. Formal closure is rarely required.
• Advance to larger (0.035 in [0.089 cm]) guide • If an open insertion was used, the vessels
wire and administer IV heparin (50 IU/kg). should be isolated and controlled before can-
• Advance serial dilators over the guide wire fol- nula removal. If the ECLS run was short, con-
lowed by an appropriately sized cannula. sider arteriotomy repair.
• Confirm cannula position with echocardiogra-
phy or image intensifier.
• If two-vessel VV ECLS is required, access the Complications of ECLS
femoral vein in the same fashion and dilate to
allow cannula insertion – aim to position can- Complications can be mechanical or patient in or-
nula tip in the upper hepatic IVC. igin. Appropriate training and meticulous atten-
• Secure cannula(e) and connect to ECLS cir- tion to detail is required to minimise circuit prob-
cuit, ensuring a bubbleless technique by irri- lems during ECLS. Simulation training is an im-
gation of saline. portant adjunct to increase experience. Most pa-
tient-related complications are due to increased
bleeding risk from heparinisation.
242 G. M. Walker and C. F. Davis
Tips
77 When securing cannulae into vessels, place a 77 Recently introduced double-lumen bicaval can-
piece of silicone “sloop” under the silk ligature nulae should avoid the need for two-vessel VV
before tying knots. This is useful during decan- ECLS in most children and adults, although the
nulation (a “Bootie”). tip of the cannula needs to be advanced into an
intrahepatic IVC position.
77 A semi-Seldinger technique may be used where
the vein is identified to aid percutaneous punc-
ture.
Common Pitfalls
77 Echocardiography and/or radiology to confirm 77 Remember that the femoral veins angle pos-
accurate cannula position is essential, especially teriorly as they pass into the pelvis – it is not a
for VV ECLS. “straight run” in a supine patient.
PAR T E
Abdomen
E1 Upper Gastrointestinal Endoscopy 245
E 1Upper Gastrointestinal Endoscopy E1
M. Steven and P. McGrogan
Procedure Technique
Tips
77 When first starting to perform endoscopy prac- 77 In the UK, the Joint Advisory Group on GI Endos-
tice different steps before trying to do every- copy (JAG) sets standards for individual endos-
thing at once, e.g. practice intubation, or keeping copists and training, and provides quality assur-
the picture central while an assistant advances ance for training at individual centres. In addi-
the endoscope. tion, they provide trainees with certification of
77 Always perform the pre-endoscopy checklist. endoscopy training. We would recommend ac-
cessing their website for further information at:
http://www.thejag.org.uk.
Common Pitfalls
• Follow the pre-endoscopy checklist as de- • A 23- to 25-G retractable injection needle is
scribed in Chap. E1. used.
• Ensure that all staff are appropriately trained • Pass the needle down the biopsy port.
and familiar with adjunct therapies. • Inject 0.5-ml aliquots of 1:10,000 adrenaline,
• Use an endoscope with a minimum diameter 0.1 to 0.3mm away from the bleeding site.
of 9.0 mm. • Repeat this in a quadrant fashion around the
• Prepare adjunct therapies: lesion (Figs. 1 and 2).
– Adrenaline diluted to a concentration of
1:10,000 in a 10-ml syringe
– Thermal probe connected and available
– Endoscopic clipping equipment available
– Multiple Bander equipment ready
Clipping
Tips
77 Endoscopic assessment should be carried out with a proton pump inhibitor intravenously for
within 24 h of the bleed but only after the pa- 72 h is recommended.
tient has been appropriately resuscitated. 77 If active ongoing bleeding, consider using the
77 All patients with a GI bleed should have an antral endoscope tip around the bleeding point for a
biopsy and CLO test to assess for Helicobacter py- tamponade effect.
lori. Eradication therapy should be carried out if 77 If you experience difficulty obtaining an ade-
possible. quate view or with the technical aspects of the
77 Postoperative supportive medical management procedure, consider rescoping within 24 h.
Common Pitfalls
77 Unfamiliarity with equipment 77 Injection needle not primed with adrenaline so-
77 Inappropriately trained staff lution
250 P. McGrogan
Application of the Multiband Ligator • The scope is re-introduced into the patient.
• The scope is moved directly onto the distal oe-
• The ligator handle is inserted into the endos- sophageal varix.
copy biopsy channel with the handle pulled out • Constant suction is applied using the endos-
into the two-way position (see Fig. 4 here). copy suction port.
• The valve of the ligator is punctured with a nee- • The varix is sucked into the sleeve of the
dle and the loading wire is passed through the bander, causing a ‘red-out of vision on the
biopsy channel until visible at the end of the monitor screen.
endoscope. • The ligator handle is turned clockwise (approx-
• The proximal end of the cord of the bander imately 180°) until the band release is felt.
is hooked into the loading wire and gradually • Suction is released and air blown down the
pulled back through the scope (Fig. 5). endoscopy channel. The varix with the band
• As the cord becomes taut, the bander is pushed should fall away from the scope (see Figs. 6
onto the tip of the endoscope. and 7)
• Ensure the cord is not nipped. • Ligation can be repeated to adjacent varices or
• The proximal end of the cord is unhooked from if necessary more proximal to the applied band
the loading wire and secured into the hole of (Fig. 7).
the slot of the ligator and the handle (in the
two-way position) and is rotated clockwise to
tighten the wire to obtain minimal tension.
• The ligator handle is changed from the two-
way position into the firing position.
Sclerotherapy
Tips
77 Having drawn the varix into the sleeve, ensure 77 Banding can be practised outside the patient to
continuous suction with the left hand, using the allow the operator to become familiar with the
right hand to turn the ligator handle clockwise. process.
77 Multibanders come with four, six or eight shoot- 77 Sclerotherapy should be considered in children
ers. All bands are black apart from the penulti- under the age of 1 year (or 10 kg), in whom intu-
mate band, which is white and allows the endos- bation of the oesophagus with the bander may
copist to be aware that there is one band left. be extremely difficult.
77 Having completed the banding or sclerother- 77 If bleeding has occurred following sclerotherapy,
apy, plan a programme of banding to eradicate press the tip of the scope against the varix to
the varices. provide a tamponade effect.
77 After endoscopic treatment for an acute variceal 77 Consider undertaking a chest x-ray postopera-
haemorrhage, the patient should receive vasoac- tively if the patient has respiratory compromise
tive treatment such as octreotide for 48 h. or chest pain, to look for evidence of oesopha-
geal perforation.
Common Pitfalls
77 Do not use a small-diameter scope, that will be 77 Avoid passing the scope beyond banded varices
too small to allow the bander to be applied to as this may displace the bands.
the tip.
252 M. Steven and P. McGrogan
E3 E3 Proctoscopy and Rigid Sigmoidoscopy
M. Steven and P. McGrogan
Proctoscopy
Rigid Sigmoidoscopy
Fig. 1 The proctoscope
Rigid sigmoidoscopy is the endoscopic examina-
tion of the rectum to the rectosigmoid junction us- • A thorough inspection of the perineum and
ing a rigid sigmoidoscope (see Fig. 3). In the ma- a careful digital rectal examination should al-
jority of cases, sigmoidoscopy is now performed ways be performed first to look for diagnostic
using a flexible instrument. stigmata and to ensure that there is no obstruc-
tion to the endoscope being inserted.
Technique • Lubricate the tip of the obturator and endo-
scope and insert gently into the anal canal/
• Both procedures are performed using direct vi- lower rectum.
sion down the endoscope. • Once inserted, remove the obturator and at-
• No bowel preparation is necessary. tach the light source.
• In children, most procedures are performed un- • Note that the rigid sigmoidoscope has a view-
der general anaesthetic. ing end-seal, comprising a clear window to see
• The child can be supine or in the left lateral de- through and an attachment for the light source
cubitus position. and air pump.
• The technique is similar for both except there • For rigid sigmoidoscopy, use the bellows to
are no bellows to insufflate air in proctoscopy, insufflate air and only advance the endoscope
as this is not necessary. when the lumen of the bowel opens and it is
safe to do so.
Mairi Steven () • It should be possible to advance to the recto-
Specialty Trainee in Paediatric Surgery sigmoid junction, which lies approximately 15–
mairisteven@doctors.org.uk
17 cm from the anal verge in children.
Paraic McGrogan • Slowly withdraw the scope in a spiral manner,
Consultant Paediatric Gastroenterologist carefully inspecting all of the mucosa.
Paraic.McGrogan@ggc.scot.nhs.uk • Biopsies can be taken as necessary.
Tips
77 Perform the pre-endoscopy checklist (see Chap. 77 The rectum lies in the hollow of the sacrum at a
E1). sharp posterior angulation relative to the anal
77 Ensure the lumen is in the centre of your view at canal. Move the external portion of the endo-
all times. scope anteriorly once you enter the rectum to re-
77 Do not advance unless you have a good view. gain a view of the lumen.
Common Pitfalls
77 Never assume that rectal bleeding is secondary 77 Always consider the need for a full colonoscopy
to haemorrhoids. (see Chap. E4).
254 M. Steven and P. McGrogan
E4 E4 Colonoscopy
M. Steven and P. McGrogan
Generally colonoscopy is considered a one-per- of the right hand causes an equal observed for-
son procedure. ward movement at the scope tip.
It is usually performed with the child supine or • When failure of “1-to-1” movement is encoun-
in the left lateral decubitus position under general tered, consider de-looping procedures (see
anaesthetic. The child may be moved during the “Tips”).
procedure into the supine (or occasionally right • Do not push through resistance to movement.
lateral decubitus) position to optimise the visual • Movement around bends is achieved by mov-
field and advancement of the colonoscope. ing the tip of the scope up/down (left thumb
Perform preprocedural endoscope equipment on large wheel) and clockwise/anticlockwise
and patient check (see Chap. E1). torque of the right hand, whilst gently advanc-
ing the scope.
• Stop this series of movements and withdraw
How to Hold the Colonoscope slightly if resistance is encountered.
• The scope should be straightened (to mini-
• Use your left hand to hold the control the head, mise the amount of scope inside the patient)
with the thumb resting on the up/down wheel regularly and in particular after rounding the
and forefinger on the air/water buttons. splenic flexure and again at the hepatic flexure.
• The right hand should hold the colonoscope This should be attempted by clockwise torque
close to its tip on entering the anus and should with the right hand and a short gentle with-
provide movement through push, pull and also drawal of the scope shaft.
torque (which is done with clockwise or anti- • The ileocaecal value is approximately 6 cm
clockwise rotation of the right hand). distal to the caecum and the scope should be
• The small cogwheel is rarely used. pulled back from the caecal pole to identify it.
The terminal ileum can be intubated by pass-
ing the scope tip over and proximal to the il-
Technique eocaecal valve, deflating the caecum partially
and pulling back gently with the scope angled
• Perform a digital rectal examination.
• Apply a little lubricating jelly to the end of the
colonoscope. avoiding the camera lens.
• Insert the colonoscope and keep the lumen
of the bowel in the centre of the picture at all
times. Only advance the scope with direct vi-
sion and with a “1-to-1” movement where push
Paraic McGrogan
Consultant Paediatric Gastroenterologist Fig. 2 Colonoscopic view of the caecum with typical tri-
Paraic.McGrogan@ggc.scot.nhs.uk angular or ‘toblerone’ appearance
Tips
77 Perform the pre-endoscopy checklist (see Chap. 77 In the UK, the Joint Advisory Group on GI Endos-
E1). copy (JAG) sets standards for individual endosco-
77 Always hold the colonoscope correctly (see Fig. pists and training and provides quality assurance
1 and text). for training at individual centres. In addition, they
provide trainees with certification of endoscopy
training. We would recommend accessing their
website for further information at http://www.
thejag.org.uk
Common Pitfalls
Incisions
Exposure
Supra-umbilical Approach
• Deliver the greater curvature into the incision • Use the tip of a closed pair of curved mosquito
using a moist cotton swab or Babcock forceps. artery forceps (hold like a pen) to deepen the
• Apply gentle traction on the swab in a ‘rock- dissection through the hypertrophied muscle.
ing-to-and-fro’ motion to deliver the antrum • Once an adequate depth is reached, turn the
and pylorus. mosquito forceps to lie parallel to the pylorus,
• If delivery is difficult, extend the incision, as ag- and open the forceps to spread the remaining
gressive traction will traumatise the stomach. muscle and expose the mucosa (Fig. 4).
• Once the pylorus is delivered, return the body
of the stomach to abdomen.
Pyloromyotomy
Fig. 4
Fig. 2
Fig. 5
Fig. 3
258 P. Sekaran and G. M. Walker
Closure
Tips
77 Practice feeling the pyloric ‘tumour’ under gen- 77 The pyloric vein of Mayo marks the distal extent
eral anaesthesia (GA) for final confirmation and of the pyloric tumour.
education. 77 Open the linea alba longitudinally as far as re-
77 The umbilical wound may be better for cosmesis quired for easy pyloric delivery.
but has a higher infection risk- consider antibiot- 77 If it is difficult to deliver the pylorus from a su-
ics at induction. pra-umbilical incision, extend the incision into an
Omega (Ω) configuration.
Common Pitfalls
77 Typically perforations occur at the duodenal end 77 Typically an inadequate myotomy occurs at the
of the pylorus as the pylorus bulges into the du- gastric end of the pylorus. Avoid inadequate my-
odenal lumen – be especially careful here (see otomy by extending onto the gastric antrum.
arrow, Fig. 6). 77 Do not attempt to obtain haemostasis on the
edges of the pyloromyotomy. This is the result of
venous congestion and will cease on returning
the pylorus to the abdomen.
Fig. 6
E5 Open Pyloromyotomy 259
C O N R A D R AMS TEDT
(1867 – 1962)
German surgeon
Conrad Ramstedt studied medicine in Berlin and Halle, and thereafter joined the Army. He
retired from the Army at the end of the First World War and settled in Munster in North
Rhine-Westphalia, Germany. His name is attached to the condition pyloric stenosis, first
described by Hirschsprung. He operated on a friend’s son who had ‘pylorospasm’ and al-
though he was attempting a pyloroplasty he was unable to approximate the muscles once he
had split them longitudinally. He therefore left the procedure half done and was surprised
that it worked. Even though Styles in Edinburgh had performed the same procedure earlier,
posterity has remembered it as the Ramstedt pyloromyotomy.
260 N. Sugandhi and S. Agarwala
E6 E 6Stamm Gastrostomy
N. Sugandhi and S. Agarwala
Fig. 1
• Lift the anterior wall of the stomach away from • Make a 0.5-cm stab incision on the anterior ab-
the posterior wall and make a stab incision in dominal at the previously marked site for the
the centre of the purse-string sutures. gastrostomy. Pass curved mosquito forceps
• Use curved mosquito forceps or a stylet to through the wound to grasp the open end of
stiffen and insert a Malecot catheter into the the Malecot catheter and deliver it out through
stomach (Fig. 3). the incision.
• Anchor the anterior wall of the stomach
around the site of the gastrostomy to the peri-
toneal surface with a series of interrupted non-
absorbable sutures, taking good ‘bites’ of trans-
versalis fascia (Fig. 4).
• Anchor the gastrostomy tube at the exit site
with a silk suture (Fig. 4).
• Close the abdomen with continuous Vicryl su-
tures to the linea alba and subcutaneous tissue
in two layers, and subcuticular Monocryl to
skin.
Fig. 3
Fig. 4
262 N. Sugandhi and S. Agarwala
Tips
77 The exit of the gastrostomy catheter should not 77 A useful technique for opening the stomach is to
be too close to the costal margin; with growth of pass a curved needle through the anterior gas-
the child, the gastrostomy tends to migrate near tric wall and to cut onto the needle with monop-
the costal margin, thus making skin care more olar diathermy.
difficult.
Common Pitfalls
77 Gastrostomy made too near the greater curva- 77 When siting the gastrostomy, avoid the gastric
ture can make subsequent creation of a gastric pacemaker. Avoid the greater curve, particularly
tube difficult. in neonates with long-gap oesophageal atre-
77 Gastrostomy made too close to the pyloric end, sia, as that site may be required to fashion a gas-
that can lead to frequent obstruction of the pylo- tric tube for oesophageal replacement; avoid
rus with the tip of the catheter. the fundus in case of future fundoplication; and
avoid the pre-pyloric antrum as a gastrostomy
here may cause gastric outlet obstruction, partic-
ularly if it is subsequently changed to a balloon-
retained device.
E7 Percutaneous Endoscopic Gastrostomy (PEG) 263
E7 Percutaneous Endoscopic Gastrostomy E7
(PEG)
B. Adikibi and C. F. Davis
Operative Technique • Palpate to ensure that the liver and spleen are
not deep to the proposed insertion site (Fig. 1).
• An upper gastrointestinal (GI) endoscopy is • Dim the theatre lights to optimise transillumi-
performed (see Chap. E1). nation through the abdominal wall. Indenta-
• Mark an appropriate site on the upper abdo- tion should be performed with a clip or finger
men. This should be well below the costal mar- under direct endoscopic vision with synchro-
gin. The usual site of placement is at a point nous gastric distension (Fig. 2). Only proceed
two thirds the way along a line running from if there is good transillumination and clear in-
the umbilicus to the midpoint of the left cos- dentation, with no suggestion of an interposed
tal margin, over the mid-portion of the rectus organ. If this is not obtained, abandon the pro-
muscle cedure in favour of an open or laparoscopic-
assisted approach.
Fig. 2
Fig. 4
Fig. 3
Tips
77 Ensure the site for the PEG tube is not too close 77 Use sharp, confident needle advancement to
to the costal margin. puncture the stomach wall. Slow, cautious at-
77 Good transillumination and indentation are im- tempts only serve to push the stomach away, in-
perative. Any uncertainty should prompt an al- creasing the risk of collateral damage.
ternative method of insertion, such as the lapa- 77 Be prepared to move to laparoscopy assisted
roscopic-assisted method. technique than abandoning the procedure.
Common Pitfalls
77 Equipment failure: always check the endoscope ment, in whom it may not be possible to transil-
before starting the case. luminate or indent the stomach below the cos-
77 Avoid over-insufflation of the stomach, as air es- tal margin.
caping through the pylorus will distend the prox- 77 The transverse colon lies anterior to the lower
imal loops of small bowel, causing them to en- margin of the stomach. This may be visible as a
croach on the intended gastrostomy insertion dark line during endoscopic transillumination.
site. Failure to achieve localised indentation on gen-
77 A laparoscopic-assisted or open approach may tle finger pressure may be indicative of inter-
be safer in patients with a history of previous ab- posed colon. Do not proceed.
dominal surgery, particularly involving the su- 77 Poor positioning of the gastrostomy either on
pracolic compartment, due to the risk of adhe- the anterior abdominal wall and/or in the stom-
sions and distorted anatomy; and in patients ach can occur (usually too close to the pylorus,
with marked scoliosis or neurological impair- causing gastric outlet obstruction).
266 L. McIntosh and R. Carachi
E8 E8Umbilical Hernia Repair
L. McIntosh and R. Carachi
Robert Carachi
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk
Fig. 3 Fig. 4
Fig. 5 Fig. 6
Fig. 7
Fig. 8
Tips
77 Some hernias with supra-umbilical portion may 77 Large hernias often have significant dead space
be better approached through supraumbilical following closure making haematoma or seroma
incision. formation probable. These should have pressure
dressing placed to reduce occurrence.
Common Pitfalls
Epigastric hernia
Supraumbilical hernia
Fig.3
Fig. 4
Fig. 5 Fig. 6
Tips
Common Pitfalls
Fig. 2
Constantinos A. Hajivassiliou
Consultant Paediatric and Neonatal Surgeon
ch27z@udcf.gla.ac.uk
Fig. 4
Fig. 5
272 P. Hammond and C. A. Hajivassiliou
Tips
77 Ensure there is adequate space behind the oe- 77 Avoid causing gastric angulation when suturing
sophagus to allow the fundus to slide through the wrap to the diaphragm edge anteriorly.
without resistance to avoid wrap ischaemia. 77 Demonstrate and preserve anterior vagal trunk.
77 A short (1- to 2.5-cm) loose floppy wrap is ideal. Posterior is usually safe if posterior dissection is
77 The aorta runs posterior to the crura – avoid ex- in loose areolar plane (not on oesophageal wall).
cessively large ‘bites’ whilst repairing the defect.
Common Pitfalls
77 Making the wrap too tight exacerbates post-op- 77 Meticulous haemostasis is essential as delayed
erative dysphagia and regurgitation bleeding may occur, especially around the hia-
77 Avoid repairing the crural defect too tightly (it tus.
should admit just the tip of the finger alongside 77 Oesophageal or fundal perforation, although
the oesophagus) rare, must be identified and repaired at the time.
77 The superior wrap suture should include the di-
aphragm at the anterior oesophageal hiatus to
prevent the wrap migrating into the chest.
E11 Gastroschisis 273
E1 G astroschisis E11
M. Steven and R. Carachi
Preoperative Management
• IV access
• Fluid replacement
• “Bowel bag” or cling film wrapped around in-
fant to prevent evaporative losses
• Nasogastric tube
Surgical Technique
Primary Closure
a
• The umbilical cord is tied off with silk. The
assistant then lifts the bowel and the surgeon
preps the skin and bowel and drapes.
• The defect is stretched with two fingers.
• The bowel is inspected for an atresia, oedema,
foreshortening and the presence of peel.
• If the bowel can be reduced into the abdominal
cavity without causing respiratory compromise
or being too tight, then primary repair should
be performed. Intravesical or intragastric pres-
sure monitoring may help in making this deci- b
sion. Fig. 1a,b
• Once the bowel is reduced, the fascia is under-
mined and closure is then performed using in-
terrupted non-absorbable suture
Robert Carachi
Professor of Surgical Paediatrics Fig. 2
Robert.Carachi@glasgow.ac.uk
Fig. 4
Silo Application
Tips
If the bowel looks ischaemic preoperatively, two 2. Place the child in the right lateral position. This
manoeuvres can help. means there is less tension on the bowel mesen-
1. With the child supine place two supports (e.g. tery.
a rolled nappy) either side of the baby so the
bowel and mesentery cannot flop to one side.
Common Pitfalls
77 The infant will need plenty of fluid because of 77 It is important to decompress the bowel prior to
ongoing losses; however, it is important not to attempt fascial closure this can be done by “milk-
‘chase the base’ [deficit], as most babies with gas- ing” intestinal contents up to the nasogastric
troschisis will have a degree of metabolic acido- tube and performing a rectal examination.
sis.
E12 Exomphalos 275
E 12Exomphalos E12
M. Steven and R. Carachi
Preoperative Management
• IV access
• Fluid replacement
• “Bowel bag” or cling film wrapped around
baby to prevent evaporative losses
• Investigations including CXR, cardiac, renal
and spinal ultrasound.
• Nasogastric tube
Operative Technique
• Primary closure
– Should be undertaken where possible to de-
crease the chance of intra-abdominal sepsis.
– Most surgeons would excise the sac unless
adherent to liver.
– There is a need to control and ligate umbil-
ical vessels.
– Careful examination and reduction of bowel
and viscera especially the liver is important.
• Stretching of the peritoneal cavity
– Undermine the skin to define the fascial lay- b
ers.
– Fascia should be closed with an interrupted Fig. 1a,b
or continuous absorbable suture if tolerated.
• Skin closed and umbilicoplasty performed Moderate to Large Exomphalos
Conservative Treatment
Mairi Steven () • Very large defects may simply be painted with
Specialty Trainee in Paediatric Surgery a disinfectant or Flamazine and observed for
mairisteven@doctors.org.uk
development of eschar.
Robert Carachi • A suitable corset is then fitted.
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk
Fig. 2
Fig. 3 Fig. 4
If the sac ruptures it may be possible to repair the This is usually performed at 6–9 months of age
defect in the sac and continue with conservative and involves excising excess skin and repairing the
management. If not a silo may be applied, how- ventral hernia.
ever, this is only a temporary measure. In very
large defects a synthetic patch or skin graft may
be considered.
E12 Exomphalos 277
Tips
77 Intra-abdominal pressure can be measured via 77 Babies with large exomphalos require a pro-
the nasogastric tube and central venous catheter longed hospital stay, and a multidisciplinary ap-
intraoperatively. proach including advice from tissue viability and
orthotics regarding corset application.
Common Pitfalls
77 A primary closure too tight may lead to abdomi- 77 It is often the associated anomalies that cause
nal compartment syndrome morbidity and mortality in these patients and
it is not only important to look for these, but to
also actively manage them, e.g. pulmonary hy-
poplasia often seen with a classic “bell-shaped”
chest.
278 N. Sugandhi and S. Agarwala
E13 E 13Loop Enterostomy
N. Sugandhi and S. Agarwala
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
Fig. 3
Tips
77 Mark the appropriate site of placement before chored at the two ends of the abdominal in-
starting the procedure. cision, with the intervening muscles and skin
77 Deliver adequate length of bowel outside to closed in layers.
fashion a proper pouting and everted stoma. 77 In a non-obstructed child the loop stoma may be
77 If a divided stoma is to be created, then the loop matured 48 h later to prevent the soiling of the
of bowel is transected and the two ends an- wound.
Common Pitfalls
77 Improper siting, near the costal margin or the il- 77 Improper anchoring to the abdominal wall, es-
iac crest pecially the centre stitch, leading to herniation
77 Mistaken identification of loop such as the sig- at this site
moid instead of the transverse colon 77 Too many anchoring sutures leading to venous
77 Twisting of loop before anchoring causing ob- congestion and ischemia
struction 77 Failure to adequately pout and evert the stoma,
77 Creating a very small incision in the muscle and causing difficulty in application of stoma bags.
fascia again leading to obstruction
280 S. Gazula and S. Agarwala
E14 E14 B owel Resection and Anastomosis
S. Gazula and S. Agarwala
Fig. 1
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com Fig. 3
Fig. 5
Fig. 4
Fig. 8 Fig. 9
Tips
77 Incising the peritoneal layer on the two sides of 77 Always start the anastamosis from the mesen-
the mesentery in a V shape either with electro- teric end so that in cases of disparity the Cheatle
cautery or with Metzenbaum scissors is useful to split (making a cut on the antimesenteric border)
visualize the vascular arcades especially in cases may help to enlarge the bowel lumen of the nar-
with inflamed, oedematous mesentery or older rower segment.
children with lot of mesenteric fat. 77 Good vascularity of the transected edges, ab-
77 The larger named mesenteric vessels may need sence of tension, noncrushed bowel ends and
to be secured with transfixion sutures. accurate apposition are essential for a good
77 Bowel may need to be decompressed before anastamosis.
anastamosis is constructed, in cases of massive 77 A peritoneal drain may be useful.
dilatation.
Common Pitfalls
77 Using clamps on neonatal bowel or on oedema- 77 Using bowel ends with doubtful vascularity for
tous bowel or bowel with compromised vascu- anastamosis can be risky.
larity may lead to ischemia of the edges.
E15 Right Hemicolectomy 283
E15 R ight Hemicolectomy E15
G. Haddock
Positioning
Abdominal Incision
Operative Steps
Operative Technique
• The peritoneal reflection lateral to the caecum
• A scalpel should be used to lightly incise the and ascending colon should be incised and the
skin. right colon mobilized. This should be a rela-
• Monopolar diathermy should be used to incise tively bloodless procedure and may best be un-
the fascia and muscle. dertaken standing on the patient’s left side.
• A full laparotomy should be undertaken, par- • Care should be taken to avoid damage to the
ticularly in Crohn’s disease and NNEC. Care right ureter, the duodenum and the right kid-
ney
• The site of division of the colon should be iden-
tified.
Graham Haddock ()
• If dissection along the transverse colon is re-
Consultant Paediatric and Neonatal Surgeon quired, an attempt should be made to dissect
Ghaddock@udcf.gla.ac.uk
Closure
Fig. 3
Fig. 4
E15 Right Hemicolectomy 285
Tips
77 For larger children, make sure that you have an 77 Ensure that older children or children above 50
adequate self-retaining retractor available to kg in weight receive prophylaxis against venous
hold the abdominal wound open. thromboembolism (use subcutaneous long-act-
77 Ensure that a urinary catheter is sited prior to sur- ing heparin and compression stockings).
gery, particularly when the extent of the disease
is not known.
Common Pitfalls
77 Beware of any discrepancy between the diame- 77 Make sure that your anastomosis and wound
ter of the small bowel and colon at the anasto- closure are meticulous, particularly if the patient
motic site. You may need to angle your incision is on systemic steroids or other immunosuppres-
when dividing the small bowel to give you more sive medication.
length to match the colonic diameter.
286 G. Haddock
E16 E16 Subtotal Colectomy and Ileostomy
G. Haddock
Indication S
teps
This procedure is undertaken in ulcerative colitis, • The peritoneal reflection lateral to the caecum
colonic Crohn’s disease or for neonatal necrotiz- and ascending colon should be incised and the
ing enterocolitis (NNEC). right colon mobilized. This should be a rela-
tively bloodless procedure and may best be un-
dertaken from the patient’s left side.
Positioning • Care should be taken to avoid damage to the
right ureter, the duodenum and the right kid-
Supine with a diathermy pad placed on thigh or ney.
back. • The terminal ileum should be mobilized and di-
vided using a linear stapling device. This main-
tains a clean operative field.
Abdominal Incision
Technique
Closure
Tips
77 For larger children, make sure that you have an 77 Ensure that older children or children above
adequate self-retaining retractor available to 50 kg in weight receive prophylaxis against ve-
hold the abdominal wound open. nous thromboembolism (subcutaneous long
77 Ensure that a urinary catheter is sited prior to sur- acting heparin and compression stockings).
gery particularly when the extent of the disease
is not known.
Common Pitfalls
77 Make sure that the splenic flexure dissection is 77 Make sure that you create an adequate spout on
carefully done to avoid damaging the spleen. the ileostomy to accept stoma bags.
77 Make sure that the hole for the ileostomy is not
tight.
290 A. Sinha and S. Agarwala
E17 E17 Small Bowel Atresia
A. Sinha and S. Agarwala
Operative Technique
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
Fig. 4
Fig. 5a,b
Fig. 6
292 A. Sinha and S. Agarwala
Tips
77 For type I atresias, make a longitudinal incision, 77 Tapering of proximal dilated segment should be
on the antimesenteric border, on the dilated considered when a long segment is massively di-
proximal bowel. Excise the web, confirm distal lated or when the atresia is near the duodeno-
patency and close the enterostomy in a single jejunal junction and resection of this segment is
layer in a transverse manner (Fig. 7). not advisable. The tapering can be done either
by hand or with a stapler.
77 In cases of multiple atresias, the entire segment
bearing the atresia can be resected.
77 In some cases the atretic segments involve only
a small length of bowel.
77 In other cases multiple anastamoses can be
made with or without a trans-luminal stent
(‘shish-kabob’ anastamoses) (Fig. 8a, b).
Fig. 7
Fig. 8a,b
Common Pitfalls
77 Failure to rule out distal atresias 77 Kinking of anastamosis while repairing the mes-
77 Retaining the distal massively dilated distal end enteric defect
of proximal bowel that is adynamic
E18 Malrotation and Volvulus 293
E18 Malrotation and Volvulus E18
L. C. Steven and C. A. Hajivassiliou
This approach is used for any child with malrota- • Use small retractors to expose the right upper
tion, with or without volvulus. quadrant (RUQ). Use sharp or bipolar dissec-
tion to divide the Ladd bands close to the ab-
dominal wall. These bands are peritoneal folds
Operative Technique from the caecum and ascending colon, extend-
ing across the duodenum to the RUQ/abdomi-
• Right transverse supra-umbilical incision, 1 nal wall (Fig. 2).
cm above the umbilicus in a neonate (Fig. 1).
Opening the peritoneum may liberate chylous
or haemorrhagic fluid if a volvulus is present.
• Deliver the small bowel carefully. If volvulus is
present, see below. If no volvulus, proceed as
follows.
Fig. 2
Fig. 3
Fig. 4 Fig. 5
E18 Malrotation and Volvulus 295
Tips
77 Ensure the incision allows adequate access to the 77 When dissecting the caecum from medial duo-
RUQ. Extend the wound early for safe exposure. denum, be aware of the biliary anatomy. It may
77 Always be cautious and mindful of the (fragile) have an unexpected configuration. Stay close to
neonatal liver. the caecum when dividing the adhesions here.
77 Note the presence and position of the spleen.
Asplenia and polysplenia may be associated.
Common Pitfalls
77 Take care to divide all of the Ladd bands. Failure 77 If a volvulus is present when devolving remem-
to do so will result in difficulties straightening ber the mesenteric base is narrow and will be oe-
the duodenum and mobilising the caecum to- dematous. Correct devolving may be difficult in
wards the LUQ. interpret.
77 When broadening the mesentery it is only the
anterior leaf of the peritoneum which is divided.
Do not incise any deeper into the mesentery.
W I L L I A M E. LADD
(1880 – 1967)
American paediatric surgeon
Considered the father of American Paediatric Surgery. He graduated from Harvard Medical
School and practiced initially as a general surgeon and gynaecologist. On 6 December 1917,
a French cargo ship at Halifax, Nova Scotia, accidentally exploded killing about 2,000 peo-
ple and injuring more than 9,000, many of them children. Ladd, who had arrived with the
US contingent to help was so moved that he dedicated the rest of his professional life to pae-
diatric surgery. His efforts led to the development of paediatric surgery as a separate disci-
pline. He published some of the earliest papers on malrotation, oesophageal atresia, pyloric
stenosis, intussusception, biliary atresia and bladder exstrophy. His classic textbook Abdom-
inal Surgery of Infancy and Childhood, written with Robert Gross, had a major impact on the
international development of paediatric surgery.
296 T. J. Bradnock and G. Haddock
E19 E19 Open Appendectomy
T. J. Bradnock and G. Haddock
Fig. 1
Graham Haddock
Consultant Paediatric and Neonatal Surgeon
Ghaddock@udcf.gla.ac.uk
Fig. 4
Fig. 2
Fig. 3 Fig. 5
298 T. J. Bradnock and G. Haddock
Fig. 6
Fig. 7 Fig. 8
E19 Open Appendectomy 299
Tips
Fig. 9
Common Pitfalls
The operative principles apply whether the vi- • The Meckel’s may be folded onto the mesentery
tello-intestinal anomaly is an expected or inci- by the vitello-intestinal artery remnant. Ligate
dental finding. The most common anomalies are this or divide with bipolar diathermy (Fig. 1).
discussed. • Place stay sutures on the ileum on either side.
Occlude the ileum using silastic ‘sloops’ to pre-
vent soiling. Take hold of the diverticulum and
eckel’s Diverticulum – Operative
M excise with a wedge of ileum using scissors or
Technique monopolar diathermy (Fig. 2).
Fig. 2
Carl F. Davis
Consultant Paediatric and Neonatal Surgeon
Carl.Davis@ggc.scot.nhs.uk
Fig. 5
Fig. 4
Fig. 6
Tips
77 As the small bowel is ‘walked’ from distal to prox- 77 Opening the peritoneum early during dissection
imal, return the small bowel already inspected of a patent vitello-intestinal duct prevents inad-
to the abdomen. This will prevent excessive oe- vertent damage to the underlying ileum.
dema of the delivered bowel and allow easier re- 77 Consider using a soft plastic wound protector to
turn of the anastomosis at the end of the proce- facilitate return of the anastomised bowel into
dure. the abdomen using laparoscopic-assisted tech-
77 If there is small bowel obstruction associated nique.
with a Meckel’s band, carefully inspect the af-
fected bowel after relief of the obstruction.
Common Pitfalls
77 A Meckel’s diverticulum can be easily missed un- 77 An inadequate size wound compromises return
less both sides of the mesentery are inspected as of the anastomosed intestine and risks damag-
it may be adherent to the mesentery on one or ing the suture line.
other side rather than truly antemesenteric. 77 Failure to perform a generous wedge or segmen-
tal resection of a Meckel’s diverticulum risks leav-
ing residual ulcerated intestinal mucosa in situ.
E21 Intussusception 303
E21 Intussusception E21
R. Kronfli and P. A. M. Raine
Always inform theatre staff of the potential need See also Chap. E14 for additional information.
for surgery prior to an attempted air enema re- • Resection is necessary if:
duction. Otherwise, proceed as for air enema re- – Bowel is not viable.
duction. – Lead point is identified.
– Open reduction is not possible.
Setup • Resect bowel to healthy edges
• Standard serosubmucosal anastomosis
• General anaesthetic – muscle relaxation • Close the mesenteric defect.
• Patient supine – prepare entire abdomen • Washout the abdominal cavity with saline.
• Closure is done in layers.
Procedure Recurrence rate is ~1 %.
Tips
77 Multiple attempts at air enema reduction can be 77 If perforation occurs during air reduction, de-
made, depending on the clinical condition of the compression may be required (for ventilatory
patient, with incrementally increasing pressures compromise) and can be achieved by placing a
of 80, 100, 120 mmHg. large bore cannula into abdomen prior to lapa-
77 If the intussusception is reduced to the ileocae- rotomy.
cal valve, it may be acceptable, if the child re-
mains stable, to reattempt further reduction af-
ter a few hours, once the oedema settles (if the
child is still stable).
Common Pitfalls
77 Traction on the intestine should be avoided 77 If the intussusception extends into the left colon,
while attempting open reduction, as this risks se- ensure that the bowel is normally rotated.
rosal tearing. 77 If there is uncertainty about the completeness
77 Be aware that an oedematous ileocaecal valve of reduction after air enema, laparoscopy may
can mimic an intraluminal mass. Failure to realise avoid a laparotomy.
this will result in unnecessary resection.
77 Even if complete reduction is not possible, re-
duce the bowel as far as possible to minimise
subsequent loss of bowel length at resection.
306 R. Partridge and A. J. Sabharwal
E22 E2 Peritoneal Drainage
R. Partridge and A. J. Sabharwal
Atul J. Sabharwal
Consultant Paediatric and Neonatal Surgeon
Atul.Sabharwal@ggc.scot.nhs.uk Fig. 1 Penrose and corrugated drains
Paracentesis
Fig. 5 Central portion of catheter is removed Fig. 6 Three-way tap and syringe to drain fluid
308 R. Partridge and A. J. Sabharwal
Tips
77 When cutting the drain tubing, cut at an angle as 77 When tying thread around a compressible drain,
this makes subsequent attachment to a chamber ensure it is not so tight as to compress its lumen.
or vacuum bottle easier. 77 Use a Z-track approach when inserting a needle
in paracentesis, to limit leak from puncture site.
Common Pitfalls
77 Ensure all drain tubing side holes are well within 77 Peritoneal cavity suction drains risk drawing
the target cavity. Failure to do so risks ingress of bowel or other viscera into the tip, with the at-
air or infection and prevents suction working. tendant risk of perforation or bleeding.
77 Remember to send ascitic fluid for microscopy,
culture and sensitivity, protein/albumin, amylase
and electrolytes.
E23 Trauma Laparotomy 309
E23 Trauma Laparotomy E23
R. Partridge and N. Brindley
• Emergency laparotomy in children is rarely See also Chap. A8 for additional information.
necessary, but when indicated it must be per- • This approach gives better exposure to abdo-
formed expeditiously. men if the child is 5 years or younger.
• There are two options for the approach, trans- • This is because in this age group, the abdomen
verse supra-umbilical and midline. has more of a square than rectangular shape.
• An exception to this would be if pelvic organ
injury, such as a ruptured bladder, were sus-
pected, in which case a lower midline incision
may be advantageous.
Fig. 0a
Fig. 0b
Nicola Brindley
Consultant Paediatric and Neonatal Surgeon
Nicola.Brindley@ggc.scot.nhs.uk
Tips
77 A retroperitoneal haematoma should be left un- creatinine is likely to be very high and serum so-
disturbed unless it is expanding or it overlies the dium low in this instance.
duodenum or pancreas. 77 If massive haemorrhage occurs, unpack the pre-
77 A large volume of clear fluid in the abdomen sumed bleeding quadrant last.
may herald a ruptured bladder – preoperative
Common Pitfalls
77 Open bowel perforations should be occluded opened by dividing the gastrocolic omentum),
temporarily with light, noncrushing clamps to subdiaphragmatic spaces and posterior abdomi-
prevent further contamination. nal wall should all be inspected.
77 If a site of injury is not obvious after a general
search of the abdomen, the lesser sac (which is
312 L. Gupta and S. Agarwala
E24 E24 Congenital Diaphragmatic Hernia
L. Gupta and S. Agarwala
Operative Technique
Fig. 2
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com Fig. 3
Fig. 4 Fig. 5
Tips
77 A right congenital diaphragmatic hernia (CDH) 77 For a very small abdominal cavity, stretching of
is more easily repaired with the trans- thoracic the wall or creation of ventral hernia may be re-
route. quired to avoid undue rise in intra-abdominal
77 Introduction of some air within the hernial sac, pressure.
with the help of a catheter, may help in reduc- 77 Hernial sac could be opened and retained as a
tion of its contents. lining on the patch if a patch closure is done.
77 In a case where the posterior rim is absent or hy-
poplastic, the posterior ‘bites’ of the diaphrag-
matic sutures may need to be taken around the
lower ribs.
Common Pitfalls
77 Failure to identify the posterior edge of the dia- 77 Failure to properly anchor the patch to the mus-
phragmatic defect, that is often curled up, may cles anteriorly and posteriorly will result in re-
make the defect to seem larger than it actually is. currence. Sutures may have to be taken around
the ribs.
314 M. Clarke and R. Carachi
E25 E25 Diaphragmatic Eventration
M. Clarke and R. Carachi
Operative Technique
move the attenuated portion of diaphragm or • If a diaphragmatic defect has been created then
sac with needle-point monopolar diathermy, it is closed in a transverse fashion in a similar
thus creating a defect. This should only be done manner.
to avoid damage to the phrenic nerve. • The result of the repair is that the muscularised
• Multiple non-absorbable mattress sutures are diaphragm edges are brought together with an
then placed in the fashion demonstrated in intervening portion of ‘gathered’ thin or weak-
Figs. 3 and 4. This has the effect of plicating ened diaphragm (Fig. 5).
the diaphragm and bringing the edges of the
more muscular tissue together.
Fig. 3
• Care must be taken to avoid the phrenic
nerve, which divides into anterior and poste-
rior branches in a medial to lateral orientation
(Fig. 4). The phrenic nerve is easier to visual-
ise using a thoracic approach.
• It is important to take bites of tissue that are
adequate enough to avoid the suture cutting
through without being deep enough to cause
damage to any adjacent viscera.
Fig. 4 Fig. 5
316 M. Clarke and R. Carachi
Tips
77 Diaphragmatic eventration can be distinguished 77 If diagnostic doubt persists then dynamic im-
from diaphragmatic herniation by the presence aging using ultrasonography or fluoroscopy to
of a smooth raised diaphragmatic outline on demonstrate paradoxical diaphragmatic move-
chest radiography. ment may be necessary.
Common Pitfalls
77 Care should be taken with suture placement in 77 Fixing the diaphragm to the thoracic wall can be
order to avoid damage both to branches of the at the expense of subsequent mobility.
phrenic nerve and any adjacent viscera.
E26 Long-Gap Oesophageal Atresia – Gastric Pull-Up 317
E26 Long-Gap Oesophageal Atresia – E26
Gastric Pull-Up
A. Sinha and S. Agarwala
Technique of Mobilization in the Neck or four-stay silk suture on the edge of the oe-
sophagostomy to assist in traction.
• Position the patient supine with a roll trans- • Develop sub platysmal flaps superiorly and in-
versely under the shoulder and neck and ex- feriorly to expose the medial aspect of sterno-
tend the neck. Turn the face to the side oppo- cleidomastoid muscle and the oesophagus. In-
site to the oesophagostomy (Fig. 1). Ask the cise the investing layer of deep cervical fascia
anaesthetist to place a stiff orogastric catheter longitudinally at the medial edge of the sterno-
in the oesophagus. Prep from the chin to the cleidomastoid muscle, and dissect between the
lower abdomen. carotid sheath laterally and the oesophagus me-
dially.
Fig. 2
(Fig. 5). If thoracotomy and oesophageal mo- • Mobilize the stomach by dividing the short gas-
bilization have been done, this step has already tric, left gastric and the left gastro-epiploic ves-
been carried out. sels. Divide the vessels of the greater omentum
• Deliver the lower oesophagus into the abdo- a little distance away from the greater curvature
men. Transect the oesophagus at the GE junc- of the stomach, taking care to preserve the vas-
tion and repair the gastric wall in two layers cular arcade arising from the right gastro-epi-
with Vicryl sutures (Fig. 6). ploic vessels (Fig. 7).
• Divide the gastrohepatic ligament again pre-
serving the arcade supplying the lesser curva-
ture and the right gastric artery (Fig. 8).
• Perform the Kocher’s manoeuvre to mobilize
the first and second part of duodenum (Fig. 6).
• In cases where a retrosternal route has been
decided on, retract the xyphoid process ante-
riorly and just posterior to it in the midline;
divide the fascia between the anterior attach-
ments of the diaphragm. With your index fin-
ger create a retrosternal space towards the neck
to meet the retrosternal space created from the
neck incision.
• Position a thick catheter from the neck to the
abdomen through the retrosternal space or the
posterior mediastinal space, as the case may be.
• With strong silk sutures anchor the fundus of
the stomach to this catheter (Fig. 9) and gently
Fig. 6 pull up the fundus into the neck wound so that
Fig. 7 Fig. 8
320 A. Sinha and S. Agarwala
Fig. 11
Fig. 9
E26 Long-Gap Oesophageal Atresia – Gastric Pull-Up 321
Tips
77 In cases where dense adhesions are expected in 77 It is advisable to fashion a feeding jejunostomy
the mediastinum, as in strictures following cor- to institute early enteral feeds. This specially
rosive ingestion, excision of oesophagus should comes in use in cases where there is an anasto-
be performed through a lateral thoracotomy. motic leak from the oesophagogastric anasta-
The oesophageal bed is prepared and a red rub- mosis.
ber catheter positioned in the oesophageal bed 77 Fashion the oesophagogastric anastamosis pref-
from the neck to the abdomen and thoracotomy erably in the neck rather than in the posterior
closed. This catheter is used in the subsequent mediastinum, as leaks from this anastamosis are
steps for the pull-up. very common.
77 Some surgeons add a pyloromyotomy or a pylo-
roplasty to aid in gastric emptying.
77 In case the pleura is breached, place an intercos-
tals drain on that side.
Common Pitfalls
77 Too much mobilization of the oesophagus in the 77 Choosing gastric pull-up in cases of scarred
neck can result in ischaemia, with resultant anas- stomach, as cases of acid ingestion, can lead to
tomotic breakdown and dysmotility later on. graft failure.
77 Inadequate mobilization in the region of thoracic
inlet can result in constriction at this level.
322 N. Sugandhi and S. Agarwala
E27 E27 D uodenal Atresia
N. Sugandhi and S. Agarwala
Operative Technique
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com Fig. 3
Tips
77 The presence of bile in a normal distal duode- attachment. Extreme caution must be exercised
num confirms the diagnosis of a pre-ampullary during web excision to avoid damaging the am-
duodenal atresia. pulla of Vater, which may open anteriorly, poste-
77 If an atretic segment is not identifiable, a naso- riorly or medially into the web or adjacent to it.
gastric tube should be advanced into the duo- Squeezing the gallbladder (as described above)
denum to exclude a type 1 atresia (a duodenal may help identify the opening. Do not excise
membrane or windsock). If doubt persists, ad- the web until the ampulla has been clearly iden-
vancing the nasogastric tube may be facilitated tified. Use a stay suture to apply traction to the
by making a small gastrostomy. central portion of the web. Dissecting scissors
77 If a duodenal web is identified, a 2- to 3-cm du- are used to excise the web, leaving a cuff of tis-
odenotomy should be made on the antimesen- sue on the duodenal wall and sparing the medial
teric bowel wall, overlying the transition from di- portion of the web where the ampulla of Vater is
lated to collapsed bowel. Applying traction to usually situated (Fig. 6).
the web puckers the duodenal wall at its point of
Common Pitfalls
Carl F. Davis
Consultant Paediatric and Neonatal Surgeon
Carl.Davis@ggc.scot.nhs.uk
Fig. 2 Laparotomy
Tips
77 Surgery for NEC can be very difficult – if in doubt, 77 Consider using an abdominal patch to increase
ask for help. the abdominal cavity size and optimise intesti-
nal and renal perfusion as well as venous return
to the heart.
Common Pitfalls
77 Be careful of the liver, that is often large and frag- 77 Regardless of surgical management of acute
ile, as haemorrhage can be catastrophic. NEC, remember that patients may develop an in-
testinal stricture, which requires a laparotomy,
resection and anastomosis.
328 N. Sugandhi and S. Agarwala
E29 E29 Wilms Tumour
N. Sugandhi and S. Agarwala
Operative Technique • Pack with large gauze swabs the rest of the ab-
dominal contents in case of Tumour rupture.
• Place the patient in the supine position. • Start dissecting at the hilum unless the tumour
• Make a long upper abdominal laparatomy. is huge or crossing the midline. In such cases
• Collect any peritoneal fluid if present and send start the mobilization laterally and then clear
it for fluid cytology. superiorly and inferiorly before approaching
• Inspect the abdominal cavity thoroughly for the hilum.
liver or peritoneal metastasis or contiguous in- • Mobilize the renal vein until its entry into the
volvement of the adjoining organs. inferior vena cava (IVC) and suspend it in a
• Enter the retroperitoneal space by mobilizing sling. Palpate it and the IVC carefully to rule
the ascending or the descending colon depend- out an intra vascular thrombus.
ing on the side of the tumour (Fig. 1). Divide • Identify and mobilize the renal artery, poste-
the peritoneal attachments of the colon to the rior and superior to the renal vein and suspend
lateral abdominal wall and mobilize the colon it in a sling (Fig. 2).
medially. On the right side, the duodenum also • Finally identify the ureter and trace it caudally
must to be mobilized medially. to the urinary bladder. Transfix the ureter and
divide it (Fig. 2).
• Transfix the renal artery and divide between
ligatures. Transfix the renal vein and di-
vide (Fig. 3).
• Now mobilize the kidney with the tumour
within Gerota’s fascia from the retroperito-
neal surface. Diathermize or ligate any large
vessels from the fascia to the retroperitoneum.
Remove the tumour specimen after mobiliza-
tion.
• Perform lymph node sampling in an orderly
fashion sampling the paracaval and para-aor-
tic supra-hilar and infra-hilar nodes in addition
to the ipsilateral iliac nodes. Biopsy any other
grossly enlarged nodes.
• Inspect the tumour bed for any residual tumour
and ensure adequate heamostasis.
Fig. 1 • Close the incision in layers.
Sandeep Agarwala
Associate Professor of Surgical Paediatrics
sandpagr@hotmail.com
Fig. 2
Fig. 3
330 N. Sugandhi and S. Agarwala
Tips
77 Occasionally the tumour may be infiltrating the 77 The adrenal is removed with the tumour in up-
diaphragm superiorly. In such cases part of the per polar tumours, but it can be preserved in
diaphragm may need to be removed with the tu- others.
mour specimen. 77 Avoid tumour rupture and spill by gentle han-
dling.
Common Pitfalls
C A R L M . W. WI LMS
(1867 – 1918)
German pathologist and surgeon
Max Wilms qualified in medicine from the University of Bonn and then trained in Cologne,
Leipzig and Basel before he was appointed to Chair of Surgery at Heidelberg. During a short
but phenomenal career, he made many innovations in the field of surgery including an ap-
proach for treating pulmonary tuberculosis by a partial rib resection. He is remembered for
his work in the pathological studies of the development of tumour cells; Wilms tumour is an
eponym for nephroblastoma.
E30 Abdominal Neuroblastoma 331
E30 Abdominal Neuroblastoma E30
N. Sugandhi and S. Agarwala
Operative Technique
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
Fig. 3
Fig. 4
E30 Abdominal Neuroblastoma 333
Tips
77 With left-sided tumours, mobilize the spleen, tail 77 Neuroblastomas usually do not invade the tu-
of pancreas and the stomach and retract medi- nica of vessels; hence a plane of dissection exists
ally. The left triangular ligament of the liver also in a subadventitial position between the vessels
needs to be divided. and the tumour. Sharp dissection over the ves-
sels can be done once in the correct plane.
Common Pitfalls
77 Attempting to dissect the tumour from the great 77 Not tackling the grossly enlarged lymph nodes
vessels in incorrect plane will lead to haemor- will leave gross residue.
rhage, tumour rupture and gross residue. 77 Continuing to dissect in the face of tumour infil-
77 Inability to correctly identify the renal vessels can tration into adjoining organs will unnecessarily
lead to their transaction and renal loss. jeopardize the patients safety.
J U DA H F OLKMAN
(1933 – 2008)
American paediatric surgeon and cancer researcher
Judah Folkman is one of the great medical scientists of the last century. During the course
of an illustrious career, he was both Chair of Paediatric Surgery and Chair of Cell Biology at
Harvard Medical School. He was an outstanding surgeon, teacher and mentor at Children’s
Hospital in Boston for many years. He brought about innovative ideas in the management
of hydrocephalus and intraventricular haemorrhages. His research work for which he is bet-
ter known founded the branch of cancer research known as Angiogenesis/Anti-angiogenesis
therapy. Judah Folkman strongly believed that anti-angiogenesis therapy would join other mo-
dalities such as chemotherapy, radiotherapy and immunotherapy in the war against cancer.
334 M. Steven and G. M. Walker
E31 E31 Meconium Ileus
M. Steven and G. M. Walker
Complicated Meconium Ileus • If the small bowel is not decompressed and pa-
tient remains stable, consider a repeat enema
A complicated meconium ileus (MI): after further period of resuscitation.
• Includes segmental volvulus, bowel perfora- • Indications for surgery include failure to de-
tion, intestinal atresia or giant cystic meco- compress post contrast enema, progressive ab-
nium peritonitis dominal distension compromising ventilation
• Requires laparotomy after preoperative fluid or an iatrogenic perforation at enema.
resuscitation, nasogastric (NG) tube insertion, • The aim of surgery is complete evacuation of
intravenous antibiotics and matching of blood obstructing meconium.
products • The approach is a transverse supra-umbilical
• Requires the approach of a transverse supra- incision.
umbilical incision • Findings can include terminal ileum obstruc-
• Definitive procedure is dictated by findings at tion with inspissated meconium pellets with
surgery (see below for surgical options). proximal bowel dilatation.
• General principles
– Resect atretic/necrotic bowel (see Chap. E17,
‘Small Bowel Atresia’) Surgical Options
– Double-barrelled enterostomy preferable
in (giant cystic) meconium peritonitis (see Enterotomy and Irrigation
Chap. E12, ‘Exomphalos’)
– Primary anastomosis may be considered in • Full laparotomy to delineate anatomy and en-
isolated volvulus or atresia (see Chap. E13, sure no atresia.
‘Loop Enterostomy’) • Simple purse-string suture is sited on antimes-
enteric border of dilated ileum 5–10 cm prox-
imal to narrowed portion of terminal ileum
Non-complicated MI containing obstructing pellets.
• Pass a 10-Fr Jacques catheter through a small
• Up to 50 % of cases can be managed non-op- enterostomy in the centre of purse string.
eratively with therapeutic contrast enema. • Tighten purse string and irrigate proximally
• NB – Ensure adequate fluid resuscitation prior and distally with saline, using a catheter-tip
to contrast enema. Contrast solution is hyper- syringe
osmolar and can cause marked fluid shift. • Consider adding N-acetyl cysteine to saline (di-
lute to 4 % concentration).
• Combination of irrigation and manipulation
breaks up thick meconium, that can be re-
Mairi Steven () moved via the enterostomy or washed out dis-
Specialty Trainee in Paediatric Surgery tally.
mairisteven@doctors.org.uk
• Once pellets are clear of terminal ileum, ex-
Gregor M. Walker clude colonic atresia by distal irrigation.
Consultant Paediatric and Neonatal Surgeon • Close enterostomy with interrupted absorbable
Gregor.Walker@ggc.scot.nhs.uk sutures.
Santulli–Blanc Enterostomy
Tips
77 Consider widening your enterostomy if pellets 77 Primary anastomosis can be performed but a
are difficult to retrieve. double-barrelled stoma is the safest option.
77 Always measure and record small bowel length. 77 Cystic fibrosis should be diagnosed promptly to
77 Construct a clear operation note and consider in- enable multidisciplinary management to com-
cluding a diagram to clarify the anatomy. mence.
Common Pitfalls
77 Close monitoring of the child’s posttherapeutic 77 After hyperosmolar contrast enema, 1.5× main-
enema or surgery is vital. Ensure adequate fluid tenance fluids may be required for 8–12 h.
and electrolyte resuscitation – deaths from hy-
povolaemic shock have been reported after con-
trast enema.
338 T. J. Bradnock and G. M. Walker
E32 E 32Rectal Biopsy
T. J. Bradnock and G. M. Walker
Fig. 1
Gregor M. Walker
Consultant Paediatric and Neonatal Surgeon
Gregor.Walker@ggc.scot.nhs.uk Fig. 2
Fig. 4 Fig. 5
Fig. 6
340 T. J. Bradnock and G. M. Walker
Tips
Common Pitfalls
77 Suction rectal biopsy – Ensure that a neonate patient has received vi-
– Do not exceed maximum suction of −20 cm tamin K before the biopsy. Significant bleed-
water. ing is rare but this is vital.
– Blunt blades reduce the diagnostic yield. En- 77 Open rectal biopsy
sure they are sharpened regularly. – Do not remove needle from apical stay; bleed-
– Always biopsy the posterior rectal wall in the ing makes closing the wound difficult after-
midline. Anterior biopsies bear the risk of wards.
perforating the rectovesical or rectovaginal
pouch.
H A R A L D H I RS CHS PRUNG
(1830 – 1916)
Danish paediatrician
It is fortunate for us that as a young man, Harald Hirschsprung decided to study medicine
rather than take over his father’s tobacco business. During the course of a career that spanned
over 40 years, he devoted himself to the care of children. He not only practiced conventional
hospital paediatrics, but he also researched and subsequently published his findings on many
conditions including rickets, pyloric stenosis, intussusception as well as a particular form of
constipation, that eventually came to bear his name (Hirschsprung diease).
Even though Hirschsprung was the first to describe Hirschsprung disease, he believed it was
the dilated proximal segment of the bowel, that was diseased rather than the distal agangli-
onic segment, as we now know.
E33 Transanal Endorectal Pull-Through for Rectosigmoid Hirschsprung Disease 341
E3 Transanal Endorectal Pull-Through E33
for Rectosigmoid Hirschsprung Disease
A. T. Hadidi
Endorectal pull-through via an abdominal ap- The principle operative steps are illustrated in
proach was first described by Soave in 1964. A Fig. 1.
primary laparoscopic-assisted endorectal pull- • Four stay sutures (on a round needle) are
through with transanal mucosectomy was de- placed around the mucocutaneous junction at
scribed by Georgeson in 1995. Three years later, the 12, 3, 6 and 9 o’clock positions.
De la Torre-Mondragon described mucosectomy, • Another four stay sutures are taken in between
colectomy and pull-through for rectosigmoid the first four sutures at the 1, 4, 7 and 11 o’clock
Hirschsprung disease, using an entirely transanal positions to open the anus and facilitate dissec-
approach, without the need for laparotomy or lap- tion.
aroscopy (TEPT). • Another circle of stay sutures are placed 1 cm
proximal to the first eight stay sutures using a
rounded needle, just above the dentate line.
• A circular incision is made in the rectal mucosa
between the two rings of stay sutures (Fig. 1).
• The submucosal dissection is continued proxi-
mally for 5 to 7 cm, using fine-needle diathermy
(Fig. 2), leaving the muscular cuff intact until
Fig. 1
Fig. 4
Fig. 3 Fig. 5
E33 Transanal Endorectal Pull-Through for Rectosigmoid Hirschsprung Disease 343
Fig. 6
Tips
77 A rigid Nelaton urethral catheter can be intro- 77 Submucosal dissection should be carried out for
duced per urethra at the start of the procedure at least 6 cm above the dentate line to ensure
to aid identification and avoid injury to the ure- the peritoneal reflection is reached before the
thra. dissection become full thickness.
77 Submucosal dissection should start at the 3 77 The muscle cuff should always be split in the
o’clock position and be continued anteriorly un- posterior midline to avoid damage to adjacent
til the 9 o’clock position is reached to ensure that structures.
the proper plane is identified safely. 77 Routinely remove all redundant hypertrophied
colon above the funnel (transition zone) to avoid
inertia and faecal stagnation in the redundant
colon.
Common Pitfalls
77 Avoid opening the muscle cuff before the peri- 77 Ensure that a tension-free anastomosis is con-
toneal reflection is reached as, this increases the structed to reduce the risk of anastomotic stric-
risk of damaging the pelvic splanchnic nerves, ture.
that run close to the rectal wall. 77 Splitting of muscle cuff should stop 2 cm above
77 Avoid twisting of the bowel during the pull- the dentate line to avoid any risk of incontinence.
through, as this may result in early mechanical 77 Splitting the muscle cuff is essential to prevent
obstruction. retraction and outlet obstruction. Splitting the
cuff reduces the risk of enterocolitis and im-
proves functional results.
344 T. J. Bradnock and G. M. Walker
E34 E34 Open Endorectal (Soave-Boley)
Pull-Through
T. J. Bradnock and G. M. Walker
This operation is increasingly being performed us- • Intravenous antibiotics are given at induction
ing laparoscopic-assisted transanal (see Chap. I16, of general anaesthetic.
Laparoscopic Splenectomy’) or purely transanal • The patient is positioned supine with the but-
approaches (see Chap. E33, Transanal Endorec- tocks at the edge of table, elevated on a rolled
tal Pull-Through for Rectosigmoid Hirschsprung towel and the legs padded, draped and sup-
Disease’). In the ‘open’ method, endorectal dissec- ported on ‘plastic skis’ off the end of the table.
tion can be carried out from the abdominal ap- • The entire operative field including the abdo-
proach, or transanally. men, buttocks and perineum is prepared.
• The surgeon stands to the left of the patient.
• Options available for the incision include:
Preoperative Management – Left paramedian, as originally described by
Soave (see Chap. A9, ‘Midline Laparotomy
• Histological confirmation of rectal agangli- and Paramedian Incision’).
onosis on rectal biopsy is done – The Pfannenstiel incision (see Chap. A11,
• Maintenance of colonic decompression: ‘Pfannenstiel Incision’) yields better cosme-
– Rectal washouts if a primary pull-through
is planned.
– Levelling enterostomy if surgical preference
for a staged pull-through, failure to decom-
press with washouts or presentation with se-
vere enterocolitis.
• Evidence of at least regain of birth weight is
important.
• Consider additional rectal washouts with or
without enemas in the days before the pull-
through.
Operative Technique
Gregor M. Walker
Consultant Paediatric and Neonatal Surgeon
Gregor.Walker@ggc.scot.nhs.uk Fig. 1
sis. This procedure is adequate for rectosig- • Once the submucosal layer is reached, develop
moid disease. plane anteriorly (Fig. 2) and continue laterally
– The hockey-stick incision with left pararec- then posteriorly, using blunt dissection with a
tal extension is required for descending co- Kittner dissector or pledgets.
lonic disease and is useful to take down a • The extramucosal dissection is facilitated when
levelling colostomy (Fig. 1). the assistant holds the edges of the developing
• Multiple antimesenteric seromuscular biop- muscle cuff (seromuscular layers) with atrau-
sies are taken as described in Chap. E37, ‘Open matic forceps or stay sutures, to provide coun-
Duhamel Pull-Through’ to identify the level of ter-traction.
the transition zone (TZ) and normal ganglionic • Bipolar haemostasis is used to coagulate larger
bowel. communicating vessels in the bowel wall.
• Divide the mesocolon close to bowel wall us- • Once the mucosal tube is completely free, the
ing serial clip and ligation with 3/0 Vicryl. seromuscular cuff is mobilised distally to a level
• The ganglionic bowel is transected with a linear 1–1.5cm proximal to the anal verge (Fig. 3).
stapling device, approximately 5 cm above the
most distal ganglionic frozen section biopsy.
• Mobilise the distal sigmoid colon and rectum
and transect ~4 cm above peritoneal reflection.
• Send the colonic specimen to pathology fresh
(to ensure adequate length above TZ).
• Two Vicryl stay sutures are placed at the apex
of the transected rectum.
• Incise the seromuscular layer of the rectum
transversely, over the anterior rectal wall, us-
ing sharp dissection or monopolar cautery (can
be facilitated by infiltration between layers with
1:200,000 adrenaline solution).
Fig. 3
Fig. 2 Fig. 4
346 T. J. Bradnock and G. M. Walker
• Adequacy of distal extent of dissection is con- • Grasp the stay sutures on the ganglionic colon
firmed by bimanual palpation with a finger in and deliver them through anal opening (Fig. 6).
the anus and one outside the mucosal tube. • The assistant in abdominal field should ensure
Wear double gloves and remove the outer pair the pull through colon is not twisted.
afterwards to maintain sterility.
• The descending colon should be mobilised us-
ing Metzenbaum scissors along the white line
of Toldt, as far as the splenic flexure if nec-
essary to ensure tension-free pull-through
(should reach pubis without tension).
Fig. 5 Fig. 7
E34 Open Endorectal (Soave-Boley) Pull-Through 347
Fig. 8
Tips
77 Performing primary surgery in the first 3 months 77 If adhesions are dense between the mucosal
of life reduces the duration of rectal washouts sleeve and seromuscular layers, use cautious
and the risk of chronic proctitis, that makes sub- sharp dissection with scissors.
sequent endorectal dissection more difficult. 77 Current trends are to leave a shorter muscle cuff
and to split the cuff posteriorly to reduce the risk
of cuff stricture and outlet obstruction (Fig. 8).
Common Pitfalls
77 Do not commence endorectal dissection un- 77 Avoid leaving too much aganglionic rectum in
til the level of the TZ has been confirmed, since situ – the colo-anal anastomosis should be no
long-segment or total colonic disease may ne- more than 1–1.5cm above the dentate line, as
cessitate an initial stoma with deferral of defini- this predisposes the patient to outlet obstruc-
tive surgery. tion, stasis and recurrent enterocolitis (Fig. 8).
77 The mucosal tube and muscle cuff are vulnera-
ble to tearing during the endorectal dissection. A
tear in the mucosal tube can be repaired with in-
terrupted 5/0 Vicryl to prevent exacerbation of
the tear.
348 T. J. Bradnock and G. M. Walker
F R A N C O S OAVE
(1917 – 1984)
Italian Paediatric Surgeon
Franco Soave was Surgeon in Chief at the Gaslini Institute Hospital and Professor of Sur-
gery at the University of Genoa. He had a lifelong interest in colon and anorectal surgery
and he is known for his work in the defining operative procedure for Hirschsprung disease.
He was an outstanding teacher and a prolific writer, who toured the world explaining and
demonstrating the Soave procedure for Hirschsprung disease.
E35 Myomectomy for Ultrashort segmentHirschsprung Disease 349
E35 Myomectomy for Ultrashort segment E35
Hirschsprung Disease
R. Carachi
Fig. 2a–c Posterior excision anorectal myomectomy (continued). a Traction on the specimen is main-
tained while the first stitch is locked in position by passing the needle back through the knotted loop.
b The specimen is excised.
Tips
77 A good retractor is essential to view the opera- 77 Avoid dissecting too deep and perforating the
tive area. A Parks retractor can be used; alterna- bowel. (This is why infiltration with fluid helps in
tively an assistant can retract both sides of the dissection.)
operative field. Another approach for retraction 77 Bleeding should be controlled; haemostasis can
could be placing four quadrant sutures (black be achieved carefully using bipolar cautery.
silk) to retract this area.
Bentley was involved in the early development of infant cardiac surgery in London and then
expanded this service in the West of Scotland. He was the first to perform a neonatal oe-
sophageal replacement using a segment of colon, and he introduced the Spitz–Holter valve
in Scotland. He was always interested in diseases of the colon and described the ultrashort-
segment Hirschsprung disease and its treatment is used to. A rectal myomectomy strip to
diagnose and treat this hitherto unrecognised condition.
Suggested Reading
Constantinos A. Hajivassiliou
Consultant Paediatric and Neonatal Surgeon
ch27z@udcf.gla.ac.uk
• Dissection extends distally around the rectum • Pass a curved clamp through this incision and
staying close to the rectal wall to avoid dam- grasp the stay sutures on the stapled end of the
age to pelvic splanchnic nerves (Fig. 3). Coag- proximal colon.
ulate all vessels under direct vision.
Fig. 4
Fig. 3
Fig. 5
• Obtain sufficient colonic length and mobil-
ity by dividing the inferior mesenteric pedicle • If no colon has been excised, divide approxi-
whilst preserving marginal vessels. mately half the outer (rectal) wall of the intus-
• Continue the dissection to the level of the exter- suscepted bowel, 1–2 cm above the everted den-
nal sphincter laterally and posteriorly but not tate line, followed by the same length of the in-
anteriorly, where 1.5 cm of intact rectal wall is ner (colonic) bowel wall. The two walls are then
left abutting the vagina or urethra. anastomosed sequentially (Fig. 5).
• Intussuscept the mobilised rectum through the • The colorectal anastomosis is performed ex-
anus, using Babcock forceps passed transanally tracorporeally using interrupted absorbable su-
to grasp either the rectal stump or intact recto- ture (e.g. 4/0 Vicryl) (Figs. 6 and 7).
sigmoid (depending on whether the bowel has • When the anastomosis is complete, the sutures
been divided) (Fig. 4). are cut, allowing the anastomosis to retract into
• Gently cleanse the rectal mucosa with chlorhex- the anus.
idine. • Antibiotic lavage is performed with normal sa-
• If a segment of colon has been excised, incise line containing 1 mg/ml cefotaxime.
the anterior rectal wall 1–2 cm from the den- • Close the Pfannenstiel in layers.
tate line, extending around half the rectal wall
circumference.
E36 Open Swenson Procedure 355
Fig. 6
Fig. 7a,b
356 T. J. Bradnock and C. A. Hajivassiliou
Fig. 8a,b
Tips
77 Use a double-gloved left hand to pass a finger 77 Adequate distal dissection is confirmed when it
into the anus to assess the extent of distal dissec- is possible to evert the anal canal completely by
tion (Fig. 8). traction on the rectum.
Common Pitfalls
77 Devascularisation of the colonic wall can lead to 77 Damage to the autonomic plexuses in the pelvis
stricture or dehiscence. is avoided if dissection remains close to the rec-
77 Leaving too much aganglionic distal segment tum and the nerve leashes are demonstrated.
can cause distal functional obstruction (Fig. 7). 77 Misalignment of anastomosed colorectal ends is
possible; ensure alignment is correct when the
proximal segment is intussuscepted distally.
E37 Open Duhamel Pull-Through 357
E37 Open Duhamel Pull-Through E37
T. J. Bradnock and G. M. Walker
• Mobilise stoma (if present) and excise limbs • Place stay sutures on distal end of pull through
with a linear stapling device (stoma is then sent and proximal end of rectal stump.
to pathology in formalin). • Expose the anus with anal retractors and make
• Commence retrorectal dissection, staying in a full-thickness semicircular incision with mo-
midline on bowel wall, using finger dissection nopolar diathermy over posterior rectal wall
or long clamp/pledgets (Fig. 2). 0.5–1.5 cm above dentate line (Fig. 3).
Fig. 5 Ganglionic bowel is delivered through the endo- mines that staple line has reached most cranial
anal incision extent of rectal stump.
• In the long Duhamel procedure (Martin mod-
ification) for total colonic disease, a second fir-
ing of the stapler from above is used to gener-
ate a long side-to-side anastomosis between the
normal ileum and aganglionic rectum, that re-
sults in a more capacious rectal reservoir, with
the aim of improving electrolyte reabsorption.
This necessitates making a short opening on
the staple line of rectal stump and fashioning
Tips
77 The Duhamel pull-though is one of the most 77 Label the mesenteric and antimesenteric bor-
commonly utilised techniques for revisional sur- ders of the ganglionic colon with different stay
gery. sutures to enable the surgeon performing the
77 Adequacy of colonic length is confirmed if the anastomosis to maintain correct orientation.
mobilised ganglionic colon can be brought 77 Although a shared abdominoperineal field is
over the infant’s pubic symphysis to reach the used, the instruments used in the perineal dis-
perineum without significant tension section must be kept separate from those in the
77 If adequate colonic length cannot be obtained, abdomen. Similarly, gloves should be changed
the inferior mesenteric artery can be ligated before returning to the abdomen.
close to its origin. Be certain to preserve the mar-
ginal artery to maintain colonic viability.
Common Pitfalls
77 The left ureter should be carefully visualised dur- 77 Failure to completely divide any residual prox-
ing the colonic mobilisation and prior to divid- imal spur in the rectal reservoir will result in
ing the peritoneal reflection between the rectum faecaloma formation, with an adverse impact on
and bladder. bowel habit and soiling.
77 During the initial colonic resection, it may be 77 The optimal level for the endoanal incision is
necessary to back resect a portion of the dilated contentious and trends have changed with time.
ganglionic colon to facilitate an easier anasto- In theory, the endoanal incision should be made
mosis with the much smaller-calibre rectum. The at least 0.5 cm above the dentate line to avoid
degree of back resection required can be min- performing a complete internal sphincterotomy
imised by good preoperative decompression with resultant soiling and incontinence. How-
with regular, effective rectal washouts. ever, an endoanal incision made more than 2 cm
proximal to the dentate line increases the risk of
faecal impaction in the rectal reservoir.
E38 Principles of Liver Surgery 361
E38 Principles of Liver Surgery E38
M. Davenport
Liver Anatomy Each half of the liver is supplied by right and left
branches of the portal vein and hepatic artery
The segmental nature of the liver is not immedi- (>90 % from celiac axis). Aside from the caudate
ately obvious from the surface; indeed what looks (which is drained by small veins directly into in-
like a large right lobe and smaller left lobe, defined trahepatic cava); venous drainage occurs via three
by the falciform ligament, is somewhat mislead- veins (left, right and middle).
ing. Knowledge of the various divisions is the ba-
sis for liver resection. The key division is between
right and left and the principle plane (of Cantlie)
extends from gallbladder bed to a point slightly to
the left of the hepatic vein confluence.
Table 1 lists the key facts for the segments there-
after.
Fig. 1
Segment Resection
I Caudate lobe Rarely excised in isolation, but part may be taken
typically with right hemihepatectomy.
LEFT II , III Left lateral Left hemihepatectomy Left lateral Extended left
segment segmentectomy hepatectomy
IV Quadrate lobe Extended right
RIGHT V, VI Anterior section Right hemihepatectomy hepatectomy
Fig. 2
Fig. 2 Portoenterostomy
M O R I O K A S AI
(1922–2008)
Japanese surgeon
Professor Morio Kasai trained in paediatric surgery in Philadelphia, but most of his aca-
demic life in Japan was in general surgery. Despite this, he trained a generation of Japanese
and overseas paediatric surgeons. His work on biliary atresia has been one of the greatest
surgical advances of the last century. The corrective procedure for this condition bears his
name, the Kasai procedure.
366 M. Davenport
E40 E40Choledochal Malformations
M. Davenport
late), lavage debris or stones until satisfied that pled (e.g. EndoGIA®) enteroenterostomy at
all liver segments can drain. Repeat this dis- this point. Close mesenteric window and po-
tally (if possible) and scope the common chan- sition the Roux limb through mesocolon to lie
nel, again removing debris. If there is ampul- adjacent to duodenum.
lary stenosis in addition to a dilated common • Hepaticojejunostomy: The diameter of the
channel – consider transduodenal sphinctero- CHD is usually more than adequate to drain
plasty (10 % of cases). the proximal biliary tree. There is no need to
• Removal of cyst: Over-sew distal CBD (e.g. 5/0 incise into the hepatic ducts unless there is de-
PDS). monstrable stenosis (<10 % of cases). Triangu-
• Mobilisation of Roux Loop: Measure ~10 cm late stay sutures. Control Roux limb with soft
from duodenal–jejunal flexure. Divide bowel bowel clamp. Insert all posterior row of sutures
with stapler. Measure ~40 cm (length of Roux (e.g. 5/0 PDS, full-thickness, internal knots) be-
limb). Perform sutured (e.g. 5/0 PDS) or sta- fore parachuting into subhepatic space. Com-
368 M. Davenport
Fig. 3 Mobilisation of gallbladder, division at level of Fig. 4 Mobilisation of duodenum and identification of
common hepatic duct distal CBD within head of pancreas
E41 Pancreatic Pseudocyst 369
E41 Pancreatic Pseudocyst E41
M. Davenport
Acute pancreatitis is uncommon in children, and located and punctured. Double –‘J’ stents are
its causes can be divided along medical and sur- passed into the cavity to keep the connection
gical lines. The commonest causes in the former open. These are then removed after 4–6 weeks.
category are related to drugs (typically chemother- • Surgical cyst gastrostomy
apy for leukaemia) and viral infections. Among
the latter group are trauma (typically related to Surgical Cyst-Gastrostomy
boys and bicycle handlebars), choledochal mal-
formations because of the common pancreatobi- • Incision: Muscle cutting left upper quadrant.
liary channel and pancreas divisum. • The stomach is usually draped, tightly over the
In the early stages of the disease, amylase-rich pseudocyst situated in the lesser sac (Fig. 1).
fluid may be exuded from the inflamed pancreas, – Stay sutures in the anterior wall of the stom-
but tends not to be confined and is panperitoneal. ach – open this longitudinally.
In the later stages, beyond 4 weeks or so, these – Identify the pseudocyst bulging into the pos-
acute fluid collections evolve into the classic pseu- terior wall. Test that is contains fluid by as-
docyst. The sites most common for these are the pirating with a needle and syringe. Using
lesser sac and within the leaves of the mesocolon. point diathermy, open into the wall and aim
to create a hole (~1-cm diameter) (Fig. 2).
Over-sew the circumference to achieve hae-
Treatment Options mostasis.
– Close the anterior wall with haemostatic,
Acute pancreatitis is managed conservatively for full-thickness sutures.
the most part with parenteral nutrition, analgesia • Alternate sites
and strict attention to fluid balance. In the early
stages, prior to formation of a substantial wall,
percutaneous aspiration under ultrasound con-
trol is the only realistic option to control symp-
toms due to intraperitoneal fluid collections. Be-
yond 4–6 weeks, the options include:
• Parenteral nutrition only: Spontaneous resolu-
tion is possible for the smaller ones.
• Aspiration can be utilized, with or without
drain insertion, under ultrasound control.
• Endoscopic cyst gastrostomy is done by us-
ing endoscopic ultrasound; the pseudocyst is
Fig. 1 Pseudocyst in the lesser sac, behind stomach
Surgery in inflammatory bowel disease (IBD) is mine the resection site, bearing in mind that this
challenging. Failure to control disease by medical may well still be affected by microscopic disease.
means and the consequences of this, usually ac-
count for the majority of cases coming to surgery.
A much smaller group of patients present acutely, 2. Small bowel strictureplasty
with complications including intestinal obstruc-
tion, toxic megacolon, acute GI haemorrhage and This operation is useful where there is a short
fistulating disease. length of strictured small bowel to avoid resection.
Steps
• The pelvic nerves and ureters should be iden- • The distal end of the small bowel is sutured to
tified and avoided during the dissection. This the proximal limb taking care to ensure that the
is best achieved by keeping the dissection close small bowel mesentery is not compromised and
to the rectal wall using monopolar diathermy. will not be divided when the linear cutting sta-
• Care should be taken in dissecting the rectum pler is fired.
off of the vagina in girls and the seminal vesi- • A small hole is created in the distal end of the
cles in boys. j-pouch and two firings of a 75mm linear cut-
• Dissection should be continued down to within ting stapler are made to create the pouch.
1 centimetre of the dentate line.
Figure 4:
• A stapling device is then placed across the
rectum and closed. Before firing, the level is
checked by placing a finger in the anal canal.
If satisfactory, the stapling device is fired and
the rectum amputated.
Fig. 5
Figure 6:
• A new loop ileostomy is fashioned using a loop
of small bowel just proximal to the pouch.
• The abdominal wound is closed using a mass
closure technique.
Fig. 6
PAR T F
Groin and Genitalia
F1 Exposure of the Inguinal Canal and Spermatic Cord Structures 377
F1 Exposure of the Inguinal Canal F1
and Spermatic Cord Structures
T. J. Bradnock and P. A. M. Raine
This approach can be used for inguinal herni- • Use dissecting scissors to deepen the incision
otomies, ligation of a patent processus vagina- and cut Scarpa’s fascia (Fig. 2).
lis (PPV), encysted hydroceles of the cord, orchi- • Use small retractors (Cat’s paw or Langenbeck)
dectomy for testicular neoplasms and open or- to clear the fat off the external oblique aponeu-
chidopexies rosis (EOA). Striated muscle is seen through the
aponeurosis (Fig. 3).
Operative Technique
Fig. 2
Fig. 1
Peter A. M. Raine
Consultant Paediatric and Neonatal Surgeon
Rainewest@btinternet.com
• Delineate the inguinal ligament by gently open- • Sharply divide the internal spermatic fascia,
ing and closing dissecting scissors perpendic- that loosely invests the cord, for clean expo-
ular to the rolled, inferior edge of EOA. No sure of the cord structures.
sharp dissection is required. • The spermatic cord can be delivered using a
• The inguinal ligament can be followed infero- pair of toothed forceps and a window created
medially to the superficial inguinal ring. posteriorly with artery forceps (Fig. 6). Alter-
• Use a scalpel to make a tiny incision in the EOA natively for an orchidopexy the undescended
1 cm above and lateral to the superficial ingui- testis is usually apparent at the superficial ring
nal ring (Fig. 4). (Fig. 7).
• Dissecting scissors are used to extend the inci-
sion and push the muscle fibres away from the
underside of the fascia, creating a ‘window’ in
the inguinal canal.
• Artery forceps are used to split first the external
oblique and then cremaster along the line of its
fibres, exposing the spermatic cord (Fig. 5).
Fig. 4 Fig. 5
Fig. 6 Fig. 7
F1 Exposure of the Inguinal Canal and Spermatic Cord Structures 379
Tips
77 It is vital to clearly delineate the inguinal liga- 77 The external oblique forms the anterior wall of
ment to ensure correct orientation and avoid in- the inguinal canal and can be windowed to gain
advertent damage to the femoral vessels. excellent access to the deep inguinal ring and
spermatic cord structures.
Common Pitfalls
77 Avoid making your incision too low or too me- 77 When opening the inguinal canal watch for the
dial. Remember the landmarks. ilioinguinal nerve which runs through the canal
77 Avoid cutting the superficial epigastric vessels superficial to the cord structures. Transection re-
which cross the medial aspect of wound sults in loss of touch sensation over the scrotum
or labia majora and medial thigh.
380 T. J. Bradnock and G. Haddock
F2 F2 Inguinal Hernia and Ligation
of Patent Processus Vaginalis
T. J. Bradnock and G. Haddock
Graham Haddock
Consultant Paediatric and Neonatal Surgeon
Ghaddock@udcf.gla.ac.uk
Fig. 4
Fig. 6
Fig. 5
382 T. J. Bradnock and G. Haddock
Tips
77 In females, the inguinal herniotomy is simplified 77 Never grasp the vas directly with an instrument,
by the absence of a vas and testicular vessels. In- as this risks causing irreversible damage.
spect and reduce an ovary if present, ligate the 77 If the sac is inadvertently opened, the situation
sac and close the superficial ring. can be retrieved by sequentially dissecting it
77 During the procedure, traction on the cord may from the vas and vessels with curved strabismus
have drawn the testis out of the scrotum. Always scissors between curved mosquito forceps.
check it is in the scrotum at the end of the case
and reduce it manually if necessary.
Common Pitfalls
77 Inadvertent damage to the ilioinguinal nerve 77 Seventy-five per cent of patients with complete
may cause sensory loss/chronic neuralgic pain. androgen insensitivity syndrome present with
77 Vasal injury during infant inguinal herniotomy is an inguinal hernia. Always inspect a gonad in
one of the commonest causes of seminal tract the sac of a phenotypically normal female to ex-
obstruction in adults. clude intra-abdominal testis. If in doubt consider
77 Failure to identify a ‘sliding’ hernia may result in karyotyping.
bladder, bowel or ovarian injury. 77 Careful handling of the vessels reduces the risk
of avoidable testicular atrophy.
S I R DE NI S BROWNE
(1892 – 1967)
British paediatric surgeon
Denis Browne qualified in medicine at the University of Sydney and served with the Austra-
lian Army’s Medical Corps before joining the Hospital for Sick Children on Great Ormond
Street in 1928. He was a pioneer in the field of paediatric surgery, who first recognized the
need for special skills in treating children. In addition to his work in the management of in-
guinal hernia, undescended testis, anorectal malformations he also refined the management
of cleft lip and palate. A gifted innovator, he designed many instruments in current use in-
cluding the Denis Browne bowel-holding forceps and the Denis Browne ring used in GI and
urological procedures.
F3 Incarcerated Inguinal Hernia 383
F3 Incarcerated Inguinal Hernia F3
B. Adikibi and R. Carachi
Fig. 2
Fig. 1
Robert Carachi
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk Fig. 3
Fig. 4
Fig. 5
F3 Incarcerated Inguinal Hernia 385
Tips
77 Once the decision has been made to attempt 77 Dissection should always be performed under
operative reduction, do not attempt further re- direct vision.
duction of the hernia sac contents, as examina- 77 Placing the patient in the Trendelenburg posi-
tion of the incarcerated bowel is an imperative tion may help encourage reduction of viable
part of the operation. bowel.
77 Always positively identify and preserve the vas
and testicular vessels.
Common Pitfalls
77 Avoid making an inadequate incision, as this 77 During the consent process for surgery, the par-
makes dissection under direct vision and care- ents should be warned that there is risk for testic-
ful assessment of the incarcerated bowel more ular atrophy following an episode of hernial in-
difficult. carceration, due to compression of the testicular
vessels. Failure to do so will make any retrospec-
tive discussion more difficult. The testicular vol-
umes should be recorded at follow-up.
386 R. Carachi
F4 F4 Femoral Hernia
R. Carachi
A femoral hernia is a (rare) herniation of extraper- • A transverse skin crease incision over the
itoneal fat or a viscus (bowel or bladder) through mass in the infrainguinal region is performed
the femoral canal in children. The femoral vein, (Fig. 1).
artery and nerve are lateral to the hernia, although • The mass is identified usually covered with fas-
the hernia may sometimes protrude and overly cia around the femoral canal. The vessels, fem-
these structures. Many approaches have been de- oral vein and femoral artery should be identi-
scribed. If there is risk of incarceration or stran- fied at this stage to avoid damage.
gulation then a suprainguinal, extraperitoneal ap- • The fascia is divided using sharp dissection and
proach is used. (This is described in the Chap. F2, the mass is lifted and dissected to the femoral
‘Inguinal Hernia and Ligation of Patent Processus canal. Often fatty tissue causes a problem and
Vaginalis’). The commonest approach however is this needs to be cleaned with a pledget. Good
directly over the hernia mass using an infraingui- views are essential for this dissection to be car-
nal approach. This approach is now described: ried out carefully (Fig. 2).
Fig. 2
Fig. 1
Fig. 4
Fig. 3
• Traction allows the hernial sac to be identified to bring together the pectinate fascia and Coo-
and to ascertain whether any contents are pres- pers ligament.
ent. • Haemostasis is used to control any bleeding
• The sac is then opened at its apex using mos- during this procedure.
quito forceps to open the sac and allow a good • The subcutaneous tissues and fascia are closed
view inside (Figs. 3 and 4). using interrupted sutures Vicryl (000).
• The sac is then twisted on itself and transfixed • A subcuticular stitch is used to close the skin
at its base with a Vicryl (000) stitch. This region Vicryl (0000).
can be doubly transfixed to avoid recurrence.
• The defect is then closed using a combination
of sutures, usually one or two interrupted ones
Fig. 5
388 R. Carachi
Tips
77 Good exposure is essential for this operation 77 If the defect cannot be closed by apposition of
to be carried out safely; if necessary extend the the fascia and the ligament then a prosthetic
wound. patch may need to be used. This is rare.
77 Careful dissection and identification of the femo- 77 The content of the hernia must be visualised to
ral vein is necessary to avoid damage and bleed- avoid damage to bowel or bladder.
ing.
Common Pitfalls
• Holding the testis firmly with the skin held • If the testis is torted (Fig. 4), untwist the cord,
taught (Fig. 1), make a transverse incision in wrap the testis in warm, saline-soaked packs
the hemiscrotum. Deepen slowly through the and explore the other side.
layers (Fig. 2) until the testis, in its tunica albu- • Repeat the incision on the contralateral hemis-
ginea, is free. crotum and deliver the healthy testis. Leaving
• Deliver the testis from the scrotum, everting the tunica vaginalis everted, fix the good testis
the tunica vaginalis, and inspect the testis and to the scrotal wall at three points (Fig. 5) using
cord structures. fine, non-absorbable sutures. Alternatively, use
• If a torted hydatid of Morgagni is found the same three-point fixation technique to fix
(Fig. 3), grasp it with toothed forceps and use the testis in a dartos pouch or directly to the
bipolar diathermy to excise it at the base. En- tunica vaginalis.
sure the testis is not torted and then proceed to • Unwrap the previously torted testis and assess
closure. viability. If in doubt, cut the tunica albuginea.
Bleeding implies viability.
• If the testis is viable, fix it in the scrotum as de-
scribed above (Fig. 5).
• If the testis is necrotic, place a large clip or ar-
tery forceps over the cord within the scrotum
and excise the testicle. Tie the cord using strong,
absorbable suture.
• Close the dartos muscle in each hemiscrotum
using absorbable suture.
• Using Alice forceps to lift up the wound edges,
suture the skin of each hemiscrotum using a
fine, absorbable suture in a continuous suture
line (Fig. 6).
– Alternative: A midline raphe incision can be
used, allowing access to both testes from a
single skin incision.
Fig. 1
Atul J. Sabharwal
Consultant Paediatric and Neonatal Surgeon
Atul.Sabharwal@ggc.scot.nhs.uk
Fig. 2
Fig. 4
Fig. 3
F5 Acute Scrotal Exploration 391
Fig. 6
Fig. 5
Tips
77 The testis usually twists towards the midline, i.e. 77 As you incise the tunica vaginalis, a small amount
right twists clockwise, left twists anticlockwise of haemoserous fluid (secondary hydrocele) may
from the examiners perspective. be liberated.
77 There are many thin layers of tissue to incise be-
fore reaching the testis. Have patience and pro-
ceed cautiously.
Common Pitfalls
77 Injudicious use of the knife when deepening the 77 Take care when placing fixation sutures not to
incision may result in inadvertent opening of the suture through the vas, vessels or epididymis.
tunica albuginea.
77 Do not use monopolar diathermy on the scro-
tum or other extremities.
392 M. Yassin and A. H. B. Fyfe
F6 F6 Varicocoele
M. Yassin and A. H. B. Fyfe
• The peritoneum is pushed medially with the injecting methylene blue into the scrotum pre-
Kittner dissector to expose the spermatic ves- operatively as described in Chap. I15.
sels above the point where they diverge from • Complete division of the testicular vessels and
the vas deferens. Placing the testis under ten- haemostasis should be confirmed.
sion caudally may help locate the vessels. • The external oblique aponeurosis is closed with
• Using a curved clamp or rubber sloupes, interrupted 3/0 vicryl sutures and skin is closed
carefully mobilize the vessels into the wound with a 4/0 continuous absorbable subcuticular
(Fig. 4). suture.
• Under magnification with Loupes, use sharp
and blunt dissection to separate all (usually
three) of the veins from the adjacent artery
and lymphatic vessels. Typically, there are sev-
eral veins next to or adherent to the testicular
artery, with an isolated vein nearby (Fig. 5).
• The dilated veins are identified first (Fig. 5a),
and mobilized carefully using non-toothed for-
ceps and curved mosquito forceps (Fig. 5b),
and a ligature is passed underneath the dilated
vein (Fig. 5c). A short section of vein is excised
between 3/0 non-absorbable ligatures (Fig. 5d).
• The testicular artery is identified and preserved
(modified Palomo) or ligated and divided in the
same way (classic Palomo).
• A further modification of Palomo’s original
operative description is to preserve the lym-
phatics that accompany the testicular vessels.
Identification of these vessels is facilitated by
peritoneal
fold
retroperitoneal
space
Fig. 2 Fig. 3
394 M. Yassin and A. H. B. Fyfe
Fig. 4
Fig. 5
F6 Varicocoele 395
Tips
77 Always explain to the patient and parents that 77 Placing the patient in the reverse Trendelenburg
there is risk of recurrent varicocoele(s) (4–20 %). position facilitates identification of the veins as
The risk of recurrence may be higher if artery- they fill with blood.
sparing surgery is attempted. 77 Very rarely, if identification of all venous collater-
77 If the artery is not apparent, bluntly strip the als is in doubt, intra-operative venography may
spermatic fascia off the cord. Dripping Papaver- be a useful adjunct.
ine solution onto the cord will make the artery
dilate and become visibly pulsatile.
Common Pitfalls
77 Postoperative hydrocoeles may occur due to 77 The overall risk of testicular atrophy is less than
lymphatic ligation. Consider using a lymphatic- 5 %. The risk is increased with techniques that
sparing approach. approach the testicular vessels distal to the deep
77 Although renal tumours are the underlying ring. In these circumstances, microvascular tech-
cause of less than 1 % of paediatric varicocoeles, niques under magnification, should be used in
this aetiology should always be considered, par- conjunction with Papaverine and intra-opera-
ticularly in right-sided varicocoeles (<10 %) or if tive ultrasound to identify and preserve the tes-
the onset of varicocoele is abrupt. Obtain a renal ticular and cremasteric arteries and the artery to
tract ultrasound if in doubt. the vas.
396 K. Maguire and R. Carachi
F7 F7 Testicular Tumour
K . Maguire and R. Carachi
• The patient should be placed in the supine po- • Reflect the aponeurosis and split the cremas-
sition. A caudal block should be used. teric fibres using curved dissecting scissors, to
• Skin-crease incision is next made, extending lat- expose the spermatic cord structures (Fig. 2).
erally from just above the pubic tubercle. • Use curved mosquito forceps to develop the
• Expose the external oblique aponeurosis as de- plane behind the spermatic cord. Pass a rub-
scribed in Chap. F1, ‘Exposure of the Inguinal ber sloupe behind the cord.
Canal and Spermatic Cord Structures’. • Identify the testicular vessels, dissect them
• Make a stab incision in the external oblique free and ligate as proximally as possible using
aponeurosis above and lateral to the superfi- a strong suture. Then ligate the rest of the cord
cial ring. structures, again as high as possible within the
• Split the incision with curved dissecting scis- wound.
sors along the line of the fibres (Fig. 1). • Use a combination of blunt dissection and bi-
• Identify the ilioinguinal nerve and preserve it polar diathermy to mobilise the distal portion
by sweeping it inferiorly off the underside of of the cord, then use gentle traction to deliver
the aponeurosis, extending incision into the su- the testis up into the wound.
perficial ring. • Gently separate the testicular attachments to
the scrotal wall using blunt dissection until the
gubernacular attachment of the lower testicu-
lar pole to the scrotal wall is reached.
• Divide the gubernacular attachment with mo-
nopolar diathermy, between curved mosquito
clips (Fig. 3).
Fig. 1
Fig. 3 Fig. 4
Tips
77 Always mark the operation side prior to surgery, 77 Always discuss the case with the duty patholo-
after carefully confirming the side of pathology gist prior to surgery. Check their availability to re-
with clinical examination and radiological find- ceive the specimen, and ask how they would like
ings. it to be orientated and received.
77 Ligate the vessels as high as possible within the
inguinal canal to minimise the risk of incomplete
resection.
Common Pitfalls
77 Never approach the tumour through the scro- 77 Retroperitoneal lymph node dissection does not
tum, as this compromises complete resection. play a role in the initial surgical management of
77 Avoid manipulating the distal cord or tumour testicular tumours in prepubescent children.
prior to ligating the vessels, as this minimises the
risk of venous embolisation of tumour cells.
398 R. Stewart and M. E. Flett
F8 F8 Circumcision and Prepuceplasty
R. Stewart and M. E. Flett
Martyn E. Flett
Consultant Paediatric Urologist
Martyn.Flett@ggc.scot.nhs.uk
Fig. 1 Fig. 2
Fig. 3 Fig. 4
400 R. Stewart and M. E. Flett
Fig. 5
Fig. 6
Fig. 7
Fig. 8
F8 Circumcision and Prepuceplasty 401
Fig. 9
Fig. 10
Fig. 11
Tips
77 The only absolute indication for circumcision is 77 Postoperative bleeding may be arrested using a
balanitis xerotica obliterans (BXO). This is rare in pressure dressing.
children younger than 5 years of age. 77 A common site of bleeding is the fraenular ves-
77 If you are performing a circumcision without as- sels, that may require ligation.
sistance, good exposure can be achieved by re-
flecting the penis over a rolled-up swab, whilst
closing the skin.
Common Pitfalls
77 Never circumcise an infant with hypospadias or a 77 A urethrocutaneous fistula may arise from injudi-
buried penis, as this may compromise the subse- cious use of bipolar diathermy or from a deep su-
quent reconstruction. Refer to Urology. ture placed to control fraenular bleeding.
77 Meatal stenosis occurs in 10 % of boys after cir- 77 Excising too much skin gives the appearance of a
cumcision (usually for BXO). Follow-up BXO cases buried penis; excising too little may cause annu-
to exclude voiding dysfunction which may re- lar scarring and phimosis.
quire meatoplasty.
402 P. Hammond and P. A. M. Raine
F9 F9 Urethral Meatotomy and Dorsal Slit
of the Foreskin
P. Hammond and P. A. M. Raine
Indication Indication
Treatment of urethral meatal stenosis (usually An indication for this meatotomy is phimosis
secondary to balanitis xerotica obliterans [BXO]) (possibly to prevent recurrent paraphimosis) or
‘buried penis’.
Operative Technique
Operative Technique
• The tip of a straight artery forceps is inserted
at the meatus to define a ‘lip’ of stenotic tissue • The dorsal foreskin is stretched distally using
dorsally (and/or occasionally ventrally). two curved mosquito forceps applied just to ei-
• The forceps is then applied across the ‘lip’ in ther side of the dorsal midline point of the pre-
the dorsal (or ventral) sagittal plane to clamp putial orifice.
and crush the tissue. • The dorsal midline foreskin in the sagittal plane
• This crushed glans tissue is cut with sharp iris is then clamped and crushed for an appropri-
scissors to achieve minimal bleeding (Fig. 1). ate distance proximally with straight artery for-
• Interrupted 7/0 Vicryl sutures are placed at the ceps. It should be left clamped for 10 s.
apex of the cut and either side to appose glan- • The crushed foreskin is then divided with scis-
ular skin and terminal urethral mucosa. sors to widen the preputial aperture.
• An appropriately sized urethral catheter may • The inner and outer preputial skin is apposed
be inserted for 24–48 h postoperatively. with interrupted 5/0 Vicryl (Fig. 2).
• This process can be repeated further proximally
until the foreskin aperture is wide enough to
easily permit retraction over the glans.
Peter A. M. Raine
Consultant Paediatric and Neonatal Surgeon
Rainewest@btinternet.com
Tips
77 Local anaesthetic gel should be applied to the 77 The dorsal slit should be performed a centime-
glans during meatotomy. tre at a time until the preputial orifice is deemed
77 Judicious use of bipolar diathermy may be re- wide enough.
quired for haemorrhage during either proce-
dure.
Common Pitfalls
77 An inadequate meatotomy may result in recur- 77 The dorsal slit must be sufficient so that the
rent meatal stenosis. glans is not exposed through a residual tight
foreskin band, as this presents the risk of para-
phimosis.
404 T. J. Bradnock and G. Haddock
F10 F10 Open Orchidopexy
T. J. Bradnock and G. Haddock
• Perform an examination under anaesthetic • In most cases, the undescended testis will be
(EUA) of the inguinal region to confirm the apparent at the superficial inguinal ring.
position of the testes • Delivery of a canalicular testis is aided by win-
• Expose the inguinal canal as described in dowing the canal (see Chap. F1), with exten-
Chap. F1 (Fig. 1). sion into the superficial inguinal ring.
• Use toothed forceps to lift the spermatic cord
from the inguinal canal.
• Hold the testis in your non-dominant hand.
Use artery forceps or finger dissection to cre-
ate a window posterior to cord (Fig. 2).
Fig. 2
• Divide lateral spermatic bands with scissors to • Use a scalpel to incise the scrotal skin over your
allow the testis to be brought into the scrotum finger, and iris scissors to create a dartos pouch
without tension. (Figs. 9 and10).
• Create a ‘tunnel’ into the scrotum by gently • Pass curved mosquito forceps from the scrotal
passing the index finger of your non-domi- to the inguinal wound, guided and protected
nant hand from the medial end of the wound by your fingertip.
to the scrotum. • Grasp the testis by the tunica albuginea at its
inferior pole and deliver into the dartos pouch,
ensuring no twisting of the cord.
• Use an absorbable 4/0 suture to ‘pex’ (an orchi-
dopexy) the lower septum of the testis to the
median raphe or alternatively, to close the neck
of the dartos pouch around the spermatic cord.
• Close the inguinal wound in layers and the scro-
tum with continuous 4/0 Vicryl.
Fig. 3
Fig. 6
Testis
Fig. 4 Fig. 7
Fig. 5 Fig. 8
406 T. J. Bradnock and G. Haddock
Fig. 9 Fig. 10
Tips
77 On occasion the dissection of the testicular ves- 77 Always ensure the spermatic cord is not twisted
sels may need to be extended extra-peritoneally before delivering the testis into the scrotum –
to gain adequate length. check position of the lateral sulcus.
77 If after extensive retroperitoneal dissection the 77 The dartos pouch should be made inferior to in-
cord remains too short to reach the scrotum, cision, so that the testis is not fixed under the
consider performing a two-stage procedure (fix wound.
the testis to the pubic tubercle initially).
Common Pitfalls
77 The superficial inferior epigastric vein traverses 77 Always inspect the gubernaculum to exclude
the medial end of the incision. Either retract it or a ‘looping vas’, which may be inadvertently di-
coagulate and divide. vided.
77 When ‘windowing’ the inguinal canal, avoid di- 77 Failure to ensure meticulous haemostasis during
viding the ilioinguinal nerve. Division results in dartos pouch creation will result in scrotal hae-
loss of sensation over the upper medial thigh matoma.
and anterior third of the scrotum.
F11 Ovarian Surgery 407
F 1O varian Surgery F11
H. Said and R. Carachi
Fig. 3
Fig. 2
Fig. 4
F11 Ovarian Surgery 409
Tips
77 Low-power magnification (surgical loupes) of- 77 If the cortex is quite friable, it is necessary to
ten assists the surgeon in identifying the correct place interrupted 6/0–7/0 non-reactive sutures
plane in the cyst wall and ovarian parenchyma. to achieve adequate approximation.
Common Pitfalls
77 Rupture of fragile cyst wall and spillage of the 77 Rough manipulation of the Fallopian tubes
pelvic cavity
77 Excessive redundant thin cortex: can present a
special problem in ovarian reconstruction
Tips
77 Gonads are sensitive to radiation. It is estimated the lethal dose required to eliminate 50 % of the
that the sensitivity of the oocytes to radiation is oocytes (LD50) of 2 Gy
Common Pitfalls
Technique Fig. 1
• A pelvic mass (the distended vagina/ uterus) • Use tissue forceps to lift each hymenal tag and
may be apparent on abdominal examination excise each in turn at the level of the introitus
at the start of the procedure. to create a concentric opening (Fig. 4).
• The lithotomy position should be used for pa- • Circumferentially over-sew the edges of the
tient placement. incision with interrupted absorbable sutures
• Prepare and drape the perineum. (Fig. 5).
• Insert a urethral catheter to clearly define the • Remove the urethral catheter.
urethral anatomy.
• Gently retract the labia minora to reveal the
bulging hymen (Fig. 2).
Fig. 4
Fig. 2
Fig. 5
Fig. 3
412 C. Keys and A. H. B. Fyfe
Tips
77 A short course of topical oestrogen cream (7–10 77 Asymptomatic labial adhesions may be man-
days) is usually curative. aged conservatively.
77 In time, all labial adhesions resolve spontane- 77 An elliptical hymenal incision is an alternative to
ously. the cruciate incision.
Common Pitfalls
77 Recurrence of labial adhesions is common after 77 In some circumstances, where the vaginal anat-
surgery. omy is grossly distorted by the hydro/haemato-
77 Beware of the lateral pudendal arteries, which colpos, it may be preferable to simply perform
lie adjacent to the introitus in the 3 and 9 o’clock a vertical hymenotomy to allow irrigation and
positions – trauma causes significant haemor- drainage, with definitive surgery deferred until
rhage. normal anatomy has been restored.
F13 Principles of Hypospadias Surgery 413
F13 Principles of Hypospadias Surgery F13
A. T. Hadidi
• Only silastic stents or catheter should be used • A broad-spectrum antibiotic (e.g. cephalospo-
and should not be left inside the urethra for rin) is recommended in hypospadias surgery, as
more than a week to avoid irritation of the ure- long as the catheter is kept inside the urethra.
thra. Suprapubic catheters are recommended
in the repair of proximal hypospadias.
• More than 150 methods of dressing after hy- Objectives of Surgery
pospadias operations have been described. The
author prefers to apply a simple dressing of The primary goal of hypospadias surgery is to cre-
dry gauze and local antibiotic ointment on the ate a good functioning penis. This means ensur-
ventral aspect of the penis and to fix the pe- ing that the penis is straight and that the child can
nis, dressing and catheter against the lower ab- micturate from the tip of the penis in a straight,
dominal wall with good adhesive plaster. This adequately wide stream of urine. The second im-
allows adequate compression of the penis as portant goal is for the penis to have a normal or
well as early mobilisation of the child who can near-normal appearance with a slit-like meatus at
sit and play a few hours after surgery. the tip of the glans.
Fig. 1 Classification of hypospadias. Source: Hadidi AT, Azmy AF (eds) (2004) Hypospadias surgery: an illustrated
guide, 1st edn. Springer, Berlin Heidelberg New York. Reproduced with kind permission
F13 Principles of Hypospadias Surgery 415
An alarming observation in recent literature The steps of hypospadias correction include as-
is that the cosmetic appearance is taking prior- sessment under anaesthesia, orthoplasty (chordee
ity over the function of the penis. Many patients correction), urethroplasty, protective intermediate
with a ‘good-looking’ penis are referred with re- layer, meatoglanuloplasty and skin cover.
current fistula and difficulty to pass urine due to
a narrow new urethra.
Fig. 2a–c Different suturing techniques in hypospadias surgery. Source: Hadidi AT, Azmy AF (eds) (2004) Hypospa-
dias surgery: an illustrated guide, 1st edn. Springer, Berlin Heidelberg New York. Reproduced with kind permission
Fig. 3a–c Different glans configurations. a Cleft glans. b incomplete cleft glans. c Flat glans
416 A. T. Hadidi
Glans Configuration and flat glans (Fig. 7). The Thiersch method and
its modification are suitable for patients with wide
Patients with hypospadias have an abnormal- urethral plates (Fig. 8). A lateral-based flap is use-
looking globular glans. The glans is classified into ful in patients with a deep chordee, that necessi-
cleft glans, incomplete cleft and flat glans based tates division of the urethral plate (Fig. 9).
on the degree of clefting and urethral plate pro- Incision of the urethral plate was first described
jection. by Reddy in 1975, Orkiszewski and Rich in 1988,
popularised by Snodgrass in 1994, and is ad-
dressed in Chap. F14.
Chordee Assessment This method has become popular because of
its simplicity and the good cosmesis that can be
The ‘artificial erection test’ (Fig. 4) is used as a achieved. However, the author does not recom-
routine by many surgeons to assess the degree of mend it, because the long-term complication rate
chordee. of the transjugular intrahepatic portosystemic
shunt (TIP) procedure has reached up to 35 % in
distal hypospadias and 66 % in proximal hypo-
spadias.
the meatus (Fig. 6c). A 6/0 Vicryl stitch is approx- Distal Hypospadias
imated, affixing the meatus at the tip of the glans
(Fig. 6d). Inverted-Y Modified Mathieu Repair
If the meatus is narrow or pinpoint; it is in-
cised to make it wide enough to accommodate a The Mathieu technique is one of the oldest pro-
10-Fr catheter or larger, according to the age of cedures, that has withstood the test of time. It has
the patient and size of the penis. A transurethral the drawback, however, of that it results in a cir-
10-Fr Nelaton catheter or larger is inserted into cular meatus which is not at the tip of the glans.
the bladder. The inverted Y–V modification avoids the draw-
A Y-shaped incision is made proximal to the back of the original Mathieu repair and results in
meatus (Fig. 6e). The longitudinal limb of the Y a slit-like meatus at the tip of the glans (Fig. 7).
incision extends from the meatus to the coronal • A Y-shaped incision is outlined on the glans.
sulcus. Extra care should be taken to avoid injury • A 10-Fr catheter or larger is inserted into the
of the very thin urethra underneath the skin. The bladder.
use of sharp scissors and traction helps to avoid • The flap is outlined so that the distance between
injury of the distal urethra. Traction is applied the meatus and the proximal end of the flap is
on the glanular wings, and the incision is deep- slightly greater than the distance from the me-
ened using sharp scissors starting proximally at atus to the tip of glans.
the coronal sulcus. The glanular wings are mo- • A U-shaped incision is made, extending from
bilized off the urethra and opened like a book. the tip of the V in the glans down to the lower
This very important step helps to wrap the glanu- end of the designed flap; this results in two
lar wings around the urethra without any tension. glanular wings.
The incision is continued around the meatus to • The Mathieu flap is mobilised, preserving its
meet the lateral limbs of the inverted-Y incision. fascial blood supply.
Local ointment is applied to the wound, nor- • Urethroplasty is performed using continuous
mal gauze is applied and adhesive tape fixes the subcuticular polyglactin 6-0 sutures.
gauze, the catheter and the penis against the lower • A protective intermediate layer is fashioned by
abdominal wall. This allows mobility of the pa- using the flap fascia or dartos fascia.
tient and secures the catheter and penis against • Both glanular wings are sutured together
the lower abdominal wall. around a neourethra using interrupted mat-
The transurethral catheter is left for 1–2 days, tress sutures.
depending on the degree of mobilization and the
degree of post-operative oedema of the penis. A
caudal block is used as a routine to reduce post-
operative pain.
Fig. 6a–f Steps of the double-Y glanuloplasty. a Glanular hypospadias with mobile meatus. b Inverted-Y Incision. c
The three flaps are elevated. d The apex of the meatus is sutured to the tip of the glans. e A 10-Fr catheter is introduced
into the urethra and a Y incision is made which surrounds the meatus and extends down to the coronal sulcus. f The
glanular wings are mobilised deep enough to wrap around the urethra and are approximated in the midline. The 6
o’clock stitch is a 3-point stitch which brings the urethra and the two medial edges of the glanular wings together, and
is magnified in the inset. Source: Hadidi AT, Azmy AF (eds) Hypospadias surgery, 2nd edn. Springer, Berlin Heidelberg
New York (in press). Reproduced with kind permission
Proximal Hypospadias Without Deep A traction suture of 4/0 nylon is placed through
Chordee the tip of the glans.
• An inverted-Y-shaped incision is outlined on
Inverted-Y Modified Thiercsh Technique the glans. The tip of longitudinal limb of the
inverted Y is at the tip of the glans and where
The inverted-Y tubularised plate technique is a the tip of the neomeatus will be located. The
modification of the Thiersch technique. It is suit- lower two limbs of the inverted Y are about 0.8
able in hypospadias patients without deep chordee. cm long and the angle between them is 90°. The
Thus, incision of the urethral plate is not needed to long vertical limb of the inverted Y is 0.8 cm.
correct deep chordee. The original Thiersch tech- The inverted-Y–shaped incision is deepened to
nique is ideal in patients with cleft glans. How- wrap the glanular wings around the new ure-
ever, it is necessary to modify the technique when thra. This results in a median inverted-V flap
the glans is flat or incompletely clefted, in order and two lateral wings. The two lateral wings are
to wrap the glanular wings around the new ure- elevated and the median flap is mobilised.
thra (Fig. 8). • A 10-Fr catheter or larger is inserted into the
bladder.
F13 Principles of Hypospadias Surgery 419
Fig. 7 Y–V modified Mathieu technique. Source: Hadidi AT, Azmy AF (eds) (2004) Hypospadias surgery: an illustrated
guide, 1st edn. Springer, Berlin Heidelberg New York. Reproduced with kind permission
• Using two fine surgical forceps, the adequate Proximal Hypospadias with Deep Chordee
diameter of the new urethra is marked around
the catheter. Lateral-Based Flap Technique
• A U-shaped skin incision is made using sharp
scissors or scalpel, size no. 15. A transverse in- The lateral-based flap technique may be used in
cision is made proximal to the meatus, using proximal hypospadias with deep chordee which
sharp scissors. necessitates incision of the urethral plate to
• If the distal urethra is thin, it is incised until a straighten the penis. It has a dual blood supply
healthy vascularised urethra is reached. and allows extensive excision of ventral chordee.
• In the glans, the incision is deepened enough It may offer patients with proximal hypospadias
to create mobile lateral glanular wings to wrap a single-stage urethral reconstruction with a good
around the new urethra. success rate (91 %) and relatively few complica-
• Two or three sutures are tied along the length tions. The operative steps for the lateral-based flap
of the new urethra to reduce tension and help technique listed below are illustrated in Fig. 9.
orientation. • A deep Y-shaped incision is made on the glans,
• The new urethra is constructed using 6/0 Vic- that goes all the way down to the coronal sul-
ryl on a cutting needle in a continuous subcu- cus. This permits two deep glanular wings and
ticular manner. a wide meatus to be formed.
• A protective intermediate layer is fashioned • The edge of the lateral skin is then sutured at
from the preputial fascia under the foreskin. two points; distally it approximates the lateral
(In proximal hypospadias without deep chor- wall to the tip of the glans, and proximally to
dee, the authors prefer scrotal dartos/tunica the meatus, thus forming ‘a new urethral plate’.
vaginalis fascia.) • A 10-Fr catheter (or larger, depending on the
• Closure of the glans follows, starting at the tip size of the penis and the age of the patient) is
of the glans to ensure a wide meatus. introduced through the meatus.
• A rectangular skin strip is outlined, extending
proximally from the urethral meatus to the tip
of the glans.
• Several interrupted stitches assist in orienta-
tion, and the urethroplasty is carried out from
420 A. T. Hadidi
Fig. 8 Steps of inverted-Y Thiersch technique. Source: Hadidi AT, Azmy AF (eds) Hypospadias surgery, 2nd edn.,
Springer, Berlin Heidelberg New York (in press). Reproduced with permission
proximal to distal in a subcuticular continuous
manner. Urethral Reconstruction Using Buccal
• The adjacent penile skin is elevated (rather Mucosa
than mobilising the flap) to preserve the vas-
cular areolar tissue. In ‘redo’ operations, it is possible to resort to buc-
• The neourethra is covered with a protective in- cal mucosa to form a wide urethral plate as a first
termediate layer (dartos or tunica). stage, and to reconstruct a neourethra in the sec-
• The neomeatus is constructed by suturing the ond stage. Bladder mucosa and one-stage repair
terminal end of the neourethra to the centre of using buccal mucosa are becoming less popular
the glans. in complicated proximal hypospadias, due to the
• The glanular wings are sutured around the neo- high incidence of complications.
urethra using interrupted mattress sutures.
• A percutaneous suprapubic catheter is inserted
into the bladder for 10–14 days.
• A compression dressing is applied for 6–24 h
for haemostasis.
F13 Principles of Hypospadias Surgery 421
Fig. 9a–h Lateral-based flap (LB flap) technique for proximal hypospadias. a Y-shaped deep incision of the glans. b
Three flaps are elevated and orthoplasty performed. c New urethral plate. d Design of the LB flap. e Urethroplasty. f
Mobilization of dartos/tunica vaginalis fascia. g Protective intermediate layer. h Skin closure. Source: Hadidi AT, Azmy
AF (eds) (2004) Hypospadias surgery: an illustrated guide, 1st edn. Springer, Berlin Heidelberg New York. Reproduced
with kind permission
422 A. T. Hadidi
Tips
Common Pitfalls
77 Avoid techniques that have a high incidence of 77 Avoid unnecessary degloving of the penis as the
meatal stenosis and recurrent fistula. chordee involves the ventral aspect of the penis.
77 Avoid using small catheters when reconstructing 77 Avoid circumcision at the same time as urethral
neourethra. reconstruction, as the foreskin may be needed to
77 Avoid meatal stenosis at the end of the new ure- treat complications and many parents prefer to
thra by wide mobilisation of the glanular wings. have foreskin reconstruction.
F14 Glandular and Coronal Hypospadias Repair 423
F 14Glandular F14
and Coronal Hypospadias Repair
E. Broadis and S. J. O’Toole
Indications
Fig. 2 Fig. 3
Stuart J. O’Toole
Consultant Paediatric Urologist
Stuart.O’Toole@ggc.scot.nhs.uk Fig. 4 Fig. 5
Fig. 9
Tips
77 The initial dissection of the skin over the urethra 77 The dissection of the corpora spongiosa is a crit-
must be as superficial as possible to minimize ical step; not only does it provide a well vascular-
bleeding and to ensure as much tissue is left ized layer to cover your urethroplasty, but it also
over the urethra as possible. leads you into the plane to dissect the glans off
the corpora and at the end of the procedure. It
provides you with a layer of dartos to cover your
repair.
426 E. Broadis and S. J. O’Toole
F15 F15 Two-Stage Hypospadias Repair:
Stage One
E. Broadis and S. J. O’Toole
Indication
Fig. 2 Fig. 3
Stuart J. O’Toole
Consultant Paediatric Urologist
Stuart.O’Toole@ggc.scot.nhs.uk
Fig. 4 Fig. 5
• The urethral plate is divided and, along with area first. Stay sutures are applied to the cor-
spongiosa, is mobilised off the corpora (Fig. 5). ners of the graft and it is dissected using scis-
• An erection test is performed. If there is resid- sors.
ual chordee, then further dissection is carried • The graft is placed on a silicone block for fur-
out ventrally. ther trimming (Fig. 9). All vessels must be re-
• If there is still residual chordee, Nesbitt tucks moved, and the graft must be thin enough to
should be performed. appear transparent.
• The urethral plate is tacked to the corporeal • Stay sutures are reapplied to the graft to ensure
bodies (Fig. 6). If the corpora are split at the correct orientation.
level of the bulbar urethra (as in a perineal hy- • The graft is applied to the penis and bedded
pospadias), then the urethral plate has to be tu- down with 8/0 Vicryl quilting sutures (Fig. 10).
bularised to reach the corporeal bodies. • Scrotal skin is brought together with inter-
rupted 6/0 Vicryl to correct the bifid scrotum.
• The nasogastric feeding tube is wrapped in
Mepitel, and the penis is tied around this to
provide pressure to the graft.
• Three or four sutures are used. They must in-
corporate the graft edge, the body of the cor-
pora and the Mepitel to allow for compression
of the graft (Fig. 11).
• The dressing is removed after 1 week, under
general anaesthetic.
Fig. 6
Fig. 7 Fig. 8
428 E. Broadis and S. J. O’Toole
Fig. 9
Fig. 10 Fig. 11
Tips
77 Start the initial dissection proximally, locate 77 When completing the skin for the first stage, re-
the spongiosa and use this as a guide to dis- tract the glans of the penis cranially so as much
sect up onto the corporal bodies. This minimises dorsal skin as possible is transposed ventrally.
bleeding.
77 Always incise the glans deeply to create as wide
a graft at this point as possible.
F16 Hypospadias Repair: Stage Two 429
F16 Hypospadias Repair: Stage Two F16
E. Broadis and S. J. O’Toole
Indication
Operative Technique
Stuart J. O’Toole
Consultant Paediatric Urologist
Stuart.O’Toole@ggc.scot.nhs.uk
Tips
77 The hardest bit of this operation is drawing the 77 On occasions the penis is again tethered down
U-shaped incision at the beginning. Make sure to the scrotum; it is nearly always possible to per-
that the glans and skin can close easily over the form releasing incisions at the base of the shaft
catheter before deciding that your urethral inci- of the penis to gain extraventral skin length.
sion is correct.
PAR T G
Urology
G1 Cystourethroscopy 433
G 1Cystourethroscopy G1
C. Keys and S. J. O’Toole
Stuart J. O’Toole
Consultant Paediatric Urologist
Stuart.O’Toole@ggc.scot.nhs.uk
Tips
77 Perform the cystoscopy sitting down. 77 When negotiating the external sphincter, the
77 Always keep the lumen of the urethra in the mid- tip of the scope may actually have to move
dle of the field of view and remember that all slightly outwards as the eyepiece of the scope is
paediatric scopes (barring resectoscopes) are off- dropped down.
set 5–10°. 77 The Crede manoeuvre may be useful to assess
77 Aim to keep the tip of the scope as steady as for posterior urethral valves. Press on the full
possible; the eyepiece is moved in all directions, bladder while viewing the verumontanum. Stop
but the tip of the scope must stay in the same the flow of water and open one of the acces-
position. sory channels so you can view the urine flow-
ing down the posterior urethra and out of your
scope.
Common Pitfalls
77 Over distension of the bladder will distort the 77 Not lowering the scope enough at the point of
anatomy, making diagnosis difficult and it in- negotiating the external sphincter and posterior
creases the risk of perforation with a subureteric urethra can also compromise the procedure.
transurethral injection (STING) procedure.
77 Driving the scope straight into the urethral wall
at the start of the procedure and getting tissue
on the lens will ruin your view.
G2 Urethral and Suprapubic Catheterisation 435
G2 Urethral and Suprapubic Catheterisation G2
C. Keys and S. J. O’Toole
Female
Suprapubic Catheterisation
Stuart J. O’Toole
Consultant Paediatric Urologist
Stuart.O’Toole@ggc.scot.nhs.uk
Fig. 2
Fig. 3
G2 Urethral and Suprapubic Catheterisation 437
Fig. 4 Fig. 5
Fig. 6 Fig. 7
Tips
77 Check the balloon on the catheter prior to inser- – Large child: 1–14 Fr
tion by inflating and deflating with the appropri- 77 Always document the procedure in the case
ate amount of sterile water. notes including the size of catheter, the volume
77 Urethral catheter sizes: of sterile water in the balloon and the residual
– Neonate: 6–8 Fr urine volume.
– Infant: 8–10 Fr
438 C. Keys and S. J. O’Toole
Suprapubic Catheterisation
Common Pitfalls
77 Trauma to the male urethra can cause stricture. 77 Urethral catheterisation in the early postoper-
Use generous lubrication and a gentle tech- ative period following hypospadias repair may
nique. disrupt the urethroplasty. Consider suprapubic
77 Inflating the balloon in the urethra; if in doubt, catheterisation and discuss the case with a urolo-
remove it. gist before proceeding.
77 Do not inflate the balloon until you see urine fill- 77 Over-filling the catheter balloon increases the
ing the catheter. risk of balloon rupture, with subsequent dis-
77 Aggressive attempts to advance a urethral cath- placement of the catheter.
eter in the face of resistance may result in false-
passage creation and stricture formation.
77 Do not perform urethral catheterisation if there
is suspicion of perineal/urethral trauma (see
Chap. H1).
G3 Open Surgical Approaches to the Kidney 439
G3 Open Surgical Approaches to the Kidney G3
L. C. Steven and M. E. Flett
Transperitoneal Approach
Anterolateral Retroperitoneal
Approach
Martyn E. Flett
Consultant Paediatric Urologist Fig. 2
Martyn.Flett@ggc.scot.nhs.uk
• External oblique, internal oblique and trans- • A transverse incision is made from the lateral
versalis are split in the lines of their respective edge of erector spinae, 2–3 cm inferior to the
fibres. Divide each layer generously, using the 11th rib.
entire length of the wound. Once transversalis • Fibres of latissimus dorsi will be seen running
is split the peritoneum will be visible (Fig. 3). posteriorly; these can be divided transversely
• Sweep the peritoneum away from the retroper- using monopolar diathermy.
itoneal space by using both of your index fin- • Beneath this layer is the tough lumbar fascia.
gers in the longitudinal plane, moving the peri- Splitting of this fascia in the line of the wound
toneum anteriorly and medially. Any breaches will reveal the pararenal space and fat. Deep
to the peritoneum should be repaired. retractors should be used to open and stretch
• The kidney will now be palpable. Continuing the fascia. The inferior pole of the kidney will
the same anteromedial mobilisation of the peri- be palpable, and blunt dissection of this space
toneum will allow the parenchyma to be visual- will expose the middle and superior poles. Once
ised. The renal fascia can be opened safely over this plane is established, the renal fascia should
the parenchyma. be safely opened away from the posterior renal
pelvis.
• The muscle layers in this approach are tough
and a strong assistant is essential.
Fig. 3
Posterior Approach
Fig. 4
G3 Open Surgical Approaches to the Kidney 441
Tips
77 If using the transperitoneal approach, always re- 77 If using the anterolateral approach be sure to
flect the colon medially to allow safe access to split the three (separate) muscle layers along the
the renal hilum. same length for each layer. This will maximise ex-
posure through the wound.
Common Pitfalls
77 When using the prone approach, failure to pro- 77 When using the posterior approach, allow gen-
tect potential pressure areas (e.g. anterior bony erous mobilisation of the lumbar fascia; other-
pelvis, arms and ankles) will result in skin necro- wise you will not achieve safe and easy exposure
sis, with or without neuropraxia. to the kidney.
442 S. Gazula and S. Agarwala
G4 G 4Open Nephrectomy
S. Gazula and S. Agarwala
Fig. 1
Sandeep Agarwala
Additional Professor of Pediatric Surgery Fig. 2
sandpagr@hotmail.com
Fig. 3
Fig. 4
Tips
Common Pitfalls
77 Avoid injury to the overlying peritoneum by in- 77 Whenever possible, secure the vessels individu-
cising Gerota’s fascia on the lateral aspect of the ally away from the hilum, and the artery should
kidney. always be ligated first.
G5 Pyeloplasty 445
G 5P yeloplasty G5
A. Neilson and M. E. Flett
• Insert a Foley catheter and administer antibi- with their respective fibres until the peritoneum
otics preoperatively. is identified (Fig. 1b).
• Arrange the patient in the supine position with • The peritoneum is swept medially and Gero-
lumbar roll. ta’s fascia identified and entered posterolater-
• A subcostal muscle-splitting incision provides ally. A Denis Browne ring retractor may help
good exposure. The incision is sited one finger- with exposure (Fig. 1c).
breadth below the lowest rib, lateral to rectus • The ureter is slung, aiding mobilisation of the
abdominus (Fig. 1a). pelvis. Stay sutures are places in the ureter,
• The external oblique aponeurosis and subse- and caudal and cranial extents of the pelvis
quent layers (internal oblique, transversus ab- (to maintain orientation) (Fig. 2).
dominis) are exposed widely; open each in line
Fig. 1b
Fig. 1a
Fig. 2 Fig. 4
Fig. 3
Fig. 5
G5 Pyeloplasty 447
Tips
77 Wide dissection of each muscle layer is essential 77 Absorbable sutures should be used.
for good access. 77 Stents are not required in uncomplicated cases.
77 Take care when splitting transversus abdominus, 77 Consider using a stent (internal with or without
as a peritoneal breech may cause an ileus. external) if ‘floppy’ kidneys or very ‘baggy’ pelvis
77 Keep knots on the outside of the pelvis, as re- is present; in such cases, redo surgery.
tained suture material acts as a nidus for stone
formation.
Common Pitfalls
77 Avoid excess manipulation of the ureter – dam- 77 When spatulating the ureter, ensure it maintains
age to the adventitial blood supply may cause a correct orientation to avoid torsion or kinking
anastomotic failure or stricture. after anastomosis.
77 Aim to cut the pelvis and ureter with a single,
smooth incision using sharp scissors to avoid
ragged edges.
448 P. Hammond and A. H. B. Fyfe
G6 G 6Ureteric Duplication
P. Hammond and A. H. B. Fyfe
Incision of Ureterocele
Operative Technique
Hemi-nephrectomy Fig. 1
Operative Technique
Alistair H. B. Fyfe
Consultant Paediatric Urologist
Fyfe7es@btinternet.com Fig. 2
Fig. 4
Fig. 3
• The demarcation between upper and lower • Haemostasis is achieved with diathermy and
moieties is usually identified easily by its ap- large absorbable sutures to the cut renal edge,
pearance. Diathermy is used to mark this line. taking in the renal capsule (Fig. 4).
• The parenchyma is divided with care not to en- • After carefully dissecting the gonadal vessels,
tering calyces (Fig. 3). the upper pole ureter is followed to the pelvic
brim, where it is then transfixed.
Tips
Common Pitfalls
77 If lower-pole calyces are opened these must 77 It can be difficult to delineate the precise anat-
be closed in a watertight manner, and the re- omy when dealing with a large ureterocele. En-
nal capsule closed over this repair (with or with- sure that you fill the bladder well, as this makes
out a corrugated drain left in situ) to reduce the it easier to identify the anatomy. Occasionally,
chance of a urinoma. it may be useful to distend the ureterocele by
manually compressing the flank containing the
hydro-nephrotic moiety.
450 A. Monaghan and A. H. B. Fyfe
G7 G7 Surgery for Renal Calculi
A. Monaghan and A. H. B. Fyfe
Open Removal
Fig. 2
Fig. 3
Fig. 4 Fig. 5
452 A. Monaghan and A. H. B. Fyfe
Tips
77 Imaging should be performed to ascertain 77 Immediately prior to surgery the patient should
whether there is any anatomical or functional have a repeat x-ray to ascertain whether the cal-
abnormality which is contributing to the forma- culi are still present and in the same position.
tion of calculi (i.e. pelvi-ureteric obstruction, neu-
rogenic bladder, etc.).
G8 Nephrostomy 453
G 8Nephrostomy G8
S. Gazula, M. Jana and S. Agarwala
S. Gazula
Senior Specialist Pediatric Surgeon and Head
suhasinigazula@gmail.com
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
Fig. 1
Fig. 2
Fig. 3
Fig. 4 Fig. 5
G8 Nephrostomy 455
Tips
77 The medial end of the incision is curved slightly 77 Ongoing care of a nephrostomy tube is impor-
downward as it passes the mid-axillary line to tant to prevent dislodgement, infection and to
avoid the subcostal nerve, and it may be ex- ensure unobstructed drainage.
tended as far as the lateral border of the rectus 77 Periodic tube replacement is recommended at
abdominis muscle. 6- to 8-week intervals. This is usually performed
77 Injection of 0.5 % bupivacaine into the fascial readily under fluoroscopic guidance once a
sheath around the intercostal nerves is helpful in chronic track has been established.
reducing postoperative pain.
Common Pitfalls
77 Avoid injury to the intercostal nerves while incis- allows better positioning of the tube and mini-
ing the muscle layers; this may cause persistent mizes the risk of injury to large intrarenal vessels.
postoperative pain or bulging in the flank, due to 77 Care must be taken to avoid entrapment of any
paresis of the denervated muscle. intercostal nerves or branches during closure of
77 It is important to ensure that the nephrostomy the muscle layers.
is made near the convex border of the kidney
and not in the anterior or posterior surface; this
• After the last dilator is removed, introduce the • Check the location of the catheter using ultra-
PCN catheter (self-retaining pigtail catheter or sound or fluoroscopy. A pigtail catheter should
Malecot catheter) over the guidewire until the have a well-formed loop in the pelvis, not in the
catheter is well within the pelvis. calyces, and all the holes should be within the
• Confirm the position of the catheter–guidewire pelvicalyceal system.
assembly using ultrasound. • Secure the catheter in place using suture at the
• Remove the guidewire, keeping the pigtail cath- skin entry site, taking care to avoid kinking of
eter stable in place (Fig. 13). Take precaution catheter.
to avoid pulling the catheter out along with the • Connect the catheter to a drainage bag.
guidewire.
Fig. 7
Fig. 6
Fig. 8 Fig. 9
G8 Nephrostomy 457
Fig. 10 Fig. 11
Fig. 12 Fig. 13
458 S. Gazula, M. Jana and S. Agarwala
Tips
77 The procedure should be done under ultrasound 77 Once the needle enters the calyx, a ‘give way’ will
guidance, with or without the use of fluoroscopy, be appreciated.
with the patient under anaesthesia or deeply se- 77 Never press the guidewire hard in a case where
dated. resistance is felt.
77 The prothrombin time should be within normal 77 In cases of planned ureteric stenting, puncture
range. the upper calyces in order to help better manip-
77 Puncture through a posterior calyx traverses the ulation.
relative avascular zone and avoids injuring major
renal vessels.
Common Pitfalls
77 Decompressing the system completely during 77 An inability to advance the catheter over the
insertion of the sheath or checking its position guidewire is usually because of a kink in the
can make further guidewire visualization diffi- catheter or guidewire. Most kinks occur at the
cult. skin or renal cortex. Put enough guidewire in-
77 The guidewire can be malpositioned while with- side, pull the kink outside the skin and proceed.
drawing the sheath.
G9 Vesicostomy 459
G 9Vesicostomy G9
P. Hammond and A. H. B. Fyfe
Indication
Alistair H. B. Fyfe
Consultant Paediatric Urologist
Fyfe7es@btinternet.com Fig. 2
Fig. 3b
Fig. 4
Fig. 3c
Fig. 5
Tips
77 Ensure the vesicostomy is as posterosuperior on 77 Make the size of the hole as wide as an 18- to 24-
the dome as possible to avoid prolapse. Fr Foley catheter to minimize the chance of ste-
nosis, but not any larger as this predisposes to
prolapse.
Common Pitfalls
The number of indications for ureterostomy has • Deepen the incision to reach Gerota’s fascia.
lessened with time. In contemporary practice, a Identify the lower pole of the kidney and lo-
ureterostomy is used to achieve temporary de- cate the ureter adjacent to it.
compression of the upper tracts in carefully se- • Mobilize the ureter from its bed cranially as far
lected cases. Many different types of ureterostomy as the pelviureteric junction and pass a sling un-
have been described, including the Sober ureter- derneath it.
ostomy, reverse Sober ureterostomy, ring ureter- • Deliver the mobilized ureter in a tension-free
ostomy, loop ureterostomy and end ureterostomy. manner to the skin at the proposed site of ure-
terostomy (Fig. 2).
Fig. 1 Fig. 2
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
Fig. 4
Fig. 3
Technique for the Sober Ureterostomy • Bring out the ureter more dilated as a stoma
at the edge of the Pfannenstiel incision. Take
• Make the initial exposure and mobilization as the contralateral ureter behind the mesentery
described for the loop ureterostomy (above). of the sigmoid colon (Fig. 8) to anastomose it
• Transect the ureter at the apex of the delivered to the side of the ureter more dilated (Fig. 9).
ureteric loop. • Form an everted stoma from the dilated ure-
• Anastomose the distal end of the transected ter, making it protrude at least 1 cm from the
ureter to the lowest part of the renal pelvis skin level (Fig. 10).
(Fig. 5). • The stoma is everted by passing the suture
• Anchor the proximal end of the transected ure- through the skin and then through the partial
ter to the muscle, sheath and the skin, as for an thickness of the ureteric wall, midway from
end ureterostomy (Fig. 5). the transected edge, and then through the full
• Close the abdominal incision in layers. thickness of the ureter’s edge before the knot
is tied on the skin’s surface.
Fig. 7
Fig. 6
Fig. 9
Fig. 10
Tips
77 Avoid excessive mobilization and subsequent 77 The proximal tracts may be drained with a Foley
devascularization of the ureter. catheter for a short period postoperatively to
77 Avoid anchoring the ureter too posteriorly, as it keep the wound dry.
becomes uncomfortable for the patient to lie su- 77 Double–barrel end ureterostomies can also be
pine. made.
77 Bilateral loop ureterostomies may be done in the 77 Incorporation of a V-shaped skin flap in an end
prone position with lumbotomy incisions. This stoma can reduce the incidence of stenosis.
avoids the need to change the position intra-op-
eratively.
Common Pitfalls
77 Excessive mobilization and devascularization of 77 Not bringing out the most proximal part of the
the ureter can occur, causing ischaemic necrosis ureter which can reach the skin level leads to
and stenosis. tortuosities and subsequent urinary stagnation
77 Twisting of the ureter while anchoring in end with persistence of urinary infection.
and loop ureterostomies leads to obstruction. 77 Dilated and tortuous ureters may be mistaken
for loops of bowel during dissection.
G11 Conduit Diversion 465
G 1Conduit Diversion G11
M. Yassin and A. H. B. Fyfe
Ileal Conduit
Fig. 1
• The stoma site is marked preoperatively.
• The patient is positioned supine. • Once clean, the proximal end of the ileal seg-
• A lower midline incision is usually used or the ment is over-sewn with interrupted 4/0 or 5/0
same incision as used for the primary proce- absorbable serosubmucosal sutures.
dure if the conduit is done concurrently. • Ileal continuity is restored with an ileo–ileal se-
• A Denis Browne, or other self-retaining retrac- rosubmucosal anastomosis, constructed using
tor, provides good exposure of the pelvis. interrupted 4/0 or 5/0 absorbable sutures.
• The parietal peritoneum is opened with dissect- • The ileal conduit is passed through the ileal
ing scissors between curved mosquito forceps. mesentery, and any residual mesenteric defect
• An appropriate 6- to 10-cm segment of ileum closed with interrupted absorbable sutures
together with its mesentery is carefully selected (Fig. 2).
for isolation and Doyen bowel clamps applied
as shown (Fig. 1).
• The distal end of the ileal segment is transected
between the clamps, approximately 15–20 cm
from the ileocaecal valve. The proximal end is
transected in the same way.
• The wound is protected with Betadine-soaked
swabs, whilst the mucosa of the ileal segment
is irrigated with normal saline to remove any
faecal debris.
Alistair H. B. Fyfe
Consultant Paediatric Urologist Fig. 2
Fyfe7es@btinternet.com
• The ureters are isolated and transected as close • The stoma is pexed (urethropexy) to the ante-
to the bladder as possible. rior rectus fascia, using interrupted serosubmu-
• Sharp-scissor dissection is used to create a sub- cosal absorbable 4/0 sutures.
mucosal tunnel in the ileal conduit. • The end stoma is matured to create a nipple,
• The ureters are spatulated and implanted with interrupted 4/0 or 5/0 sutures (Fig. 4) as
through the submucosal tunnel. described in Chap. E13.
• End-to-side uretero-ileal anastomoses are con- • The ureteric stents should be left protruding
structed over 4- or 6-Fr ureteric stents using in- from the stoma.
terrupted absorbable 6/0 sutures (Fig. 3). • The midline incision is closed as described in
Chap. A9.
Fig. 4
Colonic Conduit
Tips
77 The ideal segment of ileum for a conduit should 77 Use stay sutures to manipulate the bowel and tip
contain a rich blood supply, ideally with two ma- of the ureter during suturing.
jor vascular arcades. 77 Minimise handling of the ureter with forceps, as
77 The length of a Kocher clamp approximates the this may compromise the blood supply.
required length of ileum for a conduit in an ado-
lescent, and it can be used as a measure.
Common Pitfalls
77 Always inspect the conduit. If it appears dusky, 77 Leave a generous cuff of tissue around the distal
apply warm packs. If the adequacy of the circula- ureters to avoid compromising their blood sup-
tion remains in doubt, it is best to excise the con- ply during mobilization.
duit and start again with a new segment. 77 The inferior epigastric vessels may be damaged
77 Avoid compromising the ileal blood supply during the blind passage of forceps through the
when closing the mesenteric defect in the ileal rectus abdominis during stoma formation.
mesentery.
468 L. C. Steven and S. J. O’Toole
G12 G 12Ileocystoplasty
L. C. Steven and S. J. O’Toole
Tips
77 Once the bladder is open a Denis Browne ring or 77 The apex of the bowel segment should easily
Book–Walter retractor are useful in providing ac- reach the level of the bladder neck without ten-
cess and freeing your assistant’s hands. sion. Try it out before dividing the mesentery.
77 Be sure to mobilise the bladder anteriorly so that 77 To help opening the ileal segment it is useful to
the stay stitch is 2 cm above the bladder neck use a large catheter or similar within the lumen
and limits any further low dissection. as a guide to where to make your incision.
Common Pitfalls
77 Failure to mobilise the bladder adequately will 77 Failure to mobilise the ileal segment high in its
hinder the later steps of the procedure. Sweep- mesentery will mean the segment is under ten-
ing the peritoneum superiorly off the bladder sion when anastomosed to the bladder.
will aid with this dissection. 77 Following augmentation clean intermittent cath-
77 The sagittal incision in the bladder must extend eterisation, either urethral or via a Mitrofanoff, is
anteriorly to just above the bladder neck. If not, mandatory.
the augment will be hourglass-shaped and sub-
optimal.
G13 Continent Catheterisable Conduit 471
G13 Continent Catheterisable Conduit G13
E. Broadis and S. J. O’Toole
• This procedure is used to provide a catheteris- • Intravenous cefotaxime and metronidazole are
able conduit between the skin surface and blad- given on induction of anaesthesia.
der. • A lower-midline or Pfannenstiel incision can
• It is used in patients who require regular inter- be used (Fig. 1).
mittent catheterisation but cannot tolerate or • Appendix is assessed with regard to:
are unable to perform this by way of the ure- – Length
thra. – Size
– Suitability as a conduit
• Appendix is mobilised with its mesentery
Mitrofanoff Principle (Fig. 2)
• The tip of the appendix is excised and a naso-
The Mitrofanoff principle (also known as an ap- gastric tube passed to confirm its patency and
pendicovesicostomy) is the creation of a passage- diameter of the lumen (Fig. 3).
way for fluid which has a valve mechanism to al-
low continence.
l
lower midline
pfannstiel
Fig. 1 Fig. 2
the tip of the appendix lumen to the bladder Alternatives to Using the Appendix
mucosa.
• The proximal end of the appendix is brought If the appendix is too short or absent, there are
through the abdominal wall as a stoma (Fig. 5–7 alternative conduits that may be used:
and see Chap. G14). • Ileovesicostomy (Monti procedure)
• An indwelling catheter is left in situ for around • Detrusor tube vesicostomy
4 weeks before catheterisation is attempted.
Fig. 5
Fig. 3 Fig. 4
Tips
77 Where should the appendix enter the bladder? 77 Umbilical versus right iliac fossa skin site
– Towards the bladder base allows good drain- – Umbilical site may confer a cosmetic advan-
age but is harder to get to, and catheteriza- tage but tends to have a higher incidence of
tion can be painful as the catheter impinges leakage.
on the trigone. 77 Ways to prevent leakage
– The dome of the bladder is easier to reach sur-
– Mucosal tunnel into the bladder
gically, decreases the length of conduit within – Appendix tunnelled obliquely through the
the abdomen and may be easier to catheter- abdominal wall muscle
ise.
Common Pitfalls
77 Try to avoid over dissection and handling of the 77 Use the straightest and most direct route to
mesoappendix and small bowel mesentery, as bring the proximal end of the appendix out to
this may lead to damage to the vasculature and enable easy catheterization.
ischaemia of the appendix.
77 Take care not to kink the mesentery of the ap-
pendix as it is brought through the abdominal
wall.
G14 V-Quadrilateral-Z ( VQZ)-plasty for Stoma 473
G14 V-Quadrilateral-Z (VQZ)-plasty for Stoma G14
E. Broadis and S. J. O’Toole
Fig. 2
Operative Technique
• The appendix is delivered through the abdomi-
• A V-shaped incision is made, with the base in nal wall and sutured to the fascia. The remain-
the area where the appendix will exit. This will ing fascia is then closed (Fig. 3).
be sutured to the spatulated conduit (Fig. 1).
Fig. 3
Stuart J. O’Toole
Consultant Paediatric Urologist
Stuart.O’Toole@ggc.scot.nhs.uk
Fig. 4
Fig. 5
Fig. 7
Fig. 6
Tips
77 Take care not to twist the appendix as it is 77 Do not repair the fascia too tightly around the
brought through the abdominal wall. appendix and its mesentery, as it will compress
the blood supply.
G15 Endoscopic Treatment of Vesicoureteric Reflux 475
G 15Endoscopic Treatment G15
of Vesicoureteric Reflux
A. Sinha and S. Agarwala
Numerous implantable materials have been uti- – Leave the needle in situ for 1 min. With-
lized for the endoscopic treatment of vesicoure- draw the needle and repeat the procedure
teric reflux (VUR) including Teflon, silicone and for the other side (if required).
bovine collagen. Since its introduction in 1995, De- – HIT and Double HIT (Hydrodistension Im-
flux, a copolymer of dextranomer microspheres plantation Technique)
and non-animal, stabilised hyaluronic acid, has – The ureteric orifice is distended by di-
become the most widely used implant material. recting a pressurized jet of irrigation
fluid from the end of the cystoscope at
the opening.
echnique for Cystoscopic Injection of
T – Introduce the needle through the ureteric
Deflux orifice into the midportion of the ureteric
tunnel, and pass the needle tip into the
• Place the child in the lithotomy position. submucosal plane at the 6 o’clock posi-
• Pass an adequately sized (9.5–14 Fr) operating tion (Fig. 3).
urethrocystoscope with a side channel into the – Stop the irrigation of fluid.
bladder. – Inject a small amount of Deflux to con-
• Irrigate the bladder to allow clear visualization firm correct placement in the submuco-
of the trigone and ureteric orifices, but avoid sal plane.
overdistension. – Inject more Deflux until an adequate sub-
• Attach the standard, prefilled glass syringe to the mucosal bulge is created to oppose the
injection needle (e.g. 3.7 Fr × 23 G [tip] × 350 mm). walls of the ureteric tunnel.
• Methods of injecting Deflux (Fig. 1): – Increasingly, two intra-ureteric submuco-
– Subureteric injection (standard STING sal injections are being used (double HIT)
technique) with a second injection in the most distal
– Insert the needle through the bladder mu- portion of the ureteric tunnel. This ap-
cosa into the submucosal plane with the proach has the effect of closing the ure-
bevel up, 2–3mm below the ureteric ori- teric tunnel and orifice; it has achieved
fice in the 6 o’clock position (Fig. 2). high success rates.
– Inject Deflux under vision until you – Superior tunnel
achieve a volcano-like mound, sufficient – In difficult cases a submucosal injection
to create a crescentic ureteric orifice (usu- can be given over the superior aspect
ally 0.3–0.8 ml of Deflux per ureter). of the ureteric orifice. This technique is
rarely employed however (Fig. 4).
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
Fig. 1 Fig. 2
Fig. 3 Fig. 4
G15 Endoscopic Treatment of Vesicoureteric Reflux 477
Tips
77 Always use the needle with the bevel up for ac- 77 Following injection of Deflux, using the hydro-
curate injection of Deflux. distension technique, the loss of subsequent hy-
77 If the needle crosses the bladder wall the Deflux drodistension confirms adequate narrowing of
injection will not be met with any resistance and the ureteric orifice.
no mound will be created. 77 If two intra-ureteric injections fail to adequately
77 The needle should be kept in situ for 1 min fol- narrow the ureteric orifice, a classical subureteric
lowing injection so that the Deflux is incorpo- injection can be performed.
rated into the submucosal space and does not
extrude on withdrawal of the needle.
Common Pitfalls
77 Overdistension of the bladder displaces the ure- 77 Injecting too little material is possible, as is inject-
teric orifices laterally and causes tension in the ing the wrong area.
submucosal layer of the ureter, making implan- 77 Multiple passes of the needle through the mu-
tation of Deflux more difficult and increasing the cosa should be avoided, as this allows the im-
likelihood of extravesical placement. plant to extrude after injection.
77 The needle can be inserted too deeply, leading
to extravesical injection.
478 D. Datta and S. Agarwala
– Repair the mucosa over the ureter at the site • Close the bladder in two layers using Vicryl.
of the new hiatus. • Place the prevesical drain and close the wound
• Bring the ureteric stents out through bladder with the SPC in the middle of it and the two
wall and anchor them with catgut. ureteric stents at both the corners.
• Position a Mallecot catheter as a suprapubic • Anchor the SPC and the ureteric catheters with
catheter (SPC) at the dome of the bladder and silk sutures.
anchor this as well with catgut.
Fig. 1
Fig. 2
480 D. Datta and S. Agarwala
Fig. 3 Fig. 4
Fig. 5 Fig. 6
G16 Ureteric Reimplantation 481
Tips
77 Tease off the peritoneum superiorly from the 77 In case of inflamed, oedematous mucosa, if the
bladder surface before opening of bladder to mucosal tunnel is torn, mucosa can be sutured
avoid inadvertent opening. over ureter to create tunnel.
77 Start dissection of ureter medially as it traverses 77 In the Politano–Leadbetter procedure, the site
lateral to medial through intramural portion of of the new hiatus should be in fixed portion of
bladder. bladder base. Sometimes the submucosal tunnel
77 Avoid injury of the peritoneum and the vas dur- may be extended distally towards bladder neck
ing mobilisation of ureter. if necessary to get sufficient length.
77 Injection of saline in the submucosal plane may 77 In females the SPC can be avoided and replaced
facilitate creation of submucosal tunnel in diffi- with a urethral catheter.
cult cases.
Common Pitfalls
77 Placing too long a ureteric stent may lead to its 77 Making the hiatus too narrow may constrict the
kinking and failure to drain. ureter.
77 Mobilisation of the ureters in incorrect plane 77 Making the new meatus too near the bladder
may cause excessive difficulty, injury to the ure- neck is avoided.
teric blood supply and delayed ischaemia.
77 Making the submucosal tunnel in the wrong
plane, that is actually outside the bladder.
482 E. Broadis and S. J. O’Toole
G17 G 17Posterior Urethral Valves
E. Broadis and S. J. O’Toole
Fig. 2
Fig. 4
Fig. 3
Tips
77 The diagnosis of posterior urethral valves can be 77 A baby with posterior urethral valves can be
difficult. The final diagnosis is often made at cys- managed with a urethral catheter until an expe-
toscopy by an experienced paediatric urologist. rienced paediatric urologist is available.
77 This is a technically difficult procedure where it
is easy to damage other urethral structures and
create lifelong morbidity.
PAR T H
Perineum
H1 Perineal Injuries 487
H 1Perineal Injuries H1
C. A. Hajivassiliou
Perineal injuries can be blunt or penetrating, and All perineal wounds should be formally explored
can be classified further according to their exact under aseptic conditions for full toilet, with or
anatomical location (Fig. 1). without primary repair as appropriate.
Any child presenting with a perineal injury
should be triaged and assessed according to ad-
vanced paediatric life support (APLS) principles,
and assessed for any other concomitant trauma/
pathology.
Injury to Perineum
Blunt Penetrating
• Detailed history (time, mode, nature of injury) • Bruising in the perineal body area in males
• Full examination (usually after straddle injury) may signify par-
• IV access tial or complete urethral rupture. The decision
• Routine blood tests including blood cross- to catheterise should only be made by senior
match medical staff.
• Trauma x-ray series • Blood through the urethral meatus suggests ure-
• Abdominal/erect chest x-rays and further im- thral rupture until proven otherwise. Do not at-
aging (ultrasound scan [USS], computer to- tempt catheterisation, and if the patient is in
mography [CT]) as indicated urinary retention, insert an emergency supra-
• Position patient for abdominoperineal ap- pubic catheter (see Chap. G2).
proach (Fig. 2) • Early urethroscopy should be considered by se-
nior medical staff.
Fig. 2 Patient draped in the lithotomy position to allow access to perineum and abdomen
Pitfalls
Anal Fissure
Anal Dilatation
Fig. 3 Fig. 5
Fig. 6
Fig. 4
492 T. J. Bradnock and C. A. Hajivassiliou
Skin Tags
Tips
77 Avoid using monopolar diathermy to remove 77 Remember that the majority of anal fissures can
skin tags from the external anal sphincter, as this be managed medically. Reserve surgery for re-
practice may result in significant burns to richly fractory and troublesome fissures in which con-
sensate skin or underlying muscle. servative measures have proved ineffective.
Common Pitfalls
77 Most anal fissures occur posteriorly in the mid- 77 Always perform a biopsy if any concern.
line. Atypical, complex, multiple, indolent or
painless fissuring raises the possibility of other
conditions (Crohn’s disease, non-accidental in-
jury).
H3 Perianal Abscess and Fistula-in-Ano 493
H3 Perianal Abscess and Fistula-in-Ano H3
T. J. Bradnock and R. Carachi
• Place the patient in the lithotomy position. • If pus is liberated, send a bacteriology swab for
• Prepare the skin with aqueous Betadine. culture and sensitivity.
• Examine the perianal region for induration, • Use your index finger to manually break down
skin tags or fissures (Figs. 1 and 5). any loculations within the cavity.
Fig. 1 Fig. 2
• Perform a digital rectal examination. • Irrigate the cavity with normal saline using a
• Perform proctoscopy to exclude an internal fis- 20-ml syringe.
tulous opening (see Chap. E3). • Perform curettage of the cavity with a Volk-
• Palpate the swelling and use a scalpel to make mann spoon to remove all remaining granula-
a cruciate incision over the point of maximal tion tissue (Fig. 3).
fluctuance (Fig. 2). • Irrigate the cavity again with normal saline.
• Pack the cavity with AQUACEL or Kaltostat,
leaving a tail to facilitate change of packing
(Fig. 4).
Tim J. Bradnock () • Apply GeLonet and blue-gauze dressing.
Specialty Registrar in Paediatric Surgery • Plan for change of packing at 24 h prior to dis-
The Department of Paediatric Surgery, Dalnair Street, charge, with subsequent dressing changes per-
Yorkhill Hopsital, Glasgow G3 8SJ, Scotland, UK formed at home by the district nurse.
Email: tjbradnock@doctors.org.uk
Robert Carachi
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk
Fig. 3
Fig. 5
Fig. 4
Fistula-in-Ano
Fig. 7 Fig. 8
Tips
77 Ensure the cruciate incision is at least as wide as 77 Do not probe uncomplicated, first-time perianal
the abscess cavity to guarantee drainage contin- abscesses looking for a fistula tract, as this may
ues after surgery. lead to iatrogenic fistula formation.
77 Unlike in adults, Goodsall’s rule does not usually
apply; typically fistulous tracts are low and run
radially, straight from their mucosal origin in the
anal canal to the abscess.
Common Pitfalls
77 Complex perianal sepsis and recurrent abscesses 77 Forceful passage of a silver probe through the
raise the possibility of Crohn’s disease. A rectal bi- abscess cavity may lead to false-passage forma-
opsy should be performed and the abscess roof tion and failure to adequately lay open the fis-
sent to pathology. tula.
77 Always perform proctoscopy to exclude a fistu- 77 Although rare, avoid laying open a high fistula
lous opening in recurrent abscesses. tract, as this may result in faecal incontinence.
496 M. Ragavan and V. Bhatnagar
H4 H4 Anterior Ectopic Anus
M. Ragavan and V. Bhatnagar
Fig. 1
Fig. 2
Fig. 3
Fig. 4 Fig. 5
498 M. Ragavan and V. Bhatnagar
Tips
77 A muscle stimulator is useful to aid identification 77 Adequately mobilise the rectum and repair the
of the muscle complex. perineal body to prevent dehiscence and ante-
77 Infiltration of saline with adrenaline in the plane rior retraction of rectum.
between rectum and vagina facilitates dissection 77 The procedure can also de done in a prone jack-
between them. knife position as a minimal posterior–sagittal an-
orectoplasty.
Common Pitfalls
77 Inadequate mobilisation results in tension, that 77 Inadequate haemostasis may result in a post-
may lead to retraction of the neo-anus. operative haematoma and breakdown of the
77 Dissection in an incorrect plane will lead to dam- wound.
age of either the rectal or vaginal wall.
H5 Excision of Rectal Polyp 499
H5 Excision of Rectal Polyp H5
P. Hammond and P. A. M. Raine
Operative Technique
Peter A. M. Raine
Consultant Paediatric and Neonatal Surgeon
Rainewest@btinternet.com
Tips
Common Pitfalls
Fig. 1
Fig. 2
Suhasini Gazula ()
Senior Specialist pediatric surgeon
Department of pediatric surgery, Employees’ State
Insurance Corporation (esic) Superspeciality Hospital,
Sanath Nagar, Hyderabad, Andhra Pradesh, India
suhasinigazula@gmail.com
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
Fig. 4
Fig. 3
Fig. 5 Fig. 6
H6 Sacrococcygeal Teratoma 503
Fig. 8
Fig. 7
• Dissect the tumour free inferiorly and remove
it in toto (Fig. 6).
• A 6- or 8-Fr suction drain is placed in the peri-
rectal space, and the levator muscles are ap-
proximated to the presacral fascia using Vic-
ryl interrupted sutures (Fig. 7).
• The gluteus maximus muscles are also approx-
imated in the midline with interrupted sutures Fig. 9
(Fig. 8), followed by closure of subcutaneous
tissue.
• Excess skin may have to be trimmed before clo-
sure using continuous Monocryl subcuticular
sutures (Fig. 9).
Tips
77 A rectal saline enema is given on the morning 77 While trimming the excess skin prior to clo-
of surgery to avoid contamination of the opera- sure, it is better to remove more from the upper
tive field. flap, since this will make the subsequent closure
77 A rectal examination prior to beginning the pro- higher and away from the anus.
cedure can easily identify any deviation of the 77 Additional steps for tumours with extensive in-
rectum from the midline and help in dissection. tra-abdominal component: In these tumours,
77 Placement of few interrupted sutures to appose first a laparotomy by Pfannenstiel incision is
the superior portion of the levator muscles with done to free the tumour from the pelvic viscera
the presacral fascia aids in achieving a near nor- and to gain control over the median sacral ves-
mal configuration of the anal opening. sels and collateral blood supply. The abdomen is
then closed, the patient turned over and the rest
of the procedure completed as described above.
Common Pitfalls
77 Avoid manipulating the tumour before ligating 77 Failure to excise the coccyx or incomplete coccy-
the median sacral vessels to prevent torrential gectomy increases the risk of tumour recurrence
haemorrhage. by 30–35 % percent.
504 A. Bischoff, M. A. Levitt and A. Peña
H7 H7 Posterior Sagittal Anorectoplasty
in Females with Perineal or Vestibular
Fistulae
A. Bischoff, M. A. Levitt and A. Peña
• The patient should be placed in the prone po- • A posterior sagittal incision is made through
sition, with the pelvis elevated. the skin and subcutaneous tissue.
• Multiple 5-0 silk sutures are placed around the • The parasagittal fibres and ischiorectal fat are
fistula (mucocutaneous junction) to exert uni- divided in the midline.
form traction (Fig. 1). • The muscle complex and levator mechanism
are identified and divided exactly in the mid-
line (Fig. 2).
Fig. 1
Fig. 2
pletely dissected until the two structures are ter mechanism that has been previously deter-
separated from each other. A typical areolar mined with the use of an electrical stimulator
plane is entered once the walls are completely (Fig. 3).
separated. • The rectum is tacked to the posterior edge of
• At this point, if there is need to gain additional the muscle complex all the way to the level of
rectal length, the dissection can be carried on the levator proximally and skin distally (Fig. 4).
as close as possible to the rectal wall, dividing • Reconstruction of the posterior sagittal inci-
and cauterizing attachments and vessels until sion consists of the sequential reapproximation
the rectum reaches the perineum without ten- of ischiorectal fat, parasagittal fibres, subcuta-
sion to allow a comfortable anoplasty to be per- neous tissue and skin (Fig. 5).
formed. • The anoplasty is performed with 16 interrupted
• The perineal body is reconstructed, bring- 6-0 Vicryl sutures (Fig. 6).
ing together the anterior limit of the sphinc-
Fig. 3 Fig. 4
506 A. Bischoff, M. A. Levitt and A. Peña
Fig. 5
Fig. 6
Tips
77 Repair of the perineal fistula only requires a short 77 Always inspect the vagina under anaesthesia, as
posterior sagittal incision (the size of the sphinc- 6% of patients with vestibular fistulas have a vag-
ter). Repair of a vestibular fistula requires a lon- inal septum with two hemivaginas and hemi-
ger incision which may extend to the coccyx. uteri.
77 In perineal fistulas the rectum is intimately re-
lated to the vagina. In vestibular fistulas the rec-
tum shares a common wall with the vagina;
therefore it requires a more careful dissection.
Common Pitfalls
77 Injury to the vaginal and (or) rectal walls is pos- 77 Avoid tension on the anoplasty as this predis-
sible. poses to dehiscence, retraction, and recurrent
77 Failure to separate the rectum and vagina fully fistula.
creates tension on the anoplasty. 77 Faecal contamination and infection may occur
77 Leaving rectal sutures in front of vaginal sutures due to inadequate bowel preparation in patients
predisposes the patient to fistula formation. without colostomy or inadequate cleansing of
the distal bowel during colostomy creation.
H7 Posterior Sagittal Anorectoplasty in Females with Perineal or Vestibular Fistulae 507
A L B E RTO PENA
(1938 – )
Mexican/American paediatric surgeon
Alberto Pena trained in Paediatric surgery first in Mexico City and then in Boston. He then
practiced at the National Institute of Paediatrics in Mexico City and at the Schneider Chil-
dren’s Hospital in New York. He is now the founding Director of the Colorectal Center at
Cincinnati Children’s Hospital. One of the few areas of paediatric surgery where detailed
knowledge was still lacking was anorectal malformations. In 1982, Dr. Pena described how
the posterior sagittal approach, with the help of an electrical stimulator, could be used for the
surgical management of anorectal malformations, named PSARP, an approach and proce-
dure that has placed him with the great names of paediatric surgery.
508 A. Bischoff, M. A. Levitt and A. Peña
H8 H8 Posterior Sagittal Anorectoplasty
(PSARP) for Males with Recto-urethral
Bulbar Fistula and Prostatic Fistula
A. Bischoff, M. A. Levitt and A. Peña
Marc A. Levitt
Director, Colorectal Center,
Professor of Surgery, Cincinnati Children’s Hospital, 3333
Burnet Avenue, ML 2023, University of Cincinnati, USA
+513 636 3240
Marc.Levitt@cchmc.org
Alberto Peña
Founding Director Colorectal Center for Children,
Cincinnati Children’s Hospital Medical Center Pediat-
ric Surgery, 3333 Burnet Avenue, ML 2023 Cincinnati,
Ohio 45229
Tele 513-636-3240 Fax: 513-636-3248 Fig. 2
Alberto.Pena@cchmc.org
Fig. 4
Fig. 5
Fig. 7
Fig. 6
Fig. 8
• The levator muscle must be sutured in the mid-
line, behind the rectum.
• The posterior edges of the muscle complex are
sutured together in the midline including, with
each stitch, a bite of the posterior rectal wall,
to anchor the rectum and avoid tension on the
anoplasty and to help avoid prolapse. The is-
chiorectal space is closed with absorbable su-
tures.
• The parasagittal fibres are reapproximated.
• The posterior sagittal incision is closed up to
the skin.
• An anoplasty is performed with 16 long-term,
interrupted absorbable sutures (Fig. 10).
H8 PSARP for Males with Recto-urethral Bulbar Fistula and Prostatic Fistula 511
Fig. 9 Fig. 10
Tips
77 Prior to attempting a posterior sagittal approach, 77 Rectal dissection must be performed, remaining
ensure that a high-pressure distal colostogram as close as possible to the rectal wall.
has been performed to define the anatomy. 77 In cases of prostatic fistulas, the rectum is located
77 The lower the fistula location is, the longer the immediately below the coccyx, the common
common wall between rectum and urethra. wall is short, and the circumferential dissection
to gain length is technically demanding.
Common Pitfalls
• A total body preparation from nipples down is der is mobilized inferiorly, dividing its lateral
done, allowing for a simultaneous sterile field attachments.
in the abdomen and perineum (Fig. 1). • The bowel distal to the mucous fistula is fol-
lowed until it disappears below the peritoneal
reflection.
• The peritoneal reflection between colon and
bladder is identified. The peritoneum is divided
to reach the bowel wall. The bowel is then dis-
sected circumferentially. A silastic vessel loop
is passed around the rectum for traction.
• Applying traction on the vessel loop in a cranial
direction, the rectum is dissected distally, al-
ways remaining in contact with the bowel wall
to ensure that important pelvic structures in-
Fig. 1 cluding vas deferens, ureters and nerves vital
for bladder function are preserved.
• A laparoscopy or a lower-midline laparotomy • At the point where one can identify that there is
from umbilicus down to the pubis is performed. a substantial decrease in the calibre of the rec-
• If a laparotomy is used, a clamp is placed on tum (close to the bladder neck) four 5-0 Vicryl
the top of the bladder or urachus, and the blad- sutures are placed in the rectal wall, and the fis-
tula is transected and ligated.
• Multiple 5-0 silk stitches are placed in the distal
rectum to allow for uniform traction (Fig. 2).
Andrea Bischoff () • The blood supply of the distal bowel is studied,
Colorectal Center for Children, and distal vessels of the distal segment of the
Cincinnati Children’s Hospital, 3333 Burnet Avenue, rectum are taken in order to gain length, until
ML 2023, University of Cincinnati, USA adequate for the rectum to reach the perineum
+513 636 3240
without tension.
Andrea.Bischoff@cchmc.org
• A space is created between the sacrum and uri-
Marc A. Levitt nary tract, dissecting the abdomen as low as
Director, Colorectal Center, possible.
Professor of Surgery, Cincinnati Children’s Hospital, 3333 • Attention is then turned to the perineum. The
Burnet Avenue, ML 2023, University of Cincinnati, USA
patient may remain supine with the legs lifted
+513 636 3240
Marc.Levitt@cchmc.org (Fig. 3). A posterior sagittal incision is made
from the base of the scrotum towards the coc-
Alberto Peña cyx, dividing the sphincters, taking care to stay
Founding Director Colorectal Center for Children, exactly midline.
Cincinnati Children’s Hospital Medical Center Pediat-
• The abdominal cavity is entered from below,
ric Surgery, 3333 Burnet Avenue, ML 2023 Cincinnati,
Ohio 45229
identifying the space previously created be-
Tele 513-636-3240 Fax: 513-636-3248 tween sacrum and the urinary tract.
Alberto.Pena@cchmc.org • The bowel is pulled through (Fig. 4).
Fig. 2
Fig. 3
Fig. 4
514 A. Bischoff, M. A. Levitt and A. Peña
Fig. 5
Tips
77 A point 4 cm below the pubic bone can be used geon to ensure the adequacy of dissection while
to predict whether the rectum will reach the working in the abdomen.
perineum without tension. This allows the sur-
Common Pitfalls
Fig. 2
Fig. 3 Fig. 4
H10 PSARP with Total Urogenital Mobilization for Cloacae with a Common Channel Smaller than 3 cm 517
Fig. 7
518 A. Bischoff, M. A. Levitt and A. Peña
Tips
77 The length of the common channel should be 77 During the dissection between vagina and rec-
measured with a cystoscope prior to the oper- tum, continually check the thickness of both
ation, since cloacae with a common channel vaginal wall and rectal wall using a thick lacrimal
larger than 3 cm require a more complex recon- duct probe.
struction.
Common Pitfalls
77 Injury to the vaginal wall during its separation 77 Failure to delineate the correct anatomy and the
from the rectum length of the common channel prior to repair
H11 Colostomy Creation in Anorectal Malformation 519
H 1Colostomy Creation H11
in Anorectal Malformation
A. Bischoff, M. A. Levitt and A. Peña
Marc A. Levitt
Director, Colorectal Center,
Professor of Surgery, Cincinnati Children’s Hospital, 3333
Burnet Avenue, ML 2023, University of Cincinnati, USA
+513 636 3240
Marc.Levitt@cchmc.org
Alberto Peña
Founding Director Colorectal Center for Children,
Cincinnati Children’s Hospital Medical Center Pediat-
ric Surgery, 3333 Burnet Avenue, ML 2023 Cincinnati,
Ohio 45229
Tele 513-636-3240 Fax: 513-636-3248
Alberto.Pena@cchmc.org Fig. 2 Irrigation of the distal colon
Tips
77 The location of the proximal stoma should be in remain in place until the final repair. If there are
the middle of a triangle formed by the last rib, two hemivaginas, a window should be created in
the umbilicus and the iliac crest in order to leave the vaginal septum allowing one tube to drain
enough space to adapt a stoma bag. both hemivaginas. If the hydrocolpos reaches
77 In patients with cloaca and hydrocolpos, during above the umbilicus, it can be sutured to the skin
colostomy creation the hydrocolpos should be as a tubeless vaginostomy.
drained with a pigtail catheter which should
Common Pitfalls
• The proximal stoma is packed with Betadine- • The edges of the bowel are trimmed off.
soaked packing gauze. • A two-layer anastomosis with fine, interrupted
• Multiple 5-0 silk sutures are placed at the mu- stitches is performed (Figs. 3 and 4).
cocutaneous junction around both limbs of the • The mesenteric defect is then closed with ab-
stoma to allow for uniform traction (Fig. 1). sorbable suture.
• An elliptical wedge-type incision is made • The abdominal cavity is irrigated with copious
around the two stomas and carried down amount of saline solution, as well as each layer
through skin, subcutaneous tissue, aponeuro- during abdominal wall closure.
sis, muscle and peritoneum (Fig. 1). • The abdominal wall is closed in layers with in-
• Both stomas are completely dissected from the terrupted sutures (Fig. 4).
abdominal wall. • The skin is closed with a subcuticular running
• The packing gauze is removed. suture.
• Baby ALLEN clamps are applied and the sto- • Collodium is placed on the wound.
mas are resected (Fig. 2).
Marc A. Levitt
Director, Colorectal Center,
Professor of Surgery, Cincinnati Children’s Hospital, 3333
Burnet Avenue, ML 2023, University of Cincinnati, USA
+513 636 3240
Marc.Levitt@cchmc.org
Alberto Peña
Founding Director Colorectal Center for Children,
Cincinnati Children’s Hospital Medical Center Pediat-
ric Surgery, 3333 Burnet Avenue, ML 2023 Cincinnati,
Ohio 45229
Tele 513-636-3240 Fax: 513-636-3248
Alberto.Pena@cchmc.org
Tips
77 Apply uniform traction on the silk sutures to fa- 77 Irrigate all layers during abdominal wall closure.
cilitate the separation of the stomas from the ab- 77 Avoid faecal contamination, excessive burning of
dominal wall. tissues, dead spaces, and hematomas.
Common Pitfalls
Fig. 3
I1 Ergonomics, Heuristics and Cognitive Skills in Laparoscopic Surgery 529
Note that most high-flow insufflators have a de- aesthetic complications may account for approx-
fault setting of 1 l/min. This default setting is ex- imately a third of the few deaths associated with
cessive in infants. It is important that you choose laparoscopic tubal ligation. It is important for the
an insufflator with a low default setting of 100 ml/ anaesthetist to continuously monitor the patient
min. If you are meticulous in laparoscopy and mi- in order to quickly recognise and treat problems
nimise gas leak from your trocars and instruments, as they arise. Careful positioning of the patient
you should not need high-flow insufflation, that and padding is required to avoid potential ortho-
carries the attendant risk of hypothermia due to paedic injuries or nerve palsies.
a high flow of cold CO2. Potential anaesthetic complications reported in
laparoscopic surgery include hypothermia, hypo-
Reduction in Tidal Volume tension, oesophageal intubation, gastro-oesopha-
geal reflux, bronchospasm and narcotic overdose.
Mask anaesthesia is completely inappropriate for There are several significant anaesthetic con-
paediatric applications. Several deaths have been cerns pertaining to laparoscopy, that are discussed
attributed to using mask anaesthesia. Endotra- further.
cheal anaesthesia with paralysis and positive-pres-
sure ventilation should be used in paediatric lapa- Hypothermia
roscopy. For short procedures, the laryngeal mask
can be used. Because of their relatively small body mass, pae-
Avoid nitrous oxide anaesthesia in infants, as diatric patients are particularly at risk of hypo-
this leads to gaseous distention of the bowel and thermia from high-flow CO2 insufflation. High-
can compromise an already small abdominal cav- flow insufflation dissipates body heat rapidly, as
ity, making laparoscopy impossible. Advise your the temperature of CO2 leaving the insufflator is
anaesthetist to avoid prolonged bagging, as this 20°C or less. Keep gas flow rates low by minimis-
will very quickly lead to gaseous distention of the ing gas leaks from your instrument ports and port
bowel and may compromise your internal work- sites. The commonest cause of excessive gas leaks
ing space. It is advisable to insert an orogastric are worn washers or opened taps. Regular main-
tube and leave the drainage open at induction to tenance checks on all equipment, especially taps
avoid gaseous distention. and washers, will minimise gas leaks.
Increasing intra-abdominal pressure beyond 10 Wrap the extremities of infants with cotton
mm in an infant will increase splinting of the di- wool to minimise heat loss, use a warmer, avoid
aphragm and restrict ventilation. To avoid com- high flow and keep the patient dry.
plications the insufflator should be checked be-
fore each operation; the intra-abdominal pressure
should be set at 10 mmHg in an infant under 10 Positioning the Patient
kg, and 12 mmHg in larger children. With the ex-
ception of patients weighing less than 1 kg, it is The position of the patient can impair ventilation
not necessary to set a lower abdominal pressure and increase the risk of aspiration. For example,
limit, as there will usually be enough resilience positioning the patient in a steep Trendelenburg
in the abdominal wall to safely introduce trocars. position increases the risk of aspiration, and it
may be necessary to insert a naso gastric tube to
prevent this.
Anaesthetic Complications If you need to use image intensifier (II) intra-
operatively, check that the ‘C’ arm of your II can be
Anaesthetic-related complications have been a positioned under the area you wish to image, and
major cause of mortality in gynaecological lap- that the warmer does not interfere with your imag-
aroscopic surgery. A study from the Centers for ing. It may be necessary to run a spot check with
Disease Control and Prevention suggests that an- the II before accepting the final patient position.
532 H. L. Tan
Injury to the inferior epigastric vessels is the most suggested in this section, then the risk of bleeding
common injury reported with trocar punctures in from the puncture site should be low.
the lower abdomen. The absence of a posterior
rectus sheath in the lower abdomen does not al- Major Vessel Injury
low any tamponade to occur, and bleeding will
continue unless physically controlled. The infe- In the unfortunate circumstance of a major pen-
rior epigastric vessels are very easily identifiable etrating injury to the aorta, common iliac artery
as they run along the peritoneum. They are best or inferior vena cava, do not remove the trocar. Re-
identified just medial to the internal inguinal ring. moving the trocar will only result in catastrophic
When introducing trocars through the iliac fos- bleeding due to loss of tamponade, and you will
sae, always indent the overlying skin with a pair not be able to identify the puncture site. It is best
of mosquito forceps before inserting a trocar, to to leave the trocar in situ and proceed to imme-
avoid injury to this vessel. diate laparotomy. You should then be able to fol-
One should also make a habit of transillumi- low the trocar to the site of injury, hopefully con-
nating the abdomen before puncturing the cho- trol the bleeding and repair the damage. Do not
sen site to ensure that there are no large subcuta- forget to check the opposite side of the vessel, as it
neous vessels. Simple measures like this will min- is likely that the trocar will have gone through the
imise the risk of bleeding. far side of the damaged vessel.
Always be suspicious of major vessel injury if
Control of Abdominal Wall Bleeding the retroperitoneum is breached and inspect the
area from time to time for evidence of an expand-
Should abdominal wall bleeding occur, the follow ing haematoma. Surgical exploration is manda-
measures would control it. tory if one identifies an expanding haematoma.
Again, it must be stressed that most major vas-
Tamponade cular injuries are caused through blind Veress nee-
dle or trocar punctures, and are avoidable with the
Minor bleeding can be controlled by inserting a Hasson technique and by inserting all subsequent
larger cannula. Unless it is a major vessel bleed, trocars under direct vision.
this will stop the bleeding, allowing you to con-
tinue with the operation. If this fails, insert a large Visceral Bleeding
Foley catheter through the trocar site, inflate the
balloon, apply firm traction and clamp the cathe- This can be difficult to control, and like most com-
ter against the abdominal wall with an artery for- plications of laparoscopic surgery, is avoidable.
ceps, that will maintain the traction and tampon- Electrocoagulation will work with small bleeding
ade the bleeding. The catheter can be left in for vessels. Alternatively, one can use an endoclip to
several hours. control active bleeding.
However, one must always be aware of the sur-
Full-Thickness Abdominal Wall Suture rounding anatomy. Diathermy control of bleeding
may lead to unrecognised injury to the ureter or
Bleeding can also be controlled by passing a suture bowel, and the use of clips to control bleeding is
on a long straight needle through the full thickness a common way for common bile duct or hepatic
of the abdominal wall to one side of the bleeding artery injury to occur in cholecystectomy.
vessel, passing it out on the other side, and ligat- One can also place an ‘extracorporeal’ loop
ing the vessel. You can form a figure 8 using this around the vessel, but be careful that the vessel is
technique. not avulsed in the process by pulling too hard on
If these fail, it will be necessary to perform an the loop during tightening.
‘open’ operation to control bleeding. However, if
the necessary preventative measures are taken as
I2 Complications of Laparoscopic Surgery 535
increased in patients with previous open surgery, chus is prominent in infants, and its extension to
where bowel may be adherent to the under sur- the umbilical cicatrix could still be patent. Infra-
face of previous abdominal incisions. Many pae- umbilical cannula placement, even with the blad-
diatric exploratory laparotomy incisions are trans- der emptied, therefore could still lead to bladder
verse supra-umbilical incisions, so special care has injury. The best way of avoiding this is to watch
to be taken with the Hasson technique of intro- the tip of the trocar during insertion into supra-
ducing trocars. pubic sites.
It may sometimes be necessary to enlarge the Small bladder perforations from Veress needle
Hasson incision sufficiently to insert a finger and punctures may be managed conservatively with
sweep adhesions aside, or alternatively to make urinary catheter drainage, but large injuries should
a mini-incision well away from the site of previ- be over-sewn laparoscopically. A urinary cathe-
ous surgery. ter should be inserted for postoperative drainage.
Diathermy burns may be more extensive than
their superficial appearances. Minor burns or lac- Ureteral Injuries
erations may be managed conservatively. Small
perforations may be over-sewn, but larger ones These are often unrecognised and may present as
probably require open surgery, although with end- an acute abdomen or urinary ascites. If the injury
ostapling techniques it is technically feasible to is identified intraoperatively, it can be repaired.
resect and re-anastomose bowel entirely laparo- Small defects can be managed with stenting.
scopically. Unrecognised ureteral injury presenting in the
Wheeless reported on bowel injury in 33 pa- postoperative period require intravenous urogra-
tients. In the first 6 cases in which a burn was seen phy to confirm the diagnosis. These can be man-
endoscopically, a perforation was identified in aged with a double-pigtail catheter, but if this is
only 2 patients at open laparotomies. The next 27 difficult, a percutaneous nephrostomy should be
were all managed completely conservatively and performed to allow the situation to resolve. A
none required laparotomy subsequently. nephrostogram can then be performed at a later
Bowel injuries are often unrecognised at the stage to assess the full extent of ureteral injury,
time. The appearance of succus entericus or a fa- and an antegrade double-pigtail catheter can still
eculent odour should alert one to this possibility, be inserted to stent the ureter. Often, proximal
if it occurs during laparoscopy. drainage is all that is required.
Unrecognised bowel perforations present 3–7
days postoperatively with abdominal pain, py- Ventral Hernia
rexia and ileus. However, it can be difficult to elim-
inate the possibility of bowel injury in patients Ventral hernias have been reported, particularly
recovering from severe appendicitis after laparo- with the use of a large trocar and cannula. We ad-
scopic appendicectomy, but failure to respond to vise closing the fascia on all trocar sites except for
antibiotics or deterioration in clinical signs would 3-mm trocars in older children.
suggest an underlying problem. Postoperative umbilical hernias have been re-
ported, especially in premature infants if the can-
nula is inserted through the umbilical cicatrix. It is
Urinary Tract Injury for this reason that we recommend that the Has-
son is inserted through the linea alba.
Bladder and ureteral injuries have been reported,
mostly with pelvic surgery. However, there is a
greater risk of bladder injury in children because Other Areas of Hidden Danger
the bladder is an intra-abdominal organ in this
age group. Emptying the bladder before laparos- There is a considerable amount of new technol-
copy will reduce this risk. Be aware that the ura- ogy appearing on the laparoscopic scene, and one
538 H. L. Tan
Tips
77 Check all instrumentation, video equipment, gas 77 Avoid monopolar diathermy unless you are well
supply and diathermy before starting the oper- aware of the risks of capacitive coupling and
ation. have taken measures to avoid them. Avoid mo-
77 Start with simple procedures. nopolar when the return path may result in
77 Convert to an open procedure if unsure. It is no burns at the base (e.g. the appendix and ureters).
shame to convert. 77 Only use lasers with appropriate backstops if re-
77 Keep the patient warm. quired. Do not use lasers which utilise gas to cool
77 Use the Hasson technique. the tip. This can result in dangerously high insuf-
77 Always watch trocars from the inside when they flation pressures.
are being introduced. 77 Use the ABC with extreme care.
77 Avoid insufflators with high default settings. 77 The tip of the ultrasonic scalpel (harmonic scal-
Start with low flow. pel) can remain very hot for up to 8 s. This can re-
77 Do not open the jaws of an instrument blindly sult in contact burns.
within any body cavity unless you can fully visu-
alize the tip.
I3 Energy Sources in Laparoscopic Surgery 539
I3 Energy Sources in Laparoscopic Surgery I3
M. McHoney
Electrocautery Complications
• Minimally invasive repair of pectus excavatum cardiac evaluation to allow assessment based
is indicated for patients with a severe pectus ex- on these criteria.
cavatum deformity and associated physiologic
impairment. Specific inclusion criteria include
two or more of the following: Patient Positioning
– Computed tomography (CT) index greater
than 3.25, with associated cardiac or pulmo- • The patient is placed supine with the arms ab-
nary compression ducted to expose the lateral chest walls.
– Pulmonary function tests (PFTs) demon-
strating restrictive and/or obstructive im-
pairment Operative Technique
– Cardiology evaluation demonstrating car-
diac compression, displacement, mitral • Landmarks identified on the anterior chest wall
valve prolapse, murmurs or conduction ab- include the deepest point of sternal depression
normalities and the lateral ridges of the pectus deformity
– Documentation of progression of the de- on each side. The goal is to place the pectus bar
formity with advancing age, in association in a horizontal plane encompassing these land-
with development or worsening of physi- marks.
ologic symptoms (i.e. shortness of breath, • Using low-pressure CO2 insufflation, a 30° tho-
lack of endurance, exercise intolerance, pal- racoscope is inserted to confirm the internal
pitations or chest pain) anatomy in preparation for substernal dissec-
tion (Fig. 1). Bilateral transverse thoracic in-
cisions from mid- to anterior axillary lines are
Pre-operative made in the plane of anticipated bar place-
ment. Dissection is advanced medially to the
• All patients who present with clinical evidence
of a severe pectus excavatum deformity should
undergo workup with a noncontrast chest CT
scan, pulmonary function testing (PFTs) and
Donald Nuss
Professor of Surgery and Pediatrics, Emeritus.
1429 W. Princess Anne Road, Norfolk,Virginia 23507,USA.
Donald.Nuss@chkd.org Fig. 1
pectus ridge on each side in a subcutaneous kept in view during the entire substernal dis-
or submuscular plane, depending on the pres- section to avoid injury to the heart. Attention
ence of pectoralis muscle at the level of dissec- is focused on the electrocardiogram (ECG)
tion. Under thoracoscopic visualization, a ton- monitor during this process to detect evidence
of arrhythmia or injury pattern. If adequate
visualization of the introducer tip cannot be
achieved due to the severity of the pectus de-
formity, additional measures to optimize visu-
alization may be necessary, as explained in the
‘Tips’ section below.
• To complete the transthoracic tunnel, the intro-
ducer is advanced through the intercostal mus-
cles of the left chest medial to the pectus ridge
and into the subcutaneous/submuscular tunnel
on that side (Fig. 4). Upward traction applied
to the ends of the introducer facilitates flatten-
Fig. 2 ing of the sternum and stretching of the inter-
costal muscles. Complete correction of the pec-
sil clamp is inserted into the right pleural space tus deformity should be demonstrated at this
to create a soft tissue defect in the intercostal time.
muscles (thoracostomy), just medial to the pec- • A pectus bar of appropriate length is bent to
tus ridge. match the patient’s desired chest wall contour.
• The pectus introducer is inserted into the sub- This length is typically determined by measur-
cutaneous/submuscular tunnel and through ing the anterior chest wall circumference from
the intercostal muscle defect under direct vi- the thoracic incisions and subtracting 1–1.5 in
sualization (Fig. 2). (2.5–3.8 cm).
• Upward pressure is applied by the introducer • Umbilical tape is secured through the eyelet
to elevate the sternum, and the blunt tip facili- at the tip of the introducer and deposited in
tates dissection of the pericardium and pleura the transthoracic tunnel by withdrawing the
off the sternum to create a substernal tunnel introducer under thoracoscopic visualization
(Fig. 3). The tip of the introducer should be (Fig. 5).
Fig. 3
544 F. W. Frantz and D. Nuss
Fig. 4
Fig. 5
Fig. 6 Fig. 7
I4 Minimally Invasive Repair of a Pectus Excavatum 545
Fig. 8
• The umbilical tape is secured to the pectus bar. • Insufflated CO2 is evacuated from the right
The bar is pulled into the right pleural space pleural space by cutting the insufflation tub-
and through the tunnel in a posterior convex ing and placing the end of the tube under a wa-
orientation via gentle traction applied to the ter seal. This evacuation is facilitated by placing
umbilical tape (Fig. 6). the patient in the Trendelenburg position, with
• The umbilical tape is removed, and the bar is the right side elevated and the administration
rotated 180° using bar flippers applied on each of a series of large positive-pressure breaths.
end of the bar (Fig. 7). Complete correction of As the soft tissue and skin incisions are closed
the pectus deformity should be noted at this in layers with absorbable sutures, progressive
point. After placement, the sides of the pectus decrease and eventual cessation of bubbling
bar should rest comfortably against the lateral through the tubing should be observed. A chest
ribs and chest wall musculature. x-ray is obtained to exclude a residual pneumo-
• Pectus bar stabilization and fixation is neces- thorax. If bubbling persists, a chest tube should
sary to minimize the risk of bar displacement be inserted and secured in place.
(Fig. 8). Stabilization entails attaching a steel
rectangular stabilizer to the bar, usually on the
left side. Three-point fixation entails both lat-
eral and medial attachment of the bar to un-
derlying chest wall tissues. Lateral fixation is
achieved by placing multiple absorbable su-
tures through the holes on the end of the bar
and stabilizer, and underlying fascia/muscle on
both sides. Medial fixation involves attachment
of the bar to underlying ribs using polydioxa-
none suture (PDS) pericostal sutures of 0 or 1,
placed with the Endo Close needle under tho-
racoscopic guidance.
546 F. W. Frantz and D. Nuss
Tips
77 The optimal age for minimally invasive repair is mechanical retraction introduced via a sub-
between 10 and 14 years of age, while the chest xiphoid incision. If multiple-bar placement is
wall is still malleable. planned in this setting, the more cephalad trans-
77 Any patient with a history of eczema or atopy is thoracic tunnel, which is usually less depressed,
at higher risk of allergic reaction and should be can be created first. The introducer is then left in
tested for a metal allergy. Those patients with place at this site while dissection for the lower
positive skin tests or history of nickel allergy tunnel is undertaken.
should have titanium bars used in the procedure. 77 Multiple-bar placement should be considered
77 In female patients, inframammary incisions may in older patients and those with stiff chest walls
be preferred over transverse thoracic incisions to and/or significant sternal torsion, as this config-
enhance cosmesis. uration appears to provide better pressure distri-
77 During substernal dissection, if the sternal de- bution and bar stability.
pression is too deep or the chest wall is too stiff 77 The pectus bar should remain in place for 2–4
to allow visualization of the introducer tip, ex- years after repair to ensure permanent remodel-
ternal elevation of the sternum can be achieved ling of the chest wall.
by using the vacuum chest wall elevator or with
Common Pitfalls
77 During creation of the transthoracic tunnel, 77 Avoid single-bar placement inferior to the body
avoid thoracic entry and exit sites that are too of the sternum. Even if this is the deepest point
lateral, as this can predispose to intercostal mus- of depression and results in immediate correc-
cle stripping and subsequent bar instability. Ap- tion of the deformity after bar placement, this lo-
propriate entry and exit sites are medial to the cation is unstable and carries a higher risk of bar
greatest apex of the deformity (pectus ridge) on displacement. A bar placed inferior to the ster-
each side. This is especially pertinent in postpu- nal body (i.e. subxiphoid) in combination with a
bertal patients and those with stiff chest walls. second bar placed under the bony sternum is a
77 Ensure proper configuration of the pectus bar much more stable configuration.
after bending. The bar should have a semicir- 77 Avoid undercorrection of the pectus deformity.
cular shape with a flat central apex (to support Slight overcorrection of the deformity is actually
the sternum) flanked with gentle, convex curves felt to be most desirable. Adequate repair is con-
on each side that matches the patient’s desired firmed by complete resolution of the preopera-
chest wall contour. Bars bent on the ends only tive excavatum deformity and complete straight-
with a rectangular configuration will result in un- ening of the sternum when viewed thoracoscop-
dercorrection. Bars that are too tight on the sides ically. If these criteria are not met, a second pec-
are associated with prolonged pain due to bone tus bar should be inserted.
and muscle erosion.
I5 Thoracoscopic Lung Biopsy 547
I5 Thoracoscopic Lung Biopsy I5
S. S. Rothenberg
Lung biopsies are helpful in cases of interstitial adequate room for the endoloops or stapler. It
lung disease, infiltrates of unknown origin (espe- is placed in the lowest interspace which gives
cially in immunosuppressed patients), and possi- an acceptable approach to the biopsy site.
ble metastatic disease. • The third trocar is placed more anteriorly,
closer to the biopsy site. A grasper is used
through this site to grasp the biopsy site and
Operative Technique facilitate a wedge resection (Fig. 2).
• In smaller patients a series of two endoloops
• The room should be set up to maximize expo- (0 Ethibond or a similar braided suture) are
sure and ergonomics for the surgeon. If the site passed around the tongue of tissue to be biop-
of biopsy is in the anterior portion of the lung, sied and snared at the base (Fig. 3). The spec-
then the monitor is placed across the front of imen is then resected distally to the loops. In
the patient, and the surgeon and assistant stand larger patients the endoscopic stapler is used
at the patient’s back (Fig. 1). The reverse is done to cut out the wedge of tissue (Fig. 4).
if the site to be biopsied is posterior. If multi- • After the lung is biopsied the lung is re-in-
ple sites are to be biopsied, monitors may be flated and a drain is inserted through one of
necessary on both sides to facilitate the proce- the smaller trocars sites and is placed to water
dure. seal. Prior to extubation in the operating room
• The patient is placed in a lateral decubitus po- (OR), if there is no evidence of an air leak, the
sition, with the side to be biopsied placed up. chest drain is removed and an occlusive dress-
If a specific lesion is the target the patient may ing is applied. This can eliminate a good deal
be placed in a more supine or prone position of the postoperative pain.
to give greater exposure to that area.
• The patient is prepared and draped, and then a
Veress needle is inserted in the mid-axillary line
in the fifth or sixth interspace, and the pleural
cavity is insufflated with a low flow (1-2 l/min)
low pressure (4–8 mmHg) of CO2 to collapse
the lung.
• A 3- or 5-mm trocar is then inserted, and a 30°
lens is used to survey the chest.
• The second and third ports are placed to op-
timize the approach for the biopsy. If an ante-
rior site is being biopsied the larger port (5 or
12 mm) is placed more posteriorly to allow for
Fig. 3a–c Lung biopsy using endoloops to snare the lung in children weighing <15 kg
I5 Thoracoscopic Lung Biopsy 549
Tips
77 In general CO2 insufflation is adequate to get 77 Small lesions can often be ‘cherry picked’ (enucle-
enough lung collapse for biopsy; however if ated) using cautery or an energy-sealing device,
there are multiple sites, single–lung ventilation but in this case it is important to leave a chest
may be helpful. drain in, as the risk of postoperatively air leak is
77 If lesions are not on the pleural surface or are much higher.
smaller then 0.5 mm, it may be helpful to do pre-
operative computer tomography (CT) localiza-
tion either by marking the pleura with a blood
patch or by placing a localizing wire.
Common Pitfalls
77 Inability to locate the lesion: As recommended 77 The lesion is not located near the edge of the
above, use preoperative CT localization to avoid lung, making wedge resection difficult. Do not
this issue. In addition discuss a plan with the pa- force the stapler to take a biopsy in an area were
tient and family as to whether you will convert you can adequately get across the tissue. If nec-
to an open thoracotomy if the lesion cannot be essary, ‘core out’ the lesion and over-sew or tissue
found. seal the biopsy site.
77 There is no room to open the stapler: In general
endoloops rather than a staple should be used
in patients lighter than 10 kg because of the lim-
ited space.
550 S. S. Rothenberg
I6 I 6Thoracoscopic Lobectomy
S. S. Rothenberg
Lobectomy is indicated in cases of congenital lung is found the vessel is mobilized and ligated using
malformations such as congenital cystic adeno- clips, sutures or a vessel sealing devise (Fig. 3).
matoid malformations (CPAM) intralobar se- Dissection is continued until the inferior pul-
questrations and congenital lobar emphysema. monary vein is visualized.
Lobectomy in children is also necessary in some The fissure is then approached anteriorly to
cases of severe chronic or recurring infections re- posteriorly, exposing the pulmonary vein as it
sulting in bronchiectasis, or in acute cases of se- passes through the fissure. Gradually the pulmo-
vere necrotizing pneumonia. nary artery to the lower lobe is isolated. Often
it is necessary to dissect into the parenchyma of
the lower lobe to gain extra exposure and length
Operative Technique (Fig. 4). The vessel is then ligated and divided. In
smaller vessels a vessel sealer can be used. In larger
Lower Lobectomy patients an endoscopic stapler may be employed.
This exposes the bronchus to the lower lobe,
A lower lobectomy procedure is performed with that lies directly behind the artery, and it can of-
the patient in a lateral decubitus position. In all ten be palpated before it is seen.
cases single-lung ventilation is desirable if at all The pulmonary vein is then dissected while re-
possible, but a successful lobectomy can be per- tracting the lung up and back. It is ligated in a
formed using just CO2 insufflation to collapse the fashion similar to the that for the artery (Fig. 5).
lung. The bronchus is divided with the EndoGIA in
The room setup is shown in Fig. 1. The sur- larger children or cut sharply and closed with 3-0
geon and assistant are at the patient’s front, with polydioxanone sutures (PDS) in smaller patients
the monitor at the patients back. The chest is ini- (Fig. 6). In infants and children weighing less than
tially insufflated through Veress needle placed be- 5 kg, it is possible to seal the bronchus with en-
tween the anterior and the mid-axillary line at the doclips (Fig. 7).
fifth or sixth interspace. This is the scope port, and
it should focused over the major fissure. Middle Lobectomy
The working ports (3 or 5 mm) are then placed
in the anterior axillary line between the fifth and The initial approach for a middle lobectomy is
eighth or ninth interspace. If a staple is used a 12- the same as for the lower lobe; however the work-
mm port is placed in the lower innerspace (Fig. 2). ing ports are shifted slightly cranially to allow for
The first step is mobilization of the inferior pul- good access to the minor fissure. The middle lobe
monary ligament. During this manoeuvre care is arteries are encountered near the confluence of the
taken to look for the systemic vessel branching minor and major fissure, and should be isolated
from the aorta in cases of sequestration. If one and ligated here. The lobe is the retracted poste-
riorly to expose the middle pulmonary vein, that
comes off the superior pulmonary vein. Once the
Steven S. Rothenberg ()
artery and vein are divided, the bronchus to the
Chief of Paediatric Surgery,
the Rocky Mountain Hospital for Children, middle lobe is easily identified and enters the lobe
Denver, CO 80205, USA near its apex, and can safely be divided here.
Dr.rothenberg@pediatricsurgeon.com
Fig. 2 Trocar placement. The camera port is placed to look down on the major fissure, where most of the difficult dis-
section is performed
552 S. S. Rothenberg
Fig. 4 Completing the major fissure to expose the pulmonary artery for ligation
I6 Thoracoscopic Lobectomy 553
Fig. 8 Exposing the superior pulmonary artery by retracting the lung posteriorly and inferiorly
I6 Thoracoscopic Lobectomy 555
Tips
77 Understanding the spatial relationships in the 77 Maintain as dry a field as possible; even a small
chest is key to successful lung resection. It is best amount of blood/fluid can greatly obscure the
to work anteriorly to posteriorly in most cases, field.
rather then flipping from one side to another. 77 Whenever possible divide the arterial branches
This only results in added time, repeated loss of first. This will decrease shunting within the lung,
exposure and unnecessary manipulation of what aiding the anaesthetist, and will diminish con-
may be inflamed and friable tissue. gestion within the lobe, that can make it more
77 Allow gravity to do the majority of the retracting. difficult to manipulate.
Rotate the bed aggressively to improve expo-
sure. This will save the need for adding another
port site for an additional instrument. However if
adequate exposure cannot be obtained, do not
hesitate to add more ports.
Common Pitfalls
77 Failure to identify all segmental vessels. This can 77 Mass ligations/divisions. Avoid the temptation
result in an avulsion with uncontrolled bleeding, to place a stapler across the major fissure with-
requiring conversion to an open thoracotomy. out fully identifying all structures. You might get
The most likely suspects are the apical branch to lucky, but you are just as likely compromise ar-
the lower lobes and the lingular branch to the terial branches or bronchi to lung tissue you are
left upper lobe. not resecting.
77 Over-manipulation of the lung tissue will result
in slow bleeding, obscuring the visual field. Use
an atraumatic clamp on the lung and try to avoid
repeated grabs and excessive tension.
556 F. Becmeur, C. G. Ferreira
I7 I 7Thoracoscopic Decortication
for Empyema
F. Becmeur, C. G. Ferreira
Equipment
Operative Technique
Tips
77 The optical port and the instrument may be in- this approach, two ports are enough for a good
terchangeable: it offers a good overview of the and efficient debridement of the pleural cavity.
pleural cavity and new possibilities to remove But in some cases, a third port hole is required.
pleural peels and/or clean the pleura. Through
Common Pitfalls
77 Avoid blind introduction of any instrument, 77 Avoid tearing the pleura which causes important
which can be responsible for a severe lung injury bleeding.
77 Avoid making any incision anteriorly to the ante- 77 This surgery is a long procedure which takes
rior axillary line. They have to be far enough from time (generally more than one hour). Don’t be in
the nipple, especially in girls, to avoid damage to a hurry.
the developing breast.
558 M. McHoney
I8 I 8Thoracoscopic Diaphragmatic
Hernia Repair
M. McHoney
Thoracoscopic repair of congenital diaphrag- ble again with affected side up. The monitor(s)
matic hernia is possible in stable neonates and is placed at the foot of the patient. The surgeon
late-presenting cases. However, surgery is usually and assistant should stand on the cephalic end
contemplated only in those who stabilise and im- of the patient. During the operation, the patient
prove with medical management. The potential can be put into an approximately 5–15° reverse
advantages of the thoracoscopic approach are im- Trendelenburg position; this allows gravity to fa-
proved cosmesis, less deformity and less intra-ab- cilitate reduction of the herniated viscera into the
dominal adhesions. Attention to technical details abdomen.
are however necessary to avoid recurrences. Ex-
perienced anaesthetic management is required to
handle the increased ventilation required for the Port Positioning and Placement
CO2 load, and achieve good oxygenation in the
face of the pneumothorax. The 5-mm Hasson port is inserted by an open
technique below the tip of the scapula in the mid-
axillary line. A small incision is made and deep-
Equipment ened through the intercostal space. The last dis-
section can be done bluntly with an artery for-
• 5-mm Hasson trocar and accessory ports (×2) ceps to avoid injury to intestine/viscera on entering
• 4-mm 30° telescope the pleural space. The port is then inserted either
• 3-mm short Kelly’s dissector without a trocar or with a blunt one if deemed
• 3-mm short scissors necessary.
• 3-mm needle holder A pneumothorax is created with 5 mmHg CO2
• 3-mm Johan forceps (×2) pressure. Two further 3- or 5-mm ports are placed
• Non-absorbable suture on a small curved nee- in the anterior and posterior axillary lines under
dle visualisation.
• Patch of surgeons preference (e.g. Dacron®,
Surgisis®, Gore-Tex® or Permacol®) if needed
Operative Technique
Fig. 1
Fig. 2
560 M. McHoney
Fig. 3
Fig. 4
I8 Thoracoscopic Diaphragmatic Hernia Repair 561
After reducing the viscera the diaphragmatic technically important steps in preventing recur-
defect will become visible (Fig. 2). Occasionally rence.
the lips of the diaphragmatic defect need defin- If necessary, a patch can be used to close large
ing by dissecting from the thoracic wall or medi- defects which would otherwise be impossible or
astinum. This allows maximising the amount of result in undue tension. A suitable patch of the
muscle available for closure to reduce tension and surgeon’s choice should be trimmed to size ex-
the need for a patch repair. tracorporeally, and inserted through a small stab
A 6-cm length of non-absorbable suture on incision in the chest wall or one of the port site
half-circle needle is introduced directly into the wounds. The size of the patch can be refined if
chest through a suitable intercostal space with a necessary. It is then sutured to the edge of the de-
needle holder. fect with interrupted sutures (Fig. 4).
The muscular defect is repaired with inter- The lung is re-expanded under visualisation,
rupted sutures passed through the diaphragm to displacing the CO2 in the chest. The wounds are
close the defect (Fig. 3, in this picture an excised closed with absorbable suture to muscle and sub-
hernial sac is seen in the field). Care is taken to cuticular stitch or glue to skin. The use of a chest
avoid injury to the viscera beneath the diaphragm tube postoperatively is not mandatory, but it
when passing the sutures through the diaphragm. should be used if air leakage is suspected on re-
The posterolateral defect is often the most defi- expanding the lung.
cient and difficult to close. To achieve closure of
a slightly tight defect, the posterolateral stitches
may be tied extracorporeally (subcutaneously) us-
ing small skin incisions, after passing the suture
around a rib if necessary. This is one of the more
Tips
Fig. 2 Fig. 3
Fig. 4
ration requiring a simple mucosal repair, the pa- We do not extend the myotomy onto the fundus
tient should be fasted for 48 hours. of the stomach but identify the precise anatomi-
cal margin of the fundus, by the circular muscu-
In our experience, it has not been necessary to per- lar fibres as opposed to the longitudinal fibres of
form an anterior fundoplication, if the cardiomy- the distal esophagus.
otomy is performed in situ as the attachments of
the esophagus is left largely intact.
Common Pitfalls
77 Breaching the left pleural cavity during dis- esophagus, and a tension pheumothorax may
section of the anterior wall of the mediastinal ensue.
I10 Laparoscopic Fundoplication 565
I 10Laparoscopic Fundoplication I10
H. L. Tan and S. Cascio
Fig. 1
Fig. 2
I10 Laparoscopic Fundoplication 567
1–2 cm above the hiatus or by inserting a Na- At this point you will be able to see the gastro-
thanson retractor. phrenic ligament which attaches the fundus of the
stomach (between the spleen and left crus); that
Hiatal Exposure must be divided (Fig. 5). These ligaments will pre-
vent the fundus from being pulled through the
The hiatus is easily identified but the right crus posterior oesophageal window. Completely free-
will not be easily seen, as it will be deep to the ing this ligament will allow the fundus to be pulled
phreno-oesophageal membrane covering the cau- without tension.
date lobe and the crus. This membrane has to be Once the gastrophrenic ligament is mobilised,
divided (Fig. 3). a small posterior window is created behind the oe-
The right crus can then be identified sitting sophagus in the peritoneum between the oesoph-
snugly on the oesophagus, and can be separated agus, left gastric artery and the posterior vagus
from the loose adventitial attachments with ease. nerve, that should be easily identifiable (Fig. 6).
The peritoneum over the “white line” should be The posterior wall of the fundus should then be
completely divided to expose the underlying oe- visible and can be pulled through this hiatus af-
sophagus, this incision is followed over the crus ter enlarging the window with blunt instruments.
(Fig. 4), the left crus is seperated from the oeso You should now see if the stomach is easily pulled
phagus by incising the overlying peritoneum un- through this window.
til it meets the R crus as a V.
Fig. 3 Fig. 4
Fig. 5 Fig. 6
568 H. L. Tan and S. Cascio
Fig. 7
Fig. 8
Fig. 9
• 4 mm short 0 degree telescope A 2mm stab incision is made in the supra-um-
• 4.5 mm Hasson trocar bilical skin fold with an 11 blade knife. The in-
• 3 mm short atraumatic bowel holding forceps cision is spread along Langer’s lines using sharp
• Tan endotome pointed scissors. The linea alba is identified about
• Tan pyloric spreader 1cm above the umbilical cicatrix, grasped with
two pairs of mosquito forceps and lifted into
the wound by everting the haemostats. A trans-
Pre-operative verse incision is made in the linea alba between
the two mosquito forceps. The underlying trans-
The stomach must be emptied with an oro-gas- lucent parietal peritoneum is grasped with mos-
tric tube. quito haemostats and opened adjacent to the um-
bilical vein.
A purse string is placed in the linea alba be-
Patient positioning fore inserting the 4 mm Hasson trocar. This purse
string is tightened around the trocar with a single
The patient is positioned at the foot of the oper- throw to stabilize the trocar and prevent air leak-
ating table, with the surgeon standing at the end age. The same suture is used at the end of the pro-
of the table and the assistant surgeon to the right cedure to close the defect by tightening the purse
of the surgeon. If the video monitor is pendant string.
mounted, it should be placed directly in front of A 4 mm Telescope is inserted through the su-
the patient for the best hand-eye co-ordination, pra-umbilical 4.5 mm Hasson cannula.
There is no need to insert ports. Instead, full
thickness stab incisions are made with an 11 blade,
Salvatore Cascio () in the nipple line one finger’s breath below the cos-
Consultant Paediatric Suregeon and Urologist
tal margin. The incision is dilated with a straight
The Royal Hospital for Sick Children, Dalnair Street,
Yorkhill, Glasgow G3 8SJ, Scotland, UK mosquito haemostat just wide enough to accom-
Email: salvatore.cascio@ggc.scot.nhs.uk modate the 3mm hand instruments (Figure 2).
Fig. 1
Fig. 3
Fig. 6 Fig. 7
572 H. L. Tan and S. Cascio
I12 I 12Laparoscopic Appendectomy
H. L. Tan and S. Cascio
Salvatore Cascio
Consultant Paediatric Surgeon and Urologist
The Royal Hospital for Sick Children, Dalnair Street,
Yorkhill, Glasgow G3 8SJ, Scotland, UK
Email: salvatore.cascio@ggc.scot.nhs.uk Fig. 1 Standard laparoscopic tray for appendectomy
alba. The peritoneum is grasped with two mos- Endosurgical Loop Application
quito haemostats, and a small incision is made
with scissors to enter the abdominal cavity. A Many pretied endosurgical loops come with a
purse string is placed in the linea alba before in- 5-mm reducer which allows the loop to be intro-
serting the primary 10-mm Hasson trocar. Two duced into the abdominal cavity without disrupt-
additional ports are inserted, a 5-mm port in the ing the preformed loop. However the loop is usu-
left iliac fossa, avoiding the inferior epigastric ves- ally far too big to allow for easy manipulation,
sels for the left-handed instrument, and a second and it is necessary to reduce the diameter of the
5-mm port in the right paracolic gutter in the nip- loop before use.
ple line for your right-handed instruments. How- This is done by breaking the end of the straw
ever if a high caecum is encountered, it may be and drawing on the suture to reduce the loop to a
preferable to insert this port even higher to give suitable diameter, and withdrawing the loop into
you more internal space to manipulate the instru- the straw in its entirety (Fig. 4).
ments. The base of the appendix is ligated with the
loops, and the appendix is then divided using the
bipolar scissors (Fig. 5). The loop can be manip-
Operative Technique ulated to its correct position using some counter
traction between the appendix and the straw of
The appendix is mobilised and the mesoappendix the endo surgical loop.
at the tip of the appendix is grasped. The main ap- The telescope is transferred to the left iliac fossa
pendicular artery that runs along the free edge of (LIF) port, and the grasper is placed in the 10-
the mesoappendix is then divided using bipolar mm umbilical port to grasp the tip of the appen-
scissors (Fig. 3). This will allow to skeletonise the dix, delivered under visualisation, through the 10-
appendix down to the base using bipolar scissors, mm Hasson port.
as the vessels supplying the rest of the appendix If the appendix is gangrenous, perforated or
are less than 1 mm and easily handled. associated with an appendicular abscess, the peri-
toneal cavity is thoroughly irrigated with normal
saline until clear fluid is aspirated from the ab-
dominal cavity.
The abdomen is deflated, the purse string at the
Hasson port is tightened, subcutaneous approx-
imated with absorbable sutures and skin closed
with topical skin adhesive.
Fig. 4 Fig. 5
I13 Laparoscopic Button Placement for Antegrade Enema 575
I13 Laparoscopic Button Placement I13
for Antegrade Enema
F. Becmeur
• A colonic antegrade enema is proposed in cases the left lower quadrant in the case of a caecos-
of intractable faecal incontinence or major tomy, and in the right lower quadrant for a sig-
constipation with encopresis. moidostomy.
• This procedure allows for caecostomy button • Laparoscopy allows selecting the site for cae-
placement and a sigmoidostomy. costomy or sigmoidostomy by looking at the
Equipment
• 5-mm 0° telescope
• Atraumatic 3- or 5-mm forceps
• Simple needle holder for open surgery
Pre-operative
Operative Technique
Fig. 3 Fig. 4
Tips
77 It is essential to operate on with an empty colon. 77 The needle must slip easily in the Chait button
77 Surgery can be easier with an attendant colonos- TrapDoor®. Use oil to lubricate the lumen of the
copy, that allows checking the placement of the button.
device into the lumen of the colon. However, is
it not necessary except in case of numerous ad-
hesions.
Common Pitfalls
77 Avoid running the colon through with the nee- 77 Performing antegrade enemas too early after the
dle or piercing another bowel loop. Laparoscopic button placement can lead to peritoneal leakage
control is mandatory to avoid this accident. and peritonitis or local abscess.
77 Performing a parietal incision too narrow may
damage the button.
I14 Primary laparoscopic-assisted endorectal pull-through 577
I 14Primary laparoscopic-assisted I14
endorectal pull-through
T. J. Bradnock and G. M. Walker
Single stage pull-through for Hirschsprung’s Dis- • 1% xylocaine and 1:200,000 adrenaline for
ease has gained in popularity since its introduction port-sites.
in 1980 and is suitable for left-sided disease where • Insert the urethral catheter after draping.
colonic decompression can be achieved with rec-
tal washouts. A defunctioning stoma may be re-
quired if adequate decompression is not achieved, Patient Positioning
in cases of severe enterocolitis, perforation or
long-segment aganglionosis. • Position the patient supine and slightly head
Laparoscopy offers the advantage of intra-op- down, across the table for neonates or in a stan-
erative biopsies to determine the level of agangi- dard position for the older child.
olosis prior to any dissection, and provides excel- • Place two gauze swabs or a roll under sacrum
lent visualisation for colonic mobilisation to en- to elevate the perineum.
sure a properly rotated, tension-free pull-through. • Prepare the abdomen, perineum, buttocks and
lower limbs
• Wrap feet in crepe and then place on sterile
Equipment drape
Tips
77 Await results of frozen section analysis BEFORE 77 For the endorectal dissection, the feet can be
commencing colonic dissection. If the TZ is sub- held over head by securing the crepe bandage
sequently found to lie proximal to mid-TC, a lev- to a metal bar.
elling stoma may be more appropriate with de- 77 Elevate the rectal mucosa with 1:200,000 epi-
ferral of definitive surgery. nephrine in saline before commencing the en-
dorectal dissection.
Common pitfalls
All types of Hirschsprung disease can necessitate Neonates and small children can be positioned
this procedure. transversely at the lower end of the operating table
to allow easy access to the small pelvis and to fa-
cilitate the anal part of the procedure. If necessary
Equipment an armrest can be used to elongate the width of
the table in somewhat older toddlers. Older chil-
For the laparoscopic Duhamel procedure 3mm dren are placed at the lower end of the table in the
short re-usable instruments are used in the lithotomy position.
younger child and 3- or 5mm instruments for
older children.
For the side-to-side anastomosis a 45-mm en- Operative Technique
doscopic stapling devise is used.
• An open infra-umbilical incision is used for first
trocar.
Pre-operative Management • Under direct vision two to three additional tro-
cars are placed, one in the left and the right
The day prior to surgery the children receive an lower quadrant and another in the right up-
antegrade bowel washout with 50ml/kg Klean- per quadrant.
Prep over 4 hr through a nasogastric tube with a • Two to three subserosal biopsies are taken
rectal cannula in place. to determine the correct level of transaction
After induction of general anesthesia on the (Fig. 1).
day of surgery, the rectum is washed out again • The dissection of the mesocolon is carried out
with physiological saline to clear all residual fae- close to the intestinal wall down to the pelvic
ces. floor and up to the level of the normal biopsy
Perioperatively the child receives antibiotics ac- site.
cording to protocol for 24h. An epidural catheter
is positioned for analgesia. A urinary catheter is
introduced under sterile conditions after the pa-
tient has been draped. The legs are draped sepa-
rately to facilitate both the abdominal and peri-
neal approach.
Fig. 2
Fig. 4
Fig. 3 Fig. 5
• The rectum is tied off with a vicryl 2 × 0, 2 cm pulled through the anal incision under endo-
above the peritoneal reflection and it is trans- scopic control.
acted distal to this ligature (Fig. 2). • This prevents twisting of the bowel until the
ganglionated biopsy site becomes visible.
• Incision in the anterior wall of the transected
Anal Part colon and the proximal part of the colon is su-
tured to the anterior wall of the incision with
• An incision is made on the posterior rectal wall the two anteriorly placed sutures.
0.5 cms above the dentate line. This incision is • The incision is extended sideways and two lat-
extended both to the left and the right of the eral sutures are also placed.
mid line. • Complete resection of the pull through colon
• Two sutures are positioned outside in through and placement of the posterior suture against
the anterior side of the incision and two the upper limit of the dentate line.
more sutures are placed at the ends of the in- • Additional sutures are placed in between the
cision. stay sutures to complete the side to side anas-
• An artery clamp is guided with the help of an tomosis.
endoscopic instrument through the incision. • Introduction of 45 mm endoscopic stapling de-
• Under endoscopic guidance, the transected vice between the two anteriorly placed stay su-
rectum is grasped and the dissected colon is tures, with the upper leg in the remnant rectum
582 D. C. Van Der Zee
Tips
77 Rectal washouts prior to the procedure can pre- 77 The patient is placed transversely at the lower
vent the necessity to construct a colostomy at end of the table to allow a comfortable position
the end of the procedure, and colostomies that for the surgeon.
are in place can usually be closed in the same 77 A trans-anastomotic tube is placed for the first
procedure. 2–3 days postoperatively for decompression.
Pitfalls
77 Contamination in the case of mucosal perfo- poned until diagnosis of extension is ascer-
ration can be reduced by suturing the biopsy tained.
place. 77 Take care not to twist the pulled-through bowel.
77 In a case of inconclusive results from frozen sec- 77 Avoid leaving a “blind” rectal stump.
tion biopsies, the procedure should be post-
I16 Laparoscopic Splenectomy 583
I 16Laparoscopic Splenectomy I16
A. J. Sabharwal
Fig. 1
Pre-operative
Ports Position and Placement
In an elective setting the patient should receive pro-
phylaxis against postsplenectomy sepsis. A pneu- The visualisation port (5–15 mm) is sited in an in-
mococcal vaccine should ideally be administered 6 fra-umbilical position by an open technique and
weeks prior to surgery. Children younger than 10 pneumoperitoneum established. Three 5-mm
years old and all patients with immunosuppression ports are then sited as shown below (see Fig. 3).
or an associated immunodeficiency should be vac- These comprise an epigastric port and one to the
cinated against Pneumococcus, Haemophilus influ- left of the umbilicus in the mid-clavicular line,
enza, Meningococcus and Hepatitis B. which serve as working ports. An additional left
lateral port is used to retract the spleen with an
endopledget.
Atul J. Sabharwal ()
The surgeon and videographer stand on the
Consultant Paediatric and Neonatal Surgeon patient’s right side, with the surgeon on the right
Atul.Sabharwal@ggc.scot.nhs.uk of the videographer. An assistant stands on the
Fig. 2
patient’s left side and retracts the spleen super- Using the grasping forceps inserted into the
olaterally with an endopledget. The scrub nurse epigastric port and the Harmonic scalpel in the
stands either to the right of the surgeon or on the second working port, the gastrosplenic ligament
patient’s left if an additional monitor is available. is divided. An endopledget inserted through the
The active monitor utilised by the operators is sit- left lateral port is used to counter-tract the spleen
uated on the left side of the patient (see Fig. 4). laterally and aid dissection. Dissection is com-
menced by taking down the splenocolic attach-
ments using either the harmonic scalpel or mo-
nopolar hook diathermy. The tail of the pancreas
is visualised and care taken to avoid injury to the
gland. The cranial gastrosplenic attachments are
then divided, and the fundal short gastric vessels
dealt with using either the harmonic scalpel or
monopolar hook diathermy.
The splenic artery and vein will often branch
some distance from the hilum of the spleen, and
ligation of these vessels should be attempted be-
fore the artery has divided and the venous tribu-
taries have united. This may not be possible in all
cases, especially very large spleens, and in these
cases the individual vessels can be dealt with us-
ing the harmonic scalpel. Characteristically the
main vessels run superiorly to but closely abut-
ting the pancreas, with the vein lying posterior to
the artery. Taking the artery first interrupts most
of the splenic blood supply, reduces the risk of
major haemorrhage and reduces splenic size by
venous drainage. Care should be taken to avoid
Fig. 3 tearing venae comitantes and small arteries run-
I16 Laparoscopic Splenectomy 585
Fig. 4
ning to the spleen. A Mixter dissecting instrument The laparoscope is moved to one of the work-
is a useful aid to circumnavigate the main vessels. ing ports, and a retrieval bag inserted in to the um-
A Ligasure can then be used to coagulate and di- bilical port. The spleen is manipulated in to the
vide the main vessels. bag, care being taken not to damage the splenic
The remainder of the splenic peritoneal attach- capsule. The spleen is then retrieved piecemeal
ments can then be divided near their attachment with Rampleys forceps and suction utilised to re-
to the gastric fundus and diaphragm superomedi- move blood within the splenic body.
ally. Attention is then turned to the lateral attach- If the spleen is too large to fit in to the retrieval
ments to the abdominal wall. Prior to retrieval it bag, a Pfannenstiel incision can be used for re-
is important to ensure the spleen is free of all at- trieval.
tachments by rotating it carefully in its bed. An A final inspection to ensure haemostasis is car-
inspection of the omentum and upper abdomen ried out, the ports removed under vision and the
is made to exclude the presence of splenunculi. sites closed with absorbable suture.
586 H. L. Tan, B. Tecson and S. Cascio
I17 I 17Laparoscopic Cholecystectomy
H. L. Tan, B. Tecson and S. Cascio
B. Tecson
Associate Professor of Surgery,
School of Medicine, Saint Louis University, Baguio City.
Chairman,
Department of Surgery, Notre Dame De Chartres Hospital,
Baguio City, Phlippines
Salvatore Cascio
Consultant Paediatric Surgeon and Urologist
The Royal Hospital for Sick Children, Dalnair Street,
Yorkhill, Glasgow G3 8SJ, Scotland, UK
Email: salvatore.cascio@ggc.scot.nhs.uk Fig. 1
Patient Positioning
Operative Technique
Fig. 4
Fig. 5
Fig. 6
I18 Diagnostic Laparoscopy for Non palpable Undescended Testis 589
I18 Diagnostic Laparoscopy for Non I18
palpable Undescended Testis
S. Cascio and H. L. Tan
Approximately 1% of boys at age one year have rum electrolytes and a pelvic ultrasound are re-
an undescended testis, 20% of which are nonpal- quired. Having excluded Congenital Adrenal Hy-
pable. Laparoscopy has replaced ultrasonogra- perplasia any further test such as basal gonatro-
phy, magnetic resonance imaging and computer- phins, a human chorionc gonadotropin (hCG)
ized tomography as the modality of choice for the stimulation test with measurement of androgen
localization of the nonpalpable testis; in some of production and Mullerian Inhibitory Hormone
these patients can eliminate the need for further (MIH) can be deferred to a later stage to assess
exploration. Laparoscopy can also be used for pri- testicular function.
mary orchidopexy, for the two-staged Fowler–Ste- In the anaesthetic room under general anaes-
phens orchidopexy and for removal of the dys- thesia, a physical examination of the groin is man-
plastic/atrophic gonad in older children or in pa- datory before proceeding to laparoscopy. Approx-
tients with disorders of sex development. imately 18% of boys with a previously nonpalpa-
ble testis will have a palpable testis when examined
under general anaesthesia. The bladder should be
Equipment emptied by manual suprapubic compression.
to assess the diameter of the testicular vessels in nacular attachments and finally the measure-
the normal side (Fig. 1) and to compare with the ment of the distance between the testis and the
testicular vessels on the affected side. internal ring. Peeping testis or those located in
proximity to the internal ring (<2 cm from or
below the external iliac vessels) can usually be
Possible Intraoperative Findings mobilized into the scrotum in a single stage or-
chidopexy, either with an open or laparoscopic
• Normal vas and testicular vessels entering an approach without dividing the testicular ves-
open internal ring. Exploration of the groin is sels.
mandatory, as the testis could be present in 75– • High Intra-abdominal testis with short vessels.
97% of cases (Fig. 2). A high intra-abdominal testis is commonly de-
• Vas and either normal or hypoplastic testicular fined as when the testis lies inside the abdo-
vessels entering a closed internal ring. Inguinal men above the external iliac vessels or is more
exploration is indicated (Fig. 3). Either a tes- than 2 cm away from the internal ring. In these
ticular remnant or a small viable testis (3–25%) circumstances a staged Fowler–Stephens ap-
can be found in the inguinal canal. Excision proach is recommended.
of the testicular remnant is recommended be- • Normal vas deferens but no vessels and no ob-
cause of the small risk (0–7%) of detecting vi- vious testis near the vas. The abdomen is in-
able germ cell elements in the testicular rem- spected along the normal line of descent of the
nant that theoretically could undergo malig- testis, along the colonic gutter until the lower
nant change. pole of the kidney, and in ectopic sites in the
• Vas and atrophic testicular vessels ends blindly pelvis, beside the bladder, rectum or on the op-
before entering the internal ring – ‘vanishing tes- posite site (crossed ectopia).
tis’. Inguinal exploration is not indicated. • Normal vessels with an absent vas deferens. The
• The testis is visualized at the internal ring: peep- vessels may lead to an intra-abdominal testis or
ing testis (Fig. 4,5). It is of importance to as- may enter the internal ring, necessitating an in-
sess the length of the spermatic cord to decide guinal exploration. The contralateral internal
whether a direct open or laparoscopic orchido- ring should be inspected, as bilateral absence
pexy or a staged Fowler Stephens orchidopexy of vas deferens is considered an invariable find-
with division of the spermatic vessels should ing in cystic fibrosis. Also, patients with uni-
be performed. As part of the decision-making lateral absence of the vas deferens may have
process, it is essential to evaluate intraopera- cystic fibrosis mutations. The presence of an
tively the testis, the epididymis, the extent of the ipsilateral kidney should be confirmed post-
vasal descent into the inguinal canal, the guber- operatively with a renal ultrasonography. The
Fig. 1 Fig. 2
I18 Diagnostic Laparoscopy for Non palpable Undescended Testis 591
Fig. 3 Fig. 4
Fig. 5 Fig. 6
592 S. Cascio and H. L. Tan
I19 I 19Laparoscopic Fowler–Stephens
Orchidopexy
S. Cascio and H. L. Tan
Fowler and Stephens in 1959 describing the vascu- • Two pairs of Kellys forceps (one 3mm and one
lar supply of the testis proposed in children with 5mm)
intra abdominal testis the ligation of the testicu- • 1 Roberts forceps
lar vessels with the hope of preserving function • Disposable laparoscopic Ligaclip and bipolar
through collateral circulation through the defer- scissors
ential artery, a branch of the inferior vesical ar-
tery and the cremasteric artery, a branch of the
inferior epigastric. In their experience, orchido- Pre-operative
pexy was performed under the same anaesthetic.
Ransley introduced the practice of ligating the The bladder is emptied in the anaesthetic room
testicular vessels and waiting 6 to 12 months be- either with the insertion of a urinary catheter or
fore doing an orchidopexy to allow the deferen- with the Crede maneuver.
tial artery to increase its flow. Bloom was the first
to describe a laparoscopic approach for the first
stage and since then a laparoscopic “Fowler Ste- Patient Positioning
phens” procedure, performing both stages lapa-
roscopically has gained a wide acceptance. Stag- The patient is positioned supine with the video
ing the procedure will enable delivery of the testis monitor at the end of the table in the midline.
into the scrotum without tension and a decreased The operating surgeon and the scrub nurse should
risk of atrophy.
Equipment
• 5 mm Hasson Trocar
• 5 mm 30 degrees telescope
• One 5 mm Trocar
Hydrocele following varicocelectomy is very com- allow the sigmoid colon to fall away in a depen-
mon and occurs in up to 25% of cases. The cause dent position.
is the disruption of the lymphatic drainage of the
tunica vaginalis of the testis. We here describe high
ligation of the internal spermatic vessels via a lap- Pre-operative
aroscopic transperitoneal approach (Palomo pro-
cedure), with sparing of the lymphatic vessels. apping of the testicular lymphatics can be
M
achieved with an intravaginal injection of two
millilitres of methylene blue between the two lay-
Equipment ers of the tunica vaginalis 10 minutes before the
beginning of the operation.
• 5-mm Hasson trocar
• 5-mm 30° telescope
• Two 5-mm sharp trocars Ports Position and Placement
• Two pairs of Kelly forceps
• 5-mm laparoscopic scissors A two mm stab incision is made in the supra-um-
• Disposable laparoscopic LIGACLIP bilical skin crease with a no.11 blade and the pri-
mary Hasson cannula is placed using the open lap-
aroscopy method described in chapter I12 lapa-
Patient Positioning roscopic appendectomy. A second 5-mm incision
is made in the right iliac fossa, lateral to the rec-
The patient is positioned supine, with the testes tus muscle; the incision is widened by spreading
included in the operative field. For a left-sided a pair of straight mosquito forceps, and a 5-mm
varicocele the surgeon, assistant and scrub nurse trocar is placed under vision. A third 5-mm tro-
should stand on the right side of the patient, with car is placed on the left of the umbilicus lateral to
the video monitor placed in front of them, on the the rectus (Fig. 1).
patient’s left side, so that it is in the same visual line
to facilitate hand-to-eye coordination. The patient
should be tilted into a 30° head-down position, to Operative Technique
Fig. 1
Fig. 2
Fig. 3
I20 Lymphatic-Sparing Laparoscopic Varicocelectomy 597
Fig. 4
Fig. 5
Fig. 6
598 H. L. Tan and S. Cascio
I21 I21 Laparoscopic Inguinal Herniotomy
H. L. Tan and S. Cascio
Indirect inguinal hernias are some of the com- away from the internal rings. The monitor is po-
monest surgical conditions in infancy, and while sitioned at the bottom of the table. The surgeon
there is debate as to whether conventional or should stand on the side opposite of the hernia
open inguinal hernia repair is the preferred op- and the assistant opposite the surgeon. This al-
tion, there is now an established role for laparo- lows both the surgeon and assistant to work in
scopic inspection of the contralateral internal ring line, avoiding second-order paradox.
to exclude an open internal inguinal ring. In ne- The abdomen should be draped to include the
onates with an undescended testis and a hernia, testes, to enable the surgeon to reduce by taxis
laparoscopic closure of the internal ring is an in- any contents within the hernial sac should this
dication par excellence, as it leaves the contents be necessary.
of the inguinal canal – including the testis – com-
pletely untouched, making subsequent orchido-
pexy much easier. Ports Positioning and Placement
Patient Positioning
Operative Technique
The patient should be placed at the foot of the ta-
ble and in an approximately 15–20° degree Tren- The right (Fig. 3) and left (Fig. 4) internal rings
delenburg position to allow the small bowel to fall should be inspected first to determine if they are
patent.
In a female patient, it is important to confirm
Hock Lim Tan () that both Fallopian tubes and ovaries are present.
Visiting Pediatric Surgeon,
Absence of one or both of these structures should
Prince Court Medical Center, 56000 Kuala Lumpur,
Malaysia & Adjunct Professor Faculty of Medicine, raise immediate suspicion that they are within the
Universitas Indonesia, Jakarta, Indonesia sac or they form the wall of a slider.
Email: hockltan@yahoo.com A 6-cm length of non-absorbable suture on
a half-circle 11-mm needle is introduced directly
Salvatore Cascio
into the abdominal cavity by grasping the suture
Consultant Paediatric Surgeon and Urologist
The Royal Hospital for Sick Children, Dalnair Street, (not the needle) on the 3-mm needle holder. The
Yorkhill, Glasgow G3 8SJ, Scotland, UK curved needle can be negotiated through a thin ab-
Email: salvatore.cascio@ggc.scot.nhs.uk dominal wall alongside the needle holder.
Fig. 2
Fig. 1
Fig. 3 Fig. 4
Fig. 5 Fig. 6
600 H. L. Tan and S. Cascio
The needle is then mounted 30° from horizon- structures. The essence of laparoscopic closure
tal. The success of herniotomy and ease of closure thus is to lift the peritoneum away from the vas,
depends on correct needle placement, as it would internal spermatic vessels and the internal epigas-
be difficult to purse string the peritoneum around tric artery, that are easily visualised. The common-
the internal ring (Fig. 5), if the needle were incor- est site for ‘recurrence’ or incomplete closure is at
rectly mounted. the inferior epigastric artery, but lifting the perito-
Transperitoneal closure of an indirect inguinal neum off the artery will minimise injury.
hernia is akin to the open extraperitoneal closure. The purse string is then tightened securely and
The pre-peritoneal fascia is a definite tissue plane the needle removed (Fig. 6).
formed by loose connective tissue, that separates The purse string securing the Hasson cannula is
the peritoneum from the surrounding structures then loosened to remove the Hasson, and simply
such as the vessels and vas, and allows the perito- retightened to close the umbilical port site. If an
neum to be picked up and lifted away from these umbilical hernia is present, it is easiest to use the
umbilical defect to insert the Hasson and the um-
bilical hernia formally repaired after herniotomy.
The 3-mm instrument port sites can be closed by
topical skin adhesive.
I22 Retroperitoneoscopic Nephrectomy 601
I 2Retroperitoneoscopic Nephrectomy I22
S. Cascio, S. J. O’Toole and H. L. Tan
Equipment
Stuart J. O’Toole
Consultant Paediatric Urologist
Stuart.O’Toole@ggc.scot.nhs.uk
A transverse 12-mm incision is made lateral to the Gerota’s fascia is incised with bipolar scissors
sacrospinalis muscle, midway between the twelve close to the posterior abdominal wall and the peri-
rib and the iliac crest (Fig. 3). The subcutaneous nephric fat is visualized.
tissue is divided with diathermy. Access to the ret- A third 5-mm incision is made on the outer
roperitoneum is created by spreading the posterior border of the sacrospinalis muscle and a step tro-
and anterior lamella of the thoracodorsal fascia car is introduced.
with a pair of haemostat (Fig. 4). A balloon (as The ureter is visualized and traced down to the
described by Gaur in 1992) made by the finger of brim of the bony pelvis, divided with diathermy
a glove, double tied to a size 3 endotracheal tube scissors and tied with an endoloop in refluxing
and connected to a three-way tap to a 50 ml sy- ureters, while dilated obstructed ureters are left
ringe (Fig. 5), is introduced into the retroperito- open. The ureter is followed to the hilum of the
neal space and is inflated with 150-200 mls of air. kidney and used as countertraction to expose the
A 12-mm Hasson trocar is placed through the hilum (Fig. 6). The posterior branch of the renal
incision, and the retroperitoneal space is insuf- artery is visualized and two clips are applied prox-
flated with carbon dioxide to a pressure of 10 or imally and one distally before is divided. The re-
12 mmHg, according to the age of the child. Lo- nal vein and the anterior branch of the renal ar-
cal anaesthetic is infiltrated, and a 5-mm incision tery are clipped and divided. Alternatively the ves-
is made on the lateral aspect of the retroperito- sels can be divided either with the Harmonic scal-
neal space, the incision is widened by spreading a pel or with the Ligasure if they are less than 5 mm
pair of straight mosquito forceps along the tract in diameter. The remaining attachments of the
and a second 5-mm sharp trocar is placed under kidney laterally to the perinephric fat and to the
direct visualisation. transversalis fascia, medially and anteriorly to the
peritoneum and superiorly to the under aspect of
the diaphragm are divided with hook diathermy.
Small dysplastic kidneys are removed through the
12 mm Hasson port, larger kidneys with the use
of an EndoPouch retrieval system. The fascia and
subcutaneous are closed in layers with absorbable
suture and topical skin adhesive for skin closure.
Fig. 3
I22 Retroperitoneoscopic Nephrectomy 603
Fig. 4
Fig. 6
Fig. 5
604 S. Cascio, S. J. O’Toole and H. L. Tan
I23 I 23Retroperitoneoscopic Partial
Nephrectomy
S. Cascio, S. J. O’Toole and H. L. Tan
Fig. 1 Fig. 2
Lateral Retroperitoneoscopic
Approach for Lower-Pole Partial
Nephrectomy
Patient Positioning
• 7-mm Hasson trocar The patient is positioned laterally with the affected
• 5-mm 30° telescope side up, placed near the edge of the operating table
• Two Kelly dissectors
• Two KOH needle holders
• KOH assistant needle driver
• Laparoscopic pyeloplasty scissors
Fig. 4
Fig. 3
stabilises the pelvis, making precision suturing serted all the way into the bladder. The Teflon nee-
possible (Fig. 5). dle is withdrawn and a multilength pigtail catheter
At this stage only the anterior wall of the pelvi- is inserted over the guidewire into the bladder. The
ureteric junction is dismembered, preserving the proximal end of the pigtail is positioned into the
posterior wall. This approach makes easier to ori- renal pelvis. The redundant pelvis allows main-
entate and spatulate the proximal ureter (Fig. 6). taining counter-traction, avoiding any trauma to
The angle of the ureter is then re-anastomosed the urothelium. The placement of a stent will pro-
to the most dependent part of the renal pelvis, tect the anastomosis and prevent urinary leak.
with an accurate apical suture (Fig. 7), before the It is only after the insertion of the double-J
posterior wall is completely dismembered (Fig. 8). stent that the redundant pelvis is trimmed, and
The posterior anastomosis is completed with the anterior anastomosis completed with a sec-
a continuous suture of 6/0 or 5/0 polydioxanone. ond continuous 6/0 or 5/0 polydioxanone suture
(Fig. 9).
Stenting On completion of the anastomosis the hitch
stitch is removed, and the kidney returned to its
A transanastomotic stent is inserted transabdomi- bed and visually inspected to check that there
nally before trimming the redundant pelvis. A Tef- are no extrinsic kinks. The Hasson cannula is re-
lon needle is passed through the abdominal wall moved, the abdomen is deflated and the purse
into the proximal ureter, and a guidewire is in- string retightened to close the umbilical port site.
Fig. 5 Fig. 6
610 S. Cascio and H. L. Tan
Fig. 7 Fig. 8
Fig. 9
I25 Button Vesicostomy 611
I 25Button Vesicostomy I25
S. Cascio and M. S. Yassin
16F
Fig. 1
Musaab S. Yassin
Core Trainee in Urology
musaab.aldouri@gmail.com
Patient Positioning
Operative Technique
Fig. 4
Fig. 5
614 S. Cascio, T. J. Bradnock and H. L. Tan
I26 I 26Laparoscopic-Assisted Insertion
of a Peritoneal Dialysis Catheter
S. Cascio, T. J. Bradnock and H. L. Tan
Equipment
Port Position and Placement
• 5-mm 30° telescope
• Insertion kit, PD introducer with 16-Fr peel- • A supra-umbilical inverted-J incision is made,
away sheath and dilator (Fig. 1) extending to the left of the umbilicus (Fig. 2).
• The exit site is marked, taking into consider- A supraumbilcal “inverted J” incision is made on
ation the belt line with the patient standing. the left side of the umbilicus (Fig. 2). Monopolar
• A urethral catheter is inserted and a single dose diathermy is used to divide the subcutaneous tis-
of antibiotic is given. sue and to expose the anterior rectus sheath below
the umbilicus and with the index finger, by blunt
dissection, a space for the cuff is created between
the anterior rectus sheath and the subcutaneous
tissue. The peritoneal cavity is entered with a stan-
Salvatore Cascio ()
dard Hasson technique above the umbilicus. It is
Consultant Paediatric Surgeon and Urologist
The Royal Hospital for Sick Children, Dalnair Street, essential to remove as much omentum as possi-
Yorkhill, Glasgow G3 8SJ, Scotland, UK ble to minimize catheter blockage. The omentum
Email: salvatore.cascio@ggc.scot.nhs.uk
Tim J. Bradnock
Specialty Registrar in Paediatric Surgery
The Department of Paediatric Surgery, Dalnair Street,
Yorkhill Hopsital, Glasgow G3 8SJ, Scotland, UK
Email: tjbradnock@doctors.org.uk
is grasped with forceps and delivered outside the roscopic vision (the needle at 30 degree angle with
abdominal cavity, is tied with ligature and excised. the abdominal wall) (Fig. 3). This allow the cathe-
The abdomen is insufflated with carbon dioxide ter to be sited in the pelvis and the obliquity of the
to a pressure of 10-15 according to the age of the track to prevent leakage. The double ended guide-
child. A long oblique tract in the abdominal wall wire is advanced through the needle into the pelvis
extending from the infraumbilical space towards (Fig. 4). The needle is removed and a 16 Fr peel
the pelvis is created with a large needle under lapa- away sheath and dilator are inserted over the wire
(Fig. 5). The dilator is removed and the peritoneal
dyalisis catheter is fed through the sheath toward
the pelvis, behind the bladder (Fig. 6). Once the
catheter is inside the pelvis, the sheath is peeled
away leaving the peritoneal dyalisis catheter in the
pelvis. A 1cm stab incision is made lateral to the
rectus muscle on the left (Fig. 2). A long curved
mosquito forceps is introduced into the 1 cm inci-
sion to create a subcutaneous tunnel towards the
umbilicus. At the umbilicus the catheter is grasped
with the curved mosquito forceps and pulled to-
wards the exit site. It is important that the cuff is
at least 2 cm away from the exit site. The abdomen
is deflated, the Hasson port is closed, subcutane-
ous approximated with an absorbable suture and
skin closed with topical skin adhesive.
Fig. 2
Fig. 3
616 S. Cascio, T. J. Bradnock and H. L. Tan
Fig. 4
Fig. 5
I26 Laparoscopic-Assisted Insertion of a Peritoneal Dialysis Catheter 617
Fig. 6
Tips
77 The optimally sited catheter has: 77 The exit site should be located as far as possible
– Long, oblique course through rectus sheath from other exit sites (gastrostomies, colostomies,
to minimise the risk of leak and help maintain urostomies).
its position in the pelvis 77 The exit site should be located on the left side of
– Long, curved subcutaneous tunnel to reduce the abdomen, as the majority will require future
the risk of displacement and infection renal transplantation on the right
77 Ensure the catheter exit site does not lie over the 77 The catheter should be irrigated in theatre for
belt line; it should be above the nappy/diaper patency using 10–20 ml/kg of normal saline,
line in infants. flushed with 5 ml heparinised saline (500 U/l)
and then capped off.
Common Pitfalls
Fig. 1
Fig. 6
I27 Laparoscopic Repair of Duodenal Atresia 621
Fig. 7 Fig. 8
Fig. 9 Fig. 10
622 H. L. Tan
I28 I28 Laparoscopic excision of Choledochal
cyst and Hepatico-duodenostomy
H. L. Tan
Patient positioning liver edge taking care to avoid the inferior epi-
gastric vessels. This will allow sufficient space in-
The patient is placed at the foot of the table and side the abdomen to manipulate your hand in-
the surgeon operates from the patient’s left side of struments. This port is inserted with the patient
at the foot of the table (Fig. 1). lying flat (Fig 2).
Fig. 1
Fig. 3 Fig. 4
External traction on this hitch stitch will lift the Mobilising the cyst
liver to the anterior abdominal wall, and both
ends of the suture secured with a single artery The common hepatic artery is usually medial to
forceps for the entire duration of the operation. the choledochal cyst although the right hepatic ar-
It is usually necessary to “take down” the gas- tery can cross anterior to the choledochal cyst, and
tro-colic omentum for adequate surgical exposure extreme care must be taken dissecting the proxi-
to choledochal cyst and its deeper extension be- mal port of the choledochal cyst at its common
hind the duodenum into the head of the pancreas. hepatic duct end.
The portal vein is usually posterior and is usu-
ally very closely related to the posterior wall of
Retrograde Cholecystectomy the choledochal cyst.
Dissection is commenced at the lateral margin
A retrograde Cholecystectomy is performed, de- of the cyst, where the gall bladder, and the correct
taching the gall bladder off its fossa, but leaving tissue plane developed. While this initial dissec-
it attached to the cystic duct. The attached gall tion can be commenced with monopolar hook,
bladder serves as a very useful “handle” to ma- the development of the tissue plane and identifi-
nipulate the choledochal cyst when you are dis- cation of the common hepatic artery is best done
secting it off the common hepatic artery and por- using a needle point laparoscopic bipolar forceps
tal vein (Fig. 4). (Tan bipolar) to mininise lateral damage and to
Fig. 5
I28 Laparoscopic excision of Choledochal cyst and Hepatico-duodenostomy 625
Hepatico-Duodenostomy
Renal calculi are rare in children and accounts for the presence of upper tract infection when there
about 1–3 percent of all patients presenting with may be poor uptake of DMSA by the renal cortex.
urinary calculi. Unlike in adults where the great A MAG3 scan is better if obstruction is suspected.
majority of stones are idiopathic, it is not uncom-
mon to find an infective, or metabolic cause. An Urinalysis
underlying anatomical abnormality may also pre-
dispose to the formation of calculi, particularly Routine microscopy and urine culture should be
if the patient has had a proteus urinary tract in- performed. Other investigations of use is urinary
fection. Bladder stones are particularly prevalent calcium, urate, oxalate, cystine, and creatinine.
in children following bladder augmentation. In- Any stone should be sent for chemical compo-
fective calculi are usually soft, containing organic sition analysis.
matrix, and may be poorly opacified.
Hypercalciuria is the most common meta- Plasma
bolic abnormality, followed by cystinuria, hyp-
eroxaluria, hyperuricosuria, and unclassified hy- Blood investigations should include creatinine,
percalcemia. Aboriginal children in the outback urea, electrolyte profile, magnesium, calcium,
of Australia are particularly susceptible to uric phosphate, alkaline phosphatase, albumin, and
acid stones. urate. Reecurrent calculi strongly suggests a met-
abolic cause.
Preoperative Evaluation
Management Options
Radiology
Extracorporeal shock-wave lithotripsy (ESWL),
The main imaging modality for upper urinary Percutaneous nephrolithotomy (PCNL), and ure-
tract stones is ultrasound. Ureter may be difficult terorenoscopy (URS) have almost replaced open
to visualize in children, although indirect evidence surgery for renal calculi in children.
of mild ureteric dilatation may indicate the pres- The aim of treatment is to clear the stone bulk
ence of a stone. with minimal damage to the functioning of re-
A plain abdominal x-ray of the whole urinary nal tissue. An infected and obstructed collecting
tract may be useful in children, and a limited in- system must be drained urgently by percutane-
travenous urogram may be required to detect ra- ous nephrostomy.
dioluscent stones in the distal ureter. Any patient undergoing any form of interven-
A dimercaptosuccinyl acid (DMSA) scan or tion or stone manipulation should be adminis-
mercaptoacetyl-triglycine (Mag3) may provide tered intravenous antibiotics perioperatively on
functional information of the kidneys except in the presumption that the stone is infective in or-
igin.
Hock Lim Tan ()
The treatment modality/modalities chosen will
Visiting Paediatric Surgeon,
Prince Court Medical Centre, Kuala Lumpur depends on the age of the patient, the stone bur-
Malaysia & Adjunct Professor Faculty of Medicine, den etiology, pelvicalyceal anatomy, including any
Universitas Indonesia, Jakarta, Indonesia co-morbidities.
Operation technique
The patient is then draped with a large dispos- peel away sheath serves as an “Amplatz” sheath
able neuroincise drape which keeps the patient and can be peeled down to the appropriate length
completely dry during the procedure, to allow to accommodate the infant operating cystoscope.
fluids to run off during PCNL will into the bag. This is a very secure method of dilating the
Before commencing the procedure, the “C” arm tract. As it is “railroaded” over the guide wire with
should be positioned and a still image obtained very little chance of dislodgement or loss of tract.
to ensure that there is no radio-opaque heater el- It is not necessary to perform serial dilatations. In
ements, ECG leads etc which may interfere with earlier studies, we demonstrated that most of the
the imaging. bleeding occurs during the interchange of dila-
A small full thickness skin incision is made at tors. We have also found that performing a single
the nephrostomy puncture site and a straight hae- pass using an 18fr dilator does not split the kidney.
mostat used to dilate the underlying fascia and Nephroscopy can then be performed in a vir-
lumbar musculature. (Fig. 4) tually bloodless field and the stones fragmented.
An 18 Fr dilator is then passed over the “com- Smaller pieces of stone will be flushed out with the
mon rail”, (with its peel away sheath), and passed irrigant, but larger pieces can be removed with the
into the renal pelvis under direct radiological guid- assortment of graspers.
ance Fig. 5a, 5b. It is usually necessary to image Following stone clearance, a 8Fr “cope” neph-
the collecting system by performing a limited ret- rostomy catheter is passed over the guide wire into
rograde pyelogram using the previously inserted the ureter and then retracted slowly while tugging
angiographic catheter. on the “string” gently, to place the loop accurately
Once the tip of the dilator is correctly posi- within the renal pelvis.
tioned in the renal pelvis, evident on the imaging
(Fig. 5b), the peel away sheath is then advanced
over the dilator into the collecting system. The
Fig. 4
Fig. 5
I29 Management of Upper Urinary Tract Calculi 631
Points of technique:
Training in Paediatric Surgery in the UK is di- There are 10 modules in CST that every trainee
vided into two parts: must cover. These are:
• Core Surgical Training 2–3 years • Module 1: Basic science knowledge relevant
• Higher Surgical Training 6 years to surgical practice
• Module 2: Common surgical conditions
Details of the syllabus of both Core and Higher • Module 3 Basic surgical skills
Surgical training can be found on the Intercol- • Module 4: The principles of assessment and
legiate Surgical Curriculum Programme (www. management of the surgical pa-
iscp.ac.uk). tient
The level of skill and knowledge expected at • Module 5: Peri-operative care of the surgical
each stage of training is noted in the syllabus as patient
follows: • Module 6: Assessment and early treatment of
Level of knowledge the patient with trauma
• Level 1 knows of • Module
�����������������������������������������������
7: Surgical care of the paediatric pa-
• Level 2 knows basic concepts tient
• Level 3 knows generally • Module 8: Management of the dying patient
• Level 4 knows specifically & broadly • Module 9: Organ and tissue transplantation
• Module 10: Professional behaviour
Clinical & technical skills
• Level 1 has observed In addition, any trainee wishing to progress to
• Level 2 can do with assistance higher training in Paediatric Surgery must have
• Level 3 can do whole but may need assistance undertaken a six month post in Paediatric Sur-
• Level 4 competent to do without assistance gery and have covered the following topics in their
– trainee is at Certificate of Comple- learning plan:
tion of Training (CCT) level • Basic science
• Child with abdominal pain
Trainees in the early years of training will be ex- • The vomiting child
pected to have reached levels 1-3 in both knowl- • Trauma in children
edge and skills. Trainees nearing completion of • Child with groin conditions
training will be expected to be at level 4 in most • Abdominal wall pathology
topics and procedures. • Paediatric urology
• Child with constipation
• Head or neck swelling
Core Surgical Training (CST) • Emergency paediatric surgery
Table 1
Category Years 3-4 (Intermediate) Years 5-6 (Final 1) Years 7-8 (Final 2)
Neonatal Pyloromyotomy Operative closure of gas- Operative closure of gas-
Surgery Operative closure of gas- troschisis/exomphalos troschisis/exomphalos
troschisis/exomphalos Repair congenital dia- Repair oesophageal atresia
Laparotomy for intestinal atresia phragmatic hernia Repair congenital dia-
Colostomy Correction of malrotation phragmatic hernia
Laparotomy for NNEC Correction of malrotation
Laparotomy for simple Laparotomy for NNEC
meconium ileus Laparotomy for simple/
Duodenoduodenostomy complex meconium ileus
Neonatal inguinal herniotomy Duodenoduodenostomy
Gastro- Flexible upper/lower Subtotal colectomy Subtotal colectomy
intestinal GI endoscopy and ileostomy and ileostomy
Surgery Change or removal of PEG tube Right hemicolectomy Right hemicolectomy
Insertion of PEG tube Small bowel resection Small bowel resection
for Crohn’s disease for Crohn’s disease
Pull-through for
Hirschsprung’s disease
PSARP
Uro- Cysto-urethroscopy Distal hypospadias repair Proximal hypospadias repair
logical Circumcision Open nephrectomy Reimplantation of ureter
Surgery Exploration of acute scrotum Open heminephrectomy Open nephrectomy
Insertion of perito- Closure of vesicos- Open heminephrectomy
neal dialysis catheter tomy or urostomy Bladder augmentation
Pyeloplasty Pyeloplasty
Laparo- Laparoscopic appendicectomy Laparoscopic fundoplication Laparoscopic fundoplication
scopic Laparoscopy for im- Laparoscopic cholecystectomy Laparoscopic nephrectomy
Surgery palpable testis Laparoscopic assisted inser- Laparoscopic cholecystectomy
Laparoscopic Fowler Ste- tion of gastrostomy tube
phen’s procedure Laparoscopic pyloromyotomy
Laparoscopic liga-
tion of varicocele
Oncologi- Cervical lymph node biopsy Tumour nephrectomy Resection of neuroblastoma
cal Sur- Insertion of portacath
gery Open insertion of CVL
Percutaneous insertion of CVL
Thoracic Thoracotomy Thoracotomy and lo- Thoracotomy and lo-
Surgery bectomy for CCAM bectomy for CCAM
Thoracoscopic decortica- Thoracoscopic decortica-
tion for empyema tion for empyema
Thoracoscopic resection Thoracoscopic resection
of mediastinal mass of mediastinal mass
General Open appendicectomy Laparotomy for trauma Laparotomy for trauma
Surgery Open reduction of in- Laparotomy and divi- Laparotomy and divi-
tussusception sion of adhesions sion of adhesions
Epigastric hernia repair
Ligation of PPV
Umbilical hernia repair
Orchidopexy
Inguinal herniotomy
– non-neonatal
Subject Index 639
Subject Index
B –– peripherally inserted
central 77
–– complications 467
–– ileal conduit 465
ne 17, 20
dorsal slit of the fores-
bandage 29, 105 –– portacaths 82, 85 –– indications 465 kin 402
–– Esmarch 29, 105 chart, Lund and Brow- congenital diaphragmatic –– complications 403
Bentley, John Francis Ro- der 73 hernia 312 drain 107, 226
gers 352 Cheatle’s cut 281, 291 –– patch 313 –– chest 226
biliary atresia 364 chest tube 211 –– subcostal laparoto- –– corrugated 108
–– Kasai procedure 364 –– complications 213 my 312 –– dressings 107
biopsy 87, 90, 149, 202 –– insertion 211, 212 continent catheterisable –– fixation 107
–– core 89 –– safe triangle 211 conduit 471 –– tube 108
–– extremity tumour 202 choledochal malforma –– alternatives to the appen- –– types 107
–– fine-needle aspira tion 366 dix 472 –– Wick’s 108
tion 87 –– biliary reconstruc –– complications 472 –– Yate’s 108
–– laparoscopic 87 tion 366 –– indication 471 draping 8
–– lymph node 149 –– excision 366 –– Mitrofanoff princip- –– square 8
–– muscle 90, 91 –– forme fruste 367 le 471 –– triangular 8
–– open 87 –– King’s College Hospital contracture, flexion 64 drill, handheld twist 17, 19
–– open rectal 339 Classification 367 Cushing, Harvey 25 duct 144, 151, 165
–– percutaneous 87 circumcision 398–400 cut, Cheatle’s 281, 291 –– accessory thoracic 151
–– seromuscular colo- –– complications 401 cyst 125 –– submandibular 144
nic 345 –– urethral meatoto- –– external angular dermo- –– thoracic 151, 165, 166
–– skin 90 my 403 id 125 duodenal atresia 322
640 Subject Index
–– diamond-shaped anasto-
mosis (Kimura) 323
F –– greenstick 174, 175
–– molded cast 174
–– artificial erection
test 416
–– duodenal membrane/ fascia 171 –– plastic deforma –– chordee assess-
windsock 324 –– erector spinae 171 tion 174 ment 416
–– repair 322 –– thoracolumbar 171 –– Salter-Harris 174 –– classification of hypospa-
dura 171 fasciotomy 95 –– tibial diaphysis 190 dias 413, 414
–– compartment syndro- –– external fixation 190 –– complications 422
me 95 fundoplication 270 –– double-Y glanuloplasty
E –– lower-limb 95
femoral hernia 386
–– complications 272
–– open Nissen 270
technique 416
–– general principles 413
ear deformity 134 –– repair 386 –– glandular and coro-
elevator 17 filum terminale 171 nal hypospadias re-
–– Cobb spinal 17, 19
–– Pennybacker 17, 19
fistula 147, 224, 233
–– bronchopleural 233,
G pair 423–425
–– glans configuration 415
empyema 218 236 gastric pull-up 317 –– inverted-Y modified
–– complications 221 –– H-type tracheo-oesopha- –– complications 321 Mathieu repair 417
–– definition 218 geal 166 –– mobilization 318 –– inverted-Y modified
–– management 218 –– thyroglossal 147 –– in the abdomen 318 Thiersch technique 418
–– open decortica- –– tracheo-oesophage- –– of oesophagosto- –– lateral-based flap tech-
tion 218–220 al 224 my 317 nique 419
encysted hydrocele of the fistula-in-ano 493 –– oesophago-gastric anas- –– management princip-
cord 377, 378 –– opening 494 tomosis 320 les 413
endoscopy 245 fixation, external 190 gastroschisis 273 –– objectives of surge-
–– colonoscopy 254 flap, Buck–Gramcko 196 –– primary closure 273 ry 414
–– complications 245 Folkman, Judah 333 –– silo application 274 –– suturing tech-
–– pre-operative check- forceps 11 gastrostomy 260 niques 415
list 245 –– Adson tissue (non- –– complications 262, 265 –– two-stage hypospadias
–– proctoscopy 252 tooth) 11, 12 –– correct positioning 262 repair (1st stage) 426–
–– rigid sigmoidosco- –– Adson tissue (tooth) 12 –– percutaneous endosco- 428
py 252 –– Allis 14, 15 pic 263 –– two-stage hypospadias
–– upper gastrointesti- –– Babcock 14, 15 –– Stamm 260, 271 repair (2nd stage) 429,
nal 245 –– bipolar diathermy 21 gland 151 430
enterostomy 278 –– broad non-tooth 12 –– salivary 151 –– urethral reconstruction
–– complications 278 –– Charnley–McIndoe 12 –– thyroid 153 using buccal muco-
–– loop 278 –– curved Kelly (mosquito) Gross, Robert E. 227 sa 420
–– Bishop–Koop distal chim- artery 14, 16
ney 335
H
–– DeBakey vascular 12
–– Mikulicz double-bar-
relled 336
–– McGill’s 222
–– Mixter 14
I
–– Santulli–Blanc 335 haematoma 94 ileocystoplasty 468, 469
–– Rampley sponge-hol-
epigastric hernia 268 haemorrhage 68, 70 –– complications 470
ding 11
–– repair 268 –– control 70 ileostomy 286
–– straight artery 14, 16
ex-utero intrapartum treat- –– stabilisation 68 –– complications 289
–– forearm 174
ment (EXIT) 151 haemostasis 67 –– technique 288
–– Hyndman’s cast ra-
exomphalos 275 –– methods 67, 68 imperforate hymen 410
tio 176
–– conservative treat- –– principles 67 –– complications 412
–– manipulation 174
ment 275 Halstead, William Ste- incision 37
–– plaster of Paris 176
–– primary closure 275 wart 10 –– Bikini 51
–– diaphyseal reduc-
–– silo application 276 hemicolectomy, right 283 –– classic McBurney 50
tion 181
–– staged repair 276 Hirschsprung disease 341, –– Gridiron 50
–– unstable diaphyseal
extracorporeal life sup- 344, 353 –– hockey-stick 46, 52
fractures 181
port 239 –– myomectomy 349–351 –– Kocher 43
foreign body, bronchoscopic
–– cannulation 239 –– rectosigmoid 341 –– Lanz 50, 51
removal 222
–– technique 240 –– ultrashort segment 349 –– Mercedes-Benz 43, 45
fracture 29, 184
–– complications 241 Hirschsprung, Harald 340 –– midline 40
–– Colles’ 29
–– decannulation 241 Holter, John 159, 162 –– modified Mc-Burney 51
–– displaced supracondylar
–– principles 239 hydrocele 380 –– muscle-splitting 50
humeral 184
–– veno-arterial 239 hydrocephalus 159 –– paramedian 40
–– femoral 101, 188
–– veno-venous 239 hypospadias surgery 413 –– Pfannenstiel 47
–– forearm manupulation
Subject Index 641
–– patient posi
tioning 531
–– equipment 614
–– operative tech-
–– Santulli–Blanc enterosto-
my 335
O
–– surgical emphyse- nique 614 –– T-tube ileostomy 335 oesophageal atresia 224
ma 532 –– patient positioning 614 midgut volvulus 293 –– repair 224, 225
–– tension pneumotho- –– port positioning and molded cast 174 –– long-gap 317
rax 532 placement 614 mycobacterium, atypi- oesophagostomy 163, 317
–– trocar complica- –– pre-operative prepara cal 150 –– cervical 163, 164
tions 533 tion 614 omphaloplasty 266
–– urinary tract inju- ligation of patent processus orchidectomy 377, 378
ry 537
–– ventral hernia 537
vaginalis 377, 378, 380,
381
N orchidopexy (open) 377,
378, 404
–– Veress needle 532 –– complications 382 necrotising enterocoli- –– complications 406
–– visceral injury 536 linea alba 41 tis 325 ovarian surgery 407
–– energy sources 539 liver –– clip and drop 325 –– ovarian transposition be-
–– electrocautery 539 –– principles of surge- –– open and close laparoto- fore radiotherapy 409
–– gyrus plasma kine- ry 361 my 325 –– resection of benign
tic 539 –– resection 362 –– primary peritoneal cyst 407, 408
–– Ligasure 540 –– segmental anato- drain 325
–– ultrasonic ener- my 361, 362 –– resection and primary
gy 540
–– ergonomics 527
local anaesthesia 26–31
–– Bier’s block 29
anastomosis 325
–– resection and stoma
P
–– heuristics 527 –– digital nerve block 30, formation 325 pancreatic pseudocyst 369
–– laparoscopic sutu- 31 –– second look laparoto- –– surgical cyst-gastrosto-
ring 529 –– field block 27 my 325 my 369
–– non-stereoscopic naviga- –– inguinal block 27, 28 needle holder 15 –– treatment options 369
tion 528 –– intercostal block 29, 30 –– Crile-Wood 15, 17 parotidectomy 141
–– port positions 528 –– penile block 32 nephrectomy (open) 442, pectus excavatum, minimally
–– positioning of the video –– safety 26, 32, 33 443 invasive repair of 542
monitor 528 –– types 26 –– complications 444 –– complications 546
–– theatre layout 527 lung resection 228, 231 nephrostomy 453 –– indications 542
laparoscopic varicocelec- –– complications 230, 233, –– complications 458 –– operative tech-
tomy (lymphatic-spa- 236, 238 –– open 453, 456 nique 542, 544
ring) 595 –– right lower lobecto- –– percutaneous 455 –– patient positioning 542
–– equipment 595 my 234 nerve –– pectus bar 543
–– operative tech- –– right pneumonecto- –– accessory 151 –– fixation 545
nique 595 my 228 –– digital 30 –– flippers 544
–– patient positioning 595 –– right upper lobecto- –– facial 140, 141, 150 –– stabilization 545
–– port positioning and my 231 –– genitofemoral 28 –– pectus introducer 543
placement 595 –– wedge resection 237 –– hook 171 –– pre-operative assess-
–– pre-operative prepara –– hypoglossal 151 ment 542
tion 595 –– iliohypogastric 27, Pena, Alberto 507
laparoscopic-assisted endo-
rectal pull-through 577
M 28, 52
–– ilioinguinal 27, 28, 52,
perianal abscess 493
perineal injuries 487
–– colonic mobilisa malformation, lympha- 379, 382 –– anal injury 488
tion 578 tic 151 –– intercostal 30 –– classification 487
–– complications 579 malrotation 293 –– long thoracic 217 –– perineal body inju-
–– endorectal dissec- manoeuvre 319 –– monitor 152 ry 488
tion 578 –– Kocher’s 319, 322 –– phrenic 151 –– peritoneal injury 488
–– equipment 577 –– Pringle 362 –– recurrent laryngeal 165 –– principles of emergency
–– operative tech- meconium ileus 334 –– marginal mandibular management 487
nique 577 –– Bishop–Koop distal chim- branch 150, 151 –– urethral injury 487
–– patient positioning 577 ney enterostomy 335 –– subcostal 450 –– vaginal/labial injury 488
–– port positioning and –– complicated 334 –– superficial peroneal 95 peritoneal drainage 306
placement 577 –– enterotomy and irriga –– ulnar 187 –– closed suction 306
–– pre-operative prepara tion 334 –– vagus 151 –– complications 308
tion 577 –– Mikulicz double-barrelled neuroblastoma 331–333 –– indications 306
laparoscopic-assisted peri- enterostomy 336 –– abdominal 331 –– open 306
toneal dialysis catheter –– non-complicated 334 –– reduction 331 –– paracentesis 307
insertion 614 –– resection and primary –– percutaneous Seldin-
–– complications 614 anastomosis 335 ger 306
Subject Index 643
–– retroperitoneal lymph
node dissection 397
–– complications 217
–– mini (muscle-spa-
–– complications of surge-
ry 449
W
thermal injury 72 ring) 215 –– hemi-nephrectomy washout 192
–– assessment of depth 72 –– positioning 214 (open) 448 –– hip 192
–– burn 72 –– technique 214, 215 –– incision of ureteroce- –– knee 192
–– criteria tissue, musculoskeletal 174 le 448 Wilms tumour 328–330
–– for admission 73 toenail 204 ureteric reimplantation 478 Wilms, Carl M.W. 330
–– for PICU admis –– ingrown 204 –– Cohen technique 478 wiring 178
sion 74 –– phenolisation 205 –– complications 481 –– closed 181
–– for referral 73 –– simple avulsion 204 –– Politano–Leadbetter –– distal radius 178
–– deep dermal 72 –– wedge excision 205 technique 478 –– entry 179
–– documentation 72 –– Zadek’s procedure 207 ureterostomy 461 World Health Organisation
–– early management 72 tongue-tie 144 –– complications 464 (WHO) 3
–– examination 72 torticollis 155 –– end 463 –– Safe Surgery Guideli-
–– full thickness 72 tourniquet 105, 204 –– loop 461 nes 3
–– history 72 –– complications 106 –– sober 463 –– Surgical Safety Check-
–– resuscitation 72 tracheostomy 151, 153 urethral catheterisa list 3–5
–– scald 72 trauma laparotomy 309 tion 435, 436 wound 70, 71, 110
–– split skin graft 74 –– four-quadrant pa- –– complications 438 –– closure 70
–– superficial 72 cking 310 urethral meatotomy 402 –– delayed primary 70
–– superficial dermal 72 –– Pringle’s manoeuv- –– primary 70
Thomas splint 101 re 311 –– colonised 116
thoracoscopic decortication
for empyema 556
T-tube 335
–– ileostomy 335
V –– contaminated 116
–– debridement 70
–– complications 557 tube, trans-anasto- varicocoele 392 –– dressings 110–112
–– indications 556 motic 323 –– complications 395 –– infected 116
–– operative tech- tumour, Wilms 328–330 –– management 392 –– irrigation 71
nique 556 tunneller 17, 20 –– open Palomo procedu- –– management 110, 114,
thoracoscopic diaphragmatic tying 58 re 392 115
hernia repair 558 –– hand 58, 59 venepuncture 76 –– Napkin Care Guideli-
–– equipment 558 –– instrument 60–63 venogram 84 nes 117
–– operative tech- –– magnetic resonance 84 –– reconstruction 71
nique 558 venotomy 83 –– types 114
–– patient positioning 558
–– port positioning and
U vesicostomy 459
–– blocksom 459
wound healing 34
–– local factor 36
placement 558 umbilical hernia repair 266 –– complications 460 –– primary intention 34
thoracoscopic lobecto- upper gastrointestinal blee- –– indication 459 –– secondary intention 34
my 550 ding 248 vesicoureteric reflux 475 –– systemic factor 36
–– complications 555 –– banding (varices) 250 –– complications of endo-
–– indications 550 –– endoscopic manage- scopic surgery 477
–– lower lobectomy 550 ment 248–250 –– endoscopic treat-
–– middle lobectomy 550 –– non-variceal 248 ment 475
–– room setup 551 –– pre-endoscopy check –– hydrodistension im-
–– trocar placement 551 list 248 plantation technique
–– upper lobectomy 555 –– sclerotherapy 251 (HIT) 475
thoracoscopic lung bio- –– variceal 249 Vitello-intestinal anoma
psy 547 upper urinary tract calcu- lies 300
–– complications 549 li 627 –– Meckel’s diverticu-
–– indications 547 –– extracorporeal shock- lum 300
–– operative tech- wave lithotripsy 628 –– persistent Vitello-intesti-
nique 547 –– management op- nal duct 301
–– room setup 548 tions 627 –– Vitello-intestinal
–– trocar placement 548 –– percutaneous nephroli- band 301
–– using endoloops 549 thotomy 628–630 V-quadrilateral-Z (VQZ)-
–– using endoscopic stap- –– pre-operative evalua plasty for stoma 473
ler 549 tion 627 –– indication 473
thoracotomy 214 ureteric duplication anoma
–– axillary 215 lies 448