Pediatric Surgery Part 1

I always wondered why we don't have a lot of pediatric surgeries in our department or in our hospital for that matter. We do have occasional pediatric surgeries like circumcision, hypospadia and chordee repair, but that's it, no general surgeries, all genito-urinary surgeries.

Last week, I learned that the reason why we don't have general surgeries for babies that is because almost all of the consultants were either already based in US or training in other countries. But this week is different. A pediatric surgeon who is already based in US, comes back and ta-da suddenly we have a pediatric surgery everyday and luckily, I'm always scrubbing in their surgeries.

Yup! I considered it as a good opportunity especially if you are getting bored to the things that's happening in your life. I mean yes I'm not that yet good in scrubbing or circulating in every surgeries that there is in operating room, but scrubbing and assisting in pediatric surgeries is like a breath of fresh air. Although senior staffs are always telling me that they prefer assisting in geriatrics rather than in pediatrics because if there's an emergency the life of pediatrics is in a more immediate danger than in adults.

Anyways, the first ever surgery that I was able to assist with Dr. L is the endorectal pullthrough.

ENDORECTAL PULLTHROUGH

 Endorectal pullthrough is the treatment of choice for patients who were diagnosed to have Hirschsprung's Disease.

The procedure consists of removing the mucosa and submucosa of the rectum and pulling the ganglionic bowel through the aganglionic muscular cuff of the rectum.

 OPERATIVE PROCEDURE:

The patient was anesthetized and placed in the lithotomy position. A urinary catheter was optional. Given anorectal dilatations half a minute, the right index finger was inserted into the rectum and pressing the anterior rectum-wall onto the above pubic symphysis. The left index finger pressed the abdominal-wall onto the corresponding site above the pubic symphysis, joining the two fingers together. This was the usual peritoneal reflection on children. Then with the right hand holding oval forceps through the anus, inserted forceps into the rectum and touched the left index finger then clipped the rectal wall. Slowly pulled the anterior-rectal wall down to the anus (Figure A) to produce an artificial intussusception between the rectum and the distal sigmoid colon. Fine silk suturing was performed circumferentially at the level of that point which would be used for traction for the distal end. Another circumferential suture was performed parallel 0.5 cm distances above the original one and used for traction for the proximal intestines. The full-thickness rectal wall was truncated between the above two circumferential sutures with cautery, avoiding damaging adjacent tissues when the abdominal cavity was open (Figure B). The full thickness of rectum and sigmoid colon was mobilized out though the anus and the mesenteric vessels were carefully dissected and ligatured (Figure C). The colon was divided until at 15 cm above the most proximal normal site. A definite resection line where ganglion cells were present was determined by intraoperative rapid frozen section. The distal rectum was pulled eversion and was dissected anteriorly 2.5–3.5 cm above the dentate line. The posterior rectal wall was split longitudinally and dissected until 0.5–1.0 cm above the dentate line. The residual segment was resected. After an oblique routine anastomosis was performed (Figure D), the large intestine was pulled back and an anal tube was placed. (Source: CMJ)

THINGS TO PREPARE:

 Pediatric OR set-up

Instruments:
mosquito curve and straight
kelly

Supplies:
silk 2-0
silk 4-0T5
chromic 4-0T5
chromic 5-0
vicryl 4-0T5

Anyways, the operation per se is quite easy with unremarkable event, the difficult part is during the induction of anesthesia to the patient. The anesthesiologist is having difficulty finding a good vein to insert an IV, so instead of starting early, we were delayed for two hours.

All in all, it was fun in a sense that you'll be glad that the baby was able to survive the operation and that he/she will be having a better future. :)