Title: Pediatric surgery. Lecture notes.
Lecture notes are intended to prepare medical students for exams.
The lecture notes presented to your attention are intended to prepare students of medical universities for passing the exam. The book includes a full course of lectures on pediatric surgery, is written in accessible language and will be an indispensable assistant for those who want to quickly prepare for the exam and pass it successfully.
Lecture notes will be useful not only for students, but also for teachers.
Successful treatment of children with acute surgical diseases primarily depends on timely diagnosis and early implementation of the necessary set of therapeutic measures.
The latter includes rational preoperative preparation (the duration and intensity of which depends on the general condition of the child, the presence of concomitant diseases, etc.), as well as targeted postoperative treatment, the nature of which varies significantly depending on the age of the child, the type of disease and the degree of disruption of homeostasis.
Equally important is the correct choice of anesthesia method and sufficient experience of the surgeon in performing pediatric operations.
The difficulty of diagnosing many surgical diseases and developmental defects is mainly associated with the mental immaturity of the child and the functional characteristics of his systems and organs.
Patients of early age cannot make complaints, and anamnestic data must be obtained from the mother or the attendants of the maternity hospital. This does not always make it possible
Many acute surgical diseases of a newborn must be recognized in the maternity hospital. Early diagnosis depends on the awareness of the obstetrician, pediatrician and radiologist in these issues.
The most serious difficulties arise when diagnosing malformations of internal organs.
CONTENTS
LECTURE No. 1 Features of the treatment of children with surgical diseases
General principles of examination and diagnosis
Preoperative preparation
LECTURE No. 2 Preoperative preparation
Features of preoperative preparation for acute surgical diseases accompanied by intoxication
Preoperative preparation against the background of traumatic shock
LECTURE No. 3 Acute diseases of the lungs and pleura
1 Lung malformations Lobar emphysema
2 Complicated congenital lung cysts
LECTURE No. 4 Malformations of the esophagus
Esophageal obstruction
Esophageal obstruction
LECTURE No. 5 Esophageal-tracheal fistulas Damage to the esophagus Perforation of the esophagus
1 Esophageal-tracheal fistulas
2 Damage to the esophagus Chemical burns
3 Perforation of the esophagus
LECTURE No. 6 Bleeding from dilated veins of the esophagus with portal hypertension
LECTURE No. 7 Diaphragmatic hernias Phrenico-pericardial hernias
1 Hernia of the diaphragm itself
Complicated false hernia of the diaphragm proper 2 Complicated true hernia of the diaphragm proper
3 Hiatal hernia
4 Hernias of the anterior part of the diaphragm Complicated phrenico-pericardial hernias
LECTURE No. 8 Umbilical cord hernias
LECTURE No. 9 Strangulated inguinal hernias
LECTURE No. 10 Gastric obstruction
1 Prepyloric gastric obstruction
2 Pyloric stenosis
LECTURE No. 11 Congenital intestinal obstruction Acute congenital intestinal obstruction
LECTURE No. 12 Recurrent congenital intestinal obstruction
1 Circular intestinal stenosis
2 Ledd syndrome
3 Internal abdominal hernias
4 Compression of the intestinal lumen by cystic formations
LECTURE No. 13 Acute intussusception
LECTURE No. 14 Adhesive intestinal obstruction
1 Early adhesive intestinal obstruction
2 Late adhesive intestinal obstruction
LECTURE No. 15 Dynamic intestinal obstruction
1 Spastic intestinal obstruction
2 Paralytic ileus
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LECTURE COURSE ON PEDIATRIC SURGERY
(textbook for students and interns)
DONETSK-2006
BBK:54.5 + 57.33 i 7
K93UDC 617. D(075.8)
Course of lectures on pediatric surgery. Textbook / Under the general editorship of Professor Grona V.N. – Donetsk, 2006. – S.
^
Reviewers: Head Department of Hospital Surgery and Endoscopy Donetsk State Medical University
them. M. Gorky Doctor of Medical Sciences, Prof. Kondratenko P.G.
Head supporting department of pediatric surgery in Dnepropetrovsk
^State Medical Academy, Doctor of Medical Sciences, Prof. Sushko V.I.
In the book prepared by the team of the Department of Pediatric Surgery, Anesthesiology and Intensive Care of Donetsk State Medical University. M. Gorky, modern ideas about the etiology, pathogenesis, clinical picture, diagnosis and treatment of the main surgical diseases of childhood are outlined.
^ Authors:
Grona V.N.
Zhurilo I.P.
Vesely S.V.
Sopov G.A.
Sushkov N.T.
Muzalev A.A.
Shcherbinin A.V.
Moskalenko S.V.
Maltsev V.N.
Fomenko S.A.
Latyshov K.V.
Donetsk State Medical University
Table of contents
Developmental defects and diseases causing acute respiratory failure in newborns and young children.
Malformations of the colon in children.
Purulent-inflammatory diseases of the lungs and pleura in children.
Surgical diseases of the liver and spleen in children.
Acquired intestinal obstruction. Clinic, diagnosis and treatment of intussusception in children.
Features of the course, diagnosis and treatment of acute appendicitis in children. Peritonitis.
Tumors in children.
Malformations of the digestive tract in newborns and infants.
Purulent-inflammatory diseases in newborns and infants.
Malformations of the upper and lower urinary tract. Classification. Modern methods of diagnosis and correction.
Principles of pediatric oncology.
Differential diagnosis of abdominal diseases that cause clinical symptoms of acute abdomen in children.
^ DEVELOPMENTAL DISEASES AND DISEASES CAUSING ACUTE RESPIRATORY FAILURE IN NEWBORNS AND YOUNG CHILDREN
Purpose of the lecture: be able to diagnose developmental defects and diseases causing acute respiratory failure in newborns and young children.
^
Lecture outline:
Introduction.
Emergency syndromes in pediatric surgical pulmonology.
Classification of developmental defects and diseases causing acute respiratory failure.
Clinic, diagnosis and treatment of individual defects and diseases causing acute respiratory failure.
The term acute respiratory failure (ARF), often used when assessing a patient’s condition, includes changes in three main indicators of partial oxygen tension: arterial blood (pO 2), partial tension of carbon dioxide (pCO 2), as well as respiratory mechanics, reflecting the ventilation capacity of the lungs and efforts the body to maintain pO 2 and pCO 2 within normal limits.
In arterial blood, the partial tension of carbon dioxide (pCO 2) is normally 35-40 mm Hg, the partial tension of oxygen (pO 2) is 85-90 mm Hg. Art. Decrease in pO 2 below 80 mm Hg. Art. is called hypoxemia, and an increase in pCO 2 more than 40 mm Hg. Art. – hypercapnia. Acute respiratory failure in newborns and young children is common and is one of the causes of perinatal mortality (up to 40-50% according to WHO in 2000). Its occurrence is facilitated by: damage to the central nervous system, aspiration syndrome, malformations and diseases of the upper respiratory tract, lungs , esophagus, diaphragm, diseases of the mediastinal organs and others.
The variety of causes and the commonality of clinical manifestations of ARF caused by pulmonary and extrapulmonary factors complicate the diagnostic search and establishment of a topical diagnosis. Often, during a respiratory accident, there is a violation of the cardiovascular system as a result of decreased lung perfusion, hypertension of the pulmonary circulation, kinking of the great vessels, and others.
It is safe to say that developmental defects and diseases of one-sided failure in newborns and young children are considered emergency conditions that require emergency care and timely diagnosis.
^ Emergency syndromes in the surgical room
pediatric pulmonology
The importance of syndromic diagnosis in pediatric emergency pulmonology is difficult to overestimate. With regard to acute surgical diseases that cause ARF in newborns and young children, the following syndromes can be distinguished:
Intrathoracic tension syndrome (intrapulmonary and intrapleural).
Mediastinal tension syndrome.
Pulmonary parenchyma exclusion syndrome.
Bronchial dumping syndrome.
Cardiovascular syndrome.
Purulent-septic syndrome.
Under mediastyl tension syndrome understand pathological conditions characterized by increased pressure in the mediastinum, compression of the mediastinal organs, superior vena cava and disruption of their functions. Intrapericardial tension is most often caused by purulent pericarditis, hemopericardium, and cardiac tumor. Extrapericardial tension can be caused by mediastinitis, a tumor of the mediastinum.
^ Pulmonary parenchyma exclusion syndrome combines processes accompanied by acute obstruction of the airway and a decrease in the alveolar surface of the lung or lung malformations (spasm, obstruction, tracheal stenosis, compression of the trachea from the outside, mediastinal tumors, atelectasis, inflammatory infiltration of the parenchyma, hypoplasia and agenesis of the lung, and so on).
Under bronchial dumping syndrome understand breathing disorders that develop as a result of the release of air through a functioning broncho-pleural fistula. This syndrome is observed with destruction of the lung of various etiologies, both inflammatory and traumatic injury to the lung.
Under purulent-septic syndrome understand the complex of clinical, biochemical and pathophysiological changes occurring in the body of a child suffering from an acute purulent disease of the lungs and pleura with a tendency to generalize the infection (often found with SDL, pyothorax, suppurating lung cyst, bronchial foreign bodies, and so on).
^ Cardiovascular syndrome, usually combined with other pathological syndromes.
Classification of developmental defects and diseases,
causing acute respiratory failure
In the clinical practice of a doctor, it is quite rare to encounter an isolated diagnosis syndrome, emergency pulmonology in childhood; usually they are combined, layering one on top of the other. However, despite the above, as a rule, it is possible to identify a leading symptom, which in many cases can become a diagnostic key in establishing a diagnosis in combination with other symptoms.
When diagnosing malformations and diseases that cause ARF in newborns and young children, the symptom of mediastinal displacement is extremely valuable. The symptom of mediastinal displacement in a child with ARF convincingly confirms the presence of an intrathoracic catastrophe requiring emergency care.
Having prioritized the presence or absence of a symptom of mediastinal displacement in the classification of the causes of acute respiratory failure in newborns and young children, we, taking into account a number of authors, propose the following classification, dividing all causes into 3 groups.
Classification of developmental defects and diseases that cause ARF in newborns and young children:
Diseases and malformations accompanied by a shift of the mediastinum towards the localization of the lesion
atelectasis of the lung, lobe, segment of the lung,
agenesis, lung hypoplasia, lobes
Diseases and malformations accompanied by displacement of the mediastinum to the side opposite to the side of the lesion.
acute lobar emphysema,
tense brushes of the lung
diaphragmatic red (true, false),
pyothorax, hemothorax, pneumothorax, pyopneumothorax, chylothorax,
giant tumors of the mediastinum.
Diseases and malformations that occur without mediastinal displacement
tracheal stenosis, tracheomalacia
tracheoesophageal fistulas (isolated or in combination with esophageal atresia),
atresia joanus,
ranula,
Pierre-Robin syndrome,
macroglossia (true, false)
traumatic brain injury
Atelectasis of the lung– collapse of the lung or part of it (lobe, segment) occurring as a result of impaired aeration (obstruction of the bronchi, their spasm).
In newborns, congenital or primary atelectasis is distinguished, which is based on the structural and functional immaturity of the lungs, an increase in the surface tension of the alveoli, associated with the lack of surfactant. Secondary or aspiration atelectasis is most often caused by aspiration of amniotic fluid, mucus from the birth canal at birth or milk with various congenital defects of the esophagus and pharynx or with a violation of the swallowing reflex.
The clinical manifestation of atelectasis is characterized by signs of acute respiratory failure, the severity of which depends on the volume of atelectasis pulmonary parenchyma. Noteworthy is the child's anxiety, severe shortness of breath and tachypnea, retraction of the intercostal spaces, cyanosis, and tachycardia. Upon examination, there is a lag of the affected half of the chest in the act of breathing, and with total atelectasis - its retraction. Percussion reveals a sharp shift in the boundaries of the mediastinum towards the lesion, where a shortening of the percussion sound is determined. Auscultation of breathing on the affected side is weakened or absent.
Atelectasis of the lung or lobe is radiologically characterized by intense homogeneous shading with a concave contour, displacement of the mediastinal shadow towards the affected side, and a high position of the dome of the diaphragm on the affected side. When atelectasis is located in the middle lobe, the direct projection image shows a triangular-shaped shadow adjacent to the mediastinum; On the lateral radiograph, the shadow of atelectasis is located obliquely.
The most effective method in the treatment of atelectasis should be considered bronchoscopic sanitation, which allows, under visual control, to free the patient’s airways from aspirated fluid and mucus. In some cases, you can resort to tracheal intubation followed by sanitation of the tracheobronchial system.
Along with these methods, simpler and more accessible methods can be used (chest massage, including percussion, the use of aerosol inhalations). To treat atelectatic pneumonia, patients are prescribed antibacterial therapy.
^ Lung agenesis - a developmental defect consisting in the absence of all structural units of the lung: bronchi, vessels, parenchyma. Children with bilateral agenesis are not viable and die immediately after birth. Agenesis resembles the clinical picture of total pulmonary atelectasis. It is characterized by severe breathing disorders (tachypnea, shortness of breath, cyanosis), detected immediately after the birth of the child. An objective examination reveals a total displacement of the mediastinum towards the lesion, along with a sharp weakening of breathing. A general X-ray examination reveals homogeneous shading of the affected side with a displacement of the mediastinal organs to the same side, vicarious emphysema of a healthy lung with the formation of a “mediastinal hernia” in the upper sections. The diagnosis is clarified using bronchoscopy, in which the absence of the main bronchus is noted.
^ Lung hypoplasia represents underdevelopment of all structural units. Simple hypoplasia of the lung is a uniform underdevelopment of the lung with reduction of the bronchiolar tree. Clinically, it manifests as cough with sputum, shortness of breath on exertion, recurrent infection and pneumonia. X-ray examination reveals a decrease in the pulmonary field, a displacement of the mediastinal organs to the affected side, and a high position of the dome of the diaphragm. Bronchography reveals a decrease in the number of bronchial branches, their thinning and deformation. Cystic hypoplasia of the lung is characterized by underdevelopment of the respiratory region with the formation of multiple cyst-like expansions. The clinical picture is dominated by chronic recurrent pneumonia. Bronchography reveals multiple thin-walled cavities of varying diameters.
^ Acute congenital lobar emphysema. Lobar emphysema is characterized by a sharp increase in the volume of one of the lobes of the lung due to its overextension. Etiologically, the occurrence of congenital lobar emphysema is due to the underdevelopment of individual structural elements of the lung. They are based on: aplasia of smooth muscles, terminal and respiratory bronchi, local pulmonary hypoplasia due to a reduced number of bronchial branches, leads to excessive overextension of the lung lobe, and underdevelopment of the alveolar septa leads to an increase in the acinus. Violation of the drainage function of the bronchi leads to the formation of a valve mechanism such as an “air trap” and excessive overextension of the lung lobe. An increase in the volume of the emphysematous lobe of the lung is accompanied by compression of the surrounding normal lung tissue, displacement of the mediastinal organs in the opposite direction with the development of acute respiratory failure and impaired circulation in the pulmonary circle. Acute lobar emphysema is characterized by classic manifestations of intrapulmonary tension syndrome. Children are restless, there is shortness of breath, cyanosis, and attacks of asphyxia. When breathing, retraction of the intercostal spaces is observed. On the affected side, half of the chest bulges and lags behind in the act of breathing. Tympanitis is determined by percussion on the affected side. The boundaries of the heart are shifted to the healthy side. Auscultation on the side of lobar emphysema shows no breathing. Plain radiography reveals an increase in the volume and transparency of one of the lobes of the lung, a shift of the mediastinum to the healthy side, compression of the functioning parts of the lung, flattening of the dome of the diaphragm, a mediastinal hernia due to movement of the overinflated lobe to the opposite side.
Differential diagnosis with pneumothorax is facilitated by layered computed tomography, which reveals a delicate pulmonary pattern against a background of increased transparency. Treatment is only surgical, aimed at removing the affected lobe of the lung.
^ Congenital lung cysts - a round cavity formation filled with air or mucous contents, having a shell with an epithelial lining. Congenital lung cysts are the result of impaired development of the bronchopulmonary system during embryogenesis. In this regard, they are often referred to as bronchogenic cysts. The clinical picture of congenital lung cysts depends on the location, size of the cysts and type of complications. The acute course of the cyst is caused by the valve mechanism and the development of intrapulmonary tension syndrome. It manifests itself as severe shortness of breath, cyanosis, and anxiety. Physically: an increase in the volume of the corresponding half of the chest, a decrease in respiratory excursions, local tympanitis percussion, the borders of the heart are shifted to the opposite side. Radiologically, it is manifested by a rounded thin-walled formation, devoid of a pulmonary pattern in the area of the cyst, collapse of the surrounding areas of the lung, and displacement of the mediastinal organs in the opposite direction. Due to the rupture of a tense cyst, a tension pneumothorax develops and is accompanied by chest pain, severe shortness of breath, cyanosis, and circulatory disorders. Suppuration of the cyst is accompanied by a significant deterioration in general condition, high fever, cough with sputum production. Physically: weakened breathing, dullness of percussion sound in the area of the cyst. X-ray reveals rounded shading with clear contours, sometimes with a small horizontal level of fluid. For newborns with tense lung cysts, puncture or drainage of the cyst according to Monaldi is indicated to relieve intrapulmonary tension. For congenital lung cysts in children, only surgical treatment can be radical. The latter is justified because spontaneous disappearance of cysts is not observed, sooner or later complications arise. Observation is permissible only for small, uncomplicated air cysts in infants. The choice of the extent of surgical intervention is determined by the extent of the lesion, the localization of the cyst, and the presence of irreversible changes in the surrounding lung tissue - this can be cystectopia, segmental resection or lobectomy.
^ Congenital diaphragmatic hernia . This malformation is often accompanied by a picture of acute respiratory failure due to the gradual movement of the abdominal organs into the pleural cavity, while the lung collapses, intrapleural tension develops with displacement of the mediastinal organs and kinking of the great vessels. The incidence of diaphragmatic hernia ranges from 1:1700 to 1:5000 newborns. The most common (80%) is left-sided diaphragmatic hernia. The pathogenesis of diaphragmatic hernias is explained by a violation of the fusion in embryogenesis of all diaphragmatic anlages, with the formation of defects, most often in the posterolateral region, which leads to the development of a false diaphragmatic hernia. Violation of the formation of the diaphragm at the stage of strengthening the pleuroperitoneal membrane with muscle fibers (3-4 months) leads to thinning and protrusion of part of the diaphragm into the chest cavity with the formation of a true diaphragmatic hernia. It should be taken into account that the movement of abdominal organs into the pleural cavity can occur during intrauterine development, as a result of which secondary lung hypoplasia develops. A decrease in the alveolar surface of the lung leads to a decrease in the total number of small arterial vessels of the lung with the development of hypotrophy of their muscular elements, which is the cause of pulmonary hypertrophy and right ventricular failure. Shunting blood from right to left through the ductus arteriosus and foramen ovale causes systemic hypoxia, hypercapnia and acidosis. When a child is born with a diaphragmatic hernia, in the first 2-3 hours, attention is drawn to a scaphoid abdomen and retraction of the epigastric region during inspiration. After 3-4 hours, the clinical picture of acute respiratory failure increases due to the filling of the gastrointestinal tract with air and the development of intrapleural tension syndrome. With a false diaphragmatic hernia, as a rule, the syndrome of “asphyxial strangulation” develops, the signs of which are: shortness of breath, cyanosis, worsening when the child cries; cardiac dysfunction, vomiting. Physical examination reveals asymmetry of the chest due to bulging of its half on the side of the diaphragmatic hernia, and a sunken abdomen. Percussion tympanitis on the side of the hernia, auscultation - lack of breathing, it is often possible to listen to peristaltic sounds in the pleural cavity. The Peter-Pokorny symptom helps to recognize a diaphragmatic hernia in newborns - a gradual, for the first time 3-4 hours of life, shift of the heart impulse, tones and boundaries of the heart to the right. Relaxation of the dome of the diaphragm (true hernia) is much less likely to manifest as “asphyxial strangulation” syndrome. Protrusion of a limited area of the diaphragm into the chest cavity can be asymptomatic for a long time. Ultrasound examination during intrauterine development allows diagnosing the defect in 60-90% of cases. Polyhydramnios in pregnant women is detected in 80% of cases. An X-ray examination of the chest reveals the presence of multiple cavities (“mesh network symptom”) of irregular size on the side of the diaphragmatic hernia, displacement of the heart shadow in the opposite direction. In difficult cases, X-ray contrast examination of the gastrointestinal tract is used.
Treatment of diaphragmatic hernias complicated by “asphyxial strangulation” is performed with emergency surgery. Preoperative measures include endotracheal intubation (mask oxygenation is contraindicated), insertion of a gastric tube, central vein catheterization, medications that correct pulmonary vascular resistance and respiratory failure, intravenous administration of glucose-saline solutions taking into account diuresis.
^ Pyothorax, pneumothorax, pyopneumothorax in newborns and young children are complications most often of acute purulent destructive pneumonia, very rarely birth trauma of the lung and chest, or as a consequence of artificial ventilation in newborns with a defect causing acute respiratory failure (hypoplasia, atelectasis). Clinical manifestations pyothorax, pneumothorax and pyopneumothorax are characterized by symptoms of intrapleural tension and the development of acute respiratory failure, depending on the pathogenesis of the disease.
Pyothorax in case of ARF it is characterized by severe intoxication, respiratory failure, and in infants – abdominal syndrome. On examination, there is a lag of the corresponding half of the chest in the act of breathing. Auscultation – sharp weakening of breathing; percussion - shortening the percussion sound. X-ray: significant shadowing of half the chest with a shift of the mediastinum to the opposite side, widening of the intercostal spaces and lack of differentiation of the dome of the diaphragm and the pleural sinus.
***1. Stories of development and organization of surgical care for children in Russia, in the Sverdlovsk region.
on the initiative of K.A. Rauchfus in St. Petersburg, the first children's surgical department was opened at the hospital named after. Oldenburgsky. In Moscow, the first children's surgical department was opened in 1876 in the Vladimir Hospital, currently called the Children's Clinical Hospital No. 2 named after. St. Vladimir. V.I. was invited to head this department. Irshik is a pediatric surgeon. In 1887, a children's department was opened at the Olga Hospital (children's tuberculosis hospital). The work of this department was headed by L.P. Alexandrov was a prominent pediatric surgeon of that time, a professor at Moscow University. In 1897, a surgical department was founded in the Sofia Hospital (currently the N.F. Filatov Children's Hospital), and in 1903 - in Morozovskaya. The surgical department at the Sofia Hospital was headed by D.E. Gorokhov is a doctor of medicine, a famous pediatric surgeon, a teacher who gave lectures on pediatric surgery to university students. D.E. Gorokhov is the author of the first monograph in our country, “Pediatric Surgery.” In 1922 in Petrograd on the basis of the hospital named after. K.A. Rauchfus at the Soviet Clinical Institute for the improvement of doctors, the Department of Pediatric Surgery was organized, which was first headed by F.K. Weber, and then Professor N.V. Schwartz. In Moscow, the center of pediatric surgery was the department of the 1st Children's Clinical Hospital, headed by T.P. Krasnobaev. The main scientific direction was the problem of treating osteoarticular tuberculosis in children. For the classic work “Osteoarticular tuberculosis in children” Together with his colleagues S.D. Ternovsky and A.N. Ryabinkin, he made a significant contribution to the development of organizational issues of pediatric surgery, as well as to the treatment of osteomyelitis, pleural empyema and appendicitis. The first department of pediatric surgery in our country was organized in 1931 at the 2nd Moscow State Medical Institute. The clinical base of the department was the Children's City Hospital named after N.F. Filatova. The first head of the department was the famous topographical anatomist and highly educated general surgeon Konstantin Dmitrievich Esipov (they successfully used the functional method of treating bone fractures in children, blood transfusions, and the open method of treating body burns). In 1935, the head of the department was the prominent surgeon Vladimir Petrovich Voznesensky. Under his leadership, new research methods, original operations on children, in particular new studies of the kidneys and bladder, and primary plastic surgery of the urethra in case of injury were introduced into practice. In 1943, the department was headed by Sergei Dmitrievich Ternovsky, a student of one of the founders of domestic pediatric surgery, T.P. Krasnobaeva. Brought up in the best traditions of the three largest medical schools - A.V. Martynova, G.N. Speransky and T.P. Krasnobaeva - S.D. Ternovsky concentrated all his organizational skills on the further development of the main problems of pediatric surgery.
S.D. Ternovsky, an outstanding surgeon, founder of the national school of pediatric surgeons, after graduating from the Faculty of Medicine of Moscow University from 1919 to 1924, served in the Red Army, then worked as a general surgeon. In 1925, he organized a children's surgical department at the Institute of Maternal and Child Health, and in subsequent years he headed the surgical department of the Children's Model Hospital and at the same time worked as an assistant to G.N. Speransky. After defending his doctoral dissertation in 1943, until the last days of his life (1960), he headed the Department of Pediatric Surgery at the 2nd Moscow State Medical Institute. N.I. Pirogov. Under the leadership of S.D. Ternovsky department has become a scientific, practical and organizational center of pediatric surgery in our country. S.D. Ternovsky went from a resident to a professor, corresponding member of the USSR Academy of Medical Sciences, and Honored Scientist of the RSFSR. There is practically not a single section of pediatric surgery that he did not develop. Among the numerous scientific works of S.D. Ternovsky - three monographs (“Diagnostics of some surgical diseases in children”, “Cleft lip in children”, “Burns of the esophagus in children”), as well as a textbook on pediatric surgery. The work of the doctor and scientist S.D. Ternovsky combined with great social and organizational activities. For many years he was the dean of the pediatric faculty, chairman of the section of pediatric surgeons of the Moscow Society of Surgeons, and a member of the board of the All-Union, All-Russian and Moscow societies of surgeons. Among the students of S.D. Ternovsky - leading surgeons and scientists, healthcare organizers. Among them are academicians of the Russian Academy of Medical Sciences M.V., Volkov, Yu.F. Isakov, S.Ya. Doletsky, E.A. Stepanov, professor N.I. Kondrashin, M.V. Gromov, V.M. Derzhavin, A.G. Pugachev, V.L. Andrianov, L.A. Vorokhobov and others.
In 1961, the department was headed by Ivan Konstantinovich Murashov. Under his leadership, the clinic continued to develop issues of thoracic and abdominal surgery, urology, traumatology, as well as the problem of acute surgical infection. A number of scientific studies that began during S.D.’s lifetime have been successfully completed. Ternovsky.
Since 1966, the department has been headed by student S.D. Ternovsky - Yuri Fedorovich Isakov, academician of the Russian Academy of Medical Sciences, laureate of state prizes, Honored Scientist of the Russian Federation and Honored Doctor of the Russian Federation.
In 1968, the country's first research laboratory of pediatric anesthesiology and resuscitation was created at the department (headed by Professor V.A. Mikhelson).
In the success of treating children, the leading role belongs to the proper organization of local pediatric surgical services. Children with congenital and acquired surgical diseases must be hospitalized only in specialized pediatric surgical hospitals, which is determined primarily by the anatomical and physiological characteristics of the development of children, especially newborns and young children. The clinical picture and diagnosis, features of care, preparation for surgery, anesthesia and intensive care in the postoperative period play a decisive role in treatment.
A new form of organizing surgical care for children is a one-day hospital, where “minor surgery” operations are performed in compliance with all generally accepted laws: the child is admitted to the hospital in the morning and discharged home after a few hours.
***2. Ethics and deontology in pediatric surgery. Informed parental consent. Legal norms and ideontological principles of medical practice with a sick child, with parents in case of injuries, developmental anomalies, in cancer and intensive care patients.
Aspects of medical deontology are:
relationships between health workers and patients;
relationships between medical workers and the patient’s relatives;
relationships between medical workers.
The main goals of a nurse’s professional activity are: caring for patients, alleviating their suffering, restoring and strengthening their health, and preventing disease.
To achieve these goals, when performing her functional duties, a nurse must know and comply with the following basic ethical principles such as humanity and mercy.
The implementation of ethical principles in medicine includes:
informing the patient about his rights;
informing the patient about his health status;
humane attitude towards the patient;
respect for human dignity patient;
prevention moral and physical damage to the patient (do no harm);
respect for the patient's right to carrying out or refusing medical intervention;
respectpatient autonomy;
respect for the patient's right to high-qualityand timelymedical care;
showing careful relationship with the dying to the sick (distributive justice);
storage professional secrecy;
maintaining a high level of professional competence;
protecting the patient from incompetent medical intervention;
maintaining respect for your profession;
respectful attitude towards your colleagues;
participation in health care educating the population.
Informed voluntary consent to medical intervention is given by one of the parents or other legal representative:
firstly, in relation to a minor, as well as in relation to a person recognized as legally incompetent;
A citizen, one of the parents or other legal representative of these persons has the right to refuse medical intervention or demand its termination. The legal representative of a person recognized as incompetent in accordance with the procedure established by law exercises this right if such person, due to his condition, is unable to refuse medical intervention. The possible consequences of refusing medical intervention must be explained in an accessible form to the citizen, one of the parents or other legal representative of these persons.
An important guarantee for incapacitated persons when deciding on medical intervention or refusal of it is the possibility of a medical organization going to court to protect the interests of such a person in a situation of refusal of medical intervention necessary to save his life. The legitimate interests of these persons in this case are also protected by the guardianship and trusteeship authorities.
***3. Pediatric surgery, pediatric anesthesiology and resuscitation as specialties (sections, area of responsibility). Interaction and continuity with other clinical disciplines. Main modern directions of development.
Emergency surgery
1. Acute appendicitis in children. Etiology. Pathogenesis. Morphological classification. Typical clinical picture. Diagnostic methods. Differential diagnosis. Features of the clinical picture and diagnosis in young children. Factors that determine the unique course of the disease. Causes of the atypical course of the disease. ***Diagnostic and treatment-tactical errors at various stages of medical care. Treatment: preoperative preparation, methods of surgical treatment. Postoperative rehabilitation.
Etiology and pathogenesis of acute appendicitis. Acute appendicitis is essentially an enterogenous autoinfection, a nonspecific inflammatory process in which obstruction of the lumen of the appendix occurs. In this case, the secretion of the mucous membrane, having no exit from the appendix, accumulates in the lumen, stretching it. As a result, intraluminal pressure increases, which sometimes leads to arterial obstruction and ischemia. The mucosa undergoes focal ulcerations or even complete destruction, and then fibrinous-purulent exudate appears on the serous surface. Intestinal bacteria penetrate the altered mucosa and cause diffuse intramural damage with melting of the wall of the appendix. The combination of bacterial infection and arterial infarction leads to gangrene and perforation.
Scientists attach importance to a number of factors that contribute to the development of the infectious process in the appendix. For example, the undoubted influence of the nutritional factor (abuse of meat food), previous somatic or infectious diseases has been established.
In childhood, acute appendicitis has a number of distinctive features, which can be explained by the anatomical and physiological characteristics of the growing organism. The rarity of OA in infants is explained by the nature of food at this age (mainly liquid dairy foods) and the small number of lymphoid follicles in the mucous membrane of the appendix, which creates the background for the development of infection. With age, the number of follicles increases and, in parallel, the incidence of appendicitis increases.
There are also structural features of the nervous system in young children, one of which is hypomyelination of nerve fibers. There is also insufficient maturity of the innervation apparatus: in the ganglia of the appendix there are a large number of small cells such as neuroblasts. This is reflected in the development of the pathological process, since in tissues where the nervous system is embryonic in nature, the pathological process proceeds unusually.
Clinical and morphological classification. The classification of appendicitis is based on the clinical and morphological stages of its development. Based on the pathological picture, four forms of acute appendicitis are distinguished:
catarrhal, phlegmonous, gangrenous and perforative.
For catarrhal appendicitis the serous membrane of the appendix is hyperemic, the appendix is tense, and there may be fecal stones in its lumen.
^ For phlegmonous appendicitis characterized by purulent inflammation of all layers of the appendix. Its wall is hyperemic, often covered with fibrinous-purulent plaque. Often the process is club-shaped thickened due to the presence of pus in its lumen. This is an empyema of the appendix. The mesentery of the appendix in phlegmonous appendicitis is thickened and swollen. Serous-purulent exudate is detected in the abdominal cavity in almost half of the patients.
^ For gangrenous appendicitis destructive changes occur in the entire thickness of the process wall. It thickens, acquires an earthy color, and becomes covered with purulent deposits. The wall of the process becomes flabby and easily ruptures. The inflammatory process, as a rule, spreads to the parietal peritoneum, cecum and ileum. Serous-purulent or purulent exudate accumulates in the abdominal cavity. The modified appendix is enveloped in omentum, which is the beginning of the formation of an appendicular infiltrate.
^ Perforated appendicitis develops in cases where purulent melting of the wall of the appendix occurs and its contents exit into the abdominal cavity. This form of appendicitis occurs in older children when they do not seek medical help in a timely manner or when this disease is not diagnosed in a timely manner. In older children with perforated appendicitis, appendiceal infiltrate is more often formed, and in the younger age group (children under 3 years old) - generalized peritonitis.
Clinical picture of acute appendicitis in older children characterized by the appearance of non-localized abdominal pain that occurs gradually. Initially, pain may appear in the epigastric region or in the navel area, later localized in the right iliac region (Kocher-Volkovich method). The appearance of pain is associated with the initial obstruction of the process and acute stretching of its lumen. Nociceptive impulses from the stretched wall of the process are transmitted along visceral afferent sympathetic fibers through the abdominal ganglia to the 10th thoracic segment of the spinal cord and then to the umbilical region, which is the zone of the 10th dermatome. The highest intensity of pain is observed at the beginning of the disease, then it decreases due to the death of the nervous apparatus of the appendix, and a period of “imaginary well-being” begins. When the appendix is perforated, the pain intensifies again, and signs of peritoneal irritation appear.
The patient's facial expression clearly indicates a state of discomfort and fear. During examination and attempted palpation, the child tries to evade examination. In the first hours of the disease, older children may experience nausea and vomiting due to inflammation of the appendix. If vomiting precedes abdominal pain, then, as a rule, the child is more likely to have gastroenteritis rather than appendicitis.
Children with appendicitis refuse to eat (anorexia). This is so typical for this disease that if a child with abdominal pain asks for food and says that he is hungry, then appendicitis is usually excluded. But, of course, it should be remembered that some children may ask for food even when they are seriously ill, and therefore it is not always possible to rely on anorexia as an unconditional sign of appendicitis.
Most children have stool retention; in rare cases, tenesmus and diarrhea are observed, which can cause diagnostic errors.
Body temperature may be normal or low-grade.
The general condition of children with acute appendicitis at the onset of the disease is satisfactory. As the inflammatory process develops, it may worsen. The patient's position is typical: most often he lies on his right side, with his legs slightly bent, avoiding any movements. Sometimes the child lies on his back, but not on his left side. The right leg is often slightly bent at the hip joint. Hyperextension of the right hip increases abdominal pain. When walking, the child leans forward or supports the right hip in a bent position.
An objective examination of the patient begins with determining the pulse rate. In the presence of an inflammatory process in the abdominal cavity, a discrepancy between the pulse rate and the height of body temperature may be detected: pronounced tachycardia with low-grade fever.
At the beginning of the disease, the tongue is moist and clean. Then there is a dry mouth, a dry, gray-coated tongue.
An external examination of the abdomen in the first hours of the disease does not detect any pathology. The abdomen is not swollen and participates in the act of breathing. With the involvement of the peritoneum in the inflammatory process, protective sparing of the right iliac region in the form of its lag during the act of breathing. Superficial palpation determines the presence of tension in the anterior abdominal wall in the area where the inflamed appendix is located. Deep palpation reveals local tenderness in the right iliac region. To clarify the diagnosis, it is necessary to check a number of other symptoms characteristic of acute appendicitis. These include:
The symptom of a “cough shock” is increased pain in the right iliac region when coughing;
Sitkovsky's symptom - increased pain in the iliac region on the right when the child is positioned on the left side;
Rovsing's symptom - with the right hand they compress the lumen of the sigmoid colon in the left half of the patient's abdomen, after which with the left hand above this place they make jerking movements, under the influence of which the gas in the colon is displaced retrogradely. If there is inflammation of the appendix and the dome of the cecum, then increased pain in this area appears;
Voskresensky's symptom is determined by sliding the II-IV fingers of the doctor's right hand along the patient's shirt stretched on the anterior abdominal wall from the epigastric region to the outer third of the left and right inguinal folds. If pain in the right iliac region increases, the symptom should be considered positive;
Filatov's symptom - increased pain in the right iliac region with deep palpation;
Shchetkin-Blumberg's symptom is determined by deep gradual pressure with two or three fingers of the right hand on the abdominal wall with their rapid abduction. Increased pain in the abdomen when the arm is abducted indicates involvement of the peritoneum in the inflammatory process (a positive symptom).
Diagnostics:
History, clinical picture, palpation, symptoms of peritoneal irritation
Northern State Medical University
V. A. KUDRYAVTSEV
PEDIATRIC SURGERY
in lectures
Textbook for medical schools
2nd edition, revised
Arkhangelsk
UDC 617-089(075) BBK 54.5ya73+57.3ya73
K 88
Reviewer: Professor, Doctor of Medical Sciences V. P. Bykov
Published by decision of the editorial and publishing council of the Northern State Medical University
Kudryavtsev V. A.
To Pediatric surgery in lectures: Textbook for medical universities: Ed. 2nd, revised - Arkhangelsk: Publishing Center of SSMU, 2007. - 468 p.
ISBN 978-5-86279-157-0
The book presents lectures on pediatric surgery according to the course program for students of pediatric faculties of medical higher educational institutions. The author of the textbook, Professor V.A. Kudryavtsev, headed the Department of Pediatric Surgery at the ASMA from 1982 to 2000. Extensive practical and pedagogical experience allowed him to prepare a very original publication: a theory based on specific examples of treating little northerners. Many years of work as the chief pediatric surgeon of the Arkhangelsk region gave the author the opportunity to analyze various errors in the diagnosis and treatment of surgical diseases in children and give specific advice on avoiding these errors.
Preface
Pediatric surgery, unlike general surgery, which is as old as the world, is a very young branch of medicine - it gave its first sprouts only in the 19th century. Until this time, surgical care for children was provided by general surgeons, and they considered the size of the object of their activity to be the only difference between the surgery of children and the surgery of adults. From a medical and biological point of view, the child was considered as a “miniature adult.”
Pediatric surgery was born at the intersection of two medical specialties - surgery and pediatrics, when it became clear that a child is distinguished from an adult to a very large extent by anatomical and physiological features. With the development of science, these features were revealed more and more. In Russia, the earliest information about the characteristics of surgical diseases in children appeared in the works of the founder of the first domestic surgical school, I. F. Bush in 1807. Since 1840, the Russian pediatrician S. F. Khotovitsky (1796–1885) began to give lectures on the peculiarities of surgical diseases in children at the oldest medical university in the country, the St. Petersburg Medical and Surgical Academy. But practical medicine took up pediatric surgery only in the second half of the 19th century. In 1869, the first children's hospital in Russia was opened in St. Petersburg with a surgical department for the first time. The organizer of the hospital, its first chief physician and at the same time the head of the children's surgical department was the then famous pediatrician and surgeon K. A. Rauchfus, whose name after 1917 the hospital bears to this day. (Before the revolution, it bore the name of Prince P.-G. of Oldenburg, at whose expense it was built at the request of Rauchfus). It was an exemplary children's medical institution, which for many years served as the standard for organizing pediatric care.
In 1876, the St. Vladimir Children's Hospital was opened in Moscow, then the Sofia (1897, now named after N. F. Filatov) and Morozov (1903) children's hospitals were opened there, in which surgical departments were also deployed. All these hospitals are still operating today and are
In the periphery, pediatric surgical departments began to open at the turn of the 19th–20th centuries. The oldest department is the one created
V 1895 in Irkutsk.
IN In 1925, a clinic of pediatric surgery and orthopedics was opened in Leningrad at the Scientific Research Institute for the Protection of Maternity and Childhood (that was the name then of the current St. Petersburg Pediatric Medical Academy). The first department of pediatric surgery also appeared in the northern capital (1922) - at the Leningrad Institute for Advanced Medical Studies, it worked on the basis of the hospital named after.
K. A. Rauchfus and was headed by the then famous surgeon F. C. Weber. In 1931, the Department of Pediatric Surgery was organized at the Second Moscow Medical Institute (K. D. Esipov), and two years later - at the Leningrad Pediatric Medical Institute (N. V. Schwartz).
IN In 1934, by government decree, pediatric faculties were created in fourteen medical universities in the country, and departments of pediatric surgery were opened at them. Starting this year, the USSR began preparations unprecedented for the whole world pediatricians. The difference between it and world practice to this day is that Russia is the only country where pediatricians are trained in special faculties
V universities (in other countries, doctors receive this specialization after graduating from the general medical faculty).
The next rapid stage in the development of pediatric surgery in the country began a quarter of a century later: since 1961, pediatric surgical departments, including specialized ones, began to be created in all regional centers. Newly opened pediatric hospitals were no longer conceivable without such departments. Arkhangelsk was no exception. Here
V 1966 The first pediatric surgical department with 40 beds was opened
V surgical building put into operation at the same time 1st Arkhangelsk City Clinical Hospital. The department was headed by surgeon K. F. Shelepina. This department became the basis for organizing a pediatric surgery clinic at the Arkhangelsk State Medical Institute (now the Academy). The teaching of pediatric surgery at the Faculty of Medicine began at the State Medical Institute in 1969 at the Department of Hospital Surgery (Associate Professor V. I. Mironova). In 1973, the Arkhangelsk Regional Children's Hospital admitted its first patients, which includes several surgical departments. Six years later, the country's northernmost medical university started preparations pediatricians, and also
three years later (1982), the Department of Pediatric Surgery was organized here (Professor V. A. Kudryavtsev).
This is the brief history of the organization of surgical care for children in our country, and in particular in the North. Doctors who have made an invaluable contribution to the development of pediatric surgery have worked and continue to work in the clinics named here. Thanks to their scientific and practical activities, many discoveries have been made in this area, and a wealth of experience has been accumulated, which forms the essence of modern Russian pediatric surgery.
I will name only a few names. And first of all - an academician
Timofey Petrovich Krasnobaev(1865–1952), who worked in Moscow. He was the first in our country to begin performing pyloromyotomy and pyloric stenosis operations, and worked a lot to improve the treatment of acute appendicitis and its complications in children. But T. P. Krasnobaev has special merits in the field of treatment of bone tuberculosis (USSR State Prize) and hematogenous osteomyelitis in children.
StudentT. P. Krasnobaeva Sergey Dmitrievich Ternovsky(1896–1960)
played an outstanding role in pediatric surgery not only as a practitioner, but also as a talented organizer of healthcare and medical science. Working at the Second Moscow Medical Institute (now the Russian State Medical University), he created a national school of pediatric surgeons, which produced a galaxy of famous personalities. Among them are Academician of the Russian Academy of Medical Sciences Professor Yu. surgery, orthopedics, neonatal surgery, anesthesiology and resuscitation. In each of these branches of pediatric surgery and labor. D. Ternovsky and his students made a very significant contribution.
Student of S. D. Ternovsky Yuri Fedorovich Isakov(born in 1923) played a role in the development of pediatric surgery no less outstanding than his teacher: he managed to create a unique system of surgical care for children in the USSR and Russia, which has no analogues in the world. On his initiative and thanks to his perseverance, the system for training pediatric surgeons in domestic universities that we have today (including subordination and internship) was created. In the Center for Pediatric Surgery organized by him on the basis of the children's hospital named after. N. F. Filatov has the greatest specialists working in Moscow, his students are corresponding members of the Russian Academy of Medical Sciences, professors E. A. Stepanov, V. A. Mikhelson, etc. Many departments of pediatric surgery in Russia and the former republics of the USSR are also headed by his students.
At the Leningrad School of Pediatric Surgeons, an outstanding organizational role belongs to a brilliant surgeon Girey Alievich Bairov(1922–1999).They are known for their research and development of surgical tactics in all areas of pediatric surgery, but his special love is orthopedics and neonatal surgery. G. A. Bairov was the first in the USSR to carry out successful operations for esophageal atresia in newborns (1956), the first to develop and perform equally successful operations for biliary atresia, and proposed many modifications of already known operations for various malformations. The Department of Pediatric Surgery headed by him was the second after the clinic of S. D. Ternovsky-Yu. F. Isakov as a forge of scientific and pedagogical personnel for Russia and the USSR.
Pediatric surgeons were the first in the country to successfully develop and implement such advanced medical technologies as are now widespread, such as cryosurgery, magnetic surgery, hemosorption, gnotobiology, which have gained recognition and dissemination in other medical fields.
Among foreign pediatric surgeons, the names of R. Gross (USA) should be noted - the founder of neonatal surgery in the world, who performed a successful operation for esophageal atresia back in 1936; V. Potts (USA) - a leading scientist and specialist in the field of pediatric cardiovascular surgery; O. Svenson (USA) - a surgeon best known for his first pathogenetic operation for Hirschsprung's disease; V. Duhamel (France) - the author of the now widespread methods of inguinal hernia repair in children and the famous operation for Hirschsprung's disease; M. Groba (Switzerland) and V. Toshovsky (Czechoslovakia) - authors of excellent manuals on pediatric surgery.
The knowledge brought to the subject of our study by the scientists noted here (primarily Russian), of course, was reflected in the materials that this work offers readers today. For students,
V in particular, the textbook by Yu. F. Isakov “Surgical diseases of children” is well known. My lectures in no way replace this textbook, since they are based on regional material, on practical experience accumulated by pediatric surgeons working in the North, where the children’s body, no doubt, has its own characteristics, and they should be taken into account both when diagnosing diseases and and during their treatment.
In addition, the lectures reflect the author’s experience gained
V positions of chief pediatric surgeon of the Arkhangelsk region. This experience gave me the opportunity to analyze the quality of surgical care provided to children by pediatric and general surgeons, to subject
I will analyze numerous errors at all stages of diagnosing surgical diseases in children and shortcomings in providing assistance to them and tell you, my readers, about this. My goal was not just to talk about mistakes, mistakes and shortcomings, but to warn you, future doctors, against all this.
IN The lectures also reflect the specific experience of the ASMA Pediatric Surgery Clinic, obtained on the basis of the Arkhangelsk Regional Children's Clinical Hospital.
IN The proposed publication presents lectures on the pediatric surgery course program for students of pediatric faculties of medical universities. They are presented in the form in which have been read
V 1997/ 98 academic year. For each lecture, test tasks of the first level are offered for independent testing of mastery of the presented material before conducting a clinical practical lesson. At the end of the book are the correct answers to the questions asked in the tests.
Since the lectures were given to students who were learning the basics of the discipline, they do not contain deep scientific information of interest to professionals. Some problems are presented in a simplified form so that they are understandable to students who are coming into contact with the secrets of pediatric surgery for the first time. At the same time, their presentation took into account the students’ basic knowledge acquired while studying surgery in general and faculty surgery clinics in the third and fourth years of the academy.
I would like every word spoken here not only to reach the minds of future doctors, but also to reach their hearts, awakening
V They have love and compassion for children, qualities that are extremely necessary for a pediatric surgeon.
Features of pediatric surgery
Pediatric surgery in the pediatrician’s training program and his practical activities. Features of surgery
childhood. Deontological aspects
The program of pediatric faculties of medical universities in Russia provides for the study of pediatric surgery for 9–12 semesters. After the 10th semester, the result of training is summed up by a course exam, the study of the discipline ends with state certification, the program of which includes an exam in pediatric surgery
V as a component of an interdisciplinary examination in the specialty.
Listeners have the right to ask me: why is such a voluminous study of surgery necessary, if only a few of us will become pediatric surgeons, and the majority will work as pediatricians and mainly
V outpatient clinics institutions?
I will answer this question this way: knowledge in the field of diagnostics, principles
And tactics for treating surgical diseases in children are extremely important for everyone pediatrician, and this extreme importance is determined by many aspects.
1. To a huge, if not decisive, extent, success in the treatment of surgical diseases in children (especially those requiring emergency interventions) depends not so much on pediatric surgeons, but on so-called primary care doctors, that is, those medical workers to whom the child and his parents turn with the disease for the first time. If this specialist immediately made the correct diagnosis or at least suspected it and promptly referred the patient to a pediatric surgeon, the success of treatment is usually ensured. If the local pediatrician or emergency doctor does not have enough knowledge for this, then children are treated under other, erroneous diagnoses. The time defined as the optimal period for surgical intervention passes, serious complications appear or the possibility of their occurrence increases. This greatly complicates subsequent surgical intervention, worsens its results, and is often the main cause of disability.
And even the death of a child.
Therefore, it is so important for pediatric students to master the skills of diagnosing numerous surgical diseases in children. In co-
In accordance with this, our requirements for the quality of knowledge in all forms of current and final control (including practical exercises)
V within this discipline will be very high.
2. To ensure success in treatment, it is not enough to make a correct diagnosis of a surgical disease or suspect it. It is important to correctly navigate the tactics of this treatment. Let me illustrate this idea with an example.
Parents have contacted you with a child who has a clear clinical picture of, for example, acute hematogenous osteomyelitis. You had enough knowledge and experience to correctly suspect this disease, and you recommended that the parents contact the pediatric surgeon at your clinic. And he has already finished the appointment, or today he is conducting scheduled preventive examinations at school or kindergarten, and the next appointment will only be tomorrow (God forbid, there are weekends or holidays ahead!). Thus, you sent the child home, perhaps without even asking whether the surgeon was seeing him. But in a day, your patient will see the surgeon with even more severe, and perhaps fatal, complications. Having correctly established or suspected acute hematogenous osteomyelitis, you made a mistake due to ignorance of the tactics of its treatment, and it consists in the fact that surgical care for this disease should be provided urgently, as, for example, in acute appendicitis. And therefore, a child with such a diagnosis or if it is suspected should not wait for the next appointment with a pediatric surgeon at the clinic, but be urgently hospitalized
V the nearest children's surgical hospital, where he must be taken by ambulance.
Therefore, during the training process we will clearly define not only diagnostic, but also tactical issues in the treatment of surgical diseases and strictly control their knowledge.
3. In Russian medicine, emergency surgical care for children
V In half of the cases it turns out to be non-pediatric specialists, general surgeons who do not have sufficient training in pediatric surgery. This is especially true for remote rural areas (and there are a lot of them in the Arkhangelsk region). There, in small hospitals, it is not possible to support a pediatric surgeon, and the huge distances, impassable roads, weak transport network and high cost of transport services do not allow the child to be delivered to a specialist on time. In these conditions, the knowledge of a pediatrician working in the area is especially important. Knowledge of not only diagnostics, but also tactics, in particular emergency measures, for a particular surgical disease.
Of course, according to the vital indications of the child, a general surgeon will operate, but he must prepare the patient for the operation and manage him in the postoperative period together with the pediatrician. It is the pediatrician who is responsible for calculating the quantitative and qualitative composition of fluids for infusions, selection and dosage of medications, and treatment of concomitant diseases. I emphasize: where there is no pediatric surgeon, the pediatrician’s knowledge in these matters is extremely important. We know of cases where a child, after an operation correctly performed by general surgeons, died or became disabled due to completely illiterate therapy in the postoperative period. As a rule, these were cases of excess infusion volume due to the inability of general surgeons to calculate for a small child.
When training district pediatricians, I always convince them that they
V must be at the bedside of any child admitted the same day
V general surgical department- regardless of whether the general surgeon invited them to a consultation or not. And the younger the child’s age, the more stringent this requirement. In activities for students of the Faculty of Interests, I always follow as a red thread the requirement for strict
telny execution: A pediatrician should be involved in the treatment of any child in the general surgical department in the absence of a pediatric surgeon.
Experience shows that children of doctors and medical workers, as a rule, present with more advanced forms of disease than everyone else. The fact is that doctors, at the first signs of a surgical disease in their child, due to a lack of knowledge in pediatric surgery and psychologically explainable pity for the child and fear for him (“just not surgery!”), often begin to treat him with an erroneous diagnosis. . I would like to advise you: always, before treating your child, consult with your colleagues. They, compared to parents, are more objective in assessing the child’s condition and selecting methods of treatment. But the main thing is that I want to
highlight this fact: The more extensive and deeper your knowledge in the field of pediatric surgery, the higher the guarantee of the safety of both those entrusted to you and your own children.
Pediatric surgery has many differences from adult surgery. They are associated with the anatomical and physiological characteristics of the body of a newly born, growing and developing child.
What are these features?
STAGES OF INTRAUTERINE INTESTINAL ROTATION Before the rotation, there is a “physiological umbilical hernia”: the entire midgut is located in the umbilical cord on the embryonic umbilical-mesenteric artery Stage 1 (7-10 weeks) Counterclockwise rotation of the midgut at stage (11-16 weeks) - intestinal movement into the abdominal cavity and turn counterclockwise Stage 3 (from 17 weeks to birth) - Descent of the cecum into the right iliac region and fixation with the formation of separate mesenteries, intraperitoneal and retroperitoneal sections of the intestine.
CONGENITAL GASTROINTESTINAL OBSTRUCTION IN CHILDREN A pathological condition that develops due to malformations of the digestive tube or neighboring organs and tissues. Can occur at any age, but most often occurs in the neonatal period
DEVELOPMENTAL MALFORMATIONS LEADING TO CONGENAL GASTROINTESTINAL OBSTRUCTION IN CHILDREN Malformations of the digestive tube Disturbances of midgut rotation Anomalies of other organs and systems Congenital tumors and cysts Anomalies of the vitelline duct and urachus Congenital adhesions True congenital adhesions Internal hernias
2. Disorders of rotation and fixation of the midgut: Unrotated midgut - the large intestine is located on the left Reverse rotation - the large intestine is located on the right Hyperrotation - the ileocecal angle moves to the left Mixed rotation - common mesentery of the small and large intestines
CLINIC OF HIGH CONGENITAL INTESTINAL OBSTRUCTION - Develops in the first day - Always obstructive form - Vomiting of gastric and duodenal contents - No intestinal contents in the vomit - Clinic of obstruction increases slowly - Exhaustion increases slowly - No concern - Meconium and transitional stool are scanty, not stained with bile - Stomach overstretched, stomach sinks
CLINIC OF LOW CONGENITAL INTESTINAL OBSTRUCTION - Develops at any time after birth, more often 2-3 days - Often strangulation form - Vomiting of gastric, duodenal and small intestinal contents - Clinic of obstruction increases quickly - Exhaustion develops quickly - Painful grimace and anxiety - Meconium is scanty, stool and no gas - Abdomen is distended - Peristalsis is increased, splashing noise
PYLOROSTENOSIS – A DEVELOPMENTAL MALFORMATION OF THE PYLORICAL SECTION WITH EXCESSIVE MUSCULAR LAYER AND STENOSIS OF THE OUTLET OF THE STOMACH Clinical signs of pyloric stenosis: - Obstetric history - without features - Onset of manifestations a week of life - Vomiting - a fountain, more than fed, 1-2 hours after feeding, curdled milk with a smell, no bile - The child is calm, there is no excitement - Dehydration - develops quickly - Body weight - falls quickly - Diuresis - reduced, a symptom of dry diapers - Stool - absent - The abdomen is swollen in the epigastrium, sinks lower - Antispasmodics are not effective
DIFFERENTIAL DIAGNOSIS OF PYLOROSTENOSIS Pylorospasm (vegetovisceral disorders) Partial high intestinal obstruction (abnormal vessel, annular pancreas, incomplete intestinal rotation Salt-wasting form of congenital dysfunction of the adrenal cortex Gastric membrane with a hole
PYLOROSPASM - FUNCTIONAL SPASMA OF THE ANTRAL OF THE STOMACH Clinical signs of pylorospasm: - Obstetric history - birth trauma - Onset of manifestations a week - Vomiting - scanty, regurgitation, during feeding, fresh milk - Behavior - restless, constant crying - Dehydration - none - Body weight - none falls - Stool and diuresis are normal - Abdomen - normal shape - Antispasmodics - effective - Passage from the stomach - not impaired or accelerated
