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Lecture ped. surg.basics.pptx

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Lecture ped. surg.basics.pptx

  1. 1. Tips on using my ppt. 1. You can freely download, edit, modify and put your name etc. 2. Don’t be concerned about number of slides. Half the slides are blanks except for the title. 3. First show the blank slides (eg. Aetiology ) > Ask students what they already know about ethology of today's topic. > Then show next slide which enumerates aetiologies. 4. At the end rerun the show – show blank> ask questions > show next slide. 5. This will be an ACTIVE LEARNING SESSION x three revisions. 6. Good for self study also. 7. See notes for bibliography.
  2. 2. Pediatric Surgery
  3. 3. Pediatric Surgery • Responsible for the treatment and prevention of surgical conditions in fetus 28 weeks of gestation to adolescent at puberty excluding cardiac and orthopedic lesions.
  4. 4. • Children are not little adults
  5. 5. Pediatric Surgery • They differ in anatomy, physiology,, pathology, pharmacology from adults • You must understand these differences and appreciate them to properly assess, plan, and deliver surgical care.
  6. 6. Anatomy, Physiology
  7. 7. Anatomy, Physiology Body Surface Area is more for weight. – Head is large compared to the adult • Often in newborns it exceeds the circumference of the chest – Arms and legs are shorted and underdeveloped at birth – Urinary bladder is intraperitoneal
  8. 8. Anatomy
  9. 9. Anatomy • Musculoskeletal system – Bone growth occurs at different rates throughout the body • This affects anatomical landmarks – In the neonate, the imaginary line joining the iliac crests occurs at S1 – Sacrum is not fused normally at birth – At birth spinal column has only the anterior curvature – Cervical and lumbar curvature begin with holding head up and walking
  10. 10. Anatomy, Physiology
  11. 11. Anatomy, Physiology • Central Nervous System – Higher function are underdeveloped. – The brain at birth is 1/10 the body weight – Only ¼ of the neuronal cells that exist in adults are present in the newborn – Neuronal development finishes as age 12 – Myelination is not complete until age 3 • Primitive reflexes (Moro, grasp) disappear with myelination
  12. 12. Anatomy, Physiology • Central Nervous System – Autonomic nervous system is developed at birth, though immature – Parasympathetic system is intact and fully functional – Lower end of the cord is at L3 at birth • Receeds to L1 by 1 year of age – Dural sac shortens from S3 to S1 by 1 y/o
  13. 13. Anatomy, Physiology • Cardiovascular System – Many profound changes after birth • SVR doubles after first breath • Pulmonary vasculature dilates, decreasing PVR • Foramen ovale closes as left atrial pressure becomes higher than right atrial pressure • Flow reverses in the ductus arteriosis, preventing flow between the pulmonary artery and the aorta
  14. 14. Anatomy, Physiology • Myocardium – Stroke volume of an infant is relatively fixed • “they live for (or better yet, by) heart rate” • To increase CO, you must increase HR • Myocardium is relatively stiff • Increasing preload will not increase CO • Cardiac reserve is limited • Small changes in end diastolic volume yield large changes in end diastolic pressure
  15. 15. Physiology • Heart rate in infants is higher and decreases gradually over the first 5 years of life to near adult levels
  16. 16. Anatomy, Physiology • Respiratory System – Pediatric airway • Obligate nose breathers because of the close proximity of the epiglottis to the soft palate • Mouth breathing occurs only during crying • Obligate nose breathing is vital for respiration during feeding. • Respiration is mainly diaphragmatic.
  17. 17. Anatomy, Physiology • Respiratory System – Incompletely developed, new alveoli continue to form up to 8 years of age. – Reduced production of surfactant – Small diameter airways are prone to get blocked. – Normal respiratory rate 40-60 breaths /minute – Even Oxygen may lead to retrolental fibrosis.
  18. 18. Anatomy • Burns: Estimate of body surface burnt. • For adults Rule of 9 • For child Head is larger, LL is less • At birth Head 20% LL 10%
  19. 19. Temperature control
  20. 20. Temperature control • Large Body Surface Area. • More prone to hypothermia. • Large energy expenditure for maintaining normal body temperature. • Keep warm in ward and OT • Give warmed iv fluids.
  21. 21. Anatomy, Physiology
  22. 22. Anatomy, Physiology • Renal System – Full term infants have the same number of nephrons as adults – Glomeruli are much smaller than in adults – GFR in the newborn is 30% that of the adult – Tubular immaturity leads to a relative inability to concentrate urine
  23. 23. Anatomy, Physiology • Renal System – Fluid turnover is 7 times greater than that of an adult – Altered fluid balance can have catastrophic consequences – Organ perfusion and metabolism count on adequate hydration – Infants and children are at a much higher risk for developing dehydration
  24. 24. Anatomy, Physiology • Hepatic System – Neonatal liver is large – Enzyme systems exist but have not been sensitized or induced – Neonates rely on limited supply of stored fats – Gluconeogensis is deficient – Plasma proteins are lower, greater levels of free drug exist
  25. 25. Anatomy, Physiology • GI System – Gastroesophageal reflux is common until 5 months of age • Due to inability to coordinate breathing and swallowing until then – Gastric pH is alkaline at delivery – Gastric pH and volume are close to adult range by 2nd day of life
  26. 26. Anatomy, Physiology • Immunological status – No own immunoglobins – No antigenic experience – Deficient complement factor Thus he is a immunocompromised host
  27. 27. Fluid and Electrolyte Requirement
  28. 28. Fluid and Electrolyte Requirement • Premature-150ml/kg/d • Term 100ml/kg/d for 1st 10kg. 50ml/kg/d for 2nd 10kg 20ml/kg/d for > 20kg
  29. 29. Fluid and Electrolyte Requirement • Sodium 2-4 mEq/kg./d • Chloride 2-4 mEq/kg./d • Potassium 1-2mEq/kg./d • Energy 124 kcal/kg./d at birth to 100 kcl/kg./d at 12 years. Ideal iv fluid D5% with N/5Saline with 20 mEq/l potassium
  30. 30. The Premature infant
  31. 31. The Premature infant • Respiratory Surfactant def.> atelectasis • Temperature regulation immature • Apnoea, bradycardia • Hepatic immaturity > hyperbilirubinemia • Enteral nutrition
  32. 32. The Small for age infant
  33. 33. The Small for age infant • Placental insufficiency/in utero infection • Inadequate nutritional stores • Physiological stress factors hypoglycemia, polycythemia,pneumothorax,intracranial hemorrhage,congenital infections and congenital anomalies.
  34. 34. Pharmacologic considerations
  35. 35. Pharmacologic considerations • Pharmacologic considerations – Uptake • Route of administration affects uptake – IV – fastest – Oral and rectal routes slowest – Transdermal faster than adults, due to relatively thin skin layers – Pathological conditions of the liver and heart can significantly effect uptake
  36. 36. – Distribution • 55-70% of body weight is water in infants and children • Large ECF leads to large Vol. of distribution – In adults, ECF accounts for 20% of body weight – In children, ECF accounts for up to 40% of body weight • The concentration and effects of water-soluble agents are affected greatly by the larger Volume of Distribution Pharmacologic considerations
  37. 37. Pharmacologic considerations
  38. 38. Pharmacologic considerations – Plasma protein binding • Lower levels of serum albumin yield higher levels of free drug • Plasma protein levels are even lower in certain disease states, like nephrotic syndrome or malnutrition • Endogenous molecules, like bilirubin, can be displaced by protein bound drugs
  39. 39. Pediatric Surgery
  40. 40. Pediatric Surgery • Pharmacologic considerations – Metabolism • Soundness and maturity of the liver affect metabolism • Glucuronidation is underdeveloped in neonates • Maternal use of drugs may affect enzyme induction • Medications, like phenobarbital, induce enzymes rapidly
  41. 41. Pediatric Surgery • Pharmacologic considerations – Excretion • Drugs dependent on renal excretion, like Pancuronium and Digoxin, can be markedly affected by immature kidney function
  42. 42. Pediatric Surgery • Pharmacologic considerations – ONLY body weight or BSA should be used to calculate and determine correct pediatric drug dosages – Body weight is used in premature infants – As always, titrate to effect
  43. 43. Pediatric Surgery • Routes of administration – Oral • Sometimes it is difficult to gain cooperation • Liquid forms have greater absorption – Intramuscular • Gluteus medius muscle over age 2 • Vastus lataralus under 2
  44. 44. Pediatric Surgery • Routes of fluid administration – Intravenous – Intraosseous.
  45. 45. Pediatric Surgery • Pharmacologic considerations • Intravenous agents – Typically pediatric patients require a larger kg dose than adults
  46. 46. Pediatric Surgery • Pharmacologic considerations – Pediatric patients can be very sensitive to the respiratory depressant effects of narcotics – Careful titration is vital
  47. 47. Pediatric Anesthesia
  48. 48. Pediatric Anesthesia • Mainly endotracheal controlled inhalational anesthesia • Spinal/ Epidural/Caudal with sedation • No locoregional – Difficult airway
  49. 49. Surgical Principles
  50. 50. Surgical Principles • Transverse incisions • Single layer anastomosis. • Laparotomy closure by absorbable sutures. • Scars are worse than adults.
  51. 51. Pediatric Surgical disorders
  52. 52. Pediatric Surgical disorders • Congenital Malformations • Trauma • Malignancies • Miscellaneous
  53. 53. Congenital Abnormality
  54. 54. Congenital Abnormality • Defects in the abdominal wall (diaphragmatic hernia, gastroschisis, omphalocele) • Neurological system(brain, spinal cord, etc.) • Cardiovascular and pulmonary abnormality • Malformation of digestive system • Malformation of urological and reproductive system • Limbs and vertebra abnormality
  55. 55. Congenital Posterolateral Diaphragmatic Hernia (CDH)
  56. 56. Congenital Posterolateral Diaphragmatic Hernia (CDH) JOne of most severe conditions of neonate JDefect in diaphragm during early fetal development J left side most commonly affected Jcontent of the hernia: small bowel colon spleen stomach liver, kidney, tail of pancreatic
  57. 57. 【Embryology】
  58. 58. 【Embryology】 week8~9 : division of coelomic cavity into the pleural and peritoneal cavity by the diaphragm; a triangular area in the posterolateral site was left open. week10~12 :herniation occur through this opening into the pleural cavity at the return of midgut
  59. 59. 【pathophysiology】
  60. 60. 【pathophysiology】 1、Hypoplasia of the lung Pulmonary weight (ipsilateral+contralateral)↓ Alveoli number↓ Hypertrophy of the media of pulmonary arteriole Resistance of the vessels↑ 2、Pulmonary hypertension Abdominal viscera into the thoracic cavity → compression of the lung, PaO2↓PaCO2↑→ acidosis, hypoxemia(PH<7.30) →pulmonary vessels spasm →vessel resistance↑, right to left shunting through patent ductus arteries and foramen ovale↑→aggravate acidosis and hypoxemia in the body circulation (fetal circulation syndrome)
  61. 61. diaphragmatic hernia
  62. 62. diaphragmatic hernia Clinical manifestations: 1,Severe respiratory distress,cyanosis, vomit 2,Breath sounds: diminished on the side of hernia 3,Heart sounds: deviated to the contralateral chest 4,Scaphoid abdomen
  63. 63. 【 diagnosis 】
  64. 64. 【 diagnosis 】 Prenatal diagnosis ultrasound: abdominal organ visible in the fetal chest
  65. 65. diagnosis after birth
  66. 66. diagnosis after birth X-ray film: •Typical air-filled stomach and bowels in the chest, which continues into the abdominal cavity. •Diaphram can not be seen at the affected side. •Absence or scarcity of intestine in the abdominal cavity
  67. 67. Treatment
  68. 68. Treatment • Before delivery: cortisone could induce the maturation of pulmonary tissue • Preoperative preparation: (1)mechanical ventilation with pure oxygen (2)nasogastric tube to decompress stomach and intestine (3)semi-supine and inclined to the ipsilateral side, keep warm (4) i.v. fuild, correction of acidosis (5)surgical repair
  69. 69. Congenital Esophageal Atresia Tracheoesophageal Fistula
  70. 70. Congenital Esophageal Atresia Tracheoesophageal Fistula  Incidence: 1/3000  associated anomalies common  Impediment of recanalization and interruption of septation of trachea and esophagus
  71. 71. Congenital esophageal atresia
  72. 72. Congenital esophageal atresia Classification Ⅰ6%, Ⅱ2% ,Ⅲ85%, Ⅳ 1% 。Ⅴ 6%
  73. 73. 【 clinical finding
  74. 74. 【 clinical findings】 1、drooling saliva, unable to swallow 2、cough and choke and may become cyanotic after feeding 3、chemical and aspiration pneumonia 4、abdominal distention or scaphoid abdomen
  75. 75. 【 diagnosis 】
  76. 76. 【 diagnosis 】 1、prenatal diagnosis 2、nasogastric tube can not reach stomach. 3、 X-ray film show the coiling of the tube in the upper mediastinum
  77. 77. Preoperative preparation
  78. 78. Preoperative preparation  supine and elevated to 30~40º  Catheter was put at the blind end of the esophagus for continuous drainage  oxygen inhalation, incubator  i.v. fluid and broad-spectrum antibiotics  surgical repair 4 Prognosis: 98%~100% survival rate for the last decade (aboard), all of the 60+ cases survived since 2002 (our hospital) .
  79. 79. Hypertrophic Pyloric Stenosis 【pathophsiology】
  80. 80. Hypertrophic Pyloric Stenosis 【pathophsiology 】 1、olive shaped mass: length 2~3.5cm, thickness 0.4~0.6cm, pale in color with consistency of cartilage 2、Muscular hypertrophy of all the layers of the pylorus , most significant in the circular layer, causing the stenosis
  81. 81. Hypertrophic Pyloric Stenosis 【symptoms】
  82. 82. Hypertrophic Pyloric Stenosis 【symptoms】 1、 projectile vomiting: onset:2-3 weeks after birth and progressive with time; vomitus: non-bilious milk and milk curds 2、 jaundice :deficiency in liver enzyme and compression of the biliary tract 3、 overall condition: dehydration, weight lose, hypo- chloride metabolic alkalosis, oliguria 4、abdominal examination: distention of epigastrium, visible gastric waves, presence of a palpable pyloric tumor (unique physical sign)
  83. 83. 【Diagnosis】
  84. 84. 【Diagnosis】 1、typical vomiting and mass in the epigastrium 2、ultrsound: muscular thickness≥0.4cm, SD=thickness×2/diameter≥50% 3、GI for cases with difficulty in diagnosis: ①distention of the stomach ②strong gastric waves ③elongated and narrow pyloric channel ④delay in stomach emptying
  85. 85. 【Treatment】
  86. 86. 【Treatment】 Surgery ———— pyloromyotomy
  87. 87. Intestinal Obstruction in the Neonate
  88. 88. 【 Etiology 】
  89. 89. 【 Etiology 】 1、Malrotation of midgut around the axis of superior mesenteric artery 2、Intestinal recanalization anomaly 3、Compromise of intestinal blood supply 4、Arrest of the migration of neuroblast derived from neural crest of epiderm 5、Viscosity of meconium : cystic fibrosis 6、Maternal factors: infection, diabetes, pharmaceuticals
  90. 90. 【 Pathophysiology】
  91. 91. 【 Pathophysiology】 1、Loss of fluid from emesis: dehydration, electrolyte disturbance, acid-base imbalance 2、Aspiration and abdominal distention: chemical and bacterial pneumonia, apnea 3、Dissemination of enterobacterium: ischemia, necrosis, perforation and sepsis
  92. 92. 【Clinical manifestation】
  93. 93. 【Clinical manifestation】 Characters of neonate ileus: Bilious vomiting Abdominal distention Failure to pass meconium General condition:drowsy、hypomyotonia、 tachypnea
  94. 94. 【Neonatal Peritonitis】
  95. 95. 【Neonatal Peritonitis】 1、abdominal distention, abdominal wall erythema 2、tenderness manifested as crying, flexing legs,grimace 3、guarding reflex not obvious
  96. 96. 4、abdominocentesis as shifting dullness unobvious 5、diminished gurgling sound:enteroparalysis 6、abdominal mass:necrotizing intestinal loop、 calcification、infection General condition: drowsiness, dyspnea hypomyotonia,oliguria
  97. 97. Common causes of neonate intestinal obstruction
  98. 98. Common causes of neonate intestinal obstruction Mechanic obstruction Extrinsic : Intrinsic: •intestinal atresia meconium peritonitis and stenosis 40% •annular pancreas milk curds obstrution •Malrotation 10~15% meconium plug •intestinal duplication • meconium peritonitis(adhesion) •internal hernia, incarcerated external hernia •intussuception
  99. 99. Functional obstruction
  100. 100. Functional obstruction Hirschsprung’s disease 25~30% Necrotizaing enterocolitis Left microcolon syndrome Infection Metabolic
  101. 101. Intestinal Atresia and Stenosis
  102. 102. 【Clinical findings】
  103. 103. 【Clinical findings】 1、vomiting onset: from first time of feeding to a few days after birth vomitus: bilious or feculent 2、abdominal distention high: confined to epigastrium low: full abdomen distention 3、failure to pass meconium: normally meconium was passed within the first 24hrs of life and cleared in 2-3 days. 4、General condition
  104. 104. 【 Diagnosis 】
  105. 105. 【 Diagnosis 】 1、prenatal ultrasound 2、Clinical findings: bilious vomiting 24-48hrs after birth abdominal distention failure to pass meconium 3、X-ray: duodenal atresia--Double bubble sign jejunal atresia--triple bubble sign low intestinal atresia--multiple air-fluid level
  106. 106. 【 Treatment 】
  107. 107. 【 Treatment 】 The only option is surgery: intestinal septum excision Intestine resection and anastomosis
  108. 108. Congenital Malrotation of Intestine
  109. 109. 【Definition】
  110. 110. 【Definition】 Malrotation is the term used to define the group of congenital anomalies resulting from aberrant intestinal rotation and fixation 【Embryology】 Week 6~8: Herniation of midgut into the umbilical cord with a 180 degree of counterclockwise rotation along the axis of superior mesenteric artery Week 10: Return to the abdominal cavity with a final 90 degree of rotation to complete the 270-degree counterclockwise rotation
  111. 111. 【 Pathology 】
  112. 112. 【 Pathology 】 Nonrotation and Incomplete rotation: abnormal positioning of the proximal small bowel and the cecum Duodenum compressed by abnormal peritoneal band(Ladd’s band): high incomplete extrinsic obstruction Midgut volvulus: torsion of the narrow mesenteric pedicle produces an acute closed-loop intestinal obstruction and vascular insufficiency. Proximal jejunum fused to the ascending colon by anomalous peritoneal attachments
  113. 113. Malrotation
  114. 114. Malrotation  Pathology: Compression of duodenum Kinked and foreshortened proximal jejunum by peritoneal band Midgut volvulus
  115. 115. 【Clinical manifestations】
  116. 116. 【Clinical manifestations】 Emesis:bilious, intermittent,occur at 3-5 days after birth or asymptomatic Abdominal distention: confined in epigastrium, diffuse to the full abdomen in bowel necrosis Stool: normal meconium, bloody stool suggests volvulus and necrosis Newborn: normal meconium,intermittent vomiting after 3-5 days of birth,no abdominal distention, hard stool Children and infant:asymptomatic since birth, intermittent onset or sudden onset of volvulus
  117. 117. Clinical manifestations
  118. 118. Clinical manifestations  Symptoms of volvulus: bloody vomitus and stool, abdominal tenderness
  119. 119. 【X-ray film】
  120. 120. 【X-ray film】 1、Plain X-ray film: double-bubble sign 2、barium enema: cecum in the upper or left abdomen 3、GI: incomplete duodenal obstruction; ligament of Treitz not to the left of the midline; abnormal position of the proximal jejunal loops to the right of the midline
  121. 121. Treatment
  122. 122. Treatment Principles: Asymptomatic malrotation most recommend surgical treatment some believe operation only necessary in young children High intestinal obstruction operated on promptly, but not necessarily emergently Volulus with sign of bowel necrosis immediate operation
  123. 123. Treatment Ladds operation • All volvulus is clockwise so the small bowel must be rotated in a counterclockwise fashion • Expose duodenum by division of the Ladd’s bands • Dissection additional peritoneal bands to convert the mesenteric pedicle to a wide plane • Alignment of small bowel to the right and colon to the left of the abdominal cavity
  124. 124. Hirschsprung’s Disea Anatomy
  125. 125. Hirschsprung’s Disea Anatomy 1、distended segment: proxiaml colon enlarged with muscular hypertrophy 2、stenosis segment:distal colon spasm 3、transitional segment:between distal and proximal segments
  126. 126. Histology
  127. 127. Histology 1、lack of ganglion cell in the neural plexus of the affected segment of intestine 2、hypertrophied nerve trunk stain positive for acetylcholinesterase 3、Disarray of adrenergic fibers
  128. 128. 【Pathophysiology】
  129. 129. 【Pathophysiology】 Arrest of cranial to caudal migration of neuroblasts derived from neural crest precursors along the intestinal tract with vagal nerve fiber at 6-12 weeks of gestation, which results in aganglionosis of the distal bowel. 1、spasm of affected segment no normal peristalsis 2、internal sphincter spasm no normal defecation reflex 3、proximal bowel distended with histologic evidence of muscular hypertrophy
  130. 130. 【clinical findings】
  131. 131. 【clinical findings】 Neonate: 1、emesis:bilious or feculent 2、abdominal distention 3、delayed passage of meconium 4、rectal examination:tightness of internal sphincter,rectal emptiness,withdraw brings out meconium and gas 5、after bowel irrigation, temporary subsiding of the symptoms Children and infant: 1、History of neonate constipation 2、Malnutrition , anemia 3、Chronic abdominal distention
  132. 132. 【Diagnosis】
  133. 133. 【Diagnosis】 Barium enema Demonstration of a spasmodic distal intestinal segment with dilated proximal bowel Failure to evacuate barium from colon within 24hours simplicity of the method accuracy in neonate 80% not suitable for short segment type
  134. 134. Anorectal Manometry
  135. 135. Anorectal Manometry •Aid diagnosis through identification of the rectoanal inhibitory reflex which is absent in the vast majority of children with Hirschsprung’s disease •Drawbacks: false-positive in older children due to masking of the relaxation response by contraction of the external sphincter
  136. 136. Rectal biopsy (Definitive diagnosis )
  137. 137. Rectal biopsy (Definitive diagnosis ) Suction biopsy  Biopsy taken at 1-2cm above the dentate line  looking for the presence or absence of ganglion cells and hypertrophied nerve trunks  simplicity, accuracy, absence of complications  False-negative (age, mucosal edema, tissue quality, experience )
  138. 138. Histologic staining of mucosa
  139. 139. Histologic staining of mucosa Increased AChE content in the nerve fibers of the lamina propria and muscularis mucosae Full-thickness Rectal Biopsy Complexity and complications, possible effect on future definitive surgery
  140. 140. 【Complications】
  141. 141. 【Complications】 1、Enterocolitis Most frequently encountered and life- threatening: from constipation to diarrhea peritonitis and sepsis fever and abdominal distention digital exam:massive amount of odorant stool 2、Perforation: Cecum peforation Bowel necrosis and perforation
  142. 142. 【Treatment】
  143. 143. 【Treatment】 1、Colon irrigations: isotonic fluid one to two times a day #Do not use tape water 2、Colostomy: 3、Surgical options Swenson Duhamal Rehbein Soave Neonatal surgery Laparoscope's Transanal pullthrough
  144. 144. Anorectal Malformations (ARMs)
  145. 145. Anorectal Malformations (ARMs)  One of the most frequently encountered digestive tract abnormality  Frequency is slightly higher in males compared with females  Associated anomaly: urogenital,another gastrointestinal anomaly, cardiovascular, vertebra  Arrest of the caudal descent of the urorectal septum toward the cloacal membrane during the fourth week and ending by the eighth week of gestation.
  146. 146. ARM classification
  147. 147. ARM classification Wingspread classification : according to the relative position of retal end to the elevater ani: high:above elevater ani intermediate:within elevater ani low:pass through elevater ani Further classification according to the fistula
  148. 148. PC line: pubococcygeal line I line: ischial line
  149. 149. ARM treatment Aim:Rebuilt an anus with well functioning anal sphincte  High and intermediate imperforated anus – colostomy at birth – definitive surgery at 6-12months of age  Low imperforated anus – Trans- perineal anoplasty after birth – For female with fistula,Dilatation of fistula, anoplasty at 6-8 months
  150. 150. Hydronephrosis (Ureteropelvic junction obstruction)
  151. 151. symptoms •abdominal mass • haematuria •abdominal pain •urinary tract infection • others Diagnosis • sonograph • IVP • isotope renograph • others:CT、MRU
  152. 152. Surgical Principles
  153. 153. Surgical Principles • Always consider pyleoplasty , be very prudent to do nephrectomy • For bilateral hydronephrosis, pyleoplasty for both sides could be carried out at the same operation due to a high success rate nowadays • Index for nephrectomy: – Complete loss of function, – parenchymal thickness <3mm – sever cases of renal abscess
  154. 154. Fetal Surgical Procedures
  155. 155. Fetal Surgical Procedures Focus is on defects which can be accurately identified antenatally and which cause progressive and permanent damage to the fetus if not corrected.
  156. 156. Fetal Surgery
  157. 157. Fetal Surgery • Open procedures are investigational - performed only at a few centers • Most data on open fetal surgery comes from UCSF and CHOP, where the majority of these procedures have been performed • Some less invasive procedures are more commonly performed
  158. 158. Examples of malformations that may benefit from in utero surgical correction
  159. 159. Examples of malformations that may benefit from in utero surgical correction • Bladder outlet obstruction (posterior urethral valves) • Diaphragmatic hernia • Cystic Adenomatoid Malformation (CAM) • Sacrococcygeal Teratoma • Tracheal atresia/stenosis • Neural tube defects
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  161. 161. Get this ppt in mobile
  162. 162. Get my ppt collection • https://www.slideshare.net/drpradeeppande/ edit_my_uploads • https://www.dropbox.com/sh/x600md3cvj8 5woy/AACVMHuQtvHvl_K8ehc3ltkEa?dl =0 • https://www.facebook.com/doctorpradeeppa nde/?ref=pages_you_manage