Within the spermatic cord, do the vessels or the vas lie medially?

What is a small outpouching of testicular tissue off of the testicle?

What is a “blue dot sign”?

How is a transected vas treated?

How do you treat a transected ilioinguinal nerve?

What happens if you cut the ilioinguinal nerve?

UMBILICAL HERNIA

Chapter 67 / Pediatric Surgery 537

Vas is medial to the testicular vessels

Testicular appendage (a.k.a. the appendix testes); should be removed with electrocautery

Blue dot on the scrotal skin from a twisted testicular appendage

Repair with primary anastomosis

Should not be repaired; many surgeons ligate it to inhibit neuroma formation

Loss of sensation to the medial aspect of the inner thigh and scrotum/labia; loss of cremasteric reflex

What is it?	Fascial defect at the umbilical ring
What are the risk factors?	1.	African American infant
	2.	Premature infant
What are the indications for	1.	1.5 cm defect
surgical repair?	2.	Bowel incarceration
	3.	4 years of age
GERD
What is it?	GastroEsophageal Reflux Disease
What are the causes?	LES malfunction/malposition, hiatal hernia,
	gastric outlet obstruction, partial bowel
	obstruction, common in cerebral palsy

538 Section III / Subspecialty Surgery
What are the signs/	Spitting up, emesis, URTI, pneumonia,
symptoms?	laryngospasm from aspiration of gastric
	contents into the tracheobronchial tree,
	failure to thrive
How is the diagnosis made?	24-hour pH probe, bronchoscopy, UGI
	(manometry, EGD, U/S)
What cytologic aspirate	Lipid-laden macrophages (from
finding on bronchoscopy can	phagocytosis of fat)
diagnose aspiration of
gastric contents?
What is the medical/	H2 blockers
conservative treatment?	Small meals/rice cereal
	Elevation of head
What are the indications for	“SAFE”:
surgery?	Stricture
	Aspiration, pneumonia/asthma
	Failure to thrive
	Esophagitis
What is the surgical	Nissen 360 fundoplication, with or
treatment?	without G tube
CONGENITAL PYLORIC STENOSIS
What is it?	Hypertrophy of smooth muscle of pylorus,
	resulting in obstruction of outflow

What are the associated	Family history, firstborn males are affected
risks?	most commonly, decreased incidence in
	African American population

What is the incidence?

What is the average age at onset?

What are the symptoms?

Chapter 67 / Pediatric Surgery 539

1 in 750 births, M:F ratio 4:1

Usually from 2 weeks after birth to about 2 months (“2 to 2”)

Increasing frequency of regurgitation, leading to eventual nonbilious projectile vomiting

Why is the vomiting nonbilious?

What are the signs?

Obstruction is proximal to the ampulla of Vater

Abdominal mass or “olive” in epigastric region (85%), hypokalemic hypochloremic metabolic alkalosis, icterus (10%), visible gastric peristalsis, paradoxic aciduria, hematemesis ( 10%)

What is the differential diagnosis?

Pylorospasm, milk allergy, increased ICP, hiatal hernia, GERD, adrenal insufficiency, uremia, malrotation, duodenal atresia, annular pancreas, duodenal web

How is the diagnosis made? Usually by history and physical exam alone

U/S—demonstrates elongated ( 15 mm) pyloric channel and thickened muscle wall ( 3.5 mm)

If U/S is nondiagnostic, then barium swallow—shows “string sign” or “double railroad track sign”

What is the initial treatment? Hydration and correction of alkalosis with D10 NS plus 20 mEq of KCl (Note: the infant’s liver glycogen stores are very small; therefore, use D10; Cl and hydration will correct the alkalosis)

What is the definitive treatment?

Surgical, via Fredet-Ramstedt pyloromyotomy (division of circular muscle fibers without entering the lumen/mucosa)

540 Section III / Subspecialty Surgery
What are the postoperative		Unrecognized incision through the
complications?		duodenal mucosa, bleeding, wound
		infection, aspiration pneumonia
What is the appropriate		Start feeding with Pedialyte® at 6 to 12
postoperative feeding?		hours postoperatively; advance to
		full-strength formula over 24 hours
Which vein crosses the		Vein of Mayo
pylorus?
DUODENAL ATRESIA
What is it?		Complete obstruction or stenosis of
		duodenum caused by an ischemic
		insult during development or failure of
		recanalization
What is the anatomic		85% are distal to the ampulla of Vater,
location?		15% are proximal to the ampulla of Vater
		(these present with nonbilious vomiting)
What are the signs?		Bilious vomiting (if distal to the ampulla),
		epigastric distention
What is the differential		Malrotation with Ladd’s bands, annular
diagnosis?		pancreas
How is the diagnosis made?		Plain abdominal film revealing “double
		bubble,” with one air bubble in the
		stomach and the other in the duodenum
What is the treatment?		Duodenoduodenostomy or
		duodenojejunostomy
What are the associated		50% to 70% have cardiac, renal, or other
abnormalities?		gastrointestinal defects; 30% have
		trisomy 21
	MECONIUM ILEUS
	What is it?	Intestinal obstruction from solid
		meconium concretions
	What is the incidence?	Occurs in 15% of infants with CF

What percentage of patients with meconium ileus have CF (cystic fibrosis)?

What are the signs/symptoms of meconium ileus?

What is Neuhauser’s sign?

Chapter 67 / Pediatric Surgery 541

95%

Bilious vomiting, abdominal distention, failure to pass meconium, Neuhauser’s sign, peritoneal calcifications

A.k.a. “soap bubble” sign: ground glass appearance in the RLQ on AXR from viscous meconium mixing with air

How is the diagnosis made?	Family history of CF, plain abdominal
	films showing significant dilation of
	similar-sized bowel loops, but few if any
	air-fluid levels, BE may demonstrate
	“microcolon” and inspissated meconium
	pellets in the terminal ileum
What is the treatment?	70% nonoperative clearance of
	meconium using gastrografin enema,
	acetylcysteine, which is hypertonic
	and therefore draws fluid into lumen,
	separating meconium pellets from bowel
	wall (60% success rate)

What is the surgical treatment?

What should you remove during all operative cases?

What is the long-term medical treatment?

What is cystic fibrosis (CF)?

If enema is unsuccessful, then enterotomy with intraoperative catheter irrigation using acetylcysteine (Mucomyst®)

Appendix

Pancreatic enzyme replacement

Inherited disorder of epithelial Cl transport defect affecting sweat glands, airways, and GI tract (pancreas, intestine); diagnosed by sweat test (elevated levels of NaCl 60 mEq/liter) and genetic testing

What is DIOS?	Distal Intestinal Obstruction Syndrome:
	intestinal obstruction in older patients with
	CF from inspissated luminal contents