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OK, good evening everyone. Can you guys hear me now? I didn't look right now. Ok. I think I should be. I, I think you guys should hear me now. Good evening everyone. Uh I don't know what's going on with the sound. Uh but I'll try to be as audible as I can. Ok. Yes, someone can hear me. So, hi, everyone. Uh Welcome to today's session on a basic surgical techniques in pediatric surgery with doctor Lara Aboya. Um So she has joined us, I've just um tried to invite her to the stitch uh so that we can kick off and um uh so let me just see if she has fine. Um So last week we started uh discussing this topic, but we have some um network challenges, which is why we have to postpone uh reschedule for today. Um So I would invite the us to the stage now so we can start in the meantime, I will stop uh uh projecting the slides uh just to make you can run uh a bit more smoothly. So I would um so whenever I'm on with my audio and um video, I think it interrupts the other speaker, so I would go off. Um I will turn that off now then. Um doctor, hopefully, Doctor Lara will join us soon. Comes back. Uh Thank you again, everyone for joining. Uh Hopefully today will be his next um session. Thank you. Good evening, Doctor Fabia. Can you hear me? Ok? Good evening, good. Can you hear me now? Yes, we can hear you. Ok, great. So I guess um I guess I'm good to go since you have the slides on. Ok. Uh So should I go ahead? Have you started already or you want to? So I started already, but I might as well just say again. Uh So good evening, everyone. Welcome with um to today's session on basic surgical techniques in pediatric surgery with doctor Laura Fabre. So we'll just dive right into the topic. Uh and then we'll take questions and comments at the end of this, at the end of the session. Thank you so much everyone for joining. Uh We'll start now over to you, Doctor Lara. Ok. Thank you very much and thank you again for all being here, particularly if you were here last week and it couldn't vote for all the reasons that happened. Um As I said last week, I am, I'm glad that there are people that are interested in learning things about pediatric surgery and I wish you all the best in your journey. So just focus on it, like um talking about the ba uh background knowledge in pediatric surgery, basic things that are important. And then if you um chosen areas that I think that schools in that area may be important. And then based on your questions, I would ut on things that I may not have mentioned, but you would consider interesting. Um So yes, you understand techniques, instruments and then we'll discuss some procedures. I said last week to the child covering up the ages from new needs, infants, toddlers all the way to being a teenager. And then in reality, there really is no cap to the age where a pediatrician or a pediatric surgeon sees a patient as long as the disease. But you can for as we surge, the disease is, for instance, the congenital anomaly, even if it's a 20 year old man, we want to manage, we just may go managing with the general surgeon. Important thing before I move on are temperature control, flow control and dosage of drugs. So even if all you want to do is say, set a line for AAA new need. For instance, it's important that while that process is going, which depending on the on the majority of the baby and how long they've been in the hospital and how the align so that can go on for like 10 minutes or an uh but it's important that virus is going on. You are conscious of the baby's environment and the baby is kept warm. You can understand environment. The baby is probably under the that is kept as a control temperature because you cannot understand environment. Then it means you need to be particularly conscious about keeping that environment warm, um cool off and maybe you have warm things that are around the baby. It means that we give them and the ability of drugs. Very important as it is relevant to whatever procedure you are doing. Any basic surgical technique that we're gonna be talking about might rather be considered a, a surgical procedure in itself. And in every procedure, every stage of that procedure is important whether the pre intra or the post procedure technique. Now, depending on what the procedure is, the, this may, the degree to with this one would matter very. So is it a procedure where you would need to give fluids or drugs or intravenous analgesics or anesthetics? Then you may need to do an intravenous condition. You need to put an energy team. You, these are basic techniques that would be assumed that, you know, and, and it's important to have thought about it as well. These things are necessary before you didn't start the procedure and find out that you need this and have to worry about whether you have the s or whether you can actually get the procedures, um those things done intra procedure or intraoperatively. If it's anything major, then you need all these things. If probably assistant someone you want to know, do you need the me, do the nurses know, um, um, what level of, um, oh, an says to you what instruments do we need? What future materials do we need? Post procedure again? Depending on what you have done. Do we need to give anything for pain? Is this something we have given intraoperatively? And we don't need to give anything more. Do we need to give medications? What you have done? Does it in any way affect fe and is there any for an, these are consider that we need to have had in mind before we don't get into the nitty gritty of whatever simple or major procedure that we'll be doing for the child in talking about the surgical instruments. I'm really just gonna run through, but um I'm happy to dive in if anybody wants us to go back into that. And that to say that this is really a basic classification. There are many other complex instruments, but basically you have the ted tissue forceps and these are forceps that are used to handle tissue. Any three, anything from hemostased that are used to, to handle, to um control vessels, you know, and before tying them, hold onto this. So hold on to the tissue con continue before transfixing. They come in different sizes. They are called hemostats. You can also call them artery forceps. Um They're not in this picture. So anything from those, all that tissue forceps like the back cos up here. Um or the um of this. No, the spline forceps as is here, but that's not. So the tiss is the back cock. That's the example that's up here. The non tissue forceps is the example here, which is a um a non to handle tissue. But is this one? Thank you. Bye. Be fine with it. Not before hold it type when you are using the non tooth forceps, they're just picking something and your hand is holding onto it that tend to remain in your hand. So there are all you call the force, which is shape kind of looks like this one. No, just this lock, but you do exactly what you can be used. You also use when n is we need know, we don't often find that in typical T pack but you can find it in dressing packs because you can, you going to pick the go if you want to clean or if you want to, um, pack, um, an upset that you have drained or any stuff like that. The tractors are also the, you have a lot of the tractors. Basically one is this like an be that you can see the picture. There are many other, well, the um, or no change because someone has to hold on to that in tractors that are self however have. Yes. Um, oh um, Doctor Lara, we can't hear you anymore. You will be outside of it, but it's just to give a quick um, Luke, I think. Oh, right. So um kind of introduce it. Ok. Most, but so you most special clean that wound so gently keeps the wound together. And that wound therapy, please. However, because it, it, the material is synthetic. Well, it have a natural but it may get absorbed by the body and you have synthetic and natural. I see. Yeah. Or more filaments if we take so more means that it may be a single strand that forms that. Sure. So I show that the, the, the tiny Hi, I'm, you need to try two more particularly for that uh that time. Hi, Doctor Lara. We, I think there are some issues with the network. I don't know if we can. Mhm. What is it? Thank you. So, um this is uh Right. Yeah. Bye. OK. Can you hear me? Yes, we can hear you. Oh, great. OK. So for some reason the laptop has come up now. Thank God. OK. So where, where did you stop hearing me? Um So we didn't really hear anything about suture materials. Oh, wow. OK. Yeah. All right. So that's, yeah. So um let me, let me close this one. So that's fine to Yeah, sorry. I was talking about um the suture material is introducing us to wound closures and that sutures are one of the most common um material that we use for closing most types of wound. And I said that an ideal suture would be one that even after it has been removed or it has been, it has been absorbed, would leave the wound still uh opposed together while the rest of the healing continues over time. And I mentioned that common sutures that we use in pediatric surgery are vir monocryl and P DS. But this is by no means exclusive. But when, when it comes to the pediatric general surgery, which is usually abdominal um and if you subcutaneous superficial lumps, um we usually would not use beyond these sutures. Ok. Could you go to the next night? Yeah. So features can be absorbable or nonabsorbable. They can be synthetic or natural and they can be monofilament or multi filaments. I think the initial to speak for themselves as to what they mean for monofilament and multi filament. I explained that um in monofilament, the strand that forms the suture is just one strand of the material for multi filament sutures. Excuse me, the strands are multiple and usually are wo uh woven together. And examples would be silk and biro. And this uh my important for two relevant for two reasons. One more important one is that multi filament are are more prone to infection, not to say that I would not use a particular suture just because it's prone to infection. But because if um it then it then gets exposed to infection, you might need to remove that suture because it then allows uh it's prone to allowing microbe to stay within the filament of the suture. Whereas the monofilament usually does not have that problem. The other thing is that the monofilament suture passes through tissue easily without creating a track. Whereas um the multi filament usually will create a track. But the advantage of multi filament is that it's not swell, not do not sit and they have a very poor memory as, as against monofilament that have a good memory. And so when you tie monofilament, you need to do multiple times to ensure that it will not loosen itself. I think I need to open my. So the um skills that we're gonna be talking about include infiltration of local anesthetics, surgical, not tying. And we like our call. Can I will just go through that briefly because that's really done by pediatricians many times, but sometimes in surgery, we have to be the ones to do this processes closures and then specifically treating as regards wound closure and everything about it, rectal prolapse and reduce any the hernia. So I'll start by talking about infiltrating with local anesthetics. Most procedures I would do for a child, I mean, ranging from a baby to anything in, in teenage years. So depending on the age, but most things will be done under general anesthesia. I mean, if we want to do a rectal biopsy, um um hernias or lumps would do under local anesthesia. The patient is older, say maybe late, an early or late teen or under the circumstances, it just no fit for anesthesia or it's just best choice at that time. Then it's important to know how anesthetic and what's, what's, what is relevant here is that there are two ways that you can give local anesthesia. And this, this is really not specific for pediatric surgery. So you can, um, the, the important thing is that when you give local anesthesia, it should cover the whole area of the that you want, that you are going to be touching by your procedure so easy that you give it by a static method, which means you choose a point, you fill your syringe with the local anesthetic that you have correctly calculated the dose for age and diluted if you really need a large volume. So you fill your syringe with it and then you pick the point where you want to push fluid through and then you just continue to push the more you push. So if, if, if, if you push the needle in, save just this point where the sorry, not want controlling. So you put where the, where the needle is and then you just keep um pushing the content of the syringe into it. What happens is that you continue to expand and it's covered by the anesthetic widens. But if like have in the picture you have like this or incision is that you want to go around, they might do um either multiple static ones like that or it continues and then it continues, you push, you need to the um it that yeah. Mhm mm. Ok. That the vessel and then you push the syringe, we draw a little push, we draw a little so that you feel that anesthetic period there is no, not in the blood vessel. You feel you push in an agent in there, you push forward a little more as and you continue the continue. But what's important is whichever method we use, you infiltrate all the area that you likely to touch with your needle or with your blade in the, during the procedure that you'll be doing um for that patient. And once you have done this, the next two points are the most important, one many times are not to wait. So if you give in filtration, for instance, we expected to wait for about five minutes for it to take complete effect, which is completely numb. And then of course, the second point is to check um for sensation, either with the need to um, prick or just the, the just see the patient feels either the pressure or the pain of the prick. Ok. So the next um important thing to talk about is surgical note. So, I mean, not sutures, generally in surgery, we can either use the instrument or you can hand tie, but I won't go into that. What's important is to know which note is safe. So there is a lymph nodes there the surgical node, there's the granny node that I didn't talk about but a re not is, is the basic surgical notes. And what's important in this note, there are other safe notes that I not, I'm not talking about too because if you would be wondering that these three surgical and even do one is called not. But really all these three are safe. The the the safe ones are like what we call split nodes. And I just mention what the difference is. So you see that um the there, there are two ends of this. Let's take it from that number one that says there's the blue end and there's the red end. So what is important is that you are crossing the end? So the first node crosses the end. So red end goes like towards the my left as I'm looking at the, at the um screen and the blue and goes towards the right and you tie that way by the time you are tying next, you cross it against such that the blue end goes to the other side, there's not, it's not to be tied in a way that will make the blue end still come out on that same side. So you cross at uh over the red end and the blue end goes back, goes to the left this time around and the red end comes to the right by time you do that, you would have what you have in number three and then it goes to number four and then the tie should do something like this because by the time you then pull it together and it's a, it's a suture, you won't be seeing the figure that is forming here, but to sit well and it would not that way that not to don't lose, but many times, particularly if it is a surgical procedure, we wouldn't want to stop at the lymph node there. Those two ties, we usually want to give um, a third tie, um, which can make it a surgical note or you can make the second tie, a double tie. So when you, you use the red N and into the blue end and then you do it the second time, that's the surgical node that you have double tie on top, the single tie as the base and tie it completely for this surgical note that that and this note seems to be noted that at least six times that is, it's safe, but it can be unnecessary depending on the kind of switch that you are using. But if a monofilament suture, that's why we have to make this many um, notes just to make it safe and be sure that it does not or not. But it basic note in surgery is a if note or a surgical note and preferably three times. Ok. So if you happen to be, I mean, for most codes, it's fine to go back for most time, you don't have to go back on codes like um maybe I in the divide and you use the um clamp. If you happen to be like in the center, maybe he's brought on the clamp as, as slipped, for instance, it's probably not best to put another clamp for the strong silk suture and tie or any of that suture and tie. Um Those not the important thing that the not land will and you can, what is the important that, that lo so you land it will and then you do your notes on top. Why do I don't talk about them being cat when it comes to babies and what you need to do for them once they, once they need anything, once they need antibiotics and they understand those things. Yes, you can see the line if you think it's a one off thing. But once and, and, and that's important for when I talk about s can if once it is clear that a, a child in all, honestly, any patient is going to be needing fluids for longer than 48 72 hours, it's best to give a long term form of condition, whether that is a central line or what you call a peak, which is a peripherally inserted, um central catheter so that you already put something that can last a longer time if you have it available rather than having to prick the patients with a peripheral can on and off because this can last really are not likely to last beyond 48 hours. Um if you have a very good one or very good noses. So doctors that are taking care of the line will have 72 hours. So in babies, the like catheterization is important for procedures in pediatrics such as exchange blood transfusion, um mainly that or any patients that are going to be on IV fluids or any IV um intervention for a longer time. And so what is important is knowing what are the things that you need and how do you perform it? So maybe you should be on the I Radian room. I talked about temperature control earlier on. It's important once you are doing anything for the baby, particularly because sometimes you have to expose the baby when you are doing this procedure. Once you are doing those things, then it's important that the baby is on the I if you have that, if it's not, if you don't have that, the consideration is given to whatever you need, we need to keep the baby warm, some warm things around because they lose heat by infection by radiation. So you want to check all of those that the room temperature is warm and that if um they're gonna be exposed, then maybe warm pas are placed around them but not touching them. So we don't do born in your to sterile gum, sterile, sterile drips, small ter drip. There are specific ones for um being catheterization. If you have a pack that is just more to cover the baby and Exclu umbilic a bacterial solution like or I should be used um tape scissors. Um So, um tape is to hold the base of the, um, before you cut it down. When you're doing the procedure, you need a scissors for cutting suture, um scalpel to put a part of the, to cut off the um you know, just about a centimeter or two above the anal wall. Iri forceps is um they are tiny non tooth forceps you can use to. So you can see what you are doing non too forceps is um I like being Kar. So you need the Kaita itself. There are Kait that are factory me, but I'm sure many of us if you, if you practice in Nigeria would have seen um the small size tubes use size five or size six tubes. But sometimes you also can get the um factory made on a three way stop cock gives you opportunity to use the Kata. Both as the venipuncture. You take samples um a, a place to flush and a place to give fluids continuously. It gives you room to do all that without having to keep disconnecting the, the line, the IB tu whether that's a set or regular fluid giving set need to hold that 330 silk. So I probably use vir um, stil is not absorbable. So, and, and sit well. Um, and that's it. Ok. So, II I listed all of those things that you need because when we talked about instruments and we talked about sutures, all of those things are important in, in how you have packs. So let's say, um, you in, you need to make like a pack for this procedure. Now, you know that instrument wise, you need a needle holder for the suture that you put. You need the a non to force, you need the scissors um and all of that and then the suture will be in that pack and then the the, the drips that you need the blade, everything will be in that pack. The other things can be on the word, of course, the the fluid and all of those things. So this give you an idea of which instruments are already advance, which materials are already advance and they already packed in your pack for like having catheterization. So to talk about the procedure itself, we clean the patient drape the baby and then explain please. And then you apply the um tape at the base. That's the white thing that you can see the tape. I mean that is not um it is not thin like a suture. So it sits well there without putting too much pressure, but should you cut? So you cut the umbilic cor just about a centimeter or two, a abdominal wall So should you cut and the bleeding seems to be a little excessive. You can then always put a, put a snug tie on the umbilical tip and that should reduce the bleeding for you to get to what you want to do. And the first on top there gives you an anatomy that makes you move. The vein is so like an infected smi face is like the and the two usually by this time have gone into spa. Um And so the, the one that will be, but occasionally they dust mites and so just go to the 12 o'clock, that's the part facing the baby's head. And by the time you pried up, please open and introduce your umbilical, your leg to be. And the I black coffee, I mean, it's pretty easy, but particularly if you are doing it, if you the first, the first times baby is within a couple of days, less than 57 days, I mean, sometimes you can do two week but 57 and then, and you have all the things you need usually can be pretty straightforward. So have all those instruments, put the umbilical tape at the base of the cord, make a transverse code of co, I mean, transect co of the of the wall and they use a non to separate the tissue that are there. And in the 12 o'clock area, usually you find the space to introduce it. The can um I think is the vessel that in um have the embolism. So it means that you can see and then you pass it in centimeter. You, you, in all these, you being careful whenever you flush and you remove either that close immediately or you kink the, you kink the Canon, the catheter or, or tube to be sure that nothing is, your blood isn't just going out and wasting and it doesn't get socked in and cause an envelope you flush and then you close it and usually you wouldn't go beyond four centimeters. There are measurements according to. So majority of the baby in terms of gestational age and their age, but usually you would not go beyond 3 to 4 centimeters, um, introduce or one centimeter beyond the level at which blood started coming out when you introduced it, basically that it, and once you've done that, then you should try it down so that it doesn't just slip out, um, and put a dress in. Ok. So the next thing we're talking about, so if you have questions, then I, I can ask, uh, during the abscess is ask them as this is a, a uh uh, relatively, you know, common things in Children. You would worry if it is something that is occurring repeatedly in a particular child. In which case, you don't have to rule out that there are no, no cause for immunosuppression. Um ranging from any, um any congenital diseases to infection to diabetes and and, and really not all of those. But if it's the first event, then you don't necessarily need to start running out all those things. A common size really is the neck for Children for whatever reasons. But it can be anywhere else in the subcutaneous tissue. If that happens, what's important is to recognize it is to one recognize there's an abscess. Um The history usually be short, it will be less than two weeks in vegetated fever, the swelling is warm. It can be soft when you feel that there may be a particular region that looks like a punctum that feels even softer. Um If it is soft, other punctum and everywhere else is still a little too firm, then usually you put on antibiotics and will not be draining at that time. But um if it is soft, then you're thinking of draining occasionally even abrupt, but it's not completely empty and then you still need to drain. Um, what I was saying is that one of the things we need to find out that the area is safe, meaning you are PPI if there is any important structure that you think can be going through there, um Is it postal? It's not post, um It's not passing any important structure, then it should be, be something that you can drain. If you worried about anything, then you can ask for a scan. So you are set of the anatomy of that area. But what's important is that it is soft, you can even aspirate it. Um, and you can see that clearly it's post that's in there. And so then, you know, this is an abscess and you can plan to do a have an abscess for almost any child. Should not require general anesthesia hardly requires, it does requires antibiotics because analgesics, um when it comes to local anesthetics, it's usually not very um relevant because except you would be if you, because you can, if you infiltrate the tissue, who already the abscess is it not that effective? Um Except now infiltrating the normal tissue surrounding the whole abscess. Hopefully, then the area the abs is not too big. That might be helpful. If the abscess is big, then you can go around the whole um wall trying to infiltrate it because the process of the, the part that would you be incising is really small. And so you can go ahead with that because when you are in, in that area that's already infected the anesthesia, thy won't be effective in pain or doing anything there. And you also run the risk of now introducing infection into the skin itself. So if I drink in the abscess, um Sorry, iii I feel like I didn't look at the slides. So let me be sure I didn't miss anything in the previous slides. Yes. So you may be made a anesthetics. Um antibiotic should be given uh usually as intravenous antibiotic at that time you are given the, during the I, um, the incision and drainage, it's safer that way. If for any reason I'm not going to give IV, then it, it should be that the patient had been on oral antibiotics consistently. Perhaps they saw you days before. It didn't look like it was soft enough to be drained. They were on antibiotics. Then maybe you can drink at that time, um, without an IV antibiotic where they are seen you for the first time you want to drink, please give an IV antibiotic before draining and they can continue an oral antibiotic after that. Um We need a full blood count and give you an idea whether the patient is already septic and perhaps need more IV antibiotics then. But that can be done. That really determine that septic is a clinical determination. How ill this patient, how is there a fever that is persistent because abscess in itself will give you very high full blood counts. And so the food count may not be enough indication of systemic sepsis as it as it were. But if it does, if the patient is symptomatic, um the blood count is high, then maybe they may require more IV antibiotics or you on admission for a couple of days, but most abscesses will not. But it says beware of necrotizing fasciitis. So when you start having a spread, an abscess, you can define it. This is the abscess and when you drain it, you know that this is the end of the cavity. But when you see changes in the skin, this stand from the area of the abscess, um it, it doesn't seem like the abscess has an end, so to speak, then you fasciitis and that is more extensive, requires more special and specialty um involvement and you should not shy away from let the patient know that what is important is an be started And then they may need um they may need to see a plastic surgeon or come to a center where all of those things can be addressed. The antibiotics will start this work. It is an abscess patch that you want to drain. Yes, you can. But if there is a net um more extensive, the more might need to be done and knowing exactly when that should be done and to what extent, maybe in the view of other special uh specialist. And so you may not want to go that far, but at least recognize it because it will continue if it's not dealt with. And that can, that can be detrimental to the patient. Important structures already mentioned should be avoided. So during the um drainage itself, the traditional whatever I say, traditional, it doesn't mean we don't still do it. But the traditional teaching for how you do an I and D is to do a cruciate incision, a cruciate incision just means like a cross. You make a in incision a trans incision deep into the abscess may not, may, may not be more than 11 to 2 CME either way. But the idea is that, that opens up the abscess and then you actually cut off the edges on all four sides. So you have like a round, um we have like a circular opening into the abscess. This is supposed to prevent the healing of the edges from occurring before the abscess cavity has completely closed. So we make a clu decision, we cut the edges, we empty the abscess completely. Um If, if I either by pressing it out, expressing it until you are seeing blood. When you see blood, it's telling you they are now at the wall of the abscess. Excuse me, the content of the abscess has completely come out because what will be happening in the wall of the abscess are like new vascularization. Uh When, when the abscess has gone down and you're not pressing those ones, then there will be some bleeding by that time. That should tell you that most likely you have completely um emptied the abscess. So when you that when you have emptied the abscess, usually it would be nice to also wash off that area with normal number. That also depends on where this abscess if it is just subcutaneous. Um or it looks like it's continuing, you know, you can't see everything, then you can just put gauze and Celine and push it in to clean. Um, all of that area having cleaned this, the abscess cavity should be packed. Now, it's important to know why an abscess cavity is packed. The main reason number one is hemostatic. Like I told you, the wall would be bleeding. That's how, you know, you have completely drained the abscess. So you don't want that bleeding to continue because if that bleeding continues, it can actually fill the cavity and then give another cause for infection. So if you pack that cavity, that the pressure of your pack will um will control the bleeding and allow for clot formation and that should stop. So usually we pack for 24 hours and remove the pack and continue to dress. But if you have a large cavity, I mean, say sometimes in some not, not common in Children but sometimes some glu cell abscesses. For instance, in adults can be really huge. Some abscesses in Children too can be huge really depending on when period eventually show, depending on which areas are happening. So when they really are huge, then I mean, and your incision, you can make an incision continually to be as big as the abscess. Yes. So I talked about, I was going to say that apart from using cru incision, we also now use, we can use long in incision, we can use a linear incision depending on the size of the abscess. So if you have a huge abscess, then you can use a linear incision and it can be longer, knowing that it would heal, so it can be longer. But it, the time to take it to completely heal should have allowed the abscess to um the cavity to close before the wound that is close. But like I was saying, if the cavity is really huge or tortuous and you want to be sure that um the wound edges don't close before the cavity has closed. When you, after taking out the initial part, and I say you take out in 24 hours, then you can put a week, a week is already show in this picture is like, it's like a piece of gauze that you open up. And you know, th sometimes they there are fact to made week for abscesses. But the, the idea is to pack but pack it lightly. Not the packing really. The first time is, is, is, is because it is hemostatic when you are packing because you won't be able to absorb any, any abscess that still collects because the cavity has not closed, you pack it, you pack it lightly, but it fuse the cavity. But one has to be conscious to continue to reduce the, the length or size of this week daily. Otherwise, what the week will then do is to perpetrate the cavity and leave it there. So I'm particularly not a fan of living pas in abscesses because it just maintains the cavity. But there are a few times that you really have to because the cavity is tortuous or the cavity is white and is big. So consciously, someone has to know the length of that is put there and reduce the size of that is. And particularly if they are repack. If you are not repack, you just keep taking out some of the length, but many times you need to repack because an effective process. So want us to be cautious that, ok, so if you have to pack it with six gos is the the best day, even if you lose, like it's probably not a lot of water, but by the next day, reduce it to five goals. Um By the next, if you maintain five go for two days, then maybe have a have a plan of a system as to how you continue to reduce the, the week that's in that abscess so that the cavity gradually closes. Otherwise, what you then have is a cavity that you have now maintained and take a longer time. Um closing. Ok. So the next thing we're discussing is next slide, please. Thank you, Mo Closure. OK. So we talked about sutures earlier that you mentioned here because not on my slide, other ways of closing wounds, like I said, mostly sutures um is also the use of steri-strips. So sometimes a person gets a, a small linear laceration and it's clean so the wound can be clean and you just apply apply steri-strips. Um They come back to me, you can just apply across them because it's superficial. You just bring the wound together and put the strip together that, that, that should um be fine. If the wound is wide and needs to close the secondary cruiser, then you just keep dressing until the wound contracts by itself and it heals. But by far the, the, the most common method that we use is um suture in with using sutures to close the wound. So here, I just want to talk about the different types of suture styles that stitches. One common one is when you make simple mature stitches, which is what you are seeing. The bigger picture here, uh which is interrupted, mature stitches is probably the most common you would have to use um as a non specialist. So someone has a laceration or there's a wound or the person had surgery somewhere. Um There's wound infection, you've been doing dressings, secondary healing, but now the wound looks clean, it's gonna take a long work for the wound just to come together. You want to do secondary close or that's the stitch you do instead of the stitches. Um So what's important here is that you go the same distance on each side of the moon about 0.5 cm here, zero point same day and you land the on one side. So that particularly if it's the, if it's a non that you want to lose, um, it's easy to just pick up the on one side and cut the suture. But in Children, sometimes we still, even with inter sutures, we see there's no no absorbable suture so that we don't have to come back to get it to, to remove the stitches. But if for instance, it for secondary wound closure and you want to use no absorbable, then definitely you come back to take the stitches off. So it can be interrupted, simple mattress and it can be continuous stitches, which is the one on your, on the right side, we use continuous stitches. If you are bringing together with a skin or any tissue that is not under tension. What is it? It's long and it's not under tension, you can just run the stitches um and use continuous stitches to hold that together. Arguments that some I have against continuous stitches is therefore, if anything happens to the stitch, something cuts the knot somewhere, the whole length of the stitch is, is lost, is loosen. Whereas any one of the inter can be taken and you still have the integrity of the wrist to um intact. But that's not to say that continuous stitches can be used a whole lot. What's important is that there's no tension in the wound. Um And many times you really would think of it in the wound is long other um stitches that we use uh vertical, mature stitches or horizontal. Um mare stitches next slide. Yes. Yes. So these ones come in when there's tension when there is, you need to, to some degree forceful, bring the edges of the wound together. Of course, that because it can come together. So you, it's not to say that you have, um, edges that absolutely can't come together. No, they can come together. But if you leave them and do they probably will prior a part. So for those kind of sutures, while we, since we're talking pediatric surgery, so if we are able to get to gastroc and then on follow, but if we happen to be able to do primary closure for the gastroschisis or gastros in particular, because many times the cavity of the abdomen is not that wide. Even with the skin, I bring it together and able to bring the fascia. Many times you need to use either of these, either the or ma or the particular ma su to keep it together so that you don't find out to the, the, that the, the, that the skin or whatever the wound, um, tissue are brought together is spraying open because there is some degree of tension there. The bowel, even if you're not feeding the baby, the bowel has edema, it's trying to push upon whatever you have done, but it's not too much tension for us for you to not be worried about um abdominal complement syndrome or things like that. So whether it's on the limbs, whether it's many times for skin closure or fascia, there is some degree of tension you want to ensure a position, but there is no to the vascularity of what is underneath. We use horizontal mattress. So Hoon matress, as demonstrated here means you go perpendicular to the, to the incision or to the length of the wound. So you go in on one side, you come out on the other side and on that same side that you came out from, you go in again and come out on the, on the other side. And so you tie on the side that you came out from. So the stitch, you end up looking like this first one, you know, and this is the second one and the third one is the one that most to. So it's horizontal, um it's perpendicular to the wound. Those are the horizontal mattress, um master stitches. So even the perpendicular to the wound is how you going when the sutures stitches, like you can see, they look parallel to the wound as the apparently the stitch themselves. I'm making all these explanation because many times it gets confused. Some, some sometimes you feel like calling this the vertical mattress, but this is really the mattress, the vertical mattress, the suturing the whole of the suturing is perpendicular to the line. So there's no point where you come back, you when you OK, let me, let me explain that. So when you come back in when the result, so you go in on one side, also on that side and along that side, you give 12 centimeter, one centimeters maybe and you go back and come out on the other side in the case of vertical mattress. And so you go come out in from say you come, so there are two ways of doing this. You can either come in far, say about two centimeters from the 1.5 C from the of the wound go in and come out about the same, same distance on the other side, then go in close to the edge and come out close to the edge and turn on this side. But the picture is showing, let me, the picture is showing it showing that it went in close to the edge, came out close to the the other side, then went in again a little far from the edge, but still along that same line as Nila and then come out far on this other side. And then this time you decide to this, you know, I'm, I'm hoping that you can catch it in, in these pictures because of all the network issues. I didn't bother with videos. Uh Maybe those will be more demonstrated. But what's important is that these sutures are more relevant when we have some degree of tension and want to hold the edge of the tissue together. Subcuticular stitches are the love of pediatric surgeons. You can hardly find any pediatric surgeon that is not using this for almost for a lot. Most of our skin closures and sub stitches. Um And then there are other tissue repairs and are sub stitches. Sometimes we do hyper reps and subcuticular stitches on the skin just outside. It goes in there in one side to the other all of time. So about, I wanted to talk about that because if you see them, yeah, you can move the slide. Now if you see them. Um I remember many, many slides I have but you see them on the outside. The question is what do you do for the baby? Special? Know what to do and we can talk about that as um a theory but I wanted to say important things. So babies, the baby is born with gastroschisis. What do you dress with for transfer? So many babies are coming to us and n so I see that they are so they, they clean the bowel with maybe warm cline and so they put the warm saline on the gauze and it dress it and then it puts create bandage. Now, the thing is that the line was warm when whatever fluid was warm at the time that you did that what's going to happen that that fluid is going to become cold, it doesn't gonna become cold. The baby is gonna become cold. That's the baby that is at risk of dying because hypothermia, hypoglycemia, hypoxia, those are the, those are the danger, danger things for baby, those are things that are very likely to cause mortality. And so when that is done, you can wash it functionally. That's fantastic. But what should be done is that wrap with a bar dress which can be nylon, clean nylon or use this film, clean um clean film for, for, for, for, for ladies or other people should know them that people use to cover food in it. You use at home, the clean film is like you just wrap it around it that way it is covered, it does not allow loss of fluid. So baby is not losing f and becoming overly dehydrated, do not allow loss of heat. So baby is not becoming the last one. There is an ce if the cell is intact, that's fantastic. So if you are a baby with low and say maybe you are in the center where you know, yes, we want to refer but for some logistic reasons, you're not yet and the baby has no other problems can feed. Then phal can be addressed with what we call tics. Common one that we use this original honey. But frankly, sometimes I shy away from that. If you cannot be sure of the honey, then you can use them as in they the same one. S sulfADIAZINE, the same one used for bones to dress it and, and, and, and you can do that alternate the um by the time you do that a week, 23, you can make it twice a week. What's important is how we address it. And that I need to show here is that you don't just wrap it around the baby and, and maybe strong, but you do like a construction. So the first thing is with in the first picture showing how the wrapping is gone around it and then the wrapping then goes over it So that if you raise it to almost like is standing on its own but abdomen before you now go round the trunk to hold it. That's what that, what that achieves is that there is some degree of compression on the follow. So gradually pushing it into the abdomen but slowly to while the the membrane covering of the omphalocele is healing with the tics. But the healing takes a while because you don't need eter to happen over over time. And that can take weeks to two months to occur. And anytime along that time you do it and then you referred to the surgeon. But this can be started um wherever the baby is, if there are no other problems. Ok. So I think we, I talk about the rectal pull that the next one. Yes. Now I I added this topic so that um I can quickly also talk about rectal prolapse is about one of the common things a non pediatric surgeon can manage um in pediatric surgery. But if you see a child with erectile prolapse. The most important. First thing is to make sure it's not a prolapse, it's sexual, it terrible a prolapse. On the other hand, is an emergency. So um and it can happen at any age, for instance, maybe if this was happening in an infant, many people would be more um sensitive to the fact that eat uh many times rectal prolapse can be short. It's just starting from there. My now can can you hear me saying disconnected? Um Yes, we can hear you. OK, great. Thank. Sorry about that. I didn't realize. Yes. So rectal prolapse, I can see the time has gone. Um So I was talking about how to differentiate it. So, so II I um you know, rectal prolapse is, is prolapse of the mucosa of the rectum. Sometimes it can be full, it can be a complete prolapse. Those are not common and those are treated with um perhaps Children that have the ectopia blood um um bladder opas or other the pelvic anomaly. So, but the most common recile prolapse are mucosa. I will show to the basic, most important way of differentiating it. You would need to do a rectal examination. Um But let me doctor, right? OK. OK. Looks like I went to the my I think I'm back again, right? So it looks like my Yes, your back. All right. Thank you. So, so the most likely have had symptoms of vomiting. Um may or may not have abdominal distension, typical symptom of vomiting may have had the but again, depending on who is giving you the history, some of the missing. But clinically, one way of differentiating is to do a digital rectal. The patient with erectile prolapse. On the other hand, shouldn't have, shouldn't be vomiting. So if I have a patient with rectal supposed erectile prolapse, somebody refers and see erectile prolapse and it has a history of vomiting particularly been vomiting, then very likely it is not. So if you put your finger in the, in the anus, so now to get into the anus means either you are pushing to push back this, this prolapse or you in your finger beside the prolapse and the wall of the anus, you would in recile prolapse, you would see that your finger would touch the apex of the prolapse. You, you hit the wall within two centimeters, you're hitting the wall of the anus through which the rectum has prolapsed. Whereas if that was a prolapse in suction, you would, you would not be able to eat the pa your finger can go all the way in. I see someone has put in here that can make a oh sorry, that's about something else I thought I was going to talk about, but an ultrasound can help you with um diagnosing and C by all means. But you know that if you, if you already as you have prolapse, you wouldn't even be asking for an ultrasound ultrasound scan. Um, but just putting your finger in will make a difference. You put your finger beside the rectal prolapse and in. No, you, you can't go beyond like two centimeters. You'll be hitting the apex of the inos where the rectal rectum prolapse through. But with an inception, your finger will go all the way in and there's still no apex that you are touching. That's so important because and a prolapse inception needs um immediate surgery. You are at risk of bowel going gare and all that, which is not the case erectile prolapse. So to talk about, so I've been differentiated, show erectile prolapse. What you will do. What we should do is put the patients in the relapse with some relying um on their back or on their side and gently push in the prolapse, they able to completely push in the prolapse, clean, clean up the area. What usually we do is strap the buttock together. And now this is also dependent on how they present if it is ac case really, most times they will tell you the prolapse comes and goes. You may be present when they see you. You may, it may be that initially it was maybe grade one it comes out, it goes, but now it comes out and somebody pushes it in and able to put it in easily and have been able to push it in easily. That kind of patient doesn't require a procedure per se. Um for you to do, I have to tell them to do, but often, especially when the child passes through or whenever the prolapse comes out and they can be managed as outpatient. The one that requires doing something is um is when the prolapse is not the, the is not reducible to them being court. Um The model says they can push it back in or it's been out for some time. So you can attempt to push back in. It does not go, you might just put the patient on, sit back for like three times a day for that day. And usually by in 24 hours, you should have, um the edema should have resolved enough for you to push it in. And when you push it in, we strap the Botox, we leave that for about less than 4 48 hours and then we let them continue on sit back. We hardly ever need any surgical procedure for recile prolapse in Children while I'm at it. I mean, I know it, we are talking about the skill. So the skill was to push it back in a strap. But while you are at it, one of the reasons Children um can have rectal prolapse prone that make them prone to. It is if they've had diarrhea and all of those things. But it's also the anatomy of the child. The pelvis of the child is still more straight and not as cold as, as, as you have in an adult. And so one of the advice you give them in the child should not sit on the po po maybe sit on the big on the regular um toilet with a system for the child to so that the child can bend or again sitting up straight when using the um potty but many times with sit baths and clearing whatever on the underlying things like malnutrition and all of that erectile prolapse should resolve itself. I think the last thing is talking about reducing a hernia. So doctor next slide, I think that that should be the last slide. OK? I think I didn't add it eventually. OK. That's, that's the last slide I gonna talk about a hernia but II I think I removed it eventually. OK. So thank you. Um I gu I guess I went around a number of things. I hope I covered things that you wanted to hear. But if not, please ask questions. Um I guess you still have some time for questions. Thank you very much for listening. Thank you, Doctor FAA for taking the time. Uh We really, really appreciate um the session today. Um So far we only have one question about um ultrasound finding of intra-abdominal um bowel dilatation and um gastroschisis. Um That's the only question we have so far. Um So I was wondering if you have any um comments regarding this question? Yes, So, ultrasound finding of intradomal bowel dilatation, whether it predicts a advanced neal outcome. Right. So, there may be, there may be a study that directly predicts that. But if there is intraabdominal bowel dilatation, that already suggests a number of things, one that you may not be able to um do a primary abdominal. But two, it also might suggest that there is an associate at which means that um the anal at whether or not. And so it means there's proximal dilatation. And many times when we see gastroschisis, the first thing is you want to at least close the gastroschisis. Um, if you do recognize the atresia, then may be treated at the same time if it was not an obvious atresia come back with us to treat a couple of days later to treat it. So, having having dilatation, it suggests that there is a atresia which already tells you that the patient needs more surgery and all that, there will be difficulty um, closing the anterior abdominal wall over the gastroschisis. So definitely that can, that can affect the outcomes in that patient, you know. Um, but I'm not aware of any that direct says it predicts an adverse outcome, but it definitely suggest it even from just reading this, the bowel is dilated many times. The problems we have is that the bowel is, um, there is a pill that is already occurring in, in, in, but even when they are now born and you are getting to see them only have data. There's a lot more, um, postnatal edema that has not occurred, that makes it difficult for us to even be able to do the anal. But you do not have above all of that intra that has already occurred with that because it's atresia or for other reasons, it makes the, um, prognosis, you know, worse. So, I guess, yes, I'm agreeing with what that suggests them. Uh OK. Thank you doctor. The next question is asking about um ultrasound finding or into C section. I'm guessing that's like uh for prolapsed into C section. Yeah. Uh and OK, I can't hear you clearly. So it give me the impression you probably can hear me too. Hello? Can can you hear me? What is that? Can anyone please let me know if you can hear me? Mhm. If anyone can hear me, please? Yes, I can hear you. I think I got disconnected. All right. OK. Yes. Yeah. So, so yes, I was talking about ultrasound finding. So you on ultrasound, on the transverse section, you would see what we call a target sign that's co co percent circles. That's um the wall, the outer wall bo the outer bowel that is receiving inception and then the walls of the inception that is going into the in interceptions. So those walls are about four or five concentric walls that you would see suggest in suction. A longitudinal view would give you what we call a pseudo kidney sign. And the location can be anyway, the only thing the location tells you is how far the bowel has traveled in. Mhm. Is seen in the left iliac or pelvic region because I immediate sensation has traveled that far before coming out. I guess that, I hope thats the question. I, Doctor Pa what I right. Doctor Patel. Did you, did you hear that? What? I'm not sure if I was hurt. Um If anyone can let me know. Yeah, I, so OK. Can anyone hear me? What? Yes. Yeah. Oh, I'm out. Oh, wow. Hi, everyone. Can you guys hear me now? Can anyone hear me? Um So we're almost at the end of this session. Can anyone hear me? Ok. Um So we're almost at the end of the session, but I think we have one more question for doctor FAA. So she's trying to rejoin this. Uh OK. Yeah, she's back. Yeah. Yeah, no problem. Uh So I think we have, we have just one more question for you about erectile prolapse. OK. All right. So it says um in a situation where conservative management of rectal prolapse failed and the caregivers are apprehensive, thus demanding for further urgent care. What would be the next line of management? Ok. So, um you have exhausted conservative majors. Um Then there are surgical procedures that can be done there. I mean, there, there, there are surgical procedures that can be done there there is a TS procedure, there are other procedures that you can do intraabdominally or trans anally. So there are surgical procedures that can be done for such patient having, ensure that um whatever other pre predisposing factor has been ruled out because if there are, if there's still malnutrition for instance, and the problem is because the patient is really um undernourished. And as such small, there is no, there is no bowel fat or anything that holds, then that will not be solved by surgery or that the patient have any other um anomaly if all of those is those that been ruled out. Yes, there are procedures that can be done for the patient, but those are surgical. So these are surgical treatments for the erectile prolapse. Thank you so much, I think. Um, that's the last um question so far from what I can see on the screen. Um Thank you so much. I know it was quite a challenge we did last week and the day we really. Yes. Thank you very much everyone. Um So we'll get feedback, uh feedback forms and certificates will be issued as well um, for attending this um session. Thank you, Doctor FAA. We do look forward to having you uh join us for more sessions. Thank you so much for your time. Thank you. It was my pleasure and thank you all for coping with all that we have to go through. Thank you very much. Uh So we be rounding of, we'll be ending this session now. Um I will end the talks like shortly. Uh Thank you, everyone. Thank you. Thank you to Doctor Fabia. Um See you, see everyone again. All right, bye bye. I.