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Common Paediatric Surgical Conditions. Professor Varadarajan Kalidasan, Paediatric Surgeon

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Summary

This on-demand teaching session will cover common pediatric surgical problems that medical professionals may encounter. We will discuss the different types of hernias and hydroceles seen in kids and learn about risk factors, complications, and surgical management of these conditions. We will also discover how to differentiate between hernias and hydroceles and when and how to perform operative correction.
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Learning objectives

Learning Objectives: 1. Understand different causes of pediatric hernias and hydroceles. 2. Recognize signs and symptoms of inguinal hernia. 3. Evaluate indications for laparoscopy or ultrasound in young female patients. 4. Become familiar with risk factors for hernias and hydroceles, such as premature birth. 5. Recognize that umbilical hernias generally resolve without surgery.
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So good afternoon uh everyone. So um I'm not entirely sure where many of you are situated, but I hope that this will be of use to you wherever you are. The topic today we are going to cover is about common pediatric surgical problems. Clearly, there are numerous problems that can arise. But I have chosen the ones that in my experience of over 30 years in pediatric surgery that uh we find is useful for undergraduate students and people who are not specialist pediatric surgeons. So that that's our aim today. So I'm going to make this a full screen and please tell me if there's any problem in seeing it. I hope you can see it well. So move, I think we'll move forward. And so the first thing is that one of the commonest things we see are lumps in the groin area that is around the inguinal region and in the scrotum and sometimes in the labia majora of girls. So we, we see these presentations as lumps and so we'll just quickly see what they are and what we should be doing about them. So this is a diagram which shows an important thing because what it shows is as you know, when the testis descends from the abdomen to the scrotum, that is an outpouching of the peritoneum. And this out pouching of the peritoneum is called the processus vaginalis. Now, once the testis has descended fully and has reached the scrotum, the process is gets obliterated. So there is no actual cavity, it becomes fibrotic. So there is no opening between the peritoneal cavity and the scrotum. Occasionally the processes stays patent or stays open. Now, it may stay open fully as in this diagram here. And then you will get uh hydrocele or a hernia depending on the size. So, if the size of the opening is small, you'll just get peritoneal fluid tracking down and collecting as fluid around the testis. And that forms a hydrocele as you can see here. And so that is, it is because of the size of the opening. Now, if the opening is larger, then contents of the abdominal cavity can come into the scrotum and it forms a hernia in boys. Usually it is uh small bowel in girls. It can be the ovaries as well. So you can sometimes feel an ovary in the groin and occasionally you get incomplete hernias which are just seen in the groin and not in the scrotum. And sometimes you get the process is obliterated at, at the top and the bottom, but there is a tiny hole which forms a little cyst here. And this is called an incised hydrocele of the cord. So what are the main features of an inguinal hernia? The main features are a swelling in the groin or the scrotum. One of the important things is that as long as it's uncomplicated, you should be able to reduce the hernia. So when you push it back, it will disappear. Now, that's an important distinction between a hernia and a hydrocele. You cannot reduce a hydrocele but a hernia is reducible. Occasionally it's tender but usually it does not. Now remember that sometimes there is a condition of what is called a retractile testis. So a testis which is in the scrotum in young boys can go up and down. And so that should not be confused with a hernia and a retractile testis is a completely normal condition. It is not an undescended testis and should not require surgery. So a good clinical history is important as always in medicine and with the hernia, the parents may tell you that they can see a swelling which comes and goes. So it is not there all the time. So that's a good history. Now, the complicated hernias are what we call incarcerated or irreducible hernia or a strangulated hernia. Now, when you get an irreducible or strangulated hernia, it becomes a surgical emergency because we need to operate on it sooner rather than later to avoid complications. Now, the main complications of a strangulated hernia are either compromised or blood supply to the bowel, which can cause necrosis of the bowel and can make the child quite seriously ill. Or sometimes, even if you manage to operate and save the bowel, the pressure on the testicular vessels, the testicular arteries and vein may cause strangulation of the testicular blood supply and therefore, the testes may atrophy. So we have seen this happen sometimes. So after successful management of the hernia over a period of few months, the testes will atrophy. So when you operate on strangulated hernias, you must warn parents that this is a possibility because otherwise, they may think that it's a complication of your operation. So the in fact, when we get consent from parents, we always note down that we have told them that the test is may be atrophied later on. So the incidence of hernias is about 1 to 5% in Children. The com the highest incidence in the first year of life, hernias are more common in males than in females. And that is particularly in girls. If you get bilateral hernias, there is a concern that the child might have a condition called androgen insensitivity syndrome. In which case, the child might actually not be a girl. Though externally, the child looks like a girl and that's because of androgen insensitivity. So we often would do a laparoscopy in girls who have hernias just to make sure that they have a uterus and ovaries. And you can also then fix the hernia from the inside laparoscopically. But where you don't do routine laparoscopy, it may be if possible to do an ultrasound to determine the presence of the ovaries. And the uterus prematurity increases the risk of hernias. And that's because just as prematurity increases the risk of undescended testis, the processes may not be completely obliterated and therefore, they have a higher risk of hernia. Bilateral hernias occur in about 10 to 15% of boys and it's predominantly a right-sided uh hernia. There is a theory that the right test is design later. I'm not entirely convinced about that. And yes, hernias seem to run sometimes in families. So you may have siblings who present with hernias, hernias in Children always need surgical correction. There is no doubt about it because if you do not operate on them, there is a great risk of, as we said, uh incarceration or irreducible and strangulation. So, and it's best to operated as soon as possible. It is not an emergency, but you should try to get it done uh as quickly as you can. And it's one of the commonest things that we do in our practice. And but I also am aware that there are parts of the world where it's actually quite difficult for Children to get surgery done even electively. And there are not enough uh pediatric surgeons in many parts of the world. So some adult surgeons are trained to do these operations. Now, a Hydrocele, the pathology of the hydrocele is exactly like that of a hernia. In a child, you must remember that hernia in a child is different from hernia. In an adult. In an adult, the hernia is due to weakness of the posterior wall of the inguinal canal in Children, it is due to a patent processes, vaginalis. So the hydrocele similarly, in an adult is due to a different cause, it is due to excessive secretion of fluid within the tunica. Whereas in Children, it is due to communication with the peritoneal cavity. Now, sometimes they are called communicating and noncommunicating. Because in a communicating hydrocele, you might often see an the that the hydrocele actually extends into the ureter peritoneal space just above the groin. Whereas in a noncommunicating one, which is the most common, it is confined to the scrotum. So that is a possibility of uh the hydrocele occurring in a female too though it's uh rare and it's called a hydrocele of the canal of neck. Now, the typical features of a hydrocele in a child as in an adult is that you can transilluminate it. So if you shine a torch, it, you can see it transilluminating very well clearly. This is more obvious in fair skinned people. So similarly, the bluish color again is more obvious in fairs skinned caucasian people. It is not that obvious in people who are black or of Asian origin because the skin itself is quite dark. And so you cannot actually see the bluish color trans illumination. You must be able to see the hydrocele is not reducible and it can move with the testis or the testis can be moving within the hydrocele. It is not painful and you should be able to get above the hydrocele and feel the cord structures. So that's an important uh sign as well and it can fluctuate. So when you press, you know, you'll see fluctuation. Now, it's very important to remember that nearly all hydroceles will resolve on their own. So there is absolutely no reason to operate on hydroceles early in life. In fact, we would probably not operate on them till they are about four or even five unless they're very large. In which case, we might do it after the first two years. So it's extremely rare for hydroceles to need surgery in the first two years of life. And parents are often concerned and they will ask you if it will affect the testes or whether it'll affect fertility. And the answer is no, it never affects the fertility. And so that the testis is not affected by hydroceles and you have to reassure them. So most hydroceles will require no surgery at all. So moving on from there, uh this picture shows the bulging hernia, which is an umbilic hernia. So you will often see this at birth and again, umbilical hernias for reasons not well known are slightly higher in incidence in the black population. As compared to the Caucasian population. So, but again, what we have to remember is most of the umbilical hernias will fix themselves. So they are, they are not uh they do not require surgery though. They look quite big early on in life. Literally, all of them will reduce in size and vanish. By the time the child is about three years old, sometimes, of course, there is an ugly bit of skin left there because of a large umbilical hernia. In that case, purely for cosmetic reasons, you might do something with the skin and create a nice looking umbilicus or belly button. But generally, they do not get obstructed either. And it's extremely rare though it has been reported that umbilical hernias have been obstructed. It is so rare that, you know, we we don't generally operate on them and this is another large umbilical hernia. And I think this child is quite much older and therefore you can see this picture from on the table uh before surgery. So if the umbilical hernia does not resolve by the time they're about five, then you can consider operating on them. So as we said, it's 10 time more common, particularly in African American Children. And it's also common in premature infants. Virtually, all types of hernias are common in prematurity. So this is precisely what we have already touched upon that. After about the age of four or five, you may have to close some hernias which are quite big, supraumbilical or epigastric hernia are rare in Children and they are due to defects along the linear alba. So they are in the epigastric area, they can be symptomatic because what they usually contain is a little knuckle of preperitoneal fat. And because of that, perhaps there is a little pull on the peritoneum or the peri peritoneal fat can get slightly strangulated. So they get some pain. Occasionally they can have the omentum in it as well. And then it is painful. If there is pain, then I think there is a good reason to operate. However, even here, if you get a small epigastric or supraumbilical hernia, which is completely asymptomatic and the child is absolutely fine. There is no need to operate on them because if you examine a lot of adults, you will find that they have got epigastric hernias and they, they seem to be absolutely ok. They, they have no specific concerns or problems. But as I said, rarely, if it is painful, then it can be operated and then the defect in the linear albo is closed. Now, this is there another common and quite an important topic of an undescended testis. So, a normal testes should be in the scrotum at the bottom of the scrotum and there should be no tension on the cord. So it should sit comfortably within the scrotum. So an undescended testis is one that cannot be easily brought into the scrotum and even if you push it down, it goes back up because of the tension in the spermatic cord. Now, this has to be different from retractile testes. As we mentioned before, some boys have got a testis that can go up and come down on its own. And you can often find that by doing what is called a chromatic reflux. So if you stroke the inner side of the thigh of a young child, you will see the test is moving up and down and that's actually a normal phenomenon. Now, in some Children, because of a hyperactive chromatic reflux, the testis appears to be sitting in the groin, but then you should be able to easily bring it down to the scrotum and it will rest there comfortably. That type of test is does not require any intervention at all. So the incidence of undescended testis is about 3.5% in newborn boys. So, but of course, the incidence is higher in preterm babies or preterm boys. And that is because as you may know, testicular descent happens or mainly from the groin area to the scrotum in the third trimester of pregnancy. So it's only in the last trimester that the testis finally descends into the scrotum properly. So if a child is born prematurely, then clearly there is a higher risk that the testicular descent has not happened because there is uh the first is the intraabdominal phase of descent and then is the trans inguinal phase of descent. Now, you must remember embryologically that the testis and the kidneys actually develop quite close together. Then the kidneys are sent to their origin to their uh final position and the test is descent to their final position. So they go the in opposite directions, they say goodbye to each other. So, but in some boys, this doesn't happen spontaneously. So when you examine a newborn child, you may have around, as we said, 3.5% of boys having an undescended testis. But by the age of one, it appears to be about 1.5 to 2%. It says 1% on this slide. But actually, I would suggest it's about 1.5%. So about 1 to 1.5% seem to descend in the first six months of life. Now, there is a familial predisposition. So you might see that boys of the same family have undescended testis. There are even instances where the father has had undescended testis and then his sons have undescended testis. So it can be bilateral in about 15 to 25% of uh cases. And the le right side is more often undescended than the left. But the difference is not huge, it's 55 to 45%. So, so this shows what actually happens with this. So as we said, it develops here and you can probably see the lower pole of the kidney there. And then as we said, the kidney ascends and then the testis follows that route. And as it comes down, it brings itself the whole uh um the the whole uh leash of vessels which go to form the spermatic cord along with the vast difference. And this is the processes vaginalis which has been represented in the blue here. So you must remember that the processes which is not well shown in this picture is anchored to the bottom of the scrotum by the gubernaculum. And the testis itself of course, gets invested by the tunica and you get the tunica vaginalis testis and you get therefore, the testis also has a tubercular attachment. So what one has to remember is the processes and the gubernaculum do not pull the testers down. So they only form a path. So they open a path into which the testes drops. So it is wrong to think that something is actually pulling the testes down. The, the nothing is actually pulling the testers down. The testis follows the path taken by the processes. So it is almost like the process is laying a road in which the testes can travel. So that's an important point to remember because sometimes people think it's the gubernaculum which pulls the testes down and that's not true. So you get different types of undescended testis. You can have a testis which is actually in the groin. You can have a testis which is simply not palpable. So you examine the child and you can't feel it. So when you can't feel a testis, there are three possibilities. One is that the boy has no testis on that side. So it's an absent testis. It could be a testis which is in the abdomen or it could be a testis which is in the canal which you are not able to feel all the time because it may keep going in and out of the deep ring. So with an absent testis, there are two possibilities. The first one is that there was never a testis formed on that site. So it's a completely agenesis of the testis and we may never know why. And sometimes it is due to intraabdominal torsion of the testis. So a testis which has been formed could have vanished later on. In practice, it doesn't matter what it is. If you have no testis, you have no testis on that side. Now, an undescended testis can be felt in the groin and sometimes can even be moved to the upper part of the scrotum. Now, there is a condition where you get testes in abnormal positions and they are called ectopic testes. So these could be on the abdominal wall area, some sometimes on the thigh. I have seen one on the inner side of the thigh. I have seen one on the base of the penis and we have also seen one which for whatever reason had descended on to the opposite side. So both testes were on the same side. So these are all various types of ectopic testes. Now, there is a condition called an ascending testis. So in some Children where we have completely ascertained that they had normal testes when they were very young, when they're about 10 to 11 years old or slightly earlier, one of the testes might have gone up and stayed in the groin. Now, this condition has been termed ascending testis. Now, the reasons for these are not very well known. But the theory is that while the child grew in length or height, the spermatic cord, for whatever reason did not keep, keep pace with the growth. So the testes got pulled back up and that will require surgery. So how do we manage? Um First of all, why do we bother about an undescended testis? Why is it important for the testis to be in the scrotum? Now, the main reason is fertility. So a testis which is not in the scrotum will not produce normal sperms. And as you may know, this is because of the temperature difference. So the intrascrotal temperature is one °C cooler than the intraabdominal temperature. So, and this one degree cooler temperature is vital for normal sperm production. So, if a testis is not in the scrotum, then it will not produce sperms. And that's the main reason. The second reason is that there is a slightly increased incidence of testicular torsion if it is not properly fixed in the scrotum. So it might twist thirdly is malignancy, it has often been said that an undescended testes has a higher incidence of malignancy. This is particularly true for intra-abdominal testis. So, intra-abdominal testes have a higher incidence of becoming malignant. The main problem with that is if a testis is in the scrotum and it develops a cancer, it is quickly noted because of course, the child or the parent or in most cases, adults will be able to see that the testis is getting bigger. Whereas if the testis is left inside the abdomen and it develops a cancer, you will not see it till it is really big and perhaps advanced and has metastasis, which is why it is important to know if there is an intraabdominal testes and deal with it. So the two main reasons to remember are fertility and the detection of malignancy. So the most reliable investigation when we want to look for an impalpable test is that test is which you can't feel anywhere is laparoscopy. Ultrasound is not particularly good because it doesn't often tell you whether you're seeing a testis or a lymph node. MRI sometimes is useful, but again, is not yet very reliable. So the easiest way of finding out or dealing with the test is that you can't feel is to do a laparoscopy and then proceed depending on what you find. Now, this is important to remember because this actually shows this picture shows you an intraabdominal testis seen on laparoscopy. And so the question is, what do you do when you do a laparoscopy? What what happens? So you put in a laparoscope, you see if there is a testis. Now, if there is no test is that is the end of the story because there is nothing much to do. And you must remember to look for the test is right from the bottom of the area of the kidney right down into the pelvis to be absolutely sure that you have not missed an intra-abdominal testis. But most often, what you will find is that there is a testis and then you have to determine whether you can bring it down. Now, there are various techniques that people have said. But since I'm speaking mainly to undergraduates and people who are not pediatric surgeons, I'm not going to go into too much detail of technique. So if it is close to the deep ring, you can bring it out in one go and fix it in the scrotum. If not, if it is too far away from the deep ring, and you think you can't bring it out, then the choice is actually to remove it, especially if there is another normal testis. And the reason for removing it is as we said, you can't leave it inside because if you develop a cancer inside, then it won't be detected early. Now, that is a third, we method of dealing with it, which is only relevant to pediatric surgeons. And that's a procedure called the Fowler Stevens where you do not do anything in the first stage except ligate the testicular artery and leave. The test is in situ in the abdomen, allowing collaterals to develop. And then in the second stage, bring the testes out when it has more collateral vessels. But it's a technique that should only be done by specialized pediatric surgeons. So moving away from the groin, one of the other common things we see are Children with abdominal pain. So anybody who manages uh you know, Children or has reason to come across Children in emergency departments, we'll know that one of the commonest things that Children come for or are brought to the hospital for is abdominal pain. Now, most abdominal pain is nonspecific. So it is acute nonspecific abdominal pain, which seems to go away in two or three days. Often it has been called due to viral infection or viral abdominal adenitis, but you can never prove it and they seem to get better. So 90% of abdominal pain in Children is not surgical. It's either nonspecific abdominal pain or there are other medical reasons, but there are a few surgical problems which are important. So let me see. Yeah. So as with everything else, a good history and examination is very important and always examine the chest because sometimes Children with pneumonia present with abdominal pain. And that's because particularly if you have basal pneumonia and the sort of diaphragmatic pleura is irritated, they seem to have referred pain, which can mimic abdominal symptoms. And in fact, I know cases where people have done appendicectomy. And uh, then we have noted that the child actually has a pneumonia. So always be careful of that and always examine the testes in a boy because you can get referred pain from the testes to the abdomen if they have a testicular torsion. So you have to examine, make sure that it, you are not dealing with a boy with testicular torsion and referred pain. So the some of the common causes of abdominal pain in Children clearly appendicitis is one, the second is a condition called intussusception. And the rest are actually quite rare. So you can have obstruction probably due to sometimes intraperitoneal bands, but more commonly due to something like a Meckel's diverticulum with a band. Rarely, you can get torsion of an intraabdominal testis or ovary. Of course, you can have ovarian pathology in slightly o older girls, renal stones and renal colic. So it can be urinary tract in origin and in young girls who it we should never forget pregnancy related. So they could have an ectopic pregnancy with issues. So we should always remember that and our practice in younger girls, uh who uh in teenage years would be to do a pregnancy test if they come in with abdominal pain And so I think one cannot forget that as well. So, acute appendicitis is actually quite a common condition. And uh well, there are few things we need to remember with appendicitis that the pain in Children may not be very typical. As in the younger Children, it's more difficult to diagnose. So the typical history of central abdominal pain which moves to the right iliac fossa, you may not get. But if you get that history, that's very typical. But remember also that with acute appendicitis, the child does not usually start off with fever. For example, fever may come on later on when there is greater sepsis. But initially, when they develop appendicitis, they do not have fever. Sometimes they begin with just vomiting. So, vomiting may precede, may come before abdominal pain in some Children with appendicitis. So they may start vomiting once or twice and then develop abdominal pain. But the more typical picture is of developing abdominal pain and then developing vomiting. So abdominal pain, vomiting is very typical of appendicitis. The other thing to remember is when you examine the child, you have to look for peronism or guarding. So when you palpate the abdomen, if it is not soft, and the child actually sort of winces and the muscles go into spasm that is called guarding. And that shows that the peritoneum is inflamed. So guarding is an important sign. The second thing is what is called rebound tenderness. So you gently press the abdomen. And then when you suddenly remove the hand, the child jumps with pain and that's called rebound tenderness. And finally, if you apply pressure in the left iliac fossa, they if and the child says it has got pain or tenderness in the right iliac fossa, that is another sign of appendicitis. As we know the appendix is in the right iliac fossa. So if you press on the left iliac fossa, and the child says he or she feels pain and tenderness on the right iliac fossa, that may indicate appendicitis. And that's called rousing sign, uh named after a chap called rosing, which you don't have to remember, just remember the sign, which is what is important. The other uh sort of conditions which I have called medical conditions of abdominal pain, mesenteric adenitis, which is very difficult to prove, as we said, it could be viral and they will, it will get better within about five days at best. Constipation can cause abdominal pain but be very careful of uh assigning constipation as the cause because usually with constipation, the pain is colicky and not consistently or persistent. Whereas in appendicitis, the pain is continuous gastroenteritis, but it's often associated with diarrhea and vomiting. Now remember that you can get what I would often call spurious diarrhea. Sometimes an appendicitis if the appendix is pelvic and is dipping down into the pelvis and is in contact with the rectum, sometimes they get rectal irritation. So Children often keep passing small amounts of mucus, which the parents may wrongly tell you that the child has got diarrhea, but that's not diarrhea. So you, when you get the history of diarrhea, you got to ask for how many times what type of stools the child is producing, whether it's a large amount of watery stools and that's very important. And as we already said, we should rule out pneumonia, pyelonephritis or infection in the kidney. And purpura. Hi, purpura, which as you know is a condition that affects the blood vessels and uh can cause bleeding, et cetera can sometimes cause abdominal pain because they often have some hemorrhagic patches on the bowel and that, that uh, that can cause a problem. Now, sometimes purpura can also be a cause for intussusception, which we can talk about later. And finally, inflammatory bowel disease can also cause abdominal pain. Even rarer causes are diabetes, particularly with ketosis, sickle cell crisis can cause abdominal pain. And uh, those of you who work in parts of the world where you have more sickle cell disease, you may be aware of. This pancreatitis can occur in Children, particularly if they are on certain medications. And there is a condition called primary peritonitis. Now, primary peritonitis is when you get pu in the abdominal cavity, but you actually have no specific focus of infection. So the appendix is normal, but it's often very difficult to distinguish from appendicitis and sometimes the Children can be quite sick. So they do undergo surgery and it's only when you put in a laparoscope or you do an open operation, you find a lot of pus and, but the appendix is normal. Now, one of the, there are a couple of things, the pus is often not foul smelling in primary peritonitis because in appendicitis, if you get a lot of pus, you get the typical, uh, smell of, uh anaerobic pus or feculent pus, but in not in primary peritonitis. So that is something we should remember. And it's supposed to be caused by pneumococcal uh organisms or, or capsulated organisms. So it is something you need to remember, but it's not common. So we did uh we did say all of this and fever is a late sign in appendicitis. But once you're made a diagnosis of appendicitis, it's very important that the child gets adequate fluids. So, fluid and electrolyte imbalance is a huge problem in Children. So you have to rehydrate them quite well. You have to start them on an antibiotic. Once you made the diagnosis, do not start people on antibiotics unless you have a definitive diagnosis. So if you do not have a diagnosis, then re-examine the child, see how the pain develops and only start the antibiotic. Once you're made a clear diagnosis of appendicitis and the antibiotic that you use can be something like Aug uh call amoxiclav or Augmentin or you could use amoxicillin and metroNIDAZOLE occasionally we use uh Kelo and it, it varies from hospital to hospital. So, different hospitals have got a particular uh protocol of antibiotics for appendicitis and peritonitis. So you can check with your local hospital and if you are from a place which still does not have a protocol, maybe that's one of the things you can help them to come up with. So about four in Children, four in 1000 Children will have their appendix removed. Now, this is very interesting because it doesn't mean all of them had their appendicitis. Some of that is a negative appendicectomy rate of about 15 to 20% depending on where you work. So not all of them would have had appendicitis. And we did touch upon this as well that it's quite uh difficult in younger Children. So this is just to show that a bit of ele in a plane film uh in a child with appendicitis. So you can do a laparoscopic appendicectomy, which is the most common way of doing it in the UK now. But there's absolutely no problem in doing it uh through a small incision in the right iliac fossa too. And this is a laparoscopic picture of a very inflamed appendix. And you can see actually at the very tip, it's quite purulent and this is a diathermy hook being used to coagulate the meso appendix. Now, bowel obstruction can happen in Children due to many causes and we have touched upon a few here in the slide. But I think the main one that I would like to speak about is intussusception. So intussusception means that a proximal loop of bowel is telescoping itself into a distal loop. And usually it's the small bowel ileum which goes into the cecum. And it's used common in the age group of 3 to 12 months. It can be preceded, there may be history of a respiratory tract infection, diarrhea, and vomiting or more commonly a change in their diet. So it often happens around weaning. So when a child is being given their first solid food or change of milk, that might trigger an intussusception. Now, we do not know 100% why this happens. But the classic intussusception where we find no specific cause is supposed to be due to hypertrophy or enlargement of the pa patches. You may know that the pa patches are groups or areas of uh uh WW where we get the um the the lymphatic tissue. So they are distributed all around the bowel, but they seem to have the greatest numbers around the terminal island. So when the lymphatic tissue there enlarges due to whatever reason, either an infection in the bowel or a sort of response, almost an immune response to new food, then the pas patches itself can act as the trigger to cause the intussusception. So the typical uh history in intussusception is that the child cries but doesn't cry continuously. It is episodic So it may cry for a few minutes and then seems to go quiet and sometimes when it's actually in pain, it may vomit. It typically may drop its legs and may then go quiet. So this is the normal presentation. And initially, the child does not look ill. In fact, between the episodes of crying, the child might even be quite happy and even may be feeding. So in the initial phase, the intussusception you might easily miss. But in the late sign, it is quite typical when you get abdominal distension, persistent bilious vomiting. And you also get this jelly like stools, which are quite red because of altered blood, which in the UK we call recur jelly. But uh in some parts of the world, it may, people have not seen recurring jelly. So what you have to remember is it's jelly or mucoid stools mixed with altered blood and that's very, very typical. Now, in older Children, you have to worry about why uh intussusception being caused by specific conditions like bowel tumors and sometimes Meckel's diverticulum. So you can see here there is a diagram which shows that the small bowel has gone right up into the colon through the cecum. The part that has gone in is called the intussusception. And the part that is on the outside is called intussusception. So most of it, as we say is idiopathic. So you'll never prove what caused it. So the important thing in managing intussusception is when you examine the child, you may feel a mass, which we say is often like a sausage. If we did the rectal exam, which I wouldn't advise you to do, you may see blood in it, but be very careful in Children not to do rectal exams because it's quite painful and it's not, the child is really upset. So you'll have to do blood tests to check for electrolyte imbalance. You'll have to do an abdominal x-ray. And most importantly, you have to rehydrate these Children. Well, and you can confirm the diagnosis using an ultrasound. And one of the ways we treat the condition is to do air enema reduction. So you can put a tube through the anus into the rectum and the radiologist under image intense fire can put air under pressure and that will push the bowel the other way out. Now, that is successful in about 70 to 85% depending on how soon the child comes to hospital and how good your radiologist is. They must have experience. Otherwise you will require to reduce it uh through surgery by performing a laparotomy. It is very important that you start them on antibiotics as well. So fluid resuscitation, antibiotics are very important to reduce morbidity and mortality even in the UK. Occasionally we get Children who actually die from the, from intussusception complications because it is missed initially. So it is very important that if you have any suspicion that an ultrasound is done and you rule out intussusception because if you don't, what happens is the intussusception bowel will become necrotic and will perforate. So they get profound sepsis. So this is a picture showing obstruction caused by intussusception. And here you can see an ultrasound, this is the typical donut appearance of an intussusception, an ultrasound. And here you can see a filling defect in the gas pattern of the colon, which is again a very typical of intussusception. And this is an a enema just to show how you can use a here to push the intussusception out there. So we have said that this is a picture of operative reduction of intussusception, showing the bowel that has gone into the cecum and is being reduced. This is a similar picture. So a Meckel's diverticulum is an uncommon condition and can present either as an obstruction or with bleeding rectally. So, and you know, painless bleeding rectally, if there is nothing like a fissure in an no, then you'll have to suspect, particularly if it's large amounts of blood, you'll have to suspect Meckel's diverticulum. OK? You can do a meal scan or you can just put in a laparoscope and have a look. And this is a child who had obstruction due to the, that's the diverticulum and there is a peritoneal band there which had caused it. And in fact, the band has just been divided. I think you can see the other end of the band here. Now, the last condition which I wanted to speak about before we go to questions is pyloric stenosis pyloric. This shows what we call a visible gastric peristalsis. You can see how big the stomach looks when it is contracting against a stenosed pylorus. So pyloric stenosis occurs in at around. It's I would say any time from two weeks to about eight weeks of life and the typical child is a male child, often the first born child and the vomiting is quite forcible and it happens after feeds and is completely non bilious, it's milky. So if a child who's about 2 to 6 weeks old vomits after every feed and the vomit is quite milky, then you have to suspect pyloric stenosis. When you examine the child, you may see visible gastric peristalsis that you've shown here. You might al you should also be able to feel a little muscular olive shaped structure at the end here, which will be the thickened pylorus. Nobody knows why this happens. The treatment is good resuscitation and what you will often find is that they are hyponatremic, but more importantly, they are hypokalemic and hypochloremia. So you have to correct hypochloremia, hypokalemic alkalosis. So you'll have to give them what we normally do is give them something like half normal IGN with potassium to correct the hyperkalemia. So you can give them dextrose with half normal IGN and good potassium. It is important to get that blood sorted. Before we operate. So get the bloods, you know, potassium and chloride and bicarb all under control. And the operation, this is a ultrasound showing a thickened pylorus here. And you can see how thick the muscle is on both sides. And that's this narrow passage through which food can go. And this is to show at surgery that's the thicken pais and this is what we do. It's called pyloromyotomy named after a chap called Rams it who described it about 100 years ago. So what you do is you divide the muscle, so you split the muscle and allow the mucosa to bulge and that's all you do. You should be careful not to make an opening in the mucosa and that otherwise it complicates the procedure. So you do a ram stitch pyloromyotomy and the child can be virtually fed about four hours afterwards. And we can do this either like an open operation as shown here or it can be done laparoscopically as well. So I'm going to stop there which neatly brings us to our opportunity for the next five minutes or so to answer any questions, I can't really say so. Uh Are there any questions that people would like to put on the chat or if you want to ask me, please feel free to do so? Thank you so much, professor. Um Yeah, just if anyone has any questions put them in. Now on the chat, I see Azad has raised his hand. Yeah, please go ahead as add uh regarding the intussusception. Is it possible? Sometimes nerve blockage could be the reason when the normal persis occur and due to a nerve block, uh section of the sti not properly, not properly getting the nerve information. So while, while the peristalsis occur, the intussusception occurs. Yeah, I mean, the, the thing about intussusception in childhood is it's not a neurological problem with the bowel, bowel uh peristalsis. It is more uh vi virtually always. So for example, you don't get intussusception in Hirschprung's disease, which is as you know, associated with the absence of the parasympathetic ganglia. So you don't get that. So you do, they do talk about what is called a Gonal uh intussusception in adults, which can happen with things like anesthesia and so on. But that's not that common in Children. Usually it is something within the bowel wall and usually it is the hypertrophied or thickened pale patches or sometimes a tumor, as I said. Does that answer your question? Yes, sir. Thank you. Thank you. If anyone has any other questions, please put them in the chat was hand. Now, I'm going to end the recording for the meeting just so you can start to leave. And once again, thank you for your time today. And thanks to everybody and it's been a pleasure and I wish you the very best. I might see some of you next week when we are doing something on neonatal surgical problems. Thank you and have a good day.