ESSSxAIM presents: An Operative Approach to Anatomy - Paediatric and Urological Surgery



This on-demand teaching session is a part of a series of surgical anatomy tutorials. The current session is focused on pediatrics and urology, specifically addressing surgical cases seen in these fields. The session will cover herniotomy for congenital inguinal hernia, urethroscopy with lithotripsy for kidney stones, and adenoidectomy and tonsillectomy. The instructors will explain the role of pediatric and neurological surgeons and the pathophysiology, anatomy, clinical features, investigations, management and complications related to these procedures. The session is offered in a collaborative educational format with the option for participants to engage in polls and ask questions via chat. At the end, there will be an assessment of the content learned through multiple-choice questions. The session is recorded and can be reviewed later for further study.
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👩🏻‍⚕️👨🏽‍⚕️Want to learn more about anatomy and its theatrical (by which we mean surgical) applications, but don’t know where to start? We are pleased to announce the new webinar series, in collaboration with ESSS and AIM: An Operative Approach to Anatomy!

This is the fourth webinar of eight and will serve as an introduction to the theatre and some of the key anatomy to look out for when observing (or assisting) in Paediatric and Urological surgery.

Attendees of 6/8 sessions will receive FREE RCSEd student affiliate membership worth £15!

All medical students are welcome, we look forward to seeing you!

* Certificates will be provided to all attendees post-feedback.

Learning objectives

1. To understand the different surgical cases seen in pediatrics and urology, with a specific focus on herniotomy for a congenital inguinal hernia, urethroscopy with lithotripsy for kidney stones, and adenoidectomy and tonsillectomy. 2. To recall the pathophysiology, anatomy, clinical features, investigations, management and complications of the cases discussed. 3. To apply knowledge and learning to simulated surgical cases, making appropriate decisions based on the given scenario. 4. To be aware of the important role played by pediatric and urological surgeons and gain a deeper understanding of the surgical training pathway for these specialties. 5. To reflect on learning by completing questionnaires before and after the session to track knowledge increase and to provide feedback on the teaching.
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

I think it's loading just now. Perfect. Hi, everyone. Um I don't know if you guys can hear us in the chat. So I want you to pop a quick hello in there just to know that it's working and, and you guys can hear us. Perfect. Good stuff. Thanks. Strange. Um, it's lovely to have all of you. So, um, this is the fourth session of the surgical approach, the anatomy tutorials, um, running as our SSE five project and this week we've got pediatrics and urology for you. So, hopefully some good cases. Um, what we'll do is we'll give people a couple of minutes to roll in before we get started with kind of the nitty gritty of it. Um, but while we're getting started, I'll put a couple of polls on the chat and if you guys could just fill these in, um, really what we're doing this for, um is just to check if our teaching is um, actually useful if you guys find it useful and how your knowledge compares to kind of before and after. So I'll pop these in just for those of you who are already here. Um So you can maybe start having a look at these and then we'll start our spiel, as I say in just a wee minute. I appreciate it a few of them. So do take your time. It looks like people are absolutely trickling in. So, if you just joined, I've put a lot of polls in the chat and if you could try and give those an answer, it's just assessing your knowledge prior to the tutorial. And just so we can kind of reflect on it as part of our SSC five project. And, um, yeah, see how we're doing. Really, I think three minutes past the hour, why don't get started solar? See, could I have the next slide, please? So, just a little bit of housekeeping. Um, please use the chat to ask any questions you have. Um, we'll do our very best to answer all of them. Um, and if we can't answer them, then we'll do our best directly towards resources that maybe can answer your question. Um, this session is recorded. Um, but, uh, it'll be on metal. Um, so if there's anything that you wanna take notes on, um, or kind of are unsure of and want to review, you'll have access to this recording after the event as well. So please do make use of it if you find it helpful. Um, be aware that some of our slides do contain sensitive content by which I mean, um, some pictures of surgery, for example, um, this isn't anything that you wouldn't be exposed to during your medical school career. But we appreciate that. Not everyone loves being in surgery, not everyone loves seeing, um, kind of surgical pictures or kind of that kind of stuff. Um, so if you don't want to see it, then we'll try and warn you ahead of time. Um, and completely fine for you to head off for those 5, 10 minutes if you just don't want to see that kind of stuff. Um Please do fill out our short questionnaire as Jing Jing, kindly send this chat, please do scroll up to try and answer other polls. There should be six of them in the chat at the moment. Um And we really do appreciate it if you can answer them because it does help us on our reflection for S five. If you attend six out of eight sessions and answer our um kind of feedback form at the end, then you get free R CSE D student affiliate membership, which is worth a whopping 15 lbs, so worth it, saving yourself 15 lbs. Um And it shows like commitment to specialty in case you do wanna pursue surgery that line. Um And please follow our social media um or rather Edinburgh Student Surgical Society, social media to um see when our future events are on. And again, just to emphasize that we have really done our best to make sure that these resources we've got for you and the teaching we've got for you is sourced from reputable sites. Um, but it is pure tutoring. We are with your medical students, um, and not surgeons as of yet. So, um, there might be some mistakes if you've heard something else from a surgeon, it is likely that they're correct and we're perhaps got something wrong. But as I say, we have tried our very best. Um, the other thing that I'll say before we actually get on with the actual stuff is that the media shown on the slides is not owned by us. We've linked the size, size, uh of the sources rather that we've got them from, um, if it's not linked, it's because it will be from complete anatomy. So if you ever see any picture that's not got a link next to it, um, we've got that from Complete Anatomy, um, which hopefully you guys have access to as well and it's a very, very good resource for anatomy that, um, I definitely recommend. Can I have the next cer see. So again, please fill out the polls on the chat. Um, I'll keep chatting maybe for time's sake. Um, but, um, yeah, please do fill them in as you come along. Um, I think if you've just joined, hopefully you should still be able to see the poll. Um, but if you can't see any poll, do, let me know and I'll restart them, put them back in the chat again. Um So our learning uh kind of outcomes. Our lesson objectives for today's session is to learn a bit about the surgical cases seen in pediatrics and neurology. And the cases that we're gonna focus on today is a herniotomy for congenital inguinal hernia and we'll chat a bit about her hydrocele as well. Um We're gonna focus on urethroscopy with lithotripsy for kidney stones and we're gonna look at a bit at adenoidectomy and tonsillectomy as well. Um Hopefully you'll be able to understand the role of pediatric and neurological surgeons after the session. Um, and be able to recall some of the pathophysiology, anatomy, clinical features, investigations, management and complications of the cases that we're looking at to date. We'll test your knowledge a little bit with some kind of choose your own adventure, simulated surgical cases as we go along and there'll be just a couple of MC QS at the end, um to see if we've managed to teach you anything along the session. Um And hopefully we have, we'll have that at the end. Um Can I get the next slide clear to you? So, just a little bit intro to these actual specialties, obviously, we can't cover everything in pediatrics and we can't cover everything in urology today because there's a lot of stuff in there. Um But if you do think you'd be interested in pediatrics and urology, I highly recommend looking at the Royal College of Surgeons of England's um kind of descriptions of specialties. They've got one for every surgical specialty. Um And they've got kind of nice descriptions and a little bit about what to expect and a little bit about the surgical pathway as well. Um, in terms of pediatrics, um, pediatric surgery is pretty brilliant because you get to cover everything in the body, which usually you don't get to do in adult surgery, you're usually a bit more specialized. Whereas in pediatrics there is a level of subspecialisation of course. Um but it's defined by how old your patients are rather than what part of your patient is. Maybe not. So, um which is pretty cool. Um And in urology, well, you're covering the kidney, bladder, genitalia, urine tract, really everything to do with reproductive health, um which might not always seem like the most glamorous. It definitely didn't to me, but it's definitely an interesting, interesting topic and not worth kind of writing off from the get go in terms of surgical training. Generally speaking, there is two years of core training at the start um with kind of six years training afterwards and specialty training and the specialty training is specialized, whereas core training is relevant to kind of all surgical training pathways. Um these training pathways do change slightly over the years and always worth checking before you start to apply for um kind of specialty programs. Um when you get to that stage of your, your training. Um but it's a good thing to keep in mind that if you're wanting to do a surgical career, it is about eight years of training before you kind of reach that level where you can become a consultant. Um And that's post F YF um one and two. So that's about 10 years. Um But at least from what I've seen it, it seems like quite a good career. So I definitely recommend having a wee look if you're, you're interested. Can I get the next cycle c and the last little bit for me just again, um a bit of a text, heavy slide. Again, it's just to reiterate the range of things that you can see in pediatric and neurological surgery. So I've highlighted um two of the cases that we're gonna cover today, which is a herniotomy and our kind of treatment of bladder and kidney stones. Um But you can see that there's loads and loads of other um kind of other treatments, other surgeries that are performed in pediatric surgery and urology. And hopefully this slide kind of um highlights why we've maybe done this two in the two in one session. It seems a little bit odd maybe to put pediatric surgery in with urology. But as you can see things like circumcision um kind of overlap. Um and actually there's lots of urological issues that come up in pediatrics and many of them are congenital. Um But a great variety of things. Um appendix removals are always very fun. So if you're on your peds block, it's always worth trying to get into some pediatric surgery to see one of those. Um, but with that said, um, clearly if we can have the next slide. Ok. Hello. And can you hear me? Yes. Sorry. I think I might have interrupted you for a little bit. Um, ok, so we'll start, um, I'm Claire Sue and together with Pat, we'll move on to our first case, which is herniotomy for congenital inguinal hernia and hydrocele. So a few brief learning outcomes and at the end of this case, um you guys should be able to understand and recall normal embryological development of the inguinal canal pathophysiology of congenital inguinal hernia and hydrocele, clinical presentation and complications of congenital inguinal hernia and hernia and hydrocele. Um identify relevant anatomy of the inguinal canal, understand the procedure, herniotomy for congenital inguinal hernia and hydrocele, including any possible complications. And finally apply your knowledge of the above to relevant MC Qs and provide justification for answers to uh choose your own adventure kind of activity. Um These are quite a few learning outcomes. It might seem a little bit daunting, but hopefully by the end of it, um you should be able to do all of the above. So, um before we embark on our journey to theater, we'll cover some key anatomy and pathophysiology starting at the very beginning before birth. Um So the testes begin to descend at seven weeks gestation, um which you can kind of see here and they originate at the level of the 10th thoracic level of the spine. So here we see the testes at the posterior or the back of the body and these are retroperitoneal, which is essentially just a fancy term, meaning outside the peri peritoneal cavity. Um You see here that the testes are actually attached to a ligamentous structure here in blue called the gubernaculum, which shortens over time to pull the testes down into the scrotal sac which will start forming down here. Um So from the seventh to the 12th week, um the testes travel down to the level of the deep inguinal ring, which is the internal opening of what will become the inguinal canal. And during this time, the peritoneum evaginate forming the processes vaginalis, also known as the vaginal process, which is a small pocket of the peritoneum that folds out almost sort of like your trouser pocket lining inside out. Um This evagination also pulls out the transversalis fascia, the internal and external oblique muscles. Um and these form the inguinal canals, which you can kind of see here a little bit better. Um The testes will then remain at this level from 3 to 7 months gestation. And finally, in the last two months, the testes will be pulled completely into the scrotal sac here by the gubernaculum. So here we see a simplified diagram of what the inguinal canal and the of the testes will look like at birth. Um So we see the testes here um and they're still attached to the gubernaculum, which is now a lot shorter. Um and just anterior to this, we see the processes vaginalis or what is called the vaginal tunic at this point in time. Um And the reason for this is within the first year after birth, the processes vaginalis usually degenerates leaving the small remnant sac which you can kind of see here. Um And this is the tunic of vagina. So the vaginal tunic um and the lumen of the sac or the inside of the sac is usually collapsed and empty and fairly closed off from the, from the peritoneum, which you can kind of see here a little bit closed off. Um However, you can get problems um that can arise which will uh which I will explain on the next slide. Um So, congenital inguinal hernia versus hydrocele. Um There are two main issues that can arise when the process of vaginalis does not degenerate properly. So, the first is congenital inguinal hernia on the left side here or what we call an indirect inguinal hernia. I'll go through the type different types of inguinal hernia a little bit later, but for now, an indirect hernia occurs when the process is vaginalis does not disintegrate and remains patent or open. Um And it allows um a cavity to form where abdominal contents can herniate. Um and essentially go into this little pouch here. Um And this yellow part you can see here actually demonstrates bowels. So that's one of the different types of abdominal contents that can come into um the sac. So the second issue that can also arise is a testicular hydrocele. And this is where the processors vaginalis does degenerate to an extent but not fully. And these can leave little cysts or pockets of serous fluid, which can again vary in size. They can be small, they can be big. You can have a couple of them. You can maybe just have one. Yeah. Um Going back to the inguinal canal, it's a sharp passage that extends through the abdominal wall which allows structures to pass from the abdomen, abdominal cavity to the external genitalia due to its embryological formation that we just covered and its function. It can be an area of potential weakness in the abdominal wall, which is why it can commonly herniate. The inguinal canal contains a spermatic cord in people assigned male at birth and in people assigned female at birth, the inguinal canal will have a round ligament instead which helps to anchor the uterus cervix and vagina. In addition to this, the inguinal canal will contain the ilio inguinal nerve and the genital branch of the genitofemoral nerve. So, on the right hand side here, this is quite uh complex diagram with a lot of different things that um we might not need to go into it's a very busy image. So I've just highlighted the bits that you need to know for this case. Um And for reference, this is what the ganal canal would look like in adults, assigned male um at birth just as an example. So um here in yellow, we see this very faint little line here which is the ilioinguinal nerve that runs down through the canal where it contributes towards the sensory innervation um of the genitalia. We also have the genital branch of the genitofemoral nerve, which unfortunately is not illustrated here, but it runs sort of in the same line through the inguinal canal here to also supply the cremaster muscle and anterior scrotal skin in males and the skin of the mons pubis and the labia majora in females. Um We have the deep inguinal ring here, the superficial inguinal ring down here, which are the two openings of the inguinal canal. So, things go in here and come out here essentially. Um We have the inguinal ligament which runs sort of here from the anterior superior iliac crest of the ileum up here all the way down to the pubic tubercle of the pubic bone, sort of under hereish. Um And um down at the bottom here, we have the spermatic cord which contains neurovascular and reproductive structures that supply and drain the testes. So, um we'll now move on to the types of inguinal hernia. Um direct inguinal hernias are usually acquired in adulthood um it's very rare in Children, but there are some cases documented where it has happened. Um It's due to a weakening in the abdominal wall, creating a bulge in the peritoneum. So you can kind of see this here um which can contain abdominal content such as bowel, which pushes downwards and compresses the inguinal canal externally. So, from here, um this is different from the indirect inguinal hernia, which is congenital and again, is due to the failure of the process as vaginella to degenerate, allowing contents to enter the inguinal canal here. So, kind of going down through the canal, these can also fill with fluid creating a hydrocele which can sort of be seen or as shown here um onto clinical features. Um Inguinal hernias will most commonly present as a lump in the groin. Um As you can kind of see on this diagram here, um the hernia can be positioned slightly further down and it can also extend into the scrotum um which would cause a large bulge going down here. Um It can happen on either side of the body. So the bulge could be here going down into here as well. Um This doesn't happen all the time though and it's important to note that an empty inguinal hernia may not be visible. So, in this case, you would ask the patient to cough, which would cause the hernia to bulge outwards due to higher pressure in the abdomen. Um apart from this, many patients will not experience any other symptoms. However, some can experience growing pain or discomfort, pain in the scrotum and inner thigh along with altered sensation. Um and rarely, patients can also have an altered bowel habit and some urinary symptoms. Um and then the hydrocele will present with a painless enlarged scrotum. If patients experience pain, there may be another cause such as inflammation, infection, um torsion, things like that. So, um here, we can see the main possible complications caused by inguinal hernia as the open processes, vaginalis can fill with loops of bowel, this can cause them to become stuck. So kind of down here, um which can lead upstream to blocking um, obstruction of the bowel which can cause vomiting pain, other symptoms. Um The testes can also become damaged due to a reduced blood supply as the bowel or other contents might start um compressing into different nerves. So, um now that we've gone through the anatomy pathophysiology and clinical presentation, you are now ready to start your day in pediatric theater. So you enter theater, you scrubbed in successfully and you see multiple people in the room, but you're not sure who's who going to our first question. Theaters rely on MDT, which of the following staff are key to smooth running of a theater, a scrub nurse theater, nurse assistant or anesthetist. Do we have a poll for this one? Yeah, the poll is up. So if you guys look in the chat, there should be a poll and you can make your guesses and clear. So I yell at the most popular answer in about 30 seconds or so. Thank you. We've got one response so far. People are unsure. Uh Yes, I'll give it five more seconds. I think someone's cracked the code, but I'll tell you in a second. So you've got 100% response for theater ner, but Joshua bravely has said all of them to be honest. Yes. So, um I have been a little bit mean to you all as the answer is ABC and D so all of the above um everyone I have listed is key to a theater running smoothly. Um So as you all know, the theater team will be quite big. Um but a few members that I will introduce you, um We have the consent consultant surgeon here who is lovely and will congratulate you on getting all of your little answers correct and the questions coming in the future. Um The not so nice specialty to surgical trainee who will scold you for getting answers wrong? Unfortunately, the anesthetist theater nurse and scrub nurse um who are all lovely by the way. Um And many other staff that will also be helping. Um but you will unfortunately not see in this presentation tonight. Um So now I will hand you over to Pat, who will introduce you to our first patient. Great, thanks Cla Su. Um So Yes. So our patient today is Alex Bloggs two. So he's presented with a lump in the Inguinal region which was noticed by mom and upon examination of it, uh you, you can't get above it and there is a cough impulse present. Uh and it also does not translumination. So he doesn't really have any past medical history that is of note or any drug history that is of note as well. Um So next, please. So after the next slide, there may be some surgical pictures. So if you feel a bit woozy or a bit squeamish, you, that's totally fine to just uh take a few minutes break and come back later. Next, please. So um just before we start with the actual procedure, just differentiating between an inguinal hernia and a hydrocele. Meanwhile, these two conditions can both arise both from the processes of vaginal. It's not regressing, we should be able to differentiate. So the inguinal hernia, uh you cannot get above it. A manual examination. There is a cough impulse that can be present. Uh the hernia itself can be reduced and you cannot transilluminate this compared to a hydrocele where you can get above it and it's usually non painful. The hydrocele can sometimes come and go. So it's fluctuant in nature and if you shine a light on it, it will transilluminate. So um the management of these two conditions. So a congenital rising from a congenital inguinal hernia is called an inguinal herniotomy. So, the first step of this procedure is to make an incision uh in the groin area on the side of the hernia. After this, a hernia sac will be identified and it'll be separated from the various cord structures that are surrounding it, such as the vas deferens and the blood vessels to the testis. And then after this, if there are any contents, um herniated bowel, for example, present in the hernia sac, this will be reduced by pushing them back into the abdomen. And then the hernia sac will be tied off. And after the hernia sac is tied off, the remainder of the sac is cut off and the incision is closed. Uh I forgot to mention earlier, this operation is conducted under general anesthesia and after the incision is closed, um usually there will be local anesthetic to help with POSTOP pain as well. Next please. Um So some POSTOP complications of this procedure, there's always a risk of infection as with any surgical uh procedure, there is a risk that the inguinal hernia may come back and this will require another surgical operation to correct this. It's also quite easy to damage the surrounding structures. As as you can imagine, they're very close together and certain structures such as the sperm duct or the blood vessels can be damaged. There's also the risk of testicular stent where the testicles actually just go up um into the abdominal cavity. This will also require, um, another surgical procedure to fix. Usually, um, there's only a hernia on one side. However, some patients may, uh, have hernias on both sides as clar, who said earlier, hernias that don't have anything inside them, such as, um, loops of bowel, they can be easy to miss. So if you do the operation and it turns out that there's actually another hernia on the other side, which presents later on in life, the same operation will have to be um carried out. And lastly, there's also the risk of damage to the ileo and nerve and this can cause symptoms such as lower abdominal and pelvic pain, right? Um So just remind you of the patient again. Sure. Let's go on to the next slide, right? So, um we've started the surgery now and this is the Shoer Adventure part. So we've made the incision. Oh yeah, the pulse are, yeah, cool. So the surgeon points out a key structure. Um I'm not sure if you guys can see if the pull up right now actually, but there's two structures here. Um Which one might it be, I should say you have the poll in the way you can close it and you can answer later on. So, um if it's blocking you, please to close it and you can open up. So we'll just wait for a couple of more seconds. Allow that the polls are completely anonymous. So if you've got it wrong no one will know it's worth having a yes. All right. So, it seems like most of you chose option A, the A G nerve. Uh That is correct. Um So, yeah, the A and goal nerve, it's a key structure which can be found um when doing this procedure, it's quite close to the hernia sac. So we don't want to remove that or damage that. Right. So, um the hernia sac has been identified, it's been reduced. Um So what is the next step in this operation? So, what would you ligate? Would it be the peritoneal tissue or would it be the vas deference? No, I'll wait for a few more seconds. All right. So, um everybody went with option. A very glad you guys chose that. Um Yup. So the hernia sac is made from peritoneal tissue um as we mentioned earlier and this is the structure that we want to ligate and cut off so that the hernia doesn't come back again. 00, oops. Ok. Um Right. And lastly, so this is six months later. Um Little Alex is presented at the GP Clinic for Nonspecific unresolving pain. It seems like the pain is coming from his lower abdominal area. Um And I appreciate that nonspecific and resolving pain can really come from anything. Um But given Alex has past history, what do you think might have happened? And if you guys can just type the answers in into the chat, please just wait for a couple of more seconds. All right. So, um, testicular torsion um, would be not exactly nonspecific, I would say, um, it could present with pain in that area as well. Uh But the pain would be quite severe and it's quite specific to uh single area. And yeah, the, the answer would probably be damage to a nerve. It's, as we said before, a structure which is very close by to what we want to ligate sometimes just potentially even with rough handling of the area, it can be damaged and this can present with uh pain in the lower abdomen. Yup. And yeah, that's it for our case. I'll hand it on to crystal. We talk about um kidney stones. Yeah, that sounds great. Um I'm gonna just try to share my tab now. Ok. Mhm So can everyone see my screen? Yeah, we can see your screen. And can you see my voice? See your fancy? These are point your two. Perfect. Thank you. I've only just recently discovered this and I feel very tech savvy. Um So yeah. Uh so hi guys, I'm Crystal. Um For my part of the teaching, I'll be covering ureteroscopy with lithotripsy for kidney, for kidney stones. Um So kidney stones have many names uh and they are synonymous. So you might hear me um say renal calculi or ureteric stones here. And then, so the learning objectives for this lesson are on the slide. So I'll be covering the anatomy of the urinary system, uh pathophysiology, clinical features and investigations of renal stones and the basic principle of ureteroscopy with lithotripsy in the management of renal stones and its complications postoperatively. So, in order to understand kidney stones and their management, we must understand a bit about the anatomy of the urinary system first. So the urinary system comprises of the kidneys, um the ureters, the bladder and the urethra, as you already know the kidneys form the urine and account for the other functions attributed to the urinary system. Um But I'll explain that a bit further in the next slide. Then um the ureters carry the urine away from the kidneys to the urinary bladder. And then the urine that is stored in the bladder goes through to the u the urethra to the outside of the body when you urinate. Ok. So, the kidneys are the primary organs of the urinary system. They are responsible for filtering the blood, removing the waste and excreting the waste into urine. They are also responsible for water and electrolyte balance in the body. Um In an adult, each kidney is approximately three centimeters thick, six centimeters wide and 12 centimeters long. They are being shaped in um they are being shaped and reddish brown in color. Um and they are protected by the lower ribs right here. Um And they sit between the 12th thoracic and the third lumbar vertebrae. Um The right kidney is usually slightly lower than the left, since the liver displaces it downwards. So the regional parenchyma can be divided into two main areas. The arthro cortex right here, which is just the surrounding tissue um and the inner medulla. So right here. So the cortex extends into the medulla, dividing them into triangular shapes. These are known as your renal pyramids. These join into um these structures here called the mi minor calyx and several minor minor cas merge together to form a major calyx. So, urine passes through the minor and the ma major caly into the renal pelvis and from the renal pelvis, the urine drains into the urethra down here. So, lastly, as you can see here, the renal pelvis also has a renal artery and a renal vein entering and exiting it. Ok. So, in the medullary pyramid are the functional units of the kidneys called the nephrons. A Nephron has two parts, a renal corpuscle um and a renal tubule. So the renal corpuscle consists of a cluster of capillaries called the glomerulus. So you can see that here and then by and what surrounds it is something called a glomer capsule, also known as Bowman's um capsule. So you have an afferent arterial going into the capsule here. This is a branch of um the renal artery and then you have an efferent arterial that leaves the renal corpuscle. Ok. So once the filtering has occurred in the capsule, the filtrate will travel along the tubule of the Nephron, um it will pass the proximal convoluted tubule here, then down the descending loop of Henley and then the ascending with Henley and then into the distal convoluted tubule and then into the collecting duct here. Um This drains into the minor chelus down here, you can see this structure here. So in the tubule, if there is over saturation of urine crystal like structures can form these crystals are precipitants of electrolytes in the urine that have accumulated. So, if these crystals are small, then they can pass in the urine. But if they remain in the kidneys, then they can grow bigger and essentially become a stone. So each ureter is um is uh 25 centimeters long. Um They descend from the renal pelvis along um the posterior abdominal wall and enters the uterine bladder on posterior inferior surface. So, urine passes through the ureters um via peristalsis, which is just a fancy word for the smooth muscle contracting and relaxing. Um The ureter has three sites of constriction. One at the origin of the pelvic uh ureter, um one at the origin of the ureter and the renal pelvis right here. This is called the pelvi ureteric junction. And then the second one is where the ureter crosses the pelvic iliac arteries. This is called the pelvic brim. And then the vesicoureteric junction, which is where the ureter joins the urinary bladder down here. These are important to know because these are sites of narrowing and also the sites where renal stones can lodge. So the bladder is the temporary reservoir for your urine. Um It is located in the posterior cavity, um the posterior pelvic cavity and it's beh just behind the um pubic synthesis right here and below the peritoneum. So, the peritoneum is just the tissue that surrounds most of the organs in the abdomen. So it's just below that. So the bladder's internal layer is composed of smooth muscle. These muscle fibers are interwoven in all direction and collectively, these are called detri muscle. So, the contraction of this muscle expels urine from the bladder and right here, um there's a triangular area um and this is formed by three openings. Um Two of the openings are from the ureters and form the base of the Trigon. And the third opening at the apex of the Trigon is the opening into the urethra right here. So the urethra is the final passageway for the flow of urine. Um It is a top thin walled tube that conveys urine from the floor of the bladder to the outside. And the opening to the outside is the external urethral orifice right down here. So, in females, the urethra is quite short, um it's only about 3 to 4 centimeters long and in males, it's much longer, about 20 centimeters long. So now we've gone over the anatomy of the U system and a bit about how stones are formed. So now let's talk a bit more about renal stones then so renal stones are relatively common. Many will have kidney stones but they will mostly be small and therefore will be completely asymptomatic. Um However, around one in 11 people will get symptoms during their lifetime. So, listed here are just some key clinical features of kidney stones. So you may get some sudden onset, severe flank pain. Um So nausea, vomiting, um urinary frequency or need to micturate. If the stone is in the distal ureter, um you may also get hematuria, but this is typically non visible but can be seen on urine tests. And if the renal stone becomes infected, then you might have some associated symptoms such as rigors, fevers or lethargy. So there are a couple of things you can do to investigate renal stones as seen here. Um such as a urine dip and routine bloods to check for things like infection or renal function. However, the gold standard um investigation would be a con a non contrast ct scan of the kidneys, ureters and bladders or act K UB for short, um as demonstrated here. So now we can talk about the how to manage renal stones, specifically ureteroscopy with la laser lithotripsy. So, ureteroscopy with laser lithotripsy is a minimally invasive procedure that involves a scope, uh a scope that retrogrades up into the ureter, allowing stones to be fragmented through laser lithotripsy and the fragments can subsequently be removed naturally or by a basket the indications for the this procedure are um if the stones are less than 10 millimeters and that shockwave litts has been deemed inappropriate or contraindicated for the removal of the renal stone. And if the stone is more than 10 millimeters, then it could just be offered. So there are a couple of things that should be performed prior to surgery, preoperative urinalysis and urine cultures are important. So as to ensure that there are no um evidence of uti s after obtaining informed consent, the patients should be anesthetized and then properly prepped and draped typically in the dorsal lithotoma position, um utilizing stirrups as seen on this image here. Um And the patient should be given prophylactic antibiotics. Um I think in the NHS Lothian, you give them IV gentamicin. So this procedure has evolved in the past few decades with intro introduction of new scopes and various new accessories to help increase the safety of it. Um But just like all surgical procedures, it is not without its complications. So there you there is risk of perforation to the ureters, um urine tract infection, bleeding and hydronephrosis. Ok. So here is a case that I've made. So we have h stone 36 year old man who present wood flank pain that radiates the groin. He is ex also experiencing testicular pain and he feels the need to urinate even when bladder is not full. He doesn't have any past medical history or drug history. And he has known nn uh no known drug allergy. So after being quickly swept away to urology from pediatrics, you're told to go into theater. So you join the urology surgeons for an elective surgery. Um The surgeon pierced at you and asked if you would like to scrub in to which you can le nod at, but particularly the surgeon says that you can only do so if you answer his question correctly. So the two images above here are the patients ct scans. What is the problem? Do we have a pool up? Yes, we do have a pull up. Sorry, I was putting the pull up, which is why I didn't answer. Yeah, that's good. I'll give it about 30 seconds or so and then I'll shout out the most popular answer to you. Crystal. Yeah. Sounds great. I'll give it 10 more seconds. But it seems people are a bit unsure. Um I think the most common answer seems to be the right middle ureter. Okey dokey. Um What are the percentages by the way? So, um oh, they've just changed a little bit. It was 66 but now it's 57% for the middle ureter and 42 for the or 57 for the right and 42 for the left. Ok. So the correct answer is a um and the stone is indeed in the right middle artery. I mean, the ureter. Um but I'll just go back and I'll quickly explain why the answer B is incorrect. So CT scans are obtained in the cranial direction. So that's from feet to head. Um Current CT machine show the image opposite the patient's side as the image is produced as viewed from the patient's foot. Therefore, you're actually seeing like um a flip view of it. So therefore the right side of the image is the patient's left side if that makes sense. So I'll go on to the next case. I mean the next question. So while the surgeon completes the initial steps of the surgery, he gives you a quick brief of the case, one of the nurses in the operating theater is listening to it as well. She asks the surgeon why the patient was having testicular pain on top of his flank pain. And the surgeon tilts his head at you and says the medical student should know. So it pulls up. I'll let you know which, which one of the following is the correct answer. Ok. We'll give another 10 seconds. It's currently 60 perce, 66%. Now for genitofemoral nerve, 33% for um ilioinguinal. Mhm. Mhm. Yeah, I think we can call it there. So final results are 71% for genitofemoral, 28% for ilioinguinal. Ok. Fabulous. So the correct answer is a um but so we have that here. Uh the consulted notes that you approvingly um looks like someone knows their anatomy really well. Um But I just like to explain why it's A and it's not b so anatomically, the uterus lies closer to the genitofemoral nerve um which is a branch of the lumbar plexus. And this proximity can then result in a referred testicular pain. So here you have the genitofemoral nerve which runs down here into this region. OK. So what you can see on the slide um are just images from a video captured by um a urethroscope. So the surgeon ha now has the urethroscope inside the patient. Um A shows the stone being visualized through the scope and B the surgeon is preparing to laser the stone. Um If you can si don't know if you can see this, but there's like a tiny little spot here. Um And then um and C ND shows the laser pulverizing the stone. Um and the stone fragments are subsequently removed by a basket around here. Um In E and lastly, f shows the ureter is now stone free. So happy days for the patient. So after removing the stone, the surgeon turns around to you and asks, let's say if this patient had an upper urinary tract infection, what is the most likely type of stone they would have? The pool is up? But I'll give it about 30 seconds again or so. Sounds good. Yeah. You know. So. Ok. Mhm So far it's 100% for cystine, but we'll give it a few more seconds. I think we've had less responses in this one. So we can go with cystine. So 100% for cystine, 0% for Revi but perhaps explain why I think again. Yeah, that's fine. So there are multiple types of kidney stones and the more common ones are on the slide, you can get calcium stones which are the commonest type. So the patient that I was inspired by for my case actually had calcium oxalate stones. Um and then you can also have stones which are composed of uric acid and cystine. But the answer to um the previous question is struvite which is caused by um upper urinary tract infection. Um This is because ammonia is produced as a waste product by the bacteria. Um that's causing the infection and this makes the urine less acidic and struvite stones can only form in more alkaline conditions. Yeah. So sadly, your trip to urology theater has come to an end. Fortunately, you bumped into the same pediatric consultant that you were with earlier. The consultant invites you to see one last case and this is where I stop. And um I'm going to let, let's I take it on now. I will share my screen hopefully. Yeah. So you guys can see that. Yeah, we can see your slides. They're just not on full screen quite yet. Oh, there we go. Perfect. Perfect. Good stuff. Can you hear me? OK as well? I'm not like ST stuttering or buffering or anything. Yes, I can hear you all good, fabulous stuff in that case. Um, you are now back in pediatrics, um, joyfully you get to see lots of good, uh, cute little Children and the case that you're gonna see today is an adenotonsillectomy. So it's a combined adenectomy and tonsillectomy. Um, but before we kind of talk about that, it's probably worth chatting a little bit about the outcomes. So hopefully by the end of this case, you should be able to call the borders of the nasopharynx, oropharynx and laryngopharynx. Um And the reason we'll look at that is because the palatine and pharyngeal tonsils, um lie in the nasopharynx and oropharynx. Um And hopefully, we'll learn a little bit about the surrounding anatomy as well. Um Hopefully, you'll get a bit of an understanding of the procedure of an adenotonsillectomy um for enlarged tonsils and adenoids, including some uh possible complications of the procedure. And we'll be able to apply um your knowledge in some MC Qs um as well as a case along the way in terms of why we do this. Well, your adenoids in your tonsils um are kind of lymphatic tissue. So they're part of um the kind of tissue that's gonna react if you've got an infection um in your kind of oral or nasal passageway. And as a result that can cause them to enlarge, um they can also just enlarge by themselves. Um and that can lead to a few issues like obstruction So if you obstruct your nasopharyngeal airway or your oropharyngeal airway or your airway in general, that can lead to difficulties with breathing. So you might um have kind of problems sleeping. Um and it might also lead to swallowing if they get enlarged enough. And obviously, neither of those things are things that we want to happen. Equally. Infection, as I mentioned can cause um kind of recurrent problems and cause you to be really unwell. Sometimes Children can have febrile convulsions with their tonsillitis and obviously, that's not very good for them um on a kind of recurrent basis. Um And so if you've got recurrent or refractory infections um in your tonsils or your adenoids or even in your middle years, which correlate for reasons that will come to when we look at the anatomy. Um It might be an indication for you to get a tonsillectomy or an adenoidectomy. Really important that one infection of tonsillitis does not kind of give you a valid reason to take out a child's tonsils. It has to fit the paradise criteria, which should be um at least seven episodes in one year, at least five episodes in two separate years or at least three episodes in at least three years. Um So there's quite strict guidelines for this. Um You don't wanna make a child undergo a surgical procedure um for really something that you don't truly need. So, um there's been a bit more kind of uh kind of crack down, I guess in the past few years about who really is, um, allowed to get a tonsillectomy. Um, in terms of investigations, um, your tonsil. Well, you can see them if you look in the back of your throat. So if you've ever been in and had a doctor look in the back of your throat, they're probably looking at your tonsils. Um, so it's fairly easy to see if a child has an enlarged, um, set of tonsils just from physical examination and taking a good history from them. The adenoids a bit harder to see as we'll see on the anatomy. And so sometimes people will get a lateral x-ray because um you can see kind of the outline of your adenoid quite well there. Um Once it's been established that um a child might have enlarged tonsils or enlarged adenoid, they should undergo a preoperative assessment. Um that should include an examination of their oral pharynx. Um And that should include kind of checking at the uh submucous cleft, um and checking the actual size of the tonsils. Um just to make sure that they're appropriate for surgery, they should have a hematologic evaluation. And that's because um as we will kind of come on to again in the anatomy, um A tonsillectomy has the potential complication of having a lot of bleeding because of the vasculature around it. And so if someone is prone to bleeding disorders, for example, he hemophilia, um you might kind of reassess whether you truly wanted to operate on them in terms of cardiac evaluations, you're in peds. So don't worry about it unless the child has an actual cardiac ABN abnormality. But equally adults get their tonsils out too. Um, and adults are more likely to have certain cardiac abnormalities. So you want, want to make sure that they are still fit for surgery. Um, there is anesthetic risk and all of that as well. So you have to make sure that they're healthy enough to have a surgery and finally a polysomnogram, which really is just a fancy word for a sleep study. Um Again, this isn't necessary for all Children. Um But it is suggested if they have conditions associated with increased risk of upper airway obstruction. So if they've got kind of a risk of sleep apnea, um we'll come on to some of the complications, um, later on. Uh But as part of this, the operation, you can have swelling in your throat afterwards and if a child has a certain type of anatomy and they're prone to apneas, so it kind of pauses in their breathing during their sleep, um then the kind of operation might tip them across that edge. So you wouldn't want to put a child at risk of that. So if we start to look at the anatomy, um the first picture here on the kind of right, as I say is from complete anatomy. Um and it's there sort of to um gauge where we are in the body because as we go along, I've got some weird angles of the head. So hopefully this will help kind of guide us in the right direction. Um It's a real, also a really good picture to see um the various pharynxes we have. So the first one is the nasopharynx. As we'll see, this is where our adenoid sits. Um the nasopharynx runs kind of from the back of the nasal cavity and it runs down um the kind of posterior part of the soft palate until it reaches the uvula from the uvula to the epiglottis, which is kind of this projection here that is the oral pharynx. And as we'll see, that's why we find the tonsils. Um kind of an interesting note, this little fold here is called um the vallecula. And when you use a laryngoscope, this is usually where you kind of stick it in, so you can depress the tongue. Um And finally, the laryngopharynx, which we won't really worry about in this session. It's got nothing to do with the tonsils or the adenoid, but it's worth mentioning that it's also there and it runs from the epiglottis down to your cricoid um cartilage, you can hopefully kind of see some of those landmarks um along the way here too. But in terms of the kind of tonsils themselves, the adenoids anatomically, really their proper name are the pharyngeal tonsils and as I mentioned, they're located in the posterior um nasal pharynx as you can kind of see here. So if you were to look at someone straight in the face and imagine that their nose wasn't there, um, you'd probably see the adenoids just behind their nose. So that's kind of where you can think that they're located. Importantly. Um I mentioned the middle ear infections before and that's because the opening of the auditory tubes like really close to the pharyngeal tonsils or the adenoids. That's the adenoid here. Um It's a bit hard to see, but hopefully you can see this kind of a change in um kind of texture of the surface there. That's your adenoids. Um and your auditory tubes are here. Now, if your adenoid gets big enough, it can block these tubes and that can kind of lead to a middle ear infection, which is why sometimes Children within the large adenoids actually present with um recurrent otitis media as opposed to anything else. Your palatine tonsils are the things that we actually usually call the tonsils. So when someone says they've got big tonsils, they're thinking of the palatine tonsils and these are located um kind of in the back of your throat. And we can see that when you look into the back of someone's throat, there's multiple folds here. Now, the one at the front here, the one that's more anterior, there's, this is the palatoglossal folder, the palatoglossal arch. Um behind it. There's another wee fold and this is the palatopharyngeal arch and the tonsil sits just in between these two and that one's a little bit hard to see. But hopefully, you can see that behind this little fold here, there's this bit of kind of peachy colored tissue and that's your tonsil. I will also mention the lingual tonsils, but as you can tell from the bareness of this slide, I'm not particularly fussed about them purely because you don't really tend to do much with the lingual tonsils. They might become ac a problem if you've got certain types of cancer. Um But generally they sit kind of at the base of the tongue. Um But I mention it here just because it completes the kind of trio of the pharyngeal lingual and palatine tonsils. Now, this image here is slightly overwhelming and I think generally speaking, when you're thinking of blood supply um and drainage to any kind of ana uh anatomical structure, it can be a little overwhelming because of all the branching that's taking place. It's very unlikely that in a tonsillectomy or an adenoidectomy, a surgeon would ask you to identify a blood vessel because you really, you shouldn't be coming into contact with any of these larger vessels if you do. It's probably not a very good um situation to be in so unlikely to happen. But they might ask you what um kind of the arterial supplies or the venous drainages So I've included that here. Um So the arterial applied to the tonsils, one of which is highlighted here. And in Korea um is, well, there's a few sources, there's a tonsillar branches of the dorsal lingual artery, the facial artery, the ascending pharyngeal artery, as well as the ascending and the lesser palatine artery. So it's got quite a rich blood supply. Um in terms of the adenoids, it's a little bit simpler. It's the ascending pharyngeal artery that supplies its blood. Um They both have a plexus for venous drainage. So the tonsils have the pterygoid, the venous plexus, um and the adenoids have the pharyngeal venous plexus and again, not very worth identifying these on the diagram. But if you are interested and you do have access to complete anatomy, um then you can click at all of click on all of these individual tiny blood vessel and it'll tell you what branch of what branch of what blood vessel they are. Um And you can definitely spend hours on it if you're interested. Innervation is an important thing. Um as it's kind of been hinted at uh or kind of talked about previ in the previous cases. Um, nerve damage is always a really important risk. Um a potential complication of surgery in terms of the adenoid, it's actually got two branches of innervation. So it's got the maxillary branch of the trigeminal nerve. And the one that's highlighted in pink up here is the um glossopharyngeal or the, or the pharyngeal uh branch of the glossopharyngeal nerve. The tonsils also receive their innervation from the gloss glossopharyngeal nerve. Um but as the name would kind of give a way, it's the tonsil or branch of the glossopharyngeal nerve. So crane nerve nine has a role in innervation for both the eye and the tonsils, um which at least is only one to remember for both structures, which is kind of nice. Now, again, musculature is one of those things that I would doubt that you'd encounter very much of um during uh Adeno tonsillectomy. However, it is there beneath the tissue. And so it's worth knowing what's below the surface that you're dealing with on this image here. This kind of bulge is the tonsil and I've kind of just talked or kind of indicated some of the muscles. Um OK, looking at it from the throat, this view I appreciate is a bit tricky. Um But you can almost imagine it like you were looking kind of into the back of someone's jaw. If any of you have done your kind of uh recess training, then if you're doing a jaw thrust, the place where you put your finger, that's where we're looking into. Um So this is kind of the back of um someone's kind of jaw bone. So we've got the superior pharyngeal constrictor and then we've got this tiny little branch off of that muscle and this is the glossopharyngeal part um of the superior pharyngeal constrictor. Now, these are important muscles because they constrict your upper pharynx during swallowing. So if you want to have a safe swallow, you don't wanna be distracting these two muscles. I've also highlighted um the palatoglossus muscle which runs kind of a little bit more anteriorly um to the glossopharyngeal part of this superior pharyngeal conductor. Um And again, that's really important for elevating the tongue, um but also bringing the palatoglossal arches together. So again, a safe swallow. Um not something that should be uh disturbed during surgery, but something that sometimes surgeons like asking you about, what are the muscles below here and at least you can name a few. But with all that being said, um let's look at our case. So we have Luke you here. He's an eight year old boy and he's had recurrent tonsillitis fits the paradise criteria. His last episode resulted in febrile convulsions and really he's due for a tonsillectomy when he was examined, it was noticed that his adenoids were a bit enlarged too. So, um it was thought that an adenotonsillectomy would be a sensible choice in terms of past medical history, aside from his recurrent tonsillitis, he's also had otitis media last year and that might be due, might be due to um his adenoid kind of um encroaching on that auditory tube. He's not really on an medication, not get any history apart from that, he's had lots of antibiotics for his spondylitis, but none of that has really helped. Um And he's not really taking anything at the moment. So you go off to theater and you see that look is already under general aesthetic. He's already set up. He's got this retractor in his mouth, which might be quite hard to see on this image here. Um And the consultant super happy, thrilled to have you here to see this Adal tonsillectomy because he gets to um kind of take you through it and also quiz you a little bit. So the surgery is just about to start and you're just getting settled in and this is what you see on the screen um before removing or starting to remove the first one, which is what he's grasped on to here. The consultant asks you what orientation is the patient in on the screen? So it's the top of the screen up here where it's blue as the patient's head. Um The patient's right ear, the patient's feet or the patient's left ear. And hopefully, I should be able to put that pole in the chart. Can someone tell me if you guys can see that? No, yes, we can see perfect. I've got to of devices. So I'm feeling rather high tech at the moment. Um So if I'm looking off to one corner, that's fine, uh everyone may 10 more seconds, I appreciate. This is a little bit hard and I'll point out the key structure that will help you kind of orientate yourself. Ok. Five. I'll call it there. But it's a, well, actually it's a three-way tie from what I can see on my screen. Anyway, does someone want to cast a vote? It's anonymous? Just so we have a winner and I can pick one of these choices to see if we get the lovely consultant or the less lovely reg telling us the answer. No, it's a four way tie low is correct. Yeah. Mhm Clarity. Not to call you out. But just because you've been answering, do you want to pick an answer? I, what's changed f but now it's a two week time. Ok. Well, given that we've not seen a lot of the r I'm gonna play devil's advocate and I'm gonna say towards right ear. So you say that the screen is towards the right or top of the screen is towards the right ear. And unfortunately, the red isn't very nice about it. He scoffs a little and he says, how do you expect to follow surgery when you can't tell up from down, not a very supportive teacher. Um, but we'll go back and we'll have a look at why. So, in terms of what we're looking at, it's really hard and you'll find that whenever you watch a laparoscopic procedure, it takes quite a bit of time to orientate yourself, it's really different watching something on a screen compared to when you have someone laying down on the table, you see their legs, you see everything else. But what we have here, I don't know if I can also have a pen. This here is the UVULA. So what you can imagine is Luke's head is down here and his body is pointing up that way. So as UVULA is up here and then the rest of his not done here, she's gonna have a rather big mouth. So actually the top of the screen is pointing towards his feet. Hopefully, that makes sense. But if not do, let me know in the chat. So for those of you, you said towards the feet while done, most students do struggle to orientate themselves. It's really hard to look at um a screen and kind of know off the bat, what anatomy you're looking at. Um And honestly, the skill that I've seen F Ys and Regs struggle with some. So here we are, the surgery is progressing and what we can see here is the tonsil being slowly removed. It's slowly being cauterized away and this is done really, really gently. Um Just so you're not disrupting the structures below. If we flick next, then you can see here. Now, you've got a big clump of the tonsil away. So you've taken our time and slowly kind of steps away this tonsil that's been um it's very enlarged. Now, I'll give everyone a hint and please look at this picture closely because again, the next question might potentially be slightly mean. So this is the first tonsil it's been removed and the registrar brings it over, shows it to you and asks you which nerve could have been damaged when removing this palatine tonsil? Is it the left glossopharyngeal nerve? The left maxillary branch of the trigeminal nerve, the right glossopharyngeal nerve or the right maxilla branch of the trigeminal nerve. And I'll start the pool again if you try to think what orientation our um our patient was in before. So draw the drawing I did before which is like this. And here is his mouth with his little tonsil here, not tonsils, sorry, his little uvula. And again, I'll give you guys another 1510 seconds, something like that. Mhm. Um It's a close tie but good job in spotting. It is indeed the glossopharyngeal nerve. So um very, very good. But in this case, it is the left is the most popular and the left is completely correct. So consultant beams of pride, great. It's the tonsillar branch of the left glossopharyngeal nerve to be precise, but you're spot on. And again, if we look back back here, if our head is done here, our legs are up here. Well, that must mean that this is the left side of the of Luke's kind of body and this is the right side of Luke's body. So we've removed the left tonsil, which means that we could have and hopefully have not disrupted the left pharyngeal nerve or any tonsil or branches of the left pharyngeal nerve. Um Good. So we've removed the left tonsil and we've bumped the head, we've removed the right one as well. And now the surgeon has skipped the head. He's using this laryngeal mirror that you see here. Um Kind of looks like a mirror that you might think dentists use to visualize an enlarged adede adenoid. And you can see that this tissue here that we're seeing. So it's kind of like reflect, reflecting up towards your nose or up towards Luke's nose. In this case, you can see that there is this kind of red tissue and this is the adenoid that we're wanting to ablate. And the surgeon asks you what disturbance is an enlarged adenoid most likely to cause. Yeah, as a hint, none of these are wrong. So, focus on the most likely part again, I'll give you guys another 10 seconds fab so again, not any wrong answers. And in fact, you've gone for the most popular is recurrent ear infection, which is not actually the most common, although we've definitely talked about it. So once the adenoids enlarge to a a significant extent or eno enough, then they can block the auditory tubes and they can cause recurrent ear infections and lots of otitis media. But actually, before they do that, an enlarged adenoid will potentially just cause snoring. It's gonna start obstructing your airway a little bit kind of like when you are sick and you get a blocked nose and that kind of nasal pharynx is a bit bunged up. And so you snore when you're sick because it's blo blocked. And that's probably the first thing that's most likely to happen. So, if you've got an enlarged adenoid, you, most people will probably be snoring. Some people will get recurrent ear infections. Um If it's gone on for many, many years, you get this thing called an adenoid face. Um And it's literally the shape of your face can change the way that you hold your mouth. Um And that's if you had enlarged adenoids as a child and it wasn't ever treated. So that could be kind of an extreme example of that. And again, sleep apnea, if your adenoids are big enough, you definitely can get a sleep apnea. But that, that is a problem and especially in Children, you don't want Children to be having sleep apnea where they stop breathing um when they're sleeping. So snoring is the most likely probably the most benign cause as well. No one's gonna be particularly harmed from snoring apart from maybe if you share a room with your siblings. Um But yeah, snoring is the most likely cause hopefully, that makes sense. It's a good job. If you start snoring here we are. Hopefully you can see that compared to the red tissue before this tissue is starting to look a bit white. And that's because we're ablating away that adeno tissue. And again, as the surgery progresses towards the end, you can see that it's all this kind of milky white color no longer that inflamed, um, red looking stuff. And here we've removed kind of the tie that was around the uvula, we've removed that kind of blue dressing that was inside the mouth and Luke is pretty much nearly ready to be sent off for recovery. The operation success, everything seemed to have gone. Well, um, you can see here as well. That's quite cool. You can see that the tonsils are no longer there. So this is a space left behind from where the tonsils were. Um, but as you're about to go home, the registrar stops you and asks you what is the most likely complication of an adenotonsillectomy? And I promise this is my last question. I know. I really hammered you guys. Um, but here we go to see what you think, what would be the most likely complication again? Slightly mean, because all of these are complications, I'll give it 10 more seconds. Good. It seems the most popular seems to be bleeding. So we'll go with that. Um, the consultant nodes, nods rather. Um, given such a rich blood supply to the area, it seems logical that bleeding is one of the more common complications and really any type of head surgery, it's fair enough to say, um, that bleeding is likely really any surgery at all. So bleeding in this case is quite a common one. But as I say, all of the answers were correct, um, pain as well. You could argue is probably even more common than bleeding if you've got a surgery, um, it's gonna be painful afterwards in terms of weight loss and dehydration that can occur if the pain isn't well controlled. So, a really important thing is to make sure that, um, postoperatively, Children and adults are taking um good care of. So they're not getting really dehydrated and getting other consequences of their surgery. Fever isn't actually that common. It's usually related to local infection. So, if someone's had a surgery and they're taking fevers, I'd probably be quite concerned about them and wanna start antibiotics. Um We've already mentioned things like POSTOP airway obstruction because of the edema. You get a hematoma as well. Um, trauma to the tissues, the tonsil remnants might regrow um changes to someone's voice in terms of temporomandibular joint dysfunction, which is one of the options. Um, you could get that, um, because we've kind of pried the mouth wide open and you can imagine if the surgery for whatever reason has to be prolonged, maybe there's some kind of complication like bleeding that could potentially add to that, but it's not really one of the most common ones. You wouldn't expect joint dysfunction. It might be a bit achy for a little bit. Um, things like psychological trauma, night terrors or depression can happen. Surgery is, um, a pretty big deal for lots of people and imagine for little kids, it can be a little scary. Um, but not very common. And again, death is very uncommon and if it does occur, it will be because of the bleeding or anesthetic complications, but not common. But generally when you're wanting to consent a patient and tell him the complications, probably worth mentioning some of the pertinent ones that might matter to them. And death is usually one of those. But have those three surgeries jump from Pedes to urology and back to peds. Um You've completed another productive day of placement, you're exhausted and so you head home to review the things that you've learned today. And so before we finish up, um and hopefully, it looks like we are on time, we've just got three Mc Qs one from each case to see if you can recall some of the things um that we've kind of taught along the way. So if we look back at our first case, an inguinal hernia may develop if what structure fails to regress and I pop the yes, yeah. Um 10 more seconds and then I'll let Claire see or um pat explain what the correct answer is. Um I'll call it there. So the correct answer was Processus vaginalis. Um Do you want, if you want to give a brief explanation maybe? Uh Yeah, sure. Uh So, uh it's the process vaginalis as you might remember, uh this basically is a tubelike structure which will regress as the child develops. And if it doesn't regress, it's left patent. So things like loops of bowel or um fluid can come down from the abdominal cavity and form hydrocele or uh inguinal hernia. So, yeah, ba bas basically, if the process is vaginalis does not regress and the hole does not close and the inguinal hernia may develop and the pictures on the right are just examples of what can happen. Um Get, I hope that answers any questions. But if anyone does have any questions, pop them in the chat and I think Pat and Cla so you can see them. So um we can hopefully answer them along the way. Um Our second M CQ is which type of renal stone is not visible in plain X ray. And again, I'll pop a pull up. Yeah. No, we'll give another 10 seconds again. Yeah, I think we'll go with that crystal. I think you can see but it's uric acid is the most popular and then cystine and calcium phosphate. Um Cancer is u uric acid. OK. Yup. Um So yeah, the correct answer is uric acid. So they're radio translucent on plain x-rays. So they appear so they don't actually appear on those types of scans. Um So that's why we use non-contrast CT scans cause that picks up all types of um stones and last but not least, hopefully, which option correctly describes the borders of the oral pharynx. Is it the uvula to the follicular? So let me put this bull up in the meantime, um the U to the cricoid cartilage, the epiglossum to the cricoid cartilage, the uvula to the epiglossum are the epiglottis to the vocal cords. And again, I'll give you 10 seconds or so. So we finish off on time fab, we shall go with that. So most of you have answered the uvula to the epiglottis and that is indeed correct. Um If you think about the uvula as being the kind of dangly bit in the back of your throat and the epiglottis is kind of just behind your tongue. So that's the kind of oropharynx. Um Anything above the uvula is your nasopharynx and the uvula to the cryo cartilage, the cryo cartilage is the kind of bit in your throat that you can often feel. Um that would be your oropharynx, but also your laryngopharynx added on to that. So that'd be two sections. Um If that hopefully makes a bit of sense, um All of these slides, as you said will be available to you afterwards. So if you did find them useful, um but maybe you want a bit of more time to look at all the labels which is fair enough. Um then they will be available to you. Um Hopefully, in summary, we've kind of given you a bit of a crash course um in some of the surgical cases we see in ps in urology. So, herniotomy ureteroscopy and an adeno tonsillectomy. Hopefully, you know a bit more about what peds and neurological surgeons do. Um, some of their kind of bread and butter cases, um, as well as some of the pathophysiology, the anatomy, the clinical features, investigation, management and complications of these surgeries. Um If anyone does have any questions, please do let us know otherwise. Um Thanks for coming along. Um There is a feedback form that I will share in the chat. Um And again, if you fill this out and you've attended six out of eight sessions, then you get free um R CSE D uh affiliate membership. Um So worth doing it. But otherwise, thanks for coming along and.