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Um OK. It's slowing. OK. So I guess you can probably start to share the screen. Yeah. Do you know how many people are around? Um oh there's a couple high. Do you wanna give it like a few more minutes in case? Yeah. Yeah. Yeah. Why not? Right. 72449. Mhm. I've never used this platform before. It's a really good platform but I think from actually tomorrow they are stop posting new events. I think they're doing some changes on it all. OK. Ok. Mm so this is if we haven't arranged anything like by today, then it wouldn't be um able to facilitate it this time. Ok. We got it in just in time then. Yeah, good. My so the chat function does work I think. Ok, great. So we can use the chat for any questions as we go along um just popping the mhm It Yeah, perfect. Um The only thing is um Grace. Are you happy to keep an eye on the chat box? Because once I go onto my screen, I can't see this screen. Yeah. Yeah. No, that's why I'm here. Thank you. You're amazing. Ok. Shall we give it a start and then as people join, maybe we can go back and forth a little bit. Great. So, hi, everybody. My name is Pacha. I am a core trainee at Ain Brooks Hospital. And today I'm going to just give you a bit of an overview about all the topics that we cover for pediatric surgery in mcs. It's not a very um high scoring section of the, of the exam, but it does come in most exams and I find that candidates often get thrown a bit when it's like, oh, an infant presents with this or an eight year old girl presents with this. And the idea is for you to not kind of worry about the fact that it's a child in the question stem. So we'll just go over the main sort of pathologies that come up and um what will probably come up in the exam? Um Once I go onto my slides, I can't see the chat box anymore, but keep posting your questions in there if you do have any questions and Grace will just alert me and then I can go back and forth and I'll see if I can answer my questions, uh your questions as best as I can. And I'm just gonna go over to the slide now. So Grace, I hope you can see the slide if you can't just give me a shout. OK, the slides. Great. Thank you. So, pediatric surgery for the RC Yes. So first of all, um biliary atresia is one of the main pathologies. Um I think with questions related to biliary atresia, it's the age of the child, which is very important. So you tend to see that the infant is born and the first few weeks of life they're fine and then only after about two weeks in term infants or about three weeks in preterm infants. Do you see that or they still have jaundice? And your clue that this is not physiological jaundice is the fact that their conjugated bilirubin remains high. And plus the fact that it's lasted for so long. So, um, that's something to remember this greater than 14 day period. And in the investigations that conjugated bilirubin, sometimes you will have stems where they mention cardiac malformations or cyto inversus. So they might mention that the apex beat is on the right side. So these are just some clues to look out for. Um, the, you're not really expected to know about the hepato um immunos acid radionuclear scan. Um But the fact that conjugated bilirubin is raised is your main clue. So, the management of bilary atresia, you don't need to know a lot of details about this. But what you do need to know is that it's called a Rouw portagee nosy or a Kasai procedure. So it's basically where we connect a part of the small intestine directly to the liver. Um, because we don't have bile duct right because it's bilary atresia. Um So liver transplant is the next option if this procedure fails. So that's kind of the important points for biliary atresia. This table I think is quite important. And if any of you guys are actually interested in pediatric surgery in the future, these are the main pathologies that you might be called for as an oncall pediatric surgery sho or registrar. So, Duodenal atresia malrotation with volvulus gal ileal atresia meconium, ilus ileus or necrotizing enterocolitis. So, these are all, again, presentations in neonates and they all present with bilious vomiting and they can all be quite dangerous. So, um the important aspects of this table are to know the disorder and to know the age of presentation. So you, most of these are quite early. Um but necrotizing enterocolitis tends to come in the second week of life. So that's something that's important to remember. Um And the other thing to know is the imaging findings. So sometimes in the mrcs, I've seen a few past papers where they do put an X ray or um like a upper gi contrast study. And then that's one of the clues to help make your diagnosis. And then just to know that what kind of surgery we would do or what the treatment option would be. So the duodenal atresia, um the classic double bubble sign is what you would see on film and you would do a duodenoduodenostomy and this is again done quite quickly within probably 24 hours of um the child being born, we would take them to theater and operate. Um Sometimes we might just have to do a resection and bring out a stoma. So, but you don't need to know that many details about that. The important thing is to recognize it and diagnose it based on the imaging findings. Um malrotation ulus is also an emergency and um it's usually 3 to 7 days after birth. So you would find um compromised circulation, peritoneal signs, hemodynamic instability. So you have a very unwell child, um very unwell neonate with um abdominal distension usually. And then you go for this upper gi contrast. And the main feature is that the DJ flexure is more medially placed. So this is the main thing to look for in imaging and this is treated with a lads procedure. Um vaginal and atresia again, that's within 24 hours of birth that you see similar to um duodenal atresia. But in this case, instead of two bubbles, like a double bubble, you'll see multiple air fluid levels. So sometimes you'll see triple bubble, you'll see even more bubbles. So many, many bubbles on the scan should alert you to gag or ileal atresia. And in that case, we would go for a laparotomy with the primary section and anastomosis, which you might have to do for a Duodenal atresia as well. And it's important to note that sometimes when a child presents with duodenal atresia, they might also have a judgmental or ileal atresia. So it's in the operation. It's important to look at the entire bowel and run the bowel as we say, um, to check if there's Atresia anywhere else. Um, and then meconium ileus, this is also an important one to pick up. And I think cystic fibrosis is the main, um, cause of it. So they usually have like 15 to 20% of the babies will have cystic fibrosis. So, sorry, I II in between 15 and 20% of the babies with cystic fibrosis have my meconium ileus. Sorry about that. So when you see a baby with cystic fibrosis and also presenting with bilious vomiting. So they're basically positive on their sweat test and then they present with bilious vomiting. Meconium alis is your immediate answer in a stem like that. Um So in that case, we would usually do decompression and it might even need a resection. But I'm, I doubt that they would ask you to um, know too much about the treatment because this varies between child to child. So it's important to make the association with cystic fibrosis, abdominal distension and bilious vomiting. And um, again,