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Hi, everyone. Welcome to the session. Today. Our focus is going to be on pediatric surgery. I'm sa I'm one of the social media leads at S and today we have Ester and Sean to take us through pediatric abdominal surgery. Just a little background on them. They are 50 medical students at Cambridge and today's session is going to be quite interactive. So it would be really nice if you guys could just put your answers in the chart. If you have any questions, feel free to put them in the chart as well. And the teachers will get to you guys as soon as possible. At the end of the session, I will release feedback forms for you guys. Once you fill those in, you will get a certificate and also discount goes to pass the MRC as and teach surgery and at the end of the session as well, we will release the recordings and also the slides for today. Without any further ado, I am going to pass it on to and Shan. Ok, thank you very much, Reita. Um we are having a little technical issue with our extensions on our laptop. So um just bear with us if anything goes wrong. And thank you Reita for helping us with everything. Um Like Rohita was saying this is going to be an interactive session. So the 1st 50 60% of the session is going to be going over the most common conditions you'll see presented in pediatric abdominal surgery. What you need to be aware of for, for those conditions and the surgical involvement in each and then we're gonna have a couple of case presentations at the end to get you guys thinking about, ok, how you're managing each case and what is it presenting like? Ok, thanks, ra can you go to the third slide, please? So this is a bit of an ov of the con conditions we're going to cover. Hopefully, some of those were familiar to you guys, if not, no problem. Um hopefully by the end of the session, you'll be a bit more familiar, if not. So, uh we're gonna start with acute appendicitis. So hopefully most of you are familiar with this one. What you can see in the slide is a CT image demonstrating acute appendicitis where there's the little label there a showing the size. So what is this condition? It's the inflammation of the appendix and it's a very common surgical presentation in pediatrics. It's mostly affecting uh those aged between 10 and 30 years but can present at any age. And the overall lifetime risk is about 7 to 8% So it is very likely you will see this condition presenting to you whether you become surgeons or not. Um as it, you'll see it medically, the cause of this is a direct Luminal obstruction of the appendix. So, typically a stony mass of competitive feces or a lymphoid hyperplasia, um is the thing that's causing the obstruction. Rarely. This can also be malignancy. So it's just something to be aware of when you have the substraction. It causes um a multiplication of the commensal bacteria that's in the appendix that causes inflammation. It reduces the venous dra drainage and then there is l further local inflammation from that increases the pressure. And then the there's uh ischemia within the appendiceal wall. When that's untreated, you get necrosis and then perforation. So risk factors to be aware of for this condition is a family history. So if you're querying uh appendicitis in a child, you're saying, OK, a very important question to ask is, is their family history? Are they caucasian? And it's also seasonal. So if it's the summer months, it's more likely to be presenting next slide, please. So the image you're seeing here, uh we'll get on to why it's important. But um if you do know what these points are indicating, can you put them in the chat? So, classic presentation with acute appendicitis is abdominal pain. It's dull, it's periumbilical. So it's uh around the point of the umbilicus first, it starts off being poorly localized and then it migrates to the right iliac fossa to become localized and sharp. You should see that progression in your patients. Other possible features could be vomiting after the, the pain itself. Um uh nausea, sometimes diarrhea, um anorexias and the child really doesn't want to eat and then rebound tenderness over mcburney's point. I don't know if anyone's uh putting anything in the chart yet I can't see at the moment. But point number three, on this picture that is mcburney's point. Uh Number one, sorry, um the other points um on the pitch to be aware of. So two is obviously the umbilicus. That's why you should have the dull pain starting and then um the right iliac fossa, hopefully, you know what that is other signs to be aware of is Ros Vick's sign. So that's still on the same side. Thanks Rosa um over the right iliac fossa as it starts to localize and you'll start palpating it suddenly you should, the pain should transfer to the left iliac fossa. There's also the SOAS sign where a right iliac fossa pain with extension of the right hip starts uh becoming really pronounced that suggestive a retrocecal appendix such as abutting the soas muscle and causing that that sharp pain. So that's a very classic presentation, but a high proportion of acute appendicitis in Children will present in atypical manner. So you can expect diarrhea, urinary symptoms even left-sided pain. So always just have it in the back of your mind. If you're seeing a child with funny tummy around that age group, when you're examining a child with suspected appendicitis, as well as just doing like your general gi abdominal exam, it's really useful to also do a cardio respiratory exam and really have a keep it in your mind like urinary symptoms as well. In these cases, you need to do a genital exam um to exclude testicular torsion, um and hepatitis any child, uh less than six years old who has had symptoms for more than 48 hours, like this is very likely suffering from a perforated appendix. So you need to be actively observing them, um quite stringently. So what is investigation should you be doing when you're managing a child like this, you need to do an urinalysis if it's a woman of reproductive age. So they're sort of on the cusp of about 13, maybe 14. But you're still que appendicitis, you still have to do a pregnancy test. Um You need to do bloods for inflammatory markers. You need to do a clotting screen, um, a group and safe, particularly if you think you're about to do surgery. Um, you need to do serum B HCG because again, occurring pregnancy clearing ectopic pregnancy too. Um And then to confirm you have to do an ultrasound, which is, that's your first line and then later imaging to think about is a CT and an MRI obviously, with consideration for younger Children. And potentially if you're still growing and pregnancy, you don't want to be unnecessarily i irradiating people. But you should be aware if you know you're in a time frame where it's a very acute situation and you think you need to act quickly this clinical picture of those features that I just talked about and some biochemistry is enough for a diagnosis. You don't need to wait for something like a CT or even perhaps an ultrasound. You can proceed next slide, please. So the picture you're seeing uh in front of you is excuse me, a laparoscopic appendicectomy that is the definitive management. Once that has been excised, you send it to histopathology and you need to assess it for underlying malignancy because if you remember I mentioned malignancy is a rare cause of the obstruction that leads to this uh pathology and you're only gonna see it in a, in about 1% of cases, but you have to do it still, you do um an open approach in certain cases. But um I'm so sorry, I still, I'm so sorry to interrupt you. Um Everyone seems to be seeing only the slide. I'm not sure why, but I'm just gonna reha my screen and then sorry about that guys. Really sorry about that. Yeah. Are you guys still seeing um the Titus like right now? OK, perfect. I'm just gonna mute myself and then I'll get back to the presentation. So sorry for that. No, thank you. Sa, don't worry if you can put it on presentation mode, Rosita, because at the moment the notes um are obscuring the presentation. Ok. RSA. Can you put your, um, screen on presentation mode, please? Ok. All right. Is it still not visible? Um We can't see it, but if those guys can, we'll just go ahead. That's better than this slide. OK? All right. Let's get, let's get back to it fine. So this is, uh, a view of a laparoscopic appendicectomy and that is the management for most cases. Um, because you're thinking of complications going forward, you're thinking of recovery rates for Children and particularly you don't wanna be keeping Children who are already ill for longer in hospital because they might just get ill again. Um, when you've had an appendiceal mass, you also need to be making sure that, um, after the excision, uh, surgery, you also have antibiotic therapy, um, with an interval appendectomy then performed much later. Ok. Um, that scheduling is obviously based on the patient's presentation, how they acute they are. And can you do this, this period of antibiotics first before you go ahead with surgery or not? Um, so that's a decision that needs to be made in a clinical setting. Um, but you, you should be thinking sort of a bit intuitively here perhaps. Ok. Uh, do I, can I, uh, now, can I give this child therapy and, and then do an appendectomy? Or do we have to go in and do something laparoscopically now? Because perhaps there's been a perforation and you'll have been able to see that from your imaging. Ok. Can you go to the next slide, please? Thank you, the Rosita. Can you go to the next slide, please? What? In the child? So I'm just gonna check the chart. I'm so sorry. I think there's some issue with my laptop. No worries. Just gonna stop presenting and repeat that again. I am really, really sorry about this. I'm just gonna try again. Yeah, that's working. That's working. Is it looking for anyone else? Yeah. Amazing. Thank you. Don't worry, Rosita. Um these things happen. OK. All right. Um We're still gonna have a good teaching session out of it. So uh gastro uh sis is less of a common condition. So I'm not gonna be surprised if not everyone's fully familiar with it, but you may have heard of um what looks like. It's familiar cousin, which is an Phalle. The difference here is that this abdominal wall refect where the fetal abdominal organs are on the outside and protruding. They don't have a protective membrane around them. Ok? And that makes them very vulnerable. You get this direct exposure to amniotic fluid in utero and that leads to um lots of reactions between the fluid and the, the gut wall which uh creates a thick inflammatory feel and peel over the bowel. And then because of that an inflamed and swollen intestine. Um, it can present at birth or you can detect it at the typical 20 week scan that mother, mother should be having where you'll see dilated loops of bowel freely floating in the arm cavity. The herniation is typically on the right side of the umbilical cord, whereas the cele is typically central and then it commonly involves the small intestines, large intestines, liver and stomach. The clinical, you can do this as a clinical diagnosis. Ok. Um And that's just by seeing it. So if a child is born in front of you, you see this presentation, that's it. That's the diagnosis. Ok. It's associated with intestinal malrotation and atresia. So if you do see a child presenting itis, it should raises questions in your head. Ok. Do I need to do some further digging for other conditions that might start bothering your child very, very uh soon. So women who have babies with this condition, if it's been picked up in the 20 week scan can have normal vaginal deliveries. Um But what's important to understand is the management following delivery. So, postnatally, you need immediate fluid resuscitation and you need to maintain the adequate temperature for those um exposed guts. Uh you need a sterile, clear covering over the hernia um to protect it, to prevent loss of um liquid through evaporation, heat loss and also to prevent infection. Um the infant is then also placed on the right side cause remember I mentioned it's typically on the right side as well and that prevents kinking of mesenteric vessels. Next slide, please. So that's um when the slide comes up, this is the plastic covering that I sort of mentioned to you. Um But obviously, this is not a long term solution. This is just management post postnatally, but surgery is obviously needed to reduce the protruding organs and to close the defect in the abdominal wall. Um The larger the defect, the more of a tactical and stage surgical approach, you're going to have to return them in into the cavity gradually because you obviously can't do this all at once. There isn't the volume of the space. Um that plastic bag is called a silo and then you tighten it progressively until that tightening naturally shifts all the guts back into the abdominal cavity. And that reduces the bowel uh bit by bit until it's completely reduced. This prevents further damage to the gut due to the tight space within the a abdomen. So, can't do this all at once. After the surgical approach, you need an NG tube to insert it to decompress the bowel and then uh PN feeding to commence whilst the inflammatory peel itself recovers and the bowel starts functioning. So, whilst you preserve the lifespan of the bowel itself, whilst it's been outside of the abdominal cavity, it's been through um a massive stress um as well as when it's been in utero and exposed to the amniotic fluid. So it needs to recover, it needs to adapt to the new environment and needs to start functioning properly. Um A serious complication to be aware of here is abdominal compartment syndrome. So similar to compartment syndrome, you might be aware of um in the peripheral limbs. Um This is again a tight space. Um and you are shoving things into it that it's not used to and you're massively increasing the volume, uh the pressure within a set volume. Um, obviously, it can get infected, it become unfunctional. There can be further wound infection and surgical scarring neck is something also to be aware of in these Children. And then Short guns short gut syndrome is also um uh an association which is where their guts themselves, that the length of them are shorter. Next slide, please. Hrs you guys hopefully are aware of. Um, because it's a relatively common presentation. It's a congenital disease where the ganglionic cells are failing to develop in the large intestine. Um So it's not nothing wrong with um, the bowel itself but actually the nervous input into the bowel. Um The way this is going to be presenting is after birth, you should expect your, um your baby to be having its um first uh wee and its first poo. If it's not having its first poo, it's Meconium. You should need to be querying Hirschprung's, uh the median aid of presentation is about two days. So you are looking out for this, um, whether it's in something like TC, um, whether it's on the label ward or even if it's in NICU is something to look out for. You're going to, uh see a baby with abdominal distention, they might have bilious, vomiting, bilious. So you need to be looking out for that color staining and then obviously the failure to pass in the her itself. So you will be looking upon for staining in the nappies or in its bed. Um You can also do an abdominal exam and you might be able to palpate a fecal mass in the left lower abdomen that's just gotten stuck. So suddenly there'll be a mass and then there'll be nothing. You can also do a rectal examination and you will find an empty rectal vault. Um And actually, if you were to do a rectal exam, there might be a very sudden forceful um um discharge of gas and fecal material. There's a couple of subtypes to be aware of. Um uh they, they're not, uh they're going to not going to seriously affect your management because the most common one is the short gut segment. Uh The rarer ones, the ones that involve larger segments of the, the, the gut as in the progression of the uh a ganglionosis. So that segment that is affected and doesn't have functioning ganglions, it's going to remain a tonic state as I'm talking about why this is happening is going to have a failure of peristalsis in the bowel movements. And then you literally get this fecal mass obstructing the bowel that dilates the stents that stasis um produces bacterial proliferation. And then as with any stasis and bacterial proliferation, you can get further infection um and, and enterocolitis. So, um if this disease is not dealt with and if you aren't picking up on these signs of this child presenting, then you are um actually going to be running um a serious risk of this baby. Um getting really ill because the mortality rate of this condition is 25 to 30%. So you need to be thinking, ok, um, if this baby isn't getting better, we need to do something or we gonna need to se to sepsis. Um Risk factors are um uh male gender, um Children who are born with Down Syndrome and if there's a family history. So when you are doing your NI P, you are obviously asking your questions about was this breach presentation at 36 weeks, you know, a family history of clicky hips. It's very useful to also throw in there. Um You know, was there any problems, you know, passing um you know, uh your first bowel motions when uh your mom or dad were, were babies and it might be actually very helpful to, to spot a few things just gonna look in the chart because I can see there's a couple of things. Ok, cool. Everyone's happy. Fine. So you suspect your child has Hersh's disease. What are you gonna do? You need to do an abdominal X ray? You do. I know it's a baby. Um, and I know you're worried about irradiating but you need to see these dilated loops. Um Second line is a contrast e enema and that's really useful because then you can actually see the extent of the, er, angl aosis. Um You can't just assume that it's going to be a short segment. Um uh but because of it actually involves the entire segment of the colon, um This is actually very serious why it's serious is because, ok, you have a nonfunctioning bowel in that sense, you need to get rid of it and you need to resect it in surgery. Um So is this uh a baby that's going to have a very serious surgery or is it going to be a bit of a, you know, a, a more minor surgery just keeping an eye on the time? I just wanna um s uh speed through this one a little bit and go to the next one. Uh next slide, please. Rashida. So, anal hernia is very common to present uh in a GP practice. So you should be carrying it in that setting. Um So, groin swelling, um, abdominal pain discomfort, um you also need to be looking out for ST uh strangulated hernias. Um That's where the compression of the hernias actually compromise the blo blood supply. So it's dying because it doesn't have the nutrient supply it needs. And that is a surgical emergency. You have to do something right there. And then, um, if you are occurring, it, you need to do a genital exam. Um, that scrotal mass is going to be um, re reducible when lying flat, it's not going to transilluminate and it's going to have a positive cough reflex. Um, if it's strangulated. On the other hand, it is going to be irreducible, it's going to have a tender tense lump and it's going to be painful out of proportion. So your, your child is going to be in, in tears perhaps in your practice. So you really should be having red flags and bells ringing in your head. Your diagnosis is um, a clinical one. So you don't need to wait for any confirmatory imaging here and you need to, ok, you're worried about this. You immediately send them, um, into hospital for surgical repair of the hernia. So, herniotomy, um, that's ap performed on awful, uh, to male infants with an asymptomatic reducible inguinal hernia and you might need to have emergency surgery further, uh, for any bowel that's come through you as well. Next life, please. Um, interception. So, um, this is a bowel that is essentially telescoped, is a term that's used with this, but maybe think of it, it's just folded it on itself, um, as in the picture here and in a sense, the obstruction here is coming from the, the valve, right? Uh Because the lumen is suddenly much, much smaller, typically, this is around the ileocecal valve. Um And most cases are actually idiopathic. So we don't know why they've happened. What is your child going to presenting? Like they're gonna be in a huge amount of pain. Um And to try and alleviate that pain, they might draw their knees up to their chest. They might going to be inconsolable when they're crying. Um, you might have a delayed presentation sometimes. So you might have a child that starts up being lethargic, doesn't want to eat anything. Um And then much later on actually starts to really deteriorate. Um One thing you can also look out for is in their stools. You can ask their parents with the collateral history. Um, was there any blood in the stool? Was there any mucus in textbooks? It's described as a red co consistency, but your parent isn't gonna know what that is. So, ask, ok, what color? And was it floating? Was there any mucus? You need to examine your child? Is there distension? Is there a palpable mass? Um, in the right upper quadrant particularly are the signs of uh, peritonism. So if your child has walked into the GP surgery, they're not peritonitic, you know, they might be screaming saying, you know, my, my tongue is in pain, but if they walked in, they're not peritonitic. Um, and if they walk out too. Next slide, please. So that is what your x-ray looks like. You can see all the dilated loops, you can, um, the absence of bowel gas, um, and the Rigler sign, um, if perforation has occurred. So rigs is something to look out for. And this is often an exam question. That's where the bowel appears to have a double wall as in this image here, um, as gas which has the loosen appearance is trapped inside and outside of the bowel and that causes it to light it up due to the relative densities. Um You can also do an ultrasound that's typically preferred, um because it's got a higher sensitivity. Um And there you want to look out for the target sign. So essentially two circles in on one another and that is the bowel folding in on itself. So how do you manage this? Um If your child is in shock, if they're really unstable, if they're dehydrated, you need to do fluid rec immediately. So give them a bolus, then you insert an NG tube and you need to decompress the obstructive bowel. An air or contrast enema is used to uh reduce the interceptor bowel. Um, that's usually done by a radiologist or a pediatric surgeon at the time of the actual ultrasound. Um Any contraindications to the enema that's used, you need to be aware of obviously next slide, please. All right, neck. So neck is one of the most common uh neonatal surgical emergencies and bone. The cause isn't entirely known. It's um likely due to innate immune response to the microbiota of uh immature uh premature um infant's gut. Um So it's being dealt a challenge and it hasn't developed properly enough to deal with it yet that leads to inflammation and to injury. So, premature babies are typically at risk of this. Uh the babies that are formula fed, the ones that have had growth restriction in utero, uh any episodes of hypoxia exchange transfusion was the presentation. So they're really gonna be struggling feeding, they might be vomiting. Um There might be bile or blood in the vomit. Um, the abdomen will be distended and there might be blood in their feces too. When the neck progresses, you're going to see the tenderness of the abdomen, edema erythema and you're going to have palpable bowel loops too. So obviously, it's going to these uh gi features. But um in reality, the things that are going to be ringing your alarm bells and more of the systemic features, you're going to have a really unwell child apnea, lethargy, bradycardia, um decreased uh perfusion peripherally. So they're going to be looking like they're really unstable and that they're shutting down next slide, please. This is what your imaging is gonna look like the neck. So this is an abdominal X ray and you can see the extended bowel loops being pointed out to you there, the thickened bowel wall from the edema and the gas, uh, that's been picked up too, which looks dark on the X x-ray relative to its surroundings. Um, that is typically because of the perforation. Obviously, your basic labs, um, you need to give prophylactic, uh, treatment of steroids that's usually helpful. Um, and then management, if it's suspected you can do medical management, um, withholding oral feeds and then giving IV antibiotics for about two weeks depending on your local protocols, if it's advanced, um and you'll be able to tell that from your x-ray, depending on if there's perforation that's occurred or if there's secondary obstruction, then you go in and you need to repair the, where the site of the perforation, you need to resect um the dead gut essentially and the infected gu um just gonna, yeah, again, speed through this very quickly. We have two more um uh conditions I want you to be aware of and then we're gonna go to the case presentations. So, foal, if you remember with gastro uh uh sisis earlier in the presentation that had uh no protection around the guts that had herniated outside of the abdomen. Here, it does, which seriously affects your management. Um So whilst there is the herniation, it has its own membranous sac, um which is made up of uh peritoneum and of uh amnion, these protective membranes mean that they are healthy. So you don't need to um wait for uh function to return your management is going to be relatively similar about slowly but surely um reducing uh the size of the guts outside the abdomen and and putting them back into the abdominal cavity. But you can be a lot more confident about their functionality later on. A big risk factor for this is maternal smoking and maternal age as well. Next slide please. So that just a bit of comparison, it's also going to be more likely uh to be central periumbilical as opposed to the right. This is also a clinical diagnosis. So if you see this on ultrasound, if you see us physically, you know what the condition is quite simple. Um Alpha fetoprotein is going to be elevated in this condition. But um that's if you're seeing it on imaging um whilst the fetus um in gestation, that's something else to maybe confirm later on. But if you're seeing this in front of you, that's the condition pretty much um complications to be aware of are obviously again, abdominal compartment syndrome rupture. Um But the management is pretty similar next slide, please. And last one, pyloric stenosis. So progressive hypertrophy of the pyloric muscle which causes gastric outlet obstruction. So pretty simple as the the picture shows. Um so around 4 to 6 weeks of age, you might have a baby that presents with nonbilious vomiting that's important. There shouldn't be v in, in the vomit after every feed and it's sometimes described as projectile, it coming out with force. Um, babies are still going to be hungry. So you, they shouldn't appear um like they don't want the food, they do want the food. They just simply can't get it past the first bit of their gut. Essentially, they're going to lose weight and they might be really dehydrated when they actually present to you. So, um as well as thinking about surgical management, you also need to be managing the acute presentation in front of you. Um If there is bile in the vomiting, you need to think about malrotation. So how are you going to manage this? Um perioperatively, perioperatively, you need to obviously do um labs uh metabolite abnormalities, fluid boluses, but uh surgically um the treatment of choice is the rounds pilot my uh myotomy that's performed laparoscopically and it's done through a supraumbilical incision uh and the muscle is divided down the mucosa. So fine, you have a pillar sphincter and the PLO muscle that is too thick, too large, fine, you make it smaller. That's uh simply it um this is successful in the majority of the patients with only 1 to 2% experiencing any kind of restenosis like down the line. Thanks guys. She's gonna do the case presentations. Now, could you just move on to um a couple of slides? So, to slide 19. Yeah, there we go. Um So Esther's done a, a really nice comprehensive review of um some of the key conditions that are covered in pediatric surgery. I just have two short cases that are based mostly off MLA content. So what you would be expected to know for the MLA exam in your final year? Uh one, a bit more common, one, a bit more rare. So starting with case one, then you the ST three Reg Onco and the consultant that you're working with has been asked to review a concerning 20 week anomaly scan. And uh the information you have is that the scan has demonstrated some of the abdominal contents of the fetus are not located within the abdominal cavity. So just a bit of a brainstorm answers in the chat. Where could these abdominal contents be if not located in the abdominal cavity? So I have three slash four depending on how you categorize it. Options here. We'll just give you a minute. Yeah, amniotic sac thorax outside the body. Yeah. All of those are correct. There's one more that I was kind of as a bit of a bit of an add on. Yeah, hernias up. So, yeah, all of those are correct. Just don't uh if you just hit the next slide slash transition. Yeah. So don't forget as well that they could be in the uh in the inguinal canal as kind of outside the abdominal cavity. Um Perfect next slide, please. So um obviously, as has already gone through this, but just so that you remember, how do we differentiate between an omphalocele and gastrosis Yeah, the gastroschisis is more right sided. Yeah, it's to do primarily to do with the cover. Uh But yeah, Luke, you are right in the, the right side of nature. If we think about the embryology, sorry, if that's a bit traumatizing to bring back up the embryology of what's going on. Um in the two conditions. Um gastroschisis is caused by an incomplete closure during folding um at the folding stage of embryonal development. Whereas the omphalocele is caused by failure of the gut to descend back into the abdomen after it protrudes up into the um umbilical cord during um rotation, growth and rotation. So they're quite different processes, which is why one has the covering, one doesn't have the covering and why one tends to be lateral whereas one tends to be in the midline. Um If we just switch you on again and again, like uh as I said earlier, it's to do with the amnion and the peritoneum that cover the omphalocele. So, um in terms of managing these, these fetuses, um and specifically, this question is asking about mode of delivery and how we time our surgical approach. So what are your thoughts on that? It's a bit of a long question really now that I think about it to have to tip away on the tap. Yeah. Yeah. So some really good answers there. Um Could you just pop up the answer for me? So, um all of what you said is absolutely correct. Um But in terms of the key two things that the, um the MLA wants you to know about is mode of delivery and surgical timing. So, um mode of delivery is slightly different between the two. In reality, patient babies with gastroschisis might undergo uh a cesarean section anyway, but they are not strictly required to. Um, so they are allowed to attempt vaginal delivery if that's parental wishes. Um In contrast with an Phalle, um the expectation is that ac section would be performed and that's simply because you want that protection to occur of the um the, the sac that's covering it. You don't want it to potentially be ruptured as it's passing through the birth canal. Um And the, the whole point of that is obviously is to protect the, the abdominal contents that are protruded out into the omphalocele from external um factors. So, with the relation to that, when we talk about surgical timing for patients with gastroschisis, we would expect an early surgery. So the, the current guidelines are within four days. Um However, it's a relatively rare condition and um not all patients that have gastroschisis can undergo an early surgery within four days, especially if there's uh not a very well sized abdominal wall, um or abdominal cavity in relation to the amount of content that have been protruded out through. So, a large amount of abdominal cavity growing is determined by the pressure that is within the abdominal cavity during the growth phase of, of the fetus. So, obviously, the abdomen doesn't have that, that stimu or abdominal wall doesn't have that stimulation. Um So therefore, it doesn't grow to the correct size. So it is common for that to be a slightly more delayed, but the intention is always going to be an early um early reduction. The contrast is true for the, the omphalocele because yes, obviously, we can protect it with the sac as well. Um With the omphalocele, the amnion and the peritoneum itself will granulate and will form actually a quite a tough protective shell that covers the abdominal organs. Um And again, you can allow the abdomen time to grow under gentle pressure from the the organs itself that are sat in the omphalocele. Um and once it's grown, then it can be reduced. Um a lot further along the line, obviously, babies that have this cannot leave hospitals really. Um So it is important to also bear some of those social factors in mind as well. Uh Next slide, please. So, uh a lot more common case. Now, you have a 14 year old uh female who presented to the emergency department with uh four days of abdominal pain, pain is dull and periumbilical in nature. Pain has progressed progressively been getting worse since its onset. She reports no change in bowel habit except from some slight loosening of the stools. You order routine bloods, uh an ultrasound and request the patient to pass a urine sample whilst awaiting the ultrasound. She reports a sudden increase in her pain. Pain is now located in the right iliac fossa. And on examination demonstrates rebound tenseness and board like rigidity. The patient is clearly guarding the area. What is your most likely diagnosis and what must be excluded in this patient? First two answers in the chart. Yeah. Spot on there. So if you just hit the answer for me, it is uh acute appendicitis is probably what your mind should be jumping to right iliac fossa pain. Um And we'll come to come to that in a second. Um Probably fever, slight loosening of the stools. It's very classic. Um a several day history of dull periumbilical pain as well should raise suspicions. Um I'm not gonna give you the answer to that though. Cos that's the next question. Um So if we hit the next slide. So what is this nature, the nature of the patient's pain at initial presentation? What is the nature then after the acute deterioration? And what do we call this change? Again, quite a big question to be popping in the chart? I know. Yeah. Grace. That's right. So a couple of a couple of language things to point out here. So, um again, throwing back to a bit of embryology here, um The initial presentation is what we would um refer to as referred pain. So if you remember the midgut hindgut and full gut refers to three different places on the abdomen. So midgut typically refers to the umbilicus, which is hence this presentation here. Full gut refers to epigastric region and hindgut refers to the suprapubic region generally um on the abdomen and this is where you've got no um peritoneal contact with the inflamed appendix. So that's why we've got this dull periumbilical pain is referred pain from the mid gut. After the acute deterioration, the either the appendix is swollen or it's burst or it's um ruptured would probably be the best word for it. Um It's made contact with the peritoneum and obviously the appendix is in the right iliac fossa. So you get that sharp, right iliac fossa pain with guarding rebound tenderness and quote unquote board like rigidity is the the favorite phrase. And that is your classic description of peritonitic pain and pain that starts somewhere and moves somewhere else or referred to peritonitic. Um has the term migratory pain. Mhm OK. Last question on the next slide. Um So the key, very short principles of how they should be managed. So obviously, I know has gone through this in quite a lot of detail. Um Any sort of key things jump out at you for management, pop in the chat. Yeah, up and actually anything else? Yeah, antibiotics. So if we just pop up the answers here, so Appendectomy is obviously going to be your mainstay of treatment here. Um OK. Often the question when it comes to appendicitis is do we do interval appendectomy where we give you antibiotics and weight or do we go straight for the surgical option? Um And in this patient, because the they are now peritonitic, the interval appendectomy is no longer indicated. So this would be uh acute emergent appendectomy um sent off the theaters very poor, not very quickly but rather quickly. Um In the NHS hospital, um you would also want to be prescribing prophylactic antibiotics. And the official reason that you are expected to know for that MLA is it reduces wound infection rates. Um But obviously, I think we can all understand that it probably has some additional um advantages in terms of reducing potential sepsis from or likelihood of development of sepsis following um a peritonism. Um And then the last thing that you're expected to know in terms of an appendectomy surgery on the, um MLA is that if there is a perforated appendix, copious abdominal lavage, that's the tendencies, copious abdominal lavage is expected. Um As you need to wash out all, most often, all four quadrants of the abdomen um to remove any uh inflammatory and infectious products that have been uh disseminated across the peritoneum. So that the last question, uh we are pretty much at the end of time. But does anyone have any questions off of today's session? Uh, feel free to pop in the chat. So, hi, everyone. Let's get questions in the chart. Thank you. Guys for today's session. It was really, really good. I'm sure people are, that's really helpful. I'm gonna put the feedback form in the chart as well for everyone. So if your pillows in you will be able to get the certificate and also your discount codes, we will release the slides and the the recording of today's session soon. So keep an eye out for that otherwise follow on a social media as well. We will be posting five more SPS um after the second session which is on Thursday if I'm not wrong at 6 p.m. So if you guys find a session helpful, I'm sure you'll find Thursday's session helpful as well. And yeah, thank you guys. Oh, there's just a question here. Um Thank you very much. That was real, your help today was really, really invaluable. Um Are we considering pediatrics as a specialty? If so why? Yes, I'm considering pediatrics as a specialty. Um I actually only recently had my pediatrics blocked this year for the first time. I wasn't considering it before this year, but it's a really fantastic specialty you get to see just about everything. Um that comes under your that everything that walked into a hospital from pretty well patients through to very acutely unwell patients from babies up to teenagers, rest and cardio and gastro and often pediatric patients get, they get sick quickly, but they also get well quickly. Um um pediatric patients have the highest or some of the highest rates of um, cancer emissions. Um, it's a really rewarding specialty and pediatricians are also generally very nice, um, which makes quite a big difference as well. I agree with Sean. I'm also considering a little bit, um, it's a very rewarding specialty, the level of depth and breadth you're going to have um, as a practicing clinician or something to really be, uh, something to really be said for them. So your patients are going to be everything from premature babies to 17 year olds. So basically adults and you're going to be expected to manage that and understand, you know, all of them as human beings as well as the, you know, all the textbook medicine, right? And you are going to um you can have a lot of challenges in that. Um But I think the rewards you get back from doing work like that is really fulfilling and children's right, Children do bounce back, they're a bit like tennis balls. Um There are a couple, is there another question, what is the scope? Uh So the next session is on uh pediatric uh cardiothoracic surgery. Um And that's going to be covering a lot of um congenital heart defects and your management there. So that's going to be really interesting and it's also done by um one of our friends here at this uni what is the scope for pediatric surgery in the UK and Australia? Interesting. Um II can't comment on Australia specifically um within the UK, pediatric surgeons have a really, actually quite a wide scope. Um Obviously, neurosurgery is under neuro cardiographic is under cardio. Um But pretty much everything else I believe comes under pediatrics. So if you have a urological problem in a child, it tends to go to the pediatric surgeons rather than the urologists. There are some quite specific guidelines obviously about that, which I could sign post you to on the GMC S website um as to what the different specialties do. Um and yeah, obviously, like I said, I can't, can't comment on Australia, but actually there is quite a a wide scope of practice for pediatric surgeons in the UK. Mm. Yeah. Anything else if that is all the questions we have today? I think we can end the session here. Thank you, everyone and thank you guys. Thank you everyone. Thank you. Thanks bye bye bye. Mhm.