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Principles of Paediatric surgical care



This medical teaching session will focus on the Principles of Pediatric Surgical Care, presented by Doctor Siasia, a senior registrar in the Department of Pediatric Surgery. Doctor Siasia will discuss topics such as the changes in physiology, anatomy, and gender of children, as well as diagnosis, management, follow-up, and transition of care. Attendees will have the opportunity to ask questions and comment throughout the session, and receive valuable insight from this in-demand presenter.
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Understanding the principles of managing paediatric surgical cases.

Learning objectives

Learning Objectives: 1. Explain the different age categories of pediatric patients and how they vary in terms of physiology and anatomy. 2. Describe the history of pediatric surgery, including its first practitioners and some of the key advancements in the field. 3. Outline the different subspecialties of pediatric surgery and explain the role of non-specialists in pediatric surgery care. 4. Explain the principles of pediatric surgical diagnosis, management, follow-up, and transition of care. 5. Recognize the importance of providing specialized, tailored medical care to pediatric patients.
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Computer generated transcript

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

Ok. Hi, everyone. Can you hear me now? I think you should hear me now, please reply in the chart box if you can hear me? Ok. Can anyone hear me now? Ok. I um hello. Can anyone hear me now? I think I have some trouble with my audio. Uh I need to be a ok. Thank God. Yes, you can hear me now. Um Good evening everyone. Um Just a minute there. Just give me please. Ok. Um, good evening everyone. Um Thank you for joining us today. Um II was saying earlier, I didn't know anyone couldn't um hear me. Um So the longer waited session is here. Thank you all for joining. And um the presenter would um take over the stage um shortly uh but just to introduce him briefly. Um So our presenter today is um Doctor Siasia. He's a senior register in the Department of pediatric Surgery in um University of Learning Teaching Hospital. And um he has kindly um agreed to teach us today on the principles of pediatric surgical care. Um, so I would invite him to this stage now. So um just so we can go straight into the session and I will take um please, you can um type in your comments or questions as the session goes on. Uh We'll take all questions and comments at the end of the session. Um So thank you so much. Um Everyone and if you have any issues with the audio or the video, please just type it in the chat box so that we can make corrections um on time. Thank you. Um ok, so let's see. So. Ok. Um I don't know if our presenter can hear me. Um uh Just a minute. Yeah, I think you might be having some issues with the network. I don't know. No, no. Yeah. Ok. Um So please dont with us everyone. Um Our presenter seems to be having some issues with the network. Um So he's trying to join the um session. He'll be back shortly. Ok, I think it's back. Let's see. Ok. Um Can you see me please if someone can just reply in the chat box? Ok. Uh We're still trying to get the presenter um in will she be joining us shortly? Um Got some issues with his network? Ok. Someone can hear. Thank you. Thank you. Good. You go. Ok. Yes, it's here. Um We can use uh muted. Yeah, um or muted now. Ok. All right. Good afternoon, everyone. Good afternoon. Um So I want to interrupt. I'll just turn off my video and I'm audio it doesn't interrupt yet. Um um You sir, thank you so much. Thank you again for joining us. I um, briefly introduced you to everyone, but I guess you were not um online then. Um, so, but then I will just leave it to you so you can introduce yourself and then start the session. Thank you again for agreeing to, for, for teaching us today. Thank you. Ok, I'm going off, move out. Ok. Um, good afternoon everyone. Uh, my name is Ola in Kaoi. I'm the senior registrar with uh, pediatric surgery. Can you hear me? Yes, we can hear you, sir. We can. Yes. So my name is La la Kasha or I'm the senior registrars with, uh, pediatric surgery at UI TH learning. And, uh, I've been asked to discuss with you on, uh, the principles of pediatric surgery care and, uh, it's something that is, uh, very important for those that are interested in any specialty that operate on Children that takes care of the medical need of Children. Um, I'm trying to see how to share my slide. Sorry, I've not used this. Um, um, it's fine. Please take your time. Have you seen any option for ducks? Not yet? Ok. Um, ok, I've seen an option. Ok. Sleep. Yeah. Yeah. Ok. Sorry about that. I think I would share the screening instead since I've already. Ok, sir. Hello. Can you see the slides? Hello? Is the slide visible? And is it transitioning? Ye? Yes. Yes. It's visible. Well, not trying to, I can only see the first light, the, the first light. All right. So, yeah, just give me a minute. Ok. So now we can see this like, yes, you won't be able to sleep yet. I will. Ok. All right. Um, I, all right. Can you see it now? Um, not yet. No slight now. Yes. Yes. II can see the outline. Yes, it's transitioning now we can see. Ok, good. So I'll be talking about principle of pediatric surgery care. And um, these are just the outline I will be speaking on. Um, in pediatric surgery, we tend to take care of the surgical needs of Children. Although there are many other uh surgical specialties that do operate on Children. Um, they are more specialized and they give some specific care. Uh but pediatric surgery tends to give general care uh for those requiring settings, uh specific surgeries. And uh one of the things that is peculiar about pediatric surgery is the fact that uh consist of a wide array of patients, uh including uh someone as small as a unit and to Children that are almost adults as old as 17. And uh these uh have varying physiology and anatomy and uh therefore no particular thing fits any one of them. Uh for instance, uh among infants, infants, uh transitioning basically, when you talk about the unit, units are still transitioning from intrauterine life, which was largely dependent. And then uh by the time they become infants, they are transitioning into an extra uterine life. So there are so many things that differ in terms of physiology, they are transitional, they are transitioning in terms of their circulation system. And in terms of how uh the uh just to video stress uh such as uh surgical diseases will impact on them. So there is no particular formula that fits them all. Uh is one of the things that one is to uh take into cognizance. Then again, uh you have a wide category, wider categories of patients. Uh For instance, in terms of gender, uh we speak about Children uh being male, female or even uh ad SD, which are Children whose gender cannot be uh determined at the time of birth. And uh they have problem with their development uh in terms of sexual development. So you cannot classify them into that regular binary uh classification, the male, female. And even nowadays that uh division is getting more blood out with uh the transgender and other categories of people. Again, in terms of age, there are areas of uh we have uh infants, toddlers, those that are preschool age, those that are school age and adolescent. These are all varying divisions. But again, if you look at uh infants, for instance, among infants, there are those that are still 0 to 28 days, which are units, uh neonate means newborn. But some people have gone for that to say, uh not necessarily that uh newborn may actually be within the 1st 72 hours and then subsequent, you can refer to all of them as uh you can refer to them as other units. But what is acceptable uh worldwide is that units and newborn are actually the same and then other infants because units are also a subset of infants. The other infants are those that are one month to 11 months of age and so on and so forth. And one of the things that is quite intriguing about them is that uh all these, they undergo changes uh according to how grown they are before they are from fetal life. These two here are fetuses, but here you have a newborn the but that they are in terms of uh age, certain changes or co in terms of the head, the size of the head relative to the body, they have a very large relative to the remainder, meaning part of their body and uh the abdomen as well, the abdomen tend to be rectangular uh line on the long side. Whereas uh for those that are uh beyond school age be be beyond the the school age. Uh they have a rectangular abdomen which is sitting on the short side of the abdomen just like what are uh obtain in adults. So these are some of the changes that you find in them. Uh Let's just take a brief history. Um The first thing, the first uh pediatric uh surgery, uh interest as a specialty is that, is that in Paris where there is uh establishment of the hospital for sick Children in Paris. That's 1802. And by 1852 something similar was in UK, that is the Great Hormon Street uh hospital for six. And at the beginning, uh there was a tendency uh for it's to be only Children with uh medical needs that are taken care of at this hospital. I have Charles Dickens. The famous author is one of those known to have supported uh the care of any Children, all Children rather than only those with medical illnesses being taken care of in such hospital. And uh um some people have published the scope of surgery in the, the Great Hormon Hospital for sick Children in the medical in the British medical journal. That in and then uh t homes also did something similar in 1868. The first established pediatric surgery practice uh that was exclusive for pediatric surgery was in 1919 by Herbert Co. However, the first training program was established by William Lad, an American surgeon uh in the Children Hospital at Boston. He was the first uh surgeon in uh surgeon in chief at that Children hospital. Uh He was a general surgeon before he dedicated his practice to pediatric surgery. Uh likewise, uh Robert Gross, who was uh his first trainee who had a background in pathology, worked on uh patent doctors, arteriosis ligation based on his observation uh of infective endocarditis specimen that had been taken. And this way, uh this was this form the basis for him uh proposing how and the importance of ligating the patent doctors arter. He also published the first uh uh last walk that is the abdominal surgery of infants and Children. In 1941. Over, we all know uh describe the pathology of hash's disease and also provide a solution in the operation that is named after him. And it was a Canadian surgeon a bit more who patient the American Board of Surgery. Uh so that uh pediatric surgeons uh can all see patients or pediatric surgery. So as the basis for Vacation, the Jones in America, pediatric surgery has uh many branches but the parts that will be looking at uh for those that are specialized in pediatric surgical care. Uh that is a neonatal surgery, general, pediatric surgery, uh pediatric urology and gynecology, pediatric colorectal surgery, hepato biliary surgery, oncology. And uh of course fetal surgery, which is still an imagined uh aspect of uh pediatric surgery. All these are not is not by any means exhausted because there is also pediatric neurosurgery. But a lot of times neurosurgeons do take part in the care of Children, but they are not specialist pediatric surgeons. And in some places, pediatric surgeons have been known to do some pediatric neurosurgery. Similarly, uh orthopedics, which is even a tofa uh specialization to master. There is also pediatric orthopedics which is uh still in our own setting. In here in Nigeria, it's still a developing aspect of pediatric surgery. So what are the principles we'll be looking at? The first thing is on the issue of diagnosis, management, follow up and then on the transition of care. So that's uh child, Children forever. So, in making diagnosis, uh diagnosis, like in other aspects of surgery is based on the tripod of history, taking uh physical examination, investigation. Uh it's all these that will make up uh the diagnosis of a child. However, in addition, in pediatric surgery, we also take uh the integration of other problems that are common to Children serious. Uh The meaning is that uh we check the child in a holistic manner so that not any, there is no aspect of the child that is missed. And we follow through to ask about nutrition, we check uh the immunization and how they are growing and developing. We also want to look at uh antenatal perinatal and postpartum period to look at those things that can be a risk uh for their health. And generally speaking, as Children grow older, we tend to downplay on those other aspects. For instance, in a 12 year old, we'd say acute appendicitis, uh much emphasis will not be on the antenatal history, perinatal and postpartum, but for a unit, an infant. And indeed, even uh a lot of us uh things that we need to look at will get back into the uh perinatal events. So in other word, what we do is a compressive assessment so that we make a complete diagnosis, that we ensure holistic management. So the pediatric surgeon uh not only takes a routine history as e part on the use of that word, uh a mindless fact collector. Uh we will take a routine history and make examination and then uh we are not correlate it with anything but just miss some important clues. Uh and the person make a diagnosis which faulty. However, what we need to do is to marry the presenting complaints with the basic principles that we have from the physiology of Children as well as embryology because they are closer to the embryonic period. And AAA lot of time, pediatric surgery has to do with embryology. So we take history on that basis. Once we have that we also use the basic principles of pathology. And then this gives us an idea of the like once we have that, then this will help us guide us into a focused goal oriented history and physical examination, which will make us arrive at the appropriate diagnosis. This is what will make us illogical strategies in making a diagnosis for a child who is presenting to us. Yeah. Now, in taking history, we generally in pediatric. So you will rely on uh information that is given to us by caregivers most of the time. In addition, some Children uh maybe starting from those that are up to uh 67 years of age or even above. And as they get closer to adulthood, it becomes easy. But a child at an appropriate age, we have varying degree of contribution to the history that we can uh obtain. In addition to the regular history that we take in adults, there will be need to include the history of the pregnancy, the peripartum events as well as the postnatal. Are we supposed to take developed the immunization history as well? And then we'll also want to relate the symptoms that these two uh relief such as a child that has in developing vomiting uh about the time of b so uh something that is congenital as the cause of his vomiting, whereas in an infant that is preventing presenting with below vomiting, an infant between three years or even a toddler for that matter, uh we will be thinking of something else, especially if there has not been an ancient before. We'll be thinking of something like intususception. So these uh symptoms are usually timed with the milestones. The patient has I think. So in this one, when we take history, the first thing we have to do is to gain appropriate rapport with a child. One we have introduced ourselves, will we gain rapport with the child? And one thing about scar of Children is that you need uh Children to uh really be friends with you before you'll be able to uh attain their trust. And then you also get uh history, at least the presenting complaint as well as the visual fs from those you make a tentative diagnosis, which will give you an idea of what other histories to elicit from the patient. And then you can now do your goal oriented uh direct questions which will further help with your history. And then the diagnosis will be solidified. And you have an idea of what you will be looking for when you are going to examine. And by the time you are examining your examination will also be goal oriented and directed. And then you're able to make diagnosis, you may have some unexpected findings and then you make a new tentative diagnosis before you go on in that cycle. By the time you have uh made a goal oriented uh examination, you also be able to make appropriate inference that we direct the direction of investigation, laboratory investigation to uh refute differential diagnosis and to confirm the actual diagnosis. And once you have confirmed diagnosis, you'll be able to make current treatment. Oh physical examination. One of the things we have to bear in mind is that we have to be flexible. It's not necessarily that what you would do as uh a doctor is to examine in the order that in the predetermined order as it is in say Hutchinsons or uh no, it doesn't work that way with Children. We have to be flexible to what the child we allow at that time. And then uh the physical examination has to be designed to be convenient for the child. We, we tend to defer those things that will be painful for the child to later on when the child have been comfortable with us. And then we tailor the uh examination to the child. It's not that you want to examine every aspect at one go, but you want to do the essentials for the child so that the child will cooperate and then you'll be able to make appropriate influence. And again, a lot of times the caregiver, usually the mother should be around and within the child's field of vision. In fact, uh better still the child could be seated on the mother's laps that way the child is in a comfort zone and then you examine and usually with warm hands and instruments so that your hands do not become uncomfortable or your stethoscope do not become uncomfortable for the child. So investigation is not, uh uh it, it's not a time for us to now do routine investigations for Children. Rather what we do in terms of investigation is as required, is as required and for Children, uh, it's not right for us to be using the same specimen uh collection or even laboratory methods for their blood tests. For instance, uh for instance, you have a child, you want to do a full blood count or complete blood count. Uh electrolytes, urea and creatinine. You want to do such test for the vain bottle that collect specimen for adults generally will require uh about five meals for blood to be adequate or at the very least three meals. Otherwise, uh the sample will be too little for the anticoagulants that has been prepared in the respective bottles. Rather there are special bottles for Children such that you'll be able to collect uh adequate sample, which is not too much for the child. Because the child's blood volume is uh for a unit, 80 mill per, for a 10 units, 80 mills per kilogram body weight and as the child uh grows on and on, it becomes 70 mills per kilogram body weight like that of an adult by the time they become uh almost adult. So we need to use micro methods rather than uh the one that we use macro methods for such that if there are point of care testing device such as I start, it's better to use such rather than uh using those uh those uh techniques of blood testing that would require larger volumes. Then again, for imaging, uh imaging should be done as fast as possible and uh they should minimize radiation exposure to the child and the child should have nearby to obtain their cooperation. However, you would all agree with me that there is no single imaging modality which fills all these criteria. For instance, uh the computed tomographic scan is quite fast, but it has a lot of ionizing radiation exposure and it has about one in 1000 lifetime risk for uh inducing cancer. Whereas magnetic resonance imaging takes a longer time to obtain with no uh radiation. However, it requires that a child remain still during this period, which is almost an impossible uh requirement. So, uh as a result, Children going for MRI would require a sedation or even uh anesthesia to some extent, uh radioisotopes can use minimal dose of radio radioisotopes. And uh they are rapidly eliminated by the kidney or eliminated by a physis. In addition, they also have a short time to the time when they actually decay within the body. So, uh uh by and large, what we have to do in um getting investigation for Children is that we have to consider the risk against the benefits of the use of advanced imaging or other things where you need and where it will be possible. You use uh simple modalities provided they will give you the appropriate diagnosis. Uh Those are just some key guidelines. So we will just quickly take a look at some issues, especially with respect to radiologic investigations that is ra radiation carcinogenic risk. Uh One of the problems with Children is the fact that the they are just beginning their life. So technically speaking, you will consider the carcinogenic risk of uh a CT scan more for a five month old child than you would for a 50 year old man, because the 50 year old man in a place where the um life expectancy is say 65 the man has like 15 years and uh there is a long living the period carcinogenesis. Therefore, you tend to want to order a CT scan with caution with Children. In addition, Children have organs. That's uh all their cells are, most of their cells are dividing at this age. In fact, a lot of organs are still developing. So because they have a large percentage of cells that are still dividing, one would want to be careful in exposing them to uh carcino uh or radiation. Another thing is that their immature organs are more sensitive. So these all will make us look at uh exposing them to the risk of uh carcinogenesis. We will think about it twice before we go ahead and expose them to act scan. However, if there is no choice, 1 may have to go ahead and do act scan. Uh In addition, uh there is also the risk or the requirement for sedation and general anesthesia. And this is uh required in examination that requires two patients. Again, there are some patients that generally non cooperative Children may be uncooperative, especially as they are in a strange environment. They are not used to the environment. Uh I'm sure a radiology suit can be quite intimidating even for the adult not to talk of a uh an infant or even a toddler even be more disruptive in such an environment. Again, some procedures are quite uncomfortable. You can imagine a child needing an enema in the process. So these are all things that indicate sedation. You may have to sedate a child while giving them, uh, some of these, uh agents so that your test will be more holistic. So you may need to sedate them. Again, one of the things to consider is that for units who are prone to apnea after sedation, they are prone to developing apnea both during and then, then after sedation, they can now get uh they can become apneic. So part of the things that uh a radiologist that will require is that I will have adequate monitoring equipment, they will have capacity to bag mask uh such patients and they should also have capacity to intubate and then they should have a trained nurse within the suit and admitting privileges in less than five minute distance from where the radiologist suit is. So that if a child requires uh continuous ventilation, they will be able to admit as appropriate in the appropriate uh hospital. Another thing to consider includes the contrast studies and uh for Children that are, that requires contrast, especially uh something like beer milk, uh that would require oral contrast. The general trend is rather than using ion what would prefer to use uh water soluble contrast which uh if aspirated uh cause minimal damage compared to very what will cost uh the preference is that you use, you will use uh water soluble oral contrast. Again, some Children will fail to take this and therefore, you can use a fine ball feeding tube, pass it either through the orogastric or the nasogastric routes. And then uh instill as much as required into the stomach directly. And then you cannot obtain your images for IV contrast. Children will generally require a very good uh intravenous access so that uh with as little discomfort as possible. And then occasionally some of them will require an enema for their investigation. Uh These are just some of the radioisotope scans that are required in Children, uh especially in Children with ran out of dioxin acid or DMS E scan and then make up to acetyl Triglycerin, that's MA three scan. These are all uh renaud specific and they are good for renaud scanning. That is the DMS E and the MA three for differential renal function. One can check the, this may be indicated especially in Children with uh with the pelviureteric junction obstruction or any obstructive lesion within the uh renal tract. It will tell the relative contribution of the kidneys, each of the kidneys to the uh renal function. And then it will also tell uh where the obstruction is. Another thing is uh the uh Hida scan, which is for liver pathology, especially for Children with uh something like uh biliary atresia. So, what are the principles of the management that is principle of treatment. So number one is that attention to details is very important in Children more than in adults. And uh when we are talking about attention to details, we talk about the need to identify problems, even problems that the patient never mentioned. So once we have identified this problem, we need to itemize each of those problem so that we make sure that all these uh problems are addressed when from leading a treatment plan. And then there are some special needs in different age groups such as uh units. The fact that they, they are very prone to hypoglycemia. So they need uh to be fed one way or the other, either via the intravenous route. They need to be kept warm since they have immature Genis uh in them and they need to be infection free. We need to keep them in an environment that is like a bubble that prevents them from getting infected. In addition to this, there are such care that we need to take such as uh hand wash between units so that we don't transfer uh infection from one unit to the other. Uh We need to make sure uh people that are sick do not get near unit as these units still have developing immunity. They are still yet to be exposed to a lot of the pathogens and now exposing them to a large dose of this pathogen. Suddenly before they are, they've had time to acquire uh immunoglobulins passively from their mothers. One will need to be careful about that. So wearing face mask is not a bad idea when around unit and then we also need to make sure units are well perfused. The meaning is that a unit should ideally be pink. This will tell us that a unit is well perfused. Then another uh thing to take care of is the judicial attention to food and electrolyte balance. Uh This is a and uh we need to assess their hydration status once we have done that adequately and determine if a child is in shock or not. Uh student have um and a higher adaptation. But after the adaptation is uh exhausted, they crash quickly, unlike in adults who have lesser adaptation. But what they have is that they can actually withstand uh for free balance for a bit longer time. So we need to put uh good attention to that and look at the hydration status, looking at the PCA mucosa, how well it is and then even the skin to go, we need to pay close attention to it. And then Children that need resuscitation, fluid repletion and electrolyte repletion. We need to put them back into balance, but more importantly, food first. And then after the assessment, we can now pay more attention to electrolyte balance. Now, generally speaking, Children require more speciality care, especially uh when walking in terms of unit, uh the unit will require care not just of the pediatric surgeon, but also of the neonatologist and in some other periods uh that of a nutritionist and uh we may need in some other cases, some other Children, the care of an oncologist, depending on the challenges the child has. Uh one other thing to uh pay attention to is the dosing drug dosing, uh which is dependent on the weight of the child. Uh We need uh to pay close attention to this. We need to weigh the child before resuscitation and after resuscitation because after resus, you will now get the actual weight of the child by the time the child is uh well balanced, which can be uh made based on their urine outputs. Once you can say, oh the child is making adequate urine, then when the child at that time will be able to tell us how much the child is. Then again, another problem that can arise is that 1 may be over aggressive in a free balance and then you will now overload a child with food. The weight will also warn us of these on time, especially if there are other symptoms. Now, once you see those other symptoms, uh symptoms such as rails and creations in the chest, one would take a quick attention and then uh go on to uh resuscitate as appropriate to reduce their to restrict food and then if necessary, give diuretics. So the patient will also need to be warned, especially for infants and toddlers from units to those that are even up to five. The there is benefit from intraoperative work, especially to control their immediate environment and to reduce uh what they have to expend in terms of uh energy to keep themselves warm. Uh Generally speaking, general anesthesia is required expe except in Children that are older and for procedures that are amenable to regional technique. Now, setting attention has to be paid when talking about uh general anesthesia. Uh Children, the anesthesia in Children is generally different from that in adults. For instance, they have short neck, their uh larynx is more anteriorly placed and therefore, uh IPA extension as is done, went into beating an adult is actually uh going to give us a closed airway rather than an open airway. So uh we need to pay attention to this. In addition, uh a lot of things in the child is more rate dependent such as their respiration, the respiratory, uh the the to maintain the oxygen saturation is more dependent on rate of respiration that is uh rather than on the tidal volume. That is the rate at which they breathe is faster because they have smaller uh titer volume and lung capacities. Uh And then uh for the cardiac output is more rate dependent rather than on the stroke volume, is more dependent on the pulse rate or the heart rate rather than on the stroke volume. But as Children grow older, uh they come to be uh to more adult levels. So that by the time they have grown beyond five years of age, the rate of their hearts and also of their rest are tending towards adults that of adults. And one other important thing is in about uh the consent for Children uh when Children are older, especially for Children that are up to seven, some would say for some, they will say once they are up to 13 years of age and then there is also a wide range in between. Uh Children need to be counseled, they need to be heard even though they may not be at the end of, at the end of the day one that will make the decision. But what Children need is to hear, to have the opportunity to hear what procedure is going to be done to them. You need to co include them in counseling. You need to let them know that this is what they are about to undergo. And uh if possible, one would need their assent for surgery, especially as they reach an age like uh seven to that 13 years of age, their assent is uh needed as depending on where, which environment you find yourself in. Now, uh One final thing that I would like to talk about is on the transition of care. Of course, we said uh for adolescents, they are almost adults and uh the adolescent period is a period whereby a child transit from uh childhood into adulthood. This is gradual. It's spans a long time uh by the standard, it's from uh about 10 years of age to about 18 years of age before they attain that uh adults abolition. So at this period, one needs to find time to transit their care from uh pediatric surgery to adult surgeons. And uh it is defined as a purposeful planned movement for adolescents and young adults with chronic medical conditions from a child center to an adult oriented health system. So these are all things that uh one has to take into cognizance, for instance, a child that was managed for. Oh, sorry about the background noise. Just give me a second. Yeah, I in a room that is close to a large corridor. Sorry about that. So uh they will be transiting from uh adolescents to young adults. And for instance, in a patient that has uh HIRS disease, uh hash's disease ideally should have a lifelong uh lifelong follow up. And when you are following up such a child, one needs to bear in mind the fact that uh for a child with hash brong disease, they may develop uh hash associated enterocolitis at any time, especially if there are subtle changes that they didn't notice at the time when this thing starts to develop and they come to accept it as the norm. So for this reason, means continue to manage, for instance, also uh for patients with uh mild rotation that has had last procedure. The relative location of uh their intestines are different compared to the regular adult. So these are all things that indicate transition of care. And uh what is done is that usually we overlap here between the pediatric and adult surgeons. For instance, by the time a child is coming into a point where they become an a um adolescent, by the time they are becoming an ad adolescent uh say up to 16 years, one should be making pointed efforts especially in a place where the uh standard for pediatric care starts uh ends at 17 years. So one would start at least two years before they become adults. One would start by introducing them to adult surgeons. So the first way is to do a detailed case summary highlighting uh the initial challenge for which the child was managed, then what was done for the child and the child's current state. In addition, one would also identify any residual problems that the child may have. For instance, for someone that had hash sprung uh that had genal pull through or whatever kind of pull through for hash's disease. Such a child would require a summary highlighting what is remaining. For instance, if they have uh they still have some fecal accidents that we need to manage by B management. We need to highlight these things and then have such a child to uh be visiting the adult clinic, maybe visit the uh pediatric clinic uh this week and then the following week or the next visit will be to the adult surgeon. And this can be done over a three month period depending on how frequent the uh visit to the pediatric surgery clinic is. And then one would need uh to open a door of consultation to the child or to the adolescent or the young adult depending on who during the first year until the child is fully adapted to the care. So these are some of the things that are very germane in the care of Children. And I will say that one of the things about pediatric surgery, that is the fact that it is quite rewarding in that care of uh resuscitation of Children. Uh all uh care of Children, these are to whatever care they've gotten and uh following the care, they may adapt to such an extent that it would be as do they never had the challenge to start with. So, in conclusion, while Children uh constitute the basic template from which uh adults are produced, they are not mi miniaturized versions of adult, that vision requires careful assessment of our findings on the background of G 5 g conclusion and then we'll be able to, yeah, it back out. Thank you very much for listening. Uh I have here some resources that uh you may find uh quiet enlightening. Um Some of them are my sources for this uh lecture. Thank you. Very much, Mister ga for listening. Thank you very much, sir. Um, that was quite an enlightening um, session. Can, can you hear me? Yes, I can. Ok. Yeah. Um, so again, thank you so much, thank you for, um, for coming today to teach us this topic. I mean, it was, I know it's a broad topic but, um, you really, really, really touched on all the important things. I mean, I couldn't stop writing and, um, just trying to catch most of the important things. Uh, and thankfully, uh, would that be catch up content on the websites? I mean, that everyone can always access at any time. Um, so at this point, um, I don't know if anyone has any questions or comments. Um, so you can, uh, leave that in the chat box if you have any questions, please. Um, so we can address the questions and then, um, um, call it a day. So wait, uh, to see if anyone has questions and comments. Um, so, I mean, mine, I think is more of a personal question. Um, so, so, I mean, in your years of, um, doing pediatric surgery, what do you think? I mean, I mean, what would you say personally, uh, some of the major, um, um, back to your major challenge in pediatric surgery training, you could just explain that sort of the, and what you would also advise to. Well, pediatric surgery is one of the most rewarding, uh, surgical subspecialty that I can say actually, however, it's not without its challenges, especially in a third world country. One we believe in, I believe you all agree with me that Nigeria is a third world country. We are still battling with many things, for instance, uh diseases do not know of um third world or first world or second world for that matter if there is any such definition. But uh part of the challenges that we face here are things that are this, the environment is not friendly to Children at all. For instance, I mentioned about blood blood tests, um laboratories will still not accept samples that are not sufficient by, by their methods. And with the volume of Children that the that we take you out of in all specialties, I believe that micromethod should be made available, readily available to Children. So that's for one. Again, there are so many other things, for instance, uh operating on units. And in fact, that's uh perhaps the most heartbreaking of all you spend so much time. But because you cannot give adequate postoperative care to the unit, uh in unit will suffer needlessly from pain because you cannot give opioids because your patient cannot be placed on elective ventilation over the 1st 48 hours, 48 to 72 hours after surgery. Because ideally such patients should have elective ventilation after surgery. So these are some of the major challenges that you have. And again, uh the fact that Children are made to compete with adults for surgical care. The the space are limited, you still have to operate Children in the same suits or using the same stuff that you use for adults. This makes uh pediatric surgery quite frustrating. Ideally, newly should not be operated at the time when monitoring is pass. So all these things are things that mix uh pediatric surgery frustrating in an environment such as our, these are some of the things that make it frustrating. But by and large, we still have enough games whereby you get to have Children. You can do some stop gap surgeries. Uh for instance, Children with esophageal atresia, some have decided to stage the surgery such that they can replace the esophagus outright rather than using the native esophagus. But the child would have benefited uh once and for all from a primary esophagoesophagostomy rather than a stage surgery, which uh there are very few people in Nigeria that do that do that. So I think uh what we need is a situation whereby uh our policymakers uh pay puts their money where the amount is that is they make available funds for health of Children. It's not a, it's not a big deal. If uh child health is made to be free, it is not a big deal if there are special hospitals for Children, just like we have in uh Paris and uh in the UK, the Great Hormon, uh the Great Hormon Hospital for sick Children. These are all things that are doable here. And I believe that with time, uh maybe when a lot of private people, private individuals starts thinking about uh collaboration, especially maybe among physicians and surgeons, they can now collaborate and make available as much as possible. Uh Such facilities that can entertain Children, only Children that uh they can have exclusive care and then we can try out Children with Children. No Children with adults. Thank you very much. Uh I've been able to um Yes, sir. Yes, I think um that answered my question. Um Thank you so much, sir. I don't think we have any other um questions. Um Again, it was quite an informative session. Um Thank you. Thank you so much. Uh We also look forward to inviting you in the future. I mean, for more sessions. Um So thank you so much, sir. Um I guess we'll come to the end of the session today. Thank you, Doctor Xing. Thank you. Thank you very much. Thank you for having me and have a great uh remainder of the day. Yes, everyone. You too. Thank you. All right. Thank you, everyone. Uh We'll be ending this session now. Thank you. Uh The culture of contents uh will be made at daily. Um So we can always come back um to um just to watch the session again. Uh Thank you everyone. Um See you next.