Computer generated transcript

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

Okay. All right, everyone can hear me now. I think you should hear me now. Please reply in the chat box if you can hear me? Okay? Can anyone hear me know? Yeah. Mhm. Yeah. Um Hello. Can anyone hear me now? I think I have some trouble with my audio. Uh I need to be multiple toe. Okay. Thank God. Yes, you can hear me now. Um Good evening everyone. Um Just a minute. Just give me please. Okay. Um Good evening everyone. Um Thank you for joining us today. Um I was saying earlier, I didn't know anyone couldn't hear me. Um So the longer waited session is here. Thank you all for joining and I'm the presenter would take over the stage um shortly, but just to introduce him briefly. Um So I presented today is um doctor, she Army is a senior register and the Department of pediatric Surgery in um University of Ilorin Teaching Hospital. And um he has kindly 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 type in your comments or questions as this session goes on. Uh We'll take all questions and comments at the end of this session. Uh So thank you so much. Uh everyone and if you uh any issues with the audio or the video, please just start it in the chat box so that we can make corrections on time. Thank you. Um Okay. So let's see. So, uh okay. Um I don't know if our presenter can hear me. Um uh Just a minute. Yeah, I think you may be having some issues with a network, don't know. Yeah. No, this, yeah. Um please bear with us everyone. Um Our presenter seems to be having some issues with the next work. Um So it's trying to join the um session, it'll be back shortly. Okay? I think it's back. Let's see. Okay. Um Can you see any please if someone can just reply in the chat box? Okay. Uh What you're trying to get the presenter um in where she'll be joining us shortly? Uh Got some issues with his network. Okay. Someone. Can you? Thank you. Thank you. Go Chico. Okay. Yes. Yeah. Um We can use a muted, yeah, muted now. Okay. All right. Good afternoon, everyone. Good accident. Um So I got to interrupt. I'll just turn off my video and I'm Audie, it doesn't interrupt yet. Um um You sir. Thank you so much. Thank you again for joining us at, um, briefly introduce you to everyone, but I guess you were not online then. Um, but then I'll just give it to you to introduce yourself and then study session. Thank you again for agreeing to, for teaching us today. Thank you. Okay. I'm going off. Okay. Well, okay. Um, good afternoon everyone. Uh, my name is Ola In Cash for me. I'm the senior registrar with pediatric. Sorry. Can you hear me? Yeah. Yes, we can hear you so we can. So my name is Lola in Cash for me, the senior registrars with pediatric surgery at you. I th Lauren. And, uh, I've been asked to discuss with you, uh, the principles of pediatric surgery K and, uh, it's something that is very important for those that are interested in any specialty that or pre on Children that takes care of the car needs of Children. Um, I'm trying to see how to share my slide. Sorry, I've not used this. Um, um, it's fine. Let's take your time. Have you seen any ocean for thoughts? Not yet? Okay. Um, okay. I've seen an option. Okay. Uh huh. Yeah. Well, uh huh. Sorry about that. I think I would share the screening state since I've already. Okay. So, hello. Can you see the slides? Hello? Is the slide visible? And is it's transitioning? Yes. Yes, it's visible. We're not transitioning. I can only see the first, like the first night. All right. So it doesn't give me a minute. Okay. So now we can say this like, yes, you won't be able to sleep yet. I will. All right. Um, okay. All right. Can you see it now? Um, not yet. No. Slight. No. Yes. Yes, I can see the outline. Yes. It's transitioning now we can see. Oh, good. So I'll be talking about principle of pediatric surgery care and these are just the outline will be speaking on, um, in pediatrics, older, 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 kid uh about pediatric surgery tends to give general k uh for those requiring settings, uh specific surgeries. Uh One of the things that is peculiar about pediatric surgery is the fact that uh consist of wide array of patient's uh including uh someone as small as a preterm unit and two Children that are almost adult as old as 17. And uh this uh have varying physiology and Anna told me and uh therefore no particular thing fits any one of them. Uh for instants among infants, infants, uh transitioning, basically, when you talk about the new unit unit are still transitioning from intra uterine 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 there, transitionary, they're transitioning in terms of their circulatory 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's no particular formula that fits them all. Uh It's one of the things that one is to uh take into cognizance. Then again, you have a wide category, wider categories of patient uh for instances in terms of gender, uh we speak about Children uh being male, female or even uh D S D, which are Children whose gender cannot be uh determined at the time of bad. And they have a 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 division is getting more blood out with uh the transgender and other categories of people. Again, in terms of age, there are um areas of uh we have infants, toddlers, those that are preschool age, those that are school age and adult decent. These are all varying divisions. But again, if you look at uh infants for instants among infants, there are those that are still 0 to 28 days, which are units uh unit means newborn. But some people have gone for that to say uh not necessarily that 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 new units and newborns 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, the further they are from fetal life. These two here uh fetuses, but here you have a newborn, the body older they are in terms of uh age, certain changes or core, in terms of the head, the size of the head, relative to the body, they have a very large relative to the remainder, many parts of their body, uh the abdomen as well, the abdomen tend to be rectangular uh lying on the long side. Whereas uh for those that are uh beyond school, beyond the preschool age, uh they have a rectangular abdomen which is sitting on the short side of the abdomen just like what would uh obtaining 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 surgery uh interest as a specialty is that is that in Paris where there is establishment of the hospital for sick Children in Paris, that's 18 02 and by 18 52 something similar was in UK, that is the Great Hormone Street Hospital for six. Um and at the beginning, uh there was a tendency uh for it to the only Children with medical needs that are taking care of at this hospital. However, Charles dickens', the famous auto is one of those known to are supported. Uh the care of any Children, all Children rather than only do with medical illnesses being taken care of in such hospital. And uh some people have published the scope of surgery in the, the Great hormone Hospital for sick Children in the medical, in the British medical journal. That in uh and then uh t homes also did something similar in 18 68 the first established pediatric surgeon past practice uh that was exclusive for pediatric study was in 1919 by Herbert Co. However, the first training program was established by William Ladd uh American surgeon uh in the children's hospital at Boston. It was the first uh surgeon uh surgeon in chief at that children's hospital. Uh He was a general surgeon before he dedicated his practice too pediatric surgery. Uh Likewise, Robert Gross, who was uh his first training, who had a background in pathology, uh worked on uh patent doctors, arteriosus ligation based on his observation uh infective endocarditis, the specimen that had been taken. And this way, uh this was this form the basis for him proposing how and the importance of like getting the patent doctors that he uses. He also published the first uh last work that is the abdominal surgery of infants and Children. In 1941 over Swinson, we all know, describe the pathology of Hirschprung's disease and also provide a solution in the operation that is named after him. And it was a Canadian Gin a bit more who petitioned the American Board of Surgery. Uh so that pediatric surgeons uh can all receive special against pediatric surgery. So South as the basis for the question, idiot Christians in America. Pediatric surgery has many branches, but the parts that will be looking at for those that are specialized in pediatric surgical care. Uh that is uh you know, it'll surgery, general, pediatric surgery, pediatric urology and gynecology, pediatric could erectile surgery, hepatobiliary surgery, oncology and uh of course fetal surgery, which is still an imagine uh aspect of pediatric surgery. All these uh 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 special list, pediatric surgeons. And in some places, pediatric surgeons have been known to do some pediatric neurosurgery. Similarly, oughta peed IX, which is even a tougher uh specialization to master's. 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 will 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 Children, 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 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. Uh We check uh immunization and how they are growing and developing. We also want to look at uh antenatal perinatal and post partum 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 instances in a 12 year old, we say acute appendicitis, these uh much emphasis will not be on the antenatal history, perinatal and postpartum before in unit and infant. And indeed, even uh a lot of us uh things that we need to look at well date back into their uh perinatal event. So in other words, what we do is a compressive assessment. So that will make a complete diagnosis that we ensure holistic management. So the pediatric surgeon uh not only takes uh routine history s 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 we're not correlated with anything but just miss some important clues uh in the proof and make a diagnosis rich faulty. However, what we need to do is to marry the presenting complaint 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 a 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 no sis. 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 we make us illogical strategist in making 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 history. Are we supposed to take the new uh developed the immunization issue as well? And then we'll also want to relate the symptoms at this Children, uh relate such as a child that has a stone in developing vomiting, uh about the time of bucks, such a sweetheart. Uh something that is congenital as the cause of his vomiting. Whereas in an infant that is preventing presenting with billows, 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 antecedent before we'll be thinking of something like intussusception. So these uh symptoms are usually timed with the milestones the patient as attained. So, in this one, when we take history, the first thing we have to do is to gain appropriate rapport with a child. Once we have introduced ourselves, will we gain rapport with the child? And one thing about scare of Children is that you need Children to really be friends with you before you be able to uh attain their trust. And then you also get history at least the presenting complaint as well as the visual fuse from those you make a tentative diagnosis, which will give you an idea of what's 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'll be able to make a 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 made a goal oriented uh examination, you also be able to make appropriate inference that we direct the direction of investigation, laboratory investigation to refute differential diagnosis and to confirm the actual diagnosis. And once you have confirmed diagnosis, you'll be able to make current treatment uh physical examination. One of the things we have to be in mind is that we have to be flexible. It's not necessarily that what you would do as uh doctor is to examine in the other that in the predetermined other as it is in ST Hutchinson's or uh Hamilton Billy. No, it doesn't work that way with Children. We have to be flexible toward the child we allow at that time and then uh the physical examination has to be designed to be convenient for the child. 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 Wango, 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 inference. And again, a lot of times the caregiver, usually the mother should be around and within the child's feel the vision. In fact 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 status cope do not become uncomfortable for the child. So investigation is not, uh 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 instances, you have a child, you want to do a full blood count or complete blood count, uh electrolytes area and creatinine. You want to do such test for the vac you tina bottle that collect specimen for adults generally will require uh about five meals for blood to be adequate or at the very least meals. Otherwise, uh the sample will be too little for the antiqua glands 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 for a new unit. 80 meals per uh for a time, noon it 80 meals per kilogram bodyweight and as the child grows on and on, it becomes 70 meals per kilogram bodyweight like that of an adult by the time they become almost adults. So we need to use micro methods rather than uh the one that we use macro methods for such that if there are a point of care testing device such as I start, it's better to use such rather than 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 really a fit nearby to obtain their cooperation. However, you would all agree with me that there is no single imaging modality which feels all this criteria for instances. Uh The computer tomographic scan is quite fast but it has a lot of uniting 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 reddish in. 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, radioisotopes can use minimal dose of radio radioisotopes and they are rapidly eliminated by the kidney or eliminated by athesis. In addition, they also have a short time to the time when they actually decay within the body. So, uh by and and large, what we have to do in uh getting investigation for Children is that we have to consider the risk against the benefit of the use of advanced imaging needs while other things where you need, uh and where it will be possible, you use simpler modalities provided they will give you the appropriate diagnosis. Uh Those are just some key guidelines. So we'll just quickly take a look at some issues especially with respect to radiologic investigations. That is radio radiation castle eugenic 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 there is a long leaving the period Cassie New Genesis. Therefore, you tend to want to order a CT scan with caution with Children. In addition, Children have organs that uh all their cells, uh 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 radiation. Another thing is that they are immature organs are more reduced sensitive. So these all will make us look at uh exposing them to the risk of uh Massino genesis. We'll think about it twice before we go ahead and expose them to a city scan. However, if there is no choice, 1 may have to go ahead and do a CT scan. Uh In addition, uh there's also the risk or the requirement for sedition and general anesthesia and this is uh required in examination that requires T O patient's. Again, there are some patient's uh generally non cooperative Children may be uncooperative, especially as they are in a strange environment. They're not used to the environment. Uh I'm sure a radiology suit can be quite intimidating even for the adult not to talk of uh an infant or even a toddler who will even be more disruptive in social 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 sedition. 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 say this them again. One of the things to consider is that for new needs who are prone to apnea after sedation, they are prone to developing apnea boots during and then, then after a sedition, they can now get uh they can become ethnic. So part of the things that a radiologist to that we require is that will have adequate monitoring equipment, they will have capacity to bag mask, uh such patient's and they should also have capacity to intubate and then they should have a trained nodes 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 contrasts, especially uh something like barium meal uh that would require or are contrast. The general trend is rather than using barium. One would prefer to use uh water soluble contrast which uh if aspirated uh cause minimal damage compared to bill work billion will cause. Uh the preference is that you use, you will use uh water soluble or are contrast. Again, some Children will fail to take this and therefore, you can use a fine ball fitting to pass it either through the or gastric or the naso gastric roots. 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 uh up to scrutiny like acid or D M S A scan. Uh and then make up to estatal Triglycerin that's mark three scan. Uh These are all uh renal specific and they are good for renal scan in that is the D M S C and the mark three for differential renal function. One can check the, this may be indicated especially in Children with, with pelvi rhetoric 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 if you also tell uh where the obstruction is. Another thing is the Haida scan, which is for liver pathology, especially for Children with something like uh biliary atresia. So what are the principles of the management that is principal 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 problems so that we make sure that all these uh problems are addressed when from letting a treatment plan. And then there are some special needs in different groups such as uh unit. The fact that they are very prone to hypoglycemia. So they need uh to be fed one way or the other, either valve, the intravenous routes, they need to be kept warm since they have immature family genesis uh in them and they need to be infection free. We need to keep them in an environment that is like a bubble that prevent them from getting infected. In addition to this, there are such care that we need to take such as hand wash between units so that we don't transfer uh infection from one unit to the other. Uh We need to make sure 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 new unit should ideally be pink. This will tell us that in unit is well perfused. Then another thing to take care of is the judiciales attention to freed an electrode light balance. Uh This is a and uh we need to assess their hydration status once we have done that adequately and determined if a child is in shock or not as Children have um and a higher adaptation. But after the ad adaptation is uh exhausted, the crash quickly, unlike in adults who have lesser adaptation. But what they have is that they can actually withstand uh 4 ft balance for a, a bit longer time. So we need to put uh good attention to that and look at the hydration status, looking at the Polka mucosa, how well it is and then even their skin togo, we need to take close attention to it. And then Children that need resuscitation, fluid repletion and electrolytes 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 multi specially care, especially uh we're talking in terms of new unit. Uh the new unit will require care not just of the pediatric surgeon, but also of the neonatologist and in some other periods uh that of the nutritionists. 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 deducing 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 wait the child before association and after resuscitation because after resuscitating, you will now get the actual weight of the child by 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, we'll be able to tell us how much the child is. Then again, another problem that can arise is that one maybe over aggressive in free balance and then you'll 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, symptoms such as rails and prep titian's 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 direct IX. So the patient will also need to be warned, especially for infants and toddlers from new needs to those that are even up to five. Uh the there is benefit from intra pretty, especially to control their immediate environment and to reduce uh what they have to expand in terms of uh energy to keep themselves warm. Uh Generally speaking, general anesthesia is required expect except in Children that are older and for procedures that our main able to regional technique. Now, certain attention has to be paid when talking about general anesthesia. Uh Children, the anesthesia in Children is generally different from that in adult For instants, they have short neck, they're uh lines is more anteriorly pleased. And therefore, uh ipad extension as is done when intubating, an adult is actually uh going to give us uh closed airway rather than an open airway. So I wanted 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 to maintain the oxygen saturation is more dependent on rate of respiration. That is uh rather than on the titer volume. That is the rate at which the breathe is faster because they have smaller uh titer volume and long capacities. Uh And then uh for their uh cardiac output is more it dependent rather than on the stroke volume, is more dependent on the post rate or the heart rate rather than on the stroke volume. But as Children grew older, uh they come to be uh two more adult levels. So that by the time they have grown beyond five years of age the rates of their heart and also of their respiration attending towards adults that of adults. And one other important thing is in about 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's also a wide range in between. Uh Children need to be canceled, 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 here to have the opportunity to hear what procedure is going to be done to them. You need to, can 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 ass ent for surgery, especially as the rich and age like uh seven to uh that 13 years of age, their accent is uh needed as depending on where, which environment you find yourself in. Now, one final thing that I would like to talk about is on the transition of K. Of course, we said for adolescents, they are almost adults and uh the adolescent period is a period where by a child transit from uh childhood into adulthood. This is gradual. It spans a long time, uh by wh you standard, it's from uh about 10 years of age to about 18 years of age before they think 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 clinical um medical conditions from a child center to an adult oriented health system. So these are all things that one has to take into cognizance for instances, a child that was managed for. Oh, sorry about the background. No, it's just give me a second. Yeah, I'm in a room that is close to a large corridor. Sorry about that. So uh they will be transiting from uh adolescents, too young adults and for instances in a patient that has Hirschprung's disease, uh hash browns disease ideally should have a lifelong money, lifelong follow up. And when you are following up such a child, one needs to be in mind. The fact that uh for a child with hash browns disease, they may develop has sprung associated enterocolitis. These 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, own needs continue to manage. For instance, also for patient's with my rotation that has had large 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 what is done is that usually we have a lab here between the pediatric and adult surgeons for instances, by the time a child is coming into a point where they become and add uh adolescent, by the time they are becoming uh 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 strong uh that had translator pulled through or whatever kind of pull through for Hirschprung's disease, such a child will require a summary, highlighting what is remaining for instances if they have uh they still have some fecal accidents that we need to manage by bo management. We need to highlight these things and then have such a child to uh be visiting the adults clinic, maybe visit the 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 three months 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 jermaine in the care of Children. And I will see that's one of the things about pediatric surgery. That is the fact that it is quite rewarding in that care of resuscitation of Children, uh uh care of Children. Did you try it to whatever care they've gotten and uh following the K, 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 constitutes the basic temp it from which adults are produced, they are not miniaturized versions of dots. That region requires careful assessment of our findings on the background of jean five gene Krouge in. And then we'll be uh yeah, it backed out. Thank you very much for listening. I have here some resources that uh you may find quite enlightening. Um Some of them are my sources for this lecture. Thank you very much again. Uh Thank you very much. Uh That was quite an enlightening um position. Can, can you hear me? Yes, I can. Okay. Uh So again. Thank you so much. Thank you for, um, uh, for going to date to teach us topic. I mean, it was, I know it's a broad topic but 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 would have a catch up content on the website. I mean, that everyone can always access at any time. Um So at this point, I don't have 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 some call it a day so would wait to see if anyone ask questions and comments. Um So, I mean, my, I think it's more of a personal question. Um So, so I mean, in your years of doing pediatrics surgery, what do you think? I do? I mean, what would you say personally? Uh some of the major uh uh basically your medial challenge in pediatric century trading, you could just explain that. So, uh yeah, and what you would also advised to, okay. 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 like one we live in. I believe you all agree with me that Nigeria is a third world country. We are still battling with many things for instants, uh diseases do not know of um third world or first world or second or for that matter if there is any such definition. But part of the challenges that we face here, things that uh the environment is not friendly to Children at all. For instants, 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 care of in also specialties, I believe that micro methods should be made available, readily available to Children. So that's for one against. There are so many other things for instants uh operating on units. In fact, that's perhaps the most heartbreaking of all you, you spend so much time but because you cannot give adequate post operative care to the new needs, uh in unit will suffer needlessly from pain because you cannot give opioid because your patient cannot be placed on elective ventilation over the 1st 48 hours, 42 72 hours after surgery. Because ideally such patient 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 tia to space are limited, you still have to operate Children in the same suits or using the same stuff that you use for adults, this mix, uh pediatric surgeon quite frustrating, ideally noonish, you know, if you're protected at the time when monitoring is sparse. So all these things are things that mix uh pediatric surgery frustrating in an environment such as ours. These are some of the things that make it frustrating. But by and large, we still have enough gains whereby you get to have Children. You can do some stopgap service. Uh for instants, Children with esophageal atresia, some have decided to stage the surgery such that they can replace the sofa goes outright rather than using the native sofa goes. But the child would have benefited uh once and for all from a primary Isuf ago, the sofa goes to me rather than a stage surgery, which uh there are very few people in Nigeria that, that do that. So I think uh what we need is a situation whereby uh our policymakers pay, put their money where their mouth is that is the make available funds for health of Children. It's not a, it's not a big deal. If a child health is made to be free, it's not a video if there are special hospitals for Children, just like we have in Paris and uh in the UK, the great hormone, uh the great hormone 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 individual starts thinking about 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 act Children with Children, not Children with adults. Thank you very much. Uh Yes, yes. I think uh 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. Uh I guess we'll come to the end of this session today. Thank you, Doctor Shah me. Thank you. Thank you very much. Thank you for having me and have a great remainder of the day everyone. Thank you. All right. Thank you. Everyone will be ending this session now. Thank you. Uh The patch of contents uh would be me that the people uh so we can always come back to um just to watch the section again. Thank you, everyone. Um See you next.