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cool. I think we should be live now. Okay, Perfect. Hello, everyone. Welcome to the undergraduate surgical teaching series today. We're extremely fortunate. Mr Cameron Stewart here with us to deliver a presentation on pediatric surgery. Cameron is a registrar working in pediatric surgery at the Royal Hospital for Children and Young People in Edinburgh. He studied at the University of Edinburgh and subsequently completed F y and course surgical training in Edinburgh. Cameron is passionate about pediatric surgery and surgical training and is keen to encourage any medical students with an interest in surgery without further A do. I would like to invite Mr Mr Cameron to deliver his presentation. All right. Thanks, Lucas. Hi, everyone, Uh, looks saying my name is Cameron and one of the registrars working in pediatric surgery. It's it kids here. Um, and, uh, this is designed to give you a bit of a flavor for pediatric surgery. It's definitely not exhaustive. There's a whole lot to cover and pediatrics. One of the great things about pediatric surgery is it's so vast, and it's really general, um, including thoracic surgery, upper gi surgery, lower GI surgery, urology. Um, but what? I've tried to focus on here is not for budding pediatric surgeons. It's what I kind of expect a good g p to be able to know. And considering you get no postgraduate training and pediatric surgery at all, uh, it's, uh what I would hope that you remember some of by the time you, uh, graduate. So what we're going to cover is the common pediatric surgical emergencies that you might encounter eyebrows, a foundation doctor or working in an 80 department or even in general practice. Then I'll talk a little bit about the general surgery of childhood. Um and, um, that is particularly important to GPS because they'll be referring us in, um, lots of, uh, different, uh, Children who need various general surgical procedures of childhood. And then I'll probably stop there, uh, and give people who who who want to chance to leave before I actually start talking about the stuff that actually interests us as pediatric surgeons and the stuff that may wet your appetite for the, uh, specialty. Uh, but I'll, but I'm not going to be offended at all if you leave halfway through or have something to get to, because I mean all of this is really difficult to fit into an hour. I'll try and make it as interactive as possible. I wish I was doing this in person, but, uh, we'll make do with with what we can. The important thing to say is I'm not covering anything. I'm not covering everything. Uh, that I want to highlight this online module from the Royal College Pediatricians, Uh, and Children Health called spotting the sick child. Um, it is brilliant. I think every single doctor medical student looking after Children in any capacity should, uh, do this, um, online module. It's completely free. It takes a couple of hours and is is really good for both recognizing and treating acutely unwell Children. And it's a great introduction to it. So I highly highly recommend that so appendicitis should be covered in adult general surgery, and I don't have time to talk about it here. And despite it being quite a lot of our emergent workload, same with testicular torsion. It should be covered in neurology. I would have a lot to say about it, but I just don't have the scope within this hour, Uh, and also specific pediatric trauma and the differences between adults and Children, uh, in terms of dealing with trauma that will be covered later in your career when you eventually do ADLs and things, Um, And if it's relevant to you. But these are some of the very important things that I won't be covering today to focus on the really important things. Okay, so it's all going to be case based, and I've got a few questions dotted around throughout the presentation, which will hope they make it at least slightly more interactive. So we'll just crack on. And this is the first case. Okay, so this is a five week old boy. And as I'm going through all these cases, what I want you to really recognize is that having the age of the child is actually really, really useful when you're trying to figure out what's going on with them, because there are certain pathologies that affects some ages or are more likely at some ages and certain pathologies, which are less likely at some ages. So it's actually a really good idea to try and get familiar with how old, uh, these Children are when they present with these specific, uh, surgical conditions. So five week old boy. Non bilious vomiting and what we mean by non bilious vomiting is that it's not green. So five we called babies. They do very little apart from feed and, um, and they feed on milk so normally, when they're vomiting, uh, they have milky vomits or non bilious vomits. It's been going on for the last 89 days. Getting worse and worse and worse, has been totally well prior to this. So it was a normal baby. Normal baby check left hospital long time, um, and then has been getting since since the last eight days. The GPS been treating for reflux with PPI. But things are getting worse rather than better. Even with that looking at the child, they have cold peripheries. The capillary refill is five seconds. They look a bit dehydrated. Uh, there's no abdominal distention or tenderness, but there's maybe a little mass in the epigastrium, especially after the babies had to feed. So let me see if I can activate this. So this should hopefully pop up for you. Okay, so what's the most likely diagnosis here? So, gastroesophageal reflux really, really common in in babies malrotation volvulus. Well, maybe talk about a bit later. Pyloric stenosis. Well, maybe talk about a bit later. Meckel's diverticulitis again. Maybe talk about a little bit later. Okay, so let's see. Okay, good. Right. So from what I'm seeing, a few of you are thinking that this is still gastroesophageal reflux, that it's just for factory to the PPI and that you need to Nalgene eight as well or something. Um, some of you are thinking more rotation volvulus, and some of you are thinking pyloric stenosis. So this is a typical example of what a pyloric stenosis baby might, uh, might present. Like they're typically treated for gastroesophageal reflux. Cities were presumed gourd before, actually, it getting progressively worse and worse and worse before, uh, they come in as an emergency. So that's a typical situation to be in. Okay, um, so what is pyloric stenosis? So hypertrophic pyloric stenosis is a condition that affects, uh, infants. Typically, it affects infants between about three and six weeks of age, so they have a totally normal, um, time before that. And that's really important to recognize. One of the common misconceptions about pyloric stenosis is that it's present from birth. It's not. It's acquired And what happens is, as you can see on the picture on the left hand side of your screen, the pylorus of the stomach, which is that last area of the stomach before the Judean, um, the muscle of the Polaroids, for some reason that we really don't know the cause of hypertrophy. So the muscle gets thicker and thicker and thicker and thicker until the Lumen of the pylorus is completely obstructed. And you can see here on the right of your screen that this is a typical ultrasound picture showing pyloric stenosis. You can see the hypertrophied muscle with some, uh, measurements, so I won't go into the typical measurements for, uh, pyloric stenosis. But there are some specific measurements. Um, so, um, now I've chatted a little bit about Let me see if I can start the next one, uh, to start that. Is that working? Yeah. Okay, so, uh, so now you see that it's pyloric stenosis. Baby's been vomiting a lot. That's the key to answer in this question. And this is a typical exam questions or exam knowledge that they'll just want you to know and and this comes up in finals or and it comes up in your pediatrics block and things. Okay, So what is the most likely abnormality on the blood gas? Okay, okay. I'll give you a few more minutes or about 20 more seconds, maybe. Okay, so all of you have correctly identified that this is going to be a metabolic problem because the baby is vomiting and vomiting and vomiting, and that's what's causing the problem. And what do you lose when you when you vomit, you lose stomach acid. And what does if you're losing hpe lus ions? That makes you Alka lot ick. So it's a metabolic alkalosis iss. The other two bits of this are slightly more complicated. The hypochloremia, uh, sorry. I'll move in and show you that That's the right answer. Uh, the hypochloremia is because stomach acid is hydrochloric acid, so you're used losing the hide hydrogen ions as well as the chloride ions. So you become hypochlorite mc the hypokalemia. The potassium low potassium is actually due to in the kidney. The there's, uh, potassium hydrogen antiport to essentially if you just think of it as the body is so desperate to hang on to every single hydrogen ion that exchanges potassium in exchange for it sacrifices potassium in exchange for hydrogen ions. And that's why you get hypokalemic to so so the typical thing. And this is the typical exam answer is a hypokalemic hipaa chlorine Mick Metabolic alkalosis This so, as I said, it normally presents between three and six weeks of life. It's acquired non bilious Vomiting is what it presents with because we'll go onto the reason for it. Be non bilious, like later it's got a male predominance. Actually, it's firstborn males that are particularly affected. Don't ask me why. I don't think anybody knows. And, as I said, they get profoundly dehydrated and they get electrolyte disturbances as well. Uh, and that's because they just cannot feed and feed is how a baby hydrate. So they'll they'll. They may come in in extremists. So the important thing Sorry, I'll go back. The important thing about managing pyloric stenosis is not the fun stuff that I'm about talk about here. It's actually correcting this profound dehydration. So the thing that killed pyloric stenosis babies before operations came around that could fix it was the fact that they were profoundly dehydrated and that they were unable to be resuscitated. So the key to treating um, uh, Pyloric stenosis baby, is to make sure you get adequate IV access and that you're in essence, overhydrating the patient. And also, it's important that you put an N g tube down to monitor the losses up from the from the N G tube, and that's important for potentially replacing those losses as well. Okay, only once the blood gas has completely normalized and you're going to repeat the blood gas relatively regularly. Can you think about taking that baby to theater? Because we've shown that even if the baby's relatively resuscitated but their, um, their electrolytes aren't normal, it's still anesthetics are far more dangerous. You need to totally normalize potassium normalize chlolride normalize the hydrin islands before taking them to theater. And this is the operation, um, or the operations, uh, that you can do to help relieve this obstruction. What you can see here on your left is the laparoscopic technique and what what this instrument there is. It's, uh, it's a spreader. So there's a cut made in the muscle of the pylorus until you can see the bulging mucosa. And then the, uh, pyloric muscle is spread even further until the mucosa just bulges into the middle. Which is nicely doing this in this photo here and what's on the right of your screens. More conventional open approach, which is exactly the same thing. Uh, but via the open approach, which was more traditional. So the baby's left with very thin layer between the Lumen uh, and the peritoneal cavity. But remarkably leak into the peritoneal cavity or rupture of this is actually really uncommon. In fact, the baby can typically feed immediately after the procedure and go home the next day. And for context, this used to be a fatal condition before surgery was developed. So all of these pyloric stenosis babies used to universally die before surgery was developed in the last 60 or 70 years. And, um, these babies typically don't have any other associated, um, congenital abnormalities. So, actually, by doing this operation, you you give an individual, uh, average life expecting 75 80 years of completely normal life. Uh, and it's a really, really rewarding procedure to do. All right, so that's pyloric stenosis. Okay, so that's one of the more quizzed, uh, about pediatric surgical emergencies. Okay, this is the second case. So this is a slightly different infant. This is a 36 hour old baby who's had one green vomit but no other symptoms at all. And the fact that the vomit is green means that this is a bilious vomit. Okay, so on examination, baby looks happy and healthy. The observations are entirely normal. The baby checks entirely. Normally examine totally normally. Even the abdomen is totally soft. No distention whatsoever. Okay, so this is the next question. Let me see if I can activate it. Yeah, that looks like the right question. Okay, So what is the next most appropriate step? So a no further action. The baby looks well, and it doesn't need any exposure to radiation or or two surgeons. Be option B. Admit to the neonatal intensive care unit for antibiotics and observation. See immediate exploratory laparoscopy or a D upper GI contrast scan to try and elicit what's going on. Okay, I'll give you a couple more seconds. Just answer that. OK, Grant. So the majority of you are going for doing an upper GI contrast scan, and that's definitely what I would suggest in this situation. So, um, to answer that question. It's the main thing you need to know Is that green vomit in, uh, infant is absolutely not normal. The most likely thing that might be going on is actually neonatal sepsis. Babies get, uh, quite profound Alias when they get septic. And so that's actually the most common reason for Billy's vomiting. But there is a particular diagnosis which is demonstrated on this Upper GI contrast scan, which is a surgical emergency and needs excluded. Okay, so here what you can see is an upper GI contrast scan. And what that means is that there's, um, n G tube that's been, uh, inserted and that they've taken X rays after injecting some contrast into the stomach and then, uh, seen how it flows through the duty. Um, so as you can see, it enters the first part of duodenum, and then it kind of the caliber becomes thinner, and it kind of does this kind of spiral or a corkscrew shape and never comes over to the other side of the midline. It always it stays all on the right side of the midline. Um, that is not a normal contrast scan. What you expect is a nice C shape that crosses midline and then has an upward trajectory back up towards the stomach. So this is a condition called mall rotation volvulus. And this is, uh, rare, but really important condition to know about, uh and it's not really taught, Well, a medical school. And, um and this is why green velvet is a surgical emergency until proven otherwise. So what you can see on the right is, um, starting. Uh, sorry. Not on the right on the left of your screen. Patient's right on the left of your screen is, um uh, what the normal anatomy looks like. So normally, what happens in gut development is that the the gut completely eviscerates into the yolk sac. It then undergoes a 270 degree, um uh, counterclockwise rotation before then coming back into the abdomen and and sticking itself down in the right place. Okay, so what you see on the left is what is most is normal. Um, So, um, what you can see is that the small bowel is going from the duodenum in the, uh, on the upper left side, right down to the cecum on the right side. And that the origin of its Mesen tree is a straight line between those two places. Okay, What you see in the middle is what happens when when you have a mall rotation. So the So what's happened is these lads bands have stopped the cecum rotating. It's fulls 270 degrees to end up in the right lower quadrant, and it stops really close to duty. Um, and what that means is that the origin of the mesentery is really, really short. And it means that the whole thing like this arrow, this, uh, is showing can rotate on a pedicle and you can get a volvulus or a or a twist of your entire small bowel, which is an absolute disaster, because if you have a twist of your entire small bowel and it becomes a necrotic and dies, as you can see in this picture on the right hand side in the in when you have a marat ation with volvulus. Uh, if that all dies and you lose all of that small bowel, then it is, um it's devastating, and the child is either dependent on parenteral nutrition for life. Or, um, it's not or isn't compatible with a normal life at all. It's It's a really dangerous position to be in, and it's a time sensitive thing. So the point of surgery is to try and untwist this and take down those lads bands so that you're able to hopefully save the bowel, uh, and ensure it doesn't happen again. Um, so as you can see in this picture, this is an interruptive picture. This is what's happened here. So you you've had an entire mid gut volvulus, uh, because of this mall rotation problem. And this can happen at at any age, um, technically, but it's most common to happen within the first week of life, so it's far more common to happen the first week of life. But it gets progressively less likely until actually the likelihood of this happening as an adult. It's evolving. Even if there is a more rotation, which about 1% of adults will probably have, uh, will haven't have a more rotation, it might not convert into a volvulus, okay, but is possible for an adult to have this condition. Um, the reason that you get green vomiting with it is that it's a post, um, pillory obstruction, and what I mean by that is, if you see on the right hand side of your screen, this is the biliary tree. As you know, there's the gallbladder in the right and left hepatic duct that form the common bile duct, and that drains into your second part of your duodenum. The reason you get non bilious or milky vomiting pyloric stenosis is because you've got an obstruction that before where the ampulla comes, so there's no way that bile, which is deep green, can get into that vomit. Whereas if you've got an obstruction lowered down part bile accumulates in the do you need, um, and travels upwards through the pylorus into the stomach and then out into the vomit. And that's why green vomiting is a surgical emergency until proven otherwise in an infant. Okay, and as I say, even if they have a normal contrast scan, um, that the most likely cause of bilious vomiting is an alias due to neonatal sepsis. So it's still really important to treat these patient's really carefully to resuscitate them fully, to make sure they have good IV access even before their contrast scan. But the most important thing about all of this is recognizing it. And we would fire rather you over discuss with us. Uh, whenever you see a green, bomb it in in a child rather than not discussing with us, Uh, and missing the diagnosis. Okay, so that's really, really important. That's one of my take home messages from today. All right, so the next case is a nine month old girl. One day history of been unsettled. Intermittent abdominal pain lasts about half an hour, then goes away, but it's becoming more and more frequent. She's vomiting a lot. She's now over the last couple of hours now developed some blood and some mucus in in the rectum. Okay, uh, and she is starting to get really tired. She's pale, she's lethargic, she appears dehydrated, and when you feel into the tummy feels soft. But you can feel maybe a little mass in the right iliac fossa. Okay, let me see if I can activate. Pull again. Uh, Okay. So what is the most like the diagnosis here? Is it interception? Is that Meckel's diverticular bleed? Is it necrotizing enterocolitis or is it appendicitis? What's the most likely diagnosis? Okay, I'll give you maybe 5, 10 more seconds to Nancy. Okay, right. So the slim majority of you are going through The right answer is, and this is a really typical case of an interception. Okay? And we're going to explain exactly what interception is for those of you don't know, um, Meckel's diverticular bleeds so you can get so a meckel's diverticulum is a is a remnant of the, um, follow mesenteric duct. You don't need to remember that bit, but it's a diverticulum that can happen in the small bowel. And what can sometimes happen is you can get ectopic gastric mucosa. So just like you can get an ulcer in your gastric mucosa, you can get an ulcer in your meckel's diverticulum That bleed that erodes through and causes bleeding that is painless. So it tends to be absolutely painless bleeding. And so that's the thing that if you see you on a question stem or something like that, if they have painless um, g I bleeding, um and they're approximately two year old. Then they're probably having a meckel's diverticular bleed. This patient had a lot of pain. Necrotizing anticolitis. We may talk about later, and appendicitis doesn't really present and in this age group, appendicitis is really rare as well. Appendicitis becomes much more common above the age of five, uh, and then less common above the age of 30. And then there's a second peak when you're older, and it's all to do with this size of the Lumen of the appendix. So when you're when you're, uh, when you're small, it when you're above five, it's big enough to last, um, poo in but small enough to get blocked. When you're slightly bigger, it's It's big enough so that it doesn't often get blocked. And when you're older, it atrophies. So the Lumen gets smaller again. That's at least the theory behind it. So this is a typical example of an intersection. Okay, and this is what an interception is. Okay, so the majority of interceptions are idiopathic. We don't know what causes them, but they're common after viral illness, and most likely it's an inflamed pears patch in the distal Islay Um, uh, the terminal ileum, which acts as a lead point. As in poo. It comes past that that inflamed pears patch and drags that bit of bowel further along the bowel, and it telescopes inside. Okay, so you can see here on this picture a typical Eylea colic into deception. So the small bowel telescoping into the large bowel. And as you can see, the it will cause a narrowing, uh, and a blockage of the small bell. And you get a lot of fluid, uh, kind of building up behind the obstruction. Okay, so the 90% of interceptions present under the age of two, most present under the age of one. Okay, so if you've got a toddler with intermittent tummy pain, you have to think about interception as as a feature. Normally, the clinical features are a mixture of vomiting due to the, uh, obstruction intermittent cramping, abdominal pain. Because every time a wave of peristalsis comes, uh squeezes down in the interception. That's painful. And sometimes it's intermittent because it can resolve itself and then happen again and then resolve itself and then happen again. Um, red current jelly stools are often quoted when talking about interception. Uh, this it tends to be a very late sign. We shouldn't really be seen it if we're picking up interception night and early. But what happens is that the the mucosa of the inter, Uh, intercept. Um, which is a bit of the small intestine that goes into the colon, uh, becomes congested because the blood vessels are constricted by the obstruction and the mucosa slough off and then is passed out of the back passage. And that's what the red current jelly looks like. It looks like a bloody stool, and it's it's almost it looks like strawberry jam. Basically, you can also typically feel, uh, right iliac fossa sausage shaped mass in the yet in the right iliac fossa. But the the thing that's really important is that they get profoundly dehydrated. The reason that happens is because they get what's called third space losses. So instead of the normal reasons for having dehydration, which either you're vomiting lots of fluid up or you're losing fluid that way, um, or you're losing a lot of blood. So you're losing fluid that way. Or, um, or you're not drinking enough. Um, this is slightly different. This is about, uh, fluid being in the wrong place in your body. So because the intestine cannot can't absorb the fluid fast enough that's been produced and very month, the intestine produces a lot of of secretions. Uh, it tends to pull in the intestine just before the blockage, and you get more and more fluid just pulling inside the intestine. And the more fluid you get there, the less is available to actually go round your circulation. And it's what's called third space losses. It goes into your third, um, kind of fluid space, as it's called, which is not useful for, uh, going around your circulation. And that's what actually causes the morbidity and mortality from interception. It's not the interception itself. They don't tend to perforate unless it and and become septic. Unless they're left for a long time. It tends to be the dehydration and lack of appropriate resuscitation. That's what either causes morbidity mortality in these patient's. So it's really important to make sure they're hydrated properly. Uh, so oh, I suppose I've given away the answer answer list as I won't even open the pole. So what's the next most important step? Ultrasound? That's really important, because at the moment all you have is is, uh, toddler, who is, uh, unwell, who you're thinking might have intercept. You need to confirm the diagnosis, and ultrasounds is by far and away the best test to confirm that Diagnosis IV access and fluids are definitely the most important next thing to do. So you need to make sure that they're getting plenty of fluids. They need a bolus of fluids, and they need proper IV access. If you can't get IV access in unwell child by the second or third attempt, you really need to think very hard about intraosseous access. We have a really low threshold for intraosseous access. Okay, uh, you may sometimes need to do an exploratory laparotomy, depending on what the chance belly's feeling like, sometimes they do perforate and you know, and you can feel that through puritanism in the tummy and your clinical examination. And sometimes, um, you might get an ultrasound in the meantime while you're preparing theater because you know that child's going to need, uh, laparotomy. And then this last option is an air contrast and about which I'm about to talk about. So on the left of your screen, this is what an interception looks like. So on an ultrasound scan, what you can see is two concentric reap rings. One is one, and this is like looking at the interception end on. So instead of looking at the bowel, imagine it from the from the outside. Imagine looking at it if you cut across the bowel and look at at it from the inside and you can see a layer of bowel on the inside and then a layer of fluid and then a layer of bowel on the outside. And this is what we call a target sign. And also in this photo you can see some fluid, this dark area outside of those two concentric rings that's free fluid or interloop fluid. That signifies that there's some inflammation of that bowel there as well. So that's a typical finding of on an ultrasound. And what this diagram on the right hand side of your screen shows is, um, what we do when we do an air reduction enema. So what we actually do is we put a Foley catheter up the bum, Um, and we inject in, inflate the colon with lots of air, and we look at X rays at the time and we see over. We can see on the X ray, the interception reducing until it looks like it's fully reduced. And that's just from the pressure going all the way up the colon and pressing on the interception from the inside. Now it doesn't always work. So if that's not working after after two attempts, normally two attempts you might proceed to an operation. So in this circumstance, you can see a laproscopic approach and the left side and an open approach on the right side. You might start off with laproscopic approach, trying to tease that interception out of where it's it's nestled in the, uh in the colon. Um, and the picture on the other side shows the open approach. Sometimes you might even need to resect that area of bowel. Okay, so that's a typical interception. A typical interception is that one year old who comes with that intermittent abdominal pain if they're an older child of their six or seven, or if they're an adult with interception or it's an uncommon location for an interception such as Coehlo colic. As in this what this picture shows, or a Leo Eylea or even rarer GG know jejunal. Then, um, then they may need, um investigated further because they may have a pathological lead point that could either be a polyp as shown here in this diagram, a meckel's diverticulum can act as a lead point when it's inverted. Um, you can also get this happening when you get the associated gut inflammation with Henoch Schonlein purpura, and I'll let the pediatricians cover that when you have your Pedes block. But we often CHSP kids with tummy pain to try and exclude this interception issue. So in older Children you always have to think about. Could there be a pathological lead point that needs removed? And in these Children, it's It's much less likely that air enema will be successful. So that's that. Next case is a three year old boy who swallowed a coin two hours ago and has had some abdominal pain in the meantime. But otherwise the obs are normal. There's a bit of pain when swallowing, but he he looks happy enough. Okay, so the question is, here is the X ray. I'll have. I'll let you have a little look at the X ray. Uh, you might want to zoom in on where the foreign body is. So the questions you need to ask yourself is, where is this foreign body and what do you think it might be okay, so the next poll has just come up. Okay, So the options are what is What's the next most appropriate thing to do? No. Forever actionable passing it zone. We don't need to worry. We just need We just need to let it do its own thing be. Let's take it out in theater right now, OK? See, let's observe overnight and let's consider whether or not we retrieve it tomorrow, based on where it might be or D Just repeat the X ray and see if it's still in that place. Okay, so good. Okay, so lots of you're going for immediate retrieving theater, which is exactly right. What? What I want to kind of express with ingested foreign bodies is it's really important to, um, take, uh good. Oh, my slides of I was this was the center picture was just pop up later. But anyway, you can hopefully make out what I want you to see. So this is actually a button battery. And this is, uh, disastrous an esophageal foreign body, because the, uh, the batteries really corrosive and can perforate the esophagus or really corrode the esophagus, Uh, and really down the esophagus. It's these button batteries you can see on the left of your screen that are really dangerous. If you have to ask very specifically if they have any button batteries in the house, whether or not they've ever been playing with button battery, uh, don't just take the parents at face value. They they're going to be trying to seem like they're, uh, not, uh, not being, uh, negligent or something like that. So they're going to make Did not tell you that it was a button battery or something. You have to be really, really clear about. Is it a battery, is it not? What was it? When was it ingested? How long has it been there? Has there been any symptoms? Was there any other things that were ingested at the moment at the same time? And that's what I really want to stress with ingested foreign bodies. It's really careful history. So what you can see on the X ray, the same X ray, This is the same X ray I showed you on this right hand side screen. What you can see is that you can see this like rim around the around that circular disk that's typical of what you can see on the on the button batteries. If you see that that that's a button battery until proven otherwise, Um, and what you can see in the middle is what a button battery can do through the esophagus. So it's a surgical emergency. They need it removed immediately. Esophageal foreign bodies shouldn't be left. Even coins that are stuck in the esophagus may cause a pressure effect and may cause lots of issues. So if there's a foreign body stuck in the esophagus, uh, then it needs removed. If it's made it below the diaphragm into the stomach, then then if it's just a coin or something, it might well pass. It might not. In that situation, it's totally reasonable to consider doing another X ray in the morning, trying to see if it's moved at all that it's not moved at all. Maybe doing a retrieval, Maybe not, depending on what the foreign body is that even button batteries, because the stomach lining is, um, much more harder than the esophagus. It's safe to leave a button battery when it's in the stomach, but definitely not when it's in the esophagus. Okay, so that's so that's really important. So esophageal foreign bodies should be removed. Which team that removed by is slightly debatable, depending on where it is, if it's below the levels of clavicles in this office, so we remove it. If it's above the level of clavicles, it's the Ent team. The other foreign body that's really important from a surgical perspective is magnets. These needed neodymium magnets are really strong, and they look more and more like sweets with the way that manufacturers are manufacturing them. Okay, and what you can see in these X rays is these extras are actually in the same patient. So what's happened is they've ingested multiple magnets at different times. And that's the key thing. Multiple magnets at different times, because if you ingest all your magnets at the same time, it's unlikely to be a problem because they're all tending to stick together. However, if you if about half an hour after they've ingested one magnet set magnets and just another, that's where it becomes, uh, really issue, because what you can see in the X ray on the right of your screen is that they were separate than now together and What can happen is that you can create a fistula between two loops of bowel. With those magnets, the magnets can stick to each other and through the loops of bowel and cause a hole in the, uh, those loops of bowel and they perforate and they can become really septic and really unwell. So magnets, So the everything to be really careful of when talking about foreign bodies. The last case I have from a emergencies point of view is this four day old child born slightly early. But getting towards term, we're able to go home before before, Um, today had an eight hour history of being unsettled. There is abdominal distention and vomiting. Whenever you press on the tummy, the baby whales and pain and the heart rate goes really high. Passing frank red blood from from the back passage. And when you put an n g tube down their passing red blood up the top and they and they look like they're in pain, the grain color there's abdominal distention and lots of tenderness, and the abdomen looks looks horrendous. Okay, so, um, what do you think is going on here? Remember what I said about Meckel's in particular. Uh, previously right. Let me start the pool. Yeah, that's the right one. So which one do you think it is? Do you think it's Meckel's diverticular bleed? Do you think it's Hirschprung's disease? Hirschprung's disease is a condition that affects the, uh, migration of neural crest cells along the colon, essentially without neural crest cells, Uh, and the Myenteric plexus. You're not able to squeeze and Paris styles your colon, so you end up with bad obstruction. Um, and it's an important pediatric surgical diagnosis. See? Is it necrotizing anticolitis or D? Is it meconium ileus meconium ileus will chat about in a second and necrotizing enterocolitis. We'll chat about in a second as well. Yeah, okay, so lots of people are going for a necrotizing enterocolitis affectionately known as neck. And that's exactly right. Um, so just before I start talking about necrotizing enterocolitis just to mention meconium, ileus is a condition where there's really really thick inspissated meconium that causes an obstruction. Um, that, uh, that doesn't resolve at all, and they end up needing a laparotomy to relieve the obstruction. Uh, it's, uh, very, very common to have cystic fibrosis with meconium ileus okay. And that's the exam. Answer. They'll give you a baby with meconium ileus, and you'll have to identify the the the genetic condition with which it's associated with cystic fibrosis. So virtually every baby with meconium ileus has cystic fibrosis. But not all babies with cystic fibrosis end up presenting with meconium ileus, if that makes sense, so I'll repeat that one more time. So virtually all meconium ileus babies are cystic fibrosis babies. But not all cystic fibrosis are presenting with meconium ileus. Um, so I hope that that makes a little bit of sense. Okay, but we're going to be talking about necrotizing enterocolitis here. So next, Presenter colitis is a disease of prematurity. It affects premature gut, but importantly, And this is why I'm mentioning it in this talk. It can happen at term. Um, so it's important to know a little bit about We've recently had a really unwell term baby with any See, um uh, recently. And, uh and, uh, it was picked up by the Fife. Any that it could be any see, and they referred them to us. And the baby is doing very well now, uh, and need an operation. It's basically a mixture of lots of different things, including, uh, bacteria colonization following birth. Not happening in a, uh, normal way. Um, there's an immature intestinal barrier. Uh, and, um, uh, bacteria can trans locate across the across the, uh, the intestine. And also they get a widespread inflammatory response and they get hyperactive. They get aggregation of all the platelets, and then the gut, which is immature to start off with, doesn't like not having adequate blood supply. So it's a There's a risk emmick component as well. There's a complete spect mild to severe. This is what a baby looks like with a premature baby. This is what a premature baby looks like with really profound. Any see you can see the abdomen is really distended. It's shiny looking. It's erythema tous. You can probably see some visible distended loops through the tummy, and that's exactly the sort of baby you don't want to see. Um, so in terms of managing these these babies, you have to put them on broad spectrum antibiotics to try and and, uh, manage any infective component, it's really important to put it to try and give. Give them total gut rest and That means no enteral feeds whatsoever for at least seven days. And that means that they need parenteral nutrition. The only reason you would operate is for perforation because the bowel can, uh I think I've got something the next time. Yeah, As you can see in this kind of diagram on the right, the bowel can become necrotic and not healthy, and it can perforate. This is what a typical X ray looks like. Uh, you can see on the patient's right hand side of the abdomen. Uh, what's called regular sign where you can see wall, uh, gas on either side of the wall of the bowel. And you can also see, um, you can also see what's called pneumatosis, which is this kind of soap bubble appearance on the patient's left side as well. That's typical of, uh, any see, and this is what perforation looks like. So on the x ray on the left hand side, you can see what's called false form ligament sign. So if you look over where the liver is, you can see a vertical line stretching down where you can actually see air on both sides of that false form ligament and you can see a lucency over the liver as well. And so what they might do on this extra is to confirm the diagnosis. They might do a lateral shoot through and on this lateral shoot through on the right hand side of your screen, you can see that there's lots of free air in the tummy. This is a baby that you would ever is typically operated on with neck. Try Central colitis and doing that operation. If you ever get the chance to come in and see an innate a laparotomy, it's, uh, pretty in credible feet. The entire, um, operative window is probably about that size, um, and is, uh, seeing so many people round that tiny little, uh, thing is is really intense. It's I I I think it's it's really cool, and it's part it's really part of what makes us really want to do pediatric surgery. So that's what I had on the kind of, uh, emergencies. I've spent quite a lot of time on that. I think it's more important that I spend more time on emergencies than I do on this next bit that I'm gonna whizz through, and I mean whiz through, um, that that's lots of general surgical conditions of childhood. Okay, uh, and then after this, uh, I'll take any questions that you have. Um and then I have an extra 15 minutes or so at the end where we can talk about some of the really interesting stuff that makes us want to do pediatric surgery. But this is a slightly more boring stuff, but nonetheless important that we get referrals into our clinic with all the time with from GPS. And it's important to know a little bit about because then you'll refer the right patients to us and not the wrong patient's. The first thing to talk about is the foreskin, and this is something, Uh, we we don't particularly enjoys pediatric sessions, but we very much get in involved with so retraction of the foreskin is a gradual process. This diagram shows that from type 12 type five, the stages of retraction of the foreskin and their associated frequency underneath. So, as you can see when you're really young, when you're below the age of one, the vast majority are non retractable. But then when you get to 11 to 15, and especially 15 year. The vast majority are retractable. It's totally normal for you to have a non retractable foreskin between those ages if you're getting if you've still got non retractable foreskin by the age of 13 or 14, that's the first time I would ever consider uh, doing a circumcision for you. Uh, just purely based on the fact that it's non retractile. The only reason that you need a non retractable foreskin is for intercourse later in life. Um, the only other situations in which I order I I carry out circumcision are for recurrent balanitis, which is an infection of the entire shaft of the Penis. Redness spreading down the entire shaft of the Penis, not just a little bit of redness at the tip. That's not balanitis. That's just a bit of urine, irritating the foreskin if they're getting recurrent UTIs. There's some evidence that circumcision can help, um, or if they're getting obstruction from a condition I'm about to chat about, then that's That's another, uh, and the way that you know that you'd asked about the stream if their stream is strong, as in, it's a steady stream rather than a drip, drip, drip and they're not having to tense all the tummy muscles to get any urine out whatsoever. They don't have significant obstruction. Um, and they can be very safely left well alone. This is the scarring condition called balanitis xerotica obliterans. This is exactly, almost exactly the same as lichen, sclerosis of the female, but of the of the mail, and it's an acquired condition. So 10, uh, we've I've never really seen it in boys below five. It's a scarring condition of foreskin. If I go back to this slide and you look at type one, you'll see that that there's a narrowing and that the foreskin after that kind of almost dilates when you're trying to retract the foreskin. That's completely different to what it looks like when you're trying to retract this foreskin, which almost looks like a dome. It looks like a dome with nope out of the foreskin at all. Okay, uh, and it causes progressive obstruction. This is an absolute indication for a circumcision. You can't treat this with any other thing other than circumcision. If you're concerned about this condition, refer them to us and we will see them. Okay, The only everything from a foreskin perspective that I want to chat about is paraphimosis ISS. So if I go back to my fimosis slide, not paraphimosis iss, that's just a narrowing of the foreskin that's preventing it being retracted. Okay, um, the, um paraphimosis ISS is when you've got a narrowing of the foreskin that is able to be retracted, but then is left in that position, the glands becomes really edematous, and the and the foreskin isn't being able to be put back into the right place. So that's the difference between FIMOSIS and para fimosis. And the way to deal with paraphimosis is to reduce it, using this sort of technique, using your fingers on either side of the glands and pushing your thumbs, pushing the thumbs past the fore skin. Sometimes if that doesn't work, then you need an operation. The other thing that's really handy is a dextrose coated swab. The reason that helps is that the sugar, uh, in the Dextre swab convinces all the edema that's in the glands of Penis to, uh to leak out into the swab through osmotic effect and reduces the size of the glands. Undescended testes is something else that we see an awful lot of in pediatric surgery. So, um, the testicle normally starts off developing at the kidneys at the level of L1 and descends over time following a structure called the Gubernaculum, which attaches to the apex of the scrotum. Uh, and there's two phases. There's an abdominal phase, and there's an inguinal phase of dissent where it goes through the internal, then the external ring of the inguinal canal. And this process can stop at any point along that along that track. But most commonly, it's it stops, um, just outside the inguinal canal, in what we call the, um, inguinal pouch superficial inguinal pouch. So that's where you can feel it usually in order to examine. Uh, yes, I have a side in this in order to examine for an undescended testes. Most commonly, it will be located just outside the Anglican. Now, what you can do is what the picture be is doing. You can use your left hand to milk that down into your examining hand, which is your right hand until you can feel the testicle. And that's the way that you actually feel France ended. Test is you don't just feel an empty scrotum and give up and say, Well, they're undescended because what you sometimes they're able to do is bring that testicle down into the right place. Let go, and it stays there. And if it stays there for even 5, 10 seconds and it can come down easily, they don't need an operation, because over time it will spend more and more of its time in the right place. Those are just retractile test is, whereas the ones that you really want to do an operation on are the ones that are either ectopic. So if I go back to slide, they can happen anywhere, so they can. Even you can even get perianal. Test is if the gubernaculum inserts into the wrong place, you can get femoral. Test is in your thigh. You can get a pre penile testes. You can get all sorts of weird and wonderful things. Okay, so operations are reserved for if it's ectopic or if it's really tough to get it into the right place. Okay, hydro seals and harness. Okay. So hydro seals and hernias in Children happened for completely different reasons than in adults. Okay, so hydro seals and hernias happen for the same reason in infants. And it's that while the testes was coming from the intraabdominal space down into the scrotum, it brought with a little connection called the patent processes vaginalis, which you can see on this diagram on the left hand side in the middle of the of the, uh of the diagram. And that's a little connection between the area around the testicle and the intradomal cavity. And normally what happens is that tunnel on each side just closes up. But sometimes you're left with a tiny little opening, which allows a bit of fluid down. And that's what Hydrocele is. It's a collection of fluid, um, around the testicle that originates from inside the tummy in Children. Um, and it's due to that small opening of the processes vaginalis right, as opposed to hernia, where that opening is big and allows bowel to get through that that opening. And that's more of a problem. Okay, because hernias can can have complications associated with them, they can get stuck, and when they get stuck out, as in, you're not able to reduce them. They can get obstructed the Balcon obstruct, not allow content, and bars pass through which is a surgical emergency. Or they can strangulate as in the bowel, can lose its blood supply and become necrotic. And that's another surgical emergency as well. So if you identify an inguinal hernia, then we would operate on it. If you identify a hydrocele on clinical examination, then those tend to resolve, uh and I'll show you on this next slide. So hydro seals tend to resolve by the age of two, in about 90% of cases, if they're still there by the age of four, we would maybe off offer an operation to improve the cosmetic outcome. Okay, but generally, hydro seals don't cause complications, and they don't cause pain unless they're massive. Okay, um, hernias, on the other hand, do cause problems, and they're more likely cause problems in those below six months of age in terms of trying to figure out the difference on examination. What what you'll be able to feel with a hydrocele is you'll be able to get your fingers above the swelling and feel the normal cord structures and feel that swelling in the testicle is below you. Okay, whereas for a hernia, you won't be able to get above it because in order to get above a hernia, you'd have to be either, like you'd have to be inside the abdominal cavity to to get above a hernia, and they tend to be reducible. However, hydro seals can also somewhat be reducible if there's a really wide connection that you can squeeze all the fluid back into the abdominal cavity. So the best thing to differentiate between the two is whether or not you can get above it with your examining fingers. Okay, the last general surgery childhood thing I want to chat about is umbilical hernia. This is a different type of hernia from an inguinal hernia, right? It's incredibly common. Um, a guarantee one or two of you who are here listening to me will have had one, uh, in infancy. Um, it's even more common in African infants. They are different inguinal hernias because they never generally have complications. If an umbilical hernia has an incarceration or instructor and strangulation, then that is worthy of doing a case report. Um, one of our most experienced consultants has seen that happen twice in his career and bear in mind that it's 10% of infants. Um, it's it's It's extraordinarily rare for this to be a problem. Most resolve completely on their own. Even the very large ones can resolve completely on their own. But if they're not resolving, we would consider an operation around the age of four. Okay, So, umbilical hernias, you can leave till the age of four. Hydrocele is You can leave to the age of four inguinal hernias. We tend to operate on earlier than that. So what we covered today, you'll be glad to know that that's me about to finish speaking for the for the most part, uh, is we've covered some common pediatric surgical emergencies and pilots. No, sis, my rotation volvulus interception ingested foreign bodies. Necrotizing enterocolitis. We've covered some general surgery conditions of childhood, including everything to do with the foreskin. Um, uh, undescended testes, inguinal hernias or hydro seals and umbilical hernias. Um, I have an extra 15 minutes to chat about some more interesting pediatric surgery stuff. Um, um, if you guys are keen, but I'll do that if you guys are keen. But the main things I want you to take away from today if you forget absolutely everything that I've talked about apart from these five things. I'll be happy. These things are the things that I really want you to know. Okay, So one green vomiting and infancy is a surgical emergency until proven otherwise. I can't stress that enough. Okay, Uh, and we'd be doing you an absolute disservice if you graduated as doctors and didn't know about green vomiting. Infants being a very bad thing that you need to talk to us about, okay. And a soft. A dual foreign body is also a surgical emergency that needs removed either due to the pressure effect or if it's a button battery even worse, because it's going to be causing a pressure effect and a coro zing effect. So the initial management of interception pyloric stenosis is not surgery. Surgery is something that can happen down the line. Uh, the main most important thing for both of those conditions is adequate resuscitation IV access. Adequate fluid. Bolus is, um, reassessing and giving more fluids if necessary, making sure that they're inappropriate environment for them to be resuscitated either a resuscitation room in, um, in, uh, emergency department or in a safe space that you're taking it very seriously and that you don't just leave them to languish on a ward somewhere in general. Leave the foreskin well alone. Unless there's bxo or para from ASUs and Inguinal. Hernias need to repair. But hydro seals and umbilical hernias may resolve themselves. Try to try, if you can, to get familiar with how to examine for understanding. Test is and inguinal hernias because those are important for you to pick up. And you might save the child from coming to see us unnecessarily. If you can identify that Tesco actually comes down into the right place, no bother at all or that it's actually hydroseal, not an inguinal hernia. Okay, so those are the five things I want you to to to to focus on. Okay, Right. So I've already overrun and I apologize about that. And I realized that I think what what would be best is Does anyone have any questions? If you do have questions, just type them in the chat. Um, and I can answer them, uh, and then once I've answered those questions, if anyone still wants to, um, stick around for the extra bits and bulbs, then please let me know. Uh, and I can go through that, or if all of you are totally sick of the sound of my voice, then that's absolutely fine as well. So any questions at all, And I think, Lucas, I should be able to see, um, on the on the chat function, whether or not there's any questions, shouldn't I? Yeah, that's right. Yeah. Okay. So, yeah, I'm not seeing anything at the moment. Is that the case? Yep. Yeah. Okay, fine. Okay. I'll give you another minute or so and then if in the meantime, even if you don't have any questions, could one or two if you If you're keen for me to chat about some more much cooler stuff. If you're keen for me to chat about that, if you just send a message, please, and say yes, please. Or no, thank you. That would be really appreciated. Yes. Um, just before anyone leaves, we'd really appreciate it if you could fill out the feedback form. Um, a certificate of attendance will be provided once you complete it. Um, yeah, it should be in the chart. Just Yeah, apologies. That's pediatric surgery. The whole of pediatric surgery. It's impossible to cover it in an hour, but I think what I've done there is, even though it's a lot of me just talking and prefer to have it interactive and have it in person and things, I think what's what's what I've tried to get across is the sort of stuff that I think is really practically useful for you guys to actually know a bit about. We do a very bad job of teaching you about pediatric surgery. Uh, and there are some really, as I hope you now understand, there are some really important emergencies that it's really important to understand a little bit about, uh and be able to at least recognize and let us know about, um and it's it. Yeah, it's it's it's really important. So I'm quite passionate about you guys not graduating and and not at least having heard of or no, a little bit about some of the really important things there and the general surgery childhood stuff. Statistically, most of you are gonna be GPS, so it's it's really important that you, um, that you know a little bit about that as well, because the scary thing about being a GP is that if you don't have a specific pediatrics or pediatric surgery rotation. You won't have any other teaching on this apart from now, maybe during your pediatrics block and then nothing else before you're fully qualified. GP. You won't have any formal teaching on pediatric surgery, so it's actually really, really important. The other stuff I have, if anyone actually wants me to talk about it, is all kind of extra icing on the cake sort of stuff sometimes that it comes up as sort of like a grade questions in exams, but it's definitely optional extra knowledge rather than essential knowledge, which I've tried to keep to that first hour. So if anyone actually wants me to go ahead, uh, and talk a bit more about pediatric surgery, could you please just send a message to the chat? Uh, okay, so I've got one taker. So even if it's only for one person, I think, uh, I think I will. Oh, at least three. Fantastic. All right. So hopefully this shouldn't take more than 15. Okay? I am not intending. And please, while I'm chatting about this, if you have any questions at all about what I'm chatting about or what I've chatted about earlier I just put them in the chat. I will deal with them as I go. If you have to leave, that's no problem. I won't be offended at all. Just please do the feedback for him before before leaving, okay? And this is some of the really cool and gentle neonatal stuff. First thing I want to say is that pediatric surgery is vast. And one of the really great things about general pediatric general surgery is it's truly general surgery. Adult general surgery is becoming more and more that you do one specific operation like an IV Lewis Esophagectomy, which is a really cool operation. But the so I I was on call last night with, uh, consultant who does colorectal surgery as well as urology as their sub specialist sort of interest. But I was dealing with upper GI problems during the wrong call. Um, and, uh, I was looking after trauma patient who had been stabbed over the weekend. Very dramatic, I know. And also we're on the on our in our service currently in the hospital. Currently, we have a congenital diaphragmatic hernia which was diagnosed age 13, which was very weird and wonderful. So that's thoracic surgery as well. You've also got some head next stuff as well as vascular access. Uh, there's a lot of different things you can do in pediatric surgery. And it really, um, is really fun for someone who's more of a generalist. Okay, One of the things we do with quite a lot is, um, abdominal wall defects. This is a condition called gastroschisis. It's a condition where the abdominal wall hasn't developed properly and the baby is born with gut exposed. The amniotic fluid is normally antenatal e picked up and the, uh and it poses a dilemma of how do you get that bowel back into the stomach and close the stomach? All right, close the abdominal abdominal wall, and the way that we do that is for using these silos. If you looked at the top right, you can see this kind of plastic tubing that we put a ring on the inside of the umbilicus and we put all the bowel into this plastic bag. And over time, what we do is we squeeze that squeeze that bowel right into the abdominal cavity, and you can see what that actually looks like in a baby in an incubator just underneath. So that's gastroschisis. There's never abdominal wall defect called exam floss, which is what this looks like, and this is a slightly different problem. This is where you know how I was talking with my rotation, how the gut entirely eviscerates and does that mad 273 re rotation and then goes back in. This is what happens if it's not able. If it doesn't go back in for some reason, you're born with your gut and maybe even your liver or other organs on the outside, covered by a thin membrane. So the differences between Gastroschisis exam floss is that you've got a membrane and example loss and that it's a true umbilical defect, whereas the, uh, in Gastrus Keto is is often to the right of the umbilicus, uh, and that the bowel itself, in example, is hasn't been exposed to the amniotic fluid. So it's not nearly as irritated, and they don't take quite as long to get going. Uh, there's various ways of closing these that I won't go into, but they do tend to be associated with African gentle abnormalities, whereas Gastroschisis doesn't so you can even get associated with a very weird and wonderful condition called antalgia Cantarell, which includes, uh, a fallacy but can also include ectopia corgis where you're born with your heart beating outside on the outside of your sternum with a massive sternal cleft in your heart just visibly beating, uh, in front of you. Very cool condition. Incredibly rare, as you can imagine. But this is something we very much deal with. His pediatric surgeons. Uh, this is what I was saying earlier. So, uh, this is, uh, congenital diaphragmatic hernia. So the diaphragm develops, uh, in the womb from, uh, and due to some, uh, some biological issues sometimes that diaphragm doesn't develop and it allows all your gut to go into your chest. Okay, So that can cause the lung on that side to really not develop very well because it has no space in order to develop. It can even cause lung on the other side to not develop properly if it's massive like this, like this hernia. As you can see, all of this bowel on the X rays is in the chest cavity. Um, you can you can get profoundly unwell. Uh, neonate who aren't able to support themselves from a respiratory point of view, they might even need to go on ECMO extra corporeal membrane auction ization, which basically put them on bypass until you can fix this, get that down in the right place, and it's got a really high mortality in its in its severe form. It can be less severe, and it can even present later in life if it's a small hernia. Um, and that's what's happened to our 13 year old, who we can currently have on our ward, who got to the age of 13 with, UH, relatively similar amount of, uh, content in the chest here and then presented with a gastric volvulus with stomach twisting around itself and presented an extremist and was peri arrest and needed an emergency operation two in the morning to try and sort this out. And what was really interesting is it's a urologist who did this procedure. So it's really true general surgery, and you're taught to do a whole lot of different things in pediatric surgery. But this is, uh, there's also a kind of fetal intervention that you can do when the babies are fetus that you can occlude the trachea. Um, while they're well, they're still in the womb and that, uh, encourages what little lung there is to expand into the hernia. Um, and so there's even fetal interventions that you can do in pediatric surgery. This is what's called a tracheoesophageal fistula. This is where you have a gap in your esophagus which hasn't developed properly, So the most common is actually what you can see. I wish I had a pointer. But what you can see, which is called atresia with distal fistula. So it's middle of the top row and you get an atresia blind ending esophagus with a connection from your, uh, trachea into your stomach. Um, and this needs, uh, really extensive surgery to try and source out. And what's very cool and pediatric surgeries. We've got more and more minimally invasive surgery happening, including thoracoscopic surgery in our center. We tend to do these fluoroscopically now rather than giving them a massive incision and thoracotomy, which is their entire chest, which doesn't grow particularly well. And they get chest wall deformities and they can get splinted over their chest, can get signed it over to one side, doing it through the minimally invasive approach prevents at risk and really improves their, um, postoperative stay as well. You can also get atresia as elsewhere in the ball. This is a duodenal atresia where you've got a blockage in the duodenum or a blind and duodenum. And, um, this is a typical extra associated with it. This is a classic double bubble sign. So this is conceivably something that might come up in an exam at some point. Um, they might show you this X ray, this clear, double bubble sign. They might ask you what condition it is or if they're feeling really mean what condition it's associated with. And this just like a cardiac defects. Like VSD, your ASD is associated with down syndrome. So try Same 21 is associated with Judy know latricia, and it presents. Um, uh, with this classic typical x ray appearance, okay, and total intolerance of feeds. This is Meckel's diverticulum. This is, um, what I was alluding to earlier. This is where you can have gastric mucosa that can bleed. Can ulcerating then bleed. Uh, typically. So it's a remnant of the, um, felonies enteric duct, which is a duct that connects your, um connects the Lumen of your bowel to the to the oak sack itself. Uh, that normally spontaneously closes, but sometimes doesn't leave you with this meckel's diverticulum. It follows the rule of twos. So if you want to learn a bit more about this, look up the rule of twos for Meckel's diverticulum. So it's normally 2 ft from the higher sequel valve. It's normally two centimeters in length. It normally presents with bleeding at the age of around two, and and it's in about 2% of the population. Um, all of those are false, by the way, but they're approximately right. Uh, but if you come and do pediatric center property will tell you what the actual statistics are. Your bum can be born in the right place, and that can be a massive, uh, undertaking the worst possible. Um, um, thing you can have is this top right picture, which is called a cloaca as you if you if you happen to know, Cloaca is what birds have, uh, and it's a common Sinus between the vagina, the bladder and the rectum. So all three of those structures are just filling into this one place, and as you can imagine trying to sort out that mess and give them a functioning, uh, rectum, a functioning bladder and functioning vagina is really, really difficult. And it can be really complex. Major reconstructive plastic surgery, Essentially, but again, it's pediatric surgeons to do it. Um, in boys, you can get perianal fistulas, uh, where you get, uh, opening. Not where the bomb should be, But But elsewhere in the perineum, you can get Recto, uh, fistula between the rectum and the bladder with no anal opening, uh, really difficult to, uh, to sort out, but actually really interesting surgery. Hirschprung's disease. I chatted a little bit about earlier. This is what it is. It's all about those migration of, uh, neural crest cells from the cecum all the way down the bowel, all the way to the rectum and the anus. Okay. And if they don't make it all the way down there, you get an area of bowel that doesn't squeeze and so gets really, um um doesn't function, and you get lots and lots of obstruction. Okay, so it becomes really, really narrow, and then the area immediately above it becomes really, really distended. And you can get really, um, uh, severe condition called Hirschprung's entro colitis, where you get bacterial translocation through the through the wall of the gut and they come septic and they can become very unwell indeed. And you manage it with a very interesting operation called, uh, pull through. And there's three different types of pull through that I've shown you here in this diagram A B and C a suave I duhamel. And, uh, I can't even remember the name of the third one. But you don't. You guys definitely don't need to know that suave is most common. Duhamel and, uh, it'll come back to me. So there's also lots of complex urology. Um, so you can get, uh, uterine. You're you're a tear a pelvic junction obstruction or, uh or I think that's what the Americans call. We call it a pelvic. Oh, you're a Terek Junction obstruction called a p u J e o. Where you get a kink in the renal pelvis here before it kind of, uh obstructs and doesn't allow uh, urine to go down. They present with lots of pain and that the function of that kidney gets worse and worse and worse, and you can sort that out with, uh, intensive operation called the PYELOPLASTY, where you make an anastomosis between the ureter and the and the renal pelvis and taper the renal pelvis down into the into the right sort of position. Um, and it can be, uh, really challenging procedure. Uh, but again, it's complex urology. Um, a very interesting condition. You can get all sorts of abnormalities with the kidneys. The reason that you can get loads of congenital abnormalities with the kidneys is because you have two of them. So you have some, uh, some embry a logical resilient. So if you have a problem with one, you can have one that survives. Uh, and you can get all of these things you can get Duplex kidneys. Uh, you can, uh, with multiple. You're a Terek buds or a branch ureteric buds, which gives you, uh, duplex ureter with a single kidney, you can get a horseshoe kidney, and all of these might need surgical intervention as well. Hypospadias is complex plastic surgery where the the opening of the P tube doesn't doesn't open into the right place right at the tip, and can open even in the perineum it can be really complex and really satisfying. Uh, really Minute detailed operative, right to try and sort out. Um, And, uh, it's something that the people who like doing hyperspasticity as you really like to hypospadias surgery. We also have a lot of oncology. This is a Wilms tumor. It's the most common renal tumor or intraabdominal tumor in childhood. Um, it's a mesonephric blastoma. Um, it can be really dramatic. And it can have extension, even as you can see in this diagram on the left, even into the IBC and sometimes even up into the heart. Um, as you can see on this, uh, diagram. What the green arrow is pointing towards is the residual normal kidney. The thing that's coming off the kidney is the actual tumor. They can be absolutely huge, and they can be really challenging to remove. That normal presentation of that is that Mum will feel a mass on the, uh, through the abdomen. Uh, and it might well be painless. And we do an ultrasound and see a really, really dramatic picture. You can also get some other weird and wonderful, um uh, uncle logical, uh, work in pediatric surgery and couldn't take a coccygeal teratoma as which, uh, they can even be associated with, uh, my little ninja seals. So you even do a little bit of neurosurgery as a pediatric surgeon as well. The surgery to Ruth this is highly specialized. Um, that's a quick run through of some of the more interesting bits of pediatric surgery that that are an optional extra for you guys to know about. Um, and there's some of the things that get as excited about pediatric surgery. Um, I under I realize I've taken up very much of your time. But if there's any questions, please write them in the chat and I'll give you about a minute or two. Uh, and if there's no questions, I'll let you get on with your evening and, yes, please fill out the feedback form if you'd like this kind of talk. If I was giving it next year to be split into two sections, uh, let us know if you'd prefer it to be in a different format. If you prefer it to be face to face, let us know, uh, in the feedback as that would be really useful for the guys organizing this Okay, I'll give you one more minute. So speak now or forever. Hold your peace. Okay. Perfect. Grant. Right. I'll sign off if you don't have any questions. And I hope you found it at least relatively interesting. And that and that. We may have inspired a view of you to come hang out with us a bit and see what pediatric surgery is all about. Um, So thank you very much. And all the best. Thanks, Cameron. Take care. No problem. OK, let me know if there's anything else you need from me. All right? Okay. See you later. Bye bye.