1 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM Dr.

“Dude” Isabedra

Day 1 o Bleomycin – most important to use

I. Hemangioma (chemotherapeutic drug – side
II. Thyroglossal Duct cyst
effect pulmonary fibrosis)
III. Congenital Diaphragmatic hernia
IV. Esophageal Atresia o Ok432 – very effective, strep
V. Perineal lesion: Anal Fissure derivative injection to the lesion
(free) (Japan)
HEMANGIOMA
Infantile Hemangioma
 Most common: Hemangioma and
Lymphatic malformation  Most common tumor of pregnancy
 Lymphatic malformation can also be called  Occurring at 2-4% Male predominance
Cytic hygroma:  Lifecycle or Phases:
 Incidence: 1:12000 live births o Proliferative phase – angiogenesis,
 Diagnose at birth: 50% – 65% rapidly dividing endothelial cells,
 If not Diagnose at birth will appear at 2nd massive sinusoidal vascular
year of life channels.
 75% seen at the neck o Involuting phase - reduced
 30% axillary region angiogenesis apoptosis vascular
 Usually multinoculated, channels dilate and the tumors takes
on the longer architecture like
Patholophysiology: lymphatic malformation – liphoma (fibro – fatty structure)
maldevelopment of lymphatic jugular sacs  Types:
o Capillary
 Complication:
o Cavernous: most common
o Trauma
o Villous
o Bleeding
 Diagnostic imaging: ultrasound and MRI
o Infection (with infection, respiratory
 Management:
obstruction, dysphagia and cosmetic
complication) o Observe and wait (small tumor)
o Early management of surgery: for
 Diagnosis:
large size and has rapid growth,
o Prenatal ultrasonoragphy (1st world
dangerous locations (Facial location)
country)
and has complications
o Transillumination (if cystic or solid)
o Propanolol – latest management.
o Ultrasound is the most common diagnostic
exam THYROGLOSSAL DUCT CYST
o CT scan
o MRI Most common lesion at the midline of the neck:
 Management: Diffrential: Dermoid cyst (nice to know)
o Surgery if infected incision and drainage
debulking(?) and complete excision 7% of the population usually at preschool children
sclerotheraphy – used modernly, minimally associated with the thyroid gland development,
invasive hyoid bone and the tongue

Doc Kharl-Kilabot & Gang 

2 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM
Site of the development of the diverticulum,
foramen cecum(embryology) from base of the
tongue to the pyramidal lobe, foramen cecum
downward pass thru the hyoid bone.
Diagnosis: history and physical inspection
ultrasound thyroid scan CT scan
Management: “Can be medical but we don’t follow
that” Usually do surgical excision (cyst trunk
procedure for thyroidosal duct cyst) because of
the thyroid tissue and if the tissue isn’t in the
anatomical place it can cause cancer most common
cancer papillary carcinoma.
Branchial remnants:
 Rare
 Branchial cleft and Branchial Arc: big
physical presentation because of the
development on the 1st trimester.
 Most common defect: 1st branchial arc
(mandible and maxillary process of the
upper jaw are affected, where cleft lip and
cleft palate arise and any deformity of the
external ear and malformation of the
ossicles)
 Brancial Cleft tympanic cavity, all the
structures inside the middle ear microtia
ESOPHAGEAL ATRESIA
and oral atresia
 1st branchial arc – extra ear(congenital
defect),
 2nd branchial arc – Hyoid bone , cleft of the
tonsillar fossa, usually where internal
opening may arise
External opening is at the border of the SCM,
usually pass at the carotid sheath at the level of the
hyoid bone 95% of all the bronchial anomalis arise
at the 1nd branchial arch CONGENITAL
DIAPHRAGMATIC HERNIA
 Most important in pediatric surgery
Doc Kharl-Kilabot & Gang 
Dr. “Dude” Isabedra
 Very rare 1:5000 livebirths.
 Etilogy: unknown, maybe related to triomy
18 21 23
 30% still born 80% left sided
 Diagnosis:
o Prenatal ultrasound – amniocentesis –
decreased in sphingomyelin ratio
o chromosomal analysis - Maternal AFP
 Clinical presentation: diaphragmatic hernia,
respiratory distress, scaphoid abdomen,
assymetrical phalanges(?), (diagnose by
chest Xray, contrast xray)
 Management: prenatal care cousenling
screening fetal intervention surgery while in
the womb
 Preoperative care: identification at birth,
control of pulmonary hypertension - most
common morbidity
 Post operative care: aggressive ventilation,
hi flow, extraperforial(?) oxygenation
 2 class of CDH:
o Left sided: most common “boot the
leg” 80%
o Right or midline morgagni
 retro sternal defect 2-6%
incidental repair is surgical
 Poorly understood
 Early in the essophagus on the airway
embryology 22nd day presence of ventricle
diverticulum 34-36th day complete
separation into 2 tubes,
 Incidence 1:3000-4000 500 live births
 Male predominance
 Associated anomalies: VACTORL
o Vertebral anomalies
o Anal Atresias
o Cardiac defects
o Tracheoesophageal fistula, and or
Esophageal atresias,
3 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM
o Renal and Radial anomalies
o Limb defects
 Types of Esophageal atresia
o A – no fistula
o B – Proximal Fistula
o C – with distal Fistula (MOST
COMMON)
o D – Dual fistula with pouch
o E – H type
 Clinical manifestation:
o excessive salivation or drooling
o choking and coughing
o Abdominal distension(if with distal
fistula chemicalpneumonia - if
swallowing of saliva occurs
o Tachypnea
o Hypoxia
 Diagnosis:
o History and PE
o Inability to insert OGT
o Chest Xray
o Contrast studies (not advised
because of pulmonary aspiration
causing pneumonia)
 Management:
o preoperative recusitation
o Stage Surgery: ligate fistula, and
gastrostomy and repair after the
child reach preschool age, do stage
procedure if the patient is unstable
because of chemical pneumonia,
tachypneic and metabolic acidosis)
o Primary repair
 Complication:
o Early – anastomotic leak
o Dysphagia
o GER
o Anastomotic stricture
o Recurrent TEF Trachiomalatia
Doc Kharl-Kilabot & Gang 
Dr. “Dude” Isabedra
PERIANAL LESIONS
ANAL FISSURE: most common
Perianal abcess or fistula: can be systemic or
metabolic condition, usually seen at immune
compromise patients boys less than 2 year of old
are affected benign and self limiting
*Goodsalls rule – located anteriorly and the
external opening of the fistula, the tract is straight
Review:
 Hemangioma or lymphatic malformation:
o most common neck location
o pathophysio: lymphatic jugular sac
o treatment: bleomycin and OK43
sclerotheraphy
o lifecycle: proliferative phase and involuting
phase
o Most common type: Cavernous Hemangioma
 Thyroglosal duct cyst:
o Embryology: foramen cecum
o Procedure: Cyst trunk most common 2nd
 Congenital Diaphragmatic Hernia:
o trisomy 18, 21, 23
o left sided - boot the leg
o right sided - morgagni
o amniocentesis - decrease in sphingomyelin
o morbidity - pulmonary hypertension
 Esophageal atresia
o embryology: separation on the 34-36th week
o Type C 85% most common
o Treatment: Stage and primary
o Acute complication: anastamotic leak
o Chronic complication anastamotic stricture
4 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM Dr. “Dude” Isabedra

Day 2 midgut volvulus

I. Malrotation  Irritability
II. Intestinal atresia  Bilious vomiting (green color)
III. Duodenal atresia  GI bleeding
IV. Pyloric Stenosis  Paucity of bowel gas (upper abdominal
V. Intussuception fullness) – stomach and proximal duodenum
VI. Acute Appendicitis yung distended
VII. Omphalomsenteric duct remnants (Meckels (Take note that it is normal for babies to have
Diverticulum) lots of gas in the stomach because they cry and
swallow air a lot)
MALROTATION
-Malrotation of human intestine require… (sorry
naubo ako di ko nadinig) ….to mature phaseof
folded configuration
-Means there is wrong with the GIT rotation
-usually pag malrotation narrow base, narrow base
mesenteric and MID GUT VOVULUS (pinaka
dreaded complication, hindi lahat may ganito!)
-Primitive intestinal gut:
CLINICAL PRESENTATION IN OLDER CHILDREN
-midgut
-hindgut  chronic abdominal pain
-forgut  weight loss
-usually on 4th week of gestation  failure to thrive
 chronic pancreatitis
Normal Stage ng elementary tract:  celiac syndrome
1st herniation DIAGNOSIS
2nd rotation  Prenatal Ultrasound - operator dependent
3rd retraction  Hx and PE- mainstay, newborn patient, vomits
4th fixation green, GI bleeding (+) paucity of bowel gas,
-any arrest sa mga stage na to magiging polyhydramnios
malrotation  Plain abdominal X-Ray
 *UGIS- corkscrew, bird's beak appearance(
-Axis ng malrotation: SUPERIOR MESSENTERIC midgut volvulus) more sensitive than barium
ARTERY (walang iba!) enema
 *Barium Enema- high lying cecum
-Forms or type of malrotation  Ultrasound / CT scan
-incomplete rotation
-reverse rotation
INCIDENCE:
 autopsy prevalence = 0.5 – 1%
 incidence of clinical symptoms is lesser
 1:6000 live births
 50-75% symptomatic 1st month of life
 90% symptomatic in < 1 year of life
(In plain x-ray radiograph for Anteropostero
- shortly after birth
abdominal flat plain and lateral decubitus or
CLINICAL PRESENTATION
upright view,… kung older children… walapa
 Related to duodenal obstruction and/ or
kayong radio?... pag infant di pa makatayo AP view
Doc Kharl-Kilabot & Gang 
5 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM
saka lateral decubitus nkahiga, pag nkakatayo and
adult laging upright and supine, hanapin ang gastric
or duodenal distention SINGLE BUBBLE-
Malrotation na agad yan!)
SINGLE BUBBLE on x-ray
-minsan lumalabas yung duodenum
-hanapin mo din yung doudenojejenal junction?
Normal finding: Left
Abnormal fiding: Right
-you will see corkscrew birds beak, GOOD PROGNOSIS:
(kung lito kapadin do Contrast studies)
-BARIUM ENEMA= enhance large bowel to last
valve ileo cecal valve
-UGIS(upper GI series)= enhance stomach and
small bowel
-in malrotation di nag rorotate completely yung
cecum mo not in place, normal place RLQ pag di
nag rotate asa gitna or Left side so pag nag barium
enema ka yung ang hahanapin mo)
(kung lito kappa din do Doppler ultrasound)
-hahanapin mo ditto yung dilated duodenum and
inversion of the SUPERIOR MESSENTERIC ARTERY POOR PROGNOSIS:
AND VEIN “WHORL POOL SIGN”
-ano ulit yung axis? SUPERIOR MESSENTERIC
ARTERY
TREATMENT:
1. Preoperative Resuscitation
2. Surgery
A. LADDS Procedure- open the abdomen transversely,
untwist the midgut volvulus counterclockwise, cut
the ladds membrane, straighten the duodenum and
widen the mesentery.
B. Appendectomy- prevents the diagnostic dilemma
of misdiagnosing appendicitis. Since the surgery may
cause scar on the right side, baka akala nung doctor
na nagassess nagpaappendectomy na dati so
iruruleout na yung appendicitis.
INTESTINAL ATRESIA
 atresia- complete obstruction PRESENTATION:
 stenosis- umikot lang syajejuno ileal
segment
 localized late intrauterine vascular insult
Doc Kharl-Kilabot & Gang 
Dr. “Dude” Isabedra
(phathophysiology)
 ischemic necrosis of the sterile bowel
leading to resorption if the affected segment
(resorption because sterile yung bowel but
once na magswallow na it will cause
perforation)
 usually an isolated anomaly except type 3b
 di sya genetic exp type 4 (di ata sya sure d2)
 type 1 diaphragm or web
- no break in continuity
- connected yung bowel may mucosa,
messenty, may stenosis, indi patent yung
bowel
 type 2 atretic cord (most common)
- with break in continuity connected with
fibrous cord
- walang connection yung mucosa and serosa
pero may cord
 type 3a separation with mesenteric defect
- V shaped with break in continuity
- Mesentery disiciation
 type 3b inverted xmas tree
- large mesenteric defect and distal apple peel
anomaly on ileo colic artery
- assoc. with familial anomaly
 type 4 Multiple atresia
- sausage atresia preserve the segments,
stitch them together it will autoanastomose
after 10 days
 Polyhydramnios
 Billous Vomiting
 Abdominal Distension- differential with
6 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM Dr. “Dude” Isabedra

malrotation site of obstruction is more distal DUODENAL ATRESIA

(due to overgrowth of bacteria)
 Jaundice
 No meconium - may pass pellet stool/ pigeon
stool (white meconium) - small percentage lang
usually wala
-Most common cause of congenital duodenal
obstruction
-Results from a failure of canalization of the
duodenal lumen
-5:10,000 live birth, usually boys
-40% TRISOMY 21

DIAGNOSIS:
 prenatal ultrasound
 history and PE - Newborn, vomiting green,
no meconium with abdominal distention
 Plain abdominal x-ray - abdominal gases
 barium enema- mirco colon/ unused colon
Embrology
-3rd – 4th week duodenum develop from distal
portion of the proximal mid gut
-5-6 weeks usually duodenal canal obliterate due to
the proliferation the epithelial cell
-8-10 weeks vacuoles then form and coalesce to
create a lumen.
11 week recanalization
(duodenal atresia= Maldevelopment
Intestinal atresia= Insult)
ETIOLOGY
 failure of recanalization
o 50% with associated anomalies
o 40% have Trisomy 21
 35% prematurity
 25% other GI anomalies

PATHOLOGY
 majority are periampullary- obstruction is
also similar very similar to malrotation
therefore they have almost same s/sx
 dilated stomach and duodenum
 with vomiting in utero
(Malrotation= Single bubble;
 history of polyhydramnios
Intestinal atresia= Multiple)
(pag di na diagnose do contrast barium enema=
Type A. Duodenal web
walang gas or small lng yung gas)
B. may cord
C. desociation talaga
TREATMENT:
 without treatment intestinal atresia is
MANIFESTATIONS
incompatible with life
 Polyhydramnios
 prenatal counseling
 Sepsis
 preoperative resuscitation- correct
electrolyte imbalance  Vomiting and upper abdominal fullness
o consistent findings
 surgery
 Bilious or nonbilious vomiting
 resection or end-end anastomosis
 abdomen usually distended by the dilated
 postoperative care
stomach and proximal duodenum

Doc Kharl-Kilabot & Gang 

7 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM Dr. “Dude” Isabedra

INCIDENCE
DIAGNOSIS  more common in Caucasians than Hispanics,
 Prenatal Ultrasound Blacks, or Asian
 History & PE  1-3:1000 live births
 Plain Abdominal X-ray - confirmatory  4:1 male to female ratio
o “Double Bubble Sign” –  Maternal History: 19% boys, 7% girls
pathognomomic, also seen in  Paternal History – 5% boys, 2.5 girls
prenatal UTZ, distended  7% with associated anomalies
stomach and distended ETIOLOGY / PATHOLOGY
duodenum is seen in AP VIEW.  Congenital? Acquired? – unsure of the
(yung nag hahati sa kanila cause, not proven yet.
“pylorus”)  Genetic Evidence
o Race, male, first born, ABO type
(Multiple=Intestinal atresia  Gastric hyperacidity  muscle spasm &
Single= Malrotation hypertrophy leading to obstruction of the
Double= Duodenal atresia) gastric outlet
 abnormal pyloric innervations
TREATMENT  abnormal motility due to decrease
 Amniocentesis, Karyotyping pacemaker cells
 Counseling marked muscle hyperthrophy  partial/complete
 Preoperative Resuscitation gastric outlet obstruction
 Surgery – “Diamond
anastomosis” (walang CLINICAL MANIFESTATIONS:
nereresect, kasi usually yung -Non-bilios vomiting at 2-8 weeks of life
atretic part asa d2>ampulla -always hungry
of vater>common bile duct kaya pag tinangal -HYPOCHLOREMIC HYPOKALEMIC ALKALOSIS
mo yun wipples nay un) -visible gastric peristaltic wave
 Open the proximal and distal segment then do -palpable pyloric tumor
an anastomosis. DIAGNOSIS
 POSTOPERATIVE CARE  History & PE
 Plan X-ray not specific
COMPLICATIONS  Ultrasound- “Target Sign” (hypertrophy of
 anastomotic leak pyloric muscle)
 POA – possibility of adhesion  UGIS- “String Sign”
 functional obstruction TREATMENT
 Tapering Duodenoplasty (kase dilated yung -Preoperative resuscitation
pouch, magkaiba yung lumen nung dalawa, -Surgery FREDET-RAMSTEDT PROCEDURE
or else obstruction ) -Post operative care
-?Non-operative management
PYLORIC STENOSIS

Doc Kharl-Kilabot & Gang 

8 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM Dr. “Dude” Isabedra

INTUSSUCEPTION o Resection / EEA

 telescoping of one segment to another o Appendectomy (kase appendix yung lymphoid,
o Idiopathic or primary pag infection lumalaki yung appendix)
o Nonidiopathic or Secondary
 Iliocolic (most common) ACUTE APPENDICITIS
 ileoileal -Peak at 12-18 y/o
 colocolic -Rare in children <5y/o
 jejunojejunal -Extremely rare in <3y/o
-Prerforation rate- 20%
INCIDENCE Affect morbidity
 majority are Idiopathic -significant change in the management
 between 5-9 months of life
 >50% occur within <1 y/o PATHOLOGY
 10-20% occur in >2 y/o -a disease of multiple etiologies
-invassion of appendiceal wall by bacteria
 M:F = 3:2
1. Luminal obstruction
2. Submucosal lymphoid follicles
PATHOGENESIS
3. Enteric infection
 marked hypertrophy of the lymphoid tissue
4. Foreign body
 occur in the wake of URTI/AGE
5. Cystic fibrosis
 adenovirus/rotavirus also implicated
 different caliber of the lumens CLINICAL MANIFESTATION
 2-12% with anatomic lead points -CLASSICaa- < 50%, MOST ARE “ATYPICAL”
-Hx and PE still the hallmark of diagnosis
CLINICAL MANIFESTATION -vague pain> nausea/vomiting>somatic pain
 Sudden crampy abdominal pain in a previously -anorexia is a classic and consinten finding
well baby -12-24-viseral to somatic
o screaming, drawing up of legs, pallor, -24-48- progression of sx
sweating, & vomiting ->36-48- perforation in 65%
 well and hungry in between -usually leads to generalize peritonitis
o bilious vomiting -“Treacherous calm of dieulafoy”
o “Currant Jelly Stools” * P.E.
o “Dance Sign” * -localize tenderness – single most important
DIAGNOSIS finding
 History& PE -Dieulafoy’s Triad
 Abdominal X-ray 1. hypersesitivity of the skin
 Barium/Air Enema 2. RLQ guarding
o Diagnostic & Therapeutic 3. Mcburbey’s tenderness
 Ultrasound -rebound tenderness – should be avoided
-very painful
TREATMENT -Poor correlation with peritonitis
 Resuscitation -Rectal examination – not routinely done
 Non-operative management -uncomfortable
o Barium / Air Reduction -unlikely to contribute ti the evaluation of AA
 done under double set-up
 Resuscitation LABORATORY FINDINGS
 Operative management -individually, none are very sensitive or specific for
o Manual Reduction AA
Doc Kharl-Kilabot & Gang 
9 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM Dr. “Dude” Isabedra

-more important for the management decisions  interval

-CBC, urinalysis, electrolytes, BUN/creatinine, C-
reactive protein OMPHALOMSENTERIC DUCT REMNANTS:
MECKELS DIVERTICULUM
MEDICAL IMAGING EMBROLOGY
-plain films  5-7th wk AOG- regression of OMD
-ultrasound  Placenta replaces the yolk sac
-CT Scan  Failure of regression cause several
-MRI/WBC Scan anomalies
-Ultrasound PATHOLOGY
 >90% specificity and sensitivity  Outpouching of the mesenteric boarder
 Wall thickness >6mm  True diverticulum
 Luminal distention  Within 90 cm of the ICV
 Lack of compressibility  With distal vitelline artery remnant
 Complex mass in the RLQ  With heterotrophic mucosa
 Fecalith o Seen in symptomatic cases
 Inability to visualize the appendix in 20% CLINICAL MANIFESTATION
 A visualized normal appendix rule out AA  Rule of “2”
 Obesity  Obtrction
 Bowel distention o Volvulus
 Pain o Intussusception
 Inexpensive o Fibrous bands
 Low radiation  Bleeding
 Beneficial for adolescent females o Heterotrophic mucosa
o Painless bleeding
DIAGNOSTIC APPROACH o <5 y/o
-Diagnosis in only 50-70% on initial assessment o Episodic bleeding
-acceptable negative laparotomy – 10-20% o Peptic ulceration
-alvarado scale  Inflammation
-active observation o FB impaction
-radiologic imaging o Parasitic infection
o Rarely diagnosed preoperatively
RADIOLOGIC IMAGING  Other
 In ALL atypical cases o Tumors
 Decrease morbidity o FB impaction
 Optimize management o Parasitic infection
 Decreased negative laparotomies to <3% DIAGNOSIS
 Ultrasound is tfirst line  History
 CT Scan if UTZ not available  Physical examination
 Obese px  UGIS with intestinal follow through
 Probable advanced AA  Meckels’s scan
 Gaseous distention of bowels  Laparoscopy
TREATMENT  Incidental diverticulectomy
-antibiotic o Controversial
-interventional radiology o Lifetime risk of Meckel’s 4-6%
-appendectomy o More philosophic tha scientific
 Semi-elective o Risk is the same
Doc Kharl-Kilabot & Gang 
10 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM Dr. “Dude” Isabedra

Day 3 III. Incidence:

I. Umbilibal Hernia  true incidence is not known --kasi di siya ganoon
II. Inguinal Hernia kaimportante, for cosmetic lang sya.
III. Hydrocele  race and prematurity are predisposing factors
IV. Undescended testis usually isolated in infants --walang connection
V. Retractile testis ang infant
VI. Abdominal wall defects associated with a number of clinical anomalies
VII. Biliary Atresia like any hernia, merong direct and indirect yan, and
VIII. Choledochal cyst pediatric umbilical hernia are congenital, walang
iatrogenic yan. Kasi ang pathophysio niyan is
Guys, walang powerpoint na binigay dito. Kaya di ko persistent umbilical vein to the lesser 5cm sa
maintegrate ang pictures… idaan niyo nalang sa umbical hernia
imagination. Hehe. Pagtiyagaan nlang ito. Bale yung Other syndromes that causes umbilical hernia:
sa manual lang naincorporate ko sa trans na ito. ;) -Beckwith-Wiedemann
Yung naka BOLD is from manual (halos same lang sa -Ritters (?)
ppt ni doc) tpos the rest is yung mga explanation na -Trisomy
ni Doc. Yun lang. God Bless! ;)
Natural history:
UMBILICAL HERNIA *most are recognized at birth → pag laglag ng
pinapakita ng schematic diagram [imagine nio umbilical vein nakikita mo na kaagad yung hernia.
nlng] to show yung weakness ng abdominal wall sa * related symptoms are rare
umbilical hernia. Kasi diyan walang muscle, at ang * majority regresses with time.
fascia ay iisa; linea alba lang. Walang layer ng fat at * diameter and sharpness of fascial edge are
wala masyado layers ng subcutaneous. predictors of spontaneous closure.
I. Embryology: Sa abdominal wall, marami ibang klase ng hernia--
* somatopleura of the overhanging hand and tail ang importante UMBILICAL HERNIA and INGUINAL
folds HERNIA.
*closure of folds – umbilical ring—contracture
after cord ligatiom & thrombosis of vessels IV. TREATMENT
Expectant management:
II. Etiology: *Most will spontaneously regress, so no need
Embryologic basis: failure of the recti to surgery. If you do surgery you wait until 4-5y/o ang
approximate. patient.
-So ang umbilical hernia ay failure of the rectus to You do only surgery if there are symptoms of
approximate. Usually kasi during embryology laceration, if there is pain and >2cm defect na di pa
week development, pag nagka-fail na nagclose nagcclose until 4-5y/o and kung cosmetic region.
yun, lalabas ang abdominal contents.
INGUINAL HERNIA
Anatomic basis: -isa sa mga pinaka common na surgical case sa
1.) umbilical scar > pediatric patient.
2.) round ligament > Umbilical ring Q: Embryologically, ano ang mas mababa na
3.) umbilical fascia > testicle? Left? Or Right?
--pag ang umbilical scar and round ligament ay A: Left. Kasi una nag dedescend ang left testicle
naka-obstruct or yung umbilical fascia ay hindi kaya ang hernia pinaka-common sa right kasi mas
nagclose! maaga nag-descend ang left, mas late ang right mas
late nagcclose ang Prosesus vaginalis. So palagi
common ang right.

Doc Kharl-Kilabot & Gang 

11 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM Dr. “Dude” Isabedra

I. Embryogenesis: 2.> sedation

Testicular descent: 3.> ice pack --kung iyak ng iyak ang patient
Intraabdominal phase -influenced by MIS 4.> gentle push -- dun sa bulging mass
External Phase- influenced by testosterone  In Premature infants:
Pathology: -bilateral is more common, kaya lang wait mag
-Sac (Patent procesus vaginalis) mature ang baby bago irepair ang inguinal hernia,
-Defect kasi common ang post operative apnea --kasi wala
-Content -->non obliterated vaginalis sila sakit, common lang post-op sa premature is
II. Incidence: hindi makahinga.
0.8-4.4% in the general population -herniotomy before discharge. Then hintayin
30% in prematures kung lahat ng parameters ay normal bago ischedule
Highest at 1y/o, 1/3 are 6mos for operation.
M:F -3-10:1 Ddx of inguinal hernia is HYDROCELE, same sila ng
R-60% incarceration <6months pathophysio which is patent procesus vaginalis,
III. Clinical Manifestation kaya lang pag hydrocele fluid lang around testis. Pag
-bulge in the inguino-scrotal area: inguinal hernia, patent ang procesus vaginalis,
increase in size on straining pumapasok yung bowel.
may be evident at birth or may appear later
usually reducible HYDROCELE
Pathophysio: fluid around the testis
Pag sa adult: weak inguinal floor soft, bluish cystic swelling
Pag sa pediatric: patent procesus vaginalis usually fluctuates in size
must be differentiated from inguinal hernia.
IV. Physical Exam: Inguinal Hernia Hydrocele
1.) Palpable or visible mass Patent PV Patent PV
2.) "Silk-glove sign" - pag ininsert niyo ang finger Intestinal content Fluuid content
niyo sa inguinal canal tapos nakakapa niyo ang Irregular in shape Usually round
edematous na spermatic cord so magsslide sya sa Irreducible Can be pushed
finger mo, ang feeling na parang silk. upwards
3.) Position of the testis must be determined Less mobile More mobile
Wider inguinal neck No inguinal neck
V. Diagnosis: (-) transillumination (+) transillumination
1.) History and PE Tc as soon as Generally
2.) Herniogram - hindi na ito ginagawa sa atin. diagnosed observation
3.) Ultrasound - we do this na kasi it is cheaper and
sensitive Treatment:
4.) Laparoscopy Usually, pag hydrocele, communicating or non
5.) Re-examination communicating man...you have to observe the
*** pag di pa rin, ang newest method ngayon is hydrocele until 1 year old kasi minsan nagcclose ang
diagnostic lang pero mahal kasi it is a surgical defect.
procedure. Pag communicating type, just treat as clinical
hernia.
VI. Treatment If non communicating type --- usually observe until
Reducible -elective herniotomy as soon as 1y/o.
diagnosed
If Incarcerated -- manual reductions.
The maneuvers are
1.> trendelenburg position
Doc Kharl-Kilabot & Gang 
12 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM
UNDESCENDED TESTIS
Other name of undescended testis is
Cryptorchidism.
So magkaiba yan, ang TRUE undescended testis
nasa pathway nung normal descend ng testis,
pwedeng abdominal, pwedeng inguinal, scrotal.
Pagka ECTOPIC -- outside nung pathway ang pag
descend ng testis, may pre-penile, superficial,
ectopic, transverse scrotal, femoral, perineal, pero
very rare ang ectopic. Yung TRUE Undescended
testis, yan ang very common!
At 7 months -- sa abdominal ang testis
At 8 months -- start ng descend kasama ang
procesus
vaginalis
At 1 y/o infant --- tsaka magcocomplete ang
descended testis to the scrotum.
I. Incidence:
 3-4% at birth, 1% at 1 year of age
 30-70% in premature infants
2/3 are palpable in the inguinal area
II. Diagnosis:
By History and PE. Then Ultrasonography, if hindi
parin then do CT Scan and usually pag di parin
Makita dito kasi maliit lang around 1-2cm then do
diagnostic laparoscopy. Then if hindi parin then
schedule the patient for Inguinal exploration.
III. Treatment
Non surgical and Hormonal – pero di na ito
ginagawa. Lagi na ngayon surgical, we do
orchidopexy.
The timing of surgery is 1-1/2 years of age (eto
tlga nakalagay sa manual pati sabi ni doc)
Q: Bakit at 1 to ½ years of age?
A: So ang core temperature natin is 37°C , ang testis
ang core temperature requirement niya is 33°C. Di
siya pwede sa loob. Pag nasa loob siya in a different
environment 37°C naiinitan ang testis at
nagcoconvert siya into cancer. So nagiging cancer
siya pag nasa intraabdominal area. Ang pinaka-
common na cancer ay dalawa lang yun, YOLK SAC
and CHORIOCARCINOMA.
So may reason talaga, di lang for cosmetic.
Doc Kharl-Kilabot & Gang 
Dr. “Dude” Isabedra
Differential diagnosis of Undescended testis is
Retractile Testis.
RETRACTILE TESTIS
Kapag ang testis nagbaba sa scrotum at normal
positon, pero pumapalit. Retractile testis na yun!
And testis is normal in size usually.
transient retraction of the testis out of the
scrotum
hyperactive cremasteric muscles
common in middle childhood
must be differentiated from UDT(Undescended
Testis)
you only do conservative management
The testis can be brought fully to the bottom of
the scrotum
the testis remains in the scrotum after
manipulation w/o immediate retraction
the testis is normal in size
history that the testis is spontaneously in the
scrotum some of the time.
ABDOMINAL WALL DEFECTS. –Kabisaduhin daw
to!!!
Ibat ibang klase ang abdominal wall defects at ang
pinaka-common ay ang MIDDLE abdominal wall
defect.
1.) Upper midline defects
Pentalogy Cantrell –sa upper midline, so ano
ang naka-herniate? Yung heart. Very rare ito! Nakita
niyo sa facebook, yung bata na may hawak na heart
niya? Yun yun! So may Upper midline defect, tapos
may defect sa diaphragm kaya lumalabas ang heart.
In Pentalogy of Cantrell, usually they don’t survive
pero meron naman mangilan-ngilan.
Bukas lahat yan ang abdomen, pati liver
lumalabas. Ang ibang organs naka-herniate.
2.) Middle Abdominal Wall defects
Gastrochisis
Omphalocele – if wala ka plan to do surgery you
can do topical treatment, maglalagay ka ng
Flamazine –usually yun ang ginagamit para
magclose ang skin. Pag nag-flamazine ka sa sac na sa
area na yan, ang skin sa gilid ay umaakyat yan tapos
it covers the whole sac. Pangit tingnan but
nagssurvive ang baby. Pwede mo naman ayus-
13 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM
ayusin pag malaki na ang baby. Pangit tingnan pero
at least di na kelangan ng surgery.
Omphalocele has many different anomalies,
usually cardiac anomalies kaya hirap operahan.
3.)Lower midline defects
 Bladder exstrophy – urinary bladder lang ang
nakaherniate
Cloacal exstrophy –small bowel ang naka-
herniate AT may omphalocele.
** it is a midline defect, na lahat ng nasa lower
midline ay hindi nagfuse sa gitna so pati ang genital
organ ng bata ay hindi nag fuse. Ang problem sa
bladder/cloacal exstrophy is hindi mo alam kung
male or female ang baby. So kelangan mo magpa-
karyotype. You need karyotyping para ma-identify
ang sex ng baby. In States, pag nirepair yan,
ginagawang female muna. Kasi mas mahirap pag
gawin muna male.
How to repair Cloacal Exstrophy?
Usually iclose sa gitna, then saka nalang lagyan ng
ari ang bata paglaki niya. Kasi mahirap yan irepair.
I. Diagnosis:
 Prenatal Ultrasound
II. Management:
Counseling
Transfer to tertiary center
Thermoregulation
Local Care of Defect
Hydration
Antibiotic coverage
III. Non-operative management:
Termination of pregnancy
Topical treatment
Expectant management
Operative
Primary closure
Skin Closure
Silo
Doc Kharl-Kilabot & Gang 
Dr. “Dude” Isabedra
BILIARY ATRESIA
eto yung madalas pinapalabas sa kapwa mo mahal
ko. 
I. GENERAL CONSIDERATIONS:
not a static disease but chronic, progressive liver
problem.
40% passed meconium at birth – hindi
nadidiagnose at birth agad2x.
1:10,000-12,000 live births
no racial differences or genetic factors
M:F = 1:0.64 (MALE is predisposed!)
3 MAIN TYPES:
1.) TYPE 1 – atretic part is common bile duct
2.) TYPE 2 – common hepatic hanggang
common bile duct.
3.) TYPE 3 – hanggang common hepatic duct.
4.) TYPE 4 – buong biliary tree kasama ang
gallbladder. So ito ang pinaka-common
type!
II. CAUSE: exact cause is not known
not link to medications taken, or illnesses of the
mother
currently no genetic link known
unlikely to occur more than once in the family
III. PATHOLOGY:
ductular proliferation and portal fibrosis
** pag- nakita niyo ito sa exam question – BILIARY
ATRESIA na! Ganun lang.
IV. CLINICAL MANIFESTATIONS:
Jaundice, clay-colored stools (alcoholic stool),
and hepatomegaly
splenomegaly
active initially sequelae of cirrhosis – if with
progressive disease magkakaroon ng liver cirrhosis.
average survival (untreated) = 19 mos.
appear healthy at birth
usually asymptomatic at 2 WoL (week of life)
jaundice, clay-colored stools, dark urine and
hepatomegaly
splenomegaly – S/Sx generally non specific
average survival (untreated) = 19 mos.
V. DIAGNOSIS:
History and PE
14 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM Dr. “Dude” Isabedra

Liver function test, bleeding parameters,  Tx: Kasai portoenterotomy

serology
Hepatobiliary tree ultrasound – kasi ang pinaka-
common atretic ang buong tree (gallbladder,
common hepatic, CBD) So by ultrasound kelangan
mo Makita ang gallbladder. So pagka on ultrasound
absent ang gallbladder, biliary atresia agad ang
iconsider.
 HIDA/DISIDA scan – if by ultrasound di ka pa rin
sure you do this. Meron tayong binibigay contrast na
inaabsorb ng liver.
 Liver biopsy – golden diagnostic parameter ng
biliary atresia. Look for ductular proliferation and
portal fibrosis.
Intraoperative cholangiogram
Diagnosis should be done before 2nd mos of life.
VI. Treatment:
Kasai portoenterotomy – excise the whole atretic
biliary tree.
Liver transplantation – if di mag work ang kasai
portoenterotomy, do liver transplant.
VII. Results:
age at surgery
technique
severity of liver disease (or cirrhosis)
post operative complications
CHOLEDOCHAL CYST
relatively rare anomaly
1:100,000 livebirths
higher in Asians
I. TYPES:
1.) TYPE 1 – FUSIFORM (or cystic dilations of
the extrahepatic biliary tree) – MOST
COMMON TYPE.
2.) TYPE 2 – EXTRAHEPATIC (saccular)
3.) TYPE 3 – INTRADUODENAL (bile duct
dilatation w/in the duodenal wall)
4.) TYPE 4a – INTRAHEPATIC
5.) TYPE 4b = EXTRAHEPATIC (multiple)
6.) TYPE 5 – INTRA and EXTRA (Caroli’s disease
ang type na ito)
**ganyan classification ni doc. Pero ang sa
Schwartz kasi ang sa TYPE 4a both extrahepatic and
intrahepatic bile ducts, TYPE 4b affects
extrahepatic biles ducts only. TYPE 5 – intrahepatic
biliary cysts.

VIII. Timing of surgery:

<8weeks = 68% rate of success (BEST! Dapat
maoperahan na agad ang biliary atresia.)
61-70 days = 39%
 71-90 days = 31%
 >90 days – 15 %
II. Pathogenesis:
KEY POINTS dito Biliary atresia: 1.) Congenital weakness of the CBD
Absent gallbladder 2.) Distal CBD obstruction
walang portal vein 3.) Common channel theory
kelangan iexcise ang lahat ng fibrosis nay an para
maexpose yung porta hepatis kasi jan lumalabas ang III. Clinical manifestation:
bile mo through ducts of Luschka (accessory duct of more common in Japan
liver na nagsesecrete ng bile) M:F = 4:1
On ultrasound: atretic or nagcollapse ang intermittent jaundice
gallbladder and not developed. Dun sa right ng TRIAD of: abdominal pain, jaundice and palpable
ultrasound fibrotic ang porta hepatis. mass
Pathophysio: Ductular proliferation & portal usually patients presents with sepsis and
fibrosis cholangitis due to distal CBD obstruction in infants
Doc Kharl-Kilabot & Gang 
15 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM Dr. “Dude” Isabedra

1.) Diagnostic exam?

IV. Diagnosis: a.) Xray (cross table)
History and PE b.) CT scan
Ultrasound –if makita mo na may choledochal c.) Barium enema
cyst you do CT scan na! d.) MRI
CT scan e.) Upper GI
Percutaneous Transhepatic Cholangiograpy ***Laging Xray with cross table lateral views.
(PTC)
ERCP (Endoscopic Retrograde 2.)What is the Contraindication for surgery?
Cholangiopancreaticography) - so meron kang a.) Bilious vomiting
camera sa esophagus mo til sa ampulla of vater. b.) Peritonitis
HIDA/DISIDA Scan c.) Abdominal distention
d.) BP 110/80
Treatment: e.) Temp 38
Cyst drainage
Cyst enterostomy – pag sobrang laki at di mo 3.) What is your diagnosis?
matanggal ang cyst, pwede mo syang iconnect sa a.) Hirschprung (hindi naman nagbbloody
bowel para madrain ang content ng cyst. diarrhea)
Excision of CDC: b.) Duodenal atresia (newborn)
1.)Hepatico-J Roux-Y  common hepatic duct to c.) Intestinal atresia (newborn)
jejunum or common hepatic duct to duodenum d.) Intussusception (6mos old -2y/o)
2.)Hepatico-D --> tinanggal mo ang buong common e.) AP (teenage years)
hepatic duct tsaka common bile duct. So iakakbit mo
ang common hepatic duct sa bowel. Para madrain CASE#2: A 2 y/o female was referred to you due to
yung bile mo. vomiting whitish material patient pass meconium
within 24 hrs. PE= vital signs shows BP 90/70 HR:150
After mo maexcise iexpose mo ang common RR:26 Temp:36 Abdomen flat, not distended. OGT
hepatic duct ikabit mo sa Jejunum. Kasi pag was not tolerated. Next diagnostic exam?
duodenum, masyado magkatabi, ang problem kasi a.)
dun pag sa duodenum malapit lang sa tiyan, ang b.) Cross table lateral view
food particle umaakyat. So mataas ang rate for c.) Prone cross table lateral view
cholangitis. Kesa sa Jejunum yung kinabit mo jan, d.) Babygram
ang dumadaan jan na bile lahat yun digested na so e.) CT Scan
di na mataas yung cholangitis. Most common associated anomaly?

SA EXAM DAW! Ang mga Common ang tinatanong! Most common type?
Tapos cases! Kasi sa board exam cases. Di na uso C
yung what is the ek-ek! Most common chronic complication?
Stricture
SAMPLE CASES:
CASE #1: A 1 year old male was brought to the ER
due to villous vomiting of 3-day duration, patient
had abdominal distention for more than 24 hrs.
Patient had an episode of bloody diarrhea prior
going to the ER. BP ==110/80, HR:120 RR:30 Temp:
38C. PE=Board-like Abdomen, tympantic. DRE:
Empty rectal vault. No stool upon examining finger.

Doc Kharl-Kilabot & Gang 

16 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM Dr. “Dude” Isabedra

Day 4
I. Hirschsprung’s disease
II. Anorectal Malformation

HISRCHSPRUNG’S DISEASE

 Absence of ganglion cells

o Arrest inhibitory process of colon
o Collapse of Hirschsprung disease
 Meissner’s – submucosal
 Auerbach – intermyenteric
 Henle - submucosal
 Loss of intrinsic enteric inhibitory nerves
 Short segment (80-85%) – most common
ETIOLOGY
 Exact etiology is unknown
 Harold Hirschsprung, MD (Danish Pediatrician)
 Genetic cause:
 1800 o May affect more than one sibling
o Sibling of index patients; female: 360x, male
EMBRYOLOGY o The longer the disease, the higher the rate
of familial incidence.

GENETIC ETIOLOGY
 Deletion of 10q11.2 and q21.2
 Chromosome 13q22 recessive susceptibility
locus
 Error in endothelin B receptor gene (EDNRB)
 Neuroenteric cells migrate distally along the exon 4
course of the vagus nerve.
 5th week AOG – esophagus
 7th week AOG – midgut
 12th week AOG – complete migration
 Transmural migration of neuroenteric cells

PATHOPHYSIOLOGY

 RET proto-oncogene – a transmembrane

receptor
o Control of normal cell growth and
development, enteric nervous system
o MEN 2A and 2B

Doc Kharl-Kilabot & Gang 

17 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM Dr. “Dude” Isabedra

 (+) Enterocolitis
 Complete obstruction at birth
 Delayed passage of meconium followed by
repeated obstruction
 Mild constipation followed by acute
obstruction
 Mild symptoms followed by enterocolitis
 Mild chronic constipation
INCIDENCE
 1:2000 live births, 70-80% males DIAGNOSTIC
 Familial predisposition – rare  History & PE
 25% with associated anomalies in familial
cases
 Most are isolated in non-familial cases
 Observed in all races but is less common in
blacks
 Most common – short segment (44%) – Recto
sigmoid
 Least common – Cecum (start of colon) – 1%
 Pwede bang magkaron ng HD sa cecum pero
wala sa recto sigmoid? – NO
o Transmural migration – neuroenteric cells
 Radiography
nag arrest migration sa acending, hindi
o Plain abdominal x-ray
yan lalagtaw, hindi pupunta sa descending
 Toxic megacolon: full of gas in the
o sa recto sigmoid, hangang dun lang un –
bowel
hindi pwedeng skip lesion.

CLINICAL PRESENTATION
 Most present with intestinal obstruction and
constipation.
 Failure to pass meconium within the 1st 24
hours of life – 95% of patients with HD
 Explosive discharge of fluid stools and air on
DRE

Doc Kharl-Kilabot & Gang 

18 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM Dr. “Dude” Isabedra

MANAGEMENT
 Non-surgical
o NGT
o Colonic washout
 Surgical
o Goal: to resect the ganglionic part with the
megacolon
o 3 stage procedure
o 2 stage procedure
o 1 stage (Primary) procedure
 Open
 Laparoscopic
 Incision less

o Barium enema – to locate the transition

zone
 Transition zone – location of ganglion
normal bowel
 Anorectal Manometry
 Rectal Biopsy
o Gold standard
o Open or Suction
 <1 y/o – thin mucosa – Suction RB (sa
PGH at PCMC lang daw meron)
 >1 y/o – thick mucosa – Open RB
o Pros: cheap, no anaesthesia needed, Out-
Patient, fast technique
 Pull through procedures
 Swenson – resect lahat
 Resect the aganglionic part then
anastomose
 Soave – retain ang ganglionic colon
 Bowel is not resected but you will
pass through the ganglionic colon
then anastomose
 Duhamel - nasa posterior yung
ganglionic colon

Doc Kharl-Kilabot & Gang 

19 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM Dr. “Dude” Isabedra

 Aganglionic part is not resected but • feed 6 hours post op

you will bypass the ganglionic part • Shift IV antibiotics to oral, discontinue on the
(nerve of colon) 2nd to 3rd post op day
 Scott-Boley  Follow up 1 week postop
 Minimally invasive surgery
 Less physiological stress
• Technically easy and safe mobilization of distal
colon
• No postoperative ileus
• Less postoperative pain
• Adhesion formation, nil
 Shorter hospital stay
 Good cosmetic result
 Successful in all properly selected patients
o Acceptable operative time
o Short learning curve
o Best suited for younger patients
• Contraindicated for older patients with
megacolon

 Transanal (Incisionless)
• History and PE
• Barium enema
• Rectal biopsy
• Admitted day before the surgery
• Clear liquid diet (ORS)
• Laxative/colonic washouts
• IV antibiotics 1 hour prior to surgery
• Final colonic washout in the OR
Doc Kharl-Kilabot & Gang 
20 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM Dr. “Dude” Isabedra

DIAGNOSIS
 History
 PE
o Abdominal distention
o Flat abdomen
o No sphincter

CLASSIFICATION
ANORECTAL MALFORMATION  History and PE
o Radiography
o Babygram – AP view
o Invertogram (Rice-Wangesteen) - before
o Prone cross-table lateral view
 Anal marker: (-) rectal pouch/gas (high
tide)
o Perineal/Hypogastric ultrasound - before
o Contrast studies
 Recto-upper vagina
 Distal contonogram?
INCIDENCE o Anatomic Classification
 Not known  High
 1:4000/5000  Male: rectovesical, rectoprostatic
 2/3 of males have high types  Female: rectouppervaginal
 2/3 of females have low types  Intermediate
 VACTERL  Low
 Anocutaneous
 Anovestibular
 Anocutaneousfistula

Doc Kharl-Kilabot & Gang 

21 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM Dr. “Dude” Isabedra

MANAGEMENT
 Low lesions
o Perineal anoplasty
 High lesions
o Colostomy at birth
o PSARP at 4-6 months
o Closure of colostomy after 3 months

o Radiogrphic Classification:
 Distance of Rectal pouch from anal
marker
 High type = >1cm
 Low type = <1cm

Doc Kharl-Kilabot & Gang 

22 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM Dr. “Dude” Isabedra

Doc Kharl-Kilabot & Gang 

23 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM Dr. “Dude” Isabedra

Day 5: PEDIATRIC TUMORS  N-myc Amplification

I. NEUROBLASTOMA – Adrenal Medulla  DNA Ploidy
II. WILMS’ TUMOR - Kidney  Chromosome 1p deletion
III. HEPATOBLASTOMA - Liver  Urinary VMA/HVA
IV. TERATOMA - Gonads
TREATMENT
NEUROBLASTOMA  Multi-specialty
 2ND most common SOLID malignancy o Surgery
 Origin: Neural crest o Chemotherapy
 Can be located along the tract of neural o Radiotherapy
crest migration:
o Cranial WILMS’ TUMOR
o Trunk  Only cancer with Stage 5 – tumor involved
o Cardiac the kidney
o Vagal  WT1
o Adrenals (Adrenal Medulla) – most o A tumor suppressor gene
common o WAGR syndrome
 Embryonic tumor of the sympathetic o Deletion of 11p13
nervous system o Denys-Drash syndrome
 Involved in other syndromes:  Aniridia
o Beckwith-Wiedeman Syndrome  WT2
o Hirschsprung disease o Chromosome 11 band 15
o LoH – 16q
CHROMOSOMAL TYPE o Beckwith – Wiedeman Syndrome
 Chromosome 2  Exomphalos
 Deletion of 1p36  Gigantism
 LoH 1P  Macroglossia
 Associated anomalies
CLINICAL PRESENTATION o Aniridia
 Horner’s Syndrome – different pupil size o Hemihypertrophy
 Panda Eyes / Racoon o BWS - Beckwith – Wiedeman
o Neuroblastoma & Basilar trauma Syndrome
o Late stage of Wilms’ tumor o Urologic Anomalies
o Sympathetic spread o WAGR Syndrome
o Metastasis to the regional tissue
(muscular layer) CLINICAL PRESENTATION
 Dancing-eye Syndrome  Healthy thriving preschooler
 Asymptomatic (painless) abdominal mass
HISTOPATH  Hypertension
 Homer Wright rosettes - pathognomonic  Hematuria
o tumor cells around the neuropil  Large, smooth, firm, non-tender mass
 Abdominal pain, fever and Anemia
MARKER OF THE DIASEASE
 Not specific but can help in diagnosis DIAGNOSIS
 Neuron Specific Enolase  History / PE
 Ferritin  Blood examinations
 LDH  Ultrasound
Doc Kharl-Kilabot & Gang 
24 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM Dr. “Dude” Isabedra

 CT Scan
 MRI
TREATMENT
 Surgery TERATOMA
o Complete excision  Derived from totipotential cell with at least
o Provide accurate staging 2 germ layers
information  Cells in the proximity of Hensen’s nodes
 Biopsy  Usally midline or para-axial in location
 Chemotherapy  80% benign but can be malignant
 Gonadal – older children
HEPATOBLASTOMA  Extragonadal – younger children
 Fetal origin tissues  Sacro-coccygeal – Newborn
 All pediatric tumors = blastoma  common in females – 80%
 Most common childhood HEPATIC  incomplete twinning
malignancy  most secrte AFP, bHCG
 M:F = 1.7:1  deletion of chromosome 1 & 6
 18 mos – 3 y/o – most common  with calcification
 Secretes AFP  <10% - risk of malignancy at birth
 LoH 11p5.5 & 1p36  >75% after 1 y/o
 Trisomy 20 or 2

CLINICAL PRESENTATION
 Asymptomatic mass
 Failure to thrive
 Rarely produce sexual precocity
 Anemia – elaboration of cytokines
 Some present acutely with tumor rupture

DIAGNOSIS
 History / PE
 Liver function tests
 AFP
 Radiography
 CT Scan / MRI
 Biopsy

TREATMENT
 Surgery
o Excision
DIAGNOSIS
o Biopsy
 History / PE
 Chemotherapy
 Radiography
 Radiotherapy
 CT Scan
 Liver transplantation
 MRI

TREATMENT
 Surgery
Doc Kharl-Kilabot & Gang 
25 PEDIATRIC SURGERY (SY 2016-2017) – 1ST SEM Dr. “Dude” Isabedra

 Excision 5. A 1 year old boy was referred to you due to

 Biopsy abdominal mass. No symptoms was noted
 Chemotherapy prior to referral. On PE, note of bluish
 Radiotherapy discoloration of right eye.
a. Exploratory laparotomy
SAMPLE QUESTIONS FROM DR. ISABEDRA b. Rectal biopsy
1. Most common chronic complication: c. Barium enema
a. Anastomotic disruption d. UGIS
b. Leak e. Ct scan
c. Stricture
d. Megacolon 6. Bluish discoloration
e. Sausage shaped mass a. Aniridia
b. Panda eyes
A 2 year old boy was brought to the ER due to c. Horner’s
abdominal distention & vomiting. Vomiting started d. WAGR
3 days prior and abdominal distention was noted e. VACTERL
night before. Patient had water diarrhea since 2
days prior. On PE, 120/80, 110, 28, 37.8. Abdominal 7. 1 10 day old fenale was reffered to you due to
distention, tympanitic, DRE: empty rectal vault, no vomiting, abdomen was not distented and
blood or stool on examining finger. non-tympanitic. Patient passed meconium
within 24 hours.
2. If on PE you noted sudden gush of flatus on a. Double bubble
DRE (clue for Hirschsprung's) , and on X-ray b. Dance’s
note of massively dilated bowels, what is the c. Corkscrew
gold standard for diagnosis of this patient: d. Bird’s beak
a. Ct Scan e. Apple core
b. Exploratory laparotomy
c. Barium Enema 8. Surgery of choice
d. UGIS a. Pullthrough
e. Rectal Biopsy b. PSARP
c. Diamond anastomosis – for Duodenal
3. If on PE you noted bulging scrotal area. What is atresia
your next plan? d. Ramsted
a. Exploratory laparotomy e. Ladd’s
b. Inguinal exploration
c. Manual reduction – conserve therapy
lagi pag Perineal
d. CT scan
e. MRI

4. If on PE you noted a sausage shaped mass.

What is you diagnosis?
a. Hirschsprung’s disease
b. Toxic Megacolon
c. Intussusception
d. Neuroblastoma
e. Nephroblastoma

Doc Kharl-Kilabot & Gang 