Meera Kotagal
388 statements · 12 topics · summaries given as host listed separately
Abdominal Wall Defects
· guest expert
Colorectal / ARM & Hirschsprung
· guest expert
Etiologies (Gastroschisis/NEC/Atresia/Volvulus)
· guest expert
Inguinal Hernia
· guest expert
Intestinal Rehab
· guest expert
Neuroblastoma
· guest expert
Sarcoma (Ewing/Rhabdo)
· guest expert
Featured statements
The best way to think about IDRFs are things that touch things that are important, touching the vessels, touching the brachial plaque, touching the trachea, all of those things count as IDRS.
quote ·
Neuroblastoma
You have to keep applying pressure in a slow, gentle fashion and not just kind of come and go with your hands, because that gentle, slow pressure is what allows you to reduce the hernia.
quote ·
Inguinal Hernia
More than half of incarcerations are in patients that are less than six months, and then two-thirds of incarcerations are in patients who are less than a year.
quote ·
Inguinal Hernia
About one in 200 children have a risk of malrotation, but only about one in 30 of those children with malrotation will develop a volvulus.
There's tumor that extends into the neural foramina or that extends into other places, you're not going to go chasing it.
quote ·
Neuroblastoma
You can have malrotation without mid-gut volvulus but you can't have mid-gut volvulus without malrotation.
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Meera's statements about Appendicitis 3 statements
Open the Appendicitis collection →
Update Course 2022 - TOP PUBLICATIONS IN NON- PED SURG JOURNALS - Jose Campos
Quotation
I think in little kids, you can easily put in stam sutures, and I think that saves you when the tube dislodges. You don't have it dislodge, you know, in the stomach drop away as you might with the PEG, but that's just a personal practice.
Open
Statement
PEG tubes are difficult to change to button tubes, often requiring a second anesthetic with GI specialists to remove the PEG endoscopically before placing a button.
Open
Quotation
One of the issues also with peg is the difficulty in changing it then over to a button tube and the trauma of doing that to a child in the office and so I don't know what other institutions practices are but at ours children actually get a second anesthetic if they get a peg because they go back to the OR with the GI folks to get the peg removed under endoscopic and then they change it to a to a button.
Open
Meera's statements about Colorectal / ARM & Hirschsprung 22 statements
Open the Colorectal / ARM & Hirschsprung collection →
Suspected Hirschsprung's-associated enterocolitis (HAEC) Treatment Guideline...
Statement
Systemic signs of concern include fever, lethargy, age-adjusted tachycardia, tachypnea, hypotension, or oliguria
Open
Statement
Papers by Pastor et al and Gosain et al outline frameworks and clinical guidelines for management of enterocolitis
Open
Statement
GI symptoms in HAEC include abdominal distension, vomiting, no or minimal stool, foul smelling stool, or explosive diarrhea
Open
Statement
The guideline is most appropriate for patients with either known or suspected Hirschsprung's who present with GI symptoms and/or fever
Open
Statement
If the patient is less than four weeks out from surgery, fellows should discuss the rectal exam with an attending surgeon prior to performing it
Open
Statement
Patients should be seen and evaluated as soon as possible, ideally within one hour by someone with clinical expertise such as a surgical fellow or attending
Open
Statement
Irrigations should be repeated as frequently as every eight hours, but even every six or four hours as needed for sicker patients
Open
Statement
Patients with systemic signs who are sicker need broad spectrum antibiotics, specifically Zosyn and flagyl at Cincinnati Children's
Open
Statement
Abdominal films should be obtained upon arrival and then repeated again after an irrigation to demonstrate adequate decompression
Open
Statement
Patients should be NPO and started on IV fluids to assist with resuscitation and hydration
Open
Statement
Abdominal films can be repeated throughout the course of the hospitalization as clinically necessary
Open
Statement
Patients without systemic signs who are mostly clinically well can be maintained on either IV or oral flagyl during hospitalization
Open
Statement
A venous blood gas should be obtained for sicker patients to help evaluate resuscitation needs
Open
Quotation
As we know, enterocolitis is complicated and this guideline may not apply to all patients.
Open
Statement
Underlying anatomic issues such as a stricture or a transition zone pull through must be addressed to prevent recurrent enterocolitis
Open
Statement
After an admission for enterocolitis, patients are continued on metronidazole and irrigations for a few weeks and then slowly tapered
Open
Meera's statements about Etiologies (Gastroschisis/NEC/Atresia/Volvulus) 45 statements
Open the Etiologies (Gastroschisis/NEC/Atresia/Volvulus) collection →
Update Course 2022 - TOP PUBLICATIONS IN NON- PED SURG JOURNALS - Jose Campos
Quotation
I think in little kids, you can easily put in stam sutures, and I think that saves you when the tube dislodges. You don't have it dislodge, you know, in the stomach drop away as you might with the PEG, but that's just a personal practice.
Open
Statement
PEG tubes are difficult to change to button tubes, often requiring a second anesthetic with GI specialists to remove the PEG endoscopically before placing a button.
Open
Quotation
One of the issues also with peg is the difficulty in changing it then over to a button tube and the trauma of doing that to a child in the office and so I don't know what other institutions practices are but at ours children actually get a second anesthetic if they get a peg because they go back to the OR with the GI folks to get the peg removed under endoscopic and then they change it to a to a button.
Open
Malrotation with Dr. Meera Kotagal
Quotation
In the fourth week of gestation, that's really when we start to see development of the bowel. And as the bowel grows in length, it actually herniates into the yolk sac and along the umbilical cord and the SMA axis.
Open
Statement
In the fourth week of gestation, bowel development begins, and as the bowel grows in length it herniates into the yolk sac along the umbilical cord and SMA axis.
Open
Statement
Normal rotation involves a 90-degree rotation of the duodenal-jejunal loop, then return of bowel with 270-degree rotation of cecum and colon, resulting in duodenal-jejunal junction to the left of midline at ligament of Treitz and cecum in right lower quadrant.
Open
Statement
Malrotation involves incomplete rotation that fails to create a broad-based mesentery, which is important to reduce the risk of volvulus.
Open
Statement
In non-rotation, the gut returns without rotating, resulting in colon on the left and small bowel on the right, without the problematic Ladd bands that cause obstruction in malrotation.
Open
Statement
Intestinal rotation abnormalities fall along a spectrum rather than being simply normal or abnormal, including both non-rotation and malrotation.
Open
Quotation
We used to describe rotation as either normal rotation and malrotation. And now we've gotten more into the language of talking about intestinal rotation abnormalities because they tend to fall more along a spectrum than the black and white of either normal or abnormal.
Open
Statement
Non-rotation anatomy looks similar to the anatomy of a malrotated patient post-Ladd procedure.
Open
Statement
About 1 in 200 children have a risk of malrotation, but only about 1 in 30 of those children with malrotation will develop a volvulus.
Open
Statement
About 70% of those who will have a midgut volvulus will present in the first year of life.
Open
Statement
As children with malrotation get older without having had a volvulus, their likelihood of having a significant clinical event related to malrotation decreases.
Open
Statement
Children with congenital cardiac disease and heterotaxy especially can have associated malrotation, but their likelihood of symptomatic events is much lower, so these children are not fixed with the same frequency in infancy.
Open
Statement
Rotational abnormalities are associated with congenital diaphragmatic hernia, gastroschisis, and omphalocele due to the nature of the anatomy of those diagnoses.
Open
Quotation
About 70% of those who will have a midgut volvulus will present in the first year of life.
Open
Quotation
About one in 200 children have a risk of malrotation, but only about one in 30 of those children with malrotation will develop a volvulus.
Open
Statement
Complications of malrotation fall into two categories: obstructive symptoms (feeding intolerance from Ladd bands) and midgut volvulus (from narrow mesentery).
Open
Statement
After detorsion, the bowel is given time to rest to assess viability and determine if ischemia has been prolonged enough to compromise intestinal viability.
Open
Statement
In the neonatal period, bilious emesis is the most critical symptom and requires evaluation for midgut volvulus even if the x-ray appears normal.
Open
Statement
Other symptoms of malrotation include feeding intolerance, abdominal pain, and abdominal distension.
Open
Statement
Late signs associated with volvulus include bloody stools, peritoneal signs on exam, and abdominal wall erythema, which are suggestive of intestinal ischemia.
Open
Statement
The differential diagnosis for bilious emesis includes all kinds of intestinal obstructions: atresia, Hirschsprung disease, meconium ileus or plugs, incarcerated hernia, anorectal malformations, and necrotizing enterocolitis.
Open
Statement
Malrotation must be ruled out before pursuing other diagnoses in a child with bilious emesis because of the high risk of missing it.
Open
Statement
Upper GI series is the most frequently used imaging for diagnosis of malrotation, looking at the position and course of the duodenum to determine if it is normally or abnormally positioned.
Open
Statement
On upper GI, you want to see the total C-loop of the duodenum come back across the midline to the left, and from lateral view see it go posteriorly and cephalad to confirm normal position.
Open
Statement
Contrast enema can sometimes be used if cecal position can be determined, but current sensitivity and specificity are not sufficient to rule out significant pathology, so it has not superseded upper GI as the definitive test.
Open
Statement
Midgut volvulus is considered the number one surgical emergency in pediatric surgery.
Open
Statement
Surgical treatment of volvulus requires exploratory laparotomy with evisceration of bowel to determine the situation, then detorsion/devolvulization of the bowel, usually requiring 270-degree counterclockwise rotation.
Open
Quotation
In the neonatal period, the most critical symptom to be really aware of is biliosemesis. Even if they have a normal appearing x-ray, those kids really need to be evaluated for midgut volvulus.
Open
Quotation
We think of midget volvulus as the number one surgical emergency in pediatric surgery and so missing that is a significant problem.
Open
Quotation
You can have malrotation without mid-gut volvulus but you can't have mid-gut volvulus without malrotation.
Open
Statement
The reason for appendectomy during Ladd procedure is that the appendix will be in an abnormal anatomic position, and if left in place, families must be informed to tell providers about the abnormal location if the child presents with concerning symptoms.
Open
Statement
The Ladd procedure involves widening the mesentery by removing Ladd bands, freeing and straightening the duodenum to avoid obstruction, performing appendectomy, and placing bowel in non-rotation configuration (small bowel right, large bowel left) to keep mesentery as broad as possible.
Open
Statement
There is controversy about whether to perform prophylactic Ladd procedure in children with diagnosed malrotation or in conditions like congenital diaphragmatic hernia where malrotation is present by definition, due to long-term risks of bowel obstruction and complications.
Open
Statement
There is controversy about whether the mesentery can be successfully broadened as wide as needed by laparoscopic approach.
Open
Statement
Dr. Kotagal's approach in older children with symptomatic malrotation is to start laparoscopically and assess mesenteric width and duodenal anatomy; if mesentery is fairly broad with main problem being duodenal bands, she may complete it laparoscopically, but very narrow mesentery may be harder to address laparoscopically.
Open
Quotation
About a quarter of patients who undergo a LADS procedure will have an intestinal obstruction related to small bowel obstruction related to their OTCU bowel disease from their LADS procedure.
Open
Statement
About one quarter of patients who undergo Ladd procedure will have intestinal obstruction related to small bowel obstruction from adhesive disease.
Open
Statement
Laparoscopic Ladd procedure may have decreased adhesion rates, potentially losing the adhesive benefit that prevents volvulus.
Open
Statement
Some believe part of the benefit of Ladd procedure is widening the mesentery plus causing scar tissue that helps bowel adhere in a configuration preventing midgut volvulus.
Open
Statement
Decisions about prophylactic Ladd procedure require informed consent discussions with families about risks of both doing and not doing the operation, considering factors like access to care; families who are remote may opt for surgery accepting bowel obstruction risk, knowing acute volvulus would be harder to reach hospital for in timely fashion.
Open
Statement
In younger children with malrotation, the risk for volvulus or symptomatic malrotation is higher, so Ladd procedure is performed more commonly.
Open
Meera's statements about Hirschsprung disease 42 statements
Open the Hirschsprung disease collection →
Malrotation with Dr. Meera Kotagal
Statement
In the fourth week of gestation, bowel development begins, and as the bowel grows in length it herniates into the yolk sac along the umbilical cord and SMA axis.
Open
Quotation
In the fourth week of gestation, that's really when we start to see development of the bowel. And as the bowel grows in length, it actually herniates into the yolk sac and along the umbilical cord and the SMA axis.
Open
Statement
Normal rotation involves a 90-degree rotation of the duodenal-jejunal loop, then return of bowel with 270-degree rotation of cecum and colon, resulting in duodenal-jejunal junction to the left of midline at ligament of Treitz and cecum in right lower quadrant.
Open
Quotation
We used to describe rotation as either normal rotation and malrotation. And now we've gotten more into the language of talking about intestinal rotation abnormalities because they tend to fall more along a spectrum than the black and white of either normal or abnormal.
Open
Statement
Malrotation involves incomplete rotation that fails to create a broad-based mesentery, which is important to reduce the risk of volvulus.
Open
Statement
Non-rotation anatomy looks similar to the anatomy of a malrotated patient post-Ladd procedure.
Open
Statement
In non-rotation, the gut returns without rotating, resulting in colon on the left and small bowel on the right, without the problematic Ladd bands that cause obstruction in malrotation.
Open
Statement
Intestinal rotation abnormalities fall along a spectrum rather than being simply normal or abnormal, including both non-rotation and malrotation.
Open
Statement
Complications of malrotation fall into two categories: obstructive symptoms (feeding intolerance from Ladd bands) and midgut volvulus (from narrow mesentery).
Open
Quotation
About one in 200 children have a risk of malrotation, but only about one in 30 of those children with malrotation will develop a volvulus.
Open
Quotation
About 70% of those who will have a midgut volvulus will present in the first year of life.
Open
Statement
Rotational abnormalities are associated with congenital diaphragmatic hernia, gastroschisis, and omphalocele due to the nature of the anatomy of those diagnoses.
Open
Statement
Children with congenital cardiac disease and heterotaxy especially can have associated malrotation, but their likelihood of symptomatic events is much lower, so these children are not fixed with the same frequency in infancy.
Open
Statement
As children with malrotation get older without having had a volvulus, their likelihood of having a significant clinical event related to malrotation decreases.
Open
Statement
About 70% of those who will have a midgut volvulus will present in the first year of life.
Open
Statement
About 1 in 200 children have a risk of malrotation, but only about 1 in 30 of those children with malrotation will develop a volvulus.
Open
Statement
Surgical treatment of volvulus requires exploratory laparotomy with evisceration of bowel to determine the situation, then detorsion/devolvulization of the bowel, usually requiring 270-degree counterclockwise rotation.
Open
Statement
Midgut volvulus is considered the number one surgical emergency in pediatric surgery.
Open
Quotation
In the neonatal period, the most critical symptom to be really aware of is biliosemesis. Even if they have a normal appearing x-ray, those kids really need to be evaluated for midgut volvulus.
Open
Quotation
We think of midget volvulus as the number one surgical emergency in pediatric surgery and so missing that is a significant problem.
Open
Statement
Contrast enema can sometimes be used if cecal position can be determined, but current sensitivity and specificity are not sufficient to rule out significant pathology, so it has not superseded upper GI as the definitive test.
Open
Statement
On upper GI, you want to see the total C-loop of the duodenum come back across the midline to the left, and from lateral view see it go posteriorly and cephalad to confirm normal position.
Open
Statement
Upper GI series is the most frequently used imaging for diagnosis of malrotation, looking at the position and course of the duodenum to determine if it is normally or abnormally positioned.
Open
Statement
Malrotation must be ruled out before pursuing other diagnoses in a child with bilious emesis because of the high risk of missing it.
Open
Statement
The differential diagnosis for bilious emesis includes all kinds of intestinal obstructions: atresia, Hirschsprung disease, meconium ileus or plugs, incarcerated hernia, anorectal malformations, and necrotizing enterocolitis.
Open
Statement
Late signs associated with volvulus include bloody stools, peritoneal signs on exam, and abdominal wall erythema, which are suggestive of intestinal ischemia.
Open
Statement
Other symptoms of malrotation include feeding intolerance, abdominal pain, and abdominal distension.
Open
Statement
In the neonatal period, bilious emesis is the most critical symptom and requires evaluation for midgut volvulus even if the x-ray appears normal.
Open
Statement
After detorsion, the bowel is given time to rest to assess viability and determine if ischemia has been prolonged enough to compromise intestinal viability.
Open
Quotation
You can have malrotation without mid-gut volvulus but you can't have mid-gut volvulus without malrotation.
Open
Statement
The reason for appendectomy during Ladd procedure is that the appendix will be in an abnormal anatomic position, and if left in place, families must be informed to tell providers about the abnormal location if the child presents with concerning symptoms.
Open
Statement
The Ladd procedure involves widening the mesentery by removing Ladd bands, freeing and straightening the duodenum to avoid obstruction, performing appendectomy, and placing bowel in non-rotation configuration (small bowel right, large bowel left) to keep mesentery as broad as possible.
Open
Statement
Laparoscopic Ladd procedure may have decreased adhesion rates, potentially losing the adhesive benefit that prevents volvulus.
Open
Statement
About one quarter of patients who undergo Ladd procedure will have intestinal obstruction related to small bowel obstruction from adhesive disease.
Open
Statement
Dr. Kotagal's approach in older children with symptomatic malrotation is to start laparoscopically and assess mesenteric width and duodenal anatomy; if mesentery is fairly broad with main problem being duodenal bands, she may complete it laparoscopically, but very narrow mesentery may be harder to address laparoscopically.
Open
Statement
There is controversy about whether the mesentery can be successfully broadened as wide as needed by laparoscopic approach.
Open
Statement
There is controversy about whether to perform prophylactic Ladd procedure in children with diagnosed malrotation or in conditions like congenital diaphragmatic hernia where malrotation is present by definition, due to long-term risks of bowel obstruction and complications.
Open
Quotation
About a quarter of patients who undergo a LADS procedure will have an intestinal obstruction related to small bowel obstruction related to their OTCU bowel disease from their LADS procedure.
Open
Statement
Decisions about prophylactic Ladd procedure require informed consent discussions with families about risks of both doing and not doing the operation, considering factors like access to care; families who are remote may opt for surgery accepting bowel obstruction risk, knowing acute volvulus would be harder to reach hospital for in timely fashion.
Open
Statement
Some believe part of the benefit of Ladd procedure is widening the mesentery plus causing scar tissue that helps bowel adhere in a configuration preventing midgut volvulus.
Open
Statement
In younger children with malrotation, the risk for volvulus or symptomatic malrotation is higher, so Ladd procedure is performed more commonly.
Open
Meera's statements about Hirschsprung's-associated Enterocolitis 22 statements
Open the Hirschsprung's-associated Enterocolitis collection →
Suspected Hirschsprung's-associated enterocolitis (HAEC) Treatment Guideline...
Statement
Papers by Pastor et al and Gosain et al outline frameworks and clinical guidelines for management of enterocolitis
Open
Statement
GI symptoms in HAEC include abdominal distension, vomiting, no or minimal stool, foul smelling stool, or explosive diarrhea
Open
Statement
Systemic signs of concern include fever, lethargy, age-adjusted tachycardia, tachypnea, hypotension, or oliguria
Open
Statement
The guideline is most appropriate for patients with either known or suspected Hirschsprung's who present with GI symptoms and/or fever
Open
Statement
If the patient is less than four weeks out from surgery, fellows should discuss the rectal exam with an attending surgeon prior to performing it
Open
Statement
Irrigations should be repeated as frequently as every eight hours, but even every six or four hours as needed for sicker patients
Open
Statement
Patients should be seen and evaluated as soon as possible, ideally within one hour by someone with clinical expertise such as a surgical fellow or attending
Open
Statement
Patients without systemic signs who are mostly clinically well can be maintained on either IV or oral flagyl during hospitalization
Open
Statement
Patients with systemic signs who are sicker need broad spectrum antibiotics, specifically Zosyn and flagyl at Cincinnati Children's
Open
Statement
Abdominal films should be obtained upon arrival and then repeated again after an irrigation to demonstrate adequate decompression
Open
Statement
Abdominal films can be repeated throughout the course of the hospitalization as clinically necessary
Open
Statement
Patients should be NPO and started on IV fluids to assist with resuscitation and hydration
Open
Statement
A venous blood gas should be obtained for sicker patients to help evaluate resuscitation needs
Open
Quotation
As we know, enterocolitis is complicated and this guideline may not apply to all patients.
Open
Statement
Underlying anatomic issues such as a stricture or a transition zone pull through must be addressed to prevent recurrent enterocolitis
Open
Statement
After an admission for enterocolitis, patients are continued on metronidazole and irrigations for a few weeks and then slowly tapered
Open
Meera's statements about Inguinal Hernia 72 statements
Open the Inguinal Hernia collection →
Inguinal Hernias: Diagnosis and Management
Statement
Direct hernias are pretty rare in children and are much more commonly found in adolescents.
Open
Statement
The incidence of inguinal hernias increases to about 13% in premature infants who are less than 32 weeks of gestational age.
Open
Statement
Femoral hernias are very rare in children and, as in adults, are more common in females.
Open
Statement
The incidence of inguinal hernias overall ranges from about 1% to 5% in full-term newborns.
Open
Statement
Inguinal hernias occur as a result of the failure of the processus vaginalis to fuse.
Open
Statement
Indirect inguinal hernias in children are a congenital anomaly, meaning that they've occurred in development and are present at the time of birth.
Open
Statement
The right processus vaginalis usually obliterates after the left, which explains the higher prevalence of right-sided hernias.
Open
Statement
Other factors associated with an increased risk of inguinal hernias in kids include male sex, family history of inguinal hernias, a history of undescended testicle or hydrocele, and a connective tissue disorder.
Open
Statement
More than half of incarcerations are in patients that are less than six months, and two-thirds of incarcerations are in patients who are less than a year.
Open
Statement
If corrected gestational age is less than 60 weeks, patients have a high risk for premature apnea postoperatively and need to be admitted after surgery to monitor.
Open
Quotation
More than half of incarcerations are in patients that are less than six months, and then two-thirds of incarcerations are in patients who are less than a year.
Open
Statement
For hernia reduction, one hand guides the contents through the inguinal ring and the other hand applies gentle, steady pressure, which must be maintained in a slow, gentle fashion.
Open
Statement
One of the most important things in being able to reduce an incarcerated hernia is helping to keep the patient calm, sometimes requiring pain control and sedation.
Open
Quotation
One of the most important things, I think, in being able to reduce an incarcerated hernia is helping to keep the patient calm.
Open
Quotation
You have to keep applying pressure in a slow, gentle fashion and not just kind of come and go with your hands, because that gentle, slow pressure is what allows you to reduce the hernia.
Open
Statement
If you can reduce an incarcerated inguinal hernia, you want to go to the OR within the first 24 to 72 hours after the reduction.
Open
Quotation
Unlike in adults, we don't generally use mesh in the repair of the pediatric inguinal hernia.
Open
Statement
The most important point in pediatric inguinal hernia repair is that you need to have high ligation of the processus vaginalis, whether you do it laparoscopically or open.
Open
Statement
Unlike in adults, we don't generally use mesh in the repair of the pediatric inguinal hernia.
Open
Quotation
The most important point is that you need to have high ligation of the processus vaginalis, whether you do it laparoscopically or open.
Open
Quotation
As with all operations, the most important thing is that you do the operation that you're comfortable with.
Open
Statement
The outcomes between pediatric laparoscopic repairs and open repairs are thought to be similar, although there is some controversy on this topic.
Open
Statement
If a child needs an orchidopexy in addition to their hernia repair, most would approach that hernia in an open fashion.
Open
Statement
A floor repair should be considered in children who have longstanding or very large hernias where the floor might be blown out or unsupported.
Open
Statement
The most common complications after inguinal hernia repair in children are superficial site infection, which occur in less than 1% of kids, and recurrence, with rates varying from 1% to 5%.
Open
Statement
In general, we don't try to limit activities in children after a hernia repair; most children can return to normal activities within one to two days.
Open
Quotation
In general for children, we don't do this. Most children can return to normal activities within one to two days.
Open
Statement
A lot of times, once the patient is put under anesthesia, an incarcerated hernia that was unable to be reduced in the emergency department may actually spontaneously reduce with the patient's relaxation.
Open
Statement
If a patient has an undescended testicle that's palpable in the inguinal canal, you should plan to do an orchiopexy at the time of your inguinal hernia repair.
Open
Statement
Children with an absent vas deferens noted on hernia repair should be worked up for cystic fibrosis or for unilateral renal agenesis in the post-op period.
Open
Statement
If patients are having significant testicular pain after a hernia repair, the main concern is testicular ischemia, best evaluated with ultrasound looking for Doppler flow.
Open
Statement
In cases of testicular ischemia after hernia repair, patients are monitored and observed with pain control, and surgeons only remove a necrotic testicle, not necessarily one that is partially ischemic.
Open
Pediatric Inguinal Hernia in Brief: Presentation, Workup, Diagnosis, Perioperative Considerations
Statement
Inguinal hernia repair is the second most common surgery performed by pediatric surgeons.
Open
Quotation
Inguinal hernia repair is the second most common surgery performed by pediatric surgeons.
Open
Statement
The incidence of inguinal hernias overall ranges from about 1% to 5% in full-term newborns.
Open
Statement
The incidence of inguinal hernias increases to about 13% in premature infants who are less than 32 weeks of gestational age.
Open
Statement
Direct hernias are pretty rare in children and are much more commonly found in adolescence.
Open
Statement
Femoral hernias are very rare in children, and as in adults, are more common in females.
Open
Statement
Indirect inguinal hernias in children are a congenital anomaly, meaning that they've occurred in development and are present at the time of birth.
Open
Statement
Indirect inguinal hernias occur as a result of the failure of the processus vaginalis to fuse.
Open
Quotation
The right processus vaginalis usually obliterates after the left, so that explains the higher prevalence of right-sided hernias.
Open
Statement
The right processus vaginalis usually obliterates after the left, which explains the higher prevalence of right-sided hernias.
Open
Quotation
It's actually kind of alarming. I mean, more than half of the incarcerations that we see are in patients that are less than six months old.
Open
Statement
More than half of the incarcerations that we see are in patients that are less than six months old.
Open
Statement
If the corrected gestational age is less than 60 weeks, premature patients are at a pretty increased risk of post-operative apnea, so you got to admit those patients after you do the repair.
Open
Quotation
One of the most important things I think in being able to reduce an incarcerated hernia is helping to keep the patient calm.
Open
Statement
One of the most important things in being able to reduce an incarcerated hernia is helping to keep the patient calm, sometimes that means pain control and sedation.
Open
Statement
You have to keep applying pressure in a slow, gentle fashion and not just kind of come and go with your hands, because that gentle, slow pressure is what allows you to release the hernia.
Open
Statement
If you can reduce an incarcerated hernia, then you want to go to the OR within the first 24 to 72 hours after the reduction.
Open
Quotation
The most important point is that you need to have high ligation of the processus vaginalis, whether you do it laparoscopically or open.
Open
Statement
The most important point in pediatric inguinal hernia repair is that you need to have high ligation of the processus vaginalis, whether you do it laparoscopically or open.
Open
Statement
Unlike in adults, we don't generally use mesh in the repair of the pediatric inguinal hernia.
Open
Quotation
Unlike in adults, we don't generally use mesh in the repair of the pediatric inguinal hernia.
Open
Statement
The outcomes between pediatric laparoscopic repairs and open repairs are thought to be similar, although there is some controversy on this topic.
Open
Statement
If you're considering that the child needs an orchidopexy in addition to their hernia repair, then most would approach that hernia in an open fashion.
Open
Statement
A floor repair should be considered in children who have long-standing or very large hernias, where you note that the floor might be blown out or unsupported.
Open
Statement
Superficial site infections occur in less than 1% of kids after inguinal hernia repair.
Open
Statement
The rates of recurrence after pediatric inguinal hernia repair vary from 1 to 5% depending on which studies you look at.
Open
Statement
In general, we don't try to limit activities in children after a hernia repair, and most children can return to normal activities within one to two days.
Open
Statement
If a patient does have an undescended testicle that's palpable in the inguinal canal, then you should plan to do an orchidopexy at the time of your inguinal hernia repair.
Open
Statement
Children with an absent vas deferens noted on hernia repair should be worked up for cystic fibrosis or for unilateral renal agenesis in the post-op period.
Open
Statement
If patients are having significant testicular pain after a hernia repair, the thing that concerns you most is testicular ischemia, and the best way to evaluate that is to get an ultrasound looking for Doppler flow.
Open
Statement
In general, patients with testicular ischemia after hernia repair are monitored and observed with pain control and we only frankly remove a necrotic testicle and not necessarily one that is partially ischemic.
Open
Meera's statements about Intestinal Rehab 45 statements
Open the Intestinal Rehab collection →
Update Course 2022 - TOP PUBLICATIONS IN NON- PED SURG JOURNALS - Jose Campos
Quotation
I think in little kids, you can easily put in stam sutures, and I think that saves you when the tube dislodges. You don't have it dislodge, you know, in the stomach drop away as you might with the PEG, but that's just a personal practice.
Open
Quotation
One of the issues also with peg is the difficulty in changing it then over to a button tube and the trauma of doing that to a child in the office and so I don't know what other institutions practices are but at ours children actually get a second anesthetic if they get a peg because they go back to the OR with the GI folks to get the peg removed under endoscopic and then they change it to a to a button.
Open
Statement
PEG tubes are difficult to change to button tubes, often requiring a second anesthetic with GI specialists to remove the PEG endoscopically before placing a button.
Open
Malrotation with Dr. Meera Kotagal
Statement
In the fourth week of gestation, bowel development begins, and as the bowel grows in length it herniates into the yolk sac along the umbilical cord and SMA axis.
Open
Quotation
In the fourth week of gestation, that's really when we start to see development of the bowel. And as the bowel grows in length, it actually herniates into the yolk sac and along the umbilical cord and the SMA axis.
Open
Statement
Normal rotation involves a 90-degree rotation of the duodenal-jejunal loop, then return of bowel with 270-degree rotation of cecum and colon, resulting in duodenal-jejunal junction to the left of midline at ligament of Treitz and cecum in right lower quadrant.
Open
Statement
Malrotation involves incomplete rotation that fails to create a broad-based mesentery, which is important to reduce the risk of volvulus.
Open
Statement
In non-rotation, the gut returns without rotating, resulting in colon on the left and small bowel on the right, without the problematic Ladd bands that cause obstruction in malrotation.
Open
Statement
Intestinal rotation abnormalities fall along a spectrum rather than being simply normal or abnormal, including both non-rotation and malrotation.
Open
Quotation
We used to describe rotation as either normal rotation and malrotation. And now we've gotten more into the language of talking about intestinal rotation abnormalities because they tend to fall more along a spectrum than the black and white of either normal or abnormal.
Open
Statement
Non-rotation anatomy looks similar to the anatomy of a malrotated patient post-Ladd procedure.
Open
Statement
Children with congenital cardiac disease and heterotaxy especially can have associated malrotation, but their likelihood of symptomatic events is much lower, so these children are not fixed with the same frequency in infancy.
Open
Quotation
About 70% of those who will have a midgut volvulus will present in the first year of life.
Open
Quotation
About one in 200 children have a risk of malrotation, but only about one in 30 of those children with malrotation will develop a volvulus.
Open
Statement
As children with malrotation get older without having had a volvulus, their likelihood of having a significant clinical event related to malrotation decreases.
Open
Statement
About 70% of those who will have a midgut volvulus will present in the first year of life.
Open
Statement
About 1 in 200 children have a risk of malrotation, but only about 1 in 30 of those children with malrotation will develop a volvulus.
Open
Statement
Complications of malrotation fall into two categories: obstructive symptoms (feeding intolerance from Ladd bands) and midgut volvulus (from narrow mesentery).
Open
Statement
Rotational abnormalities are associated with congenital diaphragmatic hernia, gastroschisis, and omphalocele due to the nature of the anatomy of those diagnoses.
Open
Statement
Late signs associated with volvulus include bloody stools, peritoneal signs on exam, and abdominal wall erythema, which are suggestive of intestinal ischemia.
Open
Statement
After detorsion, the bowel is given time to rest to assess viability and determine if ischemia has been prolonged enough to compromise intestinal viability.
Open
Statement
Surgical treatment of volvulus requires exploratory laparotomy with evisceration of bowel to determine the situation, then detorsion/devolvulization of the bowel, usually requiring 270-degree counterclockwise rotation.
Open
Statement
Midgut volvulus is considered the number one surgical emergency in pediatric surgery.
Open
Statement
Contrast enema can sometimes be used if cecal position can be determined, but current sensitivity and specificity are not sufficient to rule out significant pathology, so it has not superseded upper GI as the definitive test.
Open
Statement
On upper GI, you want to see the total C-loop of the duodenum come back across the midline to the left, and from lateral view see it go posteriorly and cephalad to confirm normal position.
Open
Statement
Upper GI series is the most frequently used imaging for diagnosis of malrotation, looking at the position and course of the duodenum to determine if it is normally or abnormally positioned.
Open
Statement
Malrotation must be ruled out before pursuing other diagnoses in a child with bilious emesis because of the high risk of missing it.
Open
Statement
The differential diagnosis for bilious emesis includes all kinds of intestinal obstructions: atresia, Hirschsprung disease, meconium ileus or plugs, incarcerated hernia, anorectal malformations, and necrotizing enterocolitis.
Open
Statement
Other symptoms of malrotation include feeding intolerance, abdominal pain, and abdominal distension.
Open
Statement
In the neonatal period, bilious emesis is the most critical symptom and requires evaluation for midgut volvulus even if the x-ray appears normal.
Open
Quotation
In the neonatal period, the most critical symptom to be really aware of is biliosemesis. Even if they have a normal appearing x-ray, those kids really need to be evaluated for midgut volvulus.
Open
Quotation
We think of midget volvulus as the number one surgical emergency in pediatric surgery and so missing that is a significant problem.
Open
Quotation
You can have malrotation without mid-gut volvulus but you can't have mid-gut volvulus without malrotation.
Open
Statement
The reason for appendectomy during Ladd procedure is that the appendix will be in an abnormal anatomic position, and if left in place, families must be informed to tell providers about the abnormal location if the child presents with concerning symptoms.
Open
Statement
The Ladd procedure involves widening the mesentery by removing Ladd bands, freeing and straightening the duodenum to avoid obstruction, performing appendectomy, and placing bowel in non-rotation configuration (small bowel right, large bowel left) to keep mesentery as broad as possible.
Open
Statement
About one quarter of patients who undergo Ladd procedure will have intestinal obstruction related to small bowel obstruction from adhesive disease.
Open
Statement
Dr. Kotagal's approach in older children with symptomatic malrotation is to start laparoscopically and assess mesenteric width and duodenal anatomy; if mesentery is fairly broad with main problem being duodenal bands, she may complete it laparoscopically, but very narrow mesentery may be harder to address laparoscopically.
Open
Statement
There is controversy about whether the mesentery can be successfully broadened as wide as needed by laparoscopic approach.
Open
Statement
In younger children with malrotation, the risk for volvulus or symptomatic malrotation is higher, so Ladd procedure is performed more commonly.
Open
Statement
There is controversy about whether to perform prophylactic Ladd procedure in children with diagnosed malrotation or in conditions like congenital diaphragmatic hernia where malrotation is present by definition, due to long-term risks of bowel obstruction and complications.
Open
Statement
Decisions about prophylactic Ladd procedure require informed consent discussions with families about risks of both doing and not doing the operation, considering factors like access to care; families who are remote may opt for surgery accepting bowel obstruction risk, knowing acute volvulus would be harder to reach hospital for in timely fashion.
Open
Quotation
About a quarter of patients who undergo a LADS procedure will have an intestinal obstruction related to small bowel obstruction related to their OTCU bowel disease from their LADS procedure.
Open
Statement
Some believe part of the benefit of Ladd procedure is widening the mesentery plus causing scar tissue that helps bowel adhere in a configuration preventing midgut volvulus.
Open
Statement
Laparoscopic Ladd procedure may have decreased adhesion rates, potentially losing the adhesive benefit that prevents volvulus.
Open
Meera's statements about Malrotation 42 statements
Open the Malrotation collection →
Malrotation with Dr. Meera Kotagal
Quotation
In the fourth week of gestation, that's really when we start to see development of the bowel. And as the bowel grows in length, it actually herniates into the yolk sac and along the umbilical cord and the SMA axis.
Open
Statement
In the fourth week of gestation, bowel development begins, and as the bowel grows in length it herniates into the yolk sac along the umbilical cord and SMA axis.
Open
Statement
Normal rotation involves a 90-degree rotation of the duodenal-jejunal loop, then return of bowel with 270-degree rotation of cecum and colon, resulting in duodenal-jejunal junction to the left of midline at ligament of Treitz and cecum in right lower quadrant.
Open
Quotation
We used to describe rotation as either normal rotation and malrotation. And now we've gotten more into the language of talking about intestinal rotation abnormalities because they tend to fall more along a spectrum than the black and white of either normal or abnormal.
Open
Statement
Malrotation involves incomplete rotation that fails to create a broad-based mesentery, which is important to reduce the risk of volvulus.
Open
Statement
Non-rotation anatomy looks similar to the anatomy of a malrotated patient post-Ladd procedure.
Open
Statement
Intestinal rotation abnormalities fall along a spectrum rather than being simply normal or abnormal, including both non-rotation and malrotation.
Open
Statement
In non-rotation, the gut returns without rotating, resulting in colon on the left and small bowel on the right, without the problematic Ladd bands that cause obstruction in malrotation.
Open
Statement
About 1 in 200 children have a risk of malrotation, but only about 1 in 30 of those children with malrotation will develop a volvulus.
Open
Statement
As children with malrotation get older without having had a volvulus, their likelihood of having a significant clinical event related to malrotation decreases.
Open
Statement
Children with congenital cardiac disease and heterotaxy especially can have associated malrotation, but their likelihood of symptomatic events is much lower, so these children are not fixed with the same frequency in infancy.
Open
Statement
Rotational abnormalities are associated with congenital diaphragmatic hernia, gastroschisis, and omphalocele due to the nature of the anatomy of those diagnoses.
Open
Quotation
About one in 200 children have a risk of malrotation, but only about one in 30 of those children with malrotation will develop a volvulus.
Open
Quotation
About 70% of those who will have a midgut volvulus will present in the first year of life.
Open
Statement
Complications of malrotation fall into two categories: obstructive symptoms (feeding intolerance from Ladd bands) and midgut volvulus (from narrow mesentery).
Open
Statement
About 70% of those who will have a midgut volvulus will present in the first year of life.
Open
Statement
Other symptoms of malrotation include feeding intolerance, abdominal pain, and abdominal distension.
Open
Statement
In the neonatal period, bilious emesis is the most critical symptom and requires evaluation for midgut volvulus even if the x-ray appears normal.
Open
Statement
Late signs associated with volvulus include bloody stools, peritoneal signs on exam, and abdominal wall erythema, which are suggestive of intestinal ischemia.
Open
Statement
The differential diagnosis for bilious emesis includes all kinds of intestinal obstructions: atresia, Hirschsprung disease, meconium ileus or plugs, incarcerated hernia, anorectal malformations, and necrotizing enterocolitis.
Open
Statement
Malrotation must be ruled out before pursuing other diagnoses in a child with bilious emesis because of the high risk of missing it.
Open
Statement
Upper GI series is the most frequently used imaging for diagnosis of malrotation, looking at the position and course of the duodenum to determine if it is normally or abnormally positioned.
Open
Statement
On upper GI, you want to see the total C-loop of the duodenum come back across the midline to the left, and from lateral view see it go posteriorly and cephalad to confirm normal position.
Open
Statement
Contrast enema can sometimes be used if cecal position can be determined, but current sensitivity and specificity are not sufficient to rule out significant pathology, so it has not superseded upper GI as the definitive test.
Open
Statement
Surgical treatment of volvulus requires exploratory laparotomy with evisceration of bowel to determine the situation, then detorsion/devolvulization of the bowel, usually requiring 270-degree counterclockwise rotation.
Open
Statement
After detorsion, the bowel is given time to rest to assess viability and determine if ischemia has been prolonged enough to compromise intestinal viability.
Open
Quotation
In the neonatal period, the most critical symptom to be really aware of is biliosemesis. Even if they have a normal appearing x-ray, those kids really need to be evaluated for midgut volvulus.
Open
Quotation
We think of midget volvulus as the number one surgical emergency in pediatric surgery and so missing that is a significant problem.
Open
Statement
Midgut volvulus is considered the number one surgical emergency in pediatric surgery.
Open
Quotation
You can have malrotation without mid-gut volvulus but you can't have mid-gut volvulus without malrotation.
Open
Statement
The reason for appendectomy during Ladd procedure is that the appendix will be in an abnormal anatomic position, and if left in place, families must be informed to tell providers about the abnormal location if the child presents with concerning symptoms.
Open
Statement
The Ladd procedure involves widening the mesentery by removing Ladd bands, freeing and straightening the duodenum to avoid obstruction, performing appendectomy, and placing bowel in non-rotation configuration (small bowel right, large bowel left) to keep mesentery as broad as possible.
Open
Statement
Some believe part of the benefit of Ladd procedure is widening the mesentery plus causing scar tissue that helps bowel adhere in a configuration preventing midgut volvulus.
Open
Statement
Decisions about prophylactic Ladd procedure require informed consent discussions with families about risks of both doing and not doing the operation, considering factors like access to care; families who are remote may opt for surgery accepting bowel obstruction risk, knowing acute volvulus would be harder to reach hospital for in timely fashion.
Open
Quotation
About a quarter of patients who undergo a LADS procedure will have an intestinal obstruction related to small bowel obstruction related to their OTCU bowel disease from their LADS procedure.
Open
Statement
There is controversy about whether the mesentery can be successfully broadened as wide as needed by laparoscopic approach.
Open
Statement
Dr. Kotagal's approach in older children with symptomatic malrotation is to start laparoscopically and assess mesenteric width and duodenal anatomy; if mesentery is fairly broad with main problem being duodenal bands, she may complete it laparoscopically, but very narrow mesentery may be harder to address laparoscopically.
Open
Statement
There is controversy about whether to perform prophylactic Ladd procedure in children with diagnosed malrotation or in conditions like congenital diaphragmatic hernia where malrotation is present by definition, due to long-term risks of bowel obstruction and complications.
Open
Statement
In younger children with malrotation, the risk for volvulus or symptomatic malrotation is higher, so Ladd procedure is performed more commonly.
Open
Statement
About one quarter of patients who undergo Ladd procedure will have intestinal obstruction related to small bowel obstruction from adhesive disease.
Open
Statement
Laparoscopic Ladd procedure may have decreased adhesion rates, potentially losing the adhesive benefit that prevents volvulus.
Open
Meera's statements about Midgut Volvulus 42 statements
Open the Midgut Volvulus collection →
Malrotation with Dr. Meera Kotagal
Statement
In the fourth week of gestation, bowel development begins, and as the bowel grows in length it herniates into the yolk sac along the umbilical cord and SMA axis.
Open
Quotation
In the fourth week of gestation, that's really when we start to see development of the bowel. And as the bowel grows in length, it actually herniates into the yolk sac and along the umbilical cord and the SMA axis.
Open
Statement
Normal rotation involves a 90-degree rotation of the duodenal-jejunal loop, then return of bowel with 270-degree rotation of cecum and colon, resulting in duodenal-jejunal junction to the left of midline at ligament of Treitz and cecum in right lower quadrant.
Open
Statement
In non-rotation, the gut returns without rotating, resulting in colon on the left and small bowel on the right, without the problematic Ladd bands that cause obstruction in malrotation.
Open
Statement
Non-rotation anatomy looks similar to the anatomy of a malrotated patient post-Ladd procedure.
Open
Statement
Malrotation involves incomplete rotation that fails to create a broad-based mesentery, which is important to reduce the risk of volvulus.
Open
Quotation
We used to describe rotation as either normal rotation and malrotation. And now we've gotten more into the language of talking about intestinal rotation abnormalities because they tend to fall more along a spectrum than the black and white of either normal or abnormal.
Open
Statement
Intestinal rotation abnormalities fall along a spectrum rather than being simply normal or abnormal, including both non-rotation and malrotation.
Open
Statement
About 70% of those who will have a midgut volvulus will present in the first year of life.
Open
Statement
About 1 in 200 children have a risk of malrotation, but only about 1 in 30 of those children with malrotation will develop a volvulus.
Open
Statement
Complications of malrotation fall into two categories: obstructive symptoms (feeding intolerance from Ladd bands) and midgut volvulus (from narrow mesentery).
Open
Statement
As children with malrotation get older without having had a volvulus, their likelihood of having a significant clinical event related to malrotation decreases.
Open
Statement
Children with congenital cardiac disease and heterotaxy especially can have associated malrotation, but their likelihood of symptomatic events is much lower, so these children are not fixed with the same frequency in infancy.
Open
Statement
Rotational abnormalities are associated with congenital diaphragmatic hernia, gastroschisis, and omphalocele due to the nature of the anatomy of those diagnoses.
Open
Quotation
About one in 200 children have a risk of malrotation, but only about one in 30 of those children with malrotation will develop a volvulus.
Open
Quotation
About 70% of those who will have a midgut volvulus will present in the first year of life.
Open
Quotation
We think of midget volvulus as the number one surgical emergency in pediatric surgery and so missing that is a significant problem.
Open
Quotation
In the neonatal period, the most critical symptom to be really aware of is biliosemesis. Even if they have a normal appearing x-ray, those kids really need to be evaluated for midgut volvulus.
Open
Statement
After detorsion, the bowel is given time to rest to assess viability and determine if ischemia has been prolonged enough to compromise intestinal viability.
Open
Statement
Surgical treatment of volvulus requires exploratory laparotomy with evisceration of bowel to determine the situation, then detorsion/devolvulization of the bowel, usually requiring 270-degree counterclockwise rotation.
Open
Statement
In the neonatal period, bilious emesis is the most critical symptom and requires evaluation for midgut volvulus even if the x-ray appears normal.
Open
Statement
Other symptoms of malrotation include feeding intolerance, abdominal pain, and abdominal distension.
Open
Statement
Late signs associated with volvulus include bloody stools, peritoneal signs on exam, and abdominal wall erythema, which are suggestive of intestinal ischemia.
Open
Statement
The differential diagnosis for bilious emesis includes all kinds of intestinal obstructions: atresia, Hirschsprung disease, meconium ileus or plugs, incarcerated hernia, anorectal malformations, and necrotizing enterocolitis.
Open
Statement
Malrotation must be ruled out before pursuing other diagnoses in a child with bilious emesis because of the high risk of missing it.
Open
Statement
Upper GI series is the most frequently used imaging for diagnosis of malrotation, looking at the position and course of the duodenum to determine if it is normally or abnormally positioned.
Open
Statement
On upper GI, you want to see the total C-loop of the duodenum come back across the midline to the left, and from lateral view see it go posteriorly and cephalad to confirm normal position.
Open
Statement
Midgut volvulus is considered the number one surgical emergency in pediatric surgery.
Open
Statement
Contrast enema can sometimes be used if cecal position can be determined, but current sensitivity and specificity are not sufficient to rule out significant pathology, so it has not superseded upper GI as the definitive test.
Open
Quotation
You can have malrotation without mid-gut volvulus but you can't have mid-gut volvulus without malrotation.
Open
Statement
The Ladd procedure involves widening the mesentery by removing Ladd bands, freeing and straightening the duodenum to avoid obstruction, performing appendectomy, and placing bowel in non-rotation configuration (small bowel right, large bowel left) to keep mesentery as broad as possible.
Open
Statement
The reason for appendectomy during Ladd procedure is that the appendix will be in an abnormal anatomic position, and if left in place, families must be informed to tell providers about the abnormal location if the child presents with concerning symptoms.
Open
Statement
Some believe part of the benefit of Ladd procedure is widening the mesentery plus causing scar tissue that helps bowel adhere in a configuration preventing midgut volvulus.
Open
Statement
About one quarter of patients who undergo Ladd procedure will have intestinal obstruction related to small bowel obstruction from adhesive disease.
Open
Statement
Laparoscopic Ladd procedure may have decreased adhesion rates, potentially losing the adhesive benefit that prevents volvulus.
Open
Quotation
About a quarter of patients who undergo a LADS procedure will have an intestinal obstruction related to small bowel obstruction related to their OTCU bowel disease from their LADS procedure.
Open
Statement
Decisions about prophylactic Ladd procedure require informed consent discussions with families about risks of both doing and not doing the operation, considering factors like access to care; families who are remote may opt for surgery accepting bowel obstruction risk, knowing acute volvulus would be harder to reach hospital for in timely fashion.
Open
Statement
In younger children with malrotation, the risk for volvulus or symptomatic malrotation is higher, so Ladd procedure is performed more commonly.
Open
Statement
There is controversy about whether to perform prophylactic Ladd procedure in children with diagnosed malrotation or in conditions like congenital diaphragmatic hernia where malrotation is present by definition, due to long-term risks of bowel obstruction and complications.
Open
Statement
There is controversy about whether the mesentery can be successfully broadened as wide as needed by laparoscopic approach.
Open
Statement
Dr. Kotagal's approach in older children with symptomatic malrotation is to start laparoscopically and assess mesenteric width and duodenal anatomy; if mesentery is fairly broad with main problem being duodenal bands, she may complete it laparoscopically, but very narrow mesentery may be harder to address laparoscopically.
Open
Meera's statements about Neuroblastoma 34 statements
Open the Neuroblastoma collection →
Neuroblastoma with Dr. Meera Kotagal
Statement
Neuroblastoma makes up about 8 to 10% of all pediatric cancers and about 15% of cancer-related deaths.
Open
Statement
Neuroblastoma makes up about 8 to 10% of all pediatric cancers and about 15% of cancer-related deaths.
Open
Statement
Neuroblastomas are not typically thought of as causing elevated blood pressure despite producing catecholamines.
Open
Statement
Neuroblastomas are not typically thought of as causing elevated blood pressure despite producing catecholamines.
Open
Quotation
The best way to think about IDRFs are things that touch things that are important, touching the vessels, touching the brachial plaque, touching the trachea, all of those things count as IDRS.
Open
Statement
Image-defined risk factors (IDRFs) are best understood as things that touch important structures: vessels, brachial plexus, or trachea.
Open
Statement
Image-defined risk factors (IDRFs) are best understood as things that touch important structures: vessels, brachial plexus, or trachea.
Open
Quotation
The best way to think about IDRFs are things that touch things that are important, touching the vessels, touching the brachial plaque, touching the trachea, all of those things count as IDRS.
Open
Statement
Intermediate risk neuroblastoma patients receive neoadjuvant chemotherapy with 2, 4, 6, or 8 cycles depending on chromosomal factors, followed by surgical resection.
Open
Statement
Intermediate risk neuroblastoma patients receive neoadjuvant chemotherapy with 2, 4, 6, or 8 cycles depending on chromosomal factors, followed by surgical resection.
Open
Statement
The key surgical principle for neuroblastoma resection is to stay on the vessels and work from normal to abnormal anatomy.
Open
Statement
The key surgical principle for neuroblastoma resection is to stay on the vessels and work from normal to abnormal anatomy.
Open
Statement
Image-defined risk factors (IDRFs) are associated with increased risk of surgical complications.
Open
Statement
Image-defined risk factors (IDRFs) are associated with increased risk of surgical complications.
Open
Statement
When percutaneous core biopsies are performed by experienced practitioners who obtain multiple cores, the adequacy of these biopsies significantly improves and they are not inferior to open surgical biopsies.
Open
Statement
When percutaneous core biopsies are performed by experienced practitioners who obtain multiple cores, the adequacy of these biopsies significantly improves and they are not inferior to open surgical biopsies.
Open
Statement
At Cincinnati Children's, radiologists obtain 25 cores from different parts of neuroblastoma tumors during percutaneous biopsy.
Open
Statement
At Cincinnati Children's, radiologists obtain 25 cores from different parts of neuroblastoma tumors during percutaneous biopsy.
Open
Statement
For neuroblastoma, unlike most tumors, the goal is to get as much tumor as possible but complete resection of every ounce of tumor is not expected.
Open
Statement
For neuroblastoma, unlike most tumors, the goal is to get as much tumor as possible but complete resection of every ounce of tumor is not expected.
Open
Statement
Tumor extending into neural foramina or other difficult locations should not be aggressively pursued; the goal is maximal safe resection without causing harm.
Open
Quotation
There's tumor that extends into the neural foramina or that extends into other places, you're not going to go chasing it.
Open
Statement
Tumor extending into neural foramina or other difficult locations should not be aggressively pursued; the goal is maximal safe resection without causing harm.
Open
Quotation
There's tumor that extends into the neural foramina or that extends into other places, you're not going to go chasing it.
Open
Statement
The observation protocol for infants with neuroblastoma has been expanded from primary adrenal tumors to L1 tumors in children under 6 months.
Open
Statement
The observation protocol for infants with neuroblastoma has been expanded from primary adrenal tumors to L1 tumors in children under 6 months.
Open
Meera's statements about Pilonidal Disease 1 statement
Open the Pilonidal Disease collection →
Update Course Rewind: Pilonidal Disease 2019
Statement
Some surgeons use sinus endoscopy (cystoscopy) after pit excision to identify and remove remaining hair and granulation tissue
Open
Meera's statements about Umbilical Hernia 18 statements
Open the Umbilical Hernia collection →
Umbilical Pathologies Bonus Episode
Quotation
The History and physical are really important in the evaluation of a young child with an umbilical bulge.
Open
Statement
Differential diagnosis of umbilical bulge includes umbilical hernia, urachal cyst, patent omphalomesenteric duct, umbilical granuloma, umbilical polyp, and omphalitis (if significant erythema present).
Open
Quotation
The presence of umbilical drainage may help you distinguish whether or not it's one of these things.
Open
Statement
Operative exploration for patent urachus or patent omphalomesenteric duct uses a curvilinear incision in the infra-umbilical space, with dissection to identify attachments from umbilicus to bladder or intestine, which are then divided.
Open
Statement
An umbilical granuloma is granulation tissue or asymptomatic pink tissue at the base of the umbilicus, commonly seen in very small infants shortly after umbilical cord separation, treated with silver nitrate.
Open
Statement
An umbilical polyp is a small remnant of the omphalomesenteric duct extending from the umbilicus that is excised.
Open
Statement
African-American infants are 8 times more likely to have an umbilical hernia compared to Caucasians.
Open
Statement
Small umbilical hernia defects are more likely to close spontaneously compared to larger defects (those over 1 to 1.5 centimeters).
Open
Statement
Pediatric umbilical hernia repair involves an infra-umbilical curvilinear incision, encircling and dividing the umbilical stalk, separating the hernia sac from skin and fascia, identifying fascial edges, and closing the defect primarily.
Open
Statement
During pediatric umbilical hernia repair, it is important to close normal fascia to normal fascia, not hernia sac to hernia sac.
Open
Quotation
it is really important to make sure when you do that repair that you get all the way back to normal fashion. And that you're not closing hernia sac to hernia sac.
Open
Summaries Meera gave as host · 27 summaries
Recaps of other experts' statements, not Meera's own clinical position.
Summaries Meera gave as host · Abdominal Wall Defects 8 summaries
Open the Abdominal Wall Defects collection →
7th Annual Pediatric Surgery Update Course 2019 - FULL SHOW
Host summary
Meera Kotagal summarizing the discussion: For cervical spine clearance imaging in children, use AP and lateral x-rays; if cross-sectional imaging needed, use MRI not CT because most injuries are ligamentous not bony
Open
Host summary
Meera Kotagal summarizing the discussion: In older children, 70 to 80% of cervical spine injuries are bony injuries following adult patterns
Open
Host summary
Meera Kotagal summarizing the discussion: Cervical spine injury is about 1 to 2% of all pediatric traumas
Open
Host summary
Meera Kotagal summarizing the discussion: In younger children less than or equal to 8 years, about 50% have isolated fractures and 50% have ligamentous injury, dislocations, or SCIWORA
Open
Host summary
Meera Kotagal summarizing the discussion: 60 to 80% of vertebral injuries in kids are in the cervical spine compared to 30 to 40% in adults
Open
Host summary
Meera Kotagal summarizing the discussion: AAST study of over 12,000 children with blunt trauma found 0.6% had cervical spine injury; four independent predictors were GCS less than 14, involved in motor vehicle crash, age greater than or equal to 2 years
Open
Host summary
Meera Kotagal summarizing the discussion: Patients with cervical spine injury score of 0-1 points had negative predictive value over 99% and did not need imaging
Open
Host summary
Meera Kotagal summarizing the discussion: 46% of institutions don't have a protocol for cervical spine clearance in children
Open
Summaries Meera gave as host · Etiologies (Gastroschisis/NEC/Atresia/Volvulus) 8 summaries
Open the Etiologies (Gastroschisis/NEC/Atresia/Volvulus) collection →
7th Annual Pediatric Surgery Update Course 2019 - FULL SHOW
Host summary
Meera Kotagal summarizing the discussion: For cervical spine clearance imaging in children, use AP and lateral x-rays; if cross-sectional imaging needed, use MRI not CT because most injuries are ligamentous not bony
Open
Host summary
Meera Kotagal summarizing the discussion: AAST study of over 12,000 children with blunt trauma found 0.6% had cervical spine injury; four independent predictors were GCS less than 14, involved in motor vehicle crash, age greater than or equal to 2 years
Open
Host summary
Meera Kotagal summarizing the discussion: In older children, 70 to 80% of cervical spine injuries are bony injuries following adult patterns
Open
Host summary
Meera Kotagal summarizing the discussion: Cervical spine injury is about 1 to 2% of all pediatric traumas
Open
Host summary
Meera Kotagal summarizing the discussion: In younger children less than or equal to 8 years, about 50% have isolated fractures and 50% have ligamentous injury, dislocations, or SCIWORA
Open
Host summary
Meera Kotagal summarizing the discussion: 46% of institutions don't have a protocol for cervical spine clearance in children
Open
Host summary
Meera Kotagal summarizing the discussion: Patients with cervical spine injury score of 0-1 points had negative predictive value over 99% and did not need imaging
Open
Host summary
Meera Kotagal summarizing the discussion: 60 to 80% of vertebral injuries in kids are in the cervical spine compared to 30 to 40% in adults
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Summaries Meera gave as host · Inguinal Hernia 3 summaries
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Pediatric Inguinal Hernia in Brief: Presentation, Workup, Diagnosis, Perioperative Considerations
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Meera Kotagal summarizing a resource: Now that with laparoscopy, you don't necessarily need to wait because it's really not that much more difficult in a laparoscopic case if there's swelling. In fact, sometimes the edema can help lift the peritoneum off.
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Meera Kotagal summarizing a resource: Dr. Todd Ponsky states that with laparoscopy, you don't necessarily need to wait for bowel edema to come down because it's really not that much more difficult in a laparoscopic case if there's swelling, and sometimes the edema can help lift the peritoneum off.
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Meera Kotagal summarizing a resource: Dr. Todd Ponsky suggests that if it's in the middle of the day and you have time availability and a patient has an incarcerated hernia, you could not even try to reduce it in the emergency room and just go straight to the operating room under laparoscopy.
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Summaries Meera gave as host · Intestinal Rehab 8 summaries
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7th Annual Pediatric Surgery Update Course 2019 - FULL SHOW
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Meera Kotagal summarizing the discussion: Patients with cervical spine injury score of 0-1 points had negative predictive value over 99% and did not need imaging
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Meera Kotagal summarizing the discussion: Cervical spine injury is about 1 to 2% of all pediatric traumas
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Meera Kotagal summarizing the discussion: In older children, 70 to 80% of cervical spine injuries are bony injuries following adult patterns
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Meera Kotagal summarizing the discussion: In younger children less than or equal to 8 years, about 50% have isolated fractures and 50% have ligamentous injury, dislocations, or SCIWORA
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Meera Kotagal summarizing the discussion: 60 to 80% of vertebral injuries in kids are in the cervical spine compared to 30 to 40% in adults
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Meera Kotagal summarizing the discussion: AAST study of over 12,000 children with blunt trauma found 0.6% had cervical spine injury; four independent predictors were GCS less than 14, involved in motor vehicle crash, age greater than or equal to 2 years
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Meera Kotagal summarizing the discussion: For cervical spine clearance imaging in children, use AP and lateral x-rays; if cross-sectional imaging needed, use MRI not CT because most injuries are ligamentous not bony
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Meera Kotagal summarizing the discussion: 46% of institutions don't have a protocol for cervical spine clearance in children
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