ABS Pediatric Surgery cheat sheet

Congenital diaphragmatic hernia: prenatal liver-up and a low observed-to-expected lung-to-head ratio predict worse survival; fetal endoscopic tracheal occlusion is reserved for severe cases under research protocols.

Myelomeningocele: prenatal repair before 26 weeks reduces need for ventriculoperitoneal shunt and improves motor outcomes, but increases preterm delivery and uterine dehiscence.

Macrocystic congenital pulmonary airway malformation with hydrops: thoracoamniotic shunt can decompress the dominant cyst; microcystic disease with hydrops may be treated with maternal steroids or fetal surgery.

Sacrococcygeal teratoma: large vascular tumors can cause high-output heart failure and hydrops; prenatal options include cyst drainage, laser ablation, or open resection in selected cases.

Twin-twin transfusion syndrome: Quintero staging; severe cases before 26 weeks are treated with fetoscopic laser ablation of placental anastomoses.

Gastroschisis: right paraumbilical full-thickness abdominal wall defect without a membrane; bowel is exposed and often matted, and associated anomalies are less common than in omphalocele.

Omphalocele: membrane-covered central umbilical defect; associated chromosomal, cardiac, and Beckwith-Wiedemann abnormalities are common, and giant lesions may need staged closure.

Prenatal hydronephrosis: anterior-posterior renal pelvic diameter and Society for Fetal Urology grade guide postnatal ultrasound timing; low-grade unilateral dilatation usually undergoes observation.

Cervical teratoma or lymphatic malformation with airway risk: planned ex utero intrapartum treatment (EXIT) may secure the airway before umbilical cord division.

Necrotizing enterocolitis: Bell stage IIIB includes pneumoperitoneum; perforation requires surgery, and primary peritoneal drainage is an option for unstable very-low-birth-weight infants.

Duodenal atresia: double-bubble sign without distal gas; associated with trisomy 21 and cardiac defects; treatment is duodenoduodenostomy after stabilization.

Malrotation with volvulus: bilious emesis is a surgical emergency; urgent upper GI series shows corkscrew duodenum, and Ladd procedure is performed after resuscitation.

Hirschsprung disease: delayed meconium, distension, and transition zone on contrast enema; rectal biopsy confirms aganglionosis; pull-through is performed after leveling colostomy in high-risk neonates.

Meconium ileus: associated with cystic fibrosis; hyperosmolar contrast enema is diagnostic and therapeutic; surgery is indicated for perforation, peritonitis, or failed enema.

Pyloric stenosis: nonbilious projectile vomiting at 3-6 weeks; ultrasound shows thickened pyloric muscle; correct hypochloremic hypokalemic alkalosis before pyloromyotomy.

Congenital diaphragmatic hernia: gentle ventilation, avoidance of hypoxia and acidosis, and delayed repair after physiologic stabilization; extracorporeal membrane oxygenation for refractory failure.

Abdominal wall defects: cover exposed bowel, nasogastric decompression, intravenous fluids at 1.5-2 times maintenance for gastroschisis, and staged silo reduction if primary closure is not possible.

Neonatal ovarian cyst: simple cysts under 4-5 cm are usually observed; complex cysts, torsion, or rapid enlargement prompt surgical evaluation.

Biliary atresia: conjugated hyperbilirubinemia and acholic stools; Kasai portoenterostomy before 60 days improves native liver survival; liver transplant for progressive cirrhosis.

Choledochal cyst: complete excision with hepaticojejunostomy; risk of cholangiocarcinoma increases with age and incomplete excision.

Intussusception: age 6 months to 3 years, colicky pain, vomiting, and red currant jelly stool; ultrasound target sign; air enema reduction if stable and no peritonitis.

Appendicitis: Alvarado score and ultrasound; uncomplicated appendicitis may be treated with appendectomy or antibiotics; perforation with abscess may require drainage.

Meckel diverticulum: painless lower GI bleeding from ectopic gastric mucosa; technetium-99m scan; surgical resection for symptomatic or bleeding lesions.

Inguinal hernia in infants: indirect hernia due to patent processus vaginalis; incarceration risk is highest in the first year; repair is recommended soon after diagnosis.

Hepatoblastoma: young child, elevated alpha-fetoprotein, PRETEXT staging; cisplatin-based chemotherapy and complete resection; transplantation for unresectable liver-confined disease.

Hepatocellular carcinoma: older child, underlying hepatitis B or metabolic liver disease, variable alpha-fetoprotein; surgical resection or transplantation when feasible.

Inflammatory bowel disease: Crohn disease is managed medically when possible; ulcerative colitis may require total proctocolectomy with ileal pouch-anal anastomosis.

Wilms tumor: nephrectomy plus chemotherapy; avoid biopsy when imaging is classic; tumor spillage upstages disease; bilateral disease favors nephron-sparing surgery.

Neuroblastoma: prognostic factors include age, stage, MYCN amplification, and histology; MIBG scan and catecholamine metabolites aid diagnosis and follow-up.

Hepatoblastoma: PRETEXT grouping determines resectability; alpha-fetoprotein is a tumor marker; cisplatin-based chemotherapy is standard.

Rhabdomyosarcoma: site and histology determine risk; parameningeal and bladder/prostate sites need multimodality therapy; adequate biopsy before treatment.

Ewing sarcoma: small round blue cell tumor with EWSR1 translocation; neoadjuvant chemotherapy followed by local control with surgery, radiation, or both.

Osteosarcoma: metaphyseal bone tumor in adolescents; neoadjuvant chemotherapy and limb-salvage resection; pulmonary nodules require evaluation for metastasis.

Germ cell tumors: sacrococcygeal teratoma is common in neonates; alpha-fetoprotein and beta-human chorionic gonadotropin are markers; treatment is resection with chemotherapy for malignant histology.

Lymphoma: excisional biopsy is preferred for diagnosis; avoid corticosteroids before biopsy because they can obscure histology; staging guides therapy.

Pediatric thyroid carcinoma: papillary type predominates; total thyroidectomy with central neck dissection is common; radioiodine for selected high-risk disease.

Pediatric hypotension: systolic blood pressure below 70 mm Hg plus twice age in years for children 1-10 years; below 70 mm Hg for infants and below 90 mm Hg for adolescents.

Shock resuscitation: 20 mL/kg isotonic crystalloid bolus, reassess; 10 mL/kg packed red blood cells for hemorrhagic shock; avoid repeated boluses without reassessment.

Trauma imaging: focused assessment with sonography for trauma in unstable patients; computed tomography for stable patients with suspected solid-organ or head injury.

Splenic injury: nonoperative management for hemodynamically stable children; angioembolization for active arterial bleeding; laparotomy for instability or ongoing transfusion requirement.

Traumatic brain injury: avoid hypotension and hypoxia; maintain cerebral perfusion; hypertonic saline or mannitol for signs of herniation; neurosurgery for expanding mass.

Burn resuscitation: Parkland formula 4 mL/kg per percent total body surface area in first 24 hours; half in first 8 hours; add maintenance fluids in children.

Abdominal compartment syndrome: bladder pressure monitoring; sustained intra-abdominal pressure with new organ dysfunction suggests decompression via laparotomy.

Massive transfusion: balanced resuscitation with blood products; 10-20 mL/kg aliquots; monitor calcium, temperature, and coagulation.

ECMO: considered for refractory respiratory or cardiac failure; contraindications include irreversible neurologic injury, lethal anomalies, and uncontrollable bleeding.

Esophageal atresia: most common form is distal tracheoesophageal fistula; coiled nasogastric tube, absent gastric air in pure atresia; evaluate for VACTERL and cardiac defects before repair.

Congenital pulmonary airway malformation: asymptomatic lesions may be observed or electively resected; symptomatic, enlarging, or hydropic lesions require intervention.

Pneumothorax: chest tube for symptomatic or large pneumothorax; needle decompression for tension physiology before tube thoracostomy.

Empyema: antibiotics plus chest tube; fibrinolytics or video-assisted thoracoscopic surgery for loculated collections.

Pectus excavatum: Nuss procedure uses a retrosternal bar; Haller index above 3.25 supports surgical evaluation; complications include bar displacement and pericarditis.

Mediastinal mass: anterior mass may be lymphoma, thymoma, or teratoma; posterior mass often neuroblastoma; airway compression requires careful anesthesia planning.

Chylothorax: low-fat diet or total parenteral nutrition, octreotide, and thoracic duct ligation if conservative measures fail.

Congenital thoracic dystrophy: severe pectus or rib anomalies can impair ventilation; repair may improve pulmonary function in selected patients.

Lung sequestration: systemic arterial supply; intralobar lesion drains via pulmonary veins; extralobar lesion has its own pleural investment; resection for symptoms or recurrent infection.

Ureteropelvic junction obstruction: diuretic renography quantifies drainage; pyeloplasty for obstructive pattern, declining renal function, or recurrent infection.

Vesicoureteral reflux: grades I-V on voiding cystourethrogram; antibiotic prophylaxis for selected high-grade or recurrent febrile urinary tract infections; surgery for breakthrough infections.

Posterior urethral valves: prenatal keyhole bladder and oligohydramnios; voiding cystourethrogram confirms; endoscopic ablation relieves obstruction; monitor renal function.

Hypospadias: defer circumcision; repair at 6-18 months; chordee correction and urethroplasty; complications include fistula and stricture.

Cryptorchidism: orchiopexy by 12-18 months; risks include infertility and malignancy; impalpable testis may require laparoscopy.

Anorectal malformation: imperforate anus with or without fistula; initial colostomy for unstable neonates or high lesions; posterior sagittal anorectoplasty for definitive repair.

Testicular torsion: acute scrotal pain and nausea; Doppler ultrasound may be normal early; urgent detorsion and bilateral fixation.

Communicating hydrocele: patent processus vaginalis; repair if persistent beyond 1-2 years or associated with hernia; transillumination helps diagnosis.

Bladder exstrophy: lower abdominal wall defect with exposed bladder; initial closure and later continence reconstruction; orthopedic pelvic closure may be needed.

Thyroglossal duct cyst: midline neck mass moving with tongue protrusion; Sistrunk procedure removes cyst and central hyoid to reduce recurrence.

Branchial cleft cyst: lateral neck mass; second branchial cleft anomalies are most common; complete excision after infection control.

Infantile hemangioma: propranolol for problematic lesions; indications include airway obstruction, visual compromise, ulceration, and large size.

Lymphatic malformation: macrocystic lesions respond to sclerotherapy; airway involvement may require tracheostomy or EXIT planning.

Pediatric thyroid nodule: ultrasound and fine-needle aspiration; malignancy risk higher than in adults; papillary carcinoma most common.

Primary hyperparathyroidism: rare in children; due to adenoma or hereditary syndromes; parathyroidectomy for symptomatic or moderate hypercalcemia.

Adrenal mass: neuroblastoma common in young children; pheochromocytoma causes hypertension and catecholamine excess; adrenal hemorrhage can mimic tumor.

Soft tissue sarcoma: rhabdomyosarcoma common; biopsy and imaging for staging; multimodality therapy with surgery, chemotherapy, and radiation.

Torticollis: sternocleidomastoid tightness; physiotherapy first; surgical release for persistent deformity after 1 year.