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The second period lasts from the raising of stoma to its closure, including the definite surgical procedure. The A to Z of the Cold War. Prelude Africa Asia Europe. Imperforate anus IA is a congenital anomaly in which the natural anal opening is absent. Another essential nutrient for the human body is iron, a metallic element found in red meat and vegetables. If this coagulation profile is normal the possibilities are either stress gastritis or ulcer disease. Extensive public works were undertaken, including the construction of Autobahnen motorways.


Historian and war correspondent William L. By February , the Reichsfinanzministerium Ministry of Finance had calculated that 48 billion Reichsmarks had been paid to Germany. By the end of the war, occupation costs were calculated by the Nazis to number 60 billion Reichsmarks, with France alone paying The Bank of France was also forced to provide 4.

The Nazis exploited other conquered nations in a similar way. After the war, the United States Strategic Bombing Survey concluded Germany had obtained billion Reichsmarks in the form of occupation costs and other wealth transfers from the whole of occupied Europe, including two-thirds of the gross domestic product of Belgium and the Netherlands.

Nazi plunder included private and public art collections, artefacts, precious metals, books, and personal possessions. Hitler and Göring in particular were interested in acquiring looted art treasures from occupied Europe, [] the former planning to use the stolen art to fill the galleries of the planned Führermuseum Leader's Museum , [] and the latter for his personal collection.

Göring, having stripped almost all of occupied Poland of its artworks within six months of Germany's invasion, ultimately grew a collection valued at over 50 million Reichsmarks. France saw the greatest extent of Nazi plunder. Some 26, railroad cars of art treasures, furniture, and other looted items were sent to Germany from France.

Goods and raw materials were also taken. In France, an estimated 9,, tonnes 8,, long tons; 9,, short tons of cereals were seized and transported to Germany during the course of the war.

The valuation of this loot is estimated to be The plunder of Poland for raw materials began even before Germany had finished its invasion of the country. Poland can only be administered by utilizing the country through means of ruthless exploitation, deportation of all supplies, raw materials, machines, factory instilations, ect. Poland shall be treated as a colony.

The Poles shall be the slaves of the Greater German Reich. Following Operation Barbarossa, the Soviet Union was also plundered. In alone, 9,, tons of cereals, 2,, tonnes 2,, long tons; 2,, short tons of fodder, 3,, tonnes 3,, long tons; 3,, short tons of potatoes, and , tonnes , long tons; , short tons of meats were sent back to Germany. By the time the last German troops left Soviet territory in , some 12 million pigs and 13 million sheep had also been taken.

The total value of Germany's plunder of the Soviet Union is estimated at 4 billion Reichsmarks. This relatively low number in comparison to the occupied nations of Western Europe can be attributed to the devastating fighting on the Eastern Front. Nazi Germany's racial policy was based on their belief in the existence of a superior master race. The Nazis postulated the existence of a racial conflict between the Aryan master race and inferior races, particularly Jews, who were viewed as a mixed race that had infiltrated society and were responsible for the exploitation and repression of the Aryan race.

Discrimination against Jews began immediately after the seizure of power. Following a month-long series of attacks by members of the SA on Jewish businesses and synagogues, on 1 April Hitler declared a national boycott of Jewish businesses. The regime used violence and economic pressure to encourage Jews to voluntarily leave the country. Citizens were harassed and subjected to violent attacks. In November , a young Jewish man requested an interview with the German ambassador in Paris and met with a legation secretary, whom he shot and killed to protest his family's treatment in Germany.

Members of the SA damaged or destroyed synagogues and Jewish property throughout Germany. The Jewish community was fined one billion marks to pay for the damage caused by Kristallnacht and told that any insurance settlements would be confiscated. Emigrants to Palestine were allowed to transfer property there under the terms of the Haavara Agreement , but those moving to other countries had to leave virtually all their property behind, and it was seized by the government.

Like the Jews, the Romani people were subjected to persecution from the early days of the regime. As a non-Aryan race, they were forbidden to marry people of German extraction. Romani were shipped to concentration camps starting in and were killed in large numbers.

Action T4 was a programme of systematic murder of the physically and mentally handicapped and patients in psychiatric hospitals that mainly took place from to , and continued until the end of the war.

Initially the victims were shot by the Einsatzgruppen and others; in addition gas chambers and gas vans using carbon monoxide were used by early Mentally and physically ill people were also targeted. Most of the victims came from disadvantaged groups such as prostitutes, the poor, the homeless, and criminals.

Germany's war in the East was based on Hitler's long-standing view that Jews were the great enemy of the German people and that Lebensraum was needed for Germany's expansion. Hitler focused his attention on Eastern Europe, aiming to defeat Poland and the Soviet Union and remove or kill the resident Jews and Slavs. The Generalplan Ost "General Plan for the East" called for deporting the population of occupied Eastern Europe and the Soviet Union to Siberia, for use as slave labour or to be murdered.

Around the time of the failed offensive against Moscow in December , Hitler resolved that the Jews of Europe were to be exterminated immediately. Some would be worked to death and the rest would be killed in the implementation of Die Endlösung der Judenfrage the Final Solution of the Jewish question.

German citizens had access to information about what was happening, as soldiers returning from the occupied territories would report on what they had seen and done. Evans states that most German citizens disapproved of the genocide. In addition to eliminating Jews, the Nazis planned to reduce the population of the conquered territories by 30 million people through starvation in an action called the Hunger Plan. Food supplies would be diverted to the German army and German civilians.

Cities would be razed and the land allowed to return to forest or resettled by German colonists. Poles were viewed by Nazis as subhuman non-Aryans, and during the German occupation of Poland 2. The German authorities engaged in a systematic effort to destroy Polish culture and national identity. During operation AB-Aktion , many university professors and members of the Polish intelligentsia were arrested, transported to concentration camps, or executed.

During the war, Poland lost an estimated 39 to 45 percent of its physicians and dentists, 26 to 57 percent of its lawyers, 15 to 30 percent of its teachers, 30 to 40 percent of its scientists and university professors and 18 to 28 percent of its clergy.

Between June and January , the Nazis killed an estimated 2. Antisemitic legislation passed in led to the removal of all Jewish teachers, professors and officials from the education system. Frequent and often contradictory directives were issued by Interior Minister Wilhelm Frick, Bernhard Rust of the Reichserziehungsministerium Ministry of Education , and various other agencies regarding content of lessons and acceptable textbooks for use in primary and secondary schools.

Detailed National Socialist indoctrination of future holders of elite military rank was undertaken at Order Castles. Primary and secondary education focused on racial biology, population policy, culture, geography, and especially physical fitness. At universities, appointments to top posts were the subject of power struggles between the education ministry, the university boards, and the National Socialist German Students' League.

Religion in Germany []. When the Nazis seized power in , roughly 67 percent of the population of Germany was Protestant , 33 percent was Roman Catholic , while Jews made up less than 1 percent.

Under the Gleichschaltung process, Hitler attempted to create a unified Protestant Reich Church from Germany's 28 existing Protestant state churches , [] with the ultimate goal of eradication of the churches in Germany. Persecution of the Catholic Church in Germany followed the Nazi takeover. Catholic schools were required to reduce religious instruction and crucifixes were removed from state buildings. Pope Pius XI had the " Mit brennender Sorge " "With Burning Concern" encyclical smuggled into Germany for Passion Sunday and read from every pulpit as it denounced the systematic hostility of the regime toward the church.

Enrolment in denominational schools dropped sharply and by all such schools were disbanded or converted to public facilities. He planned the "extermination of the foreign Christian faiths imported into Germany", and for the Bible and Christian cross to be replaced in all churches, cathedrals, and chapels with copies of Mein Kampf and the swastika.

Nazi Germany had a strong anti-tobacco movement as pioneering research by Franz H. Müller in demonstrated a causal link between tobacco smoking and lung cancer. Government-run health care insurance plans were available, but Jews were denied coverage starting in That same year, Jewish doctors were forbidden to treat government-insured patients. In , Jewish doctors were forbidden to treat non-Jewish patients and in their right to practice medicine was removed entirely.

Medical experiments, many of them pseudoscientific , were performed on concentration camp inmates beginning in Josef Mengele , camp doctor at Auschwitz. Women were a cornerstone of Nazi social policy and the Nazis opposed the feminist movement, claiming that it was the creation of Jewish intellectuals, instead advocating a patriarchal society in which the German woman would recognise that her "world is her husband, her family, her children, and her home".

Courses were offered on childrearing, sewing and cooking. Women were encouraged to leave the workforce and the creation of large families by racially suitable women was promoted through a propaganda campaign. Women received a bronze award—known as the Ehrenkreuz der Deutschen Mutter Cross of Honour of the German Mother —for giving birth to four children, silver for six and gold for eight or more.

Though the measures led to increases in the birth rate, the number of families having four or more children declined by five percent between and After the war started, slave labourers were extensively used.

The Nazi regime discouraged women from seeking higher education since Nazi leaders held conservative views about women and endorsed the idea that rational and theoretical work was alien to a woman's nature since they were considered inherently emotional and instinctive — as such, engaging in academics and careerism would only "divert them from motherhood". The number of women enrolled in post-secondary schools dropped from , in to 51, in However, with the requirement that men be enlisted into the armed forces during the war, women comprised half of the enrolment in the post-secondary system by Women were expected to be strong, healthy and vital.

The BDM's activities focused on physical education, with activities such as running, long jumping, somersaulting, tightrope walking, marching and swimming. The Nazi regime promoted a liberal code of conduct regarding sexual matters and was sympathetic to women who bore children out of wedlock.

Soldier's wives were frequently involved in extramarital relationships. Sex was sometimes used as a commodity to obtain better work from a foreign labourer. With Hitler's approval, Himmler intended that the new society of the Nazi regime should destigmatise illegitimate births, particularly of children fathered by members of the SS, who were vetted for racial purity.

Existing laws banning abortion except for medical reasons were strictly enforced by the Nazi regime. The number of abortions declined from 35, per year at the start of the s to fewer than 2, per year at the end of the decade, though in a law was passed allowing abortions for eugenics reasons. Nazi society had elements supportive of animal rights and many people were fond of zoos and wildlife. In , the Nazis enacted a stringent animal-protection law that affected what was allowed for medical research.

The Reich Forestry Office under Göring enforced regulations that required foresters to plant a wide variety of trees to ensure suitable habitat for wildlife and a new Reich Animal Protection Act became law in Evans , The Coming of the Third Reich The regime promoted the concept of Volksgemeinschaft , a national German ethnic community.

The goal was to build a classless society based on racial purity and the perceived need to prepare for warfare, conquest and a struggle against Marxism. In addition to taking control of tens of thousands of previously privately run recreational clubs, it offered highly regimented holidays and entertainment such as cruises, vacation destinations and concerts.

Sub-chambers were set up to control aspects of cultural life such as film, radio, newspapers, fine arts, music, theatre and literature. Members of these professions were required to join their respective organisation.

Jews and people considered politically unreliable were prevented from working in the arts and many emigrated. Books and scripts had to be approved by the Propaganda Ministry prior to publication. Standards deteriorated as the regime sought to use cultural outlets exclusively as propaganda media. Radio became popular in Germany during the s, with over 70 percent of households owning a receiver by , more than any other country.

Radio station staffs were purged of leftists and others deemed undesirable by July As with other media, newspapers were controlled by the state, with the Reich Press Chamber shutting down or buying newspapers and publishing houses. By , over two thirds of the newspapers and magazines were directly owned by the Propaganda Ministry. Under Goebbels, the Propaganda Ministry issued two dozen directives every week on exactly what news should be published and what angles to use; the typical newspaper followed the directives closely, especially regarding what to omit.

Authors of books left the country in droves and some wrote material critical of the regime while in exile. Goebbels recommended that the remaining authors concentrate on books themed on Germanic myths and the concept of blood and soil. By the end of , over a thousand books—most of them by Jewish authors or featuring Jewish characters—had been banned by the Nazi regime.

In Berlin over 20, books being burned at the square at the State Opera. Pacifist works, as well as literature espousing liberal, democratic tendencies and attitudes were targeted for destruction, as well as any writings supporting the Weimar Republic or those written by Jewish authors. Hitler took a personal interest in architecture and worked closely with state architects Paul Troost and Albert Speer to create public buildings in a neoclassical style based on Roman architecture.

Neither structure was built. Hitler's belief that abstract , Dadaist , expressionist and modern art were decadent became the basis for policy.

The exhibition proved wildly popular, attracting over two million visitors. Movies were popular in Germany in the s and s, with admissions of over a billion people in , and Exports of German films plummeted, as their antisemitic content made them impossible to show in other countries. The two largest film companies, Universum Film AG and Tobis , were purchased by the Propaganda Ministry, which by was producing most German films.

The productions were not always overtly propagandistic, but generally had a political subtext and followed party lines regarding themes and content. Leni Riefenstahl 's Triumph of the Will —documenting the Nuremberg Rally—and Olympia —covering the Summer Olympics —pioneered techniques of camera movement and editing that influenced later films.

New techniques such as telephoto lenses and cameras mounted on tracks were employed. Both films remain controversial, as their aesthetic merit is inseparable from their propagandising of National Socialist ideals. The Allied powers organised war crimes trials, beginning with the Nuremberg trials , held from November to October , of 23 top Nazi officials.

They were charged with four counts—conspiracy to commit crimes, crimes against peace, war crimes and crimes against humanity —in violation of international laws governing warfare. The display or use of Nazi symbolism such as flags, swastikas or greetings is illegal in Germany and Austria [] [] and other restrictions, mainly on public display, apply in various countries.

Nazi ideology and the actions taken by the regime are almost universally regarded as gravely immoral. Evans remarks that the era "exerts an almost universal appeal because its murderous racism stands as a warning to the whole of humanity". The Nazi era continues to inform how Germans view themselves and their country.

Virtually every family suffered losses during the war or has a story to tell, though Germans kept quiet about their experiences and felt a sense of communal guilt, even if they were not directly involved in war crimes. Once study of Nazi Germany was introduced into the school curriculum starting in the s, people began researching the experiences of their family members.

Study of the era and a willingness to critically examine its mistakes has led to the development of a strong democracy in today's Germany, but with lingering undercurrents of antisemitism and neo-Nazi thought. From Wikipedia, the free encyclopedia. Redirected from Third reich. For the book, see Das Dritte Reich. Das Lied der Deutschen "Song of the Germans".

Administrative divisions of Germany, January Nazi one-party totalitarian dictatorship. The German state from to , under the dictatorship of Adolf Hitler. Adolf Hitler's rise to power. Anschluss and German occupation of Czechoslovakia.

Protectorate of Bohemia and Moravia. Mass suicides in Nazi Germany. Territorial evolution of Germany. Government of Nazi Germany. Economy of Nazi Germany. Nazism and race and Racial policy of Nazi Germany. Anti-Jewish legislation in prewar Nazi Germany. Porajmos and Nazi eugenics. Nazi crimes against the Polish nation. German mistreatment of Soviet prisoners of war and Generalplan Ost. University education in Nazi Germany. Other religion or irreligious 4.

Religion in Nazi Germany. Women in Nazi Germany. Animal welfare in Nazi Germany. If the experience of the Third Reich teaches us anything, it is that a love of great music, great art and great literature does not provide people with any kind of moral or political immunization against violence, atrocity, or subservience to dictatorship. List of authors banned in Nazi Germany. Nazi architecture and Art of the Third Reich. See Statistisches Jahrbuch It could not be expected that even for a brief period our Air Force could make up for our lack of naval supremacy.

Grand Admiral Karl Dönitz believed air superiority was not enough and admitted, "We possessed neither control of the air or the sea; nor were we in any position to gain it. The figure of 2 to 2. The German Red Cross still maintains that the death toll from the expulsions is 2. Goebbel's propaganda campaigns carried out in the second half of and again in had failed to convert them". Evans , p. Women in the Third Reich. The German Churches and the Nazi State. End of the Thousand Year Reich.

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Progr Pediatr Surg Diagnosis of congenital megacolon: J Pediatr Surg 7: Imperforate anus IA is a congenital anomaly in which the natural anal opening is absent. Diagnosis of IA is usually made shortly after birth on routine physical examination. The incidence of IA is approximately 1 in live births and it is more common in males. Its etiology is unknown and it runs equally through all racial, cultural and socio-economic groups. IA is classified as either "high" or "low" depending on the termination of the distal rectum.

When the rectum ends above the levator muscles the malformations are classified as high, and when the rectum ends below the levator muscles the malformations are classified as low. High lesions are more frequent in males, low ones in females. Determination of the level of the lesion by abdominal x-ray or perineal ultrasound is critical for appropriate management. Children who have IA may also have other congenital anomalies. Vertebral defects, Anal atresia, Cardiac anomalies, Tracheoesophageal fistula, Esophageal atresia, Renal anomalies, and Limb anomalies.

Repair of low IA is relatively simple and is usually treated with perineal anoplasty; however, repair of high IA is more complex. Patients are initially given a temporary colostomy and time is given to allow the child to grow.

A pull-through operation is completed at a later date. Independent of the level of the lesion, the goal of the surgery is the creation of adequate nerve and muscle structures around the rectum and anus to provide the child with the capacity for bowel control. Male patients will benefit from perineal inspection to check for the presence of a fistula wait hours of life before deciding. During this time start antibiotherapy, decompress the GI tract, do a urinalysis to check for meconium cells, and an ultrasound of abdomen to identify urological associated anomalies.

Perineal signs in low malformations that will NOT need a colostomy are: These infants can be managed with a perineal anoplasty during the neonatal period with an excellent prognosis. Meconium in urine shows the pt has a fistula between the rectum and the urinary tract.

Flat "bottom" or perineum lack of intergluteal fold , and absence of anal dimple indicates poor muscles and a rather high malformation needing a colostomy. Patients with no clinical signs at 24 hours of birth will need a invertogram or cross-table lateral film in prone position to decide rectal pouch position.

Those cases with high defect are initially managed with a totally diverting colostomy. Diverting the fecal stream reduces the chances of genito-urinary tract contamination and future damage.

These infants require a colostomy before final corrective surgery. The colostomy can be done electively before discharge from the nursery while the GI tract is decompressed by dilatation of the fistulous tract. A single orifice is diagnostic of a persistent cloacal defect usually accompany with a small-looking genitalia.

Cloacas are associated to distended vaginas hydrocolpos and urologic malformations. This makes a sonogram of abdomen very important in the initial management of these babies for screening of obstructive uropathy hydronephrosis and hydroureter. Hydrocolpos can cause compressive obstruction of the bladder trigone and interfere with ureteral drainage. Failure to gain weight and frequents episodes of urinary tract infections shows a poorly drained urologic system.

A colostomy in cloacas is indicated. Radiological evaluation will be of help along with a diverting colostomy in this cases. Perineal fistulas can be managed with cutback without colostomy during the neonatal period. The most important prognostic characteristic is the severity of the IA. Patients with low IA have a good probability of having normal stool patterns. Patients with high IA report more problems such as fecal incontinence and constipation. For patients who cannot maintain normal bowel function, the use of a special diet, underpants liners, enemas and drugs have ameliorated their lives.

Long-term follow up with both qualitative and quantitative quality of life considerations of these patients is very important. References 1- Chen CJ: The treatment of imperforate anus: J Pediatr Surg 34 Inheritance of familial congenital isolated anorectal malformations: Am J Med Genetics Do children with repaired low anorectal malformations have normal bowel function?

J Pediatr Surg 32 6: Semin Pediatr Surg 4 1: Management of anorectal malformations during the newborn period. World J Surg 17 3: Posterior sagittal approach for the correction of anorectal malformations.

Surgical treatment of high imperforate anus. World J Surg 9 2: J Pediatr Surg 17 5: Although intussusception can occur at any age, the greatest incidence occurs in infants between months of age. Over half of the cases are in the first year of life. Frequently occurs after a recent upper respiratory infection, by Adenovirus type 3 that causes a reactive lymphoid hyperplasia that act as lead point of Peyer's patch.

Meckel's diverticulum, polyps, Henoch's Schonlein purpura, hematoma, lymphoma, foreign bodies, and duplications. Most children have no lead point and it is felt that enlarged mesenteric nodes or swollen Peyer's patches may be the cause.

The baby has intermittent periods of severe discomfort with screaming, stiffening and drawing up of the legs, followed by periods of rest. Vomiting may occur and bloody, mucoid currant jelly stool may be passed. The baby may become dehydrated and appear acutely ill. Frequently, lethargy may be an early sign. To be successful, the barium must reflux into the terminal ileum.

The surgeon should be notified before an attempt at barium reduction, and should be present at the time of study.

Recently the use of gas enema reduction has been successful in patients with: Ultrasonography can be used as a rapid sensitive screening procedure in the initial diagnosis of intussusception. Previous adverse clinical features that precluded barium reduction can be replaced during gas reduction.

Predictors of failure of reduction are: Air reduction pneumocolon is a very effective alternative method since it brings less radiation shorter flouroscopy time , less costs and less morbidity in cases of perforations. Failure of hydrostatic reduction requires urgent operation through a right lower quadrant horizontal incision. The intussusception is reduced by pushing on the distal bowel like a tube of toothpaste rather than pulling the proximal bowel.

Most cases are ileo-colic intussusception, and a few are jejuno-jejunal or ileo-ileal intussusception. The traditional method of diagnosing and managing ileo-colic intussusception is barium enema contrast reduction. In China where this is the most common surgical emergency in childhood, pneumatic reduction has been used for more than 25 years.

A recent tendency toward this approach is seen in recent years in Occident. Small bowel aeration is a sign of complete reduction.

Gas enema reduction is very successful in patients with: The condition can occur in an isolated form either localized to colon or disseminated throughout the bowel , or associated to other diseases such as Hirschsprung's HD , neurofibromatosis, MEN type IIB, and anorectal malformations.

Clinically two different types of isolated IND have been described: Type A shows symptoms of abdominal distension, enterocolitis, bloody stools, intestinal spasticity in imaging studies Ba Enema since birth, is less common and associated with hypoplasia of sympathetic nerves. Type B is more frequent, symptoms are indistinguishable from that of HD, with chronic constipation, megacolon, and repeated episodes of bowel obstruction.

Management depends on clinical situation; conservative for minor symptoms until neuronal maturation occurs around the 4th year of life, colostomy and resectional therapy for life threatening situations.

The most common congenital diaphragmatic hernia CDH is that which occurs through the postero-lateral defect of Bochdalek. It is caused by failure of the pleuroperitoneal membrane to develop adequately and close before the intestines returning to the abdomen at the tenth week of gestation.

The intestines then enter the pleural cavity and cause poor lung development leading to pulmonary hypoplasia a reduced number of alveoli per area of lung tissue.

This defect is postero-lateral in the diaphragm and may vary in size. Stomach, liver or spleen may be partly in chest as well. The clinical presentation is that the newborn becomes rapidly cyanotic, acidotic, and has poor ventilation. Major findings relate to the degree of pulmonary maldevelopment. Chest films will show intestines in the chest.

Placement of a radiopaque nasogastric tube may show the tube coiled in the lower left chest. Higher risk factors are: Treatment consist of rapid intubation and ventilation with use of muscle relaxants, placement of a nasogastric tube to prevent gaseous distension of the intestines and preoperative stabilization of arterial blood gases and acid-base status.

Surgery can be undertaken when one of the following objectives are met: Operative management consist of abdominal approach, closure of hernia by primary repair or use of mesh, and correction of malrotation. Postoperative management is very difficult.

Due to hypoplastic lungs, there is frequently pulmonary hypertension leading to right-to-left shunting and progressive hypoxemia, hypercarbia, and acidosis that worsens the pulmonary hypertension.

The use of chest tubes may cause overstretching of the already hypoplastic alveoli causing: Postoperatively, the infant should be kept paralyzed and ventilated and only very slowly weaned from the ventilator.

The severity of pulmonary hypoplasia, both ipsilaterally and contralaterally, is the main determinant of outcome. ECMO extracorporeal membrane oxygenator has come to reduce somewhat the mortality of this condition. The mortality of CDH is directly related to the degree of lung hypoplasia associated.

Death is caused by persistent pulmonary hypertension and right ventricular failure. Prospective studies of prenatally diagnosed fetus prior to 25 wk. This unsolved problem has prompted investigators to develop new treatment options such as preoperative stabilization, jet-frequency ventilation, and ECMO. Another area of development is intrauterine fetal surgical repair. To achieve success fetal surgery should: Intrauterine repair has meet with limited success due to herniation of the fetal liver into the chest through the defect.

Disturbance of the umbilical circulation during or after liver reduction causes fetal death. Positive-pressure ventilation after birth reduces the liver before the baby comes for surgical repair. Harrison USFC Fetal Treatment Center has devised separate fetal thoraco-abdominal incisions to deal with this problem "two-step dance" , reducing or amputating the left lateral segment of the liver.

Another less invasive approach is enlarging the hypoplastic lungs by reducing the normal egress of fetal lung fluid with controlled tracheal obstruction called PLUGS Plug Lung Until it Grows. Infants and children will present with either respiratory or gastrointestinal symptoms such as: Occasionally the child is asymptomatic. A rise intrabdominal pressure by coughing or vomiting transmitted to any defect of the diaphragm makes visceral herniation more likely.

Diagnosis is confirmed by chest or gastrointestinal contrast imaging. Management consists of immediate surgery after preop stabilization. Most defects can be closed primarily through an abdominal approach. Chest-tube placement in the non-hypoplastic lung is of help. Surgical results are generally excellent. A few deaths have resulted from cardiovascular and respiratory compromise due to visceral herniation causing mediastinal and pulmonary compression.

First described in , Morgagni Hernias MH are rare congenital diaphragmatic defects close to the anterior midline between the costal and sternal origin of the diaphragm. Almost always asymptomatic, typically present in older children or adults with minimal gastrointestinal symptoms or as incidental finding during routine chest radiography mass or air-fluid levels. Infants may develop respiratory symptoms tachypnea, dyspnea and cyanosis with distress.

Cardiac tamponade due to protrusion into the pericardial cavity has been reported. US and CT-Scan can demonstrate the defect.

Trans-abdominal subcostal approach is preferred with reduction of the defect and suturing of the diaphragm to undersurface of sternum and posterior rectus sheath. Large defects with phrenic nerve displacement may need a thoracic approach. Results after surgery rely on associated conditions. Two types of esophageal hernia recognized are the hiatal and paraesophageal hernia. Diagnosis is made radiologically always and in a number of patients endoscopically. The hiatal hernia HH refers to herniation of the stomach to the chest through the esophageal hiatus.

The lower esophageal sphincter also moves. It can consist of a small transitory epiphrenic loculation minor up to an upside-down intrathoracic stomach major. HH generally develops due to a congenital, traumatic or iatrogenic factor. Most disappear by the age of two years, but all forms of HH can lead to peptic esophagitis from Gastroesophageal reflux. Repair of HH is determined by the pathology of its associated reflux causing failure to thrive, esophagitis, stricture, respiratory symptoms or the presence of the stomach in the thoracic cavity.

In the paraesophageal hernia PH variety the stomach migrates to the chest and the lower esophageal sphincter stays in its normal anatomic position. PH is a frequent problem after antireflux operations in patients without posterior crural repair. Small PH can be observed. With an increase in size or appearance of symptoms reflux, gastric obstruction, bleeding, infarction or perforation the PH should be repaired.

The incidence of PH has increased with the advent of the laparoscopic fundoplication. A hernia is defined as a protrusion of a portion of an organ or tissue through an abnormal opening. For groin inguinal or femoral hernias, this protrusion is into a hernial sac. Whether or not the mere presence of a hernial sac or processus vaginalis constitutes a hernia is debated.

Inguinal hernias in children are almost exclusively indirect type. Those rare instances of direct inguinal hernia are caused by previous surgery and floor disruption. An indirect inguinal hernia protrudes through the internal inguinal ring, within the cremaster fascia, extending down the spermatic cord for varying distances.

The direct hernia protrudes through the posterior wall of the inguinal canal, i. The embryology of indirect inguinal hernia is as follows: During the third month of gestation, the processus vaginalis extends down toward the scrotum and follows the chorda gubernaculum that extends from the testicle or the retroperitoneum to the scrotum.

During the seventh month, the testicle descend into the scrotum, where the processus vaginalis forms a covering for the testicle and the serous sac in which it resides.

At about the time of birth, the portion of the processus vaginalis between the testicle and the abdominal cavity obliterates, leaving a peritoneal cavity separate from the tunica vaginalis that surrounds the testicle. The typical patient with an inguinal hernia has an intermittent lump or bulge in the groin, scrotum, or labia noted at times of increased intra-abdominal pressure.

A communicating hydrocele is always associated with a hernia. This hydrocele fluctuates in size and is usually larger in ambulatory patients at the end of the day. If a loop of bowel becomes entrapped incarcerated in a hernia, the patient develops pain followed by signs of intestinal obstruction.

If not reduced, compromised blood supply strangulation leads to perforation and peritonitis. Most incarcerated hernias in children can be reduced. Associated to these episodes of incarceration are chances of: Symptomatic hernia can complicate the clinical course of babies at NICU ill with hyaline membrane, sepsis, NEC and other conditions needing ventilatory support.

Repair should be undertaken before hospital discharge to avoid complications. Postconceptual age sum of intra- and extrauterine life has been cited as the factor having greatest impact on post-op complications.

These observation makes imperative that preemies with post conceptual age of less than 45 weeks be carefully monitored in-hospital for at least 24 hours after surgical repair of their hernias. Outpatient repair is safer for those prematures above the 60 wk. The very low birth weight infant with symptomatic hernia can benefit from epidural anesthesia. At times, the indirect inguinal hernia will extend into the scrotum and can be reduced by external, gentle pressure.

Occasionally, the hernia will present as a bulge in the soft tissue overlying the internal ring. It is sometimes difficult to demonstrate and the physician must rely on the patient's history of an intermittent bulge in the groin seen with crying, coughing or straining. Elective herniorrhaphy at a near convenient time is treatment of choice. Since risk of incarceration is high in children, repair should be undertaken shortly after diagnosis.

Simple high ligation of the sac is all that is required. Pediatric patients are allowed to return to full activity immediately after hernia repair.

Bilateral exploration is done routinely by most experienced pediatric surgeons. Recently the use of groin laparoscopy through the hernial sac permits visualization of the contralateral side. Testicular feminization syndrome TFS is a genetic form of male pseudohermaphroditism patient who is genetically 46 XY but has deficient masculinization of external genitalia caused by complete or partial resistance of end organs to the peripheral effects of androgens.

This androgenic insensitivity is caused by a mutation of the gene for androgenic receptor inherited as an X-linked recessive trait. In the complete form the external genitalia appear to be female with a rudimentary vagina, absent uterus and ovaries.

The incomplete form may represent undervirilized infertile men. This patients will never menstruate or bear children. Early gonadectomy is advised to: Vaginal reconstruction is planned when the patient wishes to be sexually active.

These children develop into very normal appearing females that are sterile since no female organs are present. A hydrocele is a collection of fluid in the space surrounding the testicle between the layers of the tunica vaginalis. Hydroceles can be scrotal, of the cord, abdominal, or a combination of the above.

A hydrocele of the cord is the fluid-filled remnant of the processus vaginalis separated from the tunica vaginalis. A communicating hydrocele is one that communicates with the peritoneal cavity by way of a narrow opening into a hernial sac.

Hydroceles are common in infants. Some are associated with an inguinal hernia. They are often bilateral, and like hernias, are more common on the right than the left. Most hydroceles will resolved spontaneously by years of age. After this time, elective repair can be performed at any time. Operation is done through the groin and search made for an associated hernia.

Aspiration of a hydrocele should never be attempted. As a therapeutic measure it is ineffective, and as a diagnostic tool it is a catastrophe if a loop of bowel is entrapped. A possible exception to this is the postoperative recurrent hydrocele. The undescended testis is a term we use to describe all instances in which the testis cannot be manually manipulated into the scrotum. The testes form from the medial portion of the urogenital ridge extending from the diaphragm into the pelvis.

In arrested descent, they may be found from the kidneys to the internal inguinal ring. Rapid descent through the internal inguinal ring commences at approximately week 28, the left testis preceding the right. Adequate amounts of male hormones are necessary for descent. The highest levels of male hormones in the maternal circulation have been demonstrated at week Thus, it appears that failure of descent may be related to inadequate male hormone levels or to failure of the end-organ to respond.

The undescended testes may be found from the hilum of the kidney to the external inguinal ring. The undescended testis found in 0. Testes that can be manually brought to the scrotum are retractile and need no further treatment. Parents should know the objectives, indications and limitations of an orchiopexy: To improve spermatogenesis producing an adequate number of spermatozoids surgery should be done before the age of two.

Electron microscopy has confirmed an arrest in spermatogenesis reduced number of spermatogonias and tubular diameter in undescended testis after the first two years of life. Other reasons to pex are: The management is surgical; hormonal Human Chorionic Gonadotropin treatment has brought conflicting results except bilateral cases.

Surgery is limited by the length of the testicular artery. Palpable testes have a better prognosis than non-palpable. Laparoscopy can be of help in non-palpable testis avoiding exploration of the absent testis. Viens, MS University of Toronto. An umbilical hernia is a small defect in the abdominal fascial wall in which fluid or abdominal contents protrude through the umbilical ring. The presence of a bulge within the umbilicus is readily palpable and becomes more apparent when the infant cries or during defecation.

The actual size of the umbilical hernia is measured by physical examination of the defect in the rectus abdominis muscle, and not by the size of the umbilical bulge.

The size of the fascial defect can vary from the width of a fingertip to several centimetres. Embryologically, the cause of an umbilical hernia is related to the incomplete contraction of the umbilical ring. The herniation of the umbilicus is a result of the growing alimentary tract that is unable to fit within the abdominal cavity.

Umbilical hernias are more prevalent in females than in males and are more often seen in patients with African heritage. The increased frequency of umbilical hernias has also been attributed to premature babies, twins and infants with long umbilical cords. There is also a frequent association with disorders of mucopolysaccharide metabolism, especially Hurler's Syndrome gargoylism.

Most umbilical hernias are asymptomatic; the decision to repair the umbilical hernia in the first years of life is largely cosmetic and is often performed because of parental request, not because of pain or dysfunction. In the past, some parents use to tape a coin over the umbilical bulge, however, manual compression does not have an effect on the fascial defect.

Treatment of umbilical hernia is observation. However, surgical repair is recommended if the hernia has not closed by the age of five. The incidence of incarceration trapped intestinal loop is rare, even in larger defects. Females should especially have their umbilical hernia corrected before pregnancy because of the associated increased intra-abdominal pressure that could lead to complications.

The procedure is simple and incidence of complication such as infection is extremely rare. The repair is usually done as outpatient surgery under general anesthetic.

Inguinal and umbilical hernia repair in infants and children. Surg Clinics of North Am 73 3: Swenson's Pediatric Surgery - 5th edition. The developing human - 4th edition. Philadelphia, WB Saunders, pp. Some observations on umbilical hernias in infants. The comparative incidence of umbilical hernias in colored and white infants. J Natl Med Assoc The three most common abdominal wall defect in newborns are umbilical hernia, gastroschisis and omphalocele.

Omphalocele is a milder form of primary abdominoschisis since during the embryonic folding process the outgrowth at the umbilical ring is insufficient shortage in apoptotic cell death. Defect may have liver, spleen, stomach, and bowel in the sac while the abdominal cavity remains underdeveloped in size. The sac is composed of chorium, Wharton's jelly and peritoneum. The defect is centrally localized and measures cm in diameter.

A small defect of less than 2 cm with bowel inside is referred as a hernia of the umbilical cord. Epigastric localized omphalocele are associated with sternal and intracardiac defects i. Cardiac, neurogenic, genitourinary, skeletal and chromosomal changes and syndromes are the cornerstones of mortality. Cesarean section is warranted in large omphaloceles to avoid liver damage and dystocia. After initial stabilization management requires consideration of the size of defect, prematurity and associated anomalies.

Primary closure with correction of the malrotation should be attempted whenever possible. Antibiotics and nutritional support are mandatory. Manage control centers around sepsis, respiratory status, liver and bowel dysfunction from increased intraabdominal pressure.

The protruding gut is foreshortened, matted, thickened and covered with a peel. The IA might be the result of pressure on the bowel from the edge of the defect pinching effect or an intrauterine vascular accident.

Rarely, the orifice may be extremely narrow leading to gangrene or complete midgut atresia. In either case the morbidity and mortality of the child is duplicated with the presence of an IA. Alternatives depend on the type of closure of the abdominal defect and the severity of the affected bowel. With primary fascial closure and good-looking bowel primary anastomosis is justified. Angry looking dilated bowel prompts for proximal diversion, but the higher the enterostomy the greater the problems of fluid losses, electrolyte imbalances, skin excoriation, sepsis and malnutrition.

Closure of the defect and resection with anastomosis two to four weeks later brings good results. Success or failure is related to the length of remaining bowel more than the specific method used. Initially do an Apt test to determine if blood comes from fetal origin or maternal origin blood swallowed by the fetus.

If this coagulation profile is normal the possibilities are either stress gastritis or ulcer disease. If the coagulation profile is abnormal then consider hematologic disease of the newborn and manage with vitamin K.

The apt test is performed by mixing 1 part of vomitus with 5 part H2O, centrifuge the mixture and remove 5 ml pink. If the coagulation profile is abnormal give Vit K for hematologic disorder of newborn. If it's normal do a rectal exam. A fissure could be the cause, if negative then consider either malrotation or Necrotizing enterocolitis.

The stress includes prematurity, sepsis, hypoxia, hypothermia, and jaundice. These babies frequently have umbilical artery, vein catheters, have received exchange transfusions or early feeds with hyperosmolar formulas.

The intestinal mucosal cells are highly sensitive to ischemia and mucosal damage leads to bacterial invasion of the intestinal wall. Gas-forming organisms produce pneumatosis intestinalis air in the bowel wall readily seen on abdominal films. Full-thickness necrosis leads to perforation, free air and abscess formation. These usually premature infants develop increased gastric residuals, abdominal distension, bloody stools, acidosis and dropping platelet count. The abdominal wall becomes reddened and edematous.

There may be persistent masses and signs of peritonitis. Perforation leads to further hypoxia, acidosis and temperature instability. The acid-base status is monitored for worsening acidosis and hypoxia. The white blood cell count may be high, low or normal and is not generally of help. Serial abdominal films are obtained to look for evidence of free abdominal air, a worsening picture of pneumatosis intestinalis, or free portal air.

Therapy consist initially of stopping feeds, instituting nasogastric suctioning and beginning broad-spectrum antibiotics ampicillin and gentamycin. Persistent or worsening clinical condition and sepsis or free air on abdominal films require urgent surgical intervention. Attempts to preserve as much viable bowel as possible are mandatory to prevent resultant short gut syndrome. Complicated NEC is the most common neonatal surgical emergency of modern times, has diverse etiologies, significant mortality and affects mostly premature babies.

Consist of a right lower quadrant incision and placement of a drainage penrose or catheter under local anesthesia with subsequent irrigation performed bedside at the NICU. Initially used as a temporizing measure before formal laparotomy, some patient went to improvement without the need for further surgery almost one-third. They either had an immature fetal type healing process or a focal perforation not associated to NEC? Some suggestion made are: PPD should be an adjunct to preop stabilization, before placing drain be sure pt has NEC by X-rays, persistent metabolic acidosis means uncontrolled peritoneal sepsis, do not place drain in pts with inflammatory mass or rapid development of intraperitoneal fluid, the longer the drainage the higher the need for laparotomy.

In the initial evaluation a history should be obtained for bleeding disorders, skin lesions, and aspirin or steroid ingestion. The physical exam for presence of enlarged liver, spleen, masses, ascites, or evidence of trauma or portal hypertension. Labs such as bleeding studies and endoscopy, contrast studies if bleeding stops.

Common causes of Upper GI bleeding are: Esophagus a Varices- usually presents as severe upper gastrointestinal bleeding in a year old who has previously been healthy except for problems in the neonatal period. This is a result of extrahepatic portal obstruction portal vein thrombosis most commonly , with resulting varices.

The bleeding may occur after a period of upper respiratory symptoms and coughing. Management is initially conservative with sedation and bedrest; surgery ir rarely needed.

Treatment consist of antacids, frequent small feeds, occasionally medications and if not rapidly improved, then surgical intervention with a fundoplication of the stomach. This was thought to be uncommon in children because it was not looked for by endoscopy.

It probably occurs more often than previously thought. Treatment initially is conservative and, if persistent, oversewing of the tear through an incision in the stomach will be successful. They bleed when there is ectopic gastric mucosa present. Total excision is curative. Occasionally requires surgical intervention with local repair or ligation of hepatic vessels. Anal fissure is the most common cause of rectal bleeding in the first two years of life.

Outstretching of the anal mucocutaneous junction caused by passage of large hard stools during defecation produces a superficial tear of the mucosa in the posterior midline. Pain with the next bowel movement leads to constipation, hardened stools that continue to produce cyclic problems.

Large fissures with surrounding bruising should warn against child abuse. Crohn's disease and leukemic infiltration are other conditions to rule-out. The diagnosis is made after inspection of the anal canal.

Chronic fissures are associated with hypertrophy of the anal papilla or a distal skin tag. Management is directed toward the associated constipation with stool softeners and anal dilatations, warm perineal baths to relax the internal muscle spasm, and topical analgesics for pain control.

If medical therapy fails excision of the fissure with lateral sphincterotomy is performed. Meckel's diverticulum MD , the pathologic structure resulting from persistence of the embryonic vitelline duct yolk stalk , is the most prevalent congenital anomaly of the GI tract.

MD can be the cause of: Diagnosis depends on clinical presentation. Rectal bleeding from MD is painless, minimal, recurrent, and can be identified using 99mTc- pertechnetate scan; contrasts studies are unreliable.

Persistent bleeding requires arteriography or laparotomy if the scan is negative. Obstruction secondary to intussusception, herniation or volvulus presents with findings of fulminant, acute small bowel obstruction, is diagnosed by clinical findings and contrast enema studies.

The MD is seldom diagnosed preop. Diverticulitis or perforation is clinically indistinguishable from appendicitis. Mucosal polyps or fecal umbilical discharge can be caused by MD. Overall, complications of Meckel's are managed by simple diverticulectomy or resection with anastomosis. Laparoscopy can confirm the diagnosis and allow resection of symptomatic cases. Removal of asymptomatic Meckel's identified incidentally should be considered if upon palpation there is questionable heterotopic gastric or pancreatic mucosa thick and firm consistency present.

Histology features a cluster of mucoid lobes surrounded by flattened mucussecreting glandular cells mucous retention polyp , no malignant potential. Commonly seen in children age with a peak at age As a rule only one polyp is present, but occasionally there are two or three almost always confined to the rectal area within the reach of the finger.

Most common complaint is bright painless rectal bleeding. Occasionally the polyp may prolapse through the rectum. Diagnosis is by barium enema, rectal exam, or endoscopy. Removal by endoscopy is the treatment of choice. Rarely colotomy and excision are required. Wilms tumor WT is the most common intra-abdominal malignant tumor in children affecting more than children annually in the USA.

It has a peak incidence at 3. WT present as a large abdominal or flank mass with abdominal pain, asymptomatic hematuria, and occasionally fever. Other presentations include malaise, weight loss, anemia, left varicocele obstructed left renal vein , and hypertension.

Initial evaluation consists of: The presence of a solid, intrarenal mass causing intrinsic distortion of the calyceal collecting system is virtually diagnostic of Wilms tumor. Doppler sonography of the renal vein and inferior vena cava can exclude venous tumor involvement. Metastasis occurs most commonly to lungs and occasionally to liver. Operation is both for treatment and staging to determine further therapy.

Following NWTSG recommendation's primary nephrectomy is done for all but the largest unilateral tumors and further adjuvant therapy is based on the surgical and pathological findings. Important surgical caveats consist of using a generous transverse incision, performing a radical nephrectomy, exploring the contralateral kidney, avoiding tumor spillage, and sampling suspicious lymph nodes.

Nodes are biopsied to determine extent of disease. Stage I- tumor limited to kidney and completely resected. Stage II- tumor extends beyond the kidney but is completely excised. Stage III- residual non-hematogenous tumor confined to the abdomen. Stage IV- hematogenous metastasis. Stage V- bilateral tumors. Further treatment with chemotherapy or radiotherapy depends on staging and histology favorable vs. Non-favorable histologic characteristics are: Prognosis is poor for those children with lymph nodes, lung and liver metastasis.

They tend to occur in younger patients. Routine abdominal ultrasound screening every six months up to the age of eight years is recommended for children at high risk for developing WT such as the above-mentioned syndromes. It was originally thought that WT developed after the two-hit mutational model developed for retinoblastoma: When the first mutation occurs before the union the sperm and egg constitutional or germline mutation the tumor is heritable and individuals are at risk for multiple tumors.

Nonhereditary WT develops as the result of two-postzygotic mutations somatic in a single cell. The two-event hypothesis predicts that susceptible individuals such as familial cases, those with multifocal disease and those with a congenital anomaly have a lower median age at diagnosis than sporadic cases. It is now believed that several genes' mutations are involved in the overall WT pathogenesis.

Loss of whole portions of a chromosome is called loss of heterozygosity LOH , a mechanism believed to inactivate a tumor-suppressor gene. Children with the WAGR association shows a deletion in the short arm of chromosome 11 band 13 11p13 but a normal 11p15 region. Up to a third of sporadic WT have changes in the distal part of chromosome 11, a region that includes band p The region of the deletion has been named the WT1 gene, a tumor suppressor gene that also forms a complex with another known tumor-suppressor, p WT1 gene express a regulated transcription factor of the zinc-finger family proteins restricted to the genitourinary system, spleen, dorsal mesentery of the intestines, muscles, central nervous system CNS and mesothelium.

The important association of WT1 mutation and WAGR syndrome with intralobar nephrogenic rests immediately suggest that WT1 expression be necessary for the normal differentiation of nephroblasts.