Common Pediatric Surgery Problems

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Common Pediatric Surgery Problems Dr Osama
Bawazir FRCSI, FRCS(Ed), FRCS (glas),
FRCSC. General surgeon, Pediatric surgeon,
pediatric urologist
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Inguinal hernia

• Indirect 99
• 1 to 3 of all children
• 3 to 5 in preterm baby
• R 60 L 30 Bilateral 10-15
• Males to females ratio is 61
• Present as bulge in the groin, scrotum, or labia.
• A reliable history is sufficient to make the
  diagnosis, even if the hernia cannot identify.
• An incarcerated inguinal hernia presents as a
  mass in the labia or scrotum that does not reduce
  spontaneously.

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• What embryological events account for this
  abnormality?
• Failure of the processus vaginalis to close (it
  remains patent).
• What are your recommendations to the parents?
• The hernia should be repaired electively the
  parents should be warned about possible
  incarceration in the meantime.
• If at the time of your examination the child were
  irritable and the mass irreducible, what would be
  your approach?
• Attempt manual reduction (use sedation if
  necessary) emergency surgery if unsuccessful.

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Hydrocele

• It is a collection of fluid in the tunica
  vaginalis.
• Localized to the scrotum.
• Fluctuation of the scrotal size during the day.
• Types communicating noncommunicating hydrocele
  
• Transillumination is not a reliable
• Do not aspirate
• Treatment Observation for 1 to 2 years of age,
  before recommending repair.

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Undescended Testis

• Undescended testis occurs in 30 of premature
  boys, 3.4 of full-term boys, 0.8 of
  1-year-olds.
• must be distinguished from a retractile testis.
• Complication Failure of the testicle to produce
  viable sperm malignant degeneration of the
  testicle predisposition to torsion and traumatic
  injuries there is likely to be an associated
  inguinal hernia.
• Orchiopexy is performed after 1 year of age.

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Umbilical Hernia

• 6 to 10 times higher in blacks than in whites.
• Most umbilical hernias close spontaneously within
  the first 3 years of life.
• Small-diameter umbilical hernias close earlier
  than large-diameter umbilical hernias.
• Claims that strapping helps cure umbilical hernia
  are not supported by available data.

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Acute Scrotum

• Differential Diagnosis
• Torsion
• Torsion of appendix testes
• Epididymistis / orchitis
• Hematocele / trauma.
• Idiopathic scrotal edema

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Testicular Torsion Clinical Exam

• High riding, different transverse lie, tender
  with any movement

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Investigation

• Clinical exam
• Ultrasound/Nuclear scan
• Recall time of ischemia critical
• gt 6 hours progressive loss of tissue
• gt 12-18 hours, likely complete loss of
  spermatogenesis, risk of Anti-sperm AB in
  pubertal males

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Acute Appendicitis

• Pathogenesis (many have no demonstrable cause)
• Obstruction
• Increased intraluminal pressure and venous
  collapse
• Ischemia, bacterial proliferation, further
  inflammation
• At 48 to 72 hours risk perforation ?

• Presentation
• Vague, crampy pain begins in the periumbilical
  region it then migrates to the right lower
  quadrant and becomes well localized and sharp.
• Anorexia, nausea, and vomiting
• Diminished bowel sounds localized guarding and
  point tenderness in RLQ
• ? WBC -ve Bhcg N U/A

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• Management
• Intravenous hydration
• broad-spectrum antibiotics
• surgery.

• Why young children (less than 5 years of age)
  frequently have ruptured appendixes?
• these patients are frequently
• unable to provide a clear, detailed history of
  their complaints.
• uncooperative for performance of physical
  examination.
• a uniform response to many illnesses (fever,
  stomachache, vomiting).

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Do we need imagining ?

• No imaging studies are necessary.
• U/S sensitivity 75-83
• U/S specificity 86-100
• U/S is operator depend it
• CT sensitivity 90-100
• CT specificity 91-99
• In cases of clinically non-suspicious
  appendicitis the normal appendix seen in 50 or
  less
• When?
• Children lt5 y, neurological impaired kids, Hx of
  recurrent UTI and equivocal cases.

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Acute Abdomen

• Differential diagnosis
• (NB age dependent, history vital)
• Appendicitis
• ?Ovarian Pathology
• Ectopic pregnancy
• Follicular cyst/bleeding cyst
• Mettleshmirtz
• Torsion
• Retrograde menstrual bleeding
• ? testicular torsion
• GI surgical obstruction
• Meckels diverticulum
• Crohns disease
• Cholecystitis
• Gastroenteritis
• Psoas abscess
• Pancreatitis
• HUS and HSP

• Renal
• UTI, Pyelonephritis
• Renal stone
• Pulmonary
• pneumonia
• Metabolic/endocrine
• Diabetic keto-acidosis
• Lead poisoning
• Familiar Mediterranean fever
• Hematological
• Sickle cell crisis

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Ovarian Pathology

• History important, timing in relation to
  menses/menarche

Torsion
Cyst
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Approach to head and neck lesions

• Age
• Adult
• Neoplastic 80 role of 80
  
• Inflammatory
• congenital
• Children
• Congenital
• Inflammatory
• Neoplastic
• Location
• Midline swellings
• Lateral swellings
• Triangles
• Ant or Post
• Digastric, carotid and occipital
• Superficial or Deep

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Differential Diagnosis

• Lateral swellings
• L.N
• Thyroid
• Salivary glands
• Branchial cyst
• Cystic hygroma
• Sternomastoid tumor
• Vascular lesions
• Soft tissue tumor

• Midline
• Thyroglossal cyst
• Sublingual dermoid
• Subhyoid bursa
• Plunging ranula
• laryngeocele
• Pharyngeal pouch

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Thyroglossal Duct Cyst

• Thyroid diverticulum --gt descends week 4-7
• Through hyoid bone
• Ectodermal remnants left in persistent tract
• Ectopic tissue in 25-45, adenoCA risk?
• All of tissue --gt radioisotope scan? U/S
• Treatment Complete excision including tract and
  central hyoid
• Recurrence lt 10

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Branchial Cleft Anomolies

• Fistula gt Sinus gt Cyst in children
• Presentation is age-dependent
• All lie anterior to SCM
• Cleft deformities 2nd gtgt 1st gt 3rd gt 4th

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Branchial Cleft Fistula/Cyst

• Fistula
• Usually external
• Ostium at lower 1/3 SCM
• Palpate tract
• Platysma --gt carotid sheath --gt
• hyoid bone --gt tonsil fossa
• 10 bilateral
• Surgical repair
• Cyst
• Look like hygromas but deep, dark
• Infection common
• U/S for cysts, vessels, structures
• Complete excision including tract

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Cystic Hygroma

• Multiloculated cystic lymphatic malformation
• 1 12 000, increased in Turners, others?
• 50 at birth, 90 by 3 years
• 75 in neck, post triangle, 2x on left side
• Lining, fluid, enlargement
• Soft, mobile, cystic, Transillumination.
• Diagnosis U/S, CT, CXR
• Trouble mediastinal extension, stridor, apnea,
  dysphagia
• Complete excision, usually 2-6 months old
• Aspiration, Sclerosis, Spontaneous?

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Bowel Obstruction

• Causes
• Age
• Level
• Internal/external
• Congenital/ inflammatory/ malignancy
• Types
• Simple
• Closed-loop

• Investigations
• Physical exam plain films Diagnostic for jejunal
  ileal atresia, malrotation with volvulus and
  extremist
• ? Upper GI if concerned regarding volvulus
• Contrast enema