Common Pediatric Surgery Problems

Dr Osama BawazirFRCSI, FRCS(Ed), FRCS (glas), FRCSC.

General surgeon, Pediatric surgeon, pediatric urologist

Inguinal herniaInguinal hernia Indirect 99%Indirect 99% 1% to 3% of all children 1% to 3% of all children 3% to 5% in preterm baby3% to 5% in preterm baby R 60% L 30% Bilateral 10-15%R 60% L 30% Bilateral 10-15% Males to females ratio is 6:1Males to females ratio is 6:1 Present as bulge in the groin, Present as bulge in the groin,

scrotum, or labia.scrotum, or labia. A reliable history is sufficient to A reliable history is sufficient to

make the diagnosis, even if the make the diagnosis, even if the hernia cannot identify.hernia cannot identify.

An incarcerated inguinal hernia An incarcerated inguinal hernia presents as a mass in the labia or presents as a mass in the labia or scrotum that does not reduce scrotum that does not reduce spontaneously.spontaneously.

What embryological events What embryological events account for this abnormality?account for this abnormality?

Failure of the processus vaginalis to Failure of the processus vaginalis to close (it remains patent).close (it remains patent).

What are your recommendations What are your recommendations to the parents?to the parents?

The hernia should be repaired The hernia should be repaired electively; the parents should be electively; the parents should be warned about possible warned about possible incarceration in the meantime.incarceration in the meantime.

If at the time of your examination If at the time of your examination the child were irritable and the the child were irritable and the mass irreducible, what would be mass irreducible, what would be your approach?your approach?

Attempt manual reduction (use sedation Attempt manual reduction (use sedation if necessary); emergency surgery if if necessary); emergency surgery if unsuccessful.unsuccessful.

HydroceleHydrocele It is a collection of fluid in the It is a collection of fluid in the

tunica vaginalis.tunica vaginalis. Localized to the scrotum. Localized to the scrotum. Fluctuation of the scrotal size Fluctuation of the scrotal size

during the day.during the day. Types: communicating & Types: communicating &

noncommunicating hydrocele noncommunicating hydrocele Transillumination is not a Transillumination is not a

reliablereliable Do not aspirateDo not aspirate Treatment: Treatment: Observation for 1 to Observation for 1 to

2 years of age, before 2 years of age, before recommending repair.recommending repair.

Undescended TestisUndescended Testis Undescended testis occurs in Undescended testis occurs in

30% of premature boys, 3.4% of 30% of premature boys, 3.4% of full-term boys, 0.8% of 1-year-full-term boys, 0.8% of 1-year-olds.olds.

must be distinguished from a must be distinguished from a retractile testis.retractile testis.

Complication : Complication : Failure of the Failure of the testicle to produce viable sperm; testicle to produce viable sperm; malignant degeneration of the malignant degeneration of the testicle; predisposition to torsion testicle; predisposition to torsion and traumatic injuries; there is and traumatic injuries; there is likely to be an associated inguinal likely to be an associated inguinal hernia.hernia.

Orchiopexy is performed after 1 Orchiopexy is performed after 1 year of age.year of age.

Umbilical HerniaUmbilical Hernia

6 to 10 times higher in blacks 6 to 10 times higher in blacks than in whites.than in whites.

Most umbilical hernias close Most umbilical hernias close spontaneously within the first spontaneously within the first 3 years of life3 years of life. .

Small-diameter umbilical Small-diameter umbilical hernias close earlier than hernias close earlier than large-diameter umbilical large-diameter umbilical hernias. hernias.

Claims that strapping helps Claims that strapping helps cure umbilical hernia are not cure umbilical hernia are not supported by available data.supported by available data.

Acute ScrotumAcute Scrotum

Differential Diagnosis:Differential Diagnosis: Torsion Torsion Torsion of appendix Torsion of appendix

testestestes Epididymistis / orchitis Epididymistis / orchitis Hematocele / trauma.Hematocele / trauma. Idiopathic scrotal edemaIdiopathic scrotal edema

Testicular Torsion: Clinical ExamTesticular Torsion: Clinical Exam

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

InvestigationInvestigation Clinical examClinical exam Ultrasound/Nuclear scanUltrasound/Nuclear scan Recall time of ischemia Recall time of ischemia

criticalcritical > 6 hours = progressive loss of > 6 hours = progressive loss of

tissuetissue > 12-18 hours, likely complete > 12-18 hours, likely complete

loss of spermatogenesis, risk loss of spermatogenesis, risk of Anti-sperm AB in pubertal of Anti-sperm AB in pubertal malesmales

Acute Appendicitis Pathogenesis (many have no Pathogenesis (many have no

demonstrable cause):demonstrable cause): ObstructionObstruction Increased intraluminal pressure and Increased intraluminal pressure and

venous collapsevenous collapse Ischemia, bacterial proliferation, further Ischemia, bacterial proliferation, further

inflammationinflammation At 48 to 72 hours risk perforation 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

Why young children (less than 5 years of age) frequently Why young children (less than 5 years of age) frequently have ruptured appendixeshave ruptured appendixes??

these patients are frequently:these patients are frequently: unable to provide a clear, detailed history of their unable to provide a clear, detailed history of their

complaints. complaints. uncooperative for performance of physical examination. uncooperative for performance of physical examination. a uniform response to many illnesses (fever, a uniform response to many illnesses (fever,

“stomachache,” vomiting).“stomachache,” vomiting).

Management:Intravenous hydration broad-spectrum antibiotics surgery.

Do we need imaginingDo we need imagining? ? No imaging studies are No imaging studies are

necessary.necessary. U/S U/S sensitivity 75-83 %sensitivity 75-83 % U/S specificity 86-100%U/S specificity 86-100% U/S is operator depend itU/S is operator depend it CT sensitivity 90-100%CT sensitivity 90-100% CT specificity 91-99%CT specificity 91-99% In In cases of clinically non-cases of clinically non-

suspicious appendicitis suspicious appendicitis tthe normal he normal appendix seen in 50% or lessappendix seen in 50% or less

When?When? Children <5 y, neurological impaired Children <5 y, neurological impaired

kids, Hx of recurrent UTI and kids, Hx of recurrent UTI and equivocal cases.equivocal cases.

Acute AbdomenAcute Abdomen Differential diagnosisDifferential diagnosis

(NB: age dependent, history vital)(NB: age dependent, history vital) AppendicitisAppendicitis ♀♀::Ovarian PathologyOvarian Pathology

Ectopic pregnancy Ectopic pregnancy Follicular cyst/bleeding cystFollicular cyst/bleeding cyst MettleshmirtzMettleshmirtz TorsionTorsion Retrograde menstrual bleedingRetrograde menstrual bleeding

♂♂:: testicular torsion testicular torsion GI “surgical”: obstructionGI “surgical”: obstruction

Meckel’s diverticulumMeckel’s diverticulum Crohn’s diseaseCrohn’s disease CholecystitisCholecystitis GastroenteritisGastroenteritis Psoas abscessPsoas abscess PancreatitisPancreatitis HUS and HSPHUS and HSP

• Renal:UTI, PyelonephritisRenal stone

• Pulmonary:pneumonia

• Metabolic/endocrine:Diabetic keto-acidosisLead poisoningFamiliar Mediterranean fever

• Hematological:Sickle cell crisis

Ovarian PathologyOvarian Pathology

History important, timing in relation to History important, timing in relation to menses/menarchemenses/menarche

Torsion Cyst

Approach to head and neck lesionsApproach to head and neck lesions AgeAgeAdultAdult Neoplastic 80% role of Neoplastic 80% role of

80 80 Inflammatory Inflammatory congenitalcongenital

ChildrenChildren CongenitalCongenital InflammatoryInflammatory NeoplasticNeoplastic

LocationLocationMidline swellingsMidline swellingsLateral swellingsLateral swellings TrianglesTrianglesAnt or PostAnt or PostDigastric, carotid and occipital …Digastric, carotid and occipital … Superficial or DeepSuperficial or Deep

Differential DiagnosisDifferential Diagnosis

Midline Midline

Thyroglossal cystThyroglossal cyst

Sublingual dermoidSublingual dermoid

Subhyoid bursaSubhyoid bursa

Plunging ranulaPlunging ranula

laryngeocelelaryngeocele

Pharyngeal pouchPharyngeal pouch

Lateral swellingsL.NThyroidSalivary glandsBranchial cystCystic hygromaSternomastoid tumorVascular lesionsSoft tissue tumor

Thyroglossal Duct CystThyroglossal Duct Cyst Thyroid diverticulum --> Thyroid diverticulum -->

descends week 4-7descends week 4-7 Through hyoid boneThrough hyoid bone Ectodermal remnants left Ectodermal remnants left

in persistent tractin persistent tract Ectopic tissue in 25-45%, Ectopic tissue in 25-45%,

adenoCA risk?adenoCA risk? All of tissue --> All of tissue -->

radioisotope scan? U/Sradioisotope scan? U/S Treatment: Complete Treatment: Complete

excision including tract and excision including tract and central hyoidcentral hyoid

Recurrence < 10%Recurrence < 10%

Branchial Cleft AnomoliesBranchial Cleft Anomolies

Fistula > Sinus > Cyst Fistula > Sinus > Cyst in childrenin children

Presentation is age-Presentation is age-dependentdependent

All lie anterior to SCMAll lie anterior to SCM Cleft deformities 2nd Cleft deformities 2nd

>> 1st > 3rd > 4>> 1st > 3rd > 4thth

Branchial Cleft Fistula/CystBranchial Cleft Fistula/CystFistulaFistula

Usually externalUsually external Ostium at lower 1/3 SCMOstium at lower 1/3 SCM Palpate tractPalpate tract Platysma --> carotid sheath -->Platysma --> carotid sheath --> hyoid bone --> tonsil fossahyoid bone --> tonsil fossa 10% bilateral10% bilateral Surgical repairSurgical repair

CystCyst Look like hygromas but deep, darkLook like hygromas but deep, dark Infection commonInfection common U/S for cysts, vessels, structuresU/S for cysts, vessels, structures Complete excision including tract Complete excision including tract

Cystic HygromaCystic Hygroma Multiloculated cystic lymphatic Multiloculated cystic lymphatic

malformationmalformation 1: 12 000, increased in Turner’s, 1: 12 000, increased in Turner’s,

other’s?other’s? 50% at birth, 90% by 3 years50% at birth, 90% by 3 years 75% in neck, post triangle, 2x on 75% in neck, post triangle, 2x on

left sideleft side Lining, fluid, enlargementLining, fluid, enlargement Soft, mobile, cystic, Soft, mobile, cystic,

Transillumination.Transillumination. Diagnosis: U/S, CT, CXRDiagnosis: U/S, CT, CXR Trouble: mediastinal extension, Trouble: mediastinal extension,

stridor, apnea, dysphagiastridor, apnea, dysphagia Complete excision, usually 2-6 Complete excision, usually 2-6

months oldmonths old Aspiration, Sclerosis, Spontaneous?Aspiration, Sclerosis, Spontaneous?

Bowel ObstructionBowel ObstructionCauses:Causes:AgeAge

LevelLevel

Internal/externalInternal/external

Congenital/ inflammatory/ Congenital/ inflammatory/ malignancymalignancy

TypesTypesSimpleSimple

Closed-loopClosed-loop

Investigations

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