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1. Common
Pediatric Surgical Conditions
&
Ideal Timings for Management
Dr. Arjun A. Pawar
MBBS, MS, M. Ch. Pediatric Surgery,
DNB Pediatric Surgery, FMAS,
FIAGES.
Divine Pediatric Surgery Centre. i. a.
w.

2. Common Conditions
Phimosis
Inguinal Hernia
Umbilical Hernia
Hydrocele
Undescended testis
Hypospadias
Anorectal Malformation
Empyema
Foreign Bodies

3. Why ideal timing important
Undue worry in parents
Undue expenses
Loss of function of organ e.g. Testis, kidney.
Psychological impact e.g. UDT, HPS
Chances of development of complications
Phimosis, Hernia, UDT, PUJO,
Timely intervention – best outcome.

4. Phimosis
Phimosis
Types- Physiological & Pathological
- Diagnostic confusion
Incidence: 8 – 14.4%- true phimosis
Pathological Phimosis: Balanitis, Posthitis,
Balanoposthitis
BXO & Recurrent UTIs.
Grades – 1 to 4

7. Management
• Physiological: Settles over period
Circumcision (1%)
• Pathological: Circumcision(Soon After Diagnosis)
Religious circumcision- Any time
Contraindication
Hypospadias, DSD , Micropenis.

8. Post circumcision scar – Subcuticular Suturing Technique

9. Inguinal Hernia
• Inguinal Hernia-
• Types- Indirect & Direct
Enterocele or Omentocele

10. Female inguinal hernia
Evaluated to R/O
46XY DSD with female
phenotype.
 CAIS
 Complete Leydig cell
hypoplasia
 CAH with defects in
testosterone
biosynthesis,
 Gonadal agenesis/
dysgenesis

11. Inguinal Hernia
Will not resolve spontaneously,
Surgical closure is always indicated
Usual Advise-Let him grow, No hurry.
Wait for 6 mths,
Wait for 1 year.
Patient land up with complications &
major surgery.

12. Why to operate - Complications
Irreducibility, Incarceration, Obstruction,
Strangulation, Testicular gangrene.

13. Management- Ideal Time
Soon after diagnosis
Repair done within 2 weeks
(90% complications reduced if operated within 1
month from diagnosis)
Exceptions - Premature infants
Repair before discharge/Child weight 2 kg.

14. Ferguson’s Repair-Open Herniotomy

15. Laparoscopic
Herniotomy

16. Umbilical hernia

17. Umbilical hernia
• Usual Advise:
Repair immediately in neonatal period,
Too late- 5 to 6 yrs of age or beyond
Ideal timing for repair
• Typical umbilical hernias :
Observed up to 2 yrs. of age
• No UR contraction : Anatomical Repair
• Complications : Early Repair

18. Giant Omphalocele
Hernia Of Umbilical Cord

19. Hydrocele

20. Hydrocele
Usual advise:
 Go for immediate repair
 Referred to higher center - Neonatal period
 Wait up to 5-6 yrs. No hurry.
Ideal timing for repair:
Congenital Hydrocele - Conserve up to 2 yrs.
(Non Communicating Hydrocele)
Except:
 Communicating Hydrocele (Fluid Hernia)
 Hydrocele A/W Hernia
 Large Congenital Hydrocele causing discomfort
Immediate Repair

21. Ferguson’s Repair- Open Herniotomy

22. Undescended testis
UDT Ectopic Testis Retractile Testis
Palpable/ Nonpalpable
UL / BL
Associated with HPS --DSD
Spontaneous Descent -First 3 months,
Can wait up to 6 mths.

24. Usual Advise
Surgery after 6 to 7 yrs..
No hurry for surgery, can be done later on
Repeated USG– Unnecessary
Increased cost
MRI- Increased Cost
(Diagnostic Laparoscopy- Diagnostic &
Therapeutic)
Delay in treatment – Land up with
Complications

25. Complications
Impaired Fertility
Malignancy- 5- to 10-fold increased
High incidence -Trauma, Torsion, Inguinal
hernia
Psychologic Factors - Patient & parental
anxiety about subsequent fertility.

26. Testicular Torsion
Clinical Picture Intraop – Testicular gangrene

27. Testicular Torsion

29. Why to operate at recommended age?
High Temperature cause progressive alteration
of function
Decreased LH, T, MIS
Impaired Germ Cell Development
(40% lost by 2 years)
High Chances of development of Complications
Non Functional Testis /
Loss of Testis d/t Torsion

30. Ideal Timing for Orchidopexy
• Orchidopexy is recommended at 6 to 9
months of age.
• Centres with less experience in small children,
surgery between 12 and 18 months may be
safer

31. Hypospadias
• Urethral meatus on ventral surface ± Chordee ±
Hooded prepuce ± UDT

32. Penoscrotal HPS

33. PST + PSH + BFS

34. Hypospadias
Usual Advise
Referral to higher centre in neonatal period,
Too late presentation for repair beyond ideal
timing for repair
• Ideal time for repair:
Repair between 6 and 12 months.
At least before School Admission
Single Stage – Snodgrass Repair, Duckett tube
Staged Repair- Byar’s or Bracka’s Repairs

35. Anorectal Malformations
Absent anal opening
Abdominal distension &
Vomiting
Passing stool from introitus

40. Anorectal Malformations
Inappropriate management - Usually in female
Failure to diagnose malformation
Parents negligence in spite of diagnosis and
referral advise
Poor socio-economic condition
Inappropriate advise- Repair before marriage

41. Anorectal Malformations
Definitive repair-Male
Colostomy- At Birth
PSARP- At 3 months
Colostomy Closure- 6 wks after definitive surgery
All 3 stages completed before 6 months

42. Anorectal Malformations
Definitive repair - Female
Female with colostomy- ASARP/PSARP at 3 to
5 mths of age…
Female without colostomy : Planned for
Primary ASARP- 3 to 6 months
Cloaca- Standard 3 stage repair

43. Postop ARM- PSARP

44. Primary ASARP

45. Empyema
• Accumulation of purulent fluid in the pleural
cavity
• 1 in 150 pneumonia cases
3 characteristic stages:
 Exudative -fluid is thin ,low cellular content;
 Fibrinopurulent –fluid loculations/ Septations
 Organizing empyema -fibrinous peel.

46. Empyema
Patient presentation at higher centre:
H/O receiving antibiotics for 2 to 3 weeks-
various levels
Intermittent fever spikes
Failure to thrive
Rib cage deformity-Overcrowding of ribs
ICD in situ for weeks together but continuous
purulent discharge is persistent

47. American Pediatric Surgical Association
(APSA)
Simple effusions/Empyema < 5 days duration-
Chest tube drainage.
Symptoms > 5 days- fibrinolysis/ VATS
If symptoms persist >7 days after intervention,
CECT Chest - To determine the presence of pleural
disease

48. CECT Chest
• No pleural disease- Antibiotics alone
• Pleural disease- Loculated collection with peel
enhancement- VATS sos Open decortication
• Beyond 14 days of presentation and very thick
peel- Open decortication

53. Decortication

54. Foreign bodies
Tracheobronchial FB/Esophageal FB
Metallic/nonmetallic
Usually:
Pt referred to higher centre for asymptomatic
FB
Started on laxatives
Repeated X-ray- to look for its progression

56. Foreign bodies--TB
Tracheo Bronchial FB - Warrants urgent removal
Rigid or Flexible bronchoscopy
Warning- Any Button Battery ingestion(Toys)-
Most dangerous FB - Urgent referral to experts
May Cause :
Perforation (Tracheal, Esophageal, Intestinal)
Aquired tracheo-esophageal fistula
Management: Emergency retrieval
Rigid bronchoscopy
Upper GI endoscopy

57. Foreign bodies--Intestinal
 Asymptomatic metallic FB-
Closed Safety pin, Coin, chain, Marble etc..-
Can be observed safely-
 Sharp FB -Open safety pin, Needle, Nails etc.
Admit and observation
If symptoms of acute abdomen- Exploration
 Button battery- Emergency retrieval- RB/ ENDO
 Usually Banana eating advised ..Laxatives not warranted

58. Summary
Phimosis :- Symptomatic
Umbilical Hernia:- After 2 yrs
Inguinal Hernia:- Soon after diagnosis
Hydrocele:- After 2 yrs
Undescended testis:- 6mths to 1 yr
Hypospadias:- 1yr
ARM:- Within 6
Empyema:- depending on the
stage
Foreign Bodies

59. Thank you