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Common Surgical conditions in kids

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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.
Common Conditions
Phimosis
Inguinal Hernia
Umbilical Hernia
Hydrocele
Undescended testis
Hypospadias
Anorectal Malformation
Empyema
Foreign Bodies
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.
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
Common Surgical  conditions in kids
Common Surgical  conditions in kids

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Common Surgical conditions in kids

  • 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.
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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