Common surgical problems in children...............................................................

1. Common surgical problems
in children
Presented by
Dr. Md. Ashik Kamal Alvee (MD resident, Phase A)
Dr. Md. Mohsin Tareq (MD resident, Phase A)

2. Introduction
Pediatric medicine and pediatric surgery are two distinct entity.
But some surgical problems present in such a manner and with
such complications that sometimes they need medical
management at first. Sometimes these surgical conditions can also
mimic various medical conditions.
That is why sound knowledge about various common
surgical problems of childhood is needed for
every pediatrician.

3. Topic of discussion
Today our topic of discussion is some of the most common
surgical problems and their:
• Incidence
• Pathophysiology
• Clinical features/ presentations
• Complications
• Investigations
• Management

4. Common Surgical Problems in children
• Cleft lip and Cleft palate
• Gastroesophageal Reflux Disease
• Hirschsprung disease
• Oesophageal atresia with
Tracheoesophageal fistula
• Congenital diaphragmatic hernia
• Infantile hypertrophic pyloric
stenosis
• Duodenal atresia.
• Intussusception
• Ureteropelvic junction obstruction
• Posterior urethral valve
• Hernia and Hydrocele
• Hypospadias
• Cryptorchidism
• Phimosis and Paraphimosis

5. Cleft lip and cleft palate
Incidence
Highest amongst Asians (1 in 500) and Native Americans (1 in 300)
Lowest among the black (1 in 2,500).
Male: Female = 3:1
Cleft lip- Results from failure of fusion of
medial nasal Process and maxillary process.
Cleft palate- Result of failure of fusion of
palatine Processes of two maxilla. Fig: development of face

6. Cleft lip may be-
• Incomplete(small gap in the lip) or Complete(continues into the nose).
• Unilateral or Bilateral.
Cleft palate may be-
• complete (soft and hard palate) or Incomplete(usually soft palate)

7. Problems associated with cleft lip and cleft palate
• Difficulty in feeding.(Nasal regurgitation, inability to suck)
• Recurrent respiratory tract infection.
• Recurrent otitis media with subsequent hearing loss.
• Speech difficulty. (Misarticulation and nasal intonation)

8. Management
• Supportive
Feeding : Help baby to ‘Latch on’ at the beginning of feed.
Feeding with long handled spoon in upright position.
Palatal shield to prevent nasal regurgitation.
Treatment of infections with antibiotics
• Specific
Surgical correction. A conventional Rule of 10 is applied for surgery.
Weight Age Hemoglobin
Cleft lip 10 pounds(4.5 kg) 10 weeks 10 gm/dl
Cleft palate 10 kg 10 months 10 gm/dl

9. Esophageal Atresia and Tracheoesophageal Fistula
Esophageal atresia is the most common congenital anomaly of
the esophagus, with a prevalence of 1.7 per 10,000 live births.
Of these, >90% have an associated tracheoesophageal fistula (TEF).

10. Presentations
• History of maternal polyhydramnios
• Excessive frothing and bubbling at the mouth
and nose after birth
• Chocking on attempted feeding
• Recurrent respiratory tract infection as a result
of aspiration of saliva and gastric contents.
• Failure to pass a NG tube to stomach.

11. Investigations
• X ray of chest and abdomen
presence of coiled NG tube in the upper pouch.
in case of fistulae, gas shadow found in stomach and abdomen
in case of no fistulae no gas shadow is seen in stomach or
abdomen.
• Barium swallow X-ray
Isolated Tracheoesophageal fistulae (H type) can be
demonstrated.

12. X ray of chest and abdomen showing coiled NG
tube in esophagus and no gas shadow in gut
X ray of chest and abdomen showing coiled NG
tube in esophagus and gas shadow in gut

13. Barium swallow X-ray showing H-type
fistula (arrow). Barium is seen to
outline the tracheobronchial tree.

14. Management
Supportive
• Counselling
• Prone positioning minimizes movement of gastric secretions into
a distal fistula.
• Placing a NG tube to do esophageal suctioning for minimizing
aspiration.
• Head to be kept elevated to minimize aspiration.
• Antibiotics in suspected aspiration or RTI.
Specific
Surgery is definitive management.

15. Congenital diaphragmatic hernia
It is as a communication between the abdominal and thoracic
cavities due to congenital defect in diaphragm with herniation
of abdominal contents in the thoracic cavity.
Epidemiology
• Incidence : between 1/2,000 and 1/5,000 live births
• Female : Male = 2:1.
• More common on the left (85%) and are
occasionally (<5%) bilateral.

16. Types
• Posterolateral (Bochdalek)- 90%
• Esophageal hiatus (hiatal)
• Paraoesophageal
(adjacent to the hiatus)
• Retrosternal (Morgagni)
Depending on the position in diaphragm. It can be at-

17. Clinical features
Symptoms
Severe respiratory distress and cyanosis since birth
Signs
• Tachypnoea, tachycardia, cyanosis.
• Respiratory system-
Chest indrawing, bulged chest.
Trachea and apex beat may be shifted.
Diminished breath sound
Bowel sound heard in chest.
• Alimentary system-
Scaphoid shaped abdomen.

18. Investigations
• Chest X-ray
Coils of intestine in chest with mediastinal shifting to opposite side.
After inserting NG tube It may be visible in chest
• Arterial blood gas analysis
May show Respiratory and/or Metabolic acidosis.
• Prenatal ultrasonography (between 16 and 24 weeks of gestation)
Polyhydramnios, chest mass, mediastinal shift, gastric bubble or
liver in the thoracic cavity.

19. Fig: plain Xray of chest showing coils of intestine
in chest, shifting of mediastinum, left dome
absent
Fig: This chest radiograph shows a
stomach, nasogastric tube, and coils of
intestine in the thoracic cavity.(arrow

20. Management
Supportive
• Counselling
• Nothing per oral
• Keep the child warm
• Rapid endotracheal intubation.
• Giving oxygen in nasal cannula and avoid face mask.
• Avoiding bag mask ventilation.
• For ventilation-Conventional mechanical ventilation, ECMO
Specific
Surgical repair (at least 48 hours after stabilization)

21. Gastroesophageal Reflux Disease
Gastroesophageal reflux (GER) is the retrograde movement of
gastric contents across the lower esophageal sphincter (LES) into
the esophagus, which occurs physiologically every day.
The phenomenon becomes pathologic in infants and children who
manifest various symptoms because of frequent
Gastroesophageal Reflux.

22. Reflux is prevented by
lower esophageal sphincter(LES)
The LES is supported by
• Right crus of the diaphragm
• Angle of his.
There is balance between
intra-esophageal pressure and
intra-abdominal pressure
Normal anti-reflux mechanism

23. Diaphragm
Causes of GERD
• Esophagus
Insufficient LES tone
Abnormal LES relaxations
• Hiatal hernia
• Delayed gastric emptying
Pyloric stenosis
• Increased intra-abdominal pressure
Obesity
Ascites
Intra-abdominal mass

24. Clinical features
• Recurrent regurgitation
• Weight loss or poor weight gain
• Irritability in infants
• Heartburn or chest pain
• Hematemesis
• Dysphagia, odynophagia
• Stridor
• Cough
• Hoarseness
• Recurrent pneumonia
• Anemia
• Dental erosion
• Feeding refusal
• Dystonic neck posturing
(Sandifer syndrome)
• Apnea spells

25. Investigations
Investigations Findings
Contrast X-ray of the
esophagus and stomach
• Esophageal strictures and stenosis
• Hiatal hernia
• Gastric outlet obstruction.
pH monitoring of the distal
esophagus
pH<4 signifies distal esophageal acid
exposure.
Endoscopy with biopsy • Erosive esophagitis
• Esophageal strictures
• Grades of inflammation
Esophageal manometry To detect LES closing pressure

26. Fig:Oesophageal reflux.
Frontal (left) and oblique
(right) X-rays of the chest
and upper abdomen of a
patient.The arrow at left
points to the cardia, the
region where the contents
of the oesophagus empties
into the stomach (across
bottom). The X-ray shows
reflux of contrast media
from stomach to
oesophagus.

28. Management
Lifestyle modification
• Food
Infant- Thick frequent small feeds
Children- Avoid reflux-inducing foods and beverages (tomatoes,
chocolate, juices, carbonated and caffeinated drinks)
• Proper positioning
Infant-Seating position to be avoided.
Prone position and Upright carried
position recommended.
Children-Lateral position and
Head elevation during sleep.

29. • Drugs- Antacid
H2 receptor antagonists
Proton pump inhibitors
• Endoscopic therapy
Application of radiofrequency
therapy to LES and cardia.
• Surgery
Fundoplication.
During fundoplication,
fundus is wrapped around
the back of esophagus
wrap is secured with suture to
anchor lower esophagus below
diaphragm

30. Infantile Hypertrophic Pyloric Stenosis
Incidence
• 1-3 per 1,000 infants
Risk factors
• Infants with B and O blood groups.
• Male child (4-6 times more)
• Use of erythromycin in the 1st 2 weeks of life.
• Associated with-
Tracheoesophageal fistula,
Trisomy 18, Smith-Lemli-Opitz
syndrome,Eosinophilic gastroenteritis.

31. Clinical features
Symptoms
• Nonbilious vomiting ,usually projectile, usually follows each feeding.
• After vomiting, the baby is hungry and wants to feed again.
Signs
• May be dehydrated.
• After feeding, there may be a visible gastric peristaltic wave.
• On palpation, the enlarged pylorus , described as an ‘Olive mass’ is
palpated specially after vomiting.

33. Investigations Findings
Ultrasonography of
abdomen
• Pyloric muscle thickness 3-4 mm,
• Pyloric channel length 15-19 mm,
• Diameter of pylorus 10-14 mm.
Barium meal X ray • Hugely dilated stomach
• Contrast does not pass beyond pylorus
• String sign, shoulder sign, double tract sign.
S. Electrolyte Hypochloremic alkalosis, Hypokalemia,
Hyponatremia
S. Bilirubin Unconjugated hyperbilirubinemia.
Investigations

34. Fig: barium meal X ray showing dilated stomach
and elongated pyloric channel (string sign)
Fig: barium meal X ray showing dilated stomach and
elongated pyloric channel (string sign), bulge of the
pyloric muscle into the antrum (shoulder sign)

35. Management
Supportive
• Counselling.
• Correction of dehydration.
• Correction of electrolyte imbalance.
• Nasoduodenal feedings for patients who are
not eligible for surgery.
• Oral and I/V atropine sulfate (pyloric muscle relaxant).
Specific
Ramstedt pyloromyotomy.

36. Hirschsprung disease
Otherwise known as Congenital Aganglionic Megacolon. It is a
developmental disorder of the enteric nervous system,
characterized by the absence of ganglion cells in the submucosal
and myenteric plexus.
• Incidence : 1 in 5,000 live births.
• The male : female = 4 : 1 for short segment disease
2 : 1 for total colon involvement .
• Uncommon in Prematurity.

37. Pathology
Arrest of neuroblast migration in the gut from the proximal to distal bowel
Absence of ganglion cells in the bowel wall, extending proximally
from the anus for a variable distance.
Inadequate relaxation of the bowel wall and bowel wall hypertonicity
Failure to pass bolus leads to dilation of the bowel and abdominal
distention, bowel obstruction.
Intraluminal pressure increases, resulting in decreases blood flow (Stasis).
Stasis allows proliferation of bacteria, which can lead
to enterocolitis with associated diarrhea,sepsis.

38. Types
• Ultra short segment: Aganglionosis limited to the internal sphincter
• Short segment: Aganglionosis involving rectum and sigmoid colon.
• Long segment: Aganglionosis extends proximal to sigmoid colon
• Total segment: Aganglionosis affects entire large gut and portion of
terminal ileum.
Short segment Long segment Total segmentUltra-Short segment

39. Neonate Older children
• Failure to pass meconium
within 48 hours of life.
• Distended abdomen.
• Bilious vomiting.
• Features of Enterocolitis ,
bowel obstruction, sepsis.
• Failure to thrive
(less common).
• History of constipation since infancy,
refractory to usual treatment.
• Intermittent attacks of intestinal
obstruction.
• Distended abdomen with a
palpable mass.
• Rectal examination shows gripping of
examining finger. (anal grip)
• The rectum is usually empty of
feces and when the finger is removed,
there may be an explosive discharge
of feces and gas.
Clinical features

40. Investigations
Plain X-ray of abdomen
• Dilated proximal colon with absence of gas shadow in pelvic colon.
Barium enema
• Shows a transition zone in between dilated proximal
colon and small caliber distal colon.
• Rectal diameter is the same as or smaller than the sigmoid
colon suggests Hirschsprung disease.
Anorectal manometry
Rectal biopsy
• Absence of ganglionic cells in submucosal and myenteric plexus.
• Hypertrophied nerve trunks.

41. Plain Xray abdomen: Dilated proximal colon with
absence of gas shadow in pelvic colon
Barium enema showing dilated proximal part (A), distal
constricted part (B), and transition zone in between
them(C).

42. Management
Supportive
• Counselling
If there is feature of obstruction
• Keep the child NPO
• Intravenous fluid and antibiotics
• NG decompression
• Rectal irrigation
Specific
Surgery is the definitive treatment.

43. Congenital duodenal atresia
• Incidence : 2.5-10 per 100,000 live Births
• 50% of infants are premature.
Associated abnormalities
Congenital anomalies
• Congenital heart disease (30%),
• Annular pancreas (30%),
• Renal anomalies (5-15%),
• Esophageal atresia (5-10%),
• Skeletal malformations (5%),
Trisomy 21 (one-third of patients.)

44. Clinical features
Symptoms
Recurrent Bilious vomiting.(within hours of birth)
Signs
• Dehydration
• Abdomen may be distended.
• Peristaltic waves may be seen early in the disease process.

45. Investigations
• Plain X ray abdomen : “double-bubble” sign.
• Contrast X ray abdomen: no dye passes beyond duodenum.
• S. electrolyte: Hypochloremic alkalosis, Hypokalemia,
hyponatremia.
• Echocardiography, renal ultrasound, and Chest Xray :
Evaluation of associated anomalies.
• Fetal ultrasonography: Double-bubble shadow, polyhydramnios.

46. Plain Xray of abdomen: showing
double bubble shadow
Stomach
Duodenum

47. Management
Supportive
• Counselling
• Patient kept NPO and I/V fluid is given.
• Nasogastric/ Orogastric decompression.
• Correction of dehydration.
• Correction electrolyte imbalance.
Specific
Surgery. (Duodenoduodenostomy is done)

48. Anorectal malformation
Incidence
1 per 3,000 live births.
• Most patients presents with imperforate anus.
• Others present with fistulous connection between anus and
urethrae, vestibule, anal stenosis etc.
• Here we discuss about imperforate anus.

49. Types
• High lesion
The rectum has not descended through the sphincter complex.
• Low lesion
The rectum has descended through the sphincter complex.
• A persistent cloaca
rectum, vagina and urinary tract are joined into a single channel.

50. Clinical features
• Failure to pass meconium 24 hours after birth.
• Examination of perineum
High lesion
• Perineum appears flat.
• There may be air or meconium passed via the penis (urethra)
Low lesion
• Perineal fistula may be present.
Male- along Median raphe across the scrotum/penile shaft.
Female- may be in the vestibule
• Covered anus- A thickened raphe or “bucket handle” covers anus.

51. Perineal fistula along median
raphe across the scrotum
Fig : “bucket handle” bridge over
covered anus

52. Associated malformations
GENITOURINARY
• Vesicoureteric reflux
• Renal agenesis
• Cryptorchidism
• Hypospadias
VERTEBRAL
• Spinal dysraphism
• Presacral masses
• Meningocele
• Lipoma
• Dermoid
CARDIOVASCULAR
• Tetralogy of Fallot
• Ventricular septal defect
• Transposition of the great vessels
GASTROINTESTINAL
• Tracheoesophageal fistula
• Duodenal atresia
• Malrotation
• Hirschsprung disease
CENTRAL NERVOUS SYSTEM
• Spina bifida
• Tethered cord

53. Investigations
• Prone cross-table lateral plain x-ray
Demonstrate rectal gas shadow below the level of coccyx.
• Invertogram (the baby is turned upside down)
A coin/metal piece is placed over the expected anus. The distance
of the gas bubble in the rectum from the metal piece is noted:
>2 cm denotes high type
<2 cm denotes low type
• Ultrasonography of abdomen
• Voiding cystourethrogram

54. Fig : Prone cross-table lateral plain x-rayFig: Invertogram

55. Management
Operative repair
• If perineal fistula opens in good position, can be treated by
simple dilation. (Hegar dilators)
• In case of a low lesion - Perineal anoplasty.
• In case of high lesion - Colostomy is performed to relieve bowel
obstruction at first. Then definitive repair or posterior sagittal
anorectoplasty (PSARP) is performed at about 1 year of age.
Usually, the colostomy can be closed 6 weeks or more after the
PSARP.

57. Introduction
• Intussusception occurs when a portion of the alimentary
tract is telescoped into an adjacent segment.
• Most common cause of intestinal obstruction between 5
months to 3 years of age.
• The male : female ratio is 3:1.
• Incidence : 1-4/1000 live births.
• Commonest area: ileocolic region.

58. Etiology
• Idiopathic (90%)
• Adenovirus or other upper respiratory tract infection.
• Henoch-Schonlein Purpura and Gastroenteritis.
Recognizable Lead points :-
• Meckel diverticulum
• Intestinal polyp
• Neurofibroma
• Lymphoma

59. Pathology

60. Clinical features
• Sudden, severe and intermittent colicky abdominal pain with
screaming and drawing up of the knees.
• The child appears calm and relieved in between attack.
• Vomiting and Diarrhoea.
• Stool Looks like Red current
Jelly.
• Features Of Shock.
• Advancing intestine
prolapses through anus.

61. Abdomen
Inspection : Distended
Palpation : A tender sausage shaped mass is felt in
upper mid abdomen.
Auscultation : bowel sound may be absent.
Digital Rectal Examination : Bloody mucus in fingers.

62. Investigations
• Plain X ray abdomen
May show intussusception, bowel obstruction,
intestinal perforation.
• Contrast X ray of abdomen
Filling defect, coiled spring sign.
• Ultrasonography of whole abdomen
Longitudinal view shows a Reniform mass.
Transverse view shows a Target appearance/Doughnut
appearance.

63. Plain X-ray abdomen
Small bowel dilatation
Sausage shape density

64. FIG: plain X-ray abdomen showing sausage shaped
density in the film reflecting intussusception
FIG: contrast X-ray of abdomen showing coiled
spring appearance.
Contrast x-ray abdomen shows coiled spring
sign and filling defect

65. USG of whole abdomen
Transverse view shows a Target
/Doughnut appearance
Longitudinal view shows a
Reniform mass

66. Treatment
Medical Treatment
• Counselling.
• Nothing per oral.
• Maintenance IV fluid e.g. 10%
DA/Baby saline.
• NG tube and decompress
stomach.
• Broad spectrum antibiotic.
• Potassium correction if
necessary.
Surgical Treatment
• Non operative Reduction with barium or Saline or Air(pneumatic
reduction).
• Laparotomy with Open Reduction
• Resection of the intussusception with end to end anastomosis.

67. Ureteropelvic junction
obstruction

68. Introduction
• UPJ obstruction is the most common obstructive lesion in
childhood.
• It is the functional obstruction of junction between the renal
pelvis and ureter.
• Incidence is 1 in 2000 children with
male female ratio is 2:1.
• Bilateral in only 10% cases
and 60% cases occurs
on the left side.

69. Etiology
• Congenital stenosis
• Ureteral polyps
• Ureteral folds
• Crossing vessel causes
Ureteral compression.
• External compression.

70. Pathology
Obstruction in the ureteropelvic junction
Results in dilatation of pelvis and calyces due to
collection of excessive urine
Pressure upon the renal parenchyma
Renal function begins to affected
and parenchyma become thinner.
Pyonephrosis

71. Clinical Features
• A palpable renal mass.
• Abdominal, flank or back pain(dull constant pain or
severe spasmodic pain)
• Febrile UTI.
• Hematuria.
• Dietl’s crisis.
• Non-specific features such as anorexia, nausea, vomiting,
failure to thrive, weakness, lethargy.

72. Investigations
Investigations Characteristics
Ultra sonogram of KUB Confirm the diagnosis and grade the
hydronephrosis
Intravenous urogram Shows dilatation of calyces and the
pelvis and non visualization of the
ureter on the affected side.
Micturating
cystourethrogram
To see any ipsilateral vesicouretric
reflux
Antenatal Ultrasonography Fetal hydronephrosis may found
CBC
Urine R/E and C/S
Renal function test

73. Intravenous urogram

74. USG of KUB

75. Table : Society of fetal urology grading for hydronephrosis.
Grade Renal Pelvis Parenchymal
thickness
0 Intact : no splitting Normal
1 Mild splitting Normal
2 Moderate splitting
( confined to renal
border)
Normal
3 Marked splitting
(outside renal border,
calyceal dilatation)
Normal
4 Pelvicalyceal dilatation Thin

76. Treatment
• Grade 1 or 2 hydronephrosis : observation
• Grade 3 or 4 hydronephrosis : Pyeloplasty
• Prophylaxis of UTI
• Treatment of AKI
• Treatment of CKD

78. Introduction
• Posterior urethral valve is the most common obstructive
uropathy.
• These are tissue leaflets fanning distally from the
posterior urethra to the external
urinary sphincter.
• It affects 1 in 8000 boys.

79. Pathogenesis
Persistence of posterior urethral valves
Narrowing of the bladder outlet with
consequent obstruction of urine flow
Increased pressure in proximal organs.
Dilatation and enlargement.
Vesico-uretric reflux, hydroureter, hydronephrosis and
renal insufficiency.

80. Neonate Older Infants and children
• Palpable distended bladder
With or without palpable
kidneys.
• Weak urinary stream.
• Sepsis
• Straining during micturition
• Poor urinary stream,
dribbling of urine
• Palpable bladder
• Failure to thrive
• UTI and Renal failure
Clinical Features

81. Investigations
Investigations Findings
USG of Genito-urinary system • Bladder is thick-walled with an elongated and
dilated posterior urethra
• hydonephrosis
• kidneys may be hyperechoic with loss of normal
cortico-medullary differentiation
MCUG- Diagnostic • Dilatation and elongation of posterior urethra.
• Distal urethral stream is narrow
• Bladder may show irregular border.
Antenatal USG- • Bilateral hydronephrosis
• Distended bladder
• Oligohydramnios
• Keyhole sign.
Assessment of renal function

82. MCUG

83. Antenatal USG Postnatal USG
Keyhole sign
Hydronephrosi
s

84. Treatment
• Bladder drainage by insertion of feeding tube.
• Correction of fluid, electrolyte imbalance, acid base irregularities
and control of infection.
• Vesicostomy
• Percutaneous nephrostomy and haemodialysis.
• Surgery - Transurethral ablation of valves

85. Hernia and hydrocele
Introduction
• Hernia and Hydrocele both results from patent processus vaginalis,
a tongue like extension of the peritoneum.
• Usually the processus closes down and there is no connection
between abdomen and inguinoscrotal region.
• If the processus remains patent and opening is large, abdominal
viscera like intestines herniate into the scrotum.

86. • If the opening is small, only peritoneal fluid can
enter, forming a hydrocele.

87. Epidemiology
• The incidence of congenital indirect inguinal hernia in full-term
newborn infants is estimated at 3.5-5.0%.
• The incidence of hernia in preterm and low birth weight infants
is considerably higher.
• Male : female ratio inguinal hernia is approximately 8 : 1.
• Approximately 60% of inguinal hernias occur on the right side,
30% are on the left side, and 10% are bilateral.
• 1-2% neonate have a hydrocele.

88. Predisposing Factors
Hernia Hydrocele
• Prematurity
• Cryptorchidism
• Hypospadias/ epispadius
• Raised intraabdominal pressure
• Cystic fibrosis
• Connective tissue disorders
• Persistent patent processus
• Testicular torsion
• Epididymitis
• Testicular Tumor
• Trauma

89. Clinical Presentations
Points Hernia Hydrocele
Increase of size of
swelling
On crying or after activity. In the evening or after
an active day.
Decrease of size of
swelling
Can be reduce
spontaneously and on
gentle pressure.
On waking up in the
morning.
Features of intestinal
obstruction
may present such as
abdominal pain, distension.
Absent
Mobility Less mobile Mobile
Character Hernia are smooth, firm
and may be tender.
smooth and non
tender
Reducibility Reducible Irreducible
Get above the swelling Can not be done. Can be done.
Trans illumination test negative Positive

90. Types of Hydrocele

91. Types of Inguinal Hernia
1. Indirect hernias (99%)
2. Direct hernia (0.5-1.0%)
3. Femoral hernia (<0.5%).
Complications of hernia
1. Intestinal obstruction
2. Strangulation.

92. Investigation
USG of the scrotum
• Can help in distinguish between hernia and hydrocele.
Plain X-Ray abdomen
• Distended intestine with multiple air fluid level.

93. Treatment
Hernia
• Surgery as soon as diagnosed
• Surgery
Herniotomy with Herniorraphy.
Hydrocele
• Most congenital hydrocele resolves by 12 months of age.
• If not resolved within 12-18 months then Surgical
correction needed.

94. UNDESCENDED TESTIS
(CRYPTORCHIDISM)

95. Introduction
• Cryptorchidism means “Hidden Testis”.
• It may be single or bilateral (10%).
• When a boy is seen with single or no testicle in scrotum
indicates the testis is undescended, absent or retractile.
Aetiology
• Unknown but may be related to genetic, hormonal or
mechanical factor.
• Prematurity.

96. Epidemiology
• Most common disorder of sexual differentiation in boys.
• At birth, approximately 4.5% boys have an undescended testis
among them 30% are preterm and 3.4% are at term.
• Majority of congenital undescended testis descend
spontaneously during the 1st 3 months of life.
• If the testis has not descended by 4 months, it will remain
undescended.

97. Site of undescended and ectopic testis

98. Classification
1. Abdominal - Non-palpable
2. Peeping - Abdominal but can be pushed into the upper
part of the inguinal canal.
3. Inguinal.
4. Gliding - Can be pushed into the scrotum but retracts
immediately to the pubic tubercle.
5. Ectopic – Superficial inguinal pouch or rarely perineal.

99. Complications
1. Infertility
2. Testicular Malignancy
3. Poor testicular growth
4. Associated Hernia
5. Torsion of cryptorchid testis
6. Psychological effects.
Investigations
1. Ultra sonogram of abdomen
2. MRI or CT scan of abdomen
3. Laparoscopy – Diagnostic.

100. Treatment
Medical
Hormonal therapy with hCG or LH-releasing hormones.
Surgical
• Should be treated surgically by 9-15 months of age.
• Orchiopexy (success rate 98%).
• Orchiectomy and implantation of
testicular prosthesis

101. Hypospedias
Introduction
• Hypospadias is a urethral opening on the ventral surface of
the penile shaft.
• It affects 1 in 250 male newborn.
• Cause is unknown.
• Sometimes hypospadias is associated with Dorsal hood and
chordae.

102. Clinical Presentations
According to the position of the urethral meatus
Hypospadias is classified as-
1. Glanular - on the glans penis.
2. Coronal
3. Subcoronal
4. Midpenile
5. Penoscrotal
6. Scrotal
7. Perineal
8. Megameatal

105. Treatment
• Ideal age for repair in a healthy infant is 6-12 months.
• Circumcision should be avoided.
• The goal of any type of hypospadias surgery is to make a normal,
straight penis with a urinary channel that ends at or near the tip.
Surgery –
• Tubularized incised plate repair.
• Almost all cases are repaired in
a single operation except
Proximal cases.

106. Complications
Untreated cases
• Deformity of the urinary system.
• Sexual dysfunction
• Infertility
• Meatal stenosis.
After surgery
• Urethro-cutaneous fistula.
• Meatal stenosis.

107. Phimosis
• Inability to retract the
prepuce.
• At birth, Phimosis is
physiologic.
• 80% of uncircumscribed
boys the prepuce become
retractable by 3 years of age.
• In older child pathologic
phimosis may occur due to
inflammation and scarring at
the tip of foreskin.

108. Treatment
Medical
• Application of topical corticosteroid cream to the foreskin
3 times daily for 1 month.
Surgical
• Circumcision
• Minor operation to relieve foreskin tightness.

109. Paraphimosis
It occurs when the foreskin is retracted proximal to the coronal
sulcus and the prepuce can not be pulled back over the glans.
Results in painful venous stasis
and edema in the retracted foreskin
leading to severe pain and inability
to reduce the foreskin.
Eventually gangrene and auto amputation
of the distal penis Occurred.

110. Treatment
• Lubricating the glans and foreskin and
simultaneous Compressing the glans.
• Topical application of granulated sugar
• Injection of hyaluronidase into the edematous skin
• Emergency circumcision.

111. Thank you