This document discusses the management of general surgery emergencies in childhood and adolescence. It covers topics such as managing patients presenting with abdominal pain, acute scrotal conditions like testicular torsion, and hernias. Specific conditions discussed in more detail include undescended testes, intussusception, hypertrophic pyloric stenosis, and vomiting in children. For each topic, it provides guidance on diagnosis, initial management, indications for referral or surgery, and expected outcomes. The goal is to equip trainees with the knowledge to competently handle common pediatric general surgical emergencies.

1. General surgery of childhood

2. Key Topics 2013 General surgery
syllabus.
Management of the patient with multiple injuries. 12.2.4
 Assess and resuscitate the patient (including children) with multiple injuries
in accordance with the ATLS standards at the current time.
 Trainees should have a valid ATLS when applying for CCT
 12.2.2
 Competent to manage patients (including children ) presenting with
abdominal pain or an acute abdomen

3. Key topics
12.2.6
Manage general surgery emergencies in childhood and adolescence
Diagnosis and manage children and young adults presenting with common
general surgical emergencies, in collaboration with paediatricians when
appropriate.
Competent to initially manage patients with intussusception , referring on
when necessary.
Competent to initially manage acute groin conditions (incarcerated hernia
and testicular torsion), referring on when necessary.

4. 12.9.1General surgery of childhood
 Manage patients with acute abdominal pain, recognising when referral to a
specialist centre is required
 Manage patients with penile inflammation and acute scrotal conditions
 Manage patients with inguinal, epigastric ,umbilical or supra-umbilical hernia
and hydrocele
 Manage patients with undescended testis, recognising when referral to a
specialist centre is required.
 Assess and diagnose intussusception, referring on for radiological or surgical
treatment as appropriate.
 Assess and diagnose and refer on when appropriate patients with vomiting
(including cases of suspected pyloric stenosis.

5. 12.9.1 General surgery of childhood
 Manage patients with superficial abscess and ingrowing toenail
 Assess and manage a patient with trauma.
 12.9.2 Index procedures
 Paediatric hernia/hydrocele
 Paediatric circumcision
 orchidopexy

6. Why I do paeds surgery.
 Offer something different
 Confidence in managing the acute intake/trauma
 “complement” the skill set in the department
 Day case elective work / high throughput Outpatients
 Rewarding surgical outcomes
 Good training opportunities

7. Training requirements
 6 months after “year 4”
 Index procedures
 No exit exam requirement
 JOB PLAN
 1 list/fortnight
 1 OPD / fortnight
 Revalidation
 BAPS/ regional MDT

8. “lesson plan”
 Undescended testicles
 The acute scrotum
 circumcision
 PPV and abdominal hernias
 Vomiting in a child
 Appendicitis
 Miscellaneous topics

9. Undescended testes (UDT)
(CRYPTORCHISM)
 Normal descent governed by multiple influences ,endocrine, paracrine,
growth and mechanical
 Whilst fascinating has been very difficult to make exciting!
 Stick to the facts.
 Classification: Palpable . Non-palpable

10. Definitions
A true UDT has had its descent halted somewhere along the line of normal descent
An ectopic testicle has deviated from the normal path and can be found in the inguinal region, perineum,
femoral canal , penopubic area or contralateral hemi scrotum.
retractile testicle is a normally descended testicle that has retracted into the inguinal canal under the
influence of the cremesteric muscle and can be manipulated back into the scrotum.
Acquired UDT is a testcle that has previously identified in the scrotum but can no longer be brought down
in to the scrotum ( scar tissue from inguinal surgery, association with retractile testes)

11. My Strategy for retractile testes
 Cremesteric reflex is weak/absent for the first 2 years of life.
 Clinical examination- warm room- “calm patient!”
 Is scrotum hypo plastic
 Is contralateral side testicle hypertrophied
 Walk fingers down inguinal canal (+/- gel to lubricate)
 Can you manipulate testes into scrotum , retractile will stay without
traction. UDT will ping back up
 If retractile I will keep the child under review in opd annual appointment
till 3rd birthday.

12. Back to UDT!
3% of term male infants
33% of premature male infants
Majority of testicles descend within 9-12 months
UDT 1% at 1 year unlikely to descend after this.
UDT 66%-75% palpable within the inguinal canal or distal to the external ring
Associated anomalies PPV 70%
Epididymal abnormalities
Uncommonly Hypospadias , Posterior urethral valves, Prune Belly syndrome

13. Path of descent

14. Implications of UDT
 Fertility :- Paternity rate of men with unilateral UDT equivalent to the
normal population
Bilateral UDT paternity rate 50-65% even if corrected
Risk of malignancy:- 5-60 x greater risk of testicular cancer with
cryptorchidism
Risk greater for UDT with abdominal location
compared to inguinal location (seminomas)
15-20% tumours arise in normally descended
contralateral testicle

15. Treatment of UDT
 Early placement of testes in scrotum
 May affect fertility and malignancy risk
 Reduces risk of torsion/trauma ,
 Improves endocrine function
 Cosmetic implications
 Facilitates normal examination
 Recommendation to achieve a scrotal positon at as close to 1year of age.

16. Discussion points
Surgical access one vs two incision orchidopexy
Bilateral palpable undescended testes
Non palpable testes one
two - ? Anorchia
Medical “treatment” of UDT

18. Management of the acute scrotum
There is no place for the use of ultrasound in
the assessment of the child with scrotal pain.
Differential diagnosis
Torsion of the testis
Torsion of the appendix testis/epididymis
Epididymitis/Orchitis
Hernia/hydrocele
Trauma/ sexual abuse
Tumour
Cellulitis / Vasculitis (H-SP)

19. Testicular torsion
 Twisting of the testicular pedicle compromising blood supply and
subsequent infarction
 4-8 hour window to intervene
<6 hour 85-97% testicular salvage
>6-12 hour 55%-85% testicular salvage
(12-24hr 20-80% , >24hr 10% )
Intravaginal- more common , cord twists within tunica vaginalis
Predisposed by abnormal fixation of testis and epididymis within the tunica
“bell clapper” 12% cadaveric studies often found bilaterally.
Extravaginal torsion-perinatal event abnormality of descent tunica not fixed
in the scrotum .

20. Testicular torsion
 Testicular torsion typically occurs < 3 yrs. and after puberty
Rare in pre-pubertal boys and 25ys+
Sudden onset severe unilateral pain in testicle/groin
Examination High riding testicle +/- transverse lie absent cremesteric reflex
In reality- you can`t put a hand on them!

21. Management
 Prompt scrotal exploration
 Urinalysis revealing pyuria/bacturia can be found with
torsion
 High resolution USS with Doppler 89% sensitive, 98.8%
specific, false positive 1%
 Temporising measures
manual derotation medial to lateral “open book” will be
correct direction in 60%

22. Operative management
 Midline raphe incision
 Explore affected side- untort / warm pack/ explore contra-lateral side and
3 point fix with non-absorbable suture.
 Examine torted testicle if viable , 3point fix
 If non-viable remove.
 Antisperm antibodies -animal studies ? Relevance.
 If patients re-present with acute scrotal pain after previous surgery
Manage as per new presentation.

24. Torsion of testicular appendages
The most common cause of an acute scrotum.
Most commonly occurs between 7-11 years of age
Vestigial remnant of the Mullarian duct (Appendix
testes)
Epididymal appendage of Wolffian origin (Appendix
epididymis)
Paradidymis/organ of Giraldes
Superior and inferior vas aberrans of Haller

25. Management
Prompt scrotal exploration
Pain experienced till ischaemic necrosis of appendage
Advocates of conservative treatment NSAIDS, “comfort
measures” support and restricted movement
I explore, confirm diagnosis, remove torted appendage,
leave the other side alone
patient home “pain free” next day.

26. Epididymitis
 True bacterial epididymitis quite rare 10-15% of patients with an acute scrotum
 Retro-grade transfer of bacteria from urethra via ejaculatory ducts to
epididymis.
 Sexually active adolescence N.gonorrhoeae, Chlamydia
 Mycoplasma, coliforms in younger children
 If found at scrotal exploration do not open the other side
 UTI in a boy should be investigated with USS
renal tract and voiding cystoureathrogram.
Vesico-uretric reflux most common, but ectopic
ureter or posterior valves possible

27. Idiopathic scrotal oedema
 Age 5-9 years
 Insidious onset of swelling and erythema that starts in the inguinal region
or the perineum
 Usually not painful but may be associated with puritis
 Testes are not painful on examination
 Exclude cellulitis from an adjacent infection (inguinal/perineal/urethral)

28. ISO

29. Idiopathic scrotal oedema
 Symptomatic treatment
 Support
 Antihistamines
 Americans advocate topical steroids

30. posthititis

32. Vomiting in a child
 Multiple possible causes
 Mechanical: ATRESIA, oesophageal, pyloric, duodenal, jejunoileal colonic
 STENOSIS and WEBS, duplication cysts
 Non mechanical: Biochemical, Endocrine, infective (UTI, pneumonia
,meningitis etc.), Neurological, GORD
 BILIOUS (“GREEN”) VOMIT is a cardinal sign
and should always be investigated urgently.

33. Malrotation
 Potential abdominal catastrophe.
 Autopsy studies suggest incidence of 1%
 Literature 1:6000 live births
 Barium studies 0.2%
 Classic “malrotation” midgut volvulus
75% present during the 1st month of life in an otherwise healthy new-born
15% within the first year
That still leaves 10%

34. Malrotation 2
 Volvulus around SM pedicle
 Possible to lose from DJ to last 1/3 of transverse colon.
 BILIOUS VOMITING in a child is a presumed MALROTATION until proven otherwise.
 UGI WATER SOLUBLE CONTRAST STUDY urgently
 Identify position of DJ flexure to the right of the spine
 “coil spring” “corkscrew” “beak” appearance
 Aggressive fluid resuscitation, emergency laparotomy
 LADD`s PRODEDURE ( with incidental appendicectomy)

35. Cases
 6 year old girl one episode “green vomit” contrast study

36.  6 year old girl one episode “green vomit” contrast study
 14 yr. old boy. Recurrent abdominal pain since infant

38. Management of the infant with
Hypertrophic pyloric stenosis (HPS)
 1-4:1000 live births
 Male 4:1 Female
 “risk factors”
 Family history, gender, younger maternal age, 1st born .

39. Aetiology
 Likely multifactorial with environmental influences
 Circumstantial evidence for genetic predisposition
Race discrepancies, male preponderance birth order/family history
Environmental factors
Method of feeding (breast vs formula), seasonal variability,
exposure to erythromycin,
trans pyloric feeding in premature infants.

40. Presentation of HPS
 Classic story
 Non-bilious projectile vomiting in a full-term neonate 2-8 weeks old
Initially emesis infrequent – often misdiagnosed as reflux
Progressive , after each feed becoming more forceful (projectile)
Content –recent feed
(but coffee ground if gastritis present-not uncommon)
Clinical appearance dependent on duration of symptoms
Healthy baby – miserable/dehydrated/somnolent infant

41. Clinical findings in HPS
 Palpable pyloric tumour- test feed!
 Visible gastric peristalsis
 Clinical diagnosis is possible in 80-85% of infants
 USS has supplanted clinical diagnosis in most institutions.
(contrast study where USS not available “string sign”)

42. String sign on oral water soluble contrast
“Mushroom sign” =Kirklin sign
USS findings of muscle thickness >3mm
Pyloric channel > 15mm

43. Treatment
RESUSITATION
Metabolic derangement
HYPOCHOLRAEMIC HYPOKALAEMIC METABOLIC ALKALOSIS
Withhold feeding
IV normal saline bolus 10-20ml/kg followed by 5%D/ half NS with 20-
30 mEq/L KCL at 1.25-2 x maintenance rates.
Check electrolytes every 6 hours until normalised and alkalosis has
resolved.

44. Operation
Pyloromyotomy open vs lap
 Should be performed in a centre that provides adequate numbers and
opportunity to train in both techniques.
 Mucosal perforation 1-2% (omental patch repair)
 Duodenal injuries (39 in 901 1964-1994)
 Wound infection 1-2%
 Incisional hernia 1%
 Post operative emesis-prolonged

46. Post operative care
 AS per local surgical preference!
 UHW 4 surgeons 4 different regimes
 H2o feeds / half strength feeds/ full feeds/ 3oz every 3 hours
 Stop if vomits/reduce if vomits/ feed through the vomit
 Post operative emesis is common 80%+ prolonged emesis in 2-25%(usual
underlying GORD) consider incomplete myotomy

47. OUTCOMES
 Historically mortality 50%
 Overall complication rate 1-2%
 The most satisfying operation that I no longer
do!
(Inadequate numbers in DGH, relative inexperience of nursing staff)

48. Intussusception
 “ the acquired invagination of one portion of the intestine into the
adjacent bowel.
 Proximal (inner segment) intussusceptum
 Distal (outer receiving portion) interssuscipiens
 80-95% of paediatric intussusceptions are ileo-colic.
 As the mesentery of the proximal portion gets drawn in , venous
obstruction occurs leading to oedema and sequentially ischemia.

49. Ileo-colic intussusception

50. Idiopathic (Primary) intussusception
Vast majority do not have an identifiable lead point
Usually follow a URTI or episode of gastroenteritis
Hypertrophied Peyer`s patches (lymphoid aggregates in distal ileum)
attributed to “lead point”
3 months to 36 months most common age when infants most susceptible to
adenoviruses and rota virus . (implicated in 50% cases)

51. Secondary intussusception
Identifiable lead point 1.5-12% cases
Most common lead point Meckel's diverticulum.
Others
Polyps
Duplication cysts
Haemangiomas
Hamartomas from Peutz-Jeghers syndrome
Sub-mucosal haemorrhages in HSP
Inspissated secretions in CF
Foreign bodies

52. Clinical presentation
 Classic triad <25% of cases
Young child with crampy abdominal pain,
abdominal mass
“red current jelly stool”

53. Clinical symptoms
 Sudden onset of pain
 Stiffening or drawing up of legs
 Writhing
 Breath holding
 Followed by vomiting
 The attack usually ceases as quickly as it started.
 Further intermittent bouts, comfortable/sleeping between
 As situation evolves becomes lethargic between bouts of pain
 Bilious vomiting and worsening distension precede “red current stool” which is
indicative of ischaemia- don’t wait for this to make diagnosis.

54. Physical examination
 Dehydration- tachycardia
 “sausage shaped mass”
 Dance`s sign flat/empty right lower quadrant.
 High index of suspicion required to make an early diagnosis, repeat
clinical examination.

55. Diagnostic studies
Plain AXR
USS –low cost , lack of radiation
“Target” or doughnut sign transverse section
Pseudo kidney in longitudinal section
MRI/ CT no merit over USS
Laparoscopy
At what point do you refer?

56. AXR intussusception

57. Management of intussusception
 Fluid resuscitation
 NG tube to decompress stomach
 Non-operative management ( less success if evidence of lead point or
delay in diagnosis)
 Air or contrast enema study of choice for diagnosis and potential 1st line
treatment.
 Contra-indication- perforation
peritonitis
Persistent hypotension (inadequate resus/sepsis)

58. Hydrostatic reduction
 Not really changed since first described in 1876
 Water soluble contrast used now instead of barium (barium peritonitis if
perforates)
 Large lubricate catheter , buttocks taped together
 Fluoroscopy evaluation
 Rule of threes
 1. hydrostatic reduction kept 3 feet above the patient
 2. no more than 3 attempts
 3. each attempt no more than 3 minutes
 Success when contrast passes through I.c valve approx. 85% (42-95%)

59. Pneumatic reduction
 Quicker, safer, less mess less radiation.
 Fluoroscopy
 Air or Co2 insufflated into the rectum 80mmHg for younger infants
110mmHg-120Hg older children
Accurate pressure measure possible, reduction rates higher than hydrostatic
Perforation 0.4%-2.5%
Possible for tension pneumoperitoneum (HST venflon in hand!)
Poor visualisation of lead point-false reductions

60. Operative management
 Right lower quadrant transverse incision
 Milk lead point back towards normal position – do not pull
 Examine for lead point-resection if found
 Resect ischaemic segment (anastomose/divert)
 Perform appendicectomy
 Laparoscopy-success reported

62. Appendicitis/ Abdominal pain
 Differentials
Acute RIF pain Vague abdominal pain
Tubo-ovarian UTI
Crohn`s disease PUJ obstruction
Mesenteric adenitis Pneumonia
Caecal diverticulitis Pancreatitis
Meckel`s diverticulitis Biliary colic
Constipation
Viral gastro-enteritis
Regional bacterial enteritis (Yersinia, Campylobacter)
Broad overlapping spectrum of symptoms

63. Appendicitis
 Life time risk 8.7% males 6.7% females
 Peak incidence 12-18
 ?? Family predisposition if < 6
 The appendix is a long TRUE DIVERTICULUM with a narrow lumen
 Inflammation initiated by obstruction within the lumen
lymphoid hyperplasia, faecolith, foreign body , parasites (worms)
Sub mucosal lymphoid follicles at the base peak at adolescence and sharply
decline after 30 yrs.

64. Anomalies of appendicitis in children
 Most common reason you will get asked to see a paediatric patient.
 Young children more likely to present with perforation
85%< 5 yrs., 90-100%< 1 yrs. old
Appendicitis is very rare in Neonatal period must investigate for undiagnosed
CF or Hirschsprungs disease.
Necrotising enterocolitis can be indistinguishable from appendicitis if focally
confined to the appendix in the neonate.

65.  Gastroenteritis the most common mis-diagnosis for a missed appendix..
Diarrhoea more commonly seen in perforated appendicitis with abscess
formation- reactive diarrhoea
Gastro-enteritis more commonly associated with recurrent episodes of
diarrhoea and vomiting starting at a similar time or preceding the onset of
pain.
Blood investigations are not very sensitive or specific for acute appendicitis
Elevated WBC and CRP indicative of perforation/abscess
USS- depended which side if the Atlantic you reside
CT – Too much radiation

66. How I make the decision/diagnosis
 I see the child as early as possible from the point of referral.
 Key elements
Duration of “illness” (history of recent ENT/URTI)
Fever
Tachycardia
Anorexia
Ken Shute rule
A child with abdominal pain, a tachycardia and a temperature has appendicitis
till proven otherwise.

67. Embrace the window of opportunity!
 Don`t be pressured into making a quick diagnosis
 Repeat clinical examination is the best investigation, admit overnight if
required and re-examine early.
 If in doubt after a period of observation- I would take the appendix out.
 Caveats
 Young boys/men with anorexia and RIF pain not usually much else (beware
Crohn`s)
 Young girls/women I will be less patient and laparoscope early to avoid
risk of perforation/pelvic sepsis- USS tubes ovaries

68. Open vs laparoscopy
 No strong feelings
 Laparoscopy very useful in the adolescent female
 No difference in post operative stay or pain
 Availability of appropriate equipment/anaesthetic expertise
 Beware the pliability of the paediatric abdominal wall-risk of perforation-
enter with care

69. Appendix mass/abscess
 If you feel a fullness in the RIF
 This is the situation where USS has a use in the management of a child
with appendicitis.
 Swinging fever, late presentation high WBC/CRP may alert you to a
appendix abscess
 USS will identify if the mass is solid or has a fluid element.
 If abscess- drain under radiological guidance . Antibiotics for 5 days re-
scan to ensure resolution.
 If no improvement +/- additional drain change antibiotics
 5 days rescan – consider surgical drainage.

70. Appendix mass
 USS solid mass (consider Crohn`s)
 5-10 days antibiotics with rescan to ensure resolution.
 DGH Consultant General Paediatric surgery

71.  Do you do an interval appendicectomy?
 What do you do if you feel a mass when patient anaesthetised on the
table?

72. Miscellaneous topics
 Skin lesions
 Tongue tie
 gallstones

73. Skin

74. Skin

75. Skin

76. Skin

77. Mouth

78. Neck

79. Toes

80. Gallstones
 Constipation is not a surgical condition (Hirschsprung`s)

83. Appendicitis in
children
JOHN POLLITT

92. How do you make the diagnosis

93. What diagnostic tools are available?
 Bloods
 Scoring system—ALVARADO score
 USS
 CT-limited
 Diagnostic laparoscopy

94. The most valuable tool
 Repeat clinical examination
 Cheap
 Non-

95. What tricks do you know to help you
make a diagnosis

96. What tricks do you know to help you
make a diagnosis
 Get the child to jump/hop
 Ask them what their favourite food is-could you eat some of it now?
 Starve them!!
 Use your stethoscope to palpate the abdomen
 Use “props” toys to help examine