Diagnosis and Management of Common Surgical Problems in Children DR. MOHAMMAD SAQUIB MALLICK, FRCS Consultant Pediatric Surgeon King Fahad Medical City Riyadh, Saudi Arabia

Diagnosis and Management of Common Surgical Problems in Children Common Problems: Inguinal hernias Hydrocele Umbilical hernia. Undescended testis Acute Scrotum Foreign body aspiration Abdominal pain Pyloric Stenosis. Malrotation (midgutvolvulus)

Diagnosis and Management of Common Surgical Problems in Children Inguino-scrotal Swelling: Inguinal hernia Hydrocele Undescended testes Acute scrotum

Diagnosis and Management of Common Surgical Problems in Children 3 years old boy presented with the complain of bilateral inguino-scrotal swelling which comes and goes. Inguinal hernia Hydrocele

Diagnosis and Management of Common Surgical Problems in Children Clinical History Intermittent groin swelling Asymptomatic until incarcerated In girls, lump in upper part of labia majora Examination Can reach above the swelling Cough impulse Reducibility

Diagnosis and Management of Common Surgical Problems in Children Herniotomy WHEN ? Age is not a contraindicated for operation

Diagnosis and Management of Common Surgical Problems in Children Inguinal hernia 1-5% 9:1 male/female 99% indirect More in premature (up to 35%) More in right side Congenital in origin

Diagnosis and Management of Common Surgical Problems in Children Hydrocele Clinical History Scrotal swelling May be scroto-inguinal Asymptomatic Examination Get above the swelling Not Reducible transilluminates

Diagnosis and Management of Common Surgical Problems in Children Conservative up to the age of 2 years. Surgery (Ligation of PPV) Hydrocele in older children Trauma Inflammation Tumors

Diagnosis and Management of Common Surgical Problems in Children A 6 month old boy presented to your clinic with irritability, crying, vomiting, and painful swelling in right inguinal area. On examination: 4 by 3 cm tender, nonreducible inguinal swelling, both testes are in scrotum.No other abnormalities detected.

Diagnosis and Management of Common Surgical Problems in Children Incarcerated (irreducible) inguinal hernia Management: Sedation and analgesia Reduction Admission and Herniotomy after24 to 48 hours

Diagnosis and Management of Common Surgical Problems in Children Umbilical Hernia: Failure of closure of the fascial ring through which the umbilical cord protrudes. Male = female Mostly symptom free. More common in Dawn syndrome. Congenital Hypothyrodism Mucopolysaccharidoses

Diagnosis and Management of Common Surgical Problems in Children Diagnosis: Clinical (reducible umbilical swelling) defect at umbilicus Management: Observation. most UH closes by the age 2 to 3 years. Umbilical strapping with a coin or pledget over the hernia has no role in management. Indications for Surgery: Hernia persist beyond the age of 5 years. Defect more than 2.5cm. Incarcerated Umbilical Hernia.

Diagnosis and Management of Common Surgical Problems in Children A child with empty scrotum

Diagnosis and Management of Common Surgical Problems in Children Undescended testes: Definitions: True Undescended Testes Ectopic Retractile Incidence: At birth 3-4% At one year 1% Pre-term 30%

Diagnosis and Management of Common Surgical Problems in Children Parents/Doctors Clinical features Empty scrotum Palpable Milk it down to scrotum Yes No

Diagnosis and Management of Common Surgical Problems in Children Impalpable Undescended Testis Intraabdominal Testis Agenesis Investigations: Ultrasound ?

Diagnosis and Management of Common Surgical Problems in Children Retractile Testis: Observation Palpable UDT: orchidopexy at the age of one year. Impalpable UDT: laparoscopy (Diagnostic &Therapeutic) Best age for Orchidopexy: 1 to 2 years

Diagnosis and Management of Common Surgical Problems in Children A Child with Red, painful and Swollen Scrotum

Diagnosis and Management of Common Surgical Problems in Children D/D Testicular Torsion Torsion of testicular appendages Epididymo-orchitis Idiopathic scrotal edema Other conditions e.g. incarcerated hernia, acute hydrocele, HSP, truma

Diagnosis and Management of Common Surgical Problems in Children Testicular Torsion: Incidence: 1:4000 Common in peripubertal and perinatal Symtoms: Initially, it may be lower abdominal pain and vomiting Later localized to one side of scrotum Swollen, red scrotum Signs: Tender Cremasteric reflux absent Lies higher than contalateral tesis Horizantal in position

Diagnosis and Management of Common Surgical Problems in Children Investigations: Colour Doppler US Radionuclide Scan Management: Timing is critical 4-6 hrs Exploration if any doubt Untwist anticlockwise “Putting the clock back” if it viable Fix the other side If more than 10 hrs, it is likely to be non-viable, needs orchidectomy.

Diagnosis and Management of Common Surgical Problems in Children ACUTE ABDOMEN IN CHILDREN Surgical Causes: Acute appendicitis Intussusception Meckel’s diverticulitis Twisted ovarian cyst

Diagnosis and Management of Common Surgical Problems in Children Primary peritonitis (rare) Malrotation of midgut (rare) Acute Cholecystitis (rare) Acute pancreatitis (rare

Diagnosis and Management of Common Surgical Problems in Children Medical Causes: Acute Non-specific abdominal pain (NSAP) 30-50% (Mesenteric Adenitis) Gastroenteritis Constipation Genito-urinary infection Pelvic inflammatory disease Pneumonia Measles Sickle cell crisis Henoch-Schönlein purpura

Diagnosis and Management of Common Surgical Problems in children 7 months old boy presented to your clinic with the history of intermittent crying since 12 hours. He had bilious vomings and has passed bloody mucoid stool twice. On examination,he is mildly dehydrated with palpable mass in right site of abdomen. Intussusception Ref. to paediatric emergency

Diagnosis and Management of Common Surgical Problems in Children Intussusception Incidence: 1.5-4/1000 live births Sex: male predominance Peak Age: 6-9 months Pathogenesis: * invagination of intestine * mesentery with it * venous obs - arterial obs

Diagnosis and Management of Common Surgical Problems in Children Site: commonly - ileo-colic less commonly - ileo-ileal colo-colic Aetiology: unknown?? 95% Adenovirus or Rotavirus (Marked lymphoid tissue in ileum may act as leading point) It may be associated with upper respiratory tract infection or gastroenteritis

Diagnosis and Management of Common Surgical Problems in Children leading points: e.g. Meckel’s diverticulum Polyps Intestinal duplication Lymphomas Henoch’s purpura Haemangiomas

Diagnosis and Management of Common Surgical Problems in Children History Pain - colic every 10-15 minutes healthy, screaming suddenly pulls the legs up Stool - red mucoid, bleeding PR Vomiting - bilious History of viral gastroenteritis or URTI

Diagnosis and Management of Common Surgical Problems in Children Examination; Vital sign - stable initially dehydration, tachycardia, temperature, Abdomen - sausage shaped mass bowel sounds increased PR - blood stained stool

Diagnosis and Management of Common Surgical Problems in Children Investigations AXR supine and erect USG target lesion pseudo kidney sign Contrast enema coiled spring sign

Diagnosis and Management of Common Surgical Problems in Children Nasogastric tube Intravenous fluid therapy Antibiotics - confirmed diagnosis - >24 hour history Blood Work-up - CBC -electrolytes - cross-matching

Diagnosis and Management of Common Surgical Problems in Children Child - stable and no peritonitis treatment - hydrostatic reduction with barium/air enema Child - shock or peritonitis or perforation treatment - laparotomy

Diagnosis and Management of Common Surgical Problems in Children 4 month old child with the history sudden onset of bilious vomiting. Perfectly well before the start of vomiting. On examination: Stable vital signs, ? Upper Abdomen mildly tender but not distended. DIAGNOSIS

Diagnosis and Management of Common Surgical Problems in Children MALROTATION (MID GUT VALVULUS ) Immediate referral to paed. emergency

Diagnosis and Management of Common Surgical Problems in Children 7 weeks old child presented with non-bilious vomiting since 2 days. no other symptoms . On examination; dehydrated, tachycardic Abdomen: soft, lax, ? Small olive shaped mass palpable in RHG. Diagnosis: PYLORIC STENOSIS

How will you confirm your diagnosis? Ultrasound U&E & ABGS Hypokalemic ,hypochloremic metabolic alkalosis. Management: Correction of dehydration first than Pyloromyotomy

Diagnosis and Management of Common Surgical Problems in Children ***Cautions*** Bilious vomiting Intestinal Obstruction proven otherwise

Diagnosis and Management of Common Surgical Problems in Children Gastrointestinal bleeding in children Causes: Newborn 1 month to 1 year 1-2 year More than 2 year Upper GI tract Swallowed maternal blood, Hemorrhagic disease Esophagitis, Gastritis Peptic ulcer disease, Varices Lower GI tract Anal fissure NEC Intussusceptions Polyps, Meckel’s Diverticulum Polyps Inflammatory bowel disease

Diagnosis and Management of Common Surgical Problems in Children 5 year old child came to your clinic with the history of choking crisis while eating a fusfus yesterday for your advise. What will you do? Ref. to paediatric surgery or ENT for Bronchoscopy to exclude foreign body aspiration

Diagnosis and Management of Common Surgical Problems in Children Diagnosis of Foreign Body Aspiration; History of choking crisis. Clinical triads: cough, wheezing, decreased breath sound. X-ray : may be normal or will show air trapping or foreign body