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

2. 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)

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

4. 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

5. 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

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

7. 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

8. 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

9. 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

10. 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.

11. 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

12. 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

13. 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.

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

15. 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%

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

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

18. 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: to 2 years

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

20. 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

21. 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

22. 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.

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

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

25. 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

26. 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

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

28. 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

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

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

31. 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

32. 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

33. 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

34. 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

35. 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

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

37. 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

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

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

40. 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

41. 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

42. 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