Post on 29-Apr-2018
WHEN TO OPERATE?
Dr Prashant Jain Consultant Pediatric Surgery & Pediatric Urology
Dr BL Kapur Memorial Hospital, New Delhi
Why timely reference?
• Improves outcome of surgical correction
• Prevents complications and morbidity
• Allays Parents anxiety
Timing of Surgery
• Natural course of the disease
• Pathophysiology of the disease
• Risk of complications in case of delayed surgery
• Size of the patient
• Anesthesia safety
• Psychological response to surgery
Case 1: Scrotal Swelling
4 mth old male child
Lt scrotal swelling
Swelling constant in size
in evening
No inguinal bulge/no impulse on crying
Cystic & not reducible
What is the diagnosis?
What should be done?
2 months old male child
Painless Inguinoscrotal swelling
Inguino-scrotal bulge
Impulse on crying present
Reducible
What is the diagnosis?
What should be done?
Case 2: Scrotal Swelling
Hydrocele Hernia
Requires No Investigations
Case 1 Case 2
Same anatomic defect
If opening only small enough to admit peritoneal fluid - Communicating
hydrocele
Opening closed at upper pole of testis – Non Communicationg hydrocele
If opening large enough to admit bowel- Clinical hernia
Hernia/Hydrocele
Persistence of Processus Vaginalis leads to communicating hydroceles & hernias
Hernia/Hydrocele – Surgical timing
90% of the complications can be avoided if Hernia repair
is done within one month of diagnosis
Hernia
Surgery as early as
possible
Hydrocele
Observation till 2 yrs
Surgery
• 32 wks, 1.8 Kg premature male
newborn
• Left inguinal hernia
When to operate?
• HIGH RISK OF POST OPERATIVE APNEA
• Surgery once the child is more than 49 wks of gestational age or
weighing more than 2.2 kg
• Patient needs to be monitored in hospital for 24 hrs for risk of
postoperative apnea
3 mth old
Kindly advice EARLY HERNIOTOMY
Hernia/Hydrocele - Surgery
Open/ Laparoscopy
take him to nearby
emergency....
Case 3
2 year male, Painful scrotal
swelling
Short history associated
with vomiting
Enlarged tender swelling
What next?
What should be done?
Acute scrotum
Differential
Diagnosis
Epididymitis/
Orchitis
Incarcerated
Hernia
Torsion of
Testis
NO DIFFERENCE in
PRESENTING SYMPTOMS
Diagnostic Dilemma
0 History: Similar
0 Examination: Similar
0 Investigations: Inconclusive
Prompt diagnosis is mandatory
Testicular Torsion
Transverse lie of testis
In case of lt testicular torsion, high lie of left testis
Absence of cremastric reflux (most sensitive)
Pain not relieved on giving scrotal support (prehn’s sign)
Slightest of doubt warrants scrotal exploration
True Emergency
Golden Period 6-8 hrs
Colour Doppler 89% sensitive
In doubt- Emergent Scrotal exploration
Diagnosis is CRITICAL!!
DON’T MISS THE DIAGNOSIS
Exploration and contralateral fixation
Case 4
• Newborn male child on
examination is found to
have a normally descended
left testis but undescended
right testis(Non-Palpable).
Should an ultrasound be performed?
There is no need for radiological
evaluation for a palpable or nonpalpable
testis
Laparoscopic Orchidopexy
Surgery between 6 mths to 1 year of age
Case 5
A 12 month old boy on
routine examination is
found to have a normally
descended left testis and
undescended (palpable)
right testis.
When To Operate?
Inguinal Exploration and Orchidopexy
Palpable Non-Palpable
Age: 6mths to 12 mths
Testis MISSING-what management?
Retractile Testis
Result of hyperactive cremastric reflux
Can be brought down to the base of scrotum
without tension
Reassurance and observation
Follow up till puberty
Document the status of testes in newborn period
• 2 mth old child with umbilical
hernia
• Observation till 3-5 years of age
• Ring size > 1.5 cms
• Rare possibility of incarceration
Case 6: Umbilical hernia
Case 7
Hypospadias noted at birth
Both testes normally descended
What type of work up?
What is initial management?
When do you refer to pediatric surgeon?
Hypospadias - Management
No investigations for distal hypospadias
Proximal hypospadias- USG KUB
DO NOT CIRCUMCISE!
Refer to pediatric surgeon at 1 year of age
Always consider intersex if hypospadias associated
with undescended testis
Distal hypospadias
Proximal hypospadias
After 6 months
STAGE 1
STAGE 2
AFTER 6 MTHS
Hypospadias – Surgical timing
Surgical correction between 12-18 months of age
80-90% can be managed with single stage repair
All stages to be completed before school going age
Case 8
A 4 year-old boy presents with
phimotic foreskin.
No c/o of ballooning/
straining/infections
What can be done?
Over 90% of foreskin become retractable by the age
of 4-5 yrs
No forceful retraction of the prepuce
If symptomatic the topical steroids
(betamethasone/mometasone)
Most important: Parent education about the natural
process
Physiological Phimosis
Newborns and infants have
adhesions which are present until
preadolescence
No need to pull foreskin!
Physiologic Phimosis
Pliant, unscarred preputial
orifice
Pathologic Phimosis
Failure to retract secondary to
distal scarring of the prepuce
Indications for circumcision
Recurrent UTI
Recurrent balanoposthitis
Phimosis with scarred skin
Case 10:Tongue Tie(Ankyloglossia)
• Harmless
• Does not interfere with speech & feeding
• Surgery only for cosmetic reasons
• Between 1 to 2 years of age
• 5 year old male with
discharging neck sinus
since birth
• Recurrent infection
Case 11: Neck sinus
Neck sinus/cysts
• Surgical excision
• Timing: 6 months of age
• Delayed excision: more scarring and
incomplete excision
• Risk of malignancy
• 7 mth old, female child with a
pigmented lesion near lt eye
noticed at the age of 2 wks
• Increased in size
• No other complaints
Capillary(Strawberry) Hemangioma
Case 12:Hemangioma
Hemangioma
• Observation
• Most of these are harmless
• 50% of infantile hemangiomas show complete
involution by the of age 5 years & 70% by the age
7 years
• Parents counseled about the natural history of the
lesion
Hemangioma
• Treatment(surgery/pharmacological) should be
considered if the hemangioma….
• ulcerates
• bleeds
• causes functional
impairment
• causes infection
• grows rapidly and
uncontrollably
Beta- blockers
4 mths 14 mths
Optimal Timing of Surgery
Surgical Condition Optimum Timing of Surgery
Inguinal Hernia At Diagnosis
Hydrocele After 1&1/2 years, earlier if associated hernia
Undescended Testis Between 6 – 12 months of age
Umbilical Hernia Not before 5 years of age unless obstructed / strangulated
Hypospadias Complete all stages before school
Neck Sinus At Diagnosis
Cleft Palate 12 – 18 months of age
Cleft Lip Within 6 – 12 weeks of age
Thank you