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?

http://de.wrs.yahoo.com/_ylt=Aiajr1vSOo2SiY8IEN2jvbs.CQx./SIG=11m7d3071/**http%3A//www.flickr.com/photos/davemedia/378365202/

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