Surgical Problems in Children

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Surgical Problems in Children

• BY
• Ragheb Assaf ,MD

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Problems

• GASTROINTESTINAL
• Pyloric stenosis
• Malrotation
• Midgut volvulus
• Duodenal atresia
• Meconium ileus
• Intussusception
• Meckels diverticulum
• appendicitis
• Hirschsprungs disease

• GENITOURINARY
• Inguinal hernia
• Umbilical hernia
• Hypospadias
• Phimosis/paraphimosis
• Cryptorchidism
• Hydrocele
• Testicular torsion

• OBJECTIVES
• Recognize
• Diagnose
• Consult surgery

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Pyloric stenosis

• Hypertrophy of the gastric outlet
• 1150 males, 1750 females
• 2-12 weeks of age
• Repetitive vomiting
• Projectile
• Non-bilious
• Dehydration
• Hypochloremic alkalosis
• Exam
• Visible peristaltic wave
• Palpable olive to right of umbilicus

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Pyloric stenosis Diagnosis
UGI
Ultrasound
Delayed passage of barium through thickened
pyloric channel
Thickened, elongated pyloric channel
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Pyloric stenosis treatment
Surgical tx pyloromyotomy
Hypertrophy of pylorus
Endoscopic balloon dilation
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Surgical treatment
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Malrotation
Duodenum to right of spine

• Failure of midgut to rotate into normal anatomic
  position during development
• Colon and cecum in left
• Duodenum on right side
• Bilious vomiting
• Peritoneal (Ladd) bands cause partial bowel
  obstruction
• High risk for...

Cecum in left abdomen
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Midgut volvulus

• Twisting of bowel around its mesentery and
  vascular supply
• Leads to ischemia, infarction, perforation,
  necrosis
• Presentation lethargy, abdominal distention,
  bloody stools

!
SURGICAL EMERGENCY
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MALROTATION

• Must consider in every infant with bilious
  emesis
• 30 present within first week of life
  
• 50 within first month
• Midgut volvulus with necrosis disastrous
• Can lead to SBS, death

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CLINICAL PRESENTATION of MALROTATION

• Sudden onset of bilious emesis in 95
• Abdominal distention common
• Blood stool
• Bloody vomitus or diarrhea in 30

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RADIOLOGIC DX of MALROTATION

• KUBGasless abdomen, SBO,
  double bubble
• Contrast study spiral or corkscrew appearance
• UTS reversed position of SMA/SMV
• Study MUST be expeditious

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PREOPERATIVE PREPARATION MALROTATION WITH
VOLVULUS

• Labs / unnecessary
• Mortality remains as high as 28
• Preoperative preparation ?? NONE !!
  ...GO
  TO OR. QUICKLY

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OPERATIVE CORRECTION of MALROTATION

• Ladd procedure
• Position of corrected malrotation
• Small bowel descends on Right
• Large bowel on Left
• Appendix potentially in LUQ ? Removed
• Role of second look operation

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Duodenal atresia

• Obliteration of lumen
• Failure to recanalize
• Neonatal bilious vomiting
• Associations
• Prematurity
• Congenital heart defects
• Trisomy 21

Double bubble sign
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Complete small bowel obstruction
SURGICAL EMERGENCY
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Meconium ileus

• CYSTIC FIBROSIS
• First manifestation in 15 of CF cases
• Thick meconium impacts in ileum
• Abdominal distention
• Bilious vomiting
• Risk for
• Volvulus
• Perforation

Microcolon with meconium plugs
!
SURGICAL EMERGENCY
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Intussusception

• Most common cause of intestinal obstruction
  between 3 mo - 6 yrs
• 2/3 cases occur lt2 yrs
• Male/Female41
• 75-95 Ileocolic
• gt90 idiopathic Meckels, Peyers patches,
  tumors, polyps

• Telescoping of proximal bowel into distal
  (Terminal Ileum into Cecum depicted in diagram)

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Intussusception

• Telescoping of one segment of bowel into another
• Ileocolonic most common
• 6 mos 3 years old
• Progressive course
• Intermittent acute abd. pain
• Vomiting
• Bloody stools (currant jelly)
• Fever, lethargy
• Palpable sausage-shaped mass in upper abdomen

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Intussusception Presentation

• Abdominal pain, vomiting and rectal bleeding
  triad seen in lt 1/3 of cases.
• 85 display only colicky abdominal pain often
  1-5minutes of crying and pain separated by 3-30
  minutes of nl behavior
• 75 have vomiting (develops after 6-12 hrs)
• 40 rectal bleeding
• Up to 10 Lethargy only

U/S demonstrating target or donut sign
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Intussusception Diagnosis

• Phys Exam 25-89 may have variably tender
  sausage shaped mass Dances sign empty RLQ
• U/S target, pseudokidney, radiologist dependent
  if high suspicion, order the barium enema

• Plain films target sign,
• crescent, and obstruction,
• 30 may be normal

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Intussusception Management

• Enema diagnostic therapeutic, coiled spring
• Surgery must be consulted prior to study.
• Barium vs. Air- 80 correction if within first
  12-24 hrs.
• Air Enema- safer if perforation
• 5-10 recurrence rate in first 24-48h after
  barium enema reduction
• If free air on films or signs of peritonitis, do
  not administer barium, prepare child for surgery

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Intussusception Management

• Ultrasound Hydrostatic pressure reduces the
  intussusception
• Surgeon must be involved directly
• If enema reduction fails
• Small bowel intussusceptions require surgical
  reduction

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Intussusception
Terminal ileum telescoped into cecum
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Meckels diverticulum

• Remnant of omphalomesenteric duct
• Painless rectal bleeding
• Less commonly intuss., volvulus, perforation
• Diagnosis
• CT scan
• Nuclear medicine scan
• Endoscopy
• Treatment
• Surgical resection

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Appendicitis

• 80,000 cases in children/year /in USA
• Rare in children lt 2years
• 20-40 misdiagnosed on initial exam
• 50-70 perforation rate in pre-school
• Mortality Rates of 5 in perforated vs 0.1 in
  non-perforated appendicitis

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Appendicitis

• Pathophysiology obstruction of appendix by
  fecalith or lymphoid tissue causes congestion,
  distention, ischemia, infection perforation.

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History

• Migration of pain from initial periumbilical to
  RLQ was 64 sensitive and 82 specific
• Anorexia is the most common of associated
  symptoms
• Vomiting is more variable, occuring in about ½ of
  patients

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Physical Exam

• Findings depend on duration of illness prior to
  exam.
• Early on patients may not have localized
  tenderness
• With progression there is tenderness to deep
  palpation over McBurneys point

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Physical Exam

• McBurneys Point just below the middle of a line
  connecting the umbilicus and the ASIS
• Rovsings pain in RLQ with palpation to LLQ
• Rectal exam pain can be most pronounced if the
  patient has pelvic appendix

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Physical Exam

• Fever another late finding.
• At the onset of pain fever is usually not found.
  
• Temperatures gt39 C are uncommon in first 24 h,
  but not uncommon after rupture

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Diagnosis

• CBC the WBC is of limited value.
• Sensitivity of an elevated WBC is 70-90, but
  specificity is very low.
• CRP and ESR have been studied with mixed results

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Diagnosis

• Imaging studies include X-rays, US, CT
• Xrays of abd are abnormal in 24-95
• Abnormal findings include fecalith, appendiceal
  gas, localized paralytic ileus, blurred right
  psoas, and free air
• Abdominal xrays have limited use b/c the findings
  are seen in multiple other processes

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Diagnosis

• Limitations of US retrocecal appendix may not be
  visualized, perforations may be missed due to
  return to normal diameter

• U/S vs. CT Sensitivity and Specificity are
  90/97 and 94/94, respectively

U/S demonstrating thickened non-compressible,
fluid filled appendix
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Diagnosis

• CT appears to change management decisions and
  decreases unnecessary appendectomies in girl, but
  it is not as useful for changing management in
  boy.

CT showing fluid filled appendix (diameter gt6mm)
with fat stranding
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Treatment

• Appendectomy is the standard of care
• Patients should be NPO, given IVF, and
  preoperative antibiotics
• Antibiotics are most effective when given
  preoperatively and they decrease post-op
  infections and abscess formation

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Hirschsprungs disease

• Congenital absence of ganglion
• cells in distal rectum
• - and varying distance proximally
• Lack of peristalsis causes colonic
• obstruction
• Abdominal distention
• Failure to pass meconium
• Fever and diarrhea suggest toxic megacolon

!
SURGICAL EMERGENCY
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Hirschsprungs
AXR obstructive pattern
Suction rectal bx
Absence of ganglion cells in myenteric plexus
Barium enema Dilated proximal colon with
transition zone
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Hirschsprungs

• Surgical treatment
• Colostomy
• Pull-through and removal of
• aganglionic segment

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Transanal pull-through
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Inguinal hernia

• Most common surgical problem
• More common in male and premature infants
• Intestinal segment entering into scrotum through
  processus vaginalis
• Does not resolve spontaneously
• Painless scrotal bulge
• Increases in size with crying/straining
• Management
• Reducible refer to surgery for repair
• Incarcerated immediate surgical consult

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Umbilical hernia

• Incomplete closure of umbilical ring fascia
• More common in premature and African-American
  infants
• Usually close by 2-4 yrs
• Refer to surgery if
• Larger than 1.5 cm at 2 yrs
• Present after 4 yrs
• Supraumbilical hernia Refer to surgery

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Hypospadias

• Abnormal low position of urethral meatus
• Absence of ventral foreskin
• Associations
• Undescended testes
• Urinary tract anomalies
• Management
• Avoid circumcision
• Refer to surgeon

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Phimosis vs. Paraphimosis
Phimosis inability to retract foreskin Tx
dorsal slit or circumcision
Paraphimosis foreskin retracted behind coronal
groove tourniquet to glans Tx circumcision
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Scrotal swelling

• PAINLESS
• Hydrocele
• Varicocele
• Spermatocele
• Inguinal hernia

• PAINFUL
• Testicular torsion
• Epididymitis
• Orchitis
• Incarcerated hernia

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Hydrocele

• Mobile
• Transilluminates
• Spontaneous resolution

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Cryptorchidism

• Undescended testicle(s)
• Spontaneous descent does not occur beyond age 1
  yr
• Bilateral in 1/3 of cases
• Associations
• Inguinal hernia
• Hypospadias
• Higher incidence of
• Testicular torsion
• Infertility
• Cancer in cryptorchid testis

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Cryptorchidism

• Endocrine eval.
• Refer early 6-12 mos of age
• hCG stimulation test
• Can aid in descent
• Karyotype if hypospadias co-exists
• Surgery
• Orchidopexy
• Usually in1- 2nd yr of life

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Testicular torsion
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SURGICAL EMERGENCY

• Twisting of testis around spermatic cord
• Caused by abnormal fixation of testis to scrotum
• Vascular supply compromised
• Acute painful scrotal swelling
• Severe tenderness
• Redness or dusky color
• Testis elevated
• Cremasteric reflex absent

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Neonatal torsion

• About 10 (prenatal 70 and postnatal 30)
• It presents as a firm asymptomatic testicular
  mass with in a high or inguinal position and
  bruising of the scrotal skin.
• No viability at exploration in 80-100 of cases.

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Torsion
6 hour window for surgical detorsion
R. testis blood flow (Doppler)
L. testis lack of blood flow
The consequence of delayed diagnosis
Ultrasound
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management

• In the patient with acute surgical scrotal pain
  ,immediate surgical consultation is essential .
• Surgical exploration , detorsion and fixation.

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Outcome

• Ischemic testicular damage related to the number
  of turns of the spermatic cord and the duration
  of torsion.
• All cases with a torsion gt 360 and gt 24h
• duration will have testicular loss or severe
  atrophy if the testis left in situ .

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What to do?

• Always undress the child for exam
• Dont forget Intussusception in lethargic
  children
• Utilize imaging liberally when child looks sick
  and know your radiologists expertise

• Any type of blood in stool may be due to
  Intussusception (not only currant jelly)
• Vomiting in infants should not be taken seriously
• Be conservative with children w/ unclear dx

• Be sure that the parent(s) understand return
  precautions. If they do not, then observe child

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What not to do

• Dont tell a patient that they DO NOT have
  appendicitis
• Dont let a normal X-ray or U/S fool you
• Dont forget to ask parents/child with vomiting
  about abdominal pain

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Questions or Comments
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Thank you