Pediatric Surgery Professor - PowerPoint Presentation

1. Pediatric SurgeryProfessorDr. Ali Farooq Abdullah

2. Inguinal Hernias and hydroceleObjectives: At the end of this lecture the student should be able to:- Remember the anatomy and embryology of genitalia and inguinal canal.- Recognize the presentation and complications of the diseases.Know how to differentiate between them and when to treat the condition.Perform clinical examination for the conditions and choice the correct investigation tool.

3. IntroductionInguinal hernia (IH) repair is one of the most common operations performed by pediatric surgeons, and consultations for an inguinal hernia are among the most frequent reasons for pediatric surgical referral. An inguinal hernia in a child usually refers to an indirect inguinal hernia but much less frequently may include a femoral hernia or a direct inguinal hernia

4. Introduction……cont.Described in the Ebers Papyrus in 1552 BC, and were found in Egyptian mummies.Celsus is thought to have performed hernia repairs in 50 AD. Galen (b. 129 AD) described the processus vaginalis, defined hernias as a rupture of the peritoneum, and advised surgical repair.

5. Incidence1-5% of children, 3-5% in term newborn.The overall incidence of inguinal hernia in premature infants is estimated to be 10–30%.10% there is a positive family history.There is an increased incidence in twins, more frequently in male twins.Male to female ratio 5:1Right-sided hernias were twice as common as those on the left.

6. AssociationsCystic fibrosis: 15% of patients develop IHHydrocephalus: Ventriculoperitoneal shunts (VPS) are associated with an increased incidence of an inguinal hernia as well as increased chance of bilaterality, incarceration, and recurrence.Peritoneal Dialysis:Cryptorchidism. Abdominal wall defectsConnective tissue disorders.Mucopolysaccharidoses.Ascites.Congenital hip dislocation.Meningomyelocele.

7. Etiology:The processes vaginalis is an elongated diverticulum of the peritoneum which accompanies the testicle upon its descent into the scrotum.It pierces the anterior abdominal wall at the deep (internal) inguinal ring which is located just lateral to the deep inferior epigastric blood vessels. In most individuals, the processes obliterates during the ninth month of intrauterine life or soon after birth.If that channel remains open “PPV”, intraperitoneal fluid will slowly accumulate in the structure forming a communicating hydrocele (also known as hernia/hydrocele).

8. Etiology:If the processes is wide enough, intestines, ovaries, or omentum can herniate into the inguinal canal forming an indirect hernia.Should the processes vaginalis obliterate near its origin but remain patent distally fluid may accumulate forming a noncommunicating hydrocele.If the processes obliterates proximally and distally but remains patent in its mid portion, then it is known as hydrocele of the cord “cystic hydrocele”.

9. Etiology:The female anlage of the processus vaginalis is the canal of Nuck, a structure that leads to the labia majora. This also closes by about 7 months of fetal life, and ovarian descent is arrested in the pelvis

10. CLINICAL PRESENTATIONBulge or swelling in the inguinal region during straining.May reach the scrotum.On and off.History and picture taken by parent aid in the diagnosis.D.Dx. : retractile testis, lymphadenopathy, hydrocele, and prepubertal fat.Examination could be normal.Good history taking with the help of cell phone pictures can confirm the diagnosis.

11. CLINICAL PRESENTATIONOlder children may present with inguinal pain without a bulge.Feeling a thicken cord “silk glove sign” has a variable reliability.Reducing the contents of an inguinal bulge confirms the diagnosis.Ultrasound can detect PPV, but this is operator dependent and that is why it is not widely used in children.Incidental findings of PPV doesn’t necessitate repair.

12. HydroceleCommunicating hydrocele needs the child remains supine for hours to be resolved.Transillumination.Managing an asymptomatic hydroceleSurgery is done earlier ?Hydrocele in adolescents: Varicocelectomy Testicular tumour

13. IncarcerationIncidence : 12-17%Risk factors: Prematurity Young ageSymptoms: fussy or inconsolable infant with intermittent abdominal pain and vomiting.Signs: tender and sometimes erythematous irreducible mass is noted in the groin. Abdominal distention is a late sign, as are bloody stools.

14. IncarcerationHydrocele of the cord “D.Dx.”Trial of reduction should be done and if successful surgery is done after 24-48 hours to allow edema resolution.Signs of peritonitis and septic shock is an absolute contraindication for reduction, while symptoms of bowel obstruction is a relative one.90-95% of incarcerated hernia can be reduced successfully, while urgent surgery is in only 8%.

15. ManagementThe surgery done under general anesthesia.Overnight hospitalization is required in premature neonate with risk of postoperative apnea.IH is more common in prematurity and the risk of incarceration is 3 times more than term infants.Repair is done either by open or laparoscopic technique.

16. ManagementIn open repair: Inguinal skin crease incision Delivery of the sac The vas and vessels are separated Division of the sac with high ligation

17. ManagementLaparoscopic Repair:Usually used for bilateral cases.If you are not sure regarding contralateral PPV.

18. Postoperative ComplicationsRecurrence: < 1% elective Injury to the Spermatic Cord or Testis: 1:1000Infection: 1-3%Hematoma: Hydrocele:Iatrogenic cryptorchidism: < 1%Bladder injuryMortality: < 1%

19. UNDESCENDED TESTESObjectives: At the end of this lecture the student should be able to:Remember the anatomy and embryology of testicular development.Know the types of undescended testes.Recognize the differences between undescended testes and retractile one.- Perform clinical examination and how to treat.

20. IntroductionNormal testicular descent relies on a complex interplay of numerous factors. Any deviation from the normal process can result in a cryptorchid or undescended testis (UDT).UDT is a common abnormality that carries fertility and malignancy implications.

21. EmbryologyTesticular development and descent depend on a coordinated interaction among endocrine, paracrine, growth, and mechanical factors.Two important hormones in testicular descent are insulin-like factor 3 (INSL3) and testosterone, both secreted by the testis.Two important anatomic players are the gubernaculum testis and the cranial suspensory ligament (CSL).

22. Classification- Retractile testis is a normally descended testis that retracts into the inguinal canal as a result of cremasteric contraction; it is not an UDT.- Ectopic UDT is one that has deviated from the path of normal descent and can be found in the inguinal region, perineum, femoral canal, penopubic area, or even contralateral hemiscrotum.PalpableNon palpable

23. Incidence3% term infants.33-45% premature and/or birth weight less than 2.5Kg.The majority of testes descend within the first 6 to 12 months.1% at 1 year.2/3 -3/4 of UDT are palpable.Specific syndromes with higher rates of UDT include:Prune-belly syndrome, gastroschisis, bladder exstrophy, Prader–Willi, Kallman, Noonan, testicular dysgenesis and androgen insensitivity syndromes.

24. DiagnosisCareful history and physical examination is thus paramount. The patient should be examined in a warm room.In both supine and frog-legged sitting position.The scrotum is observed for hypoplasia and examined for the presence of either testis.In unilateral cases the other testis may be hypertrophied.Palpation maneuver: Moving the fingers from the iliac crest towards the scrotum.Soap or gel can be used

25. DiagnosisGentle mid-abdominal pressure.A cross-legged sitting or squatting position.How to differentiate between low UDT and retractile one ?On examination, both retractile testes and low UDTs may be manipulated into the scrotum. Once in scrotal position, the retractile testis appears to remain in place, whereas the low UDT does not. The ipsilateral hemiscrotum is fully developed with a retractile testis, whereas it may be underdeveloped in a UDT.

26. Diagnosis- If neither testis is palpable anorchiaAndrogen insensitivity syndrome Chromosomal abnormalityRadiographic imaging is rarely helpful in locating a UDT and is not recommended routinely.Negative imaging is not diagnostic of testicular absence.

27. DiagnosisBilateral non palpable testesBaseline FSH,LH,testosterone Yes No AnorchiaInject HCGExplorationFSH elevated > 3SD above the meanElevation in testosterone level

28. FertilityUDT and, to a lesser degree, its contralateral descended mate have been demonstrated to be histologically abnormal.Clinically, patients with a history of UDT exhibit subnormal semen analyses.Despite these findings, the infertility rate of men with a history of unilateral UDT is equivalent to that of the normal population (10%).

29. FertilityHowever, men with bilateral UDT have paternity rates of 50–65% even if corrected early, and thus are six times more likely to be infertile relative to their normal counterparts.Mechanisms of infertility in UDT appear to be associated with effects on Sertoli and Leydig cells, as well as Wolffian duct abnormalities (vasal and epididymal), which may further inhibit transport of already insufficient sperm.

30. Risk of MalignancyUDT appears to be associated with a two- to eightfold increased risk of malignancy. The risk of malignancy arising from a UDT varies with location. 1% inguinal 5% abdominal Cancer in abdominal testes are mostly seminomas 74%.Cancer in testes underwent orchiopexy are nonseminomatous in origin 63%.

31. Management and TreatmentIndications and Timing:According to guidelines, surgery is performed at 12-18 months of age as the testicles are unlikely to descend after 12 months of delivery.Repair may be undertaken even earlier if a symptomatic hernia is present.Early placement of the testes in the scrotum may affect the risk of malignancy and infertility, reduces the risk of torsion, facilitates testicular examination, improves the endocrine function of the testis, and creates a normal-appearing scrotum.

32. Management and TreatmentHormonal Treatment:The value of hormonal therapy in the treatment of UDT is controversial.LHRH agonist. “Testis is at or distal to the external inguinal ring.”Low-dose hCG therapy. “regardless of the operative plan”

33. Management and TreatmentOrchiopexyUp to 18% of nonpalpable testes may become palpable on examination under anesthesia.Unilateral and bilateral palpable UDT are managed similarly.If orchiopexy is difficult and a normal contralateral testis is present in postpubertal boy, or if the UDT is abnormally soft and small, then an orchiectomy should be performed.Orchiectomy is the treatment of choice for the postpubertal, unilateral intra-abdominal UDT because of the increased cancer risk.

34. Management and TreatmentPalpable Undescended Testes “Unilateral or Bilateral”-The mainstay of therapy for the palpable UDT is orchiopexy with creation of a subdartos pouch. This is performed through a standard two-incision (inguinal and scrotal) approach.The success rate is as high as 95%.Open processus vaginalis or hernia should be repaired.

35. Management and TreatmentNonpalpable Undescended Testes: Unilateral or BilateralFor a unilateral UDT: diagnostic laparoscopy Vs inguinal explorationDiagnostic laparoscopy:If vessels appear atretic or ‘blind ending’ as they exit the abdomen no further exploration Inguinal exploration

36. For a unilateral UDT:If the testicular vessels are seen exiting the internal ring Open ring Close ringLaparoscopic inguinal exploration Open inguinal explorationIf the vessels end blindly in the inguinal canal Tip of the vessels can be sent for pathologic examination

37. For a unilateral UDT:If diagnostic laparoscopy reveals viable intraabdominal testis:gonadal vessels are long enough Short gonadal vesselsorchiopexy may be performed Prentiss maneuver Fowler-Stephensopen or laparoscopically method

38. Acute ScrotumObjectives: At the end of this lecture the student should be able to:Know the common causes of acute scrotum.Differentiate between the causes of acute scrotum.Manage child with acute scrotum.

39. Acute ScrotumIntroduction:The term acute scrotum is defined as acute scrotal pain with or without swelling and erythema.Early recognition and prompt management are imperative because of the possibility of testicular torsion as the etiology with permanent ischemic damage to the testis.Age at presentation is important because torsion of the appendix testis/epididymis is most common in prepubertal boys, whereas testicular torsion more commonly presents in neonates and adolescents.

40. Acute Scrotum

41. TESTICULAR TORSIONResults from twisting of the spermatic cord which compromises the testicular vasculature and results in infarction.Even if the testis is not removed, the consequent ischemic damage can affect testicular morphology and fertility.There appears to be a 4-8-hour window before significant damage occurs once torsion develops.

42. TESTICULAR TORSIONTypesIntravaginal torsion is more common in children and adolescents (compared to neonates) and occurs when the spermatic cord twists within the tunica vaginalis.Intravaginal torsion develops because of abnormal fixation of the testis and epididymis within the tunica vaginalis.

43. Intravaginal torsion- The testis will then lie horizontally and the pendulous testis is predisposed to twisting with leg movement or cremasteric contraction. - This anatomic variant is classically described as the ‘bell-clapper’ deformity.- Often, it is found in the contralateral scrotum as well.

44. TESTICULAR TORSIONExtravaginal torsion occurs perinatally when the spermatic cord twists proximal to the tunica vaginalis.During testicular descent into the scrotum, the tunica vaginalis is not firmly fixed to the scrotum, allowing the tunica and testis to spin on the vascular pedicle.

45. TESTICULAR TORSIONClinical presentation:typically occurs before age 3 years or after puberty. It is less common in prepubertal boys and after age 25 years. Patients present with the sudden onset of severe, unilateral pain in the testis, lower thigh, or lower abdomen.Associated with nausea and vomiting. Episodes of intermittent testicular pain may precede the acute presentation, suggesting prior incomplete torsion with spontaneous detorsion.

46. TESTICULAR TORSIONPhysical examination may reveal an enlarged testis that is retracted up toward the inguinal region with a transverse orientation and an anteriorly located epididymis. However, it is usually difficult to obtain a good exam because of the scrotal pain and tenderness. Depending on the duration of torsion, the hemiscrotum can show varying degrees of swelling and erythema, which may obliterate landmarks and make the examination more difficult. The cremasteric reflex is often absent with testicular torsion, but a positive reflex does not reliably exclude it.

47. TESTICULAR TORSIONDiagnosis:Clinical one.GUEDoppler ultrasound sens. 89.9% sps.98.8%Detorsion ?? “open book”

48. TESTICULAR TORSIONTreatment:Exploration is typically performed using a median raphe scrotal incision. The symptomatic hemiscrotum is entered and the testis delivered, detorsed, and placed in warm moist sponges while the contralateral hemiscrotum is explored. The unaffected testis should be fixed to the scrotal wall with nonabsorbable suture in at least three points.

49. TESTICULAR TORSIONAttention is then turned back to the affected testis.If the testis is clearly nonviable, it should be removed to avoid potential damage to the contralateral testis from the formation of antisperm antibodies.If the torsed testis becomes reperfused or is bleeding from the cut surface, it should be fixed in the same fashion as the contralateral testis.Bilateral fixation reduces the probability of torsion in the future, but cases of torsion after fixation have been described

50. CONDITIONS MIMICKING TESTICULAR TORSIONTorsion of Testicular Appendages:Torsion of the appendix testis or appendix epididymis is the most common cause of an acute scrotum and is frequently misdiagnosed as acute epididymitis or epididymo-orchitis.The testicular appendage represents a vestigial remnant of the Müllerian duct, and the epididymal appendage is of Wolffian duct origin.

51. Torsion of Testicular Appendages:Torsion of these appendages occurs most commonly between ages 7 and 10 years. It is hypothesized that a prepubertal hormonal boost stimulates these structures, producing an increase in size and making them susceptible to twisting.Sudden onset of pain and nausea. Results of the urinalysis are usually normal. The examiner may be able to elicit differential tenderness between the upper and lower poles of the affected testis.

52. Torsion of Testicular Appendages:The ‘blue dot’ sign, the inflamed and ischemic appendage may be seen through the scrotal skin as a subtle blue colored mass.Ultrasound early in the presentation demonstrates a discrete appendage. However, later, it may only show increased blood flow to the adjacent epididymis and testis or, possibly, a reactive hydrocele, resulting in the misdiagnosis of acute epididymitis or epididymo-orchitis.

53. Torsion of Testicular Appendages:Torsion of these appendages is self-limited and is best treated with nonsteroidal anti-inflammatory medications and comfort measures such as restricted activity and warm compresses. The pain resolves as the appendage infarcts and necrosis and may become a calcified free body within the tunica vaginalis.

54. Torsion of Testicular Appendages:Appendage torsion can occur at five anatomic sites: appendix testis, appendix epididymis, paradidymis/organ of Giraldes, and superior and inferior vas aberrans of Haller. Exploration is indicated when the diagnosis is unclear or when the symptoms are prolonged and fail to resolve spontaneously. The torsed appendage can be easily excised through a small scrotal incision with immediate symptom relief.

55. CONDITIONS MIMICKING TESTICULAR TORSIONEpididymitis:Rare in childrenAccounting for 10% to 15% of patients with an acute scrotum.The bacterial infection extends from the bladder and urethra to the epididymis in a retrograde direction via the ejaculatory ducts and can be associated with a clinical urinary tract infection or urethritis.Scrotal pain and swelling typically have a slow onset, worsening over days rather than hours.Examination reveals induration, swelling, and tenderness of the hemiscrotum.

56. EpididymitisA positive urinalysis and culture, or urethral swab in sexually active adolescents suggests the diagnosis.Neisseria gonorrhoeae and Chlamydia “ sexually active boys” Mycoplasma species “younger children”When studies suggest a bacterial infection, appropriate antibiotic therapy is initiated and adjusted according to the culture results.If acute epididymitis is found on scrotal exploration, cultures should be obtained, but the contralateral side should not be opened to avoid spreading the infection.

57. EpididymitisAs with any urinary tract infection in a boy, a renal bladder sonogram and voiding cystourethrogram should be obtained after the infection has resolved.VUR is the most common finding, but an ectopic ureter (to the vas, ejaculatory duct, or seminal vesicle), ejaculatory duct obstruction, or urethral valves can also be found. Viral infections are believed to be a common cause for acute epididymitis but are usually diagnosed presumptively. Mumps orchitis is rare and occurs in approximately one-third of infected postpubertal boys.Adenovirus, enterovirus, influenza, and parainfluenza virus infections have also been found.Management is supportive, antibiotics are not indicated, and the pain is generally self-limited

58. CONDITIONS MIMICKING TESTICULAR TORSIONIdiopathic Scrotal Edema:Unknown etiology.5 to 9 years.Insidious onset of swelling and erythema that typically begins in the perineum or inguinal region, and spreads to the hemiscrotum.Pruritus can occur, but the testis is not tender.US shows normal testicular blood flow.Contact dermatitis, insect bites, and minor trauma are often misdiagnosed as the etiology.Treatment is with antihistamines or topical corticosteroids.

59. CONDITIONS MIMICKING TESTICULAR TORSIONHenoch–Schönlein Purpura: (1/3, <7yr.)TESTICULAR TRAUMA: (rare in children, sexual abuse, hematoma)Incarcerated inguinal hernia.Hydrocele.Voiding dysfunction.Neoplasia.

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