Surgical Conditions in

Children

Anish Dhami
Testis
• The testes develop in the retroperitoneum below the kidneys at around the 10th thoracic level.
• Evagination of the peritoneum itself, the processus vaginalis, develops adjacent to the gubernaculum and
over the subsequent weeks evaginates through the abdominal wall to create the inguinal canal.
• Testes lie at the internal inguinal ring at 3 months’ gestation and descend to the scrotum between 7 and 9
months.
• The epididymis lies on the posterior aspect of the testis
Undescended testes are palpable or
impalpable

• Incomplete descent of the testis occurs when the testis is arrested in some part of its normal path to the
scrotum.
• At birth, 4% of full-term boys have unilateral or bilateral undescended testes, but after 3 months of age the
incidence is <1%.
• The incidence is higher in preterm infants, attributed to the testis descending through the canal in the third
trimester.
• A normal testis reaches the base of the scrotum with a good length of cord above it.
• During childhood the testes are mobile and the cremasteric reflex is active so that in some boys, any
stimulation of the skin of the scrotum or thigh causes the testis to ascend and to temporarily disappear into the
inguinal canal.
• When the cremaster relaxes, the testis reappears.
Consequences
• Infertility
• Testicular torsion
• Malignancy
• Hernia
Ectopic testis
• An ectopic testis has taken a non-standard path through the body and has ended up in an unusual location.
• The commonest site being the superficial inguinal pouch, which lies just inferior and medial to the superficial
inguinal ring.
• Other rarer ectopic sites include the femoral triangle, the root of the penis and perineum( area between anus
and genitals).
Ectopic testis
• In comparison to a true undescended testis, the scrotum of a boy with such a retractile testis is normal as
opposed to underdeveloped, while a retractile testis can be gently milked from its position in the inguinal
region to the bottom of the scrotum.
• With time, retractile testes reside permanently in the scrotum.
• A palpable undescended testis ideally requires a day-case orchidopexy between 6 and 12 months of age.
• The testis and spermatic cord are mobilized and the testis is repositioned in the scrotum.
• The testis is mobilized through an inguinal incision, preserving the vas deferens and testicular vessels.
• Impalpable undescended testes are either absent or located in the abdomen or inguinal canal.
Testicular torsion

• Testicular torsion is a condition whereby the testicle twists in such a way that its blood supply becomes
compromised.
• Torsion of the testis is uncommon because the normal testis is anchored and cannot rotate.
• Most common in adolescents, but may occur at any age and is usually inside the tunica vaginalis.
• Typically there is sudden agonizing pain in the groin and the lower abdomen and the patient feels nauseated
and may vomit.
• The pain is not always scrotal and may be felt in the groin or lower abdomen.
• The scrotum is swollen and tender, while the skin is usually not erythematous initially.
• Sometimes there is a history of previous transient episodes.
• Torsion of the testis must be relieved within 6–8 hours of the onset of symptoms for there to be a
good chance of testicular salvage.
• If salvageable, three-point fixation of both testes with non-absorbable sutures is performed.
• Expert assessment of testicular blood flow by color Doppler ultrasound may help in the
differential diagnosis but the scrotum must be explored urgently if torsion cannot be excluded.
Phimosis
• At birth, the foreskin is normally adherent to the glans penis.
• These physiological adhesions between the foreskin and the glans penis begin to disappear around the age of
2 years and may persist until 6 years of age or later, giving the false impression that the prepuce will not
retract.
• True phimosis in children is where there is scarring of the prepuce such that it will not retract without
fissuring of the foreskin.
• This may result in ballooning of the foreskin during micturition and may also result in infection
(balanoposthitis).
• Scarring in adults occurs as a result of balanitis (inflammation of the glans penis), posthitis (inflammation of
the foreskin), or lichen sclerosus et atrophicus. (syn: balanitis xerotica obliterans).
• BXO is an uncommon condition in which the normally pliant foreskin becomes thickened, typically white in
appearance and forms a constricting band that prevents retraction.
• As a consequence it is difficult to keep the penis clean, there may be recurrent attacks of balanitis and there is
both a problem with hygiene and, in later life, an increased susceptibility to carcinoma.
Management
• In a young child with a non-retractile foreskin, no treatment is necessary or appropriate.
• When the foreskin is mildly scarred, then preputioplasty (surgical procedure performed to widen a tight
foreskin) is possible.
• For all other cases, circumcision is the appropriate treatment.
• In resistant cases, formal meatotomy(surgical opening of the urethral meatus) is necessary.
• In emergency situations, such as when catheterization is required, but is impossible, then it is possible to
divide the foreskin dorsally under local anesthetic (a so called dorsal slit).
• Dorsal slit: operation which involves making an incision at the top of the foreskin to relieve tightness
preventing retraction.
Preputioplasty
Paraphimosis
• A tight foreskin once retracted may be difficult to return and a paraphimosis results.
• In this condition, the venous and lymphatic return from the glans and distal foreskin is obstructed and these
structures swell, causing even more pressure within the obstructing ring of prepuce.
• Icebags, gentle manual compression and injection of a solution of hyaluronidase in normal saline may help to
reduce the swelling.
• Such patients can be treated by circumcision if careful manipulation fails.
• A dorsal slit of the prepuce under local anesthetic may be enough in an emergency.
• Hyaluronidase: facilitates reduction of paraphimosis. It acts by dispersing extracellular edema, permitting
easy reduction of the foreskin.
Meatotomy
Hydrocele
• A hydrocoele is an abnormal collection of serous fluid in a part of the processus vaginalis, usually the tunica
vaginalis.
• Acquired hydrocoeles are primary or idiopathic, or secondary to epididymal or testicular disease.
• A secondary hydrocoele is most frequently associated with acute or chronic epididymo-orchitis.
• It is also seen with torsion of the testis and with some testicular tumors.
• A secondary hydrocoele subsides when the primary lesion resolves.
Etiology

• A hydrocoele can be produced in four different ways

1. By connection with the peritoneal cavity via a patent processus vaginalis (congenital).
2. By excessive production of fluid within the sac, e.g. a secondary hydrocoele.
3. By defective absorption of fluid; this appears to be the explanation for most primary hydrocoeles, although
the reason why the fluid is not absorbed is obscure.
4. By interference with the lymphatic drainage of scrotal structures.
Clinical features
• Examination should be done in both the upright and supine position.
• The examiner should ask themselves a series of questions.
• First, is it possible to get above the swelling to palpate a normal cord?
• Second, is the swelling primarily testicular or epididymal or is it enclosing both of those structures?
• Thirdly, does the swelling transilluminate?
• In almost all cases of scrotal swelling an ultrasound is a useful adjunct.
• A hydrocoele is a swelling that encloses the testis and epididymis such that they may be impalpable, and it is
possible to get ‘above’ it to palpate a normal spermatic cord.
• Congenital hydrocoeles are treated by herniotomy they do not resolve spontaneously,
• Small acquired hydrocoeles do not need treatment.
• If they are sizeable and bothersome for the patient, then surgical treatment is indicated.
• Aspiration of the hydrocoele fluid is simple, but the fluid always reaccumulates within a week or so.
• It may be suitable for men who are unfit for scrotal surgery, although hydrocoele surgery can be undertaken
under local anesthetic.
Epididymis-orchitis
• Inflammation confined to the epididymis is epididymitis; infection spreading to the testis is epididymis-
orchitis.
• Infection reaches the epididymis via the vas from a primary infection of the urethra, prostate or seminal
vesicles.
• A general rule is that epididymitis arises in sexually active young men from a sexually transmitted genital
infection, while in older men it more usually arises from a urinary infection or may be secondary to an
indwelling urethral catheter.
Clinical features
• While there may be initial symptoms of a urinary or a genital infection, such symptoms are not always seen.
• The development of an ache in the groin and a fever can herald the onset of epididymitis.
• The epididymis and testis swell and become painful.
• The scrotal wall, at first red, edematous and shiny, may become adherent to the epididymis.
• Investigation should include a urethral swab, a urine specimen for culture, nucleic acid amplification testing
(NAAT) of either a urine specimen or a urethral swab and scrotal ultrasound.
• Urinalysis will usually show leukocytes and may show a formal urinary tract infection.
• NAAT is a sensitive way of identifying both gonococcal and chlamydial urethritis.
• Ultrasound is useful in the initial assessment of epididymitis and will identify abscess formation.
Management
• Either doxycycline (100–200 mg daily) or a quinolone should be the initial treatment in young men.
• There should be contact tracing of the partner and treatment if necessary.
• Antibiotic treatment should continue for at least 2 weeks.
• In older men, quinolones are the usual initial treatment, but if there is evidence of systemic sepsis, then
intravenous antibiotics directed at urinary pathogens may be valuable.
• If an organism is isolated from the urine, this simplifies the choice of antibiotic.
• All patients should drink plenty of fluid.
• Local measures including scrotal support and analgesia are helpful.
• If suppuration occurs, drainage is necessary.
Intussusceptions
• Intussusception is a serious condition in which part of the intestine slides into an adjacent part of the intestine.
This telescoping action often blocks food or fluid from passing through.
• Most intussusceptions in children occur from 2 months to 2 years of age.
• They are life-threatening as they can block the blood supply to the affected part of intestine.
• Intussusception typically causes a strangulating bowel obstruction, which can progress to gangrene and
perforation.
• Intussusception is classified according to the site of the intussusceptum and intussuscipiens.
• In children, more than 80% are ileocolic.
• In the majority, the cause is hyperplasia of Peyer’s patches(lymphoid tissue), which may be secondary to a
viral infection.
• Classically, a previously healthy infant presents with colicky pain and vomiting (milk then bile).
• Between episodes, the child initially appears well.
• Later, they may pass a ‘redcurrant jelly’ stool (Stool mixed with blood and mucus)
• Clinical signs include dehydration, abdominal distension and a palpable sausage-shaped mass in the right
upper quadrant.
• Rectal examination may reveal blood.
Etiology
• Bacterial enteritis: E. coli, Salmonella, Shigella
• Viral infections, eg: Rota virus, adenovirus
• Other bowel conditions
• Previous Bowel surgery
Clinical Feature
• Sudden onset of intermittent, severe, crampy, progressive abdominal
pain accompanied by drawing up of legs.
• These pain episodes occur at 15-20 min interval then gradually
become more frequent and more severe.
• Nausea and vomiting are prominent features.
• Sausage shaped mass may be felt on the right side.
• May be gross or spot rectal bleeding with mucus.
Examination
• No abdominal tenderness or tenderness esp on right side.
• Abdomen not distended
• Lethargy
• Palpable sausage shaped mass.
• A plain radiograph is rarely requested but if done it commonly shows signs of small bowel obstruction.
• Diagnosis is confirmed on an abdominal ultrasound.
• After resuscitation with intravenous fluids, broad-spectrum antibiotics and nasogastric drainage, non-
operative reduction is attempted using an air enema.
• Successful reduction is recognized if air flows into the small bowel, together with later resolution of
symptoms and signs.
• More than 70% of intussusceptions can be reduced non-operatively.
• Recurrent intussusception occurs in up to 5% of patients after non-operative reduction.
• Operative reduction can be performed open or laparoscopically.
Intestinal Obstruction
• Usually can be divided into
• Dynamic: in which peristalsis is working against a mechanical
obstruction.
• Adynamic: in which peristalsis is inadequate or absent.
• Obstruction is not immediately life-threatening unless there is
strangulation, where blood supply is compromised.
Causes
• Dynamic
• Fecal impaction
• Foreign body
• Gallstones
• Stricture
• Malignancy
• Intussusception
• Adynamic
• Pseudo-obstruction
• Paralytic ileus
Pathophysiology
• Usually in case of dynamic obstruction, the bowel proximal to
obstruction dilates.
• In order to relieve the obstruction proximal peristalsis is increased.
• If obstruction is not relieved the bowel continues to dilate.
• The distension proximal to an obstruction is caused by Gases and
Fluid (digestive juices).
Clinical features

• Usually in small bowel obstruction vomiting occurs early and

dehydration is present. Minimal distension.
• In case of large bowel obstruction pain is predominant with
abdominal distension. Vomiting and dehydration are late features.
• Abdominal pain: severe and sudden, colicky.
• Distension
• Absolute constipation
• Late features can include dehydration, oliguria, pyrexia, sepsis.
• Absence of bowel sounds.
Diagnosis
• CBC, LFT, RFT, ABG
• X-ray: Erect and supine: multiple air fluid levels.
• Barium enema
• USG abdomen: see dilated bowel and fluid in peritoneum.
• CT scan
Management
• Gastrointestinal drainage via nasogastric tube.
• Fluid and electrolyte replacement
• Relief of obstruction: surgical decompression
Difference Hernia Hydrocele
Definition Protrusion of abdominal viscera Accumulation of fluid in tunica
through the wall containing it vaginalis
Contents Omentum, Intestine, Urinary Fluid
bladder, etc
Cough impulse Present Absent
Transillumination Absent Present
Swelling Usually inguinoscrotal Usually only scrotal
Get over the swelling No Yes, can palpate the normal cord
Reducible Yes unless strangulated No
Management Mesh repair, Suture repair Surgical drainage of fluid
Bowel sounds Can be heard Not heard