Paediatric Surgery 2nd Semester Flashcards
What are the indications for the surgical treatment of varicocele?
Varicocele is a common condition, characterized by abnormal dilatation of testicular veins in the pampiniform plexus caused by venous reflux. It happens more often on the left side due to the 90-degree angle to the left renal vein. Symptoms associated with varicocele include a testicular condition affecting fertility and associated with small testis. Surgical treatment is indicated in the following cases:
1. Infertility: Varicocele is a significant factor affecting fertility in men. Studies have shown that varicocelectomy improves sperm count, motility, and morphology, leading to an increase in pregnancy rates.
2. Pain: In cases where the varicocele is associated with chronic testicular pain, surgical treatment is necessary.
3. Testicular atrophy: If the varicocele is associated with testicular atrophy, surgery is indicated to prevent further damage to the testis.
4. Young age: Varicocele in adolescent males can lead to testicular atrophy and infertility, and early surgical treatment is recommended.
5. Failure of conservative management: In cases where conservative management fails to relieve symptoms, surgical intervention is indicated.
Surgical treatment for varicocele involves ligation of the spermatic vessel, which is either performed through open surgery or laparoscopically. The procedure aims to remove the affected veins and restore normal blood flow. The procedure is performed under local anesthesia, and patients usually go home the same day. Possible complications include bleeding, infection, hydrocele, and recurrence.
What are the indications for the surgical treatment of phimosis?
Phimosis is a condition in which the foreskin is unable to retract over the glans of the penis, causing pain, difficulty with urination, and possible risk of infection. In some cases, surgery may be indicated to correct this condition. The indications for surgical treatment of phimosis include:
1. Non-responsiveness to conservative treatments: The first line of treatment for phimosis is conservative management, such as topical steroid creams. If these treatments fail to resolve the condition, surgical intervention may be necessary.
2. Recurrent infections: Phimosis can increase the risk of recurrent infections, which may require surgical treatment to prevent further complications.
3. Difficulty with urination: Severe phimosis can cause difficulty with urination, leading to urinary tract infections, and the surgical correction can alleviate this symptom.
4. Balanitis xerotica obliterans: This is a condition that can cause scarring of the foreskin, making it difficult or impossible to retract. Surgery may be indicated in these cases to prevent further scarring and improve function.
5. Aesthetic concerns: In some cases, parents or patients may request surgical treatment for phimosis for cosmetic reasons.
It is important to note that circumcision is not the only surgical option for treating phimosis. Partial or radical circumcision can also be performed, depending on the severity of the condition and the patient’s age.
Undescended testes in a newborn - is the postnatal descent possible? At what maximal age should testes be in the scrotum (physiologically and surgically)?
The incidence of cryptorchidism is approximately 1-5% in full-term newborns and 1-45% in preterm newborns. It is important to address this condition promptly as it may cause complications such as testicular torsion, infertility, and testicular cancer.
It is important to distinguish between palpable and non-palpable undescended testes. Palpable undescended testes are located in the inguinal canal, ectopic or retractile, and can be fixed into the scrotum with a relatively simple surgical procedure. Non-palpable undescended testes, on the other hand, may require further examination under anesthesia and possible laparoscopy to identify their location. In some cases, elongation of vessels may be required before the testicle can be placed in the correct position.
It is recommended that surgery be performed before the age of 12-18 months at the latest to maximize the chances of successful descent and minimize the risk of complications. In newborns with undescended testes on both sides or signs of abnormal sex development, urgent endocrinological consultation and possibly genetic evaluation are required. Bilateral non-palpable testes require observation of abnormalities in genital development.
- Treatment
○ Hormonal treatment NOT recommended
○ Surgery
§ Re-examination under anaesthesia
§ Palpable -> Inguinal canal place and fix in scrotum
§ Non-palpable -> Laparoscopy to identify location, elongation of vessels might be required, then second procedure to place testicle in correct position
Non-palpable -> Blind endings, finish exploration as testicle not developed
Nonpalpable testis - diagnostic work up.
Non-palpable testis can be classified into three categories: intra-abdominal, inguinal, and absent. The diagnostic workup for non-palpable testis includes a thorough history and physical examination followed by laboratory investigations and imaging studies.
History and Physical Examination:
* Detailed medical and family history.
* Comprehensive physical examination, including genital examination, to locate testis and assess for hernias or other abnormalities.
Laboratory Investigations:
* Serum creatinine, K, and PTH levels to assess renal function and any electrolyte imbalances.
* CBC to assess for any signs of infection or inflammation.
* Urine dipstick to evaluate for any urinary tract infections.
Imaging Studies:
* Kidney-bladder ultrasound (KBUS) to assess for the presence and location of testis, evaluate the size, masses, dilations, and artery blood flow, and identify any associated anomalies.
* MRI and CT scans may be useful in detecting the location of the testis in cases where the KBUS is inconclusive. * Radionuclide scans can also be performed to evaluate the blood flow to the testis.
Dynamic Studies:
* Voiding cystourethrography (VCUG) can be done to assess for the presence of vesicoureteral reflux (VUR) or other abnormalities.
* Hormonal stimulation test with human chorionic gonadotropin (hCG) can be done to identify the presence of testicular tissue.
List 5 indications for pediatric nephrectomy.
Pediatric nephrectomy is a surgical procedure to remove one or both kidneys in children due to various medical conditions. Here are five indications for pediatric nephrectomy:
1. Wilms Tumor: Wilms tumor is the most common type of kidney cancer in children and accounts for approximately 5% of all pediatric malignancies. Nephrectomy is often necessary as a part of the treatment protocol.
2. Multicystic Dysplastic Kidney (MCDK): MCDK is a congenital anomaly of the kidney characterized by non-functioning cystic kidney tissue. The kidney may not function and may cause hypertension or other complications, necessitating a nephrectomy.
3. Renal Cell Carcinoma: Renal cell carcinoma is a rare type of kidney cancer that occurs in children. Nephrectomy may be indicated if the tumor is large, growing, or aggressive.
4. Chronic Pyelonephritis: Chronic pyelonephritis is a long-standing inflammation of the kidney caused by recurrent urinary tract infections. If the kidney is severely damaged and non-functional, nephrectomy may be necessary.
5. Congenital Anomalies: Congenital anomalies such as renal agenesis, horseshoe kidney, and ectopic kidney may require nephrectomy in case of complications such as obstruction, infection, or hypertension
List at least 2 indications for nephron sparing surgery (NSS) in children.
Nephron sparing surgery (NSS) is a surgical technique that removes a portion of the kidney while preserving the healthy nephrons. Here are five indications for NSS in children:
Bilateral renal tumors: When a child has a tumor in both kidneys, NSS is the preferred approach to minimize the risk of renal failure. Solitary kidney: In children with a solitary functioning kidney, NSS is used to preserve renal function. Hereditary predisposition to renal tumors: Children with hereditary predisposition to renal tumors, such as von Hippel-Lindau disease or Birt-Hogg-Dubé syndrome, may benefit from NSS to prevent future renal impairment. Small renal tumors: For small renal tumors (<4 cm), NSS is preferred to avoid the need for radical nephrectomy and preserve renal function. Renal masses in patients with impaired renal function: In children with preexisting renal impairment, NSS may be indicated to remove a renal mass while minimizing the risk of further renal injury.
You’re GP. A mother with a one year old boy comes to your office, saying the boy’s grandmother recognised phimosis in her grandchild. What do You think about it? How would You conduct a visit?
As a GP, if a mother with a one-year-old boy comes to my office stating that the boy’s grandmother recognized phimosis in her grandchild, I would conduct a thorough medical assessment to confirm the diagnosis and decide on the best course of action. The following steps would be taken during the visit:
1. Medical history: Take a detailed medical history of the child, including previous illnesses, family history of any genital abnormalities, and medication use.
2. Physical examination: Conduct a physical examination of the child to confirm the diagnosis of phimosis. During the examination, I would check if the foreskin can be fully retracted over the glans penis.
3. Distinguish from normal agglutination: Determine if the phimosis is primary, caused by incomplete separation of the foreskin from the glans, or secondary, caused by scarring from previous inflammation or infection. I would also look for any signs of paraphimosis, a condition where the foreskin becomes trapped behind the glans penis and cannot be reduced.
4. Treatment options: If the diagnosis of phimosis is confirmed, I would discuss treatment options with the parents. For primary phimosis, topical corticosteroid ointment is the first-line treatment, applied twice daily, which has over 90% success rate. However, if the condition does not improve after this treatment, circumcision may be necessary. For secondary phimosis, surgical treatment in the form of circumcision is usually recommended.
5. Follow-up: After treatment, regular follow-up is necessary to ensure that the child is healing properly, and there are no complications. I would recommend that the child returns for a follow-up visit after two weeks of initiating treatment.
You’re a paediatric surgeon on call. The neonatologist calls You about the newborn that was born today with hydroneprhrosis recognised on the prenatal ultrasound examination. What would you ask the doctor? What would be your next steps?
As a pediatric surgeon, when receiving a call from a neonatologist regarding a newborn with hydronephrosis recognized on prenatal ultrasound examination, it is important to ask the following questions to determine the appropriate next steps:
1. Was the hydronephrosis unilateral (ureter obstruction, submedula part) or bilateral?
2. What is the degree of hydronephrosis?
3. Has a VCUG been performed to assess for VUR?
4. Has a renal scan been performed to assess for differential function of the kidneys?
5. Is the baby showing any signs of obstruction such as decreased urine output or abdominal distension?
Based on the answers received, the appropriate next steps would be:
1. If the hydronephrosis is mild and unilateral, close observation with follow-up ultrasounds may be appropriate. If the hydronephrosis is severe or bilateral, further investigation is needed.
2. A VCUG should be performed to assess for VUR.
3. A renal scan should be performed to assess for differential function of the kidneys.
4. If the baby is showing signs of obstruction, immediate intervention may be necessary to relieve the obstruction and prevent renal damage.
In general, the approach to a newborn with hydronephrosis recognized on prenatal ultrasound examination will depend on the degree of hydronephrosis, presence of VUR, differential function of the kidneys, and presence of obstruction. Early detection and management of these issues can help prevent long-term renal damage and improve outcomes for the child.
VCUG stands for voiding cystourethrogram, which is a radiographic test used to evaluate the function of the bladder and urethra during voiding (urination) and to detect vesicoureteral reflux (VUR).
Vesicoureteral reflux is a condition where urine flows back from the bladder up into the ureters and potentially into the kidneys, which can cause urinary tract infections, kidney damage and renal failure. It is a common anomaly in children, and often detected when evaluating a newborn with hydronephrosis.
The role of paediatric surgeon in neurogenic bladder treatment.
Neurogenic bladder is a condition in children where they are unable to control their bladder due to neurological difficulties caused by a spinal cord or general nervous system lesion. The muscle around the bladder and sphincter do not work together due to damage, leading to incontinence, urinary tract infections (UTIs), vesicoureteral reflux (VUR), and renal scarring that may require transplantation after renal failure. The condition is often associated with spinal bifida and is classified into overactive sphincter and overactive bladder. As a result, a paediatric surgeon plays a critical role in the treatment of neurogenic bladder.
Diagnostic Methods:
* Serum creatinine, K, PTH, CBC
* Urine dipstick
* Blood pressure
* KBUS (Kidney bladder ultrasound) = Size, masses, dilations, artery blood flow, stones (lithiasis)
* VCUG
* CT
* MR
* Radionuclide scans
* Dynamic studies
Management of Neurogenic bladder:
* Immediate catheterization -> Empty bladder to prevent bladder distension and further damage
* Antimuscarinic/anticholinergic medication to reduce detrusor overactivity
* Alpha-adrenergic antagonists may facilitate emptying in children with neurogenic bladder
* Botulinum toxin A injection: In neurogenic bladders that are refractory to anticholinergics
* Surgery -> Vesicostomy (opening in the abdomen to drain), bladder augmentation (bladder too small in these patients -> Cut small intestine, cut bladder, suture part of the intestine to the bladder to increase volume)
Conservative and surgical treatment of urolithiasis in children.
Urolithiasis, or the presence of stones in the ureters, is a relatively common condition in children, with a prevalence of around 1-2%. In most cases, conservative management with pain management, hydration, and anti-inflammatory medication is sufficient. However, some children require surgical intervention. In this response, we will discuss the diagnostic methods for urolithiasis and the conservative and surgical treatment options.
Conservative Treatment of Urolithiasis in Children:
* Pain management with anti-inflammatory medication and hydration
* Medical expulsive therapy with alpha-blockers to facilitate the passage of stones
* Dietary modifications to prevent the formation of stones, such as reducing sodium intake and increasing fluid intake
* Regular monitoring with imaging and laboratory tests to track the size and location of stones and assess kidney function
Surgical Treatment of Urolithiasis in Children:
* Extracorporeal shock wave lithotripsy (ESWL) uses shock waves to break up stones into smaller pieces which can then be passed naturally
* Ureteroscopy with laser lithotripsy is a minimally invasive procedure that uses a small scope to visualize and remove stones in the ureters
* Percutaneous nephrolithotomy (PCNL) is a minimally invasive procedure that involves making a small incision in the back to access the kidney and remove stones
* Open surgery may be required in some cases if the stones are too large or located in a difficult-to-reach area
Acute scrotum - clinical symptoms, possible causes. Indications for prompt surgery
Acute scrotum is a medical emergency that requires immediate attention and prompt surgery. It can be caused by testicular torsion, which is the twisting of the spermatic cord, leading to closure of the testicular vessels. This can result in discolouration, pain, and the appearance of a blue dot on the skin. Other causes of acute scrotum include trauma, epididymitis, and orchitis. In this response, we will discuss the clinical symptoms of acute scrotum, its possible causes, and the indications for prompt surgery.
Clinical Symptoms:
* Discolouration: The scrotum may appear red, blue or black.
* Pain: Severe pain in the scrotum or groin area is common.
* Blue dot sign: This refers to a blue discoloration of the skin overlying the torsion site, visible through the scrotal skin.
* Swelling: The affected testicle may be swollen and tender to the touch.
* Nausea and vomiting: These symptoms may occur due to severe pain.
Possible Causes:
* Testicular torsion: The most common cause of acute scrotum in children and adolescents.
* Varicocele: An abnormal dilation of the testicular veins in the pampiniform plexus caused by venous reflux
* Trauma: Blunt trauma to the testicles or scrotum can cause swelling and pain.
* Epididymitis: Inflammation of the epididymis, which is a structure located at the back of the testicle.
* Orchitis: Inflammation of the testicle due to infection, usually viral.
Indications for prompt surgery:
* Testicular torsion: This requires immediate surgical intervention to prevent testicular damage.
* Suspected testicular torsion: If the diagnosis is suspected, surgery should be performed without delay to prevent testicular damage.
* Failure of conservative management: If conservative management (such as pain relief and antibiotics) fails to improve the symptoms, surgery should be performed.
* Unexplained scrotal pain: If the cause of the pain is unclear, surgery may be necessary to diagnose and treat the underlying condition.
In conclusion, acute scrotum is a medical emergency that requires prompt surgical intervention in cases of testicular torsion, suspected torsion, failure of conservative management, and unexplained scrotal pain.
What are the indications for hospitalization of a child with a burn wound?
Hospitalization for a child with a burn wound is indicated based on the severity of the injury and other factors that increase the risk of complications. The following are indications for hospitalization:
Moderate or severe injury: Hospitalization is necessary for children with moderate to severe burns, as these injuries require specialized treatment and monitoring by medical professionals. Circumferential burn: A circumferential burn is when the burn affects an entire body part, such as the arm or leg. These burns can cause constriction under the burnt skin, leading to blockage of blood flow, and require hospitalization for close monitoring and potential surgical intervention. Burn injury in an area prone to shock: Burns to areas such as the face, neck, groin, and crotch can lead to airway obstruction and shock. Hypovolemic due to loss of skin, pain, then septic shock due to skin flora colonisation. Hospitalization is required for close monitoring of respiratory and cardiovascular function. Intentional injury suspicion: If there is suspicion of intentional injury, the child should be hospitalized for further evaluation and protection from further harm. Electrical, chemical, or inhaled burns: These types of burns can cause extensive damage and require specialized treatment and monitoring. Hospitalization is necessary for proper management and prevention of complications.
What are the First Aid procedures in a child with a burn wound
Burns are a common injury in children and require prompt first aid to minimize tissue damage, infection risk, and pain. The following are the first aid procedures for a child with a burn wound:
Assessment: Quickly assess the situation, remove the hot source, and remove the child's clothing to stop the burning process. It's essential to assess the extent and severity of the burn injury, including any signs of airway obstruction. Pain management: Burns can be extremely painful, and pain management is crucial in first aid. Administer pain relief medication, such as paracetamol or ibuprofen, if available. Fluids: Burns can cause fluid loss, leading to dehydration, so providing fluids is essential. Offer the child water or an oral rehydration solution, if possible, to replenish fluids lost through the skin. Cooling: Applying cool water to the burn wound is the most effective first aid method. Run cool water over the burned area for 10 to 20 minutes, ensuring that the water is not too cold to cause hypothermia.
The first aid procedures should be performed immediately to reduce tissue damage, prevent infection and pain relief. The type of treatment needed after first aid will depend on the extent and severity of the burn. In some cases, the child may require hospitalization for further treatment, and it’s essential to assess the child for any signs of airway obstruction or shock.
What is the initial hospital burns management (at the Emergency Department / at admission to the ward)?
Initial management of burns in children is crucial in preventing further tissue damage, managing pain, and avoiding complications. The first goal is to assess the severity of the injury and provide first aid measures. The following steps are taken in managing burn wounds:
Assessment and First Aid: The first step in managing burns is to remove the child from the source of the burn and assess the severity of the injury. This involves removing clothing, cooling the affected area with room temperature water or a cool compress, and providing pain relief. Fluid Resuscitation: After assessment, intravenous fluid resuscitation is started, as burns can lead to dehydration and shock. The amount of fluid given is calculated based on the percentage of the body surface area (TBSA) affected and the weight of the child. Pain Management: Pain management is crucial in burn management, as burns can be very painful. Adequate pain relief should be provided to ensure the child's comfort. Monitoring Vital Signs: Vital signs should be monitored frequently, including heart rate, respiratory rate, blood pressure, and oxygen saturation. Wound Care: After initial assessment and management, the wound is treated according to the extent and depth of the burn. Burns can be treated conservatively with dressing, open wound treatment or surgical treatment such as early burned tissue excision. In the emergency department, wounds are cleansed and debrided. Dressings are applied, and tetanus immunization is given if necessary. Infection Control: Burn wounds are susceptible to infection, and prophylactic antibiotics should be administered in cases of moderate to severe burns. Wound swabs are taken for culture and sensitivity.
What are the typical signs of non-accidental injuries in burn cases?
Non-accidental injuries or child abuse should always be considered in cases of burn injuries in children. It is essential to recognize the typical signs of non-accidental injuries to take appropriate action to protect the child. Some of the typical signs of non-accidental injuries in burn cases include:
Burns of different ages or stages of healing, suggesting that the injury was not accidental Symmetrically shaped burns, suggesting that they were inflicted intentionally Burns in unusual patterns or shapes, such as a handprint or a cigarette burn Burns that are inconsistent with the child's developmental stage, such as burns on the soles of the feet of a child who is not yet walking Delay in seeking medical attention for the burn injury Inconsistent history or lack of explanation for the burn injury Previous or ongoing physical abuse or neglect
It is crucial to consider non-accidental injuries in cases of burn injuries in children and report any suspicion of child abuse to the appropriate authorities. Early recognition and intervention can prevent further harm to the child and provide the necessary support to protect them from further abuse or neglect.
You’re a doctor in the ambulance. You are called to the 10-year old child, who got burnt by a flame from the barbeque in the face. What do You do? What are you afraid of and how do you react?
As a doctor in the ambulance, the first step in responding to the 10-year-old child who got burnt by a flame from the barbeque in the face is to ensure that their airways are clear. After making sure that the airways are clear, I would assess the child for signs of burn shock, including tachycardia, decreased respiratory rate, tachypnea, pallor, cyanosis, oliguria, and disorientation.
In managing the burn wound, it is crucial to determine the extent of the burn injury. Using the palm method, I would estimate the percentage of the child’s total body surface area (TBSA) affected by the burn. Afterward, I would calculate the amount of IV fluid required for initial management of the burn disease. The formula to calculate the amount of IV fluid needed is 4 ml saline * weight kg * % TBSA = mL given in the first 24 hours, with half given in the first 8 hours and the remaining half in the next 16 hours.
I would also assess the burn wound and initiate pain management and fluid resuscitation to prevent further injury. It is essential to manage the burn wound effectively to prevent complications such as scarring, contractures, respiratory complications, and psychological and emotional issues.
