Paediatric Surgery SC040: The Child Needs An Operation: Common Emergencies And Surgery In Childhood Flashcards
Elective paediatric surgical conditions
- Phimosis, Circumcision
- Inguinal hernia, Hydrocele
- Undescended testes (UDT)
- Common solid tumours
Benign:
- Cystic hygroma
- Haemangioma
- Dermoid / Epidermoid
Malignant:
- Teratoma
- Neuroblastoma
- Wilm’s tumour (Nephroblastoma)
- Hepatoblastoma
Scope of Paediatric surgery: defined by age group but not system
- Phimosis, Circumcision
- Non-retractable foreskin common (50% at 5 yo, ↓ by 10% per year)
- Circumcision rarely needed <4 yo
Indications:
- Balanitis xerotica obliterans (BXO)
- Recurrent balanitis
- Religious (relative)
—> usually recommend observation until older unless above
Complications:
- Bleeding
- Infection (rare)
- Meatal stenosis
- Excessive removal
- Inguinal hernia, Hydrocele (+ SpC Revision)
Presentation:
- Incidental / Noticed by parents
- Reducibility
- Variation in size relation to strain / standing
- Pain
Incidence of Inguinal hernia:
- 3-5% term infants
- Preterm mainly, Male, R 60%, L 25%, Bilateral 15%
- Pathology: Indirect, Patent processus vaginalis (~100%)
Common DDx for Inguino-scrotal swelling:
- Inguinal hernia
- Hydrocele
- Varicocele (uncommon in children (usually in teenager), suspect renal disease)
- Lymphadenopathy
- Testicular tumour
- Ectopic testis
- Both have same etiology: Patent processus vaginalis (PPV)
- Hernias are common in neonates (30% in premature babies)
- ↑ Bilateral hernias with ↓ age
- Potential complication of bowel strangulation
Normal boy:
- Processus vaginalis obliterated —> Tunica vaginalis
Abnormal:
- Processus vaginalis not obliterated (PPV)
—> small patency —> peritoneal fluid can go in —> Hydrocele (can get above, +ve transillumination, diurnal changes due to gravity)
—> large patency —> intestine can go in —> Hernia (cannot get above, -ve transillumination)
Content of hernia:
- Bowel
- Omentum
- Ovary
Hydrocele:
- Patent / Incomplete obliteration of processus vaginalis
- Physiological in newborn, usually resolve with time
Investigations:
- Inguinal hernia: Usually not required, USG may help to exclude other DDx
Treatment:
Hydrocele:
- Observation, usually spontaneously resolve by 1-2 yo
- High ligation if persists / pain
- Laparoscopic surgery also feasible but PPV may not be visualised due to small in size
Hernia:
- Persist and will not spontaneously resolve
- Risk of incarceration, strangulation
- Early herniotomy (i.e. open) to prevent complications of bowel strangulation
- Now mostly do laparoscopic (∵ can see both sides and repair both sides if necessary (20% will have bilateral hernia))
—> no need mesh repair since defect is due to PPV but not weak fascia + not want foreign body in body for life
Complications of treatment:
1. Recurrence
2. Testicular atrophy (∵ damage to vessels)
3. Vas injury
- Undescended testes (UDT) (+ SpC Revision)
- 3% of male neonates, incidence higher in premature babies
- usually picked up by paediatricians at birth
- other DDx: Retractile testes
Clinical features:
- Empty / Hypoplastic scrotum
(If both sides missing —> apart from imaging also check chromosome to see whether it is boy / girl: Disorder of sexual differentiation (DSD))
Classification:
1. Palpable (80%)
- Intracanalicular True UDT (75%)
- Retractile testis (20%)
- Ectopic testis (5%)
- Non-palpable (20%)
- Intrabdominal / Intracanalicular True UDT
- Atrophic / Vanishing
Location:
1. Undescended (True UDT)
- Intraabdominal
- Inguinal
- Suprascrotal
- Ectopic (rare)
- Perineal
- Femoral
Approach:
- Palpable testis: Inguinal, Suprascrotal —> Orchidopexy
- Impalpable testis: Intraabdominal, Absence (e.g. in-utero infarction of testis due to torsion) —> Further investigations needed: USG, MRI, Laparoscopy
Treatment algorithm:
- Palpable —> Orchidopexy
- Non-palpable —> Groin / Scrotal USG / EUA
—> Inguinal orchidopexy if palpable
—> Laparoscopy if still non-palpable
——> Absent testis
——> Intraabdominal testes
———> <2cm from internal ring —> Lap orchidopexy
———> >2cm from internal ring —> Staged Lap orchidopexy after 6 months
Treatment:
- Early orchidopexy ~6 months
—> improve possible sub-fertility on that testicle
—> improve tumour detection (∵ UDT have higher chance of malignancy (incidence still very low), but orchidopexy does not ↓ chance of malignancy)
—> reduce risk of physical injury
—> reduce risk of torsion
Staged procedure:
- 1st stage: Divide testicular artery (∵ it is the cause of stopping the testicle from descending)
—> leave testis in-situ, collaterals will grow and supply testis
—> 2nd stage (after 6 months): Orchidopexy (10-15% of atrophy risk vs single stage 40%)
(From SpC Interactive tutorial:
- Most common birth abnormality involving male genitalia (0.8% incidence at 6 months)
- All (except premature infants) will descend in first 3 months of life —> if undescended at 3 months —> Refer specialist + Plan for surgery
- Retractile testicle is a normal descended testicle that is pulled out of the scrotum by an overactive cremasteric reflex (normal position during normal situation)
P/E:
- Bimanual examination (one hand on abdomen swiping testicles down to scrotum, other hand try grasp testicle from scrotum)
—> Palpable undescended testicle (i.e. within Scrotum / Inguinal canal) —> Orchidopexy
—> Retractile testicle —> Monitor —> If ascending testis syndrome —> Orchidopexy
—> Non-palpable testicle —> EUA
—> Palpable testis —> Orchidopexy
—> Non-palpable —> Laparoscopy (try to find testicle) —>
1. Intraabdominal testicles —> Primary / Staged Fowler-Stephens Orchidopexy
2. Vas / vessels entering canal (i.e. testis should be in inguinal canal but just not enter scrotum) —> Inguinal exploration + orchidopexy
3. Blind-ending vas / vessels (i.e. no testicles at all) —> Vanishing testis
Fowler-Stephens orchidopexy:
- indication: >2 cm from inguinal ring
- clip spermatic vessels >1 cm cranial to testis
- wait >=6 months then perform laparoscopic stage 2 Fowler-Stephen orchidopexy)
- Common solid tumours: Benign tumours
Divide according to different origins
Most common:
1. Cystic hygroma (lymphatics) —> a type of Vascular malformation
2. Haemangioma (blood vessels) —> a type of Vascular tumour
3. Dermoid / Epidermoid (soft tissue)
Vascular anomalies:
- Vascular malformation
- Vascular tumour
Cystic hygroma
- Maldevelopment of lymphatics
- Cervical 70%, Axillary 20%
- Can infiltrate surrounding structures (e.g. Carotid artery, IJV, Nerve plexus) —> impossible to complete take out
Complication:
- Infection (can get big —> pressure effect)
- Haemorrhage (can get big —> pressure effect)
- Pressure (compress on airway if cervical —> important to detect antenatally —> immediate surgery after birth)
Treatment:
- Depends on type: Macrocystic / Microcystic (based on USG size)
1. Surgical excision
2. Sclerotherapy (e.g. OK432, Doxycycline (more commonly used), Tetracycline, Bleomycin)
- put in needle to aspirate
- inject sclerosants —> create inflammation within cyst wall —> stick together
- usually need to do several times to tackle multiple cysts
3. ?Sirolimus (tackle PI3K pathway)
Haemangioma
- Common condition
- Vascular tumour —> purely arterial (usually regress itself) / purely venous / mixed (not regress)
Example:
- Salmon patch
- Port-wine stain (Capillary haemangioma, associated with Sturge-Weber syndrome)
- Strawberry naevus
Complications:
1. Trauma —> Haemorrhage
2. Cardiac failure
(3. Hydrops in utero)
(4. Eyelid: Amblyopia
5. Compressive effect)
Treatment:
1. Conservative
- most resolve after puberty (except venous malformation)
- Steroid / Vincristine
- Propranolol (block VEGF)
If lesion too big:
2. Excision
3. Sclerotherapy
4. Laser
- Common solid tumours: Malignant tumours
- Teratoma (by itself benign in general, but malignant potential)
- Neuroblastoma
- Nephroblastoma (Wilm’s tumour)
- Hepatoblastoma
General principles:
- Diagnosis (by Biopsy)
—> Neoadjuvant chemo (shrink + reduce vascularity of tumour)
—> Surgery
—> Adjuvant chemo (vs in adults: Surgery straight away usually)
- Paediatric tumours are usually very chemo-sensitive
- Good prognosis even in advanced disease (SpC Revision)
Teratoma
Example:
Sacro-coccygeal teratoma
- Mostly benign when diagnosed, can turn malignant
- High AFP (monitor recurrence)
- Large tumours can cause hydrops (require obstetrician to do intervention to burn some tumour off in-utero)
- Always order a CT scan post-natal to delineate tumour (may be deep inside body, only small portion visible from outside)
Treatment:
- Early surgical excision with coccyx usually cure
—> also prevent malignant transformation + easier dissection (can excise en-bloc)
Neuroblastoma
- Most common solid childhood tumour
- 1:8000-10000 children (7-9 new cases each year in HK)
- Arises from neural crest cells
- Location: Adrenal medulla / Sympathetic chain (neck to pelvis)
- Can secrete HVA (homovanillic acid) + VMA (vanillylmandelic acid) —> Urine HVA + VMA for investigations
- Associated with n-myc oncogene (+ve: more aggressive, poorer prognosis)
Clinical presentation:
- Abdominal mass
- Abdominal pain
- Weight loss
- Anorexia
- Paraneoplastic features: HT, Cerebellar ataxia
- Metastasis: Raccoon eyes / Panda eyes
Investigation:
1. Imaging
- USG
- CT scan
- Bone scan
- MIBG scan
- PET scan
2. Tumor marker
- Urine VMA, HVA
3. Tumor biopsy
- Confirm diagnosis
- Determine prognosis
Natural history:
- Spontaneous regression
- Differentiation and maturation
- Rapid progression (majority)
Treatment:
1. Surgery (even if not complete excision —> the tumour will still respond better to chemo)
2. Chemotherapy
(3. RT, Immunotherapy, Allogeneic BM transplant for high risk)
Risk-based treatment:
- Low risk: Surgery alone
- Intermediate risk: Chemotherapy + Surgery
- High risk: Chemotherapy + Surgery + RT + Immunotherapy + Allogeneic BM transplant
Prognosis:
- Depend on stage + age —> overall 5 year survival ~70%
- Worst prognosis among Neuroblastoma, Hepatoblastoma (90%), Wilm’s (90%)
Nephroblastoma (Wilm’s tumour) (+ SpC Revision)
Associated with WT1, WT2 genes (+ve mutation: not change survival, but higher risk of bilateral tumour (can develop later —> need to preserve as much kidney during first surgery))
Clinical features:
- Abdominal mass
- Fever
- Haematuria
- Weight loss
- Anaemia / Polycythaemia
- Hypertension
- Bilateral 5%
Investigations:
1. AXR: 10% calcification, eggshell appearance
2. USG: solid tumour
3. CT: vasculature, contralateral kidney
Staging:
- 1: encapsulated
- 2: unilateral, adherence, complete surgical removal
- 3: regional LN, tumour rupture
- 4: haematogenous spread
- 5: bilateral
Treatment:
1. Surgical resection
2. Chemotherapy (good response)
Prognosis:
- 5 year survival >90%
- Best outcome compared to Neuroblastoma, Hepatoblastoma
Hepatoblastoma
- Commonest malignant liver tumour in children (95%)
- 0.8-1 per million (3-5 new cases each year in HK)
- Embryonal tumour of liver
- Highly aggressive malignancy
- Also seen with Beckwith-Wiedemann syndrome
- Tumour marker: AFP
Clinical features:
- Hepatomegaly
- Abdominal pain
- Tumour rupture
Investigations:
- ↑AFP in serum
- USG
- CT
- Biopsy
- PET (confirm malignant nature + detect extrahepatic metastasis)
Staging:
- PRETEXT system (divide liver in 4 segments)
Treatment:
1. Surgery (complete resection critical, pre-op chemo can convert unresectable tumour to resectable)
2. Chemotherapy (good response to Cisplatin, single agent + low dose already good enough —> ↓ number of agents needed —> ↓ systemic toxicity)
3. Liver transplantation?
- good therapeutic option for selected patients with HB (unresectable tumours e.g. stage 4, difficult location etc.)
- risk of immunosuppression / second malignancy (e.g. lymphoma) with prolonged immunosuppressants
Prognosis:
- Overall survival 90%
- Stage 1 >90%, Stage 4 20%
Common emergency paediatric operations
- Testicular torsion
- Foreign body ingestion
- Appendicitis
- Scald, burn
- Intussusception
Testicular torsion
- Testicle twist upon spermatic cord —> Arterial occlusion
- Incidence 1:4000 males <25 yo
Clinical features:
- Sudden onset of testicular pain (Testicular torsion until proven otherwise)
- High lying testis (JC053)
DDx:
- Epididymo-orchitis
- Torsion of testicular appendages (localised redness)
- Traumatic haematoma
Diagnosis:
- Clinical findings mainstay of diagnosis (∵ relatively short time window (6 hours))
- Always explore if clinically suspicious
- Doppler + Nuclear scan may help
Treatment:
- Untwisting + Orchidopexy +/- Orchidectomy (if already dead)
Foreign body ingestion
- Very common problem in children worldwide (4% children have history)
- Peak incidence 9-24 months
- Boys > Girls
- Fish bones, coins most common in HK (recent trend: magnetic beads —> compress 2 bowel wall —> fistula)
Management:
1. Initial conservative management (most foreign bodies will pass)
2. Endoscopy (if symptoms persist / specific FB sensation)
3. Laparotomy (only needed rarely)
Acute appendicitis
- Most common acute paediatric surgical condition
- Peak age between 4-15 yo
- “Closed loop” obstruction as etiology?
DDx:
- Mesenteric adenitis
- Cholecystitis
- Henoch-Schonlein Purpura (triad: Palpable purpura, Arthritis, Abdominal pain)
Clinical presentation (VAGUE!!!):
- Central abdominal pain
- Anorexia
- Shifting pain
Signs:
- Pyrexia
- Guarding
- Localised tenderness (no rebound) (use 1 finger usually enough to elicit)
- Rovsing’s sign (harder to elicit than adult)
- Psoas, Obturator signs (harder to elicit than adult)
Investigations:
- Leukocytosis
- USG
- CT (beware of high radiation in children)
- Plain XR (rarely)
Treatment:
- Surgery (Laparoscopic / Open)
Scald and Burn
- Scalding most common form of burn —> usually <3rd degree
- ↑ Incidence in toddlers due to new found mobility
- Rarely due to non-accidental cause
Admission criteria:
- >10% burn (∵ potential fluid loss)
- Facial burn
- ?Non-accidental injury
Treatment:
1. Conservative management
- Fluid replacement (IV / Oral)
- Daily dressing via aseptic technique
- Regular wound swab —> treat infection (NO routine antibiotics)
- Skin grafting (in more severe / extensive cases)
Intussusception
- Invagination of a portion of intestine into adjacent portion
- M>F
- Peak incidence (2 peak ages): 4-24 months (年紀大d vs Neonatal IO) (age when start to have more viral infections), Elderly (∵ luminal tumour as focal point)
- May be preceded by viral infection —> mesenteric LN enlargement —> focal points for bowel to grab onto —> too forceful peristalsis —> Intussusception
- Most common location: Ileum going into Caecum (i.e. Ileocolic intussusception)
Clinical features:
- Colicky abdominal pain (try to untangle itself)
- Vomiting (uncommon)
- Crying baby
- “Red currant jelly” per rectum (∵ mucosal sloughing due to ischaemia)
- Abdominal mass
Investigations:
- AXR (may show dilated small bowels + mass)
- USG (gold standard, usually diagnostic in experienced hands, target (transverse view) / pseudokidney sign (longitudinal view))
- Contrast enema (rarely done now)
Treatment:
1. Resuscitation
- NPO
- IV fluid replacement (if see doctor late) (drip and suck)
- NG tube decompression (drip and suck)
- Pneumatic / Hydrostatic reduction (under USG / fluoroscopy)
- Surgery
- Open / Laparoscopic reduction
- if Pneumatic / Hydrostatic reduction fail
SpC Interactive tutorial: Paediatric general surgery and oncology
Abdominal wall defect
Umbilical hernia:
- Pathological delay in closure of physiological fascial ring
Common:
- Racial: Black
- Low birth rate, Down syndrome, Hypothyroidism, Mucopolysaccharidosis
Complication:
- Almost never incarcerate
Treatment:
- >1.5cm, >5 year. Surgical repair (Simple, Double-breast)
Prognosis:
- Excellent
Umbilicus problem
Discharge:
- Pus
- Fluid: Bile stained / Clear / Secretion / Urine
Pathology:
- Granuloma, Polyp (Vitelline duct remnant)
- Urachal sinus / Persistent urachus, Persistent vitelline fistula
Treatment:
- Topical treatment for granuloma
- Exploration: Intra-abdominal cord must be excised
Meckel’s diverticulum
- True congenital diverticulum
- Remnant of omphalomesenteric duct
- Rule of ‘Twos’
—> 2% of the population
—> Usually present before first 2 yo
—> 2 types of mucosa i.e. gastric or pancreatic
—> 2 feet from IC valve
—> 2 inches long
Presentation:
- Bleeding
- Infection
- Intestinal obstruction
- Intussusception
- Volvulus
Investigations:
- Meckel scan (Technetium-99m pertechnetate scan) (sensitivity 85% for detecting ectopic gastric mucosa) (but not affect management so often skipped)
Treatment:
Acute bleeding:
- Upper endoscopy +/- colonoscopy
- Diagnostic laparoscopy +/- excision of the diverticulum
Thyroglossal cyst
- Remnants of elements of thyroglossal duct
- Squamous lining tract
- Levels:
—> Suprahyoid (20%)
—> Hyoid (15%)
—> Infrahyoid (65%) - Fistula
—> Internal opening: Pharynx
—> External opening: Skin
DDx:
1. Dermoid
2. LN
3. Lingual thyroid
4. Pyramidal lobe of thyroid
5. Metastatic Ca thyroid
Investigation:
- USG: Cystic nature, Normal thyroid
Complication:
- Infection —> Abscess
- Relapse and Chronic
- Malignancy change in 10% adult
Treatment:
- Sistrunk’s operation
—> Remove lesion + central part of hyoid bone + tract up to foramen caecum of tongue
Lateral neck mass
-
Branchial cyst / Remnant
- Pharyngeal pouch 1st -3rd
- Neck mass, discharging fistula, Infection
- Surgical excision of cyst / tract - LN
- Benign / Infection
- Haematological malignancy
- Metastatic tumour - Vascular Malformation
- Lymphatic malformation (Cystic hygroma)
- Venous / Arterial malformation
Jaundice
Pre-hepatic:
- Haemolytic disease
Hepatic:
- Hepatitis
—> Viral
—> Drug: Paracetamol, Herbal medications
—> Autoimmune
- Metabolic
Post-hepatic:
- Biliary atresia (BA)
- Choledochal cyst (CC)
