PEDS

Question 1

PEDIATRIC HERNIAS

Answer 1

Right is more common

since R testicle impeded by developing IVC and ext ileac V

Might also be why it hangs higher

CONSENT
• Damage to vas

fix upon dx

TECHNICAL STEPS
• Identify sac like you would in any hernia….99% indirect

(does that circumference around cord and pass a Penrose drain.

Peel hernia sack in cremasteric fibers off of the cord

Reduce contents

• High ligation of sac after reducing contents
• Narrow down internal ring if very wide
• No mesh plug
• Explore contralateral side if:

premature,
male

Question 2

PEDIATRIC HERNIAS

“Inguinal Surprises”

Answer 2

No vas:
investigate for CF

Find ovary n canal:
leave it in until puberty;
bx to confirm that ovary

Find nodules on hernia sac:

unlikely to be cancer in peds,

 ddx includes 
mesenteric remnant tumors 
(Mullerian, Wolffian), 
or 
lipomas; 
get bx and repair 

COMPLICATIONS
• Damage to vas, recurrence (0.3%)

Question 3

Surgical treatment of undescended testes

Answer 3

as soon as possible

after six months of age for congenitally undescended testes

definitely should be completed before the child is two years old

Spontaneous descent rarely, if ever, occurs after six months of age

Treatment before two years (ideally before one year) of age is associated with improved testicular growth and fertility potential

Exploratory surgery — Exploratory surgery for the nonpalpable testis is diagnostic and potentially therapeutic. The first surgical objective is to determine whether or not the testis is present; viable testes are positioned and fixed within the scrotum;

nonviable testicular remnants are removed.

Two surgical approaches are used in the management of boys with nonpalpable testes:

open inguinal approach

aparoscopic approach.

The laparoscopic approach usually is undertaken if the surgeon has laparoscopic expertise.

Examination under anesthesia is the first step in the surgical management of the clinically nonpalpable testis [75]. In a series of 263 nonpalpable testes, 18 percent were palpable in the groin during examination under anesthesia, obviating the need for laparoscopy

if a “nubbin” is palpated in the scrotum, rapid scrotal exploration can confirm the diagnosis of an atrophied testis

Criteria for making a diagnosis of an atrophied testis include identification of a hemosiderin deposit and/or the clear identification of atretic vas deferens and vessels.

Exploration of the groin is the first step in the open inguinal approach [83]. If cord structures or testicular remnants are found, they are removed and the procedure is terminated.

Exploration proceeds to the peritoneum if the groin exploration is negative [84].

The diagnostic laparoscopy is a safe procedure in experienced hands [85-87]. The laparoscope, placed via the umbilicus, is used to examine the inguinal rings, determine the patency of the processus vaginalis, and examine the Wolffian structures and testicular vessels.

The finding of blind-ending spermatic vessels (picture 4), confirming the absent testis, permits termination of the procedure without a groin incision.

Groin exploration is carried out if testicular vessels and vas deferens are visualized exiting the internal ring. The laparoscopic identification of an intraabdominal testis (picture 1) permits planning for the definitive procedure (eg, open versus laparoscopic).