Pediatric surgery By Rawasi Ali Mohammed Taha Supervised

Pediatric surgery By : Rawasi Ali Mohammed Taha Supervised by : Dr. Ali Farooq

Testicular Torsion

Definition Testicular torsion refers to the torsion of the spermatic cord structures and subsequent loss of the blood supply to the ipsilateral testes. This is a urological emergency; early diagnosis and treatment are vital to saving the testes and preserving future fertility. The rate of testicular viability decreases significantly after 6 hours from onset of symptoms. Testicular torsion is primarily a disease of adolescents and neonates. It is the most common cause of testicular loss in these age groups

Epidemiology -Extravaginal torsion constitutes approximately 5% of all torsions. -While intravaginal torsion constitutes 16% of cases presenting to ER with acute scrotum. -Peak incidence occurs at age 13 -14 years. -The left testes is more frequently involved.

Diagnosis History: sudden onset sever scrotal or inguinal pain associated with nausea and vomiting; also there may be a history of trauma (10% of cases). On examination: there is unilateral tender, firm testes with scrotal erythema and sewlling. The affected testes is typically higher than un affected one. Also there is no cremasteric reflex.

Mx � Establish IV access and provide analgesia. Urologist consultation. Manual detorsion by open book maneuver. Surgery.

Inguinal hernia • The most common problem in pediatric surgery. • Occurs due to patent processus vaginalis.

• It’s incidence —> 1 -2 per 100 live birth. • Almost always (99%) —> indirect type. • Direct one is rare less than (1%) and they are believed to be acquired, it’s more common in: 1 - Connective tissue disease. 2 - Conditions that increase intra-abdominal pressure. 3 - Post inguinal surgery. • More frequent in male (9 male: 1 female). • More frequent in premature than full term.

Presentation: 60% right side 25% left side 15% bilateral - Intermittent swelling overlying external inguinal ring. - Usually painless. - Evident during crying, coughing and straining. - Reduced Spontaneously during sleeping and relaxation. Manually by upward and posterior pressure directly on the mass.

• 30% have first presentation as incarcerated hernia (firm, tender, irreducible lump in groin or scrotum). • Incarcerated hernia can be reduced by sustained gentle compression (Taxis procedure) —> successful rate 80%.

1 - Sedation. 2 - Elevation of the lower half of the body. 3 - Application of ice packs on the swelling to reduce edema. 4 - Push mass upward and posteriorly by one hand with the other hand supporting the roof of inguinal canal.

• Surgery is delayed for 24 hrs to allow resolution of edema. • If taxis procedure failed —> urgent surgery is indicated.

Treatment : • Surgery is done outpatient except for premature baby who needs observation in hospital for 24 hrs after repair. • Inguinal hernia is not an emergency but should repair as soon as possible because of high risk of complications.

Complications : 1 - Incarnation, strangulation, intestinal obstruction. 2 - Testicular atrophy. 3 - Ischemia and gangrene of testis.

Hydrocele Collection of peritoneal fluid in the tunica vaginalis around the testis.

• It has three types:

* Hydroceles are unilateral or bilateral. * It’s common in first few months of life. They are usually small to moderate in size , asymptotic, resolve spontaneously in the first year of life. * So surgery indicated only if : 1 - It not resolved in boys older than 2 years. 2 - It is very large that causing pressure on the testis.

Differences between inguinal hernia and hydrocele : - Cystic - Irreducible - Transilluminable - No impulse on crying - Difficult to separate it from the testis - Can get above it

Undescended testis • Second most common problem in pediatric surgery after inguinal hernia. • If you examine the scrotum and don’t feel the testis: 1. True UDT: testis that stopped anywhere along the normal pathway of descent. It could be palpable or impalpable.

2. Ectopic testis : testis which has descended to an abnormal site (inguinal region, perineum , femoral , contralateral scrotum ).

3. Retractile testis: present in the scrotum in early infancy but pulled up into inguinal canal as a result of hyperactive cremastric reflex. 4. Iatrogenic (ascending testis) : previously normal descended testis and then have been trapped in scar tissue of previous inguinal surgery.

Incidence: • 3% —> of full term • 33% —-> of preterm Because testis descend through inguinal canal during 3 rd trimester of pregnancy. * The incidence will be 1% at age 1 year.

Investigation : • Laparoscopy: the optimum method of visualizing the anatomy, it’s sensitivity 95% for locating testis or confirming it’s absence.

• Ultrasound : has limited role in obese boy. • MRI , CT_scan. • Hormonal: in cases of bilateral impalpable testis—> rise in serum testosterone in response to intramuscular injection of HCG.

Treatment: 1 - Hormonal therapy : • Buserline (LH-releasing hormone agonist). • Pregnil (HCG-analogue). 2 - Surgical repair : • At age 1 year. • Earlier if associated with inguinal hernia. orchiopexy & orchiectomy

Complications : 1. Infertility (bilateral > unilateral). 2. Malignancy: 1% inguinal, 5% intra_abdominal. 3. Testicular torsion. 4. Testicular trauma. 5. Infection. 6. Psychosocial effect.

Omphalocele Vs Gastroschisis

Etiology Omphalocele: congenital abdominal wall defect with protrusion of abdominal vicera contained within parietal peritoneum and amniotic membranous sac. Due to failure of the midgut to return to abdomen by the 10 th week of gestation during midgut rotation.

Etiology Gastoschisis: Congenital abdominal wall defect towards the right side of the umbilicus and protruded bowel is not covered by membrane, failure of migration and fusion of the lateral folds of the embryonic disc on the 3 rd – 4 th week of gestation. Disruption of the right ophalomesenteric artery as the midgut return to the abdomen causing ischemia of the abdominal wall and weakness then herniation.

Epidemiology -Omphalocele: incidence 3 per 5000. M: F is 1. 5 : 1 , ~70% association with congenital anomalies as bowl atresia, imperforated anus. -Gastroschisis: incidence -4 per 10000. M: F is 1: 1 , 10 -15% association with congenital anomalies as VSD, cleft palate and intestinal atresia. 40% are premature SGA.

Risk factors Omphalocele: -increased maternal age. -Twins. High gravida. -consecutive children. Gastoschisis: -Young mother. -low gravida. -prematurity &SGA -

Clinical features Omphalocele: central defect of the abdominal wall beneath the umbilical ring. The defect may be 2 -12 cm (small<5 , large >8 ). Always covered with a sac(made of amino, Wharton jelly and peritoneum). Umbilical cord inserts into the sac in an apical or lateral position. Small defect contains intestinal loops only, While large may involve liver, spleen and bladder. ~70% have associated anomalies

Clinical features Gastoschisis: defect to the right of an intact umbilical cord allowing extrusion of abdominal content. Opening =<5 cm. There is no covering sac. Evisceration usually only contains intestinal loops. Bowel often thickened, matted and edematous. 10 -15 have associated anomalies.

Diagnosis Prenatal evaluation: Elevated maternal AFP- neural tube defects, abdominal wall defect , esophageal or duodenal atresia. Fetal US-after 14 weeks gestation is the confirmatory test.

Management Pre operative Mx: ABC. Heat management (sterile wrap & radiant warmer). Fluid management. Nutrition (TPN). Abdominal distention ( NG tube & urinary catheter). Infection control (ampicillin & gentamicin). Closure of the defect.

Management Omphalocele Small (<4 cm) , primary closure. Medium (6 -8 cm ) , mesh patch. Large (>8 cm), conservative Topical application betadine ointment or sliver sulfadiazine to the intact sac. -secondary eschar formation and granulation. -healing last for 12 months then repaired as ventral hernia.

Management Gastroschisis Primary closure, if the bowel easily reduced. Staged closure by silo fashioning.