surgeries in children.pdf · untitled document hydrocoeles are commonly present in infants. in a...

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DAY SURGERIES IN CHILDREN

Many operations in children are now done as ‘Day-care surgeries’ where the child is admitted and discharged on the same day. These operations include circumcision, surgeries for hernias, hydrocele, undescended testes, etc.

Parents are often apprehensive about their little ones tolerating surgery and anesthesia, and therefore, postpone seeking advice. We reassure them that for all operative procedures in children we are supported by professionals specially trained and experienced in the care of children including anesthetists, nursing and technical staff and nutritionists.

Similarly, urological conditions in children are best managed by a pediatric urologist who is a pediatric surgeon with training and experience in pediatric urology. These conditions include:

Inguinal hernia / hydrocoele What is hernia?

The testes originally develop in the back of the abdominal cavity of the foetus. Later they descend to the scrotum. During their passage out of the abdomen they drag with them a sleeve of peritoneum, the thin membrane that lines the abdominal cavity. This sleeve is present on both sides, the left and the right. Once the testes are placed in the scrotum at birth this sleeve-like connection with the abdominal cavity closes off. If it doesn't close off, then fluid from the abdomen may trickle down into the extension of peritoneum to produce a balloon like swelling in the scrotum. This is a hydrocoele. If the connection with the abdominal cavity is wider, then even intestinal loops descend down producing a swelling in the groin called hernia. Hernias and hydrocoeles are very common in children.

What are the symptoms?

The parents will notice a swelling in the groin or the scrotum. The swelling may come and go. It is usually more prominent when the child cries or strains, or later in the day. This is because any factor that increases abdominal pressure is likely to increase the swelling. Since crying increases the swelling, the parents often feel that the swelling is the cause of pain. This is not true, as the swelling does not cause the child any discomfort as long as it goes in and out. Sometimes in hernias, the intestines come out but fail to go back inside and get stuck in the hernial sac. This produces a painful tender swelling and the child becomes irritable and vomits. This is an emergency, and if the child is not immediately operated upon the intestinal loop may die and will have to be removed. No such emergency happens in cases of hydrocoele which contains only fluid.

What is the treatment?

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Hydrocoeles are commonly present in infants. In a number of them, the sac obliterates on its own in the first one or two years of life. Therefore, hydrocoeles need not be operated upon during this age unless they become very large and show no sign of spontaneous closure. Hernias on the other hand need to be operated as early as possible after the diagnosis is made. This is because of the intestines getting stuck. The operation is performed under general anaesthesia and usually lasts 30-45 minutes. During the operation, the connection with the abdominal cavity is tied off. The operation for hernia and hydrocoele is identical and is called herniotomy. The baby is able to feed shortly after the operation and there are no special restrictions on activity unlike similar operations in adults. The operation is performed as a day care procedure and admission to hospital is not required except in very small babies. With the new technique a waterproof dressing allows the baby to be bathed and the wound is repaired with absorbable stitches that do not need to be removed. There is at present no role of treatment of hernias in children using the laparoscopic technique that is so popular in adults.

What are the complications?

Even little babies can be safely operated upon for hernia, but this needs to be done by surgeons who have the experience of operating on babies. Sometimes there may be a little swelling in the scrotum after the operation, but this subsides in about a week. In 2% cases the hernia may reappear. In 10% children, a hernia may develop on the opposite side, not because of the operation but because the communication might have existed on that side as well but had not manifested earlier. If this does happen, then the other side will also need an operation.

Hernia is a protrusion of organs or structures of the abdominal cavity into a sac formed by the inner lining membrane of the abdomen. Though the problem is also seen in adults, hernias in children differ from adult hernias both in cause and in management Hernia in children occurs due to a persistence of a communication between the abdominal cavity and a canal in the groin. Normally, this communication closes about the time of birth.

A hernia presents as a swelling in the groin, which may extend down to the scrotum.The swelling appears only when the child cries, coughs or strains and disappears when he/she is quiet or is lying down.

Sometimes in a hernia can the abdominal contents coming out into the sac, get trapped, and cannot be pushed back. This leads to a strangulation of the blood supply of the intestinal segment. This is more common in hernias in infants. For these reasons, a hernia should be operated upon as early as possible even if it is a newborn baby. A hydrocele is a collection of fluid in the scrotal sac of male infants. A non-communicating hydrocele usually does not need to be surgically repaired, since it usually goes away spontaneously within six to 12 months. A communicating hydrocele needs to be surgically repaired to prevent further complications. The surgery takes about an hour and is usually an outpatient procedure (which means the patient can go home the same day of the procedure he will not have other symptoms.

● An anesthesiologist (a physician who specializes in pain relief) gives your child general anesthesia, which puts him asleep.

● A small incision, or cut, (2 cm.) is made in the skin fold of the groin.


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● The hydrocele "sac" containing the fluid is identified. ● The surgeon empties the fluid from the sac. The sac is removed. ● The muscle wall is reinforced with stitches to prevent a recurrent hernia or hydrocele

Most children will be able to go home a few hours after surgery. However, premature infants and children with certain medical conditions might need to spend one night in the hospital for observation.

Caring for your child after surgery

Usually, your child will feel fine again the evening after surgery or by the next morning. As soon as your child is able, he can resume normal eating habits and activities. You may give your child a sponge bath the day after surgery. Tub baths are permitted two days after surgery. The small pieces of tape covering your child's incisions (called steri-strips) will gradually fall off on their own. Do not pull these strips off yourself. If the strips do not fall off on their own, your health care provider will remove them at your child's follow-up appointment You might notice some minor swelling around the incision. This is normal. However, call your health care provider if your child has:

● A fever ● Excessive swelling ● Redness ● Bleeding ● Increasing pain

Undescended Testis What is an undescended testicle?

Undescended testis is a condition in which one or both testes do not lie in the scrotum, the loose bag of skin below the penis. It is a common condition that occurs in nearly 4% of all newborn babies. The testes originally develop in the back of the abdominal cavity of the foetus. Later they begin to descend to the scrotum. If the testis fails to descend all the way down and gets stuck somewhere along the path of descent it is called an undescended testes. This process of descent occurs during late pregnancy. This is why 30% of premature babies have at least one undescended testes. Some of the testes may descend even after birth, but this usually happens in the first 3-4 months. Testes that do not descend till one year will not descend and need to be treated.

How is the diagnosis made?


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The diagnosis is usually apparent. One or both testes may be missing from the scrotum. The condition, however, needs to be differentiated from retractile testis. Sometimes the testes move up and down depending on the temperature of the surroundings. If the child is in a warm bath his testes are normal, but if he is exposed to cold or stroked along his upper thigh, the testes move up towards the abdomen. This up and down movement is normal and these testes are called retractile testes. They do not require any treatment. The paediatric surgeon or urologist will be easily able to differentiate between a retractile testis and a true undescended testis. By examining the child he will also be able to locate the position of the undescended testis. Tests like ultrasound scan or CT scan to locate the testes are rarely required and are not very helpful. If the testis is not felt on repeated examination, the doctor may advise a laparoscopy examination to determine whether or not the testis is present in the abdomen. Sometimes testes can reach some place other than scrotum, a condition called ectopic testes. On examination, it is important to differentiate between undescended or atrophic testis, in latter condition, the testis is very small and can be difficult to feel.

Why is treatment needed for undescended testis?

It is very important for the boy's psyche to have two normal testes in the scrotum. This is often an underplayed argument. Testes require a temperature slightly lower than the body temperature for sperm production. If they lie too close to the body, then over time the cells that produce sperms die leading to infertility. To minimize this damage undescended testes need to be brought down to the scrotum by 6 months of age. Undescended testis are often associated with a hernia which requires surgical correction.

If the testes remain in the abdomen for a long time, they have a slightly higher chance of developing a cancer. If testis is in groin area, it is more easily injured during play or accidents.

What is the treatment?

The best treatment for undescended testis is an operation called orchidopexy. This operation is best done before 6 months of age. It is a safe procedure that is performed under general anaesthesia. Admission to hospital is usually not required. A small cut is made in the groin, the testis is freed from its attachments and its blood supply is preserved. Another small cut is made in the scrotum and a small pouch is made under the skin in which the testis is placed. The operation usually takes about an hour, the child is able to feed shortly thereafter and can walk about from the same evening. In some cases, the doctor may prescribe injections of a hormone called human chorionic gonadotropin (HCG). The role of this is not defined and may be tried only in some cases where both testes are undescended.

What if the doctor is not able to feel the testis?


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There are several possibilities in this case. Either the testis did not form. Or that it did form but underwent damage and has become useless. Or it lies somewhere inside the abdomen. This differentiation is possible by laparoscopy in which a small telescope is inserted into the child's abdomen under anaesthesia and the insides are examined to locate the testis. In the first two cases nothing further needs to be done except removing the useless testis. If the testis is inside, it will need to be brought down. In cases where one testis is missing, an artificial testis may be placed in the scrotum later so that the child does not suffer from an inferiority complex.

Cryptorchidism literally means hidden or obscure testis. It is synonymous with incomplete testicular descent. The condition may be unilateral or bilateral. The testicles descend to a scrotal position in human beings in order to optimize sperm production. The actual mechanisms of descent are unknown at present time. Certain important factors that cause proper descent include traction on testis by attachments in the scrotum, differential growth of the body wall, intra-abdominal pressure, maturation of the epididymis being responsible for migration of the testis. Multiple hormonal factors contribute also. When we see a child with an undescended testicle the ultimate diagnosis can be classified according to several different categories

● Testicular retraction: This is the most common factor resulting in the inaccurate diagnosis of an undescended testicle. It is common in boys 5-6 years old and is due to a hyperactive cremaster muscle reflex. This is basically a variation of normal. In children from 1 year to 11 years of age, 80% of fully descended testes can withdraw from scrotum and leave an empty scrotum behind due to cremaster reflex. If a testicle can be milked down to the bottom of the scrotum, it is considered a retractile testis, and no further treatment is needed. This phenomena usually disappears by puberty.

● Cannilicular testis: Here the testicle located above its natural position in the scrotum, but still outside the abdominal cavity. Tension from the external musculature of the body wall prevents normal descent into the scrotum.

● Intra-Abdominal testes: Here the testicle is located inside the abdominal cavity residing in a position along its pathway of natural descent. In such a position, it is not amenable to future examination by a physician, and it is at risk of becoming cancerous.

● Ectopic testicle: Here the testicle may be found in regions not in the usual pathway of descent into the scrotum. Five major sites of ectopia are perineum, femoral canal, superficial inguinal pouch, suprapubic area, and contralateral scrotal pouch. The etiology is believed to be misdirected attachment to the scrotum.

● Absent testicle: Such a phenomena of absent testicle can be bilateral (affecting both sides). It is believed to be associated with in utero torsion, vascular insult, or agenesis.

X-Ray studies - Generally radiologic imaging is not reliable. Ultrasound can help identify a testicle located in the inguinal canal, but is of limited use for intrabdominal testes. MRI and CT scan can be useful for intrabdominal testes, but they are often difficult to use on small children and have a high rate of false negative results.


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MANAGEMENT Bilateral undescended testes

First intersex (females with adrenal hyperplasia) should be ruled out. If the boy is less than 9 years old and he has bilateral undescended testes, hormonal work-up is needed. This work-up may lead to a diagnosis of bilateral anorchia which means the testes never formed on either side.

If the hormonal work-up is normal, an HCG stimulation test is applied and testosterone is subsequently measured. Patients with bilateral anorchia will not make testosterone in response to HCG.

Retractile testis

This is a normal variant This phenomenon usually disappears by 13 years of age

General thoughts Reasons to treat the undescended testicle

Most pediatric surgeons recommend orchiopexy by 1 to 1.5 years of age or earlier. We recommend treatment of the undescended testicle before one year of age. There is evidence that early damage to the germ cells that produce sperm begins at this age. Other reasons to treat are psychological reasons and placement of testicle in position more amenable to physical examination to pick up testis cancer. The most effective treatment is surgery, which can be performed as an outpatient. Pharmacotherapy has the advantages of avoiding anesthesia and being minimally invasive. HCG (human chorionic gonadotopin) is the drug of choice. Hcg is thought to stimulate Leydig cells of testicle to produce male hormones. The precise mechanism of action is unknown. Injections of HCG are given several times per week over several weeks. This can produce descent in some children. However, the success rates have been reported to be as low as10%. Unfortunately the results of hormone treatment have diminshed success in children less than two years of age.

Usually a maximum 5 week course is undertaken. Patients failing hormonal therapy should undergo surgical treatment

Surgical therapy

Surgery is immediately performed on ectopic testes, cryptorchids with coexisting hernias, and boys at pubertal age. When a testis is felt in the groin area we usually explore the area through a small incision. made in the skin above the scrotum called the inguinal region. Most undescended testes are associated with a hernia that must be repaired. After this is done, the testis is brought down into the scrotum and anchored in a space created in the scrotum (orchiopexy). Both Incisions (in the inguinal region and scrotum) are closed with absorbable sutures. Concealed Laparoscopic Orchiopexy


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Laparoscopy can be used to localize nonpalpable, undescended testes. The laparoscopy is performed first to find out if the testicle is located in the abdomen or if it is congenitally absent. If the testis is low in the abdomen, an orchidopexy is performed laparoscopically. A laparoscope is inserted through a small umbilical opening to locate the non-palpable testis. If the testis is healthy, a second instrument is placed through a small opening in the scrotum to move the testicle into its natural position. Sometimes the testicle is located too high in the abdominal cavity to reach in a one step operation. In this setting, the testicle will be freed of it previous blood supply and placed in a location such that it can be brought down with a second operation. The second stage is performed in 6 months.

Follow-up Long-term issues include infertility and tumorigenesis. After the initial post-operative visits, children should be seen 1 year after surgery to note the location and size of the testes. At puberty, boys should be taught how to perform monthly testicular self-examinations. The threshold for future ultrasound examination. Once the boys reach adulthood, issues regarding fertility must be further explored with a urologist. Phimosis Phimosis is when the foreskin is very tight and cannot be pulled back over the head of the penis (glans). It is normal for the foreskin to be attached to the head of the penis up until about the age of five. Parents should not try to pull the foreskin back because it can cause pain or injury. However, after the age of five, the foreskin will usually have separated by itself and can be pulled back. In some boys, phimosis can continue up to the age of 10 and, occasionally, it can continue into adulthood. Boys who have phimosis, and are under the age of six, do not usually require circumcision, but it may be considered after this age if the foreskin is damaged. Damage can happen as a result of severe or repeated infections. However, in the majority of cases, the foreskin will loosen naturally, with true phimosis only accounting for about 1% of cases. Some boys have a rare form of phimosis, which is often known as true phimosis. This is usually a congenital condition (present from birth), which prevents the foreskin from being pulled back at all. It can also develop following several infections of the foreskin and head of the penis. True phimosis is normally treated with circumcision, although parents often do not recognise the condition when their son is a baby.

In babies, following circumcision, the foreskin takes about seven to ten days to heal. However, in older boys, and men, the healing process can take up to three weeks. Dissolvable stitches (that dissolve on their own) are usually used to close up the wound following circumcision. As circumcision is a painful procedure, painkillers, such as paracetamol, or ibuprofen, will need to be taken for at least the first three days after the operation. Circumcision exposes the sensitive skin of the glans. In babies, nappies can rub against the glans, making it sore. Therefore, make sure that you tuck down your babys penis before putting the nappy in place. The penis will be red and swollen for a few days after circumcision and children, and adults may find it more comfortable to wear loose clothing for a while. Petroleum ointment put directly on to the area can also help to reduce irritation. After your son has been circumcised, you should make sure that he does not ride a bike, or use other sit-on toys, until the swelling has completely gone down. If you son is of school age, he should be able to return to school about a week after being circumcised. However, you should tell his teacher that he has had the operation. Following circumcision, you should consult your GP if:


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● there is bleeding from your childs penis, ● your childs penis remains swollen after two weeks, or ● your child still finds passing urine painful a few days after the operation.

Older boys, and men, should also see their doctors if they have any problems after a circumcision.

Oral-facial cleftsOral-facial clefts are birth defects in which the tissues of the mouth or lip don't form properly during fetal development. The good news is that both cleft lip and cleft palate are treatable. Most kids born with these can have reconstructive surgery within the first 12 to 18 months of life to correct the defect and significantly improve facial appearance. Oral clefting occurs when the tissues of the lip and/or palate of a fetus don't grow together early in pregnancy. Children with clefts often don't have enough tissue in their mouths, and the tissue they do have isn't fused together properly to form the roof of their mouths. A cleft lip appears as a narrow opening or gap in the skin of the upper lip that extends all the way to the base of the nose. A cleft palate is an opening between the roof of the mouth and the nasal cavity. Some kids have clefts that extend through both the front and rear part of the palates, while others have only partial clefting. The three common kinds of clefts are:

1. cleft lip without a cleft palate 2. cleft palate without a cleft lip 3. cleft lip and cleft palate together

In addition, clefts can occur on one side of the mouth (unilateral clefting) or on both sides of the mouth (bilateral clefting).

More boys than girls have a cleft lip, while more girls have cleft palate without a cleft lip.

Causes

Doctors don't know exactly why a baby develops cleft lip or cleft palate, but believe it may be a combination of genetic (inherited) and environmental factors (such as certain drugs, illnesses, and the use of alcohol or tobacco while a woman is pregnant).The risk may be higher for kids whose sibling or parents have a cleft or who have a history of clefting in their families. Both mothers and fathers can pass on a gene or genes that can contribute to the development of cleft palate or cleft lip.

Complications


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Kids with a cleft lip or palate tend to be more susceptible to middle ear fluid collections, hearing loss, and speech defects. Dental problems — such as missing, extra, malformed, or displaced teeth, and cavities — also are common in kids born with cleft palate. Many children with clefts are especially vulnerable to ear infections because their eustachian tubes don't drain fluid properly from the middle ear into the throat. Fluid accumulates, pressure builds in the ears, and infection may set in. For this reason, they may have special tubes surgically inserted into their ears at the time of the first reconstructive surgery. Feeding can be another complication for an infant with a cleft lip or palate. A cleft lip can make it more difficult for a child to suck on a nipple, while a cleft palate may cause formula or breast milk to be accidentally taken up into the nasal cavity. Special nipples and other devices can help make feeding easier; you'll get information on how to use the specialized feeding equipment and where to buy it before you take your baby home from the hospital. In some cases, a child with a cleft lip or palate may need to wear a prosthetic palate called an obturator to aid in proper eating.

If your baby has problems with feeding, your doctor can offer other suggestions or feeding aids.

Treatment

A child with oral clefting will see a variety of specialists who will work as a team to treat the condition. Treatment usually begins in the first few months of life, depending on the health of the infant and the extent of the cleft. The specialists will evaluate your child's progress regularly, and monitor hearing, speech, nutrition, teeth, and emotional state. They'll share their recommendations with you, and can forward their evaluation to your child's school and any speech therapists that your child may be working with. In addition to treating the cleft, the specialists will work with your child on any issues related to feeding, social problems, speech, and your approach to the condition. They'll provide feedback and recommendations to help you through the phases of your child's growth and treatment.

Surgery for Oral Clefting

Surgery is usually performed during the first 3 to 6 months to repair cleft lip and between 9 and 14 months to repair the cleft palate. Both types of surgery are performed in the hospital under general anesthesia. Cleft lip often requires only one reconstructive surgery, especially if the cleft is unilateral. The surgeon will make an incision on each side of the cleft from the lip to the nostril. The two sides of the lip are then sutured together. Bilateral cleft lips may be repaired in two surgeries, about a month apart, which usually requires a short hospital stay. Cleft palate surgery involves drawing tissue from either side of the mouth to rebuild the palate. It requires 2 or 3 nights in the hospital, with the first night spent in the intensive care unit (ICU). The initial surgery is intended to create a functional palate, reduce the chances that fluid will develop in the middle ears, and help the teeth and facial bones develop properly. In addition, this functional palate will help speech development and feeding abilities. The need for more operations depends on the skill of the surgeon as well as the severity of the cleft, its shape, and the thickness of available tissue that can be used to create the palate. Some kids require more surgeries to help improve their speech. Additional surgeries may also improve the appearance of the lip and nose, close openings between the mouth and nose, help breathing, and stabilize and realign the jaw. Later surgeries are usually scheduled at least 6 months apart to allow time to heal and to reduce the chances of serious scarring.


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Final repairs of the scars left by the initial surgery may not be performed until adolescence, when facial structure is more fully developed. Surgery is designed to aid in normalizing function and cosmetic appearance so that kids will have as few difficulties as possible

Dental Care and Orthodontia

Children with oral clefting often undergo dental and orthodontic treatment to help align the teeth and take care of any gaps caused by the cleft. Routine dental care may get lost in the midst of these major procedures, but healthy teeth are critical for kids with clefting because they're needed for proper speech. Kids with oral clefting generally need the same dental care as other kids — regular brushing supplemented with flossing once the 6-year molars come in. Depending on the shape of the mouth and teeth, your dentist may recommend a toothette (a soft sponge that contains mouthwash) rather than a toothbrush. As your child grows, you may be able to switch to a soft children's toothbrush. The key is to make sure that your child brushes regularly and well. Children with cleft palate often have an alveolar ridge defect. The alveolar ridge is the bony upper gum that contains teeth, and defects can:

● displace, tip, or rotate permanent teeth ● prevent permanent teeth from appearing ● prevent the alveolar ridge from forming

These problems can be fixed by grafting bone matter onto the alveolus, which allows the placement of the teeth to be corrected orthodontically. In about 25% of kids with a unilateral cleft lip and palate, the upper jaw growth does not keep up with the lower jaw growth. If this occurs, these kids (as teenagers or young adults) may need orthognathic surgery to align the teeth and help the upper jaw develop.

Speech Therapy

Kids with oral clefting may have trouble speaking — the clefting can make the voice nasal and difficult to understand. Some will find that surgery fixes the problem completely.

Catching speech problems early can be a key part of solving them. A child with a cleft should see a speech therapist between the ages of 18 months and 2 years. Many speech therapists like to talk with parents at least once during the child's first 6 months to provide an overview of the treatment and suggest specific language- and speech-stimulation games to play with the baby.

Dealing With Emotional and Social Issues


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Society often focuses on appearances, and this can make childhood — and, especially, the teen years — hard for someone with a physical difference. Because kids with oral clefting have a prominent facial difference, they might experience painful teasing that can damage self-esteem. Part of the cleft palate and lip treatment team includes psychiatric and emotional support personnel. Ways that you can support your child include:

● Try not to focus on the cleft and don't allow it to define who your child is. ● Create a warm, supportive, ands accepting home environment, where each person's individual

worth is openly celebrated. ● Encourage your child to develop friendships with people from diverse backgrounds. The best

way to do this is to lead by example and to be open to all people yourself. ● Point out positive attributes in others that do not involve physical appearance.

Consider encouraging your child to present information about clefting to his or her class with a special presentation that you arrange with the teacher. Or perhaps your child would like you to talk to the class. This can be especially effective with young children. If your child does experience teasing, encourage discussions about it and be a patient listener. Provide tools to confront the teasers by asking what your child would like to say and then practicing those statements. And it's important to keep the lines of communication open as your child approaches adolescence so that you can address his or her concerns about appearance.

If your child seems to have ongoing self-esteem problems, contact a child psychologist or social worker for support and information. Together with the members of the treatment team, you can help your child through tough times

Follow-up appointment

A follow-up appointment will be scheduled from 7 to 10 days after your child's surgery. Your health care provider will assess your child's wound sites and evaluate his recovery


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