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CHAPTER 12 Paediatric surgery
442
Necrotizing enterocolitis (NEC)
Key facts
• Range of intestinal infl ammation, ranging from mild mucosal injury to
full thickness necrosis and perforation.
• Perforated NEC associated with 40% mortality in neonates.
Clinicopathological features
• Associated with:
Premature delivery.•
Formula milk feeds.•
Hypoxia.•
Systemic sepsis.•
‘Micro-epidemic’ outbreaks in neonatal units.•
• Typically affects premature babies on ventilatory support.
• Features of vomiting, distension, bloody mucus passing PR.
• May shows signs of severe sepsis/shock (tachypnoea, poor perfusion,
temperature instability).
Diagnosis and investigations Plain AXR. Pneumatosis intestinalis,
portal venous gas, free gas if perforation, dilated, thick-walled (oedematous) bowel.
Treatment
Medical
• Fluid resuscitation.
• IV antibiotics.
• Bowel rest and TPN.
Surgical treatment
• Indicated by complications (perforation, failure to respond to medical
treatment, abdominal mass, systemic sepsis).
• May include:
Peritoneal drainage.•
Bowel resection (usually with stoma formation).•
Complications
• Septicaemia.
• Enteric fi stulation.
• Peritonitis.
• Adhesions.
• Enteric stricture.
• Short gut syndrome.
• Death.
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CHAPTER 12 Paediatric surgery
444
Inguinal hernia and scrotal swellings
Inguinal hernia
Key facts
• Childhood inguinal hernias derive from a persistent processus vaginalis
and are invariably indirect.
• ♂:♀, 7:1.
• Right-sided hernias (60%) are commoner than the left (25%); 15% are
bilateral.
• Higher incidence of complications (incarceration) than adult hernias.
Clinical features
• Usually noticed as a painless swelling, variable in size in the
inguinoscrotal or labial area.
• More prominent when the baby cries and may disappear
intermittently.
• Bowel entrapment causes pain and irreducibility leads to strangulation,
intestinal obstruction, perforation, and peritonitis.
• Ovarian entrapment may occur in females.
• Bile vomiting in a young infant should always prompt examination of
the inguinoscrotal area.
• Cardinal feature is a swelling in the groin above which the examining
fi ngers cannot defi ne the inguinal canal (‘cannot get above’).
• Asymmetrical thickening of the spermatic cord in the presence of a
history compatible with a hernia is strongly suggestive of the diagnosis.
Treatment
• Prompt surgical treatment is important in premature/young infants to
avoid risks of complications.
• Herniotomy alone is adequate. No need to repair the walls of the
canal; usually a simple, straightforward day case procedure.
• Acute surgery can be very diffi cult when it is irreducible or
strangulated or in very young infants.
Hydrocele
• Congenital fl uid-fi lled processus vaginalis and tunica vaginalis.
• Communicates with the peritoneal cavity in children.
• Scrotum is usually smoothly enlarged and sometimes bluish in colour
and the testis is often surrounded by the hydrocele.
• Occasionally acquired due to trauma, infection, or testicular tumour.
• Simple hydroceles may resolve spontaneously up to age of 18 months;
surgical intervention is deferred until 18 months.
• At operation, ligation of the patent processus vaginalis and drainage of
the fl uid are adequate; there is no need to excise the hydrocele wall.
Varicocele
• Due to a dilated pampiniform venous plexus of the spermatic cord.
• Onset usually after puberty.
• Has the feel of a ‘bag of worms’ during palpation of the cord.
INGUINAL HERNIA AND SCROTAL SWELLINGS
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• Indications for treatment include discomfort (aching), cosmesis, and
concern about fertility. The procedure is carried out by high ligation of
the plexus, either by open or laparoscopic surgery.
• Beware an acute left varicocele in childhood due to obstruction of the
left renal vein by tumour (nephroblastoma).
• Treatment may be surgical ligation or radiologically-guided
embolization.
Idiopathic scrotal oedema
• Aetiology unknown; possibly due to an acute allergic reaction.
• Characterized by painless, red, unilateral scrotal swelling extending to
the groin and the perineum.
• Rapidly resolves spontaneously; the clinical diagnosis precludes the
need for investigation.
445
CHAPTER 12 Paediatric surgery
446
Other childhood hernias
Umbilical hernia
Key facts
• Persistence of the physiological umbilical defect beyond birth.
• Usually close spontaneously (especially in premature infants).
• Have a low incidence of complications (incarceration/strangulation).
Clinical features Usually noticed as a painless, intermittent swelling at the
umbilicus.
Treatment
• Delay repair beyond age 4 in Caucasian children; beyond age 8 in
Afro-Caribbean children.
• Simple sutured closure of defect in surgery required.
Epigastric hernia
Key facts
• Defect in the midline linea alba between the umbilicus and the xiphoid
process.
• Very rarely closes spontaneously.
• Have a low incidence of complications (incarceration/strangulation).
Clinical features Usually noticed as a painless, intermittent swelling above
the umbilicus.
Treatment Simple sutured closure of defect required.
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CHAPTER 12 Paediatric surgery
448
Prepuce (foreskin) and circumcision
Key facts
• One of the commonest reasons for referral to a paediatric surgical
clinic.
• Prepuce (foreskin) is initially fused to the glans penis. Preputial
‘adhesions’ lyse spontaneously as part of normal development.
• Separation of the prepuce from the glans is gradual; 80% of newborns,
50% of 1y-olds, and 10% of 5y-olds will have a non-retractable
prepuce.
Non-retractable foreskin
Clinical features
• Only rarely causes problems which include dysuria, frequency, spots
of blood, ballooning, and spraying.
• Very occasionally causes recurrent balanitis with redness, soreness,
and cellulitis. Preputial ‘cysts’ are often present—these are collections
of subpreputial smegma and are part of normal development.
Treatment
• Often only reassurance and advice are needed.
• Leave the foreskin alone if asymptomatic.
• Frequent bathing and hygiene and gentle attempts at retraction.
• Hydrocortisone 1% topically relieves symptoms and may speed
separation.
• Topical or rarely, oral antibiotics only for recurrent balanitis.
• Persisting symptoms warrant retraction and separation using LA or
under GA.
Phimosis
Defi ned as a non-retractable foreskin with associated scarring that will not
resolve spontaneously.
Clinicopathological features
• May be congenital (uncommon) or acquired (usually age 5+) secondary
to infl ammation.
• Commonest cause balanitis xerotica obliterans (BXO); foreskin looks
pale, thickened, and scarred.
• Additional symptoms to those of a non-retractable foreskin are
retention of urine, paraphimosis, obstruction, and back pressure on the
upper urinary tract. Consider an ultrasound scan and ascending urinary
tract infection, in which case antibiotics are indicated.
Treatment
• Circumcision.
• Dorsal slit of foreskin.
• Preputioplasty (prepuceplasty).
• Non-surgical treatment using Plastibel is occasionally used in neonates.
PREPUCE (FORESKIN) AND CIRCUMCISION
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How to examine a child’s foreskin
• Try to ensure the boy is happy and relaxed, lying on examination
couch or parental knee.
• Normal foreskin often appears long and ‘redundant’.
• Gently hold tip of prepuce between fi nger tips, lift forward, and
spread wide open. Preputial orifi ce usually demonstrated.
• If retraction attempted, perform gently to show pouting of mucosa.
• Blanching of skin below preputial opening—normal.
• Tight, white contracted preputial orifi ce indicates fi brotic phimosis
(‘muzzling’).
449
CHAPTER 12 Paediatric surgery
450
Undescended testis
Key facts
• Testicular descent from the fetal abdominal site into the scrotum is
normally complete by birth.
• Absence of a scrotal testis (cryptorchidism) may be due to agenesis
(rare), intra-abdominal arrest, incomplete descent (intracanalicular), or
ectopic descent (inguinal, perineal, crural, penile).
• Incidence 2–4% of newborn boys, falling to 1.5% at 6 months.
• Commoner on the right side.
Clinical features
• Undescended testis can be noted at the post-natal check, by parents,
or by the GP.
• Rarely presents acutely as torsion (tender mass in inguinal region).
• A retractile testis is one that can be brought down into the scrotum
with gentle manipulation, but retracts into the superfi cial inguinal
pouch, either spontaneously or with minor pressure (see Box 12.4).
Diagnosis and investigations
• No investigations are required in palpable undescended testis.
• Chromosomal studies and HCG stimulation test may be requested in
bilateral impalpable testes.
• Ultrasound may help locate an impalpable testis.
• Diagnostic laparoscopy is defi nitive and allows further management.
Treatment
• Testis should be brought to the scrotum at 1–2y of age to avoid
secondary damage due to trauma, torsion, and increased ambient
temperature.
• Hormone manipulation is ineffective in true undescended testis.
• Intracanalicular or ectopic testis should be managed by one-stage
orchidopexy.
• Intra-abdominal testis can be brought down by one- or two-stage
orchidopexy (50–90% success).
• Laparoscopy for bilateral impalpable testes.
• Scrotal position facilitates self-examination to detect signs of neoplastic
change (74 times normal in an abdominal testis).
Complications
• Post-operative atrophy of the testis (<2%) unless intra-abdominal
position (10–50%).
• Retraction.
UNDESCENDED TESTIS
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Box 12.4 How to exclude retractile testis
• A cooperative, relaxed little boy is essential. Examine on carer’s
knee or lying down.
• Control inguinal canal with fi nger pressure (prevents retraction of
testis).
• Palpate tissues superfi cial to external inguinal ring, working down to
scrotum.
• Try to manipulate testis into scrotum—then release.
• True retractile testis should remain in scrotum briefl y.
• About 95% true retractile testes descend spontaneously before
puberty and require no follow-up (75% apparently retractile testes
become ‘ascending’).
Indications for orchidopexy
• Maximize sperm production.
• Prevent testicular torsion.
• Repair of associated inguinal hernia.
• Cosmesis.
• Reduce chance of malignancy development and improve
self-examination success.
451
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