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34 Urological Emergencies 363
Grading of Injury
As in most organs, there is a tendency to stage renal trauma and act according to the severity of injury. The staging system commonly used in urology is the
American Association of Trauma organ injury severity scale for the kidney.
Basically, grades I–III describe the magnitude of perirenal hematoma and laceration of the renal parenchyma. Stage IV entails either a laceration extending
throughout the kidney from the cortex to collecting system or a vascular injury.
Stage V includes a shattered kidney or avulsion of the renal hilum.
Managing the Renal Injury Patient
Well-staged injuries may be managed nonoperatively.
Patients must be carefully followed in an intensive care unit (ICU) setting
with frequent hemoglobin assessment.
Grade IV and V injuries often require surgical exploration.
If bleeding occurs on expectant management, angioembolization may be
therapeutic.
Renal artery occlusion by an intimal tear (deceleration injury) must be re-
paired within 6–8 hrs before the kidney dies.
Experience shows that when in doubt it is better to explore and repair the
injury rather than treat the complications.
Absolute indications for operative management include persistent renal
bleeding, expanding perirenal hematoma, and a pulsatile renal hematoma
denoting arterial renal injury. Relative indications include incomplete
staging, major urinary extravasation (with a medial urinoma; high prob-
ability of ureteropelvic junction tear that will not heal spontaneously), and
>20% nonviable renal tissue.
The Operation for Renal Injury
Exploration of an isolated renal injury is usually done for bleeding in an unstable patient or, rarely, for delayed complications. The appropriate incision is mid-
line from the xyphoid to below the umbilicus. Although the classic access for
elective nephrectomy is retroperitoneal, through the flank, in trauma one may need
to approach the major vessels, and this is easier through a long midline incision.
The old dogma maintained that the renal vessels have to be controlled at
their origin prior to exploring a perirenal hematoma, but this is easier said than
done. Today, we know that there is no real advantage for early vascular control.
In practice, the perirenal hematoma “dissects” all the planes around the kidney.
364 Jack Baniel
The surgeon opens the retroperitoneum lateral to or above the injured kidney
and evacuates the clots. The immediate aims are to mobilize the kidney—lifting
it forward and medially into the wound—and to identify the hilum to control the
renal pedicle and assess the parenchymal damage.
Parenchymal tears are repaired, closing the collecting system with delicate
absorbable sutures and then approximating the parenchyma over bolsters of
Surgicel using blunt atraumatic liver needles (absorbable sutures again).
Following repair of a major tear in the collecting system or a large partial or
heminephrectomy, a double J stent may be best inserted retrogradely through the
bladder into the collecting system to prevent urinary leak.
For a shattered kidney or when the major vessels are not amenable to repair, nephrectomy is the best option. Nephrectomy is also recommended if there
is major trauma to adjacent organs such as the pancreas or bowel since urinary
leak from an ill-performed partial repair may promote local “septic” complications. Studies in animals showed survival without dialysis on 33–50% of one
kidney. Thus, a safe rule of thumb is that if one can save half or more of the kidney it is worthwhile.
Ureter
Ureteric injuries are rare and frequently are recognized late when urine comes
out of a drain after exploration for trauma. The ureter travels in the retroperitoneum
covered on all sides by fat and is very evasive. Thus, it takes a lot of bad luck to have
a ureter transected by a bullet or cut by a knife. Some of the injuries are partial tears
due to a high-velocity missile traveling in the vicinity, injuring the ureter wall and
causing a leak. The hallmark of ureteric injury is leakage of urine, and this is what
appears on IVP or contrast CT. In the setting of penetrating trauma, suspect damage
to the ureter if the injury is in the lateral retroperitoneal areas or in the pelvis. Search
for traumatic ureteral injuries carefully; otherwise, they will be missed.
Iatrogenic ureteric injuries may occur during Caesarean sections and colorectal procedures. If diagnosed intraoperatively, they should be repaired immediately. Some accidental injuries occur during laparoscopy, and they are
usually missed and diagnosed late. Sometimes, the ureter is obstructed by a
stitch or a clip; the patient may complain of flank pain or develop asymptomatic
hydronephrosis, detected on imaging.
Managing the Injured Ureter
The ureter must be carefully examined, and any necrotic segment should be
debrided, although this may compromise its length. Always stent the anastomosis
34 Urological Emergencies 365
to secure urine drainage and augment local tissue apposition. Urine always finds
its way out through an imperfect anastomosis; this is why you see so many different types of stents and tubes in urology and why some urologists consider themselves plumbers.
Lower ureteral injuries (distal to the iliac vessels) are more common and
are easier to fix. Usually, one sacrifices the distal part of the ureter and reimplants the ureter directly into the bladder. In this situation, if the ureter is too
short, one may pull up the bladder by suturing it to the psoas (a psoas hitch) or
use a flap fashioned from the bladder (the Boari flap).
Mid- and upper ureteral injuries less than 2 cm in length are fixed by endto-end (spatulated) anastomosis with optimal apposition using fine absorbable
sutures. Longer injuries may necessitate mobilization of the ipsilateral kidney
and downward positioning, which may offer another couple of centimeters. If
there is a large gap, several options exist; one is to connect one ureter to the other
by tunneling it behind the peritoneum, a transuereto-uretrostomy. Another option, when a large gap is present, is to bridge it with small bowel, an ileal ureter.
An extreme measure would be to autotransplant a kidney in the ipsilateral pelvis, thus bridging a large gap of missing ureter. In experienced hands, these measures are all done with a high rate of success.
Two important notes:
If one encounters ureteral injury while dealing with an extensive and un-
stable trauma case, an easy solution is to clip the ureter above the injury.
When the patient is stabilized and within 24 hrs, one may insert a nephros-
tomy tube and secure drainage of the kidney. Further repair is delayed to a
more appropriate time.
Another point that is often overlooked: if a ureteral injury is very extensive
and necessitates a complex reconstruction, or diagnosed late, or when a
complex urinary fistula already exists, then if the contralateral kidney has
good function, nephrectomy may be the best option.
Bladder
Bladder injuries are usually associated with pelvic trauma. Isolated bladder
rupture occurs especially on holidays when a patient with a full bladder from overdrinking gets hit in the lower abdomen. Penetrating bladder injuries also are often
associated with trauma to other organs. Iatrogenic injuries are common, and obstetricians and gynecologists are the main offenders.
Bladder rupture presents with suprapubic pain and tenderness with gross
hematuria. A cystogram is diagnostic in nearly all cases. Care must be taken to
fill the bladder appropriately. In an unconscious patient, a minimum of 300 ml of
366 Jack Baniel
contrast are instilled through a catheter. In a conscious patient, filling may be
terminated when the patient complains of discomfort.
Bladder tears may be extraperitoneal (lateral flame shaped) or intraperitoneal (contrast outlines the small bowel contour). Extraperitoneal tears are managed by draining the bladder with a large-bore Foley catheter (20–22F) left in situ
for 10–14 days until healing takes place. A cystogram should be performed prior
to catheter extraction. All intraperitoneal injuries need to be explored and sutured primarily with absorbable sutures. Injury adjacent to the bladder neck
needs careful assessment of the ureteral orifices.
Scrotum
Blunt injury of any etiology may cause rupture of the tunica albuginea of the
testis. Blunt injury usually involves a single testis, but penetrating trauma affects
both sides of the scrotum in one-third of cases. Scrotal hematoma is a common
clinical finding but may not correlate with the extent of damage to the testis itself
as bleeding may originate from any of the other structures in the scrotum. Also,
failure to feel the testis does not mean that it is damaged. Severe testicular pain
radiating to the abdomen is suggestive that the testis has been injured. We have
treated patients screaming with pain, and resistant to narcotics, who had almost
no scrotal swelling or hematoma on examination; at operation, however, their tunica albuginea was found to be ruptured. Although ultrasound is the best imaging
modality to assess the scrotum and testis, an unequivocal report does not rule out
testicular trauma. When in doubt, it is best to explore the scrotum.
Management
Early exploration and repair of testis injury is the rule. Early repair is associated with increased testicular salvage, quicker convalescence, and preservation of
testicular function. Explore the scrotum through a transverse incision; pass
through the various layers (like cutting an onion) until reaching the tunica albuginea. When the tunica has been breached, you will see the seminiferous tubules
flowing out like tiny spaghetti. Damaged tissues should be debrided and the tunica
albuginea repaired. Even simple clot evacuation from a large hematocele will hasten recovery.
Urologists are just glorified plumbers.
Abdominal Emergencies
in Infancy and Childhood
Wojciech J. Górecki
Children are not small adults.
The well-known phrase that children are not small adults is eminently
applicable to pediatric abdominal emergencies, not only because of differences
in physiology and metabolism, but also because of a different clinical spectrum
of abdominal emergencies, their presentation, and management. This chapter
focuses on abdominal surgical emergencies in infants and small children.
Neonatal emergencies are omitted as you are unlikely to encounter them unless
you are a specialist pediatric surgeon.
The first principle to remember is that you are less likely to commit an error
if you consider an atypical presentation of a common condition than a typical
presentation of a rare condition. In other words, a pediatric acute abdomen is intussusception in infancy or appendicitis in childhood—until proven otherwise.
Another principle is that, much like with adults, watchful waiting is a prudent
strategy in children.
35
General Approach to Pediatric Abdominal Pain
The philosophy of classifying the multiple etiologies of the acute abdomen
into several well-defined clinical patterns, presented in > Chap. 3, works for chil-
dren as well. The major pitfalls in assessing the pediatric acute abdomen are
timing, history, and abdominal palpation.
Children with abdominal pain present to the emergency room at varying
stages of disease because the timing of presentation depends on the parents.
Some parents delay, while others rush their darlings to the emergency room (ER)
at the slightest sign of trouble. As a general rule—as originally stated by Sir Zachary Cope—consider any abdominal pain lasting more than 6 hrs as a potential
surgical problem.
Wojciech J. Górecki
Department of Pediatric Surgery, Jagiellonian University Children’s Hospital, Wielicka 30-663
Kraków, Poland
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_35, © Springer-Verlag Berlin Heidelberg 2010
367
368 Wojciech J. Górecki
Younger children do not give you a history, but listen to the parents because
they know their kids so well. A classical example is intussusception, for which a
description of the child’s behavior and a glance at the stool can point you to the
diagnosis even before the physical examination.
The importance of gentleness during abdominal palpation cannot be over-
emphasized. The majority of children with a sore tummy object to abdominal
palpation. Sometimes, a toy provides a temporary distraction that will allow you
to examine the abdomen, but it is pointless to persist if the child is antagonized.
Instead of the usual “head-to-toe” sequence of the physical exam in adults, take
advantage of a spell of sleep or inattention to sneak a warm gentle hand underneath the blanket to palpate the abdomen.
An infant who will not allow a gentle attempt even when held in his or her
mother’s lap should be sedated because sedation does not affect muscle guarding.
Our preference is intranasal midazolam 0.1–0.2 mg/kg.
Examination of the scrotum is essential for two reasons. First, an acute condition
in the right testicle, such as torsion, can present with pain in the right groin and iliac
fossa. Second, perforated appendicitis occasionally presents with a painful scrotal
swelling because pus enters the patent processus vaginalis, causing acute funiculitis.
Rectal examination is best left to the end of the physical examination, after
looking at the throat and ears, and is not needed if there is a clear indication for
laparotomy.
Clinical Patterns of Acute Abdomen in Kids (see also > Chap. 3)
The combination of acute abdominal pain a nd shock is rare in children and
should make you think of occult abdominal trauma with rupture of an enlarged
solid organ or a tumor (e.g., ruptured Wilms’ tumor). Contrary to adults, urgent
laparotomy is not always indicated.
Generalized peritonitis in children is most commonly due to appendicitis.
Do not try to elicit rebound tenderness as you will lose the confidence and cooperation of your patient. (This applies to adults, too!)
Localized peritonitis in the left lower quadrant can be due to acute consti-
pation, whereas right or left upper quadrant tenderness is commonly due to acute
distension of the liver or spleen, respectively.
Intestinal obstruction in a v ir gi n abdo me n is ca us ed by in tu ssuscept io n or ap -
pendicitis. One of ten children with complicated rotational anomalies of the midgut
presents after the neonatal period. The critical concern with malrotation is midgut
volvulus with acute bowel ischemia. This life-threatening condition carries the risk
of rapid transmural intestinal necrosis. Your surgical intervention should be prompt
because simple counterclockwise detorsion of the bowel may save it. The two major
pitfalls in pediatric small bowel obstruction are missing an incarcerated inguinal
hernia and waiting too long with conservative management before surgery.
35 Abdominal Emergencies in Infancy and Childhood 369
Fig. 35.1. Pediatric abdominal emergencies
A wide spectrum of nonsurgical conditions mimics abdominal emergen-
cies. Particularly in infants, any acute systemic disease may present with apathy,
vomiting, and stool abnormalities. Gastroenteritis is common in children and
typically presents with acute abdominal complaints. The converse is also true. A
child with an acute abdomen may present with a wide array of seemingly unrelated
Specific Pediatric Emergencies
The relative incidence of the conditions in the different age groups is depicted in > Fig. 35.1.
Acute Appendicitis (see also > Chap. 28)
Acute appendicitis (AA) is rare during the first year of life and is uncommon
during the second. Thereafter, the incidence rises and peaks between ages 12
and 20. AA in infancy typically presents as generalized peritonitis due to perforation. The infant looks unwell, with fever, tachycardia, and tachypnea. The abdomen
is distended and generally tender with guarding. Diarrhea is more common than
constipation. Pay attention to the useful “hunger sign”; it is rare to see a hungry
child who turns out to have AA. Consider AA in the second place on your list of
differential diagnoses for an infant with an acute abdomen and in the first three
places in a child. The white cell count is normal in many cases of pediatric AA, but
neutrophilia is more specific. Admitting children with equivocal signs for observation is a safe option as the chance of rupture under observation in a pediatric
surgical ward is less than 1% (oops—the editors asked for no percentages).
A limited helical computed tomograph (CT) with rectal contrast has
high accuracy in diagnosing AA in children, but clinical examination by an
experienced pediatric surgeon is just as good. Even if the CT scan is “positive”,
appendectomy is not indicated if the child improves clinically.
370 Wojciech J. Górecki
What is the role of laparoscopy in the doubtful case? While it offers
the advantage of a diagnostic modality that can be immediately followed by appendectomy, it will subject some children to an unnecessary operation. If you
can get the child into a CT scanner without general anesthesia, this should be
your preferred choice instead of diagnostic laparoscopy.
Although a valid alternative to the open technique, the value of laparoscopic
pediatric appendectomy remains controversial because there are no good data to
suggest that it confers an advantage in postoperative recovery. The short distances
and thin abdominal wall of children allow a port- exteriorization appendectomy,
performed via two ports, with the appendix exteriorized by pulling it out of the
right iliac fossa port, and then the entire appendectomy is performed outside the
abdomen. Or, the appendix can be pulled out of the umbilical port, and if you
have a laparoscope with a working channel, you can perform a single-port appen-
dectomy using the same technique. [This would be equivalent to a conventional
“no-port appendectomy” through a 2-cm incision—The Editors].
There is no point in culturing the peritoneal fluid in case of obvious AA
because the results are predictable, and antibiotics have usually been stopped by
the time the culture results become available. Decide on the duration of postoperative antibiotics according to the degree of contamination or infection found
in the peritoneal cavity (see > Chaps. 12 and 47).
Intussusception
Telescoping of one portion of the intestine into another (intussusception)
can turn a healthy baby into a critically ill patient within a few hours. It typically
occurs between the ages of 5 and 7 months, and the etiology is idiopathic. In children older than 2 years, look for an underlying pathology, the most common being
a Meckel’s diverticulum. Early intussusception is generally a benign condition,
although it is a strangulating obstruction eventually leading to vascular compromise. Most cases start in the ileum as ileoileal intussusception and then progress
through the ileocecal valve to become ileocolic intussusception.
The diagnosis is straightforward if the infant exhibits the classical clinical
syndrome. A previously healthy infant suddenly starts to scream, pulls up his or
her legs, and perhaps clutches the abdomen. The pain is then relieved, and the
child may relax for a while only to have a similar bout 15–30 min later. This leaves
the infant pale and ill. Vomiting and passing of “red currant jelly” stools is also
characteristic, although salmonellosis may show a similar clinical picture.
Atypical presentations are common and lead to diagnostic errors. The infant may
be fretful and restless without either pain or vomiting. Pallor and peripheral coolness due to vasoconstriction, lethargy, and seizures may also confuse the picture.
The crucial physical sign is palpation of an abdominal mass. The ultrasonographic
findings of a “target sign” on cross section and “pseudo-kidney sign” in a longitudinal view are important adjuncts to the clinical diagnosis (> Fig. 35.2).
35 Abdominal Emergencies in Infancy and Childhood 371
Fig. 35.2. Sonographic images of intussusception. On the left: longitudinal plane
showing “pseudo-kidney sign.” On the right a transverse plane showing the “target sign”
Fig. 35.3. Fluoroscopic monitoring of retrograde reduction of the intussusceptum
by means of hydrostatic barium enema, with complete reduction (in the lower figure on
the right, contrast is visible in the small bowel)
Children with diffuse peritonitis, perforation, progressive sepsis, and possible gangrenous bowel should undergo an urgent laparotomy. Early intussusception without peritonitis is reduced nonoperatively with pneumatic or
hydrostatic pressure under radiographic or ultrasonic guidance. Water-soluble
contrast is safer than barium in case of suspected perforation. Reduction is successful in the majority of cases but requires close collaboration between surgeon
and radiologist (> Fig. 35.3).
372 Wojciech J. Górecki
Operative reduction of an early intussusception: squeeze on the apex of
the intussusception while the bowel is still within the abdomen so that the intussuscepted segment begins to slide out. When the reduction reaches the region of
the hepatic flexure, it may become more difficult but after you eviscerate the
proximal colon, the reduction can be completed under direct vision. After
achieving complete reduction, remember to examine the entire bowel for a pathology serving as a lead point. If the intussusception is truly irreducible or if the
bowel has suffered a serious vascular compromise—resect it.
Meckel’s Diverticulum
Two-thirds of Meckel’s diverticula encountered by surgeons are incidental
findings; the remaining one-third will present with a complication. Pediatric surgeons encounter different proportions as the incidence of these complications is
maximal during the first 2 years of life and decreases thereafter, so that more than
two-thirds of all complications occur in the pediatric population. These complications include bowel obstruction (adhesive obstruction, volvulus, or intussusception); complications with peptic ulceration in ectopic gastric mucosa (stricture,
hemorrhage, or perforation); or acute inflammation (“second appendicitis”).
There is also a distinct tendency for foreign bodies to penetrate and perforate a
diverticulum. We have seen a 5-year-old girl with complete bowel obstruction by
a Meckel’s diverticulum filled with excessively ingested Gummi Bears candies.
Littre’s inguinal hernia contains a strangulated Meckel’s diverticulum and, like
Ri chter’s hernia, may not produce signs of intestinal obstruction.
The treatment of a symptomatic diverticulum is resection. Diverticulectomy
is possible if the base is wide and noninflamed but remember to check the base
of the diverticulum and the adjacent ileum for ectopic mucosa because the bleeding source may lie within it. If in doubt, or if there is any technical difficulty,
resect the involved segment of ileum.
What should you do with an incidentally found Meckel’s diverticulum?
Consider the degree of peritoneal infection (caused by the primary indication for
laparotomy), the patient’s age, and the shape of the diverticulum. On balance, the
arguments against removing an asymptomatic Meckel’s diverticulum are a little
stronger than those in favor, and the strength of the argument increases with the
age of the patient. Thin-walled, wide-mouthed, mobile (without a fibrous band
to umbilicus or mesentery) diverticula should be left alone.
Irreducible Inguinal Hernia
The emergency of irreducible inguinal hernia occurs primarily in boys during
their first year of life. The fundamental difference between an irreducible inguinal
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