1. Common
Pediatric Surgical Conditions
&
Ideal Timings for Management
Dr. Arjun A. Pawar
MBBS, MS, M. Ch. Pediatric Surgery,
DNB Pediatric Surgery, FMAS,
FIAGES.
Divine Pediatric Surgery Centre. i. a.
w.
3. Why ideal timing important
Undue worry in parents
Undue expenses
Loss of function of organ e.g. Testis, kidney.
Psychological impact e.g. UDT, HPS
Chances of development of complications
Phimosis, Hernia, UDT, PUJO,
Timely intervention – best outcome.
7. Management
• Physiological: Settles over period
Circumcision (1%)
• Pathological: Circumcision(Soon After Diagnosis)
Religious circumcision- Any time
Contraindication
Hypospadias, DSD , Micropenis.
10. Female inguinal hernia
Evaluated to R/O
46XY DSD with female
phenotype.
CAIS
Complete Leydig cell
hypoplasia
CAH with defects in
testosterone
biosynthesis,
Gonadal agenesis/
dysgenesis
11. Inguinal Hernia
Will not resolve spontaneously,
Surgical closure is always indicated
Usual Advise-Let him grow, No hurry.
Wait for 6 mths,
Wait for 1 year.
Patient land up with complications &
major surgery.
13. Management- Ideal Time
Soon after diagnosis
Repair done within 2 weeks
(90% complications reduced if operated within 1
month from diagnosis)
Exceptions - Premature infants
Repair before discharge/Child weight 2 kg.
17. Umbilical hernia
• Usual Advise:
Repair immediately in neonatal period,
Too late- 5 to 6 yrs of age or beyond
Ideal timing for repair
• Typical umbilical hernias :
Observed up to 2 yrs. of age
• No UR contraction : Anatomical Repair
• Complications : Early Repair
20. Hydrocele
Usual advise:
Go for immediate repair
Referred to higher center - Neonatal period
Wait up to 5-6 yrs. No hurry.
Ideal timing for repair:
Congenital Hydrocele - Conserve up to 2 yrs.
(Non Communicating Hydrocele)
Except:
Communicating Hydrocele (Fluid Hernia)
Hydrocele A/W Hernia
Large Congenital Hydrocele causing discomfort
Immediate Repair
22. Undescended testis
UDT Ectopic Testis Retractile Testis
Palpable/ Nonpalpable
UL / BL
Associated with HPS --DSD
Spontaneous Descent -First 3 months,
Can wait up to 6 mths.
23.
24. Usual Advise
Surgery after 6 to 7 yrs..
No hurry for surgery, can be done later on
Repeated USG– Unnecessary
Increased cost
MRI- Increased Cost
(Diagnostic Laparoscopy- Diagnostic &
Therapeutic)
Delay in treatment – Land up with
Complications
29. Why to operate at recommended age?
High Temperature cause progressive alteration
of function
Decreased LH, T, MIS
Impaired Germ Cell Development
(40% lost by 2 years)
High Chances of development of Complications
Non Functional Testis /
Loss of Testis d/t Torsion
30. Ideal Timing for Orchidopexy
• Orchidopexy is recommended at 6 to 9
months of age.
• Centres with less experience in small children,
surgery between 12 and 18 months may be
safer
34. Hypospadias
Usual Advise
Referral to higher centre in neonatal period,
Too late presentation for repair beyond ideal
timing for repair
• Ideal time for repair:
Repair between 6 and 12 months.
At least before School Admission
Single Stage – Snodgrass Repair, Duckett tube
Staged Repair- Byar’s or Bracka’s Repairs
40. Anorectal Malformations
Inappropriate management - Usually in female
Failure to diagnose malformation
Parents negligence in spite of diagnosis and
referral advise
Poor socio-economic condition
Inappropriate advise- Repair before marriage
42. Anorectal Malformations
Definitive repair - Female
Female with colostomy- ASARP/PSARP at 3 to
5 mths of age…
Female without colostomy : Planned for
Primary ASARP- 3 to 6 months
Cloaca- Standard 3 stage repair
45. Empyema
• Accumulation of purulent fluid in the pleural
cavity
• 1 in 150 pneumonia cases
3 characteristic stages:
Exudative -fluid is thin ,low cellular content;
Fibrinopurulent –fluid loculations/ Septations
Organizing empyema -fibrinous peel.
46. Empyema
Patient presentation at higher centre:
H/O receiving antibiotics for 2 to 3 weeks-
various levels
Intermittent fever spikes
Failure to thrive
Rib cage deformity-Overcrowding of ribs
ICD in situ for weeks together but continuous
purulent discharge is persistent
47. American Pediatric Surgical Association
(APSA)
Simple effusions/Empyema < 5 days duration-
Chest tube drainage.
Symptoms > 5 days- fibrinolysis/ VATS
If symptoms persist >7 days after intervention,
CECT Chest - To determine the presence of pleural
disease
48. CECT Chest
• No pleural disease- Antibiotics alone
• Pleural disease- Loculated collection with peel
enhancement- VATS sos Open decortication
• Beyond 14 days of presentation and very thick
peel- Open decortication
54. Foreign bodies
Tracheobronchial FB/Esophageal FB
Metallic/nonmetallic
Usually:
Pt referred to higher centre for asymptomatic
FB
Started on laxatives
Repeated X-ray- to look for its progression
55.
56. Foreign bodies--TB
Tracheo Bronchial FB - Warrants urgent removal
Rigid or Flexible bronchoscopy
Warning- Any Button Battery ingestion(Toys)-
Most dangerous FB - Urgent referral to experts
May Cause :
Perforation (Tracheal, Esophageal, Intestinal)
Aquired tracheo-esophageal fistula
Management: Emergency retrieval
Rigid bronchoscopy
Upper GI endoscopy
57. Foreign bodies--Intestinal
Asymptomatic metallic FB-
Closed Safety pin, Coin, chain, Marble etc..-
Can be observed safely-
Sharp FB -Open safety pin, Needle, Nails etc.
Admit and observation
If symptoms of acute abdomen- Exploration
Button battery- Emergency retrieval- RB/ ENDO
Usually Banana eating advised ..Laxatives not warranted
58. Summary
Phimosis :- Symptomatic
Umbilical Hernia:- After 2 yrs
Inguinal Hernia:- Soon after diagnosis
Hydrocele:- After 2 yrs
Undescended testis:- 6mths to 1 yr
Hypospadias:- 1yr
ARM:- Within 6
Empyema:- depending on the
stage
Foreign Bodies