PEDIATRIC SURGERY- 2019

1. PEDIATRIC SURGERY-2019 No. :7 Attendance: Obligatory Type of lecture: theory Place : Hall no.4 college of medicine –Mustansiriyah University . • Date : Monday 25th of March 2019. • Time : 8:00 – 9:00 AM. Students: 4th year / college of medicine / Mustansiriyah University By : Dr. Ali E. JodaM.B.Ch.B. - F.I.C.M.S. - pediatric surgeon. E. mail : ali.egab.joda@uomustansiriyah.edu.iq

2. Topics :- • Inguinal hernia • Infantile hydrocele • Undescended testes • Objectives:- • Mention the differential diagnosis of child with inguinoscrotal swelling • Realize the significance of treating inguinal hernia in pediatric as early as possible. • Differentiate inguinal hernia from infantile hydrocele • Recognize the risk of undescended testes in children

3. Inguinal hernia Embryology:- The processusvaginalis is a peritoneal diverticulum that extends through internal inguinal ring & dragged with the testis into the scrotum. The portion of the processusvaginalis that enveloping the testis is called tunica vaginalis. The remainder of the processusvaginalis in the inguinal canal is obliterated. But in 20% of population the processusvaginalis may remain patent asymptomatically throughout the life.

4. Epidemiology:- • Nearly all inguinal hernia in children is congenital indirect type (99%). • The direct one is rare less than 1% & they believed to be acquired. It is more common in connective tissue diseases & conditions with increased intra-abdominal pressure or post inguinal surgery. • Incidence of indirect inguinal hernia is 1-2 per 100 live births. • Inguinal hernia repair is the most common surgery performed by pediatric surgeons. • Male: female = 9: 1 • 60% in the right side, 25% in the left side, & 15 % bilateral. • More in premature than full term. • Inguinal hernia in children is a high risk hernia, 60% risk of incarceration in the first 6 months of age. • Timing of repair: we recommend repair of inguinal hernia soon after diagnosis. • 90 % of complications can be avoided if hernia repairs done within 1 month of diagnosis.

5. Presentation:- • Intermittent swelling overlying external inguinal ring usually painless, evident during crying, coughing, straining & may descend to scrotum. It reduced spontaneously during sleeping & relaxation or can be reduced manually by upward & posterior pressure directly on the mass. 30% of inguinal hernias have the first presentation as incarcerated hernia. If the parents gave suggestive history but on examination there is no hernia, palpation of thickened cord compared with the other side & sensation of silk glove sign (double layers of empty hernia sac) can help in the diagnosis. Or simply you can repeat the examination again when bulging appears. For older children, ask them to stand, jump up & down to reveal the hidden inguinal hernia. The opposite side should be examined & both testes confirmed to be in the scrotum. • Incarcerated hernia: omentum or a loop of bowel becomes trapped in the hernia sac & not reduced by manipulation. • Strangulated hernia: ischemia to the contents of hernia sac. • Obstructed hernia: hernia causing intestinal obstruction. • In these conditions, the infant presented with crying, tense tendered swelling in the groin, irreducible without impulse on crying, colicky abdominal pain, vomiting, abdominal distension, constipation. if ischemia developed, there will be edema, redness, hotness, indurations overlying the lump & signs of peritonitis.

6. Hydrocele :- is a collection of peritoneal fluid in the tunica vaginalis around the testes due to patent processusvaginalis. • Types:- • Non-communicated: fluid just in the tunica vaginalis without communication with the peritoneal cavity. • Communicated: fluid in the tunica & processusvaginalis communicated with the peritoneal cavity, the same as hernia. • Hydrocele of the cord (male), hydrocele of canal of Nuck (female): encysted fluid.

7. Unilateral or bilateral hydrocele are common in the first few months of life, they are usually small – moderate in size, asymptomatic & have strong tendency to resolve spontaneously in the first year of life, it require no treatment just observation by the family & surgery is indicated only if hydrocele is not resolved after the age of 1 year or if it is very large or increasing in size that causing pressure on the testis. • Communicated hydrocele can be differentiated from inguinal hernia by the following features:- • Cystic. • Irreducible. • Trans-illuminable. • No impulse on crying. • Difficult to separate it from the testis. • Can get above its proximal limits.

8. Surgery:- • Surgical repair of inguinal hernia should be done once they diagnosed because of the high risk of complications & it is better to repair inguinal hernia for a premature baby before discharging him from neonatal care unit. While the usual infantile hydrocele does not need surgery in the first year of life. The surgical procedure for both hernia & hydrocele is the same & done as outpatient surgery (discharged on the same day) except for premature baby who need observation in hospital for 24 hr after repair because of risk of apnea after G.A (general anesthesia). • For irreducible inguinal hernia, manual reduction (taxis procedure) is usually successful in reducing the herniated viscera in about 80% of cases but still surgical repair is required later on electively. This is usually done by:- • Sedation (diazepam, midazolam, chloral hydrate). • Elevation of the lower half of the body. • Application of ice packs on the swelling to reduce edema. • Experienced doctor push the mass upward & posteriorly by one hand with the other hand supporting the roof of inguinal canal.

9. If not reduced after several attempts of manual reduction, urgent surgery is indicated. • Complications of inguinal hernia:- • Incarceration, intestinal obstruction, strangulation (ischemic necrotic bowel). • Testicular atrophy due to compression of testicular blood vessels by hernia sac if prolong. • Ischemia & gangrene of the testis if there is acute severe testicular compression.

10. Undescended testes • The second most common problem in pediatric surgery after inguinal hernia. • Risk of UDT:- • Infertility: in bilateral more than in unilateral. • Malignancy: the risk for inguinal canal UDT is 1%, & for intra- abdominal UDT is 5%. • Testicular torsion. • Testicular trauma. • Infection. • Psychosocial effect. • Incidence: 3% of fullterm, 33% of preterm. The majority will descend in the first year of life so the incidence at the age of 1 year will be 1%. Their descent after 1 year age is unlikely. • True UDT: is a testis that stopped anywhere along the normal pathway of descent in retroperitoneum between kidney & scrotum. • Ectopic testis: is a testis that left the normal pathway of descent & fixed in abnormal position (in inguinal region, perineum, femoral, contralateral scrotum). • Retractile testis: is normally descended testis that pulled up into inguinal canal as a result of hyperactive cremasteric reflex. • Iatrogenic UDT (ascending testis): is previously normal descended testis & then have been trapped in scar tissue of previous inguinal surgery.

11. Classification:- • Palpable & non palpable UDT. • Intra -abdominal UDT & inguinal canal UDT. • The intra-abdominal UDT either with opened ring or with closed ring (internal inguinal ring). • Absent or vanishing testis is called monorchia. • Absent both testes is called anorchia. • Diagnosis:- • The cremasteric reflex is weak in the 1st 2 year of life so if the testis was in the scrotum at birth then become impalpable in scrotum, it is retractile testis rather than UDT. • Gentle physical examination in warm room, supine position, & squatting position. • The epsilateralhemiscrotum is atrophic with little rougal folds. • In case of monorchia, there will be hypertrophy of the solitary testis. • Gentle pressure on mid abdomen may help to push the intra-abdominal testis into inguinal canal. • Bilateral UDT can be differentiated from anorchia by HCG stimulation test.

12. Investigation:- • Ultrasound • CT scan • MRI • Laparoscopy which has 95% sensitivity for locating a testis or confirming its absence.

13. Treatment:- • Hormonal therapy for UDT is controversial. • Buserline (LH-releasing hormone agonist). • Pregnil ( HCG-analoque). • Timing of surgical repair:- • At the age of 1 year. • Earlier if associated with inguinal hernia. • Orchiopexy : fixation of testis in the subdartous pouch of hemiscrotum. • Orchiectomy: if the testis is abnormally soft tissue, rudimentary or in case of impossible orchiopexy especially in post pubertal intra- abdominal testis because of risk of malignancy.