Update on Paediatric Surgical Emergencies March 2017

Update on Paediatric Surgical Emergencies March 2017

Michael Stanton MBBS, MD, FRCS (Paed Surg)

Consultant Paediatric & Neonatal Surgeon

Southampton Children’s Hospital &

Spire Hospital Southampton

Paediatric Surgery at Southampton

Antenatal Counselling Neonatal surgery Children up to 16yrs Regional Tertiary Level Service Frimley, Chichester, Winchester, Portsmouth IOW, Dorchester, Salisbury, Poole/Bournemouth

Outline

Foreskin problems

Umbilical conditions

Groin Swellings

Scrotal swellings

Undescended testes

Head and neck swellings

Vomiting Infant

Foreskin Problems

Circumcision

Only absolute indication is

Balanitis Xerotica Obliterans

(not common, ‘never’ in < 5 years)

Rare – urinary retention

Severe recurrent balanitis

Physiological phimosis

Glans and foreskin are adherent in all babies

Separate over 5-10 yrs

Temporary ballooning

Gentle daily retractions (>5 years)

Can be difficult to reassure parents

Always a family member who has been circumcised

Smegma Cyst/Pearl

Steroid ointment:

Betamethasone, mometasone,

beclomethasone, triamcinolone,

clobetasol

More effective than manual retraction alone

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Paraphimosis

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Prepuce stuck behind corona

Glans swelling, venous engorgement

Ice

Squeeze glans

Manual reduction

GA

Manual reduction

‘Dorsal slit’

Circumcision

Day case

General anaesthesia

Not for non-medical reasons

Complications:

Meatal stenosis

Remove excess skin

Bleeding

Damage to glans

Infection

Inclusion cysts

Umbilical Hernia

Common Ethnic variation Usually asymptomatic Usually no treatment until 3-4 years even if large 80% resolve spontaneously Can be difficult to reassure Incarceration very rare (1 in 1000) Repair before school age

Epigastric Hernia

•Common

•May be asymptomatic

•Ache/discomfort

with exercise

•No risk of incarceration

Day case repair

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Discharging Umbilicus

Umbilical granuloma

Umbilical polyp

Red Flag signs:

Vitello-intestinal duct

Patent urachus

Care with topical silver nitrate

Duo testes bene pendulum

Groin Swellings

•Inguinal hernia

•Undescended testis +/- torsion

•Hydrocele of cord

•Lymph nodes

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Inguinal Hernia

Intermittent groin swelling

May extend to scrotum

Cannot get above it & can reduce

Squelches

Never there when you see them

Do not need ultrasound

More in:

Boys

Ex-premature

infants

Right > left

Irreducible hernia

• Painful, red, tender, cannot reduce

• Emergency referral

• bowel strangulation

• testicular atrophy

• – manual reduction +/- IV morphine

• If fails – surgical exploration

• Risks – testicular atrophy, recurrence

• Contralateral (metachronous) hernia

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Undescended testis

•Common – 1% at birth

•Rarely an emergency

•Elective referral – 6-9 months

– Ultrasound not required

– Orchidopexy 9-12 months

•Torsion possible – Painful, red, tender

– Usually infarcted

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Scrotal Swellings

Hydrocele Can get above the scrotal swelling Asymptomatic Ligation of PPV if >2 years and large Ultrasound not necessary

Hydrocele of the cord Acute groin/scrotal swelling, mobile, non-tender Not unwell, cannot reduce Coincides with viral illness

Acute Scrotum

Torsion

infarction<6 hours

Always refer

Always explore

Beware teenage boy with RIF pain

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Acute Scrotum

Torsion of Hydatid cyst

‘blue dot’ sign

Idiopathic scrotal oedema

extends into perineum/groin

Epididymo-orchitis

Exploration is key

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Peri-anal lesions

• Fissure – painful, bright red bleeding

• Haemorrhoid – usually external small blue swelling, can be painful, can bleed

• Prolapse – can be uncomfortable, may become irreducible

• Rectal polyp – prolapsing swelling, and/or PR bleeding

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Head and Neck Lumps

Vomiting

•Malrotation/volvulus

• Intussusception

•Pyloric stenosis

•NICE guidelines on reflux

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Dark Green Bile Vomit = Surgical Emergency

Immediate referral always

Why ?

Malrotation/Volvulus

Malrotation/Volvulus

Malrotation with Volvulus

Midgut necrosis within 6 hours

Death

Long-term TPN,

Short Gut Syndrome,

Transplantation

Other diagnoses Incarcerated inguinal hernia

Intussusception

Adhesions

Intussusception

1 in 500

9-12 months

Scream, pull legs up, go pale

Distension + bile vomit + mass

Significant fluid losses

XR – small bowel obstruction

Ultrasound confirms

Air enema - 70% success

Laparoscopic or open reduction

+/- bowel resection

Recurrence 15%

Pyloric Stenosis

1 in 300

Non-bilious projectile milky vomit

Peak 4 weeks (day 1 to 3 months)

Dehydration, weight loss

Palpable mass in RUQ (‘olive’)

↓ Na+ and ↓Cl-

Alkalosis

Fluid resuscitation (150 mls/kg/day)

Ultrasound confirmation

Laparoscopic or open pyloromyotomy

Laparoscopic Pyloromyotomy

Laparoscopic Fundoplication

Anti-reflux surgery for failed medical management Reduced PICU stay Shorter time to feeds Less opiate requirements Negligible risk bowel adhesions 85% neurologically impaired 95% success 1 yr F/U Up to 25% fail by 10 years Stanton et al Eur J Pediatr Surg 2012

Laparoscopic Cholecystectomy

Pigment stones (younger children) Haemolytic condition hereditary spherocytosis Cholesterol stones Teenagers, females Biliary colic, acute cholecystitis Ductal stones, pancreatitis Laparoscopic cholecystectomy if symptomatic Incidental gallstones

Laparoscopic Splenectomy

Haemolytic conditions

Symptomatic

Repeated transfusions

Immunisations

Penicillin for life

Retrieval in bag,

than carefully broken up

Questions ?

Summary of Common Conditions

Inguinal hernia – refer when diagnosed, emergency if irreducible

Hydrocele – operate if >2 years

Phimosis – circumcision if BXO

Paraphimosis - emergency

Undescended testes – treat at 9-12 months

Umbilical hernia – treat at >3 years

Epigastric hernia – repair > 1 year

Head and neck lumps – treat >1 year

Bile vomiting – immediate surgical referral

Acute testicular pain – immediate surgical referral

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Contact Details

Michael Stanton, Consultant Paediatric Surgeon

Michael.Stanton@uhs.nhs.uk

Private Secretary – Mrs Eira Parsons

023 8120 6171

07465 420027

Fax 023 8120 4750

Eira.parsons@uhs.nhs.uk

NHS Secretary – Mrs Julie Arnold

023 8120 6489

Fax 023 8120 4750

Julie.arnold@uhs.nhs.uk

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