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
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
Private Secretary – Mrs Eira Parsons
023 8120 6171
07465 420027
Fax 023 8120 4750
NHS Secretary – Mrs Julie Arnold
023 8120 6489
Fax 023 8120 4750
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