Paediatric Surgery: Common problems

Mr Fraser Munro Consultant Paediatric Surgeon

Common Surgical Problems in Children

Foreskin Patent Processus Vaginalis
Inguinal Hernia Hydrocele

Umbilical Hernia Undescended Testis

Development of Prepuce
Appears as a ring of epidermis at base of glans at 8 weeks Completely covers glans by 16 weeks. The epidermis of glans and prepuce are continuous. Preputial space forms by a process of desquamation. This process is rarely complete at birth.

The Fate of the Foreskin Gairdner ( BMJ 1949 : 1433-7 )

Newborn 6 months 1 year 3 years 5 -13 years 4% 20% 50% 80% 6% 14% Retractable Retractable Retractable Retractable Non-retractable Partially retractable

The Further Fate of the Foreskin Oster ( Arch Dis Child 1968 : 200-3 )
2000 boys 6 - 17 years Incidence of adhesions at various ages shown No adhesions found at 17 years Degree of adhesion less in older boys Incidence of phimosis at 17 years 1%
70 60 50 40 % 30 20 10 0 6 8 10 12 14 16 Age

Foreskin Problems
Non Retractable - Phimosis Balanitis or Balanoposthitis Ballooning Irritation / Foreskin Fiddling Paraphimosis Adhesions Sub-preputial cyst Social / Religious

Phimosis
Greek - Muzzling Persisting fibrous stricture of preputial orifice Or clinical and histological features of BXO
rare before age of 5 years

Combined incidence 1-2% of boys Rickwood 1989 - 6.6 % of boys in England circumcised for medical reasons ( 87 % phimosis )

Balanitis
Escala ( BJUro 1989 ) Redness / Swelling + Purulent Discharge Affects 4 % of boys 64 % single episode only 16 % three or more episodes Aetiology unclear Topical or systemic antibiotics

Who needs treatment?

Balanitis Xerotica Obliterans Recurrent Balanitis with unretractable foreskin - Circumcision - Steroids - Preputioplasty - Adhesiolysis - Circumcision - Steroids - Preputioplasty

Persistent unretractable foreskin peri-puberty

Topical Steroids
Randomised trial evidence of efficacy in resolution of phimosis in boys Prolonged treatment (4 12 weeks) Which steroid? Low risk of adverse effects Mechanism of action unclear
Suppression of inflammation? Increased elasticity of skin?

Is it better to circumcise at a younger age?

Processus Vaginalis
Forms during the inguino-scrotal phase of testicular descent Third trimester Closure mediated by CGRP Persistence may give rise to hernia or hydrocele

Inguinal Hernia
Incidence 0.8 - 4.4% of children Sex ratio boys : girls - 12 : 1 64% right, 29% left, 7% bilateral 29% present by 3 months, 48% by 1 year Diagnosis
History Thickened cord / Silk sign

Irreducible Inguinal Hernia

14 - 18% present with irreducible hernia 69% less than 1 year of age Strangulation of bowel is rare but may occur Testicular infarction / atrophy 2.3 - 29% Manual Reduction
Herniotomy 24 - 48 hrs later

Emergency Herniotomy

Herniotomy / ligation PPV

Hydrocele
Fluid in tunica vaginalis Patent processus vaginalis Resolution commonly occurs up to age of 2 years Operation - Ligation of PPV after age 2 years (or should it be 4?)

Umbilical Hernia
Commonest hernia occurring in humans Vast majority resolve spontaneously Strapping waste of time Incarceration extremely rare Defer surgical repair until at least 3 to 4 years of age Repair is simple closure of umbilical ring in most cases ( Inferior circum-umbilical incision )

Umbilical Hernia

Undescended Testis

Mechanism of testicular descent

Gonad develops in urogenital ridge at 8 weeks Testis descends to deep ring and then scrotum Two-stage hypothesis
Transabdominal phase Inguinoscrotal phase

Transabdominal phase
Testis maintains same distance from inguinal ring Regression of cranial suspensory ligament
Testosterone

Gubernacular swelling reaction

Insl3 MIS Testosterone

Inguino-scrotal phase
Active migration of gubernaculum Formation of processus vaginalis Androgen Genito-femoral nerve CGRP
Chemotactic effect Produces in-vitro fusion of human inguinal hernia sacs

Germ Cells
Transformation of gonocytes to type A spermatogonia occurs between 4 and 12 months Inhibition of transformation in undescended testes Late reduced germ cell population Persistent gonocyte postulated as precursor of testicular malignancy

Undescended testes
Incidence
Scorer 1960 Birth 4.3%, 1 year 0.96% 1986 1 year 1.58%

Postnatal descent occurs up to 3 months Prematurity

<1500g incidence is 60-70%

Associated syndromes
Prune belly Abdominal wall defects Neural tube defects Posterior urethral valves Arthrogryposis multiplex congenita Microcephaly syndromes

Complications of undescent
Temperature
Scrotal temp 33oC

Endocrine effects
Reduced levels of LH, Testosterone and MIS in infants

Germ cell development

Failure of gonocyte transformation Progressive loss of germ cells with increasing age

Fertility
Reduced paternity rates in bilateral UDT Not yet shown whether early surgery affects fertility

Complications of undescent (2)

Malignancy
Increase in risk 5 to 10 times normal Age at development same as for descended testes Higher the testis, higher the risk

Inguinal Hernia Torsion Trauma Psychological factors

Treatment of UDT
Hormonal
HCG injections Little convincing evidence of efficacy Also suggested as an adjunct to surgery to promote gonocyte transformation

Surgery
Bevan 1899 Dartos pouch - Latimer 1957

Timing of surgery
Referral by 6 months Surgery between 6 months and 1 year
Gonocyte transformation about 8 months

Most UK surgeons still aim for 1 to 2 years Previous practice was at puberty and more recently 4 years

Outcomes
Complication rate for orchidopexy is not higher at younger age in hands of specialist paediatric surgeons No evidence as yet of improved fertility with early surgery Conflicting evidence of a reduction in malignancy risk

Who to refer and when

Hydrocele Inguinal Hernia Umbilical Hernia UDT Foreskin 2 years At diagnosis (urgent if <3months) 4 years 3 - 6 months BXO Recurrent balanitis Persistent un-retractable foreskin peri-puberty

Questions?