GPPS Newsletter Heather Gosnell, MD

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1 Issue #3, July 2011 GPPS Newsletter Heather Gosnell, MD CACTDUCEUS REPORT A word from our president Greetings Greater Phoenix Pediatric Society! The summer has heated up and so has the excitement for our upcoming sophomore season!! Our first year post-revival was a smashing success as our society grew to 200 members strong. We were most excited about the success of society meetings which featured tasty dinners, fun socialization, professional networking, and informative presentations. This year looks to be equally productive, but we need YOUR help: 1) Please pay your dues ASAP. These dinner events are not free and we need membership dues to continue to bring you the valley s finest dining and hottest speakers. Membership dues are $75 for the year, $40 for residents and retirees. Please send checks payable to Greater Phoenix Pediatric Society. For new members, please fill out the attached application and send it in with your check. Please mail check to: Wendy Bernatativicius, M.D. Treasurer, Greater Phoenix Pediatric Society 1919 E. Thomas Road, Bldg B 2 nd floor Phoenix, AZ 85016

2 2) Sponsor a resident or medical student. This unique gathering is an excellent opportunity to encourage our next generation of Arizona doctors. Personally invite a resident or student to our meeting and pay their dues for the year. 3) Write for our newsletter. Between each meeting, GPPS sends an informative newsletter featuring a short article written by one of our members. This article is a quick read and can be an interesting case, topic discussion, or any other teaching point. We welcome any interest with open arms. GPPS is proud to announce our first meeting of our second year coming September 8 th featuring the encore performance of nationally acclaimed dermatologist, Dr. Ronald Hanson. Last year Dr. Ron ignited the GPPS revival with a charismatic sermon on Pediatric Dermatology A-Z. Like many preachers, Dr Ron only had time to discuss letters A-L. To our delight, however, he has agreed to kick off our second year with a sequel symposium, Pediatric Dermatology, M-Z! Our first meeting will be held at Dr. Hansen s home turf, Phoenix Children s Hospital. We are thankful for PCH s hospitality and generosity in sponsoring dinner for our next gathering. PCH has been a wonderful ally to GPPS providing the framework for our CME credentialing, offering technical help during meetings, and donating AV equipment. PCH is also proud of their new facility, soon to be the largest children s hospital in the country. Tours will be available before and after our event for all those interested in exploring the new campus. Our 2 nd meeting this year will be slated for the wintertime and will be held in Scottsdale. In an attempt to better meet the needs of our members, we will be sending out a list of potential CME topics to be voted on by our members. Please send any topic ideas to Nadia Day, M.D. at nadiaday1@gmail.com. Anyone who is interested in presenting a topic may also contact Nadia for consideration. We look forward to another successful year of the Greater Phoenix Pediatric Society!! See you in the fall! Matt Barcellona Continued

3 Specialty article Hernias Lisa E. McMahon, MD, FACS Pediatric Surgeon Inguinal hernia repair is one of the most common procedures performed by pediatric surgeons. Most childhood inguinal hernias occur when there is a patent processus vaginalis (pv) and the visible bulge consists of intraabdominal contents coming through the pv. The testicles develop near the kidneys and then descend through the inguinal canal to rest in the scrotum during the last trimester. The lining that that the testicle follows is the processes vaginalis (Fig.1) and it obliterates late in gestation. If it does not close it is called a patent processes vaginalis and allows intraabdominal contents to herniate. If the contents are bowel or fat, it is called a hernia. If it is only fluid, it is a hydrocele. Fig. 1 Processes vaginalis, descent of the testicle from within the abdomen to the scrotum

4 In girls, the round ligament carries the pv with it through the inguinal canal and if it remains patent, a hernia can form. The incidence of hernias in childhood varies with age with an increased incidence in prematurity. Like adult inguinal hernias, they are more common in males than females. The usual presentation for an inguinal hernia is a lump of bulge in the groin which gets larger with increased abdominal pressure, especially with crying. The bulge usually comes and goes and can get quite large with time. Large hernias are often seen in the scrotum in boys and in the labia in girls. The majority of hernias are asymptomatic and are reducible, either with manual decompression or with decreased intra-abdominal pressure. Incarcerated hernias are those that are not reducible by manual decompression. A loop of bowel may be trapped in the hernia and with time edema and inflammation develops making it difficult for the bowel loop to return to the abdominal cavity. Strangulation occurs when the blood supply to the bowel is compromised and is a surgical emergency. When presented with an incarcerated hernia, it is important to attempt reduction. Elevating the buttocks with towels and placing a padded ice pack on the area can help to decrease the edema and allow the bowel to slip back in place. Pressure is placed at the level of the internal ring and the hernia contents are slowly and steadily pushed back into place. This sometimes is done with sedation. A strangulated hernia is almost never reducible and a hernia that is not reducible by a surgeon should have prompt surgical treatment, potentially including bowel resection. If a previously incarcerated hernia is reduced, the patient is admitted to the hospital and undergoes hernia repair in the next 24 to 48 hours. This time allows the edema to resolve which facilitates hernia repair. In girls it is not uncommon to have an ovary in the hernia sac. These are sometimes difficult to reduce but are not as urgent to repair as hernias with incarcerated bowel. They are easily identified as ovaries and should be repaired within a week. It is very uncommon for an ovary to lose its blood supply in a hernia and even if it appears ischemic it should not be removed. Ultrasound studies 6 weeks after repair have shown blood flow to a normal appearing ovary following a seemingly ischemic appearing ovary. (This is also true in ovarian torsion). Repairing Hernias. Preemies through teens Preterm infants have the highest incidence of inguinal hernias, which is logical given their provenance. Patent processes vaginalis is more common in infants who have barely reached their third trimester. These hernias have a high incidence of incarceration and it is our practice to repair these hernias prior to discharge from the NICU. If the preterm patient has already been discharged home prior to finding the hernia and under 50 weeks gestational age at the time of repair, they are

5 observed in the hospital overnight with an apnea monitor. Older children are repaired electively. High ligation of the sac (pv) is the standard operation, and the floor is evaluated to determine the need to reinforce it with further sutures. The wound is closed in layers, and the 1-2 cm incision is dressed. Children are free to resume any activity except swimming for 1 week. In teenagers, it is up to the surgeon's discretion to perform a high ligation of the sac versus the tension-free Lichtenstein repair with mesh or a laparoscopic repair with mesh. The Lichtenstein repair is the gold standard for treatment of adult hernias and in older teenaged with large hernias, is appropriate. Placing a non-absorbable mesh in a young child is not advisable since the mesh will not grow with the child. Another method for treating teens is with laparoscopic repair with mesh. This method has been utilized for approximately 15 years and is either done with the TAPP (Total Abdominal Pre-Peritoneal) or TEPP (Total Extra-abdominal Pre- Peritoneal) approach. The difference in the repairs is in the access to the hernia. In the TAPP, pneumoperitoneum is achieved and then the peritoneum over the hernia is incised, the sac is dissected and the mesh is tacked in placed over the defect, with the dissected peritoneum reapproximated to cover the mesh. In the TEPP procedure, a pre-peritoneal space is created and the repair is completed extraperitoneally. Both procedures have good results, with the advantage of the TAPP being the ability to repair bilateral hernias through the same laparoscopic incisions. Complications Hernia repair is a relatively safe operation. The risk of bleeding and infection is low. The risk of recurrence is highest in premature infants with the overall recurrence rate approximately 1% - 2 %. With incarcerated hernias in boys, there is a risk of injury to the vas and vessels, either due to the repair or because of inflammation in the area. In a large retrospective study, children operated on by subspecialty trained pediatric surgeons had significantly fewer recurrences than those operated on by general surgeons. Bibliography Ein SH, Njere I, Ein A. six thousand three hundred sixty-one pediatric Inguinal hernias: a 35- year review. Journal of Pediatric Surgery. 2006, 41: Wake BL, McCormack K, Fraser C, Vale L, Perez J, Grant A. Transabdominal pre-peritoneal (TAPP) vs totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair.. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD DOI: / CD pub2.

6 Boretstein SH, To T, Wajja A, Langer JC. Effect of subspecialty training and volume on outcome after pediatric inguinal hernia repair. Journal of Pediatric Surgery 2000, 40, Issue 1, Pages Attached is the new member application form. Please recruit new members!

LAPAROSCOPIC HERNIA REPAIR

LAPAROSCOPIC HERNIA REPAIR Treating Your Hernia with Laparoscopy When You Have a Hernia Anyone can have a hernia. This is a weakness or tear in the wall of the abdomen. It often results from years of wear