Update on Paediatric Surgical Emergencies March 2017

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Lewis Baldwin
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1 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

2 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

3 Outline Foreskin problems Umbilical conditions Groin Swellings Scrotal swellings Undescended testes Head and neck swellings Vomiting Infant

4 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

5 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 Spire Healthcare

6 Paraphimosis Prepuce stuck behind corona Glans swelling, venous engorgement Ice Squeeze glans Manual reduction GA Manual reduction Dorsal slit Spire Healthcare

7 Circumcision Day case General anaesthesia Not for non-medical reasons Complications: Meatal stenosis Remove excess skin Bleeding Damage to glans Infection Inclusion cysts

8 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

9 Epigastric Hernia Common May be asymptomatic Ache/discomfort with exercise No risk of incarceration Day case repair Spire Healthcare

10 Discharging Umbilicus Umbilical granuloma Umbilical polyp Red Flag signs: Vitello-intestinal duct Patent urachus Care with topical silver nitrate

11 Duo testes bene pendulum

12 Inguinal hernia Groin Swellings Undescended testis +/- torsion Hydrocele of cord Lymph nodes Spire Healthcare

Squelches Never there when you see them Do not need

13 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

+/- IV morphine If fails surgical exploration Risks testicular

14 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 Spire Healthcare

not required Orchidopexy 9-12 months Torsion

15 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 Spire Healthcare

necessary Hydrocele of the cord Acute groin/scrotal swelling,

16 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

17 Acute Scrotum Torsion infarction<6 hours Always refer Always explore Beware teenage boy with RIF pain Spire Healthcare

18 Acute Scrotum Torsion of Hydatid cyst blue dot sign Idiopathic scrotal oedema extends into perineum/groin Epididymo-orchitis Exploration is key Spire Healthcare

Peri-anal lesions Fissure painful, bright

become irreducible Rectal polyp prolapsing

19 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 Spire Healthcare

20 Head and Neck Lumps

21 Vomiting Malrotation/volvulus Intussusception Pyloric stenosis NICE guidelines on reflux Spire Healthcare

22 Dark Green Bile Vomit = Surgical Emergency Immediate referral always Why?

23 Malrotation/Volvulus

24 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

25 Intussusception 1 in 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%

RUQ ( olive ) Na + and Cl - Alkalosis Fluid resuscitation (150

26 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

27 Laparoscopic Pyloromyotomy

requirements Negligible risk bowel adhesions 85% neurologically

28 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

29 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

30 Laparoscopic Splenectomy Haemolytic conditions Symptomatic Repeated transfusions Immunisations Penicillin for life Retrieval in bag, than carefully broken up

31 Questions?

32 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 Spire Healthcare

33 Contact Details Michael Stanton, Consultant Paediatric Surgeon Private Secretary Mrs Eira Parsons Fax NHS Secretary Mrs Julie Arnold Fax Spire Healthcare

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