update on paediatric surgical emergencies march 2017
TRANSCRIPT
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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
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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
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Outline
Foreskin problems
Umbilical conditions
Groin Swellings
Scrotal swellings
Undescended testes
Head and neck swellings
Vomiting Infant
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Foreskin Problems
Circumcision
Only absolute indication is
Balanitis Xerotica Obliterans
(not common, ‘never’ in < 5 years)
Rare – urinary retention
Severe recurrent balanitis
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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’
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Circumcision
Day case
General anaesthesia
Not for non-medical reasons
Complications:
Meatal stenosis
Remove excess skin
Bleeding
Damage to glans
Infection
Inclusion cysts
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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
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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
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Duo testes bene pendulum
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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
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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
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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
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Vomiting
•Malrotation/volvulus
• Intussusception
•Pyloric stenosis
•NICE guidelines on reflux
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Dark Green Bile Vomit = Surgical Emergency
Immediate referral always
Why ?
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Malrotation/Volvulus
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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
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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%
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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
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Laparoscopic Pyloromyotomy
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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
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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
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Laparoscopic Splenectomy
Haemolytic conditions
Symptomatic
Repeated transfusions
Immunisations
Penicillin for life
Retrieval in bag,
than carefully broken up
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Questions ?
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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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