Surgery in ChildrenRead more about the most common surgical problems in children.
Paediatric surgeons specialise in the management of surgical conditions in all children ranging from newborns to teenagers.
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Common Surgical Problems in Children
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Gastro Oesophageal Reflux
Primary gastro oesophageal reflux refers to passing of stomach content into the oesophagus (swallowing pipe). Reflux is common in the first 2 years of life, and most cases resolve without the need for invasive tests and surgery.
- Symptoms depend on your child’s age.
- In babies, symptoms can include feeding difficulty, poor weight gain, and chronic cough.
- Older children with reflux can complain of abdominal pain, heartburn or a sour taste in their mouths.
There is a valve at the bottom of the oesophagus which opens and closes, allowing food to enter the stomach. In babies, the mechanisms that control this valve are immature allowing for the inappropriate passage of feeds, gas and stomach juices back into the oesophagus. In most cases, as babies grow their anti-reflux mechanisms mature, allowing them to grow out of their reflux.
Treatment for reflux depends on your child’s age, the severity of symptoms and the cause of the reflux. Some children can be managed with a change in the way they are fed, others with medication, with only a small proportion requiring surgery. Each child’s case is treated individually and if surgery is necessary, the doctors will discuss treatment options with you to achieve the best and safest outcome for your child.
Hypertrophic pyloric stenosis (HPS) is the narrowing of the stomach outlet due to thickened muscles that usually occurs in children between 2 and 8 weeks of age. HPS prevents food and liquid from emptying out of the stomach resulting in forceful vomiting.
The most common symptom of HPS is forceful, projectile vomiting. This symptom is very different from a “wet burp” or posit that may occur at the end of feeding. Vomited milk is sometimes curdled due to the fact that it stays in the stomach for a long time. HPS can result in significant dehydration (excessive water loss from the body), so it is important to seek medical advice and treatment as soon as possible.
Other symptoms include:
- Weight loss
- Lack of energy
- Fewer bowel movements
Pyloric stenosis is treated in two stages. Vomiting from HPS can cause major changes in your child’s fluid and salt balances. Fluids are given intravenously (from a drip) to treat dehydration and restore the body’s normal chemistry.
Once this is done, surgery is carried out to release the tight ring of thickened muscles allowing food to pass from the stomach into the intestine. Usually, babies with HPS recover quickly from surgery and can start feeding as soon as the operation is over.
Inguinal hernias (IH) are one of the most common paediatric surgical problems. Inguinal hernias occur when a piece of intestine or other organ in the abdomen slips through a hole in the abdominal wall. These hernias are most common in preterm male children, but can occur in term infants and females. IH are usually noticed when children cry, cough, or strain and are recognised as a soft bulge underneath the skin in the groin or around the labia. The swelling usually disappears by itself, but occasionally hernias can get incarcerated or ‘stuck’.
IH are usually noticed by parents during nappy change. They are usually soft, easily pushed back (reducible), and are not painful.
If the IH becomes hard, painful, is associated with vomiting, a bloated tummy or the skin over the IH becomes red, the hernia may be incarcerated. This is an emergency and you should seek urgent medical attention.
All IH are treated surgically, and it is important to perform surgery when IH are not incarcerated. The surgery will happen fairly soon after the hernia is diagnosed in order to decrease the risk of incarceration. The surgery involves making a small incision in the groin, isolating the hernia sac, and tying it off. Most children undergoing IH repair go home on the day of surgery. Complication rates from IH surgery are extremely low. Wound care is easy and there will not be any stitches to remove once the wound is healed.
An umbilical hernia is a hole in the abdominal wall at the belly button. Umbilical hernias are extremely common and usually disappear within the first 3 years of life as the abdominal wall develops.
Umbilical hernias appear as swellings at the belly button. They are usually soft, easily pushed back (reducible), and are not painful.
If the umbilical becomes hard, painful, is associated with vomiting, a bloated tummy or the skin over the hernia becomes red, the hernia may be incarcerated. This is an emergency and you should seek urgent medical attention.
Most umbilical hernias close by themselves by the age of 5. If the hernia does not complicate (become incarcerated) and is not disfiguring, it may be observed till it resolves itself. If the hernia does complicate or does not resolve by itself, it will require surgical repair. Complication rates from umbilical hernia repair are extremely low. Wound care is easy and there will not be any stitches to remove once the wound is healed. Most children undergoing umbilical hernia repair go home on the day of surgery.
Like inguinal hernia (IH), hydrocoeles are also caused by a ‘hole’ in the abdominal wall. Unlike IH, hydrocoeles only accommodate fluid from the abdomen and not intestines or other organs. Hydrocoele usually present as a painless, swollen testicle. Most hydrocoeles resolve spontaneously by the age of 2 years. They are most common in preterm males, and can occur on both the right and left sides. Large hydrocoeles, and those that persist beyond 2 years of age will require surgical correction.
You may notice a swelling in your child’s groin. Importantly, this swelling is usually soft and painless, with normal overlying skin. Unlike a hernia, you cannot ‘push’ a hydrocoele back into the abdomen. Once your child starts walking you may notice that the swelling in his groin is worse at the end of the day, as opposed to when he first wakes up.
Hydrocoeles that are present after 2 years of age or result in significant scrotal swelling require surgery. The surgery involves making a small incision in the groin, draining the fluid in the scrotum, and closing off the opening between the scrotum and the abdomen. Complication rates from repair are extremely low. Wound care is easy and there will not be any stitches to remove once the wound is healed. Most children undergoing Hydrocoele repair go home on the day of surgery. This will all be discussed with you at your consultation with the doctors
The testes are formed prior to birth and gradually descend from the abdomen to the scrotum during pregnancy. Occasionally testicular descent is incomplete and boys can be born with undescended testicles. Numerous factors are involved in testicular descent, and there are many theories why this problem occurs. Undescended testicles can occur on one or both sides, and is more common in preterm males and those with abdominal wall defects. If the testes are not in the scrotum by 3 months of age, your child may require surgery. Undescended testicles are associated with multiple complications including cancer, testicular torsion, inguinal hernia, infertility and testicular trauma that may be recognised and avoided through timeous surgery. Surgery should ideally occur before the age of 1 in order to limit injury to the testis.
Undescended testes are usually noticed during routine check-up or by parents during nappy change. The scrotum may look flat, smaller than normal, and empty.
It is important to note that “retractile testicles” are not undescended. If a testicle can be brought down into the scrotum, even if it bounces back up after release, it is a retractile testis. Retractile testes typically do not require surgery.
Surgery is the treatment for undescended testes. The surgery may be open or laparoscopic (key hole surgery with a camera), depending on the position of the undescended testicle and whether the problem affects both sides or just one side. The surgery involves making a small incision in the groin, locating the undescended testis, and bringing it down (mobilising) it into the scrotum by way of a smaller scrotal incision. Complication rates from repair are extremely low. Wound care is easy and there will not be any stitches to remove once the wound is healed. Most children go home on the day of surgery.
Testicles that are located higher in the abdomen may require more extensive surgery or multiple procedures to allow the testes to be brought down into their normal position. These scenarios are extremely rare. This will all be discussed with you at your consultation with the doctors.
Children may have medical conditions or suffer trauma that makes it difficult for them to feed by mouth. These conditions include:
- Congenital (present at birth) problems of the mouth, oesophagus, stomach, or intestines
- Sucking and swallowing disorders (due to premature birth, injury, a developmental delay, or another condition)
- Failure to thrive (when a child can’t gain weight and grow normally)
A gastrostomy tube is inserted through the skin directly into the stomach, and allows these children to receive the nutrition they need. Gastrostomy tubes are placed in theatre under general anaesthetic.
They may be placed with the assistance of a camera (PEG: Percutaneous Endoscopic Gastrostomy) or via a laparotomy (Open Gastrostomy). All parents of children undergoing gastrostomy will be thoroughly counselled on the need for, use of, potential complications of, and long term management plan for their children.
Once healed, children with a gastrostomy are able to resume normal activities with little impediment.
Constipation is a common problem for children. Many children have constipation at one time or another. Being away from home, and changes in diet and activity are some of the most common causes of constipation in young children.
Children with constipation may experience abdominal pain, swollen tummies, and pain when passing stool. Important warning signs to look out for are a reliance on enemas to pass stool, a child that is not growing appropriately and a child that did not pass their first stool within the first 2 days of life.
Investigating constipation may require blood tests, x ray imaging and even a biopsy in theatre. The specific treatment of constipation for your child will depend on its cause. Most children with constipation respond well to conservative treatment, including:
- dietary changes resulting in increased dietary fibre, increased fluid intake, decrease in milk protein intake, and a decrease in intake of processed flours
You should not give your children enemas, laxatives, or suppositories unless you are told to do so by the doctor.
Hirschsprung’s disease is a congenital condition that causes blockage of the intestine. The blockage is due to a lack of nerve cells that allow muscles in the intestine to contract and move digested food into the rectum. Hirschsprung’s disease is diagnosed with a biopsy of the rectum.
Most children with Hirschsprung’s disease have symptoms within the first few days to weeks of life. The most common symptoms include failure to pass stool within the first 2 days of life, bloated abdomen, vomiting, fever, constipation and infrequently, diarrhoea. Older children can experience chronic constipation, malnutrition and a reliance on enemas to pass to stool.
The treatment for Hirschsprung’s disease is surgical with the aim to remove the abnormal bowel and connect the normal bowel to the anal canal. This should relieve your child’s constipation. Prior to definitive surgery your child may require a stoma. The actual process of diagnosing and treating Hirschsprung’s disease is complex and requires in depth discussion with your team of doctors. Outcomes for Hirschsprung’s disease are good, with most children recovering normal bowel function.
Circumcision is one of the most common surgical procedures worldwide. Every country has specific rules and laws relating to circumcision.
In South Africa, male circumcision under the age of 16 may only be performed for medical or religious reasons. When necessary for medical reasons, the doctors perform all circumcisions in older children in theatre under general anaesthesia.
Complication rates from circumcision are extremely low. Wound care is easy and there will not be any stitches to remove once the wound is healed. Most children go home on the day of surgery.
Soft Tissue Masses
Soft tissue masses that arise from the skin and its appendages (hair follicles, sweat glands), blood vessels, fat or muscle are relatively common. These masses may be congenital (children are born with them) or acquired. Soft tissue masses can appear anywhere on the body, but are often noted on the head, face, neck, and upper limbs. These masses may appear as small discoloured lumps that can progress to much larger swellings.
Soft tissue masses are often misdiagnosed, contributing to delays in treatment, and unnecessary anxiety and confusion for parents. If you have noticed a lesion on your child’s body and are concerned what it may be, seek expert advice early. Management of these masses may involve medication, surgery, or a combination of both. The doctors will discuss the optimal management options for your child, and the reasons for such during your consultation.
Tongue tie is a congenital condition and occurs when the lingual frenulum (the area between the tongue and floor of the mouth) anchors the tip of the tongue and prevents it from moving normally.
Tongue tie may result in difficulties in breastfeeding and speech impediments later in life. Tongue tie may need require surgery, but this is not always the case. Each patient will be individually assessed and the most appropriate management option pursued.
In case of the need for surger, the procedure may be performed in the consultation rooms or in the operating theatre. There is no need for further wound care and your baby can be fed immediately after the procedure.
Hypospadias is a congenital abnormality resulting in an abnormal urethral meatus, skin coverage and curvature of the penis. Essentially the opening of the urethra (urine pipe) is not located in its normal position.
The causes of hypospadias are not well understood, and it can be associated with disorders of sexual differentiation. Hypospadias is usually diagnosed after birth and will not affect your child’s ability to pass urine normally.
Hypospadias is corrected surgically after the first year of life. Multiple surgeries may be required to completely correct the abnormality.
Posterior Urethral Valves
Posterior urethral valves (PUV) are obstructive membranes that develop in the urethra (tube that drains urine from the bladder), close to the bladder. The valve can obstruct or block the outflow of urine through the urethra. When this occurs, the bladder, ureters and kidneys become progressively dilated, which can lead to damage.
Signs and symptoms
PUV are thought to develop in the early stages of foetal development. PUV occur in varying degrees from mild to severe. Due to increased use of prenatal sonar, PUV may be identified before any symptoms are present. Once your baby is born, further imaging studies will confirm the diagnosis.
Children who are diagnosed later may have the following signs or symptoms:
- Urinary tract infection
- Weak urine stream
- Difficulty with urination
- Urinary frequency
- New onset of urinary incontinence
Treatment for PUV depends on the severity of the condition, your child’s age, bladder and kidney status. The surgical goal is to preserve kidney and bladder function.
- Valve ablation: Once PUV are identified, they need to be surgically managed. During valve ablation, the doctors will insert a resectoscope, a small device with a light and a camera lens at the end. They will use this instrument to make incisions in the valves so they collapse and no longer obstruct the urethra.
- Vesicostomy: In a situation where your baby is too small to undergo ablation or when a severe obstruction is noted, a vesicostomy may be recommended. A vesicostomy provides an opening to the bladder, so that urine drains freely from the lower abdominal opening. During surgery, a small part of the bladder wall is turned inside out and sewn to the abdomen. It looks like a small slit, surrounded by pink tissue. The vesicostomy is a temporary option and can be closed in the future.
Management of PUV is complex and requires a multidisciplinary approach involving a paediatric surgeon, paediatrician and paediatric nephrologist (kidney specialist). The doctors will discuss the optimal management options for your child, and the reasons for such during your consultation.
Incontinence in children refers to the lack of controlling passage of urine. It may show as a child being unable to be fully potty trained, or may occur in a child that previously had bladder control issues. The doctors will do a thorough physical examination, and ask you a series of questions about your child’s development.
Special radiological investigations may also be required to exclude any anatomical causes for the incontinence.
Treatment of urinary incontinence in children is complex and often may involve behaviour modification, medical therapy and occasionally surgery.
The liver is connected to the intestine via the bile duct system. Bile is formed in the liver, and then carried through these channels to the intestine. Anything that causes a blockage of the bile ducts will stop bile flow towards the intestine. This will lead to jaundice and if the blockage persists, permanent damage to the liver.
There are a many causes of bile duct blockage ranging from worms, gallstones, congenital defects of the bile ducts or progressive narrowing of the ducts as seen in biliary atresia.
Your child will require assessment by the doctors to establish the cause of the obstruction and if surgical intervention is necessary to relieve it.
Conditions of the liver that may require consultation with the doctors include infections, growths (benign and malignant), trauma, vascular malformations and portal hypertension secondary to severe liver damage.
Splenic conditions that require surgical intervention are uncommon. If your child sustained trauma to the spleen, suffers from blood disorders that causes enlargement of the spleen or has a splenic mass, your child will require an assessment by the doctors.
A central venous catheter (CVC) is a type of drip that allows for long term intravenous access. CVC are usually placed in the neck, groin or chest.
How a Central Line Is Placed:
CVC can be placed in theatre or in the ward. Untunnelled lines are stitched in place with exposed access ports and covered with a sterile dressing. Tunnelled lines are not exposed to the environment, but are usually reserved for those patients requiring prolonged (months to years) intravenous access. Depending on the difficulty of incision, ultrasound or an open technique may be used in line placement.
Central lines can be complicated by failure to place the line, infection, thrombosis (blockage), and for those placed in the chest or neck (haemo) or pneumothorax (instances in which blood or air become trapped in the chest). Haemo and pneumothorax are serious complications that may require the placement of a chest drain in order to manage.