Paediatric Surgery

Introduction

The appendix is a vestigial organ, which means that it did serve some function at some point, but in the course of evolution, it has become a functionless structure. It is a worm-like organ attached to the beginning of the large bowel. Inflammation of the appendix is called appendicitis.

Appendicitis is most common in childhood and in the teens. As the appendix is made up of lymphoid tissue, it may be affected by viruses. Another cause is obstruction of its channel usually by hard material called a faecolith. The pain from appendicitis classically starts around the belly button and then moves to the right side of the abdomen. It may be associated with fever, loss of appetite, nausea and diarrhoea. However, children may develop only some of these symptoms.

Treatment

It is important not to ignore the abdominal pain and to see a specialist urgently. The best treatment for appendicitis is surgery. There are a few cases where the pain is very mild and the child may be successfully treated in hospital with antibiotics. However, this should only be done under close observation. 20% of children who are successfully treated with antibiotics will develop appendicitis again.

Surgery usually involves laparoscopic (keyhole) surgery. The procedure is performed under general anaesthesia. Three small incisions are made in order to insert a tiny camera into the abdomen along with two instruments. The appendix is removed and the part of the large bowel where the appendix was connected, is closed.

The child usually stays in hospital for 24-48 hours and I would advise that the child has two weeks’ leave from school to recover fully.

Background

Paediatric groin hernias are completely different from an adult hernia. This is due to a persistence of a connection between the testicle (in boys) or labia (in girls) and the abdominal cavity. This connection is called a patent processus vaginalis. Usually at birth, this connection becomes fused, but if it persists after birth, it may remain open. Fluid may travel down this and surround the testicle forming a hydrocele. Fat or bowel may also travel down the connection forming a hernia.

Treatment

A hydrocele can be treated conservatively and reviewed over a period of months or years. However, if it persists to over 5 years of age, it is unlikely to resolve and should be repaired.

Surgery to repair a hydrocele is the same procedure as repair of an inguinal hernia. Surgery involves general anaesthesia. A tiny incision, around 1-2 cm in length, is made in the groin. The processus vaginalis is identified, separated from the blood vessels to the testicle and the vas deferens, and divided. This simple operation is successful. I have perfected doing this surgery through a very small incision and this means that recovery from the surgery is quicker.

Introduction

When a baby boy develops inside the mother’s uterus, his testicles travel from inside his abdomen to the groin and then into the scrotum. However, this journey of the testicle is not always simple and the testicle can find itself either trapped in the groin, in the perineum, or even in the abdomen. This is why all baby boys should be examined after birth to ensure that both testicles are in the scrotum.

If the testicle has descended completely, it may spring up from the scrotum into the groin on occasions. This is not serious. It is called a retractile testis and is usually due to an exaggerated reflex involving muscles around the testicle and its blood vessels.

Treatment

Surgery is the treatment for an undescended testicle that has never been present in the scrotum. If the testicle is in the groin or perineum, the procedure is called an orchidopexy. This involves general anaesthesia. Two incisions are made, one in the groin to find the testicle, and one in the scrotum to fix the testicle there. In one third of patients, the testicle is inside the abdomen and this is usually investigated with ultrasound and MRI scans.

Although there are two incisions made which may be more uncomfortable afterwards, children recover well and usually have fully recovered after two weeks.

Introduction

Umbilical (belly button hernias) are very common and rarely cause any problems. However, they can be unsightly and are usually repaired because either the child or the child’s parents want the child to have a normal looking belly button. These hernias are usually present at birth and may resolve spontaneously without surgery, but if they are still present by the age of 5, surgery can be offered to repair the hernia.

Treatment

Surgery to repair this hernia is performed under general anaesthesia. A small incision is made below the belly button to find the hole or defect in the muscle underneath. A few absorbable stitches are then used to repair the hernia. A mesh is not used to repair this hernia in children. The child is usually discharged from hospital the same day and is fully recovered after two weeks.

The word pilonidal is derived from Latin words, pilus meaning hair, and nidus meaning nest.  This helps to explain the origin of this condition.  Pilonidal disease was first reported in 1833 and later named pilonidal sinus by Hodges in 1880.  It affects 3 per 10,000 people per year.

The most common site of this condition is in the natal cleft, or the area of the lower back between the buttocks and just behind the anus.  Some patients develop this condition associated with their belly button.  There is controversy about why some people develop this condition, but it seems to be partly related to the way that these parts of the body develop, particularly with regard to the hair follicles.  When the pilonidal sinus is removed by surgery, several hair follicles and debris are found within the sinus.

Pilonidal sinus more commonly occurs in males and children as well as young adults are usually affected.  The condition is characterised by pain and discharge.  The discharge may be bloody, but if there is an associated infection, it may contain pus.  The condition usually occurs intermittently, but once it develops, it does not disappear by itself.

What are the treatments

If there is an infected sinus, antibiotics can settle the initial infection.  However, if the infection worsens and forms an abscess, this could need a small operation to drain the pus.  This surgery would usually be performed under general anaesthesia.

Some patients are troubled by continuous pain and discharge making it difficult to sit and study or work.  For these patients, surgery offers the best long term solution.

What operations are available

Surgery should be only undertaken when it is absolutely necessary.  There have been many different operations described for pilonidal sinus.  My approach is to offer the simplest surgical solution first to see if this will remove the problem.

Curetting the sinus under general anaesthesia involves removing all the hairs and debris from the sinus.  The advantage of this procedure is that no incisions are made and complete recovery is quite quick, usually only a few days.  50% of patients will have effective relief from this procedure, but this is usually not a long term solution.

If patients have a complicated pilonidal sinus or failure after curetting, I would suggest surgery called the Karydakis procedure.  This involves general anaesthesia and removing the sinus completely.  The wound is then closed with sutures or stitches by mobilising a flap involving skin and deeper tissues to bridge the wound.  The resulting scar is away from the midline crease and helps to prevent a future pilonidal sinus developing.  My patients usually stay in hospital for 3 to 4 days and have a wound drain which helps to prevent a collection of fluid building up and opening up the wound.  I also prescribe antibiotics as any surgery in this part of the body is associated with an increased risk of infection.  I tell patients not to sit for at least three weeks to help the wound to heal and I then remove all the stitches when the wound has healed.

Results of Surgery

The vast majority of wounds heal and patients can return to normal life.  However, in a minority of patients, if an infection develops, the wound may open up and require dressings for several weeks and up to a few months.  For this reason, I stress the importance of not sitting whilst the wound heals and of keeping the wound clean with regular dressings.  I also review all my patients regularly to check that the healing process is going well.