What is Pediatric Surgery?
WHAT ARE THE PATHOLOGIES OF INGUINAL REGION (INGUINAL CANAL), HOW EMERGENT ARE THEY AND WHAT IS THE TREATMENT?
Pediatric surgery can be defined as urological surgery, general surgery, gynecological surgery and thoracic surgery applied to the pediatric population. Pediatric surgery is neither a branch of general surgery nor it is a miniaturized form of adult surgery. Due to the significant age-dependent physical and psychological differences of the children, they should be specifically considered. Best outcomes in surgical procedures of the children are also obtained if the procedures are performed by healthcare teams comprised of doctors and nurses who are specialized in the treatment of children at healthcare institutions particularly designed for this purpose.
TIMING FOR PEDIATRIC SURGERY OPERATIONS
General rules: For non-emergency cases, best time for pediatric surgery operation is dependent on particular factors: These are as follows:
I . Risks exposed to the patient by the disease or the anomaly
2. Risks associated with the operation
3. The aspect about surgical technique of the operation
4. The possibility of spontaneous improvement
5. Psychological precautions
PATHOLOGIES OF THE INGUINAL REGION:
It is the condition characterized with absence of testicles in the scrotum in male babies in the postnatal period. The incidence is around 30 % in premature babies and around 3.2 % in term infants. However, when same cases are examined when the baby is I year old, it is observed that the incidence regresses to 5.4 % in premature babies and 0.5 % in term ones. The testicle cannot be palpated inside the scrotum in the examination. The close follow-up is important in the case of mobile testicle; the condition is characterized with the ascending of the testicle which stays normally in the scrotum, but moves upside under conditions such as cold weather. It is important that the family examine the testicles in the day time when the baby is in the bath or the baby is sleeping and thus, the most common position of the testicle is determined. The specialist physician is required to follow the size and localization of testicles with physical examination performed in 3-months interval. In the presence of undescended testicle or the presence of the testicle which commonly stays in the inguinal canal, it is necessary to descend and fix the testicle into the scrotum when the baby is I year old.
When the operation is delayed in the case of undescended testicles, following complications may appear; decrease in the number and functionality of sperm, inguinal hernia, torsion (testicles twists around itself), trauma or psychological influences due to absence of the testicle in the scrotum. Moreover, there is also risk of becoming cancerous. When it is descended to its normal localization with operation, follow-up will be easier although the risk of becoming cancerous will not disappear.
Inguinal hernia: Inguinal hernia is present in I to 4.4 % of children. This rate may increase up to 30 % in premature babies. Most patients represent with swelling in the inguinal region, which is recognized by the family; the swelling becomes marked when the baby cries, coughs and strains, but disappears when such conditions end. Sometimes, the reason of the presentation can be a permanent mass in the inguinal region, the bile content in vomit and the inability to defecate. In the child, the diagnosis is made by detecting the swelling (bulge) in the inguinal region. Examining the patient when s/he cries, coughs or strains will make the swelling apparent and thus, it may aid the diagnosis. It is possible to sense the friction of opposing surfaces of the hernia sac when the index finger is placed vertically on inguinal canal and the finger is slightly rubbed to the right and the left side. This sign, referred as Silk glove sign, may aid the diagnosis of patients who has typical history, but lacks a swelling in the examination. The most striking aspect of the hernia in children is the rapid development of circulatory disorder in the incarcerated organ or in the testicle at the affected side of the concerning male child when the incarceration occurs (inability to easily push the hernial swelling into abdominal space). Occurrence of hemorrhagic necrosis in unilateral testicle may also cause damage on contralateral testicle (Figure-1). Therefore, the incarcerated inguinal hernia is an emergency condition. It is necessary to immediately reduce it (pushing the hernial swelling into abdominal space). If it cannot be reduced, the emergency operation is necessary. However, in this case, the rate of complications increases. Therefore, when the inguinal hernia is diagnosed, elective surgery should be employed as soon as possible. The differential diagnosis of incarcerated inguinal hernia include following conditions; torsion of the testicle, cord cyst as well as inflammatory enlargement of inguinal or femoral (medial inguinal region where vessels supplying legs lie) lymph nodes.
Hydrocele (accumulation of fluid around testicles): It is a frequent condition in babies. The size may increase or decrease depending on the degree of opening at superior part of processus vaginalis (the abdominal membrane associating to the testicle when the testicle descends to the scrotum). Hydrocele is characterized as a scrotal swelling (bulge) involving the testicle. The swelling makes a bottle neck in lateral part of the inguinal canal and it does not lie into inguinal canal. There is no tenderness. Moreover, the transillumination (lack of light shadow on the opposed side when a light is put on one side of the scrotum) is an important sign. It should be kept in mind that in most children with hydrocele, processus vaginalis do not completely close resulting with potential of inguinal hernia. Therefore, families should be informed about signs and symptoms of inguinal hernia and incarcerated inguinal hernia. Patients should be asked to come to the control visits and surgical treatment should be employed when the hernia is diagnosed. Otherwise, the hydrocele persisting for 18 months also requires surgical treatment.