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B. Other categories of illnesses: 2. Collagen-Vascular Illnesses 7. Trauma and Surgery |
Surgery in Pediatrics: Timing and Indications for ProceduresOne Pediatrician’s Opinion1. Pectus Excavatum: (funnel chest due to midline narrowing of the thoracic cavity) When if ever should we operate on children with this condition? Associated abnormalities: mitral valve prolapse and Wolff Parkinson White syndrome. There is some disagreement about whether this condition has cardiopulmonary compromise associated with it, or whether it is “merely” a cosmetic problem. Surgery averages about 10 days in the hospital, plus the insertion of a steel rod which stays in place 6-12 months after surgery. Two articles: --Hopkins group (J of Peds 96;128:638-643) Vital Capacity in 36 adolescents with pectus and compared the results to controls: a significant difference from controls, but still normal; Total Lung Capacity: correlated inversely with A-P diameter of chest but again this value fell within the normal ranges; Cardiac: subjective decrease in exercise tolerance, but no difference in heart rate, function, etc. was found in this study. Postoperatively there was no change in pulmonary findings, but a slight increase in exercise tolerance was observed after operation. This is thought due to an improved cardiac function after relief of cardiac compression and displacement. --- Second article: European Journal of Cardio-Thoracic Surgery 1997;12:345-50: 5 of 7 patients with asthmatic conditions improved; 75 of 77 patients pleased with results. -- Personal experience: children are quite pleased with the results of the surgery. Recommendation: consider surgery at age 5 - 6 years. 2. Gynecomastia: In teenaged male the differential should include:
3. Circumcision: Once thought to be a cosmetic procedure, now many agree that this procedure is important in preventing urinary tract infections. (J Ped 96;128:23-27) -definitely decreases the risk of symptomatic UTI in preschool boys. Also, there is information that suggests that the foreskin can transmit STDs and HIV infections and that circumcision decreases the likelihood of this transmission. Of course the other reasons for recommending circumcision still hold: ethnic, hygiene, preventing cervical carcinoma in women after the male marries. 4. Undescended Testicles: Testicular descent occurs in the 7th month of pregnancy. Therefore, the more premature the baby is, the more likely there will be undescended testes. Unilateral: 70%. Usual rule of thumb: If bilateral undescended testes (not in inguinal canals), consider work-up to include chromosomes. Refer child by 6 months of age; surgery by 12-18 mos. Spontaneous testicular descent does not occur after one year of age. Associated problems: inguinal hernia, torsion, and infarction of undescended testicle because of excessive mobility of the testicle. Indications for HCG treatment: best for bilateral undescended testes; requires 5 weekly injections. This treatment is not as good for unilateral and not indicated for retractile testes. Must differentiate this from:
How to examine a child for an undescended testis: Have child in sitting position; if possible have child sit in a squatting position. If testis then is palpable in the scrotum, it is retractile, not undescended. 5. Cleft Lip: Usually surgery is performed by 2 months of age in a full term baby. Many surgeons prefer to wait until the child is 10-11 pounds. This may need to be revised at 4-5 years of age. Z-plasty is the most commonly used technique: staggered suture line prevents notching of the lip. 6. Cleft Palate: Time of surgery of this condition will vary with the defect. However, the palate is usually closed before 1 year of age to ensure proper speech development. Often tubes are placed at the time of surgery for the palate since these will eventually be needed by children with this condition. 7. Indirect Inguinal Hernias: Most children can be repaired as outpatients; exceptions could include ex-prematures under 6 months of age. Otherwise, no matter what the age, hernias can be repaired soon after the time of diagnosis. The risk of incarceration is greatest under 12 months of age, so repair should be done before that if possible. Contralateral side: about 10% the contralateral side will develop a hernia; some surgeons choose to fix that side at the time of the initial surgery. Inguinal hernias are more common on the right (65% right-35% left). If find a hernia presenting on the left, the surgeon more likely to fix both sides. 8. Tongue-Tied: Almost never of clinical significance. In older child, if unable to protrude the tongue beyond the vermilion border, then consider clipping the frenulum. 9. Baker’s Cysts, Pilonidal Cysts, Ganglions, Lymphangiomas, Hemangiomas, Sebaceous Cysts, Neurofibromas, Osteochondromas, Exostoses, Etc: Unless these problems are causing complications, their removal can be quite difficult requiring extensive surgery. If at all possible, surgery should be avoided. When diagnoses are in doubt, of course, surgery must be done to ensure that nothing more serious is causing the physical abnormality. 10. Umbilical Hernias: Do not need to refer to the surgeon until after 5 years of age. Exceptions would be incarceration (rare) or such a huge size that know unlikely to spontaneously heal. 11. Varicoceles: If testicle is more than 2 cm smaller on side with varicocele (left), operate; if not, watch. This affects 15% of males (Peds 97:100:112-119). Catch-up growth 80% after surgery. |
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© Medical College of Georgia |
Department of Pediatrics |
Medical College of Georgia February 27, 2004 |