17: SURGERY

Published on 27/05/2015 by admin

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Last modified 27/05/2015

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CHAPTER 17 SURGERY

PAEDIATRIC PROBLEMS

HERNIA AND HYDROCELE

These usually present in the first year of life as a swelling in the groin. They may present after an episode of crying or coughing.

An obstructed hernia is tender and it is impossible to palpate above it, unlike other causes of a groin swelling:

• incompletely descended testicle

• inguinal lymphadenopathy

• groin abscess.

Referral to a paediatric surgeon is indicated. Admit to hospital any patient with a suspected obstructed hernia.

UNDESCENDED TESTES

Incompletely descended testes are seen in 0.5–0.7% of boys at 1 year of age.

Referral to a paediatric surgeon is indicated after age 1 at the first presentation, regardless of degree of maldescent.

PHIMOSIS

The foreskin is usually non-retractile until the age of 5 years. A tight meatus and spraying urinary stream may suggest the need for circumcision.

Recurrent balanitis is best treated with improved hygiene and intermittent oral antibiotics. Circumcision is indicated for persistent cases.

UMBILICAL GRANULOMA

Pyogenic granuloma of the umbilical remnant is a common problem at the 6–8-week check.

The application of silver nitrate, or alternatively ligation, are effective, simple measures.

UMBILICAL HERNIAE

The true umbilical hernia, or protruding umbilicus, usually resolves spontaneously and surgical referral should only be considered if it persists over the age of 2 years. Strangulation is very rare in these cases.

Supraumbilical and epigastric herniae should be referred, as trapping of bowel or omentum is more common.

INTUSSUSCEPTION

Intussusception is most common under the age of 2 years and presents as severe colic, vomiting and pallor, often with blood in the stool.

Admission to hospital is clearly indicated.

LEG PROBLEMS

Some normal conditions cause parental anxiety. These include: bow legs, flat feet, knock knees, in- and out-toeing and walking on tiptoes. As long as there is no pain or limp, and the examination reveals a full range of pain-free movement, the parents should be reassured that all is well.

LIMP

A persistent limp is usually pathological and referral to an orthopaedic surgeon is indicated. The acute onset of a limp with pain in the hip requires an urgent orthopaedic opinion to exclude septic arthritis and slipped femoral epiphysis.

BREAST LUMPS

All breast lumps cause anxiety in the patient until a firm diagnosis is made.

Refer patients with breast lumps to a surgeon with an interest in treating breast cancer.

LUMPY BREASTS

Anxiety about cancer in a woman with lumpy or large breasts poses a difficult problem. If normal on clinical examination, mammography may be useful.

PAINFUL BREASTS

Cyclical mastalgia in the absence of lumps can be treated by:

• reassurance that there are no lumps

• evening primrose oil, 2–3 capsules tds (only available OTC)

• furosemide 40 mg daily for premenstrual fluid retention.

GALLSTONES

The symptoms of gallstones are often confused with gastric problems. Most gallstones are asymptomatic.

Diagnosis

History.

• right hypochondrial pain

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