A Practical Introduction to Common
Pediatric Surgical Emergencies
Jan Miguel C. Deogracias, MD, FPSPS
Disclosures
None
Objectives and Outline of Discussion
1. Provide an overview on the basic principles of pediatric surgery.
2. Introduce practical concepts in diagnostic and therapeutic
approaches to common pediatric surgical conditions.
a. Acute Scrotum
i. Inguinal hernia
ii. Testicular torsion
b. Acute Abdomen
c. Neonatal surgical emergencies
i. TEF-EA
ii. Malrotation
iii. Abdominal Wall defects
iv. ARM/ HD
Basic Principles
“Children are not small adults.”
- different developing anatomy and physiology
- special pain and anesthesia considerations
- “two patients” – parents/guardians
- lifetime follow- up
Basic Principles
TIMELY REFERRAL
- a correct and complete diagnosis is NOT always mandatory to
begin an early referral to pediatric surgeon
- exploratory surgery ~ can be a part of the diagnostic process –
both diagnostic and therapeutic
Basic Principles
MULTISDISCIPLINARY MANAGEMENT
- isolated congenital anomaly multiple congenital anomaly
- multiple specialty involvement
- MDC lead to better outcomes
Basic Principles
CLEARANCE RISK ASSESSMENT
- informed consent process
- medico-legal consequences
- “can we go ahead?” to “how do we optimize?”
Common Pediatric Surgical Emergencies
Case # 1
- 13 year-old, male, grade 6 pupil
- No sexual history
- 8-hour right inguinal and scrotal pain +
dysuria
- Markedly tender right scrotum – does
not allow to be touched
- No scrotal erythema, edema
- Urinalysis done in local clinic: (+) many
WBC
Case # 1
The patient underwent right
scrotal exploration.
Intraoperative findings:
testicular torsion right; testicular
gangrene despite detorsion.
Final procedure:
Right orchiectomy, left
orchidopexy.
Case #2
- 6 year-old boy, grade 1 pupil
- Comes to the emergency room
with pain on the right scrotum
associated with nausea and
vomiting
- No fever and no dysuria
- Normal testis on the left
- Mother reports that he has
intermittent scrotal swelling
since he was a baby
Case #2
The right inguinal hernia was
successfully reduced at the
emergency room.
He was then scheduled to elective
repair of his right inguinal hernia
the next day.
Case #3
11-year old boy
right groin pain for 3
days – increasing at
first then became
steady
(+) nausea and
vomiting
No dysuria but with
right flank pain
Case #3
The patient
underwent inguinal
exploration.
IOF: undescended
testis right, inguinal
with testicular torsion
resulting to testicular
gangrene
Acute Inguinoscrotal Conditions
WHAT IS AN ACUTE SCROTUM?
- severe scrotal pain with or without scrotal swelling and
erythema
- most likely cause is AGE-DEPENDENT
- urgent exclusion of testicular torsion and incarcerated
inguinal hernia
Causes of Acute Scrotum
1. Testicular torsion neonatal testicular torsion
Infants
2. Torsion of the appendix testis epididymo-orchitis
3. Epididymitis
Pre-pubertal torsion of the appendix testis
4. Trauma
5. Incarcerated hernia Peri-pubertal testicular torsion
6. Henoch-Schönlein Purpura
7. Varicocele Post-pubertal
testicular torsion
epididymo-orchitis
8. Acute idiopathic scrotal
edema
Inguinal Hernia
“I know more than a hundred surgeons whom I would cheerfully allow to
remove my gallbladder but only one to whom I should like to expose my
inguinal canal.”
Sir William Heneage Ogilvie (1887–1971)
- congenital defect from the failure or incomplete
obliteration of the processus vaginalis
- no medical treatment available; surgical repair is the only
treatment
- can be organ or life-threatening if not expeditiously
managed
[Link]
Management of Inguinal Hernia
Universal dictum:
REPAIR AS SOON AS DIAGNOSED
- increased risk of incarceration/ strangulation
- infants have higher intra-abdominal pressure ( e.g.
when crying) > more chances of hernia incarceration
- will not close spontaneously
Surgery for Pediatric Inguinal Hernia
ELECTIVE EMERGENCY
reduce the incarcerated
close the patent
structure/s
processus vaginalis
+/- repair the inguinal floor + ensure its viability
+ repair the patent processus
vaginalis
Complications and Long-Term Follow-up
- almost all will do well after operative repair
- possible complications:
recurrence - 1-5%
infection - < 1%
testicular atrophy
injury to vas deferens
DEATH is extremely rare but are still reported
because of delayed recognition of incarcerated and
strangulated hernia
“The smallest coffins are the heaviest.”
- Ernest Hemingway
Testicular Torsion
peak incidence at
WHEN? peripubertal period and
adolescents
twisting of spermatic
cord lead to vascular
WHY? compromise of affected
testis – ischemia then [Link]
gangrene
Ship's bell — 'Cygnet',
brass, circa 1846–1876,
Museum Victoria
(Creative commons).
A brass bell with the
bell's clapper (flattened
circle with a small
tapered extension).
Kiarash Taghavi, et. al, The bell-clapper deformity of the
testis: The definitive pathological anatomy, Journal of
Pediatric Surgery, vol 56 -8, 2021, pp1405-1410,
[Link]
Testicular Torsion
- sudden onset of pain in one scrotum
- no precipitating event
- nausea, vomiting
- possible history of intermittent
HOW? scrotal pain
- high-riding testis on the side of pain
- edema or erythema – late sign
- transverse lie
- loss of cremaster reflex
Testicular Torsion
WHAT URGENT CONSULT!!!
TO DO?
- Ultrasound may delay urgent
surgical exploration
- Diagnostics are no longer indicated if
high likelihood of torsion
Is there a golden period?
Questions?
5-minute break
ACUTE ABDOMINAL PAIN in CHILDREN
pre- appendicitis
Age group Diagnoses adolescent •acute
child •complicated
any age intestinal malrotation/volvulus gallstone complications – pigment gallstones
mechanical bowel obstruction •cholecystitis
•adhesive •choledocholithiasis
•gallstone pancreatitis
•intraluminal – foreign body (non-neonate/infant), distal
epiploic fat torsion/infarction
intestinal obstruction syndrome (cystic fibrosis), constipation omental torsion/infarction
Meckel diverticulitis Henoch-Schonlein purpura
neutropenic enterocolitis viral gastroenteritis
perforated viscus ovarian torsion (female)
adolescent appendicitis
newborn neonatal obstruction, congenital lesion internal gallstone complications – pigment and cholesterol gallstones
hernia/volvulus– omphalomesenteric duct remnant, duplication cholecystitis
cyst, mesenteric cyst choledocholithiasis
necrotizing enterocolitis gallstone pancreatitis
biliary dyskinesia
incarcerated inguinal hernia
gastroesophageal reflux
infant intussusception inflammatory bowel disease
Crohn disease– partial obstruction/stricture,
incarcerated inguinal hernia
phlegmon/abscess, fistula, perforation
nonaccidental abdominal trauma ulcerative colitis- megacolon
Hirschsprungassociated enterocolitis ovarian pathology (female)
abdominal/retroperitoneal neoplasm torsion
ruptured cyst
toddler intussusception pelvic inflammatory disease(female)
appendicitis– complicated perforated gastric/duodenal ulcer
non-accidental abdominal trauma epiploic fat torsion/infarction
Hirschsprungassociated enterocolitis omental torsion/infarction
abdominal/retroperitoneal neoplasm Henoch-Schonlein purpura
urinary tract infection
pneumonia
urolithiasis
IS IT SURGICAL?
Evaluation of abdominal pain in
children is always challenge.
Pathophysiology of abdominal pain
VISCERAL
PARIETAL
REFERRED
What are the red flags?
- sudden onset
- severe pain enough to wake up from sleep
- bilious vomiting
- bleeding ( hematemesis, hematochezia/ melena/ blood via stoma)
- child is either very still or is writhing in pain
- guarding, rigidity, abdominal distension
- high-risk patients
Surgical Abdominal Pain
OBSTRUCTIVE INFLAMMATORY
Acute appendicitis in children
- most common pediatric abdominal surgical emergency
- pathophysiology similar to adults
- CONGESTIVE
- ACUTE SUPPURATIVE
- GANGRENOUS
- RUPTURED
- traditional management: antibiotics + source control
- non-operative management VS surgery
What’s different in children?
- anatomic location of the appendix
- shape of the appendix. - funnel-
shaped in infants
- lymphoid follicles reach maximal
size in adolescents
- thin and underdeveloped
omentum in young children
- ADVANCED when < 6 years-old
QUESTIONS?
2-minute break
INTUSSUSCEPTION
Intussusception
- most common abdominal
emergency in early childhood
- peak incidence between 4 months
to 36 months
- classic triad – abdominal pain +
vomiting + red-currant jelly stool
- typical abdominal pain pattern
- vomiting is 2nd most common
symptom
ULTRASOUND STAT
VERY LATE SIGNS
- peritonitis
- bloody stools
- abdominal distention
- sepsis
- anemia
Management of Intussusception
SEPSIS, PERFORATION, CGO
NON-OPERATIVE
DIAGNOSIS SURGERY
REDUCTION
NPO IF FAILED,
IV FLUIDS PERFORATION,
ANTIBIOTICS PATHOLOGIC
LEAD POINT
QUESTIONS?
