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Pediatric Surgery (Pg 68-81) - page 6 / 33





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Omphalocele – Surgery is not emergent.  Evaluated associated anomalies.  Sac eventually epithelializes and contracts leaving a ventral hernia that can be repaired electively.


Gastroschisis – may have prolonged intestinal dysfunction after surgery as result of chronic inflammation of exposed bowel.  Long-term outlook is good.

Omphalocele – prognosis is related to associated anomalies that may be present


- among oldest of surgical procedures

- most frequently performed operation on males in US

- percent circumcised:  90% boys in US, 40% of boys in Canada, 15% in Australia, and very rarely in Europe

- controversial, even within medical profession

- American Academy of Pediatrics remains neutral, stating that risks and benefits should be given to parents and parents should decide

- undersurface of foreskin is fused with glans at birth so in uncircumcised boys, attempts at retration of foreskin should be avoided until 2 to 3 years of age

- advantages:  prevents phimosis, prevents paraphimosis, lowers incidence of UTIs in infancy, prevents balanopsthisis (infection of glans and foreskin from retained secretions), prevents cancer of the penis

- disadvantages:  medically unnecessary in most boys, painful, risk of complications (low, but may include bleeding, infection, meatal ulcers, postcircumcision phimosis, necrosis)

- contraindictions:  anomalies of the external genitalia (hypospadias) because foreskin may be needed for operative correction, serious illness

Surgical Conditions in the Older Child

Inguinal Hernia and Hydrocele

Repair of both inguinal hernias and hydroceles is most common operation performed by pediatric surgeons

Hernias occur in 3% of children overall, with an incidence of 30% in very premature infants

Increased intrabdominal tissue (ascites) and connective tissue disorders may predispose to hernias

Boys are affected 6 x as often as girls

Inguinal hernias in children are almost all indirect hernias, with hernia sac coming through internal inguinal ring

Embryology:  at 3 months gestation, processus vaginalis forms and passes through internal inguinal ring, then migrates down inguinal canal to scrotum, and lies in spermatic cord

Processus is usually obliterated around time of birth

In girls:  tunica vaginalis

Pathophysiology:  continued patency of all or part of the processus vaginalis accounts for the development of hernias and hyrdoceles

If processus is open and still continuous with peritoneal cavity, intraabdominal contents may protrude through and become inguinal hernia

If processus is open but is too narrow for viscera to pass through, only peritoneal fluid may enter and form communicating hydrocele that communicates with peritoneal cavity

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