Professional Documents
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PROCESSUS VAGINALIS
Peritoneal diverticulum
that extends through the
internal inguinal ring
CANAL OF NUCK
In females
EMBRYOLOGY
EMBRYOLOGY
EMBRYOLOGY
ANATOMY OF HYDROCOELES
& INDIRECT INGUINAL HERNIAS
DIFFERENCE BETWEEN
CONGENITAL HERNIA AND
HYDROCOELE
DIAMETER OF PROCESSUS VAGINALIS
CONTENT OF SAC
INDIRECT INGUINAL
HERNIA HYDROCOELE
IDENTIFICATION OF
HYDROCOELE
HISTORY
• Fluid in scrotum
• Two types
communicating – treat as hernia
non-communicating – if present at birth, may
spontaneously resolve until 1 year
PHYSICAL EXAMINATION
TRANSILLUMINATION
GUIDELINES IN MANAGEMENT
OF HYDROCOELE
IF THE HYDROCOELE IS
NONCOMMUNICATING (EARLY ONSET WITH
NO CYCLIC CHANGES), IT MAY BE OBSERVED
FOR A YEAR
HYDROCOELE - HYDROCOELOTOMY
IDENTIFICATION OF
INGUINAL HERNIAS
HISTORY
RECURRENT GROIN SWELLING
FIRST NOTED IN THE
1ST YEAR OF LIFE
PHYSICAL EXAMINATION
1. GROIN OR SCROTAL SWELLING, OFTEN
INITIATED BY STRAINING
2. IN FEMALES, MASS INDICATES THE OVARY
3. IN MALES, CHECK LOCATION OF THE TESTIS
GUIDELINES IN THE
MANAGEMENT OF
HERNIAS
• Operate as soon as diagnosed
• High risk for incarceration esp. in 1st year of
life
TREATMENT OF INDIRECT INGUINAL HERNIA
HERNIOTOMY (CHILDREN)
• Operation is HERNIOTOMY
which means the patent processus
vaginalis is ligated high at the
internal inguinal ring
HIGH LIGATION OF HERNIAL SAC
ONE WEEK AFTER HERNIOTOMY
UNDESCENDED TESTIS
• If bilateral, may require endocrine
workup
• Descent may still occur until 1 year
• Palpate for testes in groin, perineum,
other ectopic location
• May request for UTZ
• Operation is ORCHIDOPEXY
UNDESCENDED TESTIS
DEFINITION: TESTIS CANNOT BE
MANIPULATED TO THE BOTTOM
OF THE SCROTUM
ETIOLOGY
•HORMONAL
•MECHANICAL
DIFFERENTIAL DIAGNOSIS:
•RETRACTILE TESTIS
•ECTOPIC TESTIS
•TRUE UNDESCENDED TESTIS
Undescended testis
PROBLEMS OF CRYPTORCHIDISM
•STERILITY – DECREASED SPERMATOGENESIS
•MALIGNANT CHANGES
•HERNIA
•TRAUMA AND TORSION
•PSYCHOLOGICAL/EMOTIONAL
GOALS OF TREATMENT
•IMPROVE FERTILITY
•PREVENT TRAUMA AND TORSION
•TESTIS PALPABLE FOR EXAMINATION
•PSYCHOLOGICAL REASON
TREATMENT FOR
CRYPTORCHIDISM
ORCHIDOPEXY PRIOR TO 1 YEAR OF AGE
INGUINAL, STAGED OR LAPARASCOPIC
SURGERY
CONGENITAL ABSENCE OF
PARASYMPATHETIC INNERVATION
OF THE INTESTINE
HIRSCHSPRUNG’S
DISEASE
Important points:
• First passage of meconium
• Poor weight gain
• Abdominal distension relieved with
suppositories or rectal stimulation
• Gush of air or feces on rectal exam
• Visible bowel loops
CLINICAL PRESENTATION
•DELAYED PASSAGE OF MECONIUM
MORE THAN 24 HOURS AFTER
BIRTH
•MAY PROGRESS TO MASSIVE
DISTENTION
•CHRONIC CONSTIPATION
•DIARRHEA FROM ENTEROCOLITIS
WITH DISTENTION AND
DEHYDRATION
•INTERMITTENT OBSTRUCTION RELIEVED
BY SUPPOSITORIES OR ENEMAS
ABDOMINAL
DISTENSION
DIAGNOSTIC STUDIES FOR
HIRSCHSPRUNG’S DISEASE
•BARIUM ENEMA
CONING OR TRANSITION ZONE
•ANORECTAL MANOMETRY
•ACETYLCHOLINESTERASE
DETERMINATION
TRANSITION ZONE/CONING
ON BARIUM ENEMA
Hirschsprung’ s disease
Transition zone
HIRSCHSPRUNG’S
DISEASE
Patient population
• Virgin case, for rectal biopsy
• Candidate for primary pullthrough
• S/p colostomy, for pullthrough
• S/p pullthrough, for closure of
colostomy
• Complicated cases
HIRSCHSPRUNG’S
DISEASE
Salient points:
• Good history and PE
• Look for results of labs (rectal
biopsy, barium enema, distal
colonogram)
• Assess eligibility of child for
surgery
Post-colostomy
SOFT TISSUE MASSES
• Hemangiomas
• Lymphangiomas
• Ganglion cysts, Baker’s cysts
• Lipomas
• Epidermal inclusion cysts
• Subcutaneous abscesses
HEMANGIOMAS
Congenital reddish cutaneous masses
Spontaneous regression
Large ones – Kassabach Merritt synd
May have a feeding artery
Transient increase in size during the
first year of life
HEMANGIOMAS
Diagnostic : Physical exam
Others: CBC with platelet count
angiogram
ultrasound
HEMANGIOMAS
Management:
1. Observation
2. Oral steroids – prednisolone or
prednisone
3. Surgery – partial or complete
excision
4. Laser ablation
HEMANGIOMA
LYMPHANGIOMA
LYMPHANGIOMAS
• Cystic congenital masses due to
obstructed lymphatic channels
• Known as cystic hygromas
• Excision treatment of choice ( not
always possible)
• Limited use of intralesional
sclerosants
OTHER MASSES
• Ganglion cysts – excision, aspiration
• Abscesses – drainage
• Inclusion cysts – excision
• Teratomas
UMBILICAL PROBLEMS
• Abdominal wall defects which may
not be corrected at birth or
manifest late
• Hernias, polyps, urachal remnant,
omphalomesenteric duct remant
UMBILICAL HERNIA
PATENT URACHUS
ANAL FISTULA
• May start as a perianal abscess
• Communicating tract between anal
canal and skin due to a
cryptoglandular infection
• Operation: FISTULOTOMY or
FISTULECTOMY , often with
proctosigmoidoscopy
ANAL FISTULA AND
FISSURES
FISSURES
• common in constipated child, esp
after passage of large hard stool
• Located in midline, may cause blood
streaked stool
• Stool softeners, hot sitz bath, pain
meds
CLINICAL SIGNS OF ANAL
FISSURES
•BRIGHT RED BLEEDING