Pediatric Surgery and Urology
Paediatric Surgery and Urology usually presents a neonate or infant with a classic pattern, then tests whether you would resuscitate before operating and whether you know the age-dependent answer.
Neonatal and infant emergencies
- Hypertrophic pyloric stenosis: 3-6 weeks, first-born boys, projectile non-bilious vomiting, visible peristalsis, palpable olive. Biochemistry shows hypochloraemic hypokalaemic metabolic alkalosis with paradoxical aciduria. Correct with 0.45% saline plus 5% dextrose and potassium chloride before Ramstedt pyloromyotomy; ultrasound shows muscle thickness of 3 mm or more and canal length of 15 mm or more.
- Intussusception: 6-18 months, colicky pain, drawing up the legs, redcurrant jelly stool, target sign on ultrasound. Pneumatic or hydrostatic reduction after resuscitation, provided there is no peritonitis or perforation.
- Malrotation with midgut volvulus: bilious vomiting in a neonate is a surgical emergency; upper GI contrast shows a corkscrew and treatment is urgent Ladd's procedure.
- Hirschsprung disease: delayed meconium, distension, transition zone on contrast enema; rectal biopsy shows aganglionosis.
Urology
- Testicular torsion: sudden pain, high-riding testis, absent cremasteric reflex - immediate scrotal exploration; salvage falls sharply after 6 hours. Do not wait for Doppler.
- Undescended testis: orchidopexy by 12-18 months.
- Hypospadias: never circumcise before repair, because the foreskin is needed for urethroplasty.
- Wilms tumour: smooth flank mass, haematuria; nephrectomy after chemotherapy in most protocols. Neuroblastoma crosses the midline and calcifies.
Worked example
A 5-week-old boy has projectile vomiting for 3 days with chloride 88 mmol/L, bicarbonate 32 mmol/L, pH 7.50 and hypokalaemia. This is pyloric stenosis with hypochloraemic alkalosis; correct the fluid and potassium until chloride and bicarbonate normalise, then perform pyloromyotomy.
Traps
Operating on an uncorrected alkalosis, risking postoperative apnoea; attempting enema reduction with peritonitis or perforation; circumcising a hypospadias.