Groin Surgery in Paediatrics

Groin Surgery in Pediatrics:

22 Malaysian urological conference, 23 November 2013,

Abstract page 28

Dr Clarence Lei Chang Moh, Normah Medical Specialist Centre & Sarawak GH, Kuching, Malaysia.

Introduction and Objectives:

Groin surgery in pediatrics can be performed by urologists in Malaysia.  This is partly because the urologist often covers a large geographical area.  The child is not equivalent to a small adult and the surgical technique is often different. The following are the types of groin surgery in pediatrics often undertaken by urologists: acute scrotal pain (testicular torsion versus infection), trauma, hernia, hydrocele, varicocele and testicular tumour. Testicular maldescent is another area of specialised practice.

Testicular Torsion:

Acute scrotal pain should be treated as testicular torsion, until proven otherwise. Testicular salvage is difficult after 6 hours and therefore, arrangements must be made for immediate surgery even as an emergency Doppler ultrasound is being arranged. Most patients end up with orchidectomy and fixation of the contralateral testis. Missed testicular torsion continues to be a source of litigation in Malaysia. A testicular prosthesis may be inserted by the inguinal approach at the later stage.  Torsion of appendix testis does not require surgery.  Severe orchitis can also lead to testicular infarct and delayed orchidectomy. Testicular injuries are best treated by open exploration to reduce the risk of pressure ischaemia from a testicular haematoma.

Surgery with the help of pediatric team is recommended for inguinal scrotal surgery.  A plump neonate with a large inguinal hernia is best operated with the help of a pediatric anaesthesiologist.  The surgeon should use an ocular loupe to preserve the spermatic cord structures especially the vas deferens and testicular artery.  Clinical inguinal hernia is operated as soon as possible. If there is a significant hydrocele that persists beyond 2 years, herniotomy and drainage of the hydrocele may be done electively.  Pediatric varicoceles usually do not require surgery.  Inguinal ligation of the varicocele may be performed if the varicocele is associated with a smaller ipsilateral testis.  Testicular tumour is usually in the bigger child, and treated by a radical inguinal orchidectomy. 

Undescended Testis:

If the testis is not in the scrotum by 1 year of age, surgical intervention is needed.  If the testis is palpable, a standard orchidopexy is performed. The spermatic cord should be adequately dissected to the retroperitoneum so that the testis can be brought to scrotal dartos pouch without tension. The patent processus vaginalis also needs to be transected and ligated.  A high quality ultrasound can detect most of the other testis, often lying just inside the deep inguinal ring.  Otherwise, a laparoscopy or mini laparotomy would identify any intraabdominal testis.  The unilateral high intraabdominal testis in a big child is best treated by orchidectomy. Bilateral intraabdominal testes can be treated by staged orchidopexy, so as to preserve maximal endocrine function of the testes.

Summary: Groin surgery in pediatrics can be performed carefully by the urologist with paediatric anaesthetic and nursing support.  

Keywords:   Testicular torsion, orchitis, herniotomy, undescended testis.