Pitfalls of Paediatric Groin Surgery, edited slides, 26 Nov 2017

Pitfalls in Paediatric Groin Surgery, @ 26 Malaysian Urological Conference 26 Nov 2017

Introduction and Objectives:

Groin surgery in paediatrics  often has to be performed by urologists in Malaysia.  This is partly because the urologist  covers a large geographical area.  The child is not equivalent to a small adult and special care is needed. The following are the types of groin surgery in paediatrics 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.

Surgery & anaesthesia with the support of the paediatric team is needed for inguinal scrotal surgery.  In April 2017, US FDA confirmed an earlier warning that general anaesthesia (esp repeated or duration  > 3 hours) “may negatively affect brain development in children younger than 3 years..”. There MUST be proper arrangements for pre-operative fasting (same as adults!),  paediatric equipment, proper bipolar diathermy, peri-operative temperature & pain control, postoperative close monitor and recovery.  A child with “wet” respiratory infection should have elective surgery postponed for 4 weeks. A plump neonate with a large inguinal hernia is best operated with the help of a paediatric 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 3 years, herniotomy and drainage of the hydrocele may be done electively.

Testicular Pain:  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. 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.

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 a scrotal Dartos pouch without tension. The patent processus vaginalis also needs to be  ligated.  A high quality ultrasound can detect a testis lying just inside the deep inguinal ring.  Otherwise, a laparoscopy or mini laparotomy would identify any intraabdominal testis. A 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  by the urologist with due care,  paediatric anaesthesia and paediatric  nursing support.  

Keywords:  Anaesthesia in paediatrics, Testicular torsion, orchitis, herniotomy, undescended testis.

Kuching Guide by Dr Lei, for visitors 2017

Kuching Guide by Dr Clarence Lei

Kuching is a nice place; many chose to settle in Kuching after their tour of duty! It is designed as a “healthy” city. I first wrote this for a class reunion in 2006.

You can start the day with light exercise: a brisk walk along the Sarawak Riverfront or the cool Reservoir Park! There is so much greenery and tranquility. You can experience so much unity not only amongst the people, but even the birds and insects!

Sarawak River is no longer good for swimming but the bigger hotels have pools.

AIR TRAVEL is currently the main way to reach Kuching, by Malaysian Airlines &  or AA, Air Asis from Kuala Lumpur International Airport or Johor Baru or Singapore to Kuching. Malaysian Airlines is about RM300 – RM1000 one way, depending on when you book; AA is cheaper, about RM150-300 one way + luggage.  Malindo Air is priced in the middle, but fewer flights. However, there is limited luggage connectivity with AA & Malindo Air.

ARRIVAL: Taxis from the airport are based on the coupon system, to be purchased before departure from the airport.  In town, taxis use meters or on a fixed fare,  ~      RM25. You can also uber !  Car rental available from airport or hotel eg Hertz, ~RM300 for a Toyota Unser, email: kch@hertz.simedarby.com; Tel; 082 450740; Toll free: 1-800-88-3086

TOUR AGENCIES: 

Within Pullman Hotel, Catcity  Holidays has a counter, please try to book in advance;   Tel 082-414 200 Counter opens Mond Frid 830am – 5pm; Saturday 830am - 1pm, , mice@catcityholidays.com; and inbound@catcityholidays.com  016 808 4198 (Ms Lek, whatsapp)

Within Hilton Hotel, Journey Travel Agencies Tel 082 25 11 817, HP: 019 859 8316 Mr Peter Bong  email: journeyborneo@gmail.com

I attach two updated leaflets: I recommend the Sarawak Cultural Village. Please use walking shoes as it can be slippery!

HOTELS:  You can easily book through the hotel or  websites eg Agoda.com. I can recommend Pullman, Hilton or Riverside Majestic.  Beach Hotels are an hour drive eg Damai  Beach Resort Tel: +6082-846999,  or resvn@damaibeachresort.com;   

RM 300

WALKING TOURS (just outside hotels in town):

(1)       Sarawak River Waterfront: do not carry handbag or leave unattended items (e.g. handphones) because of snatch thieves; otherwise Kuching is very safe.  You may try River Cruise  along the river or take a small boat (“sampan”) around the river to see the Governor’s residence and Malay kampungs. The NEW suspension bridge just open on 11.11.2017 !!

(2)       Waterfront shops (along Gambir Street, souvenir shops). You can get blowpipes, Orang Ulu beads, Pua Kumbu weavings, mats, pottery at reasonable prices.

(3)       Emporiums/supermarkets/fast food (e.g. KFC, MacDonald, Pizzahut, Coffee Bean, Suan Chicken Rice) are just next door to hotels. Many affordable Chinese (NON Halal)  coffee shops are nearby e.g. Fock Thai Tim Sum Café at 54 Jalan Padungan 93100 Kuching, Lau Ya Ken Porridge & Food Stall (Chef Ah Soon H/P: 019-8563128 for dinner, around RM15 per person) near GPO Post Office at Carpenter Street,  or try his sister (Madam Sim Bak Huey) at No 27 Petanak Market (Tel 257611 Restoran Didi (Malay) at Lot 202 Jln Kulas, 93400 Kuching, Tel 082 412 053.  For Sarawak Laksa, try many stalls next to Kuching Specialist Centre, or Sin Chong Choon Café. There is a good Halal seafood centre at “TopSpot”: top of a car park next door to Pullman/Hilton hotels.

(4)       Sarawak Museums (from 930 am to 445 pm,), one of the oldest museums in South East Asia. Free entrance. Tel 082 244 232. There is a small outdoor old café serving the famous Sarawak Laksa, Belachan Beehoon (Halal) and ABC ice slush. The main museum is closed for renovations but the Chinese Museum at waterfront is open.

SARAWAK TOURISM BOARD Kuching Visitors’ Information Office, opposite the Sarawak Museum/Merdeka Palace Hotel, more information and leaflets. Tel 082-410944, Fax 082-256301. Website: www.sarawaktourism.com

COMMUNICATIONS:   Broadband  Internet  is widely available, often free.

English and Malay are widely spoken.  Chinese dialects include Mandarin, Hockkien and Khek.

EXCHANGE/BANKS:

There are abundant ATM machines and credit cards are widely accepted.  There are also a number of money changers near the hotels mentioned.

PLACES OF WORSHIP  near the hotels mentioned, including Kuching Mosque, temples, Hindu temple and churches (Anglican St Thomas’s Cathedral, Tel 082-242625,  deankg@tm.net.my, Communion on Sundays at 645 am, 815 am, 530pm. RC is  St Joseph’s Church)

HOSPITALS, nearby:

(1)   Sarawak General Hospital, Tel 082-276666.

(2)   Timberland Medical Centre, Tel 082-234466.

(3)   Normah Medical Specialist Centre, Tel 082-440055.

Clarence Lei Chang Moh

11 .11.2017