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.