Inguinoscrotal swellings in paediatics provided by MedExcel

‫آﻞ ﻋﺎم واﻧﺘﻢ ﺑﺨﻴﺮ‬ Happy New Year ‫ﻣﻴﺜﺎق هﺬﻩ اﻟﻤﺤﺎﺿﺮة‬ Inguino scrotal Swellings in Children ‫ﻻ‬ ‫ﻻ ﻟﻠﻤﺤﻤﻮل‬ ‫ﻻ ﻟﻠﺘﺸﺎؤم‬ ‫ﻻ ﻟﻠﺘﺜﺎؤب‬ ‫ﻻ ﻟﻠﻤﺤﺎدﺛﺎت اﻟﺠﺎﻧﺒﻴﺔ‬ ‫ﻧﻌﻢ‬ ‫ﻟﺘﻔﺎؤﻟﻚ‬ ‫ﻻﺑﺘﺴﺎﻣﺘﻚ‬ ‫ﻟﻤﺸﺎرآﺘﻚ اﻻﻳﺠﺎﺑﻴﺔ‬ ‫ﻟﻸﺳﺌﻠﺔ اﻟﻤﻨﻈﻤﺔ‬ ‫ﻟﻼﻗﺘﺮاﺣﺎت اﻟﺒﻨﺎءة‬ Essam Elhalaby, M.D. Prof. of Pediatric Surgery Director of Quality Assurance Unit Faculty of Medicine, Tanta University Inguino-scrotal Swellings in Children InguinoCongenital inguinal hernia Hydrocele Testicular torsion Acute scrotum Varicocele Others Inguino-scrotal Swellings in Children InguinoCongenital inguinal hernia Hydrocele Testicular torsion Acute scrotum Varicocele Others ١ Incidence of Inguinal Hernia 3%-5% of full term 3%9%-11% of preterm 9%- Congenital Inguinal Hernia Incidence Pathophysiology Clinical presentation Diagnosis Investigation Treatment Complications Pathophysiology The processus vaginalis (PV) develops during the third month of gestation as an out-pouching of the outperitoneal cavity through the internal ring. It obliterates spontaneously from the internal ring to the testis after completion of the testicular descent. The PPV is a potential hernia Incidence of Inguinal Hernia Right side Left side Bilateral 60% 25% 15% Bilaterality is more common in girls Descent of Testes Embryonic Development Formation of P V Testis Fused Processus Vaginalis Descent begins at ~3 months Adult Configuration Gubernaculum ٢ Anomalies of the Processus Vaginalis Anomalies of the Processus Vaginalis Normal Partially Patent Completely Patent Normal Partially Patent Deep and Superficial Rings in Infancy Herniation Completely Patent Types of Inguinal Hernia in children ? Indirect Direct ( very rare) Inguinal versus Femoral Risk Factors for developing a Congenital hernia? A parent or sibling who had a hernia as an infant Cystic fibrosis Developmental dysplasia of the hip Undescended testes Abnormalities of the urethra ٣ Clinical Diagnosis Usually easy Inguinal versus Femoral Femoral hernia: Opening in fascia covering femoral canal May allow small bowel to slide through, causing obstruction But is not always possible A transient inguinal swelling that could not be detected clinically at the time of examination Clinical Diagnosis Clinical Diagnosis Usually easy History Clinical findings Investigation 1. Diagnostic Pneumopritonium (Goldstein’s Test) (Goldstein’ 2. 3. 4. Preoperative Herniography Intra operative laparoscopy Ultrasonography ٤ 2. Preoperative Herniography 1. Diagnostic Pneumopritonium (Goldstein’s Test) (Goldstein’ It can delineate an inguinal hernia with 90% accuracy Intramural haematoma Intestinal perforation Invasive Not cost effective Clinical interpretation of the contralateral crepitus or swelling Has a sensitivity of 92% Its false negative result is 1.8% Simple Safe Rapid 4. Ultrasonography Type I: Presence of intestine in the inguinal canal Type II: Cystic pattern in the internal inguinal canal Type III: PPV enlarges with increasing abdominal pressure Type IV: Moving material in PPV without enlargement 3. Intra operative laparoscopy sensitivity 73% specificity 92% invasive modality It might not fit the delicate narrow hernia sac It is time consuming Risk of iatrogenic complications. Ultrasonography ٥ Ultrasonography Surgery To explore or NOT to explore the contralateral side of Identification and ligation of a PPV congenital inguinal hernia Why Exploration of the Contralateral Side Contra lateral Exposure overlooking other side hernia is A big burden to the baby A big burden family A big burden resources The risk of developing contralateral hernia is 24% especially when the initial hernia was on the left side ٦ Why not to Explore the Contralateral Side High incidence of negative exploration Unnecessary lengthening of the operative time Possible increasing morbidity in those patients ٧ Inguino scrotal Swellings in Children Congenital inguinal hernia Hydrocele Testicular torsion Acute scrotum Varicocele Others Hydrocele Diagnosis Indication for surgery Timing for surgery Complications Inguino scrotal Swellings in Children Congenital inguinal hernia Hydrocele Testicular torsion Acute scrotum Varicocele Others ٨ Testicular torsion Normal vs. Abnormal Scrotum Diagnosis Timing for surgery Contralateral orchidopexy Complications Normal Testis Testicular torsion Acute scrotum Diagnostic workup Differential Diagnosis Indication of for surgery Complications Acute scrotum Testicular torsion Strangulated inguinoscrotal hernia Orchitis/ epididmo-orchitis Orchitis/ epididmo- Testicular trauma Inguino scrotal Swellings in Children Varicocoele Congenital inguinal hernia • Expansion of pampiniform plexus • Usually seen on left (why??) • Can be palpated • a. feels like a “bag of worms” Hydrocele Testicular torsion Acute scrotum Varicocele Others ٩ Inguino scrotal Swellings in Children Congenital inguinal hernia Hydrocele Testicular torsion Acute scrotum Varicocele Others Varicocele Diagnosis Indication for surgery Timing for surgery Complications Testicular Tumor: Doppler U/S Testicular tumor Generally have unknown etiology Most arise from primordial germ cells Usual symptom: scrotal mass of increasing size May be associated with pain Any firm mass or cystic mass in scrotum should be checked Endodermal Sinus and Yolk Sac Tumor Testicular tumor Biopsy is primary diagnostic tool a. Chest x-ray, IVP b. To check for direct/indirect metastasis Treatment Doppler U/S Tumor of Testis a. Surgical excision if tumor is benign b. Castration with chemotherapy & radiation if malignant ١٠ Conclusions ? O y nl in N TA TA O y nl in EG T YP ‫ﺗﺒﻘﻲ أﻧﺖ أآﻴﺪ أآﻴﺪ ﻓﻲ ﻣﺼﺮ‬ ١١ Thank You Essam Elhalaby. M.D. ١٢