Phimosis, inguinal hernia & undescended testis.pptx

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1. Common Pediatric Surgical Conditions Phimosis Inguinal Hernia Undescended Testis Dr. Arjun A. Pawar MBBS, MS, M. Ch. Pediatric Surgery, DNB Pediatric Surgery, FMAS, FIAGES. Divine Pediatric Surgery Centre. i . a. w. Vedant Bal Rugnalay & Critical Care Centre.

2. Phimosis Physiological & Pathological Diagnostic confusion Needless referrals for Circumcision Incidence: 8 – 14.4%- true phimosis

3. Etiology Pathological Phimosis Balanitis Posthitis Balanoposthitis BXO. Trauma to Prepuce and Glans

4. Meuli classification

5. Kikiros classification- Phimosis

6. Complications Paraphimosis Meatal Stenosis Recurrent balanoposthitis Recurrent UTI

7. Management Physiological: Settles over period Circumcision (1%), Reassurance and reinforcement of proper preputial hygiene Topical Steroid trial- Betamethasone(0.05%) Clobetasol proprionate 0.05%, 0.1% Triamcinolone, M ometasone dipropionate Twice daily application- 4 weeks Dilation and Stretching - EMLA Combination- Dilation with steroid

8. Surgical Treatment Prepucioplasty Dorsal slit with transverse closure Frenulotomy & Meatoplasty Circumcision- Guillotine Method Sleeve resection- Crush with artery or Bipolar Electrosurgery Laser circumcision Stapler Gomco clamp, Plastibell .

9. Clean scar after complete healing

10. Advantages Reduced risk of STD- HIV & Other Reduced risk & rate of UTI Prevention of Malignancy Proper genital hygiene Reduced risk of local infection Zero risk of complications associated with phimosis.

11. Complications Bleeding Concealed Penis Phimosis( Recurrence) Skin Bridge Infection Urinary Retention Urethro-cutaneous fistula Iatrogenic hypospadias & epispadias

12. Contraindication: Hypospadias Epispadias DSD (Intersex Disorders) Micropenis . Megalourethra Webbed Penis Bleeding Disorder Other_ Prematurity, MMC, ARM

13. Inguinal Hernia Abnormal protrusion of content or part of it through the cavity containing it. Incidence: 0.8%-4.4% Premature: 16%-25% Common age of presentation- Infants Male: Female= 3:1 to 10:1 Side: Right>>> Left(60:40) Bilateral= 10% Family History= 11%

14. Causes: Failure of complete obliteration of the processus vaginalis. Increased intra-abdominal pressure- ascites, chronic cough, constipation associated ailments- undescended testis, bladder exstrophy connective tissue disorders- ehlers danlos syndrome

15. Complaints: I ntermittent bulge in the groin, labia, or scrotum --- Apparent during episodes of crying or straining Groin or inguinal “pain” during exercise. Signs of bowel obstruction- distension, vomiting, and obstipation. Signs of bowel strangulation- signs of obstruction with local pain, redness & tenderness , systemic toxicity. Examination: Standing & Supine, (the silk glove sign, “plastic baggy sign”)

16. Inguinal Hernia Evaluated to R/O 46XY DSD with female phenotype -CAIS, CAH Direct & Indirect Complete & Incomplete Enerocele & omentocele

17. Inguinal Hernia Will not resolve spontaneously, Surgical closure is always indicated Patient land up with complications & major surgery. Complications Irreducibility, Incarceration, Obstruction, Strangulation, Testicular gangrene.

18. Testicular gangrene Bowel Gangrene

19. Management- Ideal Time Soon after diagnosis Repair done within 2 weeks (90% complications reduced if operated within 1 month from diagnosis) Exceptions - Premature infants Repair before discharge/Child weight 2 kg. Surgery: M odified Ferguson repair- Mitchell-Bank repair- EOA not opened, <1yr

20. Modified Ferguson’s Repair-Open Herniotomy

21. Ferguson’s Repair- Open Herniotomy

22. Laparoscopic Herniotomy

23. Undescended testis UDT Ectopic Testis Retractile Testis Palpable/ Nonpalpable UL / BL Associated with HPS -- DSD Spontaneous Descent -First 3 months, Can wait up to 6 mths .

24. Usual Advise Surgery after 6 to 7 yrs.. Delay in treatment – Land up with Complications

25. Complications Impaired Fertility Malignancy- increased 5- to 10-fold High incidence -Trauma, Tumor , Torsion, Inguinal hernia Psychologic Factors - Patient & parental anxiety about subsequent fertility.

26. Testicular Torsion Clinical Picture Intraop – Testicular gangrene

27. Testicular Torsion

28. Ideal Timing for Orchidopexy Orchidopexy is recommended at 6 to 9 months of age. Palpable- Open Orchidopexy Non Palpable – Single Stage Laparoscopic Orchidopexy Fowler Stephens Staged Orchidopexy

29. SSLP

30. Thank you