Most childhood health problems either resolve on their own or can be treated or controlled with medications. However, there are a number of childhood conditions that require surgery. Some of the more commonly occurring surgical conditions and procedures include the following:
Appendicitis is an inflammation of the appendix, a hollow, fingerlike pouch of tissue that connects to and opens into the beginning of the large intestine. The condition is uncommon in children younger than two years. Symptoms of appendicitis include abdominal pain, nausea, vomiting, and fever. Suspected cases of appendicitis should be evaluated by a doctor immediately because surgery to remove the inflamed appendix is necessary before it perforates (breaks open) and spreads bacteria throughout the abdomen. A doctor will determine whether surgery is necessary based on the patient's history of symptoms and physical examination findings, as well as blood tests and sometimes X-rays or other imaging studies.
An inflamed appendix is usually removed through a small incision in the abdominal wall. If the appendix is removed before it perforates, complications are rare.
The child's hospital stay is usually two or three days. If the infected appendix perforates, it must still be removed surgically, but a longer hospital stay is needed so that antibiotics can be given to kill bacteria that have spread through the abdominal cavity.
An inguinal hernia occurs when a loop of intestine or other abdominal contents push through an opening or weak area in the wall of the abdomen. Although they can occur at any age, inguinal hernias are most commonly diagnosed in the first year of life and are four times more likely to occur in boys than in girls. An inguinal hernia usually appears as a lump or swelling in the groin or scrotum (the sac containing the testicles) in boys or in the labia (the folds of skin surrounding the opening of the vagina) in girls. In infants, the first sign of a problem may be that parents observe the baby to be fussy or uncomfortable. Inguinal hernias usually don't cause symptoms, but they can pose a problem if the protruding tissue becomes trapped (incarcerated), which can cut off the blood flow to the organ involved. Surgical repair involves closing the opening in the abdominal wall through an incision made in the groin area. The procedure is usually done on an outpatient basis, and a child may go home within a few hours after the surgery. Acetaminophen may be given for pain, but most children are able to resume normal activities within a few days.
An umbilical hernia is present when the wall of the abdomen surrounding the navel does not fully close before birth, allowing part of the intestine to protrude through the opening. (For more information about umbilical hernias, see Chapter 5, "Common Newborn Medical Conditions.")
Hypospadias is a fairly common (it occurs in about 1 in 300 boys) birth defect in which the opening of the urethra—the passage that carries urine from the bladder to the outside of the body—develops on the underside of the shaft of the penis instead of at the tip. Most commonly the opening develops near the end of the penis, but in severe cases it can occur at the base of the penis where it joins the scrotum. Hypospa-dias may run in families, suggesting a genetic factor in some cases.
Doctors diagnose the condition by performing a physical examination. The foreskin of boys with hypospadias is hoodlike and doesn't cover the underside of the head of the penis as it normally should. Abnormal bands of tissue may also extend from the underside of the penis to the scrotum, causing the penis to assume a downward curve. Boys with hypospadias are more likely to have other abnormalities of the urinary tract and genitals such as inguinal hernia and undescended testicle (cryptorchidism). The doctor may order special imaging studies to look for associated abnormalities of the bladder or kidneys.
The treatment of the condition involves a surgical procedure to move the urethral opening to the normal position at the end of the penis. Because this surgery often uses the foreskin tissue to accomplish the repair, boys with hypospadias should not be circumcised before they have been fully evaluated by the surgeon. The surgery is usually done in one stage, and it should be performed before 18 months of age. If the condition is not treated early, the boy will need to sit down to urinate. Mild cases that will not interfere with urinary or sexual function do not require surgical treatment unless the cosmetic appearance of the penis is an issue.
Myringotomy (Ear Tube Surgery)
Surgical insertion of a tiny hollow tube through an incision in the eardrum, or myringotomy, is often used to treat recurrent or persistent problems related to middle ear infection (otitis media). Most children will develop one or more ear infections during the first few years of life; however, these infections usually respond well to antibiotic treatment and result in no long-term effects on hearing or other complications (for more information about ear infections, see Chapter 30, "Childhood Infections"). Myringotomy is usually considered for treatment of children with frequently recurring bouts of otitis media despite antibiotic therapy or for children with a persistent (lasting more than three months) collection of fluid behind the eardrum, particularly if the fluid is impairing the child's hearing. Blockage of the eustachian tube (the canal connecting the throat and middle ear, which normally allows air to flow in and out of the middle ear) is usually the cause of chronic ear fluid collection.
During the myringotomy procedure, small plastic tubes are inserted through an incision made in the eardrum during surgery and left in place, which allows air to enter the middle ear. This equalizes the pressure between the middle and outer ear, which can help eliminate the collected fluid, restore normal hearing, and decrease the likelihood of repeated infections. Children younger than three months or with complicating medical conditions may stay in the hospital overnight after the procedure, but other children usually go home within a few hours of the surgery. There is generally no need for further surgery to remove an ear tube. Generally, the tube stays in the ear for up to two years before falling out on its own. Although the procedure is usually effective in clearing up middle ear fluid, about 25 percent of children who require ear tubes before the age of two need to have tubes inserted again at a later time. With proper treatment and follow up, most children with recurrent or chronic ear problems will maintain hearing at a level sufficient to permit normal speech and language development.
Pyloric stenosis is a condition in which the pylorus—the muscle that controls the rate at which food moves from the stomach into the small intestine—is too tight, resulting in forceful vomiting after feedings. (For more information on pyloric stenosis, see Chapter 29, "Signs and Symptoms.")
Strabismus ("Crossed" Eyes)
Strabismus (or "crossed" eyes) is a misalignment of the eyes, in which an eye may turn in (esotropia), out (exotropia), up (hypertropia), or down (hypotropia). If an eye is chronically misaligned and not used by the child to see, weak vision (amblyopia or "lazy eye") may result. Most children with strabismus are otherwise healthy, but the condition appears with greater frequency among children with conditions involving the brain such as cerebral palsy and hydrocephalus. Strabismus may be caused by muscle weakness, eye injury, other eye diseases, or, rarely, a tumor. Symptoms of strabismus include "crossed" eyes, squinting or tilting of the head to see things, headache, eye rubbing, tearing, and double vision.
Amblyopia can be prevented by patching the eyes alternately, forcing the child to use and develop vision in both eyes. Patching must be done in the first few years of life to prevent vision loss. In some cases, corrective eyeglasses can be used to prevent amblyopia and properly align the eyes.
Often surgery on the muscles that control eye movement is necessary to achieve proper alignment. The procedure involves tightening or weakening eye muscles to create a correct balance between the pairs of muscles that help control the position of the eyes. This surgery can usually be performed on an outpatient basis. In some cases, more than one operation may be needed to achieve proper eye alignment.
The tonsils are fleshy lumps of tissue located on either side of the back of the throat. Some children require a tonsillectomy (surgical removal of the tonsils) because the tonsils have become enlarged and partially block the airway, which can cause sleep apnea (prolonged pauses in breathing with interruption of normal sleep) and chronic stress on the heart and lungs. In some cases, children who have very frequent infections of the throat and tonsils may benefit from a tonsillectomy; however, the procedure is performed much less frequently today for these symptoms than it was in the past.
The adenoids are lumps of tissue similar to the tonsils located behind the nose and hidden from view by the palate (roof of the mouth). They are usually removed if they block the nasal passages or the eustachian tubes, which connect the middle ears to the throat. Such blockages can play a role in persistent ear or sinus infections. In addition, enlarged adenoids may produce symptoms such as difficulty breathing through the nose, noisy breathing, speech problems, snoring, and sleep apnea.
Depending on a child's symptoms, a ton-sillectomy, adenoidectomy, or both (also known as a "T&A") may be recommended. T&A is the surgical removal of the tonsils and adenoids. This procedure is usually performed by an ENT (ears, nose, and throat) specialist. The child is usually able to go home within hours of the surgery with a prescription for pain medication. White patches may appear in the child's throat where the tonsils were, but these will disappear in time.
Undescended Testicle (Cryptorchidism)
Undescended testicle, or cryptorchidism, is a condition in which, during development of the fetus, one or both (both in 10 to 20 percent of cases) testicles do not fully descend from the abdomen, where they form, into the normal position in the scrotum (the sack holding the testicles). About 3 percent of term infant boys and as many as 30 percent of premature boys have this condition. In about two-thirds of cases, an undescended testicle moves down into the scrotum on its own within the first six months of life—those that do not move down usually need treatment. The future sperm-producing tissue in the testicle becomes progressively damaged if an unde-scended testicle is not brought down into the lower-temperature environment of the scrotum early in life. This increases the risk of infertility—especially if both testicles are undescended.
Doctors usually diagnose the condition by physical examination at birth or at a checkup during early infancy. True cryp-torchidism must be distinguished from a benign (needing no treatment) condition common in young boys called retractile testis, in which the muscle attached to the testicle temporarily pulls it up into the groin or abdomen when the boy is stressed or undressed or when the genital area is touched or exposed to cold. Repeated examinations may be necessary to determine whether the testicle is indeed unde-scended. Undescended testicles are also often accompanied by inguinal hernia (see Hernia in this chapter).
If the testicle does not come down, the condition should be treated by about 12 to 15 months of age to minimize damage to the testicle. In some cases, hormone therapy may be given in an attempt to move the testicle into the scrotum, but this is not often successful. Standard treatment is a procedure called an orchiopexy, which involves surgically bringing the testicle into the scrotum and fastening it there. The procedure, performed in one or two stages, is successful in the large majority of cases.
After treatment, boys develop normally (the male-hormone-producing tissue of the testicle is not significantly affected by the condition), and sexual function is unaffected. If one testicle is involved and treated, 85 percent of boys with the condition will be fertile later on. If both testes are involved, the fertility rate is lower— approximately 50 percent. Boys with unde-scended testicle have an increased risk of developing cancer of the testicle (1 in 40 to
1 in 80) as young adults, whether they are treated or not. They should be taught tes-ticular self-examination (as should all teen boys) and have regular examinations of their testes performed by a doctor through adulthood.
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