15.1 Herniotomy

Inguinal hernias are common in children. They occur in three percent of term infants and are more common in preterm infants, who are also more likely to have bilateral hernias. In adults, hernias are due to a defect in the abdominal wall, but in children they are due to a patent processus vaginalis. This leaves a peritoneal diverticulum that intestine can herniate into, or for fluid to accumulate and cause a scrotal hydrocele. An inguinal hernia usually presents as a groin lump that can be reduced. An irreducible or obstructed hernia is more common in infants and causes bowel obstruction and compression of the testicular or ovarian vessels. Infants and children with an obstructed hernia undergoing emergency surgery are at risk of regurgitation and aspiration and are intubated after a modified rapid sequence induction. Preterm neonates are more prone to obstructed hernias and their hernias are electively repaired at an early age, often before they are discharged home from the neonatal nursery.

15.2 Undescended Testis and Orchidopexy

About 3% of term boys are born with an undescended testis. Most undescended testes can be palpated in the inguinal canal and the majority will descend into the scrotum during the first year. They are associated with infertility, testicular tumors and psychological problems. They are also more susceptible to testicular torsion and infarction and are often associated with inguinal hernias. If the testis has not descended by 6–9 months of age it is unlikely to ever descend and is surgically brought into the scrotum (orchidopexy).

Orchidopexy surgery uses the same groin incision as herniotomy, as well as a scrotal incision. An ilioinguinal/iliohypogastric nerve block provides good analgesia but does not cover the scrotum. Subcutaneous infiltration over the symphysis pubis blocks the genitofemoral nerve, or the surgeon can infiltrate the scrotal incision during surgery. Opioid analgesia is usually required. A caudal block with of 1 mL/kg of local anesthetic to block to about T10 is a good choice for young children. Antiemetics are routinely given to children older than 2–3 years. Orchidopexy pain tends to be more severe and longer lasting than the pain after herniotomy and many other day stay procedures in children. Despite this, analgesia on discharge is usually successfully managed with paracetamol and ibuprofen. Older boys (pre-teens) may need oral opioids for the first 24 h after surgery.

If the testis is not even palpable in the inguinal canal, the 2-stage Fowler Stevens procedure is performed. Firstly, laparoscopy is performed and if the testis is present, the testicular vessels are clipped. In the second stage several months later, laparoscopy is performed again, and the testis is pushed into the scrotum and fixed there through a scrotal incision.

15.3 Torsion of the Testis and Surgery to Explore Scrotal Contents

Acute scrotal pain may be due to torsion of the testis or the appendix of the testis (Hydatid of Morgagni). The majority of cases occur around puberty and are due to torsion of the appendix of the testis. Surgery to explore the scrotal contents is performed urgently because of concern of testicular ischemia. Pain is not usually severe enough to delay gastric emptying, and face mask or LMA anesthesia is reasonable unless the child is not fasted or is vomiting beforehand. The procedure is not particularly painful afterwards. These children are usually too old for caudal analgesia, and instead wound infiltration is used with opioid analgesia and antiemetics.

15.4 Circumcision

Male circumcision is commonly performed for recurrent balanitis or balanitis xerotica obliterans (BXO) that results in phimosis (inability to retract the foreskin). Some children undergo circumcision during infancy for social or religious reasons. On the one hand, during infancy the risk of anesthesia is higher and there is the possibility of neurotoxicity from anesthesia. On the other hand, the risk of anesthesia is reduced if the anesthetist cares for large numbers of children each year, and a single, short anesthetic does not affect neurodevelopment in humans.

15.5 Hypospadias Repair

Hypospadias is a condition in which the urethral opening is not at the tip of the penis, located instead at some point further down the ventral side of the glans penis or shaft of the penis. More proximal urethral defects are more likely to have an associated ventral shortening and curvature, called a chordee. Several surgical repairs are used (Magpi , Wackmans), but all involve laying open the upper urethra and then closing it over a catheter to create a new, distal urinary opening. The initial repairs are usually carried out in infancy, although some mild cases are not detected until later in childhood when the boy begins to stand to urinate. Caudal analgesia is ideal for this procedure as it reliably blocks the sacral segments. Major hypospadias repairs require strong analgesia for 24–48 h. Either a caudal catheter and local anesthetic infusion can be used, or if a single-shot caudal was used, an intravenous morphine infusion is started in recovery in preparation for the caudal wearing off. Ring blocks of the penis cause local swelling and may interfere with surgery, and penile blocks may be used, but they do not cover the ventral surface well. Retrospective studies comparing penile block and caudal block for hypospadias surgery have found an association between caudal block and the occurrence of urethral fistula after surgery. However, the overall incidence of this complication is low and it is unclear if caudal analgesia causes the complication, or if it occurs because a caudal block is more likely to be performed in more difficult, proximal hypospadias cases.

15.6 Division of Tongue Tie

Although a short and simple surgical procedure, anesthesia for division of tongue tie is challenging. The frenulum tethers the tongue (tongue tie) and affects feeding in infants and speech in children. A scalpel or diathermy is used to divide the frenulum, usually with minimal bleeding. A shoulder roll helps to open the infant’s mouth and improves access for the surgeon. Anesthesia is challenging for several reasons. The procedure is commonly performed in infants and their small airway is shared with the surgeon. The procedure is brief, but very stimulating and may trigger laryngospasm. An LMA is commonly used to manage the airway. The risk is loss of the airway, either due to displacement of the LMA or laryngospasm. A key point is to ensure adequate depth of anesthesia before incision—a bolus of propofol 1–3 mg/kg is wise if there is any doubt. Fentanyl is given so the baby is not in pain after awakening, and paracetamol is adequate for analgesia after surgery.

15.7 Umbilical Hernia Repair

Umbilical hernia repair is performed under general anesthesia, most often with an LMA. There are three points of note about this procedure. Firstly, the peritoneal cavity is entered, and omentum or bowel can protrude into the wound during surgery. Although this could be prevented with muscle relaxation, acceptable operating conditions are provided by maintaining a deep plane of anesthesia with apnea and positive pressure ventilation—if the child breathes spontaneously, the tone in the abdominal wall may push the omentum into the wound. Secondly, the procedure is more painful than inguinal hernias, and a multimodal approach is needed, including a rectus sheath block or wound infiltration. Simple oral analgesics are adequate after discharge. Finally, it is associated with a high incidence of nausea and vomiting, and dual antiemetic therapy is indicated.

15.8 Laparoscopic Surgery

Laparoscopic surgery is performed for a widening range of procedures in children of all ages, including neonates. It is considered to improve outcome by minimizing tissue trauma and pain, speeding recovery and shortening hospital stay.

15.8.1 Physiological Effects of Laparoscopy

Young children absorb proportionally more carbon dioxide through the peritoneum than older children and adults. This is due to a proportionally large peritoneal surface area and a lack of intraperitoneal fat that reduces the distance between capillaries and peritoneum and would otherwise buffer carbon dioxide. Children appear to handle this increased carbon dioxide load without significant acidosis.

As in adults, carbon dioxide insufflation in children increases intra-abdominal pressure, decreases total lung compliance and functional residual capacity (FRC), and causes atelectasis and ventilation-perfusion mismatch. Infants and neonates are particularly at risk of respiratory compromise—their closing lung capacity is already close to FRC and their oxygen consumption is high. The severity of these pulmonary effects depends on the abdominal pressure, and for these reasons a lower pressure is used in neonates and infants than in children and adults. Fortunately, the infant abdominal wall is very pliable and the abdominal contents can be visualized at lower pressures.

The cardiovascular effects of the pneumoperitoneum depend on the intra-abdominal pressure and age. They are the result of four factors—mechanical compression of splanchnic vessels, postural changes, increased sympathetic tone and the release of vasoconstrictors including renin and vasopressin. At low abdominal pressures, venous return and cardiac output increase, and the systemic and pulmonary vascular resistance increases. Blood pressure and heart rate commonly increase. Cardiac output falls at pressures above 15–20 mmHg. Neonates and infants are more sensitive to the cardiovascular effects from pneumoperitoneum. Bradycardia may occur with peritoneal stretching from rapid carbon dioxide insufflation, although tachycardia more commonly occurs. Children with cyanotic heart disease are at risk of paradoxical gas embolism and may not be suitable for laparoscopic surgery.

Note

Typical pneumoperitoneum pressure to reduce respiratory and cardiovascular effects during laparoscopy

Neonates and infants younger than 4 months: 5–6 mmHg

Small children: 8–10 mmHg

Older children and adults: 10–15 mmHg

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

Pain Management in Children Disease of Childhood and Burns and Treatment of Malignancies in Children Venous and Arterial Access for Children Heart Disease