Chapter 37: Surgical Pediatrics

Abdominal emergencies (appendicitis, intussusception, malrotation, pyloric stenosis) · Trauma · Hernias · Urology (testicular torsion, hypospadias) · Tumors (neuroblastoma, Wilms) · Perioperative care
🩺 Core principles: Timely diagnosis of surgical abdomen prevents complications. Intussusception → air enema. Malrotation with volvulus → emergency laparotomy. Testicular torsion → surgical exploration <6h. Wilms tumor: avoid biopsy if classic; preoperative chemotherapy. Neuroblastoma: staging, risk‑adapted therapy.

📘 Summary: Pediatric surgical conditions

🩹 Appendicitis
Periumbilical pain → RLQ, anorexia, vomiting, fever. Ultrasound/CT. Laparoscopic appendectomy.
🌀 Intussusception
Intermittent colicky pain, currant jelly stool, sausage‑shaped mass. Air enema (diagnostic/therapeutic).
🔄 Malrotation with volvulus
Bilious vomiting in first weeks/years. Upper GI series (abnormal C‑loop). Emergency Ladd procedure.
🍼 Pyloric stenosis
Projectile non‑bilious vomiting at 3-6 weeks, olive‑shaped mass, hypochloremic metabolic alkalosis. Ramstedt pyloromyotomy.
🧬 Hernias & hydroceles
Inguinal hernia: reducible, risk of incarceration. Surgical repair. Hydrocele: non‑communicating resolves, communicating needs surgery.
⚡ Testicular torsion
Acute scrotal pain, absent cremasteric reflex, high‑riding testis. Surgical exploration within 6h.
🫘 Wilms tumor
Abdominal mass, hematuria, hypertension. CT; avoid biopsy (rupture risk). Preoperative chemotherapy, nephrectomy.
🧠 Neuroblastoma
Abdominal/thoracic mass, catecholamines, bone pain. Risk stratification (MYCN, stage). Multimodal therapy.
📊 Key imaging: Ultrasound for appendix/intussusception/testicular torsion. Upper GI for malrotation. CT for trauma/Wilms staging.

🔍 Clinical approach to pediatric surgical conditions

1
Acute abdomen assessment – History (pain migration, bilious vomiting), exam (guarding, rebound, mass). Labs: WBC, CRP, electrolytes.
2
Bilious vomiting in infant – Malrotation with volvulus until proven otherwise. Emergent upper GI series, surgical consult.
3
Scrotal pain – differentiate torsion vs epididymitis – Torsion: sudden, absent cremasteric reflex, abnormal lie. Doppler ultrasound, urgent surgery.
4
Abdominal mass in child – Wilms tumor (renal, smooth), neuroblastoma (irregular, may cross midline). Urine catecholamines, CT, avoid biopsy if Wilms suspected.
5
Trauma evaluation (blunt/penetrating) – FAST exam, CT abdomen if hemodynamically stable. Solid organ injury often managed non‑operatively.

📋 Stepwise management of common surgical emergencies

1
Intussusception – IV fluids, analgesia. Air enema (reduction rate >80%). Surgery if perforation or failed enema.
2
Malrotation with volvulus – Immediate decompression, fluid resuscitation, emergency Ladd procedure (detorsion, widen mesentery, appendectomy).
3
Appendicitis – NPO, IVF, broad‑spectrum antibiotics (piperacillin/tazobactam). Laparoscopic appendectomy.
4
Testicular torsion – Manual detorsion (if early). Surgical exploration, bilateral orchiopexy. Viability determines orchiectomy.
5
Pyloric stenosis – Correct electrolytes (normalize bicarb, Cl). Ramstedt pyloromyotomy (open/laparoscopic).
6
Inguinal hernia (incarcerated) – Attempt manual reduction (gentle, Trendelenburg). If successful, elective repair. If irreducible → emergency surgery.
⚡ Key reminders: Bilious vomiting = surgical emergency until proven otherwise. Testicular torsion: time is testis. Avoid needle biopsy of Wilms tumor (risk of rupture).

🧠 Reflex prompts – surgical pediatrics

🌀 First imaging for suspected intussusception?
Ultrasound (target sign); air enema therapeutic.
🩺 Most common cause of bilious vomiting in neonate?
Malrotation with midgut volvulus – emergent.
⚡ Testicular torsion – time to salvage?
<6 hours from onset.
🍼 Pyloric stenosis – classic electrolyte imbalance?
Hypochloremic metabolic alkalosis (loss of gastric HCl).
🫘 Wilms tumor – characteristic finding?
Smooth, non‑tender abdominal mass; hematuria, hypertension.
🧬 Neuroblastoma – diagnostic marker?
Urinary catecholamines (VMA, HVA).