What are the common newborn surgical problems?
A newborn child can have the following surgical ailments:
• A newborn can have abdominal distension
• A newborn can fail to pass stools (meconium).
• Regurgitation of milk after feeds is common if proper burping is not done. But bilious / greenish / yellowish vomiting almost always indicates some pathology.
• Respiratory distress in a newborn can often be due to surgical reasons.
• Structural anomalies are mostly visible and obvious. Common anomalies are:
a) Cleft lip and palate
b) Branchial sinus and fistulae
c) Abnormal urethral opening (epispadias, hypospadias, exstrophy bladder)
d) Absent or abnormally placed anal opening (anorectal malformation)
e) Incompletely formed neural tube (a visible sac like structure usually located near the lower back) - myelomeningocele.
• difficulty in passing urine (posterior urethral valves in male neonates).
Can we know before delivery that my child is going to have any surgical problems?
Antenatal ultrasonography can detect most of the structural anomalies, if done by a properly trained person.
My child passes stool once every 3 days? Do I need to get alarmed?
A newborn may pass stool many times a day or once in a couple of days. Both are normal, provided there is no abdominal distension, the child feeds well, and there is no vomiting. An exclusively breastfed infant may pass loose stool many times a day or he/she may be constipated.
In Hirschsprungs' disease, where there is absence of ganglion cells in varying region of the intestine, there is constipation as well as abdominal distension, because the child fails to pass flatus. These children also pass frequent loose foul smelling stool (enterocolitis).
Often constipation leads to passage of hard stool which causes a tear in the anal mucosa. This, in turn causes spasm of the internal sphincter which causes exacerbation of constipation. One has to break this vicious cycle to get optimum results. Laxatives alone can never cure a fissure and hence the constipation persists.
My child cries during micturition. Is it abnormal?
For the first couple of months occasional crying during micturition is a normal phenomenon. This is because of occasional bladder spasms. But you must always note the force / flow of urine. Poor urinary flow must always be investigated.
The prepucial skin of my 2yr son is not retractable? Does he require circumcision?
The inner layer of prepucial skin and the epithelium of the glans penis originates from the same layer of cells. At birth there is no anatomical plane of separation between the prepuce and the glans. This plane naturally develops over the next few years and by the age of four the prepuce should always be retractable. If one forces the prepuce proximally as is often advised even by the doctors, then microscopic / macroscopic tear of inner prepucial skin occurs. Later on, these tears go on to develop scars and the child lands up with iatrogenic phimosis which almost always needs surgery.
My child passed blood in stool thrice in last month. Is there anything wrong?
If this is accompanied by a painful defecation, one needs to rule out anal fissure which is the commonest cause. Painless bleeding is commonly caused by rectal polyp in pediatric age group. Other rare causes are colitis, colonic polyps, and Meckel's diverticula.
My child vomits often and is not gaining enough weight. What could be the problem?
Commonest cause is GASTROESOPHAGEAL REFLUX, which is usually cured with medical treatment failing which surgical correction is required. But sometimes we find malrotation of gut that cause the vomiting which is cured by a surgery (Ladd's procedure). Nowadays we do the procdure laparoscopically.
My child has a unilateral groin swelling. Is it a hernia or a hydrocele?
Both the testes remain inside the abdomen near the lower pole of the kidneys in the intrauterine life. They gradually descend to the scrotal positions before birth. This tract of descent of testes gets obliterated usually before birth. If it remains patent, at any time during the entire lifetime, abdominal fluid may collect in the scrotal sac. We call it hydrocele. When the processus vaginalis become large enough to allow the intestinal loops to get in we call it hernia. Any scrotal swelling which appears sometime after birth is a hydrocele / hernia and requires surgical treatment. Only if it is a hydrocele present since birth, and there is no variation in size, we can wait for spontaneous resolution.
Is laparoscopic surgery possible in young children?
Nowadays with improvement of instrumentation and surgical techniques, laparoscopic surgery is possible and safely performed not only in children, but also in infants. Almost all abdominal pathology can be dealt with effectively by laparoscopy. Besides cosmesis and early mobility, this reduces the pain to a great extent and aids earlier recovery of organ functions.
My son has a single testis in one of his scrotum and the other side is empty. How long should I wait before I visit a doctor?
Except in premature neonates, we rarely find testes impalpable at birth to descend to scrotum later in life. On the other hand there are documentary evidences to prove that the longer it stays out of scrotum, there is ongoing functional loss of the testis. The other factor that prompts us to correct this ailment early in life is the chance of torsion which may lead to complete loss of the testis.
There is a consensus among the Pediatric Surgeons now to correct all impalpable/ undescended testes by the age of 10 months.
My child has recurrent abdominal pain and nausea. Can he have appendicitis?
Of every 7 patients referred to us in our clinic with suspected recurrent appendicitis, we find that a single child is usually proved to have the disease. Pain mimicking that of recurrent / acute appendicitis may occur due to chronic constipation, mesenteric lymphadenopathy, respiratory tract infection, following gastroenteritis and sometimes following urinary tract infection.
Nowadays diagnostic laparoscopy is a modality which is relatively minimally invasive and can be utilized to put all dilemmas to rest to directly look into the abdomen and find out the cause of pain.
Do children ever have gallstones?
Nowadays we are finding more and more children with gallstones. The gold standard for treatment of gallstones in children is laparoscopic cholecystectomy. One must be very careful that he is not dealing with congenital dilatation of the biliary tree at the same time (choledochal cyst).
What are the neonatal surgical ailments which can be detected antenatally ?
Spinal dysraphism, diaphragmatic hernia, esophageal atresia, intestinal atresias, anorectal malformation, pelviureteric obstruction, posterior urethral valves, tumors, lung cysts and tumors, etc.
My son passes urine with difficulty and strains during micturition. Is there anything to worry?
Apparently he has bladder outflow obstruction. He needs a proper workup to diagnose the cause. It could be 'Posterior Urethral Valve' or 'Neurogenic Bladder' or even meatal stenosis, or phimosis, which are far more common.
The external urethral meatus of my child is abnormal and on the lower side of his penis and not at the tip. When should I get him operated? What are the chances of success?
This congenital anomaly is called Hypospadias. Like most structural anomalies, we prefer to complete all stages of surgery by the first birthday so that it does not leave any imprint in his cerebral cortex, and he can never recapitulate that he ever had any physical problem that required correction. Nowadays, we use fine suture materials and magnification and our results are comparable to anywhere in the world. All said and done, hypospadias surgery has its own share of complications. Even in the best centers of the world, the complication rates, namely fistula, stricture, infection, etc. are almost 5%.
My daughter passes stool from an orifice which is slightly anteriorly located but otherwise she is ok. Does she require any treatment?
In the modern nomenclature, we call this deformity 'perineal fistula' variant of anorectal malformation. Previously, we used to call it 'anterior ectopic anus'. This requires surgical correction for the following reasons: i) cosmetic (surgery restores normal look). ii) during childbirth, this will lead to complete perineal tear and bowel injury if she undergoes vaginal delivery as there is no perineal body.
My 2 month son has cleft lip and palate. When should he be operated?
Cleft lip is operated upon at 3-4 months of age, and cleft palate at 10 months. There are exceptions if the growth of the child is not optimum.
My child was operated for posterior urethral valves when he was 2 yrs. But he continues to have difficulty in passing urine and has an occasional pyrexia. Does he need any further investigation or treatment.
We sincerely believe that in children with PUV, surgery/ fulguration is just the beginning of treatment. These children may land up with renal failure any time till adolescence. So they require very close follow-up and bladder management to prevent the complications of 'valve bladder'.
My child is suffering from intractable constipation. She passes stool once in 4-5 days. Is there any treatment.
She needs proper evaluation for the correctable causes of constipation. She might also suffer from what we call 'habitual constipation' which though efficiently manageable by a guided 'bowel management programme', is not always fully curable.