Interactive Guide to Pediatric Surgery

Description: Protrusion of abdominal contents (intestine, fat, etc.) through a defect in the abdominal muscle wall. Inguinal hernia is more common in boys, while umbilical hernia is more common in infants and often closes spontaneously.

What to look for:

• Lump in the groin (inguinal) or navel (umbilical), which may be more evident with crying or straining.
• The lump is usually reducible (disappears with gentle pressure or sleep/relaxation).
• In inguinal hernias: excessive crying, irritability without apparent cause, or discomfort.

Red Flags (Urgency):

• Lump that cannot be reduced, is hard, and/or painful (incarceration).
• Change in skin color over the lump (red, bluish), signs of inflammation.
• Vomiting (especially bilious), abdominal distension, extreme irritability, fever (signs of strangulation).

Conservative Management: Umbilical hernias smaller than 1-2 cm usually close spontaneously before 4-5 years of age. Observation is the initial management.

Complementary Diagnosis: Generally clinical. Ultrasound can be useful in doubtful cases or to differentiate from other masses.

Description: Absence of one or both testicles in the scrotum after birth. It may be an undescended testicle (in its normal path but stopped), ectopic (outside the normal path) or retractile (moves between the scrotum and the groin).

What to look for:

• Empty or hypoplastic scrotum on physical examination.
• Try to palpate the testicle in the inguinal canal or suprapubic area.
• Carefully differentiate from the retractile testicle, which can descend into the scrotum with maneuvers (e.g. heat, relaxation, abolished cremasteric reflex).

Red Flags (Urgency): Although cryptorchidism is not an immediate emergency, persistence after 6 months of age is an indication for early referral due to the risk of long-term infertility and malignancy.

Conservative Management: Wait until 6 months of age, as many testicles descend spontaneously until then.

Complementary Diagnosis: Mainly clinical. Ultrasound can locate the testicle in the inguinal canal, but is less reliable if the testicle is intra-abdominal.

Description: **Phimosis** is the inability to retract the foreskin behind the glans. It is physiological in newborns and infants, resolving with age. **Paraphimosis** is a urological emergency where the retracted foreskin becomes stuck behind the glans penis, causing a constricting ring.

What to look for:

• In phimosis: Difficulty with hygiene, recurrent balanitis (inflammation of the glans), recurrent urinary infections, or weak/globoid urinary stream.
• In paraphimosis: Glans edematous, painful, red, with a constricting ring at the base of the glans.

Red Flags (Urgency):

• Paraphimosis: ALWAYS an emergency. Requires immediate reduction to avoid ischemia and necrosis of the glans.

Conservative Management (Physiological Phimosis): Most phimosis resolve spontaneously. Gentle hygiene is recommended and do not force retraction. In symptomatic cases, topical corticosteroid creams may be effective before considering surgery.

Complementary Diagnosis: Clinical.

Description: Accumulation of peritoneal fluid around the testicle within the scrotum, due to the persistence of a communication (patent vaginal process) with the abdominal cavity.

What to look for:

• Increase in scrotal volume that transilluminates (light is seen through it).
• The size can fluctuate throughout the day, being larger at the end of the day or with effort, and smaller when waking up.
• Generally painless.

Red Flags (Urgency): Communicating hydrocele is not an emergency, but a sudden increase in size, pain or signs of inflammation could suggest an associated inguinal hernia or complication.

Conservative Management: Many close spontaneously before 12-18 months of age. Observation is the initial management.

Complementary Diagnosis: Clinically, transillumination is key. Ultrasound to confirm liquid nature and rule out a hernia.

Description: Congenital anomalies resulting from incomplete development of the branchial arches or thyroglossal duct. They may present as masses (cysts) or tracts that drain into the skin (fistulas) in the neck.

What to look for:

• **Thyroglossal duct cyst:** Anterior midline mass of the neck, usually painless, that moves with the protrusion of the tongue.
• **Gill cyst/fistula:** Small mass or hole, usually on the side of the neck, near the sternocleidomastoid muscle.
• Intermittent drainage of clear or mucoid fluid, or episodes of inflammation/infection with pain, redness, and fever.

Red Flags (Urgency): Signs of acute infection (redness, pain, drainage, fever) or airway compromise if the mass is very large.

Conservative Management: Not applicable. Once diagnosed, they require surgical resection to avoid recurrent infections and, rarely, malignancy.

Complementary Diagnosis: Cervical ultrasound is the first-line method. In complex cases, CT or MRI may be necessary.

Description: It includes a variety of common benign masses or lesions found in the skin and subcutaneous tissue, such as lipomas (fat masses), nevi (moles), and sebaceous cysts (sebum buildup).

What to look for:

• **Size and Growth:** Any lesion that grows rapidly or changes size.
• **Color/Shape Changes:** In nevi, apply the ABCDE rule (Asymmetry, Irregular edges, Non-uniform color, Diameter >6mm, Evolution).
• **Pain or Tenderness:** Injuries that cause pain or discomfort.
• **Ulceration or Bleeding:** Any injury that bleeds or does not heal.
• **Infection:** Signs of redness, heat, pus, or pain in sebaceous cysts or lipomas.

Red Flags (Urgency): Sudden changes in nevi (suspected melanoma), signs of acute infection, or lesions that compromise function.

Conservative Management: Many benign lesions do not require intervention unless they are symptomatic, cosmetically bothersome, or there is suspicion of malignancy.

Complementary Diagnosis: Clinical. In case of suspicion of malignancy or for confirmation, biopsy is the definitive method. Ultrasound to characterize soft tissue masses.

Description: Partial or complete fusion of the labia minora in girls, common in early childhood due to low estrogen levels and local irritation.

What to look for:

• Appearance of a thin membrane covering the vagina and/or urethral orifice.
• Difficulty visualizing the vaginal introitus.
• Recurrent urinary tract infections, vulvar irritation, or urinary retention (rare).
• It may be asymptomatic.

Red Flags (Urgency): Acute urinary retention or signs of severe infection.

Conservative Management: Most asymptomatic cases do not require treatment. The first-line treatment is the application of topical estrogen creams. Manual separation under local or general anesthesia is an option if medical treatment fails or severe symptoms are present.

Complementary Diagnosis: Clinical.