OPTIMUM TIMING OF SURGERY IN PAEDIATRIC AGE
Dr.M.K.Diwakar M.S.F.A.I.S, General &Endoscopy Surgeon*
Head of Department of Surgery Govt.District Hospital Rajnandgaon (C.G). *
"A stitch in time saves nine" stand very pertinent at all times. Similarly a timely referral of a child by a treating practitioner to the surgeon saves a long chain of complications in a child if operated at the optimum time. Unfortunately even the most vigilant treating their children patients fail to do so, not deliberately but unknowingly due to either ignorance or lack of proper updating of their knowledge. It is therefore quite mandatory for every practicing physician to keep abreast with the timing in referring a case to the surgeon's knife without prejudice or love to the which at times develops in course of treatment as a human gesture. One should to the little soul for the rest of its life.

There are various reasons for deciding whether surgery is needed or not and if yes then when.
EMERGENCY CONDITIONS
A. Immediate surgery in neonatal conditions is advocated in some conditions viz:
  • Diaphragmatic hernia looking to the incipient fear of internal strangulation & gangrene of the contents, which could be fatal
  • Oesophageal atresia where aspiration of the secretions of the oesophageal pouch may turn out to be catastrophic
  • Lobar emphysema
  • Tension pneumothorax
  • Neonatal intestinal obstruction
  • Leaking meningomyelocele
  • Gastroschisis
  • Ruptured omphalocele
  • Supralevator anorectal malformations
  • Acute abscesses as they may precipitate acute septicemia

B. Wait & watch in certain conditions like Umbilical hernia, congenital hydrocele (Communicating), Ventricular Septal Defect of heart. They have a tendency to disappear with advancing age.

C. Surgery is fatal in conditions if done early, as the child cannot sustain the trauma of extensive surgery e.g., in separation of Siamese Twins.

D. Delayed surgery gives best results in some conditions because by that time the organs have developed enough so that proper handing can be done, e.g. Hypospadias.

(I) Immediate surgery: Immediate intervention is considered to give the best results

In certain conditions that are listed here:
  1. Inguinal hernia: As soon as diagnosed, as it can get strangulated any time due to narrow ring & non-cooperation from pain &fright in kids which does not allow the contents to reduce fast.
  2. CDH (Song. Dislocation Hip) within first week of birth. As the presence of head of femur in the acetabulum is the only stimulus for the growth of the Whole hip joint as a whole.
  3. CTEV - same is the reason as mentioned above.
  4. Congenital Hypertrophic Pyloric Stenosis -5-6 weeks of life. Non- intervention will lead to severe malnutrition & electrolyte imbalance, which may turn out to be fatal.
  5. Sacrococcygeal teratoma- Within 2 weeks as delay may cause malignant changes.
  6. Meningomyelocele, Malignant masses (Suspected), Congenital Hydrocephalus & PDA with complication e.g. reversal of blood flow in shunt -as soon as possible.
  7. Hermaphroditism with ambiguous genitalia -Within 1yrof birth after genetic determination of sex so as to protect the child from the greatest mental torture by fellow kids as he or she becomes social with them out of home.

(II) Elective Surgery: Where proper planning & optimum results are assured in following conditions:
  1. Congenital biliary atresia - Before 6-8 weeks of birth or the child will succumb to kernicterus.
  2. Clef-lip-2-3 months because the tissues are so pliable that ultimate cosmetic appearance is par-excellence.
  3. Vestibular anus-Anopasty is done in 3-4 month before solid faecal discharge starts infecting the region.
  4. Hydrocele-after 6 months.
  5. Syndactyly-1-2years.
  6. Tongue -tei-1year or when child learns to follow commands.
  7. Cleft-palate-1-1&half years.
  8. Undescended testis -6 months to 2 years. The age for surgery is getting less & less due to development of fine micro -surgery today which saves the fertility of the testis.
  9. Umbilical hernia: 3-4 years of age as at times it disappears due to increase in the abdominal volume with age.
  10. Phimosis: Preputial separation after 1 year - Circumcision -after 2-3 years.
  11. Hypospadias:
    • Meatotomy: any time after birth
    • Chordee correction by 2 years
    • Urethoplasty by 3 years or before school-going age
  12. Epiphediasis:
    • Chordee Correction - by 2 yrs
    • Urethoplasty - by 4yrs
  13. Exstrophy Bladder:
    • "Turn in "of bladder - 2-3 weeks
    • Chordee correction, bladder neck repair & Antireflux Surgery - 3-4 yrs
    • Urethroplasty - 2 yrs after stage two
    • Augmentation colo-cystoplasty: 8-10 years of ago
    • Supra-levator Anorectal malformations: 10-12 months of age - posterior sagittal Anorectoplasty is preferred.

  14. Hirschsprung's Disease: 12-15 months -Duhamel or Swenson's pull-through
  15. VSD, ASD, Coarctation of Aorta -5-6 years
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