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View Point Indian Pediatrics 2002; 39:648-653 |
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Optimal Timing For Pediatric Surgical Procedures |
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Anup Mohta
There are many conditions in children that require surgical intervention. There are situations when the condition is diagnosed but not referred to the surgeon at an appropriate time. On the contrary, there are conditions that merit observation and follow-up. Thus it is important to know the widely followed recommendations regarding optimal time for correction of common pediatric surgical conditions to facilitate timely referral and surgery. Factors Determining the Timing of Surgery Nature of the Condition The conditions requiring surgical correction are divided into three groups with regards to the urgency of surgery: (i) immediate group, (ii) intermediate group and (iii) elective group(1). Immediate group includes surgical emergencies like acute abdomen, intestinal obstruction due to various causes, tension pneumothorax, and various neonatal emergencies like congenital lobar emphysema(2), esophageal atresia with or without tracheo-esophageal fistula, and congenital diaphragmatic hernia. Once diagnosed, the child should be resuscitated, investigated in the shortest possible time, his hemodynamic and metabolic status corrected and only then should be taken up for surgery. Conditions causing vascular compromize of the organs including malrotation with volvulus, torsion of testis(3) and trauma causing exsanguination merit surgery without any delay. Intermediate group includes the conditions that do not need surgery on emergency basis. But these should be investigated at the earliest and operated in the immediate future in a planned manner. Further delay in surgery may predispose to complications, chance of malignant transformation, dissemination of disease or deterioration in organ functions. Examples include inguinal hernia(4), biliary atresia(5), exstrophy of bladder(6), tumors, hydronephrosis, meningocele(7) and hydro-cephalus. Elective group–The surgery in these conditions may be deferred till the child grows up. These conditions are discussed later in this article. Condition of the Patient General condition of the patient has a great impact on the outcome of the surgery. It is necessary to assess the hemodynamic, metabolic and respiratory status of the patient and correct them to the best possible levels before taking the child for surgery. This is aptly demonstrated by change in attitude and practice regarding management of congenital diaphragmatic hernia. Earlier a patient of congenital diaphragmatic hernia was rushed to operating room immediately on diagnosis but now the patient is stabilized before performing surgery(8). Presence of other congenital malformations in the neonate may necessitate delay in the surgery till the other condition is corrected if possible e.g. repair of a large omphalocele may be deferred till correction of a life threatening cardiac anomaly. Natural History of the Disease Many conditions that are apparent in the neonatal age group resolve on follow-up and do not need any surgery. These include capillary hemangioma(9), congenital hydrocele, umbilical hernia and sternomastoid tumor(10). It is best to follow-up the child regularly and intervene only if these do not resolve by a certain age or develop complications. Understanding Pathophysiology In conditions like undescended testis, earlier it was advocated to wait till the age of five years or so before subjecting the child to surgery(11). But with better understanding of the pathological changes, it is well known that waiting beyond the age of 1 year is not advisable as this leads to deterioration in the testicular function and increase in complications(12). Size of the patient Though certain conditions are amenable to surgical correction in the neonatal period, it is preferred to wait till the child achieves a certain age or weight. This allows the surgeon to work with larger tissue and avoid inadvertent injuries to structures because of small size or less working space. This applies to conditions like anorectal malformations(13), hypospadias, Hirsch-sprung’s disease and cleft palate(14). Experience of the surgeon and the technical facilities available at the center also play an important role in this decision. Better Anesthesia and Surgical Techniques With the advancements in technology and infrastructure available for anesthesia, surgery and post-operative care, preference for earlier surgery is shown by certain pediatric surgeons(15-17). Psychological Response to Surgery With more and more data available on the long-term effects on the psychological and behavioral development of the children undergoing surgery, optimal surgical timing has seen a change. This is best demonstrated by the change in recommendations for timing of surgery on the genitalia of male children(11,18), keeping in view the improved understanding of psychological implications of genital surgery in children, advancement made in technical aspects of surgery and anesthesia and clarity in the natural history of testicular descent. Table I outlines the timing of surgery in different conditions according to urgency for the same.
Immediate surgery
Surgery at Diagnosis
Conditions requiring Staged Procedures
Conditions requiring Observation Hydrocele, sternomastoid tumor, capillary hemangioma, preputial adhesions, umbilical hernia.
Suggested Recommendations for Common Surgical Conditions Hydrocephalus and neural tube defects These conditions need surgical correction whenever the child presents to the hospital. Neural tube defects should be assessed and investigated adequately for associated anomalies and prognosis explicity explained to the parents. Intact lesions in the newborn should undergo surgery within 48 hours(7). In a leaking lesion, perform surgery after administration of antibiotics. Sometimes ethical issues regarding management may pose a dilemma for the attending clinician. Sternomastoid tumor The condition usually resolves over a period of 6-12 months and does not require any surgical intervention. Indications of surgery include presentation after 1 year of age, development of strabismus or hemihypoplasia or no improvement by the age of one and a half years(1). Tongue-tie Pediatric surgeons and majority of pediatricians tend to believe that the condition is harmless, does not interfere with feeding and speech, and operative treatment is essentially carried out for cosmetic reasons and is not free of complications(19). On the contrary, speech therapists and lactation consultants believe that it interferes with feeding and has some effect on speech(20). Most pediatric surgeons tend to defer the division of frenulum till the age of two years or more and perform it only if deemed necessary at that age(21). Cleft lip and cleft palate Repair of cleft lip is guided by the ‘Millard’ rule of 10’ i.e. cleft lip should be repaired when the child is 10 weeks of age, weighs at least 10 pounds and has a minimum hemoglobin of 10 g/dl(22). Surgery is also feasible at birth. This may achieve better heeling with less scar and avoids psychological trauma to the parents leading to parental detachment. The objective of the treatment of cleft palate repair is to achieve normal speech, maxillo-facial growth, and hearing(17). To prevent deterioration in these functions of child, cleft palate repair is increasingly being done at a younger age(9-12 months) in contrast to earlier recommendations of 18 months. It is recommended to perform anterior palate repair at the time of lip repair when both are associated. Some surgeons prefer to close soft palate defects at 3-6 months. Residual hard palate is repaired at 15-18 months of age(23). Experience and personal preference of the surgeon and availability of necessary instruments is a prerequisite for performing early surgery. Neck lesions Neck lesions like cystic hygroma, branchial cyst and sinuses are operated at the time of diagnosis as elective procedure. Although cystic hygroma does not resolve on its own, treatment by injection of bleomycin and OKT 432 is recommended by some(24) for better cosmetic results. Congenital cardiac defects Refer the patients for correction of the lesion before ventricular dysfunction, pulmonary vascular changes or complications occur. A large atrial septal defect should be closed at 3-4 years; a large ventricular septal defect with congenital heart failure needs early surgery between 3-6 months of age; patent ductus arteriosus needs immediate surgery if associated with shunt and failure but can be done electively at one year if the child is stable. An excellent review is available for further information(25). Biliary Atresia The prognosis of the neonate depends on the timing of surgery in the form of Kasai’s portoenterostomy. The results are better when the procedure is done at the earliest(26,27). Kasai procedure has been found to be successful till the age of 141 days(28). Abdominal wall defects Gastroschisis and ruptured exomphalos need immediate surgical closure without or with use of silo or creation of ventral hernia. A large unruptured exomphalos associated with other anomalies may be subjected to conservative treatment with later repair of ventral hernia(29). Most umbilical hernia need closure only if the umbilical ring size is larger than 1-2 centimeter at 4-5 years of age(3). It is important not to apply any pressure causing object like coin or dressing on the hernia during the period of observation as this causes skin maceration and complications. Hypospadias The aims of correction of hypospadias are to have a normally looking straight penis with normal voiding and sexual function at a later date when child grows up. Earlier staged procedures were performed and it was recommended to complete the repair before child goes to school i.e. 4-5 years(11). Now with better understanding of psychological effects of the surgery, improvement in surgical techniques and anesthetic management, hypospadias is being repaired as single stage procedure at 6-12 months of age(18,31). Many surgeons still prefer to wait till the age of 18-24 months of age for performing urethroplasty so that larger tissue is available(32). Congenital hydrocele and inguinal hernia Avoid surgery for congenital hydrocele till the age of two years. Inguinal hernia does not resolve on its own and merit surgical correction at the earliest after diagnosis. For high-risk premature and low birth weight babies, elective repair is advocated when the infant weighs more than 2200 g. In healthy premature infants, surgery is advised at 48 weeks postconceptional age or has attained retinal maturity(33). Optimal time recommended for elective repair of indirect inguinal hernia in otherwise healthy children is within seven days of diagnosis to prevent complications(4). Undescended testis Testis develop as an intrabdominal organ and descends down into the scrotum at birth. Incidence of undescended testis in newborn is about 4.5% and is much higher in preterm neonates (30%). The testis that have to come down do so in the first few weeks of life and may do so by the age of one year in preterm children. Also, degenerative changes begin to affect the testis after that age. Surgery before the age of one year poses threat of injury to vas and other delicate cord structures. Thus it is recommended that undescended testis persisting beyond the age of one year should be surgically mobilized, brought down into scrotum and fixed there(12). It is done at an earlier age if associated with clinically diagnosed hernia. For perineal ectopic testis, it is advisable to perform orchidopexy at the time of diagnosis(34), as these do not reach the scrotum even if one waits. A retractile testis should be differentiated from undescended testis, it does not merit surgical correction and counselling is advisable.
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