COMMON SURGICAL CONDITIONS IN CHILDREN
While most childhood illnesses are generally treated through non-invasive methods, such as medications, there are several medical conditions that necessitate surgery.
Before the healthcare team decides on surgery, they will evaluate the child’s medical history and perform a physical examination. Some laboratory tests and imaging may be needed to determine the severity of the condition or if there are any complications. Examples of these include blood tests, x-rays, and electrocardiograms (ECGs). The priority is to provide non-surgical care, if possible. However, there are situations when surgery is the best option for the patient.
Types of Surgery
Major Surgery versus Minor Surgery
An operation may be classified as major or minor surgery. There is no absolute definition for these terms, but there are several factors that surgeons consider to categorize the procedure. These include:
- Type of anesthesia used
- The estimated amount of blood loss
- Number of healthcare professionals needed to operate
- Length of time needed to operate
- Need for specialized training to operate
- Need for specialized equipment
- Presence of other medical conditions that will make the operation more difficult to complete
- Estimated mortality rate (risk of death)
Major surgery often involves the chest, abdomen, head, and neck areas. These correspond to the thyroid, heart, lung, liver, stomach, and intestines but are not limited to these areas. Some types of traumatic injuries may also fall under this classification. Major surgeries most likely require general anesthesia, highly specialized training or equipment, and longer hours to perform. In addition, patients might need an extended hospital stay and closer monitoring to prevent surgical complications.
Minor surgeries usually deal with smaller pathologies or more easily accessible areas of the body, especially the skin. Most biopsies fall under this category. Local anesthesia is preferred. Patients recover faster than those undergoing major surgeries.
Open Surgery versus Laparoscopic Surgery
Open surgery is a classical method that utilizes an incision through the skin and abdominal muscles. This is typically a few centimeters wide or longer, depending on the type of procedure. Surgeons use standard surgical instruments to perform the surgery and keep the incision open.
On the other hand, laparoscopic surgery creates two to four small incisions that are roughly a centimeter long each. A surgical instrument holding a small camera, called a laparoscope, is inserted through one of these incisions so the surgical team can visualize the surgical area. Afterward, special laparoscopic instruments are inserted through the other small incisions to complete the procedure.
Preparations Before Surgery
All patients who need surgery should have adequate preparations first unless the procedure is an emergency or should be done urgently. The healthcare team will decide the preparations the patient needs; not all are strictly required depending on the clinical condition and circumstances of the patient.
Several medical conditions, such as prematurity, congenital defects, clotting or bleeding disorders, airway disorders, heart or lung problems, neurologic or behavioral disorders, kidney or liver disease, and organ transplantation, may affect how the procedure is performed. These are also considered in the type of anesthesia given. In addition, any previous intake of certain medications, like opioids and sedatives, should also be considered for the patient’s safety.
Depending on the type of procedure or prevalent medical conditions, the patient may be tested for their hemoglobin level and blood type in case excessive blood loss necessitates a blood transfusion.
Apart from surgical emergencies, the healthcare team usually explains the surgical procedure to the patient’s family or companions first. During this time, families may also share their personal or religious beliefs or preferences. Any modifications to the procedure should also be discussed.
For major surgeries, patients may be advised not to eat or drink a few hours before the procedure. This is to prevent any complications after anesthesia is given. Laboratory tests and imaging essential for the procedure should be done.
Intravenous (IV) fluids and antibiotics are usually provided before the surgery. Most maintenance medications, if any, may be given as prescribed. Local or general anesthesia is given before starting the operation. For younger children, preoperative sedation may be given beforehand to reduce anxiety and stress.
Surgical patients are attached to monitoring equipment that tracks their temperature, heart rate, respiratory rate, oxygen levels in the blood, blood pressure, and heart tracing.
Common Surgical Conditions in Children
Appendicitis and Appendectomy
The appendix is a small pouch attached to the large intestine containing lymphoid tissue. Foreign bodies, tumors, enlargement of the lymphoid tissue, or even parasites that accumulate in the appendix can block the lumen of this pouch, leading to inflammation of the appendix (acute appendicitis).
Acute appendicitis is the most common surgical condition in children, especially those 10-18 years of age. An estimated 19-28 in 100,000 children develop acute appendicitis yearly.
Most cases of acute appendicitis are treated surgically - the whole appendix is removed. Surgeons may choose either open or laparoscopic surgery, depending on several factors. Standard appendectomy is rarely an emergency procedure and is usually done within the first day of diagnosis. Several conditions or factors may affect the decision to operate.
Cholelithiasis and Cholecystectomy
The gallbladder is a pear-shaped organ that receives and stores bile from the liver. Bile is a greenish fluid secreted by the liver to help the intestines utilize fats. The gallbladder releases bile, which helps digest fats from meals. These fats become smaller, making them easier to be absorbed through the intestinal wall.
Acute cholecystitis is inflammation of the gallbladder, sometimes accompanied by gallstones. The gallbladder ducts through which bile passes may become obstructed because of inflammation in the gallbladder wall, sludge-like bile, or large gallstones. Pediatric cholecystitis is less common than appendicitis - only 4% of cholecystectomies are done in pediatric patients.
Laparoscopic cholecystectomy is the preferred surgical procedure to treat cholecystitis. The gallbladder and any gallstones in the ducts are removed.
Thyroid Disorders and Thyroidectomy
The thyroid is a small, butterfly-shaped endocrine gland found at the base of the neck. It produces the thyroid hormone, which helps regulate the body’s growth and metabolism, including protein synthesis and calcium levels.
Patients with Graves’ disease (a type of hyperthyroidism) or a thyroid mass might need thyroid removal surgery. Since the thyroid is located in the neck, it involves major open surgery. Like appendicitis, the patient’s diagnosis, medical history, and other factors are considered when deciding whether to remove the thyroid or not.
Umbilical Hernia and Herniorrhaphy
During pregnancy, an unborn child receives oxygen and nutrients from the mother through the placenta and the blood vessels in the umbilical cord. During delivery, the umbilical cord is cut. Subsequently, the part of the umbilical blood vessels still attached to the baby degenerates and becomes fibrous tissue.
In some cases, this fibrous tissue does not completely close or cover the area that the umbilical cord used to pass through, leading to a weak abdominal wall. As a result, some parts of the intestines can bulge into this area, causing a hernia. This is common in infants - around 10-30% of children may develop an umbilical hernia. Premature and low-birth-weight infants have a higher risk of developing umbilical hernias.
Not all umbilical hernias require surgery. Most uncomplicated cases are managed by regular monitoring after evaluation by a qualified healthcare specialist. If complications develop, such as incarceration or rupture, umbilical hernia repair (herniorrhaphy) is done.
Circumcision
For boys, parents may opt to have them circumcised regardless of age. This involves removing parts of the foreskin, called the prepuce, which exposes the tip of the penis. Circumcision decreases the risk of developing urinary tract infections and infections of the foreskin or penis.
Trauma Surgery
Accidents are the most common preventable cause of trauma in children. Among injuries in kids, an estimated 73% are due to road accidents. The second most common cause is falls from heights. Frequently affected organs include the liver, spleen, and kidneys. Severe injuries can lead to abdominal wall hernias, urinary bladder perforation, fractures, neurological problems, and shock.
Moderate to severe cases of trauma will need surgical intervention. Since the healthcare team must investigate all areas of the body that may have been injured, an open surgery is usually performed.
Management After Surgery
Patients often experience several symptoms after surgery. These include post-operative pain, nausea, and sore throat from anesthesia. Medications may be given to ease these symptoms. For the first few days, the healthcare team will modify the patient’s diet, depending on the type of surgery. Any wounds from the procedure will be properly cleaned and managed. There is no set number of days of confinement after surgery - this depends on the nature of the patient’s procedure and their pace of recovery.
After hospital discharge, follow-up consults may be advised, especially for patients with stitches or staples. Regular monitoring may be done to watch out for possible complications, such as bleeding or infection. The healthcare team will also provide recommendations on the type of activities the patient may participate in. Usually, strenuous activities are limited until the patient has fully recovered. Participation in school or work may depend on the assessment of the healthcare team.
Summary
Some medical conditions in children require surgical treatment, such as appendicitis, cholecystitis, and physical trauma. Before deciding on surgery, the healthcare team evaluates the patient’s medical history, physical examination, and pertinent laboratory tests. Depending on the patient’s condition, surgery may be major or minor and may be done via open or laparoscopic methods. Adequate preparations before surgery and post-operative management are crucial to ensure the success of the procedure.
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