The main surgical problems in children

There are many reasons why infants, small children or adolescents may need surgery and the moment they do, the family needs to go to a hospital with a high-quality pediatric department. Prof. Dr. Burak Tander, a very experienced pediatric surgeon, leads such a department at ACIBADEM Atakent Hospital. Professor Tander speaks in the following material about the most frequent surgical problems in little patients, and about the importance of an experienced and dedicated care team.

What are the most frequent surgical problems that you diagnose and operate in children?

Prof. Dr. Burak Tander: We are talking about three large categories: surgical problems of the chest, surgical problems of the abdomen and surgical problem of the urogenital system. In the abdomen, the digestive system, all bowels, stomach, esophagus, these are in the field of pediatric surgery and I operate these in children. Also, the lungs, the pleura and the so-called mediastinum are the systems we are operating and, for example, all of the tumors in the chest, in the abdomen and in the pelvis at the urogenital system are problems we are dealing with. The most frequent ones are the inguinal problems, the groin hernias, for example, and the problems of testicles, the problems of ovaries and the undescended testes, the hydroceles, water cysts at the testicles, these are the most frequent problems we are operating. And the other problems, the appendicitis, the intussusception, the bowel problems are the second most frequent ones. But also, we are operating the reflux problems, gastroesophageal problems. In neonates and small infants there are many congenital anomalies, inborn defects. Inborn defects of digestive system, for example, bowels and esophagus, inborn defects of liver and problems of lungs and diaphragm, especially. These are quite frequent surgical problems we are operating. And in females, in adolescent females, ovarian cysts and ovarian torsion are quite common, and these pathologies require surgeries, operations. And therefore, we are operating them. As tumors, there are chest tumors, chest wall tumors, mediastinal tumors. In the abdomen, there are some specific tumors in children, some kidney tumors, such as Wilms tumors, nephroblastoma and others. The neuroblastoma, the rhabdomyosarcoma, also lymphomas are also problems we are treating. And not just the problems of the surgery itself, there are also some pathologies requiring surgery. For example, kidney insufficiency. In kidney insufficiency we operate these children with dialysis catheters and in a laparoscopic way. Also, in some tumors, the children need insertion of catheters and we also insert these catheters. And, especially in older children there are many traumas: sport traumas, motor vehicle traumas, accidents, burns, and all these traumas require surgeries, at least surgical management, surgical consultation. And, in small children, foreign body ingestion and foreign body aspirations are urgent emergency cases and we make endoscopic interventions in these children.

You have mentioned congenital abnormalities. How important is it to operate them in early age?

Prof. Dr. Burak Tander: Some congenital abnormalities, especially some digestive system abnormalities, abnormalities of bowels, esophagus, rectum, anus are emergency cases. They should be very urgently taken care of, and many of them should be treated in the first few days of life. Otherwise the child cannot survive. Take the esophageal atresia, the congenital obstruction of tract of the esophagus, for example. If you don't operate it in a few days after birth, the baby could die. And, the anal-rectal malformations. Sometimes, the rectum is closed, and the stool cannot pass. So, the stool and every secretion would accumulate within the bowels and very severe vomiting would happen. And therefore, you need to operate such a child in 1 day or 2 days. So, since the congenital problems of the digestive tract occur within hours or within 1-2 days after birth the physicians themselves can diagnose them or at least can raise some suspicions... Only a small part of these congenital abnormalities is diagnosed after the baby is born. But this is also an important point. Why? Because there are some congenital abnormalities of the duodenum, the second part of the bowel, which are diagnosed after birth. Therefore, the parents should be careful on vomiting. If the baby vomits especially green or yellow color vomiting are alarming signs for such a pathology. And after feeding, especially breastfeeding, if you see that there is a green or yellow color vomiting, the parents should go to a hospital.

How about urinary problems or abnormalities, are there any specific symptoms?

Prof. Dr. Burak Tander: Urinary problems are quite common problems in children. Especially hydronephrosis is common and enlargement of the kidneys’ collective system. But fortunately, most of these conditions are reversible. Only some need surgical intervention, or surgical follow-up at least. Fortunately, they can be diagnosed before birth. We call it antenatal diagnosis and antenatal ultrasonography examination and the gynecologist-obstetrician should look for these abnormalities because these kidney abnormalities are quite common. And, if they detect one, the parents should go to a pediatric surgeon just after birth.

Let’s also approach the undescended testes, many parents are confronted with this diagnosis in their male infants.

Prof. Dr. Burak Tander: Undescended testes is a common abnormality. Every 2-3 children of 100 have this abnormality. And some of them can descend in some months. Therefore, the best way to manage this problem after birth is to wait, but the question is how long. To my opinion, we should decide according to the testes status and we should decide on a patient basis. Every male infant with undescended testes is unique, actually. And I decide in every patient with undescended testes according to my physical examination and sometimes imaging investigations. But there are some clues. If the testes are within the abdomen and cannot be felt by manual examination, I operate these children at 6 months of age. But if the testes are just before the scrotum, at the groin, I mostly wait until 9-12 months. The abdominal testes bring some other problems. In the testicles within the abdomen we should perform a laparoscopy to find the testicles in the abdomen. Otherwise, we cannot find the at groin examination, at groin exploration. It is impossible, almost impossible. We first make a laparoscopy at 6 months of age and at laparoscopy we find the testicles and put them into the scrotum.

You have also mentioned ovaries problems. What kind of problems could a child have, or a teenager have? These sound more like adult problems…

Prof. Dr. Burak Tander: I don't know why, but every year I operate more teenagers with ovarian problems. This might be because of the climate change, because of the pollution or because of the food problems, poor nutrition that may lead to hormonal problems. I don't know why, but the ovarian cyst is actually a public health problem in teenagers nowadays. And cysts larger than 5 cm are alarming. Why? Because of the torsion risk. Therefore, every teenager with menstruation irregularities or pains related with menstruation should have an ultrasound examination for her ovaries. If there's a cyst, larger than 5 cm - this should be observed very carefully and if the cyst diameter reaches as much as 7-8 cm, a surgical intervention is necessary. The advanced laparoscopic methods can preserve the fertility, can preserve the ovary itself and we can operate the cyst only, but there is another problem in such teenagers. There is a benign tumor, an increasing number of benign tumor and ovaries of the children. And mostly these tumors are ovarian teratomas and these tumors should be removed, otherwise, this tumor can be transformed into a malign tumor, into a cancer. Fortunately, we operate this tumor by laparoscopy. And in most cases, but unfortunately not all cases, but in most cases, we can preserve the ovary by laparoscopy. Or by laparoscopy assisted open surgery, depending on the tumor size.

Speaking of laparoscopy, almost half of the 10.000 surgeries performed by so far in your career are minimal invasive interventions. Can you tell us the benefits of this type of surgery?

Prof. Dr. Burak Tander: There are many benefits. First of all, there is a cosmetic benefit. There is almost no scar on the body. The second one, but the most important one, the child can return home earlier, can be fed earlier, can go to school earlier. Also, there is less pain after minimally invasive surgery - the pain management is very important after surgeries, and when the child is operated by endoscopic manner, by minimal invasive manner, the post-operative pain is diminished.

Is it more difficult to manage a minimal invasive surgery in a child than in an adult?

Prof. Dr. Burak Tander: Yes, absolutely yes! The main problem in children is the endoscopic minimal invasive operations difficulty because the space in children’s bodies, the space in which we should operate, is sometimes too small to make the surgery and therefore we have special instruments, very small size instruments and also special, different methods. And the learning curve - the rate of a person's progress in gaining experience or new skills - for these operations is very long. Fortunately, we have quite a good experience in minimal invasive surgery and almost all operations which can be managed through this method are operated by our team here in ACIBADEM Atakent Hospital.

You have mentioned the importance of the experience - what are the risks of performing a minimally invasive operation in a medical center with less experience?

Prof. Dr. Burak Tander: The surgery complications management is much more challenging in minimally invasive methods. I can give you an example. If you operate a child by laparoscopy and a sudden bleeding happens, you cannot manage this bleeding easily when compared to open surgery. In open surgery, you put a finger and press the bleeding point and the bleeding stops. But in minimal invasive surgery it is impossible. Therefore, you need some experience. First, an experienced minimal invasive pediatric surgeon does not cause easily bleeding problems, and, secondly, if there is a bleeding, an experienced surgeon can manage it. And therefore, we always say that experience is the most important thing in minimal invasive pediatric surgery.

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