Pediatric Surgery – Surgical Case Studies
Case Study: Intussusception
1. Case Study: Intussusception
Presentation
- Intermittent, inconsolable crying → Suggests colicky pain from intermittent telescoping
- High-pitched cry → CNS irritation (possible systemic sepsis or late-stage complication)
- Flank fullness → Consider horseshoe kidney as differential
2. Intussusception
Epidemiology
- Most common cause of intestinal obstruction in children aged 3 – 36 months
- Peak incidence: 4 - 10 months
Etiology
- 90% idiopathic (likely Peyer’s patch hyperplasia post-viral)
- Lead points (in older children): Meckel’s diverticulum, lymphoma, polyp, Henoch-Schönlein purpura
Classic Triad
- Intermittent abdominal pain
- Vomiting
- Red currant jelly stool (blood + mucus)
3. Oncology Branch-Off: Chemotherapy & Wound Healing
When to start chemo if wound is present?
- After wound has healed
Why?
- Chemotherapeutic agents like vincristine, actinomycin, doxorubicin, etoposide:
- Inhibit fibroblast proliferation
- Impair angiogenesis
- Delay healing
- Increase infection risk
Chemotherapy Protocols
| Tumor Type | Drugs |
|---|---|
| General Wilms | Vincristine + Actinomycin D |
| Focal Disease | Add Doxorubicin |
| Diffuse/Advanced Disease | Use Etoposide |
4. Embryopathogenesis of Hypospadias
Pathophysiology
- Urethral folds fail to fuse along the ventral penis
- Result: abnormal urethral opening (glans, shaft, scrotum)
- Driven by ↓ DHT or androgen insensitivity
Associated anomalies:
- Chordee (ventral curvature)
- Cryptorchidism → Consider DSD screen
5. Scar Types: Hypertrophic vs Keloid
| Feature | Hypertrophic | Keloid |
|---|---|---|
| Growth | Confined to wound | Extends beyond |
| Onset | Within weeks | Often months |
| Spontaneous regression | Common | Rare |
| Recurrence | Less common | High recurrence rate |
| Malignant potential | None | Rare sarcomatous transformation |
Mnemonic:
- Keloid = Kraken → Tentacles grow beyond boundaries
- Hypertrophic = Humble → Obeys the wound line
6. Components of Autonomic Neuropathy
| System | Manifestations |
|---|---|
| Cardiovascular | Orthostatic hypotension, resting tachycardia |
| Gastrointestinal | Gastroparesis, constipation, diarrhea |
| Genitourinary | Bladder retention, overflow incontinence, erectile dysfunction |
| Sudomotor | Anhidrosis, gustatory sweating |
| Pupils | Sluggish light reflex, Argyll Robertson pupil-like responses |
Mnemonic Scene:
A puppet controlled by the ANS has its strings snipped:
- Heart swings wildly
- Gut stalls
- Bladder leaks
- Skin dries
- Pupils dim
Consultant Challenge
You’re on rounds.
A patient with a healing post-nephrectomy wound is started on Vincristine.
- Justify or refute this choice.
- Explain the embryologic cause of his hypospadias.
- Should you screen for cryptorchidism?
Answer like your license depends on it.
Consultant Challenge Response
Case Summary:
A patient post-nephrectomy, currently healing a surgical wound, is being considered for Vincristine chemotherapy. The same patient has hypospadias, and the question arises whether to screen for cryptorchidism.
1. Justify or Refute Use of Vincristine Post-Operatively
Refute: Premature Initiation of Chemotherapy
Reasoning:
Vincristine is a cytotoxic agent that:
- Inhibits microtubule formation, affecting mitosis
- Suppresses fibroblast activity and angiogenesis
- Leads to delayed wound healing and increased risk of dehiscence or infection
Surgical Principle:
"Never start cytotoxic therapy until the wound bed has healed — clean, dry, and epithelialized."
Clinical Standard:
- Wait 10–14 days minimum post-op (or until wound is stable) before initiating chemotherapy.
Conclusion:
Starting Vincristine before complete wound healing is contraindicated. It increases risk of wound breakdown and systemic complications.
2. Embryologic Cause of Hypospadias
Normal Development:
- During weeks 8–14 of gestation, urethral folds fuse on the ventral aspect of the penis, forming the penile urethra.
- This fusion is driven by dihydrotestosterone (DHT) via 5α-reductase activation.
In Hypospadias:
- Urethral fold fusion fails → Urethral meatus opens proximally on the glans, shaft, or perineum.
- May be associated with ventral chordee (fibrous tethering)
Pathogenesis Factors:
- ↓ DHT production or action
- 5α-reductase deficiency
- Androgen receptor insensitivity
- Endocrine disruptors (e.g., phthalates, DES)
3. Should You Screen for Cryptorchidism?
Yes — Absolutely.
Justification:
- Hypospadias is often part of a spectrum of Disorders of Sex Development (DSDs).
- The co-occurrence of hypospadias + cryptorchidism → strong signal for underlying intersex condition or gonadal dysgenesis
Action Plan:
- Perform bilateral testicular palpation
- If non-palpable → Order USS/CT/MRI
- Consider karyotype analysis and hormonal studies (LH, FSH, testosterone, AMH)
Red Flag:
A child with proximal hypospadias and undescended testes MUST be evaluated for DSD. Delay in recognition = legal and clinical liability.
Final Verdict:
| Issue | Action |
|---|---|
| Chemo initiation | Delay until wound heals |
| Hypospadias cause | Urethral fold fusion failure (↓DHT) |
| Cryptorchidism screen | Mandatory — to rule out DSD |
Consultant Summary:
"If you poison the wound before it's sealed, you own the breakdown. And if you miss a DSD, you don't deserve to touch another child again. Tighten up, doctor."