Common surgical conditions treated

 
Hernias in children
 

What is a hernia?
A hernia describes a small piece of abdominal lining, and sometimes a section of the bowel, which bulges out through a weak area in the muscles of the abdominal wall. Both children and adults can have hernias. Sometimes it is present at birth. The hernia can look bigger when your child cries or strains. You may hear your child's hernia referred to as an 'inguinal hernia' or a 'femoral hernia'. These names refer to the exact part of your child's abdomen which have the muscle weakness. Both types of hernia are treated in the same way.

How common are hernias in children?
Hernias are more common in boys than girls. About one in 50 boys will have a hernia during their childhood. The condition is also more common in babies born prematurely.

Is it possible to prevent a hernia?
There is no known way of preventing a hernia.

How is a hernia diagnosed?
It is possible  to diagnose the hernia by clinical examination as it appears as a characteristic lump in your child's abdomen. Your child may not need any further diagnostic investigations.

How are hernias treated?
Your child will need a small operation. In many cases this can be carried out as day surgery – you child will arrive at the hospital, have the operation and be able to go home on the same day. Occasionally a child will need to stay in hospital for two or three days.

What happens before the operation?
You will receive information about how to prepare your child for the operation in your admission letter. Your child should not have anything to eat or drink beforehand for the amount of time specified in the letter. It is important to follow these instructions - otherwise your child's operation may need to be delayed or even cancelled.

The day you come to hospital for the operation, Mr Clarke will explain the operation in detail, discuss any worries you may have and ask you to sign a consent form. An anaesthetist will also see you to explain the anaesthetic in more detail..

What does the operation involve?
Your child  will be given a general anaesthetic and will be asleep during the operation. Mr Clarke will make a small cut over the bulge in the lower abdomen. The abdominal lining and piece of bowel will be pushed back into place. The muscle wall will be repaired and the cut will be closed with stitches. These stitches will dissolve and will not have to be removed. The inspection of the other groin may also be offered as in 10% of cases this can occur. This involves a small 3mm telescope passed through the hernia to inspect the opposite side. If there is a hernia this will be repaired at the same time.

Are there any risks?
Every anaesthetic carries a risk of complications, but this is very small. The anaesthetist is an experienced doctor who is trained to deal with any complications. After an anaesthetic, a child sometimes feels sick and vomits, has a headache, sore throat or feels dizzy. These effects are usually short-lived. Any surgery also carries a small risk of infection or bleeding.

What happens afterwards?
After the operation, your child may feel some tenderness and have bruising in the groin area but this is unusual.

If your child does feel uncomfortable, a painkiller such as liquid paracetamol will help. It's a good idea for your child to wear loose clothing while the area is sore. Babies can wear nappies as usual. You can give your child a bath two days after the operation. However, avoid long baths until the wound has settled down. Do not use cream around the wound as it may cause irritation.

Mr Clarke may ask you to come back for an outpatients appointment. In the meantime the hospital will contact your GP to tell them about the operation.

Are there any long term effects of hernia repair?
Most hernia repair operations are successful. You should see an immediate reduction or the complete disappearance of the hernia.

Starvation rules before any operation
Last milk or solids 6 hours before planned surgical time
Last water 2 hours before planned surgical time

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Undescended Testicles
 

What are undescended testicles?
This is when your child’s testicles are not in their usual place in the scrotum. While your child is in the womb, the testicles are developing inside his abdomen. Towards the end of pregnancy, the testicles travel through a passage into the scrotum. Both testicles should be in the scrotum by the time your child is one year old. Generally, only one of the testicles is affected, but on rare occasions, both testicles fail to travel to the scrotum.

In some children, the testicles may be in the scrotum for much of the time but cannot be felt there because they naturally rise back into the body through fear or cold temperatures. You can usually find this out by putting your child in a warm bath and checking whether you can feel both testicles. If this is the case, there is no cause for concern.

What are the symptoms of undescended testicles?
Usually, there will not be any symptoms at all, other than not being able to feel the testicles in the scrotum. Your child will not be in pain, and the undescended testicles will not interfere with any bodily function.

However, if one of the testicles becomes twisted (testicular torsion), this will be painful, either in the groin area or the abdomen, depending on the location of the testicle at the time.

How are undescended testicles diagnosed?
Your child’s doctor will need to determine whether the testicles are truly undescended or whether they have slid back into the body temporarily. This is usually done by feeling the abdomen and the scrotum.

What causes them?
On rare occasions, the testicle does not descend due to other problems with the testicles themselves or with the male hormones.
We do not know exactly why this happens, but it is not due to anything that happened during pregnancy.

How common are they?
This condition is more common in premature babies. Around one in 20 male babies is born with an undescended testicle. In about one in 70 cases, the testicle remains undescended.

How are undescended testicles treated and are there any alternatives?
The method of treatment depends on the suspected cause. However, whatever the cause, undescended testicles are best treated in early childhood. Your child’s testicles will need treatment as they do not seem to mature properly if left in the abdomen. The amount of sperm and fertility levels seem lower in men who have had undescended testicles, and even lower if they were not treated early in childhood. This is because the testicles need to be a few degrees cooler than the rest of the body to produce sperm. It is also impossible for men with undescended testicles to check for testicular cancer, as the testicles cannot be felt in the abdomen. If the testicles remain in the abdomen, this also increases the risk of testicular torsiona.

If the doctors suspect the testicles have not descended due to a hormone problem, they may suggest a short course of a hormone called human chorionic gonadotrophin (hCG. If the doctor does not suspect a hormone problem, or if the testicles remain in the abdomen after the hormone treatment, your child will need a short operation under general anaesthetic called an orchidopexy.

What is an orchidopexy?
This is an operation to bring the testicles down from the abdomen to their usual place in the   scrotum. This is a short operation under general anaesthetic, lasting about 45 minutes. In many cases, this can be as day surgery - your child will arrive at the hospital, have the operation and be able to go on the same day. Occasionally, a child will need to stay in hospital overnight.

What happens before the operation?
You will receive information about how to prepare your child for the operation in your admission letter and welcome booklet. Your child should not have anything to eat or drink beforehand for the amount of time specified in the letter or telephone call. It is important to follow these instructions - otherwise your child’s operation may need to be delayed or even cancelled.

On the operation day, your child’s surgeon will explain the operation in more detail, discuss any worries you may have and ask for your permission for the operation by asking you to sign a consent form. An anaesthetist will explain your child’s anaesthetic in more detail. If your child has any medical problems, such as allergies, please tell the doctor.

What does the operation involve?
The orchidopexy can either be carried out using traditional open surgery or keyhole surgery . The surgeon will move the testicle down into the scrotum, and close up the passage through which the testicle should have travelled, to stop the testicle moving back into your child’s abdomen.

On rare occasions, the surgeon will find that the testicle has not formed properly or has been damaged while in the abdomen. If this is the case, he or she will remove the damaged testicle and might secure the healthy one in the scrotum to ensure your child’s remaining testicle remains in place and can develop in the normal way. Sometimes it takes two operations to bring the testicle down to the correct place.

Are there any risks with the operation?
Every anaesthetic carries a risk of complications, but this is very small. Your child’s anaesthetist is  an experienced doctor who is trained to deal with any complications. All surgery carries a small risk of infection or bleeding. After the operation there will be some tenderness in the groin area. Occasionally there may also be some bruising. There is a small risk that the testicle may be damaged during the operation. This is more likely to occur if the testicle could not be felt while in the abdomen.

What happens afterwards?
Your child will come back to the ward to recover, and will be able to go home once he has had something to eat and drink and is comfortable. We will telephone you the following day to check your child is making a good recovery. Please tell the nurse the best time to contact you before you leave the ward.

Your child may feel sick for the first 24 hours. You should encourage, but not force, him to drink plenty of fluids. It does not matter if he does not feel like eating for the first couple of days, as long as he is drinking plenty of fluids.

Your child will have been given pain-relieving medications during the operation, but these will begin to wear off. Your child will need to have regular pain relief for at least three days, and we will give you the medications to take home with you. As well as the medications, distracting your child by playing games, watching TV or reading together can also help to keep your child’s mind off the pain.

Your child’s groin will probably feel sore for a while after the operation, but wearing loose clothes can help. The stitches used during the operation will dissolve on their own so there is no need to have them removed. If possible, keep the operation site clean and dry for two to three days to allow the operation site heal properly. If your child needs to have a bath or shower, do not soak the area until the operation site has settled down. Your child should not ride a bicycle or other sit-on toy for one month after the operation, to prevent the testicles from travelling back up into the abdomen.

Your child should be able to go back to school within a couple of days, when he is more comfortable.

You and your child will need to come back to hospital for an outpatient appointment about three months after the operation. We will send you the appointment date in the post.

What is the outlook for children with undescended testicles?
When the undescended testicles are treated in early childhood, the outlook is good. Your child will have normal fertility levels unless there were problems with the testicles themselves. If a damaged testicle was removed, leaving one healthy testicle, this should not affect your child’s fertility levels in later life to any great degree.

Your should call your GP / the ward or Mr Clarke’s secretary if:

    -     your child is in a lot of pain and pain relief does not seem to help
    -     your child is not drinking any fluids after the first day back home
    -     the operation site is red or inflamed, and feels hotter than the surrounding skin
    -     there is any oozing from the operation site.
 

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Fundoplication in Children

Why is it called a Nissen Fundoplication & what does that mean?

A Nissen’s fundoplication is an operation used to treat gastro-oesophageal reflux.It uses the top of the stomach to strengthen the sphincter so it is less likely to allow food, drink or acid to travel back into the foodpipe. Some babies and children have a gastrostomy during the same operation.

It was named after the surgeon that first described it.

What is gastro-oesophageal reflux?
Normally, when we swallow food and drink, it moves down the food pipe (oesophagus) to the stomach, where it starts to be broken down by the acids released from the stomach wall. After it has been partially broken down, it passes through to the small and large intestines, where all the goodness and excess water is removed.

When a baby or child has gastrooesophageal reflux, the food and drink travels down the foodpipe as normal, but some of the mixture of food, drink and acid travels back up the foodpipe, instead of passing through to the large and small intestines. As the food and drink is mixed with acid from the stomach, it can irritate the lining of the foodpipe, making it sore. This is gastro-oesophageal reflux disease. Some children also breathe some of the mixture into the windpipe (aspiration), which can irritate the lungs and cause chest infections.

What happens before the operation?
Your child will need to come to the hospital the day before the operation for a pre-admission check. For more information, please see our Preadmission clinic information. The doctors will explain the operation in more detail, discuss any worries you may have and ask you to give your permission for the operation by signing a consent form. Another doctor will visit you on the ward to explain about the anaesthetic. The doctors may also ask for some blood samples to check that your child is well before the operation. If your child has any medical problems, like allergies, please tell the doctors about these.

After the pre-admission check, you will be able to go home or stay in the Patient Hotel if you prefer, ready to arrive on the ward the following morning for the operation. Before you leave, the nurses will explain about fasting times for the operation. It is important that your child does not eat or drink anything for several hours before the sedation or anaesthetic. This reduces the risk of vomiting during and after the operation. After this time, your child should have nothing at all to eat or drink. You should follow these instructions exactly. Otherwise his or her operation will be delayed or even cancelled.

What happens during the operation?
Most Nissen’s fundoplication operations are carried out using keyhole surgery (laparoscopy). The surgeon uses a telescope, with a miniature video camera mounted on it, inserted through a small incision (cut) to see inside the abdomen. Carbon dioxide gas is used to inflate the abdomen to create space in which the surgeon can operate using specialised instruments that are also passed through other smaller incisions (cuts) in the abdomen.

Are there any risks?
Every anaesthetic carries a risk of complications but this is very small. Your child’s anaesthetist is an experienced doctor who is trained to prevent and deal with any complications. Any surgery carries a small risk of infection or bleeding.

There is a chance that keyhole surgery will not be possible for your child. Sometimes the surgeon will not be able to carry out an operation using the keyhole method for technical reasons, or because of unexpected findings. If this is the case, the surgeon will carry out the operation using a larger incision (cut) instead.

What happens after the operation?
Your child will return to the ward to recover and his or her breathing, heart rate and temperature will be monitored closely for the first couple of days. After an anaesthetic, children sometimes feel sick, may have a headache, sore throat or feel dizzy, but these effects do not last for long.

He or she will usually have an intravenous infusion of fluids (drip) for a few days to allow the stomach to rest and heal. Strong pain relief medicines will also be given through a drip to begin with, but are gradually reduced and replaced with milder pain relief medicines given as tablets, liquids or suppositories when your child is eating and drinking again.

After keyhole surgery, some older children may complain of shoulder pain and some crackling under the skin, caused by the carbon dioxide escaping into the tissue just under the skin; this does not usually last long and gradually improves over a day or two.

If your child does not have a gastrostomy, he or she will have a naso-gastric tube for the first few days so that air and fluid building up in the stomach can be drained away; a naso-gastric tube is inserted through the nose, down the foodpipe and into the stomach. This is inserted while your child is asleep under the anaesthetic.

Your child will be able to drink when drainage from the naso-gastric tube or gastrostomy has slowed down and the fluid draining away is clear. As he or she gets used to drinking, small amounts of soft food can be added until your child is eating and drinking normally again. It may take up to two weeks for your child’s eating and drinking to get back to how it was before the operation.

Once your child is eating and drinking as normal and has recovered well from the operation, he or she will be able to go home. Most children stay in hospital for about three to five days after this operation. Your surgeon will tell you whether or not to continue giving your child any reflux medicines as previously.

Are there any long-term effects of the operation?
Although the Nissen’s fundoplication operation is very successful at improving a baby’s gastro-oesophageal reflux disease and the symptoms associated with it, a quarter of all patients develop some lon gterm effects afterwards, some of which we are able to treat.

Changes in feeding pattern - The operation makes the stomach slightly smaller. For some children this can mean that they may need to have smaller volumes of feed given more regularly. The surgeon and dietitian will advise you on how best to feed your child after the surgery.

Burping and vomiting - After the Nissen’s fundoplication operation, some children are unable to burp or vomit. In some this is temporary, but in many this is permanent.

Gas bloat - This is the name given to wind trapped in the stomach. It can usually be corrected by giving your child smaller feeds more frequently, rather than a few large feeds each day. If your child has a gastrostomy tube, the wind can be released from it . The gastrostomy specialist nurse will show you how to do this before you leave the ward.

Dumping syndrome - This is a combination of things including nausea, retching, sweating, diarrhoea and a drop in blood sugar level. It is caused by food travelling through the stomach at a much faster rate than usual so none of the goodness in the feed is absorbed. This can also be corrected by giving your child smaller feeds more frequently. These symptoms can take up to six weeks to settle.

Recurrence of reflux - In some children, reflux symptoms can come back(10%). This is because the Nissen fundoplication operation is failing (coming undone). Your surgeon may recommend that the operation be performed again.

Sometimes your surgeon may recommend that a tube that bypasses the stomach for feeding is used for a short time ( gastrojejunostomy tube)

What is the outlook for children with gastro-oesophageal reflux disease?
In some children, the symptoms associated with gastro-oesophageal reflux disease disappear with or without treatment, usually by early infancy. However, in some children, gastro-oesophageal reflux disease is more of a long-term condition and can have a serious effect on both the child and family’s quality of life. The options for treating gastro-oesophageal reflux disease are improving all the time, with new medicines and surgical options being discovered alongside a better understanding of why a child develops gastro-oesophageal reflux disease.

Most children see an improvement in symptoms, especially after the Nissen’s fundoplication operation, although some long-term effects may continue to be troublesome.
 

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Foreskin surgery


Neonatal Circumcision
This procedure is carried out anytime between birth and 8 weeks of age with out general anaesthetic. The procedure safely removes the foreskin under a local anaesthetic block. A sutured repair is used to ensure excellent cosmetic result. All sutures dissolve within 2 weeks. You are able to be discharged with your baby straight away after the procedure . A dressing is worn overnight to ensure comfort and this easily removed the following day. All sutures dissolve within 2 weeks. Anaesthetic gel is given to go home but this rarely needed . A follow up call is made the next morning to ensure all is well.

The procedure can be carried out usually on a day of your choosing at any of the centres Mr Clarke operates. The consultation and procedure happen on the same day.

Call Samantha or Claire on 0207 042 1787

Or email Samantha.russell@phf.uk.com / Claire.Farrer@phf.uk.com

Circumcision in an older boy
This is carried out under general anaesthetic and requires several days off from usual activity . The pain is usually the most worrying aspect for any parent though with a local anaesthetic block and pain klilers this is kept to a minimum after the operation. Most boys return to normal activities within 48 hours after the procedure

Preputioplasty.
This is a widening of the natural preputial ring if tight and difficult to retract. This is carried out around 8- 16 years of age and is also under general anaesthetic. 3-5 fine sutures are used which dissolve after 2 weeks.
 

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Book an Appointment

Appointments can be made through your GP or for private patients by contacting either Mr Clarkes secretary directly or by calling the appointments line directly at your preferred hospital

Get in contact

Private Secretary : Samantha Russell / Claire Farrar
Tel: 0207 042 1787 (9am-5pm) ( out of hours email )
Fax: 0207 042 1788
Email: samantha.russell@phf.uk.com

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