SURGERY AND POST-OP INFORMATION
Circumcision
Epigastric Hernia
Hydrocele
Undescended Testis/Orchidopexy
Umbilical Hernia
Tongue Tie
Thyroglossal Cyst / Sistrunk Procedure
Skin / Subcutaneous Lesion
Periorbital / External Angular Dermoid Cyst
Labial Fusion
Ingrown Toenail / Wedge Resection Hypospadias
Foreskin Facts
Inguinal Hernia
Appendicectomy Post Operation Information
Dermoid Cyst Post Operation Information
CIRCUMCISION
What is circumcision?
Circumcision is the removal of the foreskin.
Why perform circumcision?
Medical reasons
Narrowing of the end of the foreskin, or ‘phimosis’
Recurrent infections of the foreskin (‘balanitis’)
Scarring of the foreskin
Cultural reasons
Religious reasons
What are the alternatives to circumcision?
Narrowing of the end of the foreskin, called phimosis, can often be successfully treated with steroid cream. If the cream is not successful, circumcision is usually advised.
Recurrent infections may be successfully prevented by attention to simple hygiene measures such as gently retracting and cleaning the foreskin regularly. However the foreskin should never be forcibly retracted. In small boys there is no need to routinely retract and clean inside the foreskin if there have been no problems – best simply leave it alone.
Some parents may consider circumcising their son for cultural or personal reasons.
How is circumcision performed?
Although circumcision can be performed in many ways, a paediatric surgeon / paediatric urologist performs circumcision under a general anaesthetic in the operating theatre.
The foreskin is surgically removed and dissolvable sutures are used.
What to expect after the operation
There may be a small amount of blood at the operation site. However, there should not be continuing oozing or bleeding. There may be some swelling of the penile skin.
A degree of bruising is to be expected.
The head of the penis will be exposed.
There may be a raw appearance to part of the head of the penis if an adherent foreskin had to be separated off. Later this may look a little ‘sloughy’ – this is not infection but part of the healing process.
What are some of the risks of the operation?
Bleeding can occur from the wound during the first 24 hours after the operation. (This can occur in up to 2% of cases regardless of the technique used.)
Rarely a second operation will be needed to stop the bleeding
Infection
Meatal stenosis
Narrowing of the hole in the end of the penis
Injury to the penis – very rare
POST OPERATION INFORMATION
Pain relief
o Give paracetamol for pain relief. Give every 4 hours up to 4 times a day (except when asleep) for the day of operation, then as needed after that (see instructions on the bottle).
o An anti-inflammatory medication may also be prescribed for pain relief.
Ointment and cleaning
o Please apply Bactroban ointment or Vaseline / petroleum jelly 2-3 times a day (or at each nappy change, if in nappies) to the end of the penis, for 2-3 weeks (to prevent meatal stenosis).
o Bathing can begin the day after the operation.
Activity
o Avoid exposure to over boisterous activity for the week after the operation.
o Take one week off school and 2-3 weeks off sport.
o Stay out of swimming pools, spa pools and the sea for 2-3 weeks
Follow-up
o Please ring the rooms to make a follow-up appointment for approximately 2 weeks after the operation.
o Please ring your surgeon if concerned
EPIGASTRIC HERNIA
What is an epigastric hernia?
A protrusion of fat (‘preperitoneal fat’) from just under the abdominal wall through a small hole in the ‘linea alba’. The linea alba is the strong tissue that runs down the middle between the “abs” (rectus abdominus) muscles.
If the hernia is just above the belly button (umbilicus) it is called a ‘supraumbilical hernia’.
What problems does it cause?
Cosmetic (the visible lump).
Pain (sometimes).
Progressive enlargement.
What is the treatment?
The options are:
a) Simple observation.
b) Surgical repair.
Epigastric hernias do not tend to resolve by themselves. On the other hand, they are not dangerous.
How is the surgery performed?
Under a general anaesthetic (asleep) in the operating theatre.
A mark is placed on the site of the hernia before the operation. This is because the ‘lump’ can disappear when the abdomen is relaxed under the anaesthetic.
At operation, a small transverse (cross-ways) incision is made at the marked site and the hernia is repaired.
Dissolving subcuticular (under the skin) sutures are used to close the skin.
What are some of the possible complications?
Infection.
Bruising or bleeding.
Inability to find a hernia.
Recurrence – or development of another hernia nearby.
Hypertrophic or keloid scarring.
What to expect after the operation
Your child will stay in hospital for approximately 2 hours following surgery and go home after this, when fully recovered. There will be a scar at the site where the hernia had been.
The stitches are dissolvable and usually cannot be seen because they run under the skin (‘subcuticular’).
Your surgeon or anaesthetist will usually use local anaesthetic to reduce pain after the operation.
This wears off after a few hours. At home, give paracetamol for pain relief.
POST OPERATION INFORMATION
Pain relief
o Give paracetamol for pain relief. The correct dose is on the bottle. Give every 4 hours (except when asleep) for the day of operation, then as needed after that.
Dressing
o The dressing is water-proof, so bathing can begin the day after the operation. o Leave the dressing on for 1-2 weeks. ·
Activity
o Children regulate their own activity according to how they feel after an operation.
o Allow normal activity, play etc.
o Avoid exposure to over boisterous activity for a few days.
o Stay out of swimming pools, spa pools and the sea for 2 weeks.
Follow-up
o Please ring the rooms to make a follow-up appointment for approximately 2 weeks after the operation. o Please ring if concerned.
HYDROCELE
What is a hydrocele?
A collection of fluid in the scrotum, around the testis. When a light shines into the fluid it glows (called ‘transillumination’).
Why does it form?
A small tube, called the processus, connects the abdominal cavity to a sac called the tunica, which is attached to the testis. The processus normally closes and blocks off soon after birth, but sometimes it stays open. This allows the normal fluid from the abdominal cavity to fill up the sac next to the testis making the hydrocele.
How common are hydroceles?
About 10% of babies have a hydrocele (sometimes on both sides).
However, 9 out of 10 resolve by themselves within the first year or so.
Are they dangerous?
Simple hydroceles are not dangerous, do not cause pain and do not damage the testis.
Occasionally a problem with the testis may either mimic a hydrocele or cause a secondary hydrocele. If there is any concern that there may be something wrong with the testis itself, urgent medical advice should be sought. Pain, redness or inflammation of the scrotum would be reasons to see a doctor urgently.
What is the treatment?
No treatment is recommended under 2 years of age as most will resolve spontaneously by this age. After age 2, surgical correction is recommended.
How is surgery performed?
Under a general anaesthetic (asleep) in the operating room.
The operation is sometimes called ‘herniotomy’ because it is the same procedure as for a hernia.
An incision is made in a skin crease in the part between the lower abdomen and the groin, called the ‘inguinal’ region.
The tubes going to and from the testis (blood vessels and vas) are carefully separated from the processus.
The processus is tied off and divided.
The fluid is drained away.
What are some of the risks?
Infection
Bruising or bleeding
Injury to the testicle vessels or vas
Recurrence
(all uncommon)
POST OPERATION INFORMATION
Pain relief
o Give paracetamol for pain relief. The correct dose is on the bottle. Give every 4 hours (except when asleep) for the day of operation, then as needed after that.
Dressing
o The dressing is water-proof, so bathing can begin the day after the operation.
o Leave the dressing on for 1-2 weeks.
Activity
o Children regulate their own activity according to how they feel after an operation.
o Allow normal activity, play etc.
o Avoid exposure to over boisterous activity for a few days.
o Stay out of swimming pools, spa pools and the sea for 2 weeks.
Follow-up
o Please ring the rooms to make a follow-up appointment for approximately 2 weeks after the operation. o Please ring if concerned.
UNDESCENDED TESTIS / ORCHIDOPEXY
What is an undescended testis?
Testes develop in the abdomen near the kidneys and move down into the scrotum during the last 2 months of pregnancy, or the first 3 months after birth. If for some reason the testis does not reach the scrotum it is referred to as an ‘undescended’ testis.
How common are undescended testes?
About 1 in 100 boys need an operation to correct an undescended testis. In about 1 in 10 of these, both testes are affected.
Where are undescended testes?
Most can be felt in the groin region (also known as the ‘inguinal’ region).
About 1 in 10 undescended testes cannot be felt at all and are either inside the abdomen, in the tunnel that goes from the abdomen to the groin (called the ‘inguinal canal’) or is not present at all.
What problems can occur with an undescended testis?
Testes require an environment a few degrees cooler than the rest of the body in order to develop normally. If undescended, the environment is too warm and subsequently, development is not normal.
Atrophy: If left in the undescended position long enough the testis will fail to grow (called ‘atrophy’)
Infertility: The sperm cells in the affected testis will not develop normally. If surgery is performed early in life to correct the undescended testis fertility should be almost normal. If both testes are affected the chances of fertility are less.
Testicular cancer: There is a moderately increased risk of cancer of the testis occurring in grown men who had an undescended testes as a child. This risk is approximately 1 in 100. The cancers have a good cure rate if detected early and treated appropriately. They tend to occur in men in their 20’s and 30’s.
Boys who have had undescended testes should perform testicular self examination from teenage years on. If a lump or any other abnormality is detected he should see a doctor immediately.
How are undescended testes treated?
Undescended testes at birth can be observed for a few months because many will come down. After 3 months, however, all that will come down have done and surgical management is indicated.
The treatment is surgical – an operation.
How is the operation performed?
Under a general anaesthetic (fully asleep).
If the testis can be felt, an incision is made in the inguinal region. The testis is freed up so that it can reach the scrotum. Another incision is made in the scrotum and the testis is put in a pouch in the scrotum. This operation is called an ‘orchidopexy‘.
If the testis cannot be felt, a laparoscope (like a telescope) is placed in the umbilicus (navel) to look inside the abdomen in case the testis is there. If it is, it may be able to be brought down into the scrotum at that time (‘laparoscopic
orchidopexy’) or it may need a staged procedure (a second operation done a few months later).
If the testis is not in the abdomen an incision is made in the inguinal region and it is looked for there.
Sometimes no testis is found as an event during development caused it to be damaged and it shrinks away. Usually, a small scarred remnant is found in the groin and removed. If this occurs your son will be fine with a single testis, your surgeon will discuss the long term implications of this with you.
What are some of the possible complications?
Infection
Bleeding
Recurrent undescended testis, requiring another operation
Testicular atrophy, where the testis shrinks or does not grow
These are uncommon.
What to expect after the operation
Stitches: The stitches are dissolvable and usually cannot be seen because they run under the skin (‘subcuticular’). Some stitches in the scrotum may be visible but they will dissolve and fall out by themselves.
Pain: Your surgeon or anaesthetist will usually use local anaesthetic to reduce pain after the operation. This wears off after a few hours. At home, give paracetamol for pain relief.
POST OPERATION INFORMATION
Pain relief
o Give paracetamol syrup for pain relief. The correct dose is on the bottle. Give every 4 hours (except when asleep) for the day of operation, then as needed after that.
Dressing
o The dressing is water-proof, so bathing can begin the day after the operation.
o Leave the dressing on for 1-2 weeks. ·
Activity
o Children regulate their own activity according to how they feel after an operation.
o Allow normal activity, play etc.
o Avoid exposure to over boisterous activity for a week.
o Stay out of swimming pools, spa pools and the sea for 2 weeks.
Follow-up
o Please ring the rooms to make a follow-up appointment for approximately 2 weeks after the operation.
o There will be a further follow-up at 6 months to 1 year.
o Please ring if concerned. Long-term
o Testicular self-examination should be performed monthly from teenage years on.
o If a lump or swelling is found, see your doctor without delay.
UMBILICAL HERNIA
What is an umbilical hernia?
An opening or ‘hole’ in the abdominal wall at the umbilicus (navel, or belly button) allows abdominal contents to protrude through, just under the skin. When pressure inside the abdomen increases, eg with crying or straining, the hernia enlarges.
How common is it?
Approximately one in 10 infants develop an umbilical hernia soon after birth. Nine out of 10 of these will resolve by themselves.
What problems can an umbilical hernia cause?
It is very rare for umbilical hernias in infants or young children to cause pain or complications. It is safe to wait a few years for the hernia to resolve spontaneously. Even large hernias that bulge impressively with staining or crying can be safely observed.
In school aged children the protruding belly button can look unsightly and be bothersome to the child.
In older adults and especially in pregnant women, bowel or tissue can become stuck in an umbilical hernia necessitating urgent surgery.
What treatment is recommended?
Before age 3 years, no treatment is necessary –due to the high rate of spontaneous resolution. In the past some people have tried to use straps, buttresses or even a penny to keep the hernia pushed in. Please note, these are not recommended because they can damage the skin over the hernia and do nothing to hasten resolution.
In older pre-school children where the hernia persists the odds are that it will persist rather than resolve. Therefore at some time after 3 years operative repair is recommended.
What to expect after the operation
Stitches: The stitches are dissolvable and generally cannot be seen because they run under the skin.
Pain.: Your surgeon or anaesthetist will usually use local anaesthetic to reduce pain after the operation. This wears off after a few hours. At home, give paracetamol for pain relief (see post-operative instructions).
Dressing : The dressing is waterproof so normal bathing or showering is allowed after the operation. A small amount of blood may appear underneath the dressing. This is common, but if bleeding seeps out from under the dressing or is excessive, call you surgeon.
Appearance of the umbilicus; There will be a curved scar under the umbilicus.
Because the hernia has stretched the skin, it is common for come excess skin to remain after the operation. This skin may protrude a little giving the appearance of a persistent bulge. This generally settles down over the years as the child grows.
What are some of the risks of the operation?
Bleeding
Infection in the wound
Recurrence of the hernia
All these possible complications are very uncommon. Children with rare disorders that cause weak tissues are more prone to recurrence of the hernia.
POST OPERATION INFORMATION
Pain relief
o Give paracetamol according the dosage instructions. Give every 4 hours up to 4 times a day (except when asleep) for the day of operation, then as needed after that.
Dressing
o The dressing is waterproof, so bathing may begin the day after the operation.
Activity
o Avoid exposure to over boisterous activity for the week after the operation.
o School-aged children, take one week off school.
o Stay out of swimming pools, spa pools and the sea for 2 weeks.
Follow-up
o Please ring the rooms to make a follow-up appointment for approximately 2 weeks after the operation.
o Please ring if concerned.
TONGUE TIE
What is a tongue tie?
Tongue tie (‘ankyloglossia’) prevents the tip of the tongue from protruding beyond the lip or from being able to touch the roof of the mouth. This is because a band of tissue under the tongue, called the ‘frenulum’, extends too far towards the tip of the tongue.
What problems can tongue tie cause?
A tongue tie will often cause no problems at all and does not need treatment if this is the case. Breast feeding can be affected because of difficulty latching on. This may lead to interrupted feeding, dribbling and painful nipples. Tongue tie does not affect swallowing because this is performed by the back of the tongue. Speech may be impaired, although this is unusual. Older children may be keen to have their tongue tie divided for cosmetic reasons.
What is the treatment?
Surgical release of tongue tie is a quick and simple operation. In babies this may be done without an anaesthetic in the clinic room on the day of the consultation. This is safe and well tolerated by the baby who will usually be ready to feed straight afterwards. Not all babies’ tongue tied are suitable for this, however. For these babies, and older children, the tongue tie is divided under a brief general anaesthetic.
What to expect after the operation
Recovery is usually very quick. Diiscomfort or pain is usually minimal and can be controlled with paracetamol.
What are some of the possible complications?
Bleeding
Recurrence
Injury to nearby structures
All these are very uncommon.
POST OPERATION INFORMATION
Pain relief
o Give paracetamol syrup for pain relief, if needed. The correct dose is on the bottle.
Diet
o Oral intake can begin soon after the operation.
o Avoid hard foods such as rusks or hard toast for the first day after the operation. ·
Follow-up
o Please ring the rooms to make a follow-up appointment for approximately 2 weeks after the operation.
o Please ring if concerned.
THYROGLOSSAL CYST / SISTRUNK PROCEDURE
What is a thyroglossal cyst?
A ‘congenital’ cyst (meaning born with it) that usually appears in about the middle of the neck under the chin. The cyst is usually not apparent at birth, but is discovered later as is slowly grows.
How do thyroglossal cysts occur?
When a baby develops in the womb, the thyroid gland starts to form near the back of the tongue, then moves down to its normal position in front of the thyroid cartilage, or ‘Adam’s apple’. It may leave behind a tube that runs up to the tongue (the ‘throglossal duct’) which then forms a cyst.
What problems can a thyroglossal cyst cause?
- Infection
- Cosmetically unattractive
What is the treatment?
Surgical removal.
How is this done?
The operation is called a ‘Sistrunk procedure’. The cyst is removed along with the middle of a small bone under the chin called the ‘hyoid’ bone, and the tube (the ‘throglossal duct’) within the tongue muscle is removed as well.
What are some of the possible complications?
Infection in the wound
Bleeding
Obstruction to breathing (This can occur if bleeding under the would causes excess swelling.)
Recurrence
What to expect after the operation
Your child may stay overnight or may go home the same day, at the discretion of your surgeon.
There will be a scar at the site where the cyst had been.
The stitches are dissolvable and usually cannot be seen because they run under the skin (‘subcuticular’).
Your surgeon or anaesthetist will usually use local anaesthetic to reduce pain after the operation. This wears off after a few hours. At home, give paracetamol for pain relief.
POST OPERATION INFORMATION
Swelling or Breathing Problems
o If you have any concerns about swelling under the would ring your surgeon immediately (phone number below)
o If there are any breathing problems or noisy breathing ring your surgeon immediately or go straight to Starship Hospital
·Pain relief
o Give paracetamol syrup for pain relief. The correct dose is on the bottle. Give every 4 hours (except when asleep) for the day of operation, then as needed after that.
Dressing
o The dressing is water-proof, so bathing can begin the day after the operation.
o Leave the dressing on for 1-2 weeks.
Activity
o Children regulate their own activity according to how they feel after an operation.
o Allow normal activity, play etc. o Avoid exposure to over boisterous activity for a week.
SKIN / SUBCUTANEOUS LESION
Why surgical removal?
Surgical removal of an abnormal growth or lesion in or under the skin is sometimes the safest course of action, a) to find out what it is, and/or b) to simply get rid of it.
How is the operation done?
Under a general anaesthetic (asleep) in the operating room.
An incision (cut) is made in the most appropriate orientation and the growth is removed and send to the laboratory for analysis.
At the lab the histopathologist processes the lesion, looks at it under the microscope and sometimes performs special tests to come to a diagnosis. It can take a week or more for the final results to be available.
What are some of the possible complications?
Infection in the wound
Bleeding
Recurrence
What to expect after the operation
Your child will usually stay in hospital for approximately 2 hours following surgery.
There will be a scar at the site.
The stitches are generally dissolvable and often cannot even be seen because they run under the skin (‘subcuticular’).
Your surgeon or anaesthetist will usually use local anaesthetic to reduce pain after the operation. This wears off after a few hours. At home, give paracetamol for pain relief.
POST OPERATION INFORMATION
Pain relief
o Give paracetamol syrup for pain relief. The correct dose is on the bottle. Give every 4 hours (except when asleep) for the day of operation, then as needed after that.
Dressing
o A waterproof dressing will often be used – this can be removed after 1 week.
o Stay out of swimming pools, spa pools and the sea for 2 weeks.
Bathing
o A bath or shower can be taken the day after the operation.
o If the dressing is waterproof it is fine to wet it, but carefully dab it dry afterwards.
Follow-up
o Please ring the rooms to make a follow-up appointment for approximately 2 weeks after the operation.
o Please ring if concerned.
PERIORBITAL / EXTERNAL ANGULAR DERMOID CYST
What is a dermoid cyst?
A congenital (meaning born with it) cyst lined on the inside with skin cells.
The cyst is usually not apparent at birth but is discovered later as is slowly grows.
Why does the cyst occur near the eye?
While dermoid cysts may occur in a variety of locations, near the outer end of the eyebrow is a common site. When an embryo (unborn baby) is developing there are 2 tissue folds which join in this region. A few skin cells may become trapped beneath skin level at this join and grow into a cyst.
What problems can a dermoid cyst cause?
The main problem is cosmetic as the lump continues to grow.
What is the treatment?
Surgical removal is necessary.
How is this done?
Under a general anaesthetic (asleep) in the operating room.
The location for the surgical incision depends on the exact location of the cyst but is usually just above or below the eyebrow.
What are some of the possible complications?
Infection in the wound
Bleeding and bruising around the eye
Recurrence (the lump grows back after surgery). This is uncommon.
What to expect after the operation
Your child will stay in the hospital for approximately 2 hours following surgery.
There will be a scar at the site where the cyst had been.
The stitches are dissolvable and usually cannot be seen because they are placed deep to the skin.
Some bruising or mild swelling in the area of the surgical incision is to be expected for a couple of days after the operation.
Your surgeon or anaesthetist will usually use a local anaesthetic to reduce pain after the operation. This wears off after a few hours. At home, give paracetamol for pain relief.
LABIAL FUSION
What is a labial fusion?
The inner surfaces of the labia (minora) adhere or stick together.
What is the cause?
If the skin covering the labia becomes inflamed, the raw surfaces of the labia may then stick to each other. Sometimes prior to birth, the labia fail to separate normally, although they have appeared to develop normally otherwise.
What problems can labial fusion cause?
An inflammation called vulvitis can occur. Urine can pool behind the adhesion. Dribbling into the panties can be a problem.
Often labial adhesions do not cause any problems.
How can a labial fusion be treated?
One option is to simply gently part the labia and applying petroleum jelly with a gently downward motion of the finger once or twice daily. This may gradually break down the adhesion and may cure the condition. The petroleum jelly helps stop the surfaces from sticking back together again.
If the fusion is long-standing it can be quite thick. The adhesion can then be very easily divided under a quick general anaesthetic. Separation of a labial fusion is a rapid solution to the problem. Daily application of Vaseline, or petroleum jelly, is required after the operation to prevent the fusion from recurring.
Oestrogen hormone cream can be effective in the treatment of labial fusion. Side effects from the hormone can occur with excessive or prolonged use of oestrogen cream.
What alternatives are there?
A labial fusion that is causing no concern or discomfort may be safely left untreated. The condition is self-limiting. At around puberty, with change in hormonal status and character of the skin, the labial adhesion will usually part.
What are some of the possible complications?
It is quite common for a labial fusion to recur after treatment. This is more likely to happen if your daughter is still wearing nappies due to the chance of ongoing irritation.
To help prevent this petroleum jelly should be applied (as described above) for several months after the operation.
POST OPERATION INFORMATION
Apply petroleum jelly once or twice daily for several months to help prevent recurrence.
It may sting on passing urine after the operation. The petroleum jelly coating will help prevent this.
Give paracetamol for pain relief. ·
Follow-up
o Please ring the rooms to make a follow-up appointment for approximately 2 weeks after the operation.
o Please ring if concerned.
INGROWN TOENAIL / WEDGE RESECTION
What is an ingrown toenail?
The toenail digs into the skin beside the nail as it grows, causing inflammation and infection, swelling and pain. The problem usually only affects the big toe but can involve one or both sides of a single or both big toes.
What is the cause of ingrown toenails?
The corner of the toenail does not project beyond the soft tissues. The corner then digs into the skin beside the toe. The corner is too far back either because it breaks off or is cut or trimmed back too far.
How can ingrown toenails be treated without an operation?
The two strategies are to encourage the toenail edge to grow out beyond the soft tissues, and to prevent and treat infection.
Toenail edge:
When trimming the toenail, cut it straight across.
Using a cotton wool bud, gently ease the nail edge up and out of the soft tissue after every bath or shower.
Preventing infection: Keep feet cool and dry as much as possible.
Wear sandals or bare feet as much as is feasible. If wearing shoes, leather shoes ‘breath’ better than sandshoes.
Change socks regularly.
Wash feet 2-3 times a day.
Warm sitz baths can help – place a tablespoon of table salt in a washbasin of clean warm water and bathe the feet.
Treating infection:
See your doctor for advice.. Antibiotics are often prescribed.
Why perform surgery for ingrown toenails?
Surgery may be appropriate if significant problems persist despite these non-operative measures.
How is the operation performed?
A general anaesthetic (going to sleep) is usually used for children. Local anaesthetic is also used to help relieve pain after the operation. In adults and some teenagers a local anaesthetic alone can be used.
The usual operation is a ‘wedge resection’. The ingrown side of the toenail is removed along with inflamed tissue from the adjacent skin. In addition, the base where the nail grows from, called the germinal matrix, may be removed on the affected side. This prevents that side of the nail from regrowing. If the matrix is not removed, the whole nail will eventually grow back in. This leaves the nail looking normal, whereas removing the matrix will leave the nail narrower than before. The chance of the nail ingrowing again is higher if the matrix is not removed. The decision as to whether the matrix should be removed during the operation will be made in advance as these the options will be discussed by your surgeon.
At the end of the operation, a dressing will be put on the toe and a light crepe bandage applied to the foot.
What are the risks of the operation?
Infection: Preventative antibiotics may be given before, during or after the operation to prevent this.
Bleeding: A little oozing of blood after the operation is quite common and is not a concern.
Recurrence: the toenail reg rows and digs in again.
What are the benefits of surgery?
Recurrent pain and infection may be cured. Some activities eg sport, which may have been difficult before the operation can be resumed once healing is complete.
What to expect after the operation?
After the local anaesthetic wears off the toe may be quite painful (see post-operative instructions. Taking regular pain relief for the first few days is important.
The operation site will look somewhat ‘raw’ after the dressing is taken off.
A ‘crust’ may form over the exposed nail bed where the side of the toenail has been removed.
A week of rest will be required, and 2-3 weeks off sport.
POST OPERATION INFORMATION
Pain relief
o Give paracetamol for pain relief in the recommended dose. Give every 4 hours (except when asleep) for the day of operation, then as needed after that.
o Give an anti-inflammatory, eg ibuprofen, as prescribed, when needed for extra pain relief.
Dressing
o The bandage should stay on for approximately 2-3 days.
o A community nurse, your family doctor or your surgeon can remove the dressing.
o After removal, keep the wound clean.
o Bathe the foot three times a day in a warm sitz bath.
o Apply antibiotic ointment after each bath, as prescribed.
Activity
o Rest the foot for approximately 1 week.
o Try to keep the foot elevated.
o Take 2-3 weeks off sport.
o Stay out of swimming pools, spa pools and the sea for 2 weeks.
Follow-up
o Please ring the rooms to make a follow-up appointment approximately 2 weeks after the operation.
o Please ring if concerned.
HYPOSPADIAS
What is Hypospadias?
Hypo = below
Spadon = a fissure or a ‘hole’
Hypospadias is where the opening for passing urine, called the ‘urethral meatus’, is below the head of the penis (called the ‘glans). This ‘hypospadiac’ opening can be anywhere from the glans to the base of the penis or even in the scrotum.
Hypospadias may be associated with other features:
Bent penis: This is called ‘chordee’ – some boys with hypospadias have this.
Hooded foreskin: The foreskin is only partially formed around the front of the penis.
Rotated penis: Sometimes the penis is also abnormally twisted.
Classification:
Hypospadias is classified into ‘distal’ where the meatus is near the tip of the penis, ‘proximal’ where the meatus is near the base of the penis or scrotum, and ‘middle’ in between.
How common is hypospadias?
1:300 boys are born with hypospadias.
What is the cause?
Most cases occur sporadically, for no known reason. Recent evidence genetic and hormonal factors are involved in at least some cases.
What is the treatment?
Surgical correction is usually advised for the following reasons:
Allow a straight urinary stream whilst standing.
Allow a straight erection.
Cosmetic reasons.
When should the operation be done?
Surgery can be performed anytime. It is ideal, if possible, to perform hypospadias surgery between 6 and 18 months of age.
How is the operation performed?
Under a general anaesthetic (fully asleep) in the operating room.
The 3 aims of the operation are to:
Reposition the meatus (hole) onto the head of the penis.
Check that the penis is straight and if not, straighten it.
Correct the hooded foreskin, by repair or circumcision.
More than one operation may be required to achieve these goals.
The foreskin is used for the repair. It is therefore very important that your child does not undergo circumcision prior to hypospadias repair.
What to expect after the operation
Swelling and bruising: This is very common. Often the swelling and bruising is very marked. If you are concerned, please call your surgeon.
Pain: Your surgeon or anaesthetist will generally use local anaesthetic to reduce pain after the operation. This wears off after a few hours. Further medicines will be prescribed for you to use at home.
Appearance: The penis will appear circumcised unless a foreskin preserving procedure has been performed. Swelling and irregular areas of skin may be present.
Stitches: The stitches are dissolvable.
Catheter/Stent: There will likely be a small catheter or tube to help the urine drain in the post-operative period. Your surgeon will discuss this and how to care for it before and after your son's procedure.
What are some of the possible complications?
Infection.
Bleeding / bruising.
Fistula (an abnormal side hole or ‘leak’).
Breakdown of the repair.
Meatal stenosis (where the new opening is too narrow).
Meatal retraction (where the new opening retracts back down the penis somewhat).
Stricture (narrowing) of the new urethra.
Recurrent chordee or bend.
Abnormal appearance.
Not all of these are apparent immediately after the operation. Your surgeon will be assessing your son after the operation to look out for these problems.
Overall, the complication rate is higher the more proximal, or the further down the penis the meatus is. Fistulas occur in approximately 5-10% of distal, 20% of middle and 30% of proximal hypospadias.
POST OPERATION INFORMATION
Pain relief
Paracetamol; give at regular intervals (as per the instructions on the bottle) for the first 2-3 days. After that give is if your son appears sore.
Give any other pain relief medication as needed, as per instructions.
Other medication may include:
Antibiotic syrup: One dose every evening while the stent (tube) is in the penis.
Antibiotic ointment: Apply to penis every nappy change.
Vaseline / petroleum jelly:
Apply liberally to nappy after every nappy change.
Stent / catheter
If there is a stent or catheter, please take great care of this and do not allow your child to pull it.
Double nappy technique:
One nappy is put in place after applying the ointment to the penis and plenty of petroleum jelly or Vaseline to the nappy.
The end of the catheter passes out of the first nappy, with above the waist, around the leg or through a hole in the nappy.
A second nappy is put on – the catheter drips into this nappy so that the penis itself remains dry.
If the stent falls out prior to planned removal this will probably be fine but call your surgeon to check.
Dressing
If there is a dressing over the penis your surgeon will explain how to care for it and when to remove it.
Bathing
A quick, warm, clean bath is advised 2-3 times a day for the first week or so.
A tablespoon of salt may be placed in the water (‘sitz baths’).
Change the nappy quickly if it becomes dirty and bathe if necessary.
Activity
Children regulate their own activity according to how they feel after an operation.
Allow normal activity, play etc.
Avoid exposure to over boisterous activity for a few days. Don’t allow your son to use any ride-on toys until after your follow up appointment
Stay out of swimming pools, spa pools and the sea for 2 weeks.
Follow-up
If a catheter is in place your surgeon will organise an appointment to remove it in 2-7 days
Ongoing follow-up will be at approximately 2 weeks, 6 months then yearly.
Please ring if concerned.
FORESKIN FACTS
Basic Facts
At birth in the majority of boys the foreskin is not retractable.
This is usually due to two factors. Adhesion of the inner layer of the foreskin to the glans (head) of the penis; and the tightness of the foreskin around the widest part of the glans.
The foreskin can be fully retracted in most boys by 4 or 5 years of age, but in 10% of normal boys there may still be some preputial adhesions after that age. Sometimes it is reasonable to treat adhesions that persist into later childhood.
The foreskin does not need to be retracted and cleaned in small boys. Just leave the foreskin alone.
Forcible retraction of the foreskin is to be discouraged. A small split in the foreskin can result. This may cause bleeding and pain and possibly heal with a scar.
If the foreskin is retracted back, it is important that it is subsequently returned to its normal position over the head of the penis. If the foreskin is left back it can progressively swell and become ‘stuck’ back. This condition is called ‘paraphimosis’. It is reasonable to perform foreskin hygiene after the child can easily retract his own foreskin.
Common foreskin conditions not requiring surgery
Foreskin adhesions (see above).
Smegma. This is sometimes visible under the foreskin of small boys. It appears as a semisoft lump, yellowish in colour.
Phimosis –tight foreskin- that is not causing any problems. It can be normal for the foreskin to bulge a little as a boy passes urine if the very tip of the foreskin is tight.
Indications to do a circumcision
When there is tight narrowing at the end of the foreskin or phimosis) that is causing some sort of problem and has not responded to treatment with a steroid cream or ointment or is very scarred.
Recurrent foreskin infections (balanitis).
In some circumstances, circumcision is recommended if a boy has repeated episodes of urinary tract infection.
When there is phimosis present and there is concern it may be causing a problem for the child then a topical steroid may be prescribed to help relieve a narrowing at the end of the foreskin. This steroid is to loosen the skin and speed up there otherwise normal progress of the foreskin becoming retractile.
Apply the ointment or cream twice a day for one month, or as directed by your doctor.
Gently stretch the foreskin over the head of the penis
Apply a small amount of the ointment to the narrow part at the end of the foreskin.
After one month, stop using the steroid.
If there has not been a complete response, wait 4 weeks then apply the steroid for another month. If there is not a complete response from the topical steroid then a surgical solution is indicated, either circumcision or a preputoplasty to increase the size of the foreskin opening.
Disclaimer
This information sheet is a guide only. For specific advice regarding your child, please see your doctor.
INGUINAL HERNIA
What is an Inguinal hernia?
A hernia is an abnormal protrusion through an internal ‘hole’ or defect in the body. A hernia usually appears as a ‘lump’ or ‘bulge’.
The term ‘inguinal’ refers to the inguinal region in the groin where the hernia occurs.
Sometimes the hernia is confined to the inguinal region; sometimes it extends into the scrotum (the so-called “inguino-scrotal hernia”).
90% of inguinal hernias occur in boys (and interestingly are more common on the right than the left).
The abnormal defect consists of a ‘sac’ that extends from the abdominal cavity (where the bowel, or ‘guts’, are) into the inguinal region and sometimes right down into the scrotum. Imagine a sausage-shaped party balloon that has not yet been blown up. This is what a hernia sac is like. When ‘guts’ enter the sac it is like blowing up the balloon and this forms a bulge.
Is an Inguinal Hernia Dangerous?
Yes. Gut in the hernia can become stuck out (‘irreducible’) and can obstruct or strangulate.
Obstruction means the bowel in the hernia is blocked causing abdominal (or ‘tummy’) distension and vomiting.
Strangulation means the bowel is squeezed so tightly that its blood supply is cut off and it dies and becomes gangrenous.
Obstruction and strangulation occur if the hernia is stuck out for a long time. If this happens, it can also squeeze the blood vessels going to the testicle and cause testicular damage.
These problems are much more common in young babies than in older children.
How do you treat an Inguinal Hernia?
The only effective treatment is surgery. The hernia will not resolve by itself.
Surgery is recommended for all children with an inguinal hernia.
The operation is more urgent in young babies than in older children.
How is the surgery performed?
Usually the operation can be done as a day case except in very young or premature babies who will have to stay in hospital for a night. In day case surgery, you can take your child home a few hours after the operation finishes.
Your child will be under a general anaesthetic (fully asleep).
Local anaesthetic is also used to reduce the amount of pain felt after the operation.
An incision (cut) about 3 to 5 cm long is made in the inguinal skin crease.
The hernia sac is carefully separated from the tubes going down to the testis (the blood vessels and the ‘vas’). The sac is then tied off and cut. This cures the hernia. The wound is sewn up with dissolving stitches that run under the skin. In girls, the operation is easier because the delicate tube, the fallopian tube, is safely in the abdomen. (Unlike in adults no reinforcement or mesh is required)
What are the risks of the operation?
All operations carry risks.
The operation is still worth doing because the risk of complications from the hernia (see above) is much greater than the risk of the operation. To minimise the risk a paediatric surgeon and an anaesthetist who specialises in children’s surgery will perform the operation
The risk of the anaesthetic is extremely small in healthy babies and children, and the anaesthetist will discuss this with you.
The main surgical risks are:
Infection in the wound
Bruising or bleeding (common to have a small amount but very rare to have a lot of bleeding)
Recurrent hernia
Testicular atrophy, where the testicle shrinks because the blood vessels have been damaged (rare, ~1% of elective operations, but more common if the hernia had been stuck out for a long time)
Injury to the vas
Undescended testis, where the testis is caught up in scar tissue above the scrotum.
These complications are rare
The proviso to this is after strangulation of the hernia, where testicular atrophy is more common because of pressure on the blood vessels from the strangulating hernia.
What are the benefits of the operation?
The hernia is cured. The scar usually heals up very nicely after this operation.
What happens after the operation?
Your child will wake up in the post-anaesthetic care unit. Specialist nurses will care for your child and provide any extra pain relief that is needed.
You will be in the hospital for approximately 2 hours after the operation.
POST OPERATION INFORMATION
Pain relief
o Give paracetamol syrup for pain relief. The correct dose is on the bottle. Give every 4 hours (except when asleep) for the day of operation, then as needed after that.
Dressing
o The dressing is water-proof, so bathing can begin the day after the operation.
o Leave the dressing on for 1-2 weeks.
Activity
o Children regulate their own activity according to how they feel after an operation.
o Allow normal activity, play etc.
o Avoid exposure to over boisterous activity for a few days.
o Stay out of swimming pools, spa pools and the sea for 2 weeks.
Follow-up
o Please ring the rooms to make a follow-up appointment for approximately 2 weeks after the operation.
o Please ring if concerned.
APPENDICECTOMY POST OPERATION INFORMATION
Pain relief
Give paracetamol regularly for the first day or so, then as needed after that.
Give ibuprofen, or other second line pain relief as prescribed when needed
Dressing
The dressing is water-proof, so bathing can begin the day after the operation.
Leave the dressing on for 1-2 weeks.
Activity
Children regulate their own activity according to how they feel after an operation.
Stay off school for 1 week
Sporting activities can usually be recommenced after 2 weeks
Stay out of swimming pools, spa pools and the sea for 2 weeks.
Follow-up
Please ring the rooms to make a follow-up appointment for approximately 2 weeks after the operation.
Please ring if concerned.
DERMOID CYST - POST OPERATION INFORMATION
Pain relief
Give paracetamol syrup for pain relief. The correct dose is on the bottle.
Dressing
The wound will usually be covered with a ‘steristrip’ plaster – leave this on for 1 week.
Try to keep the dressing dry.
Follow-up
Please ring the rooms to make a follow-up appointment for approximately 2 weeks after the operation.
Please ring if concerned.