Paediatric Surgery and Surgical Conditions in Children

Paediatric surgery is a specialty that encompasses all surgically relevant conditions of childhood — from congenital anomalies diagnosed before birth through to the end of adolescence. Three characteristics distinguish it from adult surgery:

• Anatomy is developmental: The inguinal hernia sac in a six-month-old infant differs entirely in size and anatomical relationships from that of a 12-year-old child. The same named condition requires a different technique at different ages.
• Physiology is age-dependent: Fluid and electrolyte balance, blood volume and thermoregulation in a newborn are fundamentally different from those in an adult. The anaesthesia team recalculates drug doses according to the child's age and weight.
• The family is part of the process: The child does not arrive alone. A consultation involves the mother, father and sometimes siblings. The child cannot give informed consent; the family must be sufficiently informed to make the decision — and that is part of the process.

Paediatric surgical practice is consultation-oriented. The answer to "watchful waiting or surgery, and when?" usually becomes clear over one or several appointments. For this reason, outside emergency indications, no surgical decision in a child is made in haste — this is a fundamental discipline.

The most frequently encountered conditions requiring surgical treatment in our paediatric surgery outpatient department include:

• Inguinal hernia: One of the most common surgical indications in infants and school-age children. Once diagnosed, an operation is planned; prolonged waiting is avoided given the risk of strangulation.
• Umbilical hernia: In the majority of newborns, this closes spontaneously by the age of 3–4 years. Surgery is planned for defects that remain larger than 1 cm after the age of 4–5.
• Hydrocoele: Fluid accumulation in the scrotum. It may resolve spontaneously within the first 1–2 years; persistent or communicating cases are candidates for surgery.
• Undescended testis (cryptorchidism): Failure of the testis to descend into the scrotum. Surgery is ideally planned between 6 and 18 months of age; in cases presenting later, fertility and malignancy risk are taken into account.
• Medically indicated circumcision: Performed where there is phimosis, paraphimosis, recurrent balanoposthitis, or urinary tract infection as an indication. Examination and parental counselling before the procedure are standard.
• Acute appendicitis: The most common paediatric surgical emergency. Diagnosis is made on clinical findings, laboratory results and ultrasound; abdominal examination is more challenging in children than in adults, so observation and serial assessment are integral to the diagnostic algorithm.
• Pilonidal sinus: A condition frequently seen in adolescent boys; the surgical approach is selected according to each patient's anatomical findings.

The decision for every procedure is reached by jointly evaluating clinical findings, age, accompanying systemic conditions and family preference.

Congenital anomalies diagnosed in the neonatal period form a distinct sub-specialty. As at reference paediatric surgery centres across Europe, these cases require prenatal diagnosis and multidisciplinary planning.

Neonatal conditions commonly assessed in the department:

• Omphalocele and gastroschisis (abdominal wall defects): Surgical emergencies requiring support immediately after birth.
• Intestinal atresia and obstruction: Conditions to be excluded in newborns presenting with bilious vomiting and abdominal distension.
• Pyloric stenosis: Presents with projectile vomiting in infants aged 3–8 weeks; diagnosed by ultrasound and treated with pyloromyotomy.
• Congenital hydronephrosis and hydroureter follow-up: For cases diagnosed prenatally, postnatal ultrasound surveillance is conducted and the surgical decision is shared with urology.
• Hypospadias (genitourinary anomaly): Detailed in a separate section below.

Onward referral principle: Not every case in paediatric surgery is resolved at a single centre. Preterm and complex neonatal cases are referred to tertiary centres with neonatal intensive care infrastructure. Op. Dr. Gönül Küçük's observer period at the Universitäts-Kinderspital Beider Basel (UKBB) in Basel provided first-hand experience of the institutional discipline behind such referral protocols; this approach is reflected in the consultative practice at Nis Clinic. Being transparent with families — making it clear that a case will genuinely be resolved at the most appropriate centre — is a fundamental part of clinical ethics.

Urogenital and anorectal complaints are among the frequent reasons for referral in childhood. Conditions assessed in this area include:

• Hypospadias: A congenital anomaly in which the urethral opening is located on the underside of the penis. Corrective surgery is ideally planned between 6 and 18 months of age; the choice of technique depends on the degree of the defect. Complex proximal hypospadias cases are managed with staged planning and, where necessary, tertiary referral is discussed.
• Phimosis and paraphimosis: Narrowing of the foreskin opening; the initial approach involves medical treatment with topical steroid cream, and circumcision is planned in resistant cases. Paraphimosis is an emergency requiring immediate intervention.
• Anal fissure: Presents with hard stools and painful defaecation. First-line treatment is dietary modification and topical ointment; surgery is rarely required in chronic cases.
• Perianal abscess and fistula: Typically seen in male infants during the neonatal period; drainage and long-term follow-up are required. Where the presentation suggests Crohn's-like inflammatory bowel disease, a gastroenterology consultation is requested.
• Labial adhesion (vaginal synechia): Common in infant girls; the majority resolve medically with topical oestrogen cream. Surgery is reserved for resistant cases only.

In a significant proportion of these conditions, surgery is the last resort. The working principle of the department is: watchful waiting and medical treatment first, then surgery if required. This sequence respects the child's developmental timeline and avoids unnecessary intervention.

Solid childhood tumours — Wilms tumour, neuroblastoma, hepatoblastoma and soft tissue sarcomas — require protocols carried out jointly by paediatric oncology, paediatric surgery and radiation oncology teams. The role of the paediatric surgery department in these cases covers two areas:

• Diagnostic biopsy and surgical assessment: Tissue sampling and staging contribution in cases with suspected masses.
• Multi-centre shared care: For cases requiring prolonged chemotherapy, surgical resection and radiotherapy, the treatment plan is coordinated with paediatric oncology centres in the TRNC and in Türkiye. Cases requiring preoperative neoadjuvant treatment are planned at a tertiary centre; surgical input can be provided at the appropriate stage.

Conservative approach: In paediatric oncology cases, "major operation" is not always the right surgical choice. Modern protocols place emphasis on function-preserving surgery. Throughout the process, priority is given to helping families understand their treatment options, the likelihood of a favourable outcome, and the long-term side-effect profile, so that they can make an informed decision.

Cases presenting with a suspicious mass are seen without waiting for a routine appointment; the diagnostic pathway is expedited and referral to the appropriate centre is made without delay.

The most important characteristic that sets paediatric surgery apart from other surgical specialties is this: the child does not arrive alone. A family attends the clinic — the mother, the father, sometimes a grandparent, sometimes a sibling. Each may have questions and concerns at different levels.

How the consultation process works:

1. Initial examination and history: Listening to the family's account, physical examination, and — where necessary — planning imaging.
2. Explaining the diagnosis and options: What the condition is, its natural course, and the treatment options (watchful waiting versus surgery) are explained in plain language. If medical terminology is used, a straightforward everyday equivalent is given immediately afterwards.
3. Time for family questions: The consultation is not rushed, so that the family can ask all their questions freely. Practical questions such as "is anaesthesia safe?", "how much pain will they be in after the operation?" and "when can they go back to school?" are a natural part of the process.
4. Communicating with the child: Where age-appropriate, the child is also told, in simple terms, "this is what will happen, this is what you will feel." Talking openly is the most effective way to reduce a child's preoperative anxiety.
5. Decision-making: Outside emergency indications, a decision is not reached in a single appointment. Families may take time to think, seek a second opinion or research independently. This is an expected and supported approach.
6. Final briefing before surgery: Once the decision to operate is made, the steps of the procedure, the anaesthetic process, the expected hospital stay, and aftercare are shared in writing as well.

Parental presence before and after the operation is standard practice. Having a parent beside the child right up to the operating theatre significantly reduces anxiety during anaesthesia induction. The family is again immediately present during the recovery phase.

Taking the family's concerns seriously rather than dismissing them is the fundamental approach of the department. "It's a straightforward operation" may be accurate from the surgeon's perspective, but for the family watching their child undergo surgery for the first time, it is never straightforward. Preserving that distinction makes the process safer for everyone.