Çocuk Kasık Fıtıklarında Cerrahi Tedavi
Özet
Çocuk kasık fıtıklarında cerrahi tedavi, fıtık kesesinin iç halka hizasından bağlanması esasına dayanan "yüksek ligasyon" yöntemiyle gerçekleştirilir. Tedavi zamanlaması hastanın yaşına ve ek hastalıklarına göre belirlenirken; özellikle prematüre bebeklerde yüksek inkarserasyon ve strangülasyon riski nedeniyle tanıdan kısa süre sonra operasyon önerilir. Cerrahi onarım açık veya laparoskopik yaklaşımla yapılabilir. Açık onarımda, 1 yaş altındaki çocuklarda inguinal kanal açılmadan Mitchell-Banks yöntemi uygulanabilirken, daha büyük çocuklarda veya sıkışmış fıtıklarda kanalın açılması gerekir. Kız çocuklarında sliding herni varlığında over ve fallop tüplerinin korunmasına, erkeklerde ise spermatik kord ve damarların yaralanmamasına dikkat edilmelidir. Laparoskopik onarım ise daha kısa ameliyat süresi, bilateral onarım imkanı ve düşük komplikasyon oranları gibi avantajlar sunar. Tek taraflı fıtıklarda karşı tarafın rutin eksplorasyonu tartışmalı olup, genellikle 6 aydan küçük bebeklerde aile onayıyla değerlendirilir. Direkt inguinal ve femoral herniler çocuklarda nadir görülür ve McVay onarımı ile tedavi edilir. Kistik fibrozis, hidrosefali veya periton diyalizi gibi özel durumlarda nüks ve komplikasyon riski artar. Operasyon sonrası nüks oranı elektif şartlarda oldukça düşüktür. Komplikasyon olarak iyatrojenik inmemiş testis, yara yeri enfeksiyonu ve kronik ağrı gözlenebilirken, prematüre bebeklerde postoperatif apne riski nedeniyle bir gece hastanede yatış önerilir.
Surgical treatment in pediatric inguinal hernias is performed by the "high ligation" method, which is based on ligating the hernia sac at the level of the internal ring. Treatment timing is determined according to the patient's age and comorbidities; operation is recommended shortly after diagnosis due to the high risk of incarceration and strangulation, especially in premature infants. Surgical repair can be performed via open or laparoscopic approaches. In open repair, the Mitchell-Banks technique can be applied without opening the inguinal canal in children under one year of age, whereas the canal must be opened in older children or incarcerated hernias. Attention must be paid to protecting the ovaries and fallopian tubes in the presence of sliding hernias in girls, and avoiding injury to the spermatic cord and vessels in boys. Laparoscopic repair offers advantages such as shorter operative time, the possibility of bilateral repair, and lower complication rates. Routine contralateral exploration in unilateral hernias remains controversial and is generally evaluated with family consent in infants younger than 6 months. Direct inguinal and femoral hernias are rare in children and are treated with McVay repair. The risk of recurrence and complications increases in special conditions such as cystic fibrosis, hydrocephalus, or peritoneal dialysis. The recurrence rate after operation is quite low under elective conditions. While iatrogenic undescended testis, wound infection, and chronic pain can be observed as complications, overnight hospitalization is recommended for premature infants due to the risk of postoperative apnea.
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