Contemporary management of abdominal surgical emergencies in infants and children. BJS 2014; 101: 24-33.

Published: 29th November 2013

Authors: L. W. E. van Heurn, M. P. Pakarinen, T. Wester


Acute abdominal complaints in children are common presentations in the emergency department. The aetiology, presentation, diagnosis and management often differ from those in adults.


This review was based on expert paediatric surgical experience confirmed by evidence from the literature obtained by searching PubMed and the Cochrane Library. Keywords used were the combinations of ‘abdominal emergencies’, ‘acute abdomen’ and the disorders ‘acute appendicitis’, ‘intussusception’, ‘volvulus’, ‘Meckel's diverticulum’, ‘incarcerated inguinal hernia’, ‘testicular torsion’ and ‘ovarian torsion’ with ‘children’. Information was included from reviews, randomized clinical trials, meta‐analyses, and prospective and retrospective cohort studies.


Presentation and symptoms of abdominal emergencies, especially in young children, vary widely, which renders recognition of the underlying disorder and treatment challenging. Critically targeted imaging techniques are becoming increasingly important in obtaining the correct diagnosis without unnecessary delay. Minimally invasive techniques have become the method of choice for the diagnosis and treatment of many abdominal emergencies in children.


Knowledge of abdominal disorders in childhood, their specific presentation, diagnosis and treatment facilitates management of children with acute abdomen in emergency departments. Imaging and minimally invasive techniques are becoming increasingly important in the diagnosis of acute abdomen in children. Urgent operation remains the cornerstone of therapy for most acute abdominal disorders.

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Kirsty McFarlane

3 years ago

Dear Sir,

I read with interest the above article. The authors stipulate in the section on inguinal hernia that an ‘irreducible ovary is not an indication for emergency surgery’ and quote in support of their assertion a paper by Boley and co-workers (1).

In fact, Boley et al. wanted to prove with their article that an irreducible ovary is at risk of torsion and therefore is an indication for emergency surgery, as the title, the work and the discussion of their paper suggests (1).

In the next section of their review, van Heurn and co-workers have correctly demanded early surgical exploration for a suspected testicular torsion.

Clearly, such inconsistencies are difficult to comprehend and defend.

Chris Houben
Chinese University of Hong Kong
Department of Surgery
Prince of Wales Hospital
Shatin, N. T.
Hong Kong

1. Boley SJ, Cahn D, Lauer T, Weinberg G, Kleinhaus S. The irreducible ovary: a true emergency. J Ped Surg 1991; 26: 1035-1038.

Kirsty McFarlane

3 years ago


We agree that an incarcerated ovary in an inguinal hernia requires emergency surgery. However, a clear distinction has to be made between an incarcerated ovary in an inguinal hernia and an asymptomatic hernia with an irreducible ovary, as mentioned in our article. An incarcerated ovary is strangulated with imminent risk for necrosis and loss of the organ. Girls with an incarcerated ovary typically present with a painful swelling, which is usually not mobile and attached to the external inguinal ring. These patients need emergency surgery. Girls with an asymptomatic hernia with an irreducible ovary present with a mobile swelling in the groin, which is difficult to reduce but not painful. This ovary has, as stated by Boley and co-workers (1), a higher risk of torsion due to a narrow mesentery. According to a survey among American paediatric surgeons, less than 50% of the surgeons would operate on a girl with an irreducible ovary in an asymptomatic hernia as an emergency. The others plan for early but elective surgery (2).

The comparison of an irreducible, asymptomatic ovary with testicular torsion is inappropriate. In testicular torsion the testis is always at risk of immediate ischaemic necrosis, while an asymptomatic ovary in a hernia sac is not.

LW Ernest van Heurn
Mikko Pakarinen
Tomas Wester

Maastricht University Medical Centre
6202 AZ Maastricht
The Netherlands

1. Boley SJ, Cahn D, Lauer T, Weinberg G, Kleinhaus S. The irreducible ovary: a true emergency. Journal of pediatric surgery 1991; 26: 1035-1038.
2. Wiener ES, Touloukian RJ, Rodgers BM, Grosfeld JL, Smith EI, Ziegler MM, Coran AG. Hernia survey of the Section on Surgery of the American Academy of Pediatrics. J Pediatr Surg 1996; 31: 1166-1169.