Most children with tumors will require one or more surgical interventions as part of the care and treatment, including making a diagnosis, obtaining adequate venous access, performing a surgical resection for solid tumors (with staging and reconstruction), performing procedures for cancer prevention and its late effects, and managing complications of treatment; all with the goal of improving survival and quality of life. It is important for surgeons to adhere to sound pediatric surgical oncology principles, as they are closely associated with improved local control and survival. Unfortunately, there is a significant disparity in survival rates in low and middle income countries, when compared to those from high income countries.The International Society of Paediatric Surgical Oncology (IPSO) is the leading organization that deals with pediatric surgical oncology worldwide. This organization allows experts in the field from around the globe to gather and address the surgical needs of children with cancer. IPSO has been invited to contribute surgical guidance as part of the World Health Organization Initiative for Childhood Cancer. One of our goals is to provide surgical guidance for different scenarios, including those experienced in High- (HICs) and Low- and Middle-Income Countries (LMICs). With this in mind, the following guidelines have been developed by authors from both HICs and LMICs. These have been further validated by experts with the aim of providing evidence-based information for surgeons who care for children with cancer.We hope that this initiative will benefit children worldwide in the best way possible.Simone Abib, IPSO PresidentJustin T Gerstle, IPSO Education Committee ChairChan Hon Chui, IPSO Secretary Paediatric oncology surgeons play a critical role in diagnosing, staging and treating malignant solid tumours. Over the years, a more tailored surgical approach of the primary tumour site and the metastatic disease has been advocated by many solid tumour protocols . WhetherThe differential diagnosis of a solid mass is strongly influenced by the patient’s age, anatomic site, organ of origin, gender, race, presence of cancer predisposition syndromes and certain infectious agents. Since some paediatric malignancies are associated with the elevation of tumour markers, including alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (βHCG), urinary catecholamine and certain hormones, a dedicated laboratory workup may help to establish the diagnosis.Neuroblastoma, and Rhabdomyosarcoma and Non-Rhabdomyosarcoma Soft Tissue Sarcoma Guidelines).Diagnosis of malignancy may be obtained from the primary tumour or its metastatic sites. Therefore, it is critical to recognise the pattern of disease dissemination for each histological subtype. The least invasive diagnostic procedure should be considered to establish a diagnosis if, following oncological guidelines, a complete resection of the primary is not possible . Bone maAdrenal tumour (Please refer to Neuroblastoma and Rare Tumours Guidelines)The most common malignant adrenal tumour in children is neuroblastoma. It remains the most common extracranial solid tumour in children with an incidence of approximately 1 per 100,000 children per year . The surUnfortunately, more than one-half of the patients with neuroblastoma present with advanced local (L2) or metastatic (M) disease. Those patients are better treated with initial diagnostic tumour biopsy to be followed by neoadjuvant chemotherapy if needed. Obtaining adequate tissue for diagnosis of neuroblastoma may be challenging due to the amount of histological and molecular tests that are necessary for a correct risk stratification. Therefore, small tissue samples may not always be fully diagnostic. A multidisciplinary discussion among surgeons, interventional radiologists and pathologists is critical in deciding the best approach to obtain adequate tissue for diagnosis. Diagnostic modalities include open tumour biopsy, laparoscopic or thoracoscopic tumour biopsy, image-guided ) biopsy, bone marrow biopsy  or biopsy of metastatic disease . The decision on the best surgical approach for diagnosis of stage L2 and M neuroblastoma is based on the disease pattern characteristics and the local resources of each institution. For patients with stage L1 who undergo upfront surgery, the extent of resection needed is uncertain .Rare Tumours Guideline).Although rare, it is critical to take into consideration pheochromocytoma and adrenocortical tumours in the differential diagnosis of an adrenal mass when considering a possible biopsy, because adrenocortical carcinoma and malignant pheochromocytoma will be upstaged by performing a biopsy . These tRenal tumour (Please refer to Wilms Tumour Guidelines)Although the International Society of Paediatric Oncology (SIOP) protocol calls for neoadjuvant chemotherapy without tissue confirmation of Wilms and the Children’s Oncology Group (COG) continues to advocate upfront surgery, there are instances, albeit different in each protocol, when biopsy of the primary is called for. The argument for biopsy of the primary tumour is similar but the timing and subsequent steps vary between the SIOP  and COG The COG protocol, which advocates upfront primary tumour resection for all children, provides a window for kidney biopsy to justify neoadjuvant chemotherapy  and it iOpen or laparoscopic primary tumour biopsy is discouraged by both protocols as it upstages the tumour. The only exception would be when a tumour is considered unresectable during an actual attempt at upfront nephrectomy.In the setting of bilateral kidney tumours, the SIOP protocol does not require tissue diagnosis to initiate neoadjuvant chemotherapy. This is based on the extreme rarity of bilateral tumours other than Wilms. Biopsy, however, should be considered when there is no response or progression while receiving neoadjuvant chemotherapy. This applies to unilateral and bilateral renal tumours. Similarly, the COG protocol recognises that biopsy is not necessary before initiating chemotherapy in most children with bilateral Wilms tumours (BWTs). It is strongly recommended in cases where there are unusual features .In 20% of BWT cases, the pathology is not the same bilaterally. Therefore, when deciding on biopsy, it is important to sample both kidneys and since anaplasia cannot be detected on percutaneous or core-needle biopsies, open biopsy remains an option.Liver tumour (Please refer to Hepatoblastoma and Hepatocellular Carcinoma Guidelines)Liver tumours are rare in children, accounting for 1% of all paediatric malignancies. Two distinct entities, hepatoblastoma (HBL) and hepatocellular carcinoma (HCC), are seen in this age group. While HBL is typically diagnosed in children younger than 4 years of age , HCC occurs in older children and adolescents. AFP is usually elevated in both histologies (>90% of patients with HBL and 60% of patients with HCC) .HBL is considered to be resectable in 30%–50% of newly diagnosed patients . HistoriDiagnosis of a pelvic tumour can be challenging, and the diagnostic work-up can be influenced by the age of the patient and the characteristics of the mass. Pelvic bony lesions are not the focus of this chapter.Germ Cell Tumours – Ovarian Tumours Guidelines and Non-GCT ovarian tumours). Although mostly benign, retrospective case series reports an incidence of malignancy in 10%–20% of cases. The ovarian mass can be an incidental finding on examination or imaging, but some children present with complaints of abdominal pain, increasing abdominal girth, nausea and/or vomiting, dysuria. An acute presentation due to ovarian torsion is possible and the caregivers of such patients should be aware of this possibility . Some clinical features are more often associated with malignancy: bilateral masses, fixed masses with irregular borders, ascites, precocious puberty.In young girls, pelvic tumours are mainly represented by ovarian tumours (Please refer to Different histotypes can be present:Germ cell tumours (GCTs) – the majority of ovarian tumours in children and adolescents are GCT, both benign (mature teratoma or gonadoblastoma) and malignant Epithelial tumours – serous or mucinous cystadenoma is rare in children, but they must be considered when cystic lesions are discovered, in particular when bigger than 5 cm, or in prepubertal girls or not showing any influence by the hormonal statusSex-cord-stromal tumours – rare in children, they may present precocious puberty, both isosexual and heterosexualTransabdominal ultrasonography is the first-line imaging, providing information about the size and origin of the mass, the consistency, the pattern of blood supply and other associated findings including the side affected. In case of large tumours or when malignancy is suspected, further information can be obtained with CT or magnetic resonance imaging (MRI). A complete panel of tumour markers, including αFP, βHCG, lactate dehydrogenase, Inhibin A and B, cancer antigen 125, oestradiol, testosterone can help in hormone secreting tumours, and if elevated can be useful in monitoring the response to treatment and/or detect early relapses. Surgery is the cornerstone of treatment, and the goals of surgical management include definitive diagnosis, complete removal of the tumour and staging for malignancy . Conservative surgery can be considered unless malignancy is highly suspected or confirmed on frozen section at the time of procedure: even huge cystic lesions can be successfully excised preserving normal ovarian cortex. The surgical approach can be open or laparoscopic, avoiding rupture and spillage of the tumour , 21.Germ Cell Tumour – Sacrococcygeal Teratoma Guidelines).Sacrococcygeal GCTs arising from the Hensen Node cells can be totally (Altman stage IV) or mainly (Altman stage III) intrapelvic. These tumours are mainly diagnosed antenatally or in infants, and in these cases they are mainly mature teratomas. Serum αFP and βHCG will confirm the benign nature of the tumour and in these cases an upfront complete resection with complete removal of the coccyx will be the unique treatment required. Oncological follow-up is still necessary for these patients since a small percentage of those might recur. In older children, malignancy is more represented, and often an elevation of the serum markers is sufficient to diagnose a Malignant GCT, with mainly a Yolk Sac Tumour or a Choriocarcinoma histotype. In this case, a complete workup is necessary to detect possible metastases, but chemotherapy can be started without further histological sampling  (Please Neuroblastoma Guidelines).Neuroblastoma can arise in the pelvis, mainly from the Zuckerkandl organ or from other lower ganglion. They are often unresectable at diagnosis due to the encasement of vessels , and therefore the diagnosis should be confirmed through a biopsy. As for neuroblastoma in other localisation, tru-cut biopsy is encouraged but laparoscopic or open biopsy can be performed, considered that the main objective of a biopsy is to obtain enough material to perform all the immunohistochemical and biological examination to characterise the tumour. Pelvic neuroblastoma often presents good prognostic factors, and after neoadjuvant chemotherapy and delayed complete or incomplete excision, has a good outcome , 24 (PleRhabdomyosarcoma and Non-Rhabdomyosarcoma Soft-tissue Sarcoma Guidelines).Soft Tissue Sarcoma, potentially arising in every site, can present as pelvic masses. Initial presentation can be determined by signs and symptoms relied to complications, such as urinary output obstruction or intestinal occlusion. In these conditions, the correct identification is often difficult at diagnosis, and a biopsy needs to be performed in order to obtain tissue for histological examination. A cystoscopy is often suggested: in case of a bladder/prostate RMS, it can be useful both for a diagnostic purpose and for a therapeutic aim, allowing to insert urethral stent and or bladder catheter in order to prevent further renal damage. A complete diagnostic workup includes a thoraco-abdominal CT scan, bone marrow biopsy, bone scintigraphy and positron emission tomography (PET) scan. After neoadjuvant chemotherapy, a re-evaluation of the tumour extension should be obtained in order to plan the better surgical plan , 26  to those requiring emergent surgical intervention (testicular torsion) to testicular or paratesticular tumours that can present with pain, more or less acute, in 15% of cases. An accurate systematic evaluation including clinical history and physical findings (location of the mass) should allow a quite affordable indication, and Doppler ultrasonography can be helpful.Germ Cell Tumours – Testicular Tumours Guidelines). In suspected malignant GCT, the treatment of choice is radical orchiectomy that guarantees both an accurate diagnosis and the local control of the disease, that in presence of a localised stage of the tumour, can be adequate and sufficient , 2524, 2Surgery for Lymphomas Guidelines). Exposure to the anterior mediastinum can be obtained with this procedure by removal of a costal cartilage preserving the perichondrium. To perform this biopsy, children should be seated in a semi-upright position and be spontaneously breathing to maximise their pulmonary function. This position will also decrease venous congestion if present. Spontaneous ventilation minimises collapse of the trachea by the negative pressure exerted by the chest wall. Following these guidelines for the use of general and local anaesthesia and the biopsy techniques discussed, a biopsy can be obtained safely in essentially all children and adolescents with an anterior mediastinal mass.Many of these non-invasive measures can be performed in parallel to expedite diagnosis and treatment. First, peripheral blood can be submitted for flow cytometry, which can sometimes be diagnostic for haematological malignancies such as lymphoma. Second, bone marrow aspiration and biopsy can be performed under local anaesthesia and can yield diagnostic information for patients with lymphoma, neuroblastoma and some other malignancies. Third, pleural effusions can be sampled by thoracentesis using anatomic landmarks or ultrasound guidance under local anaesthesia . PatientIf these guidelines do not result in successful diagnosis, patients can be treated in a preliminary fashion with either radiation therapy or steroids/chemotherapy for the most likely diagnosis based on the clinical findings. This approach often prevents accurate diagnosis or immunophenotyping of the tumour due to the rapid response to treatment and should therefore be used only as a last resort .Management of mediastinal masses is determined by the presumed diagnosis. Cystic lesions in the anterior mediastinum are generally resected. Acute enlargement in thymic cysts has been noted following a viral respiratory illness. Lymphatic malformations may involve the mediastinum with their predominant component in the cervical–facial area. Isolated mediastinal involvement is seen infrequently. Pericardial cysts are the most innocent of these lesions and if well demonstrated on scans and radiographs often are simply followed because they rarely increase in size and are unlikely to compress any vital structures.Surgery for Lymphomas Guidelines). Potential germ-cell tumours which occur in the anterior mediastinum require evaluation of tumour markers to detect malignancy (Please refer to Germ Cell Tumour Guidelines). These include beta-human chorionic gonadotropin to detect choriocarcinoma elements, or alfa-fetoprotein for endodermal sinus tumours . It has various synonyms like papillary cystic neoplasm/tumour, papillary epithelial neoplasm, solid and cystic papillary epithelial neoplasm and Frantz tumour. Its origin is not clear but pluripotent stem cells are suspected to be a likely source of this tumour. In children, it most commonly appears as a palpable mass and then followed by abdominal pain as initial symptom. Ultrasound and CT are common imaging studies performed and recently the application of fine-needle aspiration has been advocated for cytologic confirmation but this is still under debate [48]. In contrast to adult where the tumour is commonly located in the tail of pancreas, in paediatric cases, the tumour tends to be situated in head of pancreas. Complete surgical resection with negative margin is a mainstay of treatment to prevent recurrence as the role of chemotherapy or radiotherapy for this tumour has not been proven. SPT has a potential to metastasise or recur after the initial treatment and their rate have been reported as 19.5% for metastasis and 6.6% for recurrence in adult cases [49]. However, the report of recurrence or metastasis in paediatric cases is far less common. Outcome of this tumour is excellent with 95% 5-year survival [48].Pancreatic carcinomas are extremely rare in children, representing less than 5% of paediatric pancreatic tumours , 16.Acinar cell carcinoma is a particularly rare neoplasm, accounting for approximately 1% of all exocrine tumours of the pancreas in all ages . AlthougDuctal adenocarcinoma is extremely rare in the first four decades of life. However, ductal adenocarcinoma is associated with several cancer predisposition syndromes, such as hereditary pancreatitis (PRSS1 mutations), familial atypical mole and multiple melanoma (CDKN2 mutations), Peutz–Jeghers syndrome and other hereditary nonpolyposis colon carcinomas (STK11 and germline mismatch repair genes) and syndromes associated with DNA repair gene mutations (such as BRCA2 and ATM) . Age at Presenting symptoms are nonspecific, such as abdominal pain and vomiting, or they are related to local tumour growth.For the diagnostic/therapeutic guidelines of carcinoma of pancreas, it is worth referring to experts of adults. Pleuropulmonary blastoma (PPB) is a very rare and highly aggressive neoplasm arising in the lungs and presenting in early childhood, with most cases diagnosed in children less than 6 years of age. It is a dysembryonic malignancy believed to arise from the pleuropulmonary mesenchyme. PPB is classified into three interrelated clinical-pathologic subtypes, which represent a developmental continuum, according to its macroscopic appearance: Type I (cystic), Type II (solid and cystic) and Type III (solid). The solid component of both type II and III has mixed pattern including high grade sarcoma elements –5. Type PPB should be suspected in young children presenting with a pulmonary lesion with cystic, cystic and solid or completely solid appearance. A PPB diagnosis is challenging in the presence of pure cystic lesions that resemble other congenital cystic lesions of the lung.PPB in children is characterised by symptoms mimicking a respiratory infection, pneumothorax or lung malformation. The tumour is usually located in the lung, but it may extend to the mediastinal structures, diaphragm and/or parietal pleura. Type I PPB is a localised tumour ; metastaPPB can be part of the DICER1 syndrome in about 2/3 of patients. Genetic counselling should be proposed to all patients and their families so as to screen for diseases associated with DICER1 mutation –7.Laboratory tests include complete blood count, complete metabolic profile and coagulation profile.Imaging includes chest computed tomography (CT scan) and/or thoracic MRI, brain MRI, radionuclide bone scan, echocardiography. CT scan with contrast enhancement evaluates the primary tumour, its loco-regional extension, the possible involvement of lymph nodes, mediastinum and heart, as well as the diaphragm and liver.Basic information for surgical planning includes the following:Relation of the tumour with surrounding organs and vascular structuresEvaluation of bilateral disease or coexisting pulmonary malformationsEvaluation of intravascular extensionEvaluation of tumour responseA surgical procedure is necessary to obtain a tumour sample and establish the diagnosis of PPB. If an upfront complete resection is not feasible, an initial biopsy is recommended to obtain a histological diagnosis before neoadjuvant therapy. Core-needle (18 or 16 Gauge) or open surgical biopsies are both possible options: a sufficient amount of tissue should be collected to allow histological, biological and genetic tests. Cytology of pleural fluid is not recommended to be used for diagnosis.There are three main strategies to treat patients with PPB: Children’s Oncology Group (COG)/International Pleuropulmonary Blastoma Registry (IPBR), Cooperative Weichteilsarkom Studiengruppe (CWS) and International Society of Pediatric Oncology (EXpERT) , 8–11. ASurgery planning should consider the respiratory distress experienced by the patients affected by PPB. Special attention is required in patients with mediastinal compression when general anaesthesia is needed to obtain a diagnosis. Any pneumothorax or pleural effusion should be managed promptly.Surgery represents the mainstay of treatment, to establish the diagnosis and cure the patient. Although limited by number of patients, published reports have shown that complete tumour resection is a major prognostic factor , 9–12.Since these tumours are purely cystic, such lesions should be considered suspicious, especially if there is known familial history of DICER1 disease. A complete upfront resection is the treatment of choice, whenever it could be possible without performing a pneumonectomy, and it should be performed through a thoracotomy. A thoracoscopic approach is discouraged.If the number and site of cystic lesions make it impossible to perform a complete resection, the operation should be limited to the removal of the largest cysts, and the remaining lesions should be followed-up closely. In these cases, adjuvant chemotherapy might be considered to avoid the progression of a possible type I PPB to type II or III. In case of macroscopic incomplete surgery (R2 resection), a new resection should be planned.Upfront primary tumour resection should only be considered in small tumours, amenable to complete resection without any kind of demolitive surgery: this implies the lack of lymph node or metastatic disease. In all other cases, tumour resection should be considered after neo-adjuvant chemotherapy and, as in type I, upfront pneumonectomies are discouraged.In the case of a life-threatening situation, upfront surgery may be discussed, but with the aim of a complete resection of the tumour. In the rarer situation when a total pneumonectomy could be necessary to remove the tumour completely, an initial debulking surgery is preferred and a second surgery, after adjuvant chemotherapy, can be planned to remove all residual disease. After neoadjuvant chemotherapy, a second look surgery is highly recommended. In case of no residual lesion visible at imaging, delayed surgery or thoracoscopy is recommended and a biopsy/resection of suspicious lesions or fibrotic remnants are needed.A careful inspection of the pleural cavity and a palpation of the pulmonary parenchyma are needed: all remaining pleural or lung nodules should be resected or biopsied . A complete resection may imply non-anatomical lung resections and, sometimes, the additional removal of mediastinal tissues  may be required due to presence of suspicious lesions. Possible pleural effusion should be collected for cytological analysis.A total pleuro-pneumonectomy is accepted in case the tumour both showed no regression after chemotherapy, and seemed unresectable otherwise. This choice should be balanced with the possibilities of local treatment with radiotherapy.After a second look surgery had ended in an incomplete resection, a third surgical look consisting in a pneumonectomy or lung irradiation should be discussed, considering the long-term effects of the multiple procedures.All removed or biopsied tissues should be sent for histological assessment in order to define the adjuvant radiotherapy fields. The timing of delayed surgery is not defined and can depend on the regimen used: tumour resectability should anyway be evaluated after multidisciplinary board discussion.Surgery goalsTo perform and document a thorough surgical stagingTo achieve R0 resectionTo prevent tumour spillageTo mitigate complications and resection of other organs.There is no clear therapeutic need for an upfront resection of metastatic sites. Examination of viable tumours in persistent metastasis after chemotherapy may help in guiding therapy (i.e. targeted therapy) and prevent or confirm rare tumour (RT). Outcomes of patients with recurrent disease remain poor, and the role of surgery in recurrent disease is not defined.Some authors recommend to avoid leaving a chest tub in order to minimise the contamination of the pleura .When a DICER gene mutation is found, specific screening studies may be recommended to look for PPB and other conditions known to be related to DICER1. Chest screening (by chest X-ray or chest CT) for young children known to have the DICER1 gene mutation but no symptoms have in some cases allowed PPB to be diagnosed when it is at the earliest and most curable stage.Prognosis is strictly dependent on the PPB type, stage and feasibility of a satisfying local control, but also on the neo-adjuvant and adjuvant treatments available –14. Over Phaeochromocytoma (PCC) and Paraganglioma (PGL) are rare neural crest-derived neuroendocrine tumours, jointly abbreviated as ‘PPGL’ . PCC arise from chromaffin cells of the adrenal medulla and usually secrete catecholamines. PGL originate outside the adrenal gland from the paraganglia of the autonomic nervous system: PGL involving the sympathetic nervous system are usually located in the abdominal/pelvic retroperitoneum  or mediastinum and secrete catecholamines. PGL involving the parasympathetic nervous system are frequently located in the head and neck  or upper mediastinum and are mostly non-secreting.Although PCC and PGL have a distinctly different location, presentation, malignant potential and genetic background, they are frequently combined under the term ‘PPGL’. The estimated incidence of PPGL in adults is 2–8 per million per year . Around Hormone-secreting PPGL may present with headache, sweating, flushing, palpitations, blurred vision, syncope, tremor, gastrointestinal disturbance (including diarrhoea), weight loss and arterial hypertension (sustained and without paroxysms in 63%). In adults, hormone producing PPGL are associated with increased cardiovascular morbidity and mortality . Lymphomas are a heterogeneous group of malignancies of the reticuloendothelial system and are pathologically classified into two main groups – Hodgkin’s lymphoma (HL) and non-Hodgkin’s lymphoma (NHL).Lymphoma accounts for about 10%–12% of childhood malignancies, making it the third most common paediatric cancer, with NHL accounting for just less than half of the cases, and Burkitt’s Lymphoma predominating in this group .–8.5–8].Pathophysiology concepts underlying the development of NC are not fully characterised but it is thought that mucosal damage is the first step on this cascade , 10. StaStreptococcus species, Escherichia coli, Enterococcus faecium, Candida albicans, Candida glabrata, Klebsiella species, Bacteroides fragilis [Pseudomonas aeruginosa [Many microorganisms have been associated to the development of sepsis in patients with NC. Blood cultures may show fragilis –15, Pseuruginosa , 16 and ruginosa  or even ruginosa .The incidence of NC can be estimated at 2.6%–5% of paediatric patients hospitalised for leukaemia, lymphoma, AIDS or patients maintained on immunosuppressive agents , 15, andIt occurs more often in haematological malignancies than solid tumours , especiaIntensive chemotherapy and BMT are contributory factors.Drugs that may be implicated include anthracyclines and cytosine arabinoside which are known to cause mucosal ulcers, and vincristine which causes bowel hypomotility, though others may be associated.The most frequent mentioned risk factors are the presence of mucositis, neutropenia <500 cells/µL, chemotherapy in the 2 weeks before the onset of typhlitis, history of haematopoietic stem cell transplantation (HSCT), corticosteroid administration and the presence of a central venous catheter (CVC) , 12, 19.The most commonly described symptoms of NC are the triad of abdominal pain, fever above 38°C and neutropenia  , but abdClinical findings of hypotension, peritonitis, septic shock unresponsive to intravenous fluid resuscitation, septic emboli, intussusception and signs of perforation are all associated with a more severe course , 21, 22.Imaging is indicated in neutropenic patients with abdominal pain and fever. Initial diagnostic work-up includes plain abdominal X-ray to rule out pneumoperitoneum . Other rUltrasound scan (US) is helpful in the diagnosis and may reveal thickening of the caecum, transverse colon or terminal ileum of >3 mm, which is highly suggestive of NC in association with typical symptoms , 16. ThiClostridium difficile colitis. Another tomographic sign of NC includes fatty streaks on the affected bowel segment [Computed tomography (CT) imaging may confirm bowel wall thickening and reveal pneumatosis intestinalis and/or pneumobilia that may help differentiate NC from other conditions with similar clinical presentation such as  segment .To date, there is not sufficient evidence supporting the preferential use of US or CT, and imaging is accordingly utilised to local availability of the modality.Some studies report a mortality of up to 60% of patients with bowel wall thickening > 10 mm .Initial non-surgical management of NC is the treatment of choice and includes bowel rest, naso-gastric (NG) tube placement, total parenteral nutrition, administration of appropriate blood products  and broaMetronidazole as a first-line agent for pseudomembranous enterocolitis coverage and empiric antifungal coverage is also recommended, especially in patients who are neutropenic for over 96 hours , 26.In patients who are hypotensive at first presentation, administration of an initial fluid bolus of 20 mL/kg of crystalloids is advisable . PatientFeeding can recommence in the absence of abdominal pain, when bowel transit is restored, and leucocytes are above 1,500.Persistent GI bleeding after resolution of neutropenia, thrombocytopenia and correction of clotting abnormalities, especially if the site of bleeding is known. It can, however, be difficult to find the source of bleeding looking at the bowel from its serosal surface.Evidence of free intraperitoneal perforation. Perforation frequently occurs when the patient is recovering the leucocyte count after an episode of immunosuppression, when the inflammatory response is greater and facilitates perforation.Clinical deterioration requiring support with vasopressors, or large volumes of fluid, suggesting uncontrolled sepsis together. In this situation, a necrotic loop may be present. In order to decide if surgery is indicated or not, the most experienced surgeon should repeatedly evaluate the patient.Intestinal obstructionAbscess Development of symptoms of an intra-abdominal fulminating process, in the absence of neutropenia, which would normally require surgery.An algorithm for the evaluation and management of NC patients is outlined in The aim of surgical treatment in NC patients is to resect all the necrotic and compromised areas, to control bleeding, and/or divert bowel content and achieve local control of the infection , 30, 31.Standard surgical approach includes emergent laparotomy and resection of necrotic bowel. Since the caecum and the right colon are the most severely affected areas , 32, 33,If there is evidence of significant soilage of the peritoneal cavity or the patient is haemodynamically unstable, needing large volume of fluids, vasopressors or inotropes to maintain blood pressure, ileostomy and mucous fistula are the safest options. If the patient is stable and there is minimal peritoneal soilage primary intestinal anastomosis can be considered , 33–37, Less extensive procedures such as simple drainage of necrotic areas, appendectomy or cecostomy may be insufficient for the definitive management of NC as the extent of mucosal necrosis may often be greater than that which is obvious by macroscopic inspection of the bowel , 35, 36.Laparoscopy or diagnostic peritoneal lavage can be considered a diagnostic tool for perforation or necrosis, when CT is inconclusive.Complications in the post-operative period include wound infection, intra-abdominal sepsis, respiratory failure and wound dehiscence , 32. LonProgression of bowel ischaemia after exploratory laparotomy requiring ‘second-look’ surgery has been described  as well Admission to the Intensive Care Unit after the surgical procedure is recommended for haemodynamic monitoring and support. Continued postoperative sepsis until recovery of neutrophil counts should be anticipated and therefore appropriate antibiotic and antifungal therapy is of critical paramount importance , 35, 36.Parenteral nutrition is usually necessary in the early post-operative period . EnteralTransfusion support with platelets may be necessary to maintain the platelet count above 50,000/μL. If patients have coagulation defects or disseminated intravascular coagulation (DIC), fresh frozen plasma (FFP) may be needed as well to replace clotting factors. Cryoprecipitate may be necessary to treat hypofibrinogenaemia .The earlier correct clinical treatment is instituted, the less surgical treatment will be needed. Waiting for neutropenia resolution in the face of failure of conservative treatment might expose patients to a septic degradation course toward septic shock. Inadequately treated typhlitis carries a high risk of death and the lack of access to surgical management is a significant adverse prognostic factor. Delaying surgical therapy due to neutropenia, thrombocytopenia or other chemotherapy or malignancy associated reasons is not recommended and may be detrimental; however, in these circumstances, patients may still die regardless of surgical intervention .Pancreatitis is the inflammation of the pancreas and is diagnosed when the serum amylase or lipase is significantly elevated, with clinical signs and radiological findings consistent with pancreatitis. L-asparaginase associated pancreatitis is most commonly encountered.Of paediatric oncology patients who receive L-asparaginase, 1%–18% will develop pancreatitis . Asparagpancreatic pseudocyst [Patients would usually present with abdominal or back pain with nausea or vomiting. About 18% developed eudocyst .Complete blood count, serum amylase and serum lipase. Elevated levels of serum amylase and lipase would be diagnostic.Radiological imaging. Ultrasonography and CT scan would usually show oedematous pancreatitis, with necrosis, peripancreatic collections and pseudocyst formation. As both imaging techniques show a high degree of concordance in findings, good USs may be sufficient. A reasonable indication for CT scan is to distinguish acute pancreatitis from another serious intra-abdominal condition. Chest radiograph may show signs of acute respiratory distress syndrome and pleural fluid.It is usually self-limiting. The need for surgical intervention is rare and long-term sequelae are not usually observed.Non-operative management is recommended as the initial care of patients with pancreatitis. It often responds favourably to NG decompression, bowel rest and intravenous hyperalimentation. Data to support the role of somatostatin is limited. Total parenteral nutrition should be initiated, and chemotherapy suspended until acute pancreatitis resolves. Oral feeding may be commenced when abdominal pain subsides and diet advanced as tolerated.However, complications such as severe haemorrhagic pancreatitis, necrosis or pseudocyst formation may occur. Controversies exist over the management of pancreatic pseudocysts, with options of surgery, percutaneous drainage or without intervention. Surgical treatments available include endoscopic, laparoscopic or open cystgastrostomy but all require sufficient maturation of the cyst wall, which usually takes between 4 and 6 weeks. Safety in observing asymptomatic pseudocyst has been reported .Significant morbidity may arise when severe pancreatitis develops during neutropenia resulting in multi-organ dysfunction, haemorrhage, sepsis and pseudocyst formation. Mortality has been reported between 2% and 15% . ALL patCholelithiasis is a rare disease of children with an incidence of 0.13%–0.21% , 45. ChiMost cases present with jaundice, fever and abdominal pain. In few cases, the diagnosis may be incidental on ultrasound evaluation. It is important to remember that biliary obstruction resulting from external pressure due to adjacent tumour bulk could result in similar symptoms.Complete blood counts, clotting profile, liver function test.Imaging: Abdominal US.Surgery is indicated in children who develop cholecystitis. Depending on the haematological status, clinical treatment is initiated until the patient has conditions to be operated safely. Surgical management includes cholecystectomy (laparoscopic or open) or cholecystostomy, in association with intravenous antibiotics. Indications for urgent cholecystectomy include biliary peritonitis Cholecystostomy is useful for selected patients who require an operation but are considered unfit for the procedure. Bile duct stones should be treated endoscopically after recovery from immunosuppressive therapy, unless cholangitis and severe jaundice occurs, asymptomatic children with cholelithiasis should be managed nonoperatively .In a retrospective study on the management of cholelithiasis in children who underwent BMT, most did not require surgical intervention. 45% died from their primary disease, 25% had resolution of the gallstones and 15% continued survival with asymptomatic gallstones, while 15% progressed to acute cholecystitis requiring surgical intervention . Non-opeSignificant GI haemorrhage is when there is loss of blood in the GI tract requiring blood transfusion. Very often these patients have concomitant thrombocytopenia secondary to myelosuppression from chemotherapy or coagulopathy that may complicate its management. Without adequate control of the bleeding, further anti-neoplastic treatment may be delayed.There are diverse causes of GI haemorrhage in paediatric oncology patients. These include those that are a result of immunosuppression (infections like CMV or typhlitis), portal hypertension (varices), tumour recurrence with GI invasion, post-transplant lymphoproliferative disorder, steroidal effects , radiation effects , Cushing ulcer  and causes unrelated to treatment .Patient will present with varied degree of GI bleeding.Complete blood counts performed serially to monitor ongoing bleeding. Coagulation profile.Plain abdominal X-ray (to look out for toxic dilatation). Ultrasonography of abdomen.Endoscopy  is often the preferred initial evaluation as it is likely to diagnose the majority of the conditions with a potential of concurrent treatment. In the evaluation of the small intestines, technetium red blood cell scan and capsule endoscopy are available options.Adequate initial resuscitation is crucial. This is followed by the correction of any coagulopathy which may improve haemostasis and render the patient suitable for any surgical intervention if required.Many endoscopic techniques are available for haemostasis, including clip application, sclerotherapy, ligation of varices and argon plasma coagulation. Such minimally invasive techniques would allow early recovery and shorten the delay in subsequent anti-neoplastic therapy. Exploratory laparotomy with intra-operative enteroscopy would be indicated if endoscopic option of treatment did not work.Pseudomonas Spp. and Klebsiella Spp. are the most common agents involved with these conditions.Anorectal complications and severe soft tissue infections are more frequent in patients with haematological malignant diseases as compared with patients with other cancers, especially after BMT. Early identification of predisposing factors, early diagnosis and prompt treatment are mandatory for reducing morbidity and mortality. Patients may suffer from different conditions, varying from simple perianal abscess, haemorrhoids or anal fissures, to severe conditions like necrotising fasciitis involving perineum and scrotum (Fournier’s gangrene) or ecthyma gangrenosum. Soft tissue lesions in the perineum can have devastating effects (i.e. tissue destruction and sphincter damage). For these reasons, patients with any lesion in the perineum/anal area should be examined daily in order to evaluate the progression or regression of the infection locally and determine the need for surgical procedures.Nursing care is paramount, and the extent of the lesions should be marked and size changes documented. All lesions have to be examined by experienced surgeons and frequent examination of the lesion by trained nursing staff is imperative.Aplastic patients in the early phase of recovery after BMT should routinely have blood cultures, gut surveillance swabs taken and specific antimicrobic agents started intravenously in addition to intestinal decontamination to eradicate gut carriage of the organisms.Treatment should be performed by a multidisciplinary team consisting of surgeons, oncologists, microbiologists and nurses. Surgical strategies may include different procedures such as early debridement or drainage of abscess, local wound care with advanced dressing (to be performed in-consultation with plastic surgeon if required) or extensive surgical procedures including colostomy, debridement and perineoplasty with delayed skin graft in patients with frank necrosis and necrotising fasciitis.Haemorrhagic cystitis refers to is the inflammation of the bladder with bleeding. It is defined by the presence of sustained haematuria and lower urinary tract symptoms, such as dysuria, frequency and urgency. It occurs in 10%–70% of paediatric patients undergoing paediatric bone marrow transplantations . The potPaediatric patients who undergo BMT and those who received high-dose cyclophosphamide, ifosfamide and busulfan are predisposed to developing haemorrhagic cystitis. Prior or concurrent pelvic irradiation is also a risk factor. In addition, viral infections like BK virus, adenovirus and CMV may be responsible. Patients who have a predisposition for haemorrhagic cystitis include those older than 10 years of age and those who underwent allogeneic transplantations.The patients may present with various grades of haematuria, from microscopic to gross haematuria with clots causing urinary tract obstruction that may require instrumentation. Clinical symptoms may occur hours, days, weeks or years after chemotherapy administration, with recurrence of bleeding. Haemorrhagic cystitis may also be associated with vesico-ureteric reflux and hydronephrosis, leading to beyond which renal dysfunction and renal failure in selected cases.Determination of virus titres in blood and urine samples would determine its aetiology. Ultrasonography of the renal tract should be performed to detect upper tract dilatation from clot obstruction.Electrolyte, Urea and creatinine: Renal function should be monitored closely.Preventive measures are effective in reducing the incidence of haemorrhagic cystitis. Vigorous prophylaxis to minimise contact between noxious metabolites and the bladder mucosa by hyperhydration, continuous bladder irrigation or administration of thiol compound, sodium 2-mercaptoethane sulfonate (mesna). Mesna combines with the metabolites of ifosfamide and cyclophosphamide to form nontoxic compounds in the urine. This may reduce the incidence of haemorrhagic cystitis to <2 %. Once haemorrhagic cystitis occurs, hyperhydration, continuous bladder irrigation, platelet transfusion and treatment of existing coagulopathy are recommended. Oxybutinin chloride may provide symptomatic relief of the associated bladder spasms. In the presence of urinary obstruction, cystoscopic removal of clots, placement of suprapubic catheter, bladder washouts may be helpful. Intravenous or intravesical antiviral therapy is effective in the treatment of viral infections. Refractory bleeding may be treated with Nd:YAG laser-induced coagulation, electrocautery, local instillation of prostaglandin E1, alum, silver nitrate or formalin . BladderInvasive aspergillosis (IA) is one of the several types of fungal infections that have been encountered in paediatric oncology patients. It almost exclusively affects individuals with weakened immune systems due to cancer, HIV infection AIDS, leukaemia, organ transplantation or chemotherapy. It occurs in patients at HSCT (2.3%–7.3%) , at induAspergillus is an airborne infection and lung is the most common site of infection, followed by skin, sinus, nasal and cerebral disease. About 86% of the infections reported are localised  and the Complete blood count. Typically shows neutropenia. Sputum examination.Sputum stains and culture for Aspergillus, and Galactomannan enzyme immunoassay tests may be diagnostic. Often, the definitive diagnosis may require histopathologic examination of pulmonary or other involved tissue.Imaging: Chest radiographs show wedge-shaped peripheral areas of consolidation usually extending to the pleural surface, with or without cavitation. CT scan of the thorax shows nodules, cavitation, halo sign or air-crescent sign.Once IA is detected, aggressive operative treatment of fungal infections combined with antifungal chemotherapy before transplantation may offer the best hope of extended survival. Antifungal drugs currently available include amphotericin B, voriconazole, itraconazole and caspofungin. Combined administration of antifungal drugs with synergistic action improves the prognosis.Surgical intervention is indicated when antifungal therapy fails to completely eradicate IA and when confirmation of diagnosis is required. Lung-sparing resection should be the aim, though lobectomy could be performed when required. Eradication of the disease is recommended before high-dose chemotherapy or HSCT so as to avoid reactivation during myeloablative chemotherapy. No surgery should be performed in disseminated disease or when a curative resection is not feasible.Early diagnosis and aggressive treatment improve long-term survival of the patients . Immune ExtremitiesPaediatric oncology patients can develop extremity ischaemia, venous thrombosis and severe necrotising skin and soft tissue infections. Some severe lesions occur due to chemotherapy extravasation.Deep venous thrombosis is usually related to impaired venous return, such as pelvic tumours, or as paraneoplastic phenomena. It is particularly important to look for clinical signs in unconscious patients. Anticoagulation and preventive measures to avoid pulmonary embolism are indicated.Necrotising infections should be treated aggressively with antibiotics and surgery. Abscesses should be drained. Surgery and Lymphoma guideline: page 204) . AntiemeThe primary goal of surgery is to ensure adequate bowel decompression. The emphasis is on non-mutilating surgery. Primary resection of the tumour is a secondary goal if feasible. If resection is not feasible, bowel diversion via enterostomy stoma and tumour biopsy is advised, specifically in the emergency situation where the diagnosis is unknown, as chemotherapy may decrease tumour bulk and avoid extensive surgery.Bowel gangrene in abdominal malignancy may result from intussusception, malignant intestinal bands including adhesions and volvulus. Bowel perforation can result from infiltration of the bowel wall by tumours, bowel ischaemia secondary to vascular thrombosis or insufficiency and use of medications that predispose to frank ulcer formation such as prednisolone .Bowel gangrene and perforation present with fulminant peritonitis which can progress to sepsis, and septic shock. Bowel gangrene and perforation in an already immune compromised patient worsens the prognosis of any abdominopelvic tumour.Clinical presentation is that of a child with abdominal tumour with sudden onset or progressively worsening abdominal pain. There may be associated progressive abdominal distension, vomiting, passage of bloody stool and fever.Examination may reveal an acutely ill child, who is pale, febrile and dehydrated. The child may be in hypovolaemic or septic shock, and have a fast and thready low volume pulse with slow capillary refill. Low blood pressure is an ominous late sign. The abdomen may be distended, with generalised abdominal tenderness, rebound tenderness and rigidity.Relevant investigations will include complete blood count which may show elevated neutrophils and an electrolyte profile with varied anomalies and elevated serum creatinine and urea. There may be elevated serum bilirubin on liver function tests. Serum lactate may be elevated in bowel ischaemia.Plain abdominal X-ray may show free intra-abdominal air.CT scan may have findings of increased bowel wall thickness and pneumatosis intestinalis , 8. FreeBowel gangrene and perforation are indications for laparotomy. Biopsy of the tumour should be taken during surgery.Bowel gangrene: complete resection of gangrenous bowel (with preservation of adequate bowel length) and ensuring control of bowel contents either via primary anastomosis , or stoma creation if there is any concern relating to an anastomosis. In the case of severe sepsis and haemo-dynamic instability, a damage control approach with a ‘clip and drop’ procedure may be required, with a relook laparotomy when the patient is stable.Bowel perforation: simple debridement and closure of the perforation in macroscopically normal bowel if feasible or resection with primary anastomosis will be determined by the site and number of perforations. Thorough irrigation of the peritoneum should be done to control peritoneal sepsis.Tumour debulking if feasible – with the emphasis on non-mutilating surgery, should only be performed if the patient is stable enough to withstand the surgery, otherwise biopsy of the tumour should be taken.The patient should be resuscitated, this will involve:An intra-venous access and correction of fluid deficit using isotonic fluid such as normal saline or Ringer’s lactate.Passage of an appropriately sized NG tube to decompress the stomach and urethral catheter to monitor urine output.Replacement of ongoing fluid loss from the NG tube with equivalent volume of isotonic fluid.Commencement of maintenance fluid based on the child’s weight should be commenced once dehydration has been corrected and urine output is optimal.Administration of broad-spectrum intravenous antibiotics.Correction of anaemia and electrolyte imbalance.Monitoring during the pre-operative period should include vital signs, urine output and serum electrolytes.Central venous line, invasive monitoring  and total parenteral nutrition may be required. Patients with evidence of septic shock will require vasopressors.Exploratory laparotomy should be performed through a midline or transverse abdominal incision depending on the age of the child. During exploration, the tumour should be identified, involvement of contiguous structures and presence or absence of peritoneal and hepatic metastasis should be determined.For complete bowel obstruction, the site of bowel obstruction, feasibility of tumour resection, the need for bowel resection with primary anastomosis or creation of a stoma should be determined.For bowel gangrene or perforation: Control of spillage of bowel contents followed by assessment of the extent of the gangrene and decisions on the length of bowel to be resected.Following bowel resection, a stoma should be fashioned if primary anastomosis is not feasible. Biopsy of the tumour should be obtained at surgery if tumour resection is also not feasible. When considering primary anastomosis, the surgeon needs to remember that chemotherapy may be initiated soon after surgery, possibly with high doses of steroids, and it may be safer to create a stoma and restore bowel continuity after discontinuation of chemotherapy, to avoid the risk of anastomotic dehiscence, sepsis and death. If the patient has a very localised tumour, resection with primary anastomosis are viable options.Intraoperative complications include haemorrhage, tumour rupture, injuries to surrounding structures and anaesthetic complications.Early complications include wound infection or dehiscence, anastomotic leakage and intra-abdominal abscess.Late complications include adhesive intestinal obstruction and tumour relapse.The primary tumour: completely resected or presence of residual tumours during emergent laparotomy.Post-operative chemotherapy and radiotherapy.Post-operative complications.Stoma function.The intervention that will provide the best results for the patient at the time of presentation should be opted for.In case of bowel resection, primary anastomosis should be performed if distal obstruction is ruled out, the child is in a good physiological state, and the bowel to be anastomosed is not involved in the inflammatory or malignant process. In all other situations, a stoma is the safest option – bearing in mind that they do have their own complications .In the case of an unstable child, a damage control approach with ‘clip and drop’ procedure and a subsequent relook is a good option.Conserve as much bowel length as possible so as to reduce the risk of short bowel syndrome.In case a stoma needs to be created; consider a divided stoma.In non-resectable tumours, consider stoma creation and tumour biopsy instead of tumour debulking; this will reduce the risk of injury to contiguous structures.Widespread infiltration of the bowel wall may make primary anastomosis and stoma creation not feasible.High risk of internal fistula and enterocutaneous fistula during laparotomy in patients with malignant adhesions.Surgery and Lymphoma guideline: page 204) or malignant tumours (Burkitt lymphoma and carcinoid tumour) . IntussuWilms tumour guideline: page 57)Postoperative intussusception is an uncommon, but important complication, and must be suspected in every child who shows symptoms of postoperative intestinal obstruction occurring within a week following an abdominal  operation. Since the typical features of intussusception are usually absent and radiology frequently unhelpful (except for ultrasound), a high index of clinical suspicion is necessary for early diagnosis and treatment, to avoid intestinal necrosis.  show bowel within bowel  . Of noteFindings that suggest pathological intussusception include intussusception length > 3.5 cm, and evidence of bowel obstruction or an identifiable lead point , 19.The indication for surgery, especially for patients with possible Burkitt lymphoma, is the ‘acute abdomen’ with perforation of the bowel, an older child with intussusception and an identifiable lead point on ultrasound.In the case of intussusception related to a lead point, the aim is total resection of the tumour. In the case of postoperative intussusception, enema reduction can be attempted if at the ileocaecal area but as many of these intussusceptions are present in the small bowel territory, operative intervention is often needed. Reduction without resection and anastomosis is preferable, and can be performed if necrosis has not yet been established.Routine perioperative fluid resuscitation and correction of and haematological, electrolyte or hydration abnormalities needs to be performed before embarking on surgical procedures .Antibiotics may be indicated, specifically in a patient with a potentially ischaemic intussusceptum, or in patients with peritonitis.Oncology patients with a postoperative intussusception are normally in an altered physiological state due to effects of chemo and/or radiotherapy. These treatments target rapidly proliferating neoplastic tissues and the GI mucosa is also particularly vulnerable. In addition, chemotherapeutic agents cause nausea and vomiting, and may result in diarrhoea, mucositis, stomatitisand neutropenic enterocolitis. These adverse effects may all exacerbate malnutrition and dehydration. Oncology patients may have chronic nausea and vomiting or delayed gastric emptying exacerbated by opioids. These children may be at an increased risk for aspiration on anaesthetic induction and should be managed accordingly.In a patient with a suspected lead point intussusception, the approach can be via laparoscopy, be laparoscopic assisted or open. In most cases of a malignancy presenting as intussusception, the mass is easily resectable and primary anastomosis is possible. If the child is physiologically unstable or there is extensive soiling of the peritoneal cavity, or in the event of an unresectable mass, bowel content diversion by means of enterostomy is preferred. Biopsy of the tumour is then performed.Post-operative intussusception should be approached in a similar fashion as discussed above.Postoperative complications are not uncommon in this vulnerable patient group. Because of immunosuppression, preoperative chemotherapy and radiotherapy, wound infections or poor wound healing can occur.Routine observations related to electrolytes, hydration status and pain control are to be applied.Other postoperative considerations are liver function and pulmonary status, especially in patients with disseminated disease. Post-operative monitoring should incorporate assessment of all these issues.Early recognition and management is the key for early treatment.Avoid mutilating procedures.Meticulous monitoring of the patient is important for a smooth postoperative period.Intussusception in the case of a lead point should not be reduced via enema techniques.Vomiting and abdominal distention in retroperitoneal oncology procedures can be caused by intussusception.Resect and perform primary anastomosis in tumour related intussusception.Avoid a stoma if anastomosis is possible.GCT guideline: page 103) helps to locate the mass and identify its nature. MRI is particularly valuable for characterising the various fluid and tissue structures –29.Some ovarian neoplasms secrete protein or hormone biomarkers that can be assayed in either peripheral blood samples or the ovarian cyst fluid . These sThe only indication for emergency surgery with ovarian tumour pathology is clinical deterioration in the setting of an acute abdominal crisis.The surgical goals for the paediatric and adolescent population, which suffers from an acute abdomen due to ovary tumour torsion, are to minimise u spillage and preserve reproductive function.As per all emergency situations, stabilisation of the patient is the cornerstone of therapy. Abdominal tenderness and a history of ‘rapid-ischemic’ pain with vomiting in a female patient, strongly indicates likelihood of ovary torsion. Laboratory evaluation with biochemistry and serum biomarkers as well as cross match blood should be performed. Emergency pelvic ultrasound is an adjunct to timely diagnosis.et al [Many adolescent female patients present with primarily cystic lesions and most of these are benign. Laparoscopy has been widely utilised. The main controversy surrounds the ability of the surgeon to perform a cancer type procedure in cases where the exact tumour histology  cannot be determined accurately preoperatively. If the lesion is primarily solid or if the serum biomarkers are elevated, an open procedure is indicated. If the serum markers are normal and the lesion is primarily cystic, particularly if there is a very large cystic component, a less invasive technique may be considered; however, avoidance of tumour spill must be assured. One minimal access procedure involves laparoscopic excision of the tumour from its attachments, placement in a retrieval bag and delivering the neck of the bag outside of the abdominal cavity through the umbilical opening. The cyst is then punctured, the fluid removed and the cystic lesion, contained within the bag removed without spillage and sent for pathology examination. In the second technique, useful for giant ovarian cysts, the cyst is exposed through an approximate 5-cm incision, a bag glued to the cyst with cyanoacrylate adhesive as described by Shozu et al . The cysThere is another strategy regarding the timing of tumour resection in some patients with normal markers and without suspicion of malignancy during imaging evaluation. Ovarian detorsion can be considered initially through classical open approach or minimally invasive surgery, and tumour resection can be performed after 7–10 days from the first procedure. The postponement of definitive surgery gives time for oedema and tissue congestion to subside and can facilitate ovarian-sparing surgery and gonadal tissue preservation .Tumour spillage or unnecessary oophorectomy are considered major complications.Routine post-operative observations are required. In the case of elevated tumour biomarkers, these can be assayed some 5 days postoperatively. Pain management is also an important postoperative consideration.Always evaluate imaging with an experienced Paediatric Radiologist.Prefer open ‘classical’ approaches with giant ovarian cystic lesions.Avoid tumour spillage.Don’t assume a cystic lesion is benign.Adult ovarian tumours have different biology from paediatric ovary tumours. A paediatric gynaecologist or paediatric oncology surgeon is the most suitable health care professional to treat such tumours.hepatoblastoma and HCC and Wilms tumour guidelines: page 94) as opposed to those cases where neoadjuvant chemotherapy is first initiated  –43. ImprIn the case of intraoperative rupture or emergency nephrectomy is mandated due to rupture, the local stage is graded III and radiotherapy is mandatory. Outcomes in stage 3 post-rupture patients are still satisfactory; however, low-dose radiotherapy may have some adverse late effects for the child , 44.Ruptures of liver tumours occur less frequently however similar care strategies may apply. Thus, the approach at rupture may depend on the local expertise of the oncology service and current ‘PRETEXT’ grouping. Stabilisation of the patient, initiation of local therapy protocols and consideration of surgery should be carefully planned. If it is impossible to control refractory haemorrhage operation with ‘damage control’, plans should proceed. Small and favourably located tumour lesions can be resected respecting oncological rules and adequate clear margins. In case of huge tumours with high ‘PRETEXT’ when anatomical or non-anatomical resection of the tumour is impossible, the rupture should be folded closed ‘like a book’ and a tumour biopsy sample taken. From a technical point of view, Pringle’s manoeuvre may decrease bleeding and make surgery easier. In extreme cases, cardio-pulmonary by-pass or even extracorporeal circulation may be helpful. A pivotal role for radiology guided interventional endovascular procedures, particularly hepatic artery embolisation techniques, is expanding with interesting data published available –48.Malignant tumours may produce haemoperitoneum due to spontaneous rupture, blunt or surgical trauma, or chemotherapy-induced necrosis. Patients present with abdominal mass or distension, compartment syndrome, shock and low haematocrit levels. Haemorrhage control with interventional radiology has been described. At surgery, the tumour should be resected when feasible, providing the patient is stable. Otherwise, damage control surgery is indicated. Blood products should be available in the operating room before starting the procedure, since abdominal decompression usually exacerbates the bleed and makes patients unstable. Most patients require ICU admission after surgery. Malignant haemoperitoneum is a serious complication in paediatric cancer patients, with a dismal prognosis.Urinary tract obstruction from tumours can occur as a result of external compression by solid tumours or infiltration of the wall or growth of tumour within the lumen of the urinary tract. Urinary tract obstruction can be seen in about 25% of patients with pelvic and retroperitoneal tumours . ObstrucThe tumours found to cause hydronephrosis in children include neuroblastoma, immature teratoma, rhabdomyosarcoma, yolk sac tumour, ganglioneuroma, dysgerminoma, endodermal sinus tumour, desmoplastic small round cell tumour, appendix adenocarcinoma and Ewing’s sarcoma . , urea and creatinine which may reveal metabolic acidosis, hyperkalaemia, elevated serum urea and creatinine. Complete blood count may show leukocytosis, relative neutrophilia, presence of toxic granulations and immature white blood cells.Urine microscopy, culture and sensitivity may confirm the presence of a bacterial infection, the offending organism and the antibiotics the organism is likely sensitive to.Hydrocalycosis, hydronephrosis and retroperitoneal or pelvic masses will be seen on abdominal ultrasound imaging . CT scanTrucut biopsy of retroperitoneal tumours can be obtained under ultrasound guidance; biopsy of pelvic tumours may be obtained with laparoscopy while cysto-urethroscopy will aid in the visualisation and biopsy of bladder tumours. Histology of the lesion will provide information on tumour biology, grade and immunohistochemistry which will guide further treatment.Bladder outlet obstruction from pelvic or bladder tumours in most instances may be relieved with passage of urethral catheter. If this is not possible, a suprapubic catheter will be required. Preoperative chemotherapy where indicated will cause reduction in tumour size and degree of urinary tract obstruction, and possibly allow for removal of the emergently placed catheter. Indication(s) for surgery in this setting are limited to resection of the primary tumour.For upper tract obstruction, relative indication(s) for operative intervention would include:Persistent urosepsis despite antimicrobial therapiesWorsening renal functionPersistent hydronephrosis following initial treatment of primary tumourThe goals of urologic intervention include relieving urinary tract obstruction to allow free urine drainage, control of sepsis and improvement in renal function.Correct fluid and electrolyte imbalance and commencement of empirical broad spectrum antibiotics with coverage for Gram negative organisms is necessary. Antibiotics should be tailored according to antimicrobial sensitivity(s).Chemotherapy should be commenced in patients with large tumours causing urinary tract obstruction; this permits reduction in tumour bulk and relief of the obstruction. Surgery can then be performed in an elective setting to resect the primary tumour.Percutaneous nephrostomy and placement of ureteric stents can be usefully deployed to relieve malignant ureteric obstruction , 51, 52.Percutaneous nephrostomy is indicated in patients with hydronephrosis with associated urosepsis or worsening renal function. It is performed under image guidance. The procedure can be performed using local or general anaesthesia depending on the age and the clinical state of the patient. The patient should be placed prone, or supine in those with compromised cardiorespiratory function. After cleaning and draping, local anaesthetic should be infiltrated. A sterile ultrasound probe should be used in locating the posterior renal calyx below the 12th rib. An appropriately sized Chiba needle should then be introduced into the calyx under ultrasound guidance, aspiration of urine will confirm successful placement of the needle. A guidewire is then introduced into the calyx, and the tract should be dilated. An adequate sized nephrostomy tube/catheter should then be passed over the guidewire . CorrectComplications of percutaneous nephrostomy include bleeding, infection, blockage and dislodgement of the tube, and leakage –53 whileConsiderations in the postoperative period will include:Renal function monitoring in terms of patient recovery from uraemia and acute renal failure.Recovery from urosepsis.Further treatment required for the primary tumour.A high percentage of urinary tract obstruction from tumours will resolve following treatment of the primary tumour , a small percentage will require further urologic interventions as a result of persistent hydronephrosis, patients in this category usually often have a higher tumour stage, grade and poor prognosis .The use of chemotherapy in the management of the primary tumour with the aim of reducing tumour bulk and relieving obstruction in patients with impaired renal function can be challenging. This may require pharmacological reduction in the dose(s) of cytotoxic drugs to be administered in such patients.Spinal cord compression is a surgical oncological emergency that may lead to long-term or permanent neurological impairment if the diagnosis and/or the management are delayed for even only a few hours . The incThe intraspinal extension can cause acute neurological symptoms and permanent neurological sequelae with a significant impact on the patient’s daily activities and health. Back pain is often the primary symptom and when any child who has had a solid malignant tumour presents at the emergency department with back pain, spinal cord compression should be considered first until proven otherwise , 57. MotPhysical examination and neurological assessment are fundamental in the primary survey. Moreover, urgent radiological scans are a perquisite for a prompt, accurate diagnosis. Plain X-rays are diagnostic in only about 30% of all children with spinal cord compression. The modality of choice to localise the cause and site/extent of cord compression is spinal MRI under sedation or general anaesthesia if required .Prompt management is essential especially in those children with dumbbell neuroblastomas that account for about 5%–10% of all neuroblastomas index cases. Neoadjuvant chemotherapy, as per contemporary protocols, can reduce the role of surgical intervention and decrease the serious orthopaedic consequences . IntraveThere is no consensus regarding the merits and the disadvantages of different management strategies, and therapy algorithms vary between centres. The data in the literature suggest that immediate administration of chemotherapy is the first choice and is a potential valid therapeutic option in the absence of an experienced surgical team . HoweverEventually, the outcome is generally linked with the timing of diagnosis and intervention, and favourable results can be achieved in tertiary referral centres that do not need any transfer of these patients.Ventilation can be impaired by large abdominal masses, especially in neuroblastoma in patients younger than 18 months of age with massive liver infiltration by the tumour (Pepper syndrome), whose ventilation is predominately diaphragmatic. In most cases, chemotherapy and ventilatory support are enough to solve the problem in a few days; however, an open abdomen can be useful in selected patients. One has to bear in mind that this procedure poses a high risk for infection in immunocompromised patients, so it should be avoided if possible.Anterior mediastinal masses such as teratomas or thymic carcinomas or lymphomas can result in an airway compression in affected children and adolescents. The common clinical presentations include dyspnoea, cough, wheezing, stridor and pleural effusions. Such symptoms increase in the supine position. These patients present with a respiratory compromise. Prompt administration of steroids and oxygen support should be imperative. After the improvement of the general condition, a precise diagnosis is required in order to commence the definitive treatment. Certain manoeuvres such as open biopsy, imaging guided core biopsy and/or pleural aspiration are often performed for a final tissue diagnosis. The less invasive procedures should be conducted first to reduce the potential risks in these critical patients; however, if failed, invasive approaches are mandatory .Surgeons must practise and have expertise in advanced life support to treat emergencies and complications in paediatric oncology.Surgeons must be aware of the characteristics of paediatric oncology diseases and their urgencies to correctly manage patients, without impairing the oncological prognosis.Be aware that surgical complications can occur in the postoperative period.In neutropenic patients, treatment should be tailored individually. Conservative treatment often is enough for the majority of scenarios, but surgery can be needed.In case surgery is indicated, the multidisciplinary team should talk about the best timing to operate the patient and the surgeon should not be afraid to operate, if there is blood products and ICU support available. The pleural space may be the site of various emergency conditions in children with malignancies notably here malignant pleural effusions with widespread lung metastases. This space is occupied by pleural fluid, which is generated as a result of hydrostatic and oncotic pressure gradients between the pleural space and plasma. The pleural fluid is drained by lymphatics and capillaries at an estimated rate of 20 mL/hour/haemithorax in an average weight 70-kg person.Pneumothorax is defined as entry of air into the pleural space, most frequently as a consequence of trauma or local lung abnormalities, and it can result in decreased lung expansion and significant impairment of gas exchange. Massive pneumothorax may lead to mediastinal shift and cardio-pulmonary compromise. Pneumothorax has been identified as a complication before treatment or after initiation of chemotherapy, radiation or targeted biological therapy in patients with lung malignancies . RemovalPleural effusions represent the accumulation of serous fluid in the pleural space. They could be either transudative or exudative based on the composition of the fluid and the aetiology. Large pleural effusions require chest tube for drainage as they restrict lung expansion. Malignant pleural effusions may also occur in children with lung/breast cancers (rare), lymphoma or sarcomas and are almost exclusively (95% of cases) caused by metastases in the pleural space. Chemotherapy-induced pleural effusion (Gemcitabine/Docetaxel) has also been described, usually in combination with anasarca. They may require diagnostic aspiration of pleural fluid for cytology or insertion of a chest tube for therapeutic purposes  , 3. PleuHaemothorax is the presence of blood inside the pleural space. Haemothorax can be secondary to tumour rupture, tumour vascular invasion or interventions , and should be drained after correction of any clotting abnormalities to ensure lung expansion and monitoring of blood loss. Indication for thoracotomy would be a massive haemothorax, defined as 15 mL/kg initial tube drainage, or ongoing bleeding, defined as 3–4 mL/kg per hour over 4 hours.Complete drainage of blood is of essence to prevent empyema and fibrothorax. Empyema and chylothorax represent other two conditions in which chest tube insertion may be required.In cases of chylothorax, conservative treatment with diet and octreotide is the best option and mostly sufficient, unless respiratory distress develops.Drainage of the pleural space can be achieved using a sterile silicone or polyvinyl chloride tube inserted into the pleural cavity through the chest wall and connected to a drainage system. Both open and percutaneous (Seldinger) techniques can be used for insertion. The size of the chest tube depends on the nature of the fluid as well as the size of the patient. The procedure is performed in sterile conditions, either as a bedside manoeuvre or in the operating room. For the most part, tubes are inserted in the mid clavicular line in the fourth intercostal space, but certain circumstances, such as loculated effusions may require a different site. In this instance, the use of ultrasound guided techniques should be employed. Care should be taken to insert the tube over the top of a rib, to avoid injury to the neurovascular bundle that runs below each rib. Pleural drainage systems are available for connection to the chest tube, either as continuous or intermittent aspiration techniques.Special care should be taken post insertion to ensure adequate functioning of the drainage system. Kinking, obstruction, dislodging or disconnections of the chest tube are common complications that should be avoided. Local complications related to chest tube insertion such as bleeding or soft tissue injury may need specific wound care management.There are no absolute contraindications for the procedure, but coagulation parameters should be ideally normalised in children with bleeding disorders or in those receiving anticoagulant therapy to reduce the risk of ongoing bleeding.Recently, there has been a move towards the use of soft chest tubes or pigtail-like systems for pleural space drainage especially in children . Both teChest tubes are larger in size (28–40 Fr) and allow better drainage of haemothorax and thick fluids. Their insertion is more painful and requires larger skin incisions. Due to their large size, injuries to chest wall structures can occur and may result in serious complications such as bleeding from intercostal arteries or pneumothorax. Their use has also been linked to complications such as lung injury, dislodgement, open or tension pneumothorax. Their overall efficiency is estimated to be around 80% . It is rUltimately, the choice of pleural space drainage technique should be decided by the paediatric surgeon and based on the nature of drainage required as well as the available resources.Multiple lumen catheters are indicated in patients undergoing intensive treatments or stem cell transplantation, because of complexity of therapies, since administration of multiple intravenous drugs and solutions is accompanied with non-negligible risk of undesirable reactions of the drug interacting with other substance . For those reasons, dual lumen vascular access devices are often preferred and their placement is strongly encouraged by physicians. However, handling and caring of multiple lumen catheters is associated with higher risk of infection compared to single lumen devices (more manoeuvres and actions required), so their use as the first-choice device is still debated.In case of catheter-related blood stream infection, catheter removal should be considered, depending on the agent and the remaining venous access sites. This procedure should be done in a dedicated procedure room equipped with adequate facilities, under sedation, with trained medical and nursing staff and according to institutional guidelines. Surgical technique must include blunt dissection and removal of the polyester cuff together with the device. A retained cuff may remain as an innocuous foreign body, but may also be nidus for infection/chronic inflammation, may create determine a false image  at radiology and last but not least have a cosmetically unacceptable reaction on the skin of the patient. In selected cases, change of catheter over a guidewire could also be considered, in order to minimise risks of anaesthesia/surgical procedure during septic condition or in the most acute phase of aplasia.Catheter dislodgment and/or tip migration may lead to malfunction or inability to impossibility in using the device either in infuseion or withdrawing blood-draw and, in worst cases, to complete removal. Children undergoing chemotherapy and/or high dose steroids are more prone to these complications for different reasons . Strategies to reduce those events includes the use of non-cuffed third generation polyurethane  secured with both sutureless devices and subcutaneously anchored securement systems. Use of cyanoacrylate glue on the exit site has been also demonstrated to be a valid option to reduce failure of VADs also in the paediatric population Please also refer to: IPSO Guideline: Venous access for the paediatric cancer patient. page 38TLS is a metabolic and oncological emergency that is encountered in oncology clinical practice and may occur spontaneously or shortly after administration of chemotherapy. It is associated with hyperkalaemia, hyperphosphataemia, hypocalcaemia and hyperuricaemia leading to end-organ damage. Most symptoms are related to the release of intracellular chemical substances that cause impairment in various organs. This can lead to acute kidney injury, fatal cardiac arrhythmia(s) and death. Since this condition is lethal, it is imperative to promptly identify patients at high risk for developing TLS and to start preventative therapy .The diagnosis is based on laboratory and clinical criteria that were declared in 2004 to identify those patients who have metabolic abnormalities at baseline (spontaneous TLS) or after initiation of cytotoxic therapy –11. A grClose observation, monitoring of fluid status and laboratory investigations, and the use of sufficient intravenous fluid and hypouricaemic agents are the main preventative options. Prevention is focused on preservation of renal function. Prophylaxis should be started whenever possible prior to the initiation of chemotherapy, especially in those patients where tumour lysis may occur, such as patients with very large tumour burden.It is fundamental to obtain baseline values prior to the initiation of cytoreductive therapy or administration of hypouricaemic agents. Monitoring includes serum uric acid, electrolytes, lactate dehydrogenase and creatinine levels. Hydration and diuresis are essential for management. Adequate hydration improves the intravascular volume, enhances renal perfusion and glomerular filtration rate and further promotes the urinary excretion of uric acid, potassium and phosphate. This scenario may consequently delay and prevent the need for renal replacement therapy.de-novo synthesis of uric acid and it is the preferred prophylactic agent in low-to-intermediate risk patients. However, it has several limitations as it does not break down preexisting uric acid and urate nephropathy can occur. Consequently, it is not the preferred agent in the presence of hyperuricaemia. Furthermore, xanthine nephropathy should be considered in patients who develop TLS while receiving appropriate prophylactic therapy with allopurinol. Allopurinol is excreted by the kidneys and the dose should be accordingly adjusted in those patients with renal insufficiency. Additionally, hypersensitivity reactions may happen. Lastly; because allopurinol reduces purine degradation, chemotherapeutic agents such as 6-mercaptopurine and azathioprine must be dose reduced by 50%–70% when concurrently administered. Rasburicase is a recombinant urate oxidase that converts uric acid to the highly soluble form allantoin. Therefore, it is an effective alternative to allopurinol in the treatment of hyperuricaemia and it is the preferred prophylactic agent for patients at high risk of TLS. It is also the treatment of choice for established TLS.Allopurinol is a xanthine oxidase inhibitor that blocks Patients with hyperkalaemia or hypocalcaemia should be placed on intensive cardiac monitoring, and laboratory and chemical tests should be repeated every 4–6 hours due to the risk of fatal cardiac arrhythmia. A serum potassium level above 7.0 mEq/L or widening of the ECG QRS complex requires immediate intervention. Standard therapies to decrease the potassium level include loop diuretics, insulin and glucose, inhaled β-agonists, polystyrene sulphate and calcium gluconate for symptomatic hyperkalaemia or electrocardiographic changes. These measures are often a temporary bridge to haemodialysis. Hyperphosphataemia is treated by phosphate binders; however, the presence of secondary hypocalcaemia can be life-threatening and generally necessitates the use of haemodialysis.Indications for renal replacement therapy in TLS are similar to those in patients with other causes of acute renal injury. Such indications include significant fluid overload, uraemia, severe electrolytes and metabolic disturbances. This is particularly true in TLS cases with oliguria because of potentially rapid release and accumulation of electrolytes and metabolites, which could lead to sudden death. Hyperphosphataemia-induced symptomatic hypocalcaemia may also warrant dialysis, in which continuous renal replacement therapies (CRRT) may be the preferred modality as phosphate clearance with dialysis therapy is time-dependent. For these reasons, CRRT such as haemofiltration, haemodialysis and haemodiafiltration are preferred rather than peritoneal dialysis, as these approaches result in better phosphate and uric acid clearance rates and faster clinical improvement. There are no major trials showing which approach of haemodialysis is more superior to the other. For the majority of patients, intermittent haemodialysis may be enough. However, in patients with rebound of electrolytes imbalance with intermittent haemodialysis, CRRT may be required. Dialysis should be carried out until there is adequate return of renal function and urine output. Prophylactic CRRT in children at high risk of TLS was also reported to be beneficial , 13.Hyperleukocytosis (HL) is considered when peripheral blood leukocyte count exceeds 100,000/mm3, with acute leukaemia as its most common aetiology in paediatric oncology practice. The increased blood viscosity secondary to high white cell count and leukocyte aggregates, results in stasis in the small blood vessels. This predisposes to neurological, pulmonary or gastrointestinal complications. In addition, such patients are at risk for TLS due to the increased tumour burden , 15. IniHyper-hydration is indicated in all patients affected by HL, with the goal of haemodilution and reduction of viscosity. Aggressive hydration is generally performed at levels of 2–3 l/m2/d, or 200 mL/kg/d for patients with a body weight of less than 10 kg with the aim of maintaining a urine output greater than 4 mL/kg/h for infants and 100 mL/m2/h for older patients. The use of balanced or isotonic solutions related to the patient’s age, cardiac function and urine output is recommended. Potassium must not be added to the hydration fluid. Renal replacement therapy should be considered if necessary .Coagulation abnormalities include DIC, thrombocytopenia and anaemia. DIC is mainly determined by high cell turnover and associated high levels of released tissue factor that triggers the extrinsic pathway via Factor VII. Since TLS may occur as a result of spontaneous or treatment-induced cell death, DIC and TLS are closely related. The treatment of DIC is primarily directed against the cause that produces the blood coagulation disorder. It is based on platelet transfusions and standard measures to restore normal coagulation such as substitution of FFP or fibrinogen.The initiation of induction chemotherapy is an essential part of the treatment of HL and leukostasis. In some patients, it has contraindications for immediate induction treatment such as severe metabolic disturbances or renal insufficiency. Intravenous steroids should be started at low dose then gradually escalated to full dose and this can lead to significant reduction in the circulating WBC count.Leukapheresis is a procedure that involves the withdrawal of circulating blast cells from the body, with re-infusion of leukocyte-poor plasma through a mechanism of separation and retention of blood components. The aim of this procedure is to reduce the peripheral white blood count, limiting the severity of TLS and DIC. It can be continuous or discontinuous, depending on the technique of blood sampling and infusion used. It is typically reserved for patients with symptomatic HL who are unable to start induction chemotherapy immediately. Contraindications such as cardiovascular comorbidities, haemodynamic instability and coagulation disturbances should be evaluated carefully in order to avoid any extra-procedural risk for the patients.A single session of leukapheresis reduces the WBC count by 20%–50%. A reduction of 50% in the peripheral count is equivalent to an 85% decrease of the circulating WBC mass. However, the effect is generally transient since blast counts often rebound quickly after leukapheresis. The decision to perform additional leukapheresis procedures should be based on symptoms and peripheral WBC count. Leukapheresis cannot be recommended for routine therapy as a treatment in patients with high blast counts because of its potential complications. Another problem regarding leukapheresis is that it requires specialised equipment and trained personnel that are not always available as well as the positioning of a vascular access –18. PaedThe majority of apheresis procedures are centrifugation based; therefore, they require withdrawal blood flow rates of 50–150 mL/minute. In contrast, filtration therapies require a blood flow rate of at least 150–200 mL/minute. Other considerations specific to therapeutic apheresis (TA) include whether the treatment relies on discontinuous, sequential blood exchange cycles (one lumen is sufficient) or continuous processing (two lumens are needed). When a CVC is necessary for a limited (<2 weeks) course of TA, a non-tunnelled, semi-rigid polyurethane catheter should be considered. For a longer duration (>2 weeks) of TA, a tunnelled CVC is preferred over a non-tunnelled CVC due to less risk of infection. Typically, tunnelled catheters designed for long-term use (weeks to months) are made of either silicone or polyurethane, the latter has a lower incidence of rupture and the least thrombogenicity. The preferred venous site of CVC insertion are the brachiocephalic vein and the internal jugular vein, and both ultrasound guidance with fluoroscopy have been shown to be associated with a lower rate of complications during insertion. CVCs are associated with a higher total complication rate. They include infection (2%–28%), thrombosis (0.2%–11%), haemorrhage (2%–14%) and venous stenosis (10%–26%) with internal jugular catheters and up to 42% with subclavian vein catheters. In most series, the incidence of total adverse events associated with all vascular access devices is low at 1%–2%, especially when ultrasound guidance and the brachiocephalic vein are routinely considered , 21.Tracheostomy is a commonly performed manoeuvre in adult patients; however, such procedures are less often undertaken in children and conducted in about 3% of all paediatric patients . PaediatClinical assessment is usually conducted rapidly through vital signs measurement, followed by evaluation of oxygen saturation. Administration of corticosteroids may temporarily improve the airway function; however, in patients without significant improvement and with progressive respiratory distress, urgent tracheostomy is a lifesaving procedure.The procedure is performed under aseptic precautions and general anaesthesia with endotracheal intubation (with or without fibre optic guidance). The laryngeal or face mask may be other options for anaesthesia if difficulty in intubation is encountered. The tracheostomy operation is conducted in the supine position with a slight extension of the patient’s neck. A transverse skin crease incision  is deployed due to its cosmetic advantage, however a vertical one is theoretically considered less vascular. Blunt dissection is continued thereafter in the vertical plane using an artery forceps in the midline followed by retraction of the strap muscles until the trachea is visible. Haemostasis is achieved by bipolar diathermy to obtain a bloodless operative field. The isthmus of thyroid gland is dissected then the tracheal fascia is opened to expose second, third and fourth tracheal rings. Two stay sutures are placed on either side of the airway and a vertical incision created between the stay sutures. Bleeding and/or other secretions should be properly suctioned to clear the surgical field, and a suitable-sized tracheostomy tube is inserted and secured to the neck to complete the procedure. The endotracheal tube is removed once the tracheostomy is secured in place. A flexible fiberoptic bronchoscope can be used to assess the final anatomical position of the distal part of the tube that should ideally be placed alongside the second, third and fourth tracheal rings .Postoperative management of the tracheostomy tube is crucial as the majority of children may require a long-duration placement or even a permanent tracheostomy. Such care of the tube is usually performed by a trained stoma nursing team or by the parents after further training. Early and late complications of the tracheostomy procedure in children are not uncommon, with an incidence rate that varies between 7% and 40% in published studies . BleedinTracheostomy insertion in paediatric oncology patients is a critical surgical manoeuvre that needs special perioperative protocol(s) by the team care-givers to manage the child safely meanwhile avoiding any serious consequences.Surgeons must practise and have expertise in advanced life support to treat emergencies in paediatric oncology.Surgeons must be aware of the characteristics of paediatric oncology diseases and their urgencies to correctly manage patients, without impairing the oncological prognosis.Be aware that surgical complications can occur in the postoperative period.In neutropenic patients, treatment should be tailored individually. Conservative treatment often is enough for the majority of scenarios, but surgery can be needed.In case surgery is indicated, the multidisciplinary team should talk about the best timing to operate the patient and the surgeon should not be afraid to operate, if there is blood products and ICU support available. BMT patients often develop life-threatening conditions with similar clinical presentations but different aetiologies. Histological and microbiological examination of biopsies from the affected organ may be the only means of arriving at the diagnoses .Most patients manifest a wide range of non-specific symptoms and signs. The symptoms may be related to GI system, pulmonary, hepatobiliary or skin (most maculopapular rash). Radiological imaging modalities are unlikely to provide definitive diagnoses . If requComplete blood counts, clotting profile.Relevant radiological imaging associated with the condition of interest.Biopsies should be obtained by the least invasive means. Sigmoidoscopy is preferred over colonoscopy for GI biopsy. Percutaneous image-guided biopsy core needle or Tru-cut biopsy of liver and lung is preferred over an open incisional biopsy.It is essential that patients are as stable as possible before going to operating theatre. Good communication between the medical and surgical teams is critical. Patients should be adequately supported with the necessary blood products. In general, the ideal preoperative hemoglobin should be at least 10 g/dL, platelets > 80 × 109/L and INR less than 1.2. A lower haemoglobin level may be acceptable if the patient has chronic anaemia, and refractory thrombocytopenia may be overcome by platelet transfusion at the induction of anaesthesia so as to maximise the platelet concentration at surgery. The procedure should always be carefully planned to reduce the amount of time spent. Childhood cancers represent nowadays 1% of all cancers. Advances in understanding paediatric cancers and their biology allowed improving therapeutics, leading to 80% long-term overall survival . FertiliThey may result from gonadotoxic treatments as chemotherapy and radiotherapy but also from mutilating surgery .In girls: Alkylating agents (such as cyclophosphamide) which are widely used and particularly in conditioning high-dose chemotherapy are the most prone to lead to ovarian failure.Ionising radiation acts on dividing and non-dividing cells. As with chemotherapy, the effects of radiotherapy on ovarian function depend on the patient’s age, the field of treatment, the daily treatment doses and the total amount of radiation received. Doses of 10–20 Gy in children and 4–6 Gy in adults are associated with permanent ovarian failure. In addition, irradiation of the uterus in the childhood is known to predispose to premature delivery or to get offspring with low birth weight . Dose frIn boys: The prepubertal gonads are sensitive to the gonadotoxic effects of chemotherapy administrated during childhood. In males, alkylating agents may affect spermatogenesis, but testosterone secretion is usually well preserved.In contrast, radiation therapy affects both spermatogenesis and testosterone secretion. Spermatogonia are impaired by doses as low as 0.15 Gy and completely die from a dose of 2 Gy. Prepubertal boys seem to be more susceptible to the effects of irradiation on spermatogenesis and Leydig cell function than adolescent and adult males. It should be noted that, in contrast to females, fractioning doses induce a much higher toxicity than that of a single dose. Lastly, irradiation doses above 25–30 Gy on the HPA-axis can induce hypogonadotropic hypogonadism with dose-dependent relation , leadingp < 0.001)) with sperm alterations has been reported in a follow-up study including 1,600 patients treated for childhood cancer [A 50% decrease in descent has been reported in childhood cancer survivors versus random adults  and a sid cancer , 12.Blood analysis: Complete blood count and coagulation profile, if surgical treatment is being considered. In addition, if cryopreservation is planned, serologies for virus are usually required /Venereal Disease Research Laboratory (VDRL)).Imaging: No imaging is needed but in case of gonadal transposition to protect form radiotherapy, it is mandatory to share the planned radiotherapy field with the radiotherapist in order to displace the gonads appropriately.Regarding the wide spectrum of proposals for preservation of fertility which depends on the age, tumour type and treatments, it is highly recommended to discuss indication for fertility preservation in a multidisciplinary board integrating medical oncologist, radiotherapists, preservation fertility specialists.A detailed informed consent is proposed and discussed with the patient and his/her parents.In girls, ovarian sparing surgery is mandatory to preserve fertility in case of benign ovarian tumours, which represent around 90% of childhood ovarian lesions (benign germ cell tumours (GCTs) or benign epithelial tumours).Indeed, 13% of ovarian teratomas are bilateral (either synchronous or metachronous) , 15. In In everyday practice, deciding whether to spare the ovary because the lesion seems benign or to perform a total ovariectomy because signs of malignancy are present is not always straightforward. Two different situations should be considered. In asymptomatic (painless) girls, the surgeon has enough time to perform reliable imaging  and to dose tumour markers alpha-fetoprotein (AFP), human chorionic gonadotrophin (HCG), Inhibin B, anti-Mullerian hormone and Calcaemia. When the patient is complaining of acute pain due to adnexal torsion or ovarian rupture, the best approach is to perform a laparoscopic exploration in emergency. If ovarian rupture is diagnosed, peritoneal inspection, sampling of ascites is the rule. Complete ovariectomy or adnexectomy in the same operative time should be discussed only if the ovary and/or the peritoneum indicate malignant features. If adnexal torsion is seen, detorsion is recommended as it allows to approach the potential underlying diagnosis  with imaging and markers dosage in the post-operative period.Operative technique: it is highly recommended to start with laparoscopic exploration of the abdominal cavity, with sampling of ascites in the upper abdomen and pelvis and sampling of any peritoneal suspect lesions, particularly on the diaphragm. Ovarian sparing surgery is then performed through a suprapubic incision (Pfannenstiel). Although this approach is debatable, as some surgeons prefer complete laparoscopic resection, this technique allows to spare as much ovarian tissue as possible while avoiding any intraperitoneal spillage  [ponents) .Postoperative follow-up with repetitive pelvic ultrasound examinations during childhood is recommended to rule out metachronous ipsilateral or contralateral lesions at an early stage, allowing iterative sparing surgery. This follow-up also gives the opportunity to inform the young girl about the symptoms that should alert for a potential adnexal torsion and in case of an important amputation of the ovarian parenchyma of the different assisted medial procreation techniques available after puberty.Preservation of genital tract should also be considered when surgery is planned for tumours involving these structures. Different entities encountered are: rhabdomyosarcoma (RMS) of the vagina, cervix or uterus, malignant GCTs of the vagina and clear cell adenocarcinoma (mostly diagnosed later in life). Prognosis of these tumours relies on the local tumour control obtained nowadays with less radical surgical management than in past decades. For urogenital RMS, treatment may be achieved without surgery when remission is obtained after chemotherapy or may be completed by local brachytherapy avoiding mutilating surgery, which is currently exceptional , 18. ForOvarian transposition was the first procedure proposed to preserve fertility in girls with cancer and is indicated for patients with tumours requiring pelvic radiations of 42–58,4 Gy, much higher doses than those that can induce loss of ovarian function 4–20 Gy) . Prelimi Gy . PreIrrespective of the surgical technique, ovarian transposition aims to place the ovaries outside of the irradiation field. The planning target volume should be precisely defined by the surgeon and the radiotherapist before ovarian transposition. Various sites for ovarian transposition can be considered. In case of a midline irradiation field , both ovaries are usually placed away from the midline, laterally in the paracolic gutters, or laterally and anteriorly near the inguinal ring . In case of a lateral tumour (RMS or Ewing’s sarcoma), the compromised ovary is placed on the opposite site of the tumour . In some cases of Hodgkin’s lymphoma, when the irradiation field implicates the bilateral iliac chains and inguinal regions, the ovaries are placed in line with the iliac crests  .Laparoscopic ovarian transposition is performed under general anaesthesia. The bladder is emptied with a transurethral Foley catheter. The patient is positioned supine and in Trendelenburg position, which causes the intestine to fall into the upper part of the abdomen to free the pelvis and enable visualisation of the genital tract. An umbilical trocar is inserted either via an infra-umbilical incision or directly through the umbilicus. Carbon dioxide is insufflated at a pressure of 8–12 mm Hg dependent on the patient’s age and weight. Two working trocars (3–5 mm) are inserted under direct vision into the right and left hypogastric regions, almost as the same level as umbilicus, depending on the child’s age. A 0° or 30° angled camera can be used. In most of the cases, is it not necessary to section any ovarian ligament. In prepubertal girls, the ovaries are located higher in the pelvis and the ligaments are more stretchable than in adult women . The bloIn case of pelvic brachytherapy, ovarian transposition is only needed for a short time. The ovaries can then be sutured to the anterior abdominal wall by a transfixing stitch of non-resorbable suture material, knotted on the outside of the patient on a pledget. The stitch knotted on the outside holding the ovary to the abdominal wall is removed at the end of brachytherapy, to return the ovaries to their normal position without the need for reoperation .Whatever technique used, the surgical procedure should be performed as close to the time of radiation treatment as possible, due to the risk of remigration of the ovaries .Few studies have reported long-term results of ovarian transposition in children. Preservation of endocrine function has been estimated to range between 60% and 80% , 28. ConIn some cases, radiation is an important complementary treatment. But the area can involve the pelvic region and result in deleterious effect to fertility, which may affect the uterus and ovaries. Uterine and adnexal transposition to an upper abdominal region during radiation therapy may protect these organs with security. Some successful cases are described in adult women  and a reMain indications nowadays are represented by myeloablation before bone marrow transplantation, total body irradiation and high dose chemotherapy with alkylating agents .There is some controversy about the amount of ovarian tissue to retrieve as some teams propose to do a partial ovariectomy or to harvest only the cortex . Since fLaparoscopic ovariectomy for cryopreservation is performed under general anaesthesia. The bladder is emptied with a transurethral Foley catheter. The patient is positioned supine and in Trendelenburg position. An umbilical trocar is inserted either via an infra-umbilical incision or directly through the umbilicus. Carbon dioxide is insufflated at a pressure of 8–12 mm Hg dependent on the patient’s age and weight. Two working trocars (3–5 mm) are inserted under direct vision into the right and left flank, almost as the same level as umbilicus, depending on the child’s age. A 0° or 30° angled camera can be used. The ovary is grasped with atraumatic forceps. Haemostasis is performed with bipolar haemostatic forceps, and the mesovarium is cut with scissors. The ovary is placed within a bag and removed via the umbilical trocar.After isolation and fragmentation, ovarian cortex fragments are slowly frozen in an automated freezer down to temperature of liquid nitrogen, in which they are stored. Histological analysis of some fragments is mandatory as it allows searching for malignant cells in both cortex and medulla, particularly in tumours with potential ovarian spread  and also to estimate the follicular wealth of the tissue, notably in case of previous gonadotoxic treatment.in vitro maturation of primordial follicles. Since Donnez et al [et al [et al [et al [Cryopreserved ovarian fragments might further be used for either autografting or ez et al , 36 and l [et al  publishel [et al . The oval [et al  confirmel [et al  reportedl [et al .et al [in vitro culture of primordial follicle harvested from the cryopreserved tissue, a technic which is currently still experimental [A major problem raised by autografting of previously cryopreserved ovary is the risk of reintroduction of the primary disease in the patient’s organism, especially when the primary disease is likely to give metastasis to gonads such as leukaemia or lymphoma. Shaw et al  managed et al , 41. A wrimental .The most common types of prepubertal testicular tumours are GCTs: benign GCT (teratoma) and yolk sac tumours (YST) , 44. TheIn the GCT group, testicular sparing surgery has become the standard of care for teratomas, but malignant YST can only be treated by radical orchidectomy. The operation is performed through an inguinal incision, with early control of the spermatic cord at the internal ring as in radical orchidectomy. Intraoperative frozen sections can be useful to rule out malignancy.et al [Regarding sex cord-stromal tumours, although considered malignant, the excellent prognosis after inguinal orchidectomy in non-metastatic tumours –47, and et al  proposedDuring the pelvic radiation therapy, testis can be the subject of unintended exposure, due to lack of protective devices or malpractice. So the option is to protect this region with a clam shell-shaped device. It is positioned around the scrotal sac to reduce testicular exposure , 52.Temporary transposition of one or two testis in the inguinal region has been proposed for patients requiring radiotherapy to the scrotum in some cases of paratesticular RMS or in brachytherapy for bladder-prostate RMS . After sin vitro fertilisation, mainly intracytoplasmic sperm injection (ICSI) procedure.While semen cryopreservation is an established way to preserve fertility in adult male patients, it is more difficult in adolescents. Pubertal boys can be unable to provide a semen sample via masturbation for sperm banking. In these patients, semen can be obtained via penile vibratory stimulation, electro-ejaculation, testicular sperm extraction (TESE) or microdissection TESE (mTESE) under general anaesthesia . What main vitro or in vivo after reimplantation, as reported in animal models [in vitro after subsequent reintroduction into seminiferous tubules, once the patient is cured and pubertal; alternatively, conserved sperm could also be used for ICSI. Testicular tissue can also be autotransplanted into the patient’s own testis, waiting for spermatogonia to differentiate into mature sperm cells [in vitro maturation of germ cells.The technique of sperm banking cannot be applied to prepubertal boys as they lack mature spermatozoa. Thus, following the example of female patients, testicular cryopreservation in prepubertal patients has been proposed. Before gonadotoxic cancer treatment is started, part of the testicular parenchyma is harvested via an open scrotal approach under general anaesthesia. One side or two sides testis harvesting is done according to local usages. When bilateral, one longitudinal approach along the median raphe or two scrotal approaches may be performed. There is no consensus on the volume of testicular tissue to harvest. The fact that there is a heterogeneity in the distribution of spermatogonia within the testis may favour a bilateral harvesting in order to get as much as cells as possible, and has a cosmetic advantage as both testis display then the same volume. The prepubertal testis contains germ cells from which spermatozoa can potentially be derived l models –56. Immarm cells . This term cells , 59. Itsrm cells , 60. HowWhile important advances have been achieved in childhood cancer treatment, with a lower mortality and a better life expectancy, consequent loss of fertility remains an important issue. At the initial treatment planning, efforts must be made to preserve fertility in both boys and girls. Organ sparing surgery in gonadal tumours is the best and easiest way when malignancy has been excluded. In young girls treated by abdominal and/or pelvic radiotherapy, ovarian transposition is the technique of choice (with or without associated ovarian cryopreservation). In children receiving gonadotoxic treatments, ovarian and testicular cryopreservation should be proposed as they appear very promising and remain currently the only suitable method for pre- and post-pubertal children. Finally, in view of the broad range of fertility protection methods available and progress in medically assisted reproductive techniques, the best option of fertility preservation and follow-up should be established at a multidisciplinary meeting, as soon as the treatment protocol has been defined. Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual’.Palliative surgical oncology is a relatively new term for an ancient problem. Adopted from the adult nomenclature, it now has the need to explode in the paediatric field. In children, unlike with adults, the focus is not on the individual patient that needs the palliative care plan but rather necessitates intense involvement of the family, caregivers and community for successful implementation. This topic is so important and delicate that it has earned the following definition from the World Health Organization (WHO): ‘palliative’ is from the Latin term pallium – dress or overcoat of ancient Roma and the verb ‘palliation’ means to cloak or to cover. The reason to cloak or to cover a subject, could be to either hide something or to protect against something. In medical and surgical care, this coverage is not to hide but rather to protect the subject.The etymology of the word ‘surrender until the last moment of your life. There are now great advancements in paediatric oncological treatment protocols. Contrary to the early interpretation of palliative, as surrendering to an unmanageable phenomenon, it is now more appropriate to interpret it as ‘protective’ care.The discussion of palliation may seem to be a semantic or philosophical issue but it is important to get to the more correct meaning of the word, which helps us understand its clinical importance and implications. In 1967, Cicely Sunders – forerunner of palliative care said that you feel a sense of Wayne State University School of Medicine in 1985 at Detroit Receiving Hospital. The first palliative medicine programme in the United States was started in 1987 by Declan Walsh, MD, at the Cleveland Clinic, Cleveland, Ohio. This is the first comprehensive integrated programme designated as a WHO international demonstration project and accredited by the European Society of Medical Oncology as an Integrated Center of Oncology and Palliative Care. Other programmes followed: The Palliative Care Program at the Medical College of Wisconsin (1993), Pain and Palliative Care Service, Memorial Sloan-Kettering Cancer Center (1996) and The Lilian and Benjamin Hertzberg Palliative Care Institute, Mount Sinai School of Medicine (1997). Since then there has been a dramatic increase in hospital-based palliative care programmes, now numbering more than 1,400. 80% of the USA hospitals with more than 300 beds have a programme at the moment.The first United States hospital-based palliative care consult service was developed by the Ubuntu’ which basically says that one’s humanity is dependent on the appreciation, preservation and affirmation of the other person’s humanity.Recent palliative care plans involve multidisciplinary protective support in social, emotional, spiritual, mental, financial and physical aspects. Modern palliative care plans are highlighted in the African philosophy of ‘For many years, palliative care was not offered to paediatric patients and even today, in Europe, Asia and Africa, only a minority of children with incurable illnesses benefit or have the luxury of a dedicated palliative care service.Paediatric oncology is seen as one of the success stories of the cancer world. The overall survival rate in developed countries is up to 80%. Survival rates in middle- and low-income countries are, however, much lower. Unfortunately, in South Africa, the survival rate is closer to 50% and even lower in other African countries. This is due to late presentation, late diagnosis, poor accessibility to treatment and management centres and a vast variation in culture, health behaviour and beliefs. This necessitates for comprehensive palliative care teams and management programmes. A dedicated, separate palliative care service is a luxury in most of Africa and other low income countries due to resource constraints. South Africa has, however, demonstrated that effective multidisciplinary palliative care that involves the family and community of the children can be successfully implemented even in resource-limited settings. Often this success is made possible by the assistance, voluntary and unstructured forms of activities and participations.Children with life-limiting and/or life-threatening illness deserve a thorough cultural and organisational reappraisal of how we care for them when treatment is not aimed at recovery but at offering the best quality of life possible. In this respect, children with life-limiting and life-threatening conditions and their families have diverse and multiple needs:Managing signs and symptoms, such as pain, skin reactions, nutrition and development by using pharmacological and non-pharmacological means in an attempt to reach a balance between relief of adverse events and avoiding too many hospitalisations and/or focusing only on treating ailments and sacrificing other aspects of quality of life.Palliative care needs time. It cannot be rushed. It needs patient contact. It needs ‘heart’. Yes, treating the physical signs and symptoms are important, but a time will come in the management plan when the soul needs the most caring. To achieve the psychological support, there must be open and clear communication, continual emotional support to help the child, family and society to cope with the emotional issues . The care plan should offer access to resources and tools that promote the development of the child’s personality, continuation of daily routines, motivation to achieve targets and realistic future goals.It is important to have recreational opportunities that are appropriate for the individual’s needs, to have the child remain an active school participant and to be an age-appropriate socially functional community member. A comprehensive paediatric oncology palliative care plan should encourage opportunities for peer-group interactions, spiritual and religious fulfilment and partaking in family and cultural aspects.The current picture of the size of the problem (data as best collected in 2021) is illustrated in Numerous advancements in managing children with cancer have led to improved survival rates. This in turn means that there are more children surviving and longer survival periods. This results in more patients requiring palliative care and for longer periods of time. This again highlights the importance of establishing effective palliative care programmes for oncology children.life for the longest possible period of time. This may involve, but is not limited to:The role of palliative surgery is to achieve the best quality of to obtain correct and representative biopsies that facilitate confirming the diagnosisintravascular access for short- and long-term usagecurative or tumour-debulking surgeries where beneficialfunction-sparing surgery where possibleminimal access surgery, early or appropriately timed surgery to avoid lengthy and/or intensive chemotherapy or radiationprocedures to aid feeding and nutrition to allow for nourishment and growthmanagement of clinical signs, symptoms and adverse effects, such as soft tissue infections, bleeding and obstruction of the gut, urological system or biliary system, ascitis, pleural effusions, accesses to dialysis.A paediatric surgical oncologist continuously battles the conflict between science and consciousness, as they try to reach a balance between the clinical and ethical aspects of palliative care. For this dilemma, there are no guidelines that can serve as a ‘one-size-fits-all’ solution. Each patient must have an individualised care plan. Personalised considerations must be made for available, feasible and beneficial surgical options.It is more challenging to offer quality palliative care because the illness trajectory is often unpredictable. It is advisable to start introducing palliative care principles from the first diagnosis so that if the chances of cure become small, the mutual understanding between children and parents and good communication makes a rocky road easier to navigate and the grieving process less complicated. The question for the surgical management of palliative care patients remain: ‘How far is too far?’, ‘What is far enough?’ and ‘How far is not far enough?’In 2005, the American College of Surgeons published their statement on the principles of palliative care .PainBleedingObstruction FeedingVascular accessFluid collectionsIntracranial hypertensionRespiratory complicationInfections managementSelective intra-lesion therapiesTumour surgery (biopsies and resections)Pain is the first and most important sign because it hinders the quality of life. Many factors apart from physical causes may influence the pain experience [perience –3. Take perience –9. When perience –16, cryoperience –27, cordperience –68.Bleeding can be an occasional immediate life-threatening complication in paediatric cancer patients. Consider the intention of each element of treatment in palliative care. Is it comfort care, invasive therapeutic care or both? If the quality of life may be preserved with treating the bleeding, then haemorrhage must be treated by immediate transfusion of blood products and definitive stopping of the bleed .Bowel obstruction in children with cancer may be acute but is usually progressive in presentation. It may be due to many causes such as progression of tumour growth with a compressive effect on the gut, intra-luminally obstructing masses, a sequela of treatment with radiation therapy, previous surgery or aggressive medical treatment causing stenosis or occlusion. Intestinal obstruction will worsen the patient’s general condition and may negatively affect the performance status and thus influence the quality of life. The aim of treatment is to reduce the abdominal distention, relieve the obstruction and avoid respiratory compromise caused by increased intra-abdominal pressures. The principles of managing bowel obstruction in paediatric oncology patients is to relieve the obstruction and restore bowel continuity and/or bypass the obstruction while avoiding the complications of infection, metabolic and surgical adversities, while ensuring adequate feeding for meeting the nutritional requirements necessary for growth and development.Feeding is an important aspect of a good quality of life. The immediate assistance to meet nutritional requirements may be achieved by giving total parenteral nutrition (TPN) via surgically inserted central vascular catheters. Moderate- and long-term feeding options such as naso- or orogastric feeding, gastrostomy feeding tube or feeding jejunostomy can be offered.Urinary obstruction/bleeding is a symptom that requires urgent attention by urinary relief or diversion depending on the level of occlusive using transurethral catheter, supra-pubic catheter or stoma, double J stent/s or internal/external nephro-ureteral stents.Currently there is a lack of data that indicates the true incidence of urinary obstruction in paediatric patients with advanced primary or metastatic intra-abdominal malignancies and this results in a lack of clear guidelines for the management of urinary obstruction in children with cancer. The current clinical management strategies rely on liaison amongst paediatric surgeons, urologists, radiologists, interventionists, medical oncologists and the child and their support structure. With this in question, it is of fundamental importance to remember that these interventions would form part of the palliation in patients who often have terminal illness. The child’s wishes must be considered. Again, it is difficult to reach a balance on whether the benefits outweigh the burden of the intervention in palliative care.Vascular access: This is an extremely important surgical aspect of managing oncology children. Its importance is also pivotal in the paediatric oncology palliative management plan. There are two main groups of vascular access: peripheral and central. The indications of peripheral vascular lines are for intravenous fluids, medication, blood products administration and blood sampling. The surgical team is mostly relied on for the central line insertions. The role of central lines in the palliative management plan are for TPN, chemotherapy, managing the chronically ill child, long-term pharmacotherapy, emergency access, critical-care monitoring, dialysis, extra-corporeal membrane oxygenation and medication administration. Assessment must be made if the vascular access fits in with the end goals of care for each individual patient’s palliative care plan.Fluid collections: Refractory ascites may need surgical intervention to avoid abdominal distension, diaphragm lifting and splinting which may result in respiratory compromise and alterations of venous return to the heart which may affect all organ systems. Fluid collections in other organ systems  may follow and result in similar organ dysfunctions and may later result in failure of that organ system and more severely may have the sequalae of multi-organ failure. When non-operative and medical treatments such as bed rest, diet modifications drugs and fluid restriction fail, then several surgical procedures are available, if they do not impede on the child’s quality of life thereafter. Options available are drainage or shunting of the fluid to reduce the symptoms  and even organ transplantation if the child qualifies to be added onto the organ transplant waiting list. Every decision on surgical intervention must be tuned into the greater palliative management plan and idea of balancing the preservation of the quality of life and preparing the child and their community for a ‘good death’. Making objective and rational choices in emotionally painful and taxing situations is not easy because empathy and psychological defense mechanisms invariably come into play.Intracranial hypertension: Solid organ tumours make up about 30% of tumours in children. The most common solid organ paediatric tumour is brain tumours. The most aggressive sign and symptom of central nervous system tumours is intracranial hypertension which may cause neurological symptoms such as seizures, deteriorating levels of consciousness and debilitation. Quality of life can be surgically achieved by shunting  to reduce the intracranial pressure and where shunting is contra-indicated then drainage to reduce the pressure . These surgical interventions must be carefully decided on with consideration of all the parties involved in the child’s palliative management plan. In an effective palliative care plan, each surgical intervention must attempt balancing adequate pain and symptom control and avoid inappropriate prolongation of dying.Respiratory complications: What about the question of creating a tracheostomy in a child with cancer who is on a palliative management plan? Many paediatric oncology patients could benefit from a tracheostomy when treating conditions such as space-occupying lesion in the thorax, breathing fatigue or weaning patients off a ventilator. Tracheostomy procedure may aid to achieve better comfort for the patient, more effective airway suctioning, a decrease in airway resistance, an increase in patient mobilisation, simplification in the ability to speak, achieving oral feeding all of which make home management more possible and comfortable. When deciding on such interventions involve everyone whose views count in the ethical dilemma, which in the case of a tracheostomy includes the person who will be responsible for the stoma care at home. Be absolutely fair. Give each involved person a say and try not to discriminate against anyone, especially the child.Infections: The management of infections follows the same surgical principles in paediatric oncology palliative care. Infections must be treated actively to get source control . Where central line associated bloodstream infections (CLABSI) are suspected then paired  blood cultures could be done to assess for the possibility of CLABSI diagnosis. However, if the diagnosis of central line sepsis is confirmed, then the decision must be made on which decision in terms of removal of the line, replacement of the line or leaving the line in-situ will best aid in the most effective palliative care plan for the child.Selective intra-tumoural/intra-lesional therapies and minimally invasive surgical procedures must not be forgotten or underestimated by the surgical team in the palliative care plan of children with cancers. A good example is using intra-arteriolar chemo-infusion performed through super-selective catheterisation of the involved area in retinoblastoma. Image guided interventions for liver metastasis are also examples. These approaches may allow for symptom treatment with the preservation of the quality of life. When the child can tolerate the anaesthesia or sedation well for these surgical procedures to be carried out, then these surgical interventions are easily agreed upon by the whole palliation care team.biopsies to confirm the diagnosis and whether to operate resectable tumours are also usually fairly easy decisions to conclude. Ethical conflict comes into play when needing to decide on tumour debulking and resection of malignant metastases in palliative patients. The ethical decisions must be based upon beliefs, duties of all involved parties, consequences of treating or not treating, values and the rights of the child and the closely involved parties.Obtaining Protective surgical palliative care in paediatric oncology patients is of utmost importance. The surgical principles of managing palliative children with cancer is to respect the life and health of the patient, perform to acceptable standards, maximise the benefit for the patient and minimise the harm, respect the patient’s autonomy and to act rationally, honestly, fairly and professionally. The palliative care starts at the diagnosis of the condition. Each patient must have an individualised care plan which conforms to the principles discussed. The aim of palliative care is not only to help oncological children and their families to face (and hopefully overcome) cancer as peacefully and painlessly as possible, but also, if death is unavoidable, to gently support them at end of life. ‘The good physician treats the disease; the great physician treats the patients who have the disease’ – William Osler.