Initial experience with 3D laparoscopic choledochal cyst (CDC) excision and hepatico-duodenostomy (HD) in 21 children

INTRODUCTION

Minimal access surgery has gradually become the standard of care in the management of choledochal cysts (CDC). Laparoscopic management of CDC is a technically challenging procedure that requires advanced intracorporeal suturing skills, and hence, has a steep learning curve. Robotic surgery has the advantages of 3D vision, articulating hand instruments making suturing easy and thus is ideal. However, the non-availability, high costs and necessity for large-size ports are the major limiting factors for robotic procedures in the paediatric population. Use of 3D laparoscopy incorporates the advantage of 3D vision and at the same time allows the use of small-sized conventional laparoscopic instruments. With this background, we discuss our initial experience with the use of 3D laparoscopy using conventional hand instruments in CDC management.

AIM

To study our initial experience in the management of CDC in paediatric patients with 3D laparoscopy in terms of feasibility and peri-operative details.

MATERIALS AND METHOD

All patients under 12 years of age treated for choledochal cyst in a period of initial 2 years were retrospectively analysed. Demographic parameters, clinical presentation, intra-operative time, blood loss, post-operative events and follow-up were studied.

RESULTS

The total number of patients were 21. The mean age was 5.3 years with female preponderance. Abdominal pain was the most common presenting symptom. All patients could be completed laparoscopically. No patient needed conversion to open procedure or re-exploration. The average blood loss was 26.67 ml. None of the patients required a blood transfusion. One patient developed a minor leak postoperatively and was managed conservatively.

CONCLUSION

3D laparoscopic management of CDC in the paediatric age group is safe and feasible. It offers the advantages of depth perception aiding intracorporeal suturing, with the use of small-sized instruments. It is thus a 'bridging the gap' asset between conventional laparoscopy and robotic surgery.

LEVEL OF EVIDENCE

Treatment study level IV.

Posterior Sagittal Approach for Nonanorectal Malformation: Widening Spectrum

Background

Posterior sagittal is a very well accepted approach in the treatment of anorectal malformations. This approach provides good access and exposure through the perineum to the deep pelvic structures. It reduces risk of injury to important structures as dissection remains in midline.

Aims and Objectives

To access feasibility of posterior sagittal approach for non-anorectal malformation indications and to widen the spectrum.

Material and Methods

We present a series of 10 cases of non-anorectal malformations operated by this approach for 4 years.

Results

Six patients included in the study were of Disorders of Sexual Differentiation with pseudovagina, three of Y duplication of the urethra, and one of cervical atresia. All patients had good results.

Conclusion

Posterior sagittal approach is feasible, safe with minimal bleeding, and no postoperative incontinence. It can safely be used for non-anorectal indications.

An Unusual Case of Type A Posterior Cloaca Associated with 46XX Disorder of Sexual Differentiation with Y Duplication of Urethra

We report an infant reared as a girl who presented with ambiguous genitalia and urine coming per rectum. On examination, she had minimal clitoromegaly with labial fusion and Y urethral duplication. On investigations, genetic, metabolic, and endocrine causes for disorder of sexual differentiation were ruled out. This girl was operated via a posterior sagittal approach. This case was unique in that the urogenital sinus was deviated posteriorly and opened in the anterior rectal wall and the accessory urethra opened in clitoris, along with ambiguity of external genitalia, thus making it a rare variant of the posterior cloaca. The diagnosis requires a high index of suspicion in clinician and a meticulous examination of the external genitalia. Very little literature is available for this rare anomaly. Few reports have classified them as female pseudohermaphroditism with cloacal and urogenital sinus defects. Hence, we hereby discuss and review the literature for previously reported cases.

Colonic and type IV jejunal atresias with apple-peel bowel segment as the content of right inguinal hernia: A case report

Background: Colonic atresia is an uncommon entity. It may be associated with multiple anomalies. Case Presentation: We present a case, which was initially suspected to be jejunal atresia, but was found to have colonic atresia as well intra-operatively. The associated jejunal atresia with apple-peel configuration was present as the content of inguinal hernia. Conclusion: This case report highlights the rarity of the condition and the postoperative issues in the management of such patients.

Upper pouch oesophageal duplication cyst- A rare association with Tracheoesophageal fistula: A case report

Background: Oesophageal atresia (OA) has associated anomalies in 50 to 70 % of cases. The usual associations include cardiac, gastrointestinal, anorectal, renal, vertebral, or skeletal anomalies. Oesophageal duplication cyst as an association in OA is extremely rare. Despite the related embryogenesis of these two anomalies, there are very few cases reported. Case Presentation: We present a low-birth-weight neonate with Type C Tracheo-oesophageal fistula (TEF) with an associated oesophageal duplication cyst. Conclusion: Upper pouch oesophageal duplication with TEF is very rare and this is the fourth case managed concomitantly at primary surgery in English literature available.

Multidisciplinary Approach for Management of Pediatric Tumors: a Case Series

Pediatric solid tumors have wide range of presentations. Multidisciplinary approach is often needed for their optimum management. There are no reports discussing such an approach to pediatric tumors involving pediatric surgeons, oncologists and cardiothoracic surgeons together for the management. We report 5 such cases being managed in our institution from 2010 to 2016. All cases needed chemotherapy followed by resection with a team of surgeons involving pediatric surgeon and cardiothoracic surgeon.

Posterior Sagittal Approach for Uterovaginal Anastomosis in a Case of Congenital Cervical Atresia with Anorectal Malformation

Cervical atresia is a rare association with anorectal malformation (ARM) which can be missed till puberty in the presence of normal vaginal orifice. A 12-year-old girl operated for ARM in neonatal age presented with primary amenorrhea. She had a normal vaginal opening, short perineal body, and prolapsed anteposed anus and was diagnosed with cervical agenesis. As the posterior sagittal approach is standard to place the rectum in correct anatomical position, reconstruction of the anus along with adequate perineal body and uterovaginal anastomosis was performed through this approach. This report highlights the utility and versatility of this approach for the management of such complex cases.

Adrenocortical Carcinoma: A Rare Tumor in a 12-year-old Girl

A 12-year-old girl presented with intra-abdominal mass and cushingoid features. On investigation, she was diagnosed as a case of functioning adrenocortical carcinoma. Two cycles of neoadjuvant chemotherapy followed by excision of mass with right nephrectomy was performed. On 6-month follow-up, recurrence and metastasis were identified which were managed with surgery and chemotherapy.

Video-Assisted Thoracoscopic Surgery for Pediatric Empyema by Two-Port Technique: A Single-Center Experience with 167 Consecutive Cases

Background/Purpose:

The aim of our study is to determine efficacy, safety, and feasibility of video-assisted thoracoscopic surgery (VATS) in childhood empyema with a technique of only two ports and open instruments at a tertiary care center in India.

Methods:

This is a retrospective study of patients below 18 years, with empyema presenting to the Department of Pediatric Surgery of a Tertiary Care Referral Hospital in India, over a period of 9 years who underwent VATS decortication. Only two ports with open surgical instruments were used. The patients were assessed on the basis of mean duration of preoperative symptoms, duration of surgery, average blood loss, postoperative pain relief, complications, and need for redo surgery.

Results:

A total of 97 patients underwent primary VATS decortications without inserting an intercostal drainage (ICD) tube and 70 patients as a secondary procedure after ICD tube was inserted. Mean duration of symptoms was 11 days. The average blood loss during surgery was estimated to be 170 cc. The mean duration of surgery was 90 min. The most common postoperative complication was air leak seen in 19.16% of patients. Minor leaks usually settled by 24 h. In eight patients, a negative suction had to be applied to the ICD tube for persistent air leak. The average length of postoperative stay was 4 days. Two patients required a repeat open decortication procedure due to nonresolution of symptoms and poor lung expansion after VATS. Patients had minimal pain and excellent cosmetic outcome after VATS.

Conclusion:

Two-port VATS decortication procedure is as feasible and effective as three-port procedure for decortication with better cosmetic result and pain relief.

Neonatal Sigmoid Colon Perforation: A Rare Occurrence in Low Anorectal Malformation and Review of the Literature

Gastrointestinal perforation in neonates with anorectal malformation (ARM) is extremely uncommon. Delayed patient presentation is an important causative factor. A 2.5-kg neonate presented 72 hours after birth with abdominal distention and absent anal opening with meconium pearls. An abdominal X-ray revealed the presence of free gas. After adequate resuscitation patient underwent surgery. Closure of the sigmoid colon perforation with a proximal diverting loop colostomy with anoplasty was done. The literature reveals only two cases of sigmoid colon perforation with low ARM. Ours is the third case, in whom repair of the perforation and correction of the ARM was managed successfully at the same time.

Needle in a haystack: Intraoperative breakage of pediatric minimal access surgery instruments

The search for tiny bits of broken pediatric minimal access surgery (MAS) instruments in an operative field is akin to the search for a needle in a haystack. With the extension of MAS to the pediatric age group, instruments are becoming smaller and equitably more prone to breakage. When breakages occur, retrieval, especially in the pediatric abdominal cavity, can be challenging. Inability to do so would affect patient safety and also lead to a web of medico legal and ethical issues. We present two cases of intraoperative breakage: An eyeless 3-0 polyamide suture needle and a 2-mm grasper blade both of which were successfully retrieved and fortuitously escaped becoming retained surgical items.

Pyloric atresia--three cases and review of literature

Pyloric atresia (PA) is a rare congenital anomaly that constitutes approximately 1% of all intestinal atresias, and its incidence is approximately 1 in 100,000 live births. PA may occur as an isolated condition or associated with other abnormalities, the most common being Junctional epidermolysis bullosa (JEB). Evidence suggests that PA-EB (Pyloric Atresia - Epidermolysis Bullosa) Syndrome is a distinct entity. In this report, we present three cases of pyloric atresia, one of which was associated with Junctional epidermolysis bullosa. The literature on the subject is also reviewed.

Two-port laparoscopic management of a giant pseudocyst complicating ventriculoperitoneal shunt

Insertion of a ventriculo-peritoneal (VP) shunt is the most common operative procedure for the treatment of hydrocephalus in children. Of the several causes of shunt malfunction, cerebrospinal fluid (CSF) pseudocyst is relatively uncommon. There are several modalities to treat a CSF pseudocyst. Laparotomy is required, at times, more than once. We managed a patient of CSF pseudocyst with two-port laparoscopy, by deroofing the psuedocyst and repositioning of the shunt. This minimally invasive technique avoids morbidity associated with laparotomy and aids in early recovery.

To observe the intensity of the inflammatory reaction caused by neonatal urine and meconium on the intestinal wall of rats in order to understand etiology of intestinal damage in gastroschisis

Objectives:

The aim of this experimental study was to observe the intensity of the inflammatory reaction caused by neonatal urine and meconium on the intestinal wall of rats to better understand etiology of intestinal damage in gastroschisis.

Materials and Methods:

A total of 24 adult Wistar rats were used as experimental models to simulate the effect of exposed bowel in cases of gastroschisis. The peritoneal cavity of the rats was injected with substances which constitute human amniotic fluid to study the effect on the bowel. Sterile urine and meconium were obtained from newborn humans. The rats were divided into four groups according to the material to be injected. In Group I (Control group) 3 mL of distilled water was injected, in Group II (Urine group) 3 mL of neonatal urine was injected, in Group III (Meconium group) 5% meconium suspension was injected, while in Group IV, a combination of 5% meconium suspension and urine was injected. A total of 3mL solution was injected into the right inferior quadrant twice a day for 5 days. The animals were sacrificed on the 6^th day by a high dose of thiopentone sodium. A segment of small bowel specimen was excised, fixed in paraffin, and stained with hematoxylin-eosin for microscopic analysis for determination of the degree of inflammatory reaction in the intestinal wall. All pathology specimens were studied by the same pathologist.

Results:

The maximum bowel damage was seen in Group II (Urine group) in the form of serositis, severe enteritis, parietal necrosis, and peeling. A lesser degree of damage was observed in Group III (Meconium group) as mild enteritis (mild lymphoid hyperplasia). The least damage was seen in Group IV (Combination of meconium and urine) and Group I (Control group).

Conclusion:

The intraabdominal injection of neonatal human urine produces significant inflammatory reactions in the intestinal wall of rats.

Should the ovary always be conserved in torsion? A tertiary care institute experience

AIM

The aim of this study was to analyze our experience in conserving ovarian tissue in cases of ovarian torsion, irrespective of grade of necrosis at exploration.

MATERIALS AND METHODS

All children with a diagnosis of ovarian torsion admitted to our hospital from January 2009 to January 2013 were included. Patients with underlying ovarian pathology were excluded.

RESULTS

There were 13 torsions in 12 children (one bilateral). All underwent detorsion with or without evacuation of hematoma. Follow-up ultrasonography (USG) with color Doppler was done for all 13 ovaries, which showed an ovary with good vascularity and follicular development in 12 ovaries (92%). In 76% (10 of 13) of cases, intraoperatively, the ovary was judged to be moderately to severely ischemic/necrotic. Yet, follow-up sonograms showed the ovary with follicular development in all cases except one (7%). There were no major complications in our series.

CONCLUSION

Simple detorsion, instead of traditionally advocated oophorectomy, was not accompanied by an increase in morbidity. On follow-up, almost all patients studied had functioning ovarian tissue despite the grave ischemia observed intraoperatively. Detorsion should be the procedure of choice for all cases of simple ovarian torsion in children.

Trocarless laparoscopic pyloromyotomy with conventional instruments: Our experience

BACKGROUND

The incidence of hypertrophic pyloric stenosis is approximately 1-3 per 1,000 live births. Hypertrophic pyloric stenosis is seen more often in males, with a male-to female ratio of 4:1. Laparoscopic pyloromyotomy is becoming increasingly popular as the standard treatment for hypertrophic pyloric stenosis.

MATERIALS AND METHODS

We describe our initial experience with laparoscopic pyloromyotomy in 16 infants using conventional laparoscopic instruments. Laparoscopic pyloromyotomy was performed through 5-mm umbilical port with 5mm 30 endoscope. Two 3-mm working instruments were inserted directly into the abdomen via separate lateral incisions.

RESULTS

All patients were prospectively evaluated. The procedure was performed in 16 infants with a mean age of 36 days and mean weight of 3.1 kg. All procedures, except two, were completed laparoscopically with standard instruments. Average operating time was 28 mins, and average postoperative length of stay was 2.8 days. There were no major intraoperative and postoperative complications.

CONCLUSION

Laparoscopic pyloromyotomy can be safely performed by using standard conventional laparoscopic trocarless instruments.

Meckel-Gruber syndrome: A rare and lethal anomaly with review of literature

Meckel-Gruber syndrome is a rare autosomal recessive lethal malformation characterized by typical manifestations of occipital encephalocele, bilateral polycystic kidneys and post axial polydactyly. The worldwide incidence varies from 1 in 13,250 to 1 in 140,000 live births. Highest incidence was reported in Gujarati Indians. We report a rare case of Meckel-Gruber syndrome and review of literature.

An Unusual Presentation of Vallecular Cyst with near Fatal Respiratory Distress and Management Using Conventional Laparoscopic Instruments

Vallecular cyst is a rare cause of upper airway obstruction in infants and children and presentation like acute stridor with near fatal respiratory distress is extremely rare. It is one of the rare causes of difficult intubation, during which cyst aspiration can improve the access. Vallecular cyst is commonly managed using microlaryngoscope and specialized instruments. We hereby report a method of endoscopic management of these cysts using conventional laparoscopic instruments.

Minimal access surgery in newborns and small infants; five years experience

AIMS AND OBJECTIVES:

The aim of this study was to assess and present the outcome (initial experience and lessons learnt) of minimally invasive surgery for various indications in neonates and small infants (< 5 kg) at a single medical centre.

MATERIALS AND METHODS:

A retrospective analysis was performed on 65 patients (age day 2 to 10 months) managed with minimal access surgery (MAS) for various indications, between 2005 and 2010. We analyzed demographic information, procedures, complications, outcomes, and follow-up and overall feasibility of the procedure.

RESULTS:

No serious complications except one death in congenital diaphragmatic hernia (CDH) (due to other comorbidities) occurred. Intra operative hypercarbia and hypoxia were observed more frequently in thoracoscopic procedures. Intra operative hypothermia was not common and was well tolerated. Conversion to open procedure (n = 5), post operative ileus (n = 3), port site infection (n = 5) were other complications.

CONCLUSION:

MAS in neonates and small infants is a technically demanding but a feasible choice available. Some prior experience in older children is required for safe and effective outcome. Good quality optics, video equipments and instruments are required for safe and effective procedure. Intra operative measurement of oxygen saturation and temperature, and diligent post operative ICU care are mandatory for safe and successful outcome.

Biliary fascioliasis: Management in a child using endoscopic retrograde cholangio pancreatography

A 9-year-old boy presented with right upper abdominal pain and fever. The radiologic investigations revealed multiple cholangitic abscesses with cholangitis and worms in common bile duct. Endoscopic retrograde cholangio pancreatographic (ERCP) sphincterotomy, basketing, ballooning and extraction of Fasciola hepatica worms from the common bile duct were done.

Giant epignathus with midline mandibular cleft: Insights in embryology and management

A congenital teratoid tumor arising and protruding through the mouth is classified as epignathus or fetus in fetu. On review of literature, we found various reports of midline mandibular and lower lip cleft associated with flexion contracture of neck, midline cervical cord, but there is only one report of association with midline dermoid. We present an unusual case of midline cleft of mandible with an epignathus. A 2.3-kg male child, delivered transvaginally in the 38^th gestational week, was referred to us for management of a large irregular growth hanging outside the mouth. On examination, he had a wide median cleft of the mandible with tongue adherent to the “V”-shaped defect in the area of lower lip. A midline irregular mass of size 12 × 8 × 5 cm with variegated consistency was arising in the midline from the floor of the mouth between the tongue and lower lip. X-ray and computed tomography scan showed a rounded soft tissue mass arising from the alveolus with multiple calcifications within it along with a large triangular calcification and absence of hyoid bone. The mass was excised by mobilizing the tip of tongue. Staged repair was planned for the defect in the mandible. Unfortunately, the baby succumbed postoperatively to complex congenital heart disease. Histopathology was suggestive of epignathus. We discuss hereby the embryology and current management strategies of the problem.

Solid pseudo papillary tumor of the pancreas: An unusual tumor in children

An 11-year-old girl with a pancreatic solid pseudo papillary tumor (SPT) is reported. Contrast enhanced computerized tomography (CECT) & Magnetic resonant imaging (MRI) abdomen revealed a well-defined inhomogenous mass arising from the retro-peritoneum in the left upper quadrant of the abdomen possibly from the tail of the pancreas. USG guided biopsy of tumor showed benign pseudo papillary tumor of pancreas. Complete excision of the tumor was carried out. Histopathology revealed pancreatic pseudo papillary tumor. Patient did well postoperatively & is on regular follow-up.

Traumatic diaphragmatic hernia: Management by video assisted thoracoscopic repair

Report of the use of video assisted thoracic surgery for traumatic diaphragmatic hernia repair in two children

Role of hyperbaric oxygen therapy in severe head injury in children

Aim:

A brain injury results in a temporary or permanent impairment of cognitive, emotional, and/or physical function. Predicting the outcome of pediatric brain injury is difficult. Prognostic instruments are not precise enough to reliably predict individual patient's mortality and long-term functional status. The purpose of this article is to provide a guide to the strengths and limitations of the use of hyperbaric oxygen therapy (HBOT) in treating pediatric patients with severe brain injury.

Materials and Methods:

We studied total 56 patients of head injury. Out of them 28 received HBOT. Only cases with severe head injury [Glasgow Coma Scale (GCS) < 8] with no other associated injury were included in the study group. After an initial period of resuscitation and conservative management (10–12 days), all were subjected to three sessions of HBOT at 1-week interval. This study group was compared with a control group of similar severity of head injury (GCS < 8).

Results:

The study and control groups were compared in terms of duration of hospitalization, GCS, disability reduction,and social behavior. Patients who received HBOT were significantly better than the control group on all the parameters with decreased hospital stay, better GCS, and drastic reduction in disability.

Conclusion:

In children with traumatic brain injury, the addition of HBOT significantly improved outcome and quality of life and reduced the risk of complications.

Broncho-gastric fistula complicating transthoracic esophagectomy

Tracheo-esophageal and broncho-esophageal fistulas are recognized complications in advanced esophageal cancers. The common complications seen after transthoracic esophagectomy include pulmonary complications, anastomotic leaks, gastric stasis, and anastomotic strictures. A broncho-gastric fistula is a very rare complication of transthoracic esophagectomy and has been reported anecdotally in the literature. We report a patient who underwent a transthoracic esophagectomy and developed a broncho-gastric fistula caused by a staple from the stomach tube suture line eroding into the right bronchus. Diagnosis was made by fiberoptic bronchoscopy. The patient was successfully treated with re-exploratory thoracotomy and closure of the fistula.