A. W. Auldist

Ovarian torsion in inguinal hernias

Abstract The possibility of sustaining ovarian damage as a consequence of an inguinal hernia becoming strangulated is well recognised. However, the mechanism by which this gonadal damage occurs is rarely stated; it is assumed that the injury is secondary to compression of ovarian vessels by an entrapped bowel loop. Eleven cases of ovarian torsion within an inguinal hernial sac are reported. In all cases the primary aetiological event was torsion of the ovary and tube on its pedicle whilst suspended from the neck of the hernial sac. This mechanism constituted the major cause of ovarian damage within irreducible herniae in our series.

Oesophageal atresia without fistula — anastomosis or replacement?

At the Royal Childrens Hospital, Melbourne, 553 babies with oesophageal atresia and/or tracheo-eesophageal fistula have been admitted during the past 39 years; 36 (6.5%) of these had oesophageal atresia without a tracheo-oesophageal fistula. Definitive surgery was performed in 27 patients: the primary definitive procedure was oesphageal anastomosis in 15 and oesophageal replacement in 12. Aspects of diagnosis and selection of the most appropriate treatment modality are discussed, with the results of treatment presented. Our current policy is to perform an oesphhageal anastomosis whenever possible, and this has been successful in 7 of the last 11 patients.

The surgical management of neonatal necrotizing enterocolitis, 1975–1984

A review was conducted of 202 neonates with necrotizing enterocolitis (NEC) seen at the Royal Childrens Hospital, Melbourne, over a 10-year period. The study population was biased towards the more severe cases and those requiring surgical intervention for complications. Most cases had one or more obstetric or perinatal stress factors present. Radiology was important in confirming the diagnosis and identifying those who required surgery. The indications for surgical intervention and the selection of the appropriate surgical procedure are discussed. Surgery was required for acute disease in 72 cases. In most of these, necrotic bowel was excised and temporary ostomies constructed. During the period of study the overall mortality decreased from 41% to 24%. Post-NEC strictures occurred in 18 patients, of whom 6 presented with bowel obstruction. The transverse and left colon seemed particularly susceptible to stricture formation. The diagnosis and management are described in detail.

Oesophageal atresia and associated anomalies : a plea for uniform documentation

Although associated congenital anomalies are the most significant factor affecting prognosis in babies with oesophageal atresia (OA), there is considerable variation in the methods by which they have been documented. To facilitate a uniform approach to the reporting of associated anomalies, we have analysed the data from our own experience and studied the methods used by other workers. During the period 1948–1991, 618 patients with OA and/or tracheo-oesophageal fistula were admitted to the Royal Childrens Hospital, Melbourne. Concurrent congenital abnormalities were present in 344 (56%), the most frequent being cardiovascular (20.7%); urinary (21.6%); gastrointestinal (22.7%); and orthopaedic (15.7%). Not only have reports of the incidence of associated anomalies in OA involved a wide variety of classifications, but also they have varied in the extent to which co-existent lesions were sought by investigation. These factors, in addition to the criteria used for inclusion and the method of their documentation, have resulted in marked discrepancies in the apparent incidence of specific anomalies, and made valid comparisons between series difficult or impossible. We advocate a simple approach whereby: (1) data should be collected prospectively; (2) routine investigation should include renal ultrasound and echocardiography (as a minimum requirement); (3) the number of associated anomalies should be reported as a percentage of the total cohort of patients, rather than as a percentage of the anomalies themselves; (4) true congenital anomalies should be recorded separately from acquired conditions; and (5) the wide variation in the impact of associated abnormalities on the management and long-term outlook in OA should be recognized.

Liver tumours in children

Since 1955, 56 children (29 M: 27 F) with primary liver tumours have been treated at the Royal Childrens Hospital. Ranging in age from neonates to 14 years, they most frequently presented with an abdominal mass. The position, size, and vascularity of the tumour were assessed preoperatively by ultrasound +/− angiography. An elevated serum alpha-feto-protein was confirmatory evidence of a hepatoblastoma. In the malignant group (33), 70% of the children had tumour resection with 5 “surgical” deaths. The long-term survival in the resected group was 15/23 (65%). No children survived without resection. In the benign group (23), 8 children had an arteriovenous malformation (7 neonates). Six are alive and well following hepatic lobectomy with 1 dying of cardiac failure before the diagnosis was established. The other benign tumours were either removed by local excision (10), lobectomy (3), or biopsied (2). All children are alive and well. In those children requiring hepatic lobectomy, hypothermia and hypotension were used as adjuncts to anaesthesia. The commonest operative complication was blood loss (50%). The technique of total vascular isolation was introduced in 1975 and reduced the incidence to 16%. The use of chemotherapy enabled subsequent tumour resection in 4 of 5 tumours that were initially unresectable. Chemotherapy was also given postoperatively to 8 of 17 patients surviving resection.

Retained common-duct stones after open cholecystectomy and duct exploration in children

Abstract. A retrospective study was performed of 250 patients with cholelithiasis treated at the Royal Childrens Hospital, (RCH) Melbourne, over 25 years by open operation; 32 (12.8%) had proven choledocholithiasis on either preoperative imaging, operative cholangiography (OpCG), or postoperative investigation. A further 3 had underlying congenital biliary abnormalities and were excluded from further study. Thirty-one of the 32 were explored at open operation, 27 after OpCG and 4 on clinical grounds. One retained common-bile-duct (CBD) stone was undetected until the postoperative period (1/250, 0.25%). Seven ducts were not cleared, giving a duct exploration failure rate of 22.6% (7/31). All 8 retained CBD stones were identified in the early postoperative period and managed with a variety of techniques, including endoscopic retrograde cholangio-pancreatography (ERCP). The incidence of retained stones after open CBD exploration was high (22.6%), and can be attributed to difficulties in operative technique dealing with the smaller paediatric CBD. In addition, haemolytic disease seems to induce a propensity for choledocholithiasis. Given the small numbers presenting with cholelithiasis to RCH (10 per year), it is suggested that a selective approach to CBD exploration is appropriate in children. With the increasing use of laparoscopic cholecystectomy in children and the inherent technical difficulties of laparoscopic operative cholangiography, ERCP may offer an alternative solution in dealing with CBD stones rather than open or laparoscopic CBD exploration.

Anaesthetic considerations in liver tumour resection in children

Liver tumours in children are rare and occur more commonly in infants. This paper reviews our experience and aspects of management important to the anaesthetist in 31 patients who had liver lobectomies. It discusses the rationale for the use of: (1) hypothermia to provide extra protection if hypotension occurs due to blood loss or vena caval occlusion; (2) induced hypotension and vasodilators to reduce bleeding and facilitate cooling; and (3) haemodilution to minimise red cell loss and improve flow during hypothermia. Bleeding is the major operative problem. There was 1 case of intraoperative pulmonary tumour embolism. Postoperatively, hypoglycaemia, hypoproteinaemia, and sepsis can be significant problems.

Biliary cystadenoma in a young child

Biliary cystadenomas are rare slow-growing multiloculated lesions which arise from the liver, mainly in middle-aged females, and are occasionally complicated by malignant transformation into cystic adenocarcinoma. This paper reports a case occurring in a 1-year-old male child. The typical radiological appearances that would enable a preoperative diagnosis to be made are described. Careful review of the histological features suggests that the biliary cystadenoma and the slightly less rare, solitary multilocular nonparasitic cyst of the liver in childhood are the same lesion.

Congenital mesoblastic nephroma: treatment options

Congenital mesoblastic nephroma (CMN) is an uncommon tumour in the neonatal period. Many CMNs are of “typical” histology and require no therapy other than nephrectomy. However, some are of “atypical” histology and are known to recur and metastasize. The use of chemotherapy in the atypical variant and in case of recurrence has been a matter of controversy. The presence of tumour at the excision margin seems to be the only important predictor of recurrence. The role of heminephrectomy for localised lesions has not been defined. Five cases of CMN seen at the Royal Childrens Hospital, Melbourne, are discussed. Two of them were atypical histologically. One child had a heminephrectomy and is among the first to have had this procedure for CMN. Current treatment options are reviewed in relation to existing knowledge of the pathology and natural history of CMN.

Surgical anatomy and operative techniques for elective hepatic resection in children

The surgical anatomy of the liver is dependent upon division of the liver on the basis of its vascular supply. Application of this knowledge to the surgical technique of elective heaptic resection allows safe removal of one or more lobes. Blood losses can be minimised by total vascular isolation of the liver prior to lobectomy. The safety of this procedure is enhanced by the use of hypothermia as an adjunct to anaesthesia.