Anies Mahomed

Systematic review for paediatric metachronous contralateral inguinal hernia: a decreasing concern

PurposeControversy still surrounds the treatment of the asymptomatic inguinal region in paediatric patients with a unilateral inguinal hernia. The concern is the development of a future metachronous contralateral inguinal hernia (MCIH) and therefore the need for a second operation. Our aim was to provide a current systematic review of the evidence for routine contralateral exploration, and identify potential at-risk groups.MethodsComprehensive review of the literature utilising broad search terms to identify all relevant publications. Precise inclusion and exclusion criteria to identify studies that included paediatric unilateral inguinal hernia repair without routine contralateral exploration.Data analysisChi-square with Yates’ correction or a Fisher’s exact test as appropriate. Numbers needed to treat (NNT) calculated with 95% confidence intervals.ResultsA total of 7,130 titles and abstracts were screened and 61 studies included with data on 49,568 paediatric patients with a unilateral inguinal hernia fulfilling the inclusion criteria. 2,857 of these patients later developed a MCIH, revealing an overall risk is 5.76% (95% CI: 5.55–5.97%). The NNT for a MCIH is 18 (95% CI: 16.8–18) with 18 contralateral exploration required for the prevention of one MCIH. Patients <6xa0months at the time of the initial intervention were more likely to develop a MCIH; 183/1,470 (<6/12) versus 144/2,044 (≥6/12), Pxa0<xa00.0001. As were patients with an original left-sided hernia; 815/6,739 versus 865/12,615, Pxa0<xa00.0001. The NNTs for both of these groups were 9. There was no association with the gender of the patient; 888/14,480 (♂) versus 268/4,206 (♀), Pxa0=xa00.37.ConclusionsThere is insufficient evidence to support the routine contralateral inguinal exploration in all paediatric patients presenting with a unilateral inguinal hernia. However, with patients presenting with an originally left-sided hernia or who are less than 6xa0months old, a parental discussion should occur about the possible benefits and risks of contralateral exploration.

SILS: Is It Cost- and Time-Effective Compared to Standard Pediatric Laparoscopic Surgery?

The aim of the study was to review our experience with single-incision laparoscopic surgery (SILS) and to compare costs and operative time to standard laparoscopic surgery (SLS). A prospectively collected database of operative times and costs was analysed for the years 2008–2011. SILS cases were compared to standard laparoscopy on a procedure-matched basis. Patient demographics, on-table time and consumable costs were collated. Descriptive statistics and Mann-Whitney U-test were utilized with SPSS for windows. Analysis of the data demonstrate that neither consumable costs nor operative time were significantly different in each group. Comparing operative costs, SILS appendicectomy, nephrectomy/heminephrectomy, and ovarian cystectomy/oophorectomy showed cost benefit over SLS (£397 versus £467; £942 versus £1127; £394 versus £495). A trend toward higher cost for SILS Palomo procedure is noted (£734 versus £400). Operative time for SILS appendicectomy, nephrectomy/heminephrectomy, and Palomo was lower compared to SLS (60 versus 103 minutes[mins.]; 130 versus 60u2009mins.; 60 versus 80u2009mins.). In conclusion, SILS appears to be cost-effective for the common pediatric surgical operations. There is no significant difference in operating time in this series, but small sample size is a limiting factor. Studies with larger numbers will be necessary to validate these initial observations.

Outcome of lymphatic- and artery-sparing surgery for pediatric varicocoele.

BACKGROUNDnIn recent years, laparoscopic equipment, and experience with its use, has improved. We are now able to appreciate microanatomy, and dissection of individual lymphatic channels is possible. Previously, the results of laparoscopic lymphatic-sparing procedures has been reported. In this study, we report our experience of the preservation of both the lymphatic channels and the testicular artery during laparoscopic varicocelectomy and its outcomes.nnnMATERIALS AND METHODSnAll boys undergoing laparoscopic varicocelectomy between June 2004 and February 2009 were included in the study. The demographic details, operative findings, complications, and length of stay were recorded on a Microsoft Excel spreadsheet and complications at follow-up noted. The operation was performed via a transperitoneal approach, and the retroperitoneum was entered proximal to the internal ring by peritoneal division over the vessels. The spermatic vein or veins were isolated and stripped of the surrounding lymphatics and artery and secured with ligaclips. Any other tortuous veins around the internal ring were also ligated at the time of operation.nnnRESULTSnNineteen boys underwent laparoscopic varicolectomy. Complications were 1 intraoperative small bowel injury, 1 hydrocele (5%), and 4 persistent varices (21%), one of which was symptomatic, requiring a low ligation of spermatic veins through a groin approach.nnnCONCLUSIONSnThis study shows good results with regard to postoperative hydrocoele rates. The preservation of the lymphatic supply ensures adequate lymphatic drainage, therefore, minimizing the risk of developing a hydrocele postoperatively. The risk of persistent varices, compared to the traditional en-masse technique, is a source of concern and requires further study.

Risk of hernia occurrence where division of an indirect inguinal sac without ligation is undertaken.

We sought to ascertain the risk of inguinal hernia occurrence when division of the processus vaginalis is undertaken without ligation, in the context of laparoscopic Fowler-Stephens orchidopexy. A cohort of patients with intra-abdominal testes subjected to a two-stage Fowler-Stephens procedure was reviewed. Analysis of a 68-month period between November 2005 and August 2011 was performed. A comprehensive search of the literature was undertaken, and these data were compared with previously published studies of patients undergoing orchidopexy or herniotomy where the peritoneal defect was not closed. The procedure was undertaken as previously described, with a conventional first stage using a three-port technique. No attempt was made to approximate the peritoneal margins of the processus vaginalis/hernia or close the internal ring at the second stage. In our own experience 17 patients with undescended testes (2 with bilateral cases) underwent laparoscopically assisted, gubernaculum-sparing, Fowler-Stephens orchidopexy. Median age at first operation was 1.86 years (range, 1-9 years). All 17 patients had successful surgery with all 19 testes palpable within the scrotum at postoperative assessment at 3 and 6 months. No direct, indirect, or incisional hernias were noted at a mean follow-up of 2.7 years (standard deviation 1.71). Our experience and reports in the literature do support simple division of the indirect hernia sac as a tenable alternative to ligation. The result of this limited review would support a prospective randomized trial comparing ligation with simple division of hernia sacs.

Initial Success with Gubernacular-Sparing Laparoscopic-Assisted Fowler-Stephens Orchidopexy for Intra-abdominal Testes

A single surgeons 5-year experience of preserving the gubernaculum in laparoscopic-assisted Fowler-Stephens orchidopexy is reported. Thirty-six cases of impalpable testes are considered. Sixteen patients were confirmed as having intra-abdominal testes, with 20 testes considered to be absent/vanished. At follow-up, all testes had a similar volume to the contralateral testis except for one that had been considered hypoplastic at the initial operation. Mean follow-up was 612 days. The method and potential importance of gubernacular preservation in this situation are discussed.

Lymphatic sparing laparoscopic Palomo varicoelectomy

We read with interest the article by Qiangsong Tong et al, noting their outcomes after laparoscopic Palomo varicocelectomy in children [1]. Using a similar approach in 19 cases, we prospectively documented over a 4.5-year period (June 2004-February 2009) somewhat different outcomes. The mean age of our patients was 14.6 years (SD, 1.27; range, 11.9-16.4 years) all with varicoceles of grade 2 or worse. Each underwent a laparoscopic lymphatic sparing modification of the Palomo technique using 3 ports. Most (11) were done as day cases, with 4 requiring an overnight stay. At operation, 11 patients were found to have a single large spermatic vein, the rest (n = 8) had multiple veins. Of these latter patients, 3 had veins other than the spermatic vein ligated including 2, with ligation of veins of the vas deferens and in 1 a tributary of the main spermatic vein. The only intraoperative complication was a serosal injury to the bowel, which was immediately repaired, and the patient was discharged the same evening. One patient was readmitted postoperatively with abdominal pain and required a brief period of analgesia. In follow-up (mean, 2.56 years; range, 0.9-4.7 years), only one of these patients had a minor hydrocele (5%) that resolved spontaneously. Interestingly, in contrast to Tongs study, persistent varicoceles were documented in 4 boys (21%). However, the varicoceles in 3 had reduced in size after ligation and were asymptomatic. The only symptomatic patient underwent successful direct ligation of the spermatic veins through a standard open groin incision. At follow-up, none of the patients had a reduction in testicular size. Although Tongs patients as well as ours have benefited from the lymphatic sparing approach, the contrasting outcomes stresses the point that the jury is still out concerning the best approach tomanage symptomatic varicoceles (lymphatic sparing vs mass ligation) and that future prospective randomized studies are required. Rebecca Lisle Anies Mahomed Department of Paediatric Surgery Royal Alexandra Childrens Hospital Brighton, BN2 5BE East Sussex, UK E-mail address: anies.mahomed@bsuh.nhs.uk

Video Demonstration of the Technique of Laparoscopic Gastrophrenopexy for the Treatment of Symptomatic Primary Organoaxial Gastric Volvulus

AIMnThe aim of this work was to demonstrate the technique of laparoscopic gastrophrenopexy performed for intermittent partial organoaxial volvulus.nnnMETHODSnTwo pediatric patients, with an initial presentation of postprandial epigastric discomfort, were investigated by upper gastrointestinal contrast meal. These investigations revealed the presence of a rare variant of primary organoaxial gastric volvulus. Both patients underwent a laparoscopy, which confirmed gastromegaly with redundant gastrophrenic and gastrolienal ligaments. A gastrophrenopexy was performed with initial pexy of, principally, the fundus to the left hemidiaphragm, using interrupted nonabsorbable sutures. The gastrophrenopexy was performed without an esophagocardiopexy or an anterior gastropexy. A video demonstrates the technical aspects of the procedure, and the associated pre- and postoperative imaging for both patients will be presented.nnnRESULTSnBoth procedures were accomplished laparoscopically in less than 60 minutes, with no immediate postoperative complications. The patients were discharged the following day after a period of observation. Symptom resolution occurred with both patients. One patient underwent a repeat upper gastrointestinal contrast study 4 years post intervention, which demonstrated an intact gastropexy.nnnCONCLUSIONSnLaparoscopic gastrophrenopexy may be utilized for this rare variant of gastric organoaxial volvulus. This technique is durable over the medium term and is, therefore, recommended as the primary intervention in symptomatic pediatric patients.

Mycotic aneurysm of the facial artery complicating infective endocarditis

Mycotic aneurysms are uncommon complications of infective endocarditis in children. We describe a case of mycotic aneurysm of the left facial artery occurring secondary to infective endocarditis. Presentation of the mycotic aneurysm was delayed and was noted 8 weeks after admission. This followed a course of intensive antibiotic therapy. Its progress was rapid, necessitating surgery for imminent rupture. A successful outcome was achieved.

Laparoscopic Watson Fundoplication Is Effective and Durable in Children with Gastrooesophageal Reflux

Gastroesophageal reflux (GOR) affects 2–8% of children over 3 years of age and is associated with significant morbidity. The disorder is particularly critical in neurologically impaired children, who have a high risk of aspiration. Traditionally, the surgical antireflux procedure of choice has been Nissens operation. However, this technique has a significant incidence of mechanical complications and has a reoperation rate of approximately 7%, leading to the development of alternative approaches. Watsons technique of partial anterior fundoplication has been shown to achieve long-lasting reflux control in adults with few mechanical complications, but there is limited data in the paediatric population. We present here short- and long-term outcomes of laparoscopic Watson fundoplication in a series of 76 children and infants, 34% of whom had a degree of neurological impairment including severe cerebral palsy and hypoxic brain injury. The overall complication rate was 27.6%, of which only 1 was classified as major. To date, we have not recorded any incidences of perforation and no revisions. In our experience, Watsons laparoscopic partial fundoplication can be performed with minimal complications and with durable results, not least in neurologically compromised children, making it a viable alternative to the Nissen procedure in paediatric surgery.

Chronically Symptomatic Patients with Undetectable Gall Bladder on Ultrasonography Could Benefit from Early Cholecystectomy

90 percent of symptomatic patients undergoing cholecystectomy have cholelithiasis with 10% categorized as asymptomatic cholecystitis. In both instances, the gallbladder is evident on ultrasonography. In children with symptomatic biliary dyspepsia, the decision to proceed to cholecystectomy is made difficult if choleliths are not seen on ultrasonography. This decision is made even more difficult if the gallbladder itself is not seen on repeated imaging. In a cohort of 54 cholecystectomies, 3 cases, with recurrent right upper quadrant pain and undetectable gallbladders on repeat ultrasonography, were identified. After prolonged observation all underwent successful cholecystectomy. Histology demonstrated a markedly fibrotic and thickened gallbladder in all. Given this experience, we suggest that nonvisibility of the gallbladder, in fact, maybe be a feature of a chronic acalculous cholecystitis. We advise consideration of cholecystectomy for chronic biliary dyspepsia where repeat ultrasonography fails to demonstrate a gallbladder.