Antonino Appignani

Double-Cross Flap Protection: New Technique for Coverage of Neourethra in Hypospadias Repair

PURPOSE We analyzed a new urethra preserving approach, double-cross flap protection, during tubularized incised plate urethroplasty. We compared the results of 57 patients treated with this new procedure and 80 patients treated with 2 different techniques. MATERIALS AND METHODS We studied 137 patients with hypospadias between October 2002 and March 2008. Patients were divided into 3 groups. Group 1 consisted of 40 patients (mean age 50 months) undergoing tubularized incised plate urethroplasty. Group 2 included 40 patients (mean age 48 months) undergoing tubularized incised plate urethroplasty with dorsal subcutaneous flap. Group 3 consisted of 57 patients (mean age 39 months) undergoing tubularized incised plate urethroplasty with 2 de-epithelialized preputial flaps twisted ventrally and sutured individually over the neourethra. All patients were operated on by the same surgeons. Statistical analysis of postoperative complications was performed by ANOVA and chi-square test. RESULTS In Group 1 fistula developed in 6 patients (15%) and was associated with stenosis of the neourethra in 4 (10%). In Group 2 fistula developed in 4 patients (10%). In Group 3 no fistula was observed, but mild stenosis of the neomeatus developed in 3 patients (5.3%), which was treated with dilation. Thus, the incidence of fistula in group 3 was significantly less (p = 0.015). CONCLUSIONS Double-cross flap protection is safe and significantly reduces the incidence of postoperative fistula.

Laparoscopic Treatment of Symptomatic Urachal Remnants in Children

PURPOSE To evaluate laparoscopic treatment of symptomatic urachal remnants in children, the authors review their experience analyzing different approaches and results obtained in a 8-year period. PATIENTS AND METHODS From July 2005 to September 2013, 12 children underwent 13 interventions for treatment of symptomatic urachal remnants. In four patients, the technique was a laparoscopic-assisted removal of the remnant, in two patients, a laparoscopic-assisted drainage of an urachal abscess, and in seven patients, a laparoscopic excision of the remnant. One patient underwent a double intervention-laparoscopic drainage of an infected urachal remnant and its delayed laparoscopic excision. RESULTS The laparoscopic-assisted removal of the urachal remnant was performed in two cases of infected urachal sinus, in one case of symptomatic sinus, and in one cases of infected urachal cyst. The laparoscopic-assisted drainage of urachal abscesses was performed in two patients: In one patient, the abscess was because of an infected sinus while in the other patient, the abscess was caused by an infected cyst. Of the seven patients treated with pure laparoscopic technique, one had a symptomatic sinus, another had an association between a symptomatic urachal sinus and an urachal cyst, and five patients had a symptomatic urachal cyst. In all cases, intraoperative or postoperative complications and recurrences did not occur, and the cosmetic results were good. Follow-up ranged from 6 months to 8 years and 8 months. CONCLUSION Laparoscopic surgery for symptomatic urachal remnants is safe and reliable in cases of drainage of urachal abscess and in cases of excision of the remnant. Laparoscopy allows a radical excision of the remnants with all the advantages of this procedure. In case of conversion, laparoscopic-assisted technique with minimal incision could be a good alternative to open surgery.

Symptomatic Meckel's diverticulum in newborn: two interesting additional cases and review of literature.

Objectives This study aimed to review the literature about symptomatic Meckel’s diverticulum (MD) in the neonatal period with 2 additional uncommon cases. Methods The authors describe 2 interesting neonatal cases of symptomatic MD and analyze the literature on this topic, with particular reference to the prevalence of sex, age at presentation, most common signs and symptoms, treatment, histology, associated anomalies, and outcome. Results The first patient was a term newborn with bowel obstruction by a pseudocystic MD. The second patient was a preterm infant with double perforation of the MD and ileum. Literature search for published case reports and case series on this topic reveals only 18 cases of neonatal symptomatic MD. Males are more frequently involved than females, and even preterm infants may be affected. Bowel obstruction (58.3%) and pneumoperitoneum (33.3%) are the most frequent clinical manifestation. Acute inflammation of the MD is the prominent histopathological finding (75%), although it does not seem to be related with the presence of heterotopic tissue within the MD. Surgical treatment is essential. The association of neonatal symptomatic MD with other anomalies is exceptional but is otherwise life threatening despite surgery. Conclusions Bowel obstruction and pneumoperitoneum are the most frequent clinical manifestations of symptomatic MD in the newborn. Surgery is required for a definitive diagnosis and successful outcome.

Outpatient department repair of urethrocutaneous fistulae using n -butyl-cyanoacrylate (NBCA): a single-centre experience

Study Type – Therapy (case series)

Preliminary experience with a new approach for infantile hypertrophic pyloric stenosis: the single-port, laparoscopic-assisted pyloromyotomy

BackgroundRamstedt pyloromyotomy is still the procedure of choice for infantile hypertrophic pyloric stenosis; however, the best way to approach the pylorus is debated. Recent literature reports many comparisons between various open approaches and laparoscopic one. The purpose of this preliminary experience is to show a new approach to infantile hypertrophic pyloric stenosis: single-port, laparoscopic-assisted pyloromyotomy.MethodsNineteen infants underwent single-port laparoscopic-assisted pyloromyotomy. The approach to the abdominal cavity is performed through a right circumbilical incision, and then a 12-mm trocar is inserted. After the pneumoperitoneum is established, an operative telescope is introduced. Once the telescope is inserted, the pylorus is easily located, and then grasped and exteriorized via the umbilical incision. At this point, conventional Ramstedt pyloromyotomy is performed. Once the pylorus is reintroduced in the abdomen, a new pneumoperitoneum is created to control mucosal integrity and hemostasis. A retrospective statistical analysis was performed to compare patients who underwent this technique to others approached by the same team with right upper quadrant incision or right semicircular umbilical skin-fold incision.ResultsIn all 19 cases, adequate pyloromyotomy was performed in a good ranging time without any intra- or post-operative complications, achieving excellent early cosmetic results.ConclusionsThe feasibility of single-port, laparoscopic-assisted pyloromyotomy obtained in this small sample suggests that this procedure could be an excellent alternative to open or laparoscopic pyloromyotomy as long as it acts as intermediary between the two techniques.

Recurrent Ipsilateral Ovarian Torsion: Case Report and Literature Review

BACKGROUND Recurrent ipsilateral ovarian torsion at pediatric age is a rare event. Different surgical techniques for its prevention are available. We present a case of recurrent ipsilateral ovarian torsion in a prepubertal girl and we reviewed the literature about the management of this condition. CASE A 6-year-old girl presented with right ovarian torsion and underwent a laparoscopic untwisting. Nine months later an ipsilateral recurrence occurred. Laparoscopic untwisting and right-sided oophoropexy with plication to the round ligament was performed. SUMMARY AND CONCLUSION In addition to our presented case, four cases of recurrent ipsilateral ovarian torsion in pediatric patients were identified in the literature. The few available reports in the pediatric literature show different management techniques. A long-term study is necessary to define the most effective treatment.

Multicenter retrospective study on management and outcome of newborns affected by surgical necrotizing enterocolitis

BACKGROUND Necrotizing enterocolitis (NEC) is the most common surgical emergency in newborns and it is still a leading cause of death despite the improvements reached in the management of the critically ill neonate. The purpose of this study was to evaluate risk factors, surgical treatments and outcome of surgical NEC. METHODS We retrospectively evaluated a multicentric group of 184 patients with surgical NEC over a period of 5 years (2008-2012). Indications to operation were modified NEC Bell stages IIIA or IIIB. The main outcome was measured in terms of survival and postsurgical complications. RESULTS Data on 184 patients who had a surgical NEC were collected. The majority of patients (153) had a primary laparotomy (83%); 10 patients had peritoneal drainage insertion alone (5%) and 21 patients had peritoneal drainage followed by laparotomy (12%). Overall mortality was 28%. Patients with lower gestational age (P=0.001), lower birth weight (P=0.001), more extensive intestinal involvement (P=0.002) and cardiac diseases (P=0.012) had a significantly higher incidence of mortality. There was no statistically significant association between free abdominal air on the X-ray and mortality (P=0.407). Mortality in the drainage group was 60%, in the laparotomy group and drainage followed by laparotomy group was of 23-24% (P=0.043). There was a high incidence of stenosis (28%) in the drainage group (P=0.002). On multivariable regression, lower birth weight, feeding, bradycardia-desaturation and extent of bowel involvement were independent predictors of mortality. CONCLUSIONS Laparotomy was the most frequent method of treatment (83%). Primary laparotomy and drainage with laparotomy groups had similar mortalities (23-24%), while the drainage alone treatment cohort was associated with the highest mortality (60%) with statistical value (P=0.043). Consequently laparotomy is highly protective in terms of survival rate. Stenosis seemed to be statistically associated with drainage. These findings could discourage the use of peritoneal drainage versus a primary laparotomy whenever the clinical conditions of patients allow this procedure.

Laparoscopic herniorrhaphy in children.

The authors report their experience in laparoscopic repair of inguinal hernias in children. From May 2010 to November 2013, 122 patients with inguinal hernia underwent laparoscopic herniorrhaphy (92 males and 30 females). Telescope used was 5 mm, while trocars for the operative instruments were 3 or 2 mm. After introducing the camera at the umbilical level and trocars in triangulation, a 4-0 nonabsorbable monofilament suture was inserted directly through the abdominal wall. The internal inguinal ring was then closed by N or double N suture. All operations were performed in one-day surgery setting. In the case of association of inguinal and umbilical hernia an original technique was performed for positioning and fixing the umbilical trocar and for the primary closure of the abdominal wall defect. The postoperative follow-up consisted of outpatient visits at 1 week and 1, 3, and 6 months. The mean age of patients was 38.5 months. Of all patients, 26 were also suffering from umbilical hernia (19 males and 7 females). A total of 160 herniorrhaphies were performed; 84 were unilateral (66 inguinal hernia, 18 inguinal hernia associated with umbilical hernia), 38 bilateral (30 inguinal hernia, 8 inguinal hernia associated with umbilical hernia). Nine of 122 patients (6 males and 3 females) were operated in emergency for incarcerated hernia. A pre-operative diagnosis of unilateral inguinal hernia was performed in 106 cases. Of these patients, laparoscopy revealed a controlateral open internal inguinal ring in 22 cases (20.7%). The mean operative time was 29.9±15.9 min for the monolateral herniorrhaphies, while in case of bilateral repair the mean operative time was 41.5±10.4 min. The mean operative time for the repair of unilateral inguinal hernia associated with umbilical hernia was 30.1±7.4 while for the correction of bilateral inguinal hernia associated with umbilical hernia 39.5±10.6 min. There were 3 recurrences (1.8%): 2 cases in unilateral repair and 1 case a unilateral recurrence in a bilateral repair. No other complications were seen. Laparoscopic repair of inguinal hernia in children performed in this experience resulted a safe and effective procedure.

Secondary involvement of Meckel’s diverticulum by group A β-hemolytic streptococcus in a child with upper airways infection treated by laparoscopic-assisted resection

We report a case of a 5-year-old boy with acute abdomen following an upper airways infection who developed Meckel’s diverticulum perforation secondary to group A &bgr;-hemolytic streptococcus and its successful treatment by a laparoscopic-assisted intervention. To the best of our knowledge, such an event has never been reported previously.

Scrotal dog bite: unusual case and review of pediatric literature.

Animal bites to human external genitalia are rare. Only a few cases of scrotal dog bite in children have been reported. We present an additional specific case of a scrotal dog bite in a child because the lesion and its repair have not been previously reported in published pediatric studies. A traumatic resection of the right testicular vas deferens was repaired by microsurgical vasoepididymal anastomosis. A review of the published data was also performed to analyze the management of scrotal dog bite lesions.