Nitin Pant

Completely isolated enteric duplication cyst associated with a classic enterogenous duplication cyst

This report describes an 18-month-old boy with a completely isolated duplication cyst (CIDC) of the ileum associated with another classic enteric duplication cyst in the adjacent bowel and presenting as an acute abdomen due to torsion of the pedicle of the CIDC. Cysts excision was curative.

Laparoscopic Repair of Indirect Inguinal Hernia in Children: Does Partial Resection of the Sac Make Any Impact on Outcome?

PURPOSE To test the hypothesis that during laparoscopic hernia repair, partial resection of the distal sac along with suture ligation of the neck is better than simple transection and ligation. METHODS The following two techniques of laparoscopic hernia repair were compared: Group I, circumferential incision of peritoneum at the deep ring and partial resection of the distal sac and suture ligation at the neck; versus Group II, circumferential incision of the peritoneum at the deep ring and suture ligation at the neck. Twenty-five cases of inguinal hernia were randomly selected in each group between the age group of 6 months to 12 years. The outcome measures were recurrence, intra- or postoperative complications, and time taken for surgery. RESULTS There were no recurrences in either group. Other parameters for comparison were also not statistically different between the two groups. There was no conversion. CONCLUSIONS Although partial resection of the sac has been an essential step in open hernia repair over five decades, its value has been questioned by our study, because omitting this step during laparoscopic repair has not adversely affected the outcomes. Partial resection of the sac is not a necessary component of hernia repair. It is a technical necessity of the open approach. Therefore, omitting this step in laparoscopic repair does not adversely affect the outcome.

Difficult ventilation in a wide congenital tracheoesophageal fistula

To the Editor, Management of tracheoesophageal fistula (TEF) is an anesthetic challenge. It is complicated by respiratory problems and other congenital anomalies that may be present. Successful management of neonates presenting for TEF repair depends on the knowledge and ability of the anesthesiologist. Survival is directly related to adequate treatment. We report the case of a premature infant diagnosed to have TEF with esophageal atresia in whom we faced considerable difficulty with the initial ventilation. Consent for publication was obtained from the parents. A 34-week (gestational age) premature infant weighing 1.37 kg was diagnosed to have TEF with esophageal atresia (type C), and repair was planned. Preoperatively, the patient had bilateral conducted sounds in the chest, the respiratory rate was 58-60 min, and oxygen saturation (SpO2) was 90% in room air. No other abnormality was detected clinically. Inhalational induction was performed with sevoflurane and oxygen. Oxygen saturation improved to 100% on mask ventilation. After an adequate depth of anesthesia had been reached, the trachea was intubated under direct vision with a 2.5-mm uncuffed endotracheal tube (ETT). On auscultation, bilateral air entry was heard, but the SpO2 then decreased to 80%. The ETT was immediately withdrawn. When mask ventilation was applied, the SpO2 improved. A second attempt at intubation resulted in a similar SpO2 decrease, with accompanying distention of the abdomen. The ETT was again withdrawn, but gradually; when the bevel of the ETT was just inside the glottis, the SpO2 started to improve. The ETT was fixed, and intermittent positive-pressure ventilation was instituted with a tidal volume of 8 mL kg body weight and a rate of 15 breaths min. After carefully fixing the tube at the site, surgery proceeded uneventfully for 75 min. Intraoperatively, a TEF that was approximately 3 mm wide, which is nearly the size of the trachea, was identified (Figure). In retrospect, it was thought that the ETT entered the wide fistula during both intubations, which led to the decreased SpO2 and increased abdominal distention. Maintaining ventilation during TEF repair is a difficult task even more so when the fistula is broad. Anesthetic and surgical management focuses on ventilating the lungs without ventilating the fistula. This requires maintenance of spontaneous breathing, with avoidance of neuromuscular blocking agents and excessive positive pressure, until the fistula is closed. The ETT should be placed properly, and occasionally gastrostomy is performed, either preoperatively under local anesthesia or soon after induction, to decompress the stomach and prevent gastric distention. The size of a fistula in a case of congenital TEF varies from a small punctum to the size of a mainstem bronchus. Our patient’s fistula was unusually large and was nearly the size of the trachea. It was difficult to avoid the fistula and insert the tube in the trachea. Auscultating the chest for bilateral air entry may give a false-positive result, as air inflation in the stomach can easily be transmitted to the chest and be mistakenly identified as chest inflation, particularly in small infants. A Fogarty catheter or a neonatal cuffed tube may be used to occlude a large fistula until it is ligated. However, fibreoptic bronchoscopy (FOB) is the most reliable technique to confirm placement of an ETT in patients with TEF. We do not routinely use it, as we have adopted the traditional technique of introducing the ETT into the right D. Goswami, MD (&) N. Kachru, MD N. Pant, MCh Lady Hardinge Medical College & Kalawati Saran Children Hospital, New Delhi, India e-mail: drdevalina@gmail.com

Laparoscopic repair of hernia in children: Comparison between ligation and nonligation of sac

Aim: The essence of the current techniques of laparoscopic hernia repair in children is suture ligation of the neck of the hernia sac at the deep ring with or without its transection. Some studies show that during open hernia repair, after transection at the neck it can be left unsutured without any consequence. This study was aimed to see if the same holds true for laparoscopic hernia repair. Materials and Methods: Sixty patients (52 boys and eight girls, 12-144 months) with indirect inguinal hernia were randomized for laparoscopic repair either by transection of the sac alone (Group I) or transection plus suture ligation of sac at the neck (Group II). Outcome was assessed in terms of time taken for surgery, recurrence, and other complications. Result: Thirty-eight hernia units in 28 patients were repaired by transection alone (Group I) and 34 hernia units in 29 patients were repaired by transection and suture ligation (Group II). Three patients were found to have no hernia on laparoscopy. Recurrence rate and other complications were not significantly different in the two groups. All recurrences occurred in hernias with ring size more than 10 mm. Conclusion: Laparoscopic repair of hernia by circumferential incision of the peritoneum at the deep ring is as effective as incision plus ligation of the sac.

Umbilical Signs of Peritoneal Tuberculosis in Children

ObjectivesTo report the observation of involvement of the umbilicus with alteration of its morphology in association with peritoneal tuberculosis.MethodsThis is a retrospective observational case series of abdominal tuberculosis (ATB) in children, treated in the department of pediatric surgery of a tertiary-care children’s hospital in the period from January 2004 through April 2010.ResultsOut of a total of 38 cases of ATB in children, 22(57.9%) were of the peritoneal type, 14(36.8%) were of the intestinal type, and 2(5.3%) involved the mesenteric lymph nodes. Of the patients manifesting with peritoneal tuberculosis, 11 cases (50%) had involvement of the umbilicus with changes in the umbilical shape and appearance. In seven cases the umbilicus was found retracted and transversely oriented (a slit-like “smiling” appearance) with loss of the umbilical hollow. In two cases there was puckering of the umbilicus. Other findings included umbilical erythema with inflammation in one patient and a fecal fistula at the umbilicus in another patient. While seven cases responded to treatment with antituberculous therapy (ATT), four cases underwent surgery (two laparotomy and two laparoscopy). Findings were similar in all four patients, consisting of adhered dilated bowel loops studded with tubercles which also covered the parietal peritoneum and the falciform ligament. All four cases responded to postoperative ATT.ConclusionsMorphological changes of the umbilicus can provide an additional clue to the diagnosis of peritoneal tuberculosis in children.

The anomalous clinical anatomy of congenital pouch colon in girls.

BACKGROUND/PURPOSE The aim of this study was to evaluate the anomalous clinical anatomy of congenital pouch colon (CPC) associated with anorectal agenesis in 22 consecutive girls managed over a study period of 7 years. METHODS The 22 patients were categorized into 2 groups. Group A consisted of 10 patients who presented during the neonatal period (n = 9) or as a young infant (n = 1). In these patients, only preliminary assessment results were available. Group B (12 patients) comprised 5 newborns who remained on follow-up and 7 patients who presented after the age of 1 year. These 12 patients were assessed and investigated in more detail. RESULTS In group A patients, apart from absence of the normal anal opening, the appearance of the external genitalia and perineum was essentially normal. Retraction of the labial folds showed radiation of folds inward from the margins of the vulval vestibule toward the center, at a point of confluence located at a higher level. At laparotomy, the subtypes of CPC were type I (n = 4), type II (n = 5), and type III (n = 1). In 8 patients, uterus didelphys was present. In all group B patients, the appearance of the external genitalia was similar to that in group A patients. However, separate openings of the urethra, septate vagina, and vestibular fistula (if present) were visible in 5 patients, whereas in 3 patients, a single perineal opening was identified. A total of 9/12 patients (75%) had urinary incontinence. Examination under anesthesia and endoscopy revealed a septate vagina in all 12 patients and an open, incompetent bladder neck with reduced bladder capacity in the 9 patients with urinary incontinence. The terminal fistula of the colonic pouch opened just distal to the bladder neck (n = 1), just posterior and cephalad to the urethral opening (n = 2), low in the vestibule (n = 5), and undetermined (n = 4). The subtypes of CPC were type I CPC (n = 2), type II CPC (n = 9), and type III CPC (n = 1). All 12 patients had uterus didelphys. CONCLUSIONS The characteristics in the anomalous clinical anatomy of CPC in girls, as described here, appear to be almost invariable and, especially in regions where CPC is common, should alert the clinician to the presence of this malformation.

Congenital pouch colon and segmental dilatation of the colon: A report of two unusual cases

This report describes two unusual cases of anorectal malformation. The first had a type III congenital pouch colon with a colovesical fistula. In the other very similar case, segmental dilatation of the colon was present along with penoscrotal hypospadias and, distally, a length of normal colon ending in a rectourethral fistula. In both patients, the appendix was short, stubby and a Y-shaped duplication of the normal colon was present just proximal to the dilated segment of colon.

Laparoscopic or laparoscopic-assisted pelvic surgery in small infants: our experience.

OBJECTIVE The objective of this study was to review our experience of laparoscopic (LA) or laparoscopic-assisted pelvic surgery (LAPS) in small infants. MATERIALS AND METHODS The medical records of 35 patients who underwent an LA or LAPS between January 2007 and June 2010 were studied and 21 patients who were younger than 1 year or whose weight was less than 10  kg were included. Indications, procedures, results, and complications were analyzed. RESULTS The indications of surgery and procedures done were impalpable undescended testes (7 cases--3 single-stage orchidopexy and 4 Fowler Stephen stage I ligation of testicular vessels), Hirschsprungs disease (HD; 5 cases--all laparoscopic-assisted transanal pull-through), anorectal malformation (ARM; 3 cases--all laparoscopic-assisted pull-through), disorders of sexual differentiation (3 cases--1 herniotomy and 2 gonadal biopsy), sacrococcygeal teratoma (1 case--laparoscopic mobilization of pelvic component and posterior sagittal excision), and ovarian mass (2 cases; laparoscopic oophorectomy). There were 14 males, 4 females, and 3 of indeterminate sex. All procedures could be successfully completed without conversion. There was no anesthesia-related complication or need for postoperative ventilatory support. There were no immediate procedure-related complications. One female child with ARM had rectal mucosal prolapse; 1 HD case had rectovaginal fistula that healed following fecal diversion. The major advantages of laparoscopy in different indications were magnified access into the depth of pelvis and early frozen section biopsies in HD, accurate placement of neoanus in the center of muscle complex in ARM, early ligation of vessels and avoidance of laparotomy in sacrococcygeal teratoma, ease of decision making and better mobilization of vessels in undescended testes, and diagnostic accuracy and therapeutic procedure in ambiguous genitalia. CONCLUSION Laparoscopic pelvic surgery in small infants is a safe procedure with advantage of magnification, access, and cosmesis.

Type IIA2 urethral duplication: report of an unusual case

This report describes a rare case of type IIA2 sagittal urethral duplication. The presentation, investigation, and management of this rare anomaly are briefly discussed. A 3½-year-old boy presented with urinary obstruction and recurrent urinary tract infection due to a stenosed dorsal urethra and segmental stenosis of the dominant ventral urethra. The child also had left-sided vesicoureteric reflux. Staged surgical management consisted of an initial vesicostomy followed by serial dilatation of the ventral urethral stricture, left ureteric reimplantation, and a 2-cm long distal urethrourethrostomy between the dorsal urethra, opening at the tip of the penis, and the ventral urethra, which had a hypospadic opening at the base of the glans. The functional and cosmetic outcomes were satisfactory. The management needs to be individualized as best suited for the patient.

Hair Strands Within a Congenital H-Type Tracheoesophageal Fistula

Sir, A tracheoesophageal fistula (TEF) without esophageal atresia (type H or N) is rare, accounting for approximately 2% to 4% of congenital tracheoesophageal malformations [1]. This report describes a unique case of an infant with H-type TEF in whom there were strands of hair extending from inside the trachea, through the fistula, into the esophagus. A 1 mo 20 d-old breast-fed boy was brought with cough and fever of 5 d duration. There was a history of cough, hiccups and regurgitation after feeds since birth, and two previous hospitalisations for pneumonia. On examination, the child was febrile with mild respiratory distress, and auscultation of the chest revealed conducted sounds bilaterally. Blood counts showed a TLC of 12,500/cu mm with 68% neutrophils. Chest radiograph was normal. As an Htype TEF was suspected, oral feeding was stopped and the child was kept on nasogastric tube feeds. A non-ionic watersoluble contrast esophagogram delineated both the tracheobronchial tree and the esophagus and, although not clear, showed a small tract of dye passing from the posterior tracheal wall caudally towards the anterior esophageal wall at the level of the thoracic inlet (Fig. 1). Flexible tracheobronchoscopy showed a 2-mm opening in the posterior midline of the trachea, 2.5 cm distal to the vocal cords. Hair-like strands were seen to come out of this opening and extend up to the arytenoid cartilages. Surgical exploration revealed a 2-mm wide TEF 1 cm above the thoracic inlet which contained a small ball of hair with long adulttype strands of hair extending into the trachea and the esophagus (Fig. 2). The hair strands were removed and the fistula closed with interrupted sutures. Recovery was uneventful. The early diagnosis of H-type TEF is still a challenge although cineradiography and tracheo-bronchoscopy are considered the methods of choice [2, 3]. In our patient, preoperative tracheoscopy was beneficial as it clearly