Rahul Kumar Gupta

Laparoscopic inguinal hernia repair in the pediatric age group—experience with 437 children

BACKGROUND/PURPOSE A retrospective analysis of prospectively collected data of pediatric patients that underwent laparoscopic inguinal hernia repair. MATERIAL AND METHODS A retrospective review was performed of the prospectively collected data of 576 laparoscopic internal ring closures in 437 children (age, 30 days-11 years; median, 1.9 years) from June 1999 to February 2009. The internal ring was closed with a 3-0 nonabsorbable suture. Both extracorporeal and intracorporeal methods of knotting were used. All patients were asked to return at 1 week and 6 weeks postoperatively for routine follow-up. RESULTS A contralateral patent processus vaginalis was present in 13% (45/352) of boys and 15% (12/83) of girls on the right side, and 7% (25/352) of boys and 6% (5/83) of girls on the left side. Follow-up range was from 1 week postoperatively to 108 months. There were 14 recurrences (2.4 % [14/576], 11 in boys and on the right side and 3 in girls) and 2 hydroceles 0.35% (2/576). Mean operating time was 23 minutes for unilateral and 29 minutes for bilateral inguinal hernia. There was neither metachronus hernia nor testicular atrophy observed during follow-up. CONCLUSION Laparoscopic inguinal hernia repair is technically easier, as there is no need to dissect the vas deferens and vessels. The risk of metachronous hernia is reduced, and we believe the cosmetic result is better. Although recurrences were more common early in the series, currently they are much less frequent. Laparoscopic inguinal hernia repair appears to have less morbidity than open herniotomy and can be used as routine procedure in the pediatric age group.

Early management of mesenteric cyst prevents catastrophes: A single centre analysis of 17 cases

BACKGROUND Mesenteric cysts are rare intra-abdominal masses in the paediatric age group with varied presentation, ranging from an asymptomatic mass to acute abdomen. This study reviews our experience in the diagnosis and treatment of 17 mesenteric cysts in our centre, with especial reference to acute abdominal symptoms. PATIENTS AND METHODS Seventeen patients (age less than 10 years) with mesenteric cysts were managed in our hospital. The age ranged from 15 days to 10 years. Patients were admitted with acute or chronic symptoms. They were evaluated with complete history, clinical examination, blood investigations and radiological investigations (x-ray abdomen erect, ultrasound abdomen (USG) and computed tomography (CT) scan in selected cases) to reach a provisional diagnosis. The diagnosis was proven on laparotomy and histologically confirmed. RESULTS The main presenting symptoms were abdominal pain or lump. The most common mode of presentation was acute small intestinal obstruction. USG was not conclusive in all. Abdominal CT scan with intravenous contrast was diagnostic in nine patients. Five patients had volvulus on exploration. Cysts were located in small intestinal mesentery in 14 cases and three were in the sigmoid mesentery. Seven patients had complete excision, intestinal resection was required in four and marsupialisation with cauterisation of margins was done in six patients. Histologically, all were lymphangiomatous mesenteric cysts. CONCLUSION The diagnosis of mesenteric cysts should be kept in mind in any patient presenting with acute abdominal symptoms. Small bowel volvulus with mesenteric cyst constituted a significant number in children with acute abdominal symptoms. Early diagnosis and treatment yields excellent outcome.

Experience with video-assisted thoracoscopic removal of pulmonary hydatid cysts in children.

Pulmonary hydatid disease is prevalent in many parts of world including India. In our small series of 5 pediatric patients, all patients were diagnosed with clinical and radiological findings on plain X-ray chest and CT (Computed Tomography) chest. All of them received oral albendazole 10 mg/kg/day soon after diagnosis except in one patient in which preoperative differential diagnosis was bronchogenic cyst and lung abscess (case 4). All underwent video assisted thoracoscopy. Simple endotracheal intubation was utilized in all cases along with CO(2) insufflation. Complete thoracoscopic removal was successful in 3 cases, while conversion to open thoracotomy was required in 2 cases. All of them showed rapid recovery except for one patient in whom prolonged intercostal drainage was present for 2 weeks. The average duration of procedure was 150 minutes and average length of hospital stay was 4.5 days except case 2, which was discharged on day 15 due to prolonged air leak. Histopathology in all cases was suggestive of hydatid cyst. At mean follow up of 6 months, all patients are asymptomatic and doing well.

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 patients 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.

Urethral ratio on voiding cystourethrogram: A comparative method to assess success of posterior urethral valve ablation

OBJECTIVE To develop a simple, objective and reproducible quantitative measurement to assess success of posterior urethral valve ablation. METHOD In 30 patients with posterior urethral valves the diagnosis was confirmed by voiding cystourethrogram (VCUG). Our protocol was to perform valve ablation, and repeat VCUG at 12 weeks postoperatively. Urethral ratio was calculated by dividing the posterior urethral diameter by the anterior urethral diameter. Thirty males undergoing VCUG for urinary tract infections were evaluated as normative controls. RESULTS Median age of controls was 12 months (2 days-6 years) and of study group was 13 months (1 day-11 years). Mean urethral ratio in pre-fulguration group was 4.94 (+/-2.97) and in post-fulguration group was 2.134 (+/-1.19) (P<0.001). The mean urethral ratio in the control group of 1.73 (+/-0.577) was significantly different from the pre-fulguration group result (P<0.001), but not significantly different in comparison to the post-fulguration group (P=0.104). CONCLUSION Calculation of urethral ratio on VCUG as a method of assessment of outcome of fulguration is objective, reproducible, and allows preoperative and postoperative VCUG from different facilities to be compared. A post-fulguration urethral ratio of 2.5-3 represents an acceptable result postoperatively.

Minimal access surgery for multiorgan hydatid cysts.

Multiorgan hydatid cysts caused by larval growth of Echinococcus granulosus, is a rare condition in paediatric age group. There are very few reports of management of multiorgan hydatid cysts, involving lung, liver, and spleen by minimally invasive approach in paediatric age group. Herewith, we are reporting a case of hydatid cysts involving lung, liver, and spleen in a six-year-old child managed by minimally invasive surgery along with the review of literature.

Congenital alveolar fusion.

Congenital fusion of the jaws is rare. It may be unilateral or bilateral and may involve only the soft tissues or both the hard and soft tissues. This anomaly may be seen separately or in association with other syndromes. Congenital alveolar fusion restricts mouth opening, causing problems with feeding, swallowing, and respiration. Case 1 had membranous bands between the alveoli that required tracheostomy for stabilization, followed by osteotomy for release. Postoperatively, both patients had adequate mouth opening.

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 38th 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.

Neonatal lingual and gastrointestinal mucormycosis in a case of low anorectal malformation—a rare presentation

We report a 1.7 kg male infant with a low anorectal malformation treated at an outside facility and referred to us on postoperative day 11. At presentation, his upper abdomen was distended, and he had perianal mucoid discharge. The tongue had a blackish discoloration. An erect abdominal radiograph showed a few fluid-filled bowel loops in the upper abdomen with a gasless lower abdomen and pelvis, suggestive of upper small bowel obstruction. There were no specific radiological features of necrotizing enterocolitis. He underwent laparotomy and bowel resection for perforated jejunum. Histopathology of the tissue specimen was suggestive of mucormycosis. Postoperatively, he received intravenous amphotericin B (liposomal) and was started on liquid enteral nutrition after 2 weeks. However, the anterior two thirds of his tongue gradually sloughed off. He is awaiting reconstruction of the tongue. The purpose of this report is to emphasize that physicians should have a high index of suspicion for oral and gastrointestinal tract mucormycosis in neonates with metabolic disturbances who present with a discolored oral mucosa and an abdominal mass with intestinal obstruction. Early diagnosis and an aggressive approach of combined medical and surgical treatment may improve the outcome of patients with this potentially lethal invasive disease.

Gluteal flap for omphalocele repair in a case of epigastric heteropagus: A novel approach for surgical management

Epigastric heteropagus is an extremely rare congenital anomaly, in which there is asymmetrical conjoined twinning, with the parasitic twin attached to the epigastrium. A 2-day-old male, with epigastric heteropagus and omphalocele, was operated in our institution. After excision of the parasitic twin, omphalocele was covered with a gluteal skin flap available from the parasitic twin. Post-operative course was uneventful, except for infection along the edges of the skin flaps, which was managed conservatively. Only 44 cases of epigastric heteropagus twins have been reported previously in world literature. We present a novel surgical approach for the repair of the omphalocele in a case of epigastric heteropagus twins, probably the 45th case to be reported in the world literature.