Sara Riccioni

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.

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.

Massive pyuria as an unusual presentation of giant infected urachal remnant in a child

Urachal remnants (URs) are manifestations of an incomplete regression of the urachus; therefore, there may be different types of remnants such as cyst, sinus tract, diverticulum or patent urachus. The clinical presentation of a urachal anomaly includes umbilical discharge, lower abdominal pain and urinary tract infection, although a UR may also be asymptomatic. We present the case of a 2.5-year-old girl who presented with abdominal pain, stranguria and massive pyuria in which a giant infected UR was found. The diagnosis was made using abdominal MRI. The child was subjected to laparoscopic-assisted drainage and had an uneventful postoperative course.

Ultrasonographic diagnosis and minimally invasive treatment of a patent urachus associated with a patent omphalomesenteric duct in a newborn: A case report

Rational: Patent urachus (PU) is due to an incomplete obliteration of the urachus, whereas patent omphalomesenteric duct (POMD) is due to an incomplete obliteration of the vitelline duct. These anomalies are very rarely associated with one another. We describe a case of a newborn with a PU associated with a POMD, who was diagnosed by an abdominal ultrasound (US) and laparoscopy, and managed with a minimally invasive excision. Patient concern: A 28-day-old male neonate was referred to our hospital to investigate a delay in umbilical healing, with blood-mucinous material spillage for 3 weeks prior to the referral. The baby had no symptoms and was in good general health. Diagnosis: After a thorough cleaning of the umbilical stump, a clear granuloma with a suspected fistula was evident under the seat of the ligature of the stump. An abdominal US examination revealed the formation of a full communication, starting below the umbilical stump and developing along the anterior abdominal wall that connected with the bladder dome. The US also revealed a tubular formation containing air, which was compatible with POMD, in the deepest portion of the same umbilical stump. Considering these findings, the rare diagnosis of a PU associated with a POMD duct was suspected. Interventions: The child was then hospitalized for an elective laparoscopy that confirmed the US picture, and a minimally invasive excision was performed. Outcome: The postoperative course was favorable and uneventful. Lessons: Our case underlines the importance of evaluating all persisting umbilical lesions without delay when conventional pharmacological therapies fail. Using a US as the first approach is valuable and should be supported by laparoscopy to confirm the diagnosis; a minimally invasive excision of the remnants appears to be an effective therapeutic approach.

Isolated fallopian tube torsion with hydrosalpinx: Review of a debated management in a pediatric population

PURPOSE To quantify our experience with and assess the literature on diagnosis and management of isolated fallopian tube torsion (IFTT) with hydrosalpinx (HSX) in children. METHODS A PubMed search was performed on pediatric cases of IFTT with HSX to provide a comprehensive review analyzing details and management of this association, focusing on the problem of fertility preservation. RESULTS In addition to our 3 cases, 17 patients of pediatric IFTT associated with HSX were identified, for a total of 21 cases (median age 12.2 years). Menarchal status was present in 10/13 (76.9%); blood tests were reported in 9/20 (42%) showing leucocytosis in 7/9 (75%). Ultrasonography was performed in all cases except one. Laparoscopy was the surgical approach in 84.6% of the reported cases. The torsion was to the right in 36.8%, and to the left in 63.2% of the cases. In one case the torsion was bilateral and asynchronous. Performed procedures were salpingectomy (52.4%) and partial salpingectomy (14.3%); conservative management was reported in 33.3% of the cases. CONCLUSIONS The literature describes different management techniques. Salpingectomy is the most frequently performed procedure but recently conservative management seems to be increasingly applied. A long-term study is necessary to define the most effective treatment for the preservation of future fertility in pediatric patients. TYPE OF STUDY Treatment study (Retrospective Study): LEVEL IV.

Childhood Asymmetry Labium Majus Enlargement (CALME): Description of Two Cases

Background: Childhood asymmetry labium majus enlargement (CALME) is an uncommon, benign condition that occurs in pre- and early pubertal girls and is characterized by a painless, fluctuating, non-tender labial swelling with normal overlying skin. Recognition of this benign condition is essential. Differentiation with several other diseases that mimic CALME and require different diagnostic and therapeutic approaches is mandatory. Two cases of CALME are described in this report. Differential diagnoses and therapeutic approaches are highlighted. Case presentation: The first case was an 11-year-old Caucasian girl referred to our hospital for the evaluation of right labium majus, which showed a palpable, painless, soft, non-tender, non-erythematous enlargement measuring approximately 2 cm with indistinct borders. Ultrasound showed a mass 23 × 18 × 12 mm in diameter. Surgical excision of the mass was performed and in the histopathological evaluation, the tissue specimens were composed of haphazardly arranged vascular channels, adipose tissue and nervous elements that were components of the vulvar soft tissue and were compatible with the diagnosis of CALME. Case 2 was a 6-year-old Caucasian girl who presented a post-traumatic painless mass of left labium majus swelling that progressively increased in volume. Ultrasound study evidenced an ill-defined heterogeneous echotexture mass 26 × 15 × 10 mm in diameter and magnetic resonance imaging confirmed these findings. Histopathological examination was performed after bioptic sampling evidencing normal constituents of vulvar soft tissue, including fibroblast, collagen, adipose tissue, blood vessels and nerves compatible with CALME. Conclusions: CALME is a particular clinical condition that occurs mainly in pre-pubertal girls and has a benign course but poses numerous problems in differential diagnosis that can be solved only with careful clinical observation and with a careful use of radiological imaging techniques. Our cases, in agreement with recent literature, suggest that radical excision is not recommended and that surgical biopsy should be taken into consideration only in cases of doubt.

The role of laparoscopy in the management of urachal anomalies in children

Objectives Management for urachal anomalies (UAs) is controversial. Although traditional treatment of UAs has been surgical excision, recent literature report also a conservative approach. We reviewed our experience to define the role of laparoscopy in the management of UAs in children. Patients and methods From July 2005 to July 2015, 23 children underwent 24 interventions for the treatment of UAs. In four patients, the technique was a laparoscopic-assisted removal of the anomaly, in two patients a laparoscopic-assisted drainage of an urachal abscess, and a pure laparoscopic technique was started in 17 patients. Results Laparoscopic-assisted removal of the UAs was achieved in five cases. In two cases a laparoscopic-assisted drainage of an urachal abscess was performed. The remaining patients were treated by pure laparoscopic technique. Operative or postoperative complications did not occur. Follow-up ranged from 6 months to 10 years and 6 months. Conclusion The pure laparoscopic approach to UAs appears safe and effective in most urachal remnants. Laparoscopic-assisted excision is an alternative approach that is easier to perform in infants. The decision to remove the UAs must be taken after an accurate informed consent of the parents, especially in cases of asymptomatic anomalies.

Complications of Urachal Remnants

The term urachal remnants (URs) refers to a series of anomalies due to the partial or total failure of the urachus obliteration.

Meckel’s Diverticulum

Meckel’s diverticulum is a congenital true diverticulum of the distal ileum, occurring in 2–3 % of the population. It is a vestigial remnant of the omphalomesenteric duct, which normally becomes obliterated between the fifth and the seventh week of gestation. The diverticulum is usually localized within 100 cm of the ileocecal valve and may contain heterotopic gastric mucosa. Symptoms are uncommon, and most Meckel’s diverticula are incidentally found during autopsy, surgery, or barium studies. Symptoms are typically related to the onset of complications (4–40 % of patients), which may manifest as acute abdomen. Complications may occur at all ages, but they are more common in children than adults. In the pediatric population, hemorrhage is the most frequent complication, followed by bowel obstruction and inflammation. Diagnosis is difficult, but ultrasonography represents the first-level diagnostic method in emergency.

MDCT and MRI Protocols in Pediatric Non-traumatic Abdominal Emergencies

Accurate and tempestive diagnosis is essential in pediatric patients with non-traumatic abdominopelvic diseases (Singh et al. Radiographics 27(5):1419–31, 2007). In emergency management of these conditions, ultrasonography (US) and multidetector-row computed tomography (MDCT) represent the methods of the choice to identify and treat any life-threatening medical or surgical disease condition and relief from pain. Magnetic resonance (MR) imaging is a promising alternative to MDCT in the evaluation of acute abdominal pain and does not involve the use of ionizing radiation exposure (Singh et al. Radiographics 27(5):1419–31, 2007; Stoker et al. Radiology 253(1):31–46, 2009).