Satish Kumar Aggarwal

Soft tissue covers in hypospadias surgery: Is tunica vaginalis better than dartos flap?

Aim: To compare tunica vaginalis with dartos flap as soft tissue cover in primary hypospadias repair. Materials and Methods: 25 cases (age range: 12-132 months; all fresh cases) of primary hypospadias were prospectively repaired by tubularized incised plate (TIP)/TIP + graft urethroplasty using tunica vaginalis flap (TVF) as soft tissue cover to urethroplasty (group A). Their results were compared with another set (group B) of age- and anatomy-matched controls (25 patients operated during the previous 3 years) who had undergone TIP repair using dartos flap as soft tissue cover. Statistical analysis of results was done with Fischers exact test. Results: Group A: No fistula, skin necrosis, meatal stenosis, urethral stricture. One case had partial wound dehiscence that resolved on conservative treatment with no sequelae. One case required catheter removal on 3rd day because of severe bladder spasm. There was no testicular atrophy/ascent. Group B: 3 fistulae – all required surgery. There were three cases of superficial skin necrosis that healed spontaneously without sequel. There was no meatal stenosis/urethral stricture. The difference in fistula rate between both the groups, however, was not statistically significant (P = 0.4). Conclusion: TVF may have an edge over dartos fascia for soft tissue coverage of the neourethra.

Retiform pattern of Sertoli-Leydig cell tumor of the ovary in a 4-year-old girl.

Sertoli–Leydig cell tumors are rare sex cord‐stromal neoplasms that account for <0.2% of ovarian tumors. These tumors with a retiform pattern pose difficult diagnostic problems, with the majority being misinterpreted as serous papillary cystadenocarcinoma and endodermal sinus tumor. Retiform pattern Sertoli–Leydig cell tumor seen mostly in young patients is clinically malignant and has a worse prognosis, underlining the importance of recognition of this histopathologic entity. In the literature only two such cases have been described in patients under the age of 5 years; reported herein is the third case. Described here is a rare case of ovarian Sertoli–Leydig cell tumor with retiform pattern in a 4‐year‐old child without any endocrine manifestations.

Endodermal sinus tumor of vagina posing a diagnostic challenge and managed by chemotherapy and novel posterior sagittal surgical approach: Lessons learned

Vaginal germ cell tumor (GCT) is a rare gynecological malignancy with no more than 100 reported cases in the international medical literature. It is an unusual, but an important, cause of premenarchal vaginal bleeding in a child. This article describes a 2‐year‐old child with vaginal GCT, initially misdiagnosed as rhabdomyosarcoma (on imprint smear cytology) and then as clear cell adenocarcinoma. The authors highlight the salient differentiating clinical, radiological and histological features to prevent misdiagnosis in future. The report emphasizes the need for increased awareness and screening for vaginal GCT by estimation of serum α‐fetoprotein levels, in all patients with premenarchal vaginal bleeds, to prevent inadvertent operative interventions.

Renal tuberculosis in infancy

We report a case of congenital renal tuberculosis in a 34-day-old child presenting as severe hematuria. Adequate antitubercular treatment may provide protection to fetus in subsequent pregnancies.

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.

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.

Epidermoid cyst of clitoris mimicking clitoromegaly

Clitoromegaly in pediatric and adolescent age group is usually indicative of a disorder of sexual differentiation. We report a girl child presenting with clitoral enlargement due to an epidermoid cyst. The cyst was excised with complete cosmetic recovery.

Cystic Lymphangiomatous Hamartoma Masquerading as Massive Ascites

We report a 4-year-old boy presenting with a tense massive ascites and large hydrocele. History and physical examination were unremarkable. Routine laboratory studies were normal. Abdominal ultrasonography revealed massive ascites. Contrast CT was suggestive of a large cyst covering the entire peritoneal cavity. At laparotomy, a large cystic tumor was found extending into the scrotum through the left inguinal ring. Histopathologic examination diagnosed the tumor as a cystic lymphangiomatous hemartoma. Although abdominal lymphangiomas are seen in children, but presenting as massive ascites with hydrocele is very rare.

Esophageal mucormycosis in an immunocompetent child: A rare presentation

Invasive mucormycosis of the esophagus (rare) and gastrointestinal tract is emerging as an important cause of concern in children. It usually affects immunosuppressed individuals. However, infection of immunocompetent children is also seen. The diagnosis of mucormycosis is difficult both at the clinical and the laboratory level, hence leading to unsatisfactory treatment and high mortality rates. The infection is usually life threatening so an early diagnosis and prompt administration of antifungal therapy is imperative.

Laparoscopic-assisted transanal pull-through for Hirschsprung's disease: Comparison between partial and near total laparoscopic mobilization of rectum.

Background: Transanal pull-through with laparoscopic assistance is gaining popularity. How much rectal dissection to do laparoscopically and how much transanally is not clear. Laparoscopic rectal mobilization is akin to open pelvic dissection of Swensons operation — the most physiological procedure. Through this comparative study, we aim to evolve a technique that maximizes the benefits of Swensons technique and minimizes the problems of a transanal procedure. Materials and Methods: Twenty patients (19 boys and one girl, newborn to 6 years) with Hirschsprungs disease (HD) were randomized for laparoscopic-assisted transanal pull-through (LATAPT) either by near complete (Group A) or partial (Group B) laparoscopic mobilization of rectum. Patients were followed up for at least 3 months. Demographic profile; operative details (time taken, blood loss, operative difficulty, and complications); postoperative course (duration of urinary catheter, oral feeding, and hospital stay); and follow-up stooling pattern, consistency, and continence were compared in the two groups. Results: The time taken for laparoscopic mobilization was marginally higher in group A, but the time taken for transanal dissection in this group was significantly less than in group B. All other comparisons showed no significant difference in the two groups. Stool frequency and continence improved with time in both groups. Conclusion: Extent of laparoscopic mobilization of rectum does not appear to be a factor deciding the outcomes. No recommendations could be made in view of the small number of cases. However, it shows that laparoscopic assistance can be used to maximize the benefits of Swenson type of operation and a transanal pull-through.