Shandip Kumar Sinha

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.

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.

Congenital lobar emphysema: Pitfalls in diagnosis

Congenital lobar emphysema (CLE) is a rare but life-threatening congenital anomaly leading to respiratory distress in early childhood. Diagnosis requires a strong clinical suspicion. We report a case of a 31/2-month-old infant who was initially diagnosed with pneumonia requiring multiple hospital admissions. After computed tomography of the thorax, a diagnosis on CLE was made. The child was planned for surgery in the next available routine operation theatre. However, suddenly in the evening, she developed respiratory distress and needed emergency surgical intervention. The child improved dramatically after surgery, and the postoperative period was uneventful. Early diagnosis and treatment in such cases can lead to dramatic results.

Isolated hydatid cyst of the pancreas masquerading as pancreatic pseudocyst

Hydatid cyst of the pancreas is very rare and usually presents with obstructive jaundice. We report a case of a 7-year-old girl with cyst of the pancreas without any obstructive jaundice. The child was treated surgically and hydatid cyst of pancreas was found. Partial pericystectomy was performed. After 1 month on follow-up, the child developed pseudocyst of pancreas, which needed cystogastrostomy. Postoperatively, the child improved and is remaining well after 3 months of follow-up. Hydatid cysts of pancreas are very difficult to diagnose preoperatively and should be kept as a differential diagnosis of cystic intrapancreatic lesions. Serological tests can help in early diagnosis.

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.

Are Intussusceptions More Common and Severe in Malrotation? - Waugh Syndrome

Waugh syndrome-The association of intussusception and malrotation is often overlooked and underdiagnosed. Malrotation need to be diagnosed preoperatively (reversal of SMA and SMV axis on doppler) or atleast looked for intraoperatively. Here is reported a case of 8 month old male child brought with complains of pain abdomen associated with fever since 4 days and passing red current like stools since last 2 days. No history of preceding diarrhoea. Parents gave history of something coming out of rectum while crying in pain since one day. Physical examination revealed mild pallor, tachycardia with distended abdomen and decreased bowel sounds. Per rectal examination showed prolapsed congested mass. Child was taken for emergency right supraumbilical transverse laparotomy and revealed mobile ascending colon and duodeno-jejunal flexure on right side of midline, with a long intussusception of terminal ileum, appendix and cecum into transverse colon, descending colon and rectum. Standard reduction was tried and it was possible to reduce it till transverse colon. Enterotomy was made into mid transverse colon to facilitate reduction of small bowel. On reduction, terminal ileum, appendix and ascending colon were not viable and was resected. In view of sepsis, ileostomy and distal stoma were made. Child had uneventful post-operative course and stoma was reversed at 6 weeks.

Thoracoscopic excision of foregut duplication cyst: A case report and review of literature

Thoracoscopy has major advantages over thoracotomy. We report a successful management of foregut duplication cyst thoracoscopically in a child with review of literature.

Symptomatic Mullerian Duct Cyst in a Male Infant.

Symptomatic Mullerian duct cyst is a rare entity in children. A 9-month-old male infant presented with bowel and urinary obstructive symptoms. Imaging investigations revealed a cystic mass in the rectovesical pouch compressing bladder neck and rectum. At laparotomy, a Mullerian duct cyst was found. Most of the cyst was excised and the remaining cyst mucosa was cauterized. The child improved thereafter.