Relationship between preoperative nutritional status assessed using anthropometric measures and postoperative complications in pediatric surgical patients.

AIM: To determine the relationship between preoperative nutritional status assessed using anthropometric measures and postoperative complications in pediatric surgical patients. METHODOLOGY: This prospective observational cohort study included 650 patients from 6 months to 18 years undergoing elective surgery at our institution. Elective surgery included procedures such as herniotomy, orchidopexy, urethroplasty, cystoscopy, PUV fulguration, pyeloplasty, ureteric reimplantation, stoma formation/closure, anorectoplasty, pull-through, choledochal cyst excision and repair, VP shunt insertion, lipomyelomeningocele repair, diastematomyelia excision and repair, and cyst excision. Nutritional status was standardized using Z scores for weight, length, and BMI. Patients were monitored for a month following surgery to detect any complications, and they were classified into five grades using the Clavien-Dindo classification. The duration of hospital stays and readmission within 30 days following discharge were secondary outcomes. RESULTS: There were 627 patients of both sexes involved in the study: 350 patients aged 6 months to 5 years (Group A), while 277 were aged between 5 and 18 years (Group B). Wasting status was 47.71% in Group A and 41.52% in Group B. In Group A, 40% of patients were stunted, while 83.75% were in Group B. Group A had 57.14% underweight patients. The complication rate was 39.14% in Group A and 38.99% in Group B. The incidence of postoperative complications was not significantly different in malnourished patients. The patients with prolonged duration of surgery (> 2 h) developed more complications in both groups (Group A-67.2%, Group B-82.6%; p < 0.0001). In addition, the patients who experienced complications had lengthier hospital stays (p < 0.001 in both groups) and increased readmission rates (p = 0.016 in Group A and p = 0.008 in Group B). CONCLUSION: In our study, half of the patients in Group A and nearly two-third in Group B were malnourished. The preoperative poor nutritional status based on anthropometric parameters is not associated with increased postoperative complications. Randomized control trials linking preoperative malnutrition based on anthropometric measures and clinical outcomes in pediatric surgery patients are necessary to provide more robust information on this subject.

Bladder height to width ratio as a surrogate marker for non-physiological storage pressures in children with spinal dysraphism.

INTRODUCTION: Spinal dysraphism is the most frequent cause of neurogenic bladder. Urodynamic study (UDS) is an important component of the follow-up of a child with neurogenic bladder. However, it suffers from a lack of widespread availability and is further hampered by technical difficulties and difficulty in its interpretation in children. A neurogenic bladder often appears vertically elongated; only limited and sparse literature is available regarding objectively defining the bladder shape and the urodynamic parameters in the cohort. OBJECTIVES: This study aimed to investigate the usefulness of the bladder's height-to-width ratio (HWR) on cystogram as a screening tool for identifying "non-physiological" bladder pressures in children with spinal dysraphism. A prospective study was undertaken to evaluate children operated for spinal dysraphism. Cystogram, ultrasonography and UDS evaluation were performed. HWR was calculated by the ratio of the maximum height to the maximum bladder width at maximum cystometric capacity (MCC), where MCC was calculated using standard Koff's formula, given by (age in years + 2) *30 ml in children more than one year and weight *7 ml for infants. The children were categorised into groups based on maximum detrusor pressure (MDP) into two groups (MDP ≥ 30 cmH2O and MDP < 30 cmH2O). A receiver-operative characteristic curve was constructed to analyse the sensitivity and specificity of HWR in predicting the MDP. RESULTS: A total of 53 children, operated for spinal dysraphism, met the study criteria during the study period, from March 2021 to September 2022. The median age of children was 4 years (IQR-3-5.5 years). The HWR ratio was compared between the two groups and was significantly higher for the non-physiological pressure bladders than for physiological pressure bladders (mean of 1.55 vs 1.26, p = 0.001). On evaluating the sensitivity and specificity of HWR for discerning children with non-physiological bladder pressures were 87.5% and 48.28%, respectively. The area under the curve (AUC) was 0.781, with a cut-off value of 1.3. DISCUSSION: We attempted to evaluate the HWR based on bladder shape objectively. We demonstrated a moderate correlation between the bladder shape and the bladder pressures. An HWR of 1.3 or higher could be significant for identifying a non-physiological bladder storage pressure. CONCLUSION: The height to width ratio of the bladder on cystogram is a useful tool as a surrogate marker for non-physiological storage pressures in bladders of children with spinal dysraphism.

Acquired Urethrocutaneous Fistula in Children: Case Series of Unusual Presentations of a Usual Condition.

Urinary-cutaneous fistulas are typically treated by pediatric urologists and typically arise after surgical interventions. The three atypical cases of acquired urethrocutaneous fistula that we present here have variously resulted from an untreated periurethral abscess to complications of an initial urethral calculi. To prevent an intraoperative surprise, learning from our cases put emphasis on the importance of early intervention and a high index of suspicion for underlying calculi. We also cover the pathology, diagnosis, and therapy of these uncommon instances of acquired urethrocutaneous fistula.

Bilirubin in wound healing: A double-edged sword.

The impact of bilirubin levels on wound healing remains a topic of controversy. The present study is a literature review that examines the impact of increased levels of bilirubin in the bloodstream on the process of wound healing. The physiological pathways and their interrelationships, as well as the relevant research publications, were comprehensively addressed in our discussion. The present study undertook a comprehensive review of the extant literature pertaining to the impact of bilirubin concentration on the process of wound healing, with particular emphasis on its association with reactive oxygen species. This scholarly article provides an overview of several studies that elucidate the mechanisms and correlation between bilirubin and the process of wound healing. The impact of bilirubin on wound healing has been observed, and it appears to function as a modulator. This review demonstrates that there exists a spectrum of bilirubin concentrations that can function as precise regulators, although this range falls under pathological hyperbilirubinemia. Further research is required to determine the precise boundary of this range. Within a certain range, bilirubin serves as a positive regulator in the process of wound healing. Beyond this range, it has the potential to function as a negative regulator.

The understated issue of caregiver anxiety for pediatric surgical hospital admissions: opening the blindfolds.

KEY MESSAGE: Hospitalization is a nerve-wrecking experience for patients and their families (Lam et al. in Int J Nurs Stud 43:535-545, 2006). The financial burden of hospitalization is the prime perpetrator, however, multiple other factors also contribute significantly to the underlying problem which can be eliminated by efforts of the doctors and other healthcare workers and by modifying the hospital policies (Bassett et al. in J Hosp Med 15:652-658, 2020). We can reduce the number of outpatient visits and switch to telemedicine for rescheduling the cases. The pre-anaesthetic clearance and all the relevant investigations can be done on a single OPD visit thereby reducing the requirement of repeated commutes to the hospital. The free of charge category of the hospital can be extended to the patient requiring prolonged hospital stay or for solid tumor patients who require repeated hospital admissions for chemotherapy. Association with child welfare Non-government organizations (NGO's) can also solve major monetary issues for parents of patients suffering from complex congenital anomalies and solid tumors. The pre-operative NPO period can be shortened to 2-4 h, antibiotic use can be completely avoided or minimized in clean elective cases, children living in the same city requiring dressing/catheter removal after a few days (e.g. hypospadias, posterior sagittal anorectoplasty) can be discharged and called for a OPD visit after 5-7 days if the parents are willing to take care of the child at home. Patients undergoing minor elective surgeries can be followed up on telemedicine visits only. Parents of patients suffering from complex congenital anomalies should be referred to a clinical psychologist and receive periodic counseling sessions. A child psychologist should also be included in the management of cases which have social stigma attached as bladder exstrophy, anorectal malformations, spina bifida requiring lifelong follow-up and bowel washes or repeated clean intermittent catheterisation. Anxiety assessment questionnaires must be incorporated in the management of chronic patients and high-risk parents must be identified (Tiedeman in J Pediatr Nurs 12:110-119, 1997). We hereby propose adoption of family centric approach during the management of a patient as this may minimize the overall burden of the hospitalization of the family. BACKGROUND: Hospital admission of a child leads to a myriad responses in the parents. Thus, we conducted a hospital-based cross-sectional study to determine the prevalence of anxiety and depression among the primary caregivers of hospitalized children and the factors causing it. METHODS: Parents of 228 children admitted in the pediatric surgery ward at a tertiary care hospital were interviewed using the HADS-A and Hamilton Anxiety Questionnaire to assess the prevalence of anxiety and depression during hospital admission. They were also subjected to a questionnaire comprising of 52 questions spread over 5 segments-demographic details, monetary burden, effect on siblings and other family members, practical problems faced, and surgery-specific concerns. FINDINGS: Thirty percent of the parents had severe anxiety and 20% developed depression due to the hospitalization of their child. We tested the association of this depression and anxiety against 56 variables in this study. Exorbitant loan amounts (ra - 0.449, rd- 0.557), repeated commute to the hospital (ra - 0.274, rd - 0.231), monetary burden (ra - 0.193, rd - 0.186), repetitive sampling (ra - 0.248, rd - 0.203), prolonged absence from work (ra - 0.440, rd - 0.424) were found to be the chief perpetrators of this anxiety and depression. INTERPRETATION: The burden of anxiety and depression in the primary caregivers of pediatric surgical patients is enormous. Identification of the implicating factors is essential. Simple reforms such as reduction in the number of OPD visits, extension of free of charge category, association with non-governmental organizations and involvement of a clinical psychologist can significantly meliorate the hospital journey of both the patients and their parents. (rd-correlation coefficient of for depression, ra-correlation coefficient of for anxiety).

Determining the Clinical Value of Routine Post Operative follow up in Common Paediatric Surgical Conditions: A Prospective Observational Study.

Background: The traditional postoperative visit consists of an in-person hospital visit at a predetermined date which requires the investment of time and resources. This implies a need to prioritize visits rather than mandating them, which can be assessed by the requirement of clinical intervention at the time of follow-up. The purpose of this study is to determine the clinical value of routine postoperative physical follow-up in common pediatric surgery conditions, to identify factors determining follow-up, and to estimate the cost of routine follow-up. Materials and Methods: Surgical data of 226 patients admitted for routine pediatric surgical procedures were collected. The postoperative period was documented in detail and interventions done either physically or telephonically at the time of follow-up were used as a proxy measure of clinical value. Results: There were 226 patients enrolled, of which 64.60% followed up physically in outpatient department and 35.40% followed up telephonically. Maximum percentage of patients with postoperative complications belonged to the group of laparotomy at 22.22%, followed by complicated appendicitis at 15.62%. 13.27% of patients required clinical intervention at the time of follow-up. Conclusion: Patients undergoing simpler procedures such as inguinal hernia, hydrocele, and orchidopexy have lesser rate of complications which translates to requirement of fewer clinic visits, whereas those undergoing procedures such as appendectomy and laparotomy require a physical visit after discharge since they are more susceptible to develop complications requiring interventions. By selecting patients for physical visit, we can potentially eliminate unnecessary visits in patients who have low chance of developing complications.

Pattern of Preoperative Uroflowmetry in Hypospadias Patients and Age-matched Control Patients.

Aim: Patients with hypospadias often present with voiding difficulties after successful repairs. We sought to analyze the degree of uroflowmetric anomalies that may be present in children with hypospadias before a surgical repair. We, thus, undertook this study to compare the pattern of preoperative uroflowmetry study in hypospadias patients and a comparable age-matched control group. Materials and Methods: A total of 90 children underwent preoperative uroflowmetry in the Department of Pediatric Surgery at All India Institute of Medical Sciences (AIIMS), Jodhpur, India, between January 2019 and December 2020. Thirty patients with hypospadias and sixty age-matched controls who presented to the outpatient department without any associated urological or neurological anomalies were included in the study. Uroflowmetry parameters such as maximum urine flow rate (Qmax), average urine flow rate (Qavg), voided volume (VV), urination duration, duration of reaching maximum speed, and urine flow curves of the cases and the control group were measured and compared. Results: The median age of patients at the time of uroflowmetry in the hypospadias group was 7 years, while the same for the control group was 7.5 years. Median maximum urinary flow rates (Qmax) (10.7 vs. 14.45 mL/s, P = 0.01278), average urinary flow rates (Qavg) (6.5 vs. 8.5 mL/s, P = 0.0124), the ratio of maximum urinary flow rates with VV (Qmax/VV) (0.043 vs. 0.053, P = 0.0264) was found to be significant (P < 0.05). These values were significantly lower in the hypospadias group (P < 0.05). The voiding time (43.5 vs. 30 s, P = 0.0285) was significantly higher in the hypospadias group. However, there was no difference in the VV per micturition (219.5 vs. 270.0 mL, P = 0.40) and time to maximum flow rate (10 vs. 10, P = 0.43). Flow curve pattern analysis revealed plateau-shaped curves in 60% of the hypospadias group compared to 27% in the control group, while bell-shaped curve was seen in 37% of the hypospadias group as compared to 65% in the control group which were statistically significant (P = 0.003415). No statistically significant association was found between meatal localization and the uroflowmetry parameters. Conclusion: Children with hypospadias have abnormal uroflowmetry even before surgical correction and have a significantly low maximum urine flow rate. These uroflow anomalies may be due to meatal stenosis or hypoplastic proximal urethra. We postulate that these preoperative abnormal uroflow patterns in patients with hypospadias may contribute to voiding difficulties in repaired hypospadias cases. A greater understanding of the factors behind these uroflowmetric anomalies may allow surgeons to proactively tackle these intraoperatively, leading to better outcomes for patients with hypospadias.

Retrospective Analysis of the Outcome of Stoma Closure in Children without Preoperative Mechanical Bowel Preparation.

Introduction: Stoma closure is one of the most frequently performed surgical procedures by pediatric surgeons worldwide. In this study, we studied the outcome of children undergoing stoma closures without mechanical bowel preparation (MBP) in our department. Materials and Methods: This is a retrospective observational study of children <18 years undergoing stoma closure from 2017 to 2021. The primary endpoints were surgical site infection (SSI), incisional hernia, anastomotic leak, and mortalities. The categorical data are expressed in percentages and the continuous data are in medians and interquartile ranges. The postoperative complications were classified according to the Clavien-Dindo system. Results: A total of 89 patients underwent stoma closure without bowel preparation during the study. The anastomosis leak and incisional hernia were seen in one patient each. The SSIs occurred in 23 patients (25.9%), which were superficial in 21 and deep in 2 patients. The Clavien-Dindo Grade III complications occurred in 2 (2.2%) patients. The median duration to start feeds and pass first stools was significantly longer in patients with ileostomy closure (P = 0.04 and 0.001, respectively). Conclusion: The outcome of stoma closures without MBP was favorable in our study and hence it can be suggested that the use of MBP in colostomy closures can be safely avoided in children.

Effect of Cytomegalovirus Infection on Initial Presentation and Overall Prognosis of Biliary Atresia Patients.

Background and Aim: Biliary atresia is known to have a multifactorial etiology and perinatal infection with hepatotropic viruses such as cytomegalovirus (CMV) is a probable trigger in a subset of patients. The aim of the current study is to evaluate the effects of CMV association of biliary atresia on the initial presentation of patients and their response to Kasai portoenterostomy. Patients and Methods: We conducted a retrospective, single-center study on 20 patients of biliary atresia and classified them into two groups based on their CMV immunoglobulin M (IgM) positivity. We compared the age of initial presentation, the liver biochemistry at presentation, immediate and delayed follow-up, rate of jaundice clearance following Kasai portoenterostomy, and histopathology of liver between the two groups. Data were reported in terms of means, and P < 0.05 was considered significant. Results: Out of 20 cases of biliary atresia, 60% (n = 12) were CMV IgM positive. Infants with CMV-positive status were noted to be older at presentation (88.5 days [65-150 days] vs. 83 days [45-160 days] P < 0.05) were more jaundiced at presentation (total bilirubin - 13.51 mg/dl [9.09-15.99 mg/dl] vs. 11.83 mg/dl [6.5-13.5 mg/dl] P < 0.05), had higher alkaline phosphatase (751.2 IU/L [387-1951 IU/L] vs. 621.75 IU/L [172-857 IU/L] P < 0.05), higher gamma-glutamyl transferase levels (505.58 IU/L [376-1127 IU/L] vs. 376.75 IU/L [186-624 IU/L] P < 0.05), and had higher incidence of splenomegaly. The rate of resolution of jaundice postKasai portoenterostomy was also evidently less in CMV-positive patients. Four out of 12 patients have bilirubin >2 mg/dl at a 6-month follow-up. Conclusion: CMV-associated biliary atresia patients have delayed initial presentation and impaired jaundice clearance postKasai portoenterostomy. The role of antiviral therapy should be studied in this subset of patients.

A nucleotide-dependent oligomerization of the Escherichia coli replication initiator DnaA requires residue His136 for remodeling of the chromosomal origin.

Escherichia coli replication initiator protein DnaA binds ATP with high affinity but the amount of ATP required to initiate replication greatly exceeds the amount required for binding. Previously, we showed that ATP-DnaA, not ADP-DnaA, undergoes a conformational change at the higher nucleotide concentration, which allows DnaA oligomerization at the replication origin but the association state remains unclear. Here, we used Small Angle X-ray Scattering (SAXS) to investigate oligomerization of DnaA in solution. Whereas ADP-DnaA was predominantly monomeric, AMP-PNP-DnaA (a non-hydrolysable ATP-analog bound-DnaA) was oligomeric, primarily dimeric. Functional studies using DnaA mutants revealed that DnaA(H136Q) is defective in initiating replication in vivo. The mutant retains high-affinity ATP binding, but was defective in producing replication-competent initiation complexes. Docking of ATP on a structure of E. coli DnaA, modeled upon the crystallographic structure of Aquifex aeolicus DnaA, predicts a hydrogen bond between ATP and imidazole ring of His136, which is disrupted when Gln is present at position 136. SAXS performed on AMP-PNP-DnaA (H136Q) indicates that the protein has lost its ability to form oligomers. These results show the importance of high ATP in DnaA oligomerization and its dependence on the His136 residue.

Role of urinary Neutrophil Gelatinase-Associated Lipocalin (NGAL), Monocyte Chemoattractant Protein-1(MCP-1), and Interleukin-6(IL-6) as biomarkers in pediatric patients with hydronephrosis.

OBJECTIVES: The decision to surgically intervene in a hydronephrotic kidney in children is based on many debatable guidelines, some requiring repeated ultrasounds or renal scans. Urinary proteins have the potential to reflect renal disorders and hence can be the alternatives to such scans. Here, we aim to assess the role of urinary Neutrophil Gelatinase-Associated Lipocalin, Monocyte Chemoattractant Protein-1, and Interleukin-6 (IL-6) in such patients. METHODS: Seventeen children had obstructive hydronephrosis requiring pyeloplasty (UPJO), while seven were kept on conservative management in view of non-obstructive dilation (NOD). Urine samples were measured for the three urinary proteins at the time of presentation and following pyeloplasty using commercially available ELISA kits. RESULTS: The levels of all three urinary proteins were significantly higher in patients with UPJO children compared to the NOD group. Cut-off values to differentiate obstructive from non-obstructive hydronephrosis were obtained. A significant fall in the post-operative value of urinary IL-6 was also observed. CONCLUSION: This study highlights the potentiality of urinary proteins as biomarkers in identifying children with hydronephrosis and picking out the ones with obstructive hydronephrosis who will require pyeloplasty. The drop in levels after pyeloplasty can be employed to evaluate the effectiveness of pyeloplasty when sent serially.

Primary Acquired Cicatrizing Gastric Outlet Obstruction in Children.

Background: Gastric outlet obstruction (GOO) is a very rare condition in children, when infantile hypertrophic pyloric stenosis is excluded as a cause. Five cases of pediatric GOO were successfully managed at our institute. Materials and Methods: We retrospectively evaluated children with idiopathic GOO from 2009 to 2016. Medical records were reviewed for demographic data including age, sex, presenting symptoms, diagnostic investigations, treatment methods, complications, and long-term follow-up. Results: During 7 year period (2009-2016), 5 cases of GOO admitted to our hospital with a history of persistent vomiting. The vomiting used to occur 12-18 h after meal and vomitus contained foul-smelling undigested meal. There was no history of any caustic ingestion. Their age ranged from 2 to 10 years, with a median age of 6 years. Out of 5 cases, 2 were females and the rest were males. The diagnosis of idiopathic GOO was confirmed by history, clinical examination, contrast study, endoscopy, and endoscopic mucosal biopsy. The remarkable finding was the cicatrization causing stricture of the pyloric region in all cases. Out of 5 cases; we have done Heineke-Mikulicz pyloroplasty in 1 case, V-Y advancement antropyloroplasty in 2 cases and Kimura's Diamond-shaped Gastroduodenostomy in 2 cases. The length of the strictured segment determined the type of surgical procedure. All cases did well postoperatively with no mortality. Conclusions: Length of the stricture determines the procedure to be done. In long and narrow stricture V-Y advancement antropyloroplasty and in small stricture Kimura's diamond-shaped Gastroduodenostomy are better procedures to be done. Heineke-Mikulicz pyloroplasty should be avoided as it is difficult to suture transversely after vertical incision because of the presence of fibrosis in the strictured segment.

Correlation of Urethral Ratio and Bladder Wall Thickness with Cystoscopic Findings in Posterior Urethral Valve Patients to Assess Residual Valves.

Introduction: Posterior urethral valve (PUV) is life threatening congenital anomaly of urinary tract. Aim of the study was to correlate urethral ratio (UR) and bladder wall thickness (BWT) with cystoscopic findings in PUV patients to assess residual valves and to validate UR as a diagnostic tool for residual valves. It also aimed to assess the utility of bladder wall thickness in diagnosis of residual valves. Materials and Methods: A total of 31 patients were included in the prospective study done from 2017 to 2019. Calculation of UR was done in oblique VCUG films by dividing maximum posterior and anterior urethral diameter without the catheter insitu. Measurement of BWT was done at dome and bladder neck at full distension with feeding tube insitu and was done at same volume in follow up. The procedure was repeated at 3 months follow up. The findings were compared with cystoscopic findings for the status of residual valves as gold standard. Each patient served as control for self in the study. Results: Median age of presentation was 1 years with range of 1day to 10 years. The most common complains at the time of presentation in our study was straining (35.48%) followed by antenatally diagnosed patients (25.81%) and recurrent UTI (19.36%). Pre fulguration median UR was 2.45. Post Fulguration median UR was 1.20. It showed a statistically significant reduction (p < 0.001) after fulguration. Pre fulguration median BWT was 4 mm. Post fulguration median BWT was 2.5 mm. BWT showed a statistically significant reduction (p < 0.001) after fulguration as well. ROC curve was plotted for UR and BWT. BWT more than 1.95 mm (sensitivity-80%) and UR more than 1.2 (sensitivity-70%) indicates residual valves. Conclusion: A step ladder approach including BWT, UR and check cystoscopy can serve as a new diagnostic algorithm for the assessment of residual valves thereby avoiding extra radiation and general anesthesia exposure.

Conjoined Thoracopagus Twins - Our Experience of Successful Separation.

Conjoined twin is an extremely rare condition and needs a thorough knowledge of anatomy and a multidisciplinary approach is essential to successfully separate, the twins. Thoracopagus are the twins attached by chest and umbilicus and are the commonest among all the varieties but carries a poor survival rate. We describe our approach and experience of management of thoracopagus twins who were separated at eighty-three day of life and are alive and well after 4 years of follow up. The most important decisive parameter for successful separation is the extent of sharing of organs between twins but the role of a motivated multidisciplinary team is also indispensable.

Arterio-Duodenal Fistula: A Rare Complication of Laparoscopic Choledochal Cyst Excision.

Choledochal cysts (CDC) are rare biliary tract anomalies characterized by congenital dilatation of the extrahepatic and/or intrahepatic bile ducts. CDC excision with hepatico-enterostomy is the preferred surgery in modern era. Perioperative blood loss in a case of laparoscopic choledochal cyst excision (LCCE) is usually minimal and managed by conservative treatment such as blood transfusion and correction of coagulation factors. Massive hemorrhage in LCCE is rare and reported intraoperatively or within the first 3 postoperative days. Hereby, we present an unusual case of arterio-duodenal fistula, post LCCE presenting as delayed massive upper gastrointestinal bleeding in a male child and its successful endovascular management.

Laparoscopic Inguinal Hernia Repair in Children: To Cut or Not to Cut is the Question?

CONTEXT: Laparoscopic repair of pediatric inguinal hernia is gaining popularity, however there is no consensus about the technique of operation. AIMS: The aim of the study was to compare the results and complications of two techniques of laparoscopic pediatric hernia repair. SETTINGS AND DESIGN: This retrospective study was conducted at the Department of Pediatric Surgery in All India Institute of Medical Sciences (AIIMS), Jodhpur. SUBJECTS AND METHODS: All children who underwent laparoscopic inguinal hernia repair at AIIMS, Jodhpur, during the period of September 2016-March 2019 were retrospectively studied. Parameters studied included age, gender, side of hernia, technique used, operating time, complications, and hospital stay. Patients were divided into two groups depending on whether the hernial sac was divided or not divided before taking a purse-string suture. STATISTICAL ANALYSIS USED: Student's t-test and Fischer exact test were used to analyze data. RESULTS: A total of 114 patients were included in the study. The median age was 36.4 months. Hernial sac was divided before suturing in 53 patients, while sac was left intact in 61 patients. The mean follow-up was 11.4 months (range: 4-16). Age, gender, side of hernia, complications, and hospital stay were comparable in both groups. There was a significant difference between the mean operating duration in patients who underwent division of hernia sac compared to patients in whom the sac was not divided before putting purse-string suture (92.5 min [45-150] vs. 65.7 [30-90], respectively, P = 0.0101). Hernia recurrence (3.8% in Group A vs. 1.6% in Group B) was comparable in the two groups. CONCLUSIONS: Laparoscopic pediatric hernia repair done with or without dividing the peritoneal sac gives comparable results, however operative duration is less if sac is not divided.

Robotic surgery in paediatric patients: Our initial experience and roadmap for successful implementation of robotic surgery programme.

INTRODUCTION: The popularity of robot-assisted surgeries has accelerated since its advent in 1990s. Recently, we procured da Vinci surgical system in our institution; and here, we present our initial experience of robot-assisted surgeries at our hospital. We also discuss the stepwise approach for successful implementation of the robotic surgical programme at our institute. Moreover, the importance of efficient use of this advanced but expensive technology has been highlighted. MATERIALS AND METHODS: Retrospective analysis of the medical record of all the paediatric patients between the age ranges of 1-18 years who had undergone robotic-assisted laparoscopic surgery during April 2019-April 2019 was done. Medical record was reviewed for descriptive data, clinical presentation, investigations, operative details and follow-up. Statistical data were also obtained from medical superintendent office. RESULTS: During April 2018-April 2019, total of 111 cases were operated across six specialities. Approximately 73% of cases (81/111) belonged to adult urology and gynaecology speciality. Less than 5% (5/111) of patients were in paediatric age group. The department of paediatric surgery performed one pyeloplasty, 3 ureteric reimplantation and 1 bladder diverticulum excision with robot assistance. The operative duration of the cases was comparable to the standard laparoscopic techniques. All patients are asymptomatic on follow-up visits. CONCLUSION: The robotic surgery is feasible in paediatric population and has favourable post-operative outcomes. Detailed planning and stepwise approach is key to the establishment of new robotic surgery programme in any institute.

Refractory Congenital Chylous Ascites: Role of Fibrin Glue in its Management.

Chylous ascites is the accumulation of triglyceride-rich lymph in the abdomen. Its occurrence during the infantile period is quite rare. Congenital chylous ascites (CCA) is one, which occurs in children <3 months of age, due to maldevelopment of the lymphatic system. There is no clearly defined treatment protocol for CCA; however, the use of medium-chain triglycerides (MCT)-based diet or total parenteral nutrition (TPN) with octreotide has been successful. Failure of conservative management, however, leads to surgical exploration to deal with those leaking lymphatics. In our case, we had initially given a trial of managing the child with MCT-based diet followed by a TPN along with octreotide. However, the failure of both leads us to operate the child during which we incorporated the use of fibrin glue over the leaking mesenteric lymphatic vesicles, which ultimately led to the resolution of the chylous ascites.

Caecal duplication cyst: A rare disease with variable presentation and its management in the era of laparoscopy.

Duplication cysts of the intestine are a rare congenital anomaly that can occur anywhere throughout the length of intestine and can be either cystic or tubular. Around two dozen cases of caecal duplication cyst (CDC) are reported in the literature with variable presentation. We describe three cases of CDC who presented at variable age and with variable presentation. None of the imaging study could confirm the site of the duplication, preoperatively. All patients underwent laparoscopy-assisted resection and anastomosis. All patients are free of any complications at median follow-up of 24 months.