Intra-abdominal testis: histological alterations and significance of biopsy.

PURPOSE: Intra-abdominal testes represent only 5% of undescended testes. Review of the literature reveals that few data exist on the histological analysis of intra-abdominal testes. We studied histological alterations in intra-abdominal testes in relation to patient age at orchiopexy. MATERIALS AND METHODS: A total of 57 boys underwent laparoscopy for impalpable undescended testes between October 2002 and June 2005. Testicular biopsies were taken from intra-abdominal testes, fixed in 3% glutaraldehyde, embedded in Epon, sectioned at 1 micron thickness and stained with toluidine blue. Histomorphometric analysis was performed by light microscopy. Effect of age at operation on histological evaluation of abdominal testes was also studied. RESULTS: Testicular biopsies from 29 patients with intra-abdominal testes showed the histological alterations of decreased mean diameter of seminiferous tubules, germinal cell depletion (55%) and presence of microliths (6.9%). CONCLUSIONS: As age at orchiopexy increases, deviation from the norm is more evident and absence of germ cells on biopsy becomes more pronounced, reaching a rate of 93% after age 3 years. Further studies on orchiopexy with or without biopsy in the first few months of life would likely improve our understanding and treatment of cryptorchidism.

Histopathological perspective of the pulled-through colon in Hirschsprung disease: Impact on clinical outcome.

BACKGROUND: The outcome in HD has not been always satisfactory even after a technically sound operation. PURPOSE: To define the characteristic histopathological features of the pulled-through colon in patients with HD, and it is impact on clinical outcome. PATIENTS AND METHODS: The study included patients with HD who underwent surgical repair between 2010 through 2016. The proximal margin of resected bowel segments (which corresponds to the pulled through colon) was subjected to detailed histopathological examination by two experienced pathologists. Based on the frequency of postoperative attacks of HAEC (fever, vomiting, abdominal distention, fluid offensive stools), cases included in the study were divided into two groups: Group A, those with less frequent attacks of HAEC; and Group B, those with recurrent attacks of HAEC (more than 3). RESULTS: The study included 35 patients (25 in group A; and 10 in group B). Their age ranged from 0.2 to 144 months (median 6 months). Comparing the histopathological findings in the two clinical groups, we have found that Group B (recurrent attacks of HAEC) had significantly more frequent focal disarray of nerve bundles and thicker nerve bundle diameter. Also, histopathological features of acute inflammation were more prevalent in examined specimens from group B. CONCLUSION: Several histopathological features of the examined bowel specimens in HD, other than presence or absence of ganglion cells, are indicative of postoperative functional outcome. These include the thickness and maturity of nerve bundles, in addition to the presence of histopathological features of acute inflammation. LEVEL OF EVIDENCE: This is a case control study (level III evidence).

Transperineal rectovesical fistula ligation in laparoscopic-assisted abdominoperineal pull-through for high anorectal malformations.

BACKGROUND: Rectovesical fistula ligation after laparoscopic mobilization of the rectum requires either cutting of the fistula and application of endo-loop or laparoscopic endoligation or clip application. These techniques take more time and require a well-trained surgeon for performing the ligation laparoscopically. A simple technique for ligation of the fistula will be described. MATERIALS AND METHODS: Over the last 5 years, laparoscopic-assisted abdominoperineal pull-through was performed in 12 cases with high anorectal malformation with rectovesical or rectoprostatic fistula. The rectovesical fistula was mobilized initially laparoscopically. The anal site was identified using muscle stimulator and incised at its center. A Hegar dilator was passed through the center of the anal sphincter to exit behind the fistula seen by laparoscopy. The tract was dilated with Hegar dilators till reaching a suitable size for rectal pull-through. A straight clamp holding the ligature was passed through the perineal site and through the dilated tract to emerge on one side of the fistula; then, the ligature was grasped through the abdomen and turned around the junction of the fistula, forming a loop and regrasped and brought outside with the clamp. The two ends of the ligature emerging from the perineal site were tied, and the knot was pushed using the finger till it reached the fistula, and then it was ligated. The fistula was cut and the mobilized rectum was pulled through the perineal incision to be sutured at the site of the future anus. RESULTS: Twelve patients with imperforate anus with rectovesical or rectoprostatic fistula had fistula ligation with this technique. Their ages ranged from 3 to 9 months. Ligation of the fistula was possible in all patients. Operative time ranged from 90 to 120 minutes (mean 110 minutes). The ascending urethrogram showed no residual diverticulum in all but one case, which presented with difficulty in micturation and needed to be excised. CONCLUSION: Transperineal rectovesical fistula ligation in laparoscopic-assisted abdominoperineal pull-through for high anorectal malformations is an alternative technique for fistula ligation during laparoscopy. It is simple and easy to perform with acceptable postoperative results.

Laparoscopic mucosectomy for large choledochal cyst.

BACKGROUND: The laparoscopic excision of the choledochal cyst is feasible, but it entails certain difficulties while dealing with huge cysts because of the risk of injury of important surrounding structures. Mucosectomy of these large cysts is described in open surgery for huge adherent cysts, and the idea can be applied for laparoscopic excision. MATERIALS AND METHODS: Over a period of 5 years, 5 of 30 patients with a large choledochal cyst underwent the laparoscopic mucosectomy. The procedure was done under general anesthesia, with an initial operative cholangiography to delineate the anatomy of the cyst. The common hepatic duct at its junction with the cyst was dissected and cut, leaving the distal end attached to the cystic duct and gallbladder. The cyst was opened at its upper part, and the upper half with the attached gallbladder was excised en block. A plane between the mucosa and the covering of the cyst was found, and the mucosa was peeled by traction and countertraction with proper hemostasis. The procedure was completed by performing hepatico-duodenostomy. RESULTS: Five patients were operated on by this technique. Their age ranged from 3 months to 8 years. The procedure was done successfully in all patients, but a conversion was needed in 1 patient due to a difficult hepatico-duodenostomy. The operative time ranged from 125 to 180 minutes (mean, 140). The follow-up ranged from 4 months to 5 years, with a relief of symptoms in all cases and with no evidence of cholangitis or jaundice. CONCLUSIONS: Mucosectomy can be performed safely with the laparoscopy. The technique is easy, avoiding the difficult dissection of the huge adherent cyst from the surrounding important structures.

Collateral circulation after spermatic vessel ligation for abdominal testis and its impact on staged laparoscopically assisted orchiopexy.

PURPOSE: Staged laparoscopically assisted orchiopexy for abdominal testis entails initial spermatic vessels ligation followed by mobilization of the testis, preserving the vas and its vessels as a sole source of testicular blood supply. This mobilization includes all peritoneal attachments of the testis, including the gubernaculum, which may carry collateral circulation to the testis. This study considers the anatomy of the gubernaculum and the collateral circulation after spermatic vessels ligation and its possible effects on the viability of the testis. MATERIALS AND METHODS: The anatomy of the gubernaculum and the effect of spermatic vessels ligation on the collateral circulation were studied in 90 boys with 100 abdominal testes with a short pedicle. Patients with vanishing testis or those not needing ligation of the spermatic vessels were excluded from the study. The anatomy and the vascularity of the testis, gubernaculum, and vas were studied at initial laparoscopy and 6 weeks later after spermatic vessel ligation. Based on these findings, the technique for laparoscopically assisted orchiopexy were modified, preserving the gubernaculum whenever possible in cases having prominent collaterals. RESULTS: Based on the attachment and blood vessel configuration of the gubernaculum, the patients were divided into two groups: in group 1 (open internal ring), there were 46 testes in which the gubernaculum passed through an open internal ring having an inguinal attachment. In group 2 (closed internal ring), there were 54 testes with a soft gubernaculum attached to a closed internal ring without inguinal attachment. In group 1 the gubernaculum was short and tough in 32 of 46 testes, with no visible blood vessels in all cases. In group 2 the gubernaculum was long and soft in 43 of 54 testes and showing evident blood supply before clipping of the spermatic vessels in 30 testes. Subsequent laparoscopy done after 6 weeks showed prominent collateral circulation around the gubernaculum in 26 testes and around the vas in 20 testes in the group 1 patients, and around the vas in 20 and the gubernaculum in 34 testes in group 2. Preservation of the gubernaculum was possible in 43/54 (80%) of group 2 patients and in 14/46 (30%) of group 1 patients. CONCLUSION: Routine cutting of the gubernaculum is not necessary for proper mobilization of the abdominal testis: collateral circulation varies from patient to patient, and once the gubernaculum shows prominent blood supply, its preservation is mandatory. The decision to cut the gubernaculum should be taken while the performing initial spermatic vessel ligation and not during the second stage to avoid compromise of the settled collateral circulation.

The double urethra: revisiting the surgical classification.

AIM: The aim of this article was to describe our experience with 14 patients with double urethra. PATIENTS AND METHODS: We retrospectively examined the patients' records including their clinical presentations, investigations, operative findings, and outcome. In addition to Effmann's classification, we used a newly proposed classification that depends on the orientation of the double urethral channels. RESULTS: During the last 15 years, 18 patients were diagnosed to have double urethra at our pediatric surgical unit. We excluded four patients with 'Y-type' urethral duplication. The remaining 14 patients were divided into either sagittal or collateral duplication. Their age at presentation ranged from the neonatal period to 9 years. The sagittal urethral duplication included 12 male patients. All patients had two urethral channels, one above the other. The dorsal urethral channel was always characterized by poor function and ectopic course. The ventral channel was always the more functioning urethra, with a normal course from the urinary bladder to end either at an orthotopic meatus (subgroup A), or more proximally in a hypospadiac location (subgroup B). The collateral urethral duplication included two patients. Both patients were associated with duplication of the urinary bladder and the external genitalia as a part of caudal duplication syndrome. In this group, both urethrae had comparable function, lying side by side, and each draining a separate urinary bladder. CONCLUSION: The double urethra is a diverse spectrum comprising different pathologies. Our proposed classification system of duplicated urethras is clinically relevant as it guides surgical management and allows prognostication of outcome.

Pediatric minimally invasive surgery in Africa: limitations and current situation.

The second largest and most populous continent, with an exploding pediatric population, Africa has an overwhelming burden on its very limited pediatric surgical services. In an international environment of progressively advancing endoscopic and robotic surgical techniques, the authors focus on the current role of endoscopic surgery on the continent and explore the potential reasons for its delayed acceptance and implementation. They proceed to document the spectrum of what is available and, using their "African experience," expand on financially viable models of further rolling out these techniques, including discussion around suitable training models for surgeons and their teams.

Feasibility and safety of monopolar diathermy as an alternative to clip ligation in laparoscopic Fowler-Stephens orchiopexy.

PURPOSE: The aims of the study were to study the effect of Fowler-Stephens orchiopexy (FSO) on testicular histology and to assess the feasibility of using monopolar diathermy as an alternative to clip ligation during laparoscopic FSO. PATIENTS AND METHODS: The study included 20 patients with 20 intraabdominal testes and short vessels managed by laparoscopic-staged FSO. Biopsies were taken from intraabdominal testes during the first and second stages of the procedure for histologic comparison. The patients in the study were divided into 2 groups according to the method of dividing the testicular vessels in stage 1. The first 13 patients (group A) were managed by clip ligation of the vessels, whereas monopolar diathermy was used in the following 7 patients (group B). RESULTS: Biopsy findings at stage 2 revealed an overall reduction in both the total number of germ cells per tubule and mean diameter of seminiferous tubules, whereas there was no statistically significant difference between the results in groups A and B. CONCLUSION: The seminiferous cells can withstand (survive) dividing the main blood supply of the testis during FSO. The monopolar diathermy can be used as an alternative to clipping during laparoscopic procedures, having the advantages of lower expenses and using smaller instruments.