Outcomes of laparoscopic incarcerated inguinal hernia repair in children.

AIM: Laparoscopic inguinal hernia repair (LIHR) is gaining widespread acceptance, but its role in the management of incarcerated cases is not well outlined. This review analyses the outcomes of laparoscopic repair of incarcerated inguinal hernia in children. PATIENTS AND METHODS: Literature was searched on PubMed® using terms 'laparoscopic', 'incarcerated', 'inguinal', 'hernia' and 'children'. Age, sex, side, sac content, operative technique, follow-up period, complication and recurrence rate were analysed. RESULTS: Fifteen articles with 689 paediatric incarcerated inguinal hernias were identified between 1998 and 2018. Median age of patients was 22.4 months (2 weeks-16 years; M:F = 2.2:1). Side was mentioned in n = 576: n = 398 (69.1%) right and n = 178 (30.9%) left. In n = 355 (51.5%) manual reduction and delayed surgery (MRDS), in n = 34 (4.9%) manual reduction in general anaesthesia (MRGA) followed by emergency LHR and in n = 300 (43.5%) intraoperative reduction (IOR) was necessary. Incarcerated contents were documented in n = 68: intestine n = 36 (52.9%), ovary n = 14 (20.6%), omentum n = 11 (16.2%), appendix n = 5 (7.4%) and Meckel's diverticulum n = 2 (2.9%). Among the n = 18 girls in IOR group, n = 14 (77.8%) had ovaries incarcerated. For LHR, the hook method was used in 376 (54.6%) and purse-string suture in 313 (45.4%), with two conversions in IOR group. Mean followup was 15 months (3-80 months), with one (0.15%) testicular atrophy, and 4 (0.58%) recurrences in MRDS and 1 (0.15%) in IOR. All five cases were closed with pursestring technique. Total recurrence rate was 0.73%; significantly higher (P = 0.014) with pursestring (n = 5, 1.6%) than with the hook (none). CONCLUSION: Hook and purse-string methods are equally popular in LHR for paediatric incarcerated hernias, with 50% hernia reductions possible at the time of surgery. Recurrence rate is low and comparable with non-incarcerated hernias; however, it is significantly higher in purse-string method than hook technique.

Mucosectomy disrupting the enteric nervous system causes contraction and shrinkage of gastrointestinal flaps: potential implications for augmentation cystoplasty.

INTRODUCTION: Augmenting the bladder with a seromuscular gastrointestinal flap is a promising alternative approach aiming for a mucus-free bladder augmentation; however, the contraction (shrinkage) of the flaps remains a major concern. Enteric nervous system (ENS) abnormalities cause a failure of relaxation of the intestinal muscle layers in motility disorders such as Hirschsprung's disease and intestinal neuronal dysplasia. In mammals, the submucosal enteric nervous plexus contains nitrergic inhibitory motor neurons responsible for muscle relaxation. The authors hypothesize that mucosectomy disconnects the submucosal nervous plexus from the myenteric plexus resulting in flap shrinkage. STUDY DESIGN: After ethical approval, mucosectomy was performed on vascularized flaps from the ileum, colon, and stomach in five anesthetized pigs. In Group (I), only the mucosa was scraped off with forceps, creating a sero-musculo-submucosal flap, while in Group (II), the mucosa and submucosa were peeled off as one layer, leaving a seromuscular flap. Isolated and detubularized segments served as control. The width of each flap was measured before and after the mucosectomy. The ENS was assessed by neurofilament immunohistochemistry in conventional sections and by acetylcholinesterase and NADPH-diaphorase enzyme histochemistry in whole-mount preparations. RESULTS: The stomach contracted to a lesser extent of its original width, 92.82 ± 7.86% in Group (I) and 82.24 ± 6.96% in Group (II). The ileum contracted to 81.68 ± 4.25% in Group (I) and to 72.675 ± 5.36% in Group (II). The shrinkage was most noticeable in the colon: 83.89 ± 15.73% in Group (I) and to 57.13 ± 11.51% in Group (II). One-way equal variance test showed significant difference (P < 0,05) between Group (I) and (II), comparing stomach with ileum and ileum with colon. The histochemistry revealed that the submucosal nervous plexus containing nitrergic inhibitory neurons was disconnected from the myenteric plexus in Group (II) of all specimens. CONCLUSION: Mucosectomy resulted in significant immediate shrinkage of the flaps. This was more expressed when also the submucosa was peeled off, thus fully disrupting the ENS. The shrinkage affected the stomach the least and the colon the greatest. This phenomenon should be taken into consideration when planning mucus-free bladder augmentation.

[Foreign body aspiration of the lower airways in children - diagnosis in clinical practice]. / A gyermekkori alsó légúti idegentest-aspiráció diagnosztikája a klinikai gyakorlatban.

INTRODUCTION AND AIM: Rigid bronchoscopic foreign body removal is the gold standard procedure for foreign body aspiration. We have analysed our results of bronchoscopies and the accuracy of diagnosis among the paediatric population in Southeast Hungary. METHOD: A retrospective study of children admitted because of suspected solid foreign body aspiration between 2006 and 2017 was performed. RESULTS: From among 220 admitted patients, 86 were suspected of solid particle aspiration. Presenting history was certain in 68.6% (n = 59/86). Sudden choking-like symptoms were present in 61/86 patients (70.9%), coughing in 81/86 patients (94.2%). Thoracic auscultation was positive in 67/86 cases (77.9%), chest X-ray in 75/86 patients (87.2%), while fluoroscopy only in 12/75 cases (16%). 92 bronchoscopies in 86 patients were performed. In 57 bronchoscopies, solid foreign body was found (66.2%) and the removal was successful in 56 cases. Thoracic auscultation was negative in patients with foreign body only in 6/57 cases (10.5%). In the same group, chest X-ray was negative in 33/57 cases (57.9%) and fluoroscopy was positive only in 12/57 patients (21.1%). Pneumonia or prolonged bronchitis was present in 4/86 patients (4.6%). Severe bronchial bleeding occurred in 2/86 cases (2.3%). Mortality was 1.2%, a child with severe co-morbidity and chronic aspiration passed away. Bronchoscopy was negative in 29/86 patients (33.7%). Complications were significantly higher in chronic cases than in the acute ones. CONCLUSION: Rigid bronchoscopy is indicated if solid foreign body aspiration is suspected and positive anamnesis, typical symptoms (coughing, choking) or positive chest auscultations are present. Diagnosis predominantly based on radiological finding is controversial due to the high possibility of false negative results. Early intervention within the first 24 hours is recommended to avoid complications. Orv Hetil. 2018; 159(51): 2162-2166.

Mucosectomy impairs ileal microcirculation and results in flap contraction after experimental ileocystoplasty.

INTRODUCTION: Bladder augmentation with demucosalized ileal flap is a promising alternative approach for mucus free bladder augmentation; however, the contraction of the flap is still a major concern. It has been hypothesized that mucosectomy causes ischemic damage, but no direct histological evidence has been found and attention is now focused on the urothelium cover to prevent the exposure of the denuded surface to urine or the use of balloons to keep the flaps distended. OBJECTIVE: Our aim was to study the effect of mucosectomy on the microcirculation of ileal flaps during reverse clam ileocystoplasty using direct intraoperative imaging of the ileum. Since the omentum is successfully used to revascularize ischemic tissue, we also examined whether omentopexy can prevent contraction. STUDY DESIGN: Clam ileocystoplasty was performed in anesthetized minipigs with seromuscular (n = 3), seromusculo-submucosal (n = 3) reverse demucosalized ileal flaps. The velocity of the circulating red blood cells (RBCV) and the perfusion rate (PR) was measured with intravital videomicroscopy (Cytoscan A/R, Cytometrics, Philadelphia, PA, USA) before and after mucosectomy and the denuded surface of the ileum was covered with omentum after the reverse augmentation was complete (Figure). Animals were sacrificed after 8 weeks and the ileal flap dimensions were measured. RESULTS: Significant reduction in RBCV and PR was detected after mucosectomy in both groups; however, no sign of acute flap necrosis or bladder perforation was seen. The omentum was found firmly attached to the ileal flaps, but contraction of the flaps was significant in both groups. CONCLUSION: The disturbance in the microcirculation observed after mucosectomy may be responsible for flap contraction in ileocystoplasty with demucosalized ileum. Omentopexy did not help to prevent contraction. DISCUSSION: Contraction of demucosalized intestinal flaps used for bladder augmentation has been frequently reported. This study provides direct evidence the first time for severely compromised microcirculation of the ileal flaps after mucosectomy. Limitation of the study is the relative low number of animals sacrificed.

Intestinal Intramural Vascular Anastomoses.

INTRODUCTION: Present surgical techniques are rarely relying on intestinal intramural vascular anastomoses; however, this could open new limits in reconstructive surgery. Our aim was to study the efficacy of the antimesenteric and the longitudinal intramural vascular anastomoses in a porcine model. MATERIAL AND METHODS: Five minipigs were used. Antimesenteric anastomoses: jejunal loops were detubularized by cutting along the antimesenteric line (Control), in the middle between the mesenteric and antimesenteric border (Group 1) and close to the mesenteric line (Group 2). Mucosal microcirculation (red blood cell velocity, perfusion rate) was recorded with orthogonal polarization spectral imaging (Cytoscan A/R) at the long edge of the detubularized bowel. Longitudinal anastomoses: records were made on a continuous jejunal loop following antimesenteric incision, detubularization, and subsequent ligation of 2, 4, and 6 neighboring vasa recta in the middle of the loop. The same study was repeated on the free end of completely divided jejunal segments with ligation of 2, 4, or 6 vasa recta. RESULTS: Antimesenteric anastomoses: There was no statistically significant difference in red blood cell velocity and perfusion rate between Control and Groups 1 and 2. Longitudinal anastomoses: The red blood cell velocity dropped significantly, while the perfusion rate did not change significantly after ligation of 4 vasa recta in the continuous loop. In the loop with a free end, however, both parameters decreased significantly after ligation of four vessels. CONCLUSION: It is safe to rely on antimesenteric intramural anastomoses but strong limitation of longitudinal intramural vascular anastomoses should be considered in intestinal reconstructions.

New alternative Mitrofanoff channel based on spiral intestinal lengthening and tailoring.

INTRODUCTION: The occasional lack of appendix and the increasing use of the Malone anterograde continence enema (MACE) procedure have expanded the need for alternative Mitrofanoff channels. The Monti procedure does not always provide adequate length, the anastomosis of the double Monti, and the potential kink of the Casale channel is not ideal for smooth catheterisation. We tested the concept of spiral intestinal lengthening and tailoring (SILT), we developed originally for short bowel syndrome, to create a long and straight alternative Mitrofanoff channel (Figure). MATERIAL AND METHODS: After ethical approval five mini-pigs underwent spiral intestinal lengthening and tailoring (SILT) without any previous bowel dilatation procedure. (Mean bowel width was 20.5 ± 0.57 mm). The spiral line was marked on a 6-8-cm-long ileum approximately 15 mm apart with a 60° angle to the longitudinal axis of the bowel. When the incision was completed, the mesentery was incised perpendicularly where the spiral incision line met the mesentery. The maximum length segment hanging on a single 1.5-cm-wide well-vascularised mesentery was detached. The capillary red blood cell velocity (RBCV) and perfusion rate (PR) was measured at the edges of the opened bowel strip by in vivo microscopy using orthogonal polarising spectral imaging (Cytoscan A/R, Cytometrics, Philadelphia, PA, USA). The bowel strips have been reconstructed in spiral fashion over a 12F catheter and were implanted into the bladder. Viability, patency, and microcirculation were assessed 4 weeks later. Conventional microscopy with HE staining was performed. RESULTS: The mean length of the spiral channel (100 ± 26.4 mm) was longer than could have been achieved with the double Monti or Casale procedure (4 times the bowel width). A 17% and 8.3% reduction was measured in the median values of the RBCV and the PR at the edges of the bowel strip at the primary surgery. All implanted channels remained viable, straight, patent, and easily catheterisable after 4 weeks, with full recovery of the RBCV and PR. The histology showed no necrosis or fibrosis. CONCLUSION: The SILT concept is suitable for creating a long and straight alternative Mitrofanoff channel. DISCUSSION: However, the SILT technique has been reported to be successful in the clinical practice to tailor and lengthen dilated short bowel; in this study we first applied this technique on normal calibre intestine to create long alternative Mitrofanoff channel. The use of an animal model and the relative short-term observation are the limitations of this study.