INTRODUCTION: Congenital anomalies in the neck region, such as dermoid sinuses, pose diagnostic challenges in pediatrics. Surgical excisions are vital to prevent complications. PRESENTATION OF CASE: A 7-month-old male infant had presented with a congenital suprasternal dermoid sinus, which had been evident since birth. Imaging confirmed the diagnosis, prompting surgical intervention under general anesthesia. A delicate excision was performed, guided by a methylene blue dye injection, followed by histopathological confirmation. DISCUSSION: Dermoid sinuses typically manifest as cutaneous pits or sinus tracts, with a left-sided predominance and a female predilection. An accurate diagnosis relies on clinical examination and imaging studies to delineate the anomaly. Surgical excision remains crucial to prevent recurrence and complications. CONCLUSION: This case reaffirms the necessity of prompt and accurate diagnosis followed by surgical intervention for managing congenital dermoid sinuses. Ongoing research and collaborative studies are needed to further refine management strategies and improve outcomes for patients with these anomalies, particularly when presenting in atypical locations.
BACKGROUND: Laparoscopic cholecystectomy (LC) is one of the most common laparoscopic procedures performed by young surgeons nowadays. Sometimes, LC could be challenging, especially for junior surgeons leading to serious complications. Therefore, this study aims to investigate the preoperative ultrasonographic features that could predict difficult LC. METHODS: In this prospective study, patients (n = 204) who underwent LC for symptomatic cholelithiasis from January 2020 to August 2022 were included. Preoperative parameters, including the ultrasonographic findings, were evaluated for their ability to predict difficult LC. RESULTS: The difficulty of LC was evaluated using two intraoperative scores. Among the ultrasonic parameters that were assessed preoperatively, thickened gallbladder (GB) wall, contracted GB, and impacted stone in the GB neck were associated with difficult LC. However, an impacted stone in the GB neck was the only independent predictor of difficult LC according to both difficulty scores in the multivariate analysis (odds ratio [OR] = 7.56, p = .001; OR = 8.42, p = .001). CONCLUSIONS: The impacted stone in the GB neck is an ultrasonographic sign of difficult LC. It should alert the surgeon for a more appropriate preoperative preparation, and the patient should be informed about the increased risk of complications, including conversion to open cholecystectomy.
Cholecystectomy, Laparoscopic , Cholelithiasis , Humans , Cholecystectomy, Laparoscopic/adverse effects , Prospective Studies , Cholelithiasis/surgery , Gallbladder , Cholecystectomy
Background: Surgical correction is the main line of treatment for the congenital disorder Hirschsprung's disease (HD). Laparoscopic techniques proved their safety and efficacy in previous studies. LigaSure™ is the gold standard for colorectal dissection. However, other sealing methods could be used during the unavailability of LigaSure. Purpose: This study aimed to assess the safety profile of the hook diathermy technique compared to LigaSure in colorectal dissection during laparoscopic-assisted pull-through for HD. Materials and Methods: This case-control study was held in the pediatric surgery department at Assiut University Hospitals between September 2017 and January 2023. The study included 57 HD patients who were surgically operated on during a laparoscopic-assisted pull-through. They were divided into 2 groups according to the sealing methods: the ligasure group included 25 patients, and the hook diathermy group included 32 patients. Results: Both groups had no statistically significant differences regarding age, sex, or weight. The transition zone was present in all patients, and most transition zones were rectosigmoid. No cases reported intraoperative blood transfusion or conversion to an open or transanal approach. Minimum intraoperative blood loss was reported in both groups, with no significant differences. As regards postoperative complications, including bleeding, leakage, perianal excoriation, and enterocolitis, no significant differences between both groups were found. Conclusion: The LigaSure and hook diathermy techniques are safe and effective sealing methods for colorectal dissection during laparoscopic-assisted pull-through for HD.
Introduction The critical view of safety is an important concept for safe laparoscopic cholecystectomy. However, no standard step-by-step approach for achieving the critical view of safety has been established until now. Therefore, this study aims to evaluate a new approach for achieving the critical view of safety using the diagonal line of liver segment IV as an anatomical landmark. Patients and methods In this prospective non-randomized study, patients (n= 112) who underwent laparoscopic cholecystectomy for symptomatic cholelithiasis were included. The first 47 patients underwent laparoscopic cholecystectomy using the diagonal line approach (DLC group) whereas, the next 65 patients underwent laparoscopic cholecystectomy using the conventional method (CLC group). Results No significant difference between both groups regarding the preoperative characteristics, operative time, and intraoperative blood loss. Laparoscopic subtotal cholecystectomy was performed more in the DLC group (6% vs 0%, p= 0.07). Whereas, in the CLC group, there was a tendency towards conversion to open cholecystectomy in difficult cases (6% vs 2%, p= 0.40). No intra- or postoperative complications occurred in either group. Conclusion The diagonal line approach is a feasible and useful step-by-step technique to achieve the critical view of safety in laparoscopic cholecystectomy and enables surgeons to perform safe laparoscopic subtotal cholecystectomy in difficult cases.
BACKGROUND: This study compared the transversus abdominis plane (TAP) block with bupivacaine and dexmedetomidine to the same mixture in the caudal block in delivering postoperative analgesia in children after unilateral inguinal hernia surgery. METHODS: The current study included 80 children aged two to eight years who were scheduled for unilateral inguinal hernia surgery under general anesthesia. A caudal block (1 mL/kg 0.25% bupivacaine and one µg /kg dexmedetomidine) or a TAP block (1 mL/kg 0.25% bupivacaine and one µg /kg dexmedetomidine) was given to each participant at random. The time it took to request analgesia for the first time, the postoperative pain score, total analgesic use, sedation, family satisfaction, and side effects were all measured. The primary outcome was time to first analgesic request. RESULTS: The caudal block group had a considerably shorter time to first analgesic request than the TAP block group. The caudal block group received more rescue analgesia doses within 24 hours than the TAP block group. The mean total dose of intravenous paracetamol within the first 24 hours postoperatively was greater in the caudal block group. The caudal block group had much higher family satisfaction. CONCLUSIONS: The TAP block and caudal block provide good postoperative analgesia in children undergoing unilateral inguinal hernia repair. Adding dexmedetomidine to the TAP block was superior to the caudal block in terms of extending the length of the initial analgesic request, lowering analgesic requirement, and lowering pain scores without causing substantial adverse effects.
Dexmedetomidine , Hernia, Inguinal , Nerve Block , Humans , Child , Hernia, Inguinal/surgery , Bupivacaine , Abdominal Muscles
INTRODUCTION AND IMPORTANCE: Chylolymphatic cysts are benign pathology in lymphatic vessels due to obstruction in the lymphatic system. Their incidence is still unknown. However, they account for approximately 3 % to 9 % of all pediatric lymphangiomas. Most of these lesions are asymptomatic and are discovered accidentally. They can present with non-specific abdominal pain, vomiting and changes in bowel habits. Rarely, Chylolymphatic cysts can cause fatal complications such as intestinal obstruction, volvulus or even torsion. CASE PRESENTATION: A 3-month-old male presented to our unit with manifestations of acute intestinal obstruction. Abdominal examination revealed signs of generalized peritonitis and intestinal obstruction. Abdominal ultrasound revealed minimal turbid intraperitoneal collections and no motility of bowel loops. Plain erect abdominal radiograph revealed multiple small bowel air fluid levels. Abdominal exploration revealed a large Chylolymphatic cyst causing acute intestinal obstruction. Excision of the cysts was done with preservation of adjacent bowel loop. The patient was discharged in good health on the 6th day postoperative. A chylolymphatic cyst with a diameter of 5 cm was identified by histological investigation. CLINICAL DISCUSSION: Mesenteric cyst is a rare intra-abdominal tumor with prevalence of about 1: 20,000 in pediatric age group. They are benign cystic pathology lined with a thin endothelium or mesothelium occur due to gross proliferation of isolated or ectopic lymphatics in mesentery that lack communication with the rest of the lymphatic system. Regarding pathology, mesenteric cysts are classified into four types including type 1 (Pedicled) and type 2 (Sessile), which are limited to the mesentery, hence can be excised completely with or without resection of the involved gut. Type 3 and type 4 are multicentric, so they require complex surgery and often sclerotherapy because of their extension into retroperitoneum. The majority of mesenteric cysts may present as asymptomatic abdominal mass or incidental finding on imaging or during laparotomy for other abdominal conditions. Preoperative diagnosis of mesenteric cyst in most cases is difficult as they have no definite characteristic features. Abdominal ultrasound which is the imaging modality of choice can reveal mesenteric cysts as cystic tumors. Surgical removal of the cyst is the standard treatment for chylolymphatic cysts. CONCLUSION: Most Chylolymphatic cysts in infants are asymptomatic, but they can cause fatal complications such as intestinal obstruction, volvulus or even torsion.
BACKGROUND: Post-circumcision penile ischemia is a devastating complication. We will present our experience in managing children with various forms of penile ischemia. MATERIALS AND METHODS: This cohort prospective observational and interventional study was performed on all male children with post-circumcision penile ischemia between April 2017 and October 2021. A designed and approved protocol includes a combination of early pentoxifylline infusion, hyperbaric oxygen inhalation, early catheterization, and appropriate surgical debridement were applied for patients with deep ischemia 11/23, mainly the necrotic skin and subcutaneous tissues. Data of patient age, anesthesia method, monopolar diathermy usage, early presentation and positive wound culture were collected and analyzed statistically. RESULTS: During the study period 3,382 children were circumcised for non-medical reasons; 23 children were diagnosed with penile ischemia (0.7%), among other complications (9%). Most of the penile ischemia is associated with the use of monopolar diathermy (74%). The use of compressive wound dressing to control post-circumcision bleeding and infections is also responsible for ischemia in 52.2% and 43.5% of the cases. Inexperienced physicians were commonly responsible for ischemia (73.9%). Patients managed at first 24 h had better outcomes than those who were presented later (p = 0.001). CONCLUSION: In children with post-circumcision penile ischemia, a combination of hyperbaric oxygen therapy and pentoxifylline is especially effective for patients with skin and facial necrosis, this management reduces penile tissue loss.
Circumcision, Male , Hyperbaric Oxygenation , Hyperthermia, Induced , Pentoxifylline , Child , Humans , Male , Circumcision, Male/adverse effects , Pentoxifylline/therapeutic use , Penis
INTRODUCTION AND IMPORTANCE: Isolated male epispadias is a rare entity with incidence of approximately 1 in 120,000 live births. Epispadias usually presents with a phimotic preputial orifice where glans is not visible and hence is also known as concealed epispadias. Buried penis in children is defined as a congenital insufficient penile skin with an unretractable foreskin that keeps the penis deep inside the pre-pubic fat. This congenital malformation of the penile envelopes is usually isolated. However, in some cases the concealed penis hides an underlying penile anomaly. We present surgical repair of a very rare case with concealed epispadias. CASE PRESENTATION: A nine-month-old infant had buried his penis, and his mother was seeking his circumcision. Local examination revealed concealed penopubic epispadias. A pediatric surgeon operated on this patient using the modified partial penile disassembly technique. The patient was doing well at follow-up visits at one, three, and six months. There were no urethral stricture or obstructive urinary symptoms. The parents were satisfied with the cosmetic outcome. CLINICAL DISCUSSION: The embryogenesis and development of the urethra and the prepuce are linked. Urethral development defects (as in hypospadias or epispadias) are frequently coupled with faulty prepuce on the same side. The goal of surgical management for epispadias is to correct the dorsal chordee and reconstruct the epispadiac urethra and glans. Based on the cosmesis of the penis reconstruction, preservation of erectile function, and achieving urine continence, the outcome is evaluated. CONCLUSION: Concealed epispadias is frequently ignored because patients appear with buried penis, non-retractile prepuce, and a normal urine stream. Preoperative diagnosis and parent counseling are critical for the effective treatment of this uncommon entity. The modified partial penile disassembly procedure, in which the tunica albuginea is stitched to the pubic periosteum at 3 and 9 o'clock, can be used to correct buried epispadias.
INTRODUCTION AND IMPORTANCE: Infantile umbilical hernia is common in children. It has a regressive course in most cases. Conservative management is the standard in most cases before the age of 3 years unless there are complications such as incarceration, rupture with evisceration which are extremely rare and warrants emergency surgery. CASE PRESENTATION: Our case was a full term 6-month-old male of normal birth weight with history of umbilical hernia but with no obvious risk factors to develop complications. The loops evisceration was spontaneous with a small umbilical skin damage. The poor parental consultation on early surgical management and delayed presentation of the infant after evisceration could be the possible risks for ischemic changes and shock state at the time of presentation, however, prompt medical resuscitation and surgical management relatively improved postoperative outcomes. CLINICAL DISCUSSION: Infantile umbilical hernia is considered one of the most encountered abnormalities of infancy. Most umbilical hernias are asymptomatic and discovered after birth. Complications of infantile umbilical hernia as incarceration or spontaneous evisceration are very rare but fatal. Certain factors increase the risk for developing spontaneous rupture of infantile umbilical hernia including the age of the infant or child, the defect size, umbilical sepsis or ulceration and any condition which raises intra-abdominal pressure, i.e., crying, coughing or positive ventilation. CONCLUSION: Although infantile umbilical hernia is clinically benign condition with a regressive course in majority of cases, the risk of rupture of an umbilical hernia is exceedingly rare in pediatric population; physicians should be warranted with the possible risk factors for spontaneous rupture and in these patients expedite surgical repair.
BACKGROUND: We evaluated the efficacy of dexmedetomidine versus magnesium sulfate as an adjuvant to intraperitoneal (IP) bupivacaine in pediatric laparoscopic inguinal herniorrhaphy. METHODS: Ninety-seven male children, ASA I-II, 1-6 years old, undergoing laparoscopic inguinal herniorrhaphy, were randomized to receive before peritoneal insufflation, IP 2 mg.kg-1 bupivacaine 0.5% combined with either 1 µg.kg-1 of dexmedetomidine (Group D), 30 mg.kg-1 of magnesium sulfate (Group M), or normal saline (Group C). All tested drugs were diluted to the volume of 10 mL with normal saline. FLACC pain scores, need for rescue analgesics, time to flatus and first stool, emetic events, adverse effects, functional recovery, and parents' satisfaction were recorded for the first 48 h postoperatively. RESULTS: FLACC scores were significantly higher in Group C than in the other two groups at 6, 8, 12, 18, 24, and 48 hours after surgery with no differences between Groups D and M. Rescue analgesia was significantly higher in Group C with none of the children in Groups D and M requiring rescue analgesia (p = 0.001). Times to first flatus and stool, emetic events, and adverse effects did not differ among groups. Times to return to normal functional activity were comparable in all groups. Parents' satisfaction was greater in Groups D and M than in Group C (p = 0.026). CONCLUSION: Dexmedetomidine and magnesium sulfate added to IP bupivacaine improved the analgesia afforded by bupivacaine in the first two postoperative days in children scheduled for laparoscopic herniorrhaphy.
INTRODUCTION: Splenic tumours are relatively rare and include malignancies such as lymphomas, angiosarcomas, plasmacytomas, primary malignant fibrous histiocytomas, and splenic metastases. Benign tumours of the spleen such as hemangiomas, cysts, and inflammatory pseudotumours are very rare (Kaza et al., 2010, PisaniCeretti et al., 2012) [1,2]. There are fewer than 160 cases of splenic hamartoma or splenomas having been reported in the literature (Basso et al., 2012) [3]. Only 20% of the cases were detected in children (Abramowsky et al., 2004) [4]. Although multi-modality imaging findings were described preoperatively, the final diagnosis was splenic hamartoma based on histology and immunohistochemistry. CASE REPORT: Here, we report a case of a14 year old child left upper quadrant abdominal pain and worsening sickness. Multi-modality imaging detected a solid lesion of the spleen, who required splenectomy and was pathologically diagnosed as a splenic hamartoma. The postoperative course was uneventful. DISCUSSION: Splenic hamartoma is very rare. Only 20% of hamartomas occur in children. They are commonly found incidentally on imaging with no symptoms. CONCLUSION: Splenic hamartoma is a benign vascular proliferative lesion that requires a multi-modality imaging studies for diagnosis and confirmed by histopathology. It must be included in the differential diagnosis of splenic mass forming lesions.
INTRODUCTION: Near-infrared (NIR) fluorescent cholangiography (FC) using indocyanine green (ICG) in laparoscopic cholecystectomy (LC) has been used as a technique for real-time visualization of bile ducts for approximately ten years; however, no standard protocol has been determined. This study aimed to determine the optimal time of administration of ICG. MATERIAL AND METHODS: In this prospective study, patients (n = 30) indicated for LC were divided into two groups. The first group received ICG 1 h before anesthesia at a dose of 0.1 mg/kg (1 h group), whereas the other group received ICG immediately after anesthesia with the same dose (0 h group). RESULTS: The rates of identification of the cystic duct (CD) and common bile duct (CBD) using NIR FC before and after dissection of Calot's triangle were comparable between the two groups. The fluorescence intensity ratios of CD/Liver and CBD/Liver were significantly higher in the 1 h group (2.2 vs. 0.49 and 2.1 vs. 0.38, respectively, p < .001) with minimal background liver fluorescence interference in the 1 h group. CONCLUSIONS: The study illustrates that administration of ICG 1 h before surgery with a dose of 0.1 mg/kg allows superior visualization of the extrahepatic bile ducts with minimal fluorescence interference from the background liver.
Cholecystectomy, Laparoscopic , Indocyanine Green , Cholangiography/methods , Cholecystectomy, Laparoscopic/methods , Coloring Agents , Humans , Prospective Studies
INTRODUCTION: Human tails are rare congenital malformations that describe protrusions commonly located around the midline of the lumbosacral region covered by skin, representing an embryonic remnant. Human tails are broadly classified into true and pseudo-tails. The real ones represent the persistence of a remnant of the embryonic tail formed between the fourth and eighth week of gestation. PRESENTATION: A male infant aged 42â¯days presented to our institution with a tail-like structure that originated from the anal mucocutaneos junction. The parents did not bring the baby at birth because of the social stigma and ignorance. On examination, there was a tail-like structure that is about 22â¯cm in length and 1.5â¯cm in diameter originated from the mucocutaneous junction at the anus at the left side. There was no bony element on palpation. The lower vertebral column examination showed no abnormalities, and this was confirmed with an x-ray. The patient was operated on with simple excision of the tail and primary closure of the wound at the base. He was discharged on the same day well and good. The tail was taken for microscopic histopathology. DISCUSSION: There are few reported cases describing human tails. However, none of them was originating from the anal mucocutaneous junction. CONCLUSION: We report the first case of a human tail arising from the anal mucocutaneous junction worldwide. Due to its very superficial origin, it was not associated with any other anomalies.
INTRODUCTION: We present a case of a male child 8 years old presenting with a sigmoid volvulus causing ischemia of most of bowel loops resulting in a short bowel syndrome. It is the first reported case worldwide. PRESENTATION: A male child presented with a picture of intestinal obstruction. After complete laboratory and radiological investigation, laparotomy was done revealing a sigmoid volvulus compessing most of the small bowel loops with gangrenous sigmoid colon for which sigmoidectomy with end colostomy, resection of gangrenous small bowel loops and primary anastomosis of the remaining healthy part. DISCUSSION: There are few reported cases describing sigmoid volvulus in this age group. However, none of them resulted in short bowel syndrome. The median age was 7 years with a higher ratio in males than females (3.5:1). CONCLUSION: Sigmoid volvulus is not a common problem in children and adolescents, and is rarely considered as a cause of intestinal obstruction and it was never reported as a cause of short bowel syndrome. Early diagnosis and prompt treatment confer an excellent prognosis.
INTRODUCTION: We present a newborn with double penis and double scrotum as a part of a caudal duplication syndrome (CDS) which is a condition includes duplication of the distal organs of the body. It is crucial to have knowledge about it to be able to be identified. PRESENTATION: A male newborn presented with double penis, double scrotum double urethra, double colon, and double imperforate anus. After work up a low descending colostomy was done (4 stomas of duplicated colon) and started feeding with normal passage from colostomy. DISCUSSION: The cause of CDS is unknown many theories have tried to explain that, but the most accepted theory is failure of monchorial twins to separate completely. CDS may be associated with other congenital anomalies as imperforate anus, renal anomalies, and omphalocele. CONCLUSION: CDS is a very rare condition which needs multidisciplinary team to manage and needs staged repair. Most pediatricians and pediatric surgeons are unable to diagnose it, we add a case of CDS to the literature.
We aimed to compare the early results of i.v. with p.o. TAC as a primary immunosuppressant in pediatric patients undergoing LT. This retrospective study enrolled 75 children who underwent LT and received TAC-steroid regimens as a primary immunosuppressant between September 2011 and October 2015 at our institution. Thirty-five recipients received TAC i.v. and 40 received TAC p.o. Early results were evaluated and compared, including ACR, EBV, or CMV infection; renal adverse effects; and hospital stay. Comparisons of 90-day post-transplant results showed that the rates of overall viral (74% vs 40% P < 0.002), EBV (46% vs 17.5% P < 0.008), and CMV (51% vs 30% P = 0.05) infections were significantly higher in the i.v. than in the p.o. group. Neither regimen has any adverse effects on renal function. There were no between-group differences in ACR incidence and severity, serum creatinine concentration, and hospital stay. Patient and graft survival rates at 3 months and 1 year did not differ significantly between the two groups. Compared with p.o. treatment, i.v. administration of high TAC concentration did not have beneficial post-transplant effects on ACR incidence and severity, while increasing the incidence of viral infections in pediatric LT.
Immunosuppressive Agents/administration & dosage , Liver Failure/surgery , Liver Transplantation , Tacrolimus/administration & dosage , Administration, Oral , Biopsy , Child , Child, Preschool , Cytomegalovirus Infections/etiology , Female , Graft Rejection , Graft Survival , Humans , Length of Stay , Liver/pathology , Male , Pediatrics , Postoperative Period , Retrospective Studies , Steroids , Treatment Outcome
INTRODUCTION: Suprahepatic caval resection and replacement of inferior vena cava (IVC) is standard procedure in deceased donor liver transplantation for patients with Budd-Chiari syndrome (BCS). However, replacement of IVC in living donor liver transplantation (LDLT) is difficult. We report a case of BCS successfully treated by LDLT without replacement of IVC. PRESENTATION OF CASE: A 52-years-old female with a primary BCS due to IVC thrombosis. A vena cava (VC) stent placed after angioplasty without improvement of the hepatic, portal venous flow and liver functions, Transjugular intrahepatic portosystemic shunt was considered and the patient had a rapid deterioration and increased ascites. The patient was scheduled for living donor liver transplantation (LDLT). Her Child-Paugh and MELD scores were 11, 18, respectively at time of transplantation. Left lobe was obtained from her son. Preservation of the native suprarenal IVC was impossible due to massive fibrosis and thrombosed. The suprahepatic IVC was also fibrotic and unsuitable for anastomosis with hepatic vein. The retrohepatic IVC resected include suprahepatic IVC together with the liver. The supradiaphragmatic IVC was reached and encircled through opening the diaphragm around the IVC and a vascular clamp applied on the right atrium with subsequent anastomosis with hepatic vein of the graft. The hemodynamic stability of the patient was maintained throughout the operation without IVC replacement due to developed collateral vessels. CONCLUSION: Patients with Budd-Chiari syndrome with obstructive IVC are successfully treated with living donor liver transplantation without replacement of IVC.
PV reconstruction is an important aspect of LDLT, with post-transplant outcomes depending on PV reconstruction methods. However, it is unclear whether the preferential selection of these techniques is dependent on preoperative recipient characteristics. This retrospective study assessed whether preoperative recipient factors differed in pediatric patients who did and did not receive VGs for PV reconstruction. Of 113 pediatric patients who underwent LDLT from January 2010 to July 2015, 31 (27%) underwent PV reconstruction with VGs and the other 82 (73%) without VGs. The presence of collateral vessels (P<.0001) and ascites (P=.02); PV size (P<.001), thrombosis (P=.01) and the direction of flow (P=.01), Child-Pugh class A vs B/C liver function (P=.01), Alb concentration (P=.02), primary diagnosis: BA vs non-BA (P=.03), and previous abdominal surgery (P<.005) differed significantly in patients who did and did not receive VGs for PV reconstruction. PV complications, patient survival, and graft survival did not differ significantly in patients with and without VGs at 1-year follow-up. VGs should be harvested for recipients with pretransplant hypoplastic PV, intense collaterals, hepatofugal flow, poor liver status, or previous abdominal surgery.
Liver Transplantation/methods , Liver/surgery , Portal Vein/surgery , Vascular Surgical Procedures , Adolescent , Child , Child, Preschool , Female , Graft Survival , Humans , Infant , Infant, Newborn , Liver Cirrhosis/surgery , Living Donors , Male , Necrosis , Retrospective Studies , Thrombosis , Treatment Outcome
