Traumatic Abdominal Wall Hernia in Children by Handlebar Injury: When to Suspect, Scan, and Call the Surgeon.

Traumatic abdominal wall hernias (TAWHs) can be defined as a herniation through disrupted musculature and fascia associated with blunt trauma. They are seen in approximately 1% of patients with blunt abdominal trauma. Data on TAWH in the pediatric population are very limited and principally based on case reports and a few case series. Past reports have indicated that the presence of the "handlebar sign" confers an increased risk of internal injury. Concomitant internal injuries are reported with an incidence between 25% and 70%, and occult hernias may also occur and are usually detected only by abdominal computed tomography scan and ultrasonography. The treatment of TAWH consists in surgical exploration through closure of the defect. We describe 2 cases of TAWH due to blunt impact by bicycle handlebars that occurred in our department with a brief literature review. Our objectives are to describe the variable clinical presentations and management of these events. We hope to provide a useful tool for the clinician to increase early clinical suspicion and detection of this insidious injury.

Idiopathic pulmonary fibrosis and occupational risk factors.

Idiopathic pulmonary fibrosis (IPF) is a rare lung disease of unknown origin that rapidly leads to death. However, the rate of disease progression varies from one individual to another and is still difficult to predict. The prognosis of IPF is poor, with a median survival of three to five years after diagnosis, without curative therapies other than lung transplantation. The factors leading to disease onset and progression are not yet completely known. The current disease paradigm is that sustained alveolar epithelial micro-injury caused by environmental triggers (e.g., cigarette smoke, microaspiration of gastric content, particulate dust, viral infections or lung microbial composition) leads to alveolar damage resulting in fibrosis in genetically susceptible individuals. Numerous epidemiological studies and case reports have shown that occupational factors contribute to the risk of developing IPF. In this perspective, we briefly review the current understanding of the pathophysiology of IPF and the importance of occupational factors in the pathogenesis and prognosis of the disease. Prompt identification and elimination of occult exposure may represent a novel treatment approach in patients with IPF.

Obstructive internal hernia caused by mesodiverticular bands in children: Two case reports and a review of the literature.

INTRODUCTION: The mesodiverticular band (MDB) is an embryologic remnant of the vitelline circulation, which carries the arterial supply to the Meckel diverticulum. In the event of an error of involution, a patent or nonpatent arterial band persists and extends from the mesentery to the apex of the antimesenteric diverticulum. This creates a snare-like opening through which bowel loops may herniate and become obstructed. This report describes 2 rare cases of small bowel occlusion owing to an internal hernia caused by a MDB. CASES: Case 1 was a 5-year-old boy who presented to our Emergency Department with colicky abdominal pain diffused to all abdominal quadrants. He also had 5 episodes of emesis, the last with bilious vomiting. Case 2, a 12-year-old boy, presented to our Emergency Department complaining of colicky abdominal pain. He had 2 episodes of nonbilious emesis. On physical examination, both children showed distension and tenderness of the abdomen and abdominal x-ray and ultrasound confirmed an occlusive picture without an apparent etiology. In case 1, an urgent laparotomy was performed and the MDB was ligated and cut, whereas in case 2 diagnosis and excision were performed in laparotomy. In both patients, there was a positive clinical evolution. CONCLUSION: Although MDB causing internal hernia is very rare, it should be considered in patients with a clinical picture of small bowel obstruction. In these cases, early surgery is important to prevent strangulation and gangrene of the bowel and to avoid dramatic events. Moreover, laparoscopy seems a safe and effective technique in these patients, especially in children with mild abdominal distention without surgical or trauma history, highlighting that further studies on the value of laparoscopy for the treatment of small bowel obstruction in pediatric patients are urgently needed.

Isolated fallopian tube torsion with hydrosalpinx: Review of a debated management in a pediatric population.

PURPOSE: To quantify our experience with and assess the literature on diagnosis and management of isolated fallopian tube torsion (IFTT) with hydrosalpinx (HSX) in children. METHODS: A PubMed search was performed on pediatric cases of IFTT with HSX to provide a comprehensive review analyzing details and management of this association, focusing on the problem of fertility preservation. RESULTS: In addition to our 3 cases, 17 patients of pediatric IFTT associated with HSX were identified, for a total of 21 cases (median age 12.2 years). Menarchal status was present in 10/13 (76.9%); blood tests were reported in 9/20 (42%) showing leucocytosis in 7/9 (75%). Ultrasonography was performed in all cases except one. Laparoscopy was the surgical approach in 84.6% of the reported cases. The torsion was to the right in 36.8%, and to the left in 63.2% of the cases. In one case the torsion was bilateral and asynchronous. Performed procedures were salpingectomy (52.4%) and partial salpingectomy (14.3%); conservative management was reported in 33.3% of the cases. CONCLUSIONS: The literature describes different management techniques. Salpingectomy is the most frequently performed procedure but recently conservative management seems to be increasingly applied. A long-term study is necessary to define the most effective treatment for the preservation of future fertility in pediatric patients. TYPE OF STUDY: Treatment study (Retrospective Study): LEVEL IV.

Pediatric Ovarian Torsion and its Recurrence: A Multicenter Study.

STUDY OBJECTIVE: To report results of a retrospective multicentric Italian survey concerning the management of pediatric ovarian torsion (OT) and its recurrence. DESIGN: Multicenter retrospective cohort study. SETTING: Italian Units of Pediatric Surgery. PARTICIPANTS: Participants were female aged 1-14 years of age with surgically diagnosed OT between 2004 and 2014. INTERVENTIONS: Adnexal detorsion, adnexectomy, mass excision using laparoscopy or laparotomy. Different kinds of oophoropexy (OPY) for OT or recurrence, respectively. MAIN OUTCOME MEASURES: A total of 124 questionnaires were returned and analyzed to understand the current management of pediatric OT and its recurrence. The questionnaires concerned patient age, presence of menarche, OT site, presence and type of mass, performed procedure, OPY technique adopted, intra- and postoperative complications, recurrence and site, procedure performed for recurrence, OPY technique for recurrence, and 1 year follow-up of detorsed ovaries. RESULTS: Mean age at surgery was 9.79 ± 3.54 years. Performed procedures were open adnexectomy (52 of 125; 41.6%), laparoscopic adnexectomy (25 of 125; 20%), open detorsion (10 of 125; 8%), and laparoscopic detorsion (38 of 125; 30.4%). Recurrence occurred in 15 of 125 cases (12%) and resulted as significant (P = .012) if associated with a normal ovary at the first episode of torsion. Recurrence occurred only in 1 of 19 cases after OPY (5.2%). Ultrasonographic results of detorsed ovaries were not significant whether an OPY was performed or not (P = 1.00). CONCLUSION: Unfortunately, oophorectomy and open technique are still widely adopted even if not advised. Recurrence is not rare and the risk is greater in patients without ovarian masses. OPY does not adversely affect ultrasonographic results at 1 year. When possible OPY should be performed at the first episode of OT.

Recurrent Ipsilateral Ovarian Torsion: Case Report and Literature Review.

BACKGROUND: Recurrent ipsilateral ovarian torsion at pediatric age is a rare event. Different surgical techniques for its prevention are available. We present a case of recurrent ipsilateral ovarian torsion in a prepubertal girl and we reviewed the literature about the management of this condition. CASE: A 6-year-old girl presented with right ovarian torsion and underwent a laparoscopic untwisting. Nine months later an ipsilateral recurrence occurred. Laparoscopic untwisting and right-sided oophoropexy with plication to the round ligament was performed. SUMMARY AND CONCLUSION: In addition to our presented case, four cases of recurrent ipsilateral ovarian torsion in pediatric patients were identified in the literature. The few available reports in the pediatric literature show different management techniques. A long-term study is necessary to define the most effective treatment.

Symptomatic Meckel's diverticulum in newborn: two interesting additional cases and review of literature.

OBJECTIVES: This study aimed to review the literature about symptomatic Meckel's diverticulum (MD) in the neonatal period with 2 additional uncommon cases. METHODS: The authors describe 2 interesting neonatal cases of symptomatic MD and analyze the literature on this topic, with particular reference to the prevalence of sex, age at presentation, most common signs and symptoms, treatment, histology, associated anomalies, and outcome. RESULTS: The first patient was a term newborn with bowel obstruction by a pseudocystic MD. The second patient was a preterm infant with double perforation of the MD and ileum. Literature search for published case reports and case series on this topic reveals only 18 cases of neonatal symptomatic MD. Males are more frequently involved than females, and even preterm infants may be affected. Bowel obstruction (58.3%) and pneumoperitoneum (33.3%) are the most frequent clinical manifestation. Acute inflammation of the MD is the prominent histopathological finding (75%), although it does not seem to be related with the presence of heterotopic tissue within the MD. Surgical treatment is essential. The association of neonatal symptomatic MD with other anomalies is exceptional but is otherwise life threatening despite surgery. CONCLUSIONS: Bowel obstruction and pneumoperitoneum are the most frequent clinical manifestations of symptomatic MD in the newborn. Surgery is required for a definitive diagnosis and successful outcome.

Laparoscopic herniorrhaphy in the pediatric age group: what about the learning curve?

PURPOSE: To evaluate the learning curve of pediatric laparoscopic herniorrhaphy (LH), the authors report a retrospective analysis comparing results obtained with this technique and the traditional herniotomy to determine how many procedures are necessary to obtain the results described in the literature. PATIENTS AND METHODS: From May 2008 to February 2012, a total of 140 patients (110 boys and 30 girls) with uncomplicated inguinal hernia (IH) consecutively underwent surgery. Patients were divided in two groups: The "Open" group of 83 patients (M:F 64:19) with a mean age of 33.2 months who were operated on with traditional herniotomy and the "Lap" group of 57 patients (M:F 46:11) with a mean age of 34.5 months who were operated on with LH. Operative time and complications of the techniques were analyzed statistically. RESULTS: In the Open group, the mean operative time for monolateral repair was 35.4 ± 17.7 minutes compared with the Lap group time of 29.9 ± 15.9 minutes; for bilateral repair, the mean operative time for the Open group was 56.2 ± 19.3 minutes compared with the Lap group time of 41.5 ± 10.4 minutes. The analysis shows a shorter operative time for the laparoscopic repair for both monolateral (P=0.73) and bilateral (P=0.0001) hernia. Recurrences occurred in one (0.9%) patient in the Open group and in two (2.7%) patients in the Lap group (P=0.577). CONCLUSIONS: This experience shows that LH is a reliable technique. Retrospective analysis revealed a shorter mean operative time for the laparoscopic intervention both for monolateral and bilateral IH repair. Recurrences in the Lap group occurred in the first 10 patients treated, and the mean operative time was reached in 20 monolateral LHs and after 15 bilateral herniorrhaphies. From this analysis, the learning curve for the LH needs a minimum of 20 procedures.

Minimally invasive removal of urachal remnants in childhood.

OBJECTIVES: Urachal remnants are rare congenital anomalies generally treated with open surgery. In the last decade laparoscopic treatment of these anomalies became more frequent. The Authors report their experience about minimally invasive treatment of remnants. METHODS: Four children with urachal remnants underwent minimally invasive surgery. Two children with infected urachal cysts underwent delayed laparoscopic assisted excision. In the others two patients with urachal cysts diagnosed incidentally the excision of the remnant was performed laparoscopically. RESULTS: In all cases the excision of remnants was accomplished easily. Operative time ranged from 40 to 90 minutes. Intra- or post-operative complications and recurrences did not occur and the cosmetic results were very good. CONCLUSIONS: Minimally invasive surgery for urachal remnants is reliable, diagnostic and therapeutic at the same time. In case of complicated urachal cysts the delayed laparoscopic assisted treatment ensure a minimally invasive surgery with a single anesthesia.