The clinical significance of an incidentally detected open internal inguinal ring.

INTRODUCTION AND OBJECTIVE: An open internal inguinal ring (IIR) may be discovered incidentally either in the context of correcting pathology involving the contralateral side or at the time of surgical exploration for reasons unrelated to a patent processus vaginalis (PPV). The aim of this study is to determine the evolution of an incidentally encountered open IIR in patients undergoing laparoscopy for reasons not associated with unilateral inguinal hernia or cryptorchidism. MATERIALS AND METHODS: The authors conducted a prospective study of all patients who underwent laparoscopic surgery in the department of pediatric surgery at Agios Loukas hospital between 2004 and 2013 for various indications. Patients operated for inguinal hernia and cryptorchidism were excluded. During this period, 572 patients underwent laparoscopy for reasons not related to PPV. The median age at time of initial laparoscopy was 9,4 years (range 2 days-16 years). The IIRs were always inspected. No attempt was made to repair the open IIRs, as they were asymptomatic. Parents were informed after the operation, and instructions were given to inform us, in case that inguinal hernia symptoms manifested. The duration of the follow-up was 4 years. RESULTS: Among these 572 patients, 39 patients with 44 open IIRs were found (6,82%). From the 39 patients, 35 were male and four were female; 22 had a right open IIR, 12 had a left one, and five of them a bilateral open IIR. The median age was 7,82 years (3-14 years). Four patients were lost during follow-up. Of the remaining 35 patients with 40 open IIRs, four developed an inguinal hernia (11,43%) and were operated on with laparoscopically assisted (subcutaneous endoscopically assisted ligation [SEAL]) technique at the time of diagnosis. The study results are demonstrated on Fig. 1. DISCUSSION: The percentage of an incidentally discovered open IIR in this study is lower in comparison with studies including patients with PPV pathologies. There is a possibility, in those patients, of underlying pathology which can affect both sides. It is also lower in comparison with previous studies including younger patients. However, gender and side predominance is in accordance with most published studies. In this study group, the possibility of developing a symptomatic hernia from an asymptomatic open IIR is rather small. CONCLUSIONS: An incidentally discovered open IIR in patients without symptoms, excluding those with contralateral inguinal hernias or cryptorchidism, has relatively low chance of developing an inguinal hernia. Thus, the authors support the strategy of close follow-up in these patients.

Laparoscopically assisted treatment of transverse testicular ectopia with persistent Müllerian duct syndrome: a case report and review of the literature.

BACKGROUND: Transverse testicular ectopia coexisting with persistent Müllerian duct syndrome is a rare malformation and evidence regarding the optimal treatment of these patients is still unclear. Description of the case: We present the case of a 4-month-old boy in whom laparoscopy was utilized for the surgical correction of transverse testicular ectopia and excision of Müllerian remnants. CONCLUSION: Based on current literature and the presented case, we support that laparoscopy is a feasible and safe procedure in patients with transverse testicular ectopia and persistent Müllerian duct syndrome. Hippokratia 2016, 20(1): 88-89.

Correction of concealed penis with preservation of the prepuce.

INTRODUCTION: By definition, congenital concealed penis presents at birth. Children are usually referred to physicians because of parental anxiety caused by their child's penile size. OBJECTIVE: Several surgical procedures have been described to treat this condition, but its correction is still technically challenging. The present study reports a simple surgical approach, which allows preservation of the prepuce. PATIENTS AND METHODS: During the last 6 years, 18 children with concealed penis (according to the classification by Maizels et al.) have been treated in the present department (mean age 4.5 years, range 3-12 years). Patients with other conditions that caused buried penis were excluded from the study. The operation was performed through a longitudinal midline ventral incision, which was extended hemi-circumferentially at the penile base. The dysgenetic dartos was identified and its distal part was resected. Dissection of the corpora cavernosa was carried down to the suspensory ligament, which was sectioned. Buck's fascia was fixed to Scarpa's fascia and shaft skin was approximated in the midline. Penoscrotal angle was fashioned by Z-plasty or V-Y plasty. RESULTS: The median follow-up was 24 months (range 8-36). The postoperative edema was mild and resolved within a week. All children had good to excellent outcomes. The median pre-operative to postoperative difference in penile length in the flaccid state was 2.6 cm (range 2.0-3.5). No serious complications or recurrent penile retraction were noted. DISCUSSION: Recent literature mostly suggests that concealed penis is due to deficient proximal attachments of dysgenetic dartos. Consequences of this include: difficulties in maintaining proper hygiene, balanitis, voiding difficulties with prepuce ballooning and urine spraying, and embarrassment among peers. Surgical treatment for congenital concealed penis is warranted in children aged 3 years or older. The basis of the technique is the perception that in boys with congenital concealed penis, the penile integuments are normal but they have abnormal attachments, and that incision of the skin and dartos will allow the shaft to extend. Furthermore, incisions of the fundiform and suspensory ligaments facilitate this maneuver. With this technique, the blood supply of the penile skin is not interrupted and postoperative lymphedema, a difficult complication to deal with, is prevented. One major advantage is the preservation of the prepuce, giving a normal penile appearance and an excellent cosmetic result. CONCLUSION: The method proposed here is simple and has no serious complications. It is suggested that this condition be treated in pre-school-aged children in order to prevent psychological impairment.

Primary torsion of the greater omentum in children - a neglected cause of acute abdomen?

Over a two-year period, 54 laparoscopic explorations for acute abdominal pain in children have been performed. In two cases primary torsion of the greater omentum was the underlying cause. Both patients (one boy of 13 years of age, one girl aged 8 years) were obese. The clinical picture mimicked acute appendicitis, but laparoscopic exploration showed torsion of the greater omentum which was then excised. The authors believe that primary omental torsion was underestimated, because many cases were not recognised, even during laparotomy for appendicitis. Laparoscopy permits accurate diagnosis of this disease.

Laparoscope-assisted appendectomy in children: the two-trocar technique.

UNLABELLED: The conventional cannulae position in laparoscopic appendectomy does not permit good visualization of the appendix, especially if it is in a retrocaecal or pelvic position. In children, the smaller dimension of the peritoneal cavity aggravates this problem. METHOD: In order to optimize appendix visualization, we propose a modification of the cannulae position associated with extraabdominal appendectomy. Two trocars are inserted, one in the umbilicus under direct vision and one in the midline above the pubic symphysis. The telescope is inserted in the second cannula. The appendix is delivered via the umbilical trocar incision and a conventional appendectomy is performed. RESULTS: During a one-year period, 38 appendectomies were performed. In 29 cases (76.3 %) the technique was successful. In 9 patients (4 with peritonitis, 4 with a retrocaecal and one with a pelvic appendix) a third trocar was necessary to complete the operation. We had two conversions (5.2 %), one to open surgery and one to intraabdominal laparoscopic appendectomy. Mean operation time was 19 min. There were two infectious complications (one parietal and one intraabdominal). CONCLUSIONS: The excellent visualization permitted considerable time gain. Infectious complications were also low. This method is suggested as an alternative procedure for appendectomy, especially in children, because of their favorable anatomy.

A complex chromosomal rearrangement associated with Hirschsprung's disease. A case report with a review of the literature.

The authors present a de novo complex chromosomal rearrangement 46,XY,t(2q;3p;4q;13q) associated with Hirschsprung's disease. They review the literature concerning genetic aspects of Hirschsprung's disease focusing on genetic studies and recent molecular research. Genetic aspects of intestinal neuronal dysplasia are also briefly discussed.

Enterocystoplasty complications in children. A study of 30 cases.

BACKGROUND/PURPOSE: Bladder augmentation for small vesical capacity represents an important aid to these patients, but the appearance of complications is not rare. We analysed the complications of the enterocystoplasty techniques used in our Department. METHODS: From 1983 to 1997 sixteen girls and fourteen boys were treated. We performed 28 bladder augmentations (in 13 cases using small bowel, in one case using ileum and caecum and in 14 cases using sigmoid colon) and 2 bladder substitutions (in one case with ileum and sigmoid colon and in the second using a colonic segment). RESULTS: Twelve children present recurrent urinary infections. In five children bladder stones were formed (among them a case of familial cystinuria-lysinuria). Two children presented intestinal volvulus and another one a caecal volvulus. In two children a perforation of the augmented bladder was treated operatively. An 11-years-old child presented severe electrolyte disturbances. CONCLUSIONS: The complications presented in our patients confirm the view that they are associated with intestinal mucosa in the bladder and our study proves, once more, the current necessity to seek alternative tissues for bladder augmentation.

Intrapericardial teratoma diagnosed prenatally in a twin fetus.

Prenatal diagnosis at 32 weeks' gestation of an anteromediastinal tumor in a twin fetus allowed immediate neonatal intensive management after delivery at 34 weeks' gestation. At 48 h of age the patient underwent a median sternotomy; complete resection of the tumor was possible. Histologically, it was a mature teratoma. At age 1 year both twins are well.

Cricopharyngeal achalasia--a cause of major dysphagia in a newborn. A case report.

Cricopharyngeal achalasia is a rare cause of neonatal dysphagia. Its treatment is based on surgical myotomy, which is to be avoided in the presence of prematurity and neurological diseases. The authors report a case of cricopharyngeal achalasia in a full-term four-month-old female baby. Coughing and choking during feeds were the major symptoms. The diagnosis was made peroperatively although barium meal and endoscopic findings were suggestive. After cricopharyngeal myotomy, symptoms took several weeks to disappear. Seven months after surgery, she feeds normally and weighs 7,700 g. Neonatal cricopharyngeal achalasia could be a foregoing state to cricopharyngeal diverticula in adult. Some cases may remain undiagnosed either due to lack of symptoms or sudden infant death.

Reversed midgut rotation in a neonate: case report with a brief review of the literature.

The authors report a case of reversed rotation of the midgut in a neonate and review the embryology, the clinical and radiographic findings, and the operative techniques. They also present radiographs of their case, which are the first ever published of a neonate with this retroarterial type of reversed rotation.

Abdominoscrotal hydrocele.

Hydrocele is among the commonest inguinal anomalies in children. One of its most unusual variants is the abdominoscrotal hydrocele, of which no more than 22 cases have been reported in the world literature. The present case is the first one in our country. In this patient the coexistence of small bilateral scrotal hydrocele and cystic abdominal mass at the right side is described. Abdominoscrotal hydrocele is an unusual cause of lower abdominal cystic tumour in association with an inguinoscrotal hydrocele in infancy.

Gallbladder disease in patients with cystic fibrosis.

We retrospectively studied 18 patients with cystic fibrosis, who underwent surgery for gallbladder disease from 1975 to 1990. A long delay between the onset of symptoms and the diagnosis was noted (mean 8.7 months). This delay was attributed to masking of the symptoms of biliary disease by the malabsorption and pulmonary symptoms seen in this patient population. We do not recommend routine intraoperative cholangiography in patients with cystic fibrosis and gallbladder disease. Cystic fibrosis is a disease with progressive pulmonary deterioration. Cholecystectomy can be performed in these patients with relative safety if careful preoperative and postoperative care is provided. We recommend early operative intervention in the patient with gallbladder disease and cystic fibrosis.

[Anatomic abnormalities of the genital tract in ano-rectal malformations]. / Les anomalies anatomiques de l'appareil génital aux malformations ano-rectacles.

Of 152 patients with imperforate anus, 16 girls -25%), 10 boys (15%) have an abnormality of the genital tract and real frequency seems underevaluated. In girls, vaginal septum, bicornuate and didelphys uterus are mostly diagnosed, associated with severe unilateral upper urinary tract malformations. Absent vagina and uterus (Rokitansky syndrome) must be seen at birth, to preserve perineal fistula used to fashion a vagina at the time of the abdomino-perineal fistula pull through. In boys hypospadias, ectopia and uretero-vas anastomosis are the most frequent malformations.