Needlescopic Disconnection and Peritoneal Closure for Pediatric Inguinal Hernia Repair: A Novel Technique.

BACKGROUND: There are many laparoscopic techniques for pediatric congenital inguinal hernia repair. Needlescopic surgery was introduced recently in pediatric patients aiming at getting excellent cosmetic outcomes. PURPOSE: The aim of this study was to describe a novel technique for needlescopic inguinal hernia repair in children. PATIENTS AND METHODS: Needlescopic division of the hernial sac was carried out on 369 children in 6 pediatric tertiary centers during the period from August 2016 to May 2019. All hernias were repaired by a novel needlescopic procedure that replicates all the steps of the open herniotomy. RESULTS: A total of 369 patients with 410 hernias were included in this study. They were 232 (62.9%) males and 137 (37.1%) females, with a mean age of 3.58±1.26 (range=2 to 8 y) and mean internal inguinal ring diameter was 13.65±3.85 mm (range=8 to 20 mm). The mean operative time was 23.36±4.67 minutes for bilateral and 14.28±2.98 minutes for unilateral cases. All cases were completed without conversion to conventional laparoscopy. All cases were followed up for a mean of 19.6±3.2 months. None of our patients developed recurrence or testicular atrophy and the scars were nearly invisible 3 months postoperatively. CONCLUSIONS: Needlescopic pediatric inguinal hernia repair using disconnection of the hernia sac at internal inguinal ring with purse-string suture closure of peritoneum is feasible and safe with no recurrence and with outstanding cosmetic results.

Thoracoscopic surgery for congenital lung malformations: Does previous infection really matter?

BACKGROUND/ PURPOSE: Elective resection of congenital lung malformations (CLMs) is still debatable. The two main risks are malignant transformation and recurrent pulmonary infections. Our study aimed to assess the effect of previous pulmonary infection on the intraoperative and postoperative courses of thoracoscopic surgery for CLMs. METHODS: This is a retrospective study including all thoracoscopic lung resections for CLMs between 2010 and 2019. Ninety patients were included. There was a history of previous pulmonary infection in 28 patients (group A) and no such history in 62 patients (group B). RESULTS: The median age at operation for group A was 20.4 months (IQR:14.9-41.4) versus 15.1 months (IQR:9.7-20.8) in group B (p = 0.006). There were 10 conversions (35.7%) in group A and 8 (12.9%) in group B (p = 0.02). The operative time was significantly shorter in group B (p<0.002). In group A, 32.1% of patients experienced postoperative fever versus 11.3% of group B (p = 0.03), with higher antibiotics requirement (28.6% versus 6.5% respectively, p = 0.007). However, no significant differences were found in terms of postoperative complications (p = 0.99). CONCLUSION: Earlier intervention for CLMs before the development of pulmonary infection carries higher chances for the success of the thoracoscopic approach with shorter operative time and more uneventful postoperative courses.

Laparoscopic vs. Open Pyloromyotomy in Treatment of Infantile Hypertrophic Pyloric Stenosis.

Background/Purpose: Laparoscopic pyloromyotomy gained wide popularity in management of pyloric stenosis with contradictory results regarding its benefits over classic open approach. This study aimed at comparing both regarding their safety, efficiency, and outcome. Methods: This is a prospective randomized controlled study performed from April 2017 to April 2019. It included 80 patients, divided randomly into two groups, where laparoscopic pyloromyotomy was performed in group A and open pyloromyotomy in group B. Both groups were compared regarding operative time, post-operative pain score, time required to reach full feeding, hospital stay, complications, and parents' satisfaction. Results: Median operative time was 21 min in group A vs. 30 min in group B (P = 0). Pain Assessment in Neonates scores were generally higher in group B with more doses of analgesics required (P = 0). Mean time needed to reach full feeding was 15.2 and 18.8 h in groups A and B, respectively (P = 0). Median hospital stay was 19 h in group A and 22 h in group B (P = 0.004). Parents' satisfaction also was in favor of group A (P = 0.045). Although no significant difference was reported between both groups regarding early and late complications, some complications such as mucosal perforation and incomplete pyloromyotomy occurred in the laparoscopic group only. Conclusion: Laparoscopic pyloromyotomy was found superior to open approach regarding faster operative time, less need of analgesics, easier development of oral feeding, shorter hospital stay, and better parents' satisfaction. Yet, there are still some concerns about the safety and efficiency of this procedure over open technique.

Post Circumcision Intraperitoneal Rupture of the Urinary Bladder: A Rare Complication.

Circumcision is one of the most common pediatric surgical procedures performed all over the world and especially in Arab and Islamic countries. Many complications have been documented following this maneuver. We report on a rare case of intraperitoneal bladder rupture in a 7-day-old baby who was circumcised on his second day using the guillotine method. He presented to us with gangrene of the tip of the penis and a failure to void urine associated with progressive abdominal distension. Ultrasound revealed severe ascites. Aspiration and analysis confirmed the fluid to be urine. Ascending cystourethrogram was performed revealing a perforation of the posterior bladder wall near the trigone. Exploration was performed and repair done. Postoperative course was uneventful.

Novel application of the sewing machine principle; a new simplified intracorporeal suturing technique for pediatric inguinal hernia.

BACKGROUND: The desire of pediatric surgeon to reduce incision related morbidity and pain while achieving good cosmetic results has recently led to the introduction of single incision pediatric endosurgery [SIPES] and needlescopic surgery. Intracorporeal suturing and knot tying during SIPES remain challenging. The aim of this study is to introduce a novel and simple technique for intracorporeal suturing of the pediatric inguinal hernia after needlescopic disconnection of hernia sac using just needles rather than laparoscopic instruments. It is an imitation of the principles of sewing machine. METHODS: The first author discussed the idea of the technique with the coauthors and a demonstration was done on a Silicon Pad before application of the technique on children with congenital inguinal hernia [CIH] for peritoneum closure after needlescopic disconnection of the hernia sac. The main outcome measures were feasibility of the technique, suturing and knotting time and recurrence rate. RESULTS: The sutures were snugly applied to the ridges of Silicon Pad with good approximation and the knot was firmly tightened in all experiments. After applying and mastering the technique on a Silicon Pad, we shifted to use it on 373 children with 491 hernia defects. All operations were completed by the needlescopic technique without the need for insertion of any laparoscopic instruments. The time required for suturing of the peritoneum around internal inguinal ring [IIR] and knot tying, decreased considerably from 6 min 27 s in the first operation to less than 4 min after the fifth operation and stabilized at approximately 4 min 30 s. No major intraoperative complication. There was no recurrence during a mean follow-up period of 19.6 ±â€¯1.2 months. CONCLUSION: The closure of the peritoneum around the IIR using needles mimicking what is happening in sewing machine suturing is a feasible, safe and effective line of treatment of children with CIH. The cosmetic results are 42 outstanding without any recurrence.

Fifteen Years Experience with Laparoscopic Inguinal Hernia Repair in Infants and Children.

BACKGROUND: Laparoscopic inguinal hernia repair (LIHR) is gaining popularity with more studies validating its feasibility, safety, and efficacy. The aim of this work is to review our experience with LIHR in infants and children during the past 15 years, and present and evaluate our innovations of laparoscopic techniques. PATIENTS AND METHODS: A retrospective study of 1284 patients with congenital inguinal hernia (CIH) subjected to different techniques of LIHR from October 2000 to October 2015. The main outcome measurements included the following: operative time, hospital stay, hernia recurrence, hydrocele formation, testicular atrophy, iatrogenic ascent of the testis, and cosmetic results. INCLUSION CRITERIA: All patients with CIH who were managed by LIHR during the period of study. They were bilateral cases, recurrent hernias, unilateral hernia in obese child, unilateral hernia with associated infantile umbilical hernia, and unilateral hernia with questionable contralateral side. RESULTS: A total of 1284 patients with CIH were corrected with different laparoscopic procedures. They were 918 males and 366 females. The age range was variable from 6 to 78 months (mean 28.32 ± 24.46 months). All cases were completed laparoscopically without major intraoperative complications. Contralateral hernial defects were found in 294 patients (22.90%), a direct inguinal hernia (IH) was discovered in 15 patients (1.17%), and a femoral hernia was discovered in 3 patients (0.23%). Recurrence occurred in 9 boys (0.98%) who were among the early cases; however, in later group, no recurrence had been detected. Hydrocele occurred in 19 cases (males) (2.07%), without detection of testicular atrophy or iatrogenic ascent of the testis. CONCLUSION: Our results lead us to believe that LIHR by expert hands is safe and effective. It enables the surgeon to discover and repair contralateral hernia and all forms of IHs. One should be able to tailor a suitable technique for each case according to the resources and expertise.