The evolutionary saga of circumcision from a religious perspective.

Circumcision is the oldest surgical operation known to mankind. It probably originated as a less radical form of genital mutilation inflicted on prisoners of war. Over time it was adopted by the Egyptian priesthood and nobility, perhaps inspired by the mythology of Osiris. In turn, circumcision became part of the Jewish and Muslim religious cultures. In contrast, ancient Greeks valued an intact prepuce, as evident from the nude figures of Renaissance art. In the 19th century, circumcision was touted as a treatment for excessive masturbation, seizures, epilepsy, and paraplegia. Adoption of the procedure by medical science was almost akin to a religious belief. By the mid-20th century, it was widely performed on male infants on the pretext of phimosis when the prepuce was not retractable. In 1949, Gairdner documented that the tight prepuce of infants gradually becomes retractile as childhood progresses. Thus, childhood circumcision solely for non-retractile prepuce is unnecessary, which is the foundation for modern anti-circumcision movements.

Controversies of Sex Re-assignment in Genetic Males with Congenital Inadequacy of the Penis.

Sex assignment in 46XY genetic male children with congenital inadequacy of the penis (CIP) is controversial. Traditionally, children with penile length less than 2 cm at birth are considered unsuitable to be raised as males. They are typically re-assigned to female-sex and feminizing genitoplasty is usually done in infancy. However, the concept of cerebral androgen imprinting has caused paradigm shift in the philosophy of sex re-assignment. Masculinization of the brain, rather than length of the penis, is the modern criterion of sex re-assignment in CIP. This review summarizes the current understanding of the complex issue. In 46XY children with CIP, male-sex assignment appears appropriate in non-hormonal conditions such as idiopathic micropenis, aphallia and exstrophy. Female-sex re-assignment appears acceptable in complete androgen insensitivity (CAIS), while partial androgen insensitivity syndrome (PAIS) patients are highly dissatisfied with the assignment of either sex. Children with 5-alpha reductase deficiency are likely to have spontaneous penile lengthening at puberty. Hence, they are better raised as males. Although female assignment is common in pure gonadal dysgenesis, long-term results are not known to justify the decision.

Choice of Repairing Inguinal Hernia in Children: Open Versus Laparoscopy.

Inguinal hernia is a common disorder of childhood that requires surgical repair at diagnosis. Traditionally, it is operated upon by open inguinal incision. However, with the introduction of laparoscopic repair in 1990, opinion of scientific community is divided concerning the best method of pediatric herniotomy. Educated parents, who long to have the choicest of the best, often gather information from internet and prefer to discuss their concerns with primary care physicians. This descriptive review is intended to provide practicing pediatricians with updated evidence-based information which will enable them to counsel parents regarding the choice of hernia repair. Based on careful analysis of current literature, unacceptable standards are defined in this paper and rationalized recommendations are proposed. Laparoscopy appears to be beneficial in bilateral hernia of girls, giant hernia, recurrence following failed open repair and in hernia associated with undescended testis or ambiguous genitalia. On the other hand, open herniotomy appears to be advantageous in male inguinal hernia, unilateral female hernia, premature newborns, failed laparoscopic repair and in hernia associated with serious co-morbidity.

Subcutaneous entomophthoromycosis mimicking soft-tissue sarcoma in children.

AIM: Subcutaneous entomophthoromycosis (EM) is an uncommon fungal infection of childhood. This article is intended to draw the attention of pediatric surgeons to the fact that EM can mimic soft-tissue tumor. METHODS: It is a retrospective review of 16 children treated for subcutaneous EM between 2000 and 2013. RESULTS: The median age of patients was 3.5 years. The typical lesion was a discoid subcutaneous mass that can be easily lifted from deeper tissues (the doughnut lifting sign). Lesions were mostly distributed in the lower half of body. All the patients were immunocompetent. Correct clinical diagnosis was made only in 4 cases while others were mistaken for a tumor. All the 8 children who underwent wide excision of the pseudotumor had local recurrence. Supersaturated solution of potassium iodide was curative in 11 cases while addition of itraconazole was needed in one case. One child died of multi-drug resistant infection. The mean treatment duration was 4.7 months (range 2-8 months). CONCLUSION: Subcutaneous EM can mimic soft-tissue tumor. High index of suspicion is essential to avoid misdiagnosis and inappropriate treatment. A newly described "doughnut-lifting sign' may be helpful in clinical diagnosis. Emergence of multi-drug resistant infection is a source of concern.

Sixth cranial nerve palsy due to arachnoid cyst.

Sixth cranial nerve palsy is an extremely rare complication of an arachnoid cyst. A 4-year-old boy who presented with left abducens palsy and a subdural hygroma complicating arachnoid cyst is discussed. Comprehensive review of the world literature revealed only 12 additional cases.

A new technique of placing the peritoneal end of syringoperitoneal shunt.

OBJECTIVE: Syringoperitoneal shunt is an established method of treating syringomyelia. Syringeal end of the shunt is usually inserted to the patient in prone position, and the peritoneal end is inserted in supine position. This necessitates intraoperative repositioning of patient. To avoid this inconvenience, a new technique of placing the peritoneal end through posterior approach is described in this paper. METHODS AND MATERIALS: In the new technique, peritoneal cavity is approached through posterior route lateral to erector spinae at the level of L3-L4. An infant who presented with sacral meningocele, tethered cord, and syringomyelia was treated using this new technique along with excision of meningocele and de-tethering of the cord. RESULTS: There were no complications, and the short-term results at 3-year follow-up are encouraging. Theoretical advantages of the new technique include reduced risk of shunt migration and improved cosmesis of surgical scar. CONCLUSION: Posterior approach of placing the peritoneal end of syringoperitoneal shunt is technically feasible, and it appears to have advantages over the traditional method of anterior approach.

Sixth cranial nerve palsy due to arachnoid cyst.

Sixth cranial nerve palsy is an extremely rare complication of an arachnoid cyst. A 4-year-old boy who presented with left abducens palsy and a subdural hygroma complicating arachnoid cyst is discussed. Comprehensive review of the world literature revealed only 12 additional cases.

Spontaneous perforation of the colon and rectum complicating anorectal malformations in neonates.

BACKGROUND: Spontaneous perforation of the colon is a rare complication in neonates with anorectal malformations (ARMs). There are no detailed studies concerning this complication. MATERIALS AND METHODS: A retrospective review of hospital records between 1994 and 2010 revealed 8 cases of bowel perforation among 136 cases of ARM. Eighteen additional cases were culled from the literature by searching Pubmed, Indmed, Embase, and Google Scholar. RESULTS: Perforations occurred more commonly in males with ARM (85%). Low and high anomalies were equally affected. The median age at diagnosis was 48 hours. Pneumoscrotum and abdominal wall erythema were occasionally suggestive of perforation. In addition to the Rigler sign and collapsed bowel on plain radiographs, a newly described "rectal-tail sign" was useful in recognizing pneumoperitoneum in the lateral view invertogram. A lower midline incision offered optimal surgical access. Two distinct patterns of perforation were identified: type 1 (88%) occurred before surgical decompression of the obstructed colon, whereas type 2 (12%) occurred postoperatively. Type 1 cases were subdivided into cecal (type 1a, 16%), transverse colon (type 1b, 8%), rectosigmoid (type 1c, 60%), and miscellaneous (type 1d, 4%) perforations. Type 1a is best treated with cecostomy and distal colostomy; type 1b, with exteriorization of the perforation; and types 1c and 1d, with closure of the perforation and proximal colostomy. Dense fibrous adhesions caused by extravasated meconium posed technical difficulty during the definitive pull-through operation and was responsible for considerable morbidity. The overall mortality was 19%. CONCLUSIONS: Colorectal perforation is associated with considerable morbidity and mortality in neonates with ARM. Radiographs rather than clinical examination should be relied on for diagnosis of bowel perforation in ARM. Treatment options are chosen according to the subtype of perforation. Because most perforations occurred more than 24 hours after birth, early referral and surgical decompression of the colon may avoid this complication.

Knowledge of ancient Hindu surgeons on Hirschsprung disease: evidence from Sushruta Samhita of circa 1200-600 BC.

BACKGROUND: Congenital megacolon is eponymously named after Harold Hirschsprung, who accurately described the clinical features in 1886. Recent research revealed that this condition is perhaps well known for centuries before him. AIM: This article is intended to examine if ancient Hindu surgeons knew about congenital megacolon. METHODS AND MATERIALS: Sushruta Samhita is an ancient tome of Ayurvedic surgery compiled by Sushruta (circa 1200-600 bc). Passages of interest were identified by browsing the authentic English translation of the compendium. Accuracy of translation was verified by comparing to the original Sanskrit verses with the help of a Sanskrit scholar. RESULTS: A condition called Baddha Gudodaram, described in the Samhita, closely resembles Hirschsprung disease. There are indications that ancient Indians even deciphered the etiology as defective vayu alias vata (nerves). Although the ailment was considered incurable, a palliative operation has been discussed. Descriptive details of the operation match with that of sigmoid colostomy. CONCLUSION: Evidence from Sushruta Samhita indicates that Hindu surgeons of prehistoric India probably had considerable knowledge about Hirschsprung disease. Further research, corroborating other sources of evidence, is required to confirm this claim.

Epididymo-orchitis complicating anorectal malformations: collective review of 41 cases.

PURPOSE: Epididymo-orchitis is a devastating complication of imperforate anus. Without proper treatment the condition may result in infertility. Nevertheless, the exact etiology and optimal management of epididymo-orchitis in anorectal malformation are unknown. MATERIALS AND METHODS: Retrospective review of our hospital records between 1997 and 2010 identified 6 cases of epididymo-orchitis in 82 boys with anorectal malformation. Extensive search of the literature revealed 35 additional cases. Clinical details of these 41 patients were analyzed using chi-square testing. RESULTS: Epididymo-orchitis occurred predominantly (86%) in high or intermediate anorectal malformation with rectourinary fistula. Median age at onset of epididymo-orchitis was 6 months and there was no side predilection. Urinary tract infection was noted in 54% of patients. Persistent mesonephric duct syndrome (27%), urethroejaculatory duct reflux (22%), vasovesical ectopia (10%), neurovesical dysfunction (34%) and urethral stricture/stenosis (17%) were frequently associated risk factors for epididymo-orchitis. In 73% of patients epididymo-orchitis recurred with exclusive antibiotic treatment. Diverting colostomy was ineffective in preventing epididymo-orchitis. Division of rectourinary fistula was curative in 36% of patients, while in 34% epididymo-orchitis recurred even after division of rectourinary fistula. Division of rectourinary fistula is likely to resolve epididymo-orchitis in the absence of additional risk factors. Vasectomy was required in 22% of patients to prevent recurrence. CONCLUSIONS: In addition to rectourinary fistula, urinary reflux into the vas deferens and neurovesical dysfunction are major risk factors for epididymo-orchitis in anorectal malformation. Division of rectourinary fistula is curative in only a third of cases. In the remaining cases some form of surgical disruption of the vas deferens is needed to resolve recurrent epididymo-orchitis.

A modification of Winter's shunt in the treatment of pediatric low-flow priapism.

PURPOSE: Cavernous shunt operations available for treating priapism are frequently unsuitable for children owing to high chances of persistent venous leak that results in postoperative erectile dysfunction. In this article, a modification of Winter's shunt, which is suitable for treating low-flow priapism in children, is described. METHODS AND PATIENTS: Using a large bore needle, multiple punctures were made in the tip of corpora cavernosa through the glans. The needle tracks functioned as temporary cavernoglandular fistula thereby, causing detumescence. This modified technique was used in 7 children all of whom had ischemic priapism. The age range was 9 months to 17 years, and the mean duration of symptom was 11 hours (range, 5-20 hours). RESULTS: In all the patients, priapism was successfully relieved by the modified technique. Immediate recurrence of priapism was noted in only one patient. In 5 patients for whom adequate follow-up details are available, postprocedure penile erection was confirmed either by self-reporting or by observation. There were no major complications. CONCLUSION: This technical modification of the classical Winter's shunt appears to be a useful alternative in the management of pediatric low-flow priapism. A high chance of retaining erectile capacity after this technique is a significant advantage. Further clinical studies are required to confirm the observations of this preliminary report.

Reconstruction of traumatically avulsed parotid duct using buccal mucosa flap: report of a new technique.

Injury to parotid duct is frequently overlooked especially in multiple injuries settings. Consequently they are rarely reported in the literature. Treatment of these injuries is highly controversial. Short series and anecdotal case studies claim success with various approaches such as nonsurgical management, simple ligation of the proximal duct with or without antisialagogues, microsurgical primary repair, creation of sialodocho-oral fistula, and vein-graft replacement. A novel technique of sialodochoplasty using buccal-mucosa pedicle flap is described in this report. Short-term result of this method in a 4-year-old boy with traumatic loss of right parotid duct was encouraging. Hypothetical advantages of this new operation are reviewed in the background of alternative procedures. It is concluded that buccal-mucosa flap technique appears to be a promising alternative in the management of parotid duct injuries.

Releasing of zipper-entrapped foreskin: a novel nonsurgical technique.

This report describes a novel technique of releasing the zipper-entrapped penile skin. The thin blade of a small screwdriver is inserted between the outer and inner faceplates of the zip fastener, and twisting movement is made toward the median bar. This will widen the gap between faceplates disengaging the prepuce. This technique was used in 12 children and was found to be safe, effective, simple, painless, and nontraumatic. This can be done by attending pediatrician even in nonhospital settings without resorting to surgical help.