Role of laparoscopy in peritonitis

Laparoscopy has gained clinical acceptance in many subspecialties in the last decade. The conventional open surgery for peritonitis carries significant morbidity and mortality. The present study was done to extend and evaluate benefits of minimally invasive surgery in this subset of patients. This was a prospective study spanning over a period of four years. All those patients diagnosed as having peritonitis on clinical assessment and preoperative investigations and those who were stable enough haemodynamically were included in this study. After initial resuscitation for few hours, they underwent diagnostic and therapeutic laparoscopy to identify the cause of peritonitis and to confirm the pathology. All cases were done under general anesthesia, using three standard ports at appropriate sites according to pathology. Patients were treated by different procedures either laparoscopically or with laparoscopic assistance after diagnosis. Operative and post operative data was collected and analyzed. Ninety two cases of peritonitis underwent diagnostic and therapeutic laparoscopy. Mean age of patient was 46.5 years. 24 patients were diagnosed as perforated duodenal, in 14 [58.3%] patients laparoscopic suture repair was done and in 8 [33.3%] small upper midline incision was given and perforation was repaired. Out of 32 patients having perforated appendix, 25 [78.1%] patients laparoscopic appendectomy was done while in 7 [21.8%] perforation was dealt by laparoscopic assistance. Out of 14 patients of ileal perforation 6 [42.8%] with minimal contamination laparoscopic suture was applied, while in 8 [57.1%], perforated loop was brought out by making small window and perforation was closed. All 22 patients with pelvic sepsis needed only aspiration of pus and peritoneal lavage. Only one patient died post operatively and 2 [2.1%] patients developed fistula. 6 [6.5%] patients developed port site infection. Laparoscopic management is feasible, safe and effective surgical option for patients with peritonitis due to different abdominal emergencies in properly selected cases with higher diagnostic yield and a faster postoperative recovery

Management and outcome of bracka's procedure on penile shaft hypospadias

OBJECTIVES: To evaluate the outcome of Bracka's procedure in patients with penile hypospadias

MATERIAL AND METHODS: All the patients from urology, plastic surgery and Pediatric Surgery Departments at LUHMS Jamshoro from October 2007 to September 2008 having penile shaft hypospadias were included in this study. Patients who were above age 15 years, other congenital and already circumscribed penis were excluded from this study. Detailed examination of the patients such as position and size of abnormal meatus, the presence of chordee, the quality and width of urethral plate and the configuration of glans penis were noted. All the patients were operated under general anesthesia. The surgical technique applied on the basis of stage 1 and 2. The data were entered and analyzed in Statistical Program SPSS version 16.0

Results: Total number of 30 cases was included in this study. Twenty one [70%] patients had the Distal Penile Hypospadias, 6 [20%] had the Proximal penile and 3 [10%] patients had mid penile Hypospadias. Various post-operative Complications were noted, chordee 2 [6.7%], lnfection 1[ 3.3%], and loss of split thickness skin graft 1[3.3%], while after stage II, 2[6.7%] developed fistula formation and in 2 [6.7%] developed edema. In this study the outcomes of Bracka's procedure include Voiding direction and meatal opening, 29 out of 30 patients had straight voiding direction and one patient had deviated voiding direction, similarly 29 out of 30 patients had near normal meatal opening and one had abnormal meatal opening

CONCLUSIONS: From our results we concluded that on the whole Bracka's two stage technique is simple, safe and versatile adjuvant to all types of hypospadias with minimal risk of complications and better out come

Our experience of bleomycin sclerotherapy for peripheral lymphangioma in children and review of the literature

To assess the efficacy of intralesional bleomycin in peripheral lymphangioma in children. This prospective study was conducted at the Department of Pediatric Surgery at Liaquat University of Medical and Health Sciences Jamshoro/Hyderabad from January 2005 to December 2009 .Patients included in this study were only with peripheral lymphngioma, while those with visceral lesions or previously operated for lymphangiomas were excluded. Diagnostic tools for lymphangioma were physical examination and ultrasound. All patients had aspiration of lesion with 20-24 gauge needle and intralesional injection therapy with bleomycin with dosage of 0.5mg/kg body weight diluted in normal saline. The procedure was performed as out patients. Patients were followed up at four weeks interval for up to six months. Personal data, procedure, complications and follow up were recorded on pre-designed proforma. Total number of patients included in this study was 20, with13 males and 7 females. Reduction in size was noted in 75%. Excellent response was seen in 9 [45%] patients who had cystic lymphangioma, while 6[30%] patients showed good response and 5[25%] had poor response. Common site was neck [65%].Transient increase in size of lesion and cellulitis were observed in three patients and treated conservatively. Intralesional bleomycin is excellent in cystic lymphangioma, while it had good response in mixed lymphangioma. We suggest bleomycin as a primary therapy in all varieties of lymphangiomas

Congenital soft tissue Ewing's sarcoma

A 15 days old female baby presented with a 6 x 7 cm reddish lump with irregular margins on her right scapular region, since birth. Histopathology and immunohistochemistry of excised tissue revealed it to be soft tissue Ewing's sarcoma. Postoperatively, she received only one dose of chemotherapy but could not survive and expired at the age of one month

Laparoscopic cholecystectomy without the use of drain in selected cases

Objective: To observe the effects of omitting the routine drainage after laparoscopic cholecystectomy, with respect to hospital stay, morbidity, and mortality

Methodology:This comparative observational study was carried out in the Department of Surgery, Liaquat University of Medical and Health Sciences, Jamshoro, from January 2009 to December 2009. During study period 100 consecutive cases of cholelithiasis, underwent laparoscopic cholecystectomy. The patients were divided in two groups; group A without drain and group B with drain. The effects of omitting the drain, regarding hospital stay, morbidity, and mortality were observed

Results: This study consists of 100 patients [male 22 and females78] with male female ratio of 1:3.54 and mean age of 37.86 years. Post operative hospital stay in patients without drain was 2.1 days as compared to 3.58 days for those with drain [p-value 0.000]. Moreover the use of drain has also been found to be associated with significant drain site pain / discomfort. There was no mortality in any group

Conclusion: We have observed that routine placement of drain after laparoscopic cholecystectomy, not only prolongs the post-operative hospital stay; it also leads to drain site pain / discomfort

Gastric perforation in newborns: analysis of 14 cases

Objective: Neonatal gastric perforation is a rare entity with poor prognosis. Etiology of this anomaly is unknown but prematurity, low birth weight and hypoxia is considered as contributing factors. The purpose of this study is to share our experience regarding the etiology, clinical features and surgical outcome of neonatal gastric perforation

Methodology:We reviewed the data of all newborn with gastric perforation in Liaquat University Hospital as well as in private practice, from July 2003 to June 2010 with respect to age , sex, weight, parity, mode of delivery, clinical presentations, investigations, associated anomalies and surgical outcome

Results: There were 14 patients, 9 males and 5 females. Birth weight ranged from 1.6 kg to 3 kg with mean of 2.3 kg. Out of 14 babies 11[87.57%] were full term and 3[21.42%] preterm. Clinical features observed were abdominal distension, respiratory distress, vomiting and hematemesis. Associated anomalies were found in three patients, which were Down's syndrome, talipes equinovarus and bilateral inguinal herniae with hypospadias. Most of the patients had spontaneous gastric perforation and few might had ischemic cause. Nine had perforation on posterior wall of body of stomach and three on posterior wall of greater curvature of stomach while two had on anterior wall of body of stomach and anterior wall of greater curvature of stomach respectively. All the patients had primary closure of perforation along withintraperitoneal placement of drain. Complications observed in 4 [28.57%] cases, three term low birth weight and one preterm baby; wound dehiscence in two patients, who were re-operated, wound infection in one and pneumonia in one which were treated conservatively. Three patients 21.4% [two term low birth weight and one preterm] expired in this series due to septicemia

Conclusion: Prominent features in this study were low birth weight and perforation on the posterior surface of stomach. There is need to evaluate the correlation of these findings

Effect of prone versus supine position on oxygen saturation in patients with respiratory distress in neonates

To analyze the effect of prone versus supine position on oxygen saturation in neonates with respiratory distress. This comparative study was conducted in the department of paediatric medicine at Liaquat University Hospital Hyderabad during the period of six months. Total numbers of the patients enrolled were one hundred with age ranging three hours to 28 days. All the newborns with respiratory distress [RD] were kept in supine position for three hours after all necessary resuscitation measures and oxygen saturation was recorded with pulse oximeter. Then they were kept in prone position for six hours and oxygen saturation and respiratory rate was measured with two hour interval respectively for six hours. One hundred patients were enrolled in the study with age range 3 hours - 28 days, out of them 87 [87%] term, 9 [9%] preterm and 4 [4%] were post term respectively, male to female ratio was 1.2:1. The oxygen saturation in supine position was 84.84 +/- 4.20. After 2 hour in prone position saturation was 91.05 +/- 3.29, after 4 hour 91.62 +/- 3.89 and after 6 hours it was 92.63 +/- 3.02 respectively with P value of < 0.001 which is statistically highly significant. It shows that Oxygen saturation is increased by about 7%, and maximum oxygen saturation increases in first 2 hours. Similar trend was seen in respiratory rate with reduction of respiratory rate by 6 breaths / min in first two hours. Prone position improves oxygenation saturation and decreases respiratory distress as compared to supine position in neonates with respiratory distress

audit of non-idiopathic intussusception in children

Objectives: To outline the causes of non-idiopathic intussusception in children and to document the clinical characteristics of the different etiologies

Methodology: It is a retrospective review of 19 cases of proved secondary intussusception, over a span of 5 years i.e. from January 2004 to December 2008. Data was collected from private as well as from government hospitals in different centers. Patient's age ranges from three months to 12 years. Demographic data, clinical presentations, surgical management and follow up were recorded on pre designed proforma. Baseline blood investigations and radiological tests were noted. Surgery was performed in all patients due to delayed presentation and non availability of image intensifier

Results: Among 19 patients, 13 [68.42%] were boys and 6 [31.57%] were girls with male to female ratio of 2.16:1. The mean age was 2.15 years. Meckel's diverticulum was the most common cause and found in 8 [42.10%] children. Four [21.05%] had lymphoma, 2 [10.52%] had haemangiomas and 2 [10.52%] with polyps of the colon. Round worms, duplication of gut and Henoch-Schonlein's purpura were the other causes of non-idiopathic intussusceptions

Conclusion: Intussusception caused by an underlying disease or secondary to some pathological lead point is not uncommon and it is important to be vigilant for pathological lead points in children of any age

Obstructed Bochdaleck diaphragmatic hernia in a child girl

A five-year-old female child presented with intestinal obstruction. X-ray abdomen and chest showed multiple air-fluid levels in abdomen and a single gas shadow with air-fluid level in left hemithorax. Ultrasound confirmed the presence of gut loop in left side of chest. Laparotomy was carried out with repositioning of intestinal loops in abdominal cavity and closure of posterolateral diaphragmatic defect with non-absorbable suture. Patient recovery was uneventful. As soon as diagnosis of diaphragmatic hernia is made, surgical intervention should be made to prevent fatal complications

Childhood intussusception: delayed presentation and surgical outcome

Objective: to compare the clinical presentation and surgical outcome in early versus delayed presentation of childhood intussusceptions

Method and material: this comparative study was conducted in the Department of Pediatric Surgery, Liaquat University of Medical and Health Sciences Jamshoro/Hyderabad from January 2005 to July 2007.All the diagnosed patients of intussusception were categorized into early and delayed group [patient presented later than 24 hours from the onset of first symptom]. Data regarding age, sex, clinical presentation, duration of presentation [early or late], surgical findings, treatment and complications were recorded on proforma. All patients of intussusceptions were subjected to laparotomy due to non-availability of image intensifier. Parameters including clinical presentations, surgical findings, treatment options and compliations were analyzed with SPSS version 16

Results: this study was comprised of 80 patients; males 57[71.3%] and females 23[28.7%] with male: female ratio 2.5:1.Early presenting patients were 10 and delayed presenting were 70. Major clinical symptoms were pain in abdomen, vomiting and bleeding per rectum. Significant difference found in early and delayed presenting group was in bleeding per rectum [P<0.001], mass per rectum [P=0.001], mass per abdomen [P=0.029], fever [P=0.006] and abdominal distension [P=0.001]. Gangrene of bowel, complications and mortality were more common in delayed presenting group

Conclusion: pain in abdomen, disarrhea and vomiting were almost same in both groups, while distension of abdomen, palpable mass per rectum, bleeding per rectum, mass per abdomen, and fever had significant variability in both groups. There was also high morbidity in delayed presenting group. Early diagnosis and early treatment are main keys to curtail the morbidity and mortality in childhood intussusceptions

Intestinal obstruction due to lymphangioma of mesentery: a case report

A case of intestinal obstruction due to lymphangioma of mesentery in a two months old child is presented. Patient presented with signs and symptoms of intestinal obstruction. X-ray showed multiple air fluid levels, while ultrasound was insignificant. Exploration revealed a milky white cyst of mesentery causing complete occlusion at mid ileum. Cyst along with segment of ileum was resected and end-to-end anastomosis made. Post-operative recovery was un-eventful. Histopathological findings were consistent with lymphangioma of mesentery

Sinus histiocytosis with massive lymphadenopathy [rosai dorfman's disease]: a rare cause of lymphadenopathy in children

Sinus histiocytosis with massive lymphadenopathy also called as Rosai-Dorfman's disease is a benign self limiting rare histiocytic disorder with very few case reports in Pakistani literature. This case report describes a young boy of nine years age who presented with progressive, asymptomatic bilateral cervical lymphadenopathy for eight months. Open cervical lymph node biopsy confirmed the diagnosis on classical histopathological features. As the patient was asymptomatic, we kept him on observation, with follow-up. He shown remarkable reduction in cervical lymphadenopathy

Umbilical perforation: a rare complication of entriculoperitoneal shunt

A female baby of one-and-a-half-year old presented with extrusion of ventriculoperitoneal [VP] shunt through umbilicus. On exploration, the urachal remnant was found perforated by VP shunt and the tube exteriorized through umbilicus. Child was managed successfully with excision of urachal remnant, removal of VP shunt, antibiotic treatment and re-insertion of shunt

Small bowel haemangioma: a rare cause of intestinal obstruction in infant

Haemangiomas of small bowel are rare benign tumors. They present diversely, with intestinal obstruction being rare. We describe a two years old female baby with intestinal obstruction. Exploration revealed a diffusely infiltrating haemangioma of middle one third of ileum. Resection of affected segment and end to end bowel anastomosis was made. Post- operative recovery was un- eventful. Histopathological report was consistent with capillary haemangioma of small intestine

Segmental defect of intestinal musculature: a rare cause of intestinal obstruction in children

A 3 years old female child was brought in emergency department with acute abdomen. Laparotomy disclosed multiple segmental dilatations in middle Third of ileum. Which was resectied and anastomosed. Post operative recovery was uneventful. Histopathological findings showed lack of smooth and longitudinal muscles in dilated segments of intestine with intact mucosa without any evidence of necrosis and inflammation

Persistent mullerian duct syndrome with transverse testicular ectopia

A case report of a 3 months old male child is presented, who had right inguinal hernia with left impalpable testis. During herniotomy we found both testes on right side [transverse testicular ectopia] with presence of mullerian duct structures