Situs Inversus Abdominis Associated with Duodenal Atresia: A Case Report

Situs inversus abdominis is a rare congenital condition commonly associated with serious cardiac and splenic malformations. The importance of recognizing the presence of situs inversus abdominis preoperatively is emphasized by the fact that the surgical incision is placed on the incorrect side of the abdomen. A 6 day-old girl was referred to our hospital because of bile stained vomiting. A plain radiography of abdomen and chest showed the heart to be normal position and a reversed "double-bubble" picture with no other gas shadow in the rest of the abdomen. Abdominal computed tomography scan revealed situs inversus with the stomach and polysplenia on the right side and the liver on the left side. A laparotomy confirmed the diagnosis of situs inversus with duodenal atresia. The obstruction was bypassed by constructing a side-to-side duodenoduodenostomy. The postoperative course was uneventful.

Clinical Review of Spontaneous Gastric Perforation in the Newborn

Spontaneous gastric perforation in the newborn is a rare disease that requires early diagnosis and prompt surgical treatment. Between 1988 and 2001 at the Department of Pediatric Surgery, Kyungpook National University Hospital, 9 cases of spontaneous gastric perforation were treated. Seven were males and two females. The mean gestational age and birth weight were 36.7 weeks and 2,455 grespectively. All patients presented with severe abdominal distention and pneumoperitoneum on cross table lateral film of the abdomen. Perforations were located on the anterior wall along the greater curvature of the stomach in six and on the posterior wall along the greater curvature in two. One case showed two sites of perforation on the anterior and posterior wall along the greater curvature. Six patients were managed with debridement and primary closure and the others with debridement and partial gastrectomy. Peritoneal drainage was not performed. There were four deaths; two from sepsis due to leakage from the anastomotic site, one as a result of acute renal failure, and the other by associated respiratory distress syndrome. Spontaneous gastric perforation in the newborn is usually located along the greater curvature. Elevated intragastric pressure is a possible cause of the perforation. Poor prognosis is related to associated diseases and prematurity.

Ultrasonographic Evaluation in Patients with Inguinal Hernia

Between March 1999 and January 2000, 82 boys with the diagnosis of inguinal hernias (12 bilateral and 70 unilateral hernias), underwent Ultrasound (US) examination of both sides of the groin, a total of 164 inguinal imaging prior to surgery. The patients ages ranged from 3 days to 12 years with a mean of 32.6 months. Ninty four examinations were on the clinically symptomatic side and 70 were on the asymptomatic side. The US criteria for the diagnosis of an inguinal hernia were as follows: 1) visceral hernia, the presence of bowel loops, or omentum in the inguinal canal, 2) communicating hydrocele, the presence of fluid in the processus vaginalis, 3) widening of patent processus vaginalis at the level of nternal inguinal ring. The width of patent processus vaginalis at the level of internal inguinal ring over 4 mm is onsidered an occult hernia. Among the 94 symptomatic groins, US findings showed 31 (33 %) visceral hernias, 18 (19 %) communicating hydroceles, and 38 (41 %) widening of the internal inguinal ring, and 7 (7 %) groins without abnormalities. In 70 asymptomatic groins, there were 4 (6 %) visceral hernias, 5 (7 %) communicating hydroceles, 11 (16 %) widening of the internal inguinal ring, and 50 (70 %) groins without abnormalities. Among the 70 asymptomatic groins there were US abnormalities in 20 (28 %). One hundred and seven groins with positive US findings were surgically explored. Among 107 operated sites, the operative findings were compatible with the US diagnosis in 104, a sensitivity for US of 97.2 %. In patients with US findings of widening of internal inguinal ring (>4 mm), there was patent processus vaginalis in 36 out of 38 symptomatic groins and 10 of 11 asymptomatic groins. The sensitivity of US to the operative findings in widening of internal inguinal ring was 93.8 %. For visceral hernia and communicating hydrocele, the sensitivity of positive US findings was 100 %. Ultrasonography for inguinal hernias appears to be a rapid, reliable, and noninvasive screening diagnostic tool with high positive specificity. Therefore, we recommend the use of US as a routine diagnostic tool in pediatric patients with inguinal hernias and hydroceles.

Mesenteric and Omental Cysts in Infancy and Childhood

Mesenteric and omental cysts are rare lesions of childhood. These cysts are similar to cystic hygromas in other parts of the body morphologically and pathologically. From 1980 to 1997, 8 children were diagnosed and treated for mesenteric or omental cysts. Their ages ranged from 18 days to 6 years. There were 5 boys and 3 girls. The main presenting symptom was abdominal pain. Operative procedures were complete cysts excision, complete excision with intestinal resection, or complete excision with intestinal resection and colostomy. Accurate preoperative diagnosis was possible with the current ultrasonographic imaging techniques. Complete excision of the lesion was possible in all patients and resulted in an excellent outcome.

Congenital Diaphragmatic Eventration in infant

Although diaphragmatic eventration in newborn infants is generally regarded as a rare condition, the need for accurate diagnosis and appropriate intervention according to the etiological factors is well known. Recently authors experienced five consecutive cases of diaphragmatic eventration. All requiring surgery. All were seen within the second month of life ranging one to 55 days after birth. And all were male infants. All eventration were left sided. Respiratory symptoms were present in 4 cases, and the remainder had no symptoms other than inability to gain weight. The radiologic changes were pronounced in all cases, the dome of the diaphragm reaching from the third to fifth intercostal spaces. Regarding surgical technique, the authors favored Diaphragmatic plication through the abdomen, which gave excellent clinical and radiological results. No postoperative mortality was noted.

Management of Liver Injuries Following Blunt Abdominal Trauma in Children

A clinical review was done in 31 children with blunt liver injury admitted to the Department of Surgery, Kyungpook National University hospital between 1981 and 1990. 17 of the 31 children with injured liver required laparotomy. (11 hepatorrhaphy, 4 lobectomy, 2 segmentectomy) There were two deaths after laparotomy, one from associated severe head injury and one from multi organ failure and the remaining 14 children, who were hemodynamically stable after initial resuscitation and without signs of other associated intraabdominal injuries, were managed by nonoperative treatment. Patients were observed in a pediatric intensive care unit for at least 48 hours with repeated abdominal physical examination, laboratory studies, vital sign check and bed rest. The hospital courses in all cases were uneventful and there were no late complication. A follow-up computed tomography was obtained in 7 patients, showing resolution of the injury in all. The authors believe that, for children with blunt liver injuries, nonoperative management is safe and appropriate if carried out under careful continuous surgical observation in a pediatric intensive care unit.

Appendiceal Perforation in the Neonate

Appendiceal perforation is uncommon in the neonate. The first reported case was by Diess in 1908, with approximately 111 additional cases reported since that time. However, if one excludes neonatal appendicitis associated with inguinal or umbilical hernias, necrotizing enterocolitis, meconium plug, and Hirschsprung's disease, the total would appear to be approximately 36 cases. We experienced a 12 days old boy with perforation of the appendix. A male newborn weighting 3000g was born by normal spontaneous vaginal delivary at 35 weeks gestation age to a 31-year-old mother who had premature rupture of membrane. He took feeding well for the first 5 days of life. After that, he began to have emesis of undigested milk, decreased activity and jaundice. He were admitted to the pediatrics and than phototheraphy was done. A 11-days after birth, he had progressive abdominal distension, fever, decreased activity, and vomitting. Erect abdominal radiography showed pneumoperitoneum. At exploratory laparotomy, a 0.8 X 0.6 cm sized perforation was noted at antimesenteric border of midportion of the appendix. Histologic section of the specimen showed ganglion cell and transmural inflammation.