importance of portal venous gas in neonatal necrotizing enterocolitis; review of 15 cases

To find out if the presence of portal venous gas [PVG] in the abdominal radiography of neonates with necrotizing enterocolitis [NEC] indicates surgical intervention. Retrospective study of cases of NEC managed by the authors over a period of 5 years. Cases with and without PVG were compared Records of 63 neonates with the diagnosis of NEC were obtained. The overall mortality was 20 cases [31.7%]. In both the medically [48 cases] and the surgically [15 cases] treated group. The mortality rates of cases with PVG were not statistically different from those without PVG [33.3% versus 15% ; P value=0.3, for the medical, and 83% versus 66.6% ; P value=0.6, for the surgical]. At surgery, intestinal pan-necrosis was found in 3 cases with PVG [50%] and non in cases without PVG [P=0.04]. Many cases of NEC with PVG could be treated successfully without surgery, with no difference in mortality. However, the presence of this radiological sign in cases requiring surgery, based on other indications, is associated with poor prognosis

Laparoscopy for impalpable testes: is inguinal exploration necessary for hypoplastic gonadal vessels exiting the deep ring?

During laparoscopy for impalpable testes [IT], if the vas and vessels were found exiting the deep ring, many surgeons proceed to inguinal exploration as a routine, regardless the presence or absence of the processus vaginalis [PV] or the adequacy of the vessels. This is to detect an impalpable intra-canalicular testis with possible orchidopexy; if the testis is normal, or excision of a small atrophic testicular remnant; for fear of possible malignant changes later on. It is agreed that in cases of normal testicular vessels the exploration of the inguinal canal should follow. However, with hypoplastic vessels, the need for groin exploration has been questioned. The aim of this study is to assess whether routine inguinal exploration is necessary in all cases of normal vas and hypoplastic vessels passing through the deep inguinal ring during laparoscopy for IT. This is a retrospective study of cases of IT managed by the authors, where during laparoscopy, the vas deferens and the gonadal vessels; were seen passing through the deep inguinal ring. Cases were divided into 4 groups according to the condition of the PV; present [patent or closed] or absent, and the adequacy of the vessels. Findings at inguinal exploration, which was routinely done in all cases, as well as at histo-pathological examination, when done, were compared. The ends of the cord structures were "biopsied" and submitted to histo-pathological study. Cases with hypoplastic vessels were particularly compared in relation to the presence or absence of any testicular tissue on histo-pathological examination. Over a period of 4 years; 27 children had laparoscopy for 36 impalpable testes. Twenty-three cases [64%] had the vas and vessels passing through the deep ring. Eleven cases [48%] had hypoplastic vessels. Five cases [22%] had PV and on inguinal exploration, 3 cases [60%] had atrophic testes, and 2 had small "nubbin" [with calcification and fibrosis on histo-pathology] that were excised. Six cases [26%] had no PV; with 3 having blind ended vas and vessels and 3 having a small "nubbin". No case in the last group showed testicular tissue on histo-pathology. In cases of hypoplastic vessels exiting the deep inguinal ring, it is the presence or absence of PV that should determine the next step. If the PV is present, the possibility of finding an atrophic testicular tissue, which should be excised for fear of malignant changes, is high and inguinal exploration should follow. If the PV is absent, this possibility is not there, and inguinal exploration is unnecessary

Tunneled central venous lines in the neonates: Insertion in the neonatal intensive care unit

The use of central venous catheters has brought enormous benefits in neonatal care. They have been used extensively in neonatal intensive care units for administration of intravenous fluids, parenteral nutrition as well as antibiotic therapy. Tunneling the catheter through the subcutaneous tissue has been used to reduce the incidence of systemic sepsis, as the skin exit site is away from the vein puncture site. Tunneled central venous catheters have been routinely inserted in the operating room, few centers performing the technique in the neonatal intensive care unit [NICU] The aim of this study was to evaluate the feasibility and safety of their insertion in the NICU. Over a period of two years, fourteen tunneled single lumen silicone catheters have been inserted by the author in 12 neonates. They were inserted using a cut-down technique either through the internal jugular vein or the femoral vein. Cases performed in the operating room received general anesthesia, while sedation and local anesthesia were used for cases performed in the NICUs. Postoperatively, X-ray was performed to verify the catheter position. Catheters inserted in the NICU were compared to those inserted in the operative room. Indications, complications and outcomes were reviewed. The patients' weight ranged from 590 gm to 3.3 kg. The youngest was 7 days old. Six catheters were inserted in the operating room [43%], and eight [57%] in the NICU. The internal jugular vein was used in 12 cases [86%] and the femoral vein in two [14%]. Of the twelve babies, ten [83%] required the catheter for hyperalimentation, and two [17%] for both antibiotic therapy and intravenous fluid administration. Septic complications occurred in two cases [14%]; local wound sepsis in one patient [7%]; and septicemia in another [7%]. Both of them were inserted in the operative room. Tube dislodgement occurred in one case [7%] and thrombus formation in one occasion [7%]. Tunneled insertion of central venous catheters is a valuable technique in the neonates. Line insertion in the NICU was not associated with increased risk of line sepsis. Therefore, performing the technique in the NICU is not only feasible but safe as well. However, large-numbered studies are still needed

Laparoscopy assisted versus standard inguinal orchiopexy for high palpable undescended testes

In high palpable undescended testes, many surgeons perform inguinal orchiopexy routinely. Some surgeons prefer a totally laparoscopic approach. Technically, this is not always possible. However, laparoscopy could still be valuable in dissecting the testicular pedicle before proceeding to the standard inguinal orchiopexy. The purpose of this study was to evaluate the advantages of such strategy. The study included thirty-eight children, with 48 high palpable undescended testes treated by the author over 2 1/2 years. These were divided into two groups. Group [I] comprised 34 high palpable undescended testes, treated by the standard-inguinal orchiopexy without laparoscopy. Group [II] comprised 14 high palpable undescended testes treated by laparoscopy assisted orchiopexy. Both groups were compared with regard to the need to divide the spermatic-vessels, level of fixation of the testis [at the bottom of the scrotum or at a higher level], the need for second stage operation and testicular volume during follow-up. In group [I], 3 cases [8.8%] required sectioning of the spermatic vessels; 8 cases [23.5%] required a second stage, 5 cases [14.7%] had high testicular fixation, and 5 cases [14.7%] showed testicular volume reduction during follow-up. In group [II], only 1 case [7%] required spermatic cord sectioning. In high palpable undescended testes, laparoscopic dissection of the testicular pedicle before standard inguinal orchiopexy is helpful. It gives the length required for bringing the testis into proper scrotalposition, avoids compromising vascularity of the testis or expose cord structures to injury and might completely eliminate the need for a second stage intervention with its potential complications

Selective use of intraoperative pneumoperitoneum for detection of contralateral inguinal hernia in high risk children: goldstein's test revisited

Contralateral exploration [CLE] in children with unilateral inguinal hernias is still controversial. Various methods have been devised to assess the presence of contralateral patent processes vaginalis in order to rationalize the conralateral exploration. This study evaluates the selective use of the intraoperative pneumoperitoneum technique in detecting the Contralateral hernia in high-risk children. A retrospective analysis of two groups of children who underwent repair of unilateral inguinal hernias was done. Analysis included three subgroups at high-risk of developing Contralateral hernia, namely, females, left side hernias, or children less than two years of age. In group I [n=126 patients], the intraoperative pneumo-peritoneum technique was not performed with the repair, in group II [n=14 patients], the test was performed using the Goldstein technique. In group I, 28 children presented with left-side hernias, two of them [7%] developed right-side hernias later on. Twelve were females, one of them [8%] developed Contralateral hernia. Another 37 patients were less than two years, two of them [5%] developed Contralateral hernia during the follow-up period. In group II, the intraoperative pneumoperitoneum technique was performed in 14 cases; all with left-sided hernia. Eight females [57%], and 7 less than two years of age [50%]. None of these showed signs of Contralateral patent processus vaginalis and accordingly no Contralateral exploration was performed. No Contralateral hernia developed during the follow up period. The difference in the incidence of Contralateral hernia between the groups was statistically insignificant [P values > 0.05]. The intraoperative induced pneumo-peritoneum is a valuable technique to detect the associated Contralateral hernias. It is simple to perform, less invasive, less time consuming and inexpensive. Selective use in high-risk children is advised