Minimally invasive surgery.

The field of Minimally Invasive Surgery or Minimally Access Surgery (MAS) as it is commonly known has grown remarkably over the past two decades. MAS has a steep learning curve and unexpected complications with MAS are not infrequent unless approached with great caution. However it leads to a shorter hospital stay, less analgesic use, rapid return to school and a better cosmetic outcome. MAS in children started in India a decade ago, and has a great impact on the way we manage pediatric surgical problems today. This article is a brief description of most of the procedures that are being done with the help of MAS. In addition to these, new techniques, procedures and innovations are always ongoing in this fast developing field. MAS is being practiced in limited centers in our country with expanding experience and indications. Its use in children as the first option for early appendicitis, intraabdominal testis, gall stone disease and a few other conditions is now proven beyond doubt. There are other indications and areas of application of MAS which are continuously evolving and needs institutional audit and validation at every step before moving to the next phase.

Impalpable testes--is imaging really helpful?

The study evaluated the role of imaging studies in the diagnosis of impalpable undescended testes. A total of 40 children referred with 45 impalpable undescended testes had an ultrasound scan and clinical examination by a pediatric surgeon. 22 out of these 45 testes were found to be palpable on clinical examination by a pediatric surgeon. Of the remaining 23 boys (23 units of testes), 21 underwent MRI scan for identification of testes and results were compared with findings at laparoscopy. The diagnostic agreement of ultrasound and MRI in correctly localizing the testes was 19% and 52% respectively whereas the sensitivity of detection was 60% and 55% respectively. Imaging studies therefore have a limited role in pre-surgical evaluation of boys with impalpable testes.

Esophageal achalasia and alacrima in siblings.

Achalasia of the esophagus is a rare problem in children. It has been reported in siblings of consanguineous parents. Allgrove or AAA (triple-A) syndrome is an autosomal recessive condition associated with adrenal insufficiency, alacrima and achalasia of the oesophagus. We present two siblings with familial achalasia and alacrima treated at 3 months and 9 years respectively.

Cutaneous mucormycosis in children.

Cutaneous mucormycosis is a rare fungal infection in children. It is commonly found in immunocompromised children. Early diagnosis is difficult and requires a very high degree of suspicion. Recommended mainstay of treatment has been amphotericin B and extensive surgical debridement which may at times require amputation if limb is involved. The authors share their experience of two cases of successfully treated cutaneous mucormycosis.

Down syndrome with transient myeloid leukemia and urological abnormality.

Among the various anomalies associated with Down syndrome, leukemia is quite common. The variant transient myeloid leukemia is seen almost exclusively in the Down syndrome patients. On the other hand, urological anomalies are infrequently found both in the Down syndrome and leukemia patients. We report a case who had the rare combination of a urological anomaly along with Down syndrome and transient myeloid leukemia.

Laparoscopy in diagnosis of prolonged neonatal jaundice.

When managing neonatal jaundice, there is no single test or imaging modality that can reliably define biliary atresia and neonatal hepatitis. Early diagnosis is an important step for surgical success in extra hepatic biliary atresia. In many situations, exploratory laparotomy and operative cholangiography may be needed to settle the definitive diagnosis, with the risk of having negative exploration in those high risk patients with medical etiology. The use of laparoscopy may help in avoiding unnecessary exploration for such group of patients and arriving at a definite diagnosis. Six patients with conjugated hyperbilirubinemia were evaluated with a diagnostic laparoscopy, laparoscopic cholangiography and liver biopsy. Three of the six patients were diagnosed to have neonatal hepatitis and so an unnecessary laparotomy was avoided in these cases.

Thoracoscopy in management of empyema thoracis in children.

The usual treatment for empyema in children varies from a simple thoracocentesis to thoracotomy and open decortication. We studied the role of thoracoscopy in the management of empyema thoracis in 10 immunocompetent children after failure of medical management. All children recovered well with an early removal of intercostal tube and reduced postoperative hospital stay and showed complete resolution of empyema on follow up. Thoracoscopy has come as a new ray of hope for the patients with empyema, with the advantages of complete evacuation, minimal pulmonary dysfunction, reduced pain and hospital stay.