A simulation model of nail bed suture and nail fixation: description and preliminary evaluation.

BACKGROUND: Wounds of the finger nail bed represent a frequent injury, especially in children. Residents often learn nail bed repair on patients without prior training. We aimed to develop and evaluate a "low-fidelity" simulation model of nail bed repair. METHODS: The model consists of a false nail on a plastic finger and a hydrocolloid dressing, which is pasted on the nail bed site and cut horizontally. This model allows nail bed suture and nail fixation. The cost of each model is about $1. Thirty-three doctors evaluated this model on 10 items, rated out of five, concerning the realism, the difficulty of the procedure, and the educational value. The duration of the procedure was also noted. We evaluated the clinical effectiveness by comparing through Fisher's exact test the ratio of unsuitable events (revision surgeries, surgical site infections, and complaint letters) on two periods-3 y before and 18 mo after the implementation of this model in our institution, respectively. RESULTS: Average mark was 4.16/5. The model was considered reliable, reproducible, and realistic. All the testers recognized a big educational value. The overall duration of the procedure averaged 23 min for residents and 11 min for surgeons. We collected 17 unsuitable events out of 84 patients from the period "before" and 2 out of 54 patients from the period "after" (P = 0.005). Revision surgeries were 10/84 from the period before and 2/54 from the period after (P = 0.04). CONCLUSIONS: The results of the internal and clinical evaluations are encouraging. We suggest integration of this model into the training program of residents.

Idiopathic scrotal hematoma simulating a testicular torsion, in association with cryptorchidism: US findings.

BACKGROUND: An acute scrotum concerns endoscrotal organs (testicles, spermatic cord, tunica vaginalis) and is characterized by pain, swelling and hyperemia of the hemi-scrotum. It represents one of the most common surgical emergencies in children often caused by testicular torsion; the diagnosis is mostly clinical but must be supported by ultrasonographic examination of the scrotal region in association with a colour Doppler study of the spermatic cord vessels and glandular parenchyma. An idiopathic scrotal hematoma is a very rare condition that can simulate it. CASE REPORT: A 3-day-old full-term baby, otherwise in good health, showed swelling and pain of the left inguinal-scrotal region. A testicular torsion was suspected, so the baby underwent an ultrasound examination of the testis and spermatic cord that showed a left scrotal hematoma with superior displacement of the didymus; the right testicle was located in the internal inguinal canal. Surgical intervention confirmed the sonographic diagnosis of left testicular hematoma and of the right cryptorchidism. CONCLUSIONS: Although testicular torsion is the most frequent cause of acute scrotum, the possibility of a persistent idiopathic scrotal haematoma and/or haematoma secondary to a trauma of the inguino-scrotal region, must be always taken into account. US diagnosis can avoid unnecessary emergency surgical treatment, required in case of testicular torsion.

Preputioplasty associated with urethroplasty for correction of distal hypospadias: a prospective study and proposition of a new objective scoring system for evaluation of esthetic and functional outcome.

OBJECTIVE: Most surgical procedures for correction of hypospadias involve the removal of foreskin resulting in a circumcised penis. We report our experience and the medium-term results in the reconstruction of the foreskin during the correction of distal hypospadias. MATERIALS AND METHODS: Between January 2007 and December 2011, 445 patients aged between 8 and 120 months underwent surgical correction of hypospadias. In 354 out of 445 patients, we performed the reconstruction of the foreskin. Urethroplasty was performed according to either the TIPU (tubularized incised urethral plate urethroplasty; Snodgrass) technique (233/354, 66%) or MAGPI (meatal advancement glanduloplasty incorporated) procedure (121/354, 34%). In 91 out of 445 patients urethroplasty was performed using classic TIPU technique and they were circumcised. The cosmetic and functional results were evaluated using the Hypospadias Objective Penile Evaluation (HOPE) scoring system. RESULTS: At a 12 months follow-up, 300 patients (84.7%) had retractable foreskin while 54 patients (15.3%) required postoperative steroid application. We had a total complication rate of 8.7%. As for preputioplasty, 16 patients (4.5%) had partial or total dehiscence of the reconstructed foreskin, one patient was circumcised for persistent phimosis (0.2%). As for urethroplasty complications, we recorded 11 fistulas (3.1%) and three stenosis (0.9%). The complication rate of the control group of circumcised patients was of 3.3% (2 fistulas [2.1%] and 1 stenosis [1.2%]). CONCLUSIONS: Our experience shows that foreskin reconstruction can be performed successfully in selected patients with distal hypospadias. However, preputioplasty add an additional 4.7% complication rate. As for the complications of urethroplasty, it seems that preputioplasty does not increase the incidence of complications on the urethra reconstruction. We propose a new objective scoring system (modified HOPE score) for evaluation of esthetic and functional outcome.

Open versus laparoscopic appendectomy in the pediatric population: a literature review and analysis of complications.

BACKGROUND: This study aims to compare the results of laparoscopic and open appendectomy (LA and OA, respectively) in a pediatric population with particular attention to complications analysis. SUBJECTS AND METHODS: A literature search was performed using Medline, Cochrane, Embase, Sci Search, Lilacs, and PubMed databases on all studies published during the 14-year interval of 1997-2010. Comparative studies of LA versus OA in the pediatric population were included in these studies. Data concerning operative time, length of hospital stay, postoperative complications, postoperative pain, and surgical trauma were recorded. RESULTS: We recorded 52 studies, but 26 of these were excluded from our analysis because they were neither relevant nor related to the adolescent population. The 26 studies analyzed showed a population of 123,628 children and adolescents (ages 0-18 years) who underwent appendectomy by laparoscopic (LA, 42,213 [34.1%]) and open (OA, 81,415 [65.9%]) techniques. Our analysis showed that patients undergoing LA presented a lower incidence of surgical wound infection, lower incidence of postoperative ileus, a lower use of analgesics in the postoperative period, an earlier resumption of normal diet, a shorter hospitalization, and a more rapid recovery to resume normal activities compared with patients undergoing OA. This study, comparing LA versus OA in children, failed to identify any major difference between the two techniques in terms of formation of intra-abdominal abscesses. As for operative time, our analysis showed globally a significant reduced operative time in OA versus LA in complicated appendicitis, but in simple appendicitis the operative time seems to be the same. CONCLUSIONS: Our analysis of the literature showed that the LA technique presents several advantages compared with the OA technique. For this reason, if a child is hospitalized today for appendicitis treatment in a pediatric center where the laparoscopic approach is unavailable, he or she should be placed on antibiotics and transferred to a center that offers the laparoscopic approach.

Blue patent lymphography prevents hydrocele after laparoscopic varicocelectomy: 10 years of experience.

PURPOSE: Laparoscopic varicocelectomy according to the Palomo technique is the most common procedure adopted in children with testicular varicocele. This procedure involves the ligation of the internal spermatic cord and is associated with a 3%-5% incidence of recurrence and up to 30% incidence of hydroceles. We sought to determine the impact of lymphatic preservation on hydrocele formation and the success of varicocelectomy. PATIENTS AND METHODS: We retrospectively evaluated 396 patients with a mean age of 13.2 years who underwent laparoscopic varicocelectomy. Patients were divided into two groups: those who underwent a lymphatic-sparing (LS) procedure using isosulfan blue scrotal intra-dartoic injection and those who underwent a non-LS (NLS) technique. The incidences of recurrence/persistence and postoperative hydrocele formation requiring surgery or aspiration were analyzed statistically using the chi-squared test. RESULTS: Of 396 patients, 244 received a laparoscopic LS procedure, and 152 received an NLS operation. The LS patients in whom the lymphatic vessels were not identified (26/244 [10.6%]) were considered NLS repairs. The follow-up was at least 12 months. LS surgery (218 patients) was associated with a decreased incidence of postoperative hydrocele (0/218 [0%] versus 18/178 [10.1%]; chi-squared test=25.84, difference statistically significant). There was no significant difference in incidence of persistent or recurrent varicocele requiring reoperation following the initial procedure (5/218 [2.2%] versus 5/178 [2.8%]; chi-squared test=0.41, difference statistically not significant). CONCLUSIONS: Laparoscopic LS varicocelectomy using isosulfan blue is preferable to laparoscopic Palomo repair that does not preserve the lymphatics. It has a significantly lower incidence of postoperative hydroceles and still maintains a low incidence of persistence/recurrence.

Technical standardization of laparoscopic direct hernia repair in pediatric patients.

BACKGROUND: The aim of this article is to standardize the laparoscopic technique to treat direct inguinal hernia in pediatric patients. PATIENTS AND METHODS: In the last 3 years we treated laparoscopically 163 patients with a diagnosis of inguinal hernia. In 7 patients we discovered laparoscopically a direct inguinal hernia. This study is focused on the management of these 7 cases (4 girls and 3 boys; median age 4.6 years). They presented a right defect in 4 cases and a left defect in 3 cases. Six of 7 patients had been already operated for an inguinal hernia and presented a recurrence of the hernia. We used three trocars, 5-mm 0 degree optic, and two 3-mm instruments. In each case, after the resection of the lipoma using the hook cautery, the defect was closed by means of separated stitches. In every case we used the vesical ligament as an autologous patch to reinforce the closure of the defect. RESULTS: The average operative time was 35 minutes. All the procedures were performed in a day-hospital setting. We had neither conversions nor complications in our series. With a minimum follow-up of 1 year, we had no recurrence. CONCLUSIONS: Laparoscopic identification and repair of direct inguinal hernia in children is a safe and effective procedure to adopt. The key points of the technique are the resection of the lipoma, the closure of the defect using separated, nonabsorbable sutures, and the use of the vesical ligament to reinforce the suture. We believe that in case of recurrence of inguinal hernias after inguinal approach, laparoscopy is the gold standard technique to identify and treat the cause of the recurrence itself.

Long-term outcome of laparoscopic Nissen procedure in pediatric patients with gastroesophageal reflux disease measured using the modified QPSG Roma III European Society for Pediatric Gastroenterology Hepatology and Nutrition's questionnaire.

BACKGROUND/PURPOSE: Laparoscopic fundoplication (LF) represents the gold standard for surgical treatment for pediatric patients with gastroesophageal reflux disease (GERD). METHODS: We report the results of long-term outcome of 36 patients who had undergone LF from January to December 1998, with a follow-up longer than 10 years (range, 11-12 years). The patients were invited, by phone, to undergo a clinical follow-up. All patients underwent the modified European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)'s Roma III questionnaire; however, only 22 out of 36 patients accepted to be controlled in a day hospital setting, and 10 out of 36 accepted to undergo a telephonic questionnaire. Our study is focused on the data of these 32 patients. RESULTS: Twenty-eight out of 32 (87.5%) patients had completely recovered; 4 out of 32 patients (12.5%) had a mild persistent GER; 9 out of 32 patients (28%) referred a mild dysphagia; 21 out of 32 (66%) patients could burp; and only 9 out of 32 (28%) patients could vomit. The cosmetic result was good in 30 out of 32 (94%) patients. The weight/height ratio was satisfactory in 28 out of 32 (87.5%) patients. The quality of life was good in 28 out of 32 (87.5%) patients. CONCLUSIONS: Our experience shows that the long-term follow-up after LF produces a good clinical result and a good quality of life. The modified ESPGHAN's Roma III questionnaire seems an effective way to check the long-term results, because it avoids submitting patients to long and not well tolerated instrumental exams.

Current trends in the management of pediatric patients with perineal groove.

OBJECTIVE: Perineal groove is an uncommon congenital anomaly of the perineum, affecting young girls. We report our experience in the treatment of this pathology. DESIGN: Retrospective review of patients operated in our institution for a perineal groove between 1999 and 2007. SETTING: Multidisciplinary clinic for young girls with perineal groove at the Department of Pediatrics, "Federico II" University, Naples, Italy. PARTICIPANTS: Six young girls (aged between 2 and 7 years) with perineal groove. INTERVENTIONS: In the first three patients, who were operated on before 2004, the procedure consisted in resecting the groove and closing the perineal defect using interrupted sutures; in the last three, the skin was closed with similar approach and then covered with a chemical glue to impermeabilize and protect the suture. RESULTS: At a long-term follow-up, two of the three patients operated before 2004 experienced dehiscence of the perineal skin due to urine and feces contamination; in the last three patients in whom the sutures were covered with glue there was no skin dehiscence, and the postoperative course was uneventful. CONCLUSIONS: A perineal groove is a rare anomaly in young girls. Treatment consists in the surgical excision of the groove, generally after two years of age. On the basis of our experience it is preferable to cover the suture with a chemical glue to impermeabilize the suture line and protect the skin from infections.

Lessons learned from the first 109 laparoscopic cholecystectomies performed in a single pediatric surgery center.

BACKGROUND: Laparoscopic cholecystectomy (LC) is a frequent operation in adults but is seldom performed in children. A retrospective review of 109 consecutive patients who underwent LC over an 11-year period was performed to see what lessons were learned from this experience. METHODS: From January 1996 to January 2007, a total of 109 patients were referred to our unit to undergo LC. Nine adult patients were excluded from the analysis. The remaining 100 pediatric patients form the basis of this report. Isolated cholecystectomies were performed using a four-trocar technique, with a fifth trocar added for cases in which splenectomy was required. One patient with main bile duct dilatation at preoperative echography underwent peroperative cholangiography. RESULTS: We recorded three anatomic anomalies (3%), two involving the bile duct and one the cystic artery. We recorded four minor problems during surgery: In one case there was failure of the tip of reusable scissors, and in three cases there was a small perforation of the gallbladder during the dissection step. We recorded four (4%) postoperative complications, which required redo surgery: one patient with bleeding from the cystic artery; one case of dislocation of clips positioned on the cystic duct; and two patients with lesions of the main bile duct that had not been detected during surgery. The treatment consisted in choledojejunostomy on postoperative day 7 in one case and suture of the choledocus on a stent positioned using endoscopic retrograde cholangiopancreatography on postoperative day 5 in the second case. Both biliary complications occurred in patients more than 14 years of age. We also recorded one umbilical granuloma. CONCLUSIONS: LC is an effective procedure in children. On the basis of our experience, it seems that major complications can occur even with experienced surgeons, and they are more frequent in teenagers. Biliary or vascular anomalies of the gallbladder are encountered in about 3% of patients.