Surgical Technique of Glans Wings Creation with Preservation of Glanular Vascular Arcade and Creating Flaps for Tension-Free Glansplasty in Hypospadias Repair.

OBJECTIVE: The objective of this study is to report the technical nuances of glans wings creation in anatomical plane facilitating liberal glans wings mobilization with preservation of glanular vessels for tension-free glansplasty in surgery of hypospadias in primary and redo cases. MATERIALS AND METHODS: Eighty-six primary hyposapdias and 7 cases of distal hypospadias, operated elsewhere and presented with glans and urethroplasty dehiscence, undergoing tubularized-incised-plate (TIP) repair were included after ethical approval. Technical points of glans wings creation in the subfascial plane included (i) creation of Buck's fascia window, just proximal and lateral to the point of bifurcation of corpus spongiosum, (ii) creation of subfascial-pret unical plane on the tunica albuginea of corpora cavernosa up to ventral limit of laid open glanular meatus, (iii) release of pillars of corpus spongiosum off the glans base keeping the basal lamina propria covering the vascular arcade intact, (iv) release of glans base off the tip of corpora cavernosa and composite flap of corpus spongiosum pillars with Buck's fascia off the corpora cavernosa, (v) approximation of glans wings over the tubularized-incised-plate covered with dartos, and (vi) approximation of fasciospongioplasty flaps at hypospadiac meatus. Outcome measurement included (i) intra and postoperative problems and (ii) elimination of glans dehiscence. RESULTS: There occurred 1 injury to the tunica albuginea of ventral corpora cavernosa and 1 button-hole injury to subcoronal mucosal collars. Flaps for fasciospongioplasty were short in 11. One glans dehiscence occurred in flat glans. CONCLUSIONS: This technique is effective in creating glans wings in the anatomical plane with the preservation of glanular vessels and flaps for fasciospongioplasty eliminating the possibility of glans dehiscence in both fresh and redo cases.

Congenital Colonic Stenosis: A Rare Gastrointestinal Malformation in Children.

AIMS: Congenital colonic stenosis (CCS) is an extremely rare cause of low-intestinal obstruction in neonates/child. We report our experience with seven cases of CCS presenting with low-intestinal obstruction and diagnosed intraoperatively and also propose an algorithm for its appropriate treatment for the adequate outcome. MATERIALS AND METHODS: It was a retrospective study of seven patients of CCS including two neonates (5-days and 15-days old), four infants (age range - 2-11 months), and one 24-month-old child admitted from 2014 to 2019. Information regarding the age of presentation, clinical presentation, physical findings, radiological and laboratory findings, details of surgery, and outcome was retrieved and analyzed. RESULTS: The male-to-female ratio was 5:2. Patients were initially diagnosed as cases of Hirschsprung's disease in five and ileal atresia in two. A final diagnosis of CCS was made during surgery and histopathological examination of resected stenotic segment. The segment involved was ascending colon in three, transverse colon in two, and sigmoid colon and junction of descending and sigmoid colon each in one patient. Resection of stenotic colonic segment and primary end-to-end anastomosis was performed in two, divided stoma after resection of the stenotic segment and secondary anastomosis in three, and proximal loop terminal ileostomy followed by resection of the stenotic colonic segment and ileocolic anastomosis after 10-12 weeks in two. CONCLUSIONS: CCS is a rare but possible cause of large-bowel obstruction, in neonatal, infant, and children particularly when associated with a history of chronic constipation since birth. It should be kept in mind as a differential diagnosis while managing a case of neonatal and pediatric intestinal obstruction, particularly low-bowel obstruction along with a history of chronic constipation. Treatment should be individualized for each patient based on clinical status and associated anomalies to give the best results with less morbidity.

Study of Variations in Axial Pattern Vessels of Penile Dartos in Hypospadias and Implied Surgical Significance.

OBJECTIVES: To report the anatomical variations in axial pattern vessels of penile dartos in hypospadias. METHODS: Eighty hypospadias undergoing repair with tubularized incised plate urethroplasty were studied with preoperative examination of visible vein through penile skin. Course of vein proximal to root of penis was studied with vein viewer. Modified penile degloving beginning at preputial edge, splitting inner preputial urothelium off the preputial dartos and proceeding to penile shaft in subdartos plane was performed. Axial pattern veins visible on penile dartos were studied. Axial pattern penile dartos arteries were studied by recording arterial pulsations. If arterial pulsations were not seen, arterial mapping on penile dartos completed with use of Doppler and images recorded. Variations in axial pattern dartos vessels were analyzed. RESULTS: In 32 hyposapadias of 1 group, median superficial vein along the dorsal midline of penile dartos drained into left saphenous vein. In this group, dorsolateral vessels were not seen on either side in 20 cases. Unilateral dorsolateral vessel in 7 and bilateral dorsolateral vessels in five were seen. In 48 hypospadias of other group, median superficial vein was not seen. Bilateral dorsolateral vessels in 11, unilateral dorsolateral vessels in 27 and no definite pattern in 10 were seen. In both groups, superficial median artery was not discovered. Vessels were longitudinally oriented. Penile dartos was equally distributed. CONCLUSION: In hypospadias, penile dartos vessels have axial pattern course longitudinally but not identical to normal. Eight patterns can be identified which can be diagnosed on careful clinical examination of penis.

Needle Insertion in a Child: A Rare Form of Child Abuse.

Needle insertion is a rare form of child abuse that, though prevalent in the society as an attempted infanticide/homicide, remains undiagnosed and underreported. One should have strong suspicion for occurrence of child abuse in a child with history of needle injury. Here, we report an unusual case of 3-month-old boy with history of hypodermic needle extrusion from multiple sites of body and suspicion of possible child abuse.

Technique of Antireflux Procedure without Creating Submucosal Tunnel for Surgical Correction of Vesicoureteric Reflux during Bladder Closure in Exstrophy.

AIM: To report the clinical application of the new surgical technique of antireflux procedure without creating submucosal tunnel for surgical correction of vesicoureteric reflux during bladder closure in exstrophy. MATERIALS AND METHODS: Based on the report of published experimental technique, the procedure was clinically executed in seven patients of classic exstrophy bladder with small bladder plate with polyps, where the creation of submucosal tunnel was not possible, in last 18 months. Ureters were mobilized. A rectangular patch of bladder mucosa at trigone was removed exposing the detrusor. Mobilized urteres were advanced, crossed and anchored to exposed detrusor parallel to each other. Reconstruction included bladder and epispadias repair with abdominal wall closure. The outcome was measured with the assessment of complications, abolition of reflux on cystogram and upper tract status. RESULTS: At 3-month follow-up cystogram, reflux was absent in all. Follow-up ultrasound revealed mild dilatation of pelvis and ureter in one. CONCLUSIONS: The technique of extra-mucosal ureteric reimplantation without the creation of submucosal tunnel is simple to execute without risk and complications and effectively provides an antireflux mechanism for the preservation of upper tract in bladder exstrophy. With the use of this technique, reflux can be prevented since the very beginning of exstrophy reconstruction.

Antireflux Status Post Roux-en-Y anastomosis: An Experimental Study for Optimal Antireflux Technique.

BACKGROUND: Roux-en-Y hepaticojejunostomy has been a gold standard to establish biliary-enteric anastomosis for various surgical indications, but associated with variable incidences of cholangitis. This experimental study was conducted to report a modification in Roux-en-Y anastomosis for possible better alternative to provide antireflux procedure after Roux-en-Y biliary-enteric anastomosis with the aim to minimize the possibility of reflux and its consequences. MATERIALS AND METHODS: For experimental study, the required fresh segment of Lamb's small intestine was procured. Three sets of Roux-en-Y anastomosis were created for each experiment. In set 1, there was simple Roux-en-Y anastomosis. In set 2, Roux-en-Y anastomosis along with 4-5 cm long spur between the hepatic and duodenal limbs was created. In set 3, in addition to Roux-en-Y with creation of spur, additional antireflux mechanism was created at the junction of upper two-third and lower one-third of the hepatic limb. Saline mixed contrast was infused by infusion pump to raise the intraluminal pressure to more than 10 cm of H2O. X-ray was taken at that time. RESULTS: In set 1, all preparations demonstrated reflux of contrast in the hepatic limb. The set 2 also demonstrated the same findings of 100% reflux in the hepatic limb. In set 3, No reflux was observed in 8 (80%) preparations while remaining 2 (20%) preparations reveal partial reflux. CONCLUSION: This experimental study suggests that the provision of spur and additional valve may be able to decrease the possibility of reflux in Roux-en-Y biliary-enteric anastomosis.

IschioPubic Osteotomy, A Simple and Effective Technique for Pelvic Ring Closure in Repair of Classic Exstrophy Bladder.

AIM: The aim of this study is to report the technique and outcome of ischiopubic (IP) osteotomy for pelvic ring closure in classic exstrophy bladder. METHODS: A total of 85 male classic exstrophies were selected based on trapezoid-shaped space between IP ramus on three-dimensional computed tomography pelvis. Using midline scroto-perineal approach, after bladder plate mobilization and radical corporal detachment; the pelvic surface of superior pubic ramus (SPR) was exposed. Above the obturator canal, H-shaped incision was made on periosteum of the SPR. The horizontal line of H was placed above the obturator canal. Rectangular periosteal flaps above and below the horizontal line was raised. In the subperiosteal plane, curved hemostats encircled the SPR that were divided using a bone drill. On the medial aspect of ischial tuberosity, a notch was created as hinge using a bone drill. Forks of bone holding forceps hooked the pubic bone and tightened for its midline approximation, lengthening of the SPR and inward rotation of IP ramus. Linea alba and pubic bones were approximated with interrupted Polygalactin sutures. RESULTS: Midline approximation of pubic bone and linea alba was possible in all. There was no injury to obturator nerve, vessels, or other structures . CONCLUSIONS: IP osteotomy is the safe and effective technique of pelvic ring closure in patients with specific pelvic configuration.

Spontaneous common hepatic duct perforation in a child: A rare case report.

Spontaneous perforation of common bile duct is a rare phenomenon; few cases are reported in literature. Hence, there is a dilemma for the management of these cases, but with modern radiological equipment and high degree of suspicion, it is possible to diagnose early. The overall prognosis of this condition is good, provided an early surgical intervention is instituted; we are reporting a case of a 6-year-old male with spontaneous perforation of common hepatic duct. Managed by repair of rent over T-tube, postoperative period was uneventful, T-tube was removed after 3 weeks, and the patient is doing well in follow-up.

Lipoencephalocele in a Child: An Uncommon Swelling in the Occipital Region.

Neural tube defects are common congenital malformations of the central nervous system. The 3 most common neural tube defects are anencephaly, myelomeningocele, and encephalocele. Lipoencephalocele is an extremely uncommon entity with sporadic reports in the literature. We treated a 4-year-old gild with occipital lipoencephalocele. This report presents the clinical presentation and management of the patient along with a review of the relevant literature.

Surgical anatomy of the penis in hypospadias: magnetic resonance imaging study of the tissue planes, vessels, and collaterals.

OBJECTIVE: To report the surgical anatomy of the penis in hypospadias with study of vessels in relation to fascial planes, glans, corpora cavernosa, and corpus spongiosum using magnetic resonance imaging. MATERIALS AND METHODS: Twelve hypospadias presenting at older age (8-20 years) were studied with 1.5-T magnetic resonance imaging scanner and a 3-inch surface coil. Precontrast and postcontrast images were acquired using fast-spin echo sequences in sagittal, coronal, and transverse planes. The findings were processed in Volume Share 4.5, version Workstation, of General Electric Healthcare. Anatomic findings were verified during surgery. With imaging and surgical findings, a 3-dimensional conceptual diagram of surgical anatomy was created. RESULTS: Distinct layers of the skin, dartos fascia, Buck fascia, tunica albuginea, glans urothelium, lamina propria of glans, and corpus spongiosum were delineated with their spatial relationship. Axial pattern vessels of the dartos and its anastomosis with branches of dorsal penile vessels at the coronal sulcus, perforators along the corpus spongiosum, subglanular extension of the fascia, and intraglanular branches of the dorsal penile artery forming an arcade were visualized. CONCLUSION: Dorsomedial and dorsolateral axial pattern vessels are present in penile dartos with relative avascularity at dorsal midline in most cases. Subglanular extension of Buck fascia fused with the basal lamina propria of glans forms a barrier between the tip of corpora and the intraglanular arcade of vessels. Collaterals are present at coronal sulcus, along the bifurcated corpus spongiosum, and the dartos enabling blood flow between the terminal most branches of the external and internal pudendal vessels.