Laparoscopic peritoneal dialysis catheter insertion with omentopexy-sparing the omentum in children.

INTRODUCTION: Continuous ambulatory peritoneal dialysis is an important modality of renal replacement therapy in children. Catheter dysfunction (commonly obstruction) is a major cause of morbidity and is a significant concern that hampers renal replacement therapy. As omentum is a significant cause of obstruction, some recommend routine omentectomy during insertion of the peritoneal dialysis catheter. Omentopexy rather than omentectomy has been described in adults to spare the omentum as it may be needed as a spare part in many conditions. Laparoscopic approach is commonly preferred as it provides global evaluation of the peritoneal space, proper location of the catheteral end in the pelvis and lesser morbidity due to inherent minimally invasive nature. AIM: The aim of this study is to present the technique of laparoscopic peritoneal dialysis catheter placement in children with concurrent omentopexy. METHODS: We retrospectively evaluated our patients who underwent laparoscopic placement of peritoneal dialysis catheter with concomitant omentopexy or omentectomy. RESULTS: A total of 30 patients were enrolled who received either omentectomy (n = 18) or omentopexy (n = 12). Four catheters were lost in the omentopexy group (33%) and 3 in the omentectomy group (17%), but none were related to omental obstruction. Three out of 4 patients in the omentopexy group and 2 out of 3 patients in the omentectomy group had a previous abdominal operation as a potential cause of catheter loss. Previous history of abdominal surgery was present in 6 patients (50%) in the omentopexy group and 3 patients (17%) in the omentectomy group. CONCLUSIONS: As omentum was associated with catheter failure, omentectomy is commonly recommended. Alternatively, omentopexy can be preferred in children to spare an organ that may potentially be necessary for many surgical reconstructive procedures in the future. Laparoscopic peritoneal dialysis catheter placement with concomitant omentopexy appears as a feasable and reproducible technique. Although the catheter loss seems to be higher in the omentopexy group, none was related with the omentopexy procedure and may be related to the higher rate of history of previous abdominal operations in this group.

I Thought I Saw a Retrocaval Ureter; Don't Bite the Fish-Hook Sign So Easily.

Background: During the management of patients with hydronephrosis, a possibility of retrocaval ureter (RCU) may emerge indicated by a fish-hook sign or its mimickers. Owing to infrequent incidence, the proper way to diagnose or exclude an RCU is challenging and has not been discussed previously. Methods: The aim of this study was to retrospectively evaluate the children who were suspected to have an RCU during management for urinary tract dilation. An RCU may be missed or misdiagnosed owing to rare incidence. Results: The children with urinary tract dilation in whom RCU was considered are enrolled in the study (n = 13). The demographics of the patients, findings suggesting RCU, evaluation process, management, and final diagnosis are retrospectively evaluated. The final diagnosis of the patients was RCU (n = 4), ureteropelvic junction obstruction (UPJO) (n = 7), and duplicated collecting system (n = 2). An RCU was confirmed or excluded by ultrasonography (US) while there was a stent in the ureter in 6 patients and by laparoscopic exploration in the other 7 patients. Four underwent correction for RCU, 7 for UPJO, 1 for reflux, and 1 ureterocele puncture. Conclusion: The fish-hook sign is a rare conflicting radiological finding that can be encountered in imaging studies. This uncommon finding needs confirmation or exclusion of a possible RCU as missed cases manifested after failed pyeloplasty or ureteroneocystostomy were reported. Radiological evaluation (by US or cross-sectional studies) while there is a stent in the ureter is the most satisfactory radiological technique to confirm or exclude an RCU. Alternatively, being aware of a possible RCU and performing a more extensive dissection may be necessary during surgery to confirm or exclude it. If available, laparoscopy may provide this goal in a minimally invasive manner with superior visualization.

Skipping the cord during laparoscopic percutaneous internal ring suturing in children, is it reasonable?

BACKGROUND: As a minimally invasive procedure, laparoscopic inguinal hernia repair in children was introduced. Percutaneous internal ring suturing (PIRS) is a popular technique. The main concern is that the spermatic cord will be trapped and/or the vasculature of the testes will be damaged in boys. This can be avoided by performing a careful dissection or by skipping the peritoneum over the cord and/or the vessels. The aim of the study was to compare the incidence of recurrence or complication (e.g. hydrocele) in children with skipped peritoneum on the cord and/or vessels compared to those without skipped peritoneum during laparoscopic PIRS repair. METHODS: The charts of children who underwent laparoscopic PIRS repair for inguinal hernia between 2017 and 2021 were analyzed. Complications and recurrence were assessed. The video recordings were viewed, and data on skipping (group 1) or not skipping (group 2) the peritoneum on vas deferens was recorded. The rates of recurrence and complications were compared between groups. RESULTS: There were 101 boys with a total of 125 inguinal hernias in the study. There were 45 right-sided hernias, 32 had left-sided hernias, and 24 had bilateral hernias. According to the video investigation, there were 63 hernias in group 1 and 62 hernias in group 2. In each group, there were two recurrences (3% for both groups). There were no other postoperative complications. CONCLUSIONS: To avoid spermatic cord or vessel damage, skipping the cord appears to be an acceptable path that does not appear to increase recurrence or complication rates while also ensuring the safety of spermatic structures.

Direct ligation of the internal ring incorporating the medial umbilical ligament (DIRIM): a new modification for laparoscopic percutaneous inguinal hernia repair in children.

OBJECTIVE: Laparoscopic hernia repair has not gained widespread acceptance. Relatively high recurrence rate is a major cause. To reduce recurrence, we report a novel modification of laparoscopic percutaneous inguinal hernia repair in children by a retrospective cohort study. MATERIAL AND METHODS: Between February 2020 and August 2021, children who underwent a laparoscopic percutaneous inguinal hernia repair with our modified technique were retrospectively evaluated. In our modification, we included the medial inguinal ligament in the Direct ligation of the internal ring incorporating the medial umbilical ligament (DIRIM): a new modification for laparoscopic percutaneous inguinal hernia repair in children. By doing so, the medial ligament is expected to act like a flep that reinforces the repair and prevent the peritoneal shearing and migration of the ligature. RESULTS: In total, 35 children were enrolled in the study with 23 boys and 12 girls. Right inguinal hernia (n = 23) was more common than left hernia (n = 10), while bilateral cases (n = 2) were less common. The median age of the patients was 38 months and median operative time was 30 min. An extraperitoneal hematoma was encountered in one patient that did not affect the postoperative course. No other intraoperative complication was encountered. No recurrence was observed during a median follow-up of 1 month. CONCLUSIONS: Our modification of laparoscopic percutaneous hernia repair is a simple and reproducible technique that may have a place in the armamentarium of a pediatric surgeons. LEVEL OF EVIDENCE: IV.

Ultrasound-guided hydrostatic reduction of ileo-colic intussusception in childhood: first-line management for both primary and recurrent cases.

OBJECTIVE: To evaluate the results of ultrasonography-guided hydrostatic reduction in primary and recurrent ileo-colic intussusception in children. METHODS: The children (<18 years of age) who were managed for ileo-colic intussusception between January 2015 and December 2018 were evaluated retrospectively. Age, gender, presenting complaints, length of the intussuscepted segment, presence of lead point, treatment modalities, recurrence rates and duration of recurrence were evaluated. RESULTS: 108 patients with ileo-colic intussusception were enrolled in the study; 59 were male and 49 were female with a mean age of 2.04 ± 1.71 years. Two patients underwent immediate surgery without any attempt of hydrostatic reduction. Nineteen patients (18%) were managed by conservative measures initially. Seventeen (89.5%) of them have recovered with expectant management and two patients required hydrostatic enema reduction during follow-up. In total, 89 patients underwent hydrostatic reduction; 48 were male and 41were female with a mean age of 1.9 ± 1.65 years. Twelve patients (13.5%) received surgery after failed hydrostatic reduction. In the patients with successful hydrostatic reduction, one more episode of intussusception is seen in 10 patients (13%) and 2 additional episodes in 2 (2.6%). Seven patients with relapse were male and 5 were female with a mean age of 1.16 ± 1.64 years. The median duration of the first relapse episode was 67.5 days (range 18-110 days). The ultrasound-guided hydrostatic reduction was also successful in patients with recurrence. CONCLUSION: Ultrasound-guided hydrostatic reduction is a non-invasive treatment of ileo-colic intussusception with high success rates in childhood. It can be performed safely in both initial and relapse episodes of intussusception.

Comparing Different Techniques in Children With or Without a Simultaneous Fundoplication: Does the Gastrostomy Technique Matter?

Purpose: To evaluate the results of different gastrostomy techniques and the impact of simultaneous fundoplication. Materials and Methods: The patients who underwent a gastrostomy procedure between 2009 and 2019 in a single tertiary center were evaluated retrospectively. The patients are divided into groups depending on the gastrostomy techniques as open gastrostomy (OG), laparoscopic gastrostomy (LG), percutaneous endoscopic gastrostomy (PEG), and laparoscopy-assisted PEG (LAPEG). Preoperative characteristics and postoperative outcomes are compared among the groups. Results: Two hundred forty-four patients (75, 60, 91, and 18 patients in OG, LG, PEG, and LAPEG groups, respectively) are enrolled in the study. Although rates of minor or major complications did not demonstrate a significant difference among the groups, no major complications were encountered in the LAPEG group, while the lowest minor complications were observed in the PEG group (P > .05). Length of postoperative initiation of enteral feeding and length of hospital stay (LOS) were highest in the OG group (P = .000). Performing a concurrent fundoplication procedure significantly delayed the initiation of enteral feeding and increased the LOS in all of the groups (P < .005). Conclusions: Although PEG is a safe and reproducible technique of gastrostomy in selected patients, LAPEG may expand the boundaries of PEG by reducing the major complication rates. Although simultaneous fundoplication may complicate the perioperative period, it does not have significance on outcomes.

Comparison of Open Repair and Laparoscopic Percutaneous Internal Ring Suturing Method in Repairing Inguinal Hernia in Children.

Introduction An inguinal indirect hernia is one of the most frequent surgical conditions in children. In this study the experience with laparoscopic percutaneous internal ring suturing (PIRS) and open inguinal hernia surgery and their relations evaluated. Methods All children over 90 days of age and without having prior inguinal region surgery with a diagnosis of indirect inguinal hernia underwent surgical repair with open or laparoscopic PIRS technique. Patients' gender, age at surgery, inguinal hernias side, surgery duration, recurrence, complications, and follow-ups were collected. Results A total of 488 inguinal hernias of 405 patients were repaired. The diagnoses were unilateral inguinal hernia in 360 (88.9%) and it was bilateral in 33 (8.1%) patients. The operative technique was laparoscopic PIRS for 227 and open inguinal hernia surgery for 178 patients. In the PIRS group, a contralateral hernia was found in 48 of 205 children (23.4%). The surgery times were 23.3 (PIRS) and 33.7 (open) min for unilateral and 28 (PIRS) and 53.1 (open) min on average for bilateral inguinal hernia surgery. Mean follow-up was 30.4 months for PIRS and 24.4 months for open technique. Recurrence was observed in seven (3%) patients in PIRS and one (0.5%) in the open group and postoperative complications in three (1.3%) in PIRS and four (2.2%) in the open group. Conclusion PIRS method has the advantage to evaluate contralateral hernia at the same session, minimal scar related to surgery, and preserve the spermatic cord from manipulation. PIRS is an alternative feasible method and easy to perform to repair the inguinal hernia with/without communicating hydrocele in children.

Ultrasonography-guided hydrostatic reduction of ileocolic intussusception in childhood: First-line option for management of primary and recurrent cases.

OBJECTIVE: To evaluate the results of ultrasonography-guided hydrostatic reduction in primary and recurrent ileo-colic intussusception in children. METHODS: The children (<18 years of age) who were managed for ileocolic intussusception between January 2015 and December 2018 were evaluated retrospectively. Age, gender, presenting complaints, length of the intussuscepted segment, presence of leading point, treatment modalities, recurrence rates and duration of recurrence were evaluated. RESULTS: 108 patients with ileocolic intussusception were enrolled in the study; 59 were male and 49 were female with a mean age of 2.04 ± 1.71 years. Two patients underwent immediate surgery without any attempt of hydrostatic reduction. Nineteen patients (18%) were managed by conservative measures initially. Seventeen (89.5%) of them have recovered with expectant management and two patients required hydrostatic enema reduction during follow-up. In total, 89 patients underwent hydrostatic reduction; 48 were male and 41were female with a mean age of 1.9 ± 1.65 years. Twelve patients (13.5%) received surgery after failed hydrostatic reduction. In the patients with successful hydrostatic reduction, one more episode of intussusception is seen in 10 patients (13%) and 2 additional episodes in 2 (2.6%). Seven patients with relapse were male and 5 were female with a mean age of 1.16 ± 1.64 years. The median duration of the first relapse episode was 67.5 days (range;18-110 days). The ultrasound-guided hydrostatic reduction was also successful in patients with recurrence. CONCLUSION: Ultrasound-guided hydrostatic reduction is a non-invasive treatment of ileocolic intussusception with high success rates in childhood. It can be performed safely in both initial and relapse episodes of intussusception.

Ureteral reimplantation aligned laparoscopically: Pneumovesicoscopic Politano-Leadbetter reimplantation in children.

INTRODUCTION: Ureteroneocsytostomy is a well-established procedure for correction of certain ureterovesical conditions like vesicoureteral reflux and ureterevesical obstruction. Amazing developments in technology paved the way for minimally invasive surgery and conventional procedures are increasingly being performed minimal invasively during the recent decades. Although Politano-Leadbetter ureteroneocystostomy is an anatomical repair, lost its popularity against Cohen's technique as it is more challenging to perform and requires extravesical dissection which may increase the complication rates. OBJECTIVE: In this study, we evaluated our results and feasibility of laparoscopic intravesical (pneumovesicoscopic) repair of certain ureterovesical conditions by Politano-Leadbetter principle in children. STUDY DESIGN: Twenty one children who underwent pneumovesicoscopic uretero-neocystostomy are enrolled in the study. Surgical procedure is described and surgical duration, complications, conversion rate and success rates are evaluated. RESULTS: Fourteen (67%) of the patients were girls and 7 were boys (33%). Median age at operation was 6 years (1.5-15 years). Main indications for surgery were vesicoureteral reflux, megaureter and bladder diverticulum. Fourteen of the patients underwent bilateral (67%) intervention while the 5 left (24%) and 2 right (9%). Four patients were converted to open surgery (16%; 4/25). Median surgical duration was 265 min (190-320 min) for bilateral and 180 min (115-260 min) for unilateral procedures. Success rates confirmed by a contrast study were 92% for VUR. DISCUSSION: It appears that minimally invasive intravesical surgery fails to keep up with the other minimally invasive procedures secondary to restricted working field in the bladder, technically demanding procedures and well-documented high succes rates of open counterpart techniques. Although developing relatively slower, minimally invasive technology offers better vision, better cosmesis, lesser pain and lesser tissue disturbance. Although cross-trigonal reimplantation is the most popular technique, Politano-Leadbetter technique provides an anatomical alignment of ureters and is a good option for caudally located ectopic ureters. In our study, pneumovesicoscopic approach provided anatomical reimplantation, identification and sparing of vas deferens and better cosmesis. Major limitations of our study are the limited number of cases, longer operation times, higher complication rates and short follow up duration which we hope to improve with increasing experience. CONCLUSION: Although not brilliant as its open counterpart yet, initial results of pneumovesicoscopic reimplantation with Politano-Leadbetter technique is promising and growing experience would further improve the results and lower the complication and conversion rates.

Gastric duplication cyst in an infant with Finnish-type congenital nephrotic syndrome: concurrence or coincidence?

Congenital nephrotic syndrome (CNS) is a rare disorder characterized by massive proteinuria and marked edema manifesting in utero or during the first 3 months of life. CNS can be caused by congenital infections, allo-immune maternal disease or due to the genetic defects of podocyte proteins most commonly NPHS1. Here we present a case of Finnish-type congenital nephrotic syndrome along with feeding problems and abdominal distention which was diagnosed during follow-up as a gastric-duplication cyst with a novel mutation in the nephrin gene. CNS feeding problems are attributed mainly to primary disease but in literature there are case reports of patients with CNS and hypertrophic pyloric stenosis. NPHS1 is also expressed in the stomach tissue. Physicians should be aware of this rare extra-renal manifestation or coincidence of this rare disease.

Comparison of laparoscopic percutaneous internal ring suturing method and open inguinal hernia repair in children under 3 months of age.

OBJECTIVES: Laparoscopic inguinal hernia repair in younger infants has not been completely accepted worldwide. The aim of this study was to evaluate the safety and feasiblity of laparoscopic percutaneous internal ring suturing method in children aged younger than 3 months and compare the recurrence and complication rates with open repair; which may still be mentioned as the gold standard procedure. MATERIAL AND METHODS: A total of 387 children underwent inguinal hernia repair in the clinic between 2016 and 2019. One hundred and forty of them were under 3 months old and divided into two groups; children who underwent laparoscopic percutaneous internal ring suturing (Group 1) and open surgery (Group 2). Selection of the surgical method was regardless of weight, sex or any patient characteristics other than surgeon's choice. Operation durations, complications and recurrences were compared between the two groups. RESULTS: A total of 140 patients underwent surgery due to inguinal hernia. Group 1 included 85 and Group 2 included 55 children. There were two recurrences in each group (p> 0.05). Operative durations were shorter in Group 1 for both; unilateral and bilateral repairs (p <0.0001). There were no intraoperative complications in any group. There was one major postoperative complication in Group 2: iatrogenic undescended testis, and none was observed in Group 1. In the laparoscopic group, 47% of the children who were diagnosed to have unilateral hernia were revealed to have bilateral inguinal hernias (n= 31). CONCLUSION: Laparoscopic percutaneous internal ring suturing method seems favourable in terms of operative time. It also has the advantage of detecting contralateral patent processus vaginalis or asymptomatic contralateral inguinal hernia.

Sentinel nubbin: A potential pitfall in the management of undescended testis secondary to epididymo-testicular nonunion.

INTRODUCTION: Epididymal anomalies are common in boys with undescended testis. Epididymo-testicular non-union with a nubbin in the scrotum is a rare anomaly and may be confusing during management of cryptorchidism. The non-fused epididymis and vas deferens which are descended to the scrotum, may be regarded as nubbin tissue secondary to testicular atrophy and proximal testis may be overlooked. OBJECTIVE: To evaluate a relatively rare anomaly of epididymo-testicular non-union in which vas deferens and epididymis are descended to the scrotum resembling a nubbin tissue, while a separate testis remains in a proximal peritoneal fold (hernia or processus vaginalis)which could potentially be missed during the management of patients with undescended testis. STUDY DESIGN: The charts of the fourteen patients with epididymo-testicular non-union and a scrotal nubbin are retrospectively evaluated. RESULTS: Median age of the patiens was 1.5 years (0.5-12), 11 were left and 3 were right. No connection could be demonstrated between the testis and vaso-epididymal unit in any of the patients. Orchidopexy was performed in 13 patients while orchidectomy in1 patient. The scrotal nubbin tissue is excised in 4 patients and histological examination revealed sections of vas deferens and epididymis. One of the patients underwent inguinal exploration and orchidectomy for assumed testicular atrophy elsewhere but histological examination revealed vas deferens and epididymis without any sign suggesting an atrophic testis. An intrabdominal testis was found incidentally in this patient and he underwent 2 additional procedures for orchidopexy. DISCUSSION: Although epididymo-testicular anomalies are common in boys with undescended testis, nonunion is the rarest type of this anomaly. Similar cases are reported in the literature as simple fusion anomalies with indefinite clinical significance or even polyorchidism although no accessory testis could be demonstrated. However, the scrotal nubbin tissue which actually contains epididymis and vas is a potential decoy and may result in missing of the proximal testis if regarded as a sign of testicular atrophy and further evaluation is obviated. As this is retrospective study, actual incidence of the condition is yet to be determined. CONCLUSION: A scrotal nubbin tissue may be secondary to epididymo-testicular nonunion as well as testicular atrophy. As feasibility of radiological imaging studies are limited, a laparoscopic exploration may be considered to confirm or to exclude a separate testis in patients with scrotal nubbin. Prospective studies are needed to evaluate the actual incidence of the condition and gain-loss analysis of laparoscopic exploration.

Management of perinatal testicular torsion: experience of two tertiary centers.

PURPOSE: Perinatal testicular torsion is a rare condition in which testicular salvage rates are significantly low and management is controversial. We retrospectively evaluated our patients and aimed to go through our management approach. METHODS: The newborn patients who underwent surgery for testicular torsion in two tertiary referral centers between 2000 and 2019 are enrolled. Radiological and clinical findings are retrospectively evaluated. RESULTS: Thirty-two newborns are enrolled in the study. All of the cases were unilateral and 30 ended up with immediate orchidectomy while 2 received orchidopexy but both underwent atrophy on follow-up. No bilateral torsion is demonstrated neither in 16 patients with bilateral exploration nor in the follow up of the rest 16 with unilateral exploration. Intravaginal torsion was encountered in five patients (16%). No morbidity or mortality related to anesthesia is documented. No malignancy is encountered in any of the patients. CONCLUSION: Although ipsilateral testicular salvage rates are low, urgent bilateral exploration in a multidisciplinary center seems reasonable to give a chance to the ipsilateral testis and to avoid the rare but catastrophic bilateral torsion, after discussing with the family.

A Novel Technique for Bladder Wall Fixation in Pneumovesicoscopic Surgery: T-Bar.

Background: As a relatively new approach, popularity of pneumovesicoscopic surgery is increasing, but slower than expected due to complex nature of the procedure with efforts to overcome the difficult steps of the procedure. Bladder fixation is one of the crucial steps of the procedure. In this study, we present a novel and simple T-bar technique to overcome this difficulty. Methods: We retrospectively evaluated 24 consecutive patients (39 ureters) who underwent pneumovesicoscopic surgery with fixation of the bladder wall between December 2017 and September 2019. Results: Fixation by transabdominal suture (TS) was performed in 3 patients, while fixation by thread loops with needle in 3 and T-bar device in 18. Tearing of the bladder wall was encountered in 2 patients in TS, in 2 patients with thread loop groups, but none in the T-bar group. Conversion to open surgery was necessary in 3 patients in the T-bar group, but only 1 was related with the fixation technique. Conclusions: T-bar technique is an inexpensive and simple solution providing stable and reliable bladder wall and working port fixation during pneumovesicoscopy.

Laparoscopic Nephron-sparing Surgery for Metanephric Adenoma in Children: A Report of 2 Cases.

Metanephric adenoma (MA) is an epithelial benign tumor of the kidney and very rare in children. Here we present 2 cases of MA treated by laparoscopic nephron-sparing surgery in children. To the best of our knowledge, we report the first cases of laparoscopic nephron-sparing surgery for MA in children.

The characteristics and outcomes of penetrating thoracic and abdominal trauma among children.

PURPOSE: Trauma is the most important etiology of morbidity and mortality among children. Penetrating injuries to the thorax and abdomen are extremely rare in children. In the present study, we compared the characteristics of patients, management, and outcomes of penetrating thoracic and abdominal trauma in children. MATERIALS AND METHODS: Data from children who were hospitalized for penetrating injuries of the thorax and abdomen from 2006 to 2012 were evaluated retrospectively. These injuries were evaluated with respect to patient details, clinical presentation, circumstances of trauma, management, and outcomes. RESULTS: Eighty-four patients were hospitalized for penetrating injuries to the thorax and abdomen. The mean age was 10.3 ± 3.79 years. Patient injuries comprised 26 gunshots injuries and 58 stabbing injuries. Thirty-one patients were wounded in the thorax, 43 were wounded in the abdomen, and 10 were wounded in both the thorax and abdomen. Thirty-one patients had undergone surgical interventions, while the other 53 were managed conservatively. The mean hospital stay was 4.41 ± 6.84 days. CONCLUSIONS: The incidences of penetrating abdominal and thoracic trauma did not differ significantly. Penetrating injuries may be successfully managed by conservative therapy.

Complete urogenital nonunion.

A 7.5-year-old boy was admitted to our department with left undescended testis. On surgical exploration, the vas deferens and epididymis were normal in appearance in its route to the scrotum, but no obvious testis or testis-like structure was identified. Exploration was extended to the abdominal cavity via the processus vaginalis, and the testis was found near the sigmoid colon without any connection to the vas deferens and epididymis. The testis was freed from surrounding structures preserving the testicular vasculature, and an orchidopexy was performed. In cases of nonpalpable testis with the vas deferens and epididymis reaching to the scrotum, an intra-abdominal testis owing to a nonunion phenomenon must be considered, and extended exploration should be performed.

Partial duplication of vas deferens: How important is it?

This study reports a 1-year-old boy with unilateral partial duplication of vas deferens, diagnosed during surgery for undescended testis. Pediatric surgeons need to be aware of this kind of anomaly in order to avoid injury to this vital structure.