Role of Minimally Invasive Surgery in Management of Penetrating Abdominal Trauma in Children.

INTRODUCTION: Traditionally, exploratory laparotomy was used to treat penetrating abdominal trauma (PAT). At present, minimally invasive surgery (for diagnostic and therapeutic purposes) has developed and represents a rapidly evolving modality for dealing with PAT in stable children. In this article, we aim to present our experience, evaluate the effectiveness, and report the results of minimally invasive surgery (MIS) for PAT in stable pediatric patients. MATERIALS AND METHODS: This prospective study involved 117 hemodynamically stable pediatric cases of PAT (caused by gunshots, stab, and accidental stab), admitted, and managed according to the severity of injury. The information recorded for analysis included demographic data, the anatomical location of injury, the initial vital data and scoring systems, the organs affected, the procedures done, operative time, need for conversion to laparoscopic-assisted approach, length of hospital stay, complications, missed injury, and mortality rate. RESULTS: Among 117 pediatric patients with PAT, 15 cases were treated conservatively and 102 cases were managed by MIS. They were 70 males and 47 females with a mean age of 7.3 ± 0.6 years (range = 1-14 years). They included 48 cases of gunshot injury, 33 cases of abdominal stab, and 36 cases of accidental stab. Laparoscopy was diagnostic (DL) in 33.3% (n = 34) and therapeutic (TL) in 66.7% (n = 68) of cases. Of the 68 TL cases, we completely managed 59 cases (86.8%) by laparoscopy, while 9 cases (13.2%) were converted to limited laparotomy. The mean operative time was 17 ± 1 minutes (range = 12-25 minutes) for DL, 85 ± 9 minutes (range = 41-143 minutes) for complete TL cases, and 89 ± 3 minutes (range = 47-149 minutes) for laparoscopic-assisted procedures. For DL cases, the mean length of hospital stay was 2 ± 0.4 days, while for complete TL cases, it was 5.4 ± 0.83 days, and for laparoscopic-assisted cases, it was 5.8 ± 0.37 days. Postoperative complications occurred in eight cases (7.84%), with five cases (4.9%) required reintervention. No missed injury or mortality was recorded in the study. The patients were followed up for a median period of 52 months. CONCLUSION: For management of PAT in children, MIS has 100% accuracy in defining the injured organs with zero percent missed injuries.

Five years' experience of double faced tubularized preputial flap for penoscrotal hypospadias repair in pediatrics.

BACKGROUND: The success of techniques for proximal hypospadias repair using vascularized preputial flaps has led to their wide application for the last decade. From these techniques, transverse tubularized preputial flaps are particularly attractive. However, high reported rate of complications, including recurrence and urethro-cutaneous fistulae are still challenging the success of these techniques, probably related to vascular insufficiency for the lengthy neourethra. Therefore, many surgeons trying to improve the outcome by utilizing the unique vascular benefits of double faced preputial flap. AIM OF THE WORK: the present study tries" to evaluate double faced tubularized preputial flap technique for incidence of complications, in comparison with the standard ventral tubularized preputial flap, and to evaluate also surgical outcomes regarding the clinical urinary function and cosmetic results. PATIENT AND METHODS: This was a prospective controlled randomized study, included 160 patients with peno-scrotal hypospadias, conducted at Al-Azhar University hospitals, from January 2014 to January 2019. All patients submitted to one-stage repair. Eighty patients underwent double faced tubularized preputial flap technique (group A) and 80 patients underwent standard ventral preputial tubularized flap technique (group B). RESULTS: Different complications were reported in 12 patients (15%) in group A, compared to 20 patients (25%) in group B. The difference between the complication rates in both groups was statistically significant. 152 of 160 children (95%) had good clinical urinary functional outcomes (short micturition time, good urinary stream without straining or post voiding dribbling) and satisfactory cosmetic results obtained by parents' questioner at follow up visits. DISCUSSION: This article presents an evaluation of double faced tubularized preputial flap technique in comparison to standard ventral preputial tubularized flap technique (Duckett) in one-stage peno-scrotal hypospadias repair, regarding surgical outcomes, rate of complications, clinical urinary function and satisfactory cosmetic results. Double faced tubularized flap repair is a good option to reconstruct penoscrotal hypospadias after correction of chordee which have fewer complications and also shows that transferring the tube with its skin appears to achieve better ventral skin covering. CONCLUSION: Double faced tubularized preputial flap technique seems to be a superior option, that provide better vascular supply with better results when compared to standard ventral preputial tubularized flap in one-stage peno-scrotal hypospadias repair, with reported fewer complications, better urinary function and good cosmetic results.

Single-Incision Percutaneous Closure of Pediatric Inguinal Hernia: A New Modification for Intracorporeal Suture Knotting.

BACKGROUND: Single-incision percutaneous closure (SIPC) of pediatric inguinal hernia under laparoscopic guidance is a well-developed feasible technique; however, suture knotting remains a major challenge during this technique. Most laparoscopic surgeons prefer extracorporeal subcutaneous suture knotting, which may be associated with consequent formation of stitch sinus and increased recurrence rate. On the other hand, intracorporeal suture knotting necessitates the availability of special devices or homemade instruments with a long learning curve. Therefore, the present study innovates new and simple modification allowing intracorporeal suture knotting during SIPC of pediatric inguinal hernia that does not require any special operating devices or homemade instruments. Patients and Methods. Four-hundred children suffering from inguinal hernia of congenital type, submitted to SIPC using Epidural needle (EN), under laparoscopic guidance with intracorporeal suture knotting. RESULTS: Children ages were 6 months to 10 years (the range). There were 300 boys and 100 girls, and two-hundred children suffered from left side hernia, 150 with right-side hernia, and 50 children with both left- and right-side hernia. 10 ± 2.2 minutes was the recorded operation time in one side hernia repair, while 14 ± 4.3 minutes was recorded for both side repair. Postoperative results reported recurrent hernia in one child and postoperative hydrocele in 3 children which resolved spontaneously after 3 weeks of follow-up. CONCLUSION: Intracorporeal suture knotting during SIPC of pediatric inguinal hernia allows for the transformation of a formally extraperitoneal procedure to an intraperitoneal procedure. This new modification for intracorporeal suture knotting does not require any special operating devices or homemade instruments. It seems to be an attractive way during SIPC of pediatric inguinal hernia when intracorporeal suture knotting is considered.

Single-Port Needlescopic Appendectomy in Children Using a Mediflex Needle: A New Simplified Technique.

Background: Laparoscopic appendectomy is among the most common surgical procedures. Needlescopic appendectomy (NA) is an acceptable, safe technique in children, but with many drawbacks such as a high conversion rate and long operative time. We present a new technique for NA in children using only a single port, Mediflex® facial closure needle, and vascular access cannula (VAC). Patients and Methods: Single-port NA was attempted in 117 patients (51 boys, 66 girls). Under general anesthesia, a 5-mm camera port was inserted through the umbilicus. Two Mediflex needles and a 14-gauge VAC were introduced. The appendix was grasped and dissected from the surrounding tissues using Mediflex needles. In case of a mobile cecum, the appendix was pulled through the umbilical port, then an extracorporeal appendectomy was performed. In cases with a fixed cecum or severely inflamed appendix, a complete intracorporeal appendectomy was done. The suture was knotted in a sliding reef knot using a single instrument. Results: NA was completed in 117 patients (51 boys, 66 girls) with an average age of 10 years. Thirty patients underwent extracorporeal appendectomy. Eighty seven patients were treated by intracorporeal appendectomy. The mean operative time was 15 ± 3 and 25 ± 4 minutes for extracorporeal and intracorporeal appendectomy respectively. The hospital stay was 1.2 days on average (ranging 8 hours to 2 days). There was no single case of conversion. Family satisfaction was achieved in 97% of cases. Conclusion: The presented unique method for single-port NA using Mediflex® appears to be a safe, acceptable technique for appendectomy in children that allows for excellent cosmetic results.