The degree to which the size and side of an inguinal hernia is predictive of a hernia on the other side.

BACKGROUND: The indication for contralateral exploration in patients with a unilateral inguinal hernia and the implications of a contralateral patent processus vaginalis have been the subject of much debate during recent decades. The aim of this study was to investigate whether the size and side of the hernial sac on the side of presentation are predictive for the operative appearance of the processus vaginalis/hernial sac on the contralateral side. METHODS: All primary herniotomies performed by the Christchurch-based paediatric surgical service were reviewed. Patients who developed a contralateral hernia after unilateral repair were identified. In a random subset of patients who had bilateral exploration for unilateral hernias, the size of the clinical hernial sac was plotted against the size of the contralateral patent processus vaginalis/hernial sac (when present) as assessed at the time of open surgery. RESULTS: Overall, 2,124 unique patients underwent herniotomies in the period reviewed, and 44 (3.8%) metachronous contralateral hernias were identified. Girls were not at greater risk than boys of developing a metachronous hernia. There was a positive correlation between the size of the clinical hernial sac and the size of the contralateral processus vaginalis/hernial sac. There was no significant relationship between the original presenting side and the development of a metachronous contralateral hernia. CONCLUSION: It is not possible to predict reliably which patients who present with a unilateral hernia would benefit from bilateral exploration, although the size of the hernia has a positive correlation with the size of the contralateral processus vaginalis/hernial sac. Those with "massive" hernias on the presenting side were more likely to have "large" contralateral hernial sacs, but how many of these would subsequently become symptomatic remains uncertain.

Familial parathyroid carcinoma in a child.

Familial hyperparathyroidism and parathyroid carcinoma are rare diseases. A case of parathyroid carcinoma in an 8-year-old girl whose mother had previously undergone parathyroidectomy for primary hyperparathyroidism is reported. Parathyroid carcinoma in a preadolescent child has not been described previously, and may have a familial basis.

The effect of the availability of laparoscopic techniques on the treatment of appendicitis in children.

The use of laparoscopic surgery for acute appendicitis (AA) in children has increased over recent years. The aim of this study was to determine what effect the availability of laparoscopic appendicectomy (LA) has had on children admitted with suspected AA. A retrospective review of children admitted between January 1994 and June 1999 inclusive who underwent appendicectomy for suspected AA was conducted. Data recorded included standard demographic information, surgical approach, histopathology of the appendix, complications, and post-operative length of stay. After LA, children had a shorter post-operative stay, although the technique was used less frequently in advanced disease. The rate of normal histology was higher for LA. Laparoscopic surgery was performed in females in 69% of whom 48% had a normal appendix removed. The duration of surgery was longer for LA (59 vs 40 min). The rate of LA increased to 77% in the first 6 months of 1999. There was a decrease in the proportion of laparoscopic procedures converted to open appendicectomy from 50 to 6% during the period reviewed. The ready availability of laparoscopy and increased confidence in its use has resulted in more children, especially females, with suspected AA undergoing laparoscopy. There was a corresponding higher rate of normal appendix removal in this group, but the overall rate of normal histology has not changed, suggesting that the laparoscopic approach is more likely to be employed where the clinical diagnosis is less certain, particularly in older girls.

Factors that influence length of stay after appendicectomy in children.

BACKGROUND: The length of hospital stay following appendicectomy in children at Christchurch Hospital has decreased in recent years. The aim of the present study was to identify those factors that contributed to this change. METHODS: A retrospective review of children admitted to Christchurch Hospital between 1994 and 1998 inclusive who underwent appendicectomy for suspected appendicitis was conducted. Data recorded included standard demographic information, symptom duration, operative details, analgesia, antibiotics, pathology, complications and postoperative length of stay (LOS). RESULTS: Postoperative LOS decreased significantly during the period reviewed across all degrees of appendiceal inflammation, from a mean of 70.5 to 50.1 h. The main determinant of postoperative hospital stay was the severity of the appendiceal inflammatory process. Other factors that influenced LOS included surgical approach (open vs. laparoscopic), use of intra-operative local anaesthesia, type and mode of postoperative analgesia, and age of the child. Longer duration of antibiotic use and symptom duration of greater than 24 h were associated with a longer LOS, primarily as a reflection of the severity of inflammation of the appendix. Factors that appeared to have little or no influence included gender and the experience of the surgeon. CONCLUSION: The severity of the inflammatory process appeared to be the main determinant of postoperative hospital LOS; advanced appendicitis with abscess formation or peritonitis was associated with the longest LOS, irrespective of the surgical approach, although the LOS after appendicectomy was reduced by a laparoscopic approach. Intra-operative local anaesthesia during open appendicectomy reduced hospital stay, probably because it reduced the need for postoperative narcotics. Early diagnosis (< 24 h) was associated with a shorter postoperative LOS for acutely inflamed appendices.

Gastric perforation in infants with oesophageal atresia and distal tracheo-oesophageal fistula.

Gastric perforation (GP) is a well-recognised complication of oesophageal atresia (OA) with distal tracheo-oesophageal fistula (TOF), and is usually associated with extreme prematurity, hyaline membrane disease, and the requirement for assisted ventilation. The presentation is sudden, and leads to further deterioration in respiratory function because of increasing abdominal distension from pneumoperitoneum and splinting of the diaphragm. Unrelieved, the infant becomes increasingly hypoxic and may die. A review of six infants with OA and distal TOF in whom GP occurred has enabled us to develop the following guidelines for the appropriate initial surgical management of this complication: (1) Needle paracentesis of the abdomen en route to surgery if the infant continues to deteriorate; (2) Urgent laparotomy to decompress the abdomen and to occlude the lower oesophagus with a catheter introduced through the GP; (3) Thoracotomy and division of the fistula; (4) Oesophageal anastomosis if the infant's condition improves sufficiently and the anatomy is favourable; and (5) Repair of the GP and formation of a gastrostomy.

Paediatric surgical training: a system that works.

BACKGROUND: Paediatric surgical trainees going through the system at the Royal Children's Hospital (RCH), Melbourne, have been impressed with the amount of time dedicated to postgraduate training compared with other institutions. They generally felt well prepared to sit for Fellowship examinations. We decided to look at the programme offered at the RCH and objectively assess the results. METHOD: A review was undertaken of the training system at the RCH. Opinions were sought from recent and current trainees and compared with trainees in other disciplines. Figures were obtained from the RACS Examinations Office with respect to pass rates at Fellowship examinations. RESULTS: The training programme is outlined in some detail. A total of 79% of candidates passed their FRACS in paediatric surgery while at the RCH since 1985, compared with 52% from all other institutions. CONCLUSIONS: A successful training programme requires a commitment to educate one's junior colleagues. Busy consultants can contribute actively by offering to teach and by encouraging their trainees to attend rounds and tutorials. The rewards are better-educated and well-rounded surgeons as well as, hopefully, a higher pass-rate at the Part 2 examination.

Perforation during gas reduction of intussusception.

Perforation during attempted gas-enema reduction of intussusception is more common than during a barium enema. In a review of 650 consecutive attempted gas enemas, perforation occurred in 7 infants (1.1%). Gross abdominal distension from the pneumoperitoneum may be rapid and cause splinting of the diaphragm, which leads to acute respiratory distress. This complication is readily recognised at the time of the gas enema, and may require immediate intervention by paracentesis using a 14-gauge needle. A review of 7 children with intussusception in whom perforation occurred revealed that all had radiologic evidence of bowel obstruction (air-fluid levels) prior to the enema, and the patients had had a relatively long history since the onset of symptoms. No perforation occurred during a delayed repeat enema reduction. Perforation during gas enema produces minimal peritoneal contamination. No pathological lesion at the lead point of the intussusception was identified in any of the children in whom perforation occurred.