Efficacy of laparoscopically assisted high ligation of patent processus vaginalis in children.

INTRODUCTION: Laparoscopic hernia repairs have been proven to be efficient and safe for children, despite the slightly higher recurrence rate compared with the classic surgical repair. They have the advantage of easy and precise identification of the type of defect and its correction, both in ipsilateral and contralateral sides. OBJECTIVES: The objectives of this study were to evaluate the efficacy, safety and outcome of the laparoscopically assisted piecemeal high ligation of a patent processus vaginalis (PPV) in children. METHODS: A total of 40 children were enrolled into this prospective study; they were aged ≥ 6 months and had an inguinal hernia. The peritoneal cavity, including the contralateral side, was inspected for the possibility of bilateral hernias using a 3-mm 30° telescope. Another 3-mm port was introduced through the same infra-umbilical incision. The hernia was manually reduced or with the aid of a working infra-umbilical grasper. A prolene or vicryl 2/0 or 3/0 suture on a curved semicircle round-bodied taper-ended 25-30 mm needle was introduced through a very small inguinal skin-crease incision. It was passed through the abdominal wall layers to the peritoneum and was manipulated by the laparoscopic grasper to pick up the peritoneum in piecemeal all around the internal ring. The needle was then pushed to the outside near to the entrance site, thus forming a semicircle around the internal ring. The suture was then tied and the knot was subcutaneously buried. The primary outcome of the procedure was the incidence of intraoperative diagnosis and surgical repair of contralateral hernias in pre-operatively diagnosed unilateral cases. The secondary outcomes were defined as the incidence of complications and hernia recurrence. DISCUSSION: The exploratory laparoscopy found contralateral patent processus vaginalis (CPPV) with a detection rate of 28.1%. Chan et al., Esposito et al., Toufique et al. and Niyogi et al. reported similar figures for laparoscopic contralateral hernia detection rates of 28%, 39%, 39.7% and 29.2%, respectively. The limitations of this study were the small sample size, plus the risk factors and clinical significance for CPPV. CONCLUSION: Laparascopically assisted piecemeal closure of the internal inguinal ring in children is a safe and effective procedure. It helps in detecting a contralateral hernia without prolonging the operative time.

Buccal versus lingual mucosal graft urethroplasty for complex hypospadias repair.

OBJECTIVES: To compare surgical outcomes and donor site complications of buccal and lingual mucosa used as ventral onlay graft for complex hypospadias cases. PATIENTS & METHODS: Forty four cases with complex hypospadias after failed previous surgery were prospectively included. All had severely scarred penile skin with reasonable residual urethral plate. Cases were categorized into two groups: Group I (23) where buccal mucosal graft [BMG] was used and group II (21) where lingual mucosal graft [LMG] was used. Donor site complications as well as functional and esthetic outcomes were recorded for each group. RESULTS: Mean follow up was 20.8 months (range 12-24). Average graft harvesting time was 24 min for BMG and 19 min for LMG. Donor site pain was reported with both techniques but recovery was earlier with LMG. Slurred speech and difficult tongue protrusion were reported with lingual but not buccal grafts; however mouth tightness, peri-oral numbness and persistent oral discomfort were reported only with buccal grafts. Successful urethroplasty was obtained in 78.2% of BMG compared to 76.1% of LMG. CONCLUSION: Surgical outcomes of LMG urethroplasty were comparable to those of BMG in complex hypospadias cases. Compared to buccal mucosa, LMG is easy to harvest, with minimal donor site complications.

Does tubularized incised plate urethroplasty fit primary and repeat shat hypospadias repair ?

Objective To evaluate prospectively our experience using tubularized incised plate (TIP) urethroplasty in primary and repeat penile shaft hypospadias. Patients and Methods Thirty-two boys with penile shaft hypospadias were selected to undergo TIP procedure. Their age ranged from 22 months to 9 years. Twenty-two cases were primary and 10 cases were repeat hypospadias repairs. To correct penile chordee; complete degloving of the penis and lateral dissection of tethering tissues was done in every case. This was followed by tunica albuginea plication in 7 cases; while ellipse excision was needed in 3 cases. Using the preserved urethral plate; single-layer urethroplasty was done in all cases. A vascularized subcutaneous flap (36 cases) or tunica vaginalis (4 cases) was always used to cover the neourethra. A postoperative stent was used for 8 - 12 days in all cases. Results The patients were followed up for a mean of 14.2 months. Postoperative clinical evaluation revealed success rates of 95.5and 90for primary and repeat cases; respectively. Among the primary cases; only one patient had urethro-cutaneous fistula concomitant with meatal stenosis; while among the repeat cases urethro-cutaneous fistula occurred in one patient. No case of urethral stricture or wound dehiscence was encountered. Our criteria for success were a single unimpeded forward-directed urine stream; a straight penis; good cosmesis and no need for further surgery. Conclusion We feel that TIP urethroplasty in primary and repeat cases of penile hypospadias is a reasonable option in cases with chordee not severe enough to necessitate excision of the urethral plate and when midline incision of the plate yields an adequate width amenable to tubularization