Surgical technique for epigastric incisional hernia after omphalocele repair: bilateral modified composite flaps using the upper rectus abdominis muscle and the vertically inverted flap of the lower rectus abdominis fascia.

We present a patient who developed an incisional hernia, from epigastrium to umbilicus, after omphalocele repair. The hernia gradually enlarged to a 10 cm × 10 cm defect with significant rectus abdominis muscle diastasis at the costal arch attachment point. At 6 years of age, the abdominal wall defect in the umbilical region was closed using the components separation technique. For the muscle defect of the epigastric region, composite flaps were made by suturing together the flap of the upper rectus abdominis muscle, after peeling it away from the costal arch attachment point, and the vertically inverted flap of the lower rectus abdominis fascia, created with a U-shaped incision. The composite flaps from each side were reversed in the midline to bring them closer and then sutured; the abdominal wall and skin were then closed. Five months after surgery, the patient had no recurrent incisional hernia and no wound complications.

Surgical approach to three pediatric patients with ovarian tumors: laparoscopic excision using a specimen retrieval bag.

We report our experience with three pediatric patients with ovarian tumors who underwent laparoscopic excision using a specimen retrieval bag. Patient 1 was a 12-year-old girl with a left ovarian tumor. The tumor was laparoscopically placed in a specimen retrieval bag and removed through a suprapubic incision without content spillage. Patient 2 was a 14-year-old girl with a left ovarian tumor. The tumor was laparoscopically placed in a specimen retrieval bag. The contents of the tumor were aspirated, and the tumor was removed without content spillage. Patient 3 was a 13-year-old girl with bilateral large ovarian tumors. After releasing torsion of the left-sided mass, each tumor was laparoscopically placed in a specimen retrieval bag and excised. Peritoneal lavage was performed due to content spillage. The pathologic findings confirmed mature teratomas in all patients. All three girls have been doing well without evidence of chemical peritonitis or recurrence.

A case of traumatic rupture of the urinary bladder due to a fall from a chair-style ski lift.

We report our experience with an 8-year-old boy who incurred a traumatic rupture of the urinary bladder due to a fall from a chair-type ski lift. This boy felt like he needed to urinate before getting on the lift, but he did not do so. He was trembling from the sensation of needing to urinate and fell from the lift while it was at least 6 m in the air. He complained of abdominal pain, and on-site emergency physicians performed focused assessment with sonography for trauma, which showed fluid in the abdomen. He subsequently developed abdominal guarding. Enhanced abdominal computed tomography revealed a rupture of the urinary bladder. At laparotomy, two ruptures were seen along the dome of the bladder; the bladder wall was repaired in three layers. The patient was discharged with a cast on his foot for a fracture of the left heel bone on postoperative day 16.

A case of ultrashort-segment Hirschsprung's disease discovered after taking polyethylene glycol electrolyte solution for chronic constipation.

We report a case of ultrashort-segment Hirschsprung's disease (HD) involving a 4-year-old girl. She was born at 29 weeks gestation from a twin pregnancy. She weighed 1013 g. After birth, she received glycerin enemas and sodium picosulfate hydrate to facilitate defecation. She passed stool once every 4-5 days. When she was 4 years old, she was medicated with polyethylene glycol electrolyte solution. After she drank the solution twice, the abdomen distended rapidly without passage of stool. An abdominal X-ray showed a stored stool mass and a barium enema study revealed dilatation from the rectum to the sigmoid colon due to the stool mass. She underwent anorectal manometry and a rectal biopsy, and was suspected to have HD. She underwent a Soave endorectal pull-through with an oblique anastomosis. She passed stool 4-10 times a day for 6 months postoperatively, but the frequency of passing stool gradually deceased without medications.

A case of seat belt-induced small bowel rupture and Chance fracture accompanied by elevated serum amylase.

We report herein our experience with a 10-year-old girl who incurred injuries consistent with seat belt syndrome. The patient was involved in a low-speed motor vehicle accident while restrained in a three-point belt (shoulder and lap belts). She complained of abdominal pain and developed tenderness and abdominal guarding. On admission, enhanced computed tomography (CT) demonstrated a fluid collection in the pelvis and a fractured vertebra in the lumbar spine. The following day, her C-reactive protein and serum amylase levels were elevated and plain CT demonstrated free air in the left side of the abdominal cavity. A ruptured jejunum was detected on laparoscopy. The involved segment of intestine was resected and an end-to-end anastomosis performed. She had an uneventful post-operative course. On post-operative day 14, she was transferred to another facility to undergo therapy for her spinal fracture. After completing conservative therapy, she was discharged 5 weeks after the initial injury.

Abdominoperineal anoplasty with use of a rectal fistula as a substitute vagina in a cloacal malformation associated with absence of the vagina: short-term follow-up.

We report herein a patient with a cloacal malformation and an absent vagina. The patient underwent colostomy on Day 1 of life. At 7 months of age, fistulography of the cloaca showed a common channel >3 cm in length; a vagina was not visible. At the age of 11 months, the patient underwent abdominoperineal anoplasty with the repurposing of her rectal fistula as a substitute vagina. Intraoperative examination revealed a bicornuate uterus and bilateral ovaries. The rectum was resected 7 cm at the confluence of the cloaca. The colonic stump was pulled through a newly created anal canal and an anoplasty was performed. Two months after this procedure, the patient experienced anal prolapse. At the age of 17 months, she underwent partial urogenital mobilization and a modified Delorme operation, and 5 months later the colostomy was closed. At present, this patient is 3 years old and doing well.

Omphalomesenteric duct resection using an intraumbilical round incision or a transumbilical vertical incision: report of two cases.

We report our experience with two patients who underwent omphalomesenteric duct resection: one for a patent omphalomesenteric duct and the other for a Meckel diverticulum connected to the umbilicus by a fibrous cord. We used an intraumbilical round incision and a transumbilical vertical incision, respectively. The first patient was a neonate with a patent omphalomesenteric duct who appeared to have a small stoma after ligature of the umbilical cord. Contrast media, injected through a catheter inserted into the stoma, entered the lumen of the small bowel. The second patient was an infant with a Meckel diverticulum connected to the umbilicus by a fibrous cord. After bloody stool was noted, nuclear imaging using 99m technetium pertechnetate revealed a small, round area of intense tracer activity in the midabdomen, suggesting the presence of ectopic gastric mucosa. Using either an intraumbilical or a transumbilical incision is safe and provides good cosmesis.

Surgical approach and treatment for the orifice of a pyriform sinus fistula: a case report and literature review.

A 4-year-old girl underwent an open-neck surgical procedure for a recurrent pyriform sinus fistula (PSF). A catheter could not be inserted through the endoscope into the opening of the fistula. An open-neck surgical procedure with coring out of the fistula stained with a dye revealed that the fistula was missed near the upper lobe of the left thyroid. A guide wire was successfully inserted via the endoscope into the fistula, and the wire was gripped with forceps under fluoroscopic guidance and removed. As a modification of the surgical approach and treatment for the orifice of the PSF, a catheter was exchanged through the guide wire, and a nylon thread was passed into the catheter. The tip of the nylon thread from the oral side was fastened and fixed to a gauze ball. After removing the nylon thread, the orifice of the sinus fistula was recognized and sutured. She was discharged uneventfully and has done well without a postoperative recurrence for 12 months.

A case of peeping testis moving from the inguinal position into the abdomen.

We report herein a 14-month-old boy with a left-sided peeping testis. At the age of 1 month, the left testis was palpated between the inguinal canal and the scrotum. When he was 6 months old, ultrasonography showed the left testis in the inguinal canal. At the age of 13 months, the left testis was not palpable. At the age of 14 months, he underwent surgery for a planned inguinal orchidopexy with a preoperative diagnosis of an undescended testis. When the inguinal canal was opened, a patent processus vaginalis was observed and the testis was found inside the abdominal cavity. The patent processus vaginalis was closed, a dartos pouch was created and the testis was guided into the pouch and fixed to its wall. We describe a case of a peeping testis moving from the inguinal position into the abdomen.

Surgical strategy of urachal remnants in children.

A urachus is a vestigial tubular structure that connects the urinary bladder to the allantois during early embryonic development. Urachal remnants are classified as patent urachus, urachal sinus, urachal cyst, and urachal diverticulum. Ten patients with urachal remnants underwent surgery at our institution between 2015 and 2019. Six patients had a urachal sinus, and four had a urachal diverticulum. Two patients with urachal sinus underwent excision of the urachal remnant, from the umbilicus to the urinary bladder, using an umbilical approach. The other four patients with urachal sinus underwent laparoscopic surgery with excision of the urachal remnant, from the umbilicus to the urinary bladder. All patients with urachal diverticulum underwent open excision of the diverticulum through a Pfannenstiel incision. Pathologic examination of all urachal remnants showed no evidence of neoplasm and complete excision. All patients had an uneventful postoperative course and are doing well.

Ileus associated with mesenterium ileocolicum commune: two case reports and review of the literature.

Two cases of ileus associated with mesenterium ileocolicum commune are reported herein. Case 1 was a 6-year-old girl who was admitted with bilious vomiting and abdominal distension. Plain computed tomography (CT) suggested intestinal volvulus or intussusception. A barium enema revealed an incomplete obstruction or stricture. She underwent a laparotomy. The intra-operative findings revealed midgut volvulus associated with mesenterium ileocolicum commune with normal rotation of the intestine. The volvulus was 180 degrees of counter-clockwise torsion. Case 2 was a 3-year-old boy who was admitted with bilious vomiting. Enhanced CT suggested a duodenal obstruction. A barium meal revealed malrotation and it was difficult to insert an enteral feeding tube into the small intestine. He underwent a laparotomy, and the intra-operative findings revealed Ladd's bands associated with mesenterium ileocolicum commune and malrotation of the intestine. At present, both patients are doing well and there have been no recurrences.

Food protein-induced eosinophilic enteritis with intestinal stricture in a neonate: a case report and review of the literature.

The case of a 21-day-old boy with eosinophilic enteritis with intestinal stricture due to a food protein-induced allergy is reported herein. For the first 4 days of life, he was both breast-fed and formula-fed, after which he was exclusively breast-fed. At the age of 24 days, he underwent laparotomy to investigate the possibility of intestinal obstruction for bilious vomiting, and an ileal stricture was detected and resected. Pathologic analysis showed the presence of eosinophil accumulation in the lesions presented more than 20 eosinophils per high-power field and the eosinophils were oriented towards the epithelium and diffusely distributed throughout the tissue, but the margins of resection showed a few infiltration of eosinophiles. Allergen-specific lymphocyte stimulation testing showed a markedly increased lymphocyte response to lactoferrin. He was finally diagnosed as eosinophilic enteritis with intestinal stricture due to a food protein-induced allergy. The patient remained asymptomatic during a follow-up period of 12 months.

Food ileus secondary to citrus fruit associated with a Meckel's diverticulum: a case report and review of the literature.

The case of an 11-year-old boy with an orange-associated ileus in the setting of a mesodiverticular band from a Meckel's diverticulum is reported herein. Computed tomography showed a small bowel feces sign. He underwent laparoscopic-assisted surgery, and intraoperative findings revealed a Meckel's diverticulum associated with a mesodiverticular band distal to dilated small bowel. After resection of the Meckel's diverticulum and inspection of the intestinal contents proximal to the obstruction, it was apparent that undigested food material was impacted proximal to the obstruction. Upon questioning postoperatively, it was revealed that the patient ate two citrus fruits with locular membranes several days prior to his clinical presentation. It was speculated that the combination of the citrus fruit impaction with the Meckel's band led to his obstruction. He was discharged uneventfully on postoperative Day 13. It is important to avoid eating large quantities of fruit rich in fiber and also to masticate well.

An intrapancreatic accessory spleen presenting as a rapidly growing pancreatic mass after splenectomy in a patient with hereditary spherocytosis: a case report and literature review.

The case of a 16-year-old boy with an intrapancreatic accessory spleen presenting as a rapidly growing pancreatic mass after splenectomy for splenomegaly due to hereditary spherocytosis is reported herein. When he was 15 years old, the patient visited at a hospital due to jaundice and radiological examinations showed a huge spleen with a 2-cm mass near or in the pancreatic tail. Sonazoid-enhanced ultrasonography showed hypervascularity in the mass located near the pancreatic tail, which was suspicious for an accessory spleen. During splenectomy by laparotomy, the mass could not be found by inspection or intraoperative ultrasonography. One year after the splenectomy, the mass grew rapidly to 4 cm. Laparoscopic surgery was performed to aid in the differential diagnosis of the mass, and a laparoscopic ultrasonogram revealed that the mass was located in the pancreatic tail. The patient underwent laparoscopic distal pancreatectomy and was discharged uneventfully on the 11th postoperative day.

Unusual Differentiation to Pheochromocytoma-Like Cells in an Adrenal Neuroblastoma After Chemotherapy: A Case Report and Literature Review.

The authors present a case of 3-year-old female with Stage 4 neuroblastoma originating from the left adrenal gland. Biopsy of the left adrenal tumor showed neuroblastoma. After three courses of chemotherapy, the left adrenal gland including the left adrenal tumor was surgically removed. Pathological findings of the resected tumor revealed that most of the neuroblastoma tissues changed to pheochromocytoma-like cells. The tumor cells were arranged in well-defined nests surrounded by a delicate fibrovascular stroma and had granular eosinophilic cytoplasm, and round to oval nuclei. Immunohistological analysis of the biopsy samples showed strongly positive Ganglioside GD2-staining cells, whereas almost all of the tumor cells in the resected specimen were Ganglioside GD2-negative; cells were very weakly stained. The authors suggest that a part of the neuroblastoma in the left adrenal gland exhibited unusual differentiation toward pheochromocytic lineage Ganglioside GD2-negative neuroblastoma in a patient who had been treated with intensive chemotherapy.

Caudal appendage derived from a vestigial remnant of the tailgut.

The presence of smooth muscle at the basal portion of a caudal appendage is very rare. We report a 3-month-old girl in which a caudal appendage is associated with smooth muscle bundles at the perianal region. Immunohistochemistry was performed for NCAM (neural cell adhesion molecule) to identify smooth muscle. NCAM immunoreactivity was observed within the presumptive circular and/or longitudinal muscle layers of the muscularis propria. NCAM is expressed by smooth muscle during the early stages of human embryonic gut development, suggesting that the caudal appendage in the present case may be derived from a tailgut remnant.

Closure of a tracheocutaneous fistula by two hinged turnover skin flaps and a muscle flap: A case report.

INTRODUCTION: Tracheocutaneous fistula is a complication of tracheostomy. Tracheocutaneous fistulectomy followed by primary closure carries a high possibility of complications. PRESENTATION OF CASE: An 11-year-old boy underwent surgery to repair a tracheocutaneous fistula, using skin and muscle flaps. A vertical incision was made around the fistula and 3 skin flaps were prepared: 2 hinge flaps, and 1 to cover the skin defect (advanced flap). The 2 hinged turnover flaps were invaginated by multiple layered sutures, and a strap muscle flap was placed over the resulting tracheal closure. An advanced skin flap was used to cover the area of the previous defect. The patient was extubated immediately after surgery. He was discharged on the sixth postoperative day without tracheal leakage or subcutaneous emphysema. The patient is currently doing well, with no respiratory symptoms and no recurrence at the postoperative 5 months. DISCUSSION: Our technique is minimally invasive and has a low risk of lumen stenosis, other complications, or recurrence. CONCLUSION: This technique demonstrates the multiple-layered closure of a tracheocutaneous fistula, using skin flaps and a muscle flap.

Single-port laparoscopic repair of an epigastric hernia using an epidural needle.

INTRODUCTION: Epigastric hernia is a rare form of ventral hernia, occurring along the linea alba anywhere from the xiphoid process to the umbilicus. PRESENTATION OF CASE: We present the case of a 19-month-old boy with an epigastric hernia who underwent a single-port laparoscopic repair using an epidural needle. A nonabsorbable suture was threaded through an epidural needle, with one end of the suture threaded back through the needle tip to make a loop. The loop-shaped suture was left in the abdominal cavity through the rectus muscle at the site of the defect. Another suture was inserted into the looped suture through the opposite rectus muscle. The loop was pulled taut and the defect was closed by tying the suture extracorporeally with a subcutaneous knot. DISCUSSION: In epigastric hernia, the surgical technique involves overlapping muscle layers, and currently laparoscopic surgery is introduced to repair the hernia defect. Laparoscopy is a minimally invasive method of repairing epigastric hernias. CONCLUSION: The epidural needle proved a simple and cosmetically acceptable device with which to close the epigastric hernia defect.

Intrahepatic biliary ablation with pure ethanol: an experimental model of biliary atresia.

PURPOSE: We describe a new rat model of biliary atresia, induced by biliary ablation with pure ethanol. METHODS: A catheter was inserted and fixed in the common bile duct of male rats. Saline or pure ethanol was injected through the catheter and the animals were monitored for 8 weeks thereafter. We measured total bilirubin (T-Bil), aspartate aminotransferase (AST), alanine transaminase (ALT), and hyaluronic acid (HA) and examined liver biopsy specimens immunohistochemically for α-smooth muscle actin staining (α-SMA) and transforming growth factor-ß1 (TGF-ß1). RESULTS: The ethanol injection group animals were further divided into a temporary and a persistent liver dysfunction group. In the persistent group, T-Bil, AST, ALT and HA levels were significantly higher after 8 weeks in the persistent group than in the control group and the temporary group. In the ethanol injection group, α-SMA expression was prominent in the surrounding proliferative bile ducts and portal areas. The distribution of TGF-ß1 was found prominently in hepatocytes in the center of nodules and in ductular epithelial cells. CONCLUSIONS: This study characterizes the effects of ethanol-induced bile duct injury in rats, resulting in sclerosing cholangitis and its secondary effects. We believe that this experimental model will prove useful in the study of biliary atresia.