The versatility of the transumbilical approach for laparotomy in infants

Background/purpose Although the transumbilical approach became very popular for pyloromyotomy, it has not been widely used in other procedures in children. The aim of this work was to evaluate the safety and the versatility of this approach for laparotomy in infants.Patients and methods All hemodynamically stable neonates and infants with gastrointestinal surgical problems or pelvic or abdominal cystic masses were considered candidates for this approach. The umbilicus was incised nearly circumferentially, and the peritoneum was entered in the midline in a cephalic or caudal direction depending on the site of the lesion. The bowel or the mass was delivered outside the peritoneal cavity, and the procedure was completed in the standard open manner. Patients were evaluated with regard to the feasibility of the surgery and or any difficulty to complete the surgery, any complications related to the approach, and the cosmetic outcome.Results A total of 141 infants underwent transumbilicallaparotomy during the period from June 2008 to December  2013. The  primary pathology was hypertrophic pyloric stenosis (n= 65), duodenal, small-intestinal atresia/stricture (n =22), colonic atresia (n= 2), malrotation with/without volvulus (n= 10), ovarian cysts (n= 12), intussusception (n= 9), spontaneous intestinal   perforation (n =7), remnants of vitellointestinal duct (n =4), mesenteric cysts (n= 3), patent urachus (n= 3), postoperative  complications of strangulated inguinal hernia (n= 3), and complications in ventriculoperitoneal shunts (n= 1). Their age ranged  from 1 day to 22 months. The operating time ranged from 30 to 120 min. Three patients required transverse extension of the  wound. Two (1.4%) patients developed dehiscence of the wound that required wound closure. Five (3.5%) patients had superficial periumbilical cellulitis and wound infections, and one patient had suture reaction treated conservatively. Late complications  (adhesive intestinal obstruction) occurred in three (2%) patients. Parents were very satisfied with the final cosmetic outcome.Conclusion The transumbilical approach is both afeasible and a safe approach for a broad spectrum of  surgical procedures in neonates and infants. The cosmetic results are excellent.Keywords: abdominal masses, infants, laparotomy, transumbilical approac

Laparoscopy in the management of impalpable testis (Series of 64 Cases)

Background: The undescended testis represents one of the most common disorders of childhood. Laparoscopy has been widely used both in the diagnosis and treatment of non-palpable testis. In this study, we investigated and evaluated the usefulness of laparoscopy in the diagnosis and treatment of no palpable testis. Patients and Methods: From January 2003 to January 2008, we used laparoscopy in the management of 64 patients with 75 impalpable testes. Their ages varied from 1 to 15 years (median age = 4.6 years). The site and the size of the testes were localised by abdominopelvic ultrasonography in all 64 children for accurate diagnosis. One stage laparoscopic orchiopexy was performed in 26 testes, staged Fowler-Stephens orchiopexy was underwent in 17 testes, while laparoscopic orchidectomy was done in 5 testes. Follow-up by clinical examination and colour Doppler ultrasound was performed in every patient who underwent orchiopexy. Results: There were 11 patients with bilateral non-palpable testes. The overall diagnostic agreement of ultrasound with laparoscopy was seen in only 16 out of 75 testes (21.3%). The results of diagnostic laparoscopy were varied and showed various pathological. Conditions and positioned of the testes, such as 20 low intra-abdominal testes (26.6%), 17 testes were high intra-abdominal (22.7%), and 18 testes (24%) entered the inguinal canal. Associated inguinal hernia was present in 4 patients. After a mean follow-up period of 26 months (6 months – 5 years), all testes were in the bottom of the scrotum except 3 testes were retracted to the neck of the scrotum and atrophy of the testis occurred in 2 patients (2.7%). Conclusion: Laparoscopy has proven to be the only diagnostic modality where the findings provide a clear dependable direction for the definitive management of impalpable testes, so it allows an accurate diagnosis and definitive treatment in the same sitting

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially