Application of Mesh Plug Technique in The Repair of Difficult Cases of Recurrent Indirect Inguinal Hernia in Boys

Background/Purpose: The recurrence of indirect inguinal hernia vary from less than 0.5% to approximately 4%. Recurrence may be attributed to tearing of a friable sac, slipping of the ligature at the neck of the sac or failure to ligate the sac high at the internal ring. In boys, re-operations are difficult and require tedious and careful dissection of the dense fibrous tissue resulting from the earlier surgery. There are definite risks of damaging the vas deferens and testicular vessels. The aim of this study is to evaluate the feasibility and outcome of using the mesh plug technique in the repair of certain difficult cases of recurrent indirect inguinal hernia in male infants and children. Materials & Methods: This prospective study was carried out at the pediatric surgery unit, surgical department, Zagazig University Hospitals, Egypt during the period from April 2008 to September 2009. The study included 10 boys with recurrent indirect inguinal hernia. Patients were included in the study during the surgical procedure if they have one of the following inclusion criteria: marked adhesions and fibrosis surrounding the cord, distorted anatomy of the inguinal region and patulous internal ring Results: A total of 10 operations in 10 infants were performed. The patients age ranged from 3 months to 2 years with the mean age (12.1 months). All cases had severe adhesions surrounding the cord structure with marked distortion of the anatomy. Two cases had associated patulous internal ring. The operative time ranged from 20-30 minutes (mean 25 min). The follow- up period ranged from one month to 11 months (mean 5.8 months), during the follow-up period no major complications were noted. Conclusion: The application of mesh plug technique in the repair of difficult cases of recurrent indirect inguinal hernia in boys is easily applicable, safe and not expensive. Index Word: Laparoscopes, recurrent indirect inguinal hernia in children, mesh plug technique

Agent–host–environment model of blunt abdominal trauma in children: 5-year experience and preventive inferences in Zagazig University-Egypt

Background/Purpose Among children aged from 1 to 14 years, approximately 50% of mortality is related to trauma. Abdominal injuries account for approximately 10% of trauma deaths in childhood. Child injury has great effects on communities and countries. The agent–host– environment model has been used to describe the epidemiology of communicable diseases. It can be adapted for understanding childhood injuries. This study aims to evaluate the Zagazig University experience with blunt abdominal trauma (BAT) in children in light of the epidemiological (agent–host–environment) model.Patients and methods This study included 590 consecutive patients aged from 1 to 14 years, who were admitted to the Emergency Unit at the Zagazig University Hospital, after BAT incidents in the period January 2006–2010. A predesigned format was used to collect targeted data.Results The study included 590 children with BAT. They made up approximately 18% of total children trauma cases. Multisystem trauma occurred in 72.5% of patients. The causative energy in this study was mechanical energy that was most commonly transmitted through road traffic accidents (55.8%). When mechanisms of trauma were related to age groups, we found that road traffic accidents were significantly more common among children aged from 5 to 14 years (P value < 0.001), whereas falls were significantly more common among children aged from 1 to 4 years (P value < 0.001). The most common physical environment was streets. BAT was more in urban areas (65%) and in low socioeconomic states (67%).Conclusion According to this study, most BAT vulnerable children are boys aged from 5 to 14 years, living in urban areas, and with low socioeconomic status. The agent– host–environment model can be used to study causative and contributing factors to trauma. It can be utilized to structure and plan preventive interventions against BAT in children.Keywords: abdominal trauma, agent–host–environment model, blunttrauma, epidemiological mode

The Alvarado score for predicting acute appendicitis: a systematic review

Background: The Alvarado score can be used to stratify patients with symptoms of suspected appendicitis; the validity of the score in certain patient groups and at different cut points is still unclear. The aim of this study was to assess the discrimination (diagnostic accuracy) and calibration performance of the Alvarado score. Methods: A systematic search of validation studies in Medline, Embase, DARE and The Cochrane library was performed up to April 2011. We assessed the diagnostic accuracy of the score at the two cut-off points: score of 5 (1 to 4 vs. 5 to 10) and score of 7 (1 to 6 vs. 7 to 10). Calibration was analysed across low (1 to 4), intermediate (5 to 6) and high (7 to 10) risk strata. The analysis focused on three sub-groups: men, women and children. Results: Forty-two studies were included in the review. In terms of diagnostic accuracy, the cut-point of 5 was good at 'ruling out' admission for appendicitis (sensitivity 99% overall, 96% men, 99% woman, 99% children). At the cut-point of 7, recommended for 'ruling in' appendicitis and progression to surgery, the score performed poorly in each subgroup (specificity overall 81%, men 57%, woman 73%, children 76%). The Alvarado score is well calibrated in men across all risk strata (low RR 1.06, 95% CI 0.87 to 1.28; intermediate 1.09, 0.86 to 1.37 and high 1.02, 0.97 to 1.08). The score over-predicts the probability of appendicitis in children in the intermediate and high risk groups and in women across all risk strata. Conclusions: The Alvarado score is a useful diagnostic 'rule out' score at a cut point of 5 for all patient groups. The score is well calibrated in men, inconsistent in children and over-predicts the probability of appendicitis in women across all strata of risk

Alvarado score as an admission criterion in children with pain in right iliac fossa

Background: Acute appendicitis is an important differential diagnosis in children with pain in the right iliac fossa. Some patients have equivocal signs that make the diagnosis difficult. Many patients with suspected acute appendicitis are admitted for observation and finally discharged because they did not have appendicitis. We decided to design this study to investigate whether the Alvarado score could be used by emergency room doctors as a criterion for admission to hospital.Patients and Methods: This is a prospective study comprising 350 patients who attended the emergency department with suspected acute appendicitis in the period from May 2007 to April 2009. All patients were scored by Alvarado score in the emergency department before admission. TheAlvarado score is based on three symptoms, three signs and two laboratory findings. The decision for admission and surgery was made independent of the score. The diagnosis of patients who underwentappendicectomy was confirmed by both operative findings and postoperative histopathology.Results: We studied the Alvarado scores of 350 patients who presented to the emergency department with pain in the right iliac fossa; their age ranged from 8 to 14 years; 182 patients (52%) operated with theaim to treat acute appendicitis, 168 patients (48%) were discharged without surgical intervention and advised to attend the out-patient clinic after 24 hours for re-evaluation. we have found that patients with alow Alvarado score (less than 6) did not have acute appendicitis. Conclusion: Patients with equivocal signs can present a diagnostic challenge and are very often admitted to the surgical department forobservation. The Alvarado score can be used as a scoring system that help in taking the decision for admission of cases with suspected acute appendicitis especially by primary healthcare providers