A Study to Determine the Accuracy of Placement of Pull-through Bowel in Children with Anorectal Malformation who have Undergone Sacroperineal pull-through after Accurate Intraoperative Localisation of Sphincter Complex using Muscle Stimulator.

INTRODUCTION : Anorectal malformations (ARM) are relatively frequently encountered anomalies that represent an important component of paediatric surgical practice. Many in our profession have significant interest in the management of numerous variants of ARM. Malformations range from minor, easily treated defects that carry an excellent functional prognosis, to complex defects that are difficult to treat, are often associated with other anomalies and carry a poor functional prognosis. Over the last half century or more, the treatment of ARM evolved from a simple cut-back procedure / translocation anoplasty to the abdomino-perineal and later the sacro-perineal pull through procedures. The sacro-perineal pull-through was widely practiced till the introduction of the posterior sagittal anorectoplasty (PSARP operation). The current goals in the management of these defects are 1) to anatomically reconstruct all malformations, 2) to recognise and treat any associated defects that may be life-threatening and 3) to treat the functional sequeale of the malformations, in order to provide these patients with a good quality of life. The long term functional outcome after repair of intermediate and high ARM remain far from perfect. Majority of children have significant problems like soiling and constipation in the long term. Despite recent developments in the understanding of the embryology and surgical anatomy of ARM, it remains unclear which is the optimal repair of these complex anomalies. PSARP although it gives a superior exposure, it involves dividing the sphincter muscles in the midline through it and suturing the muscles back. Whenever the muscles are divided and sutured, there will be healing by fibrosis which will affect the ultimate function of the sphincter muscles which has been documented by MRI studies. The Stephen’s procedure involves blind hooking of the sphincter muscles and therefore it is possible that one may miss part of the sphincter muscles when bringing the bowel down. In our technique we have been accurately identifying the sphincter muscle complex by intraoperative muscle stimulation and pulling the bowel through it . It is hoped that this will result in a more accurate placement of the bowel within the sphincter and therefore leads to a better functional outcome. AIMS : 1. To identify the ano-rectal sphincter complex intra-operatively by direct stimulation with muscle stimulator and pulling the rectum through this muscle complex during sacro-perineal pull-through procedures for intermediate ano-rectal malformations. 2. To study the relationships of this pulled-through rectum to the ano-rectal sphincter complex post-operatively by MRI . 3. To assess the efficacy of the ano-rectal sphincter by determining resting pressure and squeeze pressure post operatively by ano-rectal manometry. 4. To determine functional outcome in these patients after colostomy closure. CONCLUSION : It is found that with intraoperative localisation of the sphincter muscle complex with muscle stimulator, the bowel can be placed in the centre of the puborectalis sling without dividing the sphincter complex, thus avoiding fibrosis and damage to the sphincter muscle complex. As a further refinement to our technique, we hope to bring the bowel exactly in the centre of the external sphincter by passing initially a fine needle through the centre of the external sphincter identified precisely by the muscle stimulator, as a guide and then dilating it with a dilator and bringing the bowel down in the centre of the external sphincter

Incarcerated Congenital Diaphragmatic Hernia mimicking Intrathoracic Mass

Congenital diaphragmatic hernia (CDH) occurs when intra-abdominal contents herniate into the thoracic cavity through a defect in the diaphragm as a result of maldevelopment of fetal organs. It can be diagnosed in antenatal period with help of ultrasonography. Postnatally it presents soon after birth as respiratory distress along with a scaphoid abdomen. Radiological findings in a chest skiagram consist of bowel gas shadows in thoracic fields. We report here a case in which these Pathognomonic features were not present making the diagnosis difficult. Repeated X ray chest films showed persistence of intrathoracic mass as no bowel shadows were visible. A CT scan with contrast of the chest was required to confirm the diagnosis later on

Hawaiian flying squid Nototodarus hawaiiensis (Cephalopoda: Ommastrephidae) in the Arabian Sea: range extension, age, and growth

The oceanic cephalopod fauna of the Arabian Sea has not been well studied. The Hawaiian flying squid Nototodarus hawaiiensis (Oegopsida: Ommastrephidae) is known to have a very broad, disjunct distribution in tropical to subtropical waters. In the present study, the squid Nototodarus hawaiiensis is reported for the first time from the Arabian Sea. Five females ranging in size from 62 to 128 mm dorsal mantle length (DML) were collected. Age estimates based on the statolith-increment analysis ranged from 79 to 132 days, with growth rates ranging from 0.78 to 0.99 (mean = 0.93) mm DML/day. Back-calculated hatch dates occurred from November to January. Stomach-content analysis revealed that the dominant prey was crustaceans