Improving the prognostic value of blunt abdominal trauma scoring systems in children

Purpose Blunt abdominal trauma (BAT) is a frequent reason for hospital admission and a significant cause of death in children older than 2 years of age. Mechanisms causing abdominal injuries are predominantly motorvehicle accidents, falls, and intentional injuries. Blunt trauma accounts for 90% of pediatric injuries. There are many scoring systems that are designed to monitor victims of BAT and to predict victims who may require conservative management and those who may require surgical intervention. None of these scoring systems is perfect and fulfill the data for accurate prediction of the prognosis of these victims. We assessed three  different clinical scoring systems and their prognostic properties alone and after their modification by adding a plain, erect, abdominal radiographic film to improve their prognostic values.Patients and methods We included all patients presenting with BAT older than 2 years and younger than 18 years. All children were subjected to three different trauma scoring systems. We evaluated all children usingPediatric Trauma Score, Clinical Abdominal Score System, and Blunt Abdominal Trauma in Children. We then added plain, erect, abdominal radiographic films to these systems.Results A total of 250 children with BAT were subjected to three different scoring systems. Among them, 58% were boys and 42% were girls. The cause for BAT in two hundred and two cases was car accidents, falling from heights in seven, and kicks and abuse in 41 cases. The mean time until hospital arrival was 2 h. The mean age was 15 years. The mean time for every scoring system was 5 min. Radiographic imaging showed positive signs of trauma (air under diaphragm, elevated copula of diaphragm) in 45 patients.Conclusion Adding a simple radiographic film in the erect position of the abdomen and lower chest markedly improved the prognostic value of the different scoring systems included. Keywords: children, scoring systems, traum

Avoiding cord extraction or mobilization during pediatric inguinal hernia repair: a step midway between conventional and minimally invasive approaches

Background: Pediatric inguinal hernia (PIH) represents one of the most common congenital defects in infants and children worldwide. Several techniques have been adopted for repair. Conventional open excision of the sac is considered the most popular and most accepted among pediatric surgeons. In the past few years laparoscopic PIH repair has started to gain popularity.Aim: The aim of this study was to minimize the intervention to be near to minimally invasive but at the same time to be conventional in approach, reducing the stretch and manipulation of the vital cord structures.Patients and methods: During the period from April 2013 to May 2015, 200 male infants who presented with PIH were operated upon in our hospital. We excluded patients with complicated inguinal hernias, hernias associated with hydroceles, undescended testis, and female infants.Results: Of the 200 male infants with PIH who were operated upon, 107 had hernias on the right side, 74 had on  the left side, and 19 were bilateral. The mean age was 4.5 months. The mean body weight was 5 kg. All infants received general anesthesia. The mean length of the incision was 10 mm. Recurrence was found in only three cases. There were no cases of testicular atrophy.Conclusion: We found our approach to be safe and easy to perform, and the vital structures in the cord did not have to be manipulated.Keywords: pediatric, inguinal hernia, repai

Surgical insertion of central venous catheters in low-birth-weight neonates

Aim: Neonatal central vascular access (CVA) represents a daily practice in  neonatal intensive care unit. Low birth weight (LBW) neonates pose a challenge to anesthetists who try the landmark technique to cannulate central veins. We reported our experience of open surgical cutdown (OSC) to insert catheters through right internal jugular vein (IJV) and assessed feasibility, operative time, durability of line, and postoperative complications of this technique.Methods: A total of 660 LBW neonates needed CVA and underwent OSC of right IJV because of medical and surgical indications. We reported operative time, whether anesthesia or sedation, whether in the theater or at the bedside, difficulties,  complications and duration of line, and causes of failure. Transverse neck incision was made 1 cm above the medial third of the clavicle, right IJV was identified,  venotomy was performed, and catheter was inserted.Results: A total of 660 LBW neonates had CVA in right IJV, ligation of vein occurred in the first 30 cases but later venotomy was repaired. Mean operative time was 11.3 min. No injury of the right carotid artery or vagus was reported. None had postoperative pneumothorax. Overall, 542 cases had lines until they were  discharged. A total of 43 cases needed redo. Thirty-five cases had line-associated infection and 40 lines were thrombosed.Conclusion: OSC of right IJV was feasible and had lower complication rates.Keywords: neonate, surgery, vascular acces

Variables determining the success of ultrasound-guided hydrostatic reduction of intussusception in infants: a tertiary center experience

Background: Intussusception represents one of the most common urgent surgical admissions during early infancy and childhood period. It’s a form of intestinal obstruction which is manifested by colicky abdominal pain, red current jelly stool and abdominal mass. Abdominal Ultrasound is the method of choice for diagnosis. Treatment of intussusception ranged from simple non operative reduction either by pneumatic or hydrostatic enema to surgical exploration. There multiple variables that may affect the result of of non operative management.Aim: We tried to study them to know whom patient would pass without surgery.Patients and methods: Two hundred patients diagnosed with intussusceptions included in this study. All of them received ultra sound guided hydrostatic reduction using warm saline. The maximum number of attempts of reduction was three times. We used intrvenous sedation in irritable infants.Results: 2 hundred cases with intussusception were treated in this study. One hundred forty were reduced (group A) and 60 cases (group B) required surgical exploration. The mean body weight in group A was 7.3 Kg while in group B 9.3Kg. seventy five cases from both groups were operated.Conclusion: Several factors affect the result of hydrostatic reduction as total leukocytic count, CRP and duration of symptoms. In addition the size of the mass and the presence or absence of free peritoneal fluid affects the non operative management.Keywords: hydrostatic, intussusception, ultrasoun

Laparoscopic versus open appendectomy in children with complicated appendicitis

Introduction: Acute appendicitis represents one of the most common causes of urgent surgical interventions in pediatric age group. With the advances in minimal invasive surgery laparoscopic appendectomy (LA) has been introduced as a suitable line of treatment. We compare between laparoscopic and conventional open appendectomy in the treatment of complicated appendicitis in children.Patients and methods: During the period from October 2012 to March 2016, 390 children with acute complicated appendicitis diagnosed clinically and with laboratory and available imaging studies were operated. LA performed for 200 cases and open conventional appendectomy for 190 cases. Three ports technique was used in laparoscopic cases. The operating table is shifted in Trendelenburg position and towards the left side. The surgeon stands on the left side of the patient. The appendicular mesoappendix was secured using electro cautery. The base was secured by extracorporeal ties and the appendix was retrieval within the umbilical port. The wounds were closed. Open appendectomy was done through McBurny incision as the traditional approach.Results: A total of 390 children diagnosed with acute complicated appendicitis were operated. The mean age was 12.04 years in group A and 12.2 in group B. There were 260 were boys and 130 were girls. The mean operative time in the laparoscopic group was 56.4 min; while in the conventional group was 63.42 min.Conclusion: LA was a suitable, effective and safe procedure in complicated cases that did not involve the base. It was associated with lower complications rate withall the advances of minimal invasive surgery when compared to the conventional open appendectomy.Keywords: appendectomy, children, complicated, laparoscopi

Laparoscopic versus open splenectomy in children with benign hematological diseases in children: a single-center experience

Introduction: Splenectomy whether open or laparoscopic addresses the role of the spleen in the hematology disorders, particularly that of the cellular sequestration and destruction and antibody production. Laparoscopic splenectomy (LS) has been increasingly used for the removal of spleen in children. However, there are still certain questions as regards the feasibility, economic reflections, appropriate splenic size suitable for LS, vascular control of that organ, and final outcomes related to either procedure.Patients and methods: In the period between May 2007 and March 2017, 70 children with benign hematological diseases underwent splenectomy, either laparoscopic or open. They were divided into group A and group B. Group A included cases who had LS, and group B included cases who had open splenectomy (OS). We performed LS while the child was in the right lateral position. In cases of normal splenic size, we used three ports and four ports in cases of splenomegaly. OS was performed in supine position.Results: A total of 70 children were subjected to splenectomy, of whom 20 were boys and 50 were girls. Thalassemia was present in 36 cases, idiopathic thrombocytopenic purpura in 24 cases, and spherocytosis in 10 cases. Five cases were converted to the traditional approach, and three of them were because of huge splenomegaly and two cases were because of accidental bleeding. In the LS group, small-sized spleens were extracted using retrieval bags, whereas large spleens were extracted through Pfannenstiel incision. OS procedure was performed through midline incision. Cholecystectomy was performed in five cases during the original procedure because of gall bladder stones: three cases in group A and two cases in group B.Conclusion: Although both LS and OS achieved the same goal for the children with benign hematological disease, the advantages of minimal invasive surgery made LS the standard approach for treatment of children with benign hematological diseases. However, the main concern is the high economic burden of LS when compared with OS.Keywords: children, laparoscopic, open, splenectom

Bipolar sealing devices versus endoscopic vascular staplers during laparoscopic splenectomy in children with benign hematological diseases

Background: Splenectomy, whether open or laparoscopic, is considered a step of management in many children with benign hematological diseases such as immune thrombocytopenia, thalassemia, autoimmune hemolytic anemia, and spherocytosis. The major challenge during laparoscopic splenectomy (LS) is the rich blood supply of the spleen. Many techniques were considered to control the vascular supply of the spleen. Staplers, clips, either titanium or hemoclips, a bipolar sealing device (BSD), or ultrasonic shears were all used to complete LS. We aimed to compare the results of using BSD versus endoscopic staplers for vascular control of the pedicle during LS.Patients and methods: The study was carried out on 30 children with benign hematological diseases who presented to the Pediatric Surgical Unit. They were grouped randomly into two groups: group A and group B. Group A included 15 patients who were subjected to LS in which BSD was used for vascular control, whereas group B included 15 patients subjected to LS in which endoscopic staplers were used for vascular control of the pedicle.Results: The mean age of the children in group A was 9.60 years, whereas the mean age of the children in group B was 10.40 years. In group A, the mean estimated amount of blood loss was 72.27 ml. However, this was 80.67ml in group B. In group A, the mean operative time required was 39.00 min, whereas it was 56.27 min in group B. The indications for splenectomy were thalassemia in 15 cases (seven for group A and eight for group B), idiopathic thrombocytopenic purpura in 13 cases (seven for group A and six for group B), and spherocytosis in two cases (one for each group). The mean splenic size in group A was 10.43 cm, whereas it was 11.73 cm in group B.Conclusion: LS has evolved over the last decade because of the advancements of BSDs and endoscopic staplers. According to our data the use of LigaSure reduces the overall operative time, operative blood loss, and associated complications compared with the use of staplers.Keywords: children, laparoscopic, splenectom

Orchiopexy through a single high transverse scrotal incision

Background: Palpable Undescended Testis (PUT) represents a common paediatric problem in many premature and some mature infants. There are several surgical techniques to correct PUT either through combined inguinal and scrotal incision or single transverse scrotal incision. This study assessed single high transverse scrotal incision for the management of PUT as regards to feasibility, postoperative success and final cosmetic results. Materials and Methods: One hundred twenty patients were managed at the Paediatric Surgery Department of Tanta University Hospital with PUT during the period from March 2010 to March 2014. They were all operated at the age of 6-12 months. We excluded recurrent cases, and cases older than 12 months. Through high transverse scrotal incision, the layers were divided, and the canal entered through the external ring, dissecting the PUT and bringing it through the incision. Hernia sac, if present, was ligated at the neck. Creation of the dartos pouch was then made through the same incision. All infants were followed-up at 1 month, 2 months and 6 months to detect any re-ascended cases, testicular atrophy and the final cosmetic appearance. Results: A total of 140 PUTs were operated upon in 120 patients. PUT was bilateral in 20 patients, right-sided in 65 cases and left-sided in 35 cases. Thirty testes were located at the external ring; the others were located within the inguinal canal. No cases needed a redo operation, and there was no case of postoperative testicular atrophy. Conclusion: Single high transverse incision was sufficient to deal with PUT especially, in young infants (age 6 months) with no need for conversion in most cases to the traditional two incisions technique, and good long term follow-up and a better cosmetic results