Russian Journal of Pediatric Surgery

BACKGROUND: The optimal laparoscopic technique for pediatric inguinal hernia continues to be discussed with a view to its further refinement.

AIM: This study aimed to ascertain the outcomes of two laparoscopic fully intra-corporeal techniques employed in our practice: herniorrhaphy and true herniotomy.

METHODS: A retrospective comparative review of patient outcomes was conducted following laparoscopic groin hernia repair: herniorrhaphy — 1st series and true herniotomy — 2nd series. Patient data was analysed using non-parametric statistics with Mann-Whitney test.

RESULTS: In total there were 328 patients, aged between 2 months and 17 years, with 402 groin hernia defects including metachronous and rare defects. The herniorrhaphy was performed for indirect hernia defects (n=186) and herniotomy — for indirect (n=206) as well as for direct (n=6) and femoral (n=2) defects. Technically, there were no intraoperative complications in any case in either series. Conversion to open procedure was required in one patient of 1st series (0,5%) with giant hernia because of the impossibility to maintain due pneumoperitoneum. The postoperative recovery was prompt and uneventful with restoration of mobility and oral intake within 3–6 hours in all patients with no difference between the series. Adverse postoperative events were noted in 10 patients after herniorrhaphy — hydrocele (n=6; 3.2%) and hernia recurrence (n=4; 2.2%) whereas after herniotomy there was only one case (n=1; 0.5%) of hydrocele and none of recurrence. The overall rate of these complications was significantly lower in the herniotomy series vs herniorrhaphy (p=0.004).

CONCLUSION: Laparoscopic intracorporeal techniques both herniorrhaphy and true herniotomy are safe and effective for pediatric hernia repair. True herniotomy appears to be a more robust technique to minimise incidence of postoperative hydrocele and recurrence.

BACKGROUND: Laser ablation is a technique which was originally used to treat various cystic and fistulous structures. Due to promising results, surgeons began to use diode lasers to treat pilonidal cysts. The authors developed their own technique of ultrasonic-guided laser ablation in patients with the discussed pathology.

AIM: To compare outcomes after laser ablation and Karidakis surgery for treating pilonidal cysts.

METHODS: A prospective non-randomized comparative study was performed. Outcomes of surgical interventions were analyzed in 71 patient with pilonidal disease: 24 patients were operated with laser obliteration technique and 47 — with Karidakis technique. The researchers compared: time of wound healing and number of recurrences, complications, length of hospital stay and duration of postoperative pain.

RESULTS: Mean operative time in the laser group was 26.45±5.41 min (20–35 min), while in the Karidakis group — 58.63±7.42 min (50–75 min). In the laser group, primary healing was registered in 23 out of 24 patients (95.8%) with an overall complication rate 20.83%. In each group, there were registered two cases with relapses after discharge. The obtained clinical results, in general, were comparable to those in the world literature. However, the quality of life of patients after laser treatment was significantly better than after traditional surgical intervention which is confirmed by less hospital stay up to 5–7 bed-days; by less surgical time, in average, 25 minutes; faster recovery — within one week after surgery; faster return to everyday life, as well as less pain syndrome in the postoperative period.

CONCLUSION: Laser ablation of the coccygeal tract is comparable to Karidakis surgery in terms of wound healing and recurrences, but it gives better results in terms of surgical time, hospital stay and postoperative pain.

The properly administered first aid is an important component in achieving better outcomes in the treatment of burn patients. One of the first stages of management of such patients is a pre-hospital one.

The purpose of the study is to analyze the literature review on medical care for children with burns in the prehospital stage, to identify critical deviations and changes that require revision of the current recommendations.

A review of trials and latest recommendations on providing medical care to burned children at the prehospital period was carried out. The search was done in PubMed, Medline, GoogleScholar, eLibrary databases, as well as in Yandex search system. Out of 8 168 sources, 17 publications were selected for the data analysis.

The performed review has identified main challenges in providing the first aid to children with burns at the prehospital stage. Children will benefit from reaching the consensus between burn specialists and emergency medical providers before patients are taken to a burn center. These data should be used as the basis for future agreements between these specialists.

Correctly placed accents on anesthesia, dressings, infusion therapy in children with burns before their arrival to the hospital dictate a need to revise the existing recommendations in our country.

In issue #1 of volume 28 (2024) of the "Russian Journal of Pediatric Surgery" journal, an international team of authors published the scientific review "Laparoscopic access in the treatment of palpable cryptorchidism (review)" (DOI: https://doi.org/10.17816/ps667). The article analyzed international publications with the results of using laparoscopic access for orchiopexy of palpable testicles. Unfortunately, in all the articles mentioned in the review the follow-up period was 12–18 months. In addition, there is no assessment of gonads state before descending in the analysed articles. It seems that a mechanistic approach was chosen: they used laparoscopic access, mobilised the testis, performed orchiopexy, made sure that there was no atrophy or retention, and assessed the result as positive. This is not sufficient to analyse and objectively evaluate the proposed method in a statistically valid manner. When choosing an orchiopexy method, it is necessary to be guided by reliable long-term results and try not to contrast traditional orchiopexy methods with laparoscopic methods.

BACKGROUND: Transoral endoscopic thyroidectomy (TE) by the vestibular access is an advanced technique in modern domestic oncology as it enables to have a perfect cosmetic results without any asymmetry caused by the scar strain on the visualized surface of the neck skin.

CLINICAL CASE DESCRIPTION: The article presents the first Russian experience, obtained in the research and clinical institution specializing in oncological diseases, in the application of transoral endoscopic TE by the vestibular access in children suffering of differentiated thyroid cancer. 9 children with thyroid cancer (TC), who were hospitalized to the A. Tsyb Medical Radiological Research Center from July 5, 2022, till December 20, 2022, were taken in the study. Tumor stage was estimated by the International Classification TMN TC (UICC, 8th ed., 2017): cT1a — 6 patients, cT1b — 3 patients. The age ranged from 6 to 17 y.o., average 15.2±1.1 (5 boys, 4 girls). All patients survived endoscopic surgery on the thyroid gland (TG) by the vestibular access: 6 patients — hemithyroidectomy (HTE) and 3 patients — TE, selective cervical lymphadenectomy (level VI).

All nine endoscopic surgeries on the thyroid gland by the vestibular access were successful, without conversion. In all patients, paratracheal, pretracheal and prelaryngeal groups of lymph nodes on the lesion side (level VI) were removed. Surgery duration ranged from 59 to 143 minutes, average 95±20.5 minutes. No complications, such as laryngeal nerve paresis or hypoparathyroidism, were observed. Intradermal hematoma and chin skin paresthesia were registered as local postoperative complications which did not require any treatment. All patients were satisfied with their cosmetic outcomes.

CONCLUSION: Transoral endoscopic thyroidectomy by the vestibular access is a safe and feasible alternative surgical intervention for neoplasms in the carefully selected infants so as to avoid scar formations on the frontal neck surface. Transoral endoscopic interventions in the thyroid gland and regional lymphatic regions by the vestibular access should be performed only in highly specialized oncological centers equipped with modern endoscopic devices.

BACKGROUND: Cushing's ulcer is a stress ulcer in the stomach or duodenum which basic etiological factor is increased intracranial pressure. The increased intracranial pressure is caused, most often, by intracranial neoplasms, cranial-cerebral injury or previous neurosurgical interventions. Cushing's ulcers are usually solitary and deep, often complicated with recurrent gastrointestinal bleedings and less often with perforations. In cases of suspected perforation in a complex anatomical localization (posterior wall of the duodenum), the method of choice according to the world literature is computed tomography with intravenous contrast. Subsequently, after brief preoperative preparation, indications for laparoscopy or laparotomy with subsequent ulcer closure are determined. In the absence of free gas in the abdominal cavity, the "gold standard" for diagnosis and treatment is esophagogastroduodenoscopy. During esophagogastroduodenoscopy, it is necessary to visualize the source of gastrointestinal bleeding and determine if it is ongoing. In cases of ongoing gastrointestinal bleeding, endoscopic hemostasis is performed. If it is not possible to establish the source of bleeding and/or if local hemostasis attempts are unsuccessful, endovascular arterial embolization is recommended. If all minimally invasive methods are ineffective, radical methods such as laparoscopy or laparotomy with visualization of the source of bleeding, cessation of bleeding, and ulcer closure are employed.

Clinical Case Description. This clinical case demonstrates the severity and unpredictability of the clinical course of Cushing's ulcer complicated by gastrointestinal bleeding. The patient underwent multiple hemostatic procedures through esophagogastroduodenoscopy and arterial embolization. However, despite all minimally invasive treatment methods, the patient's condition required radical surgical treatment.

CONCLUSION: There is no information in the world literature about the algorithm for managing recurrent gastrointestinal bleeding in the context of Cushing's ulcer. The authors recommend to covert to more radical treatment only after all minimally invasive techniques turned to be ineffective.

BACKGROUND: Foreign bodies in the gastrointestinal tract is a fairly common pathology in pediatric surgery. The proportion of all cases is about 80%; in 20% of cases, foreign bodies can stuck in the physiological colon narrowings and in 0.005% — in the appendix. It is thought that magnetic foreign bodies pose a danger, if they are two or more because they can be attracted to each other at different parts of the gastrointestinal tract. A foreign body can get into the vermiform process, if its mass exceeds the mass of caecum content. Under the gravity mechanism, the foreign body penetrates into the dilated appendix lumen, but lumen peristalsis may not be strong enough to push it back into the large intestine. Swallowed foreign bodies may be asymptomatic in the vermiform process, and can manifest clinically as the inflammation either after few hours or after many years.

CLINICAL CASE DESCRIPTION: In patient X., aged 2 years and 8 months, a magnet foreign body (a piece of magnetic pen) got into the vermiform process. The independent discharge of this object was under control, but no results. Patient's general state was satisfactory. No pathologies were observed in organs and systems. After a series of X-ray examinations of the abdominal organs, suspicion appeared that this foreign body was in the appendix. Diagnostic laparoscopy with intraoperative radiography and then laparoscopic appendectomy were performed. Macropreparation: unchanged vermiform process 6 cm long. The appendix lumen was opened, a foreign body was found — a magnetic rod with size 0.5 cm x 0.2 cm.

CONCLUSION: The postoperative period was uneventful. The child was discharged from the hospital in the recovering state after the performed surgical intervention — an elective laparoscopic appendectomy.

BACKGROUND: Non-parasitic splenic cysts is a rare pathology in children, accounting for 0.5–2% of all splenic diseases. Typically, most cysts, as a rule, are asymptomatic However, as the cyst is enlarging, clinical symptoms — such as pain, discomfort in the left abdomen, and nausea — may appear. These symptoms are indicators for surgical intervention. Splenic cysts larger than 5 cm have a higher risk of complications such as rupture, bleeding, and infection; therefore, surgical treatment is recommended in these cases. Some authors consider the surgical intervention to be appropriate for cysts sized greater than 4 cm. However, small size of splenic neoplasms can complicate their visualization and surgery, thus increasing the risk of intraoperative complications and recurrences. Currently, in cases of borderline sizes of asymptomatic non-parasitic splenic cysts, it is recommended to assess the dynamics of size changes, so as to find the optimal curative tactics for the patient.

CLINICAL CASE DESCRIPTION: Two clinical examples of non-parasitic splenic cysts in children are discussed in the article. In the first case, a splenic formation with diameter 40 mm was found in a 5-y.o. girl; the diagnosis was confirmed at ultrasound and computed tomography examinations. At the recommended dynamic follow -up , it was found out that the cyst decreased to 5 mm in diameter. In the second case, a 14-y.o. boy was hospitalized for an elective surgery, because a splenic formation was diagnosed at the regular dispensary check-up. Ultrasound and computed tomography examinations of the abdominal cavity revealed a cyst of 45 mm on the visceral surface of the upper segment of the spleen. Laparoscopy failed to visualize the splenic cyst. The follow-up monitoring with a repeated ultrasound examination of the abdominal cavity in 3-6 months was recommended. Imaging diagnostic techniques have confirmed that cyst location and size remained unchanged.

CONCLUSION: The two described clinical cases demonstrate the importance of dynamic follow-up monitoring in case of borderline-sized non-parasitic splenic cysts in children, as it helps to avoid unnecessary surgical interventions.