Simmi K. Ratan

Objectives: This study aims to determine whether ultrasoundguided pudendal nerve block (USG-PNB) provides improved postoperative analgesia compared to caudal epidural block (CEB) in children undergoing hypospadias repair. Patients and methods: This prospective, randomized, parallel-group, double-blind comparative trial included 40 male children (mean age: 5.92±2.73 years; range, 2 to 12 years) with American Society of Anesthesiologists physical status I or II who were scheduled to undergo hypospadias repair under general anesthesia between March 2023 and January 2024. Participants were randomly allocated (1:1) to either the PNB group, receiving ultrasound-guided PEB (0.3 mL/kg ^-1 of 0.25% bupivacaine), or the CEB group, receiving CEB (1 mL/kg ^-1 of 0.25% bupivacaine) following induction of anesthesia. The primary outcome was the proportion of patients requiring additional analgesia within the first 24 h after surgery. Secondary outcomes included postoperative pain scores and total 24-h analgesic consumption. Results: In the first 24 postoperative hours, 80% of children in the PNB group required rescue analgesia compared to 15% in the CEB group (pConclusion: In pediatric patients undergoing hypospadias repair, CEB provided longer-lasting postoperative analgesia, reduced analgesic requirements, and greater surgeon satisfaction compared to USG-PNB. Although previous studies have reported favorable outcomes with nerve stimulator-guided PNB, only limited evidence supports improved analgesia with USG-PNB. Since bilateral blockade is required, and the block is technically challenging when performed with ultrasound alone, the success rate may be enhanced by combining ultrasound with nerve stimulator guidance. In our view, USG-PNB should be reserved for high-volume centers with substantial expertise in this technique to ensure reliable analgesia, optimize operating room efficiency, and conserve theatre time.

Transverse testicular ectopia (TTE) is an extremely rare congenital anomaly in which both testes descend through the same inguinal canal. Patients with this condition often present with an inguinal hernia and an impalpable contralateral testis. This condition is not usually diagnosed preoperatively and the ectopic testis is usually discovered incidentally during herniotomy or findings are noted at the time of diagnostic laparoscopy. Sometimes but not commonly, TTE cases associated with intersex conditions like persistent Mullerian syndrome, which may prevent normal testicular decent. Here, we report a four year old male child presented with impalpable left undescended testis and right inguinal hernia. Diagnostic laparoscopy revealed closed left internal ring with absence of vas deferens and testicular vessels. While on the right side, vas and vessels found to be entering the wide open internal ring and left testis was located just inside the ring with its own vas and vessels supply. Consequently, trans-septal contralateral orchidopexy involving fixing the right testis in left hemiscrotum as right testis had adequate cord length and left testis was fixed in the right hemiscrotum due to its short cord length was done.

A BSTRACT: Aim: This study aims to compare the pediatric trauma score (PTS) and shock index pediatric age adjusted (SIPA) score for predicting the outcome in children presenting with trauma mainly abdomen. Methodology: Prospective study of 18 months with recruitment of trauma patients admitted to a tertiary centre with mainly abdominal trauma. After immediate resuscitation, SIPA and PTS scores were computed and reassessed 24 h later. The outcomes of injured subjects were analyzed using an indigenous morbidity scoring system and compared with SIPA and PTS scores. Statistical methods were used for demographic details, uni/multivariate analysis, and for calculating predictive values. Results: Male (aged 5–8 years) was identified as most commonly injured. Fall was noted as most frequent mechanism and maximally contributed to high morbidity. Liver was most frequently injured, whereas hollow viscous injuries (pneumoperitoneum) were associated with the poorest outcome. SIPA and PTS, both at admission and 24 h later, significantly correlated with morbidity, with 82% predictive accuracy ( P < 0.001 for SIPA; P = 0.003 for PTS). This association weakened at 24 h with normalization of SIPA after resuscitation in 70% of cases, whereas PTS maintained uniformity with consistency across 24 h. Multivariate regression analysis identified that among significant factors, pneumoperitoneum, low PTS, and infant subjects had the highest odds ratios for poor outcome following trauma to the abdomen. Conclusion: Pediatric trauma victims with abdominal injuries can be triaged using SIPA soon after injury, whereas for delayed presenters, PTS is a better alternative, albeit with suggested age-based value correction for its components.

Introduction: This study was undertaken to explore if abdominal anthropometric measurements and pressure parameters measured before closure can predict the choice of surgical procedure in neonates with gastroschisis. Materials and Methods: Twenty-two neonates presenting to our tertiary center with gastroschisis over 18 months were included. Abdominal anthropometric measurements such as defect circumference (DC), abdominal circumference (AC), abdominal height (H), anteroposterior diameter (APD), and abdominal volume (AV) were measured soon after induction and again before final closure. Simultaneously, peak inspiratory pressure (PIP) and intravesical pressure (IVP) were measured. A protocol of pressure increase of >20% from the baseline for Silo was followed. The data were analyzed segregating the subjects into two those requiring Silo (n = 16) and not requiring Silo (n = 6). Observation and Results: Non-Silo group did not differ from the Silo group for DC, AC, DC:AC ratio, Height, APD, and AV. Significant differences were noted between non-Silo and Silo groups in PIP (16 ± 1.9 vs. 12.88 ± 2.66) and IVP (1.83 ± 2.64 vs. 1.20 ± 2.08) preoperatively and pre-closure. DC:AC cut-off for predicting Silo was ≥0.31, with 73% sensitivity, and 50% specificity. DC:AC correlated positively with preoperative abdominal height, pre-closure AV, and abdominal height (P = 0.005, P = 0.008, and P = 0.007, respectively). Conclusions: Silo group had unfavorable abdominal anthropometric parameters as compared to non-Silo. DC:AC ratio which can be computed in a nursery setting and can be a promising variable to predict the type of closure for neonates with gastroschisis as it correlated with AV. A larger study is required to substantiate these conclusions.

Introduction: This study was undertaken to assess the distribution of ganglion cells (GCs) and interstitial cells of Cajal (ICCs) across different points of distal rectal pouch in anorectal malformation (ARM) patients over the three stages of repair. We hypothesize that along with the surgical factors, there could be intrinsic factors as well which can be the cause of dysmotility in these patients after surgical repair. Methodology: Full-thickness colonic biopsy specimens were taken from the proximal stoma, distal stoma, and distal rectal pouch of 21 boys aged 0–8 months undergoing 3 staged repair of ARM at our tertiary care center between August 2022 and December 2023. There was an interstage interval of approximately 12–14 weeks. All underwent high-divided sigmoid colostomy in stage 1. Biopsy specimens for GC and ICC number were routinely processed, and immunohistochemistry was done for CD117. The data was assessed and compared with respect to location and stage of surgery. Results: Both GC and ICC showed a gradual decrease in mean number over three stages for both proximal and distal ends of colostomy. For proximal stoma, the distribution of either cell type did not differ across the stages, but for distal stoma, the number of cells was significantly lower in the second stage (following colostomy, before posterior sagittal anorectoplasty). However, no difference was noted between the second and third stages. This indicates that factors during/just after colostomy itself must be responsible for decrease in ICC/GC. Conclusion: Lesser number of GC and/or ICC in the distal pouch from stage 2 onward may point toward its association with projected hypomotility in ARM patients. Apart from innate distribution, we also infer that this could be consequent to vascular insult which may occur at the time of divided colostomy. Loop stoma may be a better alternative as vascularity is uninterrupted in loop colostomy.

Major liver trauma is a potentially fatal injury. Management of liver injuries has considerably changed with an inclination towards non-operative management but in about 5–10% of cases with extensive grades of liver injuries exploration becomes mandatory. Bleeding is recognized as the most common cause of death from liver injuries and surgical measures taken by operating surgeon are mainly focused on control of life-threatening exsanguination. Damage control laparotomy with packing of the abdominal cavity and abdominal organs has become a standard surgical maneuver but peri-hepatic packing has its own associated complications. Mesh wrapping of the liver has the potential to avert the need for reoperation and decrease blood product requirements. Mesh wrapping of the liver is analogous to perihepatic packing. The significant difference is that perihepatic packing applies diffuse pressure within the abdominal cavity that often affects other organs while in mesh wrapping pressure is applied directly to the organ without affecting other abdominal organs. Here we present a case of major liver laceration after blunt abdominal trauma managed with mesh wrapping where the mesh was handwoven from polyglycolic acid (Vicryl) suture material and crafted in to a snood that covered the lacerated portion of liver.

Background: Accidental ingestion of foreign bodies in children is critical, as the inability to effectively communicate can potentially lead to devastating consequences. We aimed to determine the epidemiology of foreign body ingestion and variability according to age, gender, type, and location of foreign body, and describe its management. Aim and Objective: The aim was to study the various types of foreign body ingestions in children admitted to pediatric surgery and their management. Materials and Methods: A retrospective study was conducted from January 2020 to June 2022 on children under the age of 12 years with a confirmed diagnosis of foreign body ingestion. Patients were clinically and radiologically assessed, after which standard protocols were followed wherein patients were followed by either observation or emergent management. Emergent management included removal of the foreign body by either endoscopy or surgery. Comparisons among multiple age groups, gender, type of foreign body, location of foreign body, and their management were analyzed. Results: Out of 99 subjects in our study, there were 76 boys and 23 girls. The median age of presentation was 5 years. Most children were asymptomatic at presentation. The most frequently ingested foreign body was a coin in all age groups. The majority of the foreign bodies were suspected to be in the small bowel. The foreign bodies that had crossed the duodenojejunal flexure (n = 74, 74.7%) were managed conservatively with the observation of a variable period of a minimum of 24 h and a maximum of 48 h. 21 cases were managed by endoscopic removal, while three cases required surgical intervention. Conclusions: Overall, the most common gastrointestinal foreign body was a coin in all age groups. Button battery is the most worrisome foreign body; however, depending on its position, it can be managed conservatively. Upper GI foreign bodies can be safely removed endoscopically. Parental counseling is very important for the prevention of ingestion of foreign bodies.

Hydatid cyst is a parasitic disease caused by larval stage of small tape worm (Echinococcus), causing cyst formation in the liver and in the lung. It affects liver primarily and secondary mostly the lungs. Hydatidosis is endemic in many countries and it is more prevalent in India. We came across a case of 4 years old female child presented with concomitant hydatidosis of the lung and liver and managed by single stage surgery involving cystotomy and partial excision for the cyst located in the lung and cystotomy, partial excision and inversion of the cavity with sutures for the cyst in the liver.