Background: Over 300 different operations have been described for the management of hypospadias. In recent times, the numbers of operations used in various centres have gradually reduced as the principles necessary to ensure adequate cosmetic and functional results with minimum complications are better understood. The aim of this article was to review the different types of operations used for managing hypospadias in a tertiary hospital in a developing country, to analyse the complications of surgery and discuss the factors that contribute to complications. Materials and Methods: Patient folders, theatre, and ward records were used to obtain the required information. The age at surgery, types of hypospadias at presentation, types of operations done and complications were analysed. Results and Conclusion: With three main types of operations, tubularised incised plate urethroplasty and meatal advancement and glanuloplasty incorporated for anterior hypospadias (glanular, coronal, subcoronal, distal, midpenile), and lateral based flap urethroplasty for posterior hypospadias (proximal penile, penoscrotal, scrotal, perineal), most hypospadias were corrected with acceptable complication rates.

Background: The management of intussusception has evolved universally from the use of hydrostatic reduction through operative reduction to the use of pneumatic reduction for the acute and uncomplicated cases and surgical reduction for the complicated cases. However, the process of evolution has been very slow in the developing countries, especially sub-Saharan Africa, due to lack of requisite facilities and expertise to manage these patients nonoperatively. This study examined the trends in the management of childhood intussusception in a developing country, compared operative and nonoperative modalities of treatment, and assessed the impact of delayed presentation on the outcome of management. Patients and Methods: This was a prospective study of the management of children with intussusception at the University College Hospital, Ibadan, Nigeria. Results: Fifty-five consecutive cases of intussusception that presented to the Children Emergency Unit of the University College Hospital between January 2005 and December 2011 were prospectively studied. Details of sex, age of the patients, clinical presentation, duration of symptoms, mode of treatment, and incidence of recurrence were recorded and analyzed. The median age was 7 months. Moreover, the duration of symptoms varied from 1 to 21 days with a mean of 4 days. Twenty-two patients (40%) had attempted hydrostatic reduction; this was successful in 14 patients (63.6%), whereas 8 patients (36.4%) had failed reduction. In all, 41 patients (74.6%) had operative management of intussusceptions; primary operative intervention was carried out in 33 patients (60%) and secondary surgical management in 8 patients (14.5%) with failed hydrostatic reduction. At surgery, manual reduction of intussusception was carried out on 17 patients (30.9%) and resection of devitalized bowel with end to end anastomosis was carried out on the remaining 24 patients (43.6%). The incidence of surgical intervention for intussusception was 74.6%, mortality was 3.6%, and recurrence rate was 3.6%. Conclusions: Nonoperative management of intussusception should be adopted in carefully selected cases of intussusception in this subregion as it will help to reduce the financial burden on the parents while surgical management should be reserved for the complicated cases.

Background: Congenital epidermolysis bullosa (CEB) is a rare genodermatosis. The digestive system is very frequently associated with skin manifestations. Pyloric atresia (PA) and oesophageal stenosis (OS) are considered the most serious digestive lesions to occur.The aim of this work is to study the management and the outcome of digestive lesions associated to CEB in four children and to compare our results to the literature. Patients and Methods: A retrospective study of four observations: Two cases of PA and two cases of OS associated to CEB managed in the Paediatric Surgery Department of Fattouma Bourguiba Teaching Hospital in Monastir, Tunisia. Results: Four patients, two of them are 11 and 8 years old, diagnosed as having a dystrophic epidermolysis bullosa since the neonatal period. They were admitted for the investigation of progressive dysphagia. Oesophageal stenosis was confirmed by an upper contrast study. Pneumatic dilation was the advocated therapeutic method for both patients with afavourable outcome. The two other patients are newborns, diagnosed to have a CEB because of association of PA with bullous skin lesions with erosive scars. Both patients had a complete diaphragm excision with pyloroplasty. They died at the age of 4 and 3 months of severe diarrhoea resistant to medical treatment. Conclusion: Digestive lesions associated to CEB represent an aggravating factor of a serious disease. OS complicating CEB is severe with difficult management. Pneumatic dilatation is the gold standard treatment method. However, the mortality rate in PA with CEB is high. Prenatal diagnosis of PA is possible, and it can help avoiding lethal forms.

Background: Minimally invasive surgery is the current approach to perform heminephroureterectomy (HN) in children. This can be obtained through a transperitoneal (TP) or a retroperitoneal approach. Here, we report our experience using a TP approach. Materials and Methods: From 2005 to 2014, 22 TP laparoscopic upper poles HN were performed at our institution. There were nine girls and 13 boys aged between 20 months and 6 years (mean age 3.9). Eight patients were diagnosed prenatally, 17 patients presented with urinary tract infection (UTI) and three with vomiting and failure to thrive. The indication for HN was reflux nephropathy and UTI in non-functioning upper pole in 19 patients and cystic dysplasia in 1 patient. The surgical technique involved the following steps: Cystoscopic recognition; positioning of 3-4 trocar (right HN); identification of the kidney (detachment of the colon); isolation and low ligation of the dilated ureter; decrossing from renal vessels; section of the parenchyma by LigaSure; haemostasis with clips and LigaSure; drain. Results: The mean operative time was 154 min (range: 81-220 min). All patients were discharged from the 2 ^nd to 4 ^th day. Neither major complication nor conversion was recorded. 1 patient presented leakage of urine for 7 days from the drainage which resolved spontaneously. At ultrasound follow-up, 5 patients showed a secondary perirenal cyst, 2-5 cm diameter that resolved spontaneously. Conclusion: The results indicate that laparoscopic upper pole heminephrectomy is the treatment of choice in cases of non-functioning dilated lower segments of duplicated kidneys. The use of laparoscopic approach offers a good working space, a good visual control of the vessels and allows a very low isolation of the ureteral stump which counterbalance the peritoneal violation.

Background: Non-surgical reduction remains the first line treatment of choice for intussusception. The major complication of air enema reduction is bowel perforation. The authors developed a custom made pressure release valve to be added to portable insufflation devices, delivering air at pressures accepted as safe for effective reduction of intussusception in children under fluoroscopic guidance. The aim of this study was to develop a custom made pressure release valve that is suitable for the insufflation devices used for air enema reduction of intussusception and to put this valve into regular clinical practice. Materials and Methods: An adjustable, custom made pressure release valve was assembled by the authors using readily available components. The valve was coupled to a simple air enema insufflation device. The device was used for the trial of reduction of intussusception in a prospective study that included 132 patients. Results: The success rate for air enema reduction with the new device was 88.2%. The mean pressure required to achieve complete reduction was 100 mmHg. The insufflation pressure never exceeded the preset value (120 mmHg). Of the successful cases, 58.3% were reduced from the first attempt while 36.1% required a second insufflation. Only 5.55% required a third insufflation to complete the reduction. In cases with unsuccessful pneumatic reduction attempt (18.1%), surgical treatment was required. Surgery ranged from simple reduction to resection with a primary end to end anastomosis. No complications from air enema were recorded. Conclusions: The authors recommend adding pressure release valves to ensure safety by avoiding pressure overshoot during the procedure.

Background: The aim of the present study is to compare the success rate and complications of caudal epidural bupivacaine alone or in combination with intravenous (IV) midazolam and ketamine in awake infants undergoing lower abdominal surgery. Materials and Methods: In this double-blind, clinical trial study, 90 infants (aged below 3 months and weight below 5 kg) with American Society of Anaesthesiologists I-II, were divided into three groups of each 30: Group 1 received bupivacaine 0.25%, 1 mL/kg for caudal epidural block; Groups 2 and 3 received caudal block with same dose bupivacaine along with IV pre-treatment with midazolam 0.1 mg/kg or IV midazolam 0.1 mg/kg and ketamine 0.3 mg/kg, respectively. Results: The success rates in Groups 2 and 3 were 93.3% and 93.1%, respectively, compared with a caudal block with bupivacaine alone 80%; P = 0.015). There was no significant difference among the three groups in terms of mean systolic and diastolic blood pressures and mean heart rate at intervals of 0, 20, 40 and 60 min (P < 0.05). There were no significant differences in the pain scores >3 on the Neonatal Infant Pain Scale at three intervals (30, 60 and 120 min) after surgery among the three groups. The complications such as apnoea or desaturation were not found in any of the studied groups. Conclusions: Adding IV ketamine and/or midazolam to bupivacaine caudal epidural block in the conscious infants can positively affect block success rate.

Background: Conservative management for major omphalocoele with topical agents as escharotics therapy is well established in practice. Different agents have been used in the past, including mercurochrome and alcohol, proved later to be unsafe. The aim of this study is to evaluate the efficacy and safety of the application of Acacia nilotica paste compared to povidone-iodine solution as a primary non-surgical treatment of major omphalocoele. Patients and Methods: A double-blind, randomised study was conducted on 24 cases of major omphalocoele where they were randomly divided into two equal groups; Group A treated with topical application of A. nilotica paste and Group B treated with topical application of povidone-iodine solution. Cases with gastroschisis, ruptured major omphalocoele or minor omphalocoele were excluded from the study. The evaluating parameters were size of the fascial defect in cm, period of mechanical ventilation if needed, time required for full oral feeding tolerance, duration of hospital stay and any short- or long-term complications. Results: There was no statistical significant difference between both groups regarding their gestational or post-natal age, weight and the mean umbilical port defect. Patients from Group A tolerated full oral feeding earlier and had shorter total hospital stay duration than those from Group B, but without a statistical significant difference (P = 0.347 and 0.242, respectively). The overall mortality rate was 33.3% without a statistical significant difference between both groups (P = 0.667). Conclusions: Application of A. nilotica is a safe and effective treatment of major omphalocoele as it was associated with rapid full enteral feeding tolerance, short duration of hospital stay and low mortality rate.

Background: We aimed to create a new and less invasive experimental corrosive oesophageal burn model using a catheter without a gastric puncture (gastrotomy). Materials and Methods: We conducted the study with two groups composed of 8 male rats. The experimental oesophageal burn was established by the application of 10% sodium hydroxide to the distal oesophagus under a pressure of 20 cmH ₂ O, via 5-F double-lumen central venous catheter without a gastrotomy. The control group was given 0.9% sodium chloride. All rats were killed 24 h after administration of NaOH or 0.9% NaCl. Histologic damage to oesophageal tissue was scored by a single pathologist blind to groups. Results: The rats in the control group were observed to have no pathological changes. Corrosive oesophagitis (tissue congestion, oedema, inflammation, ulcer and necrosis) was observed in rats exposed to NaOH. Conclusion: We believe that an experimental corrosive oesophageal burn can safely be created under same hydrostatic pressure without a gastric puncture using this model.

Background: Parents are central in decisions and choices concerning circumcision of their male children and plastibell circumcision is a widely practiced technique. This study determined parental preferences for male neonatal and infant circumcisions and evaluate the early outcomes of plastibell circumcisions in a tertiary centre. Patients and Methods: This is a prospective study on consecutive male neonates and infants who were brought for circumcisions at Nnamdi Azikiwe University Teaching Hospital Nnewi, South-East Nigeria and their respective parents between January 2012 and December 2012. Data on demography, parental choices and early outcome of plastibell circumcision were obtained and analysed. Results: A total of 337 requests for circumcisions were made for boys with age range of 2-140 days. Culture and religion were the most common reasons for circumcision requests in 200 (59.3%) and 122 (36.2%), respectively, other reasons were medical, cosmesis, to reduce promiscuity and just to follow the norm. Most parents, 249 (73.9%) preferred the procedure to be performed on the 8 ^th day and 88.7% would like the doctors to perform the procedure while 84.6% preferred the plastibell method. Among those who had circumcision, 114 complied with follow-up schedules and there were complications in 22 (19.3%) patients. Parents assessed the early outcome as excellent, very good, good and poor in 30.7%, 45.6%, 18.4% and 5.3% of the patients, respectively. Conclusion: Parents request for male circumcision in our environment is largely for cultural and religious reasons; and prefer the procedure to be performed by a physician. Plastibell method is well known and preferred and its outcome is acceptable by most parents.

Background: Cleft lip (CL) and palate (CLP) management is multidisciplinary. A cleft team was formed in a Nigerian Tertiary Hospital to address the health needs of cleft patients in the centre. Aim: This paper aims at documenting the Aminu Kano Teaching Hospital (AKTH) management protocol for orofacial clefts and also to review our experience with CLP surgeries performed at AKTH since our partnering with Smile Train. Materials and Methods: A retrospective review of all the cleft patients surgically treated from January 2006 to December 2014 under Smile Train sponsorship was undertaken. A descriptive narrative of the cleft team protocol was also given. Results: One hundred and fifty-five patients (80 males, 75 females) had surgical repairs of either the lip or palate. CL patients were 83 (53.55%), while CLP patients were 45 (29.03%) and isolated cleft palate patients were 27 (17.42%). Conclusion: The inclusion of various specialities in the cleft team is highly desirable. Poverty level amongst our patients frequently limits our management to surgical treatment sponsored by the Smile Train, despite the presence of other residual problems.

Background: Paediatric endoscopy performed by adult gastroenterologists is a service delivery model that increases the access of children to endoscopy in countries where paediatric gastroenterologists with endoscopy skills are scarce. However, studies on the usefulness of this model in Nigeria and Sub-Saharan Africa are scarce. We aimed to evaluate the indications, procedures, diagnostic yield and safety of paediatric endoscopy performed by adult gastroenterologists in a Nigerian tertiary health facility. Materials and Methods: It was a retrospective study that evaluated the records of paediatric (≤18 years old) endoscopies carried out in the endoscopy suite of Obafemi Awolowo University Teaching Hospital Complex Ile-Ife, Nigeria from January 2007 to December 2014. Results: A total of 63 procedures were successfully completed in children of whom 4 were repeat procedures which were excluded. Thus, 59 endoscopies performed on children were analysed. Most (49; 83.1%) of these procedures on the children were diagnostic with oesophagogastroduodenoscopy being the commonest (43; 72.9%). Epigastric pain (22; 37.3%), haematemesis (17; 28.8%) and dysphagia (9; 15.3%) were the predominant indication for upper gastrointestinal (GI) endoscopy while haematochezia (9; 15.3%) and rectal protrusion (2; 3.4%) were the indications for colonoscopy. Injection sclerotherapy (3; 5.1%) and variceal banding (2; 3.4%) were the therapeutic upper GI endoscopic procedures conducted while polypectomies were performed during colonoscopy in 5 children (8.5%). Abnormal endoscopy findings were observed in 53 out of the 59 children making the positive diagnostic yield to be 89.8%. No complication, either from the procedure or anaesthesia was observed. Conclusion: Paediatric endoscopy performed by adult gastroenterologists is useful, feasible and safe. It is being encouraged as a viable option to fill the gap created by dearth of skilled paediatric gastroenterologists.

Background: To survey the effects of one-trocar-assisted pyeloplasty (OTAP) in the treatment of ureteropelvic junction obstruction (UPJO) in kids. Materials and Methods: Forty-four children (±3.5 years) were submitted to OTAP procedure. A flank incision under the XII rib was made, the Gerota's fascia was achieved and a balloon Hasson trocar with an operative telescope inserted for retroperitoneal access. The renal pelvis and ureter were isolated and exteriorised. Forty-two patients underwent Anderson-Hynes dismembered and one Fenger pyeloplasty . One patient was converted to an open procedure. Two patients presented an aberrant crossing vessel. In all patients, a double J stent was positioned. The operative time and length of stay (LOS) were evaluated. Renal scan and ultrasound (US) were utilised to evaluate the results from 6 to 12 months. Results: OTAP was successful in all but 1 patient. Mean operative time and LOS were 128 min and 3,5 days. We had four operative complications (9.09%). The US and a nuclear scan confirmed the resolution of the UPJO in all patients except one with the Fenger pyeloplasty who had an open Anderson-Hynes. Conclusions: The combination of retroperitoneoscopic and open procedures for dismembered pyeloplasty offers a simple, time-saving method in a minimally invasive fashion with low morbidity for patients with UPJO.

Background: To compare the results of final renal function by two methods of treatment in patients diagnosed as posterior urethral valve (PUV) (valve ablation vs. vesicostomy). Materials and Methods: Fifty-four boys diagnosed with PUV participated in this study. They were divided into top two groups. Thirty-one of the total were treated with primary valve fulguration (Group 1) and 23 were treated with vesicostomy (Group 2). One-year-creatinine level and glomerular filtration rate (GFR) were measured. Also, they were taken ultrasonography detecting hydronephrosis. Data analysed in IBM SPSS21 with t-test and Chi-square test. Presented with 95% of confidence intervals. Results: Fifty-four boys diagnosed with PUV participated in this study. The mean age of patients in Group 1 was 3.8 ± 1.48 days and Group 2 was 4.7 ± 1.85 days. One-year Cr level was 1.57 ± 1.45 in Group 1 and 1.57 ± 1.45 in Group 2 which was not statistically significant (P < 0.8). Also 1-year GFR level was 31.1 ± 4.4 in Group 1 and 33 ± 4.7% in Group 2 (P < 0.10/23) in Group 2 (43.47%) had severe hydronephrosis and 14/31 (45.16%) in Group 1 had severe hydronephrosis. Graded ultrasound results were not significantly different (P = 0.24). Conclusion: The results showed no significant difference. Vesicostomy might be a more favourable method due to less complication and follow-up in early neonatal life. Hence, the condition of the patients and decision of the surgeon are effective parameters in choosing an optimal method in patients diagnosed with PUV.

Background: Isolated oesophageal atresia without tracheo-oesophageal fistula represents a major challenge for most paediatric surgeons. Here, we present our experience with six neonates with isolated oesophageal atresia who successfully underwent immediate primary anastomosis using multiple Livaditis circular myotomy. Materials and Methods: All six neonates were gross type A isolated oesophageal atresia (6%), from among 102 neonates with oesophageal atresia, treated between January 2009 and December 2013. Five neonates were female; one was male. The mean birth weight was 2300 (range 1700-3100) g. Results: All six neonates successfully underwent immediate primary anastomosis using multiple myotomies (mean 3; range 2-4) within 10 (median 3) days after birth. The gap under traction ranged from 6 to 7 cm. One neonate died of a major cardiac anomaly. Another neonate was lost to follow-up after being well for 3 months. Three anastomotic strictures were treated with balloon dilatation, and four anastomotic leaks were treated conservatively. The mean duration of follow-up was 33 months. Conclusions: To treat isolated oesophageal atresia, an immediate primary anastomosis can be achieved using multiple myotomies. Although, this approach is associated with high complication rates, as are other similar approaches, these complications can be overcome.

Background: Primary congenital bladder diverticulum (PCBD) is related to a deficient detrusor layer allowing out-pouching of the bladder mucosa through the inadequate muscularis wall. We aimed to review our experience with symptomatic PCBD in order to correlate clinical findings with anatomical aspects and to present late outcome. Materials and Methods: We reviewed all patients operated in our institution since 2004. We evaluated the charts for complaints, radiological exams, method of treatment, complications and length of follow-up. Results: We treated 10 cases (11 renal units - [RU]), predominantly males (9/10), mean age at surgery of 5.3 years. All patients had significant urological complaints presenting either with antenatal hydronephrosis (4) or febrile urinary tract infection (5) and urinary retention in one. The ureter was found implanted inside the diverticulum in 8/11 RU. An extravesical psoas-hitch ureteroneocystostomy and diverticulum resection was performed in 10/11 cases, whereas 1 case was treated intravesically based on surgeon's preference without performing cystoscopy. Mean follow-up was 34.1 months (1-120) without complications. Conclusions: PCBD is an uncommon diagnosis and has a high probability of drainage inside the diverticulum (72.7%). We recommend the extravesical approach associated with diverticulectomy and ureteroneocystostomy as the preferred technique to treat this abnormality.

Background: Oral-facial clefts including cleft lip and palate are the most common congenital malformations of the head and neck. Environmental factors such as maternal hormonal disorders, use of psychiatric medications, vitamin and folic acid deficiency, hypoxia, cigarette smoking and maternal obesity and overweight can affect the incidence of these disorders. In Iran, one of the associated problems is a lack of accurate statistics regarding the present status of the patients, which can cause a disturbance in the health programmes of Ministry of Health and Medical Education. The aim of this study was to report the status of 398 cases of cleft lip and palate in Sheikh and Imam Reza Hospitals of Mashhad over a 10-year period. Materials and Methods: This retrospective descriptive study was performed using data collection method and included the evaluation of the recorded files and completing the data forms. In this study, the file records of 398 patients referring to Mashhad Sheikh and Imam Reza (P.U.H) Hospitals were studied, from the beginning of 2002 to the end of 2011; the obtained data from the files were collected and classified. Results: The highest frequency was related to cleft palate alone (40.7%); frequencies were lower regarding the cleft lip and palate and cleft lip alone (34.41% and 24.87%, respectively). Approximately, half of the patients were from rural areas of the city and had articulation disorders. Most of the patients were the first-born children of the family and their parents were consanguineously married; about one-third of the patients had a family history of the disease. Conclusion: According to the results of the present study, cleft lip is more frequent in males and cleft palate is more prevalent in females; the obtained results are consistent with the global statistics.

Duplication of the gallbladder is a rare congenital anomaly of the biliary system. We herein present a case of a 9-month-old full-term female with a prenatally identified gallbladder duplication cyst managed via laparoscopic excision.

Acute neonatal appendicitis is very rare in the neonatal period. It is usually associated with comorbidity including prematurity. Symptoms are non-specific. The prognosis is marked by high risk of mortality and morbidity. Here, we report a case of preterm new born who presented with sepsis, apnoea, and digestive signs. The laparotomy revealed perforated appendicitis complicated with peritonitis.

Several oral and maxillofacial surgery procedures require the simultaneous use of the oropharyngeal space by both the surgeons and the anaesthetists. This poses a lot of challenges especially in optimally securing the airway. Nasotracheal intubation or tracheostomy with their significant morbidity might even be contraindicated in these scenarios owing to several factors elucidated in the literature. Submental endotracheal intubation might be the last resort in adequately protecting the airway without interfering with the surgery. It also permits concurrent access to the dental occlusion and nasal pyramid without the risk associated with nasal intubation and morbidity of tracheostomy. Contraindications include patients who require long periods of assisted ventilation and a severe traumatic wound on the floor of the mouth. Complications include localised infection and sepsis, poor wound healing or scarring, and post-operative salivary fistula. The rationale for this study is to describe the indications, contraindications and the technique of submental endotracheal intubation as performed in our hospital.