Background: W e present our experience of sutureless and bloodless elective circumcision in neonates and infants with Gomco clamp. Patients and Methods: From March 2008 to May 2011, 200 babies with age ranging from 2 weeks to 7 months underwent Gomco circumcision. All patients were given chlorohydrate 50 mg/kg, paracetamol suppository 15 mg/kg, and local anesthesia. Procedure was done in minor operation theatre (OT) and babies were observed for 1 h in recovery room before discharging them home. Results: Two of our patients (1%) required immediate suturing on table after Gomco clamp was removed, five patients (2.5%) were shifted back from the recovery room to minor OT for suture repair and eight patients (4%) required reinforcement of primary dressing to control the minor ooze. There was no other complication. Cosmesis was to the satisfaction of the surgeon as well as the parents. Conclusion: Gomco clamp is a bloodless, sutureless, simple, and safe method of circumcision in newborns and infants. It is cost-effective and can be performed under local anesthesia and sedation with excellent cosmetic results.

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Dog bite injuries are common in children and represent an important health-care problem. Most dog bite injuries involve the face or an extremity. Victims tend to seek medical care quickly. Dog bites to the external genitalia are rarely reported, but they potentially result in morbidity if improperly managed. Morbidity is also directly related to the severity of initial wound. Guidelines for the management of dog bites include irrigation, dιbridment, antibiotic therapy, consideration of tetanus and rabies immunisation and suture of wounds or surgical reconstruction. Literature review was conducted and focused to analyze the management of dog bite lesions involving external genitalia.

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Background: Colorectal surgeries frequently require bowel preparation. In children, (is this standard of care?: this method is mostly followed) this is usually performed using normal saline, which is very cumbersome and causes unnecessary discomfort. This study compared polyethylene glycol (PEG) with normal saline for preoperative bowel preparation in children. Patients and Methods: Thirty patients, admitted in the Department of Paediatric Surgery, Rajindra Hospital, Patiala, for colonic and colorectal surgical procedures, were divided into two groups, I (PEG) and II (NS), randomly for bowel preparation with PEG and normal saline, respectively. Results: It was found that there was no significant difference in the quality of preparation (P > 0.05), but PEG use was found to be easier, more comfortable and acceptable for the patients, their relatives and the hospital staff. Overall, complications are significantly lesser for PEG preparation (P < 0.05). There was no significant difference in the overall cost. Conclusion: Thus, it can be inferred that PEG may be a safe, cost-effective and acceptable option for large bowel preparation.

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Background: Globally, the major causes of neonatal deaths are birth asphyxia, prematurity and severe infections. Little attention is paid to deaths contributed by surgically amenable conditions. This study was undertaken to determine the burden and types of surgical problems encountered in the neonatal period, their outcome and challenges encountered. Patients and Methods: This was a retrospective study. The case notes of all neonates admitted into the newborn unit of our centre between April 2002 and March 2010 with surgical conditions were retrieved and the following information extracted: Sex, diagnosis, age at presentation, surgical intervention and outcome. Results: Out of 7,401 neonates admitted within the study period, 460 (6.2%) had a surgical condition. Of the 1,657 babies that died within the same period, 196 (11.8%) of them were those with surgical conditions. Congenital abnormalities accounted for 408 (88.7%) of all the surgical cases. Intestinal obstruction 129 (31.6%), neural tube defects 101 (24.8%) and anterior abdominal wall defect 58 (14.2%) were the commonest congenital abnormalities, while fracture of the long bones following birth trauma 15 (28.8%) and perforated NEC 14 (26.9%) were the commonest acquired conditions. Surgery was performed in 166 (36.1%) and 98 (59%) had postoperative complications. Significantly, more deaths occurred in preterms than in term babies (P = 0.003) and in those delivered outside the hospital than in in-born babies (P = 0.02). The major cause of death was infection in 92 (47%). Conclusion: Neonatal surgical conditions contributed significantly to both neonatal admissions and overall neonatal mortality and thus highlights the need for investments in newborn surgical care in developing countries.

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Background: The practice and pattern of male infants circumcised is influenced by culture, religion and socio-economic classification. The debate about the benefits and risks of circumcision has made a hospital-based practice the most acceptable. Objective: The objective of this study is to evaluate the ages, indications, co-morbidity, types and methods of circumcision, usage and mode of anaesthesia and outcome of male circumcision at a tertiary health centre in Nigeria. Materials and Methods: A retrospective review of male circumcision in a paediatric surgery unit was done from January 2002 to December 2007. The data was analysed using SPSS software version 15. Results: There were 438 boys with age ranged between 6 days and 10 years (median 28 days, mean 53.6 days standard deviation 74.2). Neonatal circumcision (<29 days) was 201 (46%) and 318 (72.6%) of the children were circumcised by the 3 ^rd month of live. Religion or tradition were the major indicators in 384 (87.7%) patients while phimosis 38 (8.7%), paraphimosis 4 (1%), redundant post circumcision skin 10 (2.3%) and defective prepuce in 2 (0.5%) were other indications. Plastibel™ (PD) was used in 214 (48.9%), classical circumcision 194 (44.2%), guillotine technique (GT) and Gomco™ 10 (2.3%) cases each while 10 (2.3%) had a refashioning/re-excision post previous circumcision. There was an increase in use of PD, drop in the use of GT; and increase in the number of circumcision done over the years. Only 39.7% had anaesthesia administered and complication rate was 6.7%. Conclusion: Neonatal circumcision was highest in the hospital-based circumcision practice, which allowed the expected ideals in the use of devices in a tertiary health centre. However, the low rate of anaesthetic use is unacceptable.

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Background: The management of major omphalocoele and large incisional hernias is a common problem and constitutes a great challenge for paediatric surgeons. In most cases, the abdominal cavity is so small and does not allow immediate reduction. Prosthetic materials are becoming increasingly popular for such repair, but direct contact between the bowel and these synthetic materials carries the risk of adhesions and intestinal obstruction. The relatively new PROCEED mesh with absorbable layer in contact with the bowel and another polypropylene non-absorbable layer against the abdominal wall may not produce such adhesions. The aim of this study is to evaluate the feasibility and outcome of this relatively new prosthetic mesh for repair of ventral hernia . Patients and Methods: Between June 2009 and December 2012, a pilot study was conducted on 22 cases with large ventral hernias subjected to open surgical repair using PROCEED mesh. The inclusion criterion was cases with large ventral hernias (>4 cm). The evaluating parameters were all the early and late postoperative complications. Results: The defect size ranged from 5 to 12 cm. The early postoperative complication (≤1 month) was seroma discharged from the wound in four cases, while the late complications were recurrent herniation and stitch sinus that occurred in three cases. No manifestations of intestinal obstruction, enterocutaneous fistula or mortality were encountered in any of the 22 cases. Conclusion: The use of PROCEED composite mesh in ventral hernias is feasible and has minimal complication rates.

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Background: As a part of pre-operative evaluation, several otolaryngologists group and cross-match blood routinely for children undergoing adenoid and tonsil surgeries. This practice has generated several debates either in support or against this practice. The aim of this study is to critically evaluate the incidence of post-tonsillectomy (with or without adenoidectomy) bleeding and blood transfusions in otherwise healthy children with adenoid/tonsil pathologies conducted in the University of Port Harcourt Teaching Hospital (UPTH). Patients and Methods: A descriptive retrospective study of children who underwent adenoid and tonsil surgeries in the Department of Ear, Nose and Throat (ENT) surgery of UPTH from January 2003 to December 2012. Children with family history of bleeding disorders and derangement of clotting profile as well as different co-morbidity like sickle cell disease were excluded from this study. The patients' data were retrieved from the registers of ENT out-patient clinics, theatre registers and patients case notes. Demographic data, indications for surgery, preoperative investigations, complications and management outcomes were recorded and analyzed. Results: Out of 145 children that had adenoid and tonsil surgeries; only 100 met the criteria for this study. The study subjects included 65 males and 35 females (male: female ratio 1.9:1) belonging to 0-16 years age group (mean age: 3.46 ± 2.82 years). The age group of 3-5 years had the highest (n = 40, 40%) number of surgeries. Adenotonsillectomy was the commonest (n = 85, 85%) surgery performed on patients who had obstructive sleep apnea (OSA). The commonest (n = 6, 6%) complication was haemorrhage, and only few (n = 3, 3%) patients had blood transfusion. However, mortality was recorded in some (n = 3, 3%) patients. Conclusion: This study confirms that the incidence of post adenoidectomy/tonsillectomy bleeding in otherwise healthy children is low and rarely requires blood transfusion. We can conclude that routine preoperative blood grouping and cross-matching of blood for all children undergoing elective adenoid and tonsil surgeries seemed irrelevant and not cost effective. However, it could be carried out in only special circumstances.

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Background: In tropical countries, iatrogenic retractile quadriceps fibrosis (IRQF), the cause of walking handicap in children, is often the result of intraquadricipital injection of quinine salts. The aim of this review was to analyse the epidemiological, clinical, therapeutic aspects and outcome of IRQF in children admitted in three hospitals in Benin Republic. Patients and Methods: It was a 10-year retrospective, descriptive and analytic survey of IRQF, involving 81 children aged from 8 months to 15 years. Iterative mobilization of the knee (IMK) or modified distal quadriceps plasty by Thompson-Payr's technique (MDQTPT), with a POP on the knee in flexion position, was performed with additional functional rehabilitation. The results were evaluated on knee flexion gain and walking quality. Data were processed using Epi Info 3.2 software. Results: Patients' average age was 7.60 years. Children of 6-10 years were most affected; sex ratio was 1.02. Lesions were unilateral (71.6%) and bilateral (28.4%). The knees' stiffness was in flexion (10.57%), rectitude (64.42%) and recurvatum (25%). The amyotrophy of the thigh was found in 79.42 %. The IMK was successful in eight cases (7.69 %) and the MDQTPT was done in 98 cases (94.23%) associated with femoral osteotomy in 13 cases (12.50%). In post-surgical period, skin necrosis and fractures occurred respectively in 15.31% and 5.10%. Results were good in 92.31% of cases. Conclusions: IRQF in children do exist in our settings. The treatment that is based on MDQTPT associated to rehabilitation leads to acceptable outcome.

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Background: Adhesive small bowel obstruction (ASBO) is a feared complication after abdominal operations in both children and adults. The optimal management of ASBO in the pediatric population is debated. The aim of the present study was to examine the safety and effectiveness of non-operative management in ASBO. Patients and Methods: A retrospective review of 33 patients who were admitted for ASBO over a 5-year period was carried out. Follow-up data were available for 29 patients. Demographic, clinical, and operative details and outcomes were collected for these patients. Data analysis was done with SPSS version 15.0. P ≤ 0.05 was regarded as significant. Results: Out of 618 abdominal surgeries within the 5-year period, 34 admissions were recorded from 29 patients at the follow-up period of 1-28 months. There were 19 boys (65.5%). The median age of patients was 4.5 years. Typhoid intestinal perforation (n = 7), intussusception (n = 6), intestinal malrotation (n = 5), and appendicitis (n = 4) were the major indications for a prior abdominal surgery leading to ASBO. Twenty-five patients (73.5%) developed SBO due to adhesions within the first year of the primary procedure. Of the 34 patients admitted with ASBO, 18 (53%) underwent operative intervention and 16 (47%) were successfully managed non-operatively. There were no differences in sex (P = 0.24), initial procedure (P = 0.12), age, duration of symptoms, and time to re-admission between the patients who responded to non-operative management and those who underwent operative intervention. However, the length of hospital stay was significantly shorter in the non-operative group (P < 0.0001). Five (14.7%) patients had small bowel resection. A 43-day-old child who initially underwent Ladd's procedure died within 15 h of re-admission while being prepared for surgery, accounting for the only mortality (3.4%). Conclusion: Non-operative management is still a safe and preferred approach in selected patients with ASBO. However, 53% eventually required surgery.

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Situs inversus in association with duodenal atresia is very rare. A high index of suspicion coupled with appropriate evaluation is necessary for diagnosis and operative planning. We report a case of a 5-day-old who presented with duodenal atresia associated with polysplenia and situs inversus with a review of the medical literature.

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Background: The ilioinguinal-iliohypogastric (ILIH) nerve block is a safe, effective, and easy to perform in order to provide analgesia for a variety of inguinal surgical procedures in pediatric patients. A relatively high failure rate of 10%-25% has been reported, even in experienced hands. It is assumed that this high failure rate of the ILIH nerve block in this age group could be due to lack of special knowledge of the anatomy of these nerves in infants and neonates. There are two main techniques for landmark-based ILIH nerve block with regard to determining the best insertion point. This study compared the sucess rate and outcomes of these two techniques in children undergoing surgery in inguinal region. Patients and Methods: In a double-blind randomized clinical trial, 120 children were candidated for surgery in inguinal region, and ILIH nerve block was recruited in Tabriz Children Teaching Hospital in a 12-month period. They were randomly clustered in two groups and underwent two different methods of ILIH nerve block. In the first group, needle was inserted in a point placed between outer 1/4 and inner 3/4 of a line connecting anterior-superior iliac spine to umbilicus (n = 58), and in the second group, this point was 1 cm medial and 1 cm superior to anterior-superior iliac spine. Block failure was defined as the need for analgesia during operation. Results: There were 50 males (86.2%) and 8 females (13.8%) with a mean age of 5.55 ± 2.32 (3-11) years in the first group and 48 males (87.3%) and 7 females (12.7%) with a mean age of 5.32 ± 2.18 (3-11) years in the second group (P > 0.05). The success rate of ILIH block was 94.8% in the first group and 94.5% in the second group with no significant difference between the two groups (P = 0.64). Changes of vital signs including heart rate, systolic blood pressure, and diastolic blood pressure, as well as the SPO2 were not significantly different between the two groups during the study period. Change of pain severity after recovery was also comparable between the two groups. Time of the first dose of postoperative analgesic was not significantly different between the two groups. Conclusion: Based on our findings, success rate and outcomes of the two techniques of landmark-based ILIH block are similar in children undergoing surgery in inguinal area.

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Background: Supra-Transumbilical Laparotomy (STL) has been used in paediatric surgery for a broad spectrum of abdominal procedures. We report our experience with STL approach for small bowel atresia repair in newborns and review previous published series on the topic. Patients and Methods: Fourteen patients with small bowel atresia were treated via STL approach at our Institution over a 5-year period and their charts were retrospectively reviewed. Results: STL procedure was performed at mean age of 3.1 day. No malrotation disorders were detected with pre-operative contrast enema. Eight patients (54.1%) presented jejunal atresia, five (35.7%) ileal atresia, and one (7.1%) multiple ileal and jejunal atresias. Standard repair with primary end-to-back anastomosis was performed in all but one patient. In the newborn with multiple atresia, STL incision was converted in supra-umbilical transverse incision due to difficulty of exposition. After surgery, one patient developed anastomotic stricture, and another developed occlusion due to adhesions: Both infants required second laparotomy. No infections of the umbilical site were recorded, and cosmetic results were excellent in all patients. Conclusions: Increasing evidence suggests that STL approach for small bowel atresia is feasible, safe and provides adequate exposure for small bowel atresia surgery. When malrotation and colonic/multiple atresia are pre-operatively ruled out, STL procedure can be choosen as first approach.

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We report a case of xanthogranulomatous pyelonephritis (XGP) complicated by shaped urolithiasis, severe hydroureteronephrosis and kidney exclusion treated by laparoscopic-assisted nephroureterectomy. A 9 year-old boy was referred to us for recurrent episodes of urinary tract infection, abdominal pain and severe hydronephrosis. Abdominal CT and a Tc-99m MAG3 scan showed a non-functioning obstructed kidney with shaped urolithiasis of the distal ureter. XGP was suspected, and nephroureterectomy was performed by laparoscopic distal ureterectomy and open extraperitoneal nephrectomy. This technique avoided the need for a more extended nephrectomy incision or even a second iliac incision. It also ensured complete excision of the distal ureter with minimal risk of developing the ureteral stump syndrome, which sometimes follows nephroureterectomy. We believe that laparoscopic-assisted nephroureterectomy may be a suitable technique in those cases of difficult nephrectomy where a ureteral stump syndrome is likely to develop.

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Background: Intussusception is one of the most common causes of intestinal obstruction in children. While the outcome has improved in the developed nations, the same cannot be said of the developing countries, more especially in the sub-Saharan region. This study aims to review our current experience in the management of childhood intussusception and factors affecting surgical outcome at the Obafemi Awolowo University Teaching Hospitals Complex Ile-Ife. Patients and Methods: This was a retrospective study of 78 patients treated for intussusception at paediatric surgical unit of Obafemi Awolowo University Teaching Hospitals Complex Ile-Ife between January 1993 and December 2011. The case notes of the patients were retrieved and the following information was recorded: Demographic characteristics, month of occurrence, clinical presentation, investigations, and management as well as the post-operative outcome. The patients were divided into two groups in terms of outcome. Results: There were 58 males and 20 females (M:F = 2.9-1). The age of most of the patients was between 3 months and 9 months with peak incidence at 6 months. Most patients 46 (58.9%) were seen during the dry season of December to April. Only six patients (7.7%) presented within 24 hours of onset of illness. More than half of the patients presented after 24 hours. Passage of red currant stool, vomiting, abdominal pain, fever, and abdominal distension, passage of watery stool, anal protrusion and palpable abdominal mass in various combinations were the clinical features. All the patients had surgical operations. The most common type of intussusception was ileo-colic type in 64 patients (82.1%). Intestinal resection rate was 41%. The overall mortality rate was 15.4%. Conclusion: There was a delay in presentation of children with intussusception with high post-operative mortality.

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Background: The aim of our study was to investigate if total bilirubin (T-bil), amylase (Amy), and sodium (Na) in nasogastric (NG) aspirates can reflect gastrointestinal motility reliably. Materials and Methods: NG aspirates from all laparotomies lasting more than 150 min in children less than 12 months old were studied for 3 months. Color of aspirates and intensity of bowel sounds were graded every 3 h by nursing staff and aspirate samples for measuring T-bil, Amy, and Na were collected independently every 12 h until an oral fluid challenge was tolerated. Results: There were 26 subjects. Mean age at surgery was 5.6 months; mean body weight at surgery was 5.8 kg. No postoperative complications occurred. While there was no reduction in average volume of NG aspirates, color change was subjective, and bowel sounds could not be standardized, T-bil decreased over time (0d: 4.4 mg/dL; 0.5d: 2.7 mg/dL; 1.0d: 1.6 mg/dL; 1.5d: 1.3 mg/dL; 2.0d: 0.4 mg/dL; 2.5d: 0.33 mg/dL; 3.0d: 0.21 mg/dL; 3.5d: 0.15 mg/dL; 4.0d: 0.06 mg/dL; 4.5d: 0.05 mg/dL; 5.0d: 0.02 mg/dL; 5.5d: 0.02 mg/dL; 6.0d: 0.01 mg/dL). Amy and Na were inconclusive. Conclusion: T-bil levels in NG aspirates may be useful as a reliable objective quantitative marker of gastrointestinal motility postoperatively.

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Cloacal exstrophy is an extremely rare congenital abnormality resulting in an exstrophy of the urinary, intestinal and genital organs and associated with anomalies of other organ systems. We report a complicated case of cloacal exstrophy associated with right vesicoureteric junction obstruction.

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Background: The expected knowledge translation from discovery into practice occurs when presentations from major scientific meetings are published in peer-reviewed literature. The purpose of this study was to determine the extent of complete publication of peer-reviewed articles arising from presentations at the biennial meetings of the Pan-African Pediatric Surgical Association (PAPSA). Materials and Methods: All the abstracts accepted for presentation at the biennial meeting of PAPSA between 2006 and 2010 were identified from the conference abstract booklets and published abstracts in the African Journal of Paediatric Surgery. The presentations were searched for publication in Medline/PubMed, Google Scholar, and African Journal OnLine through October 2012, using key words from the abstract title and names of authors listed in the abstracts. Results: A total of 164 abstracts were accepted for presentation, consisting of 118 (72%) oral/podium presentations and 46 (28%) poster presentations. One hundred and thirty-three abstracts (81.1%) came from African countries and 31 (18.9%) from outside Africa. Overall, 49 (29.9%) abstracts resulted in full-text publications in 20 peer-reviewed journals. Thirty-eight of the publications were from Africa (representing 28.6% of abstracts from Africa) and 11 from outside Africa (33.3% of abstracts from outside Africa). The median time to publication was 15 months [interquartile range (IQR) 5-26 months]. The publication rate was statistically significantly correlated to the year of publication (P = 0.016) and the use of comparative statistics in the study (P = 0.005), but not to the study design, study subjects, or institution. The majority of the studies were published in the African Journal of Paediatric Surgery and Pediatric Surgery International (14 and 11 of the 49 reports, respectively). The H-index for international abstracts (median 35, IQR 35-76) was significantly higher than that of African abstracts (14, 3-35) (P = 0.002). Conclusion: Only a third of abstracts presented at PAPSA biennial meetings were ultimately published in a peer-reviewed journal. Increased efforts to improve the publication rate and facilitate the rapid dissemination of new knowledge are needed.

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Bilateral ovarian tumour in a girl presents the dilemma of conservative versus aggressive approach towards these tumours. When faced with suspicious tumour and complete replacement of the ovaries bilaterally, bilateral oophorectomy is a viable option, though the certain possibility of infertility and lifelong hormonal supplementation is unavoidable. We report a case of bilateral ovarian masses in a young girl, which on histopathological examination showed mature teratoma with aggregates of proliferating capillary and cavernous sized vessels in the tumour wall. Such associations are rare and must be differentiated from a vascular neoplasm.

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Background: Little attention is generally paid to paediatric injuries, especially in low income settings. The aim of this study is to provide an overview of the epidemiology of hospital-based paediatric injuries in a semi-urban area in Cameroon prior to the initiation of a formal registration system. Patients and Methods: A sixteen items data collection sheet derived from a newly instituted trauma registry is used to retrospectively gather hospital-based basic information about epidemiology of injuries in patients aged 15 years or below in a low income setting. Results: Two hundred and seventy seven cases representing 16% of all injury cases could be analysed. The frequency of injuries significantly increased with age with a peak between 11 and 15 years (P < 0.001). Children in school playgrounds carried a significantly higher risk of sustaining an injury (P < 0.001). Falls and interpersonal violence were the most frequent mechanisms. The face and locomotor systems were the most commonly involved. More than 60% of patients were discharged back home. Conclusions: The data from the present registration system seem to indicate a higher injury rate in pre-adolescent children and in the school playground. The institution of a formal registration system is likely to improve the quality of data recording system.

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Although thoracoscopic lobectomy for severe bronchiectasis has been reported in children, this is the first report of double lobectomy of the right middle and lower lobes performed using the video-assisted thoracoscopy in a 9-year-old girl. The post-operative course was uneventful and she is currently well after 18 months' follow-up.

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