An inguinal hernia (IH) is a protrusion of intra-abdominal contents through the inguinal canal that can arise at any time from infancy to adulthood. It is more common in males with a lifetime risk of 27% as compared to 3% in females. Most pediatric IHs are congenital and caused by failure of the peritoneum to close, resulting in a patent processus vaginalis (PPV). IH present as a bulge in the groin area that can become more prominent when crying, coughing, straining, or standing up, and disappears when lying down. Diagnosis is based on a thorough medical history and physical examination, but imaging tests such as ultrasound can be used when the diagnosis is not readily apparent. IHs are generally classified as indirect, direct, and femoral based on the site of herniation relative to surrounding structures. Indirect hernias protrude lateral to the inferior epigastric vessels, through the deep inguinal ring. Direct hernias protrude medial to the inferior epigastric vessels, within Hesselbach’s triangle. Femoral hernias protrude through the small and inflexible femoral ring. In infants and children, IH are always operated on to prevent incarceration.
Surgical correction in infants and children is done by high ligation of the hernia sac only, called a herniotomy. Here, we present a female infant with bilateral IH. Upon exploration, a hernia sac was found, and ligation was performed bilaterally. In female patients, it is believed that failure of the closure of the canal of Nuck alongside the round ligament of the uterus is the etiology. Oftentimes there is a “sliding hernia” where the ovary and or the fallopian tube is attached to the sac, sometimes the uterus itself is attached.
Cryptorchidism, or undescended testis, is a condition in which one or both testes fail to descend from the abdomen into the scrotum during fetal development. Phimosis, on the other hand, is a condition characterized by the inability to retract the foreskin over the glans penis.
This video serves as a step-by-step guide on orchiopexy to correct an undescended testicle and circumcision to correct phimosis. The importance of this surgical intervention lies in the preservation of testicular function, fertility potential, and the prevention of long-term complications associated with cryptorchidism. Early treatment is crucial, as it significantly reduces the risk of testicular damage and associated complications.
Skin is the largest organ by surface area of the body and is essential to prevent dehydration as the first barrier to infection, permit unrestricted movement, and provide a normal profile and appearance. A skin graft is a paper-thin piece of skin that has no fat or other body tissues attached and has been completely removed from its blood supply. Therefore, a skin graft can be transferred anywhere in the body as long as where placed, the so-called recipient site, does have a sufficient blood supply to nourish the skin until new blood vessels can grow into it within a short timeframe. Otherwise, if that does not occur, the graft will shrivel up and die. The downside even of a successful skin graft is the variable final color and inharmonious appearance of the skin, a tendency to contract possibly causing deformities especially limiting motion across joints, and similar healing issues at a second wound, that is the donor site of the graft itself. Nevertheless, this is a rapidly performed surgical procedure requiring but the simplest of instrumentation for the harvest of that graft that can then permit replacement of extensive skin deficiencies. In this video article, these virtues are displayed as a split-thickness skin graft is used to replace the skin missing following the removal of a large squamous cell skin cancer of the forearm.
Bilateral Syndactyly Release of Third and Fourth Fingers Sudhir B. Rao, MD1; Mark N. Perlmutter, MS, MD, FICS, FAANOS2; Arya S. Rao3; Grant Darner4 1Big Rapids Orthopaedics 2Carolina Regional Orthopaedics 3Columbia University 4Duke University School of Medicine
Amniotic band syndrome, or constriction ring syndrome, happens when a developing fetus gets tangled in the fibrous bands of the amniotic sac. Sometimes, fingers and toes can become trapped in these fibrous bands, with results ranging from amputation of the digits, to fusion of the fingers or toes, termed syndactyly. Syndactyly is amongst the most frequent congenital hand anomaly and is termed simple when the digits are connected by soft tissue only, and complex when one or more phalanges are fused. In complicated syndactyly, there are additional bony elements in between the digits making it challenging if not impossible to separate safely.
The patient in this case is a 1-year-old male with complex syndactyly of the left hand and simple syndactyly of the right hand. Here, both sides are released, with the left side involving a full-thickness skin graft taken from the patient’s groin crease. This case was filmed during a surgical mission with the World Surgical Foundation in Honduras.
This video article demonstrate surgical correction of a severe hand deformity in a teenage girl with spastic hemiplegia. This patient has a non-functioning hand due to severe spasticity. Correction of the deformity is indicated primarily to facilitate hygiene and improve the position of the fingers. In some patients with volitional control, a certain degree of prehension may be achieved. The basic principles of deformity correction include differential sectioning of sublimis and profundus tendons followed by repair in a lengthened position. The first web contracture is released by muscular release and a skin Z-plasty.
This video presents a case of bilateral open indirect inguinal herniotomy. The patient, a 12-year-old male, presented to the medical facility with complaints of bilateral protruding masses in the inguinal regions. These masses have been causing him discomfort and pain, particularly during physical exertion. Upon palpation, the masses exhibited an elastic consistency, increased in size during bearing in a standing position, and were found to be reducible when the patient was in a supine position. The patient’s mother reported that these bulges have been present since his birth. Following a comprehensive clinical evaluation, a clinical diagnosis of congenital bilateral inguinal hernia was made. Consequently, a decision was made to perform a bilateral open inguinal herniotomy with high ligation of the hernia sac.
This video demonstrates the essential steps of a bilateral indirect inguinal herniotomy in a pediatric patient, highlighting the importance of proper anatomical dissection, identification of crucial structures, and the high ligation technique for successful hernia repair in children. The detailed procedural description, coupled with the emphasis on anatomical landmarks and technical nuances, makes this video a valuable educational resource for surgical trainees, who are learning the principles and techniques of pediatric inguinal hernia repair.
This comprehensive video is intended to provide a detailed overview of the surgical technique used to repair a right inguinal hernia in Honduras on a 1-year-old boy who presented with a swelling in his scrotum, which had been present since he was two months old. The surgical procedure is narrated by an experienced pediatric surgeon, highlighting the unique challenges and innovative techniques employed in this case, which can be valuable for surgeons facing similar situations. The importance of this video lies in its educational value for surgeons, particularly those involved in surgical missions or practicing in resource-limited settings.
Occasionally, the treatment of breast cancer requires the removal of the breast while also leaving a large chest skin deficit. Especially if radiation has been done or is planned, the best way to restore the missing skin to preserve its essential function would be by the use of a vascularized flap. Sometimes this can be achieved while simultaneously providing a reconstruction of a very aesthetic breast mound. Depending on circumstances and the extent of disease, a simpler solution might be to just close only the chest wound that has been created.
A “workhorse” flap alternative that is almost always available to achieve this is the latissimus dorsi (LD) muscle from the back, as this can be moved to almost all regions of the chest. The LD muscle usually can be swung to the chest about its blood vessels that remain attached to the armpit, and so would be called a local flap that as such avoids the complexities of a transfer requiring microsurgery to reconnect the blood supply. The long-term experience by reconstructive surgeons in using the LD muscle as a local flap, not just for the chest but also the back, head, and neck, has proven its deserved accolade to be a versatile flap unparalleled by most other donor sites.
Aspiration of Ganglion Cyst on Right Wrist Jonathan E. Sledd1; Marcus Lester R. Suntay, MD, FPCS, FPSPS, FPALES2 1Edward Via College of Osteopathic Medicine – Auburn Campus 2Philippine Children’s Medical Center
Ganglion cysts are sacs containing a gel-like fluid that can form over tendons and joints. They are commonly seen as visible lumps on the hand and back of the wrist. Ganglion cysts are not cancerous, and most are asymptomatic. But if a cyst puts pressure on a nerve, it can cause pain, tingling, and muscle weakness. Initial treatment of a ganglion cyst is not surgical. Observation may be recommended because half of ganglion cysts may disappear over time. Activity often causes the cyst to increase in size, and thus immobilization may be an option. If a ganglion cyst causes pain and limits activities, aspiration of the fluid may decrease pressure and relieve pain. Surgical excision may also be recommended if symptoms are not relieved or if the cyst recurs. This article presents the case of a 51-year-old female who had a ganglion cyst on her right wrist. Treatment options were presented to the patient, and she opted to undergo aspiration over excision.
Open Proctocolectomy for Hirschsprung’s Disease Mudassir Shah Akhter, MD1; Marcus Lester R. Suntay, MD, FPCS, FPSPS, FPALES2 1Oregon Health and Science University 2Philippine Children’s Medical Center
Hirschsprung’s disease is the main genetic cause of functional intestinal obstruction. Most cases are diagnosed in the first few months of life given classical presentation and ease of testing with rectal suction biopsy. The disease is due to the absence of enteric ganglion cells in the distal colon that results in functional constipation. Resection of the affected segment and bringing the normal bowel close to the anus has been the mainstay of treatment. Due to advances in surgical treatment over the past decades, a significant reduction in morbidity and mortality has been observed, and the previously multistage procedure can now be completed in one stage, as presented here.
