Category Archives: Pediatrics

Pediatrics, Print Release, Vascular Surgery

PUBLISHED: Pediatric Ultrasound-Guided Internal Jugular Central Venous Catheter (CVC) Insertion for Chemotherapy Delivery

Pediatric Ultrasound-Guided Internal Jugular Central Venous Catheter (CVC) Insertion for Chemotherapy Delivery
Yuki Noguchi, MD, PhD; Kohga Masuda, MD, PhD; Shohei Hiwatashi, MD, PhD; Satoshi Umeda, MD, PhD; Masahiro Zenitani, MD, PhD; Keigo Nara, MD, PhD
Osaka Women’s and Children’s Hospital

Central venous catheterization is a commonly performed procedure in pediatric surgery, requiring both appropriate device selection and meticulous technique to ensure long-term function and minimal complications. This article reports the technical considerations of tunneled central venous catheter placement in a pediatric patient with neuroblastoma.

A two-year and four-month-old boy with neuroblastoma required central venous access for chemotherapy. Preoperative evaluation confirmed patency of the right internal jugular vein and other central veins. A cuffed tunneled external catheter was selected, as it allows continuous access without repeated needle puncture and is suitable for multi-lumen use, including drug administration and blood sampling. Although routine blood sampling via central venous catheters is not generally recommended, our experience suggests that the associated risks are infrequent and clinically acceptable.

The catheter was inserted via the right internal jugular vein. The anterior chest wall exit site was determined using anatomical landmarks, specifically the triangle formed by the sternal notch, right acromion, and right nipple, with the entry point positioned near its center. Key technical considerations included creation of a broad, curved subcutaneous tunnel to prevent catheter kinking, secure fixation using a cuff with additional circumferential suturing to reduce early dislodgement, and accurate tip positioning at the junction of the superior vena cava and right atrium. In practice, the optimal tip location was estimated as approximately 1–2 vertebral body units below the carina. Careful hemostasis and postoperative compression were performed to minimize hematoma formation.

General Surgery, Pediatrics, Print Release

PUBLISHED: Laparoscopic Percutaneous Extraperitoneal Closure (LPEC) for an Inguinal Hernia with Concomitant Umbilical Hernia Repair in a Pediatric Male

Laparoscopic Percutaneous Extraperitoneal Closure (LPEC) for an Inguinal Hernia with Concomitant Umbilical Hernia Repair in a Pediatric Male
Yuki Noguchi, MD, PhD; Kohga Masuda, MD, PhD; Shohei Hiwatashi, MD, PhD; Satoshi Umeda, MD, PhD; Masahiro Zenitani, MD, PhD; Keigo Nara, MD, PhD
Osaka Women’s and Children’s Hospital

This report describes the surgical management of a one-year eight-month-old boy with concurrent right inguinal and umbilical hernias, highlighting both clinical rationale and operative technique. Pediatric inguinal hernias are typically indirect and rarely resolve spontaneously, carrying a persistent risk of incarceration that necessitates surgical repair once diagnosed.

Ultrasonography confirmed a right indirect inguinal hernia with reducible protrusion of the small intestine through a patent processus vaginalis. Although the umbilical hernia showed partial improvement with external compression, the inguinal hernia was unlikely to resolve spontaneously. Therefore, laparoscopic percutaneous extraperitoneal closure (LPEC) was planned, with simultaneous umbilical hernia repair.

LPEC enables high ligation of the hernia sac with minimal dissection and excellent visualization. In male patients, careful technique is required to avoid injury to the spermatic vessels and vas deferens. Tip rotation should be avoided; instead, the needle tip is advanced perpendicularly across these structures at the shortest possible distance to minimize dissection. Gentle manipulation facilitates safe passage, and confirmation that critical structures are not entrapped within the suture loop is essential before ligation. Caudal traction of the testis may further reduce the risk of iatrogenic cryptorchidism.

General Surgery, Pediatrics, Print Release

PUBLISHED: Laparoscopic Percutaneous Extraperitoneal Closure (LPEC) for an Inguinal Hernia in a Pediatric Female

Laparoscopic Percutaneous Extraperitoneal Closure (LPEC) for an Inguinal Hernia in a Pediatric Female
Yuki Noguchi, MD, PhD; Shogo Saito, MD; Shohei Hiwatashi, MD, PhD; Satoshi Umeda, MD, PhD; Masahiro Zenitani, MD, PhD; Keigo Nara, MD, PhD
Osaka Women’s and Children’s Hospital

Pediatric inguinal hernias are indirect, resulting from a persistent patent processus vaginalis (PPV). These hernias will not spontaneously heal and carry a serious, persistent risk of incarceration. Consequently, surgical repair is typically advised soon after diagnosis to minimize the risk of incarceration.

This report details a 4-year-old girl with a reducible left inguinal hernia containing the greater omentum undergoing minimally invasive laparoscopic percutaneous extraperitoneal closure (LPEC). LPEC offers improved visualization, superior cosmetic results, and the ability to identify and repair contralateral PPV during the same procedure, which reduces the risk of metachronous hernia—particularly in girls, where the technique is technically straightforward.

General Surgery, Pediatrics, Print Release

PUBLISHED: Pediatric Laparoscopic Splenectomy for Splenomegaly due to Hereditary Spherocytosis

Pediatric Laparoscopic Splenectomy for Splenomegaly due to Hereditary Spherocytosis
Swetha Jayavelu, MD; Marc Mankarious, MD; Bryanna M. Emr, MD
Penn State Health Milton S. Hershey Medical Center

Hereditary spherocytosis (HS) is a form of inherited hemolytic anemia seen in children. HS is characterized by anemia, jaundice, splenomegaly, and complications such as gallstone formation or growth delay. While mild cases may be managed conservatively, splenectomy remains the definitive treatment for patients with severe symptoms or complications. This case presents a 10-year-old male with HS who presented with anemia, fatigue, abdominal pain, and palpable splenomegaly. He was found to have splenomegaly with a splenic length of 19.6 cm. He ultimately underwent a laparoscopic total splenectomy after receiving appropriate preoperative vaccinations. The procedure was completed successfully without complications, and the patient was discharged on post-op day 3. At follow-up, he demonstrated improved hemoglobin levels, resolution of abdominal pain, and no early complications. This case highlights the role of laparoscopic total splenectomy as a safe and effective treatment for pediatric patients with hereditary spherocytosis and massive splenomegaly, offering durable hematologic improvement with the benefits of a minimally invasive approach.

General Surgery, Ob/Gyn, Pediatrics, Print Release

PUBLISHED: Pediatric Exploratory Laparotomy and Left Ovarian Cystectomy

Pediatric Exploratory Laparotomy and Left Ovarian Cystectomy
Swetha Jayavelu, MD; Marc Mankarious, MD; Bryanna M. Emr, MD
Penn State Milton S. Hershey Medical Center

Ovarian cysts are a common gynecologic finding in adolescent females and are typically benign, often resolving without requiring intervention. However, larger cysts can cause significant symptoms and pose a risk for complications such as torsion. These cysts were traditionally removed with a full midline laparotomy. Surgery as a field has moved towards minimally invasive approaches to promote healing and aesthetics. With large benign cysts, this is achieved with controlled intentional decompression, allowing for extraction with a smaller incision. In this case, we present a 14-year-old female who presented with abdominal discomfort and was found to have a 24x20x9-cm left ovarian cyst. She underwent controlled cyst decompression into a specimen bag, minimizing peritoneal contamination prior to removal of the cyst. This was achieved in a 5-cm Pfannenstiel incision. The patient was discharged the same day without complications and demonstrated full recovery with no cyst recurrence at the 12-week follow up. This case highlights the safe, effective management of large benign ovarian cysts using controlled decompression and innovative containment strategies to enable minimally invasive surgical access.

General Surgery, Pediatrics, Print Release, Urology

PUBLISHED: Cloacal Exstrophy Repair

Cloacal Exstrophy Repair
William Remley1; Howard Jen, MD2; Carl-Christian A. Jackson, MD2; Jeremy Wiygul, MD2
1Lake Erie College of Osteopathic Medicine
2Tufts Medical Center

Cloacal exstrophy is congenital malformation marked by an abdominal wall defect with open and exposed hindgut and bladder. It is the most severe birth defect within the exstrophy-epispadias complex, and when spinal defects are also present, it is called the OEIS (omphalocele, exstrophy, imperforate anus, and spinal defect) complex. Cloacal exstrophy is rare, occurring in 1/200,000–400,000 births, but it can be diagnosed on prenatal ultrasound. The defect results in two exstrophied hemibladders separated by an exposed cecal plate, with the distal hindgut being foreshortened and blind-ending, resulting in an imperforate anus. There is diastasis of the pubic symphysis, and the genitalia are separated. In males, the phallus is usually split in half, flattened and shortened, with the inner surface of the urethra exposed. In females, the clitoris is split, the labia are widely separated, and there may be two vaginal openings. Cloacal exstrophy is also highly associated with other birth defects, especially spina bifida, which coexist in up to 75% of cases. Multidisciplinary care followed by surgical management should begin immediately following the baby’s delivery.

Surgical goals in the neonatal period include closure of the meningocele and repair of the exstrophy and omphalocele, resulting in approximation of the bladder halves and repair of the hindgut defect with colostomy creation. Closure of the bladder, with positioning within the pelvis, can either occur at the initial operation or be staged to occur after a period of monitored growth, and is best performed with pelvic osteotomies to protect the closure from tension. Subsequent surgeries over several years will address genital reconstruction and colonic pull-through for fecal continence, if the patient is a candidate. Here, we present a patient diagnosed with OEIS complex by prenatal ultrasound, with a postnatal exam confirming the diagnosis and demonstrating a closed (covered) myelomeningocele. The cloacal exstrophy and omphalocele were repaired in one stage, with primary closure of the involved bowel and the bladder, facilitated by pelvic osteotomies.

General Surgery, Global Surgery, Pediatrics, Print Release

PUBLISHED: Posterior Sagittal Anorectoplasty (PSARP) for Imperforate Anus

Posterior Sagittal Anorectoplasty (PSARP) for Imperforate Anus
Jacob Blank1; Paulo Castillo, MD2; Marcus Lester R. Suntay, MD, FPCS, FPSPS, FPALES3
1Lake Erie College of Osteopathic Medicine
2World Surgical Foundation
3Philippine Children’s Medical Center

Imperforate anus is a birth defect in which the anal opening is absent. This condition develops during the fifth to seventh weeks of pregnancy and the cause is unknown. It affects about one in every 5,000 newborns and is noted to be more common among boys than girls. Imperforate anus is usually present with other birth defects such as vertebral defects, cardiac problems, tracheoesophageal fistula, renal anomalies, and limb abnormalities, collectively known as the VACTERL association. The diagnosis is made by performing a physical exam after birth. An x-ray of the abdomen and abdominal ultrasound can help reveal the extent of the abnormalities.

Treatment is surgical creation of an opening or new anus to allow stool to pass. The type of surgery differs and depends on whether the anus ends high or low in the pelvis. In the case of a low type, an anal opening is made in a single operation, and the rectum is pulled down to the anus. For high type, surgical correction is performed in three stages. The first procedure is bringing the intestine out of the abdomen creating a stoma; the second procedure is pulling the rectum down to the anus where a new anal opening is created; and the third procedure is closure of the intestinal stoma. Here, we present a case of a 9-month-old male who was born with a high-type imperforate anus. A posterior sagittal anorectoplasty (PSARP) was done as the second of three stages of treatment. The first was an emergency sigmoid colostomy, and the third will be to close the colostomy in about 6 to 8 weeks following the PSARP.

Orthopedics, Pediatrics, Print Release

PUBLISHED: Pelvic Osteotomies for Cloacal Exstrophy

Pelvic Osteotomies for Cloacal Exstrophy
Jeffrey Gray1; Purushottam Gholve, MD, MBMS, MRCS2
1Sidney Kimmel Medical College, Thomas Jefferson University
2Tufts Medical Center

Cloacal exstrophy is part of a wide-ranging spectrum of rare congenital abnormalities resulting from the same embryological defect. Conditions include bladder exstrophy, epispadias, cloacal exstrophy, omphalocele, and more. Mortality due to complications with cloacal exstrophy was historically significant as it is among the most severe of these abnormalities. However, advancements in reconstructive surgery have improved the survival of patients. Pelvic osteotomy is typically indicated in cloacal exstrophy as it normally presents with widely separated pubic bones that require approximation as part of abdominal wall closure.

General Surgery, Global Surgery, Pediatrics, Print Release

PUBLISHED: Pediatric Infant Bilateral Open Inguinal Hernia Repair – Twin B

Pediatric Infant Bilateral Open Inguinal Hernia Repair – Twin B
Casey L. Meier, RN1; Lissa Henson, MD2; Domingo Alvear, MD3
1Lincoln Memorial University, DeBusk College of Osteopathic Medicine
2Philippine Society of Pediatric Surgeons
3World Surgical Foundation

Indirect inguinal hernia repair is a common procedure for premature infants because of the frequency of a patent processus vaginalis. Prompt surgical correction decreases the risk of incarceration, strangulation, and necrosis in children. There are various techniques for herniorrhaphy. This repair demonstrates an open bilateral indirect inguinal hernia repair in an infant that avoids high ligation by closing the internal inguinal ring, utilizing a purse-string method to keep the hernia sac intact. This approach limits the amount of anesthesia used and prevents excess bleeding, making it safe, effective and efficient.

General Surgery, Global Surgery, Pediatrics, Print Release

PUBLISHED: Colon Interposition to Replace an Absent Esophagus is the Procedure of Choice in Low-Income Countries

Colon Interposition to Replace an Absent Esophagus is the Procedure of Choice in Low-Income Countries
Yoko Young Sang, MD1; Caroll Alvarado Lemus, MD2; Domingo Alvear, MD3
1Louisiana State University Shreveport
2Mario Catarino Rivas Hospital, Honduras
3World Surgical Foundation

This surgical video article offers a comprehensive demonstration of the colon interposition procedure, highlighting the critical operative steps and technical nuances involved in performing a successful esophageal replacement, particularly in resource-limited settings, where advanced treatment options such as gastric pull-up or jejunal interposition may be limited. Colon interposition remains a viable solution for restoring swallowing function in patients with EA or other esophageal disorders requiring esophageal replacement.

By providing a detailed visual representation of the surgical process, this video serves as a valuable educational resource for surgeons and healthcare professionals involved in the care of patients with EA or related conditions. It underscores the importance of meticulous surgical technique, vascular preservation, and careful planning to ensure successful outcomes. Moreover, the video emphasizes the crucial role of multidisciplinary care in managing these complex cases. The involvement of specialists in pediatric surgery, anesthesiology, and intensive care is essential for optimizing patient outcomes and addressing potential complications.