The complications following PSARP are early complications like wound infection, bleeding, mis-located anus, wound dehiscence, bowel retraction, recurrent fistula, transient femoral nerve palsy, injury to urethra, bladder, vas deferens or ureter, peritonitis, perineal skin excoriation and bladder dysfunction. Besides, there are many delayed or late complications like ano-cutaneous stenosis, anorectal stricture, rectal mucosal prolaps, urethral stricture, neurogenic bladder, and more frequent functional problems like chronic constipation with overflow incontinence and primary fecal incontinence. The early complications can be avoided by meticulous haemostasis proper closure of the wounds without leaving any dead space, adequate dilatation of the pulled down rectal pouch without tension and good vascularisation of the pulled down rectal pouch. Concerning the late complications, one has to distinguish between 1. Neurogenic problems due to sacral malformations or injury to the neuro erigentes 2. Secondary psychological problems 3. Sphincter insufficiency 4. Altered rectosigmoid motility. For general evaluation of postoperative continence we propose a clinical score, modified according to our publication from 1983. However, this score should be used only for true or primary incontinence based on hypoplasia of sphincter muscles. For children with chronic constipation we propose a special score which involves chronic constipation and overflow incontinence. The classification concerning the degree of continence or incontinence depends on the postoperative treatment necessary. There might be no treatment necessary or special treatment to motility problems and chronic constipation or even special treatment for sphincter insufficiency. According this kind of treatment anorectal malformations are classified in type I in complete continence, in type II partial continence (IIA: continence with dietary management and/or laxative, type IIB: constipation with overflow soiling but clean with enemas and type IIC I partially insufficient muscle complex soiling occasional, no constipation). Finally there is a group III of incontinent children (Type HID: complete insufficient muscle complex encopresis, type HIE: severe motility problems, constipation not manageable). In conclusion we propose that 3 main and 5 subgroups of continence problems should be distinguished and that one should not speak anymore from degrees of continence. The details concerning the treatment of chronic constipation (conservative or operatively) and sphincter insufficiency are discussed.

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Purpose and Method: Fetal tracheal occlusion is expected to be an effective treatment for severe congenital diaphragmatic hernia. However, several problems such as preterm labor due to hysterotomy and recurrent laryngeal nerve injury are still matters of concern with this procedure. To overcome these problems, a new method of fetal tracheal occlusion that uses detachable balloons and a custom-made fetal laryngoscope was developed. Using these devises, 17 fetal lambs underwent tracheal occlusion at around 120 days'gestation. Fetuses were sacrificed after 1-2 weeks, and lung growth was evaluated. Results: Detachable balloons could be introduced to the fetal trachea via a hysterotomy as small as 1 cm and remain in the fetal trachea. Total occlusion was attained in 16 of 17 fetuses. Seven of the 17 fetuses were still alive at the end of the experimental period and were sacrified. All showed significant lung growth as measured by lung volume and weights compared with the control. Conclusion: This new approach is technically easy and allows reliable access to the fetal trachea.

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Purpose: To study whether or not ^<201>TlCl per rectum scintigraphy is clinically useful for evaluating portosystemic shunt in biliary atresia (BA). Methods: We reviewed 13 patients with biliary atresia already in the postoperative state. The patients' details were as follows: age, 4 years 6 months-18 years 7 months (mean: 12 years 7 months); male, 3 cases; females, 10 cases; type III BA, 11 cases; type I-cyst BA, 2 cases. A radioisotope (RI) of ^<201>TlCl (18.5 or 37.0 MBq) was administered via the rectum. Heart and liver counts per area were calculated respectively 30-60 minutes after RI administration, and the ratio of heart and liver (H/L ratio) was adopted as a indicator of portosystemic shunt. Results: 1) There was no correlation between the H/L ratio and laboratory examinations (T-Bil, ALT, CHE, WBC and Plt). 2) There was positive correlation between the H/L ratio and splenomegaly. Splenomegaly was evaluated using gray-scale ultrasonography. 3) There was a positive correlation between the H/L ratio and existence of esophageal varices. Esophageal varices were evaluated using barium meal upper gastrointestinal examination. 4) There was a remarkable positive correlation between the H/L ratio and the patient's age. This group of patients was restricted to that in which the laboratory liver function test was abnormal. Conclusions: The use of ^<201>TlCl via rectum scintigraphy and quantitatively conducted H/L ratio are clinically useful for evaluating the portosystemic shunt in biliary atresia. The portosystemic shunt might gradually increase with patients' age independently of the liver function, which should support our daily clinical observations.

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Purpose: Intractable aspiration in children with neurological impairment results in frequent and progressive pulmonary deterioration. The effectiveness of tracheal separation procedure and burden of nursingcare were examined. Method: During the 14 months between December 2001 and February 2003, operations were performed on 16 patients, nine of whom underwent tracheoesophageal diversion (TED) and seven underwent laryngotracheal separation (LTS). Results: Frequent oral and tracheal management for aspirated saliva were markedly improved after the operations. Aspiration pneumonia and other respiratory disorders were well controlled. Eleven children started oral intake, one of them capable of consuming half-solid foods. Respiration improved prior to rehabilitation. Tracheoesophageal anastomotic leakage and partial breakedown of tracheostomy in the first case were treated conservatively for three weeks and the fistulae were successfully closed. Bacterial contamination and grannulomatous polyp were observed. Tracheo-arterial erosion with massive bleeding was confirmed in two patients and treatment was successful for one. These vascular complaints would be prevented by appropriately arranged tracheostomy tubes of each trachea! angle. Conclusions: LTS and TED not only prevented intractable aspiration and further respiratory disorder, but resulted great progress in psychological development. In addition to marked improvement of QOL, burden on the caregiver was reduced. Visual analogue scale indicated that the parents were satisfied, except for the loss of communication by phonation.

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Purpose: To evaluate the operative outcome of laparoscopic surgery (LS) and compare it with that after open surgery (OS). Methods: The surgical records of 13 children with Meckel's divertuculum were reviewed retrospectively. Seven and six patients underwent wedge resection by OS and LS, respectively. The surgical findings and outcomes were compared between the two groups. Results: The mean operation time was 100 minutes in the OS group and 155 minutes in the LS group (p=0.1004). The mean blood loss was 11 ml in the OS group and 16 ml in the LS group (p=0.9431). The mean hospital stay was 9.7 days in the OS group and 8.7 days in the LS group (p=0.2840). No postoperative complications were encountered in either group. Regarding the port placement in LS, one port (5 mm) was placed in one patient, and two ports (5 mm and 3 mm) in three patients, and three ports (5 mm and 23 mm) in two patients. The two patients who underwent the 3-port procedure had recurrent intussusceptions and a small lesion with bleeding due to ectopic gastric mucosa, respectively. In the patient who underwent the one-port procedure, the diveticulum was located beneath the camera port, and it could be directly grasped after removal of the port. Conclusion: Laparoscopic surgery is as effective as traditional laparotomy for treating Meckel's diverticulum. The most conspicuous advantage of the laparoscopic approach was cosmetics, which would lead to a better QOL throughout the lives of the patients.

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Purpose: Pediatric surgery is not well known among the general public, although its identity seems to be established among medical societies. The aim of this study is to evaluate the identity of pediatric surgery among the general public. Materials and Methods: We organized the 40th Annual Meeting of the Japanese Society of Pediatric Surgeons, which was held from May 28-30, and the following day we organized an open lecture for the general public, with themes entitled 'What is Pediatric Surgery?' and 'How Can Children Have a Happy Life Postoperatively?' Two hundred and forty people attended the open lecture, and 165 of the 240 responded to a questionnaire that was handed out. Based on these data, we investigated a recognition of pediatric surgery, public demands, and ways to promote pediatric surgery. Results: Two-thirds of the attendants came from Kyoto Prefecture, with the remainder from other prefectures. The most effective mass media seemed to be the newspaper. Fifty four percent of the 165 or a family member had visited a pediatric surgery unit previously. Only 24% of the 165 had noticed pediatric surgery clinics near their residence. Some of them felt that they needed more pediatric surgery clinics to consult with, and some emphasized the necessity of long follow-up even after operation. Conclusion: Newspaper was the best means to promote pediatric surgery for the general public. We found that pediatric surgery is not well recognized among the general public and that more clinics should he established to meet the demand.

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Two cases of atypical malrotation in neonates are ireported. One case was a 4-day-old male infant with (duodenal stenosis due to congenital peritoneal bands with atypical malrotation in the duodenum. The ligament of Treitz was observed upon upper Agastrointestinal examination, but the position was low and distal duodenal stenosis was revealed. At the time of surgery, this configuration was associated with peritoneal bands extending across the involved distal duodenum. The other case was a 9-day-old female infant with jejunal stenosis near the ligament of Treitz due to volvulus with associated atypical malrotation. During upper gastrointestinal examination, the ligament of Treitz and complete stenosis of the proximal jejunum were observed. At the time of surgery, the cecum was incompletely rotated and mesenteric attachment was stalk-like with a 270° volvulus.

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Rotavirus is a common causative agent of human gastroenteritis, the main victims being young children and infants. Encephalopathy, convulsion and intussusception are among the rare complications of infection. Asymptomatic transient hepatic involvement is found in up to 50 to 70% of the cases of gastroenteritis caused by the virus. The case presented here is a 4-year 4-month old girl with postoperative biliary atresia. After hepaticoenterostomy, her jaundice improved, mild biochemical hepatic dysfunction remained, and esophageal varices developed. Following rotavirus gastroenteritis, her liver function was so severely deteriorated with no signs of improvement that liver transplantation turned out inevitable. In contrast to otherwise healthy children, rotavirus gastroenteritis must be carefully watched in patients with biliary atresia as a deteriorating factor of the liver.

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We report a newborn patient in which nine atresias were intraoperatively identified in the jejunum, ileum, appendix and transverse colon. The baby was born at 35 weeks of gestation with a body weight of 2016 g. He presented abdominal distention and bilious vomiting, and a laparptomy was perfomed at the age of 2 days. We resected 70 cm of jejunum and ileum including five atresias. We perfomed three anastomoses to preserve 170 cm of the small bowel and primary anastmosis for colonic atresia. The postoperative course was uneventful. He gained body weight rapidly. The patient was discharged from the hospital early. In conclusion, multiple anastomoses may be the most appropriate procedure to prevent short bowelsyndrome in infants with congenital multiple intestinalatresia. In addition, primary anastomosis without prior colostomy is a recommended procedure for congenitalcolonic atresia as compared to colostomy during the initial operation.

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We experienced the case of a 2-month-old girl with an abdominal wall abscess caused by omphalitis that had spread via the medial umbilical ligament. The patient presented right hypogastric and right inguinals welling. She was referred to our hospital with a diagnosis of abdominal tumor. Her skin around the mass was red and swollen. Pus discharge from the umbilicus was noted. An enhanced CT suspected continuity of the umbilicus and the abdominal wall mass. Intraoperatively, we found a fistula running from the abdominal wall abscess to the umbilicus along the right medial umbilical ligament. After adding a skin incision below the umbilicus, we completely removed the fistula. The clinical course of the patient after the operation has not been eventful.

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Alimentary tract duplications are relatively rare anomalies. Because their neoplastic changes have been reported, total excision or mucosal stripping have generally been performed. We report here a 20-month-old boy with colon tubular-type duplication who underwent transanal septal diversion, and review some literature referring to the relation between alimentary tract duplication and malignancy. The patient was diagnosed with an anocutaneous fistula and a cut-back operation was performed 41 days after birth. However, constipation was not improved after the surgery. Contrast enema showed colon duplication. We selected transanal septal diversion as the surgical approach, because no malignant change has been reported in cases treated by this procedure. After surgery, constipation was remarkably improved and postoperative course was uneventful.

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We report a rare case of torsion of the gallbladder in childhood. A seven-year-old boy with severe upper abdominal pain, nausea, and frequent vomiting was presented to us. An abdominal X-ray showed paralytic ileus, and increased levels of WBC, CRP, Alk-P, and LDH were noted. Ultrasonography and CT examinations revealed an enlarged gallbladder with a thick wall. No gallstones nor inflammatory changes were seen around the gallbladder. These results suggested a mechanical obstruction in the neck of the gallbladder, and torsion of the gallbladder was suspected. An emergency laparotomy was performed. On laparotomy, an enlarged, dark-reddish, and necrotic gallbladder that had been twisted clockwise 90 degrees around the narrow liver bed was found. Cholecystectomy was also performed. The patient's postoperative recovery was uneventful.

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A 1-year 5-month-old boy was noticed to have abdominal distension during therapy for colitis. He was referred to our hospital for further treatment of a huge abdominal cyst detected by abdominal computed tomography and ultrasonography. An abdominal MRI showed a cystic mass, measuring 17×10×6 cm in size, occupying the space from the right upper abdomen to the urinary bladder. With a provisional diagnosis of huge mesenteric cyst, the patient underwent laparoscopy-assisted surgery. After aspiration of 810 ml of serous fluid through a mini-laparotomy wound just below the umbilicus, we observed the general appearance of the collapsed cyst using laparoscopy. The cyst originated from the ileo-cecal to the ascending colon mesentery, and other multiple cysts were observed in close vicinity of the bowel wall. To avoid ileo-cecal resection and ascending colectomy for complete resection of the mesenteric cyst, we performed a laparoscopy-assisted subtotal cystectomy followed by sclerotherapy using OK 432 for the remnant cysts. Histopathological diagnosis from the resected specimen was mesenteric cyst. Our current operative procedure might be an alternative, minimally invasive method for young infants with huge mesenteric lymphangioma.

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Increased awareness of the late complications of splenectomy in patients of any age has led to a recent trend toward conservation of the spleen. The authors report a child who had a successful partial splenectomy for a splenic epidermoid cyst. A 7-year-old boy had a routine check-up because he had been taking INH for six months due to a positive tuberculin test. A CT scan of his chest demonstrated an incidental cystic lesion in the spleen. He denied any symptoms in the abdomen. Laboratory studies did not show any abnormalities. Abdominal CT and MRI scans demonstrated a cystic intrasplenic mass located in the upper splenic pole. Because of the increasing size of the mass and its uncertain origin, it was decided to conduct a partial splenectomy including the cyst. He was given an injection of antipneumococcal vaccine, in the event that total splenectomy would be necessary. Surgery began with a subcostal incision. The diaphlagmatic ligament was cut, and the short gastric vessels were divided. With the spleen partially mobilized, a partial splenectomy including the cystic mass, was done based on ligation of the upper polar vessels. Hemostasis was obtained by electrocoagulation, suturing and the use of Avitene (microfibrillar collagen) over the denuded splenic surface. The conserved spleen was replaced to the left upper quadrant of the abdomen. The postoperative course was uneventful. The estimated blood loss was 208 ml. There was not need for blood transfusion. The histpathologic diagnosis was epidermoid cyst of the spleen.

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We report a case of laparoscopic repair of bilateral Morgagni hernia found incidentally in a 5-year-old boy with Down's syndrome. The Morgagni hernia was separated, with the septum in the middle. On the right side, a lateral segment of the liver was herniated, and on the left side, a portion of the omentum and transverse colon was herniated. The hernial sac was inverted into the peritoneal cavity, and the diaphragm and rectus muscle were sutured, plicationing the hernia sac. The hernial sac hanging down to the peritoneal cavity was resected with a linear stapler. The patient had an uneventful postoperative recovery. Sometimes, postoperatively a retention cyst will grow in the residual hernia sac. We think that resection of the hernia sac was necessary. Here, we report a case of repairing Morgagni hernia with laparoscopic resection of the hernia sac. Laparoscopic surgery is the first choice for repairing Morgagni hernia.

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Purpose: The VEID (vein entry indicator device) is a small pressure sensor for indicating venous entry. This paper describes our experience of using the VEID in the field of pediatric surgery. Material and Methods: We used a VEID for taking blood samples from 158 patients, venous access for 23 patients and central venous catheter insertion for five patients. A survey of seven doctors using VEID was performed. Results: The VEID worked well for taking blood samples and venous access. On the other hand, it failed to work for four out of five patients for central venous catheter insertion. Three doctors felt that the VEID was very useful, four felt it was useful, and no one felt it was useless. However, four doctors thought that the VEID needes some modification. Conclusion: The VEID is not an essential device, but it could provide confidence to physicians. Furthermore, it reduces the uneasiness or tension of the patients at the time of procedure.

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