Purpose: To determine the incidence of metachronous contralateral inguinal hernia and the indications for prophylactic surgery, we examined the morphology of contralateral patent process vaginalis (PPV) at laparoscopic percutaneous extraperitoneal closure (LPEC). Methods: Two hundred forty-three patients (mean age 3.9 years old) were reviewed for retrospective evaluation. We classified these patients into a PPV-positive group and PPV-negative group. Result One hundred twelve of 228 patients (49%) who were diagnosed hemilateral inguinal hernia preoperatively demonstrated contralateral PPV at surgery. The mean diameter of the symptomatic internal ring was significantly larger than that on the contralateral side (8.9±3.2mm and4.8±2.9mm respectively). There was one case of metachronous contralateral inguinal hernia. There was no significant difference between the PPV-positive group and PPV-negative group in patient's sexuality, median age, or laterality of primary lesion. Ninety-six percent of symptomatic internal inguinal rings were larger than 4mm, while sixty-three percent of contralateral internal inguinal rings were larger than 4mm, comprising 31% of all patients diagnosed as having hemilateral inguinal hernia preoperatively. Conclusions: About fifty percent of preoperatively diagnosed cases of hemilateral inguinal hernia were demonstrated to be PPV-positive at surgery. The existence of contralateral PPV could not be predicted by sexuality, age or laterality of primary lesion. Thirty-one percent of preoperatively diagnosed cases of hemilateral inguinal hernia demonstrated contralateral PPV larger than 4mm. We consider that these cases had potential risk of metachronous contralateral hernia.

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Purpose: We have performed the laparoscopic percutaneous extraperitoneal closure (LPEC) method for pediatric inguinal hernia as the standard procedure. The aim of this study is evaluating the advantages and problems of the LPEC method. Methods: The first step of our procedure is inserting an initial port (3mm) at the bottom of the umbilicus. On the lateral abdomen we insert a working port and ligate the hernia sac at the root of it using a lapaherclosure. When the patent processus vaginalis is found on the contralateral side during the operation, we ligate it simultaneously in the same manner. Results: One patient had suffered a relapse of the inguinal hernia after LPEC method. We suppose that a cause of the relapse could be low ligation of the sac because of the long sliding of the ovarian duct. We have not experienced a contralateral hernia after instituting the LPEC method. When we diagnosed a patient with a femoral hernia instead of an inguinal hernia during the operation, we repaired it with LPEC method. We experienced an omental hernia from the umbilical incision in 2 cases postoperatively. Conclusion: The LPEC method is safe and useful. It has some advantages such as detection of the contralateral hernia sac and simplicity for repair of an incarcerated hernia. However, it may not be adequate for a patient with a long sliding of the ovarian duct.

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Purpose: Laryngotracheal separation is often performed for aspiration in severe psychophysiologic disorders. Tracheo-brachiocephalic fistula is a severe complication and causes fatal bleeding. Therefore prevention should be established. We have tried to decrease the incidence rate of tracheo-brachiocephalic fistula by modification of laryngotracheal separation. Operation: The operation is performed by an H-shaped skin incision. The trachea is not lifted up, and the skin flap is lowered to the trachea level. Results: This operation has been performed in 7 cases and had no major complication. A big tracheal stoma could be established, so it might be better against constriction of the tracheal stoma. Conclusion: This surgery should be useful to prevent tracheo-brachiocephalic fistula due to trachea position.

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Purpose: Umbilical polyps are believed to be rare and difficult to distinguish from umbilical granuloma, a common disease in infancy. We checked our cases and discussed their clinical features and differential diagnosis. Methods: In seven years, 78 infants with umbilical tumors resistant to medical therapy were referred to our hospital. Their ages, treatments, appearances of tumor and other clinical features were checked. Fifty-three cases of umbilical polyps in the Japanese literature were also discussed. Results: In 78 cases, 10 were umbilical polyps, 3 were suspected polyps and 65 were umbilical granulomas. They showed male predominance. Umbilical tumors were noticed immediately after separation of the cords. Granulomas were referred within two months after birth, responded well to treatments, and showed complete cure within three months after birth, while the average referral of polyps was 2.2 years after long periods of ineffective medical therapy. Granulomas were rough-surfaced dull-pink tumors, while polyps were smooth-surfaced and bright-red. Differential diagnosis was easy with these typical features even in the neonatal period. Nine polyps were surgically resected, and one was ligated. All were cured. Pathology revealed intestinal mucosa localized within the surface of the polypoid protrusion. Conclusions: Umbilical polyp is one of the common diseases in early infancy. An umbilical tumor which persists beyond the age of 3 months after birth has a high probability of being an umbilical polyp. Differential diagnosis is easy by its typical bright-red appearance even in the neonatal period. Proper diagnosis at the initial visit is important to avoid ineffective medical treatments.

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Purpose: Bile duct perforation (BDP) is a rare complication of choledochal cyst. We investigated the clinical features and management of choledochal cyst associated with BDP. Methods: One hundred and fifty-five patients with choledochal cyst were treated at our institution, and we reviewed clinical courses in seven patients with BDP (4.5%). Results: The age of them ranged from 1 to 5 years old, and they consisted of 2 males and 5 females. It took 3 to 13 days from onset to the first surgery. Five patients were diagnosed with choledochal cyst before the BDP. The shape of the extrahepatic bile duct was fusiform in 6 patients. The sites of perforation were in the anterior wall of the common bile duct in 5, and in the posterior wall in 2. In all cases, the initial surgical management was abdominal drainage and biliary drainage such as cholecystostomy or T-tube drainage; a biliary reconstruction was performed about one month after the first operation. Conclusions: Because infant cases with fusiform shape of the extrahepatic bile duct are one of the risk factors of BDP, we recommend careful observation with ultrasono-graphic study and blood examination in those cases. We consider that a primary biliary reconstruction is possible in selected patients with BDP, but biliary and abdominal drainage are safe initial treatment for BDP.

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A four-year-old boy who presented with abdominal pain and upper abdominal distension was referred to our hospital. His mental state was normal. Plain abdominal radiography demonstrated an extremely distended stomach with a dilated small intestine. There was no sign of mechanical obstruction with full investigations. He was diagnosed with aerophagia from the clinical feature that abdominal distension progressively increased in the daytime and decreased during sleep. Since clinical symptoms did not change after medication with famotidine and the herbal medicine Dai-Kenchu-To, we decided to retain a nasogastric tube for persistent gastric decompression. We started to administer itopride hydrochloride and mosapride citrate in order to accelerate gastric emptying; however, clinical symptoms remained unchanged one month after administration. A pediatrician could not completely rule out involvement of psychological stress, but medication with ethyl loflazepate was also ineffective. Finally, we started to use the herbal medicine Rikkunshi-To two months after the initiation of therapy, which gradually reduced the abdominal distension in two weeks, and nasogastric decompression was discontinued after the two months. It was considered that Rikkunshi-To was effective not only on the gastric emptying but also on the gastric adaptive relaxation and gastric antiarrythmic effect in this case.

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A female infant weighting 1,952g, who was born by emergency cesarean section, was diagnosed with gastroschisis. On exploration, we encountered type III A jejunal atresia at 30cm anal to the pylorus and type III A colon atresia at 10cm anal to the ileocecal valve. The size of the abdominal wall defect was 1cm in diameter. A jejunostomy with an anastomosis of the ascending colon was performed with a primary closure of the abdominal wall. On the 94th day of life, she underwent a jejunostomy closure, in which laparotomy revealed another membranous atresia at 2cm anal to the anastomosis of the colon, and multiple membranous atresia with intervals of 3 to 5cm in the distal portion of the jejunostomy. All of the atretic segments were resected and anastomosis of the jejunum as well as ascending colon was performed. We speculate multiple intestinal atresia in this case should be attributed to a small-sized abdominal wall defect that may have caused a strangulation of the bowel at multiple sites. One should be aware that multiple membranous intestinal atresia can coexist with interrupted intestinal atresia in patients with gastroschisis

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An 11-year-old premenarcheal girl who has urinary retention was admitted to the urology department in our hospital. Her clinical examination revealed a palpable lower abdominal mass, and her tumor markers were highly elevated (CA19-9 and CA125). The urologist consulted our department, doubting an ovarian tumor. The mass was detected by ultrasonography. Hydrometrocolpos was diagnosed by the abdominal CT and MRI inspection. As a result of the examination of the vulva, it was diagnosed as hydrometrocolpos because of an imperforate hymen. We performed surgical treatment with a cross incision of the hymen followed by immediate leakage of 450ml of vaginal and uterine hemorrhagic collection. The postoperative course was excellent, her menstruation promptly ensued and her serum CA19-9 and CA125 levels decreased one month after the operation. Imperforate hymen is assumed to be a comparatively rare disease. However, it is possible to diagnose it easily by examining the vulva. It seems important to keep this disease in mind when examining a lower abdominal mass in girls before their first menstruation.

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An 8-year-old boy was referred to our hospital for treatment of the ileus. He was refractory to conservative therapy and an emergent operation was done. Strangulation was the cause of the ileus and it was released. Apart from the obstruction, we found an elastic hard tumor in the ileum. It was well circumscribed, and 2cm in diameter. Partial resection of the ileum was performed. Histopathological examination revealed that it was a 15×8mm subserosal tumor with prominent eosinophilic infiltration. Immunohistochemically, the lesion was positive for CD1a and S-100. We finally diagnosed it as Langerhans cell histiocytosis (LCH). The post-operative course was uneventful and he was discharged on POD 7. Further examination revealed no other lesions, so we finally diagnosed it as the single organ-single site type. As far as we know, this was the first case diagnosed as the SS type of LCH by immunohistochemical examination. The prognosis of multiple organ-multiple site LCH involving the digestive tract is very poor, so a detailed whole body retrieval is necessary.

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An 8-year-old girl, complaining of hemoptysis, was referred to our hospital. A chest computed tomography (CT) revealed a mass in the left upper lobe and she underwent tumor resection with a left upper lobectomy through thoracotomy. The histopathological diagnosis was bronchial mucoepidermoid carcinoma (BMC). Fourteen months later, a follow-up chest CT scan revealed a left pulmonary hilar mass. A bronchoscopic biopsy was performed and the mass was diagnosed as the recurrence of BMC. She underwent left pneumonectomy thereafter. Though the postoperative course was uneventful, a mass lesion at the left mediastinum was detected by chest CT scan, six years after pneumonectomy. Therefore, tumor excision through a thoracotomy, which was made at the fifth intercostal space, was performed with a diagnosis of re-recurrence of BMC. The tumor, which was located between the pericardial pleura and the pericardium along with one of the daughter lesions palpated ventral to the descending aorta, were excised. Both specimens were diagnosed as recurrent BMC, histopathologically. The remaining daughter lesions have not grown for 11 months postoperatively. Although BMC is thought to have a good prognosis, it can recur after tumor resection, as in our case. Patients with BMC should be carefully monitored by regular follow-up diagnostic imaging.

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Case 1 was a 2-year-old male with a polyp (2.5×2cm) in the middle portion of the descending colon. Case 2 was a 12-year-old male who underwent interval appendectomy 2 months after acute appendicitis. We performed an operation for the two childhood cases using single incision laparoscopic surgery. After a Y-shaped skin incision consisting of an underumbilical incision from 9 to 3 and a midline incision (slightly less than 1cm) on the umbilical caudal side, an SILS^<TM> port was inserted. The pneumoperitoneal pressure was 8mmHg, and a rigid laparoscope (5mm, 30°), REAL HAND^[○!R] with a movable tip, and general 5-mm forceps were used. In case 1, the descending colon was mobilized under laparoscopy by sharp and blunt dissections from the retroperitoneum. In case 2, the adhering appendix was dissected, and the mesoappendix was coagulated and resected. In both patients, the SILS^<TM> port was removed, and pulled out of the abdominal cavity through the same area. In case 1, the intestine was incised, and the polyp was resected under direct vision. In case 2, the appendix was resected, and the cut end was buried with purse string sutures. The operation time was 90 minutes in case 1 and 80 minutes in case 2. Both patients were discharged without complications 6 and 4 days, respectively, after the operation. We thought that single incision laparoscopic surgery from the navel is more difficult than conventional laparoscpic surgery but superior cosmetically.

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