A 2-day-old baby boy, 38 weeks gestation, weight 2000 g was brought due to hypersalivation and imperforate anus with gasless abdomen on plain X-ray. He underwent a gastrostomy tube insertion and colostomy. In contrast study of the stomach, on the 5th postoperative day, the dye spilled into the tracheo bronchial tree and the catheter was seen,entering the right main bronchus. The patient underwent right thoracotomy and the presence of fistula and catheter were confirmed. The fistula and distal esophagus were closed and fixed to the prevertebral fascia because of a long gap. He is under follow-up and recieving home care for a later delayed primary anastomosis.

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Aim: Departmental survey of the pediatric laparoscopic and thoracoscopic procedures. Materials and Methods: It is a retrospective study from January 1999 to December 2007. The various types of surgeries, number of patients, complications and conversions of laparoscopic and thoracoscopic procedures were analyzed. Results: The number of minimally invasive procedures that had been performed over the past 9 years is 734, out of which thoracoscopic procedures alone were 48. The majority of the surgeries were appendicectomy (31%), orchiopexy (19%) and diagnostic laparoscopy (16%). The other advanced procedures include laparoscopic-assisted anorectoplasty, surgery for Hirschprung's disease, thoracosocpic decortication, congenital diaphragmatic hernia repair, nephrectomy, fundoplication, etc. Our complications are postoperative fever, bleeding, bile leak following choledochal cyst excision and pneumothorax following bronchogenic cyst excision. A case of empyema thorax following thoracoscopic decortication succumbed due to disseminated tuberculosis. Our conversion rate was around 5% in the years 1999 to 2001, which has come down to 3% over the past few years. Conversions were for sliding hiatus hernia, nephrectomy, perforated adherent appendicitis, Meckel's diverticulum, thoracoscopic decortication and ileal perforation. Conclusion: The minimally invasive pediatric surgical technique is increasingly accepted world wide and the need for laparoscopic training has become essential in every teaching hospital. It has a lot of advantages, such as less pain, early return to school and scarlessness. Our conversion rate has come down from 5% to 3% with experience and now we do more advanced procedures with a lower complication rate.

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Aims: The purpose of this study was to compare open versus laparoscopic appendicectomy (LA) in complicated appendicitis. Materials and Methods: We prospectively analyzed all children over a 2-year period who underwent appendicectomy in a single institution and found 30 cases of complicated appendicitis diagnosed on the table and confirmed by histopathology. These children were allocated randomly into Group 1 if they had LA and Group 2 if they had open appendicectomy (OA), solely based on surgeon assessment. The parameters assessed were duration of symptoms before surgery, use of postoperative parenteral analgesia, timing of initiation of feeds after surgery, postoperative complications and duration of postoperative stay. Results: Of the 30 patients with complicated appendicitis, 12 patients in Group 1 underwent LA and 18 patients in Group 2 underwent OA. The two groups were comparable for age and sex. Children in Group 1 were found to need less parenteral analgesia (two out of 12 versus six out of 18). Postoperatively, feeds were started earlier in Group 1 than in Group 2 (2.5 days versus 3.7 days). The average postoperative hospital stay was 5 days in Group 1 and 7.5 days in Group 2. There were only minor wound infections in Group1 as against two major complications in Group 2. There was no mortality in either group. Conclusions: In complicated appendicitis, laparoscopic approach carries definite advantages with less postoperative morbidity and hospital stay. It is a feasible and better alternative than the open approach in complicated appendicitis.

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Aims: To find out an easier way of reduction of intussusception during open surgery to avoid unnecessary bowel injury. Materials and Methods: Under general anesthesia, before laparotomy, warm normal saline was infused into the rectum with a Foley catheter and an intravenous drip set maintaining the level of the bottle at 80 cm above the operating table. After opening the abdomen, pressure was applied on the colon filled with normal saline distal to the intussusceptum. The pressure was transmitted to the intussusceptum and the walls of the intussuscipient and caused reduction of intussusception without any injury to the intussuscipient and intussusceptum. This procedure was performed on those patients on whom laparotomy was performed as a primary procedure due to nonavailability of fluoroscopy or ultrasonography. Results: Between August 1998 and July 2005, we had six patients of mean (range) age 11 months (7-17 months). In two cases, at laparotomy, the intussusceptions were found to have already reduced. Conclusions: Gentle finger pressure is necessary for reduction of intussusception. This subjective "gentleness" is dependant on experience of the surgeon and varies from person to person. Focal pressure on the intussuscipient and apex of the intussusceptum by the finger during reduction may be more damaging than the diffusely transmitted hydrostatic pressure even by a less-experienced surgeon. This will avoid the needless resection and anastomosis of the intestine on many occasions.

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The authors have developed a portable device for insufflation of air reliably at pressures accepted as safe for effective reduction of intussusception in children under fluoroscopic guidance. The results of reduction with the device were equal to those by saline enema reduction under ultrasound guidance.

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Aim: To evaluate the role of laparoscopy in complicated appendicitis in children. Materials and Methods: A total of 119 children were operated for appendicitis between October 2005 and May 2008 at SRMC, Chennai. Forty-one patients underwent open appendicectomy (OA), and 71 patients underwent laparoscopic appendicectomy (LA). Twenty-six cases among the LA group and 16 among the OA group had complicated appendicitis. Twenty-six cases were completed laparoscopically, and 2 needed conversion to OA. Results: Out of 26 patients in the LA group, 23 made an uneventful recovery without any complications. One had minor port site infection, and 2 had prolonged loose stools. Out of 16 in the OA group, 7 had complications. Three had wound infection, 2 had loose stools, 1 had fecal fistula and another required subsequent surgeries. Operative duration in LA was 86.7 min (range: 75 to 120 min) and 90.3 min (range: 70 to 150 min) in OA. Oral feed resumption in LA was done at average of 2.7 days and in OA at 4.3 days. IV antibiotics were administered for an average of 3.6 days in LA and 4.8 days in OA, parenteral analgesic for 2.7 days in LA and 4.2 days in OA. The length of hospital stay was 5.4 days in LA and 7.3 days in OA. Conclusion: LA is a favorable alternative in children with complicated appendicitis in view of less postoperative pain, fewer postoperative complications and quicker return to normal activity.

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Aim: Pediatric lung resection is a relatively uncommon procedure that is usually performed for congenital lesions. In recent years, thoracoscopic resection has become increasingly popular, particularly for small peripheral lesions. The aim of this study was to review our experience with traditional open lung resection in order to evaluate the existing "gold standard." Materials and Methods: We carried out a retrospective analysis of all children having lung resection for congenital lesions at our institution between 1997 and 2004. Data were collected from analysis of case notes, operative records and clinical consultation. The mean follow-up was 37.95 months. The data were analyzed using SPSS. Results: Forty-one children (13 F/28 M) underwent major lung resections during the study period. Their median age was 4.66 months (1 day-9 years). The resected lesions included 21 congenital cystic adenomatoid malformations, 14 congenital lobar emphysema, four sequestrations and one bronchogenic cyst. Fifty percent of the lesions were diagnosed antenatally. Twenty-six patients had a complete lobectomy while 15 patients had parenchymal sparing resection of the lesion alone. Mean postoperative stay was 5.7 days. There have been no complications in any of the patients. All patients are currently alive, asymptomatic and well. None of the patients have any significant chest deformity. Conclusions: We conclude that open lung resection enables parenchymal sparing surgery, is versatile, has few complications and produces very good long-term results. It remains the "gold standard" against which minimally invasive techniques may be judged.

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A 4-year-old girl with a solitary vascular anomaly of the mesentery presented with acute lower abdominal pain. Despite the use of ultrasound, computed tomography scan and image-guided core biopsies, the lesion was initially mistaken for an inflammatory intra-abdominal mass. The correct diagnosis was made at laparotomy. Solitary vascular anomaly of the mesentery is rare and its presentation as an acute abdomen has not been reported before.

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Repair of exomphalos major in the neonatal period is fraught with risks and complications. Progressive pneumoperitoneum was found to be safe and cost-effective in six patients with exomphalos major who underwent repair at an older age. The technique is particularly suitable for hospitals that do not have facilities for intensive care, ventilation and total parenteral nutrition.

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