Transinguinal Laparoscopic Examination: An End to the Controversy on Repair of Inguinal Hernia .in Children
Gad Lotan MD , Yigal Efrati MD , Sorin Stolero MD and Baruch Klin MD

Background: Contralateral exploration of the groin has been common practice among pediatric surgeons for nearly 50 years, based on the high incidence of patent processus vaginalis on the contralateral side with the potential for the subsequent development of a hernia.
Objectives: To evaluate transinguinal laparoscopic examination of the contralateral side during repair of inguinal hernia in children in order to reach a decision regarding exploration of the contralateral side.
Methods: Over a 21 month period 124 children with unilateral inguinal hernia underwent laparoscopic evaluation of the contralateral groin. The operations were performed under general anesthesia as
ambulatory procedures.
Results: Transinguinal contralateral laparoscopic exploration was positive (patent processus vaginalis) in 26 children (21%) and negative (closed processus vaginalis) in 88 (71%). Failure to introduce the telescope occurred in 10 patients (8%) due to a friable or narrow hernia sac. Twenty-five children below 2 years of age were spared exploration of the contralateral side as a result of the negative laparoscopic examination. On the other hand, 15 children aged 2±17 had their contralateral groin explored because of a positive finding at laparo-scopy.
Conclusions: Transinguinal laparoscopic examination of the contralateral side during repair of inguinal hernia in children is a simple, safe and quick method to avoid systematic bilateral explorations and should be part of every pediatric surgeon's experience.

Bicycle-related injuries in children: Disturbing profile of a growing problem
B. Klin , N. Rosenfeld-Yehoshua , I. Abu-Kishk , Y. Efrati , E. Kozer , I. Jeroukhimov ,G. Eshel , G. Lotan.

: We observed a changing pattern of bicycle-related injuries in children, with the focus changing from head trauma to thoracic and abdominal injuries, and a trend to increasingly severe injuries.
Objective: To assess the changing injury pattern, and investigate the development of preventive measures to improve safety
Design, setting, and participants: Retrospective record review of 142 paediatric patients admitted to our Department of Paediatric Surgery between 1996 and 2005 following bicycle-related injuries. Clinical, laboratory, diagnostic, and therapeutic aspects were analysed. Additional information concerning children’s bicycle-related injuries in Israel was obtained from the Gertner Institute (Israel National Center for Trauma and Emergency Medicine Research) and from Beterem (The National Center for Children’s Safety & Health, the Safe Kids Israeli Chapter) National Report on Child Injuries in Israel 2006. Main outcome measures: The nature and severity of injuries were reviewed, and two 5-year periods compared—from 1996 to 2000 (53 children—Group 1), and from 2001 to 2005 (89 children—Group 2).
Results: Head trauma was more common in the Group 1 patients (52.6% vs. 45.2%), but skull fractures and intracranial haemorrhage occurred more frequently in Group 2 (28.5% vs. 16.7%; 21.3% vs. 8.3%, respectively). Injury to the stomach or duodenum, kidneys and liver were all more common in Group 2. Splenic injury occurred with equal frequency in both groups, but more severe injuries were seen in Group 2. More children in Group 2 required intensive care (31% vs. 19.3%).
Conclusions: There is a changing pattern of bicycle-related injuries in children, with chest and abdominal injuries dominating, and an increasing incidence of more severe injury. These findings are important in decision-making regarding preventive measures

Myringotomy Knife for Pyloromyotomy
Ibrahim Abu-Kishk, MD,* Sorin Stolero, MD,w Baruch Klin, MD,z and Gad Lotan, MDz

Laparoscopic pyloromyotomy is a common procedure for treating infantile hypertrophic pyloric stenosis. Since 2006, we have been using miniature otolaryngologic instruments for pyloromyotomy due to a shortage of arthroscopic blades in our Medical Center. The purpose of this study is to determine the safety, efficacy, and cosmetic results obtained from the use of fine otolaryngologic instruments in pyloromyotomy. We retrospectively reviewed the records of 10 male infants who underwent pyloromyotomy during the years 2006 to 2007, using a fine otolaryngologic knife (myringotomy knife). Median operation time was 23 minutes, no complications were observed, all patients were discharged within 24 hours, and the scars were barely visible in 4 weeks’ time. We are proposing an alternative technique for the classic pyloromyotomy method that looks promising. Further studies are needed.

The contribution of intraoperative transinguinal laparoscopic xamination of the contralateral side to the repair of inguinal hernias in children.
Baruch Klin, Yigal Efrati, Ibrahim Abu-Kishk, Sorin Stolero, Gad Lotan

Background: Bilateral inguinal hernias are relatively common in children. This fact has led to a controversy of more than 50 years concerning the necessity of bilateral surgical exploration during the repair of unilateral inguinal hernias in children. The advent of transinguinal
laparoscopic visualization of the contralateral side is a turning point and a major contribution to the subject, offering the opportunity to reassess the systematic bilateral exploration and the "wait and see" policies currently in use at most services of pediatric surgery.
Data sources: The current information concerning intraoperative transinguinal laparoscopic evaluation of inguinal hernias in children was summarized in a didactic way. A MEDLINE search (PubMed) from 1995 to the present days was conducted.
Results: A patent processus vaginalis (PPV) is not equal to a future symptomatic hernia. There is still no definitive evidence on which PPVs will become a hernia (5.8% to 11.6%) and which remain clinically insignificant. Diagnostic intraoperative transinguinal laparoscopic evaluation of the contralateral side is today the most simple and accurate way to reduce the incidence of negative explorations.
Conclusion: Diagnostic intraoperative transinguinal laparoscopic evaluation of the contralateral side during pediatric inguinal hernia repair is a simple, accurate, fast, and effective method to assess the contralateral processus vaginalis, improving decision-making, reducing the number of negative explorations, and sparing the surgeon the embarrassment associated with the appearance of a metachronous hernia at a later date. It is easily learned and should be part of every pediatric surgeon's practice.

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