Review Article

Anal Sphincter: A Comprehensive Review

Negar Abbasi Aval, Saeid Aslanabadi, Mahshid Kharaziha, Sina Zarrintan, Farzad Ilkhchooyi

Iranian Journal of Pediatric Surgery, Vol. 3 No. 1 (2017), 3 Mehr 2017, Page 1-8

Anal incontinence is of potential clinical interest and significance. Comprehensive knowledge of anal clinical anatomy and function is essential to understand pathophysiological processes that lead to sphincter malfunction. We review anatomy, physiology and surgical pathology of the anal sphincter. We also discuss surgical procedures which are used in cases of fecal incontinence.


Original Articles

Introduction: Previous studies have shown that according to the learning curve, one’s knowledge and skills increase with experience and repetition. However, no studies have yet proved that the learning curve can be generalized to medical procedures. Therefore, this study aimed to evaluate the learning curve and complications of hand assisted laparoscopic appendectomy (HALA) in children with acute appendicitis.

Materials and Methods: In a prospective randomized study in 2016, ninety patients aged 8-16 years were selected for appendectomy. The participants were then consecutively divided into three groups according to admission time. The first, second, and third groups were operated on by an attending pediatric surgeon, an attending pediatric surgeon and a pediatric surgical fellow (a surgeon who is studying the subspecialty of pediatric surgery) and in the third group only a pediatric surgical fellow, respectively. For each surgery, duration of surgery and hospitalization was determined and recorded, and the time trend of surgery was determined and compared in all three groups using the learning curve.

Results: The mean duration of surgery of the groups operated on by an attending, an attending and a fellow, and a fellow alone was 38.7±12.8, 46.9±8.8 and 48.5±11.3 respectively, with a significant difference among the three groups (p=0.002). During the surgery, duration of surgery in the fellow and attending group and the fellow group decreased over time.

Conclusion: The learning curve can be generalized to medical procedures and experiences. Duration of appendectomy for fellows can decrease over time as they become more skilled. Usually after performing 30 surgeries and gaining experience, fellows will be able to perform appendectomy nearly as fast as attending surgeons. In the meantime, the root causes of the fluctuations observed during surgery should be scientifically examined and resolved.

Incidence and Short term Outcome of Management of Neonatal Intestial Obstructin (NIO)

Atef Abd hamid Ekiabi, Mohamed El sayed Eraki

Iranian Journal of Pediatric Surgery, Vol. 3 No. 1 (2017), 3 Mehr 2017, Page 16-20


Neonatal intestinal obstruction (NIO) is a challenging and common emergency situation in pediatric surgery. In order to successfully manage it one should make a timely diagnosis and apply standard treatment.Management of neonatal intestinal obstructions have improved in many developed countries, but still show high morbidity and mortality in developing countries. This study was done to evaluate the incidence and short term outcome of neonatal intestinal obstruction at the department of pediatric surgery, Zagazig university hospitals in Egypt.

Material and Methods:

This retrospective study included 84 patients whom presented with intestinal obstruction during their first month of life to the emergency departments of Zagazig university hospitals in Egypt from Jan 2008 to Jan 2011and were managed surgically.


Of these 84 patients 50 were males and 34 were female. The mean age at presentation was 3.5 (2-10) days for duodenal atresia, 2.5 (3-5) days for jejunoileal  atresia , 2 (1-10) days for meconium ileus with perforation, 2 (1-5) days for patients with volvulus, 7 (5-20) days for colonic atresia, 20 (10-30) days for Hirschsprung disease, 25 (5-30) days for patients with obstructed congenital inguinal hernia and 2 (1-4) days for anorectal malformations. Surgery was done for all patients after resuscitation. Death occurred in 10 patients (12%). In 3 patients with jejunoileal atresia anastomotic leakage occurred; they underwent re-operation but died. In 3 patients with duodenal atresia death occurred postoperatively from sepsis and DIC. Two patients with high anorectal malformations died 2 days post operative from associated cardiac anomalies and 2 patients with colonic atresia died post operatively from sepsis and electrolyte imbalance.


The most common cause of intestinal obstruction in neonates in our study was anorectal malformations and obstructed congenital inguinal hernia. Mortality and morbidity is still high compared with statistics from developed countries due to late presentation to pediatric surgeon and there is no specific neonatal surgical intensive care unit beside the pediatric surgery department in our center.

A Review of 2625 Isolated Hydrocele Cases in Children

Ahmet Atıcı, Derya Erdoğan, İbrahim Karaman, Ayşe Karaman, Yusuf Hakan Çavuşoğlu, Haşim Ata Maden, İsmet Faruk Özgüner, Engin Yılmaz, Çağatay Evrim Afşarlar

Iranian Journal of Pediatric Surgery, Vol. 3 No. 1 (2017), 3 Mehr 2017, Page 21-27

Introduction: Inguinal hernias and hydroceles are the most frequently performed procedures in pediatric surgery departments. In this study, we aimed to define the spontaneous regression rate in different types of  hydroceles, the regression age, the timing of surgery, and the optimal treatment approaches for each hydrocele type in cases with isolated hydroceles in children.

Material &Methods: This historical cohort study included 2625 patients which were admitted between January 2004 and December 2012. The hydroceles were classified as: ‘non-communicating hydroceles’, ‘communicating hydroceles’, ‘spermatic cord hydroceles’ and ‘abdomino-scrotal hydroceles’ (ASH). Patients were divided into two groups with regard to their ages at diagnosis as follows: those presenting in the newborn period and before 24 months of age (Younger– Group 1) and those presenting after 24 months of age (Older – Group 2). Determining the type of isolated hydrocele, the decision making for follow-up or surgery, and the follow-up period were conducted by 7 attending pediatric surgeons and 6 residents. 

Results: In Group 1, 93% of 1086 non-communicating hydroceles, 40% of 158 cord hydroceles, and 15% of 34 communicating hydroceles resolved during the follow-up, and the remaining patients with each type of hydrocele underwent surgery. In Group 2, 8.7% of 183 non-communicating hydroceles resolved during the follow-up.

Conclusion: The primary treatment of patients with isolated hydrocele should be decided regarding the type of hydrocele, along with age at admission, and accordingly, conservative or surgical treatment should be considered.

Evaluation of Staggered Osteotomy in Surgical Treatment of Trigonocephaly

Seyed Esmail Hassanpour, Seyed Mahdi Moosavizadeh, Mohammad Reza Hadi Sichani, Hamidreza Alizadeh Otaghvar, Mohammadreza Tarahomi, Daryanaz Shojaei, Amir Molaei, Leili Mohajerzadeh

Iranian Journal of Pediatric Surgery, Vol. 3 No. 1 (2017), 3 Mehr 2017, Page 28-32

Introduction: undiagnosed metopic synostosis (Trigonocephaly) have many complications for infants such as Brain damage and cognitive & behavioral disorders, they also result in poor aesthetic features. There are many surgical techniques for this malformation which have their advantages and disadvantages; but with this new method (staggered osteotomy) we can solve some of these problems and minimize damages.

Materials and Methods:  In this study, 20 infants with metopic synostosis underwent surgery in Mofid Children Hospital, Tehran.  The minimum age of our patients was 4 months and the maximum was 9 months with an average of 6.72 months. Their diagnosis was confirmed with clinical symptoms & signs also with CTscan and paraclinical findings. Age and weight before and after surgery and anthropometric indices including: biparietal width and frontal width were recorded and reported.

Results: We found significant differences in anthropometric indices before & after surgery such as lowering of biparietal width after surgery and elevation of frontoparital index after surgery. Since in this procedure, we don’t separate the frontal bone segments and it keeps its frame, less plaques and screws are needed which will decrease the costs of surgery and the surgical time is much less than other techniques. Last but not the least, the satisfactions of parents were high and there was no need for secondary surgery.

Conclusion:Based on all the perfect results we got , it is safe to say that staggered osteotomy as a surgical method for correction of trigonocephaly is useful and we can use it as a new method in correction of  metopic synostosis.

Results of Onlay Flap Versus Durham Smith in Proximal Hypospadias

Leili Mohajerzadeh, Ahmad Khaleghnejad Tabari, Haleh Noroozi, Saran Lotfollahzadeh, Khashayar Atqiaee Atqiaee

Iranian Journal of Pediatric Surgery, Vol. 3 No. 1 (2017), 3 Mehr 2017, Page 33-39

Introduction: Urethroplasty was originally used for the repair of hypospadias of the mid and distal portion of the penis but since complications of the two-stage Durham Smith technique such as mega urethra and proximal anastomotic strictures became apparent; the Onlay island flap technique has been increasingly used in more severe cases of hypospadias. The aim of our study was to compare the outcome of these two techniques in the surgical treatment of hypospadias.

Material and Methods: In this retrospective study, thirty -three patients underwent surgery for the treatment of hypospadias. The two- stage Durham smith repair was used for 17 cases and the onlay island flap technique was carried out on 16 patients. Data was analyzed using SPSS software version 21 and complication rates of the two procedures were compared.

Results: Altogether, frequency of complications was higher in the smith technique than the onlay flap procedure without any significant difference between the two techniques (47% for Smith technique and 19% for onlay repair; P=0.141). Fistula was the most frequent complication in the two techniques (41% for Smith technique and 13% for onlay repair; P=0.117). Meatoplasty was done for meatal stricture in the smith group. Moreover, the smith technique failed completely in one case who then underwent Tabularized Inside-Plate (TIP). There was a case of chordee recurrence in the smith technique; for which a dorsal Nesbit plication was carried out. The mean days of hospitalization was more with the smith technique (7.1 days vs 5.0, P=0.016). In addition, the mean cases which required reoperation was higher in the smith group than the onlay flap (1.0 vs 0.2, P=0.025).

Conclusions: The results of this study showed that the onlay flap technique had lower complications and reoperation rates than the two-stage smith technique. In addition, the onlay flap technique has fewer days of hospitalization than the smith technique, resulting in lower costs to the health system and patients.

Comparison of Two Different Method of Surgery in Ileus Meconium

Omid Amanollahi, Amin Alinejad

Iranian Journal of Pediatric Surgery, Vol. 3 No. 1 (2017), 3 Mehr 2017, Page 40-42

Introduction: meconium ileus occurs when the terminal ileum is obstructed by unusually tenacious meconium; it is more prevalent in neonates with cystic fibrosis. Up to 33% of neonatal small-bowel obstructions are due to meconium ileus. Symptoms such as: vomiting which may be bilious, distention of the abdomen and inability to pass meconium in the first days of life are some of the most common symptoms. Clinical presentation and x-rays are the basis of diagnosis. First step of treatment is contrast enemas under fluoroscopy and if it fails surgery should be carried out. Different surgical methods are used for operative management of uncomplicated meconium ileus. In our series, we have compared two different methods of surgery: Primary resection and anastomosis; and enterostomy using the Bishop-Koop method. We compared their effectiveness and complications.

Materials and Methods: Forty neonates with ileus meconium were included in the study, 20 patients in each group. Alternating allocation that is allocating every other subject to each treatment group: for the Bishop-Koop enterostomy and anastomosis (study group) or primary resection and anastomosis (control group) was carried out .Results of treatment and complications during and after the surgery were recorded in both groups and compared together.

Results: There was 3 case of mortality in the study group (%15) and 8 case of mortality in control group (%40). There was a meaningful statistical difference between mortality in the two groups (p=0/002).

Conclusion: Despite the advantages of one stage repair with primary resection and anastomosis in neonates it results in a higher rate of mortality compared to the Bishop-Koop method. Thus performing the two-stage Bishop-Koop repair seems to be a more safe approach for this anomaly.

Case Report

Cervicotomy and Sternotomy for Resectin of Cervicothoracic Neuroblastoma in Children

Amine Ksia, Nahla Hmidi, Chokri Kortas, Imen Chabchoub, Sana Mosbahi, Mongi Mekki, Lassaad Sahnoun, Kais Maazoun, Abdellatif Nouri

Iranian Journal of Pediatric Surgery, Vol. 3 No. 1 (2017), 3 Mehr 2017, Page 43-45

Introduction: We report the case of a 4 years old girl who present
a cervico-thoracic ganglioneuroblastome with none response to
chemotherapy and radiotherapy
Case presentation: The girl was operated using the Cormier
Dartevelle-Grünenwald incision which helped to remove the tumor
completely with optimal control of noble elements. The follow up
was uneventful.
Conclusion: The Cormier Dartevelle-Grünenwald incision can be a
good option in case of big cervico-thoracic malignant tumors.

Lef Congenital Mesoblasti Nephroma in a Term Male Neonate: A Case Report

Kamal Nain Rattan, Shruti Bansal, Vibha Sharma, Nikhil Sharma, Deepak Kumar Garg

Iranian Journal of Pediatric Surgery, Vol. 3 No. 1 (2017), 3 Mehr 2017, Page 46-50

Congenital mesoblasticnephroma (CMN) is a benign and very rare renal tumor, typically occurring in utero or during infancy. We are reporting a very young case of left sided classical congenital mesoblasticnephroma in a full term, small for gestational age, male neonate; who was detected with left sided flank mass immediately after birth. The patient was managed successfully by total nephrectomy. The diagnosis of CMN-classical type was confirmed on histopathological examination.