Successful Laparoscopic Excision of Type 1c Choledochal Cyst and Hepatico-Duodenostomy in a 13 years old Girl.

A 13 year old girl has been successfully treated by total Laparoscopic excision of type 1 –C Choledochal cyst and hepatico-duodenostomy . She has been having recurrent abdominal pain, post feeding discomfort, nausea, occasional fever and vomiting. After thorough evaluation a large type 1c Choledochal cyst associated with hepatosplenomegaly was diagnosed. After preparation, Laparoscopic excision and bilio-enteric anastomosis was carried out. She had highly vascular and thick fibrotic cyst wall with adhesions due to multiple cholangitic attacks. The surgery could be completed completely Laparoscopically with minimal blood loss. Child had a very comfortable post operative recovery, starting oral feeds 48 hours after surgery with excellent cosmetic outcome. Currently minimally invasive technique is being the procedure of choice for such complex anomalies with excellent outcomes.

Dr. Kamalesh Pal, Consultant Pediatric Surgery

Fetal volvulus and gangrene of intestine managed successfully.

An extremely rare case of Fetal intestinal volvulus has been successfully diagnosed and managed by the Neonatal Surgery Service,. The 32 weeker fetus was diagnosed to have Classical triad of Echogenic bowel with Whirl pool sign, polyhydramnios and fetal anaemia . A thorough counselling with the parents enabled them to take the most difficult decision of urgent delivery of the baby by Cesarean Section. Post natal evaluation confirmed the small bowel volvulus with whirlpool sign. After stabilization of the pre term baby by NICU team, emergency laparotomy was performed. Segmental volvulus involving whole of ileum with gangrene and distal ileal atresia, malrotaion of gut was detected. Resection of gangrenous bowel , correction of malrotation and doublw barrel ileostomy was performed. Baby recovered from the physiological and surgical stress quite satisfactorily, started to pass stool per stoma and started feeding. Fetal volvulous is an extremely rare condition and a challenge to diagnose and manage. Only few cases have been reported in the world literature with instances of fetal death , still births in neglected cases. It’s a complex multidisciplinary approach with state of the art NICU care which helps in survival of potentially morbid and lethal condition.

Dr. Kamalesh Pal, Consultant Pediatric Surgery

Dr. Younis Mohd. Khalid,Consultant Pediatrician & Neonatologist (Head of Department NICU & PICU)

Dr. Louay H. Zayed,Consultant Obstetrics & Gynecology, Fetal Medicine & High Risk Pregnancy

Successfully performed One stage Trans-anal Swenson’s Pullthrough for Hirschsprung Disease in a 3 months old girl child.

Pediatric Surgery Service has successfully performed One stage Trans-anal Swenson’s Pullthrough for Hirschsprung Disease in a 3 months old girl child. This child had presented with life threatening enterocolitis and left inguinal hernia 1 month back which was managed in our hospital and then she was diagnosed with Hirschsprung’s disease affecting Rectum, distal half of sigmoid colon. After intense bowel management , she underwent complete trans anal mobilization of rectum and colon upto mid sigmoid and with Frozen section guidance normal ganglionic segment was identified and excision of aganglionic segment with coloanal anastomosis was performed. Typically this procedure is done in stages with colostomy and laparotomy/laparoscopy which requires multiple surgeries, anaesthesia s and leaves a large scar. Child required minimal analgesia,could be fed few hours after surgery and passed stool spontaneously , discharged in 2 days post op. There is no scar on her abdomen or perineum which is a great cosmetic benefit to the girl child. We have been doing complex laparoscopic and hybrid surgical procedures for all varieties of Hirschsprung disease including Total colonic Aganglionosis in small children and Infants with advanced Minimally Access Modalities.

Dr. Kamalesh Pal, Consultant Pediatric Surgery

Successfully performed Pneumovesicoscopic Bilateral Ureteric Reimplantation in a 4 years old child

Pediatric Urology Service has successfully performed Pneumovesicoscopic Bilateral Ureteric Reimplantation in a 4 years old child with bilateral grade 4 Vesico-ureteric reflux and reflux nephropathy ( left kidney-30% function,Right upper pole scars, multiple episodes of pyelonephritis) . Child had a very comfortable post operative period and discharged on 3rd post op day. This procedure is a paradigm shift from the conventional open cross trigonal ureteric reimplantation where a Pfannensteil (lower transverse) incision is usually made , bladder is opened and post surgery ureteric catheters are exteriorized per abdomen, requiring 7-10 days of postop recovery ,significant amount of analgesia, leaving a large scar; or conventional Laparoscopic extra vesical reimplantation ( not always suitable for dilated high grade refluxing ureters). In this procedure all the reimplantaion steps were carried out entirely within the domain of Urinary bladder by 3mm minilaparoscopic instruments , without any post op stents. The child had very comfortable recovery with minimal analgesia and left with barely appreciable scar. This relatively new technique has tremendously improved the quality of life of the reimplantation kids

Dr. Kamalesh Pal, Consultant Pediatric Surgery

Testicular and Intestinal salvage in 2kg neonate with strangulated inguinal hernia.

A preterm, severe IUGR , low birthweight(2kg) baby presented with acute intestinal obstruction, found to have obstructed left inguinal hernia. After stabilization, urgent exploration revealed a strangulated hernia with ischaemic bowel and testis. Release of strangulation, revitalization of intestine and partial revitalization of testis was achieved on table. Hernia was repaired and the ischaemic testis was preserved for a second look assessment. After 24 hours, the exploration revealed a vitalized testis and epididymis which was fixed in scrotum successfully. The child is recovered well in NICU. The revival of ischaemic testis in strangulated hernia is extremely rare to experience. It’s management is a huge dilemma on table.

Dr. Kamalesh Pal, Consultant Pediatric Surgery

Rare bilateral Diaphragmatic hernia operated successfully

2 years old boy with trisomy 21 was referred to PICU of SGHDubai with respiratory distress and multiple Lung consolidations. Child was stabilized and assessed thoroughly which revealed presence of extremely rare bilateral Morgagni’s hernia in the diaphragm. Almost half of thoracic cavity was filled with abdominal contents leading to collapse consolidation of bilateral lung tissues. Early surgical correction was undertaken. A huge defect measuring 20×15 cm2 was found in the diaphragm through which most of colon, right lobe of liver, stomach , omentum and small bowel was found herniating into the chest. The contents were reduced into abdomen, the hernial sac was excised from chest and heart, the diaphragmatic defect was repaired and space was created for the lungs to expand and function properly. The child had critical post operative management in PICU and on 4 th post operative day he was extubated and chest tubes were removed . On 5 th day he is on room air , active and with normal respiratory efforts, started on oral diet. Considering the size and extent of this rare diaphragmatic hernia and it’s pulmonary consequences , the child had extremely favorable outcome. The critical perioperative Care was provided by PICU team and operative Anaesthesia was excellent.

Dr. Younis Khalid, Consultant Pediatrician

Dr. Kamalesh Pal, Consultant Pediatric Surgery

First time ever done in the UAE the use of intra vascular US to guide placing a stent graft in the artery

58 years old Male patient with previous heart problems, Presented with severe pain in the left leg after walking a short distance, pain was relieved by rest and occurs again when walking. CT-angio showed huge dilatation (aneurysm) of the left popliteal artery (behind the knee). First time ever done in the UAE the use of intra vascular US to guide placing a stent graft in the artery.

Dr. Mohamed Raafat Okelah , Specialist Vascular Surgery

Extremely rare combination of jejuno-ileal intussusception and suppurative obstructive appendicitis

Successful surgery on 7 year old girl with an extremely rare combination of jejuno-ileal intussusception and suppurative obstructive appendicitis. The child presented with acute abdomen and atypical symptoms leading to diagnostic dilemma. This combination is extremely rare , only 10 case reports have been found in the literature including children and adults since 1923.

Dr. Kamalesh Pal, Consultant Pediatric Surgery

Mini-Laparoscopic Pyeloplasty at Saudi German Hospital Dubai

Pediatric Urology Service at Saudi German Hospital Dubai has successfully performed mini-laparoscopic left pyeloplasty in a 6 year old girl with 3mm instruments thereby rendering stitch-less abdomimal access.The child had been suffering from frequent intermittent severe pain in left flank associated with vomiting thereby reducing her appetite and general growth. Upon evaluation, she was diagnosed to have severe pelvi-ureteric junction obstruction with enlarged renal pelvis and thinning of left kidney. Parents were eager to have early surgery and choose the laparoscopic repair for cosmetic considerations. Intraoperatively a significant lower polar vessel crossing the renal pelvis and high insertion of ureter were encountered and managed successfully. The child recovered very fast accepting oral feeds and started to move around within 6 hours of surgery. The post- operative pain and discomfort were minimal compared to open surgical repair. The cosmetic outcome, which is one of the major concerns with the child and parents has been outstanding. It is noteworthy to mention that at Saudi German Hospital Dubai, complex open and minimally invasive pediatric urological procedures are being performed successfully in children and neonates.

Dr. Kamalesh Pal, Consultant Pediatric Surgery

1.3KG Preterm with rare Type 3 Jejunal Atresia and Meconium Ileus operated successfully.

A preterm Low Birth Weight (1.3 kg) child, born with antenatally detected ventriculomegaly and bowel distension developed respiratory distress and hugely distended abdomen within 6 hours of birth. Preliminary clinical and radiological assessment revealed hugely distended proximal bowel with splinting of the diaphragm. Due to severe abdominal distension and suspected ischaemic bowel, emergency laparotomy was done at 7th hours of birth. A rare (1:10000-20,000 LIFE BIRTH) Type 3 Jejunal atresia with Apple peel deformity of distal bowel(anomalously supplied by inferior mesenteric artery trunk) and thick putty-like meconium in the hugely distended Jejunal blind loop was encountered. The bowel was decompressed, the viability of bowel was restored and a Chimney bowel repair was done. The compliance of lung was restored and ventilation could be normalized. The child has been recovering well in NICU and been started on feeds.

Dr. Kamalesh Pal, Consultant Pediatric Surgery

Successfully performed Hybridisation Surgery for a 10 months old girl who had presented to Saudi German Hospital Dubai with a diagnosis of Long Segment Hirschsprung’s Disease.

This variety of HD is extremely rare (incidence of 1:25000 live birth) affecting almost entire colon. The Hybridisation technique ( devised by Japanese )allowes part of ileum to be incorporated into a segment of right side of the colon and the composite segment is Pulled through upto the native anal canal. Most of the colon is resected out. This essentially allows the water and electrolyte absorption and chance of survival. This technique has been done for the first time in UAE . This surgery was done by incorporating endoscopic and open techniques.

Dr. Kamalesh Pal, Consultant Pediatric Surgery

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