A prospective randomized study of wound approximation with tissue glue in circumcision in children

Objective: Bleeding and wound infection are the most common complications of circumcision. Cyanoacrylate tissue glue has been claimed to have the advantage of being haemostatic, bacteriostatic and easy to use. The purpose of this study is to assess the feasibility of using the tissue glue in approximation of circumcision wound in children.
Methodology: A prospective randomized trial was carried out on 86 boys consecutively admitted into the Duchess of Kent Children's Hospital, Hong Kong. The results of wound approximation with cyanoacrylate tissue glue and suturing with interrupted 4/0 plain catgut were compared. The operations were carried out by the same surgeon using identical technique except for the wound approximation. The wound was assessed 1 day, 2 days, 3 days, 1 week and 1 month postoperatively.
Results: There was no statistically significant difference between the two groups in the rates of wound inflammation, infection, bleeding, dehiscence and cosmetic appearance, but the duration of operation was longer using tissue glue (19.8 min vs 16.5 min, P = 0.002).
Conclusions: We conclude that tissue glue approximation of circumcision wounds in children is a feasible alternative, but it offers no extra advantage when compared to suturing.     

A prospective comparison of tissue glue versus sutures for circumcision

The safety of wound closure with tissue glue after surgery has been well established. The efficacy of its use in circumcision is poorly documented. The aim of this study was to carry out a comparative study of tissue glue versus suture closure after circumcision. The duration of the operative procedure, pain score, cosmesis and postoperative complications were evaluated. There were no complications in either group. There was no statistically significant difference in the pain score in both groups. However the mean time taken for tissue glue was 16.6 minutes and the mean time taken for sutures was 23.7 minutes. (p < 0.0001) which was statistically significant. The cosmetic appearance was found to be superior in the tissue glue group as there were no suture marks on the join of the shaft skin and foreskin base.     

Sutureless skin closure with isoamyl 2-cyanoacrylate in pediatric day-care surgery

Importance of day-care surgery in pediatric age group is ever increasing and nowadays bulk of surgery is performed as a day-care procedure. Day-care procedure requires short intra-operative period and less postoperative complications. The introduction of tissue adhesive has been received enthusiastically since they may result in equivalent tensile strength-improved cosmetic appearance of the scar and lower infection rate when compared to sutures, staples and adhesive tape. We have used isoamyl 2-cyanoacrylate as a tissue adhesive for skin closure in day-care surgery. Novocryl is ideal for such procedure as it is a sterile, inert, non-toxic, biocompatible and bacteriostatic liquid topical skin adhesive containing isoamyl 2-cyanoacrylate formulation. We applied isoamyl 2-cyanoacrylate glue in 100 patients over skin cut margin after stitching subcutaneous tissue. Skin margin were held together by means of skin hook for 1–2 min. The cosmesis was better as there were no suture marks or lumpiness. There were no major complications in our study. Thus, isoamyl 2-cyanoacrylate can be considered as an alternative to skin suturing in the pediatric day-care surgery.     

Temporary umbilical loop colostomy for anorectal malformations

Transumbilical surgical procedures have been reported to be a feasible, safe, and cosmetically excellent procedure for various pediatric surgical diseases. Umbilical loop colostomies have previously been created in patients with Hirschsprung’s disease, but not in patients with anorectal malformations (ARMs). We assessed the feasibility and cosmetic results of temporal umbilical loop colostomy (TULC) in patients with ARMs. A circumferential skin incision was made at the base of the umbilical cord under general anesthesia. The skin, subcutaneous tissue, and fascia were cored out vertically, and the umbilical vessels and urachal remnant were individually ligated apart from the opening in the fascia. A loop colostomy was created in double-barreled fashion with a high chimney more than 2?cm above the level of the skin. The final size of the opening in the skin and fascia was modified according to the size of the bowel. The bowel wall was fixed separately to the peritoneum and fascia with interrupted 5-0 absorbable sutures. The bowel was opened longitudinally and everted without suturing to the skin. The loop was divided 7?days postoperatively, and diversion of the oral bowel was completed. The colostomy was closed 2–3?months after posterior saggital anorectoplasty through a peristomal skin incision followed by end-to-end anastomosis. Final wound closure was performed in a semi-opened fashion to create a deep umbilicus. TULCs were successfully created in seven infants with rectourethral bulbar fistula or rectovestibular fistula. Postoperative complications included mucosal prolapse in one case. No wound infection or spontaneous umbilical ring narrowing was observed. Skin problems were minimal, and stoma care could easily be performed by attaching stoma bag. Healing of umbilical wounds after TULC closure was excellent. The umbilicus may be an alternative stoma site for temporary loop colostomy in infants with intermediate-type anorectal malformations, who undergo radical anorectoplasty via a non-abdominal approach.     

An alternate technique to close neurosurgical incisions using octylcyanoacrylate tissue adhesive

The present authors have applied the use of tissue adhesive octylcyanoacrylate, recently approved by the FDA, in the closure of routine neurosurgical cases. The authors find this to be an excellent substitute for nylon, staples, vicryl or steristrip final layer closure of the surgical incision. This is especially useful in the pediatric neurosurgical practice where young children can be emotionally traumatized by the experience of suture or staple removal. We recommend octylcyanoacrylate closure as a safe, simple, quick, cost-effective method of skin closure that has superior applications in pediatric neurosurgical wound closure when used with proper technique. Copyright Copyright 1999 S. Karger AG, Basel     

Comparing wound closure using tissue glue versus subcuticular suture for pediatric surgical incisions: a prospective,randomised trial

Tissue adhesives have gained favour for quicker and painless closure of lacerations. To compare the tissue adhesive 2-octylcyanoacrylate with our current standard subcuticular suture for closure of surgical incisions in children, looking at outcome measures of time efficiency, cosmesis, and wound complications, a prospective, randomised, controlled trial was conducted at our institution's ambulatory surgery centre. All healthy patients undergoing unilateral or bilateral herniotomies were recruited prospectively with informed consent and randomly allocated to suture or glue. The exclusion criteria were neonates or children with allergy to tissue glue. Time of wound closure was measured from the subcutaneous layer to application of the dressing. An independent, blinded observer assessed cosmesis at 2 to 3 weeks using a validated wound scale ranging from worst (0) to best (6). Parent satisfaction with wound appearance was recorded on a 100-mm visual analogue scale (VAS). A total of 59 patients were recruited into the study with 26 in the glue group and 33 in the suture group. There was no difference in mean time of closure (glue 181 +/- 62 s vs suture 161 +/- 45 s, P = 0.18). Two patients in each group had a suboptimal Hollander wound score of 5 (7.7% glue, 6.1% suture). There was also no difference in parent satisfaction (VAS: glue 78 +/- 19 mm vs suture 81 +/- 15 mm, P = 0.68). No patient reported any rash, wound infection, or dehiscence. Tissue glue is easy to use with no complications and has equivalent cosmetic results, but is not faster than a subcuticular suture.     

Y-V plasty of the foreskin as an alternative to circumcision for surgical treatment of phimosis during childhood

PurposeTo evaluate the result of Y-V preputioplasty and to compare this with an earlier technique of prepuce-sparing phimosis treatment.Materials and methodsA total of 65 boys were treated surgically for phimosis without removing the foreskin. Indications were the failure of conservative ointment treatment, congenital uropathies (to prevent infections and to make proper cleaning of the glans and the inner preputium possible to ensure clean urine sampling), recurrent balanitis or painful ballooning of the prepuce, and/or the need for urethral instrumentation. Forty-seven patients were treated with one or two Y-V plasties to widen the narrow preputial ring; 18 were treated using transverse closure of longitudinal incisions of the narrow preputial ring.ResultsOf the 47 Y-V plasties, two patients had recurring complaints and needed further treatment (4.3%), and of the 18 patients treated by transversely closed longitudinal incisions, two patients had recurring complaints (11%). Recurrences occurred regardless of age and premedication with topical therapy. Cosmesis was considered to be excellent in all cases of Y-V plasty. Few patients complained about skin tags after longitudinal incisions.ConclusionY-V plasty of the preputial skin as an alternative to circumcision in the treatment of phimosis has good functional and cosmetic results. It is a minor operation with less impact on the penis than partial or total circumcision. The cosmetic results are superior to those after transversely closed longitudinal incisions.     

Bilateral anterior pubic osteotomy in bladder exstrophy repair: report of increasing success

 Bilateral posterior iliac osteotomy is performed in most patients undergoing primary closure of an exstrophic bladder; the aims are to facilitate abdominal-wall closure, prevent postoperative wound dehiscene, and possibly, to achieve better urinary control in older age. A new technique, anterior pelvic osteotomy of the superior pubic ramus, seems to obtain tension-free symphysis approximation safely and quickly. We report our initial experience with this osteotomy. Five neonates, four males and one female from 1 to 4 days old, all underwent closure surgery for bladder exstrophy (BE) and subsequent bilateral osteotomy of the superior pubic ramus (SPRO). Postoperatively, Bryant's traction was applied. Tension-free, complete approximation of the symphysis and uncomplicated healing were achieved in all five cases without palsy of the obturator nerve or postoperative hemorrhage. Follow-up revealed partial rediastasis with a stable anterior pelvic ring. Tension-free closure and immobilization are important factors in both initial and subsequent closure of BE. Several osteotomy techniques are currently in use. SPRO presents numerous advantages, namely, ease and rapidity, minimal blood loss, and no requirement for an extra skin incision or need to turn the patient on the operating table. A certain degree of rediastasis with growth was subsequently observed: although undesirable, this complication is common to all osteotomy techniques. We believe that SPRO is a valid and uncomplicated method to facilitate BE closure. Accepted: 14 April 2000     

Mediane Halsspalte

The CMCC (congenital midline cervical cleft) lesion is localized between the chin and suprasternal region, usually immediately below the thyroid region. A nipple-like protuberance at the upper end is typical, followed by a reddish skin depression and a sinus tract. A firm fibrous cord is found beneath these superficial skin lesions. For cosmetic reasons, as well as the increased risk of progressive contracture with age and better wound healing in infancy, prompt surgical correction is recommended. By means of ellipsoid excision of the lesion and subsequent closure with Z-plasty, a good cosmetic and functional result can be achieved.     

The scars of newborn intensive care

Many techniques used in neonatal intensive care are invasive and the risk of producing skin damage is high. To investigate this, 100 consecutive survivors of neonatal intensive care (gestation 26-42 weeks, median 32) were examined in detail by a single observer at 16-29 months of age, and the scar severity, site and likely cause noted. Scarring was present in all infants although it was usually trivial. The total number of scars was inversely related to gestational age and directly related to the duration of intensive care. Eleven children had cosmetically or functionally significant lesions caused by chest drain insertion, extravasation of intravenous fluid or skin stripping by adhesive tape. To reduce the frequency and severity of skin damage, neonatal staff need to be aware that many routine procedures may lead to long term scarring. In particular, more careful wound closure after chest drain removal is needed.     

Paediatric sutureless circumcision and modified circumcision: video demonstration

ObjectiveCircumcision is undertaken using a variety of surgical methods. Modified circumcision for the hooded prepuce or mild glanular hypospadias mandates an excellent cosmetic result. Tissue glue is an alternative to sutures for circumcision in children and has significant advantages in terms of cosmesis and postoperative pain. We present two detailed videos demonstrating our technique for sutureless circumcision and modified circumcision.MethodThe incisions were marked on the outer and inner preputial skin. Incisions were made with a scalpel. Complete haemostasis was ensured. Tissue adhesive was placed onto the wound using a 32-gauge needle to allow controlled application. It is important to ensure that the coronal sulcus is free of glue at the end of the procedure. Once the circumcision is complete the penis can be cleaned and temporarily dressed.ResultsBetween November 2008 and September 2011, we have used this technique for 57 circumcisions and 30 modified circumcisions. No complications occurred. All were followed up for a minimum of 3–6 months.ConclusionThe technique allows reproducible excellent cosmetic results, can be easily taught to junior surgical staff and should be considered as an alternative to a standard sutured circumcision.     

COMPLICATIONS IN THE TREATMENT OF HYDROCEPHALUS IN CHILDREN

ABSTRACT. Two homogenous materials of hydrocephalic children operated upon during a 20-year period (1961–1980) are compared. During the first half of the period the ventriculoatrial shunt was the only type used in 103 patients. After that there was a change to the ventriculoperitoneal shunt which was used in 104 patients, whereof 35 were converted from ventriculoatrial to ventriculoperitoneal shunts. Thus the material consists of 172 patients. The complications were less serious and the mortality rate much lower with the ventriculoperitoneal method. The revision rate, however, was about the same for both types of operation, but the revisions and the operative procedure for peritoneal shunts were generally much more simple and more rapidly performed. Therefore it is our opinion that in children the ventriculoperitoneal route is preferable to the ventriculoatrial route. With better knowledge of the underlying cause of distal obstructions in the former route we think that it will be possible to reduce the complication and revision rates even further.     

How to reduce the morbidity of wound closure following extensive and complicated laminectomy and tethered cord surgery.

Prior irradiation and surgery predispose laminectomy wounds to a higher than usual incidence of wound problems. Likewise the tightness or absence of local fascia in the tethered cord patient make wound closure more complicated. To reduce morbidity, i.e., CSF leak or pseudomeningocele formation, specific techniques are required. These methods are outlined below.     

Biliary complications of living related pediatric liver transplant patients

Patients who undergo living related left lateral segment liver transplants have been reported to have a high incidence of biliary complications and some studies suggest that most patients will ultimately need operative revision. We reviewed our experience with living related transplantation in pediatric recipients to examine the occurrence of biliary complications and the utility of percutaneous biliary procedures in their management. Over a 10-yr period, 48 living donor transplants were performed in 47 patients. Sixteen patients (33%) had biliary complications. Complications included 10 leaks (20%) and eight strictures (17%). Although leaks were treated predominantly with operation, other biliary complications were treated almost exclusively non-operatively. Self limited leaks that lead to biloma accumulation were most often treated via percutaneous catheter drainage and all strictures were treated using percutaneous transhepatic biliary cholangioplasty and stenting. Sixty-seven percent of biliary complications underwent non-operative biliary intervention. Most strictures were focal anastomotic strictures and were successfully treated with cholangioplasty although multiple interventions were necessary and patients required stenting for an average of 13 months. Three of eight strictures were diffuse in nature and these included the only patient who required retransplantation. Graft survival with respect to biliary complications was 94%; 1 yr, 5 yr and overall patient survival for those with biliary complications was 88, 88 and 81%, and for the entire living related group was 84, 81 and 77%, respectively. Although biliary complications are frequent in pediatric living related transplantation, they are not associated with decreased patient survival. Excepting significant bile leaks, the majority can be treated non-operatively via biliary cholangioplasty and stenting. Strictures are especially amenable to this technique which, in our experience, has been successful at decreasing or postponing the need for retransplantation.     

A single-pass tunneling technique for CSF shunting procedures

Implantation of ventriculoperitoneal shunts in the precoronal position is generally accomplished using a retroauricular incision for subcutaneous tunneling. Retroauricular incisions can be associated with complications, including cerebrospinal fluid leak and shunt infection. We describe a technique for 'single-pass' shunt tunneling from frontal to abdominal incisions and our initial results in a consecutive, prospective series of 15 children (age 2 days to 5 years). Eleven patients presented with congenital hydrocephalus (including 5 with myelomeningocele and 3 with posthemorrhagic hydrocephalus) and 4 with hydrocephalus secondary to central nervous system (CNS) tumors. The average length of clinical follow-up was 6 months (range 1-13 months). There were no perioperative or long-term complications of the single-pass technique. Nine of the 11 patients with congenital hydrocephalus are currently well without any further medical or surgical intervention. Two underwent shunt revision for proximal obstruction, with an intact distal system. Three of the 4 patients with hydrocephalus secondary to CNS tumor suffered secondary shunt complications during periods of severe neutropenia resulting from chemotherapy (6 weeks to 6 months after shunt insertion). For primary ventriculoperitoneal shunt insertion in infants and young children, the single-pass tunneling technique is safe and avoids one source of complications.     

Posthemorrhagic hydrocephalus. Use of an intravenous-type catheter for cerebrospinal fluid drainage

STUDY OBJECTIVE: To report a 9-year experience with the treatment of posthemorrhagic hydrocephalus (PHH) with the use of an easily inserted external ventricular drain. DESIGN: A case series with a retrospective review of hospital records and cranial ultrasound results, from 1981 through 1989, in all infants with PHH. INTERVENTION: A previously defined method of identification and bedside management of PHH was applied. If infants reached 2 kg of body weight and PHH recurred, a ventriculoperitoneal shunt was inserted. RESULTS: A total of 70 procedures were performed in 24 patients, and all were associated with a decrease in head circumference and ventricular size on ultrasound scan. One infection occurred, and only 12 infants required a ventriculoperitoneal shunt. CONCLUSIONS: This technique compared favorably with other methods of intervention to avoid early placement of a ventriculoperitoneal shunt in preterm infants and offered the advantage of consistently decreasing ventricular size. A multicenter-controlled trial will be needed to compare the safety and efficacy of therapies for PHH.     

A better incision for pectus excavatum repair: avoiding the keloid triangle

The most common approach to the pepair of pectus excavatum and pectus carinatum deformities is via a central transverse submammary incision. The subsequent suprasternal scar is conspicuous and prone to hypertrophic and keloid scarring. To avoid the keloid triangle and to produce a less noticeable scar, we have utilized bilateral inframammary incisions for repairs of five female and two male patients with pectus defects. This approach provides excellent access for cartilage resection, sternotomy, and sternal tupport without increasing opearative time or compromising operative exposure. On follow-up for up to 25 months, all patients have had excellent cosmetic and functional results. Chest wall configuration and stability, wound healing, and scar formation have all been without complication. No keloid or hypertrophic scars have developed. To date, there has been no recurrence of pectus defects. We believe bilateral inframammary incisions are a superior approach for pectus repairs by enchancing cosmesis with less noticeable scars and fewer hypertropic and keloid scars, all without compromising operative exposure or increasing operative time.     

儿童严重创伤性软组织损伤的负压封闭治疗

目的 探讨负压封闭引流技术(vacuum sealing drainage,VSD)治疗儿童严重创伤性软组织损伤的效果.方法 16例严重创伤性软组织损伤的患儿,共20个创面,创面范围约为10 cm× 15 cm～30 cm×50 cm,严格清创后采用负压封闭引流(VSD)技术,持续40～60 kPa负压引流,5～7d后再行Ⅱ期缝合、植皮、组织瓣转移闭合创面.同期13例采用传统换药或引流的患儿为对照组.结果 VSD治疗组中,15例经负压封闭引流治疗后均可见创面肉芽组织新鲜.Ⅱ期缝合、植皮或组织瓣转移全部成活,无局部和全身并发症,1例反取皮原位移植的患儿发生创面感染,多次引流后行游离植皮成功.VSD治疗组与对照组比较,在Ⅱ期缝合时间、换药次数、平均住院时间及植皮愈合率等方面均有统计学意义(P<0.05)结论负压封闭引流技术能充分引流、控制感染和刺激创面肉芽组织生长,为及早覆盖创面提供了良好的条件,而且可以免除换药和缩短治愈时间,是治疗儿童严重创伤性软组织损伤的一种简便、有效方法.     

Does age or other factors influence the incidence of ventriculoperitoneal shunt infections?

Some studies indicate that infants, especially those less than 1 month of age have a higher incidence of ventriculoperitoneal shunt infections. To look at age as well as other variables that might relate to the rate of shunt infection, we reviewed the records of all patients undergoing a ventriculoperitoneal shunt insertion or revision at our institution from January 1, 1985, to December 31, 1994. There were a total of 2,325 ventriculoperitoneal shunting procedures performed on 1,193 patients with a male:female ratio of 678:515. The overall infection rate was 3.2% (74 infections). Analyzed by age, the infection rates were as follows: <1 month 9/223 (4.0%), 1-6 months 16/449 (3.6%), 6-12 months 13/297 (4.4%), 12-18 months 3/122 (2.5%), 18-24 months 7/116 (6.0%) and 24+ months 26/1, 118 (2.3%). There was no statistically significant difference between age groups (p > 0.05). Upon selectively examining premature neonates who developed hydrocephalus secondary to intraventricular hemorrhage from the figures given above, one finds that 2/44 (4.5%) of neonates became infected, which was also not significant. The infection rate was the same irrespective of whether the procedure was to insert or revise the shunt, or whether another operative procedure was done under the same anesthesia. The etiology of the hydrocephalus was not a factor, nor was the presence of an open neural tube defect. The presence of fluid accumulation along the shunt tract or at another neurological operative site was associated with a significant increase in incidence of infection 15/168 (8.9%) when compared to those with no fluid accumulation (p < 0.001). The type of infecting organism was divided roughly in thirds, with relatively equal representation from Staphylococcus epidermidis/coagulase negative and Staphylococcus aureus. The remaining third was comprised of a wide variety of organisms.     

Treatment of burns in children

Decreases in mortality from major thermal injury over the last 20 years have been due to advances in resuscitation, control of infection, support of the hypermetabolic response, and early closure of the burn wound. Of these advances in burn care, early wound closure has progressed the most in the last five years. The restoration of the protective functions of the skin is of primary importance to the recovery of the burn patient. Biologic dressings (pigskin, amnion, human skin allograft) when applied to fully debrided, relatively uncontaminated wounds have been shown to adhere to the wound surface, reduce the wound colony counts, limit fluid and protein loss, reduce pain, and increase the rate of epithelialization over that obtained with application of topical antimicrobial agents.