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Objective: To determine the technical applicability and early postoperative outcome of anterior sagittal approach for anorectal malformations in female children., Study Design: Case series., Place and Duration of Study: Surgical Unit B of National Institute of Child Health (NICH), Karachi, from April to November 2007., Methodology: Female patients with congenital anorectal malformation who underwent anorectoplasty through anterior sagittal approach were included in the study. Surgery was done either as primary or staged procedure (with initial colostomy or cut back). Operative details were recorded. Follow-up was done in OPD., Results: Thirty patients with mean age of 11.5 months underwent anorectoplasty through anterior sagittal approach. Eighteen patients had ASARP as a primary procedure. Staged procedure with initial colostomy was done in 9 patients. Initial cut back was done in 2 cases and one redo surgery done. Vaginal tear occurred in one, while partial tear of most distal part of fistula occurred in 4 children. At follow-up, 2 patients with primary ASARP developed wound infection with superficial disruption. Bleeding with wound disruption occurred in one case. Anal mucosal prolapse, anastomotic stricture and recurrent fistula occurred in one patient each. Cosmetic appearance of perineum was good in 10, satisfactory in 5 and poor in 3. Among patients staged with colostomy, bleeding with wound disruption, anal stenosis and retraction occurred in one case each. Cosmetic results were good in 7, satisfactory and poor in one case each. Two patients with initial cut back did not have any complication and one operated for disrupted wound developed disruption again., Conclusion: Anorectoplasty can satisfactorily be done through anterior sagittal approach in females with anorectal malformations. Primary ASARP has almost the same results as staged procedure, which should be done in selected patients.

Objective: To analyze various clinical presentations and the surgical management of ovarian pathologies in pre-menarche girls., Design: Case series., Place and Duration of Study: Surgical Unit B, National Institute of Child Health, Karachi, from September 2002 to August 2004., Patients and Methods: Case records of all the pre-menarche girls child having an ovarian pathology and managed during the study period were reviewed. Age of the patients, presenting symptoms, investigations performed, surgical approaches, operative findings and final histological diagnosis were noted. Ovarian lesions were classified according to WHO criteria.System proposed by the Children's Cancer Group and the Paediatric Oncology Group was used for staging of tumors. Following resection, patients with malignant tumors were followed-up by oncologist., Results: There were 18 patients with ovarian lesions. Age range of patients was from day 1 to 13 years. Mass in abdomen was the most common presenting symptom (60% patients ) followed by pain (50%). Right ovary was involved in 12 (55%) cases and left in 6 (45%). Six patients had non-tumorous cysts, 3 had benign tumors and 9 were with malignant lesions. Of the non-tumorous cysts, 3 patients had simple follicular cysts and 2 were hemorrhagic cysts. There were 2 patients with benign teratoma and one with dermoid cyst. Four patients had malignant teratoma, 4 dysgerminoma and one yolk sac tumor. Malignant tumors were all of stage IA according to Paediatric Oncology Group staging., Conclusion: Ovarian tumors are rare in paediatric age group especially in pre-menarche girls. Except one, all malignant tumors were found in patients above 7 years of age. Benign (tumorous and non-tumorous) and malignant lesions occurred with equal frequency in pre-menarche girls in this study.

Objective: To assess the correlation of the size of undescended testis with its location in children of various age groups, per-operatively., Design: Cross-sectional study., Place and Duration of Study: Surgical Unit B, National Institute of Child Health, Karachi from February 2004 - November 2005., Patients and Methods: Children presenting with undescended testis at surgical outpatient were recruited. Physical examination and relevant investigations (haemoglobin, ultrasound for location and size of testes) were performed. Patients were divided randomly into three age groups, group I (8 months - 2.5 years), group II (2.6 - 8 years), group III (8.1-13 years). At orchiopexy location and size of undescended testis were noted. Patients were further sub-divided into groups according to peroperative location of undescended testis, group A (intra-abdominal), group B (intra-canalicular), group C (distal to superficial inguinal ring - pubic). Where no testis was found, a separate group D was assigned. The size of undescended testis at different locations in various age groups was compared with reference to normal descended testicular size in the respective age group, for statistical significance. ANOVA test was used for intergroup comparison for the size of undescended testis and Student t- test was applied for comparison with reference to normal values of the size of testis., Results: A total of 102 patients with undescended testis were included in the study. The total number of 107 testicular units were assessed. Group I had 28, group II, 41 and group III, 38 testes. There were 24 intra-abdominal, 68 intra-canalicular and 12 pubic in location. In 3 cases, no testis was found at exploration. We found no statistically significant difference amongst groups (p-value=0.090) between the size of the undescended testis at different peroperative locations. The size of undescended testis grew with the age as undescended testis of larger size were found in older age group as compared to younger age group. By applying Student t-test, we did not find statistically significant difference in relation to the size of undescended testis in various age groups in comparison to the reference of mean volume of normally descended testis in the respective age groups., Conclusion: Pre-pubertal size of undescended testis does not differ significantly from that of normal reference value of descended testis in relation to age and location. The ultimate size of the testis can only be assessed after puberty whether it is a normally descended or undescended testis.

Objective: To determine the postoperative complications of elective inguinal hernia surgery in children, Design: Descriptive study., Place and Duration of Study: Surgical Unit B, National Institute of Child Health, Karachi, from February 2004 to November 2005., Patients and Methods: Children with inguinal hernia, admitted electively through surgical outpatient, were included. Patients operated earlier and presenting with complications were excluded. Patients with concomitant diseases, regarded as predisposing factors for hernia development, were also excluded. Physical examination and relevant investigations (hemoglobin level and ultrasound of scrotum) were performed. Inguinal hernia was repaired electively by Rehbein procedure. Patients were followed at day 7, 1 month, 3 months and 9 months to note the postoperative complications of the surgery. Ultrasound was repeated at 6 and 9 months postoperatively for the size of testes., Results: A total of 223 patients with inguinal hernia were included in the study. Age ranged from 8 days to 12 years. There were 188 males with 75 patients under 1 year of age. The longest follow-up was upto 9 months in 133 patients. The complications of scrotal edema occurred in 6 (2.97%), haematoma in 1(0.49%), wound infection in 2 (0.99%) and 5 events of recurrence of hernia in 4 patients. All appeared within 3 months of follow-up. Four recurrent hernia were operated. In all cases intact sac was found. No patient developed decrease in size of testes nor ascent of testes was noted at follow-up., Conclusion: in this series, there were minimal complications observed in relation to inguinal hernia surgery.

Sirenomelia is a rare anomaly that rarely occurs as an isolated lesion. Several theories have been proposed regarding the etiopathogenesis. In this communication, we report a case of sirenomelia. Our patient was referred to hospital at the age of four hours. On examination, fusion of both lower limbs with hook shaped appendage, attached distally, absent genitalia and absent anal orifice was found. Spine was deficient in sacral region. Upper torso looked normal. Baby also had frothing from mouth. Abdomen was non-distended. Feeding tube no.10 was tried to pass through mouth, which got obstructed at the level of upper esophagus that suggested oesophageal atresia. The skeletogram revealed absence of pelvic bones, sacral agenesis, absent fibulae and fracture of both femora. The patient died at the age of 12 hours.

Two cases of congenital pyloric atresia (CPA) are, hereby, reported. One was suspected on antenatal ultrasound and turned out to be an isolated anomaly. Other patient had a rare association of aplasia cutis congenita with congenital pyloric atresia. The lesions of aplasia cutis congenita were multiple while congenital pyloric atresia was of type II. The patient with an isolated lesion survived following surgery while the other baby died of sepsis in postoperative period.

This report describes the management of a 7-month-old baby who aspirated one and ingested two paper pins at a time. Bronchoscopic removal was done for aspirated pin and ingested pins were observed for spontaneous passage in stool, which occurred in 48 hours without any untoward incidence.

A seven month old male baby presented to emergency room in shock. Patient had 3 hours history of massive fresh bleeding per rectum. Emergency laparotomy revealed Meckel's diverticulum (MD) with large vitello-intestinal artery responsible for massive bleeding. Diverticulectomy was performed.