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The aim of this study is to present our treatment protocol for impalpable testis.In a retrospective study we analyzed clinical data including diagnostic procedures, intraoperative findings, final diagnosis, treatment modality, and outcome of patients with impalpable testis who underwent surgery from January 2010 until December 2015.Ninety-one patients were admitted under the diagnosis of impalpable testis. In 39 patients ultrasound detected testis in the inguinal canal and orchidopexy was done. In 25 patients (48.08%) laparoscopy showed the entrance of the spermatic cord into the inguinal canal. Open exploration of the inguinal canal was done, testicular remnant removed, and appropriate testicular prosthesis implanted. Twenty patients (20/52) underwent orchidopexy of the abdominal testis (46.51%), 4 of which underwent Fowler-Stevens procedure in two stages, and in 16 patients deliberation of the testis and spermatic cord was sufficient to place the testis into the scrotum.Excision of the testicular nubbin is highly recommendable, as well as implantation of the testicular prosthesis at the time of orchiectomy.

Introduction. Primary hyperparathyroidism is rare pathology in children (2?5:100,000). In more than 85% of patients, a single adenoma is present, and its extirpation is usually the only treatment a patient requires. In approximately 15?80% of cases, ectopic mediastinal parathyroid tissue can be found inside the thymus. Case outline. Our patient was a 13-year-old boy, who presented with multiple bone fractures in the previous period of time, and fatigue. Parathyroid hormone levels preoperatively were extremely high (1320 pg/ml ? more than 19 times higher than normal). Serum calcium was also elevated (total 3.55 mmol/l; ionized 1.41 mmol/l). He was examined and diagnosed as primary hyperparathyroidism by a pediatric endocrinologist. Imaging procedures for the preoperative localization of parathyroid adenomas were done (99mTc sestamibi scintigraphy and magnetic resonance imaging suggested ectopic mediastinal parathyroid adenoma). The patient underwent video-assisted thoracoscopic surgery procedure. After exploration of the mediastinum and chest, no ectopic parathyroid tissue was found, so total thoracoscopic thymectomy was performed. Final pathological section confirmed parathyroid adenoma inside the thymus. Conclusion. We believe that if no parathyroid tissue is found during surgical exploration of mediastinum, in a child with preoperatively detected parathyroid adenoma in anterior mediastinum, recommendation is to think about possible intrathymic localization and consider removing the thymus. Greater sample size is necessary for higher reliability of this statement.

Pectus excavatum is the most common congenital anterior chest wall deformity, with an incidence of 1:400 to 1:1000. Surgical strategy has evolved with the revolutionary idea of Donald Nuss, who was a pioneer in the operative correction of this deformity using minimally invasive surgery. The aim of this paper is to compare the preliminary results of pectus excavatum repair in two University Centers with a moderate number of patients using the standard Nuss procedure and its modification, the extrapleural thoracoscopic approach. The statistical analysis showed no significant difference for the patient’s age (14.52 ± 3.70 vs. 14.57 ± 1.86; p = 0.95) and the CT Haller index (4.17 ± 1.58 vs. 3.78 ± 0.95; p = 0.32). A statistically significant difference was noted for the duration of a pectus bar implant (2.16 ± 0.24 vs. 2.48 ± 0.68; p = 0.03) between the Maribor and Novi Sad Center. We report 14 complications (28%), including dislocation of the pectus bar (10%), pleural effusion (8%), wound inflammation (6%), pericarditis (2%) and an allergic reaction to the pectus bar (2%). Standard and thoracoscopic extrapleural Nuss procedures are both safe and effective procedures used to correct a pectus excavatum deformity. The choice of surgical procedure should be made according to a surgeon’s reliability in performing a particular procedure. Our study found no advantages of one procedure over the other.

Background and Objectives: Acute appendicitis in pediatric patients is one of the most common surgical emergencies, but the early diagnosis still remains challenging. The aim of this study was to determine the predictive value of Red blood cell distribution width (RDW), Mean platelet volume (MPV) and Platelet distribution width (PDW) in children with acute appendicitis. Materials and Methods: This study was a retrospective assessment of laboratory findings (RDW, MPV, PDW) of patients who underwent surgical treatment for acute appendicitis from January 2019 to December 2020. Result: During this period, 223 appendectomies were performed at our Institute. In 107 (43%) cases appendicitis was uncomplicated, while in 116 (46.6%) it was complicated. WBC and RDW/MPV ratio were significant parameters for the diagnosis of acute appendicitis with cut-off values of 12.86 (susceptibility: 66.3%, specificity: 73.2%) and 1.64 (susceptibility: 59.8%, specificity: 71.9%), respectively. WBC and RDW/RBC ratio were independent variables for the diagnosis of complicated appendicitis. The cut-off values were 15.05 for WBC (sensitivity: 60.5%, specificity: 70.7%) and 2.5 for RDW/RBC ratio (sensitivity: 72%, specificity: 52.8%). Conclusions: WBC is an important predictor of appendicitis and complicated appendicitis. RDW, MPV and PDW alone have no diagnostic value in pediatric acute appendicitis or predicting the degree of appendix inflammation. However, the RDW/MPV ratio can be an important predictor of appendix inflammation, with higher values in patients with more severe appendix inflammation. RDW/RBC ratio may be an important predictor of complicated appendicitis.

Laparoscopic–endoscopic “rendezvous” procedures were introduced in surgery for common bile duct stone treatment but are now widely used in other fields of abdominal surgery. An endoscopist navigates a surgeon during the same operative procedure and, thus, enables a better visualization of the location, resection margins, bleeding control, less thermal damage, etc. Here, we present case series of 11 patients that were treated using a “rendezvous” procedure for gastrointestinal lesions on different parts of the gastrointestinal tract such as juvenile polyps on the colon (transversum, ascendens, cecum, sigma), leiomyomatosis of the stomach, Peutz–Jeghers intestinal polyposis, hyperplastic gastric polyp, ectopic pancreatic tissue in the stomach, gastric trichobezoar, and gastric schwannoma. “Rendezvous” procedures are suitable for intestinal lesions that could not be resected endoscopically due to their size, morphology and/or location. In our experience this procedure should be used for endoscopically unresectable lesions as it decreases the time of surgery, possibility of iatrogenic injury, bleeding and technical inability. Furthermore, this procedure has been shown to better navigate the surgeon during laparoscopic surgery, especially in treating polyps in particularly difficult locations such as the duodenum or cecum, and it decreases conversion rates. However, conversion is sometimes necessary, in order to assure all oncological principals are respected, and the best option in some cases.

To evaluate our single-center experience and results in management of children diagnosed with ovarian masses using minimal access surgery. Retrospective data review (2014–2016) of patients with adnexal disease was performed. Institutional ethical committee approval was obtained for this analysis. Twenty-one girls aged 9–18 years with 12 right, 7 left and 2 bilateral ovarian masses were analyzed. Of these 16 girls, 15 were operated laparoscopically based on clinical findings, ultrasound reports, computed tomography and/or magnetic resonance imaging, and tumor marker levels. There was a significant difference observed in the size of ovarian masses between operated versus non-operated group (87.1 vs. 31.8 mm; p

Introduction. Undescended testis is the most common congenital anomaly of the male urogenital tract. The main issues associated with this condition are decreased fertility and an increased risk for testicular cancer, which are minimized if early orchiopexy is performed. The objective of this study is to evaluate the age at orchiopexy at the Institute of Child and Youth Health Care of Vojvodina and to compare it to international guidelines (American Urological Association, Canadian Urological Association and European Association of Urology). Material and Methods. A retrospective study included 457 patients operated on between 2010 and 2015. The recorded data were analyzed by Microsoft Excel Office 365 using means, medians, minimums, maximums and standard deviations where appropriate. The patient age and current recommendations for timing of orchiopexy were analyzed as well. Results. The mean age at orchiopexy was 69.47 months, and the median age was 64 months. Considering each year separately, no significant differences between mean and median age at orchiopexy were found. The percentage of orchiopexies performed before 24 months was 29% and 5% were performed before 12 months of age. The mean age at orchiopexy was 51.47 months later than recommended by current international guidelines. Conclusion. This study confirmed that the age at orchiopexy in our sample was significantly delayed than recommended. It is necessary for all medical practitioners involved in child health care to share new information, trends and diagnostic-therapeutic algorithms about undescended testis and consequences of late treatment.

Introduction/Objective. Fibroadenoma, often called ?breast mice tumors? due to their mobility, are the most common breast tumors in pediatric population. Considering that some tumors have a potential for rapid growth, breast tissue damage, and that an ideal diagnostic tool has yet to be found, complete mass extirpation might be the treatment of choice. The aim of the study was to present our clinical experience in treating children with breast masses. Methods. A retrospective review (2011?2018) of patients treated for breast tumors at the Institute for Child and Youth Health Care of Vojvodina in Novi Sad was conducted. Results. In this study 29 girls (mean age 15.8 ? 1.8) were included. The majority of masses were located in the upper outer (27.6%) or lower inner (24.1%) breast quadrant. The mean mass diameter was 39.7 mm. It has been observed that the mean mass diameter in the group of girls with positive family history for breast diseases was significantly lower (p < 0.05) than in those with negative family history (27.5 vs. 43.2 mm). There were no proven malignant tumors and all tumors have been completely extirpated. The mean postoperative stay was 1.5 ? 1.02 days. Conclusion. An appropriate radical operative technique dependent on mass size and localization is still the ?gold standard? for treating breast masses in pediatric patients. Cooperation with experts in the field of oncologic breast surgery enables implementing these operative techniques in clinical practice of pediatric surgeons.

Introduction. Trichobezoars and gastric polyps are very rare conditions in children and may pose a diagnostic and therapeutic challenge. The purpose of this work is to present our successful experience using combined laparoscopic-endoscopic procedure for simultaneous treatment of a trichobezoar and gastric polyp in the same patient. Case outline. We present an unusual case of a 15-year-old girl whose symptoms included abdominal pain, non-bilious vomiting after feeding, including undigested food and sometimes hair. Positive history of trichophagia indicated that a trichobezoar could be the reason for her problems. Endoscopy and ultrasound examination revealed a trichobezoar occupying almost the entire capacity of the stomach, as well as one oval polyp in the prepyloric area of the antrum. Simultaneous combined laparoscopicendoscopic rendezvous procedure was performed. The trichobezoar (14 ? 6 cm) and the gastric polyp (2.2 ? 1.7 cm) were completely removed laparoscopically through anterior gastrotomy, with great support of an adequate endobag and mechanical fragmentation of trichobezoar. The postoperative course was uneventful. Conclusion. This case shows that diagnostic endoscopy is valuable and that the combined laparoscopicendoscopic technique is feasible, safe and recommended treatment for simultaneous removal of a gastric trichobezoar and gastric polypectomy.

Objective . To compare lung ultrasound (LUS) with auscultation findings in children with clinical suspicion of pneumonia. Patients and methods . A prospective study including 95 patients (age: from 2 months to 17.5 years; mean age: 5.1 y, SD 4.5 y) with referral diagnosis of suspected pneumonia. In all patients LUS and auscultatory examinations were performed within an hour. These findings were compared separately in each hemithorax. The radiologist performing LUS was blinded to the patient’s clinical information. Positive auscultatory findings included: crackles and/or abnormal breath sounds (decreased, asymmetric, absent, or bronchial). For LUS examinations a combined transthoracic – transabdominal approach was used. A pneumonia-positive LUS finding included subpleural consolidation with air-bronchogram, or an adjacent area of interstitial edema. For each subpleural consolidation the cranio-caudal (CC) diameter was measured, and 95% confidence intervals (CI) of the sizes of subpleural consolidations for positive and negative auscultatory findings were compared. The p-value between LUS and auscultation was calculated using McNemar’s test. Results . LUS and auscultation showed pneumonia-positive findings in 98 and 64 hemithoraces, i.e. in 67 and 45 patients respectively. In positive auscultatory findings the CI for CC diameters of subpleural consolidations ranged from 32.46 to 54.14 mm, and in negative auscultatory findings the CI was between 16.52 and 29.83 mm, which showed a statistically significant difference. McNemar’s test showed a statistically significant difference between LUS and auscultation. Conclusions . LUS showed positive findings in more hemithoraces than auscultation in children with suspected pneumonia. A cranio-caudal size of subpleural consolidation of less than 30 mm significantly reduces the possibility of auscultatory detection.

Prompt and accurate diagnosis of perforated appendicitis is crucial for proper and timely treatment. The appendix, however, cannot always be identified with sonography (US). We report the case of a 2-year-old child with atypical clinical presentation, and US detection of a free appendicolith as a sign of perforated appendicitis, without visualization of the appendix itself. Laparoscopy revealed a retrocecal, gangrenous, perforated appendix with autoamputation, fibrinopurulent peritonitis, and a free appendicolith within the abdominal fluid. US detection of a free appendicolith in a child is a very rare, but unequivocal sign of perforated appendicitis, which should be sought. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:395-398, 2016.

Introduction. The aim of this study is to present our treatment protocol for impalpable testis. Material and Methods. In a retrospective study we analyzed clinical data including diagnostic procedures, intraoperative findings, final diagnosis, treatment modality, and outcome of patients with impalpable testis who underwent surgery from January 2010 until December 2015. Results. Ninety-one patients were admitted under the diagnosis of impalpable testis. In 39 patients ultrasound detected testis in the inguinal canal and orchidopexy was done. In 25 patients (48.08%) laparoscopy showed the entrance of the spermatic cord into the inguinal canal. Open exploration of the inguinal canal was done, testicular remnant removed, and appropriate testicular prosthesis implanted. Twenty patients (20/52) underwent orchidopexy of the abdominal testis (46.51%), 4 of which underwent Fowler-Stevens procedure in two stages, and in 16 patients deliberation of the testis and spermatic cord was sufficient to place the testis into the scrotum. Conclusions. Excision of the testicular nubbin is highly recommendable, as well as implantation of the testicular prosthesis at the time of orchiectomy.

Introduction. Isolated torsion of the fallopian tube is a rare cause of acute lower abdominal pain and infrequent indication for surgical treatment. Case Outline. A 16-year-old girl was referred to the hospital due to the non-specific symptoms over period of a few months and pain acutization in the right infraumbilical region lasting for two days. Complete laboratory analyses were normal. Ultrasound examination revealed a round mass (23?14 mm) within the right fallopian tube with color Doppler whirlpool sign, normal ovary, and a simple ipsilateral paratubal cyst (50x40 mm). Laparoscopy showed a dilated and two times torquated right fallopian tube, as well as signs of chronic appendicitis. The tube was twisted about its longitudinal axis and it was livid, but not gangrenous. After appendectomy, fallopian tube was detorquated, cyst extracted and preservation of the tube was performed. Postoperatively, antibiotic therapy was administered based on antibiogram. On follow-up examinations within the next four months postoperative course was uneventful. Conclusion. Since there are no pathognomonic symptoms, clinical or laboratory findings, diagnosis of this condition is challenging. Familiarity with Doppler whirlpool sign can enable a timely diagnosis and treatment of isolated fallopian tube torsions. However, the diagnosis is rarely made before operation. Unlike in our case, surgery is often performed too late, and delay of intervention may result in failure to save the fallopian tube.

Introduction. Nuss procedure is a minimal invasive surgical technique based on retrosternal placement of a metal plate to correct pectus excavatum chest deformity. We are presenting our five?year (2006?2011) institutional experience of 21 patients. Objective. The aim of this study was to determine characteristics and advantages of minimal invasive surgical approach in correcting deformities of the chest. Methods. Surgical procedure, named after its author Nuss, involves the surgical placement of a molded metal plate, the so?called pectus bar, behind the sternum under thoracoscopic view whereby immediate controlled intraoperative corrections and stabilizations of the depression can be made. The great advantage of this method is reflected in a significant shortening of operative time, usually without indications for compensation in blood volume, and with a significantly shortened postoperative recovery that allows patients to quickly return to their normal activities. Results. In the period 2006?2011, 21 patients were operated by the Nuss procedure. The pectus bar was set in front or behind the muscles of the chest. Among the complications listed were inflammation of wounds in three patients, dislocation (shifting) of the bar requiring a reoperation in two patients, an occurrence of a pericardial effusion in one patient, and allergic response to foreign body in one patient. Five patients required extraction of the bar two years later, and three patients after three years, all with excellent results. Conclusion. Minimally invasive Nuss procedure is safe and effective. It currently represents the primary method of choice for solving the chest deformity pectus excavatum for patients of all ages. Modification of thoracoscopic control allows a safe field of operation. Postoperative results are excellent with very few complications that can be attributed to the learning curve.

Introduction. Pancreas divisum is a relatively common pancreatic duct anatomic variant, firstly described in the 17th century. Case report. We reported a 2-year-old child admitted to the Pediatric Clinic with breathing difficulties and abdominal pains. Examination and X-ray image, showed a vast right hydrothorax containing rusty coloured solution with a high degree of amylase. Ultrasound and computed tomography examination revealed pancreatic polycyclic pseudocysts; following magnetic resonance cholangiopancreatography (MRCP), the diagnosis of pancreas divisum was confirmed. The general condition of the patient worsened, requiring an urgent operation. External drainage of the perforated pancreatic pseudocyst was performed. Following external fistula maturation, a change from external to internal drainage was performed using Roux-en-Y fistulojejunostomy. A 3-year postoperative period was uneventful. Conclusion. Pancreas divisum cases are unique requiring clinical experience, rational approach, and complex multimodal management. MRCP is a valuable diagnostic method. Amongst therapeutic options, outer and internal drainage can be seen as reliable methods. Further investigations are absolutely required to determine practical and appropriate conclusions.

The Detection of the Complete Androgen Insensitivity Syndrome is not simple since diagnostic can start from different points, depending on clinical features. Four cases of complete androgen insensitivity syndrome are presented through diagnostic modalities and therapeutic approaches. The initial reasons for investigation were as follows: prenatal amniocentesis being in conflict with the postnatal phenotype, secondary clinical finding, testicle finding during hernia repair, and post pubertal primary amenorrhea. Complete chromosomal, hormonal and ultrasonographical investigations were performed in all patients. Laparoscopy or open inguinal approaches were performed for gonadectomy in all patients, and the microscopic finding was testicular tissue without malignancy. Complete Androgen Insensitivity Syndrome is a type of male pseudohermaphroditism that could be diagnosed as early as in pre-adult age, before any malignant changes appear, and early enough to reach the correct therapy in time.

Medical experts are still at issue over the most suitable management of simple neonatal ovarian cysts exceeding 40mm and complex cysts of any size. The authors present surgical treatment of these cysts by classical laparotomy and laparoscopy. The study included 13 newborn babies surgically treated for 6 simple and 7 complex ovarian cysts. The diameter of the cysts ranged from 29 to 102mm. The age of children was from 2 days to 10 months. The open classical laparotomic approach was performed in 8 babies. In the laparotomy group, cystectomy was done in 3 infants with simple cysts. The other 5, presented with ovarian torsion, required salpingo-oophorectomy. Video - assisted cystectomy was the procedure for 3 simplex and one complex cyst with torsion. Laparoscopic adnexectomy was applied in one case with autoamputated cyst. Our small study demonstrates that laparoscopy is as safe and effective as classical laparotomy in managing neonatal ovarian cysts, but with better cosmetic results.

Introduction. This is a retrospective analysis of therapeutic approaches and treatment outcomes of congenital abdominal wall defects (omphalocele and gastroschisis) in a five year period. The aim of this study was to identify factors which can affect the prognosis of future therapeutic procedures. Material and methods. We evaluated 13 children, 7 with omphalocele (2 female/5 male; mean birth weight of 2862 g; mean gestational age of 37 weeks), and 6 patients with gastroschisis (2 female/4 male; mean birth weight of 2640 g; mean gestational age of 36/2 weeks). All patients were treated at the Clinic of Pediatric Surgeiyfrom 1999 to 2003. Results. In this study, thirteen cases of congenital abdominal wall defects (omphalocele and gastroschisis) were retrospectively investigated. All patients underwent prenatal ultrasound. Omphalocele was prenatally detected in 42.8% of fetuses, and gastroschisis in 16.7%. Coexisting anomalies were present in 57.1% of patients with omphalocele and in 16.7% of newborns with gastroschisis. Three patients with omphalocele were treated operatively, and four only conservatively. The abdominal wall of patients with gastroschisis was primarily closed in three patients. Two patients required a staged abdominal wall closure. One patient with gastroschisis and intestinal atresia underwent primary closure after partial intestinal resection and enterostomy. Based on these responses, a management protocol (algorithm) was recommended. The most common postoperative complication, in 7 cases of omphalocele, was mechanical ileus (n=l), whereas among patients with gastroschisis the commonest were mechanical ileus (n=l) and intestinal perforation (n=1). The mortality of patients with omphalocele was 52% and with gastroschisis 66.7%. Conclusion. A strategy designed to optimize antenatal and neonatal factors is expected to increase the survival rate of patients with abdominal wall defects. .

Introduction. Acute pancreatitis in children is mostly due to abdominal trauma, diseases or congenital anomalies of the biliary-pancreatic tree. Both exogenous and endogenous functions of the gland could be disturbed by various levels of damage. Clinical Finding and Diagnostics. Acute abdominal pain, gastrointestinal signs and general deterioration are the main clinical findings. The examination can be completed by blood and urine tests of amylase, electrolytes level, and the C-reactive protein. In addition to these tests, ultrasound, computed tomography and endoscopy are required as well. Therapeutic Methods. The therapy of choice is non-operative treatment using medicaments to control the pain, decrease the pancreatic activity and prevent further complications. If the conservative treatment fails, the surgical approach is necessary: drainage, resections, by-pass procedures, etc. Conclusion. Acute pancreatitis is a very serious disease in childhood. Clinical experience and rational approach are very important in the diagnostic and therapeutic methods.

Adrenal rests are usually unrecognized during operation, and the incidence of ectopic adrenal cortical tissue in pediatric patients during inguinal surgery procedures is unknown. We performed 3028 groin surgical explorations in 2680 patients aged 1 month to 17 years. Ectopic adrenal tissue was found in 69 inguinal operations (2.2%): 37 during 1.524 orchiopexy (2.4%), 23 during 1.115 herniectomy (2.0%), and 9 during 389 hydrocoela operation (2.3%). Statistically there were no significant differences among those three groups. No adrenal rests were detected in females. Although a few reported cases with hormonal activity of ectopic adrenocortical tissue (EACT), the recommendation is to remove them if found.

This paper presents a historical review and development of minimally invasive surgery. The interest of physicians to "look into the internal organs" has existed since the ancient time. The first described endoscopy was by Hippocrates. He made reference to a rectal speculum. The credit for modern endoscopy belongs to Bozzini. He developed a light conductor which he called "Lichleiter" to avoid the problems of inadequate illumination. In 1853, Desormeaux first introduced the "Lichtleiter" of Bozzini to a patient. Many developments, which occurred independently but almost simultaneously, produced breakthroughs for endoscopy and laparoscopy that were bases for modern instruments. In 1901, Kelling coined the term "coelioskope" to describe the technique that used a cystoscope to examine the abdominal cavity of dogs. In 1910, Jacobaeus used the term "laparothorakoskopie" for the fist time. In 1938, Veress developed the spring-loaded needle for draining ascites and evacuating fluid and air from the chest. Its current modifications make the "Veress" needle a perfect tool to achieve pneumnoperitoneum during laparoscopic surgery. In 1970, Hasson developed a technique performing laparoscopy through a miniature leparotomy incision. The first solid state camera was introduced in 1982 that was the start of "video-laparoscopy". In 1981 Kurt Semm performed first laparoscopic appendectomy. Within a year, all standard surgical procedures were performed laparoscopically. The authors also analyzed the new surgical techniques, such as telesurgery, robotics and virtual reality in current surgical practice. They specially enmphasized the use of laparoscopic access in pediatric surgery which has become a new gold standard in surgical treatment of pediatric patients.

The immunoglobulin A (IgA) immunoregulation disorders lie at the basis of Henoch-Schonlein purpura nephritis and IgA nephropathy. Peliosis is the condition characterized by cystic formations within the parenchyma of solid organs filled with blood. The authors report a case of a girl presenting with hematuria occurring during the course of respiratory infections since her fifth year. Pathohistological examination was not performed at that time. At the age of 13, the girl was hospitalized for abdominal pain. Computed tomography examination showed the presence of multiple, relatively well-defined nodular formations located in the spleen parenchyma. Splenectomy was performed. Morphological finding completely corresponded to peliosis of the spleen, with the deposits of IgA in the lesions within it. A year and a half following the splenectomy, a typical clinical picture of Henoch-Schonlein purpura nephritis developed. Biopsy findings of the skin and kidneys detected deposits of IgA. This is the first case of a patient suffering from associated IgA and Henoch-Schonlein purpura nephritis complicated by splenic peliosis to be described in the world’s literature.