This case presented a significant medical challenge, but it also demonstrated the importance of multidisciplinary collaboration and expertise in handling complex cases.
He was 1 year old boy presented to us with complaints of abdominal distension and pain for 3 months and was diagnosed to have a large abdominal mass. The imaging was suggestive of a giant tumor involving the whole of abdomen with involvement of major vessels of lower abdomen along with ureters and urinary bladder. Many experienced doctors in the tertiary care center of Delhi –NCR hospital showed reluctance to operate due to the size and complexity of the tumor. Our team in BLK-MAX Hospital’s team undertook the task with careful planning and skillful execution.
The decision to proceed with surgery involved thorough counseling of the parents, ensuring they understood the risks involved, including the possibility of losing the right lower limb due to vascular involvement.
During the 5-hour procedure, the surgical team successfully excised the massive tumor weighing 1600 gms while ensuring the safety of adjacent vital structures. The cardiovascular team was involved for reconstruction of the right external iliac vein.
Following surgery, the patient showed rapid recovery and return to normal activities within days and is doing well after four months of follow up with no morbidities. The histopathology report confirmed the diagnosis of Lipoblastoma.
Dr Prashant Jain
Dr Ashish Prasad
Department of Pediatric Surgery and Pediatric urology,
BLK Max Superspeciality Hospital.
A 10-year-old female child presented with intermittent complaints of mild left upper abdomen pain. She was evaluated and was diagnosed with a splenic cyst in the upper pole of the spleen of approximately 4X3.5 cm. She was closely followed up for 2 years with serial ultrasounds which showed progressive increase in the size of the cyst. Contrast enhanced computed tomogram (CECT) abdomen was done which showed a upper pole splenic cyst of size approximately 6X6X5 cm (FIG 1). The cyst was involving the upper one third of the spleen. Because the child was symptomatic, and the size was increasing the child was planned for laparoscopic excision of the cyst. In view of the young age and to avoid the future risk of post splenectomy sepsis, the preferred option was splenic preservation surgery. Although technically challenging, laparoscopic surgery was planned to offer better cosmesis and faster recovery.
To plan for partial splenectomy and to avoid the risk of hemorrhage, it was important to understand the vascular anatomy of the spleen. CECT angiogram revealed a separate upper polar vessel branching from the hilum and supplying the cystic area.
On laparoscopy, the large cystic mass was identified in the upper pole of the spleen (FIG 2). A careful dissection of the hilum was done, and the upper polar branch splenic artery was identified and secured. This created a well-defined avascular plane which further facilitated the resection of the cyst with minimal blood loss.
Postoperatively, the child was stable and was discharged on second postoperative day. Histopathology was suggestive of epidermoid cyst of the spleen. After 2 years of follow up the child is asymptomatic and there is no recurrence of the cyst.
Congenital epidermoid cyst are rare and comprises 2.5% of all splenic cyst in childhood. Traditionally total splenectomy has been advocated for large cyst but it has high incidence of post appendectomy sepsis. Partial splenectomy preserving at least at least 25% splenic parenchyma can prevent risk of pneumococcal bacteremia.
Symptomatic patients and patients with cyst size more than 5 cm should be considered for surgical excision. Better understanding of the splenic segmental anatomy on imaging, need of splenic conservation, and advances in laparoscopic skills has made laparoscopic partial splenectomy a preferred treatment for splenic cysts. Laparoscopy although technically difficult and challenging, but with proper planning, is a safe and feasible option. It offers the advantage of minimal scars and early recovery.
7 year old male child, presented with c/o pain abdomen for 10- 15 days. He was evaluated and USG abdomen and CECT abdomen showed a large, well capsulated right adrenal mass of size approximately 6X7 cm. The evaluation was suggestive of a benign non functioning adrenal mass. He underwent successful laparoscopic excision of the adrenal mass. The biopsy was suggestive of benign adrenal mass (Ganglioneuroma). Post operative period was uneventful.
Laparoscopic approach for adrenal mass is preferred and safe option for management of such tumors.
It avoids large incision and morbidity of open surgery.
It ensures early recovery with excellent outcome.
Tumours of the adrenal gland, other than neuroblastoma, are extremely rare in children. Pheochromocytomas are catecholamine secreting tumors derived from the adrenal gland which presents with symptoms of palpitation, sweating and headache.
A 12 year old boy was admitted in emergency with c/o abnormal limb movements and severe headache. He was evaluated and was found to have high blood pressure. The child was stabilized and BP was controlled. The child was then evaluated and CECT abdomen/MIBG scan were suggestive of Bilateral Pheocromocytoma. The child underwent Laparoscopic bilateral adrenalectomy after adequate preoperative preparation. The child is on regular follow up with normal blood pressure.
Pheochromocytomas are rare adrenal functioning tumors. They need extensive preoperative evaluation and management. Minimal access surgery has many advantages in the management. It minimises intraopertaive and postoperative complications. Also it avoids large incision especially in cases of bilateral tumors.
A multidisciplinary team of Pediatric Surgeon, Pediatric intensivist and Pediatric endocrinologist is required for successful planning and management of such cases.
Penoscrotal hypospadias with severe chordee
Stage 1: Chordee correction and free preputial graft
Stage II: Urethroplasty
BLK-Max Super Speciality Hospital
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