Journal Appraisal

OBJECTIVE: to compare laparoscopic intracorporeal purse-string suture

ligation of the hernia defect leaving the sac intact versus disconnection of the
hernia sac with intracorporeal suturing of proximal part

• P- Male patients with Congenital Inguinal Hernia

(CIH) aged 8-36 months
• I- Purse-string suture ligation of the hernia defect
leaving the sac intact
• C- Disconnection of the hernia sac with
intracorporeal suturing of proximal part
• O- Operative time, hospital stay, postoperative
hydrocele formation, recurrence rate, and
cosmetic results
• M- Prospective controlled randomized study
 Validity Guides

Were patients randomized? Yes

Was blinding done in the study? No

Were baseline characteristics of the patients in the study groups similar? Yes

Was the follow-up adequate and complete? Yes

 Inclusion and Exclusion
Inclusion
• Male patients only
• Bilateral CIH
• Unilateral CIH with
questionable other side
• Cases of CIH associated with
umbilical hernia and
parental request
Exclusion
• Recurrent cases,
complicated cases
• Hernia of canal of Nuck in
females
• Inguinal hernia with
undescended testis
• Parental refusal,
contraindications for
laparoscopy as major lower
abdominal surgery
 132 patients with CIH
Randomization into two
equal groups by a random-
number table sequence

Group I (N = 66) Group II (N = 66)

Intracorporeal purse string suture Disconnection of the hernia
ligation of the hernia sac at IIR sac with intracorporeal suture
leaving the sac intact of proximal part at IIR
 Intervention
• Group I (Treatment): Intracorporeal purse-
string suture ligation of the hernia defect
leaving the sac intact at internal inguinal ring
[IIR].
• Group II (Control): Disconnection of the hernia
sac with intracorporeal suturing of proxi- mal
part at IIR
 Outcome
• There was statistically significant difference in the
mean duration for surgery
 Outcome
• There were no statistically significant differences
between groups regarding intraoperative
complications
 Outcome
• There were statistically significant differences
between groups regarding hydrocele formation
 Outcome
• There were statistically significant differences
in the recurrence rate between the studied
groups
• Group I: 2 cases (2.6%)
• Group II: none
 Outcome
• All patients have had minimal postoperative
discomfort and resumed normal activities
later on the same day of surgery.
• They passed uneventful postoperative reco
and discharged home on the evening of the
same day of surgery.
 Conclusion
• Laparoscopic inguinal hernia repair by
disconnection of the hernia sac at the IIR with
peritoneal closure has lower recurrence rate
than the purse string suturing leaving the sac
intact.
• This method may be safely done.
• P-Age of 48months or younger with confirmed
diagnosis of HD
• I- Probiotic
• C- Placebo
• O- Incidence of post-operative Hirschsprung-
associated enterocolitis
• M- Double blinded prospective randomized
controlled trial
 Validity Guides

Were patients randomized? Yes

Was blinding done in the study? Yes

Were baseline characteristics of the patients in the study groups similar? Yes

Was the follow-up adequate and complete? Yes

 Inclusion and Exclusion
Inclusion
• diagnosis of HD was
confirmed by suction rectal
biopsy results prior to
surgical pullthrough
• All patients within 1/2006
to 12/2009 suffering from
HD at an age of 48months
or younger
Exclusion
• Children 48 months of age
at time of pullthrough,
hemodynamically unstable,
active septicemia, major
congenital anomalies with
markedly
 Intervention: Probiotic VSL#3
• Contained 90 billion viable lyophilized bacteria (per
packet) composed of four strains of Lactobacillus, three
strains of Bifidobacterium, and one strain of
Streptococcus salivarius subsp. Thermophilus in a
vegetable capsule
• Diluted in 2 to 4 oz of expressed human milk or
formula
• Children ≤5 kg received 90 billion bacteria (one 0.25g
sachet/dose) twice a day
• Children > 5kg received 180 billion bacteria (two
sachets/dose) twice a day
• Placebo: identically the same maize starch
 Outcome
• Post-operative visit schedule of 1, 3, 6 and
12months, unanticipated clinic, emergency room
or hospital admissions
• HAEC was clinically diagnosed and documented
by the treating physician
• Secondary outcome: number of HAEC episodes,
clinical severity of HAEC, and associated
contributing factors predisposing to HAEC (e.g.,
gender, a diagnosis of Trisomy 21, length of
aganglionosis, age at diagnosis, and age at
pullthrough procedure)
Result
 Results
• Overall incidence of HAEC was 28.3%
• PLACEBO:
– 7/28 (25%) were diagnosed with post-operative HAEC
– 6 as clinical grade I
– none as grade II
– 1 as grade III
– 6 (19%) had recurrent episodes of HAEC
• PROBIOTIC:
– 10/32 (31%) were diagnosed with post-operative HAEC
– 3 as clinical grade I
– 6 as grade II
– 1 as grade III
– 6 (21%) had recurrent episodes of HAEC
• HAEC was not significantly different between the patients receiving
placebo or probiotic therapy (p=0.897)
 Conclusion
• Use of probiotic bacterial therapy was
ineffective in reducing either the incidence or
severity of post-pullthrough Hirschsprung-
associated enterocolitis
OBJECTIVE: The aim of this study was to conduct a randomly controlled
trial to compare the effectiveness and safety of the hydrostatic and pneumatic
reduction techniques.

• P- Children from 0 to 18 who were diagnosed

with intussusception
• I- Hydrostatic reduction
• C- Pneumatic reduction
• O- Success of nonoperative reduction;
Recurrence rate; Intestinal perforation rate
• M- Randomized controlled trial
 Validity Guides

Were patients randomized? Yes

Was blinding done in the study? No

Were baseline characteristics of the patients in the study groups similar? Yes

Was the follow-up adequate and complete? Yes

 Inclusion and Exclusion
Inclusion
• Children from 0 to 18 who
were diagnosed with
intussusception and visited
the West China of Sichuan
University emergency
during the period from
January 2014 to December
2015
Exclusion
• Patients who had
contraindications for a non-
operative reduction
(peritonitis, perforation
signs, and non-responsive
shock)
 Methodology
• Both techniques of reduction are composed of three
repeated 3-min procedures.
• Hydrostatic reduction: by a pediatric surgeon using
ultrasound guidance (5–10 MHz transducer). All
patients received continuous pressure from 74 to 88
mmHg with the assistance of the balloon
• Pneumatic reduction: by a radiologist in the company
of a pediatric surgeon using fluoroscopic guidance.
Fluoroscopic monitoring with a Sonialvision Safire, with
pressure from 80 to 120mmHg.
• Sedation drugs were given according to the hospital
sedation guidelines.
 Outcome
• The primary clinical outcome of the study was the
success of nonoperative reduction.
– Disappearance of intussusception
– Visualization of the normal saline or air from the
cecum to the ileum through the ileocecal valve
– normal saline or air-distended ileum
– disappearance of intussusception after reduction by
ultrasound examination.
• The secondary clinical outcomes
– rate of intestinal perforation during reduction and
recurrence after reduction.
Result
Results
Results
 Results
• A total of 147 episodes of intussusception were identified
• Median follow-up time was 12 months, however the
parents of 12 patients refused to participate in the study
• Data of 5 patients is missing.
• Six patients were excluded due to the contraindications
after the diagnosis.
• One hundred and twenty four episodes were included in
this study.
• The male to female ratio was 2:1.
• The median age of the patient was 21.50 months with a
mean weight of 12.46 kg.
 Results
• The overall success rate in this study was 90.32%.
• Success rate of the hydrostatic reduction
(96.77%) was significantly higher than that of
pneumatic reduction (83.87%) (p=0.015).
• Perforation after reduction was found in only one
pneumatic reduction case
• The recurrence rate of intussusception in the
hydrostatic reduction
• (4.84%) was not significantly different compared
with pneumatic reduction (3.23%) (p=0.648).
 Conclusion
• The study conclude that ultrasound is useful for
the diagnosis of intussusceptions, as well as to
guiding hydrostatic reductions by using saline
enema.
• The study found that ultrasound-guided
hydrostatic reduction is a simple, safe and
effective non-operative treatment for
intussusceptions in the pediatric age group, and
should be the first line of management in
appropriate patients.