Circumcision is one of the common operations performed worldwide, for various reasons. Controversy exists as to whether circumcision is an operation. This literature review discusses the indications of circumcision, benefits and complications of circumcision, and alternatives to circumcision. Relevant articles on the benefits, complications, indications and alternative to circumcision from 1964 to 2005 were reviewed, from National Library of Medicine's Pubmed database. Additional articles were obtained from the reference lists of key articles and recent reviews.

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Background: Intussusception is the commonest cause of bowel obstruction in infancy and childhood. Early diagnosis and effective management have reduced its morbidity and mortality in developed countries. Aim: To document the presentation, management and treatment outcome of intussusceptions at the Lagos University Teaching Hospital (LUTH). Patients and Methods: One hundred seventy-four consecutive cases of this condition seen in children presenting at LUTH over a 5-year period were prospectively studied. Details of symptoms and signs, pre-hospital care, treatment, and outcome in LUTH were documented. Results: The triad of abdominal pain, bloody mucoid stools and palpable abdominal mass was seen in 106 (61%) of the cases. One hundred thirty-five (77.6%) had been admitted and treated with antibiotics and intravenous fluids in primary healthcare centers for an average of 3 days before referral to the LUTH. Prolonged mean duration of recognizable symptoms of 3 days accounted for a 70.4% bowel resection rate. Wound infection occurred in 61 (36.1%), whereas fecal fistulae developed in six (3.6%), and burst abdomen in five (3%) of cases. Seven (4.1%) patients developed incisional herniae. Overall, mortality rate was 12.1%. Conclusion: The early symptoms of intussusception would seem to be missed by primary healthcare workers in Lagos, with consequently high morbidity and mortality. There is an urgent need to re-emphasize these symptoms to first-line healthcare providers and parents through public enlightenment campaigns.

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Purpose: Penoscrotal transposition may be partial or complete, resulting in variable degrees of positional exchanges between the penis and the scrotum. Repairs of penoscrotal transposition rely on the creation of rotational flaps to mobilise the scrotum downwards or transpose the penis to a neo hole created in the skin of the mons-pubis. All known techniques result in complete circular incision around the root of the penis, resulting in severe and massive oedema of the penile skin, which delays correction of the associated hypospadias and increases the incidence of complications, as the skin vascularity and lymphatics are impaired by the designed incision. A new design to prevent this post-operative oedema, allowing early correction of the associated hypospadias and lowering the incidence of possible complications, had been used, whose results were compared with other methods of correction. Materials and Methods: Ten patients with incomplete penoscrotal transposition had been corrected by designing rotational flaps that push the scrotum back while the penile skin remains attached by small strip to the skin of the mons-pubis. Results : All patients showed an excellent cosmetic outcome. There was minimal post-operative oedema and no vascular compromise to the penile or scrotal skin. Correction of associated hypospadias can be performed in the same sitting or in another sitting, without or with minimal complications. Conclusion: This modification, which maintains the penile skin connected to the skin of the lower abdomen by a small strip of skin during correction of penoscrotal transposition, prevents post-operative oedema and improves healing with excellent cosmetic appearance, allows one-stage repair with minimal complications and reduce post-operative complications such as urinary fistula and flap necrosis.

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Two male children with ano/recto-urethral fistula without anorectal malformation were managed in our institute. These patients had variable clinical manifestations and associated anomalies including congenital urethral hypoplasia, renal agenesis and patent urachus. Both were treated successfully according to their status of disease-complexes. This is to discuss these rare cases and its management with review of the literature.

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A case of reconstruction after penile skin avulsion is described in an eight-year-old boy. Penile coverage was gained by use of the avulsed skin flap itself, without a graft or local tissue flap. The procedure avoids any valuable time delay; thus, enhancing the chances to obtain adequate flap viability, avoids patient discomfort caused by perineal expansion, gives a satisfactory cosmetic appearance, and taking into account his age, avoids future psychosomatic and psychosexual problems.

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Background: In children, majority of the head injuries are minor and management of critically ill children depend on a team approach using well-rehearsed, systematic management protocols that can be implemented within hours after injury. This study was carried out to ascertain the epidemiology and management of know the demographic profile and etiology of paediatric head injury in our setting, to know the clinical and radiological characteristics of head injury patients and to know the treatment options and outcome in paediatric head injuries. Patients and Methods: Details of all children (age <16 years) with head injury seen in 1 year from 01.04.2005 to 31.03.2006 were retrospectively reviewed. Demographic profile, clinical details, investigations, treatment offered, and outcome were noted in a proforma. All data were analyzed by appropriate SPSS 11.0 statistical software tools. Results: There were total 43 patients. Young male children were more commonly affected in present series with a mean age of 7.67 years (median - 5.010 years), range 6 months-16 year. Fall (65.11%) was the most common mode of injury followed by road traffic accidents (RTAs) (25.6%). Mild head injuries (65.11%) were most common. Most common complaint was loss of consciousness and all the patients with severe head injury presented loss of consciousness. All patients with mild head showed good recovery; with moderate head injury, nine patients showed good recovery and three patients recovered with moderate disability. Patients with severe head injury (three patients) had 100% mortality. Conclusions: In urban areas of Nepal, RTAs like vehicular crashes, motor cycle accidents, and pedestrian hit by moving vehicle are more common and in rural areas fall from height are commoner. We need to develop child safety legislations and risk-specific intervention programs in Nepal.

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A trichobezoar is a mass of cumulated hair within the gastrointestinal tract. Stomach is the common site of occurrence. Intestinal obstruction due to trichobezoar is extremely rare. The authors report two cases of a trichobezoar obstructing the terminal ileum in one and the jejunum in another.

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Background: A testis located outside the scrotum is prone to a lot of complications but early detection and correction give good result. The purpose of this study was to determine the pattern of presentation, complications recorded, the surgical treatment offered and outcome in a developing country. Patients and Methods: A retrospective study of patients that presented with undescended testes at the University of Benin Teaching Hospital between January, 1997 and December, 2006. Results: A total of 76 orchidopexies and 10 orchidectomies were done on 71 patients with undescended testes during the period. They were aged 9 months and 47 years (mean 8.3 ± 7.9 years) at surgery. Only 31 (43.7%) patients presented at age 5 years and below while 40 (56.3%) presented after 5 years. Seventy-two (83.7%) testes were palpable, ultrasound scan was used to locate 10 (11.6%), while 4 (4.7%) could only be located during groin exploration. Intraoperative assessment of the testes were 54 (62.8%) normal testicular volume, 22 (25.6%) reduced volume and 10 (11.6%) atretic. All those aged 5 years and below had normal/reduced testicular volume and all had orchidopexy whereas those above 5 years with normal/reduced testicular volume had orchidopexy and those with atretic testis had orchidectomy. Post operatively, testicular growth was recorded only among the pre/pubertile boys, the testes retracted in two patients, scrotal skin infection in one, and intra scrotal haematoma in two. Conclusion: Delayed presentation resulted in morphological changes, increased complications, number of orchidectomy and reduced chance of testicular growth post orchidopexy.

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Background: Urethral mucosal prolapse is rare. This condition may be confused with tumour or sexual abuse in girls. This study aims at reporting the pathology presentation and therapeutic options of urethral prolapse in girls. Materials and Methods: A retrospective study was undertaken from January 2000 to December 2008. Authors analysed the clinical features and the treatment options. Results: There were nine cases of urethral prolapse. The ages ranged from 2.5 to 10 years (mean age: 5.08 years). The main presentation was vaginal bleeding (five cases). Physical examination revealed a soft, non-tender mass that bleeds on touch (six cases), with a length ranging from 0.75 to 1 cm. Urine culture in four patients revealed urinary infection that yielded Escherichia coli in three cases and the Staphylococcus aureus in one case. Six patients had surgical treatment while three had medical treatment. In those who had surgery, one had acute urine retention and one had recurrence that was treated successfully without operation. All the nine girls are cured. Conclusion: Urethral prolapse is a disease of the prepubertal girls of low socio-economic group. Diagnosis is clinical. The treatment of choice is surgical.

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Neonatal hydrometrocolpos is a rare condition that follows congenital vaginal obstruction. Association with urinary obstruction and upper tract dilatation has been reported in some cases. Obstruction of the gastrointestinal tract without a coexisting bowel anomaly can also occur, but this is very rare. In some cases, preoperative diagnosis may be difficult. We describe our experience with a rare case of huge hydrometrocolpos presenting as neonatal intestinal and urinary obstruction.

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Persistent Mullerian duct syndrome is a rare form of internal male pseudohermaphroditism, in which Mullerian duct derivatives (uterus and fallopian tubes) are present in a genotypic (46XY) and phenotypic male. Over 150 cases have been reported, mainly from outside the African setting. This article presents an unexpected case encountered in an African setting. Handicaps in the management were unavailability of necessary diagnostic tools as well as lack of finance to assess those available. Although a diagnosis was eventually arrived at and the parents thoroughly counseled, the patient has not represented for definitive surgery.

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Aim: To improve the results of tubularized plate urethroplasty by adding de-epithelized flap. Patients and Methods: Twenty-five cases of hypospadias who underwent Snodgrass urethroplasty using de-epithelialized flap were studied. The minimum period of follow-up in this series was 1 year. Results: The resultant neo-meatus was vertically oriented and slit like. Glans was conical which is cosmetically well accepted. Penile raphe was in the midline. None of the patient had residual chordee, penile torsion, or glans dehiscence. Excellent cosmetic results were observed in all cases. The complication rate in our series was 8% (two cases). Two patients developed fistula. Conclusion: De-epithelialized flap is a simple method to provide additional covering to the constructed neourethra after Snodgrass urethroplasty. It achieves our goal of noncrossing suture lines and providing maximum vascularity.

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Duodenal ulcer perforation is very uncommon in infants and children, that is why it is not usually considered in the differential diagnosis of acute abdomen in this age group. Moreover, the diagnosis of this condition is usually overlooked because of vague and variable symptoms and low index of suspicion on the part of the treating physicians. In this brief report, we are reporting two cases of successfully managed perforated duodenal ulcer in infancy.

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Urethrocutaneous fistula is a common complication after hypospadias repair. If congenital, it is usually associated with other genitourinary and gastrointestinal anomalies. Isolated congenital urethral fistula is a very rare anomaly. We present a 4-year old circumcised boy with this unusual anomaly. Etiology, embryology, and management are discussed. We emphasize meticulous clinical examination for the diagnosis and to rule out other associated anomalies.

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Objective: This study compared the outcome of Mathieu repair between patients who went home within 24 hours on catheter and dressing and patients who were managed in hospital for 48 hours and had their catheters and dressings removed before going home. Patients and Methods: A retrospective study of Mathieu hypospadias repair performed by the same surgeon for 11 years. Outcome measures were catheter and dressing related problems/complications. Results: Sixty five patients were included in the study; 43(66.2%) were managed in-hospital for the first 48 hours (Group A), while 22(33.8%) were managed as day-care cases (Group B). Complication rate was 6(14.0%) and 3(13.6%) respectively, with fistula rate of 2(4.7%) in Group A and 1(4.5%) in Group B. Conclusion: Day care Mathieu repair of hypospadias does not increase the occurrence of complications.

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Background: To evaluate the impact of scientific seminar on the sexual ambiguity on patients and paediatric surgeons in French-speaking African countries. Materials and Methods: This was a report of the proceeding of a teaching seminar on intersex management, which was held from December 4 ^th to 8 ^th , 2006, in the Paediatric Surgery Department of Tokoin Teaching Hospital and the Surgery Department of "Saint Jean de Dieu" Hospital of Afagnan, Togo. Results: There were 107 participants [five professors of paediatric surgery, 62 African paediatric surgeons (including 15 from African French- speaking countries), and 40 general surgeons]. The workshop involved a two-day theoretical teaching session (aimed at understanding, recognising, and treating the sexual ambiguities), and practical session; during these sessions different intersexes (one case of mixed gonadal dysgenesis, two of female pseudohermaphroditism, and two of male pseudohermaphroditism), were operated free of charge. Participants expressed satisfaction and confidence with regard to the management of intersex after the seminar. Conclusion: This scientific forum allowed possible exchange of competence among the paediatric surgeons with regard to efficient treatment of sexual ambiguities.

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Background: Mesenteric cysts are rare intra-abdominal masses in the paediatric age group with varied presentation, ranging from an asymptomatic mass to acute abdomen. This study reviews our experience in the diagnosis and treatment of 17 mesenteric cysts in our centre, with especial reference to acute abdominal symptoms. Patients and Methods: Seventeen patients (age less than 10 years) with mesenteric cysts were managed in our hospital. The age ranged from 15 days to 10 years. Patients were admitted with acute or chronic symptoms. They were evaluated with complete history, clinical examination, blood investigations and radiological investigations (x-ray abdomen erect, ultrasound abdomen (USG) and computed tomography (CT) scan in selected cases) to reach a provisional diagnosis. The diagnosis was proven on laparotomy and histologically confirmed. Results: The main presenting symptoms were abdominal pain or lump. The most common mode of presentation was acute small intestinal obstruction. USG was not conclusive in all. Abdominal CT scan with intravenous contrast was diagnostic in nine patients. Five patients had volvulus on exploration. Cysts were located in small intestinal mesentery in 14 cases and three were in the sigmoid mesentery. Seven patients had complete excision, intestinal resection was required in four and marsupialisation with cauterisation of margins was done in six patients. Histologically, all were lymphangiomatous mesenteric cysts. Conclusion: The diagnosis of mesenteric cysts should be kept in mind in any patient presenting with acute abdominal symptoms. Small bowel volvulus with mesenteric cyst constituted a significant number in children with acute abdominal symptoms. Early diagnosis and treatment yields excellent outcome.

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Background: Nonoperative management of adhesive intestinal obstruction gives good results in adults but there are scant studies on its outcome in children. This study reports outcomes and experiences with nonoperative and operative management of adhesive intestinal obstruction in children in a resource-poor country. Patients and Methods: This is a retrospective analysis of records of children who were managed with adhesive intestinal obstruction at the University of Benin Teaching Hospital between January 2002 and December 2008. Results: Adhesive intestinal obstruction accounted for 21 (8.8%) of 238 children managed with intestinal obstruction. They were aged between 7 weeks and 16 years (mean 3 ± 6.4 years), comprising 13 males and eight females (ratio 1.6:1). Prior laparotomy for gangrenous/perforated intussusception (seven, 33.3%), perforated appendix (five, 23.8%), perforated volvulus (three, 14.3%), penetrating abdominal trauma (two, 9.5%) and perforated typhoid (two, 9.5%) were major aetiologies. Adhesive obstruction occurred between 6 weeks and 7 years after the index laparotomies. All the 21 children had initial nonoperative management without success, owing to lack of total parenteral nutrition and monitoring facilities. Outcomes of open adhesiolysis performed between 26 and 48 h in six (28.6%) children due to poor response to nonoperative management, 11-13 days in 12 (57.1%) who responded minimally and 2-5 weeks in three (14.3%) who had relapse of symptoms were encouraging. Exploration of the 21 adhesive obstructions confirmed small bowel obstruction due to solitary bands (two, 9.5%), multiple bands/adhesions (13, 61.9%) and encasement, including one bowel gangrene (six, 28.6%). Postoperatively, the only child who had recurrence during 1-6 years of follow-up did well after a repeat adhesiolysis. Conclusion: Nonoperative management was unsuccessful in this setting. Open adhesiolysis may be adopted in children to prevent avoidable morbidities and mortalities in settings with limited resources.

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Background: Surgeries performed for gynaecological conditions in children and adolescents are not common in our environment. Adequate facilities and the skill to perform the required procedures may also be lacking. We were interested in reviewing the practice of paediatric gynaecological surgery in our facility. Patients and Methods: A retrospective study of case files and theatre records of children below the age of 16 years who had surgeries at the Jos University Teaching Hospital over a 10 year period was undertaken. Results: A total of 89 surgeries were performed in this age group during the period under review. Twenty-eight (33.4%) of the patients were below the age of 11. The most common surgical procedure was for the management of septic abortion (21.3%). Correction of congenital malformations of the genital tract accounted for 21.4% (19) of the surgeries performed. Fourteen (15.7%) laparotomies were performed for ovarian cysts. Conclusion: Though the number of surgeries performed on children for gynaecologic reasons may appear small, the skills required to manage them should be enhanced and the requisite facilities provided.

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Background: The aim of this study was to describe the outcome and determine the prognostic factors of outcome of childhood rhabdomyosarcoma in a tertiary hospital in a developing country. Patients and Methods: This was a retrospective review of the clinical presentation, investigation, intervention, and treatment outcomes of children with rhabdomyosarcoma in our hospital over a 7-year period. Statistical analysis was performed using Chi-square test. Results: A total of 18 patients were identified with two-thirds being males (n = 12) with median age of 7 years. Most of the children were below 10 years of age. Lower limbs tumour predominated (n = 6) followed by the upper limbs and head and neck (n = 4 each). Other sites included perianal/perineal (n = 3) and the orbit (n = 1). Two patients were Intergroup Rabdomyosarcoma Study (IRS) group I, four group II, five group III, and seven group IV. Lymph node involvement was the commonest site of metastasis. Clinical group and stage was significantly more advanced in patients older than 10 years compared to younger than 10 years (P = 0.010, P = 0.008, respectively). There were 12 patients with alveolar disease while six had embryonal type of rhabdomyosarcoma. Treatment was by combination chemotherapy, and surgical excision which was done primarily in 11, after chemotherapy in four, and after radiotherapy in one. Two had biopsy only. Five patients are alive, two of them without evidence of disease at average follow-up period of 2 years. Conclusion: Mortality from rhadomyosarcoma in our setting is still unacceptably high. Late presentation may be the major contributor to high mortality. A more aggressive multimodality treatment approach may improve the outcome.

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Objective/Purpose: This paper describes a new method of hand anastomosis to complete the Duhamel operation for Hirschsprung's disease (HD). Methodology: All patients had diagnosis of Hirschsrung's disease confirmed by rectal biopsy and had defunctioning colostomy. At the definitive operation, the ganglionic bowel was brought down in a retro-rectal position and anastomosed at the anal canal just above the dentate line. At this anastomosis, the sutures at 11 and 1 o'clock were left long as stay sutures. An incision was then made down the new bowel at the antimesenteric border from the pelvic brim. Another incision was made down the back of the native rectum. A long-curved artery forceps was then passed into the incision in the native rectum out of the anal canal. This forceps was now hooked round the anastomosis at 12 o'clock and further pushed in until the point appears through the colotomy in the ganglionic bowel. The two layers of bowel between the forceps were incised. The forceps was now inserted to grab the long sutures at 11 o'clock and 1 o'clock in turn, and delivered through the pelvis. Anastomosis between the edges of the native rectum and the neorectum was then done with interrupted PDS inside and silk outside. Results: Seven patients had the procedure done. Age ranged between 4 months and 4 years (mean 3.4 years). They were all males. One patient died early in the series from reaction to postoperative analgesia. Four older patients have bowel motions 2-3 times per day, do not soil at night, and are fully continent. Conclusion: This preliminary study shows that hand anastomosis could be used to complete Duhamel operation for patients with HD with satisfactory early results.

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Background: Ascariasis is the infestation by the largest intestinal nematode of man, a common problem in the tropics attributed to poor hygienic and low socioeconomic conditions. The aim of this research is to analyse the presentation, diagnosis and management of bowel obstruction caused by Ascaris lumbricoides, with special emphasis on the role of conservative management. Materials and Methods: This is a single centre, two consultant based 5 year retrospective study of childhood intestinal obstruction due to worms. Diagnosis in the suspected patients was based on history of passage of worms per mouth or rectum and on x-ray and ultrasonography findings. Only the patients of intestinal obstruction with documented evidence of roundworm infestation were included in the study and were followed for one year. Results: One hundred and three children with intestinal obstruction due to Ascaris lumbricoides were treated in the past five years at our centre. Abdominal pain was the most common presentation seen in 96 children followed by vomiting in 77 children. 20 children had history of vomiting worms and another 43 had history of passing worms in stool. Abdominal tenderness was present in 50 children, 48 had abdominal distension of varying degree, 50 had abdominal mass due to worm bolus, and 16 had or developed abdominal guarding or rigidity. All the children were managed as for acute intestinal obstruction along with hypertonic saline enema. The aim of management was "to starve the worm and hydrate the patient". 87 patients (84.47%) responded favourably and were relieved of the obstruction by the conservative management, 16 children (15.53%) had abdominal guarding or rigidity and underwent emergency exploration. Conclusion: Roundworm obstruction should be considered in the differential diagnoses of all cases of intestinal obstruction in children. Clinical history and examination along with X-ray and ultrasonography are very helpful for diagnosis of this surgical emergency. Most cases of intestinal obstruction due to Ascaris can be managed conservatively; however emergency surgery is needed in patients with abdominal guarding and rigidity.

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Background: Intestinal perforation resulting from complicated typhoid fever still causes high morbidity and mortality. The purpose of the present study is to evaluate the outcome of its surgical management in Nigerian children. Materials and Methods: Emergency laparotomy and repair of the ileum was performed on 46 children with typhoid ileal perforation at the Federal Medical Centre (FMC), Azare, Nigeria, between January 2004−December 2008. This was followed by copious peritoneal lavage with warm normal saline and mass closure of the abdomen. Results: There were 28 (60.86%) boys and 18 (39.13%) girls, with a mean age of 9.5 ± 3.22 (range, 15 months−15 years). Abdominal pain (45), fever (44), and abdominal distention (36) were the most common presenting symptoms and majority of the patients (36) perforated within 14 days of illness. Solitary ileal perforations were the most common pathology, found in 31 (67.4%) cases. Simple closure of the perforations after debridement of the edges was the most frequent operative procedure performed. A total of 21 patients had one or more complications which included wound infection (21), postoperative fever (16), and wound dehiscence (6). Postoperative anaemia was a problem in 23 (50%) patients. The mortality rate was (13) 28.3%. The mean duration of hospital stay for survivors was 22.9 ± 12.3 (range, 6−46 days). This was not significantly affected by the location or number of perforations on the ileum. Conclusions: The clinical course of typhoid ileal perforation may be different for the very young. The typically high rate of complications can be reduced if operation is undertaken earlier. Solitary ileal perforations can be managed safely with simple closure.

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Background: Ambiguous genitalia are a major cause of parental anxiety and can create social problems if not properly managed. Diagnosis and management can however be challenging. The aim of this study is to highlight some of the challenges in management of ambiguous genitalia in our environment. Patients and Methods: All cases of ambiguous genitalia managed at the Paediatric surgical unit of the Obafemi Awolowo University Teaching hospital, Ile Ife, Nigeria, between January 1993 and October 2007 were analysed for age, sex at presentation, investigation modality, and final sex of rearing and outcome of surgery. Result: Nine patients had surgical reconstruction for ambiguous genitalia during the study period. Their age ranges from 5 weeks to 19 years at presentation. The causes of genital ambiguity in the patients was congenital adrenal hyperplasia (CAH) in 6, true hermaphroditism in 2 and male pseudo-hermaphroditism in 1. Seven patients were reconstructed as females while 2 were raised as males. Change of sex of raring was necessary in 2 patients. Conclusion: The diagnosis and management of ambiguous genitalia is a challenging problem in our environment. Early presentation and treatment is necessary to avoid psychological and social embarrassment.

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