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LATE SENIOR SURGICAL REGISTRAR, THE HOSPITAL FOR SICK CHILDREN, GREAT ORMOND STREET, LONDONTHE results of treating 121 cases of hypospadias by the ' buried strip ' method described by Denis Browne (1949, a, b) are reported here, not only because they confirm that this method is more satisfactory than any other yet described, but in order to emphasize the importance of certain principles and technical details.These 121 cases which have been operated on either by Denis Browne himself or by one of the registrars at the Hospital for Sick Children, Great Ormond Street, are a consecutive series and include all those cases of hypospadias requiring repair which have come under Mr. Browne's care since he started to use this method in 1946. Those cases of hypospadias which have had a very mild degree of deformity and have only required a meatotomy have not been included. The series contains several cases which had had unsuccessful operations elsewhere and one case which had had the prepuce excised. In Table Z the results are set out according to the extent of the deformity and the number of cases in each group which developed fistulae is recorded. These cases are classified according to the original position of the hypospadiac meatus and not the position after the initial operation to relieve the chordee, at which time the meatus was frequently slid back as much as half the length of the penis. The cases listed as perineal hypospadias were not hypospadiacs in the strict sense, but intersexes in whom it was necessary for one reason or another to form male external genitalia. All these cases had at least a rudimentary vagina, which either opened separately into the perineum or opened in a common orifice with the urethra. The term ' midscrotal ' has been used for cases where the scrotum was cleft except for a small area posteriorly and the meatus situated well behind the base of the penis. It will be seen from the Table that only 8 of these 121 cases developed a fistula post-operatively. In the other 113 cases the meatus was satisfactorily advanced to the end of the penis in one operation. In the earlier cases in this series no attempt was made to advance the meatus beyond the corona, but in the later cases it was advanced to the tip of the glans by denuding of skin two triangular areas on the ventrolateral surfaces of the glans and drawing flaps over these.In considering the cases which developed fistulae it is interesting to note the site at which they occurred. In 5 of the 8 cases the fistula was not in the midline where the flaps had been sutured but about 4 cm. lateral to this. They were at the site of one of the ' double stop ' sutures. This was particularly well exemplified by one case which had two small fistulae, one on each side of the midline exactly opposite to each other. There can be no doubt that the fistulae in these 5 cases were caused by drawing a ' double stop ' suture too tightly. When the post-operative swelling occurred the suture caused a small area of pressure necrosis followed by a small slough which ...
Aorto-pulmonary septal defects and anomalous origins of left coronary artery from pulmonary artery are briefly discussed. The difficulties of diagnosis and surgical correction are put forward in a situation when the left coronary artery arises from a site of high pressure and saturation, such as the pulmonary artery in the presence of an aorto-pulmonary septal defect, as in the case described.This report describes the clinical, haemodynamic, angiographic, and necropsy findings in an infant with anomalous origin of the left coronary artery from the pulmonary artery, small ventricular septal defect, aorto-pulmonary septal defect, right aortic arch, and left brachiocephalic trunk. We have been unable to find a report of a similar combination of defects, though the brief details are recorded of a haemodynamically comparable patient with aorto-pulmonary septal defect, right aortic arch, and anomalous origin of the right coronary from the pulmonary artery which was corrected successfully by surgery (Morrow, Greenfield, and Braunwald, I962). Case reportThe patient, the only child of healthy parents, was a spontaneous normal hospital delivery at 42 weeks' gestation following an uneventful pregnancy, birthweight 3,2oo kg. There was no difficulty in onset of respiration. He was noted to be tachypnoeic from birth and fed poorly, though there was no other evidence of heart failure, and no heart murmur was heard. He was admitted to another hospital at the age of 2 months with probable cyanosis, a grade 3/6 systolic murmur, and congestive heart failure. The latter responded slowly to medical treatment, and he was discharged two months later on no maintenance therapy. He failed to thrive, developed a persistent cough, and was referred to Brompton Hospital at the age of 6 months. On examination he was an ill infant with mild central cyanosis on crying. The length and weight were both below the third percentile. He had grunting respiration (rate 6o/ min.), with conspicuous indrawing of both sides of the chest, right more than left, and suprasternal retraction. The peripheral pulses were 'waterhammer' in type, blood pressure go/50 mm.Hg. The heart was overactive and the second sound was single. There was a grade 3/6 long ejection murmur best heard at the upper left sternal border and no diastolic murmur. The lungs were normal on auscultation. The liver edge was felt 2-3 cm. below the right costal margin. No other abnormality was detected on routine clinical examination, except for a mild degree of hypospadias and shovel pinnae. Relevant investigations were: femoral arterial oxygen saturation 88 per cent; chest x-ray showed cardiomegaly with pulmonary plethora; electrocardiogram showed biventricular and biatrial hypertrophy with a mean frontal plan QRS axis of + 700 with clockwise rotation.Cardiac catheterization via the right axillary route was performed under local anaesthesia (see Table). The right ventricular pressure was at systemic level. There was a small left-to-right shunt at
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