Laparotomy Research Articles

Cyclic pulse loads generate the new concept in abdominal wall reconstruction: suture closure

Aim: Incisional hernias frequently occur after open abdominal surgery. Up to 30% of elective midline laparotomy closures result in an incisional hernia. The properties of a safe abdominal wall reconstruction must be assessed under lifelike conditions to obtain a realistic estimate of the durability. The interplay of the biomechanical qualities determines the long-term stability of a repair. Various suture materials and techniques for optimal closure of the abdominal wall are still under discussion. The results of this experimental study might significantly affect the active discussion about optimal suturing techniques for median abdominal wall closure. Methods: For this purpose, a bench test was developed that delivers repetitive cyclic pressure impacts to the abdominal wall, simulating coughs. This allows the assessment of the reconstructed abdominal wall as a compound. We used stiff porcine abdominal walls and elastic bovine flanks as model tissues. We chose two different types of defects. Type one consisted of a 15 cm long medial incision, whereas for type two, a 5 cm circular defect was added in the center of the incision. The incisions were solely sutured in large-bite (0.8-1.2 mm bites) or small-bite (0.5-0.8 mm bites) technique with Monomax® or PDS® sutures USP 2-0 or USP 1. The suture to wound length (SWL) ratio had to exceed 4:1. After suturing, the tissues were subjected to repetitive cyclic loading on a validated bench test. Results: We found that regardless of technique and material thickness, secure closure of median abdominal wall incisions is feasible by suturing. In larger defects, the small bites technique using Monomax® sutures achieves a safer closure compared to PDS® sutures. Conclusion: Based on the results of this experimental study, a tailored standardized closure technique after midline incision of the abdominal wall, including an optional mesh augmentation, is recommended.

Achilles Tendon Rupture Repair Using the Mini-Open Approach in a Supine Position.

Achilles Tendon Rupture Repair Using the Mini-Open Approach in a Supine Position.

Comparison of transumbilical and periumbilical median incisions in ovarian cancer surgery

The umbilicus is traditionally circumvented while performing a vertical midline abdominal incision. There is a gap in knowledge pertaining to avoiding the umbilicus. Our aim was to investigate whether a transumbilical (TU) or periumbilical (PU) midline incision conferred any advantage to the patient. This was a retrospective cohort study of patients undergoing ovarian cancer surgery with a midline incision, from the pubic tubercle to the xiphoid. All surgery was performed by the same team of gyneacological oncologists. Patients were classified into two groups according to the midline incision used, TU or PU. The primary endpoint was the incision wound complication rate. TU and PU midline incisions were performed in 54 and 68 patients, respectively. There were no differences between the two groups in terms of patient characteristics and operative details. The two groups had comparable rates of complications, including wound infection (7.4% vs. 10.3%, p=0.75), deep surgical site infection (11.1% vs. 4.4%, p=0.18), evisceration (3.7% vs. 4.4%, p=0.99) and incisional hernia (33.3% vs. 33.8%, p=0.99). Our findings suggest that circumventing the umbilicus during laparotomy did not have any advantage. Future prospective randomized trials are warranted to validate this finding.

6:1 Suture or Wound length ratio with the short stitch technique – a reality check on practicability and short term outcome

Aim: To analyze laparotomy closure of conventional midline and transverse abdominal incisions in elective and emergency laparotomies with a longterm, absorbent, elastic suture material. Method: Prospective, single centre, non randomised, controlled cohort study on short stitches with a longterm resorbable, elastic suture (material: poly-4-hydroxybutyrate) aiming at a 6:1 suture to wound (SL/WL) length ratio in midline and transverse, primary & secondary laparotomies for elective & emergency surgery. Results: We included 351 patients (♂: 208; ♀: 143), midline (n=194), transverse (n=103) and a combined midline/transverse L-shaped (n=54) incisions. There was no stitch performance quality difference between elective (n=296) and emergency (n=55) operations, while results in the first 150 patients showed a significantly reduced SL/WL-ratio to the following 200 suture closures (SL/WLratio: 5.64±2.5 vs 6.1±2.3, p<0.001). Average SL/WL-ratio in general was better for midline than transverse incision sutures (6.62±2.5 vs 4.3±1.51, p<0.001). SL/WL-ratio varied among the 6 surgeons participating, although results steadily improved and eventually approximated each other. Conclusions: We could show that a 6:1 SL/WL-ratio with a 2-0 single, ultra-long term, absorbent, elastic suture material can be significantly performed better in midline than transverse incisions. Transverse incisions should preferably be closed in 2 layers in order to achieve a sufficient SL/WL-ratio equivalent to the median incision. While on an individual level, results varied between surgeons, quality will improve and eventually approximate.

983. Pathogen-specific PET/CT imaging for Gram negative implant-associated spinal infections

983. Pathogen-specific PET/CT imaging for Gram negative implant-associated spinal infections

Comparison between Interrupted X Suture and Continuous Suture for Closure of Midline Incision in Emergency Laparotomy : A Randomized Controlled Trial

Background: Wound dehiscence is disruption of any or all of the layers in a wound. At around 7–10 days post operatively leakage of clear sero-sanguinous fluid from the wound is usually the first indicator of burst abdomen. The patient usually feels something ‘giving away’ at this time.It may occur in 3-14.5% cases and is very distressing to the patient.Number of methods of closure of midline laparotomy wound have been introduced in the past to prevent this outcome. The study to compare the result of continuous and interrupted closure of midline emergency laparotomy in respect of burst abdomen.
 Materials and methods: This randomized controlled trial study was carried out in the Department of Surgery Chittagong Medical College Hospital, Chattogram, duration January 2017 to December 2017. A total of 500 patients were enrolled in this study. Data were collected, statistical analyses were obtained by using window based computer software devised with Statistical Packages for Social Sciences (SPSS-23).
 Results: 250 patients in group A and 250 in B. Surgical wound related post-operative complications were found in 30.4% of the study subjects (n=152).Wound dehiscence was found in 11% subjects, surgical site infection was found in 18.4% subjects and incisional hernia in 1%.All these complications were significantly higher in continuous suture group than interrupted group (p<0.001).Wound dehiscence in 20 subjects, treated with interrupted sutures and in 40 subjects (35 wound dehiscence and 5 incisional hernia)treated with continuous suture. The Relative Risk (RR) of developing wound dehiscence post-operatively was found to be 0.63 (95% CI 0.33 – 0.72) for interrupted suture. This was statistically significant (p<0.05).
 Conclusion: The interrupted X suture technique is better than continuous suture technique in prevention of burst abdomen in emergency midline laparotomy.
 Chatt Maa Shi Hosp Med Coll J; Vol.21 (2); July 2022; Page 52-56

The Best Closure Technique Without Mesh in Elective Midline Laparotomy Closure.

Introduction: The risk of developing an incisional hernia after primary elective median laparotomy is reported in the literature as being between 5 and 20 percent. The basic of an optimal outcome after midline incision is the appropriate closure technique with or without a prophylactic mesh. The objective of this paper is to critically examine the various closure techniques and, in particular, to present a detailed comparison of the long stitch and short stitch techniques. Method: Based on the available literature, the characteristics of the different closure techniques are described in detail, advantages and disadvantages are compared, and the current status of a practicable recommendation is discussed. Special attention is paid to the criteria of the short stitch technique, such as the suture to incision length ratio, number of stitches and distances, as well as suture material. Results: For elective midline closures, the use of a continuous closure using a slowly absorbable suture material in the small-bites technique with suture to wound ratio of at least 5:1 result in significantly lower risk of complications such as bursting abdomen and less incisional hernia rates compared to the large-bites technique. Conclusion: Based on the present evidence in midline closure after elective laparotomy the small bites technique can be recommended to significantly reduce the rate of incisional hernia.

Laparoscopic-assisted liver transplantation: A realistic perspective

Laparoscopic approach was rarely described in recipients for liver transplantation (LT). We report the feasibility and safety of laparoscopic-assisted LT (LA-LT) in patients with unresectable liver metastases of neuroendocrine tumors. Total hepatectomy was performed laparoscopically with graft implantation through an upper midline incision. Liver grafts were retrieved from deceased donors. From July 2019 to July 2021, six patients (4 women, 2 men) underwent LA-LT. Median age and BMI were 46 (29-54) and 24 (19-35) kg/m2 , respectively. Implanted grafts were reduced (n= 3), full (n= 2), and a right split liver (n= 1). Median surgical time was 405 min (390-450) and median blood loss was 425 ml (250-600). Median cold and warm ischemia times were 438 min (360-575) and 35 min (30-40), respectively. Median anhepatic phase was 51 min (40-67) and midline incision was 14 cm (13-20) long. On postoperative day 5, median prothrombin index and serum bilirubin levels were 95% (70-117) and 11 (10-37) μmol/L, respectively. No Clavien-Dindo > III complications were encountered. Median hospital stay was 12 days (10-14). After a median follow-up of 8 (8-32) months, all patients were alive without tumor recurrence or adverse event. This preliminary series suggests that in selected patients, LA-LT is a safe and effective option.

A midline retroperitoneal approach for complex abdominal aortic repair: Case description and operative technique.

In the current endovascular era, open repair of complex aortic aneurysms is becoming a rare, but indispensable, part of vascular surgeons' skill set in specific scenarios. For young, low-risk patients and patients with connective tissue disorders, early target vessel bifurcation, a horseshoe kidney, or pedunculated intraluminal aortic thrombus, fenestrated-branched stent graft technology will not be applicable without significant risks. Thus, an open surgical approach has been recommended for these patients. Most vascular surgeons will be familiar with a transperitoneal approach or a retroperitoneal approach with a lateral incision. For patients with a horseshoe kidney, an inflammatory aneurysm, or a history of multiple intraperitoneal procedures, a retroperitoneal approach should be preferred. In the present report, we have described in detail the optimization of a retroperitoneal approach through a midline incision that provides excellent exposure to the paravisceral aorta, improves exposure to the right renal artery and right iliac artery bifurcation (which is limited using the left flank retroperitoneal approach), and avoids division of the lateral abdominal wall muscles, which has often been associated with iatrogenic muscle denervation and postoperative bulging for four patients who had required complex aortic reconstruction.

Treatment of Achilles insertional calcific tendinosis using alongitudinal midline incision approach/central tendon splitting approach

Treatment of Achilles insertional calcific tendinosis through alongitudinal midline incision approach with optional resection of the retrocalcaneal bursa and calcaneal tuberosity (Haglund's deformity). Calcific Achilles tendinosis, dorsal heel spur, insertional tendinosis. General medical contraindications to surgical interventions. Fracture, infection. Longitudinal skin incision medial of the Achilles tendon. Exposure and midline incision of the Achilles tendon with plantar detachment from the insertion site preserving medial and lateral attachment. Resection of adorsal heel spur and intratendinous calcifications. Optional resection of the retrocalcaneal bursa and calcaneal tuberosity (Haglund's deformity). Partial weight bearing 20 kg in 30° plantar flexion in along walker boot for 2weeks. Afterwards 2weeks of progressively weight bearing in 15° plantar flexion and another 2weeks in neutral ankle joint position in along walker boot. Atotal of 26feet of 26patients with calcific Achilles tendinosis were treated with midline incision of the tendon. In all feet calcific tendon parts were resected. In10 (38%) feet, aprominent dorsal spur was resected, in 12feet (38%) retrocalcaneal bursa, and in24 (92%) feet acalcaneal tuberosity. Mean follow-up was 34.5months (range2-64months). Preoperative Manchester-Oxford Foot Questionnaire (MOXFQ) score was 58.2 (±8.1) and postoperatively the score was 22.75 (±6.0). In all, 7 (26.9%) patients stated delayed wound healing; 1suffered from deep vein thrombosis. Shoe problems were reported by 50% of patients, and 23.1% suffered from par- or dysesthesia. No revision surgery was required.

Anesthetic management of patients with class 3 obesity undergoing elective Cesarean delivery: a single-centre historical cohort study

PurposeThe preferred neuraxial anesthetic technique for patients with class 3 obesity undergoing elective Cesarean delivery is still under debate. We aimed to describe the anesthetic technique used in our tertiary institution across body mass index (BMI) groups and different surgical incisions.MethodIn this historical cohort study, we reviewed medical records of patients with a BMI ≥ 40 kg·m–2 undergoing elective Cesarean delivery between July 2014 and December 2020. We collected data on patient characteristics, anesthetic and surgical technique, and procedural times. For data analysis, we stratified patients by BMI into three different groups: 40.0–49.9 kg·m–2, 50.0–59.9 kg·m–2, and ≥ 60.0 kg·m–2.ResultsWe included 396 deliveries, distributed as follows: 258 with a BMI 40.0–49.9 kg·m–2, 112 with a BMI 50.0–59.9 kg·m–2, and 26 with a BMI ≥ 60.0 kg·m–2. For patients with a BMI 40.0–49.9 kg·m–2, the anesthetic technique of first choice was predominantly spinal anesthesia (71%), whereas for those with a BMI ≥ 60.0 kg·m–2, spinal anesthesia was never used as the anesthetic of first choice. With regard to the surgical incision, spinal anesthesia was almost exclusively used for patients undergoing Pfannenstiel incision and was rarely used for a higher supra- or infraumbilical transverse or midline incision. The overall incidence of general anesthesia was low (7/396, 1.8%). Anesthetic time, surgical time, and operating room time increased almost twofold in patients with a BMI ≥ 60.0 kg·m–2 compared with those with a BMI of 40.0–49.9 kg·m–2.ConclusionNeuraxial anesthesia was successfully used in approximately 98% of patients with class 3 obesity undergoing elective Cesarean delivery. The choice of regional anesthesia technique varied with increasing BMI and with the planned surgical incision. Procedural times increased with increasing BMI. This information should prove useful for comparing anesthetic choices and outcomes in this challenging population.

Umbilical Complications following DIEP Flap Breast Reconstruction: Demonstrating the Added Benefit of Preoperative Imaging.

Despite the umbilicus being an essential aesthetic unit, current literature on umbilical outcomes following abdominally based breast reconstruction is limited. In this study, the authors aim to elucidate the incidence and predictors of umbilical complications following deep inferior epigastric perforator (DIEP) flaps, with a particular emphasis on past abdominal surgery by type and measures that can be obtained easily from preoperative imaging. An institutional review board-approved retrospective review of 258 patients who underwent DIEP flap reconstruction from 2011 through 2020 was performed. Patient demographics, preoperative laboratory studies, and intraoperative factors were appraised. Preoperative computed tomographic angiography or magnetic resonance angiography was used to measure umbilical stalk height (SH), abdominal wall thickness (AWT), and total fascial diastasis. Patients with and without perfusion-related umbilical complications were compared. Forty patients (15.5%) developed umbilical complications, including 20 patients with epidermolysis or scab, 12 with dehiscence, and 14 with partial necrosis. Patients with complications had a significantly higher rate of hypertension, previous abdominal midline incision, more lateral perforators per flap, longer umbilical stalk, and larger SH/AWT ratio ( P < 0.05). Logistic regression revealed that SH ( P = 0.006) and SH/AWT ratio ( P < 0.001) were the only significant predictors, with the latter having a greater area under the receiver operating characteristic curve (area under the curve, 0.79; P < 0.001). Radiographic measurements of umbilical SH and SH/AWT ratio reliably predict the occurrence of umbilical complications, with the ratio having a more robust predictive ability. The authors propose the use of routine preoperative imaging to identify high-risk patients who may benefit from prophylactic measures. Risk, III.

Assessment of the urinary bladder prior to cesarean delivery in women with multiple abdominal scars through operation table ultrasonography: a case report

Bladder injury is a rare but serious complication that can occur during cesarean deliveries with an incidence of between 0.25% and 0.9%. Most bladder injuries (53%) occur upon entering the peritoneal cavity as a consequence of either extensive adhesions, a distorted pelvic anatomy, or an unexpectedly high-situated bladder owing to previous operations including a previous cesarean delivery. Patients with a previous abdominal operation can benefit from a preoperative ultrasound to identify the upper limits of an unexpectedly enlarged urinary bladder, even after preoperative catheterization. A modified surgical approach can then be applied to allow entry into the peritoneum above the bladder, thus preventing severe bladder injury. Surgeons may consider the use of preoperative sonography before operating on women with a previous abdominal surgery, especially following midline incisions, to improve safety and to potentially modify abdominal entry into the peritoneal cavity to avoid bladder injury.

Minimally-Invasive Radical Nephrectomy and Left-Sided Level II Caval Thrombectomy: A New Combined Technique

To present a combined multiport robotic and open approach for left radical nephrectomy and inferior vena cava thrombectomy in patients with a primary left renal mass and level II inferior vena cava (IVC) tumor thrombus. A 69-year-old female was diagnosed with an 8.9cm left renal neoplasm with level II IVC thrombus. She was placed in the left-side-up flank position. The descending colon was mobilized and the left gonadal vein was identified. The left renal vein was identified and fully dissected. The left renal artery was dissected and stapled. The kidney was dissected and left detached with exception of the renal vein. The robot was undocked and the patient was positioned supine. Through a supra-umbilical midline incision, the ascending colon and duodenum were mobilized medially. The right renal vein and IVC were identified and dissected to the level of hepatic veins. The IVC was clamped using a Satinsky clamp. The right renal artery and vein remained patent during thrombectomy. The IVC was opened, the thrombus was evacuated, and IVC was closed. Clamps were removed and the kidney was removed. Operative time was 405 minutes. IVC clamp time was 14 minutes. Estimated blood loss was 500cc. Recovery was uncomplicated. Length of stay was 4 days. Pathology showed clear cell carcinoma with negative margins. IVC thrombectomy is challenging on left sided tumors. Combining a robotic and open technique together is feasible and allows a smaller supra-umbilical midline incision compared to standard open incision.

Hand-Assisted Versus Pure Minimally-Invasive Distal Pancreatectomy: Is There a Downside to Lending a Hand?

Hand-assisted laparoscopic distal pancreatectomy (HALDP) is suggested to offer similar outcomes to pure laparoscopic distal pancreatectomy (LDP). However, given the longer midline incision, it is unclear whether HALDP increases the risk of postoperative hernia. Our aim was to determine the risk of postoperative incisional hernia development after HALDP. We retrospectively collected data from patients undergoing HALDP or LDP at a single center (2012-2020). Primary endpoints were postoperative incisional hernia and operative time. All patients had at minimum six months of follow-up. Outcomes were compared using unadjusted and multivariable regression analyses. Ninety-five patients who underwent laparoscopic distal pancreatectomy were retrospectively identified. Forty-one patients (43%) underwent HALDP. Patients with HALDP were older (median, 67 vs. 61years, p = 0.02). Sex, race, Body Mass Index (median, 27 vs. 26), receipt of neoadjuvant chemotherapy, gland texture, wound infection rates, postoperative pancreatic fistula, overall complications, and hospital length-of-stay were similar between HALDP and LDP (all p > 0.05). In unadjusted analysis, operative times were shorter for HALDP (164 vs. 276min, p < 0.001), but after adjustment, did not differ significantly (MR 0.73; 0.49-1.07, p = 0.1). Unadjusted incidence of hernia was higher in HALDP versus LDP (60% vs. 24%, p = 0.004). After adjustment, HALDP was associated with an increased odds of developing hernia (OR 7.52; 95% CI 1.54-36.8, p = 0.014). After propensity score matching, odds of hernia development remained higher for HALDP (OR 4.62; 95% CI 1.28-16.65, p = 0.031) p = 0.03). Compared with LDP, HALDP was associated with increased likelihood of postoperative hernia with insufficient evidence that HALDP shortens operative times. Our results suggest that HALDP may not be equivalent to LDP.

Embryology and anatomy of anorectal malformations

The etiology of anorectal malformations (ARM) is complicated because of the spectrum of anomalies seen clinically, many of which are isolated and seemingly unique. Recent studies suggest that ARMs result from abnormal cloacal membrane (CM) development that contributes to disrupt normal local muscle and nerve development. If CM maldevelopment is severe, the rectal pouch lies above the pelvic floor, resulting in asymmetric and/or deviated musculature, so a midline incision is likely to cause trauma or be detrimental. Autonomic nerve plexuses can be associated with a fistula tract in ARMs and are also at risk for damage during surgery and contribute to genitourinary complications. Understanding the anatomy and development of the perineum is crucial for treating the broad spectrum of anomalies associated with ARMs and may assist in predicting/managing other related morbidity.

A Robotic Completely Intercorporeal Jejunal Pouch Reconstruction after Gastrectomy.

Robotic surgery is increasingly gaining importance. While initial results suggest an advantage of the robotic over the minimally invasive approach in patients with gastric cancer, definitive proof of its superiority has yet to be provided. There are numerous approaches to recreate a gastric reservoir after a total gastrectomy. However, a major disadvantage of most conventional reconstructions are long term effects such as dumping syndrome, afferent loop syndrome and poor nutrition intake with severe impact on the patient quality of life. The jejunal pouch reconstruction is a beneficial reconstruction, which provides a larger reservoir capacity after gastrectomy and prevents anastomotic stenosis and dumping syndrome. The completely intercorporeal approach with a Pfannenstiel incision instead of an unfavorable midline incision can potentially decrease delayed complications such as incision hernias. With the increased deployment of robotic surgery, a complete intercorporeal reconstruction is now possible without major increase in operating time or further technical weak points. We provide for the first time a detailed technical explanation of the completely intercorporeal robotic jejunal pouch reconstruction after gastrectomy.

Continuous Intravenous Lidocaine for Acute Pain Management Post Laparotomy Surgery: A Case Series

Introduction: Acute post-operative pain can lead to prolonged use of opioids and progress to chronic pain. Multimodal analgesic approaches have replaced the use of opioid monotherapy, but opioid use continues and contributes to inadequate acute pain management. Intravenous lidocaine has analgesic, anti-hyperalgesic, and anti-inflammatory effects. This study aims to describe post-operative pain management using intravenous lidocaine.&#x0D; Case presentation: There were two cases. The first was a 32-year-old female patient with suspected interrupted ectopic pregnancy who underwent emergency laparotomy under spinal anesthesia and, after 2 hours, was converted to general anesthesia. Postoperatively, the analgesic lidocaine was given as a 52 mg intravenous bolus followed by a continuous 36 mg/hour/syringe pump. The patient's VAS scale was initially 2/10, and on the third day, 1/10 continued treatment. In the second case, an 18-year-old male patient with suspected acute appendicitis underwent a midline incision laparotomy appendectomy with spinal anesthesia. Postoperatively, lidocaine was given a slow bolus of 75 mg intravenously, finished in 5 minutes, then 50 mg/hour/intravenously. The patient's VAS scale was initially 2-3/10 until on the third day. He was transferred to a room with a VAS of 1-2/10.&#x0D; Conclusion: Lidocaine is an effective intravenous analgesic to treat acute pain after laparotomy surgery. Administration of relatively low doses can achieve post-operative analgesia without concern for toxicity.

Low Cost Gastroschisis Silo for Sub-Saharan Africa: Testing in a Porcine Model.

Gastroschisis mortality in sub-Saharan Africa (SSA) remains high at 59-100%. Silo inaccessibility contributes to this disparity. Standard of care (SOC) silos cost $240, while median monthly incomes in SSA are < $200. Our multidisciplinary American and Ugandan team designed and bench-tested a low-cost (LC) silo that costs < $2 and is constructed from locally available materials. Here we describe in vivo LC silo testing. A piglet gastroschisis model was achieved by eviscerating intestines through a midline incision. Eight piglets were randomized to LC or SOC silos. Bowel was placed into the LC or SOC silo, maintained for 1-h, and reduced. Procedure times for placement, intestinal reduction, and silo removal were recorded. Tissue injury of the abdominal wall and intestine was assessed. Bacterial and fungal growth on silos was also compared. There were no gross injuries to abdominal wall or intestine in either group or difference in minor bleeding. Times for silo application, bowel reduction, and silo removal between groups were not statistically or clinically different, indicating similar ease of use. Microbiologic analysis revealed growth on all samples, but density was below the standard peritoneal inoculum of 105CFU/g for both silos. There was no significant difference in bacterial or fungal growth between LC and SOC silos. LC silos designed for manufacturing and clinical use in SSA demonstrated similar ease of use, absence of tissue injury, and acceptable microbiology profile, similar to SOC silos. The findings will allow our team to proceed with a pilot study in Uganda.

Clinical analysis of 59 cases of pediatric nasal dermal sinus cysts with midfacial infection as the first symptom

Objective:To review the clinical and radiological presentation and management of infected nasal dermal sinus cysts（NDSC） in children. Methods:Clinical data were collected from 59 NDSC children with secondary fronto-orbital area infection who presented to Beijing Children's Hospital from January 2007 to December 2021. All patients underwent preoperative imaging workup, including MRI and CT. All patients underwent endoscopic excision of a NDSC under general anesthesia. Results:A total of 59 patients were included in the study,while 58 presented with a sinus, 1 presented with a cyst.The main lesions of NDSC included nasal root in 20 cases （33.9%）, nasal bridge in 34 cases （57.6%）, nasal tip in 4 cases （6.8%）, and nasal tip and nasal root in 1 case （1.7%）. The depth of lesions included 6 cases （10.2%） of superficial type of nasal frontal bone, 33 cases （55.9%） of nasal frontal bone, 19 cases （32.2%） of intracranial epidural type, and 1 case （1.7%） of intracranial epidural type. The main sites of infection included inner canthus in 15 cases （25.4%）, nasal dorsum in 22 cases （37.3%）, nasal root in 16 cases （27.1%）, and forehead in 6 cases （10.2%）. Among 59 cases, 7 cases （11.9%） were complicated with other diseases, and 4 cases（6.8%） had external nasal deformities. Surgical approaches included transverse incision in 12 cases（20.3%）, minimal midline vertical incision in 41 cases （69.5%）, external rhinoplasty in 4 cases （6.8%） and bicoronal incision with vertical incision in 2 cases （3.4%）. The range of lesions was completely consistent with MRI results.All cases were successfully operated without one-stage nasal dorsum reconstruction. All patients were followed up from 7 to 173 months（average 52.2 months）. There were 6 cases of recurrence, all of which were in situ recurrence. The operation was performed again, and no recurrence has occurred since the follow-up, No nasal deformity was noted, and cosmetic outcome were favorable for all patients. Conclusion:NDSC infection in children with midfacial infection as the first symptom is rare in clinical practice, and its manifestations are diverse. Early diagnosis and rational treatment are very important to improve the cure rate.Preoperative high resolution MRI combined with CT scanning is of great significance in judging the course of NDSC, especially the intracranial extension. The treatment goal is to achieve minimally invasive and individualized treatment under the premise of complete excision of the lesion, and take into account the cosmetic needs.