Impact of prior surgery on the feasibility of laparoscopic surgery for children: a prospective study

Diagnosing granulomatous disease during appendectomy

Difficulties during surgery are uncommon situations in appendectomy. For granulomatous appendicitis, literature is insufficient about surgical findings. The procedure of a 17-year-old male patient was a struggle due to adhesions. I thought a surgeon could expect granulomatous diseases by evaluating the macroscopic appearance of the appendix during surgical procedure.

Impact of previous abdominal surgery on the outcome of laparoscopy-assisted open appendicovesicostomy (Mitrofanoff) creation in children: a comparative study

INTRODUCTION AND OBJECTIVE

For patients who require self-intermittent catheterization, a continent catheterizable stoma is a viable option. This patient population often has had previous abdominal surgery (PAS), a risk factor for complicated laparoscopic procedures. Therefore, the authors aim to determine whether PAS has an impact on the peri-operative outcomes of the laparoscopic-assisted Mitrofanoff procedure in children.

MATERIALS AND METHODS

A research ethics board-approved retrospective review was performed to assess peri-operative outcomes among pediatric patients who underwent laparoscopic-assisted Mitrofanoff procedures in the authors institution from May 2000 to March 2016. Patients with no PAS were compared with those with intraperitoneal PAS. Demographic/baseline characteristics and peri-operative outcomes such as operative time, estimated blood loss, hospital stay, unanticipated additional operations, stomal stenosis, and urinary continence were compared. To ensure there is no confounding based on PAS characteristics, subgroups were created to compare the recency (PAS <1 year ago) and extent (ventriculoperitoneal (VP) shunt vs non-VP shunt PAS) to assess their peri-operative outcomes. Fisher's exact test and Mann-Whitney U test were used to determine statistical significance.

RESULTS

Thirty-four patients (15 no PAS and 19 PAS) were included in the analysis. No significant difference in demographics and baseline characteristics was noted between the patient groups. The median age was 6.5 years (interquartile range [IQR] 4.8-14.0) and 9.9 years (4.2-14.3), respectively (NS). Peri-operative outcomes of operative time, estimated blood loss, and hospital stay were similar between the PAS and no PAS groups. There was no statistical difference in complications requiring surgical intervention (n = 3, 20.0%; n = 9, 47.4%). The median follow-up period was 25.9 (IQR 7.7-47.2) months and 28.0 (IQR 13.0-53.0) months, respectively (NS). Patients with VP shunts as their only PAS had higher estimated blood loss compared with no PAS group (50 [IQR 25-150], 25 [IQR 25-50], respectively) but without other differences in peri-operative outcomes.

DISCUSSION

Findings support the use of a minimally invasive approach in this patient population as it is feasible, comparable, and safe but with careful consideration for risk factors that may predispose PAS patients to postsurgical complications requiring intervention. Although limited by small sample size, this study provides valuable insight into performing laparoscopic operations in children who have undergone prior surgeries and invites future studies to compare the outcomes between patients undergoing open, pure laparoscopic, and robotic-assisted laparoscopic Mitrofanoff procedures for children with PAS.

CONCLUSION

Laparoscopic-assisted Mitrofanoff creation may be safely performed in children with PAS.

Laparoscopic-assisted Versus Open Appendicovesicostomy Procedure in Patients With Prior Abdominal Surgeries: A Comparative Study

OBJECTIVE

To determine the differences in perioperative and postoperative outcomes between laparoscopic-assisted approach and open approach for appendicovesicostomy operations without concomitant procedures, among patients with prior abdominal surgeries.

METHODS

A Research Ethics Board-approved retrospective cohort study was performed to review all laparoscopic-assisted vs open appendicovesicostomy procedures performed without concomitant procedure in patient with prior abdominal surgeries from January 2000 to January 2015 in our institution. We evaluated the baseline characteristics, perioperative and postoperative outcomes such as operative time, hospital stay, estimated blood loss, complications, and long-term continence. Fisher exact test and Mann-Whitney U test were performed to compare the 2 surgical groups.

RESULTS

A total of 23 patients (11 open and 12 laparoscopic-assisted) were included. Baseline characteristics between the groups were not significantly different. Procedure time was comparable (Open median 289 [interquartile range {IQR} 230-335] vs laparoscopic-assisted median 231 [IQR 170.5-284]; P = .090). Significantly lower estimated blood loss and shorter hospital stay were noted among the laparoscopic-assisted group (median 100 [IQR 75-200] vs 50 [IQR 25-100], P = .048; median 6 [IQR 5-8] vs 3.5 [IQR 3-5], P = .029; respectively). Complication rates of Clavien-Dindo class 3 in both groups were not significantly different (6 of 11 vs 8 of 12, P = .68). Stomal stenosis and continence rates were also not significantly different between the groups (36.4% vs 25%, P = .667 and 63.3% vs 83.3%, P = .371).

CONCLUSION

Laparoscopic-assisted approach to create catheterizable stomas among patients with prior abdominal surgeries seems to be comparable to the open technique with the advantage of lower blood loss and shorter hospital stay.

Is single-port laparoscopy feasible after liver transplant?

The role of laparoscopy following liver transplant in children is debated. Herein, we report the first two cases of SIPES post-liver transplant. In both patients, SIPES access was carried out using Olympus TriPort. Patient 1 was an 11 yr old born with biliary atresia, who had four previous major laparotomies: Kasai portoenterostomy, followed by liver transplant and two laparotomies for lymph node biopsies for PTLD. The child was referred for suspected PTLD relapse due to enlarged nodes on CT scan. At SIPES, following adequate adhesiolysis, the lymph node biopsy was achieved successfully. Patient 2 was a five yr old with bilateral intra-abdominal testes who had undergone liver transplant aged two yr. He underwent a left one-stage orchidopexy and right first-stage Fowler-Stephen procedure at five yr of life, followed by a second stage Fowler-Stephen surgery on the right side, nine months later. All procedures were successfully performed by SIPES, and both patients were discharged home on first post-operative day. We conclude that SIPES could be safely carried out in patients who have had liver transplant. In case of diffuse intraperitoneal adhesions, SIPES is beneficial to create space by blunt and sharp dissection and decreases post-operative stay.

Towards a near-zero recurrence rate in laparoscopic inguinal hernia repair for pediatric patients

OBJECTIVE

The aim of this study was to assess whether the median or lateral umbilicus ligament covering the internal hernia opening region after the purse-string knot could eliminate recurrence in laparoscopic inguinal hernia repair in pediatric patients of all ages.

METHODS

About 482 laparoscopic inguinal hernia repairs in 428 children of various ages were prospectively study in our institution from January 2000 to January 2004. The patients were divided into two groups randomly. In group A, the patients were accepted laparoscopic purse-string knot closing the internal hernia opening only; in group B, the patients were accepted the median or lateral umbilicus ligament covering the internal hernia opening region after the laparoscopic purse-string knot. The data from both groups of operations were then compared.

RESULTS

A total of 239 hernias were repaired in group A (214 patients), whereas 243 in group B (214 patients). The differences between the sex ratio of boys to girls (199:15 versus 197:17) and the mean ages (51.05 ± 49.65 versus 50.59 ± 48.87 months) in the two groups were not statistically significant. The recurrence rate in group B was lower than that in group A and was statistically significant (0.00% versus 4.18%, P < .05). There were no postoperative testicular atrophy in either group of the patients.

CONCLUSION

It is possible to achieve a near-zero recurrence rate in laparoscopic hernia repair in pediatric patients of all ages, especially for the patients with large hernia sac (diameter >1.5 cm) and the age over 5 years.

[Minimally invasive pediatric surgery]

In recent years minimally invasive surgical techniques in children have made substantial progress. The feasibility and safety of a wide spectrum of laparoscopic and thoracoscopic procedures have been confirmed in numerous studies. Moreover, it was reported that minimally invasive pediatric surgery is associated with lower morbidity, a shorter hospital stay, lower costs, better cosmetics and clinical results similar to those achieved by open surgery. The present article reviews information on established as well as feasible but not yet established surgical procedures. The discussion of potential hemodynamic, respiratory and organ perfusion effects of the CO(2) pneumoperitoneum and the notation of special logistic aspects should support the reader in the process of decision-making to schedule infants and children for minimally invasive surgery.

Laparoscopic management of obstructive hepatoduodenal adhesions after open antireflux procedure

The case of a 3-year-old child who underwent open antireflux surgery for severe gastroesophageal reflux is presented. One month after the procedure, the child presented with abstinence from feeds, and vomiting after food intake. Esophagogastroscopy ruled out pathology in the area around the wrap. Upper gastrointestinal contrast studies demonstrated a kinking of the duodenal loop. Laparoscopy revealed severe adhesions between the duodenum and liver with kinking of the duodenum. The adhesions were taken down with careful dissection using hooked laparoscopic scissors. The symptoms subsided immediately after surgery and the further course and follow-up examinations were uneventful. The complication of mechanical ileus due to hepatoduodenal adhesions with severe kinking of the duodenum after antireflux surgery and with successful laparoscopic management has never been reported to date.

Minimal access surgery of pediatric inguinal hernias: a review

Inguinal hernia is a common problem among children, and herniotomy has been its standard of care. Laparoscopy, which gained a toehold initially in the management of pediatric inguinal hernia (PIH), has managed to steer world opinion against routine contralateral groin exploration by precise detection of contralateral patencies. Besides detection, its ability to repair simultaneously all forms of inguinal hernias (indirect, direct, combined, recurrent, and incarcerated) together with contralateral patencies has cemented its role as a viable alternative to conventional repair. Numerous minimally invasive techniques for addressing PIH have mushroomed in the past two decades. These techniques vary considerably in their approaches to the internal ring (intraperitoneal, extraperitoneal), use of ports (three, two, one), endoscopic instruments (two, one, or none), sutures (absorbable, nonabsorbable), and techniques of knotting (intracorporeal, extracorporeal). In addition to the surgeons' experience and the merits/limitations of individual techniques, it is the nature of the defect that should govern the choice of technique. The emerging techniques show a trend toward increasing use of extracorporeal knotting and diminishing use of working ports and endoscopic instruments. These favor wider adoption of minimal access surgery in addressing PIH by surgeons, irrespective of their laparoscopic skills and experience. Growing experience, wider adoption, decreasing complications, and increasing advantages favor emergence of minimal access surgery as the gold standard for the treatment of PIH in the future. This article comprehensively reviews the laparoscopic techniques of addressing PIH.

Minimally invasive pediatric surgery: Increasing implementation in daily practice and resident's training

BACKGROUND

In 1998, the one-year experience in minimally invasive abdominal surgery in children at a pediatric training center was assessed. Seven years later, we determined the current status of pediatric minimally invasive surgery in daily practice and surgical training.

METHODS

A retrospective review was undertaken of all children with intra-abdominal operations performed between 1 January 2005 and 31 December 2005.

RESULTS

The type of operations performed ranged from common interventions to demanding laparoscopic procedures. 81% of all abdominal procedures were performed laparoscopically, with a complication rate stable at 6.9%, and conversion rate decreasing from 10% to 7.4%, compared to 1998. There were six new advanced laparoscopic procedures performed in 2005 as compared to 1998. The children in the open operated group were significantly smaller and younger than in the laparoscopic group (p < 0.001 and p = 0.001, respectively). The majority (64.2%) of the laparoscopic procedures were performed by a trainee. There was no difference in the operating times of open versus laparoscopic surgery, or of procedures performed by trainees versus staff surgeons. Laparoscopy by trainees did not have a negative impact on complication or conversion rates.

CONCLUSIONS

Laparoscopy is an established approach in abdominal procedures in children, and does not hamper surgical training.