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

Impact of surgical site infection after open and laparoscopic surgery among paediatric appendicitis patients: A meta-analysis

Operative site wound infection is one of the most frequent infections in surgery. A variety of studies have shown that the results of laparoscopy might be superior to those of an open procedure. Nevertheless, there is still a lack of clarity as to whether there is a difference between open and laparoscopy with respect to the occurrence of wound infections in different paediatric operations. In this review, we looked at randomized, controlled studies that directly measured the rate of wound infection following an appendectomy with a laparoscope. We looked up four main databases for randomized, controlled studies that compare the treatment of paediatric appendicitis with laparoscopy. The surgeries included appendectomy. Through our search, we have determined 323 related papers and selected five qualified ones to be analysed according to the eligibility criteria. Five trials were also assessed for the quality of the documents. In the 5 trials, there were no statistically significant differences in the incidence of post-operative wound infection among the paediatric appendectomy and the open-access group (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.34-1.15, p = 0.13). The four trials did not show any statistically significant difference in abdominal abscesses among the laparoscopic and open-access treatment groups (OR, 1.64; 95% CI, 0.90-3.01, p = 0.11). The four trials did not reveal any statistically significant difference in operating time (mean difference, -4.36; 95% CI, -17.31 to 8.59, p = 0.51). In light of these findings, the use of laparoscopy as compared with the open-approach approach in paediatric appendectomies is not associated with a reduction in the risk of wound infection.

Laparoscopic versus Open Pediatric Surgery: Three Decades of Comparative Studies

INTRODUCTION

 Despite its wide acceptance, the superiority of laparoscopic versus open pediatric surgery has remained controversial. There is still a call for well-founded evidence. We reviewed the literature on studies published in the last three decades and dealing with advantages and disadvantages of laparoscopy compared to open surgery.

MATERIALS AND METHODS

 Studies comparing laparoscopic versus open abdominal procedures in children were searched in PubMed/MEDLINE. Reports on upper and lower gastrointestinal as hepatobiliary surgery and on surgery of pancreas and spleen were included. Advantages and disadvantages of laparoscopic surgery were analyzed for different types of procedures. Complications were categorized using the Clavien-Dindo classification.

RESULTS

 A total of 239 studies dealing with 19 types of procedures and outcomes in 929,157 patients were analyzed. We identified 26 randomized controlled trials (10.8%) and 213 comparative studies (89.2%). The most frequently reported advantage of laparoscopy was shorter hospital stay in 60.4% of studies. Longer operative time was the most frequently reported disadvantage of laparoscopy in 52.7% of studies. Clavien-Dindo grade I to III complications (mild-moderate) were less frequently identified in laparoscopic compared to open procedures (80.3% of studies). Grade-IV complications (severe) were less frequently reported after laparoscopic versus open appendectomy for perforated appendicitis and more frequently after laparoscopic Kasai's portoenterostomy. We identified a decreased frequency of reporting on advantages after laparoscopy and increased reporting on disadvantages for all surgery types over the decades.

CONCLUSION

 Laparoscopic compared with open pediatric surgery seems to be beneficial in most types of procedures. The number of randomized controlled trials (RCTs) remains limited. However, the number of reports on disadvantages increased during the past decades.

Surgical site infection after open and laparoscopic surgery in children: a systematic review and meta-analysis

Surgical site infections (SSIs) are the most common healthcare-associated infections in patients undergoing surgery. Various randomised control trials (RCTs) indicate that laparoscopic procedures can be associated with better outcomes compared to open procedures. However, how open versus laparoscopic approaches compare across various paediatric procedures with respect to SSI rate remains poorly defined. In this review, we examined RCTs that directly compare SSI rates after open versus laparoscopic operations for appendicitis, gastro-esophageal reflux, inguinal hernia, and pyloric stenosis. MEDLINE, Embase, and Web of Science were searched for RCTs comparing four types of open versus laparoscopic operations in children. The operations included appendectomy, fundoplication for gastro-esophageal reflux, inguinal hernia repair, or pyloromyotomy. 364 records were identified and screened, 54 full-text articles were assessed for eligibility, and 17 RCTs were included in the analysis. SSI rate was the primary outcome. Operative time and length of stay (LOS) were the secondary outcomes. A meta-analysis was conducted using RevMan 5.4 software. Laparoscopic appendectomy had a lower SSI rate than open appendectomy (odds ratio of 2.22 [1.19, 4.15] p = 0.01). Laparoscopic fundoplication for gastro-esophageal reflux, inguinal hernia repair, or pyloromyotomy for pyloric stenosis were not associated with lower SSI rate compared to open surgery. Operative time was shorter in open fundoplication (- 71.22 min [- 89.79,  - 52.65] p < 0.00001) than laparoscopic fundoplication. There was no significant difference in operative time of any of the other procedures. There was no significant difference in LOS between open and laparoscopic procedures for all types of operations analysed. Based on the findings of this review, it is recommended to utilise the laparoscopic approach over the open approach to reduce SSI risk in paediatric appendectomy.

Development and evaluation of a low-cost part-task trainer for laparoscopic repair of inguinal hernia in boys and the acquisition of basic laparoscopy skills

PURPOSE

To examine the fidelity of our model of laparoscopic inguinal hernia repair (LIHR) in boys and evaluate its value in resident training programs and the learning of basic laparoscopy skills.

METHODS

We created a simulation model with inexpensive, easy-to-obtain equipment. Study participants from 34 university hospital departments received a user manual and an evaluation questionnaire (11 items rated on a 5-point Likert scale). We considered that the evaluation was positive when the median overall score was 4 or over. We compared the results for residents (n=26) vs. expert surgeons (n=29) (t tests).

RESULTS

The duration of the procedure was significantly longer among the residents (30.0±16.8 min) than among the expert surgeons (20.5±11.7 min; p=0.01). In both groups, the participants rated the model favorably with regard to the overall impression (median score: 4.0±1.0), realism (4.0±0.9), ease of access to the required equipment (5.0±0.6), the quality of the user manual (5.0±0.6), ease of assembly (5.0±0.8), ease of the procedure (5.0±0.8), value in resident training programs (4.0±0.9), and value in learning basic laparoscopy skills (5.0±0.8)). The evaluation was positive (4.0±0.9).

CONCLUSION

Our low-cost model was an effective teaching and training tool for LIHR and basic laparoscopy skills.

LEVEL OF EVIDENCE

Level IV.

Thirty Years of Minimally Invasive Surgery in Children: Analysis of Meta-Analyses

INTRODUCTION

 In the last three decades, minimally invasive surgery (MIS) has been widely used in pediatric surgery. Meta-analyses (MAs) showed that studies comparing minimally invasive with the corresponding open operations are available only for selected procedures. We evaluated all available MAs comparing MIS with the corresponding open procedure in pediatric surgery.

MATERIALS AND METHODS

 A literature search was performed on all MAs listed on PubMed. All analyses published in English, comparing pediatric minimally invasive with the corresponding open procedures, were included. End points were advantages and disadvantages of MIS. Results of 43 manuscripts were included. MAs evaluating the minimally invasive with the corresponding open procedures were available for 11 visceral, 4 urologic, and 3 thoracoscopic types of procedures. Studies included 34 randomized controlled trials. In 77% of MAs, at least one advantage of MIS was identified. The most common advantages of MIS were a shorter hospital stay in 20, a shorter time to feeding in 11, and a lower complication rate in 7 MAs. In 53% of MAs, at least one disadvantage of MIS was found. The most common disadvantages were longer operation duration in 16, a higher recurrence rate of diaphragmatic hernia in 4, and gastroesophageal reflux in 2 MAs. A lower native liver survival rate after laparoscopic Kasai-portoenterostomy was reported in one MA.

CONCLUSION

 In the available MAs, the advantages of MIS seem to outnumber the disadvantages. However, for some types of procedures, MIS may have considerable disadvantages. More randomized controlled trials are required to confirm the advantage of MIS for most procedures.

Validation of an inanimate low cost model for training minimal invasive surgery (MIS) of esophageal atresia with tracheoesophageal fistula (AE/TEF) repair

We present the results of the validation of an inanimate model created for training thoracoscopic treatment of esophageal atresia with lower tracheoesophageal fistula (EA/TEF).

MATERIALS AND METHODS

We used different domestic materials such as a piece of wood (support), corrugated plastic tubes (PVC) of different sizes to simulate ribs, intercostal spaces, trachea and spine and tubular latex balloons to simulate the esophagus and lungs to make the basic model. This device was inserted into the thoracic cavity of a rubber dummy simulating a 3kg newborn with a work area volume of 50ml. The model was designed taking into account the experience of doing this procedure in neonates. The cost of the materials used was 50 US$. Regular video endoscopic equipment and 3mm instruments were used. Thirty-nine international faculty or pediatric surgeons attending hands on courses with different levels of training in minimal invasive surgery (MIS) repair of EA/TEF performed the procedure in the model. We compared the performance of the practitioners with their experience in thoracoscopic repair of EA. A Likert-type scale was used to evaluate results. Previous experience in MIS, anatomical appearance of the model, surgical anatomy compared to a real patient, and utility as a training method were analyzed. We also used a checklist to assess performance. We evaluated: number of errors and types of injuries, quality of the anastomosis, and duration of procedure. To analyze the results we used a T-test, chi-square test and Excel® database to match up some results.

RESULTS

Thirty-nine questionnaires were completed. Seven surgeons were experts (≥30 TEF/EA repairs as surgeon), 10 had intermediate level of experience (5 to 29 repairs as surgeon) and 22 were beginners (less than 5 repairs). To simplify the analysis we divided the respondents into low experience LE (<5 real procedures-beginners; n=22) and high experience HE (intermediate, 10; and experts, 7; n=17). In relation to the anatomical characteristics of the model, 94.48% (n=37) respondents considered that the model has a high degree of similarity or good similarity; in relation to surgical anatomy 88.2% (n=34) respondents considered that the model has a high degree of similarity or good similarity; 87.17% (n=34) respondents considered that the model can generate a good amount of skills and/or can generate great majority of skills to EA/TEF repair; and 12.82% (n=5) respondents consider that it can generate some skills or a few skills, only in relation to trocar placement, one of the surveyed items. The number of errors was 29±7 SD (20 to 51) for the low experience group (LE) and 9±6 SD (1 to 20) for the high experience group (HE) (P value<0.0001). Time in minutes was significantly lower in the HE group (40±9 SD; 26 to 58min), in relation with LE (81±19 SD; 49 to 118min) (P<0.0001, T-test). Deficient or incomplete anastomosis also showed differences: 7 (32%) in the LE group and 1 (6%) in the HE group (P = 0.04, chi-square test). We saw a correlation between the previous experience of the surgeon and their performance in the model considering operating time, quality of anastomosis and peripheral tissue damage. According to the suggestions registered in the questionnaires, we have now improved the model. We have also started using it in a scenario to simulate the whole neonatal MIS operative room setting and team work.

Laparoscopy in pediatric surgery: Implementation in Canada and supporting evidence

BACKGROUND/PURPOSE

The purpose of this study was to assess the diffusion of laparoscopy usage in Canadian pediatric centers and the relationship between uptake of laparoscopic surgery and the level of evidence supporting its use.

METHODS

National data on four pediatric laparoscopic operations (appendectomy, pyloromyotomy, cholecystectomy, splenectomy) were analyzed using the Canadian Institute for Health Information Discharge Database (2002-2013). The highest level of evidence to support the use of each procedure was identified from Cochrane, Embase, and Pubmed databases. Chi-square test for trend was used to determine significance and time to plateau.

RESULTS

There were 28,843 operations (open: 12,048; laparoscopic: 16,795). Use of laparoscopic procedures increased over time (p<0.0001). A plateau was reached for cholecystectomy (2006), splenectomy (2007), and appendectomy (2012), but not for pyloromyotomy. Laparoscopic pyloromyotomy in 2013 remains less diffused than the other procedures (p<0.0001). Laparoscopic appendectomy and pyloromyotomy are supported by level-1a evidence in children, whereas cholecystectomy and splenectomy are supported by level-1a evidence in adults but level-3 in children.

CONCLUSIONS

In Canada, it has taken a long time to reach high-level implementation of laparoscopic surgery in children. Laparoscopic cholecystectomy first reached plateau, whereas laparoscopic pyloromyotomy continues to increase but remains low despite high level of evidence in support of its usage compared to open surgery.

Neonatal brain oxygenation during thoracoscopic correction of esophageal atresia

Background

Little is known about the effects of carbon dioxide (CO₂) insufflation on cerebral oxygenation during thoracoscopy in neonates. Near-infrared spectroscopy can measure perioperative brain oxygenation [regional cerebral oxygen saturation (rScO₂)].

Aims

To evaluate the effects of CO₂ insufflation on rScO₂ during thoracoscopic esophageal atresia (EA) repair.

Methods

This is an observational study during thoracoscopic EA repair with 5 mmHg CO₂ insufflation pressure. Mean arterial blood pressure (MABP), arterial oxygen saturation (SaO₂), partial pressure of arterial carbon dioxide (paCO₂), pH, and rScO₂ were monitored in 15 neonates at seven time points: baseline (T0), after anesthesia induction (T1), after CO₂-insufflation (T2), before CO₂-exsufflation (T3), and postoperatively at 6 (T4), 12 (T5), and 24 h (T6).

Results

MABP remained stable. SaO₂ decreased from T0 to T2 [97 ± 3–90 ± 6 % (p < 0.01)]. PaCO₂ increased from T0 to T2 [41 ± 6–54 ± 15 mmHg (p < 0.01)]. pH decreased from T0 to T2 [7.33 ± 0.04–7.25 ± 0.11 (p < 0.05)]. All parameters recovered during the surgical course. Mean rScO₂ was significantly higher at T1 compared to T2 [77 ± 10–73 ± 7 % (p < 0.05)]. Mean rScO₂ levels never dropped below a safety threshold of 55 %.

Conclusion

The impact of neonatal thoracoscopic repair of EA with insufflation of CO₂ at 5 mmHg was studied. Intrathoracic CO₂ insufflation caused a reversible decrease in SaO₂ and pH and an increase in paCO₂. The rScO₂ was higher at anesthesia induction but remained stable and within normal limits during and after the CO₂ pneumothorax, which suggest no hampering of cerebral oxygenation by the thoracoscopic intervention. Future studies will focus on the long-term effects of this surgery on the developing brain.

Interactive Instrument-Driven Image Display in Laparoscopic Surgery

BACKGROUND

A significant limitation of minimally invasive surgery is dependence of the entire surgical team on a single endoscopic viewpoint. An individualized, instrument-driven image display system that allows all operators to simultaneously define their viewing frame of the surgical field may be the solution. We tested the efficacy of such a system using a modified Fundamentals of Laparoscopic Surgery™ (Society of American Gastrointestinal and Endoscopic Surgeons, Los Angeles, CA) bead transfer task.

MATERIALS AND METHODS

A program was custom-written to allow zooming and centering of the image window on specific color signals, each attached near the tip of a different laparoscopic instrument. Two controls were used for the bead transfer task: (1) a static, wide-angle view and (2) a single moving camera allowing close-up and tracking of the bead as it was transferred. Time to task completion and number of bead drops were recorded.

RESULTS

Thirty-six sessions were performed by surgical residents. Average time for bead transfer was 127.3±21.3 seconds in the Experimental group, 139.1±27.8 seconds in the Control 1 group, and 186.2±18.5 seconds in the Control 2 group (P=.034, by analysis of variance). Paired analysis (the Wilcoxon Signed-Rank Test) showed that the Experimental group was significantly faster than the Control 1 group (P=.035) and the Control 2 group (P=.028).

CONCLUSIONS

We have developed an image navigation system that allows intuitive and efficient laparoscopic performance compared with two controls. It offers high-resolution images and ability for multitasking. The tracking system centers close-up images on the laparoscopic target. Further development of robust prototypes will help transition this in vitro system into clinical application.

Brain oxygenation during laparoscopic correction of hypertrophic pyloric stenosis

BACKGROUND

Concern remains about the safety of carbon dioxide (CO2) pneumoperitoneum (PP) in young infants having surgery for pyloric stenosis via laparoscopy. Interests here mainly focus on possible jeopardized organ perfusion and in particular brain oxygenation with possible adverse neurodevelopmental outcomes. The aim of this study was to investigate the intraoperative effects of CO2 gas PP on cerebral oxygenation during laparoscopic surgery for hypertrophic pyloric stenosis in young infants.

PATIENTS AND METHODS

In this single-center prospective observational study, we investigated brain oxygenation in 12 young infants receiving laparoscopic pyloromyotomy with CO2 PP, with a pressure of 8 mm Hg and a flow rate of 5 L/minute. Intraoperative hemodynamic parameters and transcranial near-infrared spectroscopy to assess regional cerebral oxygen saturation (rScO2) were monitored continuously during the whole procedure. Parameters were analyzed in four intervals: before insufflation (T0), during (start [T1] and end [T2]), and after cessation (T3) of the CO2 PP.

RESULTS

Blood pressure and end-tidal CO2 (etCO2) increased during the procedure: mean arterial pressure, 35±5 mm Hg at T0 to 43±9 mm Hg at T2; etCO2, 35±4 mm Hg at T0 to 40±3 mm Hg at T3. The rScO2 remained stable throughout the whole anesthetic period. In none of the patients did the rScO2 drop below the safety threshold of 55% (rScO2, 68±14% at T0 to 71±9% at T3).

CONCLUSIONS

Our results indicate that a laparoscopic procedure with a CO2 PP of 8 mm Hg can be performed under safe anesthetic conditions in the presence of gradually increasing blood pressure and etCO2 without altering regional brain oxygenation levels.

Laparoscopic treatment of intussusception in children: a systematic review

BACKGROUND

Idiopathic intussusception is one of the most common causes of small bowel obstruction in children. In the event of failed radiological reduction, laparotomy remains the treatment of choice. There is still no agreement in pediatric surgery about safety and effectiveness of the use of minimally invasive surgery in this common pediatric condition. By reviewing available data we aimed to establish whether laparoscopy should be the primary technique in the surgical reduction of intussusception.

METHODS

A systematic review of all publications on the laparoscopic treatment of pediatric intussusception from January 1990 to April 2012 was performed. The following variables were analyzed: age, laparoscopic success rate, reason for conversion, enterotomy rate, operative time, complications, and length of stay (LOS).

RESULTS

Ten retrospective studies treating 276 cases of laparoscopically reduced intussusception were identified. A total of 80 conversions corresponded to a 71.0% laparoscopic success rate. Only one case of intraoperative iatrogenic intestinal perforation was reported (0.4%). Postoperative complications occurred in 8 patients (2.9%), and adhesive small bowel obstruction was reported in 1 case (0.4%). Recurrence rate after laparoscopy was 3.6%. Three of 10 papers compared results between laparoscopic and open reduction of intussusception showing a shorter mean LOS in the former group (4.0 vs. 7.1 days, p<0.01).

CONCLUSION

Laparoscopy is safe and effective in the treatment of pediatric intussusception. Tertiary centers with adequate minimally invasive skills should establish laparoscopy as the primary surgical technique in the treatment of this condition.

Evaluation of a video telescopic operating microscope (VITOM) for pediatric surgery and urology: a preliminary report

INTRODUCTION

Optical magnification is an essential tool in the practice of pediatric surgery. Magnifying loupes are the most frequently used instrument, although their use often comes at the expense of neck pain experienced by the operating surgeon. Recent advances have led to the development of a compact video microscope (VITOM(®); Karl Storz Endoscopy GmbH, Tuttlingen, Germany) that displays high-definition magnified images on a flat screen. This study was designed to evaluate VITOM as a potential substitute for loupes in complex open pediatric procedures and to explore VITOM as an effective intraoperative teaching modality for open surgery.

SUBJECTS AND METHODS

Three surgeons used the VITOM II exoscope in 20 operations: 14 hypospadias repairs, 2 inguinal hernia repairs, 1 sacrococcygeal teratoma resection, 1 recurrent tracheoesophageal fistula repair, and 2 additional procedures. Surgeons, trainees, and surgical technicians subjectively evaluated image quality; surgeons evaluated handling of VITOM, degree of neck strain, and fatigue. Three midlevel surgical trainees assessed the VITOM potential for teaching value. Overall impressions of each group and consensus opinions were generated.

RESULTS

All procedures were completed without complication. The consensus opinion of the entire group was that image quality was excellent. The surgeons found VITOM easy to use, and all agreed that neck strain and fatigue were reduced. Surgical trainees felt that VITOM imaging aided in their understanding of procedures and anatomy. Surgical technicians perceived improved operation flow through better visualization of the procedure.

CONCLUSIONS

VITOM provides excellent visualization of pediatric operations with improved surgeon comfort and may serve as a substitute for loupes. Secondarily, we found enhanced trainee learning and potential improvement in the flow of surgical procedures. Further study of VITOM with a larger sample size and validated tools is needed.

Enthusiasm, evidence and ethics: the triple E of minimally invasive pediatric surgery

Minimally invasive techniques are applicable in more than 60% of abdominal and thoracic operations in children. Enthusiasts promoted these techniques for many years. However, level 1 evidence on advantages of minimally invasive surgery in children remains limited. Randomized controlled trials have been conducted for some types of procedures such as laparoscopic appendectomy, fundoplication, pyloromyotomy, and inguinal hernia repair. The results of these studies confirm some advantages of minimally invasive surgery, but for most types of laparoscopic and all types of thoracoscopic procedures, such data remain to be established. This article also focuses on reports on complications and disadvantages which are relevant for final conclusions and recommendations. The ethical implications of the application of new techniques in children are also discussed. On the basis of evidence based data and ethical principles, minimally invasive techniques may be appropriately used in the future.

Laparoscopic treatment of gastric and duodenal perforation in children after blunt abdominal trauma

Minimal invasive surgery has not yet gained wide acceptation for the care of patients that sustained an abdominal trauma. We describe the complete laparoscopic surgical treatment of two patients after a single blunt abdominal trauma. One patient sustained a handle bar injury and presented with a gastric perforation. The other sustained a duodenal rupture by falling on a sharp edge of a table. The patients were assessed and treated laparoscopically. The perforations were identified and closed. Both patients had an uneventful postoperative recovery. Therapeutic laparoscopic treatment of patients with upper gastrointestinal perforation is feasible. We would recommend this approach to experienced laparoscopic surgeons in hemodynamically stable patients.

Scope and limitations of minimal invasive surgery in practice of pediatric surgical oncology

Management of Solid tumors in children needs a comprehensive multimodality protocol based treatment plan. Open surgical removal of the tumors occurring in any of the sites such as abdomen, thorax, chest wall, HFN (head, face, neck), brain and extremities, is the option which has been traditionally practiced even in the present era and in most of the centers. Nevertheless with the advances in science and technology and with ever increasing usage and expertise of laparoscopy in children, it's application has extended to treatment of solid tumors in children. A review of the scope of such intervention as well as the limitations of minimal invasive surgery in this specialized field of pediatric surgery has been attempted in this article.

Ectopic extralobar pulmonary sequestrations in children: interest of the laparoscopic approach

BACKGROUND

Extralobar pulmonary sequestrations (EPS) are a rare benign congenital bronchopulmonary foregut malformation. Complete resection is necessary to confirm the diagnosis with histopathologic examination. The aim of this study was to describe the laparoscopic minimally invasive surgery (MIS) for a small series of ectopic EPS in small children and to show its feasibility and safety.

METHODS

From January 2001 to December 2008, 12 cases of EPS were prenatally diagnosed and retrospectively reviewed. From this group, we isolated 6 children with ectopic EPS. Ages ranged from 15 days to 14 months. Three infants were symptomatic, and the others showed persistence of the lesion with parental anxiety. All prenatal diagnoses were confirmed by postnatal Doppler ultrasound and intravascular contrast computed tomography scan with 3-dimensional reconstructions. Postnatally, all were ectopic lesions: 3 were hiatal and intradiaphragmatic, 3 infradiaphragmatic and left paramedian. Laparoscopic MIS consisted of 4 small trocars and low-pressure pneumoperitoneum. We carried out a retroesophageal dissection in 4 cases, an elective control of systemic vessels, and a removal of the EPS with histologic study.

RESULTS

We performed 5 procedures laparoscopically and 1 thoracoscopically. There were 2 abdominal conversions. Nevertheless, no intraoperative or immediate postoperative complications occurred. Hospital stay ranged from 1 to 5 days (mean, 2.7 days). The diagnosis of pure pulmonary sequestration with feeding vessels in 5 cases was confirmed by histopathology. Follow-up ranged from 13 to 84 months (mean, 43 months). Late complications were benign.

CONCLUSIONS

Laparoscopic MIS for ectopic EPS in small children is a feasible and safe technique. The great magnification provided by the endoscopic procedure allows for the search of associated congenital anomalies, meticulous retroesophageal dissection, and control of the systemic vessels. Resection provides definitive diagnosis and treatment, and confers the benefits of a minimal access technique.

Robot-assisted pediatric surgery: how far can we go?

BACKGROUND

The purpose of this study was to assess the safety and feasibility of performing robot-assisted pediatric surgery using the da Vinci Surgical System in a variety of surgical procedures.

METHODS

A retrospective review of 144 robot-assisted pediatric surgical procedures performed in our institution between June 2004 and December 2007 was done. The procedures included the following: 39 fundoplications; 34 cholecystectomies; 25 gastric bandings; 13 splenectomies; 4 anorectal pull-through operations for imperforate anus; 4 nephrectomies; 4 appendectomies; 4 sympathectomies; 3 choledochal cyst excisions with hepaticojejunostomies; 3 inguinal hernia repairs; two each of the following: liver cyst excision, repair of congenital diaphragmatic hernia, Heller's myotomy, and ovarian cyst excision; and one each of the following: duodeno-duodenostomy, adrenalectomy, and hysterectomy.

RESULTS

A total of 134 procedures were successfully completed without conversion; 7 additional cases were converted to open surgery, and 3 were converted to laparoscopic surgery. There were no system failures (e.g., setup joint, arm, or camera malfunction; power error; monocular or binocular loss; metal fatigue or break of surgeon's console hand piece; software incompatibility). There was one esophageal perforation and two cases of transient dysphagia following Nissen fundoplication. The mean patient age was 8.9 years, and the mean patient weight was 57 kg.

CONCLUSIONS

Robot-assisted surgery appears to be safe and feasible for a number of pediatric surgical procedures. Further system improvement and randomized studies are required to evaluate the benefits, if any, and the long-term outcomes of robotic surgery.

Is conversion a complication of laparoscopic surgery

INTRODUCTION

In this paper, we review our laparoscopic and thoracoscopic experience and look specifically at the cases that resulted in conversion.

METHODS

Data were retrieved on all minimally invasive surgical procedures performed in our institution.

RESULTS

There were 1,759 cases performed between 1997 and 2007. Of these, 1,648 cases were laparoscopic and 111 thoracoscopic. There were 508 appendicectomies (34 interval), 216 fundoplications (21 redo), 183 diagnostic laparoscopies, 137 pyloromyotomies, 35 cholecystectomies, 27 splenectomies, 98 Fowler-Stephens procedures,79 nephrectomies (including heminephrectomies), 48 Palomo procedures, 75 assisted percutaneous endoscopicgastronomies, 31 pull-through procedures for Hirschsprung's disease, and 210 others. There were 45 conversions (2.6%) over the time period; 40% of all cases converted were in children who had previously had surgery, and 13% of the conversions were enforced due to bleeding or visceral injury at the time of surgery.Looking at the conversion for specific operations, this was 1.4% for appendicectomies, 2% for pyloromyotomies,and 1% for fundoplications. The rate was highest for thoracoscopic cases and nephrectomies at 10%; 82% of all conversions occurred during the first 1,000 cases (56% of our experience).

CONCLUSION

Our conversion rate is 2.6%. There has been a significant fall in our conversion rate over the 11 years, despite the increased number, breadth, and complexity of our caseload. We attribute this to the learning curve associated with minimally invasive surgery. Conversion is more common in patients who have had previous surgery, thoracoscopic procedures, and nephrectomies.

Is conversion a complication of laparoscopic surgery

INTRODUCTION

In this paper, we review our laparoscopic and thoracoscopic experience and look specifically at the cases that resulted in conversion.

METHODS

Data were retrieved on all minimally invasive surgical procedures performed in our institution.

RESULTS

There were 1,759 cases performed between 1997 and 2007. Of these, 1,648 cases were laparoscopic and 111 thoracoscopic. There were 508 appendicectomies (34 interval), 216 fundoplications (21 redo), 183 diagnostic laparoscopies, 137 pyloromyotomies, 35 cholecystectomies, 27 splenectomies, 98 Fowler-Stephens procedures,79 nephrectomies (including heminephrectomies), 48 Palomo procedures, 75 assisted percutaneous endoscopicgastronomies, 31 pull-through procedures for Hirschsprung's disease, and 210 others. There were 45 conversions (2.6%) over the time period; 40% of all cases converted were in children who had previously had surgery, and 13% of the conversions were enforced due to bleeding or visceral injury at the time of surgery.Looking at the conversion for specific operations, this was 1.4% for appendicectomies, 2% for pyloromyotomies,and 1% for fundoplications. The rate was highest for thoracoscopic cases and nephrectomies at 10%; 82% of all conversions occurred during the first 1,000 cases (56% of our experience).

CONCLUSION

Our conversion rate is 2.6%. There has been a significant fall in our conversion rate over the 11 years, despite the increased number, breadth, and complexity of our caseload. We attribute this to the learning curve associated with minimally invasive surgery. Conversion is more common in patients who have had previous surgery, thoracoscopic procedures, and nephrectomies.