Laparoscopic surgery in children

"Double N": Evolution of the Surgical Technique for Laparoscopic Herniorrhaphy After 10-Year Experience in a Single Center

INTRODUCTION

We describe our experience with the use of a modified technique for laparoscopic internal inguinal ring closure (peritoneal incision and double "N" stitch placement). We evaluate the technique in terms of feasibility, efficacy, and safety.

MATERIALS AND METHODS

From November 2003 to March 2014 we performed 1700 herniorraphies by laparoscopy. We selected 123 patients treated with the "double N" technique by the same surgical team, and we reviewed their notes analyzing demographic data, operative times, intra- and postoperative complications, and recurrence rate. The technique used is a modification of the Schier technique. Our technique consists of a partial lateral peritoneal 180° incision around the internal inguinal ring and in the placement of a double stitch. The first stitch is used to approximate the muscles with the inguinal ligament, and the second one is used to close the peritoneum above them.

RESULTS

The female to male ratio was 22:101. Mean age at surgery was 4.3 years (range, 1 month-12 years). Mean operative time was 30 minutes (range, 20-50 minutes). There were 60 bilateral cases. There were no intraoperative complications. Two patients had reactive hydrocele treated conservatively, and 1 patient developed umbilical infection. We did not identify any recurrence.

CONCLUSIONS

Our early results suggest that the "double N" laparoscopic technique to close the internal inguinal ring in children is safe and efficient. We therefore suggest using this approach in children with a patent internal inguinal ring of >1 cm. The recurrence rate is low, but it should be better assessed by studies with longer follow-up.

Two decades of minimally invasive pediatric surgery-taking stock

BACKGROUND

The past 2 decades have seen a rapid integration of minimally invasive surgery (MIS) to pediatric surgical practice. This study endeavored to delineate the current status of MIS in pediatric surgery.

METHODS

Three hundred six pediatric surgeons were invited to participate in an anonymous Web-based survey. Apart from demographic details and opinion regarding robotic surgery, surgeons were asked to choose between "perform MIS," "do not perform MIS but recommend it," and "MIS not indicated" for common pediatric surgical conditions.

RESULTS

Responses were received from 117 pediatric surgeons (38.2%). Sixty-one percent of respondents did more than 10% of their work using MIS, and 85% had more than 5 years experience in MIS. Cholecystectomy, nonpalpable testis, and exploration for abdominal pain scored highest among the positive recommendations for MIS, whereas liver tumors, biliary atresia, Wilms' tumor, and inguinal hernia scored highest among the negative recommendations for MIS. Fifty-one percent of the respondents had more than 20 years experience as a pediatric surgeon and were categorized as "senior" surgeons. Compared with the young surgeons, the senior surgeons were more likely to recommend MIS as a contraindication for simple and complicated appendicitis, reduction of intussusception, gastrostomy, fundoplication, pyloromyotomy, adhesiolysis, splenectomy, adrenalectomy, nephrectomy for dysplastic kidneys, heminephrectomy, pyeloplasty, anorectal malformations, pyeloplasty, achalasia cardia, hiatal hernia repair, lung resection, and diaphragmatic hernia repair. More than half the respondents believed that robotic surgery has a role for children in the future.

CONCLUSIONS

A widespread integration of MIS into the pediatric surgical practice is evident from this study. Current practice and recommendations of the surveyed surgeons have been outlined. Significant differences between the young and senior surgeons reflect the evolving nature of the recommendations.

Laparoscopic full-thickness intestinal biopsies in children

BACKGROUND

Laparoscopy may reduce postoperative pain and hospital stay, compared with laparotomy. The use of laparoscopic surgery to obtain full-thickness intestinal biopsies in children has not been previously reported.

METHODS

Eleven children aged 1.6 to 19 years (median, 4.5 years) underwent laparoscopic full-thickness biopsy of the stomach, small bowel, colon, or a combination thereof. Each procedure used one 12-mm and two 5-mm ports.

RESULTS

Eight children with obstructive symptoms after a pull-through for Hirschsprung disease underwent multiple colon and small bowel biopsies (range, 3-6; median, 5); intestinal neuronal dysplasia was found in two. Two patients with cystic fibrosis had diffuse colonic narrowing; a diagnosis of enzyme-induced fibrosing colonopathy was made in one and nonspecific inflammation was found in the other. One child had a thickened stomach, and a gastroscopic-directed full-thickness biopsy revealed plasmacytoma. Nine of the 11 patients had a previous laparotomy, and ports were placed through preexisting scars. Median hospital stay was 2 days. No patient required more than 24 hours of narcotics. There were no leaks, and no other morbidity or mortality occurred. None of the patients required conversion to an open procedure. Biopsy results significantly affected treatment for each patient.

CONCLUSIONS

Laparoscopic full-thickness intestinal biopsy is safe and effective for a variety of gastrointestinal problems in children. This technique is associated with a short hospital stay, minimal pain, and a very low risk of complications and can be performed even in patients who have had a previous laparotomy.