Single incision laparoscopic surgery (SILS) for ovarian masses (including teratoma) in adolescent girls

Single-incision versus conventional laparoscopic pyloromyotomy for pediatric hypertrophic pyloric stenosis: a systematic review and meta-analysis

PURPOSE

To assess the safety and efficacy of single-incision versus conventional laparoscopic pyloromyotomy in pediatrics, we conducted a systematic review and meta-analysis.

METHODS

A literature search was conducted to identify studies that compared single-incision laparoscopic pyloromyotomy (SILP) and conventional laparoscopic pyloromyotomy (CLP) for infants with hypertrophic pyloric stenosis (HPS). Meta-analysis was used to pool and compare variables such as operative time, time to full feeding, length of hospital stay, mucosal perforation, inadequate pyloromyotomy, wound infection, incisional hernia and overall complications.

RESULTS

Among the 490 infants with HPS in the seven studies, 205 received SILP and 285 received CLP. There was significant longer time to full feeding for SILP compared with CLP. However, pooling the results for SILP and CLP revealed no significant difference in operative time, length of hospital stay and postoperative complications.

CONCLUSIONS

SILP is a safe, feasible and effective surgical procedure for infants with HPS when compared to CLP. SILP is equivalent to CLP in terms of operative time, length of hospital stay and postoperative complications. We conclude that LS should be considered an acceptable option for HPS.

Approaches to the management of pediatric ovarian masses in the 21st century: Systematic review and meta-analysis

BACKGROUND

Laparoscopy is increasingly being adopted for the treatment of ovarian pathologies in adults. However, its implementation for the management of pediatric ovarian masses varies and the evidence, to date, has not been comprehensively analyzed. This review aims to compare laparoscopic and open surgical management of pediatric ovarian masses.

METHODS

We searched PubMed, Cochrane Library and Google Scholar from the year 2000 till April 2017. Studies selected for this included those on epidemiological trends of pediatric ovarian lesions, assessing outcomes of laparoscopic management and comparison of laparoscopic and open surgical techniques for pediatric ovarian masses. A meta-analysis comparing outcomes of both modalities was performed using standard methodology.

RESULTS

A total of 44 studies met the inclusion criteria of which 15 were on histological types of ovarian lesions, 24 assessed laparoscopic management only and five compared laparoscopy with open surgery for pediatric ovarian masses. Nonneoplastic lesions were the most common ranging from 36.5% to 73.7%, with cystic lesions being the most prevalent. Neoplastic lesions ranged between 26.3% and 63.5%, with germ cell tumors being the most common, while malignancy ranged between 3.5% and 10.8%. Laparoscopic management was generally advocated for managing benign lesions with a cautious approach for suspicion of malignant lesions. In comparison to open surgery, laparoscopic surgery had shorter operating time (MD = -33.24 min, 95% CI = -34.29 to -32.19, p < 0.0001), less intraop bleeding (MD = - 61.46 ml, 95% CI = -62.69 to -60.24, p < 0.0001), and reduced length of hospital stay (MD = -2.78 days, 95% CI= -2.82 to -2.74, p<0.0001). Complication rates were equivocal between the two approaches. Spillage rates could not be assessed.

CONCLUSION

Limited evidence suggests that laparoscopic approach to presumptively benign ovarian masses have better outcomes when compared to open surgery with regards to operating time, blood loss and hospital stay. However, complication rates were similar between the two approaches. Studies with rigorous scientific methods are needed for a definitive recommendation, especially in resource limiting settings. However malignant lesions should still be managed with an open surgical approach to avoid upstaging of disease status.

LEVEL OF EVIDENCE

II.

Single-Incision Single-Instrument Adnexal Surgery in Pediatric Patients

Introduction. Pediatric surgeons often practice pediatric gynecology. The single-incision single-instrument (SISI) technique used for appendectomy is applicable in gynecologic surgery. Methods. We retrospectively analyzed the records of patients undergoing pelvic surgery from 2008 to 2013. SISI utilized a 12 mm transumbilical trocar and an operating endoscope. The adnexa can be detorsed intracorporeally or extracorporealized via the umbilicus for lesion removal. Results. We performed 271 ovarian or paraovarian surgeries in 258 patients. In 147 (54%), the initial approach was SISI; 75 cases (51%) were completed in patients aged from 1 day to 19.9 years and weighing 4.7 to 117 kg. Conversion to standard laparoscopy was due to contralateral oophoropexy, solid mass, inability to mobilize the adnexa, large mass, bleeding, adhesions, or better visualization. When SISI surgery was converted to Pfannenstiel, the principal reason was a solid mass. SISI surgery was significantly shorter than standard laparoscopy. There were no major complications and the overall cohort had an 11% minor complication rate. Conclusion. SISI adnexal surgery is safe, quick, inexpensive, and effective in pediatric patients. SISI was successful in over half the patients in whom it was attempted and offers a scarless result. If unsuccessful, the majority of cases can be completed with standard multiport laparoscopy.

Single-incision pediatric endosurgery: a systematic review

BACKGROUND

Single-incision pediatric endosurgery (SIPES) is defined as minimally invasive surgery performed through a unique incision in the abdomen, chest, or retroperitoneum. Several publications exist, but no previous systematic review has been made to evaluate the real benefits of this approach in terms of feasibility and clinical outcomes.

MATERIALS AND METHODS

We performed an electronic search in PubMed up to March 2012 with the terms "single AND incision OR site OR port OR trocar AND children" including related articles and obtained 197 articles. After applying our inclusion criteria, 78 articles were reviewed.

RESULTS

We identified prospective controlled trials (n=1), case-control studies (n=12), case series (n=49), and case reports (n=16). In total, 4212 patients had been operated on by SIPES and were separated by systems: gastrointestinal (n=2888), urologic (n=390), gynecologic (n=27), other abdominal (n=874), and thoracic (n=33) procedures. The most common procedure was SIPES appendectomy, and a unique prospective controlled trial supports its safety and effectiveness. Technically demanding surgeries such as hepatojejunostomy and colonic surgeries were described. Multichannel ports and multiple ports, standard and articulated instruments, transparietal instruments, retraction sutures, and magnets were used. Operative times, length of stay, and complications similar to standard laparoscopic surgery were described. A low conversion rate (to a reduced port, standard laparoscopy and open procedures) was also mentioned. No comparable measure for pain and cosmesis assessment was used.

CONCLUSIONS

A wide experience in SIPES and feasibility has already been described with good clinical outcomes and low rate of conversion. Appendectomy is the unique procedure in which SIPES has been demonstrated to be safe and effective. It is pending the execution of prospective controlled trials for other operations to demonstrate, with objective evidence, the real benefits of this less invasive approach.

Single-incision pediatric endosurgery for ovarian pathology

BACKGROUND AND OBJECTIVES

Despite being pioneered by gynecologists, single-incision endosurgery has not been widely reported for the treatment of ovarian and adnexal pathology in neonates, children, and adolescents. We describe our initial experience using single-incision pediatric endosurgery (SIPES) for these indications and discuss advantages and drawbacks.

SUBJECTS AND METHODS

All children who underwent SIPES with a preoperative diagnosis of ovarian or adnexal pathology were included in the study. Data on age, operative time, complications, length of hospital stay, and outcomes were collected.

RESULTS

From January 2010 until January 2012, 19 girls (mean age, 11.4 years; range, 6 days-17 years; weight range, 4.0-90 kg) underwent SIPES procedures for ovarian or adnexal diagnoses, including hemorrhagic/follicular/paratubal cysts (n=8), torsion (n=7), tumor (n=3), and parauterine cyst (n=1). The operations included cyst unroofing (n=4), detorsion and oophoropexy (n=7), (salpingo)oophorectomy (n=5), marsupialization of cyst (n=2), and cyst aspiration (n=1). Median operative time was 42 ± 29 minutes; there were no conversions to conventional laparoscopy or open surgery. Fifteen patients (79%) were discharged within 24 hours after the procedure. There were no peri- or postoperative complications. Histopathology showed hemorrhagic/follicular/paratubal cyst (n=7), necrotic/calcified ovarian tissue after torsion (n=6), cystadenofibroma (n=1), granulosa cell tumor (n=1), and mature teratoma (Grade 0) (n=1).

CONCLUSIONS

SIPES is an excellent alternative to conventional laparoscopy for the treatment of adnexal pathology. Using a single umbilical incision that can be enlarged instead of three smaller trocar sites facilitates the resection and extraction of ovarian masses without compromising cosmesis.

Single-incision multiport laparoscopy does not cause more pain than conventional laparoscopy: a prospective evaluation in children undergoing appendectomy

BACKGROUND

The benefit of single-incision multiport laparoscopy (SIMPL) remains a matter of vivid discussion. For good reason it has been speculated that SIMPL causes more postoperative pain, because a minilaparotomy is required to place the multiport system. We prospectively evaluated postoperative pain scores and requirement of analgesic medication following conventional laparoscopic (CL) versus SIMPL appendectomy in children.

METHODS

The access for laparoscopic appendectomy was decided upon the surgeon's preference. Between April and October 2010, individual abdominal pain scores at 8, 16, 24, 48, and 72 hours postoperatively as well as the incidence of umbilical or shoulder pain and the total amount of peri- and postoperative analgesics, operative time, length of hospital stay, and demographics were assessed. Analgesics (paracetamol and/or metamizole, 15 mg/kg body weight) were administered regularly or on inquiry of the patient. Data are presented as means±standard deviation tested at a significance level of P<.05.

RESULTS

All operations were laparoscopically completed without conversion or addition of extra ports. Thirty-nine patients (8 SIMPL appendectomy) at a mean age of 12.3±2.4 years and a mean body mass index of 19.16±3.2 kg/m(2) were included. Equal operation times were observed (SIMPL: 68.5±19.9 minutes versus CL: 66.2±19.5 minutes). There were no significant differences for the individual pain scores or the incidence of umbilical and shoulder pain between study groups. The total amount of required analgesic medication was significantly lower after SIMPL appendectomy (SIMPL: 65.73±43.8 mg/kg versus CL: 106.39±46.4 mg/kg, P=.04).

CONCLUSION

In summary, the present study substantiates the evidence that SIMPL appendectomy in children and adolescents is not only feasible but also beneficial for the patient without translation into increased postoperative pain. Presently, we are conducting a randomized, blinded study to validate these findings.