Single-incision pediatric endosurgery (SIPES) splenectomy: a case-control series

20 Years of Single-Incision-Pediatric-Endoscopic-Surgery: A Survey on Opinion and Experience Among International Pediatric Endosurgery Group Members

Aim/Background: Assessment of current role and future trends of Single-Incision-Pediatric-Endoscopic-Surgery (SIPES) in pediatric surgery among International Pediatric Endosurgery Group (IPEG) members two decades after introduction. Materials and Methods: An online survey was conducted between December 2019 and April 2020 on behalf of the IPEG Research Committee. All IPEG members were contacted by e-mail and asked to complete an anonymous questionnaire that included 39 items on SIPES. Results: One hundred eighty-four practicing pediatric surgeons completed the questionnaire from a pool of 890 IPEG members. The majority (76%) of respondents performed SIPES for more than 6 years with the following caseload per month: 1 case (31%), 2-5 cases (30%), 6-10 cases (24%), and >10 cases (17%). The four most commonly performed procedures were appendectomy (95%), Meckel diverticulectomy (55%), treatment of ovarian pathologies (43%), and U-stitch gastrostomy (40%). Complex reconstructive SIPES procedures were performed rarely. Most surgeons (95%) stated that better cosmesis is the predominant advantage of SIPES procedures. The majority of respondents (70%) felt that there is no convincing scientific evidence that SIPES offers benefits to multi-port minimally invasive procedures. Conclusion: Twenty years after introduction of SIPES, this technique has found its place in pediatric endoscopic surgery. Eighty percent of participating IPEG members of this survey apply SIPES for cases of lower complexity, such as appendectomy mainly for cosmetic reasons. The fact that 70% of respondents state that the scientific evidence for the benefits of SIPES is not convincing suggests that further studies and discussion on this technique are needed.

A Comparison of Single-Incision Versus Multiport Laparoscopic Splenectomy in Children

Background: Although single-incision endoscopic splenectomy (SIES-Sp) has been shown to be feasible and safe, few have compared the SIES-Sp with multiport laparoscopic splenectomy (MPLS). The purpose of this study was to compare the two techniques in children undergoing total splenectomy. Materials and Methods: We reviewed all children (age <18 years) who underwent minimally invasive total splenectomy at a single tertiary referral center from January 1, 2000 to January 1, 2019. The primary outcome was complication rate 30 days after discharge defined by maximum Clavien-Dindo score. Secondary outcomes included conversion, operative time, hospital length of stay, postoperative pain scores, and readmission within 30 days of discharge. SIES-Sp and MPLS were compared using univariate analysis. Results: Of 48 children undergoing laparoscopic total splenectomy, 60% (n = 29) were SIES-Sp and 40% (n = 19) were MPLS. Subjects were 48% female (n = 23). Common diagnoses were idiopathic thrombocytopenic purpura (33% [n = 16]), hereditary spherocytosis (29% [n = 14]), and other congenital hemolytic anemias (23% [n = 11]). There were no differences in age, gender, or diagnosis between groups (all P > .05). One in three cases involved additional procedures. Spleens were smaller in both greatest dimension (13.0 cm versus 16.4 cm) and weight (156.5 g versus 240.0 g) in SIES-Sp compared with MPLS patients (both P < .05). Readmission and reoperation rates were similar (both P > .05). Complications occurred in 7% (n = 2) of SIES-Sp and in 11% (n = 2) of MPLS patients (P > .99). Severe complications included: cardiac arrest in 1 SIES-Sp patient and bleeding requiring reoperation in 1 MPLS patient. Conclusion: SIES-Sp is a safe alternative to the traditional MPLS for children. Additional procedures do not preclude a less invasive approach, but larger spleens may present a challenge.

Systematic review and meta-analysis of single-incision versus conventional multiport laparoscopic splenectomy

BACKGROUND

There is no consensus that single-incision laparoscopic surgery splenectomy (SILS-SP) is on a par with conventional multiport laparoscopic surgery splenectomy (CMLS-SP).

AIMS

The aim of this systematic review and meta-analysis was to assess feasibility and safety of SILS-SP when compared with CMLS-SP.

MATERIALS AND METHODS

Eligible articles were identified by searching several databases including PubMed, EMBASE, CNKI (China) and the Cochrane Library, up until February 2016. Studies were reviewed independently and rated by Newcastle-Ottawa Quality Assessment Scale. Evaluated outcomes were complications, operative time, post-operative hospital stay, blood loss, starting diet, post-operative pain scores, conversion and analgesic requirements.

RESULTS

Ten retrospective studies met the eligibility criteria. Overall, there was no significant difference between SILS-SP and CMLS-SP in complications, operative time, post-operative hospital stay, blood loss, starting diet, post-operative pain scores, conversion and analgesic requirements.

CONCLUSIONS

SILS-SP is feasible and safe in certain patients, with no obvious advantages over CMLS-SP. Therefore, it may be considered an alternative to CMLS-SP. We await high-quality, double-blind RCTs. These should include clear statements on standard scores of post-operative pain and cosmetic results, longer follow-up assessment and cost-benefit analysis.

Operative and Immediate Postoperative Differences Between Traditional Multiport and Reduced Port Laparoscopic Total Splenectomy in Pediatric Patients

BACKGROUND

Laparoscopy offers many benefits to splenectomy, such as reduced incisional pain and shortened hospital duration. The purpose of this study is to evaluate procedural and outcome differences between multiport (MP) and reduced port (RP) splenectomy when utilized to treat children.

PATIENTS AND METHODS

An institutional review board approved retrospective analysis of all consecutive laparoscopic total splenectomies performed at a single institution between January 2010 and October 2015 was conducted. We evaluated demographics, surgical technique, instance of conversion, operative duration, estimated blood loss, need for intraoperative blood transfusion, postoperative length of stay, time to full feeds, complications, and follow-up duration.

RESULTS

Over a 5-year period, 66 patients less than 20 years of age underwent laparoscopic total splenectomy. RP splenectomy was attempted in 14 patients. The remaining 52 were MP operations. Populations were comparable with regard to demographics. Preoperative splenic volumes (mL) were greater in the RP population (median [IQR]: 1377 [747-1508] versus 452 [242-710], P = .039). RP splenectomy demonstrated no difference compared to MP splenectomy in operative time (153 versus 138 minutes, P = .360), estimated blood loss (120 versus 154 mL, P = .634), or percent of cases requiring intraoperative blood transfusion (14 versus 23, P = .716). By the first postoperative day, 57% of RP and 17% of MP patients could be discharged (P = .005). Thirty-day readmission rates were similar, at 7% for RP and 8% for MP operations. Fever was the indication for all readmissions. Mean duration of follow-up is 28 months for MP and 13 months for RP cases.

CONCLUSION

A reduced number of ports can be safely utilized for total splenectomy in pediatric patients without increasing procedural duration or need for intraoperative blood transfusion. In addition, rate of discharge on the first postoperative day was significantly higher in the RP splenectomy group.

Perioperative spleen embolization as a useful tool in laparoscopic splenectomy for simple and massive splenomegaly in children: a prospective study

OBJECTIVE

The purpose of this prospective study is to evaluate the efficiency of perioperative spleen embolization prior to laparoscopic splenectomy indicated for hypersplenism.

METHODS

We conducted a prospective study exploring a technique combining ultra-selective perioperative embolization and splenectomy. Between January 2008 and March 2013, 16 splenectomies were performed in children suffering from hypersplenism due to varying hematologic diseases. Spleen embolization was performed by an interventional radiologist in the operating room (OR) just before splenectomy and during the same general anesthesia. Ages varied from 3 to 17 years. Spleen volume was measured by preoperative ultrasound. One patient underwent a laparotomy because of suspected adhesions due to previous surgery. All other operations were performed laparoscopically.

RESULTS

One complication arose from embolization: a perforation of the splenic artery. After immediately placing a platinum coil proximal to the perforation, the splenectomy was carried out as usual. Fourteen children (87.5 %) had splenomegaly, of which eight (50 %) had massive splenomegaly. There were no deaths, no conversions to laparotomy, no reoperations and none of these patients had to be transfused.

CONCLUSIONS

Perioperative spleen embolization performed in the OR by an interventional radiologist makes laparoscopic splenectomy a safer procedure. We propose a preoperative method for spleen measurement that is adapted to children: simple and massive splenomegaly is defined through patient body weight and a preoperative ultrasound. We conclude that spleen size is no more a limiting factor for laparoscopic splenectomy in children.

Single-incision laparoscopic splenectomy

Background and Objectives:

The single-incision approach in laparoscopic surgery is a relatively new concept. This systematic review of the literature was performed to appraise the existing clinical evidence concerning the use of the single-incision technique for spleen resection.

Methods:

We performed a systematic search of the PubMed and Scopus databases, and the studies retrieved were included in our review. The references of the included studies were also hand searched.

Results:

Thirty-one relevant studies were found in the field including 81 patients with an age range from 0.6 to 90 years and a body mass index range from 18 to 36.7 kg/m². Splenomegaly (44.6%), idiopathic thrombocytopenic purpura (31%), and immune thrombocytopenic purpura (6.8%) were the most common indications for the procedure. Concerning the applied port system, multiple single ports (5 to 12 mm) were used in 54.4% of patients, the SILS port (Covidien, Mansfield, Massachusetts) was used in 26.6%, the TriPort (Advanced Surgical Concepts, Wicklow, Ireland) was used in 7.6%, glove ports were used in 6.3%, and the GelPort (Applied Medical, Rancho Santa Margarita, California) was used in 5.1%. The median operative time was 125 minutes (range, 45–420 minutes), and the median quantity of blood loss was 50 mL (range, 10–450 mL). No conversion to open surgery and no transfusion were needed. The length of hospital stay was between 1 and 9 days. Low rates of complications and no patient deaths were found. The existing evidence on cosmesis is limited.

Conclusion:

Single-site/single-port laparoscopic surgery is a minimally invasive procedure that seems to be a challenging alternative in the management of spleen resection.

Routine utilization of single-incision pediatric endosurgery (SIPES): a 5-year institutional experience

BACKGROUND

Single-incision pediatric endosurgery (SIPES) allows operation through one access site, eliminating the multiple sites traditionally used. There are few large series evaluating the versatility of SIPES. The purpose of this study is to review a 5-year single-institution experience with routine SIPES use.

PATIENTS AND METHODS

This is an Institutional Review Board-approved retrospective analysis of prospectively collected data. All SIPES cases from March 2009 to December 2013 were included. Our database contains demographics, procedure type, operative duration, estimated blood loss, instance of added ports or conversion to open, complications, and follow-up duration.

RESULTS

Of 1322 SIPES operations performed, most (82.1%) were appendectomies and cholecystectomies. Of 871 (66%) patients seen in follow-up, with a median duration of 26 days, 53 (6.1%) experienced postoperative complications. Forty-two cases (4.8%) were surgical-site infections, of which 4 required drainage. Less frequent complications that required operative intervention include recurrent inguinal hernia (n=4), umbilical hernia (n=3), intraabdominal abscess (n=1), bleeding (n=1), abdominal compartment syndrome (n=1), bowel obstruction (n=1), stitch granuloma (n=1), and persistent postoperative pain (n=1).

CONCLUSIONS

Operative times and complication rates are comparable to those in prior reported multiport laparoscopic series, allowing safe integration of SIPES into the routine of a surgical practice for most common procedures.

The international experience of single-incision pediatric endosurgery: current state of the art

PURPOSE

As application and awareness of single-incision pediatric endosurgery (SIPES) are increasing, various techniques and indications have been independently described by select centers around the world. In order to facilitate a cooperative approach toward advancing and investigating the practice of SIPES, we conducted a survey among members of the International Pediatric Endosurgery Group (IPEG), asking them about their experience and attitudes toward single-incision endosurgery.

MATERIALS AND METHODS

After institutional review board approval, an invitation to participate in an online survey was sent to all IPEG members. Questions focused on demographic information, practice patterns, indications, and equipment used regarding SIPES.

RESULTS

Of the 560 contacted active IPEG members, 115 completed the survey (recall 21%). The respondents represented pediatric surgeons from 32 countries on six continents. Of respondents, 97% had heard of, while 71% had performed, SIPES. Reasons for not having performed SIPES included disbelief in benefit (59%), lack of proficiency (34%), and inadequate resources (28%). The most commonly performed SIPES procedures were appendectomy (85%), cholecystectomy (66%), splenectomy (42%), pyloromyotomy (35%), and intestinal surgery (13%), as well as Nissen fundoplication and gynecologic adnexal pathology (7%). The equipment and techniques utilized showed large variation and included some self-devised, innovative, low-resource approaches. Complications with SIPES reported by the survey participants included technical difficulties, wound infection, and prolonged operating time.

CONCLUSIONS

SIPES is being performed worldwide for a large spectrum of common indications in pediatric surgery. The equipment and techniques used vary with geographic location and resources. Some encountered complications are common to those seen with conventional minimally invasive surgery, whereas others may be SIPES-specific. Different respondents reported diverging views on pain, operating time, and cost.