Single-incision pediatric endosurgery for ovarian pathology

Single port laparoscopic-assisted ovarian cystectomy using optical forceps in neonates: a brief technical report

Background

The management of neonatal ovarian cysts is often demanding. However, offering surgery as a definitive treatment for patients who lack easy access to healthcare for follow-up is reasonable. Minimally invasive, ovary-sparing surgery provides benefits, including shorter operative times, hospital stay, and superior cosmesis. The novel modification described here renders added value because it utilizes readily available and reusable instruments, averts the need for multiple ports and large incisions, and is essentially time-saving.

So, the aim of the study is to evaluate the safety and feasibility and describe the use of optical forceps during single-port laparoscopic-assisted (SPLA) ovarian cystectomy in a specific cohort of neonates with simple/complicated ovarian cysts.

Results

Neonates who required ovarian cystectomy/salpingo-oophorectomy, admitted from January 2015 to December 2019 and fulfilled the inclusion criteria, were treated with optical forceps during SPLA. After the surgery, we put in place a follow-up protocol to monitor complications and recurrences.

Twenty-one neonates were included. The average gestational age was 37.2 ± 1.6 weeks, operative time was 43.2 ± 2.4 min, and length of hospital stay was 2.4 ± 0.5 days. In our experiment, there was no encounter with complications, recurrences, or ones that required conversion to laparotomy, nor did we require the use of extra ports.

Conclusion

SPLA procedures using optical forceps for managing neonatal cysts requiring surgery appear to be a safe and achievable option by allowing complete visualization of the cyst/lesion. It also has an excellent cosmetic result with a near-normal umbilicus scar. Further research is required to compare this method to open and laparoscopic standards.

Ensuring safety and feasibility for resection of pediatric benign ovarian tumors by single-port robot-assisted laparoscopic surgery using the da Vinci Xi system

Background

Single-port robot-assisted laparoscopic surgery (S-RALS) is rarely applied in pediatric surgery. There is still no study on the application of S-RALS for resection of pediatric benign ovarian tumors. The current study aimed to investigate the safety and feasibility of S-RALS for resection of pediatric benign ovarian tumors using the da Vinci Xi system.

Methods

The clinical data of three patients who underwent S-RALS for resection of benign ovarian tumors in the Department of Pediatric Surgery, Zhongnan Hospital of Wuhan University from May 2020 to September 2021 were retrospectively analyzed. The mean age of these children was 7.9 years (5.8–9.3 years). One was a case of bilateral ovarian tumors, and the other two were cases of right ovarian tumors.

Results

All three patients successfully underwent the resection of ovarian tumors through S-RALS without conversion to laparotomy. The average operation time was 180 min (118–231 min). The average amount of blood loss was 20 ml (10–35 ml). No drainage tube was placed. All postoperative pathological types of ovarian tumors were mature cystic teratomas in the three cases. All patients started a liquid diet 2 h after surgery. The average length of postoperative hospital stay was 4.7 days (3–7 days). No tumor recurred, no surgical site hernia occurred, and the wound healed very well with a cosmetic scar in the lower umbilical crease during the postoperative follow-up for 6–18 months.

Conclusion

S-RALS has the advantages of less surgical trauma, quick postoperative recovery, and a cosmetic scar in the lower umbilical crease. It is safe, effective, and feasible for pediatric benign ovarian tumors.

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 laparoscopic surgery using the glove technique with improved maneuverability achieved through fulcrum creation via a simple ring technique

INTRODUCTION

Single-incision laparoscopic surgery (SILS) is widely used in many surgical procedures in various specialties. Among the access methods used in SILS, the glove technique, which is typically similar to the multi-trocar approach, is simple, convenient, and inexpensive. However, given the absence of a fulcrum supporting the endoscopic surgical forceps, the technique is less advantageous than methods using commercially available access devices because of the poor maneuverability of the forceps.

MATERIALS AND SURGICAL TECHNIQUE

By creating a fulcrum as a support to use with existing surgical forceps in the glove technique, we designed and used a novel method known as the "ring technique." This technique aimed to improve the maneuverability of endoscopic surgical forceps.

DISCUSSION

Placing a fulcrum resulted in the improvement of the forceps' maneuverability, which helped to ameliorate a weakness of the glove technique. The ring technique could be a useful option as a method of access in SILS.

Review of Laparoscopic Management of Mature Cystic Teratoma of Ovaries in Children

Ovarian cystic mature teratomas (OCMTs) are the most frequent ovarian tumors in childhood. This review aimed to determine the feasibility and safety of laparoscopic management of OCMT. Literature was searched for terms “mature,” “ovarian,” “teratomas,” and “laparoscopy.” Primary endpoints were age at surgery, laparoscopic and surgical technique, intraoperative complications, postoperative morbidity, and associated pathology. Literature search revealed 11 articles published between 1998 and 2014 that met the inclusion criteria. There were 105 (n = 95 unilateral; n = 10 bilateral) patients for this analysis, with mean age at surgery being 13 years. Four laparoscopic approaches were opted: gasless transumbilical laparoendoscopic single-site (LESS) surgery (n = 19), gasless multiport surgery (n = 24), single-incision laparoscopic surgery (SILS) (n = 3), and pneumoperitoneum multiport laparoscopy (n = 59). The 10 patients with bilateral OCMT underwent ovary-sparing surgery: LESS-assisted extracorporeal bilateral cystectomy in which tumors were punctured by a balloon catheter (n = 2), intracorporeal cystectomy for gasless multiport laparoscopy (n = 5) with use of endobags to prevent spillage, and transperitoneal multiport laparoscopy (n = 3). OCMT was associated with ipsilateral and unilateral ovarian torsion in five and bilateral ovarian torsion in one patient with bilateral OCMT. In four patients with unilateral OCMT, salpingo-oophorectomy was performed. Intraoperative complications were laceration of utero-ovarian ligament and bladder injury during a suprapubic port placement. The mean follow-up was 31.9 months. Patients with unilateral or bilateral OCMT can be offered ovarian-sparing surgery laparoscopically with one of the following techniques: LESS, SILS or multiport laparoscopy with pneumoperitoneal or gasless. Long-term follow-up of these techniques has shown no recurrence with low postoperative morbidity and low intraoperative complications.

Homemade Glove Port for Single-Incision Pediatric Endosurgery (SIPES) Appendectomy-How We Do It

Introduction  Single-incision pediatric endosurgery (SIPES) for the treatment of acute appendicitis in children has recently gained popularity due to its advantages including minimization of postoperative scars or less incisional pain. The principal disadvantages of SIPES include the limited degrees of freedom of movement and high health care costs. To overcome these issues, some surgeons have reported to use noncommercial ports for SIPES appendectomy.

Case Report  In this report, we present a case of a 10-year-old female patient with acute appendicitis undergoing SIPES appendectomy using own homemade glove port and straight rigid instruments.

Conclusion  SIPES appendectomy using the glove port is a low-cost alternative to commercially available port systems. It is easy to set up and use.

Ovarian torsion in children: Development of a predictive score

The aim of this study was to identify clinical signs and symptoms of ovarian torsion (OT) in children and to develop a simple predictive score.A chart review of patients with acute adnexal pathologies treated at the University Children's Hospital Basel, Switzerland, between March 2006 and June 2015 was performed. Medical records were screened for demographic and clinical data. These included clinical symptoms, laboratory studies, imaging, and type of treatment. The diagnosis OT was defined as intraoperative visualization of the torsed ovary around its pedicle at least 360 degrees. Variables predictive for OT were identified and the following score for the likelihood of having OT was developed: age (points = number of years) minus 3 points (if vomitus = "yes") and plus 1 point (if "pain duration >12 hours").A total of 80 patients with acute adnexal pathologies were identified. OT was recorded in 17 (21%) cases and ovarian cysts (OC) only in 63 (79%) cases. Patients who presented with OT were significantly younger than patients with OC only (P = .001). Correspondingly, 11 (65%) of the patients with OT had no menarche compared to 3 (5%) patients with OC only (P = .001). Vomiting (P = .001), a shorter pain duration (P = .01), and an elevated C-reactive protein (CRP) (P = .01) were observed significantly more often in patients with OT. The sensitivity of a positive OT score was 0.81 and increased to 1.00 if restricted to girls between 2 to 12 years of age.The presence of vomiting, short duration of abdominal pain, and elevated CRP level have a predictive value for the diagnosis of OT. In these patients, an exploratory laparoscopy should be conducted without delay. The presented OT score appears to be a helpful tool in diagnosing OT in children.

Pediatric oncologic endosurgery

Despite increasing popularity of minimal-invasive techniques in the pediatric population, their use in diagnosis and management of pediatric malignancy is still debated. Moreover, there is limited evidence to clarify this controversy due to low incidence of each individual type of pediatric tumor, huge diversity of the disease entity, heterogeneity of surgical technique, and lack of well-designed studies on pediatric oncologic minimal-invasive surgery. However, a rapid development of medical instruments and technologies accelerated the current trend toward less invasive surgery, including oncologic endosurgery. The aim of this article is to review current literatures about the application of the minimal-invasive approach for pediatric tumors and to give an overview of the current status, indications, individual techniques, and future perspectives.

[Giant paraovarian cyst in childhood - Case report]

INTRODUCTION

Paraovarian cysts are very uncommon in children

OBJECTIVE

To present a case of giant paraovarian cyst case in a child and its management using a modified laparoscopic-assisted technique

CASE REPORT

A 13-year-old patient with a 15 day-history of intermittent abdominal pain, located in the left hemiabdomen and associated with progressive increase in abdominal volume. Diagnostic imaging was inconclusive, describing a giant cystic formation that filled up the abdomen, but without specifying its origin. Laboratory tests and tumor markers were within normal range. Video-assisted transumbilical cystectomy, a modified laparoscopic procedure with diagnostic and therapeutic intent, was performed with a successful outcome. The histological study reported giant paraovarian cyst. Cytology results were negative for tumor cells. The patient remained asymptomatic during the postoperative follow-up.

CONCLUSIONS

The video-assisted transumbilical cystectomy is a safe procedure and an excellent diagnostic and therapeutic alternative for the treatment of giant paraovarian cysts.

Update on the surgical management of ovarian neoplasms in children and adolescents: analysis on 32 cases

This study analyzes updated clinical, diagnostic, and surgical directions for the treatment of ovarian neoplasms in children and adolescents, comparing them with a retrospective analysis of 32 cases treated in two Pediatric Surgery University Institutions. From January 2005 to December 2015, 32 pediatric patients were surgically treated for 32 ovarian tumors: 28 (87.5%) benign and 4 (12.5%) malignant neoplastic lesions. Median age at surgery was 11.2 years (12.8 years in patients with benign neoplasms, 7.25 years in patients with malignant ones). All patients with malignant and 25% of patients with benign ovarian lesions had elevated serum level of tumors markers. The surgical approach was laparotomic in 62.5% and laparoscopic in 37.5%; 81.2% surgeries were performed in elective surgery and 18.8% in emergency. Intraoperative frozen section analysis was performed in 18.75% of patients. The most frequent surgery (96.8%) was unilateral oophorectomy. After a median follow-up of 76 months (range 6-132 months), 31/32 patients are alive and disease-free. In case of malignant tumors, fertility-sparing surgery with accurate staging must be performed. Laparoscopic multiport is the gold standard approach for benign pediatric ovarian neoplasms, but the use of laparoscopy in full respect of oncological principles also for early stage malignant tumors is currently increased.

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.

The role of minimally invasive surgery in pediatric solid tumors

During recent years, minimally invasive surgery (MIS) has become the standard approach for various operations in infants and children. MIS in pediatric thoracic and abdominal tumors is a controversial approach in the surgical management of childhood cancer. Meanwhile, more and more oncological biopsies and resections are being performed laparoscopically or thoracoscopically. Despite its increasing role in pediatric tumor surgery, the different national and international multicenter trial groups have not yet implemented MIS within guidelines and recommendations in most of the current treatment protocols. An increasing number of retrospective reports describes a potential role of MIS in the management of different pediatric oncological entities. Over the time, there has been a diverse development of this approach with regard to the different neoplasms. Nevertheless, there is a lack of prospective randomized trails assessing MIS. This still represents a requirement for evidence-based medicine and judging the advantages and disadvantages of this approach. The purpose of this state-of-the-art article is to review the current literature to describe the application of MIS in pediatric solid tumors.

3-Dimensional (3D) laparoscopy improves operating time in small spaces without impact on hemodynamics and psychomental stress parameters of the surgeon

BACKGROUND AND PURPOSE

Three-dimensional (3D) imaging, a recent technical innovation in laparoscopic surgery, has been postulated to enhance depth perception and facilitate operations. However, it has never been evaluated in conditions where the focus is close to the optical system. Thus, it is unclear whether 3D cameras can improve laparoscopic surgical performance in neonates and infants. We tested 3D versus two-dimensional (2D) vision during laparoscopic surgery in rabbits, mimicking the size of a neonatal patient.

MATERIALS AND METHODS

Cadaver New Zealand white rabbits (mean weight 2,755 g) were operated by two surgeons experienced in 2D laparoscopic surgery and two surgical residents (with basic skills in 2D laparoscopy). All surgeons had never performed 3D laparoscopic surgery. Animals underwent six operations: Nissen fundoplication, small bowel anastomosis, and closure of a diaphragmatic defect using either 2D or 3D. Primary endpoint was cumulative operating time and operating time of each operation. Secondary endpoints included the hemodynamic response and psychomental stress level of the surgeons. Finally, subjective data on depth perception were assessed by questionnaires.

RESULTS

Cumulative operating time of all three types of operations was significantly shorter with 3D laparoscopy in experts (3D: 23.01 ± 5.65 min vs 2D: 29.51 ± 7.51 min, p < 0.01) and residents (3D: 27.95 ± 3.69 min vs 2D: 33.95 ± 6.21 min, p < 0.05). This effect could be shown for each operation in the expert group and the Nissen fundoplication in the resident group. There were no differences in the hemodynamic response as well as the psychomental stress level between 2D and 3D imaging. 3D provided better depth perception.

CONCLUSION

3D laparoscopy in small spaces is associated with a significant shorter operating time. It induces no additional physical or psychomental stress in surgeons naive to 3D imaging. 3D may therefore facilitate minimal invasive surgery in neonates and infants.

Minimal invasive surgery in the newborn: current status and evidence

The evolution of minimally invasive surgery (MIS) in the newborn has been delayed due to the limited working space and the unique physiology. With the development of smaller instruments and advanced surgical skills, many of the initial obstacles have been overcome. MIS is currently used in specialized centers around the world with excellent feasibility. Obvious advantages include better cosmesis, less trauma, and better postoperative musculoskeletal function, in particular after thoracic procedures. However, the aim of academic studies has shifted from proving feasibility to a critical evaluation of outcome. Prospective randomized trials and high-level evidence for the benefit of endoscopic surgery are still scarce. Questions to be answered in the upcoming years will therefore include both advantages and potential disadvantages of MIS, especially in neonates. This review summarizes recent developments of MIS in neonates and the evidence for its use.

Management of pediatric and adolescent adnexal masses by gasless laparoendoscopic single-site surgery

OBJECTIVE

To evaluate the safety and feasibility of gasless transumbilical laparoendoscopic single-site (LESS) surgery for the management of adnexal masses in pediatric and adolescent girls aged 19 years or younger.

STUDY DESIGN

Retrospective study of 28 pediatric and adolescent girls each undergoing gasless LESS surgery and gasless multiport laparoscopic surgery for adnexal masses. In each case, laparoscopic surgery was performed by the abdominal-wall lift method under endotracheal general anesthesia. The two groups were compared for their patient demographics and surgical outcome measures.

RESULTS

In the LESS surgery group, median age of the patients including three pre-menarcheal girls was 17.5 years. The most common symptom was abdominal pain. Median tumor diameter in the LESS surgery group was 7.4cm. There were no statistical differences in clinical features between LESS surgery and multiport laparoscopic surgery groups. In the LESS surgery group, adnexal masses were managed by unilateral cystectomy (n=20), unilateral salpingo-oophorectomy (n=5), bilateral cystectomy (n=2), and unilateral salpingectomy (n=1). Emergency LESS surgery was performed for seven cases due to adnexal torsion and one case due to cyst rupture. Preservation of affected ovary was not achieved in three emergency cases with adnexal torsion due to severe necrosis, and in one case each of recurrent mucinous cystadenoma and huge mucinous cystadenoma. In 24 adnexal masses from 22 girls who received adnexal cystectomy by LESS surgery, LESS-assisted extracorporeal cystectomy, was possible in 14 masses while intracorporeal cystectomy was required in other 10. In a case of dermoid cyst managed by LESS-assisted extracorporeal cystectomy, additional hemostasis was required by intracorporeal suturing due to laceration of utero-ovarian ligament. Median-excised tissue weight in the LESS surgery group was 111g. Significant differences between LESS surgery and multiport laparoscopic surgery groups were not noted in surgical outcomes and pathological diagnosis, except for significantly lower C-reactive protein value on postoperative day 3 in the LESS surgery group.

CONCLUSION

Gasless LESS surgery for pediatric and adolescent adnexal masses is a safe and feasible alternative to multiport laparoscopic surgery.

Single incision laparoscopic surgery for pediatric adnexal pathology

PURPOSE

Minimally invasive surgery is commonly used to treat gynecologic disease. Literature in the adult population supports that single incision laparoscopic surgery (SIL) is feasible and safe for the treatment of adnexal disease; however, there is little evidence for SIL in the pediatric population.

METHODS

A retrospective review of patients with gynecologic disease who underwent SIL from August 2009 to April 2012 was performed. All demographic data, clinical history, radiologic studies, indications for and type of operation, operative time and complications, and pathology were recorded.

RESULTS

Thirty-four patients with a mean age of 12.5 years (range 3.6-17.4 years) underwent SIL for adnexal pathology. Operative interventions included cystectomy (56%), salpingo oopherectomy (26.5%), detorsion (8.8%), adnexal biopsy (5.9%), and oophoropexy (2.9%). Forty-four percent of the patients also underwent appendectomy. The mean operative time was 42.8 minutes. There was 1 wound infection (2.9%) and 2 patients (5.9%) required additional ports.

CONCLUSIONS

Single incision laparoscopy provides a safe and effective approach to diagnostic laparoscopy with the ability to carry out operative interventions in multiple quadrants without adding additional ports. Single incision laparoscopy may be particularly effective in young women with abdominal pain requiring operative intervention.

Minimally invasive surgery in the management of abdominal tumors in children

The application of minimally invasive surgical techniques to pediatric abdominal tumors is a controversial application towards the surgical management of childhood cancer. Although general pediatric surgeons practice minimally invasive surgery techniques in a vast array of abdominal cases, its role in pediatric oncology is still developing, with no consensus in North America about its use for pediatric solid abdominal tumors. The purposes of this article are to review the current literature about the use of minimally invasive surgery in pediatric abdominal oncology and to examine established indications, procedures and technologic advances.

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.