Single-incision pediatric endosurgery: a systematic review

Single-Incision Pediatric Laparoscopic Surgery: Surgical Outcomes, Feasibility Indication, and the Systematic Review

Background: Single-incision laparoscopic surgery (SILs) has reported the evidence in basic and advanced pediatric laparoscopy. The objective was to review the feasibility and outcomes between basic and advanced procedures of the conventional laparoscopic surgery (CLs) and the SILs at our institute, and to compare the results with the published studies in a systematic review and meta-analysis. Patients and Methods: A retrospective study was conducted from January 2017 to March 2020. Demographic data, operations, conversion rate, and complications were collected and analyzed. The MEDLINE and PubMed were searched in relation to the pediatric SILs and the pediatric CLs in the published series from 1985 to 2021. We combined our retrospective study with a systematic review for meta-analysis. Results: Two hundred twenty-seven patients underwent pediatric laparoscopic surgery during the study period. The procedures included 199 (87.7%) for basic laparoscopy (appendectomy, cholecystectomy, testicular vessel ligation, closure of indirect inguinal hernia, and hydrocele) and 28 (13.3%) for advanced laparoscopy (Meckel diverticulectomy, pull-through operation for Hirschsprung's disease, choledochal cyst excision, and Nissen fundoplication). There was no statistical significance in operative time, length of stay (LOS), conversion rate, recurrence, and complication. The systematic review demonstrated 19 studies and, combined with our present study, produced 2865 patients for analysis. The meta-analysis reported increased LOS in the SILs group in cholecystectomy (mean difference [MD] 0.23 day, 95% confidence intervals [CI] 0.02-0.43 day, P = .03 and I² = 0%) and choledochal cyst excision (MD 0.18 day, 95% CI 0.02-0.33 day, P = .03 and I² = 0%). There was no statistical difference in operative time, LOS, conversion, and complication in other procedures. Conclusion: The SILs is a feasible indication and safe for surgical pediatric laparoscopy including basic to advanced procedure laparoscopy. It is demonstrated that there were no statistical differences in the operative time, LOS, and the complication. However, LOS in some procedures seems to be different due to the complexity and guideline.

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.

Single-Instrument Thoracic and Abdominal Surgery in Children: Minimizing Minimally Invasive Surgery

Introduction: The use of single-port surgery is widely accepted in pediatric surgery, but the majority of reports are on its use for appendectomy or inguinal hernia repair using multiple instruments. The aim of this report is to demonstrate that both thoracic and abdominal single-instrument procedures are feasible and safe in children. Materials and Methods: The following cases were managed in our department for the past 12 months. Two types of telescopes (10- and 5-mm) with inbuilt working channels were used in all cases. Results: The 10-mm endoscope with a 6-mm inbuilt channel was used to partially reduce and then exteriorize an intussusception secondary to Meckel's diverticulum in a 9-year-old boy, to reduce a left ovarian torsion in a 8 year-old girl, and to perform a thoracoscopic exploration and lung decortication in a 16 year-old girl with empyema. A 5-mm endoscope with a 3-mm working channel was used to perform bilateral 2-level thoracic sympathotomy in a 13-year-old girl with palmar primary hyperhidrosis. There were no perioperative complications and follow-up was uneventful in all patients. Conclusion: Minimally invasive surgery is well established at present. Thoracic and abdominal single-port single-instrument procedures are safe and effective in children. This is a unique report on single-port single-instrument use in four completely different procedures and the first to describe its usage for thoracoscopic sympathotomy in children. Increasing technology development, allied to surgeons' skills, is crucial to worldwide adoption of this surgical modality.

Single Incision Pediatric Endoscopic Surgery: From Myth to Reality a Case Series

Laparoscopic surgery has continued to evolve to minimize access sites and scars in both the adult and pediatric populations. In children, single-incision pediatric endoscopic surgery (SIPES) has been shown to be effective, feasible, and safe with comparative results to multiport equivalents. Thus, the use of SIPES continues over increasingly complex cases, however, conceptions of its efficacy continue to vary greatly. In the present case series and discussion, we review the history of SIPES techniques and its current application today. We present this in the setting of five common myths about SIPES techniques: limitations against complex cases, restrictions to specialized training, increased morbidity outcomes, increased operative lengths, and increased operative costs. Regarding the myth of SIPES being limited in application to simple cases, examples were highlighted throughout the literature in addition to the authors’ own experience with three complex cases including resection of a lymphatic malformation, splenectomy with cholecystectomy, and distal pancreatectomy with splenectomy. A review of SIPES learning curves shows equivalent operative outcomes to multiport learning curves and advancements towards practical workshops to increase trainee familiarity can help assuage these aptitudes. In assessing comorbidities, adult literature reveals a slight increase in incisional hernia rates, but this does not correlate with single-incision pediatric data. In experienced hands, operative SIPES times average approximate multiport laparoscopic equivalents. Finally, regarding expenses, SIPES represents an equivalent alternative to laparoscopic techniques.

Single-Incision Pediatric Endosurgery Cholecystectomy Performed by Residents in Children with Sickle Cell Disease

Introduction: Few centers worldwide have advanced single-incision pediatric endosurgery (SIPES) for pediatric age group. Up to our knowledge this is the first study assessing the safety of SIPES cholecystectomy in children with sickle cell disease (SCD) done by surgical residents. Aims: To determine the feasibility, safety, and expediency of SIPES cholecystectomy in children with SCD performed by surgical residents. Materials and Methods: Retrospective study of all SIPES cholecystectomies performed in our unit from April 1, 2011 to March 31, 2018. We compared the outcome of SIPES cholecystectomy done by fellows and residents. SIPES Covidien 5-12 mm port was inserted through umbilicus. Long 50 cm laparoscope, straight regular instruments, and transabdominal gallbladder traction suture were used in all patients. The cystic duct and artery were identified and divided. The gallbladder is then dissected off the liver and extracted from the abdomen through the port. Results: Forty-three SCD patients underwent SIPES cholecystectomy for 7 years. Mean HbS was 37.56%. Mean age was 10 years. Twenty-four cases (56%) and 19 (44%) were performed by 8 fellows and 10 residents, respectively. Nine other procedures were done simultaneously with cholecystectomy and were excluded from the mean operative time (MOT). The MOT for all cases was 85 minutes, 78 minutes for fellows and 94 minutes for residents (P value is <.001). One extra port was inserted in 2 patients at the beginning of the series. Conclusion: SIPES cholecystectomy in children with SCD is safe and feasible if done by residents under supervision. Stepwise training is essential in this challenging surgery. Involving residents with other SIPES procedures and hands-on minimally invasive surgery single port workshops help them in improving their skills.

Is It Safe for Trainees to Perform Single-Incision Pediatric Endosurgery Splenectomy?

INTRODUCTION

Few centers worldwide have advanced single-incision pediatric endosurgery (SIPES) splenectomy. The safety and feasibility of SIPES performed by trainees were not assessed before. SIPES splenectomy is a demanding technique that needs high level of skills. This is the largest series of 39 SIPES splenectomies performed by 14 trainees in one single center.

AIMS

To assess the safety, feasibility, and technical challenges of SIPES splenectomy performed by trainees and to compare it with other published series.

MATERIALS AND METHODS

Retrospective study of all patients operated with SIPES splenectomy for 7 years. SIPES port was inserted through 1.5 cm umbilical incision. One type of port and straight regular instruments were used in all cases.

RESULTS

Forty-nine patients underwent SIPES splenectomy. Eighty percent was done by our trainees. Six cholecystectomies were done simultaneously. Forty-five patients with sickle cell disease, two with thalassemia, one spherocytosis, and one Fanconi's anemia. Mean operative time (MOT) for splenectomy was 182 minutes (130-190) and 251 minutes for splenectomy with cholecystectomy (230-270) depending on severity of adhesions and size of the spleen; P value <.001. Two conversions have to be opened due to bleeding. There is neither wound infection nor incisional hernia up to date.

CONCLUSION

SIPES splenectomy is safe and feasible when performed by surgical trainees without adding any morbidity to the patient. Learning curve can quickly improve with more exposure of trainee to different SIPES procedures and hands-on workshops. More than one procedure could be done at the same time. It has excellent cosmesis and almost invisible scar.

A systematic review of the quality of conduct and reporting of systematic reviews and meta-analyses in paediatric surgery

OBJECTIVE

Our objective was to evaluate quality of conduct and reporting of published systematic reviews and meta-analyses in paediatric surgery. We also aimed to identify characteristics predictive of review quality.

BACKGROUND

Systematic reviews summarise evidence by combining sources, but are potentially prone to bias. To counter this, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was published to aid in reporting. Similarly, the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) measurement tool was designed to appraise methodology. The paediatric surgical literature has seen an increasing number of reviews over the past decade, but quality has not been evaluated.

METHODS

Adhering to PRISMA guidelines, we performed a systematic review with a priori design to identify systematic reviews and meta-analyses of interventions in paediatric surgery. From 01/2010 to 06/2016, we searched: MEDLINE, EMBASE, Cochrane, Centre for Reviews and Dissemination, Web of Science, Google Scholar, reference lists and journals. Two reviewers independently selected studies and extracted data. We assessed conduct and reporting using AMSTAR and PRISMA. Scores were calculated as the sum of reported items. We also extracted author, journal and article characteristics, and used them in exploratory analysis to determine which variables predict quality.

RESULTS

112 articles fulfilled eligibility criteria (53 systematic reviews; 59 meta-analyses). Overall, 68% AMSTAR and 56.8% PRISMA items were reported adequately. Poorest scores were identified with regards a priori design, inclusion of structured summaries, including the grey literature, citing excluded articles and evaluating bias. 13 reviews were pre-registered and 6 in PRISMA-endorsing journals. The following predicted quality in univariate analysis:, word count, Cochrane review, journal h-index, impact factor, journal endorses PRISMA, PRISMA adherence suggested in author guidance, article mentions PRISMA, review includes comparison of interventions and review registration. The latter three variables were significant in multivariate regression.

CONCLUSIONS

There are gaps in the conduct and reporting of systematic reviews in paediatric surgery. More endorsement by journals of the PRISMA guideline may improve review quality, and the dissemination of reliable evidence to paediatric clinicians.

Early Experience with Single-Incision Laparoscopic Total Abdominal Colectomy in Children

PURPOSE

Single-incision laparoscopic surgery for pediatric colorectal disease has been shown to be feasible and safe; however, the literature is scarce regarding the outcomes of single-incision laparoscopic total abdominal colectomy (SIL-TAC) in the pediatric population. The purpose of this pilot study was to review our initial experience and outcomes with SIL-TAC.

MATERIALS AND METHODS

A retrospective review of patients who underwent SIL-TAC from 2013 to 2015 was performed. General demographic and outcome data were analyzed.

RESULTS

Five patients were included. Indications included ulcerative colitis (n = 4) and colonic dysmotility (n = 1). The median age was 13.5 years (8.5-19.4 years) and the median body mass index (BMI) percentile was 77.4 (2.2-98). The median operative time was 182 minutes (163-244 minutes). One case was converted to an open procedure. The median postoperative self-reported pain score was 2.8 (1.2-4.5). The median time until initiation of a diet was 2 days (1-8 days). The median length of hospital stay was 5 days (3-11 days). There were no 30-day complications.

CONCLUSION

SIL-TAC is feasible and safe in children and offers improved cosmesis.

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.

Single-incision laparoscopic appendectomy using homemade glove port at low cost

PURPOSE:

The aim of this study was to report homemade glove port technique for single-incision laparoscopic appendectomy (SILA).

MATERIALS AND METHODS:

Our homemade glove port was composed of a size 6 latex sterile surgical glove, a sterilized plastic bangle, and three pieces of silicon tube (5 cm in length) that were used as the suction tube. Clinical data were retrospectively collected from those patients who underwent SILA at Bucheon St. Mary's Hospital, Bucheon, Gyeonggi-do, South Korea between February 2014 and June 2014, including patient demographics, and operative and postoperative outcomes. To compare the outcomes, a retrospective review was performed for those patients who underwent conventional laparoscopic appendectomy (CLA) between October 2013 and January 2014. Both SILA and CLA were performed by the same surgical team.

RESULTS:

The SILA and CLA groups included 37 and 57 patients, respectively. The mean age, weight, body mass index (BMI), operation time, and pathologic diagnosis of gangrenous appendicitis were not significantly different between the two groups. However, the mean hospital stay in the CLA group was significantly (P = 0.018) longer than that in the SILA group (4.2 days vs 3.5 days). There was no conversion to open surgery in both the groups. Of the cases who underwent SILA, 10 (27.0%) needed insertion of additional port and drain. There was one (3.2%) complication of umbilical surgical site infection.

CONCLUSION:

In this study, SILA, with homemade glove port, was technically feasible and safe at low cost.

Laparoendoscopic single-site surgery (LESS) for major urological procedures in the pediatric population: A systematic review

BACKGROUND

Improvements in laparoscopic surgery have led to the introduction of laparoendoscopic single-site surgery (LESS) as an alternative to conventional laparoscopy conferring a number of possible advantages. In this review, we aim to elucidate the aspects of LESS for major urological procedures in the pediatric population.

MATERIALS AND METHODS

An in-depth search of the literature was performed in the databases of PubMed and Scopus, for studies investigating the technical aspects and clinical outcomes of partial nephrectomies, nephrectomies, nephroureterectomies, varicocelectomies and pyeloplasties in children. Data on parameters such as operation time, instrumentation, perioperative complications, hospital stay and follow up period were collected and further analyzed cumulatively.

RESULTS

Twenty nine studies met the inclusion criteria incorporating 386 patients who underwent 401 procedures. There were no major intraoperative complications, with only 19 patients (4.73%) facing postoperative complications. No perioperative deaths were reported.

CONCLUSIONS

In the hands of experienced surgeons LESS seems a feasible, efficient and less invasive alternative to standard laparoscopy in the field of pediatric urology. There is an eminent need of well-designed randomized controlled trials comparing the two techniques.

Congenital anomaly rectified at birth: one-stage single-incision laparoscopic-assisted anorectoplasty for newborns with anorectal malformations and recto-urethral fistula

OBJECTIVE

Currently, staged procedures involving stoma formation and closure are the widely accepted treatment for newborns suffering from anorectal malformations (ARM) with recto-urethral fistula. This study aims to evaluate the safety and efficacy of one-stage single-incision laparoscopic-assisted anorectoplasty (SILAARP) as an alternative to the conventional approach.

METHODS

Newborns with ARMs and recto-urethral fistula who underwent one-stage SILAARP between June 2013 and December 2014 were reviewed. The procedure involved decompression of the meconium via a small temporary incision of the proximal sigmoid colon followed by a laparoscopic-assisted pull-through.

RESULTS

Sixteen ARM newborns [recto-prostatic fistula (6), recto-bulbar fistula (10)] successfully underwent a one-stage SILAARP. The mean age of the neonates at operation was 42.1 h. The average operative time was 2.4 h. The actual pull-through took 1.7 h, which did not differ significantly from 1.9 h in the pull-through procedure of our three-stage SILAARP control group. The median follow-up period was 16 months (8-26 months). No complications were encountered. Postoperative pelvic magnetic resonance imaging verified the centrally placed rectum within the muscle complex. Most patients started having bowel movements on postoperative day 1. Two constipated patients periodically required an enema for 1-3 months.

CONCLUSIONS

One-stage SILAARP is safe and effective. It provides complete rectification of ARM with recto-urethral fistula immediately after birth with good cosmesis.

Laparoscopic esophagomyotomy for achalasia in children: A review

Esophageal achalasia in children is rare but ultimately requires endoscopic or surgical treatment. Historically, Heller esophagomyotomy has been recommended as the treatment of choice. The refinement of minimally invasive techniques has shifted the trend of treatment toward laparoscopic Heller myotomy (LHM) in adults and children with achalasia. A review of the available literature on LHM performed in patients < 18 years of age was conducted. The pediatric LHM experience is limited to one multi-institutional and several single-institutional retrospective studies. Available data suggest that LHM is safe and effective. There is a paucity of evidence on the need for and superiority of concurrent antireflux procedures. In addition, a more complete portrayal of complications and long-term (> 5 years) outcomes is needed. Due to the infrequency of achalasia in children, these characteristics are unlikely to be defined without collaboration between multiple pediatric surgery centers. The introduction of peroral endoscopic myotomy and single-incision techniques, continue the trend of innovative approaches that may eventually become the standard of care.

Single port laparoscopic orchidopexy in children using surgical glove port and conventional rigid instruments

PURPOSE

We review the literature and describe our technique for laparoendoscopic single-site orchidopexy using a glove port and rigid instruments. We assessed the feasibility and outcomes of this procedure.

MATERIALS AND METHODS

We retrospectively reviewed the case records of all children who had undergone laparoendoscopic single-site orchidopexy by use of a surgical glove port and conventional rigid instruments for a nonpalpable intraabdominal testis between January 2013 and September 2014.

RESULTS

Data from a total of 20 patients were collected. The patients' mean age was 18 months. All cases had a nonpalpable unilateral undescended testis. Fourteen patients (70%) had an undescended testis on the right side and six patients (30%) had an undescended testis on the left side. Seventeen patients underwent primary orchidopexy. Three patients underwent single-port laparoscopic Fowler-Stephens orchidopexy for the first and the second stage. Average operating time was 57 minutes (range, 40 to 80 minutes). No patient was lost to follow-up. At follow-up, 2 testes were found to have retracted out of the scrotum and these were successfully dealt with in a second operation. One testis was hypoplastic in the scrotal pouch. There were no signs of umbilical hernia.

CONCLUSIONS

Single-port laparoscopic orchidopexy using a glove port and rigid instruments is technically feasible and safe for various nonpalpable intraabdominal testes. However, surgical experience and long-term follow-up are needed to confirm the superiority of this technique.

Single-incision pediatric endosurgery in newborns and infants

This study focuses on the successful application of single-incision pediatric endosurgery in the treatment of congenital anomalies and acquired diseases in neonates and infants. The purpose of this scientific review consists in highlighting the spectrum, indications, applicability, and effectiveness of single-port endosurgery in children during the first 3 postnatal months.

Validation of a pediatric single-port laparoscopic surgery simulator

BACKGROUND

This study aims to adapt an existing multiport pediatric laparoscopic surgery simulator to be suitable for pediatric single-port laparoscopy and to investigate construct validity for its use as a resource for skills training and assessment.

METHODS

An existing pediatric-sized box trainer was modified to accommodate a commercially available port. A total of 41 participants (18 novices, 16 intermediates and 7 experts) were recruited to complete four curriculum tasks via a single-port access approach. Objective task performance scores were evaluated.

RESULTS

Task completion times and performance scores were significantly different between novices and experts for the peg transfer (P = 0.02, P = 0.008 respectively), pattern cut (P < 0.001, P < 0.001 respectively) and ligating loop (P = 0.038, P = 0.035 respectively). There were significant differences in outcomes between novices and intermediates for all tasks, including the intracorporeal suture task (P ≤ 0.001). There were no significant differences in outcomes between intermediates and experts for all tasks.

CONCLUSIONS

The Pediatric Laparoscopic Surgery (PLS) simulator can be easily adapted for single-port laparoscopic surgery to be construct valid for the peg transfer, ligating loop and pattern cut tasks. There is scope for additional tasks to be developed that focus on the unique technical challenges and skills associated with single-port techniques.

Impact of experience on quality outcomes in single-incision laparoscopy for simple and complex appendicitis in children

BACKGROUND

Single-incision laparoscopic appendectomy (SILA) is an effective treatment for appendicitis in children. We report our experience with SILA, focusing on how surgeon experience may impact quality outcomes.

METHODS

A retrospective review of patients who underwent SILA from August 2009 to November 2013 was performed. Patients were grouped by early experience, late experience without surgical trainees, and late experience with trainees and further stratified into simple and complex appendicitis.

RESULTS

SILA was performed on 703 patients with a mean age of 11.8±3.9years. Four hundred eleven (58.5%) patients were diagnosed with simple and 292 (41.5%) with complex appendicitis. There was a significant decrease in operative time between early and late groups for both simple and complex appendicitis. Following the introduction of surgical trainees, there was a significant increase in operative time compared to the late group for simple appendicitis. There were no significant differences in complication rates between any of the groups.

CONCLUSION

The adoption of SILA requires a significant learning curve even for the experienced laparoscopist with the potential for decreased operative times with experience. While there may be an increase in operative time with the introduction of trainees, this does not impact quality outcomes.

Single-port laparoscopic surgery in children: A new alternative in developing countries

BACKGROUND

Single-incision laparoscopic surgery (SILS) is a technique in laparoscopic surgery, which is based on the idea that all the laparoscopic trocars are inserted through a single umbilical incision. This paper documents a single-centre experience, which performed the single-port surgery in children using an improvised trans-umbilical glove-port with conventional rigid instruments.

MATERIALS AND METHODS

We prospectively studied the outcomes of SILS procedures between January 2013 and June 2014. Materials required making our homemade trans-umbilical port consisted on: A flexible ring, a rigid larger ring, one powder-free surgical glove, a wire-to-skin and standard standards laparoscopic trocars.

RESULTS

A total of 90 consecutive procedures had been done in our institution: 15 girls and 75 boys (mean age: 7.5 years). We used SILS on 59 appendectomies with an average operative time of 48 minutes. We needed conversion to conventional surgery in three cases (two with perforated appendicitis and one for difficulty to mobilize the appendix). SIL cholecystectomy was performed for four patients with symptomatic cholelithiasis; mean operative time was 60 min. All patients were discharged on postoperative day 2. Eighteen boys with non-palpable testis were explored and treated. Other procedures included: Varicocelectomy (n = 2), intra-abdominal lymph node biopsies (n = 2), ovarian cystectomy (n = 1), ovarian transposition (n = 1), aspiration of renal hydatid cyst (n = 1), explorative laparoscopy in research to Meckel's diverticulum (n = 1) and intestinal intussusceptions (n = 1). No post-operative complications were seen in all cases.

CONCLUSIONS

SILS in the paediatric population using conventional rigid instruments is feasible, safe and effective. It may be an alternative to the costly commercially available single-port systems especially in a developing country like Tunisia.

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.

Single-incision laparoscopic-assisted anorectoplasty using conventional instruments for children with anorectal malformations and rectourethral or rectovesical fistula

BACKGROUND

This study aims to evaluate the safety and efficacy of single-incision laparoscopic-assisted anorectoplasty (SILAARP) for children with anorectal malformations (ARM) and rectourethral or rectovesical fistula.

METHODS

Children with ARMs and rectourethral or rectovesical fistula who underwent SILAARP between May 2011 and December 2012 were reviewed. The operative time, early postoperative and follow-up results were analyzed.

RESULTS

Thirty-one patients (ARM with rectovesical vs. rectoprostatic fistula vs. rectobulbar fistula: 9/6/16) successfully underwent SILAARPs without conversions. Mean ages at operation were similar in 2 groups (ARM with rectovesical or rectoprostatic fistula vs. ARM with rectobulbar fistula: 4.94 months vs. 5.67 months, p=0.46). Average operative time in ARM children with rectobulbar fistula was 1.94 hours, which did not differ from 1.78 hours in ARM children with rectovestical or rectoprostatic fistula (p=0.39). All patients resumed feeding on postoperative day 1. The median follow-up period was 20 months. No injuries of vessels, urethral or vas deferens occurred in operations. No mortality or morbidities of wound infection, rectal retraction, recurrent fistula, urethral diverticulum, anal stenosis, or rectal prolapse was encountered.

CONCLUSIONS

SILAARP is safe, feasible and effective for ARM with rectourethral or rectovesical fistula. One-stage SILAARP may offer a viable alternative treatment for ARM children with rectourethral or rectovesical fistula.

Single port laparoscopic appendectomy in children using glove port and conventional rigid instruments

PURPOSE

To further improve the advantages of minimally invasive surgery, single port laparoscopic techniques continue to be developed. We report our initial experience with single port laparoscopic appendectomy (SPLA) in children and compare its outcomes to those of conventional laparoscopic appendectomy (CLA).

METHODS

Clinical data were prospectively collected for SPLA cases performed at Chung-Ang University Hospital by a single surgeon between March 2011 and December 2011, including operative time, perioperative complications, conversion rate, and length of hospital stay. Each case of SPLA was performed using conventional laparoscopic instruments through Glove port placed into the single umbilical incision. To compare outcomes, a retrospective review was performed for those patients who underwent CLA between March 2010 and December 2010.

RESULTS

Thirty-one patients underwent SPLA and 114 patients underwent CLA. Mean age (10.5 years vs. 11.1 years, P = 0.43), weight (48.2 kg vs. 42.9 kg, P = 0.27), and operation time (41.8 minutes vs. 37.9 minutes, P = 0.190) were comparable between both groups. Mean hospital stay was longer for CLA group (2.6 days vs. 3.7 days, P = 0.013). There was no conversion to conventional laparoscopic surgery in SPLA group. In CLA group, there were nine complications (7.9%) with 3 cases of postoperative ileuses and 6 cases wound problems. There was one complication (3.2%) of umbilical surgical site infection in SPLA group (P = 0.325).

CONCLUSION

The results of this study demonstrated that SPLA using conventional laparoscopic instruments is technically feasible and safe in children. SPLA using conventional laparoscopic instruments might be popularized by eliminating the need for specially designed instruments.

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.