Minimal access surgery in children - 5 years institutional experience

A Safe and Minimally Invasive Method for Thoracoscopic Lung Biopsy in Interstitial Lung Disease

Background: Interstitial lung disease (ILD) represents a spectrum of lung diseases that may contain different levels of fibrosis and inflammation. Sometimes, the clinical picture and imaging studies are insufficient to determine the diagnosis and lung biopsy becomes crucial, which may be performed in a thoracoscopic or open manner. The aim of this study was to present a new minimally invasive biopsy method that seems to be technically easy, safe, and inexpensive. Herein, we present a minimally invasive method for thoracoscopic lung biopsy using a Vicryl loop. Methods: The charts of patients with suspected ILD who underwent thoracoscopic lung biopsy using a Vicryl loop between 2007 and 2017 were analyzed retrospectively. Results: Nine patients were identified, four were boys and five were girls. The median age was 76 months. The mean weight of the patients was 10.9 kg. The mean chest tube removal time was 3.8 days. The mean surgical time was 37 minutes. There was an air leakage for 13 days in one child postoperatively. Conclusions: Thoracoscopic lung biopsy with a knot and scissors is an easily applicable and minimally invasive method that may be performed in children with suspected ILD.

Outcomes of laparoscopic resection of Meckel's diverticulum are equivalent to open laparotomy

PURPOSE

Meckel's diverticulum (MD) is a common congenital anomaly caused by failure of involution of the omphalomesenteric duct. Enthusiasm for minimally invasive surgery (MIS) in children has burgeoned as technologies have advanced, but the outcomes of laparoscopic resection in comparison to open laparotomy for MD remain poorly defined. We queried a large national database to compare current practice patterns and clinical outcomes between surgical approaches for MD in the pediatric population.

METHODS

The National Surgical Quality Improvement Program-Pediatric (NSQIP-Ped) database was queried for patients undergoing surgical intervention for MD (2011-2014). Patients were stratified by surgical approach. Baseline characteristics, intraoperative variables, and perioperative complications were compared by univariate analysis using Pearson's χ² test for categorical variables and Kruskall-Wallis test for continuous variables. Primary outcomes of interest were length of stay (LOS), rate of readmission, and 30-day mortality. Secondary outcomes included operative time, anesthesia time, postoperative complications, and rates of reoperation.

RESULTS

A total of 148 cases of MD were identified, of which 73 (49.3%) were initially managed with a laparoscopic approach and 75 (50.7%) were managed with an open approach. We found a high rate of conversion from laparoscopy to an open approach (20/73 or 27.4%). The median age of the laparoscopic group was higher than the open group (8.3 vs. 2.5years, p<0.001). Operative and anesthesia time, LOS, 30-day mortality, post-operative complications, and rates of reoperation and readmission were similar between groups (all p>0.05).

CONCLUSION

Nearly half of all resections for MD in children are now approached laparoscopically. This approach has equivalent outcomes to traditional open laparotomy. More widespread use of a hybrid approach with laparoscopy and exteriorization of the small bowel through an extended port site may facilitate avoiding open laparotomy. Routine conversion to open for palpation of the MD or segmental small bowel resection should be avoided in the absence of compelling intra-operative findings or operative complications.

LEVEL OF EVIDENCE

Level III (retrospective comparative study).

Chronic Pediatric Pain in Low- and Middle-Income Countries

Chronic pain is a serious health concern and potentially debilitating condition, leading to anxiety, depression, reduced productivity and functionality, and poor quality of life. This condition can be even more detrimental and incapacitating in the pediatric patient population. In low- and middle-income countries (LMICs), pain services are often inadequate or unavailable, leaving most of the world’s pediatric population with chronic pain untreated. Many of these children in LMICs are suffering without treatment, and often die in pain. Awareness and advocacy for this population must be prioritized. We reviewed the available literature on the chronic pediatric pain burden in LMICs, barriers to treatments, and current efforts to treat these patients.

First 100 laparoscopic surgeries in a predominantly rural Nigerian population: a template for future growth

BACKGROUND

Minimal access surgery has revolutionized surgery practice. Its proven advantages, such as reduced postoperative pain, early return to unrestricted activities, and better cosmesis, have become important drivers for its rapid development. In sub-Saharan Africa this development has been slow. The aim of the current study was to describe the challenges and outcomes of laparoscopic procedures in a public hospital that caters to a predominantly rural population.

MATERIAL AND METHODS

The first 100 patients who underwent laparoscopic procedure in the Department of Surgery at Federal Medical Centre, Owerri, Nigeria were retrospectively analyzed. Data were retrieved from the medical records department as well as the surgical theater procedure register. The focus of the study was on patient demographics, indication for surgery, procedure performed, length of hospital stay, and morbidity and mortality data. Staff training was done locally and abroad.

RESULTS

Altogether, 100 patients had laparoscopic surgery in our general surgery unit from September 2007 through July 2013. The ages of the patients was 5-75 years (median 36.5 years). The three main procedures were cholecystectomy (36 %), diagnostic laparoscopy (29 %), and appendectomy (21 %). The other operations performed included liver abscess drainage (7 %), adhesiolysis (3 %), hernia repair (1 %), and Heller's myotomy (1 %). Four cases were converted to open surgery. There were no deaths. There were 14 grades I and II postoperative complications in nine patients.

CONCLUSIONS

Our study suggests that basic laparoscopic procedures could be offered safely to our resource-poor rural population. It is a platform on which we can hopefully introduce advanced laparoscopic surgical operations.

Laparoscopic nephrectomy in children for benign conditions: indications and outcome

AIM

To analyze the indications and outcome of laparoscopic nephrectomy for benign non-functioning kidneys in children.

MATERIALS AND METHODS

The data of all patients operated over a 10 year period was retrospectively analyzed.

RESULTS

There were 56 children, aged 4 months to 12 years with a male: female ratio of 2.3:1. The most common presentation in boys and girls was urinary tract infection (UTI) (61.5% and 47.05% respectively). Incontinence due to ectopic ureter was a close second in girls (41.17%). The most common underlying conditions were vesico-ureteric reflux (42.85%) and multicystic dysplastic kidney (23.2%). There were 6 nephrectomies, 4 heminephroureterectomies and the remaining nephroureterectomies. All children tolerated the surgery well. One patient underwent a concomitant cholecystectomy. The post-operative problems encountered were UTI (1), urine retention (1), pyonephrosis in the opposite kidney and development of contra-lateral reflux (1). All others had resolution of pre-operative symptoms with good cosmesis.

CONCLUSIONS

As per available literature, this appears to be the largest Indian series of pediatric laparoscopic nephrectomies for benign non-functioning kidneys. Laparoscopic approach gives excellent results provided pre-operative investigations rule out other causes for the symptoms with which the patient presents. Often it is not the kidney but the dilated dysplastic ureter which is the seat of stasis and infection or pain and therefore should be completely removed.

Pediatric minimally invasive surgery: laparoscopy and thoracoscopy in infants and children

This article discusses the potential benefits and challenges of minimally invasive surgery for infants and small children, and discusses why pediatric minimally invasive surgery is not yet the surgical default or standard of care. Minimally invasive methods offer advantages such as smaller incisions, decreased risk of infection, greater surgical precision, decreased cost of care, reduced length of stay, and better clinical information. But none of these benefits comes without cost, and these costs, both monetary and risk-based, rise disproportionately with the declining size of the patient. In this review, we describe recent progress in minimally invasive surgery for infants and children. The evidence for the large benefits to the patient will be presented, as well as the considerable, sometimes surprising, mechanical and physiological challenges surgeons must manage.

Minimal access surgery in children:a 5 year study

Over a period of 5 years, we analyzed our data on outcome, feasibility, and safety of Minimal Access Surgery (MAS) in 211 children. The outcome was compared objectively with age matched controls with similar diagnosis undergoing open surgery over the same period. There was no significant difference between mortality, morbidity, re-exploration rates and analgesic requirement between MAS and open surgery. There was a significant difference in the length of stay in hospital, in favour of laparoscopic cholecystectomy, appendectomy, nephrectomy, splenectomy, surgery for intra-abdominal testis compared to open surgery but not for children undergoing surgery for appendicular perforation and intestinal pathology. All parents preferred the cosmetic outcome of minimal access surgery.

Laparoscopic assisted two port open appendicectomy

OBJECTIVES

The laparoscopic appendicectomy can be performed using one to several ports. We present our experience of two port laparoscopic assisted open appendicectomy. The objective was to assess the results retrospectively in terms of complications and its limitations.

METHODS

Between years 1998-2007, a two port laparoscopic assisted appendectomy was attempted in 2380 adult patients with suspected appendicitis. The patients with localized or generalized peritonitis were included. The appendicectomy was performed via an assisted two port method using 10 mm umbilical optical port and another 10 mm port in right iliac fossa. The children aged 12 and below and pregnant patients were excluded. All patients had their laparoscopic appendicectomy within 48 hours of admission.

RESULTS

Two port laparoscopic assisted appendicectomy was successful in 86.9% of cases. Acute appendicitis was the cause of acute abdomen in 88.9% of the patients. The accessory port was required in 8.5% of patients to complete the appendicectomy and the conversion rate to open was 4.6%. The mean operation time was 25 minutes and the mean hospital stay was 1.5 days. The port site infection was seen in 14, bleeding in 20, parietal wall abscess in three cases and intra-abdominal abscesses in 4 patients.

CONCLUSION

This approach is simple, can be converted to total intracorporeal by inserting accessory port or to open appendicectomy when required and has advantage of full laparoscopy of abdomen. It has its limitations in cases of extreme obesity, thick mesentery, gangrenous appendix, very large and thick appendix, and difficulty in finding the appendix, control of bleeding, division of adhesions and to deal with other associated pathology. Cost was minimized by using non-disposable port. The overall morbidity was low. There were no specific complications related to this technique and incidence of port site infection was similar to other approaches of laparoscopic appendicectomy.