Pediatric Endosurgery & Innovative TechniquesVol. 8, No. 3 Literature Review and CommentTrials or Tribulations?Hanmin Lee and Craig T. AlbaneseHanmin LeeSearch for more papers by this author and Craig T. AlbaneseSearch for more papers by this authorPublished Online:30 Sep 2004https://doi.org/10.1089/pei.2004.8.227AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail "Trials or Tribulations?." , 8(3), p. 227FiguresReferencesRelatedDetails Volume 8Issue 3Sep 2004 InformationCopyright 2004, Mary Ann Liebert, Inc.To cite this article:Hanmin Lee and Craig T. Albanese.Trials or Tribulations?.Pediatric Endosurgery & Innovative Techniques.Sep 2004.227-227.http://doi.org/10.1089/pei.2004.8.227Published in Volume: 8 Issue 3: September 30, 2004PDF download
Achalasia is an uncommon pediatric disease. An association with a benign esophageal stenosis is even rarer. We report this interesting case of a 9-year-old with concomitant achalasia and benign esophageal stenosis. Diagnosis was based on radiologic, endoscopic, and operative findings. The patient was successfully treated with laparoscopic Heller's esophagocardiomyotomy and Watson's fundoplication. Details of this unique case and operative technique are highlighted.
Purpose: Traditionally, a thoracotomy, thoracolumbar, or flank incision has been utilized for exposure to the thoracolumbar spine for anterior release, diskectomy, and fusion (RDF) for correction of significant scoliosis or kyphosis. Following the anterior procedure, posterior fusion and instrumentation have been performed through a long posterior midline incision.Methods: This is a retrospective study of a single institution's experience with the first 50 patients undergoing thoracoscopy and retroperitoneoscopy for correction of their spinal anomalies.Results: The first 50 patients underwent 51 operations between 1995 and 1999. The patients ranged in age from 2 to 21 years (mean, 14.3 years) and 32 were female. Forty-three operations involved thoracoscopic RDF and three additional operations occurred primarily in the retroperitoneum. Each of these was followed by open posterior fusion and instrumentation except in the seven young patients with congenital hemivertebrae. In five additional operations, ante...
Introduction: Laparoscopy is being used for assistance in ventriculoperitoneal (VP) shunt placement. We have found it especially useful to guide distal catheter placement in children who have had multiple VP shunt revisions and previous abdominal surgery. We therefore reviewed our experience utilizing laparoscopy for VP shunt placement over the past year. Methods: We conducted a retrospective review of all children undergoing laparoscopy for VP shunt who have had previous abdominal surgery. Results: Nine children underwent 11 laparoscopic procedures for VP shunt placement. All children had undergone multiple abdominal procedures, and all had previously undergone open VP shunt placement. The mean age of all children undergoing laparoscopy was 11.4 years. Shunt infection (in 6 children) and shunt malfunction (in 5 children) were the reasons for VP shunt revision. A single 3-mm port was used in 9 of 11 procedures. All children had adhesions visualized, 2 required adhesiolysis, and in one VP shunt was not possible. The mean operative time was 90.6 minutes. There were no complications directly related to laparoscopy. Postoperative length of stay was 3.5 days. Four patients have not needed another revision (mean, 243 days), while 4 patients (6 cases) have needed subsequent revision (mean, 32 days). Conclusion: Laparoscopy can be safely performed in children requiring VP shunt revision who have undergone previous abdominal surgery. It facilitates successful minimally invasive placement of VP shunts in these children, who otherwise would require a more extensive procedure.
We report the first successful laparoscopic segmentary splenectomy for a spleen neoplasm in pediatrics. Splenic hemangioma is a rare disorder, but remains the most common benign neoplasm of the spleen. The diagnosis is most often made after histological findings of a resected solid spleen tumor. A 2-year-old male presented with recurrent abdominal pain. Ultrasonography and CT showed a hypoechogenic mass involving the spleen pedicle. A laparoscopic approach showed a solid tumor in the lower pole of the spleen extending up to the main vessels. We used four ports: an umbilical 10 mm port for the lens; one in the left lower quadrant 5 mm for the surgeon's right hand; one epigastric 5 mm for retraction and suction; and one 5 mm in the midline, between the umbilicus and the epigastric port, for the surgeon's left hand. The bipolar vessel sealing system was used successfully as the primary method for vessel occlusion. Approaching the upper border of the tumor, we found a splenic upper pole vascular pedicle which was preserved. Transection of the splenic tissue was completed using a monopolar hook and the bipolar vessel-sealing device, following signs of ischemia on the surface of the spleen. The resected spleen was extracted in a bag through a small Pffannestiel incision. Operative time was 75 minutes. The patient was discharged on postoperative day 2. Histologic exam showed a capillary hemangioma. Doppler ultrasound indicates blood supply has been preserved to the residual spleen at 5 months followup. This is the second splenic solid tumor treated by laparoscopy in our institution, and the first successfully resected, preserving splenic tissue. The type of vascular supply and the use of the bipolar system device made a safe and bloodless segmentary splenectomy possible.
Pediatric Endosurgery & Innovative TechniquesVol. 8, No. 2 Literature Review and CommentSealing Your FateCraig T. AlbaneseCraig T. AlbaneseSearch for more papers by this authorPublished Online:30 Jul 2004https://doi.org/10.1089/1092641041360896AboutSectionsPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail "Sealing Your Fate." , 8(2), pp. 81–82FiguresReferencesRelatedDetails Volume 8Issue 2Jun 2004 Information© 2004 Mary Ann Liebert, Inc.To cite this article:Craig T. Albanese.Sealing Your Fate.Pediatric Endosurgery & Innovative Techniques.Jun 2004.81-82.http://doi.org/10.1089/1092641041360896Published in Volume: 8 Issue 2: July 30, 2004PDF download
At the April 2000 International Pediatric Endosurgery Group (IPEG) meeting we presented the first patient to undergo laparoscopic sigmoid vaginal replacement. Here we update our experience with this procedure in 14 consecutive patients. The mean age of our patients was 16.3 years. Eleven patients had Mayer Rokitansky syndrome and 3 were male pseudohermaphrodites. A total of 4 ports was used: a 10 mm umbilical port, a 12 mm port in the right lower quadrant, and two 5 mm ports (left lower quadrant and hypogastric). The lens was initially introduced through the umbilical port and afterwards inserted through the right lower quadrant port in order to achieve a better visualization of the vascularization of the sigmoid. After isolating a segment of the sigmoid using endoclips, bipolar or ultrasonic devices, and two endostaplers, we undertook a perineal dissection, creating a space between the urethra and the rectum under laparoscopic vision. Colo-colonic anastomosis was achieved using a circular mechanical suture through the rectum and taking outwards the proximal end of the colon through the umbilicus. Both the joining and stapling were done under laparoscopic control. The peritoneum near the pouch of Douglas was incised in order to allow the passage of a forceps from the perineum to enable the descent of the isolated bowel. Mean operative time was 3.5 hours. There were no intra- or postoperative complications except for one accidental opening of the bladder, which was sutured laparoscopically. All patients were able to tolerate food after 24 hours and 11 were discharged 48 hours after the operation. Viability and patency of the neovagina are excellent after a mean follow-up of 6 months (range, 4–36 months), and 5 patients are sexually active.
Laparoscopic management of the intra-abdominal testis (IAT) typically involves division of the gubernaculum and passage of the mobilized IAT into the scrotum through the floor of the inguinal canal. However, this approach transects potentially vital gubernacular collaterals and may predispose patients to future direct inguinal hernias. We therefore present our experience with a modified two-stage laparoscopic orchidopexy (TSLO) with gubernacular preservation. The TSLO involved an initial testicular vessel transection 2–3 cm proximal to the testis. A few months later, the testis was mobilized laparoscopically with an adjacent peritoneal flap preserving collaterals between the vas and the testicular hilum. Gubernacular collaterals were preserved and the testis delivered through the internal ring and inguinal canal via a standard inguinal incision. Fourteen patients (with 17 IAT) underwent first stage testicular vessel ligation. Thirteen patients (mean age, 2.9 years) with 15 IAT have completed TSLO (mean, 6.5 months after first procedure). Of these 15 TSLO with mean followup of 6 months, 14 were found in the scrotum. One was found at the external ring. By palpation, all testes were viable. TSLO with gubernacular preservation is a reliable means with which to bring an IAT into the scrotum.
Objective: This study presents the clinical outcome of laparoscopic Nissen fundoplication in neurologically impaired children with severe and resistant gastroesophageal reflux (GER). Patients and Methods: Forty-two neurologically impaired children who had failed medical treatment for severe GER underwent laparoscopic Nissen fundoplication. Indications for surgery included feeding difficulty in all, emesis in 16, respiratory symptoms in 9, and mixed emesis and respiratory symptoms in 13. Thirty-six patients (86%) were profoundly impaired with cerebral palsy and 19 (45%) had severe scoliosis. The laparoscopic procedure was performed using a five-trocar technique with 5-mm instruments. Results: Two children required conversion to open procedure. The remaining 40 children underwent laparoscopic procedures without intraoperative complications. There was no operative mortality. Although early morbidity was high (30%), most of the complications were relieved within a few months. All patients with emesis had improved clinically and were free of vomiting, whereas only 5 of 9 patients (56%) with respiratory symptoms improved postoperatively. Three children (7%) with recurrent reflux underwent open redo fundoplication. To date, 8 children (19%) have died. Five died of respiratory disease and 3 died of their background condition. Conclusions: Our results suggest that the outcomes of laparoscopic Nissen fundoplication in neurologically impaired children compare favorably with those of the open procedure. Because of the high incidence of late death in patients with persistent respiratory symptoms, prophylactic airway management should be considered to reduce long-term mortality.
Purpose: Repair of recurrent tracheoesophageal fistula (RTEF) can be a technically challenging problem. Various forms of endoscopic treatment of RTEF have been described. The exact role of endoscopic treatment in the management of RTEF remains unestablished. This study describes the long-term clinical outcome of patients who have undergone endoscopic diathermy coagulation (EDC) of RTEF. Materials and methods: EDC of RTEF was performed in seven patients by a single surgeon between 1993 and 1999. In the first 3 patients, EDC was performed because formal thoracotomy was either considered too risky or had been unsuccessful. In the last 4 cases, however, it was used as the procedure of choice. EDC was performed by applying a standard coagulation current to the tracheal end of the RTEF. The exposed tip of the metal stent of a 3F ureteric catheter was positioned at the mouth of the fistula via a rigid bronchoscope. Sufficient current was applied to the proximal end of the stent to cause coagulation of the mucosa, and coaptation of the margins of the tracheal end of the RTEF. Results: The mean followup period has been 4.42 years (16 months to 8 years). One patient has been lost to follow up. Thirteen EDC procedures have been performed on the remaining 6 patients with RTEF. Five out of these 6 patients have been successfully managed with EDC. Three patients have been managed solely with EDC. Thoracotomy for failure to control symptoms with EDC has so far been required in only one patient. Four out of the 5 cases successfully managed with EDC required more than one attempt (maximum number of attempts, 3). Conclusions: EDC is technically simple to perform and tolerated easily (requiring only an overnight stay in hospital). It is safe, can be repeated without added risk, and does not require expensive equipment. Therefore EDC should be considered as an option in all cases of RTEF.
Pediatric Endosurgery & Innovative TechniquesVol. 8, No. 1 Literature Review and CommentFrom Stick Figures to da Vinci?Craig T. AlbaneseCraig T. AlbaneseSearch for more papers by this authorPublished Online:8 Jul 2004https://doi.org/10.1089/109264104773513188AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail "From Stick Figures to da Vinci?." , 8(1), p. 75FiguresReferencesRelatedDetails Volume 8Issue 1Mar 2004 To cite this article:Craig T. Albanese.From Stick Figures to da Vinci?.Pediatric Endosurgery & Innovative Techniques.Mar 2004.75-75.http://doi.org/10.1089/109264104773513188Published in Volume: 8 Issue 1: July 8, 2004PDF download
Background: During thoracoscopy, chest tubes can be placed via thoracoscopy ports with relative ease. In contrast, chest tube placement in an awake child can be a traumatic event both for the operator as well as the patient. This report describes a method of tube thoracostomy utilizing a minimally invasive technique at the bedside. Patients and Methods: After performing thoracoscopic chest tube placement on multiple patients under general anesthesia, a similar technique was used at the bedside utilizing the Step trocar system for tube thoracostomy (STEP-TT). Thirty children and infants from 1 month to 15 years of age required thoracostomy; 8 pneumothoraces, 15 pleural effusions, 3 traumatic hemopneumothoraces, 2 chylothoraces, one pneumatocele, and one arrest resuscitation. After administration of sedation and local anesthetic, a small incision was made. The Veress needle and radially expandable sleeve were advanced into the thoracic cavity, followed by dilation with a cannula. A chest tube was placed via the port. Results: All chest tubes were successfully placed in good position as documented by chest radiograph and 29/30 were initially therapeutic. Procedural time was approximately 20 minutes. Conclusion: The STEP-TT can be performed at the bedside and is safe and effective in children of all ages. This minimally invasive technique permits faster as well as more precise tube thoracostomy placement and is better tolerated by patients, with little morbidity.
Infection with the acid-fast bacilli Mycobacterium avium and Mycobacterium intracellulare, collectively referred to as the Mycobacterium avium complex (MAC) is a substantial diagnostic and clinical problem in children with human immunodeficiency virus (HIV) infection. Because blood cultures in patients with M. avium infection (MAI) are frequently negative, tissue biopsy and culture are often required to confirm the diagnosis or rule out malignancy. The use of laparoscopic mesenteric lymph node biopsy in three children presenting with clinical symptoms and radiographic findings (abdominal lymphadenopathy) consistent with MAC infection is described here. Three ports were utilized and positioned dependent upon CT findings. Adequate specimens for diagnosis were obtained without morbidity in all three children. This experience supports the use of laparoscopy as the preferred method of confirming intra-abdominal MAC infection in HIV infected children.
Laparotomy for complicated appendicitis with a mass has been the traditional approach in the presence of acute lower abdominal pain, generalized peritonitis, and fever. Generous right iliac fossa incisions are routinely done to deal with these cases, as the appendectomy can be difficult due to visceral adhesion, omental wrapping, and early abscess formation within the mass. Laparoscopic appendectomy can result in decreased pain due to smaller wounds, as well as providing superior cosmesis. In a two-year study, 11 patients with appendicular masses were treated by laparoscopy. The procedure took an average of 120 ± 20 min. All patients were ambulatory within 2 days. Hospital stay postsurgery was an average of 6 days. There was a single minor umbilical wound infection. Laparoscopic appendectomy can be recommended even in the presence of a preoperatively diagnosed appendicular mass and/or abscess. It does take longer than an open procedure, while cosmesis is superior and postoperative pain is less.
Background and Purpose: Gastric volvulus in children may be a surgical emergency or may present more subtly. The classic symptoms of gastric volvulus include the triad of unproductive retching, epigastric distention, and the inability to pass a nasogastric tube, but these symptoms are inconsistent in children. The accepted surgical treatment for acute, subacute, or intermittent gastric volvulus is anterior gastropexy, and others have reported that this can be accomplished laparoscopically. We present further clinical experience documenting the safety and efficacy of a laparoscopic approach to gastric volvulus. Methods: This is a case series of 4 children (2 girls and 2 boys, ranging in age from 8 months to 12 years) with gastric volvulus. Two presented as emergencies, one was asymptomatic, and one presented with a feeding problem. Results: Gastric volvulus was successfully treated by laparoscopic gastropexy in all cases. Two children also had a gastrostomy tube placed for postoperative feeding. Postoperative hospital stay ranged from 3 to 12 days, the latter due to unrelated medical problems in one child. There were no direct surgical complications or noted recurrence of volvulus. All children were well at follow-up. Conclusion: Our small experience supports laparoscopic gastropexy as a safe and effective treatment for gastric volvulus in children, with no serious complications, and minimal postoperative morbidity.
Introduction: Hirschprung disease (HD) is a common cause of neonatal intestinal obstruction and chronic constipation. Advances in instrumentation and in laparoscopic experience have made laparoscopic correction possible in recent years. Methods: Medical records of children who underwent a laparoscopic Duhamel (LD) procedure from February 1995 to June 2002 in our institution were reviewed. Operative technique was always the same, using 4 ports (5, 5, 10, and 12 mm) and wall suspension. We recorded birth weight, clinical features, age and weight at procedure, morbidity, and followup. Results: Fifty-five children, 46 boys and 9 girls, with a median birth weight of 3046 g, were operated on. They ranged in age from 25 days to 8 years (mean, 13 months). Four cases of enterocolitis and 16 cases of sepsis necessitated 20 colostomies and 5 ileostomies (total colonic aganglionosis). Average operative time was 140 minutes (range, 100–330 minutes). Four conversions were necessary. There were no deaths. There was 1 anastomosis leakage (colostomy and Swenson 6 months later), 1 retrorectal abscess (local drainage), and 1 ileal perforation during total colectomy (ileostomy). Postoperative complications included 2 cases of urinary infection and 1 blood sepsis. There were no cases of enterocolitis and no anastomosis stenosis. Followup, ranging from 3 months to 7 years, found 40 excellent results, 6 resections of spur, and 8 children with persisting constipation requiring laxative. Conclusion: LD is feasible in cases of left, right, or total colonic aganglionosis. There were excellent early and late results, similar to those in the open technique, without adhesions and scars.
Purpose: We report our preliminary experience with laparoscopic repair of anterior midline (Morgagni) diaphragmatic hernia and identify technical issues. Methods: Four consecutive children undergoing laparoscopic Morgagni hernia repair over 3 years were reviewed. Results: The ages ranged from 13 months to 13 years. Three were found incidentally, and one presented with sudden onset of left side chest pain; none had obstructive symptoms. At operation the hernia contained omentum in all cases and bowel in three cases. All four underwent primary laparoscopic repair with interrupted nonabsorbable sutures. A small residual eventration was left along the edge of the pericardium in the one patient with a sac. The patient who presented with chest pain was found grossly and histologically to have acute appendicitis within the left chest, requiring dissection of the inflamed viscera from the mediastinum and chest wall; laparoscopic appendectomy was also done. Median time to full diet was 3 days, morphine was given for a median of 36 hours, and median postoperative hospital stay was 4.5 days. There were no complications, and no cases were converted. Followup chest radiograph demonstrated complete resolution of the hernia in three patients, and a small amount of residual bowel in the unrepaired pericardial portion of the eventration in the other patient. All children remain clinically well. Conclusion: Laparoscopic repair of Morgagni diaphragmatic hernia in children is a safe technique that provides rapid recovery and superior cosmetic results. Many unexpected technical challenges can be managed effectively without converting to an open approach.
Background: This study reviews ten years' experience in our institution with minimally invasive surgery in infants. It evaluates the feasibility, safety, and efficacy of performing advanced endoscopic procedures in infants under 5 kg. Methods: From October 1992 through October 2002, 846 infants weighing 1.1 to 5.0 kg underwent 881 procedures using minimally invasive techniques. The majority of the procedures were performed using 3 mm instruments and 2.7 or 4 mm scopes. Procedures include Nissen fundoplication, pyloromyotomy, colon pull-through, patent ductus arteriosus (PDA) closure, Ladd's procedure, colon resection, congenital diaphragmatic hernia repair, tracheoesophageal fistula repair, and exploration. Results: Ninety-eight percent of procedures were completed successfully endoscopically. There were two intraoperative complications and no mortality. Days to discharge for patients admitted for their specific procedure were Nissen 1.1, PDA 1.3, pyloromyotomy 1, pull-through 2.6. Conclusions: This study demonstrates that advanced endosurgical techniques in infants are safe, effective, and associated with the same benefits as those seen in older patients.
Background: In many institutions, laparoscopic appendicectomy (LA) has become the preferred technique for the treatment of uncomplicated acute appendicitis in children, although the role of laparoscopic techniques with advanced appendiceal disease (when the appendix is perforated or has produced an abscess) remains controversial. This study examines the complication rate and outcome in these patients. Method: A retrospective review was conducted of all children with perforated appendicitis undergoing LA at one institution during a five-year period. Complications and key parameters of outcome were analyzed. Results: Laparoscopic appendicectomy was completed in 49 children with perforated appendicitis evident at operation and confirmed on histopathology. Nine children (18%) developed some type of complication: six (12%) developed an intra-abdominal abscess that required drainage; two (4%) required readmission and intravenous antibiotics to treat a phlegmon; and one child (2%) developed a small bowel obstruction that required surgical intervention and adhesiolysis. Preoperative duration of symptoms, operative appearance, and operative time did not affect the rate of complications. Length of antibiotic use and the experience of the surgeon seem to influence the rate of complications. Conclusions: Rates of postoperative phlegmon and intra-abdominal abscess after laparoscopic management of perforated appendicitis in children would appear to be higher than those of open series, although the overall complication rate appears to be declining. Laparoscopic experience may affect the complication rate. The decision to perform a laparoscopic approach on the child with advanced disease and suspected perforated appendicitis should be based on the level of laparoscopic expertise of the surgeon.
We describe the use of intestinal transposition to create a neovagina using laparoscopy and avoiding minilaparotomy when performing the restoration of bowel continuity. A 16-year-old girl with mutiple congenital abnormalities, including absent vagina—Mayer- Rokitansky-Kuster-Hauser (MRKH) syndrome—underwent a sigmoid vaginoplasty under laparoscopy. After isolation of the distal sigmoid, a hysterectomy was performed. At the perineum, a cruciform incision was made in the hymeneal region. The uterus was extracted through the perineal approach. The stapled end of the sigmoid was pulled through the perineal opening in order to insert the anvil of a 28-mm circular stapler. The sigmoid was pulled back in the abdomen. Continuity of the digestive tract was restored transrectally, by performing a sigmoidorectal anastomosis with the circular stapler. The vaginoplasty was then completed by pulling the isolated segment to the perineum and creating an introitus. The patient was discharged on postoperative day 4. Mucus discharge is minimal and the introitus wide enough. Different approaches have been described to treat vaginal atresia, with advantages and inconveniences for each. The choice between the various forms of vaginoplasty remains highly controversial, as no vaginal substitute is perfect. Laparoscopic transplant of an isolated segment of sigmoid to create a neovagina is a new option in the treatment of vaginal atresia.
