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 Achalasia is an uncommon disease in children, but when present can result in severe disabling symptoms often requiring surgical intervention. This report describes the authors' experience with thoracoscopic (TH) and later laparoscopic Heller (LH) myotomy for definitive treatment of this disease. METHODS Nine patients with achalasia were referred for surgical therapy. Ages ranged from 5 to 17 years and weight from 23 to 78 kg. All had undergone at least one dilatation with recurrence of symptoms. The first 4 were treated by TH and the last five by LH. The 5 LH procedures also included a partial fundoplication. RESULTS All procedures were completed successfully using minimally invasive techniques. Operating times averaged 95 minutes for TH and 62 minutes for LH. One patient undergoing TH had a small esophageal perforation repaired primarily. The other 3 TH patients were started on clear liquids within 1 day and discharged on day 2. One patient had recurrent symptoms at 6 months and underwent a LH for an incomplete TH. All 5 LH patients were discharged on postoperative day 1. One had an esophageal perforation 4 days after operation requiring laparoscopic repair. Seven of 9 patients are asymptomatic. Studies of pH levels in 2 asymptomatic TH patients show mild gastroesophageal reflux (GER). CONCLUSIONS Minimally invasive Heller myotomy is a safe and effective procedure in children. TH results in a slightly longer operating time and hospital stay and, without a partial fundoplication, also may be associated with a higher incidence of silent GER. From these results, we prefer LH with a Dor fundoplication for treatment of achalasia in children.

BACKGROUNDEndosurgery is difficult for the senior pediatric surgeon to master because the technique has a steep learning curve, lacks tactile sense, uses elongated instruments, and is ergonomically tiring.METHODSThe senior author, starting at age 53, has performed more than 300 endoscopic procedures at both children and community hospitals. A full year was required to master laparoscopic Nissen fundoplications. Conversion to open procedures from bleeding and enterotomies were committed in the first year of endosurgery. Facility with endosurgery is gained by performing common and frequent procedures as appendectomies.CONCLUSIONThe advantages of endosurgery in pain control and shortened hospitalization make the technique deserving of commitment by the senior pediatric surgeon.

PURPOSE:This clinical study was undertaken to examine the feasibility of a laparoscopic approach for the treatment of documented malrotation. METHODS:From May 1994 through January of 1997, 12 patients, aged 5 days to 4 months, weighing 3 to 7 kg, underwent laparoscopic Ladd's procedure for malrotation. All patients had symptoms of intermittent upper intestinal obstruction, and malrotation was documented by an upper gastrointestinal contrast study. None of the patients had acute volvulus or compromised bowel. The procedure was performed using 3 trocars of 3.5 mm diameter. Ports were placed in the infraumbilical ring, and the right and left mid to lower quadrants. A standard Ladd's procedure with appendectomy was performed in all cases. RESULTS:All procedures were completed successfully through the laparoscope. Operative times averaged 58 minutes (35 to 120 minutes). One patient with Pierre-Robin underwent a laparoscopic Nissen fundoplication and gastrostomy tube placement at the same time requiring 120 minutes. Feedings were started on postoperative day (POD) 1 in 10 cases and POD 2 in two cases. Hospital stay ranged from 2 to 4 days (average, 2.2) in the patients with isolated malrotation. The patient with Pierre-Robin had a prolonged hospitalization because of chronic respiratory problems not associated with surgery. There were no complications. All patients had resolution of their symptoms. CONCLUSIONS:Laparoscopic Ladd's procedure is a safe and effective technique. It can be performed in neonates in times equivalent to standard open techniques, and it appears to allow for earlier feeds and decreased hospital stays.

From December 1994 to May 1997, 12 patients with idiopathic thrombocytopenia purpura (ITP) refractory to medical management underwent laparoscopic splenectomy. The primary indication for surgery was persistence of a platelet count less than 50,000 despite treatment with steroids or gamma globulin. Ages ranged from 6 to 22 years and weight from 18 to 110 kg. A four-port technique was used to perform the procedure, and laparosonic coagulating shears (Ethicon Endosurgery, Inc., Cincinnati, OH) was the primary instrument used to perform the procedure. All 12 procedures were completed successfully laparoscopically. Operative time averaged 68 minutes (range 35–110 minutes). No patient required blood or platelet transfusion, and blood loss was less than 20 cc in each case. Eleven patients were discharged on the first postoperative day and one on day 2. There were no intraoperative or postoperative complications. This series shows that laparoscopic splenectomy in patients with refractory ITP is safe, fast, and effective. The decreased postoperative morbidity makes it a superior technique to the standard open laparotomy.

Background: This study evaluates the feasibility, safety, and efficacy of performing advanced endoscopic procedures in infants under 5 kg. Methods: Over a 51-month period 183 infants weighing 1.3 to 5.0 kg underwent 195 procedures using minimally invasive techniques. The majority of the procedures were performed using 3.5-mm instruments and 2.7-mm scopes. Procedures include Nissen fundoplication, pyloromyotomy, colon pull-through, patent ductus arteriosus closure, Ladd's procedure, colon resection, congenital diaphragmatic hernia repair, ovarian cyst excision, and exploration. Results: All but two 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 2.1, patent ductus arteriosus 2, pyloromyotomy 1, and pull-through 3.4. Conclusions: This study demonstrates that advanced endosurgical techniques in infants is safe, effective, and associated with the same benefit as that seen in older patients.

Data from 505 patients (1976 through 1995) who underwent anterior spinal exposure were retrospectively analyzed. There were 222 boys and 283 girls with a mean age of 14.5 years; 166 had thoracic exposure (T), 300 thoracoabdominal (TA), 44 retroperitoneal (R), and 7 transperitoneal (TP); 17 had repeat exposure (5 had initial exposure elsewhere); 70% had scoliosis, 25% kyphosis, 27% a neuromuscular disorder (NMD) and 6.7% a tumor. Average intensive-care-unit stay was 2.5 days, 6.2 days for NMD (P < .05); average ileus was 3.4 days, 4.1 days for NMD (P < .05); and average length of stay was 15.4 days for all patients, 19.3 days for NMD (P < .05). Mechanical ventilation over 96 hours was required in 31 patients, 66% had an NMD (P < .05). The morbidity rate was 9.8%, 10.1% for NMD; the morbidity rate was zero for tumor and repeat exposures. Mortality was zero. Over half of the vessel injuries (57%) and the urinary tract infections (60%) occurred in NMD patients. Differences between the 1976 through 1985 period and the 1986 through 1995 period were a shorter length of stay and a majority of one-stage combined exposures in the latter period. The authors conclude that anterior exposure of spinal deformities is well tolerated by most pediatric patients, and that this technique is easily adaptable to the resection of retroperitoneal and thoracolumbar tumors.

This report reviews the results of advanced endosurgical procedures in neonates and infants weighing less than 5 kg. Over a 2½-year period, 106 patients underwent 111 laparoscopic or thoracoscopic procedures. Ages ranged from 2 days to 20 weeks and weights from 1.5 to 5.0 kg. Procedures (numbers performed [n] and average operative times [t] in minutes) include Nissen fundoplication and gastrostomy (n = 58, t = 54), pyloromyotomy (n = 15, t = 15), patent ductus arteriosus (PDA) occlusion (n = 6, t = 50), pullthrough for Hirschsprung's disease (n = 4, t = 180, Ladd's procedure (n = 5, t = 65), ovarian cystectomy (n = 5, t = 35), lung biopsy (n = 5, t = 35), congenital diaphragmatic hernia repair (n = 3, t = 75), and other (n = 8, t = 12). The majority of procedures were performed with specially designed 3.4-mm instruments and a 2.7-mm 0° scope. Abdominal insufflation was kept at pressures of 10 to 14 mm Hg. All procedures were completed successfully endoscopically and the complication rate was 4.5%. The only death occurred after life support was removed after the results of a lung biopsy. Postoperative hospital stays were significantly shorter than standard open surgery (historical controls). This study demonstrates that advanced endosurgical techniques in infants are safe, effective, and associated with the same minimal morbidity and decreased hospital stays as in older patients.

Hirschsprung's disease in infants has routinely been treated by a three- or four-stage process requiring a rectal biopsy, diverting colostomy, pull-through procedure, and then colostomy takedown. This algorithm requires multiple hospitalizations and surgeries over several months. The authors have adopted a laparoscopic approach that allows the surgery to be performed in one stage with a marked decrease in morbidity and hospital stay. From March 1995 to May 1996, 15 infants and children, ages 7 days to 8 years and weighing 2.3 kg to 40 kg, underwent laparoscopic pull-through procedures. Eleven underwent primary pull-throughs, while four underwent a previous diverting colostomy. The laparoscopic portion of the pull-through was performed using three or four ports, size 3.5 mm or 5 mm and an ultrasonic dissector. The final submucosal dissection was performed transrectally starting 1 cm above the pectinate line. The rectal anastomosis was hand sewn, and no patient was left with a diverting colostomy. Operative time averaged 2 hours and 50 minutes. Average time to feeds was 1.3 days and the average days to discharge was 3.4. There was one intraoperative pathology misdiagnosis and one patient with an anastomotic stricture. All patients are excreting stools spontaneously at least daily and there have been no episodes of colitis. This preliminary report shows that the one-stage laparoscopic pull-through is safe and effective.

Thoracoscopic techniques were used to perform lung biopsies and limited resections in 36 consecutively treated cases. Biopsies were performed for interstitial lung disease in 27 cases, presumed metastatic lesions in 5, and cavitary lesions in 4. Histological diagnosis was obtained in 35 of the 36 cases, and therapy was directly affected by the results in 30 of 36 cases. There were no postoperative complications, and the average hospital stay for patients admitted the morning of surgery was less than 2 days. Limited thoracoscopic resection provides a safe and effective means for diagnosing and treating parenchymal disease of the lung.

The authors have developed a technique of thoracoscopic closure of patent ductus arteriosus (PDA) that significantly reduces the surgical morbidity, recovery time, and hospital costs traditionally associated with the standard open procedure. Ten patients have undergone the procedure, with nine completed successfully. One patient required conversion to an open thoracotomy. There were no operative complications, and closure of the ductus was confirmed in all cases with a postoperative echocardiogram. Eight of ten patients were discharged in under 24 hour, and hospital charges were on the average 30% to 40% less.

Seventy-seven animal models of diseases pertinent to pediatric surgery and its subspecialties are analyzed to determine their similarities and differences in comparison to human conditions. References are appended for the various models as well as general references for fetal surgery, animal anesthesia, animal pathology, model sources, and veterinary literature.

James Milman Coley was born on 30 August 1784 in Shropshire. Having studied under John Abernethy at St. Bartholomew's Hospital, Coley qualified as MRCS England in 1806 and practiced at Bridgnorth. In 1844 he was admitted as Licentiate of the Royal College of Physicians and commenced practice in London. In 1846, he published A Practical Treatise on the Diseases of Children: “I am not aware, ..., that any author, British or Foreign, has published a work comprehending all the diseases incident to children, and their appropriate surgical as well as medical treatment.” Among the surgical topics discussed were hernias, respiratory and intestinal foreign bodies, hare-lip, ranula, thyroglossal duct cyst, intussusception, imperforate anus, anal prolapse, bladder stones, empyaema, pneumothorax, and burns. Although the surgical management was primitive and leeches, bleeding, and purgatives were utilised freely, Coley was a pioneer and preceded the works of Forster [13] and Holmes [15], two more prominent London surgeons. He authored 15 journal articles and five books (urinary retention, caesarean operation and puerperal metritis, remittent fever and hydrocephalus internus, and medical advice for travelers in Belgium and Llandudno). Mr. Coley died on 12 November 1867 at South Lambeth.

We reviewed 187 cases of documented neonatal necrotizing enterocolitis (NEC) from 1976 to 1988. Of these patients, 111 infants underwent celiotomy for acute surgical complications. The following protocol of operative indications was employed: pneumoperitoneum, localized mass, abdominal wall erythema, portal venous air, and clinical deterioration, singly or in any combination. Clinical deterioration was defined as falling platelet count, rising or falling white blood cell count, left shift in the myeloid series, persistently or progressively low pH, and increasing frequency of apnea or bradycardia. Overall mortality was 15% (28 of 187). For the patients who underwent celiotomy, all had histologic confirmation of NEC. Ninety-five had localized disease, and 16 had diffuse disease. All of the former had resection and diverting enterostomy with 85 (89.5%) surviving; none with diffuse disease survived, P less than 0.0001. Forty-one infants with NEC weighed less than 1,000 g; 25 underwent surgery and 15 (60%) survived. Fifty-one of the 159 surviving neonates (32%) developed intestinal strictures. All neonates with strictures have had resection and successful reconstruction of their gastrointestinal tract. These indications and surgical principles resulted in a high degree of diagnostic accuracy and a low degree of surgical mortality.

The risk of fatal hemorrhage may limit the completeness of resection in hepatic malignancies and in vascular extensions of Wilms' tumors. We have used Ein's technique of deep hypothermia (average 17 degrees C) with cardiac arrest (average 39 minutes) and exsanguination in performing five hepatic and two intravenous Wilms' tumor resections. The initial hepatic resection takes less than 15 minutes to perform in a bloodless field and the specimen is immediately examined by frozen section for determination of adequacy of margin. Additional resection is easily performed. Of four trisegmentectomies and one left lobectomy, two required additional resections. Mattress sutures were used to control hemorrhage during recirculation. One patient died from bleeding and cardiac decompensation and another from recurrence of tumor. The Wilms' tumors extended from the iliac vein into the right atrium in one child and from the right renal vein to the right atrium with extensions into the hepatic and lumbar veins in another. After nephrectomy, the atria and inferior vena cava were opened and the tumor extracted under direct vision. Both patients are well.

From 1976 to 1986 inclusive, 122 patients were cared for with Hirschsprung's disease. Sixteen of these were treated for total colonic aganglionosis, with or without small bowel involvement. The male to female ratio was 2.2:1. Two children died prior to definitive surgical therapy and two others were transferred following initial therapy. Twelve children underwent Martin's procedure with a 0% mortality rate and an 81.8% morbidity rate. This study would indicate, as do others, that even though the Martin procedure can safely be performed, the long-term results require close scrutiny. A re-evaluation of this procedure and its alternatives is necessary in order to improve long-term results.

Hepatoblastomas are the third most common malignant intra-abdominal tumor and are universally fatal without resection. Resections of these tumors are often difficult due to their size. Chemotherapy is frequently used to reduce the size of the tumor and allow resection. Hepatic resection is often complicated with excessive bleeding and with an attendant mortality of 10 to 30%. Cardiopulmonary bypass with total circulatory arrest was used on three patients for hepatic resection. The extracorporeal circuit consisted of a membrane oxygenator and a pulsatile flow pump. Pulsatile flow was utilized for its advantageous effects on cooling and rewarming times. An average time of 13 minutes was needed to cool the patient to a rectal temperature of 17°C. Upon reaching this temperature, systemic circulation was stopped and the patient was exsanguinated into the extracorporeal circuit. During circulatory arrest, tumor resection was performed. Circulatory arrest time averaged 37 minutes. After resection was completed, the patients were rewarmed to 37°C with an average time of 27 minutes and were gradually weaned from cardiopulmonary bypass. This technique allows tumor resection in a bloodless environment and free retraction without fear of diminished circulation. Also, blood usage is minimal and blood conservation can be optimized.

Two weeks old pregnant New Zealand White rabbits were placed in a hypobaric chamber and maintained at 3657 meters (1200 feet) until delivery (30±1 days). The newborn pups were sacrificed by cervical dislocation, autopsied, and a ring of mainsten pulmonary artery removed. The right ventricle, left ventricle, and intraventricular septum were weighed. The vessel was placed in a 30ml modified Kreb's solution aerated by 95% oxygen 5% carbon dioxide, secured to a stay pin, and attached to a force transducer. Dose response curves were generated for histamine and epinepherine. While the total heart weights of the two groups were similar, the right ventricle to left ventricle plus intraventricular septal weight ratios of the hypobaric pups (0.65±0.11) were significantly (p<0.05) increased from controls (0.60±08) indicating pulmonary hypertension. The pulmonary artery segments of hypobaric hypoxia bred pups responded in a significantly exaggerated fashion as compared to control vessels when exposed to histamine or epinepherine. Significance was found at 5×10−5M histamine and 5×10−8M epinepherine. This model provides a means for examining the mechanism of induced pulmonary hypertension and may be useful in the assay of antihypertensive pharmacologic agents.

The classic jejunostomy for enteral feedings has several major complications including intraperitoneal leakage and intestinal obstruction. In some children, severe adhesions from previous surgery makes the finding and isolation of the proximal jejunum both tedious and hazardous. A jejunostomy may be easily placed into the retroperitoneal duodenojejunal flexure without entering the peritoneum. This is accomplished by a flank muscle splitting incision displacing the descending colon anteriorly and the kidney posteriorly. A Broviac catheter with a Dacron cuff is used as the conduit. The catheter is secured to the skin until fibrous adhesions have anchored the Dacron cuff. Four retroperitoneal jejunostomy tubes have been placed. The first tube was inserted with an incomplete Dacron cuff and "accidently" extracted on the day after surgery. The second tube was placed for temporary nutritional support until definitive surgery was performed. The tube was in place for 3 months with the patient gaining 2.4 kg. The third and fourth tubes were placed for permanent nutritional support and have been in for 4 and 2.5 months. The patients have gained 1.3 and 3.0 kg, respectively. Both tubes have been transected through carelessness, but easily repaired using the Broviac repair kit.