Comparing Outcomes of Single-Incision Laparoscopic Herniorrhaphy in Newborns and Infants.

BACKGROUND: As surgical techniques progress, laparoscopic herniorrhaphy is now performed more often in premature babies. The aim of this study was to analyze the outcomes of newborns and infants who underwent single-incision laparoscopic herniorrhaphy (SILH) at our center. METHODS: We retrospectively reviewed patients younger than 12 months old who received SILH at our department from 2016 to 2020. SILH involved a 5 mm 30-degree scope and 3 mm instruments with a 3-0 Silk purse-string intracorporeal suture for closure of the internal ring. At the time of surgery, Group 1 newborns, whose corrected age was 2 months and below, were compared to the Group 2 infants, whose age was above 2 months. We assessed the patients' characteristics, anesthesia, surgical data, and complications. RESULTS: A total of 197 patients were included (114 newborns in Group 1 and 83 infants in Group 2). The mean age and body weight in Group 1 were 1.2 months and 3.8 kg, respectively, whereas in Group 2, they were 3.2 months and 6.7 kg, respectively. There were no significant differences in operative time (Group 1 = 34.1 min vs. Group 2 = 32.3 min, p = 0.26), anesthetic time (Group 1 = 80.0 min vs. Group 2 = 76.3 min, p = 0.07), length of hospitalization (Group 1 = 2.3 days vs. Group 2 = 2.4 days, p = 0.88), postoperative complications including omphalitis (Group 1 = 5.3% vs. Group 2 = 1.2%, p = 0.13), wound infection (Group 1 = 0.9% vs. Group 2 = 1.2%, p = 0.81), and hydrocele (Group 1 = 0.35% vs. Group 2 = 8.4%, p = 0.14). No recurrence, testicular ascent or atrophy, or mortality was observed in either group during the 2-year follow-up period. CONCLUSIONS: Single-incision laparoscopic herniorrhaphy is a safe and effective operation for inguinal hernia repair in infants, even those with prematurity, lower body weight at the time of surgery, or cardiac and/or pulmonary comorbidities. Comparable results revealed no significant differences in perioperative complications despite younger ages and lower body weights.

Splenic Torsion in Heterotaxy Syndrome with Left Isomerism: A Case Report and Literature Review.

Splenic torsion is an unusual condition that results in congenital abnormality, especially in the visceral abnormal arrangement. We report the case of an 8.5-year-old boy with features in the right upper quadrant. Radiological investigations revealed heterotaxy syndrome with polysplenia and a hypodense tumor in the right upper quadrant adjacent to several spleens. We initially treated it as an intra-abdominal tumor. Laparoscopy was performed to check the tumor condition and revealed a congestive tumor located in the abdomen of the right upper quadrant below the central liver, which was suspected to be a torsion spleen without attaching ligaments. Laparoscopic splenectomy was successfully carried out without complications. The pathological report shows splenic tissue with hemorrhagic infarction. Physicians should be vigilant of the differential diagnosis of the acute abdomen in adolescents.

Transumbilical laparoscopy-assisted Malone procedure for fecal incontinence in children.

BACKGROUND: Transumbilical laparoscopy-assisted Malone procedure (TULAM) is a single-incision laparoscopic procedure in which the appendicostomy is made at umbilicus. The aim of this study is to evaluate the outcomes of TULAM. METHODS: With IRB approval, the medical records of the patients who underwent TULAM were retrospectively reviewed between July 2013 and December 2018. The data collected included ages, gender, underlying diseases, operative techniques, complications, stoma continence, parental satisfaction and follow-up duration. RESULTS: Fifteen patients underwent TULAM at the median age of 5.0 years (2.9-10.7 years). There were 4 girls and 11 boys. Thirteen patients had anorectal malformations or cloaca; the other two patients had spina bifida. All patients presented with fecal incontinence; 9 of them had concomitant constipation. TULAM was successfully accomplished in 14 patients; one patient required conversion to the three-port procedure. The median follow-up period was 1.7 years (0.5-3.2 years). One patient required tube replacement under endoscopy guidance in the operation room. One patient required surgical revision because the appendix was disrupted after an episode of enterocolitis. All patients were socially continent with antegrade enemas. 12 patients were stoma continent, and 3 patients had minor leaking less than once a month. The stoma cosmesis was satisfactory. All parents expressed satisfaction with TULAM. CONCLUSION: TULAM is effective in the management of fecal incontinence and constipation, and provides a continent stoma with excellent cosmesis.

A Rare Case of Prostatic Utricle with Crossover Vas Deferens in Children.

Background: A prostatic utricle (PU) is an unusual pathology with most patients being asymptomatic. However, approximately 29% of patients may show lower urinary tract symptoms, recurrent urinary tract infections (UTI), postvoid dribbling, urethral discharge, epididymo-orchitis, stones, and secondary incontinence caused by urine trapping in the pouch and urinary retention. The standard treatment is through surgical resection, but it is only offered to patients with symptoms. Case summary: We report a case involving a six-year-old boy with congenital hypothyroidism and penoscrotal hypospadias who had previously undergone onlay urethroplasty for the proximal shaft, chordee release, orchidopexy for bilateral undescended testis, and laparoscopic herniorrhaphy for left inguinal hernia. However, the patient later evolved the repetition of UTI and right epididymo-orchitis. Cyclic voiding cystourethrography confirmed the presence of a cystic lesion communicating with the prostatic urethra from the utricle. The PU was then excised laparoscopically. The utricle was identified posterior to the bladder, and insertions of the vas deferens crossover into the utricle were detected by laparoscopy. The post-procedure course was uneventful. Conclusions: Laparoscopic resection of PUs offers a better exposure field, improved wound appearance, complete resection, and reduces the incidence of complications. During laparoscopy, the PU was clearly distinguished from the bladder or other pelvic organs. An incidental finding of vas deferens crossover has rarely been reported. A combined cystoscopy and laparoscopy for PU resection is executable, safe, and valid in this patient population.

Single-site laparoscopic burnia for inguinal hernias in girls: comparison with open repair.

BACKGROUND: Burnia is a suturless repair for inguinal hernias in girls. It is performed under laparoscopy by grabbing the sac, inverting it into the peritoneal cavity, and cauterizing. The aim of this study is to report our experience with single-site laparoscopic burnia (BURNIA) and compare them with open repair (OPEN). METHODS: With IRB approval, pediatric female patients younger than 18 years of age who underwent inguinal hernia repair between January 2015 and December 2017 were enrolled. Medical records were retrospectively reviewed. The patients were divided into two groups, BURNIA and OPEN. RESULTS: 198 patients were included. In BURNIA, 49 patients underwent bilateral repairs, and 50 patients underwent 51 unilateral repairs (one patient had metachronous contralateral hernia). In OPEN, 27 patients underwent bilateral repairs, and 72 patients underwent 77 unilateral repairs (five patients had metachronous contralateral hernias). The mean age of BURNIA was similar to OPEN for bilateral repairs (49.1 ± 36.6 vs. 43.7 ± 26.4 months, p = 0.46), but significantly older for unilateral repairs (54.6 ± 29.8 vs. 29.0 ± 31.4, p < 0.01). The mean operation time of BUNIA was similar to OPEN for bilateral repairs (24.2 ± 7.6 vs. 22.4 ± 8.6 min, p = 0.35), but significantly longer for unilateral repairs (19.2 ± 7.0 vs, 13.6 ± 8.8 min, p < 0.01). The mean follow-up duration of BURNIA was significantly shorter than OPEN for bilateral and unilateral repairs, respectively (32.5 ± 8.8 vs. 45.4 ± 4.8 months, p < 0.01) (30.2 ± 8.8 vs. 39.1 ± 9.6 months, p < 0.01). No conversion was required in BURNIA. There were no complications and no recurrence in all patients. CONCLUSIONS: Single-site laparoscopic burnia is technically feasible, and as safe and effective as open inguinal hernia repair.

Should single-incision laparoscopic appendectomy be the new standard for pediatric appendicitis?

BACKGROUND: To compare single-incision laparoscopic appendectomy (SILA) with conventional (CLA) and transumbilical laparoscopic appendectomy (TULA). METHODS: This is a retrospective cohort study. Patients were divided into three groups, SILA, CLA, and TULA. SILA was defined as performing appendectomy extracorporeally or intracorporeally by using a glove-port incorporated with 3 trocars. TULA was defined as exteriorizing appendix and performing extracorporeal appendectomy by using an operative telescope. Statistical analysis was conducted in patients with simple (SA) and complicated appendicitis (CA), respectively. RESULTS: A total of 315 patients were enrolled, including 161 in SILA, 105 in CLA, and 49 in TULA. Demographic data were similar. In patients with simple appendicitis, operation time of SILA was shorter than CLA but longer than TULA (62.8 ± 22.5 vs. 82.2 ± 24.3 and 51.6 ± 22.3 min, p < 0.01). SILA had shorter hospital stay than CLA, and similar to TULA (56.1 ± 20.4 vs. 71.5 ± 37.8 and 56.9 ± 19.0 h, p < 0.01). In patients with complicated appendicitis, SILA had shorter operation time than CLA, but a similar time to TULA (80.9 ± 22.4 vs. 105.7 ± 28.8 and 82.5 ± 31.2 min, p < 0.01). Conversion to open surgery was not required in all groups. The rates of complications, such as wound infection, intraabdominal abscess and adhesion ileus, were similar. SILA required fewer additional ports than TULA in both simple and complicated appendicitis (1.1% vs. 13.5%, and 9.6% vs. 41.7%, p < 0.01). CONCLUSION: SILA has the advantages of shorter operation time and hospital stay over CLA as well as a lower rate of additional ports than TULA.

How much do we know about constipation after surgery for anorectal malformation?

BACKGROUND: To evaluate the occurrence of constipation after anorectal malformations (ARM) repair and the results of laxative treatment. METHODS: Between August 2012 and July 2017, the clinical data of patients with ARMs was prospectively collected. The patients were divided into two groups, good types and poor types. Good types included rectoperineal, rectovestibular, rectourethral bulbar, and no fistula. Risk factors were defined as spinal cord anomalies, sacral ratio <0.4, or cognitive impairment. Success was defined as that laxative could be tapered. RESULTS: Eighty-four patients were enrolled with mean age of 6.3 ± 7.8 (0.6-59.9) years. The mean age of onset of constipation was 12.8 ± 8.3 months and the mean interval was 5.9 ± 5.1 months after reconstructions. The interval was not significantly different between patients with good types and poor types. In 23 patients with severe constipation being treated for >6 months, 14 of 18 (77.8%) patients with good types were classified as success, whereas only 1 of 5 (20%) patients with poor types was (p = 0.02). In patients with good types, 9 of 9 (100%) patients with no risk factors were successful; however, only 5 out of 9 (55.6%) patients with risk factors were successful (p = 0.02). CONCLUSION: Constipation occurs shortly after operations. Patients with good types and no risk factors are susceptible to weaning laxatives.

Seasonal variations in the occurrence of acute appendicitis and their relationship with the presence of fecaliths in children.

BACKGROUND: Acute appendicitis (AA) is the most common surgical condition in children. Although a higher incidence of AA in summer has been reported, the reason for this observation remains unclear. The purpose of this study was to compare the clinical findings of AA patients who underwent appendectomies during the summer months with those who underwent the procedure during the non-summer months. METHODS: The clinical data of 171 patients who underwent appendectomy from January 2013 to December 2016 were reviewed. The patients were divided into a summer group (from May to October) and a non-summer group (from November to April) based on the month when appendectomy was performed. All patients were under 18 years of age at the time of surgery. The medical records including laboratory data, computed tomography scans, pathology reports and operative notes were reviewed. RESULTS: The number of patients with AA was higher in the summer group than in the non-summer group (101 vs. 70 patients). No significant differences in the laboratory results between the two groups of patients were observed. The percentage of AA patients who presented with a fecalith was significantly lower in the summer group (33.6%) than in the non-summer group (55.7%). No significant differences in the incidence of appendiceal perforations and abscesses, as well as postoperative complications were observed between the two groups. CONCLUSIONS: The percentage of AA patients with fecaliths in summer was lower than that in the non-summer months. The increase in the number of AA patients in summer may be due to the increased occurrence of lymphoid hyperplasia, which may be correlated with the yearly outbreak of enterovirus infection during this period.

Transumbilical minilaparotomy in low-birthweight newborns for complicated conditions.

BACKGROUND: The purpose of this study is to examine the outcome of transumbilical minilaparotomy for infants and compare the results between normal birthweight (NBW) and low birthweight (LBW). METHODS: Between July 2010 and March 2017, infants who underwent abdominal surgery through transumbilical minilaparotomy were enrolled. Medical records were retrospectively reviewed. Patients were divided into two groups, NBW and LBW. Complexity was defined as complicated conditions other than intestinal atresia and malrotation. RESULTS: Totally, 16 patients were included. The diagnosis included intestinal atresia (n = 3), meconium peritonitis (n = 4), bowel infarction/necrosis (n = 4), spontaneous intestinal perforation (n = 2), segmental volvulus and necrosis (n = 1), necrotizing enterocolitis (n = 1), and malrotation (n = 1). The median gestational age and body weight were 32 (24-40) weeks and 1731 (560-4200) grams respectively. The median age at operation was 3 (1-41) days. The surgical procedure included primary repair of the intestine (n = 14), ileostomy (n = 1) and Ladd's procedure (n = 1). Postoperative complications included anastomotic leakage (n = 2), adhesion ileus (n = 1), and missed rectal atresia (n = 1). There was one mortality due to extremely low birthweight and poor lung maturation. Re-operation was required in 3 patients for anastomotic leakage (n = 2) and missed rectal atresia (n = 1). Mean birthweight was 2932 ± 97 and 1263 ± 667 g in NBW (n = 5) and LBW (n = 11), respectively (p < 0.01). Complexity rate was 40% and 90.9%, respectively (p = 0.034). The mean operation time was 139.4 ± 65.8 and 124.3 ± 46.1 min, respectively (p = 0.60). The complicated rate and reoperation rate were similar. CONCLUSIONS: Transumbilical minilaparotomy is technically feasible and an alternative option of minimally invasive surgery for LBW infants and complex conditions.

Single-incision laparoscopic surgery for idiopathic intussusception in children: Comparison with conventional laparoscopy.

BACKGROUND: The aim of this study is to evaluate the feasibility of single-incision laparoscopic surgery (SILS) for idiopathic intussusception in children and compare the outcomes with conventional laparoscopy (CLS). METHODS: Between January 2011 and December 2012, patients who underwent CLS for idiopathic intussusception were assigned into the group of CLS. Between January 2013 and March 2017, patients who underwent SILS were assigned to the group of SILS. For patients who failed to reduce by SILS, bimanual transabdominal approach was conducted. RESULTS: A total of 23 patients were enrolled, including 7 and 16 patients in SILS and CLS, respectively. The mean age was similar in both group (22.4 ±â€¯18.7 vs. 24.6 ±â€¯18.6 months, p = 0.80). There is no difference in gender distribution. The main indication was radiological reduction failure in both groups (85.7% vs. 75%, p = 0.58). Ileocolic intussusception was found in 6 (85.7%) and 15 (93.8%) patients of SILS and CLS, respectively (p = 0.25). The level of intussusception was at ascending colon in 3 (42.9%) and 12 (75.0%) patients, respectively (p = 0.11). The operation time was similar in both groups (64.9 ±â€¯53.7 and 70.9 ±â€¯26.1 min, p = 0.79). There were 2 (28.6%) and 1 (6.2%) conversions, respectively (p = 0.15). For the two patients in SILS, the intussusception was successfully reduced by bimanual transabdominal approach. There was no significant difference in time to feeding (1.9 ±â€¯1.1 vs. 1.4 ±â€¯0.7 days, p = 0.21). The mean length of postoperative hospital stay was 3.9 ±â€¯1.6 and 3.1 ±â€¯1.1 days, respectively (p = 0.17). CONCLUSIONS: SILS for pediatric intussusception is technically feasible and has comparable results to CLS. Transabdominal bimanual reduction is applicable in cases of failed laparoscopic reduction. LEVEL OF EVIDENCE: III.

Bilateral Ureteral Obstruction Caused by Stone Formation After Laparoscopic Appendectomy in Children.

In children, urologic complications are rare after laparoscopic appendectomy (LA). In this article, we report the case of a 9-year-old boy with bilateral hydronephrosis caused by ureteral calculi 10 days after he had undergone LA. The patient's urinary output normalized and renal function recovered after stone extraction and bilateral ureteral stent insertion.

A nationwide survey of incidence rates and risk factors of inguinal hernia in preterm children.

PURPOSE: Clinical observations showed a higher incidence rate of inguinal hernia (IH) in preterm infants. In this study, we calculated the incidence rate of preterm IH from the National Health Insurance Research Database (NHIRD) of Taiwan. METHODS: From NHIRD, 92,308 subjects born in the year of 1997-2005 were randomly selected as the study cohort. The medical claims of these subjects from birth to 6th year of age were analyzed. Preterm births were defined using ICD code 765.1*. Risk factors such as birth weight, lung disorders, and ventilator supports before IH repairs were investigated. The risk of incarceration and bowel resection were also evaluated. RESULTS: From 92,308 subjects, 2560 preterm births were identified. IH was repaired in 231 preterm (9.02%) and 3650 term subjects (4.07%). Male (preterm 13.3% and non-preterm 6.3%) had more hernia repairs than female (preterm 3.8% and non-preterm 1.6%). The incidence rate of IH is 13.7% for those under 1500 g, 8.2% for those 1500-1999 g, 7.7% for those 2000-2499 g, and 6.3% for those above 2500 g. The incidence rate of IH in preterms with past history of lung disorders and ventilation supports is 8.7 and 13.6%, respectively. There was no significant difference in the incidences of incarceration and bowel resection between preterms and non-preterms. CONCLUSIONS: Birth weight under 2500 g is a significant risk factor for IH repairs. Other risk factors are male gender, past history of lung diseases, and ventilator supports.

Extracorporeal and intracorporeal approaches of single-incision laparoscopic appendectomy in children: is one superior to another?

BACKGROUND: Single-incision laparoscopic surgery has been widely popularized for pediatric appendicitis. Various techniques have been proposed with two main approaches: extracorporeal and intracorporeal. The purpose of this study is to compare the result of different approaches in single-incision laparoscopic appendectomy (SILA) in children. MATERIAL AND METHODS: With IRB approval, patients less than 18years of age who underwent SILA were enrolled from July 2012 to December 2015. The patients were divided into three groups based on surgical approach: extracorporeal (Extra), mixed (Mix), and intracorporeal (Intra) approaches. Parameters were retrospectively reviewed, including age, gender, white blood cell (WBC), operation time, operative findings, time to diet, length of hospital stay (LOS), and complications. Statistical analysis was performed separately for simple and complicated appendicitis. RESULTS: There were 32, 32, and 24 patients with simple appendicitis in Extra, Mix, and Intra respectively. There were 27, 15, and 31 patients with complicated appendicitis in the three groups, respectively. No significant difference was noted in the mean age, gender distribution, or WBCs between the different groups. A higher percentage of patients with complicated appendicitis received intracorporeal approach than those with simple appendicitis (42.5% vs. 27.3%, p=0.044). In simple appendicitis, the LOS was significantly longer in Extra as compared to Mix (p=0.043). Otherwise, the mean LOS, time to diet, and complications were not significantly different. The mean operation time was similar between groups of simple appendicitis (56.5±19.5, 63.6±23.5, and 70.1±23.1 min, p=0.08), whereas it was significantly shorter in Extra of complicated appendicitis (67.6±16.4, 86.6±19.0, and 89.9±23.4 min, p<0.001). Multivariate analysis showed that intracorporeal approach is an independent factor for prolonged operation time in both simple and complicated appendicitis. CONCLUSIONS: Different approaches of SILA in children have similar outcomes for both simple and complicated appendicitis. Extracorporeal is the most time efficient; however, intracorporeal can be helpful to deal with complex situations. LEVEL OF EVIDENCE: III.