Safety and Cost Savings Using Polymeric Clips in Appendectomies in the Pediatric Population: Single-Center Experience.

INTRODUCTION: Although laparoscopic appendectomy is standard management for appendicitis, management of the appendiceal stump remains debated. Even though most surgeons can agree on the safety and effectiveness of various closure methods for the appendiceal stump, such as the surgical stapler (SS) or the Endoloop, the cost of these methods should also be considered. A relatively new alternative method, the polymeric clips (PC), has been gaining acceptance in the surgical community as it has repeatedly proven to be as safe as other methods, while being significantly cheaper. METHODS: For the period of January 2019 to December 2021, we performed a retrospective chart review of a single surgeon's laparoscopic appendectomies in children 18 years or younger for acute, non-complicated appendicitis and grouped the cases by appendiceal stump management (SS or PC). Demographics collected included gender, age, BMI percentile, race, and ASA score. Surgical variables included length of stay, surgical time, and anesthesia time. Outcomes were number of intra- and post-operative complications, reoperations, ER visits within 30 days, and total implant cost. Mann-Whitney U tests were performed to test for differences between SS and PC groups in surgical variables. Chi-square or Fisher's exact tests were performed to test differences in demographics and outcome variables. RESULTS: There were 107 patients identified. The PC group represented 16% (n = 17) of our study population. The PC group was significantly younger than the SS group at 10 years (2.8) vs 12 years (3.5) p = 0.04. No differences were observed in length of stay and anesthesia time between the two groups. However, a significantly longer length of surgery was observed in the PC group at 33.5 min [30.0-43.3] when compared to the SS group at 28.0 min [23.0-36.0] (p = 0.003). No significant differences were seen in post-op complications, post-op ED visits and reoperations within 30 days. The median total implant cost of the PC closure method was significantly lower than the SS method ($35.36 vs. $375.67 p = <0.001). CONCLUSION: There were no significant differences in clinical outcomes. However, the significant difference in the implant cost between the 2 methods could favor the use of PC for selected cases. The increase in length of surgery can be attributed to the learning curve associated with a new device.

Multicenter Assessment of Cryoanalgesia Use in Minimally Invasive Repair of Pectus Excavatum: A 20-center Retrospective Cohort Study.

OBJECTIVE: To assess the clinical implications of cryoanalgesia for pain management in children undergoing minimally invasive repair of pectus excavatum (MIRPE). BACKGROUND: MIRPE entails significant pain management challenges, often requiring high postoperative opioid use. Cryoanalgesia, which blocks pain signals by temporarily ablating intercostal nerves, has been recently utilized as an analgesic adjunct. We hypothesized that the use of cryoanalgesia during MIRPE would decrease postoperative opioid use and length of stay (LOS). MATERIALS AND METHODS: A multicenter retrospective cohort study of 20 US children's hospitals was conducted of children (age below 18 years) undergoing MIRPE from January 1, 2014, to August 1, 2019. Differences in total postoperative, inpatient, oral morphine equivalents per kilogram, and 30-day LOS between patients who received cryoanalgesia versus those who did not were assessed using bivariate and multivariable analysis. P value <0.05 is considered significant. RESULTS: Of 898 patients, 136 (15%) received cryoanalgesia. Groups were similar by age, sex, body mass index, comorbidities, and Haller index. Receipt of cryoanalgesia was associated with lower oral morphine equivalents per kilogram (risk ratio=0.43, 95% confidence interval: 0.33-0.57) and a shorter LOS (risk ratio=0.66, 95% confidence interval: 0.50-0.87). Complications were similar between groups (29.8% vs 22.1, P =0.07), including a similar rate of emergency department visit, readmission, and/or reoperation. CONCLUSIONS: Use of cryoanalgesia during MIRPE appears to be effective in lowering postoperative opioid requirements and LOS without increasing complication rates. With the exception of preoperative gabapentin, other adjuncts appear to increase and/or be ineffective at reducing opioid utilization. Cryoanalgesia should be considered for patients undergoing this surgery.

Postoperative Respiratory Complications in SARS-CoV-2 Positive Pediatric Patients Across 20 United States Hospitals: A Cohort Study.

INTRODUCTION: Data examining rates of postoperative complications among SARS-CoV-2 positive children are limited. The purpose of this study was to evaluate the impact of symptomatic and asymptomatic SARS-CoV-2 positive status on postoperative respiratory outcomes for children. METHODS: This retrospective cohort study included SARS-CoV-2 positive pediatric patients across 20 hospitals who underwent general anesthesia from March to October 2020. The primary outcome was frequency of postoperative respiratory complications, including: high-flow nasal cannula/non invasive ventilation, reintubation, pneumonia, Extracorporeal Membrane Oxygenation (ECMO), and 30-day respiratory-related readmissions or emergency department (ED) visits. Univariate analyses were used to evaluate associations between patient and procedure characteristics and stratified analyses by symptoms were performed examining incidence of complications. RESULTS: Of 266 SARS-CoV-2 positive patients, 163 (61.7%) were male, and the median age was 10 years (interquartile range 4-14). The majority of procedures were emergent or urgent (n = 214, 80.5%). The most common procedures were appendectomies (n = 78, 29.3%) and fracture repairs (n = 40,15.0%). 13 patients (4.9%) had preoperative symptoms including cough or dyspnea. 26 patients (9.8%) had postoperative respiratory complications, including 15 requiring high-flow oxygen, 8 with pneumonia, 4 requiring non invasive ventilation, 3 respiratory ED visits, and 2 respiratory readmissions. Respiratory complications were more common among symptomatic patients than asymptomatic patients (30.8% vs. 8.7%, p = 0.01). Higher ASA class and comorbidities were also associated with postoperative respiratory complications. CONCLUSIONS: Postoperative respiratory complications are less common in asymptomatic versus symptomatic SARS-COV-2 positive children. Relaxation of COVID-19-related restrictions for time-sensitive, non urgent procedures in selected asymptomatic patients may be reasonably considered. Additionally, further research is needed to evaluate the costs and benefits of routine testing for asymptomatic patients. LEVEL OF EVIDENCE: Iii, Respiratory complications.

Warning Labels and High-Powered Magnet Exposures.

BACKGROUND AND OBJECTIVES: High-powered magnets are among the most dangerous childhood foreign bodies. Consumer advocates and physicians have called for these products to be effectively banned, but manufacturers assert warning labels would sufficiently mitigate risk. METHODS: Subjects from Injuries, Morbidity, and Parental Attitudes Concerning Tiny High-powered Magnets (IMPACT of Magnets), a retrospective, multicenter study of children with high-powered magnet exposures (ie, ingestion or bodily insertion), were contacted. Consenting participants responded to a standardized questionnaire regarding the presence and utility of warning labels, magnet product manufacturer, and attitudes around risk. RESULTS: Of 596 patients in the IMPACT study, 173 parents and 1 adult patient were reached and consented to participate. The median age was 7.5 years. Subjects reported not knowing if a warning label was present in 60 (53.6%) cases, whereas 25 (22.3%) stated warnings were absent. Warnings were present in 28 (24.1%) cases but only 13 (46.4%) reported reading them. A manufacturer was identified by families in 28 (16.1%) exposures; 25 of these were domestic and 27 had warnings. Subjects reported knowing magnets were dangerous in 58% of the cases, although 44.3% believed they were children's toys and only 6.9% knew high-powered magnets were previously removed from the United States market. CONCLUSIONS: Over 90% of subjects from the IMPACT study didn't know if warning labels were present or failed to read them if they were, whereas almost half believed high-powered magnets were children's toys. Warning labels on high-powered magnet products are, therefore, unlikely to prevent injuries in children.

Association between COVID-19 related elective surgery cancellations and pediatric inguinal hernia complications: A nationwide multicenter cohort study.

BACKGROUND: Optimal inguinal hernia repair timing remains controversial. It remains unclear how COVID-19 related elective surgery cancellations impacted timing of inguinal hernia repair and whether any delays led to complications. This study aims to determine whether elective surgery cancellations are safe in pediatric inguinal hernia. METHODS: This multicenter retrospective cohort study at 14 children's hospitals included patients ≤18 years who underwent inguinal hernia repair between September 13, 2019, through September 13, 2020. Patients were categorized by whether their inguinal hernia repair occurred before or after their hospital's COVID-19 elective surgery cancellation date. Incarceration and emergency department encounters were compared between pre and postcancellation. RESULTS: Of 1,404 patients, 604 (43.0%) underwent inguinal hernia repair during the postcancellation period, 92 (6.6%) experienced incarceration, and 213 (15.2%) had an emergency department encounter. The postcancellation period was not associated with incarceration (odds ratio 1.54; 95% confidence interval 0.88-2.71; P = .13) or emergency department encounters (odds ratio 1.53; 95% confidence interval 0.94-2.48; P = .09) despite longer median times to inguinal hernia repair (precancellation 29 days [interquartile range 13-55 days] versus postcancellation 31 days [interquartile range 14-73 days], P = .01). Infants were more likely to have the emergency department be their index presentation in the postcancellation period (odds ratio 1.69; 95% confidence interval 1.24-2.31; P < .01). CONCLUSION: Overall, COVID-19 elective surgery cancellations do not appear to increase the likelihood of incarceration or emergency department encounters despite delays in inguinal hernia repair, suggesting that cancellations are safe in children with inguinal hernia. Assessment of elective surgery cancellation safety has important implications for health policy.

Stellate Hypopigmentation in a Pediatric Patient After Treatment with Intralesionally-Injected Corticosteroid.

BACKGROUND Several factors contribute to keloids in post-operative patients, including skin mechanics, genetics, and inflammatory processes. One of the most widely used treatment modalities for keloidal scars involves the intralesional injection of corticosteroids, such as triamcinolone acetonide (TAC). TAC is a first-line treatment option for keloids due to its proven efficacy and effectiveness in reducing collagen synthesis, glycosaminoglycan synthesis, inflammatory processes, and proliferation of fibroblasts. Some common adverse effects of intralesional corticosteroid injection include localized hypopigmentation, depigmentation, skin atrophy, and lipoatrophy. CASE REPORT In this report, we describe the case of a 3-year-old African American male patient who presented for dermatologic evaluation of a diffused stellate hypopigmentation attributed to intralesional corticosteroid injection following a keloid removal. Specifically, we summarize this case's clinical features, diagnosis, and outcomes. CONCLUSIONS The case illustrates self-limiting hypopigmentation that repigmented successfully without clinical intervention. Although previous reports of corticosteroid injections' adverse effects resulting in hypopigmentation have been published, this condition is uncommon or poorly reported in pediatric patients. This report aims to contribute to our understanding of the effects of administering corticosteroids in pediatric patients by virtue of diversifying the cases reported in the currently available literature.

High-Powered Magnet Exposures in Children: A Multi-Center Cohort Study.

BACKGROUND AND OBJECTIVES: High-powered magnets were effectively removed from the US market by the Consumer Product Safety Commission (CPSC) in 2012 but returned in 2016 after federal court decisions. The United States Court of Appeals for the 10th Circuit cited imprecise data among other reasons as justification for overturning CPSC protections. Since then, incidence of high-powered magnet exposure has increased markedly, but outcome data are limited. In this study, we aim to describe the epidemiology and outcomes in children seeking medical care for high-powered magnets after reintroduction to market. METHODS: This is a multicenter, retrospective cohort study of patients aged 0 to 21 years with a confirmed high-powered magnet exposure (ie, ingestion or insertion) at 25 children's hospitals in the United States between 2017 and 2019. RESULTS: Of 596 patients with high-powered magnet exposures identified, 362 (60.7%) were male and 566 (95%) were <14 years of age. Nearly all sought care for magnet ingestion (n = 574, 96.3%), whereas 17 patients (2.9%) presented for management of nasal or aural magnet foreign bodies, 4 (0.7%) for magnets in their genitourinary tract, and 1 patient (0.2%) had magnets in their respiratory tract. A total of 57 children (9.6%) had a life-threatening morbidity; 276 (46.3%) required an endoscopy, surgery, or both; and 332 (55.7%) required hospitalization. There was no reported mortality. CONCLUSIONS: Despite being intended for use by those >14 years of age, high-powered magnets frequently cause morbidity and lead to high need for invasive intervention and hospitalization in children of all ages.

Recurrence after laparoscopic high ligation in adolescents: A multicenter international retrospective study of ten hospitals.

PURPOSE: Inguinal hernia repairs are among the most common operations performed by pediatric surgeons. Laparoscopic high ligation is a popular technique, but its recurrence rate in adolescents is unknown. We hypothesized that recurrence after laparoscopic high ligation in adolescents would be similar to open repair (1.8%-6.3%). METHODS: We evaluated adolescent patients (12-18 years old at the time of surgery) who underwent laparoscopic high ligation across eleven hospitals. At least six months postoperatively, they were contacted by telephone for follow-up. Variables analyzed included demographics, operative details, recurrence, and other complications. RESULTS: A total of 144 patients were enrolled. One hospital (n=9) had a recurrence rate of 44.4%, compared to 3.0% (4/135) for the other hospitals. By accounting for 50.0% of recurrences, it represented a statistical outlier and was excluded, leaving 135 patients for analysis. The median age was 14 years, and 63.7% were male. Recurrence with the excluded center was 5.6% (8/144). Use of absorbable suture (OR 42.67, CI 4.41-412.90, p<0.01) and braided suture (OR 12.10, CI 1.54-95.25, p=0.02) was weakly associated with recurrence. Recurrence was not significantly different from published results. CONCLUSION: Laparoscopic high ligation of adolescent inguinal hernias has a recurrence rate similar to open repair when performed by experienced surgeons. TYPE OF STUDY: Prognosis study (retrospective study) LEVEL OF EVIDENCE: Level II.

Variability in perioperative evaluation and resource utilization in pediatric patients with suspected biliary dyskinesia: A multi-institutional retrospective cohort study.

INTRODUCTION: Biliary dyskinesia (BD) is a common indication for pediatric cholecystectomy. While diagnosis is primarily based on diminished gallbladder ejection fraction (GB-EF), work-up and management in pediatrics is controversial. METHODS: We conducted a multi-institutional retrospective review of children undergoing cholecystectomy for BD to compare perioperative work-up and outcomes. RESULTS: Six hundred seventy-eight patients across 16 institutions were included. There was no significant difference in gender, age, or BMI between institutions. Most patients were white (86.3%), non-Hispanic (79.9%), and had private insurance (55.2%). Gallbladder ejection fraction (EF) was reported in 84.5% of patients, and 44.8% had an EF <15%. 30.7% of patients were initially seen by pediatric surgeons, 31.3% by pediatric gastroenterologists, and 23.4% by the emergency department with significant variability between institutions (p < 0.001). Symptoms persisted in 35.3% of patients post-operatively with a median follow-up of 21 days (IQR 13, 34). On multivariate analysis, only non-white race and the presence of psychiatric comorbidities were associated with increased risk of post-operative symptoms. CONCLUSION: There is significant variability in evaluation and follow-up both before and after cholecystectomy for BD. Prospective research with standardized data collection and follow-up is needed to develop and validate optimal care pathways for pediatric patients with suspected BD. STUDY TYPE: Case Series, Retrospective Review. LEVEL OF EVIDENCE: Level IV.

Neonatal Intestinal Anastomosis Using a 5 mm Laparoscopic Stapler.

Recently, a 5 mm laparoscopic stapler entered the market and is currently used for a wide variety of pediatric applications. The aim of this article is to be the first report of the use of this 5 mm laparoscopic stapler for open neonatal intestinal anastomosis in humans. We used JustRight (Justright Surgical) 5 mm laparoscopic stapler® in 5 patients, with a total of six anastomoses being constructed. Enteroenterostomies after bowel resection were performed in these neonates with diagnoses of closed gastroschisis with ileal atresia, multiple intestinal atresia, ileal atresia, and jejunal atresia. Side-to-side, functional end-to-end, stapled anastomoses were performed in the standard antimesenteric manner. Using 2.5 cm long staple loads, the anastomoses approximated 1.5 cm. Minimal staple line overlap was incurred. Enteral feedings were initiated, and nutritional goals met, on postoperative days 8 and 15.2, respectively (means). Postoperative recovery was uneventful, notably without anastomotic complications of leak or stenosis. No long-term follow-up was done. The 5 mm laparoscopic stapler offers an attractive alternative in open neonatal intestinal anastomosis, particularly in both ease and time of anastomosis. Its more generalized use in neonatal intestinal reconstruction awaits further scientific investigation.

Concurrent testicular torsion and acute incarcerated inguinal hernia in an adolescent boy.

Testicular torsion and acute incarcerated inguinal hernia are both common surgical emergencies in the paediatric population. We present the unusual case of a 16-year-old adolescent boy who presented with both of these conditions concurrently. He had a history of a right inguinal hernia, but ultrasound confirmed a testicular torsion and we employed manual detorsion in the emergency department prior to taking him to the operating room. We successfully salvaged the testicle in addition to performing inguinal hernia reduction and repair. The goal of this report is to emphasise the importance of maintaining a broad differential and early utilisation of ultrasound in the patient with acute groin pain.

Palpable Undescended Testes: 15 Years of Experience and Outcome in Laparoscopic Orchiopexy.

BACKGROUND AND PURPOSE: Most of the current literature concerning laparoscopy in patients with cryptorchidism reports on those with nonpalpable testes. The purpose of this study is to share our experience and outcome in laparoscopic orchiopexy on patients with palpable undescended testes. PATIENTS AND METHODS: From January 1999 to July 2014, 240 cryptorchid testes were treated of which 192 (155 patients) were palpable and were operated on by laparoscopy. Before starting, the bladder is emptied with a Foley catheter. Four trocars are used: One 5 mm for the lens (45 degree), one 10 mm (transscrotal), and two 3 mm placed at the subcostal midclavicular line for the instruments. We localize the deep inguinal ring and open the peritoneum. The spermatic vessels and vas deferens are dissected in a cephalic direction. The epigastric vessels are dissected and sectioned to facilitate the localization of the testicle inside the canal. Once found, the testis is dissected and taken into the abdominal cavity where the gubernaculum testis is cut. A 10-mm trocar is introduced through the scrotal sac into the peritoneal cavity. The testicle is grabbed and pulled down to the scrotum where it will be fixed with a 5-0 polypropylene suture in the usual manner. RESULTS: Of 192 cryptorchid palpable testes treated with laparoscopy, only one procedure was converted to conventional open orchiopexy because of an ectopic testicle (above the aponeurosis of the oblique muscle). The rest of the testicles could be moved down to the scrotal sac. Our follow-up ranges from 6 months to 15 years, and we have not found atrophy in any of the testicles. To date, only two (0.4%) testicles have reascended. CONCLUSION: Laparoscopy is a great and safe option for patients with palpable undescended testes, regardless of its position in the inguinal canal.

Laparoscopic extravesical ureteral reimplantation (LEVUR): a multicenter experience with 95 cases.

INTRODUCTION: Minimally invasive techniques have been used to treat vesicoureteral reflux (VUR) on pediatric patients. The aim of this study is to review the experience of the laparoscopic approach for VUR by the laparoscopic extravesical ureteral reimplantation (LEVUR) Lich-Gregoir technique. MATERIALS AND METHODS: We performed a multicentric retrospective study. From 2001 to 2009, 81 pediatric patients with VUR constituting 95 ureteral units underwent LEVUR. Reflux was grade II in 32%, grade III in 55%, and grade IV in 8%. RESULTS: LEVUR was performed successfully on the 81 patients with 95 ureteral units. Mean operative time was 105 minutes for left-sided reimplants, 70 minutes for right sided, and 180 minutes for bilateral reimplants. Mean hospital stay was 1.6 days. Urinary catheter was kept in place for a mean time of 0.5 days. Follow-up was achieved for at least 1 year with regular clinic visits, urinalysis, ultrasound, and voiding cystourethrogram. Four patients (4.2%) had evidence of recurrent VUR in a follow-up of 6 to 36 months after antireflux surgery. CONCLUSIONS: Although new endoscopic techniques have been widely available for VUR, they have a lower success rate and might require multiple attempts before success. We report that LEVUR has an acceptable success rate (95.8%) and durability compared with open and endoscopic procedures.

Totally laparoscopic approach for failed conventional orchiopexy.

INTRODUCTION: About 0.2-10% of patients with prior orchiopexy will require reoperation for recurrent cryptorchidism. The most common approach for these patients has been an open inguinal repeat orchiopexy. The aim of this report is to show results and feasibility with the totally laparoscopic approach for failed prior open orchiopexy. SUBJECTS AND METHODS: Nine patients with 11 recurrent undescended testes were treated by the totally laparoscopic orchiopexy approach. We used a four-port technique, starting with laparoscopic dissection of the vas deferens and spermatic vessels as high as possible in order to get adequate length of these structures. The inguinal internal ring was opened, and the testis was dissected to finally bring it into the abdominal cavity. A transcrotal trocar was introduced all the way to the abdominal cavity to finally pull through the testis into the scrotum. RESULTS: Laparoscopic orchiopexy was performed satisfactorily in all but 1 case in a mean time of 90 minutes. We did not experience any perioperative complications. In a mean follow-up of 25 months there has not been any recurrent cryptorchidism or atrophic testis. DISCUSSION: Laparoscopy offers the advantage of achieving an extensive mobilization of spermatic vessels and a careful dissection of the vas deferens. The totally laparoscopic approach for a failed orchiopexy represents a feasible, safe, and successful procedure.

Laparoscopic pediatric inguinal hernia repair: no ligation, just resection.

BACKGROUND: There have been descriptions of several techniques for congenital inguinal hernia (CIH) repair in the pediatric population by doing high ligation of the sac, without a definitive advantage over the open procedure. High recurrence rates have been reported with using these minimally invasive techniques in which the patent processus vaginalis has been ligated and left in place completely or partially. METHODS: With approval of the ethics committee, a proper informed consent was obtained. During July 2003 to April 2008, we performed the inguinal hernia repair on 91 patients (76 males and 15 females), using a laparoscopic technique in which we completely resected the patent processus vaginalis and the parietal peritoneum surrounding the internal inguinal ring. This allowed the peritoneal scar tissue to close the area of the ring. Also, this scarring occurs in the extent of the inguinal canal where the dissection took place, therefore causing the same peritoneal scarring and sealing of the inguinal floor. In this series, a purse string was done only in the cases with an internal ring wider than 10 mm. RESULTS: There were no conversions. Operative time was in the range of 35-72 minutes (average, 40). Close follow-up in the clinic has been 5 months to 4 years without a single recurrence. In 4 cases, 3 months later, we did a laparoscopic evaluation of the contralateral side due to associated cryptorchidism, in which we were able to confirm a complete closure of the interior inguinal ring. Two small hematomas were followed until they were gone, without further need for intervention. DISCUSSION: No recurrences have been observed. We conclude that laparoscopic repair of CIH is feasible using this technique of complete resection of the processus vaginalis and surrounding parietal peritoneum. This series does not conclude on the need for the internal ring to be closed when found to be wider than 10 mm.

Laparoscopic choledochal cyst excision: lessons learned in our experience.

BACKGROUND: Choledochal cyst (CDC) is a rare biliary disorder. Surgical treatment consists of CDC excision and biliary-enteric reconstruction. Recently, some institutions have reported successful CDC excision by using minimally invasive techniques. In this study, we report our experience with the laparoscopic management of CDC, with a focus on key operative maneuvers that enhance the likelihood of successful excision. METHODS: Following institutional review board approval, we performed a retrospective review of patients who underwent the laparoscopic excision of CDC and Roux-en-Y hepaticojejunostomy. Between October 2003 and November 2007, we performed laparoscopic CDC excision in 9 patients (8 female and 1 male). Median age was 4 years (range, 8 months to 16 years). There were 7 type I and 2 type IV cysts, according to Todani's classification. Average cyst size was 4.4 cm (range, 1.3-8.5). The procedures were performed by utilizing four or five trochars. RESULTS: Six of 9 children presented with preoperative pancreatitis, 1 with abdominal pain, 1 with jaundice, and 1 was found incidentally. Three patients required the conversion to laparotomy due to dense adhesions, secondary to pancreatitis. Six patients underwent successful laparoscopic procedures, 5 had complete cyst excisions, and 1 underwent a proximal excision with distal mucosectomy. Of the 3 patients who required conversion, 2 underwent complete excisions; the other underwent a proximal excision, distal mucosectomy. There were no intraoperative complications. One patient had a postoperative bile leak that required an open hepaticojejunostomy revision. Eight patients had an uneventful recovery. Oral feedings were resumed within an average of 3.4 days (range, 2-9). Average time to discharge was 6.1 days (range, 5-12). Average follow-up time was 18 months (range, 4-48). No further laboratory abnormalities were detected in any of the patients. CONCLUSIONS: Laparoscopic resection of CDC and Roux-en-Y hepaticojejunostomy in children is an excellent treatment option. Preoperative pancreatitis may cause increased technical difficulty, necessitating a conversion. Proximal excision with distal mucosectomy

Thoracoscopic repair of neonatal diaphragmatic hernia.

INTRODUCTION: The use of minimally invasive surgery (MIS) in the neonatal population is increasing. Thoracoscopic intervention for congenital diaphragmatic hernia (CDH) is no exception. In this report, we describe our initial experience with thoracoscopic repair of left-sided diaphragmatic defects in neonates. MATERIALS AND METHODS: We performed retrospective chart reviews on all neonates who underwent thoracoscopic repair of CDH between November 2004 and January 2008. Neonates that underwent thoracoscopic repair were physiologically stable with resolved pulmonary hypertension and minimal to moderate ventilatory support. They had no associated cardiac anomalies. RESULTS: We identified 15 neonates with CDH who underwent thoracoscopic repair during the study period. Ten neonates underwent primary repair of the diaphragmatic defect. Five neonates with large defects required closure with a synthetic patch, which was placed thoracoscopically. The average operating room time was 134 minutes. There were no instances of intraoperative respiratory or cardiac instability. Three patients had a recurrence. One recurrence was seen after thoracoscopic patch repair. Two recurrences occurred following primary repair of left diaphragmatic hernias. There were no deaths. Follow-up has been 4-40 months. CONCLUSIONS: Neonatal MIS for CDH should be limited to stable patients. The ideal candidate is the newborn without associated anomalies, not requiring extracorporeal membrane oxygenation, on minimal ventilatory support, and without evidence of pulmonary hypertension. It is technically possible to perform thoracoscopic repair with a patch.

Incidence and management of the inguinal hernia during laparoscopic orchiopexy in palpable cryptoorchidism: preliminary report.

During the laparoscopic approach of undescended testis, an associated inguinal hernia is a frequent finding that must be treated at the same time. The objective of this presentation is to show the incidence and management of the inguinal hernia that were found during laparoscopic orchidopexy, reporting how the scar tissue will join the edges of the canal and the parietal peritoneum will grow above. Between January 1999 and December 2002, 31 patients with 33 palpable and nonpalpable undescended testes were treated by laparoscopic orchidopexy. Patients were between 6 months and 9 years. We used four ports, and 2 mm instrument. When an associated inguinal hernia were found we only removed the membranes of the processus vaginalis and did not close the defect. All cases were treated by the same surgeon. The average surgical time was 50 min that included the orchiopexy and the treatment of the associated inguinal hernia. We found inguinal hernia in 23 cases (69.9%). We did not find any inguinal hernia in the opposite side of the undescended testis. In two patients with bilateral undescended testis that were approached in two stages 3 months later we confirmed the closure of the hernia defect. These 23 patients have 21.5 months average follow up and confirm no recurrence. With an average follow up of 21.5 months, we found no inguinal hernia in any of the patients. A larger volume study with longer follow up is needed to confirm that there is no need for closure of the internal inguinal ring during laparoscopic orchidopexy.