Laparoscopic inguinal hernia repair (LIHR): the benefit of the double stitch in the largest single-center experience.

AIM: To review our experience of laparoscopic inguinal hernia repair (LIHR) regarding complication rates, the practice of closing the asymptomatic patent processes vaginalis (PPV), and comparison of complication rates between pre-term (< 37 week gestation) and term infants. METHODS: Retrospective review of LIHR performed between 2009 and 2021. Repair was performed by intracorporal single or double purse string/purse string + Z-stitch using a non-absorbable suture. Data were analyzed using Chi-squared/Mann-Whitney and are quoted as median (range). RESULTS: 1855 inguinal rings were closed in 1195 patients (943 (79%) male). 1378 rings (74%) were symptomatic. 492 (41%) patients were pre-term. Corrected gestational age at surgery was 55 weeks (31 weeks-14.6 years) and weight 5.9 kg (1-65.5). Closure of contralateral PPV was higher in the premature group (210/397 [53%] vs. 265/613 [43%] p = 0.003). There were 23 recurrences in 20 patients, of whom 10 had been born prematurely. The only factor significantly associated with a lower recurrence was use of a second stitch (p = 0.011). CONCLUSION: This is the largest single-center reported series of LIHR. LIHR is safe at any age, the risk of recurrence is low, and can be corrected by re-laparoscopy. Use of a Z-stitch or second purse string is associated with a significantly lower rate of recurrence.

Aortopexy for tracheomalacia via a suprasternal incision.

AIM: Tracheomalacia is flaccidity of the tracheal wall leading to tracheal collapse, particularly on expiration. When severe it can warrant surgical intervention. Aortopexy is one surgical option and has been described using a variety of approaches. We report outcomes of aortopexy performed via a suprasternal incision in a single centre by a single surgeon. METHODS: All patients undergoing aortopexy between February 2016 and May 2018 were prospectively included. Patients were managed by a multi-disciplinary team (MDT) and underwent standardized work-up, including dynamic flexible bronchoscopy (DFB) and contrast enhanced CT. Aortopexy was performed via a suprasternal skin crease incision. Surgery was guided by intra-operative flexible bronchoscopy. Data regarding pre-operative symptoms, degree of tracheomalacia, and outcomes were recorded. RESULTS: Twenty-two patients were included, 18 boys, median age 5 months (range 1 month-5 years). Two aortopexy sutures were used in all cases, and three patients required an additional tracheopexy suture. Median operating time was 1 h 24 min (range 47 min-2 h 35 min). Median pre-operative tracheal collapse on DFB was 85% (range 80-95%), improving to 35% (35-80%) intra-operatively. Median length of stay was 4 days (range 1-118). CONCLUSIONS: Aortopexy via a suprasternal incision is a useful treatment modality for tracheomalacia with short operating times and rapid recovery. Outcomes vary with the best results in the TOF and premature groups. Careful patient selection and MDT work-up are essential to optimize outcomes. LEVEL OF EVIDENCE: Level 3 (Case Series).

Autologous intestinal reconstructive surgery to reduce bowel dilatation improves intestinal adaptation in children with short bowel syndrome.

OBJECTIVES: Intestinal failure (IF) is a common consequence of neonatal small bowel pathology. In our experience, bowel dilatation is often responsible for the IF state in patients who fail to adapt despite adequate residual bowel length. The aim of the present study was to investigate the role of surgery to reduce bowel dilatation, and thus favour PN independence, for these children. METHODS: Data were collected prospectively for all of the patients referred to our unit for a 7-year period (2004-2011). Eight patients (2 congenital atresia, 2 gastroschisis with atresia, 1 simple gastroschisis, 3 necrotising enterocolitis) with gut dilatation who failed adaptation despite a bowel length >40 cm were identified. Preoperatively, all patients were totally dependent on parenteral nutrition (PN). Patients were managed by longitudinal intestinal lengthening and tailoring (n = 3), serial transverse enteroplasty (n = 2), or tapering enteroplasty (n = 3). RESULTS: Median age at time of surgery was 273 days (103-1059). Mean gut length increased from 51 (35-75) to 73 cm (45-120) following surgery (P = 0.02). Incidence of sepsis (P = 0.01) and peak serum bilirubin levels (P = 0.005) were reduced postoperatively. PN was discontinued after a median of 110 days (35-537) for 7 patients; 1 patient remains on PN 497 days after surgery. CONCLUSIONS: These data indicate that reconstructive surgery to reduce bowel diameter may be an effective technique for treating IF in patients with short bowel syndrome, without sacrificing intestinal length. We suggest that this technique may reduce the need for bowel transplantation in this group of patients.