Robotic infant surgery with 3 mm instruments: a study in piglets of less than 10 kg body weight.

No data exist concerning the appication of a new robotic system with 3 mm instruments (Senhance®, Transenterix) in infants and small children. Therefore, the aim of this study was to test the system for its feasibility, performance and safety of robotic pediatric abdominal and thoracic surgery in piglets simulating infants with a body weight lower than 10 kg. 34 procedures (from explorative laparoscopy to thoracoscopic esophageal repair) were performed in 12 piglets with a median age of 23 (interquartile range: 12-28) days and a median body weight of 6.9 (6.1-7.3) kg. The Senhance® robotic system was used with 3 mm instruments, a 10 mm 3D 0° or 30° videoscope and advanced energy devices, the setup consisted of the master console and three separate arms. The amount, size, and position of the applied ports, their distance as well as the distance between the three operator arms of the robot, external and internal collisions, and complications of the procedures were recorded and analyzed. We were able to perform all planned surgical procedures with 3 mm robotic instruments in piglets with a median body weight of less than 7 kg. We encountered two non-robot associated complications (bleeding from the inferior caval and hepatic vein) which led to termination of the live procedures. Technical limitations were the reaction time and speed of robotic camera movement with eye tracking, the excessive bending of the 3 mm instruments and intermittent need of re-calibration of the fulcrum point. Robotic newborn and infant surgery appears technically feasible with the Senhance® system. Software adjustments for camera movement and sensitivity of the fulcrum point calibration algorithm to adjust for the increased compliance of the abdominal wall of infants, therefore reducing the bending of the instruments, need to be implemented by the manufacturer as a result of our study. To further evaluate the Senhance® system, prospective trials comparing it to open, laparoscopic and other robotic systems are needed.

Transumbilical laparoscopic-assisted versus 3-port laparoscopic and open appendectomy: a case-control study in children.

INTRODUCTION: Aim of this study was to compare the short-term outcome of transumbilical laparoscopic-assisted (TULAA) with laparoscopic (LA) and open appendectomy (OA) in a case-control study. MATERIALS AND METHODS: Our first 20 consecutive children with appendicitis treated with TULAA were matched to 20 patients treated with LA and OA, respectively. Matching criteria were age, sex, and the histology of appendicitis. The children were retrospectively evaluated for outcome, efficacy, and complications. RESULTS: No significant differences between the groups were found, except that children operated by OA required less analgesics than children operated by LA and TULAA. DISCUSSION: TULAA appears to be a safe procedure with no disadvantage except for postoperative pain, which needed a longer course of analgesics compared to OA. Whether TULAA has advantages over LA and OA has to be evaluated in larger prospective series.

Differentiation of epididymitis and appendix testis torsion by clinical and ultrasound signs in children.

OBJECTIVE: To identify the signs that can help to differentiate torsion of the appendix testis (AT) and epididymitis and to establish the incidence of the various pathologic entities in boys with an acute scrotum. MATERIALS AND METHODS: A retrospective study was performed of the data from all boys treated at our institute from January 2008 to January 2012 for the diagnosis of an "acute scrotum." The clinical and, if available, ultrasound findings were documented. Differences between groups were calculated using a chi-square test or analysis of variance and classification and regression tree analysis. RESULTS: A total of 241 boys with acute scrotal pain were included and underwent surgical exploration. Of the 241 boys, 163 (70%) had AT, 44 (18.5%) had epididymitis, 31 (13.3%) had testicular torsion, and 3 (1.3%) had idiopathic scrotal edema. The incidence of AT was significantly increased in the colder months (P = .01). We found that AT and epididymitis shared several aspects but differed regarding dysuria (epididymitis, P ≤.001), a painful epididymis on palpation (epididymitis, P = .028), increased epididymal echogenicity (epididymitis, P = .043), augmented peritesticular perfusion (epididymitis, P = .05), and a positive blue dot sign (AT, P <.001). The classification and regression tree analysis showed that the presence of dysuria, a positive blue dot sign, and a painful epididymis are the best factors for distinguishing AT and epididymitis. CONCLUSION: Most children with an acute scrotum will have AT or epididymitis. It will be possible to differentiate most cases using the clinical and ultrasound findings. In our study, the best predictors were dysuria, a painful epididymis on palpation, and altered epididymal echogenicity and increased peritesticular perfusion found on ultrasound studies for epididymitis and a positive blue dot sign for AT.

Rectum perforation after broomstick impalement in a 17-year-old: case report and review.

Impalement injuries are uncommon, especially in the pediatric population. Because of the rarity of these injuries, physicians may have difficulty recognizing and treating impalement injuries appropriately. Clinical findings are sometimes innocuous, but can be life threatening. Therefore, evaluation of suspected impalement injury should involve careful history and thorough physical examination, even if there is no evidence of trauma to the perineum. We report a very rare case of rectum perforation after transanal introduction of a broomstick with almost no clinical findings. Impalement injuries are difficult to recognize, and severity may not be reflected by their external appearance. To diagnose these injuries in time, it is important to use a well-organized workup.

Clinical predictors of testicular torsion in children.

OBJECTIVE: To distinguish the prognostic factors that decrease the probability of a negative exploration for "acute scrotum." In some institutes, patients with "acute scrotum" undergo immediate exploration after clinical evaluation. Because testicular torsion (TT) accounts only for a fraction of these cases, most infants can be treated conservatively. METHODS: We performed a retrospective study of all patients treated at our institute from January 2008 to December 2009 for the diagnosis of "acute scrotum." Differences between groups were calculated using the chi-square test or analysis of variance and Mann-Whitney-Wilcoxon test for univariate or multivariate analysis, expressed as odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: The data from 138 patients were analyzed. The mean age was 9 years, 8 months. Of the 138 patients, 19 (13.8%) had TT. This group was compared with the boys without TT at exploration. The patients with TT were older on average (11 years, 1 month vs 9 years, 1 month, p = .035). Pain for <24 hours (OR 4.2, 95% CI 1.3-13.4), nausea and/or vomiting (OR 21.6, 95% CI 4.9-93.4), abnormal cremasteric reflex (OR 4.8 95% CI 0.7-35.2), and a high position of the testis (OR 18.0 95% CI 1.8-177.1) were associated with an increased likelihood of torsion. In the group of boys with ≥ 2 of these findings present, 100% had TT at exploration, with 0% false-positive results. CONCLUSION: TT is uncommon among the group of boys treated for "acute scrotum." In particular, a pain duration <24 hours, nausea or vomiting, a high position of the testis, and an abnormal cremasteric reflex had a positive prognostic value for TT. A clinical score might help to avoid unnecessary explorations. In the future, we intend to test the diagnostic set described combined with ultrasonography.