Comparison of surgical outcomes between laparoscopic percutaneous extracorporeal closure (LPEC) and open repair for pediatric inguinal hernia by propensity score methods and log-rank test analysis.

BACKGROUND: Despite a number of studies comparing laparoscopic inguinal hernia repair (LH) and open herniorrhaphy (OH), the putative advantage of LH remains controversial due to a paucity of firm evidence. We hypothesized that LH has both advantages and disadvantages compared to OH and sought to clarify them by comprehensively analyzing the retrospective data using the combination of multiple statistical methods. METHODS: Operative data for inguinal hernia during the period from February 1999 to December 2019 were examined. The patients were assigned into two groups according to the surgical procedure: laparoscopic percutaneous extraperitoneal closure (LPEC, n = 2410) and OH (n = 2038). Operative and anesthesia times and incidence of postoperative complications were evaluated using the propensity score methods and log-rank test. RESULTS: In comparison with OH, operative time of LPEC was longer for unilateral repair (21.59 ± 8.1 min vs 18.01 ± 8.0 min; p < 0.001) and shorter for bilateral repairs (28.55 ± 10.1 min vs 33.23 ± 11.7 min; p < 0.001), while anesthesia times were longer for both unilateral repair (57.67 ± 10.1 min vs 40.62 ± 11.9 min; p < 0.001) and bilateral repairs (65.95 ± 12.5 min vs 56.35 ± 15.1 min; p < 0.001). LPEC significantly reduced the risk of metachronous contralateral hernia (MCLH) (0.52% vs 9.29%; p < 0.001), but the recurrence rate was higher (0.21% vs 0.04%; p = 0.002) than OH. Orchiectomy due to testicular atrophy or torsion was required in 3 cases of OH (0.19%), whereas it was not seen in LPEC. CONCLUSIONS: LPEC had a less risk of MCLH and testicular complications but was associated with a higher recurrence rate and longer anesthesia time. Propensity scoring techniques can enhance the robustness of retrospective comparisons between groups over several years of data collection, which is frequently required in pediatric surgery studies.

Can Intraoperative Video Recordings Contribute to Improving Laparoscopic Percutaneous Extraperitoneal Closure in Children with Inguinal Hernia and Prevent Recurrence? A Pilot Study.

Aim: We reviewed intraoperative video recordings (IVRs) of laparoscopic percutaneous extraperitoneal closure (LPEC) for inguinal hernia in children blindly to assess performance. Methods: IVRs of 183 LPEC performed between April 2013 and March 2016, graded by the operating surgeon as difficult (D; n = 8), straightforward (S; n = 96), or easy (E; n = 79), were scored by a panel of reviewers with advanced (group A; >400 LPEC cases; n = 5), intermediate (group I; 50-150 cases; n = 5), and basic (group B; <10 cases; n = 5) experience, according to suturing, dissection plane, vas/vessel dissection, bleeding, and peritoneal injury. They also allocated a recurrence risk rank (RRR; highest = 6; lowest = 1) for each IVR. Mean score variance for each IVR was also compared between reviewers. Results: There was one recurrence (R; 4-year-old male; level E). RRR were: 1, 2, and 2 for reviewers A, I, and B, respectively. Reviewer A scores for "suturing" and "bleeding," and reviewer I scores for "dissection plane" and "peritoneal injury" correlated significantly with RRR. No reviewer B scores correlated with RRR. Score variance between A and I and A and B for cases D1 and D2 were statistically significant. Conclusion: Advanced reviewers showed greatest variance, questioning the validity of whether experience alone improves surgical technique.

The learning curve of laparoscopic percutaneous extraperitoneal closure (LPEC) for inguinal hernia: protocoled training in a single center for six pediatric surgical trainees.

BACKGROUND: Laparoscopic percutaneous extraperitoneal closure (LPEC) has become a common procedure for repairing inguinal hernia. As a laparoscopic approach, pediatric surgical trainees require more training to learn LPEC than a traditional open approach. This study aimed to clarify the experience needed to acquire the skill to perform LPEC adequately. METHODS: This descriptive single-center study used clinical data from patients who underwent LPEC between May 2009 and May 2016. The mean operative time for ten consecutive unilateral repairs was used as an index of proficiency with the procedure. The number of repairs performed before the mean operative time became less than 20 min was evaluated for each trainee. RESULTS: During the study period, six pediatric surgical trainees participated in the training independently. The number of the patients was 987. The total number of repairs was 1436, including 538 unilateral repairs and 449 concurrent bilateral repairs. Overall, the mean operative time was 21.8 ± 8.1 min for unilateral repair and 31.4 ± 9.7 min for concurrent bilateral repairs. The mean number of repairs performed before the acquisition of skill for dexterous LPEC was 125.1 ± 29.5. CONCLUSIONS: Although there were individual differences, all trainees acquired the skill to perform LPEC adequately within one year. With appropriate guidance, LPEC can become a standard technique for pediatric surgical trainees, along with traditional open surgery. These results provide valuable information for planning LPEC training.

Comparison of laparoscopic percutaneous extraperitoneal closure versus conventional herniotomy in extremely low birth weight infants.

PURPOSE: Laparoscopic percutaneous extraperitoneal closure (LPEC) has become routine for repairing pediatric inguinal hernia (IH). Reports on the effective repair of IH in challenging cases, such as extremely low birth weight infants (ELBWI) who become symptomatic soon after birth and have surgery before 1 year of age, are rare; and conventional herniotomy (CH) in ELBWI requires extensive experience of neonatal surgery. We compared LPEC with CH for treating ELBWI with IH. METHODS: Consecutive ELBWI with IH treated by either LPEC (n = 17) or CH (n = 22) before 1 year of age between 2012 and 2017 were reviewed. LPEC were performed by consultant pediatric surgeons (CPS; n = 3) with experience of at least 200 cases each. In CH, 11 cases were treated by CPS and 11 by CPS-supervised surgical trainees. RESULTS: There were no intraoperative complications. Operative time and anesthesia time for bilateral IH repairs were both shorter in LPEC. Postoperative sequelae were recurrence (LPEC; n = 1; repaired by redo LPEC 2 months after the initial repair) and intravenous rehydration (CH; n = 1; for persistent post-anesthetic vomiting). Recovery was unremarkable in all cases without additional analgesia. CONCLUSION: LPEC would appear to be a viable option for treating IH in ELBWI, especially bilateral cases.

Anatomical Segmentectomy with a Hybrid VATS Approach in a Patient with Intralobar Pulmonary Sequestration after Severe Pneumonia: A Case Report.

Anatomical segmentectomy is an advantageous procedure because it spares healthy lung that has potential to show compensatory growth after lung resection and decreases the risk of air leak and residual resection, which becomes a problem in wedge resection. However, anatomical segmentectomy has not become a common procedure in pediatrics because it requires more complicated procedure than lobectomy or wedge resection, especially in patients with a history of pulmonary infection. In this case report, anatomical basal segmentectomy was safely performed with magnified vision by a hybrid video-assisted thoracic surgery (VATS) approach in a 6-year-old girl with intralobar pulmonary sequestration after severe pneumonia. The result suggests that the indications for hybrid VATS segmentectomy can expand further to include segmental lesions in children.

Blunt pancreatic duct injury in children.

Case: A 10-year-old boy sustained a blunt injury to the pancreatic neck with complete transection of the main pancreatic duct. Because endoscopic catheterization across the rupture site was not possible, an endoscopic nasopancreatic drain was inserted through the proximal pancreatic duct into the retroperitoneum. An emergency laparotomy was carried out, during which time the tube was used as a guide for identifying disrupted pancreatic ducts. Damaged tissue was removed, the proximal pancreatic duct was ligated, and a Roux-en-Y distal pancreaticojejunostomy was carried out. Outcome: The patient was discharged 49 days after surgery. Conclusion: Preoperative catheterization of the transected pancreatic duct is an option for detecting a disrupted main pancreatic duct.

[Two cases of gastrointestinal stromal tumor (GIST) of the stomach and a consideration of its malignancy potential and treatment strategy - report of two cases].

We report two cases of large gastrointestinal stromal tumor (GIST) of the stomach both of which were assessed as highly malignant, but took different clinical courses. Case 1: A 72-year-old male. Case 2: A 63-year-old female. The tumor size of Case 1 was suggestive of high malignancy, but only a partial gastrectomy was selected because it did not show any invasive findings. This patient has been followed up for 3 years post-operatively and no recurrence or metastasis has been noted. Case 2 had liver and lymph node metastases, which was consistent with high malignancy. We performed a total gastrectomy with distal pancreatosplenectomy and segmental liver resection. But after surgery, liver metastasis recurred therefore, imatinib mesylate was administered as adjuvant chemotherapy and since then, the tumor has been diminishing in size. No definitive evidence for adjuvant therapy has been established so far, but we suggest that post-operative adjuvant therapy is effective for high-risk GIST.

Laparoscopic splenopexy for wandering spleen: extraperitoneal pocket splenopexy.

Wandering spleen is a very rare disease. It is a very dangerous condition due to the risk of splenic ischemia from persistent pedicle torsion. Here, we describe a case of wandering spleen diagnosed by ultrasound and computed tomography scans in an 11-year-old boy who suffered from frequent urination and enuresis. A laparoscopic splenopexy was successfully performed with fixation of the spleen in an extraperitoneal pocket. Since the operation, the organ has remained in place with good perfusion. The details of the procedure are described.