Adolescent inguinal hernia repair: a review of the literature and recommendations for selective management.

BACKGROUND: The choice of how to repair inguinal hernias in adolescents has historically been a matter of experience and differed between pediatric surgeons who traditionally performed a high ligation of the sac and general surgeons who typically perform a repair using mesh. This up-to-date review thoroughly examines the subject and discusses the suitability of both types of repairs in this unique age group. METHODS: A 20-year Pub Med search was performed for the following terms: adolescent hernia repair including reports of mesh hernia repair in adolescents and postoperative complications including chronic inguinal pain and recurrences. RESULTS: The evidence in the literature suggests that while there appears to be no difference between the two types of repairs with regards to recurrence and complications, changes in the pelvic floor physiology in adolescents suggest that a selective, individualized approach can be recommended depending on the size and nature of the presenting pathology. CONCLUSIONS: A selective approach to the inguinal hernia in adolescent patients based on the size of the defect appears justified.

Glucagon deficiency and hyperaminoacidemia after total pancreatectomy.

The first goal of this study was to investigate whether totally pancreatectomized patients are glucagon deficient and if so, to what degree. Immunoreactive glucagon (IRG) concentrations in peripheral plasma of nine pancreatectomized patients were not significantly different from those of 10 normal controls as measured by two antisera (30-K and RCS-5) both detecting the COOH-terminal portion of the molecule and one (RCS-5) postulated to be specific for pancreatic glucagon. Plasma from six of nine pancreatectomized patients were fractionated over Sephadex G-50 and IRG was measured with both antisera in the column eluates. Using 30-K, 80.8 +/- 9% of the IRG eluted within the void volume. This material was rechromatographed on Sephadex G-200 and found to have an apparent mol wt of approximately 200,000. Only 18.3 +/- 9% eluted in the IRG3500 region. IRG3500 was significantly reduced in pancreatectomized patients as compared to normal controls (49 +/- 9 vs. 18 +/- 9 pg/ml, P less than 0.05). Using RCS-5, all IRG (corresponding to 20 +/- 6 pg/ml of plasma) eluted in the IRG3500 region. The second goal of this study was to investigate the effects of chronic glucagon deficiency on plasma amino acids. In the nine pancreatectomized patients studied, postabsorptive plasma concentrations of serine, alanine, arginine, glycine, threonine, citrulline, alpha-aminobutyrate, and tryosine were significantly elevated compared to values obtained from 20 normal controls. Physiological glucagon increments produced in two pancreatectomized patients by infusion of glucagon (6.25 and 8.0 microgram/h, respectively) resulted in normalization of the hyperaminoacidemia within 22 h. We conclude (a) that pancreatectomized patients are partially glucagon deficient because of diminished basal as well as diminished stimulated glucagon secretion; (b) that fasting concentrations of certain glucogenic amino acids are elevated in pancreatectomized patients probably as result of reduce; hepatic gluconeogenesis; and (c) that the RCS-5 antiserum is not "pancreatic glucagon" specific.

The current role of laparoscopic surgery for gastroesophageal reflux disease in infants and children.

BACKGROUND: The benefits of surgery for gastroesophageal reflux disease (GERD) in infants and children have been questioned in the recent literature. The goal of this review was to determine the best current practice for the diagnosis and management of this disease. METHODS: The literature was reviewed for all recent English language publications on the management of GERD in 8- to 10-year-old patients. RESULTS: In infants and children, GERD has multiple etiologies, and an understanding of these is important for determining which patients are the best surgical candidates. Proton pump inhibitors (PPIs) have become the mainstay of current treatment for primary GERD. Although laparoscopic surgery appears to be better than open surgery, there remains some morbidity and complications that careful patient selection can minimize. CONCLUSION: Surgery for GERD should be performed only after failure of medical management or for specific problems that mandate it.

Two-year experience with minimally invasive herniorrhaphy in children.

BACKGROUND: Laparoscopic herniorrhaphy in pediatrics is rarely performed. We evaluated our 2-year experience of minimally invasive inguinal herniorrhaphy in children. METHODS: All procedures were performed under general anesthesia using <2-mm instruments and scopes and a surgical awl to accomplish high ligation of the hernia sac under direct vision. RESULTS: A total of 90 consecutive children (76 males and 14 females) older than the age of 6 months underwent a minimally invasive herniorrhaphy (60 unilateral and 30 bilateral; total of 120 hernias repaired). Seventeen children underwent herniorrhaphy in conjunction with another procedure. All children who underwent herniorrhaphy alone were discharged immediately and allowed unrestricted activity. Only four patients requested a narcotic analgesic. There was one recurrence early in the series (0.83%), prompting a change in technique. CONCLUSIONS: Minimally invasive inguinal herniorrhaphy in children is a safe alternative for the experienced pediatric laparoscopist. There is a similar recurrence rate as that of the traditional open approach with a superior cosmetic result.

Selective management of injured spleen.

During the past 6 years, 68 consecutive children suffering from splenic trauma have been treated according to a selective management plan. Twenty-two patients (32%) underwent splenectomy, parenchymal repair was performed on 16 occasions (24%), and nonoperative treatment was employed in 30 children (44%). Overall results have been good in all three groups. Two children (3%) died as a result of their injuries, and 10 complications were recorded. Both deaths and 7 of the 10 complications occurred in the patients undergoing splenectomy. By utilization of a basic management plan that favors nonoperative treatment over splenic repair and repair over splenectomy, splenic salvage has been successfully accomplished in 86% of the 49 patients treated since 1977.

Vascular sling with tracheomalacia: surgical management.

Surgical repair of pulmonary artery sling without concomitant correction of associated tracheal abnormalities has yielded poor results in the past. We combined vascular sling repair done during cardiopulmonary bypass through a median sternotomy incision with tracheopexy for severe associated tracheomalacia in 2 infants. Neither experienced substantial postoperative respiratory difficulties and both had patent vascular anastomoses at 1 year after repair, thus supporting this approach when this combination of lesions is present.

Rhabdomyosarcoma presenting as a cutaneous nodule.

Two patients with rhabdomyosarcoma presented clinically with dermal nodules on the face. The first patient was a 12-month-old girl with a 2 X 3-cm-diameter red nodule on her left cheek that had begun as a small red papule when she was 3 months old and had progressively increased in size. The second patient was a 19-year-old girl who presented with an enlarging mass on her right cheek that had begun as a pea-sized nodule three months previously. In both cases, biopsies revealed a rhabdomyosarcoma in the underlying soft tissue with extension into the overlying dermis. Rhabdomyosarcoma presenting as a dermal nodule is rare. It usually presents as an asymptomatic papule without distinctive clinical features and therefore may result in delayed diagnosis unless a biopsy is performed.

Epithelioid hemangioendothelioma of the lung (intravascular bronchioloalveolar tumor) in a young girl.

This report describes a 7 year old girl who presented with scoliosis and a small right hemithorax. Findings on spine roentgenographs were pleural thickening on the right and parenchymal densities. Computed tomography of the chest and abdomen revealed multiple pulmonary nodules and two hypervascular lesions within the liver. The diagnosis established by lung biopsy was intravascular bronchioloalveolar tumor (epithelioid hemangioendothelioma of the lung). This is the youngest reported case of this rare tumor.

Ibuprofen therapy in experimental porcine gram-negative septic shock.

To evaluate the effects of ibuprofen on gram-negative septic shock, immature piglets were subjected to fecal-Escherichia coli peritonitis. Group I (n = 5) received a 12.5 mg/kg bolus of ibuprofen in 0.9% benzyl alcohol, followed by a continuous infusion of 6.25 mg/kg/h. Group II (n = 5) received the vehicle, benzyl alcohol, and Group III (n = 5) received lactated Ringer's solution. Mean survival times among the three groups were not significantly different. Ibuprofen-treated animals had a mean survival time (+/- S.E.M.) of 17.1 +/- 2 h vs. 19.2 +/- 2.4 h in the benzyl alcohol group and 15.7 +/- 2.7 h in the animals receiving lactated Ringer's solution. Thromboxane B2 levels were not significantly different in the treatment vs. non-treatment groups while 6-keto-PGF1a levels were significantly lower in the ibuprofen-treated animals. Neutropenia and thrombocytopenia were not prevented by treatment with ibuprofen.

Treatment of intestinal ischemia with oxygenated intraluminal perfluorocarbons.

Liquid perfluorocarbons are biologically inert compounds capable of dissolving up to 40 percent oxygen by volume. This remarkable and reversible oxygen solubility has encouraged investigations into therapeutic application in situations where tissue oxygen delivery is impaired. One such setting is intestinal ischemia. Identically prepared devascularized segments of rat intestine were treated with either intraluminal oxygenated perfluorocarbon (perfluorotributylamine) or physiologic saline solution. After timed sacrifice, blinded quantitative histologic evaluation for ischemic injury was performed. The perfluorotributylamine treatment groups had histologic scores indicative of less severe injury between 1 and 4 hours. These scores achieved statistical significance (p less than 0.05). We conclude that intraluminal oxygenated perfluorocarbons have a significant protective effect in this model of intestinal ischemia. This quantitative analysis is unique and is an important aspect of the preclinical evaluation of the perfluorocarbon preparations.

Hexosaminidase: a biochemical marker for necrotizing enterocolitis in the preterm infant.

To evaluate hexosaminidase as a biochemical marker for the early detection of necrotizing enterocolitis in preterm infants, 33 preterm infants without necrotizing enterocolitis and 18 preterm infants with necrotizing enterocolitis had hexosaminidase activity measured during the course of their hospitalization. Although hexosaminidase activity could not identify those preterm infants with necrotizing enterocolitis who had impending perforation, the data strongly suggest that measurements of serum hexosaminidase activity may provide an early biochemical indication of the presence of necrotizing enterocolitis in the preterm infant. Hopefully, early detection of necrotizing enterocolitis in these infants will reduce the morbidity and mortality of this disease.

Evolving uses of laparoscopy in children.

As the technology evolves, the number of procedures that can be performed laparoscopically will continue to expand (Table 3). The impact on the field of pediatric surgery, which encompasses surgical oncology, gastrointestinal surgery, trauma, and gynecologic surgery, will be significant. There are several hurdles for the pediatric surgeon to overcome before beginning operative laparoscopy. The acquisition of the initial instrumentation is expensive, and the credentialing process may be time-consuming. And there remains a healthy suspicion on the part of many pediatric surgeons that these techniques represent a fad. We believe that operative laparoscopy has advantages and disadvantages. Some of the procedures require more time and are frequently tedious, thus trying the patience of the surgeon. It is difficult for experienced surgeons to subject themselves electively to the learning curve associated with a new procedure. While the benefits are mostly in the postoperative period, we believe exposure is vastly improved in obese patients. Patients appear to have less pain and postoperative ileus, and they may return to unrestricted activity sooner. We are still discovering which laparoscopic procedures can be done safely to the patient's advantage. Solving the dilemma of what procedures should be performed using laparoscopic techniques will require extensive experience and study, and minimally invasive surgery will be a subject of controversy and debate for many years. It is difficult to imagine that open cholecystectomy would once again become the standard. We predict that we will see a continued expansion in the types of procedures to be performed using minimal-access techniques. And in the future, we may have to justify our opening of a patient's abdomen when the procedure could have been performed laparoscopically, as is now the case for cholecystectomy in some areas of the country.

Laparoscopic fundoplication.

For many years Nissen fundoplication has been the standard for surgical correction of gastroesophageal reflux. Fundoplication now can be performed laparoscopically as well. Advantages to the laparoscopic approach may include decreased complications, such as adhesive bowel obstruction, wound complications, and postoperative pulmonary complications. Moreover, there appears to be a shorter hospitalization time and an earlier return to enteral alimentation and unrestricted activities.

Cholelithiasis and cholecystitis in children.

With advances in medical technology, including intensive care, new medications, alterations in the composition of parenteral nutrition, and the institution of minimally invasive surgery, our understanding of the spectrum of diseases of the gallbladder resulting in stone formation or inflammation, and the management of these disorders has changed over the past few decades. The discussion herein focuses on our thinking about the current diagnosis and treatment for these disorders.

Acute abdomen. The role of laparoscopy.

The child with an acute abdomen presents the perfect opportunity to take advantage of the benefits of minimal-access surgery. There are a wide variety of conditions, acquired and congenital, for which minimal-access techniques provide the distinct advantages of a cost-effective diagnosis and therapy with minimal discomfort for the patient. In the present report, the management of children with abdominal pain of unclear etiology is outlined, along with discussions of the value of minimal-access surgery in appendicitis and other conditions. Several algorithms are provided as a guideline for suggested approaches to management.

Laparoscopic surgery in girls and female adolescents.

The realm of laparoscopic surgery has extended to include the neonate as well as the pediatric patient. The advent of new and smaller instrumentation has facilitated this goal. Previous procedures exclusively relegated to laparotomy can now be accomplished as outpatient procedures. Removal of the acute appendix, correction of torsion of an adnexa, as well as the appropriate diagnosis and initial treatment of acute pelvic inflammatory disease are now well established laparoscopic procedures. This article provides insight into the laparoscopic evaluation and management of a number of challenging clinical problems for the endoscopic surgeon, thus providing a minimally invasive approach for patients ranging from neonates to adults.

Current status of laparoscopic appendectomy in children.

Appendectomy is the most common surgical emergency in children. Laparoscopic appendectomy (LA), first performed by Semm in 1983, has increased in popularity for both uncomplicated and ruptured appendicitis. The authors perform early laparoscopic appendectomy for acute uncomplicated appendicitis, but use aggressive antibiotic therapy for obvious ruptured appendicitis. Patients presenting with accessible abscesses have drainage using image guidance. Antibiotic therapy is continued at home until the fever has resolved and the white blood cell and differential counts have normalized. An interval appendectomy is performed 2 to 3 months later. Children with ruptured appendicitis for whom aggressive medical management had failed usually had a persistent pattern of small bowel obstruction noted 72 hours after initiation of treatment. The authors' preferred technique for laparoscopic appendectomy employs linear stapling of the mesoappendix and appendix. LA patients had a shorter hospital stay and a lower wound infection rate. The operating times for open and laparoscopic appendectomy were similar.

Controversies in the management of paratesticular rhabdomyosarcoma: is staging retroperitoneal lymph node dissection necessary for adolescents with resected paratesticular rhabdomyosarcoma?

PURPOSE: Use of retroperitoneal lymph node dissection (RPLND) in paratesticular rhabdomyosarcoma (PTRMS) is controversial and has changed over the past 2 decades. The Intergroup Rhabdomyosarcoma Study Group (IRSG) required ipsilateral RPLND (IRPLND) for all patients with PTRMS treated on IRS-III (1984-91), but changed to clinical evaluation of RPLNs using computerized tomography (CT) in IRS-IV (1991 through 1997). In IRS-IV, only those patients with identified lymph node involvement on CT required surgical evaluation of the RPLNs. Nodal radiation therapy was administered only to patients with RPLNs recognized as positive; such patients received more intensive chemotherapy as well. Thus, they compared the incidence of recognized RPLN involvement using these 2 different approaches. They then analyzed patient outcome to determine whether this change in management affected outcome. METHODS: Eligible patients with group I or II PTRMS who were treated on IRS III (n = 100) or IRS IV (n = 134) were analyzed. Failure-free survival (FFS) and survival (S) rates were estimated using the Kaplan-Meier method and compared using the log-rank test. RESULTS: There was a significant change in the distribution of patients with group I versus II tumors from IRS-III to IRS-IV (group I, 68% in IRS-III versus 82% in IRS-IV). This was the result of decreased node recognition when CT was used to stage RPLNs in IRS-IV and was most notable for adolescents (>10 years of age). Overall, 3-year FFS was 92% for patients treated on IRS-III and 86% for those treated on IRS-IV (P =.10), whereas survival estimates were 96% and 92%, respectively (P =.30). Adolescents were at higher risk of RPLN relapse than were children (<10 years of age) and their FFS and survival were worse, regardless of IRS protocol. Furthermore, adolescents with recognized group II tumors experienced better 3-year FFS than those with group I tumors on IRS-IV (100% versus 68%, P =.06), most likely as a result of receiving radiotherapy and intensified chemotherapy. CONCLUSIONS: Use of only CT scan evaluation of RPLN in IRS-IV led to a decrease in identification of RPLN involvement in boys who present with localized PTRMS, and a higher rate of regional relapse as compared with IRS-III. Adolescents had much higher likelihood of RPLN disease, and they fared significantly worse than did younger children on both studies. Furthermore, adolescent boys with group I tumors experienced worse FFS than those with Group II tumors on IRS-IV, probably because some patients with group II tumors were not identified by CT imaging and thus received less effective therapy. These data suggest that adolescents should have ipsilateral RPLN dissection as part of their routine staging, and those with positive lymph nodes require intensified chemotherapy as well as nodal irradiation.

Laparoscopic pancreatectomy for persistent hyperinsulinemic hypoglycemia of infancy.

BACKGROUND: A 4-week-old male infant (4.9 kg) with persistent hyperinsulinemic hypoglycemia of infancy (PHHI) underwent a laparoscopic pancreatectomy to evaluate its feasibility. Preoperative medications included diazoxide and glucagon to maintain adequate blood glucose levels. METHODS: Laparoscopic pancreatectomy was performed using a 5-mm cannula at the umbilicus, external fixation, transcutaneous suture-assisted gastric retraction to expose the lesser sac, and three additional 3.5-mm cannula sites. The pancreas was resected from the splenic hilum to the mesenteric vessels. The splenic vein was dissected from the under surface of the pancreas using electrocautery, and the spleen was easily preserved. Surgery time was 75 min, and minimal blood loss occurred. RESULTS: The child required no narcotic medication and tolerated a regular diet immediately after surgery. Serum glucose levels did decrease postoperatively, and the child required diazoxide, dextrose infusion, glucagon, and octreotide. On postoperative day 7, the child underwent an open near-total pancreatectomy, after which he remained asymptomatic. Essentially no scarring was found in the lesser sac, and the remaining pancreatic remnant was resected without difficulty. CONCLUSIONS: Laparoscopic pancreatectomy can be performed safely, even in a newborn patient, without prolonged operative time or unnecessary risk. The technique using external fixation and transcutaneous suture-assisted gastric retraction provides excellent exposure to the pancreas and lesser sac. In patients with PHHI, in whom reoperative additional pancreatectomy is very likely, this technique is the ideal initial surgical approach.

The role of laparoscopy in the management of common bile duct obstruction in children.

BACKGROUND: Laparoscopic common bile duct exploration is commonplace in adults; however, this procedure is not often performed in children. The goal of this study was to evaluate the results of laparoscopic common bile duct exploration in children. METHODS: Of 50 patients undergoing laparoscopic cholecystectomy, six patients (12%) had obstructing lesions of the common bile duct (CBD). Five children underwent laparoscopic common bile duct exploration, and one child had a preoperative endoscopic sphincterotomy and stone removal. RESULTS: The mean age at laparoscopic CBD exploration was 11.6 years (range, 5-16). The obstructing lesion was visualized by intraoperative cholangiography in all five patients. The mean operative time for laparoscopic cholecystectomy along with CBD exploration was 215 min (range, 160-282). The transcystic laparoscopic CBD exploration was performed using a 7-Fr, multichannel rigid, or 10-Fr flexible fiberoptic cystoscope. The stones were either pushed into the duodenum with the scope or extracted through the cystic duct using a 3-Fr Segura basket. In one patient, a candidial ball disintegrated during an attempt to remove it with the basket. A repeat cholangiogram at the end of each procedure showed an anatomically normal CBD with free flow of contrast into the duodenum. All patients enjoyed a quick recovery. They were started on a regular diet on the same day of surgery and discharged on the 1st or 2nd postoperative day. One patient with sickle cell disease developed a pulmonary infarction and required 5 additional days of hospitalization. One patient developed recurrent choledocholithiasis 6 months after laparoscopic exploration and was treated successfully with endoscopic sphincterotomy and stone extraction. CONCLUSIONS: Laparoscopic CBD exploration can be performed safely at the time of the cholecystectomy in children. Endoscopic sphincterotomy before cholecystectomy is not necessary. We recommend laparoscopic CBD exploration for obstructing lesions of the CBD. Endoscopic sphincterotomy should be reserved for recurrent lesions of the CBD after laparoscopic cholecystectomy.