Caeco-peritoneal band as a potential cause of right iliac fossa pain in children.

BACKGROUND: A caeco-peritoneal band (CPB) has been observed during diagnostic laparoscopy for chronic right iliac fossa (RIF) pain. This has a veil-like configuration and arises along a broad base from the caecum and ascending colon and attaches to the anterior abdominal wall. METHODS: Retrospective analysis of a prospectively collected database of 31 patients, aged 11-16, who underwent diagnostic laparoscopy for ongoing RIF pain over a 10-year period was analysed for intra-operative presence of the CPB. The patients' symptoms, past medical history, diagnostic workup, surgical findings and outcome were evaluated. RESULTS: CPB was identified in five patients. All presented with chronic RIF pain and had inconclusive preoperative investigations. Two patients underwent previous surgery. In all cases, the CPB was the sole abnormal finding on diagnostic laparoscopy. Symptoms resolved following division of the CPB with no recurrence of pain at a mean follow-up of 575 days. CONCLUSIONS: CPB is a potential cause of chronic RIF pain in patients with unremarkable examination findings and negative serological and radiological investigations. Laparoscopic identification and division of the CPB has produced symptom resolution in this cohort of patients.

Mapping testicular blood supply in gubernaculum-sparing second-stage Fowler-Stephens procedure.

BACKGROUND: Testicular survival following second-stage Fowler-Stephens (FS) procedure depends upon adequate arterial supply. There is evidence that testicular survival rates are greater following gubernaculum-sparing second-stage FS procedure. The importance of collateral vessels in preservation of the testis has been hypothesised, but never shown in the literature. We aim to map the collateral blood supply to the testicle in gubernaculum-sparing, laparoscopic-assisted, second-stage FS procedure for intra-abdominal testicles. METHODS: Selected patients undergoing a second-stage FS procedure were photographed prior to pexy in the Dartos pouch. Photographs were evaluated for the extent of vascular collateralisation between gubernacular, deferential and the ligated spermatic artery. RESEARCH: Twenty-five patients with 28 undescended testicles underwent staged FS procedure over a 7.5-year period between 2005 and April 2013. Mean age at operation was 2.44 years, and all testicles were delivered to the scrotum. Mean follow-up was 3.29 years, and all patients were reviewed by the operating consultant. Testicular survival rate was 100 %. Representative photographs clearly demonstrate substantial cremasteric vessels running along the gubernaculum with robust collateralisation to the deferential vessel and the spermatic arterial stump. CONCLUSION: These images confirm the presence of robust collateral between the cremasteric and deferential vessels at second-stage FS procedure. Preservation of these collaterals in a gubernaculum-sparing approach may explain the excellent results seen in this series.

Perforated Meckel's diverticulum in neonates: a report of six cases and systematic review of the literature.

Background: Perforation of Meckel Diverticulum (MD) is a rare cause of pneumoperitoneum in neonates. We hereby report six cases of perforation of MD in neonates, with addition of 53 cases from systematic review of the literature. A systematic review was performed using Mesh terms "Neonate, Meckel Diverticulum, Perforation, Pneumoperitoneum." All reports of perforated MD in the English literature were identified. Details of our 6 cases were analyzed in similar fashion. Results: A total of 3027 manuscripts were screened and 59 cases including 6 of our own were identified. The vast majority (78%) were female. Fifty patients (84.7%) presented in the newborn period. Half of the cases (52.5%) had associated anomalies and 13 neonates (22%) required oxygen supplementation including CPAP or ventilatory support before surgery. In 73% of the cases, a resection of gut was undertaken. Histopathological assessment in 44 cases (74.6%) revealed no ectopic gastric mucosa. Three cases demised prior to treatment. The outcome in the vast majority was excellent with 84.7% surviving and discharged well. Conclusion: Perforated MD is an unusual cause of a pneumoperitoneum in the newborns. Diagnosis is established at laparotomy and it rare to find ectopic mucosa histopathologically. The overall outcome is excellent.

Systematic review for paediatric metachronous contralateral inguinal hernia: a decreasing concern.

PURPOSE: Controversy still surrounds the treatment of the asymptomatic inguinal region in paediatric patients with a unilateral inguinal hernia. The concern is the development of a future metachronous contralateral inguinal hernia (MCIH) and therefore the need for a second operation. Our aim was to provide a current systematic review of the evidence for routine contralateral exploration, and identify potential at-risk groups. METHODS: Comprehensive review of the literature utilising broad search terms to identify all relevant publications. Precise inclusion and exclusion criteria to identify studies that included paediatric unilateral inguinal hernia repair without routine contralateral exploration. DATA ANALYSIS: Chi-square with Yates' correction or a Fisher's exact test as appropriate. Numbers needed to treat (NNT) calculated with 95% confidence intervals. RESULTS: A total of 7,130 titles and abstracts were screened and 61 studies included with data on 49,568 paediatric patients with a unilateral inguinal hernia fulfilling the inclusion criteria. 2,857 of these patients later developed a MCIH, revealing an overall risk is 5.76% (95% CI: 5.55-5.97%). The NNT for a MCIH is 18 (95% CI: 16.8-18) with 18 contralateral exploration required for the prevention of one MCIH. Patients <6 months at the time of the initial intervention were more likely to develop a MCIH; 183/1,470 (<6/12) versus 144/2,044 (≥6/12), P < 0.0001. As were patients with an original left-sided hernia; 815/6,739 versus 865/12,615, P < 0.0001. The NNTs for both of these groups were 9. There was no association with the gender of the patient; 888/14,480 (♂) versus 268/4,206 (♀), P = 0.37. CONCLUSIONS: There is insufficient evidence to support the routine contralateral inguinal exploration in all paediatric patients presenting with a unilateral inguinal hernia. However, with patients presenting with an originally left-sided hernia or who are less than 6 months old, a parental discussion should occur about the possible benefits and risks of contralateral exploration.

Technique of laparoscopic transperitoneal lower pole heminephroureterectomy.

BACKGROUND: Laparoscopic transperitoneal nephrectomy is technically feasible in most cases of benign renal disease. To date, there have been isolated reports of laparoscopic transperitoneal heminephroureterectomy of principally the upper moiety of a duplex system. Rarely reported are lower moiety nephroureterectomies. AIM: The aim of this IPEG submission is to present a 3-minute video demonstrating the technical details of a transperitoneal laparoscopic, right, lower moiety, heminephroureterectomy in a 3-year-old. METHODS/TECHNIQUES: A child with marginally functioning (<5%) lower moiety of a right duplex system was subjected to a transperitoneal heminephroureterectomy. The patient was placed in a left lateral position and an umbilical camera and two working ports (right iliac fossa, epigastric), all 5 mm, were utilized. The ascending colon was reflected to the left and the underlying lower moiety ureter identified and isolated. With traction on the ureter, the pelvis was brought into view and control of blood supply to the lower moiety was achieved by using a combination of ultrasonic scalpel and hook diathermy. A critical step at this stage was definition of the superior limit of the pelvis, which corresponded to the level of vascular demarcation. The renal parenchyma was transected at this point by using the ultrasonic scalpel, which ensured reasonable hemostasis. Complete hemostasis was assured by approximating the divided kidney with a series of three interrupted intracorporeal sutures. The subtending ureter was dissected close to the bladder base, where it was ligated and divided. A drain was placed percutaneously in the renal bed and the specimen retrieved via an extended umbilical incision. RESULTS: The patient was started on fluids on recovery with oral feeds introduced the next morning. The drain was removed prior to discharge on day 2. At 6 months post-resection, the patient remains well. CONCLUSION: Laparoscopic transperitoneal lower pole heminephroureterectomy is technically feasible for benign renal disease in children. The combination of ultrasonic scalpel and intracorporeal suturing is adequate to control bleeding of the transected kidney. Dissection of the ureter distally to bladder neck is easily achieved without change in port position. Recovery is robust with minimal requirement for analgesia. The wider space, better view, and ability to access all of the urinary tract make this a tenable alternative to other laparoscopic approaches.

Technical aspects of the laparoscopic management of a late presenting duodenal web.

The value of laparoscopy in repair of congenital duodenal webs is yet to be established and techniques are evolving. Described are technical details of a successful laparoscopic web ablation without duodenoplasty.

Improving outcome from Plastibell circumcisions in infants.

Circumcisions are among the most frequently performed operations in children and numerous techniques are employed often with varying results. Use of the Plastibell (Hollister Incorporated, Illinois, USA), under local anesthetic, is popular for cultural and religious circumcisions but is not without its problems. Complications of Plastibell (slippage, migration, bleeding and serious infection) have been reported. Described is a prospective series of cases in which modifications to the standard Plastibell technique were utilized to improve outcomes, in particular, the risk of bleeding.

Ovarian reconstitution following laparoscopic decapsulation of congenital cyst.

Laparoscopic management of congenital ovarian cysts is widely practiced but there is a dearth of information on the performance of the gonad where organ-preserving surgery is undertaken. Presented is a radiological diary documenting the progress of a complex congenital ovarian cyst from the antenatal period to a year post-laparoscopic decapsulation.

Cost analysis of minimally invasive surgery in a pediatric setting.

AIMS: The aims of this study was to determine whether an active policy of cost curtailment would impact on the theater cost of laparoscopic surgery in a pediatric setting; to document the extent of cost changes over time and to identify factors that adversely influence expenditure; and to investigate whether the surgeon is a significant factor in the price of the procedure. MATERIALS AND METHODS: A prospective audit of laparoscopic procedures was performed in a single unit over a 36-month period. Detailed costs of theater inventory for all procedures were compiled on a case-by-case basis and recorded on a database. The cost of six index procedures were collated and changes over the period of the study analyzed. The factors responsible for increased expenditure were flagged and appraised to enable the implementation of cost-saving measures. The prices of the laparoscopic equipment were based on invoiced figures provided by hospital managers, and no long-term outcome measures were taken into account. RESULTS: A total of 179 cases were performed by six surgeons over a 3-year period between January 1, 2003 and December 31, 2005, with no adverse intraoperative events. The procedures studied in further detail were appendicectomy (n = 50), fundoplication (n = 25), cholecystectomy (n = 12), nephrectomy (n = 10), Fowler Stevens for undescended testes (n = 10), and modified Palomo operations for varicocoele (n = 7). The mean cost of these procedures fell year by year over the period of study but was significant only in appendicectomy (P = 0.017). For this procedure, there was a significant difference in costs between the various surgeons (P = 0.007), but this trend was not noted with the other procedures. There were no major intraoperative events, although 2 patients required conversion owing to technical difficulties posed by the cases. Among the factors that influenced costs were the use of disposables, particularly for hemostasis and suctioning, and an inability to procure reuseable instruments. CONCLUSIONS: The costs of commonly performed laparoscopic procedures are falling year by year. The surgeon is a factor in the costs of some procedures. A cost-saving strategy has not been compromised of patient safety; however, some cost-saving measures, though attractive, are labor intensive and are not practical. An overall commitment to the sensible use of health care resources translates into savings for hospitals, thereby strengthening the case for laparoscopic surgery.

Laparoscopy in diagnosis and management of Meckel's diverticulum.

OBJECTIVE: The aim of this paper is to demonstrate that laparoscopy can successfully diagnose otherwise elusive Meckel's diverticuli and at the same time offer a therapeutic access for successful resection. MATERIALS AND METHODS: Two patients with anemia of unknown cause and a further patient with acute small bowel obstruction underwent diagnostic laparoscopy. A Meckel's diverticulum was identified in each case and successfully resected through a minilaparotomy. RESULTS: All three patients were successfully investigated and treated with laparoscopy with no morbidity or mortality. CONCLUSION: Laparoscopy is a safe and effective surgical modality for diagnosis of atypically presenting Meckel's diverticulum and has a therapeutic role that results in an excellent cosmetic result.

Laparoscopic Appendectomy for Chronic Right Iliac Fossa Pain: Correlating Histology with Outcome.

BACKGROUND: Chronic right iliac fossa (CRIF) pain in children is associated with repeated hospital attendance, inconclusive investigations, and missed school days. There is increasing evidence for the role of laparoscopic appendectomy for the management of CRIF pain. However, currently there is no substantial evidence to correlate histological changes identified in the appendixes removed with resolution of pain. METHOD: This study collected prospective data for a single surgeon's series of laparoscopic appendectomy performed for CRIF pain between 2003 and 2014. RESULTS: Forty patients with a median age of 13 years (range 5-19 years) underwent laparoscopic appendectomy for CRIF pain. Twenty-nine patients (73%) had macroscopically normal appendixes, but histological changes were identified in 28 patients (70%). Other findings at laparoscopy included gynecological pathology (ovarian/para-ovarian cysts), unfixed mobile caecum, and a well-defined peritoneal band extending from the caecum to the anterolateral abdominal wall (caeco-peritoneal band). Patients were followed up for a median of 2 months (range 1-15 months). All patients reported resolution of CRIF pain. DISCUSSION: Laparoscopic appendectomy appears to be an effective treatment for CRIF pain, while also providing the opportunity to diagnose and treat potential sources of CRIF pain other than the appendix. Consistent with the literature, a small number of patients appear to have resolution of pain, despite no histological change being identified in the appendix removed and no other pathology having been identified. The same histological changes commonly seen have also been demonstrated in appendixes removed incidentally. Caution therefore should be applied when interpreting the significance of histological changes seen.

Elective laparoscopic appendicectomy for chronic right iliac fossa pain in children.

AIM: To determine whether elective laparoscopic appendicectomy is justified for chronic right iliac fossa (RIF) pain of undetermined origin. METHODS: A retrospective audit of all laparoscopic appendicectomies between January 1997 and August 2003 was performed. The expanded medical audit system (EMAS) and a Microsoft Access database of operative records were used to identify patients with chronic RIF pain subjected to elective appendicectomy. Case notes were retrieved and analysed for patient profile, duration of symptoms including clinic visits and admissions, operative findings, histological analysis, and postoperative performance. A correlation between histological findings and final outcome was investigated. RESULTS: Ninety-eight patients underwent laparoscopic appendicectomy during the period of the study. A total of 11 cases with chronic RIF pain were identified. Nine were female and 2 male. Age ranged from 9 to 14 years with a mean of 11.9 years. The number of clinic visits and admissions for chronic RIF pain ranged from 2 to 8, with a mean of 4. Duration of symptoms ranged from 1 to 36 months, with a mean of 12.1 months. Detailed history, clinical examination, and serological and radiological investigations failed to reveal the cause of the pain in all cases. Patients were followed up in postoperative clinics for between 1 and 72 months, with a mean of 16.1 months. Histology of resected appendices showed acute inflammation (3 cases), fecoliths (2 cases), lymphoid hyperplasia (LH) (1 case), LH and a foreign body reaction (1 case), LH and mucosal hyperplasia (1 case), and Enterobius vermicularis parasites in 1 case. The appendix was normal in 2 cases. Eight patients had complete resolution of RIP pain. Seven of these had pathology within the appendix and 1 was histologically normal. Two patients with resolved RIF pain, but with pain elsewhere, had lymphoid hyperplasia noted within the appendix. One patient with persistent pain 6 years postoperatively had a normal appendix. CONCLUSION: This study demonstrates that a significant number of patients with chronic RIF pain have pathology within the appendix. The majority of these cases will benefit from elective appendicectomy. It is critical however that all other possible causes of pain in the RIF are excluded. Laparoscopy is an integral part of the diagnosis and management of this particularly difficult group of patients.

Pediatric ovarian torsion: an uncommon clinical entity.

Pediatric ovarian torsion is an infrequent diagnosis and it often mimics acute appendicitis. Most cases are due to underlying ovarian pathology and if left untreated, ovarian torsion may eventually cause peritonitis. Emergency exploratory laparoscopy represents a valuable diagnostic and therapeutic tool in suspected ovarian torsion.

In children undergoing umbilical hernia repair is rectus sheath block effective at reducing post-operative pain? Best evidence topic (bet).

A best evidence topic was constructed according to a structured protocol. The question addressed was: In children undergoing umbilical hernia repair is a rectus sheath block (RSB) better than local anaesthetic infiltration of the surgical site, at reducing post-operative pain? From a total of 34 papers, three studies provided the best available evidence on this topic. One randomised clinical trial showed RSB had a better analgesic effect in the immediate post-operative period. In another randomised trial opioid consumption in the peri-operative period was found to be significantly lower in patients administered RSB. These improvements in pain and analgesia consumption need to be balanced against the expertise, training, equipment required, time implications and complications of performing a RSB.

Laparoscopic watson fundoplication is effective and durable in children with gastrooesophageal reflux.

Gastroesophageal reflux (GOR) affects 2-8% of children over 3 years of age and is associated with significant morbidity. The disorder is particularly critical in neurologically impaired children, who have a high risk of aspiration. Traditionally, the surgical antireflux procedure of choice has been Nissen's operation. However, this technique has a significant incidence of mechanical complications and has a reoperation rate of approximately 7%, leading to the development of alternative approaches. Watson's technique of partial anterior fundoplication has been shown to achieve long-lasting reflux control in adults with few mechanical complications, but there is limited data in the paediatric population. We present here short- and long-term outcomes of laparoscopic Watson fundoplication in a series of 76 children and infants, 34% of whom had a degree of neurological impairment including severe cerebral palsy and hypoxic brain injury. The overall complication rate was 27.6%, of which only 1 was classified as major. To date, we have not recorded any incidences of perforation and no revisions. In our experience, Watson's laparoscopic partial fundoplication can be performed with minimal complications and with durable results, not least in neurologically compromised children, making it a viable alternative to the Nissen procedure in paediatric surgery.

Chronically symptomatic patients with undetectable gall bladder on ultrasonography could benefit from early cholecystectomy.

90 percent of symptomatic patients undergoing cholecystectomy have cholelithiasis with 10% categorized as asymptomatic cholecystitis. In both instances, the gallbladder is evident on ultrasonography. In children with symptomatic biliary dyspepsia, the decision to proceed to cholecystectomy is made difficult if choleliths are not seen on ultrasonography. This decision is made even more difficult if the gallbladder itself is not seen on repeated imaging. In a cohort of 54 cholecystectomies, 3 cases, with recurrent right upper quadrant pain and undetectable gallbladders on repeat ultrasonography, were identified. After prolonged observation all underwent successful cholecystectomy. Histology demonstrated a markedly fibrotic and thickened gallbladder in all. Given this experience, we suggest that nonvisibility of the gallbladder, in fact, maybe be a feature of a chronic acalculous cholecystitis. We advise consideration of cholecystectomy for chronic biliary dyspepsia where repeat ultrasonography fails to demonstrate a gallbladder.