Characterization of technical skill progress in a standardized rabbit model for training in laparoscopic duodenal atresia repair.

BACKGROUND: Laboratory skills training is an essential step before conducting minimally invasive surgery in clinical practice. Our main aim was to develop an animal model for training in clinically highly challenging laparoscopic duodenal atresia repair that could be useful in establishing a minimum number of repetitions to indicate safe performance of similar interventions on humans. MATERIALS AND METHODS: A rabbit model of laparoscopic duodenum atresia surgery involving a diamond-shaped duodeno-duodenostomy was designed. This approach was tested in two groups of surgeons: in a beginner group without any previous clinical laparoscopic experience (but having undergone previous standardized dry-lab training, n = 8) and in an advanced group comprising pediatric surgery fellows with previous clinical experience of laparoscopy (n = 7). Each participant performed eight interventions. Surgical time, expert assessment using the Global Operative Assessment of Laparoscopic Skills (GOALS) score, anastomosis quality (leakage) and results from participant feedback questionnaires were analyzed. RESULTS: Participants in both groups successfully completed all eight surgeries. The surgical time gradually improved in both groups, but it was typically shorter in the advanced group than in the beginner group. The leakage rate was significantly lower in the advanced group in the first two interventions, and it reached its optimal level after five operations in both groups. The GOALS and participant feedback scores showed gradual increases, evident even after the fifth surgery. CONCLUSIONS: Our data confirm the feasibility of this advanced pediatric laparoscopic model. Surgical time, anastomosis quality, GOALS score and self-assessment parameters adequately quantify technical improvement among the participants. Anastomosis quality reaches its optimal value after the fifth operation even in novice, but uniformly trained surgeons. A minimum number of wet-lab operations can be determined before surgery can be safely conducted in a clinical setting, where the development of further non-technical skills is also required.

Thoracoscopic repair of congenital diaphragmatic hernia: review of the results.

Congenital diaphragmatic hernia (CDH) remains one of the major challenges in neonatal surgery. Survival rate has increased in the last decades mainly due to perinatal care and surgical technique improvements. Classically, a laparotomy has been performed after cardiovascular and respiratory stabilization. Introduction of thoracoscopy in the repair of CDH brought the known advantages of reduced postoperative pain and better cosmesis. However, its safety and effectiveness have been questioned in the last few years. Although there is lack of high evidence data, it seems consensual that thoracoscopy is associated with: 1) longer operative time on account of the learning curve; 2) increased acidosis during surgery whose effects have not been clarified but there is evidence suggesting that neurodevelopment is not affected; 3) reduced morbidity, namely postoperative ileum and adhesions, pain and scar formation; 4) similar mortality rate; 5) higher number of recurrences. While the majority of outcomes are comparable between open and thoracoscopic repair, reduced postoperative morbidity and better cosmesis are advantages to be considered. Technique improvements are still required to reduce recurrence rate. Division of the pleura from the peritoneum is a major step of the procedure; suture type and quality must simulate those in the open repair. The authors believe that careful and meticulous execution of the principles of open surgery will improve outcomes regarding recurrence.

Orchiectomy after torsion testis: Simultaneous prosthesis placement versus staged procedures.

BACKGROUND/PURPOSE: Testicular torsion(TT) with unsalvageable testis has a significant psychosocial impact. Orchiectomy can be performed with optional testicular prosthesis(TP) placement, commonly deferred(dTP). Orchiectomy and simultaneous testicular prosthesis placement(sTP) may be a feasible and safe option and has been implemented in our department since 2018. AIM: The authors aim to perform a reflective analysis of the patient's experience and assess the feasibility, safety, and satisfaction of the sTP, by comparing it with the dTP. METHODS: All patients with TT and unsalvageable testis submitted to orchiectomy were included in the study. An anonymous questionnaire assessed the patients' experience. Those submitted to orchiectomy and TP placement were divided in sTP and dTP groups and their clinical details, satisfaction and quality-of-life were analyzed and compared. RESULTS: Scrotal exploration due to TT was performed in 185 patients, 54 were submitted to orchiectomy and 37 placed a TP(17 sTP, 20 dTP). All dTP patients and 66.7% of those without TP, would prefer having a prosthesis placed at the time of the orchiectomy. No significant differences in clinical details and outcomes were found, except prosthesis position (higher in dTP, p = 0.011) and operative time (13 min longer in sTP, p = 0.015). Both groups reported being satisfied with the prosthesis. Only one patient regretted placing a prosthesis(in dTP). CONCLUSION: The sTP approach is as safe and effective as dTP. The patients preferred the sTP, as it avoids a second operation and possibly by having a lower psychological impact. LEVELS OF EVIDENCE: Level III.

Minimally Invasive Surgical Treatment of Pilonidal Disease: Mid-Term Retrospective Analysis of a Single Center.

Background: Sacrococcygeal Pilonidal Disease (PD) is commonly treated with excision and primary closure techniques (EPC). Minimally invasive techniques (MIT), such as EPSiT and Pit-picking, had been recently advocated promising better outcomes. We analyzed mid-term results from our center after introduction of MIT to treat PD. Methods: Patients submitted to MIT (n = 44) with a median follow-up of 37 months were analyzed and compared with patients submitted to EPC (n = 70) with a median follow-up of 5 years. Both groups included patients operated in our department between 2011 and 2016 and have similar demographic and clinical characteristics. We compared operative time and post-operative parameters such as time with pain, dressing time and time to relapse. Results: The post-operative time with pain was significantly lower, whereas the dressing time was significantly longer, in MIT when compared to the EPC group. The relapse rate was similar in both groups but the follow-up is shorter in the MIT group. In addition, the analysis of patients free of disease using Kaplan-Meier curves revealed that relapse tends to occur more precociously in MIT than in EPC patients (p = 0.014). Interestingly, in the subgroup of patients with previous surgery, MIT's relapse rate was significantly lower than in the EPC group (30 vs. 100%, p < 0.001). Conclusions: MIT has the advantage of having a shorter time with pain in the postoperative period, while EPC benefits from a shorter dressing time. In general, the relapse of the disease tends to manifest more precociously in MIT patients. Moreover, in the subgroup of patients with previous surgery, MIT seems to have significantly better results when compared to EPC.

Perioperative Complications of Congenital Diaphragmatic Hernia Repair.

Although improvements have been made, the management of congenital diaphragmatic hernia (CDH) remains a major challenge for perinatologists and neonatal surgeons. Many aspects of the disease remain unknown and, being a rare entity, evidence-based data are hard to find. Surgical morbidity is considerable and affects long-term quality of life. Perioperative complications have been reviewed focusing on thoracoscopic repair. Intraoperative acidosis was more severe during thoracoscopy when compared with open surgery (OS), though it is possible that later neurodevelopment was not affected. Even so, strategies have been outlined to reduce acidosis, such as decreasing carbon dioxide (CO2) insufflation after reduction of the herniated viscera into the abdomen is complete. The risk of pleural complications decreased after introduction of gentle ventilation techniques and minimally invasive surgery (MIS); thus, the use of a prophylactic intraoperative thoracic tube is not routinely required. Recurrence rate was higher in large CDH and following MIS repair. Technical demands play an important role, therefore, in avoiding complications; every step of the OS technique must be strictly accomplished. In large defects, the use of prosthetic patch might reduce recurrence rate, even by MIS repair, once again only if technical demands are overcome with meticulous rules of suturing. Thoracoscopy significantly reduced the incidence of bowel obstruction and recovery time and improved cosmesis. The best approach of CDH is yet to be found, and it goes far beyond the management of perioperative complications. Meanwhile randomized controlled studies, namely on the outcome of thoracoscopic repair, are required to inform further practice.

Learning Curves for Laparoscopic Repair of Inguinal Hernia and Communicating Hydrocele in Children.

INTRODUCTION: We analyzed the department and surgeon learning curves during implementation of the percutaneous internal ring suturing (PIRS) technique in our department. METHODS: Children proposed for inguinal hernia or communicating hydrocele repair were included (n = 607). After mentorship, all surgeons were free to propose open or PIRS repair. From gathered data, we assessed department and surgeon learning curves through cumulative experience focusing in perioperative complications, conversion, ipsilateral recurrence, postoperative complications, and metachronous hernia, with benchmarks defined by open repair. RESULTS: Department-centered analysis revealed that perioperative complications, conversion, and ipsilateral recurrence rates were higher in the beginning, reaching the benchmarks when each surgeon performed, at least, 35 laparoscopic repairs. Postoperative complications and metachronous hernia rates were independent from learning curves, with the metachronous hernia rate being significantly lower in PIRS patients. During the program, the percentage of males in those operated by PIRS progressively increased reaching the percentage of males, in our sample, when department operated over 230 cases. CONCLUSION: Thirty-five laparoscopic cases per surgeon are required for perioperative complications, conversion, and ipsilateral recurrence reach the benchmark. The gap between the percentage of males, in those operated by PIRS and in those proposed for surgery, monitors the confidence of the team in the program.

Ultrasound-guided dissection and ligation of the internal inguinal ring for hernia repair in pediatrics: an experimental animal study.

PURPOSE: We aimed to test the feasibility and reliability of ultrasound-guided percutaneous internal inguinal ring suture in rabbits, as a model for inguinal hernia repair in pediatric population. METHODS: Twenty-eight rabbits were divided in 2 groups: group I (female morphology) - persistence of the peritoneal-vaginal duct with gonads placed in intraperitoneal position; group II (male morphology) - persistence of the peritoneal-vaginal duct with gonads kept intact inside the duct. Under exclusive ultrasound-guided image we tried to perform a complete pre-peritoneal ligation of the peritoneal-vaginal duct at the level of the internal inguinal ring using a 20G peripheral IV catheter and 2-0 non-absorbable suture. Afterwards, an exploratory laparoscopy was performed to evaluate the ligation. RESULTS: Ultrasound allowed characterization of inguinal-crural structures. Group I - complete and reliable suture 66.7%, incomplete but reliable suture 16.7%, inappropriate ligation 16.7%; group II - complete but unreliable suture 76.9%, incomplete and unreliable suture 11.5%, inappropriate suture 11.5%. No acute complications were logged. CONCLUSIONS: Percutaneous dissection and ligation of internal inguinal ring through exclusive ultrasound guidance was feasible and likely reliable, namely for female inguinal hernia repair.

Anatomic Thoracoscopic Repair of Esophageal Atresia.

BACKGROUND: The thoracoscopic approach to repair esophageal atresia (EA) with tracheoesophageal fistula (TEF) provides excellent view, allowing the most skillful surgeons to spare the azygos vein by performing the esophageal anastomosis over (on the right side) the azygos vein. Seeking the most anatomic repair, we started to perform the esophageal anastomosis underneath (on the left side) the azygos vein: anatomic thoracoscopic repair of esophageal atresia (ATREA). We aim to compare results of ATREA with the classic thoracoscopic repair. METHODS: During the last 4 years, in our center, all infants with EA with distal TEF were operated by thoracoscopy sparing the azygos vein. According to the surgical technique, two groups were created: Group A-treated with ATREA and Group B-treated with classic thoracoscopic repair over (on the right side) the azygos vein. We retrospectively collected data regarding features of the newborn (gestational age, gender, karyotype changes, associated anomalies, birth weight), surgery (operative technique, operative time, and surgical complications), hospitalization (duration of mechanical ventilation, thoracic drainage, time for the first feeding, time of admission, and early complications) and follow-up [tracheomalacia, gastroesophageal reflux disease (GERD), anastomotic stricture, recurrence of fistula]. RESULTS: Group A had seven newborns and Group B had four newborns. There were no statistically significant differences between both groups concerning the evaluated variables on surgery, hospitalization, and follow-up. Nevertheless, in Group A, there was an infant with a right aortic arch where ATREA was particularly useful as it avoided that the azygos vein and the aortic arch were left compressed in between the esophagus and trachea. Postoperatively, one patient of Group B had a major anastomotic leak with empyema requiring surgical re-intervention. During follow-up, anastomotic stricture requiring esophageal dilation occurred with similar rates in both groups. In Group B, one patient had severe and symptomatic tracheomalacia requiring aortopexy and severe GERD requiring fundoplication. No patients developed recurrent fistula. CONCLUSION: The ATREA is feasible in the great majority of patients with EA with TEF without compromising long-term results and might be particularly useful for those infants with malformations of the cardiac venous return vessels and/or major aortic malformations.