Single incision versus standard 3-port laparoscopic appendectomy: a prospective randomized trial.

BACKGROUND: Laparoscopic appendectomy through a single umbilical incision is an emerging approach supported by several case series. However, to date, prospective comparative data are lacking. Therefore, we conducted a prospective, randomized trial comparing single site umbilical laparoscopic appendectomy to 3-port laparoscopic appendectomy. METHODS: After Internal Review Board approval, patients were randomized to laparoscopic appendectomy via a single umbilical incision or standard 3-port access. The primary outcome variable was postoperative wound infection. Using a power of 0.9 and an alpha of 0.05, 180 patients were calculated for each arm. Patients with perforated appendicitis were excluded. The technique of ligation/division of the appendix and mesoappendix was left to the surgeon's discretion. There were 7 participating surgeons dictated by the call schedule. All patients received the same preoperative antibiotics and postoperative management was controlled. RESULTS: There were 360 patients were enrolled between August 2009 and November 2010. There were no differences in patient characteristics at presentation. There was no difference in wound infection rate, time to regular diet, length of hospitalization, or time to return to full activity. Operative time, doses of narcotics, surgical difficultly and hospital charges were greater with the single site approach. Also, the mean operative time was 5 minutes longer for the single site group. CONCLUSION: The single site umbilical laparoscopic approach to appendectomy produces longer operative times resulting in greater charges. However, these small differences are likely of marginal clinical relevance. The study was registered with clinicaltrials.gov at the inception of enrollment (NCT00981136).

The lack of efficacy for oral contrast in the diagnosis of appendicitis by computed tomography.

BACKGROUND: Oral contrast is often used with computed tomography (CT) for the diagnosis of appendicitis. This adjunct adds time to evaluation, not all patients can tolerate enteric bolus, and the diagnostic advantages have not been well defined. Therefore, we reviewed our experience to evaluate the impact of oral contrast on diagnostic efficiency and its impact on the patient. METHODS: After obtaining IRB approval, a retrospective review was conducted on patients who underwent CT with oral contrast for the indication of appendicitis over the last 4 years. Data recorded included demographics, CT results, emergency room course, operative findings, and pathology interpretation. All images were reviewed to identify presence/absence of contrast at or beyond the terminal ileum. RESULTS: There were 1561 patients, of whom, 652 (41.8%) were diagnosed with appendicitis and 909 (58.2%) were not (non-appendicitis). Contrast was identified at least to the level of the terminal ileum in 72.4% of the entire population. The contrast was present in 76.2% of the non-appendicitis patients and 67.0% of the appendicitis patients (P = 0.01). Mean time from oral contrast administration to CT imaging was 105.5 min, which was longer in patients with appendicitis (112.2 min) compared with non-appendicitis patients (100.9 min) (P = 0.01). Emesis of the contrast occurred in 19.3% of those with appendicitis and 12.9% of those without appendicitis (P = 0.001). Nasogastric tubes were placed in 5.8% of those with appendicitis and 5.1% of those without (P = 0.37). Appendicitis was confirmed at operation in 94.3% of those with contrast in the area and 94.4% of those without (P = 1.0). Pathology confirmed appendicitis in 90.6% of those with contrast in the area and 94.0% of those without (P = 0.17). CONCLUSION: Nearly 30% of patients receiving oral contrast for the CT diagnosis of appendicitis do not have contrast in the point of interest at the expense of emesis, nasogastric tube placement, and diagnostic delay. These detriments are amplified in patients who have appendicitis. Further, there appears to be no diagnostic compromise in those without contrast in the terminal ileum.

Esophageal perforation in children: a review of one institution's experience.

BACKGROUND: The current approach to esophageal perforation treatment in children has shifted towards conservative management. However, the consensus of what constitutes conservative management is unclear, with various therapies and protocols described, including the need for various decompression and drainage procedures. Our institution utilizes conservative management with minimal intervention guided by the patient's clinical course. The purpose of this study is to report our management and add to the growing evidence for conservative management of esophageal perforation in children. METHODS: We performed a retrospective chart review of all patients with an ICD-9 diagnosis of esophageal perforation from January 1995 to July 2009. Patients with postoperative anastomotic leaks with drains in place were excluded, although patients with anastomotic leaks that were not controlled by drains were included. Data collected included patient demographics, etiology, diagnosis, treatment, complications, and outcome. RESULTS: Eight patients were identified who met inclusion criteria. Mean age was 28 mo (1 d-10 y), and the average time from causative event to diagnosis was 1.4 d (0-2 d). The etiology for esophageal perforation included esophagoscopy with dilation (n = 4), button battery ingestion (n = 1), coin ingestion (n = 1), nasogastric tube placement (n = 1), and leak after stricture resection (n = 1). All the patients were treated conservatively without primary surgery or thoracic drainage, and the mean time to perforation healing was 10.2 d (1-24 d). The average length of antibiotic therapy was 10 d (0-26 d). Enteral nutrition was utilized in five patients, and total parenteral nutrition (TPN) was utilized in five patients. No patient developed a new-onset esophageal stricture. CONCLUSION: Conservative management, guided by the patient's clinical course, with antibiotics and nutritional support is a safe and effective treatment for esophageal perforations in children.

Laparoscopic cholecystectomy in obese and non-obese children.

BACKGROUND: Obesity is an increasing problem in the pediatric population. Despite abundant data on the impact of obesity in adults, little data exist that examines the impact of obesity on surgical outcomes in children. We reviewed our experience with laparoscopic cholecystectomy to evaluate the impact of obesity. METHODS: We performed a retrospective chart review of patients who underwent laparoscopic cholecystectomy between September, 2000 and June, 2009. Demographics, indication, length of operation, length of stay, and complications were examined. Body mass index (BMI) was calculated and BMI percentage according to gender and age was determined. RESULTS: There were 312 patients identified, 150 patients were normal weight (BMI less than 85%), 65 patients were overweight (BMI = 85%-95%), and 97 patients were obese (BMI > 95%). The mean age of the patients was 14 y (range 0-20), and 76% were female. The overweight and obese groups had more females (P = 0.022 and P = 0.0016) and the obese group was older (P = 0.0003). No differences were found between the groups in the indication for cholecystectomy. There was no difference in operative time, length of stay, or complications between normal weight patients and overweight or obese patients. CONCLUSION: Despite the known surgical challenges with overweight patients, laparoscopic cholecystectomy is a safe and equally beneficial procedure in overweight children.

A review of single site minimally invasive surgery in infants and children.

Videoscopic surgery has become the standard approach for most thoracic, abdominal, and pelvic procedures in adults and children. These procedures have widely recognized benefits including decreased postoperative pain, improved cosmesis, and decreased convalescence. In a recent attempt to further improve the cosmetic result of these operations, surgeons have begun to employ a single incision through which all the operating instruments are placed. This article seeks to review the current and future application of innovative minimally invasive surgery to pediatric surgery.

Overnight observation in former premature infants undergoing inguinal hernia repair.

BACKGROUND: Overnight observation for apneic events is standard practice in former preterm infants. However, the literature supporting current protocols is dated. Therefore, we retrospectively evaluated the post-anesthetic risks in these patients. METHODS: A retrospective review was conducted on former preterm infants admitted after an inguinal herniorrhaphy between 1/00 and 10/09. The protocol for overnight admission was for patients born before 37 weeks gestation who are less than 60 weeks post-conceptional age (PCA). RESULTS: There were 363 patients, of which 23 were <40 weeks PCA (group 1), 244 were 40 to 49.9 weeks PCA (group 2), and 96 were 50 to 60 weeks PCA (group 3). Events registered by alarms occurred in 4 patients (1.1%), 2 from group 1 and 2 from group 2. In Group 1, one occurred during nasogastric tube placement and resolved spontaneously. In group 2, one was apnea-induced bradycardia that resolved spontaneously, and one was in a patient on home monitors with an event similar to home reports. There were no events in group 3. CONCLUSION: Conservative guidelines for overnight observation after inguinal hernia repair could be set for patients born before 37 weeks gestation who are under 50 weeks PCA.

Quality of life assessment between laparoscopic appendectomy at presentation and interval appendectomy for perforated appendicitis with abscess: analysis of a prospective randomized trial.

PURPOSE: The current study examined the impact of immediate laparoscopic surgery vs nonoperative initial management followed by interval appendectomy for appendicitis with abscess on child and family psychosocial well-being. METHODS: After obtaining Internal Review Board approval, 40 patients presenting with a perforated appendicitis and a well-formed abscess were randomized to surgical condition. Parents were asked to complete child quality of life and parenting stress ratings at presentation, at 2 weeks postadmission, and at approximately 12 weeks postadmission (2 weeks postoperation for the interval appendectomy group). RESULTS: Children in the interval arm experienced trends toward poorer quality of life at 2 and 12 weeks postadmission. However, no group differences in parenting stress were observed at 2 weeks postoperation. At 12 weeks postadmission, participants in the interval condition demonstrated significant impairment in both frequency and difficulty of problems contributing to parenting distress. CONCLUSION: Families experience significant parenting distress related to the child's functioning and disruption in the child's quality of life that may be because of the delay in fully resolving the child's medical condition. In addition, parents experience negative consequences to their own stress as a result of the delay before the child's appendectomy.

Morgagni hernia repair in children: comparison of laparoscopic and open results.

INTRODUCTION: Morgagni hernias are anteromedial diaphragmatic defects that are typically simple to repair. As opposed to posterolateral defects, which are very difficult to expose laparoscopically, the anterior defects can be easily seen with this approach. We reviewed our experience with laparoscopic and open repair of Morgagni hernias in children and their associated outcomes. MATERIALS AND METHODS: A retrospective review was conducted on all patients who underwent repair of Morgagni hernia from January 1994 to May 2009. RESULTS: Seventeen patients were identified, of whom 9 underwent laparoscopic repair and 8 underwent an open repair. The mean age at operation was 3 years (newborn to 14 years) with a mean weight of 20.7 kg (3.6-87.6 kg). Intraoperatively, the diaphragmatic defect size in maximal dimension ranged from 3 to 11 cm. There was no difference in the average age, weight, and defect size among both groups. Of those who underwent laparoscopic hernia repair, 5 patients were closed with a Surgisis-Gold (SIS) patch, 1 was closed primarily with interrupted sutures, and 3 were closed with transabdominal sutures. In the open group, 7 were closed primarily and 1 required SIS patch for closure. Mean length of stay was 3.0 ± 1.5 days in the open group compared with 1.1 ± 0.4 days in the laparoscopic group (P < 0.01). There were no intraoperative complications and no recurrences. CONCLUSIONS: Laparoscopic repair of Morgagni hernias is a relatively simple and effective method of repair in children with accentuated advantages of minimally invasive surgery.

A novel measure for pectus excavatum: the correction index.

OBJECTIVE: The Haller Index (HI), the standard metric for the severity of pectus excavatum, is dependent on width and does not assess the depth of the defect. Therefore, we performed a diagnostic analysis to assess the ability of HI to separate patients with pectus excavatum from healthy controls compared to a novel index. METHODS: After institutional review board approval, computed tomography scans were evaluated from patients who have undergone pectus excavatum repair and controls. The correction index (CI) used the minimum distance between posterior sternum and anterior spine and the maximum distance between anterior spine most anterior portion of the chest. The difference between the two is divided by the latter (×100) to give the percentage of chest depth the defect represents. RESULTS: There were 220 controls and 252 patients with pectus. Mean HI was 2.35, and the mean CI was 0.92 for the controls. The mean HI was 4.06, and the mean CI was 31.75 in the patients with pectus. In the patients with pectus, HI demonstrated a 47.8% overlap with the controls, while there was no overlap for CI. CONCLUSIONS: The Haller index demonstrates 48% overlap between normal patients and those with pectus excavatum. However, the proposed correction index perfectly separates the normal and diseased populations.

Outcomes of perforated appendicitis in obese and nonobese children.

INTRODUCTION: Despite abundant data on the impact of obesity in adults, little data exist that examine the impact of obesity on surgical outcomes in children. Therefore, we analyzed the impact of obesity on children with perforated appendicitis. METHODS: We analyzed data from 3 prospective trials on perforated appendicitis between 2005 and 2009. Perforation was defined as a hole in the appendix or fecalith in the abdomen. There was no difference in abscess rate in the 6 arms of these trials. Body mass index (BMI) was calculated, and BMI percentile was identified according to sex and age. The obese group was defined as BMI greater than 95th percentile. Data were compared between nonobese and obese patients. RESULTS: There were 220 patients, of which 37 patients were obese. The obese group was older with no other differences in presentation. Mean length of stay was 7.9 days in the obese patients compared with 5.8 days for the nonobese (P < .001). Mean operative time was 55.2 minutes in obese patients compared with 43.6 for nonobese (P = .003). Abscess rate was 35% in obese patients compared with 15% for nonobese (P = .01). CONCLUSIONS: Obese children undergoing laparoscopic appendectomy for perforated appendicitis experience longer operative times and suffer worse outcomes.

Outcomes in children with hypoplastic left heart syndrome undergoing open fundoplication.

BACKGROUND/PURPOSE: Some institutions recommend early fundoplication in patients with hypoplastic left heart syndrome (HLHS) with signs of gastroesophageal reflux disease because of the risk of reflux-related cardiac events. However, their cardiac physiology may impose high perioperative morbidity and mortality. Therefore, we reviewed our experience with fundoplication in this population to allow for assessment of the risk-benefit ratio. METHODS: A retrospective review of patients with a diagnosis of HLHS who underwent a fundoplication from January 1990 to July 7, 2009, was performed. All patients underwent open fundoplication between first and second stages of cardiac repair. RESULTS: Thirty-nine patients were identified. There were 3 intraoperative complications: hemodynamic instability (n = 2) and a pulmonary hypertensive crisis requiring extracorporeal membrane oxygenation and termination of the procedure (n = 1). There were 27 postoperative complications in 16 patients. There were 2 deaths (4%) within 30 days, and there were 9 deaths (23%) in patients between their first and second stage of cardiac repair during the study period. CONCLUSIONS: Noncardiac surgical procedures in patients palliated for HLHS have a high morbidity and mortality. We recommend that routine fundoplication in this population should only be performed under prospective protocols until the relative risk of operation vs risk of reflux is delineated.

Single-incision laparoscopic surgery in children: initial single-center experience.

BACKGROUND: In continued efforts to further improve the advantages of minimally invasive surgery to patients, surgeons have developed single-incision laparoscopic techniques. We report our initial experience in children with a variety of single-site procedures. METHOD: A retrospective chart review was performed on patients who underwent a single-site procedure from April 2009 to April 2010. RESULTS: There were 142 consecutive procedures: 24 cholecystectomies, 103 appendectomies for nonperforated appendicitis, 2 splenectomies, 1 combined splenectomy/cholecystectomy, 8 ileocecectomies, 2 Meckel diverticulectomies, 1 small bowel duplication resection, and 1 jejunal stricture resection. There were 12 conversions to conventional laparoscopy: 10 during appendectomy and 2 during cholecystectomy. Mean operative time was 34 minutes for appendectomy, 73 minutes for cholecystectomy, 90 minutes for splenectomy, 116 minutes for combined splenectomy/cholecystectomy, 86 minutes for ileocecectomy, and 43 minutes for the small bowel procedures. The only complications were umbilical surgical site infections after appendectomy in 6 patients. CONCLUSION: This institution's preliminary experience suggests that single-incision laparoscopic surgery in children has at least comparable outcomes to conventional laparoscopic surgery. However, prospective data are needed to prove that single-incision laparoscopic surgery is superior to conventional laparoscopy.

Laparoscopic ileocecectomy in pediatric patients with Crohn's disease.

INTRODUCTION: Definitive management for medically refractory ileocecal Crohn's disease is resection with primary anastomosis. Laparoscopic resection has been demonstrated to be effective in adults. There is a relative paucity of data in the pediatric population. We therefore audited our experience with laparoscopic ileocecectomy in patients with medically refractory ileocecal Crohn's disease to determine its efficacy. METHODS: We conducted a retrospective review of all pediatric patients who underwent laparoscopic ileocecal resection for medically refractory Crohn's disease at a single institution from 2000 to 2009. RESULTS: Thirty patients aged 10-18 years (mean: 15.3 years) with a mean weight of 50 kg (standard deviation: ± 15.5 kg) underwent laparoscopic ileocecectomy for Crohn's disease. Five of these were performed using a single-incision laparoscopic approach. The indications for surgery were obstruction/stricture (21), pain (10), abscess (3), fistula (3), perforation (2), and bleeding (1). Some patient's had multiple indications. There were a total of five abscesses encountered at operation. Eight patients were on total parenteral nutrition at the time of resection. Twenty-five patients (83.3%) were being treated with steroids at operation. The anastomosis was stapled in 26 patients and hand-sewn in 4. Two patients developed a postoperative abscess, and both of them were taking 20 mg of prednisone daily. One patient developed a small bowel obstruction due to a second Crohn's stricture that manifested itself after the more severe downstream obstruction was relieved with ileocecectomy. Of the 5 patients who underwent a single-incision laparoscopic operation, 3 underwent for obstruction/stricture and 2 for perforation. There were no intraoperative or postoperative complications. The patients were followed up for a maximum of 80.7 months (average: 14.7 months; median: 9.7 months). There were no anastomotic leaks or wound infections. DISCUSSION: This series demonstrates that laparoscopic ileocecectomy, both single-incision laparoscopic approach and standard laparoscopy, is safe and effective in the setting of medically refractory Crohn's disease in pediatric patients.

The utility of computed tomography in the management of patients with spontaneous pneumothorax.

BACKGROUND: Spontaneous pneumothorax may result from rupture of subpleural blebs. Computed tomography (CT) has been used to identify blebs to serve as an indication for thoracoscopy. We reviewed our experience with spontaneous pneumothorax to assess the utility of CT in these patients. METHODS: A retrospective review was conducted of all patients who underwent an operation for spontaneous pneumothorax from January 1999 to October 2009. All procedures were performed thoracoscopically. RESULTS: We identified 39 pneumothoraces in 34 patients who underwent evaluation and a procedure for spontaneous pneumothorax. Mean age was 16.1 years (range, 10-23 years), with an average of 1.7 spontaneous pneumothoraces before operation (range, 1-4). Preoperative chest CT scans were obtained in 26 cases. Blebs were demonstrated on 8 CT scans. The presence of blebs was confirmed at operation in all 8 patients. Of the 18 negative scans, 14 (77.8%) were found to have blebs intraoperatively, 7 of these patients were initially managed nonoperatively and developed recurrence. The sensitivity of CT for identifying blebs was 36%. CONCLUSIONS: Chest CT does not appear to be precise in the identification of pleural blebs and a negative examination does not predict freedom from recurrence. Operative decisions should be based on clinical judgment without the use of preoperative CT.

Single-incision laparoscopic surgery and the necessity for prospective evidence.

Laparoscopic surgery has become the standard approach for most thoracic, abdominal, and pelvic procedures in adults and children. We now know that laparoscopy has proven benefits; however, at its introduction, laparoscopy was adopted without appropriate clinical evidence to justify the approach as an alternative to open surgery. In continued efforts to increase the benefits of minimally invasive surgery to their patients, surgeons have innovated new techniques to further decrease the impact of the operation on patients. These innovations range from decreasing the size of ports and instruments to the current group of techniques termed "scarless" surgery. In the current era of evidence-based medicine, it is the surgeon's responsibility to prove that the benefits outweigh the risk before new techniques are widely applied to patients. This article seeks to review the history of laparoscopic surgery, apply lessons learned to the evolution of single-incision laparoscopic surgery, and make a statement urging for sound prospective evaluation.

Outcomes of laparoscopic and open total colectomy in the pediatric population.

INTRODUCTION: Total colectomy, performed either with proctecomy and ileal pouch anal anastomosis or with ileorectostomy, is standard for pediatric patients with ulcerative colitis or familial adenomatous polyposis syndrome, respectively. The complication rates from adult series have been reported to be as high as 40%-50%. We audited our experience to define the complication rates in children and determine whether the use of laparoscopy has the potential to lessen the number or change the type of complications. METHODS: We conducted a retrospective review of all pediatric patients who underwent total colectomy with either proctectomy with ileal pouch anal anastomosis or with ileorectostomy at a single institution from 1998 to 2008. Data are expressed as mean +/- standard deviation. Continuous variables were analyzed using a Student's t-test; and discrete variables were analyzed using a Fisher's exact test, where appropriate. Significance was set as P < or = 0.05. RESULTS: Forty-four patients aged 58 days to 18 years (mean 11.7 +/- 5.3 years) underwent total colectomy from 1998 to 2008. The indications for surgery were ulcerative colitis (27), familial adenomatous polyposis syndrome (11), total colonic Hirschprungs (2), and others (3). Follow-up was significantly greater in the open group (2.8 years) than in the laparoscopic group (1.1 years, P = 0.02). Nineteen patients (43%) suffered major complications (other than pouchitis). There was 1 anastomotic leak. There were no statistically significant differences found between the laparoscopic and open approaches with regard to postoperative small bowel obstruction, postoperative abdominal or pelvic abscess, anal stricture requiring dilation, wound infection, other complications, or time to complication. Patients who underwent laparoscopic ileal pouch anal anastomosis had one occurrence of pouchitis (1/10) compared with 19/34 in the open group (P = 0.03). CONCLUSIONS: This series demonstrates that laparopscopic colectomy yields similar outcomes as the traditional open method, both in type and severity of complications. Patients who had an ileal pouch created through the laparoscopic approach had fewer occurrences of pouchitis.

Treatment of adolescent gynecomastia.

PURPOSE: Adolescent gynecomastia is common but variable in severity. The disease may be self-limited. Although antiestrogen therapy can be used in persistent gynecomastia, results are mixed. Subcutaneous mastectomy via a circumareloar incision is familiar to most pediatric surgeons and provides excellent cosmetic results in most cases. Severe gynecomastia may require alternative procedures. There is little information in the pediatric surgical literature to provide the pediatric surgeon with treatment options for these children. A variety of techniques have been used by plastic surgeons for female patients requiring breast reduction and are sometimes a useful addition to the surgical repertoire for the management of very large breasts in adolescent gynecomastia. We reviewed our experience with the use of inferior pedicle reduction mammaplasty and subcutaneous mastectomy in adolescents with gynecomastia and describe the techniques used. METHODS: After obtaining institutional review board approval, a retrospective review was conducted on all patients operated on for gynecomastia from January 1999 to March 2009. Data recorded included patient demographics, diagnostic evaluation, medical and surgical treatment, complications, and outcome. RESULTS: Twenty patients underwent an operation for gynecomastia. Eight patients had bilateral inferior pedicle reduction mammaplasty, and 12 patients underwent either unilateral or bilateral subcutaneous mastectomy. The mean age at operation was 15.5 years (range, 14-18 years). In all cases, the histopathologic feature was consistent with gynecomastia. There were no postoperative wound infections. One patient developed a seroma after subcutaneous mastectomy requiring drainage. The mean amount of tissue removed after bilateral reduction mammaplasty was 275.1 g. No patients had devascularization of the nipple-areolar complex or nipple loss. One patient had mild subcutaneous asymmetry after a reduction mammaplasty that required no further intervention. Seven patients (87%) had an excellent cosmetic outcome after reduction mammaplasty. Mean length of follow-up was 18.8 months. CONCLUSIONS: Although many adolescents with true gynecomastia have mild or self-limited disease, operative treatment may provide significant benefit to the remainder. Milder grades of gynecomastia can be managed with subcutaneous mastectomy. Selected severe cases can be safely and effectively treated with reduction mammaplasty.

15-Year experience in the treatment of rectal prolapse in children.

BACKGROUND: Rectal prolapse is a common and usually self-limited condition in children. Several surgical techniques have been advocated for refractory prolapse. We reviewed our experience with treatment and the outcome of refractory rectal prolapse. METHODS: Retrospective review was conducted on patients undergoing surgery for rectal prolapse from January 1993 to March 2009. Patients with imperforate anus/cloacal abnormalities, Hirschsprung disease, spina bifida, or prior pull-through were excluded. RESULTS: Twenty patients underwent 23 procedures for rectal prolapse. There were 10 posterior sagittal rectopexies, 6 transabdominal rectopexies, 5 laparoscopic rectopexies, 1 hypertonic saline injection, and 1 anal cerclage. The mean duration of symptoms was 1.6 years (range, 1-10 years). The mean age at operation was 6.8 years (range, 4 months-19 years), with a 5:1 male predominance. There was no operative or perioperative mortality. Median length of follow-up was 7.2 months; 2 patients were lost to follow-up. The overall recurrence rate was 35%. All recurrences followed posterior sagittal rectopexies, which had a 70% recurrence rate. Four patients required reoperation, all done transabdominally (2 open and 2 laparoscopically). None of the 3 remaining patients with mild recurrences required reoperation. CONCLUSIONS: A variety of options for management of refractory rectal prolapse in children exist. Laparoscopic rectopexy seems to be safe and a comparatively successful option in these children.