Are Cardiac Anomalies and Persistent Fetal Circulation a Risk Factor for Cardiovascular Events During Minimally Invasive Surgery in Neonates?

Introduction: Minimally invasive surgery (MIS) in neonates is progressively performed. The aim of this study was to evaluate the risk for cardiovascular events during endoscopic surgery in neonates and to analyze the influence of persistent fetal circulation and/or cardiac anomalies. Materials and Methods: This is a retrospective single institution study including all neonates undergoing MIS. The charts were reviewed for intraoperative cardiovascular events and operative procedure was performed. Special attention was paid to cardiac anomalies and persistent fetal circulation. In addition, a review of the literature was performed. Results: Between January 2004 and December 2012, 108 neonates underwent MIS at our institution. Laparoscopic surgery was performed in 91 (84.3%) and thoracoscopy in 17 (15.7%) babies. None of these 108 patients developed a cardiovascular event during endoscopic surgery (0.0%). Persistent fetal circulation and/or cardiac anomalies were evaluated in 50 of 108 (46.3%) neonates. In the additionally performed review of the literature, four single case reports were identified. All 4 authors published a major cardiovascular event during laparoscopic surgery in neonates. In all 4 patients, gas embolism through a patent umbilical vein was assumed to be responsible for the cardiovascular event. Conclusions: In our opinion, the main risk factor for the development of a major cardiovascular event during MIS in neonates is vascular injury of a persistent umbilical vein. Persistent fetal circulation and/or cardiac anomalies seem to be less important. In case of injury of a persistent umbilical vein, the risk of gas embolism has to be respected and conversion to the open approach has to be considered.

Laparoscopy in the Surgical Treatment of Disorders of Sexual Development.

INTRODUCTION: Disorder of sexual development (DSD) is a rare condition. The surgical treatment of these patients includes investigation of the internal genitalia, evaluation of the gonads, and if necessary gonadectomy. The prevention of germ cell tumors is the most important issue in the surgical treatment of this varied and special group of patients. This study aimed to evaluate the role of laparoscopy in the surgical treatment of patients with DSD. MATERIALS AND METHODS: Over a 4-year-period, all patients presenting with DSD who underwent laparoscopic surgery at our institution were retrospectively reviewed. Operative procedure, age at the time of surgery, and histopathological results were evaluated. In addition, karyotypes and phenotypes were investigated. RESULTS: Altogether, 12 patients undergoing 14 laparoscopic procedures were included. Median age at the time of surgery was 6 years with a range from 9 months to 17 years. Explorative laparoscopy was performed in all patients. In seven children, laparoscopic gonadectomy was necessary. Histopathologic examination revealed germ cell tumors in four children. In two patients, a gonadoblastoma was identified; in two patients, a dysgerminoma was found. Inguinal exploration was performed in four patients and led to removal of gonadal remnants in one case and gonadopexy in three cases. In two patients presenting with repeated urinary tract infections, laparoscopic removal of an utriculus was performed. CONCLUSIONS: Laparoscopic gonadal biopsy, gonadopexy, and gonadectomy can be performed successfully, even in patients with germ cell tumors. To define guidelines for the surgical treatment of patients with DSD, further prospective and multicenter studies are necessary.

The Role of Laparoscopy in the Acute Neonatal Abdomen.

IntroductionThe surgical treatment of the acute neonatal abdomen still poses a challenge in pediatric surgery. Various underlying etiologies require different surgical procedures. Until today the role of laparoscopy in the surgical treatment of the acute neonatal abdomen is controversial. The aim of this study was to analyze our experiences with laparoscopy and to perform a review of the literature. Methods Retrospective, single-institution study including all term and preterm neonates initially undergoing laparoscopy due to an acute abdomen. Results Altogether, 17 neonates presenting with an acute neonatal abdomen initially underwent laparoscopy. Unnecessary laparotomy could be avoided in 9 of 17 (53%) neonates. After diagnostic laparoscopy, 2 patients did not require any further surgical intervention. Eight neonates presented midgut atresia intraoperatively, 5 of them underwent laparoscopic-assisted correction. Successful laparoscopic derotation of an acute volvulus (n = 1) and laparoscopic appendectomy (n = 1) could be performed. Conversion to open surgery was necessary in 8 neonates (47%) due to creation of a stoma (n = 5), multiple intestinal bands causing poor visualization (n = 2), and bowel necrosis (n = 1). Conclusions Laparoscopy is a useful diagnostic tool to evaluate the need for further surgical intervention in the acute neonatal abdomen and enables immediate surgical treatment of acute volvulus, appendicitis, or intestinal atresia. In case of conversion to laparotomy, precise localization of the incision is guaranteed. Minimization of the surgical trauma and avoidance of unnecessary laparotomy are the most important benefits of the minimal-invasive approach for the critically ill neonate.

Gender-related differences of inguinal hernia and asymptomatic patent processus vaginalis in term and preterm infants.

INTRODUCTION: The aim of this study was to analyze the gender-related differences of inguinal hernia (IH) and patent processus vaginalis (PPV) in term and preterm infants. METHODS: Over a nine-year-period 411 infants underwent laparoscopic herniorrhaphy within the first six months of life. 246 term (191 male; 55 female) and 165 preterm (118 male; 47 female) infants were included in this retrospective study. Initial presentation of IH and intraoperative anatomical findings of PPV were reviewed. RESULTS: We found that term boys (58.6%) and girls (58.2%) predominantly presented with right-sided IH whereas preterm boys (36.4%) and girls (44.7%) mostly presented with bilateral IH. Female babies had a higher incidence of initial left-sided IH. Term and preterm girls with initial left-sided hernia were found to have highest incidence of PPV. Male term babies with initial left-sided IH were found to have the lowest incidence of PPV (25.0%). The highest incidence of PPV in male was found in preterm boys with either left- or right-sided IH. CONCLUSION: Incidence and laterality of IH and PPV differ between term and preterm girls and boys. In open hernia repair decision concerning contralateral groin exploration should consider term/preterm birth as well as gender.

Comparison of inguinal hernia and asymptomatic patent processus vaginalis in term and preterm infants.

INTRODUCTION: The aim of this study was to evaluate the characteristics of inguinal hernia (IH) and patent processus vaginalis (PPV) in term and preterm infants less than the age of 6months. METHOD: Between January 2004 and December 2012, 246 term and 165 preterm infants underwent laparoscopic herniorrhaphy within the first 6months of life. Preoperative clinical presentation and intraoperative anatomical findings during the laparoscopic procedure were evaluated. Additionally, initial side of hernia, laterality of IH and PPV were analyzed in term and preterm infants. RESULTS: In the group of term infants, most infants presented with a primary right-sided IH (58.5%) versus 17.9% left-sided and 23.6% bilateral IH. Babies with primary unilateral IH were found to have a contralateral PPV in 41.0% of cases. A difference between left-sided PPV and right-sided PPV could not be identified. In the group of preterm infants, initial bilateral presentation was predominant (38.8%) versus right-sided (30.3%) and left-sided IH (30.9%). Infants with primary unilateral IH were found to have a contralateral PPV in 56.4%. We identified a slight difference between left-sided PPV (54.0%) and right-sided PPV (58.8%). CONCLUSION: IH is predominantly right sided in term infants, whereas preterm infants mostly present with bilateral IH. The incidence of PPV was found to be significantly higher in the preterm group. Regarding the incidence of a contralateral PPV in term and preterm infants, no difference between initial left-sided and right-sided IH could be identified between both groups.

Hemodynamic effects of thoracoscopic surgery in neonates with cardiac anomalies.

INTRODUCTION: Thoracoscopic repair of esophageal atresia (EA) and congenital diaphragmatic hernia (CDH) repair is increasing in popularity. However, minimally invasive surgery is avoided in infants with heart defects. The aim of this study was to clarify whether cardiac anomalies are a reasonable contraindication to thoracoscopic surgery in term and preterm neonates. PATIENTS AND METHODS: In this retrospective, single-institution study 15 neonates (8 boys and 7 girls) with cardiac anomalies underwent thoracoscopic repair of either EA or CDH. Between January 2004 until November 2012 4 preterm and 11 term neonates were identified. Type of cardiac anomaly, operative procedure performed, operative time, intrapleural pressure, and early postoperative complications were evaluated. RESULTS: Over this 9-year period, 10 neonates underwent thoracoscopic EA repair, and 5 neonates underwent thoracoscopic CDH repair. Median operative time was 177 minutes with a median intrapleural pressure of 9 mm Hg. Cardiac anomalies ranged from persistent foramen ovale to atrium septal defect to ventricular septal defect and tetralogy of Fallot. In the postoperative course hemodynamic impairment was noted in only 1 patient. This patient presented cardiorespiratory instability already preoperatively and required dobutamine until postoperative Day 6. CONCLUSIONS: From this experience it appears that thoracoscopic surgery can be performed safely in term and preterm neonates with cardiac anomalies. Even in babies with multiple cardiac anomalies and complex heart defects, thoracoscopic repair of EA or CDH could be performed without hemodynamic instability. Nevertheless, further studies are necessary to gain sufficient information about the effects of thoracoscopy in neonates with heart defects.

Cardiorespiratory complications after laparoscopic hernia repair in term and preterm babies.

PURPOSE: The aim of this study was to clarify the incidence of postoperative complications in infants undergoing laparoscopic hernia repair within the first six months of life. METHODS: Retrospective, single-institution study comparing term and preterm babies undergoing surgery between March 2005 and September 2012. The charts were reviewed for postoperative complications and pre-existing diseases. RESULTS: In the term group 188 of 199 babies (94.5%) had an uneventful postoperative course. Eleven patients (5.5%) presented postoperative complications, three of them (1.5%) developed severe respiratory complications. A relation between pre-existing diseases and postoperative complications could be identified in two patients. Laparoscopy possibly induced cardiorespiratory instability in one infant. In the preterm group 109 of 137 babies (79.6%) had an uneventful postoperative course. 28 preterm infants (20.4%) developed postoperative complications, seven of them (5.1%) presented severe respiratory complications. Pre-existing diseases were identified as an influencing factor in 22 preterm infants. In one patient laparoscopy possibly caused minor instability of a pre-existing cardiac anomaly. CONCLUSIONS: Postoperative complications are low in both groups, although the incidence is increased in preterm infants. Pre-existing diseases are a major influencing factor for preterm infants. In very few infants laparoscopy may have induced instability of cardiac anomalies.

Hemodynamic effects of laparoscopic surgery in term and preterm infants with cardiac anomalies.

PURPOSE: The aim of this study was to clarify whether cardiac anomalies are a reasonable contraindication to laparoscopic surgery in infants. METHODS: Between January 2004 and January 2013, 131 term and preterm infants with cardiac anomalies underwent laparoscopic surgery within the first 6 months of life. In this retrospective study type of cardiac anomaly, performed operative procedure, operative time, intraabdominal pressure and postoperative complications were evaluated. RESULTS: Over this 9-year period, 80 preterm and 51 term infants underwent different complex and even long-lasting laparoscopic procedures. Median operative time was 67 min with a median intraabdominal pressure of 13 mmHg. Cardiac anomalies ranged from persistent foramen ovale, atrium septal defect to ventricular septal defect and tetralogy of Fallot. In the postoperative course hemodynamic impairment was noted in three infants (2.3 %). Only one of them presented cardiorespiratory instability. CONCLUSION: In this study different laparoscopic procedures could be performed in numerous infants with cardiac anomalies. Due to the inhomogeneity of this group of patients and individual combinations of heart defects with or without hemodynamic relevance, preoperative evaluation by a firm pediatric cardiologist is crucial. Prospective studies are necessary to further clarify the use of laparoscopic surgery in this distinct group of patients.

The role of laparoscopy in the treatment of duodenal obstruction in term and preterm infants.

PURPOSE: The aim of this study was to evaluate the role of laparoscopy in the surgical treatment of intrinsic and extrinsic duodenal lesions referring to the underlying cause of obstruction. METHODS: Retrospective chart review of all cases of duodenal obstructions undergoing surgery at our institution between April 2004 and March 2012. RESULTS: Twenty patients underwent surgery for duodenal obstruction (11 female, 9 male). Seven infants were born prematurely. Eleven infants had extrinsic, seven had intrinsic and two had a combination of intrinsic and extrinsic duodenal lesions. A laparoscopic procedure was initially started in 18 of 20 patients (90 %). Thirteen of the 18 infants (72 %) underwent various laparoscopic procedures: laparoscopic duodenoduodenostomy, resection of a duodenal membrane and the transsection of Ladd's bands. In five patents, a conversion became necessary due to poor visualisation of the duodenum. In three patients (15 %) with extrinsic duodenal lesion a reoperation was necessary. Two of the 20 patients (10 %) were operated with an "open" approach to begin with. CONCLUSION: Laparoscopy is feasible and safe in most cases. The few conversions were early in the series due to a lack of experience and necessitated by poor visualisation, most often caused by malrotation.

Gastric outlet obstruction in a neonate because of Peutz-Jeghers syndrome.

Neonatal detection of Peutz-Jeghers syndrome is unusual with only 2 cases previously reported in the literature. We describe a neonate presenting with gastric outlet obstruction owing to 2 large Peutz-Jeghers polyps. The child's father and grandmother were known to have Peutz-Jeghers syndrome. On the ninth day of life, the infant underwent colonoscopy, abdominal exploration, and complete surgical resection of 3 polyps. The postoperative course was uneventful, and the patient was discharged home at the age of 3 weeks on full oral feeds. This is the first case report of inherited Peutz-Jeghers syndrome causing gastric outlet obstruction in a neonate.