Imaging Diagnosis for Intradiaphragmatic Pulmonary Sequestration: A Pilot Study.

OBJECTIVES: Extrapulmonary sequestration (EPS) within the diaphragm (ID-EPS) is rare and requires additional procedures such as incision or detachment of the diaphragm from the lesion for diagnosis. This study aimed to describe the imaging findings and evaluate the diagnostic accuracy of ultrasonography and computed tomography (CT) for ID-EPS. MATERIAL AND METHODS: Split diaphragm sign, shape of lesion edge, drainage vein into intra-abdomen on ultrasound and CT, and lesion characteristics on ultrasound were compared between patients with ID-EPS and with above-diaphragm EPS (AD-EPS) using Fisher's exact test. RESULTS: Three and nine patients were diagnosed with ID-EPS and AD-EPS, respectively. Significant differences were observed between the two groups in the split diaphragm sign on ultrasound (presence/absence in patients with ID-EPS vs AD-EPS, 2/1 vs 0/9, P = .046), shape of lesion edge on ultrasound/CT (round/beak in patients with ID-EPS vs AD-EPS, 3/0 vs 0/9, P = .005 on both CT and ultrasound), lesion characteristics on ultrasound (presence/absence of cystic area within lesion in patients with ID-EPS vs AD-EPS, 0/3 vs 7/2, P = .046), and the drainage vein into the abdomen on CT (presence/absence in patients with ID-EPS vs AD-EPS; 2/1 vs 0/9, P = .046). No drainage veins were visualized in the abdomen on ultrasonography and no significant differences in the presence/absence of the split-diagram sign on CT (presence/absence in patients with ID-EPS vs AD-EPS and ID-EPS; 0/3 vs 0/9, P > .999; 1/2 vs 0/9, P = .250) were observed between the two groups. CONCLUSION: A combination of postnatal ultrasonography and CT was useful in predicting EPS located within the diaphragm.

Anastomotic time was associated with postoperative complications: a cumulative sum analysis of thoracoscopic repair of tracheoesophageal fistula in a single surgeon's experience.

PURPOSE: This study aimed to evaluate the learning curve of thoracoscopic repair of tracheoesophageal fistula (TEF) by a single surgeon using a cumulative sum (CUSUM) analysis. METHODS: Prospective clinical data of consecutive Gross type-C TEF repairs performed by a pediatric surgeon from 2010 to 2020 were recorded. CUSUM charts for anastomosis and operating times were generated. The learning curves were compared with the effect of accumulation based on case experience. RESULTS: For 33 consecutive cases, the mean operative and anastomosis times were 139 ± 39 min and 3137 ± 1110 s, respectively. Significant transitions beyond the learning phase for total operating and anastomosis times were observed at cases 13 and 17. Both the total operating time and anastomosis time were significantly faster in the proficiency improvement phase than in the initial learning phase. Postoperative complications significantly decreased after the initial anastomosis learning phase but not after the initial total operating learning phase. CONCLUSIONS: Thoracoscopic repair of TEF is considered safe and feasible after 13 cases, where the surgeon can improve their proficiency with the total operation procedure, and 17 cases, which will enable the surgeon to achieve proficiency in anastomosis. Postoperative complications significantly decreased after gaining familiarity with the anastomosis procedure through the learning phase.

Incidence and diagnostic performance of ultrasound for perianal abscess or fistula-in-ano in pediatric patients with perianal inflammation.

OBJECTIVES: To describe the incidence and diagnostic performance of ultrasound for perianal abscess or fistula-in-ano in pediatric patients with perianal inflammation. METHODS: We included 45 patients with perianal inflammation who underwent ultrasonography. To demonstrate the diagnostic performance of ultrasound for fistula-in-ano, a definite diagnosis of perianal abscess, and fistula-in-ano was determined as that proven through magnetic resonance imaging (MRI) or computed tomography (CT). The absence or presence of perianal abscess and fistula-in-ano on ultrasonography was recorded. RESULTS: Among the 45 patients, on ultrasound, perianal abscess and fistula-in-ano were detected in 22 (48.9%) and 30 (68.2%) patients, respectively. Nine patients had MRI or CT and a definite diagnosis of perianal abscess or fistula-in-ano; accuracy, negative predictive value, and positive predictive value of ultrasound for perianal abscess were 77.8% (7/9; 95% confidence interval [CI]: 40.0%-97.1%), 66.7% (2/3; 95% CI: 9.4%-99.2%), 83.3% (5/6; 95% CI: 35.9%-99.6%), and those of fistula-in-ano were 100% (9/9; 95% CI: 66.4%-100%), 100% (8/8; 95% CI: 63.1%-100%), and 100% (1/1; 95% CI: 2.5%-100%), respectively. CONCLUSIONS: Perianal abscess and fistula-in-ano were detected by ultrasound in half of the patients with perianal inflammation. Accordingly, ultrasound has an acceptable diagnostic performance for perianal abscess and fistula-in-ano.

Evaluation of minimally invasive surgical skills training: comparing a neonatal esophageal atresia/tracheoesophageal fistula model with a dry box.

BACKGROUND: Pediatric surgeons require highly advanced minimally invasive surgical skills to perform rare and complex surgeries in a very vulnerable population. We developed a neonatal esophageal atresia (EA) model to improve thoracoscopic surgical skills. This study aimed to evaluate the concurrent validity of the model by undertaking pre- and post-training skills assessments in two groups of students with no prior experience performing minimally invasive surgery, using the EA model and a dry box (DB). METHODS: A pilot study was performed. The participants were randomly divided into two groups: one trained using the DB and one trained using the EA model. Both groups practiced a minimally invasive surgical suture task. The task completion time, 29-point checklist score, modified suturing error sheet score, and three-dimensional forceps movement in both groups were compared pre-and post-training by video analysis. RESULTS: The EA model task was significantly more difficult than that of the DB. Both groups showed significant improvement in the task time, 29-point checklist score, and modified suturing error sheet score; however, the EA model training was more efficient in improving each error item. Regarding forceps movement, the EA model training significantly decreased wasted motion, whereas the DB was limited in this regard. CONCLUSIONS: Short-term training on the EA model, which was more technically demanding than the DB, decreased technical error and wasted motion, and allowed learners to acquire surgical skills more efficiently than training with the DB model. These facts revealed the concurrent validity of the EA model.

Comparison of single-incision laparoscopic percutaneous extraperitoneal closure (SILPEC) and open repair for pediatric inguinal hernia: a single-center retrospective cohort study of 2028 cases.

BACKGROUD: Recently, laparoscopic percutaneous extraperitoneal closure (LPEC) has gained increased popularity for pediatric inguinal hernia repair. To improve cosmesis, we developed single incision LPEC (SILPEC). The aim of this study was to assess the safety and feasibility of SILPEC compared with traditional open repair (OR). METHODS: This was a single-center retrospective cohort study of 2028 children who underwent inguinal hernia repair between April 2005 and August 2014. Nine hundred and ninety-five patients underwent OR and 1033 patients underwent SILPEC. Medical records were reviewed with respect to operative time, recurrence, incidence of contralateral metachronous inguinal hernia (CMIH), and complications. Patient satisfaction with cosmetic result was also investigated using questionnaires sent by mail. RESULTS: All SILPEC procedures were completed without conversion. Operative time was longer in the SILPEC group than in the OR group for both unilateral and bilateral surgery regardless of sex (unilateral male: p = 0.0006, unilateral female: p < 0.0001, bilateral male: p < 0.0001, bilateral female: p < 0.0001). There was no statistically significant difference in recurrence rate (p = 0.43). The incidence of CMIH was significantly higher in the OR than in the SILPEC group (p < 0.0001). No postoperative testicular atrophy was found in either group. There was no statistically significant difference in ascending testis (p = 0.09), but the frequency of surgical site infection was higher in the SILPEC than in the OR group (p = 0.0013). According to the questionnaire, operative scar was more invisible in the SILPEC than in the OR group (p < 0.0001), but both procedures had equally high levels of satisfaction for cosmetic results (p = 0.58). CONCLUSION: SILPEC proved to be a safe and feasible procedure compared with OR with an equally low recurrence rate, more effectiveness for preventing CMIH, and more invisible scar.

Mesh hiatal reinforcement in laparoscopic Nissen fundoplication for neurologically impaired children is safe and feasible.

Fundoplication is a standard treatment for gastroesophageal reflux disease (GERD) in neurologically impaired children. However, it has a high recurrence rate due to wrap herniation and disruption resulting from the failure or enlargement of the esophageal hiatus suture site. In adult patients with GERD, reinforcement of the sutured esophageal hiatus with a mesh significantly reduces the recurrence rate after surgery for esophageal hiatus hernia. In children, there are no big series of fundoplication with mesh reinforcement. Therefore, we confirmed the safety and feasibility of an expanded polytetrafluoroethylene mesh hiatal reinforcement with fundoplication as an additional procedure for neurologically impaired children. Neurologically impaired children (age, ≥5 years) who underwent laparoscopic fundoplication and gastrostomy at our institution between 2011 and 2013 were included in this study. The operative time, bleeding amount, complications, and recurrence were retrospectively evaluated. Thirteen patients were included in this study. The mean age at operation was 147.2 ± 37.8 months, and mean body weight was 18.5 ± 7.9 kg. The complication rate of epilepsy and scoliosis was 100% and 84.6%, respectively. The operative time was 265.1 ± 38.1 minutes, and mean blood loss was 26.5 ± 34.7 mL. There were no peri- or postoperative complications. None of the patients showed recurrent symptoms such as repeated vomiting and aspiration pneumonia during the mean follow-up period of 2.5 ± 0.6 years. The mesh hiatal reinforcement with fundoplication for neurologically impaired children is safe and feasible.

A multi-degree-of-freedom needle driver with a short tip and small shaft for pediatric laparoscopic surgery: in vivo assessment of multi-directional suturing on the vertical plane of the liver in rabbits.

BACKGROUND: Laparoscopic Kasai portoenterostomy has been performed in infants with biliary atresia at several institutions, but laparoscopic anastomosis requiring multi-directional suturing on a vertical plane of the liver remains a challenge. To assist multi-directional suturing, we developed a multi-degree-of-freedom (DOF) needle driver whose tip length was 15 mm and shaft diameter was 3.5 mm. The tip of the multi-DOF needle driver has three DOFs for grasp, flection and rotation. The aim of this study was to evaluate the performance of the multi-DOF needle driver in two kinds of in vivo experiments. METHODS: Surgeons were asked to perform four-directional laparoscopic suturing on a vertical plane of the liver in six rabbits using the multi-DOF needle driver or a conventional needle driver. The needle grasping time, the needle handling time, the number of needle insertions, the number of liver lacerations, the suturing width and depth, and the area of necrotic tissues were analyzed and compared. Additionally, one surgeon was asked to perform laparoscopic hepato-jejunostomy in four rabbits to assess the feasibility of Kasai portoenterostomy using the multi-DOF needle driver. RESULTS: The suturing depth using the multi-DOF needle driver was significantly larger than that using the conventional needle driver in both the right and downward suturing directions. No statistically significant differences were found in other metrics. Liver lacerations were observed only when suturing was performed using the conventional needle driver. The experimental laparoscopic hepato-jejunostomy using the multi-DOF needle driver was successful. CONCLUSIONS: Using the multi-DOF needle driver, uniform multi-directional suturing on a vertical plane of the liver could be performed. The short distal tip of the multi-DOF needle driver demonstrated its advantages in multi-directional suturing in a small body cavity. The multi-DOF needle driver may be able to be used to perform complex tasks in laparoscopic Kasai portoenterostomy.

Laparoscopic side-to-side pancreaticojejunostomy for chronic pancreatitis in children.

Surgical pancreatic duct (PD) drainage for chronic pancreatitis in children is relatively rare. It is indicated in cases of recurrent pancreatitis and PD dilatation that have not responded to medical therapy and therapeutic endoscopy. We performed laparoscopic side-to-side pancreaticojejunostomy for two paediatric patients with chronic pancreatitis. The main PD was opened easily by electrocautery after locating the dilated PD by intraoperative ultrasonography. The dilated PD was split longitudinally from the pancreatic tail to the pancreatic head by laparoscopic coagulation shears or electrocautery after pancreatography. A laparoscopic side-to-side pancreaticojejunostomy was performed by a one-layered technique using continuous 4-0 polydioxanone (PDS) sutures from the pancreatic tail to the pancreatic head. There were no intraoperative or postoperative complications or recurrences. This procedure has cosmetic advantages compared with open surgery for chronic pancreatitis. Laparoscopic side-to-side pancreaticojejunostomy in children is feasible and effective for the treatment of chronic pancreatitis.

Influence of surgical intervention on neurodevelopmental outcome in infants with focal intestinal perforation.

BACKGROUND: Intestinal perforation is known to correlate with neurodevelopmental outcome in very low-birthweight (VLBW) infants, and its two major causes are necrotizing enterocolitis (NEC) and focal intestinal perforation (FIP). Infants with FIP are reported to have better neurodevelopmental outcome than infants with NEC, but outcome has not been compared with that in infants without diseases that require surgery. The aim of this study was to compare neurodevelopmental outcomes between FIP survivors and infants without diseases that require surgery. METHODS: Records of VLBW infants with FIP and infants without surgical diseases were retrospectively analyzed. Neurodevelopmental outcome was compared between eight infants with FIP and 24 case-matched control infants without surgical diseases using the Kyoto Scale of Psychological Development. Control group members were individually matched with FIP survivors for sex, gestational age, birthweight, and intraventricular hemorrhage (IVH) grade. Those with an episode of sepsis or severe IVH (grade 3-4) that occurred irrespective of FIP were excluded. RESULTS: Three FIP survivors and 12 infants without surgical diseases were classified as neurodevelopmentally normal (37.5% vs 50%, P = 0.69) at a corrected age of 18 months-3 years. All neurodevelopmentally normal FIP survivors were born at a gestational age ≥ 26 weeks. CONCLUSION: Excluding the influence of sepsis or severe IVH, no significant difference was found in neurodevelopmental outcome between FIP survivors and infants without surgical diseases. None of the FIP infants born before 26 weeks of gestation, however, had normal neurodevelopment, suggesting that longer gestation might be needed to overcome the stress associated with FIP.

Massive hemorrhage after Kasai portoenterostomy in a patient with a congenital extrahepatic portosystemic shunt, malrotation and a double aortic arch: report of a case.

A newborn female was transferred to our hospital presenting with severe respiratory distress. She underwent tracheal intubation and nasogastric tubing. Investigations revealed a congenital extrahepatic portosystemic shunt (CEPS) type 1, biliary atresia, heterotaxia, polysplenia, malrotation and a double aortic arch (DAA). She underwent the Kasai portoenterostomy and the Ladd procedure when she was 29 days old. On postoperative day 20, she developed sudden hematemesis with bright red blood. Endoscopy showed massive bleeding from an esophageal ulcer, and endoscopic therapy was performed successfully. During left thoracotomy, an aortoesophageal fistula (AEF) was detected and repaired by direct suturing. The postoperative course was uneventful. CEPS type 1 is commonly associated with other congenital malformations; however, there have been no previous reports of an association between CEPS and DAA. Nasogastric tube insertion in a patient with DAA can result in catastrophic AEF. The treatment strategy should be carefully considered in patients with CEPS type 1 and multiple congenital fetal anomalies.

Urethroscopic holmium: YAG laser ablation for acquired posterior urethral diverticulum after repair of anorectal malformations.

Two patients with acquired posterior urethral diverticulum that is a complication of laparoscopic assisted anorectoplasty underwent urethroscopic holmium: YAG laser ablation. After the ablation therapies, the size of the diverticulum markedly decreased in both patients. Holmium: YAG laser is safe and easy to handle in the small pediatric urethra.

Comparison of Postoperative Respiratory Function Between Patients After Thoracoscopic and Open Lobectomy.

Purpose: This study aimed to compare respiratory functions of patients after thoracoscopic lobectomy (TS) with those after thoracotomy (TR). Methods: This retrospective study was conducted in two centers, one of which adapted TS as a standard procedure in 2009 and the other performs it via TR. Data on patients who underwent lobectomy for congenital lung disease between 2009 and 2021 and underwent pulmonary function test (spirometry) were collected. Results: Ten patients underwent TS and 36 underwent TR. Distribution based on sex, prenatal diagnosis, pathological diagnosis, and resected lobe were similar between the two groups. The median [interquartile range] age at procedure in the TR group was significantly smaller than that in the TS group (13 [11-18] months versus 38 [13-79] months, P = .03). The procedure duration in the TR group was significantly shorter than that in the TS group (230 [171-264] minutes versus 264 [226-420] minutes, P = .02). Pulmonary function test was conducted at the age of eight in both groups, but the interval between the procedure, and the test was significantly shorter in the TS group (TR: 7 [5-8] years versus TS: 5 [2-7] years, P = .03). The ratio of forced vital capacity compared to predicted one (TR: 86.6 [76.6-95.3] versus TS: 88.7 [86.8-89.1], P = .58) and the ratio of forced expiratory volume in 1 second against that predicted (TR: 84.0 [80.5-88.7] versus TS: 88.7 [86.8-89.1], P = .08) were not significantly different between the two groups. Conclusions: Although TR was performed earlier than TS, respiratory function was similar between the two groups.

Single-incision laparoscopic-assisted appendectomy in children: exteriorization of the appendix is a key component of a simple and cost-effective surgical technique.

PURPOSE: Single-incision laparoscopic appendectomy was recently introduced as a less-invasive surgical technique than existing methods, and is increasingly being performed worldwide. We have started to perform transumbilical laparoscopic-assisted appendectomy (TULAA) in children. In this study, we assessed its feasibility, efficacy, and cost-effectiveness compared with conventional multiport laparoscopic appendectomy (MLA). METHODS: We retrospectively reviewed all of the patients who underwent MLA or TULAA between August 2009 and December 2012. Patient characteristics, operative time, length of hospital stay, postoperative complications, cost-effectiveness, and cosmetic results were analyzed. RESULTS: A total of 88 patients underwent laparoscopic appendectomy, with MLA in 48 patients and TULAA in 40 patients. TULAA was successful in 36/40 patients. There were no significant differences in mean operative time or mean length of stay between the two groups of patients. There were no postoperative complications in the TULAA group. The cost of TULAA was much lower than that of MLA. TULAA also provided nearly scarless surgery. CONCLUSION: TULAA, in which the appendix is exteriorized via a combination of open and laparoscopic techniques, is a safe and effective procedure for treating appendicitis in children. TULAA is a cost-effective treatment that provides excellent cosmetic results.

External stabilization for severe tracheobronchomalacia using separated ring-reinforced ePTFE grafts is effective and safe on a long-term basis.

PURPOSE: Tracheobronchomalacia is a respiratory disorder that results from abnormal cartilage development. Since 2003, we have performed external stabilization for severe tracheobronchomalacia using separated ring-reinforced expanded polytetrafluoroethylene (ePTFE) grafts. The aim of this study was to analyze the short- and long-term outcomes of our procedure. METHODS: We reviewed the charts of patients who underwent external tracheobronchial stabilization from January 2003 through December 2012. Separated ring-reinforced ePTFE grafts were fixed to the anterior and posterior lesions of malacia independently, with confirmation of a well-opened lumen by bronchoscopy. RESULTS: Five children with severe tracheobronchomalacia underwent six operations. The median follow-up period was 43 months (range 11-109 months). There was no operative mortality associated with the procedure. One patient required removal of a section of the graft owing to the development of bronchial granulation tissue at the site of fixation. All patients showed improved respiratory function, and tracheal growth was confirmed by follow-up computed tomography. CONCLUSIONS: External stabilization with separated ring-reinforced ePTFE grafts for severe tracheobronchomalacia is effective, less invasive than alternatives and preserves the growth potential of the affected airway segment.

Point-of-Care Ultrasound for Mimicker Lesions of Incarcerated Inguinal Hernia.

Inguinal hernia is the most common surgical disease in pediatric patients, and urgent intervention such as manual reduction is needed for incarcerated inguinal hernia. Torsion of undescended testes, inguinal herniated ovarian torsion, and purulent lymphadenitis are mimickers of this condition. If these mimicker lesions are misdiagnosed as incarcerated inguinal hernia, manual reduction usually fails, and edematous and erythematous changes may occur in these mimicker lesions due to manual reduction. For physicians in the emergency department, prompt decisions and familiarity with the sonographic appearance of different contents within an inguinal hernia are important to accurately diagnose these mimickers. In this case series, we present sonographic images of a typical case of incarcerated inguinal hernia (an 11-month-old male with right incarcerated inguinal hernia) and three cases of mimicker lesions (a 7-month-old female with herniated ovarian torsion, a 7-year-old boy with undescended testicular torsion, and a 2-month-old male with purulent lymphadenitis). The incidence of incarcerated inguinal hernia is reported to be higher in males (80%), on the right side (60%), and in infants and toddlers. This information is important for diagnosing mimicker lesions. In addition, to prevent manual reduction in mimicker diseases, point-of-care ultrasound before manual reduction in suspected cases of incarcerated inguinal hernia is important.

Stapled intestinal anastomosis is a simple and reliable method for management of intestinal caliber discrepancy in children.

PURPOSE: Popularity of minimally invasive surgeries has led to the development of stapled intestinal anastomosis for adults. The advanced instruments used in this technique are getting suitable with the small intestinal lumens of neonates and infants. We reviewed and compared the intraoperative and postoperative results of stapled and hand-sewn anastomoses in children. METHODS: The operative data of children who underwent stapled and hand-sewn anastomoses between March 2005 and December 2011 were collected and analyzed retrospectively. Furthermore, we compared patients who underwent anastomoses for colostomy closure of anorectal malformation (4 stapled, 9 hand-sewn) and those who underwent anastomoses for treatment of ileal atresia (3 stapled, 11 hand-sewn). RESULTS: In the 47 patients who underwent stapled anastomosis, no intraoperative complications were observed and postoperative complications included wound infection (n = 3), delayed gastric emptying (n = 1), and ileus (n = 1). No complications suggesting anastomotic dilatation were identified. It was observed that patients who underwent stapled anastomosis for colostomy takedown with caliber discrepancy had significantly shorter surgery time than those who underwent hand-sewn anastomosis. CONCLUSION: Our results suggest that stapled anastomosis is safe and effective for various surgical diseases in neonates, infants, and children.

[A case of breast adenocarcinoma changed to squamous cell carcinoma after neoadjuvant chemotherapy].

Squamous cell carcinoma(SCC)of the breast is a rare pathological-type cancer with an unclear origin. It has been suggested that breast SCC may originate from squamous metaplasia of the ductal epithelium. We report a case of SCC of the breast which histological carcinoma type changed after neoadjuvant chemotherapy. A 66-year-old woman visited our hospital for a tumor of the left breast. Mammography indicated breast cancer. On CT scan the tumor was 40mm in diameter, and was located in the upper lateral quadrant of the left breast. Because she requested breast-conserving surgery, core needle biopsy(CNB)was performed. The histological findings showed solid-tubular adenocarcinoma, PgR(-), ER(-), HER2(-), cT2cN1cM0, cStage II B. She received neoadjuvant chemotherapy consisting of 4 courses of CEF(cyclophosphamide, epirubicin, 5-fluorouracil)and 3 courses of paclitaxel. After chemotherapy, she was considered to have progressive disease, and a modified radical mastectomy was performed. The resected tumor was cystic and 60mm in diameter, containing muddy fluid. Histopathological examination showed pure squamous cell carcinoma, PgR(-), ER(-), HER2(-), pT3pN0pM0, pStage II B. The cancer metastasized with the light axillary lymph nodes at the 6th month after the operation, and she underwent chemo-radiation therapy. She died 6 years after the operation from brain metastasis.

Comparison of Three- and Two-Dimensional Laparoscopy in Pediatric Nissen Fundoplication.

Aim: This study aimed to evaluate the usefulness of three-dimensional (3D) versus conventional two-dimensional (2D) vision in pediatric laparoscopic Nissen fundoplication. Materials and Methods: Medical records and procedure videos of patients 18 years old or younger who underwent laparoscopic Nissen fundoplication at a single institution between January 2015 and August 2018 were retrospectively reviewed. The total pneumoperitoneum and wrapping times were measured. The number of errors during the first stitch of the wrapping was counted. Three-dimensional laparoscopy was introduced in January 2017, and data were compared between the previous 2D and current 3D groups. A questionnaire was provided to each surgeon who performed the 3D procedure. Results: Laparoscopic fundoplication was performed under 2D vision in 32 patients and under 3D vision in 19 patients. Mean ages and weights at surgery were similar between the groups. There was no significant differences in pneumoperitoneum and wrapping times between the two groups. Significantly more errors were counted in the 2D versus 3D procedure, but all patients recovered without any complications related to intraoperative errors. On the questionnaires, all 8 surgeons desired a decreased scope diameter and multidirectional visual axis. Four surgeons (50%) experienced eyestrain and 1 experienced double vision. Conclusions: This study showed no reduction in surgical time with 3D versus 2D scope use. Three-dimensional vision decreased the technical errors in creating the wrap, but its clinical merit remains unclear. Decreasing the scope diameter and adding multidirectional vision capabilities are needed for the 3D scope to gain more widespread approval and use in pediatric surgery.

A new laparoscopic triangle fixation technique for gastrostomy: a safe and effective procedure for reduction of the wound infection rate.

Gastrostomy is often performed with fundoplication in handicapped children. We devised a new laparoscopic triangle fixation technique for gastrostomy. In this study, 100 patients underwent gastrostomy with fundoplication between January 2008 and January 2016. We retrospectively reviewed the early postoperative results between the new laparoscopic procedure (NLP) group (n = 63) and conventional procedure (CP) group (n = 37). In the CP, the gastrostomy tube was inserted with a purse-string ligature at the gastric wall, and the gastric wall was sutured to the peritoneum under a small laparotomy. In NLP, three sutures were placed on the gastric wall, forming the three sides of a triangle, and the tube was inserted into the center of the triangle. The ends of each suture were pulled directly through the abdominal wall using a laparoscopic percutaneous extraperitoneal closure needle to join the gastric wall and peritoneum. Both groups showed no significant differences in age, body weight, and external leakage rate. The wound infection rate was significantly lower in the NLP group. In conclusions, the NLP is straightforward and can achieve firm fixation between the stomach and abdominal wall by suturing in the form of a triangle. The NLP was associated with a lower complication rate, especially concerning infection.

Evaluation of Surgical Devices Using an Artificial Pediatric Thoracic Model: A Comparison Between Robot-Assisted Thoracoscopic Suturing Versus Conventional Video-Assisted Thoracoscopic Suturing.

BACKGROUND: Pediatric robot-assisted surgery is increasingly being performed, but it is difficult to perform this procedure in infants. A pediatric thoracoscopic model of a 1-year-old patient was developed in our previous study, and this model was used to evaluate the use of a surgical robot for infant surgery. METHODS: Eight pediatric surgeons performed an intracorporeal suturing and knot-tying task using the da Vinci Xi Robotic Surgical System. The task completion time, number of needle manipulations, and force applied during suturing of the robot-assisted thoracoscopic surgery (RATS) group were compared with those of the video-assisted thoracoscopic surgery (VATS) group whose data had been collected from the same 8 surgeons in our previous study. RESULTS: The RATS group showed a significantly shorter completion time than the VATS group in the knot-tying phase (P = .016) and in the total phase (P = .0078). The RATS group showed a significantly smaller number of manipulations than the VATS group in the total phase (P = .039). The RATS group showed a significantly smaller pushing force index than the VATS group in the suturing phase (P = .031), knot-tying phase (P = .031), and in the total phase (P = .031). A seventh rib in the model was dislocated in all RATS group cases. CONCLUSIONS: The da Vinci Surgical System might be useful in infants because of fast movement and small pushing force. However, the robotic 8 mm instruments were too large for use in the thoracic cavity of the 1-year-old infant.