Fetoscopic techniques for prenatal covering of gastroschisis in an ovine model are technically demanding and do not lead to permanent anchoring on the fetus until the end of gestation.

INTRODUCTION: This is the cumulative technical report on the operative procedures and limitations of fetoscopic bag insertion, intestinal bag placement, and bag fixation to the fetus in a series of pilot studies in an ovine model for prenatal treatment of gastroschisis. MATERIAL AND METHODS: In 24 German blackhead sheep, a surgically created gastroschisis was managed by fetoscopic placement of the extruded intestines into a bag. The bag was then fastened onto the fetal abdominal wall. Different materials (sterile gloves, latex condoms, laparosopic retrieval bags) and different fixation techniques (laparoscopic staplers, interrupted and continuous sutures) have been examined. The fetuses were retrieved and evaluated at the end of gestation. RESULTS: Uterine bag insertion was successful in 15 of 24 (62.5%) and intestinal bag placement in 10 of 15 available fetuses (66.6%). The main factor limiting fetoscopic procedures was chorioamniotic separation (CAS). Sterilized condoms provided the most appropriate type of bags and the V-Loc™ running suture, the most expedient type of fixation, which was achieved in 9 of the 10 fetuses (complete = 2, partially = 7) by using a three port access (5 mm and 2 × 3 mm). All bags were encountered completely or partially dislocated from the fetus at the end of gestation. CONCLUSIONS: Fetoscopic intestinal bag placement and fixation in gastroschisis technically demanding. None of the evaluated techniques led to permanent anchorage of the bag to the fetus. The development of specially designed instruments, bags and fixation methods is required to optimize this approach.

Degradation of Extracellular DNA Significantly Ameliorates Necrotizing Enterocolitis Severity in Mice.

BACKGROUND: Necrotizing enterocolitis (NEC) is one of the most devastating diseases in neonates and is characterized by high morbidity and mortality. It has been suggested that neutrophils play a crucial role in NEC pathogenesis and contribute to the hyperinflammatory reaction after bacterial colonization, which ultimately induces NEC. The aim of this study was to investigate whether dissolution of neutrophil extracellular traps (NETs) by systemic DNase1 therapy reduces NEC manifestation and morbidity. METHODS: NEC was induced in neonatal mice by gavage feeding of lipopolysaccharide mixed in Neocate, followed by hypoxia q12 h for 5d. Inactivated DNase1 and DNase1 were administered intraperitoneally twice daily in the control and treatment groups, respectively, starting on day 5 for 72 h. Survival, NEC score, intestinal damage (Chiu score, malondialdehyde [MDA], glutathione peroxidase [GPx]), inflammation (neutrophil elastase [NE], myeloperoxidase [MPO], toll-like receptor 4 [TLR4]), and NETs markers (SYTOX orange, cell-free DNA [cfDNA], DNase, citrullinated Histone 3 [H3cit]) were then assessed. RESULTS: In total, 44 neonatal mice were used in the experiment. Mice in the treatment group demonstrated significantly reduced NEC rates (44 versus 86%, P = 0.029) and improved survival in comparison to controls (65 versus 35%, P = 0.01). Furthermore, mice treated with DNase1 showed significantly less tissue damage (cfDNA, Chiu score), oxidative stress (MDA, GPx), and inflammation (NE, MPO, H3cit, TLR4), which ultimately lead to a significant reduction in mortality. CONCLUSIONS: The results of the study indicate that systemic DNase1 treatment leads to a significant reduction in tissue damage, NEC severity, and mortality. Therefore, after validation of our findings in human subjects, DNase1 treatment should be considered as a therapeutic option in neonates diagnosed with NEC.

The spaced learning concept significantly improves training for laparoscopic suturing: a pilot randomized controlled study.

BACKGROUND: Spaced learning has been shown to be effective in various areas like traditional knowledge or motor skill acquisition. To evaluate the impact of implementation of the spaced learning concept in laparoscopic training was the aim of this study. METHODS: To evaluate the effectiveness of spaced learning, subjects were asked to perform four surgeon's square knots on a bowel model prior and post 3 h of hands-on training. All subjects were medical students and novice in laparoscopic suturing. Total time, knot stability (evaluated via tensiometer), suture accuracy, knot quality (Muresan score), and laparoscopic performance (Munz checklist) were assessed. Moreover, motivation was accessed using Questionnaire on Current Motivation. RESULTS: Twenty students were included in the study; after simple randomization, ten were trained using "spaced learning" concept and ten conservatively. Both groups had comparable baseline characteristics and improved after training significantly regarding all aspects assessed in this study. Subjects that trained via spaced learning were superior in terms of suture performance, knot quality, and suture strength. Ultimately, spaced learning significantly decreased anxiety and impression of challenge compared to controls. CONCLUSION: The spaced learning concept is very suitable for complex motor skill acquisition like laparoscopic suturing and knot tying. It significantly improves laparoscopic performance and knot quality as shown by the knot score and suture strength. Thus, we recommend to incorporate spaced learning into training courses and surgical programs.

Taurolidine specifically inhibits growth of neuroblastoma cell lines in vitro.

BACKGROUND: Neuroblastoma is a common pediatric solid tumor with poor outcome for metastatic disease. Thus, novel therapeutic options are of main interest. The anti-neoplastic properties of taurolidine have been demonstrated on a variety of human cancer cells. However, data on neuroblastoma is lacking. Therefore, our aim was to evaluate the effect of taurolidine on growth of neuroblastoma cell lines. MATERIALS AND METHODS: Neuroblastoma SK-N-BE(2)-M17 and SK-N-SH cells and nonmalignant human umbilical vein endothelial cells as controls were incubated with increasing concentrations of taurolidine (100, 250, 500 µM). Cell growth was examined after 12, 24, and 48 hours of exposure. RESULTS: Inhibition of cell growth by taurolidine was seen in both malignant cell lines. When compared with human umbilical vein endothelial cells, the neuroblastoma cell lines were significantly more responsive to taurolidine. CONCLUSIONS: The observed negative impact on cell growth, highly distinctive in SK-N-BE(2)-M17 and SK-N-SH, implies a taurolidine-specific mode of action that appears dependent on differences on cellular and molecular level. Further investigations are warranted to evaluate its mechanism and probable clinical use.

Gut inflammation and expression of ICC in a fetal lamb model of fetoscopic intervention for gastroschisis.

BACKGROUND: The pathogenesis of intestinal dysmotility in gastroschisis is not completely understood. Peel formation and disorganization of interstitial Cajal cells (ICC) have been proposed in humans. The aim of this study was to evaluate the impact of prenatal coverage of gastroschisis on gut inflammation and expression of ICC in a fetal lamb model. METHODS: Twenty-one German blackhead sheep with an abdominal wall defect that was created fetoscopically on day 77 of 145 days gestation were used in this study. Intrauterine surgery with the aim to cover the defect was performed 3 weeks later; two fetuses were covered completely, 5 partially and 11 remained uncovered. Three fetuses without gastroschisis were used as controls. All fetuses were retrieved by cesarean section at day 135. Samples of the small intestine were stained with hematoxylin and eosin for histologic analysis of peel formation and serosal and muscular thickness. For ICC detection, immunohistochemistry using anti-CD117 (c-Kit) antibody was used. RESULTS: In all samples with exposure to amniotic fluid, peel formation and significantly decreased ICC were found. Complete coverage reduced peel formation and disorganization of ICC compared to uncovered animals almost to the level of controls. CONCLUSIONS: Peel formation and ICC derangement were significantly reduced by prenatal coverage of gastroschisis. Moreover, this animal model mimics the histopathological bowel changes as seen in human gastroschisis and may, therefore, be used for further research on the pathophysiology and fetal therapy of this malformation.

Early prediction of complex midgut volvulus in neonates and infants.

INTRODUCTION: Prognosis of midgut volvulus in neonates and infants younger than 1 year remains poor, as diagnostic findings may not be apparent until gut infarction had occurred. To characterize factors that help to predict complex midgut volvulus early was aim of this study. METHODS: Institutionally approved retrospective analysis of all children younger than 1 year treated for midgut volvulus at the author's center from January 2002 to December 2011. Medical history, symptoms, laboratory and radiologic findings as well as sequelae of midgut volvulus were evaluated. RESULTS: In 10 years, 37 children fulfilled the inclusion criteria. Of these, 43% developed complications, and mortality rate was 16%. In 30% of the patients, the only clinical sign was a sudden worsening of the general condition and abdominal distension (complex 19% vs. simple 38%). In one child with simple midgut volvulus, all clinical, laboratory and radiologic signs were negative. CART analysis identified a base excess below -1.70 and preterm birth (<36 weeks) as the best discriminators of complex and simple midgut volvulus. A score >1pt (comprised of these two factors) was found in all children with complex and in 14% of simple midgut volvulus (p < 0.001). A positive score (>1pt) offers a sensitivity of 100% (81.7-100%), specificity of 85.7% (71.8-85.7%), a PPV of 84.2% (68.8-84.2%) and NPV 100% (83.8-100%). DISCUSSION: The study shows that midgut volvulus has a substantial morbidity and mortality. Unfortunately, not all affected children get picked up by history, laboratory and imaging. However, the proposed score helps to identify subject with increased risk of complications. It has the potential to facilitate and accelerate diagnosis of complex midgut volvulus; ultimately, it might help to reduce morbidity and mortality.

Clinical and sonographic features predict testicular torsion in children: a prospective study.

OBJECTIVE: To test the clinical and sonographic predictors of testicular torsion (TT) with the aim of reducing negative exploration rates. PATIENTS AND METHODS: We performed a prospective study of all boys treated for 'acute scrotum' at our institute between January 2001 and April 2012 and clinical findings were documented. If available, ultrasonography (US) was added to the diagnostic evaluation. A prediction of the diagnosis was based on clinical and sonographic features, and was followed by surgical exploration in all patients. RESULTS: A total of 104 patients were included in the 16-month period of the study. No single finding excluded TT. The clinical features (pain <24 h, nausea/vomiting, abnormal cremasteric reflex, high position of the testis) appeared predictive (100% sensitivity) and the clinical scoring system was proven to be reliable, reducing the negative exploration rate by >55%. Ultrasound predictors alone were not able to identify all boys with TT. CONCLUSIONS: It is safe to refrain from routine surgical exploration in every child with acute scrotum if the clinical score is applied, which results in a marked reduction of negative explorations. A reliable diagnosis could not be obtained based on US alone. As scrotal US is unpleasant for the child, we propose to refrain from this if the clinical score is positive. Patients with a negative clinical score are suitable candidates for US to establish and secure diagnosis.

Abdominal wall incision with or without exteriorization of bowel: results from a fetal lamb model for the embryogenesis of gastroschisis.

INTRODUCTION: The embryogenesis of gastroschisis is not completely understood. The aim of our study was to evaluate the impact of a simple abdominal wall defect versus a defect including eviscerated intestine or omentum for the development of gastroschisis in a fetal lamb model. MATERIAL AND METHODS: At mid-gestation (day 77) an abdominal wall defect was fetoscopically created with three different approaches in 19 German blackhead sheep. The intestine was eviscerated in 7 fetuses (group 1). The peritoneum was incised and a patch of the omentum pulled through the incision in 5 fetuses (group 2). In 7 fetuses (group 3) the skin and rectus muscle were incised until the peritoneum was visible. In this group, no abdominal contents were exteriorized and the peritoneum was left intact. A second fetoscopic procedure was performed 21 days later, assessing the condition and extension of eviscerated bowel. The fetus was retrieved by Cesarean section on day 132 and evaluated. RESULTS: The second fetoscopy acting as a control for the creation of gastroschisis demonstrated eviscerated and inflamed intestine in all 3 groups. The amount of eviscerated intestine did not appear to depend on the size of the defect nor on its duration. DISCUSSION: It appears that a simple incision of the abdominal wall with intact peritoneum is sufficient for the development of gastroschisis in a fetal sheep model. This finding may improve the understanding of the etiology of gastroschisis.

Editorial for the Special Issue "Current Development of Pediatric Minimally Invasive Surgery" of the Journal Children.

Dear colleagues, [...].

Mobile Dressing Trolleys Improve Satisfaction and Logistics on Pediatric Surgery Wards.

BACKGROUND: Evidence-based data on the effect of dressing trolleys on children's postoperative recovery are not available. The aim of this study was to evaluate a specific pediatric surgical dressing trolley on patient and caregiver satisfaction, as well as temporal and logistical aspects of the dressing change procedures. METHODS: In a prospective observational non-randomized study, a total of 100 dressing changes were observed before (group 1) and after (group 2) the introduction of a pediatric surgical dressing trolley and the satisfaction, time and logistical factors were recorded on site. RESULTS: The median preparation time, the duration of the dressing change and the total time decreased significantly from group 1 to group 2 by 1:11 min (p < 0.001); 1:56 min (p = 0.05) and 5:09 min (p = 0.001), respectively. The patient's room was left significantly less often in group 2 to retrieve missing bandages. The median satisfaction of the medical staff increased by 12% in group 2 (p < 0.001). The satisfaction of the parents increased by 2.5% in group 2 (p = 0.042), and that of the nursing staff increased by 9.25% in group 2 (p = 0.015). CONCLUSIONS: Our results demonstrate the positive effects of a dressing trolley for pediatric surgical dressing changes by minimizing postoperative handling and manipulation of the child. It improves time and logistical factors as well as the satisfaction of those involved, which may lead to a faster recovery.

Evaluation of the Versius Robotic System for Infant Surgery-A Study in Piglets of Less than 10 kg Body Weight.

BACKGROUND: We were able to demonstrate the feasibility of a new robotic system (Versius, CMR Surgical, Cambridge, UK) for procedures in small inanimate cavities. The aim of this consecutive study was to test the Versius® system for its feasibility, performance, and safety of robotic abdominal and thoracic surgery in piglets simulating infants with a body weight lower than 10 kg. METHODS: A total of 24 procedures (from explorative laparoscopy to thoracoscopic esophageal repair) were performed in 4 piglets with a mean age of 12 days and a mean body weight of 6.4 (7-7.5) kg. Additional urological procedures were performed after euthanasia of the piglet. The Versius® robotic system was used with 5 mm wristed instruments and a 10 mm 3D 0° or 30° camera. The setup consisted of the master console and three to four separate arms. The performance of the procedure, the size, position, and the distance between the ports, the external and internal collisions, and complications of the procedures were recorded and analyzed. RESULTS: We were able to perform all surgical procedures as planned. We encountered neither surgical nor robot-associated complications in the live model. Whereas all abdominal procedures could be performed successfully under general anesthesia, one piglet was euthanized early before the thoracic interventions, likely due to pulmonary inflammatory response. Technical limitations were based on the size of the camera (10 mm) being too large and the minimal insertion depth of the instruments for calibration of the fulcrum point. CONCLUSIONS: Robotic surgery on newborns and infants appears technically feasible with the Versius® system. Software adjustments for fulcrum point calibration need to be implemented by the manufacturer as a result of our study. To further evaluate the Versius® system, prospective trials are needed, comparing it to open and laparoscopic surgery as well as to other robotic systems.

Fetoscopic management of gastroschisis in a lamb model.

BACKGROUND: Gastroschisis is a malformation consisting of an abdominal wall defect with eviscerated bowel. Its standard treatment is postnatal repositioning or temporary prosthetic bag placement. The aim of our study is to evaluate the feasibility of its fetoscopic management in a lamb model. METHODS: At mid-gestation (day 75), gastroschisis was created in eight German blackhead sheep. A second fetoscopic procedure was performed on day 105, assessing the viability, extension, and potential for repositioning of eviscerated bowel. The fetus was retrieved by Cesarean section on day 132 and evaluated. RESULTS: In six fetuses gastroschisis could be successfully created and assessed with fetoscopy. Two fetuses were lost due to technical complications. Primary repair by repositioning the intestine into the abdomen was not possible because it grew into an inflammatory conglomerate too large for the small fetal abdominal cavity. CONCLUSIONS: Although technically demanding, we were able to produce and reassess six cases of gastroschisis by fetoscopy. As primary repositioning appears unfavorable, fetoscopic prosthetic bag placement may become an alternative.

Robot-assisted scaffold implantation and two-stage flap raising of the greater omentum for reconstruction of the facial skeleton: Description of a novel technique.

BACKGROUND: Bone regeneration in the greater omentum is a promising strategy in facial skeleton reconstruction. This feasibility-study aims to perform robot-assisted scaffold implantation and second-stage flap raising. METHODS: Firstly, scaffolds were implanted into the greater omentum using the da Vinci Xi surgical system or conventional technique in five miniature pigs, respectively. After 3 months a free flap including the gastrocolic vascular pedicle was harvested and procedures were evaluated. RESULTS: The average operation time was 59.2 min for open surgery and 73.8 min for robot-assisted surgery. The average incision length of open surgery was 11.6 cm. Both techniques led to successful scaffold implantation without any complication. In all cases the scaffolds were integrated as intended and resulted in bone formation. CONCLUSIONS: Current study demonstrated that the implantation of scaffolds into the greater omentum and flap harvesting using da Vinci Xi surgical system is a promising minimally-invasive approach in regenerative surgery.

Fetal Surgery for Gastroschisis-A Review with Emphasis on Minimally Invasive Procedures.

(1) Background: The morbidity of gastroschisis is defined by exposure of unprotected intestines to the amniotic fluid leading to inflammatory damage and consecutive intestinal dysmotility, the viscero-abdominal disproportion which results in an abdomen too small to incorporate the herniated and often swollen intestine, and by associated pathologies, such as in complex gastroschisis. To prevent intestinal damage and to provide for growth of the abdominal cavity, fetal interventions such as amnio exchange, gastroschisis repair or covering have been evaluated in several animal models and human trials. This review aims to evaluate the reported techniques for the fetal treatment of gastroschisis by focusing on minimally invasive procedures. (2) Methods: We conducted a systematic database search, quality assessment and analyzed relevant articles which evaluate or describe surgical techniques for the prenatal surgical management of gastroschisis in animal models or human application. (3) Results: Of 96 identified reports, 42 eligible studies were included. Fetal interventions for gastroschisis in humans are only reported for EXIT procedures and amnio exchange. In animal models, particularly in the fetal sheep model, several techniques of open or minimally invasive repair of gastroschisis or covering the intestine have been described, with fetoscopic covering being the most encouraging. (4) Discussion: Although some promising minimally invasive techniques have been demonstrated in human application and animal models, most of them are still associated with relevant fetal morbidity and mortality and barely appear to be currently applicable in humans. Further research on specific procedures, instruments and materials is needed before any human application.

Preputioplasty as a surgical alternative in treatment of phimosis.

Preputioplasty denotes various surgical techniques directed at resolving phimosis without the need for radical or partial circumcision. This narrative review summarizes the best-known surgical techniques of preputioplasty. A MEDLINE and EMBASE-based literature search of original manuscripts and case reports published in English has been carried out using the following key words: "circumcision", "partial circumcision", "phimosis", "paraphimosis", and "preputioplasty". Six different procedures are explored in more detail and illustrated. The complication rates of all surgical procedures presented here are reported to be low. In cases of medical (rather than cultural and religious) indications, foreskin-preserving procedures present useful alternatives to circumcision in the routine clinical practice of urologists and pediatric surgeons.

Minimally Invasive Bimanual Fetal Surgery-A Review.

BACKGROUND: The aim of this review is to discuss experimental and clinical techniques and interventions of fetal surgery which have been performed minimally invasively by the means of a three-port approach for the fetoscope and instruments for the left and right hand of the surgeon (bimanual minimally invasive fetal surgery). METHODS: a print and electronic literature search was performed; the titles and abstracts were screened and included reports were reviewed in a two-step approach. First, reports other than minimally invasive fetal surgery were excluded, then a full text review and analysis of the reported data was performed. RESULTS: 17 reports were included. The heterogeneity of the included reports was high. Although reports on human fetoscopic surgical procedures can be found, most of them do not pick out bimanual fetal surgery as a central theme but rather address interventions applying a fetoscope with a working channel for a laser fiber, needle or flexible instrument. Most reports were on experimentation in animal models, the human application of minimally invasive fetoscopic bimanual surgery is rare and has at best been explored for the prenatal treatment of spina bifida. Some reported bimanual fetoscopic procedures were performed on the exteriorized uterus via a maternal laparotomy and can therefore not be classified as being truly minimally invasive. DISCUSSION: our results demonstrate that minimally invasive fetoscopic bimanual surgery is rare, even in animal models, excluding many other techniques and procedures that are loosely termed 'minimally invasive fetal surgery' which we suggest to better label as 'interventions'. Thus, more research on percutaneous minimally invasive bimanual fetoscopic surgery is warranted, with the aim to reduce the maternal, uterine and fetal trauma for correction of congenital malformations.

Evaluation of the Versius Robotic Surgical System for Procedures in Small Cavities.

BACKGROUND: The Versius® is a recently approved robotic surgical system for general surgery procedures in adults. Before any application in children, data of its feasibility and safety in small cavities has to be compiled, beginning with inanimate models. Therefore, the aim of this preclinical study was to assess the Versius® system for its performance in small boxes simulating small body cavities. METHODS: In total, 8 cardboard boxes of decreasing volumes (15.75 L to 106 mL) were used. The procedures, two single stitches with two square knots each, were performed in every box, starting in the largest and consecutively exchanging the box to the next smaller one. The evaluation included procedure time, port placement and pivot point setup, arrangement of the robotic arms and instrumentation, amount of internal and external instrument-instrument collisions and instrument-box collisions. RESULTS: All procedures could be successfully performed in all boxes. The procedure time decreased due to the learning curve in the first four boxes (15.75 to 1.87 L) and consecutively increased from boxes of 1.22 L up to the smallest box with the dimensions of 4.4 × 4.9 × 4.9 cm3. This may be based on the progress of complexity of the procedures in small cavities, which is also depicted by the synchronous increase of the internal instrument-instrument and instrument-box collisions. CONCLUSION: With the use of the Versius® robotic surgical system, we were able to perform robotic reconstructive procedures, such as intracorporal suturing and knot tying, in cavities as small as 106 mL. Whether this system is comparable or even superior to conventional laparoscopic surgery in small cavities, such as in children, has to be evaluated. Furthermore, before any application in newborns or infants, ongoing evaluation of this system should be performed in a live animal model.

Robotic infant surgery with 3 mm instruments: a study in piglets of less than 10 kg body weight.

No data exist concerning the appication of a new robotic system with 3 mm instruments (Senhance®, Transenterix) in infants and small children. Therefore, the aim of this study was to test the system for its feasibility, performance and safety of robotic pediatric abdominal and thoracic surgery in piglets simulating infants with a body weight lower than 10 kg. 34 procedures (from explorative laparoscopy to thoracoscopic esophageal repair) were performed in 12 piglets with a median age of 23 (interquartile range: 12-28) days and a median body weight of 6.9 (6.1-7.3) kg. The Senhance® robotic system was used with 3 mm instruments, a 10 mm 3D 0° or 30° videoscope and advanced energy devices, the setup consisted of the master console and three separate arms. The amount, size, and position of the applied ports, their distance as well as the distance between the three operator arms of the robot, external and internal collisions, and complications of the procedures were recorded and analyzed. We were able to perform all planned surgical procedures with 3 mm robotic instruments in piglets with a median body weight of less than 7 kg. We encountered two non-robot associated complications (bleeding from the inferior caval and hepatic vein) which led to termination of the live procedures. Technical limitations were the reaction time and speed of robotic camera movement with eye tracking, the excessive bending of the 3 mm instruments and intermittent need of re-calibration of the fulcrum point. Robotic newborn and infant surgery appears technically feasible with the Senhance® system. Software adjustments for camera movement and sensitivity of the fulcrum point calibration algorithm to adjust for the increased compliance of the abdominal wall of infants, therefore reducing the bending of the instruments, need to be implemented by the manufacturer as a result of our study. To further evaluate the Senhance® system, prospective trials comparing it to open, laparoscopic and other robotic systems are needed.