Development and assessment of a loop ligation simulator for laparoscopic appendectomy.

OBJECTIVE: Loop ligation of the appendix is a challenging surgical skill and well suited to be trained in a simulator. We aimed to develop an affordable and easy-to-build simulator and test its training effect. DESIGN AND PARTICIPANTS: Different materials were tested, and the best training modality was identified by researching the literature. The developed simulator training was tested on 20 surgical novices. RESULTS: A video was produced including an instruction on how to build the simulator and a step-by-step tuition on how to ligate the appendix. The Peyton approach was utilized to guide learners. Training with the simulator leads to reliable skill acquisition. All participants improved significantly in completing the task successfully during the structured learning. CONCLUSION: We succeeded in developing a simulator for loop ligation of the appendix during laparoscopic appendectomy. Participants significantly improve in handling the loops. The transferability of the skill learned during simulation to the operating room will be subject of a follow-up study.

Risk factors for mortality in preterm infants with necrotizing enterocolitis: a retrospective multicenter analysis.

It is difficult to predict the risk of mortality in necrotizing enterocolitis (NEC). This study aimed at identifying risk factors for severe NEC (Bell stage III) and mortality in preterm children with NEC. In this multicenter retrospective study, we analyzed multiple data from 157 premature children with confirmed NEC in the period from January 2007 to October 2018. We performed univariate, multivariate, stepwise logistic regression, and receiver operator characteristics (ROC) analyses. We were able to demonstrate that low Apgar scores (notably at 1' and 5'), low hemoglobin concentration (Hgb), and high lactate level at disease onset and during disease correlated with NEC severity and mortality (P < 0.05, respectively). Severe NEC was related to congenital heart disease (CHD - OR 2.6, CI95% 1.2-5.8, P 0.015) and patent ductus arteriosus (PDA - OR 3.3, CI95% 1.6-6.9, P 0.0012), whereas death was related to the presence of PDA (OR 5.5, CI95% 2.3-14, P < 0.001).Conclusion: Low Apgar scores, low Hgb, high lactate levels, and the presence of CHD or PDA correlated with severe NEC or mortality in children with NEC. What is Known: • It remains difficult to predict which infant that suffers from necrotizing enterocolitis at risk of death. • Several clinical and laboratory parameters tools to predict fatal outcome in NEC. What is New: • The following laboratory parameters were associated with the risk of death from NEC: Hemoglobin concentration, base excess and lactate level. • The following clinical variables were associated with the risk of death from NEC: Apgar scores, as well as the presence of congenital heart disease and patent ductus arteriosus.

Para-testicular injection of indocyanine green for laparoscopic immunofluorescence-guided lymphatic-sparing Palomo procedure: Promising preliminary results.

Lymphatic-sparing Palomo procedure with intra-testicular injection of indocyanine green (ICG) has shown good results but the injection might harm the testes. This article describes the results of twelve consecutive patients where visualization and sparing were carried out successfully with para-testicular injection of ICG. Procedural details are reported thoroughly. Early experience shows convincing results, we believe that para-testicular injection leads to equally good visualization of testicular lymphatic vessels without the risk of testicular lesions. We will continue to use para-testicular injection and encourage others to do so to increase the amount of available data, allowing for evidence-based result in the future.

Surgical simulation of hypospadias repair - High-fidelity, reproducible and affordable animal tissue model.

INTRODUCTION: Teaching methods in hypospadias repair are still traditional. Available simulators often lack authenticity in terms of haptic feedback and realistic tissue handling. OBJECTIVE: Our aim was to develop a high-fidelity, easily reproducible, and affordable animal tissue model for the advanced surgical simulation of hypospadias repair with realistic haptic feedback and tissue handling. MATERIAL AND METHODS: A regular-sized chicken leg and a lamb tenderloin are used to assess the feasibility of simulating hypospadias correction by using the example of a Snodgrass Tubularized Incised Plate-Repair. The model preparation is incorporated into the training process. RESULTS: A detailed description of the high-fidelity model is provided. All steps of a hypospadias repair can be trained while providing realistic anatomy, adequate size, and multilayer tissue properties. Haptic conditions highly resemble human tissue properties. Fine tissue handling corresponds to intraoperative conditions. Limitations to this surgical model apply as in other animal tissue models. CONCLUSION: We developed a high-fidelity, easily reproducible, and affordable hypospadias animal tissue model. Due to the multilayer animal tissue properties, this model provides realistic haptic feedback and thus an inexpensive and reproducible model for hypospadias simulation. External validation is mandatory prior to implementation into urological training.

Surgical Simulation of Posterior Sagittal Anorectoplasty for Rectovestibular Fistula: Low-Cost High-Fidelity Animal-Tissue Model.

PURPOSE: To provide a high-fidelity, animal tissue-based model for the advanced surgical simulation of a Posterior Sagittal Anorectoplasty (PSARP) for rectovestibular fistula in anorectal malformation (ARM). MATERIALS AND METHODS: A chicken cadaver was used to assess the feasibility of simulating a PSARP for rectovestibular fistula in ARM. No modification was required to implement the surgical simulation. RESULTS: A detailed description of the high-fidelity surgical simulation model is provided. The PSARP can be simulated while providing realistic anatomy (e.g. common wall between rectovestibular fistula and vagina), adequate rectal size, location and placement of the rectovestibular fistula, and proximity to the vagina. Haptic conditions of the tissue resemble human tissue and operative conditions as well. DISCUSSION: Concerning the decreased exposure of index cases of pediatric surgical trainees and pediatric surgeons in practice, simulation-based training can provide means to acquire or maintain the necessary skills to perform complex surgical procedures [1-5] Surgical simulation models for ARM are limited. Few low-cost trainers are available with predominant artificial and mostly unrealistic tissue [6-8] Animal models have the advantage of realistic multilayer tissue haptic feedback [6]. CONCLUSION: We provide a low-cost, high-fidelity model for correcting a rectovestibular fistula in a child with ARM, a complex operative procedure with low incidence but high-stake outcomes. The described tissue model utilizing the chicken cloaca anatomy provides a high-fidelity model for operative correction of rectovestibular ARM. For simulation purposes in the treatment of ARM, this model appears to be promising in terms of providing realistic pathology and haptic feedback in pediatric dimensions. LEVEL OF EVIDENCE: V.

Is There Gender (In)Equality in Pediatric Surgery? An Online Survey on Gender-Related Career Opportunities.

INTRODUCTION: The highest percentage of female surgeons is found in pediatric surgery but most departments are led by men. The aim of this study is to evaluate gender-related career goals, perceived career opportunities, and reasons for differences. MATERIALS AND METHODS: An online questionnaire was created and distributed to pediatric surgeons in Germany, Switzerland, and Austria between July and September 2020. Participants were asked to state current position, career goals, and perceived career opportunities in comparison to a colleague of the opposite gender. Reasons for gender-related differences were asked for as free-text comments. RESULTS: A total of 182 questionnaires were analyzed. The overall gender ratio was balanced but junior positions were predominantly held by women, while there were more men in leading positions. Most women pursued a position as a consultant, while the majority of men aimed for a leading position. Men mostly regard both genders to have the same career opportunities, whereas most women believe the chances of men to be better. From the free-text answers, three following categories for gender-related differences in career chances were derived: (1) absences due to maternity, (2) differing support and bias arising from gender-related stereotypes, and (3) assumed personality traits. CONCLUSION: There are gender-related differences in career opportunities in pediatric surgery. Gender equality is needed not only to overcome injustice but also to maximize team efficiency and collaboration. Career support needs to be gender-independent and (unconscious) bias needs to be recognized and eradicated.

Thoracoscopic Resection of a Foregut Duplication Cyst with the Use of a 5-mm Stapling Device in an Infant-A Case Report.

Esophageal foregut duplication cysts are a rare congenital anomaly predominantly diagnosed in children. With possible growth foregut duplication cysts may cause compression on thoracic or mediastinal structures, respectively. Due to the presence of ectopic gastric mucosa and its potential malignant alteration resection of foregut duplication cysts is recommended. More recently, the use of a thoracoscopic approach for resection has shown to be an advantageous alternative to a conventional open approach. A case of a complete thoracoscopic resection of an esophageal foregut duplication cyst using a 5-mm stapling device is presented.

A Novel Tool to Predict Postoperative Opioid Need after Laparoscopic Appendectomy in Children: A Step toward Evidence-Based Pain Management.

BACKGROUND: Optimizing postoperative pain treatment is essential to minimize morbidity, lower costs, and ensure patient and parent satisfaction. This study aims at identifying pre- and intraoperative parameters predicting opioid needs after laparoscopic appendectomy to enable timely and adequate postoperative pain control. MATERIALS AND METHODS: A retrospective analysis of patients treated with laparoscopic appendectomy for appendicitis between January 2018 and March 2019 was performed. Multiple logistic regression was applied to identify predictors of opioid demand. RESULTS: Based on our analysis, we developed a prediction tool for opioid requirements after laparoscopic appendectomies in children. The integrated parameters are: presence of turbid fluid, age, white-blood-cell count, symptom duration, and body temperature. CONCLUSION: We developed an algorithm-based predictor tool that has the potential to better anticipate postoperative pain and, thereby, optimize pain management following laparoscopic appendectomies in children. The proposed predictor tool will need validation through further prospective studies.

A qualitative analysis of critical incident reporting in a paediatric hospital: benefits and weaknesses.

AIMS OF THE STUDY: The value of critical incident reporting systems (CIRSs) has been shown before but data for paediatric facilities are scarce. We aimed to evaluate a CIRS in a paediatric hospital to analyse its benefits, weaknesses and opportunities. METHODS: In a qualitative analysis, all incidents reported in 2018 with the anonymous reporting tool (CIRS) of the Children's Hospital Lucerne were evaluated. In an iterative process, categories to group the incidents were created and the data analysed accordingly. The focus was on the problem created through the incident, the type of error and possible avoidance. RESULTS: 496 incidents were reported in 2018: 307 incidents led to medical errors directly effecting patients, 82 incidents led to organisational problems increasing expenditure and 107 incidents were found to not result in any problem. In the majority of cases (398/496) there was no evidence that the caregiver responsible was informed. Personal feedback was documented in 46 cases. Fifty-two incidents were self-reported. CONCLUSION: A number of reported incidents helped to identify system-based errors and for these the reporting system proved indispensable. Many of the reported errors were found to have an individual component, or only organisational or no consequences. Our data give evidence that instead of giving direct personal feedback, the anonymous reporting system was utilised. The CIRS is essential to identify system-based errors, but personal feedback needs to become obligatory so caregivers can learn from their error: an additional tool to ensure individual feedback and overcome communication difficulties needs to be created.

Successful Treatment of a Single Giant Renal Cyst in a Newborn with Drainage and Sclerotherapy.

Simple renal cysts are a scarce entity in pediatric patients and their etiology is unknown in most cases. Usually, they are monitored with ultrasound and regular follow-up of renal function. Surgical treatment is rarely indicated. We report the case of a newborn with a single giant renal cyst that could be treated successfully with drainage and sclerotherapy. Single giant renal cysts require careful investigation and monitoring. In cysts without communication to the pelvico-caliceal system, sclerotherapy by instillation of doxycycline is a therapeutic option.

Laparoscopic Pyeloplasty for Ureteropelvic Junction Obstruction.

For ureteropelvic junction obstruction (UPJO), the standard of surgical care is dismembered pyeloplasty. This applies both for intrinsic but also for extrinsic etiology of the UPJO. When in 1995, Peters described for the first time laparoscopic pyeloplasty in children, the era of laparoscopic pediatric urological surgery began. Nowadays, laparoscopic dismembered pyeloplasty in children has evolved to become the gold standard. In this article, we report a standardized technique of laparoscopic transperitoneal dismembered pyeloplasty for infants and children. The described single steps of the procedure are reproducible regardless of age and weight and thus offer a high surgical success rate.

Surgery of uretero-pelvic junction obstruction (UPJO).

Uretero-pelvic junction obstruction (UPJO) is the most common cause of hydronephrosis in infants and children. Historically, this condition has been approached surgically through a retroperitoneal approach as described by Anderson and Hynes aiming for an open dismembered pyeloplasty. A true evolution of laparoscopy in pediatric urology took place within the last 30 years. Laparoscopy developed from a merely diagnostic tool for non-palpable testes to "interventional" laparoscopy for extirpative surgery. Finally the era of reconstructive pediatric laparoscopic urology started, when in 1995 Peters described the first laparoscopic pyeloplasty in a child. Laparoscopic dismembered pyeloplasty now has become the preferred surgical treatment of UPJO. It offers excellent visualization of the anatomy, accurate anastomotic suturing, thus the precise reconstruction of the UPJ along with good functional outcome. This article aims to provide the current status, indication and operative technique of laparoscopic dismembered pyeloplasty for UPJO in infants and children.

Management of adolescent varicocele.

Varicocele is defined as an abnormal dilation and tortuosity of the internal spermatic veins found within the pampiniform plexus. It is a common finding in adolescents and adult men alike, however its diagnosis in the adolescent population poses different dilemmas in regard to indications for treatment than in adults. Failed Paternity is a clear-cut indication for repair in adult men attempting to father children. In adolescents, the physicians, family and patients must consider potential for future fertility problems which may or may not actually become of concern. Assessing the degree of negative effect of the varicocele on an adolescent's testicular health can also be difficult as teenagers typically are not asked to provide semen for analysis and thus surrogate markers for testicular health such as testicular size differentials must be used. Treatment options for the adolescent varicocele are similar to options in adult populations. While risks and benefits of various techniques can be considered, the gold standard for varicocele repair in adolescents has not been clearly defined. We aim to discuss diagnosis of varicocele, considerations for initiating treatment of varicocele in the adolescent, and techniques for management.

Acquired undescended testis: When does the ascent occur?

BACKGROUND: Little is known about the timeframe in which acquired undescended testes occur. To guide recommendations for screening examinations, we aimed to (1) specify the ratio of acquired undescended testes in orchiopexy cases and to (2) identify a predisposing age for the development of acquired undescended testis. METHODS: Three-hundred-forty cases of orchiopexy were retrospectively analyzed and classified as congenital or acquired cases of undescended testis. In acquired cases, the time of the last documented physiological testicular position was obtained. The time of testicular ascent was approximated by calculating the mean between the last physiological finding and orchiopexy. RESULTS: In 151 cases (44.4%) prior physiological position of testes was documented and acquired undescended testis was assumed. In 115 of these cases (76.2%) details on the age at last physiological position were available. Ascent occurred between the age of one and fourteen. The 50th, 75th, 85th, 90th and 95th percentile for the estimated age at ascent was 5.8, 7.3, 8.4, 8.7 and 11.1 years, respectively. CONCLUSIONS: Acquired undescended testes are a common cause of cryptorchidism. Ascent occurs throughout all prepubertal ages, emphasizing the need to regular follow-up of testicular position until puberty. TYPE OF STUDY: Prognosis study. LEVEL OF EVIDENCE: Level II.

What are the participants' perspective and the system-based impact of a standardized, inter-professional morbidity/mortality-conferences in a children's hospital?

BACKGROUND: Morbidity and mortality conferences (MMC) are well established but little data exists on inter-professional aspects, system-based outcomes and characteristics in pediatric departments. Our study aim was to analyze the system-based impact and to assess participant's perspectives on standardized, inter-professional MMCs in a children's hospital. METHODS: In a prospective observational analysis the inter-professional MMCs held at a tertiary teaching children's hospital in Switzerland were analyzed for (I) resulting clinical consequences and (II) participants perception on format, usefulness and no-blame atmosphere. RESULTS: Eighteen MMC, discussing 29 cases were analyzed. Twenty-seven clinical errors/problems were identified and 17 clinical recommendations were developed: ten new or changed clinical guidelines, two new therapeutic alternatives, three new teaching activities, and two guidelines on specific diagnostics. Altogether, the 466 participants evaluated the conferences favorably. Little differences were seen in the evaluations of physicians of different disciplines or seniority but non-physicians scored all questions lower than physicians. Overall, three quarters of the participants felt that there was a no-blame culture during the conferences but results varied depending on the cases discussed. CONCLUSIONS: An inter-professional MMC can have relevant impact on clinical practice and affect system-based changes. Inter-professional conferences are profitable for all participants but evaluated differently according to profession. A standardized format and the presence of a moderator are helpful, but not a guarantee for a no-blame culture. Highly emotional cases are a risk factor to relapse to "blame and shame". A time gap between the event and the MMC may have a beneficial effect. KEYWORDS: Inter-professional communication; inter-professional health care; learning from failure; morbidity and mortality conference (MMC); patient safety; psychological safety.

[Uretero-pelvic junction obstruction due to crossing pole vessel: contra vascular hitch]. / Subpelvine Stenose/Kreuzendes Gefäß ­ kontra vascular hitch.

Hydronephrosis in infants and children is most commonly due to a congenital, intrinsic obstruction of the uretero-pelvic junction. The Gold standard of care is defined as a dismembered pyeloplasty, nowadays mostly performed in a minimally-invasive procedure, either through a laparoscopic (also robotic-assisted) or retroperitoneoscopic approach. Less common is an extrinsic obstruction of the ureter or the uretero-pelvic junction caused by an aberrant crossing pole vessel, a condition more likely to affect children beyond infancy. This entity most often becomes apparent when it causes intermittent abdominal or flank pain. For this entity, Hellström described a surgical procedure avoiding dismembered pyeloplasty by hitching the crossing vessel in a tunnel at the pyelon. This has been increasingly advocated as a valuable therapeutic alternative to dismembered pyeloplasty. The discussion on whether dismembered pyeloplasty or a vascular hitch procedure is preferable to resolve the obstruction is controversial and ongoing. There is evidence in the literature that in the case of a crossing pole vessel an intrinsic stenosis of the ureter may additionally be present in up to 57 % of cases. However, this finding can only be proven histologically. The intraoperative aspect of a crossing pole vessel and the uretero-pelvic junction does not serve to discriminate between intrinsic and extrinsic stenosis. Therefore, a vascular hitch procedure bears the risk that a remaining intrinsic obstruction will be disregarded, which, in turn, may lead to urodynamic obstruction and consecutive loss of differential renal function. In addition, there is a general risk of compromising the perfusion of the affected kidney while hitching an aberrant vessel providing significant blood supply. Dismembered pyeloplasty can avoid a false selection of patients. In addition, there is sufficient evidence showing that dismembered pyeloplasty is a procedure with a low complication rate ranging from 2 to 3 %, providing very good results in functional outcome in terms of improving drainage and preserving differential renal function. Therefore, we prefer dismembered pyeloplasty as the method of choice for both the treatment of intrinsic as well as extrinsic uretero-pelvic junction obstruction.

Complete Resection of a Large Mediastinal Calcifying Fibrous Tumor.

Calcifying fibrous tumor (CFT) is a benign tumor entity which can present in a variety of different sites. Till date, eight cases with a mediastinal manifestation have been published in literature. Surgical removal is the treatment of choice for this often incidentally detected tumor. Surgery of thoracic CFT may be challenging due to its localization within the mediastinum. A 10-year old boy with a right-sided thoracic pectus carinatum-like deformity was referred for further evaluation, incidentally, revealing a mediastinal mass in computed tomography (CT). Laboratory results were all within normal range. Magnetic resonance imaging (MRI) showed a large tumor in the upper anterior mediastinum suggesting expansive but not infiltrative character. The tumor was displacing surrounding structures like the heart and the diaphragm. Lower venous stasis with dilation of the inferior cava vein could be demonstrated. The tumor was considered to be of benign dignity and surgical removal was indicated. Complete tumor resection could be achieved through a sternotomy approach, along with thymectomy. A partial resection of both the pericardium and diaphragm was required due to adhesion with soft tissue at those sites. The specimen's size was 320 mm × 145 mm × 100 mm, histologically confirmed as CFT. The patient showed no residual tumor at 3- and 9-month follow-up. This case is a report on a large mediastinal CFT which underwent successful complete surgical removal. Following tumor resection, prognosis is considered to be good; however, key issue is complete resection to avoid local tumor recurrence.

Pyeloplasty in children: is there a difference in patients with or without crossing lower pole vessel?

INTRODUCTION: Most of the children with hydronephrosis do not require any surgical intervention. However, in individual cases, irreversible loss of renal function can develop. Predictive criteria have been proven ineffective so far in determining in which children obstruction will lead to renal damage. The aim of our retrospective study was to determine the role of a crossing lower pole vessel (CV) in children undergoing pyeloplasty. MATERIALS AND METHODS: Between 1996 and 2003, 137 patients (age between 6 weeks and 16 years) with unilateral ureteropelvic junction obstruction and no associated urological pathologies underwent Anderson-Hynes dismembered pyeloplasty. A total of 112 patients were evaluated with complete data. One of the following criteria was considered to be indication for surgery in children with grade 4 hydronephrosis: differential renal function (DRF) <40%; clinical symptoms such as pyolenephritis and flank pain; during follow-up renographies, a reduction of DRF >10% and washout patterns II or III b according to O'Reilly. We looked at the age during surgery and the kind of presentation. DRF was measured using diuretic renography preoperatively and 1 year postoperatively. A postoperative change in DRF of group A (children without CV, n = 84) was compared to that in group B (children with CV, n = 28). RESULTS: Median age at the time of surgery was 5 months in group A compared to 23 months in group B. Only in 21.4% of the children with CV compared to 60.7% without CV hydronephrosis was diagnosed by ultrasound examination antenatally. We found a preoperative DRF of 42.4% +/- 11.2 SD in group A, and of 38.9% +/- 11.7 SD in group B. The percentage of postoperative improvement was 3.3% in group A and 15.4% in group B. CONCLUSIONS: Children with ureteropelvic junction obstruction and CV received a delayed surgical treatment and showed a greater reduction in differential renal function preoperatively, in contrast to patients without CV. Our data show that CV is a risk factor for deterioration of renal function in children with hydronephrosis and we advocate for an early pyeloplasty in these children, especially if they have a high-grade dilatation and equivocal washout patterns in diuretic renographies. Further prospective studies are necessary in order to understand the natural history of CV and to reveal the importance of the crossing lower pole vessel as a structural anomaly lacking maturation.

Applications of Laparoscopic Transperitoneal Surgery of the Pediatric Urinary Tract.

Application of laparoscopy in pediatric urology has evolved over more than 30 years coming from a merely diagnostic use for non-palpable testes to "interventional" laparoscopy to extirpative surgery and finally to the era of reconstructive pediatric laparoscopic urology, when in 1995 Peters described the first laparoscopic pyeloplasty in a child. Laparoscopic surgery in pediatric urology became implemented increasingly in the twenty-first century with now present-day applications including the complete variety of all kind of indications for surgery for pediatric urological pathology. This article aims to provide a comprehensive overview of current indications, techniques, and outcomes of laparoscopic transperitoneal surgery of the upper as well as of the lower urinary tract for urological pathology in the pediatric patient population.