Results of using the method of full extraperitoneal endoscopically assisted ligation of the hernial sac with inguinal hernia in children.

BACKGROUND/PURPOSE: The aim of this study was to evaluate the effectiveness of a new technique for inguinal hernia repair in children: pediatric hernia extra-peritoneal ligation and percutaneous suturing (PHELPS) in comparison with another laparoscopic technique, subcutaneous endoscopically assisted ligation (SEAL). METHODS: We demonstrate the results of laparoscopic treatment of 680 patients with inguinal hernias. Of these, 206 patients were operated using the new PHELPS technique. The remaining 474 children received the SEAL technique. The difference between the methods is that PHELPS consists of ligating the hernia around the neck of the hernial sac, including an intra-peritoneal component (aponeurosis and muscles), while the SEAL technique ligates the hernia sac only. We examined whether this factor may lead to more recurrence and hydrocele in the SEAL technique. RESULTS: Both groups of patients were comparable in terms of age, body weight at the time of surgery, and gender. The average total duration of inguinal herniorraphy, including the time of surgery in patients with one-and two-sided hernia localization, was comparable in both groups (17.50 min versus 17.22 min; p = 0.518). The study demonstrated a faster recovery of patients after using the PHELPS technique for the treatment of inguinal hernias, consisting in a statistically significantly lower number of doses of postoperative analgesia (1.01 versus 1.31; p < 0.001) and a shorter time of patient stay in the hospital (8.06 h versus 8.78 h; p = 0.031). Despite the fact that there were no statistically significant differences in the frequency of postoperative hydrocele (0 versus 6; p = 0.090), we found a statistically significant difference between the groups in terms of recurrence (0 versus 17; p < 0.001). CONCLUSIONS: The PHELPS technique shows improved results in terms of recurrence and hydrocele as compared to SEAL. LEVEL OF EVIDENCE: Level III TYPE OF STUDY: Retrospective Comparative Study.

Bowel Resection Through a Single Umbilical Incision: A Case Series.

Background: The advent of laparoscopy has revolutionized surgery. The surgeon strives to minimize incisions and their adverse consequences. Although laparoscopy has gained widespread popularity, several advantages in open surgery are thereby lost. Tactile sensation of the tissue, hand-sewn anastomosis, and nonthermic vascular control are most prominent. To combine both approaches, single incision laparoscopic-assisted surgery (SILS) was advanced, trying to combine the best in both worlds. This approach is widely used in appendectomies. After having gained experience in this approach, we expanded the indications and hereby present our experience with bowel resections utilizing SILS. Patients and Methods: Data were collected retrospectively from operations performed during the past 3 years. We found 11 cases of SILS bowel resections: 3 sigmoidectomies, 3 small bowel atresia repairs, 1 subtotal colectomy, 1 Meckel's diverticulectomy, and 3 resections of bowel duplications. The age of the patients ranged from 2 days to 17 years. In all cases, a working 10 mm scope was inserted through the umbilicus, the bowel was extracted outside the abdomen through the umbilicus, dissection and resection with anastomosis were performed outside the abdomen in the classic open approach, and the bowel was returned to the abdomen. Results and Conclusions: All patients recovered promptly with no need for further intervention. There were no cases of wound infection, leak, or intra-abdominal abscess formation. Cosmesis was excellent with a small umbilical scar. We conclude that this approach is feasible and safe in a select population.

Laparoscopic Treatment of Type I of Pyloric Atresia: Case Report.

Objective: Pyloric atresia is one of the rarest surgical diseases in newborns. Laparotomy is the most common approach to correct this abnormality. In the modern scientific literature, there is only one report on the endosurgical treatment of pyloric atresia. The case of laparoscopic correction of gastric outlet atresia presented in this study is another reference to the successful treatment of this condition. Methods: The clinical case is presented by a newborn boy in whom a prenatal ultrasound (US) examination at 31 weeks of gestation revealed polyhydramnios and an enlarged stomach. The baby was born on 37th week of gestation, his birth weight was 2660 g. In the 1st hours of life, the child showed symptoms of high intestinal obstruction in the form of vomiting of gastric contents. Postnatal US and X-ray examination established the diagnosis of pyloric atresia. During laparoscopy, performed on the 2nd day of life, the morphological type of anomaly was assessed and type I atresia, represented by a membrane, was established. A laparoscopic membranectomy with Heineke-Mikulicz pyloroplasty was performed. The early and late results of the operation were investigated. Results: The duration of the operation was 70 minutes. The postoperative period was uneventful. Enteral nutrition was started on the postoperative day (POD) 3. A complete enteral diet became possible on day 7. The newborn was discharged from the hospital on the POD 9. Histological examination confirmed the diagnosis of membranous type of pyloric atresia. During follow-up for 12 months, no complications associated with the surgical procedure were found. Conclusion: Description of the case of laparoscopic treatment of type I pyloric atresia in a newborn expands the use of laparoscopy in pediatric practice.

Toward asleep DBS: cortico-basal ganglia spectral and coherence activity during interleaved propofol/ketamine sedation mimics NREM/REM sleep activity.

Deep brain stimulation (DBS) is currently a standard procedure for advanced Parkinson's disease. Many centers employ awake physiological navigation and stimulation assessment to optimize DBS localization and outcome. To enable DBS under sedation, asleep DBS, we characterized the cortico-basal ganglia neuronal network of two nonhuman primates under propofol, ketamine, and interleaved propofol-ketamine (IPK) sedation. Further, we compared these sedation states in the healthy and Parkinsonian condition to those of healthy sleep. Ketamine increases high-frequency power and synchronization while propofol increases low-frequency power and synchronization in polysomnography and neuronal activity recordings. Thus, ketamine does not mask the low-frequency oscillations used for physiological navigation toward the basal ganglia DBS targets. The brain spectral state under ketamine and propofol mimicked rapid eye movement (REM) and Non-REM (NREM) sleep activity, respectively, and the IPK protocol resembles the NREM-REM sleep cycle. These promising results are a meaningful step toward asleep DBS with nondistorted physiological navigation.

Laparoscopic Treatment of Congenital Nonparasitic Liver Cysts in Newborns.

Background: Congenital nonparasitic liver cysts in newborns are rare. Surgical excision of these formations is necessary to prevent complications. Reports of laparoscopic treatment of simple liver cysts in children are sporadic. We present a series of 3 patients with liver cysts treated laparoscopically in a single center. We added a short review of the literature. Methods: Data of 3 patients with nonparasitic liver cysts were collected at our center, from 2014 to 2019. Early and long-term results of laparoscopic operations were studied. Results: All patients were newborns, and of these, 2 were girls and 1 boy. The primary diagnosis was established during prenatal ultrasound examination. The laparoscopic approach was used in all patients. Complete resection of the cysts was achieved laparoscopically in all cases. Pathology reports were consistent with nonparasitic liver cysts. The early postoperative period was uneventful with prompt discharge. In the long-term follow-up period, there were no recurrences of the disease. Conclusions: The study presents one of the largest series of laparoscopic excision of nonparasitic liver cysts in newborns. We conclude that laparoscopy is a safe and effective method of treating of congenital hepatic cysts.

Colorectal carcinoma in childhood: a retrospective multicenter study.

OBJECTIVES: Colorectal carcinoma, a common adult malignancy, has an estimated childhood incidence of 0.3 to 1.5/million in Western countries and 0.2/million in Israel. Diagnosis is difficult because adult screening measures are unfeasible in children. The tumor is frequently associated with predisposing genetic factors, aggressive biological behavior, and poor prognosis. The aim of this multicenter study was to document the clinical profile, treatment and prognosis of colorectal carcinoma in children in Israel. PATIENTS AND METHODS: The clinical, laboratory, therapeutic, and prognostic parameters of all 7 children from 4 medical centers in Israel who were diagnosed with colorectal carcinoma over a 25-y period were reviewed. RESULTS: Patients presented with rectal bleeding (4 of 7), abdominal pain (2 of 7), and abdominal distension (2 of 7). Average time to diagnosis was 6 months. Six patients underwent surgery (1 refused), and 5 received chemotherapy. Histopathological studies showed poorly differentiated mucinous adenocarcinoma, signet-ring type, in 4 cases, moderately differentiated adenocarcinoma in 2, and well-differentiated carcinoma in 1. Three patients died of the disease, 2 shortly after diagnosis. One patient with recurrent metastatic disease was lost to follow-up. CONCLUSION: Colorectal carcinoma in children is characterized by aggressive tumor behavior and delayed diagnosis, resulting in a worse prognosis than in adults. Heightened physician awareness of the possibility of this disease in children, with special attention to adolescents with predisposing factors and rectal bleeding, could help to improve outcome.

Neonatal sigmoid volvulus.

BACKGROUND: Neonatal sigmoid volvulus is a rare entity. It is associated with Hirschsprung's disease. Presentation is acute abdominal distention, vomiting and obstipation. Abdominal radiograph will show the "coffee bean" sign, but this is frequently missed and the diagnosis requires a high index of suspicion. Treatment options include contrast enema, colonoscopy or laparotomy, depending on the condition of the baby and local availability. POPULATION AND RESULTS: During the last 6years, 6 infants with sigmoid volvulus were treated in our department. Four presented during the first 48h since birth, and 2 presented at the age of 2 and 7weeks of age. One child was operated and 5 had primary contrast enema with radiologic de-volvulus. Rectal biopsy was performed in all cases; three children had Hirschsprung's disease. Those with normal biopsies responded well to rectal washouts. Two patients had early one stage transanal pullthrough and one had 2 further occasions of sigmoid volvulus prior to definitive surgery. All three recovered with an uneventful course. CONCLUSIONS: Neonatal sigmoid volvulus requires a high level of suspicion. Contrast enema is efficient for primary de-volvulus. Rectal biopsy should be performed and if positive for Hirschsprung's disease, surgery should be performed sooner rather than later.

Transaldolase Deficiency: A New Case Expands the Phenotypic Spectrum.

Transaldolase (TALDO) deficiency has various clinical manifestations including liver dysfunction, hepatosplenomegaly, anemia, thrombocytopenia, and dysmorphic features. We report a case presenting prenatally with hyperechogenic bowel and intrauterine growth restriction. The infant was born small for gestational age, with cutis laxa and hypertrichosis. Postnatally, meconium plug was identified, complicated with intestinal obstruction necessitating laparotomy, partial resection of the intestine, and ileostomy. Liver biopsy revealed cholangiolar proliferation and portal fibrosis. He also suffered from persistent congenital thrombocytopenia requiring platelet transfusions and severe hypothyroidism with normal anatomical and structural gland responding only to the combination of T3 and T4 treatment. Neurologically, severe hypotonia and anisocoria were noted at the age of 2 months. Brain MRI was normal. Shortly after the abdominal surgery, a rapid liver failure ensued, which eventually led to his death. Specific metabolic tests ruled out glycosylation disorders, yet urine analysis using 1H NMR showed accumulation of sedoheptulose which was previously described in patients with transaldolase deficiency. Sequencing of the gene-encoding transaldolase (TALDO1) revealed a homozygous stop mutation c.669C>G; p.Tyr223*. In conclusion, we present an infant with a novel homozygous mutation in TALDO1, causing TALDO deficiency, and extend the clinical characteristics of this rare syndrome.

A new job for an old device: a novel use for nerve stimulators in anorectal malformations.

Muscle stimulation of the perineum is a crucial step in the repair of anorectal malformations. This allows the surgeon to assess muscle function and locate precisely the sphincter muscles during a pull-through operation. Presently, the device commonly used is very expensive. In searching for a cheaper and amenable device we explored utilizing the nerve stimulator MiniStim (model MS-IIIA, Life-Tech, Inc., Houston, TX) normally used for the "train of four" sign in assessing paralysis during general anesthesia. We have used this device in seven consecutive posterior sagittal anorectoplasties and compared its effectiveness with the regular muscle stimulator. In our experience, the nerve stimulator is easier to work with and is a common device in the operating theater. It gave us information that was at least equal to the regular muscle stimulator.