Laparoscopic repair of incarcerated inguinal hernia. A safe and effective procedure to adopt in children.

BACKGROUND: The purpose of our retrospective study was to describe the efficacy and the advantages of laparoscopic approach to treat incarcerated inguinal hernia (IIH) in pediatric patients. METHODS: In a 2-year period, 601 children underwent a laparoscopic inguinal hernia repair, 46 (7.6 %) of them presented an IIH. Our study will be focused on these 46 patients: 30 boys and 16 girls (age range 1 month-8 years). RESULTS: Twenty-one/46 hernias (45.6 %) were reduced preoperatively and then operated laparoscopically (RH), 25/46 (54.4 %) were irreducible and they were operated directly in laparoscopy (IRH). We have no conversions in our series. The length of surgery in RH group was in median 23 min and in IRH group was in median 30 min. Hospital stay was variable between 6 h and 3 days (median 36 h).With a minimum follow-up of 14 months, we had 2/46 recurrences (4.3 %). CONCLUSION: The laparoscopic approach to IIH appears easy to perform from the technical point of view. The 3 main advantages of laparoscopic approach are that all edematous tissue are surgically bypassed and the cord structures are not touched; the reduction is performed under direct visual control, and above all, an inspection of the incarcerated organ is performed at the end of procedure.

Comparison of femoral and carotid blood pressure during laparoscopy in piglets.

PURPOSE: The impact of a capnoperitoneum on the known blood pressure (BP) difference of the upper and lower limb was studied in piglets. METHODS: Eleven German Landrace piglets (body weight, 4.3-7.4 kg; mean body weight, 6.2 kg) were studied. Arterial lines were placed in the right carotid and right femoral artery for pressure monitoring. Intraabdominal pressure levels were increased in steps of 6 mm Hg up to 24 mm Hg. RESULTS: We found that elevated intraabdominal pressures up to 24 mm Hg did not change the preexisting systolic BP difference between the carotid and femoral arteries. Systolic femoral artery pressure constantly remained 5% higher than its carotid counterpart. In addition, mean and diastolic values were not affected. CONCLUSIONS: Arterial BP measurements recorded at the legs of piglets when abdominal pressure is increased by up to 24 mm Hg can be used for intraoperative assessment of systemic arterial BP.

Laparoscopic inguinal hernia repair in premature babies weighing 3 kg or less.

PURPOSE: This retrospective study aims to evaluate the feasibility, safety and complication rate of laparoscopic inguinal hernia repair for small babies weighing 3 kg or less. METHODS: A retrospective analysis was performed on the surgical charts of 67 infants (47 boys and 20 girls) weighing 3 kg or less who underwent laparoscopic hernia repair in a 3-year period. A regular 5-mm scope was used for visualization, and 2 or 3-mm instruments were used for the closure of the inner inguinal ring using 3/0 non-absorbable suture. The median weight at surgery was 2,600 g (range 1,450-3,000 g). All except three were premature. RESULTS: Of the 67 infants, 15 (22.3 %) presented with an irreducible hernia. In three cases of irreducible hernias, we also performed a transumbilical appendectomy at the end of the hernia repair. Minor problems related with anesthesia were noted in four cases. Hernia recurrence was observed in three patients (4.4 %). No cases of testicular atrophy occurred. In 10 boys, we observed 12 cases of high testes, only 4 testes requiring subsequent orchiopexy. CONCLUSIONS: Laparoscopic inguinal hernia repair for babies weighing 3 kg or less is feasible, safe and perhaps even less technically demanding than open inguinal herniotomy.

Etiopathological aspects of achalasia: lessons learned with Hirschsprung's disease.

The etiology of primary esophageal achalasia is largely unknown. There is increasing evidence that genetic alterations might play an important but underestimated role. Current knowledge of the genetic base of Hirschsprung's disease in contrast is far more detailed. The two enteric neuropathies have several clinical features in common. This association may also exist on a cellular and molecular level. The aim of this review is to enlighten those etiopathogenetic concepts of Hirschsprung's disease that seem to be useful in uncovering the pathological processes causing achalasia. Three aspects are looked at: (i) the genetic base of Hirschsprung's disease, particularly its major susceptibility gene rearranged during transfection and its potential reference to achalasia; (ii) the altered motor functions in both conditions with loss of inhibitory innervation and interstitial cell pathology; and (iii) the involvement of these motility disorders in genetic syndromes.

Stent-free tubularized incised plate (TIP) repair of distal and mid-shaft hypospadias irrespective of age.

PURPOSE: Aim of this study was to report our experiences with tubularized incised plate (TIP) repair without placement of a postoperative urethral stent in 41 cases. PATIENTS AND METHODS: Since October 2005, we have performed TIP repair for distal penile hypospadias without using a postoperative urethral stent. A urethral stent is used intraoperatively for the tubularization of the neourethra and is removed at the end of the procedure. Follow-up included clinical examination and a structured telephone interview on parental satisfaction. RESULTS: The group included 41 boys, 60% with coronal or distal hypospadias and 40% with mid-shaft hypospadias (aged 6 months to 16 years, median: 3 years). In 7 cases, the prepuce was also reconstructed. There were 2 cases with fistula and one case of meatal stenosis. No glans dehiscence, severe bleeding, or wound infection was observed. No urinary retention requiring catheterization was observed, irrespective of age. All but one patient was discharged the day after surgery. Follow-up ranged from 8 to 48 months (average: 22 months). Most parents (87.5%) were satisfied or very satisfied. CONCLUSION: Based on our preliminary experiences, patient comfort and safety, parental satisfaction and the rate of complications seem to be promising with this technique.

Laparoscopic inguinal herniorrhaphy in premature infants.

INTRODUCTION: We report the clinical, operative, and outcome results in 58 premature infants (with maximum weight of 5,000 g at time of surgery) undergoing laparoscopic herniorrhaphy. PATIENTS AND METHODS: This study was designed as a prospective, non-randomized single center feasibility study. The inclusion criteria were: symptomatic inguinal hernia, gestational age up to 37 weeks and maximum weight of 5,000 g at the time of surgery. Out of 58 premature infants (42 boys and 16 girls), 24 had bilateral, 20 had right-sided and 14 had left-sided hernias. 14 (24.1%) infants were operated on for an irreducible hernia. RESULTS: The median gestational age at birth was 33 weeks (range 23-37) and the median gestational age at operation was 41 weeks (range 33-52). The body weight at surgery ranged from 1,450 g to 5,000 g (median 3 900 g); 11 infants (19%) weighed less than 2 500 g. No intraoperative surgical complications occurred. Anesthesia complications were noted in 7 cases. At median follow-up of 25 months (range 6-51 months), there were 3 hernia recurrences in 2 infants (3.6%). In 5 boys, we observed high testes requiring subsequent orchiopexy. Regression analysis showed that the risk of undescended testes increased by 65.5% for every 1 kilo lower weight at surgery. CONCLUSION: Based on our early results, it seems that laparoscopic hernia repair in preterm infants and very low birth weight babies is a safe and feasible procedure and has some procedural benefits compared to the standard open technique.

CD rats as an animal model in the experimental study of laparoscopic hernia repair.

PURPOSE: The aim of this study was to evaluate the technical feasibility and efficacy of a sutureless laparoscopic hernia repair in a small animal model. The objective was to occlude the processus vaginalis with biocompatible fleece and/or fibrin glue as an alternative to suturing. METHODS: Sixty-three male CD rats were randomly assigned to one of three groups. In group A (n=21), the internal inguinal ring was filled with 0.5 ml fibrin glue. The second group (B, n=21) also received fibrin glue, and a biocompatible fleece was placed on top. The third group consisted of control animals (C, n=21). Eleven rats in each group underwent laparoscopic surgery. The remaining rats were operated using an open technique, and the paraductal lipomas were resected in addition to inguinal ring closure. RESULTS: Complete closure of the internal hernia ring was not achieved in any of the rats, neither in the laparoscopic group nor in the open group or the control group. The paraductal lipoma grew back to its normal size, although resection of the lipoma was performed during the first procedure. CONCLUSION: The physiology of paraductal lipomas in this animal appears to make it an inadequate model for the study of laparoscopic inguinal hernia repair.

[Capitate fracture in an 11-year-old boy]. / Fraktur des Os capitatum bei einem 11-jährigen Jungen.

We report the case of an isolated non-displaced fracture of the capitate in an 11-year-old boy. On the basis of the relevant literature we present a survey of the diagnostic and treatment options. To the best of our knowledge this is the first description of a paediatric capitate fracture in the German-speaking area.

Microlaparoscopy for recurrent abdominal pain in children.

PURPOSE: This prospective study evaluated the diagnostic and therapeutic feasibility and safety of microlaparoscopy for the management of chronic abdominal pain in children. METHODS: The study included 45 children (13 boys and 32 girls; age range from 6 to 16 years, average 9.5 years) undergoing diagnostic microlaparoscopy for chronic abdominal pain. Microlaparoscopy (the exclusive use of 2 mm instrument sets and small diameter scopes, i. e. 1.7 mm, 1.9 mm and 2.4 mm) was performed after common organic diseases were ruled out by careful baseline investigations. RESULTS: No complications occurred which were related to the exclusive use of 2 mm instruments and small scopes. CT scans were avoided in all patients. No intraoperative pathological findings were found in 18 children. In another 18 children, the intraoperative findings indicated the need for further surgical intervention. At follow-up, 26 patients reported that they were totally pain-free; 10 children had partial resolution after surgery, and 8 children reported only minimal resolution. In 20 cases, the procedures were accomplished as an outpatient surgery. CONCLUSION: Microlaparoscopy seems to be a safe and effective diagnostic tool with a favorable diagnostic accuracy, minimal access trauma and superior cosmesis in children.

High-intensity transient signals during laparoscopic surgery in children.

BACKGROUND: Laparoscopic interventions in children gain increasing popularity. Pneumoperitoneum as applied during laparoscopic surgery can induce gas emboli formation, but it is unclear whether this is associated with cerebral embolic events. To investigate the hypothesis that pneumoperitoneum causes cerebral emboli in children, the number and intensity of high-intensity transient signals (HITS) detected using transcranial Doppler ultrasonography were assessed before and after induction of pneumoperitoneum. METHODS: Twenty children were monitored during laparoscopic surgery. General anaesthesia was performed using sevoflurane and sufentanil or alfentanil. Pressure-controlled ventilation was adapted to maintain end-tidal Pco(2) (Pe'(co(2))) between 4.7 and 6.0 kPa. Baseline measurement of HITS rate, cerebral blood flow velocity, and mean arterial pressure (MAP) were recorded during steady-state anaesthesia before skin incision and during pneumoperitoneum with intra-abdominal pressure of 1.6-2.0 kPa applied using CO(2). RESULTS: In 14 children (70%), HITS were detected during baseline and pneumoperitoneum. Three additional children (15%) developed HITS during pneumoperitoneum only and another three children (15%) presented no HITS during the investigation period. MAP and cerebral blood flow velocity increased with pneumoperitoneum. CONCLUSIONS: HITS are present in 70% of paediatric surgical patients under balanced anaesthesia before surgical interventions. Pneumoperitoneum further increased the occurrence of HITS.

Ovarian tumours: late extramedullary recurrence of acute leukaemia.

OBJECTIVE: Isolated extramedullary relapse, especially ovarian recurrence, of acute leukaemia is rare. Local therapy such as irradiation or extensive surgical resection of the mass is ineffective and unnecessary. MATERIALS AND METHODS: Over a 20-year period we observed two girls with ovarian relapse of acute lymphoblastic leukaemia (ALL) in over 300 treated children for ALL. Pre-B ALL was diagnosed in a girl at the age of three. Treatment was initiated according to the CoALL 82-protocol. At the age of 11, the girl presented with a huge abdominal mass. Chemotherapy and low-dose radiotherapy succeeded in shrinking the tumour mass, making it operable. A salpingo-oophorectomy was performed. In the second case, a 14-year-old girl in whom pre-B ALL was diagnosed was treated according to the protocol CoALL 06-97. After having achieved complete haematological remission in the bone marrow, she stayed in remission for 18 months. Subsequently, she developed a painless abdominal tumour. Laparoscopic lymph node staging was performed and biopsies were taken. Chemotherapy was initiated according to the BFM protocol for ALL recurrence. Extensive surgical resection of the leukaemic mass, as well as additional radiation was avoided. CONCLUSION: Because we experienced favourable results with laparoscopic biopsy in our patients, we are of the opinion that laparoscopy-assisted biopsies are well suited for the management of intra-abdominal tumours in systemic malignant disease.

Laparoscopic transabdominal pyeloplasty in children is feasible irrespective of age.

PURPOSE: We assessed the feasibility of laparoscopic transabdominal dismembered pyeloplasty in 46 infants and children with regard to patient age. MATERIALS AND METHODS: A total of 46 consecutive infants and children (31 male and 15 female) underwent laparoscopic transabdominal dismembered pyeloplasty using a 3 to 4-trocar technique. All patients had confirmed unilateral deterioration of renal function on isotope renography. The 46 patients were divided into 3 age groups--1 to 12 months (group 1, 14 patients), 1 to 7 years (group 2, 15 patients) and 7 to 18 years (group 3, 17 patients). Followup included clinical and ultrasound assessment, and isotope renography at 3 months. RESULTS: Laparoscopic pyeloplasty was feasible in 44 of 46 patients (96%). Mean operative time was 175 minutes (range 120 to 270). The operation was converted due to impracticality of stenting the PUJ in 1 patient, and due to bleeding in 1. Mean operative time in 44 successful laparoscopic procedures was not significantly different among the 3 age groups (171 minutes in group 1, 169 minutes in group 2 and 173 minutes in group 3). Two patients required operative intervention for PUJ leakage, and 1 underwent percutaneous nephrostomy with a further uneventful course. Mean followup was 29 months (range 3 to 86). A total of 44 patients (96%) were asymptomatic and had improved PUJ drainage on isotope renography. Two patients underwent redo pyeloplasty due to recurrent hydronephrosis at 1 month and 2 years. CONCLUSIONS: Laparoscopic transabdominal dismembered pyeloplasty is effective and safe in infants and children. The feasibility is also excellent in patients younger than 1 year. The transabdominal approach revealed good exposition without a disadvantage for the patient.

Laparoscopic resection of congenital choledochal cyst, choledochojejunostomy, and extraabdominal Roux-en-Y anastomosis.

BACKGROUND: The feasibility of laparoscopic resection of choledochal cyst and hepaticojejunostomy in children is still unclear. This report presents the author's experience with a first series of patients. METHODS: Data from 11 consecutive children (median age 17.5 months, SD 22, range 2 to 70) with choledochal cyst scheduled for laparoscopy were collected prospectively. There were nine type I and 2 type V cysts according to Todani's classification. All except one patient had intermittent jaundice or recurrent pancreatitis. The laparoscopic technique included excision of the cyst. A Roux-en-Y anastomosis was constructed after exteriorization of the small bowel via the infraumbilical trocar incision. After repositioning of the bowel an end-to-side hepaticojejunostomy was carried out laparoscopically. RESULTS: The procedures were carried out in nine children without intraoperative events and a median duration of 289 min (SD 62). In two patients, the operation was converted after 60 and 90 min due to a lack of overview at the dorsal margin with problems in separation of the portal vein. Oral food intake was started within 2 days and tolerated well in all except one patient, in whom biliar fluid from the drain led to laparoscopic reevaluation on day 1. A small leak was resutured and the patient was discharged on day 5. In one patient, recurrent cholangitis and a dilated Roux-en-Y loop led to correction of some kinking of the loop via laparotomy after 3 months. All other patients are well with bile-stained stools after a mean follow-up of 13 months. CONCLUSIONS: Laparoscopic resection of congenital choledochal cyst and choledochojejunostomy in children is feasible. We feel that there is a considerable learning curve with the technique. Future studies will have to prove the feasibility of laparoscopic Roux-en-Y bowel anastomosis without the need for bowel exteriorization.

[The internet presentation of medical departments: an example of a pediatric surgical department]. / Die Internet-Darstellung einer Klinikabteilung für Kinder am Beispiel einer Kinderchirurgie.

INTRODUCTION: In times of easy world wide information transfer and reduced economic resources of the community, the presentation of medical departments in the internet becomes more and more important. But realisation is often insufficient. METHOD: The welcome page is the most important element. It should be appealing and easy to understand. Menues should lead to further information like "employees", "premises", "approach" and "medical information". Quick loading times are neccesary to make surfing more comfortable. DISCUSSION: The internet presentation becomes more and more essential in our days. Legal restrictions, although being reduced in the last years, have to be observed.

Rare inguinal hernia forms in children.

Rare inguinal hernia forms are encountered more frequently in the laparoscopic technique than in the open approach. The reasons are subject to speculation. The incidence of unusual inguinal hernia forms was studied in a series of inguinal hernias corrected laparoscopically in 452 children (334 boys and 118 girls aged 4 days--14 years, median age 1.6 years). The videos were retrospectively evaluated. Direct hernias were found in 10 children (2.2%), femoral hernias in five (1.1%), hernias en pantalon in three (0.7%), and a combination of indirect and femoral hernia and a combination of indirect, direct, and femoral hernia in one child each (0.2%). Routine videorecording during laparoscopy provides for the first time an objective and absolute picture of the true incidence of these unusual hernia forms.

Occult, life-threatening, cardial tumor in syndactylism in Gorlin Goltz syndrome.

Pediatric, orthopedic, plastic, and hand surgeons perform the surgical correction of syndactylism. It is sometimes forgotten, however, that syndactylism can be part of a syndrome. The components of such a syndrome can each be life threatening. A 7-month-old boy was hospitalized for correction of cutaneous syndactylism. The mother claimed that, with the exception of the syndactylism, her son was healthy. However, review of the admission documents found that the family physician suspected Gorlin Goltz syndrome. A preoperative echocardiography showed 3.9-cm intramural tumor in the wall of the left ventricle. Electrocardiography documented ventricular tachycardia. Because of the danger of life-threatening malignant ventricular tachycardia, the tumor was resected. Before the resection, cardiac transplantation was considered because of the size of the tumor. Histologic examination found a fibroma. When observing syndactylism, one must always be aware of the possibility of a syndromic disease. It is particularly important that screening investigations, including electrocardiography and echocardiography, are performed before surgical treatment.

Pansclerotic morphea in childhood: a case report.

Scleroderma can be differentiated into progressive systemic and circumscript forms. The extensive form with lethal outcome is known from case reports of children and adolescents. The present case report concerns a boy who died at 16 years of age. In the 5th year of life, he experienced weight loss and developed multiple, firm, partially atrophic plaques in the skin of the extremities. These plaques gradually became confluent and extended over the whole torso and head. Plaque ulceration resulted in massive mutilations to the body. Later the patient's cachexia worsened and he developed keratose, moderately differentiated squamous cell carcinoma of the right leg. The prognosis of pansclerotic morphea for children is worse than for adults. No successful therapy is known.

Left ventricular regional wall motion abnormalities during pneumoperitoneum in children.

BACKGROUND: In adult patients, certain levels of PEEP (16 and 20 cm H(2)O) have been associated with left ventricular (LV) regional wall motion abnormalities. Since any increase in intra-abdominal pressure (IAP) exerted by a pneumoperitoneum is transmitted to the intrathoracic cavity, similar effects on LV regional wall motion cannot be ruled out. METHODS: To investigate the effects of pneumoperitoneum on LV regional wall motion, we performed a post hoc analysis of a transoesophageal echocardiography study in eight small children (mean age 3 yr, range 15-63 months) undergoing laparoscopic herniorrhaphy under anaesthesia with sevoflurane in nitrous oxide/oxygen and a PEEP of 5 cm H(2)O. During carbon dioxide insufflation, end-tidal carbon dioxide concentration ()was kept constant by increasing minute volume. RESULTS: An IAP of 12 mm Hg caused significant septal hypokinesia compared with baseline, while anterior and posterior wall motion was not affected. In addition, a lateral hyperkinesia occurred, though this change was not statistically significant. CONCLUSIONS: Pneumoperitoneum may affect LV regional wall motion in paediatric patients undergoing laparoscopic surgery.

Laparoscopic herniorrhaphy in children.

BACKGROUND: We report our clinical experience with 403 inguinal hernias in 279 children. They were treated via a purely laparoscopic approach using 2-mm instruments, obviating the need for a groin incision. METHODS: Laparoscopic herniorrhaphy was performed in children ages 4 days to 15 years. A 5-mm laparoscope was inserted through the umbilicus, and two 2-mm needle holders were inserted through the inferolateral abdominal wall. The open inner inguinal rings were closed by placing Z-sutures of monofilamentous nonabsorbable material. RESULTS: The mean operating time was 14 min for unilateral hernias and 21 min for bilateral hernias. We found 3.9% direct hernias. Hydroceles occurred in 1.7% of patients, testicular atrophy was noted in one patient, and no hernia was found in 2.3%. In girls with inguinal hernias, a contralateral asymptomatic patent processus vaginalis (PPV) was found in 45.2%, regardless of whether the hernia was on the right or the left side. In boys with inguinal hernias, contralateral PPVs were found on the right side in 21.9% and on the left in 8%. There were no major complications. One conversion to an open procedure was necessary because of a dilated bowel. The mean follow-up period was 23 months. There were 2.7% hernia recurrences; this rate was slightly higher than that seen with the open technique. The incidence of direct inguinal hernias was higher than has been previously reported. CONCLUSIONS: Laparoscopic herniorrhaphy allows the surgeon to identify the type of defect and proceed with immediate treatment. This technique is safe, reproducible, and technically easy for experienced laparoscopists. Bilaterality is of no concern. The cosmetic results are excellent; and in patients with recurrence of a hernia, this procedure is preferable to the open technique.