Subcutaneous Endoscopic-Assisted Ligation of the Internal Ring for Inguinal Hernia Repair in Neonates Under Spinal Anesthesia.

Introduction: While laparoscopy is now widely accepted for inguinal hernia repair in infants, it traditionally has required general anesthesia. We sought to evaluate the safety of laparoscopic inguinal hernia repair in infants under spinal anesthesia. Materials and Methods: We performed a retrospective cohort study of all inguinal hernia repairs at a single institution between December 2011 and June 2019 in patients younger than 6 months of age. Four groups were compared: laparoscopic under general anesthesia, laparoscopic with spinal anesthesia, open with spinal anesthesia, and open under general anesthesia. Main outcome measures include operative time, cost, and postoperative outcomes. These were assessed using Kruskal-Wallis median comparison. Results: Of the 226 patients meeting inclusion criteria, 54% (122/226) of patients underwent general anesthesia, while 46% (104/226) had spinal. When compared to general anesthesia, spinal anesthesia was associated with significantly shorter procedure times (P < .01) and lower cost (P < .01) for both open and laparoscopic approaches. Complications were few and underpowered to calculate significance across each group. Conclusions: Laparoscopic inguinal hernia repair can be safely performed in infants under spinal anesthesia without significant compromise of early perioperative outcomes. Advantages may include shorter procedure time and lower cost.

Return of the Banana Knife: An Alternative Instrument for Laparoscopic Pyloromyotomy.

Background: When the disposable arthroscopic banana knife (Linvatec, Largo, FL) became unavailable, many pediatric surgeons adapted the use of spatula tip cautery for laparoscopic pyloromyotomy; however, reusable arthroscopic knives remain readily available and are well suited to the procedure. Methods: We compared laparoscopic pyloromyotomy with a reusable arthroscopic banana knife (Sklar, West Chester, PA; catalog no. 45-6050) to those using spatula tip cautery at a single institution between September 1, 2012, and December 31, 2019. Mann-Whitney U test was used to compare operative time, room time, and time to discharge between groups. Results: Overall, 109 patients underwent pyloromyotomy for hypertrophic pyloric stenosis during the study time period. Of these, 12 were open and one was undertaken with the Storz pyloromyotomy knife, so these were excluded. A total of 74 (77.1%) laparoscopic cases with spatula tip cautery and 22 (22.9%) with the banana knife were included. Mean age at the time of surgery was ∼37 days. The majority of patients in each group were white, male, and full term. The most common comorbid conditions were reactive airway disease and neonatal abstinence syndrome. There were no significant differences in operative time (P = .61), room time (P = .41), or time from surgery to discharge (P = .26) between procedures using the banana knife and those using the cautery spatula tip. There were no perforations or recurrences. Conclusion: Our findings suggest that the reusable banana knife is a safe and effective alternative to spatula tip cautery for laparoscopic pyloromyotomy, with no difference in operative time, time from surgery to discharge, or complications.

Appendicitis in children less than 5 years old: influence of age on presentation and outcome.

PURPOSE: Appendicitis is the most common emergency surgical condition of the abdomen in children. This study sought to delineate the presentation and the outcome of appendicitis in children younger than 5 years old. METHODS: A retrospective review was conducted of all children younger than 5 years of age who underwent appendectomy for acute appendicitis over a 12-year period. RESULTS: One thousand eight hundred thirty-six patients younger than 19 years of age underwent appendectomy. Two hundred eighty-one children with an age range of 6 months to 4.9 years were included in this study. Perforation rates were higher in the younger patients (86% <1 year, 74% 1-1.9 years, 60% 2-2.9 years, 64% 3-3.9 years, and 49% 4-4.9 years), but the youngest children had fewer postoperative abscesses. CONCLUSIONS: In children less than 5 years old with appendicitis, age has a direct correlation to the stage of disease. The youngest children present with more advanced appendicitis but are less likely to develop postoperative abscesses.

Nonoperative correction of pectus carinatum with orthotic bracing.

BACKGROUND: This study sought to evaluate the efficacy of nonoperative compression in correcting pectus carinatum in children. MATERIALS AND METHODS: Children presenting with pectus carinatum between August 1999 and January 2004 were prospectively enrolled in this study. The management protocol included custom compressive bracing, strengthening exercises, and frequent clinical follow-up. RESULTS: There were 30 children seen for evaluation. Their mean age was 13 years (range, 3-16 years) and there were 26 boys and 4 girls. Of the 30 original patients, 6 never returned to obtain the brace, leaving 24 patients in the study. Another 4 subjects were lost to follow-up. For the remaining 20 patients who have either completed treatment or continue in the study, the mean duration of bracing was 16 months, involving an average of 3 follow-up visits and 2 brace adjustments. Five of these patients had little or no improvement due to either too short a follow-up or noncompliance with the bracing. The other 15 patients (75%) had a significant to complete correction. There were no complications encountered during the study period. CONCLUSION: Compressive orthotic bracing is a safe and effective alternative to both invasive surgical correction and no treatment for pectus carinatum in children. Compliance is critical to the success of this management strategy.

Posterior urethral valves in a newborn with imperforate anus: clinical presentation and management.

Anorectal malformations are frequently associated with urinary tract abnormalities, which generally consist of vesicoureteral reflux, renal agenesis, and bladder dysfunction. Posterior urethral valves associated with anorectal malformations are exceedingly rare. We report the third case described in literature and the unique management.

Ductal carcinoma in situ in a 16-year-old adolescent boy with gynecomastia: a case report.

Ductal carcinoma in situ (DCIS) of the male breast is rare. Even more rare is the finding of DCIS in association with gynecomastia. After an extensive literature search, only two cases have been reported in the literature, both in adults. Here we present the case of a 16-year-old adolescent boy who presented with pubertal gynecomastia that was treated with bilateral subcutaneous mastectomies. A DCIS focus was found in the right breast specimen, and the patient underwent bilateral completion total mastectomies uneventfully. Despite its rarity, surgeons should be aware of the possibility of the breast of adolescents with gynecomastia harboring a neoplastic focus.

Feasibility of thoracoscopic U-clip esophageal anastomosis: an alternative for esophageal atresia reconstruction.

BACKGROUND: The authors propose that U-Clips can significantly decrease the technical difficulty of performing thoracoscopic esophageal reconstruction, thus, reducing operating time, the incidence of postoperative leak, and stricture rate. METHODS: After obtaining Institutional Animal Care and Use Committee approval, 3 4-kg female piglets underwent complete thoracoscopic esophageal transections. The esophagus was reconstructed thoracoscopically using S50 and S60 U-Clips over an 8F transanastomotic tube. Esophagrams were performed on postoperative day (POD) 7, 21, 44, and 77. RESULTS: Mean operating time was 57 minutes (45 to 75 min). Two of 3 piglets had no evidence of leak on POD 7 esophagrams. One animal had a small leak that resolved spontaneously on antibiotics. All 3 piglets tolerated a formula diet orally by POD 8. Over a 77-day survival period all 3 piglets had steady weight gain on an oral diet. CONCLUSIONS: U-Clips are a feasible alternative to sutures for esophageal reconstruction in thoracoscopic surgery. Further study is warranted to investigate the full potential of U-Clips in minimally invasive pediatric surgery.

Quantitation of lung sealing in the survival swine model.

PURPOSE: Small intercostal spaces and limited pleural space significantly limits the use of 12-mm stapling devices in pediatric thoracoscopic surgery. The goal of this study was to compare sealing of lung tissue by the 5-mm Ligasure (Valley Lab, Boulder, CO) device to a standard 12-mm Endo-GIA stapler (US Surgical, Norwalk, CT). METHODS: Institutional Animal Care and Use Committee (IACUC) approval was obtained (#A3-02). Sixteen 10-kg female swine were divided between 2 survival surgical groups. Lung biopsy sections of the lingula were taken by 2 methods: group A, left anterolateral thoracotomy employing a 12-mm Endo-GIA stapler and group B, left thoracoscopy employing the Ligasure 5-mm instrument. After a 7-day survival period, lung burst pressures were measured by flow-controlled insufflation into the trachea. RESULTS: Burst pressure measurement reflects the first air leak. By Student's t test analysis there were no statistically significant differences between the burst pressures, biopsy weights, or operating times. Fifty percent (4 of 8) of the animals in group A (Endo-GIA), and 50% (4 of 8) of the animals in group B (Ligasure) developed the first air leak in the nonoperative lung. Two animals, one from each group, had evidence of intrapleural infections at the time of necropsy. These were asymptomatic and did not appear to affect burst pressure measurement. CONCLUSIONS: After 7 days of healing, lung biopsy sites created with both the Ligasure and the Endo-GIA stapler have burst strengths equal to or greater than that of normal lung tissue in the swine survival model.

Pediatric hand treadmill injuries.

The great popularity of physical fitness in modern society has brought many pieces of exercise equipment into our homes for convenience and privacy. This trend has come with an increasing rate of injuries to children who curiously touch moving parts, including treadmill belts. Experience with a recent series of treadmill contact burns to children's hands is described in this article. A retrospective chart review at a tertiary referral center from June 1998 until June 2001 found six children sustaining hand burns from treadmills. The patients' ages at presentation ranged from 15 to 45 months (average of 31 months, three boys and three girls). All injuries occurred in the home while a parent was using the treadmill. Burns involved the palmar aspect of the hand, mostly confined to the fingers, and the severity ranged from partialto full-thickness burns. All patients were initially managed with collagenase and bacitracin zinc/polymyxin B powder dressings to second- and third-degree burns, along with splinting and range-of-motion exercises. Two patients required skin grafting at 2 weeks and 2 months for full-thickness tissue loss and tight joint contracture, respectively. At an average follow-up of 12 months, all patients had full range of motion and no physical limitation. The rate of children injured by exercise equipment is expected to increase. Friction burns to the hands remain a concern, although early recognition and appropriate management are associated with excellent functional outcomes. Protective modification of exercise machines seems to be the best approach to eliminating these injuries.