Preliminary experience with robotic cholecystectomy illustrates feasibility in a canine cadaver model.

OBJECTIVE: To evaluate the feasibility and describe the relevant differences between robotic cholecystectomy (RC) and laparoscopic cholecystectomy in a canine model. SAMPLE: Canine cadavers (n = 4) weighing between 30 and 42 kg. METHODS: Dogs were positioned in dorsal recumbency. A surgical robot was used to perform the RC and was placed at the cranial aspect of the surgical table. One 12-mm and 3 8-mm robotic ports and 1 5-mm laparoscopic port were placed as needed to perform the RC. The specific steps of the procedure were described and timed. Perceived differences between psychomotor skills between robotics and laparoscopy were noted. RESULTS: RC was successful in all dogs, but minor intraoperative complications did occur during the manipulation of the gallbladder in 1 dog. The median length of time for ports to be appropriately docked was 19.5 minutes, and the median procedure time was 119.5 minutes. Psychomotor skills specific to robotics can be learned during this procedure. CLINICAL RELEVANCE: Robotic cholecystectomy is feasible. RC allowed for experience with the different psychomotor skills utilized with robotic instrumentation and may be an appropriate training procedure for veterinary surgeons wishing to gain basic experience with robotic instrumentation.

Anti-reflux surgery in children with congenital diaphragmatic hernia: A prospective cohort study on a controversial practice.

INTRODUCTION: Gastro-esophageal reflux disease (GERD) is the most frequent long-term morbidity of congenital diaphragmatic hernia (CDH) survivors. Performing a preventive fundoplication during CDH repair remains controversial. This study aimed to: (1) Analyze the variability in practices regarding preventive fundoplication; (2) Identify predictive factors for fundoplication. (3) Evaluate the impact of preventive fundoplication on gastro-intestinal outcomes in children with a CDH patch repair; METHODS: This prospective multi-institutional cohort study (French CDH Registry) included CDH neonates born in France between January 1st, 2010-December 31st, 2018. Patch CDH was defined as need for synthetic patch or muscle flap repair. Main outcome measures included need for curative fundoplication, tube feed supplementation, failure to thrive, and oral aversion. RESULTS: Of 762 CDH neonates included, 81 underwent fundoplication (10.6%), either preventive or curative. Median follow-up was 3.0 years (IQR: 1.0-5.0). (1) Preventive fundoplication is considered in only 31% of centers. The rates of both curative fundoplication (9% vs 3%, p = 0.01) and overall fundoplication (20% vs 3%, p < 0.0001) are higher in centers that perform preventive fundoplication compared to those that do not. (2) Predictive factors for preventive fundoplication were: prenatal diagnosis (p = 0.006), intra-thoracic liver (p = 0.005), fetal tracheal occlusion (p = 0.002), CDH-grade C-D (p < 0.0001), patch repair (p < 0.0001). After CDH repair, 8% (n = 51) required curative fundoplication (median age: 101 days), for which a patch repair was the only independent predictive factors identified upon multivariate analysis. (3) In neonates with patch CDH, preventive fundoplication did not decrease the need for curative fundoplication (15% vs 11%, p = 0.53), and was associated with higher rates of failure to thrive (discharge: 81% vs 51%, p = 0.03; 6-months: 81% vs 45%, p = 0.008), tube feeds (6-months: 50% vs 21%, p = 0.02; 2-years: 65% vs 26%, p = 0.004), and oral aversion (6-months: 67% vs 37%, p = 0.02; 1-year: 71% vs 40%, p = 0.03). CONCLUSIONS: Children undergoing a CDH patch repair are at high risk of requiring a curative fundoplication. However, preventive fundoplication during a patch repair does not decrease the need for curative fundoplication and is associated with worse gastro-intestinal outcomes in children. LEVEL OF EVIDENCE: II - Prospective Study.

Testicular rupture after blunt scrotal trauma in children: A case report and literature review.

Blunt testicular trauma with rupture of albuginea is one of the rarest emergencies in children. Medical history and Testicular Doppler Ultrasound lead to diagnosis. Appropriate management is necessary to preserve the testis. Follow-up to adulthood is recommended to assess the impact on fertility.

Robot-assisted continent urinary diversion according to the Mitrofanoff principle: results of a bicentric study.

PURPOSE: To assess the outcomes of continent urinary diversion according to the Mitrofanoff principle by robot-assisted laparoscopic surgery in terms of continence, catheterization and repeat surgery. METHODS: All adult patients who underwent procedures for continent urinary diversion via a robot-assisted laparoscopic route between October 2014 and November 2018 were enrolled retrospectively. Abdominal continence and clean intermittent catheterization ability were noted, as well as patient characteristics, details of the technique, intra- and perioperative parameters, and complications. RESULTS: Ten patients were included. Bladder-sphincter disorders were due to neurological causes in nine patients, and one patient had idiopathic bladder sphincter dyssynergia. A continent catheterizable channel was created using the appendix in six cases and the ileum in four cases. The median operative duration was 245 min (IQR 228-370). Two patients had a Clavien 3 complication requiring laparoscopy to separately drain a haematoma and a pelvic abscess. The median follow-up was 21 months (IQR 17-27). Abdominal continence without further intervention was obtained in 6/10 patients (60%). Two patients needed an open revision of the continent urinary diversion, one required injection of Deflux® and one an intradetrusorian injection of botulinum toxin type A (Botox®). Further surgery was needed for two patients to improve urethral continence. At the end of follow-up, all patients were continent and clean intermittent catheterization was possible. CONCLUSION: Continent urinary diversion performed according to the Mitrofanoff principle is possible via a robot-assisted laparoscopic route and yields good outcomes on abdominal continence in the short term in patients with clean intermittent catheterization ability.

Co-existing infantile hepatic hemangioma and mesenchymal hamartoma in a neonate.

Infantile hepatic hemangioma (IHH) and mesenchymal hamartoma (MH) form the first and second most common benign hepatic tumors in children. In this case report, we present a newborn child in whom a growing hepatic mass was discovered at the age of 7 days. She suffered also from anemia, respiratory and renal failure. No signs of heart disease or cutaneous lesions were detected. Alpha-fetoprotein was elevated for her age (3562.2 ng/ml). Imaging studies showed multifocal large cystic lesions associated with heterogeneous small solid lesions with arterial enhancement of the liver. Non-anatomical liver resection was performed initially and synchronous MH and IHH GLUT-1 positive were discovered in the pathological analysis. Segmental IV hepatic resection and later on selective cysts excision were done for persistent hepatic lesion despite medical treatment. After 14 months of beta-blockers treatment, clinical follow-up shows a healthy child with no residual cystic lesions.

One-Year Outcome for Congenital Diaphragmatic Hernia: Results From the French National Register.

OBJECTIVE: To evaluate the status of congenital diaphragmatic hernia (CDH) management in France and to assess predictors of adverse outcomes. STUDY DESIGN: We reviewed the first-year outcome of all cases of CDH reported to the French National Register in 2011. RESULTS: A total of 158 cases were included. Of these, 83% (131) were prenatally diagnosed, with a mortality rate of 39% (44 of 112) for live born infants with a known outcome at hospital discharge. Mortality increased to 47% (60 of 128) including those with termination of pregnancy and fetal loss. This contrasts with the 7% (2 of 27) mortality rate of the patients diagnosed postnatally (P = .002). Mortality worsened with 1 prenatal marker of CDH severity (OR 3.38 [1.30-8.83] P = .013) and worsened further with 2 markers (OR 20.64 [5.29-80.62] P < .001). Classic postnatal risk factors of mortality such as side of hernia (nonleft P = .001), prematurity (P < .001), low birth weight (P = .002), and size of the defect (P < .001) were confirmed. Of the 141 live births (114 prenatal and 27 postnatal diagnosis) with known outcomes, 93 (67%) survived to hospital discharge, 68 (60%) with a prenatal diagnosis and 25 (93%) with a postnatal diagnosis. The median time to hospital discharge was 34 days (IQR, 19.25-62). Of these survivors, 71 (76%) were followed up for 1 year. CONCLUSIONS: Despite advances in management of CDH, mortality was high and associated with prenatal risk factors. Postnatally, severe persistent pulmonary hypertension was difficult to predict and presented persistent challenges in management.

The normal radiological anteroposterior alignment of the lower limb in children.

INTRODUCTION: The development of reconstructive surgery of the lower limbs aimed at multilevel correction demands a precise knowledge of the physiological variations in general radiological parameters of the lower limbs in children of various age groups. It is crucial in systemic skeletal diseases, when deformities affect limbs and the surgeon does not have an intact limb as a reference. The aim of this retrospective study was to establish the normal radiological values of lower limb parameters used in the surgical correction of deformities in children of various age groups. MATERIAL AND METHODS: Teleradiographs of the lower limbs taken in children with unilateral congenital or posttraumatic deformity were retrospectively reviewed. Weight-bearing full-length anteroposterior radiographs of the entire lower extremities were taken in a standing position. The study involved 215 extremities of 208 children (93 girls and 115 boys); the ages ranged from 2 years 1 month to 15 years 11 months old. Key variables included the anatomic medial proximal femoral angle (aMPFA), anatomic lateral distal femoral angle (aLDFA), anatomic medial proximal tibial angle (aMPTA), anatomic lateral distal tibial angle (aLDTA), mechanical axis deviation (MAD), the angle formed by the femoral anatomical axis and the mechanical axis of the lower limb. RESULTS: The means and dynamics of variations, standard deviations (SD) and 95% confidence intervals of each parameter were calculated for each age and gender group. Simple regression analysis was performed to determine the relationship between the patient's age and the magnitude of aMPFA, aLDFA, aMPTA and aLDTA. Simple regression analysis showed a significant inverse correlation between patient age and the magnitude of aMPFA: the correlation coefficient was -0.77. A statistically significant inverse correlation between the MAD and the angle between the anatomic femoral axis and mechanical limb axis was found: the correlation coefficient was -0.53. CONCLUSION: In general, the received values were concordant to results of other studies. It concerned the MAD, aLDFA, aMPTA and angle between the mechanical limb axis and anatomic femoral axis. This is the first chronological evaluation of aMPFA and aLDTA from a relavively large series of patients. These normative data should be taken into consideration when evaluating lower limb alignment in children or applied in practice for planning and evaluation of the quality of surgical correction of complex deformities.