Laparoscopic Extraperitoneal Hernia Repair Versus Open Repair in Boys with Inguinal Hernia: A Meta-Analysis.

OBJECTIVE: Pediatric inguinal hernia is a common surgical problem in boys. Open hernia repair surgery (OH) has been traditionally used to treat this condition, but it leads to complications, such as testicular complications. Laparoscopic hernia repair by using the extraperitoneal method (LHE) is performed through the percutaneous insertion of sutures and extracorporeal closure of patent vaginalis processus; thus, injury to spermatic cord structures is avoided. However, a meta-analysis comparing LHE and OH is lacking. METHODS: PubMed, EMBASE, and Cochrane Library databases were searched for relevant studies. A meta-analysis of the retrieved studies was performed, and a random-effects model was used to calculate the pooled effect size. The primary outcome was testicular complications, including ascending testis, hydrocele, and testicular atrophy. The secondary outcomes were surgical metachronous contralateral inguinal hernia (MCIH), ipsilateral hernia recurrence, and operation time. RESULTS: In total, 6 randomized controlled trials (RCTs) and 20 non-RCTs involving 17,555 boys were included. The incidence of ascending testis (risk ratio [RR]: 0.38, 95% confidence interval [CI]: 0.18-0.78; p = 0.008) and MCIH (RR: 0.17, 95% CI: 0.07-0.43; p = 0.0002) was significantly lower in LHE than in OH. The incidence of hydrocele, testicular atrophy, and ipsilateral hernia recurrence did not differ between LHE and OH. CONCLUSION: Compared with OH, LHE led to fewer or equivalent testicular complications without increasing ipsilateral hernia recurrence. Moreover, MCIH incidence was lower in LHE than in OH. Hence, LHE could be a feasible choice with less invasiveness for inguinal hernia repair in boys. LEVEL OF EVIDENCE: Treatment study, LEVEL III.

Inter-rater and intra-rater reliability of the current assessment model and tools for laparoscopic suturing.

BACKGROUND: Moorthy checklist (MC) and laparoscopic skill competency assessment tool (LS-CAT) are tools commonly used to evaluate the quality of laparoscopic suturing. The current assessment model is single measurement by multiple raters. Our aim is to examine the reliability of the current assessment model and tools. METHODS: With IRB approval, participants of three different backgrounds, namely medical students, trainees, and surgeons, were enrolled. The participants each accomplished a standardized laparoscopic suturing task. The performances were video-recorded and reviewed with LS-CAT and MC independently by three blinded raters. Intraclass correlation coefficients (ICC) were calculated for inter-rater and intra-rater reliability. RESULTS: 26 participants were enrolled, comprising 10 students, 10 trainees and 6 surgeons. In regard of inter-rater reliability, ICC values (95% CI) were 0.909 (0.768-0.961) and 0.868 (0.608-0.948) in LS-CAP and MC, respectively. For students, ICC values were 0.908 (0.682-0.976) and 0.815 (0.408-0.951) in LS-CAT and MC, respectively. For trainees, ICC values were 0.812 (0.426-0.947) and 0.717 (0.102-0.925), respectively. For surgeons, ICC values were 0.720 (0.064-0.955) and 0.868 (0.608-0.948), respectively. In regard of intra-rater reliability, ICC values of the mean scores from the three raters were 0.956 (0.905-0.980) and 0.925 (0.842-0.966) in LS-CAP and MC, respectively. CONCLUSION: LS-CAT and MC are both qualified assessment tools for laparoscopic suturing. LS-CAT is more reliable particularly for medical students and trainees. The current assessment model of single measurement by multiple raters provides excellent reliability.

Appendicitis as a Leading Manifestation of Kawasaki Disease in Older Children.

Kawasaki disease (KD) is a systematic inflammatory disease with multiple organ involvement. Timely diagnosis and prompt management are essential for successful treatment. KD, with an atypical presentation, remains a diagnostic challenge for physicians. We report a five-year-old boy who presented with appendicitis. An appendectomy was performed; however, his fever persisted. The boy was diagnosed with KD and intravenous immunoglobulin was administered. His symptoms resolved, and he had an uneventful recovery. Furthermore, we performed a literature review with 13 cases identified in the literature. Most cases were male, and the average age was older than typical for KD. In conclusion, KD may present with abdominal complaints and appendicitis may be a rare initial presentation of KD. Multidisciplinary cooperation and high awareness are warranted for timely diagnosis, especially in older children experiencing persistent fever after an appendectomy.

Laparoscopic Hernia Repair with the Extraperitoneal Approach versus Open Hernia Repair in Pediatric Inguinal Hernia: A Systematic Review and Meta-Analysis.

OBJECTIVE: This systematic review and meta-analysis investigated the feasibility and effectiveness of laparoscopic hernia repair with the extraperitoneal approach in pediatric inguinal hernias. SUMMARY BACKGROUND DATA: Inguinal hernia repair is the most common operation in pediatric surgical practice. Although open hernia repair (OHR) is a well-established procedure with good outcomes, studies have reported acceptable or even better outcomes of laparoscopic hernia repair with the extraperitoneal approach (LHRE). However, a meta-analysis comparing LHRE with OHR is lacking. METHODS: PubMed, EMBASE, and Cochrane Library databases were searched for randomized controlled trials (RCTs) and comparative studies (prospective or retrospective). Outcomes were metachronous contralateral inguinal hernia (MCIH), hernia recurrence, surgical site infection, operation time, and hospitalization length. A meta-analysis was performed, and risk ratios (RR), weighted mean difference (WMD), and 95% confidence intervals (CI) were calculated using random-effects models. RESULTS: Five RCTs and 21 comparative studies involving 24,479 patients were included. Lower MCIH incidence (RR: 0.11, 95% CI: 0.07 to 0.17; p < 0.00001) and a trend of shorter operation time (WMD: -11.90 min, 95% CI: -16.63 to -7.44; p < 0.00001) were found in the LHRE group. No significant differences in ipsilateral recurrence hernias, surgical site infection, and length of hospitalization were found between the groups. CONCLUSIONS: LHRE presented lower MCIH incidence and shorter operation times, with no increase in hernia recurrence, surgical site infection, or length of hospitalization. As more surgeons are increasingly becoming familiar with LHRE, LHRE would be a feasible and effective choice for pediatric inguinal hernia repair.

Transumbilical laparoscopy-assisted Malone procedure for fecal incontinence in children.

BACKGROUND: Transumbilical laparoscopy-assisted Malone procedure (TULAM) is a single-incision laparoscopic procedure in which the appendicostomy is made at umbilicus. The aim of this study is to evaluate the outcomes of TULAM. METHODS: With IRB approval, the medical records of the patients who underwent TULAM were retrospectively reviewed between July 2013 and December 2018. The data collected included ages, gender, underlying diseases, operative techniques, complications, stoma continence, parental satisfaction and follow-up duration. RESULTS: Fifteen patients underwent TULAM at the median age of 5.0 years (2.9-10.7 years). There were 4 girls and 11 boys. Thirteen patients had anorectal malformations or cloaca; the other two patients had spina bifida. All patients presented with fecal incontinence; 9 of them had concomitant constipation. TULAM was successfully accomplished in 14 patients; one patient required conversion to the three-port procedure. The median follow-up period was 1.7 years (0.5-3.2 years). One patient required tube replacement under endoscopy guidance in the operation room. One patient required surgical revision because the appendix was disrupted after an episode of enterocolitis. All patients were socially continent with antegrade enemas. 12 patients were stoma continent, and 3 patients had minor leaking less than once a month. The stoma cosmesis was satisfactory. All parents expressed satisfaction with TULAM. CONCLUSION: TULAM is effective in the management of fecal incontinence and constipation, and provides a continent stoma with excellent cosmesis.

Single-site laparoscopic burnia for inguinal hernias in girls: comparison with open repair.

BACKGROUND: Burnia is a suturless repair for inguinal hernias in girls. It is performed under laparoscopy by grabbing the sac, inverting it into the peritoneal cavity, and cauterizing. The aim of this study is to report our experience with single-site laparoscopic burnia (BURNIA) and compare them with open repair (OPEN). METHODS: With IRB approval, pediatric female patients younger than 18 years of age who underwent inguinal hernia repair between January 2015 and December 2017 were enrolled. Medical records were retrospectively reviewed. The patients were divided into two groups, BURNIA and OPEN. RESULTS: 198 patients were included. In BURNIA, 49 patients underwent bilateral repairs, and 50 patients underwent 51 unilateral repairs (one patient had metachronous contralateral hernia). In OPEN, 27 patients underwent bilateral repairs, and 72 patients underwent 77 unilateral repairs (five patients had metachronous contralateral hernias). The mean age of BURNIA was similar to OPEN for bilateral repairs (49.1 ± 36.6 vs. 43.7 ± 26.4 months, p = 0.46), but significantly older for unilateral repairs (54.6 ± 29.8 vs. 29.0 ± 31.4, p < 0.01). The mean operation time of BUNIA was similar to OPEN for bilateral repairs (24.2 ± 7.6 vs. 22.4 ± 8.6 min, p = 0.35), but significantly longer for unilateral repairs (19.2 ± 7.0 vs, 13.6 ± 8.8 min, p < 0.01). The mean follow-up duration of BURNIA was significantly shorter than OPEN for bilateral and unilateral repairs, respectively (32.5 ± 8.8 vs. 45.4 ± 4.8 months, p < 0.01) (30.2 ± 8.8 vs. 39.1 ± 9.6 months, p < 0.01). No conversion was required in BURNIA. There were no complications and no recurrence in all patients. CONCLUSIONS: Single-site laparoscopic burnia is technically feasible, and as safe and effective as open inguinal hernia repair.

Should single-incision laparoscopic appendectomy be the new standard for pediatric appendicitis?

BACKGROUND: To compare single-incision laparoscopic appendectomy (SILA) with conventional (CLA) and transumbilical laparoscopic appendectomy (TULA). METHODS: This is a retrospective cohort study. Patients were divided into three groups, SILA, CLA, and TULA. SILA was defined as performing appendectomy extracorporeally or intracorporeally by using a glove-port incorporated with 3 trocars. TULA was defined as exteriorizing appendix and performing extracorporeal appendectomy by using an operative telescope. Statistical analysis was conducted in patients with simple (SA) and complicated appendicitis (CA), respectively. RESULTS: A total of 315 patients were enrolled, including 161 in SILA, 105 in CLA, and 49 in TULA. Demographic data were similar. In patients with simple appendicitis, operation time of SILA was shorter than CLA but longer than TULA (62.8 ± 22.5 vs. 82.2 ± 24.3 and 51.6 ± 22.3 min, p < 0.01). SILA had shorter hospital stay than CLA, and similar to TULA (56.1 ± 20.4 vs. 71.5 ± 37.8 and 56.9 ± 19.0 h, p < 0.01). In patients with complicated appendicitis, SILA had shorter operation time than CLA, but a similar time to TULA (80.9 ± 22.4 vs. 105.7 ± 28.8 and 82.5 ± 31.2 min, p < 0.01). Conversion to open surgery was not required in all groups. The rates of complications, such as wound infection, intraabdominal abscess and adhesion ileus, were similar. SILA required fewer additional ports than TULA in both simple and complicated appendicitis (1.1% vs. 13.5%, and 9.6% vs. 41.7%, p < 0.01). CONCLUSION: SILA has the advantages of shorter operation time and hospital stay over CLA as well as a lower rate of additional ports than TULA.

How much do we know about constipation after surgery for anorectal malformation?

BACKGROUND: To evaluate the occurrence of constipation after anorectal malformations (ARM) repair and the results of laxative treatment. METHODS: Between August 2012 and July 2017, the clinical data of patients with ARMs was prospectively collected. The patients were divided into two groups, good types and poor types. Good types included rectoperineal, rectovestibular, rectourethral bulbar, and no fistula. Risk factors were defined as spinal cord anomalies, sacral ratio <0.4, or cognitive impairment. Success was defined as that laxative could be tapered. RESULTS: Eighty-four patients were enrolled with mean age of 6.3 ± 7.8 (0.6-59.9) years. The mean age of onset of constipation was 12.8 ± 8.3 months and the mean interval was 5.9 ± 5.1 months after reconstructions. The interval was not significantly different between patients with good types and poor types. In 23 patients with severe constipation being treated for >6 months, 14 of 18 (77.8%) patients with good types were classified as success, whereas only 1 of 5 (20%) patients with poor types was (p = 0.02). In patients with good types, 9 of 9 (100%) patients with no risk factors were successful; however, only 5 out of 9 (55.6%) patients with risk factors were successful (p = 0.02). CONCLUSION: Constipation occurs shortly after operations. Patients with good types and no risk factors are susceptible to weaning laxatives.

Single-incision laparoscopic surgery for idiopathic intussusception in children: Comparison with conventional laparoscopy.

BACKGROUND: The aim of this study is to evaluate the feasibility of single-incision laparoscopic surgery (SILS) for idiopathic intussusception in children and compare the outcomes with conventional laparoscopy (CLS). METHODS: Between January 2011 and December 2012, patients who underwent CLS for idiopathic intussusception were assigned into the group of CLS. Between January 2013 and March 2017, patients who underwent SILS were assigned to the group of SILS. For patients who failed to reduce by SILS, bimanual transabdominal approach was conducted. RESULTS: A total of 23 patients were enrolled, including 7 and 16 patients in SILS and CLS, respectively. The mean age was similar in both group (22.4 ±â€¯18.7 vs. 24.6 ±â€¯18.6 months, p = 0.80). There is no difference in gender distribution. The main indication was radiological reduction failure in both groups (85.7% vs. 75%, p = 0.58). Ileocolic intussusception was found in 6 (85.7%) and 15 (93.8%) patients of SILS and CLS, respectively (p = 0.25). The level of intussusception was at ascending colon in 3 (42.9%) and 12 (75.0%) patients, respectively (p = 0.11). The operation time was similar in both groups (64.9 ±â€¯53.7 and 70.9 ±â€¯26.1 min, p = 0.79). There were 2 (28.6%) and 1 (6.2%) conversions, respectively (p = 0.15). For the two patients in SILS, the intussusception was successfully reduced by bimanual transabdominal approach. There was no significant difference in time to feeding (1.9 ±â€¯1.1 vs. 1.4 ±â€¯0.7 days, p = 0.21). The mean length of postoperative hospital stay was 3.9 ±â€¯1.6 and 3.1 ±â€¯1.1 days, respectively (p = 0.17). CONCLUSIONS: SILS for pediatric intussusception is technically feasible and has comparable results to CLS. Transabdominal bimanual reduction is applicable in cases of failed laparoscopic reduction. LEVEL OF EVIDENCE: III.

Extracorporeal and intracorporeal approaches of single-incision laparoscopic appendectomy in children: is one superior to another?

BACKGROUND: Single-incision laparoscopic surgery has been widely popularized for pediatric appendicitis. Various techniques have been proposed with two main approaches: extracorporeal and intracorporeal. The purpose of this study is to compare the result of different approaches in single-incision laparoscopic appendectomy (SILA) in children. MATERIAL AND METHODS: With IRB approval, patients less than 18years of age who underwent SILA were enrolled from July 2012 to December 2015. The patients were divided into three groups based on surgical approach: extracorporeal (Extra), mixed (Mix), and intracorporeal (Intra) approaches. Parameters were retrospectively reviewed, including age, gender, white blood cell (WBC), operation time, operative findings, time to diet, length of hospital stay (LOS), and complications. Statistical analysis was performed separately for simple and complicated appendicitis. RESULTS: There were 32, 32, and 24 patients with simple appendicitis in Extra, Mix, and Intra respectively. There were 27, 15, and 31 patients with complicated appendicitis in the three groups, respectively. No significant difference was noted in the mean age, gender distribution, or WBCs between the different groups. A higher percentage of patients with complicated appendicitis received intracorporeal approach than those with simple appendicitis (42.5% vs. 27.3%, p=0.044). In simple appendicitis, the LOS was significantly longer in Extra as compared to Mix (p=0.043). Otherwise, the mean LOS, time to diet, and complications were not significantly different. The mean operation time was similar between groups of simple appendicitis (56.5±19.5, 63.6±23.5, and 70.1±23.1 min, p=0.08), whereas it was significantly shorter in Extra of complicated appendicitis (67.6±16.4, 86.6±19.0, and 89.9±23.4 min, p<0.001). Multivariate analysis showed that intracorporeal approach is an independent factor for prolonged operation time in both simple and complicated appendicitis. CONCLUSIONS: Different approaches of SILA in children have similar outcomes for both simple and complicated appendicitis. Extracorporeal is the most time efficient; however, intracorporeal can be helpful to deal with complex situations. LEVEL OF EVIDENCE: III.

Infected congenital splenic cyst associated with duodenal duplication cyst and malrotation--a case report.

Congenital splenic cyst is a rare entity. A potential complication of this anomaly is infection. We report on an 18-month-old boy who had Salmonella enterocolitis and 2 weeks later was found to have an infected splenic cyst. At surgery, a duodenal duplication cyst and malrotation of the gut were incidentally found. Infected splenic cysts usually occur in older children or adults. To the best of our knowledge, congenital splenic cyst has not previously been reported in association with other malformations.