Clinical application and technical standardization of indocyanine green (ICG) fluorescence imaging in pediatric minimally invasive surgery.

PURPOSE: We reported our preliminary experience using ICG fluorescence in pediatric minimally invasive surgery (MIS) with the aim to standardize indications, dose, timing, and modality of administration of ICG according to different organs. METHODS: ICG technology was adopted in 46 MIS procedures performed in our unit over the last 18 months: 30 left varicocele repairs; 5 cholecystectomies in obese adolescents; 3 tumor excisions; 3 nephrectomies; 2 partial nephrectomies; 3 lymphoma excisions. ICG solution was injected intravenously in all cases except for varicocelectomy in which it was injected into the testis. The ICG injection was performed intra-operatively in all cases except for cholecystectomy in which it was injected 18 h prior to the procedure. RESULTS: All procedures were completed laparoscopically without conversions or intra-operative complications. No adverse or allergic reactions to ICG were reported. CONCLUSION: Our preliminary experience showed that ICG fluorescence is a safe, useful, and versatile technique to adopt in pediatric MIS to achieve a better identification of anatomy and an easier surgical dissection or resection in challenging cases. Currently, the main indications are varicocelectomy, difficult cholecystectomy, tumor excision, nephrectomy, and partial nephrectomy. The main limitation is the needing of a special equipment to use ICG technology.

Pediatric Endoscopic Pilonidal Sinus Treatment: An Effective Procedure for Children with Recurrent Pilonidal Sinus Disease After Failed Open Surgery.

Background: The traditional open excision of pilonidal sinus disease (PSD) is associated with a painful postoperative course and high recurrence rates. We recently published our technique of pediatric endoscopic pilonidal sinus treatment (PEPSiT). We aimed to report our long-term outcome including using PEPSiT for recurrent PSD after failed open repair. Methods: All patients with recurrent PSD after open excision who underwent PEPSiT in our unit over the past 2 years were included in the study. During surgery a fistuloscope was introduced through the fistula's orifice. All identifiable hairs were removed using endoscopic forceps. Thereafter, the cavity was debrided with endobrush and ablated with monopolar electrode. External openings were not closed. Results: In the past 2 years, 40 patients with PSD underwent PEPSiT. Ten of 40 patients (6 boys and 4 girls with an average age of 16.8 years [range = 14-18]) had recurrent PSD after open surgery and were included in the study. The average operative time was 27.7 minutes (range = 24-43). No perioperative complications occurred. The average analgesic requirement was 20 hours (range = 16-26) and the average hospitalization was 22.4 hours (range = 18-36). The average time to return to full daily activities was 2.3 days (range = 1-5) and all patients were highly satisfied of postoperative course. At 1 month postoperatively, the external openings were completely healed. No recurrence was recorded at a mean follow-up of 18 months (range = 6-24). Conclusions: Our results demonstrated that PEPSiT is an excellent technique for surgical treatment of PSD in children and teenagers. In fact, it is technically easy and fast to perform, with a short and painless hospital stay and it allows to the operated patients an early return to full daily activities without any physical limitations compared with open repair. In addition, it is also effective for treatment of recurrent PSD after failed open repair.

Indocyanine Green Fluorescence Lymphography: A New Technique to Perform Lymphatic Sparing Laparoscopic Palomo Varicocelectomy in Children.

BACKGROUND: Laparoscopic Palomo varicocelectomy is one the most common approaches adopted to treat pediatric varicocele, but postoperative hydrocele still remains a potential problem with this procedure. This study aimed to evaluate the outcome of a new technique of lymphography using indocyanine green (ICG)-enhanced fluorescence to perform lymphatic sparing laparoscopic Palomo varicocelectomy. PATIENTS AND METHODS: The records of 25 patients who underwent laparoscopic left varicocelectomy in our unit from March 2017 to March 2018 were retrospectively evaluated. The average patients' age was 13.7 years (range 12-16). All patients had a high degree varicocele associated with left testicular hypotrophy and symptoms. All procedures were performed in laparoscopy using three trocars. After trocars' positioning, 2 mL of ICG solution was directly injected into the left testicle. Using ICG fluorescence, the lymphatic vessels were clearly identified and spared, and then the entire spermatic bundle was clipped and divided according to Palomo's principle. RESULTS: The average operative time was 18 minutes (range 10-25). No conversions to open surgery and no allergy or other adverse reactions induced by ICG were reported. At a maximum follow-up of 18 months, no recurrence of varicocele or postoperative hydrocele was recorded. CONCLUSIONS: Our preliminary experience showed that ICG fluorescence lymphography is a safe and effective option to perform lymphatic sparing laparoscopic Palomo varicocelectomy in children and adolescents with high degree varicocele. The intratesticular injection of ICG and use of fluorescence vision allowed identification of lymphatic vessels in 100% of cases. No allergy to ICG or postoperative hydrocele was reported in our experience.

Pediatric Endoscopic Pilonidal Sinus Treatment, a Revolutionary Technique to Adopt in Children with Pilonidal Sinus Fistulas: Our Preliminary Experience.

AIM: This study aimed to report our preliminary experience with pediatric endoscopic pilonidal sinus treatment (PEPSiT). PATIENTS AND METHODS: We retrospectively reviewed the reports of 15 patients, 6 girls and 9 boys, with an average age of 16 years (range 13-18) with noninfected pilonidal sinus disease who underwent PEPSiT in our institution over an 18-month period. Four cases were redo-procedures, for recurrence of disease after open excision repair. Surgical outcomes of sinus healing, recurrence of disease, postoperative pain, hospital stay, analgesic requirements, and patient satisfaction levels were evaluated and a comparison analysis with classic open repair was performed. RESULTS: All procedures were performed under subarachnoid spinal anesthesia. We always adopted a fistuloscope, an endoscopic forceps, and a monopolar electrode to remove the hairs and to heal the fistula. The average length of surgery was 28.5 minutes (range 26-41). No intraoperative or postoperative complications were reported. The average pain score evaluated using Visual Analogue Scale (VAS) pain scale during the first 48 postoperative hours was 3.2 (range 2-5). The average analgesic requirement was 22 hours (range 16-28). The average hospital stay length was 28 hours (range 22-48). They changed dressing daily, by applying a topical solution of eosin 2% and a silver sulfadiazine spray. At 1 month postoperatively, the external openings were closed in all patients and no recurrence was recorded at a mean follow-up of 6 month. PEPSiT was associated with a significantly shorter, painless, and better outcome compared to open technique. CONCLUSION: On the basis of our preliminary experience, we believe that PEPSiT is a promising technique for surgical treatment of pilonidal sinus in children. It is technically easy and quick to perform, with a short and painless hospital stay, without recurrences in our series. It allows operated patients an early return to full daily activities without restrictions that happen for the classic treatment.

Two decades of experience with laparoscopic varicocele repair in children: Standardizing the technique.

BACKGROUND: Controversy still exists about the indications and the gold standard approach for varicocele treatment in pediatric population. OBJECTIVE: The authors report their 23 years of experience in laparoscopic varicocele repair in the pediatric population. STUDY DESIGN: We retrospectively evaluated the data of 345 consecutive patients who underwent laparoscopic left varicocelectomy from January 1993 to December 2015. Average patient age was 12.5 years (range 8-17). Seven out of 345 patients (2%) had a recurrent varicocele, and five out of 345 patients (1.4%) had a varicocele on a single testis. In 335/345 patients (97.1%) we performed a Palomo procedure, and in 10/345 patients (2.9%) an artery-sparing Palomo procedure. After 2010, in 105/345 patients (30.4%) we performed a lymphatic sparing procedure using isosulfan blue injection preoperatively. RESULTS: All procedures were completed in laparoscopy (Figure), without conversions or intraoperative complications. The average operative time was 17 min (range 14-45) for the Palomo procedure and 26 min (range 18-50) for artery-sparing Palomo. In 45/345 patients (13%) we performed additional procedures. We recorded 4/345 (1.3%) recurrences/persistences in patients undergoing Palomo, while we recorded 1/10 (10%) recurrence/persistence after artery-sparing Palomo. On 230 Palomo procedures performed in the pre-isosulfan blue era, we recorded 25 cases of hydrocele (10.8%), 13 of these were treated with transcrotal puncture and 12 required surgical operation. The last 105 patients undergoing isosulfan blue injection had no postoperative hydrocele. We also reported 10 other complications (I grade Clavien-Dindo) such as umbilical granuloma or instrumental problems. DISCUSSION: Analyzing the international literature of the last 25 years, most papers focused on the minimally invasive treatment of pediatric varicocele. There are several reasons to perform laparoscopic repair of pediatric varicocele. First of all, it is technically easy to perform, the average operative time is very short, and it has excellent outcome in regard to varicocele persistence/recurrence. In addition it has a very low complication rate, and in particular adopting the intradartoic/intratesticular isosulfan blue injection before surgery we recorded no postoperative hydrocele. CONCLUSION: On the basis of our 23 years of experience with varicocele repair, we clearly believe that laparoscopic Palomo lymphatic sparing varicocelectomy should be considered the standard of care for the treatment of pediatric patients with varicocele. Laparoscopic varicocelectomy is technically easy and quick to perform, painless, and scarless, with a recurrence rate of about 1%. The use of a preoperative injection of isosulfan blue completely eliminates postoperative hydrocele formation.