[Minimally invasive surgery in childhood]. / Minimalinvasive Chirurgie im Kindesalter.

Similar to surgery in adults, minimally invasive techniques have also become established in pediatric surgery for a wide variety of indications and partially replaced the corresponding conventional open surgical procedures. This applies not only to laparoscopy for abdominal surgical interventions but also to thoracoscopic procedures. The therapy spectrum in pediatric surgery includes all congenital and acquired diseases of the growing organism, from neonates to adolescents and for this reason the indications that are suitable for minimally invasive surgical procedures are corresponding versatile. According to the literature almost every operation in pediatric surgery was performed via a minimally invasive access route. Of course, not every generally feasible minimally invasive technique can be considered as being suitable to replace proven and established open conventional procedures in pediatric surgery.

[Percutaneous laparoscopic hernia repair in children]. / Die perkutane laparoskopische Leistenbruchkorrektur beim Kind.

Laparoscopic repair of inguinal hernia in children is not established in the clinical routine so far. Especially the higher rate of recurrences was the main reason to choose open conventional herniotomy. With the development of microinvasive percutaneous extraperitoneal closure, the recurrence rate decreased significantly and is now comparable to that after open hernia repair. Different clinical studies as well as our own experience have confirmed these outcomes.

[Minimally invasive paediatric surgery in other than paediatric surgical departments]. / Minimalinvasive Kinderchirurgie ausserhalb kinderchirurgischer Kliniken.

Minimally invasive techniques are well established in numerous paediatric surgical departments. They are safely applied to children of all age groups. Numerous types of procedures have been established specifically for children and, therefore, the necessary expertise cannot be derived from general surgical experience. Advantages in postoperative symptoms, convalescence and cosmesis have been confirmed. However, data or recommendations concerning the use outside of centres of paediatric surgery are lacking. In the opinion of the authors, minimally invasive paediatric surgery should only be considered for departments with a volume of paediatric specialty operations similar to that of paediatric surgical centres. In addition, an adequate number of operations, specific expertise of the surgeons in minimally invasive paediatric surgery, and specific expertise of anaesthesiologists is mandatory. Today, these prerequisites can only be assumed for non-paediatric specialty operations, such as laparoscopic appendectomy. In conclusion, before recommendations can be made for minimally invasive techniques in specialty paediatric operations outside of paediatric surgical centres, the feasibility and safety under these conditions has to be investigated.

Congenital atresia of the portal vein and extrahepatic portocaval shunt associated with benign neonatal hemangiomatosis, congenital adrenal hyperplasia, and atrial septal defect.

A rare case of congenital atresia of the portal vein and ductus venosus, extrahepatic portocaval shunt, benign neonatal hemangiomatosis, congenital adrenal hyperplasia, and an atrial septal defect is reported. Twenty-two cases of congenital extrahepatic end-to-side shunts have been described before. Although additional anomalies are common in this type of shunt, hemangiomatosis has been described only once. Adrenal hyperplasia has never been reported in this anomaly.

Laparoscopically assisted performance of gastrostomy--a simple, safe and minimal invasive technique.

We developed a new and simple technique for a gastrostomy, which combines the benefits of the laparoscopic and open approach: under visual control, the correct site at the gastric wall is defined laparoscopically and, via a second trocar, the stomach is pulled out onto the abdominal wall to insert a Kasper catheter and place the sutures. Evaluated in a rat model, this procedure demonstrates safety and surgical feasibility on the grounds of a minimal invasive access. The case report of a 1-year-old boy may also prove the clinical benefit.

Fetal adrenal transplants respond to ACTH and prevent addisonian crisis in adrenalectomized rats.

The present study investigates whether fetal adrenal transplants into the omentum of adrenalectomized rats will be integrated into the recipient's endocrine system to provide competent adrenocortical function. The results demonstrate that fetal adrenals graft with a rich vascular supply, mature histologically, and produce increasing levels of corticosterone. When bilateral adrenalectomy is performed in the recipient, survival is prolonged and addisonian crisis can be prevented. Moreover, adrenocorticotrophic hormone levels decrease with increasing levels of corticosterone, indicating that the fetal grafts are integrated into the physiological pituitary-adrenocortical feedback system.

Atypical hemihepatectomy during primary CDH-repair in a neonate on ECMO.

We report the case of a newborn with a large left-sided congenital diaphragmatic hernia (CDH) who required extra corporeal membrane oxygenation (ECMO) for severe respiratory insufficiency. CDH repair had to be performed on bypass circulation. Intraoperatively, an atypical hemihepatectomy of the herniated lobe was conducted, because reposition of the liver led to a kinking of the vena cava and to a torsion of the right lobe, resulting in ischemia and compromised venous flow. The extraordinary anatomical indication and the potential danger of uncontrollable bleeding are discussed.

Thoracoscopic surgery of the oesophagus in rats: a training concept for the treatment of tracheo-oesophageal malformations in preterm infants

In extremely preterm babies with type Vogt III b oesophageal atresia, the primary operative management can be restricted to a gastrostomy and ligation of the fistula. Some of these patients, however, may not even tolerate a thoracotomy or placement on the operating table. We developed a minimally invasive procedure to prepare and ligate the oesophagus thoracoscopically and perform laparoscopic gastrostomy in a rat model. In 15 operations we observed only one complication. This study implies that after adequate practice, thoracoscopic dissection of the oesophagus with ligation of a tracheo-oesophageal fistula could be performed even in every small infants.

Thoracoscopic surgery of the oesophagus in rats: a training concept for the treatment of tracheo-oesophageal malformations in preterm infants.

In extremely preterm babies with type Vogt III b oesophageal atresia, the primary operative management can be restricted to a gastrostomy and ligation of the fistula. Some of these patients, however, may not even tolerate a thoracotomy or placement on the operating table. We developed a minimally invasive procedure to prepare and ligate the oesophagus thoracoscopically and perform laparoscopic gastrostomy in a rat model. In 15 operations we observed only one complication. This study implies that after adequate practice, thoracoscopic dissection of the oesophagus with ligation of a tracheo-oesophageal fistula could be performed even in every small infants.

Fetal adrenal transplantation: success of a laparoscopic technique in rats.

BACKGROUND/PURPOSE: The present study investigates a new laparoscopic technique for fetal adrenal transplantation in rats. RESULTS: The procedure was successful in 9 of 10 cases (one hole in the omentum) with no postoperative complications. On examination 4 weeks postoperatively, all but one graft showed macroscopic integrity, vascular supply, and histological maturation to normal zonal differentiation. When bilateral adrenalectomy was performed in the recipient to assess endocrine competence of the fetal adrenal grafts, survival was prolonged and Addison crisis was prevented in the animals that underwent transplantation. Levels of aldosterone dropped within the first week after adrenalectomy, but recovered steadily. Analysis of corticosterone demonstrated that levels fell to 25% of sham operated rats in the first week, but then steadily climbed to 70%. CONCLUSIONS: To the authors' knowledge this report presents the first study for laparoscopic transplantation of fetal tissues. Laparoscopic transplantation of fetal adrenal glands seemed feasible and successful in rats. The fetal adrenal transplants matured and served for a prolonged survival.

[Surgery of atresia of the gastrointestinal tract]. / Chirurgie der Atresien des Gastrointestinaltraktes.

The most common sites of atresia in the gastrointestinal tract are the oesophagus, the duodenum and the anorectum. Surgical intervention is always necessary. Because of the rapid progress in surgical techniques and peri- and postoperative intensive care management, lethality has been minimized, even when treating very small premature infants. In the meantime, the surgical intervention itself is no longer the great risk it was; associated congenital malformations such as complex cardial defects are now much greater risks.

Patient controlled analgesia (PCA) in paediatric surgery: a prospective study following laparoscopic and open appendicectomy.

Patient controlled analgesia (PCA) has not yet gained universal acceptance for the management of postoperative pain in paediatric surgery. In a prospective study we evaluated feasibility and complications of PCA following 90 cases of laparoscopic or open appendicectomy. PCA proved to be a safe and feasible method with few complications (2% of medical complications, no abort of application, 17 technical checks in a total running time of 4125 h). Acceptance by patients was high and children of all age groups worked the system properly. Assessment of application protocols showed, that the consumption of analgesics was significantly reduced following laparoscopic appendicectomy (P < 0.05). PCA is a safe and feasible method for the management of postoperative pain in children and PCA recording provides an excellent insight into the consumptional behaviour of patients, enabling staff to evaluate postoperative pain for various procedures.

Ventriculoscopy-aided implantation of ventricular shunts in patients with hydrocephalus.

Ventriculoscopy represents a new concept in the surgical treatment of children with hydrocephalus. Optimal catheter position can now be achieved with the help of a new method consisting of endoscopically controlled implantation of ventricular shunts. In addition, interventional ventriculoscopy enables or improves new operative procedures such as the fenestration of intracranial cysts or the removal of dislodged parts of catheter tips from the corresponding ventricle under direct optical control. Ventriculoscopy has been performed on 17 pediatric patients, with no complications to date.

Endoscopic appendectomy in childhood--technical aspects.

Since March 1992 we initially performed 87 laparoscopic appendectomies applying two cat-gut loops for ligation of the stump. Since we postoperatively found abscess formation twice, we modified the technique in the following aspects: After the introduction of the scope at the umbilicus, 2 working trocars with a diameter of a 5 mm are placed in the left lower quadrant of the abdomen, so that the surgeon can skeletonize the appendix bimanually until it can be dissected with an Endo-GIA. This procedure we carried out in 41 cases and did not see any postoperative complications yet. Thus we consider it an appropriate alternative to conventional surgery.

Transplantation of fetal adrenal glands in syngeneic rat strains.

In a syngeneic rat model we investigated the feasibility of fetal adrenal gland transplantation into adult recipient animals. We determined the optimal site of graft implantation by morphological criteria. Transplantation into the omentum majus proved superior to transplantation underneath the fascia of the rectus abdominis muscle possibly due to superior access to vascular supply. We assessed transplant function by sequential determinations of serum corticosterone, aldosterone, sodium and body weight. We compared rats which received syngeneic fetal adrenal transplants and underwent excision of their own adrenal glands four weeks thereafter to control animals without adrenalectomy or transplantation and to adrenalectomized animals without prior transplantation. The total study period was 16 weeks. Whereas all adrenalectomized rats without prior transplantation died within 2 weeks, all the animals which had received fetal adrenal grafts survived. Their serum sodium remained within normal limits. Weight gain and serum corticosterone levels were decreased when compared to control animals. Aldosterone levels dropped intermittently but had normalized by 16 weeks. We conclude that fetal adrenal grafts may be able to substitute for the animals' own adrenal glands in the syngeneic model.

Fetal intestinal transplantation: a new therapeutic approach in short-bowel syndrome.

Intraperitoneally transplanted fetal rat intestine can be anastomosed to the intestine of the host after 4 weeks of maturation. In syngeneic transplant combinations morphological findings as well as functional parameters suggest that the intestinal transplant might provide a substitute for normal intestinal tissue. Four weeks after fetal intestinal transplantation in adult Lewis rats we resected the total small bowel of the host and interposed the matured transplant. Resection of total small bowel without transplant interposition led to a decline of body weight in control animals but was prevented in the transplanted group. After total small bowel resection and cecectomy (a lethal resection in the control group) we found a 40% (4/10) survival in the group in which the transplant had been anastomosed to the remaining bowel.

Intraperitoneal fetal small bowel transplantation as therapy for the short bowel syndrome: an animal experimental study.

After demonstration of the morphologic integrity of fetal rat intestinal transplant and in vitro evidence of both digestive and resorptive function in the transplanted small bowel, in another experimental approach we tried to assess intestinal function in vivo. In this experiment, fetal intestinal grafts were placed in host animals and allowed to mature for 4 weeks. Then we resected the whole small bowel of the host from the ligament of Treitz to the ileo-cecal valve, afterwards interposing the matured fetal intestinal segment. A control group of animals (their small bowels were resected but they received no graft replacement) showed massive weight loss. The animals with fetal small bowel transplant replacement thrived. This shows that in the rat model fetal small bowel, previously transplanted into a host, can be an actual functioning substitute for normal small bowel.

Allogeneic transplantation of fetal rat intestine: anastomosis to the normal bowel of the host.

We have examined the functional integrity of the transplanted fetal rat intestine following anastomosis of the transplant to the intestine of the host after successful allogeneic transplantation of fetal rat intestine into the peritoneal cavity of the host. In the syngeneic group all the 10 animals survived after end-to-side anastomosis. After end-to-end anastomosis 11 of 20 rats survived in the syngeneic group. In the allogeneic group we saw a marked host versus graft reaction (HVGR) after end-to-end anastomosis when treated orally with cyclosporin A in a dosage of 10 mg/kg per day. After administering the cyclosporin A parenterally, the survival rate in the allogeneic group after end-to-end anastomosis was 45%.

[Differential "adrenal gland tumor-adrenal gland hemorrhage" diagnosis. A sonographic follow-up]. / Zur Differential-diagnose "Nebennierentumor-Nebennierenblutung". Eine sonograpische Verlaufsbeobachtung.

A case report with typical sonographic follow-up findings of adrenal hemorrhage in neonates is presented. The most important follow-up criteria to differentiate adrenal malignoma from hemorrhage sonographically are significant reduction of size, loss of echogenity as well as formation of a capsula within the first 10 days of life. Otherwise - even with insignificant laboratory findings - malignoma, especially congenital neuroblastoma, has to be suspected.

[Intraoperative sonographic diagnosis of the ventricular position of shunt systems in infants with hydrocephalus]. / Intraoperative sonographische Lagediagnostik ventrikulär gelegener Shuntsysteme bei Säuglingen mit Hydrozephalus.

Intraoperative ultrasound is performed in hydrocephalic newborn who were undergoing placement of a ventriculoperitoneal shunt. It is possible to show intraoperatively the tip of the ventriculoperitoneal shunt tube. By this method the optimal positioning of shunt tube is assured and the postoperative complication rate may be reduced. The use of this method is demonstrated by case reports.