Anterior approach retroperitoneal laparoscopic renal surgery in children.

Retroperitoneoscopic renal surgery is performed by lateral or posterior approaches. Iterative modification led to development of an alternative 'anterior' approach. The study authors' experience with this novel approach in a prospective series of 69 children that includes 17 infants is reported. Mean operating time was 225 min for reduction pyeloplasty. Peritoneal tear is not uncommon (22%) but often does not require conversion. In the study authors' early experience, the conversion rate was 17% and postoperative complications 2.9%. This approach overcomes many existing challenges with retroperitoneoscopy. Benefits of exposure, orientation, and working space achieved with a transperitoneal approach are afforded while preserving the advantages of retroperitoneoscopy.

Early experience of tele-robotic surgery in children.

BACKGROUND: The application of robotic technology in paediatric and adult surgery is limited. We report our early experience in children. METHODS: Selected children from the age of 3 years who underwent da Vinci robotic surgery were included. All procedures were carried out by the senior author (A.N.), using three robotic ports and an accessory laparoscopic port if and when necessary. The telescope port was placed using an open technique and all port sites were closed in layers at the end of the procedure. Post-operatively all patients were offered overnight intravenous morphine. All data was collected prospectively. RESULTS: During March 2006-July 2007 there were 50 procedures in 40 children: fundoplication (5), fundoplication and gastrostomy (6), Heller's myotomy and fundoplication (2), cholecystectomy (1), splenectomy (1), cholecystectomy and splenectomy (1), re-do rectal mobilization (1), excision of Müllerian remnant and bilateral orchidopexy (1), partial nephroureterectomy (1), nephroureterectomy (4), neprectomy (4) and transperitoneal pyeloplasty (13). The mean age was 10.2 (range 3-17) years. The mean docking time was 11.9 (range 4-20) min. Forty-seven procedures in 37 children were successfully completed. There were three conversions, one robot-related (mechanical failure) and two non-robot-related (severe adhesions, difficulty with placing a guide wire for nephrostent) but no other operative complications. Post-operative complications were not robot-related (one wound infection, one urine extravasation from a displaced ureteric stent). The mean hospital stay was 2.4 (range 1-6) days, and this was affected by the patients' pre-existing clinical and social conditions. CONCLUSIONS: In children robotic surgery is safe and applicable to a wide range of surgical conditions. Further experience is required in order to establish its full potential.

Splenogonadal fusion: a rare cause of testicular enlargement.

Splenogonadal fusion is a rare congenital abnormality found in boys and girls. There is fusion of the developing splenic anlage and the gonadal mesoderm at approximately week 5 of intrauterine life. It commonly presents as a testicular mass treated with an unnecessary orchidectomy. We report two cases of the discontinuous type presenting with testicular swelling and review the literature.

Results of laparoscopic antireflux procedures in neurologically impaired children.

Although laparoscopic fundoplication is now performed commonly in children, its long-term results in neurologically impaired (NI) children is unknown. We present a single surgeon's experience. During an 8.5 year period, 54 consecutive NI children (age 5 months to 16 years; weight 2.7 to 42 kg) who had failed medical treatment for severe gastroesophageal reflux (GER) underwent laparoscopic Nissen fundoplication without (7) or with (47) gastrostomy. Indications for surgery included failure to thrive and feeding difficulties in all, major vomiting in 42, recurrent chest infections in 44, and inability to take oral medication in 14. Hiatus hernia was present in 14 and delayed gastric emptying in 6 patients. Eight (15%) had undergone previous abdominal surgery. Access was modified according to individual anatomy and 4 or 5 cannulae were used in each patient. Postoperative epidural/morphine analgesia was used in the first 12 to 24 hours, and fluid intake and feeding were started on day 1 and 2, respectively. The average operating time for fundoplication was 2.2 hours (range 1.05 to 3) and for fundoplication and gastrostomy 2.3 hours (range 1.22 to 4.10). Three patients had conversion to open surgery (1 perforated esophagus, 1 hypercarbia and hepatomegaly, 1 camera failure). There were no other operative complications or mortality. One child with Down syndrome developed a food bolus obstruction 3 days postoperatively. The vast majority of patients were discharged home 3 to 4 days following fundoplication and 5 to 7 days following fundoplication and gastrostomy. Postoperative gas bloat was common, diarrhea developed in 4, dumping in 3, and major gastrostomy infection in 1 case. During follow-up (median 5.2, range 3 months to 8.6 years), 9 (16%) children showed signs of persistent/recurrent problems. Investigations showed a recurrent hiatus hernia in 1 (requiring re-operation) and minor reflux in 3 patients. To date 6 (11%) children have died of their background conditions. In NI children, laparoscopic fundoplication is safe and successful. Awareness of the differences in access and risks for NI and normal children is important. Compared with historical data for open technique, laparoscopic fundoplication produces lower mortality and morbidity and similar intermediate and long-term results.

Laparoscopic orchidopexy in children.

BACKGROUND: Cryptorchidism is a common condition in boys. Approximately 20% of undescended testes are nonpalpable and may be located within the abdominal cavity. Given the potential of these gonads for malignant transformation and infertility, it is essential to determine the presence or absence of a nonpalpable testis. METHODS: Radiologic imaging and open surgical exploration have proved to be unreliable. In the hands of experienced surgeons, laparoscopy has become the method of choice for evaluating the nonpalpable testis. RESULTS AND CONCLUSION: An increasing number of surgeons are applying laparoscopy in the treatment of nonpalpable testes, and early results are encouraging. Both diagnostic and therapeutic laparoscopy necessitate operative skills. The exact advantages of laparoscopy over conventional surgery in orchidectomy and single- or two-stage orchidopexy need to be determined.

Transperitoneal laparoscopic nephrectomy in children.

Over a 40-month period, 24 consecutive children (1-15 years) underwent laparoscopic nephrectomy. The indication for surgery was a poorly functioning kidney (<6% on DMSA isotope scanning) secondary to a variety of causes, with or without pain or infection. Four cannulas were used in each patient. The kidney was approached through a small incision in the upper paracolic gutter without mobilization of the colon. The procedure was successful in all but one child, who had conversion to open technique because of poor laparoscopic viewing. In 12 children who required nephroureterectomy, the distal ureter was approached by an open technique through either a small extension of the iliac fossa cannula site or a Pfannenstiel incision for combined bladder surgery. The average operating time for laparoscopy was 85 (range 40-160) minutes. The children undergoing nephrectomy or nephroureterectomy alone had an average hospital stay of 2 (range 1-4) days. There were no laparoscopic or surgical complications. Laparoscopy provides a safe and successful approach to pediatric nephrectomy. The technique combines well with an open approach to the distal ureter when nephroureterectomy is indicated.

Laparoscopy in the management of the impalpable undescended testis.

BACKGROUND: This study evaluates the role of laparoscopy for managing the intra-abdominal testis. METHODS: Over 30 months, 48 children (six with previous groin explorations) underwent laparoscopy for a unilateral impalpable undescended testis. The patients' age ranged from 1 to 9 years. RESULTS: Eleven children required insertion of 'working ports' for mobilization of obscuring colon before the diagnosis could be established. Twenty-eight children had an absent testis. In nine, vas and vessels entered the internal ring. In 19, vas and vessels ended blindly above the internal ring. Twenty children had an intra-abdominal testis. Ten underwent a laparoscopic single-stage orchidopexy (eight without and two with ligation of vessels); at a minimum follow-up of 2 years, one testis in this group had atrophied, three were located in the lower half of the scrotum and six in the upper half. The remaining ten children underwent a laparoscopic two-stage Fowler-Stephens operation. At a minimum follow-up of 6 months, eight of these testes were palpable in the lower half and two in the upper half of the scrotum. CONCLUSION In the majority of cases, laparoscopy obviates the need for groin exploration. Technically a first-stage Fowler-Stephens procedure can be performed easily and effectively via the laparoscope. However, the second-stage Fowler-Stephens procedure or single-stage orchidopexy requires laparoscopic skills and may not necessarily provide sufficient length to the testicular attachment.

Thoracoscopy for empyema in children.

METHODS: During a 19-month period, seven children with empyema underwent thoracoscopy. The average age was 7.5 years (range, 3 to 15 years) and the duration of illness before surgery 16.5 days (range, 7 to 42 days). All patients received preoperative antibiotics, underwent ultrasound or CT scan and thoracentesis. Two patients had preoperative intercostal tube drainage. Indications for operations were lack of response to antibiotics of loculation of pleural fluid on imaging. All procedures were performed under general anesthesia with a single lumen tube. RESULTS: Thoracoscopy allowed for good access and complete clearance in two patients. In the remaining patients, thoracoscopy failed to clear the disease because of difficulty with access, instrumentation, and clearance of thick debris. These patients underwent thoracotomy with two requiring decortication. CONCLUSIONS: This experience suggests that even in the early stage of empyema formation, thoracoscopy is not as effective as thoracotomy. Larger experience and studies are required to define the place of thoracoscopy in the management of childhood empyema.

Laparoscopic gastrostomy in children.

During a 30-month period, 28 children aged 6 months-15 years underwent fashioning of a laparoscopic gastrostomy. Indications for operation included: feeding difficulties and failure to thrive in neurologically impaired children (13); chronic renal failure (9); and others (6). There were 17 conventional tube and 11 button gastrostomies. Twelve children had insertion of a gastrostomy alone; the others underwent a concomitant laparoscopic Nissen fundoplication (NFP). The average operation time for gastrostomy alone was 65 min (range 35-104) and for gastrostomy plus NFP 155 min (range 130-246). There were no specific laparoscopic complications. Two patients who required large volumes of eternal drugs and peritoneal dialysis from the 1st post-operative day developed minor external leaks from their stomas. It appears that laparoscopy provides for safe and precise positioning of any standard balloon or button gastrostomy. It is a particularly attractive technique for use in patients already undergoing a laparoscopic fundoplication and those in whom other minimally invasive techniques are contraindicated or fail.

Laparoscopically assisted percutaneous endoscopic gastrostomy.

The percutaneous endoscopic approach is an established method for fashioning a gastrostomy. However, the technique is not without complications. Visualising the peritoneal cavity via a small laparoscope may provide additional safety to percutaneous endoscopic gastrostomy.

Laparoscopy in the management of pediatric varicoceles.

BACKGROUND/PURPOSE: The authors present their early experience with laparoscopic ligation of varicoceles in children. METHODS: Over a period of 30 months, 17 children underwent laparoscopic treatment of unilateral varicoceles (age range, 7 to 16 years). Nine underwent ligation of veins alone and eight (including four children who had recurrent varicoceles) underwent ligation of testicular veins and artery. In three patients, vas-associated veins were ligated in addition to the main testicular vessels. RESULTS: The average operation time was 30 minuts (range, 14 to 75) and hospital stay, 11 hours (range, 4 to 22). There were no technical failures. Minor scrotal emphysema developed in one child, and a painful, tender swelling above the epididymis developed in another. At an average follow-up of 24 months (range, 6 to 30), all patients were asymptomatic and had marked reduction in the size of the varicoceles. CONCLUSION: Further experience and long-term follow-up are clearly required before the efficacy of this procedure is established.

Intussusception treated laparoscopically after failed air enema reduction.

We report the case of a 10-month-old boy with intussusception. Following two failed air enemas, successful reduction of his ileocolic intussusception was achieved laparoscopically. We do not advocate abandoning safe and established surgical techniques used to treat irreducible lesions, but we are encouraged by this experience to further explore the role of laparoscopy in the treatment of this common condition.

Laparoscopic Nissen fundoplication in disabled infants and children.

During a 16-month period, 15 neurologically impaired infants and children for whom medical treatment failed underwent laparoscopic fundoplication. The indications for surgery included feeding difficulties, vomiting, and recurrent chest aspiration. The patients' weight range was 3.9 and 42 kg (6 weighed less than 12 kg). Access was modified according to each patient's size and shape. The average operating time was 2.2 hours (range, 1.4 to 3) for fundoplication and 3.1 hours (range, 2.3 to 4.1) for fundoplication with gastrostomy. Two patients had conversion to open surgery because of hypercarbia or perforated oesophagus. Use of postoperative analgesia was limited to the first 24 hours, and fluid intake and feeding were begun on days 1 and 2, respectively. Gas bloating was common postoperatively, and diarrhoea developed in three children. Twelve patients had clinical improvement, and a recurrent hiatus hernia developed in one. Laparoscopic fundoplication can be successful; however, awareness of the differences in technique for paediatric (disabled children in particular) and adult patients is essential. The technique deserves further investigation.

Is inguinal exploration for the impalpable testis an outdated operation?

OBJECTIVE: To evaluate the reliability of open inguinal exploration for the investigation of the impalpable testis by reviewing laparoscopic findings after previous negative inguinal exploration. PATIENTS AND METHODS: Laparoscopy was performed in 18 boys (with a total of 22 impalpable testes) in whom previous inguinal exploration in their referring hospitals had yielded negative or inconclusive findings. Subsequent management of the impalpable testes was based on laparoscopic findings. RESULTS: Despite previous negative surgical findings at inguinal exploration, laparoscopy revealed that 13 of the 22 impalpable testes (59%) were present, 12 within the abdomen and one in the inguinal canal. Absence of the remaining nine testes was positively confirmed by visualizing confluent blind ending vas and vessels. CONCLUSION: Inguinal exploration is an unreliable method of investigating the impalpable testis, with an unacceptably high incidence of false-negative or inconclusive findings. Laparoscopy should be undertaken as the initial diagnostic manoeuvre of choice.

Early experience with laparoscopic pyloromyotomy for infantile hypertrophic pyloric stenosis.

The authors report on 37 infants with infantile hypertrophic pyloric stenosis who underwent successful laparoscopic pyloromyotomy. The average age was 6 weeks and average weight was 4.5 kg. Three 4-mm ports were used in each procedure. The average operating time was 29 minutes (range, 7 to 60 minutes). Feeding was begun an average of 5.2 hours (range, 3 to 12 hours) postoperatively, and the average time of discharge was 28 hours (range, 16 to 52 hours) postoperatively. There were no technical failures. One patient had minor surgical emphysema, which resolved spontaneously. Laparoscopic pyloromyotomy can be safe and successful in infants with hypertrophic pyloric stenosis.

Emergency reduction of paraphimosis.

Paraphimosis in uncircumcised or incompletely circumcised children is a serious and painful condition requiring prompt reduction to prevent possible necrosis of the glans or urinary obstruction. Techniques described to reduce oedema distal to the constricting ring include application of ice packs, compressive elastic bandages, and making a dorsal slit which necessitates later circumcision. We have used a simple "puncture" technique to treat successfully an uncircumcised 12-year-old boy with severe paraphimosis. An 18 gauge hypodermic needle was used to puncture the oedematous foreskin at multiple sites, followed by gentle manual compression. This resulted in rapid diminution of the swelling, permitting easy manual reduction of the prepuce. Circumcision can then be performed if so desired.