One-trocar transumbilical laparoscopic-assisted appendectomy in children: our experience.

The authors report their experience with one-trocar transumbilical laparoscopic assisted appendectomy (TULAA). From January 1998 to June 2000, 150 patients underwent appendectomy using this technique. Ages ranged from 2.5 to 17.4 years. The procedure was completed using only one trocar in 116 cases (77.3%); in 28 patients (18.7%) one or two additional cannulas were needed. Conversion to open surgery became necessary in 6 cases (4%). Mean operative time was 35 minutes, mean hospital stay 3.5 days. There were no major complications and no mortality in this series. The advantages of a one-trocar appendectomy compared with open surgery are the same as those reported for conventional laparoscopic appendectomy: i.e., excellent exploration of the abdominal cavity, the possibility of discovering extra-appendiceal lesions, easy and rapid localization of the appendix and a shorter hospital stay. The additional advantages of TULAA compared with conventional laparoscopic appendectomy are a low rate of intraoperative incidents, minimal scarring, less postoperative pain and a more rapid return to unrestricted activities.

Advantages of prenatal diagnosis and early surgery for congenital cystic disease of the lung.

Prenatal ultrasonography makes possible the diagnosis of congenital cystic lung disease in utero, enabling elective surgery for the lesions early in infancy before development of respiratory distress or potentially life-threatening infection. From 1986 to 1994, ten infants with congenital lung cyst underwent corrective surgery. Nine of them had a prenatal diagnosis of congenital lung cyst confirmed by ultrasound or computed tomography (CT) after birth. In 7 of these infants, congenital adenomatoid malformation (CAM) was found at surgery, and pulmonary sequestration was found and removed in two other infants. Two of the nine infants had respiratory distress at birth; the seven others were asymptomatic when surgery was performed (between 2 and 6 months of age). In 4 out of 9 newborn a plain chest radiography at birth was normal and a CT scan only showed the cysts prenatally observed at ultrasound. Intraoperative measurement of pulmonary function in the asymptomatic infants demonstrated significant improvement after resection of the affected lobe. One other infant had normal lung fields at the time of prenatal diagnosis. However, a severe acute pneumonia with abscess of the lobe became life-threatening at 4.5 months. CT showed a large congenital lung cyst, treated initially with antibiotics and extirpated at age 6 months with great difficulty. Pulmonary function did not improve postoperatively. Examinations on follow-up (8 months-8 years; 5 of 10 infants longer than 4 years) have shown that all 10 of the infants are healthy and have normal pulmonary function. Pneumonia in the controlateral lung was found in 3 children (3-6 years after the operation), one of them had respiratory distress at birth and another had the life-threatening pneumonia preoperatively. Thus, early surgery is indicated when prenatal diagnosis of congenital cystic disease has been confirmed after birth.

Prenatal diagnosis of gastrointestinal obstruction: a correlation between prenatal ultrasonic findings and postnatal operative findings.

The impact of prenatal sonographic diagnosis of oesophageal and gastrointestinal obstructions has been analysed over a 10-year period. Three groups of patients were evaluated. The first group consisted of 46 newborns with abnormal prenatal sonograms, 41 of which were confirmed to have intestinal obstruction postnatally. The second group consisted of 17 neonates with normal prenatal sonograms who had intestinal obstruction postnatally. The third group included 56 newborns who did not undergo a prenatal sonogram but who had intestinal obstruction confirmed at surgery. Polyhydramnios without the appearance of a stomach on ultrasound was diagnostic of pure oesophageal atresia. Polyhydramnios with intestinal dilation was diagnostic of intestinal obstruction. Although surgery was performed earlier in the infants diagnosed prenatally with ultrasound, mortality was no less than in the group that did not undergo a prenatal sonogram, probably because of the high incidence of associated anomalies.

Prenatal ultrasonography and early surgery for congenital cystic disease of the lung.

With the recent advent of prenatal ultrasound as a routine screening procedure, diagnosis of congenital cystic lung disease has been made in utero, raising the possibility of elective surgery for these lesions early in infancy before the patient develops respiratory distress or potentially life-threatening infection. From 1979 to 1989 six cases of congenital lung cyst were diagnosed in utero by prenatal ultrasound and followed during pregnancy. Two of the six were not confirmed after birth because the mothers preferred an abortion. The remaining four cases were studied periodically during gestation by ultrasonography. At birth, the first infant developed respiratory distress and underwent urgent left upper lobectomy and left lower segmentectomy at age 18 hours. The other three underwent elective lobectomy at age 10 days, 3 months, and 7 months, respectively. The fourth infant had a normal chest x-ray and ultrasound at birth, and the congenital cysts were confirmed by computed tomography scan. The pathological diagnosis in all four cases was cystic adenomatoid malformation. In two cases, intraoperative measurement of pulmonary function demonstrated significant improvement after resection of the affected lobe. We conclude that congenital lung cysts can be accurately diagnosed by prenatal ultrasound "screening" as early as 18 to 24 weeks' gestation. Advantages of early diagnosis include the option of moving the mother and unborn child to a high-risk obstetrical center for urgent operation on the newborn infant if necessary. Otherwise, once the diagnosis is confirmed, surgical correction can be performed electively and safely before respiratory distress or pulmonary infection complicates the infant's growth and development.

Predictability of duration and severity of congenital hydronephrosis as a cause of smooth muscle deterioration in pyelo-ureteral junction obstruction.

Between 1989 and 1990, 31 new unilateral PUJO, prenatally diagnosed (16th-37th week of gestational age), underwent pyeloplasty between 19 and 105 days of age. The correlation between severity (V) (volume of hydronephrotic kidney) and duration (dT) of congenital hydronephrosis from its first detection in utero to surgery and histological findings were prospectively evaluated in this series. A dT longer than 70 days and a V larger than 50 ml., were considered as predictable for hypotrophy with fibrosis of the upper urinary tract smooth musculature. In conclusion, time seems to play an important role in the increase of the volume of the obstructed urinary tract to the extent of a large-scale hydronephrosis.

[Ureteric peristalsis in congenital vesico-ureteral pathology. Integrated sonographic and scintigraphic studies]. / La peristalsi ureterale nella patologia congenita del giunto uretero-vescicale. Studio integrato ecografico e scintigrafico.

Ureteric peristalsis is a key point for urinary progression. Its preoperative evaluation is important to assess indications for surgery. The study of the distal ureter is possible by means of ultrasound. Renal scintigraphy allows for a complete study of urinary progression along the ureter. A combined ultrasound and 99mTc-MAG3 preoperative work-up, has been performed in 32 urinary tracts (16 children ranging in age between 45 days and 11 years). Urinary progression occurs whenever peristaltic contraction makes the ureter lumen unpatent.

Increased sodium requirement following early postnatal surgical correction of congenital uropathies in infants.

Serum electrolyte equilibrium and plasma aldosterone concentrations were monitored in 19 infants who had severe obstructive uropathy or grade 5 vesico-ureteral reflux and were undergoing surgical correction in the first 2 months of life. Before surgery high plasma aldosterone levels were observed in 8 patients, but serum sodium and potassium concentrations were normal. Plasma concentrations of aldosterone were elevated in all patients during the week following surgery and 7 patients developed severe hyponatraemia, hyperkalaemia and weight loss despite very high plasma aldosterone concentrations. As a consequence 5 infants were infused with sodium chloride (4 mEq/kg per day) before and for 36 h after surgery; this prevented metabolic imbalance. We conclude that infants undergoing surgical correction of uropathies may require a high sodium intake to maintain electrolyte balance and adequate growth.

Duration and severity of congenital hydronephrosis as a cause of smooth muscle deterioration in pyelo-ureteral junction obstruction.

A potential relationship between duration and severity of obstructive hydronephrosis and the histological structure of the upper urinary tract smooth musculature has been studied in a series of prenatally diagnosed cases. Between 1981 and 1988, fifty-five monolateral pyelo-ureteral junction obstructions (PUJO), prenatally diagnosed (16th-37th week of gestational age), underwent pyeloplasty between 4 and 90 days of life. Gestational age at the diagnosis, delta t (duration of hydronephrosis from first detection in utero to surgery) and V (volume of the hydronephrotic kidney) were related to the frequency of muscle hypotrophy and fibrosis of both pelvis and ureter just above and below the junction. A close correlation between duration (delta t) and the severity of the involvement of the smooth musculature of the upper urinary tract was found. The larger the volumes (V), the more severe the muscular damage. In the long-term follow-up, poor results were obtained only in 5 of the 19 newborn who had severe hypotrophy and fibrosis of the pelvis. In conclusion, in PUJO, the shorter the delta t and the lower the V, the better one expects the smooth musculature of the upper urinary tract to be.

Persistent tubular resistance to aldosterone in infants with congenital hydronephrosis corrected neonatally.

Renal function of 18 infants who had undergone surgery in the neonatal period because of severe congenital hydronephrosis was followed up for 5 to 36 months (mean +/- SD 21 +/- 10 months). In all cases the diagnosis was made prenatally by sonography and confirmed at birth by intravenous urography. Creatinine clearance developed normally in all the children. Eight had a reduction in maximal urinary concentrating ability after intranasal DDAVP; this defect was transient and resolved after 4 to 5 months in all but one child, in whom it persisted. However, other tubular abnormalities were present. Throughout the observation period, patient serum potassium concentrations were significantly higher than normal, paralleled by a significant increase in plasma aldosterone concentration but with normal excretion fraction of sodium and potassium. There were no disturbances of acid-base balance. These findings may be accounted for by a persistent partial reduced sensitivity of the distal tubule to the action of aldosterone despite normal renal function. This alteration is usually mild, but may constitute a persistent metabolic risk despite successful surgical intervention.