Evaluation of the Appropriate LigaSure™ Device to Transect the Appendix-A Comparison between 5 mm and 10 mm Laparoscopic Devices in an Ex Vivo Trial.

Background and Objectives: A topic of greatinterest in the surgical field comprises cost and time reduction operative techniques with high efficiency rates. Thus, the aim of this paper is to evaluate whether a transection of the appendix using only a laparoscopic LigaSure™ device is feasible and, if so, which size of the laparoscopic device is optimal. Materials and Methods: Appendectomy specimens were sealed and cut using LigaSureTM V (5 mm) and LigaSure AtlasTM (10 mm) devices ex vivo. Analysis criteria included handling, resistance to bursting pressure of the appendicular stump (adequacy), eligibility, durability and airtightness. Results: Twenty sealed areas were measured. While the 5 mm instrument was not able to transect the appendix in one attempt in any of the cases, the 10 mm device could be applied successfully without any handling difficulties. The adequacy of the sealed area was rated as complete and dry in all 10 cases using the 10 mm device and as oozing in 8 of the cases using the 5 mm device. There was no leakage in terms of air and liquid tightness using the 10 mm device, in contrast to six sealed segments with air and liquid leakage when using the 5 mm device. The resistance to bursting pressure was on average 285 mmHg and 60.5 mmHg with the 10 mm and 5 mm devices, respectively. The durability and eligibility of the 10 mm device were rated as very sufficient in 9 of 10 cases (1 perforation) in contrast to the 5 mm device, where the sealing in 9 of 10 cases was not sufficient (9 perforations). Conclusions: Using the 10 mm laparoscopic LigaSure™ device for the transection of the appendix seems to be feasible, safe and resistant to 300 mmHg bursting pressure. The 5 mm LigaSure™ instrument is inadequate to seal the appendix in humans.

Evaluating Cardiac Lateralization by MRI to Simplify Estimation of Cardiopulmonary Impairment in Pectus Excavatum.

BACKGROUND: The severity of pectus excavatum is classified by the Haller Index (HI) and/or Correction Index (CI). These indices measure only the depth of the defect and, therefore, impede a precise estimation of the actual cardiopulmonary impairment. We aimed to evaluate the MRI-derived cardiac lateralization to improve the estimation of cardiopulmonary impairment in Pectus excavatum in connection with the Haller and Correction Indices. METHODS: This retrospective cohort study included a total of 113 patients (mean age = 19.03 ± 7.8) with pectus excavatum, whose diagnosis was verified on cross-sectional MRI images using the HI and CI. For the development of an improved HI and CI index, the patients underwent cardiopulmonary exercise testing to assess the influence of the right ventricle's position on cardiopulmonary impairment. The indexed lateral position of the pulmonary valve was utilized as a surrogate parameter for right ventricle localization. RESULTS: In patients with PE, the heart's lateralization significantly correlated with the severity of pectus excavatum (p ≤ 0.001). When modifying HI and CI for the individual's pulmonary valve position, those indices are present with greater sensitivity and specificity regarding the maximum oxygen-pulse as a pathophysiological correlate of reduced cardiac function (χ2 10.986 and 15.862, respectively). CONCLUSION: The indexed lateral deviation of the pulmonary valve seems to be a valuable cofactor for HI and CI, allowing for an improved description of cardiopulmonary impairment in PE patients.

Prevalence and One-Year Survival of Selected Major Congenital Anomalies in Germany: A Population-Based Cohort Study.

INTRODUCTION: Congenital anomalies play an important role in infant mortality worldwide. The present study aims to present the current data on the prevalence rates and the 1-year survival rates for selected major congenital anomalies in Saxony-Anhalt, Germany. MATERIALS AND METHODS: The data were collected systematically by the Malformation Monitoring Centre Saxony-Anhalt. Cohort from 2000 to 2017 was retrospectively analyzed to determine the prevalence rates and the survival rates of nine major congenital anomalies. The survival analysis was conducted, including all pregnancy outcomes and various risk factors. RESULTS: In total, 1,012 cases of the selected congenital anomalies were registered. The total prevalence rates ranged from 2.5 (congenital diaphragmatic hernia [CDH]) to 5.8 (spina bifida [SB]) per 10,000. The live birth prevalence was lower. In total, 88.3% of live-born cases survived the first year. The 1-year survival rate of all cases, including fetal losses, was merely 61.7%. There was no continual improvement in survival during the study period noted. The 1-year survival rate was 35.7% for "genetic" malformations, 57.6% for "multiple congenital anomalies," and 68.6% for "isolated" cases, with 44.6% for prenatally detected anomalies and 85.2% for postnatally identified anomalies. Gestational age less than 31 weeks and birth weight below 1,000 g affected the survival rate adversely. CONCLUSION: The survival rate of infants suffering from congenital anomalies in Saxony-Anhalt is comparable to that reported by national and international studies. Registering all pregnancy outcomes irrespective of whether they result in a live birth, stillbirth, or fetal loss in a malformation register seems to be important as it affects the statistical survival analysis in general.

Surgeons' requirements for a surgical support system to improve laparoscopic access.

Creating surgical access is a critical step in laparoscopic surgery. Surgeons have to insert a sharp instrument such as the Veress needle or a trocar into the patient's abdomen until the peritoneal cavity is reached. They solely rely on their experience and distorted tactile feedback in that process, leading to a complication rate as high as 14% of all cases. Recent studies have shown the feasibility of surgical support systems that provide intraoperative feedback regarding the insertion process to improve laparoscopic access outcomes. However, to date, the surgeons' requirements for such support systems remain unclear. This research article presents the results of an explorative study that aimed to acquire data about the information that helps surgeons improve laparoscopic access outcomes. The results indicate that feedback regarding the reaching of the peritoneal cavity is of significant importance and should be presented visually or acoustically. Finally, a solution should be straightforward and intuitive to use, should support or even improve the clinical workflow, but also cheap enough to facilitate its usage rate. While this study was tailored to laparoscopic access, its results also apply to other minimally invasive procedures.

Differences in myocardial strain between pectus excavatum patients and healthy subjects assessed by cardiac MRI: a pilot study.

OBJECTIVES: To evaluate differences in myocardial strain between pectus excavatum (PE) patients and healthy subjects (HS) assessed by cardiac MRI using the feature-tracking algorithm. METHODS: Cardiac MRI was performed in 14 PE patients and 14 HS (9:5 male to female in each group; age 11-30 years) using a 3T scanner. Post-examination analysis included manual biventricular contouring with volumetry and ejection fraction measurement by two independent radiologists. Dedicated software was used for automated strain assessment. RESULTS: In five of the PE patients, the right ventricular ejection fraction was slightly impaired (40-44 %). PE patients had a significantly higher left ventricular longitudinal strain (P=0.004), mid (P=0.035) and apical (P=0.001) circumferential strain as well as apical circumferential strain rate (P=0.001), mid right ventricular circumferential strain (P=0.008) and strain rate (P=0.035), and apical right ventricular circumferential strain (P=0.012) and strain rate (P=0.044) than HS. The right ventricular longitudinal strain and strain rate did not differ significantly between PE patients and HS. CONCLUSIONS: Myocardial strain differs significantly between PE patients and HS. Higher myocardial strain in the mid and apical ventricles of PE patients indicates a compensation mechanism to enhance ventricular output against basal sternal compression. KEY POINTS: • The right ventricle is frequently affected by the pectus excavatum deformity. • Cardiac MRI revealed differences in myocardial strain in pectus excavatum patients. • Pectus excavatum patients exhibited higher strain in the mid/apical ventricles. • A compensation mechanism to enhance ventricular output against sternal compression is possible.

Impact of Pectus Excavatum on Cardiopulmonary Function.

BACKGROUND: Pectus excavatum is classified using the Haller Index (HI) or the Correction Index. However, no correlation between the HI and CI and cardiopulmonary impairment has been described in detail. METHODS: This prospective cohort study included 99 otherwise healthy patients with pectus excavatum who underwent cardiopulmonary exercise testing and magnetic resonance imaging at inspiration and expiration to correlate cardiopulmonary function with the grade of thoracic dysmorphia. RESULTS: Probands with an HI exceeding 3.25 had first an increase in heart rate at anaerobic threshold (from 148.0 ± 16.0 beats/min to 155.9 ± 15.0 beats/min, p = 0.036), with an HI of more than 3.6 a reduction in oxygen pulse at anaerobic threshold (from 10.7 ± 2.6 mL/beat to 9.3 ± 2.9 mL/beat, p = 0.017), with an HI exceeding 3.8 a reduction of maximum oxygen pulse (from 13.9 ± 3.4 mL/beat to 11.9 ± 3.7 mL/beat, p = 0.010), and with an HI of exceeding 4.0 a decline in maximum oxygen uptake (from 43.7 ± 6.5 mL · kg-1 · min-1 to 40.4 ± 7.4 mL · kg-1 · min-1, p = 0.025). The CI of more 27% reflects cardiopulmonary changes earlier than the corresponding HI exceeding 3.25 (p = 0.01 for maximum oxygen pulse; p = 0.017 for oxygen pulse at anaerobic threshold; p = 0.015 for heart rate at anaerobic threshold). CONCLUSIONS: The inspiratory HI and CI reflect the effect of pectus excavatum on cardiopulmonary function. The cardiopulmonary system reacts first with an increase in heart rate at anaerobic threshold, followed by a decrease in stroke volume at anaerobic threshold and maximum stroke volume. Increased severity of the deformity then leads to a decrease in cardiac output.

Laser Doppler spectroscopy of testes after unilateral orchiopexy.

OBJECTIVE: Undescended testes are the most common urogenital malformation in boys. Impaired microcirculation is among other factors addressed as a potential complication of surgery and scar formation, leading to long-term suboptimal results. OBJECTIVE: Our aim was to compare the postoperative microcirculation in operated versus non-operated contralateral testis groups after unilateral orchiopexies versus a healthy control cohort. METHODS: Ninety-nine consecutive patients were included after unilateral orchiopexy procedures at the age of 3.5 years (±2.9 years) at a single center for pediatric surgery. Eight-five patients were examined with a combination of laser Doppler (blood flow determination) and white-light spectroscopy (oxygen saturation and hemoglobin amount determinations) to determine the microcirculation at two different depth levels non-invasively. All relevant surgery data were obtained retrospectively. RESULTS: The right side was operated in 53.5% of cases. Previous hormone treatment had been prescribed in 46.5%. There were no significant differences in perfusion measurements between patients with previous hormone therapy and patients without. There was no significant difference in age and clinical pubertal stage between groups; however, 65% of patients underwent surgery after their second birthday. When comparing oxygen saturation (So2), relative hemoglobin (rHb), flow, and velocity in the operated testis with the contralateral testis of the same patients, we found significantly higher flows and velocities for the contralateral testes (p = 0.041, p = 0.022). Similar higher flows and velocities were found in the healthy controls (p < 0.001). The differences between healthy controls and contralateral testis that were not operated on did not reach statistical significance. There was no difference in measurements at 2 mm depth (skin and subcutaneous tissue) between groups to rule out systemic or capillary differences. DISCUSSION: Important limitations include the limited and relatively heterogeneous samples that were obtained for follow-up and retrospective surgery data collection. An additional limitation is missing presurgical data, which we hope to obtain in future studies. Hormonal data or bone age could not be obtained for study reasons. The age in our study was on average above the recommended age for orchiopexy in Germany (6-12 months), which could also restrict generalizability. In terms of complications, we observed reascending testes within the range but a rather high incidence of wound infections. The combination of Doppler and white-light spectroscopy was easily applicable and produced reliable data at 2 and 8 mm depth simultaneously in a standardized setting. CONCLUSIONS: After orchiopexy, differences were found in the microcirculation between the operated and contralateral testes or healthy controls. It remains unclear if this is an effect of primary disease or surgery. The microcirculation of contralateral testes was also seemingly different from controls. This is most likely not a consequence of surgery alone, but a common problem for both testes in the affected patients.

Second study on the recurrence risk of isolated esophageal atresia with or without trachea-esophageal fistula among first-degree relatives: no evidence for increased risk of recurrence of EA/TEF or for malformations of the VATER/VACTERL association spectrum.

BACKGROUND: Esophageal atresia with/without trachea-esophageal fistula (EA/TEF) denotes a spectrum of severe congenital malformations. The aim of this systematic study was to determine both the recurrence risk for EA/TEF, and the risk for malformations of the VATER/VACTERL association spectrum, in first-degree relatives of patients with isolated EA/TEF. METHODS: A total of 108 unrelated patients with isolated EA/TEF were included. These individuals had 410 first-degree relatives including 194 siblings. The presence of EA/TEF and malformations of the VATER/VACTERL association spectrum in relatives was systematically assessed. Data from the EUROCAT network were used for comparison. RESULTS: None of the first-degree relatives displayed any form of EA/TEF. In two families, a first-degree relative presented with malformations from the VATER/VACTERL association spectrum. However, no increase in the risk for malformations of the VATER/VACTERL association spectrum was found compared with the control cohort (p = 0.87). In three families, one more distantly related relative presented with EA/TEF. CONCLUSION: In contrast to previous studies, our results suggest a very low recurrence risk for isolated EA/TEF and/or for malformations of the VATER/VACTERL association spectrum among first-degree relatives.

Decline in infantile hypertrophic pyloric stenosis in Germany in 2000-2008.

BACKGROUND AND OBJECTIVE: The incidence of infantile hypertrophic pyloric stenosis (IHPS) is highly variable over time and geographic regions. A decline in IHPS incidence was recently reported in Sweden, the United States, Denmark, and Scotland. In Sweden, the IHPS decline seemed to be concurrent with a declining incidence in sudden infant death syndrome (SIDS), which suggested a common cause; the latter was attributed to campaigns against the prone sleeping position. We investigated the time course of the IHPS incidence in all German federal states (N = 16) between 2000 and 2008. We examined correlations between the IHPS incidence and the SIDS incidence. METHODS: Data were extracted from the public report of health (Gesundheitsberichterstattung des Bundes). We collected the numbers of IHPS (International Classification of Diseases, 10th Revision [ICD-10], code 40.0), SIDS (ICD-10, R95), and live births (LB; male/female) in each federal state for 2000-2008. RESULTS: The IHPS incidence declined in Germany from 2000 (3.2086/1000 LB [range: 1.67-5.33]) to 2008 (2.0175/1000 LB [1.74-3.72]; P = .005). The recorded incidence was highly variable in different federal states and over time. The SIDS incidence also declined during the same time period (2000, median: 0.759/1000 LB [interquartile range: 0.54-1.029]; 2008, median: 0.416/1000 LB [interquartile range: 0.285-0.6485]; P = .0255). However, the SIDS regional distribution was different from that of IHPS. CONCLUSIONS: The IHPS incidence declined by ∼38% nationwide. A parallel decline in SIDS displayed a different pattern in regional distribution; thus, a common cause was unlikely. The regional differences indicated that etiologic factors remained unresolved.

Pectus excavatum: history, hypotheses and treatment options.

Pectus excavatum and pectus carinatum represent the most frequent chest wall deformations. However, the pathogenesis is still poorly understood and research results remain inconsistent. To focus on the recent state of knowledge, we summarize and critically discuss the pathological concepts based on the history of these entities, beginning with the first description in the sixteenth century. Based on the early clinical descriptions, we review and discuss the different pathogenetic hypotheses. To open new perspectives for the potential pathomechanisms, the embryonic and foetal development of the ribs and the sternum is highlighted following the understanding that the origin of these deformities is given by the disruption in the maturation of the parasternal region. In the second, different therapeutical techniques are highlighted and based on the pathogenetic hypotheses and the embryological knowledge potential new biomaterial-based perspectives with interesting insights for tissue engineering-based treatment options are presented.

Pectus carinatum--first ultrastructural findings of a potential metabolic lesion.

The histological and ultrastructural findings of rib specimens after two re-interventions in the case of recurrence of pectus carinatum (PC) are presented in this report. A 15-year-old boy developed recurrences of mild PC after re-chondroplasties using the Ravitch technique. Histological study of the resected cartilage showed markedly degenerative changes of the sternocostal cartilage. For the first time, intracellular crystalline inclusions in some of the chondrocytes were found. These findings indicate metabolic changes as a possible pathogenetic parameter in PC.

Microlaparoscopic hernia repair in children: initial experiences.

INTRODUCTION: This study reports the authors' experience with the exclusive use of 2-mm instrument sets and small diameter scopes in 100 children undergoing microlaparoscopic herniorrhaphy. METHOD: This prospective study was designed as a pilot feasibility study; all data related to patients and procedures were prospectively collected. A pneumoperitoneum was established, and 1.7 to 2 mm 0° or 30° scopes were introduced for visualization. Exclusively 2-mm instruments were used. RESULTS: This study included 100 children (aged 15 days to 11 years, median age 2.3 years) undergoing microlaparoscopic hernia repair. A total of 140 hernias were treated. The average operative time for the microlaparoscopically experienced surgeon was 16 minutes for bilateral inguinal hernia and 12 minutes for unilateral hernias. All procedures were completed microlaparoscopically. Hernia recurrence was observed in 2 patients. CONCLUSION: Based on the authors' early experience, it is found that microlaparoscopic hernia repair in children seems to be a safe and feasible procedure.

Comparison of a novel technique of the microlaparoscopic pyloromyotomy to circumbilical and Weber-Ramstedt approaches.

INTRODUCTION: The aim of this retrospective comparative study was to compare the surgical results and outcomes of the newly inaugurated approach of microlaparoscopic pyloromyotomy with open techniques. METHODS: The surgical charts of 110 infants (85 boys and 25 girls, ages ranging from 10 to 98 (average 28) days) undergoing pyloromyotomy microlaparoscopically (28), through the circumbilical approach (56), or via the right upper quadrant access (26) were reviewed. The variables were compared between the three surgical approach groups, and the statistical analysis was performed. RESULTS: There was a significant difference between Bianchi and microlaparoscopy in terms of operation time (average 38.5 vs. 20.5 min, p < 0.0001) and time to full enteral feed (average 48 vs. 32 h, p = 0.001). There was no significant difference in postoperative length of stay (75 vs. 82 h, p = 0.12). The operative time for the surgeons experienced in microlaparoscopy was in average of 14 min (range, from 9 to 18 min). When comparing the Weber-Ramstedt procedure and microlaparoscopy, microlaparoscopy required significantly less operative time (50 vs. 20 min, p < 0.0001), a shorter time to full enteral feed (70 vs. 32 h, p < 0.001), and a shorter postoperative length of stay (90 vs. 82 h, p = 0.04). There were no cases of mucosal perforation or incomplete pyloromyotomy. CONCLUSION: Despite the small sample size included in the present study, it seems that microlaparoscopic pyloromyotomy is safe and feasible with the lowest rate of complications and the shortest operative time. The Bianchi approach is a good alternative to achieve a small scar without laparoscopy.

Microlaparoscopic cholecystectomy with an unorthodox scope position.

PURPOSE: We report our initial experiences with microlaparoscopic cholecystectomy (MLCE) in children using a 2.4-mm mini-scope placed to the right of the umbilicus. The umbilicus was used as the working trocar for large-diameter instruments. METHODS: The mini-scope was inserted 2-3 cm to the right to the umbilicus and slightly above the umbilical line. A miniport for the 2-mm grasper was inserted laterally through the right abdominal wall, and a 5-mm working trocar was inserted infra-umbilically. The three-angle principle of laparoscopic instrumentation remained, as the trocar positions were merely shifted to the right side of the abdominal wall. With the patient in the supine position, the surgeon stood on the left side of the patient, facing the monitor. RESULTS: MLCE was successfully performed in 12 children (average age: 15 years, average body weight: 46.4 kg). In two cases, the optic trocar was repositioned one cm laterally, because the initial trocar position was too close to the umbilicus and was colliding with the 5-mm instruments. The view at the cystohepatic triangle was sufficient. There were no specific complications due to the rearranged trocar positions or the use of a mini-scope. It was possible to displace the scope out of the umbilical area without compromising the superior cosmesis allowed by using only miniports. CONCLUSION: Based on our early experiences, MLCE is safe and feasible. This technique helps reduce the access trauma and operative time while allowing for superior cosmesis.

A microlaparoscopically assisted pull-through procedure for Hirschsprung's disease: initial experiences.

PURPOSE: The purpose of this prospective study was to evaluate the efficiency, feasibility, and surgical outcomes of microlaparoscopy-assisted pull-through (MAPT) for Hirschsprung's disease. METHODS: Starting in 2005, pull-through procedures for Hirschsprung's disease were performed exclusively using 2-mm instruments and miniscopes (microlaparoscopy). Three miniports were inserted laterally in the right abdominal wall in one line, with the miniscope at the level of the umbilicus and the working trocars cranially/caudally of the scope. The left colon was dissected, and transanal pull-through was performed. RESULTS: MAPT was performed in 16 children (10 boys and 6 girls; average age: 5.7 months). Six patients had previous abdominal surgeries. A 1.9-mm cystoscope or a 2.4-mm arthroscope was used in the first 5 cases. In the remainder, a recently developed 2.4-mm miniscope was used for visualization. The length of the resected colon segment was up to the left colonic flexur in 5 children, up to the middle of the descending colon in 4 cases and up to the sigmoid-descending segment in 7 children. The average operation time was 185 minutes (range: 120-330 minutes). The only intraoperative complication that occurred was an injury of the right iliac vein by inadvertent slippage of an electrocautery hook requiring laparotomy. At follow-up, 80% of the parents were unable to identify the scars after microlaparoscopy. CONCLUSION: MAPT is a safe and practical procedure regardless of age or previous surgery.

Laparoscopic inguinal herniorrhaphy in babies weighing 5 kg or less.

BACKGROUND: This retrospective study aimed to evaluate the feasibility, safety, and complication rate of laparoscopic inguinal hernia repair for small babies weighing 5 kg or less compared with the traditional open herniotomy. METHODS: A retrospective analysis was performed on the surgical charts of 147 infants weighing 5 kg or less who underwent laparoscopic hernia repair. Either a regular 5-mm scope or a microlaparoscope was used for visualization, and 2-mm instruments were used for closure of the inner inguinal ring. RESULTS: Of the 147 infants (100 boys and 47 girls; 41 bilateral, 77 right-sided, 29 left-sided hernias) 39 (26.5%) presented with an irreducible hernia. The median weight at surgery was 3.9 kg (range, 1.45-5 kg). Of the infants, 11 (7.5%) weighed less than 2.5 kg, and 58 (39.4%) were premature. The median operative time for the bilateral hernia was 20 min. No serious intraoperative surgical complications occurred. Anesthesiologic complications were noted in eight cases. After a median follow-up period of 26 months (range, 6-52 months), 124 children were clinically examined. In the boys, testicular volume and echogenic texture were studied ultrasonographically, and testicular perfusion was measured using the O2C device. Hernia recurrence was observed in four patients (2%). According to a linear regression analysis, the risk of recurrence was increased by 14.16% for children classified as American Society of Anesthesiology (ASA) 3 or more. No cases of testicular atrophy occurred. In five boys, we observed seven cases of high testes requiring subsequent orchiopexy (4% of 172 hernia repairs among the boys). The regression analysis showed that for every 1 kg less body weight, the risk of an undescended testis increased by 65.5%. CONCLUSION: Laparoscopic inguinal hernia repair for babies weighing 5 kg or less is feasible, safe, and perhaps even less technically demanding than open herniotomy.

Closure of the cystic duct during laparoscopic cholecystectomy in children using the LigaSure Vessel Sealing System.

BACKGROUND: The goal of the present study was to evaluate the efficacy of the LigaSure(™) Vessel Sealing System (LVSS) when used for cystic duct closure during laparoscopic cholecystectomy in children and adolescents. METHODS: The laparoscopic cholecystectomy was performed beginning with visualization of Calot's triangle, and dissection of Calot's triangle was achieved using a monopolar cautery device. Once the cystic duct was exposed, sealing was performed proximally and distally, and the cystic duct was divided midway using the LVSS. The procedure was completed in the standard fashion. RESULTS: The closure of the cystic duct was performed in seven cases of simultaneous cholecystectomy and splenectomy and in 15 cases of microlaparoscopic cholecystectomy. The patients' ages ranged from 7 to 21 years (average = 14.5 years), and body weight ranged from 42 to 83 kg (average = 58 kg). There was no bile leakage noted, and the closure of the cystic duct was sufficient in all cases. We noted one case of common bile duct obstruction on postoperative day 1. In this case, an exploration of the biliary tree was performed by laparotomy. No direct injury to the common bile duct was found during exploration, but thermal changes were detected in the surrounding tissues as a result of transmitted thermal energy caused by bipolar cautery device. CONCLUSION: The closure of the cystic duct using the LVSS is feasible and effective in laparoscopic cholecystectomy in children. However, it is important to keep a safe distance from other intra-abdominal structures when using thermal energy devices to prevent thermal collateral damage.

Microlaparoscopic pyloromyotomy in children: initial experiences with a new technique.

INTRODUCTION: We conducted a prospective feasibility study to evaluate the value of microlaparoscopic pyloromyotomy for hypertrophic pyloric stenosis in infants. METHODS: All data were prospectively collected, and the procedures were documented by video recording. Patients were selected based on the availability of the equipment and consultant surgeons experienced in microlaparoscopy. Microlaparoscopic (exclusive use of 2-mm instruments and small-diameter scopes, 1.7-1.9 mm in diameter) pyloromyotomy was performed. All procedures were done under general anesthesia with endotracheal intubation. RESULTS: This study includes 21 infants, 14 boys and 7 girls (aged 3-12 weeks, average 4.8 weeks). Weight at admission averaged 4,100 g (range 3,200-5,500 g). Mean wall thickness of pyloric muscle measured by ultrasound was 4.5 mm (range 3.8-7.8 mm). Average operative time was 13 min for the consultant surgeon. Full feeding was attained on the first postoperative day in 16 infants. Postoperative length of stay averaged 87 h. Eighteen infants were re-examined to assess cosmesis. CONCLUSION: Despite the limited patient population included in this study, we conclude that use of microlaparoscopic pyloromyotomy for hypertrophic pyloric stenosis is safe and feasible, and the technique provides minimal access trauma and superior cosmesis.

The use of a plastic bag from a drain package instead of an endobag in children: a safe, effective, and economical alternative.

PURPOSE: The standard endobags require large trocars; because the authors routinely use 2- to 5-mm instruments, they were looking for complementary specimen retrieval device alternatives. For this purpose, they recently used a plastic bag from a drain package to exteriorize abdominal masses during laparoscopy in children. METHOD: A plastic bag from a drain package--the innermost cover--was placed into the abdominal cavity trough a 5-mm trocar. The plastic bag was intraabdominally uncoiled with 2-mm instruments. Bag plus specimen were exteriorized via the umbilicus. RESULTS: During the last 4 years, the authors have removed various specimens in 135 cases. The specimens were successfully retrieved in all cases. No rupture of the bag or slippage was observed. One commercial endobag costs the same as 359 "plastic bags." CONCLUSION: Based on the authors' experience in pediatric laparoscopy, they feel that the use of plastic bags for retrieval of abdominal specimens is feasible, safe, and economical.