Use of Barbed Sutures for Congenital Diaphragmatic Hernia Repair.

BACKGROUND: Congenital diaphragmatic hernia (CDH) repair can be challenging, particularly when a larger defect is present. Barbed sutures prevent the suture from slipping back after approximation of the tissues. Although introduced almost 2 decades ago, barbed sutures have not been widely used for CDH repair. We report our initial experience and pitfalls. METHODS: All patients presenting with CDH from 2021 onward underwent repair using barbed sutures. Demographics, operative parameters, complications, and outcomes were prospectively recorded. RESULTS: A total of 13 patients underwent CDH repair during the study interval (median age 6 days, range 3 days to 5.75 years). Median operative time was 89 min (range 46 to 288 min). Five thoracoscopic and eight open procedures were performed. Severe pulmonary hypertension and ECMO (extracorporeal membrane oxygenation) were considered contraindications for thoracoscopic repair. The included patients were compared to a historic controlled group performed without barbed sutures. The barbed suture facilitated easy and quick closure of the defects in most cases and obviated the need for knot tying. One patient in the thoracoscopic group had a patch placed due to high tension after the barbed sutures tore the diaphragm. At a median follow-up time of 15 months (range 2 to 34 months), one patient had died, and one patient with complete diaphragmatic agenesis was home-ventilated. There were no recurrences. Median operative time trended lower (89 min) than in the historic control group repaired without barbed sutures (119 min, p < 0.06) after eliminating outliers with large, complex patch repairs. CONCLUSIONS: Barbed sutures simplify congenital diaphragmatic hernia repair regardless of whether a minimal-invasive or open approach is performed. Patch repair is not a contraindication for using barbed sutures. The resulting potential time savings make them particularly useful in patients with cardiac or other severe co-morbidities in which shorter operative times are essential. In cases with high tension, though, the barbs may tear through and produce a "saw" effect on the tissue with subsequent damage.

Reply to Peña, A. Comment on "Küppers et al. Percutaneous Anorectoplasty (PARP)-An Adaptable, Minimal-Invasive Technique for Anorectal Malformation Repair. Children 2022, 9, 587".

Thank you so much for your thoughtful comments [...].

Percutaneous Anorectoplasty (PARP)-An Adaptable, Minimal-Invasive Technique for Anorectal Malformation Repair.

BACKGROUND: Anorectal malformations comprise a broad spectrum of disease. We developed a percutaneous anorectoplasty (PARP) technique as a minimal-invasive option for repair of amenable types of lesions. METHODS: Patients who underwent PARP at five institutions from 2008 through 2021 were retrospectively analyzed. Demographic information, details of the operative procedure, and perioperative complications and outcomes were collected. RESULTS: A total of 10 patients underwent the PARP procedure during the study interval. Patients either had low perineal malformations or no appreciable fistula. Most procedures were guided by ultrasound, fluoroscopy, or endoscopy. Median age at PARP was 3 days (range 1 to 311) days; eight patients were male. Only one intraoperative complication occurred, prompting conversion to posterior sagittal anorectoplasty. Functional outcomes in most children were highly satisfactory in terms of continence and functionality. CONCLUSIONS: The PARP technique is an excellent minimal-invasive alternative for boys born with perineal fistulae, as well as patients of both sexes without fistulae. The optimal type of guidance (ultrasound, fluoroscopy, or endoscopy) depends on the anatomy of the lesion and the presence of a colostomy at the time of repair.

Successful Foley catheter tamponade of an epigastric vessel trocar injury in a toddler - A case report.

INTRODUCTION AND IMPORTANCE: Injuries to the inferior epigastric vessels during laparoscopic surgery are rare but reported. They can lead to significant morbidity. We report the successful tamponade of a bleeding epigastric vessel during laparoscopic inguinal hernia repair in a child using a Foley catheter. A Foley catheter has not been routinely used in pediatric surgery for this indication so far. CASE PRESENTATION: A 32-month-old boy underwent laparoscopic left inguinal hernia repair. During insertion of a 2 mm trocar, the left inferior epigastric vessels were lacerated, leading to a brisk bleed into the abdominal wall and into the abdomen through the trocar site during the procedure. When the hemorrhage was noted, the trocar was removed. The trocar tract was slightly dilated using a blunt forceps and a 12 F Foley catheter was introduced into the abdomen. The balloon was insufflated with 10 ml of water and the catheter was retracted towards the abdominal wall, tamponading the bleed. The inguinal hernia repair was completed, and after desufflating the catheter at the end of the procedure, the hemorrhage had stopped. CLINICAL DISCUSSION: Postoperatively, the hemoglobin had dropped by 1.5 g/dl to 9.3 g/dl. The patient was observed and then discharged on the same day. Besides an additional 2 mm scar in the right lower quadrant, he had no further sequellae or adverse effects. CONCLUSION: Hemorrhage resulting from trocar injury of the inferior epigastric vessels during laparoscopy can be controlled by Foley catheter insertion and tamponade in children. Pediatric surgeons should be aware of this useful maneuver to manage this complication.