The effect of intermittent intraabdominal pressure elevations and low cardiac output on the femoral to carotid arterial blood pressure difference in piglets.

BACKGROUND: Our previous work in a laparoscopic setting in piglets revealed that the systolic femoral artery pressure was approximately 5 % higher than its carotid counterpart, whereas the mean and diastolic values showed no significant difference. This remained idem when the intraabdominal pressure (IAP) was gradually increased. In this study, we aimed to investigate the effect of (1) intermittent IAP elevations and (2) a low cardiac output (CO) on the blood pressure (BP) difference cranially (carotid artery) and caudally (femoral artery) of a capnoperitoneum (ΔP = P a fem-P a carot). METHODS: A total of twenty-two piglets (mean body weight 11.0 kg; range 8.9-13.3 kg) were studied. Of these, 14 underwent intermittent IAP elevations at 8 and 16 mmHg, and ΔP was measured. In another 8 piglets, a model of reduced CO was created by introducing an air embolism (2 ml/kg over 30 s) in the inferior caval vein (VCI) at 12 mmHg IAP to further assess the influence of this variable on ΔP. RESULTS: Systolic ΔP remained at a mean of 5.6 mmHg and was not significantly affected by insufflation or exsufflation up to an IAP of 16 mmHg. Diastolic and mean values showed no differences between P a carot and P a fem. P a fem, systol remained higher than its carotid counterpart as long as the cardiac index (CI) was above 1.5 l/min/m2, but fell significantly below P a carot, systol at a low CI. There was no CO-dependent effect on diastolic and mean ΔP. Repeated IAP elevations do not significantly influence ΔP. CONCLUSIONS: Intermittent IAP elevations do not significantly influence ΔP. Despite of a CO-dependent inversion of systolic ΔP, mean BP measurements at the leg during laparoscopy remain representative even at low CO values.

The Role of Laparoscopy in the Acute Neonatal Abdomen.

IntroductionThe surgical treatment of the acute neonatal abdomen still poses a challenge in pediatric surgery. Various underlying etiologies require different surgical procedures. Until today the role of laparoscopy in the surgical treatment of the acute neonatal abdomen is controversial. The aim of this study was to analyze our experiences with laparoscopy and to perform a review of the literature. Methods Retrospective, single-institution study including all term and preterm neonates initially undergoing laparoscopy due to an acute abdomen. Results Altogether, 17 neonates presenting with an acute neonatal abdomen initially underwent laparoscopy. Unnecessary laparotomy could be avoided in 9 of 17 (53%) neonates. After diagnostic laparoscopy, 2 patients did not require any further surgical intervention. Eight neonates presented midgut atresia intraoperatively, 5 of them underwent laparoscopic-assisted correction. Successful laparoscopic derotation of an acute volvulus (n = 1) and laparoscopic appendectomy (n = 1) could be performed. Conversion to open surgery was necessary in 8 neonates (47%) due to creation of a stoma (n = 5), multiple intestinal bands causing poor visualization (n = 2), and bowel necrosis (n = 1). Conclusions Laparoscopy is a useful diagnostic tool to evaluate the need for further surgical intervention in the acute neonatal abdomen and enables immediate surgical treatment of acute volvulus, appendicitis, or intestinal atresia. In case of conversion to laparotomy, precise localization of the incision is guaranteed. Minimization of the surgical trauma and avoidance of unnecessary laparotomy are the most important benefits of the minimal-invasive approach for the critically ill neonate.

Work-related upper limb musculoskeletal disorders in pediatric minimally invasive surgery: a multicentric survey comparing laparoscopic and sils ergonomy.

PURPOSE: Surgeons are at risk for developing work-related musculoskeletal symptoms (WMS). The present study aims to compare laparoscopy and SILS ergonomy among pediatric surgeons. METHODS: A questionnaire formed by 17 questions was mailed to 14 pediatric surgeons, seven with a large experience in laparoscopy and seven in SILS. All surgeons completed the survey. The questionnaires were focused on the type of laparoscopic or SILS activity, location and type of pain, need for drugs and its physical consequences. Results were analyzed using χ(2) test. RESULTS: Results indicated a similar incidence of WMS with shoulder symptoms (>75%) in both groups. In laparoscopic group this pain is evident only after a long lasting procedure, while in SILS group the pain is present after each procedure performed. SILS surgeons used painkillers and other therapies statistically more frequently than laparoscopic group (χ(2) = 0.001). CONCLUSIONS: This study confirms there is a strong association between WMS and MIS surgery. The incidence of pain is similar in both groups. Pain was present only after long lasting procedures in laparoscopic group, while SILS surgeons have pain after each procedure performed. In addition SILS surgeons use more frequently painkillers and other therapies compared to laparoscopic surgeons. In conclusion, it seems that SILS has a worse ergonomy compared to laparoscopy.

Air in the insufflation tube may cause fatal embolizations in laparoscopic surgery: an animal study.

BACKGROUND: The aim of this study was to evaluate the risk of an air embolization with the volume of the insufflation tube during induction of laparoscopy. A further objective was to determine the LD50 of air in young piglets. METHODS: End-tidal carbon dioxide pressure ([Formula: see text]), pulmonary arterial pressure (P pa), heart rate (f c), and mean arterial pressure (P a carot) were measured in 17 piglets divided into three groups: group 1 (n = 6), bolus application (CO2 embolization, followed by air embolization, 2 mL/kg each), group 2 (n = 7), continuous air embolization (30 min, 0.2 mL/kg/min), and group 3 (n = 4), continuous CO2 embolization (30 min, 0.4 mL/kg/min). RESULTS: All animals survived CO2 embolism. Air embolization as a bolus (2 mL/kg) or with an accumulated volume of 3.1 mL/kg led to death. Decreases in [Formula: see text] indicated air or massive CO2 embolization only. There was a good correlation between [Formula: see text] and P pa in case of air embolization (r = -0.80, p < 0.0001). In contrast, no dependency was recognized during CO2 embolism (r = -0.17, p = 0.2). CONCLUSIONS: In order to minimize the lethal risk of gas embolization, the insufflation system has to be completely filled with CO2 before connecting to the patient.

Hemodynamic effects of laparoscopic surgery in term and preterm infants with cardiac anomalies.

PURPOSE: The aim of this study was to clarify whether cardiac anomalies are a reasonable contraindication to laparoscopic surgery in infants. METHODS: Between January 2004 and January 2013, 131 term and preterm infants with cardiac anomalies underwent laparoscopic surgery within the first 6 months of life. In this retrospective study type of cardiac anomaly, performed operative procedure, operative time, intraabdominal pressure and postoperative complications were evaluated. RESULTS: Over this 9-year period, 80 preterm and 51 term infants underwent different complex and even long-lasting laparoscopic procedures. Median operative time was 67 min with a median intraabdominal pressure of 13 mmHg. Cardiac anomalies ranged from persistent foramen ovale, atrium septal defect to ventricular septal defect and tetralogy of Fallot. In the postoperative course hemodynamic impairment was noted in three infants (2.3 %). Only one of them presented cardiorespiratory instability. CONCLUSION: In this study different laparoscopic procedures could be performed in numerous infants with cardiac anomalies. Due to the inhomogeneity of this group of patients and individual combinations of heart defects with or without hemodynamic relevance, preoperative evaluation by a firm pediatric cardiologist is crucial. Prospective studies are necessary to further clarify the use of laparoscopic surgery in this distinct group of patients.

The role of laparoscopy in the treatment of duodenal obstruction in term and preterm infants.

PURPOSE: The aim of this study was to evaluate the role of laparoscopy in the surgical treatment of intrinsic and extrinsic duodenal lesions referring to the underlying cause of obstruction. METHODS: Retrospective chart review of all cases of duodenal obstructions undergoing surgery at our institution between April 2004 and March 2012. RESULTS: Twenty patients underwent surgery for duodenal obstruction (11 female, 9 male). Seven infants were born prematurely. Eleven infants had extrinsic, seven had intrinsic and two had a combination of intrinsic and extrinsic duodenal lesions. A laparoscopic procedure was initially started in 18 of 20 patients (90 %). Thirteen of the 18 infants (72 %) underwent various laparoscopic procedures: laparoscopic duodenoduodenostomy, resection of a duodenal membrane and the transsection of Ladd's bands. In five patents, a conversion became necessary due to poor visualisation of the duodenum. In three patients (15 %) with extrinsic duodenal lesion a reoperation was necessary. Two of the 20 patients (10 %) were operated with an "open" approach to begin with. CONCLUSION: Laparoscopy is feasible and safe in most cases. The few conversions were early in the series due to a lack of experience and necessitated by poor visualisation, most often caused by malrotation.

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.

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.

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 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.

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.

Feasibility of microlaparoscopy for surgical procedures of advanced complexity in children.

UNLABELLED: Abstract Purpose: We conducted a prospective study to determine the value and the feasibility of the microlaparoscopic approach for surgical procedures of advanced complexity in children. We report our experience with these small instruments. We also report the preliminary results of a recently developed 2.4 mm prototype scope, specifically developed for the present study. METHODS AND PATIENTS: This study includes 15 children (aged two weeks to 11 years; median, 2.8 years). Eighteen procedures with advanced complexity were carried out: Nissen fundoplication, thoracoscopic congenital diaphragmatic hernia repair in a newborn, hiatoplasty with repair of an upside-down-stomach, laparoscopically assisted pull-through for Hirschsprung's disease in a newborn, laparoscopic transperitoneal pyeloplasty and laparoscopy for acute abdominal illness. RESULTS: No complications occurred due to the exclusive use of 2 mm instruments. All microlaparoscopy procedures were performed successfully except one fundoplication that was converted to an open procedure due to anatomical deformities. The average operative times for the 5 mm and 2 mm groups were similar compared across a similar age and type-of-intervention population. CONCLUSION: The microlaparoscopic approach for surgical procedures of advanced complexity in pediatric surgery is feasible, safe, and effective in conditions where they are indicated and are practical in terms of the surgeon's experience and the facilities. The advantages of microlaparoscopy are obvious: minimum access trauma, "nearly scarless" healing, less risk of damage to abdominal organs, the possibility of fewer adhesions and less postoperative pain. We suggest the further consideration of the use of the microlaparoscope for advanced laparoscopic procedures in children.

Microlaparoscopic-assisted gastrostomy in children: early experiences with our technique.

INTRODUCTION: The aim of this prospective study was to evaluate the feasibility and safety of a new technique for microlaparoscopic-assisted gastrostomy (MAG) in children and infants by using a 1.9-mm scope only. In this paper, we report our early experiences with this method. MATERIALS AND METHODS: In a prospective study, MAG was performed on 12 children (7 boys and 5 girls) after a primary percutaneous endoscopic gastrostomy procedure was considered not feasible or unsafe. The median patient age at the time of surgery was 1.2 years (range, 4 months to 4 years). A 1.7- or 1.9-mm 0-degree scope was introduced at the umbilicus. A 5-mm port was placed over the stomach at the designated site for the tube placement. The stomach was grasped and exteriorized. The gastrostomy was opened, and a balloon gastrostomy tube was placed. RESULTS: In 12 children, the procedure was successfully completed without conversions. Mean operative time was 19 minutes (range, 13-35). No intraoperative complications occurred. Feeds were instituted 5 hours postoperatively and quickly advanced the following day in 11 of 12 children. The procedure may be performed as day surgery. CONCLUSIONS: In our opinion, MAG is a feasible, safe procedure in children. Technically, it is a simple method, particularly in cases where percutaneous tube placement is not feasible. It combines the advantages of microlaparoscopy and open surgery. It is easy to perform in children and allows a primary gastrostomy tube placement. Parents and nursing staff also seem satisfied.

Evaluation of severely displaced radial neck fractures in children treated with elastic stable intramedullary nailing.

BACKGROUND: We performed a retrospective case study of 28 consecutive severely displaced radial neck fractures (Judet types III and IV) in children treated with elastic stable intramedullary nailing using the Metaizeau technique. METHODS: We reviewed all preoperative radiographs and classified the injuries according to Judet. All patients were asked to return for later assessment. They underwent physical examination; radiographs were taken; and they were asked for subjective assessment. An evaluation of clinical results was performed using the Mayo Elbow Performance Score (MEPS). RESULTS: According to Judet classification there were 13 type III and 15 type IV fractures. Using the MEPS, excellent results were achieved in 23 cases (82%) and good results in 5 cases (18%). The average MEPS was 97 points. Five patients complained of mild pain. Three malunions were observed. CONCLUSIONS: Elastic stable intramedullary nailing is a minimally invasive technique, allowing stable fixation and providing excellent to good outcomes with a low complication rate. LEVEL OF EVIDENCE: We performed a retrospective level 4 study of case series.

Characteristics of laparoscopic inguinal hernia recurrences.

PURPOSE: This is so far the largest series of recurrences after laparoscopic inguinal hernia repair. METHODS: Video documents of 1,071 laparoscopic inguinal hernia repairs were retrospectively studied with respect to the affected side, anatomical appearance, gender, history and time interval between operation and recurrence. Only indirect, clinically manifest hernias were included. RESULTS: Recurrences occurred in 32 children (3%), 26 boys and 6 girls, aged 62 days to 14 years (median 3). The right side was affected in 21 children, the left in 10 and a bilateral recurrence was noted in 1 child. A total of 25 recurrences occurred medially to the previous suture and 7 laterally. The knot became loose in three cases. An experienced surgeon had only half the recurrences of a less experienced surgeon. The median time interval between surgery and recurrence was 3.8 months. Children up to the age of 2 years had the highest risk of recurrence. The right/left incidence of recurrences roughly was in proportion to the statistical incidence of hernias. CONCLUSIONS: Boys had more recurrences than girls. Most recurrences occur medially. The more experienced the surgeon was, the fewer recurrences he had. The stitches at the medial aspect of the hernia, close to the vas, seem to be the most crucial ones.

Are Cardiac Anomalies and Persistent Fetal Circulation a Risk Factor for Cardiovascular Events During Minimally Invasive Surgery in Neonates?

Introduction: Minimally invasive surgery (MIS) in neonates is progressively performed. The aim of this study was to evaluate the risk for cardiovascular events during endoscopic surgery in neonates and to analyze the influence of persistent fetal circulation and/or cardiac anomalies. Materials and Methods: This is a retrospective single institution study including all neonates undergoing MIS. The charts were reviewed for intraoperative cardiovascular events and operative procedure was performed. Special attention was paid to cardiac anomalies and persistent fetal circulation. In addition, a review of the literature was performed. Results: Between January 2004 and December 2012, 108 neonates underwent MIS at our institution. Laparoscopic surgery was performed in 91 (84.3%) and thoracoscopy in 17 (15.7%) babies. None of these 108 patients developed a cardiovascular event during endoscopic surgery (0.0%). Persistent fetal circulation and/or cardiac anomalies were evaluated in 50 of 108 (46.3%) neonates. In the additionally performed review of the literature, four single case reports were identified. All 4 authors published a major cardiovascular event during laparoscopic surgery in neonates. In all 4 patients, gas embolism through a patent umbilical vein was assumed to be responsible for the cardiovascular event. Conclusions: In our opinion, the main risk factor for the development of a major cardiovascular event during MIS in neonates is vascular injury of a persistent umbilical vein. Persistent fetal circulation and/or cardiac anomalies seem to be less important. In case of injury of a persistent umbilical vein, the risk of gas embolism has to be respected and conversion to the open approach has to be considered.

Gender-related differences of inguinal hernia and asymptomatic patent processus vaginalis in term and preterm infants.

INTRODUCTION: The aim of this study was to analyze the gender-related differences of inguinal hernia (IH) and patent processus vaginalis (PPV) in term and preterm infants. METHODS: Over a nine-year-period 411 infants underwent laparoscopic herniorrhaphy within the first six months of life. 246 term (191 male; 55 female) and 165 preterm (118 male; 47 female) infants were included in this retrospective study. Initial presentation of IH and intraoperative anatomical findings of PPV were reviewed. RESULTS: We found that term boys (58.6%) and girls (58.2%) predominantly presented with right-sided IH whereas preterm boys (36.4%) and girls (44.7%) mostly presented with bilateral IH. Female babies had a higher incidence of initial left-sided IH. Term and preterm girls with initial left-sided hernia were found to have highest incidence of PPV. Male term babies with initial left-sided IH were found to have the lowest incidence of PPV (25.0%). The highest incidence of PPV in male was found in preterm boys with either left- or right-sided IH. CONCLUSION: Incidence and laterality of IH and PPV differ between term and preterm girls and boys. In open hernia repair decision concerning contralateral groin exploration should consider term/preterm birth as well as gender.

Risk of Malignancy and Need for Surgery in Pediatric Patients with Morris or Y-chromosome Turner Syndrome: A Multicenter Survey.

STUDY OBJECTIVE: The management of intersex patients with Y-chromosome Turner or Morris syndrome remains a challenge. We report our experience with a multicenter European survey. DESIGN: We collected the data on 18 patients (mean age 10.2 years, range 2-17 years) with Morris (10 patients) or Turner (8 patients) syndrome harboring the Y chromosome who were treated in 1 of 6 European centers of pediatric surgery between 1997 and 2013. All patients were evaluated by use of a multidisciplinary diagnostic protocol. All patients received a bilateral gonadectomy via laparoscopy; only 1 center performed ovarian cryopreservation. Seven patients received a concomitant genitoplasty. Operative notes and histology were reviewed for details. RESULTS: No conversions to laparotomy and no complications were recorded. For the patients receiving only the gonadectomy, the length of hospital stay was 24-48 hours, whereas for the patients receiving an associated genitoplasty, it was 6-10 days. Specimens were negative for tumors in 83.3% of cases, whereas in 3 patients (16.6%), benign abnormalities (Sertoli cell hyperplasia in 1 patient and ovotestis in 2 patients) were recorded. A malignant tumor was not recorded in our series. CONCLUSION: If the risk of malignancy is considered as the main indication for surgery in case of Turner or Morris syndrome, on the basis of our study, this indication should be reevaluated. However, based on the non-negligible rate of benign abnormalities reported in our series (16.6%), the performance of cryopreservation to preserve fertility and the possibility of performing genitoplasty during the same anesthetic procedure represent additional valid indications for surgery.

Hemodynamic effects of thoracoscopic surgery in neonates with cardiac anomalies.

INTRODUCTION: Thoracoscopic repair of esophageal atresia (EA) and congenital diaphragmatic hernia (CDH) repair is increasing in popularity. However, minimally invasive surgery is avoided in infants with heart defects. The aim of this study was to clarify whether cardiac anomalies are a reasonable contraindication to thoracoscopic surgery in term and preterm neonates. PATIENTS AND METHODS: In this retrospective, single-institution study 15 neonates (8 boys and 7 girls) with cardiac anomalies underwent thoracoscopic repair of either EA or CDH. Between January 2004 until November 2012 4 preterm and 11 term neonates were identified. Type of cardiac anomaly, operative procedure performed, operative time, intrapleural pressure, and early postoperative complications were evaluated. RESULTS: Over this 9-year period, 10 neonates underwent thoracoscopic EA repair, and 5 neonates underwent thoracoscopic CDH repair. Median operative time was 177 minutes with a median intrapleural pressure of 9 mm Hg. Cardiac anomalies ranged from persistent foramen ovale to atrium septal defect to ventricular septal defect and tetralogy of Fallot. In the postoperative course hemodynamic impairment was noted in only 1 patient. This patient presented cardiorespiratory instability already preoperatively and required dobutamine until postoperative Day 6. CONCLUSIONS: From this experience it appears that thoracoscopic surgery can be performed safely in term and preterm neonates with cardiac anomalies. Even in babies with multiple cardiac anomalies and complex heart defects, thoracoscopic repair of EA or CDH could be performed without hemodynamic instability. Nevertheless, further studies are necessary to gain sufficient information about the effects of thoracoscopy in neonates with heart defects.

Comparison of inguinal hernia and asymptomatic patent processus vaginalis in term and preterm infants.

INTRODUCTION: The aim of this study was to evaluate the characteristics of inguinal hernia (IH) and patent processus vaginalis (PPV) in term and preterm infants less than the age of 6months. METHOD: Between January 2004 and December 2012, 246 term and 165 preterm infants underwent laparoscopic herniorrhaphy within the first 6months of life. Preoperative clinical presentation and intraoperative anatomical findings during the laparoscopic procedure were evaluated. Additionally, initial side of hernia, laterality of IH and PPV were analyzed in term and preterm infants. RESULTS: In the group of term infants, most infants presented with a primary right-sided IH (58.5%) versus 17.9% left-sided and 23.6% bilateral IH. Babies with primary unilateral IH were found to have a contralateral PPV in 41.0% of cases. A difference between left-sided PPV and right-sided PPV could not be identified. In the group of preterm infants, initial bilateral presentation was predominant (38.8%) versus right-sided (30.3%) and left-sided IH (30.9%). Infants with primary unilateral IH were found to have a contralateral PPV in 56.4%. We identified a slight difference between left-sided PPV (54.0%) and right-sided PPV (58.8%). CONCLUSION: IH is predominantly right sided in term infants, whereas preterm infants mostly present with bilateral IH. The incidence of PPV was found to be significantly higher in the preterm group. Regarding the incidence of a contralateral PPV in term and preterm infants, no difference between initial left-sided and right-sided IH could be identified between both groups.