Technical aspects of the thoracoscopic repair of a late presenting congenital H-type fistula.

Congenital H-type fistulae are a rare abnormality. They commonly present with only minor respiratory complications and can, therefore, be difficult to identify. Conventionally, correction is via a ligation performed via either a cervical or thoracotomy incision, dependant on the fistula site. Thoracoscopic repair is emerging as a tenable alternative to traditional approaches and offers some advantages. This paper details the technical aspects of the thoracoscopic ligation of an H-type fistula.

Does the placement of a FRECA gastrostomy at the time of laparoscopic fundoplication impact on outcome?

AIM: To assess the performance of a paediatric cohort having a FRECA PEG (FP) placed at the time of laparoscopic fundoplication. METHODS: This is retrospective study of a single surgeon's experience of laparoscopic fundoplications over a decade. Patient details were retrieved form a Microsoft Excel database and demographic, operative, and performance measures analysed. RESULTS: Of a series of 67 laparoscopic fundoplications, 20 with neurological compromise underwent FP placement at the time of surgery. Mean age was 3.37 years with a male to female ratio of 1.1:1. A size 9 French FRECA was placed in patients less than 10 kg (12) with larger patients (8) having a size 15 device. A Watson anterior wrap was performed in 16 cases with the rest having a Nissen fundoplication. Seven of these cases had pre-existing FPs which were taken down before replacement post fundoplication. Feeding was resumed the next morning except in three with delayed gastric emptying. Other complications (3) were seen but were not PEG related. The median stay for the series was 4 days (SD 3) and patients were followed up for a mean of 684 days. Over this period four patients relapsed and resumed medical treatment. A single mortality occurred in a syndromic 3-year-old a year later from problems unrelated to surgery. FPs were changed to a button device under general anaesthetic 3-24 months following placement. CONCLUSION: FP placement at the time of laparoscopic fundoplication does not appear to compromise the outcome of surgery. Neither the size of patient nor the type of wrap is an impediment to its placement and the device can be used shortly after surgery in the majority allowing for an early discharge. Complications are infrequent; however, change to a button device within 2 years of initial placement requires general anaesthetic.

Paediatric cholecystectomy: Shifting goalposts in the laparoscopic era.

BACKGROUND: Laparoscopic cholecystectomy is the treatment of choice in symptomatic paediatric cholelithiasis. However, controversy exists about its role in asymptomatic cholelithiasis and biliary dyskinesia. We have reviewed the experiences of two UK paediatric centres with laparoscopic cholecystectomy over an 8.5 year period and critically evaluated the indications and outcomes of surgery. METHODS: Patients who underwent laparoscopic cholecystectomy by a single surgeon at the Royal Aberdeen and Royal Alexandra Hospitals between May 1996 to August 2003 and September 2003 to December 2005, respectively, were studied. Information was extracted from prospectively held databases and analysed. RESULTS: A total of 27 cholecystectomies were performed during the period of study. The mean age of patients was 11.7 years with a female preponderance. Symptomatic idiopathic cholelithiasis was the main indication for surgery (14). Cholecystectomy was also performed for haemolytic disease (3), acute recurrent pancreatitis of unknown cause (2), gallbladder trauma (1), and for asymptomatic calcific non-resolving stones (7). All patients were investigated with ultrasound scans with four patients undergoing magnetic resonance cholangiopancreatography (MRCP) for suspected common bile duct (CBD) stones. A standard four-port approach was used with the gallbladder extracted through the umbilical port. The mean operative time in the latter 13 cases was 105 minutes with a median postoperative stay of one day for the whole series. Histology revealed chronic cholecystitis in all but three cases. All patients were discharged after a six-month follow-up period. CONCLUSIONS: The advent of laparoscopy has resulted in an expansion of the traditional indications for cholecystectomy. MRCP is a useful investigation in selected children to exclude choledocholithiasis and avoid intraoperative cholangiography. There appears to be no clear correlation between histology and presenting symptoms. The natural history of asymptomatic gallstones in children is not known although a consensus is emerging to support cholecystectomy for all calcific non-resolving gallstones.

A two-center experience with the exclusive use of laparoscopic transperitoneal nephrectomy for benign renal disease in children.

BACKGROUND: This study aimed to evaluate a two-center experience with pediatric transperitoneal laparoscopic nephrectomy, specifically focusing on the outcome parameters of operative time, complication, analgesic requirement, and postoperative stay. METHODS: This ambispective study was conducted over a 4-year period between May 2001 and May 2005 in two tertiary pediatric surgical centers. Data were prospectively recorded from an in-house expanded medical audit system (EMAS) and a Microsoft Excel database. Information on patient demographics, operative time, complications, analgesic requirement, and length of hospital stay were retrieved and analyzed. RESULTS: A total of 30 consecutive patients with a mean age of 4.43 years (range, 3 months to 15 years) underwent laparoscopic nephrectomy. All the patients underwent unilateral nephrectomy/nephroureterectomy for multidysplastic kidney (n = 12), reflux nephropathy (n = 13), pelvicoureteric junction obstruction (n = 4), or cystic disease of indeterminate cause (n = 1). The mean operative time was 93 +/- 30 min. The principal hemostatic devices used were the Harmonic Scalpel (20 cases), liga clips (5 cases), and hook diathermy and endoshears exclusively (4 cases). There were no conversions, but the intraoperative complications of bleeding (n = 2), difficult location (n = 1), difficult extraction (n = 1), and requirement for a liver retractor (n = 2) were encountered. An additional five patients had problems in the immediate postoperative period, two of whom went on to have long term difficulties with recurrent urinary tract infections resulting from a residual ureteric stump, which required surgery. Nearly one-third of the patients required morphine for analgesia in the immediate postoperative period, with the figure falling to 20% by day 1. The median postoperative hospital stay was 1 day (range, 0-16 days). At this writing, all the patients remain under surveillance with a mean follow-up period of 2.88 years, and no patients have experienced complications secondary to intraabdominal adhesions. CONCLUSION: Transperitoneal laparoscopic nephrectomy is technically feasible in most cases of benign renal disease. The intraoperative complications are minimal, and recovery for most is robust. Two-thirds of the patients are discharged within 24 h. In this study, narcotic analgesics were prescribed in about a one-third of all the cases for a limited period. Further problems may be seen when refluxing ureters are incompletely excised. However, the transperitoneal approach does not mitigate against complete excision because the exposure to the pelvis is adequate. At the midterm follow-up assessment, adhesive obstruction was not encountered, confirming this approach as a tenable alternative to other laparoscopic approaches for nephrectomy.

Laparoscopic nephrectomy for unilateral multicystic dysplastic kidney in children.

The contemporary management of children with unilateral multicystic dysplastic kidney remains controversial. With the potential risks of hypertension, infection, and malignant transformation of the dysplastic kidney, conservative management necessitates long-term review with frequent ultrasound scans, urine analyses, and blood pressure checks. Operative management has traditionally used open nephrectomy with its associated patient morbidity. The introduction of laparoscopic procedures has allowed the development of techniques that reduce patient morbidity, hospital stay, and analgesia requirement. This article reports a series of 13 children who underwent elective laparoscopic nephrectomy for unilateral multicystic dysplastic kidney and discusses the advantages this procedure has to offer for their management.

Laparoscopy in a case of pediatric blunt abdominal trauma.

The use of laparoscopy in the assessment and treatment of blunt abdominal trauma has been reported for both adults and children. With increasing surgical experience and improvements in equipment, an expanding range of therapeutic interventions is available. The management of a 7-year-old boy who sustained blunt abdominal trauma during a fall from a bicycle is described. He was hemodynamically stable, but his abdomen remained tender, with guarding in the right upper quadrant. Serial ultrasound scans showed a thick-walled gallbladder and increasing intraabdominal fluid. Laparoscopy was used both as a diagnostic tool, and then as a therapeutic method. Diagnostic laparoscopy showed a ruptured gallbladder treated by laparoscopic cholecystectomy. A 3-cm grade 1 liver laceration also was identified, which required no intervention. Free bile was aspirated and the peritoneal cavity thoroughly lavaged. The child made a rapid postoperative recovery. The ultimate aim in the management of blunt trauma is to avoid unnecessary laparotomy while preventing undue delay in the detection of significant intraabdominal pathology. Computed tomography scanning, ultrasound scanning, and diagnostic peritoneal lavage all have strengths for detecting different injury types, but they also have a low specificity in determining the need for laparotomy. The advantages and limitations of laparoscopy in hemodynamically stable children who have sustained injuries from blunt trauma are discussed. The authors recommend laparoscopy in experienced hands as an additional tool for the optimal management of selected trauma cases.

Laparoscopy in the diagnosis and management of a complicated paraovarian cyst.

Paraovarian cysts account for 10% of adnexal masses and are most common in the 3rd and 4th decades of life. They vary from small asymptomatic lesions to larger cysts, which may undergo hemorrhage or torsion. Children are rarely affected, and the diagnosis--particularly if pain presents in the right lower quadrant--may be difficult because the differentials diagnosis is wide. We report the case of a child who presented with a complicated paraovarian cyst. Laparoscopy enabled immediate diagnosis and appropriate management. We discuss the role of laparoscopy and the value of the Harmonic Scalpel in the management of these rare cysts.

Outcome after intra- and extra-corporeal laparoscopic appendectomy techniques.

BACKGROUND: This study aimed to assess the outcome after intracorporeal (IC) and extracorporeal (EC) laparoscopic appendectomy technique in a single institution over a 5-year period. METHODS: Records of all children ( n = 60) who underwent laparoscopic appendectomy at the Royal Aberdeen Children's Hospital between February 1997 and March 2002 were retrieved and evaluated. Observations were made regarding operative technique, anesthetic time, intra- and postoperative complications, postoperative analgesic requirement, and postoperative hospital stay. RESULTS: There were 30 children in each group who had a similar demographic profile. The magnitude of appendicitis severity in both groups was similar. The mean anesthetic time was 67.8 min for the IC group and 50.7 min for the EC group (p = 0.001). There were no recorded intraoperative complications, although a single case in the EC group required conversion to open procedure. The postoperative analgesic requirement in both groups was similar. The mean postoperative stay was 2.1 days in the IC group and 2.5 days in the EC group. Two postoperative complications were noted in the IC group; one intraperitoneal collection and one postoperative chest infection. Four complications occurred in the EC group; one intraperitoneal collection and three minor port-site wound infections. CONCLUSIONS: The authors' experience shows the EC technique to be significantly quicker, although with a slightly increased complication rate. Either technique can be applied safely for acute appendicitis.

Primary cricopharyngeal achalasia in infancy--myotomy treatment of choice.

Dysphagia secondary to primary cricopharyngeal achalasia (PCA) is infrequently seen in paediatric patients. Two female children with PCA who had recurrent attacks of aspiration pneumonia are presented. A cricopharyngeal myotomy was successfully performed in both cases, confirming its efficacy. Investigation and management of this rare condition are reviewed.

A Semicircular Incision in the Superior Umbilical Fold for SILS Preserves the Umbilical Profile.

Background. Single Incision Laparoscopic Surgery (SILS) has been highlighted in the recent literature as a means of performing a range of common, minimal access, paediatric surgical procedures. The primary attraction is the absence of visible scarring. Aim. This study aims to describe a cosmetically advantageous means of SILS port placement in children, which preserves the umbilical profile. Methods. We describe a paediatric case series utilising a semicircular incision in the superior umbilical fold for SILS procedures. The linea alba is exposed over 2 cm just superior to the umbilical ring and stay sutures are applied. A vertical incision is made over this distance without entering the umbilical ring. Data were recorded prospectively in a Microsoft Excel database. Results. Twenty-one cases were performed in a 1-year period. Ten appendicectomies, 5 ovarian/paraovarian cystectomies, 2 Palomo procedures, 3 nephrectomy/heminephrectomies, and 1 Meckel's diverticulectomy were performed. There was 1 wound infection. No incisional hernias occurred. Discussion. We believe that our technique, which maintains the integrity of the umbilical ring and allows preservation of the umbilical profile, offers a distinct cosmetic advantage over other incisions for SILS which distort it. Conclusion. We have demonstrated the aesthetic benefits of utilising a superior umbilical-fold incision for SILS in children.

The benefits of a curved suture needle in laparoscopic partial fundoplications in infants.

A modified Watson fundoplication technique is described using curved needles introduced through the anterior abdominal wall. This technique has clear advantages over ski needles, allows for a wider choice of sutures and helps curtail costs in laparoscopic fundoplication in the small child.

Laparoscopic decapsulation of congenital splenic cysts: a step forward in splenic preservation.

PURPOSE: The aim of this study was to evaluate the role of laparoscopic decapsulation in the management of congenital splenic cysts in children. METHODS: Patients who presented over the last decade with congenital splenic cysts and were treated with laparoscopic decapsulation were reviewed retrospectively. The authors performed 4 procedures in 3 patients aged 10, 11 (and later 13), and 13 years. In all cases there was progressive enlargement of a single cyst, which lay in the upper pole of the spleen in 3 instances and in the lower pole in the fourth. Pneumoperitoneum was induced using the Veress needle technique, and 3 or 4 ports were utilized. Cysts were aspirated initially before marsupialization with excision of around two thirds of the cyst wall. Both endoshears and the harmonic scalpel were used with good hemostatic effect. RESULTS: All patients had a good outcome with cyst resolution on long-term follow-up using serial ultrasound scanning. The first patient (in 1993) remained 3 days as an in patient postoperatively, and the others stayed overnight only. One patient had a new cyst near the first 30 months after the initial procedure. This again was dealt with laparoscopically, with patient discharge the following day. There were no complications in the short or long term. Histology in all cases confirmed a simple epithelial cyst. Median follow-up was 2 years (range, 6 months to 8 years). CONCLUSIONS: Our experience shows that laparoscopic decapsulation is an effective means of managing congenital splenic cysts and that both harmonic scalpel and endoshears are satisfactory dissecting instruments. Extensive marsupialization is probably unnecessary in these larger cysts, because long-term follow-up has shown no increased risk of recurrence after leaving a significant proportion of the cyst wall behind. This approach helps avoid major surgery in these cases.

Mediastinal lipoma in children.

Mediastinal masses are uncommonly encountered in childhood. These tumours are often interesting because of the varied mediastinal tissues from which they arise. Despite extensive investigations, a large percentage of these lesions remain undiagnosed prior to operation. We describe two rare cases of mediastinal lipoma. The first was incidentally diagnosed whereas the second patient presented with respiratory symptoms. The definitive diagnosis was established at surgery, which was curative.

Computed tomographic cholangiography in the diagnosis of bile duct injury in children.

A case of avulsion of the extrahepatic bile duct from the duodenum is described in association with severe liver trauma in a child. The value of computed tomographic (CT) cholangiography and laparoscopy in the diagnosis of this rare condition is outlined, and a paradigm for management is described.

Enterobius vermicularis and perianal sepsis in children.

Specific aetiological factors are responsible for a significant proportion of cases of perianal sepsis in children. A rarely implicated pathogen is Enterobius vermicularis, an obligate parasite with a ubiquitous presence in children. The authors describe two unequivocal instances of threadworm involvement in perianal sepsis, suggesting a pathophysiological basis.

Congenital funnel anus: investigation and novel management strategy.

Congenital funnel anus is a rare and poorly documented condition in which treatment strategies are still evolving. The authors present 2 cases and describe the findings after magnetic resonance imaging along with the treatment regime used successfully in these children.

Recurrent cervical abscess: life-threatening presentation of chronic granulomatous disease in twin infants.

Non-identical male twins presented at 12 and 13 weeks of life, respectively, with recurrent cervical abscesses and signs of imminent upper-airway obstruction (UAO). Despite adequate initial surgical drainage, airway patency became seriously jeopardised in both cases by recurrent abscess formation requiring further intervention. Chronic granulomatous disease was eventually diagnosed in both cases. The unusual presentation of this rare condition with life-threatening UAO in twin infants, a scenario not previously described, is reported and a management protocol suggested.

Is there a role for balloon dilatation of pelvi-ureteric obstruction in children?

PURPOSE: The aim of this study was to examine the effectiveness of balloon dilatation with double J stenting in the management of children with pelvi-ureteric junction (PUJ) obstruction. METHODS: A retrospective study of a 4-year experience of PUJ balloon dilatation in children was conducted in a single unit. Information was collected on patient demographics, clinical presentation, the procedure of balloon dilatation, renal function, and antero-posterior renal pelvis diameter both pre- and postoperatively. RESULTS: There were 10 patients with a median age of 12.5 years (range, 21 months to 15 years). Four cases presented with ipsilateral flank pain, 3 with urinary tract infection, and 3 were discovered incidentally. Retrograde dilation was performed in all cases. Dilation was considered an initial success in 8 of 10 cases, and 1 patient deteriorated after 17 months. Double J stents were placed in all cases and remained in situ for a median of 7.5 weeks (range, 7 to 8.5). Median in-hospital stay was 2 days. Median follow-up was 34 months (range, 7 to 48). Ipsilateral renal excretion times (on MAG III isotope scanning) improved markedly from a median of 84 minutes (range 13 to 200) preoperatively to 7 minutes (range, 1 to 200) at 3 months and 7 minutes (range 1 to 113) at 12 months postoperatively. Median pelvic AP diameter reduced from 30 mm (range 22 to 74) to 16 mm (range, 8 to 36) at 2 months and 10 mm (range, 4 to 41) at 7 months. There were 2 immediate failed procedures, both occurred in patients who went on to open pyeloplasty and were found to have aberrant renal vessels causing extrinsic PUJ compression. One child deteriorated between 10 and 17 months and went on to open pyeloplasty. Twenty-two patients underwent open pyeloplasty in the unit during the same time period with a 95% success rate. Median stay was longer at 5 days and median age younger at 22 months (range, 6 weeks to 13 years). CONCLUSION: Balloon dilatation is a viable option in the management of PUJ obstruction, carrying minimal morbidity in experienced hands.

Acute appendicitis: the continuing role for active observation.

We present the results of a 6-year review of appendicitis. In the event of diagnostic doubt, a policy of active observation was instituted. This review endorses the validity of such a policy, indicating that it does not expose patients to increased morbidity. Data were collected prospectively over a 6-year period on 1,479 children admitted with suspected acute appendicitis (AA); 1,028 (69.5%) were discharged with a diagnosis of non-specific abdominal pain after a mean observation period of 2.5 days, whilst in the remaining 451 a clinical diagnosis of AA was confirmed. The male-to-female ratio was equal, with no difference in the mean age of males (11 years) or females (12 years); 95% of patients were over the age of 5 years. In 324 (72%) cases surgery was performed on the day of admission, whilst in the remaining 126 (28%) it was deferred for 1 to 6 days because the clinical diagnosis of AA remained doubtful. The mean hospital stay was 4 days (range 1-32). Analysis of the histological reports of all 451 cases confirmed a positive predictive value for clinical assessment alone of 97.9% and a normal appendicectomy rate of 2.6%. No mortality was observed; surgical morbidity was recorded at 6% with no correlation between postoperative morbidity and timing of surgery evident (Spearmans correlation coefficient = -0.079, p = 0.9). Active observation for suspected AA thus remains a valid technique for achieving an accurate diagnosis and successful outcome.