[Laparoscopic cholecystectomy: what we can learn about]. / Colecistectomía laparoscópica en niños y adultos: lo que podemos aprender.

BACKGROUND: Laparoscopic cholecystectomy (LC) is a very usual procedure within adult population, but not as frequent in childhood. The aim of this study was to assess the outcome of LC in children compared with those performed in adulthood. MATERIALS AND METHODS: We reviewed 39 consecutive patients who underwent LC between 2003 and 2013 at our Department and a similar sample of patients from 18 to 40 years of age from the General Surgery Department. RESULTS: 39 children and 40 adults fulfilled criteria to be included in the study. The most frequent indication was cholelithiasis in both groups. The mean operating time was significantly higher among children (127 min, adults 71 min, p < 0.01) but we didn't find differences neither in conversion nor in complication rates (children 5% and 7.7%, adults 2.5% and 15% respectively). In regard to preoperative factors, only male gender was correlated to a higher complication rate (p 0.037). On the other hand we found out that, in absence of complications, both the average length of stay (children 2.1 days, adults 0.5 days) and mean time to first feeding (children 21 hours, adults 8 hours) were significantly higher among children (p < 0.01). CONCLUSIONS: 1) LC in childhood is a safe procedure that does not imply more morbidity than the same intervention in adults, even though a more prolonged operating time. 2) We believe that our longer hospital stay is due to certain lack of confidence with the technique and, in the future, the trend should be bent on encouraging a shorter time to first feeding and an earlier discharge.

Thoracoscopic pneumonectomy in a 4 year-old-child with destroyed lung following viral pneumonia. / Tiroidectomía transoral endoscópica con abordaje vestibular (TOETVA): una nueva opción para el tratamiento de pacientes pediátricos.

Pediatric pneumonectomies are exceptional nowadays, being reserved for cases with destroyed lungs with frequent exacerbations and reinfections and only two cases of thoracoscopic pneumonectomy have been previously published. We present the case of a 4-year-old patient with no relevant history who developed complete atelectasis of the left lung (LL) after influenza A pneumonia, followed by secondary recurrent infections. A year later a diagnostic bronchoscopy without alterations was performed. A complete loss of volume and hypoperfusion of the LL (right lung perfusion 95%, LL perfusion: 5%) with bronchiectasis and hyperinsufflation and herniation of the right lung into the left hemithorax was observed in a pulmonary perfusion SPECT-CT. After unsuccessful conservative management and recurrent infections a pneumonectomy was indicated. The pneumonectomy was performed through a five-port thoracoscopy. The dissection of the hilum was made using hook electrocautery and sealing device. The left main bronchus was sectioned with an endostapler. There were no intraoperative complications. An endothoracic drain was removed the first postoperative day. The patient was discharged on the fourth postoperative day. The patient has not presented any complications 10 months after surgery. Although pneumonectomy is an exceptional surgery in children, it can be performed by minimally invasive surgery with success and safety in centers with extensive experience in pediatric thoracoscopic surgery.

Hoy en día, las neumonectomías pediátricas son algo excepcional. El procedimiento se reserva para aquellos casos en los que los pulmones están destruidos y presentan exacerbaciones y reinfecciones frecuentes, con tan solo dos casos de neumonectomía toracoscópica publicados hasta la fecha. Presentamos el caso de un paciente de 4 años sin antecedentes de interés que desarrolló atelectasia completa del pulmón izquierdo (PI) tras neumonía por gripe A, seguido de infecciones secundarias recurrentes. Un año después, se le practicó broncoscopia diagnóstica, sin que esta mostrara alteraciones significativas. Tras realizársele un SPECT-CT de perfusión pulmonar, se evidenció pérdida completa de volumen e hipoperfusión del PI (perfusión del pulmón derecho: 95%; perfusión del pulmón izquierdo: 5%), con bronquiectasia e hiperinsuflación y herniación del pulmón derecho hacia el hemitórax izquierdo. Tras fracasar el manejo conservador y registrarse infecciones recurrentes, se estableció la indicación de neumonectomía. La neumonectomía se llevó a cabo mediante toracoscopia por cinco puertos. La disección del hilio se realizó mediante gancho de electrocoagulación y dispositivo de sellado. El bronquio principal izquierdo se seccionó con endograpadora. No se registraron complicaciones intraoperatorias. El drenaje endotorácico se retiró al día siguiente de la intervención, mientras que el paciente fue dado de alta a los cuatro días, sin que haya presentado complicaciones transcurridos 10 meses desde la cirugía. Aunque la neumonectomía es una intervención excepcional en niños, puede llevarse a cabo de manera exitosa y segura por cirugía mínimamente invasiva en centros con amplia experiencia en cirugía toracoscópica pediátrica.

[Role of laparoscopy in premature infants with suspicion of necrotizing enterocolitis]. / Papel de la laparoscopia en prematuros con sospecha de enterocolitis necrotizante.

INTRODUCTION: The indication of surgery in necrotizing enterocolitis (NEC) can be difficult in the absence of pneumoperitoneum or peritonitis. We propose laparoscopy for early diagnosis of intestinal perforation or necrosis in order to avoid unneccessary laparotomies. MATERIAL AND METHODS: A new protocol was proposed which included diagnostic and therapeutic laparoscopy in cases of uncertain surgical ECN indication. Subsequently, a prospective study of the 7 patients who underwent laparoscopy was performed, analyzing pathophysiological effects in the premature, technical difficulties of the procedure, and postoperative diagnostic consistency. RESULTS: The mean gestational age at birth was 27 weeks (range 25 to 31) with an average weight of 1.147 kg (range 0.900 to 1.600) two trocars were placed as the focal oriented scanning or radiography, using a pneumoperitoneum 6-10 mmHg for an average of 17 min. Laparoscopy avoided laparotomy in a patient who did well after washing and drainage and magnified lesions in one patient who did not require laparotomy after intestinal bypass. In other cases, laparoscopy was followed by minilaparotomy oriented to the lesions and stoma formation. There were no surgical complications attributable to the procedure, which was well tolerated in all cases. CONCLUSIONS: Laparoscopy can be a useful tool for evaluation of lesions of NEC in cases of uncertain surgical indications. In our experience, it is well tolerated in neonates of low weight, allowing oriented minilaparotomies or even to avoid laparotomy.

[Utility of radioguided surgery in splenosis]. / Utilidad de la cirugía radioguiada en la esplenosis.

Splenosis is a common finding after traumatic rupture of the spleen or therapeutic splenectomy, defined as a heterotopic autotransplantation of the spleen in peritoneal cavity and surface. In splenectomized patients due to hematologic disease, splenosis can lead to disease recurrence. We present a case of splenosis in a patient with idiopathic thrombocytopenic purpura who relapsed after splenectomy. For its localization, conventional imaging and scintigraphy with (99m)Tc-denatured red cells was performed, and at least five splenic foci were observed. Given the difficult intraoperative localization of these nodules, radioguided surgery was performed, with excellent localization and removal of all known nodules and multiple peritoneal implants of millimeter size that were not previously observed. We conclude that radioguided surgery is an excellent tool for locating foci of peritoneal splenosis, which have difficult access, thus avoiding early recurrence of the disease.