Pediatric Endosurgery and Innovative Techniques

To evaluate outcomes after open and laparoscopic herniotomy, and analyze potential risk factors that led to recurrence.

Is laparoscopic inguinal hernia repair a safe and effective alternative procedure in children?

One hundred and ninety-five consecutive infants underwent an open herniotomy (group 1), and 44 infants underwent laparoscopic herniotomy (group 2) between January 1994 to July 2002. The end-point was successful herniotomy without recurrence.

The mean period of follow-up for group 1 was 37 months vs. 7 months for group 2. The incidence of synchronous bilateral hernia in group 1 was 24% vs. 31% in group 2 (p = 0.453) and of bilateral metachronous hernia was 17% vs. 21% in group 2 (p = 0.232). Hernia recurred in 3 cases in group 1 (1%) vs. 4 cases (5.7%) in group 2. Regression analysis showed that the potential risk factors that increased the incidence of recurrence in group 2 were: prematurity (<32 weeks of gestational age) (p = 0.0001); intra-uterine growth retardation (p = 0.0001); chronic lung disease (p = 0.0001); and stadium configuration of the internal ring (p = 0.0001). There were no identifiable risk factors in group 1.

Laparoscopic herniotomy is a viable option for the management of infantile inguinal hernias.

Gastric volvulus in children may be a surgical emergency or may present more subtly. The classic symptoms of gastric volvulus include the triad of unproductive retching, epigastric distention, and the inability to pass a nasogastric tube, but these symptoms are inconsistent in children. The accepted surgical treatment for acute, subacute, or intermittent gastric volvulus is anterior gastropexy, and others have reported that this can be accomplished laparoscopically. We present further clinical experience documenting the safety and efficacy of a laparoscopic approach to gastric volvulus.

This is a case series of 4 children (2 girls and 2 boys, ranging in age from 8 months to 12 years) with gastric volvulus. Two presented as emergencies, one was asymptomatic, and one presented with a feeding problem.

Gastric volvulus was successfully treated by laparoscopic gastropexy in all cases. Two children also had a gastrostomy tube placed for postoperative feeding. Postoperative hospital stay ranged from 3 to 12 days, the latter due to unrelated medical problems in one child. There were no direct surgical complications or noted recurrence of volvulus. All children were well at follow-up.

Our small experience supports laparoscopic gastropexy as a safe and effective treatment for gastric volvulus in children, with no serious complications, and minimal postoperative morbidity.

To demonstrate the technique of computer-assisted robot-enhanced surgery (CARES) for esophago-esophagostomy in an animal model the size of a human newborn.

The major enhancements offered by the Zeus^® MicroWrist Robotic Surgical System (Zeus) for minimally invasive surgery are: tremor filtration, motion scaling, the addition of a wrist to the instruments, safe and rapid instrument exchange, and voice control of the view and instrument modifications. These allow the surgeon to take advantage of the magnification (10× to 15×) associated with endoscopic surgery.

Newborn piglets (2–3 kg) underwent a CARES esophago-esophagostomy.

The Zeus allowed precise needle placement, suture positioning, and knot tying in the very small working space with minimal assistance. Port placement is particularly important because of the small space available for working and to avoid the robotic arms interfering with each other extracorporeally.

Zeus CARES facilitates a minimally invasive approach to complex surgery even in the limited space of the infant chest. The surgical tasks may be more precise and consistent, and the visualization better, than with open operations; however, a significant amount of work must be devoted to develop each procedure.

Nonparasitic splenic cysts are uncommon and may be congenital or post-traumatic in origin. Complications may include enlargement with pain, rupture, and infection. Traditional management includes total or partial splenectomy, partial cystectomy with marsupialization, percutaneous drainage, and sclerotherapy. These techniques are associated with the undesirable consequences of splenic loss and cyst recurrence, especially in patients with congenital epithelial lined cysts. A technique designed to minimize the risk of splenic loss and cyst recurrence is presented.

A 4-year-old and a 13-year-old presented with large splenic cysts measuring 5.4 and 5.7 cm, respectively. Symptoms included left upper quadrant pain and there was no history of trauma. Both patients were managed with laparoscopic partial cystectomy using the harmonic scalpel to divide the cyst wall at its junction with the spleen proper, followed by complete obliteration of the remaining intrasplenic cyst wall using the argon-beam coagulator.

Both patients had an uneventful postoperative course and were discharged home within 24 hours of surgery. Operative time was under one hour and blood loss was minimal. Pathology showed a congenital epithelial (mesothelial) cyst and a post-traumatic cyst, respectively.

Laparoscopic partial splenic cystectomy with obliteration of remaining intrasplenic cyst wall can be performed safely. This technique preserves the spleen and minimizes the risk of recurrence, regardless of the origin of the cyst.

Tracheomalacia is known to be associated with esophageal atresia (EA) and requires treatment if life-threatening. We describe a novel technique of thoracoscopic aortopexy.

A 55-day-old male infant with a history of EA and tracheoesophageal fistula repair with subsequent severe gastroesophageal reflux presented after a life-threatening apneic event associated with feeding. Work-up revealed severe tracheomalacia. The patient underwent thoracoscopic aortopexy with a four-segment fixation of the ascending aorta and the base of the innominate artery. One 3.5-mm and two 5-mm trocars were placed. After partial thymectomy and exposure of the ascending aorta and innominate artery, a 2- 0 prolene suture on an RB-1 needle was passed through the vessels' adventitia. The needle was then cut off and a 20-gauge spinal needle was inserted at an angle through the sternum via a 2-mm stab wound. A single suture tail was passed retrograde through the spinal needle. The spinal needle was then removed and reinserted at a different angle through the same stab wound, and the second suture tail was passed retrograde. This procedure was repeated for the three other sutures, which were then tied under direct thoracoscopic visualization of the great vessels with concomitant bronchoscopic visualization of the trachea. After completion of the aortopexy, a laparoscopic Nissen fundoplication was performed.

The patient was discharged home 9 days later. Follow-up revealed appropriate growth and no feeding or respiratory difficulties.

A transsternal spinal needle allows easy retrograde passage of sutures through the sternum and the use of conventional curved needles for the great vessels. Coupled with precise suture placement through a bridge of sternal bone, this technique provides excellent anterior fixation.

To report two unique cases of minimally invasive surgery that were performed in children. The cases illustrate that combined endoscopic and laparoscopic drainage of a pancreatic pseudocyst in children can be accomplished successfully.

Two patients, ages 3 and 5 years old, were referred for pancreatic pseudocysts of traumatic origin. A trial of nonoperative treatment and radiologic drainage was unsuccessful. Cystgastrostomy was completed with an endolaparoscopic transgastric stapled anastomosis.

The average operative time was 100 minutes (range, 90–110 minutes). There was minimal blood loss and no complications. An adequate biopsy specimen was obtained in each patient. A transgastric cyst drainage tube was placed. Diet was resumed the following day. A computed tomography (CT) scan on postoperative day (POD) 5 showed resolution of the pseudocyst. The patients were discharged on POD 5. A 6-month follow-up CT scan showed no recurrence of the pseudocysts, and at follow-up at 12 and 22 months, the children are symptom-free.

This report of the first pediatric experience with combined endolaparoscopic cystgastrostomy shows that it is safe and effective. With improved pediatric instrumentation and experience, surgical problems can increasingly be managed with more innovative minimally invasive techniques.