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Background: Simulation-based training plays a significant role in surgical education, especially in minimally invasive pediatric surgery and urology. This study aimed to evaluate a novel 3D-printed model as training tool for endoscopic injection of bulking agent., Methods: Forty-three attendees and ten teaching faculty members were invited to complete a post hoc questionnaire after completing training sessions using the Fish Tank Simulation Model (FTSM). The survey consisted of a 7-question 5-point Likert scale to assess the model's realism (face validity) and its effectiveness as training tool (content validity)., Results: Regarding the training status, 20/53 (37.7%) participants were fellow and/or specialist in pediatric surgery and 33/53 (62.3%) were surgeons in training. Their level of confidence in endoscopic injection procedure was defined as novice (< 10 procedures per year) in 33/53 (62.3%), intermediate (10-20 procedures per year) in 10/53 (18.9%), and expert (> 20 procedures per year) in 10/53 (18.9%). Regarding both face validity and content validity assessments, no statistically significant differences were found between scores given by novice vs intermediate/expert groups. Similarly, no statistically significant differences emerged between scores given by participant vs faculty groups assessing the content validity of the FTSM. The FTSM was considered a good teaching tool for beginners by 44/53 (83%) and for pediatric surgeons/urologists by 38/53 (71.7%)., Conclusions: The 3D-printed Fish Tank Simulation Model proved to be a valuable, high-fidelity, easily accessible, cost-effective, hygienic, and domestic-use training tool for pediatric surgeons/urologists conducting the procedure. The model's user-friendly design and realistic environment enhanced learning opportunities for trainees, regardless of their experience level or training status. Nevertheless, further development is necessary, particularly in enhancing the realism of the ureteral hiatus and reproducing more complex anatomy, to make it beneficial for the training of advanced surgeons., (© 2024. The Author(s).)

Background: Anal fistula and perianal abscess are commonly acquired anorectal pathologies in children. Surgical treatment options commonly adopted are fistulotomy, fistulectomy, cutting seton placement, and more recently video-assisted anal fistula treatment (VAAFT). Optimal postoperative wound dressing remains debated. This study aimed to report our series of pediatric patients, who received VAAFT and postoperative wound dressing using ozonide oil., Methods: All patients who underwent VAAFT between August 2018 and May 2023 were included in the study. Demographics, clinical features, pre-operative imaging, surgical details, outcome, and mid-term outcome data were retrospectively reviewed for each patient. All VAAFT procedures were performed under general anesthesia and using a 10-Ch fistuloscope., Results: Thirty-three VAAFT procedures were performed in 30 patients over the study period. The median patient age was 5.7 years (range 1.75-14). Anal fistula was idiopathic in 26/30 (86.6%), iatrogenic in 2/30 (6.7%), and secondary to Crohn's disease in 2/30 (6.7%). The median duration of surgery was 23 min (range 18-40). All patients received ozonide oil dressing twice a day for 5 weeks postoperatively. The median hospital stay was 24 h (range 9-36). The median healing time was 28 days (range 17-39). With a median follow-up of 2 years (range 0.5-5), disease recurrence occurred in 3/30 (10%) patients with idiopathic fistula, who were re-operated using the same technique, with no further recurrence. No fecal incontinence or soiling was observed., Conclusion: Our series confirmed that VAAFT is a safe and effective technique to treat children with perianal fistula. The technique is versatile, allowing to treat fistulae of different etiologies. Postoperative course was painless and fast. Future comparative prospective studies are needed to better establish these conclusions., (© 2024. The Author(s).)

Background: Surgical techniques for treatment of gynecomastia are increasingly less invasive. We described technical standardization of pediatric endoscopic subcutaneous mastectomy (PESMA) with liposuction., Methods: All adolescents with primary gynecomastia, operated using PESMA with liposuction over the period June 2014-July 2021, were included. The video recording of procedures was analyzed to standardize the operative technique. After patient installation, 3 trocars were placed on the mid-axillary line. The technique included 5 steps: (1) subcutaneous injection of lipolysis solution and liposuction; (2) creation of working space using an inflated balloon; (3) gland dissection using 5-mm sealing device; (4) specimen extraction through the largest trocar orifice; and (5) placement of suction drainage tube., Results: Twenty-four male adolescents, operated for Simon's grade 2B and 3 gynecomastia using PESMA with liposuction over the study period, were included. Mean patient age was 16 years (range 15-18). Gynecomastia was bilateral in 19/24 (79.2%) and unilateral in 5/24 (20.8%). One (4.1%) conversion to open was reported. The mean operative time was 87 min (range 98-160) for unilateral and 160 min (range 140-250) for bilateral procedure. The mean length of stay was 2.2 days (range 1-4). Patients wore a thoracic belt for 15 up to 30 days postoperatively. Post-operative complications occurred in 5/24 (20.8%): 2- or 3 mm second-degree burns in 4 (16.7%) and subcutaneous seroma in 1 (4.1%). All complications were Clavien 2 grade and did not require further treatment. Aesthetic outcomes were very good in 21/24 (87.5%). Three (12.5%) boys had persistent minimal breast asymmetry but did never perceive it negatively., Conclusion: PESMA combined with liposuction was feasible and safe for surgical treatment of gynecomastia in this selected cohort of patients. Although challenging, this procedure provided good aesthetic results, with no scars on the anterior thoracic wall. Standardization of the operative technique was a key point for successful outcome., (© 2022. The Author(s).)

Background: Pediatric robotic-assisted surgeries have increased in recent years; however, guidance documents are still lacking. This study aimed to develop evidence-based recommendations, or best practice statements when evidence is lacking or inadequate, to assist surgical teams internationally., Methods: A joint consensus taskforce of anesthesiologists and surgeons from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP) have identified critical areas and reviewed the available evidence. The taskforce comprised 21 experts representing the fields of anesthesia (n = 11) and surgery (n = 10) from clinical centers performing pediatric robotic surgery in the Italian cities of Ancona, Bologna, Milan, Naples, Padua, Pavia, Perugia, Rome, Siena, and Verona. Between December 2020 and September 2021, three meetings, two Delphi rounds, and a final consensus conference took place., Results: During the first planning meeting, the panel agreed on the specific objectives, the definitions to apply, and precise methodology. The project was structured into three subtopics: (i) preoperative patient assessment and preparation; (ii) intraoperative management (surgical and anesthesiologic); and (iii) postoperative procedures. Within these phases, the panel agreed to address a total of 18 relevant areas, which spanned preoperative patient assessment and patient selection, anesthesiology, critical care medicine, respiratory care, prevention of postoperative nausea and vomiting, and pain management., Conclusion: Collaboration among surgeons and anesthesiologists will be increasingly important for achieving safe and effective RAS procedures. These recommendations will provide a review for those who already have relevant experience and should be particularly useful for those starting a new program., (© 2022. The Author(s).)

Background: In the last few years, indocyanine green (ICG) fluorescent cholangiography (FC) has been adopted to perform intra-operative biliary mapping during laparoscopic cholecystectomy (LC). This study aimed to compare the results of LC with and without use of ICG-FC., Methods: All LC operated from June 2017 to June 2021 in our unit were retrospectively reviewed. Pre-operative workup included ultrasonography to assess dilation of main biliary tree. The ICG dosage was 0.35 mg/kg and the median timing of administration was 15.5 h pre-operatively. We evaluated, analyzing videorecorded procedures, 3 parameters in both groups: the total operative time (T1), the time of cystic duct isolation, clipping and sectioning (T2), and the time of gallbladder removal from hepatic fossa (T3)., Results: Forty-three LC were operated in the study period: 22 using standard technique (G1) and 21 using ICG-FC (G2). There were 27 girls and 16 boys, with median age at surgery of 11.5 years (range 7-17) and median weight of 47 kg (range 31-110). No conversions were reported in our series. In all ICG cases (except one patient under therapy with phenobarbital) the biliary tree was perfectly visualized during dissection. Intra-operative complications occurred in 3 G1 patients (13.6%): 2 bleedings from the Calot's triangle and 1 bleeding from the liver bed during the gallbladder removal. LC was significantly faster in G2 than in G1 (p = 0.001). In fact, the parameters analyzed (T1, T2, T3) were all significantly greater in G1 than in G2 (p = 0.001)., Conclusions: Based upon our experience, we strongly recommend the use of ICG-FC in all pediatric patients undergoing LC. ICG-guided fluorescence provided an excellent real-time visualization of the extrahepatic biliary tree and allowed faster and safer dissection, minimizing the risk of bile duct injuries. Furthermore, ICG use was clinically safe, with no adverse reactions to the product., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Recently, we reported the feasibility of indocyanine green (ICG) near-infrared fluorescence (NIRF) imaging to identify extrahepatic biliary anatomy during laparoscopic cholecystectomy (LC) in pediatric patients. This paper aimed to describe the use of a new technology, RUBINA™, to perform intra-operative ICG fluorescent cholangiography (FC) in pediatric LC., Methods: During the last year, ICG-FC was performed during LC using the new technology RUBINA™ in two pediatric surgery units. The ICG dosage was 0.35 mg/Kg and the median timing of administration was 15.6 h prior to surgery. Patient baseline, intra-operative details, rate of biliary anatomy identification, utilization ease, and surgical outcomes were assessed., Results: Thirteen patients (11 girls), with median age at surgery of 12.9 years, underwent LC using the new RUBINA™ technology. Six patients (46.1%) had associated comorbidities and five (38.5%) were practicing drug therapy. Pre-operative workup included ultrasound (n = 13) and cholangio-MRI (n = 5), excluding biliary and/or vascular anatomical anomalies. One patient needed conversion to open surgery and was excluded from the study. The median operative time was 96.9 min (range 55-180). Technical failure of intra-operative ICG-NIRF visualization occurred in 2/12 patients (16.7%). In the other cases, ICG-NIRF allowed to identify biliary/vascular anatomic anomalies in 4/12 (33.3%), including Moynihan's hump of the right hepatic artery (n = 1), supravescicular bile duct (n = 1), and short cystic duct (n = 2). No allergic or adverse reactions to ICG, post-operative complications, or reoperations were reported., Conclusion: Our preliminary experience suggested that the new RUBINA™ technology was very effective to perform ICG-FC during LC in pediatric patients. The advantages of this technology include the possibility to overlay the ICG-NIRF data onto the standard white light image and provide surgeons a constant fluorescence imaging of the target anatomy to assess position of critical biliary structures or presence of anatomical anomalies and safely perform the operation., (© 2021. The Author(s).)

Background: Very limited informations are currently available about the best approach to perform retroperitoneoscopic surgery. This multicentric international study aimed to compare the outcome of lateral versus prone approach for retroperitoneoscopic partial nephrectomy (RPN) in children., Methods: The records of 164 patients underwent RPN in 7 international centers of pediatric surgery over the last 5 years were retrospectively reviewed. Sixty-one patients (42 girls and 19 boys, average age 3.8 years) were operated using lateral approach (G1), whereas 103 patients (66 girls and 37 boys, average age 3.0 years) underwent prone RPN (G2). The two groups were compared in regard to operative time, postoperative outcome, postoperative complications, and re-operations., Results: The average operative time was significantly shorter in G2 (99 min) compared to G1 (160 min) (p = 0.001). Only 2 lateral RPN required conversion to open surgery. There was no significant difference between the two groups as for intraoperative complications (G1:2/61, 3.3%; G2:6/103, 5.8%; p = 0.48), postoperative complications (G1:9/61, 14.7%; G2:17/103, 16.5%; p = 0.80), and re-operations (G1:2/61, 3.3%; G2:4/103, 3.8%; p = 0.85). Regarding postoperative complications, the incidence of symptomatic residual distal ureteric stumps (RDUS) was significantly higher in G2 (7/103, 6.8%) compared to G1 (1/61, 1.6%) (p = 0.001). Most re-operations (4/6, 66.6%) were performed to remove a RDUS ., Conclusions: Both lateral and prone approach are feasible and reasonably safe to perform RPN in children but the superiority of one approach over another is not still confirmed. Although prone technique resulted faster compared to lateral approach, the choice of the technique remains dependent on the surgeon's personal preference and experience. Our results would suggest that the lateral approach should be preferred to the prone technique when a longer ureterectomy is required, for example in cases of vesico-ureteral reflux into the affected kidney moiety, in order to avoid to leave a long ureteric stump that could become symptomatic and require a re-intervention.

Background: There is a limited and conflicting evidence about the most appropriate method for appendiceal stump closure during laparoscopic appendectomy (LA). We aimed to compare endoloop (EL) versus endostapler (ES) for stump closure during LA for complicated perforated appendicitis in children., Methods: We retrospectively reviewed the records of 708 patients (463 boys and 245 girls with an average age of 9.8 years) who underwent LA for complicated appendicitis in 5 international centers of Pediatric Surgery over a 5-years period (January 2011-December 2016). The appendix was perforated with localized peritonitis in 470 cases and diffuse peritonitis in 238 patients. EL was used in 374 cases (G1), whereas ES was adopted in 334 cases (G2)., Results: No intra-operative complication occurred in both groups but 5 conversions to open surgery were reported in G1 (1.3%) and 4 in G2 (1.1%) (OR 1.1; 95% CI 0.30-4.19). Use of EL was significantly associated with higher incidence of intra-abdominal abscess (OR 1.36; 95% CI 0.84-2.18), postoperative ileus (OR 3.61; 95% CI 0.76-17.11), and re-operations/readmissions (OR 6.46; 95% CI 1.46-28.62) compared to ES. The average cost of supplies for LA was significantly higher in G2 (€ 915.60) compared to G1 (€ 578.36) (p = 0.0001). The average cost of re-operations/readmissions was significantly higher in G1 (€ 4.091,39) compared to G2 (€ 2.127,88) (p = 0.0001) (OR 1.72; 95% CI 1.47-2.01)., Conclusions: Our study is the first in the pediatric population to demonstrate that the method used for appendiceal stump closure may influence the outcome of LA in complicated appendicitis. Although ES is more expensive compared to EL, our results demonstrated that appendix stump closure should be performed using ES rather than EL in complicated perforated appendicitis since its use was associated with a lower incidence of postoperative intra-abdominal abscess and postoperative ileus and lower re-operations and readmissions rates and costs.

Background: Minimal access adrenal surgery (MAAS) for adrenal pathologies is the standard for many pediatric surgical centers. However, the literature offers few reports and minimal evidence from small case series. The aim of this study was to evaluate the outcomes of pediatric MAAS through a multi-center data analysis., Method: Pediatric patients who underwent MAAS between January 2002 and December 2013 were retrospectively included. Data analysis was conducted using Spss software (Welch's t-test, X-square, Fisher tests, multiple regression model)., Results: Six European centers participated, 68 patients were included with mean age of 5.2 years (2 months-16 years). Lesion volume was of 18.1 cc (0.78-145.6), with a mean diameter of 2.8 cm (1.1-6.5). Localization was 50% left-sided masses, 45.6% right-side masses, and 4.4% bilateral. Histological examination revealed 36 neuroblastomas, 15 adenomas, nine pheochromocytomas, three ganglioneuromas, two ganglioneuroblastomas, one bilateral hyperplasia, one adrenocortical carcinoma, an alveolar sarcoma, and a calcification. Surgical access was transperitoneal in 63 (92.6%) and retroperitoneal in 5 (7.4%). Mean operative time was 170 ± 87 min (285 ± 30 min for bilateral lesions). Mean hospital stay was 4.2 ± 2.5 days. Complications included blood loss requiring transfusion in five patients (7.4%) and a diaphragmatic tear. Infiltration of surrounding structures correlated with intraoperative complication rate (p = 0.027) and operative time (p < 0.01). No mass rupture, conversion, or post-operative complications were observed. Median follow-up was 52 months (1-161). Two recurrences occurred in patients with pheochromocytoma. Age, weight, symptoms, characteristics at imaging, chemistry, volume, or histology, did not influence operative time, hospital stays, or complication rate., Conclusions: Pediatric MAAS was safe adopted for masses up to 145.6 cc, with a very low rate of complication. Conversion to open is not necessary even in the presence of infiltrations. MAAS should represent the first-line treatment for selected cases in centers experienced in laparoscopy.

Background: This study aimed to standardize the surgical correction technique of congenital Morgagni diaphragmatic hernia (CMDH), analyzing the results of an international multicentric survey., Methods: The medical records of 43 patients (29 boys, 14 girls) who underwent laparoscopic repair of CMDH in 8 pediatric surgery units in a 5-year period were retrospectively reviewed. Their average age was 3.3 years. Ten patients (23.2%) presented associated malformations: 9 Down syndrome (20.9%) and 1 palate cleft (2.3%). Thirty-five patients (81.4%) were asymptomatic, whereas 8 patients (18.6%) presented symptoms such as respiratory distress, cough or abdominal pain. As for preoperative work-up, all patients received a chest X-ray (100%), 15/43 (34.8%) a CT scan, 8/43 (18.6%) a barium enema and 4/43 (9.3%) a US., Results: No conversion to open surgery was reported. Average operative time was 61.2 min (range 45-110 min). In 38/43 (88.3%) patients, a trans-parietal stitch was positioned in order to reduce the tension during the repair. In 14/43 cases (32.5%), the sac was resected; in only 1/43 case (2.3%) a dual mesh of goretex was adopted to reinforce the closure. Average hospital stay was 2.8 days. The average follow-up was 4.2 years, and it consisted in annual clinical controls and chest X-ray. We recorded 2 complications (4.6%): one small pleural opening that required no drain and one recurrence (2.3%), re-operated in laparoscopy, with no further recurrence., Conclusions: To the best of our knowledge, this is the largest series published in the literature on this topic. Laparoscopic CMDH repair is well standardized: The full-thickness anterior abdominal wall repair using non-resorbable suture with interrupted stitches is the technique of choice. Postoperative outcome was excellent. Recurrence rate was very low, about 2% in our series. We believe that children with CMDH should be always treated in laparoscopy following the technical details reported in this paper.

Background: The role of laparoscopy in pediatric inguinal hernia (IH) is still controversial. The authors reported their twenty-year experience in laparoscopic IH repair in children., Methods: In a twenty-year period (1995-2015), we operated 1300 infants and children (935 boys-365 girls) with IH using laparoscopy. The average age at surgery was 18 months (range 7 days-14 years). Body weight ranged between 1.9 and 50 kg (average 9.3). Preoperatively all patients presented a monolateral IH, right-sided in 781 cases (60.1 %) and left-sided in 519 (39.9 %). We excluded patients with bilateral IH and unstable patients in which laparoscopy was contraindicated. If the inguinal orifice diameter was ≥10 mm, we performed a modified purse string suture on peri-orificial peritoneum, in orifices ≤5 mm, we performed a N-shaped suture., Results: No conversion to open surgery was reported. In 533 cases (41 %), we found a contralateral patency of internal inguinal ring that was always closed in laparoscopy. In 1273 cases (97.9 %), we found an oblique external hernia; in 21 cases (1.6 %), a direct hernia; and in 6 cases (0.5 %), a double hernia on the same side (hernia en pantaloon). We found an incarcerated hernia in 27 patients (2 %). Average operative time was 18 min (range 7-65). We recorded 5/1300 recurrences (0.3 %), but in the last 950 patients, we had no recurrence (0 %). We recorded 20 complications (1.5 %): 18 umbilical granulomas and two trocars scar infections, treated in outpatient setting., Conclusions: On the basis of our twenty-year experience, we prefer to perform IH repair in children using laparoscopy rather than inguinal approach. Laparoscopy is as fast as inguinal approach, and it has the advantage to treat during the same anesthesia a contralateral patency occured in about 40 % of our cases and to treat also rare hernias in about 3 % of cases.

Background: One-trocar laparoscopic appendectomy (OTA) is routinely adopted in children with acute appendicitis. In case of a difficult appendectomy, it is necessary to add additional trocar/s to safely complete the procedure. This technique is called multiport hybrid laparoscopic appendectomy (HLA). We aimed to compare the outcome of multiport HLA versus OTA., Methods: We retrospectively reviewed the data of 1,092 patients underwent LA in 5 European centers of pediatric surgery in the last 5 years. We compared 2 groups: G1 of 575 patients (52.6 %) (average age 10 years) underwent OTA and G2 of 517 patients (47.4 %) (average age 8.2 years) underwent multiport HLA., Results: No intra-operative complications occurred in both groups. An additional pathology was treated in 12 cases (8 Meckel's diverticulum, 2 carcinoids, 2 ovarian cysts) in G2. Operative time was significantly shorter in G2 compared to G1 (47.8 vs 58.6 min; p < .001). The average analgesic requirement was significantly shorter in G2 compared to G1 (44 vs 56 h; p < .001). As for postoperative complications, the incidence of port-site infections was similar between the two groups, while the incidence of postoperative abdominal abscesses (PAA) was significantly higher in G1 compared to G2 (4.7 vs 0.2 %; p < .001). The cosmetic outcome was excellent in all patients of both groups. A subgroup analysis between complicated and uncomplicated appendicitis showed that only in complicated cases, the average operative time, the average VAS pain score, the average analgesic requirements and the incidence of PAA were significantly higher in OTA group compared to multiport HLA group (p < .001)., Conclusions: Our results suggest that OTA is a valid and safe procedure for the uncomplicated cases, while additional trocars are required in case of complicated appendicitis. Multiport HLA significantly reduces the operative time, the incidence of abdominal abscesses and the analgesic requirements compared to OTA.

Background: Nephrectomy is probably the most common urological indication for minimally invasive surgery (MIS) in children. The authors reported their experience in laparoscopic and retroperitoneoscopic nephrectomy analyzing their 20 years of experience in this procedure., Methods: In a 20-year period (1995-2015), the authors performed 149 nephrectomies in children using MIS (87 left, 62 right). One hundred and one nephrectomies were performed using laparoscopy (LN) and 48 using retroperitoneoscopy (RN). Patients included 90 girls and 59 boys (average age 5.7 years). All the removed kidneys were nonfunctioning because of benign diseases: VUR (84), UPJO (38), MKDK (20), xanthogranulomatosis pyelonephritis (4), nephropathy causing uncontrollable hypertension (2) and nephrolithiasis (1)., Results: We had no conversion in laparoscopy. As for RN, we had 2 conversions to laparoscopy at the beginning of experience due to peritoneal opening. Operative time varied from 30 to 130 min in laparoscopy (average 47 min) and from 60 to 150 min (average 78 min) in retroperitoneoscopy. We recorded 8 complications (5.3 %): 3 small bleedings (2 RN, 1 LN) during dissection, 2 peritoneal perforations during RN requiring conversion in LN, 1 abdominal abscess in case of xanthogranulomatosis pyelonephritis after LN requiring a redo surgery to drain the abscess, 1 instrumentation failure (LN) and 1 refluxing ureteral stump after RN requiring a redo surgery to remove it., Conclusions: LN is easier and faster to perform compared to RN. Complication rate was higher after RN compared to LN. In case of xanthogranulomatous pyelonephritis or other kidney infections or in case of previous renal surgery, retroperitoneoscopy is contraindicated. In case of VUR, LN is preferable to RN because it is fundamental to remove all the ureter. On the basis of our 20-year experience, we clearly prefer to perform nephrectomy using laparoscopy rather than retroperitoneoscopy leaving the indication to adopt RN only for the rare cases of MKDK.

Background: We aim to report a 5-year retrospective multicentric European survey about the outcome of laparoscopic partial nephrectomy in infants and children with duplex kidneys., Methods: The data of fifty-two children underwent laparoscopic partial nephrectomy (42 upper-pole nephrectomies and 10 lower-pole nephrectomies) in six European centers of Pediatric Surgery, were collected and analyzed. Median age at surgery was 5.1 years (range 6 months-9.7 years). There were 32 girls and 20 boys. In 37 patients, the left side was affected and in 15 patients the right side. For the right side, 4 trocars were used and for the left side 3/4 trocars. Special hemostatic devices were used for dissection and parenchymal section in all centers. We assessed intraoperative and postoperative morbidity., Results: Median length of surgery was 166.2 min (70-215 min). No conversion to open surgery nor intraoperative bleeding was reported. Mean hospitalization was 3.5 days. We recorded 10/52 complications (4 urinomas, 2 recurrent UTIs, 4 prolonged urinary leakage), all managed conservatively. Reoperation rate was 0%. No loss of renal function on the residual kidney moiety was recorded in all operated patients., Conclusions: Laparoscopic partial nephrectomy remains a technically challenging procedure performed only in pediatric centers with high experience in minimally invasive surgery. Although the median operative time was higher than 2 h, we recorded no conversions in our series. The complication rate remains high (10/52-19.2%). All were II grade complications according to Clavien-Dindo classification and were treated conservatively without the need of other surgical procedures.

Background: Laparoscopic inguinal hernia repair is rarely reported in pediatric patients. We report our 15-year experience on this topic to show the long-term results of this technique., Methods: During a 15-year period, we operated 596 boys for unilateral inguinal hernia using laparoscopy. The age range was variable from 6 months to 15 years (median, 54 months), with a median body weight of 18.5 (range, 8-54) kg. Preoperatively, 352 boys had a right hernia and 172 had a left hernia. We always used three trocars. We used the laparoscopic herniorrhaphy described by our group 15 years ago; it consists of sectioning the sac distally to the inguinal ring and performing a pursestring suture around the periorificial peritoneum using a 4/0 nonresorbable suture., Results: The median operating time was 19 min. All procedures were performed in a day-hospital setting. As for laparoscopic findings in 95 of 596 patients (15.9%), we found a contralateral patency of the processus vaginalis. In these 95 cases, we performed bilateral herniorrhaphy. In 7 of 596 patients (1.2%), we discovered a direct hernia. With follow-up between 1 and 15 years, we have only 11 recurrences (1.5%)-all reoperated by laparoscopy., Conclusions: We believe that laparoscopic repair of inguinal hernia performed by expert hands is a safe and effective procedure to perform with long-term follow-up. Its ability to repair simultaneously all forms of inguinal hernias together with contralateral patencies has cemented its role as a viable alternative to conventional repair.

Background: Few reports have elucidated the role of minimally invasive surgery (MIS) for pediatric malignancies. This study aimed to review the results of a multicenter study on the management of thoracic tumors in children using MIS., Methods: A 5-year retrospective review of all MIS procedures for the treatment of pediatric malignancies performed in seven centers belonging to the Italian Society of Videosurgey in Infancy is reported. The data from 145 pediatric oncologic patients (80 girls and 65 boys) ages 30 days to 17 years (median, 7.2 years) were analyzed. Of the procedures performed, 87 were laparoscopies (60%), 55 were thoracoscopies (38%), and 3 were lumboscopies (2%). This study focused only on the results of the 55 thoracoscopic procedures performed for diagnostic purposes in 19 cases (34.6%) and for therapeutic purposes in 36 cases (65.4%)., Results: The duration of surgery was 15 to 180 min (median, 65 min). Metastasectomies were performed for various etiologies in 31 of the 55 cases. Of the 55 patients, 5 underwent resection of a mediastinal tumor, and 19 underwent a diagnostic thoracoscopy. During a mean follow-up period of 25.6 months, 2 (3.6%) of the 55 patients experienced perioperative complications., Conclusions: The role of MIS in tumor resection for children is currently limited, but may be used in individual cases when the preoperative workup shows it to be feasible. Its indication is strictly dependent on the thoracoscopic experience of the surgeon and the tumor site for preoperative imaging techniques. When the indication for thoracoscopy is correct, this approach has high therapeutic applicability (65.4% in our series). Our preliminary experience shows that careful patient selection and an appropriate level of technical skill make thoracoscopy a reasonable and safe option for the treatment of pediatric malignancies.

Background: Some technical aspects of laparoscopic spleen surgery still are debated, although efforts have been made to standardize them. The position of the patient, the approach to the spleen, vessel identification and division, and spleen extraction can vary from center to center., Methods: This retrospective muticentric study led by the Società Italiana di Videochirurgia Infantile (SIVI) examined indications, surgical details, and complications of laparoscopic spleen surgery in the pediatric population during a 5-year period., Results: The study period from January 1999 to December 2003 (5 years) involved nine centers and included 85 patients with a mean age of 10 years (range, 2-17 years). Hypersplenism or severe hemolysis in cases of hematologic disorders represented the most important indications. More than 90% of the patients underwent total laparoscopic splenectomy. Specific technical details from each center were collected. Intraoperative complications occurred in 19% of the patients (hemorrhage in 8% and technical problems in 14%), and 6% of the patients required conversion to the open approach. No deaths occurred, and no reoperations were required. Postoperative complications were experienced by 2% of the patients., Conclusion: Laparoscopic spleen surgery is safe, reliable, and effective in the pediatric population. On the basis of the results, some technical details for laparoscopic spleen surgery can be suggested. The patient is preferably kept supine or lateral, approaching the spleen anteriorly. Moreover, the ilar vessels should be identified selectively and individually, with initial artery division performed to achieve spleen shrinking. Any hemostatic device proved to be effective in experienced hands. Once freed, the spleen is preferably extracted via a suprapubic cosmetic transverse incision (faster, easier, and safer), although a bag can be used. Finally, the size of the spleen does not represent a contraindication for a trained and experienced surgeon. Nevertheless, this parameter must be considered when laparoscopic spleen surgery is planned.

Background: Nissen fundoplication is the most popular laparoscopic operation for the management of gastroesophageal reflux disease (GERD). Partial fundoplications seem to be associated with a lower incidence of postoperative dysphagia, and thus a better quality of life for patients. The aim of this study was to compare the long-term outcome in neurologically normal children who underwent laparoscopic Nissen, Toupet, or Thal procedures in three European centers with a large experience in laparoscopic antireflux procedures., Methods: This study retrospectively analyzed the data of 300 consecutive patients with GERD who underwent laparoscopic surgery. The first 100 cases were recorded for each team, with the first team using the Toupet, the second team using the Thal, and the third team using the Nissen procedure. The only exclusion criteria for this study was neurologic impairment. For this reason, 66 neurologically impaired children (52 Thal, 10 Nissen, 4 Toupet) were excluded from the study. This evaluation focuses on the data for the remaining 238 neurologically normal children. The patients varied in age from 5 months to 16 years (median, 58 months). The median weight was 20 kg. All the children underwent a complete preoperative workup, and all had well-documented GERD. The position of the trocars and the dissection phase were similar in all the procedures, as was the posterior approximation of the crura. The short gastric vessels were divided in only six patients (2.5%). The only difference in the surgical procedures was the type of antireflux valve created., Results: The median duration of surgery was 70 min. There was no mortality and no conversion in this series. A total of 12 (5%) intraoperative complications (5 Nissen, 5 Toupet, 2 Thal) and 13 (5.4%) postoperative complications (3 Toupet, 4 Nissen, 6 Thal) were recorded. Only six (2.5%) redo procedures (2 Thal, 2 Toupet, 2 Nissen) were performed. After a minimum follow-up period of 5 years, all the children were free of symptoms except nine (3.7%), who sometimes still require medication. The incidence of complications and redo surgery for the three procedures analyzed with the Mann-Whitney U test are not statistically significant., Conclusions: For pediatric patients with GERD, laparoscopic Nissen, Toupet, and Thal antireflux procedures yielded satisfactory results, and none of the approaches led to increased dysphagia. The 5% rate for intraoperative complications seems linked to the learning curve period. The authors consider the three procedures as extremely effective for the treatment of children with GERD, and they believe that the choice of one procedure over the other depends only on the surgeon's experience. Parental satisfaction with laparoscopic treatment was very high in all the three series.

Background: This multicenter survey includes neonates and infants who underwent surgery for primary gastroesophageal reflux (GER) who presented with supraesophageal symptoms of unknown origin with a minimum of 12 months postoperative follow-up., Methods: A total of 726 patients underwent GER surgery in 10 European Centers in the period 1998-2002. Respiratory symptoms were present in 204 patients (28%); 135 patients (17%) had surgery under 1 year of age, and 46 of them (6.3%) because of respiratory symptoms. Surgery was performed without any previous medical treatment in 10 cases (21%). The type of procedure included 37 complete 360 degrees wraps (80%) (Nissen, 12, and Rossetti, 25) and nine partial wraps (20%) (Thal five, Lortat Jacob one, Toupet one, others two). Gastrostomy was associated in 17 cases (37%) (6 PEG and 11 modified Stamm). No gastric emptying procedures were recorded., Results: No major intraoperative complications were reported. Six patients developed complications (13%) and a redo operation was performed in three (6.5%). Respiratory outcome after antireflux surgery was good in 35 patients (76%) and fair with significantly improved respiratory symptoms in 11 (24%)., Conclusions: This multicenter survey underlines that GER has to be suspected and aggressively treated in infants with difficult-to-treat supraesophageal symptoms, and also in high-risk cases, in order to prevent major complications.

Background: Feeding difficulties and gastroesophageal reflux (GER) are major problems in severely neurologically impaired children. Many patients are managed with a simple gastrostomy, with or without fundoplication. Unfortunately, fundoplication and gastrostomy are not devoid of complications, indicating the need for other options in the management of these patients., Methods: Since January 2002, seven patients (age range, 5-14 years) have been treated by creating a jejunostomy with the laparoscopic-assisted procedure. The procedure was performed using two 10-mm trocars. The technique consists of identifying the first jejunal loop, grasping it 20-30 cm away from the Treitz ligament with fenestrated atraumatic forceps, and exteriorizing it to the trocar orifice under visual guide. The jejunostomy was created outside the abdominal cavity during open surgery. At the end of the jejunostomy, the correct positions of the intestinal loop and feeding tube were evaluated via laparoscopy., Results: Surgery lasted 40 min on average, the laparoscopic portion only 5 min. There were no perioperative complications; hospital stay was 3 or 4 days for all patients. At the longest follow-up (18 months), all patients had experienced a significant weight gain, with a high level of parental satisfaction. One patient died 1 year after the procedure of unknown causes. All the others are well, without complications or problems, and their parents are extremely satisfied with the improved quality of life of their children., Conclusions: Laparoscopic-assisted jejunostomy is a safe and effective procedure to adopt in neurologically impaired children with feeding problems and GER. This procedure solves these patients' feeding problems even if the reflux is not completely eliminated. We advocate the use of this procedure in neurologically impaired patients with feeding problems and reflux due to its overall practicability and because there is minimal surgical trauma. This technique is extremely safe because the surgeon is able to verify, at the end of procedure, the status of the jejunostomy from outside and inside the abdominal cavity. The improvement in the quality of life of these children after the jejunostomy seems to be the major advantage of this procedure.

Background: In the last few years, robotics has been applied in clinical practice for a variety of laparoscopic procedures. This study reports our preliminary experience using robotics in the field of general surgery to evaluate the advantages and limitations of robot-assisted laparoscopy., Methods: Thirty-two consecutive patients were scheduled to undergo robot-assisted laparoscopic surgery in our units from March 2002 to July 2003. The indications were cholecystectomy, 20 patients; right adrenalectomy, two points; bilateral varicocelectomy, two points; Heller's cardiomyotomy, two points; Nissen's fundoplication, two points; total splenectomy, one point; right colectomy, one point; left colectomy, 1 point; and bilateral inguinal hernia repair, one point. In all cases, we used the da Vinci surgical system, with the surgeon at the robotic work station and an assistant by the operating table., Results: Twenty-nine of 32 procedures (90.6%) were completed robotically, whereas three were converted to laparoscopic surgery. Conversion to laparoscopy was due in two patients to minor bleeding that could not be managed robotically and to robot malfunction in the third patient. There were no deaths. Median hospital stay was 2.2 days (range, 2-8)., Conclusions: The main advantages of robot-assisted laparoscopic surgery are the availability of three-dimensional vision and easier instrument manipulation than can be obtain with standard laparoscopy. The learning curve to master the robot was >or= 10 robotic procedures. The main limitations are the large diameter of the instruments (8 mm) and the limited number of robotic arms (maximum, three). We consider these technical shortcomings to be the cause for our conversions, because it is difficult to manage bleeding episodes with only two operating instruments. The benefit to the patient must be evaluated carefully and proven before this technology can become widely accepted in general surgery.

Laparoscopy has raised great interest in the past few years in the field of pediatric urology. It has evolved from a simple diagnostic maneuver to complex operative procedures. The aim of this study was to review urologic laparoscopy literature and provide a critical review of this field to establish current indications for videosurgery in pediatric urology. In general, from an anatomic point of view, retroperitoneoscopy seems to be more suitable than the transperitoneal laparoscopic approach for reaching the upper urinary tract. It also is less invasive and complies with the criteria for open renal surgery. With respect to current indications for videosurgery in pediatric urology, the authors have identified several well-established clinical procedures, although no large series have been published for any of the procedures, except for the treatment of varicocele, nonpalpable testis, and nephrectomy. In conclusion, the data reviewed suggest that videosurgery is a safe and feasible technique in pediatric urology if performed by expert surgeons, and that it certainly will develop further in the next few years.

Pyriform sinus fistula is a very rare branchial apparatus malformation, often appearing in the form of a cervical inflammatory process (abscess or suppurative thyroiditis), especially in infants. Failure to diagnose this lesion may result in unexpected recurrence. A case of recurrent suppurative thyroiditis caused by pyriform sinus fistula in a 9-year-old girl is reported. In the latency period of infection, the fistula tract was identified by a barium meal contrast study. Direct endoscopy showed the fistula internal orifice at the apex of the left pyriform fossa. The fistula was completely obliterated by injection of fibrin glue. Suppurative thyroiditis is reported mainly in the pediatric literature, and the reported case is the first to be managed endoscopically by injection of fibrin adhesive.

Background: Due to technological improvements, the use of tissue adhesives and glues for tissue approximation and hemostasis in surgery has increased. We report our preliminary experience with this technology in pediatric endosurgery., Methods: Between 1997 and 2000, we employed tissue adhesives in 48 pediatric patients during laparoscopic procedures. In 25 patients, the glue was adopted for the hemostasis of parenchimal organs (liver in 24 cases and spleen in one). In three cases, the glue was used to repair organ perforation, in 19 it was used to close the distal part of a patent processus vaginalis in case of congenital inguinal hernia. In the final case, the glue was adopted to achieve optimal airtightness in case of pulmonary biopsy. The glue was injected with the aid of a needle positioned transparietally., Results: The procedure was easy and rapid in all cases, and there were no problems or complications related to glue positioning at a mean follow up of 51 months., Conclusion: Tissue adhesives are a very versatile product for use in pediatric laparoscopic surgery. It is likely that their usage will increase as the technology improves and more effective products are developed.

Background: Esophageal achalasia is not a frequent disorder in children and different treatments have been proposed during past decades. This study reviews the results of the laparoscopic Heller-Dor procedure performed in pediatric patients in two different surgical units., Methods: We included the patients aged <14 years with a minimum follow-up of 6 months operated on in the period 1994-2001. A single longitudinal anterior esophageal myotomy (Heller) and a 180 degrees anterior gastropexy (Dor) were laparoscopically performed. The patients were checked to detect intra- or postoperative complications and recurrence., Results: Twenty children were operated on. Mean follow-up was 45 months (range 6-102). Postoperative clinical score was Visick 1 in 15 cases and Visick 2 in five., Conclusions: As complication and recurrence rates are very low we consider modified Heller myotomy and Dor gastropexy through a laparoscopic approach our first choice to treat esophageal achalasia in the pediatric population.

Background: In the past decade, cryptorchidism has generally been treated in the first 36 months of life using an inguinal approach, in the case of palpable testis, or using laparoscopy, in the case of nonpalpable testis. Nevertheless, before this period some children were managed incorrectly. This case report shows how laparoscopy and the collaboration between pediatric surgeons and urologists may lead to optimal results., Case Report: A 19-year-old male was referred to our unit following routine medical examination for enrollment in the military service with a diagnosis of right cryptorchidism. The clinical history showed the anamnesis of right cryptorchidism diagnosed at birth as a right nonpalpable testis, confirmed at 2 years of age with clinical examination and computer tomography. The patient came to our attention to again undergo a clinical examination, ultrasonography, computed tomography, and magnetic resonance imaging. We found a left, well-positioned testis of 20 ml in volume and an empty right scrotum; all the instrumental examinations were negative. The patient was thus scheduled for a diagnostic laparoscopy. A pediatric surgeon with extensive experience in this pathology performed the procedure. The 10-mm 30 degrees optics introduced through the umbilicus showed a closed right inguinal ring, with no evidence of either vas deferens or inner spermatic vessels at the level of the inguinal region or pelvis. Two more trocars were introduced and a testis of 15 ml in volume was found under the ascending colon 10 cm away from the cecum. An orchiectomy was performed via laparoscopy., Conclusion: This case clearly shows that some males with nonpalpable testis may have been treated incorrectly in the prelaparoscopic era and may now have an intraabdominal testis. In addition, our experience shows that intraabdominal testis may sometime be in an unusual location, and a laparoscopic surgeon with experience in this pathology is fundamental to finding the testis. In the case of adults with nonpalpable testis, when echography, computed tomography, and magnetic resonance imaging are not useful, the only effective diagnostic procedure is laparoscopy.

Background: The aim of this study was to investigate the feasibility and results of laparoscopic antireflux procedure in neurologically impaired children., Methods: Over a 5-yr period, 259 children affected by gastroesophageal reflux disease underwent laparoscopic antireflux procedure. Eighty of them (30.8%) were neurologically impaired. In 58 children we performed an anterior fundoplication according to Thal and in 22 patients a 360 degrees fundoplication according to Nissen. Forty-eight children underwent an associated gastrostomy placement at the same time as the laparoscopic antireflux procedure., Results: We recorded 4/80 intraoperative complications; in all cases the complication was managed laparoscopically and no conversion was needed. Follow-up ranged from 6 months to 6 yrs (median 3 yrs). We recorded 24/80 postoperative complications, 5 of which required a redo procedure. We have a mortality rate of 17.5% but in only one case was the event related to the antireflux procedure., Conclusions: Laparoscopic fundoplication can be performed safely and with acceptable results in neurologically impaired children. The indication to add a gastrostomy should be tailored to the needs of the individual patient. Mortality rate in neurologically impaired children patients with gastroesophageal reflux disease is high but in most cases unrelated to the antireflux procedure.

Background: The aim of this paper is to show the efficacy of laparoscopy using only one umbilical trocar to treat abdominal complications of hydrocephalic children with ventriculoperitoneal shunts (VPS)., Materials and Methods: In a 15-year period, 14 laparoscopies were performed on as many children with VPS complications: in the last 4 patients only one trocar was used to solve the complications, and this subgroup will be the object of the present study. Concerning the indication for surgery, the patients presented one catheter lost in the abdominal cavity; one cerebrospinal fluid pseudocysts; one bowel obstruction; and one malfunctioning peritoneal limbs of the catheter. We used the one-trocar laparoscopic approach in all the 4 patients, and the 10-mm trocar was always introduced through the umbilical orifice in open laparoscopy., Results: The laparoscopic technique was curative in all four cases and permitted the solution of the complication., Conclusions: One-trocar laparoscopic surgery can be considered as the ideal procedure in case of abdominal complications of VPS in children with hydrocephalus.

Background: Skepticism is still present today about the laparoscopic treatment of gastro-esophageal reflux (GER) in children. We present the prospective experience and short-term results of eight Italian pediatric surgical units., Methods: We included all the children with complicated GER, operated after January 1998 by single surgeons from eight different centers. Diagnostic aspects, type of fundoplication, and complications were considered. All the patients were followed for a minimum period of 6 months in order to detect complications or recurrences., Results: 288 children were prospectively included. Mean age was 4.8 years (3 m-14 y). Nissen fundoplication was done in 25%, floppy Nissen in 63%, Toupet in 1.7%, and anterior procedures (Lortat Jacob, Thal) in 10%. Gastrostomy was associated, if neurological impairment or feeding disorders were present. Mean follow-up was 15 months and reoperation was necessary in 3.8% of cases., Conclusions: This experience underlines that minimal invasive access surgery in children is safe and that the laparoscopic approach is considered in eight centers the golden standard for surgical repair of gastro-esophageal reflux disease maintaining the same indications and techniques of the open approach.

Usually the word conversion implies conversion from a laparoscopic procedure to an open procedure to solve complications occurring during laparoscopy. In this article we report a conversion from an open procedure to a laparoscopic one, to treat a vascular complication that occurred during an orchiectomy performed in open surgery. A 2-year-old boy came to our center for a right orchiectomy. The clinical history of this baby showed the presence of a right atrophic testis positioned in the medial part of the inguinal canal, a finding also confirmed by ultrasonography. One of our residents performed a right orchiectomy via an open inguinal procedure. After removing the testis, and before ligating the inner spermatic vessels at the level of the internal inguinal ring, the forceps that held the vessels was inadvertently opened, causing a contraction of the spermatic vessels. Since we were unable to identify the vessels and achieve hemostasis via the inguinal opening, a conversion to laparoscopic surgery was decided. A 10-mm 0 degrees optics was introduced through an umbilical trocar and revealed a large retroperitoneal hematoma along both the inner spermatic vessels and the deferential vessels, for about 3-4 cm from the internal inguinal ring. Two 5-mm trocars were positioned in triangulation and hemostasis was achieved by positioning clips on the vessels at the level of internal inguinal ring and proximally to the hematoma. Surgery lasted 1 hour; the laparoscopic procedure, 25 minutes. The baby was discharged 2 days after surgery. At a 9-month follow-up the clinical and ultrasonographical evaluation was normal. This case clearly shows the usefulness of laparoscopy in pediatric surgery, as well as to solve complications due to open surgery. We think that nowadays the use of laparoscopy should be considered indispensable by every pediatric surgical team.

One of the main advantages of laparoscopy in children is the fact that it enables a magnified view and the possibility to explore the whole abdominal cavity. This case report clearly shows these advantages. We report the case of a 3-yr-old girl, suffering from severe GERD and right inguinal inguinal hernia, who had already been operated at birth for esophageal atresia. We performed a laparoscopic fundoplication according to Nissen and, at the end of procedure, we decided to turn the optic down to control the right inguinal region to confirm the presence of an inguinal hernia. To our great surprise we found a right oblique external hernia as well as a direct inguinal hernia on the same side. Both hernias was treated successfully in laparoscopy. At a 1-year follow-up, the patient presented no reflux and no recurrence of the inguinal hernias. The laparoscopy in this case permitted operation on two different pathologies involving the upper and lower parts of the abdominal cavity using the same ports and without enlarging the incision, as would happen in laparotomy. The main relevance of this case is that laparoscopy allowed the detection of an associated pathology like a direct inguinal hernia that would have been certainly overlooked in open surgery and could have caused a recurrent hernia if operated via open surgery.

Background: Some reports have suggested that laparoscopic splenectomy (LS) can be successfully performed in adults. However, several aspects of this procedure remain as yet undefined; therefore, several attempts have been made to modify the standard technique to try to optimize the procedure. Herein we analyze our experience with 105 laparoscopic splenectomies., Methods: From 1993 to 2000, 105 patients underwent LS at our hospital. Twelve of these patients also underwent a concomitant cholecystectomy. There were 66 women and 39 men whose ages ranged between 4 and 78 years (median, 27.7). All patients underwent an elective laparoscopic splenectomy. Seventy five patients had thrombocytopenia (ITP), 14 had hereditary spherocytosis, eight were affected by b-thalassemia, two had splenic cysts, two had lymphoma, (two had myeloid chronic leukemia, one patient presented with a splenic abscess and one had incurred an iatrogenic spleen lesion during adrenalectomy. The first patients in this series were positioned in dorsal decubitus; however, as the team's experience increased, the right lateral decubitus became the position of choice because it provides better exposure of the splenic hilum. This procedure requires the use of only four trocars., Results: Mean operating time was 95 min (range, 35-320). Hospital stay ranged from 2 to 21 days (median, 4.5). There was only one conversion to open surgery. One patient died in the postoperative period due to the evolution of a preexisting malignant disease. We recorded nine complications-four subphrenic abscesses, two cases of pleuritis, two episodes of postoperative bleeding, and one intestinal infarction 16 days after surgery. Only two patients needed redo surgery., Conclusions: We believe that the laparoscopic approach is a valid alternative to open splenectomy, but mastery of some of the technical details of this procedure could greatly help avoid its complications. On the basis of our experience, it seems that the lateral approach should be considered the position of choice because it provides exposure and easier dissection of the splenic hilar structures. We also found that a 30 degrees scope and an ultrasonic dissector allowed for perfect vision and optimal hemostasis during the procedure. At the end of procedure, the spleen should be fragmented and then extracted using an extraction bag.

Background: The aim of this study was to evaluate the incidence and management of complications of videosurgical procedures that occurred during a 4-year period in eight Italian pediatric surgery centers., Methods: Between 1996 and 1999, 2305 videosurgical procedures were performed in 11 centers of pediatric surgery. The data from 3 centers, for a total of 616 procedures, were largely incomplete and were thus excluded from the study. We analyzed the data from 8 centers only, for a total of 1689 laparoscopic or thoracoscopic operations on patients aged between 15 days and 16 years. The type of operations performed ranged from basic videosurgical interventions, such as varicocelectomy and cryptorchidism, to advanced laparoscopic procedures, such as splenectomy, total colectomy, and esophageal achalasia. Each patient's file was examined for any complications that may have occurred during the surgical procedure and for a record of how these were managed., Results: We recorded 79 complications (4.6%) in our series. In 57 cases (72.2%) the problem was solved by videosurgery. Twenty-two cases (27.8%) required conversion to open surgery. There was no mortality in our series. At a maximum follow-up of 4 years, all children were alive and had no problems related to the videosurgical complications., Conclusions: We believe that the routine use of open laparoscopy in pediatric patients is a key factor to avoiding complications related to the Veress needle and blind introduction of the first trocar. Moreover, the surgeon's laparoscopic experience, the correct indications for laparoscopic surgery, and the verification of the laparoscopic equipment before surgery are also important rules to follow to reduce the incidence of complications. In the beginning, it is preferable to have the assistance of an expert laparoscopic surgeon to decrease the complications related to the learning curve period.

Background: Laparoscopic appendectomy is a feasible and a safe alternative to open appendectomy. Several laparoscopic procedures have been described that use one or more trocars. We report our experience with the treatment of acute appendicitis using a laparoscopy-assisted technique by means of only one transumbilical trocar., Methods: From February 1996 to February 1999 we performed 65 laparoscopic appendectomies. In the procedures, a 10-mm operative telescope was used, with a 450-mm atraumatic grasper introduced through the operative channel. After the intraabdominal laparoscopic dissection, the appendix was exteriorized through the umbilical trocar. The appendectomy was performed outside the abdomen as in the open procedure. The procedure was completed using only one trocar in 55 patients (84.6%). Regarding the other 10 cases (15.3%), in 5 we used more than one trocar and in 5 conversion to open surgery was needed., Results: The average operating time in our series was 25 min and the median time to discharge was 2 days. There were six (11%) postoperative complications (three serous umbilical secretion and three umbilical hematomas)., Conclusions: Our results suggest that this technique, which combines the advantages of both the open and the laparoscopic procedures, is a valid alternative for the treatment of acute appendicitis. However, this procedure cannot always be completed using only one trocar, as happened in 10 cases in our series.

Background: The aim of this study was to show the feasibility of an experimental model of gastroschisis using fetoendoscopic surgery on sheep fetuses, and also to perform amnioinfusion until delivery using an in-dwelling intraamniotic catheter., Methods: We analyzed the data from 18 pregnant ewes having 26 fetuses, which underwent surgery at 80 days of gestation (full term, 145 days). The fetendo technique was used to create a gastroschisis in 15 fetuses. The fetal abdominal wall was opened on the left side of the cord using scissors. The omentum and the intestinal loops were eviscerated using atraumatic forceps. Eleven fetuses were used as a control group. Twenty-one fetuses underwent amnioinfusion; a simple exteriorized catheter was used in seven cases and an intraamniotic catheter with an implantable port was used in the other 14. All ewes and fetuses were killed at the end of the experiment by an intravenous injection of pentotal; thereafter, the fetuses underwent necropsy., Results: Twelve fetuses died and 14 survived (53.8%); seven of the 15 that underwent gastroschisis survived (46.7%). An amniotic infection occurred in nine fetuses (34.6%); of these, six died and three that were administered antibiotics survived., Conclusions: Our experience shows that this experimental model of gastroschisis is feasible and reproducible, and that a repeated amnioinfusion can be performed with an in-dwelling catheter in pregnant ewes. The use of an implantable port is safer than a simple exteriorized catheter.

Background: The purpose of our study was to evaluate the results and complications of laparoscopic cholecystectomy in a case series of 110 infants., Methods: Over a 5-year period (1993-98), we performed laparoscopic cholecystectomy in 110 pediatric patients. Surgery was performed at different institutions by three different surgeons. The patient population was composed of 69 girls and 41 boys; their ages ranged from 1 to 16 years (median, 8.5). All of the 110 children had symptomatic cholelithiasis, which was confirmed at ultrasound examination. An associated pathology was present in 27 patients (sickle cell disease in 17 cases, hereditary spherocytosis in seven cases, thalassemia in three); the other 83 infants were affected by idiopathic cholelithiasis. In 107 patients, the operation was performed using four ports; in three patients, it was done using five ports. In three patients, we also performed a concomitant splenectomy., Results: Median duration of simple cholecystectomy was 45 min (range, 25-75) and hospital stay ranged from 1 to 10 days (median, 2). Only 15 children required drainage. We had 17 complications in our series (15.5%), including a gallbladder perforation during dissection in 11 patients, a fall of stones into the abdominal cavity during extraction in one patient, and a trocar orifice infection in the postoperative period in five patients. At a maximum follow-up of five years (range, 1-5), all patients were doing well., Conclusion: Laparoscopic cholecystectomy in children seems to be as effective as open surgery in cases of symptomatic cholelithiasis. In pediatric patients more than in adults, an accurate and precise dissection and a sound knowledge of possible congenital biliary abnormalities are essential to avoid any kind of complication.

We report our experience with a case of vena cava injury during laparoscopic right adrenalectomy. A laparoscopic right adrenalectomy was performed in a 22-year-old woman who suffered from a right surrenalian adenoma. Four trocars were used for the transperitoneal laparoscopic approach with the patient in the lateral decubitus position. After isolation of the medial margin of the gland and clipping and sectioning of the main adrenal vein, the right side of the vena cava was injured during dissection of the right upper pole, due to the use of monopolar scissors. The hemorrhage was managed immediately with the aid of fenestrated atraumatic forceps and an aspiration probe. A fifth trocar was inserted to evaluate the size of the lesion, which was then sutured laparoscopically with croised 5/0 nonresorbable stitches. No transfusion was needed. Operating time was 210 min. The post-operative course was uneventful. Hospital stay was 7 days. At 10-month follow-up, the patient had no problems related to the intraoperative complication. Our preliminary experience shows that the laparoscopic approach enables safer management of lesions involving large abdominal vessels. We believe that the transperitoneal approach is the preferential route for laparoscopic adrenalectomies. Monopolar coagulation can be dangerous and must be avoided when dissecting large vessels.

Background: Several surgical procedures have been described for the management of nonpalpable testis. Following a vast experience with a complete laparoscopic two-stage Fowler-Stephens procedure, we report our experience with laparoscopic orchiopexy performed without dividing the spermatic vessels., Methods: Over a 24-month period, 70 boys with nonpalpable testes (72 overall) underwent laparoscopic diagnostic exploration. Twenty patients (27.8%) of this series who showed an intraabdominal testis underwent laparoscopic orchiopexy without sectioning the spermatic vessels. In seven cases, the testis was just proximal to the internal inguinal ring; in 13, it was in the high intraabdominal position. The technique consisted in sectioning the gubernaculum (when present), opening the peritoneum laterally to the spermatic vessels, and mobilizing the testicular vessels and the vas deferens in a retroperitoneal position for 8-10 cm. The testis was then brought down into the scrotum through the internal inguinal ring (11 cases), if this was open, or through a neo-inguinal ring (nine cases) created medially to the epigastric vessels. In every case, we closed the inguinal ring at the end of the operation using one or two detached sutures., Results: Operating time ranged between 40 and 75 min (median, 55). All the testes were successfully brought down into the scrotum. We had only one (5%) intraoperative complication. In the second patient treated with this procedure, there was an iatrogenic rupture of the spermatic vessels due to excessive traction., Conclusion: On the basis of our experience, we believe that laparoscopic orchiopexy without division of the spermatic vessels should be the treatment of choice in the management of nonpalpable testes, because it does not affect normal testicular vascularization and is minimally invasive. A blunt dissection and a delicate manipulation of the testis without excessive traction are the best ways to avoid any kind of complication.

Background: The aim of this study was to assess the complications associated with the laparoscopic treatment of gastroesophageal reflux disease (GERD) in children., Methods: From March 1992 to March 1998, we used the laparoscopic approach to treat 289 children affected by gastroesophageal reflux disease. The patients' ages ranged between 4 months and 17 years (median, 4.3 years), and their body weight ranged between 5 and 52 kg. In 148 children (51.3%), we adopted a Nissen-Rossetti procedure and in 141 (48.7%) a Toupet technique., Results: The duration of surgery ranged between 40 and 180 min (median, 70). There were no deaths and no anesthesiological complications in our series. We recorded 15 (5.1%) intraoperative complications: six pleural perforations, four lesions of the posterior vagus nerve, two esophageal perforations, two gastric perforations, and one pericardiac perforation. Conversion to open surgery was necessary in only four cases (1.3%). We recorded 10 (3.4%) postoperative complications: one peritonitis due to an esophageal perforation not detected during the intervention that required a reoperation, five cases of herniation of the epiploon through a trocar orifice, three cases of dysphagia that disappeared spontaneously after a few months, and one case of delayed gastric emptying that subsequently required a pyloroplasty. We had six recurrences of GERD (2.1%). In two cases, a new fundoplication was performed using the laparoscopic approach; in the other four, the GERD was controlled with medical therapy., Conclusion: Our results show that laparoscopic fundoplication is an adequate treatment for children with GERD that has a low rate of complications. When severe complications do occur, they can be treated effectively via the laparoscopic approach.

Background: Albeit rare in children, achalasia is a disorder with severe symptoms that causes growth impairment. The treatment of choice in children is the esophagomyotomy, although there are variations in the surgical approaches available and differences of opinion regarding the inclusion of an adjunctive antireflux procedure. The recent advent of the laparoscopic approach has had a profound impact on the treatment of achalasia in both adults and children., Methods: In this report, we describe eight patients with severe achalasia who were treated by laparoscopic Heller's operation associated with a fundoplication according to either Dor's or Toupet's technique. The patients' ages ranged between 2 and 13 years. A five-port technique was used: a 10-mm port placed infraumbilically for the optics and four 5-mm ports. One was placed in the right abdominal quadrant for retraction of the left hepatic lobe, one in the left abdominal quadrant for the first operative instrument, one below the xyphoid appendix for the second operative instrument, and the last one to introduce a 5-mm cannula laterally to the umbilicus to retract the stomach below. A 7-8-cm laparoscopic Heller esophagomyotomy was completed, followed by an anterior Dor fundoplication in six cases and a Toupet in two. The longitudinal division of the anterior esophageal musculature was performed with a scalpel or scissors. The myotomy was made along the stomach, extending for >/=2-3 cm., Results: Mean operating time was 120 mins. Three complications were recorded. There were two perforations of the gastroesophageal mucosa; the first was sutured in laparoscopy and the second required a second operation. The third complication was a case of dysphagia resolved by dismounting a fundoplication that was too tight. At follow-up, which lasted from 6 months to 5 years, the children were all free of symptoms., Conclusions: Laparoscopic Heller esophagomyotomy appears to be a complex and difficult operation, but it is as safe and effective as laparotomy in children with achalasia. However, complications can be numerous and severe at the beginning of a surgeon's experience.

Background: We set out to analyze the results of the first 19 laparoscopic splenectomies performed by our team in order to show the advantages and limitations of the laparoscopic approach to this kind of procedure in children., Methods: Between March 1994 and June 1997, 19 children underwent laparoscopic splenectomy; two of them also had a concomitant cholecystectomy. Their ages ranged between 4 and 14 years (median, 7.2 years). There were 14 girls and 5 boys. All the patients underwent elective laparoscopic splenectomy: seven children had hereditary spherocytosis, six were affected by a beta thalassemia, five had an idiopathic thrombocytopenia purpura, and one presented with sickle cell disease., Results: Mean operating time was 145 min (range, 110-240 min). Hospital stay ranged from 2 to 5 days (median, 3 days). In three patients, the spleen was removed with a 7-cm mini-laparotomy, according to the technique of Pfannenstiell, in the suprapubic region. In the other 16 cases, the spleen was captured into a extraction bag, finger-fragmented, and removed from the umbilical orifice., Conclusions: Laparoscopic splenectomy can be performed only when the spleen can be removed through the umbilical orifice with an extraction bag. For this reason, preoperative ultrasonography is necessary to measure the exact spleen volume. When the spleen is very large, an open splenectomy is preferable.

Background: Cysts are the most common ovarian masses found in newborn girls. Spontaneous regression, which occurs in approximately 25-50% of cases, is more frequent with smaller cysts. Pre- or postnatal complications are common; these complications may consist of intracystic bleeding, torsion of the cyst or corresponding annex, or self-amputation of the cyst. When the cyst is <4 cm it is possible to perform a simple echographic monitoring to check for the possibility of spontaneous involution; all other cases require surgery., Methods: Between February 1985 and June 1997, we treated 22 neonatal ovarian cysts laparoscopically. In 14 cases, the right side was involved; in eight cases, it was the left. The patients' ages ranged between 7 days and 5 months (median, 45 days). In all cases, we used three trocars. An intraperitoneal cystectomy was done in eight cases, a transparietal cystectomy in four cases, an ovariectomy in seven cases, and the simple removal of the cyst in one case where self-amputation had occurred. In two cases of bilateral pathology, the cysts, which were <1 cm, were left untreated., Results: Average operating time was 40 min (range, 25-60 min). Intraabdominal pressure never exceeded 6-8 mmHg during the intervention. The postoperative course was always under 3 days. No intra- or postsurgical complications were recorded, and long-term ultrasonographic follow-ups were all normal., Conclusion: Our experience indicates that the laparoscopic approach is a reliable and safe technique in the treatment of neonatal ovarian cysts.

Laparoscopic appendectomy is a safe alternative to open appendectomy to treat appendicitis. The author reports his experience in performing laparoscopic appendectomy with the use of only one trocar in pediatric patients. Between 1 January 1994 and 30 October 1995 at the Department of General and Pediatric Surgery, Division of Pediatric Surgery of the "Federico II" University of Naples, we performed 51 laparoscopic appendectomies. Patient age varied from 4 to 16 years with a mean age of 7 years. In the last 25 patients of our series we performed the one-trocar appendectomy, positioning only one trocar infraumbilically with the use of a 10-mm operative telescope. The appendix is identified, dissected when necessary, grasped laparoscopically with a 450-mm operative atraumatic instrument introduced through the operative channel of the laparoscope, and then exteriorized through the umbilical cannula. The appendectomy was performed using traditional method outside the abdominal cavity. We had no intra- or perioperative mortality or morbidity. The mean overall hospitalization time was 2 days (1-4 days). At a maximal follow-up of 20 months the children have no clinical problems nor any visible scar related to the laparoscopic appendectomy. In conclusion, the author considers the one-trocar appendectomy an appropriate alternative procedure to other techniques of laparoscopic appendectomy.