Search

Introduction: Intraoperative imaging, such as ultrasound, provides subsurface anatomical information not seen by standard laparoscopy. Currently, information from the two modalities may only be integrated in the surgeon's mind, an often distracting and inefficient task. The desire to improve intraoperative efficiency has guided the development of a novel, augmented reality (AR) laparoscopic system that integrates, in real time, laparoscopic ultrasound (LUS) images with the laparoscopic video. This study shows the initial application of this system for laparoscopic hepatic wedge resection in a porcine model.Materials and Methods: The AR system consists of a standard laparoscopy setup, LUS scanner, electromagnetic tracking system, and a laptop computer for image fusion. Two liver lesions created in a 40-kg swine by radiofrequency ablation (RFA) were resected using the novel AR system and under standard laparoscopy.Results: Anatomical details from the LUS were successfully fused with the laparoscopic video in real time and presented on a single screen for the surgeons. The RFA lesions created were 2.5 and 1 cm in diameter. The 2.5 cm lesion was resected under AR guidance, taking about 7 minutes until completion, while the 1 cm lesion required 3 minutes using standard laparoscopy and ultrasound. Resection margins of both lesions grossly showed noncoagulated liver parenchyma, indicating a negative-margin resection.Conclusions: The use of our AR system in laparoscopic hepatic wedge resection in a swine provided real-time integration of ultrasound image with standard laparoscopy. With more experience and testing, this system can be used for other laparoscopic procedures. [ABSTRACT FROM AUTHOR]

Background: Pancreatic ductal obstruction leading to ductal dilation and recurrent pancreatitis is uncommon in children. Treatment is dependent upon etiology but consists of decompression of the pancreatic duct (PD) proximally, if possible, by endoscopic retrograde cholangiopancreatography (ERCP) intervention or surgical decompression with pancreaticojejunal anastomosis.Methods: After institutional review board approval, we retrospectively reviewed the records for 2 children who underwent lateral pancreaticojejunostomy for pancreatic ductal dilation. Data, including demographics, diagnostic studies, operative details, complications, outcomes, and follow-up, were analyzed.Results: Case 1 was a 4-year-old female with pancreatic ductal obstruction with multiple episodes of recurrent pancreatitis and failure of ERCP to clear her PD of stones. She underwent a laparoscopic cholecystectomy with a lateral pancreaticojejunostomy (Puestow procedure). She recovered well with no further episodes of pancreatitis and normal pancreatic function 4 years later. Case 2 was a 2-year-old female who developed recurrent pancreatitis and was found to have papillary stenosis and long common bile-PD channel. Despite multiple sphincterotomies, laparoscopic cholecystectomy, and laparoscopic hepaticoduodenostomy, she continued to experience episodes of pancreatitis. She underwent a laparoscopy converted to open lateral pancreaticojejunostomy. Her recovery was also smooth having had no episodes of pancreatitis or hospital admissions for over 2 years following the Puestow.Conclusions: Indication for lateral pancreaticojejunostomy or Puestow procedure is rare in children and even less often performed using laparoscopy. In our small experience, both patients with pancreatic ductal obstruction managed with Puestow's procedure enjoy durable symptom and pain relief in the long term. [ABSTRACT FROM AUTHOR]

Introduction: We studied operating team acceptability of Video Telescopic Monitor (VITOM®) exoscope by exploring the ease of use of the device in two centers. We also assessed factors affecting surgeon musculoskeletal discomfort.Methods: We focused on how the operating team interacted with the VITOM system with surrogate measures of usefulness, image quality, ease of use, workload, and setup time. Multivariable linear regression was used to model the relationships between team role, experience, and setup time. Relationships between localized musculoskeletal discomfort and use of VITOM alone, and with loupes, were also analyzed.Results: Four surgeons, 7 surgical techs, 7 circulating nurses, and 13 surgical residents performed 70 pediatric surgical and urological operations. We found that subjective views of each team member were consistently positive with 69%-74% agreed or strongly agreed that VITOM enhanced their ability to perform their job and improved the surgical process. Unexpectedly, the scrub techs and nurses perceived more value and utility of VITOM, presumably because it provides them a view of the operative field that would otherwise be unavailable to them. Team members rated perceptions of image quality highly and workload generally satisfactory. Not surprisingly, setup time decreased with team experience and multivariable modeling showed significant correlations with surgeon and surgical tech experience, but not circulating nurse. An important finding was that surgeon neck discomfort was reduced with use of VITOM alone for magnification, compared with use of loupes and VITOM. The most likely explanation for these findings is improved posture with the neck at a neutral position when viewing the VITOM images, compared with neck flexion with loupes, and thus, a less favorable ergonomic position.Conclusion: This study suggests that there may be small drawbacks associated with VITOM use initially, but these reduce with increased experience and benefit both the surgeon and the rest of the team. [ABSTRACT FROM AUTHOR]

Purpose: Minimally invasive procedures for enteral access in children have evolved over the years, resulting in various techniques of gastrostomy tube placement. The two most common techniques are laparoscopic gastrostomy (LG) and percutaneous endoscopic gastrostomy (PEG). Our study compares the outcomes of both procedures exclusively in children under the age of five.Methods: All procedures relating to enteral access in children <5 years of age were reviewed retrospectively from July 2009 to July of 2014 as approved by our Institutional Review Board. Demographics, techniques, and complications were collected and analyzed.Results: Of 293 patients in our study, 150 patients underwent PEG, 75 LG, and 68 LG with Nissen fundoplication (LNG). The most common indication for enteral tube placement was failure to thrive and feeding intolerance. Operative time was less in the PEG group than in the other two groups (P = .001). Overall complication rate was 60% for LG and LNG and 58% for PEG (P = NS). The major complication rate was 3.3% in the PEG group and 0.7% for the LG and LNG groups. There were two deaths in the PEG group. Sixty-eight patients (45.3%) from the PEG group underwent tube changes under anesthesia, requiring additional trip to the operating room with general anesthesia compared with LG and LNG groups (2%) (P = .001). From the PEG group, 134 patients (89%) required many fluoroscopic interventions for tube dislodgments and conversion to gastrojejunostomy tubes for significant reflux and inability to use the gastrostomy (P = .001).Conclusion: PEG tubes had a higher major complication rate than LG tubes with or without fundoplication in children <5 years of age. Despite longer operative time, LG seems to be the procedure of choice for children of this age for enteral access. Elimination of unnecessary tube changes under anesthesia and the fluoroscopic interventions after the PEG would be beneficial. [ABSTRACT FROM AUTHOR]

Background: Solid pancreatic pseudopapillary tumors make up 1%-3% of all pancreatic tumors, occur predominantly in females, and usually present in the third and fourth decades of life. Less frequently, these tumors may present in children. Complete surgical excision is the treatment of choice with excellent outcomes. Usage of a laparoscopic approach has become more common for adult patients. However, the laparoscopic approach is not routinely used in the pediatric population. Materials and Methods: A literature review was performed noting 13 documented cases of solid pancreatic pseudopapillary tumors resected laparoscopically in children. We report our case series of three children with a solid pancreatic pseudopapillary tumor treated through a minimally invasive approach. Results: In the literature, most patients had the tumor in the body or distal pancreas. The most common complication was pancreatic fistula, which was managed with total parenteral nutrition. In addition, there were reports of recurrence after biopsy of the tumor. In our case series 2 of the 3 patients received a splenectomy because of the proximity of the tumor to the spleen. There were no intraoperative or postoperative complications. Follow-up length from 13 to 36 months revealed no evidence of recurrence. Conclusions: In the pediatric population, solid pancreatic pseudopapillary tumors located in the body or tail of the pancreas can be managed with a laparoscopic distal pancreatectomy. [ABSTRACT FROM AUTHOR]

Purpose: Traumatic pancreatic transection is uncommon. The role of laparoscopy in the setting of this injury has not been well described. Patients and Methods: Six large-volume pediatric trauma centers contributed patients <18 years of age who underwent a distal pancreatectomy for traumatic pancreatic transection from 2000 to 2010. Results: Twenty-one patients without another indication for emergency laparotomy underwent a distal pancreatectomy for Grade III pancreatic injuries, of which 7 underwent laparoscopic distal pancreatectomy. Mean (±SD) age was 8.6±4.7 years, and 67% were male. There was no difference in the presence of other injuries between the two groups (43% in each group). Computed tomography revealed a transected pancreas in 85% of the laparoscopic patients and 75% of the open group ( P=1.0). Mean operative time was 218±101 minutes with laparoscopy compared with 195±111 minutes with the open procedure ( P=.7). Median duration of hospitalization was 6 days (range, 6-18 days) in the laparoscopic group compared with 11 days (range, 5-26 days) in the open group ( P=0.3). Postoperative morbidity was not different between the two groups (57% versus 21% for laparoscopic versus open, P=.2). Conclusions: Laparoscopy is equivalent to open distal pancreatectomy in children with select traumatic pancreatic injuries. [ABSTRACT FROM AUTHOR]

Background: With the evolution of surgical techniques and instrumentation, surgeons have adapted methods to provide safe and effective therapy through less invasive operations. Conventional laparoscopy utilizes several small incisions in well-separated areas of the body, but more recently, surgeons have been performing minimally invasive procedures through a single incision. Specially designed ports and instruments have been employed to offset the disadvantage of losing the ability to have instruments separated in space while working through a single incision. We have reviewed our initial experience with single-incision laparoscopic cholecystectomy (SILC) in children using conventional straight laparoscopic instruments compared with those who underwent standard laparoscopic cholecystectomy (SLC). Methods: During the study period, a retrospective chart review was performed on 54 consecutive children who underwent laparoscopic cholecystectomy. Twenty-seven patients who underwent SILC (1 patient had splenectomy with cholecystectomy) were compared with 27 patients who underwent SLC by a single pediatric surgeon. Outcomes measured included successful completion rate, operative time, length of hospital stay, blood loss, and postoperative complications. Results: Fifty-four cholecystectomies were performed laparoscopically with no conversions to open. In the SILC group, 24 of 27 (89%) were successfully completed. Two patients required one additional trocar/incision (laparoscopic splenectomy with cholecystectomy) and another two additional trocars/incisions to complete the procedure. Operative time was longer in the SILC group than in the SLC group (116 versus 61 minutes; P value <.0001). Two umbilical wound infections occurred in the SILC group (7.4%) and 1 patient in the SLC group developed postoperative choledocholithiasis. Conclusions: In our experience, SILC in children using standard straight laparoscopic instruments is a safe and effective alternative to conventional four-incision laparoscopic cholecystectomy. This technique, although safe, may lead to longer operative times since there is a loss of instrument triangulation provided with SLC or use of articulating instruments. [ABSTRACT FROM AUTHOR]

Background: Despite the reported efficacy and the presumed benefits of minimally invasive surgery (MIS) for ovarian lesions in adults, questions remain as to the surgical indications, results, and outcomes for these procedures across pediatric age groups. The aim of this study was to review our experience with the management of ovarian disease in children to determine if there has been a shift in the management of these lesions from open surgery (OS) to an MIS approach in the pediatric population. Methods: An institutional review board (IRB)-approved retrospective chart review included all patients who underwent surgical management of ovarian disease from January 1, 1992 to July 10, 2007. Patients with ectopic pregnancy, known pelvic inflammatory disease, or concominant illness requiring operative management at the time of ovarian surgery were excluded. Demographics, clinical signs and symptoms, diagnosis, surgical outcomes, and history of prior abdominal procedures were obtained. Statistical analysis included comparison of means, paired t-test, chi-squared test, and multivariate analysis, where indicated. Results: A total of 231 patients were evaluated in this study, with a mean age of 12.8 years (range, 3 weeks to 20 years). There were 221 (95.7%) benign lesions and 10 (4.3%) were malignant. There were 156 simple or hemorrhagic cysts (70.5%) and 46 mature teratomas (20.8%). Three complications (1.3%) occurred, which were associated with surgery and no mortalities. Abdominal pain (82.3%), nausea or vomiting (24.2%), and abdominal tenderness (10.0%) were the most common presenting symptoms or signs. Operative outcomes for benign disease ( n = 221) were compared between MIS and open cases over the entire time period as well as within three consecutive 5-year time intervals. Conclusions: There was a notable shift toward the management of benign ovarian disease in using MIS techniques over the course of three different 5-year intervals. This approach was also associated with shorter hospital stay, less operative blood loss, and shorter operative times, when compared to an open approach. When indicated, a laparoscopic approach should be performed for presumed benign ovarian disease in children. [ABSTRACT FROM AUTHOR]

Background: Pancreatic pseudocysts are problematic sequelae of pancreatitis or pancreatic trauma causing persistent abdominal pain, nausea, and gastric outlet obstruction. Due to the low volume of disease in children, there is scant information in the literature on the operative management of pseudocysts with minimally invasive techniques. We conducted a multi-institutional review to illustrate several technical variations utilized in achieving laparoscopic cystgastrostomy in the pediatric population. Methods: A retrospective review was conducted of all patients who underwent laparoscopic cystgastrostomy in five institutions. Patient data, operative techniques, and postoperative course were analyzed. Results: There were 13 patients with a mean age of 10.4 years and mean weight of 52.1 kg. The etiologies of pancreatitis included: trauma (4), gallstones (3), chemotherapy (2), hereditary (1), and idiopathic (3). Preoperative radiographic measurements of the maximal cyst diameter averaged 11.7 cm. Cystgastrostomy was approached by using transgastric exposure in 5 cases and intragastric ports in 8 cases. An average of four ports were used to complete these operations. Mean operative time was 113 minutes. There were no conversions in this series. Cystgastrostomy was performed by using an endoscopic stapler (average 3.8 loads) in 6 cases, sutures in 6 cases, and 1 was formed solely with the Harmonic Scalpel (Johnson and Johnson). Gastrotomy sites were closed by using a stapler in 4 cases and suture techniques in 9. Mean time to initial and goal feeds was 3 and 4 days, respectively. Postoperative imaging revealed persistent pseudocyst in 1 patient, who was treated with a distal pancreatectomy. Therefore, 92% required no further operative intervention and remained asymptomatic upon recovery from their pancreatitis. Conclusion: A laparoscopic approach to pancreatic cystgastrostomy for chronic pseudocyst proved to be safe and effective in this five-institution survey. Techniques varied, but 92% had complete resolution with minimal morbidity and rapid recovery. Laparoscopic cystgastrostomy should be considered as an appropriate first-line treatment for chronic pseudocysts in children. [ABSTRACT FROM AUTHOR]

Tracheomalacia resulting from vascular compression of the trachea may require aortopexy for symptomatic relief. Several operative approaches have been described for infants and children. The authors describe the technique of aortopexy by means of a right-sided thoracoscopic method as the initial approach to relieve tracheal compression in 2 children. Intraoperative bronchoscopy is mandatory to assess the adequacy of aortopexy prior to the completion of suture placement. This procedure was very successful in relieving tracheal compression in a 17-month-old boy with an aberrant innominate artery take-off and in a 2-year and 7-month-old boy with a history of esophageal atresia/tracheoesophageal fistula repair and severe tracheomalacia. A right-sided thoracoscopic approach to aortopexy in infants with severe tracheomalacia may be successfully performed as the initial operative intervention in infants with vascular compression of the trachea. [ABSTRACT FROM AUTHOR]

Purpose: There is persistent controversy regarding the optimal surgical therapy for children with appendicitis. We have recently adopted laparoscopic appendectomy in lieu of the open technique for children with perforated appendicitis. We hypothesized that laparoscopic appendectomy would be as effective as open appendectomy in preventing postoperative complications. Materials and Methods: We reviewed the medical records of children admitted to our hospital over a 5-year period with the diagnosis of perforated appendicitis. Patients were divided into two groups based on the operative approach: laparoscopic vs. open appendectomy. Demographic data, duration of presenting symptoms, initial white blood cell (WBC) count, length of stay, and complications were abstracted. Data were compared using appropriate statistical analyses. Results: There was no difference between the laparoscopic (n = 43) and open (n = 77) groups with respect to gender, duration of presenting symptoms, initial WBC, or length of stay. However, patients in the laparoscopic group had a significantly lower complication rate than those in the open group (6/43 vs. 23/77, P = 0.05). Infectious complications were no different between groups. Patients in the laparoscopic group tended to be older than patients in the open group (10.6 ± 3.3 years vs. 8.5 ± 4.1 years, P = 0.003). Conclusion: Laparoscopic appendectomy for children with perforated appendicitis has the same infectious complication rate and a lower overall complication rate than open appendectomy. A prospective study with standardized postoperative care would be needed to determine whether laparoscopic appendectomy for children with perforated appendicitis is the treatment of choice, but until then it remains an attractive alternative. [ABSTRACT FROM AUTHOR]

Introduction: Laparoscopic adrenalectomy is now being recognized as the standard approach for adrenalectomy for benign lesions in adults. The published experience in children and adolescents has been limited to sporadic small case series. Therefore, we conducted a large multicenter review of children who have undergone laparoscopic adrenalectomy. Methods: After Institutional Review Board's approval, a retrospective review was conducted on all patients who have undergone laparoscopic adrenalectomy at 12 institutions over the past 10 years. Operative times included unilateral adrenalectomy without concomitant procedures. Results: About 140 patients were identified (70 males [50%]). Laterality included 76 (54.3%) left-sided lesions, 59 (42.1%) right, and 5 (3.6%) bilateral. Mean operative time was 130.2±63.5 minutes (range 43-406 minutes). The most common pathology was neuroblastoma in 39 cases (27.9%), of which 23 (59.0%) had undergone preoperative chemotherapy. Other common pathology included 30 pheochromocytomas (21.4%), 22 ganglioneuromas (15.7%), and 20 adenomas (14.3%). There were 13 conversions to an open operation (9.9%). Most conversions were because of tumor adherence to surrounding organs, and tumor size was not different in converted cases ( P=.97). A blood transfusion was required in 2 cases. The only postoperative complication was renal infarction after resection of a large neuroblastoma that required skeletonization of the renal vessels. At a median follow-up of 18 months, there was only one local recurrence, which was in a patient with a pheochromocytoma. Conclusions: The laparoscopic approach can be applied for adrenalectomy in children for a wide variety of conditions regardless of age with a 90% chance of completing the operation without conversion. The risk for significant blood loss or complications is low, and it should be considered the preferred approach for the majority of adrenal lesions in children. [ABSTRACT FROM AUTHOR]

Background: There have been multiple reports in the adult literature stating that previous open operations should no longer be considered a contraindication to the laparoscopic approach. However, there are little data on this topic in the pediatric population, particularly in patients with neonatal abdominal pathology unique to the newborn population. Therefore, we reviewed our experience with laparoscopic fundoplication after a variety of previous abdominal conditions and operations in the pediatric population. Methods: An institutional review board–approved retrospective chart review was performed on all patients undergoing laparoscopic fundoplication after a previous open operation between October 2000 and December 2007. The data collected demographics, comorbid conditions, previous abdominal operations, gastrostomy tube placement, time interval between the initial operation and laparoscopic fundoplication, conversions, and complications. Results: Forty-five patients underwent a laparoscopic Nissen fundoplication after an open operation during the study interval. Mean age was 41.3 months (range, 1–233) with a mean weight of 14.3 kg (range, 2.9–63.6), and 31 were (78.9%) male. A total of 61 previous abdominal operations were performed (range, 1–4). Mean time between last open operation and laparoscopic fundoplication was 27.3 months (range, 0.5–147). Mean operative time was 161 minutes (range, 73–420). There were no conversions and 3 perioperative complications occurred (splenic hematoma, clogged gastrostomy tube, and liver bleed). Early reoperations were performed in 2 patients (4.4%): 1 for bleeding on day 2 and the other for leaking gastrostomy day 12. Conclusion: Our data demonstrate that laparoscopic fundoplication after a previous open operation is feasible and safe. [ABSTRACT FROM AUTHOR]

In this paper, we describe the first reported case of a laparoscopic Nissen fundoplication and gastrostomy tube for gastroesophageal reflux disease in a 3-month-old infant with complete abdominal situs inversus. [ABSTRACT FROM AUTHOR]

Introduction: Laparoscopic adrenalectomy is well established as the standard technique for all indications of adrenalectomy except adrenal carcinoma; however, some also consider large adrenal masses a relative contraindication. We present a video of a laparoscopic excision of a large ganglioneuroma and right adrenalectomy in a 12-year-old female. Methods: Our patient was noted to have a right suprarenal mass on a computed tomography scan following complaints of back and abdominal pain. Upon surgical consultation, she underwent a magnetic resonance imaging, which showed a 7.9 × 4.4 × 5.6 cm heterogeneously enhancing suprarenal lesion that was either arising from or compressing the right adrenal gland. The patient's preoperative work-up included normal urinary metanephrines, alpha-fetoprotein, and beta-HCG. After discussion with the patient and family, the decision was made to proceed with laparoscopic excision of the mass. Results: The patient underwent successful laparoscopic excision of the suprarenal mass and right adrenalectomy and was discharged from the hospital on postoperative day 2. During the procedure, retraction was achieved by using a combination of 5-mm grasping instruments, Endokittner® dissectors (Ethicon Endosurgery Cincinnati, OH), and a suction irrigator to provide traction and counter traction. A flexible 5-mm liver retractor (Mediflex®; Velmed, Inc., Wexford, PA) was placed directly through the abdominal wall without a trocar in order to elevate the liver from the area of the right adrenal and retroperitoneum. This enabled us to “rotate” the lesion out from behind the vena cava and from along the vertebral bodies. The pathology revealed an 8.5 × 7.0 × 3.0 cm ganglioneuroma, with primarily neural and Schwann cell–type tissue with interspersed large, prominent ganglion cells, and a normal adrenal gland. Conclusions: As demonstrated by our video, large adrenal masses in the pediatric population can be successfully excised laparoscopically with appropriate surgeon comfort and experience. [ABSTRACT FROM AUTHOR]