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Purpose: The purpose of this study was to assess the safety, efficacy, and learning curve for transaxillary, totally endoscopic (TATE) head and neck endocrine surgery in children., Materials and Methods: Between June 2005 and October 2009, 31 children with head and neck endocrine problems were subjected to the TATE approach. Safety, efficacy, complications, and time of operation were assessed., Data: Thirty-one children (mean age, 12.7 years; F:M, 5:1) underwent a TATE approach. Glands ranged in size from 10 g (in a small 5-year-old) to 63 g (in one 16-year-old). No cervical incisions were required and there were no conversions to open surgery. Three patients in our early experience underwent a robot-assisted procedure. Two patients suffered from hyperparathyroidism and had adenomas removed, using rapid PTH in the operating room to confirm immediate success. Of the remaining 29 children, 2 girls had an adenoma of the right thyroid lobe removed uneventfully, and the reminder all had Graves disease, which was treated successfully. Complications included transient hypocalcemia in 3 patients who were also on steroids for unrelated medical problems; transient neuropraxia in 3 patients with very large glands; 1 postoperative, lateral, subcutaneous hematoma that resolved uneventfully; and 1 asthmatic with a spontaneous apical pneumothorax that presented as subcutaneous gas in the neck, 6 hours after the surgery and which resolved with chest tube placement. Average operative time for the first 10 patients was 288 minutes and for the subsequent patients was 155 minutes (range, 92-210 minutes)., Conclusions: The TATE approach appears to be as safe and effective as open surgery for cervical endocrinopathies in children. Only transient, minor complications were observed. Operative time significantly decreases with experience, making the length of surgery comparable to its open counterpart.

This lecture summarizes the elements of innovation and demonstrates how one can apply the principles every day to be an effective surgical innovator., (Copyright 2010. Published by Elsevier Inc.)

Objective: To report our initial experience with the transaxillary totally endoscopic (TATE) approach to the thyroid gland., Study Design: A historic cohort study of patients undergoing TATE procedures compared with open procedures for hemithyroidectomy with isthmusectomy., Setting: Private-practice otolaryngology group., Subject and Methods: Patients selected for benign thyroid disease confirmed by fine-needle aspiration and requiring hemithyroidectomy with isthmusectomy. A historic cohort study of 24 patients who underwent TATE procedures for hemithyroidectomy with isthmusectomy. Comparison of the first 10 TATE approaches to a control group of 10 consecutive open approaches by the senior author's group., Results: All 24 TATE patients were successful without the need to convert to an open procedure. The TATE approach had longer operative times than the open group (142 vs 105), but these operative times decreased as the number of procedures increased (first five TATE = 170, last five TATE = 114, n = 24, average = 114). No patients had peri- or postoperative complications., Conclusions: The TATE approach to the thyroid gland is safe and effective. Operative time is longer but decreases with experience. The TATE approach is one option to treat young patients with unilateral benign thyroid disease who are seeking to avoid visible scars and limit morbidity.

Eight children underwent minimal-access surgery (MAS) for duplications of foregut derivatives. The efficacy and safety of this approach are reviewed. The seven patients with mediastinal lesions had video-assisted thoracoscopic resection. One lesion presented as a subdiaphragmatic esophageal diverticulum, which was excised laparoscopically. Between March 1991 and October 1997, eight children were treated. Mean age was 27 months and mean weight was 11. 4 kg. Mean operating time was 106 min, and mean postoperative hospital stay was 4.5 days (median = 2 days). Persistent air leaks occurred in two patients who had centrally-located bronchogenic cysts. One of these, who had undergone subtotal excision with laser photoablation of the remaining cyst mucosa, developed a recurrence that was excised at thoracotomy. We conclude that esophageal and bronchogenic cysts and duplications may be safely excised by MAS in children, with excellent cosmetic and functional outcome. Two technical points are noted: (1) a thoracostomy tube is required for central mediastinal lesions; and (2) complete excision is required to prevent recurrence.

The pediatrician must be cognizant of the extensive applications of endoscopic surgery in the pediatric patient. The ability to provide either outpatient surgery or short-stay surgery appears to be cost-effective and appropriate state-of-the-art medical care. As the array of surgical instruments continues to evolve, new and innovative endoscopic procedures will become increasingly available.

Minimal access surgery (MAS) is becoming an accepted modality in the management of adult trauma, but its use in children is rarely reported. Recently, we began using minimal access surgery to evaluate injured children. The purpose of this report is to review our preliminary experience with the use of laparoscopy and thoracoscopy in blunt and penetrating pediatric trauma. Eight children aged 2-14 years old were evaluated using MAS. Two children with blunt injuries had persistent abdominal pain despite normal radiologic studies. Laparoscopy documented a disrupted gallbladder and a small bowel perforation. Laparoscopy was also used to evaluate five hemodynamically stable children with penetrating wounds to the abdominal wall with potential peritoneal penetration. Only one child was converted to a laparotomy. Four were found to have either tangential penetrating wounds or nonbleeding solid organ injuries and were spared an open exploration. Two children with penetrating trauma with potential mediastinal injury were assessed with thoracoscopy. MAS was also used as a therapeutic modality in two children who had diaphragmatic lacerations repaired with an endoscopic "hernia" stapler. MAS accurately identified all injuries. All children were subsequently discharged without complications. We conclude that MAS is a safe and effective way to evaluate and manage hemodynamically stable children with both penetrating and blunt traumatic injuries.