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Introduction: Total nephrectomies for the treatment of Wilms' tumor (WT) are more and more performed by laparoscopy, although indications for this approach following the UMBRELLA guidelines are currently very restrictive. The purpose of this study was to assess the compliance to the criteria of the UMBRELLA protocol for minimally invasive approach of WT., Methods: This retrospective multicenter study included children operated on by laparoscopic total nephrectomy for suspected WT before 2020. Imaging was reviewed centrally., Results: Fifty-six patients (50 WT and 6 nephrogenic rests) were operated on at a median age of 3.3 ± 2.6 years. Thirteen (23%) patients had metastasis at diagnosis. The mean operative time was 213 ± 84 min. There were eight (14.3%) conversions and five peroperative complications. A local stage III was confirmed in seven (12.5%) cases, including two for tumor rupture. Only one (1.8%) of the procedures followed the SIOP-UMBRELLA indications for laparoscopy. The criterion "ring of normal parenchyma" was met only once. Conservative surgery seemed possible in ten (17.9%) cases. The extension of the tumor beyond the ipsilateral edge of the vertebra after chemotherapy and a volume over 200 mL were associated with an increased risk of conversion (p = 0.0004 and p = 0.001 respectively). After a mean follow-up of 5.2 ± 4.0 years, although there was no local recurrence, one death occurred due to metastatic progression at 15 months postoperatively., Conclusions: The laparoscopic approach of WT beyond the UMBRELLA recommendations was feasible with low risk of local recurrence. Its indications may be updated and validated., (© 2024. Society of Surgical Oncology.)

Purpose: Duplication enucleation (DE) has been described as an alternative to intestinal resection with primary anastomosis (IRA) for intestinal duplications, but no comparative study exists. The aim of this study was to compare both surgical procedures for intestinal duplication., Methods: A retrospective study was performed, including all children treated for intestinal duplication (2005-2023). Patients that underwent DE were compared to those that underwent IRA. Statistical significance was determined using p < 0.05. Ethical approval was obtained., Results: A total of 51 patients (median age: 5 months) were treated for intestinal duplication, including 27 patients (53%) that underwent DE and 24 IRA (47%). A cystic image was detected prenatally in 19 patients (70%) with DE and 11 patients (46%) with IRA (p = 0.09). Enucleation was performed using laparoscopy in 7 patients (14%). Patients that underwent DE had shorter time to first feed (1 vs 3 days, p = 0.0001) and length of stay (4 vs 6 days, p < 0.0004) compared to IRA. A muscular layer was identified in 68% of intestinal resection specimens., Conclusion: Compared to intestinal resection with anastomosis, duplication enucleation is associated with decreased postoperative length of stay and delay to first feeds without increasing post-operative complications. Regarding histological analysis, enucleation seems feasible in most cases., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Surgery is one of the cornerstones of Wilms tumor treatment. In this article, we present technical advancements that are finding their way into the armamentarium of pediatric cancer surgeons. We discuss the current approaches, challenges, opportunities, and future directions of minimally invasive surgery (laparoscopic and robotics), image-guided surgery, and fluorescence-guided surgery. Furthermore, we discuss the use of intraoperative ultrasonography, as well as the use of new techniques to improve the quality of lymph node sampling., (© 2023 Wiley Periodicals LLC.)

Background: The safety of the laparoscopic treatment of intestinal malrotation remains controversial. This study compared the outcomes of laparoscopic and open surgical treatment of intestinal malrotation., Methods: A multicentric retrospective study included pediatric cases of intestinal malrotation operated on between 2005 and 2016., Results: This study included 227 children with a median age of 17 days (0-17.2 years), including 161 with a midgut volvulus. Forty-six(20.3%) procedures were started by laparoscopy and 181(79.7%) by laparotomy. Laparoscopy was more frequent for elective surgery (45.9%) than for emergency procedures (10.8%, p < 0.001). Conversions were significantly more frequent during emergency procedures (66.7% vs 17.9%)(p = 0.001). Considering only 61 elective surgeries, the mean hospital stay was significantly shorter after laparoscopy (5.3 days +/-5.2 vs 10.1 days +/-13, p = 0.01), the overall complication rate was comparable (15.8% vs 21.7%, p = 0.7) but post-operative volvulus was significantly more frequent after laparoscopy (13% vs 0%, p = 0.04). Outcomes of the two approaches were not significantly different after 166 emergency procedures., Conclusion: Laparoscopy can be performed by experienced team for the treatment of selected cases of intestinal malrotation. Conversion to open surgery should be done with a low threshold, as the rate of volvulus recurrence is concerning., Level of Evidence: Level III., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Respiratory manifestations of gastroesophageal reflux disease (GERD), particularly chronic cough, are being recognized with increased frequency in children. This survey aimed to investigate the efficacy of laparoscopic Nissen fundoplication for treatment of GERD-related respiratory symptoms not responsive to medical therapy in neurological normal children., Materials and Methods: We collected data of children with GERD-related respiratory complaints not responsive to medical therapy who underwent laparoscopic Nissen fundoplication in four European centers of Pediatric Surgery over a 10-year period. We excluded children with neurological impairment., Results: A total of 220 laparoscopic Nissen procedures were performed in the period 2005-2015. Twenty-four (12 boys and 12 girls, average age 9.5 years) out of the 220 patients (10.9%) presented with chronic cough and other respiratory manifestations, including asthma, reactive airway disease, and recurrent pneumonia. Average operative time was 65 minutes (range 45-100). As for postoperative complications, two tight wraps requiring endoscopic dilatation (IIIb Clavien) and two relapses of GERD for slipped Nissen requiring reoperation (IIIb Clavien) were recorded. None of these complications occurred in the group of patients with GERD-related respiratory symptoms. At follow-up evaluation, respiratory symptoms disappeared with a significant improvement of quality of life scoring (I Grade Visick) in 22/24 patients (91.6%)., Conclusion: Our results confirm that GERD should be investigated as one of the possible etiologic factors in any child with persistent respiratory complaints. In patients with symptoms not responsive to medical therapy, laparoscopic Nissen fundoplication is the treatment of choice with a very high success rate (>90% in our series), a very low morbidity, a significant improvement in airway symptoms, and a marked reduction in the need for medications.

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.

Introduction  Splenectomy in children is nowadays widely performed by laparoscopy, the major risk being operative hemorrhage. We hereby compare the results of two different techniques of vascular control. Materials and Methods  We retrospectively reviewed all patients undergoing a laparoscopic splenectomy (LS) for hematologic disease at a single institution from 2004 to 2013. LS was performed by a lateral approach. The 10-mm optic port was placed in the umbilicus and two 5-mm working ports were placed in the left lower quadrant and in the right upper quadrant near the midline.An additional port was added in the epigastrium if needed. The classic technique (CT) consisted in the separate sealing and section of the splenic artery and vein above the pancreas tail. The modified technique (MT) consisted in the dissection of each segmental splenic vessel, at the lower, middle, and upper parts of the spleen. They were then divided without individualizing the artery from the vein. Results  Total 69 patients were operated on at a mean age of 7.8 ± 0.6 years, 30 by CT and 39 by MT. In 20 patients (6 CT, 14 MT) a cholecystectomy was associated. The operative time, length of hospitalization, and number of postoperative complications for CT/MT were respectively 139/117 mn ( p  = 0.04), 3.8/3.0 days ( p  = 0.01), 12/3 ( p  = 0.002). An additional port was less needed with MT ( p  = 0.03). Conclusions  The joint sealing of segmental splenic artery and vein appeared safe, efficient and quicker for LS, with no increased risk of operative bleeding and postoperative complications., (Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: Although surgical residency training is a structured, regulated system for surgical skill acquisition, after residency or fellowship, no good method exists for practicing surgeons to learn new, developing techniques. Because 1-2-day simulation courses are probably inadequate for teaching a new technique and because it is often unrealistic for a practicing surgeon to leave his or her practice for an extended period of time, surgical telementoring may be a solution by allowing an expert to support a trained surgeon through the learning curve of a new procedure while overcoming geographic distance. In the past we have presented 6 cases of transcontinental telementoring with pediatric surgeons in the United States. We have since expanded the concept to trans-Atlantic telementoring and performed 2 cases with pediatric surgeons in France., Materials and Methods: The two telementors and one of the two telementees had previously met through a professional society but had never operated together before this experience. The first procedure was an interval laparoscopic appendectomy to test the process. The second procedure was a thoracoscopic total thymectomy. The technology consisted of the VisitOR1® telementoring robot (Karl Storz GmbH & Co. KG, Tuttlingen, Germany)., Results: Both procedures were completed successfully with high satisfaction from both the telementors and telementees. Latency was low, and there was no loss of connection. The telestration and laser pointer features of the robot facilitated the telementoring experience. Challenges included lack of a prior surgical relationship between the mentees and mentors that limited the depth of advice but did not impair the quality of the surgery, as well as poor audio quality that was overcome using headsets., Conclusions: From this experience, several challenges were identified and addressed. Telementoring may be an effective means of improving adoption of new surgical techniques, ultimately improving patient care.

Background: Minimally invasive surgery (MIS) is still not a well-accepted surgical approach to remove neuroblastic tumors. We aimed to assess the indications and limits of MIS in this childhood tumor according to tumor location and image-defined risk factors (IDRFs)., Procedure: Between 2006 and 2012, 39 patients underwent MIS for neuroblastic tumors, using thoracoscopic (n = 20), retroperitoneoscopic (n = 1) or laparoscopic approaches (n = 18). The tumor locations were paravertebral (n = 18; thoracic n = 15, lumbar n = 3), perivascular (n = 5; abdominal n = 2; thoracic n = 3), adrenal (n = 13), pleural (n = 2) and pelvic (n = 1). Two patients were treated for relapses. According to the INRG staging system, IDRFs were absent in 20 patients and present in 19 patients. Ten patients received chemotherapy preoperatively. Mean largest diameter was 35 mm for thoracic tumors (range: 7-85 mm) and 34 mm for abdominal tumors (range: 10-75 mm). Mean follow-up was 25 months (range: 5-116 months)., Results: Resection was macroscopically incomplete (R2) for six thoracic tumors and one adrenal tumor. Conversion was necessary for three thoracic L2 tumors. Postoperative complications consisted of chylothorax in three patients with L2 paravertebral thoracic tumors, Horner's syndrome in a patient with a cervicothoracic tumor, and renal atrophy in a patient with a L2 abdominal tumor. No perioperative or postoperative complications occurred in patients with adrenal and abdominal paravertebral tumors. The overall survival rate was 98%., Conclusion: In carefully selected cases, MIS permits safe and efficient resection of neuroblastic tumors in children. Open surgical approach should be considered if organ or vascular control or quality of resection is jeopardized. Pediatr Blood Cancer 2015;62:257-261. © 2014 Wiley Periodicals, Inc., (© 2014 Wiley Periodicals, Inc.)

Background: High-dose irradiation is the cornerstone treatment of bone cancers of the pelvic rim. To protect the small bowel from irradiation and following consequences, we described the laparoscopic use of the sigmoid to perform a hammock., Materials and Methods: Three patients were diagnosed with metastatic Ewing's sarcoma, localized malignant peripheral nerve sheath tumor, and localized BCOR-CCNB3 (Ewing-like) sarcoma of the pelvic rim at 13.1, 5.7, and 12.9 years, respectively. After neoadjuvant chemotherapy, the 2 female patients underwent a hemisacrectomy under S2 only by the posterior approach, whereas no orthopedic surgery was required for the male patient because of excellent local response to chemotherapy. A 54-Gy intensity-modulated radiotherapy of the posterior part of the pelvis was intended for all patients., Results: The laparoscopic procedure consisted in the fixation of the sigmoid loop to the anterior parietal wall on a transverse line just below the umbilicus, associated with a colostomy in the right iliac fossa. The anterior transposition of the two ovaries, uterus, and rectum and the dissection of left iliac vessels to move them anteriorly were added in female patients. Stomas were closed around 6 months after completion of the radiotherapy course, associated with the repositioning of the uterus, ovaries, and colon. With a mean follow-up of 22 months, all patients are alive without any recurrences or radiation-related symptoms., Conclusions: The laparoscopic "hammock technique" both protects the small bowel from irradiation and secures the orthopedic procedure by displacing the abdominal organs forward.