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Background: Congenital ovarian cysts rarely auto amputate. An unusual complication of this event is secondary intestinal obstruction. The mechanism may be consequent to a direct pressure effect or to adhesions induced by the cyst. Case Presentation: A neonate presented with an abdominal mass and intestinal obstruction. On exploration, she had a mass hanging over the small intestine and one ovary was absent. Mass was excised and it turned out to be an auto-amputated ovary Conclusion: Although it is a rare pathology in neonates, surgeons must suspect it, particularly if an ovary is absent.

Chronic right iliac fossa (CRIF) pain in children is associated with repeated hospital attendance, inconclusive investigations, and missed school days. There is increasing evidence for the role of laparoscopic appendectomy for the management of CRIF pain. However, currently there is no substantial evidence to correlate histological changes identified in the appendixes removed with resolution of pain.This study collected prospective data for a single surgeon's series of laparoscopic appendectomy performed for CRIF pain between 2003 and 2014.Forty patients with a median age of 13 years (range 5-19 years) underwent laparoscopic appendectomy for CRIF pain. Twenty-nine patients (73%) had macroscopically normal appendixes, but histological changes were identified in 28 patients (70%). Other findings at laparoscopy included gynecological pathology (ovarian/para-ovarian cysts), unfixed mobile caecum, and a well-defined peritoneal band extending from the caecum to the anterolateral abdominal wall (caeco-peritoneal band). Patients were followed up for a median of 2 months (range 1-15 months). All patients reported resolution of CRIF pain.Laparoscopic appendectomy appears to be an effective treatment for CRIF pain, while also providing the opportunity to diagnose and treat potential sources of CRIF pain other than the appendix. Consistent with the literature, a small number of patients appear to have resolution of pain, despite no histological change being identified in the appendix removed and no other pathology having been identified. The same histological changes commonly seen have also been demonstrated in appendixes removed incidentally. Caution therefore should be applied when interpreting the significance of histological changes seen.

Congenital liver cyst is an uncommon disease in infancy and is usually asymptomatic. However, even rarer are congenital giant liver cysts which by virtue of their size are problematic. We discuss a case of a newborn with a giant hepatic cyst who was successfully treated surgically but experienced a postoperative bile leak as a complication. We review the management of this entity and propose an algorithm of care.

A caeco-peritoneal band (CPB) has been observed during diagnostic laparoscopy for chronic right iliac fossa (RIF) pain. This has a veil-like configuration and arises along a broad base from the caecum and ascending colon and attaches to the anterior abdominal wall.Retrospective analysis of a prospectively collected database of 31 patients, aged 11-16, who underwent diagnostic laparoscopy for ongoing RIF pain over a 10-year period was analysed for intra-operative presence of the CPB. The patients' symptoms, past medical history, diagnostic workup, surgical findings and outcome were evaluated.CPB was identified in five patients. All presented with chronic RIF pain and had inconclusive preoperative investigations. Two patients underwent previous surgery. In all cases, the CPB was the sole abnormal finding on diagnostic laparoscopy. Symptoms resolved following division of the CPB with no recurrence of pain at a mean follow-up of 575 days.CPB is a potential cause of chronic RIF pain in patients with unremarkable examination findings and negative serological and radiological investigations. Laparoscopic identification and division of the CPB has produced symptom resolution in this cohort of patients.

Testicular survival following second-stage Fowler-Stephens (FS) procedure depends upon adequate arterial supply. There is evidence that testicular survival rates are greater following gubernaculum-sparing second-stage FS procedure. The importance of collateral vessels in preservation of the testis has been hypothesised, but never shown in the literature. We aim to map the collateral blood supply to the testicle in gubernaculum-sparing, laparoscopic-assisted, second-stage FS procedure for intra-abdominal testicles.Selected patients undergoing a second-stage FS procedure were photographed prior to pexy in the Dartos pouch. Photographs were evaluated for the extent of vascular collateralisation between gubernacular, deferential and the ligated spermatic artery.Twenty-five patients with 28 undescended testicles underwent staged FS procedure over a 7.5-year period between 2005 and April 2013. Mean age at operation was 2.44 years, and all testicles were delivered to the scrotum. Mean follow-up was 3.29 years, and all patients were reviewed by the operating consultant. Testicular survival rate was 100 %. Representative photographs clearly demonstrate substantial cremasteric vessels running along the gubernaculum with robust collateralisation to the deferential vessel and the spermatic arterial stump.These images confirm the presence of robust collateral between the cremasteric and deferential vessels at second-stage FS procedure. Preservation of these collaterals in a gubernaculum-sparing approach may explain the excellent results seen in this series.

Ultrasound is a versatile tool, which is well suited to imaging children. It may be the only imaging necessary, or act as a guide to further relevant imaging. This pictorial review aims to give an overview of the role of ultrasonography in the management of common paediatric surgical abdominal emergencies in the UK, correlating ultrasound appearances with surgical and intraoperative findings and with other imaging modalities. A historical perspective is given into the evolution of ultrasound and surgical techniques. A comprehensive and carefully researched up-to-date reference list for further reading is included.

Background: Large ovarian cysts are rarely seen in the paediatric population and can now be managed by a variety of surgical approaches. Case Presentation: We report a case where a substantial right ovarian cyst in a 13 year old was removed through a single incision in the superior umbilical fold leaving no discernable scar. The placement of a purse string facilitated safe decompression of the cyst allowing delivery into the wound where the lining was stripped before being returned to the abdomen. Conclusions: Subsequent single incision laparoscopic surgery (SILS) port placement through the same wound allowed for a full inspection of the pelvis and abdomen. This approach represents an advance on conventional surgery and is a tenable alternative to an exclusive laparoscopic technique.

Congenital H-type fistulae are a rare abnormality. They commonly present with only minor respiratory complications and can, therefore, be difficult to identify. Conventionally, correction is via a ligation performed via either a cervical or thoracotomy incision, dependant on the fistula site. Thoracoscopic repair is emerging as a tenable alternative to traditional approaches and offers some advantages. This paper details the technical aspects of the thoracoscopic ligation of an H-type fistula.

Achalasia is an uncommon pediatric disease. An association with a benign esophageal stenosis is even rarer. We report this interesting case of a 9-year-old with concomitant achalasia and benign esophageal stenosis. Diagnosis was based on radiologic, endoscopic, and operative findings. The patient was successfully treated with laparoscopic Heller's esophagocardiomyotomy and Watson's fundoplication. Details of this unique case and operative technique are highlighted.

A single surgeon's 5-year experience of preserving the gubernaculum in laparoscopic-assisted Fowler-Stephens orchidopexy is reported. Thirty-six cases of impalpable testes are considered. Sixteen patients were confirmed as having intra-abdominal testes, with 20 testes considered to be absent/vanished. At follow-up, all testes had a similar volume to the contralateral testis except for one that had been considered hypoplastic at the initial operation. Mean follow-up was 612 days. The method and potential importance of gubernacular preservation in this situation are discussed.

Gastroesophageal reflux (GOR) affects 2–8% of children over 3 years of age and is associated with significant morbidity. The disorder is particularly critical in neurologically impaired children, who have a high risk of aspiration. Traditionally, the surgical antireflux procedure of choice has been Nissen’s operation. However, this technique has a significant incidence of mechanical complications and has a reoperation rate of approximately 7%, leading to the development of alternative approaches. Watson’s technique of partial anterior fundoplication has been shown to achieve long-lasting reflux control in adults with few mechanical complications, but there is limited data in the paediatric population. We present here short- and long-term outcomes of laparoscopic Watson fundoplication in a series of 76 children and infants, 34% of whom had a degree of neurological impairment including severe cerebral palsy and hypoxic brain injury. The overall complication rate was 27.6%, of which only 1 was classified as major. To date, we have not recorded any incidences of perforation and no revisions. In our experience, Watson’s laparoscopic partial fundoplication can be performed with minimal complications and with durable results, not least in neurologically compromised children, making it a viable alternative to the Nissen procedure in paediatric surgery.

Introduction: Interruption of intestinal rotation and fixation during any point in the development of the midgut results in an anatomic spectrum encompassed by the term 'malrotation'. Case presentation: We present an unusual variant of malrotation in a neonate conceived by In vitro fertilization. Discussion: Assisted reproductive techniques have been recognized to be associated with a higher risk of congenital anomalies. However, there have been inconsistent reports regarding an increased risk of gastrointestinal anomalies. Recent reports have also linked assisted reproductive techniques to an increased risk of genetic imprinting disorders. There is evidence to suggest that some cases of malrotation may have a genetic aetiology. The fact that the case presented was conceived by In vitro fertilization may be entirely incidental, however the unusual bowel orientation has led us to speculate whether assisted reproductive techniques might be associated with rarer forms of malrotation.

In recent years, laparoscopic equipment, and experience with its use, has improved. We are now able to appreciate microanatomy, and dissection of individual lymphatic channels is possible. Previously, the results of laparoscopic lymphatic-sparing procedures has been reported. In this study, we report our experience of the preservation of both the lymphatic channels and the testicular artery during laparoscopic varicocelectomy and its outcomes.All boys undergoing laparoscopic varicocelectomy between June 2004 and February 2009 were included in the study. The demographic details, operative findings, complications, and length of stay were recorded on a Microsoft Excel spreadsheet and complications at follow-up noted. The operation was performed via a transperitoneal approach, and the retroperitoneum was entered proximal to the internal ring by peritoneal division over the vessels. The spermatic vein or veins were isolated and stripped of the surrounding lymphatics and artery and secured with ligaclips. Any other tortuous veins around the internal ring were also ligated at the time of operation.Nineteen boys underwent laparoscopic varicolectomy. Complications were 1 intraoperative small bowel injury, 1 hydrocele (5%), and 4 persistent varices (21%), one of which was symptomatic, requiring a low ligation of spermatic veins through a groin approach.This study shows good results with regard to postoperative hydrocoele rates. The preservation of the lymphatic supply ensures adequate lymphatic drainage, therefore, minimizing the risk of developing a hydrocele postoperatively. The risk of persistent varices, compared to the traditional en-masse technique, is a source of concern and requires further study.

The value of laparoscopy in repair of congenital duodenal webs is yet to be established and techniques are evolving. Described are technical details of a successful laparoscopic web ablation without duodenoplasty.

This article highlights the difficulties posed by initial radiological investigations that misleadingly interpreted a linear opacity in the ascending colon of a 2-year-old to be a complicating calcified Ascaris. Final surgical management revealed an unusual cause for the tram tracking effect so pathognomonic of Ascaris infestation. Of interest are the images of the abdominal x-ray, ultrasound scan, and barium study.

Background: Partial fundoplication is an alternative to a complete wrap and is reputed to offer lower long-term risks. Watson et al. described an anterior 120° fundoplication in 1991, whic...

Background: Spontaneous pneumothorax hardly occurs in healthy children. Diagnosing its etiology can be difficult. Chest X ray and Computerized Tomographic scan (CT) are useful investigations but have limitations. CT scan in combination with video assisted thoracoscopic surgery (VATS) improves diagnostic accuracy and facilitates appropriate management of non-resolving spontaneous pneumothorax. Showcased are images demonstrating how effectively CT complements video assisted thoracoscopic surgery (VATS) in managing a recalcitrant case of spontaneous pneumothorax caused by a solitary bulla. Objectives: A 15 year old boy presented to the referring hospital with a right sided spontaneous pneumothorax which occurred whilst playing football Case report: A 15 year old boy presented to the referring hospital with a right sided spontaneous pneumothorax which occurred whilst playing football. His symptoms were shortness of breath and right pleurisy chest pain. His oxygen saturations were more than 95% on air. A needle aspiration was performed yielding 2300mls of air, however the pneumothorax persisted. Conclusions: In cases of pontaneous pneumothorax, Chest X ray and Computerised Tomographic scan have limitations. CT scan in combination with video assisted thoracoscopic surgery improves diagnostic accuracy and facilitates appropriate management of nonresolving spontaneous pneumothorax.

We read with interest the article by Choi et al. However, the incidence of bilateral inguinal hernias/patent processus vaginalis (PPV) (infants—61 %, older children—35 %) seen at laparoscopy is significantly higher than other published studies and our own experience. Our 2011 systematic review of 61 studies of pediatric inguinal hernia repairs, published in this journal, identified 2,857 patients from a total of 49,568 who developed a metachronous contralateral hernia after their initial unilateral repair [1]. The incidence of bilateral inguinal hernias in children under 6 months of age was just 12.4 % with an overall incidence of 5.6 %. In the light of these discrepancies, the clinical significance of many inguinal canal defects seen at laparoscopy must be low. As there are risks involved in laparoscopic hernia repairs, especially to the testis in males, it seems sensible that the criteria for correction of sub-clinical contralateral abnormalities should be re-defined to enable convergence of these widely disparate figures.

90 percent of symptomatic patients undergoing cholecystectomy have cholelithiasis with 10% categorized as asymptomatic cholecystitis. In both instances, the gallbladder is evident on ultrasonography. In children with symptomatic biliary dyspepsia, the decision to proceed to cholecystectomy is made difficult if choleliths are not seen on ultrasonography. This decision is made even more difficult if the gallbladder itself is not seen on repeated imaging. In a cohort of 54 cholecystectomies, 3 cases, with recurrent right upper quadrant pain and undetectable gallbladders on repeat ultrasonography, were identified. After prolonged observation all underwent successful cholecystectomy. Histology demonstrated a markedly fibrotic and thickened gallbladder in all. Given this experience, we suggest that nonvisibility of the gallbladder, in fact, maybe be a feature of a chronic acalculous cholecystitis. We advise consideration of cholecystectomy for chronic biliary dyspepsia where repeat ultrasonography fails to demonstrate a gallbladder.

Background. Single Incision Laparoscopic Surgery (SILS) has been highlighted in the recent literature as a means of performing a range of common, minimal access, paediatric surgical procedures. The primary attraction is the absence of visible scarring.Aim. This study aims to describe a cosmetically advantageous means of SILS port placement in children, which preserves the umbilical profile.Methods. We describe a paediatric case series utilising a semicircular incision in the superior umbilical fold for SILS procedures. The linea alba is exposed over 2 cm just superior to the umbilical ring and stay sutures are applied. A vertical incision is made over this distance without entering the umbilical ring. Data were recorded prospectively in a Microsoft Excel database.Results. Twenty-one cases were performed in a 1-year period. Ten appendicectomies, 5 ovarian/paraovarian cystectomies, 2 Palomo procedures, 3 nephrectomy/heminephrectomies, and 1 Meckel’s diverticulectomy were performed. There was 1 wound infection. No incisional hernias occurred.Discussion. We believe that our technique, which maintains the integrity of the umbilical ring and allows preservation of the umbilical profile, offers a distinct cosmetic advantage over other incisions for SILS which distort it.Conclusion. We have demonstrated the aesthetic benefits of utilising a superior umbilical-fold incision for SILS in children.

Aim: To demonstrate the use of inexpensive, routinely available equipment in intraoperative laparoscopic cholangiography. Methods: The video shows introduction of a ureteric catheter throu...

Background: Laparoscopic transperitoneal nephrectomy is technically feasible in most cases of benign renal disease. To date, there have been isolated reports of laparoscopic transperitoneal hemi-nephroureterectomy of principally the upper moiety of a duplex system. Rarely reported are lower moiety nephroureterectomies. Aim: To present a 3-minute video demonstrating the technical details of a transperitoneal laparoscopic, right, lower moiety, hemi-nephroureterectomy in a 3-year-old. Method/Technique: A child with marginally functioning (5%) lower moiety of a right duplex system was subjected to a transperitoneal hemi-nephroureterectomy. The patient was placed in a left lateral position, and an umbilical camera and two working ports (right iliac fossa and epigastric), all 5 mm, were utilized. The ascending colon was reflected to the left and the underlying lower moiety ureter identified and isolated. With traction on the ureter, the pelvis was brought into view, and the blood supply to the lower mo...

Introduction: Congenital splenic cysts are usually of the epidermoid variety.1 These cysts have a propensity for progressive enlargement with a risk of infection, hemorrhage, rupture, and becoming symptomatic. Diagnosis is usually made on abdominal ultrasonography or a computed tomography scan. Management options, from simple cyst aspiration to partial splenectomy, have been employed to preserve splenic function. However, more conservative measures such as cyst aspiration and limited decapsulation risk cyst persistence or recurrence and are generally not advocated. Radical cyst decapsulation has been deployed to achieve cyst control.2–6 Presented is a video of a giant epidermoid cyst managed by radical decapsulation performed laparoscopically. Highlighted is the technique of cyst decompression, segmental vascular control, and decapsulation of >90% of the cyst with preservation of the normal lower pole. Materials and Methods: The patient is placed in a supine position with the left side raised 30°...

Long gap oesophageal atresia is a clinically and technically challenging condition to manage. Documentation of the gap between the upper and lower pouches is critical to deciding the timing and feasibility of a primary anastamosis. Integral to this process is the role of radiology. We present a case of long gap oesophageal atresia accompanied by chronological radiography demonstrating its' staged management and highlighting some common complications.

The aim of the study was to review our experience with single-incision laparoscopic surgery (SILS) and to compare costs and operative time to standard laparoscopic surgery (SLS). A prospectively collected database of operative times and costs was analysed for the years 2008–2011. SILS cases were compared to standard laparoscopy on a procedure-matched basis. Patient demographics, on-table time and consumable costs were collated. Descriptive statistics and Mann-WhitneyU-test were utilized with SPSS for windows. Analysis of the data demonstrate that neither consumable costs nor operative time were significantly different in each group. Comparing operative costs, SILS appendicectomy, nephrectomy/heminephrectomy, and ovarian cystectomy/oophorectomy showed cost benefit over SLS (£397 versus£467;£942 versus£1127;£394 versus£495). A trend toward higher cost for SILS Palomo procedure is noted (£734 versus£400). Operative time for SILS appendicectomy, nephrectomy/heminephrectomy, and Palomo was lower compared to SLS (60 versus 103 minutes[mins.]; 130 versus 60 mins.; 60 versus 80 mins.). In conclusion, SILS appears to be cost-effective for the common pediatric surgical operations. There is no significant difference in operating time in this series, but small sample size is a limiting factor. Studies with larger numbers will be necessary to validate these initial observations.

Aim: To present a video of laparoscopic oesophagocardiomyotomy in a 16-year-old achalasia patient with two failed attempts at balloon dilatation. Demonstrated is a technique of myotomy wit...

Background: Several previous reports have demonstrated that the laparoscopic Swenson technique is a viable alternative to the open procedure and that it has several advantages, including shorter length of hospital stay, earlier return of bowel function, and, most importantly, fewer complications.1–3 Aim: A video demonstrating the technique of laparoscopic Swenson procedure. Case Report: A 6-month-old infant presents as a neonate with abdominal distention and failure to pass meconium. Rectal suction biopsies demonstrate evidence of Hirschsprung's disease, and further laparoscopic biopsies confirm short segment involvement. A primary laparoscopic Swenson procedure is performed at 6 months of age. Technique: A 4-port approach using a 10-mm umbilical port and three 5-mm ports (umbilical & right & left iliac fossa) are utilized. Intra-abdominal insufflation pressure is maintained at 10 mmHg. Once pneumoperitoneum is established, a 2-0 silk stay is passed through the anterior abdominal wall and the bla...

Background: High-grade intestinal obstruction with massive abdominal distension is considered to be an absolute contraindication to laparoscopy. However, improvements in skill level and operator experience makes therapeutic laparoscopy in the above context possible.1–3 Aim: To present video material demonstrating the diagnostic and therapeutic value of laparoscopy, for nonadhesive, high-grade intestinal obstruction, in children. Methods: Two patients, a 4- and a 15-year-old, with no previous abdominal surgery, present with a 24-hour history of abdominal colic, bile-stained vomiting, and massive distension. Abdominal X-ray confirms high-grade distal small bowel obstruction. Emergency laparoscopy via an umbilical (10 mm) and 2 suprapubic ports (5 mm) established the cause of obstruction to be caused by a vitello-diverticular band and a constrictive Meckel's band with volvulus, respectively. A therapeutic division of the band and unravelling of the Meckel's instantly relieved the obstruction. Both d...

Key Clinical Message Pediatric ovarian torsion is an infrequent diagnosis and it often mimics acute appendicitis. Most cases are due to underlying ovarian pathology and if left untreated, ovarian torsion may eventually cause peritonitis. Emergency exploratory laparoscopy represents a valuable diagnostic and therapeutic tool in suspected ovarian torsion.

Circumcisions are among the most frequently performed operations in children and numerous techniques are employed often with varying results. Use of the Plastibell™ (Hollister Incorporated, Illinois, USA), under local anesthetic, is popular for cultural and religious circumcisions but is not without its problems. Complications of Plastibell™ (slippage, migration, bleeding and serious infection) have been reported. Described is a prospective series of cases in which modifications to the standard Plastibell™ technique were utilized to improve outcomes, in particular, the risk of bleeding.

Laparoscopic management of congenital ovarian cysts is widely practiced but there is a dearth of information on the performance of the gonad where organ-preserving surgery is undertaken. Presented is a radiological diary documenting the progress of a complex congenital ovarian cyst from the antenatal period to a year post-laparoscopic decapsulation.

The expectant management of high grade renal injuries in hemodynamically stable children has gained increasing acceptance amongst paediatric surgeons. However, patients with grade 1V injury with complete renal transection have been identified as a subgroup with a poor outcome that may benefit from early operative intervention. Interestingly, both internal and external drainage have been independently utilised as part of the expectant approach. The former is more widely practiced and was first suggested by Haas et al who used it successfully in 5 patients with grade 1V renal trauma. Yet to be clearly established in this context is the value and timing of external drainage, particularly, when used in combination with internal stenting. Described is a child with complete renal transaction who was successfully managed with a combination of internal and external drainage.

To assess the performance of a paediatric cohort having a FRECA PEG (FP) placed at the time of laparoscopic fundoplication.This is retrospective study of a single surgeon's experience of laparoscopic fundoplications over a decade. Patient details were retrieved form a Microsoft Excel database and demographic, operative, and performance measures analysed.Of a series of 67 laparoscopic fundoplications, 20 with neurological compromise underwent FP placement at the time of surgery. Mean age was 3.37 years with a male to female ratio of 1.1:1. A size 9 French FRECA was placed in patients less than 10 kg (12) with larger patients (8) having a size 15 device. A Watson anterior wrap was performed in 16 cases with the rest having a Nissen fundoplication. Seven of these cases had pre-existing FPs which were taken down before replacement post fundoplication. Feeding was resumed the next morning except in three with delayed gastric emptying. Other complications (3) were seen but were not PEG related. The median stay for the series was 4 days (SD 3) and patients were followed up for a mean of 684 days. Over this period four patients relapsed and resumed medical treatment. A single mortality occurred in a syndromic 3-year-old a year later from problems unrelated to surgery. FPs were changed to a button device under general anaesthetic 3-24 months following placement.FP placement at the time of laparoscopic fundoplication does not appear to compromise the outcome of surgery. Neither the size of patient nor the type of wrap is an impediment to its placement and the device can be used shortly after surgery in the majority allowing for an early discharge. Complications are infrequent; however, change to a button device within 2 years of initial placement requires general anaesthetic.

Laparoscopic cholecystectomy is the treatment of choice in symptomatic paediatric cholelithiasis. However, controversy exists about its role in asymptomatic cholelithiasis and biliary dyskinesia. We have reviewed the experiences of two UK paediatric centres with laparoscopic cholecystectomy over an 8.5 year period and critically evaluated the indications and outcomes of surgery.Patients who underwent laparoscopic cholecystectomy by a single surgeon at the Royal Aberdeen and Royal Alexandra Hospitals between May 1996 to August 2003 and September 2003 to December 2005, respectively, were studied. Information was extracted from prospectively held databases and analysed.A total of 27 cholecystectomies were performed during the period of study. The mean age of patients was 11.7 years with a female preponderance. Symptomatic idiopathic cholelithiasis was the main indication for surgery (14). Cholecystectomy was also performed for haemolytic disease (3), acute recurrent pancreatitis of unknown cause (2), gallbladder trauma (1), and for asymptomatic calcific non-resolving stones (7). All patients were investigated with ultrasound scans with four patients undergoing magnetic resonance cholangiopancreatography (MRCP) for suspected common bile duct (CBD) stones. A standard four-port approach was used with the gallbladder extracted through the umbilical port. The mean operative time in the latter 13 cases was 105 minutes with a median postoperative stay of one day for the whole series. Histology revealed chronic cholecystitis in all but three cases. All patients were discharged after a six-month follow-up period.The advent of laparoscopy has resulted in an expansion of the traditional indications for cholecystectomy. MRCP is a useful investigation in selected children to exclude choledocholithiasis and avoid intraoperative cholangiography. There appears to be no clear correlation between histology and presenting symptoms. The natural history of asymptomatic gallstones in children is not known although a consensus is emerging to support cholecystectomy for all calcific non-resolving gallstones.

The aims of this study was to determine whether an active policy of cost curtailment would impact on the theater cost of laparoscopic surgery in a pediatric setting; to document the extent of cost changes over time and to identify factors that adversely influence expenditure; and to investigate whether the surgeon is a significant factor in the price of the procedure.A prospective audit of laparoscopic procedures was performed in a single unit over a 36-month period. Detailed costs of theater inventory for all procedures were compiled on a case-by-case basis and recorded on a database. The cost of six index procedures were collated and changes over the period of the study analyzed. The factors responsible for increased expenditure were flagged and appraised to enable the implementation of cost-saving measures. The prices of the laparoscopic equipment were based on invoiced figures provided by hospital managers, and no long-term outcome measures were taken into account.A total of 179 cases were performed by six surgeons over a 3-year period between January 1, 2003 and December 31, 2005, with no adverse intraoperative events. The procedures studied in further detail were appendicectomy (n = 50), fundoplication (n = 25), cholecystectomy (n = 12), nephrectomy (n = 10), Fowler Stevens for undescended testes (n = 10), and modified Palomo operations for varicocoele (n = 7). The mean cost of these procedures fell year by year over the period of study but was significant only in appendicectomy (P = 0.017). For this procedure, there was a significant difference in costs between the various surgeons (P = 0.007), but this trend was not noted with the other procedures. There were no major intraoperative events, although 2 patients required conversion owing to technical difficulties posed by the cases. Among the factors that influenced costs were the use of disposables, particularly for hemostasis and suctioning, and an inability to procure reuseable instruments.The costs of commonly performed laparoscopic procedures are falling year by year. The surgeon is a factor in the costs of some procedures. A cost-saving strategy has not been compromised of patient safety; however, some cost-saving measures, though attractive, are labor intensive and are not practical. An overall commitment to the sensible use of health care resources translates into savings for hospitals, thereby strengthening the case for laparoscopic surgery.

Considering the fantastic pace of change in the world of minimally invasive surgery, it is indeed the brave who take on the challenge of putting together a textbook on this subject. Chief editor Azad Najmaldin is, therefore, to be complimented for his effort in pooling the skills of leading paediatric surgeons to produce a current and pertinent text on paediatric minimally invasive surgery. The information is delivered in 65 selected topics, which are categorised into general, gastrointestinal, thoracic and urology sections. For obvious reasons, gastroenterology has the greatest weighting but coverage of this continually expanding specialty is very adequate in all areas. A standard format is followed throughout the book, giving an easy flowing style with consistency, and the book is also well indexed with bold subheadings allowing for easy access to the information. Despite the varied authorship, there has clearly been investment by the editors to ensure an even spread of quality throughout the book. There are parts, especially in the thoracic and urological sections, that are written from a perspective of vast experience and stand above the rest. Deficiencies, on the other hand, are hard to find and the reader is not going to be disappointed. The detail of the historical perspectives, particularly in the earlier sections, is tortuous but this is more than compensated for by the class in the ‘problems, pitfalls and solutions’ section, which is delivered with clinical precision. The authors have deliberately avoided controversy, concentrating instead on the facts, which is a positive aspect of the book. Where coverage of technical options is necessary as in antireflux surgery and nephrectomy, these are informative, cutting edge and comprehensive. Further reading lists are limited to key sources and sometimes not offered at all, thereby leaving enthusiastic readers who seek more information to conduct an independent search of the literature. Critical to this type of publication are the technical descriptions that feature at the core of minimally invasive and endoscopic practice. Herein lies the appeal of the textbook, which delivers this aspect in sufficient detail using simple language, without the chaff. Equipment requirements are appropriately bullet pointed as are the concise peri-operative and technique descriptions. Illustrations are for the most part relevant and complementary to the text but trainees who lack surgical experience (and to whom the book is principally directed) may have to rely on powerful imagination to make up for some of the rather unprofessional sketching. At £165 this is an expensive buy considering the absence of glossy prints. For the price, however, the purchaser acquires an excellent operative manual in a highly specialised area of paediatric practice, written by leaders in their respective fields. This book, which is currently without competition, should do well but purchasers would have to be cautious to judge by content and not cover.

Objective: The aim of this paper is to demonstrate that laparoscopy can successfully diagnose otherwise elusive Meckel's diverticuli and at the same time offer a therapeutic access for successful resection. Materials and Methods: Two patients with anemia of unknown cause and a further patient with acute small bowel obstruction underwent diagnostic laparoscopy. A Meckel's diverticulum was identified in each case and successfully resected through a minilaparotomy. Results: All three patients were successfully investigated and treated with laparoscopy with no morbidity or mortality. Conclusion: Laparoscopy is a safe and effective surgical modality for diagnosis of atypically presenting Meckel's diverticulum and has a therapeutic role that results in an excellent cosmetic result.

To determine whether elective laparoscopic appendicectomy is justified for chronic right iliac fossa (RIF) pain of undetermined origin.A retrospective audit of all laparoscopic appendicectomies between January 1997 and August 2003 was performed. The expanded medical audit system (EMAS) and a Microsoft Access database of operative records were used to identify patients with chronic RIF pain subjected to elective appendicectomy. Case notes were retrieved and analysed for patient profile, duration of symptoms including clinic visits and admissions, operative findings, histological analysis, and postoperative performance. A correlation between histological findings and final outcome was investigated.Ninety-eight patients underwent laparoscopic appendicectomy during the period of the study. A total of 11 cases with chronic RIF pain were identified. Nine were female and 2 male. Age ranged from 9 to 14 years with a mean of 11.9 years. The number of clinic visits and admissions for chronic RIF pain ranged from 2 to 8, with a mean of 4. Duration of symptoms ranged from 1 to 36 months, with a mean of 12.1 months. Detailed history, clinical examination, and serological and radiological investigations failed to reveal the cause of the pain in all cases. Patients were followed up in postoperative clinics for between 1 and 72 months, with a mean of 16.1 months. Histology of resected appendices showed acute inflammation (3 cases), fecoliths (2 cases), lymphoid hyperplasia (LH) (1 case), LH and a foreign body reaction (1 case), LH and mucosal hyperplasia (1 case), and Enterobius vermicularis parasites in 1 case. The appendix was normal in 2 cases. Eight patients had complete resolution of RIP pain. Seven of these had pathology within the appendix and 1 was histologically normal. Two patients with resolved RIF pain, but with pain elsewhere, had lymphoid hyperplasia noted within the appendix. One patient with persistent pain 6 years postoperatively had a normal appendix.This study demonstrates that a significant number of patients with chronic RIF pain have pathology within the appendix. The majority of these cases will benefit from elective appendicectomy. It is critical however that all other possible causes of pain in the RIF are excluded. Laparoscopy is an integral part of the diagnosis and management of this particularly difficult group of patients.